ortho

ORTHOPEDICS Dr. C. Hutchison Kurt Droll and Christopher Gallimore, editors Markku arkku Nousiaine Nousiaine n, associate e d itor AN APPROACH TO ORTHOPEDICS History Physical Examination Investigations

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FEMUR Femoral Diaphysis Fracture Fracture s Supracond ylar Fem Fem oral Fracture Fracture .

SHOULDER General Principles Physical Physical Examination Examination o f the Shoulde r Acromioclavicular Joint Joint Spra in Clavicular Clavicular Fracture Ante rior rior Should er Dislocation Dislocation Poste rior Shoulde r Dislocation Dislocation Rotato r Cuff Cuff Le Le sions Impingeme nt Syndrome Syndrome Frozen Frozen Shoulde r .

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HUMERUS Humeral Shaft Fracture Proximal Humeral Fracture .

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ELBOW Supracond ylar Fracture Fracture Rad ial Head Fracture Fracture Olecranon Fracture Fracture Elbow Dislocation .

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FOREARM FRACTURES General Principles Nightstick Fracture Galeazzi Fracture Comp li lications cations o f Forearm Forearm Fractures Fractures WRIST Scaphoid Fracture Fracture Colle Colle s’ Fracture Smith’s Smith’s Fracture Barton’s Fracture SPINE Differe Differe ntial Diagno sis o f Back Back Pain Dege ne rative Back Back Pain Cauda Equina Syndrome Trauma Thoracic and Lumb ar Spine HIP Differential Diagnosis of Hip Pain Pelvic Fractures Hip Dislocation Dislocation Hip Fracture Arthritis o f the Hip AVN of the Fem oral He ad .

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PATELLA Patella Dislocation Dislocation Chond romalacia romalacia Pate llae Patellar Fracture .

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TIBIA Tibial Plateau Fracture Tibial Diaphysis Fracture .

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MCCQE 2000 Re vie w No t e s a n d Le ctu re Se rie s

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ANKLE Evalution of Ankle Complaints Ankle Fractures Ligament ous Injuries Re curren curren t Ankle Subluxation .

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KNEE Common Knee Symptom Symptom s Evaluation Evaluation o f Kne e Comp laints Ligament ous Injuries Injuries o f the Kne e Anterior Cruciate Ligament Tear Poste rior rior Cruciate Cruciate Ligament Tea r Me dial Collate Collate ral Lig Ligame ame nt Te ar Lateral Collateral Ligament Tear Meniscal Tear Patella/Quadriceps Tendon Rupture Dislocated Knee .

FRACTURES - GENERAL PRINCIPLES Rad iograp iograp hic Description o f Fractures Fractures Cli linical nical Featu res of Fractures Fractures Initial Manage Manage me nt Definitive Management Open Fractur Fractures es Fracture Fracture Healing Comp li lications cations of Fractures Fractures Compartme nt Syndrome Syndrome Avascular Necrosis

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FOOT Talar Fracture Calcaneal Fracture Achilles Tendonitis Achilles chilles Ten do n Rup ture Plantar Fasciitis Bunions Me tatarsal Fracture Fracture ORTHOPEDIC ORTHOPED IC INFECTIONS INFECTIONS Osteomyelitis Joint Infection s .

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PEDIATRIC ORTHOPEDICS Fracture Fracture s in Childre Childre n Evaluation of the Limping Child Epiph yseal Injury Injury Pulled Pul led Elbow Elbow Developme ntal Dysplasia Dysplasia of the Hip Hip Le gg-C gg-Calve-Perthe alve-Perthe s Dise ase Sl Slippe ippe d Capital Femoral Epiphysis Congenital Talipes Equinovarus (CTEV) Scoliosis BONE TUMOURS Benign Bone Tumours Benign Aggressive Bone Tumours Malignant Bone Tumours .

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Orth o p e d ics 1

AN APPROACH TO ORTHOPEDICS

Notes

HISTORY Identification t identifying data • name, age, occupati occupation, on, hobbies, hand d ominance ominance t chief complaint t past orthopedic history • injuri injuries, es, p ast non-surgic non-surgical al trea trea tmen t, past surgery ical history history t othe r med ical • pa st surgery, surgery, allergi allergies, es, me dications, med ical ical ill illnes nes ses History of Present Illness important to ob tain de tails regarding regarding onset and progression of symptoms pain, weakness, deformity, stiffness, crepitus • OPQRST OPQRST (Onse t, Provoking / Alleviating lleviat ing facto facto rs, Quality, Radiation, Site, Timing) • muscular, bo ny, or joint joint pa in ? • numb er of joints joints involved involved a nd symme try of involv involvem em ent t inflammatory symptoms • morning stiff stiffne ss (> 30 min), te nd erne ss, swe swe lling, lling, red ne ss, warmth warmth t mechanical/degenerative symptoms • worse at e nd o f day, bette r with with rest / worse worse with with use • locking, giving way, way, inst ab ility infectious symptoms t neo plastic and infectious • p ain which which is is constant , occurs at night • fe ver, night sweats • anore xia, fatigue, wea wea knes s, weight weight loss Barnum Loves Kids: history of P • P.T. Barnum of P rostate, Thyroid, B reast, cancer (most common common mets to b one) Lung or Kidney cancer t activities of daily living • gett ing up , sitting sitting down, using b athroo m, comb comb ing hair, hair, transferring transferring t referred symptoms • shoulde r pain from from the he art or diap hragm hragm • arm pain pain from from the the ne ck  • cardiac, cardiac, pulmonary, pulmonary, GI GI history as ne ed ed • leg pain from back  • ba ck pain from from the kidne y, aortic aortic ane urysm, urysm, duod en al ulcer ulcer t t

P HYS HYS ICAL ICAL EXAMINATION Look, Feel, Move always examine examine the joint joint ab ove and be low t always skin, shap e, p osition osition t look - skin, Swelling, Erythema, Atrophy, D eformity, Skin changes • SEADS: Swelling, soft tissue , bo ny, ny, or articular articular abnormalities abnormalities t fee l - palp ate soft • te nde rness, palp able de formity, ormity, effusion, effusion, temp erature affecte d joint(s) joint(s) t move the aff • active active a nd p assive ROM ROM,, crep crep itus, abnormal mobility mobility • p assive ROM > active active ROM sugges ts soft tissue inflammation inflammation or muscle muscle wea kness rovascular ar tes ts t neu rovascul • pu lse, refl reflexes, exes, power, power, sensation t power: use MRC scale • 0=no movement • 1=twitch 1=twitch • 2=movem 2=movem ent with gravi gravity ty eliminate eliminate d • 3=movem 3=movem ent vs grav gravity ity • 4=mov 4=moveme eme nt vs some some resistance resistance • 5=movem 5=movem ent vs full full resistance cial tests de pe nd on joint joint t spe cial • e .g. Lachman, McM McMurray for for the knee t observe gait • walking alking,, heel-to-toe, on hee ls, on toes • Trend ele nburg gait gait in hip disorde rs • anta lgic, lgic, high ste pp ing, circumd circumd uction Ort h o p e d ics 2

MCCQE 2000 Re vie w No t e s a n d Le ctu re Se rie s

AN APPROACH TO ORTHOPEDICS

Notes

HISTORY Identification t identifying data • name, age, occupati occupation, on, hobbies, hand d ominance ominance t chief complaint t past orthopedic history • injuri injuries, es, p ast non-surgic non-surgical al trea trea tmen t, past surgery ical history history t othe r med ical • pa st surgery, surgery, allergi allergies, es, me dications, med ical ical ill illnes nes ses History of Present Illness important to ob tain de tails regarding regarding onset and progression of symptoms pain, weakness, deformity, stiffness, crepitus • OPQRST OPQRST (Onse t, Provoking / Alleviating lleviat ing facto facto rs, Quality, Radiation, Site, Timing) • muscular, bo ny, or joint joint pa in ? • numb er of joints joints involved involved a nd symme try of involv involvem em ent t inflammatory symptoms • morning stiff stiffne ss (> 30 min), te nd erne ss, swe swe lling, lling, red ne ss, warmth warmth t mechanical/degenerative symptoms • worse at e nd o f day, bette r with with rest / worse worse with with use • locking, giving way, way, inst ab ility infectious symptoms t neo plastic and infectious • p ain which which is is constant , occurs at night • fe ver, night sweats • anore xia, fatigue, wea wea knes s, weight weight loss Barnum Loves Kids: history of P • P.T. Barnum of P rostate, Thyroid, B reast, cancer (most common common mets to b one) Lung or Kidney cancer t activities of daily living • gett ing up , sitting sitting down, using b athroo m, comb comb ing hair, hair, transferring transferring t referred symptoms • shoulde r pain from from the he art or diap hragm hragm • arm pain pain from from the the ne ck  • cardiac, cardiac, pulmonary, pulmonary, GI GI history as ne ed ed • leg pain from back  • ba ck pain from from the kidne y, aortic aortic ane urysm, urysm, duod en al ulcer ulcer t t

P HYS HYS ICAL ICAL EXAMINATION Look, Feel, Move always examine examine the joint joint ab ove and be low t always skin, shap e, p osition osition t look - skin, Swelling, Erythema, Atrophy, D eformity, Skin changes • SEADS: Swelling, soft tissue , bo ny, ny, or articular articular abnormalities abnormalities t fee l - palp ate soft • te nde rness, palp able de formity, ormity, effusion, effusion, temp erature affecte d joint(s) joint(s) t move the aff • active active a nd p assive ROM ROM,, crep crep itus, abnormal mobility mobility • p assive ROM > active active ROM sugges ts soft tissue inflammation inflammation or muscle muscle wea kness rovascular ar tes ts t neu rovascul • pu lse, refl reflexes, exes, power, power, sensation t power: use MRC scale • 0=no movement • 1=twitch 1=twitch • 2=movem 2=movem ent with gravi gravity ty eliminate eliminate d • 3=movem 3=movem ent vs grav gravity ity • 4=mov 4=moveme eme nt vs some some resistance resistance • 5=movem 5=movem ent vs full full resistance cial tests de pe nd on joint joint t spe cial • e .g. Lachman, McM McMurray for for the knee t observe gait • walking alking,, heel-to-toe, on hee ls, on toes • Trend ele nburg gait gait in hip disorde rs • anta lgic, lgic, high ste pp ing, circumd circumd uction Ort h o p e d ics 2

MCCQE 2000 Re vie w No t e s a n d Le ctu re Se rie s

AN APPROACH TO ORTHOPEDICS

. . . CONT.

Notes

INVESTIGATIONS Diagnos Diagnos tic Imaging radiograph s (sinogr (sinograph aph y) t plain or contrast radiograph CT/mye lograp logra p hy, MRI, MRI, EMG EMG / NCS t CT/mye t 99Tc (Technetium) bone scan • refle refle cts oste ob lastic activity activity or infl inflamma amma tory reaction • po sitive with with fractures, tumours gallium scan t gallium • positive whe whe n uptake on gallium gallium is greate greate r than on 99Tc • reflects reflects hype rvascular rvascularity ity,, taken up by leukocytes leukocytes • po sitive with infe infe ction Blood Te Te s ts for Painful, Swollen Joint Joint CBC, Rhe Rhe uma toid to id Factor, ANA ANA,, ESR, ESR, C-rea C-rea ctive p rote in t CBC, • use te sts as warr warrante ante d b y history and p hysical hysical Othe r Tes Tes ts synovial fluid fluid analysis • 3 C’ C’s: Crystals Crystals,, Cytology, Cytology, Cultu Cultu res

t

FRACTURES FRAC TURES - GEN GENERAL ERAL P RIN RINC CIP IPLES LES t

mechanism: reme reme mbe r the p rocess rocess le ading to the fracture fracture • traumati traumaticc • path ologic ologic - tumour, tumour, metab olic olic bone d isease , inf infection, ection, osteopenia • stress - rep etitive mechanical mechanical loading

CLINICAL FEATURES OF FRACTURES

t t t t t

pain and tende rness rness loss of function deformity abnormal mobility and crepitus (should not be elicited) altered neurovascular status

INITIAL MANAGEMENT

t t t t t

ABCDE's li limb mb - atte nd to n eurovascular eurovascular status (above and be low) low) r/o r/o oth er fractures/i fractures/injur njuries ies (esp ecially ecially joint joint ab ove a nd be low) low) r/o open fracture take an AMPLE history - Allergies, Medications, P ast h istory, istory, Last meal, Events surrounding injury fracture ture - makes p atient more comfortable, comfortable, d ecrease s t splint frac progression of soft soft tissue injury injury,, de creas creas es blood loss • don’t don’t forg forget et ana lgesia lgesia t x-ray fracture (rule of 2's) pre- and post-reduction

RADIOGRAPHIC DESCRIPTION OF FRACTURES

t

t t t t

rule o f 2's 2's • 2 sides: bilateral bilateral • 2 views: AP and late ral • 2 joints: joints: above and b elow • 2 times: be fore and after after red red uction uction pat ient iden tific tification ation ide ntify ntify views ope n or closed closed • gas in in the s oft oft tissue indicates an op en fracture fracture or soft soft tissue infe infe ction such as ne crotizing crotizing fascitis fascitis site • which hich bon e • de cribe cribe b y thirds: thirds: proximal/ proximal/midd midd le/distal • extra-ar extra-artic ticular ular:: diaphysis/ metap hysis • intra-articular intra-articular

MCCQE 2000 Re vie w No t e s a n d Le ct u re Se rie s

Ort h o p e d ics 3

FRACTURES FRAC TURES - GEN GENERAL ERAL P RIN RINC CIP LES t

. . . CONT.

