“ORTHOPEDIC – SURGERY”

TRAUMA

FRACTURES
-Complete or incomplete break in continuity of bone.
-causes; high energy mechanism(MVA, Fall) and stress fractures.

Pathologic fracture- Secondary to chronic osteotomy or cause by tumor, osteogenesis imperfecta.

Kids; tendons are stronger than bones.

Soft tissue-most important in fracture managing fractures.

Splint vs cast
SPLINT – for Acute injury-allow room for swelling. Should be well padded and comfortable.
Don’t place too much pressure in one segment, should have equal pressure to all area.

CAST – apply when swelling subsided, definitive treatment.

Traction devices – to do temporary alignment, decrease spasm and decrease bleeding.

Types:
Skin traction- ex: fracture on distal femur
Skeletal traction

External fixators- for open fracture, comminuted fractures, soft tissue is compromised.
- Part of Damage control orthopaedics, control haemorrhage.

Internal fixators- when fracture is closed, heal na.

Open reduction- Open incision

Closed reduction- no incision
Internal fixation- alignment
External fixation- put wires, no need to open.

PRINCIPLES OF MANAGEMNT:
Reduction- for alignment, to maintain function , bring fracture fragment to close apposition to each
other.
(when you have diaphysial fracture regain length axis rotation, to provide relative stability.)
(When you have intraarticular fracture retain anatomic reduction, need an absolute stability, no
micromotion.)

Open reduction internal fixation

- Contraindications: Infections, bone to weak, medical conditions (surgical abdomen)

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 Fracture complications;
1. INFECTIONS
2. MALUNION- analignment
3. DELAYED UNION
4. NON UNION- failure to produce healing.

PEDIATRIC ORHOPEDICS
Genu valgum- 6 yrs of age turns to normal (Physiologic)

CASE;
2 wks old infant multiple UE and LE deformities:
What would you request? ULTRASOUND- dislocated bilateral elbow, knee, hip (Lars syndrome?)
if you have a kid who have only club foot u can do casting.

Management:
Predominantly of non surgical treatment; Casting orthos serial monitoring.
Timing of surgery if needed.

SPORTS MEDICINE

Anterior Cruciate ligament (ACL) Tear- ACL is for tibia not to dislocate anteriorly.
Reconstruction- Arthroscopy (ACL not repairable, not heal, it need to be remove and place another
tendon)

Meniscal tear (menismus- shock area of knee)

Red zone injury- (vascular)can be repair.
White zone- (not vascular)cant be repair.

Shoulder dislocation- torn capsule

Do bankart repair- special procedure. Tighten antero-posterior of the capsule, para di na matanggal.

DEGENERATIVE CONDITION

- Goal of tx; relief tx, resotore fxn.

- Give pts. NSAID, hyaluronic acid, physical therapy.

JOINT replacement:
Acetabular component and fibular component.
Knee joint ( femur, prox tibia, patella compartment)

TUMORS

- Do MRI, Biopysy (Trocar)

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Soft tissue mass: Poor prognostic.

BONY LESION: Malignant (Theres wide zone of transition)

Benign (Narrow zone of transition)

LEVELS OF AMPUTATION:
- Marginal zone- has a cup of soft tissue
- Radial margin- remove the compartment.

CASE: INFECTED JOINT;

management-
Xray, no bony changes its only acute infection or septic joint.
Joint aspiration- see if theres necrotic material or purulence, if purulence, drain it and flush it
completely. if left untreated leads to bone infection.

CASE: 45 yo male, deformed thigh, AP view of femur, theres am implant and fracture, theres active
infection.
- Remove the implant, remove all the bones, apply clindamycin (antibiotic)
- Bone infected (sequest?) principle of treatment: IV antibiotics, adequate debridement and
provide stability (LALABAS SA EXAM!)
- External fixator- proved stability, so the segment will not move, allowing the soft tissue to heal.

FRACTURES:
Upper extremity Injuries:

Clavicle
-most commonly fractured bone.
Mode of injury: fall outstretched hands, direct injury to shoulder.
Management:
Children- pain medications and immobilisation for 3 weeks.
Adult- conservative

Indicators; neurovascular injury, open fractures, bony fragment tenting the skin.

Shoulder dislocation:
One of the most common shoulder injuries: 80-90%teenager. (Labrum provides deepens of the bones)
Bankart Lesion-Avulsion of anterior Labrum from anteriorInferior glenoid. Appreciated by MRI
Bony bankart lesion- fracture of ant. Inferior glenoid.
Hill Sachs-

Shoulder anatomy:
Static constrains- bone, capsule, labrum
Dynamic constraints- provides stability or movements (rotator cuff and biceps muscles).

