ORTHOPAEDIC Complete 2nd Ed

(YEAR 3 & 5 MODULE)
-Student Edition-
Second ed.
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INDEX
TOPICS PAGE
1. Fracture healing 4
2. Fracture 6
3. Approach to fracture 8
4. Principles of management for closed fracture 10
5. Principles of management for open fractures 18
6. Problems around shoulder and arm 20
7. Problems around elbow and forearm 30
8. Problems around hands and wrists 42
9. Problems around the knee 51
10. Problems around ankle and foot 58
11. Problems around hips and thigh 68
12. Cervical spine injuries 84
13. Examination of spine 87
14. Diabetic foot ulcer –foot at risk 89
15. Necrotizing fasciitis 95
16. H Hands infections 96
17. Infection of bones and joints 99
18. Degenerative disease of spine 109
19. Osteoarthritis 119
20. Comparison and summary of types of arthritis 122
21. Metabolic bone disease 124
22. Bone tumor 133
23. Peripheral nerve injuries 139
24. Nerve Entrapment Syndrome 147
25. Thoracic Outlet Syndrome 148
26. Soft tissue problems 149
27. Congenital anomalies 153

FRACTURE HEALING
Rate of repair depend on:
1. Type of bone (cancellous bone heal faster than cortical bone- because highly vascularised)
2. Type of fracture (spiral fracture heal faster than transverse fracture)
3. State of blood supply (poor circulation=poor healing= slow healing)
4. General constitution (healthy bone= faster healing)
5. Age (2x faster in children than adults)
6. Amount of movement at fracture site
Average times for fracture healing
Upper limb Lower limb
Callus visible 2-3 weeks 2-3 weeks
Union 4-6 weeks 8-12 weeks
Consolidation 6-8 weeks 12-16 weeks
Method 1: Healing by callus Method 2: Healing without callus
Secondary bone healing/Indirect bone healing Primary bone healing/Direct bone healing
In mobile bone (absence rigid fixation) In immobilized bone (need rigid fixation)
Step 1: Tissue destruction & haematoma -no need for callus; new bone formation occur
formation directly between fragments
Step 2: Inflammation & cellular proliferation -gaps between # surfaces invaded by new
Step 3: Callus formation capillaries
Step 4: Consolidation -bone forming cells growing in from edges
Step 5: Remodelling *Narrow gap (<200µm): osteogenesis produces
lamellar bone directly
Callus: is the respond to movement at fracture site. It *Wider gap: filled by woven bone (gap healing)
serve to stabilize fragments as rapidly as possible-  before remodeled to lamellar bone
necessary precondition for bridging by bone
-Bone healing depends on metal implant for its

-Less direct (need proliferating cells to form strength due to absence of callus (as implant
cellular mass together with woven bone & diverts stress away from bone- reduce weight
immature cartilage forming callus), but ensure bearing of bone)  bone not fully recover until
mechanical strength while bone ends heal metal prosthesis removed & bone may become
osteoporotic
TESTING FOR FRACTURE UNION

Impossible to tell from clinical & x-ray features precisely when bone fragments have joined
More important what patient want to know:
1) Do fracture shows sign of healing
2) When bone strong enough to withstand normal load on fracture site
Encouraging sign of healing: If fracture internally fixed:
1. Absence of pain during daily activities -Callus formation usually sparse
2. Absence of tenderness at fracture site -Definite x-ray signs: trabecular
3. Absence of pain on stressing the fracture continuity
(gentle bending movement) -Wait several months before
4. Absence of mobility at the fracture site removing fixation implants
5. X-ray signs: Sign of callus formation  bone bridging across
fracture  trabeculation across old fracture site

STEPS IN FRACTURE HEALING BY CALLUS
Step 1: Tissue destruction & haematoma formation
 Tissue damage and bleeding at fracture site (haematoma
formation)
 Bone ends die back for a few milimetres
 Site become swelling and painful
Step 2: Inflammation & cellular proliferation

 Within 8 hours, inflammatory cells appear in haematoma
(proliferation under periosteum & within breached
medullary canal)
 Fragment ends surrounded by cellular tissue which
bridges the fracture site
 Clotted hematoma slowly absorb and fine new capillaries
grow into the area
Step 3: Callus formation (soft callus)

 Cells change to osteoblasts & osteoclasts
*Osteoblasts: Synthesis osteoid
*Osteoclasts: Erode/reabsorb dead bone
 Formation of immature bone (woven bone)
*form callus or splint on the periosteal and endosteal
surfaces
 Woven bone more densely mineralized, movement at
fracture site decrease, fracture begin to unite
 Process driven by inductive protein:
*fibroblast growth factors, transforming growth factors,
bone morphogenic protein
Step 4: Consolidation (hard callus)
 Woven bone transformed to lamellar bone
 Fracture had united
*Osteoclasts burrow through debris at # site
*Osteoblasts fill reminding gaps between fragments with
new bone
Step 5: Remodelling
 Newly formed bone remodeled to resemble normal
structure by continuous process of alternating bone
resorption and formation
*thicker lamellae: laid down at ↑ stress area
*unwanted buttresses: carved away
*medullary cavity: reformed

FRACTURE
Definition: Break in the structural continuity of bone (crack, crumpling, splinting, complete break)
May involve:
1. Surrounding soft tissues (local oedema, inflammation, severe tissues damage, vascular
impairment)
2. Joint: strained ligaments, subluxation of joint, dislocation of joint, combination joint & bone injury
(fracture-dislocation), articular cartilage damage
CAUSES OF FRACTURE:
1. Fractures due to trauma 2. Stress or fatigue fractures 3. Pathological fractures
-single highly stressful, -repetitive stress of normal -normal stress acting on
traumatic incident degree persisting to the point abnormally weakened bone
-direct force: break at the point of mechanical fatigue -eg: osteoporosis (skeletal
of impact insufficiency), paget’s disease
-indirect force: break at (brittle bone), bone tumor
distance from where force (osteolytic lesions)
applied
TYPE OF FRACTURE
SKIN BONE PHYSEAL
Closed/Simple fracture Complete fracture Physeal fracture
-overlying skin remains intact -bone completely broken into 2 -fracture through growing
or more fragments physis
-damage to the cartilaginous
Incomplete fracture growth plate
Open/Compound fracture -bone incompletely broken & -give rise to progressive
-overlying skin breached periosteum remains in deformity out of proportion to
-liable: contamination & continuity apparent severity of injury
infection
COMPLETE Fracture INCOMPLETE Fracture
1. Transverse- # perpendicular of long axis of bone 1. Greenstick: bone buckled & bent (children)
2. Oblique- single fracture in oblique 2. Stress: initially break in one part of the
3. Spiral-ragged break due to twisting (typical low cortex
E #) 3. Compression: cancellous bone crushed
4. Segmented-break into 2/3 segments
(a typical high energy #)
5. Comminuted -more than 2/3 fragments
6. Impacted -fragments jammed tightly together,
facture line indistinct
7. Avulsion: due to several strain on ligaments

FRACTURE DISPLACEMENT (followed complete fracture)
Displaced= broken end Describe in terms of:
move out of place 1. Translation (SHIFT)
-fragment displaced and lose its surface contact
Why displaced? 2. Alignment (ANGULATION)
1. By the force of injury -fragment tilted or angulated
2. By the gravity 3. Rotation (TWIST)
3. By the pull of -bone look straight but limb in torsion deformity
muscles 4. Altered length
-shortening of bone- due to muscle spasm
SOFT TISSUE DAMAGE (great impact in fracture healing)
Low energy (low velocity) fractures High energy (high velocity) fractures
-cause only moderate soft tissue damage -cause severe soft tissue damage
-eg: closed spiral fracture -eg: segmental and comminuted fracture (open
or closed)
Common type of fracture and site it’s commonly happened

APPROACH TO FRACTURE
History taking
Main Usually PAIN (followed by history of trauma
complaint
Mechanism of 1. How, what happened?
injury in 2. Which side involved, position fall
chronologically 3. Velocity of injury (speed, condition of vehicle) *high velocity- multiple #
4. Safety: wearing helmet, seat belt
5. How get help?
6. Treatment given in A&E
Symptoms 1. Pain (SOCRATES)
2. Swelling (Usually diffuse swelling from where to where, which side, onset)
3. Bruising
4. Obvious deformity
5. Loss of function
Other history Category of fracture
1. Closed or opened fracture
i. Wound
ii. Bleeding
2. Complete or incomplete fracture
i. Deformity (eg: rotation of leg)
ii. Rotation of leg (eg: knee cap pointing outward)
iii. Obvious shortening
Nerve involvement
1. Numbness of the distal part
2. Movement of the distal part
3. Sensation of the distal part
Vascular involvement
1. Any skin colour changes
2. Temperature
3. Pulse
4. Collosity
*tight & shiny, loss of hair- bad signs!
Other 1. Pain at other side
complaints 2. Wound at other side
3. Bleeding at other side
Systemic 1. CNS: LOC, headache, dizziness, visual disturbances, memory, concentration
review 2. CVS/RS: Chest pain, SOB, palpitation
3. GIT: difficulty to swallow, nausea, vomiting, pain
4. GUT: difficulty in passing urine, blood in urine
Current Symptoms patient has now
symptoms Progression of disease
Other history 1. Past medical history (anaesthesia and operation purpose)
2. Past surgical history (previous injuries or any other MSSK abnormalities)
3. Drug/Allergy history
4. Social history (smoking, alcohol, support, financial)
5. Family history

Examination
General 1. Conscious, alert, orientated to time, place, person
examination 2. Position of patient
3. Breathing
4. Attachment (cannula, wound dressing- state the side)
5. Observe any obvious skin/deformity (scar, pigmentation, swelling)
Head-toes 1. Hands: Palm warm, pink, dry, CPR <2s
(systemic 2. Eye: Jaundice, Pallor, Pupil equal & reactive to light
review) 3. Mouth: Central cyanosis, oral hygience, hydration
4. Neck: swelling, LN enlargement
5. Chest tenderness
6. Abdominal tenderness/guarding
7. Pelvic tenderness
8. Lower limb: Oedema
Vital signs PR, BP, RR, Temperature
Local LOOK FEEL MOVE + SPECIAL TEST
examination 1. Gait (for lower limb) 1. Temperature 1. Active (patient do by
2. Obvious things noted 2. Tenderness self)
-external fixation, back -position max tenderness 2. Passive
slab, POP, leg elevation 3. Crepitation *always report in range
3. Swelling, bruising 4. Bony irregularity *never move broken
4. Skin intact- wound 5. Measurementlower bone- just move relevant
5. Skin colour limb & important joints
-tell-tale signs of nerve -important as affect gait *only in unconscious pt
-vessel damage 6. Sensation (nerve)
6. Posture of distal limb -light, deep (dull,sharp), Special test
-external/internal rotation vibration *for stiffness, ligament
-knee cap position 7. Vascular (blood vessel) tear, carpal turnel
-genu varus/valgus -1 proximal A: Popliteal A syndrome- never for
7. Shortening of limbs -2 distal A: DPA, PTA fracture: following
MVA/Trauma or in pain
*fail exam if patient shout in pain!
Other test Neurological examination Vascular examination
1. Sensation 1. Capillary refill time
(follow dermatome & myotome) 2. Peripheral pulses (1proximal, 2distal)
2. Grade the muscle strength -do Allen’s test for upper limb
3. Deep tendon reflex
4. Anal tone in spinal trauma
Investigation
X-ray In all trauma case, take 4 x-ray: Chest + Pelvic + Cervical + Concern parts
2 Views 2 Joints 2 Limbs 2 Injuries 2 Occasions
-AP & Lateral-above & -for children, -for severe force -if difficult to detect
below immature epiphyses injury often involve # soon after injury,
confuse with #, so >1 level injury. So, take another x-ray in
Remember, Rule of 2!! take also uninjured fracture of 1-2weeks after
limb calcaneum or femur,
also take pelvis &
spine x-ray
CT/MRI For displaying fracture in difficult sites: vertebral column, acetabulum, calcaneum
Radioisotope Helpful in diagnosing a suspected stress fracture or other ‘occult’ fracture

Other investigation (for management purpose- anaesthesia, fit for surgery, healing ect)
Blood 1. Full blood count- check for Hb, lagi?
2. Electrolyte imbalance
3. Grouping & cross-match
4. Coagulation profile
5. Check for blood glucose level
1. REDUCTION
PRINCIPLE MANAGEMENT FOR CLOSED FRACTURE 2. HOLD
3. EXERCISE
1. REDUCTION
Aim 1. Adequate apposition
2. Normal alignment of bone fragments (allow bone back to its correct position)
*greater contact surface area, more likely healing to occur
*articular fracture- need reduction as near to perfection because any irregularity
will predispose to degenerative arthritis
Reduction 1. When there is little or no displacement
UNnecessary 2. When displacement doesn’t matter (eg: some # of clavicle)
3. When reduction is unlikely to succeed (eg: compression # of vertebrae)
Challenging Swelling of soft tissues during first 12 hours (always do CMR before muscle spasm)
Method 1: CLOSED REDUCTION Method 2: OPEN REDUCTION
Indications: Indications:
1. All minimally displaced fracture 1. Closed reduction failed
2. Most fracture in children -difficult to control the fragments
3. Fracture that likely to be stable after reduction -soft tissues interposed the fragments
2. Large articular fragment that need accurate
*Most effective if muscle & periosteum (soft positioning
tissues) on one side of fracture remain intact 3. For avulsion fracture
-will prevent over-reduction & stabilized fracture -fragments are held apart by muscle pull
after it has been reduced 4. Operation needed for associated injuries
*for powerful muscle pull (# femoral shaft)- -eg: arterial damage
difficult to reduce by manipulation (need 5. Fracture need internal fixation to hold it
mechanical traction) (ORIF-Open Reduction Internal Fixation)
Method to do it:
1. Used anaesthesia & muscle relaxation
2. X-ray before and after reduction
3. Reduced by 3-fold manoeuver (maybe specific
for fracture location & pattern)
1)Traction & counter-traction in line of bone
2)Fragments reposition as they disengage
-by reversing original direction of force
-manipulation to disimpact fragments
3)Alignment adjusted in each plane
-continued manipulation to press the distal
fragment into reduced position
4. Correct/restore length, rotation & angulation
5. Immobilize joint above and below (put on
splint)

Successful reduction indicated by
1. Restoration of normal surface anatomy
2. Rapid improvement in pain & neurovascular
deficits
*CMR= closed manipulative reduction
2. HOLD ‘immobilization’ avoided- because objective seldom complete immobility

Aim ‘Splint the fracture, not the entire limb’
1. To prevent displacement
2. To restrict movement  to reduce pain
3. To promote soft-tissues healing
4. To allow free movement of unaffected parts
NON-OPERATIVE Methods OPERATIVE Methods
Indication Indication
1. Fracture with intact soft tissues 1. Fracture with severe soft tissues damage
2. Inherently unstable fractures
3. Multiple fractures
4. Fractures in confused or uncooperative
patients
Methods Methods
1. Sustained traction 1. External fixation
2. Cast splintage 2. Internal fixation
3. Functional bracing
NON-OPERATIVE METHODS
1. Sustained traction (continuous traction)
Principle Traction applied to distal limb of fracture (exert a continuous pull in long axis of
bone)
Need counterforce pressure
Indication Useful for spiral fractures of long bone shafts (femur/tibia) & displaced by muscle
pull
Avoided in: elderly & younger patients
Advantages & Can move joints- thus able to exercise muscles
disadvantages Cannot hold fracture still (hold: not perfect) but traction is safe (provided not
excessive)
Sustained lower limb keep patient in bed for a long time
-↑ likelihood of complications -thromboembolism, RS problems, general weakness
Technique 1. Traction by gravity
 Indicated in fractures of humerus- allowing weight of arm to supply traction
 Forearm: supported by wrist sling, Upper arm: by sleeve cast or brace
Traction by gravity
Balanced skin traction
2. Balanced traction
 Counter-traction: supplied by raising foot of bed & relying on opposing
patient’s body weight
 Supported for comfort & prevent sagging (eg: Braun’s frame- for tibia #)

3. Fixed traction
 Same principle as balanced traction
 Except no counter-traction
 Limb held in Thomas’s splint (for femur #)
 Useful when patient has to be transported
Skin traction Skeletal traction

-Adhesive strapping by bandages -Stiff wire or pin through bone distal to #
-Weight: no more than 4-5kg -Weight: 20% of body weight
-Complication: Vascular compression -Complication: Pin infection, nerve &
vascular injury
*preferred of temporizing long bone,
pelvic, acetabular # until operative tx
Skeletal traction
Russell skin traction Fixed skin

traction
Traction pin types & placement

Thin wire versus Steinman pin
1) Thin wire more difficult to insert with hand drill & requires tension traction bow
2) Steinman pin maybe either smooth or threaded
*smooth: stronger but can slide if angled
*threaded: weaker, bend easier with higher weigh but not slide & advance easily during
insertion
-diameter pin for adult: 5-6mm
Traction pin placement

1. Sterile field with limb exposed
2. Local anesthesia + sedation
3. Insert pin from known area of neurovascular structure
*Distal femur: Medial  Lateral
*Proximal Tibial: Lateral  Medial
*Calcaneus: Medial  Lateral
4. Place sterile dressing around pin site
5. Place protective caps over sharp pin ends

Type of plaster of Paris
2. Cast splintage (conversional cast) 1. POP (Gypsum)
1. Plaster of Paris (OLC- orthopedic casting lab): calcium sulfate (Gypsum) 2. Lime plaster
-Indication: distal limb fracture and for most children’s fracture 3. Cement plaster
-Cannot be move & liable to stiffness
*Adhesion bind muscle fibers to each other & bone (after swelling & hematoma resolve)
*How to minimized complication
1) Delayed splintage- use traction until movement regained  apply POP
2) Starting with conventional cast until limb can be handled without too much discomfort
 replace cast by functional brace which permits joint movement
2. Fiberglass (Orthoglass) Plaster of Paris (POP)

-strong & lighter (comfortable to use) -cost-effective, non allergic, easy to mould
-cool, water resistant & radiolucent -heavy & fragile if contact with water
-expensive & difficult to mold -radio-opaque (occlude # line)
Splint (eg: slab) or cast?

Type Splint/Slab Cast
Definition only a part of limb circumference encircle whole circumference of limb
Indication 1. Definitive mx for selected type of #? 1. Definitive mx for simple, complex,
2. Soft tissues injuries (sprains, unstable, or potentially unstable #
tendons) 2. Severe, non-acute soft tissue injuries
3. Acute mx awaiting orthopedic which unable to be managed by
intervention splinting
Advantage 1. Allows for acute swelling 1. More effective immobilization
2. Decreased risk of complications
3. Faster and easier application
4. May be static (prevent motion) or
dynamic (functional; assisting with
control motion)
Disadvantage 1. Lack of compliance 1. Higher risk of complications
2. Increase range of motion at injury 2. More technically difficult to apply
site
3. Not useful for definitive care of
unstable or potentially unstable #
Rules of application of POP cast/slab

-(length) from 1 joint above to 1 joint below (posterior aspect)
-(depth) for Upper limbs: 12-16 layers; for Lower limbs: 16-20 layers of plaster
-(width) for Upper limbs: Size 10; for Lower limbs: Size 15 or 20
-backslab: apply in ‘V’ shaped- proximal part of UL/LL bigger than distal part
-immobilized in functional anatomy
Functional anatomical
 Elbow: Elbow in 90° flexion, in supination
 Wrist: Wrist in 25° extension
 Hand: Metacarpophalangeal in 70-90° flexion, proximal/distal interphalangeal in 5-10°
flexion
 Thumb: ‘holding a soda can’
 Knee: Knee in 5-20° flexion
 Ankle: Ankle in dorsiflexion (no equinus), knee flexion (to relax the gastroc)
 *always free the distal fingers and toes

Cast application steps:
1. Clean skin & apply dressing if there is wound
2. Adequate padding/ortho bandage
(min 2 layers- 50% overlap- extra at fibular head, malleoli, patella &
olecranon)
3. Soak plaster in water (room °C) till air bubble ceases
4. Apply plaster by unrolling bandage as it rests on limb. Start from
distal to proximal. Make sure not too tight or too loose (just follow the
limbs)
5. Mould plaster evenly, rapidly & without intervention (used palm, not
fingers)
-Mold applied to produce 3 point fixation
6. Assess pulse & capillary refill after application
After care of POP casts

1. Come immediately if symptoms develop (numbness, tingling, increase pain)
2. Keep plaster cast dry
3. Mobilize all joints which are not incorporated in the plaster to full range of motion
4. Don’t stick anything down to splint to scratch or itch. May lead to injury & infection
Local complications of POP

Due to tight cast Due to loose cast Due to improper applications
1. Vascular compression (complaint (because swelling which 1. Joint stiffness
of diffuse pain, bluish discolouration occurred after reduction 2. Skin abrasion & laceration
of digits) subside) (complaint of nipping or
2. Pressure sore/necrosis (complaint 1. Delay wound healing pinching during plaster
localized pain over pressure spot as & produce permanent removal)
early as 2H- bony prominence) deformity 3. Plaster breakage
3. Compartment syndromes
4. Peripheral nerve injuries
(complaint of inability to move
fingers, reduce sensation of digits)-
direct compressed by bone end or
plaster pressure or indirect
compressed by oedematous tissue
or tourniquet effect or reduced
blood flow
Systemic complication POP: DVT leading to pulmonary embolism
Removing of plaster casts

-using plaster shears or electric saw

Common Splinting techniques
1. Sugar-Tong 2. Humeral Shaft # Coaptation 3. Fracture Bracing
-Acute management of distal -Medially splint ends in axilla -Allow for early functional ROM
radial & ulnar # and must be well padded to and weight bearing
avoid skin breakdown -Relief on soft tissues and
-Lateral aspect of splint extends muscles envelope to maintain
over deltoid alignment & length
-Commonly used for humeral
shaft & tibial shaft fractures
Volar/Dorsal forearm Ulnar gutter Thumb spica

-Soft tissue injuries to hand & -4th & 5th proximal/middle -Injuries to scaphoid/trapezium
wrist phalangeal shaft # -Non-displaced non-angulated,
-Acute carpal bone # (exclude -Boxer’s # (distal 5th metacarpal extraarticular 1st metacarpal #
scaphoid/trapezium) #) -Stable thumb # ± CMR
-childhood buckle # distal
radius
Buddy taping (dynamic Mallet finger splint Patella Tendon Bearing (PTB)
splinting) -Extensor tendon avulsion from -molding around tibia condyles
-Non-displaced base of distal phalanx ± -fx: to lock tibia when patient
proximal/middle phalangeal avulsion # able to partially weight bearing
shaft # & sprains (after 3days of POP)
3. Functional bracing (functional brace)

 It prevent joint stiffness while still permitting fracture splintage and loading
 Segmental cast applied to shafts of bone only (leaving joint free)
 + segmented cast above & below joint connected by metal or plastic hinges
(to allow movement in plane)
 Used for fracture of femur or tibia
 Brace not very rigid, thus applied only when # begin to unite- after 3-6w of
traction or restrictive splintage

OPERATIVE METHODS
1. External fixation
Principle: Bone is transfixed above and below fracture
*with screws or pins or tensioned wires
*clamped to frame or connected to each other by rigid bars
Applicable to long bones and pelvis but still can be used for fracture of almost any part of skeleton
Benefits:
1. Permits adjustment of length and angulation
2. Allow reduction of fracture in all 3 planes
Indications:
1. Fractures with severe soft-tissue damage (wound left open for inspection, dressing, definitive
coverage)
2. Open fractures (to minimized infection complication with usage of internal fixation)
3. Severe communited & unstable fractures (held out to length until healing commences)
4. Fracture of pelvis (cannot be controlled quickly by any other method)
5. Fracture associated with nerve & vessel damage
6. Ununited fracture (dead or sclerotic fragments can be excised and the remaining ends brought
together in the external fixator)
Complications:
1. Damage to soft tissue structures (nerves, vessels, tether ligaments, joints)
-Crucial to know local anatomy and ‘safe corridors’ for inserting pins
2. Over distraction
-If there is no contact between the fragments, union may be delayed or prevented
3. Pin-track infection
-Pin-site care is essential + antibiotics immediately if infection occurs

2. Internal fixation
Advantage: precise reduction, immediate stability, early movement
Disadvantage: sepsis
Risk of infection depend upon:

1. Patient- devitalized tissues, a dirty wound, unfit patient
2. Doctor- inadequate training, high degree surgical dexterity, inadequate assistance
3. Facilities- guaranteed aseptic routine, full range implants, staff familiar with use
Indications:
1. Fracture that cannot be reduced except through operation (where muscle pull very strong)
2. Fracture that inherently unstable & prone to re-displacement after reduction
3. Fracture that unite poorly and slowly (fracture of femoral neck)
4. Multiple fracture (early fixation reduce risk of general complications)
5. Pathological fractures (malignancy or osteoporosis fractures)
Type of internal fixation:

(a) Screws Interfragmentary screw (lag screws)
For fixating small fragments onto main bone
Wires Kirschner wires
Often inserted percutaneously without exposing fracture
Used in situation where fracture healing is predictably quick
External splintage (cast) applied as supplementary support
(b) Plates & For treating metaphyseal fractures of long bones &
screws For treating diaphyseal fractures of radius & ulna
In tubular bones; firm coaptation of fragments achieved by compression devices
before tightening the screws
Intramedullary For long bone fractures (especially femur & tibia)
nails *why not plate? Closed # need to do long incision to skin/muscles - introduce
infection  delayed union/non-union (bcoz interfere with 1st stage healing &
foreign body)
A nail (long rod) inserted into medullary canal to splint the fracture ±
Locking screws transfix the bone cortices and nail proximal and distal to fracture
(resisted the rotational forces)
Minimum 2 years: after that may think of taking it out
(however Dr Biju said: usually stay forever as it’s not that easy to take it out)
(c) Intramedullary nail

d) Locked intramedullary nail
Complications: (due to poor technique, poor equipment, poor operating condition)

1. Iatrogenic infection- most common cause of chronic osteomyelitis
*predispose causes: quality of patient’s tissues & open operation (metal doesn’t predispose infection)
2. Non-union
*causes: excessive stripping of soft tissues, unnecessary damage to blood supply, rigid fixation with a gap
between fragments
3. Implant failure
*due to excessive stress at the fracture site before fracture united (metal subject to fatigue)
4. Refracture
*causes: early removal of metal implants & early full weight bearing (several weeks)
*removal minimum time= 1 year (safer after 18-24months)

3. EXERCISE ‘Restore function’
Objectives:
1. Reduce oedema (swelling)  tissue tension, blistering, joint stiffness
2. Preserve joint movement
3. Restore muscle power
SOFT TISSUES CARE PRINCIPLE:
4. Guide patient back to normal activity
Elevate & Exercise;
Suggested activity: Never dangle, Never force
1. Active exercise
2. Assisted movement (continuous passive motion)
3. Functional activity (everyday tasks)
PRINCIPLE MANAGEMENT FOR OPEN FRACTURE

Initial management
At scene of accident In hospital
1. Splinting the limb 1. Address any life-threatening conditions
2. Cover the wound & left undisturbed 2. Wound inspection -size, shape, tidy or ragged,
*to reduce risk of further contamination & clean or dirty, communicate with fracture
wound desiccation 3. Assess soft tissues, circulation & nerve supply
Gustilo’s classification for open fracture
Type I Puncture wound (<1cm long)

Risk of infection:
Type II Skin damage (>1cm long)
-Type I: >2%
Type III Severe, big wound (>10cm)
III A Soft tissue enough to cover wound -Type III: >10%
III B Soft tissue not enough to cover wound + bone being -↑ with delay soft
exposed tissue coverage
III C Vascular damage
*in open # always assume to be contaminated; aim of treatment to prevent from becoming infected
Contaminated Infected
Passage of bacteria from injury site Bacteria multiply & cause inflammation
-early debridement & early antibiotics (Present of body reaction)
Principle of treatment of OPEN fracture

1. Urgent wound & fracture debridement
-under GA, remove pt’s clothing while maintaining traction on injured limbs
-any dressing replaced by sterile pad and surrounding skin cleaned & shaved
-pad taken off and wound irrigated thoroughly- using copious amounts of warm normal saline
-wound extended and ragged margins excised to leave healthy skin edges
-remove all foreign materials and tissue debris
-wash wound again (6-12L warm normal saline may needed for irrigation & clean # of long bone)
-recognized devitalized tissues, dead muscles and excised them
-leave traumatic nerves and tendons (suture if expertise available) Dead muscles signs:
1. Purplish colour
2. Antibiotics prophylaxis
Benzylpenicillin + Flucloxacillin or second generation cephalosporin 2. Failure to contract (stimulate)
-given 6 hourly for 48 hours 3. Failure to bleed (when cut)
Heavily contaminated (cover gram negative & anaerobes)
-adding gentamicin or metronidazole and continue treatment for 4-5 days
3. Stabilization of the fracture

Method of fixation:
1)degree of contamination
2)length of time from injury to operation
3)amount soft tissue damage
Open fracture up to grade IIIA + Treatment same for closed injuries (cast splintage,
no obvious contamination + time intramedullary nail, plating, external fixation)
lapse <8 Hours (Gustilo
classification)
More severe injuries Require combine approach by experienced plastic &
orthopaedic surgeons
4. Early definitive wound closure

Uncontaminated sutured within a few hours of injury (after debridement & incision)
wound type I & II
Contaminated Left open, lightly packed with moist, sterile gauze  inspect again after 24-
wound 48H
*if clean & tidy- can be sutured or skin-graft (delayed primary closure)
Wound type III need debridement more than once & need for plastic surgery (for skin
closure)
Extensive skin Loco-regional fasciocutaneous or musculocutaneous flap
loss over fracture Free flap- if blood vessels preserved
or blood supply
suspected
Post-operative treatments
1. Elevated the limbs
2. Careful circulation charting
3. Antibiotics cover is continued
4. If wound left open: inspect again after 2-3days (if much skin loss- need for plastic surgery)

