Orthopedic

Answering of
Clinical exam

Batch 20
Group C
‫خ‬
1
Complications of supracondylar fracture of the humerus in
children
1. Pin migration
2. Infection
3. Cubitus valgus
4. Cubitus varus
5. Recurvatum
6. Nerve palsy from injury
7. Vascular Injury
8. Volkmann ischemic contracture
9. Postoperative stiffness

Rhumatiod arthritis , clinical picture , diagnosis ,treatment , and

complications
 Definition: is a chronic systemic autoimmune disorder causing a
symmetrical polyarthritis
 Clinical picture:
Symptoms
o insidious onset of morning stiffness and polyarthropathy
o usually affects hands and feet
 DIP joint of hand is usually spared
 may also affect knees, cervical spine, elbows, ankle and
shoulder
Physical exam
o subcutaneous nodules in 20% (strong association with positive
serum RF)
o ulnar deviation with metacarpophalangeal (MCP) subluxation,
swan neck deformity
o hallux valgus, claw toes, metatarsophlanageal (MTP)
subluxation
 o joints become affected at later stage in disease process

 diagnosis : by
1) clinical picture
2) labs :
 anti-CCP (cyclic citrullinated peptide )anti-citrullinated
protein/peptide antibody( most sensitive and specific test)
 anti-MCV (mutated citrullinated vimentin)
 elevated ESR
 elevated CRP
 positive RF titer (most commonly IgM)
a. targets the Fc portion of IgG
b. elevated in 75-80% of patients with RA
 joint fluid testing
c. decreased complement
d. may have elevated RF levels

3) Radiographs
 periarticular erosions and
osteopenia
 protrusio acetabuli
o medial migration of
femoral head past the
radiographic teardrop
o Also seen in Marfan's
syndrome, Paget's
disease, Otto's pelvis
and other metabolic
bone conditions
 joint space narrowing
 central glenoid erosion

4) Diagnostic Criteria
• Morning stiffness ≥ 1h
• Swelling in ≥ 3 joints
• Rheumatoid nodules
• Radiographic changes of the hand including bony erosions and
decalcification
• Symmetric arthritis
• Serum rheumatoid factor
• Arthritis of the hand (MCP, PIP) and wrist
• have ≥4 of 7 criteria for a 6 week period

EULAR Criteria for the Diagnosis of RA) greater than 6 (

 treatment
pharmacologic treatment
 indications
o mainstay of treatment
 medications (see table below)
o first line includes NSAIDS, antimalarials,
remittent drugs (gold, sulfasalazine,
methotrexate), steroids, cytotoxic drugs
o more aggressive approach with DMARDs is
now favored over pyramid approach
 KEY ELEMENTS IN MEDICAL TREATMENT
 Identify patients with RA as early as possible
 Start disease-modifying antirheumatic drugs(DMARDs) immediately
 Consider combination therapy with multiple DMARDs
 If DMARDs fail, progress rapidly to biological therapies such as the TNF
inhibitors infliximab, etanercept and adalimumab
Complications
1. Joint damage: RA causes inflammation in the joints, which can lead
to the destruction of cartilage and bone. Over time, this can result in
joint deformities and irreversible damage.
2. Rheumatoid nodules: These are firm lumps that can develop
under the skin, usually around pressure points or joints affected by
RA. While they are usually harmless, they can sometimes cause pain
or become infected.
3. Cardiovascular complications: RA is associated with an increased
risk of cardiovascular diseases, such as heart attacks and strokes.
Chronic inflammation and certain RA medications can contribute to
this risk.
4. Lung complications: RA can affect the lungs and lead to conditions
like pleurisy (inflammation of the lining of the lungs), pulmonary
fibrosis (scarring of lung tissue), or rheumatoid nodules in the lungs.
5. Eye complications: RA can cause inflammation in the eyes, leading
to conditions like dry eyes, scleritis (inflammation of the white part of
the eye), or uveitis (inflammation of the middle layer of the eye).
6. Osteoporosis: Chronic inflammation and the use of corticosteroids
in RA can increase the risk of osteoporosis, a condition characterized
by weak and brittle bones.
7. Increased infection risk: RA and its treatments can weaken the
immune system, making individuals more susceptible to infections.
8. Emotional impact: Living with a chronic condition like RA can have
a significant emotional toll, leading to feelings of depression, anxiety,
and decreased quality of life.
 2
Rickets , osteomalacia , osteoporosis , definition diagnosis and
treatment

