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1)Definition of traumatology and orthopedics as science.

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traumatism, kinds of a traumatism. Definition traumatic disease

a)TRAUMATOLOGY (Gk. trauma – injury and logos – science)

-clinical medicine studying pathogenesis of mechanical injuries
system and developing methods of their diagnostics, treatment and
ORTHOPEDICS (Gk. ortos – straight, paidos – child)
-clinical medicine studying etiology and pathogenesis of diseases
musculoskeletal system and developing methods of their diagnostics,
treatment and prophylaxis
- is the totality of the traumas repeating for certain circumstances at
groups of the population for the certain period of time

c)kinds of a traumatism
 Occupational traumatism (10,4%):
 Industrial
 Agricultural
 Nonproductive traumatism
 Household - 51,8%
 Street - 24,9%
 Road and transport - 12,0%
 Intentional
 Sports
 Children's (school, preschool)

d)The traumatic disease

- is structural and functional injury of organism's homeostasis, caused
by mechanical damages or their combination to other exogenic
2)Explain of trauma, definition of the acute and chronic trauma.
Mechanism of a trauma: its kinds, definition, diagnostic value, clinic

a)The trauma
-is effect of external factors (mechanical, chemical, thermal etc.) on
an organism, resulting in morphological and functional damages of

b) acute trauma
- is a single-stage damaging effect of an external factor.
chronic trauma
-is a damage arising as a result of regular or periodic and repeated not
Intensive influences of same injuring agent.

c) Mechanism of a trauma: its kinds, definition, diagnostic value, clinic

 The direct mechanism of a trauma.
- Damage arises in a place of damaging action of an traumatic
Eg: direct impact
 The indirect mechanism of a trauma.
-Damage arises in a distance from a place of damaging action
of traumatic agent.
Eg :rotation of a leg
3)Definition of bruise, sprain and rupture. Theirs clinical symptoms,
differential diagnostics

 Bruise (contusio) is the closed damage of the soft tissue which has
arisen as a result of the short-term direct a trauma, accompanying with
a hemorrhage at preservation of anatomic integrity of hurting organ.

 Sprain (distorsio) is rupture of some fibres of elastic tissues

(muscular, tendinous, ligamentous), caused by force as the traction,
not breaking an anatomic continuity of an organ.

1st degree-is a tear of only a few fibres of is charecterised by

minimal swelling,localized tenderness but little functional disability

2nd –almost all fibres of ligament disrupted.present pain,swelling,inability

to use limb.joint movement are normal,DS made on performing a stress

3rd –complete tear of the ligament.there is swelling & pain over the torn
ligament.pain is minimal.DS made on performing a stress test,MRI

 Rupture (ruptura) is disturbance of anatomic integrity of tissues of a

organ, caused by force as traction.
4)Definition of crush and crush syndrome. Clinical manifestation of
these conditions; differential diagnostics.

 Crush (conquassatio)
- damage of anatomic and structural integrity of the tissue,
caused by direct
influence of injuring force.

 Crush syndrome (crush-syndromum)

-massive long compression of soft tissues or main vessels of the
extremities, causing the specific traumatic illness of an organism
accompanying a traumatic toxicosis, haemolysis with affection of
tubule of the kidney and development of the renal
sufficiency,apathy,restlessness,delirium takes 2-3 days to appear

TM-application ot tourniquet
5)Definition of a dislocation and a fracture. Theirs clinical symptoms,
differential diagnostics

• Dislocation (luxatio) ̶ persistent complete disconnection

(incongruence) of the articular surfaces.
Pain,deformity,swelling,loss of movement,shortening of limb,

• subluxation ̶ partial incongruence of the articular surfaces.

• Fracture (fracturae) – damage of integrity of a bone tissue.

-Check to see if skin is intact
-Check to see if the skin is stretched over a projecting fragment of the bone
-Note the posture of the distal extremity and the colour of the skin.
-Crepitus and abnormal movements only checked in unconscious patients.

X-ray examination:-
- 2 views must be obtained (anterior-posterior and lateral views).
-The joint above and the joint below the fracture must be included because
they may also be dislocated or fractured.
6) A bone as organ: parts and types of a bone. Tissues of a bone as
organ. Functions of a bone as organ and as bony tissue.

a)Three types of bone :

Trabecular bone
- (also called cancellous or spongy bone) consists of delicate
beams and sheets of bone, trabeculae, which branch and
intersect to form a sponge like network. The ends of long bones
(or epiphyses) consist mainly of spongy bone.
Compact bone
- does not have any spaces or hollows in the bone matrix that are
visible to the eye.
Woven bone
- immature, disorganized bone.

b) Tissues of a bone as organ

- bone tissue takes part in a metabolism of an organism.

-The bone includes tissues various by origin and physiological significance;
proper bone tissue
bone-marrow (red and yellow)
cartilaginous tissue in sites of joints of bones

c)Bone functions:
• mechanical - gives the skeleton the necessary rigidity to function as
attachment and lever for muscles and supports the body against
• biochemical - Calcium homeostasis & metabolism
• hemopoietic
7)organic and mineral components of a bone tissue. Cells of a bone
tissue, theirs functions. Development of cells of a bone.

a)Organic compenent 30-35%

a.bone cells 2%-osteoblast

b.matrix 98%-collagen
-non collagen
-bone protein

mineral components 65-70%

calcium phosphorus salt esp hydroxyapatite 95%

b)Cells of a bone tissue, theirs functions.

-the formation and organization of the extracellular matrix of bone and its
subsequent mineralization.
-synthesis of collagen & other bone proteins.
-Precursors are unknown
-The size up to 30 microns

-a mature cell of a bone tissue
-provides integrity of matrix due to biosynthesis of organic components
-excretes the enzymes stabilizing mineral structure of matrix
-It is formed from osteoblasts
-The bone without osteocytes is exposed of resorption

-Carries out resorption of bone tissue
-It is formed of cells of a bone brain macrophage-monocyte's lines
c)Development of cells of a bone
8)Reparation of a bone tissue. The kinds of callus. Stages of fracture
healing of a bone.

a)Reparation of a bone tissue

b) The kinds of callus

 Immature callus arises between direct contacting bony fragments,

the space between which should be no more than 0,1 mm, under the
condition of maximal stability of fragments.
 Periosteal callus arises as the result of rapid reproduction of cells of a
cambial layer of periosteum.
 Central callus is formed on the internal surface of a intramedullar
canal out of cells of endosteum and marrow of both fragments.
 Paraosseous callus arise out of soft tissues adjoining to a site of a
c) Stages of fracture healing of a bone.

1. Hematoma. Mainly the blood and necrotic tissue are between

fragments of a bone. ≈ 1 - 2 weeks.
2. Formation of a fibrous tissue. The stage is finished by commissure
of fragments that exclude theirs displacement on length and width. ≈ 2
- 6 weeks.
3. Formation of a bony callus. ≈ 6 - 12 weeks.
4. Consolidation of a fracture. The full load on a bone is possible.
5. Structural (architectonic) change of a bone. It is restoration of
architectonics of a bone tissue according to an orientation of a vector
of a load, and of metabolic activity of cells.
9)General schema of examination of traumatologic and orthopedic
patients. Complaints: definition, peculiarities of detection.

• Complaints – by the stereotyped pattern
• History of disease:
 where, when, how, why there was a trauma (arose disease)?
 who, when, where and from what result was rendered assistance
(carried out treatment) up to the moment of examination?
• History of life - by the stereotyped pattern
• The general objective research
• The local status

b) Complaints:
-Complaint is outspoken dissatisfaction of a patient by his own health
-Detection of the complaint is carried out by active interrogation with
detail of subjective sensations
10)Case history – peculiarities of detection. Basic methods of
examination in

Traumatology and orthopedics.

a)Case history
where, when, how, why there was a trauma (arise disease)?
who, when, where, what and as well as with what result was rendered
medical aid (was carried out treatment) up to the moment of inspection?

Patient's life history

Devote special attention to
• inheritable diseases,
• the diseases affecting musculoskeletal system
• neoplasm
• social status
• professional work

b)methods of examination
• Inspection
• Palpation
• Auscultation
• Investigation of function of a movement
• Radiodiagnostics
• Additional special methods of examination
11)Inspection of a patient. Positions of patient or extremity (diagnostic
value, clinic examples).

• Appearance of a patient
• Position of patient
1. passive position
2. forced position
3. active position
• Determination of the static deformations
• Inspection of region of a lesion

b)Positions of patient or extremity (diagnostic value, clinic


a. passive position of a hand at paralysis of a radial nerve;

b. passive rotation of the left leg to outside at fracture of a femoral
c. forced posture of the child with tuberculous spondylitis of a cervical
d. forced skewness of the pelvis at shortening of the left leg;
e. active posture of the fencer
12)Detection of axis of extremities (technique, variants of norm and
pathology, clinic examples).

a. normal axis of the upper extremity;

b. valgus angulation;
c. varus angulation;
d. normal axis of the lower extremity;
e. varus angulation;
f. valgus angulation

line Rozer – Nelaton
line Günter
triangle Günter
13)Palpation and auscultation at examination of patients with
traumas and diseases of musculoskeletal system

• temperature of a skin in comparison;
• localized pain;
• condition of a skin: humidity, dryness, mobility;
• disorder of a skin sensitivity;
• turgor of soft tissues, and condition of muscles.

The palpation of fracture’s region allows to determine its level of

damage, presence of pathological mobility of fragments, a crepitation and
deformation of region of damage.

• function of lungs;
• subcutaneous emphysema;
• crepitus at fractures (bony crepitus), osteoarthrosis, tendovaginitis et
• audible clicks at rupture of menisci, stenosing ligamentitis
14)Examination of function of the musculoskeletal system: volume of
movements in joints; muscle strength; condition of the
neuromuscular apparatus.
-measured with help of a goniometer
-Measure of rotational movements
-Placing of branches of a goniometer at the determination of volume of
movements in joints

The method of neutral zero position

Each joint has own neutral position (zero position), stipulated by the
maximal relaxation of muscles. Movement in a joint and opposite to it in
one of normal planes is characterized by three numbers, denoting
marginal points of amplitude of movement and zero position. If an
extremity passes zero position, number 0 is written between degrees
denoting marginal positions.
15)Detection of volume of movements in joints. Write about
ankylosis, rigidity, contracture, superfluous mobility, pathological
mobility, norm.

-measured with help of a goniometer

• ankylosis – complete absence of movements in a joint;

• rigidity – conservation of swaying movements (no more 5°);
• contracture – limitation of movements in a joint;
• superfluous mobility – augmentation of borders of physiologically
possible locomotions;
• pathological mobility – mobility in atypical planes, not conforming
to a normal form of articular surfaces of a researched joint;
• norm.
16)Measurement of the length of extremities. Kinds of the changes of
length of extremity: true (anatomical), relative, seeming (projecting).
Clinic examples

• true (anatomical) – it is caused anatomical change of length of a
• relative (dispositional) – it is caused dislocation of jointed bones
relative each other
• seeming (projective) – it is caused by restriction of locomotions in a

Change of a length of an extremity (usually shortening) can disappear

due to deformations of the pelvis and (or) scoliotic curvature of the spine.
Such shortening (or elongation) is named functional.

Comparative length of a circumference of an extremity (volume of an

extremity) allows to determine an edema and an atrophy of muscles

Measurement is carried out in symmetric points on identical distance

from bony reference points (acromion, internal condyle of humerus,
greater trochanter, articular space of the knee,.)
17)Significant symptoms of diaphyseal fractures
(Draw picture urself)

a.Appearance of bone’s fragments in a wound

-characteristic only for open penetrating fractures, not in all cases

-Open fracture is damage of a bone and soft tissues with skin wound at a
level of fracture regardless of its depth.

b.Pathological mobility of fragments is displacement of one bone's

fragment relatively another
-Is absent at the incomplete and impacted fractures.
-The sign can not be determined at intra- and juxta-articular fractures.

c.Bony crepitus is sensation of crackling at contact of one fragment

with another

Is absent at incomplete and impacted fractures and at interposition by a

soft tissue.

d.deformity is change of the form’s segment as a result of

displacement of fragments

Kinds of displacement
-by length
-Impacted fracture
-at angles


• absolute (anatomical)- with fracture (displacement on length)

• relative – without fracture
• seeming (projecting) – contracture, movement of joint
18)Deformity of segments at diaphyseal fractures. Kinds of
displacement of bone fragments. Types of angular deformations.
(draw picture urself)

a. Kinds of displacement
-by length
-Impacted fracture
-at angles

b. Types of angular deformations

19) Algorithm of reading of X-ray photograph of long tubular bone’s
fractures. Types of fractures (according the shape of the fracture


• On X-ray photograph of the left (right) shin of the patient of date in

two projections are determined …
• splintered, spiral (transverse, longitudinal, oblique etc.) …
• fracture of tibia in the distal one-third of bone …
• with displacement of fragments by length with shortening on 0,5 sm,
by width cortical a layer, and at angles open in (5 °).

