21 - Toronto Notes 2011 - Orthopaedics

OR
Orthopaedics
Frederick Cheng, Chris Farlinger and Caroline Scott, chapter editors
Alaina Garbens and Modupe Oyewumi, associate editors
Adam Gladwish, EBM editor
Dr. Jeremy Hall, Dr. Markb Nousiainen and Dr. Herbert von Schroeder, staff editors
Basic Anatomy Review ................... 2
Differential Diagnosis of Joint Pain . . . . . . . . . 4
Fractures- General Principles . 5
Fracture Description
Management of Fractures
Fracture Healing
General Fracture Complications
Orthopaedic Emergencies ................ 7
Trauma Patient Work-Up
Open Fractures
Septic Joint
Osteomyelitis
Compartment Syndrome
Cauda Equina Syndrome
Hip Dislocation
Pelvis ................................ 10
Pelvic Fracture
Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1
Shoulder Dislocation
Rotator Cuff Disease
Acromioclavicular {AC) Joint Pathology
Clavicular Fracture
Frozen Shoulder
Humerus ............................. 15
Proximal Humeral Fracture
Humeral Shaft Fracture
Elbow ................................ 16
General Principles
Supracondylar Fracture
Radial Head Fracture
Olecranon Fracture
Elbow Dislocation
E pica ndyl itis
Forearm .............................. 18
Radius and Ulna Fracture
Monteggia Fracture
Nightstick Fracture
Galeazzi Fracture
Wrist ................................ 19
Calles' Fracture
Smith's Fracture
Complications of Wrist Fractures
Scaphoid Fracture
Hand ................................. 21
Evaluation of Hand Complaints
Spine ................................ 22
Fractures of the Spine
Cervical Spine
Thoracolumbar Spine
Toronto Notes 2011
Hip .................................. 26
Hip Fracture
Arthritis of the Hip
Hip Dislocation after THA
Femur ................................. 28
Femoral Diaphysis Fracture
Distal Femoral Fracture
Knee .................................. 29
Evaluation of Knee Complaints
Cruciate Ligament Tears
Collateral Ligament Tears
Meniscal Tears
Quadriceps/Patellar Tendon Rupture
Dislocated Knee
Patella ................................ 32
Patellar Fracture
Patellar Dislocation
Patellofemoral Syndrome
Tibia .................................. 33
Tibial Plateau Fracture
Tibial Shaft Fracture
Ankle .................................. 34
Evaluation of Ankle and Foot Complaints
Ankle Fracture
Ligamentous Injuries
Foot .................................. 35
Talar Fracture
Calcaneal Fracture
Achilles Tendonitis
Achilles Tendon Rupture
Plantar Fasciitis
Bunions (Hallux Valgus)
Metatarsal Fracture
Pediatric Orthopaedics ................... 38
Fractures in Children
Stress Fractures
Evaluation of the Limping Child
Epiphyseal Injury
Slipped Capital Femoral Epiphysis (SCFE)
Developmental Dysplasia of the Hip (DOH)
Legg-Calve-Perthes Disease (Coxa Plana)
Osgood-Schlatter Disease
Congenital Talipes Equinovarus (Club Foot)
Scoliosis
Bone Tumours .......................... 42
Benign Active Bone Tumours
Benign Aggressive Bone Tumours
Malignant Bone Tumours
Articular Cartilage Defects ................ 44
Properties of Articular Cartilage
Common Medications ................... 45
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Orthopaedic:a ORI
OR2 Orthopaedics
Basic Anatomy Review
t.llnll cutlniOUI-----1
DIMI af fanlann
(sensory}
AIIXIlrdijlllftllll
s..,erficillis
f'llmll8fll0ry
b111ncha of madim
nM'VI'I
C5
C6
C7
C6
Tl

pnrfunU
(medi114,5 digit&)
ANTERIOR VIEW
F"IIJIRI 1. Malian, Muac1hatenaG11 allll Ulnar Nama: lnnarvalian of Upper Umll M111cl
1'oroDio 2011
Mlllllcutl..au
..,.of ... nn
(sensory)
'IbroDlo Nota 2011
Axillrf
Circl.lllfiiX[

Superficial palmar arch
ANtERIOR VIEW
Figun 2. !Lift) IIDOd SuppiJ tv tile Upp Limb
Buic Anatomy Review
Abduc!Dr

(senaary)
(Rigtd) AdiiJ and Ralial Nem11: lnnarvriDII of the Uppar Limb
Tllllla 1. Saaary and Mlltllr Innervation of tile NerYM in dia Upper and Lowar Exlnmitiaa
Adary Dellail'TEII!!! Miner 1..B1Eni Upper Arm (SagiBII's Patch)
.............. L.atn F011111111
llldilll Triceps L.atn DaiiW11 of tha l*d
EldBn&GII Meclal Forelnn
r.w
'Mist AIIXDII llld Allcllctllrs Vlilr 'l'lauRito Rlldiallh ci Ring Filger
Flaxian ci 1he 1
11
- llijts
111111' 'Mist Aex1111llld Adciu:bn Medial Flnlrm
Orthopudla OR3
POStERIOR VIEW
....
"

....
"lhu.Up": PIN !Radial Nerv11)
"OKS9f: AIN (MINIIn Nerve)
Alllian of 1he .fh - 5I" Digi11 Medial Dolunn Vel of Hand (111111' of Ring and
"Spraad Fingen": Ul111!' NIMI
S" IJVII
Dial Artie Plnlr Aaxiln Slilaffaot
Kn11Raian
lftllt Tae Aexion
lkl,..ticill'--1 AJtil Evrnian Danun of Feat
0., l'lra1elll AJtle Dlniftexian and Inversion 1
11
W&bSpa
Extension
lklrlll I..BIEni Foot
..... u
Anl8ramedial Anlda
OR4 Orthopaedics Basic Anatomy Reriew/DlfFermtial. Diagnoais of Joint Pain 1'oroDio 2011
ANlERIOR VIEW
Common iliac Brtay ---fl-+c.e-
lrrtemal iliac artay
Extamlll iliac Brtay
fiiHnll_,. - -=i!!".iilll'
Lllllnl CUIIIIIIDUI
niiMI of1ha 1liah
Medial CUIIIIIIDUI
niiMI of1ha 1liah
Oblurwbl" narva -!"--!::>"!-!!*--a
Profunda hmoril Brtaly
fi!Hnll utery
Cammanfitu
IPeronaall nerva
SaphanaUI narva
O.ep filM
IPeranaall narva
Suplllficial fitu
IPeronaall nerve
F"111r1 3. Narvas d Arterias Df l.owlr Limbs
POSTERIOR VIEW
I
II
1
,' - l'rvfwld1 hmaris 1rt8ry
flllanllltlry
Mil---Tibial'*""
Cammon fi!ar (pnnlllll)
niiMI
t:at.leal
'I lmnll plllnla' niMI
Medial plantar rw
Madill plllnlllr llt8!y
1.mn11 plllnla' wry
'----l'lln1Br IIIIBry
Differential Diagnosis of Joint Pain
Extrinsic
neurologic (nerve root compression, herpes zoster, etc.)
generalized (fibromyalgia, po1ymya1gia rheumatk:a, siclde cell (ischemic),
dermato/polymyositis)
referred pain
pain originating from surrounding organs
Intrinsic
articular
arthritis (degenerative, rheumatoid. crystal-induced, septic, avascular necrosis)
neoplastic
traumatic (fracture, soft tissue damage, neuropathic arthropathy)
non-articular
bursa. tendons, llgaments. muscle (bursitis, tendonitis, myositis)
'IbroDlo Nota 2011
Fractures - General Principles
Fracture Description
--------------------------------
1. Integrity of Skin/Soft Tiuua
cl.oaed: skin/soft tissue over and near fracture Is intact
open: akin/soft tissue over and near fracture is lacerated or abraded, fracture exposed to
outside environment. continuous bleeding from puncture sl1e or fat droplets in blood suggest
communication with fracture
2. Location (Figure 4}
epiphyse&!: end ofbone, forming part of the adjacent joint
metaphyBeal: the flared portion of the bone at the ends of the shaft.
diaphyseal: the shaft of a long bone (proximal, middle, distal)
physis: growth plate
3. Ortentatlon/Fracture Pattern (Figure 5)
transverse: perpendicular fracture line, direct force, high energy
oblique: angular fracture line, angular or rotational force
buttmly: slight comminution at the fracture site which looks like a butterfly
segmental: a separate segment of bone bordered by fracture lines, high energy
spiral: complex, multi-planar fracture line, rotational force, low energy
comminutedlmultl-fragmenary: more than 2 fracture fragments
intra-articular: fracture line crosses artlcu1ar ca.rtllage and enters joint
compression/Impacted: impaction of bone, e.g. vertebrae, proxlmal. tibia
torus: a buckle fracture of one cortex. often ln children (Figure 49)
green-stick: an incomplete fracture of one cortex, often in cbildren (Figure 49)
pathologic: fracture th.rough bone wakened by disease/tumour
4. Displacement (Figure 5)
nondisplaced: fracture fragments are in anatomic alignment
displaced: fracture fragments are not in anatomic alignment
distracted: fracture fragments are separated by a gap
angulated: direction of fracture apex. e.g. varus/valgus
translated: percentage of overlapping bone at fracture site
rotated: fracture fragment rotnted alxrut long axis of bone
,;-
- - I\ ,,_ \
K.lllpcl8d
L ..
1
a. a..... o.......... F. eanm.lltad H. Anplllllllll
J ......
C Clllfy VuiDTiee 2D11
Figun 5. Fnctun TYJHII
Management of Fractures
ABCs, primary survey and secondary survey (ATLS protocol)
rule out other fractureslinjurles
rule out open fracture
AMPLE history - Allergies, Medications, Past medical history, Last meal, Events IUlTOunding
injury
consider pathologic fracture with history of only minor trauma
additional himrryfphysical:
baseline functional status -handedness (upper extremity) vs. ambulatory ability (lower
ertremlty- note distances, stairs, and use of assistlve devices such as canes, walkers,
wheelchairs, etc.)
Orthopaedla ORS
. -. _Articul.-
......._ cartiiiQI
-......EpPrfAallilll
--l'llriotteum
-CGmpactbn
--MadiJIIry
CIVily
Figure 4. Schamltic Diagram of
tha Lang BDna
...... ' ,

X.IIIJ ..... ., r.
2 lidBI = biillenll
2 villwll = AP + IIIIBnll
2 joints - joint allove + bllow
21inll = blllo11 + 1ft. l'llllctico
...... ' ,
.
VI..,_ ... DIIpllletlll
VIm = Apax -.y frvm midlina
VI._- Apax1oward midlilll
NOTE: dilplllc.ment ref8rl Ia 4hction
"' dabll hgmllll
lnllclli-fllr llpln llldllltiln
NDCAIT
N-nDIHI'Iion
a - opan fraclln
C - n-.Jravuculllr campmmila
A - intrwrtia.llw irlcbn
I - Saller-Harria 3,4,5
1 - polvtnwma
OR6 Orthopaedics
'' ,
..
..._.For liptlelf
Reduces pain
Reduces fur1har dlllliiQII to VBIIIIa,
niii'VIS end ski'l
Reduces risk of inad'IW18ntly
canvatilg cloud ta open fractura
Faclitatas petilllll transport
Flaura I. HsterotGplc
Ollllificatio of Femoral Diaphyllia
aftar fHiur fnleblre 11d
lntrameduiiiY Nailillll
' ,
. .---------------,
Httlrotopic Ollilic:6n
The fomullion of bone in abnormal
IDC81ions (a.g. in IICCindlry tD
pathology.
"' ,
,.---------------,

lschanill to bone due to dilrupted blood
supply; carrmanly in ba11111 covnd by
cartilage.
'' ,
. .---------------,
F1M:tJn .illtw
Flllm!llion of vasidas or bulaelhllt
occur on aclnlltousllll:in avellying 1
frlc1lnd bona.
CRPIII'bllu lynplllhlllir; IJplnJphy
M 11X1Q01i ated raspons1 to an insult in
lhe 8X11'8mitiea; ehanlcblrizacl by iltanse
p.m, llmpandUra uynvnllly, IIIIBma
IDI m1lladnnsary chlngu.
Fradurel- General 1'oroDio 2011
occupation and smoking status
mecbanism of injury
past medical history (note any contraindications to or general anesthetic)
neurovascular status
analgesia
imaging
splint extremity
1. obtain the .reduction (refer to Table 22 for appropriate IV sedation)
closed reduction
apply traction in the long am of the llmb
reverse the mechanism that produced the fracture
reduce with IV sedation and muscle relaxation (fluoroscopy can be used if available)
indications for open reduction - NO CAST (see sidebar, OR5)
other indications include
failed closed reduction
cannot cast or apply traction due to site (e.g. hip fracture)
pathologic fractures
potential fur improved function with open reduction and Internal fiDtl.on (ORIF)
potential compUcations of open reductions
infection
mal-union
non-union
implant failure
new fracture
re-check. neurovascular status after .reduction and obtain post-reduction x-ray
2. maintain the reduction
mernal stabilization - splints, casts, traction, external fixator
internal stabilization -percutaneous pinning, atra.rnedullary fiDtl.on (screws, plates, wires),
intramedullary fixation (rods)
fullow-up- ewluate bone healing
3. rehabilitate to regajn function and avoid joint stiffness
Fracture Healing
Nann11IH--.
Weelcl (H Hematuma, matn111hiiQIII urvund fnll;tura1ite
Wllllks Ostloclasts rllllOW sharp adglls, cellus forms within hematoma
Weelcl 6-12 Bone fonm within lhe ellllu., bridging frln"'-
Months 6-12 Cortical gap ia bridged by bone
Veers 1-2 r Normalarr:lltacbn isacl'iawd tlnugh r1111odalling
Rara 7. Slag of Bone Hllng
Evaluation of Healing: Testa of Union
cJinical.: no longer tender to palpation or streslling on physk:al eum
x-ray: trabeculae cross fracture site. vlslble callus bridging site on at least 3 of 4 cortices
General Fracture Complications
Table 2. General FI'ICture CompliCiti1111s
Early
Compal1ment ByRtama
iliiiY

