Review of Orthopedics – 2012/2013 – Brodno Szpital
Orthopedics – Brodno
TRAUMATOLOGY
1. Non-unions
Definition and Risk Factors/Prevention:
– It is a fracture that fails to unite in 4-6 months
– Nonunions happen when the bone lacks adequate stability
and/or blood flow. Factors that can increase the risk of
nonunion include: smoking, older age, severe anemia, diabetes,
anti-inflammatory drugs (e.g. aspirin, prednisone),
malreduction, and infection.
– Nonunions are more likely to happen if the injured bone has
a limited blood supply. They are also more likely if the bone
suffers severe trauma, even if it has an adequate blood supply.
– Often occurs when a fracture is ‘missed’ on x-ray and thus
the correct treatment is not administered (e.g. immobilization
in a cast).
– Nonunions with more blood supply and some degree of
micromotion will produce more callus and nonunions with no
or excess motion and poorer blood supply will produces less
callus.
Classification (Weber and Cech):
– Hypertrophic: viable bone ends: possess the biology but lack
the stability to unite:
1. Elephant’s foot: laying down exuberant callus
2. Horse foot
3. Oligotrophic: no callus
– Atrophic: nonviable ends, they lack the biology to heal.
Clinical Feature:
– Swelling, pain, tenderness, deformity, and difficulty bearing
weight.
– Patients with nonunions usually feel pain at the site of the
break long after the initial pain of the fracture disappears. This
pain may last months, or even years. It may be constant, or it
may occur only when the broken arm or leg is used.
Diagnosis:
– If union has not occurred by 6 months, then it is unlikely to
do so without intervention. Typically a diagnosis of non-union
requires an x-ray (or CT) at >6 months demonstrating non-
union of the fractured ends of the bone.
– One should evaluate joints above/below nonunion; degree
of shortening/deformity of affected limb must also be
determined.
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Treatment:
– Hypertrophic nonunions: Stimulation of osteogenesis by
external forces:
1. Mechanical forces: (external support) – also by surgical
means: placement of rod/compression plating. Usually used
for elephant’s foot
2. Electrical stimulation: stimulate dormant chondrocytes &
mesenchymal cells: Usually in combination w/ mechanical
3. Biological enhancement: autogenous cancelous bone graft
(mostly from iliac crest) = potent stimulator of fracture
healing.
– Atrophic nonunions: surgically ‘freshen up’ the avascular
bone ends and rigid internal fixation and autogenous bone
grafting.
– Complex A/H: Ilizarov method – in combination with
autogenous bone grafting: enables bony union, treatment of
any accompanying deformity, segmental bone loss, or
shortening.
Complications:
– If left untreated: a pseudoarthrosis (false joint) with an actual
synovial-lined capsule enveloping the bone ends (with fluid
left in the cleft) may form. Thus formation of a joint between
the two ends will need surgical intervention.
2. Mal-union
Definition:
– A malunion is a fractured bone that has healed in an
unacceptable position that causes significant impairment. This
can happen in almost any bone after fracture.
Mechanism and Cause:
– Is a fracture that is healed with an unacceptable amount of
angulation, rotation, or overriding that has resulted in
shortening of the limb.
– A Mal-union may be caused by inadequate immobilization of
the fracture, misalignment at the time of immobilization, or
premature removal of the cast or other immobilizer.
– In general, a shortening and angulatory deformities are
better tolerated in upper than in the lower limb. More than 2,5
cm is poorly tolerated in the lower extremity.
Diagnosis:
– History: History is of a fracture that may or may not have
been treated by a physician. The individual may report pain,
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Review of Orthopedics – 2012/2013 – Brodno Szpital
swelling (edema), instability, or deformity at the site of a
previously broken bone. If the fracture was in a lower
extremity, the individual may report difficulty bearing weight
through the limb.
– Physical exam: The exam reveals the deformity of a
malunion or the instability of a nonunion. Touching with the
hands (palpation) may reveal tenderness.
– Tests: Plain x-rays demonstrate the fracture malunion or
nonunion. CT scan, MRI, or bone scan may help further
define the condition.
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Diagnosis and Treatment:
– There is a localized pain and tenderness over the involved
bone.
– X-ray films may not show fracture for 2 weeks
– On x-ray it may look like Ewing/bone-forming sarcoma.
– Bone scan is positive in 12-15 days
– Treatment is rest from strenuous activities (stop physical
stress) to allow remodeling (for 4 weeks)
– Differential diagnosis: sarcomas, nonossifying fibroma,
fibrous cortical defect

Treatment:
– Smaller discrepancies: use a shoe lift
– Indication for surgery: when the deformity is sufficient to
cause pain/impairs fixation.

Surgical Procedure:
– Osteotomy: closing wedge (wedge of bone removed);
opening wedge (wedge of autogenous/allograft bone is added)
= alters limb length
– Limb-lengthening
– Proper fixation and usually autogenous cancellous bone
grafting to ensure that the osteotomy heals.

3. Stress fractures
4. Dislocations

Definition and Mechanism:

– These are fractures resulting from repetitive loading – each
load being below the endurance limit, but through
accumulated stress creates a level of force that causes a bone
to fail. These injuries are typical in the proximal tibia, the
second metatarsal, and the femoral neck.
– They are common in young (<30yrs) athletes.
– May be due to:
1. Insufficiency fracture: stress applied to a weak or
structurally deficient bone.
2. Fatigue fracture: repetitive, excessive force applied to
normal bone
– It is most common in adolescent athletes
– Tibia is most common site
– Usually occurs several weeks after a sudden increase of
physical activity for which the patient is not properly
conditioned.
Types:
– March fracture: common in soldiers/pilgrims; found in
metatarsal bones of the foot; x-ray may not show injury until
3-4wks after onset of pain; common in weight bearing bones
(i.e.: tibia); caused when the bones are under too much stress;
rest is best and only treatment.
– Metaphyseal-diaphyseal areas of long weight-bearing bones:
Early x-rays look normal before periosteal new bone begins to
form; most-sensitive DEXA scan (bone scan).
– Post-menopausal women: can occur with minimal physical
activity; i.e.: osteoporotic stress fractures in the sacrum
General about Dislocations:
– Complete loss of articular contact between two bones in a
joint
– There is a severe injury to ligaments and capsular tissues;
distal piece described in relation to the proximal joint/bone
Most require urgent reduction to prevent complications – with
general anesthesia/IV sedation
– On physical examination there is pain, loss of motion,
shortening of extremity, sometimes neuronal or vascular injury
– Nursemaid's elbow is a partial dislocation common in
toddlers. – The main symptom is refusal to use the arm.
Nursemaid's elbow can be easily treated in a doctor's office.
Shoulder Dislocation:
– Background: The shoulder is the most frequently dislocated
joint. It moves almost without restriction but pays the price of
stability. The shoulder's integrity is maintained by the
glenohumeral joint capsule, the cartilaginous glenoid labrum
(which extends the shallow glenoid fossa), and muscles of the
rotator cuff.
– Types:
1. Anterior dislocations occur in as many as 98% of cases.
Anterior displacement of the humeral head is the most
common dislocation seen by emergency physicians and is
depicted in the image below.
2. Posterior displacement is the next most frequently
occurring dislocation.
3. Inferior (luxatio erecta), superior, and intrathoracic
dislocations are rare and are usually associated with
complications.

