Ortho Cases

Osteomyelitis

1. Clinical Picture

a. General Toxic features as fever pallor, sweating, nausea and vomiting and tackycardia.
b. Local - Severe pain (of sudden onset). -Swelling. – Pseudoparalysis.
c. redness & edema over the skin.
d. Localized tenderness over the bone (The earliest sign).
e. Sympathetic effusion of the adjacent joint.

2. Pathogenesis

• Inadequate treatment of acute OM / Foreign implant / Open fracture

• Inflammatory process continues with time together with persistent infection by
Staphylococcus aureus
• Persistent infection in the bone leads to increase in intramedullary pressure due to
inflammatory exudates (pus) stripping the periosteum
• Vascular thrombosis
• Bone necrosis (Sequestrum formation)
• New bone formation occur (Involucrum)
• Multiple openings appear in this involucrum, through which exudates & debris from the
sequestrum pass via the sinuses (Sinus formation)

3. Diagnosis

a. Laboratory:
i. CBC: ↑TLC & ↑ ESR & CRP.
ii. Blood culture (at time of fever).
iii. The most certain is to aspirate pus from metaphysis + C&S.
b. Radiographs:
• Soft tissue swelling.
• Hyperemia, demineralization of the bone.
• Lysis (when > 40% resorbed)
• Periosteal reaction
• Sclerosis (late)
c. X- Ray .
• 1st 2 weeks → -ve . End of 2nd wk → faint extra-cortical outline (periosteal new
bone formation) .
• After 3 weeks → chronic sequestrum.
d. U/S → Subperiosteal abcess + Joint effusion + U/S guided aspiratlon .
e. MRI.
• MRI T1 Dark
• T2 Bright/Mixed
f. CT scan (when M.R.l. is contraindicated )

4. Management (start immediately once suspected)

a. General:
 • Hospitalization, bed rest & immobilization (until inflammation subsides).
b. Medical :
• Analgesic. Antibiotics. Antipyretics + fluids.
• Early administration of high dose empiric broad spectrum antibiotics
(flucloxacillin, augmentin or vancomycin) + gentamycin for gram -ve
organisms then specific antibiotic according to culture and sensitivity.
• Parenterally for 1-2 wks then Oral for 4-6 weeks (minimum duration 6 weeks)

c.Surgical (Indications)
• Obvious collection of pus which must be drained.
• lf no improvement on antibiotics within 48 hours (from onset of fever) (we have
to interfere before chronicity = subperiosteal elevation)
• lf the patient is first seen after 48 hours.
• Procedure: Drainage of subperiosteal abscess + drill holes in the cortex (6-8
holes).
• Postoperative antibiotics for 6 weeks
5. Complications

• General:
o Toxemia.
o Septicemia & pyemia (if immunocompromised)
• Local :
o Chronic osteomyelitis
o Spread: suppurative arthritis (only if metaphysis is intra-capsular e.g. Hip joint).
o Disturbed bone growth (deformity and/or shortening).
o Pathological fractures

Osteonecrosis

1. Clinical picture
• Limp
• Antalgic gait
• Restricted ROM
• Tenderness around bone
• Joint deformity
• Muscle wasting
• Crescent Sign
• Snowcapping
• Areas of lucency
• Flattening of joint surface

2. Pathophysiology
• Vascular occlusion
• Altered lipid metabolism
• Intravascular coagulation
• Healing process
• Primary cell death
• Mechanical stress
 3. Diagnosis
• X-ray
o May be the first test the doctor recommends.
o X-rays are not sensitive enough to detect bone changes in the early stages of the
disease.
o In later stages of osteonecrosis x rays may show bone damage, and once the
diagnosis is made they are often used to monitor disease progression.
•MRI
o Is the most sensitive method for diagnosing osteonecrosis in the early stages.
o Detects chemical changes in the bone marrow.
o May show diseased areas that are not yet causing any symptoms
• Bone Scan
• CT
• Biopsy
4. Management
• Offloading affected joints with use of crutches
• Immobilization
• Analgesia
• Bisphosphonates to delay femoral head collapse
• Stains in patients on high dose corticosteroids — reduced lipid deposition
• CORE DECOMPRESSION
o Indicated in stages I and II
o 8 — 10 mm anterolateral core of bone
o Filled with bone graft
o Decompresses medullary cavity, reduces pain
• REALIGNMENT OSTEOTOMY
o Indicated in stages III & IV
o Used to relocate necrotic area from weight bearing portion of femoral head
o Angular osteotomies more common • Multiple techniques for holding the
fixation
• ARTHROPLASTY
o Indicated in stage IV onwards
o Main aim is pain reduction
o Young patients will need revision
o Higher failure rates than in OA
o Hemi arthroplasty an option

