Dr.

Ma§oud Page 1
 :
Major General Dr.
Hesham El-Ashry,
FRCS. Cap.Dr.
”Head of orthopedic Mahmoud Massoud,
trauma surgery Dep. MsD.
Helmya Military hosp. “A.Lecturer of orthopedics
& Ilizarov consultant” AFCM, Military Academy ,
Helmya Military hosp.”
Major General Dr.
Mahmoud Sami,
FRCS. Reference Sources:
“Orthoopedic consultant - American Academy of Orthopaedic Surgeons.
Helmya Military hosp. (AAOS) emergency book.
Pelvis trauma surgery & - AO Journals of orthopedic trauma.
Arthroplasty”
- Rockwood and Green's Fractures in Adults.
Brig. General Dr. - Netter's Orthopaedic Clinical Examination.
Ihab Hosney, - Netter's Concise Orthopaedic Anatomy.
- Campbell's Operative Orthopaedics.
MD. - Handbook of Fractures (Zukerman).
“Orthoopedic consultant at - McRaes Orthopaedic Trauma.
Helmya Military hosp. - Orthobullet trauma.com
& Spine Endoscopy
consultant” - Decision Making in Orthopaedic Trauma.
Lieut.Col.Dr. - Comprehensive Review in Orthopaedics.
Mohamed Kamal, - Harborview Illustrated Fracture Surgery.
- Trauma and Orthopaedics at a Glance.
MD. - Clinical Orthopaedic Rehabilitation.
“Lecturer of Orthopedics - Royal collage orthopedic trauma.
Surgery AFCM - Orthopaedic Knowledge Update.
& Arthroscopy - Low back pain algorithm paper.
consultant” - Orthopedics Quick Review.
- Hand Secrets book.
- Google images.

- Helmya Military hosp. Scintific Meeting days.

- Military Academy Lectures & workshops
- AFCM Orthopedics basic lectures.

Dr. Ma§oud Page 2

 By, Cap.Dr. Mahmoud Massoud, MsD.
“A.Lecturer of orthopedics AFCM, Military Academy , Helmya Military hosp.”

-1st you should know the basics from simple book I prefere McRaes Orthopaedic Trauma
book for its simplesity & comprehensive talk.→
-You should minded Scheme inside the frame very well, every point has a meaning and
significance as collected information.
-Then you can use the Algorithm for each topic, I begin with management for its
importance then added the extra-information outside the frame & labeled red for
operative data or referenced in operative books.
-I recommends key Techniqes in orthopedic & K-wiring Techniqes as
complementery operative books to our book→
-You may face or asked for a single point inside a topic you must
collect it from both Scheme & Algorithm.
- Extra notes outside Algorithm I write it with italic blue font .
-Arabic words inside is for assistance & memorization not part of
Algorithm & not written in exams.

First and above all thanks to ALLAH.

My sincere thanks to my colleges in Helmya Military
hospital & AFCM orthopedic department.
To my son, Eyad.

Dr. Ma§oud Page 3

Dr. Ma§oud Page 4
*Definition: -Investigations (Vx) + imp.:
Discontinuity of a bone/joint surface. 1.X Ray: is mandatory as part of examination
*Historical background: Adequate :A. contain name age date
-1st mentioned(BC) B. 2 views: AP/lateral for all except hand &foot
-1st surgical intervention(around…s) AP/oblique + other specific, 2 joints: above
bellow , 2limbs compare, 2 occasions: some
*Anatomic consideration: occult #appear later(stress #)
-emberiologic(ossify)
C. Comment: OLD ACID
-surgical - biomechanics
O: open or closed# L: location
*Incidence: D: displacement A: articular
-common age, sex, place C: comminution I: intrinsic bone quality .
-risk factors D: degree
*Aetiology (mode) Ae.: 2.CT: Best view for bone and articular surface
- high-low injury with details Spine fracture 3D CT is agood
- direct -indirect injury reconstructive Hazard for dangerous irradiation
-pathological NB.Bone appear white & water black
3.MRI (see more soft tissue)
Search for water in widest view eg csf, synovial
*Diagnosis: T1(black): show pathologic lesions (tumors)
-History & Pt complaint(C/o): T2(white):Water = edema= effusion
What brings patient to the hospital X OCD Structures appear dense Ligaments eg ACL PCL
Onset,Coarse,Duration X MCL LCL Cortical bone Disc , spinal cord
1.Pain + history of trauma NB . expensive but high resolution
‫معاه ايه‬/‫بيقل بايه‬/‫بيزيد بايه‬/‫بيسمع فين‬/‫فين‬ 4.Ultrasound (US is the new part of
2.Swelling: site,size,shape,surface,consistency examination) : for soft tissue & joints capsule,
............... +Deformity. ligaments- one of the best imaging techniques
3. Disturb of function: in musculoskeletal radiology because it is low in
 Stiffness  Instability cost, has high spatial resolution, wide
Locking Giving away availability in hospitals, is well-tolerated by
4.Other: Snap (click), Tingling,Numbness(level). patients and is not biologically invasive, as it
5.associated injuries: chest, abd. uses sound waves and non ionizing radiation.

-Examination (Ex.): whole limb, bared

*Look : 3D / 5S imp.: diagnostic, prognostic, communication
skin,scar,swelling,sinus, symmetry(m.wasting).
*Feel: T T TRUCK 5. Lab.
temperature,tenderness, crepitus -CBC (WBCs) in sepsis exceeds 50,000/μL, with
*Move : ‫برضاه وغصب عنه‬ more than 75% PMNL , CRP (  withen 2hrs
active then passive + ROM + m.power 2ds) early dx , ESR  (  withen 2ds 2wks)
*special tests + imp. follow up.
*Neurovascular: intact / impaired. ‫مهم مهم مهم‬ -Pre-&post-op. profile: bleeding, HB%, liver,
document, medicolegal kid., DM, viruses, Hs

Dr. Ma§oud Page 5

*Complications:
Choose the commom for the site
#General early: shock:
*Neurogenic(pain) ttt by morphia
*hypovol. ttt resustation fluids
#General late: prolonged bed recumbancy
*chest: infection, atelectiasis, pulmonary
embolism
*GIT: gastric ulcers, paralytic ilus,
constipation
*UT: UTI, stones, retention
*LL: ulcers, m.atrophy, DVT
#Early ← Local → # late
* injury skin……….……….......*Sepsis OM
* injury SC….....................*Volkmanns isch
* injury muscle………..…....*Myositis ossi.
* injury tendon……………..….*Deformity
* injury N…………….…*Seudeuk atrophy
* injury Vs……….….......*Compartement $
* injury growth plate………....*Gross arrest
* injury joint…….…………….....*Arthritis
* bone………….....*Delayed/Non/Malunion
* injury viscera………...….*Psychoneurosis
3. local analgesia (best, no general
complications, best done using US)
Hematoma block or N block
4. Mechanical analgesia (reduction+ slab)
↓ pain , swelling & NVcompression
-Local:
1-conservative:
Indication(i.), method
2-operative:
Indication(i.), method, approach, postop.
IMN (i.)-segmental-open-failed plate
-pathologic-osteoprotic
Ex fix (i.)-open-infected-burn-bone loss
DCO ( damage control orthopedic) do
minimal surgery allow less general
damage by systemic inflammation till
return general normal function prevent DIC.

*Treatment (ttt): Operative indications: ( PV ON U ) 333

P *Polytrauma pt with multiple #
-Aim: *Bilateral #
1. releif pain, regain function(ROM) *Pathological#
2. stability,bone reduction, joint congruity V Vascular injury
3. decrease complication O Open #
N Neurologic injury (spine)
-Factor affecting ttt:‫انا والعيان والكسر‬ U *Uncompliance pt
Surgeon: capability, facilities *Union (non,mal)
Patient: age, general codition, occupation *Unstable
Hand dominant (UL), ambulation(LL) (shaft>50% displacement/
Fracture: pattern, comminution, deformity, angle >200_400/ no rotation
soft envelope, bone quality. accepted)
(Articular surface >2mm )
-General:
ABCD…Resus. Stabiliz the pt.
1st aid immobilization -TTT of complication don’t forget?
Analgesics lines & complications of ttt ?
1.Morphia: nalophen/ pethiden amp.
‫سم عند اللزوم‬٢ ‫سم و يعطى‬٠١‫يحل على‬
2.NsAID+paracetamol (perflgan vial)

Dr. Ma§oud Page 6

 -Follow up: Estimated Time to Return to Work:

-from early-till recovery

-Clinic:
General :operation skin scar swelling
Local: union/3
h/ no pain, Ex.no pain on ROM active &
passive, x ray callus
Standard x ray true/dead views:
J. AP Lat.
Hip & Mid limb Tilt pt 450
Shoulder roration ‫واقف‬ ‫مايل‬
Knee & Patella )T&C) 2 condyles ‫واحد‬
elbow forward F.(H.)seen as 1
Ankle & Foot (hand) 2 malleolus (RU)
hand forward overlap

-Physottt :
Open / Closed chain exercises. After clinical examing the pt:
Stretching/Strenthing. % Functional recovery = 4/ ‫مجموعهم‬
Rehabilitation: (%Pain recovery + %ROM gain + %ability to bear
*Rest 1week RICE protocol )rest-ice- weight + %muscle strength recovery)
compression-elevation ) ‫االلم خف بنسبة اد ايه؟‬
*(PAPAR F) ‫بابار فيل‬ ‫الحركة رجعت بنسبة اد اية؟‬
PAPAR F ‫المدة‬ ‫تقدر تشيل وزن زى االول؟‬
Pendulum 2w - ‫من بعد اسبوع‬ ‫العضالت اتحسنت ؟‬
Assisted -4w ‫حتى اخر الشهر‬ %Pain recovery = VAS
(not full ROM)
Passive >4w- ‫من بعد شهر‬
Active -6w ‫حتى شهر ونص‬
Resisted = WB >6w‫من بعد شهر ونص‬
Free ROM >12w ‫ شهور‬3 ‫من بعد‬
* NWB: non wt bear
then progressive partial weight bearing
WBAT :wt bear as tolerated (25%/week)
till FWB:full wt bear
* Orthosis for rest 1st w /then 6w in public
or complications
(brace for bone-hinge for joint 150/w).
*Distal is distal ‫البعيد عنك بعيد‬
Distal H, F, T, Talus, Calc. if un stable need
longer period habilitation >6m.

Dr. Ma§oud Page 7

Dr. Ma§oud Page 8
Polytrauma Patient Acute Pain Management
Algorithm Algorithm
-Assess ABCs per ATLS guidelines -splinted in the ER,
-Chest X-ray Pelvis X-ray -limb elevated and iced,
-Signs of Hemodynamic Instability -consider regional block
Systolic BP < 90 - short acting IV opioid of choice
Heart Rate > 100

Plan for a narcotic tapering protocol over

the first 2 weeks after surgery LONG acting
oral opioid

-Hemorrhagic shock III, IV ?

- Resuscitate with blood products in a 1:1:1
(PRBC:FFP:PLT)
-Hemodynamic stability achieved?
No yes Contraindications
Consider exploratory Parameters Inability to understand/use PCA
laparotomy, Suggesting Need of Increased intra-cranial pressure
extra-peritoneal Further.Resuscitation Sleep apnea or respiratory compromise
pelvic packing or -Mean Arterial
interventional Pressure < 60 -NSAIDS
radiology for angio/ -Heart Rate > 100
embolization -Urine output <
depending 30cc/hour
on surgery protocols -Lactate > 2.5
-Base deficit >5
-Gastric Mucosal
pH<7.35
DCO Contraindications (BARS)
ICU Bleeding (Coagulopathy)
Asthma (10% of asthmatics)
Renal Disease
Stomach (peptic ulcer/gastritis)

Dr. Ma§oud Page 9

 Ballistic Injuries
Algorithm

-High velocity
Treat as open fractures
-Low velocity
Non-operative Operative Intra-articular Pelvis/Aceta
fracture fracture fractur bulum
IV +Surgical Arthroscopic Bowel
cephalosporin I&D as vs. open I&D involvement
for 24 hours required to ?
PO during remove Broad
cephalosporin fracture osteochondral spectrum
Limb assessment: for 7 days fixation fragments antibiotics
Vascular injury
Fracture IMN: and foreign for
Motor and sensory function
immobilization superficial bodies 2 weeks
Compartment syndrome
Bedside, I&D Fixation as Operative
Size of wound
superficial ORIF: necessary for fracture?
Degree of soft tissue damage
I&D extensive large Surgical
Fracture stability
I&D articular I&D as
Fracture fragments, required for
Injury assessment: fixation excision of
Suspected Mangled extremity? fixation
small
Suspected vascular Injury?
articular
Unstable fracture pattern?
fragments
Adequate tetanus immunity?
PRN – "Pro Re Nata" –
as circumstances arises.
I&D – Irrigation and Debridement

Dr. Ma§oud Page 10

Vascular injuries Nerve Injury Algorithm
Algorithm -Motor or sensory deficiencies
closed Open fracture or
-Any limb injury should be suspected for
Wounds dislocation
having a vascular injury
Ultrasound Treat open Urgent
-Diminished or absent pulses
to rule out wounds reduction
-Reduce dislocation or fracture
nerve If possible,
-if present/Absent pulses?
disruption explore
- Assess pulse with Doppler
the nerves
- Measure ABIs
-Obtain NCS/EMG in 10 to 14 days

-ABI < 0.9

- CT angiography
- Plan for joint revascularization and
fracture fixation surgery
Neurapraxia Axonotmesis Neurotmesis
Observe Regeneration Exploration
Expect – 1mm/day Nerve repair
recovery Repeat Nerve
within NCS/EMG reconstruction
8 to 12 in 2 to 3
weeks months

