ABC orthopedics.pdf

Orthopedics ABCs of medicine By / Ahmed Abd Elmotlb shadan aqeel  ‫بسم هللا الرحمن الرحيم‬ History taking ❖ The first principle step for any diagnosis is hi...

Orthopedics ABCs of medicine By / Ahmed Abd Elmotlb shadan aqeel  ‫بسم هللا الرحمن الرحيم‬ History taking ❖ The first principle step for any diagnosis is history taking ❖ History taking should include about 6 main components 5) past history 1) Personal data 2) Chief or presenting complaint 6) Drug history 3) Present illness 7) Family history 1) Personal data: Name: for identification, communication, registration. Sex: some diseases affect particularly one sex more than the other. e.g. muscular dystrophy (Duchenne type) occurs almost exclusively in boys. Age: certain disorders are seen in certain ages e.g. cerebral atherosclerosis usually doesn’t occur before middle age. Occupation: this might expose the patient to trauma or intoxication, e.g. manganese miner develops Parkinsonism syndrome. Residency: A disease may be endemic in certain localities, as leprosy in certain areas of upper Egypt Marital status Date of admission Complaint: ▪ The patient is asked to mention his present complaints and the duration of each. One must use words by the patient and not their scientific (medical terms), e.g. when he says fainting attacks, you must NOT use syncope instead use fainting ▪ They are arranged chronologically ❖ From gender related diseases Hemophilia in males Gall bladder and thyroid diseases in females  ❖ From age related diseases Hypertension and diabetes mellitus type 2 for elderly people Anemia for children ❖ Note In premenopausal Females, Dyslipidemia is less than in males due to the protective effect of X Chromosome. while, in Post-menopausal Females, Dyslipidemia has the same morbidity as in males. ❖ Residence EX: Rural areas are more liable to bilharziasis ❖ special habits EX: Smoking leads to diseases such as (Respiratory, heart ,GIT diseases) 2)chief or presenting complaint IT should be recorded in patient's own words The complaints should be recorded with their onset & duration If there is more than one complaint, it should be written according to Chronological order 3) present illness site: localized or diffused onset: sudden, acute, sub-acute Duration Course: progressive , regressive , stationary Character: Colicky , burning… Radiation: renal colic is felt in the loin, chest pain is felt in the retrosternal region Pain severity Pain aggravating Factors Pain relieving factors Negative data: ask the patient about symptoms he did not mention 4)Past history Any previous similar attack Chronic diseases: DM or Hypertension Endemic diseases: chronic hepatitis c and B Allergy, Detailed operative/ surgical history 5) Drug history Poly medications: We should take care of the side effects of any new medications Ding to drug interaction Drug hypersensitivity or allergy : We should Perform allergy test every Time before penicillin injection like in tetanus injection 6) Family history Pandemic or infections diseases Familial diseases Consanguinity ❖ If there is marriage between relatives, we should check for possibility of occurrence of conditions such as Down syndrome and hereditary (Congenital) anomalies in the upcoming generation.  Introduction to Fractures: Definition A fracture is break or loss of Continuity of a bone Mechanism of injury. Mechanism of injury The precipitating factor of all fractures is trauma which could be : I. Direct Trauma: In which the injuring force is directly applied the o the bone involved which consequently breaks at the point of impact. The associated soft tissue damage is usually severe. 2. Indirect Trauma: The bone breaks at a distance from the point of impact. It may be torsional (twisting or rotation), hinging (angulation). axial compression or combination of one or more of these forces. Soft tissue damage is usually mild. 3. Muscle violence: Commonly seen at bony prominences at which strong muscles are inserted. e.g. the anterior superior iliac spine, the lesser trochanter, the olecranon and the patella. This is sometimes described as an avulsion fracture  Clinical Features of Fractures: ❖ The history is very important (fall , twisting , direct blow.......