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Kristanto’s compilation of
L & K’s ORTHOPAEDIC NOTES 2008
1. List of Important Orthopaedic Classifications
2. Short Cases - examination techniques
3. Hands and Wrists
4. Elbows
5. Hip
6. Knee
7. Neck
8. Back
9. Hip fractures
10. OA knees
11. Osteoporosis
12. Diabetic Foot
13. Bones and Joints infection
14. Bone Tumours and cysts
15. Ankylosing Spnodilitis
16. Paeds Ortho
17. Lower Limb Fractures summary
18. Upper Limb fracture summary
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1
1) List of Important Orthopaedic Classifications
Fracture types
Simple
Comminuted
Hairline
Greenstick
Compression
Avulsion
Impacted






Transverse (<30o)
Oblique (>30o)
Spiral
Spiral wedge – torsional forces
Bending wedge – characteristic butterfly fragment
Comminuted wedge – bending wedge # with fragmented butterfly
fragment

Complex spiral – >1 spiral fragments

Complex segmental – double #

Complex irregular – bone lying btwn main elements is fragmented
If not detected on XR initially:

Do oblique XR

Repeat film after 7-10 days

Children

Elastic spring of periosteum may cause recurrence of angulation,
hence plaster fixation must be well done.

Rapid healing
Common sites

Vertebral bodies

Heels
Common sites

Base of 5th metatarsal (peroneus brevis)

Tibial tuberosity (quadriceps) (Osgood-Schlatter’s disease)

Lower pole of patella (Johansson-Larsen’s disease)

Upper pole of patella (quadriceps)

Lesser trochanters (iliopsoas)
One fragment driven into another
Open Fractures: Gustilo Classification
Type I
Type II
Type IIIA



Type IIIB




Type IIIC
<1cm AND clean
>1cm AND no extensive soft tissue damage, avulsions or flaps
Extensive soft tissue damage, avulsions or flaps but adequate soft tissue
coverage of bone OR
High-energy trauma cause irregardless of size of wound
Extensive soft tissue loss with periosteal stripping and exposure of bone.
Massive contamination common
Arterial injury requiring repair
Haemorrhage in Fractures
Close # of femoral shaft
Haemothorax
Pelvic #
2-3L
3-5L
3-5L
Epiphyseal Plate Injuries: Salter-Harris Classification
Type

Whole epiphysis separated from shaft
1
Type

Epiphysis is displaced together with a metaphyseal fragment
2
Type

Separation of part of the epiphysis
3
Type

Separation of part of the epiphysis with a metaphyseal fragment
4
Type

Crushing of part or all of the epiphysis
5
*Cxs: avascular necrosis, growth arrest
Describing Fractures
1.
Level
2.
Displacement
3.
Angulation
4.
Axial rotation
5.
Open / Close
Anatomical – epiphysis, epiphyseal plate, metaphysic,
diaphysis OR

Thirds – proximal, middle, distal

Direction of displacement in terms of movt of distal fragment

Degree of displacement in % of # surfaces in contact

Described in terms of the direction the point of # angulation is
pointing towards (eg anterior angulation in Colles’ #)

Easily missed, hence always examine the joints above & below
the #
Open

Gustilo Classification

Open from within or without – latter has  risk of infxn,
hemorrhage & injury to muscles, nerves or bld vessles. Also
usually comminuted & more difficult to manage.

Upper limb
Colles’ #
Smith’s #
Galeazzi #dislocation
Monteggia #dislocation
# distal radius w/in 2.5 cm of wrist (aka dinner-fork #)
Anterior & ulnar angulation
Dorsal & radial displacement of distal fragment
Impaction of fragments.
# distal radius w posterior angulation  anterior displacement (aka reversed Colles’ #)
# of radius, inferior radioulnar joint dislocation (GUD)
Ulna fracture + anterior dislocation of head of radius (MUF)
Trigger Finger
Stage
Pre-triggering
Triggering
Features
Pain, no trigger
Correctable by active extension
Mx
NSAIDs
H&L
2
K&L’s Ortho – Last updated March 2005
Triggering & Lock
Contracture
Correctable by passive extension
Fixed flexion deformity
H&L, Sx sheath incision
Sx release
B
C
Transcervical
Basilar
resulting in AVN (12-33% of all #NOF
Extracapsular
Phases of AVN
I
Only head involvement
II
Progress to secondary OA & acetabulum is affected as well
Pelvic Fractures: Tile classification
Type A
Stable #s
Type B
Rotationally unstable,
vertically stable
Type C
Rotationally &
vertically unstable
A1
A2
B1
B2
B3
C1
C2
C3
Intertrochanteric Fracture of the Femur
No involvement of pelvic ring
Stable, minimally displaced # of the pelvic ring
AP compression # (“open book” #)
Lateral compression #, ipsilateral
Lateral compression #, contralateral
Unilateral
Bilateral
Associated acetabular #
Evans’ Classification
I
2 fragments, undisplaced
II
2 fragments, displaced
III 3 fragments w/o posterolateral support (ie # of the greater trochanters)
IV 3 fragments w/o medial support (ie # of the lesser trochanter)
V
4 fragments
R
Reversed oblique # - prone to displacement
*Alternative classification: according to number of fragments + reversed oblique #
Perthes’ Disease
Ankle Fractures
Catterall grading– according to degree of femoral head involvement
Grade
Severity
Px
1
involve anterior portion of epiphysis only. No
Revascularisation may be
collapse or sequestrum
complete w/o bone collapse
2
Bony collapse inevitable
 50 % involvement with a sequestrum
3
~75% involved, with collapse & sequestrum
Bony collapse inevitable. Poor Px
4
whole epiphysis involved
Weber’s classification
Type Level of fibular #
A
Distal to syndesmosis
B
Involve the syndesmosis
C
Proximal to syndesmosis
Pott’s Classification
First degree
# of a single malleolus (medial or lateral)
Second degree
# of both medial & lateral malleoli
Third degree
# of medial, lateral & posterior malleoli
Fracture of Neck of Femur:
Anatomical Classification
A
Subcapitate
10
Scoliosis
Fixation by:

Cannulated screws / pins

DHS
 >65YO – hemiarthroplasty.
o Unipolar (Moore’s or
Thompson’s)
o Bipolar – for younger PTs
 <65YO – attempt joint salvage
Intracapsular – risk of severing retinacular vessels
Risk of AVN (%)
Garden Classification
Type 1 Incomplete fracture (Inferior cortex not
broken)
No displacement
Abduction #
Trabeculae are angulated
Type 2 Complete fracture line (inf. cortex broken)
No displacement
Trabecular lines interrupted but not
angulated
Type 3 Complete fracture line
Slight-moderate displacement
Rotation of femoral head – prox frag
abducted & int. rotated
Type 4 Severe displacement
List of Causes
Non

20 structural

Structural



30

40


Limb length discrepancy (apparent or true shortening of one leg)
Hip contracture
Muscle spasm – eg 2o to PID
Adolescent idiopathic (commonest, 80%)
Infantile idiopathic – may resolve or progress
Osteopathic – due to congenital vertebral anomalies
Neuropathic – eg 2o to polio or CP. Due to asymmetrical muscle
weakness
Myopathic – due to muscular dystrophies
Neurofibromatosis
3
<-2.5
<-2.5 + fragility fracture
Spondylolisthesis

Causes
1. Dysplasia – congenital lumbosacral facet jt dysplasia
2. Isthmic (spondylolytic) – break in the pars interarticularis
3.
4.
5.
6.

Elderly (degenerative) – OA degeneration of facet joints
Trauma
Suspicious (pathological) – neoplasm
Elderly(degenerative)
Post-op – due to laminectomy for decompression
Osteoporosis
Severe osteoporosis
Spondylolytic
Pathological
Rheumatoid Arthritis
Operative
Trauma
Dysplastic



Stage 1 (synovitis) – pain, chronic swelling, large effusion, thickened synovium
Stage 2 (articular erosion) – joint instability, ROM. X-ray: loss of jt space & marginal
erosion, but lack of osteophytes c.f. OA
Stage 3 (deformity) – pain, deformity, instability & disability. X-ray: bone destruction
Meyerding classification
Grade
% translation of VB
I
0-25
II
25-50
III
50-75
IV
75-100
Bone Tumours
Enneking’s Classification
Grade
G0
(surgical)
G1
G2
Site
T0
T1 (A)
T2 (B)
Metastasis
M0
M1
Benign
Low grade malignant
High grade malignant
Benign Intracapsular & intracompartmental
Intracompartmental
Extracompartmental
No regional / distant mets
Regional / distant mets
Staging for Malignant Neoplasia
IA
G1
T1
IB
G1
T2
IIA
G2
T1
IIB
G2
T2
IIIA
G1 or 2
T1
IIIB
G1 or 2
T2
M0
M0
M0
M0
M1
M1
Staging for Benign Neoplasia
1
Latent
G0
T0
2
Active
G0
T0
3
Aggressive G0
T1 or 2
M0
M0
M0 or 1 (giant cell tumour)
Osteoporosis
BMD T-score
>-1
-1 to -2.5
Definition
Normal
Oteopenia
4
2) Orthopedics Short Cases
Peripheral Nerves
‘Examine the hands of this patient’
Brachial Plexus Injury
‘Examine the arms of this patient’
Inspect:
Horner’s syndrome
 Suggests proximal BP injury
Bruises at neck, arm
 Suggests brachial plexus injury
Posture
 Waiter’s tip – arm adducted, shoulder internally rotated, wrist and fingers flexed
o
Erb’s palsy (C5,6,7)
 Arm flail, hanging loose – suspect complete brachial plexus palsy
Muscle Wasting
 Deltoid Muscle (C5,6,7)—axillary nerve
 Intrinsic muscles of Hand (C8, T1. C5,6,7 also)
Examine power, reflexes
 Standard neuro exam
 Reflexes, likely LMN; if UMN suspect motor neurone disease
Determine level of brachial plexus lesion
 Push against wall – serratus anterior supplied by long thoracic nerve (C5,6,7)
 Horner’s syndrome – T1 carries cervical sympathetic
o
Others:
 Ask pt to put hand on hip, ask pt to push elbow back, feel rhomboid
contraction which is medial to scapula – rhomboid
 Put hand above spine of scapula, ask patient to abduct, feel
contraction of supraspinatus
 If any of these shows weakness, it suggests BP injury is proximal
This patient has brachial plexus injury, lesion is:
 Supraganglionic – if Horner’s positive
 At roots – if winging of scapula
 Distal to roots – i.e. trunks, divisions, cords
Causes
 BP injury – avulsion from motorcycle accident, congenital
 CA spread – breast, osteosarcoma
 Radiotherapy
Is it:
 High or low median,or carpal tunnel syndrome?
 High or low radial?
 High or low ulnar?
Inspect
Wasting of small muscles of hand
 Suggests either ulnar nerve lesion, OR C8-T1
 To differentiate, test abductor pollicis – supplied by C8T1 component in median nerve
o
thus will be weak in root lesion BUT NOT in ulnar nerve lesion
Claw hand – ulnar nerve palsy
Thenar (Median n. palsy) &/or Hypothenar (Ulnar n. palsy) wasting
Screen
 Extend wrist and fingers
o
Both cannot – high radial nerve

Common sites of injury – axilla, spiral groove
o
Wrist can extend, finger cannot extend – posterior interosseous branch
(=deep branch) of radial nerve affected, hence it is low radial nerve

Common sites of injury – fracture of proximal head of radius,
dislocation of radial head
 Close hand
o
o
Benediction sign – median nerve

If Benediction sign present, test flexion of IPJ of thumb

If weak flexion, suggests a high median nerve lesion
o
Supracondylar fracture of elbow

If strong flexion, test for sensation over lateral palmar
surface, and do Tinel’s
o
No sensation

Injury at wrist
o
Sensation intact

Carpal tunnel

Place hands on pillow, abduct against resistance
If weak – ulnar nerve

Then test little finger flexion at DIPJ

If no little finger DIPJ flexion, high elbow ulnar
o
Distal brachial plexus lesion
o
Cubitus valgus causing tardy ulnar nerve
palsy

If DIPJ flexion present, low ulnar
o
Wrist injury
5
Detailed examination of relevant nerve
Shoulder Joint
Ulnar (C7,C8, T1)
‘patient has ulnar nerve palsy, lesion is above/below the elbow as evidenced by weakness/ strength
of the flexor digitorum profundus’
supplies all interossei, medial 2 lumbricals, adductor pollicis, hypothenar eminence, medial half of
flexor digitorum profundus, flexor carpi ulnaris, palmar dorsal sensory of medial 1.5 fingers
 Abduct fingers against resistance – test little finger
 Adduct fingers with paper – hold paper betw little & ring finger
 Adduct thumb – Froment’s sign
 Little finger flexion at DIPJ – differentiate betw high & low lesion
 Sensory distribution (medial 1.5 fingers)
Causes of ulnar nerve palsy
 Distal brachial plexus injury
 At medial epicondyle – check for cubitus valgus
 At wrist
L umbricals
I nterossei
A dductor Pollicis
F lexor digitorum profundus
Median (C6,7,8,T1)
‘Benediction sign is present suggesting median nerve palsy’, I would like to test the muscles
supplied by median nerve and sensation





Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis – IPJ flexion of thumb (‘OK’ sign)
lateral half of Flexor digitorum profundus – DIPJ flexion of index finger
sensation palmar lateral 3.5 digits
L umbricals
O pponens pollicis
Press wrist for 30s for parasthesia
A dductor Pollicis
Phalen’s test – flexion of wrist for 2 minutes for parasthesia
F lexor digitorum profundus
Tinel’s test – tap wrist repeatedly for parasthesia
 if any of these 3 positive, suggests carpal tunnel syndrome
Radial (C5,6,7,8)
Test muscles distal to proximal






Tri ceps
B rachioradialis
Extensor pollicis longus & brevis
S upinator
test fingers and wrist extension
supinator strength
brachioradialis – flex arm in semipronated position
triceps – extension (weak in high lesion)
Extensor lollicis longus (thumb extension at IP jt) & brevis (extension at MCP jt)
test sensation – variable, over posterior arm, and over dorsal aspect of skin proximal to lateral
3.5 fingers
‘Examine the shoulder joint’
Inspect
 sternoclavicular joint
 clavicle
 acromioclavicular
 deltoid wasting
 scapula
o
small scapula and webbing of neck (Klippel-Feil)
o
winging of scapula (C5,6,7 radiculopathy or long thoracic n inj)
Palpate
 sternoclav joint  clavicle  acroclav  deltoid
Screening movements
 Abduct, adduct, flex, extend, external/internal rotate in 90o abduction
If abduction restricted
 Cannot initiate – rotator cuff injury
 Painful arc – tendonitis/ rotator cuff impingement
 Restricted movements – fix scapula; if after fixing scapula cannot abduct at all it suggests fixed
glenohumeral joint with previous movements entirely scapular
 Apprehension test
 Ganz and Gerber drawer test
 Biceps tendon test
 Job’s sign
 Neurological exam – power/reflexes/sensation
 Pulses
 Offer to examine the neck



Teres minor tear: pain on ext rotation agst resistance
Subscapularis tear: pain on int rotation agst resistance
Supraspinatus:
Job’s sign: clench fist with thumb sticking out and pointing
down; hold arms out straight, extended at 30 degrees (in
scapular plane). The patient should attempt to abduct his
arms against the examiner's resistance
6

Back
‘Examine the back’
 Stand the patient
 Look
o
o
o
o
 Feel
o
o
o
 Move
o
 Power
o
o
 Tests
o
o
Scoliosis (postural –improves on flexion - or structural?)
Kypohosis
Lumbar lordosis/ loss of it
Tuft of hair/ lipoma
o
o
o
o
Offer to examine the back of the knee – lie patient prone

Look for bulges

Midline bulge – capsule

Side bulge – bursa

Above joint line – semimembranous bursa

Below joint line – Baker’s cyst

Do Apley’s test, and Apley’s distraction test
o
Offer to examine the back!
Feel every spinous process and interspinous ligament
Step deformity
Paravetebral spasm
Flexion/ extension/ lateral flex extend/ rotation
Tip toes
Stand on heels
Lachman test – flex knee 20o shift articular surfaces forward and
backward
Lachman’s test
Menisci - McMurray’s test (LIME)

Lateral meniscus – Internal rotate, ADduct, flex

Medial meniscus – External rotate, ABduct, flex
Patellar apprehension test for recurrent dislocation/subluxation

Press patella laterally with thumb, ask patient to flex – if in pain,
apprehensive, suggest impending subluxation
Screen hips first – test internal and external rotation with hip and knee
flexion
Lie patient supine

SLR test

Dorsiflex foot when pain

Bowstring sign – at level of pain, flex knee and press
popliteal fossa

L/L power

L/L sensation
Knee
‘Examine the knee’
 Inspect – swelling, scars, atrophy, abnormal posturing
 Feel
o
bulk of quadriceps (ask patient to press down against your hand)
o
patellar effusion – cross fluctuation/ patellar tap/ bulge test
o
feel around joint lines

medial and lateral collateral ligaments

condylar surfaces

patellar ligament (both sides)
 Move
o
Flexion + extension
 Tests
o
Medial and Lateral Collateral ligaments