Management: reduction and immobilization followed by therapy.

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Arthrosporic bankart repair.
Risk factors: <20y.o, male,contact sports

Proximal humerus
Indirect or direct mechanishm
Indirect: fall of outreched hand
- Direction of twist is external.

Classification: based on anatomy.

-Surgical neck: 2 part fracture
-Greater tuberosity and surgical neck: 3 fractures
-4 fractures: surgical neck, ….
Management: Displaced and undisplaced fracture
- Undisplaced- immobilization
- Displace: reduction and immobilization

Humeral shaft
Case:
Distal and middle 3rd humerus fracture:
Radial N. palsy: Austin lewis fracture
Tx: acceptable
30 degree varus
…. …

Distal humerus fracture

Consist of: supracondylar area, single columnae area, bicolumn fracture.
Intercondylar fracture- most common pattern.

Tx: operative tx: open reduction and internal fixation

Elbow Dislocation
Tx: anatomic reduction and relative stability

Forearm fracture- radius/ulna. Common in men.

Classification:
Pt: gross deformity, swelling, pain
Case: midlle 3rd fracture radius and ulna; transverse, simple.
Managemant: surgical

-Distal radius fracture:

Most common orthopedic injury accounts for 18% injuries, common in female.
Intraarticular 50%
- Radial ht: 11-12mm
- Radial inclination- 23 degrees.
Ulnar variance- negative or neutral.

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AP angulation- 5 degree molar knee..
Colles fracture- dinner fork deformity (non articular, want callus formation) outstretched phonation
Smith fracture- outstretched supinated hand.
Chauffer fracture- compression of scaphoid against styloid process of distal radius. Undisplaced
fractures.
Barton fracture- reticular fracture-
Tx:
Conservative extraarticular <5mm

Lower extremities
Femoral neck- intracapsular
- Synovial fluid lyses blood clot formation.
- Lacks periosteal layer- limited callous formation. Poor blood supply leads to vascular necrosis
and nonunion. (2 yrs after injuyry pt. still not walking)
- Anatomy: neck shaft angle; 130 degree

Pauwel classification- 1-3:unstable to most unstable

Cases:Hip complete fracture of femoral nect: garden stage 3.Pouwel 3- unstable.

X ray- pelvis AP
MRI or bone scan
If xray is normal but suspected femoral neck fracture. Rule out in pt with inguinal pain.
Tx: Observation alone: considered in pt. who are non ambulators have minimal pain, who are high risk
for surgical Intervention.

Open reduction internal fixation: displaced fracture <65 yo. Stable.Garden 1 incomplete fracture despite
of age.
Joint replacement- >65 y.o, unstable, Pauwels 3, 44 yo.

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Case: fracture of femoral neck: 72 yo female, pauwels 3- management: replace.

Intertrochanteric fracture
Calcar femorale- provide stability in dense area.

Evans classification; calcar femorale- lateral wall blew out-, unstable

Stable vs. Unstable

Stable- use dynamic screw- gumagala control collapse.
Unstable- cant allow micromotion, it will collapse.can apply rigid form of fixation, because its weight
bearing area. Lateral, postero wall, reverse inquity

Case: Hip: fracture interochanteric area- unstable type. Comminuted of posteromedial cortex.
Management: rigid fixation

Femoral shaft fracture

Femur- largest bone of the body.
- Principal load bearing bones of the LE.
Undisplace- usually ang femoral fracture.
Typical complaint of inguinal pain.
mas masakit thigh area- do hip xray as well.

Classifications

Management:
Intramedullary nail of femur- length axis and callus formation.

For pediatric: place elastic nails.

Pts who have not medullary cannal; nagkatumor: place a plate (relative stability)

Distal femur-
Alignment anatomy:
- 10 degreee slope lateral and 25 degree medial.
- Medial condyle more extends than lateral condyle. It is more farther.

Gastronectemius- extends distal fragment (apex posterior)

Harmstring and extens cause shortening.

Classification; intaarticular or extraarticular. Simple or comminuted.

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Tibia plateau fractures-
Lateral tibial plateu- convex; proximal to the medial plateu
medial tibial plateu- concave

classification: Schatzer

Inspect and rule out an open injury

Palpate for possible compartment syndrome- leading to ischemia

Ankle brachial index:

( .91) normal range,( .4)- severe disease- this index to test for vascularity.
Tx: conservative: hinged knee brace and after 8-12 weeks do——-

Operative management- external fixation or ilizarov ring fixation.