B.Types of fractures(draw piture urself)

1. Transverse fracture
2. Oblique fracture
3. Spiral fracture
4. Comminuted fracture
5. Compression fracture
6. Greenstick fracture
20)Goals and principles of fracture treatment. The factors
influencing a fractures healing

a.Principles of treatment of traumatized patients

1. The principle of urgent,

2. The principle of anaesthesia,
3. The principle of reposition,
4. The principle of fixation,
5. The principle of function,
6. The principle of complex treatment,
7. The principle of rehabilitation

 Restoration of a patient to optimal functional state
 Prevention of complications
 Rehabilitation of a patient as early as possible

c.The factors influencing a fractures healing

-The energy damaged effect
-State of tissues in damaged region
 presence or absence of a diastasis between a bone’s
 micro-movement or no movement
 blood circulation of the bony fragments
 nerve supply of the bony fragments
 no infection
-The state of a patient
-The method of treatment
21)The principle of urgency. Algorithm of actions on a place of

The principle of urgent: first aid and treatment of the victim should be
urgent and begin on a place of incident

Algorithm of actions on a place of incident

1) To remove influence of injuring agent if it continues to act.
2) Diagnosis of functioning of life's ensuring organs and systems of
an organism
3) Restoration of function of life's ensuring systems of an organism
4) Diagnosis of other damages
5) The first medical aid of a pre-hospital stage
6) Transportation to the hospital
22) The pre-hospital medical aid at open and close fractures. Rules of
application of transportation splints

The pre-hospital medical aid at fractures:

1. anaesthesia,
2. transport immobilization,
3. transportation to the hospital

1. stopping bleeding,
2. anaesthesia,
3. aseptic bandage,
4. transport immobilization,
5. transportation to the specialized hospital

Rules of application of transportation splints are as follows:

a) Splint should be properly applied, well-padded at bony prominences and

at fracture site.
b) Bandage of splint should not be too tight as it may produce sores, or if too
loose lest it be effective
c) Patient should be encouraged to actively exercise the muscles and joints
inside splint as much as permitted
d) Any compression of nerve or vessel , usually due to tight bandage, should
be detected early and managed accordingly
e) Daily checking and adjustments, if required, should be made.
23) The principle of anaesthesia. The basic methods of anesthesia.

The principle of anaesthesia: medical aid and all medical manipulations

should begin with anesthesia.

The basic methods of anesthesia

 immobilization,
 narcotic and not narcotic analgesics,
 local and regional anesthesia,
 narcosis,
 physiotherapeutic methods of anesthesia,
 cold,
24) The principle of reposition. The basic methods of reposition.

The principle of reposition:

all displaced or disconnected tissue should be reduced or connected

The basic methods of reposition

1. Conservative
 simultaneous closed reposition
 skeletal extension
2. Operative
 open reposition
 devices of external fixing
25) The principle of fixation. The basic methods of fixation.

The principle of fixation:

everything, that is reduced or connected, should be fixed during accretion of
the damaged tissue

The basic methods of fixation

1. Conservative
 external immobilization,
 skeletal extension.
2. Operative
 osteosynthesis,
 devices of external fixing.
26) The principle of function. The basic methods restoration of function
of musculoskeletal system.

The principle of function: in an ideal simultaneously with repair of

anatomy of the damaged tissue function
of extremity should be repaired

The basic methods repairing function of musculoskeletal system

1. medical exercises
 active
 isometric
2. functional splints
3. electromechanical splints for passive exercises
27) The principle of complex treatment and the principle of

The Principle of Complex Treatment: to treat not a damage but of a

patient with an optimum combination of medical methods.

Algorithm of realization:
 determination of gravity of a patient’s condition,
 anamnestic and clinical detection of the concomitant diseases,
 the prognosis of development of a complications,
 optimum combination of essential methods of treatment and
prophylaxis of complication

The Principle of Rehabilitation: ultimate goal of treatment of the victim is

restoration of morphology of the damaged tissue and function of
musculoskeletal system

In a narrow conception this term rehabilitation means restoration of function

of the damaged organ and it is realized by three basic methods:
 physiotherapy exercises
 physiotherapy
 massage
28) Delayed union and nonunion: definitions, causes, clinical, basic
principles of treatment.

• Complications of fractures at which for average term of consolidation

there are no clinical and radiological signs of union are named
delayed union.
• Complications of fractures at which in double average term of
consolidation there are no clinical and radiological signs of union are
named nonunion.

Causes of Delayed Union and Nonunion are as follows:

• a mobility of fragments in region of a fracture

• excessive diastasis
• inadequate fixation,
• infection,
• soft tissue interposition,
• inadequate blood supply.

The following are some of the clinical findings which suggest delayed
union and non-union:

-persistent pain
-pain on stressing the fracture
-mobility(in non-union)
-increasing deformity at fracture site(in non-union)
Treatment: Most fractures in delayed-union unite on continuing the
conservative treatment. Treatment of non-union depends upon site of non-
union and disability caused by it.

-Bone grafting: This is the commonest operation performed for non-union.

The grafts are taken from iliac crest. Internal fixation is required in most

- Excision of fragments: Achieving union’s difficult and time consuming

compared to excision of one of the fragments, where this can be done
without the loss of functions.

- Ilizarov’s method: Prof. Illizarov from the former USSR designed a

special external fixation apparatus for treating non-union.
29) False joints: definition, classification, basic phases of surgical

The false joints (pseudoarthrosis) are classified as

• hypervascular (hypertrophic)
• avascular (atrophic)

It is based upon of their capability to biologic reaction (vitality of the

bone ends).

Basic phases of surgical treatment of a false joint

• resection of a false joint – removing of fibroses and cartilaginous

tissue between fragments, opening of medullary canals
• decortication – excision of thin layers of the cortical shell until
appearance of bloody fluid
• bone grafting
• fixation of fragments
30) Malunion: definition, basic clinical symptoms and methods of

Malunion is union in a clinically significant abnormal position.

Basic clinical symptom of malunion is

a lesion of anatomical axis
of an extremity. Malunion also results in deformity, shortening of limb, and
limitation of movements.

Basic methods of treatment of malunion are as follows:

a) Osteoclasis(refracturing the bone): it is used for correction of mild to

moderate angular deformities in children. Under general anesthesia,
fracture’s reproduced, angulation corrected, and limb immobilized in plaster.

b) Corrective osteotomy: the deformity is compensated for by an

osteotomy at a site away from the fracture e.g. osteotomy for mal-union of
supracondylar fracture of the humerus.

c) Excision of protruding bone: In fracture of clavicle, bone spike

protruding under skin may be shaved off.

d) Illizarov’s apparatus of external fixation.

31) Traumatic osteomyelitis: definition, clinical picture, X-ray
diagnostics, basic principle of treatment.


Traumatic osteomyelitis is osteomyelitis arising after traumas, more often


Clinical picture:

Usually a suppuration arises in wound, contaminated by microbes from the

outside environment, more often by anaerobes that in result of natural
selection in wound change to coccuses flora
In these cases a zone of bone’s damage are less, than at gunshot wounds,
but can occur cases with “loss” of significant fragments of a bone.

Traumatic osteomyelitis

• osteomyelitis after open fracture of a bone

• firearm
• postoperative
A bone is particularly liable to infection, when loses soft tissues and periost.
Degeneration of a bone arises as result of contact with outside environment
– specific osteomyelitis is developing. A leg is usual localization of such a

Such osteomyelitis manifests itself as ulcer, it has bottom is a bone.

X-ray diagnostics:

-thickening and irreugularity of cortices

-patchy sclerosis giving rise to honey-combed appearance
-bone cavity: this is seen from an area of rarefaction surrounded by sclerosis
-sequestrum: a sequestrum may be visible in soft-tissues
- involucrum and cloacae may be visible

Basic principle of treatment:

The method of choice at treatment of such damages is compression-

distraction osteosynthesis, and later cutaneous-plastic operations .
32) Fractures of the clavicle: mechanism of trauma; clinical picture and
diagnosis; the first medical aid; treatment and complications.

Fracture of clavicle(collarbone) :
-this is a common fracture at all age groups, results from a fall on the shoulder
or sometimes on an outstretched hand.

Mechanism of trauma:

• Clavicle fractures are common injuries and they can occur

different ways.
• Indirect - patients fall on an outstretched hand.
• Direct - Broken collarbones can also occur from a direct hit to
the clavicle.
• In babies, clavicle fractures occur at birth during passage
through the birth canal.

Clinical picture and diagnosis:

• Clinical picture:-
A) general symptoms:
- pain
- swelling
- bruise
- increase local temperature
- lesion of function

B) Authentic symptoms of fracture :

- appearance of bone fragment in a wound (at open fractures).
- Pathological mobility of fragments.
- Crepitus.
- Deformation.
- Anatomic (true) shortening of a clavicle.
Diagnosis:- i) clinical diagnosis :-
• History of fall
• Pain on movement of shoulder
• Patient usually supports the flexed elbow with
normal hand
• There is swelling and tenderness over fracture site.
ii) instrumental :-
• X-ray – anteroposterior
- it may be cracked with no displacement or
displaced fracture with outer fragment
depressed and displaced medially. Inner
fragment displaced upwards.
1 medical aid:
When patient has fracture of clavicle, begin with general anesthesia, a)not
narcotic (ketonal, analgin, toradol and others). b) narcotic analgesics
(promedol 10%, 1-2 ml subcutaneously, omnopon, tramal
intramuscularly/intravenously) to stop the pain. Next, we immediately
immobilize the patient with figure-of-8-bandage at the displaced fracture. A
triangular sling can also be put on patient and patient is asked not to move
and rest. Finally, we transport the patient to hospital through emergency


-Fractures of clavicle unite readily even if widely displaced , hence

reduction of the fragment is not essential.
-Triangular sling is sufficient in most cases.
-Active shoulder exercises should be started as soon as initial pain subsides,
usually 10-14 days after injury.
-Figure of 8 bandage, Smirnov-Vanshtein bandage, Delbe rings bandage
may be applied to young adult with displaced fracture.
- surgical treatment : i)intramedullary osteosynthesis. ii) extramedullary
osteosynthesis. iii) rod-shaped apparatus of extrinsic fixation.

Early complication: fractured fragment may injure subclavian vessels or
brachial plexus.
Late complications: Shoulder stiffness is common, especially in elderly
patients. It can be prevented by shoulder mobilization as soon as the patient
becomes pain-free. Malunion and non-union often cause no functional
disability and need no treatment.

33) Luxations of an acromial end of the clavicle: mechanism of trauma;

clinical picture and diagnosis; the first medical aid; treatment and

Luxations of acromial end of clavicle/subluxation or dislocation of acromio-

clavicular joint is an uncommon injury, caused by a fall on the outer
prominence of the shoulder.

Mechanism of trauma:

Uncommon injury, caused by a fall on the outer prominence of the shoulder.

• Indirect – a damage of the acromial end of the clavicle in many
respects depends on anatomical features of acromioclavicular joint.
a) sharp angle – to luxation of clavicle.
b) right angle – to fracture clavicle.
• Direct
• Mixed

The injury may result in partial or complete rupture of acromio-clavicular or

coraco-clavicular ligaments. It is divided into 3 grades upon severity:

Grade 1-minimal strain to acromio-clavicular ligament and joint capsule

Grade 2- rupture of acromio-clavicular ligament and joint capsule

Grade 3- rupture of acromio-clavicular ligament, joint capsule and coraco-

clavicular ligaments.

Clinical picture and diagnosis:

A) General symptoms:-
• Pain.
• Swelling
• Increase temperature
• Lesion of function.

B)Authentic symptoms:-
• Shortening of shoulder girdle.
• Deformation of shoulder girdle (prominent acromial end
of clavicle over acromion (symptom ‘key’).
• pathological mobility of acromial end of clavicle.

- X-ray with acromio-clavicular joints of both sides, for comparison, in same
film will show subluxation or dislocation.
-In Grade 3 injury lateral end of clavicle may be unusually prominent

1st. medical aid:

Begin with general anesthesia, Promidol 10% 1-2ml subcutaneous injection

to relieve pain. Next, immobilize the patient by applying a triangular sling
on the affected side. Then, transport patient to hospital as soon as possible.

Treatment and complications:

Such injury is treated by rest in a triangular sling and use of analgesics, like
Lidocaine. If the injury’s more severe like grade 3, we have to treat patient
by surgical repair.

Complications which may arise are as follows:

-injury of the suprascapular artery and nerve
-shoulder stiffness may also arise
34. Shoulder dislocations : mechanism of trauma; clinical picture and
diagnosis; the first medical aid; treatment and complications.

Shoulder dislocation is the commonest joint in the human body to be

dislocated. Occurs more in adults and rare in children. Ant. dislocation is
much more common than posterior.

Mechanism of trauma
• A fall with an out-stretched hand with the shoulder abducted and
externally rotated is the common mechanism of injury of ant dislocation.
• Occasionally, it results from a direct force pushing the humerus head
out of the glenoid cavity.
• A posterior dislocation may result from a direct blow on the front of the
shoulder,driving the head backwards. Posterior dislocation is the consequence
of an electric shock or an epileptiform convulsion.
• According to classification, dislocation of shoulder divided into:-
 Anterior dislocation:head of humerus comes out of glenoid
cavity and lies anteriorly. Can be divided into:-
a) Preglenoid – the head lies in front of the glenoid.
b) Subcoracoid – the head lies below the coracoid process.
c) Subclavicular – the head lies below the clavicle.
 Posterior dislocation: the head of the humerus lies posterior to
the glenoid.
 Luxatio erecta: head lies in the subglenoid position.

Clinical picture

General symptoms:-
• Pain
• Swelling
• Bruise
• Increase temperature
• Lesion of function

Diagnosis :-
1) Complaints:- a) enters casually with shoulder abducted and elbow
supported with the opposite hand.
b) history of fall on out stretched hand followed by pain and
inability to move the shoulder and may have similar
episodes in the past.
2) Examination:- a) arm is abducted.
b) normal contour of the shoulder joint is lost and it
c) may notice fullness below the clavicle due to the
displaced head.
d) for anterior dislocation it is associated with the
following signs:
• Dugas’s test : inability to touch opposite
• Hamilton ruler test : because of the flattening
of the shoulder, it is possible to place a ruler on the lateral side of the arm.
This touches the acromion and the lateral condyle of the humerus
• Callaway’s test: in dislocation of the
shoulder, vertical circumference of axialla is increased compared to the
normal side.

The first medical aid.

Treatment and complications.