Notes

type • • • • •

sp iral - rotat rotat ional force, force, low e ne rgy oblique - angular angular and rotational forc forcee transverse - direct forc force, e, high energy comminuted (> 2 pieces) - direct direct forc force, e, high high ene rgy rgy note : in in d istingui istinguishing shing oblique from spiral frac fractures, tures, if  fracture line greater than 2x bone width ––> spiral fracture t soft tissue • calcif calcification, ication, gas, foreign bod ies laceme nt (po sition sition of distal frag fragme me nt with with res pe ct to p roximal) roximal) t disp laceme • app osition/translati osition/translation on - de scribe scribe s what what pe rcent rcent age of surfaces surfaces remain in contact contact • angulation angulation - de scribe scribe s which which way way the ape x is faci facing ng • rotation - distal frag fragmen men t compared to p roximal roximal frag fragmen men t • shortene shortene d - due to overlap overlap or impacti impaction on

DEFINITIVE MANAGEMENT

t

goals • reduce • stab il iliz izee • rehabilitat rehabilitatee

attempt closed reduction s u cce s s fu l

u n s u cce s s fu l

s t a b iliza t io n • cast cast • external fixation fixation • t ra ct io n

o p e n re d u ct io n s t a b iliza t io n • internal fixation fixation rehabilitate

Figure 1. Fracture Fracture Manage men t Reduction t is reduction nece ssary? • may not b e for clavi clavicl cle, e, fibula, fibula, verteb ral comp comp ression factures factures displaceme nt unaccep unaccep table t reduce when amount of displaceme rfect ap po sition sition may be accep accep tab le whil whilee imp erfect erfect t impe rfect alignment alignment is rarely rarely accepta ble t closed when possible t indications for open reduction - remember NO CAST • N - Non-union fracture • O - Ope n fracture • C - neurovascular Compromise • A - intra-Artic intra-Articular ular fractures fractures (req uire an atom ic re re d uction) Salter-Harriss III III, IV IV, V and /or sp ecial situa tions d ep e nd ing on s ite • S - Salter-Harri • T - polyTrauma Stabilization iliz izee t he fracture fracture site b ut d o not comple tely immobiliz immobilizee th e limb if pos sible t stab il t external stabilization 1. splints/tape 2. casts 3. traction 4. external fixator t internal fixation 1. percutaneous pinning 2. extramed ullary fix fixation ation (scre (scre ws, p late s, wires) wires) 3. intramedullary fixation (rods) - biomechanically advantageous Rehabilitation t to avoid joint stiffness exercises to avoid mu scle scle atrophy t isometric exercises t ROM for adjacent joints t CPM following rigid fixation of fracture allows joint motion to p reve nt s tiff tiffne ss for intra-articular intra-articular fractures fractures Ort h o p e d ics 4

MCCQE 2000 Re vie w No t e s a n d Le ctu re Se rie s

FRACTURES - GENERAL PRINCIPLES

. . . CONT.

Notes

t

aftercast/splint removed and fracture he aled ––> resistive muscle strengthening t evaluate bone healing (clinical, x-ray)

OPEN FRACTURES t t

e me rgency! fracture comm unicate s with skin su rface e xamine fracture carefully to classify

Table 1. Clas s ification of Ope n Fractu res Size

So ft Tis s u e In ju ry

An t ib io t ic s

Type 1 < 1 cm

minimal

Ance f  

Type 2 >1cm

mod erat e; no de ad soft tissue

Ancef 

Type 3 >1cm

exten sive muscle da mage; includ es gunshot wound s, major vascular injury barnyard injury

Ancef, Genta mycin, Flagyl

t

initial managemen t 1. do not red uce op en fractures unless there is neu rovascular comp romise from p osition of fracture 2. remo ve gross de b ris i.e. turf, rocks 3. all ope n fractures are contaminated , there fore obtain culture and cover wound with ste rile d ressing 4. administer tet anus vaccine /booste r (see indications be low) 5 start antib iotics 6. splint 7. NPO and prepare for OR 8. irrigation and de bridement, 9. red uction and stab ilization after I&D t must get t o OR within 6 hours, since risk of infection increase s after this time t re-examine, with possible repeat I&D in 48 hours Table 2. Indica tions for Te tan us Vacc ination Te t a n u s Hi s t o ry

Cl e a n Wo u n d

D ir t y Wo u n d

Td

TIG

Td

TIG

unknown o r <3 Td doses

Y

N

Y

Y

>3 Td doses

N*

N

N**

N

* Y if >10 years since last d ose ** Yif >5 years since last d ose Td=0.5 mL adsorbed tetanus toxoid TIG=250 units te tanus immune globu lin

Complica tions of Ope n Fractu res t osteomyelitis t soft tissue d amage t neurovascular injury t blood loss t nonunion

MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 5

FRACTURES - GENERAL PRINCIP LES

. . . CONT.

Notes

FRACTURE HEALING Normal Healing

wee ks 0-3

he matoma , macropha ges surround fracture site

wee ks 3-6

oste oclasts remove sharp ed ges, callus forms within he matoma

wee ks 6-12

bo ne forms within the callus, bridging fragment s

months 6-12

cortical gap is bridge d by bo ne

years 1-2

normal architecture is achieved through remodelling

Figure 2. Stage s o f Bone Hea ling Evaluation of Healing - Tests of Union t clinical - no longer te nd er to palp ation or angulation stre ss t x-ray - trab e culae cross fracture site , visible callus b ridging site

COMP LICATIONS OF FRACTURES Table 3. Comp lications of Fractu res Early

Late

Local

neurovascular injury infection compartment syndrome im pla nt fa ilu re fracture blisters

malunion nonunion osteonecrosis o ste omye litis heterotopic ossification pos t-traumatic arthritis reflex sympathetic dystrophy

Systemic

sepsis DVT/PE fat embolus ARDS he morrhagic shock 

COMPARTMENT SYNDROME t

in anatomical "compartments" where muscle and tissue bounded by fascia and bon e (fibro-osseous compartment ) with little room for expansion (i.e. forearm, calf) t increase d p ressure in compartmen t excee ds cap illary perfusion pre ssure (app roximately 30 mmHg) which le ads to mus cle necrosis and eve ntually nerve ne crosis Etiology t fracture, d islocation t soft tissue d amage and muscle swelling t crush injury t arterial compromise t muscle anoxia t venous obstruction t increased venous p ressure t constrictive dressing, cast, splint

Orthop e d ics 6

MCCQE 2000 Re vie w Note s and Le cture Se rie s

FRACTURES - GENERAL PRINCIPLES

. . . CONT.

Notes

Pathogenesis

Figure 3. Pathog en es is of Compartme nt Syndrome Diagnosis t classically the tibial compartme nts t also in forearm flexor compartment • may le ad to Volkmann ischemic contracture t clinical signs • pain on pas sive move men t (out of prop ortion to injury) • pain does not resp ond to normal dose of analgesics • pallor • paralysis (inab ility to move limb) • pulses are usually still prese nt • tens e, swollen skin • parasthesis t compartment pressure monitoring • in unresponsive or unreliable p atients Table 4. Signs of Compa rtme nt Syndrome in Ante rior Leg and Forearm Ante rior leg

fracture type weakness pain sensory

tibial fracture toe, foot extension toe, foot flexion 1st dorsal web space

Volar forearm

supracondylar (humerus) finger, wrist flexion finger, wrist extension volar aspect of fingers

Treatment t remove constrictive d ressings t bivalve casts down to skin and spread open t place limb at level of heart t eme rgency fasciotomy to release compartmen ts if differe nce b etwee n diastolic blood pressure and compartment p ressure is less than 30 mmHg (treat within 4-6 hours of onset symptoms)

AVASCULAR NECROSIS Caus e s t ste roid us e (inflammat ory arthritis, IBD, alle rgies , renal disease, asthma); NOT dose related t alcohol t post-traumatic fracture/dislocation t sep tic arthritis t sickle cell disease t Gauche r’s dise ase t Caisson’s d isease - d ee p sea diving/the be nds t idiopathic

MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 7

FRACTURES - GENERAL PRINCIP LES

. . . CONT.

Notes

Tab le 5. AVN Clas s ificat ion Sta g e

Clinica l Fe atu re s

X-ra y Fe ature s

1

p re clin ica l p ha se o f isch emia and ne crosis; no p ain

no p la in x-ra y a bn orm alit y; may b e d e te ctab le on MRI

2

painful

early radiographic changes i.e. fragment appears dense, normal bone contour

3

painful

radiographic changes obvious, abnormal bone contour

4

very painful

collapse of articular surface and signs of arthritis on both sides of the joint

Mechanism t occurs following disruption of blood supply to bone t occurs es pe cially in those bon es extensively covered in cartilage which rely on intra-osse ous b lood sup ply and distal to p roximal blood sup ply, i.e. head of femur, proximal pole of scaphoid, body of talus t results in ischemia t pa thologic changes include resorption, sub chondral fractures and loss of cartilage

SHOULDER GENERAL PRINCIPLES t

t t t t t

shoulde r is a comp lex 4 part joint • gleno hume ral joint • acromioclavicular joint • scapulothoracic joint • ste rnoclavicular joint examination sh ould involve each of the joints in isolation the joint is highly mobile there fore d ecrease d sta bility dislocations and subluxations following trauma are common rotator cuff and te ndo n de gene ration are more common than OA may be referred pa in from C-spine

PHYSICAL EXAMINATION OF THE SHOULDER t

LOOK - insp e ct b oth shou lde rs anteriorly and p oste riorly, clavicle, de ltoids, scapu la • look for SEADS t FEEL - for tenderness, swelling, temperature changes, muscle characteristics • sup raste rnal notch ––> ste rnoclavicular joint ––> clavicle ––> coracoid p rocess ––> acromioclavicular articulation ––> acromion ––> greater tuberosity of humerus ––> glenohumeral joint ––> bicipital groove • spine of scapu la, C-spines, axilla (R/O ad enop athy, masses ) t MOVE - Active/Passive Active ROM • forward flexion and abd uction • external rotation (elbows at side and flexed 90 de gree s, move arms away from mid line) • internal rotation (with hitchhiker thumb p lace hand s be hind small of back and mo ve up back) Passive ROM • abd uction – 180 degree s • add uction – 45 de gree s • flexion – 180 degree s • extension – 45 de gree s • internal rotation – leve l of T4 • external rotation – 40 - 45 de gree s

Orthop e d ics 8

MCCQE 2000 Re vie w Note s and Le cture Se rie s

SHOULDER . . . CONT.

Notes

X-Ray t radiograph ic views of the shoulde r should include • AP, trans-scap ular, and axillary views (at le ast) • stre ss views of the AC joint whe re indicate d t look for the Mercedes Benz sign (see Figure 4) • in the t rans-scapu lar rad iograph to look for dislocation • hume ral hea d should occupy the circle and b e overlapp ing gleno id

Figure 4. Merce de s Be nz Sign Adapted with permission from McRae, Clinical Orthopedic Examination, 3rd ed. Churchill Livingstone, New York, 1994.

