Orthopedics Comprehensive Summary PDF

Done By: Alanoud AlZamil, Ahlam AlMutairi, Dana AlOlayet, Heba AlSharif, Hessah AlShehri, Khulood AlRaddadi, Lama AlHomayin, Latifah AlFahad, Maha Adosary, Manar AlEid, Moudi AlDegether, Marwah Zummo, Reem AlAnazi, Rawan AlMutairi, Shroog AlHarbi and Samma AlBukhayyet....

Done By: Alanoud AlZamil, Ahlam AlMutairi, Dana AlOlayet, Heba AlSharif, Hessah AlShehri, Khulood AlRaddadi, Lama AlHomayin, Latifah AlFahad, Maha Adosary, Manar AlEid, Moudi AlDegether, Marwah Zummo, Reem AlAnazi, Rawan AlMutairi, Shroog AlHarbi and Samma AlBukhayyet. Team Leader: Khulood AlRaddadi [email protected] Color Code: Slides Doctor’s Notes Team Notes Important 431 team work Arabic Words Books’ notes Other Sources Orthopedics SUMMARY Table of Contents Lecture 1: Introduction to Orthopedics......................................................................................2 Lecture 2: Diagnostic Imaging & Investigations.....................................................................3 Lecture 3: Compartment Syndrome & Acute Joints Dislocation......................................4 Lecture 4: Principles of Fractures.................................................................................................4 Lecture 5: Degenerative Joint Disorders....................................................................................6 Lecture 6: Open Fracture..................................................................................................................8 Lecture 7: Cauda Equina Syndrome & Acute Spinal Injuries.......................................... 10 Lecture 8: Common Paediatric Fractures............................................................................... 11 Lecture 9: Bone & joint infection................................................................................................ 12 Lecture 10: Common Lower Limb Disorder.......................................................................... 13 Lecture 11: Common Spine Disorders..................................................................................... 16 Lecture 12: Common Adult Fractures...................................................................................... 17 Lecture 13: Common Paediatric Hip Disorders................................................................... 18 Lecture 14: Bone Tumors.............................................................................................................. 21 Lecture 15: Metabolic Bone Disorders..................................................................................... 26 Lecture 16: Sport & Soft Tissue Injuries.................................................................................. 29 Lecture 17: Chronic Shoulder Disorder................................................................................... 31 Lecture 18: Peripheral Nerve Injuries..................................................................................... 34 Lecture 19: Common Foot & Ankle Disorder........................................................................ 35 1 Orthopedics SUMMARY  RED FLAGS: Open Fractures, Complicated Fractures, Compartment Syndrome, Acute joint Dislocations, Multiple Trauma or Pelvic Injury, Cauda Equina Syndrome and Infection of Bone, Joint and Soft Tissue: Osteomyelitis, Septic Arthritis and Cellulitis.  Valgus: when the limb go lateral and the joint go medial.  Varus: when the limb go medial the joint lateral.  Orthopedic Diseases: Congenital and Acquired.  To describe a dislocation, you start by Distal to Proximal fragment: Anterior, Posterior, Inferior, or Superior.  Acute dislocation may be complicated by neurovascular injury.  Acute dislocations require urgent reduction  Intra-articular Fractures: If displaced; should always be treated by ORIF= (Open Reduction and Internal Fixation). Failure to reduce and fix such fracture results in loss of function, deformity and early degenerative changes.  Lachman’s test: To diagnose injury of the anterior cruciate ligament (ACL).  When the mother complains of difficulty in changing the baby’s diaper, think about Developmental Dislocation of Hip (DDH).  Slipped Capital Femoral Epiphysis (SCFE) develops during periods of accelerated growth, shortly after the onset of puberty.  Hyperlordosis is an excessive inwards curvature of the lumbar (lower) spine. It’s very common among females in our society.  