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Review of Orthopedics – 2012/2013 – Brodno Szpital
– Etiology: peak incidence in men aged 20-30 years (with a
male-to-female ratio of 9:1) = sports-related; women aged 61-
80 years (with a female-to-male ratio of 3:1) = collagen fibers
have fewer cross-links, making the joint capsule and
supporting tendons and ligaments weaker and dislocation
more likely; fall-related; sports, assaults, falls, seizures,
throwing an object, reaching to catch an object, forceful
pulling on the arm, reaching for an object, turning over in bed,
or combing hair; tend to recur
– Clinical features: severe shoulder pain and limited ROM
– Diagnosis: imaging: Anteroposterior (AP) and axillary or
scapular "Y" views
1. Anterior dislocation: is characterized by subcoracoid
position of the humeral head in the AP view. The dislocation
is often more obvious in a scapular "Y" view, where the
humeral head lies anterior to the "Y." In an axillary view, the
"golf ball" (ie, humeral head) is said to have fallen anterior to
the "tee" (ie, glenoid).
2. Posterior dislocation: the AP view may show a normal
walking stick contour of the humeral head, or it may resemble
a light bulb or ice cream cone, depending upon the degree of
rotation. The scapular "Y" view reveals the humeral head
behind the glenoid (the center of the "Y"). In an axillary view,
the "golf ball" falls posteriorly off the "tee."
3. Inferior dislocation (luxatio erecta): the AP view may
show the arm raised over the head with the radial head inferior
to the glenoid
4. Arteriography, angiography, and Doppler flow studies
may be used to evaluate suspected vascular injury.
– Treatment: Kocher's original method: Bend the arm at the
elbow, press it against the body, rotate outwards until
resistance is felt. Lift the externally rotated upper part of the
arm in the sagittal plane as far as possible forwards and finally
turn inwards slowly.
1. Procedural sedation and analgesia (PSA) protocols, intra-
articular lidocaine, and ultrasound-guided brachial plexus
nerve block assist in making reduction an easier and more
comfortable procedure. Using US-guided interscalene block
reduces time spent in the ED and lessens one-on-one health
care provider time compared to procedural sedation.[8]
Immobilize the shoulder after reduction.
Perform careful prereduction and postreduction neurovascular
exam
Elbow Dislocation:
– Background: it is most common in children. 50% are sports
related. Posterior dislocation accounts for 90%.
– Types:
1. Posterior elbow dislocations: the patient often describes
falling on an outstretched hand (ie, the FOOSH injury) as the
mechanism of injury. Some clinicians speculate that the elbow
is more likely to dislocate when it is slightly abducted and
flexed. When compressive forces are directed on to the
outstretched hand, the radius and ulna, along with the valgus
force at the elbow, suffer the common posterolateral
dislocation. These forces also contribute to associated
fractures. In addition, hyperextension at the elbow has been
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seen with elbow dislocations.
2. Anterior dislocation: is usually the result of a direct
posterior blow to a flexed elbow. Associated fractures of the
olecranon are commonly seen.
3. Divergent dislocations: very rare injury which is
associated with significant high-energy trauma to the elbow.
In children, radial head subluxations often occur when the arm
is pulled. The child commonly holds the arm pronated, mildly
flexed, and abducted against the body and refuses or fights any
manipulation of the affected arm.
– Diagnosis:
1. History: early diagnosis is important to prevent loss of
function or neurovascular compromise. Essential elements of
the dislocation history include the mechanism of the injury,
the time between the injury and presentation, functioning,
previous attempts at reduction/manipulation, swelling,
location, and the type of pain.; neurovascular compromise
must be assessed.
2. Imaging: AP & lateral X-rays
– Treatment: closed reduction: prone position with the
affected elbow flexed at 90° and the humerus supported by
the table (see the image below). The hand of the affected arm
should be pointing toward the ground. Apply downward
traction to the forearm, which is held in slight pronation, while
using the other hand to grasp the humerus, and apply pressure
to the olecranon in a downward motion to facilitate reduction
Physical therapy; surgery if chronic residual instability
Complications: brachial/radial a compromise & median n;
compartment syndrome
Hip Dislocation:
– Symptoms: inability to bear full weight and there is an
excessive mobility of the limb with crepitus.
– Types:
1. Anterior:
A. Etiology: force to the posterior part of the knee when
hip is abducted
B. Diagnosis: shortened, ABducted, external rotated limb
C. Treatment: closed reduction & post-reduction CT
2. Posterior:
A. Etiology: severe force to the knee when hip is flexed &
Adducted
B. XX: knee into dashboard in MVA
C. Diagnosis: shortened, ADDucted & internally rotated
limb
D. Treatment: closed reduction & post reduction CT,
ORIF if unstable
2. Central (rare): traumatic injury where femoral head is
pushed into pelvic cavity
– Complications: avascular necrosis, post-traumatic arthritis,
fracture of femoral head/shaft; sciatic neural palsy (25%),
thromboembolism, heterotrophic ossification
Patellar Dislocation:
– Definition: Lateral displacement of patella after contraction
of quadriceps against flexed knee
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Review of Orthopedics – 2012/2013 – Brodno Szpital
– Physical Examination: knee catches/gives way w/walking;
severe pain, tenderness anterior medial from rupture of
capsule, weak knee extension/inability to extend leg unless
patella reduced; positive patellar apprehension test (patient is
apprehensive when examiner laterally displaces patella); often
recurrent, self-reducing
– Imaging: X-rays: X-Rays (A/P, Lateral, skyline –
patellofemoral joint; check for fracture of medial patella &
lateral femoral condyle)
– Treatment:
1. Non-operative: done first; knee immobilization 4-6wks,
progressive weight bearing & isometric quadriceps
strengthening
2. Surgery: tightening of medial capsule & release of lateral
retinaculum, possible tibial tuberosity transfer, proximal tibial
osteotomy
5. Sprain/Strain
Sprain:
– Definition: a partial/full tearing of a ligament away from its
bone attachment
– Types/subtypes:
1. First degree: little/no swelling; minimal pain
2. Second degree: localized swelling without tenderness,
moderate-severe pain, abnormal motion and deformity, unable
to bear weight
3. Third degree: total disruption of ligament; loud ‘snap’ or
‘pop’, sever pain, abnormal motion, deformity, unable to bear
weight
Strain:
– Definition: a ‘pull’ in a tendon, ligament/m caused by
excessive stretch/force; twist/tear of tendons; over-
stretching/pulling the muscle or tendon
– Symptoms: Pain (may radiate), spasms, loss of fixation,
severe weakness, disfigurement
– Treatment: RICES: Rest Ice Compression Elevation Support
Cervical Sprain:
– A strain refers to an injury to a muscle, occurring when a
muscle-tendon unit is stretched or overloaded. Cervical
muscles that are commonly strained include the
sternocleidomastoid (SCM), the trapezius, the rhomboids, the
erector spinae, the scalene, and the levator scapulae.
– Etiology: 1ary MVA: predominantly = whiplash; 2ary =
sports-related (e.g. American football (e.g. linemen); wrestlers,
etc).
– Diagnosis:
1. History: Mechanism of injury; how, when, and where the
injury took place, with particular attention regarding the
position of the head and neck at the time of the injury;
Location of the pain; Aggravating and relieving factors (eg,
sneezing, coughing, traction); Presence, location, and duration
of any neurologic symptoms;
2. Physical Examination: full neurological exam, cervical ROM
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3. Imaging: A cervical spine series usually includes
anteroposterior (AP), lateral, oblique, and odontoid views.[10]
All 7 vertebrae must be visualized, and the disc spaces should
be approximately equal throughout the cervical spine.
CT scanning is performed in patients who have abnormal
plain radiographs or in whom there is a strong clinical
suspicion of a fracture with inconclusive radiographs
MRI is usually indicated in athletes with neurologic deficits
and when plain radiographic films and CT scans do not
provide enough information for definitive management.
– Classification: Quebec taskforce of whiplash association
disorders:
0 – no neck pain, no physical signs
1 – neck pain, stiffness/tenderness, no other physical
symptoms
2 – neck complaints & musculoskeletal signs (<ROM and
patient tenderness)
3 – neck complaints & neurologic signs (weakness, sensory
& reflex changes)
4 – neck complaints w/fracture +/or dislocation
– Treatment: NSAIDs, m. relaxants, soft cervical collar (2-
3wks) physical therapy, electrical stim, chiropractic care; if not
improving = rigger point injections, typically along the medial
border of the scapula, may help decrease trigger zones and
referred pain and help improve muscular flexibility
Ankle Sprain (twisted ankle):
– Definition: 1 or more ligaments are torn. The anterior
talofibular ligament is most commonly involved. 85% of ankle
sprains involve the lateral aspect.
– Etiology: happens when foot is rolled/turned beyond
normal motion – sports or walking on uneven surface; Lack of
conditioning/warming up/stretching, previous history,
inadequate shoes
– Symptoms: redness, inflammation, swelling, n become more
sensitive (throbbing pain), warmth
– Classifications:
Grade 1 – slight stretching w/minimal damage to ligament
Grade 2 – tearing & ankle jt moves in abnormal ways
Grade 3 – severe injuries; complete tears
– Treatment: RICE, ankle brace
6. Fracture
Definition and Mechanism:
– Structural break in bone continuity.
– A fracture may be due to trauma, pathology (tumor,
osteopenia, infection), stress (reparative mechanical loading).
Complications of Treatment:
– Infection, painful implants (i.e.: internal fixators), non-
healing fractures (nonunion/malunion), decreased
ROM/function as before fracture.
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Clinical Feature:
– Pain, tenderness, loss of fixation, deformity, muscle
guarding, swelling and bruising, abnormal motility and
crepitus, altered neuronal or vascular status.
Evaluation:
– Vascular function (pulse, capillary refill) and neurologic
function (sensation and motor function)
Characteristics:
– Classifications: fractures may be open/closed,
transverse/oblique/spiral/butterfly/green-stick, simple (two
parts)/comminuted (>2 parts), proximal/middle/distal,
extra/intra-articular,
angulation/displacement/rotation/shortening/apposition
– Integrity of skin/soft tissue:
1. Closed fracture: skin/soft tissue over and near fracture is
intact.
2. Open fracture: skin/soft tissue over and near fracture is
lacerated/abraded. There might be continuous bleeding from
the puncture site. Fat droplets in the blood may suggest
communication with the fracture.
– Location:
1. Epiphyseal (end of bone), metaphyseal (flared portion of
bone at the ends of the shaft), diaphyseal (shaft of long bone),
and physis (growth plate)
– Orientation:
1. Transverse, oblique, butterfly, segmental, spiral,
comminuted/multi-fragmenary, intra-articular (fracture line
crosses articular cartilage & enters joint),
compression/impacted (i.e.: vertebrae, proximal tibia)
2. Greenstick: incomplete fracture of one cortex (often in
children)
3. Pathologic: fracture through bone is weakened by a
disease or tumor.
Diagnosis – Plain X-Rays:
– Rule of 2’s:
1. Two sides: bilateral
2. Two views: AP and lateral
3. Two joints: above and below the site of injury
4. Two times: before and after reduction.
– Site: which bone, if extra-articular (diaphysis/metaphysis),
if diaphyseal decribe by thirds (proximal/middle/distal), or if it
is intra-articular.
Management:
– Limb: attend to neurovascular status (above and below) and
rule out other fractures/injuries (especially joint above and
below).
– Rule out open fracture
– AMPLE history: Allergies, Medications, Past medical
history, Last meal, Events surrounding injury
– Analgesia
– Splint fracture: makes patient more comfortable, decreases
progression of soft tissue injury, decreases blood loss
– Imaging
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7. Pathologic fracture (PF)
Definition and Etiology:
– A PF is a broken bone caused by disease, most commonly
osteoporosis but also cancer, osteomalacia, Paget’s disease (i.e.
tumors, infections, and other disorders)
– PFs are due to an underlying disease process that weakens
the bone to the point of fracture (with normal daily activities)
– Fragility fracture: results from a fall from standing
height/less: this may be vertebral fractures, neck of femur, and
Colles fracture of the wrist
Treatment:
– The treatment include: treatment of both the fracture itself
and the underlying process that weakened the bone, e.g.
infection.
Pathologic Hip Fracture:
– Related to hyperparathyroidism (fracture of femoral neck in
elderly); metastatic disease (Tx: cemented solid stem or total
hip arthroplasty); Pagets Disease (disorder of problem with
bone remodeling = enlarged & misshapen bones; The
excessive breakdown and formation of bone tissue causes
affected bone to weaken, resulting in pain, misshapen bones,
fractures, and arthritis in the joints near the affected bones;
– Treatment: non-displaced fractures may be treated with
internal fixation); neurologic disease; Parkinson’s disease –
femoral neck fracture (related to 6 month mortality of 60%);
spastic hemiplegia (stroke) – fraction tends to occur on
hemiplegic side w/ varying degrees of flexion & adduction
contracture associated w/hypertonicity of muscles)
8. External fixation
Definition:
– External fixation is a surgical treatment used to set bone
fractures in which a cast would not allow proper alignment of
fracture; immobilization for a fracture to heal.
Definition:
– Holes are drilled into uninjured areas of bones around the
fracture and special bolts/wires are screwed into the holes
– Outside the body a rod or curved piece of metal with special
ball - and - socket joints joins the bolts to make a rigid support
(clamps & rods form the external frame)
– The fracture can be set in the proper anatomical
configuration by adjusting the ball & socket joints
– External fixator is used in OR under general anesthesia;
remove = special wrenches with no anesthesia!
– Used ONLY when internal fixation is contraindicated for
open-fractures, limb lengthening
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9. ORIF (Open Reduction Internal Fixation)
Indications:
– NO CAST: Non-union; Open Fracture, neurovascular
Compromise, intro-Articular fracture, Salter-Hariis 3,4,5,
multiple trauma
– Serious fractures such as comminuted/displaced fractures or
in cases where the bone would not heal correctly in
cast/splinting alone
Definition:
– Implementation of implants and open reduction (setting) of
the bone:
1. Open reduction: open surgery to set bones
2. Internal fixation = uses of screws, plates, intramedullary
bone nails) to enable/facilitate healing
A. Rigid fixation prevents micro-motion across lines of
fracture to enable healing & prevent infection which happens
when implants (like plates) are used
Internal Fixation:
– Internal fixation: involves the surgical implementation of
implants for repairing a bone (internal fixator = stainless
steel/titanium; consist of bone screws, metal plats, pins, rods,
Kirschner wires, intramedullary devices like Kuntscher &
interlocking nails).
Open Fracture: Gustillo Classification
I Open fracture, clean wound, wound <1 cm in length
Open fracture, wound > 1 cm in length without extensive soft-tissue
II
damage, flaps, avulsions
Open fracture with extensive soft-tissue laceration, damage, or loss
or an open segmental
fracture. This type also includes open fractures caused by farm
III
injuries, fractures requiring
vascular repair, or fractures that have been open for 8 h prior to
treatment
Type III fracture with adequate periosteal coverage of the fracture
bone despite the extensive
IIIA
soft-tissue laceration or damage
Type III fracture with extensive soft-tissue loss and periosteal
IIIB
stripping and bone damage.
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Usually associated with massive contamination. Will often need
further soft-tissue coverage
procedure (i.e. free or ratational flap)
Type III fracture associated with an arterial injury requiring repair,
irrespective of degree of
IIIC
soft-tissue injury.
Complications:
– Bacterial colonization of bone, infection, stiffness and loss
of range of motion, non-union, mal-union, damage to muscles,
neuronal damage & palsy, arthritis, tendonitis, chronic pain
associated with plates, screws, pins, compartment syndrome,
deformity, audible popping and snapping
10. CRIF (Closed Reduction Internal Fixation)
Definition and Indication:
– CRIF is a reduction (setting of bone) without any open
surgery followed by internal fixation.
– It is an acceptable alternative in unstable displaced lateral
condylar fractures of humerus in children, but if fracture
displacement after closed reduction >2mm, ORIF is
recommended.
11. Scaphoid fractures
Epidemiology and Etiology:
– A transverse fracture that is common in young men, not
common in children or patients beyond middle age.
– Most commonly occur in patients who fall on an
outstretched or extended hand (FOOSH) where the wrist is
bent backwards, resulting in a transverse fracture through the
waist (middle) of the Scaphoid. The fracture is usually
undisplaced.
Clinical Features:
– Pain on wrist movement
– Tenderness in scaphoid region: Anatomical “snuff box”
– Some patients have obvious fractures on day one and in
some cases the fractures can be significantly displaced.
Diagnosis:
– X-ray may not show anything until 2 weeks after pain started
– A patient presenting with wrist pain, a negative X-ray and
tenderness over the thumb side of the wrist should be
considered to have a scaphoid fracture until proven otherwise.
– Secondary X-rays 2 weeks later, or MRI on occasions can
confirm diagnosis.
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Treatment:
– Non-displaced: long-arm thumb spica cast for 4-6 weeks
followed by short arm cast until radiographic evidence of
healing is seen (2-3 months).
– Displaced: Open (percutaneous) screw fixation.
– Most of the non-displaced fractures will heal with
appropriate casting. The problem is that they are very slow to
heal, making patients feel the casts are intolerable. “I have to
be able to work!”
Complications:
– Avascular necrosis, delayed union, non-union, osteoarthritis
12. Thumb fractures (incl. I metacarpal)
Definition:
– Fracture involves the distal/proximal phalange, 1st
metacarpal bone: 2 types
1. Transverse or short oblique fracture across the base of the
metacarpal
2. “Bennett’s fracture-subluxation”: Oblique fracture
entering the CMC joint at about the middle of the articulate
surface. This type is intra-articular.
Symptoms:
– Pain, swelling, decreased ROM, extreme tenderness,
deformity, numbness/coldness
Treatment:
– Reduction of displacement under anesthesia. It can be
difficult to maintain reduction in the case of Bennet fracture.
Use a plaster including forearm and wrist, keeping thump
extended at CMC joint. Check with x-ray if there is a good
position.
– Screws or a percutaneous Kirschenner wire (obliquely
through base of metacarpal into trapezium) can be used to
fixate the thumb, later a plaster should be used for 4-6 weeks.
13. Boxer’s fracture
Definition:
– 2nd/3rd metacarpal transverse neck fracture that is more
likely to occur from a straight punch (absorb most of force);
‘Bar room fracture’: metacarpal neck (knuckles) fracture
particularly involving the 4th/5th due to fighting.
– Can be prevented with hand wraps and boxing gloves.
Treatment:
– Surgical with Kirschenner wire (<12w) if > 40 degrees tilt,
otherwise reduction of the displacement which is easy to do
but hard to maintain. Often the function remains but may
leave a cosmetic deformity.
– Initial: Jahss maneuver: MCP & PIP jts are flexed to 90*;
usually full rehabilitation takes 3-4 months in minor fractures.
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14. Fractures of the distal radius (ex. Colles fr)
Definition:
– Fractures of the distal radius account for approximately 14%
of all fractures.
– Bimodal distribution: In young (18-25) it is mainly due to
trauma and in older (>65) it is due to falls.
– The fractures are due to: FOOSH, sports injury, etc.;
Classification:
– The AO classification emphasizes the location as extra-
articular, partial articular, and completely articular.
Subtypes:
– Colles fracture: involves the distal metaphysis of the radius.
He described the resulting volar angulation, dorsal
displacement, loss of radial inclination and resultant radial