rmction

Fracture blisters
SIPS is
Deep win 1tmJiiOiii(DVI)
Pulm1111ry amblils !PEl
Al:ule raspi'alary dmss synciane {ARDS)
llamallhagic shack
MallniiHIIIilll
AVBUIII' necllltiis (AVN)
Osteomyelitis
ossilicati111 (Ill)
Post-trunatic arthriW.Icd: llitrnall
Onnic pain synd111ma typa 1 (a!PSVReftaK
dystrophy {RSD)
Toronto Notes 2011 Orthopaedic Emergendea
Orthopaedic Emergencies
Trauma Patient Work-Up
Etiology
high energy trauma e.g. motor vehicle accidents, fall from height
may be associated with spinal injuries or life-threatening visceral injuries
Clinical Presentation
local swelling, tenderness, deformity of the limbs and instability of the pelvis or spine
decreased level of consciousness
consider involvement of alcohol or other substances
Investigations
trauma survey (see Emergency Medicine. Initial Patient Assessment/Management, ER2)
x-rays: !at cervical spine, AP chest, abdo x-ray, AP pelvis, AP and lateral of all long bones
suspected to be injured
other vieWll of pelvis: AP, inlet and outlet; Judet view for acetabular fracture (see Table 15 for
classification of pelvic fractures)
Treatment
ABC DEs and initiate resuscitation to life threatening injuries
assess genitourinary injury (rectal exam/vaginal exam mandatory)
external or internal fixation of all fractures
DVT prophylaxis
Complications
hemorrhage -life threatening (may produce signs and symptoms of hypovolemic shock)
acute respiratory distress syndrome (ARDS)
fat embolism syndrome
venous thrombosis - DVT and PE
bladder/bowel injury
neurological damage
possible obstetrical difficulties in future
persistent sacro-iliac joint pain
persistent pain/stiffness/limp/weakness in affected extremities
post-traumatic arthritis of joints with intra-articular fractures
sepsis if missed open fracture
Open Fractures
Definition
fractured bone in communication with the external environment
Emergency Measures
removal of obvious foreign material
irrigate with normal saline
cover wound with sterile dressings
IV antibiotics (see Table 3)
tetanus status booster
splint fracture
NPO and prepare for OR (bloodwork, consent, ECG, CXR)
operative irrigation and debridement within 6-8 hours to decrease risk of infection
traumatic wound often left open to drain but vac dressing may be used
re-examine with repeat I&D in 48 hrs
Orthopaedics OR7
It'
Orthop...&c Emer.-ils
VON CHOP
Vascular compromise
Open fracture
Nlurolovical compromisr/Ceudalquina
5yndrome
Cornpanmentsyndroma
Hip dislocation
Ostllomyalilif/SIIplic lll1luilis
Unstable Pelvic fnlcture
...... , ,
.. .----------------.
Buck' Tractian
A ay&tBrn of wuighll, puUsy1 and
ropes 1hat are lttlched 1D the end of
a patient' I bed exerting alongiludinll
fDn:a on 1h1 distal and of a fnlcbn,
improving its alignment.
...... , ,
.. .----------------.
33'110 of patilllll$ wi1t1 open fnlc:turvs
hav1 mullipla injuries.
OR8 Orthopaedics
.... , ,
..
Plllm film fblinp in Saptlc Joint
[0-3 days) - usuelty normal.
May snow soft-tissue $Welling or joint
space widening from loclllizad adama
LD [4-6 days) -joint lfiiC8
niiTOWinQ and destruction of cartilage
.... , ,

Pllin flm findinp of 0......,_.
1. Soft tissueiW&lling
2. Lytic bone destruction
3.1'8riomel r1111dion [funnation of new
bone, Blplcially in raspon11 to#)*
*G-raDy not sean on plain films until
10-12 days after onset of infection.
.... , ,

Acute osteomyelitis is medical
amarvancy which raquil'lll an allly
diagnosis ll1d approprim antimicrobial
and surgical traatmant
Orthopaedic Emergencies
Teble 3. Gustilo Classification of Open Fractures
Gustilo l.englll of Open Descriptian
Gl'lde Wound
I < 1 em Mininal contamination and soft tissue
injury
1-10cm
Ill* >10cm
or mini11111lly conminuted
lraclure
Moderate contamination
Soft tissue injury
lilA: Ex11111siw soft tissue injury with
ade abiity of soft tissue to cover
wound
IIIB: Extensive soft tissue injury with
pariosteal stJ1lping and bone axposure;
inadequlllll soft tissua1D covar woL.Ild
IIIC: Vascular injury/compromise
Toronto Notes 2011
First generation cephalosporin (cefazclinl for
3days
First generation cephalosporin (cefazclinl for
3 days plus
Gram.f'legative coverage (gentamicin! for at
l1111st 3 days
First generation cephalosporin (cefmlinl plus
Gram.f'legative coverage (gentamicin! for at
least 3 days
For soil contamilation, penicillin is added for
clostridial coverage
Ant injury; carminuted filiCIJ.ne, Viat p. conllrninllian, eliiiiJU8111 mlllorl. ar frlcture more 1liln 8 hcus old is cllssilied IS
linda Ill
Septic Joint
--------------------------------------------------------
Etiology
most commonly caused by Staphylococcus aureus in adults
consider coagulase-negative staph in patients with prior joint replacement
consider Neisseria gonorrhoeae in sexually active adults
most common route of infection is hematogenous
inability/refusal to bear weight, localized joint pain, erythema, warmth, swelling with pain on
active and passive ROM, fever
Investigations
x-ray (to r/o fracture, tumour, metabolic bone disease), ESR, CRP, WBC, blood cultures
joint aspirate (WBC >80,000 with >90% neutrophils, protein level >4.4 mg/dL, joint blood
glucose level, no crystals, positive Gram stain results)
rule out heart murmurs
Treatment
IV antibiotics, empiric therapy (based on age and risk factors), adjust pending joint aspirate
C&S
for small joints: needle aspiration, serial if necessary until sterile
for major joints such as knee, hip, or shoulder: urgent decompression and surgical drainage
Osteomyelitis
Etiology
most common organism is Staphylococcus aureus
consider Salmonella typhi in patients with sickle cell disease
neonates and immunocompromised patients are susceptible to Gram-negative organisms
hematogenous (bacteremia) or exogenous (open fractures, surgery, local infected tissue) spread
localized extremity pain fever or swelling 1 to 2 weeks after respiratory infection or infection
at another non-bony site
Investigations
blood culture, aspirate cultures, ESR, CRP, CBC (leukocytosis)
x-ray, bone scan (increased uptake within 24-48 hours after onset in majority of patients), MRI
most sensitive/specific
Treatment
IV antibiotics, empiric therapy, adjust pending blood and aspirate cultures
surgical decortication and drainage local antibiotics (e_g. antibiotic heads) ifMRI suggests an
abscess or if patient does not improve after 36 hours on IV antibiotics
serial I&D (if required), IV antibiotics eventually changed to PO, splint limb for several weeks
followed by protective weight-bearing of the limb
Toronto Notes 2011 Orthopaedic Emergendea
Compartment Syndrome
----------------------------------
Definition
increased interstitial pressure in an anatomical "compartment" (forearm. calf) where muscle
and tissue are bounded by fascia and bone (fibro-osseous compartment) with little room for
expansion
interstitial pressure exceeds capillary perfusion pressure leading to muscle necrosis (in 4-6 hrs)
and eventually nerve necrosis
Etiology
intracompartmental: fracture (particularly tibial shaft fractures, pediatric supracondylar
fractures, and forearm fractures}, crush injury, revascularization
extracompartmental: constrictive dressing (circumferential cast), circumferential bum
lncrllln;ud pr866Ln from blood
and intracomparantal swellilg I
Dacraasad vanous dn1inaga into tissue
Decrauad lymphdic lhinaga surrounding
t
lntncompartmental pressure Leaky basement
greater th1111 perfusion pressure
t
Acidosis ..._ _______ Muscle and ----- Musc:leand
nerve anoxia nerve necrosis
Figura B. Pathogenesis of Comparbnent Syndrome
Physical Examination
pain with passive stretch
5 P's: late sign (see sidebar}
Clinical Features
pain with active contraction of compartment
pain with passive stretch
swollen, tense compartment
suspicious history
Investigations
usually not necessary as compartment syndrome is a clinical diagnosis
in children or unconscious patients where clinical exam is unreliable, compartment pressure
monitoring with catheter AFTER clinical diagnosis is made (normal = 0 mmHg; elevated
0!:30 mmHg or S30 mmHg of diastolic BP)
Treatment
non-operative
remove constrictive dressings (casts, splints}, elevate limb at the level of the heart
operative
urgent fasciotomy
48-72 hours post-op: wound closure necrotic tissue debridement
Specific Complications
rhabdomyolysis, renal failure secondary to myoglobinuria
Volkmann's ischemic contracture: ischemic necrosis of muscle, followed by secondary fibrosis
and finally calcification; especially following supracondylar fracture ofhumerus
Cauda Equina Syndrome
see Neurosurgery. NS27
Orthopaedics OR9

5 P" of Compulnlm Syndrome
Pain
Out of proportion for inilrf
Not relieved by .,lllgesics
lncllliiSed with pBSSive mtl:h
rJf compartment musdas {most
11)8Cilicl
Pallor: 111111 finding
Pamthesill
Pmlysis: late finding
Pulsalessnen: 111111 findilg
', ,

MDR impDrlenl aign ill incraasud p11in
with passive stretdl. Most important
symptom ill pain out of proportion to
injwy.
', ,

Cauda equina syndrome ill a survical
lnlll'glllCY.
ORlO Orthopaeclica
'' I ..
Up 1o 50'J. "' palientlll willt lip
dillacationa suffar fnlctum aluwhn
at 1ht ti11111 of injry.
3. Exilmll mtatian
2. lniMIII mtatian-.<L '.
- --;- t l'
I
I.
'il l

0 Jonll SM Clan 20Q8
F"111111 9. Rachadar Method
, I

llllchallblr Mdloo to llad11:8
Dillacllil11
Patiantlyilg 1141ila wi1h lip .. d lcnaa
flexed on injullld tide
Surgaan llbnla an pllianl'a injlnd
side
Surgeon ,._ one arm 111dar
pltianl's flarad tnll, IBIIChilg to
place111at hind Dn patianl's Dlhlr
knee llNl 8Uppclrtmg patient';
irj.Jred legl
Willi Dlhar hind, 8UrgBDII tp1p1
Pllillllt' lOde an ililllld ide.
applying 1nldion
RIDrction vii. lnll:tion, int. ralldion,
1htn ut. rotnan once fwmcnl hllld
ci11811IIC8!Bilulao- m.
Figur.1 D. Nvic Calums
Anbrior
co 111m
1'oroDio 2011
Hip Dislocation
full trauma survey (see see Rmelency Medicine, Initial Patient Assessment/Msmagement, ER2)
examine for neurovascular injury PRIOR to open or clo&ed reduction
reduce hip dislocations ASAP (ideally within 6 bOUill) to decrease risk of AVN of the femoral
head
hlp precautions (no extreme hlp flexion, adduction, internal or external rotation) for 6 weeks
post-reduction
also see Hip Dislocation after THA, OR28
ANTERIOR HIP DISLOCATION
mechaniam: posteriorly directed blow to knee with hlp widely abducted
clinical features: shortened, abducted. externally rotated limb
treatment
clo3ed reduction under consdous sedation/GA
post-reduction CT to assess joint congruity
POSTERIOR HIP DISLOCAT10N
most frequent type ofhip dislocation
mechanism: severe force to knee with hip flexed and adducted
e.g. knee into dashboard in motor vehicle accident (MVA)
clinical features: shortened, adducted and internally rotated U:mb
treatment
closed reduction under conscious sedation/GA only if associated femoral neck fracture
ORIF if unstable, intra-articular fragments or posterior wall fracture
post-reduction CT to assess joint congruity and fractures
if reduction is unstable, put in traction x 4-6 weeks
CENTRAL HIP DISLOCATION (rare)
traumatk: injury where femoral head la pushed through acetabulum toward pelvic cavity
COMPUCAT10NS FOR ALL HIP DISLOCAT10NS
post-traumatic art:hriti8
AVN
fracture of femoral head. neck. or shaft
sclB.tic nerve palsy in 2596 (1096 permanent)
heterotopic osslfica.tion (HO)
thromboembolism- DVT/PE
Pelvis
Pelvic Fracture
Mechanism
young: high energy trauma, either direct or by force transmitted longitudinally through the
femur
elderly: fall from standing height. low energy trauma
Clinical Features
local swelling. tenderness
deformity of lower extremity
pelvic instability
Investigations
x-ray: AP pelvis, inlet and outlet for pelvic fracture
Judtt films (obturator and iliac oblique) for acetabular fracture
6 cardinal radiographic Unes of the acetabulum: illoischial Une, iliopectlnealllne, tear drop.
roof, posterior rim. anterior rim
CT scan useful for evaluating posterior pelvic injury and acetabular fracture
Toronto Notes 2011 Pelvis/Shoulder
Classification
Table 4. Tile Classification of Pelvic Fractures (see Figure 11}
Type Stability Description
A Rotationally stable A 1 : fracture not involving pelvic ring
Vertically stable A2: minimally displaced fracture of pelvic ring {e.g. ramus fracture)
B
c
Rotationally unstable
Vertically stable
Rotationally unstable
Vertically unstable
Treatment
ABCs
81 : open book
82: lateral compression- ipsilateral
83: lateral compression- contralateral
C 1 : unilateral
C2: bilateral
C3: associated acetabular fracture
assess genitourinary injury (rectal exam, vaginal exam, hematuria, blood at urethral meatus)
if involved, the fracture is considered an open fracture
stable fractures - nonoperative treatment, protected weight bearing
indications for operative treatment
unstable pelvic ring injury
disruption of anterior and posterior SI ligament
symphysis diastasis >2.5 em
vertical instability of the posterior pelvis
Specific Complications (see General Fracture Complications, OR6)
hemorrhage (life-threatening) - 1500-3000 ml blood loss
injury to rectum or urogenital structures
obstetrical difficulties
persistent sacroiliac (SI) joint pain
post-traumatic arthritis of the hip with acetabular fractures
high risk of DVT /PE
Shoulder
Shoulder Dislocation
the glenohumeral joint is the most commonly dislocated joint in the body since stability is
sacrificed for motion
Prognosis
recurrence rate depends on age of 1st dislocation: <20 yrs = 65-95%; 20-40 yrs = 60-70%;
>40 yrs = 2-4%
tuberosity fracture, glenoid rim fracture (Bankart lesion), humeral head impaction (Hill-Sachs
lesion)
rotator cuff or capsular tear, shoulder stiffness
injury to axillary nerve/artery, brachial plexus
recurrent/unreduced dislocation (most common complication)
ANTERIOR SHOULDER DISLOCATION (>90%)
Mechanism
abducted and externally rotated arm or blow to posterior shoulder
Clinical Features
pain
arm held in slight abduction, external rotation; internal rotation is blocked
"squared off" shoulder
+ve apprehension test: apprehension with shoulder abduction and external rotation to 90 since
humeral head is pushed anteriorly and recreates feeling of anterior dislocation
+ve relocation test: a posteriorly directed force applied during the apprehension test relieves
apprehension since anterior subluxation is prevented
Orthopaedics ORll
Type A
Stable Awlsion Fracture
Type A
Unstable Vertical Fracture
Figure 11. Illustration ofthe Tile
Classification of Pelvic Fractures
', ,

There are 4 Joints in the Shoulder:
glenohumeral, acromioclavicular (AC),
sternoclavicular (SC), scapulothoracic.
', ,