Dr. Ma§oud Page 11


Venous Thrombo-embolism
(VTE) Prevention Algorithm
-Every patient admitted to the ortho trauma
should be assessed daily for VTE
- Is patient on Warfarin or OAC?
- Is patient on antiplatelet treatment?
- Is patient at risk for VTE?
- Is fracture/procedure high/moderate
risk for DVT?
- Daily exam for signs of DVT
- Duplex ultrasound LL
Dr. Ma§oud
-Dyspnea=PE Perform chest CT angiogram
- Encourage early mobilization ‫ مرتبة هوائيه‬-
Intermittent Pneumatic Compression (IPC)
- SC Enoxaparin 40mg qd ‫كليكسان‬
*Stop Enoxaparin 12-24h before surgery
*Start at 10 am day after surgery
*Continue prophylaxis:
Moderate risk: 14 days
High risk: 6 weeks
Until patient is ambulatory
-For PE start Enoxaprarin 1 mg/kg q12h
-Contraindication for Chemoprophylaxis
Brain aneurysm
Intracranial hematoma
Spine injury and spine surgery
(controversial)
Ongoing bleeding
Major uncorrected coagulopathy
Page 12
 Embolic Disease Management
Algorithm

-Monitor patients for signs of

hypoxia/tachypnea/tachycardia/pleuritic
-Administer oxygen 10 L/min
-Obtain D-dimer, ABGs-Obtain ECG
-Consult ICU
- Pulmonary CT angiogram
No PE Sub- Segmental/
+Signs or segmental Central PE
risk of fat PE
embolism? small PE?
Discharge on observation Lovenox 1
anticog. PE recurrent mg/kg Q12h
Consider Consider Stop when
Prednisolone lifetime INR 2-3and
Warfarin Warfarin
10mg Q24h

Dr. Ma§oud Page 13

Post-operative Infection
-Acute
within 2 weeks of post-op. R/H/T/S/P
(red-hot-tender-swallen-pus)
-Baseline CBC, CRP, ESR
-I&D and ≥3 sets of
-cultures
-Obliterate dead space and provide drainage
-Consider use of Dakin solution
-Consider adding absorbable antibiotic
Cement
-IV antibiotics Adjust according to culture
-Assess biweekly CRP including 2 weeks
after completing IV antibiotics
-Chronic
Signs of infection around a year
or more after fracture fixation
-Classify patient (host) according
to Cierny/Mader classification
Dr. Ma§oud
-Is this a type B host?
Take action to correct/optimize as many
of the identified comorbidities as possible
-CT – for assessment of bone involvement,
MRI – for soft tissue involvemen
-Take at least 3 culture & pathology.from
deep tissues specimens
Consider removal of all hardware
I&D up to well perfused soft tissue
& bleeding bone ("paprika sign").
Preserve as much tissue as possible
dead space in the wound?
Fill dead space with antibiotic cement,
muscle flap, acute shortening, or
bone transport
bone stable?
Add external or interal fixation
2nd recurrence Non-eradication?
Consider muscle flap to needed area
Patient Comorbidities Affecting
Treatment & Outcomes:
Local factors:
Chronic edema-Venous stasis-Large vessel
disease-Arteritis-Extensive scar-Radiation
fibrosis-Obesity-Foreign body
Systemic Factors:
Malnutrition-Immune deficiency-Hypoxia
Malignancy-Diabetes-Old age
Organ failure-Bleeding diathesis
Nicotine abuse-Intravenous drug abuse
Drug inhibitors of bone healing
(e.g Dilantin or fluoroquinolones)
Skin colonization
Page 14
Mangled Extremity Algorithm Compartment Syndrome Algorithm

-Crush injury -Any significant limb injury should be

-Evaluate limb viability assessed for CS
(calculate MESS score) -High-moderate risk injury for CS?

Patient alert and oriented?

No Clinical
- Limb viable? signs of CS?
No Yes Continuous Worsening Full release
Amputation surgery shared decision with 4h CP trend of all
patient and family compartment or compartments
regarding pressure (CP) CP>45mmHg
Limb salvage measurements or
surgery (measure all CP
External fixation, compartments within
wound management, near the 30mmHg of
and antibiotics fracture site). diastolic
Keep limb in pressure
- Key Results of LEAP Study Sickness neutral
Impact Profile and return to work is not elevation
significantly different between amputation Consider negative pressure dressing
and reconstruction at 2 years. Delayed Primary Closure possible?
Loss of plantar sensation is not a contra Skin graft
indication for reconstruction.

Dr. Ma§oud Page 15

Compartment Syndrome
-is an increased pressure within one of the
body's anatomical compartments results in
insufficient blood supply to tissue (stop
tissue perfusion) within that space.
-Acute Pain out of proportion, Paresthesia,
Paralysis Pallor and pulselessness is the end.
Chronic chronic exertional compartment
syndrome
Dx intracompartment pressure higher than
30 mmHg of the diastolic pressure
Ttt removal of the external compression
Surgical decompress the compartments
(fasciotomy urgent) Key p.74 / 225
Volkmann's contracture
-is a permanent flexion Contracture of the
hand at the wrist,
-acute ischaemia and necrosis of the muscle
fibres resulting in a claw-like deformity
(DD.) of the hand and fingers.
klumbeks#/ulnarN#/ burn /Dupytren
-Passive extension of fingers is restricted
and painful.clinical dx.
-Prevention is best treatment good splint
position.+ vit.C
Dupuytren's contracture
Viking disease
-small, hard nodules (tenosynovitis )just
under the skin of the palm, hen worsens over
time until the fingers can no longer be
straightened. While typically not painful,
some aching or itching may be present. The
ring finger followed by the little and middle
fingers are most commonly affected
- Risk factors include family history,
alcoholism, smoking, thyroid problems,
liver disease, diabetes, previous hand
trauma, and epilepsy
-Ttt. steroid injections / physical therapy
radiation therapy, needle aponeurotomy
(NA), collagenase injection
surgical: dermofasciectomy ( Recurrence
rates are high)
arthrodesis.
Dr. Ma§oud
Complex regional pain syndrome
(CRPS)
also known as reflex sympathetic
dystrophy (RSD)
Type I does not exhibit demonstrable nerve
lesions Seudeuks atrophy,
Type II, formerly known as causalgia
evidence of obvious nerve damage
*Stage" one is characterized by severe,
burning pain at the site of the injury, muscle
spasms, joint stiffness, restricted mobility,
rapid hair and nail growth, and vasospasm.
*Stage" two is characterized by more
intense pain. Swelling spreads, hair growth
diminishes, nails become cracked, brittle,
grooved and spotty, osteoporosis becomes
severe and diffuse, joints thicken, and
muscles atrophy.
*Stage" three is characterized by
irreversible changes in the skin and bones,
while the pain becomes unyielding and may
involve the entire limb. There is marked
muscle atrophy, severely limited mobility of
the affected area, and flexor tendon
contractions
Dx by NCS
Ttt prophylactic better
Neurotonics + Gaptin+ physo ttt
Myositis ossificasns
-Heterotopic ossification mesenchymal stem
cells in fracture hematoma turn into
osteocytes & deposit ca in muscle tissues.
Dx 2 weeks earlier by ultrasound (US) non
hereditary myositis ossificans - myositis
ossificans progressiva (also referred to as
fibrodysplasia ossificans progressiva) is an
inherited affliction, autosomal dominant
pattern 3 weeks of oral indomethacin
regimen prophlactic
Surgical excision is reserved for those who
failed the non-surgical treatment after 6 to
18 months following injury.
Page 16
Heterotopic Ossification (HO)

-Common site :
* hip > elbow > shoulder > knee
* flexors and abductors >
extensors and adductors
* medial > lateral
* Male > female

-X-ray follow-up up to 1 year after surgery

shows presence of bone is soft tissue when
bone normally does not exist
- Ultrasound for early diagnosis of hip HO
- CT useful for preoperative planning
- Triphasic bone scan best for early
diagnosis
NB. fibrodysplasia ossificans progressiva
(Munchmeyer's Disease)
-Consider surgical HO resection
-extremely rare connective tissue disease.
wide exposure and surgical resection
It is a severe, disabling disorder with no
current cure or treatment
- Complications
-gentic mutation autosomal dominant
1.Hematoma and intraoperative bleeding
-causing fibrous tissue including muscle,
2. Infection : higher rate of infection
tendons, and ligaments to be ossified
following joint arthroplasty if HO is present
3. Fractures of osteoporotic bone
osteopenic from disuse during surgery or
physiotherapy
4.Recurrence : correlates with neurological
injury greater
5. AVN : if extensive dissection or
stripping is required

Dr. Ma§oud Page 17

Non union
Stop in the fracture repair process,
non healing of a fracture of a bone
-delayed union:
taking longer than expected to heal, failure
to reach bony union by 6 months post-injury
Anatomical: large segmental bone defects
Pathophysiology: (Classification:)
Local
1. inadequate fracture stabilization
(hypertrophic nonunion-oligotrophic)
2.poor blood supply(atrophic nonunion)
3.infection(Septic non union)
4. pseudoarthrosis
Genseral: (atrophic nonunion)
DM ,smoking, excess NSAIDs
Immune suppression, malnutrition.
C/P: persistant pain+ mobility at #
Imaging: x-ray/CT better
Lab.: CBC,ESR,CRP exclude infection
Delayed
Nonoperative
fracture brace immobilization
bone stimulators(Ca+vit D)
Infected nonunion
- need to remove all infected/devitalized
soft tissue.
- use antibiotic beads, VAC dressings to
manage the wound .
-with significant bone loss, bone transport
may be an option.
-muscle flaps can be critical in wound
management with soft tissue loss.
Pseudoarthrosis
-pseudo capsule may be encountered with
operative exposure
-removal of atrophic, non-viable bone
ends
- internal fixation with mechanical
stability
-maintenance of viable soft tissue
envelope
Hypertrophic nonunions
internal fixation with application of
appropriate mechanical stability
Dr. Ma§oud
Atrophic nonunions
-ensure biologically viable bony
-fixation needs to be mechanically stable
bone grafting :
(osteoinductive) autologous iliac crest
(osteoconductive) BMPs, agents (ie.
crushed cancellous chips, DBM)
-Establishment of healthy soft tissue
flap/envelope
+Bone stimulators: electrical stimulation
decrease osteoclast activity and increase
osteoblast activity, calcification
1. direct & alternating current
2. pulsed Ultrasound
3. pulsed & combined electromagnetic
fields
4. Extracorporial shock wave
+ Bone Growth Factors:
I- Bone Morphogenetic Protein (BMP)
Mechanism
Osteoinductive, leads to bone formation
activates mesenchymal cells to transform
into osteoblasts and produce bone
FDA-approved uses
1. rhBMP-2: in spine fusion, open tibial
shaft fractures before union
2. rhBMP-7: bone nonunions
contraindications : skeletal immaturity,
pregnancy, allergy, infection, tumor
II- Transforming Growth Factor-B (TGF-B)
Mechanism
stimulates osteoblast and osteoclasts,
Type II collagen synthesize
III- Insulin-like Growth Factor 1 (IGF-1)
Mechanism
induce proliferation without maturation
of the growth plate and thus induce
linear skeletal growth ‫يطول‬
IV- Insulin-like Growth Factor 2 (IGF-2)
V- Fibroblast Growth Factor (FGF)
VI- Platelet-derived growth factor (PDGF)
Mechanism
stimulates type I collagen production
stimulates cartilage matrix synthesis
stimulates cellular proliferation
stimulates bone formation.
Page 18
 Bone Defects Fresh Dried
Better structure Demineralized
After eradication of infection Osteoinductive More osteoconductive
Defect < 6cm? >6cm Articular
Bone graft Bone transport 5.Synthetic: cancellous BG substitutes Eg.
Osteogentic Osteoinduction Osteoconduction
- Bone graft (BG) -BM -BMP -Ca-S
(i) fill defect ( + - / ) bridging -Reamer -Demineralzed -Ca-P
Cyst-nonunion-arthrodesis aspirator Bone matrix -Collagen polymer
-Structure: irrigator -Bioactive glass
cortical cancellus
osteocoductive osteogentic -Graft techniques: Wire p.172
Support-scaphold Contain active cells 1. On lay ( cortical + cancellous) > defect
Better dual onlay- bridge –stability
So better combine.
But < metal stability ‫محشور‬
-Function:
2.In lay: inside < defect eg.arthrodesis
Osteogentic Osteoinduction osteoconduction 3.Multi chips: cancellous/ ilium
Remain + stem cells Scaffold for cells 4.Hemi cylindrical: large defect femur tibia
alive in new differantiat into & vessels 5.Whole bone transport: fibula?
site osteoblast Large –less disability- vascular
-Source : Replace tibial defect, Distal1/3 radius
1.Autograft: from same person 6.Membrane induced Masqulete technique:
Adv. no immune reaction regection Stage1-Use cement spacer (MMA) in
Disadv. Delayed ambulation, donor site defect induce formation of bioactive
comorbodites membrane (+ Benha Ortho.dep. modify
Eg. use of k wire int.fixation special fram )
*Tibia prox.medial part. Stage 2-Spacer removed 4-8w later & put
*Femur prox. Lat part (Troch.) cancellous BG
*Tibia & Femur RAI Adv. prevent graft absorp- promot
(Reamer aspirator irrigator) Revascularization-consoldation new bone
*Fibula: Iliac crest (gold standard)
Prox.1/3 Mid1/3 Give: Corticocancellous / pieces-chips-BM
Hyaline Vascularized BG Whole - ant. 2/3 - post.1/3
cartilage microsurgery one cortex- medulla-wedge
For DER AVN… Risk : superficial NS neuroma eg. Ilioing
Distal fibula
Sup. Cluneal 8cm from ASIS – LFCN.
2.Allograft: from other person
-in children no enough support
-osteoprotic periprosthetic#
-OCD
3.Heterograft: from other spicies
Face graft rejection
4.Bone bank: safe- sterile- usefull
Screen toxin infection malignant
Sterilize by EO or irradiation
Stored by deep freez( -700c)
Dr. Ma§oud Page 19
Pathological Fractures Algorithm
- Fragility fracture: bone fracture caused by
weakness of the bone structure
- most commonly due to osteoporosis,
cancer or a bone cyst, infection (such as
osteomyelitis), inherited bone disorders.
- vertebral fractures, fractures of the neck of
the femur, and Colles fracture of the wrist.
-Suspected pathological fracture on X-ray
-Radiographic lesion appears aggressive?
-CT C/A/P (CT of Chest, Abdomen and
Pelvis) and WBBS (Whole Body Bone
Scan) to look for primary malignancy and
other skeletal metastases
-Image guided biopsy or as an open biopsy
prior to fixation
Dr. Ma§oud
Complete fracture?
Impending fracture?
Lytic, proximal, painful?
>⅔ of diaphysis, ‫لببد‬
-Harington's criteria
* > 50% destruction of diaphyseal cortices
* > 50-75% destruction of metaphysis
(> 2.5 cm)
* Permeative destruction of the
subtrochanteric femoral region
* Persistent pain following irradiation
Resection and intercalary spacer
Intramedullary nail & Arthroplasty
Plates and screws (less preferred)
- Post-operative radiotherapy treatment to
decrease pain/slow progression/ treat
remaining tumor burden not removed at
surgery
Page 20
Pediatric Fractures Algorithm Salter–Harris fracture is a fracture that
involves the epiphyseal plate or growth plate
Usually incomplete fractures ? of a bone15%, specifically the zone of
provisional calcification
distinct fracture patterns due to the unique
- named for Robert B. Salter and William H.
properties of growing bones.
Harris, who created and published this
The periosteum in growing bones is thicker
classification system in the Journal of Bone
and stronger than in adult bones, which is
and Joint Surgery in 1963 .
why children are more prone to more
incomplete fractures eg. greenstick and SALTER mnemonic for classification
I – S = Slip (separated or straight across).
torus or buckle .
Fracture of the cartilage of the physis (growth
plate) II – A = Above Away from the joint ‫حته فوق‬
Buckle -Disruption of the cortex on the
Conseve: Cast + close follow up
/torus side of the compressive force
III – L = Lower. The fracture is below th
‫بظت‬ (concave side), which appears as
in the epiphysis. ‫حته تحت‬
a bulge, IV – T = Through metaphysis, physis, and
The convex side is intact. epiphysis. ‫تحت‬+‫حته فوق‬
- Mild or no angulation
Operative: reduction +K wire Wire p.110-171-182
-eg. radius at the junction of the
V – E = Enclose physis (crushed).
metaphysis and diaphysis
VI - 'R' for 'Ring' of Ranvieer
ttt. Immobilization with a splint
Op. attempt to distract physis by Ex.fix
or a cast for 3–4 weeks.
Follow up shortening
<2cm 2-5 cm >5cm
Green- -Disruption of the cortex and
Follow up+ Contralat. Ilizarov
stick periosteum on the side of tension
High heel Epiphysiodesis lengthening
fracture (convex side) with an intact
shoes ‫جزمه‬ 8plate/staples
‫عود اخضر‬ periostium and cortex on the sie
of compression (concave side).
-Some degree of angulation is
usually present
eg.Diaphysis of the radius, ulna,
or fibula