Abduction and adduction at 30o
o
Cruciate ligaments

Flex knees, put feet together, look for sag sign (PCL tear)

Drawer test with examiner sitting on feet
7
3) Important Orthopaedic Short Cases in the Hands &
Wrists

Types of cases




Lumps
Ganglion
Pigmented villonodular synovitis
Implantation dermoid cyst
OA – Heberden’s & Bouchard’s
nodes
 RA hands

 Ulnar n palsy
 Median n palsy
 Radial n palsy
 Carpal tunnel syndrome
 de Quervain’s dz
 Tenosynovitis
 RA – Swan neck & Boutonniere
deformities, tendon rupture
 Colles’ #
 Smith’s #
 Scarphoid #
 Bennett’s #
Joint
Vascular
Nerve
Muscle /
tendon
Bones




Haemangiomas
Pseudoaneurysms
SCC
Glomus tumours





OA hands
Radiculopathies
Erb’s palsy (C5-6)
Klumpke palsy (rare) (C8-T1)
Joint
Periarticular
RA
OA
Infection
De Quervain
Tenosynovitis
Instability
HANDS
Muscle / tendon disorders
DDx: skin contracture (scars present), tendon contracture (‘cord’ moves on passive
flexion of finger)
Nodular hypertrophy & contracture of palmar aponeurosis
a/w diabetes, AIDS, phenytoin, alcohol
Features: nodular thickening of palm, flexion deformity of MCPJ & PIPJ of little or ring
fingers, thickened dorsal knuckle pads
Rx: Fasciotomy, post-op splintage & physioRx
Muscle contracture
Forearm

 Trigger finger
 Dupuytren’s contracture
 Mallet finger

 Scaphoid dislocation
 Lunate dislocation
 Gamekeeper’s thumb





Intrinsic
muscles
Ischaemic contracture of forearm muscles, commonly caused by:
o
Volkmann’s ischaemic contracture: # causing compartment syndrome
resulting in muscle ischaemia & necrosis. Infracted muscles replaced by
fibrous tissues
o
Tight plaster cast & limb swelling
Shortening of long flexors causing flexion deformity of fingers which is only
correctable on wrist flexion (tendodesis effect)
May be a/w ulnar and/or median nerve palsies
Rx: muscle release & tendon transfer
MCPJ flexion, IPJ extension & thumb adduction
Causes: spasticity (eg CP), scarring
Mx: muscle release
Mallet finger
Trauma
Infection
Inflammation
Degeneration
Tumour
DDx of Painful Elbow & Hand
Painful Wrist
Referred
Cervical spondylosis




Pathologies
1.
2.
3.
4.
5.
Dupuytren’s contracture



Injury to extensor tendon of terminal phalanx
Loss of active extension of DIPJ, normal passive extension of DIPJ
Rx: splint with DIPJ extension & PIPJ flexion
Trigger Finger (Stenosing tenosynovitis)
Painful Hand
Neck
Shoulder
Mediastinum
RA
OA
Carpal tunnel
Tenosynovitis
Infection
Epidemiology: 55- 60 years old, male > female
Clinical feature: - triggering on extension, snapping sensation, crepitus, tenderness over A1
pulley
- palpable nodule on line of flexor dig superficialis just distal to MCP jt
- fixed flexion deformity
- look for signs of assoc condition & triggering in other fingers
- exclude infection

Thickening of fibrous tendon sheath or nodular thickening in a flexor tendon.

Flexor tendon trapped at entrance of tendon sheath; forced extension causes opening
snap. Tender nodule may be felt in front of sheath at the MCPJ

Most commonly ring & middle fingers (thumb> ring > middle finger. Usu dominant hand)

Causes: local trauma causing sheath thickening, RA, overuse, DM, decrease T4, psoaritic
arthritis)

DDx: RA, Dupuytren’s contracture, septic arthritis, suppurative tenosynovitis, focal
dystonia, tumour of tendon sheath, dislocation

Staging & Mx
Stage
Pre-triggering
Features
Pain, no trigger
Mx
NSAIDs, rest, splint
8
K&L’s Ortho – Last updated March 2005
Triggering
Triggering & Lock
Contracture
Correctable by active extension
Correctable by passive extension
Fixed flexion deformity
H&L (50- 75%) success
H&L, Sx sheath incision
Sx release (Cx: digital n inj,
cutting of A2 pulley)



Lumps
Pigmented Villonodular Synovitis (PVNS)







Benign proliferative disorder of synovial lining of joint, bursa & tendon sheaths
Commonest hand lump disorder
2 types
i) diffuse form – affects entire synovial lining of a joint, bursa or tendon sheath.
Affects large joints
ii) localized form – affects tendon sheaths around small jts of hands & feet (termed
nodular tenosynovitis)
PTs 20-50YO
Site: localized form (flexor aspect of fingers), diffuse form (knee, hip, ankle,
shoulders)
Presentation: solitary, well circumscribed, tan colored, and sometimes has pale
yellow regions of lipid deposition. Insidious onset, dull aching jt pain, nodular or
diffused jt swelling, ROM, locking of joint.
X-ray: joint swelling, periarticular erosions (saucerisations) joint space narrowing, sub
chondral cyst, osteophytes formation

Muscle / Tendon
De Quervain’s disease (Stenosing Tenovaginitis)
DDx: arthritis thumb MCP jt, scaphoid fracture



Implantation Dermoid Cysts

Usually sited along the volar surfaces of the fingers & palms
Cystic degeneration of joint capsule or tendon sheath. Most commonly on back of
wrist
Well defined, cystic, non-tender
Types:
1. Simple
2. Compound –chronic inflammation distends tendon sheath above & below the
flexor retinaculum ( a/w TB, RA)
3. Occult
4. Intereosseous
Rx: usually disappears after some months. Aspiration (recurs 6-12 mths later),
excision for cosmesis or if ganglion is causing pain (recurs in 15-20%)


Inflammation & thickening of sheath containing the extensor pollicis brevis & abductor
pollicis longus (1st dorsal compartment of the wrist)
Cause: wringing out clothes
Features: women 30-50 YO, pain on radial side of wrist, swelling along course of
thumb tendons, thickened tendon sheath. Pain on thumb abduction & extension.
Weak grip. Finkelstein’s test (pain on forced ulnar deviation of wrist with thumb in fist)
Acute features: pain localized to radial styloid, aggrav by movemt of thumb & wrist,
radiate up forearm, improves with rest
Chronic features: Persistent pain, stiff thumb & wrist, swelling/ cyst over 1st dorsal
compartment
Rx: NSAIDs, cold compression, H&L injection, splinting, Sx release of tendon sheath.
Cx of Sx release: infxn, radial n palsy, snapping of extensor tendon
Glomus Tumours

Small, vascular & tender swelling, usually occurs at the region of the nail beds.
WRISTS
Nerves
Carpal Tunnel Syndrome
Joint Disorders



Chronic Carpal Instability






Causes: injury, arthritis, Kienböck’s dz (patchy lunate AVN after trauma)
Features: pain, weakness, clicking on movt
Commonest type: Scapholunate dissociation – X-ray shows Terry Thomas sign (abN
gap btwn scaphoid & lunate)
Rx:
o
Acute: reduction & fixation with plaster or K-wires
o
Chronic: splintage, analgesics, H&L injections, arthrodesis
Lumps
Ganglion

Compression ischaemia of nerve
40-50YO, women > men
Risk factors: DM, thyroid dz, prox. Compression syndrome, menopause, pregnancy,
RA, OA wrist, old Colles’ #
DDx: Cervical spondylosis of C6-7 level
Features:
o symptoms may present at night or with certain activities eg driving, reading
newspaper
o Night symptoms: pain & paraesthesia over median n distribution, relieved by
shaking arm.
o Wasting of thenar eminence, weak thumb abduction, Tinel’s & Phalen’s tests +
Rx: Vit B, NSAIDs, H&L, splint, operative division of anterior carpal ligament
Ulnar Tunnel Syndrome



Compression of ulnar n as it passes btwn pisiform & hook of hamate
Small muscle wasting, weakness of hand, sensory disturbance on volar aspect of
little finger.
Causes: ganglions, trauma, ulnar artery disease, old carpal or metacarpal #s
9


Mechanism: fall on outstretch hand, commonly in elderly osteoporotic women

S/S: wrist pain & tenderness over distal radius, characteristic deformity

DDx: scaphoid #

Mx:
JOINT DISORDERS of WRIST & HANDS
Manipulation
Indicated if displaced, deformity or angulation present, joint line in lateral X-ray
tilted 10o posteriorly
Rheumatoid Arthritis
Reduction
1. Bier’s block or GA

Pathology: synovitis  joint & tendon erosion  joint instability & tendon rupture 
method
2. Disimpaction: apply traction in line of forearm with countertraction applied by
progressive deformity & loss of function
asst to flexed elbow

Bilateral symmetrical joint involvement of hands & wrists
3. Maintain traction with elbow extended

Clinical features
4. Correct ant angulation & post displacement: apply pressure anteriorly
 Pain
 MCPJ: Ulnar deviation
 Rheumatoid nodules
5. Correct radial displacement by pushing distal fragment ulnarwards
 Stiffness
& volar subluxation
6. Correct Ulnar angulation by putting wrist in full ulnar deviation
 ROM & function
K&L’s Ortho – Last updated March 2005
 Joint swelling
 Swan neck deformity
Backslab
 Apply backslab w wrist in full pronation, full ulnar deviation & slight palmar
 Deformities
 Boutonniere deformity
flexion
 Extensor tendon
 Z-deformity
 Plaster should extend from olecranon to metacarpal heads
rupture – finger drop
 Wrist: subluxation &
 Final moulding with pressure over post-lat aspect of distal fragment
prominent radial head
External fixation
If # is unstable
o
Boutonniere deformity – PIPJ flexion & DIPJ hyperextension deformity due to
Post reduction
X-ray: Repeat to ensure adequate reduction
interruption of central slip & separation of lateral slips of the extensor tendon
F/U: check circulation & assess swelling, complete plaster if swelling is minimal
o
Swan neck deformity – PIPJ hyperextension & DIPJ flexion due to imbalance
Finger, elbow & shoulder exercises
of extensor vs flexor action

Cxs

X-ray: soft tissue swelling & periarticular osteoporosis  jt space narrowing &
Malunion / persistent deformity
Radial drift of distal fragment
periarticular erosions  articular destruction, joint deformity & dislocation
Sudeck’s atrophy
 Pain, trophic skin changes, vasomotor instability &

Mx:
osteoporosis due to sympathetic overactivity - swelling,
Medical
Control of systemic dz
erythema, warmth, changing to cyanosis with blotchy, cold &
Splint
Reduce pain & swelling, improve mobility
sweaty skin
Persistent synovitis H&L injection, Sx synovectomy
 Mx: physioRx, rest & splintage for pain, chemical sympathetic
blockade if severe
Deformity
Tendon rupture repairs, tendon transfers, arthroplasty, arthrodesis
reconstructive surgery
Carpal tunnel syndrome
Delayed rupture
 Of the extensor pollicis longus.
 Mx: tendon transfer
Osteoarthritis
Radioulnar jt subluxation

Primary OA: usually in DIPJ in postmenopausal women.
Assoc scaphoid #

Secondary OA: hx of trauma or # eg scaphoid #, Kienbock dz (lunate AVN)
Comminution of radial fragment

Features: bilateral pain, swelling & tenderness. Bony thickening around the DIPJ
Persisting stiffness
Shoulders & fingers
(Heberden’s nodes), PIPJ (Bouchard’s nodes) & carpometacarpal joint of thumb. 
ROM & crepitus

X-ray: narrowing of jt spaces, osteophytes, bone sclerosis
Smith’s Fracture (aka reversed Colles’ #)

Mx: symptomatic, rest, splint

Ant displacement & post angulation of distal fragments caused by fall on back of
hands

Mx: M&R, splintage with wrist extended, above elbow cast for 6 wks
DDx: Cubital tunnel syndrome, cervical spondylosis
BONE DISORDERS of WRIST & HANDS
Barton’s Fracture
Colles’ Fracture




Fracture of radius within 2.5 cm of wrist (deformity)
‘Dinner-fork’ deformity: anterior & ulnar angulation (AUA), dorsal & radial
displacement (DRD) of distal fragment, torsional deformity, inferior radioulnar jt
disruption (ulnar styloid avulsion or tearing of fibrocartilage)
Distal radial # with fracture line running into the wrist joint; ant displacement of distal
fragment carrying the carpus with it
Mx: inherently unstable, therefore require reduction and internal fixation
Scaphoid Fracture

Mechanism: falls on outstretched hands
10


Tenderness on lat aspect of wrist & anatomical snuffbox
X-ray: often hard to see, 3 view required (AP, lat & oblique), repeat in 14 days if
unsure

Mx:
Initial Mx
scaphoid plaster & sling, repeat X-rays in 2 wks
Undisplaced #
Scaphoid plaster for 6 wks: Fix hand in full pronation, radial deviation &
moderate dorsiflexion. Plaster to extend from below elbow to just below
MCP & IPJ of thumb
If delayed union at 6 wks, continue plaster cast for another 6 wks
Internal fixation if non-union found at f/u at 12 wks
Displaced #
ORIF

Cx:
o AVN of proximal pole causing secondary radiocarpal OA – excise scaphoid,
arthrodesis
o Non-union – plaster fixation, internal fixation & bone grafting. Excision of radial
styloid if OA threatens
Lunate Dislocation




Rotation & anterior displacement of lunate
X-ray: crescent moon shape of bone becomes obvious on AP view
Cx: median n. palsy, Sudeck’s atrophy, AVN (& secondary OA)
Rx: closed reduction under GA + plaster fixation, open reduction if closed reduction
fails
Scaphoid Dislocation


Displacement is usually anterior
Rx: closed reduction + plaster fixation in stable position. If instability is present, fix
with K-wires
Bennett’s Fracture


# base of thumb with # line involving the trapezometacarpal joint & a small medial
fragment of bone. Proximal & lateral subluxation of thumb metacarpal present
Rx: closed reduction & plaster fixation
Gamekeeper’s Thumb (Rupture of Ulnar Collateral Ligament)




Mechanism: forced abduction of thumb
Progressive MCPJ subluxation and impaired grasp results, with tenderness over
medial side of MCPJ.
May be a/w alvulsion #
Rx: Scaphoid cast for 6 wks if minimally displaced. Internal fixation, Sx repair, MCPJ
fusion depending on severity of displacement / tear
H & L injections



Common hand indications: trigger finger, De Quervain’s tendosynovitis, CTS, RA
Up to 2 injections on the same digit (interval of at least 3 mths)
Cx: tendon rupture
11
4) Important Orthopaedic Conditions in the Elbows &
Forearms

Cubitus Varus (Gunstalk deformity)




Cause: Malunion of supracondylar #
Rx: wedge osteotomy of lower humerus
Cx: median nerve palsy
Cubitus Valgus



Cause: non-union of # lateral condyle (a/w bony knob on medial elbow)
Mx: undisplace-- backslab
Mod displacemt—closed reduction and backslab
Unstable—K-wire and cast
Rotated—open reduction and K-wire
X-ray wkly to detect slipping
Cx: Tardy ulnar nerve palsy – Mx: transpose ulnar n anterior to elbow
RA



Features: pain, tenderness, swelling, stiffness, usually bilateral
X-ray: bone erosion, radial head destruction, widened trochlear notch of the ulna
Rx: splint, radial head resection, partial synovectomy, arthroplasty
OA



Cause: intraarticular #s, loose bodies, crystal deposition dz
Features: pain, stiffness, ROM,  ulnar n palsy
X-ray:  Jt space, bone sclerosis, osteophytes, loose bodies
Olecranon bursitis

Causes: pressure, friction, infxn, gout (a/w tophi), RA (a/w polyarthritis & SQ nodules
over the olecranon)
Tennis Elbow (Lateral epicondylitis)



Cause: minor trauma to origin of wrist extensors eg painting, carpentry.
Features: lateral epicondylar pain, aggravated by shaking hands & opening doors.
Pain on active wrist extension with a straight elbow. N ROM.
Rx: rest, H&L injection
Golfer’s Elbow (Medial epicondylitis)

Similar to tennis elbow, but affecting flexor origin at medial epicondyle
Cubital Tunnel Syndrome



Compressive ulnar neuropathy at the elbow, in the retrocondylar groove or as ulnar n
passes btwn the 2 heads of the flexor carpi ulnaris
Caused by constriction of fascial bands, subluxation of ulnar n over medial
epicondyle, cubitus valgus, bony spurs, tumours, ganglions, repetitive elbow flexion &
extension
Presentation: paraesthesia along ulnar 1.5 fingers & weak grip, wasting of intrinsic
muscles (rare)
DDx: cervical spondylosis, ulnar tunnel syndrome (compression at Guyon canal at
the wrist) – preserved strength of wrist and 4th & 5th digit flexors
Rx: Simple decompression, medial epicondylectomy if a/w non-union of epicondyle #,
anterior transposition
Supracondylar Fractures


#s in distal 1/3 of humerus prox to bone masses of the trochlea & capitulum
Common childhood #. Adults: More prox, commonly with comminution, spiraling &
angulation

Mechanism: fall on outstretched hand

Features: pain over elbow, swelling, deformity

DDx: dislocation of elbow (equilateral triangle by epicondyles & olecranon is
disrupted)

X-ray: fracture line across distal humerus, posterior tilt/displacement of distal
fragment,  medial or lateral displacement. (Flexion type rare, with ant displacement
of fragment. 5%)

Mx:
Indications for
 Arterial obstruction
reduction
 # displacement &/or angulation
 <50% bony contact
 Backward tilt 15%
 Medial or lat tilting of 10% (may cause tardy ulnar n palsy)
 Severe torsional deformity
Manipulation
 Manipulation under GA
technique
1.Disimpaction: Traction applied at 20o flexion with countertraction applied to
arm
2.Reduce post tilt/displacement: Flex elbow to 80o while maintaining traction
3.Correct lat displacement/torsional deformity: manipulate epiphyseal
complex
Fixation
 Fix with elbow at greatest angle of flexion possible w/o compromising
circulation (check radial pulse)
 Never apply a complete plaster due to risk of swelling
Check radiographs
 AP & lateral
Remanipulation if
 Up to 2 remanipulations may be attempted – asstant apply traction to
reduction is poor
forearm, surgeon push distal fragment fwd with thumb while ctrlling prox
fragment with fingers
 K-wires & plaster backslab may be used for unstable #
 No more than 2 remanipulations due to risk of swelling. Employ
continuous traction instead (eg Dunlop traction)
Observation
 Overnight, esp for complications of vascular compromise
Support
 Collar & cuff for 3 wks
 Sling for another 3 wks to avoid extension, but flexion is allowed.