Rickets osteomalacia osteoporosis

definition Clinical syndromes A metabolic bone a bone mineral density

that result from disease where defecti (BMD) more than 2.5 SDs
inadequate bone mineralization results below the young normal
mineralization in a large amount or mean. ( WHO )
unmineralized osteoid.
In children Osteoporosis as a clinical
In adult disorder is characterized by an
abnormally low bone mass and
defects in bone structure

Diagnosis 1- history : - History:

A: bone pain. 1- Postmenopausal female
patient or elderly patient.
B: pathological fracture.
2- steroid chronic use
C: myopathy ( muscle weakness, cramps,
patient.
spasms).
3- Endocrinal disease
D: failure to thrive.
patient.
E: restless, crying , sweating.
4- risk factors.
F: late closure of fontanelle.
5- repeated fracture due to
G: delayed teething. micro trauma.

I: bone deformity. Investigation:

2- investigations : 1- Laboratory:

Laboratory: In primary: normal Ca, P,

PTH.
Dec. Ca+ & P
2- DXA (Dual-energy X-ray
Inc. ALP. & PTH.
Absoptiometry):
Imaging:
T Score: > -1 SD ....
Decrease bone density. Normal.
 Growth plate widening in Rickets.
Long bone deformity.
treatment Nonoperative Vitamin D deficiency
a. calcitriol20-30
mg/kg/day split into 2-3
doses in children 0.5-0.75
μg/day split into 2 doses
in adult
1. Vitamin D-resistant
(familial
hypophosphatemic)
Rickets
2. type I Vitamin D-
dependent rickets
:b. phosphate
replacement
20-40 mg/kg/day split
into 3-5 doses in
children
ii. 750-1000 mg/day split
into 3-4 doses in adults
1. Vitamin D-resistant
(familial
hypophosphatemic)rickets
c. Vitamin D: 5000
IU/day for 6-10 weeks
1. Vitamin D-deficient
(nutritional) rickets
T Score: between -1 & -2.5
.... Osteopenia.
T Score: less than -2.5 ....
Osteoporosis.
Drug Therapy in Osteoporosis
 Vitamin D + Ca  Estrogen has a definite
therapeutic effect and
 fracture was used extensively as
management HRT but cannot be
recommended now due to
serious possible side
 correct deformity effects
if needed
 Adequate intake of
calcium and vitamin D
is mandatory
 Drugs which inhibit
osteoclast activities :
e.g. Bisphosphonates like
sodium alendronate
FOSAMAX , BONVIVA
 Drugs which enhance
osteoblast activities :
bone stimulating agents
like PROTELOS, FORTEO
Management of Fractures in
Osteoporosis
 Use of load shearing
implants in fracture
internal fixation instead of
plating
Management of OVC Fractures
 Pain relief
 2. type II Vitamin D-  Prevention of further
dependent rickets fracture

 Prevention of instability

Surgical  Vertebroplasty

a corrective surgery  Kyphoplasty

(multilevel
osteotomy)

Compartment syndrome , definition , clinical picture , treatment

 Definition: is a condition in which elevated pressure in an enclosed space
can damage irreversibly the contents of space.
 Clinical picture
The four Ps of compartment:
 Pain- out of proportion to the injury , increased with passive
motion or stretch of involved muscle.
 Paresthesias- distribution of the sensory nerve traversing
the involved compartment.
 Paralysis- if treatment delayed until muscle is noted
clinically, full function rarely returns.
 Pulselessness- unless arterial injury has occurred peripheral
pulses and capillary refill of the digits remain normal in most cases.

