Surg Ortho

Orthopedic Surgery
Dr. Angel Cayetano | April 20, 2022

Trans by: Banan, Gumpad, Lacaden, Lin
OUTLINE II. FRACTURE DIAGNOSIS

I. Introduction IV. Open Fractures
A. Branches of V. How to Do Debridement
Orthopedics VI. Questions and Answers
II. Fracture Diagnosis VII. Reference
III. Stages of Fracture
I. INTRODUCTION
• The branch of medicine dealing with the correction of deformities
of bones and muscles
• This is a complete diagnosis. “Fracture close complete

transverse displaced junction middle-distal 3rd femur right.”
[Doc. Cayetano]
Open or Close
• Orthopedics comes from the Greek words “Orthos” meaning

straight or right and “paideia” which means rearing of
children. Meaning you have to keep the baby straight or the
child straight. That is the original meaning of orthopedics.
[Doc. Cayetano]
A. BRANCHES OF ORTHOPEDICS
• Trauma
• Adult Orthopedics
→ 18 years old and above
→ Neglected Trauma> 1month • When you say close, there is no wound, when you say open
→ Sports, Foot and Ankle, Shoulder Sx. Hip and Knee there is a wound.
→ Elizarov, Tumor
• Child Orthopedics Complete or Incomplete
→ Neglected Trauma > 2 weeks
→ 17 years old and Below
• Hand Surgery
• Spine
• The biggest branch in the Philippines is Trauma. These
include, fractures, dislocation, muscular trauma.
• Adult orthopedics is the main branch in other parts of the
world
• Child tumor concerns also about tumors and deformities of
the kids. [Doc. Cayetano]
Trauma/ Fracture
• A deformation or discontinuity of bone produced by forces that
exceed the ultimate strength of the bone
• Soft tissue injury with a broken bone (AO)
• Before, we look at fracture like a break in the bone but these
days, they look at fracture as a soft tissue injury with a
broken bone. We are focusing more on the soft tissue • For us to tell if this is complete or incomplete, we must look at
injuries because it dictates the treatment and the healing the orthogonal view of the bone, it’s a 90-degree view like the
process of the bone. left picture that is an anteroposterior view. And the right side is
• The meaning of AO is a German word Arbeitsgemeinschaft a lateral view. This is for us to tell if the fracture line expands
für Osteosynthesefragen that means the study of the from the medial cortex to the lateral corteX on the AP view then
internal fixation of the bone. [Doc. Cayetano] on the lateral view it should extend from the anterior cortex to
the posterior cortex.
Trans # 23 Orthopedic Surgery 1 of 5

Fracture pattern • Butterfly Fracture
• Transverse Fracture → Produced by a pure bending force
→ Plane of fracture is perpendicular to the long axis of the bone
→ Produced by a distracting or tensile Force
• Comminuted Fracture
→ Broken into many pieces with the energy of combined forces
→ Multiple Fracture Fragments
• Oblique Fracture
→ Forms an angle with the axis of the shaft at 30 degrees or
more
→ In oblique fracture there is a tendency of the bone to slide. At
around 30 degrees the bone will slide. If it it around 10 degrees
then it is still transverse and it will not slide
• Segmental Fracture
→ There is a intact bone, proximal segment, middle segment and
distal segment, which is produced also by a combination of
forces
• Spiral Fracture
→ Produced by a torsional force
→ Pencil Tip deformity.
Non-displaced/Minimally displaced/Displaced
• Non-displaced
→ The medial and lateral cortex are in line with each other on the
AP view and the anterior and posterior cortex are in line with
each other in the lateral view
• Minimally displaced
→ There is a 50% cortical position in both the AP and Lateral
view
• Displaced
→ There is no continuity seen in the AP and lateral view
Anatomic Location and Laterality

• Anatomic Location either proximal, middle or distal
• Laterality refers to being on the Right or the Left
→ Important because some of the implants we are using is
particular to either the right or the left.

III. STAGES OF FRACTURE bone. However, fracture with a wound must be considered
open until proven otherwise, with that we could treat fracture
• Stage of Impact as open and lessen the possibility of an infection [Doc. Cayetano]
• Stage of Inflammation
• Early Reparative Phase (stage of soft callous formation)
• Late reparative phase (Hard callus)
• Remodeling phase
A. STAGE OF IMPACT
• Seconds
→ At the onset of the trauma, there is already a fracture healing
that is happening.
→ Energy is absorbed until failure
B. STAGE OF INFLAMMATION
• 1 to 2 weeks
• Hematoma attracts inflammatory cells
• Cytokines are released which stimulate mesenchymal cells A. DETERMINANTS OF OUTCOME
which will later on form bone • Amount of devitalized soft tissue
→ Open fracture has poorer outcome than closed fracture [Doc.
• When we have fracture, what we usually give are NSAIDs in Cayetano]
order for the fracture to lessen the pain and inflammation. • Level and type of bacterial contamination
Giving NSAID is not actually good, it is detrimental to the → The more bacterial load, the worst the outcome [Doc. Cayetano]
fracture healing because if you want to stimulate healing it B. CLASSIFICATION
needs to undergo the stage of inflammation. If you want to Type I
give NSAID you will decrease the stage of inflammation. [Doc.
• <1 cm wound, Clean to minimal contamination, simple fracture
Cayetano]
with minimal comminution
C. EARLY REPARATIVE PHASE (SOFT CALLOUS • Bone piercing from the inside to outside
FORMATION)
• Stage of soft callus formation Type II
• Weeks to months (6 to 8 weeks) • >1 cm wound, moderate contamination, moderate comminution
• Granulation tissue forms in fracture gaps with moderate muscle damage
• Dead bone is resorbed • Soft tissue stripped from bone is none to minimal
• Osteoblastic proliferation at the periphery
• Cartilage forms in the central area (hyaline) Type III
• >2 cm wound
• Dead bone is resorbed. There will be pieces of bone that is • Further classified into type A,B,C
not connected to the soft tissue. Remember that the current
definition of fracture is a soft tissue injury with associated Gustilo Classification
fracture • Grade I- Clean skin opening of less than 1 cm, usually inside to
• Soft tissue determines the fracture healing. So when there is out
no soft tissue attachment of bone, that bone will be resorbed • Grade II- Open between 1 and 10 cm, extensive soft tissue injury,
and that would be a dead bone . [Doc. Cayetano] minimal to moderate crushing
D. LATE REPARATIVE PHASE (HARD CALLUS) • Grade III- Open more than 10 cm, extensive tissue including
• Weeks to months muscle damage , high energy
• Cartilage calcifies → IIIA- Laceration with adequate bone coverage, segmental
• Gradually replaced by osteoblastic bone formation features, gunshot injuries
• Clinical union occurs → IIIB- Soft tissue injury with periosteal stripping, usually
associated with massive contamination
→ IIIC- any of the above with an associated vascular injury
• Calcium forms in the cartilage and it is in this stage that you
could see the callus formation on Xray . [Doc. Cayetano]
• For Type 3A, A for Adequate bone coverage, meaning
E. REMODELING STAGE when we do our debridement, we could close the wound in
• Months to years such a way that there is no bone that is exposed
• Woven bone- lamellar bone through coupled resorption and • For Type 3B, B for bone exposure, or soft tissue with
formation periosteal stripping, periosteum is removed so the bone is
exposed
• The cartilaginous bone or the woven bone will form into a • For Type 3C, C for circulatory problem [Doc. Cayetano]
lamellar bone through a coupled bone resorption (osteoclast)
and bone formation (osteoblast). [Doc. Cayetano] Special Type 3
IV. OPEN FRACTURES • Even if less than 1 cm wound but with contamination and high
energy
• Break in the skin and underlying soft tissues (subcutaneous • Contamination
tissue, muscle, fascia) leading directly into or communicates with → Exposure to soil, water (lakes/pools), fecal materials, oral flora
the fracture → Delay >12 hrs
• Fracture with a wound must be considered open until proven
otherwise
• The skin lesion should communicate with the fracture. For
example, there’s a break in the skin but the fascia is intact or
the muscle is intact then that is not an open fracture
• The only way to ascertain that is when you do debridement
that you could poke your finger or an instrument going to the

• High energy A. SKIN AND SUBCUTANEOUS FAT
→ Segmental fracture • Incision
→ Bone loss → Provides effective debridement
→ Compartment syndrome → Appropriate visualization of neurovascular structures and
→ Crush mechanism bone ends
→ Extensive degloving B. FASCIA
→ Requires flap (any size) • Any nonviable, damaged, or contaminated fascia should be
excised
C. EXAMINATION OF THE WOUND AN INITIAL
EMERGENCY MANAGEMENT C. MUSCLE
• No exploration of the wounds in the emergency department • Subject to hydraulic damage by fluid waves
• Delay >1 hour- the wound is flushed gently with 1 to 2 L of sterile • Necrotic muscle is the major pabulum for bacterial growth
saline • Viability of muscle: color, consistency, contractility, and capacity
• Reduction (alignment) should be done promptly to bleed [Gregory]
• Don’t do debridement at the ER, it should be done on the • When we say color, it should be pink. When we say
OR. But if you expect a delay of debridement >1 hr then the consistency, it should be firm, it should not be fragile. So,
wound should be cleansed with sterile saline or great when we hold it with a pick-up, it should not be torn apart.
amount of water to lessen the bacterial contamination Then contractility, so when you use the cautery or when you
pinch the muscle it should contract. And of course, when you
• Never reduce an open fracture at the ER, it should be done
are cutting the muscle, there should be bleeding. [Doc. Cayetano]
after cleaning the wound or debridement in the OR.
Reduction means alignment. [Doc. Cayetano] D. TENDONS
How to determine if it is open fracture or not • Preserve the peritenon
• Do a formal debridement • Not debride peritenon but rather copiously irrigate it.
• Saline or methylene blue injection E. BONE
→ If the saline or MB goes outside the skin or out of the wound • Bone tissue is essentially defenseless to bacteria.
then it is an open fracture • Bits of cortical bone that are free of any soft tissue attachments
D. ACUTE MANAGEMENT OF OPEN FRACTURES should be removed.
• Address hemorrhage with direct pressure • Small fragments of cancellous bone are retained especially in
bone edges (if not contaminated because they are needed to
→ To stop the bleeding, do not suture, instead stop it with direct
reconstruct the joints)
pressure and the management if it is an open fracture would
be debridement in the OR [Doc. Cayetano] F. JOINTS
• Initiate antibiotics • Any wound that enters a joint mandates exploration.
→ Grade 1 and 2- CEFAZOLIN 1g-2g IV
→ Grade 3- CEFAZOLIN plus Gentamicin 2mg/kg IV • Any open joint mandates exploration. Because if you have a
▪ Gentamicin for gram negative bacteria contaminated joint, what will happen there is that there will
→ Farm injuries or gross contamination- add Penicillin be bacterial seeding there, and that bacteria will eventually
→ Apply saline soaked gauze dressing to wound consume your cartilage, and you call that septic arthritis. [Doc.
Cayetano]
E. PREPARATION FOR SURGICAL DEBRIDEMENT
• Several fixation devices should be available G. NERVES AND VESSELS
• Proper patient position • Bleeders require immediate ligation (tie the blood vessel) or
• Tourniquet may be applied coagulation (involves cautery).
→ If there is too much bleeding • Loss of blood supply greater than 8 hours nearly always results
in amputation.
Irrigation
• When you have a type III C, there is already a circulatory
• Gregory: “Irrigation is the single most essential maneuver”
imbalance, meaning there is no perfusion already. So, if
• Gustilo: “10 liters” there is no perfusion for greater than 8 hours, there will
• At the level of muscle and bone (type 2 or higher) = at least 6 L already be a myonecrosis or there will be a necrosis distal to
of saline is used the blockage of the blood. And that will nearly always result
→ With initial 2 L and the final 2 L containing antibiotic solution to amputation. [Doc. Cayetano]
→ This results in a minimum irrigation of 10 L • Do a very quick debridement then proceed with vascular repair.
• Kellam and associates: “Irrigation of fracture with solutions of • In larger vessels: bone before vessel.
povidone-iodine (Betadine) or hydrogen peroxide resulted in
marked decrease in osteoblast function” VI. QUESTIONS AND ANSWERS
• There is no need to place betadine or hydrogen peroxide Pain Management

when we are flushing the wound. But in actual practice we Question: Nasabi niyo po kanina na yung NSAIDs po is detrimental
are doing this. But in the US they just use irrigating solution. to healing, ano po yung binibigay na alternatives for NSAIDs para
[Doc. Cayetano] po sa pain?
Importance of Irrigation Doc: Pwedeng Tramadol, Paracetamol. Those are weak opioids,
• Flushes away blood and other debris yun ang mas tama. Pero actually kung minsan, when there’s too
• Clears the wound for inspection much swelling. Actually, in reality we give NSAIDs, kasi in terms of
pain relief, the NSAIDs is actually more effective because it has an
• Floats undetected necrotic fronds of fascia, fat or muscle
anti-inflammatory effect, which is not present in weak opioids.
• Restores its normal color
• Reduces the bacterial population Debridement Preparation
V. HOW TO DO DEBRIDEMENT Question: In the practice po kasi, I observed po yung Betadine with
soap as preparation for debridement. Is that generally acceptable
• Cleaning of wounds po?

Doc: Yah, I emphasized that before, di ba, toxic siya sa osteoblast?
Pero in practice kasi sa Philippines talagang gumagamit kaming
Betadine tsaka Hydrogen Peroxide. So maybe, these are some of
the reasons that maybe delayed yung healing or hindi ganoon
kabilis yung healing ng fracture, because it tends to destroy the
osteoblasts. But of course, it helps with the killing of the bacteria.
Because remember? The determinants of outcome are the bacterial
load, kind of bacteria and the soft tissue condition.
But as I have said, in the US, noong nag-train ako doon, ayaw talaga
nila eh. Gusto nila tubig-tubig lang. But the difference is in that other
part of the world, they could do the debridement immediately.
Sports Medicine
Question: Doc yun po bang orthopedics po is pwede po siyang in-
line po siya sa Sports Medicine po doc?
Doc: Di ba I told you before na Orthopedics, the major categories
are Trauma, then you have Adult Orthopedics, yung sa Adult
Orthopedics nandoon yung Sports Medicine. Sa Sports Medicine
kasi it’s actually talking about yung mga joints, so like shoulder
surgery, knee surgery, mga ganoon.
Question: Kasali pa po doon Doc yung rehabilitation ng sports yun
or hindi na?
Doc: No no, hindi na, Rehab Medicine naman na yun.
VII. REFERENCE
• Dr. Cayetano’s ppt and lecture

Basic Urology
Randy A. Pasco| April 23, 2022
Trans by: Becyagen, Jacob, Prudencio, Tabago
OUTLINE
I. Clinical Decision Making C. Infection stones
A. Evaluation of Urologic D. Benign Prostatic
Patient Hyperplasia
B. Urinary Tract Imaging IV. Genito-Urinary Tumors
C. Digital Rectal Exam A. Prostate
D. Urinary Tract Imaging B. Kidney
II. Infections of Urinary Tract C. Adrenal
III. Common Urologic D. Urothelial/ Bladder
Diseases E. Testicular
A. Urolithiasis V. References
B. Calcium
nephrolithiasis
I. CLINICAL DECISION MAKING

Figure 2. The right ureter, illustrated by retrograde injection of contrast material.
A. EVALUATION OF UROLOGIC PATIENT UO, ureteral orifice in the bladder; UPJ, uteropelvic junction; I, upper ureter,
extending to the upper border of the sacrum; II, middle ureter, extending to the
Genitourinary Pain Intraperitoneal pain lower border of the sacrum; III, distal or lower ureter, traversing the pelvis to end
Confused with intraperitoneal Radiates to back/shoulder in the bladder. Arrows indicate the course of the common iliac artery and vein
origin
Radiates to abdomen, inguinal, Seldom colicky • Three physiologic constrictions:
tip of penis, scrotum, labia → Locations where a stony ureter might lodge
Colicky Lie motionless ▪ Ureteropelvic conjunction
Often moves ▪ Iliac vessels
Ex. Urinary stone - no position Ex appendicitis – lying on one ▪ Ureterovesical conjunction - narrowest
could ease pain position, side-lying with the
dominant position on the right to • Three portions of the ureter:
ease pain → Upper ureter – extending to the upper border of the sacrum;
proximal third
Renal Pain
→ Middle ureter – starts at the superior border of the sacrum
• Ipsilateral costovertebral angle and ends or extending to the lower border of the sacrum
• Radiate across the flack toward the abdomen and umbilicus to → Distal or lower ureter – traversing the pelvis to end in the
testis or labium bladder; distal third
• Pain due to inflammatory-steady
• Pain due to obstruction-fluctuates in intensity Vesical/Bladder pain
→ Ex. Stone in ureter – intensity of pain changes, increases or • Overdistention / inflammation
decreases from time to time • Constant suprapubic pain that is unrelated to urinary retention is
• Associated with gastrointestinal symptoms seldom of urologic origin.
→ Shared innervation in the sympathetic ganglion → Not all suprapubic pain is urologic in origin
→ Close proximity ▪ Negative diagnostics = refer to OB-Gyne or consider
colonic pathology
→ Ex. Kidney stones often times presented with constipation
• Cystitis sharp, stabbing
Ureteral Pain • Suprapubic pain at the end of micturition (strangury)
• Acute and secondary to obstruction.
Prostatic pain
• Often with referred pain/mimics
• Secondary to inflammation
→ Mid-ureter: appendicitis/diverticulitis; scrotum/labium
▪ Example • Poorly localized
− Stone in the mid-ureter mimics appendicitis (RLQ pain) → Prostate in located in the perineal area and sometimes
associated with hypogastric pain, right or left lower quadrant
− Diverticulitis (LLQ pain)
pain, low back pain
→ Lower ureter: vesicle irritability; suprapubic pain; meatal pain
• Associated with irritative urinary symptoms (frequency / urgency
▪ Example
/ nocturia)
− 28 year old patient male came to ER complaining of pain
at the head of the penis Penile Pain
o To consider: balanitis, stone at the meatus • Flaccid penis - inflammation in the bladder or urethra
− Hypogastric pain • Paraphimosis
o May be related to the bladder or stone in the lower → Common in children; foreskin can no longer be pulled forward
third of ureter over the tip of the penis. This causes the foreskin to become
swollen and stuck, which may slow or stop the flow of blood to
Figure 1. The ureter the tip of the penis; circumcised
demonstrating sites of • Erect penis – Priapism / Peyronie disease
normal functional or
anatomic narrowing at the
uteropelvic junction (UPJ),
the iliac vessels, and the
ureterovesical junction (UVI).
Note also the anterior
displacement and angulation
of the ureter, which occurs
over the iliac vessels.
Trans # 24 Basic Urology 1 of 15

Figure 3. Peyronie’s disease
Figure 6. Cross section of the penis, demonstrating the relationship between

the corporal bodies, penile fascia, vessels and nerves.
Figure 4. Paraphimosis
Priapism
● Full or partial erection with or without stimulation >4hrs.
● Ischemic (low flow/pain)
● Non-ischemic (high flow)
● Urologic emergency
Figure 7. Tear in the Buck’s Fascia. “Eggplant deformity” – Triad of rigid,
● Common in blood dyscrasia slipping, popping sound; Urologic Emergency
● When the blood enters the cavernosal sinuses, they are being
trapped due to dysmorphic blood Testicular/Scrotal Pain
● Primary or referred
● Acute: epididymitis / orchitis / torsion
● Folliculitis / Fournier gangrene
● Chronic: hydrocele / varicocele
Epididymo- Testicular torsion Fournier gangrene
orchitis
• Mimics torsion • Pre-adolescent • Surgical emergency
• Irritation and • Bell clapper • H“Tip of the iceberg”
Inflammation of deformity
testis and → loss of
epididymis epididymotestic
→ Due to ular ligaments
infection that keeps the
testis fixed at
• Mimics position; free-
testicular torsion floating testis.
• Elicits Normally, testis
cremasteric should be
reflex attached to the
scrotum at fixed
Figure 5. Priapism position
● Insert a needle to evacuate dysmorphic or clotted blood • Urologic • Necrotizing fasciitis

● Draining at the glans penis for decompression emergency → multimicrobial in
● The longer the penis maintained erect, there may be a need for origin
surgical intervention – higher risk for erectile dysfunction • Phrens test -test • Common in patients
to differentiate it with diabetes or any
Penile fracture from immunocompromise
• Priapism epididymoorchitis d patients
• Buck fascia - While the patient is
→ Surrounds both cavernosal bodies dorsally and splits to standing, lift the • Sometimes
surround the spongiosum ventrally affected testis interpreted as a
- When the pain simple folliculitis
→ Bleeding from a tear in the corporal bodies (penile fracture) is subsides upon
usually contained within buck fascia, and ecchymosis is lifting – orchitis • Tip of the iceberg
limited to the penile shaft - When the pain → Assessed only
remains – torsion the tip and not
- Together with the inside of the
Ultrasound with scrotum
Doppler → Treatment of
- If orchitis = detects choice: surgery
blood flow; debridement
hypervascular due
to inflammation • Testis is spared or
protected due to
- If torsion = low to different blood → Urgency
no blood flow supply ▪ Cannot hold urine for few minutes; common in BPH;
overwhelming need to get to a restroom immediately;
• Twisting of the sometimes can't make it to the bathroom in time or if the
spermatic cord
causes
urge to urinate comes on very suddenly
compromise of the → Nocturia
blood supply of ▪ Condition in which you wake up during the night because
testis you have to urinate; normally 2 times only at night more
→ Urologic than 2 is abnormal, irritative
emergency • Obstructive/voiding
→ Must undergo → Weak stream
surgery within
6-8 hours → Intermittency
• Pre-adolescent = ▪ Sudden interruption during urination
age range when → Straining
testis is becoming → Incomplete emptying
more developed;
becomes heavier
• Usually occurs
during cold season
Figure 8. Urinary Obstruction

• Incontinence
→ Involuntary urination
▪ Continuous – fistula
▪ Stress - happens when physical movement or activity —
such as coughing, laughing, sneezing, running or heavy
lifting — puts pressure (stress) on your bladder, causing
you to leak urine; weakness of sphincter
▪ Urgency - uncontrolled urination
▪ Overflow
Hematuria → Enuresis - bedwetting; normal age is up to 2 to 5 years old;
• Significant hematuria beyond 5 years must be lessened
→ Non trauma: >3/hpf B. PHYSICAL EXAMINATION
→ Trauma: 5/hpf Kidneys
• Gross vs microscopic • Difficult to assess in adult
• Timing of urethra • Children/thin women: may palpate lower pole
→ Initial: urethra • Supine-best position
→ Terminal: prostate/bladder neck → The kidney is lifted from behind with one hand in the
→ Total: bladder/upper tracts costovertebral angle
• Association with pain-upper tracts → In deep inspiration, the examiner’s hand is advanced firmly
• Presence/shapes of clots: into the anterior abdomen just below the costal margin
→ Vermiform clots: kidney/ureter → At the point of maximal inspiration, the kidney may be felt as
→ Amorphous clots: bladder it moves downward with the diaphragm
• The most common cause of gross hematuria in a patient older
than age 50 years is bladder new growth
• NOTE:
→ Test: Urinalysis - Specific gravity, pH, protein, WBC, RBC
→ Microscopic: non trauma or trauma
→ Gross: important to determine timing
→ Timing of hematuria determine the origin of pathology of
bleeding
Urethral discharge
• Venereal infection
→ Gonococcal- purulent, thick, profuse, yellowish Figure 9. Bimanual Examination of the Kidney
→ Nonspecific urethritis- scant, watery • NOTE:
• Bloody discharge- carcinoma of urethra → CVA starts at the lateral border of the spine and the inferior
• NOTE: border of 12th rib
→ Whitish discharge = chlamydia → On examining the kidney, hand is placed at the back of the
Lower Urinary Tract Symptoms (LUTS) kidney, then lift, deep inspiration then advanced firmly to the
• Irritative/storage anterior abdomen
● Transillumination: <1 year of age with palpable flank mass
→ Frequency
▪ Need to urinate many times during the day, at night ● Fluid-filled-cysts or hydronephrosis: dull reddish glow
(nocturia), or both but in normal or less-than-normal ● Solid masses-tumors: do not transilluminate
volumes; characterized as urination with interval of less
than 2 hours
Bladder
• Begins by percussing immediately above the symphysis pubis
and continuing cephalad until there is a change in pitch from dull
to resonant
• Bimanual examination
→ Under anesthesia
→ Assessing extent of bladder tumor
Figure 14. Scrotal Structure