….etc.) Symptoms: a- Pain at the site of fracture b- inability to use the fractured part or loss of function (inability to use the upper limb, or inability to stand or to walk). c- Any neurological complaint as in case of fracture spine (loss of sensations; motor power or both). Diagnostic tools: 1- Plain X-rays: The injured part must be examined in at least two views; anteroposterior and lateral views. X-rays must include the joint above and joint below the fracture. as concomitant dislocation may exist. X-ray is important as it shows the level and nature the fracture which any affect the line of treatment The rule of two applies here i.e. - 2 views : anteroposterior and lateral - 2 Joints: above and below the fracture - 2 Limbs: for comparison in some cases (especially in children) 2- CT scan: ls very important as an accurate tool to Visualize the details of the fracture, especially in fractures of the spine. and for all intra-articular fractures. 3- MRI: Essential in diagnosis of son tissue damage as ligaments, muscle, menisci and spinal cord injuries  Treatment of Closed Fractures: I. First Aid treatment: - The aim of the first aid treatment is to save the patient's life by combating shock. arrest of external bleeding and diminishing the soft tissue injury caused by movement at the fracture site. First aid treatment must start at the site of the accident and ends when the patient arrives at the hospital and his shock is overcome. This involves: I- Maintenance of a free airway. 2- Arrest of external hemorrhage. 3- Splintage of the fracture (to minimize pain and prevent further soft tissue damage). 4- Pain killers or sedatives to diminish pain. 5- Plasma and Blood transfusion if needed. 6- Early diagnosis and treatment of visceral injuries. Splints: These are appliances which support or fix a limb. Types of splints include : 1- Improvised splints; which are derived from the scene of the accident and used on the spot e.g. a stick or a piece of wood. 2- Natural splints; when one part of the patient's body is used as a splint, e.g. healthy leg used to splint the fractured one. 3- Fabricated splints, e.g., Thomas splint, back support, forearm splint, cast, sling.... etc. Indications of splints for acute trauma patients: I- Pain relief by immobilization of fracture site 2- To immobilize a limb or part of a limb after injury to minimize soft tissue damage. 3- Prevent further fracture displacement II. Reduction and Immobilization of Fractures: - Reduction is not needed in undisplaced fractures. ln displaced fractures anatomical reduction is the objective. Methods of reduction: 1- Manipulation under anesthesia. 2- Continuous traction. 3- Open reduction.  Indications of open reduction and internal fixation: Failure of conservative treatment. Unstable fractures and segmental fractures, intra-articular fractures. Avulsion fractures as fracture of the olecranon. Presence of soft tissue interposition. Multiple fractures., Pathological fractures. To avoid prolonged recumbency, especially in old age. Methods of Immobilization: The aim is to maintain the corrected position and to apply uninterrupted rigid immobilization until the fracture consolidates. 1- Plaster of Paris (plaster casts): It is the commonest method of immobilization. The rule is to fix one joint above and one joint below the fracture 2- Continuous Traction: Traction overcomes the tendency of a fracture to re- displace because it counteracts the muscle pull. It is especially helpful in fractures of the femur and cervical spine. Traction could be skin traction; when traction is achieved by applying skin strapping on either side of the limb. Or, skeletal traction; when traction is applied trough a Pin or thick wire passed through a bony prominence 3- External Fixators These are special devices which arc applied through the skin to fix fractures of long bones. Usually, they arc a temporary method of fixation commonly used in open fractures, and fracture pelvis. ❖ There are two types of External fixators (Tubular and Circular ) 4- Internal Fixation Usually follows open reduction. Ill. Rehabilitation: - The aim is the restoration of function of the injured part. In fact it begin on the first day after Fixation of Fracture and becomes more active after discarding immobilization.  Types of Implants: 1. Kirschner wires. Used mainly in children and in fixation of small bones as the metacarpals and phalanges 2. Tension band wiring: Used mainly for fractures of the Olecranon and patella. Two K-wires are inserted into the bone fragments after reduction of fracture. Then malleable stainless-steel wire is tied around them to induce compression of the fracture site 3. intramedullary nails: The best example is the interlocking nail fixed by transverse screws passing through holes at both ends of the nail to prevent rotation. 1t is inserted under X-ray control without exposing the fracture site (closed nailing) as for fractures of the femur, tibia and humerus 4. Plate and Screws: A plate is applied to the bone surface and fixed by multiple screws as: fracture shall humerus. 