1) reduction under sedation or general anesthesia.
- technique : a) Kocher’s maneuver – the steps are : 1st reduction,
2nd external
rotation, 3rd adduction.
b) Hippocrates maneuver
2) Immobilization of the shoulder on the chest – arm bandage for 3 weeks.
3) Remove bandage and begin shoulder exercises.
1) Early – injuries to the axillary nerve resulting in the paralysis of the
deltoid muscle with areas of anesthesia over the lateral aspects of the
2) Late – recurrent dislocation of the shoulder due to : Marfan syndrome,
inadequate treatment of the 1st episode of dislocation leading to improper
healing of soft tissues, an epilectic patient.
35. Fracture of the proximal part of humerus : clinical picture and
diagnosis; the first medical aid; treatment and complications

• Neer-Codman classification
-Fractures are classified by anatomical location and the number of main

-According to Codman's observation, fractures of the proximal humerus

produce a combination of the 4 following segments:

 articular surface
 humeral shaft
 greater tuberosity
 lesser tuberosity

According to the Neer classification system includes 4 segments -- I,

II, III, and IV -- and also rates displacement and vascular isolation. The 4
segments are as follows:

• greater tuberosity
• lesser tuberosity
• humeral head
• shaft

-According to Neer, a fracture is displaced when there is more than 1 cm of

displacement and 45° of angulation of any one fragment with respect to the

-Two-part fractures involve any of the 4 parts and include 1 fragment that is

-Three-part fractures include a displaced fracture of the surgical neck in

addition to either a displaced greater tuberosity or lesser tuberosity fracture.

-Four-part fractures include displaced fractures of the surgical neck and both
• Mechanism of injury
i. a fall on the outstretched hand from a standing height.
ii. In younger patients, high-energy trauma
iii. violent muscle contractions from seizure activity,
iv. electrical shock
v. athletic events.
vi. direct blow to the proximal humerus

The fracture pattern depends on the applied force. Indirect forces cause most
shoulder fractures.

-Injury forces are tension, axial compression, torsion, bending, and axial
compression with bending.

-The primary fracture patterns from these forces are transverse, oblique, and

• Principles of treatment
i. Medical therapy:
a. Immobilization

-achieved with a sling, shoulder immobilizer, or a sling with an

accompanying swathe.

b. Physical therapy may be initiated after 3 weeks

ii. Surgical therapy: The type of surgical management of proximal

humerus fractures may be divided by fracture type or by the method
of fixation

(eg, closed reduction with no fixation, percutaneous fixation, open

reduction with internal fixation, proximal humeral head replacement
associated with tuberosity fixation).
• Complications

 Neurologic and brachial plexus injuries

 Vascular injuries ( axillary artery)
 Stiffness or frozen shoulder
 Avascular necrosis
 Malunions
36. Fractures of a diaphysis humerus: clinical picture and diagnosis; the
first medical aid; treatment and complications.

 Clinical picture and Diagnosis

 Clinical features:
o History of fall on
o Pain.
oSprains and
strains can
be as
painful as
o Swelling.
d in
end of
o Loss of function
o Deformity
EXTRA: Humeral shaft fractures result in localized pain, swelling, and
tenderness. Shortening of the upper extremity may occur with displaced
fractures. An associated radial nerve injury is common and will be manifested
by a wrist drop and decreased sensation over the dorsal first web space. The
humerus is also a common site of pathologic fractures.
 X-Ray (AP & L view). The diagnosis of humeral shaft fractures is
usually obvious on anteroposterior and lateral radiographs of the

 Treatment
Conservative treatment :
a) - U slab – Is a plaster slab extending from the base of the neck over
the shoulder onto the lateral aspect of the arm. Under the elbow to the
medial side of the arm.
- should be moulded on lat side of the arm in order to prevent lateral
- The U Slab is supported with a triangular sling. Once the fracture
unites, the slab is removed ( approximately 6-8 weeks) and shoulder
exercises started.
b) hanging cast : it’s used in some cases of lower-third fractures of the
c) Chest –arm bandage- The arm is strapped to the chest.
 Non operative:
oModerate displacement.
- Immobilize the affected shoulder in a triangular sling.
- As soon as the pain subsides, shoulder mobilization is started.
o Fragments are widely displaced.
- Reduced by manipulation under anesthesia.
- Once reduced, fracture can be stabilized by multiple K-wires
passed percutaneously under image intensifier control.
 Operative:
oOperative reduction & internal fixation.

Complications: 1) Nerve injury – The radial nerve is commonly injured in

a fracture of the humeral shaft
- The radial nerve injuryt results in paralysis of the wrist, finger and thumb
extensors ( wrist drop), brachioradialis and the supinator.
2 Delayed and non union. – fracture of the shaft of the humerus, especially
transverse fracture of the midshaft, often go into delayed or non-union. The
causes of non-union are generally inadequate immobilization or distraction at
fracture site because of the effect of gravity.
37. Fractures of a distal part’s humerus: mechanism of trauma; clinical
picture and diagnosis; the first medical aid; treatment and complications.

1) Mechanism of trauma : The fracture is caused by a fall on an out-

stretched hand. As the hand strikes the ground. The elbow is forced into
hyperextextension resulting in fracture of the humerus above the condyles.

2) Clinical pictures and diagnosis

The general symptoms:
- a pain,
- a swelling, a bruise (there can be a fluctuation),
- increase of local temperature
- lesion of function.

- X-Ray (AP & L view).

These fractures are often undisplaced.
- Combination of any of the following displacement may occur:
- Angulations : commonly medial & anterior.
- Shift : in any direction.
- Rotation : the proximal & distal fragments lie in different positions.

3) The first medical Aid, Treatment and Complications.

 Treatment
- Undisplaced fractures required immobilization in an above elbow
plaster slab, with the elbow in 90 degrees flexion.
- In all displaced fractures, the child should be admitted to a hospital
because serious complication can occur within the first 48 hours.

 Closed reduction by manipulation under general anesthesia.
 Immobilization in an above elbow plaster cast.

 Open reduction & internal fixation.

 Complications
 Infection.
 Volkmann’s ischemia. – Is an ischaemic injury to the muscles
and nerves of the flexor compartment of the forearm
 Delayed & non union.
 Mal union.
 Cross union.
38.Luxations of the forearm: mechanism of trauma; classification,
clinical picture and diagnosis; the first medical aid; treatment and

1) Mechanism of trauma : Usually mechanism of trauma is indirect.

Mechanism of trauma at posterior luxation of both bones of the forearm.

2) Classication : Luxation of both bones of the forearm – posterior

( usually=90%)
anterior, exterior, interior, divergent.
- Luxaiton of the radious : anterior ( usually subluxation at
posterior , exterior
- Luxation of the ulna.

3) Clinical picture and diagnosis :

The general symptoms:
pain, a swelling, a bruise (there can be a fluctuation), increase of local
temperature, lesion of function.
Authentic symptoms: deformation – disorder of the Gunter’s triangle and
line, relative shortening of forearm,symptom of springy resistance at an
attempt of passive movements forced semi-straightening position .

4) The first aid on place of an incident

 anesthesia: not narcotic (ketonal, analgin, toradol and others) or
narcotic analgesics (promedol, omnopon, tramal) i.m. or i.v.
 transport immobilization: Kramer's splint from the shoulder joint to the
wrist joint as position of upper extremity as is (without change of the
position of the extremity)
 transportation to the hospital.

5) treatment and complications.

 anesthesia: usually narcosis;
 closed reduction:
 position of the arm is abduction and semi-extension in the elbow joint,
 traction is carried out along axis of the forearm by shoulder and hand,
 reduction is carried out by pressure by thumbs on olecranon when
simultaneously shoulder is drawn back.
 immobilization posterior plaster splint from proximal one-third of the
shoulder to the heads of the metacarpal bones at flexion of forearm on
the angle 90°
 period of immobilization is 5 – 10 days
 next rehabilitation: exercise therapy, physiotherapy

Complication: Mal-union occurs commonly in cases treated convervatively

because of an undetected redisplacement within the laster. It causes deformity
of the forearm and limitation of the elbow and forearm movements.
39.Fractures of an olecranon: mechanism of trauma; clinical picture and
diagnosis; the first medical aid; treatment and complications.
1) Mechanism of trauma : -Usually the mechanism of trauma is direct.
- fractures of olecranon are intraarticular.

2) Clinic picture and diagnosis . Complaints: pain in region of the

olecranon, impossibility of movements in elbow joint.
General symptoms: The arm is straightened; patient spares its, holding its
healthy arm. Edema and bruise. Palpatory tenderness, especially at
pressure on the olecranon. Passive movement is possible, but painful.
Active flexion is impossible.
Authentic symptoms: At fracture with displacement is determined a fissure
or a retraction.

3) The first aid on place of an incident

 anesthesia: not narcotic (ketonal, analgin, toradol and others) or
narcotic analgesics (promedol, omnopon, tramal) i.m. or i.v.
 transport immobilization: Kramer's splint from the shoulder joint to the
wrist joint in position of extension of the forearm (≈ 120 - 130°)
 transportation to the hospital
4)treatment and complication.
Conservative treatment is only at fractures of the olecranon without
displacement or with diastasis no more than 2 mm
 Plaster bandage from the shoulder joint to base of the fingers at angle
of 100° in neutral position between pronation and supination.
 Immobilization – 4 week
 X-ray control in 3 – 5 days and 4 week
 Exercise therapy on 2 day
Treatment of fractures of the olecranon with diastasis btw splinters more
than 2 mm.
 Operations such as open reposition and osteosynthesis by wire and
tension band wire is done.

---Postoperative rehabilitation
 immobilization by cravat bandage during 4 weeks
 exercise therapy
Complication : 1) non-union is a common complication in cases with a gap at
the fracture-site which prevents the fracture from uniting. Treatment is by
open reduction, internal fixation and bone grafting.
2) Elbow stiffness occurs in some cases. Treatment is physiotherapy. In
selected cases surgical release ( arthrolysis) may required
3) Osteoarthritis occurs late, often after many years in some cases. Because of
the irregularity of the articular surface. Treatment is physiotherapy. In
selected cases elbow replacement may be required
40. Shaft fractures of bones of a forearm: mechanism of trauma; clinical
picture and diagnosis; the first medical aid; treatment and complications.
1) Mechanism of trauma : Mechanism of trauma is direct and indirect.

2) Clinical Picture and diagnosis. The general symptoms: a pain, a

swelling, a bruise (there can be a fluctuation), increase of local temperature,
lesion of function.
Authentic symptoms:deformation, anatomical shortening of
forearm,pathological mobility of splinters, crepitation,
at open fractures it is possible a penetration of splinters in a wound
-general-pain,swelling,bruise,increase local temperature,lesion
-authentic-bone fragments in wound,pathological mobility of
fragments,crepitation,deformation,anatomic/true shortening
-wrist drop in radial and injury
-x-ray of whole arm and elbow

-u-slab is supported with tranguled sling.After unite,the slab is removed and
start shoulder exercise
-hanging cast-some cases of lower 1/3 of fractures
-chest arm bandage-arm strapped to chest.Usually in children <5yrs

-in cases where reduction is not possible by closed manipulation or if
fracture is unstable open reduction and internal fixation
-fixed well with plate and screws and intramedullary nailing
If fracture with open or infected using external fixators

-injury to radial and paralysis of fingers,thumb and drop wrist
-delay and non union-if fracture localize in middle 1/3 of shaft
41. Distal radius fractures: mechanism of trauma; clinical picture and
diagnosis; the first medical aid; treatment and complications.
Colles fracture - distal end of radius fracture,Cortico-cancellous
junction[commonest fracture in ppl >40yrs & women cos of post-
menopaused osteoporosis]

1)Mechanism of injury
-results from a fall on an out-stretched hand

2)Clinical picture and diagnosis

clinically-pain,swelling,wrist deformation
-on examination-tenderness,irregularity of lower end of radius
-classic “dinner-fork deformity”[radial styloid process lies at same
level or a little higher than the ulnar styloid process
-x-ray findings-dorsal tilt displacement,
-lateral & AP-lateral tilt
 Loss of radial height (>5mm)
 Loss of radial inclination (Normal 20-25º)
 Dorsal tilt (Normal 10º volar)
 Comminution

a)undisplaced-immobilazation with below elbow plaster cast 6wks
b)displaced-manipulation reduction,immobilazation in Colle’s cast

*comminuted fractures-fixation percutaneously after immobilazation

-stiffness of joints
-mal union
-subluxation inferior radial-ulnar joint
-carpal tunnel syndrome
-Sudecle’s osteodystropy
-rupture of extensor pollicis longus tendon
42. Fractures of navicular bone: mechanism of trauma; clinical picture
and diagnosis; the first medical aid; treatment and complications.
1) Mechanism of trauma : Mechanism of trauma is direct- fall onto
outstretched hand or direct blow on palm and indirect - punch or fall onto
clinched fist.

2) Clinical picture and diagnosis : - slight edema and palpatory tenderness

in region of radiocarpal articulation (especially in region of “anatomic
-axial load along I and II fingers is painful
-movements in a joint are painful and limited, especially in dorsal and
radial direction
-weakness of a catch of objects by the hand
-impossibility of complete compression hand to fist

3) Treatment of a navicular fractures without displacement of splinters

 fracture of tubercle of a navicular bone: immobilization 4 – 6 weeks
 fracture of body and distal one-third of a navicular bone:
immobilization 10 – 12 weeks
 The hand is in position of slight flexion and radial deviation. The first
is fixated in position of moderate abduction
 Osteosynthesis- Autologous bone grafting by a bone nail and
Osteosynthesis by wires.