Kyphosis is an exaggerated curvature of the upper (thoracic) spine that creates a hunchback appearance.  Scoliosis it is the lateral deviation of the spin from the mid line. o Most of the time it's painless and o Developmental (but it could be congenital). o Mostly affect female more than male. 2 Orthopedics SUMMARY 1. ABCS approach - Assess adequacy of x‐ray which includes proper number of views and A penetration. - Assess alignment of X-rays. Examine bones throughout their entire length for fracture lines and/or B distortions. C Examine cartilages (joint spaces) for widening. S Assess soft tissue for swelling/effusions 2. 2. LANGUAGE OF FRACTURES: Type Open vs closed fracture Distal, Mid, Proximal. Anatomic location Intra‐articular or not Transverse, Oblique, Spiral, Fracture line Comminuted. Relationship of fracture (angulation, displacement, fragments dislocation, etc). o Neurovascular status 3 Orthopedics SUMMARY  Develops when there is excessive, sustained increase of local tissue pressure in a closed compartment so that the process of exchange becomes affected. Normally the pressure of the compartment should be lower than the diastolic pressure by at least 30 mmgh.  Risk factors (causes): Edema – Trauma - Burns – Injection – Bleeding - Prolonged vascular occlusion - Tight bandage - Post-surgery. Compartment syndrome Diagnosis:  Early: Most important sign is PAIN. It increases while stretching and the Presence of Risk Factors.  Late: 4 Ps: Paralysis, Paresthesia, Pallor and Pulslessness.  Time window for CS is 6 Hours. Management:  Initial (undeveloped CS): Maintain normal BP - Remove any constricting bandage - Keep limb at heart level - Regular close monitoring (15-30 minute intervals) - Avoid nerve blocks, sedation and strong analgesia to obtain patients feedback.  Fully developed CS: Maintain normal BP - Remove any constricting bandage - Keep limb at heart level - Diuresis to avoid kidney tubular injury if late - Urgent surgical decompression (Fasciotomy).  Joint stability: bony stability and dynamic stability.  It takes higher energy to dislocate a joint with bony stability than a joint with mainly soft tissue stability.  Connective tissue disorders may lead to increased joint instability due to abnormal soft tissue stabilizers.  Dislocation of a major joint should lead to considering other injuries. Acute Joint Dislocation  Risk group: Major trauma victims - Athletes and sport enthusiasts - Connective tissue disorder patients.  Diagnosis: Hx and PEx – X-ray urgent (no delay) (special views). Management principles: Exclude other injuries - Pain control - Urgent reduction - Check stability - Check NV after reduction – X-ray post reduction - Protect the joint – Rehabilitation - Look for late complications. Complications:  Early: NV injury – CS – Fractures - Osteochondral lesion/fracture - Heterotopic calcification.  Late: Stiffness - Chronic instability - AVN/ avascular necrosis - Arthrosis. 4 Orthopedics SUMMARY Bones Types: 1) Lamellar Bones. 2) Cancellous Bones. 3) Woven Bones. Bones Composition: o Cells (osteocytes, osteoblasts, osteoclasts). o Extracellular Matrix (Organic (35%) Inorganic (65%)). Fracture: Can be described in different ways: Extent – Location – Morphology - Mechanism - Associated soft tissue injuries. Fracture Healing: 1) Indirect bone healing:  A- Hematoma formation (Inflammation phase) (1-2 weeks)  B- Soft Callus (2-3 weeks)  C- Hard Callus (3-12 weeks) D- Remodeling (Years) 2) Direct bone healing. Healing Factors: Complexity, Soft tissue damage, Close vs. open, Periosteal stripping, Malnutrition, Smoking. Principles of Evaluation: o History (What? How? (Mechanism of injury) When? Where?). o Physical Exam (inspection, palpate, range of motion cannot be assessed, vascular exam, peripheral nerve, check the compartment tightness), R/O open fracture, compartment syndrome and N/V injuries. o Investigations (Basic blood works, X-rays of interest, advanced radiological exams if needed). Treatment Pathway: o Reduction (re-align). o Immobilization (Fractures hurt, immobilization relieves pain). o Definitive treatment (indicated when reduction cannot be achieved or held at initial stage). o Rehabilitation (to restore the limb’s function). 5 Orthopedics SUMMARY  Articular Cartilage has poor repairing properties, mostly repaired with fibrocartilage which is less effective than hyaline cartilage.  Synovium is the target of autoimmune reactions.  