 Treatment
The treatment of choice for compartment syndrome is early
decompression.
Delay in adequately decompressing the offending compartment can result in
permanent damage to underlying tissues. Nerves have been found to
demonstrate functional abnormalities (paresthesias and hypoesthesias)
within 30 minutes of the onset of ischemia. Irreversible functional loss
begins after 12 to 24 hours of total ischemia. Muscle shows functional
changes after 2 to 4 hours of ischemia, with irreversible functional loss
beginning after 4 to 12 hours. Ischemia lasting 4 hours gives rise to
significant myoglobinuria, which reaches a maximum about 3 hours after the
circulation is restored but persists for as long as 12 hours. Contractures are
 produced after 12 hours of total ischemia. Capillary endothelium
permeability is pathologically altered after 3 hours, resulting in postischemia
swelling of 30% to 60%.
Initial decompression should be done by immediate splitting or removal of
casts or other compromising circular dressings.. By augmenting venous
flow through the affected limb, reductions in soft-tissue swelling and
intracompartmental pressures have been observed. The place, if any, of
this device in the treatment of the spectrum of compartment syndromes
remains to be defined. If the tissue pressure remains elevated in a patient
with any other signs or symptoms of a compartment syndrome, adequate
 decompressive fasciotomy must be performed as an emergency
procedure.
(Using the criteria of Whitesides and associates, elevation means that
thetissue pressure rises to within 30 mm Hg of the diastolic pressure.)
 The technique of fasciotomy is a matter of surgical choice. It can be done
either subcutaneously or through limited or extensive skin incisions.
 The classic lower extremity fasciotomy does not provide
adequatedecompression of all four muscle compartments of the leg.

3
Complications of femoral neck fracture
The most common complication is:
1) Loss of reduction and hardware failure.
2) Nonunion and Malunions.
3) Avascular necrosis of the femoral head.
4) Secondary degenerative joint disease.

DDH definition , early diagnosis , prevention and treatment

Definition : A disorder of abnormal development resulting in dysplasia and

possible subluxation or dislocation of the hip

early diagnosis :
 Present of Risk factors ( +ve family history, breech
presentation, Leg or Knee Deformity (
 Physical examination
o Neonates: upto 3 months
 Instability
 Positive Ortolani test : dislocate dislocatable hip
by adduction and depression of the flexed femur)
 Positive Barlow test : reduces a dislocated hip by
elevation and abduction of the flexed femur
o Infants : > 3 months
 Limited Abduction
 Positive Galeazzi test (Shortening) : apparent limb
length discrepancy due to unilateral dislocated hip
with hip and knee flexed at 90 degree
 Femur appears shortened on dislocated sided
o Toddler
 Limited Abduction
 Positive Galeazzi test
o Walking child : > 1 year
 Pelvic obliquity
 Lumber lordosis (due to hip contracture resulting
from the dislocation)
 Trendelenburg gait : result from abductor
insufficiency
 Tow walking: compensate for relative shortening
of affected side
 Imaging
o US :
 Useful before femoral head ossification <4-6
months
 Too sensitive: detects a lot of hip anomalies
 Operator dependent
o X-ray :
 Early infancy: Not reliable
 Infancy 2-3 months: Reliable
 AP Veiw:
o Draw reference lines
 o Acetabular index :
 Less 30° : Normal
 30-40° :Questional
 More 40° : Abnormal
 Von Rosen Veiw:
 45° Abduction

prevention :
1. Positioning during pregnancy: Maintaining proper positioning of
the fetus during pregnancy
2. Avoiding tight swaddling: When swaddling the baby, ensure that
the legs and hips have enough room to move freely.
3. Safe babywearing practices:
During use a baby carrier or sling, make sure it supports the
baby's hips and allows for proper positioning.
4. Avoiding prolonged use of baby equipment:
Limiting the time that baby spends in devices like car seats,
bouncers, and swings can help prevent hip problems. Prolonged
immobilization or incorrect positioning in these devices can
increase the risk of DDH.
5. Regular check-ups: Regular visits to pediatrician are essential for
monitoring your baby's growth and development