PROBLEMS AROUND SHOUDLER & ARM
INDEX:
1. Fracture of clavicle
2. Acromioclavicular joint injury
3. Glenohumeral dislocation
4. Fracture of proximal humerus
5. Fracture shaft of humerus
6. Adhesive capsulitis (frozen shoulder)
7. Rotator cuff syndrome
8. Lesion of bicep tendon
9. Fracture of supracondylar of humerus
10. Fracture of lateral & medial condyle
FRACTURE OF CLAVICLE
Common fracture at all age group
Mechanism of injury :
DIRECT INDIRECT
 Fall on the point of shoulder (91%)  Fall on outstretched hands (1%)
 Trauma over the clavicle due to MVA (8%)
Clinical features:
 History of trauma followed by pain, swelling, deformity, crepitus at the site of trauma
 Inability to raise the shoulder
Displacement:
 Outer fragment displaces medially and downward because of
gravity and pull of pectoralis major muscle
 Inner fragment displaces upwards because of pull by
sternomastoid muscle
Classification:
Group I – Fracture involving middle 1/3rd
Group II – Fracture involving lateral 1/3rd
Group III – Fracture involving medial 1/3rd
***According to site of fracture
Complications:
o Early- injury to subclavian vessel or medial cord of brachial plexus (ulnar nerve) by
fracture ligament
o Late- shoulder stiffness (elderly)
Treatment:
o Conservative
- Cuff and triangular sling - Ideal for undisplaced fracture
- Active shoulder exercise
o Operative: VERY RARE

ACROMIOCLAVICULAR JOINT INJURY
 Uncommon injury caused by fall on the outer prominence of the shoulder
 May result in a partial or complete rupture of the acromio-clavicular or coraco-clavicular
ligaments
 Diagnosis :
o Pain and swelling localised to the acromio-clavicular joint
o On X-ray with the acromio-clavicular joint on both sites, will show subluxation or
dislocation at the affected site
Grading and treatment

Grade I Minimal strain to acromioclavicular join and joint o Rest in a triangular sling
capsule o Analgesics
Grade II Rupture of acromioclavicular ligament
Grade Rupture of acromioclavicular ligament + coraco- o Surgical repair (especially in
III clavicular ligament young athletic individuals)
GLENOHUMERAL DISLOCATION
o Commonest joint in the human body to dislocate
o Common in adults
o Anterior dislocation > posterior dislocation
 Causes of Anterior / Posterior Dislocation:

Traumatic Atraumatic
i. Sprains i. Voluntary
ii. Acute subluxation ii. Involuntary
iii. Acute dislocation iii. Congenital
iv. Recurrent dislocation
v. Unreduced dislocation
Classification of dislocation
ANTERIOR DISLOCATION POSTERIOR DISLOCATION
 A fall on an out-stretched hand with  Direct blow on the front of the shoulder,
shoulder abducted & externally rotated driving the head backwards
 Results from a direct force pushing the  (Dashboard injury)
humerous head out of the glenoid cavity
 (Throw)
The head of humerous comes out of the The head of humerous comes out to lie
glenoid cavity and lies anteriorly. posteriorly, behind the glenoid
 Preglenoid – the head lies in front of the  Subcromial – head lies below cromion
glenoid process
 Subcoracoid – the head lies below the  Subglenoid – head lies below glenoid
coracoid process  Subspinous – head lies below the spine
 Subclavicular – the head lies below the
clavicle

Associated lesions
1. Bankart’s lesion
Fracture of anterior glenoid rim.
The head thus lie in front of the scapular neck.
2. Hill-Sach’s lesion
Impaction fracture of posterolateral surface of
humeral head due to impaction of humeral
head against anterior rim of glenoid during
dislocation. Bankart’s lesion
What it is?- damage to labium of bone
(cartilagous bone of rim) cause by anterior
3. Roundening off of anterior glenoid rim dislocation
occurs as head dislocates over it. So what is the problem?- lead to recurrent
dislocation because will not heal
4. May be associated fractures of greater This patient will need surgery for reinforcement
(to get back stability)
tuberosity of the humeorus or rim of the
glenoid
Presenting complaints Presenting complaint
 Severe pain  Severe pain
 Arm is held in abduction and external  Arm is held in medial rotation and is locked
rotation in that position
 History of fall on an outstretched hand  Abduction is restricted
On examination On examination
o Normal round counter of the shoulder joint o Loss of normal round contour of the
is lost shoulder
o Posterior aspect is flat o Fullness of the posterior part of the
o Anterior aspect shows fullness below the shoulder
clavicle due to displaced head and can be o Flat anterior aspect
felt by rotating the arm o Prominent corocoid process
o Coracoid process is not identified
o Apprehension test
 Investigation :  Investigation :
 Xray of shoulder shows Bankart’s  Xray of shoulder shows anterolateral
lesion, Hill-Sach’s lesion and erosion of defect, light bulb sign (in AP view) and
rims of glenoid trough line
 Transthoracic lateral Xray shows C- (AP not helpful, need lateral view but
shaped rolling line not commonly done)
 Arthrography to evaluate rotator cuff  Transthoracic lateral Xray shows V-
tears due to previous dislocation shaped rolling line
 CT scan to detect the defect in the  Arthrography to evaluate rotator cuff
head more accurately tears due to previous dislocation
 MRI to evaluate both soft tissue and  Ct scan to detect the defect in the head
bone injury more accurately
 MRI to evaluate both soft tissue and
bone injury

 Treatment  Treatment :
Conservative Conservative
- Reduction under sedation or GA followed - Reduction distal traction on the injured
by immobilisation of the shoulder in a chest limb with lateral rotation of the upper
arm bandage for 3weeks (U-slab) arm under GA
- Kocher’s maneuver : Most effective and
commonly followed method
(stimson/hipocrates)
Anterior dislocation mx
 Documented axillary palsy before &
after MRI
 Check axillary nerve intact or not before
& after CMR- check sensation at deltoid
Operative : open reduction

Indication :
 Failed closed reduction
 Soft tissue interposition
 Greater tuberosity fracture
 Displacement >1cm after reduction
 Large glenoid rim fracture
 Complications:  Complication :
 Early- Axillary nerve injury resulting in 1 Recurrent dislocation
paralysis of deltoid & small area of 2 Unreduced dislocation
anesthesia over the lateral aspect of
shoulder
 Late – Recurrent dislocation,
Unreduced dislocation, Traumatic OA
Luxatio Erecta (rare) and Pathological changes Inferior glenohumeral dislocation
The head lies in the subglenoid position. Obviously presented- cannot be missed out
Pathological changes (Anterior Dislocation):

FRACTURE OF THE PROXIMAL HUMERUS
 Occur after middle age, commonly in osteoporotic individuals
 Due to fall on the outstretched hand, fracturing the surgical neck
 Special features:
 Pain
 Large bruise in the upper arm
 Signs of axillary nerve or brachial
plexus injury.
Diagnosis from x-ray in elderly
 A transverse fracture extends across the surgical neck and the greater tuberosity
 The shaft is usually impacted into the head in an abducted position
 In younger patient: The proximal end of the humerus may be broken into several pieces
Neer’s Classification:
 Complications
 Shoulder dislocation- Dislocation should be reduced (may need operation) and the fracture
can then be tackled
 Vascular and nerve injuries- May occur in3-part and 4-part fractures
 Stiffness- Shoulder stiffness is common. Minimized by starting exercises

FRACTURE OF SHAFT OF HUMERUS
 Spiral fracture: a fall on the hand, which may twist the
humerus
 Oblique or transverse fracture: a fall on the elbow with
the arm abducted may hinge the bone
 Transverse or comminuted fracture: a direct blow to the
arm causes a fracture
 In elderly: fracture of the shaft may be via a metastasis
 Treatment:
o Immobilization: the weight of the arm with external cast
 (U SLAB+ triangular sling OR HANGING CAST!!)  to prevent lateral angulation!
 Middle & upper  U-slab
 Distal  hanging cast
o Do ORIF- if unstable fracture, obese or prolonged discomfort, large open fracture
o Exercise of the shoulder can be started within a week but avoid abduction until fracture has
united
o Fixation: if the fracture is very unstable or if it is pathological fracture
 Internal fixation :
 Plate and screw
 Long intramedullary nail with locking screw
 External fixation
 Complications:
1. Nerve injury 2. Non-union
a) Radial nerve palsy (wrist drop) a) Mid-shaft sometimes fail to reunite
b) Paralysis of the metacarpophalangeal b) Treated by bone grafting & internal
extensor fixation
ADHESIVE CAPSULITIS “ FROZEN SHOULDER”

 Progressive pain & stiffness resolves
spontaneously after about 18 months
 Clinical features
 40-60 years old
 History of trauma followed by pain
 Gradually increases in severity & often
prevent sleeping on the affected side
 As pain subsides, stiffness becomes more of a problem
 Gradually movement is regained but may not return to normal
 Physical signs  Differential diagnoses
o Slight muscle wasting o Post-traumatic stiffness
o Some tenderness o Disuse stiffness
o Movements are always limited o Regional pain syndrome
o Severe case : shoulder is extremely o Arthritis
stiff
History of trauma, sudden stiffness, reduce range of movement, dull aching pain & cannot comb hair, 3 months
very stiff then after 3 months recovering. X-ray normal.

ROTATOR CUFF SYNDROME
SUBACUTE TENDINITIS CHRONIC TENDINITIS ROTATOR CUFF TEAR
(painful arc syndrome) (impingement syndrome)
 Develops anterior shoulder  40-50 years old  Progressive fibrosis &

pain after vigorous or  History of recurrent attacks disruption of the cuff
unaccustomed activity of subacute tendinitis  > 45 years old
 Competitive swimming  Pain  History of refractory
or a weekend of house  Settling down with rest shoulder pain with
decorating /anti-inflammatory increasing stiffness &
 Shoulder looks normal but treatment weakness
acutely tender along the  Worse at night (cannot  Long standing cases :
anterior edge of the lie on affected site) secondary OA, severely
acromion  Restrict simple restricted movements
 Point tenderness is most activities
easily elicited by palpating
this spot with the arm held  Physical signs  Partial tears
in extension  Coarse crepitation or  To diagnose : pain can be
 Placing the palpable snapping over eliminated by injecting local
supraspinatus tendon the rotator cuff when anesthetic into the
in an exposed position the shoulder is subacromial space
anterior to the passively rotated  Active abduction possible :
acromion process  Partial tear or marked partial tear
 Arm flexion : tenderness fibrosis  Active abduction impossible
disappears : complete tear
Management
 Mild-moderate: NSAIDs or  Full thickness tear
aspirin  Follow a long period of
 Severe: Local chronic tendinitis
corticosteroids  Occasionally occurs
spontaneously after a
MRI indicated to rule out sprain or jerking injury of
rotator cuff tear  need the shoulder
surgery  Sudden pain
 Unable to abduct the arm
Supraspinatous- abduction
Infraspinatous- external rotation
Teres minor- external rotation
Subscapularis- internal rotation
“SITS muscles”

TESTS FOR ROTATOR CUFF SYNDROME “Empty BIN”
 Empty can test (supraspinatus)
 Belly press test/ Lift off test (subscapular test)
 Infraspinatus and teres minor test
 Neer’s test / Hawkin’s (Impingement test)
 Painful arc (60-120)
ROTATOR CUFF TEAR

Supraspinatus: abduction Infraspinatus & teres minor: Subscapularis: internal rotation
(“empty can” test (Jobe’s test) external rotation (Subscapularis lift off test or belly
• Positioned sitting or standing • Arms at the sides press test)
• Arm abduct to 90 degree • Elbows flexed to 90 degrees • Arms at the sides
and bring forward by 30 • Patient externally rotates • Elbows flexed to 90 degree
degree arms against resistance • Internally rotates arms
• Thumbs down against resistance
• Elbow locked straight
• Attempts to elevate arms
against resistance
IMPINGEMENT SIGNS
Neer’s sign Hawkin’s sign
• Arm fully pronated and placed in forced • Arm placed forward flexed to 90 degree
flexion • Then forcibly internally rotated
• Trying to impinge subacromial structures with • Pain = test is positive
humeral head
• Pain= test is positive

LESION OF BICEP TENDON
TENDINITIS TORN LONG HEAD OF BICEP ‘SLAP’ LESION
 May be involved in the  Degeneration & disruption  Fall on the outstretched

impingement syndrome is common and often arm which damage the
 Rarely, presents as isolated associated with rotator cuff superior part of the glenoid
problem in young people problems labrum anteriorly and
after unaccustomed  Middle-aged or elderly posteriorly (SLAP)
shoulder strain  Feels something snap while  History fall followed by pain
 Pain & tenderness are lifting heavy object in the shoulder
sharply localized to the  Shoulder aches for a time &  Patient continues to
bicipital groove bruising appears over the experience a painful ‘click’
 Speed test: Anterior front of the arm on lifting the arm above
shoulder pain with flexion  Elbow flexion : muscle shoulder height
of shoulder while elbow is contracts into prominent  Loss of power when using
extended and forearm lump arm in that position
supinated  Function is usually so little  Complain of an inability to
 Yergason test: Pain and disturbed throw with affected arm
tenderness over bicipital
groove with forearm
supination with elbow
flexed and shoulder in
adduction
 Rest, local heat & deep
transverse frictions usually
bring relief
 Delayed recovery:
corticosteroid injection
may help
 Popeye deformity

SUPRACONDYLAR HUMERUS FRACTURE
• Commonest fracture in children
• Due to fall on outstretched of the hand or falls directly on the elbow
• Posterior displacement > anterior displacement
 Clinical features:
o Swelling within first few hours
o S-shaped deformity in a posteriorly displaced
fractureextension type
o Distal humeral tenderness
Awal2  Unusual posterior prominence of the point at tip of olecranon
Tapi triangle kat elbow still intact sbb dia above epicondyle
 Test for radial and median nerve function

Complication
Early Late
 Injury to the brachial artery  Malunion :Gunstock deformity
 Injury to median, radial nerve  Elbow stiffness and myositis ossificans
 Peripheral ischemia
 Compartment syndrome
FRACTURE OF LATERAL CONDYLE FRACTURE OF MEDIAL EPICONDYLE

o Falls on the hand with elbow extended and o Fall from a height involving either direct blow
forced into varus to the point of the elbow or a landing on the
o Fragment will be pulled by extensors outstretched hand with the elbow forced into
valgus
Clinical Features : o Fragment may displaced by the pull of flexor
o Elbow is swollen and deformed muscle group
o Tenderness over the lateral condyle
o Passive flexion of wrist can be painful Clinical features:
o Pain and swelling
Complications : o In younger children the medial condylar
o Non union or mal union epiphysis is cartilaginous and not visible in xray
o Recurrent dislocation
Complication:
o Recurrent dislocation
o Stiffness of elbow
Treatment
Conservative  above back slab with 90 degree flexed
If displaced into joint  ORIF

PROBLEMS AROUND ELBOW AND FOREARM
Index:
1. Dislocation of the elbow
2. Isolated dislocation of the radial head
3. Pulled elbow
4. Fractures of the proximal end of the radius
5. Fractures of the olecranon process
6. Fractures of the radius and ulna
7. Fractures of the single forearm bone
8. Monteggia fracture
9. Galaezzi fracture
10. Colles’ fracture
11. Smith’s fracture
12. Barton’s fracture (Fracture- subluxation of the wrist)
13. Fracture of the radial styloid process
14. Comminuted intra-Articular fractures in young adults
15. Distal forearm fractures in the children
1DISLOCATION OF THE ELBOW

Introduction • Due fall on the outstretched hand
• 90% of case: forearm bones are push backwards and dislocate posterolaterally
Special o Deformity, pain and swelling
features o Should examine the hand for signs of vascular or
nerve damage
o X-ray: to confirm the presence of dislocation
and identify any associated fractures
Treatment Uncomplicated dislocation Fracture-dislocation

 Patient should be fully relaxed under  Associated fractures of
anaesthesia the humeral condyles
 Dr pulls on the forearm while the elbow is or epicondyles, or
slightly flexed olecranon process, will
 With 1 hand, sideways displacement is need internal fixation
corrected, then the elbow is further flexed while  Hinged external
the olecranon process is pushed forward fixation (to maintain
 Unless almost full flexion can be obtained, the mobility while the
olecranon is not in the trochlear groove tissues heal) in case
 After reduction, put the elbow through the full where the elbow
range of movement to see it stability remains unstable after
 Check nerve function and circulation bone and joint has
 Repeat x-ray been restored
 The arm is held in light cast with elbow flexed to
just above 90o and wrist is supported I collar
and cuff
 Remove cast after 1 week, and do gentle
exercise
 At 3 weeks, discard the collar and cuff

Complication 1. Vascular injury
o Brachial artery may be damaged. (warning: absence radial pulse)
o Any signs of ischemia, must remove the splints and elbow should be
straightened
o If no improvement, do arteriogram of brachial artery
2. Nerve injury
o Median or ulnar nerve injury
o Spontaneous recovery occurs after 6-8 weeks
3. Stiffness
o Loss of 20-30o of extension after elbow dislocation is uncommon
o Avoided forceful manipulation
4. Heterotopic ossification
o Heterotopic bone formation may occur in the damaged soft tissues in
front of the joint
o Must alert of the signs of excessive pain, tenderness and tardy (delayed)
recovery of active movement
o X-ray: soft tissue ossification as early as 4-6 weeks after injury
o Treatment:
• Stop exercise
• Elbow is splinted in comfortable flexion until pain subsides
• Anti-inflammatory may help to reduce stiffness and prophylactically
to reduce the risk of heterotopic bone formation
• Bone mass which restricts the movement and elbow function should
be excised once the bone is ‘mature’
5. Osteoarthritis
o Secondary osteoarthritis is late complication
o Treat conservatively, may consider total elbow replacement if pain and
stiffness are intolerable
ISOLATED DISLOCATION OF THE RADIAL HEAD

 Very rare
 If it is seen, look carefully for an associated fracture of
the ulna (Monteggia injury)
 Difficult to detect in children often due to incomplete
fracture
PULLED ELBOW
 In young children due to sharp tug on the wrist
 Clinical features: pain, elbow held in extension,
not allowed to move
 X-ray: no changes
 Pathology: radius has been pulled distally and
orbicularis ligament has slipped up over the head
of radius
 Treatment: forcefully supinating and then flexing
the elbow; ligament slips back with snap

FRACTURES OF THE PROXIMAL END OF THE RADIUS
Introduction Common in:
 Children: fracture the neck of radius (because the head is largely
cartilaginous)
 Young adult: may fracture the head of radius
A fall on the outstretched arm with the elbow extended and the forearm pronated
cause the impaction of the radial head against the capitulum
Special Following a fall on the outstretched arm:
features  Pain
 Local tenderness on palpation of the radial head
 Pain ↑↑ at lateral side of joint on pronation and supination of the forearm
 Restriction elbow movement
X-ray Adults: Children:
o Vertical split fracture through the radial o Fracture is through the neck
head o The proximal fragment maybe
o Less often with marginal fragment and tilted forwards and outwards
sometimes the head is crushed or
comminuted
o Wrist: to exclude concomitant injury of
the distal radio-ulnar joint
Treatment Undisplaced fractures of radial head: If fractures of radial neck, up to 30o
• Supporting elbow in a collar and cuff for radial head tilt and up to 3mm of
3/52 transverse displacement:
• Encourage active flexion, extension and • Arm rested in collar and cuff
rotation • Exercises are commenced after
1week
Displaced fractures:
• By open reduction and fixation with Displacement >30o radial head tilt:
small screws • Extended, traction and varus of
the elbow are applied  then
Comminuted fractures: pushed the displaced radial
• By excising the radial head fragment into position
• If there is associated forearm injuries or • If failed: open reduction is
disruption of distal radioulnar joint  performed
risk of proximal migration of the radius - No need for internal fixation
is considerable  may develop - After operation: the elbow is
intractable symptoms of pain instability splinted in 90o for 2/52
in forearm  thus, need reconstruction
of the radial head Head of the radius must never be excised in
children because this will interfere with the
• If excised, should be replaced by silicon
synchronous growth of the radius and ulna!!
or metal prosthesis
Complication 1. Joint stiffness:
 Common and may involve both elbow & radioulnar joint
2. Recurrent instability of the elbow:
 If the medial collateral ligament was injured and the head of radius is
excised
3. Osteoarthritis of the radiocapitellar joint:
 Late complication of adults injuries. May need excision of radial head

FRACTURES OF THE OLECRANON PROCESS
Introduction 2 broad type of injuries
COMMINUTED FRACTURE TRANSVERSE FRACTURE

• Due to direct blow or fall on • Due to traction when patient fall onto
elbow hand with triceps muscle contracted
Special • Graze or bruise over elbow • Palpable gap in elbow

features • Triceps intact • Unable to extend elbow against resistance
• Able to extend elbow against
gravity
Treatment Management when triceps intact Undisplaced transverse fracture
• Treated conservatively • Immobilized elbow in cast about 60 degree
(as severe ‘bruise’) flexion for 2-3 weeks
• Arm rested in sling until pain • Then begun exercises
subsides • Repeat x-ray to exclude displacement
• Repeat x-ray to ensure no
displacement Displaced transverse fracture
• Encourage active movement • Operative treatment
Method 1: fixation with long cancellous
screw
Method 2: tension-banding wiring
• Encourage early immobilization
Method 1: Fixation with long cancellous screw

- Inserted screws from tip of olecranon
(make sure that the screw doesn’t
penetrate the ulnar cortex distally)
Method 2: Tension-banding wiring

- 2 stiff wires driven across fractures, leaving
their ends protruding proximally and
distally to anchor a tight loop of wire- will
pull fragments together
Complication EARLY LATE
1. Non-union 1. Stiffness
- After inadequate - Minimized by secure internal fixation
reduction and fixation & early immobilization
- Can be ignore if elbow 2. Osteoarthitis
function is good - If reduction is less than perfect 
- If not- need rigid internal treated symptomatically
fixation & bone grafting

FRACTURES OF RADIUS AND ULNA
Introduction Mechanism of injury
 Fractures of the shafts of both forearm bones
occur quite commonly
 A twisting force (usually a fall on the hand)
produces a spiral fracture with the bones
broken at different levels
 An angulating force causes a transverse
fracture of both bones at the same level
 A direct blow causes a transverse fracture of
just one bone, usually the ulna
Special The fracture is usually quite obvious
features • Bleeding
• Swelling
• The pulse must be felt and the hand examined for circulatory or neural deficit
• Repeated examination is necessary in order to detect an impending
compartment syndrome
• Both bones are broken, either transversely and at the same level or obliquely
with the radial fracture usually at a higher level
• In children – incomplete
• In adults – displacement may occur in any direction
X-ray Children Adult
Greenstick # in children
Treatment - Closed reduction - Most surgeons opt for open
- Full length cast extending from the reduction and internal fixation from
axilla to the metacarpal shaft (to the outset
control rotation) - The fragment are held by plates and
- The cast applied with the elbow at screws
90 degrees - The deep fascia is left open to
- Throughout this period hand and prevent build-up of pressure in the
shoulder exercise are encouraged muscle compartment , and only the
skin and subcutaneous tissues are
sutured
- After the operation , the arm is
elevated until swelling subsides
Complication  Nerve injury (usually caused by the surgeon!)
 Compartment syndrome (incision to relieve)
 Delayed union and non-union (bone grafting)
 Complications of plate removal

FRACTURE OF SINGLE FOREARM BONE
Introduction  Is uncommon
 Deformity or shortening of one bone (while the
partner one remains intact) usually involves a
concomitant disruption of either proximal or
distal radioulnar joint
Special  Ulnar fractures are easily missed – even on x-ray

features  If there is local tenderness, a further x-ray a week or two later is wise
X-ray • The fracture may be anywhere in the radius or ulna
• The fracture line is transverse and displacement is light
• In children, the intact bone sometimes bends without actually breaking (‘plastic
deformation’)
Treatment Isolated fracture of the ulna Isolated fracture of the radius

- The fracture must be perfectly - Radial fracture are prone to rotary
reduced displacement;to achieve reduction
- Even a slight angulation will affect - The forearm need to be supinated for
rotation at the distal radioulnar upper-third fractures
joint - Neutral for middle-third fractures and
- Surgical fixation will ensure an pronated for lower-third fractures
anatomical reduction and obviate - Preferred internal fixation with a
the need for a cast compression plate and screws to hold

MONTEGGIA FRACTURE GALEAZZI FRACTURE
Introduction  Fracture of the shaft of ulnar  The counterpart of Monteggia #
associated with the dislocation of the  Fracture of the distal third of the
proximal radio-ulnar joint and radius and dislocation or sublaxation
radiocapitellar joint of the distal radioulnar joint
 Nowadays the term includes also
fracture of the olecranon combined with
radial head dislocation
Mechanism  Fall on the hand; at the moment  Fall on the hand , superimposed
of injury body is twisting its momentum may rotation force
forcibly pronates the forearm
 The radial head usually dislocates
forward and the upper third of the
ulna fractures and bows forward
 Sometimes: hyperextension
Special  Swelling due to dislocation head of  Prominence or tenderness over the
features radius lower end of the ulna is the striking
 Pain & tenderness on the lateral side feature
of the elbow  Test for ulna lesion which is
common
X-ray
• Head of radius is dislocated forward • A transverse or short oblique # is seen

• # of upper 1/3 of ulnar with forward at lower 1/3 of radius, with angulation
bowing or overlap
• Distal radio-ulnar joint is subluxated or
dislocated
Treatment • Restore the length of the fractured • Restore the length of the fractured
ulna; only then can the dislocated bone
proximal radioulnar joint be fully • In children , close reduction is often
reduced and remain stable successful
• In adults this means an operation • In adults , reduction is best achieved
• The ulnar fracture must accurately by open operation and compression
reduces and fixed with a plate and plating of the radius
screws • X-ray is taken to ensure the distal-
• Test for full range of movement after radioulnar joint is reduced and
10 days stable
• Immobilized for about 6 weeks if • If still unstable , fixed with Kirshhner
doubt wire and forearm is splinted in an
above-elbow cast for 6 weeks

Complication 1. Nerve injury
2. Mal-union
3. Non-union
Plate & screw K-wire
Explain X-ray (Galeazzi)

Transverse # at distal radius
with displacement of radio-
ulnar joint. So ulnar laterally
and proximally (in AP view)
**MU dekat dengan hari- so monteggia, proximal ulnar**

MU: # proximal (shaft) of ulnar  displacement of radiocapitellar joint  dislocation of radial head (bone shorten)
GR: # distal end of radius  displacement of radio-ulnar joint  dislocation of ulnar head

**most common presentation at ED (must know how to do CMR)
COLLES’ FRACTURE SMITH’S FRACTURE
Introduction Transverse fracture of radius just above the • Distal fragment is displaced and
wrist with dorsal displacement of distal tilted anteriorly
fragment • Sometimes it is called ‘Reversed
Colles’
Typical history:
 Older woman/>45 years old
 Osteoporosis
 History of falling on outstretched
hand
Mechanism  Force is applied in the length of the  Caused by a fall on the back of the
of injury forearm with the wrist extension hand
 Fractures at the corticocancellous joint =
extra-articular fracture
 Associated with ulnar styloid fracture
(60% cases)
Special • Pain • Wrist injury

features • Swelling • ‘Garden spade’ deformity
• ‘Dinner-fork’ deformity
Components
1. Dorsal displacement
2. Dorsal tilt
3. Radial shortening
4. Radial displacement

X-ray Xray of the hand & wrist joint Xray of hand & wrist
• Transverse fracture of the radius at the • Fracture through the distal radial
corticocancellous junction metaphysis
• (2cm from the wrist) • Distal fragment is displaced and
• Associated with fracture of ulnar styloid tilted anteriorly
• Dorsal angulation of the distal fragment
• Dorsal displacement of the fragment
How to identify
 Identify the thumb or
 Identify MCP- short, plump and away from other fingers
 See displacement- dorsal (ke-atas) or ventral (ke bawah)
Treatment Undisplaced # • Reduce fracture by traction,
• Apply dorsal splint / backslap for one or supination and wrist extension
two days until swelling subsides • Forearm is immobilized by cast
• Apply below elbow cast on the affected for 6 weeks
part • Xray should be taken at 7 – 10
• Stabilize fracture and the cast can be days to ensure fracture has not
removed after 4 weeks to allow slipped
mobilization • Unstable fractures should be
fixed with percutaneous wires or
Displaced # plate
• Reduction under anaesthesia
• Traction is applied to disimpact
fragment
• Distal fragment is pushed into place
• Dorsum is pressed
• Manipulation of wrist into flexion, ulnar
deviation and pronation
• Check position by X-ray
• Satisfactory, dorsal plaster slab is
applied (below elbow)
• Slab can be removed after 6 weeks
Complication Early Late
• Circulatory • Malunion
problems • Delayed union
• Nerve injury • Non union
• Reflex • Stiffness
sympathetic • Tendon rupture
dystrophy
• Triangular
Fibrocartilage
Complex (TFCC)
Injury

BARTON’S FRACTURE
FRACTURE- SUBLUXATION OF THE WRIST
Introduction  Intra-articular shearing fracture with
subluxation at radio-carpal joint
 Depends on fragment’s location, it can be
classified as volar subluxation or dorsal
subluxation
Volar subluxation Dorsal subluxation

 Fracture line runs obliquely across  Line of fracture runs obliquely across
the volar lip of the radius into the the dorsal lip of radius and carpus is
wrist joint carried posteriorly
 Since the fragment is small and
unsupported, fracture can be
unstable
X-ray
Treatment  This fracture can be easily reduced but can be easily re-displaced
 Internal fixation using the anterior buttress plate is recommended (for both)
**Easier to control than the volar’s
 Closed reduction is done & forearm is immobilized in cast for 6 weeks
Barton’s  buttress
FRACTURE OF THE RADIAL STYLOID PROCESS

 Is caused by forced radial deviation of the wrist and may occur after a fall, or when a starting
handle ‘kicks back’-the so called ‘chauffeur’s #’
 The # line is transverse, extending laterally from the articular surface of the radius
 The fragment much more than radial styloid is often undisplaced
 The radial styloid can be # as part of far more serious trans-scaphoid perilunate #
Treatment
• Reduced the displacement
• Wrist is held in ulnar deviation by plaster slab round the outer forearm
(Extending from below elbow to the metacarpal neck)
• Imperfect reduction may lead to osteoarthritis
• If closed reduction is imperfect, fragment should be screwed back or
held by k-wires

COMMINUTED INTRA-ARTICULAR FRACTURES IN YOUG ADULTS
Introduction  In young adult, it is a high energy injury
 A poor outcome will result unless intra-articular congruity, # alignment and
length are restored and movement start STAT
 Other than AP and lateral view, oblique view and often CT scan are useful to
show the fragment alignment
Treatment • Manipulation and cast immobilization
• If not restored, do open reduction
• The medial (ulnar site) complex must be anatomically reconstituted via dorsal
and palmar approached
Complication 1. Carpal instability
2. Secondary OA
DISTAL FOREARM FRACTURES IN CHILDREN