Postoperative treatment
 Immobilization of a hand in medium-physiological position during 6 –
8 weeks
 exercise therapy
 physiotherapy

Indication to preoperative treatment

 fractures of a navicular bone with considerable displacement
 a delayed union
 a false joint
 aseptic necrosis
4) Complications
Complications, such as a delayed union, a false joint or aseptic necrosis,
may be even at absent of a displacement of splinters and at sufficient
immobilization. It depends on a degree of blood supply disturbance of
a navicular.
43. Fractures of the first metacarpal bone: mechanism of trauma; clinical
picture and diagnosis; the first medical aid; treatment and complications.
1) mechanism of trauma : Mechanism of trauma is direct-The fracture is
astable with volar angular displacement because of prevalence of a tonus of
palmar interosseous muscles and indirect. * diagram* Usually fractures of a
neck of a metacarpal bone are instable as they have small splinters of a
cortical bone on volar surface. Here, as a rule, it is established indications to a
little invasive osteosynthesis.

2) Clinical Picture and diagnosis :

• Kind of fractures : a) Bernet’s fracture.
b) Roland’s fracture.
c) transverse fracture of a shaft.
d) oblique fracture of the shaft.

Treatment. Conservative treatment is sufficient in most cases. It consist of

immobilization of the hand in a light dorsal slab for 3 weeks.
-A minimal displacement is acceptable, but in cases with sever displacement
or angulation, reduction is necessary.
So-called “90 – 90” the method of reduction allows reducing and holding
splinters, but it cannot be used as the method of fixation
- this is achieved in most cases by closed reduction. In some , particularly
those with multiple metacarpal fractures, internal fixation with K –wires or
miniplates may be required.
44. Fractures of metacarpal bones: mechanism of trauma; clinical picture
and diagnosis; the first medical aid; treatment and complications. answer
3) mechanism of trauma : Mechanism of trauma is direct-The fracture is
astable with volar angular displacement because of prevalence of a tonus of
palmar interosseous muscles and indirect. * diagram* Usually fractures of a
neck of a metacarpal bone are instable as they have small splinters of a
cortical bone on volar surface. Here, as a rule, it is established indications to a
little invasive osteosynthesis.

4) Clinical Picture and diagnosis :

• Kind of fractures : a) Bernet’s fracture.
b) Roland’s fracture.
c) transverse fracture of a shaft.
d) oblique fracture of the shaft.

Treatment. Conservative treatment is sufficient in most cases. It consist of

immobilization of the hand in a light dorsal slab for 3 weeks.
-A minimal displacement is acceptable, but in cases with sever displacement
or angulation, reduction is necessary.
So-called “90 – 90” the method of reduction allows reducing and holding
splinters, but it cannot be used as the method of fixation
- this is achieved in most cases by closed reduction. In some , particularly
those with multiple metacarpal fractures, internal fixation with K –wires or
miniplates may be required.
45. Anatomical peculiarities of a pelvic. Mechanism of trauma,
classification of pelvic fractures.
1. Anatomical peculiarities of a pelvic - The pelvic ring is formed by
iliac bones, pubic bones ischium bones & sacrum bones.
All bone’s joints kinds exist in the pelvic ring:
• syndesmosis
• synostosis
• synchondrosis
• diarthrosis

-Pelvic ring : the pelvis is a ring-shaped structure joined in the front by the
pubic symphysis and behind the scaro-iliac joints.
- There are projecting iliac wings on either side , a frequent site of fractures.
- The pelvic ring is formed , in continuity from the front , by pubic
symphsis, pubic crest, pectineal line of pubis, arcuate line of the ilium and
ala and promontory of the sacrum.

-Stability of the pelvis- The stability of the pelvic ring depends, posteriorly
on the sacro-iliac joints and anteriorly on the symphysis pubis. The sacro-
iliac joints are bound infront and behind by the strong ,band like , sacro-iliac
- Nerve in relation to the pelvis. The obturator nerve and the sacral plexus
pass over the ala of the sacrum and corss the pelvic brim.

2. Meachansim of trauma – i) Direct mechanism - a blow from the side –

the fracture of wing of Iliac bone or acetabulum
- a blow from the front – the fracture of kind “butterfly”, rupture of
pubic symphysis
- a blow from behind – rupture of iliosacral syndesmosis, the fracture of

ii) Indirect mechanism – AP compression and Lateral compression

3. Classification of pelvic fractures –

i) Classification of M.Tile – AO/ASIF
A Stable damages: border's fractures, fractures of back or front semi-
A Instable damages – horizontal partial instability
A Instable damages – vertical complete instability
ii) Classification of fractures of acetabulum
 Complete – incomplete
 With displacement – without displacement
 With dislocation of thigh-bone – without dislocation of thigh-bone
46. Clinical diagnostic of damages of the pelvis. X-ray examination. The
first medical aid on a place of incident.
1. Clinical diagnostic of damages of the pelvis
• Complaints
• Anamnesis
• Appraisal of general condition of a patient including the clinic of
traumatic shock, pseudo abdominal syndrome
• Local medical examination
• Local medical examination
• The general symptoms of damages:
a pain, a swelling, a bruise (there can be a fluctuation), increase of local
temperature, lesion of function.
• Significant symptoms of fractures: appearance of bone’s fragments in
a wound by open fractures, pathological mobility of fragments, crepitus,

Manipulation is traumatic. Carry out carefully and at clinical necessity.

2. X-ray examination
Pelvis with both hips AP is the basic X-ray required for screening purposes.
In case there is a pelvic injury , special views ( Inlet/outlet views) are
sometime necessary.
C.T scan may be needed for better evaluation in cases where operative
intervention is comtemplated.

X-ray examination of pelvis in direct posterior projection

X-ray examination of pubic symphysis in direct posterior projection

3. The first aid medical on a place of incident

a. The first medical aid on a place of incident
b. Anesthesia:
narcotics, if no close trauma of abdomen and (or) cerebral trauma,
novocaine intrapelvis blockade, if no clinic of shock,
c. Immobilization:
on hard stretcher
in the Volcovich’s
pose (frog's)
d. Pneumatic anti-shock suit with clinic of
shock (e.g. “PASG”, “Kashtan”)
e. Infusion therapy
glucose, solution of Ringer,
f. Transportation
in hospital
47. Differential diagnostics of pelvic fractures and injuries of internal
pelvic organs (bladder, urethra, rectum, vagina, uterus, ovaries).
Conservative and surgical treatment of fractures of a pelvis.
1. Pelvic fractures with damage organ’s of pelvic (bladder, urethra, rectum,
vagina, uterus, ovaries)
Mechanism of trauma:
i) a damage by splinters, ii) a damage as a result of strain of the ligaments of
the urinary bladder
-direct trauma:
 a blow from the side – the fracture of wing of Iliac bone or
 a blow from the front – the fracture of kind “butterfly”, rupture of
pubic symphysis
 a blow from behind – rupture of iliosacral syndesmosis, the fracture of
-indirect trauma:
 AP compression
 Lateral compression
Types of damages: i) bruise, hematocyst; ii) partial rupture,
iii) full rupture: a) intra-peritoneal and b) extra-peritoneal ruptures.
Clinic: anuria, haematuria, symptom Zeldovich, peritonitis (by intra-
peritoneal ruptures).
Diagnostic: catreterization of bladder, urography, uroscopy.

Ruptures and injuries of an urinary bladder are to be urgent surgical

treatment with a possibility of preoperative preparation and antishock
therapy till 6 hours.
-inspection urinary bladder,
-wound (defect) closure,
-draining of a pelvic cavity and urinary bladder.
Injuries of a urethra
-Isolated injuries meet more often (60%)
-Commonly injuries of a urethra meet at men
-More often as a result of traffic accident or of falling with of the big height:
direct compression on perineum opposite of pubic arch
injuries of a urethra
 Isolated injuries meet more often (60%)
 Commonly injuries of a urethra meet at men
 More often as a result of traffic accident or of falling with of the
big height: direct compression on perineum opposite of pubic
-pain in a perineum
-impossibility of an independent diuresis
-urethrorhagia (blood in the urine)
-hematoma of a perineum, scrotum, internal surfaces of femurs
-retrograde urethrografy
-rectal digital inspection
-infusion urografhy
injuries of a urethra
Urgent operation with an possibility of preoperative preparation
(during first 6 hours)
-cystotomy, retrograde conduction of a permanent catheter
-primary urethroplasty
- epicystostomy with the further deferred urethroplasty

2. Conservative treatment of fractures of a pelvis

• Volkovich pose ( 3-6 wks), skeleton extension
• Crutches, ambulation
• Surgery only if needed.
- The method of skeletal extension
- position in a hammock
48. Dislocations of femur

1. mechanism of injury(indirect)
• Posterior: force directed along shaft of femur, with flexed hip; usually
in motor accidents (dashboard injury)
• Anterior: when legs are forcibly abducted & externally rotated

2. classification
• Central fracture- dislocation (into acetabulum)
• Obtuating (ant. Inf)
• Pubic (ant.inf)
• Sciatic (post. Inf) –Rozer nelaton line
• Iliac(post. Sup)- Rozer nelaton line

3. diagnosis
• Posterior: history of trauma; pain, swelling, deformity (flexion,
adduction, internal rotation), shortening of leg, may be able to feel
head of femur in gluteal region
x-ray: femoral head is out of acetabulum, lesser trochanter less
prominent, shenton;s line is broken
• Anterior: history of trauma, deformity ( extension, abduction, external
rotation), lengthening of leg

4. treatment
Immediate reduction under general anaesthesia to reduce chance of
Open reduction if:
 Closed reduction fails
 There is intraarticular loose fragment which doesn’t allow concentric
 Acetabular fragment is large & is from the weight- bearing part of

5. complications
1. injury to sciatic nerve
2. avascular necrosis of femoral neck
3. osteoarthritis
myositis ossifican

49. Femoral neck fractures.

Mechanism of trauma

Features of vascularity.
1. The blood supply to the proximal end of the femur, divi-ding it into
three major groups: (1) an extracapsular arterial
ring located at the base of the femoral neck;
(2) ascending cervical branches of the arterial ring on
the surface of the femoral neck; (3) arteries of the
ligamentum teres
2. The extracapsular arterial ring is formed posteriorly by a large
branch of the medial femoral circumflex artery and anteriorly by a
branch from the lateral femoral circum-flex artery

a. Mechanism of injury

 Fracture of the neck of the femur in another term is intra-

capsular fracture of the neck
 Trivial injury eg. Slipping on the floor, missing a step,etc
 Osteoporosis

b. Classification
Garden Classification
 Based amt of fracture displacement evident in AP X-ray of

Stage 1
 Fracture incomplete, head tilted in a posterolateral dir, impacted
Stage 2
 Fracture are complete, undisplaced
Stage 3
 Fractures are complete d partially displaced, as judge by the
directn of the trabecular stream in the yhead fragment, but 2
fragment remain in contact w each other
Stage 4
 Fracture fragment are completely displaced and trabecula of
femoral head are out of contact w trabecula of femoral neck

Anatomy classification
 Alternative class based on angle of fracture line makes w d
horizontal plane-class femoral neck fracture

I. Subcapital w slight displacement

eg. Fracture at the base of the neck
II. Transcervical
Eg. Fracture in mid of neck
III. Subcapital, non-impacted, displaced
eg. Fracture just below the head

Subcapital w slight displacement

 Garden 1: Impacted in valgus more than 15°
 Garden 2: Impacted in valgus less than 15°
 Garden 3: Non-impacted

 Basic cervical (basal)
 Midcervical adduction
 Midcervical shear

Subcapital, non-impacted, displaced

Pauwell Classification
 Based on the angle of inclination of fracture, line makes in
relation to the horizontal plane
 I degree -30°, II degree -50°, III degree -70°
 The more the angle, the more unstable is the fracture, worse
c. Diagnosis
Clinical pict:
- Little pain in the groin
- Elderly Pt- inability to move limb or bear
weight on the limb following a ‘trivial” injury
- External rotation of the leg, patella facing
- Shortening of leg, usually slight
- Tenderness in the groin
- Attempted hip movement painful, severe spasm
- Active straight-leg raising not possible

Radio Features
 X-ray of pelvis w both hips
 Break in medial cortex of neck
 External rotation of femur, lesser trochanter more prominent
 Overriding of greater trochanter, lies at the level of the head
of the femur
 Break in the trabecular stream
 Break in Shenton’s line

d. Treatment
• Difficult to treat coz:
o bld supply to proximal fragment is impaired
o diff to achieve reduction of the fracture d maintain it coz the
prox frag is too small
• Surgery:
a. Impacted fracture
o Conservative,Thomas splint (adults), hip
spica(children), fix w screws
b. Unimpacted or displaced fracture
o Internal fixation
o In elderly patient: head excised and replaced by
a prosthesis as a primary procedure
o Younger patient open reduction of fracture
o In some: an inter-trochanteric osteotomy called
McMurray’s osteotomy is preferred
c. Internal fixation:
o Multiple cancellous screws
o Smith-Peterson nail(S.P.nail)
o Dynamic hip screw
o Multiple Knowle’s pins/
o Moore pins used in children
o Deyerele apparatus
d. Asnis screws: fracture site impacted by impactor and
wound is closed
e. McMurray’s osteotomy: oblique osteotomy at the inner-
trochanteric region
f. Meyer’s procedure: fracture is reduced by exposing it
frm behind, fixed w multiple screws d supplemented w a
vascularized muscle pedicle bone graft taken frm the femoral
attach. Of quadratus femoris muscle
g. Replacement arthroplasty-in patient over 60 years

General: internal fixation, closed reduction, femoral neck pinning,


e. Complications
 Non-union: due to inadequate immobilization and poor bld
supply to proximal segment, can overcome this by neck
 Vascular necrosis, Loss of fixation
50. Trochanteric and subtrochanteric fractures of a femur.
Mechanism of trauma.

 common fracture in elderly (greater incidence of osteopenia)

 in osteopenic individual, fracture may precede simple fall (muscle
stronger than bone)
 in younger individual, fracture related to high energy injury
 marked displaced
 associated with other injuries

Boyd and Griffin classified fractures in the peritrochanteric area into four
types. Their classification included all fractures from the extracapsular part
of the neck to a point 5 cm distal to the lesser trochanter.
Boyd and Griffin classificcation of the fractures in peritrochanteric area
Type 1: Fractures that extend along the intertrochanteric line from the
greater to the lesser trochanter. Reduction usually is simple and is
maintained with little difficulty. Results generally are satisfactory.
Type 2: Comminuted fractures, the main fracture being along the
intertrochanteric line but with multiple fractures in the cortex.
Reduction of these fractures is more difficult because the comminution
can vary from slight to extreme. A particularly deceptive form is the
fracture in which an anteroposterior linear intertrochanteric fracture
occurs, as in type 1, but with an additional fracture in the coronal plane,
which can be seen on the lateral roentgenogram.
Type 3: Fractures that are basically subtrochanteric with at least one
fracture passing across the proximal end of the shaft just distal to or at
the lesser trochanter. Varying degrees of comminution are associated.
These fractures usually are more difficult to reduce and result in more
complications, both at operation and during convalescence.
Type 4: Fractures of the trochanteric region and the proximal shaft, with
fracture in at least two planes. If open reduction and internal fixation are
used, two-plane fixation is required because of the spiral, oblique, or
butterfly fracture of the shaft. Characteristic history, unable to bear
weight on affected limb

Principles of classification
Evans devised classification system based on the division of fractures
into stable and unstable groups.
In type I fracture, the fracture line extends up-ward and outward from the
lesser trochanter.
In type II, the reversed obliquity fracture, the major fracture line
extends outward and down- ward from the lesser trochanter.