shortening as a "silver fork deformity."
– Smith's fracture, or reverse Colles' fracture, is a dorsally
angulated fracture of the distal radius, with the hand and wrist
displaced volarly with respect to the forearm. The fracture may
be extraarticular, intraarticular, or a part of a fracture-
dislocation involving the wrist. It is reduced by closed
manipulation, underarm plaster with hand in dorsiflexion and
complete supination for 6 weeks, checking for displacement
with x-ray meanwhile.
– Barton's fracture is a fracture-dislocation with an
intraarticular fracture in which the carpus and a rim of the
distal radius are displaced together. Reduction isoften
imperfect and is therefore operated with attachment of a plate
with screws.
– The Chauffeur's fracture is a radial styloid fracture,
described initially in car drivers operating automobiles, which
required hand cranking to start. When the engine engaged, the
crank would "kick back," and the Chauffeur's fracture would
result.
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Review of Orthopedics – 2012/2013 – Brodno Szpital
Diagnosis and Treatment:
– X-ray is the main diagnostic tool.
– Nonsurgical treatment: (many can be treated this way):
casting if bone in good position (non-displaced) for 6w; long
casts only needed if ulna is unstable
– Surgical treatment: if radius is displaced, irreducible, or
reducible but unstable
– Indications for surgery:
1) intra-articular displacement of 1mm or more
2) dorsal tilt: no more than 0-10*
3) Radial length shortening of more than 2mm
15. Colles fracture
Definition and Epidemiology:
– It is the most common fracture in those >40 years, especially
in women and those with osteoporotic bone.
– It is a transverse distal radius fracture (about 2,5 cm
proximal to the radiocarpal joint) with dorsal displacement
with or without ulnar styloid fracture (60%).
Mechanism:
– The fractures are due to: FOOSH.
– In elderly: extra-articular; in younger = intra-articular
because of higher force needed to break the bone.
– The risk increases with osteoporosis.
Clinical Feature:
– There is acute pain, tenderness, bruising (eccymosis), carpal
tunnel syndrome, and swelling.
– Frequently, the wrist hangs in an odd or bent way
(deformity): “dinner fork” deformity
– Median nerve may be compressed: check via OK sign with
fingers.
Diagnosis and Treatment:
– X-ray is the main diagnostic tool.
– Non-displaced fracture: cast
– Volar forearm splint: temporary immobilization of forearm,
wrist and hand fractures
– Mild angulation and displacement: closed reduction
– Significant angulation and deformity: open reduction &
internal/external fixation
Complications:
– Mal-union, compression of the median nerve
16. Injury of the distal radio-ulnar joint (DRUJ)
Definition and Risk Factors:
– DRUJ injury may be the result of ligamentous disruption or
fracture, which compromises joint stability.
– DRUJ injuries can occur in isolation or in association with
distal radius fractures, Galeazzi fractures, Essex-Lopresti
injuries, and both-bone forearm fractures.
– Risk factors: activities, sports, osteoarthirits, RA
Edited By: Marsel Toplić
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Diagnosis and Treatment:
– Diagnosis: Patients history, physical examination, a
radiograph and possible CT scan can further identify the
extent of the damage and area of instability. Axial CT scans are
pathognomonic. Diagnostic arthroscopy may also be used.
– Treatment: If a DRUJ injury occurred as the result of a
fracture, the associated fracture is first addressed. Depending
on the level of joint instability, additional fixation of the joint
may also be required.
17. Nightstick fracture
Definition, Symptoms, and Treatment:
– Isolated fracture of Ulna often caused by a direct blow to the
arm (holding up arm to protect face)
– Symptoms: pain, deformity and swelling of forearm.
– Treatment:
1. Nondisplaced: below-elbow cast (distal 2/3 of forearm)
for 10 days and the forearm brace (8 weeks)
2. Displaced: ORIF if> 50% shaft displacement or >10
degrees angulation
18. Monteggia fracture
Definition and Mechanism:
– Fracture of the proximal 1/3 of Ulna with anterior
dislocation of radial by:
1. Direct blow to posterior arm
2. Hyperpronation
3. Fall on the hyperextended elbow
– Types: there are 4 types of Monteggia fractures. First type is
the most common: extension (60%): anterior dislocation of
radial head and fracture of ulnar diaphysis with anterior
angulation
Clinical Features:
– Decreased rotation of forearm and palpation lump at radial
head
– Ulna angled apex anteriorly and radial head displaced
anteriorly.
Diagnosis:
– AP, lateral, and oblique X-rays of elbow
– Also rule out: annular ligament tear, nerve injury (radial
nerve)
Treatment:
Treatment = ORIF of Ulna with indirect radius reduction in
90%. If elbow is completely stable use a splint and early post-
op ROM, otherwise immobilization in plaster w. elbow flexed
(6 weeks).
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Review of Orthopedics – 2012/2013 – Brodno Szpital
19. Fractures of distal humerus
Epidemiology and Definition:
– Most common in children (~7 years), unusual in adults
– Usually due to high-energy injury; these fractures can lead to
significant functional impairment.
– Distal humerus fractures most commonly involve both the
medial and lateral columns.
– Classified by AO
Clinical Feature:
– Anterior Interosseous nerve injury is common
– POTENTIALLY DANGEROUS: damage to Brachial
Artery
96% = extension injury via FOOSH (= Fall On an Out
Stretched hand), the lower fragment of humerus is often
displaced backwards and tilted backwards.
Diagnosis:
– AP and lateral x-rays; CT is further info needed
– Duplex Doppler studies or angiography should be
performed if there is a suspicion of brachial artery injury.
Treatment:
– Non-operative: if non-diplaced with cast in 90 degrees
flexion for 3 weeks
– Operative: if displaced, vascular injury or open fracture.
Percutaneous pinning followed by limb cast w elbow flexed>
90 degrees. ORIF in adults.
– Elderly patients with poor bone quality: total elbow
arthroplasty (TEA).
Complications:
– Arterial occlusion: Nerves may get ischemic: Volkmann’s
Ischemic contracture (= muscles become fibrous tissue when
ischemic o contracts, causing hand and wrist into flexion)
– Median nerve damage
– Deformity from mal-union
20. Fractures of humeral condyles
Definition:
– Uncommon, serious, mainly children, from a fall mostly.
= Intra-articular, Lateral condylar fracture which extends
obliquely upwards and laterally from the capitular surface.
adolescence; lateral more common
Treatment:
1. Simple crack fracture: plaster for a few weeks + mobilizing
exercises
2. Displaced fracture: A) Reduce displacement under
anesthesia + plaster in 90 degrees
B) If reduction fails: Surgery, Condyle attached w. small screw
Edited By: Marsel Toplić
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Complications:
Complications = Non-unions (can lead to deformity of elbow
and osteoarthritis)
Deformity ( by persistent upward displacement of fractured
condyle or by damage to growing epiphyseal
cartilage)
Frictional neuritis of the Ulnar nerve (If cubitus valgus
=deformity of lateral condyle)
Osteoarthritis
Epidemiology, Diagnosis, and Complications:
– Affects adolescence; lateral condyle more than medial
– Diagnosis: assess radial (finger extension), median (finger
flexion) and ulnar (finger abduction) nerves.
– Complications: nonunion, mal-union, valgus angulation,
avascular necrosis
Lateral Condyle:
– Etiology: peak in 6 yr olds
– Type: Saltar-Harris IV
– Symptoms: FOOSH, pain, swelling, crepitus
– Treatment: if displaced: Surgical (ORIF) reduction should be
performed within 48hrs; open reduction for type II and type
III fractures, Type I is, 2mm of displacement
Medial Condyle:
– There is a fracture line through medial metaphysis and
epicondyle; fracture line involves the trochlear surface; Saltar
Harris IV which crosses the physeal plate; <15mm
displacement may be treated nonoperatively
Specifics: FOOSH, elbow forced into valgus, fall on apex on
flexed elbow, olecranon creating the fracture. Avulsions by
flexor and pronator muscles (arm wrestling)
Tx: Saltar Harris IV with ORIF
21. Olecranon fracture
Mechanism and Epidemiology:
– By direct trauma to posterior part of elbow (fall onto the
point of the elbow fall on point of elbow with avulsion by
triceps or fall on outstretched arm).
– It is fractured rather frequently in adults (rarely in children:
because olecranon is short, thick and strong; instead there are
supracondylar fractures of the humerus).
– There may be a loss of active extension due to triceps
tendon avulsion.
Types – Mayo Classification:
– Type I: Undisplaced – stable to flexion & extension, early
mobilization
– Type II: Displaced fragments but collateral ligaments are
intact
– Type III: Displaced, unstable forearm in relation to
humerus’ fracture-dislocation
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Review of Orthopedics – 2012/2013 – Brodno Szpital
Diagnosis and Treatment:
– Diagnosis: AP and lateral X-ray.
– Treatment:
1. Undisplaced: above elbow cast immobilization at 40
degrees of flexion for 2 weeks, early ROM; full flexion after 6
weeks
2. Displaced (more than 2 mm of articular displacement):
ORIF (plate, band wire), above elbow slab x 1 week, early
ROM
22. Radial head fracture (proximal radius)
Mechanism and Epidemiology:
– Due to: FOOSH with elbow extended and forearm
pronated.
– It is a common fracture of the upper limb in young adults
Clinical Features:
– There is progressive pain due to hemarthrosis with loss of
ROM and pain on lateral side of elbow aggravated by forearm
pronation or supination.
Diagnosis:
– X-ray: may not be seen: anterior or posterior fat pad sign
”sail sign”.
– Mason classification:
1. Undisplaced fracture: usually normal ROM
2. Displaced segmental fracture: ROM is compromised
3. Comminuted (more than 2 fragments) fracture
4. Comminuted with posterior elbow dislocation
Treatment:
– ORIF is performed if angulation is >30°, 3-mm
displacement, or depression greater than one third of the
articular surface
– Early excision can be performed for severely comminuted
fractures
– Type 1: elbow slab, sling 3-5 days, early ROM
– Type 2: ORIF radial head
– Type 3/4: excision of radial head +/– prosthesis
Complications:
– Joint stiffness; recurrent instability if medial collateral
ligament is injured and radial head excised; Myositis ossificans
23. Elbow dislocation
Epidemiology and Mechanism:
– Usually affects young people in sporting events or high
speed Motor vehicular accidents (MVA).
– > 90% are posterior or posterior-lateral
– It is the third most common joint dislocation after shoulder
and patella
– Mechanism: FOOSH: rule out concurrent radial head or
coracoid process fractures
Edited By: Marsel Toplić
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Types:
– Posterior elbow dislocations: patients FOOSH (probably
slightly abducted and flexed).
– Anterior elbow dislocations: result of a direct posterior blow
to a flexed elbow. Associated fractures of the olecranon are
commonly seen.
– Divergent dislocations: are very rare injuries and are
associated with significant high-energy trauma to the elbow.
Clinical Features and Diagnosis:
– There is an elbow pain, swelling, and deformity
– Might also be a flexion contracture
– There might be an absence of radial or ulnar pulses
– AP and lateral radiographs
Treatment:
– Closed reduction under anesthesia (post-reduction x-rays
required)
– Long-arm splint with forearm in neutral rotation and elbow
in 90º flexion
– Early ROM (<2 weeks)
Complications:
– Stiff elbow (loss of extension)
– Neurovascular injury to ulnar or median nerve, brachial
artery
– Entrapment of bone fragments within the joint space
– Compartment syndrome
24. Fractures of the proximal humerus
Epidemiology and Mechanism:
– Young: High energy trauma: MVA
– Older (primary): FOOSH from standing height in
osteoporotic individuals; major cause of morbidity in the
elderly population.
– Accounts for 4-5% of all fractures and F:M:3:1
Symptoms:
– Pain, swelling and tenderness around the shoulder (especially
around greater tuberosity)
– Fracture involves: proximal humeral diaphysis (surgical
neck); +/– greater tuberosity; +/– lesser tuberosity
– Classified into 2, 3, and 4 part fractures
Classification:
– The Neer classification system is based on displacement
criteria of 1 cm or fragment angulation of 45°. The type of
fracture then is divided into segments. Four segments are
possible: articular segment, the lesser tuberosity, the greater
tuberosity, and the surgical neck.
Diagnosis:
– Test axillary nerve function
– X-rays: AP, trans-scapular and axillary
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Review of Orthopedics – 2012/2013 – Brodno Szpital
– CT scan (this is a fracture where you could argue that you
should be generous with CT scan)
Treatment:
– Non-operative:
1. Sling immobilization (nondisplaced): begin ROM in 7-10
days to prevent stiffness
2. Closed reduction (minimally displaced)
– Operative:
1. ORIF (anatomic neck fractures, displaced, dislocated)
2. Hemiarthroplasty: three-part (elderly, poor bone stock)
and four-part (except: older debilitated patient and severe
diabetic).
Complications:
– AVN, axillary nerve palsy, malunion, post-traumatic arthritis
25. Humeral shaft fracture
Mechanisms and Clinical Feature:
– Direct blows and high energy trauma is most common,
FOOSH, twisting injuries and metastases (in the elderly).
– Different Types of shaft fractures:
1. Bending force produces transverse fracture of the shaft
2. Torsion force will result in a spiral fracture
3. Combination of bending and torsion produce oblique
fracture (Holstein-Lewis: oblique distal third) with or without
a butterfly fragment
4. Compression forces will fracture either proximal or distal
ends (distal third) of humerus
– There is arm pain, deformity, and swelling. The arm is
shortened, with motion and crepitus on manipulation.
Diagnosis:
– Rule out radial nerve function (before and after treatment)
– X-rays: AP and lateral including shoulder and elbow joints
(Doppler and Compartment pressures)
Treatment:
– Non-operative (most common): deformity can be accepted
due to compensatory range of motion of shoulder hanging
cast (weight of arm in cast provides traction across fracture
site) with sling immobilization x 7-10 days, then Sarmiento
functional brace
– Operative:
1. Indications: open fracture, neurovascular injury,
unacceptable fracture alignment, polytrauma, segmental
fracture, pathological fracture, “floating elbow” (simultaneous
unstable humeral and forearm fractures), intra-articular
2. Procedure: compression plating (most common),
intramedullary rod (nail) insertion, external fixation
Procedure: Compression plating, intramedullary rod or
external fixation.
Edited By: Marsel Toplić
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Complications:
– Radial nerve injury (up to 18%): expect spontaneous
recovery in 3-4 months, otherwise send for EMG: Holstein-
Lewis fracture is more associated with radial nerve palsy than
other types of humeral shaft fractures.
– Non-union/mal-union
– Compartment syndrome
26. Shoulder dislocation
Background and Types:
– The gleno-humeral joint is the most commonly dislocated
joint in the body (since stability is sacrificed for motion).
– Types:
1. Anterior dislocations: >90% of cases.
2. Posterior dislocation (up to 5%):
3. Inferior (luxatio erecta), superior, and intrathoracic
dislocations are rare and are usually associated with
complications.
Anterior Dislocation:
– Mechanism: abducted and externally rotated arm or blow to
posterior shoulder
– Clinical feature: pain
– Diagnosis:
1. X-rays: AP, trans-scapular, axillary: dislocation (Mercedes-
Benz sign), Hill-Sachs lesion, bony Bankart lesion
2. Neurovascular exam including: axillary nerve (sensory
patch over deltoid and deltoid contraction); musculocutaneous
nerve (sensory patch on lateral forearm and biceps
contraction).
– General Treatment: closed reduction with IV sedation and
muscle relaxation; 2 methods:
1. Traction-Countertraction:
2. Stimson: Patient lies prone with arm over table edge with
a weight for 15-20 min.
– Other Treatment:
1. Check post reduction X-rays and neurovascular status.
2. Sling for 3 weeks followed by shoulder rehabilitation
3. Surgery reserved for patients with recurrent instability
– Clinical Signs used:
1. Positive apprehension test: apprehension with shoulder
abduction and external rotation to 90 degrees since humeral
head is pushed anteriorly and recreates feeling of anterior
dislocation
2. Positive relocation test: a posteriorly directed force applied
during the apprehension test relieves apprehension since
anterior subluxation is prevented.
3. Sulcus sign: presence of subacromial indentation with
distal traction on humerus indicates inferior shoulder
instability.
Posterior Dislocation:
– Mechanism: adducted, internally rotated, flexed arm;
FOOSH; 3 E’s (epileptic seizure, EtOH, electrocution); or
blow to anterior shoulder
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– Diagnosis: – 2 main ligaments attach clavicle to scapula: acromioclavicular
1. X-rays: AP, trans-scapular, axillary: dislocation (Mercedes- (AC) and coracoclavicular (CC) ligaments.
Benz sign), reverse Hill-Sachs lesion, reverse bony Bankart
lesion Diagnosis and Treatment:
2. Up to 60-80% are missed on initial presentation due to – X-rays: AP, Zanca view, axillary
poor physical exam and radiographs – Treatment:
– Clinical feature: 1. Non-operative (most-common): sling 1-3 weeks, ice,
1. Arm is held in adduction and internal rotation; external analgesia
rotation is blocked 2. Operative:
2. Anterior shoulder is flattening; there is a prominent A. Indications: AC and CC ligaments are both torn and/or
coracoid and a palpable mass posterior to shoulder. clavicle displaced posteriorly
3. Posterior apprehension (“jerk”) test: with patient supine, B. Procedure: excision of lateral clavicle with AC/CC
flex elbow 90º and adduct, internally rotate the arm while ligament reconstruction
applying a posterior force to the shoulder; patient will “jerk”
back with the sensation of subluxation. 29. Metatarsal fractures
– Treatment:
1. Closed reduction: inferior traction on a flexed elbow with
pressure on the back of the humeral head
Definition and Mechanism:
– Classified into acute fractures or stress fractures.
2. Obtain post-reduction x-rays
– Seen in: dancers, runners, military, etc;
3. Check post-reduction neurovascular status
– More stress is placed on the second and third metatarsals
4. Sling x 3 weeks, followed by shoulder rehabilitation
during ambulation; thus, these bones are at increased risk for
stress fractures.
27. Clavicle fractures
Symptoms, Diagnosis, and Treatment:
Epidemiology and Mechanism: – Symptoms: pain with exercise: pain with rest; tenderness,
– It is common in children (unites rapidly without redness, swelling
complications) – Diagnosis: test for RA (ESR and rheumatoid panel); x-ray
– Mechanism: it may be due to fall on shoulder (87%), direct may be negative at first, bone scanning (very sensitive), MRI
trauma to clavicle (7%), or FOOSH (6%). Clavicle fracture is – Treatment: ice, stop exercise, orthotics, rare to need surgery;
associated with rib fractures, scapula fractures, other fractures rehabilitation & physical therapy
about the shoulder, pulmonary contusion etc.
Fracture Mechanism Clinical Treatment
Classification – Allman with Neer Modification: Type
– Group I fractures: are middle third injuries (80%) Avulsion of Sudden Tender base Requires ORIF
base of 5th inversion of 5th MT if displaced
– Group II fractures: are lateral (distal) third injuries (15%)
MT followed by
– Group III fractures: are medial (medial) third injuries (5%) contraction of
peroneus brevis
Treatment: Midshaft 5th Stress injury Painful shaft Non weight
MT of 5th MT bearing, below
– Proximal and middle third clavicular fractures: sling for 1-2 (Jones knee cast (NWB
weeks; early ROM and strengthening once pain subsides; if fracture) BK) for 6w
ends overlap >2 cm, consider ORIF ORIF if athlete
– Distal third clavicular fractures: undisplaced (with ligaments Shaft 2nd, Stress injury Painful shaft Symptomatic
3rd MT of 2nd or 3rd
intact): sling for 1-2 weeks; displaced (Coracoclavicular (March MT
ligament injury): ORIF fracture)
1st MT Trauma Painful 1st ORIF if
MT displaced
28. Injuries of the acromio-clavicular joint otherwise
NWB BK cast x
3 wks then
Mechanism and Clinical Feature: walking cast x 2
– May be due to fall onto shoulder with adducted arm (fall wks
onto tip of shoulder): after bicycle wrecks, contact sports, and Tarso-MT Fall onto Shortened ORIF
car accidents. fracture – plantar flexed forefoot (Lisfranc
dislocation foot or prominent fracture)
– There is a palpate step deformity between distal clavicle and direct crush base
acromion (with dislocation) injury
– There is pain with adduction of shoulder and/or palpation
over AC joint; there is also limited ROM