ACROMIOCLAVICULAR JOINT SPRAIN t t

t

t

t t t t

AC joint is usually injured after fall onto shoulder with adducted arm 2 main ligaments which attach clavicle to scapula • acromioclavicular (AC) ligame nt • coracoclavicular (CC) ligame nt acromioclavicular sp rains • Type I: p artial injury, no insta bility, no disp laceme nt • Type II: disrupt e d AC ligame nt, intact CC ligame nt • Type III: disrupt ed AC and CC ligame nts with sup erior clavicle disp laceme nt • Type IV: clavicle d isplace s sup e riorly and p oste riorly through trape zius • Type V: clavicle disp laced infe rior to acromion or coracoid (beware plexus injury!) physical examination • palpable step be twee n distal clavicle and acromion • pain with adduction (touch opp osite shoulde r) radiograph ically app arent o n stres s view (hold weights in hand) trea t typ e I or II with ice, immob ilization, e arly ROM and stre ngthe ning treat t ype III the same or repa ir if skin compromise imminent ope rative rep air of type IV and V • excision of late ral clavicle with recons truction of CC and AC ligament

CLAVICULAR FRACTURE t t t t t

fall on shoulde r or onto outstre tched hand cosmetically po or but n ot d isabling brachial plexus and arterial injuries in 10% classified by proximal, middle (most common), or distal third of clavicle treatment of proximal and middle third clavicular fractures • closed red uction with figure -of-eight b race or sling x 1-2 we e ks • early ROM and stre ngthening t distal third clavicular fractures are unstable and may require ORIF

ANTERIOR SHOULDER DISLOCATION t t

over 90% of all shoulde r dislocations , usually traumat ic may be of two gene ral type s: • involuntary: trauma tic, unid irectional, Bankart lesion, re sp ond s to surgery • voluntary: atrauma tic, multidire ctional, b ilateral, reha b, surgery is last re sort t occurs when ab ducte d arm is externally rotated or hype rexten de d t recurrence rate d ep end s on age of first d islocation • at a ge 20: 80%; at age 21-40: 60-70%; at age 40-60: 40-60%; at age >60: <10% MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 9

Notes

SHOULDER . . . CONT. t

associated with Hill-Sachs lesion • inde ntation of hume ral hea d after impa ction on gleno id rim t also associated with Bankart lesion • avulsion of capsule when shou lder dislocates • associated bon y avulsion called "Bony Bankart Lesion" • occurs in 85% of all ante rior dislocations t axillary nerve and musculocutane ous ne rve at risk  t some associated injuries mo re common in elde rly • vascular injury and fracture of greate r tube rosity Physical Examination t “squ ared off” shoulde r t loss of internal rotation with anterioinferior humeral head t axillary nerve may be dama ged , therefore che ck sen sation and contraction over late ral de ltoid; for musculocutaneous nerve check  se nsation of late ral forearm and contraction of bicep s t app rehe nsion test : for recurrent shoulde r instab ility • with patient sup ine, gen tly abd uct and externally rotate p atie nt’s arm to a p osition where it may e asily d islocate. If  shoulde r is dislocatab le, patie nt will have a look of app rehe nsion on face X-Rays t hume ral head ante rior in trans-scapular view • hume ral head ante rior to Merced es Benz sign t AP view may show Hill-Sachs lesion if recurrent t r/o associated humeral neck fracture Treatment t intraveno us se dation and muscle relaxation t gentle longitudinal traction and countertraction t +/– alternating internal and external rotation t Hippocratic Method • foot use d in axilla for count e rtraction t alternatively place patient prone with wrist weight for recurrent dislocator t sling x 3 we e ks with move me nt of elb ow, wrist, fingers • rehab ilitation aimed at strengthening dynamic stab ilizers and avoiding the u nstab le p osition (i.e. e xternal rotation and ab duction) t recurrent instability and dislocations may req uire surgery

POSTERIOR SHOULDER DISLOCATION t t

5% of all shoulde r dislocations caused by force ap plied along the axis of the arm • shoulde r is add ucted , internally rotated and flexed t the four E's which cause po sterior dislocation a re: • Epilep tic seizure • Ethano l intoxication • Electricity (ECT, Electro cution ) • Encep hialitis t often missed due to poor physical exam and radiographs t if caused by se izure, often bilateral shoulde r dislocations Physical Examination t ante rior shoulde r flattening, prominent coracoid t blocked e xternal rotation, limited ab duction X-Rays t hume ral hea d p oste rior in trans-scapu lar view • hume ral head po sterior to Merced es Ben z sign Treatment t inferior traction on flexed elb ow + pressure on b ack of hume ral head t may require reduction under GA

ROTATOR CUFF LESIONS t

the rotator cuff is a shee t of conjoined ten don s • SITS: Supraspinatus, Infraspinatus, Teres minor, Subscapularis t stabilizes the head of the humerus in the glenoid, when arm extended or abducted t ab out 80%of 80 year old s ha ve rota tor cuff lesions Orthop e d ics 10

MCCQE 2000 Re vie w Note s and Le cture Se rie s

Notes

SHOULDER . . . CONT.

supraspinatus

infraspinatus

teres minor

subscapularis joint capsule

Figure 5. Muscles of the Rotato r Cuff and Pos ition at th e Glenoid Drawing by Kevin Millar 

IMPINGEMENT S YNDROME t t

also calle d "Painful Arc Synd rome " de scribes impingeme nt of supraspinatus tendon b etween • humeral head/greater tube rosity and anatomic arch be twee n anterior edge and undersurface of acromion, AC joint and CA ligament

Physical Examination t painful arc be twee n 90-130 de gree s of abd uction t pain on pa lpation of rotator cuff  t impingement te st • forward fle xion, inte rnal rotat ion of 90 de gree e levate d forward flexed arm reproduces pain • may have asso ciate d oste oph ytes und er acromion or AC joint Types of Impinge me nt Syndrome t mild (“wear”) • inflamed rotator cuff  • aching, reversible, +/– weakne ss • trea tme nt is conse rvative (ph ysio, NSAIDs) t moderate ("tear") • tend on is thick and fibrotic, microtears • night pain and shoulder weakness prominent • conservative treatme nt +/– ste roid injection t seve re ("rep air") • tear of rotator cuff, cannot st art abd uction • may req uire surgical rep air

FROZEN SHOULDER t

process which involves adh esive capsulitis

Primary Adhe s ive Caps ulitis t idiopathic, usually associate d with diab ete s me llitus t may resolve sp ontane ously in 9-18 months Secon dary Adhe s ive Caps ulitis t due to prolonged immobilization • "Shoulder-Hand Syndrome " - hand in cast, immobilized shoulder • following MI, stroke, should er trauma Treatment t active a nd pas sive ROM (physiotherapy) t NSAIDs and steroid injections if limited by pain t MUA (manipulation under anesthesia) or arthroscopy for debridement/decompression t diabetics usually have poor outcomes MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 11

Notes

HUMERUS HUMERAL SHAFT FRACTURE t t

gene rally treate d non-surgically complications include radial nerve injury and nonunion

Treatment t und isplaced fracture +/– rad ial nerve palsy • collar and cuff x 4-6 wee ks, then active e xercises for shoulder, wrist and hand if fracture united • radial nerve palsy usually improves sponta neo usly over 3-6 months; if no improvement at 3 months than EMG t disp laced fracture • app ly collar and cuff or sugar-tong plaster sp lint cast and reasse ss radial nerve • immobilize 2-3 wee ks then go to frontal brace and be gin active up pe r limb e xercise s • ORIF indicate d if 1) po or close d re du ction, 2) p olytrauma, 3) segme ntal fracture 4) path ologic fracture, 5) neurovascular comp romise , 6) asso ciated fracture of proximal ulna “floating elbow”

P ROXIMAL HUMERAL FRACTURE t t t

es pe cially common fracture in oste opo rotic pe rson fall on outstre tched hand fracture involve s • p roximal hume ral diap hysis (surgical ne ck) • +/– grea ter tuberosity • +/– lesser tuberosity t classify into 2, 3, and 4 pa rt fractures Treatment t if needed, treat for osteoporosis t undisplaced • stab le/impacted , use Velp eau sling x 1 wee k then active ROM • unstab le (unusual), use Velpe au sling x 3 wee ks then gen tle ROM t disp laced > 1 cm or angulate d > 45º • atte mpt closed red uction, Velpe au sling x 2 wee ks, gentle ROM • ORIF if unsa tisfactory re d uction t fracture with dislocation o f glenoh ume ral joint • high incide nce of neurovascular injury and oste one crosis • ORIF; he miarthroplasty may be nece ssary Fractures in this region may involve the anatomical ne ck (rare) (1), the surgical neck (2), the greater tuberosity(3), or the lesser tuberosity (4) Combinations of these injuries are common and may involve two-part (5), three-part (6), and four-part fractures (7)

Figure 6. Fracture s of the Proximal Hume rus Reproduced with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989.

Orthop e d ics 12

MCCQE 2000 Re vie w Note s and Le cture Se rie s

ELBOW

Notes

Figure 7. Anatomy of the Elbow

SUPRACONDYLAR FRACTURE

Figure 8. Displace d Supracondylar Fracture of Hume rus t t

usually in children fall on outstre tched hand

Treatment t children • closed red uction +/– pe rcutane ous p inning in OR with fluoroscopy • cast in flexion x 3 we eks t adult • undisplaced fracture, may be treated in cast • disp laced fracture, ORIF since close d red uction usually inadequate Complica tions t stiffnes most common t see complications of fractures se ction

RADIAL HEAD FRACTURE t t t

mechanism: fall on outstretche d arm clinically: progressive pain due to hemarthrosis with loss of ROM careful, may not b e see n radiographically

Mas on t Type t Type t Type t Type

Clas s ificat ion 1: und isplaced segme ntal fracture, usually normal ROM 2: displaced segmental fracture, ROM compromised 3: comminuted fracture 4: Type 3 with poste rior dislocation

Treatment elb ow slab, sling 3-5 days, early ROM t Type 1: ORIF radial head t Type 2: t Type 3/4: excision of radial he ad +/– prosthe sis

MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 13

Notes

ELBOW . . . CONT. OLECRANON FRACTURE t t t

fall on point of elbow with avulsion by triceps or fall on outstretched arm active extension absent gross displaceme nt can not be red uced closed be cause of pull of triceps

Treatment t und isplaced: ab ove e lbow cast 2 weeks, e arly ROM t d isplace d : ORIF, ab ove elb ow slab x 1 we e k, early ROM

ELBOW DISLOCATION t t t t

usually young pe ople in sporting events o r high sp ee d MVA > 90%are p oste rior or po ste rior-lateral fall on outstre tched hand r/o concurrent radial head or coranoid process fractures

Treatment of Posterior Dislocation t closed reduction: traction then flexion t ab ove e lbow ba ckslab with e lbow 90 de gree s and wrist p ronated t open reduction if unstable or loose body (unusual) Comp lications t stiffness t intra-articular loose bod y • usua lly from joint surface cartilage • not obvious on x-ray • occasionally me dial ep icond yle is pulled into joint, esp ecially in childre n t he terotop ic ossification (bone formation) • prevented by indomethacin t recurrent dislocation is extremely rare

FOREARM FRACTURES GENERAL PRINCIPLES OF FOREARM FRACTURES t t t

more commonly fracture of bot h b one s, usually disp laced if only one bone fractured look for dislocation of other forearm fractures in children are usually of the greenstick type, in which only one cortex is involve d

NIGHTSTICK FRACTURE

Figure 9. Nightst ick Fracture Drawing by Chesley Sheppard  t t

isolated fracture of ulna, with minimal displacement me chanism: from holding arm up to p rotect face from b low

Orthop e d ics 14

MCCQE 2000 Re vie w Note s and Le cture Se rie s

FOREARM FRACTURES t t t

. . . CONT.

Notes

r/o radial injury by e xamining all of radius clinically and radiograp hically treatment: below elbow cast 6 weeks for distal 1/3 fractures if angulation o r proximal 2/3 seve re con side r ORIF

GALEAZZI FRACTURE

Figure 10. Gale azzi Fractu re Reproduced with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989. t t t

fracture of distal radius dislocation of distal radio-ulnar joint (DRUJ) at wrist treatment: immobilize in supination to reduce DRUJ, ORIF

COMP LICATIONS SP ECIFIC TO FOREARM FRACTURES t t t t

cross un ion - radius malunites to ulna loss of pronation/supination loss of extens ion of elbow difficult to red uce an d maintain close d • accurate red uction is e ssen tial, usually req uires ORIF t shoulder-hand syndrome

WRIST SCAPHOID FRACTURE

Figure 11. Scaphoid Fracture Reproduced with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989.