• Testis
→ Oval, firm, smooth
→ Adult: 6cm length x 4 cm width
→ Epididymis: postero lateral to testis
→ A firm or hard area within the testis should be considered a
Figure 10. Bimanual Examination of the Bladder in Female malignant tumor until proved otherwise
• Inguinal Area: Hernia

→ To examine for a hernia, the physician’s index finger should
be inserted gently into the scrotum and invaginated into the
external inguinal ring
→ Once the external ring has been located, the physician should
place the fingertips of his or her other hand over the internal
inguinal ring and ask the patient to bear down (valsalva
maneuver)
Figure 11. Bimanual Examination of the Bladder in Male
Penis
• Check for the ff:
→ Circumcised
→ Meatal opening: hypospadias/epispadias
→ Mass/lesion
→ Curvature
→ Urethra (palpation)
Figure 15. Examination of the Inguinal area
Figure 12. Hypospadias
Figure 16. Inguinal Hernia

• NOTE:
→ A hernia will be felt as a distinct bulge that descends against
the tip of the index finger in the external inguinal ring as the
Figure 13. Epispadia patients bears do
• NOTE: → When anything touches the distal third of finger, or if external
ring is too laxed or loose, consider hernia as differential
→ Hypo/epispadia - circumcision is highly contraindicated
diagnosis
▪ skin to be removed is highly needed during hypospadias
repair → When presented with patency of procesus vaginalis, bowel
can extend down to scrotum and sometimes only bulging at
Scrotum and Content the inguinal canal.
• Detect the ff:
→ Lesion
→ Position of testis: undescended/retractile
→ Size/consistency of testis (must be firm)
→ Epididymis
→ Spermatic cord- palpate
Figure 17. Neglected Hernia

• Neurogenic test
• NOTE [Balasik trans]
→ Can be routinely done as early as 35 years old if with family
history of prostate cancer
→ For females, one or two fingers; male one finger only
▪ Neurogenic tests done in DRE
− Bulbocavernosus reflex = check for sphincter
tightness especially for patients presented with
neurogenic bladder or acute urinary retention
→ In OPD: standing is preferred
Figure 18. Undescended Testis

• Undescended Testis
→ Commonly located just above the external ring
→ Important to be detected because there is higher tendency of Figure 21. Digital Rectal Exam
up to 4 folds to harbor testicular tumor
• Scrotum
→ The external spermatic fascia derives from the external
oblique fascia and remains firmly attached to the borders of
the external ring.
→ The cremasteric muscle and fascia arise from the internal
oblique muscle and attach laterally
→ The internal spermatic fascia is a continuation of the
transversalis fascia
→ Visceral tunica vaginalis are derived from the peritoneum
Varicocele: Pain and Infertility
• Bag of worm appearance due to dilatation of pampiniform plexus
Figure 22. Rectal Examination Positions
• Recurrent
• Low sperm count or infertility D. URINARY TRACT IMAGING
• Most common in left side (longer)= venous drainage of gonadal
vein 1. ULTRASOUND
→ right = directly to vena cava [Balasik Trans] • Mostly available
• Low sensitivity
• Detects stone/mass
• Cystic vs. solid
• Simple preparation
• Blind spot
• No radiation
→ Differentiate cystic vs solid
→ Disadvantages:
→ Low sensitivity
→ Blind spot = ex. Whole tract of ureter cannot be observed just
Figure 19. Varicocele by doing ultrasound alone (better with CT sonogram)
Hydrocele
• Illumination is helpful in determining whether scrotal masses are
solid(tumor) or cystic (hydrocele, spermatocele)
Figure 20. Hydrocele
C. DIGITAL RECTAL EXAM

• Should be performed on male >40 Figure 23. Normal kidney and with hydronephrosis
• Detects prostate cancer
• Estimate prostate size

2. PLAIN X-RAY II. INFECTIONS OF URINARY TRACT
• Low sensitivity Definitions of Terms
• radio opaque stone • UTI: Inflammatory response of urothelium to bacterial invasion
• NOTE [Balasik trans] usually associated with bacteruria and pyuria
→ Plain X-ray cannot view luscent stone (ex. Matrix stone, uric → First/isolated UTI – patient who never had UTI
acid stone) → Unresolved UTI – infection not responded to therapy
3. INTRAVENOUS PYELOGRAPHY (IVP) → Recurrent UTI – infection occur after documented resolution
→ Reinfection UTI – reintroduction of bacteria from outside
• Old fashioned
→ Bacterial persistence UTI – recurrent UTI caused by same
• Limited use bacteria from within
• Needs normal renal function • Bacteriuria: presence of bacteria in urine
• Risk of contrast nephropathy • Pyuria: presence of WBC in urine
• NOTE [Balasik trans] • NOTE [Balasik trans]
→ Avoided if patient has impending deterioration of the kidney → Patients can have pyuria without bacteuria
→ But used especially in rural areas ▪ E.g., Sterile pyuria = form of pyuria that occurs without a
• How does IVP work? detected presence of bacteria
→ In the IVP exam, iodine injected through a vein in the arm → Microscopic hematuria = due to strenuous exercise
collects in the kidneys, ureters and bladder, giving these areas → TB in the GU tract = WBC in urine without bacteria; also called
a bright white and sharply defined appearance on the x-ray sterile pyuria
imagers
• How is IVP performed? Urinary Pathogens
→ Outpatient basis • E. coli
→ The patient is positioned on the table • Proteus
→ The contrast material is then injected, usually in a vein in the • Klebsiella
patient’s arm, followed by additional still images • E. faecalis
→ Hold very still • S. saprophyticus
→ As the contrast material is processed by the kidneys a series • Enterobacter
of images is taken Factors that suggest complicated UTI
4. CT Sonogram • Functional or anatomic abnormality of urinary tract
• Gold standard for stone • Male gender
• 90-98% sensitivity • Pregnancy
• No contrast • Elderly pregnant
• No preparation • Diabetes
• Hounsfield unit (HU) - determines the integrity the stone; detects • Immunosuppression
of hard stone or soft stone • Childhood UTI
• NOTE: [Balasik trans] • Recent antimicrobial agent use
→ CT sonogram • Indwelling urinary catheter
→ Yellow Arrow: calcification at the kidney • Urinary tract instrumentation
→ Very detailed; visible patency of the ureter • Hospital-acquired infection
• Symptoms for more than 7 days at presentation
Table 3. Hounsfield unit for the various parts of the body.
Substance HU
→ Male = longer urethra; usually has underlying cause
Air -1000 → Female = urethra is short; close to anus
Lung -500 → Childhood UTI = recurrent febrile UTI; whether male or female;
Fat -100 to -50 higher incidence of vesicoureteral reflux
Water 0
CSF 15 Key points: Pathogenesis
Kidney 30 • Most UTIs are caused by bacteria, usually originating from the
Blood +30 to +45 bowel flora
Muscle +10 to +40 • Bacterial virulence factors, including adhesion, play a role in
Grey Matter +37 to +45 determining which bacteria invade and the extent of infection
White Matter +20 to +30 • Increased epithelial cell receptivity predisposes patients to
Liver +40 to +60 recurrent UTIs and is a genotypic trait
Soft Tissue Contrast +100 to +300 • Obstruction to urine flow is a key factor in increasing host
Bone +700 (cancerous bone) to susceptibility to UTIs
+3000 (dense bone) • NOTE [Balasik trans]
→ Urine Culture – most reliable diagnosis
→ Then start with antimicrobial therapy once detected
→ Fever, flank pain, leukocytosis = triad of acute pyelonephritis
Figure 24. CT sonogram

Management 1. URETERIC COLIC
• Presents at the ER- manage the pain
• Manage with strong analgesics
→ Hyoscine
→ NSAIDS – Diclofenac, Celecoxib, Rofexocib
→ Ketorolac
→ Tramadol
→ Meperidine - acts fast and good for pain control; central and
smooth muscle relaxation
→ Off label effect of tramadol
→ Prolongs ejaculation
→ Taken at least 2 hours before usage
2. STONES IN THE URINARY TRACT
• Urinalysis- microhematuria
• Ultrasound + plain KUB X-ray
• CT stonogram
→ No preparation needed
→ Can be done anytime
→ No contrast medium needed- can be performed even with
elevated BUN, Creatinine
→ Examination is fast- results obtained within 30 mins
• KUB IVP
• Cystoscopy- retrograde studies
Figure 25. Management of recurrent UTI
Figure 27. CT Stonogram: mildly hydronephrotic and calcification [Balasik trans]

→ Additional workup:
→ If with history of urinary stone = may request for CT stonogram
(98% in detecting stone-gold standard)
• Prevalence of kidney stones
Figure 26. Management of acute pyelonephritis → The peak incidence of urinary calculi is from the 20s to 40s
→ Male to female ratio is 3:1
III. COMMON UROLOGIC DISEASES → Upper tract stones found in affluent developed societies
→ Bladder stones seen in developed nations
A. UROLITHIASIS
→ Stones often recur at 7% per year or 50% at ten years
• First stone was uncovered in El Amrah, Egypt in 4800BC
Predisposing factors
• 19th century bladder stones were removed via the perineum;
• Family history
there was a high risk of death from bleeding or infection
• Dietary factors
• There is a dramatic presentation of excruciating pain
→ High calcium
→ Usually in urinary stone – require immediate strong analgesic
to calm → High oxalate
→ High uric acid
Kidney Stone Symptoms → Blood factors
• Most common symptom: PAIN → High salt content (calcium uric acid)
→ Range from mild (barely noticeable) to intense (requires • Medical conditions
hospitalization) → Renal tubular acidosis
→ Colicky - can get worse and better but does not completely go → Medullary sponge kidney
away; occurs in the flank or the lower abdomen → Hyperparathyroidism
• NOTE [Balasik trans] → Hyperuricemia
→ Sometimes patient present only numbness on the flank area • Other factors
▪ then patient presents with large stone
→ Climate changes
→ Not all patient with kidney stones present with pain – staghorn
→ Immobilization
calculi
→ Infection Types of kidney stones
→ Foreign body Type Relative proportion
• Urine passage
→ Abnormality with blockage Calcium oxalate 80%
• Kidney factors Calcium phosphate (apatite/brushite) 6%
→ Kidney excretes too much salt (calcium uric acid)
• Urine factors Combination
→ Too much salt
Magnesium ammonium phosphate 13%
→ Too little urine (struvite)
→ Too little inhibitor substance (citrate) Uric acid 15%
→ Infection Cysteine 2%
→ Too much acid Miscellaneous (drug crystals)
Treatment
• Can be managed medically
• Majority would pass out spontaneously
• Ureteric expulsion if less than 5mm
• Ureteric stones 5mm or less managed with:
→ Hydrotherapy - 2.5 L of urine output a day
→ Physical activity - jar the stone to loosen it
→ Medications
[Balasik trans]
Figure 28. Cystolithiasis
• Spontaneous passage: Width
B. CALCIUM NEPHROLITHIASIS → 4mm- 80%
Clinical Features → 4-6mm- 59%
• 75-90% of kidney stones → >6mm- 21%
• Composition: calcium oxalate - hardest • Stone location
• Typical calcium phosphate core → Proximal- 22%
• Calcium phosphate stone (apatite/brushite): uncommon → Middle- 46%
• Characteristic calcium oxalate crystals (envelope) → Distal- 71%
Uric acid crystals
MANAGEMENT [Balasik trans]
• Incidence: 10% of kidney stones
• Ureteroscopic ICL and Stone basket
• Radiolucent on plain abdominal film (unless secondary calcified
→ Ureteroscope is inserted in the ureter trying to locate the stone
• Crystalluria: rhomboid or football shaped
and retrieving through stone basket or through intracorporeal
• Occasional staghorn stone formation
laser lithotripsy to pulverized then allowed to pass out
• Association with gout, chronic diarrheal disease or ileostomy,
diabetes, and congenital disorders of purine metabolism (rare)
→ Not seen on KUB or CT
→ Staghorn = ginger – like appearance
C. INFECTION STONES
Clinical Features
• Stone composition: magnesium ammonium phosphate (struvite)
and carbonate apatite (triple phosphate)
• Chronic or recurrent urinary tract infection, anatomic abnormality
of urinary tract (neurogenic bladder, indwelling prosthetic devices)
→ Spinal cord injury, prolonged indwelling catheter, previous
urinary instrumentation [Balasik trans]
Figure 30. Uteroscopy
• Renal or perinephric abscess; renal insufficiency
• Extracorporeal shock wave lithotripsy (ESWL)
• Crystalluria: coffin-lid crystal
→ Absolute contraindication
▪ Pregnancy
▪ Ongoing UTI
▪ Uncontrolled bleeding tendencies
▪ Distal obstruction
▪ Uncontrolled hypertension
▪ Super obesity- F2 cannot be focused
→ NOTE [Balasik trans]
▪ Contraindicated also to patients taking blood thinner
▪ Patient does not have to be admitted
▪ OPD basis
▪ 300 shocks given for 1 hour then send patient home
▪ HU 600-700 = hard stone; tends to have multiple sessions
Figure 29. Infection Stones; B. Staghorn calculi = around 12 cm; most of the
time due to infective stone; mostly do not present severe flank pain [Balasik trans]

Figure 31. Extracorporeal shock wave lithotripsy (ESWL)
• Percutaneous Nephrolithotripsy • DA Vinci Robotic System

→ Innovation in urology
→ Used in kidney stones, genitourinary tumor
→ Has 36- degree movement of control system
Figure 32. Percutaneous nephrolithotripsy

• Open Surgery
→ Last option and if contraindicated to other management
D. ENLARGED PROSTATE (BPH)

DEFINITION OF TERMS
• Benign Prostatic Hyperplasia (BPH)
→ Histologic process of hyperplasia, which can be demonstrated
microscopically
• Benign Prostatic Enlargement (BPE)
→ Increase in total prostate volume because of BPH
• Benign Prostatic Obstruction (BPO)
→ Kidney is also removed, nonfunctional
→ Obstruction has been proven by pressure flow studies, or is
highly suspected from flow rates and if the gland is enlarged
• Bladder Outlet Obstruction (BOO)
→ Generic term for all forms of obstruction to the bladder outlet
(including BPE, urethral stricture)
• Laparoscopic Removal of Kidney and Ureteric

→ One way
ETIOLOGY
• Histopathologically
→ Increased number of epithelial and stromal cells
▪ Molecular etiology is uncertain
→ Impaired programmed cell death
• Role of Androgens
→ Needed in cell proliferation
▪ Does not directly cause BPH
→ Inhibits programmed cell death
• Diagnostic Examinations
→ Urinalysis
DIAGNOSIS ▪ To rule out hematuria and UTI
• Goal: Establish that symptoms are due to BPH via: → PSA
→ History ▪ If detection of cancer will alter management (10- year life
→ PE expectancy)
→ Diagnostic tests ▪ If contemplating 5-ARI therapy
• International Prostate Symptom Score SIGNS AND SYMPTOMS
→ Consists of 8 questions • Displeasure from residual urine
▪ 1-7 refers to urinary symptoms • Weak urine
▪ 8 refers to quality of life
• Urgent urine
• Frequent urine at night
• Much force needed
• Losing libido
TREATMENT

• Medical Therapy DIAGNOSIS
→ Alpha blockers • Digital Rectal Exam (DRE) 56%
→ 5-a-reductase inhibitors • PSA 17%
→ Combination therapy → Glycoproteins
→ “Patients presenting with absolute indication for → Prostate specific
intervention should be discourage from selecting medical → Seen in semen and blood
therapy” → 0-4 ng/mL
▪ Refractory Urinary Retention → No single cut-off values
▪ Failed Medical Treatment → Increases with disturbance of normal prostatic architecture
▪ Persistent Gross Hematuria
▪ Recurrent UTI STAGING
▪ Renal Insufficiency
▪ Upper Tract Deterioration
▪ Bladder Calculi
• Minimally Invasive and Endoscopic
→ Transurethral Resection of Prostate (TURP)
→ Transurethral Incision of Prostate (TUIP)
→ Transurethral Microwave Therapy (TUMT)
→ Transurethral Vaporization of Prostate (TUVP)
→ Transurethral Holium Laser
• Open Surgery
→ Open Prostatectomy
▪ Very large gland
▪ Previous urethral surgery
▪ Cystolithiasis
▪ Bladder diverticulum
▪ Inguinal hernia
▪ Positioning problem
▪ Retropubic/ Suprapubic
IV. GENITO-URINARY TUMOR
A. PROSTATE
1. PROSTATE CANCER
• Prostate cancer is now the third leading cause of death among
Filipino men
• 19.3 out of every 100,000 Filipino men are afflicted with the
disease (Based on NKTI) ACTIVE SURVEILLANCE
ETIOLOGY/ RISK FACTORS • Very low risk/ low risk
• Greater than or equal to 10 years life expectancy
• Age
• Actively monitor course of disease
• Race
• Defer unnecessary treatment and side effects
→ African American
• Intervene with curative intent if cancer progresses
• Genetic/ Familial
MONITORING
• PSA not more often than every 6 months
• DRE not more often than every 12 months
• Biopsy not more often than every 12 months, unless clinically
indicated
TREATMENT
• Surgery
→ Radical prostatectomy if localized
• Radiation
→ ERBT/ Brachytherapy
METASTASIS
• Environment • Common site of metastasis:
• Chronic Inflammation → Bone
• Infection → Lymph nodes
• Exposure to Androgen/ Estrogen → Liver
• Vitamin D and Calcium → Lung
• Sexual activity • Treatment:
• Smoking → Chemotherapy
• Dietary fat → LHRH agonist/ antagonist
• Obesity → Anti- androgen
• Alcohol consumption → Orchiectomy
SIGNS AND SYMPTOMS • Timetable
• Asymptomatic → Detection of prostate cancer to metastasis
• Lower urinary tract symptoms ▪ Average: 8 years
• Low back pains → Metastasis to death
▪ Average: 3-5 years
• Numbness of lower extremities
B. RENAL WORK-UP
Anatomy of Kidney • Contrast CT scan
• 150 g in males • Metastatic evaluation
• 135 g in females → CXR
• 10-12 cm X 5-7 cm X 3 cm → Liver function tests
• Gerota’s fascia envelopes the entire kidney except inferiorly → Bone scan
→ Systematic review of abdominal or pelvic CT
Diagnostics • Renal biopsy (?)
• Ultrasound
STAGING
→ Wide use has resulted in early detection of renal tumors
• Contrast CT scan
→ Diagnostic modality of choice
→ Renal masses which enhance on contrast CT by more than
15 HU should be considered RCCA unless proven otherwise
• MRI
• Note: 10-20% of small, solid enhancing renal masses turn out to
be benign after excision
1. BENIGN RENAL TUMORS

• Renal Cyst
→ Most common benign lesion (70%)
→ More common in men
→ Prevalence increases with age
→ Category:
▪ Bosniak I (0%)
▪ Bosniak II (0-5%)
▪ Bosniak III (50%)
▪ Bosniak IV (75-90%)
• Renal Cortical Adenoma
→ 7-23%
• Metanephric Adenoma
• Oncocytoma
• Angiomyolipoma
• Cystic Nephroma
• Mixed Epithelial Stromal Tumor of the Kidney
• Leiomyoma
• JG tumor (Reninoma)
2. RENAL CELL CANCER/ CARCINOMA
• 2-3% of all adult malignancies
• Most lethal of all urologic cancers
• Arises predominantly from the proximal convoluted tubule
(Clear cell and Papillary types)
• Von Hippel-Landau disease (VHL) is the familial form of the
common variants
• Hereditary papillary RCC (HPRCC) is the 2nd type
SIGNS AND SYMPTOMS
• Classic Triad (fever, flank pain, hematuria) is no longer
pathognomonic
• Incidental finding on abdominal UTZ
PATHOLOGY
• RCC’s are adenocarcinomas derived from the tubular epithelial
cells
• Conventional (Clear Cell) RCC (70-80%)- has a worse prognosis
• Chromophobe (Papillary) RCC- 2nd most common type (10-15%)
with high tendency for multicentricity (40%) TREATMENT
• Collecting duct (Bellini) RCC- most rare
PARANEOPLASTIC SYNDROMES
• Found in 20% of patients
• Hypertension and polycythemia
• Stauffer’s syndrome
→ 3-20%
→ Non-metastatic hepatic dysfunction
→ Hepatic function normalizes after nephrectomy (60-70%)
• Hypercalcemia
→ 13% of patients
→ Osteolytic bone mets
→ IV Biphosphates are the standard of care
• Surgery- remains the mainstay for cure

→ Nephron sparing surgery/ partial nephrectomy
→ Radical Nephrectomy (RN)
▪ Approach (retroperitoneal, transabdominal,
thoracoabdominal) will depend on the preference of the
surgeon and the location of the tumor
▪ Laparoscopic RN- fast emerging as the treatment of
choice
▪ Routine retroperitoneal lymphadenectomy (RPLND)-
controversial
→ Partial Nephrectomy
▪ Treatment of choice for all T1a(<4cm) tumors
▪ Recommended for all T1 (<7cm) tumors
▪ Open partial nephrectomy is still considered the gold
standard
▪ Laparoscopic and robotic assisted PN show comparable
results
C. ADRENAL TUMOR
• Renal Biopsy
→ Patients who refuse or are unfit for surgery (candidates for
active surveillance, RFA, cryoablation)
→ Patients with Metastatic RCC prior to systemic therapy
→ Renal metastasis
• Metastatic RCC
→ RCCA is generally poorly responsive to chemo and radiation
therapy
→ Cytoreductive nephrectomy was, historically, the primary
treatment option with no effect on survival if used alone
→ Systemic therapy was limited to Cytokines (Interleukin 2,
interferon alfa)
▪ Limited due to toxicity
▪ Limited clinical benefit
FOLLOW-UP
ANATOMY
• Medulla
→ innervated by presynaptic SYMPATHETIC fibers and secrete
CATECHOLAMINES
• Cortex
→ Outer- Zona glomerulosa (Aldosterone)
→ Middle- Zona fasciculata (Glucocorticoids)
→ Inner- Zona reticularis (Androgens)
1. CUSHING’S SYNDROME
• Caused by excess circulating glucocorticoids
• More common in young adults and females
• Therapeutic steroid use is the most common cause