treatment:
 Infants 0 – 6 months
o Hip instability (dislocatable)
o Established dislocation (reducible)
 Should be actively treated until hip is normal clinically and radiographically
 Pavlik harness
 Hip Spica Cast
 6 – 12 months
 Initially non operative – closed reduction
 Reduction under anesthesia and immobilization in hip spica cast
 Preliminary traction yes / no
 Adductor tenotomy yes / no
 Position : Human
o Avoid severe abduction
o Avoid Frog position
 Must be stable and concentrically reduced
Closed Reduction
• Deep & stable : Hip spica cast
• Deep & stable but Tight adductors :
Adductor tenotomy & hip spica cast
• Stable but not deep ( unconcentric ) :
Arthrogram: open reduction if there is
obstruction to closed reduction
• Hip stable only in excessive abduction : open reduction
• Hip irreducible or reduction tenuous : open reduction

12 – 18 months
• Possibly closed reduction
when hip stable and concentrically reduced
• Possibly open reduction
when hip unstable or not concentrically reduced
or irreducible
• Arthrography guided
Closed Reduction
• Concentric reduction :
- less than 5 mm lateralization
- non obstructing limbus
• Hip spica cast 6 weeks
• Hip spica / Broom stick 6 weeks
• Continue cast until hip stabilizes (3 months)
confirm reduction with CT scan in spica cast
• Night time abduction splint until acetabulum normalizes
 OPEN REDUCTION
• Indications :
Any age :
- Unconcentric closed reduction
- reduction stable only in excessive position
Primary option in older children
• Aim :
- remove obstacles
- stabilize the hip
• Approaches :
medial / anterior / anterolateral / lateral

Operative treatment
Simultaneous Open Reduction, Femoral Shortening, and Pelvic Osteotomy
• Above 3 years : almost routinely
• Between 18 months – 3 years :
- can delay pelvic osteotomy
- acetabular remodeling most dramatic
within 6 – 12 months after reduction
4
posterior hip dislocation , classification , clinical presentation ,
treatment , and complication

Classification :

(Thompson and Epstein classification) :

o Type I – dislocation with no more than minor chip fractures
o Type II – dislocation with single large fragment of posterior
acetabular wall
o Type III – dislocation with comminuted fragments of posterior
acetabular wall
o Type IV – dislocation with fracture through acetabular floor
o Type V – dislocation with fracture through acetabular floor and
femoral head.

clinical presentation
The involved limb is classically
shortened, internally rotated, and
adducted

treatment

Classically, the dislocation or fracture dislocation

is treated by immediate closed reduction.
Open reduction is reserved for those patients in
whom
(1) Closed reduction is not successful,
(2) The reduction is unstable,
(3) Fracture fragments are trapped between the
joint after reduction.
 Gravity Method of Stimson
  Allis Maneuver.
In the Allis maneuver, the patient is supine and the
pelvis is stabilized by pressure placed on both anterior
spines by an assistant.
The essential feature of an Allis maneuver is traction
in the direct line of the deformity followed by gentle
flexion of the hip to 90°. The hip is gently rotated
internally and externally with continued longitudinal
traction until reduction is achieved.

 The Bigelow Maneuver for posterior dislocation

The patient lies supine, and an assistant applies countertraction by
downward pressure on the anterosuperior iliac spines. The surgeon
grasps the affected limb at the ankle with one hand, places the
opposite forearm behind the knee, and applies longitudinal traction
in the line of the deformity. The adducted and internally rotated
thigh then is flexed 90° or more on the abdomen. This relaxes the Y
ligament and allows the surgeon to bring the femoral head near the
posteroinferior rim of the acetabulum. While traction is maintained,
the femoral head is levered into the acetabulum by abduction,
external rotation, and extension of the hip.

Management After Reduction

Repeat assessment of neurovascular function is required, as is
Postreduction radiography and CT scan.
After closed reduction, light skin or skeletal traction (5 to 8 lb) is
recommended to provide comfort and allow capsular healing.

