Venn Watson Classification of polydactyly

1. Post Axial (lateral side of foot)

- Y – metatarsal
- T – metatarsal
- Wide metatarsal head
- Complete duplication
2. Central (not part of original classification)
Duplication of the second, third and fourth toe
3. Pre axial (medial side of the foot)
- Short block first metatarsal
- Wide metatarsal head

Source :
McGlamry’s Comprehensive Textbook : Foot And Ankle Surgery. Volume 1 Third Edition
Classification Non Union Fracture

1. Septic Non Union

2. Pseudoarthrosis
- typically adequate vascularity
- excessive motion / instability
- false joint form over significant time
3. Hypertrophic Non union
- Caused Inadequate Immobilization with adequate blood supply
- Collagen type 2 is elevated
- Typical heal once mechanical stability is improved
- Callus (+) without bridging bone
- Elephant foot  abundant callus
- Horse hoof  less abundant callus
4. Atrophic Non Union
- Caused inadequate immobilization with inadequate blood supply
- Callus (-)
- Ischemic or cold on bone scan
5. Oligotrophic Non Union
- Produce inadequate reduction with fracture fragment displacement
- Minimal callus
- Vascularity is present in bone scan
- Occurs after major displacement / distraction fragment

Avascular non union

 Torsion wedge non union

intermediet fragment heal to one fragment but not to the other
 Comminuted non union
Intermediet fragment are necrotic
 Atrophic non union
Internediet fragment are missing and scar tissue that lacks osteogenic
 Defect non union
Loss fragment diaphysis bone

Source :
Textbook of Disorder and Injuries of The Musculosceletal system, Robert Bruce Salter. Third
edition
Classification Nerve Injury (Seddon) :

1. Neuropraxia
- Slight damage to the nerve
- Focal nerve compression
- Transient loss of conductivity, particularly in motors fibers
- Wallerian degeneration (breakdown of the myelin sheaths into lipid material and
fragmentation of the neurofibril)
- Histopathology shows focal demyelination of the axon sheath
- Usually caused by local ischemia
- Complete recovery may be expected within a few days
2. Axonotmesis
- Injury damage the axon
- Prolongations of the cells in the spinal cord
- Endonerium remains intact
- Fibrillation and positive sharp waves on EMG
- Does not damage the structural frame work nerve itself
3. Neurotmesis
- Disruption of endonerium
- Structural framework and the enclosed axon are divided torn or destroyed
- Wallerian degeneration occurs in distal segment, because axon on the proximal
segment have lost their nerve tube
- No recovery unless surgical repair performed

Seddon Myelin Axon Endoneuri Wallerian

Degree Reversible
Type Intact Intact m Intact Degen.
Neurapraxia 1st No Yes Yes No reversible
Axonotmesi
2nd No No Yes Yes reversible
s
Neurotmesis 3rd No No No Yes irreversible

Sunderland Classification
1st degree
Same as seddon neuropraxia
2nd degree
Same as seddon axonotmesis
3rd degree
- Included within seddon neurotmesis
- Injury with endoneurial scarring
- Most variable degree of ultimate recovery
4th degree
 - Included within seddon neurotmesis
- Nerve in continuity but at the level of injury there is complete scarring acroos the
nerve
th
5 degree
Included with seddon neurotmesis

Sunderland Myelin
Axon Endoneurim Perineurium Epineurium
Grade Sheath
I Disrupted Intact Intact Intact Intact
II Disrupted Disrupted Intact Intact Intact
III Disrupted Disrupted Disrupted Intact Intact
IV Disrupted Disrupted Disrupted Disrupted Intact
V Disrupted Disrupted Disrupted Disrupted Disrupted

Source :
Textbook of Disorder and Injuries of The Musculosceletal system, Robert Bruce Salter. Third
edition

Degeneration Wallerian :
Degeneration that result when nerve fiber is cut and the part axon distal to injury (farther from
neuron cell body degenerate
Eponym Distal Radius Fracture

Die Punch Fracture :

Depressed fracture of the lunate fossa of the articular surface of the distal radius

Burton fracture :
Fracture dislocation radiocarpal joint with intraarticular fracture involving dorsal and volar lip
Chauffer fracture :
Styloid radius fracture

Source :
Textbook of Disorder and Injuries of The Musculosceletal system, Robert Bruce Salter. Third
edition

Evans Classification
Type I :
Fracture line extend to upward and outward from lesser trochanter. Type I fracture can be further
subdivided as :

IA : undisplaced two fragment fracture

IB : displaced two fragment fracture
IC : Three fragment fracture without posterolateral support, owing displacement greater
trochanter fragment
ID : three fragment fracture without medial support, owing displacement lesser trochanter or
femur arch fragment
IE : four fragment fracture without posterolateral and medial support.