Clinical picture and diagnosis.

• Pain, swelling, bruise, lesion of function, increase local temperature.
• Characteristic history, unable to bear weight on affected limb
• Limb shortened, externally rotated, painful syndrome
• X-ray AP of pelvis and lateral of involved hip
• If findings equivocal – bone scan and tomograms

Non-operative treatment:-

 Horowitz reported a mortality rate of 34.6% for trochanteric fractures

treated by traction and 17.5% for those treated by internal fixation.
Rigid internal fixation of intertrochanteric fractures with early
mobilization of the patient should be considered standard treatment.
 Stable fractures are treated by internal fixation after anatomical
 Unstable fractures usually can be treated by anatomical reduction with
the use of a collapsible fixation device, such as a hip compression

Operative treatment:-
The goal of operative treatment is strong, stable fixation of the fracture
fragments. The following variables as those that determine the strength of
the fracture fragment implant assembly:
• bone quality
• fragment geometry
• implant placement.
• reduction
• implant design
The surgeon can control only the quality of the reduction and the choice of
implant and its placement.

Subtrochanteric femoral fractures

subtrochanteric fractures have been variously defined, but most authors limit
the term to fractures between the lesser trochanter and the isthmus of the
diaphysis. These fractures account for 10% to 34% of all hip fractures.
Fielding’s classificcation of the subtrohanteric fractures
Type 1 fracture is at the level of the lesser tro-chanter
Type 2 fracture is between 2.5 and 5 cm below the lesser trochanter
Type 3 fracture occurs 5 to 7.5 cm below the lesser trochanter

Seinsheimer developed the following classification system based on the

number of fragments and the location and configuration of the fracture

Type I: Nondisplaced fracture or one with less than 2 mm of displacement

Type II: Two-part fracture
Type IIa: Transverse fracture
Type IIb:Spiral configuration with lesser trochanter attached to proximal
Type IIc:Spiral configuration with lesser trochanter attached to distal
Type III: Three-part fracture
Type IIIa: Three-part spiral configuration with lesser trochanter a part of the
third fragment
Type IIIb: Three-part spiral configuration with the third part a butterfly
Type IV: Comminuted fracture with four or more fragments
Type V: Subtrochanteric-intertrochanteric configuration
Russell and Taylor classification

-Type II fractures extend proximally into the greater trochanter and involve
the piriformis fossa, as detected on the lateral roentgenogram of the hip,
which complicates closed nailing techniques.
 Type IIA fractures extend from the lesser trochanter to the isthmus
with extension into the piriformis fossa, as detected on lateral
roentgenograms, but significant com-minution or major fracture of
the lesser trochanter is not present
 In type IIB fractures the fracture extends into the piri-formis fossa
with significant comminution of the medial femoral cortex and loss
of continuity of the lesser tro-chanter.
IA Piriformis fossa and lesser Standart interlocking IM
trochanter intact nail

IB Piriformis fossa intact, lesser Reconstruction IM nail

trochanter fractured

IIA Piriformis fossa fractured, Slider hip screw or

lesser trochanter intact reconstruction IM nail

IIB Piriformis fossa and lesser Sliding hip screw with bone
trochanter both fractured graft or reconstruction IM
Question 51.

Fracture shaft of the femur.

1) Mechanism of injury.
a) Mechanism of injury may be direct or indirect
b) Indirect- twisting or bending force
c) Direct- traffic accidents.

2) Common patterns of fracture

a) May occur at any site and is almost equally common in the upper,
middle and lower thirds of the shaft.
b) It may be transverse, oblique, spiral or comminuted depending on the
nature of the force.
c) Proximal fragment is flexed, abducted and externally rotated while
distal fragment is adducted.

3) Diagnosis.
a) General symptoms:
i) Pain
ii) Swelling
iii) Bruising
iv) Local increase in temperature
v) Lessening of function
vi) Clinics of shock
b) Authentic symptoms:
i) Deformation
ii) Anatomical shortening
iii) Crepitation
iv) Penetrating bone fragment (if open fracture)
v) Pathological mobility
c) X-ray
i) Must be done on anterior-posterior and lateral views
ii) Must include the whole shaft
iii) Additional x-ray of pelvis must be done to rule out associated
injury to pelvis.

4) Treatment
a) Pre hospital aid
i) Anaesthesia
ii) Immobilization- using Diterix’s splint
iii) Infusion therapy- in case of clinics of shock or blood loss
iv) Transport to hospital
b) Hospital management
i) Urgent hospitalization
ii) Novocaine blockade- if bp 70mmHg
iii) Infusion therapy to prevent or treat shock
iv) Skeletal extension as temporary immobilization to prepare for
v) Optimal time for operation is first 3 days. In case of severe shock
or complications, 12-14 days.
vi) Oeteosynthesis by:
(1) Intramedullary nail a.k.a. K-nailing (Kuntscher’s)
(2) Plating with interfragmentary joining screws
(3) Interlocking nailing

5) Complications
a) Early
i) Shock: even in closed fracture 1-1.5L of blood is lost and can
result in hypovolaemic shock.
ii) Fat embolism: symptoms seen after 24-48hours after fracture.
Prevent by avoiding shifting of patient without proper splintage
iii) Injury to femoral artery: most common in fracture at junction
between middle and distal thirds.
iv) Infection: in open fractures. Can lead to osteomyelitis
b) Late
i) Delayed union: if union is insufficient to allow unprotected weight
bearing after 5 months, considered delayed.
ii) Non-union: frank mobility, pain, or tenderness at fracture site. May
lead to fractures of the plat or nail.
iii) Mal-union: generally lateral angulation and external rotation.
iv) Knee stiffness: full movement can be regained with physiotherapy.
Can be caused by:
(1) Intraarticular and periarticular adhesions
(2) Quadriceps adhering to the fracture site
(3) Associated knee injury

52. Dislocation of knee.

Mechanism of trauma.

The expression “Dislocation of the knee” implies the dislocation of a

tibia essentially, because a fibula is not joint with articular surface of a
 The mechanism of trauma is direct and indirect
 Dislocation of the knee is accompanied by considerable injuries of
capsule and ligaments
 Severe complications are injuries of the skin (open dislocation),
fractures of the condyles of femur, tibia and patella, the injury of
neurovascular fascicle.

Clinical picture and diagnosis

 A knee joint’s oedema and bruise, sometimes diffusive along a leg
and foot
 The straightened position and significant shortening of an extremity is
 Active and passive movements in the knee joint are not possible
 It is necessary to define pulse on the foot, degree of a disorder of
blood circulation, sensibility and movement function

• Emergency reduction (a delay can lead to a disorder of blood
circulation and as a result to gangrene of an extremity)
• Aspiration of blood from a joint it is carried out after reduction
• Plaster removable joint-immobilizer or bandage during 8 – 10 weeks
• Isometric exercise therapy at second day
• Later, if as a result of a dislocation instability of a joint will develop,
realize surgical treatment - to plastic ligaments’ a joint.

Question 53: Fracture of patella

1) Mechanism of injury
- this is a common fracture
- result from a direct or indirect force
- in a direct injury, occur by blow on the anterior aspect of the flexed knee,
usually a comminuted fracture result
- comminution maybe limited to a part or whole of patella a.k.a. stellate
- sudden violent contraction of quadriceps pulls fragments apart leading to a
separated fracture of the patella with some comminution

2) Common patterns of fracture

i- an undisplaced crack across the patella which is probably due to a direct
ii- a comminuted or stellate fracture, due to a fall or a direct blow on the
front of the knee
iii- a transverse fracture with a gap between the fragments - this is an
indirect traction injury due to forced, passive flexion of the knee while the
quadriceps muscle is contracted; the entire extensor mechanism is torn
across and active knee extension is impossible

3) Diagnosis
- knee is painful and swollen and sometimes gap can be felt i.e. diastasis
- pathological mobility of fragments
- impossibility raising of straigthened leg
- usually there is blood in the joint
- X-Ray diagnosis:
~ AP and lateral x-ray knee are sufficient
~ in undisplaced fracture, skyline view of patella required
~ a fracture with wide separation of fragments is easy to diagnose via
lateral X-Ray
~ 3 types of fracture can be distinguished, but important not to confuse a
crack fracture with congenital bipartite patella in which smooth line extends
obliquely across superolateral angle of bone

4) Treatment
- depends upon the type of fracture and also the ages of patient
- types or treatment are as follows:

a) Undisplaced fracture:
~ aimed primarily at relieving pain
~ plaster cast extending from groin to just above malleoli with the knee in
full extension (cylinder cast) given for 3 weeks followed by physiotherapy

b) Clean break with separation of fragments (2 part fracture)

~ pull of quadricep muscle keeps the fragments apart, thus operation is
always neccesary
~ operation consists of reduction of fragments, fixing thme with tensor
band wiring (TBW) and repair extensor retinaculae
~ knee can be mobilized early following operation
~ in cases when not possible to achieve accurate reduction of fragment,
better to excise the fragment (patellectomy) and repair extensor retinaculae
~ in cases where one of fragments constitutes only one pole of the patella,
it is excised
~ major fragments are preserved and the extensor retinaculae repaired
(partial patellectomy)
~ such operations on patella are followed by support in cylinder cast for 4-6

c) Comminuted fracture
~ comminuted fracture with displacement, difficult to restore smooth
articular surface, so excision of patella (patellectomy) is preferred option

5) Complications
- knee stiffness
~ due to intra- and peri-articular adhesion. Treatment by physiotherapy
and arthroscopic release of adhesion maybe required
- extensor weakness
~ results from an inadequate repair of the extensor apparatus or due to
quadriceps weakness
- osteoarthritis
~ patello-femoral osteoarthritis occuring few years after the injury

Question 54. Injuries of the ligaments of the knee.

1. Mechanism.
Most often from indirect, twisting or bending forces on the knee
The various mechanisms :-
a) Medial collateral ligament
i) Damaged if the injuring force has the effect of abducting
the leg on the femur (valgus force)
ii) It ruptures most commonly from its femoral attachment

b) Lateral collateral ligament

i) Damaged by adduction of the tibia on the femur (varus
ii) Commonly, the ligament is avulsed from the head of the
fibula with a piece of bone.
iii) Uncommon injury bcoz knee is not often subjected to
varus force.

c) Anterior cruciate ligament

i) Most commonly damaged, often in association with the
tears of medial or lateral collateral ligaments.
ii) Commonly, it occurs dt twisting force on a semi-flexed

d) Posterior cruciate ligament

- Damaged if the anterior aspect if tibia is struck with the
knee semi-flexed so as to force the tibia backwards on to the

O’Donoghue triad – injury to medial collateral ligament, medial

meniscus &
anterior cruciate ligament which often occur

2. Classification.
1st degree sprain
i) It’s a tear of only a few fibres of the ligament.
ii) Clinical picture – minimal swelling, localized tenderness but
little functional disability.

2nd degree sprain

i) It’s a tear from a third to almost all the fibres of a
ii) Clinical picture – pain, swelling & inability to use the
– normal joint movements
iii) Diagnosis – stress test

3rd degree sprain

i) It’s a complete tear of the ligament.
ii) CP – pain (often minimal) & swelling over the torn
iii) Diagnosis – stress test, MRI, arthrography, arthroscopy

3. Diagnosis.
a) Clinical examination
• Often history of deforming force at knee (valgus / varus)
followed by the sound of something tearing.
• Pain – over the torn ligament (collateral lig injury)
• Vague pain (cruciate lig injury)
• Swelling (haemarthrosis) is variable but appears early after the
Stress test – assess medial & lateral collateral ligament injury
• Pain at site or an abnormal opening up of the
joint indicate a tear.

• Cruciate lig prevent anterior-posterior

gliding of the tibia.
i) Injury to anterior cruciate - Anterior drawer test &
Lachmann test.
ii) Injury to posterior cruciate - Posterior drawer test
- a posterior sagging of the upper tibia may be obvious

b) Radiological examination
i) Plain XR may be normal or a chip of bone avulsed from the
ligament attachment may be visible.
ii) May be possible to show an abnormal opening up of joint on
stress X-rays

c) Other investigation – arthro-graphy/-scopy if doubt


4. Treatment.
a) Conservative treatment
i) The knee is immobilized in a cylinder cast or a Robert-
Jones bandage for 3-6 weeks.
ii) Successful in most cases of grade I & II injuries.
iii) After a few weeks, swelling subsides.
iv) Physiotherapy.

a) Operative treatment – indicated in grade III

injuries, esp in young atheletes.
i) Repair of the ligament
- Done in fresh, grade III collateral lig injuries.
- In cases after 2-3 weeks, an additional reinforcement is
provided by a fascial or tendon graft.
ii) Reconstruction
- Done in cases of lig injuries presenting late with features
of knee instability.
- A lig is ‘constructed’ using pt’s own tendon or fascia
lata, allograft or a synthetic lig.
55. Tears of the menisci of the knee.