Factors Causing Shoulder Instability
o Shallow glenoid
o loose capsule
o ligamentous laxity
1. Manubrium
2. Sternoclavicular joint
3. Clavicle
4. Coracoid process
5. Acromioclavicular joint
6. Acromion
7. Humerus
8. Glenohumeral joint
9. Scapula
Figure 12. Shoulder Joints
ORI2 Orthopaeclica
Silica sign
PaltlriDr 11111'111....-liga
Figure 1 3. Apprehlllion Tam
f"llllnl 14.
Traction-CaiiiiiBrtractiaa
R
.
E

i
0
Figure 1 5. AIIIBriar DiiiDCatiaa
C.111i1111 Hii-Sachs and Banmt
LIISia
Shoulder 1'oroDio 201 1
+ve sukus sign: presence of subaaomial indentation with distalttacti.on on humerus lndl.cates
Inferior shoulder instability
neurovascular enm including:
uillary nerve (sensory patch over deltoid and deltoid contraction)
musculocutaneous nerve (sensory patch on lateral forearm and biceps coutraction)
Tabla 5. AI EBM Parapactin aa Taibi af AIIIBriar sauldar llllblblity
Appnhllllilll Rakaliaa
....
landivq 52..78% 45.83% 63.89%
Spacificily 98.91% 54.35% 98.91!o
PPV 97.m 43.8&r. 98.221
NPV 1l.m 56.26% 77.86!.
Investigations
x-rays: AP, trans-sapular, axillary
X-Ray Findings
dislocation
uillary view: humeral head is anterior
trans-scapular view: humeral head is anterior to the centre of the "Mercedes-Benz sign"
Hill-Sachs lesion: divot in posterior humeral head due to forceful impaction of an anteriorly
dislocated humeral head against the glenoid rim {Figure 15)
bony Banbrt lesion: avulsion of the anterior glenoid labrum (with attached bone
from the glenoid rim
Treatment
closed reductl.on with IV sedation and muscle rel.uation
2methods
traction-countertraction: assistant stabilizes torso with a folded sheet wrapped across the
chest: while the MD applies gentle steady traction (see Figure 14)
Stimson: whlle patient lies prone with arm hanging over table edge, hang a 5lb weight on
wrist fur 15-20 min
obtain post-reduction .x-rays
check post-reduction neurovascular status (NVS)
sling x 3 weeks, followed by shoulder rehabilitation
POSTERIOR SHOULDER DISLOCATION (5%}
up to 60-8096 are missed on initial presentation due to poor physical cum and radiographs
Mechanism
i adducted, Internally rotated, fleud arm
::1 fall on an outstretched hand (FOOSH)
i 3 E's (epileptic seizure, EtOH, electrocution)
o!! blow to 81112rior shoulder
0
Clinical Features
arm is held in adduction and internal rotation; external rotation is blocla:d
anterior shoulder flattening, prominent coracoid, palpable mass posterior to shoulder
posterior apprehension ("jerk") test with patient supine, 8eJ: elbow and adduct, internally
rotate the arm whlle applying a posterior force to the shoulder; patient will "jerk"' back with the
sensation of subluxation
Investigation
x-rays: AP, trans-scapular, axillary
X-Ray Findings
dislocation
AP view: partial vacancy of glenoid fosaa (vacant glenoid sJgn) and >6 mm space between
anterior glenoid rim and humeral head (positive rim sign), humeral head may resemble a
Ughtbulb due to internal rotation (Ughtbulb sign)
axillary view: humeral head is posterior
trans-scapular view: humeral head is posterior to centre of"Mercedes-Benz sign
reverse Hill-Sachs lesion (7596 of cases): divot in anterior humeral head
reverse bony Bankart lesion: avulsion of the posterior glenoid labrum from the bony glenoid
rim
'IbroDlo Nota 2011 Shoulder
Treatment
cloaed reduction: inferior traction on a flexed elbow with presmre on the back of the humeral
head
obtain post-reduction x-rays
check post-reduction neurovascular status
aUng .1: 3 weeks, fullowed by shoulder rehabilltat!on
Rotator Cuff Disease
rotator cuff am&lsts of 4 muscles that act to stabilize humeral head within the glenoid
fossa
Tillie I. RotaiDr Cliff Muacl81
Muse Ia r.\llcloAIId..-s
NineS-
...........
....... inalu ..,. greallr tub1111Sity af .scap.dar IWilMI AbiU:Iian
hl.llleiUS
ScaptAB ..,. grea11!r tuberosity of scap.dar nerve ExlemBI rablliiJI
h1.11181U1
T-Mi1ar StaptAB greallr tub1111Sity af AxililryiWilMI Exlemlll ratltiiJI
h1.11181U1
...... ri. StaptAB IIISSIII' tullerollily llf lramal nrtation and adduelion
humerus
SPECTRUM OF DISEASE: IMPINGEMENT. TENDONITIS, MICRO OR MACRO TQRS
Etiology
compression of rotator cuff tendons (primarily supraspinatus) and subacromial bursa between
the head of the humerus and the acromion; leads to bursitis. tendonitis and. if left untreated. can
lead to rotBtDr cuff thinning and tear
anything that leads to a narrow subacromial space
1. glenohumeral muscle weakness leadiDg to abnormal motion of humeral head
2. scapular muscle weakness leading to abnormal motion of acromion
3. acromial abnormalities such as congenital narrow space or osteophyte formation
Clinical Features
night pain and difficulty sleeping on affi:cted side
pain wone with active motion
weakness and loss of range of motion (e.g. trouble with overhead activities)
tenderness to palpation over greater tuberosity
Tillie 7. RotaiDr Cliff 5Jieclal TIIIB
Tilt Ellllnilllliln
Jalle'alllll Supraspinatus - plica tha llhauldar il 90 dagi'IIBS of abcD:tian and Waalinass with IIC!iva ra&istance suggasll
30 daw- of folward flaxiln and in!lmllly ra1B111tla11111 aa lhBI !Bilr
1he 1lum is pointing tuwlld the floor (Fii!IR 171
IJI.oll Tilt - iamlly 1'011118 arm aa dcnaiiUrface Dllald 111118 llllbility ta ICiivaly lift 111111 tiNIV !Jan bD
Ill klwar bact Patient ins1nl:tad to actively lift 111111 Wft/ from Suggesl$ I &lisclp!Mri& till
bade agailst IICIIminer resis1Jrlce (Fi!Ju8 171
l'lllllriDIIGIII and Teres mincr-11111 positioned at patiem's side in Weabess with active resislllnce suggests
Tilt 90 of llalticn Patient instructad ID llldemlly 1'011118 arm pas1iliar cuff tallr
agailst lhi18Sistlnca af 1lla mminer (Figura 1 1)
Nwa Tilt RalaiDr OM - passMI aluudar ftaxian (IVJre 181 Pain elic:itad blltwaan 130-170
IUUIJIIIII
II_... RalaiDr OM -shoulder flexillll ta 90 de!Jees and Pain with internal mbdion suggests
r.-fr'lilll: passivllmlllllralltian(Fp191
PlllfU An: 'llllt RalaiDr OM Tend patient instructed ID activefv abduct Pain with abduction piiB" than 90 degrees
lhllhrMdll' IUUIJIIIII tandinopalhy
Ortbopaedia OR13
......_rCulfiiiUGIII
1111
Supraspinalus
lrfrupinatus
r..mnur

Figura 16. Macias Ill' the RatatDr
CuH
Jobe's1811
Paltaiar cuff 1811
Figura 17. RatatDr Cuff TIIIB -
Jabe's. l..ift.Oft, Posterior Cliff
ORI4 Orthopaeclica
Figure 11. Neer's Test
Figure 1 1. Tallt
.... ,

l'naumlllhlnx or canllllian
n po111nti., complitations of SIIVTft
ecromiociiiViwar joirt ditlocation
.... ' ,

lnjlrilll wilh CliMe
FriCtlnl
Up to IR of cl11Viw1r fnlctureur&
a..oc:iabld with vther fnlcturw (mo.t
CD11111Dnly rib fnlchnsl
Ml.iDrity Df brachial pl1111111
BrB INOCiated with pnlllimal tl*d
fl'lctJna
Shoulder 1'oroDio 201 1
lnvestignions
X-1'11}'!1: AP view may show high riding humerus relative to glenoid, evidence of chronic
tendonitis
MRI: coronallsagittal oblique and axial orientati.Oil8 are useful for assessing full/partial tears
and te:ndinopathy, arthrogram: geyser sign (injected dye leaks out of joint through rotator cuff
tear)
arthrogram: see full thickness tear, difficult to assess partial thl.ckness tears
Treatment and Prognoais
mild ("wear")
treatment is non-openrt:i.ve (physiotherapy, NSAIDs)
moderate ("tear")
non-operative treatment steroid Injection
severe ("repair")
impingement that is refractory to 2-3 months physio and 1-2 injecti0118
may require surgical repair, i.e. acromiopl.asty, rotator cuff repair
Acromioclavicular (AC) Joint Pathology
2 main ligaments attach clavicle to scapula; acromioclavicular (AC) and coracoclavicu1a (CC)
lig8lllents
Mechanism
fall onto shoulder with adducted arm (fall onto tip of shoulder)
Clinical Features
palpate step deformity between distal clavicle and acroml.on (with dislocation)
pain with adduction of shoulder and/or palpation over AC joint
limited ROM
Investigations
x-rays: AP, Zanca view (10-lSO cephalic tilt), axillary stress views (10 lb weight in patient's
hand)
Treatment
non-operative (most-common): sling 1-3 weeks, ice, analgesia
operative
indicati0118: AC and CC ligaments are both tom and/or clavicle displaced posteriorly
procedure: excision of lateral clavicle with ACJCC ligament reconstruction
Clavicular Fracture
J.nddence: pnWmal (5%), middle (80%), or distal (IS%) third of clavicle
common in children (unites :rapidly without complications)
Mechanism
fall on shoulder (8796), direct trauma to clavicle (7%}, FOOSH (696)
Clinical Features
pain and tenting of skin
arm is clasped to chest to splint shoulder and prevent movement
Treatment
evaluate neurovascular status of entire upper limb
proximal and middle third clavicular fractures
sling X 1-2 weeks
early ROM and strengthening once pain subsides
if ends overlap >2 em. consider ORIF
distal third clavi.culn fractures
undisplaced (with ligaments intact): sling x 1-2 weeks
displaced (CC ligament inJury): ORIF
Speclflc Complications (see General Fmcturt CompUcattcns, OR6)
cosmetic bump usually only complication
shoulder stiffness, weakne511 with repetitive activity
pneumothorax. injuries to brachial plaus and subclavian vessel (all very rare)
'IbroDlo Nota 2011 Shoulder/Humerus
Frozen Shoulder (Adhesive Capsulitis)
-----
Definition
diamder characterized by progressive pain and lrti1fneas of the shoulder usually resolving
spontaneolllly after 18 months
Mechanism
primary adhesive capaulit:is
idiopathic, usually ast1ociated with diabetes mellitus
may resolve spontaneously in 9-18 months
secondary adhesive capsulitis
due to prolonged immobilization
shoulder-hand syndrome -type of chronic regional pain syndrome (reflex sympathetic
dystrophy) charact:erlzed by arm and shoulder pain, decreased motion and diffuse swelling
following myocardJaliDfarct:lon. stroke, shoulder trauma
Clinical Features
gradual onset (weeks to months) of diffuse shoulder pain with:
decreased active and passive ROM
pain worse at night and often prevents sleeping on affucted side
increased stiffness as pain subsides: continuea for 6-12 months after pain has disappeared
Investigations
x-nys may be normal, or may show demineralization from disease
Treatment
active and passive ROM (physiotherapy)
NSAIDs and steroid injections iflimited by pain
MUA (manipulation under aneathesia) and early physiotherapy
arthroscopy for debridement/decompression
Humerus
Proximal Humeral Fracture
Mechanism
o young: high energy trauma (MVA)
o older: FOOSH from standing helght in osteoporotic .individuals
Clinical Futures
pain, swelling, tenderness, painful ROM
Investigations
test a:xillary nerve function (deltoid function and skin over deltoid)
o x-.rays: AP, trans-scapular, uill.ary are essential
o CT scan: to evaluate for artl.cular involvement and fracture displacement
Classification
Neer classification is based on 4 fracture fragments: head, greatln' tuberosity, lesser tuberosity;
shaft
nondisplaced: displacement <1 an andJor angulation <45
displaced: displacement >1 em and/or angulation >45
dlslocatedJsubluxed: humeral head dislocated/aubbw:d from glenoid
Treatment
o non-operative
sling immobilization (nondlsplaced): begin ROM in 7-10 days to prevent stiffness
closed reduction (minimally displaced)
operative
ORIF (anatomic neck fractures, displaced. dislocated)
hemiarthroplasty may be necessary, especially in elderly
Spec:Hic Complications (see General Fracture ComplU:mlons, OR6)
AVN, u:illary nerve palsy, malunion, post-traumatic arthritis
Ortbopaedia ORlS
....
.. .--------------.
Colldltlan5 Alnclltld ..
1.....-lnddtncelll.........,.
C.,Uilil
PrDIQ!Id immobiilll:ion !mOlt
lignilicllllj
Femala galdar
AaB>49'!'1111
DiiiiMills meltul {Sx)
Cervical dille dilaua
Hyper1hyroidism
0 Streb
Myucerdi .. infvl:tian
T11U111 and SLI!iJWV
.... ,

Anldamic nack lractuiBI
blood sup!IIY to tha humeral hd 1nd
IIIIIIICUar (AVNJ allhlllllmnl
haadm.., ....
GIIII!Brtuberolity
....... lubiRIIity
Figur. ZD. mGbuBS of tha
Proximal Hu111er
..... ,
. .--------------.