5. Nail plate implants: The best example is the Dynamic Hip screw (DAS) used in Fixation of trochanteric fractures of the femur 6. Prostheses: Examples include the Bipolar prosthesis for hemiarthroplasty of hip in cases of fracture neck of the femur 7. Special implants for fixation of the spine: (Kyphosis, scoliosis) pedicular screw and rods. special spinal Plates and cages  OPEN FRACTURS: Definition: An open fracture is one in which a break in The skin allows For direct communication of the fracture site or fracture hematoma with the environment. The term compound fracture was previously used to describe this injury: however. it is nonspecific Principles of Management: I-Provide airway management and urgent resuscitation Before detailed evaluation of an open fracture takes place, the patient should be stabilized and potential life-threatening injuries must be evaluated and treated. Once the patient is stable, a thorough and systematic search for associated injuries is performed. 2-lmmobilize the injured extremity and apply sterile dressing to the wound. If the patient will be going to surgery within I or 2 hours of injury, the wound can be covered with a sterile bandage and the patient transported to the operating room for definitive irrigation and debridement. If operation is delayed for several hours or the timing is uncertain, we prefer To irrigate the wound with I to 2 L of saline fluid before placing the sterile dressing. Once the sterile dressing is placed, no further wound inspection should be done until the patient is in the operating room. 3-Radiographic evaluation of the injured extremity... Anteroposterior and lateral radiographs are the minimum to properly assess a fracture. Radiographs should be obtained of the joint above and below the site of a fracture in the extremities. The presence of air or gas in the soft tissues on initial radiographs in the presence of a fracture strongly suggests an open fracture. 4. Administer early intravenous antibiotics. It is important in all these cases, as these wounds arc particularly liable 10 infections which include pyogenic organisms, i.e., staphylococcus, Tetanus and Gas gangrene. Prophylactic tetanus toxoid should be given in all cases. 5-Pcrform urgent operative wound debridement and irrigation. These injuries should be operated on within 6 hours of occurrence. where possible, as They are all Potentially infected. 6- Leave the wound open or vacuum seal technique. The biggest risk of primary closure is anaerobic infection resulting in gas gangrene. This can occur even in benign-seeming wounds. [f the surgeon is inexperienced or in doubt, it is wise to leave the wound open. LOCAL NEGATIVE-PRESSURE DRESSINGS: (Vacuum seal technique (VST)) It is the application of negative pressure to wound bed using closed system. Vacuum seal technique (YST) is used to enhance wound healing through negative pressure dressing 7-Skeletal stabilization After initial debridement, stabilization is the next priority. Unless the fracture is inherently stable, some form of skeletal stabilization is usually necessary. The goals of skeletal immobilization are as follows: Restore length and alignment of long bones. Reduce articular surfaces displaced by fracture. Allow access to the traumatic wound. Facilitate further reconstruction procedures. Allow early use of The limb. Facilitate fracture union and return of function. ❖ Plates, screws, and wires must not normally be inserted into open fractures except in special cases: a- clean wounds b- When vascular repair necessitates internal fixation 8-Perform repeated debridement, as needed. A two-phase surgical debridement of the wound may be advisable for severely contaminated wounds. 9-Delay wound closure (delayed primary or secondary suture)/coverage. COMMON COMPLICATIONS OF OPEN FRACTURES 1)Chronic osteomyelitis (bone infection) 2) Delayed union & Non-union.  Humeral fracture: 1-Proximal humeral fracture The surgical neck of the humerus is a constriction below the two tuberosities of the greater tubercle and lesser tubercle. -> lt is much more frequently fractured than the anatomical neck of the humerus ❖ Mechanism of injury o fall on to an outstretched ann. o during seizures or electric shock. o result from a direct blow. o Middle age/elderly are most commonly affected. ❖ Presentation: o History of trauma. o Pain, loss of shoulder/arm function, swelling and bruising ❖ Assessment: o Determine the injury mechanism. o Establish whether osteoporosis is likely. o Assess for associated injuries to the arm/shoulder/chest wall/lungs. o Perform a neurological examination, particularly examining the axillary nerve by o testing for sensation in the regimental badge area over the deltoid muscle. o Assess for brachia! plexus injury through distal neurological examination. o Check peripheral pulses. ❖ Investigations X-rays CT scan ❖ Management: o The fracture should be immobilized as soon as possible. o Most fractures are extra-articular and minimally displaced. They can be treated nonoperatively in a sling or a shoulder immobilizer. ▪ If displaced surgery may be needed : Surgery involves either closed reduction with percutaneous fixation. open reduction and internal fixation, or proximal humeral head replacement. ❖ Complications: 1. Nerve injury 2. Axillary artery injury 3. A vascular necrosis of the humeral head 4. Malunion. 