Etiology t second most common wrist fracture, common in young adults t maintain a high inde x of susp icion with falls on outstretche d hand t blood sup ply is from distal to p roximal poles of scaphoid Diagnosis t clinical • pain on wrist movement i.e positive scaphoid te st • tend erne ss elicited in anatomical snuff box and over scaphoid tubercle MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 15

Notes

WRIST . . . CONT. t

x-ray • AP/lateral/scaphoid views required • x-ray alone may not re veal scaphoid fracture • +/– bo ne scan and /or CT scan

Treatment Suspected Scaphoid Fracture

und isp lace d –ve

x-ray

cast 2 we eks (thumb sp ica)

displace d +ve

ORIF

cast 8 we eks (check wee kly x 3)

repe at x-ray –ve

+ve

clinical e xam –ve

+ve

STOP

bone scan

cast off   fracture healed ye s

STOP

no

cast +/– OR

Figure 12. Scaphoid Fracture Algorithm Comp lications t nonunion +/– AVN t highe st incide nce of AVN (30%) is with fracture of proximal 1/3 t high incide nce o f nonu nion an d AVN with significant d isplace me nt

COLLES' FRACTURE

Figure 13. Colles ' Fracture and As so ciate d Bony De formity Adapted with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989.

Etiology t most common wrist fracture t fall on outstre tched hand t most common in osteoporotic bone

Orthop e d ics 16

MCCQE 2000 Re vie w Note s and Le cture Se rie s

Notes

WRIST . . . CONT. Diagnosis t clinical • swelling, ecchymosis, ten de rness • “d inne r fork” de formity • assess neurovascular status (carpal tunnel syndrome) t x-ray: distal fragment is 1. dorsally displaced with dorsal comminution 2. dorsally tilte d fragmen t with ap ex of fracture volar 3. supinated 4. radially deviated 5. shortened (radial styloid normally 1cm d istal to ulna) +/– fracture of ulnar styloid Treatment t if needed, treat for osteoporosis t nondisplaced • short arm cast ap plied to wrist und er gentle traction • neu tral wrist p osition t displaced 1. ane sthe sia - hematoma b lock commonly used 2. disimpa ction - axial traction with incre asing force ove r 2 minute s (pull on thumb and ring finger, with countertraction at the elbow) 3. red uce b y pulling hand into • slight flexion • full pronation • full ulnar deviation 4. maintain red uction with d irect p ressure to fracture site, ap ply well moulde d dorsal-radial slab (splint) 5. post -red uction x-ray (AP/late ral), goal to correct d orsal angulation a nd regain radial length 6. che ck arm afte r 24 hours for swe lling, neu rovascular status 7. circular cast after 1-2 weeks check cast a t 1, 2, 6 we e ks cast o ff afte r 6 we eks, p hysio (ROM, grip stre ngth) t if inade quat e red uction at any time • try close d redu ction unde r GA • ORIF

SMITH’S FRACTURE

Type a

Typ e b

Typ e c

Figure 14 . Smith’s Fract ure Drawing by Marc Dryer 

Diagnosis t clinical prese ntation and radiograph ic evide nce t fracture similar to Colles’ but volar displacement of distal radius Treatment t anesthesia b lock  t close d red uction in s upination an d slight flexion t splint t ORIF if unst ab le re du ction MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 17

Notes

WRIST . . . CONT. BARTON’S FRACTURE

Do rs a l

Ve n t ra l

Figure 15 . Barton’s Fractu re Drawing by Marc Dryer 

Diagnosis t clinical prese ntation and radiograp hic evide nce t intraarticular fracture o f distal rad ius re sulting from she aring force t classified as d orsal or volar de pe nding up on location of fragmen t Treatment t attempt closed reduction although rarely adequate t do rsal: slight e xten sion, pronation, sp lint t volar: slight flexion, su pina tion, sp lint t usually requires ORIF if unstable reduction Complications of wrist fracture s t most common complications a re p oor grip st rength, stiffne ss, and radial shortening t 80% have normal function in 6-12 mon ths t early • d ifficult red uction +/– loss of red uction • compartment syndrome • extensor p ollicis longus (EPL) tend on rupture • acute carpal tunnel syndrome • finger swe lling with venou s or lymph atic block  t late • malunion, radial shortening • painful wrist se condary to ulnar prominence • frozen should er ("shoulde r hand syndrome ") • pos t-traumatic arthritis • carpal tunnel syndrome • RSD

Orthop e d ics 18

MCCQE 2000 Re vie w Note s and Le cture Se rie s

Notes

SPINE DIFFERENTIAL DIAGNOSIS OF BACK PAIN t

t t t t t

d ege ne rative (90% of all b ack pain) • mechanical (de gene rative, facet) • spinal stenosis (congenital, oste op hyte, central disc) • pe riphe ral nerve compression (disc he rniation) cauda eq uina syndrome neoplastic • primary, meta static trauma • fracture (comp ress ion, dist raction, translation, rotat ion) spondyloarthropathies • e.g. ankylosing spond ylitis referred • aorta, renal, urete r, pancreas

Epidemiology t common p roblem t L4-5 and L5-S1 most common site s t 10%ne rve root comp ress ion t less than 2%results from tu mour, trauma, other d isease s

DEGENERATIVE BACK PAIN Pathogenesis t loss of vertebral disc height with age results in • bulging and t ears of annulus fibrosus • change in alignmen t of facet joints • osteophyte formation t pain sensation is transmitted by branches of adjacent nerve root, which innervates disc and facet joints • results in both localized pain and referred p ain down adjacent sp inal nerve • radiating pain typ ically occurs in buttocks and do wn legs t p ain may originate from d isc +/– facet joints t disc herniations are most commonly post erolateral or late ral • post erolateral herniations (common) affect the ne rve root be low the disc (i.e. the L4-L5 disc compresses L5 root) • lateral herniations (rare) affect the ne rve root abo ve the d isc (i e. the L4-L5 disc comp ress e s L4 root) t natu ral history: 90%improve with conse rvative trea tme nt within 3 months t conservative • modified activity • back strengthening • NSAIDs Table 6. Type s of Low Back Pain Mec hanical Back Pain

Direct Nerve Root Compres sion

Disc Origin

Facet Origin

Spinal Ste nos is

Root Compre ss ion

pain dominance

back

b ack

le g

le g

aggravation

flexion

extension sta nd ing, walking

exercise, extension walking, sta nd ing

flexion

onse t

gradual

more sud de n

conge nital or acquire d

acute le g ± back pain

duration

long (wks, months)

shorte r (d ays, wks)

acute or chronic history (weeks to months)

short e p isod e attacks (minutes)

treatment

relief of strain, e xe rcise

relief of strain, e xe rcise

relief of strain, e xe rcise

relief of strain, e xe rcise + surgical decompression if  progressive or se vere deficit

MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 19

Notes

SPINE . . . CONT. t

spinal stenosis • acquired ste nosis be st thought of as a progression or end stage degenerative disc disease, in which osteophytic growth results in a narrowed spinal canal

Table 7. Differe ntiat ing Claudica tion Neurogenic

Vascular

aggravation

with stand ing or exten sion walking d istance variable

walking se t distan ce

alleviation

change in pos ition (usually flexion, sitting, lying down)

stop ping walking

time

re lie f in 10 minute s

re lie f in 2 minute s

ch ara ct e r

n e uro ge n ic ± n e uro lo gica l deficit

m us cu la r cra mp in g

X-Rays t AP, late ral, ob lique s t indicated for new onset b ack pain (i.e. r/o tumour, congenital deformities) • look for "Winking Owl sign” ––> signifies t umour invasion of pe dicle t CT scan/mye lograp hy, MRI • for spinal stenosis, cauda eq uina syndrome, disc hemiation t x-rays not very helpful for chronic degenerative back pain • radiograph ic de gene ration doe s not correlate well with back pain

CAUDA EQUINA SYNDROME t t

most freq uent cause is large central disc herniation progressive neurological deficit presenting with • saddle anesthesia • de crease d anal tone and reflex • fecal incontinence • urinary rete ntion • SURGICAL EMERGENCY! will cause pe rmane nt urinary/b owel incontinence

Table 8. Lumbar Radiculopathy/Neuropathy Ro ot

L4

L5

S1

motor

quadriceps tibialis anterior

ankle dorsiflexion great toe extensor hip abductor

ankle plantarflexion

sensory

posteromedial

lateral calf or 1st web space

lateral aspect of foot

reflex

knee reflex

hamstring reflex

ankle reflex

test

limitation of femoral stretch

limitation of straight leg raise

limitation bowstring

Orthop e d ics 20

MCCQE 2000 Re vie w Note s and Le cture Se rie s

SPINE . . . CONT.

Notes

Figure 16. Dermatome s of the Uppe r and Lowe r Limbs

TRAUMA C-Spine X-rays t can you see C1 to superior portion of T1? - if not, film is INADEQUATE t should have swimmers view for adequate visualization of C7-T1 t ope n mouth odo ntoid view for ade qu ate visualization of atlanto-axial joint t identify 1) alignme nt (on late ral films - see Figure 17) • ante rior bod y (1) • post erior bod y (2) should curve to a nterior foramen magnum • facet joints (3) • laminar fusion line (4) shou ld curve proximally and po int to post erior base of foramen magnum 2) vertebral bodies • height and width 3) cartilage 4) soft tissues • pre verte b ral soft tissue : C3=3-5 mm, C7=7-10 mm

Figure 17. Alignme nt o f Ce rvical Spine Adapted with permission from McRae, Clinical Orthopedic Examination, 3rd ed. Churchill Livingstone, New York, 1994.

MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 21

Notes

SPINE . . . CONT. Clearing C-spine X-rays x-ray (AP/lat/od onto id) abN

N

uncons

cons

neck pain

yes

CT

abN

no

flex/ext x-ray

N

cleared

Figu re 18 . Algorit hm for Cle aring C-sp ine X-rays Table 9. Ce rvical Radicu lopat hy/Ne uropa thy Ro ot

C5

C6

C7

C8

motor

deltoid sup rasp inatus biceps

biceps brachiora dialis

triceps

digital flexors intrinsic

sensory

axillary nerve (middle deltoid)

thumb and index finger

middle finger

ring and little finger

reflex

b ice p s middle deltoid

b rachiora dialis reflex

trice p s

finge r je rk   reflex

THORACIC AND LUMBAR SPINE Table 10. Elem e nts of 3 Column Spine An t e r io r Co lu m n

Mi dd le Co lu m n

P o s t e r io r Co lu m n

anterior longitudinal ligament

posterior longitudinal ligament

posterior body elements

anterior annulus fibrosis

posterior annulus fibrosis

supraspinous, intraspinous ligaments

anterior 1/2 of vertebral bod y

poste rior 1/2 of vertebral bod y

facet joints ligame ntum flavum

Etiology t mechanism of injury 1. compression: vertical loading leads to failure in anterior column, include s ante rior and lateral wed ge compre ssion and axial comp ress ion (“b urst”) fracture 2. distraction: tensile failure in all three columns i.e. Chance fracture 3. rotation: most se rious with high d egree of neural dam age t disruption of poste rior and midd le columns is req uired for acute instability X-Ray t oblique views show "Scottie Dog" t look for disrup tion of "Scottie Dog" to ide ntify spo nd ylolysis Orthop e d ics 22

MCCQE 2000 Re vie w Note s and Le cture Se rie s

Notes

SPINE . . . CONT.

S N P I

-

superior facet transverse process pars interarticularis inferior facet

Figure 19 . Scottie Dog Adapted with permission from McRae, Clinical Orthopedic Examination, 3rd ed. Churchill Livingstone, New York, 1994.