Cx:
12
K&L’s Ortho – Last updated March 2005
1.
2.
3.
Arterial obstruction: Brachial arterial kinking by prox fragment. Arterial wall damage
results in Volkmann’s ischaemic contracture. Symptoms = Pain, Pallor, Paraesthesia,
Paralysis, Perishing cold, swelling & bruising)
Median nerve injury
Malunion – cubitus varus (may cause ulnar tunnel syndrome)
Elbow Dislocation





Mechanism: fall on outstretched hand
Assoc injuries routinely checked for: #s of epicondyles, lateral condyle, coronoid &
radial head & neck
X-ray: posterolateral dislocation of elbow
Cx: exclude ulnar n, median n & brachial arterial injuries. Elbow stiffness, myositis
ossificans.
Rx:
o Apply strong traction in the line of the limb under GA. Slight flexion might be
required.
o Alternative: clasp humerus from behind & push olecranon fwd & medially while
asstant applies traction in moderate flexion
o Support with sling for 3 wks.
Medial Condylar Injury



Mechanism: direct violence or avulsion by ulnar collateral ligament on forceful
abduction
Mx: immobilize in plaster cast for 2-3 wks
Cxs:
1. Tardy ulnar n. palsy
2. Trapping of medial epicondyle in the elbow joint
Forearm Fracture-Dislocations
Monteggia
Galeazzi
 # upper ulnar (shortening & angulation) + radial head dislocation (MUF:
Monteggia Ulnar Fracture)
 Mechanism: direct violence on forearm or forced pronation (eg fall on
outstretched hand with trunk rotation)
 # lower radius + inferior radioulnar joint dislocation with ulnar
displacement (GUD: Galeazzi Ulnar Dislocation)

Mx:
o
Principle: Restore length of fractured bone, then reduce dislocation
o
Children: manipulation + plaster fixation
o
Adults or children w displaced #s: ORIF, plaster fixation in 90o flexion with
supination

Cx: due to persistent unreduced dislocation or late Dx
Monteggia
Ant protrusion of radial head  elbow ROM – Rx: excise radial head
Tardy ulnar n palsy – Rx: transposition of ulnar nerve
Galeazzi
Prominent ulna & chronic wrist pain – Rx: excise distal ulna
Causes of tardy ulnar nerve palsy:
1) lat condyle fracture (a/w gunstalk deformity)
2) monteggia fracture
3) med condylar fracture?
Radial Head Fracture




Mechanism: direct violence, or fall on outstretched hand
Features: elbow pain, swelling, bruising, restricted elbow extension
X-ray: # radial head,  subluxation of distal end of ulna. Addition AP projections in
mid-prone & full pronation required. Assess type of #.
Mx:
# type
Rx
Hairline
Light compression bandage & sling for 3 wks, +
backslab if pain is severe. Excellent outcome
Undisplaced (marginal or segmental)
Displace (marginal or segmental)
Conservative Rx, r/v in 3 mths. Late excision of
radial head if movts are severely restricted
Comminuted
Radial head excision w/in 48hrs  silastic
prosthetic replacement, splint for 3 wks
Radial Neck Fracture


Mechanism & Dx: Similar to radial head #
Mx:
Minimal tilting
Conservative
Marked tilting (>20o adults,
Manipulate – apply traction, pronate & supinate, apply
>30o children)
pressure when prominent part of radial head presents, + Kwire if unstable
13
 Tight iliopsoas
5) Important Orthopaedic Short Cases in the Hip

Causes of Painful Hip
Referred pain
Joint disorders
Periarticular disorders





Discogenic dz
Infxn
OA
RA
Hernia
 Perthes’ dz
 Osteonecrosis
 Slipped Capital
Femoral
Epiphysis
 Bursitis / synovitis
 Tendinitis
o
o
o

Common Hip Disorders by Age
<1YO
1-5YO
5-10YO
10-20YO
Adults
CDH
Transient synovitis (commonest cause of hip pain in child)
Septic arthritis
Perthes’ disease
Juvenile Chronic Arthritis
SCFE
OA, AVN, RA

Greater trochanter
Lesser trochanter
Neck of femur




Bone texture
Density of femoral
head
Shenton’s line
Neck/shaft angle





‘Tear-drop’ (medial to
the femoral head)
Sacroiliac joint
Acetabular margins
Joint space
Ischium
Gait analysis
Anthalgic
Adductor lurch
Toe to heel
Circumduction
Trendelenburg
Broad based
High steppage
Short stance phase
‘Sound side sags’
Infxn, inflammation, transient synovitis
Hip dysplasia, CP
CP, club foot, idiopathic
Painful foot, limb length discrepancy
contralat abductor weakness, hip dislocation/
subluxation, short NOF, hip pain
Ataxia
Proprioception loss, foot drop
Congenital Dislocation of the Hip (CDH) / Developmental Dysplasia of
the Hip (DDH)




Easily dislocatable hip secondary to shallow acetabulum – usu. posterior & superior
dislocation
2 per 1000, girls > boys, left hip > right, bilat in 30%
 familial Hx of congenital dislocation, acetabular dysplasia or joint laxity
Possible causes:
 intrauterine
 Postnatal posture (hip
 Shallow acetabulum
malposition (a/w
extension)
(acetabular dysplasia)
breech
 Hypertrophic lig teres
 Fibrous tissue in
presentation)
 Hourglass capsule
acetabulum
Assymetrical skin creases, short limb, external rotation of leg,  hip abduction
ROM
Ortolani’s test – impeded hip abduction + clunk as dislocation reduces
Barlow’s test – attempt to dislocate fem head on adduction & abduction
Trendelenburg’s test – positive
Invx
U/S Hip
X-ray
Abnormal acetabular shape and femoral head position
Abnormal sloping of acetabular roof
shallow acetabulum
small underdevted femoral head
femoral head displaced upwards & outwards
Mx
3-6mths old
U/S Hip screen
Abduction pillow
If family hx, extended breech delivery, clinical hip instability
All 3-6mth old babies with + Ortolani’s or Barlow’s tests for 6
wks
Abduction
For all babies with persistent hip instability despite abduction
splintage
pillow. Use Von Rosen’s splint or Pavlik harness
6 mths – 6 yrs old (Persistent dislocation)
Closed reduction
Traction via vertical frame (Gallow traction)
Splintage
Plaster spica (hold @ 200 int rotation, 400 abduction, 600
flexion
Operation
If above methods fail. Open reduction  innominate
osteotomy
>6 years old
Operation
Reduction  innominate osteotomy of the pelvis/ corrective
osteotomy of the femur
Features of AP hip X-ray to note



PE:
o

Prognosis
o
o
Good results if treated btwn 6mths – 6 yrs
Otherwise leads to progressive deformity, disability & secondary OA
hip
Dislocation of the Hip
Cause
Pyogenic arthritis
X-ray
Absent fem head
Muscle imbalance
Valgus fem head
Trauma
Look for assoc acetabular
rim #

Mx
Traction, open reduction,
varus osteotomy of femur
As for CDH + muscle
rebalancing operation
Reduction, ORIF if rim #
present
Posture
o
Anterior dislocation: hip flexion, abduction and external rotation
14
K&L’s Ortho – Last updated March 2005
o

Posterior dislocation: hip flexion, adduction & internal rotation,
shortened leg
Complications
o
o
o
o
o
o
o
o
# femoral head, NOF, femoral shaft
Slipped upper femoral epiphysis
AVN femoral head
Sciatic nerve palsy (esp when rim # is present)
Femoral vein compression – causing thrombosis & embolism
Secondary OA hip
Recurrent dislocation
Myositis ossificans
Perthes’ Disease (Coxa plana)








Femoral head necrosis secondary to disturbance in blood supply
DDx: non-specific transient synovitis
4-8YO, boys:girls = 4:1, 5-10% bilat
Ppting event: effusion, trauma or synovitis occluding bld supply to femoral head
o
Stage 1: ischaemia causing femoral head bone death. Normal X-ray
o
Stage 2: revascularisation & repair. X-ray shows  bone density
o
Stage 3: distortion & remodelling. Epiphyseal collapse, flattening or
enlargement may result
Clinical features: hip pain & irritation, limp, shortened leg,  abduction & internal
rotation
X-ray:
o
Apparent widening of jt space
o
 epiphyseal density – healing & reossification
Small dense capital
o
flattening, fragmentation & lat displacement of epiphysis
epiphysis
o
subchondral #
o
metaphyseal rarefaction & broadening
Catterall grading– according to degree of femoral head involvement
Grade
Severity
Px
1
involve anterior portion of epiphysis only. No
Revascularisation may be
collapse or sequestrum
complete w/o bone collapse
2
Bony collapse inevitable
 50 % involvement with a sequestrum
3
~75% involved, with collapse & sequestrum
Bony collapse inevitable. Poor
Px
4
whole epiphysis involved
Mx:
Initial
Definitive

Skin traction until pain resolves
Gd Px: onset <6YO, partial fem
head involvement, no metaphyseal
rarefaction, N fem head shape
Poor Px: onset >6YO, complete fem
head involvement, severe
metaphyseal head rarefaction, lat
fem head displacement
Slipped Capital Femoral Epiphysis (SCFE)


usu very tall or fat pubertal (~15YO) boys w delayed gonadal devt. Boys > girls
Hx: pain in groin  radiation to knee, anterior thigh or knee (referred), limp, hx of
trauma

PE: coxa vara deformity, externally rotated short leg,  abduction & internal rotation,
pain on movt

X-ray:
o
Wide & “woolly” epiphyseal plate
o
Trethowan’s sign: femoral head falls below line drawn along superior surface
of femoral neck (normally cuts through fem head)

Complications
o
AVN
o
Coxa vara – Rx: osteotomy to prevent secondary OA
o
Secondary OA
o
Bilat SCFE: 1/3 of cases

Mx
Manipulation is contraindicated!!!
Displacement <1/3 epiphyseal width
Accept position, fix epiphysis with pins
Displacement 1/3 to ½ of epiphyseal
Pinning
width
Osteotomy: if residual deformity is present even
after remodelling
Displacement >½ of epiphyseal width
Surgical correction: epiphyseal replacement &
pinning OR epiphyseal fixation + osteotomy
Pyogenic Arthritis


Children <2YO, usu staph by haematogenous or local spread (from femoral OM)
Mx: aspiration, local ABx instillation, hip traction or abduction splint.
Transient Synovitis


Commonest cause of irritable hip
Usu presentation is of a limping child
TB Hip



No Rx needed
Groin / thigh pain, limp, muscle wasting, limb shortening, hip deformity, ROM
X-ray: general rarefaction, femoral epiphyseal enlargement, bone abscess, articular
destruction, healing by fibrous ankylosis
Rx: anti-TB drugs, skin traction, evacuate abscess, joint debridement, arthrodesis or
joint replacement if joint is destroyed
RA Hip
Containment of fem head

Abduction splint OR

varus osteotomy of
femur OR

innominate osteotomy of
pelvis



Multiple joint involvement, groin pain, limp,  & painful movt
X-ray: osteoporosis,  jt space, periarticular erosion and bone destruction
Rx: total joint replacement
OA Hip

Causes:
Young adults
congenital subluxation, Perthes’ dz, coxa vara, acetabular deformities /injury
15



Older adults
RA, AVN, Paget’s dz, pri OA
Clinical features: Groin pain  radiation to knee, jt stiffness, synovial hypertrophy &
capsular fibrosis, limp, Trendelenburg +, fixed flexion deformity, leg in ext rotation &
adduction posture,  ROM
X-ray:  jt space, subarticular sclerosis, cyst formation, osteophytes (‘elephant trunk’
osteophytes)
Rx: analgesics, NSAIDs, physioRx, walking aids, osteotomy, arthroplasty
Instability




syringomyelia, myelomeningocele
Ligamentous instability (ACL, PCL, med & lat collateral ligs)
Osteochondritis dissecans
Recurrent dislocation of patella
RA
Meniscal tears
Approach to hip pain:
1) Dx site of pathology
 hip pain—usu at groin
 pain at gluteal region—usu lumbar pathology
2) Dx cause of pathology
Vascular: Perthe’s disease, AVN
Infection: OM, TB, Transient synovitis
Trauma: OA, dislocation, fracture
Autoimmune: RA
M
I
N
Congenital: SCFE, CDH
6) Important Orthopaedic Short
Ankle, Foot
History & PE

Mechanism: twisting injury, usually during sports (esp football)

Locking of knee in partial flexion: torn portion of menisci jammed btwn femur & tibia,
3) Look for predisposing factors eg. Osteoporosis blocking extension. Unlocks with flexion. Suggestive of bucket-handle type meniscal
and fall risk
tear.

Pain, swelling, effusion.
4) Look for Cx of pathology

Tenderness: medial meniscal tear (well localized med joint line tenderness); lateral
meniscal tear (ill-defined joint line tenderness)
5) Assess premorbid status (goal for mx is to 
Course: Symptoms resolves, recurs periodically w twists/strains. Sometimes, knee
recover to premorbid status)
gives way spontaneously.