5. Associated glenohumeral dislocation. 6. Associated rotator cuff injury. 2-Humeral shaft fractures: History of trauma is important ,Arm pain, swelling and deformity. ❖ Mechanism of injury: o a simple fall o by direct trauma or indirect trauma due to torsion injury to the upper limb. o Blunt injury and bending forces usually cause transverse fractures. o Torsional force tends to result in spiral fracture. ❖ Assessment: o Neurovascular examination should be performed. o Particular attention should be paid to radial nerve injury. ❖ Investigations: AP and lateral X-rays of the humerus and shoulder include views of the shoulder and the elbow. ❖ Management: o Most fractures can be treated non-operatively in a hanging arm cast or U-shape splint (a splint from the axilla to the nape of the neck with a stirrup around the elbow) followed by afunctional arm brace (this has an anterior and posterior plastic shell held together by adjustable Velcro straps) after 1-3 weeks. o Mildly displaced/overlapping humeral shaft fractures may be treated by closed reduction and long arm splint from shoulder to wrist. After any humeral closed reduction, neurovascular assessment and X-rays should be repeated. o Surgical fixation may be needed if the fracture is displaced, segmental or if there is vascular compromise. This involves open reduction and the use of plates and screws or intramedullary nailing. -> Radial nerve injury is a risk in any operative procedure. ❖ Complications: 1- Radial nerve injury ii- Brachial artery injury. iii- Non-union. 3- Fractures of the distal humerus: ❖ Mechanism of injury: Supracondylar fractures are more common in children. While intercondylar fractures are more common in the elderly. ❖ Clinical features: The patient usually presents with elbow swelling and pain. Careful examination should be made for neural or vascular involvement due to risk of damage to the brachia! artery and nerves. Marked swelling of the forearm or palpable induration of forearm flexors, with pain on passive extension of the fingers, suggests acute volar compartment syndrome requiring emergency fasciotomy. ❖ Investigations: AP and lateral X-rays of the elbow.  Femural fractures 1-Fractures of The Proximal Femur: 1)Fractures of the Neck of Femur: classification of Garden: based on the amount of displacement apparent in the pre-reduction x-rays. o Grade I: is an incomplete impacted fracture in which the femoral head is tilted into valgus in relation to the neck. o Grade II : is a complete but undisplaced fracture. o Grade Ill: is a complete fracture , with moderate displacement. o Grade IV: is a severely displaced fracture. Clinical features: There is usually a history of a fall, followed by pain in the hip. Unless the fracture is impacted. the patient lies with the limb externally rotated. Femoral neck fractures in young adults result from high energy trauma and therefore are often associated with multiple injuries. X-rays : Assessment is done following the Garden classification.  Treatment: If an elderly patient is frail with an undisplaced Garden I fracture, conservative treatment is chosen. Displaced fractures will not unite without internal fixation. Internal fixation: Intra-operatively closed reduction of femoral head should be correctly reduced in both anteroposterior and lateral views under image intensifier control. If a grade IIT or JV fracture cannot be reduced closed, and the patient is under 60 years of age. open reduction 1s performed. Once the fracture is reduced. it is held with cannulated screws or a DHS which attaches to the femoral shaft. Prosthetic replacement: In older patients fracture fixation is not justified. Prosthetic replacement is preferable because: 1- Non-union is very common and therefore replacement carrier a much lower need for revision surgery (nearly four times less) when compared to internal fixation. 