Treatment t compression • we dge : conse rvative if < 50% comp ress ion • burst: may push mate rial into sp inal canal therefore surgical correction (distraction an d IF for stab ilization) t distraction • chance: only bony involvem ent the refore full healing achieve d conservatively • soft tissue : surgical stab ilization t rotation • burst type : inherently unstab le therefore internal stabilization

HIP DIFFERENTIAL DIAGNOSIS OF HIP PAIN t

traumatic • fracture, d islocation t arthritic • sep tic, de gene rative (OA), inflammatory (see Rheum atology Notes) t referred • hip pa in is felt in the groin area and ante rior thigh • spine u sually involves b uttock and p oste rior thigh • knee , abd ominal viscera, vascular (intermittent claudication) t other • AVN of femo ral hea d • neop lasm (primary or second ary) X-Ray Dia gn os is t views: AP, lateral, Judet (oblique) views Table 11. Radiological Diagnosis of Hip Path ology Findin g

OA

AVN

Hip Fract ure

loss of joint space

localize d

none

none

subchond ral scle rosis

+++ ace tabulum and he ad

++ he ad only

none

oste ophyte s

+++

none

none

e rosions

none

none

none

le g shorte ning

+/–

none

+++ if displace d

t

Note: AVN be comes s ame as OA later in dise ase process, and hip fracture may have preexisting OA

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Orthop e d ics 23

HIP

Notes

. . . CONT.

P ELVIC FRACTURES t

most common fracture involves pubic rami, followed by ilial, ischial, acetabular, coccygeal and sacral bones

Tile Clas s ificat ion (see Figure 20) t Type A: stab le, minimally disp laced , include s avulsion fractures and fractures not involving pelvic ring, e.g. rami fracture t Type B: pa rtially unst ab le, rotationa lly unst ab le, b ut ve rtically stable, e.g. “open book” fracture from external rotational force to pelvis t Type C: unstab le, rotationally and vertically unstable, associated with rupt ure o f ipsilate ral ligamen ts, e .g. vertical she ar fracture

Type A St ab le Avu ls io n Fra ct ure

Type B Op e n Bo ok

Typ e C Un st ab le Ve rt ica l Fra ct ure

Figure 2 0. Illustration o f the Tile Class ification of Pe lvis Fractures Drawing by Seline McNamee

Diagnosis t history of injury, high e ne rgy trauma t examination reveals local swelling, tend erne ss; if unstab le, may have de formity of the hip s and instability of pelvis with p alpation t x-rays (i.e. AP, inlet, and outlet views) Treatment t ABC's t assess GU injury (rectal exam/vaginal exam mandatory) t Type A - bedrest and mobilization with walking aids t Type B/C - external or internal fixation Comp lications t he morrhage - life threate ning t blad de r/bowel injuries t neurological damage t obstetrical difficulties t persistent sacro-iliac joint pain t post-traumatic arthritis of the hip with acetabular fractures

HIP DISLOCATION t

mainly se en with artificial hips

Anterior (rare) t blow to kne e with hip wide ly abd ucted t clinically: limb fixed, externally rotated and abducted t attemp t closed reduction unde r GA t then CT of hip to assess joint congruity Posterior t se vere forces to kne e with hip flexed and a dd ucted (e.g. knee into dashboard in MVA) t clinically: limb shorte ned , internally rotate d and ad ducte d t sciatic nerve injury common Orthop e d ics 24

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HIP t t t t t t

Notes

. . . CONT.

assess knee, femoral shaft for other injuries/fractures +/– fracture o f poste rior lip o f acet ab ulum or intra-articular fracture atte mp t closed red uction unde r GA +/– image intensifier the n CT to ass ess congruity and acetab ular inte grity traction x 6 wee ks, the n ROM ORIF if unstab le, intra-articular fragment s, or p oste rior wall fractures

Ce nt ral t associated with acetabular fracture Complica tions t post-traumatic arthritis due to cartilage injury or intra-articular loose body t fem oral he ad injury including ost e one crosis + fracture; 100% if  > 12 hours b efore red uction t sciatic nerve pa lsy in 25%(10% pe rmane nt) t fracture o f fe moral sha ft or ne ck  t knee injury (PCL tear with dashboard injury)

HIP FRACTURE Epidemiology t common fracture in e lde rly (greate r incide nce of osteop enia) t female > male t in osteo pe nic individual, fracture may p reced e simple fall (muscle stronger than bone) t in younger individual, fracture related to high energy injury • markedly displaced • associated with other injuries Diagnosis t characteristic history, unable to bear weight on affected limb t limb shortened, externally rotated, painful ROM, antalgic gait t obtain AP of pelvis and lateral of involved hip t if findings eq uivocal - bone scan and tomograms Subcapital (Intracapsular) Intertrochanteric (Extracapsular)

Subtrochanteric (Extracapsular)

Basicervical (Intracapsular)

Figure 21. Blood Supply to Femoral Head and Fracture Class ification Adapted with permission from McRae, Practical Fracture Treatment, 2nd ed. Churchill Livingstone, New York, 1989.

1. Subcapital Fracture s t fracture b etwee n fem oral head and intertrochante ric line t main vascular supply to femoral head from distal arterial ring to proximal head through femo ral neck  t fracture interrupts blood supply • articular surface restricts blood sup ply to femoral head • AVN risk de pe nds on d egree of displacemen t

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Orthop e d ics 25

HIP

Notes

. . . CONT.

Table 12. Garde n Clas s ificat ion of Subcap ital Fractu res Type

Exte nt

Displace men t

Alignme nt

Trabecu lae

I 2 3 4

Incomp le te Comp le te Comp le te Comp le te

Imp acte d None Some Marke d

Valgus Ne utral Varus Varus

Malaligne d Aligne d Malaligne d Aligne d

Treatment t if nee de d, treat osteop orosis t restore anatomy, attemp t to save he ad (AVN head CAN heal) t type of treatment de pe nds on displaceme nt and patient age t und isplaced (Garde n 1,2) - ORIF to p revent d isplacemen t t displaced (Garden 3,4) - dep end s on p atient • olde r pa tient, poor he alth ––> unipo lar hem iarthroplasty • younger patient with higher de mand lifestyle ––> bip olar hem iarthroplasty vs. total hip rep laceme nt vs. red uction and internal fixation • younger patient with OA of hip ––> total hip rep laceme nt Comp lications t AVN t non-union 2. Intertrochante ric Fracture t extra-capsular fracture, therefore good femoral head viability t fracture stab ility dete rmine d b y amount of comp romise to calcar femorale (medial cortex at neck/shaft junction) t greater and lesser trochanters may be separate fragments t po sterior fragment may be avascular, therefore p ossible d elayed union Clas s ification t 2 part - stab le, trochante r intact t 3 part - one trochanter sep arated , unstable if large calcar fragmen t t 4 part - unstable, both trochanters se parated Treatment t ORIF (sliding hip screw) to preserve femoral head 3. Subtrochant eric Fracture t least common hip fracture t transverse, spiral or oblique fracture p asse s be low lesse r trochanter t younger population with high energy injuries t x-rays show flexed and abducted proximal fragment, from pull of  iliopsoas on les ser trochanter, gluteus me dius and minimus on greate r trochanter Treatment t usually ORIF t malunion common

ARTHRITIS OF THE HIP t

many caus es (oste oarthritis, po st-trauma tic, DDH, RA, et c...)

Diagnosis t usually in an olde r individual t gradual onset of groin/medial thigh pain, increasing with activity t limb shortening t de creas ed internal rotation/abd uction of hip t fixe d flexion d e formity t po sitive Trend ele nbu rg sign t x-ray - joint space narrowing, sclerosis, subchondral cysts, osteophytes Orthop e d ics 26

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HIP

. . . CONT.

Notes

Treatment t conservative • we ight loss, walking aids , physioth erap y, NSAID t surgery • realign - oste otomy • replace - arthroplasty • ablate - arthrod esis, excision Trendelenberg Test t pat ient stand s on affecte d le g, normally gluteus me dius muscle on ipsilateral side contracts to kee p p elvis level t a p ositive t est is if the contralate ral side drop s or if pa tient compensates by leaning way over supp orted leg

Figure 22. Caus e s of a Pos itive Trendelenberg Sign t

may occur anywhere along line "ab" • e.g. weak ab du ctors, avulsion of glute us me dius, trochante ric fracture/removal t may occur anywhe re alon g line “bc” • e.g. painful hip d ue t o oste oarthritis, femoral neck in varus, acetabular instability t may occur anywhe re a long line “ac” • e.g. fractured pe lvic side wall

AVN OF THE FEMORAL HEAD (see Avasular Necrosis Section)

Clinical t sudd en onset of severe p ain, related to weight-bearing t worse at night t rapid p rogression (compared to OA) Diagnosis t x-ray - r/o hip fracture t bon e scan - see hea ling fracture t MRI (best) Treatment t early: vascularized fibular graft to preserve femoral head, rotational osteotomy in young patient with moderate disease t late: hip replaceme nt

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Orthop e d ics 27

Notes

FEMUR FEMORAL DIAPHYSIS FRACTURES t t t t t t

high energy (MVA, fall from height, gunshot wounds) low en e rgy (spiral fracture in childre n) high mo rbid ity/mortality (he morrhage, fat e mb olism, ARDS, MODS) blood rep laceme nt often req uired freq uen tly comminuted soft tissue trauma

Clinical t leg is shortened , externally rotated t unable to weight b ear t assess neurovascular status t r/o: open fracture, soft tissue compromise t r/o: child abuse with spiral fractures in children Treatment t ABCs of trauma are es se ntial t immob ilize le g with Thoma s Splint t ade quate analgesia t surgical fixation (intramedullary nail) within 24 hours • high rate of surgical union after 6 to 12 wee ks ea rly mobilization of hip and knee t

SUPRACONDYLAR FEMORAL FRACTURE t t t t

high e nergy, multiple trauma knee joint is d isrupte d seve rely with b icond ylar fracture po or p rognosis with comminuted fractures high incidence of post-traumatic arthritis

Treatment t internal fixation and early knee ROM t quad riceps strengthening

KNEE

Figure 23. Diagram of Right Tibial Plateau Adapted with permission from McRae, Clinical Orthopedic Examination, 3rd ed. Churchill Livingstone, New York, 1994.

COMMON KNEE SYMPTOMS t

locking = spon tane ous b lock to extension • torn meniscus, loose body t pseudo locking = restricted ROM without mechanical block  • arthritis (e ffusion, p ain), muscle sp asm following injury t instab ility = “giving out” • torn ACL, pate llar subluxation, torn meniscus, loose bod y t traumatic knee swelling • effusion, usually rep rese nts hemarthrosis • ligamentous injury with hema rthrosis • men iscal injury • traumatic synovitis Orthop e d ics 28

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KNEE . . . CONT. t

Notes

non-traumatic knee swelling without trauma • se pt ic or crystalline arthritis • se rone gative arthritis (AS, Re iter's, Psoriatic, IBD) • se ropo sitive arthritis (RA, SLE) • avascular necrosis • sickle cell dise ase

EVALUATION OF KNEE COMPLAINTS History t ligament injuries require high energy force t men iscal injury in young p erson req uires mod erate force, while in olde r pe rson only req uires mild force Physical Examination t LOOK: SEADS, alignment t FEEL: effusion, crepitus t MOVE: gait, strength, ROM Special Tes ts of the Kne e t Ante rior and Poste rior Drawe r Tes ts • de monstrate torn ACL and PCL, respe ctively • knee flexed at 90 degree s, foot immobilized , hamstrings release d • if ab le to sub lux tibia ant e riorly the n ACL may be torn • if able to sub lux tibia po ste riorly then PCL torn t Lachmann Te st • de monstrates torn ACL • hold knee in 10-20 de gree s flexion, stabilizing the femur • try to sub lux tibia ante riorly on femu r • similar to ante rior drawer te st, more reliable t Posterior Sag Sign • de monstrates torn PCL • may give a false p ositive an terior drawer sign • flex knees and hips to 90 de gree s, hold ankles and knee s • view from the lateral aspect • if one tibia sags poste rior than the othe r its PCL is torn; loss of  prominence of tibial tube rosity t Pivot Shift Sign • de monstrates torn ACL • start with the kne e in extension • internally rotate foot, app ly valgus force to kne e • look and fe el for ante rior sub luxation of late ral tibial condyle • slowly flex while p alpa ting kne e a nd fe el for p ivot which is the tibiofemo ral red uction t Collateral Ligame nt Stre ss Te st • palp ate ligament for "opening" of joint sp ace while te sting • with knee in full exte nsion ap ply valgus force to t es t MCL, ap ply varus force to t es t LCL • repe at te sts with knee in 20 degree s flexion to relax joint capsule • ope ning only in 20 de gree s flexion due to MCL da mage only • ope ning in 20 de gree s of flexion and full exte nsion is due to MCL, cruciate , and joint cap sule dam age t tes t for Men iscal te ar • Crouch Comp ression te st (C2) is most sen sitive te st • joint line p ain whe n squat ting • McMurray te st use ful collaborat ive information • with knee in flexion palpate joint line for painful “pop” • internally rotate foot, varus stress, and e xte nd kne e to test lateral meniscus • externally rotate foot, valgus stress, and e xten d kne e to test med ial meniscus X-Rays of the Knee t AP stand ing, late ral t skyline view • with knee s in flexion, beam is aimed from anterior tibia to ante rior femur • allows for view of p ate llofe moral joint t ob lique s for intra-articular fractures MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 29