There are two types of Osteoarthritis primary (idiopathic), secondary Metabolic, inflammatory (RA), endocrine, trauma, etc.  Causes of Osteoarthritis (OA) are increased mechanical stress or weakening of the articular cartilage. Prevalence:  OA is the commonest of all joint diseases.  More common in female.  Osteoarthritis is much more common in some joints (hip, knee, spine and the fingers). The cardinal (major) features of osteoarthritis: 1) Progressive loss of articular cartilage thickness. 2) Subarticular cyst formation and sclerosis. 3) Osteophyte formation. 4) Synovial irritation (synovitis). 5) Capsular fibrosis. Clinical features: Intermittent course, with periods of remission sometimes lasting for months. Symptoms:  Pain: Localized or rarely referred aggravated by exertion and relieved by rest. The most common cause of that is Bone pressure.  Stiffness  Loss of function. Signs: Swelling, deformity (Varus mal-alignment and fixed flexion in OA and valgus and hyperextension in RA), tenderness, limited movement, crepitus and instability. Risk factors: Old age, obesity and trauma. X-rays findings of OA:  Asymmetrical narrowing of the joint space. Symmetric narrowing in inflammatory OA.  Subarticular cyst formation and sclerosis  Osteophyte formation at the margin  Evidence of previous disorders that may have increased OA risk. 6 Orthopedics SUMMARY  Late features: Mal-alignment, Joint subluxation, Bone loss, Loose bodies. Complications:  Capsular herniation  Rotator cuff dysfunction  Spinal stenosis  Loose bodies  Spondylolisthesis at L4/5 Treatment: Depends on Joint (or joints) involved, stage of the disorder, severity of the symptoms, age of the patient and functional needs.  Early Stage of Treatment: o Maintain movement and muscle strength (Physiotherapy). o Protect the joint from ‘overload (Weight-reduction, Shock-absorbing shoes Walking stick). o Modify daily activities (avoiding activities like climbing stairs and squatting) o Medications (paracetamol or NSAIDs).  Intermediate stage of the disease: Indications of surgery: Pain (most common), Sub-laxation, and severe bone erosion.  Joint Debridement (Arthroscopy).  Corrective Osteotomy done in Young, active, mild OA.  Late stage of the disease:  Arthroplasty (Joint Replacement). Two types (total and partial).  Arthrodesis (Fusion) in Small joints like: hand, foot and spine. 7 Orthopedics SUMMARY Open fractures:  A fracture that at some point communicated with the environment.  The bone could be visible within the opening wound at time of presentation or not. That’s why any wound close to a fracture is potentially an open fracture until proven otherwise!!!  If a small wound continuously oozing blood + you see fat droplet within the blood, it is an open fracture for sure.  If poly trauma apply ATLS  If isolated take full Hx (time since injury, past surgical/medical history, allergy, drugs, smoking, when was the last meal)  Asses the affected limp for: (soft tissue , bone , neurovascular status)  Remember to check neurovascular status on arrival, post reduction, and after splinting, before OR, and after OR. Document everything.  Open fracture grade:  Grade 1: less than or equal to 1 cm, < 6 h since injury, clean wound, non- segmental nor severely comminuted.  Grade 2: same as grade 1 except > 1 cm  Grade 3: anything that does not apply on 1 or 2:  3A: any size, > 6 h, no need for soft tissue coverage, extensive contamination of soft tissue.  3B: any open fracture needs soft tissue coverage.  3C: any open fracture needs vascular repair To know whether it is 3B or 3C check for pulse. st  Grade 1 give 1 generation cephalosporin (gram +ve) Ex: cefazolin  Grade 2 cover both gram –ve and +ve by adding Gentamicin  Grade 3 add penicillin to cover for anaerobes such as clostridium  In real life we try to cover for both gram –ve and +ve in grade 1.  In OR: irrigate with normal saline, debride necrotic tissue.  Remove bone fragments without soft tissue attachment except those with articular surface.  Do not close wound on first look. Recheck again after 48-72 hours.  Avoid internal fixator, we use external fixator. 8 Orthopedics SUMMARY Vascular injury:  Hard sign >>> do realignment>>>improved>>> close observation.  Hard sign >>> do realignment >>> persistent >>> vascular intervention.  Orthopedic surgeon goes first to do quick fixation then vascular surgeon to do repair. Nerve injury:  Close fracture that does not needs surgery for fixation but with nerve injury  observe.  