Complications: post traumatic arthritis

Case 9: knee: articular, comminuted,fracture 35 yo male. Mgt: Perfect alignment of jt.

Tibial shaft fracture- Most common long bone fracture, 1/3 of tibial surface is subcutaneous- open
fractures common.
Assoc conditions: compartment syndrome, bone loss, ipsilateral..

Compartment of the leg- memorize the muscles!

Anterior- tibialis anterior, extensor digitorum longus, fibularis tertius, extensor hallucis longus.
Posterior- gastocnemius and soleus and plantaris
Deep-posterior- popliteus, flexor digiturum longus, flexor hallucis longus, tibialis posterior.
Lateral- fibularis longus and brevis muscles.

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Tibia shaft fracture treatment:

Nonoperative- closed reduction followed by cast and mold immobilization.

- <5 degrees of varus valgus angulation
- <10 degrees of posterior angulation.
- <1cm shortening
- <10 degrees rotational malalignment

Triple Antibiotic administration- most important factor in reduction infection.

Case: 67/f
3 month history of left knee to left hip pain, (-) hx of trauma

Differentials:
a.Rheumatoid arthritis- inflammation (swelling) of synovium atleast 6 week.
-formation of pannus.
-insidious and systemic.. (unlike osteoarthritis: only involves jt.)
- radio: late: punch out periarticular erosion (bone erosion)
- Lab-test:
antiCCIP- most sensitive.
Synovial fluid analysis(Wbc: 5000-7000cells)
Incidence: 1% of adult population.

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Synovium- lining of joint is inflamed in RA, unlike orthoartritis which is is not inflammatory.

b.) Gout- urate crystal disposition arthropathy.

- Common in male (90%), >30y.o
-hyperurecimia(not yet gout, just high uric acid) 2-3x value of uric acid to say that it is gout.
Pathology: joint is chalky or creamy. Seen in synovium, cartilage, ligaments and periarticular jts.
Tophi- urate disposition.
Radiology: punch- out periarticular erosion.
Monosodium urate aspirate: Strongly negatively bidfridgement

c) Degenerative osteoarthritis
Etiology:
- mechanical, dystrophic, immune genetic factors
-failed attempt of chondrocytes to repair damage cartilage

Primary OA- no underlying cause

Secondary OA- antecedent injury

Pathology:
-articular cartilage : deterioration
-reduced compressive stiffness and resiliency
-unable to withstand mechanical stress- inadequate chondrocytes.
S/s: stiffness of the joints knees, pain, slight tenderness and enlargement(boucharnodes, heberden
nodes- only found in OA)
Management:
- NSAIDS,
- Physical therapy (strengthen muscle, improve stability, lessen pain),
- Intraarticular injection of steroids.
- (PRP) platelet rich plasma- not really advised
Surgery:
- total joint replacement; for advance stage, (severe limitation to daily activities, deformity..)
-osteostomy; corrected deformity and help relieve pain.
- Arthrodesis or joint fusion
-arthroplasty.

Diagnosis: degenerative osteoarthritis

- Total hip arthroplasty: (what we did to the pt. sa case ntin.)
- Partial hip- proximal femur is only replaced.
-
Most common cause of jt. Dislocation: malpositioning of implants.

Complications:
-infection.
-Intraoperative fracture.
-Nerve injury(commonly sciatic nerve) incidence of <1%).
-Deep venous thrombosis (leads to pulmonary embolism- that’s why we apply blood thinners to prevent
DVT).

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-Dislocation (posterior approach).
-Leg length discrepancy (upto 2 inches).
-Aseptic loosening/ osteolysis.

ORTHOPEDIC INFECTIONS:

Case: JB 40 y.o male: nahulog, nagpahilot.

cc: pain distal thigh
-difficulty walking
-sinuses(connection of external envirment from the inside, dito lumalabas mga discharge)
Requested: cbc; bacterial imfxn.,
Diagnosed; Chronic osteomyelitis (left thigh)
- Infection of the bone.
- Progressive inflammatory destruction.
- Disposition of new bone.
Risk:
- recent trauma or multple trauma,
- recent surgery,
- immunocompromised. (pt. natin nag pahilot- theres trauma, compress bv, cell death in the
bone, prone to infection, dead cells in left thigh is the new home of infection.
- Illicit drug used
If theres acute injury apply cold, don’t bring to manghihilot, bring to a doctor.