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Review of Orthopedics – 2012/2013 – Brodno Szpital
30. Lisfranc injuries
Anatomy and Incidence:
– Lisfranc joint: is the point at which the metatarsal bones &
tarsal bones connect;
– Lisfranc ligament: is a tough band of tissue that joins the 2
of these bones
– Incidence: Lisfranc injuries may be seen in MVA, military
personnel, runners, horseback riders, football players, and
contact sports/missing a step on a staircase
Types of Injuries and Mechanism:
– Sprains: Lisfranc ligament and other ligament of bottom of
midfoot are stronger than those on the top of the midfoot;
weakened through a spring (stretching of a ligament), patients
experience instability of joint in the middle of the foot
– Fractures: break in bone in the Lisfranc joint can be either
an avulsion fracture (small piece of bone is pulled off) or break
through the bone/bones of midfoot
– Dislocation: bones may be forced from their natural
positions
Symptoms, Diagnosis, Treatment, Complications:
– Symptoms: swelling, pain, bruising, inability to bear weight,
abnormal widening
– Diagnosis: mistaken for sprains, how it occurred, X-ray
– Treatment: elevate, ice, immobilize (cast), NSAIDs, physical
therapy (post-swelling)
1. Non-operative: dislocation < 2mm, casting 6 wk,
immobilize and no weight bearing.
2. Operative: internal fixation with screws, no weight bearing
for 6-12 wk.
– Complications: compartment syndrome, arthritis
31. Fractures of the talus
General about Fractures of Talus:
– Mechanism: axial loading or hyperdorsiflexion due to MVA,
snowboarding (soft boot, not rigid enough), falls: 50 % of
fractures occur at talar neck.
– Symptoms: acute pain, inability to bear weight, swelling,
tenderness
– Diagnosis: x-ray, CT (if x-ray not enough)
– Treatment: predominantly surgery; unless bones still aligned
= just cast; post-surgery = cast for 6-8 weeks
– Complications: osteonecrosis or AVN.
– Treatment:
1. Undisplaced: non-weight bearing below knee cast x 20-24
weeks
2. Displaced: ORIF (high rate of nonunion, AVN)
Edited By: Marsel Toplić
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32. Calcaneus fracture
General about Fractures of Calcaneus:
– Mechanism: axial loading: fall from a height onto heels (fall
or jump from height.).
– Incidence: 5 % bilateral, 10 % associated with compression
fracture of lumbar or thoracic spine.
– Types: based on sub-talar joint involvement:
1) Intra-articular:
2) Extra-articular
– Symptoms: pain over heal, tenderness, inability to bear
weight, swelling, redness, hematoma
– Diagnosis:
1. X-rays: AP, lateral, oblique (Broden’s view)
2. Loss of Bohler’s angle
3. CT: assess intraarticular extension
– Treatment:
1. Non-surgical: extra-articular when calcaneal weight-
bearing surface and foot function are not compromised:
closed reduction with or without fixation; 2-3mo of reduced
movement with gradual build-up
2. Surgical: intra-articular with displacement; closed
reduction with percutaneous fixation: associated with less
wound complications, better soft tissue healing; ORIF
33. Ankle fractures
Mechanism and Classification System:
– Pattern of fracture depends on the position of the ankle
when trauma occurs
– Generally involves: ipsilateral ligamentous tears or transverse
bony avulsion and contralateral shear fractures (oblique or
spiral).
– Classification systems:
1. Danis-Weber
2. Lauge-Hansen: based on foot’s position and motion
relative to leg
Classification – Danis-Weber:
– Based on level of fibular fracture relative to syndesmosis
– Type A: infra-syndesmotic: subtypes
1. Pure inversion injury
2. Avulsion of lateral malleolus below plafond (plafond: an
anatomical part/surface that is farthest from midline of body
esp the articular surface of the distal end of the tibia) or torn
calcaneofibular ligament
3. May include shear fracture of medial malleolus
– Type B: trans-syndesmotic
1. External rotation & eversion
2. +/- avulsion of medial malleolus OR rupture of deltoid
ligament
3. Spiral fracture of lateral mallelous starting at plafond
– Type C: supra-syndesmotic
1. Pure external rotation
2. Avulsion of medial malleolus OR torn deltoid ligament
3. +/- posterior malleolus may be avulsed
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Review of Orthopedics – 2012/2013 – Brodno Szpital
4. Maisonneuve fracture: if proximal fibula is fractured
5. Frequently tears syndesmosis
Treatment:
– Undisplaced: non-weight bearing below knee cast
– Indications for ORIF: all fracture-dislocations; most of type
B, and all of type C; trimalleolar (medial, posterior, lateral)
fractures; talar tilt >10º; medial clear space on XR greater than
superior clear space; open fracture/open joint injury
34. Ankle sprain (Twisted Ankle)
Definition and Mechanism:
– Most common musculoskeletal injury: 1 or more ligaments
are torn; anterior talofibular ligament is most commonly
involved;
– Lateral aspect accounts for 85% of ankle sprains
– Happens when ankle placed into abnormal position and
overstretching of ligaments. Occur with side-to side motion,
during sports.
Symptoms and Classification:
– Symptoms: redness, inflammation, swelling, nerves become
more sensitive (throbbing pain), warmth
– Diagnosis: X-ray; MRI; Anterior drawer test
– Classification:
1. Grade 1: slight stretching with minimal damage to
ligament
2. Grade 2: tearing and ankle joint moves in abnormal ways
3. Grade 3: severe injuries; complete tears
Treatment:
– Microscopic tear (Grade I): rest, ice, compression, elevation
(RICE)
– Macroscopic tear (Grade II): strap ankle in dorsiflexion and
eversion x 4-6 weeks; PT: strengthening and proprioceptive
retraining
– Complete tear (Grade III): below knee walking cast 4-6
weeks; PT: strengthening and proprioceptive retraining; ƒ
surgical intervention may be required if chronic symptomatic
instability develops
35. Achilles tendon rupture
Epidemiology and Etiology:
– Peak age: 30-50y
– It occurs with loading activity; stop-and-go sports (squash,
tennis, basketball): eccentric contraction of gastrocnemius-
soleus muscles; it is also secondary to chronic tendonitis, and
steroid injection.
– The rupture occurs at 3-6 cm proximal to the insertion on
the calcaneus where blood supply is poor.
Edited By: Marsel Toplić
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Clinical Feature:
– There is a sudden pain (“pop”) after a push-off movement,
– The patients is able to do dorsiflexion of toes and there is
swelling above heel.
Diagnosis:
– Based on clinical history (felt like being ‘kicked or shot
behind the ankle’), usually palable gab, there is a positive
Thompson test
– There is an audible pop, sudden pain with push off
movement; sensation of being kicked in heel when trying to
plantar flex; palpable gap; apprehensive toe off when walking;
weak plantar flexion;
– Thompson Test: with patient in prone position, squeeze calf
->passive plantar flexion = intact Achilles tendon; +ive = no
passive plantar flexion (no movement of ankle) = ruptured
tendon.
– To rule out any avulsion fracture: do MRI, US, X-ray.
Treatment:
– Non-surgical: ’low demand’/elderly: cast foot in plantar
flexion (relax tendon) = 8-12 weeks
– Surgical: ‘high-demand’/younger and older active patients:
surgical repair, then cast as above = 6-8wks
36. Pilon fractures
Definition and Mechanism:
– When a bone breaks and hits another one which breaks;
usually intra-articular fracture of distal tibia.
– It may be due to axial force during MVA or fall from a
height on feet.
Diagnosis and Treatment:
– Diagnosis: X-ray, CT
– Treatment:
1. Type 1 and 2: non-operative. Splint and plaster cast.
2. Type 3: require surgical treatment: external fixation,
internal fixation, and ankle fusion
37. Ligamentous injuries around the knee
Anatomy and Incidence:
– There are 4 major ligaments around knee:
1. Medial and lateral collateral ligament (MCL, LCL)
2. Anterior and posterior cruciate ligament (ACL, PCL)
– The MCL is the most commonly injured ligament.
– ACL tear much more common than PCL tear
Symptoms:
– CLIPS: Clicking, Locking, Instability, Pain, Swelling
Tests:
– Ant/post drawer test: Tibia sublux ant (ACL may be torn);
Tibia sublux post (PCL may be torn)
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Review of Orthopedics – 2012/2013 – Brodno Szpital
– Lachmann test: torn ACL – hold knee in 10-20 degree
flexion, stabilizing femur; try to sublux tibia ant on femur
– Posterior sag sign: torn PCL; may give a false positive
anterior draw sign; flex knees and hips to 90 degrees, hold
ankles and knees; view from lateral aspect; if one tibia sags
post compared to other, its PCL is torn
– Pivot shift sign: torn ACL, start with knee in extension,
internally rotate foot, slowly flex knee while palpating and
applying a valgus force; normal knee will flex smoothly; if
incompentent ACL -> tibia will sublux ant on femur at start of
maneuver. During flexion, the tibia will reduce and externally
rotate abt the femur (the ‘pivot’); reverse pivot shift (start in
flexion, externally rotate, apply valgus, and extend knee) ->
suggests torn PCL
– Collateral ligament stress test: palpate ligament for ‘opening’
of joint space while testing; with knee in full extension, apply
valgus force to test MCL, apply valgus force to test LCL
Anterior Cruciate Ligament:
– Mechanism: Sudden deceleration; Hyperextension and
internal rotation of tibia on femur
– History: Audible “pop”; swelling; Inability to continue
activity
– Physical Examination: Effusion (hemarthrosis);
Posterolateral joint line tenderness
Positive anterior drawer test, Positive Lachmann, Pivot shift
– Treatment: Stable knee with minimal functional impairment:
immobilization 2-4 weeks with early ROM and strengthening
Posterior Cruciate Ligament:
– Mechanism: Sudden posterior displacement of tibia when
knee is flexed or hyperextended (dashboard MVA injury)
– History: Audible “pop”; swelling; Cannot descend stairs
– Physical Examination: Effusion (hemarthrosis);
Anteromedial joint line tenderness
Positive posterior drawer test, Reverse Pivot shift
– Treatment: Unstable knee or young person/high-demand
lifestyle: ligament reconstruction
Collateral Ligaments:
– Mechanism:
1. Valgus force to knee: medial collateral ligament (MCL)
2. Varus force to knee: lateral collateral ligament (LCL)
– Clinical Features:
1. Swelling/effusion
2. Tenderness above and below joint line medially (MCL) or
laterally (LCL)
– Treatment:
1. Partial tear: immobilization x 2-4 weeks with early ROM
and strengthening
2. Complete tear or multiple ligamentous injuries: surgical
repair of ligaments – not for MCL or
LCL on their own
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38. Meniscal injuries
Incidence and Mechanism:
– Medial tears more common than lateral.
– Peak age: 30-40 y, after 50 y of age tears are more commonly
due to arthritis than trauma.
– Mechanism: twisting force on knee when it is partially flexed
(e.g.: stepping down and turning); requires moderate trauma in
young but only mild in elderly due to degeneration
– Lateral tears may be associated with ACL tears and sports
injuries.
Clinical Features and Diagnosis:
– Clinical Feature: immediate pain, difficulty weight-bearing,
instability and clicking; increased pain w/ squatting/twisting;
effusion -> insidious onset 24-48hrs after injury; joint line
tenderness medially or laterally; locking of knee (= torn
meniscus – also very painful)
– Tests: McMurray’s test: with knee in flexion, palpate the
joint line for painful ‘pop/click’
1. Lateral meniscus: internally rotate foot, varus stress &
extend knee
2. Medial meniscus: externally rotate foot, valgus test, &
extend knee
– Diagnosis: MRI, arthroscopy
– Treatment:
1. If not locked: ROM and strengthening
2. If locked or failed above: arthroscopic repair/partial
meniscectomy
39. Tibial plateau fractures
Mechanism and Incidence:
– Axial loading (e.g. fall from height)
– Femoral condyles driven into proximal tibia
– Can result from minor trauma in osteoporotics
– Lateral fractures more common than medial
– Peak age: 30-40 y in men, 60-70 y in women.
– Can be classified with Schatzker classification (I-VI):
Diagnosis, Treatment, and Complications:
– Diagnosis: X-rays: AP and lateral
– Treatment:
1. If depression on x-ray is <3 mm: straight leg
immobilization x 4-6 weeks with progressive ROM weight
bearing
2. If depression is >3 mm: ORIF often requiring bone
grafting to elevate depressed fragment
– Complications: ligamentous injuries, meniscal lesions,
delayed union, AVN (bone infarction);
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40. Distal femur fractures
General about Distal Femur Fractures:
– Mechanism: Direct high energy force (young, low energy in
older women)/axial loading
– Types: supracondylar, condylar, intercondylar
– Physical Examination: extreme pain, effusion, shortened,
externally rotated leg is displaced
– Treatment: ORIF, early mobilization & strengthening
– Complications: femoral a. tear, extensive soft tissue injury,
angulation deformities, post-traumatic arthritis, n. injury
41. Patellar fractures
Mechanism and Clinical Features:
– Mechanism:
1. Direct blow to the patella
2. Indirect trauma by sudden flexion of knee against
contracted quadriceps
– Clinical Feature: marked tenderness, inability to extend knee
or straight leg raise, proximal displacement of patella, patellar
deformity, effusion
Diagnosis and Treatment:
– Diagnosis:
1. X-rays: AP, lateral, skyline
2. Consider bipartite patella: congenitally unfused
ossification centres with smooth margins on x-ray
– Treatment:
1. Non-displaced (<2 mm): straight leg immobilization 6-8
weeks; PT: quadriceps strengthening
2. Displaced: ORIF (>2 mm)
3. Comminuted: ORIF; may require partial/complete
patellectomy
42. Patellar dislocation (acute)
General:
– Mechanism: lateral displacement of patella after contraction
of quadriceps against flexed knee
– Clinical Feature: knee catches/gives way with walking; severe
pain, tenderness anteriormedially from rupture of capsule, wk
knee extension/inability to extend leg unless patella reduced;
1. Positive patellar apprehension test: patients apprehensive
when examiner laterally displaces patella; often recurrent, self-
reducing
– Imaging: X-rays: X-Rays (A/P, Lateral, skyline –
patellofemoral joint; check for fracture of medial patella &
lateral femoral condyle)
– Treatment:
1. Non-operative first: knee immobilization x 4-6 weeks; ƒ
progressive weight bearing and isometric quadriceps
strengthening
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2. If recurrent: surgical tightening of medial capsule and
release of lateral retinaculum, possible tibial tuberosity transfer,
or proximal tibial osteotomy
43. Fracture of the femoral shaft (Diaphysis)
Mechanism:
– High energy trauma (MVA, fall from height, gunshot
wound);
– In children, can result from low energy trauma (spiral
fracture)
Clinical Features and Diagnosis:
– Shortened, externally rotated leg (if fracture displaced)
– Inability to weight-bear
– There is usually blood loss: 0,5-1,5l
– Often open injury, always a Gustilo III
– Diagnosis: AP pelvis, AP/lateral hip, femur, knee
Treatment and Complications:
– Stabilize patient and immobilize leg early
– ORIF with intramedullary nail, external fixator, or plate and
screws within 24 hours
– Complications: hemorrhage requiring transfusion, fat
embolism leading to ARDS, extensive soft tissue damage,
ipsilateral hip dislocation/fracture, and nerve injury
44. Subtrochanteric fracture
Mechanism and Incidence:
– Seen in osteopenic elderly with low-impact fall and in young
patients with high-trauma cases
– It is seen under lesser trochanter to 5cm distal from it
Clinical Feature, Diagnosis, and Treatment:
– There is shortening of the extremity, swelling tenderness,
inability to flex hip/abduct leg, and hemorrhage.
– Diagnosis: AP X-ray; Seinsheimer: (Grades) classification
– Treatment: predominantly surgical – external fixation, open
reduction, intramedullary fixation (1ary choice)
45. Femoral neck fractures
Mechanism and Diagnosis:
– Mechanism:
1. Young patients: car accident/fall from height;
2. Old patients (>60): a simple fall onto the hip: fatigue
fracture
– Diagnosis: acute onset of hip pain, unable to bear weight,
shortened, externally-rotated leg, painful range of motion
x-ray: A/P, lateral hip, A/P pelvis
Mechanism and Diagnosis:
– Treatment:
1. Garden I/II: internal fixation
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2. Garden III/IV: depends on age of patient and function; 1. Causes:
older/low function: hemiarthroplasty; young/high function: A. Isolated injuries (rare): forceful contractions (force
reduction w/internal fixation avulsion) of the iliopsoas muscle in adolescents or by benign
– Complications: DVT, non-union & avascular necrosis or malignant bone tumors in the elderly.
– One of commonest causes of morbidity due to increasing B. Combination with other fracture types (most common):
component of intertrochanteric fracture
incidence in the ageing population. – Greater Trochanter fracture:
– Whenever possible surgery should be done within 24-48h. 1. Causes:
A. Isolated injuries (rare): usually occurs in elderly patients
46. Hip dislocation due to a direct trauma to the outside of the hip or indirectly
due to contraction of the gluteus medius and gluteus minimus
muscles.
Clinical Feature: B. Combination with other fracture types (most common):
– Inability to bear full weight, excessive mobility of the limb component of intertrochanteric fracture
and crepitus at joint
Treatment:
Types: – Bedrest, stretches to regain hip function, and if bone
– Anterior Dislocation: fragment > 1cm, ORIF - wires
1. Etiology: force to the posterior part of the knee when hip
is abducted: Forced abduction and lateral rotation of limb 48. Pelvic fractures
2. Diagnosis: shortened, ABducted, external rotated limb
3. Treatment: closed reduction and post-reduction CT
Incidence and Mechanism:
– Posterior Dislocation – Most Common:
– Young: high energy trauma, either direct/by force
1. Etiology: severe force to the knee when hip is flexed and
transmitted longitudinally through the femur
adducted: knee into dashboard in MVA
– Elderly: fall from standing height, low energy trauma
2. Diagnosis: shortened (2-3cm), ADDucted and internally
– Classifications: Tiles and Young&Burgess
(medially) rotated limb
3. Treatment: closed reduction and& post reduction CT,
Clinical Feature and Diagnosis:
ORIF if unstable
– Clinical: local swelling, tenderness, deformity of lower
– Central Dislocation - Rare:
extremity, pelvic instability
1. Etiology: traumatic injury where femoral head is pushed
– Diagnosis:
through the medial wall of acetabulum toward pelvic cavity, by
1. X-ray: AP pelvis, inlet and outlet for pelvic fracture; Judet
a heavy lateral blow upon the femur.
films (obturator and iliac oblique) for acetabular fracture
2. CT scan: posterior pelvic injury and acetabular fracture
Treatment:
– Notes:
– Posterior dislocation: Use general anesthesia; reduce by
1. Acetabular fractures: lead to early coxarthrosis
longitudinally (vertically) pulling the femur while hip and knee
2. Femoral head dislocations: lead to AVN
is flexed to a right angle and rotated laterally.
3. Anterior and posterior column: classified into simple and
– Hip reductions should be reduced as soon as possible, i.e.
complex fractures
within 6hrs to decrease the risk of avascular necrosis of the
femoral head).
Treatment and Complications:
– Up to 50% of patients with hip dislocations suffer fractures
– Stable fractures: nonoperative treatment, protected weight
elsewhere at the time of injury.
bearing
– Examine for neurovascular injury prior to open/closed
– Indications for operative treatment: unstable pelvic ring
reduction
injury; disruption of anterior and posterior SI ligament; ƒ
– Hip precautions for 6wks post-reduction (no extreme hip
symphysis diastasis >2.5 cm; vertical instability of the
flexion, adduction, internal/external rotation)
posterior pelvis; CREF or ORIF or total hip arthroplasty
– Complications:
Complications:
1. Hemorrhage (life-threatening): 1500-3000 ml blood loss
– AVN, post-traumatic arthritis (osteoarthritis), fracture of
2. Injury to rectum or urogenital structures
femoral head/shaft; sciatic nerve palsy (25%),
3. DVT/PE risk
thromboembolism, heterotrophic ossification
49. Cervical sprain (Whiplash)
47. Trochanteric fractures