McMurray’s & Apley’s grinding test positive
6) Assess carer support
Invx

Arthrography

MRI
Prognosis & Mx
Outer 1/3
Good vascular supply, good healing. Attempt operative repair
Post-op physioRx
impt in all cases
Middle 1/3
Intermediate vascular supply & healing
Inner
1/3
Avascular,
poor
healing.
Excision
required
Cases in the Knee,
Cx

Recurrent synovial effusion & articular cartilage damage due to loose meniscal tag.
Meniscal Cysts
Knee DDx
Lump
Pain
Generalised
 OA
 RA
Deformity
Anterior
 Osgood-Schlatter dz
 Housemaid’s knee
 Clergyman’s knee
Posterior
 Baker’s cyst
 Semi-membranous
bursa cyst
 Popliteal aneurysm
Lateral
 Meniscal cyst
 Chondromalacia
 Meniscal tear (med
patellae
& lat)
 Patellofemoral OA
 Osteochondritis
dissecans
 Meniscal disorders
 Tendinitis
 Bursitis
 Osgood-Schlatter’s dz
 RA
 TB
 Recurrent dislocation of patella
 Genu varum / valgum
 Charcot jt: DM, perineuropathy, tertiary syphilis, tabes dorsalis,



Tender & tense swelling arising from outer part of meniscus along the joint line (usu
lateral)
Hx of joint injury may be present
Rx: if symptomatic, arthroscopic decompression or removal
Chronic ligamentous instability



Chronic instability – sense of joint wanting to or actually giving way
 pain & recurrent swelling
O’ Donoghue’s triad (aka Unhappy triad): ACL tear + med meniscal tear + med
collateral ligament tear
PE

PCL tear: Sag sign (Galeazzi Sign); posterior drawer, Lachman & Apley’s distraction
test +

ACL tear: anterior drawer, Lachman & Apley’s distraction test +

Medial & Lateral collateral ligament tears: Valgus & Varus stress tests + respectively
Mx

Conservative – hamstring & quadriceps exercise, physioRx, external brace

Stabilization / Reconstruction –
16
o Reattachment (tightening of loose lig / capsule),
o Reinforcement (diversion of healthy muscles or tendons to strengthen weak
structures), using hamstrings, patellar, quadriceps
o Replacement (rerouting living structures or inserting synthetic material)
Osgood-Schlatter disease






Traction injury of apophysis which patellar ligament inserts into (partial avulsion of
tibial tuberosity cos of unequal growth rate betw patellar ligament and bone)
Tender lump over tibial tuberosity
Pain after activity, usually on active knee extension
Usu. young adolescent
X-ray: fragmentation/displacement of tibial apophysis
Rx: Restrict activities esp sports. Spontaneous recovery is the rule.
Osteoarthritis



Usually >50 YO obese PT
Hx: Pain worse after use, jt stiffness, swelling
PE: bow-leg deformity, quadriceps wasting, tenderness when pressure is applied on
patella, ROM, patellofemoral crepitus

Usually medial compartment is affected – a/w genu varum

Predisposing factors: injury, torn meniscus, lig instability, knee deformity
X-ray:

3 views – AP wt bearing, lateral & skyline

Joint space narrowing, Subchondral sclerosis, Lipping, Osteophytes, Loose bodies
Mx:

Conservative: physioRx, exercise, wt reduction, paracetamol, NSAIDs, COX2
inhibitors, tramadol, intraart. steriod, glucosamine, hyaluronic acid injection

Operative: arthroscopic washout, high tibial osteotomy, microfracture technique, TKR,
chondrocyte transplant
Osteochondritis dessecans





Separation of small osteocartilaginous fragment of medial femoral condyle, usu a/w
hx of trauma
Intermittent ache or swelling, locking, giving way, effusion
15-20 YO, Bilateral in 50%, male > female
X-ray – tunnel view: Loose fragment in joint, crater on the medial femoral condyle
Rx: removal of small fragments, fixation of larger fragments, cast for 6 wks.
Recurrent Dislocation of the Patella




Girls > Boys
Usually bilateral
Apprehension test +: Lateral dislocation of patella if quadriceps contract when knee is
in flexion. Results in pain and inability to extend knee.
Predisposing factors: lax ligaments, abnormalities of patella (high, low or lateral) or lat
fem condyle, genu valgus, tibial tubercle malalignment
Rheumatoid Arthritis


Stage 1 (synovitis) – pain, chronic swelling, large effusion, thickened synovium
Stage 2 (articular erosion) – joint instability, ROM. X-ray: loss of jt space & marginal
erosion, but lack of osteophytes c.f. OA
Stage 3 (deformity) – pain, deformity, instability & disability. X-ray: bone destruction

Rx:

Conservative – splintage, intraarticular steroid injection

Operative – osteotomy, TKR
Baker’s cyst (Popliteal cyst)
Mx:

Reduction & backslab

Quadriceps strengthening exercise

Operation: repair of torn medial structures / soft-tissue realignment / transposing
patellar lig medially
Fluctuant swelling in popliteal fossa, usually below the joint – Synovial sac bulging from
back of knee joint
a/w chronic knee arthritis
DDx: popliteal aneurysm, semi-membranosus bursa (usu. above the joint line)
Rx: treat underlying cause, aspiration, intraarticular steroid injection. Operation is unhelpful
as recurrence is common.
Chondromalacia patellae
Housemaid’s knee (Prepatellar bursitis)
Anterior knee pain in adolescent girls – worse on climbing stairs
Retropatellar tenderness, friction test +, effusion
Chronic / recurrent overload of patellar articular surface due to malcongruence of
patellofemoral surfaces OR abnormal tracking of patella during flexion/extension.

A/w development of OA
Invx: skyline views of patella, CT, arthroscopy
Rx:

Conservative: analgesics, reduce activities, physioRx, quadriceps strengthening
exercises

Operative: shaving of articular cartilage, arthroscopy lavage, realignment of patella,
patellectomy



Swelling over patella due to friction btwn skin & patella
Rx: firm bandaging, avoid kneeling, aspiration, excision if chronic
Clergyman’s knee (Infrapatellar bursitis)
Swelling superficial to patellar ligament & distal to the patella
Rx: firm bandaging, avoid kneeling, aspiration, excision if chronic
Semimembranosus bursa
Painless fluctuant swelling in medial part of popliteal fossa
Enlargement of bursa betwn semimembranousus & medial head of gastrocnemius.
Rx: excision if symptomatic (pain)
17
Charcot’s joint
Causes: peri neuropathy, DM, tertiary syphilis, tabes dorsalis, syringomyelia,
myelomeningocele,
cauda equine lesion
Rapidly progressive OA
Gross jt deformity, but painless
Unstable jt, effusion, no warmth
Mx: Rest, immobilize
Stabilize with cast/ calipers
Surgical arthrodesis
 Mx: Acute – plaster cast with foot in equines to approximate tendon ends + shoes with
raised
heels for 6 wks
Operative – repair to equines , plaster and raised heels for 8 wks
Ankle and Foot
Congenital Talipes Equinovarus(Congenital club foot)
 Polygenic, male:female 2:1, bilat in 1/3
 a/w spina bifida & arthrogryposis
 features: ankle in equinus
foot supinated & adducted, sole facing medially
small and high heels, thin calf
fixed deformity not correctable by passive manipulation
 Rx: - correct the deformity early and fully
- hold the corrected position until foot stops growing
- splint and stretch with plaster casr
- operative – lengthen tendo archilles, elongate or divide invertors & plantar
flexors
- orthoses/ night splint - after op, until puberty
- if dx late: bone reshaping, lat wedge tarsectomy, or triple arthrodesis
Hallux Valgus
 Varus angulation of 1st metatarsal => lat angulation of big toe
 Causes: congenital, loss of muscle tone, RA
 Assoc deformities: inflamed bunion, hammer toe, metatarsalgia, secondary OA of 1st
MTP jt
 Rx: - corrective osteotomy of 1st metatarsal (adolescent)
- adults: wides shoes
tendon (adductor hallucis) release
tighten medial capsule
metatarsal osteotomy
- elderly: bunion removal and excision arthroplasty (Cx: metatarsal stress #)
Ruptured Tendo Archilles






Degenerate tendon ruptures during pushing off (jumping/ running)
>40 years old, a/w long term steroid use
unable to tip toe
gap felt 5cm above insertion of tendon
weak plantar flexion, not a/w tautening of tendon
Simmond’s test: lack of plantar flexion on squeezing calf
18
Cervical Spondylosis (orthopaedic degenerative disease of the C-spine)







IV disc degenerate & flatten + bony spurs on ant & post margins of vert bodies
Posterior spurs may encroach upon the IV foramina compressing nerve roots
>40YO, male > female, usually C5/6
DDx: thoracic outlet syndrome (a/w ulnar n. palsy), carpal tunnel syndrome, rotator
cuff lesions (abnormal shoulder movts, no neuro signs), cervical tumour (symptoms
are constant)
S/S
o
Neck pain & stiffness, worse in the morning
o
Radiation: occiput, scapular muscles, down one or both arms.
o
Paraesthesia, weakness, clumsiness
o
Periods of exacerbation & quiescence
o
Posterior neck & scapular tenderness
o
 neck ROM throughout with pain
o
Limb numbness, weakness,  reflexes
X-ray: narrowed IV disc space, bony spurs (‘osteophytes’), encroachment of IV
foramina in oblique view
Mx:
o
Conservative: Heat & massage, NSAIDs, cervical collar, physioRx
o
Sx: discectomy  anterior fusion, corpectomy, laminaplasty, laminectomy 
foraminectomy. Indication: progressive neuro deficits, multiple levels of cord
compression
 "finger escape sign" (the patient is asked to hold out their hand with fingers
extended and the medial fingers drift into flexion)
o
 urinary retention (rare)
Invx: Plain X-rays, CT (bony spurs & ligament ossification), MRI (disc prolapse & cord
compression)
Pavlov's Ratio: ratio of the distance from the posterior aspect of the vertebral body to
the anterior aspect of the lamina to the AP width of the vertebral body. Normal:  1
Abnormal: 0.85
Mx: as for cervical spondylosis
o
7) Important Orthopaedic Conditions in the Neck



Cervical Myelopathy (Neurological disease with possible ortho cause)




C5-6 > C4-5 > C3-4 > C6-7
Causes of cervical myelopathy

Cervical spondylosis –

Infection

Degenerative conditions
due to bony spurs &

Vascular disease

Demyelinating disorders
thickened ligament

Trauma

Tumors
Causes of compression
o
Anterior: protruding disc or posterior osteophytes
o
Anterolateral: joints of Luschka
o
Lateral: cervical facets
o
Posterior: ligamentum flavum
S/S
o
Weakness and clumsiness of the hands, paresthesias in the hand
o
Tightness, hot or cold sensations in the trunk
o
Tingling in the legs
o
Gait disturbances (ataxic, broad based, clumsy, shuffling)
o
Lower motor neuron findings at the level of the lesion
o
Upper motor neuron findings below the level of the lesion/cord compression
o
UL usually show a mix of UMN & LMN signs, while LL usually show UMN signs
only
o
Skipping of the face & head
o
 Clonus, Lhermitte's sign (electric shock-like, radiating down body on neck
flexion), Babinski and Hoffman's pathologic reflexes
19
K&L’s Ortho – Last updated March 2005


8) Important Orthopaedic Conditions in the Back
Prolapsed Intervertebral Disc (usu younger pts)

Acute posterior or post-lateral herniation of nucleus pulposus causing pressure on
nerve root

Young adult

DDx: AS, TB spine, vertebral tumours, nerve tumours

L4/5 commonest (a/w L5 radiculopathy) followed by L5/S1(a/w S1 radiculopathy)

Symptoms
o
Backache (pressure on post longitudinal ligaments)
o
Sciatica (pressure on dural envelope or nerve root)
o
Radiculopathy (usu L5 or S1): Numbness, paraesthesia & muscle weakness in
leg or foot (compression of nerve root)  relieved by flexion to 1 side (listing)
o
Aggravated by coughing, straining, lifting, flexion of spine

Signs
o
Listing (to relieve compression on nerve root), paravertebral muscle spasm,
protective scoliosis, loss of lumbar lordosis
o
Restricted ROM
o
SLR limited, + bowstringing / sciatic nerve stretch test
o
Cross sciatic tension +
o
Segmental myotomal/ dermatomal deficits – sensory deficits, power, reflexes

Cx: Cauda equina syndrome – urinary retention, saddle anaesthesia, lower limb
weakness

Invx:
o
X-rays: AP, lat, oblique to exclude bone disease
o
CT/MRI/myelogram

Mx
Conservative

Bed rest

NSAID

Epidural steroid injection

PhysioRx

Back care education
Surgical

Fenestration & discectomy OR microdiscectomy

Usually only alleviate symptoms of radiculopathy, but not of LBP

Indications: failure of 3 mths of conservative mx (ie progressive
neuro deficit, persistent pain), cauda equina syndrome
Myopathic – due to muscular dystrophies
Neurofibromatosis
Adolescent Idiopathic Scoliosis


Progression: greatest during pubertal growth spurt, minimal progress post-puberty.
Deformity:
o
Fixed 1o curve may be in thoracic or lumbar spine.
o
Vertebrae are rotated with spinous processes pointing to the concavity of the
curve.
o
Ribs on the convex side are carried around to form a prominent hump
o
Shoulder is elevated on side of convexity, hip sticks out on side of concavity
o
Mobile 2o curves may devt above &/or below 1o curve to maintain normal head &
pelvic position

X-ray:
o
full length AP spine X-ray (measure Cobb’s angle – sup & inf extent of scoliosis
is where both sides of the intervertebral space is of equal height)
o
lateral flexion X-rays,
o
X-ray pelvis (Risser’s sign – iliac apophysis ossification & fusion indicating
skeletal maturity)

Cxs:

Pulmonary – TLC & FVC due to thoracic lordosis deformity when Cobb’s
angle >70o

Cardiac – Right heart dz causing pul HPT. Usu when Cobb’s angle >80o

Listing

Limb length discrepancy

Backache

Radiculopathies

Mx:
Age
Cobb’s Angle
Mx
Pre-pubertal / <20o
4mthly F/U & full length spine X-ray to check for progression of
Pubertal
scoliosis
20-40o
Supports (eg Milwaukee brace)
>40o
Spinal fusion + supports post-op to prevent recurrence
Post-pubertal >50o
Spinal fusion
Lumbar Spondylosis

Scoliosis
Causes
Nonstructural
Structural







Limb length discrepancy (apparent or true shortening of one leg)
Hip contracture
Muscle spasm – eg 2o to PID
Adolescent idiopathic (commonest, 80%)
Infantile idiopathic – may resolve or progress
Osteopathic – due to congenital vertebral anomalies
Neuropathic – eg 2o to polio or CP. Due to asymmetrical muscle
weakness




Cause: flattening of disc & displacement of posterior facet joints, due to 2o OA facet
joint
Usually >40YO
S/S
o
Backache – intermittent; aggrav by standing, walking & prolonged sitting;
relieved by lying down
o
Pain referred to buttocks and sometimes extends down leg
o
Acute incidents of pain, locking or giving way
o
Reduced lumbar ROM
X-rays – narrowed disc space, osteophytes
Mx:
20
K&L’s Ortho – Last updated March 2005
o
o
Conservative – modify activities, exercise, manipulation, NSAIDs, lumbar
corset
Surgical – spinal fusion
Elderly (degenerative) – OA degeneration of facet joints
Operative
10. Trauma
11. Suspicious (pathological) – neoplasm
9.

Spinal Stenosis (usu older pts)



Causes: disc degeneration, OA & hypertrophy of post disc margin & facet joint,
degenerative spondylolisthesis (usu L4/5 level), spondylolytic spondylolisthesis (usu
L4/5 or L5/S1)
Causes of spinal stenosis can cause radiculopathy as well
S/S:
o
Neurogenic claudication: Thigh aches, numbness, paraesthesia after standing
upright / walking. Claudication distance is variable
o
Relieved by spine flexion / sitting
Patient stands in slight flexion
o
Limited spinal extension
o
Segmental sensory deficits, power, reflexes
Neurogenic claudication

Variable claudication distance

Better walking uphill due to spine
flexion. Worse on walking downhill

Pain even on standing

‘park bench to park bench’ – pain
requires spine flexion to be relieved.

No pain at night – PT sleeps on lateral
decubitus fetal position
Vascular claudication

Constant claudication distance

Better walking downhill as effort is
less. Worse on walking uphill

‘shop window to shop window’ – pain
relieve simply by resting, even if
standing up

Pain at night

Trauma
Elderly
12. Post-op – due to laminectomy for decompression
Dysplastic
S/S
o
Backache – intermittent, worse on exercise or straining
o
‘Stepping’ of spine
o
Stiffness (for degenerative type)
X-ray:
o
Fwd shift of upper spinal column
o
Elongation of the archs / defective facets
o
Gap in the pars interarticularis on oblique view (Scottie dog sign)

Meyerding classification
Grade
% translation of VB
I
0-25
II
25-50
III
50-75
IV
75-100

Mx
Conservative – bed rest & supporting corset
Operative – spinal fusion
Old PTs, non-disabling symptoms
Disabling symptoms, young adult, neurological
compression

Invx: lat X-ray, CT myelogram (waisting of dye column, posterior indentation, partial
or complete block)

Mx:
Conservative
Education on spinal posture
Surgical
Nerve root compression
Decompression
Nerve root compression & spinal
Decompression & spinal
instability
fusion
Spondylolisthesis


Fwd translation of upper vert body over the lower vert body, usu at L4/5 or L5/S1
level
Causes
7. Dysplasia – congenital lumbosacral facet jt dysplasia
Spondylolytic
8. Isthmic (spondylolytic) – break in the pars interarticularis
Pathological
21
PID vs Spinal stenosis
Symptoms:
PID
Signs:
Inspection
Straight leg raise
Neurological signs
Listing, scoliosis, loss of lumbar
lordosis, paravertebral spasm
 SLR elecits nerve root
compression (ie
radiculopathy)
 SLR, SNST, Bowstring and
cross SLR +ve
Radiculopathy (usu L5 &/or S1)
Spinal stenosis
Pt stands in flexion
SLR, SNST, Bowstring and
cross SLR may or may not
be +ve (dep whether nerve
root is compressed by
underlying cause of spinal
stenosis)
 Spinal stenosis: LMN
signs at level of
compression, UMN signs
downwards (but signs are
variable depending on
severity of stenosis)
 Radiculopathy(dep
whether nerve root is
compressed by
underlying cause of
spinal stenosis
Patient age
LBP aggravating
factors
LBP relieving factors
Neuro symptoms
younger
 Increase in abd pressure
(laughing, coughing, lifting,
straining)
 Spine flexion, prolonged
sitting
Listing to 1 side
Pain, numbness, paraesthesia,
weakness
Older (unless cause is PID)
Neurogenic claudication
symptoms
Spine flexion
Pain, numbness,
paraesthesia, weakness
22
9) Proximal Femoral Fractures Summary
DDx of hip #: - pubic rami #
- acetabular #
- isolated # of greater trochanter
- trochanteric bursitis/ contusion
Blood supply of Femoral Neck