Bowing No disruption of the cortex or

fracture periosteum
-Angulation is present.
-Diaphysis of the ulna (most
common) or fibula

Dr. Ma§oud Page 21

Historical background
The ancient Egyptians: 5000ys BC papyrus scroll in Luxor, The text provides an outline on the diagnosis,
management principles, and expected outcome, including soft tissue injuries, fractures, joint dislocations.
Hippocraties: The Father of Medicine , Greek physician 370 BC, Greek medical texts
Ancient China: Lin Priest the treatment of fractures, dislocations and deformities, monograph
Ibn Sina: 1020AD medical text “Canon of Medicine”
19th Century : anathesia intervention, antiseptic use, Röntgen’s German physicist discovery Xray 1895
Early 1800s Late
Heine described fixation e- intramedullary ivory peg ‫مسمار عاج‬
Parkhill application of external fixation
Hansmann used eraly plate osteosynthesis
1900s Schöne intramedullary fixation of diaphyseal fractures of the forearm using a silver wire.
the 20th century, plate osteosynthesis quickly spread across Europe and North America owing to the influence
of Lambotte and Lane.
After the World War II, plate osteosynthesis became the surgical treatment of choice for diaphyseal fractures.
Bone 1st mentioned , 1st intervention
Open # -1800 BC Ancient Egyptians mandatory coverage of the bone
-400 BC, amputation was the treatment of choice
-Hippocrates said that “not to reduce an open fracture & increase the chance of death, wound
lavage with wine solutions and unguents before use of bandages
- Ancient China: enlarged with a sharp knife, then washed with boiled water
- Ibn Sina: advising open drainage for the wounds even if malunion
- Baron Napoleonic surgeon: concept of debridement
-World War II :introduction of penicillin antibiotic
Clavicle obstetric mismanagement. broken collar bone sling‎
SH. D. Eary BC Descriped in Pharonic paper, 300BC Hippocratic reduction
H. Hippocratic reduction e-rope , 19th C distinguishing from a dislocation
Elbow D. Terrible triad poor outcomes , evolved in the past few decades
Forearm Nonsurgical for centuries, nonunion and malunion were common
DER Irish surgeon, Abraham Colles(1700s),French surgeon Dupuytren intervention
Carpal D. French surgeon Louis Petit (1600s) descriped
Pelvis, - the ancient Egyptians :5000 ys BC roller bandages around pelvis.
hip,NF, -1800s Charles Moore British surgeon first report & descriped central dislocation.
troch. - At same time Malgaigne seminal French surgeon described the resulting injury as a “double
fracture” of the anterior and posterior pelvic ring, diagnosis In the absence of radiographic
imaging was established by physical exam,‘key’ to successful management of these injuries was
the restoration and maintenance of lower extremity length., closed reduction maneuver, aided
by vaginal and/or rectal palpation. The reduction maneuver was followed by maintenance in a
modified traction bed, with application of a pelvic sling, for a minimum of 45 to 50 days.
-1900s Sir Frank Wild Holdsworth Professor of Orthopaedics in Yorkshire, England:
1st classify 1) dislocation of the sacro-iliac joint; 2) fracture of the ilium or sacrum,
separation of the symphysis pubis, or fracture of both pubic rami “open book” pattern, the
“crescent” lateral compression pattern, and the “vertical shear” injury.
-Pennal and Sutherland in 1961 classification: 1) avulsion fractures, )2) ‘stable’ fractures, and
)3) ‘unstable’ fractures

Dr. Ma§oud Page 22

 - In 1980, Pennal and Tile: classification, early reports from the 1950s on internal fixation for
acute pelvic fractures
- original classification system from 1980, and the classification by Young & Burgess
femur Open + Skeletal traction was used till world war II
knee -casting was used to treat ligamentous knee injuries and fractures about the knee e- residual
knee stiffness and functional instability
- Knee orthoses originally were designed to treat congenital and acquired deformities around
the knee, including genu varum and quadriceps paralysis in polio patients
- Sarmiento used knee orthoses in a rehabilitative setting to treat fractures of the knee while
preventing loss of range of motion
tibia Open+ Nonsurgical for centuries, nonunion and malunion were common
Foot During the Napoleonic Wars, Jacques Lisfranc: soldier who suffered secondary gangrene of
Lisfranc the foot after a fall from a horse, performed an amputation at the level of the tarsometatarsal
injury joints
spine -The ancient Egyptians first described paraplegia due to injury of the spine
- Hippocrates: describe traction to reduce these injuries
- Roland of Parma: used manual extension for the treatment of fractured spine
- United Kingdom Cooper (1768–1841) and Charles Bell (1774–1842), were interested in the
treatment of spinal injuries. ooper described in detail the clinical manifestations of spinal
injury and recorded that his teacher, Henry Cline (1750–1827), had performed the first
laminectomy for this condition.
- Germany: Wagner (1848–1900) first successful account of the management of spinal injuries,
Paul Stolper (1865–1906) with anatomy of the spinal column, pathology of injury, the
mechanism of injury, the symptomatology, and practical treatment including the indications
for surgery, described in detail how a dislocated cervical spine could be reduced
- FIRST WORLD WAR: all emphasised the vital necessity of teamwork, regular turning, and
the need to give primacy to nursing care and physiotherapy, laminectomy sources of concern.
All the papers from that time reported high mortality.
- THE UNITED STATES: Charles Frazier (1870–1936) had looked after spinal injury
patients in the first world war and wrote a book major textbook on the subject., comprehensive
survey-
Donald Munro (1889–1973) father of the treatment of paraplegia He set up the first effective
treatment centre for spinal injuries at the City Hospital in Boston. & Harvard Medical School
Neurological Unit
- SECOND WORLD WAR:
- 1939 George Riddoch (1888–1947) was appointed consultant neurologist to the army with
the rank of brigadier., spinal injury units
- Ludwig Guttmann (1899–1980) the founder of the modern treatment of spinal injuries
well established ideas on spinal cord physiology, neurosurgical techniques, and rehabilitation

Dr. Ma§oud Page 23

AO classification coding
Algorithm

- Types/Group:
- Bone: Each has a number 1,2,…9 Shaft
- Segments, location: A B C
prox.1/mid2/distal3 Simple Wedge Complex
+ neck femur, Malleolus

Articular
Extra Partial Complete

Exept :
A B C

Proximal Humerus
Unifocal Bifocal Articular

Proximal femur
Trochanter Neck Head

Malleolus
Infrasyndysmotic Trans Supra

Dr. Ma§oud Page 24

Dr. Ma§oud Page 25
Dr. Ma§oud Page 26
Sternoclavicular Dislocation
Algorithm
- Clinical signs lead to suspected SCD
Swelling, Deformity(prominant)
Shortness of breath, Dysphagia

- Serendipity X-ray (40° cephaled tilt)

-CT angio or MRI angio of upper chest

- Rule out associated injuries:

Notes: Scheme+
-rare
-stability=lig./ /post>ant.//costoclav.lig
-Up-down350 rotate50
-Closed reduction under general sedation -FOOSH
-Failed ? (PV ON U) open reduction and -Classify
suture repair Ant post
-Recurrent dislocation? Ligament
Safe but ↑ recurrent Danger but stable
reconstruction.
-Complications:
1.vascular:subclavian , carotid
2.pneumothorax

-fixatin better with suture not wire (migrate)

Dr. Ma§oud Page 27

 Clavicle Fractures Algorithm

-Suspected clavicle Fracture

-X-rays
Shoulder AP, lateral, and scapular Y
Clavicle AP and cephalic tilt (apical oblique)

Physottt:
-4 weeks Wrist, finger ROM Pendulum
exercises for (any ROM allowed below 90
of shoulder flexion/abduction) then
-4 to 6 weeks AROM
-At 6 weeks, WBAT and full ROM

Notes: Scheme+

(5-10%) (80%) (10-15%) -most common #around shoulder>50%

90% children (loss Moro reflex) conserve
Anterior Non-op treatment
Displacement Sling/NWB for -ROM=Rotation
(epiphyseal in 6 weeks Elbow
children) 1st bone to ossify, last bone physis closure.
(1.5% nonunion
Meet surgical rate)
Indications? -op.options: 1.plate: Wire p.149
Sup. Ant.inf.
Less scare More safe
2.intramedullary pin/Nancy:
Antegrade/retro ,
Posterior ORIF A-stable Adv.simple,
displacement -(i) Non op. disadv.migration
ORIF with (15% nonunion B-unstable
CT/vascular rate) operative -Complications: Scheme+
surgeon on Wire p.146 1.vascular:subclavian risk e- sup.plate.
standby 2.N#: brachial plexus
3.malunion>non
↑ e- sever initial trauma, open, refracture, soft
interposition, inadequate stability
4.AC arthritis (degenerate discoid meniscus in
normal at 45)

Dr. Ma§oud Page 28

Acromioclavicular Separation
Algorithm
- Bilateral X-rays
AP, axillary,stress and Zanca view
- Rockwood 1-2
-Sling for comfort
-Weight bearing up to 5lb as tolerated
for 6 weeks
-Early range of motion exercises, try to
regain full range of motion in 6 weeks
-Return to normal activity in 12 weeks

-Rockwood 3-5
Discuss with patient comparable results of
operative versus nonoperative treatment

-Rockwood 6
Consider hook plate –needs to be removed
after 6 months to avoid shoulder pain or
erosion of the acromion
-Classify according to
-late presentation or recurrent,
consider coracoclavicular ligament
reconstruction

Notes: Scheme+

-A-1.3cm-C
-Stability=lig.( AC, CA, CC)
AC CC
I tender No Wire p.145
II tender tender
III + tent wide
IV Displace post.
V Displace sup.
VI Displace inf.