Complication
 Early Complications
1) Sciatic Nerve Paresis.
2) Irreducible Posterior Dislocations.
3) Missed Knee Ligament Injuries.
 4) Recurrent Dislocation in Traction.
 Late Complications
1) Recurrent Posterior Dislocation.
2) Myositis Ossificans.
3) Post-traumatic Arthritis.
4) Aseptic Necrosis.

 Meniscal injury clinical manifestations , physical

examination and treatment

clinical manifestations

1- History of characteristic trauma during playing a match , the player

suddenly feel pain in the knee , fall and cannot resume the match .
2- Swelling & effusion in the knee .
3- Locking of the knee .
4- Tenderness on the medial aspect of the joint line .

physical examination
- McMurry’s sign :
• The knee is flexed then the leg is externally rotated and abducted .
• If pain & click felt during extension of the knee , tear in the medial
meniscus is diagnosed .

Treatment

Conservative treatment is acceptable if the knee does not lock .

• Intial treatment : Rest , ice , compression , elevation and NSAID.

[Type text]

• Fixation of knee for 2-3 weeks and physiotherapy to strength the muscles
around the knee .
2- Surgical treatment for recurrent symptoms interfere with daily activity
• Meniscal suture in peripheral tear .
 • Partial meniscectomy : For central tear , excision of the affected
part of the meniscus, usually through arthroscopy or rarely nowadays by
open surgery .
• Total meniscectomy not recommended as it causes more instability
and so predisposes to secondary osteoarthriti

5
Same as question number 24
6
Anterior hip dislocation , mechanism of injury , clinical
presentation , methods of reduction

 mechanism of injury
 They occur in automobile accidents when the
knee strikes the dashboard with the thigh
abducted.
 In falls from heights.
Secondary to a blow to the back of the patient while
in a squatted position.

 clinical presentation ( as general principles + )

1) May reveal slight shortening.
2) The hip is extended and externally rotated in superior
dislocation.
3) Femoral head is palpable.

 methods of reduction
Reverse Bigelow reduction

The position of the hip in the reverse Bigelow maneuver is

partial flexion and abduction. Bigelow suggests two methods
of reduction. First is the lifting method, in which a firm "jerk"
is applied to the flexed thigh. This method often results in
reduction except in pubic dislocations.
If this "lifting method" fails, traction is applied in the line of deformity. The
hip then is adducted, sharply internally rotated, and extended

1. The Allis reduction Maneuver

The patient is placed in the supine position. The
knee is flexed to relax the hamstrings. An
assistant stabilizes the pelvis and applies a lateral
traction force to the inside of the thigh.
Longitudinal traction is applied in line with the
axis of the femur, and the hip is slightly flexed.
The surgeon gently adducts and internally rotates
the femur to achieve reduction.

Osteoarthritis , definition , clinical presentation , treatment ,

complications

 Definition
degenerative disease of synovial joints that causes progressive loss of
articular cartilage.

 clinical presentation
 symptoms
o function-limiting knee pain
 effect on walking distances
o pain at night or rest
o activity induced swelling
o knee stiffness
o mechanical
 instability, locking, catching sensation
 Physical exam
• inspection
 limb alignment
 effusion
 skin (e.g. scars)
o range of motion
 lack of full extension (>5 degrees flexion contracture)
  lack of full flexion (flexion <110 degrees)
ligament integrity

 treatment
 Nonoperative
o non-steroidal anti-inflammatory drugs
 indications
 first line treatment for all patients with symptomatic
arthritis
o tramadol
o rehabilitation, education and wellness activity
 indications
 first line treatment for all patients with symptomatic
arthritis
 technique
 self-management and education programs
 combination of supervised exercises and home
program have shown the best results
 these benefits lost after 6 months if exercises
are stopped
o weight loss programs
 indications
 patients with symptomatic arthritis and BMI > 25
 technique
 diet and low-impact aerobic exercise
o controversial treatments
 acupuncture
 viscoelastic joint injections
 glucosamine and chondroitin
 needle lavage
 lateral wedge insoles