Definition and Mechanism:

Incidence and Mechanism:
– A strain refers to an injury to a muscle, occurring when a
– It often affects older people (75-85y)
muscle-tendon unit is stretched or overloaded.
– Lesser Trochanter fracture:

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Review of Orthopedics – 2012/2013 – Brodno Szpital
– Cervical muscles that are commonly strained include the
SCM, the trapezius, the rhomboids, the erector spinae, the
scalenes, and the levator scapulae.
– Causes include:
1. MVA: whiplash (Occupants of cars stuck violently from
behind.) – Most common
2. Sports-related
Clinical Feature and Diagnosis:
– Clinical Feature: pain, stiffness, headache, or decreased
cervical ROM.
– Physical Examination: neurological exam, cervical ROM
– Imaging:
1. X-ray: AP, lateral, oblique, and odontoid views.
2. CT scanning: abnormal X-ray or suspicion of fracture.
3. MRI: in athletes with neurologic deficits
Treatment:
– NSAIDs, muscle relaxants, soft cervical collar (2-3wks)
physical therapy, electrical stimulation, chiropractic care
50. Fractures of the lumbar spine
Mechanism and Types of Fractures:
– Mechanism: may be caused by: MVA, fall from height, sport
accidents, gunshot wound, osteoporosis (crush fractures od
the vertebral body), or tumors
– Types:
1. Compression fracture:
2. Axial burst fracture: fall from height
3. Flexion/distraction fracture: vertebrae is pulled apart
4. Transverse process fracture: from rotation/extreme
sideways bending
Clinical Feature and Diagnosis:
– Clinical Feature: moderate to severe back pain (worse by
movement), numbness, tingling, weakness, or bowel/bladder
dysfunction.
– Diagnosis: Emergency stabilization, neurological tests,
imaging (X-rays, CT, MRI)
Treatment and Complications:
– Treatment: brace for 6-12wks (most compression injuries
like compression and burst fractures), surgery for unstable
burst fractures that have: significant comminution, severe loss
of vertebral body height, excessive forward
bending/angulation, significant n. injury due to parts of the
vertebral body/disk pinching the spinal cord
– Complications: DVT, PE, pneumonia, pressure sores,
bleeding, infection, spinal fluid leak, nonunion
. – General:
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ORTHOPEDICS
1. Arthrodesis (artificial ankylosis/joint fusion)
Definition:
– It is an artificial induction of joint ossification
(ankylosis/syndesis) between two bones via surgery.
Use:
– It relieves joint pain in patients which cannot be managed by
pain medication, splints, etc. The causes of such pain are
fractures which disrupt the joint and in arthritis e.g.
osteoarthiritis.
– Most commonly performed on joints of spine, hand, ankle
and foot.
Procedures:
– 1. Autograft (bone from elsewhere in patient’s body) or
allograft (donor bone) used to create a bone graft between 2
bones; autograft is preferred
– 2. Metal implants can be used to attach the 2 bones in a
position that favours bone growth
– 3. Synthetic bone that mimics the bone, can also be used
– 4. Combo of 1-3
2. Synovectomy
Definition and Use:
– The surgical removal of a part/all of an inflamed lining of
the synovial membrane of a synovial joint. This leaves the
capsule intact. It is indicated before cartilage damage.
– It will reduce local pain and swelling.
– Used in certain diseases involving the synovium: RA,
juvenile idiopathic arthiritis, hemarthrosis, pigmented
villonodular synovitis, and synovial osteochondromatosis.
– Procedure: conducted arthroscopically or classic arthrotomy.
– Complications: infection, neural palsy, phlebitis
3. Instability of the knee
Etiology and Classification:
– It is due to acute/chronic injury of:
1. Anterior cruciate ligament (ACL): probably by twisting,
pivoting, or turning
2. Posterior cruciate ligament (PCL): probably due to probls
going down stairs/slopes
3. Medial collateral ligament (MCL): Injury that abducts the
tibia upon the femur (subluxation). Wide abduction of tibia
upon femur cannot occur unless the cruciate and capsule are
also torn in the injury.
4. Lateral collateral ligament (LCL): less common, there is an
adduction of the tibia upon femur
Diagnosis:
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1. The timing of an effusion (acute hemarthrosis usually
occurs within 2 hours) and hearing or feeling a “pop” (highly
suggestive of an ACL injury) are significant events.
2. Chronic instabilities: present with mechanical symptoms
such as locking, catching, clicking, or giving way, particularly
with twisting movements.
– According to injury:
1. MCL injury: AP X-rays are taken while an abduction stress
is applied to the tibia.
2. ACL injury: Anterior drawer test
3. PCL injury: Posterior shift when backward force applied
below patella.
Terms:
– Laxity: is the measured amplitude of joint movement within
the constraints of its ligaments.
– Physiological Laxity: implies no ligament is stretched
pathologically.
– Pathological Laxity: means a ligament has been stretched by
injury.
– Instability: is a complaint by a patient that they lose single
leg stance because the joint
subluxates due to pathological laxity.
– Disability: is instability that interferes with the required
function of the knee.
Treatment:
– General:
1. Grade 1-2 (incomplete tear): no surgery needed:
mobilization, physiotherapy, and reevaluation in about 2 weeks
may be adopted.
2. Grade 3 (complete tear): need surgical
repair/reconstruction.
– According to injury:
1. MCL injury:
A. Conservative: Aspiration of blood stained effusion.
Knee is afterwards supported in a long-leg plaster (reatined
after 6 weeks).
B. Operative: sutured ligaments with 6 weeks support in
plaster.
2. ACL injury: Most surgeons prefer to await events and to
reconstruct the ligament secondarily if significant disability
persists after a long period of rehabilitation. (ligament
reconstruction seldom restores full stability; may also
deteriorate with time due to stretching)
3. PCL injury: reconstruction, only when disability justifies it.
In case of reconstruction: By substitution of a strip of
aponeurosis or tendon (usually patellar tendon). Important
with intensive exercises to redevelop the quadriceps muscle.
4. Instability of the ankle
Definition and Etiology:
– Rupture of the lateral ligament of the ankle
– Strains can also cause instability
– In cases of sever adduction injury
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– If ankle ligament do not heal adequately
– Complete rupture of the talo-fibular and calcaneo-fibular
ligaments with consequent tilting and subluxation of the talus.
– May be mistaken for simple strain of the ligaments.
Clinical Features and Diagnosis:
– Clinical Feature: swelling and edema, tenderness over the
lateral ligaments.
– Diagnosis: AP radiographs while an adduction stress is
applied to the heel. (tilting of talus is not seen in strain)
Treatment:
– If treated as a simple strain with early exercises and activity,
the torn ligaments may fail to heal and recurrent subluxation
of the ankle may occur.
– Conservative treatment: ligament protected by a below-knee
plaster for at least 8 weeks.
– If disability is slight, it may be sufficient to strengthen the
evertor (peroneus longus) muscles with exercise. Severe
disability may require surgery: new tendon inserted taken from
peroneus brevis/tertius.
– Strengthening peroneal m may help control ankle joint and
improve joint stability; surgery to tighten ligaments around
ankle
5. Glenohumeral (shoulder) joint instability
Definition and Classification:
– Definition:
1. Instability: of the shoulder is defined as abnormal or
symptomatic motion, usually translocation of the humeral
head with respect to the glenoid.
2. Laxity: describes the passive motion characteristics of the
joint.
– Classification: Can be traumatic or non-traumatic; anterior,
posterior or multidirectional. Anterior and posterior instability
refers to shoulder dislocation (question 26; traumatology).
Multidirectional Joint Instability (MDI):
– MDI is a common condition that may be a bilateral
occurrence and is usually atraumatic in nature.
– MDI is characterized by diffuse capsular laxity due to
inadequate ligament structures. This laxity is referred to as
MDI because of the increase in mobility of the glenohumeral
joint (ball and socket of shoulder) in all directions.
– Clinical features: pain (sore shoulder that worsens with
activity or specific arm movements – overhead activities,
carrying items, overuse, injury), dislocations (subluxation)
– Diagnosis: symmetrical finders, hyperlaxity may be shown
through a positive sulcus sign (inferior laxity), anterior and
posterior capsule testing. Routine x-rays may be obtained but
are most often negative. MRI evaluation may demonstrate
abnormalities of the labrum (cartilage that encircles the cup of
the shoulder) and generalized capsular laxity.
– Treatment:
1. Initial: supportive care, NSAIDs, ice;
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2. Arthoscopic surgery: shoulder capsule is tightened by
electrothermal or suture technique; then rehabilitation and
physical therapy
6. Glenoid labrum injury
Anatomy, Definition and Etiology:
– Anatomy: Glenoid labrum increases depth of should cavity
making the shoulder joint more stable; glenohumeral ligaments
and shoulder capsule attach to glenoid labrum.
– Etiology: repetitive overhead throwing, lifting heavy objects
below shoulder height/catching heavy objects and FOOSH.
Classification:
– Glenoid labrum injuries are classed as either superior or
inferior towards the bottom of the glenoid socket.
– Superior injury: is known as a SLAP lesion (superior labrum,
anterior (front) to posterior (back) and is a tear of the rim
above the middle of the socket that may also involve the
biceps tendon.
– Inferoir injury: is a tear of the rim below the middle of the
glenoid socket is called a Bankart lesion and also involves the
inferior glenohumeral ligament.
Clinical Feature:
– Clinical Feature: shoulder pain which cannot be localized to
a specific point, pain is made worse by overhead
activities/when arm is held behind the back, weakness,
instability in shoulder, pain on resisted flexion of biceps and
tenderness over front of shoulder.
Treatment:
– Treatment:
1. Rest
2. Cold therapy: reduce pain and inflammation
3. NSAIDs
4. Rehab to restore full function
5. Unstable injuries: surgery to re-attach labrum to glenoid;
following surgery the shoulder will usually be kept in a sling
for 3-4wks
7. Tennis elbow (Lateral Epicondylitis)
Definition, Mechanism, and Clinical Feature:
– Definition: inflammation of the common extensor tendon
(extensor carpi radialis brevis muscle tendon) as it inserts into
the lateral epicondyle.
– Mechanism: it is due to repeated or sustained contraction of
the forearm muscles: overuse/repetitive strain caused by
repeated extension of the wrist (e.g. tennis,
badminton/squash) but also common after periods of
excessive wrist use in day-to-day life. Inflammation is rare but
increased pain receptors in the area makes the region
extremely tender.
– Clinical Feature: pain about 1-2cm down from bony area at
the outside of the elbow (lateral epicondyle), there is weakness
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in wrist, pain on outside of elbow when hand is extended at
wrist, pain on outside of elbow when trying to straighten
fingers.
Treatment:
– Generally a self-limited condition, but may take 6-18 months
to resolve.
– Combination of therapy:
1. Apply ice/cryotherapy to elbow (15mins up to 6x/day):
this will reduce pain and inflammation if present;
2. Rest;
3. NSAIDs; or corticosteroid injections
4. Use brace/strap;
5. Surgery: percutaneous or open release of common tendon
from epicondyle (only after 6-12 months of conservative
therapy)
8. Benign tumors of the musculoskeletal system
General about Benign Tumors:
– Minimal trauma may precipitate pathologic fractures; if there
were no symptoms prior to time of fracture, chances are
that tumor is benign. On other hand, if fracture has been
preceded by dull, aching pain, possibility of malignant primary
bone tumor or metastasis is likely.
– Example of benign tumors:
1. Osteoid Osteoma
2. Osteochondroma
3. Enchondroma
4. Cystic Lesions
5. Giant Cell Tumors/Aneurysmal Bone
Cyst/Osteoblastoma
Characteristics of Benign Bone Tumors:
– Benign bone tumors generally do not extend beyond the
cortex of bone;
– Often these tumors are surrounded by a radiodense margin
of bone;
– Whereas metaphyseal tumors are common, diaphyseal
tumors are uncommon;
Osteoid Osteoma:
– Incidence: 2nd and 3rd decades, M>F.
– Affects: tibia and femur mostly
– Clinical Feature: produces severe intermittent pain, mostly at
night (diurnal prostaglandin production)
– Treatment and complications: characteristically relieved by
NSAIDs (treatment only necessary if symptomatic) and it is
not known to metastasize.
Osteochondroma:
– Incidence: 2nd and 3rd decades, M>F. It accounts for 45%
of all benign bone tumors.
– Affects: the metaphysis of long bone (distal ends of
femur/proximal ends of humerus). (“mushroom” on x-ray)
– Clinical Feature: generally very slow growing and
asymptomatic unless impinging on neurovascular structure.
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– Treatment: resection
– Complications: malignant degeneration occurs in 1-2%
(becomes painful or rapidly grows).
Enchondroma:
– Incidence: 2nd and 3rd decades
– Affects: 50% occur in the small tubular bones of the hand
and foot; others in femur, humerus, ribs
– Treatment: treatment only necessary if symptomatic
– Complications: malignant degeneration occurs in 1-2% (pain
in absence of pathologic fracture is an important clue)
Cystic Lesions:
– Incidence: children and young adults
– Pathology: includes unicameral/solitary bone cyst (most
common), fibrous cortical defect
– Clinical Feature: local pain, pathological fracture (50%
presentations) or incidental detection
– Treatment: treatment of unicameral bone cyst with steroid
injections ± bone graft; curettage and bone graft
9. Malignant tumors of the musculoskeletal system
Osteosarcoma:
– Incidence: 2nd decade of life (60%); history of Paget’s disease
radiation.
– Affects: distal femur (45%), proximal tibia (20%) and
proximal humerus (15%)
– Clinical Feature: painful, poorly defined swelling, decreased
ROM ; metastasis to lung,
– Diagnosis: x-ray shows Codman’s triangle
– Treatment: complete resection (limb salvage, rarely
amputation), neo-adjuvant chemotherapy; survival: 70%
Chondrosarcoma:
– Incidence:
1. Primary (67%): normal bone; patient over 40
2. Secondary (33%): malignant degeneration of pre-existing
cartilage tumour such as enchondroma or osteochondroma,
younger age group and better prognosis than primary
chondrosarcoma
– Affects: most commonly occurs in pelvis, femur, ribs,
scapula, humerus (with metastasis to the lung)
– Clinical Feature: pain, pathological fracture, flecks of
calcification
– Treatment: unresponsive to chemotherapy, treat with
aggressive surgical resection + reconstruction
Ewing’s Sarcoma:
– Incidence: most occur between 5-20 years old
– Clinical Feature: affects diaphysis of long bone; metastases
frequent without treatment