Introduction  Distal radius and ulnar are among the commonest site of childhood fracture
 The break may occur through the distal radial physis or in the metaphysis one or
both bone
 Metaphyseal fracture are often incomplete or greenstick in nature
Mechanism • A fall on the outstretched hand with the wrist is extension
of injury • The distal end is forced posteriorly (juvenile colles fracture)
• Sometime, the wrist is in flexion and fracture is angulated anteriorly
Special  Painful wrist
features  Swollen
 Sometime obvious dinner fork deformity
X-ray Physeal # Metaphyseal #
 Salter-Harris type I or II, with  Appear as mere bulking of the
epiphyseal shifted or tilted backward cortex, as angulated greenstick # or
and radially complete # with displacement and
shortening
Treatment Physeal # Buckle #
 Reduction under anaesthesia by  Required no more than 2 weeks in
pressure on distal fragment plaster, followed by 2 weeks of
 Immobilized in full-length cast with restricted activity
wrist flexed and ulnar deviated and
elbow 90o
Greenstick # Complete #
 Reduction and applied POP  Manipulated in same way as Colles #
Child <10 y.o: angulation up to 30o  Check reduction by Xray
Child >10 y.o: angulation up to 15o  Full length POP applied with wrist
 Changed cast after 2 weeks natural and forearm supinated
 Re-xray  After 2 weeks, check x-ray and cast is
 If redisplaced, further manipulation kept on for 6 weeks
can be carried out  If fracture is true slips, stabilized
 Discarded cast after 6 weeks with K-wires
• Forearm swelling • Mal-union
• Threatened compartment • Radio-ulnar discrepancy
syndrome

PROBLEMS AROUND HAND AND WRISTS
Index:
1. Schapoid fracture
2. Scapholunate dislocation
3. Lunate and perilunate dislocation
4. Metacarpal fracture (Boxer’s fracture)
5. Bennett’s fracture-subluxation
6. Rolando’s fracture
7. Phalanges fracture
8. Fracture of the tuft
9. Tears of triangular fibrocartilage (TFCC)
10. Mallet finger
11. Swan neck deformity
12. Boutonniere deformity
13. Tendonitis & Tenosynovitis & Tenovaginitis (De Quervain’s)
SCHAPOID FRACTURE- 75% of all carpal fracture***

 Usual mechanism- Fall on hand with wrist extended (dorsiflexion and radial deviation)
 With unstable fracture = disruption of the scapholunate ligament and dorsal rotation of lunate
 Blood supply to schapoid
-Proximal part = scaphoid branches of the radial artery entering the dorsal ridge
-Distal part = palmar & superficial palmar branches of radial artery
**There are no anastomoses between the dorsal and palmar vessels- prone to AVN
Other sites prone to AVN

1. Scaphoid
2. Neck of femur
3. Talus
4. Ordontoid –C1 (open mouth view)
 5 site of fractures
1. Proximal third ( proximal pole ) 25%
2. Middle third ( waist ) most common 65%
3. Distal third 10%
4. Tuberosity
5. Distal articular surface (osteochondral #)
 Clinical features
1. Appearance may be deceptively normal
2. Slight fullness in the anatomical snuffbox
3. Precisely localized tenderness in the same place is an important diagnostic sign
4. Palpable scaphoid from the front and back of the wrist + tenderness
5. Pain on proximal pressure along the axis of the thumb

 X-ray finding
o Anteroposterior, lateral and oblique views are essential (foot & hand- perlukan 3 views)
o Sometimes the fracture is not seen 1st few days after the injury- take another x-ray after 2
week
o Look for carpal displacement or instability signs
1. Obliquity of the fracture line
2. Angulation of distal fragment
3. Opening of fracture line
4. Foreshortening of the scaphoid image
 Treatment
 Undisplaced #: Immobilize on below elbow cast for 8 weeks
(Position immobilize: wrist in dorsiflex, thumb forwards in glass holding position)
 Displaced #: CMR  open reduction and compression screw
 Complication
1. Avascular necrosis- Distal third # -1% / Middle third # -20% / Proximal third # –40%
2. Non union
3. Osteoarthritis

SCAPHOLUNATE DISLOCATION
Subluxation of scaphoid + distruption of ligaments between scaphoid and lunate
Features: foreshortening scaphoid and large gap between scaphoid and lunate
Tx: if diagnose <4 weeks after injury, reposition bones by open reduction + Kirschner wires + repair
ligaments with interosseous sutures. Immobilized in cast for 8 weeks.
If diagnose missed: will end up with chronic carpal instability
LUNATE AND PERILUNATE DISLOCATION

 Fall with hand forced into dorsiflexion, may tear ligaments tear the carpal bones
 Features: painful wrist which held inmobile, swollen. If carpal tunnel compressed, CF of CTS
LUNATE DISLOCATION PERILUNATE DISLOCATION
Lunate goes forward (anteriorly) Lunate remain attach to radius
Other carpal bones remain Other carpal bones displaced backwards
Xray on AP view Xray on AP view
1. Abnormal shape of lunate (triangular instead 1. Carpus decrease in height
of quadrilateral) 2. Bone shadows overlap abnormally
3. Carpal bones maybe fractured (usually
Xray on lateral view scaphoid)
1. Dislocated lunate is tilted forwards and
displaced in front of radius Xray on lateral view
2. Capitate & metacarpal bones in line with 1. Lunate is not dislocated forwards
radius
Closed reduction Open reduction
-CMR: pulling hand with wrist in extension -CMR failed, do open reduction
-Plaster slab *carpus exposed by anterior approach (give
-Percutaneous Kirschner wires advantage of decompressing carpal tunnel)
-Lunate immobilized by Kirschner wires
-Ligaments repaired through palmar and dorsal
approaches
-At the end, wrist splinted (removed after 8w)
Complication
1. Avascular necrosis (lead to progressive increase in bone density)

METACARPAL FRACTURE- Boxer’s fracture (EMQ)
 Vulnerable to blows and falls upon the hand, or the force of a boxer’s punch
MID-SHAFT FRACTURE NECK FRACTURE
 Angular deformity is usually not marked  Particularly the neck of the 5th metacarpal
 If persists, not interfere much with function  Small distal fragment may be tilted markedly
 Rotational deformity - serious and may result towards the palm
in malposition of the entire ray when the hand
is closed in a fist
 Bump on the back of the hand or one of the knuckles may be flattened
 Swelling and local tenderness
X-ray finding: X-ray finding:
 Transverse or oblique fracture line  Forward tilting of the distal fragments
 Shortening or angulation of fragments
Undisplaced fracture of shaft  Angulation up to 40◦ in 4th and 5th

 Only require a firm crepe bandage (for metacarpals and 20◦ in 2nd and 3rd
comfort) metacarpals
 Worn for 2 or 3 weeks  All other displaced metacarpals fractures –
 Should not be allowed to interfere with active reduced by traction and pressure
movements of the fingers, must be practised  Held by plaster slab extending from the
assiduously forearm over the fingers (damaged ones), for
3 weeks
Displaced fracture of shaft  Undamaged fingers are exercised
 Displaced or shortening – open reduction and  Because of the risk of stiffness in the splinted
internal fixation with mini-plates and screws finger, fixation with percutaneous wires or a
 Movements started after operation as soon as low-profile plate is usually preferred
possible
Complication
1) Malunion
 Angulation – result in a visible bump or a flattened knuckle, function is usually good
 Rotational deformity – more serious, patient cannot properly close the fist
 Need correction by osteotomy
2) Stiffness
 Minimal splinting – to permit movement in uninjured fingers (as a prevention)

BENNETT’S FRACTURE – SUBLUXATION
• Fracture of the base of the thumb metacarpal with extension into the carpometacarpal joint
• Smaller fragment remains in contact with trapezium while major portion of metacarpal
subluxates proximally
• Unstable injury, easy to reduce, difficult to control
Treatment
• Stable: Closed reduction – pulling on the thumb, abducting and extending it
• An attempt can be made to hold the position with a plaster cast, worn for 4 weeks
• X-ray not showing perfect position – fixed with a small screw or Kirschner wire (wrist is held in a
plaster slab for 4 weeks) for unstable fracture
Complication
1) Osteoarthritis
- if carpometacarpal joint is seriously damaged or subluxed
- conservative treatment
- surgery if pain becomes intolerable (arthrodesis of the joint or excision of the trapezium)
*arthrodesis=artificial induction of joint ossification between 2 bones via surgery
ROLANDO’S FRACTURE***
 3 parts or comminuted intra-articular fracture-dislocation of base of thumb (proximal 1st
metacarpal)
 Usually due to an axial blow to a partially flexed metacarpal, such as a fistfight
 Communited Bennet’s fracture
 Typically T or Y-shaped
 Immediate severe pain on the thumb side of the wrist, rapid swelling, thumb may appear
deformed depending on the level of bone displacement
Treatment
 Reduction – external fixation, internal fixation (reconstruction of articular surface by using K wire)
 Immobilisation – using thumb spica splint
 Rehabilitation

PHALANGES FRACTURE
• The fingers are usually injured by direct violence
• It can happen due to tools such as knock by a hammer, sports (basketball, baseball, boxing)
Clinical features: (features of fracture) Phalanx can be fractured in various ways
 Swelling or open wounds i. Transverse fracture of the shaft
 Painful fingers ii. Spiral fracture of the shaft
 Deformed fingers iii. Comminuted fracture
 LOF: lifting and gripping object iv. Avulsion of a small fragment of bone
v. Metaphyseal fracture
vi. Intra-articular fractures
UNdisplaced fracture DISplaced fracture
 Treated by ‘functional splintage’ It must be reduced and immobilized
 Movements encouraged from outset If a reduction cannot be achieved, surgery is needed
 Splintage is retained for 2–3 weeks It is essential to check for rotational correction by
 Recommended to check the position with 1) Noting the convergent position of the finger
x-ray in case displacement has occurred when the MCP joint is flexed
2) Seeing that the fingernails are all in the same
plane
1. Plate fixation
2. Percutaneous screw fixation- for spiral #
3. Percutaneous wires
FRACTURES OF THE TUFT  The fracture is disregarded and treatment is

*common- kena hentam dgn pintu focused on controlling swelling and regaining
movement
 The painful haematoma beneath the finger nail
should be drained by piercing the nail with a hot
paper clip or a small drill
TEARS OF TRIANGULAR FIBROCARTILAGE (TFCC)

TFCC fans out from base of ulnar styloid process to the medial edge of distal radius
Clinical features
1. Chronic pain in wrist related to old sprain
2. Loss of grip strength
3. Clicking on supination of forearm
Diagnosis confirmed by arthroscopy
Treatment: repaired the peripheral tears or removed ragged fragments

MALLET FINGER
After a sudden flexion injury (e.g. stubbing tip of finger) the terminal
phalanx droops and cannot be straightened actively
Three types of injury are recognized:

1. Avulsion of the most distal part of extensor tendon
2. Avulsion of a small flake of bone from the base of the terminal phalanx
3. Avulsion of a large dorsal bone fragment, sometimes with subluxation of
TIP joint
Tx: TIP immobilized in slight hyperextension using mallet-finger splint for 6 weeks
Complication
1. Non union
2. Persistent droop
3. Swan neck deformity
SWAN NECK DEFORMITY

Hyperextension deformity of the PIP joint + Flexion of DIP joint (reverse boutonniere)
Caused by imbalance of extensor versus flexor action and laxity of palmar plate
Occur if Primary lesion is lax volar plate that allows

1)PIP extensor overact hyperextension of PIP. Causes include:
-due to intrinsic muscle spasm/contracture • trauma
-after mallet finger • generalized ligament laxity
-following volar subluxation of MCP joint • rheumatoid arthritis
2)PIP flexors are inadequate
-inhibition or division of flexor superficialis Secondary lesion is imbalance of forces on the
3) The palmar plate of PIP joint fails PIP joint (PIP extension forces > PIP flexion
-in RA, lax-jointed individuals or trauma forces). Causes of this include:
 mallet injury
 intrinsic contracture
Non-surgical:
 Simple figure of eight ring splint to maintain the PIP joint in few degree of flexion
 If deformity fixed, temporary K-wire fixation in few degrees flexion

BOUTONNIERE DEFORMITY
Flexion deformity of the PIP joint + Extension of DIP joint
 Due to interruption or stretching of the central slip of the
extensor tendon where it insert into the base of middle
phalanx
 Lateral slips separate and the head of proximal phalanx
thrust through the gap like a button through a buttonhole
Initially the deformity is slight and correctable, but later the
soft tissue contract and may result in fixed flexion of PIP and
hyperextension of DIP joint
Symptoms develop immediately following an injury or may develop a week to 3 weeks later
 Finger cannot be straightened at the middle joint
 Fingertip cannot be bent
 Swelling and pain occur and continue on the top of the middle joint of the finger
Special test
1. Curl affected finger around edge of table (PIP is bend 90°)
2. Place pressure over middle phalanx & patient try to resist
3. Intact central slip: examiner able to feel tension of finger
being extended
4. Ruptured central slip: cannot feel tension, patient unable
to extend PIP joint
Non-surgical
• Splinting the PIP joint in full extension ( 6 weeks)
• DIP joint moved passively to prevent lateral bands from sticking
• Open injuries of central slip should be repaired with the joint protected by K-wire (3 weeks)
• Exercises ( stretching exercise)
• Protection ( if involve in sports)
Surgical (indication)
 Deformity results from rheumatoid arthritis
 The tendon is severed
 Large bone fragment is displaced from its normal position
 The condition does not improve with splinting
 Surgery can reduce pain and improve functioning, but it may not be able to fully correct the
condition and make the finger look normal

TENDONITIS & TENOSYNOVITIS & TENOVAGINITIS (De Quervain’s)
TENDONITIS TENOSYNOVITIS/TENOVAGINITIS
Definition Is inflammation of tendon Is inflammation of Is inflammation of sheath
itself synovium surrounding surrounding tendon
tendon
Causes  Overuse  Overuse
 Stretching  Repetitive minor trauma
 Impact  Spontaneously in middle aged women or pregnancy
Clinical  Generalized swelling  Usually woman aged 30-50
features  Tenderness  Complaint of pain on radial side of wrist- acute at tip
 Inability to flex wrist of radial styloid
 May have visible swelling over radial styloid
 Tendon sheath may feels thick and hard
Finkelstein test positive (++)

1. Placed thumb in closed fist
2. Turn wrist sharply towards ulnar side
3. Pain over radial styloid
-painless with repetitive movement when thumb is free
Treatment EARLY cases
 Rest
 Anti-inflammatory (NSAIDs) medication
 Injection corticosteroids into tendon sheath
 Hand therapy (ultrasound, frictions, splintage)
RESISTANT cases
 Operation- slitting the thickened tendon sheath
 Rehabilitation
*Care to prevent injury to dorsal sensory branches of radial nerve- may cause
intractable dysaesthesia
1st dorsal compartment (most commonly
affected) in De Quervain tenosynovoitis
• Abductor pollicis longus
• Extensor pollicis brevis
2nd dorsal compartment (also commonly

affected)
• Extensor carpi radialis longus
• Extensor carpi radialis brevis (most
powerful extensor wrist)
6th dorsal compartment (also commonly

affected)
• Extensor carpi ulnaris

PROBLEMS AROUND THE KNEE Problems around the knee are frequently asked in examination
Make sure you know how to perform COMPLETE KNEE EXAMINATION
Index:
1. Approach to knee injury
2. Supracondylar fracture of femur
3. Tibial fracture
4. Patella fracture
5. Ligament injuries
6. Meniscus injury

APPROACH TO KNEE INJURY
Hx of • Pain  maximum point of tenderness!
knee • Swelling  localised/diffuse/time of onset
injury • Stiffness fluctuates/onset
• Locking/unlocking
• Deformity  unilateral/bilateral/valgus/varus/fixed flexion/hyperextension
• Giving way  muscle weakness/torn meniscus/faulty patellar extensor mechanism
• Loss of function
PE of 1) LOOK (SSAWD)
knee POSTION  Compare both side – valgus, varus, incomplete extension, hyperextension
injury SWELLING  Either the joint as a whole / lumps in localised areas
WASTING  Quadriceps (sure sign of joint disorders)
MEASUREMENT  Fixed distances from joint line on both side
2) FEEL
SKIN TEMPERATURE
• Comparing both sides – from proximal to distal
• Increase in temp at knee joint – increased vascularity (inflammation)
SOFT TISSUE & BONY OUTLINES
• Palpated systematically – abnormal outlines & tenderness
• Easier if joint is flexed
• Point of max tenderness indicates the anatomical site of pathology
PATELLA FRICTION TEST
• Knee in 30 degree flexion position
• Examiner grasp the edges of the patella with the thumb & middle finger, & tries to lift the patella
forward
• Shift patella laterally to elicit tenderness
• Positive indicates subluxation of patella
PATELLA TAP
• To assess intraarticular fluid collection
• Squeeze the fluid in the suprapatellar pouch towards the knee, with left hand kept on left pouch, tap
the patella vertically downwards
• Examiner will be able to feel the knock of patella against the femur
FLUID SHIFT (Bulge)
• Detect smaller amount of intraarticular fluid
• Shift the fluid from medial parapatellar fossa, then shift the fluid back from lateral parapatellar fossa
immediately  can see bulge at medial site
3) MOVE
ACTIVE MOVEMENT
PASSIVE MOVEMENT
• Most easily performed with the patient in lying position.
• Full knee flexion is considered to be approximately 135° (Range 120-150°).
• Hyperextension may occur, (Range 0° to 15°).
Internal & External rotation – no more than 10
Special Anterior Drawer Maneuver:
tests Examines for any • Patient lying on their back with knee Before test :
tearing or laxity of bent 90°  Make sure both knee are at
the anterior cruciate • Place both hands behind tibia and the same level
ligament (ACL) pull the tibia forward  Make sure there’s no
Posterior Drawer Maneuver: sagging of tibia. If there is,
Examine the • Patient lying on their back with knee correct it
Posterior Cruciate bent as 90°  Make sure the hamstrings
Ligament (PCL) • Place both hands behind the tibia, are relaxed
and push backwards on the proximal  Sit on both legs to stabilize
shin/tibia looking for instability  Place the thumb at tibial
backwards tuberosity and fingers
encircling the tibia

Valgus Test Maneuver:
Check for medial • Patient lying on their back
joint laxity, which • Position one hand at the joint line on
usually represents an the outer part of the knee (left hand)
injury to the medial • Right hand fixed on the ankle of the
collateral ligament affected side
(MCL) • Flex the knee between 20° and 30°
and apply a medial or valgus force to • Do this test in 2 positions
the ankle • Full extension of the knee
Varus Test Maneuver: • Repeat the test with knee
Check for joint laxity • Patient lying on their back flexed to 20 degree
on the outside of the • Position right hand at the joint line on
knee, which usually the outer part of the knee
represents an injury • Fix the left hand on the ankle of the
to the lateral affected side
collateral ligament • Flex the knee between 20° and 30°
(LCL) and apply a lateral or varus force to
the ankle
McMurray's Test Maneuver:
Check for meniscal • Full flexion of the knee
tears • Externally rotate the foot and
maintain the external rotation
(Medial Meniscus) throughout the test
• Valgus stress on the knee and
maintain the valgus stress throughout
the test
• Extend the knee slowly
• Feel of clicking of the knee while
Positive Findings:
extending the knee
• Painful clicking along the
• Patient may feel pain on the medial
joint line, or any pain over
knee joint line
the joint line that
McMurray's Test Maneuver:
reproduces the patient’s
Check for meniscal • Full flexion of the knee
symptoms is considered to
tears • Internally rotate the foot and maintain
be a positive test
the internal rotation throughout the
(Lateral Meniscus) test
• Varus stress on the knee and maintain
the varus stress throughout the test
• Extend the knee slowly
• Feel for clicking of the knee while
extending the knee
• Patient may experience pain on the
lateral knee joint line

SUPRACONDYLAR FRACTURE OF THE FEMUR
Groups of • Young adults - high-energy trauma
people • Elderly - osteoporotic individuals
Mechanism • Direct violence – usual cause
of injury • Fracture line – just above the condyles
• May branch off distally between them
Special • Knee - swollen and deformed
features • Movement – too painful to be attempted
• Tibial pulses – should always be palpated
X-ray • Fracture – just above the femoral condyles
• Transverse or comminuted fractures
• Distal fragments – often tilted backwards
* Entire femur must be x-rayed (to look for proximal femur fracture or dislocated hip)
Management • If fracture only slightly displaced and extraarticular, or reduces easily

• Skeletal traction through proximal tibia
• The limb is craddled on Thomas splint with knee flexion splint
• Movements are encouraged
• If distal fragment is displaced by gastrocnemius pull
• A second pin above the knee and vertical traction
• 4-6 weeks, fracture begins to unite – replace with a cast-brace, patient is
allowed up, partially weight-bearing with crutches
Complications • Joint stiffness
 Almost inevitable
 Long period of exercise is necessary
 Full movement is rarely regained
• Malunion
 Varus or valgus deformity
• Osteoarthritis
 Late complication
 Supracondylar fracture – often extend into joint surface
 Accurate reduction is necessary

TIBIAL PLATEAU FRACTURE
Mechanism • Strong bending forces combined with axial loads
of injury eg: a car striking a pedestrian on the side of the knee (bumper fracture)
• Fall from a height in which the knee is forced into valgus or varus
• Younger patients – most common pattern of fracture is splitting
• Older, more osteoporotic patients – depression fractures typically are sustained
Special •
Joint is swollen
features •
Has the doughy feel of a haemarthrosis
•
Diffuse tenderness on the side of the fracture, also on the opposite side if a
ligament is injured
X-ray Multiple views are needed – true extent of fracture
Management Undisplaced & minimally displaced fractures of the lateral epicondyle
o Conservatively
o Haemarthrosis is aspirated, a compression bandage is applied
o As the acute pain and swelling have subsided, a hinged cast-brace is fitted,
patient is allowed up
o ORIF
Markedly displaced and/or comminuted fractures of the lateral condyle

o Open reduction & internal fixation
o Fixation – with lag screws and a buttress plate
Fractures of the medial condyle

o Open reduction and fixation with a buttress plate and screws
o Associated lateral ligament damage will need repair
Bicondylar fractures
o Usually high-energy injuries
o Best if reduced and stabilized surgically
o A combination of screw fixation and circular external fixation offers
satisfactory stabilization – lower risk of wound complications
Osteoporotic condylar fractures

o Elderly (osteoporotic fractures) – treated along the same lines as above
o Total knee replacement
Complication 1. Compartment syndrome
• With severe condylar fractures
• Leg & foot – examined repeatedly for suggestive signs
**The rest same with supracondylar

PATELLA FRACTURE
Mechanism of Direct injury
injury o Fall onto the knee
o Direct blow (such as against the dashboard of a car)
o 2 part function or comminuted ‘stellate’ fracture
Indirect injury
o Forced, passive flexion of knee while the quadriceps muscle is contracting
o Transverse fracture with a gap between fragments
Clinical • Swollen and painful knee
features • Crepitus
• Abrasion or bruising over the front of joint (hemarthrosis)
• Patella is tender and sometimes gap can be felt.
Active knee extension should be tested. IF patient CAN LIFT the straight leg,
quadriceps mechanism still intact
**kalau undisplaced kena buat skyline view baru nampak
Management Undisplaced or minimally displaced fracture
• Haemarthrosis (bleeding into joint spaces) should be aspirated
• Cylinder cast 3-4 weeks, followed by quadriceps exercises every day to be
practiced
Two-part fx : TBW sebab ada quadriceps pull! If x Berjaya reduce  patellectomy
Comminuted fracture
• With displacement- patellectomy because it is the undersurface of the patella is
irregular and there is a serious risk of damage to the patellofemoral joint
Complication ++ extensor weakness
LIGAMENT INJURIES
Mechanism of • Most ligament injuries occur while the knee is bent, which is when the capsule
injury and ligaments are relaxed and femur is allowed to rotate on tibia
Types of Anterior CL Posterior CL Lateral CL Medial C L
injury • Hyperextension • Simple misstep • Rarely • Contact on the
• Legg twist at • Fall on flexed knee injured lateral side of the
opposite direction • Front of the knee knee
hit the ground • Accompanied by
sharp pain on the
inside of the knee
Clinical • Pain, often sudden and severe
features • A loud pop or snap sound during the injury
• Swelling and bruising
• A feeling of looseness in the joint
• Inability to put weight on the point without pain
Imaging Plain x-rays: May show that the ligament has avulsed a small piece of bone
o MCL : Medial edge of femur
o LCL : Fibula
o ACL : Tibial tuberousity
o PCL : Back of upper upper tibia
Stress films:- Show whether the joint hinges open on one side.
MRI
• To distinguish partial from complete ligament tears
• May also reveal 'bone bruising', up to now still poorly recognized source of pain

Management Sprains and partial tears Complete tear Combined injuries
o Spontaneous healing o Isolated tears of MCL : o ACL and collateral
will occur long cast-brace is ligament injuries :
o Active exercises to worn for 6 weeks and joint bracing and
prevent adhesions, thereafter graded physiotherapy , ACL
facilitated by exercises are reconstruction.
aspirating a tense encouraged. o Combined injuries
effusion, applying ice o Isolated tears of LCL : involving PCL : joint
packs and sometimes can be treated bracing and
by injecting LA into conservatively as for physiotherapy, all
tender area MCL tears damaged structures
o Put heavily padded o Isolated tears of ACL : need to be repaired
bandage or functional may be treated by
brace to protect from early operative
rotation or angulation reconstruction
strains (professional
sportsman)
o Isolated tears of PCL :
treated
conservatively.
Complications • Adhesions
• Ossification in the ligament
• Instability
MENISCAL INJURY
 Sustained when player is standing in semiflexed knee, twist his body to one side
 Medial meniscus is more common (less mobile, fixed to collateral ligament
 Keywords : Active patient  Recurrent episodes of pain  Sudden JERK when walking 
SWELLING after few hours, persistent PAIN after few days with little or no swelling 
LOCKING of the knee (femoral and tibia ada fragment)
 Mx: - If no locking : Robert jones bandage (immobalized only)
 Chronic – Athrotomy (excise torn meniscus)
Randomly
Differential diagnosis of knee pain
Knee cap pain
1. Patella pain syndrome
2. Jumpers knee or osgoodschlater (tibial tuberosity)
Outside knee
1. Laterall ligament injury
Back of knee
1. Baker’s cysts associated with OA
2. Hamstring tendon injury
Inside knee
1. Medial meniscus injury
2. Medial colleteral ligament tear
Knee joint
1. ACL tear
2. PCL
3. OA
4. Articular cartilage tear

PROBLEMS AROUND ANKLE AND FOOT
Index:
1. Pilon fracture of ankle
2. Malleolar fracture of ankle
3. Fracture of talus
4. Fracture of calcaneum
5. Mid-tarsal injury
6. Tarso-metatarsal injury
7. Metatarsal bone injury
8. Metatarsophalangeal joint injury
9. Fracture of toes
10. Pott’s fracture
11. Peroneal tendonitis
12. Posterior tibial tendinitis
13. Achilles tendinitis
14. Plantar fasciitis
15. Hallux valgus
16. Metatarsalgia
17. Sesamoiditis
18. Freiberg’s disease
19. Morton’s disease
PILON FRACTURE OF THE ANKLE

Introduction less common
Severe axial compression of the ankle joint that shatters the tibial plafond
Considerable damage to the articular cartilage and subchondral bone may be
broken to several pieces
Comminuted fractures
High energy injury – fall from a height
Clinical  Severe swelling
features  Fracture blisters
X-ray  Comminuted fractures of the distal end of tibia, extending into the ankle joint
 Fracture of the fibula
Management  Control of swelling by elevation
 Treat the blisters
 Once the skin has recovered, open reduction and fixation
with plates and screws (usually with bone grafting) may
be possible
 After fixation, elevation and early movement help to
reduce the oedema
 Usually take several months to heal
 Post-opt: physiotherapy is done and it is focused on joint
movement and swelling reduction

MALLEOLAR FRACTURE OF THE ANKLE
Introduction More common
Mechanism o Ankle is twisted and the talus tilts / rotates forcibly in the
of action mortise, causing low-energy fractures of one or both malleoli
with/without ligament injuries
o If a malleolus is pushed off, it fractures obliquely
o If a malleolus is pulled off, it fractures transversely
Clinical • History of twisting injury usually with ankle going into inversion
features • Followed by immediate pain, swelling and difficulty in weight bearing
Classification Weber classification (must remember!)
Type A Type B Type C

 Transverse fracture  Oblique fracture of  More severe
of fibula below fibula at level of  Above level of
syndesmosis syndesmosis syndesmosis
 Assoiated with  Assoiated with  Associated with tibia-
fracture medial fracture medial fibular ligament torn
malleolus malleolus
Mechanism  Adduction + internal • External rotation of  Severe abduction +
of injury rotation of foot foot external rotation
Management  Screw in medial malleolus  Plate & screw is inserted
 Removal of loose fragment between tibia & fibula
 Plate & screw ( if really unstable)  Srew is transversely
 Tension band wiring (if still unstable) inserted between tibia &
fibula
Principal of Management :
i. Fracture of below the tibiofibular joint - Reduction, Immobilisation, Stabilisation
ii. Fracture of above the tibiofibular joint : - Assess presence of displacement on
inferior tibiofibular ligament
iii. Medial injury or fibular displacement: - Internal Fixation
iv. Isolated Medial Malleolar Fracture: - Plaster immobilisation for 3 week
• Vascular injury • Incomplete reduction
• Infection • Non-union
• Wound breakdown • Stiffness
• Osteoarthritis
EMQ TIPS
• Vertical compression injury (adalah impact # fall from height)
• 3 common site:
a) # on foot & heel
b) #of hip
c) # of spine (thorocolumbar #)

