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Orthopaedics Text Bk

Orthopaedics Text Bk

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04/30/2013

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ORTHOPEDICS
Dr. H. von Schroeder Paul Kuzyk, Mark Shekhman and Adam Sidky, chapter editors Anna Kulidjian, associate editor 
 AN APPROACH TO ORTHOPEDICS
. . . . . . . . .
2
HistoryPhysical ExaminationInvestigations
FRACTURES - GENERAL PRINCIPLES
. . . . . .
3
Clinical Features of FracturesInitial ManagementRadiographic Description of FracturesDefinitive ManagementOpen FracturesFracture HealingComplications of FracturesCompartment Syndrome Avascular Necrosis (AVN)
SHOULDER
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
General Principles Acromioclavicular Joint SprainClavicular Fracture Anterior Shoulder DislocationPosterior Shoulder DislocationRotator Cuff LesionsImpingement SyndromeFrozen Shoulder 
HUMERUS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
Humeral Shaft FractureProximal Humeral Fracture
ELBOW
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
Supracondylar FractureRadial Head FractureOlecranon FractureElbow Dislocation
FOREARM FRACTURES
. . . . . . . . . . . . . . . . . . . .
13
General PrinciplesNightstick FractureGaleazzi FractureMonteggia FractureComplications of Forearm Fractures
 WRIST
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
Scaphoid FractureColles’ FractureSmith’s FractureBarton’s FractureComplications of Wrist Fractures
SPINE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16
Differential Diagnosis of Back PainDegenerative Back PainCauda Equina SyndromeTraumaThoracic and Lumbar Spine
HIP
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20
Differential Diagnosis of Hip PainPelvic FracturesHip DislocationHip Fracture Arthritis of the Hip Avascular Necrosis (AVN) of the Femoral Head
MCCQE 2002 Review NotesOrthopedics OR1
FEMUR
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24
Femoral Diaphysis FracturesSupracondylar Femoral Fracture
KNEE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24
Common Knee SymptomsEvaluation of Knee ComplaintsLigamentous Injuries of the Knee Anterior Cruciate Ligament (ACL) Tear Posterior Cruciate Ligament (PCL)TeaMedial Collateral Ligament (MCL)Tear Lateral Collateral Ligament Tear Meniscal Tear Patella/Quadriceps Tendon RuptureDislocated Knee
PATELLA
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
Patella DislocationChondromalacia PatellaePatellar Fracture
TIBIA
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29
Tibial Plateau FractureTibial Diaphysis Fracture
 ANKLE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29
Evalution of Ankle Complaints Ankle FracturesLigamentous InjuriesRecurrent Ankle Subluxation
FOOT
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32
Evaluation of Foot ComplaintsTalar FractureCalcaneal Fracture Achilles Tendonitis Achilles Tendon RupturePlantar FasciitisBunionsMetatarsal Fracture
ORTHOPEDIC INFECTIONS
. . . . . . . . . . . . . . .
34
OsteomyelitisSeptic Arthritis
PEDIATRIC ORTHOPEDICS
. . . . . . . . . . . . . . . .
36
Fractures in ChildrenEvaluation of the Limping ChildEpiphyseal InjuryPulled ElbowDevelopmental Dysplasia of the HipLegg-Calve-Perthes DiseaseSlipped Capital Femoral EpiphysisCongenital Talipes Equinovarus (CTEV)Scoliosis
BONE TUMOURS
. . . . . . . . . . . . . . . . . . . . . . . . . .
39
Benign Bone TumoursBenign Aggressive Bone TumoursMalignant Bone Tumours
SURGICAL PROCEDURES
. . . . . . . . . . . . . . . . . .
41REFERENCES
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42
 