Dr. Ma§oud Page 29

Anterior Shoulder dislocation
Algorithm

-Suspected dislocation
-Obtain shoulder X-rays
AP, axillary and transscapular Y

-Closed reduction
Kocher-Milch-Stimson-Hippocratic
- Suspected bone # on X-ray
NO : Non-operative treatment
Sling for 1 week Begin ROM 1 week
-Recurrent instability event?
- High risk patient? - ISIS score
Yes : CT & MRI
Hill-Sachs ALPSA or HAGL

Engaging? ISIS?
No, Yes, ≤6 >6 Notes: Scheme+
-most common D.
Glenoid Consider Arthrosco Open -Stability=lig.+m
bone remplissag pic repair Repair Active Passive
loss bone m.RC+Bi+ Lig.+capsule+synovial+
%? grafting coordination -ve intraarticular P.
*Complications:
-Bankart: #labrum
≤15% soft tissue ALPSA – Anterior
-Hill sach lesion: bony head defect
labrum repair Labroligamentous
-HAGL:humeral avulsion GH lig.
15-30% Periosteal Sleeve
*Types D
Latarjet procedur Avulsion
Ant. Post. Inf. Sup.
≥30% HAGL – Humeral
common missed Luxitio erecta #AC
Cortico-cancellous Avulsion of the
-stiffness more common in old age so better
bone graft Glenohumeral
↓duration of sling
Key p.14-20 Ligament

Dr. Ma§oud Page 30

Scapula Fractures Algorithm
Notes : un common #
-Suspected scapula fracture
-CT with 3D reconstruction
for accurate measurements
- Large cassette Radiographs to include
whole scapula to better visualize
(i.e. Grashey, scapular Y, axillary)
-body# conserve
-Surgical indication?
1.Coracoid (i-base/ ii-tip)
Op.:base # : Coraco clav. screw
2.Acromin impinging subacromial space.
Tension band
DD.-os acromial: rounded un fused apophysis
↑glenoid hypoplasia, neck dysplasia
3.Glenoid>5mm (APIS+)
4..Neck>400
5.STD
Measurement
-SSSC =Superior Shoulder Suspensory Complex
(Continous ring: glenoid-coracoid-ACJ-acromion)
douple disruption= floating shoulder.
Dr. Ma§oud
-Nonsurgical rehabilitation:
First 6 weeks: Sling for comfort, full PROM
or AROM
After 6 weeks: gradual increase of weight
bearing and activities
-Surgical rehabilitation:
Immediate AROM and PROM, NWB
After 6 weeks: Begin strengthening and
resistance with gradual increase in weights
After 12 weeks : Begin full strength and
endurance program
Scapulothoracic Dissociation
Algorithm
-Danger compartement s.
-Massive shoulder/arm swelling,
ecchymosis, and/or mottling(Comoli sign)
-Chest X-ray PA (Scapula index >1.07)
Vascular Neuro injury↑↑↑
-Treatment
-Fixation of associated bony injuries
-Stabilization of scapulothoracic joint
-forequarter amputation
Differential Diagnosis
locked scapula: intrathoracic locking of the
inf.angle scapula between two ribs(3D CT)
Closed reduction+sling
Page 31
 Proximal Humerus Fractures Rehab: For non-operative management:
-Shoulder brace with pillow for 6 weeks
Algorithm -Start pendulum exercises at 10-14 days
-Start active & active assisted range of motion at
Neer Classification 2 weeks
After surgical management:
-Shoulder brace with pillow for 6 weeks
-Start pendulum exercises postop day #1
-Start active and active assisted range of motion
postop day #1
-For both non-operative and surgical
-Start passive range of motion at 6 weeks
- -Start resisted exercises at 12 weeks
-X-ray : Grashey, scapular Y, and axillary
-Cannot rule out dislocation or evaluate Notes :
fracture pattern/ displacement? -common in female osteoprotic
-CT scan with 3D -Anatomy: 4 osseous segments, head retroverted 400
-Fracture dislocation? forces affecting 4 S-IT-S+ deltoid+ pect.major
<65 years >65 years 4 as. A,PCHA give 2 arcuate as.
Axillary N. # at high risk
ORIF rTSA
-pediatric# in birth or sport( pseudoparalysis)
-Fracture Clavicle #-br.plexus#-sh D.
One part 2 parts 3- or 4-parts Neer (displacement)+Salter H.
>65y GT fracture Arthroplasty I II III IV
<45°, LT fracture <65 y/o: hemi <5mm 1/3 2/3 >2/3
<1cm >5mm if can repair Ttt.+ Accepted criteria
displacement ORIF plate tuberosities neoborn 1-4ys 5-12y >12
>65 y/o: Fix e-adhesive Sling U shaped K.wires
conserve surgical rTSA against chest 10d slap III & IV
neck Key p.34 Angulation<70 <40 <20
locking plate Loss of Displce any shaft 1/2 1/3
vs. proximal medial
humerus buttress and Shoulder arthroplasty (Periprosthetic Fracture)
IMN metaphyseal
vs wires comminution
Key p.29 Augmentation
Wire p.140 fibular shaft
150-155 allograft

Glenoid stable? Glenoid unstable?

Consider revision glenoid surgery Treat accordingly to
with possible bone graft scapula fracture Algorithm
Dital to stem # at stem
Consider treating -Stem stable ORIF
non-operatively -Unstable : revision

Dr. Ma§oud Page 32

Humeral Shaft Fractures
Algorithm
-X-rays AP & lateral of humerus, elbow, and
shoulder Radial nerve palsy (Hewlstein Lewis 33%):
Observe Surgery Explore
EMG at 6 to 12 Contused Severed
weeks if no return of Observe Repair or tag for
function later repair
Wait 3m before Rad.N.exploration?
Time enough to recover neuropraxia-bone heal-
percise N.lesion.good recovery.

Notes :
-Bl. Nutrient From perforating of brachial a.
-Classify: site 1/3 1/3 1/3 open/closed
Shape:TV /Spiral/oblique/comminuted/articular
Displased/ non- bone quality
Does it meet surgical indications?
-Operative data: Key p.40 Wire p.141
-Coaptation splint Sarmiento brace at 1
-approach
week with films in brace
Ant. Post.
-Films every 1 to 2 weeks to check
alignment until fracture “sticky” (less Better for prox 1/3 Better for mid, inf.1/3
mobile on exam) Easy find Rad.N Risk Rad.N
-Accepted criteria: AP 200, varus 300, -Plate:best fun.result:4.5 DCP 6 cortices + lag s
50%, 3cm apposition Direct reduction-stable fixation-not affect RC
-Discontinue brace when fracture stable -ILNH: Tv-segmental-pathological-osteoticoprotic
on exam and pain controlled Antegrade (sh.pain↑) Retrograde
-WBAT when films show 3 of 4 cortices Risk axillary N# Risk Radial N#
united -Ex.fix: open-infected-burn

Dr. Ma§oud Page 33

Distal Humerus Fractures
Algorithm
-Foosh elbow pain
-X-ray AP & lateral of elbow (fat pad sign) Notes :
- CT with thin cuts + 2D & 3D -carrying angle70?
Extra Simple Complex Trochlea> Capitulum 4-80 valgus-ER
articular articular articular -General: anatomic reduction-stable fix.-axial
alignment-early ROM
ORIF (dual ORIF (dual Active patient
-Classification
column column ORIF (dual
Extra articular Articular
plating) plating) ± column
without olecranon plating) and SCH, Epicond. Condylar,inter,trans
olecranon osteotomy olecranon Milch
osteotomy osteotomy I-lat.ridge troch.intact
-Elderly, Low demand patient II- lat.ridge troch.#
-dual plate :
-Adequate -Poor bone Risk of
Medial Posteriolateral
bone surgery
-High -Low outweighs
-pediatric elbow:
articular articular benefits
-Bl.supply non anastamotic (2 for T/1for C)
fracture fracture
-ossific centers CRITOE 1,3,5,7,9,11 female
-No arthritis -Arthritis
-5-7ys : ↑remodeling, ↓diameter, lig.lax
ORIF (dual Total elbow Non-op -Bowman angle = Metaphyseal diaphyseal angle
column Arthroplasty treatment ↑ # ↓
plating) and “bag of
olecranon Key p.60 bones”
osteotomy
Rehab:
-Splint ~ 3days to allow incision to heal
-Full ROM, NWB for 12 weeks once splint
is removed
-Full ROM, WBAT after 12 weeks
(except TEA, which has lifetime
5lbs weight limit)
-Gartland classification types
NWB – Non Weight Bearing Extension 98% ‫للوراء‬ Flexion ‫لالمام‬
TEA – Total Elbow Arthroplasty I- Non displaced: AEC -900-2W
WBAT – Weight Bearing As Tolerated II- # ant.cortex #post.cortex
Reduction reverse direction+cast 3w
Complications: + If unstable k wire
-Osteonecrosis(fish tail deformity) III- complete displacement
-Lateral spur overgrowth IV- complete periosteal disruption
-Most common e-#: N#Median > ulnar N. -Precut.pins k wire
(dalayed ulnar N palsy e- cubitus valgus) -Unreducable modified mini-open lateral
-on surgery ulnar N > median N side+finger manipulation
-Volkmans ischemic contractions -NV. ORIF
Myositis ossificans-stiffness.

Dr. Ma§oud Page 34

Elbow Dislocation Algorithm
Terrible Triad Injury

Rehab.:
-Non-weight bearing for 6 months
-Elbow dislocation -Start range of motion exercises
-AP, lateral, and radial head view X-rays
- neurovascular exam Notes :
- Immediate closed reduction -Stability? Bony articulation congruance
- Re-assess neurovascular exam Lig. LCL / LUCL ‫ضعيف‬/ MCL / MUCL ‫قوى‬
Simple elbow subluxation Hori circle: capsulolig.structure ) # lat> med )
Dislocation /dislocation -NV#: ulnar N , Brachial a
stable between 0°-30° -unstable: D. e- supination-pronation
-Divergent D. ulna (go ant.)-radius (go post.)
Assess stable range But Stable beyond
or ulna (go med.)-radius (go lat.)
of motion 30° flexion in all
-Coronoid process #
Flex/extension forearm rotations
With Rotation Hinged elbow brace
-Sling for comfort 30°
for 1-2 weeks -full flexion
-Indomethacin for Gradual increase of
heterotopic extension at 3-4
ossification weeks
prophylaxis Wire p.137
Non-operative: Type I, II, and III that are minimally
Complex elbow dislocation: displaced with stable elbow
Op.: Type I, II, and III with persistent elbow instability or
-With # Or Unstable >30°
posteromedial rotatory instability
-CT scan with 3D
for Type I: No. 5 suture for Type II or III : Retrograde
-Surgical stabilization through ulna drill holes cannulated screws or plate
-may need ex.fix with gross unstability. lateral ligament repair for posteromedial rotatory instability
Key p.303
Wire p.123

Dr. Ma§oud Page 35

Capitellum Fractures Algorithm Radial Head Fractures Algorithm
-FOOSH - FOOSH
- mechanical block to flexion/extension - mechanical block to flexion/extension
and/or rotation and/or rotation
- Assess stability through range of motion - Suspected radial head fracture
-AP, lateral, and radialhead view X-ray -AP, lateral, radiocapitellar views
-CT scan with 3D -Forearm and wrist AP and lateral views
Wrist pain? Consider Essex Lopresti injury
( #Rad. Head+D.+disrupt inteross.lig. +DRUJ)
- ≥3parts
-Displacement ≥ 3 mm
-Articular surface involvement > 30%
-Neck>300
-Comminuted---CT
yes No
-ORIF ‫ يمكن تجميعها‬Sling for comfort
-Radial head ‫ال‬ NWB 6 weeks
replacement‫يمكن‬ Active and passive
Key p.49 ROM exercises
Notes :
-Never excise: Essex Leprosity(unstable),
Pediatric(growing into valgus)
-Mason classification:

minimally displaced -Displaced >1-2mm

<1-2mm
Stable? ROM unStable? ROM
Non-operative -Type I: ORIF
rehabilitation: -Type II&III:
•Non-weight bearing Excision vs. ORIF
for 6 weeks - Type IV: ORIF
• Gradual increase of (lateral approach
range of motion headless screw fixation
• Hinged elbow or
brace minifragment screw)
• Start ROM
exercises on day #1

Dr. Ma§oud Page 36

Olecranon Fractures Algorithm
- Fall on flexed elbow
-Suspected olecranon fracture
-AP & lateral X-rays elbow
Displaced? Triceps mechanism intact?
Tip olecranon Distal to tip
conserve Consider ORIF
Immobilize for 2 w Tension band
ROM 0-90° for 4 w Key p.54
Full ROM 4-6 weeks
Comminuted? Consider CT
ORIF with plate
Notes :
-Semilunar = sigmoid notch
-Mayo classification
-Non displaced -Displaced
-Tri. Fun.Good -disturbed
A-non B-comminuted
Conserve AEC Op. ORIF
A :T .band
B: Plate
-Schatzkar classification:based on pattern
Tv-oblique-comminuted-impacted
Tie of figure 8 prefere at tip olecranon for easy
removal mini open.
Dr. Ma§oud
Forearm Fractures Algorithm
-Suspected forearm Fracture
-AP & lateral X-ray of forearm
Stable? ≥50% apposition <15° angulation
Forearm Clamshell brace or AEC for 6
weeks NWB, full ROMfor 6 w.
Un stable Isolated ulnar shaft fracture
(poor bl.= non union) Key p.66
ORIF 1/3 plate+Lag or DCP (compression)
Un stable Isolated radius shaft fracture
Take care during op.leash of Henry
ORIF 3.5 plate+Lag or DCP (compression)
Unstable U-H Notes :
-Anatomy : radial bow
Non union -insertion of supinators & pronators : in radius
Excision + -classification: open-closed//comminuted-
repair triceps segmental//angulation-translation-rotation
tendon -#ulna, Montegia(moon) #prox 1/3+prox RU
Bado classification
#ulna / D. Head R.
I-ant. II-post. III-lat. IV- #BB.
D. Head R.: re-D. postop. ..excision or replace
# ulna accepted 100 angulation, 50% translation
- # radius, Galiazze(ground) #distal1/3+distal RU
Nb. Reverse Galiazze: #distal ulna+ RU
-complication:+ ↑ nonunion-
Radioulnar synestosis( # same level-single
incision-infection-delay op.2w)
Pediatric <10ys acceptance for cast:
<200, Bayonett apposition <1cm. Wire p.113..
Page 37
Distal Radius Fractures -Assess reduction:
Acceptable reduction?
Algorithm X ray every week + Assess cast width
- Female old osteoprotic FOOSH
-AP, lateral, oblique(scaphoid) wrist X-ray