2- fracture is pathological and needs excision. Hip prostheses used for femoral neck fractures are categorized as either: Hemiarthroplasty: Only the femoral part is replaced. Older types are the Thompson prosthesis and the Austin Moore prosthesis Currently. the bipolar prosthesis is preferred. Complications: 1. General complications 2. A vascular necrosis of the femoral head 3. Non-union 4. Osteoarthritis of the hip -------------------- 2) Intertrochanteric Fractures: Mechanism of injury The fracture is caused either by a fall directly onto the greater trochanter or by an indirect twisting injury. Clinical features The patient is usually old and is unable to stand. The leg is shorter and externally rotated and the patient cannot lift his or her leg. Tenderness is maximal over the trochanteric area. X-rays Undisplaced, stable fractures may show a thin crack along the intertrochanteric line. More often the fracture is displaced and there may be considerable comminution. The lesser and greater trochanters show as separate fragments. By X-rays the fractures arc classified into stable and unstable fractures. Treatment: intertrochanteric fractures are treated by early internal fixation to get the patient up and walking as soon as possible and thereby reduce the complications associated with prolonged recumbency. Fracture is fixed with an angled device called OHS which maintains the integrity of the fracture by sliding into a stable position. Postoperatively: exercises are started on the day after operation and the patient allowed up and partial weight bearing as soon as possible. Complications: EARLY: Are those of prolonged recumbency such a deep vein thrombosis. pulmonary embolism, pneumonia and bed sores in those elderly patients. LATE: 1. Failed fixation 2. Malunion 3. Non-union -------------------- 3)Sub-trochanteric Fractures Clinical features: The thigh is markedly swollen. Movement is very painful. X-rays: The fracture extends distally through or below the lesser trochanter. It may be transverse. oblique or spiral and is frequently comminuted. The upper fragment is flexed, and the shaft is adducted and displaced proximally. Treatment: Open reduction and internal fixation is the treatment of choice. Two main types of implants are used for fracture fixation: 1-. An interlocking nail with a proximal 2-Dynamic compression screw (DCS) locking sere: which is a 95 degree hip screw-and-plate that can be directed into the femoral device shaft. Complications: I. Mal union 2. Non-union -------------------- 2-Femoral Shaft fractures: ❖ Mechanism of injury: in adults are almost always the result of high-energy trauma. ❖ Clinical evaluation: The patient presenting non-ambulatory with pain, variable gross deformity, swelling, and shortening of the affected extremity. Thorough examination of the ipsilateral hip and knee should be performed. Major blood loss into the fracture hematoma may occur 40% of patients ultimately require transfusions. ❖ Radiographic evaluation: Anteroposterior (AP) and lateral views of the femur, hip, and knee as well as an AP view of the pelvis should be obtained.  ❖ Classification: Descriptive, various presentations of femoral shaft fractures can occur: ❖ Treatment: A-Nonoperative treatment Type IV Skeletal Traction: Only in patients with such significant medical morbidities that operative management is contraindicated. B-Operative treatment Operative stabilization is the standard of care for most femoral shaft fractures. I. intramedullary (IM) 2. External Fixation 3.Plate Fixation ❖ Complications: 1- Neuro-vascular injury II- Compartment syndrome iii- Infection. iv- Nonunion and delayed union. v- Malunion. vi- Heterotopic ossification may occur. 3-Fractures of the distal femur: ❖ Mechanism of injury: In young adults. this force is typically the result of high-energy trauma such as motor vehicle collision or fall from a height. In the elderly, the force may result from a minor slip or fall onto a flexed knee. ❖ Clinical picture: Patients typically are unable to ambulate with pain. swelling, and variable deformity in the lower thigh and knee. Assessment of neurovascular status is mandatory. ❖ Radiological evaluation: Anteroposterior, lateral, and oblique radiographs of the distal femur should be obtained. Radiographic evaluation should include the entire femur. ❖ Classification: i. Open versus closed ii. Location: supracondylar, intercondylar. iii. Pattern: spiral, oblique, or transverse iv. Articular involvement ❖ Treatment: Non-operative o Indications include no displaced or incomplete fractures. impacted stable fractures in elderly patients, severe osteopenia or advanced underlying medical conditions. o In stable, undisplaced fractures. treatment is mobilization of the extremity o a hinged knee brace, with