Intact before reduction, absent after reduction: usually observe Close fracture requires open reduction and internal fixation but there is nerve injury  limited exploration.  Open fracture with nerve injury  explore, tag nerve ends for later repair. Pelvic fracture:  Fall on one leg causing vertical sheers pelvic fracture. Extremely unstable. Lateral compression, e.g. car accident.  Anterior force causing open book. More survival with open book then lateral compression and least is the. Tetanus vaccination (depends on the wound):  Clean wound: if booster less than 10 years do nothing, if more than 10 years or patient does not know or unconscious give 0.5 ml Td.  Other wounds: if booster less than 5 year do nothing, more than 5 years give 0.5 ml Td. If not known or patient unconscious give 0.5 ml Td + TIG 250U (immunoglobulin). 9 Orthopedics SUMMARY  Red Flags for BACK PAIN: Bowel or bladder dysfunction, Anesthesia (saddle), Constitutional symptoms / malignancy, Khronic disease, Paresthesias, Age >50 yr, IV drug use, Neuromotor deficits.  In order to see both C1&C2 and their articulation; Open mouth (odontoid ) x- ray is required.  Stable injury: One column only (Wedge fracture in anterior column). Treated conservatively.  Unstable injury: Two or more columns. Treated surgically (intervention).  Sympathetic tone loss if fracture above T6.  Central cord syndrome: Characterized by disproportionally Motor deficit worse in UE >LE, sacral sparing.  Anterior cord syndrome: Characterized by loss of corticospinal and spinothalamic tract with preserved posterior column. Which mean loss sense of pain, temperature and motor LE>UE and preserved deep touch, proprioception and vibration.  Brown-Sequard syndrome: Ipsilateral deficit LCS tract & DC and contralateral LST tract.  Conus-medullaris syndrome: Seen in T12-L1 injuries. Mixture of UMN & LMN.  Cauda Equina Syndrome: LMN sign, Bilateral sensory loss, Sciatica (low back pain radiating to thighs and legs) and Sexual dysfunction (late presentation). MRI is mandatory and treated by Emergency decompression.  Wedge fracture (flexion/compression) managed conservatively.  Burst (compression), Chance (flexion/distraction) managed surgically. 10 Orthopedics SUMMARY Children have different physiology and anatomy that’s why they have different fractures. Physeal Classification: Salter-Harris Indications for surgery: o Head injury. o Multiple injuries. o Open fractures. o Displaced intra articular fractures (Salter-Harris III-IV). o Adolescence. o Failure of conservative means (irreducible or unstable fractures). o Severe soft-tissue injury or fractures with vascular injury. o Neurological disorder. o Malunion and delayed union. o Compartment syndrome. Methods of Fixation: o Casting o K-wires o Intramedullary wires, elastic nails. o Screws o Plates o IMN Intramedullary nail o Ex-fix o Combination Common Pediatric Fractures:  Upper limb:  Clavicle: Type I: Middle third, Type II: Lateral third, Type III: Medial third.  Supracondylar Fracture: Flexion Type and Extension Type. Pucker sign.  Distal Radius: Physeal Injuries and Metaphyseal Injuries.  Lower Limbs:  Femur fractures: In children younger than walking age, 80% of these injuries are caused by child abuse. 11 Orthopedics SUMMARY  The causal organism is usually Staphylococcus aureus (found in over 70% of cases).  Sickle-cell disease are prone to infection by Salmonella typhi.  Bone infarction (Sequestrum) = Dead bone. Acute Osteomyelitis  Subperiosteal (Involucrum) = New bone.  C-reactive protein: 4-6hrs (the most sensitive monitor).  ESR: 24-36hrs (takes time to rise).  MRI is the modality of choice.  Bone scan (very sensitive but not specific.  X-ray is not diagnostic.  Definitive diagnosis depends on seeing organisms at direct smear, or culturing organisms.  Empirical IV antibiotic treatment to be started immediately after sending samples for culture.  Sinus tract formation  may occasionally develop squamous cell carcinoma Osteomyelitis  Best test to identify the organism  Operative sampling of deep specimens from Chronic multiple foci.  CT and MRI are invaluable.  Empirical therapy is not indicated. IV antibiotics  must be based on deep cultures. Septic arthritis  Symptoms: like acute osteomyelitis.  Signs: hot swollen joint which is painful to any motion, inability to bear weight  Joint aspiration: WBC >50,000 (>90%PMNL), damaged WBC and No crystals  Rx: Admission for Emergency arthrotomy and washout, broad spectrum IV antibiotics and splintage it’s an emergency.  