.... 0 ... .,..., ... _
1. Gl'llllb.-T ... llJiily
2.1.8surTub-ity
3. Humnl Head
4. Shift
TW111111n frmu111: any allhll4 par111
with 1 displacad
displacad fracture
neck + dilplaced IPitlr
b.tlellJiily or
Fa1111111n fnlclln: diiPIK&d fracture of
SLI!iJir:ll neck + biJ1h bilarositias
OR16 Orthopaeclia
'.,
..
Acce,...._
u.tarntill for Na....-nriM
TreltrHnt
< 20" anlrlrior .. gl.tation
< 30" VlllllnngLtllion
< 3 4:111 ohhorter*lg
Rillk of radial n. and brachial L injury!
Rgura 21. X-Ray af Trannana
Displacad Supncaadtlar frllctura
Df HaiHIWS with ElbGw
DialaAtion
Haml:nuiElbow 10ronto Nota 2011
Humeral Shaft Fracture
Mechanism
direct blowsJMVA (most common), POOSH, twisting injuries, metastases (in elderly)
Clinical Features
o pain, swelling, shortening. mot:lon/aepitus at fracture site
o must test ra.d1al. nerve function before and after treatment
Investigations
x-rays: AP and lateral radiographs of the humerus including the shoulder and elbow joints
Treatment
in general. humenl shaft fr:actu.res are t:n:ab:d non-opezatively
non-operative (most common)
redu.c:ti.on- am accept defunnity due m compensatory range of motion of shoulder
hanging cast (wcight of arm in cast provide& traction across fracture site) with sling
immobilization x 7-10 days, then Sarmiento functional brace
o operative
indications: open fracture, neurovascular injury, unacceptable fracture alignment,
polytrauma. segmental fracture. pathological fracture, "floating elbow" (simultaneoUll
unstable humeral and furearm fractures), intra-articular
procedure: compression plating (most common), Intramedullary rod Insertion. enemal
fixation
Specific Complications (see General Practure Complkations, OR6)
o radial nerve Injury: expect spontaneoUll recovery In 3-4 months, otherwise send for
electromyography (BMG)
decreased ROM
compartment syndrome
Elbow
General Principles
articulation between distal humerus, proximal ulna. proDmal radiUll (humeromdial.
hwneroulnar and radioulnar joints}
o fractures and disl.ocatl.ons of the elbow are evident on AP, lateral and oblique radiographs
Supracondylar Fracture
most common in pediatric population (peak age -7 years old), rarely seen In adults
o anterior interosseous nerve (AIN) injury commonly usodated with extension type
Mechanism
>96% are atensl.on injuries via FOOSH (e.g. fall off monkey bars); <496 are flexion Injuries
Clinical Features
pain. swelling. point tenderness
neurovascular Injury- assess median and radial nerve, radial artery
Investigations
x-rays: AP,latc:xal of elbow; asaess fur fat pad sign
Treatment
non-operative
nondisplaced: cast in 900 :flexion for 3 weeks
0 operative
Indications: displaced, vascular injury, open fracture
requires perc11taneous pinning followed by limb cast with elbow flexed >90"
in adults, ORIF is necessary
Specific Complications (see General Fracture Complialtions. OR6)
brachial artery injury, median or ulnar nerve injury, compartment syndrome (leads to
Volkmann's iachemic contracture), malallgnment cubitus varus (distal fragment tilted into
varus)
'IbroDlo Nota 2011
Radial Head Fracture
a common fracture of the upper limb in young adults
Mechanism
FOOSH with elbow extended and forearm pronated
Clinical Features
marked local tenderness on palpation over radial head (lateral elbow)
decreased ROM at elbow, mechanical block to forearm pronation and supination
pain on pronation/supination
Investigations
.J:-ray: enlarged anterior fat pad (-san sign") or the presence of a posterior fat pad indicate occult
radial head fractures
Tallie I. end Treatlll..t vf R-.liel He-.! Frec:t.res
I
z
Cammioolad frlclln
Bbow 511b or sq x 3-5 days with a.tv ROM
ORFI: ai1\Palilll >30", invalm aflh8 radial hlad. mm
of joid incongruity exim
Radial bald axcililll plllllhaais 3
4 Commilded fnlciiR wi1h pos!eliar Radial head excisi111 :!:: plllllhesis
lllow cillacalicn
SpecHic Complications (see General Fracture Compltaltions, OR6)
myositis ossiftcans
recurrent inst8bility (if medial collateral ligament injured and radial head excised)
Olecranon Fracture
Mechanism
direct trawna to posterior aspect of elbow (fall onto the point of the elbow)
Clinical Features
loss of active extension due to avulsion of triceps tendon
Treatment
undisplaced ( <2 mm, sbl.ble): cast x 3 weeks (elbow in 45 flexion) then gentle ROM
displaced: ORIF (plate and Screwti or tension band wiring) and early ROM if stable
Elbow Dislocation
third morl common joint dislocation after shoulder and patella
most commonly occurs in young people (5-25 yean) in sporting events or high speed MY .As,
dislocation of ulna
9096 are posterior/posterolateral. anterior are rare
collateral ligaments disrupted
Mechnism
elbow hyperextension via FOOSH or valgus/supination stress during elbow flexion
Clinical Features
elbow pain, swelling. defOrmity
fienon contracture
absent radial or ulnar pulses
Treatment
closed reduction under anesthesia (pori-reduction x-rays required)
long-ann splint with forearm in neutral rotation and elbow in 90" flexion
early ROM ( <2 weeks)
SpecHic Complications (see General Fracture Compltaltions, OR6)
sti1fness (loss of atension), intra-articula.r loose body, neurowscular injury (ulnar nerve,
median nerve, bra.chial. artery), radial head fracture
Ortbopaedia OR17
.... ,

r.ntll Trld
, . Radillll"lll&d frac;bn
2. CDI1lllllid fracbn
3. ElbGw dillocation
Du nut WllmobiliZII -'bPW jon
> 2.J waaks to IMiid llliffnus.
Rgure Z3. Lateral VIew of Ellow
ORIS Orthopaeclica
Figure 24. MOIIteggla fl'lcblre
.... ,
.
ilollded ulna fladurea, .._
pnncirnalradiua ID rula out 1 Mon1Bggi1
fnu:lln.
Elbow/Forearm ToroDio 2011
Epicondylitis
lateral epicondylitis = "tennis elbow", inflammation of the common extensor tendon as it inserts
into the lateral epicondyle
medial epicondylitis = "golfer's elbow': inflammation of the common flexor tendon as it inserts
into the medial epicondyle
Mechanism
repeated or sustained contraction of the forearm muscles
Clinic:el Features
point tenderness over hwneral epicondyle
pain upon resisted wrist atension (lateral epicondylitis) or wliBt: flenon (medial epicondylids)
generally a self-limited condition. but may take 6-18 months to resolve
Treatment
rest. ice, NSAIDs
use brace/strap
PT, stretching and strengthening
corticosteroid injection
BUrgery: percutanOOWi or open release of common tendon from epicondyle (only after
6-12 months of conservative therapy)
Forearm
Radius and Ulna Fracture
Mechanism
commonly a FOOSH or direct blow
Investigations
x-ray: 1) AP and lateral of forearm; 2) AP, lateral, obliqu.e of elbow and wrist
cr if fracture is close to joint
Treatment
goal is anatomic reduction aince imperfect alignment significantly limits fureann
pronation and supination
ORIF with compresslon plates and screws
Complications (see General Fracture Compliamons. OR6)
Monteggia Fracture
Definition
fracture of the proximal ulna with radial head clialoca.tion
Mechanism
direct blow on the po!terlor aspect of the furearm.
hyperpronation
fall on the hypereuended elbow
Clinic:el Features
decreased rotation of furearm palpation lump at the radial head
ulna angled apex anterior and radial head dislocated anteriorly (mrely the reverie deformity
occurs)
Treatment
ORIF of ulna with indirect radius reduction in 9096
splint and early post-op ROM if elbow completely stable; otherwise immobilization in plaster
with elbow flexed for 6 weeks
radial/posterior interosseous nerve (PIN) injury
decreased ROM
'IbroDlo Nota 2011 ForearmJWrist
Nightstick Fracture
Definition
isolated fracture of ulna
Mechanism
direct blow to forearm (holding arm up to protect face)
Treatment
non-displaced: below elbow cast (10 days) followed by forearm brace (-8 weeks)
displaced: ORIF if >5096 shaft displacement or > 10 angulation
Galeazzi Fracture
Definition
fracture of the distal radial shaft with disruption of the distal radioulnar joint (DRUD
most commonly in the distall{3 of radiw; near junction of metaphysis/diaphysis
Mechanism
w;ual cause is fall on the hand (mechanical axial loading of pronated forearm)
lnvestigtltions
x-rays
shortening of distal radiw; >5 mm relative to the distal ulna
widening of the DRUJ space on AP
dislocation of radiWI with respect to ulna on true lateral
Treatment
ORIF of radius
ifDRUJ is stable, splint with early ROM
ifDRUJ ill unstable, DRUJ pinning and long arm cast in supination x 6 weeks
Wrist
Colles Fracture
Definition
transverse distal radius fracture (about 2 an pro:dmal. to the radiocarpal Joint) with dorsal
displacunent ulnar styloid fracture
Epidemiology
most common fractuie In those >40 years, espedal1y in women and those with osteoporotic
bone
Mechanism
FOOSH
Clinical Features
dinner fork'" deformity
swelling, ecchymosis, tenderness
lnveatigations
findings on x-ray (Figure 27)
Tnatmant
goal. ill to restore radial height, radial inclination (22), volar tilt (11 ) and articular congruity
dosed reduction (think. opposite of the deformity):
hemamma block (sterile prep and drape, local anesthetic injection directly into fracture site)
or conscious sedation
closed reduction -traction with extension (exaggerate injury), then traction with ulnar
deviation, pronation, flexion of distal fragment - not a:t wrist)
dorsal slab/below elbow cast for 5-6 weeks
x-ray ql week to eD.51lre reduction is maintained
obtain post-reduction films immediately; repeat reduction if nece8sary, consider external
fixation or ORIF
Ortbopaedia OR19
\
.
Fiaare Zfi. &elellli fnlctura
..._,,
i
l
I
i!ii
0
.
For al isollted radiJs frlclu1111 .....
DRW til nil out a Galellli frlclure.
:;::-... .....___
.
---
..... .
,:-::>" ii-"*
APvinr
1. Dol'llltllt
2. Dol'lll diaplac:ement
3. Ullllll' lllytaid fnx:lln
4. llldial displacrment
5. Radial tilt
6. Shortaning
Fiaare Zl. Call' fnlctura anlll
AssacilbMI Bony Dllfllrmity

I
Ill
..
3
0
OR20 Orthopaedics
+---Radius
Scaphoid
Metacarpal
bones (1-5)
Figure 28. Carpal Bones
Figure 29. ORIF Left Scaphoid
Wrist Toronto Notes 2011
Smith's Fracture
Definition
volar displacement of the distal radius (i.e. reverse Colles' fracture)
Mechanism
fall onto the back of the flexed hand
Treatment
usually unstable and needs ORIF
if patient is poor operative candidate, may attempt non-operative treatment
closed reduction with hematoma block (reduction opposite of Colles')
long-arm cast in supination x 6 weeks
Complications of Wrist Fractures
most common complications are poor grip strength, stiffness, and radial shortening
distal radius fractures in individuals <40 years of age are usually highly comminuted and are
likely to require ORIF
80% have normal function in 6-12 months
early
difficult reduction loss of reduction
extensor pollicis longus (EPL) tendon rupture
acute carpal tunnel syndrome
finger swelling with venous or lymphatic block
late
mal-union, radial shortening
painful wrist secondary to ulnar prominence
frozen shoulder ("shoulder-hand syndrome'')
post-traumatic arthritis
carpal tunnel syndrome
complex regional pain syndrome (reflex sympathetic dystrophy (RSD))
Scaphoid Fracture

Epidemiology
common in young men; not common in children or in patients beyond middle age
Mechanism
FOOSH resulting most commonly in a transverse fracture through the waist (middle) of the
scaphoid
Clinical Features
pain on wrist movement
tenderness in scaphoid region (anatomical "snuffbox")
usually undisplaced
Investigations
x-ray: AP, lateral, scaphoid views with wrist extension and ulnar deviation q2 weeks
bone scan
CT,MRI
Note: a fracture may not be radiologically evident up to 2 weeks after acute injury, so if a patient
complains of wrist pain and has anatomical snuffbox tenderness but a negative x-ray, treat as if
positive for a scaphoid fracture and repeat x-ray 2 weeks later to rule out a fracture. If x-ray still
negative order CT or MRI
Treatment
non-displaced= long-arm thumb spica cast x 4 weeks then short arm cast until radiographic
evidence of healing is seen (2-3 months)
displaced = open (or percutaneous) screw fixation
A VN of the proximal fragment (since the scaphoid has distal to proximal blood supply, the more
proximal the fracture, the greater incidence of A VN)
delayed union (recommend surgical fixation)
non-union (must use bone graft and fixation to heal)
Toronto Notes 2011 Wrist/Hand
Prognosis
fractures of the proximal third of the scaphoid have 70% rate of non-union or AVN
waist fractures have healing rates of 80-90%
distal third fractures have healing rates close to 100%
Hand
see PUO
Evaluation of Hand Complaints
History
hand dominance, AM stiffness, location of pain, swelling, mass, trauma, activity, neurological
symptoms, history of arthritis
deformities
fracture: rotational or angular
rheumatoid arthritis: ulnar deviation, swan neck, boutonniere, mallet finger
finger position
Dupuytren's contracture: flexion contracture of 4th/5th finger
swelling/masses
Heberden's node: DIP swelling
Bouchard's node: PIP swelling
rheumatoid arthritis: MCP swelling
skin changes
nail changes: dubbing, koilonychia, leukonychia, Lindsay's nails, Terry's nails, onycholysis
muscle wasting: thenar, hypothenar, intrinsics
range of motions, crepitus, joint line tenderness, joint stability
all bones, including carpal bones, can be palpated to identify maximum tenderness
neurovascular examination
Special Tests of the Hand
test of flexor digitorum profundus
flex DIP while holding MCP in extension
if unable to flex DIP, then suggestive of flexor digitorum profundus pathology
test of flexor digitorum superfici.alis (sublimes)
flex PIP while holding MCP in extension
if unable to flex PIP only, then suggestive of flexor digitorum superficialis pathology
test of thumb instability
apply a valgus stress to thumb while stabilizing metacarpal; keep MCP flexed slightly while
testing
if there is laxity in thumb, then suggestive of ulnar collateral ligament rupture
test of finger instability
apply varus and valgus stress to finger while stabilizing PIP
if there is laxity in PIP, then suggestive of collateral ligament damage
Allen's test
occlude both ulnar and radial artery; release one at a time to determine patency of each
artery
Finklestein's test
place thumb in palm and cover with all fingers and move wrist into ulnar deviation
if pain is reproduced at radial styloid region, then suggestive of tenosynovitis of 1st
compartment (EPB, APL tendons)
test of carpal tunnel syndrome
see Plastic Sur.gery; PUS
Orthopaedic:a OR21
OR22 Orthopaeclica
F"IIJra 31. Bunt. Camprauioll and
DillacatiDII Fracblra
Spine
Spine
lnf8rior
ar1icular prociSS
Spinous
..-ss
Flgara 30. Schematic Diagram of VartaJiral Anltamy
,o!,Splad Iran Atlot8'l "* 274 - A&D
Fractures of the Spina
see NS34
4 mam types of :fractures (see Table 9)
Tabla 9. Fracture Type aad Calamn lnvolnmaat
Anllrior Stable
Burst Antariot nildla lhblbla
Midlle, poslerior lnblllle
Cervical Spina
1'oroDio 2011
Spinoua
PIOCIIIJI
Su,...ar VI8W

Hig!Hnargy IXill laeding + fllllion
WNA (lap belt any) caaing flexi111 and disbaction
(C.ce lrlctu11l
cent force lllPiiad to spine (flexion. axtensian,.
distraction, rotation. shear or axial load)