Notes

KNEE . . . CONT. t

3 foot standing view • radiograph from hip to foot with p atient in stand ing position • use ful in evaluating leg length and genu varus / valgus

LIGAMENTOUS INJURIES OF THE KNEE t t t

may have he marthrosis and /or effusion in acute p hase de celeration or p ivoting injury must che ck for effusion and ten de rness on physical exam

ANTERIOR CRUCIATE LIGAMENT TEAR History t indirect varus b low to kne e t hyperextend ed knee + internal rotation t audible pop, knee instability, “giving way” t immed iate s welling t inability to continue activity Physical t poste rolateral joint line tend erness t positive Lachmann, pivot shift, anterior drawer, t e ffusion, +/– hem arthrosis +/– associated medial meniscus tear, MCL injury (O'Donahue's Unhappy Triad) Treatment t ba sed on activity and functional impairment t stable with minimal functional impairment • early mob ilization • physio and quad riceps strengthening t instability with functional impairment / high demand lifestyle • ACL recons truction

POSTERIOR CRUCIATE LIGAMENT TEAR t

much le ss com mon than ACL injury

History t fall onto flexed knee with plantar flexed foot t hit anterior tibia on d ashb oard in motor vehicle accide nt t hyperflexion or hyperextension with anterior tibial force Physical t po sitive p oste rior sag sign t false pos itive a nterior drawer t true positive posterior drawer Treatment t conse rvative vs. surgical PCL reconstruction

MEDIAL COLLATERAL LIGAMENT TEAR History t valgus force to knee t +/– "pop" heard t se vere p ain with partial tears t complete tear may be painless Physical t swelling t tend er ab ove and be low med ial joint line t asse ss joint sp ace o pe ning with valgus force • pain • MCL laxity with en d p oint - partial tea r • abse nce of end p oint - complete te ar • r/o ACL and med ial me niscus te ar Treatment t minor • immob ilize brie fly, e arly ROM and s tren gthe ning t moderate • EUA, cast o r brace • e arly PT with ROM and stre ngthe ning t severe or combined • surgical repair of associated injuries • surgical rep air of isolate d MCL te ar is controve rsial Orthop e d ics 30

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Notes

LATERAL COLLATERAL LIGAMENT TEAR t t t t

varus force to knee similar history, physical to MCL r/o common p erone al nerve injury treatment as for MCL

MENISCAL TEAR t t t

med ial meniscus torn 8x more tha n lateral 1/2 are traumatic, 1/2 are degenerative usually associated with other ligamentous injuries if traumatic

History t twisting force when the knee is partly or completely flexed e.g. squatting and then rotating rapidly, skiing, football, tennis t acute • imme diat e p ain, difficulty we ight be aring, +/– locking t chronic • pain, swelling, instability Physical t effusion t lack of full extension (locking) t pinpoint joint line tend erness t McMurray's test Diagnosis and Treatment t MRI is diagnostic only t conservative (unless locked ) • ROM and stre ngthening exercises • NSAIDs t failed conservative • arthroscopy (diagnostic and the rape utic)

PATELLA/QUADRICEPS TENDON RUPTURE t t t

low energy injury, sudden forceful contraction during attempt to stop fall partial or comple te more common in patients with diabetes, SLE, RA, steroid use

History t fall onto flexed knee t inability to extend knee Physical t palpab le gap be twee n patella and quad riceps t may have hemarthrosis / effusion of knee Investigations t knee radiograph s to rule out pa tellar fracture t joint asp irate may show hemarthrosis Treatment t surgical repair of tendon

DISLOCATED KNEE t t

bad high e nergy injury associated injuries • pop liteal artery intimal tear or disruption 35-50% • capsular, ligamen tous and common p erone al nerve injury

Investigations t angiogram Treatment t close d red uction, above knee cylinde r cast x 4 wee ks t alte rnate ly, external fixation e sp ecially if vascular re p air t surgical repair of all ligaments if high demand patient MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 31

Notes

PATELLA PATELLA DISLOCATION Etiology t commonly see n in young ad ults t pa tella d islocates laterally over flexed knee t pre disp osition - weak vastus me dialis muscle and tight lateral retinaculum, valgus knee s t can be acute, chronic or recurrent • acute o ccurs with direct b low, excess ive muscular forces • recurren t type is associate d with shallow inte rcond ylar groove or pat ella alta (high riding pate lla) t may have a ssociated oste ochondral fracture o f anterior lateral femo ral condyle or avulsion of med ial pate lla Diagnosis t severe pain t d ifficulty exte nd ing knee t positive patellar apprehension sign • sublux pate lla laterally over extend ed knee • pain if sub luxation is rep roduced , patie nt app rehe nsive t chronic pat ient rep orts cat ching, giving way with walking or turning Treatment t acute - conservative • reduce patella • gentle ROM • strengthen quad ricep s, esp ecially vastus me dialis • sup port during sp orts activities t chronic / recurren t • often conservative treatme nt unsuccess ful • lateral retinacular rele ase (surgical) plus me dial plication • tibial tube rcle transfer corrects line of force by reinse rting pat ella med ially and d istally

CHONDROMALACIA PATELLAE t t t t

also known as pat ellofemo ral syndrome commonly seen in young adults, esp ecially fema les softening of articular cartilage, usually medial aspect of patella et iologies : malalignment, trauma, congenital abnormal shap e of pate lla or femoral groove, recurrent patellar subluxation or dislocation, excessive knee strain (athletes)

History t de ep aching anterior knee pain t exacerbate d by p rolonged sitting, strenuous athletic activities, stair climbing Physical t pa thognomonic: pain with firm compression of pate lla into med ial fe moral groove t tend erness to palpation of unde rside of med ially displaced pate lla t pa tellar inhibition test t pa in with e xten sion against resistance through terminal 30-40 de gree s X-Rays t AP, lateral, skyline Treatment t conservative treatment • physio (isome tric qua ds strengthening) • NSAIDs t surgical treatment with refractory patients • tibial tubercle elevation • arthroscopic shaving and d eb ride ment and lateral release

Orthop e d ics 32

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PATELLA . . . CONT.

Notes

PATELLAR FRACTURE History t direct - blow to pate lla t indirect - sudd en muscular contraction t immediate pain Physical t marked tend erness, pain t pat ellar de formity t inability to extend knee t proximal displaceme nt of pate lla t unab le to straight leg raise b ecause disruption of extensor mechanism X-Ray t AP, lateral (nee d to e xclude bip artate p ate lla) Treatment t isolate d vertical fractures - conse rvative treatme nt - p laster cast 6 weeks, early ROM t transverse displaced fracture - ORIF t comminuted fracture - ORIF; may req uire complete or p artial pa tellectomy

TIBIA TIBIAL PLATEAU FRACTURE t

result from femoral condyle(s) being driven into the proximal tibia often due to a valgus or varus force t lateral > med ial Treatment t if de pre ssion is < 3 mm • long le g cast-b race x 6 we eks, e arly ROM • NWB x 2 month s t if de pre ssion > 3 mm, displaced or comminuted • ORIF to reconst ruct knee joint • +/– bon e graft to elevate fragment

TIBIAL DIAPHYSIS FRACTURE t t t t

t

high intensity injury • asso ciated with crush injuries an d MVAs soft tissue, ne rve and vesse l injury common • asse ss ne urovascular status • r/o ope n fracture displacement is difficult to control good reduction is required • shortening: < 1 cm • angulation in varus/valgus p lane: < 5 degree s • angulation in ante ro-post erior plane : < 10 de gree s • rotation neutral to slight external rotation • apposition: ≥ 50% healing time: 16 weeks on average

Treatment t ABCs t close d injuries = closed red uction • long le g cast x 4-6 we eks • followe d b y BK cast until heale d t open injuries • ORIF with e xte rnal fixato r • wound s on ante rior surface he al poorly and ma y necrose t unstab le injuries or failed close d red uction req uire IM nail t high risk of compartment syndrome • closed reduction and cast; admit and ob serve for compartment syndrome surgery; prophylactic fasciotomy if operating on tibia fracutre MCCQE 2000 Re vie w Note s and Le cture Se rie s

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Notes

ANKLE EVALUATION OF ANKLE COMP LAINTS t t

history physical examination • neu rovascular status • look, fe el, move (do rsiflexion, plant arflexion) • asse ss for ten de rness at kne e (Maisonneuve ), lateral and med ial malleoli

X-ray t views • AP, Late ral and Mortise (15 d egre e s interna l rotat ion) • Mortise gives true view of talus in tibiotalar joint • spa ce be twee n talus ––> tibia and talus ––> fibula • spa ce should b e symme tric and < 4 mm with no talar tilt • disrupte d sp ace signifies ligamentous or bony injury t whe n to x-ray - Ottawa ankle rules (Stiell et al., JAMA, 1994) • ankle x-ray is only req uired with • pain in malleolar zone AND • bon y tende rness over distal 6 cm of med ial or late ral malleo lus OR inability to weight b ea r both immed iately and in ER • foot x-ray se ries is only req uired with • pain in midfoot zone AND • bon y tend erne ss over navicular or ba se of fifth met atarsal OR inability to weight b ear b oth imme diate ly and in ER

ANKLE FRACTURES

Figure 2 4. Ring Principle of Ankle Fracture s and Danis -We be r Clas s ificat ion Adapted with permission from Dandy, Essential Orthopedics and Trauma, 2nd ed. Churchill Livingstone, New York, 1993.

Ring Principle o f the Ankle t the ankle can be thought of as a ring (see Figure 24) • a: lateral malleolus • b: med ial malleolus • c: pos terior malleolus (pos terior med ial malleolus) • d: de ltoid ligament • e: synde smotic ligament (synde smosis) • f: calcane ofib ular ligame nt fractures o f the ankle involve t • ipsilateral ligamentous te ars or bony avulsion • contralate ral she ar fractures t pattern of fracture • de termined by mechanism of injury • avulsion fractures are transverse • she ar fractures are ob lique if pu re inversion / eversion • she ar fractures are s piral if rotationa l force Danis -We be r Clas s ification t leve l of fibular fracture relative t o tib ial plafond t Type A (infra-synde smot ic) • pure inversion injury Orthop e d ics 34

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ANKLE . . . CONT.