4. INCIDENTALLY DISCOVERED ADRENAL MASS
• Hypertension, hypokalemia, hypernatremia, metabolic alkalosis,
periodic paralysis
• Solid tumors 6cm and above should be considered malignant
unless proven otherwise
TREATMENT
• Adrenalectomy
• Adjuvant therapy is generally ineffective
• Mitotane (adrenolytic drug) is the only agent shown to have
clinical response as adjuvant therapy (34%)
• Note: Adrenal metastasis is seen in 50% of patients with
Malignant melanoma, breast and lung cancer and 40% in
patients with RCCA
D. BLADDER CANCER
WORK-UP
• 24-hour urine cortisol (2-3 consecutive specimens)
• Dexamethasone suppression test
• Late night salivary cortisol
• Concurrent measurement of plasma ACTH and cortisol
• CT scan
TREATMENT
• Steroid withdrawal • 3x more common in men than women
• Adrenalectomy • Painless gross hematuria (>85%)
• Metapyrone • Median age at diagnosis is 70 y/o
• Ketoconazole • Cigarette smoking (fourfold increase in risk)
• Aminoglutethimide • Most cancers are TCCA/ urothelial (<90%)
2. PHEOCHROMOCYTOMA • Squamous cell and AdenoCA- most common non-urothelial
• Chromaffin cells secrete epinephrine, norepinephrine and tumors
dopamine • Diagnosis of Squamous cell and AdenoCA usually yield
• VMA advanced disease and progression is similar to that of high-grade
→ Primary urinary metabolite of catecholamine urothelial CA
• Metanephrine, normetanephrine and their derivatives contribute • Almost all patients with metastases develop muscle invasive
to total metabolic products disease before or at the time of recognized metastatic disease
• Intractable hypertension → Liver (38%), Lung (36%), Bone (27%), Adrenals (21%),
• 10% of patients- are normotensive Intestine (13%)
• 10-20%- are malignant → Lymphatic spread occurs earlier and is independent of
hematogenous mets.
TREATMENT • Pelvic lymph nodes:
• Antihypertensives → External iliac (65%)
• Adrenalectomy → Obturator (74%)
• Excision of extra-adrenal lesions → Paravesical nodes (16%)
3. CONN’S SYNDROME → Internal iliac (25%)
• Hypertension, hypokalemia, hypernatremia, metabolic alkalosis, STAGING
periodic paralysis
• Primary physiologic control is Angiotensin II
TREATMENT
• Adrenalectomy
• Spironolactone/ Eplerenone (aldosterone receptor antagonist)
STAGING TESTS
• CT scan/ CT urogram
• CDE MRI
• IVP
• CXR/ Chest CT scan
• Bone scan
TREATMENT
• Radical Cystectomy
→ The gold standard
→ Radical cystectomy (cystoprostatectomy for males, anterior
pelvic exenteration for females) + bilateral PLND
→ Recurrence free survival 85% at 5 years, 82% at 10 years for
organ-confined disease
→ 58%-5 year, 55% 10-year survival in extra-vesical disease
→ 35% 5-year, 34% 10-year survival in node positive
ROLE OF CHEMOTHERAPY
• Neoadjuvant Chemotherapy
→ Potential tumor downstaging
→ Treatment of micrometastasis
→ Cisplatin based regimen- showed best results
→ Potential improvement in overall survival (57% improvement
vs 43% 5-year survival, SWOG trial)
→ 5-6% improvement in survival
E. TESTICULAR TUMOR
• Germ Cell Tumors
→ Pure seminoma
→ Non-seminoma: Yolk sac, Embryonal, Choriocarcinoma,
Teratoma
• Non-Germ Cell Tumors
→ Sex Cord/Stromal Tumors: Leydig, Sertoli Cell Tumors
→ Sex Cord/ Gonadal with Germ cell containing:
Gonadoblastoma
• Secondary Tumors
→ Lymphoma, Leukemic Infiltration, Metastatic Tumor
PRESENTATION
• More common on the Right (cryptorchidism R>L)
• Painless solid testicular mass
• Swelling and tenderness- associated with orchitis and
infarction component
• Gynecomastia- 30-50% of Leydig or Sertoli Tumors
• Bilateral tumors- lymphoma most common
• Back pain or abdominal mass- for retroperitoneal metastasis
DIAGNOSTIC WORK-UP
• History and Physical examination
• Testicular ultrasound
• CBC, serum creatinine, liver function tests
• Chest x-ray
• Abdominal CT scan
• Chest CT scan- if with (+) abdominal CT findings
• Inguinal orchiectomy to confirm diagnosis
• Sperm banking- for any interventions that may compromise
infertility; RPLND, radiation, chemo Tx
TREATMENT
• Surgery: Radical Orchiectomy
• Chemotherapy: Sensitive
• Radiotherapy: Sensitive
V. REFERENCE
• Dr. Pasco’s pdf slides

Upper Extremity Trauma
Doc Cayetano | April 23, 2022
Trans by: Cayabas, Dela Rosa, Gonzales
OUTLINE
I. Clavicle Fractures B. Proximal Humerus
II. Scapula Fractures
III. Shoulder Dislocations IV. Humeral Shaft Fractures
A. Dislocations of the V. References
Glenohumeral Joint
I. CLAVICLE FRACTURES
Clinical Evaluation
• Inspect and palpate for deformity/abnormal motion
• Thorough distal neurovascular exam
→ Example: underneath your clavicle is your subclavian artery.
If you have laceration in your subclavian artery, no pulse in
your wrist
• Auscultate the chest for the possibility of lung injury,
hemothorax, or pneumothorax
→ Take Xray afterwards Figure 3. Displacement
Radiographic Exam Treatment
• Closed Treatment
→ Sling immobilization for usually 3-4 weeks with early ROM
encouraged (to prevent frozen shoulder)
• Operative Intervention/Indications
→ Fractures with neurovascular injury (palpate radial and ulnar
pulse distally to check subclavian vessel)
→ Fractures with severe associated chest injuries (ex: when you
have pneumothorax, fix the clavicle. Because even if you have
drained from the chest wall, the clavicle will pierce it again.
What pierces lung? Distal Clavicle because proximal
displaces superiorly due to sternocleidomastoid muscle)
→ Open fractures (debridement. Open wound to expose fracture
then fix it)
Figure 1. AP Chest Radiograph (To see if the fracture goes up or goes down)
→ Type II fractures (Why fixate? Very common to nonunion.
Usually it will not heal that’s why operative is a must)
→ Cosmetic reasons, uncontrolled deformity
→ Nonunion
→ Shortening and displacement >2cm (ex: sternocleidomastoid
has pulled the clavicle >2cm)
• Surgical Treatment
→ Plate
Figure 2. Serendipity View (to look underneath the clavicle. To see if there is a
fracture going anteriorly or posteriorly)
Figure 4. Plate with screws going into the bone providing stability
Allman Classification of Clavicle Fractures
• Type I: Middle Third (80%)
• Type II: Distal/Lateral Third (15%)
• Type III: Medial Third (5%)
Displacement
• When you have fracture at middle third clavicle (Type I), proximal
and medial fragment will be pulled superiorly because of the
action of Sternocleidomastoid muscle. Also, because of the
pectoralis, which is inserted in the lateral of bicipital groove,
pulling your shoulder towards the midline, so there is a tendency
of the lateral fragment to go medially. And because of the weight
of your arm, distal fragment will displace inferiorly while medial
fragment will displace superiorly.
Trans # 25 Upper Extremity Trauma 1 of 11
→ Pin Treatment – Scapular Body Function (Type IV)
• Non-surgical (because this is just like sandwich between 2
muscles. Anterior to scapula is subscapularis, posterior is
infraspinatus and teres minor)
Treatment – Coracoid Fracture
• Tip of the coracoid – avulsion of the conjoint tendon (surgical).
Short head of biceps and coracobrachialis muscles = Conjoint
tendon
• Between the coracoacromial and coracoclavicular – non-surgical
• Base of the coracoid – usually non-displaced (non-surgical)
• Basal fracture extending to glenoid – surgical. Especially if 1cm
medial displacement and 40’ angulation of glenoid
Treatment – Scapular Spine Fracture
• Generally treated closed (non-surgically)
Treatment – Acromion Fracture
• Surgical when:
→ Avulsion with significant muscular detachment of short head
Figure 5. Pin goes into the intermedullary canal of the clavicle of biceps and coracobrachialis muscles
(Not discussed which one is better and its biomechanics. At your level, just know
that what we can do is plate or pin) → Impingement of the subacromial space
→ Component of the subacromial space
II. SCAPULA
SSSC: Superior Shoulder Suspensory Complex
Ada-Miller Classification • Bone and soft tissue ring
• 1a – acromion When you trace your spine of your scapula at your → Glenoid process
back and trace it anteriorly, anteriorly it will become the acromion. → Coracoid process (anterior projection)
Anterior projection - lateral) → Coracoclavicular ligament
• 1b – base of acromion → Distal clavicle
• 1c – coracoid (anterior projection – more medial and inferior) → AC (Acromioclavicular) joint
• IIa – neck lateral to the base of the acromion, spine → Acromial process
• IIb – neck extended to base of acromion
• IIc – neck transverse type (will go just below glenoid process)
• III – Intra-articular type (will go to glenoid process)
• IV – body of scapula
Figure 8. SSSC
• Double disruption: ORIF (Open Reduction and Internal Fixation)
is recommended at one site) (any 2 portion of these SSSC
mandates surgery)
III. SHOULDER DISLOCATIONS
Figure 6. Ada-Miller Classification
Treatment – Glenoid Fracture
• Surgical Indication:
→ Displaced function with humeral head subluxation
→ Angulation of >40’ or with 1 cm medial displacement
Figure 9. Shoulder Dislocation

• Fracture – break in the bone
• Dislocation – displacement of the bone on the joint. Shoulder
dislocation = glenohumeral joint
Epidemiology
• Anterior: Most common (in contrast to hip dislocation: posterior)
• Posterior: Uncommon, 10%, Think Electrocutions & Seizures
Figure 7. In this case, No subluxation of angulation.
• Inferior (Luxatio Erecta): Rare, hyperabduction injury (when you
elevate your arm at about 90’-100’, your greater tuberosity will hit
your acromion. When your hit your acromion, further elevation of

arm is caused by rotation of scapula. However, if too much force • Nerve: Axillary nerve neuropraxia
is exerted after greater tuberosity bangs on acromion, humeral
A. DISLOCATIONS OF THE GLENOHUMERAL JOINT
head will be displaced inferiorly)
Anterior
Clinical Evaluation
• Most common
• Examine axillary nerve (deltoid function, not sensation over
lateral shoulder). (Upper third deltoid is supplied by • External rotation and hyperextension of the arm in overhead
supraclavicular nerve. Middle third deltoid is supplied by axillary direction
nerve. Inferior third is supplied by radial nerve. So, make sure → Most common way to dislocate it
you are testing the middle third when checking axillary nerve) → Like for example you are going to throw a ball.
• Examine Musculoskeletal nerve (biceps function and → We term that as ABER (abduction, external rotation)
anterolateral forearm sensation) • Damage: anterior labrum may be torn, rotator cuff torn or avulsed,
glenoid rim may be fractured
Radiographic Evaluation
→ When you have shoulder dislocation that is anterior, your
• True AP shoulder Xray (check if it is dislocated superiorly or anterior labrum may be torn and we call this Bankart,
inferiorly) → The rotator cuff could be torn or avulse, or the glenoid rim may
• Axillary Lateral (check anterior or posterior dislocation) be fractured specially in the anterior inferior aspect of the
• Scapular Y (check anterior or posterior dislocation) glenoid rim and we call that bony Bankart
• Stryker Notch View (Bony Bankart) • Hill-Sach’s defect: posterolateral recoil of humeral head against
→ Bankart injury – injury to anterior-inferior aspect of glenoid, the anterior glenoid rim
capsule is detached from that area when you have dislocation. → Caused about by banging of the posterior aspect of the
Apart from the capsule, there could be a bone there → Bony humeral head against the anterior aspect of the glenoid
Bankart • Axillary nerve palsy – 9-10%
Anterior Dislocation Recurrence Rate • Avulsion of rotator cuff – unable to abduct arm
• Age 20: 8-92% → This is like presenting an axillary nerve palsy – motor nerve of
→ Most of the dislocations happen below 20 y/o because most the axillary nerve.
of the sport activities are being done in this age[doc] → What will make you differentiate between a rotator cuff tear
• Age 30: 60% and axillary nerve palsy?
• > age 40: 10-15% → Take an MRI, because your physical exam will be the same-
Look for concomitant injuries: the patient could not elevate his arm. In MRI, you could see
an avulsion of the rotator cuff.
• Bony:
→ Bankart – it is an avulsion of the capsule along with the bone Posterior
in the anterior aspect of glenoid[doc] • Adduction/Flexion/Internal rotation at time of injury
→ Hill-Sachs lesion – is an impression on the posterior aspect • Electrocution and seizures cause overpull of subscapularis and
of the head of the glenoid. Remember, the most common latissimus dorsi
dislocation is anterior, so when your anterior head dislocates • Reduce with traction and gentle anterior translation (avoid ER
anteriorly, the posterior aspect of humeral head will bump arm →Fx)
against the anterior-inferior aspect of glenoid and that → This is more common in electrocution injury or when you have
impression on the humeral head specially in the posterior a seizure which is caused about by the overpull of
aspect is called Hill-Sachs lesion. [doc] subscapularis and latissimus dorsi.
→ Glenoid fracture → Subscapularis is a muscle originating anteriorly from the
→ Greater tuberosity fracture – also associated with shoulder anterior aspect of scapula inserting into lesser tuberosity.
dislocation[doc] Latissimus dorsi originates posteriorly from the spine and
• Soft tissue: subscapular tear, rotator cuff tear (older pts with inserts to the floor of the bicipital groove. Both of these, the
dislocation) subscapularis and latissimus dorsi which are actually a very
→ In older people when they have dislocation the focus is big muscle, their strength is very tough.
the tear of the rotator cuff. As in contrast for younger → Latus – muscle; Imus – biggest; dorsi – back. So, it’s the
population, the focus is the stability of the shoulder joint. biggest muscle on your back. And subscapularis is among the
[emphasized by doc] rotator cuff which is the biggest one. Even if the other muscle
→ When we say rotator cuff tear, almost always we are talking contracts, these two muscles have the greatest force.
about the supraspinatus. So, when your supraspinatus is Because of their orientation, they tend to internally rotate the
torn, the patient could not elevate the arm. shoulder. It will forcefully internal rotate your humeral head
→ If the patient cannot elevate his arm, either his deltoid is off against your glenoid and that will cause posterior dislocation.
(meaning the axillary nerve is problematic), or you have a tear → How are you going to reduce posterior dislocation?
of supraspinatus. ▪ Reduce it with traction and gentle anterior translation. We
• Vascular: Axillary artery injury (older patients with should avoid external rotation of the arm because it is
atherosclerosis) usually locked in place. If you force an external rotation,
→ Axillary nerve is around 5 cm inferior to acromion. So, right you might have a fracture.
there it could be injured.
→ How will you examine the axillary nerve? Remember axillary
nerve innervates the deltoid. After realignment or after
reduction, you could check for the strength of the deltoid and
that is being accorded by the axillary artery. But prior to
reduction, what you could test is the sensation of the axillary
artery and how are you going to take note of the sensation of
the axillary artery? We look at the mass of the deltoid:
▪ superior part of the deltoid prominence is being supplied
by supraclavicular nerve
▪ middle part of that is being supplied by the axillary nerve
▪ inferior aspect of deltoid prominence is being supplied by
the radial nerve.
***(Remember these! These might be given in the exam)

Figure 10. Posterior Dislocation
Inferior Dislocations
• Luxatio Erecta Figure 13. Modified Axillary View
→ Hyperabduction injury • Axillary view on Xray
→ Arm presents in a flexed “asking a question” posture (it’s like ▪ Green – coracoid process
raising their arm). ▪ Red – glenoid
▪ Yellow – humeral head
Figure 11. Luxatio Erecta Figure 14. Axillary Lateral View

• When you do your abduction, your greater tuberosity will bang
against your acromion at 90 degrees or about 100 degrees and • So, this is dislocated posteriorly because the coracoid process is
further elevation of that will cause turning or rotation of scapula. anterior. This is the value of doing axillary lateral, you could tell if
But if you do that forcefully, you might tear the inferior aspect of it is dislocated anteriorly or posteriorly.
the capsule and it will cause the humeral head to dislocate
inferiorly, and we call the Luxatio Erecta.
X-rays to request when your suspecting a shoulder
dislocation:
• Axillary lateral
Figure 15. Reverse Hill-Sach

• In the humeral head you will notice an impression, this is banging
on the posterior aspect of the glenoid. This is called reverse Hill-
Figure 12. Axillary Lateral
Sach. If I show you this Xray in the exam and ask if this is a Hill-
• Modified axillary view sach’s lesion, a bony bankart, or reverse Hill-Sach? The answer
is reverse Hill-Sach. Remember Hill-Sach’s lesion? It is an
→ If abduction is too painful for the, patient we do this. impression of humeral head caused about by the banging of
humeral head against the anterior aspect of your glenoid.

Non-operative Treatment → You can tell the patient to relax or sleep. Afterwards, you will
• Close reduction. hear or feel a pop on his shoulder and you take an X-ray and
→ Reduce the shoulder dislocation in general, it will be aligned or reduced.
→ It should be done promptly after adequate clinical evaluation
and appropriate sedation.
• Reduction maneuvers
→ or how are we going to make our hilot in order for the shoulder
to realign.
• Immobilization: sling in internal rotation (3 weeks)
→ In general, we would immobilize the shoulder in a sling in
internal rotation for 3 weeks then after 3 weeks we would
remove the arm sling and the person could start a
rehabilitation exercise or in other words, just move it.
• Rehabilitation exercises (range of motion and rotator cuff
strength)
Reduction Maneuvers
• Traction – counter traction
→ Generally used with a sheet wrapped around the patient and
one wrapped around the reducer
→ Most common method
→ Place a towel around the axillary area and the assistant should
pull on this gently while the surgeon pulls the arm
longitudinally. Figure 18. Modified Stimson Technique
Operative Indications
• Irreducible shoulder dislocation (soft tissue interposition)
• Displaced greater tuberosity fractures
• Glenoid rim fracture bigger than 5 mm (Bankart)
• Elective repair for younger patients
• Meaning of operative intervention (take note of this one):
→ Operations that we do either we could not align the shoulder
in the first place, or it keeps on dislocating even if we have
aligned it already. Because we are talking of trauma, we are
talking of something that is acute in nature.
B. PROXIMAL HUMERUS FRACTURES
Figure 16. Traction-counter Traction

• Hippocratic technique
→ Effective for one person
→ One foot placed across the axillary folds and onto the chest
wall then using gentle internal and external rotation with axial Figure 19. Proximal Humerus Fracture
traction • ANATOMY OF THE SHOULDER GIRDLE
→ Four anatomic components:
▪ Head
▪ Greater tuberosity
− Where supraspinatus and infraspinatus are attached
▪ Lesser tuberosity
− Insertion of subscapularis
▪ Shaft
Figure 17. Hippocratic Technique

• Modified Stimson Technique
→ Patient is placed in a prone position with the affected extremity
allowed to hang free. Gentle traction may be used.

vascular supply could be cut off and that will produce avascular
necrosis.
• In the 3rd part of axillary artery we have anterior humeral
circumflex artery which will ascend as arcuate artery going to
humeral head
Figure 20. Anatomic Components of Shoulder Girdle

• Muscle attachments
→ Greater tuberosity: Supraspinatus and infraspinatus
→ Lesser tuberosity: subscapularis
→ Humeral shaft: pectoralis major and deltoid
Figure 23. Vascular Anatomy
• The posterior circumflex artery provides 64% of the blood supply
to the humeral head overall, whereas the anterior head
circumflex artery supplies the 36%.
• Majority of the supply of the humeral head comes posteriorly. It
will justify our idea of approaching our incision anteriorly.
More recently described fracture types:
• How are we going to tell if the humeral head is going to die by
looking in an X-ray?
• Impacted-valgus fractures: residual vascularity may be
maintained through an intact medial soft tissue sleeve (impacted
valgus = humeral head is pointing up; this is okay because it
tends to maintain medial soft tissue sleeve and will prevent
Figure 21. Humeral Head avascular necrosis)
• Deforming force
→ Displacement secondary to muscle pull
→ Shaft: pulled medially and anteriorly by the action of deltoid
and pectoralis muscle
→ Greater tuberosity: pulled posteriorly and superiorly by the
action of supraspinatus and infraspinatus muscle
→ Lesser tuberosity: pulled medially by the action of
Subscapularis
→ Articular surface: pointing up, down, posteriorly, or anteriorly
depending on the initial force that was applied
→ Fracture occurs posterior to the groove.
• Vascular anatomy of the humeral head
Figure 24. Impacted Valgus Fracture
• Varus fracture – (will tend to cause more damage to vascular
supply)
Figure 25. Varus Fracture

• Fractures with partial articular involvement – (will tend to
decrease the vascularity)
Risk of Avascular Necrosis (based on number of fragments)
Figure 22. Vascular Anatomy • 3-part fracture – will cause 12-25% of avascular necrosis
• This is specifically important because when we are talking about
proximal humeral fracture there could be a tendency that the

• 4-part fracture – (head is detached, the greater tuberosity is
detached, lesser tuberosity is detached from the shaft) 21-75%
avascular necrosis
• Valgus 4-part fracture – 8-26% (if pointing up; has a greater
chance of survival)
• Why do we want to know the risk of avascular necrosis? Because
when you have so much risk for avascular necrosis like for
example you have a 4-part fracture, it is not wise to fix the fracture
anymore, it is not wise to do ORIF. If we are expecting high level
of avascular necrosis, we will just replace the head with a metal
and we call that shoulder replacement (see Adult Orthopedics
discussion)
Figure 29. The lateral displacement of the head the medial hinge displacement
and <8mm displacement of the metaphyseal area, will dictate 97% of avascular
necrosis. This is most likely to die.
Figure 30. This one looks more terrible. However, if we’re going to use the
research by Hurtle, the medial hinge is not displaced and the metaphyseal head
Figure 26. Displaced Fractures extension is > 8mm so this head is likely viable.
2 Criteria to Predict Ischemia: (other ways to measure
avascular necrosis; by Hurtle) Diagnostics
• 97% positive predictive of ischemia if both factors are present • Standard:
→ Metaphyseal head extension < 8mm (the more extension, the
better chance of living)
Figure 31. AP
Figure 27. Metaphyseal Head Extension
→ Medial hinge displaced > 2mm (the one on the left, non-
displaced, has better chance of survival)
Figure 32. Scapular Y
Figure 28. Medial Hinge Displacement

→ Hemiarthroplasty (partial shoulder replacement – replacing
the humeral head)
→ Total shoulder arthroplasty (replacing the glenoid and
humeral head – replacing the glenoid and humeral head)
→ Reverse shoulder arthroplasty
Closed/Minimally Invasive Reduction & Percutaneous
Fixation
• 2-part surgical neck fractures
• 3-part and valgus-impacted
• 4-part fractures in patients with good bone quality, minimal
metaphyseal comminution, and intact medial calcar
Figure 33. Axillary
Planning Treatment
• 3D-CT (sometimes, X-ray is not enough. The best way to plan for
intervention is to do 3D-CT)
→ Accurate assessment of the degree of subluxation and
angulation of the humeral head
→ Extent of separation of the shaft from the head (you will see if
there is a split of the head because head splitting fracture is
indicative for avascular necrosis and we you have head
splitting fracture it’s better to do replacement than fixing the
head)
→ Degree of separation of any marginal fragments of tuberosity
→ Presence of any marginal fragments of the articular surface
attached to the tuberosities
Treatment Options
• Non-operative: sling immobilization followed by progressive Figure 35. Closed/Minimally Invasive Reduction & Percutaneous Fixation
rehab indications (***involves multiple pins)
→ 85% minimally displace Intermedullary Nailing
→ Minimally displaced surgical neck fracture (the proximal • Surgical neck fractures or 3-part greater tuberosity fractures in
humerus has two necks: anatomical and surgical. Anatomic younger patients
neck is the area just distal to articular surface. The surgical • Combined proximal humerus and humeral shaft fractures
neck is between the greater and lesser tuberosity, that is • We insert a nail when we place multiple screws)
where the fracture usually happens and surgery is indicated.
But when you have minimally displaced surgical neck fracture,
you can do non-operative intervention)
Figure 36. Intermedullary Nailing