Routes bacteria can travel to your bones:

• Hematogenous- transported by blood
-vetebra(most common loc.)
- Staph aureus- most common hematogenous agent. gram postive, round cocci. Request
staining.

• Contiguous focus(surgery trauma)

• Direct inoculation (penetrating injury)
• Biofilm- cover necrotic bone and hardware, antibiotic have difficulty penetrating biofilm.
• Organisim- varies by age of pt, S aureus most common in adults.

Goals: eliminate infectious, bone uniun. (recurrence rate; 30%)

S/s: pain, fever (most common: acute osteomyletis)
Xray: lytic region, radiolucent, surrounded by sclerosis. May mimic neoplastic process.
Sequestrum- dead or devitalised bone, serves as nidus for infectious
Involucrum- new bone formation
MRI-early diagnosis.
Lab test; CBC (wbc elevated), blood culture (sinus tract culture- not reliable.)
Gold standard: bone culture and bone biopsy: then start antibiotics after getting the specimens.
*Ceimy and Mader Classification:
Type 1- medullary osteomyelitis
Type 2- Superficial osteomyelytits
Type 3- Localized osteomyelytis

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Type 4- Diffuse osteomyelitis

Non operative tx:

IV antibiotics: 4-6 wks.
-draining the pus (debdridment- removing dead tissue)
Surgical fixation techniques

Complications of osteomyelitis
- Persistent extension of infection
- Amputation
- Sepsis
- Malignant transformation (Marjolis..)

Management on our Case: give debridement- corticotomy and antibiotics.

INFECTIOUS ARTHRITIS- infection of the joint.

Bacterial (stap. Aureus- most common)
- Hematogenous or direct extension from an osteomyelitis.
- Cartilage destruction (proteolytic enzyme)
Pyogenic arthritis
s/s: severe joint pain, inflammation
diagnosis: joint aspirate (>50,000wbc)
Tx: emergency arthrotomy, antibiotic IV atleast 6 wks.

Tuberticulous arthritis
Xray:Phemister triad(osteopenia- weaking bone, jt. Narrowing, bone erosion)
Diagnose: Biopsy (spine- CT scan guided)

Tx: medication(rifampacin, isoniazid

Physical therapy

Spinal arthritis (potts dse)

- Commonly seen in HIV
- Location: 15% extraplumonary involvement. spine- most common extra-pulmonary site
(thoracic vertebra).
- (Mycobacterium tuberculosis- commonly goes to anterior elements, TB in lungs at apical
segments (taas) because of high oxygenation area. )
- Imaging: chest xray can be requested but not required.
- Diagnosis; spine radiographs- 2 views, AP and Lateral.
Lab: Gold standard; TB culture and TB DNA.
Tx: If not severe: medication, physical therapies
If severe- surgery.
Complication; deformities

Xray: Mortise view- 50 degress of the foot.

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2mm displacement-acceptable in joint injury.

- Case 11: joint fracture of bimalleolar fracture. Weber B. - Anatomic reduction needed.

Weber classification -

Case: painful, swellimg right ankle. Weber c (high fracture)

PEDIATRIC ORTHOPEDICS

Pediatric fractures
- Good healing potential- requiring minimum tx.
- Depends on age.
- Often missed (hx of trauma, not enough communication of the child.)
*Non accidental trauma
Child abuse.

ELBOW
Fractures- 4 headings
a.) Fracture of birth- humeral shaft, clavicle, femur
- Epiphydid(growth plate) – hypertropic zone, injury happens. SALTER CLASSIFICATION (type 2:
thorson holland- most common. Type 3: must be reduced accurately if growth abnormalkties
are to be prevented.
b.) Fracture of long bones.
- Overgrowth phonemenon- 2ndary to periosteal hyperimea.
- Greenstick fracture- incomplete fracture
- Traction in children-
3 point fixation.
- Insetion of the nail
- Most complex part of the nail
- - tip of the nail
c) Pathologic fracture
- fracture through infected bone- chronic osteomylitis
- benign bone tumor- cyst
- malignant bone tumor

Congenital abnormalities
- Packaging deformity

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 a) torcoicolis
- s/s: head tilt and rotation
- not painful
- tx: stretching (side lying, side to sit straightening.)
- if fails; >1yr old. operative: z plasty lengthening or bipolar release
- unipolar release-
b) radial head deformity- almost always bilateral
s/s: limited ROM. Pt. asymptomatic
PE: radial head prominence.
Cx: Radial N. injury: Wrist drop (laceration nerv palsy)
Tx: observation (30-40 degrees flex)
*Differentiated from traumatic dislocation:
-Bilateral involvement
c) Synostosis- bony bridge between proximal radius and ulna.
s/s: painless
-mgt: observation- especial if its unilateral
Operative: severe pronation deformity

HIP
Dislocation- complete displace ent with no contact between original articular surface.
Subluxation- displacement of a joint with some contact remaining between the articular surface.
Dysplasia- deficient development of acetabulum.
- Main stimulus of acetabulum to be mature; femoral head away from the joint.