Septic arthritis

1. Clinical picture

• Symptoms:
o Pain (night and rest pain are characteristic): severe , sudden, throbbing.
o Swelling at the joint area.
o lnability to move the joint.
• Signs :
o Redness, swelling and discharging sinus (if neglected).
o Deformity (late)
o Hotness and tenderness on palpation.
 o Complete loss of all movements (active & passive)

2. Pathophysiology

• Bacteria deposits in synovium producing inflammation

• Spreads to synovial fluid and multiplies
• Products of inflammation destroys joint components (Swollen, painful joint)
• Sequalae
• Infant
o Destroy the epiphysis, which is still largely cartilaginous.
• Children
o Vascular occlusion lead to necrosis of epiphyseal bone

3. Diagnosis

• Laboratory:
o ↑TLC. ↑ ESR and CRP +ve.
o Joint aspiration +/- U/S guidance : as diagnostic and therapeutic.
• U/S : accurate for detection of effusion
• Radiology:
o Early: soft tissue shadow.
o Later: decreased joint space then complete obliteration bony ankylosis

4. Management
• General
o Bed rest + immobilization.
o Antibiotics
o Analgesics + fluids.
o Antipyretics.
• Specific: it is a surgical emergency
o Washout of the infected joint:
o ln knee, ankle and shoulder joints → arthroscopic washout or open arthrotomy
+ washout .
o ln hip joint sepsis → only open arthrotomy.

5. Complications

• Bone destruction.
• Pathological dislocation.
• Growth disturbance.
• Bony ankylosis.
• Toxemia, septicemia & pyemia.

Club foot

1. Clinical picture
• Heel is small and high.
 • Deep creases appear posteriorly and medially.
• Abnormal thin calf.
• One or both feet are rotated inwards and downwards
• The soles of the feet face each other.

2. Pathology

• Deformity:
o Planter flexion of the foot at the ankle.
o inversion of the foot.
o Adduction of the forefoot
• Shortening of all ligaments on the medial side of the foot.

3. Diagnosis

• Presence of specific deformity (triad) at birth which cannot be corrected passively & consists
of:
o inversion of the foot → subtalar joint.
o Adduction of forefoot → tarso metatarsal joint.
o Equines (planter flexion) → ankle joint.
• Complete neurological examination must be done to exclude paralytic and spastic types of
deformity.
• IMAGING X-ray
o to assess progress of treatment:
o AP View:
✓ Talo-calcaneal angle (Kite’s angle) is decreased.
normal 20-40 degree, clubfoot angle almost parallel
✓ A line projecting the long axis of talus forward passes laterally.
• Lateral View:
➢ Tibio-calcaneal (Turco view)angle is obtuse
➢ Normal angle : 40 degree If less 20 degree
➢ shows deformity

4. Management
• Conservative:
✓ Correction of the deformity: -
✓ Starting from distal to proximal (begin in the 1st wk. of life)
• Maintenance of the correction by:-
✓ Adhesive strapping (in the 1st 2-3 wks).
✓ Plaster of Paris.
• To avoid recurrence of deformity use of a Denis Browne splint at night time is
recommended until age2 years.
• Splinting is not required during day time

• Operative lndications: (3R)

o Resistant, Residual, Relapsing deformity:

o < 2ys "soft tissue deformity" → posteromedial release.
 o 2-10ys "bonny deformity also" → bone reshaping.
o >10ys → triple Arthrodesis.