Hemiarthroplasty
• Anatomic neck fractures in elderly (initial varus malalignment >
20 degrees)
• Severely comminuted 4-part fractures and fracture-dislocations
• Rotator cuff compromise
• Glenoid surface is intact and healthy
• Chronic nonunions or malunions in the elderly
Figure 34. Minimally displaced surgical neck fracture. • We are replacing the humeral head
• Greater tuberosity fracture displaced < 5mm
• Elderly patient with underlying comorbidities neurological, stroke,
unable to use that arm ((this is the most common indication of
non-operative treatment; doing the surgery might be risky for
them already or for example they have stroke in that arm or they
could not elevate their arm anymore because for rotator cuff
injury, it is wiser not to operate)
→ *** start early range of motion within 14 days (when should we
remove the arm sling? Around 2 weeks) (ROM and pain score
are the same in non-operative and operative treatment for
elderly patients)
• Operative
Figure 37. Hemiarthroplasty
→ CRPP (closed reduction percutaneous pinning) (hilot – in
• Younger old active 4-part head-splinting fractures with
order to align the fracture; percutaneous pinning – poke a
incongruity of humeral head
metal/pin going to fracture with the guidance of X-ray) • Humeral head impression defect of > 40% of articular surface
→ ORIF with plates • Detachment of articular blood supply (most 3- and 4-part
→ Intramedullary rodding fractures)

Reverse Total Shoulder Arthroplasty
• Elderly individuals with non-reconstructible tuberosities
• Anatomic total arthroplasty (first pic below) – the head looks like
a head, the glenoid looks like a glenoid
• Reverse shoulder arthroplasty (second pic below) - the head
looks like a glenoid, the glenoid looks like a head
Figure 40. Plates
IV. HUMERAL SHAFT FRACTURES
Figure 41. Humeral Shaft Fractures

• Radiographic Evaluation
→ AP and lateral views of the humerus
→ Traction radiographs may be indicated for hard to classify
secondary to severe displacement or a lot of comminution (if
there is too much comminution (second pic above), you might
not be able to understand how the fractures will interdigitate
each other so you could do a traction film)
• Non-surgical Treatment (placement of functional brace)
→ Good results
→ Very high union rates
→ Treated initially with hanging arm cast or sling
→ Humeral functional brace (2-3 weeks’ post-injury)
→ Active ROM is advised (to prevent stiffness of elbow and
shoulder)
Figure 39. Total vs Reverse Shoulder Arthroplasty
Plates for Proximal Humerus
• Locking Proximal Humerus
• Plate – synthes

Figure 42. Functional Brace
• Conservative Treatment: hanging arm cast followed by a
functional brace Figure 44. Internal Fixation with Plates and Screws
→ 20 degrees of anterior angulation • Intramedullary Nail – humerus (applied intramedullary in the
→ 30 degrees of varus angulation bone)
→ Up to 3 cm of shortening are acceptable (this is the only bone → Flexible nails or more rigid interlocking nails
in the body that a 3 cm shortening is allowable without
functional impairment; unlike in femur, if there is 1 cm
difference, there will be limping; or in radius-ulna, forearm
rotation will be affected)
Figure 45. IM Nail

→ Anterograde or retrograde
Figure 43. Hanging Arm Cast ▪ Anterograde (insert the rod from proximal going distal) –
• Operative greater tuberosity, shoulder pain, 95% union rate
→ Open fractures (Type II and greater) (if you have type I, non- ▪ Retrograde (from distal going proximal) – weakens distal
operative can do) humerus, 91% union rate
→ Unacceptable alignment (more than 20-degree angulation
anteriorly, more than 30 degree varus/valgus)
→ Floating elbow (fracture of humerus and forearm) or shoulder
(fracture of clavicle or scapula plus humerus)
→ Bilateral humeral fractures (the mobility of patient is
decreased)
→ Pathological fractures (pathology in the bone prior to fracture
such as infection, malignancy, osteoporosis)
→ Polytrauma (head injuries, burns, chest trauma, multiple
fractures)
→ Nonunion fractures with intra-articular extension
→ Most commonly treated with plates and screws but also
intramedullary nails.
• Internal fixation with plates and screws (applied on the
surface of the bone)
→ Considered an excellent method of treatment
→ Need for exposure
→ Radial nerve concern

Figure 46. IM Nail
Radial Nerve Palsies
• one thing to look for because radial nerve winds around the radial
groove in the posterior aspect of the arm
• Usually neuropraxia due to fracture displacement
• Spontaneous recovery occurs within 3-4 months after injury in
90% to 100% of patients
• Open fracture with radial nerve palsy is an indication for surgical
exploration
• Holstien Lewis – oblique, distal third (associated with radial
nerve palsy)
• Middle 3rd – most common site of injury because radial
tuberosity is there
Figure 47. Radial Nerve Palsies
V. REFERENCES
• Doc Cayetano’s Discussion

Upper Extremity Trauma Part 2
OUTLINE → Medial collateral ligament (Ulnar)

→ Lateral collateral ligament (Radial)
I. Elbow Dislocation E. Treatment
A. Epidemiology F. Associated Injuries → Annular ligament- encircles the humeral head
B. Mechanism of Injury II. Olecranon Fractures
C. Radiographic III. Forearm Fractures
Evaluation IV. Reference
D. Anatomy
I. ELBOW DISLOCATION
Proximal Fragment
Figure 1. Medial collateral ligament

• MCL (medial collateral ligament) bands:
→ Anterior – STABILITY
Distal Fragment → Posterior
→ Oblique
A. EPIDEMIOLOGY
• Posterior dislocations - most common
B. MECHANISM OF INJURY
• Posterior dislocation following hyperextension, valgus stress,
arm abduction, and forearm supination
• Anterior dislocation ensuing from direct force to the posterior
forearm with elbow flexed (not very common)
• Most common dislocations (distal fragment):

Shoulder- anterior (humeral head)
Hip- posterior
Elbow- posterior (olecranon fossa)
• When we’re talking about anterior posterior, we’re talking
about distal fragment [Doc. Cayetano]
C. RADIOGRAPHIC EVALUATION
Figure 2. Lateral collateral ligament
E. TREATMENT
• AP and lateral elbow films should be obtained both pre and post
reduction
• In any view (because AP and lateral view might not be
possible due to the dislocation), your radial head should
always be congruent to your capitulum, the radiocapitellar
joint. [Doc. Cayetano]
D. ANATOMY • This is the way we would relocate the elbow dislocation, we
could either pull on the arm (pull on the forehand) or we could
• 50% of elbow stability is provided by skeletal anatomy of trochlea push on the olecranon. Because remember the most common
and olecranon dislocation for the elbow is posterior. [Doc. Cayetano]
• Soft tissue stability:
Trans # 26 Upper Extremity Trauma Part 2 1 of 5

• Classified as:
→ Simple- no associated fractures
→ Complex- with associated fracture
F. ASSOCIATED INJURIES
• Medial or lateral epicondylar fracture (12-34%)
→ When you have an elbow dislocation, consider that you might
have additional injury, so you should look for the medial
collateral epicondyle
• Coronoid process fracture (5-10%)
→ Type I
▪ Fracture of the intraarticular tip of the coronoid
▪ Treated with early mobilization
→ Type II
▪ Involves 50% of the coronoid
▪ If stable, treated as type I injury
▪ ORIF: unstable joint, (+) fragment block
→ Type III
▪ Involves >50% of the coronoid with posterior elbow
instability
▪ Tx: ORIF
Treatment
• Non displaced fractures or those displaced <2mm w/o
mechanical block (treated with early motion and functional
rehabilitation)
• Displaced fracture >2mm articular step off, >20-30% depression
or bony block require surgical treatment
→ Surgical excision of ORIF
• Multifragment or comminuted fractures are reconstructed with lag
screw and plate fixation
• Hemiathroplasty may be necessary when an axial forearm
(Essex Lopresti lesion) or valgus elbow (elbow dislocation)
stabilizer is required
• Metal modular prostheses allow improved reconstruction of
Figure 3. Coronoid fractures patient’s preinjury anatomy
• Radial head fracture (5-11%)
→ Examination of the MCL, DRUJ, interossseous membrane is
critical
→ The radial head is a secondary stabilizer to valgus load at the
elbow, and resist proximal migration of the radius when there
is injury to DRUJ (Distal radioulnar joint) and interosseous
membrane
• Essex Lopresti lesion

→ Radial head fracture plus dislocation of DRUJ and
interosseous membrane disruption
• Mason classification:
→ Type I: non displaced
→ Type II: marginal fx with displacement (impaction,
depression, angulation)
→ Type III: comminuted fxs involving the entire head
→ Type IV: associated with dislocation of elbow • If we have a comminution of the radial head, the treatment
could be one, excision. But with excision there is a risk for

proximal migration, especially if you have Essex Lopresti.
Another thing you could do is ORIF by placing a plate, but if
you could not really do ORIF because the fracture is really
comminuted, we will do Hemiarthroplasty. [Doc. Cayetano]
II. OLECRANON FRACTURES

A. MECHANISM
• Tension bending
→ Movement results to transverse or oblique fracture (due to
sudden force)
→ Hanging on to hand to avoid falling
• Direct load Figure 7. Plate
→ Results in comminution with depressed articular fragments
→ Hitting olecranon directly on the floor/hard surface
III. FOREARM FRACTURES
B. TREATMENT
A. ULNAR FRACTURES
• Non-displaced fractures (displacement of <2 mm) with intact
extensor mechanism can be treated non-surgically Nightstick Fracture
→ Long arm cast (4-6 weeks)
→ Splinting/brace • Isolated fractures of the ulna,
• Intact extensor mechanism - it's when you try to extend the typically transverse and
elbow and the patient could extend that elbow [Doc. Cayetano] located in the mid-diaphysis
and usually resulting from a
• Displaced fractures without intact extensor mechanism direct blow
→ ORIF (tension band or lag screw & neutralization plate)
→ Fragment excision with extensor mechanism reconstruction
Monteggia fracture
Figure 5. Tension Band Wire
• Fracture of the proximal or distal ulna with an associated radial

head dislocation
• To rule-out radial head dislocation, a line that passes through the
radial head and neck should align with the capitellum on
radiographic views
Galeazzi or Piedmont fracture
• Fracture of the
radius with associated
dislocation of the
radioulnar joint
• A reverse Galeazzi
Figure 6. Lag Screw denotes a fracture of the
distal ulna with
• Disruption of the
radioulnar joint

B. SIGNS OF DISRUPTION OF DISTAL RADIOULNAR JOINT Smith Fracture (Reverse Colles)
• Ulnar styloid fracture • Fracture with volar

• Widening of the distal angulation (apex
radioulnar joint space on the dorsal) from a fall on
AP xray a flexed wrist
• Dislocation of the radius
relative to the ulna on the
lateral xray
• Radial shortening >5 mm
Barton Fracture
C. FRACTURES OF NECESSITY
• Necessary to do an ORIF to have a good result
• Monteggia fracture
• Galeazzi fracture
D. FRACTURE OF RADIUS AND ULNA
• Indications for Open Reduction of Fractures of the Shafts of the
Radius and Ulna
→ All displaced fractures of radius and ulna in adults
→ All isolated displaced fractures of the radius
→ Isolated fractures of the ulna with angulation greater than 10°
→ All Monteggia fractures
→ All Galeazzi fractures
→ Open fractures
→ Fractures associated with a compartment syndrome,
regardless of the degree of displacement.
E. TREATMENT
• Plates and screw
F. FRACTURES OF DISTAL RADIUS
• Radiographic evaluation
→ Three views of the wrist including AP, Lateral, and Oblique
→ Normal Relationships
▪ Radial height: tip of styloid 10mm above ulna (if <10mm,
means radius has collapsed)
▪ Radial tilt: Angle from base of distal radius to tip of styloid;
normally about 23° (<23° = collapsed)
▪ Palmar tilt: Palmar angulation of distal articulating surface;
normally about 11°
▪ Ulnar Variance: Tip of ulna should be shorter than radius;
if longer, (+) ulnar variance [Normal should be Ulnar
Negative Variance; positive - Ulnar abutment syndrome]
G. EPONYMS • Fracture with dorsal or volar rim displaced with the hand and
carpus
Colles Fracture
Chauffeur Fracture (Radial Styloid Fracture)
• Combination of intra and extra articular fractures of the distal

radius with dorsal angulation (apex volar), dorsal
displacement, radial shift, and radial shortening
• Most common distal radius fracture caused by fall on
outstretched hand

• Avulsion fracture with extrinsic ligaments attached to the
fragment
H. TREATMENT
• Displaced fracture requires an attempt at reduction
→ Hematoma block-10cc of lidocaine or a mix of lidocaine and
marcaine in the fracture site
→ Hang the wrist in fingertraps with a traction weight
→ Reproduce the fracture mechanism and reduce the fracture
→ Place in sugar tong splint
Treatment for Distal Radial Fracture

• Closed Reduction-Internal Fixation
• Ligamento-Axis
• ORIF Plating
IV. REFERENCE

Lower Extremity Trauma
OUTLINE • Your hip dislocation is almost always posterior in comparison

to the shoulder which is almost always anterior and your
I. Hip Fracture VI. Femoral Shaft Fractures
elbow which is also posterior [Doc. Cayetano]
II. Femoral Head Fracture VII. Biomechanism of Nailing
III. Femoral Neck Fracture VIII. Distal Femur Fractures
IV. Intertrochanteric Hip IX. Knee Dislocations
Fracture X. References
V. Subtrochanteric Femur
Fracture
I. HIP FRACTURE
Hip Dislocations
• Significant trauma
→ Usually MVA
• Clinical Diagnosis: Posterior: Hip flexion, IR, Add- most

common.
• Posterior dislocation, the hip is in flexion, internal rotation and
adduction [Doc. Cayetano]
• Blood supply
→ Extracapsular arterial ring at the base of the femoral neck:
▪ Formed posteriorly by the large branch of MFCA (medial
femoral circumflex artery)
▪ Formed anteriorly by smaller branches of LFCA (lateral
femoral circumflex artery)
• Clinical Diagnosis: Anterior: Extreme ER, Abd/ Flex. [Doc.

Cayetano]
• Extreme internal rotation, flexed and abduction
• Sciatic Nerve
• Most of the blood supply of the lateral head comes from the
lateral femoral circumflex artery
• The more dominant artery in the hip is the MFCA this is the
one coming posteriorly and this is larger. Almost always the
posterior is the bigger one in terms of the nerve and
vascular,
→ Xray – Pelvis AP/ Lat
• LFCA is smaller and is coming anteriorly
→ CT- Scan- if associated with small fractures of the head and
• Los Angeles (helps me remember that the Lateral FCA is
acetabulum
coming Anteriorly) [Doc. Cayetano]
→ MRI - if we want to see if we have soft tissue injuries
Trans # 27 Lower Extremity Trauma 1 of 8

• Patient is supine and we try to pull on the upper extremity.
[Doc. Cayetano]
→ East Baltimore Lift
• Treatment is closed reduction meaning we have to align it

immediately
• Risk of avascular necrosis and impingement of sciatic nerve
makes this an emergency. [Doc. Cayetano]
• Emergent Treatment: Closed Reduction

→ Dislocated hip is an emergency
→ Goal is to reduce risk of AVN (avascular necrosis) and DJD
(degenerative joint disease)
• Again here, we try to do an anteriorly directed force [Doc.
→ Allows restoration of flow through occluded or compressed
Cayetano]
vessels
→ Literature supports decreased AVN with earlier reduction
→ Requires Proper anesthesia • Judet View
→ General anesthesia with muscle relaxation facilitates → Oblique pelvis
reduction → Additional projection to the pelvic series when there is
→ Conscious sedation is acceptable (putting the patient in GA suspicion of an acetabular fracture
with muscle relaxation is better for orthopedic surgeons)
• Closed Reduction
→ Gravity Method of Stimson
• Special views that you can request, one is the Judet view
aside from AP/Lateral, you can also request oblique view
• The value of this view is to assess the acetabulum [Doc.
Cayetano]
• They have the patient hang onto the edge of the table and II. FEMORAL HEAD FRACTURE
we place a downward force in order to reduce the hip.
Remember that the most common fracture is posterior is • Concurrent with hip dislocation due to shear injury
they are putting the force anteriorly. [Doc. Cayetano] • Pipkin Classification
I. Fracture inferior fovea: Nonoperative: non-
→ Allis Maneuver displaced; ORIF if displaced
▪ Assistant stabilizes pelvis with pressure on ASIS II. Fractured superior to fovea: ORIF
▪ Surgeon stands on stretcher and gently flexes hip to III. Femoral head + acetabulum fracture: ORIF both
90degrees, applies progressively increasing traction to the sides
extremity with gentle adduction and internal rotation IV. Femoral head + femoral neck fracture: ORIF of
▪ Reduction can often be seen and felt hemiarthroplasty

• If there is already a vascular necrosis, we could do a
hemiarthroplasty [Doc. Cayetano]
III. FEMORAL NECK FRACTURE
• Functional Classification
→ Stable (I/II)
→ Unstable (III/ IV)
• X-Ray
• We request for X-ray AP and in internal rotation

• We take an xray just to confirm our diagnosis. If our
• Incidence impression is femoral neck fracture then we request for
→ Less than 5% of all femoral neck fractures occur in pelvis AP a pelvis in internal rotation of the lower extremity
individuals younger than 50 years of age • In relaxed position, the femoral neck is directed anteriorly or
anteverted as contrast to your proximal humerus which is
retroverted. When you take an x-ray, you cannot see the
• This fracture almost always happens in older population [Doc.
profile of your anterior neck because it is pointing anteriorly
Cayetano]
so you would like to internally rotate the foot in order for it to
become transverse against the x-ray beam to see the
transverse profile of the femoral neck [Doc. Cayetano]
• Adult • Computed Tomography

→ 90% of the time resulting from a simple fall (which is low → Occult fracture or a fatigue or stress fracture
energy, either from the bed or form standing height), they are → Distinction between pathologic and non-pathologic fractures
associated with a high morbidity and mortality
• Garden Classification • If you have a high index of suspicion, you can confirm your
I. Valgus impacted – it is pointing up or pointing north diagnosis through CT scan [Doc. Cayetano]
II. Non- displaced
III. Complete: Partially displaced • Magnetic resonance Imaging
IV. Complete: Fully displaced → Acute hip pain consistent with femoral neck fracture, but no
apparent fracture on plain radiographs
→ Avascular changes following fracture
• You want to see if there is avascular necrosis of your femoral
head [Doc. Cayetano]
• Treatment Options • In the older population we just replace the head and allow the
→ Non-Operative metal head to be articulating against the native bone of the
▪ Very limited role acetabulum because they are not walking so much anymore
▪ Activity modification and will die sooner theoretically as compared to the younger
▪ Skeletal Traction old and the young population of course [Doc. Cayetano]
• We are only doing non-operative treatment if the patient
cannot walk anymore[Doc. Cayetano] • Outcomes
→ Prosthetic replacement can be expected to provide a long
→ Operative lasting stable hip
▪ ORIF (Open-reduction Internal Fixation → After an 11 year follow up, a 94% implant survivorship has
been reported with only 3.5% of patients experiencing any
• But this is specifically true in younger population. Older pain ( Haidukewych)
person is prone to AVN [Doc. Cayetano]
IV. INTERTROCHANTERIC HIP FRACTURE
• Extra-capsular femoral neck
• To inferior border of the lesser trochanter
• Site of fracture is between greater trochanter and lesser
trochanter
▪ Hemi arthroplasty (Endoprosthesis)
• Site of fracture is between greater trochanter and lesser

trochanter
• Characteristic of intertrochanteric hip fracture is already
outside the capsule
• So one of the peculiar for femoral neck fx is that the fracture
there is being backed by synovial fluid
• When we say hemiarthroplasty as the name implies, is just
partial hip replacement. Meaning we are only replacing the → So if there is synovial fluid in the femoral neck fx the
head and not the acetabulum chances of healing is small
• Total hip replacement, we mean we are replacing the head • In contrast, for intertrochanteric fracture there is high potential
and the acetabulum [Doc. Cayetano] for healing
→ Because it is a cancellous bone, particularly a metaphyseal
▪ Total Hip replacement bone [Doc. Cayetano]
A. PHYSICAL FINDINGS
• Shortened / ER posture
→ It could be shortened because of a pulled muscle
• Obtain Xrays: AP Pelvis, Cross table lateral
• Young patients
→ Urgent ORIF (<6hrs)
• Elderly patients
→ ORIF possible (higher risk AVN, Non-union and failure of
fixation)
→ Hemiarthroplasty – older patients (older old- meaning those
in their 80s and 90s)
→ Total hip replacement - -young patients (including older
young meaning in their 50s to 60s)
• In younger population, we replace with total hip replacement • It could be shortened because of a pulled muscle or an
because eventually the head will corrode on the acetabulum external rotation

• Xray AP pelvis or internal rotation to see the profile of neck C. TREATMENT OPTIONS
to see if the neck is involved • Stable
• Cross table lateral- to take an xray actually, we have to → Dynamic Hip screw/ Sliding hip screw
rotate the hip but since it is painful it can’t be done, we just ▪ With this implant, we insert a screw going to the head,
take xray across the table meaning that we don’t move the with some device on the femoral side such as a plate
patient but we move the xray [Doc. Cayetano] which is attached outside the bone. [Doc. Cayetano]
B. CLASSIFICATION
• Number of parts
→ Head/neck, Greater trochanter, Lesser trochanter, Shaft
Stable
• Resist medial and compressive loads after fixation
• Unstable/Reverse
→ Proximal Femur Nail
▪ when we say nail it goes inside the canal [Doc. Cayetano]
Unstable
• Collapses into varus or shaft medializes despite anatomic
reduction with fixation
V. SUBTROCHANTERIC FEMUR FRACTURE

• Classification
→ Located from LT to 5cm distal into shaft
→ Intact Piriformis Fossa
• Treatment
→ IM Nail
→ Cephallomedullary IM Nail
→ ORIF with Plate
→ This is unstable because when you compress the proximal
part (yellow square) against the distal part it will tend to
collapse
Reverse Obliquity
• Form of an unstable fracture
→ Mother of all unstability because of obliquity of the fracture
• If Piriformis fossa is not intact, that could be an

intertrochanteric hip fracture
• Sometimes it is difficult to tell if it is Intertrochanteric or
→ If you direct a force (blue arrow), because of its obliquity it will subtrochanteric fracture,
tend to slide [Doc. Cayetano] → If it is difficult to tell, we just use the term peritrochanteric
fracture [Doc. Cayetano]
• In intertrochanteric fracture the bone there is cancellous bone,
while here the shaft is a cortical bone which heals slower
• So your subtrochanteric fracture is a transition between a hard • Distal fragment will be displaced proximally and medially
bone and a soft bone, and there is so much stress in the area. because of the pull of your adductors .[Doc. Cayetano]
It is an area concentration of stress.[Doc. Cayetano]
VI. FEMORAL SHAFT FRACTURES