General Princ:iples
Cl = atlas: no vertebral body, no spinous process
C2 = axis: odontoid= dens
7 cervical vertebrae; 8 cervical nerve roots
nerve root exits above vertebra (Le. C4 nerve root exits above C4 vertebra)
radl.culopathy = Impingement of nerve root
myelopathy = Impingement of spinal cord
Special Testing
Compression test pressure on head wonena radicular pain
Diattaction test: traction on head relieves :radicular symptoms
VaJsalva test: Valsalva maneuver lnaeases intrathecal pressure and cauaes ra.dicular pain
Toronto Notes 2011
Table 1 0. Cervical Radiculopatlly/Neuropathy
Root C5 C6
Malar Deltoid Biceps
Biceps Brachioradialis
Wrist ax11111sion
s ... ry Axillary nerve {patch ovar Thlmb and indax. finger
lat&ral daiiDidl
Reftp Biceps Biceps
Brachioradialis
X-Rays for C-Spine
AP spine: alignment
AP odontoid: atlantoaxial articulation
lateral
Spine
Cl
Triceps
wrist flexion
Finger axtansion
Middle finger
Triceps
ca
Interossei
Digillll flexors
Ring and little finger
Fingarjsrk
vertebral alignment: posterior vertebral bodies should be aligned (translation >3.5 mm is
abnormal)
angulation: between adjacent vertebral bodies {> 11 o is abnormal)
disc or facet joint widening
anterior soft tissue space (at C3 should be S:3 mm; at C4 should be S:8-10 mm)
oblique: evaluate pedicles and intervertebral foramen
swimmer's view: lateral view with arm abducted 1800 to evaluate C7-T1 junction if lateral
view is inadequate (must see C7-T1 in all trauma situations)
lateral flexion/extension view: evaluate subluxation of cervical vertebrae
Differential Diagnosis of C-Spine Pain
trapezial sprain, whiplash, cervical spondylosis, cervical stenosis, rheumatoid arthritis
(spondylitis), traumatic injury
C-SPINE INJURY
see NS34
Thoracolumbar Spine
General Principles
spinal cord terminates at conus medullaris {Ll)
individual nerve roots exit below pedicle of vertebra (ie. lA nerve root exits below lA pedicle)
Special Tests
Straight leg raise (SLR): passive lifting of leg (30-70) reproduces radicular symptoms of pain
radiating down post/lat leg to knee, into foot
Lasegue maneuver: dorsiflexion of foot during SLR makes symptoms worse or, if leg is
less elevated, dorsiflexion will bring on symptoms
Femoral stretch test: with patient prone, flexing the knee of the affected side and passively
extending the hip results in radicular pain
Table 11. Lumber Radiculopathy/Neuropatlly
Root L4 L5 S1
Malar lkladriceps {knee extension + hip
adduction I
Tibialis anterior {artie inversion +
dorsiflexion I
S111111ry Madialllllllleolus
Reftp
Test
'lklralilbla
Knee {Patellar)
Femanl stretch
EHL {extensor hallucis lon!Jlsl Peroneus longus + brevis {artie
Gluteus medius (hip abduction! eversion I
Gastrocnemius + soleus {plantar flaxionl
1 rt donal webspace and lat&ral l.ataral foot
leg
Medial hamstring
Straight leg raise
Ankle {Achilles I
Straight leg raise
Orthopaedic:a OR23
Red Flqsfar
BACK PAIN
Bowel or bladder dysfunction
Anesthesia (Addle)
Conritutional symplomf/malillfiiiiiC'(
!Chronic di5ease
Parllllhuaiu
AQa >50
IV drug u.e
ruuromator dllicitl
.... ,
.. .----------------.
Clllllllliln Capm lm (CCR)
Used blguids irTIIIging for alert
IGCS = 1 51 and s11b1e patients wi1t1
-puclud C-$11in8 injury
Obtain radiovraphy if:
Agu >65
Pamthasia in the extremities
Inability Ill rotate neck >45"
Dlln!IIIIIUI 1111Chanism of injury
(e.g. high speed fall fnlm
ei8VIIion > 5ft. etc.)
lletlrmce: CJEM ZOOZ;4(2):84-90
....... ,

lmmedillt8 immobilization of C-spile
at scene of accident wilh spine board,
C.coU.and sandbags.
OR24 Orthopru:clia
..... , '

Cui equi111 t'jlldrom and Nptured
aartic lllllrflll118111 ca.u af law
biiCk pain thllt are conlidencl 11111iCII
emrgenci.
Figure 32. Disc H1111illlian
Spine 10ronto Nota 2011
Diffarantial Diagnosis af Bilek Pain
1. mechanical or nerve compression (>9096)
degenerative (disc, facet, ligament)
peripheral nerve compression (disc herniation)
spinal stenosis (congenital. osteophyte, central disc)
cauda equJna syndrome
2.others
neoplastic (primary. metastatic, multiple myeloma)
infectious (osteomyelitis, TB)
metabolic (osteoporosl.s)
traumatic fracture (compression, distraction, translation, rotation)
spondyloarthropathies (ankylosing spondylitis)
referred (aorta, renal, ureter. paru:reas)
DEGENERATIVE DISC DISEASE
l.os8 of vertebral disc height with age results Jn:
bulging and tean of aDnul.us fibrosus
change in alignment of fucet joints
osteophyte formation
can cause back-dominant pain
management
nan-operative
staying active with modified activity
back strengthening
NSAIDs
do not treat with opioid&; no proven efficacy of spinal traction or manipulation
operative - rarely indicated
decompression fusion
no difference In outcome between non-operative and su.rgk:al management e.t 2 years
Tabl 12.. Typa of Law Back Pam
leg Leg
flaidlll Extnicn ExEile, axl8nsilll, flaldlll
StandiQ. Willing WBIDQ, llllndir,)
More llllllclan CGngamal or IC4Ii'ed Acu181eg back pein
Long (weeb. Slxntl!r (dlrts, weeb) Acute or clmic listory Shm
(waab 11111"10Nha) AlfM:b lninut.)
llalisf of sll'llil. 8K81'Ci&a Relief of linin, axsrcise of mil. axsrcise llalisf of sll'llin, ...-ci&e
+ IUJ'llital decomrnuion
if proglllliw or IMr&
dalicit
SPINAL STENOSIS
definition: 1liii'l'OWing of spinal canal <10 mm
etiology: congenital (idiopathic, osteopetrosis, achondroplaai.a) or acquired (degenerative,
iatrogenic- post spinal surgery, ankylosmg spondylosis, Paget's disease, ttauma)
clinical features
blle.teral bade and leg pain
neurogenic claudication (see Thble 13)
motor weakness
normal back flexion; difficulty with back extension
investigations: cr 1MRI reveals narrowing of spinal canal, but gold standard = cr myelogram
treatment
non-operative: vigorous PT (flexion exercises, stretch/strength exmises), NSAIDs, lumbar
epidural. steroids
operative: decompression surgery if conservative methods failed >6 months
Toronto Notes 2011
Table 13. Differentiating Claudication
AIIIViltian
Wrth standilg tw exercise
Walking distance variable
Change in position (usually flexion,
sitting, lying downl
Relief in -1 0 min
Neurogenic neurological deficit
Spine
Yllscullr
Walking set distance
Stop walking
Relief in -2 min
Muscular Clllmping
Back Pain
I

Callltllnt
lnflammlllilry
Mechanical

Bilek Dominant
I

+
lntermitlllnt
I
Disc Hemilllion (cenlnll) Facet Joint
Figure 33. Approach to Back Pain
MECHANICAL BACK PAIN

Collltllnt
Lug Dominant
I
Herniation (latsrlll)
+
Intermittent
Spi1111l Sbmo1ii
definition: back pain NOT due to prolapsed disc or any other clearly defined pathology
clinical features
dull backache aggravated by activity
morning stiffness
no neurological signs
treatment: symptomatic (analgesics, PT)
prognosis: symptoms may resolve in 4-6 weeks, others become chronic
LUMBAR DISC HERNIATION
definition: tear in annulus fibrosus allows protrusion of nucleus pulposus causing either a
central, posterolateral or lateral disc herniation, most commonly at LS-Sl > 14-5 > L3-4
etiology: usually a history of flexion-type injury which tears the annulus fibrosus allowing for
protrusion of the nucleus pulposus
clinical features
back dominant pain {central herniation) or leg dominant pain {lateral herniation)
tenderness between spines at affected level
muscle spasm loss of normal lumbar lordosis
neurological disturbance is segmental and varies with level of central herniation
motor weakness (L4, LS, Sl)
diminished reflexes (14, Sl)
diminished sensation (L4, 15, Sl)
+ve straight leg raise
+ve Lasegue test
bowel or bladder symptoms, decreased rectal tone suggests cauda equina syndrome due to
central disc hernation - surgical emergency
investigations: MRI
treatment
symptomatic
extension protocol (PT)
NSAIDs
90% resolve in 3 months
surgical discectomy reserved for progressive neurological deficit, failure of symptoms to
resolve within 3 months or cauda equina syndrome due to central disc herniation
Orthopaedic:a OR25
... ' ,

MRI abnormalities are quite common in
both qympb)matic lll1d l'fiTIP!omalic
individuals and 1111 not necasurily
an indiclllion for irt111V811!ion without
clinical corrallllion .
OR26 Orthopaedics
Figure 34. Spondylolysis,
Spondylolisthesis
', ,

X-Ray Features of Subcapital Hip
Fractures
Disruption of Shenton's line (a
radiographic line drawn along
the upper margin of the obturator
foramen, extending along the
inferomedial side of the femoral neck)
Altered neck-shaft angle (nonnal is
120-130)
' , ,

DVT Prophylaxis in Hip Fractures
LMWH (i.e. enoxaparin 40 mg SC bid)
on admission, do not give < 12 hrs
before surgery.
Spine/Hip Toronto Notes 2011
SPONDYLOLYSIS
definition: defect in the pars interarticularis with no movement of the vertebral bodies
etiology
trauma: gymnasts, weightlifters, backpackers, loggers, labourers
clinical features: activity-related back pain
investigations
oblique x-ray: "collar" break in the "Scottie dog's" neck
bone scan
CT scan
treatment: activity restriction, brace, stretching exercise
SPONDYLOLISTHESIS
definition: defect in pars interarticularis causing a forward slip of one vertebrae on another
usually at LS-Sl, less commonly at L4-5
etiology: congenital (children), degenerative (adults), traumatic, pathological, teratogenic
clinical features: lower back pain radiating to buttocks
Table 14. Classification and Treatment of Spondylolisthesis
Class Percentage of Slip Treatment
0-25%
25-50
50-75
75-100
>100
Symptomatic operative fusion only for intractable pain
2
3
4
5
Decompression for spondylolisthesis and spinal fusion
may present as cauda equina syndrome due to roots being stretched over the edge of LS or
sacrum
Hip
Hip Fracture
General Features
acute onset of hip pain
unable to weight-bear
shortened and externally rotated leg
painful ROM
Normal joint Subcapital fracture Intertrochanteric
fracture
Figure 35. Subcapital. Intertrochanteric, Subtrochanteric Fractures
Subtrochanteric
fracture
Toronto Notes 2011
Table 15. Overview of Hip Fractures
Fracture Type Definition Mechanism
Hip
Special Clinical
Features
Femoral Neck
(Subcapital)
lntracapsular Young: MVA, fall from Same as general
(See Garden Classification, height
Table 16) Eldery: Fall from standing,
rotational force
Investigations Treabnent
X-ray: AP hip, AP pelvis, cross See Table 16
table lateral hip
Orthopaedics OR27
Complications
DVT, Non-union
Intertrochanteric
Fracture
Extracapsular fracture
including the greater and
lesser trochanters and
transitional bone between
the neck and shaft
Direct or indirect force
transmitted to the
intertrochanteric area
Ecchymosis at back X-ray: AP pelvis, AP/Iateral hip Closed reduction DVT, varus displacement
of upper thigh under fluoroscopy of prox. fragment,
Stable: intact
posteromedial cortex
Unstable: non-intact
posteromedial cortex
then dynamic hip malrotation, non-union,
screw or IM nail failure of fixation device
Subtrochanteric
Fractures
Fracture begins at or below Young = high energy Eccymosis at back
of upper thigh
X-ray: AP pelvis, AP/Iateral hip Closed reduction Malalignment, non-union,
the lesser trochanter and trauma
involves the proximal Older = osteopenic
femoral shaft bone + fall, pathological
fracture
Table 16. Garden Classification of Femoral Neck Fractures
Type Displacement Extent Alignment Trabeculae
I None Incomplete Valgus Malaligned
II None Complete Neutral Aligned
Ill Some Complete Varus Malaligned
IV Complete Complete Varus Aligned
Type I Type II Type Ill
Figure 36. Garden Classification of Femoral Neck Fractures
Arthritis of the Hip
Treatment
Internal fixation to prevent displacement
Internal fixation to prevent displacement
Elderly: Hemi-/total hip arthroplasty
Young: ORIF
Elderly: Hem-/total hip arthroplasty
Young: ORIF
Type IV

Etiology
osteoarthritis (OA), inflammatory arthritis, post-traumatic arthritis, late effects of congenital
hip disorders or septic arthritis
Clinical Features
pain (groin, medial thigh) and stiffness aggravated by activity
morning stiffness, multiple joint swelling, hand nodules (RA)
decreased ROM (internal rotation is lost first)
crepitus
fixed flexion contracture leading to apparent limb shortening (Thomas test)
Trendelenberg sign
Investigations
x-ray
OA: joint space narrowing, subchondral sclerosis, subchondral cysts, osteophytes
RA: osteopenia, joint space narrowing, subchondral cysts
bloodwork: ANA, RF
under fluoroscopy wound infection
then plate fixation
or 1M nail
..... ,
,
AVN of Femoral Head
Distal to proximal blood supply along
femoral neck to head (medial femoral
circumflex artery)
Susceptible to AVN if blood supply
disrupted
Etiology: femoral neck fracture,
chronic systemic steroid use
..... ,
,}-------------------.
DVT Prophylaxis in Elective THA
(continue 2-3 weeks post-op)
low molecular weight heparin or
coumadin.
OR28 Orthopaedics
c!J liS