Not Acceptable reduction? Operative

- Smith #: volar tilt(operative )

Colles#:.dorsal tilt -Closed reduction ( traction

3 min-hyperextension-hyperflexion-ulnar
deviation)
+Cast with 3 point fixation

-Die punch:depressed intraarticular

-comminuted (Ex.fix with ligamentotaxis)

Notes :
-Anatomy : metaphysis cancellous + cortical shell
-articular e- scaph.lunate, notch for TFCC
-Lig. Volar stronger > dorsal, still intact after #
Can use it in reduction ( ligamentotaxis )
-Redisplacment after reduction??
High initial displacement-elder osteopriotic
collapse bone- metaphysis comminution-
early displacement.
Key p.92 / 98
Wire p.94 / 99 / 101 / 103 / 104 / 107

Dr. Ma§oud Page 38

Scaphoid Fractures Algorithm Other carpal bone fractures
Algorithm
-Suspected scaphoid fracture -lunate( keystone bone in wrist) very rare #
-Mechanism: FOOSH in radial deviation Well protected -good lig.s-good vascularity
- Clinical Signs Suggestive of a Scaphoid The common is perilunate # or D.
Fracture: Anatomic snuffbox tenderness Spilld tea cup sign Wire p.106
Pain with scaphoid compression test
Tenderness of scaphoid tubercle
- X-ray: AP, lateral, oblique wrist and
scaphoid view (ulnar deviation)
fracture visible? No
Thumb spica splint 2w repeat x-ray
fracture visible? Yes
Proximal Pole Waist Distal Pole
ORIF Displaced >1mm ORIF
Herbert S No, Thumb Spica cast,
Wire p.84 8-12 w
-Triquetrum: 2nd most common # fracture carpals
-Piziform& Hamate: rare, but risk Ulnar N. in
Guyons canal
-Trapezium & Trapezoid: OA 1st, 2nd MC
-Capitate: osteonecrosis with mid carpal collapse

Chronic (old #)
- Is there associated arthritis (radial styloid,
radio-carpal, or mid-carpal)?
No Yes
Consider nonunion Consider salvage
repair and bone procedure
grafting -scaphoid excision
(+/- vascularized) -4- corner fusion, ---
with -proximal row
internal fixation carpectomy,
-wrist fusion
Non displaced: non op. splint 6 w
Notes : Ulnar-radial-dorsal-thumb spica
-Anatomy: blood supply come from distal to prox. Displaced: small piece but causing pain or block
-#prox.↑ non union, osteonecrosis Wire p.90 movement…excision
-Scapholunate : angle 470- space <2mm >1/3 bone #: fix by kwire or lag screw
-on wrist flexion scaphoid act as stent transmit
wt, in# S….SL lig unstable….DISI
-Approach : volar open reduction+ dorsal fixation
↑biomech.stable, ↓ #bl.supply

Dr. Ma§oud Page 39

Perilunate Dislocation Algorithm
Notes :
- PA and lateral wrist X-ray
-Anatomy: great arc bony, lesser arc soft

-common trans scaphoid perilunate fracture

dislocation (DeQurvain fracture)
# S-L lig. Widing>3mm (Terry Thomas sign)
-Reducion by 5 min traction then volar to dorsal
reduction+k.wire

-Carpal dislocation:
Clunk test-dynamic test

-ulnocarpal dislocation:
#TFCC,Fron styloid ulna(sublax dorsal)
MRI, arthroscopy
Reduction+k.wire

Wire p.74 / 88 / 106

- Emergent closed reduction with sedation

-Failed, Open reduction and scapholunate
ligament repair
- Median nerve dysfunction ?
Not Improving post-reduction?
Acute carpel tunnel syndrome
Emergent carpal tunnel release +
open reduction and ligament repair

Dr. Ma§oud Page 40

Metacarpal Fractures Algorithm
-dorsal hand, swelling/bruising
- AP, lateral, oblique hand X-rays
-Surgical Options
CRPP (K-wires) Wire p.61
ORIF (miniplates, screws, K-wires)
Bone grafting indicated for segmental loss

-Non-operative Management Indications

Shortening <4mm
Closed, stable fracture patterns
No clinical rotation/scissoring

- Rehab
Early motion for stable fixation
Casting for 4 weeks for CRPP
and fracture dislocation at CMC

Notes : -accepted criteria: Key p.114

Head: anatomic reduction<1mm
-Fracture? PV ON U Neck & Shaft
rotation test to scaphoid
>50% apposition
angulation...0..

-1st MCB (thumb) base intraarticular#

Bennett # Rolando#
Partial aricular Y-T-comminuted
Unstable by abd.poll.traction

Kwire-miniplate Kwire-arthroplasty
Key p.86- Wire p.65 Wire p.63

Dr. Ma§oud Page 41

Metacarpophalangeal (MCP)
Dislocations Algorithm
- Hyperextension injury,
most common index finger.
- Look for swelling, prominence over volar
metacarpophalangeal joint.
-If skin dimpling in proximal palmar crease,
likely complex dislocation.
X-Ray: Hand Ap/ Lateral/Oblique
Pre-Post
-Complex (typically interposition of volar
plate or sesamoids)
x ray sesamoids in joint space
OR for surgical reduction:
volar or dorsal approach
Notes :
-commonly D. to dorsal except thumb valar??
Thumb has one side collateral lig on D. sublax
volar with rotation.
-volar plate tear repair with suture anchors
-Stener lesion: adductor apponurosis prevent UCL
to heal in its place Need op. repair
Dr. Ma§oud
Phalanx Dislocations Algorithm
-Suspected phalanx dislocation
- AP, true lateral X-rays of finger
- DIP dislocation (typically dorsal)
Reduce: initially hyperextend joint with
gentle traction, then pull distal phalanx volar
to reduce
Does it reduce?
Yes, No,
Begin gentle ROM Open reduction,
- PIP dislocation (typically dorsal)
Dorsal: Reduce with hyperextension of
joint and flexion
Volar: Reduce by flexing joint with traction,
then extend
Notes :
-commonly D. dorsal = simple reducable
-volar, lateral D. = Irreducible = Noose effect?
Head pp pass between central & lat.slip band
Need open reduction
Page 42
Finger Fractures Algorithm Finger Replantation Algorithm
- Suspected finger fracture
- Examine finger for evidence of rotation
with flexion (Should point to scaphoid)
- AP/Lateral/Oblique X-ray of injured finger

- Distal phalanx fracture? Wire p.16..

Tuft, <40% consider trephination
Nailbed if painful (+antibiotc)
injury? >40%, nailbed repair, splint
DIP
Consider surgical intervention
Shaft if >50% displaced (CRPP)
Displaced? Splint DIP in full extension x
4 weeks
Fracture? Splint DIP in full extension for
(Base) 6 weeks, full-time, then 6
Avulsion: weeks at night only
Ext.Mallet If >40% articular suface, - Traumatic finger amputation?
// Flex. consider fixation (extension- Wrap amputated part in moist gauze, place
Jersey block pinning, ORIF, or in bag, and place bag in ice. Apply direct
CRPP) pressure and dressing (not tourniquet) to
wound to stop bleeding. (~RICE)
- Proximal and middle phalanx fracture? Provide IV antibiotics, check
Open / Closed? Displaced?? tetanus status
No Yes -X-ray: AP/lateral/oblique of hand and
splint in intrinsic Close reduce to amputated digit
plus 3-4 weeks correct angulation, - Warm ischemia <12 hours?
buddy tape to Cold ischemia <24 hours?
adjacent digit and
dorsal block splint
Unstable? CRPP/ORIF/Exfix Wire p.28.39.

Dr. Ma§oud Page 43

Extensor Tendon Lacerations
Algorithm Notes:
-incision is extension wound into Z
-Repair by modified Kessler knot
- Clinical suspicion of a finger extensor
injury laceration over dorsum of hand;
inability to extend finger

- Splint according to zone

- Obtain AP, lateral & oblique hand or finger

X-rays to rule out fracture or retained
foreign body
Bony Avulsion (mallet finger, Zone I)
-If bony fragment is <40% and joint
concentric on lateral X-ray, splint DIP in full
extension for 6 weeks.
-If joint not concentric, consider operative
fixation.
-Laceration < 50% of tendon? ‫فى النص‬
Consider non-operative management if
patient can actively extend against resistance
Fight bite (Typically zone V, high risk of
joint infection(
Immediate irrigation and debridement
in the OR
Injury older than 3 weeks?
Reconstruction or tendon transfer

- Tendon repair with 3-0 or 4-0 braided,

non-absorbable suture, at least 4 strands
across laceration
Key p.104

Dr. Ma§oud Page 44

Flexor Tendon Injuries
Algorithm

Classify according to zone of injury
Complete? >60%
Zone If laceration <1cm from insertion
I repair FDP directly to bone,
otherwise FDP repair
Zone Tendon repair
II&V (ideally within 10 days)
Zone Tendon repair often associated
III with neurovascular injury
Zone Tendon repair often associated
IV with median nerve injury
Key p.109

<60% partial laceration? Incomplete

Conserve
Dorsal block splint with wrist flexed 10-20
degrees, MPs flexed 70 and IPs resting

Dr. Ma§oud Page 45

Dr. Ma§oud Page 46
Pelvic Ring Fractures Algorithm
high energy blunt trauma
-Resustation?
-X-ray for pelvis fracture
- Pelvic exam Rectal/ Urogenital/ leading
to open pelvis fracture diagnosis
-Pelvis CT for surgical planning
their will be extensive Hge intrapelvic from
post.pelvis plexus of vs with sudden shock
-Anti shock:
Hamok: with bed sheet at level of troch.
Pelvic binder & MAST: military antishock trouser
Ant.ex fix & C-clamp
-X ray views

Vertically stable?
Yes No
Possible binder ex-fix

Notes :
-Anatomy: pelvic ring circle ( sacum ilium pubis)
-stability = ligs.
Inside ring TV Ouside ring Longtudinal
Resist rotation force Resist shear force
-pub-pub -iliolumber
-sacro –iliac ‫االقوى‬ -lumbosacral
-sacro-tuberus
-sacro-spinous
Structures pass : pins
Greater sciatic notch lesser
Infrapiriform m.
P: posterior cutaneous P: pudendal nerve
nerve of thigh I: internal pudendal
I: inferior gluteal artery and vein
artery, vein and nerve N: nerve to obturator
N: nerve to quadratus internus
femoris TO: tendon of obturator
S: sciatic nerve internus

-Ttt.:
1ry survey: ABCDE trauma
2nd survey: whole lower limb
Radiographic signs of instability
-AP-LC test: ant.post & lat. Compression
- > 5 mm displacement of posterior
-look : massive buttock hge
sacroiliac complex
-feel: ant. pubis ‫و‬post.SI sepration - presence of posterior sacral fracture
-move: limb IR/ER gap
-PV & PR - avulsion fractures (ischial spine, ischial
Hemodynamic: 1st clot is the best clot tuberosity, sacrum, transverse process of 5th
Large in pelvic bed Most of clotting factors lumbar vertebrae)
consumed inside , long time till resynth. So if you
disturb it with dilution (washing or extra fluids)

Dr. Ma§oud Page 47

 Tile classification Principles of pelvic instrumentation
-Challenging:-↑risk-3D orientation-long learning
-pre-op.planning:
1. site: ring ant(symph, rami)-post (SI, sac.)
Order:Fix. axial→peripheral
A stable B unstable C unstable 2.size: displacement
rotationally vertically + 3.shape: implant 4.surface: approach
-minimally -ER open book Uni & Bi 5.x ray views
displaced ring -IR bucket lateral
- avulsion handle
Non op. Operative Operative

Young-Burgess Classification
Anterior Posterior Compression (APC)

Symph open< >2.5 cm+ + posterior SI 6. instruments : prepare whole set

2.5 cm Ant. SI
diastasis
# sy.pub +# SI,ST lig. +# SS lig.
Non-operative. Anterior + SI screws
Protected symphyseal
weight bearing plate
Lateral Compression

# ramus + post.ilium + APC

7.Reduction: prepare whole set
(#D.) contralateral
crescent # windswept pelvis
Non-op. ORIF ilium Post.fixation
Vertical shear
Posterior and superior directed force.
Associated with the highest risk of hypovolemic
shock (63%); mortality rate up to 25%
Posterior stabilization with plate or SI screws as
needed. Percutaneous or open based on injury
pattern and surgeon preference.

Dr. Ma§oud Page 48

8. Implant: prepare whole set ORIF
Recon plate straight, curved Long screws, drill pit

Ex.fix Wire p.164

9. Approaches:

10.percut.concept

Wire p.161

Dr. Ma§oud Page 49

 Sacral Fractures
-25% are associated with neurologic injury ( lower extremity
sensory, motor/ urinary / rectal /sexual dysfunction)
-Nerves anatomy:
L5 nerve root runs S1-S4 nerve from S1 and S2 carry
on top of sacral ala sacral foramina higher rate of injury
* lower sacral nerve roots (S2-S5) Function anal sphincter tone
voluntary contracture - bulbocavernosus reflex -perianal
sensation * ( unilateral preservation of nerves is adequate for
bowel and bladder control )
Denis classification-prognostic
zone 1 zone 2 zone 3
commonest through foramina medial to foramin
lateral to foramina shear ↑unstable ↑↑↑ neurologic
nerve injury rare 5% deficit (60%)

Transverse U-type spino-pelvic dissociatio

higher incidence of nerve higher incidence of nerve
dysfunction dysfunction

Rehabilitation Ttt: *Nonoperative : <1 cm displacement and no

-non surgical neurologic deficit
patients may mobilize immediately with progressive weight bearing +/- orthosis
protected weight bearing after stable fracture *Operative: displaced fractures >1 cmneuro
pattern in confirmed (may require post- compromise persistent pain after non-operative
mobilization views to confirm stability) surgical fixation with decompression for neuro
-treated surgically Percutaneous Posterior Iliosacral Decompression
patient mobility and weight bearing depend screw fixation astension band And of neural
on the location of the posterior pelvic ring fracture sacroiliac, plating lumbopelvic elements
mobility includes weight-of-limb weight trans-sacral fixation
bearing ipsilateral to the posterior pelvic injury laminectomy
with full weight bearing on contralateral side or
patients with bilateral posterior pelvic ring foraminotomy
injuries limited to bed-to-chair transfers only
when radiographic healing has occured weight
bearing can be gradually advanced.