Nutrient artery of femur
Retinacular Arteries (from medial and lateral circumflex arteries)
Artery through ligamentum teres (from obdurator artery)
In NOF fracture
o
nutrient artery severed
o
if significant displacement, retinacular vessels severed AVN
o
only ligamentum teres vessels remain
Predisposing factors
Non-modifiable
Modifiable
Old Age
Early menopause
Female Sex
Nulliparity
Caucasian
Family History of fractures
Personal History of fractures
Anything that causes increased risk of falls, e.g.
 Poor vision, vestibular dysfunction
 LL weakness
 Hazards at home
 Significant co-morbitidies e.g. CCF, CVA
Reduction of bone strength
 Osteoporosis, low Ca intake
 Steroids, alc, smoking, thyroxine, increased/decreased T4
 Physical immobility
 Pathological bone conditions
 Chronic liver and renal failure
Clinical Findings
History
Fall
What happened
How she fell – e.g. landed on bum
Pain, tenderness, deformity
Can walk? (If yes => impacted # or Garden 1#, which is undisplaced
=> need to admit to prevent progression to displaced # which has
poorer prognosis)
before fall
Predisposing factors
Bone weakness
to fracture
Predisposing factors to recurrent falls
Comorbidities
Premorbid functional status
Osetoporotic Risk Factors
Physical examination
 Shortened
 Externally rotated
 Bruising (suggest extra capsular #)
 Tenderness over femoral neck
 Painful limited hip movements
Investigations
 Confirm diagnosis, determine severity
 Pre-operative investigations
Radiological
AP Pelvis
Lateral affected hip joint
Preop
FBC
U/E/Cr
PT/aPTT
urinalysis
GXM
CXR
ECG
Initial management




Analgesia
Pre-op traction for pain relief and to ensure union takes place in a good position
Thromboembolism prophylaxis (SC heparin 5000 units bd)
Antibiotics if infection suspected
Types of Fractures according to site
NOF
Intracapsular
Extracapsular
Other
Subcapital
Transcervical
Basal
Intertrochanteric
Pertrochanteric
 Involves the trochanter(s) which are themselves
fractured
Garden Classification of NOF Fractures
1
Undisplaced
Inferior cortex not completely broken
Fracture line not complete
May have some angulation of trabeculae
23
2
3
Displaced
4
Inferior cortex completely broken
Fracture line complete
Minimal displacement
Inferior cortex completely broken
Fracture line complete
Significant displacement
Head internally rotated, abducted (distal fragment ext.
rotated)
Inferior cortex completely broken
Fracture line complete
Complete displacement
Head retains neutral position in acetabulum
K&L’s Ortho – Last updated March 2005
Management
Conservative: if undisplaced, clinically stable & ROM is full and painless
Total hip replacement: for OA hips, pathological #, acetabular involvement, or revision hip
NOF
Age
Young
<60, fit
>60
Garden
1,2,3,4
1,2
3,4
Management
Closed procedure
 Fixation with dynamic hip screw
 Reduction and placement of screw using image
intensifier
Open
 ORIF
Hemiarthroplasty
IF should be attempted
Hemiarthroplasty if fail
If fit, premorbidly active
 Bipolar Hemiarthroplasty – can withstand more activity
Not so fit
 Unipolar Hemiarthroplasty
Thompson better for osteoporotic patients
Lifespan: 10 yrs
Material: ultra high molecular wt polyethylene and surgical grade stainless steel
After-care:
Weight bearing
Implant
 Try to get pt to sit up by 24h, walk by 72h
Internal fixation
 Sit up by 24h
 Encourage mobility with non-wtbearing (wheelchair)by 72h
 Do not weight bear until healing of # occurs, else high risk of
cutout
Physiotherapy
Preserve joint movement
Restore muscle power
Assess what type of mobility aids needed
Treat osteoporosis and comorbidities
Complications of femoral #
 Non-union in 30%
 Redisplacement
 Avascular necrosis in Intracapsular NOF only, rarely occurs in intertrochanteric


o
Undisplaced – 10-30%
o
Displaced – 50-80%
o
Manage by total hip replacement
Erosion of femoral head in unstable IT fractures causing coxa vara
Cx: delayed union, non-union, malunion (coxa vara), OA
Intertrochanteric/ Pertrochanteric
 Internal fixation with a dynamic hip screw will suffice usually
NOTE: Total Hip Replacement involves replacement of the acetabulum also, usu reserved for
patients with OA, pathological #, revision of implant – will see on Xray that acetabulum is metal as
well
Thompson
(has neck, no holes,
need cement)
Austin Moore
(has 2 holes, no neck, no
need cement)
DHS Plate
and Screw
24
Complications of Hip Replacement
General
Use GS notes. In particular, DVT & PE due to immobilization & pelvic op.
Specific
Immediate
Periop # while doing procedure
Short-term
Osteomyelitis
Postoperative dislocation
Long-term
Disuse osteoporosis
Tissue atrophy
Myositis ossificans
Implant failure
 Wearing of articular surfaces (esp acetabulum)
 Loosening
 Erosion, cut-out etc
 Peri-prosthetic #
Post-op management
 Use GS principles
 Ask abt relevant social hx & family support
Outcome of NOF fractures




25% 1y mortality
33% ambulating +/- walking aid
33% wheelchair bound
10% bedbound
Union take abt 3 mths.
Causes of bone necrosis:
1) Arterial supply interruption:

fracture

dislocation

infection
2) Arterial occlusion:

sickle cell disease

vasculitis

Laisson disease
3) Capillary compression:

Steroids

Gaucher’s disease
10) Osteoarthritis (Knees)
o
o
Most common joint disease in the world
Degenerative joint disease
Morphological changes
 Cartilage degeneration
o
Fissuring
o
Pitting
o
Eburnation as joint motion polishes surface
 Bone Hypertrophy
o
Osteophyte formation
 Mild synovitis
Two types
Primary
Secondary
Joints affected:
 Trauma – acute or chronic
 PIPJs of hands (Bouchard’s nodes)
 Rheumato - Rheumatoid Arthritis
 DIPJs of hands (Heberden’s nodes)
 Metabolic – Hyper PTH
 Thumb joints
 Infections - Syphilis
 MTPJ of big toe
 Cervical and lumbar spine
 Hip
 Knee
* frequency of OA: Asians: knees > hips; Caucasians: hip > kness
Other risk factors




Obesity
Competitive contact sport
Deformities – e..g genu valgus/varum
Recreational running is NOT a risk factor
Differentials – need to exclude other DDx of hip/knee pain from history
 Referred pain from hip, back
 VITAMIN
 Vascular – AVM
 Infections – warmth, fever, inoculation e.g. intra-articular injection by GP
 Traumatic
 Autoimmune/ inflammatory
 Metabolic – Gout, tophi
 Neoplastic – LOW/LOA, SOB, goiter, urinary, GIT
25
History
Investigations
 NO systemic involvement
 Joint pain
o
The usual 6 points about pain
o
Which joints?
o
Insidious onset
o
Morning stiffness not prominent
o
Worsened by activity
o
Alleviated by rest
 ASK ABOUT BACK PAIN, HIP PAIN WHICH CAN BE REFERRED TO THE KNEE
 Precipitating causes
o
Trauma
o
History of contact sports / occupation
o
Associated conditions – RA, syphilis
o
BMI of patient
 Functional Loss
o
Job scope
o
Recreational activity restriction
o
Premorbid status: function & mobility
 Social hx – ask about housing (floor, lift landing)
 Treatments tried
 GI bleed risk
o
History of ulcer disease and/or GI bleeding
o
High dose or multiple NSAIDs
o
Concomitant use of corticosteroids and/or warfarin
o
Age >60 yrs
 To confirm diagnosis and exclude differentials
 To look for causes (not applicable usually)
 To look for complications (not applicable usually)
Radiological
AP weight bearing
Lateral
Skyline (tangential) view
To view all 3 compartments – medial,
lateral, patellofemoral compartment
Joint space narrowing
Lipping
Sclerosis
Osteophytes
Loose bodies
Physical Examination










Genu varum/valgus predisposes to OA – usually genu varum
Fixed flexion deformity
If joint swelling, is MILD
Joint line tenderness
Crepitus
Decreased ROM
Examine other joints as well
Note absence of rheumatoid nodules/ tophi/ rashes/ Sjogren’s
Examine HIP, BACK
Neuro exam – SMART – sensory, motor, autonomic, reflexes, trophic changes
26
Management
Nonpharmacological
Physiotherapy
Exercise
Load reduction
Pharmacological
Paracetamol
NSAIDs
COX-2 inhibitors
Glucosamine with
chondroitin
Tramadol
Intraarticular
injections of
corticosteroids
Intraarticular
hyaluronic acid
injections
(e.g. Synvisc)
Surgical
Minimally invasive
(Arthroscopic)
High tibial osteotomy
Preservation and improvement of joint mobility
Range of motion and muscle strengthening exercises
Body weight reduction if obese
Use of walking aids
Knee replacement
Should be first line drug; effective in a proportion of patients
Must be used with special care in
 >60y
 previous history of GI bleed
 concurrent warfarin/ steroid medications
 renal dysfunction
Prescribe with PPI/H2RA in patients with increased likelihood of
GI bleeding
Vioxx a/w increased risk of stroke and cardiac events.
Glucosamine has anti-inflammatory properties
Chondroitin inhibits cartilage breakdown and stimulate cartilage
repair
Have been found to be at least as effective as NSAIDS, with the
added advantage of fewer side effects
Consider in patients with highly-resistant pain
Consider is patients with highly resistant pain. It is recommended
that no more than 4 glucocorticoid injections be administered to a
single joint per year because of the concerns with long-term damage
to cartilage
Marketed as ‘joint replacement’ substances; expensive
Osteotomy permits redistribution of weight
Contraindications
 Inflammatory arthritis
 Severe flexion deformity >15o
 Varus/ valgus >15o
 >5mm loss of subchondral bone
 lateral thrust while walking
When symptoms are severe
Try to avoid doing in patients <60 as TKRs usu last only ~10y
 can be
o
Unicompartmental
o
Total +/- preservation of PCL; PCL
preservation preserves proprioception
function but  wear of prosthesis
Complications
 Wear of polythene surfaces
 Loosening of prosthesis-bone junction
 Thromboembolism (DVT, PE, stroke)
 Vascular & nerve injuries
 Infection: Management: 2 stages
 Removal of implant, plus 6 weeks IV antibiotics
 Reimplantation after Abx completed
Cartilage regeneration procedures
Chondrocyte
Harvest condrocytes from non weight-bearing sites, e.g. patellofemoral
transplant
surface, culture, reimplant
Microfracture
Subchondral penetration of bone, inducing regrowth of fibrocartilage
Mosaicplasty
Cylindrical cartilage taken from non-weight bearing areas, implanted
on knee joint surface to form a new layer of cartilage, comprised of the
intact original cartilage and the transplanted grafts
Post-surgical
Physiotherapy
Continuous Passive Movement (CPM)
For early degenerative arthritis
Alternative to osteotomy and total knee replacement if the patient is
reluctant to have more aggressive surgery
Techniques include
 Washout and debridement
 Cartilage regeneration procedures
o
Chondrocyte transplant
o
Microfracture of subchondral bone
o
Mosaicplasty
Arthroscopic surgery may defer definitive operation by up to 5
years
Only in certain cases e.g. unicompartmental involvement.
To maintain joint ROM & muscle power
27
11) Osteoporosis
Approach to OA knee
1) Confirm Dx of OA knee: pain and its characteristics
Clinical description
2) Exclude other sites of pathology
a) back – pain, PU claudication
b) hip
c) ischaemic pain or neuropathic pain
Ischaemic pain




Fixed claudication distance
Better walking downslope
Recovers quickly with rest
Pain present at night
 A bone disease characterized by
Neuropathic pain




Decreased bone mass
Weakening of microarchitectural structure of bone
o
Increase in bone fragility and hence fractures, commonly at
1. distal radius (Colles’)
2. Spine (compression #)
3. Hip # (NOF or intertrochanteric)
4. Head of humerus
5. Pubic rami
 Leading to
Variable claudication distance
Better walking upslope
Recovers slowly with rest
Pt usu sleep in kyphosed position
with no pain
3) exclude DDx
a) malignancy – other bone pain, LOW, LOA etc.
b) septic arthritis – fever, tenderness, swelling, trauma, intraarticular injectn
c) RA – other jts, morning stiffness, pain
d) gout – precipitant, inflammation
o
o
Lab definition, by bone marrow density at the hip
BMD T-score
>-1
-1 to -2.5
<-2.5
<-2.5 + fragility fracture
Definition
Normal
Oteopenia
Osteoporosis
Severe osteoporosis
Indications for BMD screening of Osteoporosis:






Previous fragility fracture
Patients with strong risk factors
High risk postmenopausal women as categorized by OSTA
Radiological evidence of osetopenia/ vertebral deformity
Women who are considering prevention therapy for osteoporosis
Monitoring of treatment
Risk factors
Osteoporosis Selfassessment Tool
for Asians (OSTA)
Nonmodifiable
Modifiable






Use age-weight=x




Weight (lean ppl predisposed to osteoporosis)
Drugs – smoking, alcohol, steroids, thyroxine, anticonvulsants
Early menopause (<45YO)
Comorbidities – hyperthyroidism, Cushing syndrome, liver disease,
COPD, CRF, RA, organ transplant etc.
Immobilization
Lack of physical exercise


If x>20, measure BMD
If x=0-20, measure if other risk factors present
x<20 low risk, no need to measure unless positive hx of fragility #
Previous adult fracture history
Previous family history fracture
28
Investigations
K&L’s Ortho – Last updated March 2005






X-Ray if applicable
Ca/ PO4 to exclude osteomalacia
FBC, ESR
U/E/Cr
Others if suspect underlying associated disease
o
TFT
o
LFT
o
Tumor markers and myeloma screen (FBC, ESR, bone marrow aspiration, urine
electrophoresis, skull X-ray)
Measurement of BMD
o
Dual X Ray absorbimetry of hip for diagnosis, spine for monitoring of treatment is
the investigation of choice
o
Other rarely done investigations include
 U/S heel/ tibia
 Quantitative CT scan
Management:
BMD T-score
>+1
1 to -1
-1 to -2.5
<-2.5
<-2.5 + fragility fracture
Action
Re-BMD in 5y
Re-BMD in 2y
Medical prevention, F/U BMD @ >1yr
Medical treatment, F/U BMD @ >1yr
Lifestyle measures, to be encouraged in everyone
Nutrition
Age
Exercise
Smoking, alcohol cessation
Fall prevention
 hypersensitivity
 take medicine sitting up, keep upright for 30min after
swallowing, wkly dosing
Selective Estrogen
Receptor
Modulators
(SERM)
Synthetic Steroid
Risedronate
Raloxifene
(EVista)
Tibolone
 Hot flushes, sweating, leg cramps
 Increased risk of clots e.g. DVT, PE
 Teratogenic
Has also been shown to be protective against breast CA
 Has progestogenic and some androgenic properties
as well as oestrogenic effects
(Livial)
Others
Also has value in controlling hot flushes
 Intermittent PTH Rx
 Cyclical etidronate
 Calcitonin
 Calcium & Vit D
K&L’s Ortho – Last updated March 2005
Calcium
Vitamin D
11-18
1000mg
400IU
18-65
800mg
400IU
>65
800mg
Weight bearing exercises (3x30min/wk)
(Fosamax)
800IU
Remove hazards
Treat comorbidities which predispose to fall e.g. cataract,
blah blah
Medications available
HRT
Not to be used if osteoporosis is the only problem
Use only if other indications e.g. unbearable hot flushes
Bisphosphonates
Aledronate
Stop when menopausal symptoms abate and switch to
other treatments
 esophageal reaction e.g. heartburn
29
12) The Diabetic Foot

Foot Problems in Diabetes
Peripheral Vascular
Disease
Neuropathy
Infections
Claudication
Trohpic Changes
Ulceration
Gangrene
Motor Neuropathy
Sensory Neuropathy
Autonomic Neuropathy
All these contribute to Charcot joint
Ulcers
Cellulitis
Deep Infections – osteomyelitis, deep abscesses, tendinitis
Osteoporosis
History
Presenting Complaint