• Mechanism
-The meniscus is a C-shaped fibrous piece of cartilage which is found in
certain joints and forms a buffer between the bones to protect the joint. The
meniscus also serves as a shock-absorption system, assists in lubricating the
joint, and limits the joint flexion and extension.

-A meniscal tear is a tear of the cartilage of the knee. Tears are most
commonly caused by

 twisting or over-flexing the joint ( sports injuries)

- meniscus is sucked in and nipped as rotation occurs between the
condyles of femur and tibia
 associated with ligament rupture
• Types of meniscal tear

i. Longitudinal
ii. Radial
iii. Bucket-handle
iv. Post.horn tear
v. Ant.horn tear

Clinical features

 A "pop" noted at the time of injury

 Joint pain
 Knee pain
 Recurrent knee-catching
 Locking of the joint
 Stiffness and swelling.
 Tenderness in the joint line.
 Collection of fluid ("water on the knee").

 Blockade of the knee
 Baikov’s symptom
 Shtaman-Bucchard
 McMarry
 Loading deviation of extended leg

• Examination

i. History
ii. Physical Examination
-Tenderness is elicited by deep palpation (examination using the
hands) along the joint line.
-Twisting the knee while flexing it will occasionally cause or
reproduce the patient's symptoms.
iii. Testing
a. McMurray's test.

-you lie on your back while holding the heel of your injured leg
with your leg bent.
-Pressure is placed on the outside of the knee with the doctor hand,
and the leg is straightened with the foot turned in (internally
rotated). Pain or a click over the inner part the joint means an inner
(medial) meniscal tear.

b. Apley's compression test.

-lie on your back with your knee bent at a 90 degree angle. The
provider will grab your foot with both hands and rotate it to the
outside (lateral rotation) while a downward force is applied to
the foot. The provider's knee and thigh may be used to stabilize
your thigh.
-Pain in the inner part of the joint may indicate an inner
(medial) meniscal tear.
c. A ballottement test for synovial effusions (excess joint fluid) is
positive in meniscal tears, indicating swelling with fluid around
the joint.
iv. Knee MRI
v. Knee joint x-ray
vi. Anthrography
vii. Anthroscopy

• Treatment

Conservative: RICE

 Rest
 Ice
 Compression by Robert-Jones bandage
 Elevation

Surgical repair :
-anthroscopic surgery depending on patient’s age/age of tear/size and
-Trims of damaged edges of cartilage

 Partial menisectomy
 Meniscus repair
-Four techniques for meniscal repair are used: Open meniscal repair,
arthroscopic inside-out repair, arthroscopic outside-in repair, and
arthroscopic all-inside repair
 Transplantation of meniscus

56. Injuries of a leg.

Mechanism of trauma.
- tibia n fibula may be fractured by
1. direct injury
- road traffic accidents r com. cause mostly dt direct violence
- occurs at abt the same level in both bones
- frequently the object causing fracture lacerates the skin over it resulting
in an open
2. indirect
- a bending or torsional force on the tibia result in an oblique or spiral
fracture respectively
- sharp edge of fracture may pierce the skin fr within resulting in an open

b) Common patterns of fracture

- fracture may be closed or open
- fracture may occur at diff levels eg upper, middle, lower 3rd
- occasionally may be single bone fracture
- displacements may be sideways, angulatory or rotational
- sometimes fracture may remain undisplaced

- classification of tibia fracture

1. Type A simple : a single circumferential disruption of the diaphysis - may

• Spiral
• Oblique ( angle more than 30 deg)
• Transverse (angle less than 30 deg)

2. Type B multifragmentary / wedge : a fracture with one or more

intermediate fragments in which after reduction, there is some contact btw
the main fragments- may be:
• Spiral wedge
• Bending wedge
• Fragmented wedge

3. Type C Multifragmentary / complex : a fracture with one or more

intermediate fragments in which after reduction , there is no contact btw the
main prox and distal fragments- may be:
• Spiral
• Segmental
• Irregular

c) Diagnosis
1 clinical features
- a history of injury to leg followed by classic feature of fracture ( visible
fracture, pain, swelling, deformity, etc )
- there may be wound communicating w the underlying bone
2. radiological features
- diag confirmed by X-ray exam
- evaluation of anatomical configuration of the fracture on X-ray helps in

d) Treatment
* fr book :
- non-op Tx acc types of fracture
1. closed fracture
- both in adults n children r by closed reduction under anesthesia + above
knee plaster cast
- in child fracture unites in abt 6wks, adults in 16-20wks
- if reduction is not achieved or fracture displaces in the plaster → open
reduction n int fixation is required
- unstable tibial fractures is treated w closed interlock nailing
2. open fracture
- aim is to convert it into closed fracture by care of wound n maintain
good alignment
- following methods used acc grade of open fracture
 Grade 1 : wound dressing thru a window in an above knee plaster
cast + Abc
 Grade 2 : wound debridement + primary closure ( if < 6hrs ) +
above knee plaster cast. Wound may need dressings thru a window
in the plaster cast
 Grade 3 : wound debridement + dressing + ext fixator application.
The wound is left open
- open reduction n int fixation ( op Tx ) is necessary when it is impossible to
achieve a satisfactory alignment of fracture by non-op method
- int fixation device may be a plate or intra-medullary nail depending upon
the configuration of the fracture
- interlocking nailing provides possibility of internally fixing a wide
spectrum of tibial shaft fractures
- op Tx is often indicated in case of
• Delayed-union
• Non-union
• Mal-union

* fr teacher’s note
Closed injury
1. Nonoperative
- best for fracture without significant comminution, shortening or
displacement at the time of fracture. ie low energy fracture
- AKPOP for 6/52, then convert to cast brace or PTB
- union in approx 16 wks for simple fracture, longer for more complex injury
(av 18 wks)
- 90% healed with 1cm or less shortening
- nonunion rate 2.5%
2. Operative
- indicated in :
• pt requires early return to work
• displaced ie higher energy fracture
• Failure of closed treatment
- IM nailing
- infection rate ~ 1-2%
- angulatory deformities rare
- shorter hospital stay, less OPD visits
- earlier return to work

Open Fractures
- Wound management as for any compound fracture
- IM Nailing
- acc grade :
1. Grade 1 : IM nailing - same figures as for closed fracture
2. Grade 2 : infection 3.8%
3. Grade 3
• A: infection 5.6%
• B: infection 12.5%
- External fixation: Use for grade 3B and 3C
- rates of infection same as nailing for grade 3B with added problem of pin
tract infection, delayed union also a feature of ext fixation.
- sometimes need to convert from ext fix to IM nail → risk of infection in
the face of recent pin tract infection is ~ 20%
- However if the ext fix is removed within 3 wks of application + wait
another 2 wks, can nail with infection rate of ~ 5%

e) Complications
1 delayed n non-union
- Tx : bone grafting w or w/o int fixation
- options of Tx r
 Nailing w bone grafting
 Phermister grafting
 Ilizarov’s method
 Others eg electromagnetic stimulation
2. mal-union
- Tx : correction of deformity by redoing fracture n fixing it by plating or
nailing n bone grafting
3. infection
- Tx : dressing + Abc, Ilizarov’s method
4. compartment syndrome
- Tx : op decompression of the compartments
5. injury to maj vessels n Nvs

57. Ankle injuries

a) Classification of Lauge-Hanson
 adduction injuries
- inversion : inversive force w the foot in plantar-flexion results in
sprain of the lateral ligament of the ankle
- may be partial or complete rupture of lateral ligaments
- result in F of lateral malleolus and medial malleolus
 abduction injuries
- eversion : medial struc are subjected to distracting force and lateral
structure subjected to compressive force
- results in rupture of deltoid ligament or low-lying transverse F of
medial malleolus on medial side; on lateral side, F of lateral malleolus at
ankle-mortice level with comminution of outer cortex occurs
 pronation-external rotation injuries
- occurs when a pronated foot rotates externally
- may result a transverse F of medial malleolus at ankle-mortice level or
rupture of medial-collateral ligament
- with futher rotation of talus, anterior tibio-fibular ligament is torn,
followed by spiral F of lower end of fibula
- F of fibula above ankle-mortice indicate disruption of tibio-fibular
 supination-external rotation injuries
- with foot supinated, talus twist externally within mortice; producing
spiral F at level of ankle-mortice
- futher rotates result transverse F where tibio-fibular syndesmosis
remains intact
 vertical compression injuries
- dt vertical compression force
- resulting in either anterior marginal F of tibia or comminuted F of
tibial articular surface w F of fibula – Pilon F

b) Diagnosis
- present history of twisting injury to ankle which followed by pain and
- crepitus may be noticed if F present
- ankle may lie deformed
- in radiological exam, anterior-posterior and lateral x-ray sufficient in
most cases
- F line can be studied and helps in treatment
- tibio-fibular syndesmosis are carefully exam, so that lateral or posterior
subluxation of talus is not missed
- soft-tissue swelling in absence of F should be exam thru stress x-ray or
clinical exam

c) Treatment
- principle of Tx is to achieve anatomical reconstruction of ankle mortice
to regain good func and min. possibility of osteoarthritis development
F without displacement
- usually sufficient to protect ankle in a below-knee plaster for 3 – 6
weeks, followed by physiotherapy
F with displacement
- aim to ensure anatomical reduction of ankle-mortice
- initially, closed reduction is attempted to realign displaced parts; then
plaster is put, followed by physiotherapy
- in general, operative reduction and internal fixation is useful when closed
reduction is not successful or reduction has slipped during course of
conservative treatment
i) Operative method
- nowadays, internal fixation without closed reduction is applied to achieve
perfect alignment and stable fixation of fragments
- eg of internal fixators : tension-band wiring, compressive screw, buttress
- all injured ligaments should be repaired
ii) Conservative method
- can achieve good reduction by manipulation under GA
- to restore alignment without operative method
- once reduced, below knee plaster is applied for 8 – 10 weeks
- frequent x-ray is taken to ensure no displaced F
- plaster removed after 8 -10 weeks and physiotherapy proceed
External Fixation
- used when closed methods cannot be used eg. open F with bad crushing
and skin loss

d) Complications
- simple types of ankle injuries almost free of complications
- but improper treatment of serious F-dislocation may be complicated
i) Stiffness of ankle : can follows immobilization in plaster
- common in elder
- necessary to continue ankle exercise for a long period ( 6 – 8 mths )
ii) Osteoarthritis
- due to short of perfect anatomical reduction which leads to tear and
wear of articular cartilage
- this leads to start of degenerative osteoarthritis
- ptt complains of pain, swelling and joint stiffness
- once established, osteoarthritis cannot be reversed
58. fracture of the talus.
Mechanism of trauma.
Indirect – inversion or eversion injury of foot

 Injuries of the tarsus
 Fractures of the talus
 Fractures of the calcaneus
 Other injuries of the tarsal bones
 Fractures of the metatarsal bones and phalanges of the toes
 Fractures of the metatarsal bones
 Fractures of the phalanges of the toes
 Fractures of the corpus of the talus
 Fractures of the neck of the talus
Type I: fractures of the neck of the talus without displacement
Type II: fractures of the neck of the talus with displacement and subluxation
in articulatio subtalaris
Type III: fractures of the neck of the talus with dislocation it of the corpus
 Subluxation in articulatio subtalaris
 Dislocation of the talus

2. Common pattern of fracture

• Talus
i. Fracture of corpus
ii. Fracture of neck
• Fracture of neck without displacement
• Fracture of neck with displacement & sublaxation
of articulatio subtalaris
• Fracture of neck with dislocation of corpus
3. Diagnosis
• Talus
i. General and specific symptoms
ii. Pain of active movement of ankle
iii. On X-ray – fracture is seen, sublaxation of joint
Treatment of the fractures of the talus without displacement is
 immobilization 6 – 12 weeks
 loading in plaster may be begin every 2 – 4 weeks
 medical exercises
 massage
 physiotherapy
 insole-supinator
• Talus – avascular necrosis & non-union, osteoarthritis
59. Fractures of the heel bone.
Mechanism of injury.
• Calcaneus
i. Direct – fall of heel
Clinical picture.
 The general symptoms of damage:
a pain, a swelling, a bruise, increase of local temperature, lesion of
function, flat-footed.
 Authentic symptoms of fractures: crepitus, deformation.
Possible appearance of bone’s fragments in a wound for open penetrating

Common pattern of fracture

• Calcaneus
i. Marginal/vertical fracture of calcaneal tuberosity
ii. Horizontal/coracoid fracture of calcaneal tuberosity
iii. Isolated fracture of supported projection
iv. Compressed fracture of corpus
• Calcaneus
i. General & specific symptoms but pathologic mobility as
a rare symptom
ii. Pain on dorsiflexion maybe possible
iii. On X-ray – fracture is seen
• Calcaneus
i. Conservative treatment
• Immobilize for 6-12 weeks
• Loading in plaster every 2-4 weeks
• Exercises, massage, physiotherapy
• In-sole supinators
ii. Surgical treatment
• Open reduction
• Osteosynthesis
• Internal fixators