 Operative
o high-tibial osteotomy
 indications
 younger patients with medial unicompartmental OA
 technique
  valgus producing proximal tibial oseotomy
o unicompartmental arthroplasty (knee)
 indications
 isolated unicompartmental disease
o total knee arthroplasty
 indications
 symptomatic knee osteoarthritis
 failed non-operative treatments
o controversial treatments
 arthroscopic debridement or lavage
 arthroscopic meniscal debridement

 complications
1. chronic pain
2. joint stiffness
3. joint deformity
4. reduced range of motion
5. muscle weakness
6. loss of function
7. emotional impact

7-12
 Shoulder dislocation types, diagnosis methods of reduction?
a. Types
 Anterior dislocation.
1. Sub coracoid
2. Sub glenoid
3. Sub clavicular
 Posterior dislocation.
 Inferior dislocation.
b. Diagnosis
 Clinical
 X-ray

c. Methods of ttt?
 Ant dislocation → ‫باإلختبار نذكر هذه الثالث الطرق اللي يشتيها الدكتور‬
 1. Stimon’s technique.
The patient is left prone with the arm hanging over the
Side of the bed. After 15 or 20 minutes the shoulder
May reduce.
2. Hippocratic methods
a. Traction is applied to the arm with the shoulder is
slight Abduction while an assistant applied firm
counter-Traction to the body.
b. The heel of the foot is placed against the Humeral
head in the axilla And longitudinal traction is
applied to The arm.
3. Kocher’s method
a. The elbow is bent to 90 and hold close to the
Body. No traction should be applied .The arm is
slowly rotated 75 laterally. The Point of the elbow
is lefted forward and The arm is rotated medially.
b. Dr. Saeed said: apply abduction + ext rotation +
pull the arm to down → then adduction + int
rotation + pull the arm down → ‫وبكذا نسمع صوت‬
.‫كرقة المفصل ونعرف أنه رجع لمكانه‬
 Post dislocation
The acute dislocation is reduced (usually under General
anaesthesia ) By pulling on the arm with the shoulder in
Adduction. A few minutes are allowed for the Head of
the humerus to disengage and the arm is Rotated
laterally while the humeral head is Pushed forward. If
reduction feels stable the arm Is immobilized in sling
Otherwise the Shoulder is Held widely abducted And
laterally roated in Airplane type splint for 3-6week to
allow capsule To heal in shortest postion
 Inf dislocation
1. Reduction by pulling head upward in the line of
abducted Arm with counter -traction downward over
the top of The shoulder.
 2. If the humeral head is stuck in soft tissue with soft tissue
Injury we must do open reduction We must examin
vascular and nerve befor and after Reduction.
 Etiology, Pathology, Diagnosis and treatment of acute hematogenous
osteomyelitis?
a. Etiology?
 90% → Staphylococcus Aureus
 10%
1. Streptococcus Hemolyticus
2. Pnumococcus,
3. Hoemphilus influenze
4. Typhoid.
5. E.coli.
6. Others
 Source Of Infection
1. Infected umbilical cord in infants
2. Boils, tonsilitis, skin abrasions
3. In adults UTI.
b. Pathology?
 Starts at metaphysis
 Trauma ? → stimulation of edema+ irritation
 Vascular stasis
 Acute inflammation
 Suppuration
 Necrosis
 New bone formation
 Resolution
c. Diagnosis?
 History & Clinical features
1. Severe Pain.
2. May be unable to move the affected extremity
(pseudoparalysis)
3. Fever.
4. General malaise.
 5. History of a recent upper respiratory infection or other
infection that offers a clue as to the source of
bacteremia.
6. A history of previous trauma is quite common in children
with bone or joint sepsis.
 Laboratory:
1. FBC (full blood count), with diff.count.
2. B.C.(Identification of the pathogen, sensitive to
antibiotic)
3. ESR (elevated has been traditionally monitored but not