FRACTURE OF TALUS
Introduction Relatively uncommon
Usually involve considerable violence (car accidents, fall from a height)
Mechanism  Fracture of talar neck is produced by violent hyperextension of the ankle
of action  Fracture of the body is usually a compression injury due to a fall from a height,
or an exerting force across the body fracturing the lateral process
 Avulsion fractures are associated with ligament strains around the ankle and
hindfoot
Clinical History of MVA or fall from a height
features - Painful and swollen foot and ankle
- Obvious deformity or the skin may be tented or split in displaced fracture
- Tenting is a dangerous sign
Complication  Malunion
 Avascular necrosis
 2o osteoarthritis
FRACTURE OF CALCANEUM
Introduction Most commonly fractured tarsal bone
The patient falls from a height onto one or both heels
The calcaneum is driven up against the talus and is split or crushed
Clinical History of MVA or fall from a height
features Elderly osteoporotic people even a minor injury may fracture the calcaneum
- The foot is painful, swollen and bruised
- The heel may look broad and squat
- The tissues are thick and tender and the normal concavity below the lateral
malleolus is lacking
- The subtalar joint cannot be moved but ankle movement is possible
- Always check for the signs of compartment syndrome
Investigation X-ray
o Plain x-ray should include lateral, oblique and axial views
o Extra-articular fractures are usually fairly obvious
o Intra-articular fractures can often be identified in the plain films and if there is
displacement of the fragments the lateral view may show flattening of the
tuber-joint angle (Bohler’s angle)
CT-scan
o For accurate definition of intra-articular fractures

Management Undisplaced fracture Displaced avulsion fracture Displaced intra-
 Exercises are  Displaced fracture of the articular fracture
encouraged from the tuberosity should be  Best treated by
outset reduced & fixed with open reduction &
 When the swelling screws internal fixation
subsides, a firm  Immobilized in slight with plates &
bandage is applied equinus to relieve screws
 The patient is allowed tension on the tendo  Bone grafts are
up, non-weight-bearing Achilis used to fill any
on crutches for 4-6  Weight-bearing can be defects
weeks permitted after 4-6  Postoperatively,
weeks the foot is lightly
splinted &
elevated
 Exercises are
begun as soon as
pain subsides &
after 2-3 weeks
the patient can
be allowed up,
non-weight-
bearing on
crutches
 Partial weight-
bearing is
permitted only
when the
fracture has
healed and full
weight-bearing
about 4 weeks
after that
• Swelling • Malunion
• Blistering • Talcocalcaneal stiffness
• Compartment syndrome • Osteoarthritis

MIDTARSAL INJURY
1. Medial Stress Injury 2. Longitudinal Stress Injury 3. Lateral Stress Injury
• Caused by violent • Most common type of injury • Caused by falls - foot is
inversion of foot • Severe longitudinal force with the forced into valgus
• Fracture-sprains - foot plantarflexion • Injuries include fracture,
caused by inversion • The navicular is compressed fracture-subluxation of
strains of the foot between the cuneiform and talus cuboid and the anterior
• Fracture-subluxations resulting in fracture of navicular end of calcaneum and
and dislocations - The and subluxation of the midtarsal avulsion injuries on the
forefoot is displaced joint medial site of the foot
medially, leaving the 4. Plantar Stress Injury 5. Crush injury
hind foot in normal • Fracture-sprains-These were • Caused by the foot of a
alignment with the caused by falls with the foot motor-cyclist being
tibia twisted under the body or by crushed by an oncoming
• Swivel dislocations - motor-cycle accidents car, and a fourth by a ton
High falls accounted - Fragments are avulsed from weight falling on the foot
for most of these and the dorsum of the navicular or • Usually cause open
for the fracture- talus and from the anterior comminuted fractures of
subluxations and process of the calcaneus the midtarsal region
dislocations. A medial • Fracture-subluxations and
force applied to the dislocations-Falls with the foot
forefoot disrupts the trapped and more severe motor-
talo-navicular joint but cycle accidents caused these
leaves the calcaneo- injuries
cuboid joint intact - Impaction may occur at the
calcaneocuboid articulation
inferiorly
Clinical features
• Foot is bruised and swollen
• Diffuse tenderness across the midfoot
• Painful during movement- restricted
• Medial midtarsal dislocation- acute club foot
• Lateral dislocation- valgus deformity
Management
Undisplaced fractures Displaced fracture Comminuted fracture
- Elevate the foot to counter - Open reduction and - Usually can’t be reduce
act swelling screw fixation - Focus is put on soft tissue injury
- After 3-4 days, apply below- that might lead to ischemia of foot
knee cast or removable - Splinted and elevated until swelling
splintage boot subsides
- Allow up on crutches with - Artificial induction of joint
limited weightbearing ossification between two bones via
- Retain plaster 4-6 weeks surgery with stable fixation
Fracture dislocation Ligamentous strains
- Under GA- closed reduction - Foot may be bandaged until the
- If there is tendency to re-displaced, percutaneous K- acute pain subsides
wires are applied - Thereafter, movement is
- Immobilized foot in a below knee cast for 6-8 weeks encouraged
- If accurate reduction can’t be achieved by the closed - Re-examine and re-xray the foot if
manipulation, do open reduction and screw fixation not settled after few weeks

TARSO-METATARSAL INJURY METATARSAL BONE INJURY
Introduction Twisting & crushing are the usual causes, Relatively common
with the foot buckling or twisting at the Four types
midfoot-forefoot junction i. Crush # d/t direct blowing
ii. A spiral # of the shaft d/t twisting
injury
iii. Avulsion # d/t ligament strains
iv. Insufficiency # d/t repetitive stress
Clinical After high velocity car accidents and falls - Pain

features - Pain - Swelling
- Swelling - Bruising
- Severe injury-deformity
Management Undisplaced : immobilization for 6weeks Undisplaced:
Dislocation : - Support below knee cast
- Reduction by traction & - Foot is elevated
manipulation under GA - Active movement is encouraged
- Position by k-wire or screw & - Partial weight-bearing for 6weeks
cast - Exercise
- K-wire removes & rehabilitation
Displaced:
- Reduced by traction under GA
- Immobilized in cast
Complication  Compartment syndrome
METATARSOPHALANGEAL JOINT INJURY

• Sprains and dislocation of the metatarsophalangeal joint is common in dancer and athlete
Treatment :
• Simple sprain requires light splinting, strapping a lesser toe (2nd to 5th) to its neighbour for a
week or two
• If the toe is dislocated, reduced by traction and manipulation  apply cast for few weeks

FRACTURE OF TOES
• A heavy object falling on the toe my cause fracture
• If skin is broken, it must be covered with a sterile dressings and antibiotic should be given
• A contaminated wound will require formal surgical washout and exploration
• Fracture is disregarded and the patient is encouraged to walk in a supportive boot or shoe
• If pain is marked, toe may be splinted by strapping for 2-3 weeks
POTT'S FRACTURE
 Also known as Pott’s syndrome I and Dupuytren fracture
 Is an archaic term loosely applied to a variety of bimalleolar ankle fractures
 The combined fracture of the medial malleolus, lateral malleolus, and the posterior margin
of the distal end of the tibia is known as a "trimalleolar fracture”
 Not to be confused with Pott's disease

PERONEAL TENDONITIS POSTERIOR TIBIAL ACHILLES TENDINITIS
TENDINITIS
Achilles tendon injuries

- Characterized by tissue include inflammation of
damage and swelling of the Parthenon and partial
the posterior tibial tendon or complete tears
- Usually following overuse Common in running
and resulting in pain athletes
located at the inner aspect Calf muscles (gastrocnemius &
of the lower leg and ankle soleus) attach to the calcaneus
via the Achilles tendon
Clinical Features Clinical Features Clinical Features :
 Pain over the lateral aspects  Pain in the instep area of • Pain in the back of hell
of ankle foot • Occasional swelling due to
 Worse with activity  Swelling along the course thickening of tendon
 Improved with rest & NSAIDs of the tendon • Tender when squeeze with
 Onset insidious  Flatfoot deformity in case fingers
 Associate with an acute injury of tendon rupture
Common Cause of Injury:
Physical examination Repetitive forces (running)
 Pain along the course of the + insufficient recovery time
peroneal tendons = inflammation in the
 Pain and weakness is noted tendon paratenon (fatty
with resisted eversion of foot areolar tissue that
surrounds the tendon)
Increase in exercise
intensity
Investigation Investigation
MRI = May help distinguish MRI = To confirm whether the
between tendonitis and a tendon tendon has ruptured
tear
Treatment Treatment Treatment :
Non-surgical Non-surgical 1) Anti-inflammatory
1) Mild: NSAIDs, activity 1) Use firm arch support medications
modification, ankle brace inserted into the shoes 2) Physical therapy (gentle
2) Advanced: cast 2) NSAIDs calf muscle stretching)
immobilization 4-6 weeks 3) Corticosteroid injection 3) Ice therapy
3) Diagnostic injection with 4) Immobilization
bupivacaine is given into the Surgical
tendon sheath occasionally 1) Tendon debridement
2) Tendon repair
Surgical 3) Tendon graft
1) Recommend for patients who
fail conservative treatment

HALLUX VALGUS PLANTAR FASCIITIS METATARSALGIA
The plantar fascia is the thick

Lateral connective tissue which supports the
deviation/subluxation of arch on the bottom of the foot
the great toe and medial Pain at the site of the attachment of
deviation of 1st the plantar fascia and the
metatarsal bone calcaneus, with or without
accompanying pain along the
medial band of the plantar fascia
Risk Factors Causes
• Heel shoes - Runner
Generalized ache in
• Elderly people - Dancer
the forefoot –
• Rheumatoid arthritis - Obesity
common expression of
• Family history - RA
foot sprain
- Occupation involve walking or
Due to faulty weight
standing on a hard surface for a
long period distribution
Flattening of
Clinical Features Clinical Features
metatarsal arch
• Pain over the bunion • Sharp pain at the bottom of the
Shortening of 1st
• Deformity of the 1st MTP heel with weight bearing,
metatarsal Prolonged
joint and the big toe particularly when first arising in the
walking, marching,
• Standing- planovalgus morning. (5-10 minutes)
climbing, standing
hindfoot collapse may • Pain usually eases with walking or
become apparent activity and comes back worse after
resting
Hallux Valgus Angle : • Pain decreases during sleeping
- Intersection of
longitudinal axis of 1st Diagnosis
MT & prox phalanx • Pain reproduced by calcaneal
- Normal < 15 degree pressure during dorsiflexion
• X-ray – presence of calcaneal spurs
Intermetatarsal Angle :
- Intersection of 1st & 2nd
MT
- Normal < 9 degree
Treatment Treatment
Non-surgical - Splinting, stretching and cushioning
- Bunion pad - NSAIDs
- Footwear modification - Weight loss
- Cold ice massage
Surgical
- When symptoms not
reduce with footwear
modification

SESAMOIDITIS FREIBERG’S DISEASE MORTON’S DISEASE
 Caused by irritation and  Traumatic osteonecrosis of  Common problem with

inflammation of the the subarticular bone in neuralgia
peritendinous tissues bulbous epiphysis  Affect single distal
around the sesamoids –  Usually affect the 2nd metatarsal interspace
medial (tibial) sesamoid metatarsal head (rarely 3rd) in
(most stress during young adults, mostly women
weightbearing)
Causes
 Acute: Direct trauma
 Chronic: Possibility of
sesamoid displacement,
local infection / AVN
Clinical features Clinical features Clinical features

 Pain and tenderness  Patient complain of pain at  Patient typically complains
directly under first the MTP joint pain on walking, with the
metatarsal head  A bony lump (enlarged head) sensation of walking on a
 Aggravated by walking of is palpable and tender pebble in the shoe
passive dorsiflexion of  MTP joint is irritable  Pain is typically reproduced
the great toe by laterally compressing the
forefoot whilst also
compressing the affected
interspace
Treatment: Treatment Treatment
 Reduce weight-bearing  If discomfort: a walking  Simple offloading of the
and a pressure pad in plaster or moulded sandal – metatarsal head by using
the shoe reduce pressure on metatarsal dome insole and
 Resistant cases: Local metatarsal head wider fitting shoes
injection of  If pain and stiffness persist:  Not improved: Steroid
methylprednisolone and operative synovectomy, injection into interspace
LA debridement and trimming of (relief in about 50% of cases)
 Shaved down/remove the metatarsal head is  Surgical intervention:
sesamoid considered releasing the nerve by
dividing the tight transverse
intermetatasal ligament
(90% successful)

PROBLEMS AROUND HIP AND THIGH
Index:
1. Isolated fracture: intact pelvic ring
2. Fracture of pelvic ring
3. Fracture of acetabulum
4. Injuries to sacrum and coccyx
5. Fracture around hip and femur
6. Hip dislocation
7. Slipped femoral epiphysis
8. TB of hip
9. Osteoarthritis of hip
10. Pyogenic arthritis
11. Hip bursitis
12. Perthes’ disease
ISOLATED FRACTURE: INTACT PELVIC RING

Avulsion fractures Direct fractures Stress fractures
 A piece of bone is pulled off by  Direct blow to the  Fractures of the pubic
violent muscle contraction pelvis, usually after a fall rami are common in
 The sartorius pull off the ASIS, rectus from a height severely osteoporotic or
femoris, anterior inferior iliac spine,
 Fracture the ischium or osteomalacia patients
adductor longus, a piece of the pubis
and hamstrings part of the ischium the iliac blade  More difficult to diagnose
 Seen in sportsmen and athletes  Mx: Bed rest until pain are stress fractures
 Mx: rest for a few days and subsides around the sacroiliac
reassurance; if persistent joints; an uncommon
symptoms, open reduction and cause of ‘sacroiliac’ pain
internal fixation in elderly osteoporotic
 Pain may take months to  Also common in
disappear individuals and long
 Because there is often no distance runners
history of impact injury, biopsy  Obscure stress fractures
of the callus may lead to an are best demonstrated by
erroneous diagnosis of a tumour radioisotope scans
FRACTURES OF THE PELVIC RING

Introduction  Break at one point in the ring accompanied by disruption at a second point, d/t
rigidity of the pelvis
 Exceptions are # due to direct blows (including # of the acetabular floor), or ring
# in children, whose symphysis and sacroiliac joints are springy
 The second break usually is not visible – either because it reduces immediately
or the sacroiliac joints are only partially disrupted
 Classified by YOUNG BURGESS classification  to judge stability of pelvic ring

Clinical  Stable ring: not severely shocked but has pain on attempting to walk
features  Unstable ring: severely shocked, great pain, unable to stand. Unable to pass
urine, widespread tenderness
Classification Anterior Posterior
Lateral Compression Vertical Shear
Types Compression
I Symphysis widening <2cm Transverse anterior pubic Vertical displacement,
ramus fracture with anterior and posterior
ipsilateral sacral compression through sacroiliac joint

II Symphysis widening >2cm LC I + crescent (iliac wing)
Anterior SI ligament is fracture
torn and disruption of
sacrospinous and
sacrotuberous ligaments
III Anterior and posterior SI LC I + LC II + contralateral AP
ligament are torn compression injury
Shift of SI joint (unstable)
Mechanism  Frontal collision (eg a  Side to side compression  Fall from height
of injury pedestrian and a car) causing the ring to break onto one leg
 Pubic rami fracture or (Eg side-on impact in a  The innominate
the innominate bones road accident or fall from bone on one side is
are sprung apart and a height) displaced
externally rotated  Anteriorly the pubic rami vertically, pubic
(open book injury) on one or both sides are rami # and
 Anterior sacroiliac #, posteriorly there is a disrupting the
ligaments are strained severe sacroiliac strain or sacroiliac region on
or may be torn or may # of sacrum or ilium, the same side
be fracture of the either on the same side  Usually severe,
posterior part of ilium or opposite unstable with gross
tearing of soft
tissues and
retroperitoneal
hemorrhage
Management  APC I: bedrest, posterior sling or a pelvic binder
 Others: external fixation. Internal fixation needed if; first few days of injury and
patient requires laparotomy/later when gap cannot be closed by less radical
method
 AP III and VS: Reduction by skeletal traction combined with external fixator and
remain in bed for 10 weeks
 Immobilization: Anterior external fixation and posterior stabilization using
screws across sacroiliac joint, plating anteriorly and iliosacral screw fixation
posteriorly
Complication  Thromboembolism
 Sciatic nerve injury
 Urogenital problems – stricture, incontinence, impotence
 Persistent sacroiliac pain – unstable fracture will cause sacroiliac joint disruption
Vertical shear

FRACTURES OF THE ACETABULUM
Introduction  Anterior column: from symphysis pubis, along superior pubic rami, across
acetabulum to anterior part of ilium
 Posterior column: from ischium, across posterior aspect of acetabular socket
to sciatic notch and posterior part of innominate bone
Mechanism  When head of femur driven into pelvis
of injury  Direct blow on the side (fall from a height) or blow on the front of the knee
(dashboard injury – femur may be fractured)
Clinical  Patient maybe severely shocked
features  Bruising around the hip and limb may lie in internal rotation (if there is
dislocation)
Pattern of Column # Transverse # Complex #
fracture • Anterior column • T type
• Posterior column • Both column fracture
Simple fracture involving T-type Both column fracture,

Transverse
either the anterior or the fracture resulting in a ‘floating’
fracture
posterior wall or column involving two acetabulum with no part
columns of the socket attached to
the ilium
X-ray findingIlioischial line:- Indicates fractures involving the
posterior column or fractures in the transverse group
Iliopectineal line:- Indicates anterior column
involvement or one of the transverse-type fractures
Shenton’s line
 Imaginary line drawn along the inferior
border of the superior pubic ramus and along
the inferomedial border of the neck of femur Standard AP view, Pelvic inlet view,
 Indicates fractured neck of femur Two 45 degree oblique view
Management  Emergency treatment
 Counteract shock and reduce dislocation with skeletal traction on distal
femur and definitive tx only when patient is fit enough for surgery
Non operative if: Operative
 Acetabular fracture with min  Patient with isolated posterior
displacement (<3mm) wall fracture or dislocation
 Does not involve roof of the acetabulum immediate OR is required
 The both-column fracture that retains the otherwise deferred for 4 to 5
ball and socket connection days
 Elderly
 Those contraindicated for surgery
Complication  Iliofemoral venous thrombosis  Avascular necrosis
 Sciatic nerve injury  Loss of joint movement and
 Hereterotopic bone formation secondary OA

INJURIES TO SACRUM AND COCCYX
Mechanism  A blow from behind or fall onto the “tail”
of action  Women affected more than men
Clinical  Bruise and tenderness in the coccyx area
features  Sensation may be lost on the distribution of sacral nerve
Management  Reduction → use rubber ring cushion when sitting ( if pain persist →
LA/excision of coccyx)
FRACTURE AROUND HIP AND FEMUR

FRACTURE OF FEMORAL NECK
Mechanism  Commonest side of fracture in elderly
of action  Elderly: simple fall
 Younger patient: fall from a height or blow sustained in an accident
 Athletes or military personnel: stress fracture
Clinical  History of fall followed by pain in the hip
features  Displaced – lie with limb laterally rotated and the leg looks shorter (but not
so obvious compared to intertrochanteric fracture)
Classification GARDEN classification (Must remember!)
I. Incomplete #, minimally displaced: valgus impacted
II. Complete #, non-displaced
III. Complete #, displaced <50%, capsule intact
IV. Complete #, displaced >50%
**the higher it goes, the poorer the prognosis
X-ray finding  Alligment: vagus or varus deformity or not
 Bone- look for shenter line
 If loss indicated displacement
 Cartilage- look for increase joint space between femur and acetabular
 Displacement- look at femoral head
 III- look at tribicular line between acetabulum and ilium- NOT parallel
 IV- look at tribicular line between acetabulum and ilium- PARALLEL
(complete fracture, rotate to back completely, back to normal position)
Management  Pain relieve > splinting > operative treatment

 Reduction under GA and internal fixation
 Prosthetic replacement
Undisplaced Displaced (type III & IV)
 Canullated o Younger:
screw fixation CMR under anaesthesia  success  canullated screw
If reduction not possible  mc murray osteotomy or
canullated screw
o Older (>60 years old)
Immediate prosthetic hip replacement
If hip normal, no co-morbid, no OA  partial hip
replacement
If hip with pre-existing OA  total hip replacement
Complication  Avascular necrosis
 Non union
 OA- joint stiffness

INTERTROCHANTERIC FRACTURE
Introduction  Extracapsular fracture between greater trochanter and lesser trochanter
 Simple low-energy fall fracture
 Commonly seen in elderly female patients
Etiology 1. Increased bone fragility of the intertrochanteric area of femur (osteoporosis)
2. Decreased agility & decreased muscle tone in area secondary to aging
Clinical History of fall followed by
features  Pain
 Swelling (more obvious compared to neck of femur fracture)
 loss of function (unable to stand)
 ± obvious deformity (shortening of limb, external rotation)
X-ray of  Fracture from greater to lesser trochanter (run diagonally)
femur  Comminuted & severely displaced
 Hardly see crack (not all)
Management 1. Analgesics- for pain
2. REDUCE: Reduced with skin traction under x-ray control
3. HOLD: Early internal fixation
 Young age (<60 years): dynamic hip screw
 Older age (>60 years): intramedullary nails with interlocking screws
 To obtain best possible position
 To get patient up and walking as soon as possible
4. EXERCISE: allowed to walk, partially weight bearing using crutches until # unite
(8-12w)
**Treatment without surgery- as heal well (unite faster than fracture neck of femur)
Complication Failure of fixation
 Screws cut out the osteoporotic bone if reduction is poor or fixation
incorrectly positioned
 Need to redo reduction and fixation
Malunion
 Due to displacement
 Varus & external rotation deformities
 Seldom severe & rarely interfere with function
Older age group  bedridden problem while fracture united

**AVN- practically NO!

Differentiate neck of femur and intertrochanteric fracture
NECK OF FEMUR FRACTURE INTERTROCHANTERIC FRACTURE
Maximum 2 cm below mid inguinal point At ASIS
tenderness
Clinical  Swelling not obvious  Swelling more obvious
features  Bleeding less  Bleeding more
 Deformity not obvious  Deformity more obvious
 Not easily displaced  Easily displaced
 Shortening not obvious  Shortening more obvious
Braynt triangle  Shortening  Not sure
Complication  Avascular necrosis  No avascular necrosis
 Non-union  Mal-union
Prognosis Bad Better
Treatment Must do surgery- if not never united Can treat conservatively
(eg: can used skin traction but risk of mal-union)
SUBTROCHANTERIC FRACTURE
Introduction Extracapsular fracture
Etiology In elderly patients
 Minor slips or falls that lead to direct lateral hip trauma
 This age group is also susceptible to metastatic disease that can lead to
pathologic fractures
In younger patients
 high-energy trauma, either from direct lateral trauma (eg, [MVA]) or from
axial loading (eg, a fall from height)
Clinical History of fall or trauma followed by
features  Excruciatingly painful
 Markedly swollen
 Loss of function (unable to stand)
 Obvious deformity (shortening of limb, external rotation)
X-ray of  Fracture below or through lesser trochanter
femur  Comminuted fracture
Management 1. REDUCE: open reduction
2. HOLD: internal fixation
• Young: Compression (dynamic) hip screw and plate
• Elderly: Intramedullary nails with locking screws into femoral head
3. EXERCISE: partially weight bearing using crutches until # unite
**non weight bearing- foot never, never, ever touch the floor
Complication  Malunion
• Varus & external rotation deformities
• If marked- need operative correction

SUBTROCHANTERIC FRACTURE
Etiology In elderly patients
 Even after low energy fall
In younger patients
 High-energy trauma
 Twisting or a blow to the front of the flexed knee in motor vehicle accident
Clinical History of fall or trauma followed by
features  Excruciatingly painful
 Markedly swollen
 Loss of function (unable to stand)
 Obvious deformity (shortening of limb, external rotation)
 Severe blood loss (up to 1500 mL )  Look for signs of shock (LOC, pallor,
tachycardia, cold and clammy skin, hypotension)
Deformity Femoral shaft well padded with muscles
seen 1. Protect the bone from powerful forces
2. Fracture severely displaced by muscle pulled (reduction difficult)
3. Well-vascularized muscles
▫ Profunda femoris artery- If injured may lead to severe blood loss
X-ray of  Comminuted fracture
femur  Also do x-ray of pelvis and knee
*rule of fracture: x-ray involved joint above and below the fracture site (principle of fracture x-ray)
Management 1. REDUCE
 early stabilization
 transport using limb splints
2. HOLD
 Traction & bracing
 Open reduction & plating
 Intramedullary nailing
 External fixation
3. EXERCISE
Complication Immediate Early Late
 General  Femoral artery injury  Delayed union
complication of  Sciatic nerve injury (should unite in
trauma  Infection (in open fracture 100days ± 20days)
• Shock or following internal  Non union
• Fat embolism fixation)  Malunion
• Acute respiratory  Long bed rest/traction  Joint stiffness
distress syndrome • Thromboembolism
(ARDS) • Bed sore
SHOCK DAFIC JOM

CONDYLAR FRACTURE SUPRACONDYLAR FRACTURE
Fracture at the condyle of femur (may Fracture just above the condyles
fracture only one or both of femoral (may branch off distally between condyles)
condyles)
YOUNG ADULTS: High energy trauma; ELDERLY: Osteoporotic individuals
Clinical Features
 History following a fall or trauma  History following a fall or trauma
 Clinical features of fracture  Clinical features of fracture
• Swollen knee • Movement too painful to be attempted
• Loss of function (unable to stand) • Markedly swollen (but just above knee)
• Doughy feel of haemarthrosis • Loss of function (unable to stand)
• Obvious deformity (gastrocnemius tilt distal
fragment backward)
• Never missed to palpate tibial pulse!
• Unusual & tense swelling of popliteal area
(nerve and vessel damage)
• Sign of pallor/Lack of pulse
Investigation (X-ray)
 One condylar fracture and shifted  Fracture just above the femoral condyles
upward  Transverse or comminuted fracture
 Condyles split apart  Distal fragment tilted backward
 Present supracondylar fracture  Xray must included entire femur
 Never miss proximal # or dislocated hip
Treatment
 Undisplaced Fracture Undisplaced
• Aspiration of joint to remove blood 1. Knee flex for slightly displaced and extra-articular
• Traction for at least 4 weeks until 2. Skeletal traction through proximal tibia (Thomas’
fracture sufficiently united to be splint) to encourage movement
safe in the cast 3. Vertical traction
4. After 4-6weeks (# begin to unite) replace traction
 Displaced Fracture with cast-brace
• Open reduction & internal fixation 5. Allow partial weight bearing with crutches
• One condyle involved : fixed onto If closed reduction failed
femur with screws 1. Open reduction & internal fixation with an angle
• Both condyles : treated as compression device
supracondylar fracture 2. After 12 weeks (# consilated) unprotected weight
bearing may allowed
Locked intramedullary nails
 introduced retrograde through intercondylar notch
 provide adequate stability (even in presence of
osteoporotic bone)
Complication
 Knee stiffness  Knee stiffness
 Osteoarthritis  Non-union
 Osteoarthiris

Review
Traction  Rarely used now unless surgery is contraindicated
 Adequate longitudinal traction needed for the first 24H to overcome muscle spasm and
shortening
 Check radiograph twice/wk for the first 2 weeks & weekly thereafter
 Indication
1. Fracture in children
2. Contraindication for anaesthesia
3. Lack of suitable skill or facilities for internal fixation
Open reduction Fixation with plate and screws but very high complication rate
& plating Main indication
1. Combination of shaft and femoral neck fracture
2. Shaft fracture with vascular injury
Not in long bone- plate and screw (preferred intermedullary nails)

1. Prevent hematoma formation
2. High risk of infection
Intramedullary Provides longitudinal stability, alignment & enable patient to be mobilized early- Advent of
nail locking nails (screws inserted through the bone & nail) to allow rotation
External Fixation  Indication
1. Used for contaminated fracture (severe open #)
2. Emergency situation with multiple injuries (to reduce operating time)
3. Severe bone loss by technique of bone transport
4. Femoral # in adolescents
HIP DISLOCATION
POSTERIOR DISLOCATION* ANTERIOR DISLOCATION CENTRAL DISLOCATION
Mechanism of Injury
 Common in MVA • Extreme abduction with  Common in
• Someone seated in a car external hip rotation • Fall on the side
• Thrown forward • Anterior hip capsule can be • Blow over the greater
• The knee strikes the torn or avulsed trochanter
dashboard • Femoral head is levered out • Force directed along
 What happens anteriorly the length of femur
• Femur thrust upwards  What happens
• Femoral head is forced • Greater trochanter
against the socket may force the femoral
head medially through
Often, a piece of bone at the back the floor of
of acetabulum is sheared off – acetabulum
making a fracture-dislocation  Although it is called
central dislocation, it is
Terkangkang tapi tak keluar Terkangkang, terkeluar really a # of acetabulum
Clinical Features
 Shortened associated leg  Externally rotated  Depends on nature &
 Internally rotated  Flexed hip extent of penetration
 Flexed hip  Abducted hip into pelvis
 Adducted hip  Shortened associated leg
Physical Examination  Can be abducted /
 Pain to palpation and adducted
attempted motion of hip  Can be internally /
 Possible neurological externally rotated
impairment
• Sciatic nerve injury
(do straight leg rising
test- pain shooting down
to toes)

• Nerve damage by bone
fragments
• Feber test (Positive in
posterior-iliac joint
dysfunction)
Thompson and Epstein CT SCAN
Classification Most helpful after hip reduction
Reveals:
 Non-displaced fractures
 Congruity of reduction
 Intra-articular fragments
 Size of bony fragments
Management
• Must be reduced under GA • Almost identical to posterior
(flexed the hip & knee to 90 dislocation except that while
degree and pull thigh the flexed thigh is being
vertically upwards) pulled upwards, it should be
• X-ray to confirm reduction adducted
& to exclude fracture • Apply lateral traction to the
• CT if suspected bone thigh
fragments trapped in the
joints
• Apply traction for 3 weeks
• Movement & exercise
begun as soon as pain allow
Complication
Early Late
 Sciatic nerve injury  Avascular necrosis (10%)
 Vascular injury (superior gluteal artery)  Unreduced dislocation
 Associated fracture of femoral shaft  Myositis Ossificans
 Osteoarthritis