Notes

• avulsion of lateral malleolus b elow plafond or torn calcaneofibular ligament • +/– she ar fracture of med ial malleolus t Type B (trans-syndesmotic) • external rotation and e version • avulsion of med ial malleolus or rupture of deltoid ligame nt • sp iral fracture of late ral malleolus sta rting at plafond t Type C (supra-syndesmotic) • pure external rotation • avulsion of med ial malleolus or torn de ltoid ligamen t • fibular fracture is ab ove p lafond • freque ntly tears synde smosis • Maisonn eu ve fracture if at p roximal fibula • post erior malleolus avulsed with post erior tibio-fibular ligame nt Treatment t und isplace d fractures: NWB BK cast t disp laced fractures: reduction asap t indications for ORlF • all fracture-d islocations • all type C fractures • trimalleolar (lateral, me dial, p oste rior) fractures • talar shift or tilt • failure to achieve or maintain close d red uction t prognosis dep end ent upon anatomic red uction • high incide nce of post-traumatic arthritis

LIGAMENTOUS INJURIES Med ial Ligamen t Complex (deltoid ligament) t resp onsible for medial stability t usually avulses m ed ial or poste rior malleolus • post erior malleolus = pos terior part of med ial malleo lus

Figure 25. Late ral View of Ligame nts of Le ft Ankle Lateral Ligament Complex (ATFL, CFL, PTFL) t resp onsible for lateral stability t clinical: swe lling a nd d iscoloration t diagnosis: stress x-rays and mortise view • talar inversion produces joint separation excee ding the unaffected side by six degrees Ant e rior Talofibula r Liga me nt (ATFL) t most common ligamentous ankle injury t sprained by inversion and p lantar flexion t swelling and te nde rness ante rior to lateral malleolus t ant erior drawer te st for ankle p ositive with Grad e III ATFL injury • atte mpt to sublux talus anteriorly • if pos itive then stre ss othe r late ral ligaments t inversion stress test for integrity of other ligaments

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Orthop e d ics 35

Notes

ANKLE . . . CONT. Grading and Treatme nt of Ligamen tous Ankle Injuries t Grade I (ligament sprain) • pain • RICE (Re st, Ice, Comp ress ion, Ele vation) t Grade II (ATFL tear) • pain on motion • strap ankle in dorsiflexion and eve rsion • no more th an 6 wee ks, physio for propriocep tive re -training t Grad e III ATFL + CFL te ar • unstable ankle • talar tilt app arent on mortise view • BK walking cast x 3 we e ks, PT for p ropriocep tive re -training RECURRENT ANKLE SUBLUXATION t etiology • ligamentous laxity • internal de rangeme nt of anatomy • intra-articular loose bod y • joint (loss of normal propriocep tion) t treatment de pe nds on cause • ligame nt recons truction for late ral laxity and talar tilt • arthroscopy / arthrotomy for inte rnal de rangeme nt • strengthen ing and b alance training for neuropath ic joint

FOOT TALAR FRACTURE t

60% of talu s covered b y articular surface • blood su pp ly to talus: distal to proximal • fractures of the ne ck at risk of AVN me chanism: MVA or fall from he ight t • axial loading or hype r-p lantar flexion injury • talar neck driven into tibial margin t r/o p ote ntial associate d injuries • spinal injuries • femoral neck fractures • tibial plate au fractures X-Rays t AP/lateral films with CT scan or tomograms of talus Treatment t ORIF: to red uce d isplace me nt and p reve nt AVN or non-un ion Comp lications t undisplaced: 0-10% risk of AVN t displaced: 100% risk of AVN

CALCANEAL FRACTURE t t

mechanism is axial loading r/o p ote ntial associate d injuries • sp inal injuries (10%) • femoral neck fractures • tibial plate au fractures

Physical t heel viewed from behind is wider, shorter, flatter, varus tilt t may be swollen, with bruising on soles X-Rays t Brode n’s views (oblique views of sub talar joint) t Bohler's Angle decreased (normal: 20 - 40 degrees) Orthop e d ics 36

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Notes

FOOT . . . CONT.

BA

BA

Figure 26. Bohle r's Angle Drawing by Marc Dryer 

Treatment t goal is to prevent wide ned hee l and maintain subtalar joint congruency t NWB, early ROM t ORIF if depressed centrally or tongue-type fracture t close d vs. ope n treatme nt is controversial

ACHILLES TENDONITIS t t

chronic inflammation from running and shoe-wear (high heels) may de velop hee l bump s (inflammation of supe rficial bursa overlying lateral insertion of achilles ten don into calcane us)

Diagnosis t pain, aggravate d b y passive stretching t tenderness, swelling t crepitus on plantar flexion Treatment t rest , gen tle stre tching, NSAIDs t proper footwear +/– orthotics t do NOT inject ste roids (prone to rup ture)

ACHILLES TENDON RUPTURE t t

mid tendon or musculotendinous junction spontaneously ruptures • during load ing activity (e.g. sq uash, tennis) • second ary to steroid injection

Diagnosis t history of pain and inability to walk  t ten de rness, palpa ble gap , weak plantar flexion t app rehe nsive to toe -off whe n walking t Thomp son's Test (patient lying prone) • sque ezing calf doe s not p assively plantar flex foot Treatment t low demand or elderly patient • cast with foot in p lantar flexion t high demand or young • surgical re pa ir vs. cast (controve rsial) MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 37

Notes

FOOT . . . CONT. PLANTAR FASCIITIS t

repetitive strain injury of plantar fascia • common in runne rs, jumpe rs, ballet dance rs, obe sity t chronic inflammation due to microtears of plantar fascia History t intense pain o n waking or after re st t subsides as patient walks t may be associated with systemic diseases • diabetes mellitus • ent hes opat hies including seronegative and p ositive arthritis Physical t swelling, local tenderness over plantar fascia • mostly at med ial calcaneal tube rcle t pain with toe dorsiflexion (stretches plantar fascia) X-Ray t some times sho w hee l spur at inse rtion of fascia into me dial calcaneal tubercle t NB spu r is reactive, not the cause of pain Treatment t conse rvative (90% reso lve) • rest a nd NSAIDs x 4-6 mont hs • steroid injection • ultrasound and st retching exercises • supp ortive shoes with hee l cup t surgical in re fractory cases (must r/o ne rve e ntrapme nt as cause of pain first) • release of plantar fascia • 50%e ffe ctive at p ain relief  • spur removal not req uired • can now be done e ndoscopically

BUNIONS t t

two primary causes: heriditary, shoewear Hallux Valgus • may be associated with metatarsus primus varus • valgus alignmen t of MTP joint is aggrevate d b y eccentric pull of EHL and intrinsics • second ary exostosis forms with bursa and thick skin creating the bunion

Treatment t treatme nt is cosmetic and for pain with shoes t conse rvative first • prope rly fitted shoe s and toe spacer t surgical • remo val of b union with rea lignme nt of 1st MTP joint

METATARSAL FRACTURE t

as with the hand, 1st, 4th, 5th metatarsals (MT) are relatively mobile, while the 2nd an d 3rd are fixed

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Notes

FOOT . . . CONT. Table 13. Types of Met atars al Fractures Fra ctu re

Me cha nis m

Clinica l

Tre at me nt

Avulsion of Base of 5th MT

sudden inversion followe d b y contraction of peroneus b revis

tender base of 5th MT x-ra y foot

requires ORIF if displaced

Jone s Fra cture midshaft 5th MT

stre ss injury

p ainful shaft of 5th MT

NWB BK cast x 6 we e ks ORIF if athlete

March Fracture shaft 2nd, 3rd MT

stre ss injury

p ainful shaft of 2nd or 3rd MT

symp tomatic

1st MT Fracture

trauma

painful 1st MT

ORIF if displaced otherwise NWB BK cast x 3 wee ks then walking cast x 2 weeks

Lisfranc Fracture Tarso-MT fractured islocation

fall onto p lantar flexed foot or direct crush injury

shorte ne d fore foot prominent base

ORIF

ORTHOPEDIC INFECTIONS OSTEOMYELITIS t t

b acte rial, viral or fungal infe ction of bone OR b one marrow infants, young childre n, and immuncompromised more sus cept ible than healthy adults t infection can be due to d irect (trauma, surgery) or hem atogenous route • S. aureus (most common cause of hematogenous route) • mixed infection i.e. Staph, Enterobacteriaceae, Pseudomonas (trauma, p ost-op, d iabe tic or IV drug use ) • Salmonella (Sickle Ce ll Dise ase ) • H. influenzae (young children) • M. tuberculosis (affects both sides of joint) History t asymptomatic (chronic) t acute se psis • fe ver, chills, de hydration , leth argy • MEDICAL EMERGENCY t pre sen tation is typically les s acute in ad ults Physical t febrile t local tenderness, swelling, heat at metaphysis, decreased joint motion t neonates • pseudoparalysis • associated with sep tic arthritis t often few signs and symptoms in the adu lt; usually te nde r, inflammation Diagnostic Tests t bloodwork  • ele vate d ESR, serial WBC, C-reactive p rote in • blood cultures b efore antibiotics started (often ne gative in ad ults) t cultures and gram stain from wound or bone biop sy t x-rays • acute: often normal, lucencies ap pe ar after 2-4 wee ks • chronic: onion-skin app earance t bone scan • Indium, Gallium and Techne tium show locally increas ed upt ake; Gallium m ore sp e cific for infection MCCQE 2000 Re vie w Note s and Le cture Se rie s

Orthop e d ics 39

ORTHOPEDIC INFECTIONS

Notes

. . . CONT.

Treatment t blood cultures the n start antibiotics emp irically t surgically drain ab scesse s t if infection occurs after insertion of prosthesis, often have to remove it

JOINT INFECTIONS SEPTIC ARTHRITIS t

routes of spread • hematogenous (most common) • direct spread from adjacen t infection • inoculation

Table 14. Organisms in Septic Arthritis Ag e

Org a n is m s

An t ib io t ic Ch o ic e

0-6 months

S. aureus E. coli

Cloxacillin Tobramycin / Gentamycin

6-36 m on th s

S. aureus H. influenzae

Cloxacillin +/– Ampicillin

>36 m on th s

S. aureus stre p tococci

Cloxacillin +/– Pe nicillin G

Adults

S. aureus N. gonorrhoeae (especially adults < 30 years)

Cloxacillin (S. aureus) Ceftriaxone (N. gonorrhoeae)

t S. aureus - most common cause in ad ults t N. gonorrhoeae - can affect multiple joints;

if disseminated can have te nosynovitis, skin lesions, young adult males t M. tuberculosis - often accompanies bone lesions t others • B. burgdorferi (Lyme dise ase ) • S. schenckii (most common fungal cause) • Salmonella (Sickle Cell disease) • Pseudomonas (IV drug use) History t severe pain t acute sepsis • feve r, chills, d eh ydration, le thargy • MEDICAL EMERGENCY! Physical t local joint tend erne ss, swelling, hea t t neonate s get pse udop aralysis t joint held in slight flexion to reduce intra-articular pressure t unable or unwilling to move joint Diagnostic Tests t blood and throat swab cultures t joint as p irate for cultures , WBC, Gram sta in, ESR, C-reative prot ein t bo ne scan (hip only) • not used to make diagnosis • asse sse s viability of femo ral hea d Treatment t me dical: IV fluids a nd antib iotics, analgesia t surgical: aspiration or I&D

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. . . CONT.

Notes

Complica tions t early • sep tic dislocation • AVN femo ral hea d (increas ed intra-articular pressure due to p us) t late • cartilage and e piphyseal destruction • osteomyelitis Othe r Joint Infe ction s t Reactive Arthritis • post infectious • most common cause streptococci • do not nee d antibiotics (culture is sterile) t Viral Arthritis • hepatitis B, rubella, mumps, parvovirus B19

PEDIATRIC ORTHOPEDICS FRACTURES IN CHILDREN t t t

t

t

t

t t

different from fractures in adults pe rioste um is thicker and stronger in children type of fracture • usually gree nstick or buckle be cause p eriosteum is intact on one or both side s • adults fracture through both cortices ep iphyseal growth p late • plate often m istaken for fracture and vice versa • x-ray opp osite limb for comp arison ligamentous injury • rarely occur in children • mechanism which causes ligame ntous injury in ad ults causes growth p late injury in childre n anatomic redu ction • gold stand ard with adults • may cause limb length d iscrep ancy in childre n (overgrowth) • accep t greater angular de formity in childre n (remo de lling) • intra-articular fractures have worse conse qu ence s in children be cause the y usually involve the growth p late time to heal • shorter in childre n always be aware of the possibility of child abuse • make sure injury mechanism compatib le with injury • high inde x of susp icion, look for othe r signs, includ ing x-ray evide nce of healing fractures at othe r sites

EVALUATION OF THE LIMPING CHILD History t always have high suspicion of abuse t pain, gait t joint stiffne ss (e sp e cially on waking) t systemic symptoms • fe ver, rash, fatigue , we ight loss, GI symp toms t pas t me dical and family history Physical Basic Screening Tests t CBC, differential, blood smear, ESR t radiograph s includ ing joint ab ove and be low Investigations (based on History and Physical) t blood tests • ANA, RF, comp lem e nt • blood culture • CK, APTT, sickle ce ll pre p • immunoglobu lin ele ctroph oresis MCCQE 2000 Re vie w Note s and Le cture Se rie s

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PEDIATRIC ORTHOPEDICS

Notes

. . . CONT.

t t t

urinalysis synovial fluid analysis for crystals, culture, cytology PPD skin te st • +/– ches t x-ray t slit lamp examination t diagnostic imaging • bone scan • gallium scan • ultrasound • CT / MRI t bo ne marrow asp irate Differential Diagnos is t Congenital • de velopme ntal/congenital dysplasia of the hip (DDH / CDH) t Infectious • cellulitis • ne crotizing fasciitis • sep tic arthritis • osteomyelitis t Neoplastic • leukemia • primary bone tumour • ne uroblastoma t Endocrine • SH versus GH imbalance in slipp ed capital femo ral epiph ysis (SCFE) • hypo thyroid ––> b ilateral SCFE t Trauma • joint trauma • Legg-Calve-Perthes d isease (idiopath ic) • SCFE • Osgood -Schlatte r dise ase • pat ello femo ral syndrome t Vascular/hematologic • hemop hilia • sickle cell anem ia • Henoch-Schonlein purp ura t Drugs t Autoimmune • juvenile rhe umat oid arthritis (JRA) • seronegative spondyloarthropathies • SLE • transient synovitis t Toxic/metabolic • osteochondritis dissecans t Other • abuse • hypermobility • growing pa ins • psychogenic

EPIPHYSEAL INJURY

Figure 25. Salte r-Harris Clas s ification o f Epiphys e al Injury Adapted with permission from Dandy, Essential Orthopedics and Trauma, 2nd ed. Churchill Livingstone, New York, 1993.