DDH

1. Clinical picture

a. Neonates
• mother observes asymmetry, clicking hip or difficult in applying the napkins (
due to limited abduction).
• Ortlani test
o The examiner's thumb is placed over the patient's inner thigh.
o The index finger is gently placed over the greater trochanter.
o The hip is abducted, and gentle pressure is placed over the greater
trochanter.
o ln the presence of DDH, a clunk, similar to turning a light switch on or
off, is felt when the hip is reduced.
• Barlow test
o Performed with the hips in an adducted position, in which slight gentle
posterior pressure is applied to the hips.
o A clunk should be felt as the hip subluxes out of the acetabulum.
b. Infants and child
• Unilateral cases
o Asymetrical gluteal creases.
o Present with a limb (the affected leg tends to be short and externally
rotated Trendelenburg gait (after walking).
• Bilateral cases:
o Broad perineum and waddling gate.
c. Adolescent
• discomfort after exercise (X-ray may show dysplasia and possibly subluxation)
d. Adult
• pain is the usual complain as a result of degenerative osteoarthritis (X-ray may
show dysplasia and degenerative changes.)
• Trendelenburg gait: is an abnormal gait (as with walking) caused by weakness of
the abductor muscles of the lower limb, gluteus medius and gluteus minimus.
• Wadling gate: is a form of gait abnormality.
• The "waddling" is due to the weakness of the proximal muscles of the pelvic
girdle. The patient uses circumduction to compensate for gluteal weakness.
2. Pathology

• Acetabulum
o Shallow (looks like a saucer instead of a cup)
o The roof slopes too steeply
o Anteverted
• Femoral head
o Dislocated(post. and sup.)
o Delayed ossific center
• Femoral neck : Unduly anteverted
• Capsule
 o Stretched
o ± hourglass by iliopsoas
• Limbus
o Superiorly the acetabular labrum and its capsular edge may be pushed into the
socket by the dislocated femoral head .
o This fibrocartilagenous structure may obstruct closed reduction.
• Lig. Teres
o Elongated
o Hypertrophied

3. Diagnosis

• Ultrasound:
o It has been of significant benefit in the assessment and treatment of children
with hip dysplasia. Used to control and monitor hip stability and as screening
test between 4-6 weeks particularly in at risk patient.
• x-ray:
o Had little value before the age of 1 year old as the head of femur is
cartilagenous till this age.
o At the age of 1 yr or older:
o Shallow acetabulum.
o Ossification center of the head is displaced upwards & outwards.

4. Management
• Neonate
o Most of neonates with instability sign at birth, spontaneously
corrected, so it is better to wait till 3 weeks before intervention.
o After 3 weeks → reduction & splinting in abduction.
o lf U/S confirm the diagnosis of CHD → VonRosen splint for 3-6 months
is a must.
• At the age of 6 months to 6 years:
o Reduction in plaster cast with maintained abduction for 6 wks.
o After 6 wks → replace the cast with splint that prevent adduction but
allow movement.
o Follow up by serial X-ray films.
a. lf failed reduction → surgery is performed either:
b. Open reduction followed by fixation by plaster cast Or
c. If the acetabulum is markedly shallow, it can be deepened by a
concomitatnt pelvic osteotomy
• After the age of 6 years:
o Unilateral dislocation → operative reduction + corrective osteotomy.
o Bilateral dislocation: -
o Painless not noticed waddling → better to avoid operative reduction.
o lf there is noticed waddling → operative reduction + corrective
osteotomy.

Osteosarcoma

1. Clinical picture
 • Symptoms .

o General –

➢ Anemia, cachexia, fever, malaise, lethargy. - Metastasis (e.g.: cough, hemoptysis...).

o Local: -

➢ Pain is early. it is constant, worse at night and gradually increases in severity.

o Swelling.

➢ Pathological fracture is uncommon because the patient is bed ridden due to pain).

• Signs .

o General: fever, cachexia. .

o Local:

✓ lnspection: -

✓ Swelling.

✓ Overlying skin: dilated veins.

✓ Palpation: - Bone swelling which is: --- Warm, tender, identified.

✓ Firm to hard with soft areas.

✓ Local tenderness.

✓ LNs: affected late.

2. Pathology

Site :
➢ Metaphysis of long bone (rule of 80).
Cell of Origin:
➢ Osteoblasts → osteogenic.
Macroscopic picture:
➢ Osteosarcoma destroys and replaces the normal bone.
➢ The tumor rapidly infiltrates towards the bone marrow early, but it respects the epiphyseal
cartilage and hence does not invade the epiphysis or the joint.

 it may be osteogenic or osteolytic.