• Calcaneus – osteoarthritis, stiffness of subtalar & midtarsal joints

60. Injuries of a spinal column.

a. Stable and unstable injuries

• Stable injury is one where further displacement between two vertebral
bodies doesn’t occur. (Because of the intact ‘mechanical linkages’)
• Unstable injury is one where further displacement can occur because
of serious disruption of the structures responsibles for stability.
• Often, it’s difficult to decide whether the spine is stable or not. Thus
it’s safer to treat them as unstable injury.

b. classification
• Flexion-injury
• Flexion-rotation injury
• Vertical compression injury
• Extension injury
• Flexion-distraction injury
• Direct injury
• Indirect injury due to violent muscle contraction.

c. Clinical features.
• Basic symptoms
o Local pain
o Radicular pain
o Bruise
o Excoriation
o Losing of function
o Pseudo-abdominal syndrome
o Injury of lumbar vertebra
• Important symptoms
o Pain in Axial loading on spine
• Authentic symptoms
o Deformation (only)

d. Treatment.
• Treatment on incident place
o Anaesthesia
o Immobilization, on hard surface.
o Transport to specialized hospital.
• Conservative treatment for stable injury.
o Immobilization : hard surface of bed
o Traction : extension on inclined plane
o Reclination : reclinator (shaft) under place of injury
o Medical exercise
o Physiotherapy
o Massage
• Three period of medical exercise.
o Immediate : 1st day after trauma
• E.g breathing exercise, Movement of upper and lower
o Approx 2-3 week.
• Movement of segment near from injury.
• E.g femur, cervical, shoulder girdle
o More than 3 week.
• Stretch muscle in place of injury

• Corsets allow early mobilization of patient but aid development of

atrophy of back muscle
• Sugical treatment is indicated for unstable fracture (e.g use of
transpediculate spondylodesis)

61. Clinical picture and diagnostics of injuries of a spinal column.

Clinical picture
• Basic symptoms
o Local pain
o Radicular pain
o Bruise
o Excoriation
o Losing of function
o Pseudo-abdominal syndrome
o Injury of lumbar vertebra
• Important symptoms
o Pain in Axial loading on spine
• Authentic symptoms
o Deformation (only)

Detection of a level of a spinal injury. Investigation of sensitivity
Level of Level of the loss of Level of Level of the loss of
injury sensitivity injury sensitivity
CII occiput LI femoral pulse
CIII thyroid cartilage LII - III middle of thigh
CIV jugular incisure LIV knee
CV infraclavicular fossa LV external surface of leg
CVI thumb SI external surface of foot
CVII forefinger SII-IV perianal region
CVIII little finger
TIV line of nipples
TX umbilicus

The level of intact Character of possible

spinal cord movements

CIII – C v diaphragmatic respiration

CV flexion in the elbow joint
CVI extension in the wrist joint
CVII extension in the elbow joint
CVIII opening of the fingers
LII flexion of the femur
LIII – LIV extension in the knee joint
LV – SI dorsiflexion of the foot
SI - SII plantar flexion of the foot
Algorithm of medical actions at acute period of a spinal column and a
spinal cord’ injuries

Refer in paper

62.The first medical aid on a place of the incident at a spinal column’s

injuries. Conservative treatment of stable injuries. Indications for surgical

1) 1st aid at the site incident

i) anesthesia – naalgesics / narcotics.
ii) transport immobilization- careful lying of patients of hard stretcher if
lumbar and thoracic injury.
- if damage of cervical spine is suspected use
head brace,
Glisson’s loop and etc…
2) Conservative treatment for stable injuries:
a) immobilization – hard surface of bed
b) traction – extension on inclined place ( elevate head part )
c) reclination – shaft under place of injury
d) medical exercise
e) physiotherapy, massage
f) cervical injury – extension with the help of Glisson’s loop when
flexional and
extensional fracture of the bodies of the vertebrae.
g) corsets – allows early mobilization of patient, but they aid in
development in atrophy
of back muscles ( necessary regular kinestherapy when
fixation by corset ).
- 3 suppurting areas to correct posture: sternum, lumbar, pubic.
3) Indication for operation: unstable fracture vertebra, transpedicular
- in acute cases / emergency cases:
a) compression of spinal cord
b) penetrating wound of spine
c) continuous bleeding
d) unstable condition of essential function
- surgical debrimant of wound, laminectomy
- eliminate compression, reduction and fixation of fragment by various

63.Etiologic factors and pathogenesis of osteoarthrosis.

• Mechanical, acute & chronic overloading dysplasia

• Hormonal
• Hereditary
• Inflammatory
• Ischemic
• Neurogenic
• Idiopathic
Avascular necrosis: alcoholism, liver pathologies, over dose steroids, post-
partum osteonecrosis, sickle-cell anemia.

Several mechanisms have been suggested for the pathogenesis:
• Matrix loss is caused by the action of matrix metalloproteinases such as
collagenase(MMP-1)gelatinase(MMP-2) & stromelysin(MMP-3).These r
secreted by chrondrocytes in an inactive form.Extracellular activation then
leads to the degradation of collagen & proteoglycans.
• Tissue inhibitors of metalloproteinases (TIMPs) regulate the MMPs.
Disturbance of this regulation may lead to increased cartilage degradation
& contribute to the development of OA.
There is synovial inflammation in OA, producing interleukin-1 (IL1) & tumour
necrosis factor(TNF-alfa). These cytokines stimulate metalloproteinase
production & IL-1 inhibits type II collagen production

• In woman, weight bearing sports produce a two- to threefold increase in

risk of OA of the hip & knee.
• In men, there is an association between hip OA & certain occupations-
farming & labouring.
• Obesity is a risk factor for developing OA in later life.

64.Clinical and X-ray classification of osteoarthritis. Clinical picture and


1)Radiological classification
Stage 1-not significant changes.narrowing of joints space.Small
prominence of articular surfaces.

Stage 2-significant changes.Narrowing of joint space.Osteophytes.Slight

Sclerosis.Incongruence of articular surface.

Stage 3-more significant changes.Narrowinf of joint space.Large osteophytes.

Subchondral sclerosis.Incongruence of articular surface.Changing of

Stage 4-all changes in 3rd stage plus fibrotic ankylosis,cyst formation.

• Clinical classification:
-compensation: not damage
-subcompensation: no significant changes
-decompensation: significant changes r present

.Clinical features:
• Pain- Earliest symptom, it occurs intermittently in beginning, but becomes
constant over months or years. Initially dull pain, comes on starting an
activity after a period of rest; but later becomes worse & cramp like pain
appears after activity.
• Crepitus- Painless
• Swelling- Late feature & its due to effusion caused by inflammation of
synovial tissues
• Stiffness- Initially due to pain & muscle spasm but later capsular
contracture & incongruity of joint surface.
• Feeling of instability of joint
Locked knee- Absence, periodic, partial locked or full locked

65.Conservative and surgical treatment of osteoarthrosis.

Conservative treatment:-
 Medicamentous
-Symptomatic treatment:-Analgetics,vitamins,sedatives.

 Physiotherapeutic treatment
 Orthpedics complex

Operative treatment:-
-Corrective osteotomy
-Palliative grow

66.Instable of the shoulder: the concept "a recurrent dislocation of the

shoulder" and instable of the shoulder; principles of treatment.

-The concept "a recurrent dislocation of the shoulder" is only a special case, a
separate sign of wider concept - instability of the shoulder joint
-Instability of the shoulder joint can be evident not only a recurrent
dislocation, but also recurrent subluxation, voluntary dislocation and
subluxation (arising of patient’s own free will), that is any clinically showing
disorder of active or passive stabilization of a joint
- Instability of a shoulder joint is the morbid condition of a joint which
has the set of the following attributes:
• injury of support function of a joint:
a perversion or inferiority of a load on articulate surfaces
• injury of movement function of a joint:
an outlet of movement function from under the control in any moment of
motion appearance new, not inherent moving for articulate surfaces of a joint

Operative treatment of patients with instability of a shoulder joint is

effectively in 90 – 96% cases, but at some kinds of instability (multiplane
voluntary) negative results can amount to 50% and more at treatment by their
standard methods.

Principles of operative treatment are focused on features of pathogenesis of a

concrete pathology:
*restoration of integrity of a capsule of a shoulder joint and (or) a glenoid
labrum of a scapula at their damage (operation Bankart, Putti—Platt, Boichev,
*increase of tonus of musculus subscapularis at its insufficiency (operation
Putti—Platt, Magnuson—Stack, etc.)
*strengthening of margo anterior and increase of the area of cavitas
glenoidale of a scapula at its destruction (operations Bristow-Laterjet, Eden-
Hebbinette, etc.);
*deducing from under a load of impressed defect of the head of humerus and
elimination of axial inconformity of proximal part of a shoulder and an
articular process of a scapula (rotatory osteotomy Saha, Weber).

67.Cubitus valgus and cubitus varus: etiology, diagnostics, methods of


.Cubitus valgus
If the angle of the elbow joint is increased, so that the forearm is abducted
excessively in relation to the upper arm, the deformity is known as cubitus

1.previous fracture of the lower end of the humerus or capitulum with
2.interfere with epiphysial growth on the lateral side from injury or
Do know

1.slight uncomplicated deformity is best left alone.
2.if angulation is severe , correction by osteotomy near the lower end
of the humerus .
3. if the fxn of the ulnar nerve is impaired the nerve should be
transported from its post humeral goove to a new bed at the front of
the elbow.

Cubitus varus
a decreased carrying angle, also known as a "Gunstock Deformity", usually
due to an improperly reduced supracondylar fracture or epiphyseal
abnormality during growth.

1. previous fracture with mal- union (especially supracondylar
fracture of the humerus )
2.interfere with epiphyseal growth on the medial side.
Do know

Treatment :
1.minor degree of deformity can safely be left uncorrected .
2. if the angulation is severe it may be corrected by osteotomy through
the lower end of the humerus.
68.Osteochondritis dissecans of the elbow: etiology, diagnostics, methods of

-The disorder is characterized by necrosis of part of the articular cartilage

and of the underlying bone, with eventual forming of this fragment of an
intra-articular loose body.
-Probably it is an impairment of blood supply of the affected segment of
bone and cartilage with thrombosis of an end-artery.
-Usually osteochondritis dissecans meets at adolescents and young adults
-Radiographs show a clearly defined shallow excavation into the articular
surface of the bone , a discrete bone fragment lying either within the cavity
or elsewhere in the joint.
 If problems do not resolve with rest, surgery is recommended,
including loose-body removal with curettage or drilling, sometimes a
chondroplasty under indications.
 The prognosis is good with early diagnosis and treatment. Left
untreated, OCD may progress to degenerative joint disease.
 Prevention includes strengthening and stretching exercises and limits
on throwing activities.

69.Tennis elbow (epicondylitis): etiology, diagnostics, methods of treatment

It is an extra-articular affection characterized by pain and acute tenderness in

insertion site of the extensor muscles of the forearm
The cause is a strain of the forearm extensor muscles at the insertion site of
their to the bone

Reduce inflammation and pain
Promote tissue healing
Retard muscular atrophy
Treatment regimen
Exercise therapy: stretching in region of the elbow joint to increase
flexibility; extension and flexion of the wrist; extension and flexion,
supination and pronation of the forearm.
High-voltage galvanic stimulation (HVGS)
Friction massage
Iontophoresis (with an anti-inflammatory drug)
Avoiding painful movements

Improve flexibility of a tissue
Increase muscular strength and endurance
Increase of functional activities
Treatment regimen
Exercise therapy

70.Carpal tunnel syndrome: etiology, diagnostics, methods of treatment

The syndrome is stipulated by compression of tendons and a median nerve
in the carpal tunnel.
The causes - 78%
• Malunion fracture of the radius in typical place
• Fractures and dislocations of wrist’s bones
• Compression of the median nerve

Another causes: chronic tenosynovitis, pigmented villous-nodular

synovitis, professional overstrain, hormonal diseases

Diagnostic test
• Test of a flexion of the hand: the passive maximal flexion of a hand
and fixation of it in this position during 1 minute result in paresthesia
I - II fingers
• Test of an erect hand: the elevation and retention of both hands in
this position during 1 minute result in paresthesia in the diseased hand
• Test of tourniquet: pneumatic tourniquet during 1 minute →
numbness and paresthesia
• Tinnel’s Test: percussion of a carpal tunnel → paresthesia of the
fingers, irradiation to antecubital fossa
• Test of local compression: pressure by a finger on the carpal tunnel
during 1 minute → paresthesia in the zone of innervation of the
medial nerve

1.conservative treatment by supporting the wrist for 3 weeks with a simple
2. if this is unsuccessfull full relief is assured by dividing the flexor
retinaculum to decompress the nerve.

71.Volkman’s ischemic contracture: etiology, diagnostics, methods of

treatment, prophylaxis.

This is persistent flexion contracture of the wrist and fingers as a result of

ischemia of a extremity
 injury or obstruction of the brachial artery near the elbow (for
example, at extension supracondylar fractures of the humerus)
 tense oedema of the soft tissues of the forearm (for example,
compression in plaster bandage)

clinical features
=markd athropy of the forearm with flexion deformity of the wrist abd
=skin over

treatment: *mild deformities can be corrected by passive stretching of the

contracted muscles using a turn buckle splint (volkmann’s splint)
*for moderate deformity a soft tissue sliding operation where the
flexor muscles are released from their origin at the medial epicondyle and
ulna is performed (maxpage operation)
*for severe deformity bone operations such as shortening of the
forearm bones,carpal bone excision may required.

- requires restoration of blood flow;
- reduction of compartmental pressure

72.Avascular necrosis of the femoral head: etiology and pathogenesis, clinical

picture and diagnostics, methods of treatment.