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Notes

Salte r-Harris Clas s ificat ion t SALT(E)R t Stable (Type I) • transverse through growth plate t Above (Type II, most common) • through met aph ysis and along growth plate t Low (Type III) • through ep iphysis to plate and along growth plate t Throu gh (Type IV) • through ep iphysis and me taphysis t Ram (Type V) • crush injury of growth p late Treatment of Epiphyseal Injury t Type I and II • closed red uction and cast immob ilization • he als well, 95%do not a ffe ct growth t Type III and IV • anat omic re du ction by ORIF since intra-articular, and also to preve nt growth a rrest t Type V • high incide nce of growth arrest • no spe cific treatme nt

PULLED ELBOW t

t t

t t

annular ligament slips between radial head and capitellum • follows pu ll on child's forea rm • rule out child abuse 2-6 years old, due to unde rdeveloped radial head forearm is pronated, painful and “will not move” • point tend erness over radial head • pse ud oparalysis of arm radiographs • not for diagnosis, but to rule out fracture treatment • gent le sup ination while moving from extens ion to flexion • pain relieved and function ret urns immed iately • may immob ilize x 1 da y in sling for comfort

DEVELOPMENTAL DYSPLASIA OF THE HIP t t t

formerly called congenital dysplasia of the hip (CDH) due to ligamen tous laxity and abn ormal slope of acetab ular roof  p red ispo sing factors (5F’s) • Family history, Females (> males), Frank breech, First bo rn, leFt side t spe ctrum of conditions • dislocated fem oral he ad complete ly out of acetab ulum • dislocatable head in socket • head sub luxes out of joint whe n provoked • dysp lastic acetab ulum, more sha llow and m ore vertical than normal t if painful suspe ct se ptic d islocation Physical t d iagnosis is clinical t limited abd uction of the flexed hip (< 50-60 de gree s) t asymmetry in skin folds and glutea l muscles, wide pe rine um t Barlow's test (for dislocateable hip) • flex hips and knee s to 90 de gree s and grasp thigh • fully add uct hips, push p oste riorly t Ortolani's test (for dislocated hip) • initial pos ition as above b ut try to red uce hip with fingertips during ab duction • palp able clunk if redu ction is a positive te st t Galleazzi's Sign • knees at uneq ual heights when hips and knees flexed • dislocated hip on side of lower knee t Trend ele nb urg test an d gait use ful if olde r (> 2 years) MCCQE 2000 Re vie w Note s and Le cture Se rie s

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Notes

. . . CONT.

Imaging t can U/S in first few months to view cartilage t follow up radiograph after 3 months t CT scan (rarely do ne ) Treatme nt and Complications t 0-6 months: Pavlik harness to maintain abduction and flexion t 6-18 months: adductor tenotomy, traction, hip spica (if Pavlik harness fails) t > 18 months: open reduction and pelvic osteotomy t complications • red islocation, inade qua te red uction, stiffne ss • AVN of fe moral hea d

LEGG-CALVE-PERTHES DISEASE t t t

t t

t

t t

self-limited AVN of femoral head e tiology unknown, 20%b ilateral, males more common clinical picture • limping child usua lly 4-10 yea rs old • ten de r over ante rior thigh • de crease d internal rotation, abd uction d iagnosis is clinical x-ray may show • lateral subluxation of femoral head • sub chondral fracture • metap hyseal cyst treat to preserve ROM and preserve femoral head in acetabulum • physiotherap y for ROM • brace in flexion and ab duction x 2-3 years • femoral or pe lvic oste otomy prognosis better in • males < 5 years old with < 1/2 hea d involved complicated by e arly onset OA and de crease d ROM

SLIPPED CAPITAL FEMORAL EPIPHYSIS t t t

Type I Salter-Harris e pip hyse al injury most common ad olescent h ip d isorder, pe ak at 12-15 years risk: male, o be se, h ypothyroid

Etiology is Multifacto rial t genetic (AD, Blacks > Caucasians) t me chanical (growth sp urt, overweight) t endocrine (SH vs. GH imbalance) History t limp with med ial kne e or anterior thigh pain Physical t Whitman ’s sign: with fle xion the re is an ob ligate exte rnal rotation of the hip t restricted internal rotation, abduction, flexion t pa in at e xtreme s of ROM t tender over joint capsule X-Rays t ne ed AP and frog-leg late ral views t posterior and medial slip • if mild slip, AP vie w may b e n ormal or slightly wide ne d growth plate compared with opposite side Treatme nt and Complications t gent ly re du ce with traction, ORIF with p ins, crutches and NWB t complications • AVN (most common), chond rolysis, p in pe ne tration, premature OA, chronic loss of ROM Orthop e d ics 44

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Notes

CONGENITAL TALIPES EQUINOVARUS (CTEV) t t

t

t t

t

also known as club foot 3 parts to d eformity • Talipe s: talus is plantarflexed and me dially rotated • Equinus: ankle is plantarflexed • Varus: heel and forefoot are in varus (supination) may be idiopathic, neurogenic, or synd rome-associate d • examine hips for associated DDH • examine knee s for de formity • examine b ack for dysraphism (unfused verteb ral bod ies) 50%b ilateral, males = fem ales treat b y changing cast q 3 wee ks • correct deformities in orde r • forefoot adduction, ankle inversion, equinus surgical rele ase in refractory case (50%) • posteromed iolateral release of hee l cords and capsule • de layed until 3-4 months of age

SCOLIOSIS Table 15. Etiology of Scolios is Type

Cause

Idiopathic

most common (90%)

Congenital

verteb rae fail to form or se gment

Seconda ry

leg length discrep ancy, muscle spa sm

Neuro muscula r

UMN or LMN lesion, myop athy

Other

oste ochondrod ystrophies, ne oplastic, traumatic

t t

age: 10-14 years more freque nt and more severe in females

Physical t asymmetric shoulder h eight when b ent forward • Ad am’s Te st: rib hum p when b e nt forward t scapulae prominent , flank crease d, p elvis asymmet ric t associated po sterior midline skin lesions • cafe-au-lait spots , dimples, neurofibromas • axillary freckling • hema ngiomas, hair patche s t pe lvic obliquity t associated pes cavus or leg atrophy t apparent leg length discrepancy X-Rays t 3 foot stan d ing films • use Cobb 's method to measure curvature t may have associated kyphosis Treatme nt Base d on Deg ree of Curvature t < 20 degree s: obse rve for changes t > 20 de gree s or p rogressive: bracing (many type s) t > 40 de gree s, cosmetically unaccepta ble or resp iratory problems • requ ire s urgical correction

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Orthop e d ics 45

Notes

BONE TUMOURS t t

primary bon e tumo urs are rare after 3rd de cade metastases to bone are relatively common after 3rd decade

Diagnosis t pa in, swelling, tend erne ss t routine x-ray - describe by: • location (which bone , diaphysis, met aphysis, epiph ysis) • size • involveme nt (cortex, med ulla, soft tissue) • radiolucent , radiode nse or calcified • reaction of surround ing bon e (sclerosis, bo rders) • margin • any path ological fracture t malignancy is suggeste d by rap id growth, warmth, tend erne ss, lack of  sharp de finition t staging should include • bloodwork  • CT chest • liver function test s • bone scan t as much information as pos sible on anatomic extent of tumour (includ ing plain films, tomograp hy, bone scanning, angiograph y,CT, +/– MRI if necessary) should be ob tained prior to biop sy t should be referred to specialized centre prior to biopsy t “if you are not going to resect it don’t biopsy it” t classified into b enign, be nign aggressive, a nd malignant

BENIGN BONE TUMOURS 1. Osteoid Osteoma t age 10-25 years t small, round radiolucent nidus (< 1 cm) surround ed by de nse b one t tibia and femur; diap hyseal t produces severe intermittent pain, mostly at night t characteristically relieve d by ASA 2. Osteochondroma t me taph ysis of long bone t cartilage-cappe d bo ny spu r on su rface o f bone (“mushroom” on x-ray) t may be multiple (hereditary form) - higher risk of malignant change t generally not painful unless impinging on neurovascular structure t malignant degeneration occurs in 1-2 % 3. Enchon droma t age 20-40 years t 35%occur in the s mall tub ular bone s of the hand ; othe rs in fe mur, hume rus, ribs t benign cartilage growth, develops in medullary cavity t single/multiple e nlarged rarefied areas in tubular bone s t lytic lesion with specks of calcification on x-ray 4. Cyst ic Le s ions t include s unicameral b one cyst, ane urysmal b one cyst, fibrous cortical de fect t children and young adults t local pain, pathological fracture or accidental detection t translucent area on me tap hyseal side of growth p late t cortex thinned /expa nde d; well de fined le sion t treatme nt of unicameral bone cyst with steroid injections +/– bon e graft Treatment t in gene ral, curett age +/– bo ne graft

BENIGN AGGRESSIVE BONE TUMOURS 1. Gian t Ce ll Tumo urs t 80% occur > 20 years, avera ge 35 years t distal femur, proximal tibia, distal radius t pa in and s welling t cortex app ears thinne d, expand ed ; well de marcate d sclerotic margin t 1/3 be nign, 1/3 invasive, 1/3 me tast asize t 30% reccur within 2 ye ars o f surgery Orthop e d ics 46

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. . . CONT.

Notes

2 . Os t e o b l a s t o m a t aggressive tumour forming osteoid t lesions > 2 cm in size and grow rapidly t painful t most freq uen t in spine and long bon es (hume rus, femur, tibia) Treatment t controversial, should d o m eta static work up t wide local excision +/– bon e graft

MALIGNANT BONE TUMOURS 1 . Os t e o s a r c o m a t bimodal age distribution • age s 10-20 (60%) • > 50 with history of Paget's d isea se t invasive, variable h istology; freq uen t me tastase s t p red ilectio n for dis tal femu r (45%), tibia (20%) and p roximal hume rus (15%) t history of trauma common t painful, te nd er, poorly de fined swelling t x-ray shows Codman's Triangle: characteristic periosteal elevation and spicule formation repres ent ing tumour exten sion into pe rioste um with calcification t treatme nt with comple te rese ction (limb salvage, rarely ampu tation) adjuvant chemo, radiotherapy 2. Chon dros arcom a t primary: previous normal bone , patie nt over 40; expand s to give pain/pathological, fracture flecks of calcification t second ary: malignant d ege neration of p ree xisting cartilage tumour such as enchondroma or osteochondroma t occurs in pelvis, femur, ribs, shoulder t x-ray shows large exostosis with calcification in cap t highly resistant to chemotherapy, treat with aggressive excision 3. Ewing's Sarcoma t thought to arise from bon e marrow vascular end othe lium t florid periosteal reaction in diaphysis of long bone; ages 10-20 t pre sen t with mild feve r, anemia, leukocytosis and ele vated ESR t moth-eate n ap pe arance with pe rioste al "onion-skinning" t metastases freq uent t treatme nt: chem othe rapy, resection, radiation 4. Multiple Myelom a t most common p rimary malignant tumo ur of bon e in adults t anemia, anorexia, renal failure, nephritis, ESR elevated t oste op orosis, pun ched out lesions, compression fracture t weakness, bone pain t diagnosis • serum/urine p rotein electrophoresis • bone marrow asp irate 5 . B o n e Me t a s t a s e s t PT Barnum Loves Kids t 2/3 from Breast or Prostate t also consider Thyroid, Lung, Kidney t usually osteolytic; prostate occasionally oste ob lastic t bone scan may be helpful Treatme nt (for 4 and 5) t stabilization of impending fractures • inte rnal fixation • IM rods • bone cement

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Orthop e d ics 47