partial weight bearing. Operative o most displaced distal femoral fractures o articular fractures require anatomical reconstruction of the joint surface and fixation with inter fragmentary lag screws Implant screws plates external fixation ❖ Complications i. Neuro-vascular insult around the knee. ii. Mal union. iii. Nonunion and delayed union. iv. Posttraumatic osteoarthritis due to failure to restore articular congruity. v. Infection  Shoulder Dislocation: The gleno-humeral articulation has the greatest range of motion of any joint in the body and as a result is particularly susceptible to subluxation and dislocation. (Mobility on the expense of stability). Classifications: 1- Anterior dislocation: In over 95% of shoulder dislocations, the humerus is displaced anteriorly. ln most of those, the head of the humerus comes to rest under the coracoid process, referred to as Coracoid dislocation. Anterior dislocations are usually caused by a fall the outstretched arm or a direct blow. The patient typically holds his/her arm externally rotated and slightly abducted. Damage to the axillary artery and axillary nerve (C5,C6) may result. Axillary nerve damage results in a weakened or paralyzed deltoid muscle and as the deltoid atrophies unilaterally, the normal rounded contour of the shoulder is lost. 2- Posterior dislocation: Posterior dislocations are occasionally due to the muscle contraction from electric shock or seizure Or fall on outstretched arm with the shoulder adducted and internally rotated Patients typically present holding their arm internally rotated and adducted, and exhibiting flattening of the anterior shoulder with a prominent coracoid process. 3- Inferior dislocation: Inferior dislocation is the least likely, occurring in less than I%. This condition is also called Luxation erecta because the arm appears to be permanently held upward or behind the head.IT is caused by a hyper abduction of the arm that forces the humeral head against the acromion. Such injuries have a high complication rate as many vascular. neurological, tendon, and ligament injuries are likely to occur from this mechanism of injury. Signs and symptoms (Anterior Dislocation): Significant pain, sometimes felt along the arm past the shoulder. Inability to move the arm from its cu1Tent position. Numbness of the arm. Loss of shoulder contour. Some dislocations result in the shoulder appearing unusually square. Empty glenoid cavity. Patient hold the shoulder in external rotation and slight abduction. Associated Injuries: I - Greater tuberosity fracture ii- Axillary nerve injury Diagnosis: By Plain X-rays AP Axillary Lateral in scapular plane Treatment: Acute dislocation: By closed reduction (manipulation under anesthesia). Traction followed by external rotation, then an arm sling immobilization for 4 weeks. Complications.· I - Associated fractures ii- Neglected. iii- Axillary nerve palsy causing Deltoid muscle paralysis with Loss of abduction of shoulder. iv- Recurrence: Most common complication Causes: immobilization. Bony defects Associated glenoid labral tears Treatment: Open or arthroscopic capsulolabral reconstruction  Hip Dislocation: Because of its inherent stability, the pelvis must be subjected to a considerable trauma to cause hip dislocation. Hip dislocations are classified according to the direction of the femoral head displacement. 1. POSTERIOR DISLOCATION Mechanism of injury This is the commonest type of hip dislocation. It usually occurs in a road traffic accident when someone seated in a car is thrown forward, striking the knee against the dashboard. The femoral head is forced out of its socket. In most cases, the dislocated head breaks the posterior wall of the acetabulum, making it a fracture-dislocation. Clinical features The limb is shortened and lies in flexion, adduction and internal rotation. 1n many cases the sciatic nerve is injured by the posteriorly displaced femoral head. Diagnosis X-rays : in the Anteroposterior film the femoral head is seen out of the acetabulum. A segment of the posterior lip of the acetabulum is usually fractured. Plain Films are not enough and therefore a CT scan should always be made to show details of the injury Treatment Closed reduction of the dislocation must be reduced as soon as possible under general anesthesia. Open reduction is resorted to if closed reduction fails or if the reduction is unstable. In this case the posterior acetabular fracture is fixed by plate and screws. 