SLIPPED FEMORAL EPIPHYSIS
• An unusual disorder of the adolescent hip Salter-Harris fracture – fracture that
• Also called as Slipped Capital Femoral Epiphysis involves epiphyseal plate of bone
(SCFE) or Slipped Upper Femoral Epiphysis (SUFE)
• Occurs when the ball of upper end of femur slips
off in a backward direction
• Often results from Salter-Harris Type 1 physeal
fracture
• Can also be due to the weakness of the growth
plate
• Most often, it develops during periods of
accelerated growth, shortly after onset of puberty
Risk Factors
Mechanical Inflammatory conditions Others
 Local trauma  Neglected septic  Growth hormone deficiency
 Obesity arthritis  Vitamin D deficiency
 Hypopituitarism
 Hypothyroidism
Clinical Features
 Complaint of discomfort in hip, medial thigh or knee (referred) during walking
 Aggravated pain by running, jumping or pivoting activities
 Increase suspicion if the patient is obese
 If patient complains of knee pain, always examine the hip as well
 Determine patient’s ability to bear weight
 Decreased and painful internal rotation
Acute Acute on chronic Chronic
 Severe pain – the child  Pain, limping and  Mild symptoms – child able to
unable to stand or altered gait occurring walk with altered gait
ambulate several months  Hip motion – Reduced internal
 Alterations in gait –  Then can suddenly rotation & additional external
limping, external rotation become painful rotation
of gait  Mild to moderate shortening of
 Limited movements of hip affected leg
Diagnosis
 Do anteroposterior and (frog leg) lateral X-ray of the leg
• Determine the amount of head displacement off the
femoral neck as percentage (33%, 33%-50%, >50%)
• Note any bony changes in femoral neck and head
• In AP radiograph, draw Klein line to look for
Trethowan’s sign-In lateral view, draw straight line
through centre of femoral neck
~“BOW TIE”~
 CT scan & MRI are not routinely performed – but can
accurately measure the degree of displacement &
epiphyseal perfusion
Management
Goal of treatment:
 Prevent any additional slipping until growth plate closes
 Give immediate treatment (24 – 48 hours)

How?
 Internal fixation using a single cannulated screw
 Grade III slippage may require gentle repositioning to improve alignment
 Children, revision of screw fixation is advisable – they can ‘outgrows’ the screw, causing a risk for
a repeat slip
 Corrective osteotomy may be needed in severe deformities after patient has stopped growing
Complications
Chondrolysis Avascular Necrosis
 Degeneration of articular cartilage  Occur at the epiphysis
 Major complication  Blood supply to femoral head has permanently
 Can cause the hip to be stiffen altered due to the slipping
TB OF HIP
Introduction • May start as a synovitis/osteomyelitis in one bones
• Once arthritis develops, destruction is rapid and may result in pathological
dislocation
• Healing usually leaves a fibrous ankylosis with considerable limb shortening and
deformity
Clinical ▫ Aching in the groin and thigh
features ▫ Slight limp
▫ The joint is held slightly flexed and abducted
▫ Extremes of movement are restricted and painful
▫ If arthritis supervenes, the hip becomes flexed, adducted and medially
rotated,muscle wasting becomes obvious
X-ray  Early: general rarefaction but with a normal joint space and line; the femoral
epiphysis may be enlarged or a bone abscess visible; with arthritis
 There is destruction of the acetabular roof (wandering acetabulum) or the
femoral head
 The joint may be subluxed or even dislocated or both
 With healing the bones re-calcify
Management  Antituberculous drugs are essential
 Skin traction
 Abduction frame ;in children
 Arthrodesis
 Total joint replacement
Outcome  If properly treated, may heal leaving a normal or almost normal hip
 Once the articular surface is destroyed the usual result is an unsound fibrous
joint

OA OF HIP
Pathology • The articular cartilage becomes soft and fibrillated
• The underlying bone shows cyst formation and sclerosis
Causes
Clinical ▫ Pain is felt in the groin but may radiate to the knee
features ▫ Typically it occurs after periods of activity but later it is constant
▫ Stiffness at first is noticed chiefly after rest;
▫ Limp is often noticed
▫ The affected leg usually lies in external rotation and adduction, so it appears
short; there is nearly always some fixed flexion
X-ray  Early: decreased joint space, usually maximal in the superior weightbearing
region but sometimes affecting the entire joint
 Late: subarticular sclerosis, cyst formation and osteophytes
Management  Analgesics and anti-inflammatory drugs may be helpful, and warmth is soothing
 Operative treatment(indication)
 Intertrochanteric realignment osteotomy
 Arthrodesis(artificial induction of joint ossification between two bones via
surgery)
PYOGENIC ARTHRITIS OF THE HIP

Pathology  Usually seen in children under 2 years of age
 The organism (usually a staphylococcus) reaches the joint either directly from a
distant focus or by local spread from osteomyelitis of the femur
 Femoral head is liable to be destroyed by the proteolytic enzymes of bacteria
and pus
 Adults, also, may develop pyogenic hip infection
 As a primary event in states of debilitation
• Secondary to invasive procedures around the hip (more often)
Clinical ▫ Child is ill (fever) and in pain
features ▫ But it is often difficult to tell exactly where the pain is (may be almost
asymptomatic)
▫ The affected limb may be held absolutely still and all attempts at moving the hip
are resisted
Investigation  The diagnosis is confirmed by aspirating pus or fluid from the joint and
submitting it for laboratory examination and bacteriological culture
 X-rays  show soft-tissue swelling, displacement of the femoral head and a
vacuum sign in the joint
 Ultrasonography  joint effusion
Management  Intravenous antibiotics
 joint is aspirated under general anaesthesia
 if pus is withdrawn, anterior arthrotomy is performed
 the wound is closed without drainage
 Systemic antibiotics (oral & IV) are essential
 hip is kept on traction or splinted in abduction
Complication Head and neck of the femur may be destroyed resulting pathological dislocation

HIP BURSITIS
Bursitis and Tendinitis around the hip Bursae
 Trochanteric bursitis Small fluid-filled sacs that reduce friction
 Gluteus medius tendinitis between moving parts in your body's joints
 Adductor longus strain or tendinitis
 Iliopsoas bursitis
 Snapping hip
Trochanteric Bursitis Gluteus Medius Tendinitis Adductor Longus Strain or Tendinitis Iliopsoas Bursitis Snapping Hip
Clinical features Clinical features Clinical features Clinical features Clinical features
 Pain over the lateral aspect of the  Pain and localized tenderness just  Pain in the groin and tenderness  Sharp increase in Pain on  Complains of the hip ‘jumping out
hip and thigh behind the greater trochanter can be to the adductor longus adduction and internal rotation of of place, or ‘catching’, during
 Sometimes crepitus on flexing and  Particularly in dancers and origin close to the pubis the hip in the groin and anterior walking
extending the hip athletes  Swelling below this site may thigh  Usually occur in a young woman
 Swelling is unusual but post- signify an adductor longus tear  May be guarding of the muscles  Usually painless but it can be quite
traumatic bleeding can produce a Treatment  Due to overuse injury overlying the lesser trochanter distressing, especially if the hip
bursal haematoma 1. Rest  Often seen in footballers and  Hip movements are sometimes gives way
 Due to local trauma or overuse, 2. Injection of local anaesthetic and athletes restricted
resulting in inflammation of the corticosteroid  Condition may arise from synovitis Causes
trochanteric bursa which lies deep Treatment of the hip since there is often a  Thickened band in the gluteus
to the tensor fasciae latae 1. Acute strain  rest and heat potential communication between maximus aponeurosis flipping
2. Chronic strains  prolonged the bursa and the joint over the greater trochanter
X-rays findings physiotherapy  Swing phase of walking: band
 Evidence of a previous fracture, or moves anteriorly
a protruding metal implant or  Stance phase: the gluteus
trochanteric wires dating from maximus contracts and pulls the
some former operation hip into extension, the band flips
 May also be calcification or back across the trochanter,
shadows suggesting swelling of causing an audible ‘snap’
the soft tissues
Investigations
Treatment  Contrast arthrography
1. Rest  Arthroscopy
2. Administration of non-steroidal
anti-inflammatory drugs and Treatment
(provided infection is excluded) 1. Usually unnecessary but needs an
injection of local anaesthetic and explanation and reassurance
corticosteroid 2. If discomfort; band can be either
3. If a haematoma is present it divided or lengthened by a Z-
should be aspirated plasty

PERTHES’ DISEASE (EMQ!)
Introduction  Painful disorder of childhood characterized by avascular necrosis of the
femoral head
 Uncommon, and boys:girls are 4:1
 Slightly retarded growth of the trunk and limbs
Etiology  Trauma (in half of the cases)  effusion  capsular tamponade
 Non-specific synovitis
Pathology Stage 1: Ischaemia and bone death
Stage 2: Revascularization and repair
Stage 3: Distortion and remodelling
Clinical  Typically a boy of 4–8 years
features  Complains of pain and starts limping
 Symptoms continue for weeks on end or may recur intermittently
 Appears to be well, though often somewhat undersized
 Associated urogenital anomaly
 Hip looks deceptively normal, though there may be a little wasting
 Early: joint is irritable so that all movements are diminished & extremes painful
 Later: most movements are full; but abduction (especially in flexion) is nearly
always limited and usually internal rotation also
X-ray of  Early: widening of the ‘joint space’ and slight of the femoral head
femur  Later: increased asymmetry of the ossific centres
 Radionuclide scanning: shows ‘void’ in the anterolateral part density of the
ossific nucleus due to the new bone formation
 Lateral view: crescentic subarticular fracture
If not heal: femoral head becomes mushroom-shaped, larger than normal and
laterally displaced in a dysplastic acetabular socket
Management  Analgesia and modification of activities are often sufficient
 Hospitalization for bed rest and short periods of traction are necessary
 Movement (cycling and swimming) is encouraged after 3 weeks
 Clinical and radiographic features are then reassessed
 Bone age is determined from x-rays of the wrist
Symptomatic treatment Containment Operative reconstruction
• Gentle exercise to Prevent displaced during healing and • Can improved containment
maintain movement remodelling period and early mobilization
and regular a) By holding the hips widely • Femoral head is much
reassessment abducted, in plaster or in a better ‘contained’
• Avoid strenuous removable brace (ambulation,
activities though awkward, is just possible,
but the position must be
maintained for at least a year)
b) By operation, either a varus
osteotomy of the femur or an
innominate osteotomy of the
pelvis, or both
Osgoodschltter disease
Small child active in sport presented with sudden knee pain after patella ligament avulsion. He heard a snapping
sound. Lump at tibial tuberosity after vigorous exercise

CERVICAL SPINE INJURIES
Mechanism of Description & examples
injury X-ray of spines
1.FLEXION  Injuries cause compression #
 E.g Osteoporotic lady fall down, got compression #
(Compression  But if more than 50% compression, height will reduce (UNSTABLE)
Wedge)
2. FLEXION +  Involve bilateral & unilateral facets

ROTATION  Flexion injury
 Subluxation of dislocated vertebral more than half AP diameter of
(Dislocation) vertebral body below it
 Most severe injury- BECAUSE extremely unstable with high incidence of
spinal cord injury
3. FLEXION +  Unstable
AXIAL  Lateral view:- Anterior-inferior C6 vertebral corner ‘teardrop’ # fragment
COMPRESSION  Facet joint of C6/C7 is widened- compare with level above
(Teardrop #)

4. FLEXION +
DISTRACTION
(Seatbelt/
Chance #)
5. WHISPLASH
INJURY
(Soft tissue
injury)
*hyprextension +
flexion
*get hit from
behind
6. AXIAL
COMPRESSION
(Burst #)

7. EXTENSION #  Involves the pars interarticularis of C2 on both sides, and is a result of
hyperextension and distraction
(Hangman,
Cervical 2 #)
8. AVULSION
(Clay Shoveler)
9. JEFFERSON ▫ Compression and/or bursting fracture of C1

FRACTURE ▫ Unstable fracture secondary to axial compression load
o Fall or strike on head
(#C1) o Neurologic injury is rare but can occur if there is involvement of C2
o Axial load on C1 lateral masses- cause them to be compressed
against the superior articular facets of C2
o

EXAMINATION OF SPINE
CAUSES of back pain: Arthritis, PID, muscular injuries, sciatica, spondylolisthesis, osteoporosis
LOOK
1. Aids & adaptions- walking stick/wheelchair
2. Gait- smoothness, speed, symmetry, turning, antalgic, Trendelenburg
From behind
1. Scars
2. Wasting/prominent of muscle- paraspinal, trapezius, gluteal, hamstrings, calf muscles
3. Symmetry of each side (any scoliosis- lateral curvature of spine [S shape])
4. Abnormal hair growth- spinal bifida (hair tuft)
5. Pelvic tilt
From side
1. Cervical lordosis- hyperlordosis (spondylolisthesis, osteoporosis, discitis)
2. Thoracic kyphosis- hyperkyphosis [>45°] (vertebral #, scheuermann’s kyphosis)
3. Lumbar lordosis- hyperlordosis (obesity, tight lower back muscles)
4. Gibbus- acute angulation of spine in Pott’s disease
From front
1. Posture of head and neck- torticollis
2. Symmetrical of shoulder
FEEL- Temperature, Tenderness, Muscle spasm, Swelling, Spinal level
1. Along entire length of spine
2. Each spinous process- most prominent spinal process T1
3. Sacroiliac joints
4. Paraspinal muscles
*because difficult to observe patient’s face, ask regularly for discomfort and pain
MOVE (performed actively- what restrict the movement? pain/stiffness/muscle spasm)
For cervical movement

1. Lateral flexion: ask patient to place ear on shoulder
2. Rotation: ask patient to look over shoulder
3. Flexion: ask patient to put chin on chest
4. Extension: ask patient to put head back to look at ceiling
For thoracic movement

1. Right and Left rotation: ask patient to turn to each side
For these movement need to fix the pelvis by
1.Patient sitting at the edge of back with arm crossed across chest or
2.Examiner hold pelvis down
For lumbar movement

1. Flexion and Extension: ask patient to touch toes with legs straight & lean backwards as far as possible
2. Lateral flexion (left & Right): ask patient to run hand down to the outside of leg, keeping legs straight
SPECIAL TEST
1. Straight leg raise test (± sciatic stretch test): to assess nerve entrapment such as sciatica, PID
2. Schober’s test: to test range of motion in lumbar spine, may reduced in ankylosing spondylitis
3. Femoral nerve stretch test
NEUROLOGICAL EXAMINATION (Upper limb- cervical, Lower limb- lumbar)
VASCULAR EXAMINATION
*examine oral cavity, ear, nose, throat- as infection can cause spasmodic torticollis

NEUROLOGICAL EXAMINATION
UPPER LIMB LOWER LIMB
Inspection Muscle wasting, fasciculation, deformity
Tone Shoulder, elbow, wrist, hand joints Leg- by rolling leg on bed
Knee- by pulling it up
Ankle clonus- by turning leg outwards, moving ankle
joint a few times to relax it, then sharply dorsiflex it.
further movement of joint suggest clonus
Power Shoulder: abduction & adduction Hip: flexion, extension, abduction, adduction
Elbow: flexion & extension Knee: flexion, extension
Wrist: flexion & extension Plantar: dorsiflexion, plantarflexion
Fingers: flexion, extension, abduction Toes: flexion, extension
Thumb: abduction & adduction
Reflexes Biceps reflex Knee reflex (patella reflex)
*patient -rest patient’s arm, flexed at 60°, place -rest patient’s leg, flex knee at 60°, hit patella tendon
clench teeth thumb over biceps tendon, hit thumb Ankle jerk
to Triceps reflex -rest patient’s leg by laterally rotated their hip on bed,
exaggerate -rest patient’s arm across their chest, hit pull foot into dorsiflexion, hit calcaneal tendon
reflexes triceps tendon just proximal to elbow Plantar reflex
Supinator reflex -stroking up the lateral aspect of plantar surface.
-rest patient’s arm on their abdomen, Abnormal reflex with great toe extending
place 3 fingers on supinator tendon as it
crosses radius, hit fingers
Sensation Light touch- test following dermatomes
Pin prick- test following dermatomes
Vibration- along bony prominence: once feel vibration stop!
Propriception
Function Touch their head with both hands Walking: observe gait and abnormalities
Pick up a small object (coin) with hands Romberg test: stand with feet apart, close eyes,
Coordination Finger-nose test, dysdiadochokinesia observe for swaying (suggest posterior column
Drifting test: Arm straight, close eyes pathology)
GAIT EXAMINATION
Shuffling gait
High stepping gait
Antalgic gait
Heel walking
Toes walking

DIABETIC FOOT ULCERS
Definition: Infection, ulceration or destruction of deep tissues associated with neurological
abnormalities & peripheral vascular disease
Epidemiology: Lifetime risk DM developing DFU is 15-50% (annual incidence 3-10%)
Pathophysiology Diabetic Foot Ulcer (DFU)- major causes underlying DFU

Peripheral 1. Autonomic neuropathy
neuropathy -Function: regulate sweating & perfusion of limb
-Loss autonomic control  inhibit thermoregulatory function & sweating
 produce dry, scaly, stiff skin  prone to cracking  portal of bacteria entry
2. Sensation neuropathy
-If involve large fiber: loss in light touch & proprioception
-If involve small fiber: loss in pain & temperature
-Loss of above modalities  loss of protective sensation (damaging stimuli or
trauma perceived less well or not at all)  ulceration
-Start distally to proximally in ‘stocking’ distribution
3. Motor neuropathy
-Instrinsic muscle wasting  abnormal walking pattern or abnormal loading of
plantar aspect of foot or equinal contracture (condition in which ankle dorsiflexion
is restricted)
-Claw toes  pressure ulcers in interdigitally or on the dorsal and plantar side of
toes
Peripheral Ischemic problems 30x more prevalent in DM
arterial Diabetics get arthrosclerosis obliterans or ‘lead pipe arteries’ due to calcification of
diseases tunica media
± Infection Most common pathogen
-Aerobic gram positive cocci- mainly Staphylococcus species
Co-pathogen infection
-Aerobic gram negative in chronic infection or follow antibiotic treatment
-Oblique anaerobes in ischemia or necrotic wounds
Immuno- -Hyperglycemia → lessen the phagocytic activity of WBC → immunity↓
compromised -Hyperglycemia → glucose (thicken the endothelial wall) + fructose (↑sorbitol in
blood → vasoconstriction)
Common DFU infection:

Pseudomonas –alkali
So to treat: admit wad &
plan for wound
debridement under spinal
anesthesia (clean using
acidic solution)

FOOT AT RISK evaluation!! References: Malaysia DM CPG 4th ed
Risk factors for diabetic foot ulcers
1. Previous history of amputation (50% risk of another amputation within 2-3years)
2. Previous history of ulceration
3. Peripheral neuropathy
4. Peripheral vascular disease
5. Foot deformity
6. Visual impairment
7. Diabetic nephropathy (especially dialysis patient)
8. Poor glycaemic control
9. Cigarette smoking
PATIENT’S RESPONSIBILITIES
Daily foot examination (by close relatives if patient unable to do it)
What to look for- any abnormality, consult doctor
1. Early ulceration, Trauma to foot, Callosities
2. Colour changes, swelling, breaks in skin, pain, numbness
Patient education
1. Daily feet examination (especially those with reduced feet sensation)
2. Footwear- wear flat, soft, well-fitted shoes to avoid callosities, ensure no foreign objects in
shoes before putting feet in, have one pair of shoes for indoor use, never walk barefoot
3. Moisturising areas of dry skin
4. Hygience (daily washing & careful drying of feet)
5. Nail cutting to avoid paronychia (nail fold infection) or claw toes
6. Dangers associated practices (eg: skin removal including corn removal)
DOCTOR’S RESPONSIBILITIES
Noted patient which has foot at risk- examine feet at least once a year
Assess neuropathy with 10g monofilament + on other modality
*Loss of protective sensation (LOPS) considered if ≥1 tests abnormal
1. 10g monofilament
2. Other modality
i. Pin prick test
ii. Vibration test using 128Hz turning fork
iii. Ankle reflexes
iv. Vibration perception threshold test using biothesiometer
Assess vasculopathy by asking symptoms of claudication + examination of distal pulses (DPA/PTA)
AIM: identify those who required intensive education on self care to avoid ulcers and amputation
Classify foot risk (reference from NICE guideline)

Low current risk Normal sensation, palpable pulses
Mx: TCA yearly. Improve knowledge, encourage self-care, minimize inadvertent
self-harm
Increased risk Neuropathy or absent pulses or present of other risk factors
Mx: TCA 3-6monthly for feet inspection, vascular assessment, evaluates
footwear, enhance foot care education
At high risk Neuropathy or absent pulse with deformity or skin changes or previous ulcer
Mx: TCA 1-3monthly for feet inspection, vascular assessment, evaluate
footwear, intensified foot care education, specialist footwear & insoles, skin &
nail care
Ulcerated risk Need more intensive care

APPROACH TO DFU
Differential (may take one of these following forms- So history & examination RULE OUT THESE!)
1. DFU Wet gangrene (no blood supply + bacterial infection), no pain
(neuropathic ulcer)
2. Arterial ulcer Punch out ulcer, very pain, Parasthesia, Pulselessness, Pale, Perishingly cold,
(ischemic ulcer) at tips of toes, dry gangrene (no blood supply)
3. Venous ulcer Slopping ulcer, Associated with varicose vein, Inverted Champaign leg,
Hyperpigmentation
4. Malignant ulcer Cauliflower – like appearance, long duration h/o, bleed a lot on touch (high
vascularity)  undermined edge
5. Cellulitis Tender, non-raising skin lesion
No ulcer or wound exudates
6. Deep skin & soft Acute ill with painful soft tissues extremity
tissues infections Usually no wound discharge- if present foul smelling
7. Osteomyelitis Pain at the involved bone
Usually no fever & regional lympadenopathy
Later signs: Local redness, swelling, warmth & oedema
(indicate present of foul smelling pus)
8. Necrotizing Aggressive, life-threatening fascia infection
Fasciitis Occurs in Immunocompromised patients
Often diabetic, alcoholics or intravenous drug abusers
History & Examination

Diabetic 1. Duration of DM, medication (insulin/OA), follow up
history 2. Control of DM, glucose level, other complication of DM
Ulcer 1. Size, Shape, Location, pus/discharge, foul smelling, necrotic patches
evaluation 2. Can used TIME as guided
3. Had dressing been done before? How often? Where? Progression ulcer?
4. History of ulcer, trauma, insect bite, self prick
Other 1. Limited range of motion due to? (pain, swelling, weakness, stiffness)
symptoms 2. Features of infection: Fever, erythema, increased discharge
3. Orthopaedic: ulceration, deformity, swelling, contracture, skin discolouration,
gait problem
3. Neuropathy- numbness
4. Vasculopathy- calf claudication
Other history 1. Check fit for surgery or not (any other co-morbidities)
2. Condition that effect wound healing (anemia?)
Examination 1. Examination of wound or ulcer
2. Test foot sensation using 10g monofilament or other test (Pin prick test,
Vibration test, Ankle reflexes, Vibration perception threshold test, ABKI)
3. Palpation of distal pulses
4. Inspect of any foot deformity and footwear
5. Examination to confirm & assess patient’s complaint (eg: swelling, pain,
weakness)

Investigation
Blood glucose Check blood glucose level and control
Do VBG & HbA1c
X-ray of foot 1. Lead pipe arteries
2. Bony destruction (charcot or osteomyelitis)
3. Calcification of soft tissues swelling
4. Gas (air shadow- repitus
5. Foreign body
Charcot foot acute localized inflammatory condition that may

lead to varying degrees and patterns of bone + joint destruction,
swelling, subluxation, dislocation, and deformity of foot (loss of
function)
Tissue/Pus swab For culture and sensitivity
FBC Check for TWBC- indicate infection leukocytosis
Other blood test RP, Fasting lipid profile
Arterial droppler To check the blood flow (to detect peripheral arterial problem)
CT scan To visualize bony anatomy for abscess and extend of disease
MRI scan Role in uncertain cases of osteomyelitis- suspect deep abscess
*these not usually done in practical setting

10g Semmes-Weinstein Monofilament Ankle Brachial Pressure Index (ABPI)
Purpose: Purpose:
Steps: Steps:
1. Show 10g monofilament to the patient- touch 1. Apply cuff above ankle
to patient forehead or sternum so that 2. Using Doppler, find DPA or PTA
sensation is understood 3. Start inflated cuff until sound disappear
2. Instruct patient to say ‘yes’ every time 4. Deflate the cuff until sound reappear- take the
monofilament stimulus is perceived systolic reading
3. Patient’s both eye closed, apply
monofilament at 90° with enough pressure to
bend filament for 1.5 seconds
4. Do at 10 locations on each foot
Result: (systolic in leg ÷ systolic in arm)

1.0-1.2 Normal range
0.9-1.0 Acceptable range
<0.9 Peripheral arterial diseases (PAD)
Result:

Screening for DFU
1. Foot examination (inspection, monofilament)
2. ABPI
3. Arterial Doppler
Principles of mx
1. IV antibiotic
2. Cleaning and wound dressing
3. Glycemic control
4. Patient education
Management of DFU
Affective management of DFU: Indication for amputation: If infection emergency surgery!
1. Proper control of DM and foot 1) Uncontrolled infection Mx- give GIK regime
care or sepsis
2. Correction of metabolic 2) Inability to obtain Glucose Prevent
abnormalities plantar grade, dry foot hypoglycaemia
3. Appropriate antibiotic therapy that can tolerate Insulin Prevent
 Empirical antibiotic  weight bearing (Short hyperglycaemia
ampicillin-sulbactam 3) Non-ambulatory acting) (RASH)
(unasyn) patient Potassium Prevent cardiac
 Broad spectrum  arrest
gentamycin
4. Appropriate wound care If not give GIK bfore surgery, pt will
5. Debridement and resection of LOC d/t DM ketoacidosis
dead tissues (arthrotomy)
6. Surgical drainage
7. Amputation when indicated

Classification of ulcer
1. Wagner’s classification
-Only accounts for wound depth and appearance
-Does not consider the presence of ischemia or infection
Types Management
0 Skin intact (impending ulcer)  Foot at risk Shoes modification, counseling on foot care
1 Superficial ulcer Wound dressing + antibiotic
2 Deep ulcer deep to tendon, ligament and Dressing and wound debridement +
bone antibiotic
3 Osteomyelitis Dressing and surgical wound debridement +
antibiotic
4 Gangrene of toes or fore foot Ray amputation
5 Extensive gangrene (entire foot) Below knee amputation
2. Texas classification
-Addresses ulcer depth
-Also includes the presence of infection and ischemia
Stage Grade O Grade I Grade II Grade III

Pre or post operation Superficial wound not Wound Wound penetrating
lesion completely involving tendon, penetrating to to bone or joint
epithelialized capsule, bone tendon, capsule
A No infection or ischemia
B Infection Infection Infection Infection
C Ischemia Ischemia Ischemia Ischemia
D Infection & ischemia Infection & ischemia Infection & Infection &
ischemia ischemia
Amputation Removal part of body through the bone; Disarticulation Removal at joint level

NECROTISING FASCIITIS
Introduction  Aggressive, life-threatening fascial infection
 Occurs in immunocompromised patients (DM, alcoholic, IVDU)
 Polymicrobial infection involving:
o Falcutative aerobes
o Streptococcal sp or E. coli
o anaerobes
 Exotoxins produce severe systemic toxicity
Clinical  Often presents similar to cellulitis
features  Warning features include
Severe pain - out of proportion to the clinical signs
Severe systemic toxicity
Cutaneous gangrene
Hemorrhagic fluid leaking from a wound
 Untreated it progresses to multiple organ failure
 Overall has about a 30% mortality
 X-ray may show gas in the subcutaneous tissue
Management  Requires high clinical suspicion and early diagnosis
 Patients should be managed in high dependency unit
 Need fluid resuscitation and organ support
 Early aggressive surgical debridement is essential
 Amputation or fasciotomies may be required
 Antibiotic cover should include metronidazole and gentamycin
 Hyperbaric oxygen therapy may be of benefit

HAND INFECTIONS
Index
1. Human bites
2. Felons
3. Paronychia
4. Chronic paronychia
5. Tenosynovitis
HUMAN BITES
 The wound that results from a punch to the mouth may appear insignificant initially
 Often results in immediate inoculation of the subcutaneous tissue, the subtendinous space
and the MCP joint with saliva
 Human saliva may contain over 108 microorganisms per ml.
 Over 42 species of bacteria identified
 Thus polymicrobial infection occurs
 Common organisms: S. Aureus, Strep sp, Eikenella
 Tx:
 Debride, irrigate, pack open
 Antibiotics
 +/- admission to follow response
 Surgery: Established joint space penetration, & more severe infections
FELONS
Introduction  Distal phalanx is a closed sac separate from the remainder of the digit
o Closed pulp space divided into a latticework by multiple septa
o Interstices filled with eccrine glands & fat
o Dorsum is rigid (bound by Dorsal Plate & perionychium)
 An increase in pressure of this compartment can adversely affect the blood
supply to the soft tissue & bone
Clinical  Palmar closed-space infection of the distal pulp
features  Severe pain, redness & swelling
 Hx of minor penetrating trauma is usually present:
 Minor cuts
 Splinters
 Glass slivers
 Most frequent causative agent: S. Aureus
 Untreated felons can:
 Extend toward the phalanx  osteomyelitis
 Toward the skin  draining sinus
 Obliterate vessels  skin slough or necrosis
 Suppurative flexor tenosynovitis or septic arthritis of the dipj
Management  If recognized early (mild cellulitis): Antibiotics
 Late (abscess formation): Surgical drainage
 Principles:
 Avoid injury to n/v structures
 Utilize an incision that won’t leave a disabling scar
 Do not violate flexor sheath (stay distal)
 Produce adequate drainage
 Incise on lateral aspect of digit 5mm dorsal & distal
to the DIP flexion crease

PARONYCHIA
Introduction  Infection in and around the nail fold
 Any break in the seal between the nail and nail fold may serve as a portal of
entry for infection
o manicures
o nail biting
 Usual causative agent: S. Aureus
 In more advanced infections, pus may accumulate beneath the nail plate,
separating it from the underlying nail bed
Management  If recognized early (mild cellulitis): Antibiotics

 Larger infections: drainage through the nail fold
 Remove 1/4 of nail
 If this doesn’t allow drainage, incise fold away from matrix
CHRONIC PARONYCHIA
 Marked by exacerbations & remissions
 Etiology: proximal nail fold obstruction + fungal infection
 Often seen in people whose hands are constantly in a moist environment
 Usual causative agent: fungus, gram negative bacteria
 Treatment: topical antifungal + surgery

TENOSYNOVISTIS
Anatomy
 Flexor sheaths are closed spaces

 Extend from the mid-palmar crease to the DIPJ
 Flexor sheath of small finger is continuous proximally with the Ulnar
Bursa, while the sheath of the thumb is continuous with the Radial Bursa
Introduction  Flexor sheath infections most often as a result of penetrating trauma
o More likely at joint flexion creases
o Sheaths are separated from skin by only a small amount of
subcutaneous tissue here
 Also, Felons can rupture into the distal flexor sheath
 Usual causative agent: S. Aureus
 Most commonly affected digits: Ring, middle & index fingers
Clinical Kanavel’s 4 cardinal signs:

features  Tenderness over & limited to the flexor sheath
 Symmetrical enlargement of the digit (“fusiform”)
 Severe pain on passive extension of the finger (> proximally)
 Flexed posture of the involved digit
Most reliable sign: pain w. passive extension
Management -Early infection < 48 hrs (& usually lacking all 4 signs) may initially be treated with
IV Abx, splinting & elevation
 Failure to respond within 24 hrs. Should necessitate drainage
-Established pyogenic tenosynovitis is a surgical emergency
 Requires prompt surgical drainage
 Delays may result in tendon &/or skin necrosis