OR2Orthopedics MCCQE 2002 Review Notes
 AN APPROACH TO ORTHOPEDICS
HISTORY
Identification
identifying datainclude: occupation, hobbies, hand dominance
chief complaint
past orthopedic historyinjuries, past non-surgical treatment, past surgeryinvestigations: Xray, CT scan, MRI, etc.
other medical historypast surgery, medical illnesses, allergies, medications
History of Present Illness
important to obtain details regarding onset and progression of symptoms
pain
OPQRST
(
O
nset,
P
rovoking / Alleviating factors,
Q
uality,
R
adiation,
S
ite,
T
iming)muscular, bony, or joint pain ?number of joints involved and symmetry of involvement
inflammatory symptomsmorning stiffness (> 30 min), tenderness, swelling, redness, warmth
mechanical/degenerative symptomsincreased with activity, decreased with restlocking, giving way, instability
 weakness, deformity, stiffness, crepitus
neoplastic and infectious symptomsconstant pain, night painfever, night sweatsanorexia, fatigue, weakness, weight lossmets from (
PT B
arnum
L
oves
K
ids):
P
rostate,
T
hyroid,
B
reast,
L
ungs,
K
idney
activities of daily livinggetting up, sitting down, using bathroom, combing hair, transferring
referred symptomsshoulder pain from the heart or diaphragmarm pain from the neckleg pain from backback pain from the kidney, aortic aneurysm, duodenal ulcer, pancreatitis
PHYSICAL EXAMINATION
Look, Feel, Move
always examine the joint above and below
look - skin, shape, position - compare sides
SEADS: S
 welling,
E
rythema,
 A
trophy,
D
eformity,
S
kin changes
feel - palpate soft tissue, bone, joint lineassess: tenderness, temperature, effusion, deformity
move the affected joint(s)active and passive range of motion (ROM), crepitus present?, instability?passive ROM > active ROM suggests soft tissue inflammation or muscle weakness
neurovascular testspulse, reflexes, power (grade with MRC scale), sensation(most accurate method of eliciting sensory deficits is by ‘two-point discrimination’)
special tests depend on joint
observe gait: walking, heel-to-toe, on heels, on toes
INVESTIGATIONS
Diagnostic Imaging
plain X-rays: 2 views taken at 90º to each other 
CT/myelography, MRI, EMG (electromyelography) / NCS (nerve conduction study)
99Tc (Technetium) bone scanreflects osteoblastic activity or inflammatory reactionpositive with fractures, tumours, local reaction
gallium scanpositive when uptake on gallium is greater than on 99Tcreflects hypervascularity, taken up by leukocytespositive with infection
Blood Tests for Painful, Swollen Joint
CBC, ESR, Rheumatoid Factor (RF), ANA, C-reactive protein (CRP)
 
MCCQE 2002 Review NotesOrthopedics OR3
FRACTURES - GENERAL PRINCIPLES
mechanism: remember the process leading to the fracturetraumaticpathologic - tumour, metabolic bone disease, infection, osteopeniastress - repetitive mechanical loading
CLINICAL FEATURES OF FRACTURES
pain and tenderness
loss of function
deformity
abnormal mobility and crepitus (avoid)
altered neurovascular status (important to document)
INITIAL MANAGEMENT
 ABCDEs
limb - attend to neurovascular status (above and below)
rule out other fractures/injuries (especially joint above and below)
rule out open fracture
take an
 AMPLE
history -
 A
llergies,
M
edications,
P
ast medical history,
L
ast meal,
E
vents surrounding injury
analgesia
splint fracture - makes patient more comfortable, decreasesprogression of soft tissue injury, decreases blood loss
Imaging
RADIOGRAPHIC DESCRIPTION OF FRACTURES
rule of 2s2 sides: bilateral2 views: AP and lateral2 joints: above and below the site of injury2 times: before and after reduction
patient identification
identify views
open or closed (gas in soft tissue = open)
sitewhich boneif diaphyseal decribe by thirds : proximal/middle/distalextra-articular: diaphysis/metaphysisintra-articular 
typespiral - rotational force, low energy (# line > 2x bone width)oblique - angular and rotational forcetransverse - direct force, high energycomminuted (> 2 pieces) - direct force, high energy
soft tissuecalcification, gas, foreign bodies
displacement (position of distal fragment with respect to proximal)apposition/translation - describes what percentage of surfaces remain in contactangulation - describes which way the apex is facingrotation - distal fragment compared to proximal fragmentshortened - due to overlap or impaction
DEFINITIVE MANAGEMENT
goals – “Obtain and Maintain Reduction”reducestabilizerehabilitate
attempt closed reductionsuccessfulunsuccessfulstabilizationopen reduction• cast• external fixationtractionstabilization• internal fixationrehabilitate
Figure 1. Fracture Management

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