2. ANTERIOR DISLOCATION Anterior dislocation is rare. It occurs by a posteriorly directed force on an abducted and externally rotated hip may push the femoral head out in front of its socket. The femoral head will then lie superiorly (type l - pubic) or inferiorly (type II - obturator). Clinical Features The leg lies externally rotated, abducted and slightly flexed (compare with posterior dislocation). X-rays Plain views will show the dislocation. CT scan is mandatory to show details of the injury. Treatment Closed reduction under anesthesia is performed. Reduction is maintained by skin traction. 3. Central Hip Dislocation A fall on the side, or a blow over the greater trochanter, may force the femoral head medially through the medial wall of the acetabulum. COMPLICATIONS OF HIP DISLOCATION EARLY 1. Sciatic nerve injury: The sciatic nerve is damaged in about I0 percent of cases. In most instances it is in the form of nearapraxia and eventually recovers. If , after reducing the dislocation, a sciatic nerve lesion is diagnosed, the nerve should be explored to ensure it is not trapped by the reduction manoeuvre. 2. Vascular injury: Occasionally the superior gluteal artery is tom and bleeding may be profuse. The tom vessel may need to be repaired or ligated. LATE 1. A vascular necrosis (AVN) of the femoral head: Necrosis is due to interruption of femoral head blood supply when the hip is dislocated. The rate of A VN increases if reduction is delayed by more than 12 hours and therefore early reduction of dislocation is vital. Radiological evidence in the form of increased density of the femoral head may not be seen for at least 6 weeks, and sometimes very much later. A VN usually leads to severe degenerative arthritis which might require total hip replacement. 2. Myositis ossjficans (Heterotopic ossification): This is less common than AVN. The radio logical features of myositis ossificans are faint soft tissue calcification separated from the periosteum by lucent zone. 3. Osteoarthritis of the hip: Secondary osteoarthritis is not uncommon and is due to cartilage damage at the time of the dislocation or ischemic necrosis of the femoral head. In the older patient, total hip replacement is required. ln young patients it is usually delayed.  Osteoarthritis Definition A common degenerative disease Characterized by local degeneration of joint cartilage New bone formation at the base of the cartilage lesion at the joint margins (osteophytes) osteoarthritis is the result of both mechanical and biologic events that destabilize the normal coupling of degradation and synthesis of articular cartilage and subchondral bone there is narrowing of the joint space Risk factors Old age Sex : women are more likely to develop osteoarthritis accident, may increase the risk of osteoarthritis Bone deformities: some people are born with malformed Joints or defective Cartilage, which can increase the risk of osteoarthritis Joint injuries: such as those that occur When playing sports Obesity: carrying more body weight places more stress on your weight- bearing Joints, such as your Knee Other diseases: Bone and Joint diseases that increase the risk of OA include gout, rheumatoid arthritis Paget's disease of bone and septic arthritis Treatment Weight loss Physical therapy (range of motion and strengthening exercises) Occupation therapy (assistive devices , joint protection) Patient education Chemicals: acetaminophen, non-steroidal anti-inflammatory drugs, chondroitin sulfate ,glucosamine Intra-articular injection : glucosamine, steroids , PRP Total hip...replacement -------------------------------------------------------------------------------------- Carpal tunnel syndrome Operation: https://youtu.be/YVPe5WTl5yg https://youtu.be/ub4jKbV_5TI Videos for anterior drawer test: https://youtu.be/CPqex9vMc5Y Knee exam lachman test" ACL injury": https://youtu.be/gfN-p-xZx24 Osteoarthritis: https://youtu.be/sUOlmI-naFs Dislocation of the shoulder joint: https://youtu.be/fbra7BIR2Ns Dislocation of the hip: https://youtu.be/-AmrpUM1Omg Femoral neck fracture fixation: https://youtu.be/yaH3sl3HIq4 Clavicle fracture fixation: https://youtu.be/3x5EQPdvG14 Humeral shaft fracture: https://youtu.be/AGEg0TqwgPo https://youtu.be/UUBm6V1e0fg Lecture about plates designs and functions: https://youtu.be/_2QkHDNRh3Q Lecture about open fractures: https://youtu.be/_5bzvxRFvC4 Lectures of step1: 1:https://drive.google.com/file/d/1lPyFeY1e6GfFdyttwfzsTfBXIoUkzCJk/view?usp=sharing 2:https://drive.google.com/file/d/1dZU2RVPcWed-kCxqmCyl2qYQJWg91MFL/view?usp=sharing 3:https://drive.google.com/file/d/1Hx-23bo_BE5S7PtXn_8R76D89rkbHWRi/view?usp=sharing 4:https://drive.google.com/file/d/1WICCkwAkaRtOPq7_nKT0lAbJL0SiYmg9/view?usp=sharing 5:https://drive.google.com/file/d/1jonylq_qHVR7O_i5I_IprT8Wh88-5BYj/view?usp=sharing " ‫" و من أحياها فكأنما أحيا الناس جميعا‬