Pain – ask the 6 chx of pain

Ulcer

site, any other ulcers, duration, painful/painless, discharge

Swelling/ Redness

Join Deformity/ swelling

Gangrene
Ask for symptoms to screen other foot problems

PVD

gangrene, ischemic ulcers

ask for vascular claudication symptoms
Spinal Claudication
Vascular Claudication
Pain comes on after variable
Pain comes on after fixed distance
distance
(‘bustop to bustop’)
Pain better on climbing stairs
Pain worse on climbing stairs
Relief of pain takes longer after rest
Relief of pain rapid once patient rests
‘no’ night pain
night pain, relieved by hanging legs
down

neuropathy

Motor – weakness

Sensory – parasthesia, glove and stocking loss

Foot deformity

neuropathic painless ulcers

Infections

Osteoporosis – previous history of foot fractures
‘Brief’ history of DM

when diagnosed

medications

compliance



DM complications

3 macrovascular – CVA, IHD, PVD

3 microvascular – retinopathy, nephropathy, neuropahty

2 others – cataracts, recurrent infections

2 more – hypoglycemia, DKA/ HHNK
previous episodes of diabetic foot complications – e.g. ulcer, gangrene, amputations
footcare advice prescribed by doctor, compliance
other DM history
Physical Examination

General signs – temperature esp

full DM exam

Lower limb exam, LL neuro exam, PVD exam

CVS – AF, murmur, cardiac failure, carotid bruit

Abdo – AAA, renal bruit, bruit along course of LL arteries
Look
DM features – diabetic dermopathy, necrobiosis lipoidica diabeticorum
PVD – duskiness, shiny skin, loss of hair, ulcers over pressure areas,
gangrene
neuropathy

motor – claw foot, pes cavus, clawing of toes

Charcot deformity

ulcers
infections – cellulitis, boils, abscesses
Feel
Ulcer

base

size

grey-yellow slough; lack of
granulation tissue 
shape
ischaemic ulcer

site

tenderness

depth – use Wagner’s
classification

discharge

edge - punched out etc.

surrounding tissue
warm - neuropathic ulcer
cold - ischaemic ulcer
Move
Sensation
Reflexes
Foot and LL pulses, capillary refill
Buerger’s test
Feel ligaments, joints
Ankle joint – plantar/ dorsiflexion
Subtalar – inversion/ eversion
Midtarsal – toe movements
Charcot Joints  LMN signs

may have signs of inflammation – swelling, erythema

severity of pain surprisingly less than expected tor severity of foot
damage/ deformity

deformity – club foot, rockerbottom feet

instability – ‘bag of bones’

loss of ROM
Glove and Stocking
Loss of DTRs in Charcot joints
Investigations
30
FBC: anaemia secondary to DM nephropathy
U/E/Cr
Wound culure
Blood C/S
HbA1C, plasma glucose
Lipid profile
ESR
X-ray: OM, Chartcot’s jt, gas (infection)
ABPI, colour duplex scan, arteriography/ MRA
Pre-op: ECG, CXR, PT/PTT
Management
Depends on main problem

Infection

Ulcers

classify according to Wagner classification (Grade)
0
at risk foot
Gram positive cocci +++
no open lesion
Gram negatives - - Anaerobes - - 1
superficial ulcer with no
penetration into deeper tissue
2
deep ulcer eroding into muscle,
tendon, bone, ligament
3
infection of deep tissue eg.
tendinitis, osteomyelitis, deep
Gram positive cocci - - abscess
Gram Negatives +++
4
gangrene of forefoot
Anaerobes - - 5
gangrene of whole foot
Management of Infected Ulcers

culture + sensitivity, in the meantime give empiric antibiotics

Superficial Ulcer: Grade 1 – oral flucloxacillin 7-14d

Deep ulcer – Triple Therapy – fluclox, cipro, metronidazole

Deep ulcer + cellulitis – IV antibiotics

PVD

Ankle-Brachial Pressure Index (ABPI) Doppler

Normal = 1

Claudication = 0.9-0.6

Rest pain = 0.6-0.3

Gangrene = <0.3

Colour Duplex Imaging

Arteriography

Management

WAIT FOR GS LECTURES

If pain no gangrene

Mild to moderate claudication

cut risk factors – control DM, cut smoking





aspirin, beta blockers?
Disabling Claudication

Balloon angioplasty

Reconstructive arterial surgery (thromboendarterectomy, bypass –
Dacron/ PTFE/ vein graft)
If dry gangrene

leave to drop off by itself, but must monitor regularly to watch for
development of wet infected gangrene
Wet infected gangrene

amputation

wait for GS lectures
Charcot Joint Management

Investigations

X-Ray

10g monofilament testing (Semmes-Weinstein 5.07 monofilament test)

neurosthesiometer

Management
Acute
Immobilisation
Casting, allowing ambulation while
preventing worsening of deformity
do for 3-6 months
serial Xrays to review progress
Load Reduction
Total non-wieght bearing
Partial non-weight bearing with crutches,
walkers
Chronic
Protect foot from
Braces
additional stresses Special Footwear

Charcot restraint orthopedic walker
Surgical
internal fixation
reconstruction surgery
tendon transfer
Types of Amputations
 Toe disarticulation
 Ray amputation – removal of phalanges and metatarsal of toe
 Midtarsal amputation
 Syme’s ankle disarticulation – malleoli cut level with inferior surface of tibia
 Below Knee Amputation – 10-12cm below tibial tuberosity
 Above Knee Amputation – 22-25cm below greater trochanter
 Hip Disarticulation
Others
 foot care education
 Amputation counseling
- indications
- procedure
- risks & benefits – might be life threatening, may require AKA in future
- Prognosis
- Prosthesis
31
13) Bone & Joint infections

Complications

Spread – septic arthritis, metastatic OM (ie to other bones)

Growth disturbance – shortening / deformity if physis is damaged

Chronic OM

Mx

Empirical ABx first, changing when C/S returns
Adults/older children – flucloxacillin & fusidic acid (IV 3/7, PO 3-6/52)
Children <4YO or G negative organisms cultured – Cephalosporin

Analgesia

CRIB & splintage (+ traction in upper femur OM to prevent hip dislocation)

Drainage – for subperiosteal abscess or persistent pyrexia & local tenderness of > 24
hrs
Types:
1.
2.
3.
4.
5.
6.
Acute haematogenous osteomyelitis
Subacute haematogenous osteomyelitis
Post-traumatic/operative osteomyelitis
Chronic osteomyelitis
Acute suppurative arthritis
TB infxns of bone & joints
Waldvagel Classification:
A – haematological spread
B – a/w wound
C – contiguous spread from local infection
Subacute Haematogenous Osteomyelitis
3 things to consider:
1) type of organism
2) site of infection
3) host response (immunocompromised?)




Acute Haematogenous Osteomyelitis

Common organisms:

Adults: Staph. Aureus

Children <4YO: H. influenzae

Hx of sickle cell anaemia: salmonella

<1YO: GBS, Staph A, E Coli
1-16YO: Hib, Staph A, Strep, Enterobacter
Adults: Staph, Strep, Pseudomonas, E Coli
Milder form of acute OM – less virulent organism or better resistance in PT
Common sites: distal femur, prox & distal tibia
PT: child/adolescent
X-ray: Brodie’s abscess (small oval cavity surrounded by sclerotic bone) (DDx: osteoid
osteoma)
Mx: drainage & ABx cover
Post-traumatic / operative Osteomyelitis


Site:

Adults: anywhere, esp thoracolumbar spine. Adults are usu immunocompromised

Children: usu. metaphysis of growing long bone. Growth plate limits spread towards
epiphysis.

Infants: risk of epiphyseal extension, jt involvement & growth disturbance.



Pathology

Infxn spreads to form subperiosteal abscess

Bone dies, forming a sequestra encased by the involucrum (periosteal new bone)

Chronic osteomyelitis: pus discharges through cloacae (perforations) in the involucrum


Clinical features

Pain, malaise, fever, toxaemia

Cellulitis, swelling, oedema, erythema, warmth, tenderness, ROM

Invxs

X-ray: normal in first 10 days. Later, rarefaction of metaphysis & periosteal new bone
formation. Sclerosis when healing occurs

FBC: leukocytosis

ESR 

Blood C/S

Bone scan (usu. technetium or gallium radioisotopes used): turns + before x-ray
changes appear. For doubtful cases.
Risk factors: DM, old age, immunosuppressed, steroid Rx, chronic dz, obese, multiple ops at
same site, difficult / long ops, haematoma formation, tight dressings, wound tension
Organism: Staph. Aureus
Opley classification:
A
Early – 1 mth
B
Intermediate – 1mth to 1 yr
C
Late – >1 yr
Mx:

Clean Sx technique

Thorough debridement

Drainage

ABx cover

External fixation of unstable/unfixed #
Chronic Osteomyelitis


Sequelae of acute haematogenous, post-traumatic & post-op OM
Recurrent flares of acute infxns – pain, pyrexia, erythema, tenderness, discharging sinus,
non- healing ulcer

Invx:

X-ray: bone rarefaction surrounded by sclerosis  sequestra

Bone scan: to reveal hidden foci of infxn
Mx:

Incise abscess, remove necrotic bone, fill with bone chips

32
K&L’s Ortho – Last updated March 2005


ABx – fusidic acid or cephalosporins
Sequestrectomy

Pathology

Spreads to skeleton by haematogenous seeding

May spread to articular surfaces causing jt destruction and fibrosing ankylosis

May spread to soft tissue to form subacute abscess, which may form a chronic
discharging sinus

Clinical features

TB symptoms: fever, wt loss, night sweats etc

Jt symptoms: chronic course, pain, swelling, wasting, synovial thickening, ROM, joint
stiffness and deformity

Spine: vertebrae may collapse causing a Pott’s gibbus (usu. thoracic)
Acute Suppurative Arthritis

Common organisms:

Adults: Staph. Aureus

Children <4YO: H. influenzae

Clinical features

Acute monoarthropathy – usu. hip in children & knee in adults

Swelling, erythema, warmth, tenderness, fluctuation, ROM, pain, spasm

Invx

Blood C/S

Jt aspiration, pus microscopy & C/S

X-ray: widened joint space & soft tissue swelling; subarticular bone destruction if late
stage

U/S: joint effusion
Invx:

X-ray: soft tissue swelling, rarefaction of bone, joint space narrowing & irregularities w
bone erosion on both sides of joint, periarticular osteoperosis

Synovial biopsy

ESR 

Mantoux test +

Mx:






Cxs:

Dislocation

Epiphyseal destruction & pseudoarthrosis

Growth disturbance – shortening or deformity if physis is damaged

Ankylosis – if articular cartilage is eroded

Sepsis – 25% if untreated

Mx:





ABx – as for pul. TB (isoniazid, rifampicin)
Rest, traction, splintage, operation
If articular surfaces are destroyed – Immobilize joint
Long term – Joint arthrodesis or replacement
Joint aspiration
Systemic ABx
Splintage
Drainage and joint washout
Rehab: increasing movement when jt is not inflamed. If cartilage has been destroyed,
keep immobile to allow ankylosis to occur
Tuberculosis

Common sites (wt bearing joints)

Spine (50%)

Hip

Knees

Main TB entities in orthopaedics

TB spondylitis

TB osteomyelitis

TB arthritis

TB tenosynovitis

TB myositis
33
K&L’s Ortho – Last updated March 2005
14) Bone Tumours & Cysts
osteochondroma OR Central
medullary
Pelvi
(OSCE oriented)
Dx of Bone tumours & cysts:
Impt differentiating features

Site of lesion

Patient’s age

Special x-ray features
Bone tumours by Patient age
Children / Adolescents
(<20YO)
Bone tumour Classifications
Malignant Bone tumours by frequency
1.
2.
3.
4.
5.
Metastatic
Multiple Myeloma
Osteosarcoma
Chondrosarcoma
Ewing’s sarcoma
Common Pri site of metastatic tumours:

Thyroid

GI
*Midline & paired

NPC

Renal
structures

Breasts

Prostate
*Most are osteolytic

Lungs

Testes
except prostatic CA mets
Bone tumours by cell type
Cell type
Bone
Cartilage
 Metastatic
Fibrous tissue
Marrow
Benign

Osteoid osteoma

Chondroma

Osteochondroma

Fibroma

Eosinophilic granuloma
Vascular
Uncertain


Malignant

Osteosarcoma

Chondrosarcoma





Haemangioma
Giant-cell tumour
Young Adults (20-40YO)
Middle age / Elderly (>40YO)
















Chondroma (arise @ puberty, presents ~30YO)
Osteochondroma
Osteosarcoma
Osteoid osteoma (<30YO)
Non-ossifying fibroma
Ewing’s tumour
Simple bone cyst
Aneurysmal bone cyst
Giant cell tumour
Chondroma (arise @ puberty, presents ~30YO)
Osteoid osteoma (<30YO)
Chondrosarcoma
Multiple myeloma
Osteosarcoma (~50YO)
Metastatic tumours
Fibrosarcoma
Ewing’s sarcoma
Myeloma
Angiosarcoma
Malignant giant-cell tumour
Bone tumours by Site
Long bones
Metaphysis
Diaphysis
Non-specific
Spine
Hands & feet
Others
Red marrow populated areas
Cartilage cap of




















Osteochondroma
Simple bone cyst
Aneurysmal bone cyst
Giant cell tumour (prox tibia, distal radius,
distal femur)
Non-ossifying fibroma (cortex)
Osteosarcoma (esp knee & prox humerus)
Chondrosarcoma
Ewing’s tumour
Osteoid osteoma
Chondroma
Metastatic
Aneurysmal bone cyst
Giant cell tumours
Multiple myeloma
Metastatic
Chondroma
Giant cell tumours (calcaneum)
Multiple myeloma
Metastatic
Chondrosarcoma
34
Features of Bone Tumours & Cysts
Bone tumour
Osteoid osteoma
Osteochondroma
Chondroma
(enchondroma)
Simple (solitary) bone
cyst
Aneurysmal bone cyst
Non-ossifying fibroma
(fibrous cortical
defect)
Giant cell tumour
Osteosarcoma
Chondromsarcoma
Ewing’s tumour
 X-ray findings
 Small round/oval radiolucent area surrounded by dense sclerosis
 DDx: Brodie’s abscess
 May be single or multiple
o
Multiple exostosis has AD inheritance & low rates of malig
change
 2 main types:
i)conical (well defined)
ii)cauliflower with partial calcification of cartilage cap
 Well defined rare area in medulla
 Characteristic speckles of calcification w/in area of rarefaction
Site

Femur, tibia
Age
<30


Edge of epiphyseal plate
Long bone metaphysis
Adolescence


Tubular bones of hands & foot
Long bones
 Excise / curette & replace w bone graft
 Risk of malig change, esp if multiple lesions are present
 Translucent areas on shaft side of growth disc
 Bone expansion with cortical thinning
 Fallen fragment sign
 Well defined margins around a rare area
 Eccentrically placed
 Bone expansion with cortical thinning
 Confined to metaphyseal side of growth plate (c.f. Giant cell tumour
which extends to articular surface)
 Diameter of cyst usu > diameter of bone
 Cortex
 Well defined sclerosed margins

Prox ends of humerus, femur,
tibia.
Usually in the metaphysis
Spine
Metaphysis of long bones
Arise @ puberty,
presents ~30YO.
Need to rule out
chondrosarcoma
if >30YO
Children up to
puberty
Young adults
 Curette & filled w bone chips

Cortex of long bone
metaphysis
Child
 No Rx unless #ed.
 Rarefied area situated asymmetrically
 Extends to articular surface (MUST, otherwise excluded)
 Soap bubble appearance
 Cortex is thinned, may be ballooned / perforated
 Sunray appearance
 Bone areas of rarefaction in medulla
 Subperiosteal new bone formation
 Codman’s triangle = lifting of periosteum prox to tumor @ the edge of
the ‘sunray’
 Central medullary type: initially appears like a chondroma. Destructive
medullary tumour with flecks of calcification
 Malig change in cartilage cap of osteochondroma type: large
exostosis surrounded by flecks of calcification in the cartilage cap
 Bone destruction
 Overlying ‘onion-skin’ layers of periosteal new bone

End of long bones (prox tibia,
distal radius, distal femur)
Vertebral body
Calcaneum
Meaphysis of long bones
Knee & prox humerus
20-40YO


Central medullary tumour OR
malignant change in cartilage
cap of osteochondroma
>40YO











Diaphysis of long bone
10-20YO







Bimodal
distribution:
10-20YO; ~50YO
(a/w Paget’s dz)
Others
 Aspirin (pain relief)
 Excision
 Bony hard lump  pain or disturbed tendon fx
 Excise if symptomatic or growing (risk of malign
change)
 Intralesional steroid injection
 Curette & filled w bone chips
Hx of patho #
High rate of recurrence if not completely excised
Curette & fill with bone chips
Excision & bone graft/ prosthetic replacement
Metastasize readily esp to lungs
ALP  by 3-4X
Biopsy to confirm dx
ChemoRx  RT
Resection / amputation
Tend to metastasize late
 Rare, arise from vascular endothelium
 Amputation, RT, chemoRx
35
K&L’s Ortho – Last updated March 2005
Multiple myeloma
(single tumor =
plasmacytoma)
 Overall reduction in bone density
 Multiple punched out defects (skull XR is often shown)