BONE AND JOINT INFECTION
Index:
1. Acute haematogenous osteomyelitis
2. Subacute haematogenous osteomyelitis
3. Chronic haematogenous osteomyelitis
4. Acute Septic Arthritis (acute suppurative arthiris)
5. Tuberculous arthritis
6. TB of spine (Pott’s spine)
ACUTE HAEMATOGENOUS OSTEOMYELITIS (2-3weeks)

Risk factor • Children
• Recent trauma/surgery
• Immunocompromised
• IVDU
• Poor vascular supply
Follow surgical implants:- S. epidermidis is the commonest pathogen

Pathology • Metaphysis is commonest site of osteomyelitis because:
 It is highly vascular
 Has a hairpin-like capillary arrangement
 Has sluggish blood flow
 Has relatively fewer phagocytic cells than physis or diaphysis
 Thin cortex
Inflammation  Suppuration  Bone Necrosis  Reactive New Bone Formation 

Resolution and Healing
Clinical Infants Children (>4 years old) Adult
features • Fever *** • Severe pain, malaise and • History of urological
• Crying*** fever procedure followed by
• Metaphyseal tenderness • Refuses to move one fever and backache
(Pain near the joint)*** limb (thoracolumbar spine)
• History of birth • Recent history of • Local tenderness
difficulties infection • Other bone involvement
• Failure to thrive • Local redness, swelling,
• Resistance to joint warmth and edema
movement
Cardinal Signs
• Pain, Fever***
• Refusal to bear weight
• Elevated WBC count
• Elevated ESR
Investigation X-ray (>2WEEKS)
1) Faint extra-cortical outline due to periosteal new bone formation
2) Periosteal thickening becomes obvious
3) Patchy rarefaction of metaphysis
**Moth eating appearance
4) Ragged features of bone destruction
5) Late sign: combination of regional osteoporosis with localized segment of
apparently increased density
Ultrasonography -May detect Subperiosteal collection of fluid

C-reactive protein elevated within 12-24 hours

MRI-can differentiate btw soft-tissue infection & OM
 Confirm clinical diagnosis by aspirating pus/fluid from metaphyseal subperiosteal
abscess, the extraosseous soft tissues or an adjacent joint;
 Tissue aspiration positive 60% of cases
 Blood culture positive 50% of cases
Management Supportive treatment Antibiotics Drainage
• Pain management:  Flucloxacillin Indications:
Analgesics  Cefotaxime  Symptoms don’t
• Hydration: IV Fluid  IV administration for improve within 36
(fever and septicemia 2-4 weeks hours of treatment
can cause severe  Oral administration for  Signs of deep pus
dehydration) 3-6 weeks (swelling and edema)
• Splintage- for comfort
and to prevent joint Pus is aspirated under GA
contractures
Complication • Epiphyseal damage and altered bone growth
• Suppurative arthritis
• Metastatic infection
• Pathological fracture (uncommon but can occur if delayed treatment)
• Chronic osteomyeliti
SUBACUTE HEMATOGENOUS OSTEOMYELITIS (4-5weeks)

Introduction • Osteomyelitis may present in a relatively mild form, because:
 The organism is less virulent or
 The patient more resistant.
• The distal femur and the proximal and distal tibia are the favourite sites
• The patient is usually a child or adolescent who has had pain near one of the
large joints for several weeks
Investigation X-ray
 Small, oval cavity surrounded by sclerotic bone = classic brodie’s abscess
(differential diagnosis- osteoid oestroma = neiders abscess)
 Sometimes the lesion is more diffuse
A radio-isotope scan
 Will show increased activity
(a, b) The classic Brodie’s
abscess looks like a small walled-
off cavity in the bone with little or
no periosteal reaction
(c) Sometimes rarefaction is
more diffuse and there may be
cortical erosion and periosteal
reaction
(rarefraction = reduce density,
that’s why it looks black on x-rays)
Treatment  Treatment may be conservative if the diagnosis is not in doubt

 Immobilization
 Antibiotics (Flucloxacillin in combination with Fusidic Acid)
o Intravenously for 4 or 5 days
o Then orally for another 6 weeks
 If the x-ray shows that there is no healing after conservative treatment, open
curettage may be indicated

CHRONIC HAEMATOGENOUS OSTEOMYELITIS (>6 weeks)
Introduction  Dreaded sequel to acute haematogenous osteomyelitis
 follows an open fracture or operation in modern days
1) An area of bone has been destroyed by the acute infection
2) Cavity containing pus and pieces of dead tissues (Sequestra) surrounded
by dense sclerosed bone
3) Sequestra provoke a chronic seropurulent discharge
4) Discharge escapes through a sinus at the skin surface
5) Bacteria can remain dormant for years
6) Risk of recurrent acute flares & purulent discharges
Pathogen  The usual suspects are S. aureus, E. coli, S. pyogenes, Proteus and Pseudomonas
 Surgical implants, Staph. epidermidis are the commonest pathogen
Clinical  Recurred ‘Flare’ presented with
features o Discharging Sinus***
o Pain, pyrexia, redness & tenderness – sign of inflammation
 In longstanding cases:
o The tissues are thickened, puckered or folded inwards
o Scar or sinus adheres to the underlying bone
o Seropurulent discharge & excoriation - surrounding skin
 In post-traumatic osteomyelitis -bone deformed or un-united
Cierny-
Mader
classification
Investigation 1) X-ray Features

Sequestrum = dead tissues
i. Bone resorbption Involuctrum = new bone formation
ii. Sequestrum Cloaca = opening in involuctrum for
iii. Involuctrum pus & sequestrum to pass through
iv. Periosteol reaction- Sclerotic age
v. Pathological fracture
2) Sinogram - Help to localize the focus of active infection,
3) Bone Scans -revealing hidden foci of inflammatory activity
4) CT and MRI -extent of bone destruction

Chronic Osteomyelitis may follow
on acute. This young boy in (a)
Presented with draining sinuses at
the site of a previous acute
infection. The x-ray shows densely
sclerotic bone. (B) In adults, chronic
osteomyelitis is usually a sequel to
open trauma or operation
Management 1) Antibiotic treatment

 Fusidic Acid, Clindamycin & Cephalosporins
 Vancomycin & Teicoplanin -MRSA)
 Antibiotics are administered for 6 weeks
2) Colostomy paste
 Can be used to stop excoriation of the skin
3) Urgent incision and drainage,- acute abscess
4) Operation (indication for radical surgery)
 Chronic haematogenous infections (Intrusive symptoms, failure of
adequate antibiotic treatment, and/or clear evidence of a
sequestrum or dead bone)
5) Wound debridement
6) Dealing with the ‘dead space’
Porous antibiotic-impregnated beads, cancellous bone graft, muscle
flap transfer
7) Aftercare
Local trauma must be avoided and any recurrence of symptoms, -
investigated
Saucerization: Excavation of tissue to form a shallow depression,
performed in wound treatment to facilitate drainage from infected
areas
Management in short
o Chronic mainly surgical
o Antibiotics coverage
o Surgical sequestrectomy
 Wait till sufficient involucrum has formed before doing sequestrectomy
to minimize risk of fracture deformity & segmental loss (preferable time
3-6weeks)
 So sementara tuh boleh bagi gentabeads (gentamycin in beads form to
fill the dead space)
o Aftercare- avoid local trauma + antibiotics
Complication  Cancer- squamous cell carcinoma (sinus tract malignancy)
 Pyogenic arthritis/septic arthritis
 Pathological fracture
 Joint stiffness
 Amyloidosis

ACUTE SEPTIC ARTHRITIS = ACUTE SUPPURATIVE ARTHRITIS
Introduction • Septic arthritis is inflammation of a synovial membrane with purulent effusion
into the joint capsule, due to infection
• A joint can be infected due to (pathogenesis)
i. Direct penetration (wound, injection-IVDU, arthroscopy)
ii. Direct spread from adjacent bone abscess
iii. Blood spread from distant side
Causative • Causative agent is usually S. Aureus.
agents • In children between 1-4 years old, H. Influanzae is an important pathogen
• Occasionally other microbes, such as Streptococcus, E. Coli and Proteus, are
encountered
Predisposing • Rheumatoid arthritis, chronic debilitating disorders (eg: DM, HTN), IVDU,
condition immunosuppressive drug therapy & AIDS
Pathogenesis
If left untreated, it will spread to the underlying bone and out of joint to form
abscess and sinus
Healing with:
1. Complete resolution & return to normal
2. Partial loss of articular cartilage and fibrosis of joint
3. Loss of articular cartilage and bony ankylosis
4. Bony destruction and permanent deformity
Clinical Infants Children (>4 years old) Adult
features  More on septicaemia • Acute pain in single large • Often in the superficial
 rather than joint pain joint(especially hip) joint (knee, wrist or ankle
 Baby is irritable & • Pseudoparesis )
 refuse to feed • Child is ill, rapid pulse and • Joints painful, swollen &
 Tachycardia with swinging fever inflamed
fever • Overlying skin looks red & • Warmth and marked local
 Joints are warmth, superficial joint swelling tenderness & movement
 tenderness, • Local warmth & restricted
resistance tenderness • Look for gonococcal
 to movement • All movements are infection or drug abuse
 Umbilical cord and restricted by pain or spasm • Patient with rheumatoid
inflamed IV site • Look for source of arthritis and especially
infection from septic toe those on corticosteroid
or discharge ear (otitis may develop “silent” joint
media or injury site) infection (silent=no pain
as mask by steroids)

Physical • Lower limb  antalgic limp / cannot walk
examination • Upper limb  affected part is closedly guarded
• Marked tenderness, active and passive range of motion are limited
•Examine for synovial effusion, erythema, heat and tenderness
•Positive patellar tap- wajib buat + horse shoes shape swelling (due to patella)
•Spasm of muscles
•Patient may hold the joint in a position to reduce the intra-articular pressure to
minimize pain
Investigation 1. Ultrasonography
o More reliable in revealing a joint effusion in early cases
o Widening of space between capsule and bone of > 2mm indicates effusion
 Echo-free  transient synovitis
 Positively echogenic  septic arthritis
2. Blood investigations
3. Synovial fluid analysis (confirmatory test)
4. X ray
o Early Stage – Normal
 Look for soft tissue swelling, loss of tissue planes, widening of joint
space and slight subluxation due to fluid in joint
 Gas may be seen with E. coli infection
o Late stage – Narrowing and irregularity of joint space
 Plain film findings of superimposed osteomyelitis may develop
(periosteal reaction, bone destruction, sequestrum formation)
Narrowing of joint space

and irregularity of Joint space loss Subchondral erosions Osteonecrosis and
subchondral bone and sclerosis of the complete collapse of the
femoral head femoral head
5. MRI- may help diagnose septic arthritis in obscure sites such as sacroiliac and
sternoclavicular joint

Management Supportive treatment Antibiotics Surgical
 Analgesics  Treatment is  Surgical Drainage
 IV fluids started once the (arthrotomy)
blood and samples  Arthroscopic debridement
Splintage are obtained and copious irrigation
 The joint must be with normal saline
rested either on a
splint or in a widely
split plaster
 In neonates and
infants,-joint is held
abducted & 300
flexed, on traction to
prevent dislocation
Complication • Bone destruction and dislocation of the joint (especially Hip)
• Cartilage destruction - may lead to either fibrosis or bony ankylosis in adult
partial destruction of the joint will result in secondary osteoarthritis
• Growth disturbance - presenting as either localised deformity or shortening
of the bone
Differential 1) Acute osteomyelitis
diagnosis 2) Other infections (psoas abscess/local infection of pelvis)
3) Trauma
4) Irritable joint
5) Rheumatic fever (JONES criteria)
6) Juvenile rheumatoid arthritis
7) Gout and pseudogout
Summary for • It is emergency, OT ASAP!
acute septic • Common organism is S. Aureus
arthritis • In adults gonococcal infection is almost as common
• The joint is swollen, painful and inflamed, pseudoparalysis
• TWBC & ESR are elevated
• Aspiration reveals pus in the joint; fluid should be sent for bacteriological
investigation, including anaerobic culture
• Treatment – antibiotic & joint drainage by arthroscopy, begin movement after
inflammation subside, weightbearing is deferred for 4–6 weeks
Difference with OM
SA- at joint, OM- near the joint (metaphysis)

TUBERCULOUS ARTHRITIS
Introduction • Infection of the joints due to tuberculosis
• Generally, skeletal manifestations are seen in the spine and large joints, but
may happen anywhere
Predisposing • Diabetes
conditions • Prolonged corticosteroid therapy
• AIDS
Pathology • Mycobacterium tuberculosis enters body via lung or gut or rarely through skin
• It causes a granulomatous reaction with tissue necrosis and caseation
(Langerhans giant cell in histology)
Primary complex Secondary spread Tertiary lesion

 The initial lesion in  Widespread  Bones and joints are
lung, pharynx or gut dissemination via affected in about 5%
with lymphatic blood stream (miliary of patient with TB
spreads to regional tuberculosis)
lymph nodes  Occurs months or
years later
Clinical • Complains of pain and swelling (in a superficial joint)

features • Fever, night sweats, lethargy and loss of weight
• Regional lymph nodes maybe enlarged and tender
• Muscle wasting is characteristic and synovial thickening is often striking
• Movement are limited in all direction
• As articular erosion progresses, the joint becomes stiff and deformed
Investigation 1. X-ray
 Shows marked osteoporosis and soft tissue swelling
 The bone ends take on a ‘washed-out’ appearance and the articular space
is narrowed
 In children: enlarged epiphyses
 Erosion of the subarticular bone
 In the spine the characteristic appearance is one of bone erosion and
collapse around a diminished intervertebral disc space, the soft-tissue
shadows may define a paravertebral abscess

2. ESR usually raised
3. Positive Mantoux test
4. Synovial biopsy for histological examination and culture is often necessary
Management 1. REST
 Involved splintage of the joint and traction to overcome muscle spasm and
prevent collapse of the articular surfaces (no longer mandatory)
 Varied according to the need of the individual patient
2. CHEMOTHERAPY : combination of anti-tuberculous drugs (“PERI”)
 Should always include rifampicin and isoniazid.
3. OPERATION: cold abscesses need immediate aspiration or drainage
TB OF THE SPINE (POTT’S SPINE)

Introduction • The spine is the most common site of skeletal TB, accounting for 50% of all
musculoskeletal TB
• Also known as tuberculous spondylitis
• Rare in developed countries
• Common areas affected are, the lower thoracic and upper lumbar vertebrae
regions
Pathology 1) Secondary (lung/intestine/lymph node)
2) Spine *anterior part of vertebral body near intervertebral disc
3) Progressive bone destruction
4) Infection spreads across disc into adjacent
vertebral body
5) 2 vertebrae may collapse forward
6) Sharp angulation/gibbus
Clinical Very variable (from non-specific pain at the back to complete paraplegia)
features 1) Back pain
o Long history of ill health and backache
o Maybe diffuse localised
o Radicular pain
Cervical root: arm
Dorsal root: girdle pain
Dorso lumbar roots: abdominal pain
Lumbar roots: groin pain
Lumbo sacral roots: ‘sciatic’ pain
o Local tenderness in the back and spinal movements are restricted
2) Stiffness
o Early symptoms
o Due to protective mechanism of body (para-vertebral muscle go into spasm
to prevent movement of affected vertebrae)
3) Cold abscess
o May present 1st time as swelling
o Pointing in the groin/ with paraesthesia and weakness of the leg
4) Paraparesis
5) Deformity- gradual increasing prominence of the spine (GIBBUS) *late
6) Constitutional symptoms: Fever, Weight loss
Special 1) Mantoux test
investigation 2) ESR
3) No neurological signs- needle biopsy to confirm histological & microbiological ix
4) Sign of neurological involvements- operative debridement and decompression
of the spinal cord is required

Other 1. Imaging (X ray of the spine)
investigation  Entire spine should be x-rayed
 Look for early sign : local osteoporosis of two adjacent vertebrae and
narrowing of the invertebral disc space, with fuzziness of the end plates
 Late: bone destruction and collapse of adjacent vertebral bodies into each
other
 Paraspinal soft tissue shadows : sign of abscess or oedema
 Signs of healing: bone density increases, ragged appearance disappear and
paravertebral abscess may undergo resolution, fibrosis /calcifications
 MRI/CT Scan: any hidden lesions, paravertebral abscess, an epidural
abscess and cord compression
 Myelography
Management 1. Ambulant chemotherapy
• Early or limited disease with no abscess formation/neurological deficits
• Rifampicin 600mg daily + Isoniazide 300mg daily + Pyrazinamide 2g
daily for 6-12 months
2. Continuous bed rest and chemotherapy
3. Operative treatment:
Indication :
• Abscess than can be readily drained
• For advance diseased with marked bone destruction and threatened or
actual severe khyposis
• Neurological deficit (paraplegia) not responding to drug therapy
Complication 1. Vertebral collapse resulting in kyphosis
2. Pott's paraplegia
3. Psoas abscess

DEGENERATIVE CONDITION OF THE SPINE
INDEX:
1. Prolapse intervertebral disk (PID)
2. Lumbar spondylolysis
3. Spondylolithesis
4. Spinal stenosis
PROLAPSE INTERVERTEBRAL DISC (PID)

Etiology • Degeneration of intervertebral disc due to strenuous physical activity eg lifting
object
• Common, painful disorder of the spine, in which the annulous fibrosus ruptures
and part of its nucleus pulposus goes out (herniation)
• About 95% of disc prolapses occur in the lumbar, and some can occur in the
cervical spine too
• Commonly occur between L4, L5 and L5, S1
Dics herniation stages
Clinical Fit adult aged 25-40 yo (above 25, the nucleus becomes dehydrated, above 40, it
features becomes fibrous, so less likely to herniate)
History of severe back pain during lifting/stooping
Pain in buttock and lower limb (sciatica)
Paraesthesia and numbness in leg/foot
Muscle weakness
Cauda equina compression rare but may cause urinary retention and perineal
numbness
 Depends on site of herniation and degree of compression

 If it irritates the dural covering > pain
 If it compresses the spinal root > numbness > eventually muscle weakness
 Herniation in L4-L5 will compress L5 nerve root

Perlu 2 dari CF L4/L5 DISC PROLAPSE
untuk locate
• Pain along the posterior or posterolateral thigh with radiation to top of the
site of injury
foot
• Weakness of dorsiflexion of the great toe and foot
• Paraesthesia and numbness of top of foot and great toe
• No reflex changes noted (knee L4, ankle S1)
L5/S1 DISC PROLAPSE

• Pain along posterior thigh with
radiation to the heel
• Weakness on plantar flexion (may be
absent)
• Sensory loss in the lateral foot
• Absent ankle jerk reflex (ankle S1)
Physical Look
examination • Sciatic scoliosis (bend test: structural vs postural)
Both berdiri nampak S (abnormal)
Bila bongkok, postural akan disappear (normal), tp structural memang
nampak sengit (abnormal)
• Muscle wasting (seen in gluteal, calf)
Feel
• Tenderness in midline of the affected side (palpate along the spine,
paravertebral mscle, check for any deformity)
• Paravertebral spasm (bulging)
• Muscle weakness
• Diminished reflex
• Sensory loss
Move
• Decrease range of movement due to pain
• Sciatic nerve stretch test/straight leg raising test (+ve 20° -70°)
Femoral stretch test positive

• Irritation of higher nerve roots - L4 and above

Imaging Xrays:
 Narrow disc space and small osteophytes
 Hyperthrophy of facet joint
 Syndesmophyte seen
Myelography: to confirm
nerve root distortion
using iopamidol
(Niopam) but will cause
side effects
CT & MRI: best choice
Mx Rest
o In bed with hip & knee in slight flexion (so sciatic nerve is not stretched)
o NSAIDs
Reduction
o Pelvic traction (20kg) for 2 weeks
o Epidural injection of corticosteroid and LA
o Chemonucleolysis (chymopapain): to dissolve part of the disk & relieve
pain
Removal (laminectomy and discectomy):
o Indication:
 Cauda equina compression syndrome-
Triad signs: saddle anaesthesia (perineum area only), bladder
incontinence, back pain
 Neurological deterioration while in conservative treatment
 Persistent pain and sign of sciatic tension
o Laminectomy: procedure that removes part of a lamina of the vertebral
arch in order to decompress the corresponding spinal cord and/or spinal
nerve root
Rehabilitation
o Teach patient isometric exercises
4R- rest, reduction, removal, rehabilitation

LUMBAR SPONDYLOLYSIS
Introduction  Are defects that represents a stress fracture in the pars interarticularis
 Pars interarticularis is a narrow strip of bone located between the lamina and
inferior articular process below, and the pedicle and superior articular
process above
 It always between l4 and l5, or between l5 and the sacrum
 It can occur unilaterally or bilaterally
Spondylolysis- dissolution of, or a defect in, the pars interarticularis of a vertebra

Spondylolisthesis-anterior or posterior slipping or displacement of one vertebra
on another
Spondyloptosis-vertebra that is completely or essentially completely dislocated
• Congenital malformation, known as a pars defect, of the neural arch and the facet
joints (spinal bifida) in combination with degenerative changes
Pathophysiology The pars interarticularis is found in Spondylolysis occurs when there is a
the posterior portion of the vertebra fracture of the pars portion of the
vertebra
Spondylolysis is a defect in the pars interarticularis that may or may not be
accompanied by forward translation of one vertebra relative to another
(spondylolisthesis)

Causes 1. Genetics
 An individual may be born with thin vertebral bone and therefore
may be vulnerable to this condition.
 Significant periods of rapid growth may encourage slippage.
2. Overuse
 Sports-gymnastics, weight lifting, and football, athletes constantly
overstretch (hyperextend) the spine resulting is a stress fracture on
one or both sides of the vertebra.
Pain usually spreads across the lower back and may feel like a muscle strain
Clinical features  Most common cause of low back pain in the adolescent athlete
 Accounts for up to 47 % of the symptomatic back pain in this population
 the extension range of motion is often painful and stiff
 The pain brought on by having the patient stand on one leg, then being
guided into extension
Diagnosis Bone scintigraphy using SPECT to be the gold standard followed by a CT scan
1. X-ray (oblique view)
NORMAL L5 PARS DEFECT
The parts of the dog are as follows:

• the transverse process-the nose
• the pedicle-the eye
• the pars interarticularis-the neck
• the superior articular facet-the ear
• the inferior articular facet-the front leg
Oblique view of the lumbar spine,

the outline of a scottish dog can
be seen
 A break in the neck of the dog, corresponds to a fracture in the region of

the pars interarticularis, which is specific for spondylolysis.
 It is important to recognize as it is a cause of low back pain.
 Occasionally no fracture is seen, but presents as an elongated pars
interarticularis as a result of repeated stress on the bone, resultant
microfractures, bony healing, ultimately producing an elongation of the
bone

2. Bone scanning with SPECT (Axial, coronal or sagittal plane) *GOLD
STANDARD
 If one suspects a "stress reaction" to be occurring in the lumbar
spine, and x-rays show no pathology, the most accurate method of
assessment, for a symptomatic pars interarticularis, is bone scanning
with SPECT
3. CT (computed tomography)
 CT scans are able to distinguish between an acute or chronic
spondylolysis and the type of fracture, providing important
information with regards to making a treatment plan
4. MRI
Tx 2 types:
1. Nonsurgical Treatment
 Initial treatment for spondylolysis
 The individual should take a break from the activities (rest) until symptoms
go away, as they often do
 Anti-inflammatory medications, such as ibuprofen, may help reduce back
pain.
 Back brace and physical therapy may be recommended.
 Stretching and strengthening exercises for the back and abdominal muscles
can help prevent future recurrences of pain
2. Surgical Treatment
 May be needed if slippage progressively worsens or back pain not respond to
nonsurgical treatment and interfere with activities of daily living
 A spinal fusion is performed between the lumbar vertebra and the sacrum.
Sometimes, an internal brace of screws and rods is used to hold together the
vertebra as the fusion heals

SPONDYLOLITHESIS
Introduction • ‘Spondylolisthesis’ means forward translation of one segment of the spine
upon another
– Spondylo = Spine
– Listhesis = Slide down a slippery path
• The shift is nearly always between L4 and L5, or between L5 and the sacrum
• Normal discs, laminae and facets constitute a locking mechanism that prevents
each vertebra from moving forwards on the one below
• Forward shift (or slip) occurs only when this mechanism has failed.
Pathology Slippage → instability → anterior dislocation → spinal canal narrowing →
neurological deficit
History Children : Painless
• Carer will notice protruding abdomen & peculiar stance
Adolescence & adults :

• Backache (low back pain)
– Often intermittent
– Coming after exercise or strain
• Nerve compression symptoms (numbness, tingling, slowed reflexes, muscle
weakness in the legs)
Elderly :
• Backache (low back pain)
• Sciatica symptoms
• Sometimes claudication due to spinal stenosis
Physical exam
Look  Semi kyphotic posture
 Atrophy of gluteal muscle (buttock looks flat)
o Can lead to gait disturbances
Feel  High Myerding grade type can result in tenderness at lower back area
 Palpable step-off can be felt over the spinous process at the level above the
slipped vertebra
Move  Hamstring tightness can result in abnormal gait
 Patient unable to flex the hip with knees extended
 Bending forward, backward or sideways are restricted due to pain
Investigation X-ray
• Lateral views show the forward shift of the upper part of the spinal column
on the stable vertebra
• Elongation of the arch or defective facets can be seen
• **The gap in the pars interarticularis is best seen in the oblique views

CT SCAN:
• Better evaluation of bone pathology
MRI:
• Better evaluation of soft tissue pathology
– Nerve compression
– Spinal compression
– Disc eruption
Types Of Spondylolisthesis
TYPE 1 – DYSPLASTIC • The superior sacral facets are congenitally defective
SPONDYLOLISTHESIS (malformed)
• Slow but inexorable forward slip leads to severe
displacement
• Associated anomalies (usually spina bifida occulta) are
common
Type 2– ISTHMIC / SPONDYLOLYTIC • The commonest variety (50%)

SPONDYLOLISTHESI • Type of defect:
• Defect in pars interarticularis (micro fractures)
• Repeated breaking and healing leads to new bone
formation filling the gap
• Ends with stretched pars interarticularis and pars
elongation
• Common in those whose spines are subjected to
extraordinary stresses (competitive gymnasts, weight
lifters)
Type 3-DEGENERATIVE • Consequence of the general aging process in which the
SPONDYLOLISTHESIS lumbar facet joints degenerates
• Laminae is intact
• The alteration will allow forward or backward vertebral
displacement

Type 4-TRAUMATIC • Associated with acute fracture of posterior structures
SPONDYLOLISTHESIS (pedicle, lamina or facets)
Type 5-PATHOLOGIC • Occurs due to structural weakness of the bone 2° to a

SPONDYLOLISTHESIS disease process (osteoporosis, infection, tumour)
Type 6-POSTOPERATIVE • Occasionally, excessive operative removal of bone in

SPONDYLOLISTHESIS decompression operations
• Results in progressive spondylolisthesis
Management Conservative management
Back braces: limited spine movement
Analgesic: NSAIDs, steroid epidural injection
Physical therapy:
 Stabilization exercise
 To strengthen abdominal/ or back muscle, minimizing bony movement
spine
Surgical management
Indication:
o If the symptom is disabling and
interfere with daily activities
o If the slip is more than 50% and
progressing
o If neurological compression is
significant
Children
o Posterior transverse fusion in situ
almost always successful
o If neurological signs appear,
decompression can be carried out
later
Adult
o Decompressive laminectomy
o Remove part of bone pressing on nerve but can leave the spine unstable
o Spinal (anterior / posterior) fusion
o A piece of bone transplanted to back of spine to stabilize it

SPINAL STENOSIS
Introduct -spinal stenosis is used to describe abnormal narrowing of the central canal, the lateral
ion recesses or the intervertebral foramina to the point where the neural elements are
compromised.
-When this occurs, patient can develop neurological symptoms & signs in the LL
Etiology 1. Congenital vertebral dysplasia
2. Chronic disc protrusion & peri-discal fibrosis or ossification
3. Displacement & hypertrophy of facet joints
4. Osteoarthritis of facet joints
5. Hypertrophy, folding or ossification of ligamentum flavum
6. Bone thickening due to Paget’s disease
7. Spondylolisthesis
History • Usually elderly male
• Complains of aching, heaviness, numbness & paraesthesia in thighs and legs
• Comes on after standing upright / walking for 5-10 minutes
• Relieved by sitting, squatting or leaning against a wall to flex the spine
• Patient may refer walking uphill than downhill (spine is flex)
• Patient may have previous history of disc prolapse, chronic backache or spinal
operation
Physical  Ask patient to reproduce symptoms by walking
exam  Neurological deficit may present in the lower limbs
 Intact pedal pulses would confirm claudication as spinal rather than arterial
Ix • X-rays will usually show features of disc degeneration and proliferative osteoarthritis
or degenerative spondylolisthesis
• Measurement of the spinal canal can be carried out on plain films, but more reliable
information is obtained from myelography, CT and MRI
Q: How to measure any abnormal swelling or narrowing of spinal canal?
Two measurements are used:
1) Mid-saggital (anteroposterior)
2) Interpedicular (transverse)
Abnormal value:
1) Anteroposterior <11mm
2) Transverse <16mm
MRI:
• Thickening of the ligamentum flavum
• Facet joint hypertrophy and synovial cysts
• Vertebral endplate osteophytes and obliteration of perineural fat in the neural foramina
Mx Conservative
• Advice patient to avoid uncomfortable postures
Operative
• Done if the discomfort worsens or daily activities become restricted
• Perform large laminotomy with flavectomy, medial facetectomy and
discectomy
– At every relevant level, on every relevant side
– Can relieve the leg pain but not the back pain
• In patients under 60 the operation is sometimes combined with spinal fusion