sensitive) ‫يتغير بعد يومين ثالث‬
4. CRP (more sensitive index of infection.) ‫يتغير بسرعة‬
 Imaging:
1. X-ray
2. CT (has limited application in the diagnosis or
management of osteoarticular infection.)
3. MRI (best for soft tissue pathology) → more acurate.
4. U/S (is most useful in demonstrating of fluid collection;
whether the collection in the hip joint or in a
subperiosteal location. It can serve as an aid when
performing aspiration.)
d. Treatment? → must do culture because we will give the pt antibiotics
for long period.
 Aspiration appropriate cultures have been obtained.
 Supportive treatment for pain and dehydration.
 Splintage and bed rest.
 Antibiotics IV administration of antibiotics should be started.
Empirical antibiotic coverage usually is best begun with
first-generation Cephalosporin. However the choice of
antibiotics should provide coverage for any specific
pathogens that the patient's history suggests may be present,
recently with a short course of IV antibiotics (average of 4
days), followed by Oral antibiotic for a total of 3 to 4 weeks
 of antimicrobial therapy. And the patient clinical course CRP,
and ESR were closely followed.
 Surgery:
When? Indications?
1. If the response to antibiotic therapy is not rapid .
2. If any signs of abscess appear
3. Open drainage
 After surgical drainage the wound may be left open to heal
by secondary intention.
 Or may be the wound closed over suction drains or suction -
irrigation system.
e. Complications
 Systemic sepsis
 Growth deformity (physeal arrest or stimulation)
 Pathologic fracture
 Osteonecrosis.
 Chronic infection.
 Although there have been reports of cardiopulmonary
complications secondary to osteomyelitis (e.g.
bronchopneumonia, cardiac failure from septic pricardaitis,
septic pneumonia).
8
 Knee dislocation, mechanism of injury, clinical presentation, treatment,
complications?
1- Mechanism of injury?
Traumatic knee dislocations are uncommon yet serious injuries that
historically have had variable prognosis. A knee dislocation describes
complete disruption of the integrity of the tibiofemoral
articulation Such disruption will result in a multiligament knee injury,
defined most commonly as rupture to at least two of the four major
knee ligament structures. Half of them are secondary to road traffic
accidents (high-velocity dislocations), approximately a third are
sports injuries (low-velocity dislocations) and nearly 10% are from
simple falls (ultra-low-velocity dislocations).
 2- Clinical presentation?
 Gross deformity
 Rupture of the joint capsule produces a leak of the
haemarthrosis,
 Severe bruising and swelling.
 The circulation in the foot must be examined because
the popliteal artery may be torn or obstructed. Repeated
examination is necessary as ischaemia may evolve and
compartment syndrome is also a risk.
 Common peroneal nerve injury occurs in nearly 20% of
cases distal sensation and movement should be tested and
documented carefully
3- TTT?
 Reduction under anesthesia
 Once achieved, limb is stricted on a back slab with knee
in 15 degree flexion
 Plaster cylinder is not use because of swollen knee
 Anterior external fixation
 Can be applied if knee joint is unstable *Surgery
 If open wound/vascular damage – operation need and
repair of the ligament and capsule can be done (otherwise
these structure left undisturbed)
 Cast will be applied for 12 weeks
 Quadriceps muscle exercise
4- Complications?
1-Neurovascular
 Popliteal artery injury
 Peroneal nerve injury
2-Knee stiffness
3-Chronic instability