Areas containing red
marrow. Esp skull and
vertebrae
45-65YO
Metastatic tumours
 Usually osteolytic EXCEPT prostatic CA mets which are
osteosclerotic
 Moth eaten appearance
 Generalised osteoporosis
 Look for lung metastases

Areas containing red
marrow
Esp axial & long bones
50-70YO

 Osteoporosis + high ESR
 Urinalysis – Bence-Jones proteins
 Serum / urine electrophoresis –
monoclonal immunoglobulin band
 ChemoRx & RT, int fixation of #, brace
for spinal #
 Other problems
o Nchormic Ncytic anaemia
o Hyperviscosity syndrome
o Renal stones
o Gout & hyperuricaemia
o Abnormal globulin: albumin ratio
 Palliative ChemoRx & RT
 Int fixation of #s
 Sx decompression & fusion of
vertebrae to prevent neuro deficit
Enneking Classification
Grade
(surgical)
Site
Metastasis
G0
G1
G2
T0
T1 (A)
T2 (B)
M0
M1
Benign
Low grade malignant
High grade malignant
Benign Intracapsular & intracompartmental
Intracompartmental
Extracompartmental
No regional / distant mets
Regional / distant mets
Staging for Malignant Neoplasia
IA
G1
T1
IB
G1
T2
IIA
G2
T1
IIB
G2
T2
IIIA
G1 or 2
T1
IIIB
G1 or 2
T2
M0
M0
M0
M0
M1
M1
Staging for Benign Neoplasia
1
Latent
G0
T0
2
Active
G0
T0
3
Aggressive G0
T1 or 2
M0
M0
M0 or 1 (giant cell tumour)
36
BONE TUMOURS
Cell type
Benign
Malignant
Bone
Osteoid osteoma
Osteosarcoma
Cartilage
Chondroma; osteochondroma
Chondrosarcoma
Fibrous tissue
Fibroma
Fibrosarcoma
Marrow
Eosinophilic granuloma
Ewing’s sarcoma; myeloma
Vascular
Haemangioma
Angiosarcoma
Uncertain
Giant-cell tumour
Malignant giant cell tumor
Birth – 5
►
►
5 – 20
Leukaemia
Metastatic
neuroblastoma
► Eosinophilic
granuloma
20 – 40
► Ewing’s sarcoma
► Osteosarcoma
► Chondroblastoma
► Giant cell tumour
► Osteoid osteoma
► Osteoblastoma
► Ewing’s sarcoma
► Osteosarcoma
► Enchondroma
Beyond 40
► Metastatic bone
disease
► Multiple myeloma
►
►
►
►
Chondrosarcoma
Fibrosarcoma
Paget’s osteosarcoma
Malignant fibrous
histiocytoma
► Lymphoma
Multiple myeloma = Commonest cause in men over 45
Symtoms
 Fever
 Loss of weight, loss of appetite
 Symptoms of anaemia
o Lethargy
o Shortness of breath
o Palpitations
o Pallor
Investigations







Plain X-Rays
Radionuclide scans
CT
MRI
Blood tests
Biopsy
Others - Mammography
Osteochondroma (exostosis)
- Thyroid scan
- Gallium scan – lymphoma
- MRI brain – neurological deficits
• Full Blood Count
Hb : to exclude anemia
WBC : to exclude infection
ESR, CRP : markers of inflammation  ESR, or C-reactive
protein to help distinguish between neoplastic and infectious
processes.
• Liver Function Tests
ALP : measure level of bone activity  Elevations in serum
calcium or alkaline phosphatase also can provide evidence for
neoplastic bone processes.
LDH : elevated in certain bone tumors (e.g. Ewing’s Sarcoma)
•
Others
37
Serum Calcium Level (note hypercalcemia)
Serum Albumin
Serum Phosphate
PTH
• “Secondaries”
Thyroid : TSH, T3, T4
Tumor Markers (e.g.PSA )
Serum Protein Electrophoresis (MM)  Specific studies such as
serum electrophoresis or urine electrophoresis also can be
performed to evaluate the likelihood of multiple myeloma or
plasmacytoma.
Urine Bence Jones protein (MM)





ESR
CRP
Myeloma panel
Tumor markers
PSA, CEA, CA19-9
• Albumin Correction for serum Ca2+
Only unbound Ca2+ biologically active
serum level must be adjusted for abnormal albumin levels
For every 1-g/dL drop in serum albumin below 4 g/dL,
measured serum calcium decreases by 0.8 mg/dL
Without this correction, an abnormally high serum calcium level
may appear to be normal.
Alternatively, serum free (ionized) calcium levels can be directly
measured, negating the need for correction for albumin.
Beware ‘cold’ scans for Bone scans – myeloma, Renal cell carcinoma
mets
 Not specific
 false positives in trauma, infection – requires
radiographic confirmation
Blood tests




Full blood count
Urea and electrolytes
Calcium, phosphate, SAP
Liver function tests
38
Diaphyseal intramedullary lesions:
Favored location for Ewing's sarcoma, lymphoma,
myeloma. Common for fibrous dysplasia and
enchondroma
Diaphyseal lesions centered in the cortex:
Adamantinoma, osteoid osteoma
Metaphyseal lesions centered in the cortex:
Classic location for a non-ossifying fibroma (NOF).
Also, a common site for osteoid osteoma.
Metaphyseal intramedullary lesions:
Osteosarcoma is usually centered in the metaphysis.
Chondrosarcoma and fibrosarcoma often present as
metaphyseal lesions. Osteoblastoma, enchondroma,
fibrous dysplasia, simple bone cyst, and aneurysmal
bone cyst are common in this location.
Metaphyseal exostosis:
Osteochondroma
Epiphyseal lesions:
Chondroblastoma (Ch) and Giant Cell Tumor (GCT)
are almost invariably centered in the epiphysis.
Chondroblastoma is a rare tumor seen in children and
adolescents with open growth plates. GCT is the most
common tumor of epiphyses in skeletally mature
individuals with closed growth plates. GCT often shows
metaphyseal extension.
•
•
•
•
•
Overall, the most common locations of skeletal metastasis are
spine, ribs, pelvis, skull and proximal femur.
Secondaries to hands and feet are uncommon and most often
from lung primary.
Spinal metastases – most commonly the anterior and middle
columns.
Pelvis & femur metastases – 50% femoral neck, 20%
intertrochanteric, 30% subtrochanteric.
Upper limb metastases – rare, only 10% – 15% of bony
secondaries; humerus accounts for most.
METHODS OF TREATMENT




Tumour excision
Multi-agent chemotherapy
Radiotherapy
Symptomatic
Chemotherapy





Reduce size of primary lesion, prevent metastatic seeding.
Drugs: Methotrexate, cyclophosphamide, vincristin, cisplatin.
Treatment starts 8-12 weeks pre-op.
Examine resected tumour to assess effect.
6-12 months maintenance chemotherapy.
Radiotherapy
Secondary bone tumours:
- In children, the culprits are neuroblastoma, rhabdomyosarcoma
and retinoblastoma.
•
•
The skeleton is the 3rd most common site of metastatic disease.
Only the lungs and liver have a higher incidence of metastasis
than the skeleton.
 Radio-sensitive tumours (eg: Ewing’s sarcoma), tumours in
inaccessible sites, inoperable lesions, metastatic deposits,
marrrow-cell tumours.
 Radiotherapy + adjuvant chemotherapy
 Given in divided doses over 4 weeks
 Multiple myelomas are generally sensitive to radiation and
chemotherapies.
39
Bisphosphonates  inhibits osteoclastic bone resorption and are
effective in tx of hyperCa due to conditions causing increased bone
resorption and malignancy-related hyperCa.
Mithramycin  blocks osteoclastic function and used for severe
malignancy-related hyperCa. Has significant hepatic, renal and marrow
toxicity.
40
15) Ankylosing Spondylitis


Chronic inflammatory arthritis
Predilection for sacroiliac jts & spine – progressive stiffening & fusion of axial skeleton
Synovial fluid
complement levels
X-ray
Epidemiology




15-25 YO
Male : Female = 4:1
HLA-B27
First degree relatives at risk of psoriatic arthritis, IBD & Reiter’s syndrome
Characteristic syndesmophyte (new bone) formation at junction of IV disc & vertebral bodies
Enthesopathy (disorder of muscular or tendinous attachment to bone)
Peripheral joint – similar changes as in RA
Symptoms
Bone scan








Eye
Insidious onset
Recurrent LBP & stiffness radiating to buttock or thighs
Symptoms worse in mornings & after inactivity
Loss of spine extension
Costovertebral joint involvement: chest pain on breathing
Plantar fasciitis, Achilles tendonitis
Tenderness over bony prominences (iliac crest, ischial tuberosity, greater trochanter)
Extra-articular manifestations
Acute anterior uveitis
2C
Cauda equine synd
Iritis
Cardiac conduction defects
Spinal cord Myelopathy due to atlantoaxial subluxation
6A
Ant uveitis
Cauda euina syndrome
Atlantoaxial subluxation
Heart
Aortic regurgitation
Aortic regurg
Cardiac conduction defects
Apical lung fibrosis
Lung
Apical pulmonary fibrosis
Amyloidosis
Systemic
Amyloidosis
Archilles tendonitis
osteoporosis

May present as peripheral arthropathy or pauciarticular juvenile idiopathic arthritis
Signs






decreased lumbar lordosis
Kyphosis
Restricted lumbar spine movt in all planes
Restricted chest expansion - <5cm at 4th intercostal space
Spinal fusion
Extra-articular manifestations – Iritis, uveitis, myelopathy, AR, arrhythmia, pul fibrosis
Invx
ESR
Rh factor
FBC
ECG

Neg
Normochromic anaemia
Conduction defects






Squaring of vertebrae
Vertebral fusion
Bamboo spine – due to syndesmophyte formation
Erosion & sclerosis at anterior corners of vert
Facet jt fusion
Atlantoaxial dislocation


SI jt – fuzziness, irregularity, erosion, marginal sclerosis, fusion
Erosive arthritic feactures in symphysis pubis, ischial tuberosities &
peripheral joints
Whiskering – calcification of tendons attached to ischial tuberosity
Osteoporosis / OA changes ( jt space, sclerosis, ossified bone cysts)


Pathology



Not depressed, decreased viscosity, leukocytosis

Apical lung fibrosis

Costovertebral jt involvement
Sacroilitis & spinal involvement
Grades of Sacroilitis
I
II
III
IV
Widening of joint
Joint erosioni
Sclerosis on both sides
Ankylosis
Rome criteria
NY criteria
Bilat Sacroilitis > grade I or unilat Sacroilitis >
grade 2 + any of the following:

LBP of inflammatory nature

 lumbar spine movt in sagittal & frontal
planes

 chest expansion
Bilateral sacrolitis > grade I + any of the
following:

LBP + stiffness > 3 mths not relieved by
rest

Thoracic pain or stiffness

 lumbar spine ROM

 chest expansion

Hx of uveitis
Management
Aims:

Relieve pain & stiffness

Maximise skeletal mobility

Avoid development of deformities
NSAIDs (usu indomethacin)
Sulphasalazine
Radiotherapy
Local corticosteroid injection
Systemic steroids
Hip stiffness
Spine flexion deformity
Others
Pain relief (ask abt renal function, hx of GI bld, coagulant Rx)
For persistent peripheral arthritis. Not useful for axial disease
If drug therapy is ineffective
For plantar fasciitis & enthesopathy
For acute iritis
Total hip replacement
Vertebral osteotomy
Exercise, ensure good posture
41
K&L’s Ortho – Last updated March 2005
16) PAEDS ORTHO
CONGENITAL TALIPES EQUINOVARUS
•
•
•
The foot is in pointing downwards (equinus)
Hind foot is in tilted inward (varus)
Mid, fore foot adducted and supinated
Causes
• Genetic defects
• External influences during pregnancy
• May be associated with other birth defects (spina bifida)
Conservative treatment
–
–
Begins early
Repeated manipulation and adhesive strapping or
application of plaster of Paris casts
Operative treatments
•
•
•
•
•
•
– Indicated when cases are resistant
Complete release of joint tethers
Lengthening of tendons
Foot is immobilized in the corrected position
Kirshner wires can be inserted across the intertarsal and ankle
joints
Cast and wires are removed after 6-8 weeks
Baby will then be put in Dennis Browne boots (hobble boots)
FLAT FOOT (PES PLANUS)
- absence of longitudinal arch
Classification – Flexible: -ligament (ligamentous laxity)
- Muscle
- Bone
- Rigid: - Congenital
- acquired
Complications
 Lower leg pain or weakness
 Pain or swelling on the inside of your ankle
 Foot pain





