Islam’s notes Al Dhaid hospital

Orthopaedics notes

• Common gate in CP patient is crush gait

o Internal rotation
o Flexion of all three joints (hip knee and ankle)
o Scissoring and crossing
• perth disease ( Tb and it reach the cartilage level if affects the spine ) while any stap in
spine will not affect the cartilage.
• Transient synovitis is the most common cause for pain in hip joint mainly in
children following respiratory infection.
• Muscle are active and contracted in standing.
• Check for limping by measuring true length and apparent length

• Bryant tringle
o To check for it clinical you will draw two lines (patent should be supine)
o First line from ASIS and the bed
o Second line from ASIS and the transverse axis
Islam’s notes Al Dhaid hospital

• Thomas test: (you should know when it is positive and what does it indicate)
• We have two different angles for hip joint
o First angle: (anteversion angle) is fixed in both (adult and children) (normal
15° -20° ).
o Second Angle: Neck shaft angle
▪ Adult: 25°-30°
▪ Children 15°-20°
• To assess any X-ray, you need to have 2 views in hand and foot you will ask for AP view
and Oblique view (not lateral). All other areas you can ask for AP view and lateral view.
• Rembert rule of 2 for each Xray
o 2 views
o 2 joints (above and below).
o 2 times (before manipulation and post manipulation).
• To check for pedicles in spine injury you need lateral or oblique view.
• Fracture femur shaft > in most cases it is associated with fracture neck femur
and dislocation of hip joint so for any case of shaft fracture you should check for
all of them to avoid missing any of them ( by asking for Joint above and below
image).
• Ultrasound will be more superior to Xray and more helpful only on two cases:
(other cases you can do X-ray >> still in doubt then do CT >> MRI (not helpful) )
o Newborn tell the age of 6 months (below 6 months always ask for US)
o In case there is effusion in the joint space you should ask for US.
• CT better for bone
• MRI for soft tissue (you will ask for it only in two cases osteomyelitis and AVN)
• In synovial fluid sample (cell count level will be helpful)
o <50000 most likely it is inflammatory arthritis
o 50000-100000 most likely it is septic arthritis
• How to check for syndesmosis intraoperatively >> use the hock ( not by vision or
Xray )
Islam’s notes Al Dhaid hospital

• Know and revise ankle ligaments ( know which one is affected with any ankle
injury )

• Remember that you can always do Open reduction and internal fixation for any
fracture but should no be your first answer) you can remove the screw or the plate
after 18 -24 months
• It is not recommended to remove the screw or plate in any upper limb injury
(specially ulna and radius) because the risk of reinjury or refracture is high (keep
them lifelong).
• The most stupid question (how many muscles are attached to talus bone ??) no
muscles attached to talus bone.
• How you can differentiate between Ankle ligament injury and Ankle bone fracture
clinically?
o Ligament injury > patient can weight pair and tolerate standing
o Bone fracture > patient not able to pair weight and can’t stand.
• Classical ideal description for any Xray image should include the following:
o Type of Skelton: (skeletally mature or immature)
o View (AP or lateral or others)
o Classification of fracture: (closed or open fracture)
▪ To check for them by Xray image only you should look of the
fracture bone if it moves through the shadow of soft tissue)
o Location of the fracture
▪ (which bone?)
▪ Which third if its long bone
Islam’s notes Al Dhaid hospital

o Type of fracture (transverse, oblique, comminuted….ect)

o Displacement (displaced or not displaced) (always depend on distal
segment not proximal one)
▪ AP view (medial or lateral Displacement)
▪ Lateral view (anterior or posterior displacement).
o Alignment (draw a line in the centre)

Example: this an Ap view Xray image for (demographics) skeletal

mature patient showing closed transvers fracture of the middle third of
the femoral. Which is displaced lateral and alignment is affected.

• For any fracture

o translation is accepted
o angulation is accepted up to 10-20°
o no rotation is accepted

• If both radius and ulna are fracture you should consider it as intraarticular
fracture and in no prober, fixation done this will affect the neurovascular status
of upper limb. We need to do ORIF in this case
• Don’t forget to evaluate and document the neurovascular status with each
fractur.
• Indications for open reduction and internal fixation (remember > No CAST)
• Indications for external fixation (revise them).
• Example of sesamoid bone (patella, thumb, and big toe) no periosteum.
• In spiral fracture you may use lag screw for fixation ( it will be outside the plate
and should be added before the plate )
• For patellar fracture we will use K wire (vertical wire ) or cannulated screw
with tension bad wire ( circular wire ).
• What are the clinical signs for patellar fracture?
o Gap in the skin above the knee
o Patella is laterally wide displaced
o Massive swelling due to hemorrhage and bleeding
Islam’s notes Al Dhaid hospital

• What are the complication of K wire ?