Supracondylar Condylar

Intercondylar
Figure 37. Distal Femoral
Fractures
Hip/Femur Toronto Notes 2011
Treatment
conservative: weight reduction, activity modification, PT, analgesics, walking aids
operative: realign = osteotomy; replace = arthroplasty; fuse = arthrodesis
complications with arthroplasty: component loosening, dislocation, heterotopic bone formation,
thromboembolus, infection, neurovascular injury
arthroplasty is standard of care in most patients with hip arthritis
Hip Dislocation after THA
Etiology
total hip arthroplasty (THA) that is unstable when hip is flexed, adducted and internally
rotated or extended and externally rotated (avoid flexing hip >90 degrees or crossing legs for
approximately 6 weeks after surgery)
Epidemiology
occurs in 1-4% of primary THA and 10-16% of revision THAs
risk factors: neurological impairment, post-traumatic arthritis, revision surgery, substance abuse
Treatment
external abduction splint to prevent hip adduction
constrained acetabular component for recurrent dislocation if no issue with position of
acetabular/femoral implants
Complications
sciatic nerve palsy in 25% (10% permanent)
heterotopic ossification (HO)
Femur
Femoral Diaphysis Fracture
Mechanism
high energy trauma (MVA, fall from height, gunshot wound)
in children, can result from low energy trauma (spiral fracture)
Clinical Features
shortened, externally rotated leg (if fracture displaced)
inability to weight-bear
often open injury, always a Gustilo III
Investigations
AP pelvis, AP/lateral hip, femur, knee
hemorrhage requiring transfusion
fat embolism leading to ARDS
extensive soft tissue damage
ipsilateral hip dislocation/fracture
nerve injury
Treatment
stabilize patient
immobilize leg
ORIF with intramedullary nail, external fixator, or plate and screws within 24 hours
early mobilization and strengthening
Distal Femoral Fracture
Mechanism
direct high energy force or axial loading
three types (Figure 37)
'IbroDlo Nota 2011 Femur/Knee
Futures
direct high energy force or axial loading
extreme pain
knee effilsion (hemarthrosis)
shortened. externally rotated leg if displaced
Treatment
ORIF
early mobilization and strengthening
Complications (see General Fracture Complications, OR6)
femoral artery tear
nerve injury
eDensl.ve soft tissue injury
angulation deformities
Knee
Evaluation of Knee Complaints
History
general orthopaedic history
also inquin: about common knee symptmns
locking: mechanical block to atension
torn meniscuslloose body in joint
pseudo-locking: limited ROM without mechanical block
effusion, muscle spasm after injury, arthritis
painful clicking (audible)
torn meniscus
giving way: instability
cruciate ligament or meniscal tear, patcllar dislocation
general orthopaedic physical exam (do not forget to evaluate hip)
Special Tests of the Knee
Anterior and Polter.lor drawer testa (see Figure 39)
demonstrate tom ACI. and PCI., respectively
knee flexed at 900, foot immobilized, hamstrings released
if able to sublux tibia anteriorly, then ACL may be torn
if able to sublux tibia posteriorly, then PCL may be torn
Lacbmano tat
demonstrates torn ACL
hold knee in 10-20" fleJ:ion, stabilizing the femur
try to sublux tibia anteriorly on femur
similar to anterior drawer test, more reliable due to less muscular stabilization
Polter.lor aag lip
demonstrates tom PCI.
may give a false positive anterior draw sign
flex: knees and hips to 90", hold ankles and knees
view from the lateral. aspect
if one tibia sags posteriorly compared to the other, its PCL Is tom
Pivot lh1ft lipl
demonstrates torn ACL
start with the knee in atension
internally rotate foot, slowly flex knee while palpeting and applying a valgus force
normal knee will flex: smoothly
if incompetent ACL, tibia willsublux anteriorly on femur at 5tart of maneuver. During
flex:lon, the tibia will reduce and extemally rotate about the femur (the "pivot"')
reverse pivot 5hlft (start in flmon, mernally rotate, apply valgus and mend knee) suggests
tomPCI.
Collateral Upment stre88 felt
palpate ligament for opening" of joint space while testing
with knee in full extension, apply valgus force to test MCL, apply VllrWI force to test LCL
repeat tcst5 with knee in 20" flexion to relax joint caprule
opening only in 200 fiWon due to MCL damage only
opening in :zoo of :flenon and full a1eD&ion Is due to MCL, crudate, and Joint capsule damage
Ortbopaedia OR29
1. I'Ditlriar ham of 111111111 meniKus l!i
1. Anl8rior ham of menilc:ul til
1. I'Ditlrior cn.:iatllligamant :;
Anl8rior cruciat81ig1ment If
5. I'Ditlriar ham of medial menia:111 l
li. Anl8rior hom of mllllilll o
Rgure 38. Diagram uf 'lfle Rig ..
Tibial Plata
.I

8 .,.._of Freldl11 of tllllllee
1. - and ext.
2. Ext. end inL I'Gtalion
3. VIrus and Yllgua
4. Ant. and poll glile
5. Mad. nllllllhift
6. Compression 111d disb8ction
111811 Hflltary
CUPS
Cli:kilg
Lacking
Nblbility
,... (lacatian)
lw161g
.....

diflic!Jt i-1 acute
knee injuri11. lmmllllililllleg and r-.-
eamine in one west.
--
Antariar D..-Tast
Figera 311. Antarior 111d Pestarior
Drawer Tall
OR30 Orthopaeclica
,f,l
61.;/ -
,..,..AJ
T"'- _ _.. - -- .. ) L
.. -r - . -- iS
- - -- -1
b..mlnllllan far l.ltll'll I
M .. iscBITar o
F"1111ra 41. T1 MRI of Ta .. ACL
.... ,

PartialligamentoUI '-" n mora
panullh .. camplallliga11111111DLII'hlln.
..... ,

li-Sourca far ACL
llllciiii!NI:tian
I.Hallllb'ing
2. Middla 1/3 pallllllr tandan
(bon&1111J11r-bona)
3. AIDgmt (e.g. ead11111r)
Knee 1'oroDio 2011
1Cstl for men!KJd tear
Crouch compression test
joint line pain when squatting (anterior pain suggests patellofemoral pathology)
McMurray's test useful collaborative information (see Figure 40)
with knee in flexion, palpate joint line for painful "pop/click"
intemally robrte foot. varus stress, and extend knee to test lateral menisCUll
externally rotate root, valgus stress, and extend knee to test medial menisCUll
X-Rays
AP standing. lateral
skyline - tangential view with knees flexed at 45 to see patelklfemoral jolnt
3-foot standing view - useful in evaluating leg length and varusfva1gus alignment
see Ottawa Knee Rules (Emer,pncy Medicine, ERl7)
Cruciate Ligament Tears

ACL tear much more common than PCL tear
Tabla17. af ACL and PCL ljuria
lillary
Sudden decelendi111
llyperaxienlian end inllmll rotatiln af ttl ill on iem!J'

kmlediate SWilling
Jnee ilivilg Wfl(
nbility ID activity
Bfusion (hemerthrallis)
PalllarDiatanll pnl h tandemass
Pasilive antm diiiWS
Positive lBclmm
Pivot fit
Tat for MCI., meniscal
Stable lcnaa with nilirnal functional -innant
imtabimtian Z-4 weaks wilh early ROM and
llrq1henilg
Collateral Ligament Tears
MCL tear more common than LCL tear
Mechanism
valgus force to knee =medial collateral ligament
varus force to knee = lab:ral collateral ligament
Clinical Features
swelllngleffusion
Sudden posl2rior dispiiiCI!ment a! tibia wl1m kn!e is
flaxad ar hyperaxtanded (daiNialrd MVA qury)

kmlediate SWilling
Fain with push alf
Camot descend stairs
Bfusion (hemertlrallis)
Anllmnadial jainllina lllldarnass
Pasilive p0118riar-..
Reverse liwl iHt
Other liQII18IIWI.. bonr i1juriaa
UnsliMe llnee or yamg parsJrVhigll-damand lifaslyla:
ligarnanl: IICGnslrucliiiJ
Posterior sag
tenderness above and below joint line medially (MCL) or laterally (LCL)
joint laxity with varus or valgus force to knee
lamy with endpoint suggests partial tear
lamy with no endpoint suggests a complete tear
test for other injuries (e.g. O'Donahue's triad), common peroneal nerve injury
Treatment
partial tear: immobilization x 2-4 weeks with early ROM and strengthening
complete tear or multiple ligamentous inJuries: surgtcal repair of ligamenta- not for MCL or
LCL on thdr own
Maniacal Tears
medial tear much more common than lateral tear
Mechanism
twisting furce on knee when it is partially fl.eud (e.g. stepping down and turning)
requires moderate trauma in young person but only mild trauma in dderly due to degeneration
Toronto Notes 2011 Knee
Clinical Features
immediate pain, difficulty weight-bearing. instability and clicking
increased pain with squatting and/or twisting
effusion (hemarthrosis) with insidious onset (24-48 hrs after injury)
joint line tenderness medially or laterally
locking of knee (if portion of meniscus mechanically obstructing extension)
Investigations
MRI, arthroscopy
Treatment
if not locked: ROM and strengthening
if locked or failed above: arthroscopic repair/partial meniscectomy
Quadriceps/Patellar Tendon Rupture
Mechanism
sudden forceful contraction of quadriceps during an attempt to stop
more common in obese patients and those with pre-existing degenerative changes in tendon
DM, SLE, RA, steroid use, renal failure on dialysis
Clinical Features
inability to extend knee or weight-bear
possible audible "pop"
patella in lower or higher position with palpable gap above or below patella respectively
may have an effusion
Investigations
ask patient to straight leg raise
knee x-rayto rule out patellar fracture
lateral view: patella alta with patella tendon rupture, patella baja with quadriceps tendon rupture
Treatment
nonoperative treatment for incomplete tears with preserved extension of knee
surgical repair of tendon indicated for complete ruptures
Dislocated Knee
Mechanism
high energy trauma
by definition, caused by tears of multiple ligaments
Clinical Features
classified by relation of tibia with respect to femur
anterior, posterior, lateral, medial, rotary
knee instability
effusion
pain
ischemic limb
Investigations
x-rays: AP, lateral, skyline
associated radiographic findings include tibial plateau fracture dislocations, proximal fibular
fractures and avulsion of fibular head
ankle brachial index (abnormal ifless than 0.9)
arteriogram if abnormal vascular exam
Treatment
urgent closed reduction
complicated by interposed soft tissue
assessment of peroneal nerve, tibial artery; and ligamentous injuries
repair of associated injuries; also may need decompressive fasciotomy especially if vascular
repair undertaken fasciotomy
knee immobilization x 6-8 weeks
Orthopaedic:a OR31
OR32 Orthopaedics
Undisplaced Vertical
Lower/Upper Pole Comminuted
Displaced
Osteochondral
Julio Saunders 2003
Figure 42. Types of Patellar
Fractures
Figure 43. Q-Angle
Knee/Patella Toronto Notes 2011
high incidence of associated injuries
popliteal artery tear
peroneal nerve injury
capsular tear
chronic: instability, stiffness, post-traumatic arthritis
Patella
Patellar Fracture
Mechanism
direct blow to the patella
indirect trauma by sudden flexion of knee against contracted quadriceps
Clinical Features
marked tenderness
inability to extend knee or straight leg raise
proximal displacement of patella
patellar deformity
effusion
Investigations
consider bipartite patella: congenitally unfused ossification centres with smooth margins on
x-ray
Treatment
non-displaced ( <2 mm)
straight leg immobilization 6-8 weeks
PT: quadriceps strengthening
displaced: ORIF (>2 mm)
comminuted: ORIF; may require partial/complete patellectomy
Patellar Dislocation
Mechanism
lateral displacement of patella after contraction of quadriceps against a flexed knee
Risk Factors
young, female
obesity
high-riding patella (patella alta)
knock-knees (genu valgum)
Q-angle (quadriceps angle) increased
shallow intercondylar groove
weak vastus medialis
tight lateral retinaculum
Clinical Features
knee catches or gives way with walking
severe pain, tenderness anteromedially from rupture of capsule
weak knee extension or inability to extend leg unless patella reduced
+ve patellar apprehension test
patient apprehensive when examiner laterally displaces patella
often recurrent, self-reducing
Investigations
x-rays: AP, lateral, skyline view of patella
check for fracture of medial patella and lateral femoral condyle
Treatment
non-operative first
knee immobilization x 4-6 weeks
progressive weight bearing and isometric quadriceps strengthening
if recurrent
surgical tightening of medial capsule and release oflateral retinaculum, possible tibial
tuberosity transfer, or proximal tibial osteotomy
Toronto Notes 2011 Patellati'ibia
Patellofemoral Syndrome (Chondromalacia Patellae)
Mechanism
softening, erosion and fragmentation of articular cartilage, predominantly medial aspect of
patella
commonly seen in active young females
predisposing factors
malalignment causing patellar maltracking (patellofemoral syndrome)
post-trauma
deformity of patella or femoral groove
recurrent patellar dislocation, ligamentous laxity
excessive knee strain (athletes)
Clinical Features
deep, aching anterior knee pain
exacerbated by prolonged sitting (theatre sign), strenuous athletic activities, stair climbing,
squatting
sensation of instability, pseudolocking
tenderness to palpation of underside of medially displaced patella
pain with extension against resistance through terminal30-400
swelling rare, minimal if present
Investigations
Treatment
non-operative
continue non-impact activities
NSAIDs
PT: quadriceps strengthening
surgical with refractory patients
tibial tubercle elevation
arthroscopic shaving/debridement
lateral release of retinaculum
Tibia
Tibial Plateau Fracture
Mechanism
axial loading (e.g. fall from height)
femoral condyles driven into proximal tibia
can result from minor trauma in osteoporotics
Clinical Features
lateral fractures more common than medial
Classification
Schatzker classification (see sidebar)
Investigations
Treatment
if depression on x-ray is <3 mm
straight leg immobilization x 4-6 weeks with progressive ROM weight bearing
if depression is >3 mm
ORIF often requiring bone grafting to elevate depressed fragment
ligamentous injuries
meniscallesions
AVN
infection
Orthopaedic:a OR33
.... , ,

Pain with firm camprusion of
pliiEIII. iniD medial femlnl groove is
pathognomonic of chondromalacia
paldlle.
.... , ,

Typ1 Ducriptian
Ill
IV
v
VI
Involvement of lirteral plateau
&plit hcturu
lnvolvemllll of lateral plateau:
&plit depression
lnvolvemlllll of lllta111l plateau:
pul'll deprNSion fnlc1ul'll
Medial plateau fractun
pllltaau fracturu
8il:andyl11r with meblphy5saV
diaphyseal involvement
OR34 Orthopaeclica
.... ,

1ibi1lllhllft hcturu hlwaliltl
ilcidanca of ccmpartment syndrome
and .-e oft8n QIIOC:iabld with wfttiAue
iljuriaa.
Flgare U. lllllal &aft Frachlre
Treated wlllllnti1Hiedulary Nail
dlcrawa
.... ,