– Diagnosis: mild fever, anemia, leukocytosis and increased
ESR/LDH
– Treatment: resection, chemotherapy, radiation
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Multiple Myeloma:
– Incidence: most common primary malignant tumor of bone
in adults; 90% occur in people >40 years old
– Pathology:
– Clinical Feature: anemia, anorexia, renal failure, nephritis,
increased ESR, bone pain (cardinal early symptom),
compression fractures, hypercalcemia; high incidence of
infections (e.g. pyelonephritis/pneumonia)
– Diagnosis: CT-guided biopsy of lytic lesions
– Treatment: chemotherapy, radiation, surgery for
symptomatic lesions or impending fractures
Bone Metastasis:
– Incidence: 2/3 from breast or prostate; also consider
thyroid, lung, kidney
– Pathology: usually osteolytic; prostate occasionally
osteoblastic
– Clinical Feature:
– Diagnosis: bone scan for musculoskeletal (MSK)
involvement, MRI for spinal involvement may be helpful
– Treatment: stabilization of impending fractures: internal
fixation, IM rods; bone cement
10. Osteoporosis
Definition and Etiology:
– Definition: “porous bones," causes bones to become weak
and brittle. There is thinning of bone tissue and loss of bone
density over time (reduction of total bone mass). A common
result of osteoporosis is fractures, most of them occur in the
spine, hip or wrist.
– Etiological risk factors: post-menopausal female (estrogen
deficiency), increasing age, Vitamin D deficiency, low dietary
Ca intake, smoking, alcohol abuse, glucocorticoid therapy,
drugs, anticonvulsants, endocrine disease (Cushing’s,
hyperthyroidism, hyperparathyroidism), MM
– Pathogenesis: there is an increased bone breakdown by
osteoclasts and decreased bone formation by osteoblast.
Clinical Feature:
– There is an sudden onset of back pain in spine often
radiating around to the front: suggests vertebral crush
syndrome (but only 1/3 of vertebral ractures are symptomatic)
– There is a loss of height over time and a stooped posture
(Kyphosis).
– Fractures: of the vertebra, wrist (Colles fracture), hip or
other bone
– Fracture of proximal femur: due to falling on side/back
Diagnosis:
– Dual energy X-ray absorptiometry (DEXA) scan: measures
area in bone density usually of lumbar spine and proximal
femur. If patient >75: DEXA not needed.
– Bone density less than 2.5 standard deviations below young
adult mean value
– X-ray: fracture and asymptomatic vertebral deformities
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Review of Orthopedics – 2012/2013 – Brodno Szpital
Treatment:
– New vertebral fractures: bed rest for 1-2wks, strong
analgesia, muscle relaxants.
– Therapy against osteoporosis:
1. Subcutaneous calcitonin (salmon calcitonin)
2. Physiotherapy, Exercise
3. Calcium and Vitamin D
4. Smoking and alcohol abuse cessation
5. Bisphosphonates:
6. Selective estrogen receptor modulators (SERM):
raloxifene
11. Scoliosis
Definition, Epidemiology, and Etiology:
– Definition: Lateral curvature of spine with vertebral rotation
– Epidemiology: just before puberty: affects 10-14 year olds;
F>M
– Etiology:
1. Idiopathic: most common (90%)
2. Ccongenital: vertebrae fail to form or segment
3. Neuromuscular: Upper motor neuron (UMN) or lower
motor neuron lesion (LMN) lesion, myopathy
4. Other: osteochondrodystrophies, neoplastic, traumatic
5. Postural: leg length discrepancy, muscle spasm
Clinical Feature, Diagnosis, and Treatment:
– Clinical Feature:
1. Might be back pain: usually adults
2. Asymmetric shoulder height when bent forward;
prominent scapulae, creased flank, and asymmetric pelvis
3. Adam’s test: rib hump when bent forward
4. Non-idiopathic scoliosis: is associated with café-au-lait
spots, dimples, neurofibromas
5. There is a primary curve with secondary compensatory
curves above and below
– Diagnosis: x-ray: measure curvature (Cobb’s angle); might
also be an associated kyphosis; CT; MRI
– Treatment – Based on degree of curvature:
1. <20º: observe for changes
2. >20º or progressive: bracing (many types) that halt/slow
curve progression but do NOT reverse deformity
3. >40º: cosmetically unacceptable or respiratory problems:
surgical correction (spinal fusion)
12. Scheuermann’s disease (Juvenile Kyphosis)
Definition and Etiology:
– Diagnosis and Incidence: is a deformity (kyphosis) in the
thoracic or thoracolumbar spine in children (esp. boys 13-16).
This means that there is a forward rounding (>50deg) of your
upper back (Hunchback). There is osteochondrosis of the
secondary ossification centers of the vertebral bodies
– Etiology: Osteoporosis, degenerative arthritis of spine,
ankylosing spondylitis, CT disorders, tuberculosis, or cancer.
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Clinical Feature, Diagnosis, and Treatment:
– Clinical Feature: pain in thoracic spine in active state;
Slouching posture or hunchback. Back pain may subside then
and come back later in life with OA. There is also spinal
stiffness or tenderness.
– Diagnosis: physical exam. Forward bend test. Patient bend
forward from the waist while the spine is viewed from the
side. With kyphosis, the rounding of the upper back may
become more obvious in this position. Spinal imaging tests, X-
ray, MRI.
– Treatment: Mild case no treatment. Pain: brace or plaster
jacket. Exercise for back muscles. Worst cases: surgery,
excision of intervertebral discs with grafting, spinal fusion
instrumentation.
13. Legg-Calve-Perthes disease (LCPD)
Definition, Epidemiology, and Etiology:
– Definition and incidence: LCPD is avascular necrosis (AVN)
of the proximal femoral head epiphysis resulting from
compromise of the tenuous blood supply to this area.
– LCPD usually occurs in children aged 4-10 years. M>F.
– Etiology: idiopathic (unknown); it is associated with family
history, low birth weight, abnormal pregnancy, and hip
trauma.
Clinical Feature, Diagnosis, and Treatment:
– Clinical Feature: the child has hip pain and intermittent limp
(abductor lurch); there is tenderness and pain over the anterior
thigh (atrophy of muscles), and there is a flexion contracture
(decreased internal rotation and abduction of hip).
– Diagnosis: X-rays may be negative early, but eventually there
is a characteristic collapse of the femoral head (diagnostic)
which appears widened and flattened (coxa plana). Bone scans
– Treatment: the therapy goal is to preserve ROM and
preserve femoral head in acetabulum.
1. ROM exercises and minimal weight bearing
2. Brace in flexion and abduction for 2-3 years
3. Femoral or pelvic osteotomy
– Complications: early onset osteoarthritis and decreased
ROM.
14. Developmental dysplasia of the hip joint (DDH)
Definition and Etiology:
– Definition: DDH is seen in patients who are born with (or
during or after birth) dislocation or instability of the hip,
which may then result in hip dysplasia. DDH was called
congenital dysplasia of the hip (CDH).
– Etiology: due to ligamentous laxity, muscular
underdevelopment, and abnormal development of acetabulum
(roof), proximal femur, labrum, capsule and other soft tissues.
– Risk factors: family history, breech position, female, first
born, and left hip.
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Review of Orthopedics – 2012/2013 – Brodno Szpital
Clinical Feature:
– Terms and Tests:
1. Subluxation: incomplete contact between the articular
surfaces of the femoral head and acetabulum.
2. Dislocation: complete loss of contact between the articular
surface of the femoral head and acetabulum.
3. Instability: consists of the ability to subluxate or dislocate
the hip with passive manipulation.
4. Ortolani test: palpable "clunk" is present when the hip is
reduced in and out of the acetabulum
5. Barlow’s test (for dislocatable hip): flex hips and knees to
90º and grasp thigh then fully adduct hips, push posteriorly to
try to dislocate hips
6. Galeazzi’s Sign: knees at unequal heights when hips and
knees are flexed; dislocated hip on side of lower knee; difficult
test if child <1 year
– Clinical Features:
1. Dislocation: early manifestation seen with Ortolani test
2. Asymmetry of the gluteal thigh or labral skin folds.
3. Decreased abduction on the affected side.
4. Affected leg shortening
Diagnosis:
– Physical examination: diagnosis is clinical:
– Investigation: USG (view cartilage), x-ray after 3 months
– Investigations: USG (view cartilage), x-ray after 3 months
Treatment and Complications:
– Treatment:
1. 0-6 months: reduce hip using Pavlik harness to maintain
abduction and flexion
2. 6-18 months: reduction under GA, hip spica cast for 2-3
months (if Pavlik harness fails)
3. >18 months: open reduction; pelvic and/or femoral
osteotomy
– Complications: redislocation, inadequate reduction, stiffness;
AVN of femoral head
15. Torticollis (spasmodic torticollis)
Definition:
– Definition and Incidence: head and neck dystonias that are
painful. In this condition the neck muscles contract
involuntarily, causing head to twist or turn to one side. It is a
rare disorder that can occur at any age, even infancy (types:
congenital or aquired) and F>M.
Types:
– Congenital torticollis: Congenital muscular torticollis is rare
(< 2%) and is believed to be caused by local trauma to the soft
tissues (SCM) of the neck just before or during delivery.
– Acquired torticollis: any injury or inflammation of the
cervical muscles or cranial nerves from different disease
processes.
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Clinical Feature and Diagnosis:
– Clinical Feature:
1. Head twisting: in a variety of directions (Chin toward
shoulder (most common), Ear toward shoulder, Chin straight
up, Chin straight down).
2. Neck pain that can radiate into the shoulders
3. Headaches.
– Diagnosis: Physical exam. MRI. EMG.
Treatment:
– There is no cure: only symptomatic relieve: Botulinum toxin,
Parkinsons drugs, Muscle relaxants, Pain medications,
exercises that improve neck strength and flexibility.
– Surgery: muscle and nerve cutting if nothing helps.
16. Low back pain syndrome
Definition, Classification, and Etiology:
– Definition: it is a symptom that affects about 90% of
persons aged 18-55 years in their lifetime.
– Classification:
1. Acute: <6 weeks
2. Subacute: 6-12 weeks
3. Chronic: >12 weeks
– Etiology: soft tissue sprain/strain during loading of back
(99%); sciatic nerve entrapment (compression of sciatic nerve),
herniated nucleus pulposus, direct trauma, muscle spasm due
to chronic overuse injury or muscle strain or sprain, or
piriformis syndrome, osteoporosis, spinal degeneration,
lumbar spinal stenosis.
Clinical Feature and Diagnosis:
– Symptoms: Chronic pain in the buttocks. This pain may
radiate to the lower leg and worsens with walking or squatting.
There might be pain when getting up from bed and the pain is
exacerbated by hip adduction and internal rotation. Patients
have an intolerance to sitting.
– Diagnosis: CT and MRI to exclude herniated disc, spinal
tumor, or abscess. Electromyography.
Treatment:
– Conservative: application of heat/cold; physical therapy,
continued activity within limits of pain; exercise (prevention).
– Acute back pain: NSAIDs/paracetamol, muscle relaxants,
physical activity
– Chronic non-specific back pain: physical activity, TCA,
acupunture, intensive multidisplinary Tx programs,
behavioural therapy, spinal manipulation
– Surgery: especially with development of neurologic
symptoms (e.g.: leg weakness, bladder/bowel incontinence as
seen in severe central lumbar disc herniation): microdisectomy,
discectomy, laminectomy, formainotomy, spinal fusion, spinal
cord stimulator; lumbar artificial replacement.
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Review of Orthopedics – 2012/2013 – Brodno Szpital
Piriformis syndrome:
– General: is characterized by pain and instability. The
location of the pain is often imprecise, but it is often present
in the hip, coccyx, buttock, groin, or distal part of the leg. The
female-to-male incidence ratio is 6:1.
17. Spondylolisthesis
General:
– Definition: defect in pars interarticularis causing a forward
slip of one vertebrae on another usually at L5-S1, less
commonly at L4-5
– Etiology: congenital (articular processes; children),
degenerative (osteoarthritis; adults), traumatic, pathological,
teratogenic, stress fracture
– Clinical features: lower back pain radiating to buttocks
– Diagnosis: X-ray. CT, MRI.
– Treatment: NSAIDs; physical therapy, corset. If it is severe,
surgery can be performed with internal brace of screws and
pins to hold together the vertebra.
– Complications: Cauda equina syndrome
18. De Quervain's disease
Definition:
– Other names: Also called De Quervain's tendinitis,
washerwomans sprain, radial styloid tenosynovitis, and De
Quervain tenosynovatis.
– Definition: idiopathic inflammation in 1st extensor
compartment (abductor pollicis longus (APL) and extensor
pollicis brevis (EPB)). This means that it is an entrapment
tendinitis.
Clinical Features:
– Positive Finkelstein’s test: pain over the radial styloid
induced by making fist, with thumb in palm, and ulnar
deviation of wrist.
– Pain localized to the 1st extensor compartment
– Tenderness and crepitation over radial styloid may be
present
Treatment:
– Mild: NSAIDs, splinting and steroid injection into the
tendon sheath (successful in over 60% of cases)
– Severe: surgical release of stenotic tendon sheaths (APL and
EPB); remember there may be 2 or more sheaths
19. Avascular bone necrosis
General:
– Definition: cellular death of bone components due to
interruption of the blood supply. The bone structures collapse,
resulting in bone destruction, pain, and loss of joint function.
– Affects: bones with a single terminal blood supply, such as
the femoral head, carpals, talus, and humerus.
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– Risk Factors: chemotherapy, alcoholism, excessive steroid
use, post trauma, (decompression sickness), vascular
compression, hypertension, vasculitis, arterial embolism and
thrombosis
– Symptoms: depend on affected joint; pain (may be at rest
and night); restricted ROM; may be asymptomatic and is
occasionally discovered incidentally on x-ray.
– Diagnosis: Xray. MRI. Bone scan. CT.
– Treatment: No medical treatment has proven effective in
preventing or arresting the disease. Pain medications.
Immobilization may be helpful in some cases. Limit stress and
weight bearing on affected joints. (Crutches). Surgery: Core
decompression, Osteotomy, Total hip arthroplasty, Bone
grafts.
20. Osteochondritis dissecans
General:
– Definition: Localized disorder of convex joint surfaces in
which a segment of subchondral bone becomes avascular and,
with the cartilage that covers it, may slowly separate and form
a loose body. This may occur from repetitive trauma.
– Symptoms: pain; joint popping or locking (due to loose
body); joint weakness; decreased ROM; swelling and
tenderness. Commonly seen in knee and elbow
– Diagnosis: X-ray (still attached with a line of demarcation, or
loose in the joint with a cavity in articular surface). CT. MRI.
– Treatment: restore the normal functioning of the affected
joint and to relieve pain, as well as reduce the risk of
osteoarthritis: physical therapy; surgery, if conservative