Dr. Ma§oud Page 50

Acetabulum Fractures Algorithm
Notes :
-high energy trauma
-Anatomy: 2 column inverted Y
-Hip short, rotated and painful to any motion
corona mortise anastomosis of external iliac (epigastric)
Hip Dislocation, Acetabular fracture-
and internal iliac (obturator) vessels at risk with lateral
Femoral neck fracture Intertrochanteric. dissection over superior pubic ramus
Judet views
-Acetabular fracture on AP and Judet X-rays

-CT scan with thin cuts 2D and 3D

-Isolated wall fractures?

Posterior wall Anterior wall
*>40% articular Displaced more
Involvement than 2 mm,
ORIF <200 roof arc angle
*<40% Touch Down ORIF Judet and Letournel Classification
Weight Bearing

Columnar Fracture?
Non operative

roof arc angle of

Matta =450 =
stability

Dr. Ma§oud Page 51

Ant.column acetab. Post.column acetab.

Wire p.163
For high #

Dr. Ma§oud Page 52

Wall
Conventional plate, S
Spring plate, subchondral S

Factors considered for fiaxtion methodology

location (column and/or wall) and level (high or low)
Center acetab. Quadrilateral plate amount of displacement-marginal impaction
1/3 tub., Brim plate, dedicated assoicated injury+ D.hip

approaches
Anterior Posterior Extensile Modified
(Ilioinguinal) (Kocher- (extended Stoppa
Langenbach) iliofemoral)
(i) • post. wall only single • access to
• ant. wall and post.column approach quadrilateral
ant.column • most that allows plate to
• both column transverse and direct both buttress
fracture T-shaped columns comminuted
•post. • late 21 medial wall
hemitransverse days after fractures
injury
• posterior
comminution
Co= • increased HO • massive Corona
• femoral nerve risk compared heterotopic mortis must
• LFCN injury with anterior ossification be exposed
• thrombosis of approach • posterior and ligated
femoral vessels • sciatic nerve gluteal in this
• laceration of injury (2-10%) muscle approach
corona mortis in • damage to necrosis
blood supply of
femoral head
(medial femoral
circumflex

Dr. Ma§oud Page 53

Hip Dislocations Algorithm Femoral Head Fractures
Algorithm
-Hip short, rotated and painful to any motion
-Hip Dislocation, Acetabular fracture -Suspected femoral head fracture e- D.
Femoral neck fracture , Intertrochanteric. -X-ray of hip and pelvis with Judet views
-CT, MRI ( if suspect?)
-X-ray AP pelvis, cross table lateral of hip

-Hip Dislocation
-Emergent reduction undersedation (ER or
OR)
-Hip still Dislocated?
Open reduction after 3 attempts

-CT pelvis ‫الزم‬

Pre-post reduction : assess congruity

-Pipkin I -Pipkin II With

-Pipkin II with >1mm displacement
<1mm displacement Intra-articular debris
Joint congruent - Pipkin III/IV
TDWB 6 weeks Young age : Consider
Nonconcentric Concentric
Restrict abduction ORIF with headless S
reduction reduction
ant. Or anterolateral
Loose bodies in the Loose bodies in the approach
joint? Urgent open joint? Arthroscopic Old age: THA
reduction and vs. open removal Low demand:
removal of loose of loose bodies if hemiarthroplasty
bodies fragments interfere
Close radiographic follow up
Allis methode with hip motion
Post reduction position LL in abd-ER +
crutches 6w ‫مخدة بين رجلية وهو نايم‬
Notes:
Types of D.
Ant.15% Post. common
Suprapubic e- #acetab or not
Infra-obturator
CO= …+ Osteonecrosis head femur Notes: Key p.123
↑ e- recurrent D./Neglected/long duration 70% post traumatic arthritis
How? Impaction-avulsion lig.teres
approach i
TDWB: touch down wt bear
kocher Posterior for sciatic exploration 2nd congruity: non anatomic, head e- # parts
Smith Anterior for head # #both column (spur sign)
Ant.lat NF#

Dr. Ma§oud Page 54

Femoral Neck Fractures
Algorithm

-Hip short, rotated and painful to any -age>55? Active lifestyle?

motion Yes No
-Hip Dislocation, Acetabular fracture
Total hip replacement Cemented hemiarthroplasty
Femoral neck fracture , Intertrochanteric
Key p.134 Key p.142
-X-ray AP pelvis, cross table lateral of hip

-age<55y? Physiologically young?

-Type 1-2? Grade 3-4?
In situ -Obtain anatomic
+ fixation with reduction by closed
inverted ▼ or open technique +
3 cannulated fixation with sliding Notes:
screws >6.5mm hip screw and
-Incidence
anti-rotation screw
Old: low E. trauma,
young: high E trauma or pathologic #
-Risk: old , osteoprotic, postmenopause, smoking,
Alcoholic, decrease night vision
Non union?? 1. Intracapsular hematoma
dissolved by synovial fluid
2. has no campian layer (osteogenic)
biomech:
Body wt/ hip
-Walk=1/2
-Stand one
leg=1.5
-run=5
-jump on one
leg=25

Dr. Ma§oud Page 55

 Reduction: Mid
Flexion-traction-slow ER-IR
Accepted reduction

-classification
*anatomic: subcapital-transcervical-basicervical
*Pawel: angle # e- horizontal
I-stable II III-unstable
<30 0 30-70 >70

*Garden:
I II III IV
Non Non Partial Complete
displaced displaced displaced displaced
Impacted Impacted complete complete
incomplete complete trabecula not trabecula
parallel parellel

Co= groin pain CT Ttt. THA

-Non union: Pain ↑extension
-osteonecrosis
-fixation failure
*Door:
I II III
bone stock ↑ mid ↓
Narrow canal mid Wide canal
THA cementless ? cemented

Dr. Ma§oud Page 56

Periprosthetic Fracture THA: Periprosthetic Fracture THA:
Acetabulum Algorithm Femur Algorithm
Type I: Intra-operative insertion
IA IB
Non-displaced Displaced fracture
crack, Remove cup
cup stable ORIF fracture
Multiple screws Ream again lineto-line
through cup Re-insert cup, multiple
TTWB x 6 week screws through cup

Type II: Intra-operative, removal with

bone loss & Vancouver A
Type IV: Post-operative, osteolysis AL (# lesser AG (# greater trochanter)
IIA: IIB: trochanter)
Hemispherical cup Hemispherical cup Non- •Non-operative Abductor
inherently stable not inherently stable operative bracing
(>50% fit) (<50% fit) management TTWB
Revision shell, Revision shell with • Carefully • Significant displacement
multiple screws Screws , Augments, evaluate and abductor dysfunction?
through cup Cage calcar ORIF
• WBAT -Consider head/liner
Type III: Post-operative, trauma exchange to increase head
IIIA: IIIB: size
Cup stable Cup loose Revision -Consider allograft for
TTWB for 6 weeks THA, see Type II osteolytic lesions
-Wires/cerclage vs. claw
Type V: Pelvic discountinuity plate
VA: VB: VC: Vancouver B
Inherently Cup not Post B1 Stable B2 – Loose B3 – Loose
stable cup after inherently radiation implant implant implant with bone
ORIF or stable despite Cemented loss
distraction of ORIF or cup -Long -Revision THA -Diaphyseal
discontinuity distraction locking plate -May need extended engaging stem,
Multiple Augments to span trochanteric allograft structs
screws Cage entire femur osteotomy -Impaction grafting
through cup -Variable for implant removal a cemented stem
------------------------------------------------------ angle -Diaphyseal -Allograft
Vancouver C: Fracture distal to THA locking to engaging stem prosthetic
-Long locking plate to span entire femur aim around -Cerclage proximal Composite
-Variable angle locking to aim around prosthesis fragments around -Tumor prosthesis
prosthesis proximally -Cables new stem
-Cables proximally

Dr. Ma§oud Page 57

Intertrochanteric Fractures
Algorithm
-Hip short, rotated and painful to any motion
-Hip Dislocation, Femoral neck fracture Lag screw cut out : 20% ‫عيب‬
Intertrochanteric, Acetabular fracture ‫العيان‬ ‫الكسر‬ ‫الدكتور‬
-X-ray AP pelvis, cross table lateral of hip osteoprotic unstable 2nd reaming channel
-Evans classification Eccentric place lag
Inadequate engage barell

Pre-reduction unstability , post-reduction stability

-Unstable?
-Reverse oblique
-Lateral wall fracture (subtroch. extension)
-Posteromedial communition Notes:
CMN(Cephalomedullary nail) -extracaps.# , good bl. No osteonecrosis.
γ nail (PFN) Co= Malunion> nonunion
↓bl.loss, ↓tissue damage, ↓ bending,↑ stable Commonest malrotation
Basicx: along IT line, extracaps.but↑ ON Ttt Rotation osteotomy
No cancellous interdigitation so rotate during -#G.& L troch.
implant insertion ‫تلف مع الالج‬ Direct-indirect(m .avulsion)
DHS + antirotation S. before lag. Non op.usually
Comminuted/ failed γ nail (PFN) Op. if pain with movement
hemiarthroplasty T. band or hook plate Screw med.approach
-NV# rare superficial fem. a by lesser troch.
-Stable? Not above
DHS(Dynamic, Sliding Hip Screw)
1300-1500 1cm subchondral at center head

-reduction technique:
Traction table ‫شدة ع حصان‬
Traction-add.-IR

Dr. Ma§oud Page 58

Pediatric hip Algorithm Subtrochanteric Fractures
Algorithm
-AP X-rays of pelvis
-AP & lateral X-rays of hip
-AP & lateral X-rays of full femur
-Consider long femoral nailing? Except
At age of 4ys > lig. teres a.
So capsulotomy doesn’t disturb bl.supply
But IT# do

If suspect CT pelvis

Classification (Delpt) use

Subcap Trans cx Basi cx IT ‫كبار‬
Trans Trans cx Cervico IT ‫اطفال‬
epiphys. trochanteric
CRIF Hip spica ORIF Pediatric
e- pins cast + DHS
Key Abd Cast
p.293 45/90 Rehab:
Consider touch down weight bearing and
full range of motion exercises.
Co=
Osteonecrosis head - Notes:
Head collapse (Ratliff) -subtroc.anatomy
I II III From LT to 5cm below
complete focal neck Calcar: med.cortex thick bony plate
Bad prognosis good fair -relative low bl supply
Disabiling No pain Don’t devitalize bone during op.
<500 ROM >500 -classification: Russell Taylor
OA Mild deformed I II
intact piriform fossa # extend to piriform
A B A B
LT LT Stable comminuted
attached detached calcar

Dr. Ma§oud Page 59

operative Bisphosphonate fracture characteristics?
1.cephalomedullary nail
1st generation 2nd generation
centromedullary Cervicomedullary
Enter GT must intact Enter piriforms
Eg. PFN γ nail Eg.recon nail

2.DCS:dynamic condylar screw

95 fixed angle plate more compression
Beaking present?
Adv.1.easy inserted
consider prophylactic nailing
2.act as tension band plate for the calcar
of contralateral femur
3.additional screw in calcar through plate
Why cant use DHS? Follow with DEXA scan
1.entery point fractured
2. no lag effect by DHS

Dr. Ma§oud Page 60

Femoral Shaft Fractures
Algorithm
- Suspected femoral shaft fracture classification
- Exam for compartment syndrome, open-closed
open fracture and neurovascular status site: 1/3 1/3 1/3
- High energy mechanism rule out isthma-infra-supracond.
femoral neck fracture Size:= comminution
No <50% 50-100 On cortical contact
- AP pelvis X-ray Shape: Tv / oblique / spiral /butterfly / seg
AP & lateral X-ray of femur Surface: angulation-displasment
AP & lateral X-ray of knee
Operative:
- Assess length, alignment and rotation -ILN better than plate?
of well leg with fluoroscopy ILN plate
↓ exposure-dissection- ↑) minimal invasive)
- Proximal shaft ↓ infection-scar
Consider closed cephalomedullary nailing Maintain # hematoma, disturb
periost.
- Femoral midshaft fracture early function, rapid Late
nailing with 10 mm diameter nail or more union(load sharing) (load bearing)
Key p.151 restore length alignment May shortening
Reaming: osteoinductive-conductive
- Distal shaft Get large nail But risk pulm.emboli
Consider retrograde nailing Antegrade Retrograde
Entry Entry Through knee
Rehab -Piriform :risk - i-#NF, Troch ‫تبعد‬
WBAT unless highly comminuted fracture #a./AVN #patella, prox. F ‫بالمرة‬
fixed and statically locked with -G.troch.: easy
<12 mm nail -obeise -pergnant
Need valgus-bow -amputation- TKA
CI-#NF, Troch‫تبعد‬ -CI- ROM<600, P.paja
- Additional femoral neck fracture
Fix femoral neck 1st Special cases #femur +
Consider retrograde nailing -NF#: (retrograde + lag S) (Recon nail)
Rehab: Touch down weight bearing for 12 -Distal f.#: (long plate/douple plate/nail& plate)
weeks -open-infected: ex fix