• Extra-capsular femoral neck
• Fracture of the diaphysis occuring 5cm distal to the lesser
trochanter and 5 cm proximal to the adductor tubercle
A. FRACTURE CLASSIFICATION B.
• Winquist and Hansen classification
→ It is based on comminution comminution
• Type I
→ Minimal or no comminution
• Type II
→ Cortices of both fragments at least 50% intact
• Type III
→ 50-100% cortical comminution
• Type IV
→ Circumferential comminution without cortical contact
• When your fracture is very distal to the distal femur, your distal
fragment will be flexed because of the action of gastrocnemius
which is attached to the distal femur that is attached to the
chondal[Doc. Cayetano]
• Clinical importance
→ Danger of vascular supply around the site of fracture. Because
in this area you have the femoral artery and politeal artery[Doc.
Cayetano]
[Winquist and Hansen classification]
B. DEFORMING FORCES
A. C. TREATMENT OPTIONS
• IM Nail with locking screws
• ORIF with plate/screw construct
• External fixation
• Consider traction pin if prolonged delay to surgery
D. NON-OPERATIVE TREATMENT
Skin Traction
• For young children (definitive fracture management)
→ We don’t do operative intervention we just do application of
cast.
→ But if we expect a delay we can do traction first
• Bryant and Split Russel Traction
→ For adults, emergency fracture immobilization in the field
• When you have a fracture at the proximal femur, the proximal → Disadvantage
fragment will go into a flexion because of the action of iliopsoas ▪ Inability to apply sufficient forces to limb to effect reduction
muscle (attached to the lesser trochanter) which tends to flex the without causing slippage or skin necrosis.
fracture.[Doc. Cayetano] Skeletal traction
• Used for early fracture care before definitive operative treatment
→ In cmvc, we do a lot of skeletal traction because we expect
delay on the operative intervention because of the scheduling
or because of the implant [Doc. Cayetano]
• Can be applied through the DISTAL FEMUR or PROXIMAL
TIBIA
• Allows sufficient force to be applied to the limb to affect fracture
reduction
• Used together with various limb suspensions, most are
modifications of the Thomas splint with Pearson attachment
• Goal: Restore anatomic length of fractured femur within first 24
hours
→ If we couldn’t restore it on the first 24 hours, there will already
be a myostatic contracture, meaning your muscle will already
contract and you will have difficulty in lengthening the muscle
later on when you will be doing the definitive procedure[Doc.
Cayetano]
• Compared with plates or external fixators, IM nails have a center

of motion closer to the center of motion of the bone and thus are
subjected to lesser loads, this makes the intramedullary nail less
likely to fail in fatigue than plates
→ plate it is applied on the outer surface of the bone
[Skeletal traction]
Cast bracing ⚫ In skin traction, we just place a tape on the skin and we pull
• Allows early ambulatory treatment with early hip and knee motion on that one
to minimize joint contractures ⚫ The idea in putting a traction is to reduce the fracture
• Indications: ⚫ In skeletal traction, the pin is transversed or poked to the
→ Distal 3rd fractures bone and we give traction through the bone.[Doc. Cayetano]
→ Comminuted shaft fractures who
are not surgical candidates
→ Supplemental support to the • When we place an implant there is actually a micromotion on
femur after non rigid internal that implant, when we place it on the center of the bone there
fixation would be a lesser bending movement as compared to when
we place the implant on the lateral side of the femur.
• If it is placed on the lateral side there would be microbending
of the plate
• So when the bone will not be unite on time there will be fatigue
or stress fracture on the implant.[Doc. Cayetano]
E. EXTERNAL FIXATION
• Indications A. STABILITY
→ Severe grade III-B open • Dynamic
fractures with medullary → There is a motion on the fracture site
contamination or muscle loss • Static
→ Grade III-C open fractures → There is no motion on the fracture site
requiring rapid stabilization • Interlocking
before vascular repair → We place a screw or interlocking nail (yellow circle)
→ Polytraumatized patient in → The value of placing interlocking screw is to prevent rotation
extremis who cannot tolerate or shortening of the fracture
open surgery → Site of interlocking screw is locked
• Static interlocking
→ Placing 2 screws in between the fracture site making the
fracture static
VII. BIOMECHANISM OF NAILING

• Nails provide predictable restoration of femoral shaft alignment
and at least in simple mid shaft fractures
• Nails automatically correct alignment of the bone as they fill the
medullary canal

• Dynamic interlocking
→ Placing one screw either proximal or distal
→ For winquist type 0 or type 1 fracture
▪ Type 0 (no comminution)
▪ Type 1 (minimal comminution)
IX. KNEE DISLOCATIONS

• High association of injuries
→ Ligamentous injury
▪ ACL, PCL, Posterolateral Corner
▪ LCL, MCL
→ Vascular injury
▪ Intimal tear vs. Disruption
VIII. DISTAL FEMUR FRACTURES ▪ Obtain ABI’s- (+) Arteriogram
• Distal Metaphyseal Fractures ▪ Vascular surgery consult with repair within 8hrs
• Look for intra-auricular involvement → Peroneal Tibial N. injury
• Plain films
• CT
***to be continued in the next discussion
X. REFERENCES
• Treatment:
→ Retrograde IM Nail
▪ We place the nail coming distally going proximally
▪ We place the nail through the joint [Doc. Cayetano]
→ ORIF open vs MIPO (minimally invasive plate osteosynthesis)

▪ MIPO is very common now, because the target now is we
will just need to make a small wound (to preserve soft
tissues) then insert a plate and use an xray to see if the
bone is reduced or aligned[Doc. Cayetano]
Lower Extremity Trauma (Part 2)
Dr. Angel Cayetano| April 30, 2022
II. PATELLAR FRACTURES

OUTLINE
A. PHYSICAL EXAM
I. Knee Dislocations III. Tibia Fractures
II. Patellar Fractures A. Proximal Tibia • Inability to perform straight leg raise against gravity (e.g.
A. Physical Exam Fractures (Tibia Extensor mechanism still intact?)
B. Etiology Plateau) → Such is like, when the patient is lying down, you hold the feet
C. Radiographic B. Tibial Shaft Fractures of the pt., you assist him/her in elevating that leg, then you ask
Evaluation and C. Distal Tibia Fractures the pt. to maintain that posture. So, when you have a patellar
Findings (Tibial Pilon/ Plafond) fracture, that leg will fall- you have a disruption of the extensor
D. Treatment IV. Ankle Fractures mechanism.
V. References → Extensor mechanism consists of your quadriceps muscle,
quadriceps tendon, patella, and the patellar tendon
• Inability to extend the knee in the presence of a fracture indicates
I. KNEE DISLOCATIONS
a tear in both the medial and lateral retinacula
• High association of injuries → On Figure 2, the patella, there is a retinaculum on its lateral
→ Ligamentous Injury and medial side. So, when that is intact, even if you a fracture
▪ Anterior Cruciate Ligament (ACL), Posterior Cruciate right there, the patient- could still elevate the leg, but when the
Ligament (PCL), Posterolateral Corner retinaculum is disrupted-pt. could not extend the knee
▪ Lateral Collateral Ligament (LCL), Medial Collateral anymore
Ligament (MCL)
→ Vascular Injury
▪ “Referring to the artery on the posterior part of the knee
which is the Popliteal Artery”, Doc
▪ “Remember, your femoral artery becomes the popliteal
artery when it ends at the Hunter’s canal”, Doc
▪ Intimal tear vs. Disruption
▪ Obtain Ankle Brachial Index (ABI’s)→ (+) →Arteriogram
− “You should look at the BP in the brachial or in the arm
vs. the BP in the leg”, Doc
− “If it’s positive, meaning there’s a large discrepancy
between the Brachial BP vs the leg BP, then with that Figure 2. The patella.
you have to suspect that you have a vascular injury
B. ETIOLOGY
(could be an intimal tear or disruption).
• Divided into a Transverse or Comminuted Fracture
− To confirm, request for Arteriogram (X-ray in which they
inject a dye into the blood vessel and then you take an • Either Direct or indirect trauma
X-ray- able to see the patency of the popliteal artery)”, → Majority occur from direct injuries such as comminuted
Doc → Indirect Injury
▪ Indirect injuries occur from a near fall from a height
− It’s like when you jump and you try to land on your foot,
such that the force is being absorbed by your knee
▪ Occurs when the forces from the extensor mechanism
exceed the intrinsic strength of the patella
▪ Usually result in a transverse fracture with some inferior
pole comminution
− When you see a transverse fracture, that is usually an
indirect injury, and what usually happen is that you will
have a tear on the medial and lateral aspect of your
retinaculum, patient may not be able to extend the knee
Figure 1. (L) image- X-ray of the Knee. (R) image- Popliteal Arteriogram
▪ Vascular surgery consult with repair within 8 hours should

be done Figure 3. Patellar Transverse Fracture with
Medial and Lateral Retinaculum Tear
− If its greater than 8 hours, chances are, there’s already
an irreversible myonecrosis which is happening in the
leg, meaning that leg will die and eventually it will need
an amputation
→ Peroneal and Tibial Nerve injury
▪ Most common nerve that is injured
▪ Distal branches of the sciatic nerve (Sciatic Nerve- at the
→ Direct Injury
distal part of the thigh, it will divide into peroneal nerve and
▪ You mean, your knee is banging against a hard surface,
the tibial nerve, the tibial nerve will go into the posterior
there will be a comminuted fracture of the patella- the
compartment of the leg , then the common peroneal nerve
medial and lateral retinaculum could be intact, and in that
will divide into superficial peroneal nerve- which will go to
way the patient might be able to extend the knee
the lateral compartment of the leg while the deep peroneal
nerve in the anterior compartment of leg)
Trans # 28 Lower Extremity Trauma (Part 2) 1 of 6

C. RADIOGRAPHIC EVALUATION AND FINDINGS D. TREATMENT
• AP, lateral and sunrise view NON-DISPLACED FRACTURE
• Closed treatment should meet the following indications:
→ Fragment separation less than 3mm
→ Articular step off less than 2mm
→ Intact extensor mechanism (patient can elevate the foot)
• Extension splinting for 4-6 weeks using a cylinder or long leg cast
→ You have to splint it in extension so that you will be relieving
the tension effect against the patella, so that the fragments will
not separate more
DISPLACED FRACTURE
A B C • Defined as:
Figure 4. (A) AP View; (B) Lateral View: (C)Sunrise View of the patella.
For the Sunrise View, you will be able to see a vertical fracture of the → Separation of more than 3mm
patella, if you have a vertical fracture of the patella, you could not actually → Articular incongruity of 2mm or more
see it in the AP view, because the view is being obscured by the femur,
so in order for you to see a vertical fracture, you should be asking for a • Operative Treatment Options
Sunrise View. → Tension band wiring technique
→ Partial patellectomy
→ Partial patellectomy combined with tension band wiring
→ Total excision or patellectomy
• Modified Anterior Tension Band

→ Tension Band- conversion of tension force into a compression
force. Tension force tend to separate the fracture fragment
and a compression force to tend make the fracture closer
together. [doc]
Figure 5. (L) image- Patella baja. (R) image-Patella alta
• A low riding patella or “patella baja” may be indicative of

quadriceps rupture.
→ Patella moves downward, you may have an injury on your
quadriceps tendon
• A high riding patella or “patella alta” may be a sign of patellar
tendon rupture
• It is easier to diagnose if there is really complete disruption, but Figure 7. Modified Anterior Tension Band
when you don’t have a complete disruption, then you have to rely
on X-rays III. TIBIAL FRACTURES
→ In the normal knee, the most reliable assessment of patella • Proximal Tibia Fractures (Tibial Plateau)
height is the method of Insall-Salvati • Tibial Shaft Fractures
▪ In order to measure Insall-Salvati, you have to look at the • Distal Tibia Fractures (Tibial Pilon/Plafond)
lateral X-ray, you have to measure the length of your
patellar bone and the patellar tendon A. PROXIMAL TIBIA / TIBIAL PLATEAU FRACTURES
• X-rays: AP/Lateral View of Knee +/- traction films
• CT Scan (after ex-fix if appropriate)
• In terms of your Tibial Plateau or your lateral tibia, you should be
asking for an X-ray AP or Lateral view of your knee and if there’s
a fracture overlying against each other and you want to see like
a real picture of the fracture then you could do a traction film.
• A traction film is just, you take an AP while somebody is pulling
the leg that is like in order to solve the puzzle. And the when you
could not still figure out the personality of the fracture then maybe
we could request for a CT scan and that is after we placed an
external fixation.
• So let me explain this “after ex-fix”. So, when we have a fracture
of the proximal tibia the problem with that is you have so much
Figure 6. (A) Insall-Salvati Assessment. swelling. If you have so much swelling, you could not operate on
that, you could incise on that so what we could do is to put an
▪ Insall: ratio of the greatest diagonal patella length to patella external fixator. We pull on the leg, we placed an external fixator
tendon length in order for us to maintain the tension or the reduction and after
▪ Normal knee, the ratio is 1:0 placing an external fixator we request for a CT scan. [doc]
▪ So when patellar tendon is longer than your patellar bone
or the patella has gone up, it is called patella alta. When
you have patella baja, meaning your patellar tendon is
transected

ANATOMY
• Blood Supply:
→ Nutrient artery – posterior tibial artery
→ Anterior tibial artery
→ Peroneal artery
• Now in order to give you a perspective, there are three arteries
found in your leg, the Posterior tibial artery, Anterior tibial
artery and your Peroneal artery. The largest one of the three is
the posterior tibial artery so it would be easy to remember that
the nutrient artery supplying the bone is the posterior artery. [doc]
Figure 8. Schatzkker Classfication of Plateau Fracture
• So, the classification for a proximal tibial fracture is Schatzker

Classification. For I to III, these are for lower energy fracture and
IV to VI are for high energy fracture. So, for type I, it’s just a split
fracture of your lateral tibial plateau, type II is a combination of
split depression fracture of your lateral tibial plateau, type III is
just a depression fracture of your lateral tibial plateau. So, when
we talk of type I to III, we are just talking of the lateral tibial
plateau. Now when you talk about IV to VI, you are now talking
about the medial as well as the lateral tibial plateau. For type IV,
it is a fracture of your medial tibial plateau with an extension on
the lateral compartment, type V is a fracture of your lateral and
medial tibial plateau and type VI, it is a fracture of your lateral
tibial plateau, medial tibial plateau and the shaft. [doc]
TREATMENT
• Spanning external fixator may be appropriate for temporary Figure 10. Blood Supply
stabilization and to allow for resolution of soft tissue injuries
→ So, the treatment is centered on soft tissue. Again, as I have Gustilo and Anderson Classification of Open Fracture
told you the current definition for fracture now is a soft tissue Gustilo and Anderson Classification
injury with associated fracture. So, what really happens when of Open Fracture
you have proximal tibial fracture is that you have so much Grade Wound Injury
swelling on your lateral tibial plateau. So, with that there might 1 <1cm Minimal muscle contusion,
be a problem with your soft tissues. usually inside out
→ The definitive treatment tibial plateau fracture is to put an mechanism
internal fixator or internal plate but the problem is you could 2 1-10cm Extensive soft tissue
not incise because it is swollen so what we could do acutely is damage
to place an external fixator until there is a resolution of soft 3
tissue swelling. [doc] 3a >10cm Adequate bone coverage
3b Periosteal stripping
• Definitive ORIF for patients with varus/valgus instability, >5mm requiring flap advancement
articular step off or free flap
→ So the definitive treatment will be to place an internal fixation 3c Vascular injury requiring
in the form of plate. So we could either place a plate on the repair
lateral aspect when you have Schatzker I to III then when you
have type VI it will be best to use double plating of your lateral Tscherne Classification of Soft Tissue Injury (For Close
and medial plateau but to start with we have to place an Fracture
external fixator initially. [doc] Tscherne Classification of Soft Tissue
Grade Injury
0 negligible soft tissue injury
1 superficial abrasion or contusion
2 deep contusion from direct trauma
3 extensive contusion and crush injury with

possible severe muscle injury
Figure 9. Double Plate for Proximal Tibia
B. TIBIAL SHAFT FRACTURES ACCEPTABLE REDUCTION

• Open fractures of the tibia are more common that in any other • Less than 5 degrees of Varus/valgus angulation
long bone • Less than 10 degrees of anterior/posterior angulation deformity
• Most common long bone fracture • Less than 1 cm of shortening, (5 mm of distraction may delay
healing for 8 to 12 months)
→ Remember, what is the bone that will allow the greatest number
of shortening, its you HUMERUS- will be able to accept a 3cm of
shortening, but your tibia and femur is only allowed to have 1 cm
shortening such as the function of that extremity will still be ▪ For fractures extending into the metaphysis (proximal or
acceptable distal) or epiphysis
• More than 50% cortical contact.
• These are your indications of your non operative treatment. [doc]
TREATMENT
• Non-Operative
→ Closed reduction followed by:
▪ Long leg cast
▪ Patellar tendon bearing cast
▪ So, when you say non operative treatment what will you
do? The first cast that is to be applied is a long leg cast. It
is placed around 2 finger breadths below your gluteal folds
up to the metatarsophalangeal joints. Then after 4 weeks it Figure 15. Plates and screws
will be converted into a short leg cast (Patellar tendon → Intramedullary (IM) Nailing fracture
bearing cast) because the load here is being borne by your ▪ Advantage of preservation of periosteal blood supply and
patellar tendon. [doc] significant reduction of soft tissue damage
− When we place intramedullary nail, we usually don’t
open up the fracture site, we just open up the entry of
the nail, with that there will be a preservation of the
periosteal blood supply
▪ Biomechanical advantage of ability to control alignment,
translation, and rotation
− Rotation could be prevented by placing locking screws
▪ Recommended for most fracture patterns
▪ Advantages of IM nailing
Figure 11. Long leg cast − Lower non-union rate
− Smaller incisions
− Earlier weightbearing and
function
▪ Reamed vs unreamed
− Reamed
o We make the canal larger
o For closed fractures
o Allows excellent
intramedullary splinting
Figure 12. Patellar tendon bearing cast (made up of Plaster of Paris or fiber
of the fracture
glass)
o Use of a larger, stronger
nail
− Unreamed
o We don’t make the canal
larger
o Designed to preserve
intramedullary blood
supply in open fractures
(because the periosteal
blood supply when you
Figure 13. Patellar bearing orthosis (more expensive than patellar tendon
bearing cast)
have a fracture is
• Operative destroyed)
o Disadvantage is it is
→ External fixation
significantly weaker than the large, reamed nail
▪ Used to treat open fractures, also indicated in unstable
o Full weight bearing not advised
closed fractures complicated by compartment syndrome,
concomitant head injury, burns or impaired sensation
▪ In terms of Open type fracture, we only use external fixator
from Gustilo Grade 3b and 3c. For Gustilo Open Grade 1
to 3a, with that we can convert into close fracture and we
can do internal fixation later
Figure 17. IM nailing fracture
C. DISTAL TIBIA (TIBIAL PILON/PLAFOND FRACTURES)

• Fractures involving distal tibia metaphysis and into the ankle joint
• Soft tissue management is key!
→ In proximal and distal tibia, what dictates the outcome is the
Figure 14. External fixation condition of the soft tissue
→ Plates and screws • Initial Evaluation
→ Plain films (AP and lateral), CT scan (in order for us to really X-ray Views
know the personality of the fracture) • AP Ankle
→ Spanning External Fixator → We talk about medial and lateral malleolus in this view Dr.
▪ When there’s so much swelling in this area (there’s not Cayetano
much soft tissue, after skin we already have the bone, when
we do an incision there when there’s so much swelling, we
could not close the wound anymore, what we do is we wait
for the swelling to go down, and while waiting we place a
Spanning External Fixator
→ Delayed Definitive Care to protect soft tissues and allow for
soft tissues swelling to resolve
→ The parameter for us to say that the soft tissue has healed is
whenever we have a WRINKLE SIGN
Figure 22. Ankle AP View

→ Tibiofibular overlap
▪ <10 mm is abnormal and implies syndesmotic injury
▪ At least 1cm overlap of your tibia and fibula. A greater than
half cm is abnormal Dr. Cayetano
Figure 18. X-ray Tibial Pilon Fracture → Tibiofibular clear space
→ When we say pilon, there’s actually a component of articular ▪ >5 mm is abnormal
injury, meaning the fracture goes into the joint − Implies syndesmotic injury
TREATMENT OPTIONS • Lateral View

• Intramedullary (IM) nail with limited
ORIF
• ORIF with plate
• External fixator
→ Could be used as initial treatment or
a definitive treatment Dr. Cayetano
COMPLICATIONS
• Mal or Non- union (Varus)
• Soft tissue complications
→ Do not operate immediately because
the soft tissue might break down Dr. → Posterior malleolar fractures
Cayetano
→ Anterior/ Posterior subluxation of the talus under the tibia
• Infection → Displacement/ Shortening of distal fibula
• Potential amputation → Associated injuries
→ If too much injury, better to do ▪ E.g. dislocation between talus and calcaneus
amputation rather than fix the limb
Dr. Cayetano CLASSIFICATION SYSTEMS
• Lauge- Hansen
IV. ANKLE FRACTURES → Based on cadaveric study
• “It is difficult to distinguish ankle fracture from pilon fracture. The → First word- refers to position of foot at time of injury
basic distinguishing characteristic of ankle fracture is it affects the → Second word- refers to force applied to foot relative to tibia
medial and lateral malleolus. If you have fracture in the medial at time of injury
malleolus and lateral malleolus, it is termed as ankle fracture” Dr.
Cayetano
Syndesmosis Anatomy
Figure 21. Anatomy of Ankle

→ Fibula: Lateral HOW TO MEMORIZE?
→ Tibia: Medial → SAD- Supination Adduction
→ Anterior Tibiofibular Ligament: Anterior → SER- Supination External Rotation
▪ Ligament that joins the tibia and fibula anteriorly → PAB- Pronation Abduction
→ Posterior Inferior Tibiofibular Ligament: Posterior → PER- Pronation External Rotation

• Weber- Danis
→ Based on the level of fibular fracture and its relation to
mortise view Dr. Cayetano
A- Fibula fracture distal to mortise

B- Fibula fracture at the level of the mortise
C- Fibula fracture proximal to mortise
*Mortise- joint between the talus and tibia Dr. Cayetano
INITIAL MANAGEMENT
• Closed reduction
→ Conscious sedation may be necessary
→ If ankle is dislocated, we do closed reduction Dr. Cayetano
• AO splint
• Delayed fixation until soft tissues stable
INDICATIONS FOR NON- OPERATIVE CARE

• Nondisplaced fracture with intact syndesmosis and stable
mortise
• Less than 3 mm displacement of the isolated fibula fracture with
no medial injury
• Management:
→ Short leg cast for 4-6 weeks
INDICATIONS FOR OPERATIVE CARE

• Bimalleolar fractures
→ Fractures on both medial and
lateral malleolus
• Trimalleolar fractures
→ Fractures on medial, lateral and
posterior malleolus (seen on
the lateral view)
→ Posterior malleolus is the
posterior part of distal tibia
• Talar subluxation
• Articular impaction injury
• Syndesmotic injury
• Management: ORIF
→ Fibula
▪ Lag screw if possible plus
plate
− Put screw from distal going
to proximal Dr. Cayetano
▪ Confirm length/ rotation
→ Medial Malleolus
▪ Open reduce
▪ 4- 0 cancellous screws VS
tension band
→ Posterior Malleolus
▪ Fix if >30% of articular
surface
▪ Generally, posterior malleolus
is not fix unless there is >30% of articular surface Dr. Cayetano
V. REFERENCE
Dr Cayetano’s PPT and Discussion