OSTEOARTHRITIS
Pathogenesis 1. Increase in water content
2. Alteration in proteoglycan
3. Collagen abnormalities (in old age, reduced quality)
 Healthy cartilage years of stress and irritation  caused eburnation  crack
in the cartilage  subchondral bone exposed  irritate the synovium more
production of synovial fluid (swelling). Exposed subchondral bone irritated 
crack  synovial fluid enter  subchondral cyst
Classification Inflammatory Infective Degenerative
 Crystal deposit  Gonococcal
 Sero positive (RA, SLE)  Non-
 Sero negative (Spondyloarthropathies, gonococcal
ankylosing spndylitis, ulcerative collitis, (TB, fungal,
crohn's disease) bacteria)
Clinical 1) Destruction of cartilage
features  Pain at the affected joint
 Unlike cartilage that has no nerve supply, 2 bones that directly move against
each other will produce pain due to presence of nerve supply
2) Fragment/particle of cartilage
 Irritate the synovium causing it to produce more synovial fluid which
resulted in swelling
 Occur especially when walking
3) Thinning of cartilage
 Causes genu varus deformity
 As medial compartment is more commonly affected, weight of the patient
will be distributed more on lateral compartment as he tries to avoid pain
Examination Click and locking joint
 While pt is walking normally, suddenly pt cannot move & extend the knee
 It is relieved by jerking movement & wobbling of the leg
 Due to destruction of cartilage
Swelling
 DIPJ - Heberden's nodes. Form by osteophyte. Found in primary OA
 PIPJ - Bouchard's nodes. Rare
Fixed and flexion of knee

 Contracture of surrounding tissue
 Cause muscle strain
 Knee is usually relax in slightly flex and externally rotated
Range of movement
 Cannot flex wrist actively - problem in muscle tendon, neve (sensation reduced)
 Can flex wrist passively - no joint problem
 Cannot flex wrist actively & passively - joint problem

Special test
Patella tap
 Milking down fluid from suprapatellar pouch
 Press the patellar by using 2-3 fingers
 Patella felt to be hit the femur and bouncing back
 False negative: very much less fluid
 If there is fixed flexion of knee/no patella, cannot perform patella tap
Test for medial meniscus (Mc Murray’s test)

 Fully flex the knee & hip
 Externally rotated
 Apply valgus stress at the knee
 Slowly extend knee (positive when there is pain or clicking sensation)
Investigation X-ray
1. Reduce/narrowing joint space - thinning of cartilage
2. Osteophyte - unequal distribution of pressure causes bone to grow at the side to
accommodate the stress
3. Subchondral sclerosis - reactive bone formation
4. Subchondral cyst - cartilage not intact bone crack  synovial fluid leak
through the crack and collected in the bone  subchondral cyst
Synovial analysis

Differential
1) Ankylosing spondylitis
diagnosis  Age of onset: 20 - 25 y/o
 Back stiffness at axial skeleton, not relieved by exercise
 X-ray : Bamboo spine (joint, ligament become fused)
2) Rheumatoid arthritis
 Autoimmune condition that attack synovial membrane
 Synovium irritation -> proliferating synovium -> constatnt swelling -> Press
on capsule -> pain
 Palpation: Fluid + doughy consistency (synovium)
 X-ray: juxta-articular punch out lesion of subchondral bone
 Deformity: swan neck, boutonniere deformity
3) Gout
 Accumulation of uric acid in blood causing crystal deposition
 Middle age male
 Joint stiffness/pain especially in big toe or MCP joint after eating seafood
(severe pain, swelling, redness, sometimes febrile)
 Tophi: deposition of uric acid
crystal in soft tissue (can be like
punch out lesion in x-ray but in
juxta-articular)
 Acute attack: Colchicine (usually
give continuously until the pain
relieved)
 Prophylaxis: Allopurinol
Management Conservative (relieve pain)
 Non pharmacological
o Lifestyle modification
 Reduce weight
 Non weight bearing exercise (isometric, 1st thing to do in
pain stage)
 Swimming, cycling
 Should avoid climbing stairs
 Change toilet sit (squat -> sitting)
 Pharmacological
o Non selective
 NSAIDS
 Avoid in old age (if want to use, must + PPI)
 Mefenemic acid, voltaren
o Selective
 Celecoxib
o Glucosamine supplement
o Intraarticular injection of hyaluronic acid compund
2) Operative
 Therapeutic arthroscopy (make nano #)
 Realignment osteotomy
 Knee arthroplasty
 Joint debridement (remove FB, osteophyte, cartilage fragment)
 Fusion of knee

Comparison and Summary of Types of Arthritis
Disease Location Examination Presentation Epidemiology & Investigations Treatment
Aetiology
OA Hands, Hips, Knees 1. Pain on joint movement Gradual onset (years) Age related 1. X-ray Conservative-
2. Reduced ROM Gradual ↑ in intensity -Unusual <60y -joint space narrowing 1. Non pharmaco
-Polyarthritis 3. ‘Squaring of the hand’ – Gradual ↓ in function -sclerosis of bone margins Lifestyle modification, reduce weight,
-Monoarthritis deformity of the CMC joint Can be 2ndary to joint damage -cyst formation exercise
-Oligoarthritis of the thumb -e.g. trauma, RA -osteophyte formation 2. Pharmacology
Pain relief (PCM  NSAIDs +/- PPI)
↑ incidence in Glucosamine with chondroitin sulphate
-sportsmen Steroid IV
-women Hyaluronic acid compound
-trauma case Surgery
1. Arthroscopy + joint debridement
2. Knee arthroplasty
3. Realigment osteotomy
Rheumatoid Hands (most apparent), 1. Deformities Very variable Can be any age 1. Rheumatoid factor Steroids – can be used to induce remission in acute
Arthritis shoulders, feet, -subluxation -Acutely overnight or -commonly 30-50 -only in 50% cases disease. Sometimes given long-term, low dose.
sometime knees -swan neck deformity -Gradually: weeks or
(hyperextension of PIP joints. months Gender 2. Anti-CCP DMARD’s – disease modifying anti-rheumatid drugs
-polyarthritis compensatory flexion of DIP -2x as common in women -more specific e.g. methotrexate, sulfasalazine, hydrochlorequine –
Symmetrical, bilateral joints) Often the first signs in reduce irreversible joint damage. Most require
-z-thumb (hyperextension of the feet (walking on Genetic factors involved 3. Blood tests regular blood monitoring.
the interphalangeal joint, marbles) -HLA-DL1 &4 -show anaemia
fixed flexion and subluxation (Associated with worse prognosis) -↑ ESR and CRP Anti-TNF-α – highly effective, given IV, reduced
of the metacarpophalangeal Joint stiffness on disease progression, and improves symptoms. VERY
joint) morning >30 minutes ↑ incident in *Diagnosis usually clinical, EXPENSIVE – NICE only recommends it to be used
-Smoking imaging not widely used when DMARD’s have failed
2. Nodules common on the -Stress
forearm (pressure points) -Infection
3. Signs steroid used

Gout Hands, feet Acute – episodes last up to 7 days. Hot, red, tender, Age related 1. Aspiratie joint Acute – use NSAID’s (ibuprofen) to relieve acute
swollen joint -urate acid levels ↑ with age -rule out infection attack, then start on allopurinol
-Monoarthritis -check for crystals (needle
Chronic – presents with gouty tophi Gender shaped, negatively Chronic – allopurinol is the treatment of choice
-10x common in men birefringent)
Most common site for gout 2. Serum urate *Dont give allopurinol in an acute attack! – it can
1. Pinna of ear (sebab sejuk- uric senang buat crystal) Genetic factor involve -raised in 60% (not make it worse! Allopurinol will not relieve an acute
2. Metatarsal pharangeal joint on big toes -Some genetically inherited (X- diagnostic) attack
3. Olecranon busae linked) 3. Inflammatory markers
4. Arcillis tendon -Most have a genetic component ↑
4. X-ray
Upper limit of uricemia Associated with -punched out erosions
• 0.42mmol/L -high diet in purines (meat) -flecked calcifications
-alcohol
Description of acute attack gout -thiazide diuretics (↑ risk)
-red,shinning skin, joint hot and tender + swelling -anything that ↑ level of purines or
urates in the blood
Description of chronic gout (e.g. high rate of cell death –
-polyarthicular gout, joint erossion causing stiffness and deformity joint, chemotherapy)
present of gouty tophi, renal calculi

Psedogout Knee, hands, elbows, 1. Hot, red, tender, swollen joint Acute – hot, Increase with age 1. Aspiratie joint -rule out NSAID’s not as useful as gout, but may still be
shoulder, tarsal joints red, tender infection beneficial for some
swollen joints Often accompany OA -check for crystals
-Monoarthritis (rhomboid, positively Intra-articular steroid injections, or oral steroids are
Chronic – can Phosphate metabolism disorders birefringent) usually the first line
resemble RA or
OA. Often No real ‘allopurinol’ equivalent
interspersed
with acute
episodes
Systemic Systemic multi-organ Hands & arms Any age Antibodies
sceloris involvement CREST SYNDROME -often 30-50 years old 1. Positive anti
(lung & oesophagus) centrimear antibodies
with hand signs Gender 2. Positive anti topo
-4x common in women isomerase 1 antibodies
Genetic factors involve
**come with SOB- pulmonary fibrosis (due to calcium

deposition)  pulmonary HTN (loud P2)
SLE Systemic 1. Hand signs similar to RA – but the Often lots of Any age 1. ANA’s – present in 90% DMARD’s and steroids used in a similar way to RA.
Photosensitive skin deformities will reduce under non-specific -often 25-35 years old & of cases but non-specific Treat organ and nerological involvements specifically
rashes (over face) pressure and function is usually not symptoms – 50-60 years old 2. Anti-dsDNA – present and individually
+ organ involvement affected low-grade fever, in 60% of cases and
(kidney) 2. Look for rash on face, arms, chest tiredness, Gender specific
and shoulders general malaise. -10x common in women 3. Blood test
May also have -anaemia
SOAP MD BRAIN multi-organ Genetic factors involve -leukopenia
involvement. -thrombocytopaenia
Mouth ulcers, ↑ incidence with -↑ESR and CRP
hair loss, -Smoking
Reynaud’s, -Stress
depression
*IF joint is hot, red, tender and swollen – then always aspirate it! – it is joint sepsis, until proven otherwise

METABOLIC BONE DISEASE
INDEX:
1. Osteomalacia: osteoid insufficiency mineralized
(Ricket- children)
2. Osteoporosis: bone mass is abnormally low
3. Secondary osteoporosis
4. Osteitis fibrosa: PTH over-production leads to bone resorption and replacement by fibrous
tissues
5. Paget’s disease
*Diagram is an important basics need to know

RICKETS OSTEOMALACIA
Additional effects on physeal growth and Osteoid throughout the skeleton is incompletely
ossification, resulting in deformities of the calcified and the bone is therefore soften
endochondral skeleton
Causes
• Metabolic pathway of vitamin D • Decreased 25-hydroxylation(liver disease,
• Nutritional lack anticonvulsant)
• Underexposure to sunlight • Reduced 1a-hydroxylase (renal disease,
• Intestinal malabsorption nephrectomy
• Hypophosphataemia • Calcium deficiency
Pathology
1) Inadequate provisional calcification and 1) Newly formed osteoid matrix is inadequately
failure of cartilage to mature and mineralized
disintegrate 2) Excess of persistent osteoid
2) Overgrowth of epiphyseal cartilage 3) Bone is weak and vulnerable to gross
3) Distorted, irregular masses of cartilage fractures and microfractures
4) Deposition of osteoid matrix on 4) Commonly affecting vertebral bodies and
inadequately mineralized cartilaginous femoral necks
remnants 5) Deranged bone remodeling
5) Disruption of orderly replacement of 6) Osteomalacia
cartilage by osteoid matrix
6) Stress on inadequately mineralized, weak,
poorly formed bone and microfractures
7) Abnormal overgrowth of capillaries and
fibroblasts
8) Deformation of skeleton due to loss of
structural rigidity of developing bones
9) Rickets
Clinical features
• Children (Rickets) • Adults (Osteomalacia)
• Failure to thrive, muscular flaccidity • History of bone pain, backache, muscle
• Deformity of skull (craniotabes) weakness
• Thickening of knees, ankles and wrists from • Vertebral collapse causes loss of height
physeal overgrowth • Existing deformities (mild kyphosis or knock
• Enlargement of costochondral junctions knees) may increase later in life
(rickety rosary) • Unexplained pain in hip or long bone is a
• Lateral indentation of chest (Harrison’s warning sign of stress fracture
sulcus)
• Tetany and convulsion (due to hypocalcemia)

Investigation
X-ray: Rickets (children) X-ray: Osteomalacia (adult)
▫ Thickening and widening of growth plate ▫ Looser zone (thin transverse band of
▫ Cupping of metaphysis rarefaction in normal-looking bone) due to
▫ Bowing of diaphysis incomplete stress fractures which heal with
▫ Signs of secondary hyperparathyroidism callus lacking in calcium
(sub-periosteal erosions at sites of ▫ Biconcave vertebra (disc pressure due to slow
maximal remodelling) fading of skeletal structure)
(medial borders of proximal humerus, ▫ Lateral indention of acetabula (trefoil pelvis)
femoral neck, distal femur) ▫ Spontaneous fractures of ribs, pubic rami,
femoral neck or metaphyses above and below
the knee
Indentation of the
acetabula producing the
trefoil or champagne
glass pelvic
a) Widening of metaphyses, cupping, and fraying in Looser’s zone (arrow) in

the distal ends of the radius and ulna the pubic rami and left
b) Cupping and fraying at distal end of the femur femoral neck
and proximal tibia - suggestive of rickets
Biconcave vertebrae
Other Investigations
• Biochemistry
▫ Diminished levels of serum calcium, phosphate
▫ Increase alkaline phosphatase
▫ Diminished urinanry exrection of calcium
▫ Calcium phosphate product (multiply calcium and phosphorus levels in mmol/L) <2.4
• Bone biopsy
▫ For less typical cases
Treatment
• For nutritional lack of vitamin D: vitamin D (400-1000 IU per day) and calcium supplements for
• For intestinal malabsorption: vitamin D (50 000 IU per day)
• Osteotomy may be required to correct deformity

OSTEOPOROSIS
• Characterized by an abnormally low bone mass and defects in bone structure
• Cancellous region are more porous
• Cortices thinner than normal
• Existing bone is fully mineralized
• Bone resorption > bone formation
X-rays and bone densitometry
Characteristic finding of osteoporosis on x- rays are:
- Osteopaenia (bone appearing less dense than normal in x-ray)
- Loss of trabecular definition
- Thinning of the cortices
- Insufficency fractures
- Compression fractures on vertebral bodies
- Biconcave distortion of vertebral end plates
Other investigations
Assessment of Bone Mineral Density (BMD)
1. Radiographic Absorptiometry
2. Single energy X- ray Absorptiometry
3. Dual Energy X-ray Absorptiometry (used now)
Types
Primary Secondary
 Post menopausal osteoporosis  Nutritional
 Age-related osteoporosis  Inflammatory disorder
Postmenopausal osteoporosis Senile osteoporosis (type II)  Drug induced
(type I)  Bone loss due to increased  Endocrine disorder
Estrogen deficiency causes: bone turnover  Malignant disease
 increases proliferation and  Malabsorption
activation of osteoclasts  Mineral and vitamin
 prolongs survival of deficiency
osteoclasts  Affect bone trabecular and
 Affects trabecular bone cortical bones.
Risk factor for postmenopausal osteoporosis
• Family history of osteoporosis • Early hysterectomy
• History of aneroxia nervosa and • Nutritional insufficiency
amenorrhea • Chronic lack of exercise
• Early onset of menopause • Cigarrete smoking
• Unusually slim or emaciated build • Alcohol abuse
• Oophorectomy

Clinical features
• Back pain and increase thoracic kyphosis – noticed height had diminished
• Low energy fracture of the distal radius (colles’), hip or ankle
• Xrays – wedging or compression of one or more vertebral bodies
• DXA- significantly reduced bone density in the vertebral bodies or femoral neck
Prevention and treatment
• Bone densitometry used to identify women who are at more than usual risk.
• Routine DXA-reserved for women with multiple risk factors and particularly those with
suspected estrogen deficiency (premature or surgically induced menopause)
• Women approaching menopause –advised to maintain adequate levels of dietary calcium and
vitamin D
• Advised;
 Keep up high level of physical activity
 Avoid smoking
 Avoid excessive alcohol
Hormone replacement therapy Biphosphonates
 Effective to maintain bone density.  Preferred medication for postmeanopausal
 However increased risk of osteoporosis
thromboembolism, breast cancer,  Reduce osteoclastic bone resorption and the
uterine cancer general rate of bone turnover
 Prevent bone loss and reduce risk of fracture of
vertebral and hip
 Alendronate- orally once weekly for both
prevention and treatment

SECONDARY OSTEOPOROSIS
Nutritional Endocrine disorder Malignant disease
• Malabsorotion • Gonadal insufficiency • Leukemia
• Malnutrition • Hyperparathyroidism • Multiple myeloma
• Scurvy • Thyrotoxicosis
• Cushing’s disease Other
Drug induced • Smoking
• Corticosteroid Inflammatory disorders • Pulmonary disease
• Excessive alcohol • Rheumatoid disease • Osteogenesis
• Anticonvulsant • Ankylosing spondylitis imperfecta
• Heparin • Tuberculosis • Chronic renal disease
• Immunosupressive
Hypercortisonism
• Glucocorticoid overload – d/t cushing’s disease or prolonged use of corticosteroid
• It suppress the osteoblast function, reduced calcium absorption, increase calcium excretion
• Treatment:
1. minimum dose of corticosteroid
2. Calcium supplement
3. Vitamin D supplement
4. Bisphosphonate in postmenopausal and elderly men
5. Treat the fracture if present
Hyperthyroidism
• Thyroxine speeds up the rate of bone turnover, but the resoption exceeds the formation.
• Treatment: treat both hyperthyroid and the osteoporosis
Multiple myeloma
• Generalized osteoporosis, anaemia and high ESR are characteristic of myelomatosis and
metastatic bone disease
• Bone loss- overproduction of local osteoclast-activating factors.
• treatment: bisphosphonate to reduce risk of fracture
Hyperparathyroidism Hypoparathyroidism
 Primary-adenoma or hyperplasia • Endocrine disorder characterized by absent or
 Secondary-persistent hypocalcaemia inappropriately low levels of parathyroid
 Tertiary-when secondary hyperplasia hormone (PTH), hypocalcemia and
leads to autonomous over activity hyperphosphatemia
Causes
• Thyroidectomy, parathyroidectomy or radical
neck dissection leading to deficient PTH
• Inability of parathyroid gland to produce PTH
• Inability of the kidneys and bones to respond to
PTH being produced by normal parathyroid gland
Hypoparathyroidism results in
• Decreased mobilization of calcium from bone
• Decreased reabsorption of calcium by kidney
tubule cells
• Decreased absorption of calcium by the
gastrointestinal tract
• Increased reabsorption of phosphate by kidney
tubule cells

Clinical features
Hypercalcaemia Hypercalciuria Neuromuscular Cardiac symptoms
• Anorexia • Polyuria symptoms • Prolonged QT interval
• Nausea • Kidney stones • Muscle cramping, • Heart failure
• Abdominal pain • Nephrocalcinosis twitching, tetany,
• Depression spasm
• Fatigue Bone disease • Numbness/ tingling
• Muscle  Generalized of mouth area and
weakness osteoporosis extremities
• Seizure
Investigation
X-ray Biochemical tests
• Typical features: osteoporosis & areas of • hypocalcaemia
cortical erosion • hyperphosphataemia
• Classical and almost pathognomonic • Undetectable serum iPTH confirms the diagnosis
feature: sub-periosteal cortical
resorption of the middle phalanges
• Non-specific features: renal calculi,
nephrocalcinosis, chondrocalcinosis
Biochemical test
• hypercalcaemia, hypophosphataemia
and a raised serum PTH concentration
• Serum alkaline phosphatase is raised
Treatment
• Mainstay of treatment is a combination of oral calcium with vitamin D
• To correct the hypocalcemia
Conservative
• Adequate hydration
• Decreased calcium intake
Parathyroidectomy
Indications:
• Marked & unremitting hypercalcaemia
• Recurrent renal calculi
• Progressive nephrocalcinosis
• Severe osteoporosis
• Postoperatively: danger of severe hypocalcaemia due to brisk formation of new bone

• Treated promptly with fast-acting vitamin D metabolites

PAGET’S DISEASE
 Characterized by enlargement and thickening of the bone,
but the internal architecture is abnormal and the bone is unusually brittle
 The cause is unknown and uncommon in Asian
Pathology
 Cortices are thickened but irregular, at one stage more porous than usual and at another more
sclerotic
 This is due to alternating phases of rapid bone resorption and formation
 While resorption predominates, the bone is easily deformed
 In the late stage, the bone becomes increasingly sclerotic and brittle
 The characteristic cellular change is a marked increase in osteoclastic and osteoblastic activity
Clinical features
 Affects men and women equally
 The disease may localize to a single bone many years
 Commonest sites: pelvis & tibia
 Most people are asymptomatic
 Diagnosed on incidental finding of x-ray or raised in serum alkaline phosphatase level
 Pain: dull and constant

 Deformities
 Mainly in the lower limbs. The limb looks bent and feels thick, and the skin is unduly warm
 The skull may enlarges
 There may also be considerable kyphosis, so the patient becomes shorter and ape-like with
bent legs and arms
 Nerve compression
 Cranial nerve compression: impaired vision, facial palsy, trigeminal neuralgia or deafness.
Vertebral thickening may cause spinal cord or nerve root compression

Investigations
X-ray Biochemical test
• During the resorptive phase there may • Serum calcium and phosphate are usually normal
be localized areas of osteolysis. • Serum alkaline phosphatase level correlates with the
• Later the bone becomes thick and activity and extent of disease
sclerotic with coarse trabeculation. • 24hour urinary excretion of pyridinoline cross-links is
• Pathological fracture a good indicator of disease activity and bone
resorption.
Treatment
 No symptoms = no treatment required
 Patients should be examined regularly for signs of increased bone activity such as local
tenderness and warmth or a rise in the alkaline phosphatase level
The indications for specific treatment:

 Persistent bone pain
 Repeated fractures
 Neurological complications
 High-output cardiac failure
 Hypercalcaemia due to immobilization
 Preparation for major bone surgery where there is a risk of excessive haemorrhage
Calcitonin Biphosphonates
• It reduces bone resorption by decreasing both • Bind to hydoxyapatite crystals and inhibiting
the activity and the number of osteoclasts. their rate of growth and dissolution.
• Serum alkaline phosphatase and urinary • Alendronate can be given orally but dosage
hydoxyproline levels are lowered.
should be kept low. Less impaired bone
• Maintenance injections once or twice weekly
may have to be continued indefinitely mineralization results in Osteomalacia.
Operative
• Pathological fracture
• An osteosarcoma if detected early may be resectable
Complications
Fracture
• Common in weight bearing bone
• Fracture line is partly transverse and oblique
Nerve compression and spinal stenosis
• May need definitive surgical treatment
High output cardiac failure
• Due to prolonged and increased bone blood flow
Hypercalcaemia - #Immobilized patients for long period
Bone sarcoma- Malignant transformation

BONE TUMORS
WHO CLASSIFICATION OF BONE TUMOURS

Predominant
Benign Malignant
tissue
Osteoma
Osteosarcoma : central, peripheral,
Bone forming Osteoid osteoma
parosteal
Osteoblastoma
Chondroma
Cartilage Osteochondroma Chondrosarcoma : central, peripheral,
forming Chondroblastoma juxtacortical, clear-cell, mesenchymal
Chondromyxoid fibroma
Fibroma
Fibrous tissue Fibrosarcoma
Fibromatosis
Mixed Chondromyxoid fibroma
Giant cell
Benign osteoclastoma Malignant osteoclastoma
tumours
Marrow Ewing’s tumour
tumours Myeloma
Haemangioma Angiosarcoma
Vascular tissue Haemangiopericytoma
Malignant haemangiopericytoma
Haemangioendothelioma
Other Fibroma Fibrosarcoma
connective Fibrous histiocytoma Malignant fibrous histiocytoma
tissue Lipoma Liposarcoma
Neurofibroma Adamantinoma
Other tumours
Neurilemmoma Chordoma

The Bone – Forming Tumors
Malignant Benign
OSTEOSARCOMA OSTEOID OSTEOMA
Definition Osteo = bone / osteoid tissue Benign tumor of the osteoid
Sarcoma =malignant tumor of “20 something boy, pain at end of long
connective tis bones, worsen at night but relieved by
aspirin”
Epidemiology  Common
 Children and young people  Male > Female
 Male > Female
Age Children – adolescent < 30 years old
Location / Long bones = femur and humerus 50% = femur
Distribution 1. Distal femur Intertrochanteric / intracapsular
2. Proximal tibia Tibia
3. Proximal humerus
4. Metaphyseal (89%)>
Diaphyseal (10%) > epiphyseal
(1%)
Pathology Malignant tumor arising within the
bone  rapidly spreading outwards to
the periosteum and surrounding tissue
Histology:
1. Spindle cells in an osteoid
matrix
2. Cartilage cells / fibroblastic
tissue with little or no osteoid
Clinical  Constant pain, worsen at night and  Continuous, deep and intense pain
Features gradually increase in severity worsen at night
 Lump  Relieve by aspirin
 Swelling & local tenderness  Young patient with pain in the back or
 Late cases: Palpable and inflamed neck, painful scoliosis or referred –
tissue type pain into the lower limb or
 ESR and Serum ALP raised shoulder
 Swelling (diaphyseal lesions)

Imaging
Findings
A tiny radiolucent area called nidus.
1. Poorly defined margin

2. Osteolytic at long bones
3. Sunburst appearance = breached
cortex and extends into adjacent
tissue
4. Codman’s triangle = tumor
emerges from cortex, reactive new
bone forms in angle between
periosteum and cortex  normal
(seen in rapidly growing tumor)
Diagnosis Imaging is done before bone biopsy 
don’t want to disrupt the tissue plane /
to look exact location / to exclude
other tumor
Treatment 1. Pain management Effective treatment = complete removal
2. Amputation / limb salvage of nidus
3. Neoadjuvant chemotherapy Lesion is localized by x-ray or CT and
4. Prosthesis excised in a small block of bone
5. Psychosocial – counsel the Medical treatment: Aspirin / NSAIDS
family
Prognosis  Long term survival after wide
resection and chemotherapy = > 60%
 Risk of aseptic loosening at 10 years is
o 10% for hip prostheses
o 30% for prostheses around the
knee

Cartilage – Forming Bone Tumor
Malignant Benign
CHONDROSARCOMA OSTEOCHONDROMA
Definition Benign tumor of the cartilage
Epidemiology Common Common
Slow growing Teenager / young adults
Various form:
1. Primary Chondrosarcoma
2. Secondary Chondrosarcoma
3. Central Chondrosarcoma
4. Peripheral Chondrosarcoma
5. Juxtacortical Chondrosarcoma = arise
from outermost layer of cortex, deep
to periosteum
6. Clear – cell Chondrosarcoma = typical
location in head of femur (Not
important)
7. Mesenchymal Chondrosarcoma
Location / Central Chondrosarcoma = tumor Fast growing ends of long bones and
Distribution develop in medullary cavity either crest of ileum
tubular or flat bones
Peripheral = arise from cartilage cap of an
exostosis (exostosis of pelvis and scapula)
1. Metaphysis of long tubular
bones
2. Pelvis
3. Ribs
Pathology 1. Plumpness
2. Hyperchromasia
3. Mitoses
Clinical Slow-growing (red flag: bone maturity  Pain due to overlying bursa
Features dah stop tapi bone continue to grow) impingement on soft tissue
Dull ache  Parasthesia due to stretching of
Gradually enlarging lump adjacent nerve
Pathological fractures (medullary lesion
of Chondrosarcoma)
Imaging Central 1. Well defined exostosis emerging
Finding Chondrosarcoma from metaphysis
2. Cartilage cap may not be seen in X
-Rarefaction of – ray
bone with central 3. Large lesion undergo cartilage
flecks of degeneration and calcification
calcification 4. X – ray shows bony exostosis
surrounds by clouds of calcified
material
Diagnosis: Biopsy

Treatment Excision and prosthetic replacement Excision if tumor causes symptoms
(slow growing tumor with late (Excision includes the periosteum over
presentation usually come at late the exostosis)
presentation)
If there is already loss of function of the
limb – amputation is preferred
Prognosis Prognosis is determined by cellular grade
Tendency to recur late (should follow up
for > 10 years)
GIANT CELLS TUMOR MARROW TUMOR

“40 years old lady, left tibia swelling expanding EWING’S TUMOR
radioluscent area – soap bubble appearance”
Neoplasm arising from non-bone forming Definition: Tumor arising from the endothelial
supportive connective tissue of marrow with cells in the bone marrow
network of stromal cells regularly interspersed
with giant cells. GCT aka OSTEOCLASTOMA
Epidemiology: Epidemiology
 5% malignant, 20% benign tumors 10 – 20 years of age
 15 – 40 years old
 Malignant GCT more common in males
Location / Distribution: Location / Distribution
 Distal end of femur Tubular bone
 Proximal end of tibia 1. Tibia
 Distal end of radius 2. Fibula
 Upper end of humerus 3. Clavicle
 Lower end of tibia
Clinical Features: Clinical Features
 Swelling of end of long bones  Pain – throbbing
 Overlying skin is stretched and shiny  Generalized illness and pyrexia
 Egg shell crackling  Warm and tender swelling
 Vague persistent pain  ESR raised
 Pathological fractures

Pathology Pathology
 Early lesion: Homogenous, friable, Macrospcopically: Tumor is lobulated and fairly
reddish brown mass large. May look grey or red if hemorrhage has
 Late lesion: Variegated appearance, occurred into it.
blood filled areas Microspcopically: sheets of small dark
polyhedral cells with no regular arrangement
and no ground substance are seen
Imaging Finding
Multinucleated giant cells lying in

stroma composed of round and
polyhedral tumor cells. Numerous Typical case: Lytic lesion in medullary zone of
mitotic figures present. the midshaft of long bone with cortical
destruction and new bone formation layers –
Differential Diagnosis ‘onion peel appearance’
1. Brown tumor of hyperparathyroidism
2. Chondroblastoma Atypical case: Tumor located at metaphysis (may
3. Aneursymal bone cyst be confused with OM)
Predominant soft tissue component with cortical
Diagnosis: Biopsy is done destruction
CT scan and MRI:
1. Large estra-osseous component
Radioisotope scan:
Multiple areas of activity in skeleton
Treatment: Diagnosis :Biopsy is done – Finding: malignant
1) Well – defined lesion round–cell tumor-Must exclude bone
-through curettage or ‘stripping’ of the cavity infectx(OM)
with burrs and gouges -> swabbing with Treatment
hydrogen peroxide of by the application of Combined therapy:
liquid nitrogen 1) Neoadjuvant chemotherapy
2) More aggressive tumors 2) Wide excision/ amputation or radiotherapy
- excision/ bone grafting or prosthetic followed by local excision
replacement 3) Chemotherapy for 1 year
Key point malignancy