treatments don’t help, patients may need surgery to remove
loose fragments or to reattach fragments to the bone.
21. Ganglion cyst
General:
– Definition: the most common soft tissue tumor of hand and
wrist (60% of masses). It is a fluid-filled synovial lining that
protrudes between carpal bones or from a tendon sheath; it is
most commonly carpal in origin.
– Clinical features:
1. It is most common around scapholunate ligament junction
2. More common in younger persons; F>M:3:1.
3. It is often non-tender although tenderness increased when
cyst smaller (from increased pressure within smaller cyst sac)
4. There might be pain, limitation of activity, and
compression of the median nerve.
– Treatment:
1. Conservative treatment: watch and wait (can compressed
until it bursts in the early stages).
2. Aspiration (recurrence rate 65%)
3. Consider operative excision of cyst and stalk (recurrence is
possible)
4. Steroids if painful
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Review of Orthopedics – 2012/2013 – Brodno Szpital
22. Meniscal injuries
General:
– SEE QUESTION 38 - TRAUMATOLOGY
23. Chondromalacia Patellae (Patellofemoral
Syndrome) – Runners Knee
Mechanism and Incidence:
– Softening, erosion and fragmentation of articular cartilage,
predominantly medial aspect of patella
– It is commonly seen in active young females (15-18)
– Risk factors: post-trauma, deformity of patella or femoral
groove, excessive knee strain (athletes.
Clinical Features, Diagnosis:
– Clinical Features:
1. There is a deep, aching anterior knee pain which is
exacerbated by prolonged sitting (theatre sign), strenuous
athletic activities, stair climbing, and squatting.
2. There is also a sensation of instability, pseudolocking, and
tenderness to palpation of underside of medially displaced
patella.
– Diagnosis: X-ray: AP, lateral; arthroscopy
– Treatment:
1. Non-operative: RICE (Rest, Ice, Compression, Elevation);
continue non-impact activities; NSAIDs
2. Surgical with refractory patients: tibial tubercle elevation;
arthroscopic shaving/debridement; lateral release of
retinaculum
24. Golfer's elbow (Medial Epicondylitis)
Definition, Etiology, and Clinical Feature:
– Definition: inflammation of the common flexor tendon as it
inserts into the medial epicondyle
– Etiology: repeated or sustained contraction of the forearm
muscles
– Clinical Feature:
1. Point tenderness over humeral epicondyle
2. Pain upon resisted wrist or wrist flexion (medial
epicondylitis)
Treatment:
– Generally a self-limited condition, but may take 6-18 months
to resolve.
– Combination of therapy:
1. Apply ice/cryotherapy to elbow (15mins up to 6x/day):
this will reduce pain and inflammation if present;
2. Rest;
3. NSAIDs; or corticosteroid injections
4. Use brace/strap;
5. Surgery: percutaneous or open release of common tendon
from epicondyle (only after 6-12 months of conservative
therapy)
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25. Dupuytren's contracture
Definition:
– Flexion contraction of/from thickening and shortening
longitudinal palmar fascia (aponeurosis), forming nodules
(usually painless), fibrous cords and eventually flexion
contractures at the metacarpophalangeal (MCP) and
interphalangeal joints.
– Flexor tendons are not involved
– Dupuytren’s diathesis: early age of onset, strong family
history, and involvement of sites other than palmar aspect of
hand.
Epidemiology:
– It is a genetic disorder with high incidence in northern
Europeans. It affects men > women and often presents in 5th-
7th decade of life.
– It is associated with but not caused by alcohol use and
diabetes.
Mostly Ulnar part of aponeurosis affected (ring and little
finger)
Clinical Features:
– It mostly affects the ulnar part of the aponeurosis: ring >
little > long > thumb > index
– It may also involve feet (Lederhosen’s) and penis
(Peyronie’s)
Treatment:
– Intra-lesional steroids may help in early stages
– Surgery, only effective treatment
– If slow progressing, better to let be, especially in the elderly
– It may recur, especially in Dupuytren’s diathesis
26. Shoulder joint instability
General:
– If the shoulder joint dislocates more than 1-2 times or is
frequently partially slipping out and then returning into its
place.
– Joints: Glenohumeral, Acromioclavicular, Sternoclavicular,
Scapulothoracic
– SEE QUESTION 26 - TRAUMATOLOGY
27. Rotator cuff injury
Anatomy:
– The rotator cuff is a series of 4 muscles and tendons that act
to stabilize humeral head within the glenoid fossa:
Supraspinatus, Infraspinatus, Teres minor and Subscapularis.
Epidemiology, Definition, Etiology:
– Epidemiology: Rotator cuff disease can occur in any age
group but occurs predominantly in ages 50-70.
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Review of Orthopedics – 2012/2013 – Brodno Szpital
– Definition: A rotator cuff tear occur more often gradually,
chronic over time than as a concequence of trauma. Early
signs of rotator cuff diseases is things like tendonitis or bursitis
or any muscle weakness that narrow subacromial space,
eventually progressing on to become a partial or full tear.
– Etiology: compression of tendons (primary supraspinatus)
and subacromial bursa, result is bursitis, tendonitis, and rotator
cuff thinning and tearing; narrowing of the subacromial space.
Clinical Features:
– Night pain or difficulty sleeping on affected side
– Pain worse with active motion (eg trouble with overhead
activities), loss of range of motion and weakness
– Tenderness to palpation over greater tuberosity
Diagnosis:
– Jobe’s test: Supraspinatus tear
– Posterior cuff test: Infraspinatus och Teres minor tear
– Lift-off test: Subscapularis tear
– Neer’s test: Rotator cuff impingement
– Hawkins-Kennedy test: Rotator cuff impingement
– Painful arc test: Tendinopathy
– X-rays: AP view of humerus relative to glenoid, high riding
humerus may be sign of tendonitis
– MRI
– Arthrogram: Geyser sign: Injected dye leaks out of joint
through rotator cuff tear
Treatment:
– Mild: “wear”: Non-operative: physiotherapy and NSAIDs
– Moderate: “tear”: Non-operative but maybe steroid injection
– Severe: “repair”: May require surgical repair: rotator cuff
repair or acromioplasty
28. Carpal tunnel syndrome (CTS)
Definition, Etiology, Epidemiology:
– Definition: median nerve compressed by nearby anatomic
structures as it passes through the transverse carpal ligament
(flexor retinaculum).
– Etiology:
1. There is a median nerve entrapment at wrist where the
primary cause is idiopathic.
2. Secondary causes: space occupying lesions (tumors,
hypertrophic synovial tissue, fracture callus, and osteophytes),
metabolic and physiological (pregnancy, hypothyroidism, and
RA), infections, neuropathies (associated with diabetes mellitus
or alcoholism), and familial disorders
3. CTS may also be due to job/hobby related repetitive
trauma, especially forced wrist flexion
– Epidemiology: CTS affects females more than men (4:1) and
it is the most common entrapment neuropathy.
Clinical Features:
– There is a sensory loss in median nerve distribution i.e. radial
3.5 digits
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– The discriminative touch is often lost first
– Patients are usually awakened at night with numb/painful
hand, relieved by shaking/dangling/rubbing
– There is a decreased light touch, 2-point discrimination,
especially fingertips
– In advanced cases there is thenar wasting and weakness
Diagnosis:
– Tests – CTS is a clinical diagnosis:
1. Tinel’s sign: tingling sensation on percussion of nerve
2. Phalen’s sign: wrist flexion induces symptom
3. Durkan test: direct compression of median nerve in carpal
tunnel for 30 seconds reproduces numbness and tingeling in
one or more of the radial digits.
– Investigations: nerve conduction velocities (NCV) and EMG
may confirm, but do not exclude, the diagnosis
Treatment:
– Avoid repetitive wrist and hand motion, wrist splints when
repetitive wrist motion required
– Conservative: night time splinting to keep wrist in neutral
position
– Medical: NSAIDs, local corticosteroids injection, oral
corticosteroids
– Surgical decompression: transverse carpal ligament incision
to decompress median nerve
– Indications for surgery: numbness and tingling ± sensory
loss, weakness ± muscle atrophy, unresponsive to conservative
measures
– Complications: injury to median motor branch, palmar
cutaneous branch or superficial transverse vascular arch, local
pain (pilar pain), scar
29. Stenosing Tenosynovitis (Trigger finger)
General:
– Definition: inflammation (not main feature) of synovium
causes size discrepancy between tendon and sheath/pulley
(most commonly at A-1 pulley): locking of thumb or finger in
flexion/extension: thickening of the fibrous sheath at the base
of a finger or thumb leads to interference with “gliding of the
tendon” and hence, inability to extend digit.
– Etiology: idiopathic or associated with RA, diabetes,
hypothyroidism and gout
– Clinical Feature:
1. Thumb, ring and long fingers most commonly affected
2. Patient complains of catching, snapping or locking of
affected finger
3. Tenderness to palpation/nodule at palmar aspect of MCP
over A1 pulley
4. Women are 4 times more likely than men to be affected
– Conservative treatment: NSAIDs, steroid injection, ƒ
surgical flexor tendon release, injections less likely to be
successful in patients with DM or symptoms greater than 6
months
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Review of Orthopedics – 2012/2013 – Brodno Szpital
– Surgical treatment: incise A-1 flexor tendon pulley to permit
unrestricted, full active finger motion
30. Hallux valgus (Bunions)
Mechanism and Epidemiology:
– Valgus alignment on 1st Metatarsophalangeal (MTP) (hallux
valgus) causes eccentric pull of extensor and intrinsic muscles:
the great toe is deviated laterally at the metatarso-phalangeal
joint.
– Reactive exostosis forms with thickening of the skin creating
a bunion
– Most often associated with poor-fitting footwear (high-
heels) but can be hereditary
– It is 10 times more frequent in women
Clinical Feature:
– Painful bursa over medial eminence of 1st metatarsal head
– Pronation (rotation inward) of great toe
– Numbness over medial aspect of great toe
Treatment:
– Cosmetic and to relieve pain
– Non-operative first: properly fitted shoes (low heel) and toe
spacer
– Surgical: osteotomy with realignment of 1st MTP joint
31. Plantar fasciitis (Heel Spur Syndrome)
Mechanism and Epidemiology:
– It is due to repetitive strain injury causing microtears and
inflammation of plantar fascia: causing an inflammatory
process at the plantar fascia, the connective tissue at the
bottom of the foot (anterior part of calcaneus).
– It affects mostly females
– Plantar fasciitis is common in athletes (especially runners)
but it is also associated with obesity, DM, seronegative and
seropositive arthritis.
Clinical Feature:
– There is morning pain and stiffness and an intense pain
when walking from rest that subsides as patient continues to
walk.
– Other findings include swelling and tenderness over the sole
– The spur is greatest at medial calcaneal tubercle and 1-2 cm
distal along plantar fascia
– Pain is also seen with toe dorsiflexion (stretches fascia)
Diagnosis:
– Plain radiographs should be taken to rule out fractures
– Exostoses (heel spurs) can often be seen at the insertion of
fascia into medial calcaneal tubercle
– The spur is reactive to inflammation, but does not cause the
pain
Edited By: Marsel Toplić
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Treatment:
– Rest, ice, NSAIDs, steroid injection
– PT: stretching, ultrasound
– Orthotics with heel cup: to counteract pronation and
disperse heel strike forces
– Endoscopic surgical release of fascia in refractory cases: spur
removal is not required
32. Achilles tendinopathy (Tendonitis)
General:
– Mechanism: it is due to chronic inflammation (more due to
degeneration) from activity or poor-fitting footwear. There
might also be a development of heel bumps
(retrocalcaneobursitis).
– Physical Examination: pain, stiffness and crepitus with
ROM. There is also a thickened tendon and a palpable bump.
– Treatment: rest, NSAIDs, gentle stretching, deep tissue calf
massage, orthotics, and open back shoes. Steroids should
NOT be injected due to the risk of tendon rupture.
– Complications: Achilles tendon rupture (severe pain)
33. Rheumatoid arthritis (RA)
Definition and Epidemiology:
– Definition: chronic, symmetric, autoimmune, systemic
inflammatory disorder that may affect many tissues and
organs, mainly synovial (synovitis with pannus formation)
joints: erosive synovitis of peripheral joints (i.e. wrists, MCPs,
MTPs).
– Epidemiology: RA affects 1% of adult population (F>M).
The age of onset is 20-40 years. It is associated with HLA-
DR4/DR1 association (93% of patients have either HLA type)
Etiology and Pathophysiology:
– RA is an autoimmune disorder with unknown etiology.
– The hallmark of RA is hypertrophy of the synovial
membrane. There is an activated rheumatoid synovium
(pannus) that grows into and over the articular surface
resulting in destruction of articular cartilage and subchondral
bone.
Diagnostic Criteria – ARA: 4 must be met:
– Morning stiffness
– At least 3 joints involved
– Hand – at least one area in wrist, metacarpal or PIP
– Symmetrical
– Rheumatoid nodules
– Rheumatoid factor
– Radiological changes typical for RA
– Destruction of joint cartilage and narrowing cartilage space,
sometimes localized erosion in bone ends
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Review of Orthopedics – 2012/2013 – Brodno Szpital
Clinical Feature:
– Joints become swollen, tender, warm, and there is morning
stiffness greater >1hr.
– There is usually a polyarthritis (symmetrical), primarily in
small joints of hands, feet, and cervical spine (larger joints like
shoulder and knee can also be involved).
– The joint involvment can lead to loss of movement and
erosion of joint surface causing deformity and loss of function.
– Specific deformities: ulnar deviation, boutonniere deformity,
swan neck deformity, and Z-thumb
– Systemic: rheumatoid nodule over olecranon, calcaneal
tuberosity & MCP jointss; fibrosis of lungs, renal amyloidosis,
atherosclerosis, MI, stroke, episcleritis, and anemia
Diagnosis:
– X-ray, USG for synovium (color Doppler shows vascular
signs in synovitis),
– MRI;
– Blood tests: rheumatoid factor, ESR, CRP, CBC, renal
function, liver enzymes, ANA
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Diagnosis:
– Biopsy: monosodium urate crystals in synovial fluid/tophus
with polarized light microscopy;
– Blood tests: hyperuricemia, ESR, WBC
– X-rays: may show tophi as soft tissue swelling, punched-out
lesions
Treatment:
– Acute gout: NSAIDs: high dose, then taper as symptoms
improve; corticosteroids (intra-articular, oral or intra-muscular)
if renal, cardiovascular or GI disease and/or if NSAIDs
contraindicated or failed; colchicine within first 24;
allopurinol can worsen an acute attack (therefore do not start
during acute flare)
– Chronic gout: avoid foods with high purine content (e.g.
visceral meats, sardines, shellfish, beans, peas); allopurinol.
Clinical Tests