Hand, Spine, & Spinal Cord
OUTLINE Tendon Sheath Infections

• puncture wounds or lacerations
I. Hand B. Low Back Strain
A. Hand Infections C. Degenerated Disc • Staph. Aureus
B. Skin D. Herniated Disc • Gram negative infection in 20%
II. Spine III. Spinal Cord Injury • Kanavel’s cardinal signs:
A. Low Back Pain IV. Reference → Tenderness
→ Pain on passive extension
I. HAND → Flexed finger
→ Fusiform swelling of digit
A. HAND INFECTIONS
• Most common seen next to hand fractures.
Cellulitis
• inflammation of subcutaneous tissue and skin
• swelling, erythema, ascending lymphangitis
• no pus, no fluctuation
• Strep. Pyogenes
• elevation, splintage, antibiotics (oral or IV)
Figure 3. Tendon Sheath Infections
• prompt recognition and immediate drainage. Failure to recognize
will lead to rupture and more infection
• IV antibiotics
• Irrigation
• Leave open – Secondary closure
• active ROM exercises after 48 hours to prevent fibrosis
Figure 1. Cellulitis
Paronychia & Eponychia
• most common hand infection
• mixed anaerobes and aerobes
• Paronychia: infection in the nail fold; Eponychia: nail fold Figure 4. Secondary Wound Closure
underneath the nail Web Space Infections
• elevation, antibiotics • Web space or Collar button abscess
• I&D, removal of lateral nail, bacteria & fungal culture • Dorsal and volar collections communicating through common
• chronic – consider TB, atypical mycobacteria, fungal infection, channel
gout (check uric acid), CA • Require dorsal and volar incisions
• complications – osteomyelitis • Midpalmar abscess: only incise in the middle of the palm
Figure 2. Eponychia
Felon
• abscess of distal pulp space
• Eponychium (infection underneath nail fold) vs Felon
(subcutaneous infection on the distal part of the finger
• S. aureus Figure 5. Web Space Infections
• antibiotics, I&D, Longitudinal distal incision on the Non-contact Bites
side of digit, remove septae bluntly from periosteum leave open • dog 70%
• Do the incision on the radial side, not the ulnar side. Because • cat 10%
when you hold something, you use your ulnar side to feel for • human 15%
something. But on the radial side, when you grasp something, it • venomous creatures
will be out of the way • tetanus & rabies
Trans # 29 Hand, Spine, & Spinal Cord 1 of 6

1. Dog Bites ▪ a. Thin STSG (0.008in-0.012in) – takes more easily
• rarely involved hand than thicker grafts, best where graft survival is at risk
• Streptococcus, Staphylococcus, Pasteurella multocida (thinner the skin graft, better survival)
• irrigation, debridement, delayed primary to suture ▪ b. Thick STSG (>0.016in) – more durable wound
coverage and contract less than thinner grafts, donor
• Augmentin useful
site morbidity
• most common antibiotics used: Co-amoxiclav
• Appropriate donor sites – lower extremities, buttock, trunk,
2. Cat Bites
and occasionally upper extremities
• more frequently lead to infection, deeper penetration
• Scalp – best donor site for the face
• >50% Pasteurella mutocida
• Place donor site in areas where patient for not lie
• rapid inflammatory response (within 24 hrs)
• Avoid selecting a donor site immediately adjacent to the
• antibiotics and surgical drainage recipient wound
• Augmentin • 10-20% of the graft’s surface is lost via primary contraction
3. Human Bites
• more frequently lead to infection, deeper penetration
• >50% Pasteurella mutocida
• rapid inflammatory response (within 24 hrs)
• antibiotics and surgical drainage
• Augmentin
B. SKIN
• Largest organ in the body
• Semipermeable membrane
Figure 7. Split Thickness Skin Grafting
• Barrier to undesirable substances
• Temperature regulation and sensibility
• Composed of a thick of dermis covered by epidermis (5% of the
thickness)
Skin Grafting
• healing of the donor area occurs by epithelialization and very little
dermal regeneration
• deeper the graft, better the quality but less left in the donor site
to aid healing
• deeper graft increase chance of re-innervation and restoration of
sensibility on the recipient site
Figure 8. Skin Mesher (We put stab incision on the skin in order to make the skin
bigger or larger
Figure 6. Skin Grafting

• Response to Injury
→ wound contraction
→ fibroblasts migrate to the edge of the wound and differentiate
into myofibroblast Figure 9. Meshed skin
→ contract and pull the wound edges together 2. Full Thickness Skin Grafting
→ not altered by epithelization • transfers all the skin appendages and nerve endings except
→ continue unchecked until the tension in the wound equals the the sweat glands located in the subcutaneous tissue
tension in the stretched skin • Advantage of restoring sensibility and quality of coverage
• Effect of Infection Wound Healing • taken from relatively hairless area to minimize subsequent
→ estimated that 1000 organisms per gram of tissue is normally hair growth
present in the hair follicles, crevices and recesses • When we take it from the inguinal area to the hand. When we
→ 1000 organism a fairly critical level of contamination do that, expect to have hairs on the hand
• Vascularity of the Wound • Lower and lateral abdomen – good donor sites
→ nourished by transudate from the wound
II. SPINE
→ plasmatic circulation/imbibition
→ anything that acts as a barrier to this process will cause loss A. LOW BACK PAIN
of graft • A syndrome characterized by a constellation of factors causing
→ blood and hematoma – most potent, will kill even in the pain at the lumbosacral area that impairs activities of daily living
absence of infection • Most common spine problem you will be encountering in your
Types of Skin Graft practice.
1. Split Thickness Skin Grafting • Pain sensitive anatomical areas of spine
• sheet of skin consisting of the entire epidermis and dermis → Bones and joints
• thickness of a particular STSG – based on the demands of the → Ligaments
wound, availability of donor sites and training of surgeon → Muscles and tendons
→ Intervertebral discs Possible Risk Factors
→ Nerve structures • Obesity
Pathophysiology • Smoking
• Mechanisms of pain: • Gender
→ Biomechanical • Age
▪ There could be a compression of the nerve that is exiting in • Heavy lifting/ vibrations/ stresses
the foramen • Prolonged sitting/poor posture
→ Biochemical • Job dissatisfaction
▪ Sometimes, intervertebral discs secrete an irritating Diagnosis
compound that can irritate the nerve exiting the foramen • Common Low Back Disorders
→ Vascular → Low back strain
▪ As years go by the vascularity of the disc will decrease and ▪ Muscular problem
that will translate to low back pain → Degenerative disc disease
Epidemiology → Herniated disc
• The lifetime prevalence of LBP is 50%-80%
• 2-5% of people affected yearly
• Most common cause of disability in persons younger than 45
years’ old
Etiology
• Musculoskeletal causes
→ Muscle strain
▪ most common for younger people and in people who
doesn’t have much physical activity then later they carry
something and hear a pop or a snap in their back. [Doc]
→ Discogenic
▪ Bulging disc or a degenerated disc Figure 11. Herniated Disc
→ Structural
B. LOW BACK STRAIN
▪ Listhesis – one vertebra is going anteriorly than the other
that could impinge a nerve on the foramen • History:
▪ Lysis → Lifting heavy weights
→ Degenerative → Use of vibrating equipment
▪ Osteoarthritis → Prolonged sitting and poor postural habits
▪ Stenosis → Difficulty of assuming the erect position
→ Infectious and inflammatory – TB • Physical Exam:
→ Metabolic, mainly osteoporotic → Diffuse tenderness at the low back and sacroiliac region
• Non-Musculoskeletal causes → Asses for muscle spasm
→ Vascular (aneurysm) → Usually normal reflexes and motor strength
→ GU (UTIs, lithiasis) • X-ray
▪ Take note that when you have back problem don’t just → Straightening od the lumbar lordosis
focus on the lumbar area, you also have to see if the patient ▪ If it’s curved, there might be a nerve impingement
has genitourinary problem like UTI or lithiasis. Request for • Rule out other conditions
urinalysis, and if you really think that the patient have
C. DEGENERATIVE DISC DISEASE
lithiasis, request for an ultrasound of the kidney, ureter, or
• Low back pain radiating to the buttocks
bladder.
• Aggravated by bending, lifting, stooping, twisting
→ Gynecologic
• Straightening of the lumbar lordosis
▪ Pelvic inflammatory disease
→ Tumors (intrapelvic) • May have intermittent sciatica
→ Psychogenic → Sciatica means there is pain from the buttocks going to the leg
• Persistence of symptoms for months to years
• Sleep disturbance due to pain
• Physical Exam Findings:
→ Low back stiffness
→ Tenderness of LS and SI joints
• X-ray Findings:
→ Anterior osteophytes
→ Decreased height of intervertebral disc
Figure 10. Other Pathologic Causes

Figure 15. MRI at T2 Weighted Image Scan
→ Normally the color of the disc is white because of the presence
of water, but when you have dehydration of the disc, it will
become black. This is an example of disc herniation impinging
of the thecal sac.
Treatment Options
Figure 12. Degenerative Disc Disease X-ray
• Non-Pharmacologic
D. HERNIATED DISC → Activity modification (e.g. Tell the patient not to carry heavy
• History loads)
→ Strenuous back activity → Physical rehabilitation (work on strengthening the core
→ Abrupt onset of leg pain accompanied by low back pain muscles esp. back and abdominal muscles)
→ Previous back pain may disappear as the leg pain worsens → Pain lessening modalities (e.g. deep ultrasound, deep heat,
→ Pain is reproduced by straining, coughing and sneezing transcutaneous electrical nerve stimulation)
→ Pain radiates posteriorly from the buttocks to the leg and foot → Manipulation (e.g. chiropractor)
▪ The patient comes to you the first time complaining for back • Surgical
pain and then after a week they will go back complaining of → Indications for Surgery (Disc Excision)
back pain that has disappeared, but there is leg pain now. ▪ Absolute
− Rapidly deteriorating neurologic deficits
− Cauda equina syndrome
▪ Relative
− Recurrent incapacitating sciatica
− Gross motor deficits
− Failure of non-operative treatment
Figure 13. Bending of the trunk “list” & Herniated Disc Diagram
• Physical Exam
→ Positive list: trunk shifted to one side
→ Positive Straight Leg Raise at 45 degrees
Figure 16. Bone Graft
Figure 14. Straight Leg Raise Test

→ Weakness of ankle dorsiflexion or big toe extensors
→ Asymmetric knee and or ankle reflexes
→ Pain on tip toe walking
▪ In tip toe walking, you are using the L5-S1, L4-L5 (the most Figure 17. Cage & Screws
common site of herniation)
→ Numbness at calf area and side of foot
• MRI Findings
→ May be useful in confirming neurologic level

• If the patient is seen within 3-8 hours, the infusion continues for
48 hours
• Supplemental oxygen should be administered to all include SCI
patient to maintain O2 saturation rate at 100% because ultimately
what is important is that the oxygen must be delivered to the
tissue that has injury
• Patients presenting with a neurologic deficit and evidence of
cervical spine injury should be placed in cervical traction
• Intravenous midazolam is used for sedation and cervical muscle
relaxation (when the patient is awake he is too anxious so he will
use too much oxygen for metabolism so you want to lower down
the metabolic rate of the patient by giving sedatives)
Figure 18. Pedicular Screws. Screw is placed from the back going anteriorly to
the spine.
III. SPINAL CORD INJURY

Pathophysiology
• Compression, contusion, laceration, blast injury and ischemic
Figure 19. SCI Management
injury
• Primary mechanical trauma (example in vehicular accident or fall, The American Spinal Injury Association (ASIA)
these are the things that will happen to your spine) • Sensory function is graded as follows
→ Hemorrhage → 0 = insensate (does not feel anything)
→ Edema → 1 = impaired sensation (cervical trauma – there is impaired
→ Ischemia sensation in the extremities; the patient can feel sensation on
→ Autonomic dysfunction: hypotension, bradycardia (in general, the face more than the extremities)
when you have trauma, like too much blood loss, there will be → 2 = normal sensation
hypotension but heart rate will go up. But if you have → NT = not testable
autonomic dysfunction, you will have hypotension and • Motor function:
bradycardia instead of tachycardia.) → 0 = total paralysis
• Secondary Injury → 1 = palpable or visible contraction
→ Free radical theory → 2 = active movement with full range of motion but not against
gravity
▪ oxygen free radicals accumulate in the injured central
→ 3 = active movement (full ROM) against gravity
nervous system
→ 4 = active movement (full ROM) against moderate resistance
▪ free radicals attack membrane lipids, proteins and nucleic
→ 5 = active movement (full ROM) against full resistance
acid, producing lipid peroxidases that cause cell membrane
failure and eventually cell death Surgical Therapy
▪ even if you remove the compression, there will be neuronal • Surgical priorities are realignment, decompression and
cell death due to accumulation of free radical stabilization
→ Calcium influx theory • If there is adequate space for the cord for realignment, then
▪ Cites the intracellular flow of calcium ions into neurons as decompression is unnecessary and only stabilization or fusion is
the propagator of secondary injury necessary (we could look for the space on the cord using MRI;
▪ Calcium ions activate phospholipases, proteases and when it is not compressed, it will be stabilized with metals and
phosphatases, which results in disruption of the fusion is done).
mitochondrial activity and cell membrane dysfunction
→ Opiate receptor theory Classification of Spinal Cord Injury
▪ Based on evidence that endorphins may be involved in • Complete – the person could not totally feel anything with his
promoting secondary SCI hands and feet and he cannot move them
▪ The therapeutic effect of opioid antagonists may be dose
• Incomplete
dependent
→ Anterior cord syndrome
→ Inflammatory theory ▪ Characterized by injury to the anterior horn cells opposite
▪ Inflammatory mediators are released in the acutely
the area of the spinal injury with alteration of the
traumatized spinal cord
anterolateral white matter column function controlling pain
▪ Thus causing further tissue damage and neurologic loss and temperature sensation
▪ These mediators include prostaglandin, leukotrienes,
▪ The posterior columns and posterior horn areas of the gray
platelet activating factor and serotonin
matter are variously spared, controlling deep pressure and
posterior sensation (anterolateral white matter is
Treatment
responsible for pain and temperature)
• You must treat the primary injury which is the compression ▪ Poorest prognosis, with return to function being rare
• Prevention of secondary injury (will ultimately cause cell death) → Posterior cord syndrome
• Within 3 hours of injury ▪ Rare
→ Methylprednisolone 30 mg/kg as a loading dose followed by a ▪ Loss of sensation below the level of the injury
23-hour infusion at a rate of 5.4 mg/kg/h (we should be able ▪ Prognosis is uncertain
to bring the patient to the emergency room and this treatment ▪ The motor is okay, but what is not okay is the sensory
should be promptly in order for the secondary injury to not innervation.
happen) → Central cord syndrome
▪ Upper extremity weakness is more pronounced than lower
extremities
▪ Motor and sensory loss
→ Brown-Sequard Syndrome
▪ Best prognosis of all incomplete syndrome
▪ Caused by transverse hemisection of the cord and results
in weakness and proprioceptive sensory loss on the side of
injury, with pain and temperature loss on the contralateral
side (the pain and sensory loss will be on the side of
hemitransection; e.g. gunshot wound or stabbing injury to
the neck)
IV. REFERENCE
• Dr. Angel Cayetano’s Discussion

Shoulder
Dr. Angel Cayetano | May 1, 2022
OUTLINE
I. The Shoulder C. Rotator Cuff Tear
A. Shoulder Pain D. Adhesive Vasculitis
B. Impingement E. Calcific Tendinitis
Syndrome II. References
I. THE SHOULDER
A. SHOULDER PAIN
Clinical Presentation
• Challenging to diagnose because they have similar histories,
pain patterns, and findings on physical examination: Pain +
weakness + loss of motion
• Impingement syndromes, rotator cuff tears, calcific tendinitis,
adhesive capsulitis, and nerve entrapment syndromes
Physical Examination - Inspection
• Undressed above the waist
• Women = strapless dress Figure 2. Hawkins-Kennedy Test
→ Subtle atrophy Jobe Test
→ Swelling • Supraspinatus test
→ Deformity • 90 degrees of abduction
→ Ecchymosis • 30 degrees of forward flexion because scapula is not directed
Neer Impingement Sign and Impingement Test laterally rather it is directed 30 degrees anteriorly
• Patient seated • Thumbs down
• Raises the affected arm in forced forward elevation • If there is weakness → insufficiency of the supraspinatus
• Stabilizing the scapula with your other hand holding the scapula (pain/tear)
• causing the greater tuberosity to impinge against the acromion
→ positive for impingement syndrome
• Impingement Sign: just raise the arm and if there’s pain = +
• Impingement Test: Insert lidocaine at subacromial space and if
the pain disappears, it means that the pain is coming from
underneath the subacromial space
Figure 3. Jobe Test

Speed Test
• FF=90 degrees
• Elbow extended
• Forearm supinated
• Ask the patient to raise the hand against your resistance
• (+) pain localized to the bicipital groove → Biceps tendinitis/SLAP
Figure 1. Neer Impingement Test

Hawkins-Kennedy Test
• Forward flexing the humerus to 90 degrees
• Forcibly internally rotating the shoulder
• Drive the GT father under the coracoacromial ligament,
reproducing the impingement pain
Figure 4. Speed Test

Trans # 30 Shoulder 1 of 6
Belly Press Test
• Patient presses the abdomen with the flat of the hand
• The elbow should not drop backward (it should be on the lateral
because if it drops backwards, you will not be using your
subscapularis)
• (+) elbow falls backward → Subscapularis tear
→ *subscapularis – internally rotates shoulder
Figure 5. Belly Press Test

Figure 8. Axillary Lateral View
External Rotation Stress Test
• Test external rotators = infraspinatus and the teres minor • Supraspinatus outlet view or Scapular Y
• Arms on side → Assists in the evaluation of patients with rotator cuff disease
• Neutral on side → Lateral view of the scapula with the tube angled 10 degrees
• Neutral flexion and abduction caudad
• Externally rotated against resistance 45 to 60 degrees
• Patient ER: Examiner counteracts this force
Figure 9. Scapular Y
Figure 6. External Rotation Stress Test
Imaging
→ Acromion – flat (Type 1), curved (Type 2), hooked (Type 3)
1. Plain radiographs – XRAY → Hooked acromion = cuff disease; it tends to produce more
tear on supraspinatus
• Anteroposterior view
→ Reveal exostoses, greater tuberosity cysts or sclerosis,
→ Neutral AP view and subacromial sclerosis (Sourcil sign), which indicate
→ Internal rotation AP view – Hill-Sachs lesions (anterior chronic cuff tears
shoulder dislocation where posterior aspect of humeral
head bangs against the anterior aspect of glenoid)
→ External rotation AP view – greater tuberosity and proximal
humeral physis
→ Grashey view or True AP view – best evaluation of the
articular cartilage of the glenoid and the humeral head;
taken perpendicular to the scapula
Figure 10. Acromion
Figure 7. AP View
• Axillary lateral view

→ Glenoid rim
→ The acromion
→ Coracoid
→ Proximal humerus
→ Yellow: subscapularis inserted to lesser tuberosity (blue),
Red: coracoid process
B. IMPINGEMENT SYNDROME
Primary Impingement
• Intrinsic
→ Structures passing beneath the coracoacromial arch become
enlarged
→ Abutment against the arch
▪ Thickening of the rotator cuff
▪ Calcium deposits within the rotator cuff (Calcific Tendinitis)
▪ Thickening of the subacromial bursa (Bursa is like a
padding between coracoacromial arch and supraspinatus
tendon
Figure 11. Sourcil Sign
→ know that this is your acromion (yellow star). So if there is
whitening of the inferior of your acromion (arrow), it could
indicate a tear on your rotator cuff due to the constant
banging of the tendons against the under the surface of the
acromion.
2. MRI
• Most commonly used test for evaluation of a rotator cuff
pathology. Xray will only tell you about the bone while MRI will
tell you about the soft tissue as well
• Size of rotator cuff tears
• Status of the rotator cuff muscles
• Partial tears
• Tendinopathy
→ Coronal Oblique
▪ Supraspinatus retraction
▪ Size Figure 14. Primary Impingement
▪ Quality of the supraspinatus muscle • Extrinsic
→ Space available for the rotator cuff is diminished
→ Subacromial spurring
→ Acromial fracture or pathological os acromiale
▪ Os acromiale – non ossification of acromion
→ Osteophytes off the undersurface of the acromioclavicular
joint
→ Exostoses at the greater tuberosity
C. ROTATOR CUFF TEAR
History
• Insidious onset of progressive pain and weakness
• Concomitant loss of active motion
Figure 12. MRI
• Pain at night at the deltoid insertion
→ For MRI, there is T1 and T2 weighted images. For T2, water • Passive motion is full initially but can develop adhesive capsulitis
is bright. The supraspinatus tendon (star) here is black at the later course of the disease
because there is no water but if there is tear, it will be → Adhesive capsulitis “frozen shoulder” (since the patient cannot
brighter or white elevate his hand actively)
3. Ultrasound • Rotator cuff tear - almost always supraspinatus. The first one
• Advantages: rapid, noninvasive, and inexpensive that is torn is the supraspinatus and the tear will propagate
• Disadvantage: highly dependent on doctor and Quality of towards the posterior (infraspinatus, teres minor)
machine • Belly press test: To test for tear in the subscapularis
• Dynamic Ultrasound because tendon is moving Partial Thickness Tears
→ Impingement syndrome • Articular sided = 91% in young athletes
→ Glenohumeral laxity • Bursal sided
→ Identifying biceps tendon pathology • Intratendinous – most common (cannot be seen in MRI. only
seen cadaveric studies)
Figure 13. Ultrasound

− Secondary goal: functional improvement → not as
predictable
Treatment
• Diagnostic arthroscopy
→ Arthroscopy – a method where a small camera is inserted
inside the shoulder (9 mm tube) [doc]
→ Tear and size can be confirmed
→ Intraarticular pathology
• Arthroscopically
• Arthroscopically assisted (mini open)
• Convert to an open procedure when the pathology is very large
Figure 18. Arthroscopy

Figure 15. Partial Thickness Rotator Cuff Tear: Bursal and Articular Side
Figure 16. Articular Sided Tear

Figure 19. Arthroscopy Performed by Dr. Cayetano
D. ADHESIVE CAPSULITIS
• Underlying Pathological Changes
→ Synovial inflammation
→ Reactive capsular fibrosis
→ Cytokines and metalloproteinases have been implicated in the
process
***But: the initial triggering event in the cascade is unknown
Figure 17. Bursal Side Tear

• Partial thickness tears treatment:
→ Non operative:
▪ Activity modification
▪ Stretching
▪ Strengthening exercises
▪ Anti-inflammatory medication
→ Operative:
▪ Subacromial decompression of with outlet impingement
− Removal of part of the bursa underneath the acromion Figure 20. Frozen Shoulder
▪ Debridement or repair of partial-thickness rotator cuff tears • To diagnose:

→ Jobe’s test: supraspinatus
▪ If <50% of cuff thickness: acromioplasty and debridement
▪ If longer or thicker: elliptical excision of the diseased tendon → Belly press test: subscapularis
and repair are indicated → conversion to full thickness → Resisted external rotation test: infraspinatus and teres minor
→ Goal of treatment → Speed’s test: biceps tendon
▪ Primary goal: Pain relief → predictable results → Yergason’s test: SLAP (Superior labral anterior posterior)
− Most of those w/ tears is in older population. Pain relief
for them is important.
▪ If these are negative, there is no tear in the supraspinatus → Supervised physical therapy (in order to regain ROM better)
or biceps tendon, consider a problem in the capsule that → Nonsteroidal anti-inflammatory medications
prevents the elevation of the hand. → Oral corticosteroids
• Adhesive Capsulitis Shoulder is increased in: → Intra-articular steroid injections
→ Female gender – 70% of patients → Distention arthrography (you just inject fluid inside the joint
→ Age older than 49 years and that fluid will distend the capsule)
→ Diabetes mellitus (5x more) → Closed manipulation (might lead to fracture) (see video)
→ Cervical disc disease → Open surgical release
→ Prolonged immobilization → Arthroscopic capsular release
→ Hyperthyroidism Surgery
→ Stroke or myocardial infarction • We have to transect MGHL (middle glenoid humeral ligament)
→ Presence of autoimmune disease and IGHL (inferior glenoid humeral ligament)
→ Trauma • Release of the coracohumeral ligament
• Loss of Motion: • Re-establish of the interval between the supraspinatus and
subscapularis
→ Internal rotation frequently is lost initially
▪ Difficulty reaching the back. In females, they may have
difficulty hooking their bra.[doc]
→ Loss of flexion
→ External rotation
Diagnosis
• Internally rotate only to the sacrum (when u want to describe
internal rotation, you describe how the patient could move his
hand to his back, maybe he could just place his hand to his
sacrum, lumbar or thoracic area.)
• 50% loss of external rotation
• Less than 90 degrees of abduction
Clinical Course of Primary (Idiopathic) Frozen Shoulder (no
tear nor tendinitis)
• Phase I – pain
→ Gradual onset of diffuse shoulder pain (patient cannot recall
history of trauma like fall/VA) Figure 22. MGHL & IGHL
→ Progressive over weeks to months E. CALCIFIC TENDINITIS
→ Pain usually is worse at night (like rotator cuff tear) • Painful (MOST)
→ Patient uses the arm less -> pain leading to stiffness • Largely self-limited
• Phase II – stiffness (there will be inability of the patient to raise • Tendons are infiltrated with calcium deposits
or internally rotate his hand)
• Most common site SST (supraispinatus)
→ Pain relief by restricting movement
→ 1.5 to 2 cm away from the tendon insertion on the greater
→ Lasts 4 to 12 months tuberosity
→ Difficulty with activities of daily living • Older than 30 years old, and it affects 10% of the population
▪ Trouble getting to their wallets in their back pockets
• 10% = bilateral deposits (1 out of 10 patients with unilateral pain
▪ Trouble with fastening brassieres
might also have calcium deposits on the opposite shoulder)
→ Dull ache is present nearly all the time (especially at night)
• Women > men
→ Sharp pain during range of motion at or near the new end
• Most individuals with deposits are asymptomatic
points of motion.
• Suggested Causes
• Phase III – thawing (the pain will go down but the difficulty of
shoulder movement stays for a long time) → Vascular etiology
→ Degeneration of the tendon fibers preceding calcification
→ Weeks or months
→ Aging of the tendon – diminishing of the vascularity to the
→ Motion increases, pain diminishes
supraspinatus as a normal course of events
→ Without treatment
Chronological Progression by Sarkar and Uhthoff
▪ Motion return is gradual
▪ Never return to normal • Phase I – pre-calcification stage
→ diminished blood supply – fibrocartilaginous metaplasia
→ asymptomatic
• Phase II – calcification stage
→ Phase of formation calcium
▪ Deposits on gross inspection are dry and chalky
→ Resting phase – fibrocartilage gradually is replaced and
eroded
▪ Pain may be minimal
▪ X-ray: well-marginated, mature-appearing deposits
→ Resorptive phase: vascular channels appear at the periphery
of the deposit and calcium resorption ensues.
▪ Exceedingly painful
▪ Calcium deposits: cream or toothpaste
Figure 21. Frozen Shoulder Clinical Course ▪ As the calcium is resorbed, the dead space is filled with
Treatment granulation tissue
• Traditionally: self-limiting condition, lasting 12 to 18 months
→ Benign neglect (we could just explain that he will undergo
phases of frozen shoulder and hoping that it will be okay in the
later part of the course of the disease)
Figure 23. Phase II
• Phase III – post-calcification phase
→ Granulation tissue matures in to mature collagen
→ Aligned along stress lines with the longitudinal axis of the
tendon
→ Reconstitution of the tendon
→ Pain subsides markedly during this phase (if we let the natural
course of the disease go through its natural process,
eventually the patient will go into post-calcification phase and
the patient will be okay)
Treatment
• Only the patients in the resorptive phase (very painful phase)
should have treatment directed at the calcium deposit itself
• Essentially all patients eventually recover from calcific tendinitis
and non-operative management is the initial treatment of choice
Non-operative Treatment
• Physical therapy
• Exercises
• Anti0inflammatory medications
• Steroid injections
Surgical Treatment
• Symptom progression
• Constant pain that interferes with activities of daily living
• Absence of improvement after conservative therapy
Arthroscopic Technique
• Preferred technique if symptom is warranted
• Removal of calcium deposits is done with a mechanical shaver
II. REFERENCE
• Dr Angel Cayetano’s Lecture ☺
Shoulder Dislocation, Diabetic Foot, Osteoarthritis, Sports
Dr. Angel Cayetanoo | May 1, 2022
OUTLINE
I. Shoulder Dislocation II. Diabetic Foot
A. Immobilization III. Osteoarthritis
B. Bone Loss IV. Sports
C. Matsen’s Classification V. Reference
D. SLAP Lesions
I. SHOULDER DISLOCATION
• Shoulder- most unstable and frequently dislocated joints
→ Because it has the greatest range of motion (ROM).
• Factors that influence the probability of recurrent dislocations
→ Age
▪ Younger—higher chance of having recurrent dislocation
→ Return to contact or collision sports
→ Hyperlaxity Figure 1. Normal vs. Bone-deficient glenoid
→ Presence of a significant bony defect in the glenoid or humeral
head C. MATSEN’S CLASSIFICATION
• This will tell you about the disease itself and the treatment of
A. IMMOBILIZATION choice.
• TUBS (Traumatic, Unidirectional Bankart Surgery)
Clinical Scenario: You have a patient who had a shoulder → This is the usual traumatic shoulder dislocation.
dislocation, then we tried to reduce the shoulder dislocation, now we → Traumatic because these are the sports injury; Unidirectional
are going to put the tent in arm sling. because this is usually anterior; Tx: Bankart Surgery
→ Bankart Surgery-- when you say Bankart tear/injury, what you
• Duration does not seem to affect stability mean is you have a tear in the anterior-inferior aspect of your
→ They say before that the patient you had shoulder dislocation, glenoid. So it just could be a capsular tear (Bankart lesion) and
should be place in arm sling for about 4 weeks, in order for the if there is a plaque of bone that is attached to the capsule, we
capsule to heal. Because remember when you have shoulder call that bony Bankart.
dislocation, you have a bankart lesion—meaning your • AMBRII (Atraumatic, Multidirectional, Bilateral, Rehabilitation,
anterior-posterior capsule is torn. Recent study says that Inferior capsular shift, Interval Closure)
duration of immobilization are placed in the patient on an arm
→ Atraumatic- no trauma; Multidirectional- could be both
sling does not seem to affect stability. So now, we just ask the
anterior/posterior; Bilateral- right and left
patient to wear arm sling for just 2 weeks and let him move.
→ Tx: Rehabilitation
• There is no benefit for conventional sling immobilization longer
→ If rehabilitation doesn’t work-- Inferior capsular shift, Interval
than 1 week for primary anterior dislocation
Closure. You have to close the interval between your
• Immobilization in external rotation is thought to decrease supraspinatus and subscapularis, that’s the rotator-interval.
recurrence rates, but this has not been proven. D. SLAP LESIONS (Superior Librium Anterior Posterior)
→ Let me expound on this one. There was a research in Japan
by Ted Itoi, in which he described the immobilization in Clinical Features
external rotation so with that, you could not place the patient • Pain in shoulder, increased with overhead activity.
on just arm sling. You have to make use of other device in
→ Specifically true in younger population
order for you to immobilize at an external rotation. Their
• Painful “catching” or “popping” in the shoulder
contention was, the capsule will heal in its proper place when
you do external rotation. But the later research did not prove → There is pain, then later on it will pop, and the pain disappears.
this concept. • In the throwing: lesions can present as “dead arm” syndrome.
→ Dead arm syndrome: it’s like when you try to throw a ball, it
• Obtain Xrays: AP Pelvis, Cross table lateral seems like you couldn’t because it seems that you will have
paralysis of your arm. Throwing phase, you are pulling your
B. BONE LOSS biceps from its insertion (insertion-is in the lacrum).
• Glenoid bone loss >20% results in instability and increase
recurrence rates (Bukhart and DeBeer, Sugaya et al., and Itoi et Normal Anatomy
al).
• Hyaline cartilage covers the superior rim of the glenoid
→ If you have more than 20% bone loss cause about the banging
• Biceps tendon either inserts directly into the supraglenoid
of your humeral head, 20% bone loss on the glenoid side, there
tubercle of your glenoid or inserts directly into the superior labrum
might be a recurrent dislocation.
Why do we want to know if there might be a recurrent dislocation?

Because we want to know who are the patient that needs surgical
stabilization.
→ Anterior dislocations: 95% of recurrent dislocations
→ Posterior dislocations: 5%
→ 50% of posterior shoulder dislocations can be missed.
Trans # 31 Shoulder Dislocation, Diabetic Foot, Osteoarthritis, Sports 1 of 8

A B C
Figure 5. 3 Subtypes of SLAP Lesion Type II. A. Anterior (37%) B. Posterior

(31 %) C. Combined Anterior and Posterior (31%).
• Type 3
Figure. 2. This drawing here, is as if you are looking at your shoulder from → Bucket handle tear that displaced in to the joint while the
the side. This is your biceps, supraspinatus, middle glenohumeral biceps root remains stable.
ligament (MGHL), inferior glenohumeral ligament (IGHL).
→ This is the one that usually presents with the popping
sensation. It’s like the patient has pain, then he moves his arm,
then it pops, and there is no pain. It pops because it goes back
Classification to its original position and there will be no pain at that stage.
• Snyder et al. initially classified SLAP lesions into 4 categories
• Type 1
→ Characterized by fraying and a degenerative appearance of
the superior labrum and is uncommon source of clinical
symptoms.
Figure 3. This is how your

biceps insertion look like in older
population. If you poke an
instrument here you will see that
there is just fraying *pointed by
the yellow arrow* of the tendons.
Figure 6. Type 3, bucket handle tear *yellow arrow*. Biceps root remain
stable; so when you poke an instrument here *blue circle* you will see that
your biceps tendon is intact but there is a rim of a tendon or rim of a labrum
but is detached, which looks like a handle of a bucket.
• Type 4
→ Bucket handle tear where the tear propagates into the
biceps tendon.
• Type 2
→ Detachment of the superior labrum from the supraglenoid
tubercle.
Figure 7. SLAP Lesion Type 4.
Figure 4. If you look at this one (black arrow) there is a detachment of the • Maffet and coworkers: Went further to describe SLAP Lesions
superior labrum from the glenoid tubercle. So, when you poke an instrument Type 5-7 which denotes more global detachment of labrum.
right here, when you try to move this one, it moves. • Nord and Ryu: Also describe SLAP Lesions Type 8-10.
→ 3 subtypes have been identified

▪ 37% anterior
▪ 31% posterior
▪ 31% combined anterior and posterior

II. DIABETIC FOOT • Tx: Relieve pressure
→ total contact casting
• Causes ▪ we place a padding, it’s like, *imagine your slipper* then
→ Primary where in the part where there is ulcer, we make a hole on
▪ peripheral neuropathy the slipper so that when the patient wears that
− Small nerves at the foot have diminished sensation → slipper/shoes, that area with sore will have no pressure
So what happens is, even when something has poked, then we put a cast around it.
thru your shoes or slippers, the patient with diabetic foot → orthotic devices
could not feel that anymore. → pads
▪ Arteriosclerosis
→ brace
− there is thickening intimal wall of capillaries and
→ Resection of bony structure
arterioles.
▪ what happens here is that there might be ulcer here *refer
to the white circle on figure 9*, we debride ulcer and it
keeps coming back. Then when we see the x-ray, we see
that the bone is larger in that area so what we would do is
we have to resect the bone structure.
III. DEGENERATIVE OSTEOARTHRITIS
Osteoarthritis
• Non-inflammatory degenerative joint disease characterized by
articular cartilage degradation, subchondral sclerosis,
osteophyte formation and changes in soft tissues including
synovial membrane, joint capsule, ligaments and muscle
A. DISEASE CLASSIFICATION
Figure 8. Diabetic Foot • Primary Osteoarthritis
• Secondary Osteoarthritis
• Effects of Neurologic disorders → Mechanical incongruity of the joint
→ Lesser toe deformities ▪ Ex. the patient had prior trauma in which the alignment of
→ Ischemic clawing the joint is altered
→ Dry flaking skin → Prior inflammatory joint disease
→ Bone disease (Paget’s, Osteonecrosis)
→ Bleeding Dyscrasias
→ Neuropathic Joint
→ Excessive Intra-articular steroid injection
▪ One of the tx for primary osteoarthritis is steroid injection,
and again it works like magic. It tends to decrease the
inflammation and with that, the patient will get better for
some time. However, because of the intra-articular
injection, especially if it’s a repeated treatment, it would
also promote arthritis other that treating the disease itself.
Other than treating the disease itself, it could promote the
disease that it is treating.
→ Endocrinopathies and metabolic disorder
Figure 9. A. Dry flaking skin because of the atherosclerosis, in which there
is already a diminished blood supply on the end arterioles. B. Ischemic B. PRIMARY DEGENERATIVE OSTEOARTHRITIS
clawing. Clawing of the toes. Pathogenesis
A. CLINICAL PROBLEMS AND TREATMENT • AGE – main culprit
• Non-healing plantar ulcer → The ability of the articular cartilage to withstand fatigue testing
is diminished with age.
→ Excess pressure due to bony prominences.
▪ As you age, your articular cartilage will lose its structural
There might be exostosis in the metatarsal phalangeal joint,
support.
which will give extra pressure. And remember these diabetic
patients, they don’t feel much so even if there is an increase • Mechanical Factors (Wear and Tear)
there, they could not feel that and eventually because of the → Microtrauma in the subchondral bone affect the ability of the
increase pressure, there might be oreness in this area. joint to absorb the force of impulse loading leading to the
degeneration of cartilage.
Figure. 10. Non-healing plantar ulcer on a diabetic foot. • Genetic Factor
→ The collagen content of the cartilage and the ability of the
chondrocytes to synthesize PG are genetically pre-
determined.
→ Polymorphism of the type 2 collagen.
Pathology
1. Structural breakdown of the cartilage
⚫ Fibrillation and fissuring
⚫ Focal and diffuse erosion of the cartilage surface
⚫ Thinning and complete denudation of cartilage.

Figure 14. Bony thickening with eburnation with reactive proliferation of
new bone and cartilage at the joint periphery *pointed by the black arrow*.
Clinical Presentation- Physical Exam
• Tenderness over the joint
→ With warmth and swelling (Synovitis)
▪ Synovitis—synovium is producing more fluid because it
needs to lubricate the joint.
• Pain on weight-bearing
• (-) pain on passive ROM
→ if you look at the joint and compare the left and right
Figure 11. Arthritic cartilage. A. Fibrillation and fissuring. B. Focal and diffuse
erosion of the cartilage surface *pink-colored part*. Remember that the specifically when we are talking about the knee, the arthritic
cartilage is WHITE, so when you see the PINK thing here, this is already your one will appear larger because of the synovitis and the
subchondral bone—meaning your white articular surface is already eroded, eburnation which is happening on the subchondral bone.
because of the thinning and complete denudation of the cartilage. • Joint enlargement
• Limitation of motion
2. Changes in the subchondral bone → as the disease progress
• When you say subchondral bone, you are talking of the bone • Crepitus
underneath your cartilage. → specifically, when the cartilage is denuded and when you
• Subchondral bony sclerosis already have an exposed of subchondral bone
• Cyst formation • Gross deformity
• Bony thickening with eburnation → in the knee— the most common deformity is valgus then
• Reactive proliferation of new bone and cartilage at the joint there might be subluxation of your joint.
periphery. • Subluxation
C. KNEES
• Most common joint affected
• Locking of the knees- loose joint bodies
• Medial compartment
→ Most frequently affected – GENU VARUS
▪ So if you have a patient, and you asked which is more
painful is it the medial or the lateral side of the knee? More
often than not, it is the MEDIAL side. And if you look at the
angulation of the knee it become GENU VARUS.
• Lateral compartment
→ Genu Valgus
• Patellofemoral disease
→ Patella losses side to side mobility, 10% of flexion/extension
Figure 12. This is an example of bony sclerosis. In X-ray, it will appear whiter
*pointed by the black arrows*.
Figure 15. A. Knee. Arrow pointing on the medial compartment. B. X-ray of

Figure 13. A. Cyst Formation. B. Cyst formation on CT scan. the lateral knee. Pointed by the black arrow is an osteoarthritis of the
patellofemoral join; there is bony eburnation, subchondral sclerosis and an
overgrowth of the bones.

D. TREATMENT Total Knee Replacement
• Non- pharmacologic Therapy • Primary indication is to relieve pain with or without significant
• Pharmacologic deformity
→ Analgesics • Indicated in older patients with more sedentary life-styles
→ NSAIDs • Deformity can become the principal indication for arthroplasty
→ Corticosteroids
F. TUMORS
• Surgical
• Primary Bone Tumors
Corticosteroid → Malignant Bone Tumors
• Oral steroid has no role in Osteoarthritis ▪ Sarcomas
→ In some studies, however, they say that oral steroids has no → Benign Bone Tumors
role in osteoarthritis. • Metastatic Bone Tumors
• Intra-Articular injection Sarcomas
→ Use judiciously in OA of 1 or 2 inflamed joints
→ Should not inject > 3x/year • Metastasize primarily via hematogenous route
▪ As this will promote secondary osteoarthritis. • Lungs – most common
• Whenever we have a bone tumor, the first thing that we have
E. SURGICAL TREATMENT to look at is the lungs. So, we take an x-ray and we take a CT
• Non-Arthroplasty scan. So, if the tumor is already there, then it’s already stage
→ Arthroscopic debridement/synovectomy 4. So, the treatment might just be palliative. [Doc. Cayetano]
→ Wash out [meaning we take out the dirty content of the joint] G. DIAGNOSIS OF TUMOR
→ Osteotomy
→ Arthrodesis (meaning we fuse the bone) • Age
→ Autologous osteochondral Allografts • Number of bone lesions
• Arthroplasty • Anatomic location within the bone
→ Partial Joint Replacement • Effect of lesion on the bone
→ Total Hip or Knee Replacement • Response of the bone to the lesion
• Matrix Characteristics
Arthroscopic Debridement/Synovectomy
Age (most common tumors by age)
• Resection of unstable of meniscal segments
• Excision of osteophytes • Birth to 5 y/o
• Removal of loose bodies → Leukemia
• Drilling - break to the dense subchondral bone to vascular • 10-25 y/o
marrow → Osteosarcoma
• Abrasion chondroplasty - stimulate cartilage regeneration → Ewing’s
→ Fibrous dysplasia
Osteotomy • 40-80 y/o
→ Metastatic bone disease
→ Myeloma
→ Lymphoma
Anatomic location within the bone
• Adamantinoma- tibia in the young
• Chondroblastoma- epiphysis
• Osteosarcoma- metaphysis of the distal femur and proximal tibia
Effects of lesion on the bone
• High grade malignant:
→ Spread rapidly though medullary canal
→ Rapid cortical destruction and spread through soft tissue
Response of the bone to the lesion
• Periosteal response
• 'Unloading" of the involved joint compartment by:
→ correcting the malalignment Matrix characteristics
→ redistributing the stresses
Arthrodesis
• Fusing the joint in a more medical
term is Arthrodesis
• Indicated for severe disability,
especially in young active patients
• Beneficial when the knee is in varus
or valgus position and its ligaments
are relaxed
Unicompartmental
Arthroplasty

• Cartilage • Wide
→ calcification appears as stippled or arcs or rings → With a cuff of normal tissue
→ 10%recurrence rate
• Radical
→ Tumor and the compartment (most likely, very low
recurrence rate)
IV. SPORTS
A. MENISCAL INJURY
• Anatomy
→ On the peripheral 20-30% of the medial and 10-25% of the
lateral meniscus area vascularized
→ Medial/lateral genicular arteries
• Osteoid
→ Mineralization is cloud-like
H, PRINCIPLES OF BIOPSY
• Should not compromise subsequent definitive resection

→ The biopsy tract should be excised en block at the time of
definitive resection
• Incision should be oriented longitudinally
• Approaches used in general orthopedics might be
contraindicated
• Meticulous Hemostasis • If you look at the meniscus here, your lateral and medial/ you
→ Prevent seeding should consider that it’s only the periphery that is
→ Bone holes should be plugged [we use a bone wax] vascularized and not the one on the middle.
→ Drain • This means that healing will happen on the lateral side, but if
▪ Should exit line with the biopsy there’s a tear on the inner side, healing will not happen
• No contamination o the compartments that are not involved because the blood supply is coming from the periphery from
• Obtain tissue from the periphery of the viable tumor the lateral and medial genicular arteries [Doc. Cayetano]
• “Culture what you biopsy. Biopsy what you culture”
• Avoid iatrogenic complications such as Fractures → Medial Meniscus
→ Biopsy the soft tissue [when the tumor has gone out to the soft ▪ More C-shaped
tissue] ▪ 3x more commonly injured
→ Bone → Lateral meniscus
▪ area of maximal cortical thinning ▪ More circular (You can tell that it is the lateral since your
▪ Oval / round window (because a square window will fibula is there as a marker)
produce a stress riser effect)
• When we say stress riser, what we mean is that we could

concentrate the stress in that area, such that there might be a
fracture there. [Doc. Cayetano]
I, LIMB SALVAGE
• 1. Location of the lesion must be at least equal to that of
amputation
• 2. The limb that has been saved must be functional
• Sometimes when the amputation has greater function as

compared to limb salvage, it’s better to do amputation. For • Function
example, when tumor in your leg already encroached on → Deepen the articular surface
your tibial nerve. When you take out the tumor, you also take → Stability
out the tibial nerve, which gives nerve supply to the sole of → Lubrication
your foot via your lateral/medial plantar nerve. SO, when → Nutrition
you don’t have sensation in your foot anymore and you use • Your proximal tibia is actually flat, in order for the surface to
that for walking, it will have wound time and again. With that accommodate the round distal femur, there should be
it’s better to do amputation since you could just replace that meniscus that’s why it deepens the articular surface [Doc.
with a prosthesis [Doc. Cayetano] Cayetano]
Surgical Margins
• Intralesional
→ Through the tumor
→ 100% recurrence rate
• Marginal
→ Through the reactive zone
→ 25-50% recurrence rate

• Clinical Assessment
→ Pain on axial loading and rotation
→ Catching, popping, giving away, swelling, locking
→ Joint line tenderness
→ Tests: Apley’s, McMurray’s
B. ACL INJURY
• Anterior cruciate ligament
• Tibial insertion
→ Just anterior to and between the intercondylar eminence
• Femoral Attachment
→ Posteromedial aspect of the lateral femoral condyle
• 33mm long and 11mm wide
• For McMurray’s you flex the leg about 30degrees and apply
valgus and external rotation and if there is pain, there could
be injury to your meniscus as well [Doc. Cayetano]
• Meniscal Injury
→ Degenerative
→ Traumatic • In clinical practice, if you want to pull on your tibia, the ACL
• Non- surgical treatment is the one that is preventing you in doing that.
→ <5mm in length (seen in MRI or diagnostic arthroscopy) • When you do your PCL exam, if you push your tibia going
→ Tears that cannot be displaced > 1-2 mm (viewed from an posterior to your femur then that could give you an idea that
arthroscopic view) you have PCL injury [Doc. Cayetano]
• Treatment options for meniscal tear
→ Partial meniscectomy • Clinical Diagnosis
→ Meniscal Repair → Non-contact pivoting injuries
• When the injury is in the inner side, we go for meniscectomy → Audible pop with immediate hemarthrosis
but when the injury is on the outer side we go for repair, this → Lachman’s Test
is due to the inner side being avascular [Doc. Cayetano]

• If you could pull it anteriorly, ACL could have an injury, if you
could push it posteriorly PCL could be injured [Doc. Cayetano]
• Treatment
→ Intra-articular reconstruction
→ For complete disruption living an active lifestyle
• For example, you have a young patient actively engage in
sports like basketball, soccer then we should do an ACL
reconstruction. Specially for active soldiers, but for those
inactive, then ACL might not be so much of a need to you.
• This has the highest strength but also has the highest
morbidity as well[Doc. Cayetano]
• Grafts
→ Bone-patella, tendon bone
• Removing a tendon with bone from the patella and bone
from the tibial side and we place this to try and reconstruct
the ACL using this graft. This is from the same person [Doc.
Cayetano]
→ Four strand Hamstring