Type II :
Fracture line extend downward and outward from lesser trochanter. These fracture are unstable
and tendency to drift medially
Source :
Rockwood and green fracture in adults vol : 2. Philladelphia : Lippincot Williams and Wilkins

Complication Intertrochanter Femur fracture :

1. Implant Failure and cutout
Incidence : most common complication
: usually occurs within 3 months
Cause : tip – apex distance > 45 mm associated with 60% failure rate
Treatment : young  corrective osteotomy and revision ORIF
: elderly  total hip arthroplasty
2. Anterior perforation of the distal femur
Incidence : can occur following intramedullary screw fixation
Cause : mismatch of the radius of the curvature femur (shorter) and implant
(longer)
3. Non union
Incidence : < 2%
Treatment : revision ORIF with bone grafting
: proximal femoral replacement
4. Malunion
Incidence : varus and rotational deformities are common
Treatment : corrective osteotomies

Source :
Rockwood and green fracture in adults vol : 2. Philladelphia : Lippincot Williams and Wilkins
Type of Mallet Fingers (doyle’s classification)

Type I - closed injury with or without small dorsal avulsion fracture

Type II – open injury (laceration)
Type III – open injury (deep soft tissue abrasion involving loss skin and tendon substance)
Type IV – mallet fracture
A – distal phalanx physeal injuries
B – fracture fragment involving 20 – 50% of articulare surface
C – Fracture fragment > 50% of articular surface

Etiology Mallet Finger

Finger deformity caused by disruption terminal extensor tendon distal to DIP joint. The
disruption may be bony or tendinous

Mechanism injury
1. Traumatic impaction blow (sudden force flexion to the tip of the finger in the extended
position)
2. Forces the DIP joint into forced flexion
3. Dorsal laceration

Source :
Salter, R.B. text Book Of Disorder and Injuries of The Musculosceletal System

Difference between classical – modified henry approach

Classical Modified
Approach Between brachioradialis Between flexor carpi radialis tendon
and radial artery and radial artery
Radial to radial artery Ulnar to the radial artery

Dangers of henry approach

1. Posterior Interosseous nerve (arcade of frohse)

- The arch is formed by thickened edge of the superficial head of supinator muscle
- Compression of the nerve produce paralysis of extensor (PIN entrapment syndrome)
- Injury lead to neuropraxia that takes 6-9 months to resolve

Step to protect PIN :

- Dissecting supinator of radius subperiostally

- Don’t place retractor on posterior surface of radial neck
- Avoid excessive radial retraction of supinator

2. Superficial radial nerve

Damage can cause painful neuroma
3. Radial artery
Rundown middle of forearm under brachioradialis

Source :
Rockwood and green fracture in adults vol : 2. Philladelphia : Lippincot Williams and Wilkins
Damage Control Orthopaedic
Definition :
 Definitive treatment delay until physiology already improved
 Popularized in 2000
 Replaced the 1980s philosophy early total care (ETC), concept fixing long bone fracture
as soon as possible because patient were “too sick not to operate”
 ETC lead exacervation second hit patient with haemodynamic unstable, head injury
Purposed :
to avoid worsening of the patient condition by the “second hit” of major orthopaedic procedure
and to delay definitive fracture repair until time when the overall condition of the patient is
optimized.
Minimally invasive surgical technique such as external fixation are used initially.
Involves staging definitive management to avoid adding trauma to patient during vulnerable
period.
- The decision to operate and surgical timing on multiple injured trauma patient
remains controversial.
- Intraoperative hypotension increases mortality rate in patient with head injury.

Parameter that help decide who should be treated with DCO

1. ISS > 40 (without thoracic trauma)

2. ISS > 20 with thoracic trauma
3. GCS 8 or below
4. Multiple injury with severe pelvic / abdominal trauma and hemorrhagic shock
5. Bilateral femur fx
6. Pulmonary contusion
7. Hypothermia < 35 degree
8. Head injury with AIS of 3 or greater
9. IL -6 values above 500 pg/dl

Optimal time of surgery

Patient are at increased risk of ARDS and multisystem failure during acute inflammatory
window (period from 2-5 days characterized by a surge in inflammatory marker)Therefore only
potentially life threatening injuries should be treated in this period :

- Compartement syndrome
- Fracture with vascular injuries
- Unreduced dislocation
- Cauda equine
- Unstable pelvic fracture
- Traumatic amputation
- Unstable spine fracture
 - Open fracture

Stabilization followed by staged definitive management

To minimize trauma initially stabilization should be performed and followed by staged definitive
management. Include initial pelvic volume reduction via sheet, pelvic packing, skeletal traction,
external fixation.