TB Follicles (tubercle): Lmyphocyte – monocytes, endothelial cells, Langhans Granulamatous bone infection=TB giant cells, Coalesce, Caseation.  Musculoskeletal TB is Secondary to other primary TB lesions (Pulmonary, Renal, LN).  Route of spread: Hematogenous.  MSK targets: Spine (50%), Thoracic (50%).  Neurological compromise (motor>sensory).  Present with Constitutional symptoms: Fever, Weight loss, Night sweats, Anorexia.  T.B of The Spine: (Pott’s disease): Affects the anterior part of the vertebral endplates Causing erosion and destruction and finally anterior wedging of the vertebrae.  Indications of surgery: (Spinal instability requiring stabilization, Abscess drainage if resistant to conservative treatment). 12 Orthopedics SUMMARY 1- Leg ache: is a benign Growing Pain, No functional disability - Diagnosis by exclusion of other Causes of the pain (Tumor – Trauma – Infection). - Pain at long bones of L.L, can be without activity & at night. - Management: Symptomatic (Analgesia, rest, massage), Reassurance. 2- Limp: Abnormal gait due to pain, weakness or deformity. - Antalgic gait (unilateral)  (Trauma – Tumor – Infection). - Painless gait (bilateral)  (Syndromic – Congenital). - Weakness  (general or nerve or muscle), Deformity  (bone or joint). - Above pelvis  (scoliosis) / below pelvis  Hips, knees, ankles, & feet. - Management: treat the cause. 3- In-toeing & out-toeing - Physical Examination: (Foot progression angle, hips rotational profile, Foot Thigh Axis, relation between the forefoot and the hindfoot).  In-toeing: Causes & management: 1. Cerebral palsy and (DDH) 2. Femoral Anteversion  sit cross legged 3. Tibial Torsion spontaneous improvement 4. Forefoot Adduction anti-version shoes, or proper shoes reversal 5. Adducted Big Toe  spontaneous improvement “Allow spontaneous correction (observational management) until 8 years of age”  Out-toeing: - Causes: SCFE and Neuromuscular disorders, external tibial tortion, - Usually does not improve spontaneously - Operative correction: After the age 8y Foot propagation angle >30° Version: Describes normal variations of limb rotation. It may be exaggerated. Torsion: Describes abnormal limb rotation Internal or external 4- Limb Length Inequality: - True (what you Measure) and apparent (what you observe) - Etiology: Congenital (DDH), Developmental (Blount’s), Traumatic, 13 Orthopedics SUMMARY Infection, Metabolic and Tumor. - Adverse effects: Gait disturbance, Equinous deformity, Back pain, Scoliosis. - Evaluation: Clinical: Measuring tape & Giliazi test. Imaging: Centigram. - Management: For shorter limb: Shoe raise, Bone lengthening. - For longer limb: Epiphysiodesis, Bone shortening. 5- Genu Varum and Genu Valgum: - Bow legs (genu varus), Knock knees (genu valgus). - Etiology: Physiologic (bilateral) / Pathologic (unilateral). - Management: Physiological  Observation, Pathological  must treat underlying cause, as rickets. Epiphysiodesis, Corrective osteotomies. 6- TIBIA VARA (BLOUNT DISEASE): - Damage of proximal medial tibial growth plate of unknown cause in Overweight & Dark skinned. - Types: Infantile  < 3y, Juvenile  3 -10 y, Adolescent  > 10y. - Radiological classification M.D.A (metaphyseal diaphyseal angle). - MRI is mandatory in severe cases & Recurrence. - Treatment: Mostly surgical. 7- Clubfoot: - Etiology: Postural fully correctable. - Idiopathic (CTEV) partially correctable. - Secondary (Spina Bifida)  rigid deformity. - Differentiate by exclusion:  Neurological: (Spina Bifida).  Abnormalities Arthrogryposis, Myelodysplasia.  Congenital anomalies: “Proximal femoral focal deficiency” tibial hemimelia.  Syndromatic: Larsen’s syndrome, Amniotic band. - Examination:  Hind foot: Equinus (Ankle joint)=FPF, Varus (Subtalar joint),  Mid & fore foot: Midfoot Cavus, Forefoot Adduction. - Management: Manipulation and serial casts:  Ponseti technique: Validity up to 12 months.  Dennis Brown splints: maintain correction until 3-4y old  Follow up till 9y old. - Indications of surgery: after 12 months Complementary to conservative treatment - Failure of conservative – Recurrence. 