Plate: anatomic reduction i-

1.narrow medulla:congenital-infected-closed
Notes:
2. malunion/nonunion
-longest- largest 3.vascular#
Isthmus: narrowest part of medulla Approach: open-submuscular
2 nutrient as from profunda fem. A. Length: 5#5 holes (8 cortices)
On # disturb edosteal circulation so don’t disturb
periostium (Don’t devitalize)

Dr. Ma§oud Page 61

 Distal Femur Fractures
Pediatric # femur Wire p.169
Algorithm -bimodal : 2ys – woven bone remodel
12ys-growth spurt
-ttt. Age related
<6m Spica cast for prox.#
Split for mid-distal #
Any position accepted
6-4ys Immediate Spica cast
Reduction acceptance:
1-2cm overriding
- Suspected distal femur fracture <100 varus-valgus-rotation
-AP & lateral X-rays <200 pro-recurvatum
I II III IV V VI 4-12ys Nancy nail retrograde
Lat. Med Coronal Bi Inter Comm >12ys Nail through GT
Cond. Cond. Hoffa # Cond. Cond. inuted -Consider orthosis: Pavilic Harness
- Supra-condylar fracture -open: ex fix
non-displaced displaced -#SC: plate
Non-operative Operative treatment -physeal: Salter Harris
treatment Good bone stock? Co= m weakness
Well padded long leg -Open versus closed Shortening<2cm >2cm
cast for 6 w retrograde IMN +
followed by hinge multiple distal Periprosthetic Fracture around
knee brace for 6 interlocking screws
weeks - ORIF with lateral
TKA Algorithm
locked plate
Femoral or Tibial component loose?
- Inter-condylar fracture
CT scan No Yes
Non-displaced intercondylar Precut. 6.5 Fracture Arthroplasty
split or isolated Multiple lag fixation
lateral Hoffa fragment in screws on -Option 1: Revision TKA
addition to supracondylar good bone IMN Bone loss dealt with via
fracture stock -Option 2: augments and stems,
Simple inter- Lateral locked plate ORIF with Increase constraint as needed,
condylar split Or DCS ‫زمان‬ lateral Careful flexion/extension
locking gap balancing
Comminuted Lateral parapatellar
intercondylar approach for intercondylar NB.
fracture reduction and -IMN possible for diaphyseal fractures
Good bone Trans-articular Approach if an anterior starting point is available
stock? and Retrograde Plate
Osteosynthesis (TARPO)
No TKA Key p.182
Wire p.166
-Rehab
12 weeks NWB with Full ROM exercises
WBAT after 12 weeks

Dr. Ma§oud Page 62

Knee Dislocation Algorithm Quadriceps Patellar
tendon # tendon #
- Deformity >40y <40
- AP and lateral X-rays Anatomy: thick long tendon, collagen I
- Assess and document NV 4-6mm/4-6cm
- Signs for Compartment Syndrome? Ae: post tendenitis rupture
- Signs for Vascular Injury? Steroid(G,L),DM, RF, RhA, SLE
- Immediate closed reduction in the ED Common avulsion with bone 1cm
Traction + prox. Tibia manibulation C/P: forced contract knee feel pop ‫طقت‬
-Not, Successful? Look: effusion hemoarthrosis
Post.lat.D.irreduceble? Feel: papable defect
Button hole med.fem.condyle on med. Move: loss AROM
Capsule(dimple sign), need release Xray: lat.+flex knee300 patellofemoral Blumensat
Open reduction in the OR Withen 8 hrs line
-Intraop.post reduction examin knee
ligamens or at follow up:

P.baja P.alta

MRI-US: diagnostic
Can extend knee, elevate leg straight?
-Gross instability?
Partial tear
No Yes Wire p.174 Conserve in cylindrical cast for 4w
Knee immobilizer Knee spanning Then physottt strengthing
0
In 20 flexion ‫جبيره‬ external fixator Cannot extend knee, elevate leg straight?
- MRI Complete tear operative repair
Identify injured structures and definitive #mid tendon End tendon e-bone frag.
treatment based on age and activity level Repair e- multi Kessler Screw
Early repair/ reconstruction suture modified multi Or
of all injured structures Kessler technic Tension band
-Rehab modified multi (baseball) Key p.217
technic + bone tunnel
(baseball)

Dr. Ma§oud Page 63

Patella Fractures Algorithm Patellar D.
- Suspected patella fracture -Female 14ys lax lig.
- Clinical assessment of whole LL -Ae: P.alta, hypoplasia, congeita
hip, femur, tibia and ankle Hyperplasia lat.retinacula
- AP, lateral, and skyline view X-rays -displased patella usually lat > med> intraarticular
+ Patient able to raise a straight leg? -X ray : AP-lat-skyline
(Better after injecting 10cc 1-2% Lidocaine ‫حضن جامد‬ ‫اخدت المرشال‬ ‫لورين‬
Hematoma block) Hugston 550 Merchant 450 Laurin 200
- Step< 2-mm, Gap < 4mm Patellar index Congruence angle Lat.angle

Sulcus angle P-F index

-Operative? Classify P.fracture? P. alta (above) ,P.baja (below)

Transverse avulsion Stellate Vertical

fracture? fracture? fracture? fracture?
-ORIF -suture -Cerclage ORIF
tension repair wire ‫بالعرض‬
band - Basket - mesh
-Repair plate plate Wire
retinaculu - Partial - Partial p.175
Key p.211 patellect patellecto
‫متنساش‬ omy my
EUA: Confirm 0-90 motion with
stable fixation in the OR

Notes:
- largest Sessamoid bone
-has 7 facets, 2 large med/lat
(Largest=Lateral ( ‫امتحان تشريح‬
-Immediate reduction in ER
Just extend knee , medial push patella+ splint
-Operative?
intra articular D. (open reduction)
# med.retinaculum –Recurrent:
Lat.relaese-med. Plication
Prox-distal patellar realignment

Dr. Ma§oud Page 64

Tibial Plateau Fractures
Algorithm
- Suspected tibial plateau fracture
Axial load + varus/valgus
- NV: compartment S.
- AP & lateral knee X-ray
Lipohemoarthrosis?
- Tibial plateau fracture
Dr. Ma§oud
Non-operative treatment
-Minimally displaced
Advanced osteoporosis
Poor general state
Non-weight bearing for 6 weeks
Hinged knee brace Early range of motion
>6w Mobilization and graduated
weight bearing and walking
-Operative: Displaced fractures
- Classify according to Schatzker’s
- skin condition Poor skin condition
(swelling and/or blistering)
type I-III type IV-VI
applying posterior applying spanning
long leg splint external fixator
- CT thin cuts, 2D and 3D
-Arthroscopic assisted surgery,
percutaneous screw fixation Wire p.179
- ORIF (Butress plate) L/T Key p.199
-Ilizarov with or without limited open
reduction of the joint surface
For –comminuted
--bad skin condition
-Old age osteoprotic bone
Douple plate or locked plate
Notes:
- anatomy :
lateral convex prominent ↑injury
Page 65
Tibial Shaft Fractures Algorithm

-Suspected tibia shaft fracture

Notes:
-Open fracture?
-Signs of compartment syndrome? - anatomy :
- Vascular injury? *Periost.-endostium blood circulation
-Bone loss? If endost. Circulation disrupted by # don’t detach
periostium , reverse flow nutrient
*Water shed area mid1/3-distal1/3
-AP & lateral X-rays of tibia
*# ant.tibial a. may be with intact dorsalis pedis
+ ipsilateral knee and ankle
pulse? Has other communication with peroneal a.
- CT : Extension suspected to tibial plateau
* fibula for m attach, transmit body wt only 7%,
or plafond?
for bone graft, #shaft ‫رباط ضاغط‬
* N common per. Sub cut at neck fibula take care
-Classification
*open
*closed (Tscherin)
0 1 2 3
NO Superficial m. m.laceration
contusion contusion compartment S
Long leg cast for 4 weeks - RICE Bulle bad sign ‫تاجل العملية اسبوعين‬
Convert to functional cast until union -Co=……+
Weight bearing as tolerated & Non union : >9m+ gap e-sclerotic edges
Weekly X-rays follow-up -hard ware faiure

-Surgical? -Operative:
-Proximal 1/3 -ILN
Consider proximal tibia plate or IM nail -p&s
-Nancy nails (pediatric)
NB. Polar screws or frame for reduction
-Ex. Fix (open)
-Rush pins (open)
-Middle 1/3
-Ilizarov (open)
IM nail Key p.205 Wire p.185 / 193

-Distal 1/3
distal tibia plate(cloverleaf) or IM nail

• 2 weeks in a posterior splint with the foot

plantigrade (ankle at 90).
• After 2 weeks ROM exercises for knee and
ankle
• Stable fracture - WBAT /
Unstable fractures NWB for 6 weeks

Dr. Ma§oud Page 66

Tibial Plafond (Pilon) Fractures Ankle Fractures Algorithm
Algorithm
-Suspected ankle fracture
-Suspected tibial plafond fracture -x ray AP, lateral, and mortise views of the
-AP, lateral, & mortise X-rays of ankle ankle
2 views of ipsilateral knee X ray Clear AP Tf Mortise
3 views of ipsilateral foot space overlap Tf overlap
-CT ankle with axial, coronal, normal <2mm >10mm >1mm
and sagittal cuts abnorm >2mm <10mm <1mm
-Delay definitive surgery until soft tissue is Lateral : Talar dome over plafond
ready for surgery, which can be 2-4 weeks ant/ post malleolus #

4- steps ORIF

-Weber A
Consider non-operative treatment of
-Valgus mechanism?
lateral malleolus
adding an antero-lateral tibial plate
-Weber B/C
-Varus mechanism?
Surgical fixation of fibula Key p.237
adding a medial tibial plate
-Talus appears stable in the ankle
Rehab:
mortise? Stress view X-ray
-Splint for 2–3 weeks
- medial/posterior malleolar fracture
-12 weeks of non weight bearing
- Syndesmosis instability
-Passive and active range of motion
Assess by dorsiflexion and external
Notes:
rotation stress of the foot,
- How? with stabilization of the tibia
*compression axial load #:
Calc → plafond → T plateau → acetabulum →
-Rehab:
lumber vertabrae
-Splint 2 weeks WBAT in CAM boot 4
*shear: valgus varus
weeks and ROM exercises
-Classification: (Ruedi) CT based
-Diabetic or severe osteoporosis?
1 2 3
NWB 12 weeks Cast 6 weeks
Full ROM exercises 6-12 weeks
One part # displaced Comminuted
Non displaced
Non op. ORIF Ex.fix
Cast 6w Ilizarov
Arthrodesis : salvage if failure

Dr. Ma§oud Page 67

Assessment of Ankle Fracture Reduction
-Fibula length, rotation and alignment
• Equal joint space
• Intact Shenton line of the ankle
(fibular beak)
• Unbroken curve between the lateral
talus and the peroneal groove of the
fibula (dime sign)
• Bimalleolar and talocrural angles
• Distal fibula shape
Syndesmosis
• Distal tibia-fibula clear space widening
of more than 6mm or more than 2mm
compared to the contra-lateral side
• Lack of distal tibia-fibula overlap
of 6mm (or 40% of fibula width)
on the AP or 1mm on the mortise views
Medial space widening is a sign
of deltoid ligament injury and can
accompany malreductions of the lateral
malleolus, medial malleolus and
syndesmosis.
A pseudo widening can result from imaging
the ankle in plantar flexion
Notes:
- anatomy: stability
*Hinge j, uni > bi > tri #
*axis ankle ER 200 (Mortise)
*syndesmosis:Fibrous inf. T-F J
*plafond wide ant > post
So dorsiflexion > planter
*deltoid lig: resist lat. Talus displace
*fibular collateral lig.
Ant., post (to talus): resist ant-post displace
Central (to calc) : resist med. Displace
Dr. Ma§oud
How to know mechanism of injury from
Lauge Hanssen Classification:
Start e- lat. X ray lat. malleolus
Spiral# = ER Tv # = S/P
Start # from post. Tv # = Pron-abd
= PER
Start from ant. Vertical #
=SER = SA ‫سبحان هللا‬
Tailux #: ankle # + # ant. Tibial margin
Maisonneuve #: ankle # + prox.TF J
Carbston#: # post malleolus
*Dislocated ankl e should be reduced immediately
in ER to preserve talar dome
Reassess Nv post reduction
Operative: Key p.237 Wire p.188
Lat.malleolus:
*P& S Buttress (five cortices)
* lag S
Med malleolus:(open clear space)
*3.5 cancellous S on washer 45-50mm
*small frag. T. band
Post malleolus:(>25% #, >2mm displace, talus sublax post.)
A-P or P-A lag S
*Syndesmotic S ( Fully threaded cancellous 3.5 on washer ,
at 200 post, foot dorsiflexed)
From F to T ? To prevent fibla displace e talaus movement
Page 68
Ankle Sprain Algorithm Achilis tendon rupture
Algorithm
Low = MCL/LCL# >40y male
Stress tests: varus / valgus stress Anatomy: thickest longest tendon, collagen I
A / P drawer 10mm/10cm , no sheath has paratenon
Heel ecchymosis = subtalar lig.# Ae: post tendenitis rupture or acute injury
Steroid(G,L),DM, RF, RhA, SLE
Common avulsion with bone 1cm
C/P: forced contract ankle feel pop ‫طقت‬
Look: ecchymosis
Feel: papable defect
Move: loss AROM
Test: Thompson test
MRI-US: diagnostic
Can flex ankle?
Partial tear
High = Syndesmosis# Conserve in above knee cast in planter flexion 4w
Tender ant. Ankle
then below knee 6-8w ( gradwal plantigrade)
Squeeze test ( T-F)
Then physottt strengthing
ER test (foot ankle)
Cannot flex ankle?
X ray : open >1cm
Complete tear operative repair AC bond suture
Edward-Delee classification
Post med longitudinal approach or lazy S
I II III IV Risk sural N
Lat. Lat.D. Post.D. Sup.D. #mid tendon End tendon e-bone frag.
sublax
Repair e- multi Kessler Screw
Conserve Operative reduction +2 S suture modified multi Or
Kessler technic Tension band
modified multi (baseball) Key p.244
technic + bone tunnel
(baseball) drilled