Etiology devt of dysplasia of hip:

- Ligamentous laxity-
- Breech presentation- 20% chance; frank breech
- Racial- black and asia: low incidence of DDH
- Girls > boyd
Blocks reduction- everything inside the joint. Ligamentum teres, elongated. Capsul thickened as well as
transverse ligament.
*Iliospsoas- being tightened when pulling down. Muscle Blocks reduction.

<25 degreees- acetabulum index; spherical

If >25 degrees: dysplastic.
Neonatal period-
-Barlow test- hip gently adducted and put pressure posteriorly, will dislocate the hip (bad)
-Ortolani test- from adducted position the hip gently abducted while lifting trochanter anteriorly.
Reduce the hip joint (good).

Infant
For bilateral DDH:
klisic sign- line in umbilicus
duck like gait; waddling gait
trendelenberg test- weakness of gluteus medius, opposite hip elevated.
Older 2-6 age same manifestation.

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1-6months; place pavlik harness for infants after hip reduces.
6 months of age imaging of choice: ultrasound.
6-18 months of age with dysplasia: closed reduction then placed in cast, open reduction (bikinitype) .
18-24 months- close vs open reduction, pelvic osteotomy (cut the bone for alignment correction)
24- 6 years: open reduction and femoral shortening with or without pelvic osteotomy..

KNEE:
Most common knee pathology; Genu recuvatum- assoc with deformity of the spine.
- Grade 1- mild, bone to bone contsct
- Grade 2- bony contact subluxation
- Grade 3- dislocation.
Non operative-
treat knee first, cant get palvik harness on hip if knee is dislocated.

Genu varum- risk factors: over wt,. early walker

Prognosis: best outcome with early diagnosis
normal below 2 yrs of age
Correct na dapat pagka 3 y.o
4 yrs of age- genuvalgum normal.
Tx: Metaphyseal diaphhseal and tibiofemoral angle
Non operative- bracing(KAFO) stage 1 and 2 in children less than 3 yo.

Operative- morethan 4 yrs of age.

LEG
Bowing of the tibia
Posterior medial- physiologic. Assoc with
Anteromedial- absence of fibula.
Anterolateral- psudoarthrosis

Type1- proximal part absent

Type 1b- 30% of fibula absent
Type 2- complete absent.
-Without fibula, no stability of the foot.
Goal of tx: stability and level of the foot and ankle functionas well as the degree of limb shotening

Anterolateral bowing- assoc. with neurofibromatosis 1. (low resolution)

FOOT
Congenital vertical talus- rigid rockerbottom deformity
-talus oblique not vertical.
Non operative- serial manipulation and casting for 3 months.
Operative- surgical relase

Metatarsum aductus- adduction of forefoot, no deformity.

Complaining of in-toeing.
Bleck classification:

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Tx: benign: tickle lat. Side of the foot. Resolves in 90%
If it does not work: Serial maipulation and Casting-

Club foot- uinovarus

Presents: hindfoot varus, forefoot adduction, midfoot cavus, hindfoot equinus.
Tx: ponseti method: serial casting until corrected.
- If not responding: >5 yrs old; soft tissue realeases.
C: relapse, dynamic supination.

Osteogenic imperfecta-decrease amount of type 1 collagen.

- There are four types:
- Type 1; most common
- Type 2 most fatal.
Management; supportive management; fracture immobilization, biphosphonates.
- Frequency of fractures decrease upon skeletal maturity.
-
Muscle dystrophy- worsening neurologic dysfunction. Weakness of proximal muscles first to distal
mjscles. Gait abnormalities (delayed walking, cljmsy, difficulty climbing stairs).
- CPK level are up, muscle biopsy, EMB ( work up)
- Unable to walk around 10 yrs of age.
- 15 age- wheelchair bound
- 20 age- cardiopulmorary arrest.
-

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