1. Clinical Tests in Orthopedics – Not All Though

Treatment:
– Goals: alleviate current symptoms and prevent future
destruction of joints Ott Test:
– NSAIDs, steroids, –
– Disease modifying anti-rheumatic drugs (DMARDs):
methotrexate; antiTNF (etanercept), monoclonal antibiodies
Bragard’s Test:
–
– Other: weight loss and orthotics
Thomas’ Test:
34. Gout (Podagra/Rich Mans Disease) –

Definition, Etiology, and Pathogenesis: McMurray’s Test:

– Definition: derangement in purine metabolism resulting in –
hyperuricemia; monosodium urate crystal deposits in tissues
(tophi) and synovium (microtophi). Big toe (1st metatarsal Appley’s Test:
phalangeal at base) is commonly the first place to be affected. –
– Etiology and Pathogenesis: sources of uric acid: diet and
Derbolowsky Sign:
endogenous sources; overproduction, renal undersecretion
–
(most common), genetics, medical conditions (obesity, DM,
hypertriglyceridemia, and hyperthyroidism), drugs (diuretics). Schober’s Test:
–
Epidemiology and Clinical Feature:
– Epidemiology: Gout is most common in males >45 years Mennel’s Test:
old. It is extremely rare in premenopausal female. –
– Signs and Symptoms:
1. Recurrent episodes of acute inflammatory arthritis Valsalva Test:
2. Acute gouty arthritis: severe pain, redness, and joint –
swelling, usually involving lower extremities: attack will
subside spontaneously within several days to weeks; may recur Trendelenburg-Duschenne Sign:
3. Tophi: urate deposits on cartilage, tendons, bursae, soft –
tissues, and synovial membranes: common sites: first MTP, ear
helix, olecranon bursae, tendon insertions (common in
Lasegue Sign:
Achilles tendon) –
4. Kidney: gouty nephropathy and uric acid calculi
Soto-Hall Test:
–

Edited By: Marsel Toplić 28

Review of Orthopedics – 2012/2013 – Brodno Szpital 1.0.0
Neer’s Test: References:
– – The Toronto Notes for Medical Students 2011
– Wheeless' Textbook of Orthopaedics
Lachmann’s Test: – Current Diagnosis and Treatment in Orthopedics, 4th
– – Slides

Anterior Draw Test:

–

Pivot-shift Test:
–

Golfer Sign:
–

Anvil Test:
–

Patrick’s Sign:
–

Posterior Draw Test:

–

Thompson Squeezed Test:

–

References

1. Reference List

Edited By: Marsel Toplić 29