ANFH is multiple-factor or polyetiologic disease. The initial starting

mechanism of its is bound up with disorder of the microcirculation

Factors promoting dev of AVFH

Trauma of a hip joint is the cause of development of ANFH at 10 - 50% of
patients in the nearest or remote periods
• bruises,
• fracture of femoral neck,
• dislocations,
• surgical interference in the region of a hip joint, transferred at
Disorder of blood supply and ischemia of a femoral head underlie
pathogenesis of avascular necrosis of the femoral head (ANFH)

 infarcts as a result of a thrombosis of arteries,

 the latent prolonged insufficiency of arterial blood supply,
 venous stasis,
 associated disorders of
an arterial and venous network.
Clinical picture
1.w/o symptom , light pain in the hip joint
2.significant cp, limpingand pain
3.contraction in hip joint
Hypertrophy or atrophy of thigh muscles
4.cp of osteoarthritis

x-ray (1-2 dregree)
1. roentgenogram by launshtein
2.mri frontal plane
3.mri horizontal plane
Hyper fixation of radioactive drug in diseased site
1.medical regime
Optimal orthopaedics regime and medical exercise
Walking in mid. Tempo and on stairs.
2.medication theraphy
Rheologic drug : tentral, curantyl
Drugs of calcii : fosamaks
chondoprotectors : Alflutop
other analgesics
Decompression drilling
Long term interbone blockade

73.osteochondropathy of femoral head; etiology and pathogenesis ,cp and

diagnostics , method sof treatment
(morbus calve – leg g–perthes)

It is the cause of childhood disability is 8.5 %

Etiology and pathogenesis
- local disturbance of blood supply is believed to be the major factor, but the
precise cause of the vascular disturbance is unknown
- stages of the disease : -necrosis
-imprssion fracture
Clinical picture
- pain in the region groin or thigh and noticed to limp
- on examination: only striking sign is moderate limitation of all hip
movements, with pain and spasm if movement is forced

clinical outcome -osteoarthritis

- old untreated perthes’s diseases
- the femoral head is markedly flattenedand the femoral neck is short
- there is already some narrowing of cartilage space, suggesting early

normal rbc sedimentation rate and blood count


1.medical regime
Optimal orthopaedics regime and medical exercise
Walking in mid. Tempo and on stairs.
2.medication theraphy
Rheologic drug : tentral, curantyl
Drugs of calcii : fosamaks
chondoprotectors : Alflutop
other analgesics

Decompression drilling
Long term interbone blockade

4. long time unloading w skeletal extension

74. Dysplsia of the hip joint – etiology, clinics, and diagnostics, treatment.

The factors of risk

Family heredity flattening of the acetabulum,
Sex at girls in 4 - 5 times more often

Presentation at bre
ech presentation in 10 times more often
Quantity of a pregnancy of the at children from the first pregnancy in 2
mother time more often

Anomalies of the uterus myomatosis, oligohydramnios , e. c.

Diagnosis of congenital dislocation of the hip (or dysplasia) has to be

determine already in a maternity hospital
Obligatory examination by pediatrician (and necessarily by orthopedist):
 in a maternity hospital on the birth
 in 3 – 4 weeks
 in 3 month

Critical evaluation of the phenomenon

of Roser - Ortholani
Research of the joints is necessary to carry out as early as possible (better on
1 - 2 day of a life). It lets to ascertain a displacement of a femoral head. The
symptom disappears already on 3 - 4 days.

The scheme Hilgenreiner and the line Shenton

The angle C < 30° in norm

Radiographs show a clear zone of transradiance within the bone. The area
has a homogenous ‘ ground –glass’ apprance
If the lesion is seen to be extending , the affected segment of bone should be
excised and replace by bone graft.
75. A foot as organ of movement, support and amortization. Methods of
feet’s investigations. Classification of static deformations.

Methods of feet’s examination.

 Anamnesis
 Inspection
 Palpation
 Measurement
 Function
Method of feets investigation
Index of podometry = hx100/. = 29-31

Determination of the axis of the foot, of the angle of turn, of width and
length of feet, of degree of longitudinal platypodia and valgus angulation of

Computer optic-topographic plantography

Radiographic examination

Podography - ambulation on a conducting path. Time of a sustentaculum on

a heel, for all foot, on the toe, of transfer of the foot by air, of double-seat
period are determined
Dinamometr platforms - measurement of a load at standing and ambulation
Pedography - measurement of vertical load by changes of capacity of

Classification of static deformation.

I. Static deformations
1. Functional insufficiency
2. Longitudinal platypodia (planovalgus
3. Transversal platypodia (broad foot)
4. Fibro-osseous excrescences in region of heads of I metatarsal bones
5. Hallux valgus
6. Hammer-shaped (or claw-shaped) and others deformity of toes

II. Paralytic deformations of feet

1. paralytic flat foot
2. paralytic short cavovarus deformity
3. paralytic heel foot
4. paralytic tip foot
5. talipes paralyticus
6. hypermobility of foot

III. Congenital deformities of feet

1. congenital flat foot
2. congenital clubfoot
3. congenital adducted foot
4. congenital deformity of toes

76. Longitudinal flat foot

 Causes
 Paralytic – Flaccid flat foot.
 Traumatic – Fracture calcaneum.
 Arthritic – Rheumatoid arthritis.
 Spasmodic – Due to peroneal spasm.
 Pathogenesis: muscle imbalance –fibular muscle
-ant . and post. Tibial muscle
 Clinical picture & Diagnosis
 Clinical features:
o Pain, swelling, fatigue, deformation.
o Longer foot.
o Flatting longitudinal arch of foot.
o Wide in middle part of foot.
o Decrease height of foot.
o Valgus deviation of foot.
o Prominence osnavicularis (scaphoid) on the medial side.

 X-ray (AP & L view).

 Treatment
 Conservative:
oMedical exercise.
oSole supinator.
oOrthopedic shoes.
oTibial muscle stimulation & relaxation peroneus muscle.

 Surgery:
oTendon achiles longitudinal – young patients.
oArtrodesis – old patients.

77. Broad Foot

- due to injury, illness, unusual or prolonged stress to the foot, faulty
biomechanics, or as part of the normal aging process.

- arch appears when the person dorsiflexes (stands on tip-toe or pulls the toes
back with the rest of the foot flat on the floor).

Treatment of flat feet may also be appropriate if there is associated foot or
lower leg pain, or if the condition affects the knees or the back. Treatment
may include using arch supports/orthotics, foot gymnastics or other
exercises as recommended by a podiatrist or other physician. Surgery, while
a last resort, can provide lasting relief, and even create an arch where none
existed before, but is usually very costly.

78. Hallux valgus

a) Causes
- rheumatoid arthritis, wearing pointed shoes with heels, idiopathic.
b) Clinical and radiological features
• Clinical - Hallux valgus is considered to be a medial deviation of the
first metatarsal and lateral deviation and/or rotation of the hallux with
or without medial soft tissue enlargement of the first metatarsal head.
This condition can lead to painful motion of the joint or difficulty with
• Radiological - Width and uniformity of the joint space normally, the
joint space appears uniform. Increase or irregularity is indicative of
degenerative changes. Therefore, if the osteoarthritis is severe enough,
a joint-destructive procedure should be treated.

Other radiographic findings

• Hallux valgus: No valgus rotation, as noted by the symmetrical
concavity of the borders the medial and lateral shafts, should be
evident. Asymmetry would indicate the need for a procedure to the
proximal phalanx to derotate the hallux.
• Medial eminence: The normal metatarsal head is free from excessive
bony proliferation. The presence of bony proliferation is indicative of
the imbalance of the joint with excessive medial tension occurring.
• Soft tissue: The soft tissues are evaluated for evidence of edema,
bursae, calcification, or other signs of chronic inflammatory changes.

• Another aspect that should be evaluated is the presence of osteophytes

at the articular margins. The normal joint is free of osteophytes. The
presence of osteophytes is another indication of severity of

c) Principles of treatment
• Adapting footwear - Spot-stretching shoes or using of shoes with
wider and deeper toe boxes might be considered. Padding and
strapping have limited success, other than to relieve footwear or
digital pressure in long-term management. Sole suppinator, orthopedic
• Pharmacologic or physical therapy - Nonsteroidal anti-inflammatory
drugs and physical therapy can also be offered to relieve acute,
episodic inflammatory processes. Corticosteroid injections can also be
offered in the management of acute inflammatory conditions to the
first metatarsophalangeal joint.
• Functional orthotic therapy - Functional orthotic therapy might be
implemented to control the biomechanics. This approach can relieve
symptomatic bunions, though the foot and first metatarsophalangeal
joint must still have some degree of flexibility. Massages. Medical
• Operation txn – congruent joint, incongruent/ sublaxed joint, joint
with arthrosis

79. definition of scoliosis: etiology and pathogenesis

Definition: -is a lateral spinal curvature on 10 degree and more

- structural (morphologic ) scoliosis is stipulated by anatomical
anomalies of the spine or its supported structures
- functional scoliosis (fs) is cozed by application to spine
external forces. Fs is connected w shortening of limb.
-idiopathic scoliosis
-dysonogenetic scoliosis
-infection, trauma, grave burn on
trunk,paralysis,poliomyelitis,neurofibromatosis, rheumatoid arthritis

epiphysis of disk of vertebrae

primary disturbance of disturbance of muscular

growth balance

torsion, curvature, wedge-shaped

form of vertebrae

80. clinical presentation of Scoliosis-. Examination of pt. classification of

severity of scoliosis
Clinical presentation
- complaint onpain in back, in lumbar or thoracal part
- pain increased at axial loads and reduced in dormancy
- asymetrics scapulae w flaring one of them
- asymmetric triangle of waist and iliac crest
- asymmetric deformity of trunk
-plummet dropped from a occiput , appears sideways from an
average line.
-costal humpback observable at inspection of back in a
horizontal plane.

Examination of pt
- photometry at scoliosis


1dregree- 5-10 degree

2degree- 11-30 degree
3 degree- 31-60 degree
4degree- > 60 degree

81 treatment of scolosis, indication for surgical treatment

• Aim of treatment is asses of prognosis of the curves. It depends on
type of curve, site of curve & age of onset.
• Postural scoliosis & structural curves of lesser then 30degrees & well
balanced double curved doubled curved treatment by non-operatively.
1. Non-operative treatment:-
• Medical exercises
• Braces like Milwaukee, boston, localizer cast &
reisser”s-turn-buckle cast.
• Prognosis of curve monitored radiologically & clinically
every 6 months.
2. Surgical treatment:-
• Indications are congenital scoliosis specially thoracic
vertebrae, scoliosis associated with backache, curve
shows deterioration by radiologically.
3. Methods:-
• Fusion of spine
• Stretching done pre-operation by control traction,
localizer brace, Harrington”s distraction system, halo
pelvic distraction, dywer”s compression, luque-harts-

82. Osteochondrosis of the spinal column : definition, etiology and


Osteochondrosis is degeneration and dystrophy of the intervertebral disks of
a spinal column, which is accompanied by their progressive deformation, by
decrease of height and by stratification with the following involvement of
bodies of adjacent vertebrae, intervertebral joints, the ligamentous apparatus,
a spinal cord and its roots, and frequently, with a disorder of blood supply of
structures a spine column.
Osteochondrosis affects all parts of spinal column, but usually it is meets in
the most mobile parts: in cervical and lumbar, i.e. in the most functionally
loaded segments.
Cervical part – CV-VI, then CIV-V и СIII-IV.
Lumbar part ― LIV-V
In a thoracal part the osteochondrosis is usually localized at a level TIII-VII

• Infectious theory
• Autoimmune (rheumatoid) theory
• Traumatic theory
• Dysontogenetis theory
• Involutory theory
• Muscular theory
• Endocrine and metabolic theory
• Theory of heredity

• An effect of endogenous and/or exogenous factor
• A disorder of microcirculation in vertebral segment
• Degenerative changes of cartilage
• Autoimmune inflammation of the changed cartilage and nucleus
• Atrophy, thinning, decrease of buffer properties of a cartilage
• Functional change of the overloaded bone, directed to the
consolidation of the bone (a subchondral osteosclerosis) and to
decrease of a load by unit of a support surface - marginal osteophytes

83)Clinical presentation of osteocondrosis;

ii)compression,hypo and hyperesthesia,change in reflex,pain
iii)radicular paralysis(paresis)
Syndrome:-Static disorders,neuralgic disturbances,vascular and trophic
changes of vertebra and extravertebral origin
Acute condition-spontaneous pain,improper position or forced,weak muscle
tone,functional block of segment of vertebrae,disturbances in root,
Remission-pain in uncomfortable position,change of position increase
pain,root symptoms absent but function dec
Regression-intensive pain,static dynamic
disturbances(walking,sitting),,intensive pain and weakness in muscles,block
in the vertebral column, root disturbances and fuction disturbances.

84)Basic principles of treatment of osteochondrosis

Conservative treatment:regime(3-7days bed rest,lie on hard surface,in
straight position),medical drugs(analgesic,vascular drugs,vit B,synaptic
mediators,local therapy,treatment for other disease),physiotherapy,massage
and reflectotherapy,medical exercise,orthopaedic complex
Physiotherapy-dynamic therapy,UV radiation,local
darsonvalization,amplipulse,phonophoresis of analgesics,electrophoresis of
euphyllin,novocaine,thermal procedures,radon baths.


Vertebral painful syndrome:-

-rest,analgesics,NSAID,muscle relaxant,vibroextension,manual
therapy,psychotropic drugs,acupuncture
-first 2days is manual therapy,fixation of backbone by bandages,spinal
support,axis traction
-some days after onset;NSAID,paravertebral novocaine block,muscle
-end of 3 wks gv biostimulants,vit group B
-protrusion of disc(outpouching of disc to side of vertebral canal with
vascular embarrassment and nerve compression
-medical measures-rest,analgesic drugs,NSAID,muscle
relaxant,paravertebral block,block of spinal nerves,epidural(anesthetics with
corticosteroids) Next manual therapy and vibroextension is carried out for 3-
4wks for rehabilitation