.,...... ........... Enmn;y
llldU& ERill
Q Di"lr l'llqUillld 1:
P'ain in lh maiiiiOI zone AND bony
bnlamau _.lha podarior
of lhe medial or lld811111111111101ua
OR inability 10 weiclttt bear both
ilmllldiablly lifter and in lhe E.R.
TihWADkle 1'oroDio 2011
Tibial Shaft Fracture
Mechanism
nwneroua, including MVA, falls, sporting injuries
Clinical Features
open vs. closed
amount of dJsplacement
neurovascular status
most commonly fractured long bone
most common open fracture
Investigations
x-rays: AP,lateral. skyline
Treatment
closed
minimally displaced: straight leg cast x 4-6 weeks with early weight bearing
diapla.ced: ORIF with reamed IM nail. plate and screws, or external fimtor
open
atc:mal fixation or IM nail
vascularized coverage of soft tissue defects (often heal poorly)
Specific Complications (see General Fmcture Com.pllcatkms, OR6)
high incidence of neurovascular injury and compartment syndrome
poor soft tissue awerage
Ankle
Evaluation of Ankle and Foot Complaints
Spec:ial Tests
Bllterior drawer: examiner attempta to displace the foot Bllteriorly against a fixed tibia
talar tilt: foot is stressed in inversion and Bllgle of tala.r rotation is evaluated by x-ray
X-Ray
AP, lateral
mortise view: ankle at 15 of internal rotation
gives true view of ankle joint
joint space should be symmetric with no talar tilt
Otn!.wa Ankle Rules should guide use ofx-my (see sideba.r)
cr to better characterize fractures
Ankle Fracture
Mechanism
pattern of fracture depends on the position of the ankle when trauma occurs
generally involves
lpsll.ateralligamentous tears or transverse bony avulsion
contnlateml shear fractures (oblique or spiral)
classification systems
Danis-Weber (see below)
Lauge-Hansen: based on foot's position and motion relative to leg
Danls-Webar Classification (F.igure 45)
based on level of fibular fracture relative to syndesmosis
Type A (infra-syndesmotic)
pure inversion injury
avulsion of lateral malleolus below plafond or tom calcaneofibular ligament
shear fracture of medial malleolus
Type B (trans-syndesmotic)
external rotation and eversion (most common)
avulsion of medial malleolus or rupture of deltoid Ugament
spiral fracture ofla.teral ma.lleolus starting at plafond
'IbroDlo Nota 2011 Ankle/Foot
Type C (supra-syndesmotic)
pure eztemal rotation
avulsion of medial malleolus or tom deltoid ligament
p08terior malleolus may be avulsed with p08terior tibio-fibular ligament
fibular fracture is above plafond (called Maisonneuve fracture if at proximal fibule)
frequently telll'!l synde.mmsis
Treatment
undisplaced: non-weight bearing below knee cast
indications for ORIF
all fracture-dislocations
most of type B, and all of type C
trimalleolar (medial, posteriru; Imeral) fractures
talar tilt > 10
medial clear space on XR greater than superior clear space
open fracture/open joint injury
high inc.l.dence of post-traumatic arthritis
Ligamentous Injuries
Medial Ugament Complex (deltoid ligament)
evenl.on lnjury
usually avulses m.edlal or posterior malleolus and strains syndesmosis
Lateral Ligament Complex (ATF, CF. PTF)
invenri.on injury
ATF most severely injured if ankle is plantar flexed
swelling and tenderness anterior to lateral malleolus
++ ecchymoses
+w ankle anterior drawer
may have significant medial talar tilt on inversion stress x-ray
Treatment
microscopic tear (Grade I)
rest. ice, compression, elevation (RICE)
macroscopic tear (Grade In
strap ankle In dorsi1leDon and eversion x 4--6 weeks
PT: strengthening and proprioceptive retraining
complete tear (Grade DI)
below knee walking cast 4-6 weeks
PT: strengthening and proprioceptive retraining
surgical intervention may be required if chronic symptomatic instability develops
Foot
Talar Fracture
Mechanism
axial loading or hyperdorsiftcdon (MVA, fall from a height)
60% of talU5 covered by articular cartilage
tenuous blood supply runs distal to proDma1 along taiar neck.
high risk of AVN with displaced fractures
Investigations
x-rays: AP, lateral
cr to better characterize fracture
MRI can clearly define extent of AVN
Treatment
undisplaced: non-welght bearing below knee cast x 20-24 weeks
displaced: ORIF (high rate of nonunion, AVN)
Ortbopaedia OR35
-
Figura 45. Ring Priadpla af tha
Aalda and DMII..Wibar
Cllalllcatlon
PIT
TC
ATT
Figura 4&. Anld1 Lig.....t
CGIIIpiiXII
.... ' ,

With a hiltury af 1nllmll frDm axial
loading of loww limb always consider
pinlll injuriA. femo111l nlldt. 1ilial
tlllar/cah:anllll hcbnl.
OR36 Orthopaedica
...._, I
..
C.lcannl lftcture TI'Mtmlllt
Princ:iplp
1. Avoid wound compliclllions
2. Restore articular congruity
3. Rastora normal calcaneal width end
1\eight
4. Maximum functional r&eOV81'f may
tag langtr then 12 months
...._, I
.. .----------------,
The mast common site of Achilles
tendon rupture is 2-6 em from its
insertion where the blood supply is the
poorest.
Foot Toronto Notes 2011
Calcaneal Fracture
Mechanism
axial loading: fall from a height onto heels
10% of fractures associated with compression fractures of thoracic or lumbar spine
5% are bilateral
swelling, bruising on heel/sole
wider, shortened, flatter heel when viewed from behind
Investigations
x-rays: AP, lateral, oblique (Broden's view)
loss of Bohler's angle
CT - assess intraarticular extension
Treatment
closed vs. open reduction is controversial
non-weight bearing cast approximately 3 months with early ROM and strengthening
Achilles Tendonitis
Mechanism
chronic inflammation from activity or poor-fitting footwear
may also develop heel bumps (retrocalcaneobursitis)
pain, stiffness and crepitus with ROM
thickened tendon, palpable bump
Treatment
rest, NSAIDs
gentle stretching, deep tissue calf massage
orthotics, open back shoes
DO NOT inject steroids (risk of tendon rupture)
Achilles Tendon Rupture
Mechanism
loading activity, stop-and-go sports (e.g. squash, tennis, basketball)
secondary to chronic tendonitis, steroid injection
Clinical Features
audible pop, sudden pain with push off movement
sensation of being kicked in heel when trying to plantar flex
palpable gap
apprehensive toe off when walking
weak plantar flexion, +ve Thompson test: with patient prone, squeezing the calf muscles should
passively plantar flex the foot to demonstrate intact Achilles tendon
+ve test = no passive plantar flexion = ruptured tendon
Treatment
low demand or elderly: cast foot in plantar flexion (to relax tendon) x 8-12 weeks
high demand: surgical repair, then cast as above x 6-8 weeks
Plantar Fasciitis (Heal Spur Syndrome)
Mechanism
repetitive strain injury causing microtears and inflammation of plantar fascia
female:male = 2:1
common in athletes (especially runners)
also associated with obesity, DM, seronegative and seropositive arthritis
'IbroDlo Nota 2011 Foot
Futures
morning pam and stiffness
intense pain when walking from rest that subsides aa patient continues to walk
swelling, tenderness over sole
greatest at medial calc:aneal tubercle and 1-2 em distal along plantar fa.K:I.a
pain with toe dorsiflexion (stretches fascia)
Investigations
plain radiographs m rule aut fractures
often see exostoses (heel spurs) at insertion of filsda into medial calcaneal tubercle
(see Figure 47)
spur is reactive to inflammation. not the cause of pain
Treatment
rest, ice, NSAIDs, steroid injection
PT: stretcbing, ultrasound
orthotics with heel cup
m counteract pronation and disperse heel strike forces
endoscopic surgical release of :lUcia in refractory cases
spur removal is not required
Bunions (Hallux Valgus)
----------------------------
Machan lam
valgus alignment on 1st MTP (hallux valgus) causes eccentric pull of extensor and lntrlnslc
muscles
reactive exostosis forms with thickening of the skin creating a bunion
most often associated with poor-fitting fuotwar but can be hereditary
lOx more frequent in women
Features
pamful bursa over medial eminence of 1st metatarsal head
pronation (rotation inward) of great toe
numbness over medial aspect of great toe
Treatment
cosmetic and to relieve pam
non-operative first
properly frtted shoes Oow heel) and toe spacer
surgical
osteotomy with realignment of 1st MTP joint
Metatarsal Fracture
as with the hand, 1st, 4th. 5th metatarsals (M'l1 are relatively moblle, whlle the 2nd and 3rd are
fixed (Table 18)
use Ottawa Foot Rules to determine need fur x-nry (see sl.debar)
Tillie 1 I. Types of M81Btarul Fracturas
frldu .. Mdllllm Cllll:ll
Ortbopaedia OR37
Figu111 47. X-Ray of Banr Hl
Spur
Nonnalangle <15"
Hallux Valgus ar9& > 1 5'
Figu111 41. Hallu: Valgus
Awbsian of basa af 5th MT Suddlln invnion fulluMd by Tendllr bad 5th MT
camction of pernneus brevis
Raq.Jiras ORIF if li&ji!CIId .... , !
Midllhaft:5thMT
(Jclles lracbnl
2nd, 3rd MT
(March frac1unl)
1stMT TIIIIDII
Pllinfulllhllt of 5th MT
Pllinfulllhllt of 2111 II" 3111 MT
Painful 1st MT
"NWB BK cast x 6 wkll
OIIIF if alllleta

OIIIF if displaced otherwile
NWB Blcast x3 wb thlll
walicDII CISt X 2 \\b
Tlna-MT fnu:lln- clslacatilll Fal CdO !Enter fliiiC8d foal II" SlialtSned farafocn prominent Oil IF
diad CIIISh injiJY ba (l.islnrle frac:lu11)

DIMnfottWH
Xrays only ,..quired if:
1'8in in lha milfuDI: mna AND bcmy
llndemns owr the nwicul or bas.
Ill the liflh melltllul OR inability ID
waight -.. bDih immadhrtllly .rtar
inj..y and in tha ER.
OR38 Orthopaeclica
....,, ,
..
Gr.1111ick lractmlllara aay tD raduca
but can radisplaca i'l cast u 1o
mact
'
Praxinal RlldUI Praxinal RlldUI
f"IIGII8 49. Graaraslick (1..., 11111
Tarus (rigllt) Fnc:tures
Type I
Type II
Type Ill
Type IV
Type
Pediatric Orthopaedia 1'oroDio 2011
Pediatric Orthopaedics
Fractures in Children
typeoffracture
usually greenstick or buckle because periosteum is thicker and stronger
adults fracture through both cortices
epiphyseal growth plate
plate often mistaken for fractu.n: and vice versa
x-ray opposite limb for comparison
meche.nism which causes ligamentous injury in adults canses growth plate injury in children
intra-articular fractures have worse consequences in children because they usually involve
the growth plate
anatomic reduction
gold standard with adults
may cause limb length discrepancy in children (overgrowth)
accept greater angular deformity in clilldren {remodeling minimizes deformity)
time to heal
shorter in children
always be aware of the possibility of child abuse
make sure mecbanlsm compatible with injury
high J.nda of suspicion. look for other signs, including x-ray evidence of healing fractures at
other sites
Stress Fractures
Mechanism
insufficiency fracture
stress applied to a weak or structu.rally deficient bone
fatigue fracture
repetitive. excessive force applied to normal bone
most common in adole&eent athletes
tibia is most common site
Diagnosis and Treatment
localized pain and tenderness aver. the involved bone
plain films may not show fracture for 2 weeb
bone scan +ve in 12-15 days
treatment is rest from strenuous activities to allow remodeling (can take several months)
Evaluation of the Limping Child

see Pediatrics. P95
Epiphyseal Injury
Tabla 19. Sllltar-llania Claailil:ltian af Epiphpallllnjury
SALT(EIR-&ril Type Tllllnlant
through;
hile)
II (Above)
ll(l.aw)
Through mllaphysis plate
Closed reiB:Iian and cast imlmlimlian heals 95'1
ckl nat lllfect IJDWih
Through ta plata Md IIana growth Anatomic reduction by ORF 1c prmnt IJQWih e1T81t
plate
& IV {llmdJ 101 tlmQI) Through Sid 11181Bphysis
i
f"IIGII8 50. Sllltar-llarril
Classification
V!Ram) Crusll of H1 incidiiiC8 af pMh aiT86t; no specific tJaalmant
Toronto Notes 2011 Pediatric Orthopaedic.
Slipped Capital Femoral Epiphysis (SCFE)
type I Salter-Harris epiphyseal injury
most common adolescent hip disorder, peak at pubertal growth spurt
risk factors: male, obese, hypothyroid
Etiology
multifactorial
genetic: autosomal dominant, blacks > caucasians
cartilaginous physis thickens rapidly under growth honnone (GH) effects
sex honnone secretion, which stabilizes physis, has not yet begun
overweight: mechanical stress
trauma: causes acute slip
Clinical Features
acute: sudden, severe pain with limp
chronic: limp with medial knee or anterior thigh pain
tender over joint capsule
restricted internal rotation, abduction, flexion
Whitman's sign: with flexion there is an obligate external rotation of the hip
pain at extremes of ROM
Investigations
x-rays: AP, frog-leg, lateral radiographs
posterior and medial slip
----
if mild slip, AP view may be normal or show slightly widened growth plate compared with
opposite side
Treatment and Complications
mild/moderate slip: stabilize physis with pins in current position
severe slip: ORIF or pin physis without reduction and osteotomy after epiphyseal fusion
complications: A VN (most common), chondrolysis, pin penetration, premature OA, loss of
ROM
Developmental Dysplasia of the Hip (DOH)
formerly called congenital dysplasia of the hip (CDH)
due to ligamentous laxity, muscular underdevelopment, and abnormal shallow slope of
acetabular roof
spectrum of conditions that lead to hip subluxation and dislocation
dislocated femoral head completely out of acetabulum
dislocatable head in socket
head subluxates out of joint when provoked
dysplastic acetabulum, more shallow and more vertical than normal
painless (if painful suspect septic dislocation)
diagnosis is clinical
limited abduction of the flexed hip ( <50-600)
affected leg shortening results in asymmetry in skin folds and gluteal muscles, wide
perineum
Barlow's test (for dislocatable hip)
flex hips and knees to 90 and grasp thigh
fully adduct hips, push posteriorly to try to dislocate hips
Ortolani's test (for dislocated hip)
initial position as above but try to reduce hip with fingertips during abduction
positive test: palpable clunk is felt (not heard) if hip is reduced
Galeazzi's Sign
knees at unequal heights when hips and knees flexed
dislocated hip on side oflower knee
difficult test if child < 1 year
false positive if congenital short femur
Trendelenburg test and gait useful if older (>2 years)
Investigations
U/S in first few months to view cartilage
follow up radiograph after 3 months
Orthopaedia OR39
""' I

In alipped capital hmo .. IIPiphysis,
bilirte11l inwlvement occurs in llbout
25%.
.... '