14 Orthopedics SUMMARY - Types of surgery  Soft tissue  Bony  Salvage 8- Lower Limb Deformities in CP child - A non-progressive brain insult that occurred during the peri-natal period. Cause by skeletal muscles imbalance that affects joint’s movements. - Physiological classification:  Spastic (most common), Athetosis, Ataxia, Rigidity and Mixed. - Topographic classification:  Monoplegia >one limb affected  Diplegia> all limbs are affected but the lower limbs are more  Paraplegia>only lower limbs  Hemiplegia >one side of the body (arm &leg) affected  Bilateral hemiplegia > both sides are affected but uppers more than the lowers  Triplegia >three limbs affected  Quadriplegia or tetraplegia>all four limbs (+/- trunk, tongue and windpipe) affected. - Examination:  Hip: Flexion, Adduction, Internal rotation.  Knee: Flexion.  Ankle: Equinus, Varus or valgus.  Gait: Intoeing, Scissoring.  - Management: Multidisciplinary approach. - Options of Surgery: Neurectomy, Tenotomy, Tenoplasty, Muscle lengthening, Tendon Transfer, Bony surgery Osteotomy/Fusion. 15  Orthopedics SUMMARY A) Degenerative disc disease. B) Facet osteoarthrosis. Presentation: 1- Mechanical pain: due to joint degeneration or instability. Degenerative spinal disorder (Spondylosis) A. “Axial pain” in the neck or back. B. Activity related-not present at rest. C. Associated with movement: - Sitting, bending forward (flexion). - Standing, bending backward (extension). 2- Neurologic symptoms: due to neurologic impingement: A. Spinal cord –Presents as myelopathy, spinal cord injury. - Myelopathy: chronic.  Loss of motor power and balance.  Loss of dexterity  UMN deficit  Slowly progressive - Spinal cord injury: acute  Spinal stenosis B. Cauda equine: - Radiculopathy: (LMN deficit.) - Conservative treatment is first line of treatment in Spinal Spinal cord or root stenosis. entrapment - Conservative treatment is first line of treatment for mild sciatica without motor deficit (Disc herniation). - Surgical treatment is Indicated for:  Cauda-equina syndrome.  Motor deficit  Failure of 2 months of conservative treatment. Osteoporotic o Treat the underlying cause. Fractures Vertebral o Osteoporosis and osteoarthritis (they happen in old people) but they are not the same. Osteoporosis is metabolic bone disease, and osteoarthritis is a degenerative disease. o Scoliosis: Deformity of the spine in the Coronal plane Deformities o Kyphosis: Deformity of the spine in the Sagittal plane. Spinal o Spondylolisthesis: Translation of one vertebra over another. o Spondylolisthesis: Defect in pars interarticularis causing a forward slip of one vertebra on another usually at L5-S1, less commonly at L4-5. 16 Orthopedics SUMMARY  Clavicle fracture: - Commonly in the middle third of clavicle. - Management mostly is conservative.  Humerus fracture: A- Proximal humerus fracture: - Commonly in the surgical neck. - Can be associated with axillary nerve injury. Upper extremity fractures - In x-ray, we do here 3 views (AP, lateral and axillary view). - Management: if fracture is displaced, surgery is indicated. B- Humerus shaft fracture: - Associated with radial nerve injury. - Treatment usually is non-surgical.  Both bones forearm fractures: I- Both bone fracture. II- Monteggia fracture (i.e proximal/middle third of ulna fracture+dislocation of radius proximally). III- Galeazzi fracture (distal radius fracture+ disruption of DRUJ).  Always this type of fracture is treated with ORIF.  Distal radius fracture: I- Extra-articular (like colle’s and smith fractures). II- Intra-articular* (like Barton’s fracture).  Intra-articular fractures usually treated with ORIF.  Hip fracture: (older) - Lethal. A- Intra-capsular: (supcapital and transcervical). B- Extra-capsular: (basicervical and intertrochantric). Lower extremity fractures - Management differs according to the presence of displacement. Femoral neck fracture (young): take to OR for ORIF within 6 hours  Femur shaft fracture: - Management starts with ATLS then early surgical fixation. - Might be associated with fat embolism and ARDS.  Tibia shaft fracture: - Carries the highest risk of compartment syndrome. - Most common complication is non-union.  Ankle fracture: - Lateral malleolus: Weber’s classification (A,B,C) - Weber’s C is always managed by surgery. 