 There are four main pathological features:
1. Bone destruction.
2. Tumor bone formation (radiologically appears as sunray appearance).
3. Reactive bone formation (radiologically appears as codman's triangle).
4. Soft tissues infiltration.

3. Diagnosis

 Radiologically .:No single feature is diagnostic.

 X-ray:
➢ lll-defined destructive lesion:
➢ Start in metaphysis.
 ➢ Destroys the cortex.
➢ lnvades the soft tissue.
➢ New bone formation:
➢ Sun ray appearance (stretched blood vessels around which new bone formed).
➢ Codman's ▲. ( Reactive at the angle between the periosteum and the shaft called a Codman's
triangle)
➢ Soft tissue mass around the bone:

4. Treatment

 Local control of the disease is by either

➢ Amputation: The level of amputation should be proximal to the joint above the tumor, e.g.,
osteosarcoma of the tibia is treated by above knee amputation. or
➢ Wide local excision and prosthetic replacement.
❑ Adjuvant chemotherapy has markedly improved the prognosis.

Open fracture management

1. Firs Aid (A’B’C’D’E)

2. Resuscitation ,Monitoring and Neurovascular evaluation.
3. Definitive Treatment:
• Redution(if displaced.)
• Fixation.
• Rehabilitation(passive and active)
 • Treatment of complications.

1. First AID
• General → lf poly-traumatized patient.
o Primary Survey
✓ This includes a pre-hospital phase and a hospital phase.
ABCDE
A - Airway:
Assessment: if the patient is able to speak freely, his airway is patent.
Action:
1. Clear airway.
2. Protect airway: oropharyngeal airway, tracheal intubation or
cricothyroidotomy.
3. Cervical spine control.

B- Breathing:
Assessment: inspection, palpation, percussion and auscultation
Action: e.g. Needle decompression for tension pneumothorax

C- Circulation :
Assessment: general examination for hemorrhagic, cardiogenic or neurogenic
shock.

Action:
1. Control bleeding.
2. Restore the lost blood.

D- Disability:
Assessment:
AVPU evaluation (alert, vocal, painful stimulation
unresponsive), followed by Glasgow coma scale in the secondary survey.

E- Exposure:
✓ insert Foley's catheter and nasogastric tube
✓ Radiological assessment .
✓ AMPLE history (may be done in the secondary survey).
o Secondary Survey
After establishment of the general condition of patient, 2ry survey has to be
done.

2. Definitive treatment at hospital

(local treatment)
l. Reduction:
Aims: .
▪ Allows end to end alignments.
▪ Allows shortest time for union.
▪ Allows full function of limb.
❑ Types: .
1. Closed:
-(checked by x-ray)
-Done under sedation/anesthesia.
Methods:
▪ Gravity.
▪ Closed manipulation.
▪ Traction. This is particularly for fractures of long bones of the L.L. skin or skeletal traction is used
to keep reduction of the fracture.
2-Open:
➢ Indications:
❑ Failed closed reduction (unstable).
❑ Open fractures.
❑ Other indications for internal fixation (injury of vessels, nerves & viscera). –
❑ lntra-articular fracture: for accurate (anatomical) reduction to avoid traumatic 2ry arthritis.
❑ Late unreduced fractures( neglected).

II. Fixation

❖ Simple Non Rigid

▪ Either POP (plaster of paris) or
▪ Traction( skin or skeletal)
❖ Rigid fixation :
▪ External skeletal fixators: for compound fx, severe soft tissue damage, neuro vascular damage
and infected fractures.
▪ Internal fixators: for -difficult fractures(prone to non union as femur neck # or to malunion as
ankle joint # or to be pulled by muscle contraction as patella and olecranon fxs).
▪ -Unstable and -Pathological fxs.

III. Rehabilitation

Physiotherapy & active movement.

Aims:
1-To prevent 5
▪ To prevent stiffening of joints. –
▪ To prevent wasting of bones & muscles.
▪ To prevent osteoporosis.
▪ To prevent secondary syndromes.
▪ To prevent edema
2- Early: to maintain the function of the uninjured parts.
3- Later: restoring function of the injured parts, once fracture healing occurs.
 . Methods:
- Active exercise.
- Assisted movements.
- Functional activity.