o Hard wire complication
▪ Stiffness
▪ Irritation
▪ Pain
• Fall from hight is associated with several injuries most common fracturs are
o Calcaneal fracture
o Lateral tibia
o Mid shaft of femur
o Neck of femur
o Lumber spine
• How you can differentiate between bipartite patella and fracture of patella?
o Bipartite > congenital / fracture acquired
o You should check for sclerotic age of the bone
o Fracture line is sharp while in bipartite is not sharp.
• We have 6 extensor compartment in the hand (know the contents for each
one )
o First compartment > dequivers tenosynovitis > Finkelstein's test
o Second compartment is deep
o First and Third compartment relation to anatomical snuff box
• Anatomical snuff box binderies
• Know the anatomical location for flexor retinaculum ( Tinel test and Phalen
test )
• How to check for deep fekixior muscle tendon
o Hold the middle finger and ask for flexion
• Axillary nerve give sensory supply upper lateral part of deltoid. .
• Revise the brachial plexus
• Remember that extensor carpi redials take innervation before radial nerve
reach elbow
• Brachialis supply by two nerve
• O TEST for median nerve (flexor muscle )
Islam’s notes Al Dhaid hospital

• Recurrent median supply 4 muscle (LOAF)

• Revise muscle of hand
Islam’s notes Al Dhaid hospital

• From this point tell the end you should know every Xray for every
fracture mentioned
• How to approach a trauma patient in ER
o ABC rule
o Insert venous cannula
o Monitor the vitals and stabilize the patient
o Control source of bleeding if any is present
o History and physical examination (mention neurovascular assessment)
o Back slap for pain control and Xray and labs
• Anterior shoulder dislocation can be diagnosed easily be Xray and it is more
come while posterior can be missed.
• Posterior elbow and hip dislocation are more common than anterior.
• Hill-sachs sign on Xray >> indicate recurrent shoulder dislocation
• What is the most common way for reduction in case of Clavicle fracture?
o Arm sling ( no back slap don’t be dump )
• How to mange mid humeral shaft fracture
o Close reduction and manipulation with POP
o If failed open reduction internal fixation
• How to mange olecranon fracture
o Remember it is intraarticular fracture so it should be surgical manged
by tension band wire
• Supracondylar fracture
o Most common complication is brachial artery injury >>> lead to Volkmann
ischemic contracture
o Neural injury > median nerve
• Fracture head of radius
• Fracture ulna
• Anatomical snuff box tenderness and swelling sign of scaphoid fracture not
always appear on Xray
o If fracture doesn’t appear on Xray >> put back slap and redo Xray after
one week (fracture will appear late due to action of osteoclast)
Islam’s notes Al Dhaid hospital

• monteggia fracture vs. Galeazzi fracture (know the management )

• Colle’s fracture vs smith fracture

o colle’s:
▪ distal segment posterior
▪ fork deformity (planter flexion splint)
o smith:
▪ distal segment anterior
▪ dorsiflexion splint

• Green stick fracture

o Affect Pediatrics
o Management back slap
Islam’s notes Al Dhaid hospital

o Know the classification

• Scaphoid fracture
o MOST Common complication is AVN to proximal part ( not distal )
o Management: put back slap for 5-10 day then complete plaster of paris
(POB)
• Pelvic fracture we do Thomas splint
• Check distal pulsation with femur fracture (
o Posterior tibial and dorsalis pedis
• Hip dislocation (4 clinical features)
o Positioning
▪ Flexion, Adduction, and internal rotation of hip joint
▪ Flexion of knee joint
o Inability to move or walk
o Previous history of trauma or dashboard injury
o Cant palpate femoral artery ( ….. sign )
• Fracture neck of femur
o Complication AVN of head
o How to manage
▪ Young patient > multiple screw fixation
▪ Old patient > hemiarthroplasty but if the acetabulum is affected do
total hip replacement
• Trochanteric fracture
o Management: dynamic hip screw due to rich blood supply
• DDH (revise the angles and the lines from Doctor Assam lecture)
• Patella fracture
o Nondisplaced > back slap
o Displeased > K-wire with tension band wire

• Leg fracture: any lower limb fracture should be managed by the following steps
o Nailing ( if difficult )
o Open reduction and internal fixation with plate and screw.
• Open fracture ( X-ray tibia )
o External fixation
Islam’s notes Al Dhaid hospital

o Don’t forget that you should clean the would and due debridement
• Fall from hight you should do 3 Xray
o Calcaneus
o Pelvis
o Lumbar spine

• Bone tumour
o Age Below 18 years old >> aneurysmal bone cyst
o Age above 18 years old >>> Giant cell tumour
o Treatment for both excessive curettage and bone graft
• Osteoid osteomas > pain at night relieved by aspirin > Do CT scan
• Osteosarcoma
o Metaphysical lesion
o Anemia
o Sunshine appearance on Xray
• Ewing sarcoma
o On diaphysis
o Onion layers appearance
• Perth disease ( revise it )
• Osteomyelitis ( 4 findings )
o Bone cavity formation
o Sinus
o Dead bone sequestrum
o involucrum Bone lesion

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