• Onion spring appearance- erwing sarcoma
• Soap bubble- giant cell
• Sunburst appearance- osteosarcoma
• Lucency in long bone- osteosarcoma
Multiple myeloma- malignancy

• More in adult, elderly
• Cancer of plasma cells- in bone marrow sangat banyak
plasma cells (autoimmune causes)
• Dence-john protein
• Xray findings:-
• Skull- punch out lesion on skull
• (other site dalam ortho yang ada punch out lesion- in gout)

PERIPHERAL NERVE INJURY
Quick anatomy review

 Peripheral nerves= bundle of axons conducting afferent (sensory) and efferent (motor) impulses
 Some nerves predominantly motor, some predominantly sensory, some mixed (the larger trunk)
 All motor axons and large sensory axons serving touch, pain and proprioception
 Also convey sudomotor (stimulation sweat glands) & vasomotor (stimulation blood vessel)
Afferent (sensory):
 from peripheral receptors to the spinal cord
 via posterior (dorsal) root of ganglion
Efferent (motor):
 from spinal cord to muscles
 via anterior (ventral) horn cell
Structure of typical nerve
Neurone  Not capable for replication but able to repair

 Part of neurone: dendrite, axon, cell body
Glial cells Schwann cells (not glial cells actually)
 Capable for replication and repair
 Form myelin sheath in PNS (CNS done by oligodendrites)
 Provide structural and mechanical support
 Guide where to grow during regeneration of nerve
Satellite cells
 Surround neurone in dorsal root of ganglia (only in pseudounipolar neurone)
 ANS has no satellite cells because it is multipolar neurone
Myelin  Function: to conduct impulse more faster by formation of Node of Ranvier (internodule
sheath segment)
 Depletion of myelin sheath causes slowing- and eventually complete blocking of axonal
conduction
 Capable of demylenation as long as schwann cells are there =)
Covering of nerves
Blood supply of nerve

 By blood vessels that run longitudinally in epineurium
 penetrate into various layers to become endoneurial capillaries

Pathology of nerves Transient ischemia
Nerve can get injured by:  Due to transient endoneurial anoxia
1. Ischemia  Leave no trace of nerve damage
 Acute nerve compression causes:
2. Compression o Numbness & tingling within 15 minutes
3. Traction o Loss of pain sensibility after 30 minutes
o Muscle weakness after 45 minutes
4. Laceration
 Relief of compression is followed by:
5. Burning o Intense paraesthesia lasting up to 5 minutes
o Feeling is restored within 30 seconds
o Full muscle power after about 10 minutes
Degree Of Nerve Injury At The Axon
Neurapraxia  Full stretch of the axon (TAK PUTUS LAGI)
 Commonest- after surgery due to compression
 Presented with loss of sensation & muscle power
 Spontaneous recovery after a few days or weeks
 Demyelination without axon damage
Axonotmesis  Partial cut of the axon- nerve still in continuity and neural tubes is intact
 Typically after closed fracture and dislocation
 Wallerian degeneration takes only a few days
-axons distal and proximal to lesions disintegrate & reabsorb by phagocyte
 Denervated motor end plates & sensory receptors gradually atrophy
-if not re-innervated within 2 years, will never be recovered!
 Axonal regeneration starts within hours of nerve damage
-proliferation of Schwann cells and fibroblasts lining endoneurial tubes
-new axonal process grow at speed of 1-2mm per day
-eventually join to denervated end-organs  enlarge  start functioning again
Neurotmesis  Whole cut of axon- disruption on the continuity of axon & supporting structures
 Typically happened in open wound
 Due to damage in endoneurial tube; regeneration of segment impossible-
regenerating fibres combine with proliferating Schwann cells and fibroblasts in a
jumbled know (neuroma) at site of injury
 Thus always indicated for surgical intervention
-even after repair many new axons fail to reach distal segments because of
 Function may be adequate but is never normal
*if cell body injured: never can nerve regenerated!
All presented with

1. Decrease sensation
2. Muscle wasting
3. Loss of function

Principle Of Treatment
1. Open injuries
Need for nerve exploration and primary repair
 If cleanly divide: do end-to-end suture
 If ragged cut: need paring of stumps with sharp blade
 If too large gap or nerve stumps retracted and cannot be brought together without
tension: need immobilization of nerve
 If still difficult to bring end together without tension: need nerve grafts (from sural nerve)
Post-operative: physiotherapy to retain joint movement
 If doubt about tension on nerve: splinted limb in position which keeps nerve relaxed for
2weeks before starting physiotherapy
2. Closed injuries
If axon intact: wait at least until muscle recovered
(6-8w BP, 12w OBP, 6w SAN, 8w AN (surgery best performed within 12w injury), 8-12w RN)
If no sign of recovery: nerve exploration is indicated
3. Delayed repair
Indication for late repair (weeks or months after injury)
i. Closed injury with no sign of recovery at the expected time
ii. Diagnosis missed and patient presented late
iii. Failed primary repair
iv. To regain protective sensation in the hand
Nerve repair not indicated
i. Patient adapted to functional loss
ii. High injury lesion and re-innervation is unlikely within 2 year period
iii. Pure motor loss which can be treated by tendon transfer
iv. Excessive scarring and intractable joint stiffness
Indication for nerve resection (then do nerve suture or grafting)
i. Nerve is scarred
ii. No conduction on electrical stimulation
Nerve resection not indicated
iii. Nerve is in continuity- only slightly thickened and soft
iv. Conduction present across the lesion on electrical stimulation
4. Tendon transfers
Indicated when motor recovery not occur within 18-24 months of injury
Principle to be observed
i. Donor muscle should be expendable and adequate power
ii. Recipient site should be mobile and stable
iii. Transfer tendon routed subcutaneously in straight line of pull
5. Care of paralysed parts

Skin must be protected from friction damage and burns
Joint should be moved through full ROM 2x daily to prevent stiffness and to minimize work
required by muscles when recovered (may use dynamic splints)

Making a diagnosis
1. What are the neurological symptoms
-numbness, tingling, muscle weakness
2. What are the neurological signs
-abnormal posture, weakness in specific muscle groups, change in sensibility
-also check for vascular injury
3. What is the level of lesion
4. What is the type of injury
5. What is the degree of damage
6. Is there any sign of nerve recovery
-Tinel’s sign: classic sign for progressive nerve recovery (peripheral tingling provoked by percussion of
nerve at the site of injury)
PERIPHERAL NERVE INJURY OF UPPER LIMB

1) BRACHIAL PLEXUS (C5-T1)
 Most vulnerable to injury, either a stab wound or severe traction (fall on side of neck or shoulder)
 Level of the lesions:
1) Supraclavicular lesion (roots & trunks) : in motorcycle accidents
2) Infraclavicular lesion (cords & brunches): associated with # or dislocation of the shoulder
 The injury to the nerve:
1) Pre-ganglionic lesions (disruption of the nerve roots proximal to the dorsal root ganglion)
 Cannot recover or surgically irreparable
 Features suggesting pre-ganglionic root
avulsion:
 Burning pain in an anesthetic hand
 Paralysis of scapular muscles or
diaphragm
 Horner’s syndrome
 Severe vascular injury
 Associated # of the cervical spine
 Spinal cord dysfunction
 Histamine test: POSITIVE
 Afferent axons remain intact
 Normal triple response with flare seen
 CT myelography or MRI : pseudomeningoceles produced by root avulsion
2) Post-ganglionic lesions
 Can be repaired and capable of recovery
 Histamine test: NEGATIVE (d/t continuity between skin & dorsal root of ganglion
interrupted)
 Sensory cell body and axon separated
 Afferent axons degenerated
 Redness and wheal but no flare response
 The level of lesion
1) Upper plexus injuries (C5 and C6)
 Typically the arm hangs close to the body and internally rotated
 Sensation lost : along the lateral aspect of the arm and forearm
 Paralysis of the: Shoulder abductor, External rotators, Forearm supinator
2) Lower plexus injuries (rare)
 Paralysis of intrinsic muscles of the hand result in clawing
 Sensation lost : along the medial aspect of the arm
3) Total plexus lesions
 Result in paralysis and numbness of the entire limb

2) RADIAL NERVE Nerve root: C5-T1 continuation from posterior cord
Arise in axilla, exit posteriorly to brachial artery
Descend down the arm, travelling in radial groove
Move inferiorly and wraps around humerus laterally
Enter the forearm, move anteriorly over lateral
epicondyle, through cubital fossa
Terminate into 2 branches:
 Deep (muscle posterior compartment of forearm)
 Superficial branch (sensory innervations of hand &
fingers)
Level of lesion &

Sensory Motor
Mechanism of injury
Very high lesion Loss of sensation over lateral & Triceps muscles wasted and
 Pressure in the axilla posterior arm, posterior forearm, paralysed
(Crush palsy) dorsal surface of lateral 3 and Below muscles also affected-
half fingers unable to extend forearm, wrist
and fingers
Wrist drop deformity
Elbow drop
Fingers drop
High lesion Loss sensation on back of hand Obvious wrist drop
 # of humerus at the base of thumb -due to weakness of extensors
 Prolonged tourniquet Finger drop
pressure
 Fall asleep with arm Triceps brachii may be weakened
dangling over chair but not paralysed
(Saturday night palsy)
Low lesion If lesion at superficial branch If lesion at deep branch
 # radial head dorsal surface of lateral 3 and Posterior compartment of forearm
 Posterior dislocation of half fingers affected- except supinator and
radius at elbow joint extensor carpi radialis longus
-cannot extend the MCP joints
-no wrist drop, why? bcoz ECRL is
strong extensor of wrist
Finger drop only

**the higher the lesion, the greater the deformity**

3) ULNAR NERVE
Nerve root: C8-T1 continuation from medial

cord
Descend down the medial side of arm
Enter the forearm, pass posteriorly to medial
epicondyle (easily palpable and
vulnerable to injury)
In forearm, pierces the two head of flexor
carpi ulnaris and travel alongside ulna
bone
Divide into 3 branches:
 Muscular branch (anterior
compartment of forearm)
 Palmar cutaneus branch (skin medial
half of palm)
 Dorsal cutaneus branch (skin medial 1 &
half fingers & palm)
At wrist, travel superficially to flexor
retinaculum and enter hand via ulnar
canal (Guyon’s canal)
Terminate into 2 branches: Superficial and
Deep branches
Level of lesion &

Sensory Motor
Mechanism of injury
High lesion Loss sensation over Less claw hand
-# around medial epicondyle of ulnar one and half -due to half of flexor digitorum profundus
humerus fingers paralysed
Low lesion Hypothenar wasting
-pressure (deep ganglion) Obvious claw hand
-laceration over wrist -due to paralysis of intrinsic muscles
Finger abduction weak
Thumb adduction loss (pinch difficult)
**the lower the lesion, the greater the deformity- ulnar paradox**
 Profundus get knock out – less deformity force in 2 fingers

4) MEDIAN NERVE
Nerve root: C6-T1 continuation from medial &

lateral cord
Descend down arm, initially lateral to brachial
artery. Halfway, crosses over brachial artery and
situated medially
Enter anterior compartment of forearm via
cubital fossa
In forearm, travels between flexor digitorum
superficialis
Give 2 branches:
 Anterior interosseous (deep anterior
compartment forearm)
 Palmar cutaneus (innervate lateral palm)
Enter hand via carpal tunnel and terminate into
2 branches:
 Recurrent branch (innervate thenar muscles)
 Palmar digital branch (innervate palmar
surface and fingertips of lateral 3 and half
fingers + 2 lumbrical muscles)
Level of lesion &

Sensory Motor
Mechanism of injury
High lesion Loss sensation over radial 3 and Long flexors to thumb, index &
-# forearm half digits middle fingers paralysed
-elbow dislocation
Low lesion Trophic changes may be seen Thenar muscle wasted
-cut in front of wrist *trophic change?- Thumb abduction (APB) and
-carpal dislocations opposition (OP) weak
Median nerve- function dekat thumb saja (can test the thumb to know function of median nerve)
 Opposition, flexion, extension, abduction (adduction- ulnar nerve)
 Wasting at thenar muscle (hypothenar- ulnar nerve)

Untuk OSCE bleh Tanya ulnar, medial, radial nerve
Median nerve- case maybe carpal tunnel syndrome
Median nerve Radial nerve Ulnar nerve

Flex- buat fist will have pointing Wrist drop Claw hand
index Elbow drop
Fingers drop
Thenar muscle wasting Triceps muscle wasting Hyperthenar wasting
Opposition of thumb Extend elbow Adduction of thumb
Abduction of thumb Extend wrist
Flexion of thumb Extend fingers Card test (use ring and little
“OK sign” (tengok bleh buat tak) fingers)- to check adduction
 Palmar untuk adduction
Thenar sign
Phalen sign Froment’s test ++ (using book)
when patient flex the thumb to
keep the paper due to ulnar
nerve injury- it is compensated
by flexor follicis longus (supply
by median nerve)
DAB-Dorsal abduction
PADD- Palmar adduction
+ do sensation following dermatome distribution
5) OTHER UPPER NERVE

LONG THORACIC Supplied serratus anterior
NERVE May be damaged in
1) Shoulder or neck injuries
2) By carrying heavy loads in shoulder
Classic signs:
1) Winging of scapula- on pushing forward forcefully against a wall
Recover spontaneously (may take year or longer)
SPINAL ACCESSORY Supplied sternomastoid muscle & upper half trapezius

NERVE May be damaged in
1) Stab wounds
2) Injury in the posterior triangle (operation or lymph node biopsy)
Signs and symptoms
1) Pain in the shoulder
2) Weakness on abduction of arm
3) Mild winging of scapula on active abduction against wall
4) Wasting of trapezious and drooping shoulder
AXILLARY NERVE (C5) May be damaged in
1) Shoulder dislocation
2) Fractures of the humeral neck
Signs and symptoms
1) Cannot abduct the shoulder (even when pain subside)
2) Deltoid weakness
3) Small patch of numbness over deltoid

6) OBSTETRICAL BRACHIAL PLEXUS INJURIES
After delivery: Baby has a floppy or flail arm
Type of brachial plexus will be defined a day or two later
2 patterns:
1. Upper root injury (Erb’s palsy) -C5, C6 and (sometimes) C7
 In overweight baby with shoulder dystocia at delivery
 Paralysis of abductors and external rotation of the shoulder
and forearm supinators
 The arm is held to the side, internally rotated and pronated
2. Complete plexus injury (Klumpke’s palsy)
 After breech delivery of smaller baby
 The arm is flail and pale, all finger muscle are paralysed, and may also be vasomotor
impairment and ipsilateral Horner’s syndrome
PERIPHERAL NERVE OF LOWER LIMB

FEMORAL Injured in gunshot wound, traction during operation, bleeding into thigh
NERVE Weakness of knee extension (quadriceps) and numbness anterior thigh & medial leg
Depressed knee jerk
SCIATIC Rare- gunshot wound & operative (iatrogenic- during hip replacement surgery)
NERVE Foot drop, numbness & paraesthesia in leg and foot
Direct injury to sciatic nerve: Painful limb + muscle leg paralysed + sensation leg
absent
Injured to deep (peroneal) nerve: Incomplete paralysed leg + wasting calf + trophic
ulcers
COMMON Damaged lateral ligament injuries when knee forced into varus, pressure of splint,
PERONEAL lying leg externally rotated
NERVE Foot drop (weak dorsiflexion & eversion), sensation loss over front & outer half of leg
& dorsum of foot
Involve superficial branch: peroneal muscles paralysed, eversion loss, dorsiflex intact.
Loss sensation over outer leg & foot
Involve deep branch: threatened in anterior compartment syndrome. Complaint of
pain, abnormal sensation, weakness of dorsiflexion, sensation loss over 1 st web space
on dorsum of foot
NERVE ENTRAPMENT SYNDROME

Complaint of unpleasant tingling or pain or numbness, altered in sensation
Motor weakness and muscle wasting
Symptoms intermittent and related to postures which compromise nerve
1) CARPAL TUNNEL SYNDROME 2) CUBITAL TUNNEL SYNDROME
Compression median nerve on wrist Compression ulnar nerve at the elbow
Wrist in flexion or hyperextension Leaning of elbow, holding elbow in flexion
Do nerve conduction velocity: but infallible, should not be used as substitute for clinical assessment
Treatment- self limiting:
1. Avoid compression postures (may used light-weight splint)
2. Corticosteroid injection if inflammation to reduce swelling
3. Operation decompression indicated if there is muscle weakness and wasting

THORACIC OUTLET SYNDROME
Group of disorders that occur when the blood vessels or nerves in the space between the collarbone
and the first rib (thoracic outlet) become compressed (C8 and T1)
Clinical features:
1) Woman in 30s complaint of pain & paraesthesia from shoulder  ulnar aspect of arm and
medial 2 fingers
2) Worse at night
3) Aggravated by bracing shoulders (wearing backpack or working with arms above shoulder
height)
4) Weakness and slight wasting of instrinsic muscles in the hand
5) Vascular signs: cyanosis, coldness of fingers, increased sweating (uncommon)
6) Reproduce by provocative manoeuvres
i. Adson’s test
Neck extend and turned towards affected side + breathes deeply
-compressed interscalene space, cause paraesthesia and obliteration of radial pulse
ii. Wright’s test
Arm abducted and externally rotated
-symptoms recur and pulse disappear on abnormal side

SOFT TISSUE PROBLEMS IN ORTHOPAEDIC
Index:
1. Biceps tendinitis
2. Trigger finger (digital tenovaginosis)
3. Tennis elbow (lateral epicondylitis)
4. Golfer’s elbow (medial epicondylitis)
5. Carpal tunnel syndrome
BICEPS TENDINITIS
• An inflammatory process of the long head of the biceps tendon
• Can result from impingment or as an isolated inflammatory injury
• Frequently occurs from overuse syndromes of the shoulder, common in overhead athletes
Clinical Presentation
• Achy anterior shoulder pain, exacerbated by lifting or elevated pushing or pulling
• Location of pain is vague, may improve with rest
• Patients might have traumatic biceps tendon ruptures- sudden and painful popping sensation,
‘Popeye’ deformity
Physical examination
• Local tenderness over the bicipital groove (3 inches below the anterior acromion)
• Speed test (popeye minta spinach- makan spinach jadi cepat-speedddddyyy)
 Anterior shoulder pain with flexion of shoulder while elbow is extended & forearm supinated
• Yergason test: Pain and tenderness over bicipital groove with forearm supination with elbow
flexed and shoulder in adduction
Treatment
• Rest, local heat and deep transverse friction usually bring relief
• If recovery is delayed, a corticosteroid injection into the bicipital groove will help
• For refractory cases, surgical solutions such as arthroscopic decompression, biceps tenotomy
and biceps tenodesis can be performed
TRIGGER FINGER (DIGITAL TENOVAGINOSIS)

• A flexor tendon may become trapped by thickening at the
entrance to its sheath; on forced extension it passes the
constriction with a snap (‘triggering’)
• The underlying cause is unknown but it is more common in
patients with diabetes and rheumatoid disease
Clinical features
• Thumb, ring and middle fingers are most commonly affected
• Patient notices click when bending finger, when extending fingers the affected finger initially
remains bent at the proximal interphalangeal joint but with further effort it suddenly straightens
with a snap
• A tender nodule felt in front of MCP joint
Infantile Trigger Thumb
• The infant is unable to straighten the thumb- “snapping thumb”
• Often mistaken as dislocated thumb or congenital deformity as it is resistant to correction
Conservative treatment Operative treatment
Injection of corticosteroid at the mouth Incision over the distal palmar crease or MCP crease of
of the tendon sheath thumb, A1 section of the fibrous sheath is incised until the
tendon moves freely
In babies: Wait until the child is about 3 years old as spontaneous recovery often occurs

TENNIS ELBOW (LATERAL EPICONDYLITIS)
• Common among tennis players and in activities that require repetitive wrist extension
o Housewife: cannot use screw driver, cannot rinse clothes, opening jar (TAK BOLEH PUSING-PUSING)
• May result in small tears, fibrocartilaginous metaplasia, microscopic calcifications and painful
vascular reactions
• Common in extensor region- all extensor muscles
Clinical Features
• Patients are usually 30-40 year old active individuals
• Gradual onset (usually after a prolonged period of wrist extension)
Aggravated by movements such as pouring out tea, turning a stiff door handle or shaking hands
• Elbow looks normal, and flexion and extension are full and painless
• Localized tenderness at or just below the lateral epicondyle; pain can be reproduced by passively
stretching the wrist extensors (by the examiner acutely flexing the patient’s wrist with the
forearm pronated) or actively by having the patient extend the wrist with the elbow straight
• X-ray is usually normal, but occasionally shows calcification at the tendon origin
Treatment
Conservative Operative
• 90% resolve spontaneously within 6-12 months • Rarely done
• RICE (place ice for awhile over the area upon • Origin of the common extensor muscle
completing exercise) is detached (excised) from the lateral
• Rest- restrict activities that cause the pain epicondyle
• NSAIDs- ibuprofen • Division of the orbicular (annular)
• Physiotherapy ligament is sometimes done
• Local steroid injections
GOLFER’S ELBOW (MEDIAL EPICONDYLITIS)

Pain and tenderness over the medial epicondyle of the elbow or bony insertion of forearm flexor and
pronator muscles
o Cannot do gardening, chop woods
Physical examination
• Valgus stresses are placed on the elbow by activities such as throwing and golfing (the golf
swing)
• Ulnar collateral injury should be excluded
• Often there is ulnar nerve neuropathy as well
• Golfer’s Elbow Test: The patient should be seated or standing and should have his/her fingers
flexed in a fist position. The examiner palpates the medial epicondyle with one hand and grasps
the patient’s wrist with his/her other hand. The examiner then passively supinates the forearm
and extends the elbow and wrist. A positive test would be a complaint of pain or discomfort
along the medial aspect of the elbow in the region of the medial epicondyle
Treatment
Same as Tennis Elbow (lateral epicondylitis)

“Clerk, repetitive using computer, feeling tingling sensation and paraesthesia, cannot sleep at night”
CARPAL TUNNEL SYNDROME
• Collection of symptoms and signs that occurs following entrapment of the median nerve within
the carpal tunnel
• Usual symptoms include numbness, paresthesias, and pain in the median nerve distribution.
Causes
• Pregnancy “MeDIAN TRAP”
• Demographic : Increasing age, Female sex, o Myedema
Dominant hand, Race (white) o DM
• Genetic : Thickened transverse ligament, o Idiopathic
Short stature o Agromegaly
• Medical Condition : Diabetes, Thyroid o Neoplasm
disease, Hereditary neuropathy, Arthritis o Trauma
• Occupation : Due to repetitive movement o Rheumatoid arthritis
• Injury or trauma o Amyloidosis
• Most cases have no known cause o Pregnancy (most common)
Pathophysiology
 The tendons of the hands are wrapped with a lining that produce a synovium fluid which
lubricates the tendons
 With repetitive movement of the hand, the lubrication system may malfunction
 This reduction in lubrication results in inflammation and swelling of the tendon area
 Abnormally high carpal tunnel pressures exist in patients with carpal tunnel syndrome
 This pressure causes obstruction to venous outflow, back pressure, edema formation, and
ultimately, ischemia in the nerve
Signs and Symptoms
• Tingling in the fingers • Change in touch or temperature sensation
• Numbness in the fingers • Clumsiness in hands
• Aching in the thumb, perhaps moving up as far • Weakness of grip, ability to pinch and other
as the neck thumb actions
• Burning pain from the wrist to the fingers • Swelling of hand and forearm
• Change in sweat functions of hand
How to Diagnose
Sensory Abnormalities in sensory present on the palmar aspect of the first 3 digits and radial
examination one half of the fourth digit
Motor Wasting and weakness of the median-innervated hand muscles (LOAF muscles) may
examination be detectable.
• L - First and second lumbricals
• O - Opponens pollicis
• A - Abductor pollicis brevis
• F - Flexor pollicis brevis
Special Test 1. Hoffmann-Tinel sign
• Gentle tapping over the median nerve in the carpal tunnel region elicits tingling
in the nerve's distribution.
2. Phalen sign
• Tingling in the median nerve distribution is induced by full flexion (or full
extension for reverse Phalen) of the wrists for up to 60 seconds
3. The carpal compression test
- This test involves applying firm pressure directly over the carpal tunnel, usually
with the thumbs, for up to 30 seconds to reproduce symptoms

Management
1. Light splint
2. Steroid injection into the carpal tunnel, as is oral prednisone
3. Open surgical division
Complication
• May lead to increase median nerve damage, leading to permanent impairment and disability
• Some individuals can develop chronic wrist and hand pain
Prognosis
• Appears to be progressive over time and can lead to permanent median nerve damage
• Whether any conservative management can prevent progression is unclear
• Even with surgical release, it appears that the syndrome recurs to some degree in a significant
number of cases possibly in up to one third after 5 years

CONGENITAL ANOMALIES
POLYDACTYLY SYNDACTYLY MACRODACTYLY
Definition Definition Definition

Additional toes present from Adjacent digits are not Overgrowth of the underlying
the normal 5 digits with or completely separate from each bone and soft tissue of hands
without corresponding other or toes
metatarsal duplication
Treatment
Epidemiology Epidemiology Surgery
Autosomal dominant 2 Boys : 1 girls
Associated with Ellis – van Associated with Down, Apert’s
Creveld, Patau and Down’s and Poland syndrome
syndrome
Classification Classification
 Preaxial: extra great toe  Simple: involve soft tissue
 Post axial: extra toe on  Complex: involve bone +/-
lateral side nail
 Central: 2nd, 3rd or 4th toes  Fenestrated: joined by tissue
duplicated but with gaps
 Polysyndactyly: extra
Treatment webbed digit
No surgery if can be correctly
aligned Treatment
Surgery at 12 months old for Surgery rarely done
misaligned toes If surgery done, only one side
of digit can be released to
prevent ischemic complications

TALIPES EQUINOVARUS DEVELOPMENTAL DYSPLASIA OF HIP (DDH)
Definition Clinical diagnosis is by Ortolani’s test and Barlow Maneuver
Congenital clubfoot Galeazzi sign (6-8 weeks)
Epidemiology
Boys > Girls Epidemiology
50% cases are bilateral Girls 7x > Boys
Left hip is more affected and 1/5 cases are bilateral
Treatment
Non operative: Stretching and
casting (Ponsetti method) Classification
Operative: Complete release of  Acetabular dysplasia w/o displacement
joint tethers and lengthening of  Sublaxation
tendon so foot can be  Dislocation
positioned normally  Malarticulation leading to dislocation
Treatment
< 6 months = no treatment unless acetabular dysplasia or hip
instability present.
6 months – 6 years + persistent dislocation = closed reduction of
the hip and splint with plaster spica. If not achieved, do open
reduction.
> 6 years old = unilateral: operative reduction + osteotomy

SPRENGEL’S SCAPULA CONGENITAL TORTICOLIS PSEUDOARTHROSIS
Definition Definition Definition

Incomplete descent of An infant holds his or her head A ‘false’ joint, which can be a
scapulae by 3rd month of fetal tilted to one side and has congenital childhood condition
life difficulty turning the head. or occur in adults (non-union)
Sternocleidomastoid muscle - is
Epidemiology tight and shortened Treatment
Clinical features: High scapula, Tibia = excise affected bone,
shoulder elevated, smaller Epidemiology close the gap with external
scapula, neck is shorter Cause is unknown however fixator
muscle may have suffered Fibula = can be treated or not if
Treatment ischemia from distorted deformity, treat
Mild cases – untreated position in utero or injured at Radius and ulna = surgery by
Marked limitation or severe birth bone grafting
deformity – surgery to lower
the scapula Treatment
• Non-surgical - exercise
program to stretch the
sternocleidomastoid muscle
• Surgical - lengthen the
short sternocleidomastoid
muscle
CONGENITAL KYPHOSIS CONGENITAL SCOLIOSIS

Epidemiology 5. Spinal deformity in which a sideways
 Less common than congenital scoliosis curvature of the spine
 D/t failure of formation or failure of 1:1.4 of M: F
segmentation
 Occurs at the front part of one or more Classification
vertebral bodies and disc 1. Failure formation
 If left untreated can cause paraplegia 2. Failure segmentation
3. Mixed
Types
1. Failure of formation Treatment
2. Failure of segmentation 1. Operative
3. Defects of segmentation 2. Non operative
4. Defects of formation

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ORTHOPAEDIC Complete 2nd Ed

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(YEAR 3 & 5 MODULE)

Salam and hi. This e-book consists of medical notes we made

To our beloved doctors, lecturers, consultants, medical textbooks and

Second edition: Update on 8 August 2016

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-Bone healing depends on metal implant for its

TESTING FOR FRACTURE UNION

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Step 2: Inflammation & cellular proliferation

Step 3: Callus formation (soft callus)

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Common type of fracture and site it’s commonly happened

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2. HOLD ‘immobilization’ avoided- because objective seldom complete immobility

Balanced skin traction

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Skin traction Skeletal traction

Russell skin traction Fixed skin

Traction pin types & placement

Traction pin placement

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2. Fiberglass (Orthoglass) Plaster of Paris (POP)

Splint (eg: slab) or cast?

Rules of application of POP cast/slab

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After care of POP casts

Local complications of POP

Systemic complication POP: DVT leading to pulmonary embolism

Removing of plaster casts

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Volar/Dorsal forearm Ulnar gutter Thumb spica

3. Functional bracing (functional brace)

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Risk of infection depend upon:

Type of internal fixation:

(c) Intramedullary nail

Complications: (due to poor technique, poor equipment, poor operating condition)

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PRINCIPLE MANAGEMENT FOR OPEN FRACTURE

Type I Puncture wound (<1cm long)

Principle of treatment of OPEN fracture

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3. Stabilization of the fracture

4. Early definitive wound closure

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Grading and treatment

 Causes of Anterior / Posterior Dislocation:

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Operative : open reduction

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ADHESIVE CAPSULITIS “ FROZEN SHOULDER”

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 Develops anterior shoulder  40-50 years old  Progressive fibrosis &

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ROTATOR CUFF TEAR

MU dekat dengan hari- so monteggia, proximal ulnar