If hemodynamic stable  proceed CT scan chest abdomen pelvic

If hemodynamic unstable  consider pelvic angiography and embolization

Definitive treatment delay for :

- 7-10 days for pelvic fracture

- Within 3 weeks for femur fracture (conversion from exfix to IMN)
- 7-10 days for tibia fracture (conversion from external fixation to IMN)

hemorrhagic shock classification – fluid resuscitation

Class % blood HR BP Urine PH MS Treatment

loss
I 15 % - Normal Normal 30 ml/hr Normal Anxious Fluid
<750 ml
II 15-30% - > 100 Normal 20-30 Normal Confused Fluid
750- ml/hr
1500ml
III 30-40% - > 120 Decrease 5-15 Decrease Lethargy Fluid +
1500- ml/hr blood
2000 ml
IV > 40% - > 140 Decrease negligible Decrease Letarghy, Fluid +
> 2000 coma blood
ml

Source :
Journal of Bone & joint Surgery. Volume 87 number -2
Floating shoulder

Whereas an isolated fracture of the glenoid neck is stable, if there an associated fracture of the
clavicle or disruption of the acrominon clavicular ligament the glenoid mass may become
markedly displaced.

Scapular neck fracture associated AC joint separation or clavicula fracture

Source :
Apleys System of Orthopaedics and Fracture. Ninth edition. Luis Solomon, David Warwick.
Page 735-7

Classification osteomyelitis

1. Timing classification :
- Acute : within 2 weeks
- Subacute : within one to several months
- Chronic : after several months
2. Cierny mader classification (describe the anatomical involvement, host, treatment and
prognosis)
 Anatomical location
- Stage 1 : medullary
- Stage 2 : superficial
- Stage 3 : localized
- Stage 4 : diffuse
 Host type
- Type A : normal (good system immune)
- Type B : compromise locally or systemic
 - Type C : treatment is worse to patient than infection, require suppressive no
treatment, minimal disability, not surgical candidate
Principle treatment osteomyelitis :
 Improve general condition
 Eradication infection with debridement, sequestrectomy, IV antibiotic
 Stable fixation
 Managing dead space

Xray osteomyelitis :
A : shortening, rotation, valgus deformity
B : multiple site bone rarefaction, sequester, involucrum, osteopenia bone
C : bone rarefaction, articular sclerotic change in hip and knee

Operative treatment :
Irrigation and debridement followed organism specific antibiotic
Indication :
- Stage III and IV osteomyelitis
- Abcess formation
- Draining sinus
Surgical fixation technique :
- Ilizarov technique
- Intramedullary nail with or without external fixation
- Masquelet technique
- Free tissue transfer
- In situ reconstruction
Source :
Apleys System of Orthopaedics and Fracture. Ninth edition. Luis Solomon, David Warwick.
Page 30-42

Prophylactic treatment
1. Prevention of post operative sepsis
For clean surgical cases, administer 1 hour pre operative and continue 24 hour
postoperatively
2. Perioperative use
First generation cephalosporin in cases necessitating hardware
3. Shorter course of prophylactic antibiotic
Decrease the likehood that bacteria will develop resistance
Initial care after an open traumatic wound
1. Type 1 and 2 open fracture
First generation cephalopsporin are the treatment of choice
Some authorities suggest adding an aminoglycoside or second generation cephalosporin
2. Type 3 A open fracture
First generation cephalosporin plus aminoglycoside
Penicillin added for grossly contaminated (type B)

Source :
Review of Orthopaedic. Sixth edition. Mark D. Miller. Page 102
 Description of Musculosceletal Tumor Radiology

Patient identity Name, age, sex

Photo quality
1 identification

Region

Projection AP, PA, Lateral, Oblique

Epifisis Metaphysis Diafisis

2 Location

Central Excentric Cortical Junxts

cortical

3 Lesion lytic Blastic mixed

Geographic Moth eaten Permeative

Narrow Well defined margin

4 Transition
zone
Wide Ill defined margin

Solid butressing Expansion septation

Osteoid
5 Matrix
Chondroid

Non aggresive Codman triangle

Periosteal
6
2 reaction
aggresive Sunburst app

hypodens Laminated
7 Soft tissue

Hyperdens Half on end