Plantar fasciitis
Achilles tendonitis and posterior tibial tendinitis
Stress fractures in your lower leg
Hallux valgus
Calluses
Conservative treatment
 Orthotic devices
 Cast/ Brace
 Corticosteroid injection
Surgical treatment
 Arthrodesis
 Osteotomy
 Excision
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)
- Displacement of femoral head from acetabulum posteriorly and
superiorly.
•
•
Left hip > Right hip
F:M = 7:1
42
Pathophysiology
Investigations
• X ray
• Ultrasound – Dynamic Sonography
•
•
•
Treatment
Shallow acetabulum
Capsular laxity
Femoral head slides out posteriorly and proximally
•
Clinical presentation
•
•
Early (postnatal screening)
Ortolani’s test- Flex infant’s hip and knee to 90°
- Abduct thigh
- Palpable and audible ‘click’ as hip reduces
•
Barlow’s test- Flex hip
- Adduct thigh while pushing posteriorly in line of
the femur shaft
- Dislocation is palpable as femoral head slips out
of acetablum
•
Late
- clinical symptoms
- x-rays
Clinical symtoms
• Limited abduction
• Hip externally rotated
• Thigh is shortened
• Asymmetry of skin folds
• Glaze's sign
• Telescoping of femur
• Trendelenburg’s gait
• Hyper-lordotic lumbar spine
Depends on:
 Age of child
 Severity of DDH
Under 6 mths
• Double napkin
• Abduction pillow
• Abduction split
 Von Rosen’s splint
 Pavlik harness
6mths to 6 years
• Closed reduction by Gallow traction
• Splintage using plaster spica
•
•
Open reduction
Corrective osteotomy of femur or pelvis
Over 6 years
• Open reduction
• Corrective osteotomy of femur or pelvis
SLIPPED UPPER FEMORAL EPIPHYSIS
 Displacement of the proximal femoral epiphysis
(Epiphysiolysis)
 An insufficiency fracture through the hypertrophic zone of the
cartilaginous growth plate (the weakest point)
43
 Occurs in very tall or fat children with delayed gonadal growth.
 Slippage occurs through the growth plate.
 The femoral epiphysis remains in the acetabulum, while the
metaphysis move in an anterior direction.
 The term slipped capital femoral epiphysis is a misnomer
because the epiphysis is held in the acetabulum by the
ligamentum teres; thus, the metaphysis actually moves
proximally and anteriorly while the epiphysis remains in the
acetabulum.
 Limb shortening by 1 to 2 cm (supratrochanteric)
 Irritable hip and pain during all movements, Antalgic gait
Classifications
Treatment – Conservative
- Surgical : - insitu Knowles pins
- Osteotomy
Determine whether the SCFE is acute, chronic, or acute on chronic.
- Prodromal symptoms (eg, hip or knee pain, limp, decreased range
of motion) for less than 3 weeks are deemed acute.
- Prodromal symptoms for more than 3 weeks are deemed chronic.
- If a patient reports symptoms of greater than 3 weeks' duration but
presents with an acute exacerbation of pain, limp, inability to bear
weight, or decreased range of motion with or without an associated
traumatic episode, the SCFE is categorized as acute on chronic.
Determine whether the SCFE stable or unstable.
- Stable patients are able to bear weight on the affected limb with or
without crutches or assistive devices. Unstable patients are not able
to bear weight because of pain.
Xray – trethowan sign
Complicatons – Secondary OA
- Slip on the other side
- AVN
- Coxa vara
FRACTURES IN CHILDREN
•
•
Most common fracture in children is at the distal radius and
physis.
Zone of hypertrophy, where most germination occurs is the
most vunerable.
•
Posterior fat pad sign is the MOST reliable
Determine the radiographic classification.
- This is determined by the percentage of displacement of the hip in
relation to the neck. Type I is less than 33% displacement, type II is
33-50% displacement, and type III is greater than 50%
displacement.
Signs
 External rotation of the hip with limitation of abduction &
Internal rotation
44
Complications
•
•
•
•
•
•
•
•
•
Supracondylar fractures
•
•
•
3rd most common fracture in children and most common elbow
fracture
Peak age is 4-7years
Falling on a hyperextended hand
Classification
Type I
Type II
Type III
Implications
Undisplaced, periosteum
intact with significant
inherent stability of the
fracture
Displaced, with an intact
posterior cortex
Management
Simple immobilization with a
cast applied at 90o elbow
flexion
M&R (‘K’ wires) followed by
(i) Immobilization with a
cast applied at 90o
elbow flexion
(ii) Insertion of 2 lateral
pins
Periosteum completely torn, M&R followed by insertion of
no cortical contact
2 crossed pins
Brachial Artery Injury
Neurological Deficit
Compartment Syndrome
Cubitus varus deformity
Compartment Syndrome
Elbow Stiffness
Myositis Ossificans
Non-union
AVN of the trochlear
Green stick fracture
GENU VARUS
Causes
• Blount Disease (Bowing only)- Impaired growth of the
medial part of the proximal tibial epiphysis and physis
• Rickets- Disease effecting from a deranged Vitamin D
metabolism resulting in incomplete mineralization of
bone
• Skeletal/ Fibrocartilaginous Dysplasia
• Post-traumatic
45
Impt Hip & Lower Limb #s and Ds
(plus impt tendon ruptures)
Type
Treatment
Remarks & specific
Cxs
Acetabulum, #
o minimal displc/ highly frag 
Traction, Hamilton-Russell
o main part intact, fem head displc 
ORIF w cancellous screws & plates
Cxs
o Hemorrhage > 5L
o Ruptured urethra,
bladder
o Bowel injury
o Muscle relaxant + Reduce, flex knee,
hip 900, correct add & int rot, lift fem
head into acetabulum
o OR if irreducible
o ORIF if a/w #s elsewhere
Cxs
o Irreducible due to
in-turned labrum
or bony frags in
acetabulum
o # (fem head, NOF,
patellar, fem shaft)
o Sciatic nerve palsy
o AVN due to
tearing of capsule
o 20 OA
o Recurrent D
o Myositis Ossifcans
(post exploration
or D a/w head
injury)
Hip, post. D
-- Hip is flexed,
add & int rot
Hip, ant. D
-- Hip is abd, ext
rot
o Muscle relaxant + Reduce, flex knee,
hip 900, correct abd & ext rot, push
down, convert to post. D, lift fem
head into acetabulum
Fem epiphysis,
slipped
-- fem shaft
move up & ext
rot on epiphysis
o IF w screws + Manipulate if slip >
30% + epiphyseal closure
o Subtroch Osteotomy if epiphysis
closed (chronic)
o AVN
o Involvement of
Other Hip
Neck of Fem (intracap)
#
-- shortened, ext rot
-- 1. subcapital, 2.
transcervical
-- osteoporosis impt
factor
Garden Classification
o Typ 1: incomplete #,
trabeculae angulated
o Typ 2: complete #,
trabeculae disrupted
but NOT angulated
o Typ 3: complete #, fem
head rotated,
trabeculae disturbed,
displc
o Typ 4: complete #,
totally displc
Neck of fem, basal
(extracap) #
-- shortened, ext rot
Intertroch #
-- shortened, ext rot
Types:
1) # line thru mass of
Great Troch,
2) (1) + separation of
Less Troch,
3) separation of Great
& Less Troch,
4) 4. w a spiral # down
prox fem shaft
o Undisplc --> CRIF
o Displc --> Arthroplasty
o unfit for multiple Sx or
badly displc, typ 4, avn
& non-union likely -->
Hemiarthroplasty/
Total hip replacement
w/o tryring CRIF
o Displc/ Undisplc -->
ORIF w DHS or
Gamma Nail, fixation
not removed unless pat
< 45 y.o or pain
o Stable, little frag 
DHS w long plate
o Unstable  DHS w
long plate or Gamma
Nail, then non-weight
bear crutches after 48
hrs to 16 weeks
o Alt -->Traction +/Thomas’s splint
Tx principles
o Young (< 50 y.o.) 
CRIF
o Elderly -->
arthroplasty
Cxs
o AVN  disruption
of arterial ring @ base
of neck
o Non-union  typ 3
& 4, bone graft
(young), arthroplasty
(elderly)
Cxs
o AVN & non-union
NOT common
Cxs
o Failure of fixation
(cutting out of
fixation device) 
coxa vara*
*if early, bedrest &
skeletal traction
46
Fem shaft #
o Traction to overcome pull of
-- leg is
quads & hams
shortened, ext o Intramed Nail
rot, abd 
o Alt --> Traction, EF (Ilizarov),
due to pull of
Plating
quds & hams
o Fem & Tib #  Cx rate high,
early mobilisation by
Intramed Nail
o Metastatic #  Intramed Nail
+ packed cement to relieve
pain & give support
o Fem shaft # w nerve palsy 
exploration w repair + IF
o Fem neck & prox shaft #
DHS + long Plate
o Fem shaft & patellar #  close
nailing for both, mobilise
knee early
o Open # deribement + IF
o Open #, IIIB,C conservative
or EF
Fem Supra,
Uni, T & Y
condylar #
o Child supracondylar 
plaster
o Others  IF for good
reduction & permit early
mobilisation
o If displc, grossly comminuted
 conservative w traction
Patellar D
Patellar #
Cxs
o Hypovolemic
shock
o Fat embolism
o Delayed Union,
Non-union 
esp.
conservative
o Mal-union
lat.
Angulation 
Tx = osteotomy
o Limb
Shortening
o Knee stiffness
 due to quads
tethering, knee
jt invovlement
or prolonged
immobilisation
o Infection
o CR, plaster backslab x 3/52, knee
exercise
o
o
o
Tibial
tubercle,
avulsion
o
o
Quads
tendon,
rupture
o
Patellar
ligament,
rupture
o
Remarks
vertical # --> cylinder cast 6/52 w Injuries to
crutches during first 2/52, physio patellar &
extensor
after cast removal
apparatus of
horizontal, undisplc # --> as of
knee
above
(patellar #,
horizontal, displc # --> 1. sight
rupture of quads
communition: ORIF, 2. limited
tendon, rupture
damage to patellar: partial
of patellar
patellectomy, 3. major damage:
ligament,
patellectomy, repair quads
avulsion of tibial
insertion & lateral expansions
tubercle) due to:
1) direct force on
CRIF (w screw)
knee
ORIF (risk of premature
2) violent
epiphyseal fusion in child)
contraction of
Tendon reattachment, plaster
quads
cast, quads exercises at 2nd week,
weight bear at 4th week, felxion
Every knee
at 6th week
injury, exclude:
As of above
o damage to
extensor
apparatus
o lateral D of
patellar w
spontaneous
reduction
o torn ligaments
o torn mensici
47
Tibial
plateau, #
o all involve
articular
surface
o key is to get
knee f(x) vs
pretty x-ray
o knee
exercises
ASAP
o “bumper #”
o commonly
lat. tibial
condyle
Tibia &
Fibula, #
o Usu. # both,
esp. adult
o commonly
open
o usu. spiral #
o minimally displc --> aspirate
hemarthrosis, compression
bandage, CPM & active
exercise, weight bear after 6/52
o comminuted--> aspirate,
compression bandage, sk
traction, CPM & exercise
crutches after 6/52
o depressed # --> CR or ORIF,
active exercises ASAP, castbrace after 2/52
o closed, minimally displc --> full
cast x 12/52 (upper thigh to MT
necks, knee slight flexion, ankle
at 900), exercise foot, ankle, knee
ASAP
o closed, displc --> MUA (IF
when CR fails), full cast x 12/52,
exercise ASAP
o comminuted --> EF x 6/52 +
partial weight-bear, then f(x)al
brace
o open --> Ab ASAP, debride,
clean, leave open (above grd II),
EF to stabilise, WI, suture or
graft when granulate
Cxs
o Compartment
syndrome
o Valgus
deformity
o Joint stiffness
Cxs
o Infection
o Vascular
injury (prox #
damage pop
artery)
o Compartment
Syndrome
o Delayed,
Non-union -->
Intramed Nail
+ bone graft
indicated
o Malunion -->
angulated -->
osteotomy
Ankle, ligament
injury
o partial/ complete
tear of lateral
ligament
o bruising,
swelling,
tenderness
o painful passive
inversion
o complete tear -->
excessive
movement
Ankle #
o normally talus
seated in mortise
o one or both mall
can be #
o eversion + ext rot
= oblique # of lat
mall (pushed
off), transverse #
of med mall
(pulled off); viceversa for
inversion
o partial --> crepe bandage,
activity ASAP
o complete --> plaster
immobilisation or
operative repair
o 1 mall # --> reduce, cast x
6/52 (below knee), IF with
screw if frag large
o 2 mall #, below tibiofibular
jt --> CR, +/- IF ,cast
o 2 mall #, above tibiofibular
jt --> unstable, IF with
screw for frag & plate for
fibula, +/- transverse
screws between tibia &
fibula
Cxs
o Adhesions
o Recurrent
subluxation
Tx principles
o reduce to
restore shape of
mortise
o plaster x 8/52
Cxs
o Joint stiffness
o OA (not
common)
48
Distal tibial &
fibular epiphyses,
#-separation
o physeal injury
Calcaneum #
o fall from height
o calcaneum driven
up against talus
o flattened Bohler’s
angle
o check hip, pelvis,
spine for #
o extra-art -->
involve posterior
part, calcaneal
processes
o intra-art -->
oblique # line, run
to superior
articular surface
o Salter-Harris 1,2 --> MUA, full cast
x 3/52, below knee cast x next 3/52
o Salter-Harris 3,4 (undisplc) --> as
above, re x-ray 5d after to ensure
good reduction
o Salter-Harris 3,4 (displc) --> ORIF,
below knee cast x 6/52
o undisplc --> exercise ASAP,
bandage after swell subside, nwb
crutches x 6/52
o displc, avulsed tuberosity --> CRIF,
immobilise in equinus (relieve
tension of tendon Ach), wb after
6/52
o displc, intra-art --> ORIF + bone
grafts, splint & elevate, exercises
ASAP, nwb crutches after 3/52, wb
after 12/52
Cxs
o Mal-union
(valgus)
o Asymmetric
al growth (#
thru
epiphysis
may cause
fusion of
physis)
o Shortening
of leg
Tx principles
o elevate leg +
ice packs -->
decrease
swelling
o x-rays, CT
scans (better
views)
Cxs
o Broadening
of foot
o Talocalcanea
l stiffness -->
subtalar
arthrodesis
or triple
arthrodesis
# = fracture
D = dislocation
art = articular
mall = malleolus
fem = femoral
pop = popliteal
displc = displaced
undisplc = undisplaced
add = adducted
abd = abducted
int rot = internal rotation
ext rot = external rotation
lat = lateral
med = medial
prox = proximal
MUA = Manipulation Under Anaesthesia
ORIF = Open Reduction, Internal Fixation
OR = Open Reduction
CRIF = Closed Reduction, Internal Fixation
IF = Internal Fixation
EF = External Fixation
wb = weight bearing
nwb = non-weight bearing
f(x)al = functional
Alt = alternative
esp. = especially
impt = important
grd = grade
Cxs = complications
ASAP = As Soon As Possible
Ab = antibiotics
OA = Osteoarthritis
AVN = AVascular Necrosis
General Mx of #
Prelim skin traction  relieve pain, minimize further displc
Analgesics
IV fluids, packed cells, whole blood  if hypovolemic
For displc/ undisplc, compare continuity of trabeculae lines
Traction: things to note
Traction can be skin or skeletal
Skeletal traction can be with Thomas’s splint or pulley frame or both
Traction care
Ring pressure (Thomas’s splint)
Pressure sores: Buttocks, Tendo Achilles, under heel
Common peroneal palsy  weakness of dorsi flexion
Loosening of Steinmann pin
49
Upper limb fractures dislocations by Lee
Yizhi
Fracture
Clavicle
Method
Sling 3/52
Supracondylar
Remarks
Malunion in adults
Excellent remodeling in
children
GENTLE physio
Physio
Scapula body:
Scapula neck:
AC subluxatn:
AC dislocatn:
Sternoclavicular
dislocatn
Anterior dislocatn:
Sling & physio
ORIF if # dislocatn
Sling ~1/52 & physio
young and active :
Arthrodesis, 3/52 rest,
physio
Inactive: Sling & physio
Late OA: excision outer
1/3 clavicle
Anterior: conservative
Posterior: ORIF
Reduction under GA
Hippocrates/Kocher’s
Sling 3/52
Posterior dislocatn:
Physio
# prox humerus: ORIF
Recurrent: Surgery
GA Reductn
Associated with 1)rib #
2)lung contusion
3)hemo/pneumothorax
Body # by crushing force
Partial dislocatn: AC
ligaments torn
Complete dislocation: CC
ligaments torn (conoid &
trapezoid)
Tenting of skin may
cause necrosis
Post dislocatn: Tracheal
and vascular compressn
X-ray to exclude #
Axillary n often damaged
95% of shoulder
dislocatns
Prox humerus:
Neers 1: Sling 6/52
Neers 2: Collar cuff 6/52
Neers 3: ORIF/HemiA
Neers 4: HemiA
All followed by physio
Shaft of humerus
Lateral condyle
Undisplaced: C&C 3/52
Displaced: ORIF (Kwire)
Proximal radius in
adults:
Mason 1: C&C 3/52,
gentle physio
Mason 2: ORIF plate &
screw
Mason 3: Excision in
48hrs
Mason 3 with Essex L:
Prosthesis, splint 2/52,
physio
<20o: C&C 2/52
>20o: MUA, if fail OR. If
unstable, IF (K-wire)
Stable & undisplaced
(<2mm + no change in
flexion + extend against
grav): C&C 3/52
Displaced: tension band
wiring
Displaced +
comminuted: plate &
screw
MUA (tractn, flexion,
push olecranon) then
C&C 3/52 or above
elbow backslab
In children:
Olecranon
Commonly missed!
4% of shoulder dislocatns
Elbow dislocation
Usually seen in
osteoporotic pple >50yrs
Try to conserve head in
young pts even with
Neers 3/4
Suspect mets in elderly!
Radial head
dislocation
Same as ant dislocatn
If very unstable,
plate/nail
Closed reductn ASAP
C&C 3/52 then sling 3/52
ORIF (dbl plating) in
adult for early f(x)
U-slab 3-6/52 + sling
Pulled elbow
trauma: MUA
(supination, direct
pressure), cast 6/52
Sling 3/7 or
Cx: Shortening, angular
deformity (gunstock),
decreased ROM
Acute: Brachial A inj,
compartment sx,
volkmann’s ischaemia
Myositis ossificans
Cubitus valgus, tardy
ulnar palsy: corrective
osteotomy
Posterolateral most
common
Cx= brachial A, median
(AIN)/ulnar, stiffness,
myositis ossificans,
associated #s
Monteggia #, PI Nerve inj
50
Pain, lateral tenderness,
Supinate + flex elbow
Radius and ulnar in
adults:
in
children:
Single forearm bone
Monteggia’s:
Galeazzi’s:
Both in children:
Colles’
Smith’s (reverse
Colles’)
Barton’s
Radial styloid/
Chauffeur’s
Undisplaced
scaphoid
Displaced scaphoid
Trans-scaphoid
perilunate dislocation
Peri-lunate
dislocation
ORIF
(plates/screws/rods)
Long arm cast 6/52,
check x-ray at 2/52
ORIF or long arm cast
12/52
ORIF (ulnar plating,
reduce radial head), long
arm cast 90o flexion,
partial supinatn
ORIF (radial plating,
reduce ulnar head), long
arm cast in supination 68/52
Reduction under GA,
immobilisatn 6/52
Undisplaced: Splintage
in plaster slab
Displaced: MUA (Bier’s/
hematoma block), below
elbow backslab 6/52 in
neutral or slight flexion,
xray @ 2/52
As for Colles’ but with
wrist extension
ORIF with buttress plate
Percut K-wire/ lag screw
Below elbow cast
(exclude PIPJ) 10/52
ORIF, cast 3/52
refusal to move arm
9m-6yrs
No X-ray findings
Radial head slips out of
annular lig
Compartment sx, PIN/
AIN inj, delayed/non/malunion, PIN
Non-union!
Cross-union
Radial/ PIN palsy (Mont),
ECU & EDM inj (Gal)
myositis Ossificans, nonunion, missed dislocation
Metacarpal
Bennet’s (intra-art #
dislocation @ base of
CMCJ of thumb)
Phalangeal
Mallet finger
EPL rupture, malunion,
median n compression,
Sudeck’s atrophy, DRUJ
subluxatn, hand shoulder
stiffness
Game-keeper’s
thumb
of scaphoid # if present,
CTR and ligamental +
capsular repair
Undisplaced: Crepe
bandage 3/52 and finger
exercises
Displaced: Closed
reduction, plaster slab
3/52, finger exercises
Displaced + unstable:
ORIF with K-wire
CRIF with precut kwires
Undisplaced: buddy
splintage 3/52
Displaced: MUA,
plasterslab 3/52 or IF
with Kwires
Splinting in extension
6/52
Partial tear: short arm
cast w thumb spica
Gross instability:
ligamental repair
Rotational malunion,
stiffness
Treat open wounds first!!
A/w lunate dislocatn
AVN, non-union,
scaphoid collapse, OA
Chronic carpal instability
Closed reduction, cast
6/52
If irreducible, OR with IF
Median n compression
Lunate AVN leading to
OA
51