17 Orthopedics SUMMARY 1- Developmental Dysplasia of the Hip (DDH): o The head of femur is not articulating the acetabulum. o The acetabulum is shallow. o DDH is not due to an injury during delivery. Causes: Hormonal (relaxin and oxytocin), Familial, Genetics (more common in females and twin), Mechanical: Pre-natal (Breach, oligohydrominus, primigravida), Post-natal (Swaddling, strapping). Risk factors: Parents who are relatives, Positive family history: 10X, 1st child, Breach presentation: 5-10 X, Oligohydrominus, Twins: 40%, A baby girl: 4-6 X, Torticollis: CDH in 10-20% of cases, Foot deformities and Knee deformities. On Examination: o External rotation o Lateralized contour o Shortening o Asymmetrical skin folds o Limited abduction o Special test (depending on the age):  Galiazzi sign  Ortolani: Pull and abduct, Barlow: Pull and adduct test only till 4- 6 m of age  Hamstring Stretch test  Trendelenburg sign: older comprehending child  Limping:  Unilateral one sided limping  Bilateral waddling gait (Trendelenburg gait) Investigations: o 3 weeks - 3 months: U/S o > 3months: X-ray o After 6 months: reliable Treatment: o Birth – 6m: In OPD: reduce + maintain with Pavlik harness or hip spica (H.S). o 6-12 m: GA + Closed reduction + maintain with hip spica + Open reduction if not return. 18 Orthopedics SUMMARY o 12-18m: GA + Open reduction + maintain with H.S 6w, then B.S cast for months. o 18 – 24 m: GA + Open reduction + Acetabuloplasty + maintain with hip spica 6w, then B.S cast 6wks. o 2-8 years: GA + Open reduction + Acetabuloplasty + femoral shortening + H.S 6w, B.S 4-6wks. o Above 8 years: GA +Open reduction + Acetabuloplasty (advanced) + femoral shortening + (H.S). 2- Slipped capital femoral epiphysis (SCFE): At level of growth plate – Physis - (separating the epiphysis from the metaphysis) Types: 1- Radiological: o Acute < 3wks. o Chronic > 3wks, can see start of callus formation. o Acute on chronic. 2- Clinical: o Unstable: cannot weight bear on that limb. o Stable: can put weight (walk). Typically: o 8-12 years old o In males o In obese o In black o 20 - 25 % chance that the other hip will be affected, within 18m post the 1st hip affection. On Examination: o Hip in ER (external rotation). o With hip flexion the limb goes in spontaneous ext. rotation. o Limited internal rotation & Abduction. o Usually painful ROM. Investigation: o X-ray of pelvis: Positive “Klein Line” Or just wide physis. Treatment: o Aim: prevent further slippage & fuse the physis. o Pin threads pass the physis, & stops 5mm before the articular surface to prevent “Chondrolysis”. 19 Orthopedics SUMMARY 3- Perhes Disease: o At the level of head of femur. o Decreases vascularity of head of femur (avascular necrosis). Cause: unknown Theories of its cause: o Minor trauma (hyperactive child). o A.V malformation. o Virus infection. Typically: o 4-8 years younger than SCFE. o More in males. o More in obese. o Bilateral in 10 – 12% of patients. On Examination: o Decreased Abduction. o Decreased IR (internal rotation). o Usually painful range of motion –decreased- o Limping (painful). o Thigh muscle wasting (disuse). Treatment: o Control pain. o Maintain ROM. o Hip containment. 20 Orthopedics SUMMARY Bone tumors 3- malignant 1- tumor like lesions 2- Benign primary secondary How to describe bone tumors? By describing the Site, centric, border, matrix, periosteal reaction, Geographic appearance and Soft tissue extension. Benign VS malignant: Description Benign Malignant Border Well-defined ill-defined Periosteal reaction Smooth PR Characteristic PR (PR) Matrix Lytic or sclerotic Lytic & sclerotic Soft tissue extension NO Usually Geographic Uniform shape Doesn't have specific shape appearance Usually swelling proceed Usually the pain proceed Symptoms the pain the swelling Tumor like lesions 1- Simple bone cyst (unicameral cyst): o The most common tumor like lesions. o Usually in children age group up to 20 years old Male > Female. o Sites: Common in the end of long bones (e.g. proximal humerus). o Presentation: Usually its presentation is incidental, but patient may present with pathological fracture that cause pain. o Radiological feature: x-ray is the main investigation in benign tumors. 1. Metaphysic lytic lesion. 2. Sclerotic margin, well define. 21 Orthopedics SUMMARY 2- Aneurysmal bone cyst: o Aggressive and balloon-like. o Fusiform cyst and Arteriovenous formation. o Site (common site): Upper humerus, Upper femur, Spine, Proximal tibia and Scapula. o Presentation: The usual presentation is swelling. o Radiological feature: X-ray shows different content inside aneurysmal cyst unlike simple cysts. Benign tumors 1- Fibrous Cortical Defect (Non Ossifying Fibroma): o Benign lesion since birth. o Ec-centric lesion. o Site: Around knee: (lower femur, upper tibia) and Lower tibia. o Presentation: Asymptomatic discovered incidentally. o Radiological Feature: - Metaphyseal lytic lesion - Well defined, sclerotic margin. 