Dr. Ma§oud Page 69

Talus Fractures Algorithm

-Suspected talus fracture

Notes:
-AP , lateral X-ray & canale view
- anatomy:

-CT scan of foot with thin cuts and 2D

-Dislocation?
Attempt closed reduction in ER
*
Failed, Urgent open reduction in OR
-Why neck most common #?
Wire p.203
Lig.attached (under tension) ‫مشدوده‬
-Determine fracture pattern Has angle 250 ‫معوجة‬
Non-displaced? Vascular foramina‫مخرومة‬
Cast or percutaneous fixation -aviator #‫نط بالبراشوت‬
Fall from high in dorsiflexion
-displaced? Wire p.216 -classification: Hawkin ‫نايل سات‬
Neck Body Process I II III IV
ORIF ORIF with -Posterior Non Subtalar D. +Ankle D. +Talonav.D.
dual medial process ORIF displased + displaced + displaced (pan talar D.)
approach malleolus posteromedial Conserve ORIF
anteromedial osteotomy approach Cast 3m NB. Not predict AVN as it depend on
and - Lateral NWB vascularity not fixation.
anterolateral process ORIF Hawkin sign: good sign
sinus tarsi radiolucency= good vascularity
approach sclerosis= bad vascularity

-Surgical approach Risk

Ant.med: neck & body Saph. VN
Ant.lat: lat.neck & subtalar Open sinus tarsi
Combined: neck Skin necrosis
Post.lat: post.process & body percutanus

Dr. Ma§oud Page 70

Calcaneus Fractures Algorithm
-AP & lateral X-ray of foot Harris heel view
-CT scan of calcaneus per standard protocol Sanders classification:
CT coronal based on post.facet
I II III IV
1 part # 2 part 3part Commin
Non A/B/C Central uted #
displaced depressed
AB/AC/BC
I- Non II-percutaneous III- Delayed IV-
operative minimally ORIF 2 to 3 Consider
bulky invasive weeks Until arthrodesis
dressing fixation ± Sinus wrinkle test
-Measure Bohler & Gissane angles X-rays tarsi approach? is normal
- NWB 6-12 weeks Early ROM (after 2 weeks)

Essex leprosity classification:

Intra Articular Extra articular
Post facet # Post facet intact
1ry # line # ant. process
2nd #line #med.process
J/Tongue/depressed/ #lat.sust.tali
Varus/blow out #body #tuberosity
Op: Displaced Op: # 25% /Displaced >1cm
>2mm
Aim: restore
anatomic
Subtalar J
Calc.cub.J
Neutraliz varus
Bohlar angle
Wire p.206
-Co=……
Wound deheisence need flap
Peroneal tendinitis
Sural N injury
Subtalar arthritis
Post facet

Dr. Ma§oud Page 71

Lisfranc Fractures Algorithm
-Suspicion for Lisfranc Injury
Notes:
Lisfranc: lig/Joint/injury/dislocation
- anatomy: Tarso-metatarsal D.
Lisfranc lig. Connect base 2-5 MT
No lig.connect 1st 2nd MT

-AP, oblique, lateral X-rays

-Widening between Medial Cuneiform and
2nd MT Base? -X ray:
AP 2nd MT in line e- 2nd cuniform
Or inbetween 2nd 3rd C.
Lat.dorsal displace MT
Flake #: # base 2ndMT + lig. + Navicular
-Classification:
1.Quenu & kuss
Homolat 1st /2nd diverge All diverge
In coronal &
sagittal plane
2.Merson:
Incongruent Divergent
-Bilateral weight bearing X-rays Total (med-lat) Partial – Total
-Consider CT Scan (dorsal-planter)
Partial (isolated)
-Fractures? TMT joints with -Co=:…..+ compartement S, Seudecks
severe subluxation or dislocation?
Reducible: Navicular Fractures Algorithm
Consider primary arthrodesis of TMTJ 1-3 -AP, lateral, 45° oblique X-rays
Cast/splint for 6 weeks -Non-displaced fracture Avulsion
Progression of weight bearing for 6 to 12 w Cast for 6 weeks NWB
Full weight-bearing at 12th week -Body Fracture -Foot CT scan
Non reducible Type I Type II Type III
Consider ORIF with incision over 1-2 ORIF ex-fix or Spanning plate to
webspace, add 3-4 webspace incision if maintain length
needed.(Key is fix 2nd MT) Splint for 2 weeks then Ex-fix: removal at 6 weeks,
Rigid fixation (S.) for 1-3rd TMT, k-wire CAM boot, ankle and NWB 3 months.
fixation 4,5 TMT. Wire p.226 subtalar ROM Bridge plate: removal at 3-4
NWB for 8 weeks then months, NWB
progressive weight 3 months Wire p.221
bearing (25%/week)

Dr. Ma§oud Page 72

Metatarsal (MT) Fractures Toe Fractures Algorithm
Algorithm

-Foot injury suspected of MT fractures -Suspected toe fracture

-AP, lateral, 45° oblique X-rays -Foot AP, lateral & oblique foot X-rays

-1st MT Stiff sole shoe for 6 weeks WBAT +

No Displace?
-1st toe:
NWB cast for 6 weeks ORIF Key p.248
Proximal /distal phalanx Displaced?
Wire p.222 Consider CRPP Wire p.242
-Subungal hematoma: Decompress
-Central Metatarsal (2nd-4th MT)
-Sesamoid fracture in Athlete?
->10 degrees deformity?
> 4 mm translation? Diastasis Not improved
Multiple fractures? Surgical repair of Sesamoidectomy
yes no plantar plate
Consider CRPP Stiff sole boot for
vs. ORIF 6 weeks WBAT -Lesser toe:
Correct alignment and rotation, apply buddy
tape ‫مشمع قطن الصق‬
-5th MT
Non Acceptable alignment with taping?
Consider CRPP Wire p.245

Toe Dislocation Algorithm

Johss classification:
I II A IIB
Volar plate # lig inter- # sessamoid
avulsion sessamoid bone
Trial closed reduction 2times
Zone I Zone II/III Failed? ORIF wire
Stiff sole Athlete? Consider IM screw Neglected? arthrodesis
boot for No, NWB cast for 6 weeks
6 weeks Key p.260
WBAT Wire p.230

Dr. Ma§oud Page 73

Dr. Ma§oud Page 74
Spinal Cord Injury (SCI)
Algorithm
-Complete ATLS primary and secondary
survey

-Neurogenic shock?
After initial fluid or blood product,
initiate Dopamine or Norepinephrine

-Neurologic exam possible grade as either

ASIA impairment scale -CT+MRI

Gun Shot Wound SCI Complications

Consider non-op Pressure ulcers
management unless: Deep vein thrombosis
-Progressive neurologic (DVT)
deficit with bullet in canal Urosepsis
-Retained bullet fragment Bradycardia
-Cauda Equina Syndrome Orthostatic hypotension
Early (6-12hrs) surgical Autonomic dysreflexia
decompression & Depression
stabilization

Dr. Ma§oud Page 75

PRINCIPLES OF MANAGEMENT Adult C-Spine Clearance After
OF MAJOR SPINAL TRAUMA
Blunt Trauma Algorithm
1. assumed to have an unstable spinal injury
2. At the scene of injury, the patient is
immobilized with a spinal board, a rigid -Any high energy mechanism
cervical collar, neck blocks and straps.
3. Emergency Department management
Primary survey
This follows the ABCDE +
Airway: don’t‎do‎head‎tilt‎chin left airway
compromise may be caused by the
development of a retropharyngeal
haematoma
Breathing: impaired after a cervical or
thoracic spine injury
Circulation: Neurogenic / spinal shock
Disability: rapid assessment of central
neurological function is made using
AVPU and the Glasgow Coma Scale
Exposure: Patients should be completely
exposed to allow examination. This involves Normal Abnormal
cutting their clothing free whilst preserving Cervical spine is Cervical CT
warmthand dignity. clinically cleared ↘↘
•‎Logroll the patient to allow inspection of and hard collar is
the back and to remove debris and clothing discontinued.
- Cervical CT scan
Normal Abnormal
Neurologic deficit -Continue log roll
attributable to spinal precautions
injury? → → -Consider MRI

Secondary survey
clinical examination of the neck and back is
performed. Where there is no evidence of
spinal‎injury,‎the‎spine‎is‎‘cleared’

-CT angio if vertebral artery is suspected

Dr. Ma§oud Page 76

Radiological assessment of the
injured spine

Dr. Ma§oud Page 77

NB. Spinal cord injury without radiological
abnormality (SCIWORA)
occurs primarily in children and can range in
severity from minor cord contusion to complete
cord disruption. Neurological dysfunction can
be delayed or progressive in the first few days.
MRI will often show cord or surrounding soft
tissue contusion. A child who has presented with
signs of any cord dysfunction following trauma
should have spinal instability excluded and,
once fit for discharge, be advised to avoid
contact sports for 3months.
Occipitocervical Dissociations (OCD) Algorithm
-Suspected occipitocervical dissociation
-Detailed neurological exam, including cranial
nerves
-CT & CTA
-MRI with STIR
-Occipital to C2 fusion
-Avoid halo in the treatment of OCD

Steroid dose with spinal cord injury?

Amp=1000mg 2amp shot
→4x1→3x1→2x1→1x1

Non op. Orthopaedic management of

spinal injuries

Dr. Ma§oud Page 78

Atlas (C1) Fractures and C2 Odontoid (dens) Fractures
Transverse Ligament Injuries Algorithm
Algorithm
-Neck pain after trauma
-Neck pain after trauma -CT scan
-Fracture of the Atlas -Odontoid fracture
-CT scan +/- CTA if vertebral artery injury
Suspected
-MRI to determine status of transverse
ligament

-Type I, III
Cervical orthosis for 6 weeks with
radiographic follow up

- Type II Young patient Wire p.158

Not Displaced Displaced
-Transverse ligament? HALO vs. cervical Closed reduction and
intact ruptured orthosis for 6-12 ORIF with odontoid
Hard collar or Halo -Halo vest for 8-12 weeks screw if amenable
vest for 8-12 weeks weeks or Consider C1-2 PSIF
- Posterior C1/2 if required
fusion, possible - Type II Old patient
occiput to C2 fusion Not Displaced Displaced
Cervical orthosis C1-C2 fusion via
for 12 weeks Harms technique

Dr. Ma§oud Page 79

C2 Traumatic Spondylolisthesis
Algorithm
-Neck pain after trauma
-CT scan
-C2 Traumatic Spondylolisthesis
(hangman’s fracture)

Treat in cervical hard collar for 6-12 weeks

Treat with closed reduction consisting of

traction, followed by Halo for 6-12 weeks

Treat with closed reduction consisting of

EXTENSION, followed by Halo for 6-12
week

Open Reduction Internal Fixation

-Assess for fusion with CT

and stability with dynamic X-rays (flexion /
extension)

Dr. Ma§oud Page 80

C3-C7 Facet Dislocations C3-C7 Lateral Mass Fractures
Algorithm Algorithm
-Perched or Jumped Facets -Lateral Mass Fracture
-Neurological exam -CT and CTA to assess for vertebral artery
-Immediate CT and CTA for assessment of injury
vertebral arteries -MRI to assess disc integrity, ALL, PLL

-Urgent MRI to assess for disc herniation or -Disc and ALL +/- PLL intact
canal compromise Hard Collar for 6-12 weeks
Anterior Discectomy,
Open Reduction in OR -Disc Disruption with involvement of ALL
+/- PLL
-No disc herniation or risk for spinal cord Facet # Facet # Facet #
compression with reduction+ Radiculopathy neuro radiculopathy (floating)
Urgent closed vs open reduction intact Lamina #
pedicle #
-Definitive treatment Single Short segment posterior Two level ACDF
Unilateral Facet Bilateral Facet Level fixation with foraminotomy Key p.272
Reduced Persistent Reduced or ACDF or possible ACDF
Dislocation Dislocation Persistent
Dislocation
ACDF Posterior ORIF
+/- ACDF

Anterior fusion of the cervical spine

Dr. Ma§oud Page 81

Geriatric Vertebral Compression
Fracture (VCF) Algorithm
-Back pain with no traumatic mechanism
-X-ray demonstrates VCF
Thoracolumbar
InjuriesAlgorithm
-Detailed neurological exam
-CT scan
-Consider urgent MRI if Neurological injury,
or injury to posterior ligamentous complex

-Neurological injury?
Early (<6-12 hrs) anterior and/or posterior
decompression and instrumented fusion

-Determine type of injury

- CT scan Compression (Chance Translation
Fracture fracture or injuries
-Suspected Malignancy burst or
MRI spine and malignancy workup fractures) dislocations
? Failure of ?
-Osteoporotic workup + posterior or
Attempted Mobilization anterior
Spinal Orthosis Kyphoplasty tension band
Stable alignment Consider Open
Conservative Treatment percutaneous reduction
Consider TLSO or Jewett instrumented and
brace. stabilization. instrumented
Kyphotic angulation If lig.injury, fusion
Posterior and/or consider Key p.267 /
anterior instrumentation instrumented 279
and fusion fusion.

Dr. Ma§oud Page 82

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