5 F's1Ut l'nldispue 1D
Dftlllapmental Dpplnia af IIIII Hip
F.,ily hiltory
Female
Frank bnlech
Firstborn
Left hip
OR40 Orthopaedica Pediatric Orthopaedica Toronto Notes 2011
Treatment and Complications
0-6 months: reduce hip using Pavlik harness to maintain abduction and flexion
6-18 months: reduction under GA, hip spica cast x 2-3 months (if Pavlik harness fails)
> 18 months: open reduction; pelvic and/or femoral osteotomy
complications
redislocation, inadequate reduction, stiffness
AVN offemoral head
Legg-Calva-Perthes Disease (Coxa Plana)
self-limited AVN of femoral head. presents at 4-10 years of age
etiology unknown, 20% bilateral, males> females, 1/10,000
associations
family history
low birth weight
abnormal pregnancy/delivery
history of trauma to affected hip
key features
A VN of proximal femoral epiphysis, abnormal growth of the physis, and eventual
remodelling of regenerated bone
Clinical Features
child with hip pain and limp
tender over anterior thigh
1lexion contracture: decreased internal rotation, abduction ofhip
Investigations
x-rays
may be negative early
eventually, characteristic collapse of femoral head (diagnostic)
subchondral fracture
metaphyseal cyst
Treatment
goal is to preserve ROM and preserve femoral head in acetabulum
PT: ROM exercises
brace in flexion and abduction x 2-3 years
femoral or pelvic osteotomy
prognosis better in
males <5 years old. <50% of femoral head involved, abduction >30
50% of involved hips do well with conservative treatment
complicated by early onset osteoarthritis and decreased ROM
Osgood-Schlatter Disease
Mechanism
repetitive tensile stress on insertion of patellar tendon over the tibial tuberosity causes minor
avulsion at the site and subsequent inflammatory reaction (tibial tubercle apophysitis)
most common in adolescent athletes, especially jumping sports
Clinical Features
tender lump over tibial tuberosity
pain on resisted leg extension
anterior knee pain exacerbated by jumping or kneeling, relieved by rest
Investigations
x-rays: fragmentation of the tibial tubercle, ossicles in patellar tendon
Treatment
benign, self-limited condition
may restrict activities such as basketball or cycling
flexibility, strengthening exercises
'IbroDlo Nota 2011 Pediatric Orthopaecll.a
Congenital Talipes Equinovarus (Club Foot)
fixed deformity
3 partB to defonnity
talipes: talus is inverted and internally rotated
eq_uinus: ankle is plantar flexed
varus: heel and forefoot are In varus (supillated)
may be idiopathic, neurogenic, or syndrome-associated
1-211,000 newborns, 5096 bilateral, occurrence M>P, severity P>M
ex:amine hips fur associated DDH
examine knees for deformity
examine back for dysrapbiam (unfused vertebral bodies)
Treatment
correct deformities In the following order (Ponseti Technique):
furefoot adduction, ankle inversion, equinus
change strapping/C81it ql-2 wecb
surgical release in refractory case (50%)
delayed until 3-4 months of age
3 year recurrence rate = S-10%
mild recurrence common; affected foot is permanently smaller/stiffer than normal foot with calf
muscle atrophy
Scoliosis
Definition
lateral cu.rvature of spine with ftl'tebral rotation
Epidemiology
age: 10-14 years
more frequent and more severe in females
Etiology
idiopathic: most colDllWn (90%)
congenital: vertebrae fail to form or segment
neuromuscular: UMN or LMN lesion, myopathy
other: osteochondrodystrophies, neoplastic, traumatic
portural: leg length discrepancy, muscle spum
Clinical Features
0 back. pain
o 1 o where several vertebrae affected
2 above and below fixed 1 o to try and maintain normal posltlon ofhead and pelvis
asymmetric shoulder height when bent forward
o Adam's test: rib hump when bent forward
prominent scapulae, creued flank, asymmetric pelvis
aaaodated posterior midline skin leslons in non-idiopathic scoUoses
cafe-au-lait spots, dimples, neuro1ibromas
Wllary freckling. hemangiomas, hair patches
o aaaodated pes c:avus or leg atrophy
apparent leg length discrepancy
X-Raya
3-foot standing
measure curvature - Cobb Angle (Figure 52)
may have associated kyphoala
Treatment
based on degree of curva.ture
<20": observe for changes
>20" or progressiw: bracing (many types) that halt/slow curve progression but do NOT
reverse deformity
>40", cosmetlcally unacceptable or respiiatory problems: sw-glcal correction (spillal fusion)
Ortbopaedia OR41
Fllre 51. The Club Foot-
Depicting tha GnJU 11d BaQ
hfDnnity
B
Flaure sz. CoiJb Allgla - 1181d to
monilllr lila proarauio af lila
ICOiiatic Cllr8
.... ,

In lllruclul'lll or mr.t acalilnlia. ._ndilg
foMads makas th1 CUM 1110111
Gbvioul.

IW!ullll tcllio em by
comcting 1111 undallying probla11.
OR42 Orthopaeclica
Ralflllgll
ParsisiBnt skllrtll pain
LIICIIized Ulnd81118M
Sponmn1111111 fnctura
Enlqing mast/soft tiss1111swelling
53. Codml.-s Triangla -
a radiographic llndlnl In
malignaacy, wllara lila
Daifiad isliftad off
th1 CDrtax by DIDplastic tiuu1
Figure 54. T1 MRI of Femoral

Bone Tum.oun 1'oroDio 2011
Bone Tumours
primary bone tumours are rare after 3rd decade
metastases to bone are rela.tively common after 3rd decade
Diagnosis
pain, swclling. rarely regional adenopathy
routine x-ray
location (which bone, diaphysis, metaphysis, epiphysis)
size
lytic/lucent vs. scluotic
ilivolvement (cortex, medulla, soft tissue)
matrix (radiolucent, radiodense or calcified)
periosteal reaction
margin (geographic n. permeative)
any pathologic:al fra.cture
soft tissue swelling
malignancy is suggested by rapid growth, warmth, tenderness, lack of sharp definition
staging should include
bloodwork Including liver enzymes
CTchest
bone scan
bone biopsy
should be referred to specialized centre prior to biopsy
classified into benign, benign aggressive. and malignant
MRl of affected bone
Benign Active Bone Tumours
1. Ostaold Osteoma
peak incidence In 2nd and 3rd decades, M:F = 3:1
small, round radiolucent nidus ( <1 an) surrounded by dense bone
tibia and femur most common
produces severe intermittent pain. mostly at night (diurnal prostaglandin production)
characteristically relieved by NSAIDs
not known to metutasize
2. Ostaochondroma
2nd and 3rd decades, M:F = 1.8:1
4596 of all benign bone tumours
metaphysis oflong bone (distal ends offemurlproximal ends of humerus)
cartilage-capped bony spur on mrface of bone ('"mushroom" on x-ray)
may be multiple (hereditary, autosomal dominant form) - higher risk of malignant chELDge
generally very slow growing and asymptomatic unless impinging on neurovascular structure
malignant degeneration occurs in 1-296 (becomes painful or rapidly grows)
3. Enchondroma (Figure 54)
2nd and 3rd decades
5096 occur in the small tubular bones of the hand and foot; others in femur, humerus, ribs
benign c:artilagenous growth. develops in medullary cavity
singlelm.ultlple enlarged rarefied areas in tubular bones
lytic lesion with sharp margination and central caldficatl.on
malignant degeneratl.on occurs in 1-296 (pain in absence of pathologic fracture is an important
clue)
not known to metastasize
4. Cystic Lesions
includes unicameral/solitary bone cyst (most common), fibrous cortical defect
children and young adults
local pain. pathological fracture (5096 presentations) or incldental detection
lytic translucent area on metaphyseal side of growth plate
cortex thinned/expanded; well defined lesion
aspiration cystic fluid: grecnlyellow colour with high ALP
treatment of unicameral bone cyst with steroid injections bone graft
Treatment
treatment only necessary if symptomatic
osteochondroma: resection
cystic lesions: currettage and bone graft
'IbroDlo Nota 2011 Bone Tumoura
Benign Aggressive Bona Tumours
Giant Cell Tumours/Aneurysmal Bone Cyst/Osteoblastoma (Figure 55)
affects patientll of skeletal maturity, peak 3rd decade
fuund in the distal femur, proximal tibia, distal radius, sacrum, tarsal bones, spinal
(osteoblastoma)
cortex appears thinned. expanded; well-demarcated sclerotic margin; T2 MRI enhances fluid
within lesion (hyper-intense signal)
local tenderness and swelling
15% recur within 2 years of surgery
giant cell tumour occasionally met:astasizes (1-2%)
Tnabnent
intralesional curettage + bone graft or cement
wide local adsion of ezpendable bones
Malignant Bone Tumours
Tallie 20. Mast Cammon Maliaaiiii:Tumaar Types fur Age
<1
1-10
Nalllileltoml
Ewilg's af tubullr bcxiiiS
Ostaoslrcarna. Ewing's afllat banas
3().4() lleliaJUn cell SIII'CIIliB,. fboslmJma. periosteal asleoslmJma. 011lignant giant eel Unaur, iyn'flhama
>40 Meblsbltic c:arciiiRII, nr.dtiple myelDRII, chandi'CISIIrcDRII
1. Osteo5an:oma (Figure 56)
most frequently diagnosed in 2nd decade of life (60%)
history of Paget's disease radiation
predilection fur distal femur (45%), proximal tibia (20%) and proximal hwnerus (15%)
invasive, variable histology; frequent metastases without treatment Oung most common)
painful. poorly defined swelling. decreased ROM
Hay shows Codma.ns triangle (Figure 53)
characteristic periosteal elevation and spicule formation representing tumour extension into
periosteum
destructive lesion in metaphysis may cross epiphyseal plate
treatment: complete resection (limb salvage, rarely amputation), neo-adjuvant cbemo
survival- 70%
2. Chondrosarcoma (Figure 57)
primary (213 cases)
previous normal bone, patient over 40; expands into cortex to give pain, pathological
fracture. flecks of calcification
secondary (1/3 cases)
malignant degeneration of pre-existing cartilage tumour such as enchondroma or
osteochondroma, younger age group and better prognosis than primary chondrosarcoma
most commonly occurs in pelvis, fennu; ribs, scapula, humerus (with metastasis to the hmg)
unresponsive to chemotherapy, treat with aggressive surgical resection+ reconstruction
3. Ewing's Sarcoma
most occur between 5-20 years old
ft.orid periosteal reaction in diaphysis oflong bone
moth-eaten appearance with perioneallamellated pattern (onion-&dnning)
present with mild fever, anemia, leukocytosis and increased ESRJLDH
metastases frequent without treatment
treatment - resection, chemotherapy, radiation
survival- 70%
4. Multiple Myeloma
most common primary malignant tumour of bone in adults
90% occur in people >40 yelll'll old
present with anemia, anorexia, renal failure, nephritis, increased ESR, bone pain (cardinal early
symptom), compression fractures, hypercalcemia
bigb J.ncJ.denc:e of lnfections (e.g. pyelonephrttlslpneumonia)
Ortbopaedia OR43
Figura 55. X.aay of Anearpmal
Bane Cyst_ Nota tha aggrassive
dastructian of bona
Fllare 51. X-Ray of Olte0111rcama
of Dlml
Figura 57. X-lay af Femanll
Cllondroaarcoma
OR44 Orthopaedica

Breast Breast
lung lung

Kidllll'( Kidney

liLT wllh a lasher Pickle
llrlllst

Thyroid
Kidney
Promrte
Bone Tumours/ Articular Cartilage Defects Toronto Notes 2011
diagnosis
Cf-guided biopsy of lytic lesions at multiple: bony sites
serum/urine protein electrophoresis
treatment chemotherapy, radiation, surgery for symptomatic lesions or impending fractures
see Hematolog)'> H47
5. Bone Metastases
2/3 from breast or prostate; also consider thyroid, lung, kidney
usually osteolytic; prostate occasionally osteoblastic
bone scan for MSK involvement, MRI for spinal involvement may be helpful
stabilization of impending fractures
internal fixation, IM rods
bone cement
Articular Cartilage Defects
Properties of Articular Cartilage
lacks blood supply and does not have innervation or lymphatic drainage
varies in thickness from 2 mm to 4 mm and is thickest at periphery of concave surfaces and
central portions of convex surfaces
composed of type 2 collagen, water, proteoglycans, and chondrocytes
collagen provides resistance against tensile stresses and transmits vertical loads
water and proteoglycans provide turgor and elasticity and help to limit friction
chondrocytes synthesize the cartilage matrix and control matrix turnover rate
Etiology
overt trauma or repeated minor trauma; most commonly from sports injuries
early stage osteoarthritis
genetic degenerative diseases such as osteochondritis dissecans
Clinical Features
very similar to symptoms of osteoarthritis (joint line pain with possible effusion, etc.)
often have predisposing factors such as ligament injury, malalignment of the joint (varus/
valgus), obesity, bone deficiency (avascular necrosis, osteochondritis dissecans, ganglion bone
cysts), inflammatory arthropathy, and familial osteoarthropathy
may have symptoms oflocking or catching related to the torn/ displaced cartilage
Investigations
arthroscopy to visualize focal pathology and guide treatment strategy
MRI may also be used to visualize the defect
Table 21. Outerbridge Classilicl1ion of Chondral Detects
Gl'lde Chandl'll 011111111
I Softening and swellng of cartilage
II Fragmentation and fissuring < 1/2 ilch in diameter
Ill Fragmentation and fissuring > 1/2 ilch in diameter
IV Erosion of cartilage down to bone
Treatment
arthroscopic lavage and debridement of the joint
marrow stimulation techniques (microfracture, drilling, abrasion arthroplasty)
involves creating a site of bleeding where new growth/healing can take place
osteochondral grafts; also known as the OATS procedure or mosaicplasty
involves transferring osteochondral fragments from non-weightbearing surface to area of
defect
autologous chondrocyte: implantation (ACI)
currently only available in the U.S. and Europe
involves harvesting patient's cartilage, growing it in culture: medium outside of the patient,
then reinserting the newly cultured chondrocytes back to fill the chondral defect
osteochondral allograft; only used in limited circumstances when defect is very large
Toronto Notes 2011 Common Medications Orthopaedic:a OR45
Common Medications
Table 22. Common Medications
Dnlg Nama Dosing Sclu1dulll lniiCIIIions Calllllllllls
cefamlin (Arx:eftl 1-2 g rl q8h PnlphylBCtically bsfore Fi11t genllrlllion ceph&l011p0rin; do
trlhopaedic surgery not use with penicillin allergy
heparin 51XXJIU SC q12h To IR\'efll venous thcrdiosis Moniter pllllelets, follow P1T
!lld pulmonary emboli which should rise 1.5-2x
l.MWH
dalteparin (Fragmin
1111
1 5000 IU SCOD DVT iJ'Ophylaxis asp. i1 hip Fixed dose, no
enaxaparin (lovenox<ll 30-40 mg SC bid 111d knee surgery improved bioavaiability,
fondaparinux (Arixtnl
1111
1 2.5mgSCOD increased bleeding rates
midazolam (Versedillll 0.02 mgilqj IV Conscious sedation lor short Medications used tDgether during
iJ'Ocedures fracture reduction- monitDr lor
respiat!lry depression
fentanyl (Sublimazel O.S-3 fliVkll IV Conscious sedation lor short Short acting anesthetic used
procedures i1 conjunction with midazolam
(Versedillll
triamcinolone (Aristocortl- an 0.5-1 ml of 25 mglml Suspension (injected into Potent anti-inflammatory effect
injectable steroid inflllll8d joint or bursa) Increased pain lor 24 hours,1'11'81y
causes fat necrosis and skin
depigmentation
naproxen 25G-500 mg bid Pain due to inflammation, NSAID, may cause gastric erosion
soft tissue and bleeding
misoiJ'OslOI (Cytotec
1111
) 200 flQqid Prophylaxis of heterotopic Use with indomethacin
ossification after THA
indomethacin (lndocicPI 25 mg PO tid Prophylaxis of heterotopic Use with misoiJ'OslOI
ossification after THA
ibuprofen (Advir, Motrin
1111
) 200-400 mg tid Pain {including post-op), NSAID, may cause gastric erosion
inflammation {including arthitis) and bleeding
propofol {Diprivan
1111
) 1-2 m!Vkg IV Conscious sedation for short Short acting llleslhetic often
iJ'Ocadures used in conjunction with f&ntanyl
(Sublimaze
1111
)
OR46 Orthopaedica References
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