• We get it from the semitendinosus and the gracilis and we
clip it to get an 11mm graft [Doc. Cayetano]
→ Quadriceps
→ Allograft
V. REFERENCE

Child Orthopedics
Dr. Cayetano | May 19, 2022
OUTLINE • Most common brachial plexus palsy

• Traction or tear of the upper trunk of brachial plexus (C5 and C6
I. Birth Injuries II. Pediatric Fractures
roots)
A. Brachial Plexus Palsy III. Developmental Disease
B. Cerebral Palsy IV. Chronic Osteomyelitis → Dorsal scapular nerve
V. References → Subclavius nerve
→ Suprascapular nerve
I. BIRTH INJURIES → Lateral pectoral nerve
→ Thoracodorsal nerve
A. BRACHIAL PLEXUS PALSY • Appearance:
• Occurs in two births in every 1000
→ “Not so common but can be seen in practice” Dr. Cayetano
• Risk Factors:
→ Large birth weight
▪ “If it is gestational diabetes, it is expected to have large birth
weight babies” Dr. Cayetano
→ Forceps delivery
→ Breech presentation
→ Prolonged labor
• Represents a stretch injury on the nerve roots
• Management:
→ While awaiting return of neurologic and motor
▪ Therapy
▪ Passive exercise to preserve motion
▪ “Rule of thumb: they recover more often than not. However, Figure 3. Erb Palsy [ppt]
if it is severe, surgical repair is warranted. But in the
Philippines, no one is doing surgical repair for brachial → Limb hangs by side
plexus” Dr. Cayetano ▪ Paralysis of abductors
→ Surgical repair- for severe cases → Medially rotated
▪ Paralysis of lateral rotators
→ Forearm is pronated
• Nerves involved:
→ Nerve to subclavius
▪ Innervates the subclavius
→ Musculocutaneous and axillary nerves
▪ Musculocutaneous Innervates the brachialis and biceps
▪ Axillary innervates the teres minor and deltoid
→ Suprascapular
▪ Innervates the supraspinatus and infraspinatus
• “The bottom line is they possess nerve fibers from C5 and C6
roots” Dr. Cayetano
[ppt]
Figure 1. Anatomy of Brachial Plexus Palsy
Lower Lesions of the Brachial Plexus (Klumpke Palsy)
• 1st thoracic nerve is usually torn
Upper Lesions of the Brachial Plexus (Erb Palsy)
• Ulnar and median nerves supply all the small muscles of the hand
• Hyperextension of the metacarpophalangeal joins and flexion of
interphalangeal joints
Figure 4. Hyperextension of the metacarpophalangeal joins and flexion of

interphalangeal joints [ppt]
Figure 2. Roots, Trunks, Divisions, Cords, and Terminal Branches of the

Brachial Plexus [ppt]
Trans # 32 Child Orthopedics 1 of 9

B. CEREBRAL PALSY Treatment
• Tendon lengthening
• Release of contractures
• Tendon transfers- to maintain motion and function
• “Remember that cerebral palsy is a brain disorder and
orthopedics has nothing to do with the brain. Orthopedics will
concern on the problems of the extremities specifically the
spastic type- muscle contracture, tendon contracture” Dr. Cayetano
Problems in Cerebral Palsy

• HIP DISLOCATION
Figure 5. Cerebral Palsy [ppt]

• Injury to the brain which may be associated with mental
impairment
• Nonprogressive brain disorder
→ “If you have it at birth, you will have it all through out your life”
Dr. Cayetano
• Typical cerebral palsy patient:

→ Hyperreflexic
→ Increased muscle tone
→ Spasm
[ppt]
Figure 8. Pelvic Osteotomies
Classification of Cerebral Palsy
• Spastic
→ Problem in the abductor muscles
→ Most common about 90% of all cases
→ Treatment:
→ Muscles are stiff and their movements may look stiff ▪ Abductor tendon releases
→ Problem stems from an upper motor neuron lesion in the brain ▪ Tendon balancing procedures
• Athetotic ▪ Open reduction of a hip joint
− “Place back the head to the socket” Dr. Cayetano
▪ Acetabular reconstruction
− “If it is very severe such that the shape of the head and
acetabulum is already different. What we do is
acetabular reconstruction or osteotomy of proximal
femur” Dr. Cayetano
− Example is Staheli, which is the reconstruction of the
glenoid by putting a bone graft shelf to increase the
surface area for the articulation of the head” Dr. Cayetano
▪ Osteotomy of proximal femur
Figure 6. Athetosis [ppt]
• KNEE/ HAMSTRING CONTRACTURES
→ Dyskinetic cerebral palsy → Due to hamstring tightness
→ The injury is in the basal ganglia → Treatment: Hamstring Lengthening
→ Hypertonia and hypotonia
▪ Due to the affected individual’s inability to control muscle • FOOT AND ANKLE DEFORMITIES
tone → “There might be imbalance like your peroneal tendon might be
▪ “The problem here is the loss of muscle tone” Dr. Cayetano affected” Dr. Cayetano
• Ataxic
Figure 9. (L) image- Hemiplegia in right side. Hip and knee contractures and
talipes equinus. (R)image- Diplegia (lower limbs, more affected).
Contractures of Knees and ankle. [ppt]
Figure 7. Ataxia [ppt] • EQUINOVALGUS FOOT

→ Least frequent form of cerebral palsy → Most common foot deformity in cerebral palsy
→ Damage to cerebellar structure → Caused by:
→ Problems in coordination, specifically in their arms, legs, and ▪ Heel cord contracture
trunk (in short whole body) Dr. Cayetano − Achilles tendon is contracted meaning gastrocsoleus
→ Most common manifestation of ataxic cerebral palsy is complex is contracted
Intention (Action) tremor ▪ Peroneal spasm
▪ “If they will try to move their hands, they will have tremors” ▪ “Peroneal tendon is at the lateral side of the foot. If it is in
Dr. Cayetano the lateral side, it will cause eversion which is synonymous
to equinovalgus” Dr. Cayetano

→ Treatment: Diaphyseal Injuries in a Pediatric patient
▪ Tendon balancing • Generally treated closed
▪ Body reconstruction if severe • Pediatric patients- capable of extensive remodeling
→ The good thing about child fracture is that you will intensive
remodeling, so even it’s like a 30°angulation, that will
eventually become straight bone
• Internal fixation- physis is avoided
→ But if its just a pin which is smooth, it could actually cross the
physis without any problem later on
[internet]
Figure 10. Equinovalgus Foot
II. PEDIATRIC FRACTURES

• Pediatric patient
→ Epiphyseal growth plate is unossified
→ At risk of fracture
• Reduction and stabilization of epiphyseal fractures is critical to Figure 13. Diaphyseal injuries and Internal fixation [ppt]
minimize permanent growth disturbances
Fractures of the Pediatric Hip
Salter- Harris Fracture • Treated with a spica cast
• Most common fracture in pediatrics → Include the abdomen, lower back, pelvis, and lower limb
• Type 1- fracture through the growth plate
→ Physis is destructed
• Type 2- fracture through growth plate and metaphysis
• Type 3- fracture through growth and epiphysis
• Type 4- fracture through all three elements (metaphysis,
epiphysis, physis)
• Type 5- crush injury of growth plate
→ Physis is compressed
Figure 14. (L) image- 1 & ½ Hip Spica. It includes the abdomen, lower back,
pelvis, and the lower limb. Done only in a child, not done in adolescent and adult
because it will be very stressful to the patient. (R) image- Fracture of the femoral
neck[ppt]
Fractures of the Femoral shaft

• Can be treated with hip spica or internal fixation
• Younger than six years old- spica cast
• >6 y/o: internal fixation with a flexible intramedullary nail
• 14 y/o: adult type with intramedullary nail
Figure 11. Salter-Harris Fractures [ppt]
Treatment of Growth Plate Injuries

• Anatomic reduction of the fragments
• Avoids placing hardware across the growth plate
→ Meaning avoid placing large hardware across the growth plate
because the pin is just a small-sized implant that would
A B C
actually cross the growth plate without deformity later on
Figure 15. Image (A)- Hip spica. (B) Flexible intramedullary rod- use for
→ Minimize premature closure younger than 14 y/o, very smooth even it crosses the physis, there will be no
→ On Figure 11- (R) pin which crosses the growth plate, actually problem. (C) Intramedullary fixation, which is also for adult, large so if it
counter intuitive, very small that it will not cause damage to crosses the physis, there will be a growth a problem later on. [ppt]
the growth plate
Extraarticular Fractures
• Managed with Long Leg cast
→ Distal Femur
→ Proximal Tibia
Figure 12. Growth plate pin [ppt]

A B
Figure 19. Developmental hip dysplasia [ppt]
DIAGNOSIS
C
Figure 16. Image (A)-Distal femur fracture. (B) Proximal tibia fracture.
(C)Long leg cast[ppt] Ossific
Elbow Fractures Nucleus
• Fracture of the distal humeral epiphysis can be misdiagnosed as
a dislocation if the elbow
• Its very difficult to diagnose an elbow fracture in a child because
it has not ossified yet, so what we usually do is you have to take
an x-ray of the other side/ contralateral side then we compare
Figure 17. Elbow Fracture[ppt]
• Treatment: closed reduction and percutaneous pinning

• Injury to the brachial artery, the radial, ulnar, and median nerves
are possible
Figure 20. Hilgenreiner’s line, Perkin line, Shenton’s line, & Acetabular
index[ppt]
• Horizontal line (Hilgenreiner line)
→ Line drawn between each triradiate cartilage (cartilage of the
ilium, pubis, and ischium) or at the base of your ilium
• Perkin line
→ Line drawn perpendicular to hilgenreiner line through
superolateral edge of acetabulum (Perkin line), dividing hip
into 4 quadrants
• Proximal medial femur should be in the lower medial
quadrant
→ Ossific nucleus- will only appear at aged 4-7 months
→ When the patient is just less than 4 y/o, you cannot see the
ossific nucleus at the lower medial quadrant
Figure 18. Vessels and Nerves of the elbow[ppt]
→ If you have a pt. younger than 3 y/o, 2 y/o, or at birth, in order
for you to diagnose a DDH or that the hip is not congruent, you
III. DEVELOPMENTAL DISEASE have to request for an ultrasound and you have to do your PE
• Rare • Acetabular index
A. DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) → Angle between Hilgenreiner line and line drawn from triradiate
• Seen in firstborn cartilage to lateral edge of acetabulum.
• Females → Angle decreases with age (meaning as the pt. increases in
• Positive family history age, acetabulum will become more horizontal because the
• Breech birth problem with DDH is, it becomes more vertical or the
• A congenital or developmental deformation or misalignment of acetabular angle will become higher- so want your angle to be
the hip joint low in order to accommodate your hip) and should measure
• Patients who are born with dislocation or instability of the hip, less than 20°by 2 years of age
which may then result in hip dysplasia • Shenton line
→ Or if at birth, patient already have a dislocated hip, so later on the → Line is drawn from the medial aspect of femoral neck to inferior
shape of the femoral head will not be round then the shape of the border of pubic rami
acetabulum will not be round, such as that if you try to match the → Should create smooth arc that is not disrupted
femoral head and the acetabulum, they would not match anymore → Disruption of the Shenton line indicates the presence of some
degree of hip subluxation.

Figure 21. Shenton line. Left arc is normal, Right arc is disrupted [ppt] Figure 24. Ultrasound of a hip dysplasia [internet]
Physical Examination Early Treatment

• Newborns examined for hip instability within the first 72 hours • Abduction and flexion in a Pavlik harness
• Ortolani’s test • Avoid severe abduction to avoid avascular necrosis of the head
→ Gentle elevation and abduction of the femur- palpable click in
• Mild to moderate dysplasia – put the patient in a Pavlik harness
the relocation of a dislocation
for 6 to 12 weeks
• Barlow test
• Severe cases – do adductor tenotomy
→ Adduction and depression of the femur which causes a
palpable click as a hip slip into a dislocated position
Figure 25. Pavlik Harness

• For Mild to moderate dysplasia meaning the acetabulum and the
femoral head have a little bit of incongruency but when you do
your Ortolani you could still align the hip you can just keep your
patient in a Pavlik harness for 6 to 12 weeks however if you
already have a severely deformed acetabulum or severely
deformed head such that when you try to relocate the hip you
could not already relocate then it’s time to do adductor tenotomy
meaning we have to tenotomize the adductors, the iliopsoas in
particular. [doc]
Delayed Treatment
• Open reduction
• Anterior approach the pulvinar can be removed and the femoral
head located
• Severe cases: Adductor tenotomy and femoral shortening
• Complications: osteonecrosis of the femoral head --> pain and
decreased motion
Figure 22. Barlow and Ortolani Test [ppt] • Delayed treatment usually happens when the pediatrician was
not able catch the patient early such that the mother only noticed
• Dislocated or Dislocatable Hip that the patient is Iimping when he is trying to walk before 1 yr
→ Note for apparent length discrepancies of the femur when hip old. Pulvinar is a fibrofatty tissue within the acetabulum so
is positioned in 90° meaning at birth of course it is not dislocated but in the passage
in the birth canal it dislocates then there will be nothing in the
acetabulum, the head will not be there, so there will be blood that
will be in the acetabulum so later on that blood will form into
fibrous tissue accompanied by fatty tissues and you call that
pulvinar. [doc]
Severe DDH Treatment

• Pelvic Osteotomy = done for the acetabular site
• Varus osteotomy of the proximal femur = for the femoral site
Figure 23. Ask the pt. lie on his/ her back, then you flex the knee making sure
that the feet is on level ground, and you look at the knee, Left side knee is
lower, you may conclude that the hip is dislocated, but of course you have to
take an x-ray or ultrasound before you make your final diagnosis
Imaging
• X-ray- not reliable because acetabulum and femur head are not
yet ossified
• Ultrasound-look for dislocated or dislocatable hip
• Treatment:
→ Percutaneous screw fixation through the femoral neck
▪ To engage the epiphysis
▪ One screw is enough [Dr. Cayetano]
→ Reduction of the slipped epiphysis is not recommended
▪ Because of an increased risk of avascular necrosis
Figure 26. Varus osteotomy (left) and Pelvic osteotomies (right)

B. LEGG-CALVE-PERTHES DISEASE (LCPD)
• Flattening of the femoral head caused by osteonecrosis of the
proximal femoral epiphysis
• Avascular necrosis
• Typical patient is a 7-year-old male
• Common in boys, who are hyperactive, with small stature for age,
who have delayed bone age and some minor congenital
anomalies. Figure 29. Percutaneous screw fixation [Dr. Cayetano’s ppt]
• Groin or knee pain, decreased hip motion and a limp
Klein’s Line
• So how do we diagnose SCFE, we have to go back to the x-
ray, we have to look at Klein’s line. [Dr. Cayetano]
• Line along the superior edge of the neck of femur
• Should normally intersect the lateral part of the superior
femoral epiphysis
Figure 27. Normal Femoral head (left) and Femoral head with Legg-Calve-
Perthes (right)
Treatment
• Traction
• Physical therapy
• Abduction
• Exercises
• Crutches
• Femoral and pelvic osteotomies (extreme cases)
C. SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
• Typical patient: 10 to 16 years old
• Displacement of the epiphysis on the femoral neck
• No history of injury (important)
→ This is important because when there is a history of injury
like sports injury or motor vehicular accident and you see
this one it is not SCFE, it is just a fracture of the physis.
Figure 30. Klein’s line [Dr. Cayetano’s ppt]
→ SCFE is not a diagnosis of trauma. [Dr. Cayetano]
• African American heritage D. TALIPES EQUINOVARUS/ CLUBFOOT
• Obesity….(unlike in LCPD= small stature) • Deformity of the foot
• More common in boys than in girls • Also called congenital talipes equinovarus (CTEV)
• 25% bilateral
• Groin and anterior thigh or even knee pain and decreased in
motion
Figure 31. Congenital talipes equinovarus (CTEV) [Dr. Cayetano’s ppt]
Figure 28. Slipped capital femoral epiphysis [Dr. Cayetano’s ppt]

• Four Elements of clubfoot:
→ Hindfoot equinus
→ Hindfoot varus
→ Metatarsus adductus
→ Talonavicular subluxation
• Components of deformity
→ Talar neck: medial and plantar deviation
→ Medial rotation of the calcaneus
→ Medial displacement of navicular and cuboid
Figure 35. Adductus [Dr. Cayetano’s ppt]
• Ponseti Method
→ correct first then maintain
→ Correction Phase
▪ Specific manipulation and casting 4-8 weeks
▪ It is very important where you put your fingers…
Figure 32. Components of deformity [Dr. Cayetano’s ppt] ▪ Weekly manipulation and casting
• 4 Components → Maintenance Phase
▪ Bracing 23 hours/day for 3 months
→ C-A-V-E
▪ Sleep-time bracing until 4-5 years old
→ Cavus (Midfoot): clubfoot deformity 1
▪ Talk to parents from the start (especially about the braces)
→ Adductus (Midfoot): clubfoot deformity 2
• 4 steps of deformity correction
▪ What happens to bines in adductus?
→ Cavus: elevate 1st metatarsal
− Navicular rotates and dislocates medially
→ Adductus: abduct foot
− Calcaneum also rotates under talus
→ Varus: automatically corrects
→ Varus
→ Equinus: perform percutaneous Achilles tenotomy
→ Equinus
Figure 36. Ponseti Method. The foot abduction brace (FAB)S [Dr. Cayetano’s ppt]
Figure 33. Cavus [Dr. Cayetano’s ppt]
Figure 34. Adductus [Dr. Cayetano’s ppt]

Figure 37. Correction Phase [Dr. Cayetano’s ppt]
Figure 38. Maintenance Phase [Dr. Cayetano’s ppt]

• Percutaneous Achilles Tenotomy
→ Just a small incision that we do in the clinic [Dr. Cayetano]
Figure 39. Percutaneous Achilles Tenotomy [Dr. Cayetano’s ppt]

Figure 42. X-ray of Osgood-Schlatter disease [Dr. Cayetano’s ppt]
• Final cast after tenotomy
→ 50-70° abduction IV. CHRONIC OSTEOMYELITIS
→ Maximal gentle dorsiflexion (>15 degrees)
• Inflammation of bone caused by an infecting organism
→ Cast for 3 weeks, then fit brace
• Localized → marrow, cortex, periosteum, and soft tissue
surrounding the bone
→ It starts inside the bone, in the marrow. It may go through the
skin where it forms sinus and forms oozing pus in that area.
[Dr. Cayetano]
• May arise as a result of inappropriately treated acute

osteomyelitis, or trauma
• Systemic symptoms usually subside, but one or more foci in the
bone may still contain purulent material, infected granulation
tissue, or a sequestrum
• Hallmark: infected dead bone within a compromised soft tissue
envelope
• Classification
Front From above → Based on duration and type of symptoms
▪ Acute
▪ Subacute
Figure 40. Final cast after tenotomy [Dr. Cayetano’s ppt]
▪ Chronic
• Mechanism of infection
E. OSGOOD-SCHLATTER DISEASE
→ Exogenous form
• Athletically active adolescents
▪ Trauma, surgery (iatrogenic), or a contiguous infection
• Ossification in the distal patellar tendon at the point of its tibial
→ Hematogenous form
insertion
▪ Known or unknown bacteremia
• Result from mechanical stress on the tendinous insertion
− For example, the patient has sepsis, the bacteria may
• X-ray: calcified ossicles within the tendon at its insertion
lodge in the bone. [Dr. Cayetano]
• Signs and symptoms: severe local pain and tenderness in the • Surgery for chronic osteomyelitis consists of sequestrectomy and
area of the tibial tubercle resection of scarred and infected bone and soft tissue
• Treatment: activity restriction • The goal of surgery is eradication of the infection by achieving a
→ May resume athletic participation if symptoms improve viable and vascular environment
• Symptoms regress after skeletal maturity • Radical debridement may be required to achieve this goal
Cierny and Mader
• Physiologic
→ Class A: normal response to infection and surgery; in a
healthy patient [Dr. Cayetano]
→ Class B: compromised patients with local systemic, or
combined deficiencies
→ Class C: when results of treatment are potentially more
damaging than the presenting condition
• Anatomic
→ Superficial
→ Localized
→ Medullary
→ Diffuse
Figure 41. Osgood-Schlatter disease [Dr. Cayetano’s ppt]

Figure 43. Diagnosis: Chronic osteomyelitis humerus, right, Cierny Mader
Type IV-A. Type IV because it is diffuse and A because let’s assume this is a
healthy patient. [Dr. Cayetano’s ppt]
Figure 44. Sequestrectomy and curettage. We

have to remove the bone
and curette the inside of the bone. We need to remove the
medullary dirty materials. [Dr. Cayetano]
V. REFERENCE
Dr. Cayetano’s lecture

Surg Ortho

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Orthopedic Surgery

Dr. Angel Cayetano | April 20, 2022

OUTLINE II. FRACTURE DIAGNOSIS

• This is a complete diagnosis. “Fracture close complete

• Orthopedics comes from the Greek words “Orthos” meaning

Trans # 23 Orthopedic Surgery 1 of 5

Anatomic Location and Laterality

Trans # 23 Orthopedic Surgery 2 of 5

Trans # 23 Orthopedic Surgery 3 of 5

• There is no need to place betadine or hydrogen peroxide Pain Management

Trans # 23 Orthopedic Surgery 4 of 5

Trans # 23 Orthopedic Surgery 5 of 5

I. CLINICAL DECISION MAKING

Trans # 24 Basic Urology 1 of 15

Figure 6. Cross section of the penis, demonstrating the relationship between

● Insert a needle to evacuate dysmorphic or clotted blood • Urologic • Necrotizing fasciitis

Figure 8. Urinary Obstruction

Figure 14. Scrotal Structure

• Inguinal Area: Hernia

Figure 15. Examination of the Inguinal area

Figure 12. Hypospadias

Figure 16. Inguinal Hernia

Figure 17. Neglected Hernia

Figure 18. Undescended Testis

Figure 20. Hydrocele

C. DIGITAL RECTAL EXAM

Trans # 24 Basic Urology 5 of 15

Figure 24. CT sonogram

Trans # 24 Basic Urology 6 of 15

Figure 25. Management of recurrent UTI

Figure 27. CT Stonogram: mildly hydronephrotic and calcification [Balasik trans]

Trans # 24 Basic Urology 8 of 15

• Percutaneous Nephrolithotripsy • DA Vinci Robotic System

Figure 32. Percutaneous nephrolithotripsy

D. ENLARGED PROSTATE (BPH)

• Laparoscopic Removal of Kidney and Ureteric

Trans # 24 Basic Urology 10 of 15

1. BENIGN RENAL TUMORS

• Surgery- remains the mainstay for cure

Trans # 24 Basic Urology 13 of 15

Trans # 24 Basic Urology 15 of 15

Figure 9. Shoulder Dislocation

Trans # 25 Upper Extremity Trauma 2 of 11

Trans # 25 Upper Extremity Trauma 3 of 11

Figure 11. Luxatio Erecta Figure 14. Axillary Lateral View

Figure 15. Reverse Hill-Sach

Trans # 25 Upper Extremity Trauma 4 of 11

Figure 16. Traction-counter Traction

Figure 17. Hippocratic Technique

Trans # 25 Upper Extremity Trauma 5 of 11

Figure 20. Anatomic Components of Shoulder Girdle

Figure 25. Varus Fracture

Trans # 25 Upper Extremity Trauma 6 of 11

Figure 27. Metaphyseal Head Extension

Figure 32. Scapular Y

Figure 28. Medial Hinge Displacement

Trans # 25 Upper Extremity Trauma 7 of 11

Figure 36. Intermedullary Nailing

Trans # 25 Upper Extremity Trauma 8 of 11

Figure 40. Plates

IV. HUMERAL SHAFT FRACTURES

Figure 41. Humeral Shaft Fractures

Trans # 25 Upper Extremity Trauma 9 of 11