2- Osteoid Osteoma: o Usually affects young patients 10-35 and more in males. o May arise in the cortex of long bones, or occasionally in the cancellous bone of the spine and less commonly talus. o Presentation: Usually well localized pain that is worse at night and prevents patients from sleep (Main presentation is pain). o Character of pain: 1. Pain at the site of tumor. 2. Aggravated by activity. 3. Relived by aspirin & NSAID. o Radiological features: - Metaphyseal or diaphyseal lesion. - Lytic lesion (Nidus) inside patch of sclerotsis. 3- Endochondroma: o 15-50 age group. o Tumor grows within the bone and expands it (ballooning). o It composed of translucent hyaline cartilage and content inside is chondroid. o Sites: Mainly small bone e.g. phalangese in hand & foot. o Presentation: - Usually found incidentally. - Swelling. 22 Orthopedics SUMMARY - Pathological fracture which may cause pain. - Affect one side e.g. one hand. o Radiological features: - Metaphyseal or diphyseal lytic lesion. - Well defined. - Sclerotic margin. - Multicentric. 4- Osteo chondroma: o Usually in 10-20 age group and Male > Female. o Painful in children due to growth plate compression and pressure effects on adjacent nerve or vascular structures. o Sites: The commonest are (around knee) distal femur + proximal tibia o Presentation: - Swelling: it can reach huge size o Symptom of complication : 1- Pressure symptom (Pseudo-aneurysm, parasethesia, rendering the movement). 2- Fracture especially with pedunculated type. o Radiological feature: - Metaphyseal lesion. - Mushroom-like stalk of the bony tumor. 5- Giant cell tumor: o From bone marrow. o Occurs most commonly in young adults, 20-40 age groups. o Benign aggressive tumor. o It's only the benign bone tumors that can metastases to the lung. So it's important to get chest x-ray. o Sites: Most common distal epiphysis of radius o Presentation: - Mostly patient present first with: pain, then swelling & later on pathological fracture. - Osteopenia. o Radiological feature: - Epiphyseal lytic lesion. - No new bone formation b/c this new bone will be eaten by the osteoclast. - Radiograph shows lucent regions, lytic destruction of the bone with expansion of the cortex, without a sclerotic rim. 23 Orthopedics SUMMARY Malignant tumors 1- Ewing's sarcoma o Origin: from the endothelial lining of the bone marrow canal. o Most of the Ewing's sarcoma is miss-diagnosed firstly as acute osteomyelitis. o Young age group 5-25 o Pulmonary metastasis can occur. o Sites: - It is the only bone tumor which takes it origin from diaphysis → so; we will find a diaphyseal lesion. - The diaphyses of the femur are the most common sites. o Presentation: Very characteristic: - Febrile patient. - High WBC's. - Local Pain & redness like the presentation of infection - Ulceration of skin. - Swelling. o Radiological feature: X-ray: peal onion reaction. - You think it is AOM→YOU do aspiration for drainage of pus → there will be no pus & you will find tumor tissue →biopsy → Ewing's sarcoma. - So, it is a diaphyseal lytic lesion (not sclerotic). o Investigation: Definite diagnosis made by MRI and biopsy. 2- Osteo sarcoma o 10- 25 year old and Male > Female o Sites: - Arises from primitive bone-forming cells. - Around the knee, Common in the lower femur, upper tibia, and upper humerus. o Presentation: Patient present firstly with pain, then swelling, lastly pathological fracture and Overlying skin is warm due to high vascularity. o Radiological presentation: - Very dense. - Irregular medullary and cortical destruction of the metaphysis. - Sun rise periosteal reaction (surrounded by low dense). o Definite diagnosis made by biopsy. 24 Orthopedics SUMMARY 3- Multiple myeloma: o Arise from plasma cells in the bone marrow. o Occur in old adults > 50 and predominantly Males. o Bence Jones proteins test found in 24-hour urine collection. o Site: Central bones (axial skeleton): skull, ribs, pelvic girdle & spine. o Presentation: - Pt ill (decreased immunity). - Sclerotic (no more elasticity) so more prone to fractures. - In skull there will be pepper (lytic) &salt (sclerotic). - P.t came with bone ach (backache) + osteopenia. o The only one definitive to diagnose it, is Bone marrow aspiration. "Biopsy". 4- Metastatic lesions: o Tumor outside the bone. The most common tumors are: prostate, thyroid, breast, lung and kidney. o More than 45 in age, F