 Potts disease, potts paraplegia, clinical presentation, methods of

diagnosis, treatment?
1- Pott’s disease?
 TB of the spine
2- Pott’s paraplegia?
Is complication of Pott’s disease, you see Signs of spinal cord
compression, as Weakness or paralysis in the lower limbs with
or without sensory impairment or disturbance of bladder or
bowel function (Pott’s paraplegia)
3- Clinical presentation?
 Back pain
 Stiffness in the Back
 Visible deformity of the back
 Localized swelling (abscess)
 Weakness of legs or visceral dysfunction (involvement of
the spinal cord)
4- Methods of diagnosis?
Hx, Physical Ex, Clinical features, Lab, Radiology (X-ray, CT,
MRI)
 On examination:
1. Looks ill
2. Local tenderness
3. Kyphosis (visible or palpable)
4. Abscess (may be detected the thoracic wall or in the
flank, iliac fossa, or upper thigh.)
5. Pott’s paraplegia: Signs of spinal cord compression.
 Radiological:
1. It is typical to see more than one vertebra involved
(average, 3.4 vertebrae)
2. The most common finding is narrowing of the disc space
and vertebral osteolysis.
3. In more advanced disease, a paravertebral shadow is
produced by extension of the tuberculous granulation
tissue and formation of an abscess in the paravertebral
region later, Vertebral collapse and angulation of the
spine occur.
 Laboratory
1. ESR
 2. Lymphocytosis
3. The Mantoux test is positive.
4. Tubercle bacilli can sometime be isolated from aspirated
pus, biopsy.
5- Treatment?
 Conservative treatment
1. Chemotherapy fore a year or year and half to two year
2. Local treatment for spine (plaster jacket, or reinforced
corset for relief of pain)
3. An abscess that is superficial should be either aspirated
or drained.
 Operative
1. If open biopsy is required, Hodgson et al. suggest
definitive debridement and grafting at the same time.
2. Radical removal of the diseased area and anterior spinal
arthrodesis.
3. The indications for surgery in the absence of
neurological symptoms vary widely.
a. Involvement of more than one vertebra
significantly increases the risk of kyphosis and
collapse.
b. Open biopsy for diagnosis, debridement, and
grafting may offer the most direct approach in
these patients.
c. Resistance to chemotherapy and recurrence of
the disease are other indications for radical
surgical treatment.
d. Early or late disease as severe kyphosis with active
disease,
e. Signs and symptoms of cord compression,
progressive impairment of pulmonary function,
and progression of the kyphotic deformity.
4. Primary contraindications to surgery are cardiac and
respiratory failure.
 9
 Humeral shaft fracture, method of shoes for treatment, complication
indication of operative treatment?
a. Humeral shaft fracture?
b. Method of shoes for treatment?
 Conservative
1. U-shaped plaster
2. Immobilization for 6wks, Then
3. Physiotherapy for joints (shoulder, elbow, wrist & finger
joints)
 Operative → internal fixation with Rush nail
c. Complications?
 Early:
1. Vascular injury: injury of brachial artery.
2. Nerve injury: Radial nerve injury is very common and in
%90 of cases improve within 3 months without
intervention
 Late:
1. Delayed union and non-union .
2. Stiffness of shoulder or elbow joints
d. Indication of operative treatment?
 Failure of closed reduction
 Bilateral fractures
 Segmental fracture associated with vascular injury
 Pathological fracture.
 Chronic osteomyelitis, clinical presentation, classification, treatment,
complication?
a. Chronic osteomyelitis?
 May follow acute OM
 May start De Novo following operation &open #
 Difficult to eradicate completely.
 Systemic symptoms usually subside.
 One or more foci in the bone may still contain purulent
material.
  Infected granulation tissue, or a sequestrum.
 Secondary infections are common, and sinus tract cultures
usually do not correlate with cultures taken by bone biopsy.
Multiple organisms may grow from cultures taken from sinus
tracts and soft tissues and from the bone biopsy
b. Clinical presentation?
 Symptoms:
1. History of acute Osteomyelitis may be given
2. Pain & swelling in the affected bone
3. A sinus discharging pus (the commonest presentation)
 Signs:
1. Atrophy of the surrounding muscles ? painful limitation
movement
2. The affected bone is thickened, tender with sinuses that
are lined by red granulation tissue, exuding pus
3. When the sinus is probed, the probes reaches the bone.
c. Classification?
Anatomical criteria consist of four types:
 Type I, an endosteal or medullary lesion.
 Type II, superficial steomyelitis, limited to the surface of
bone.
 Type III, a localized infection involving a stable, well-
demarcated lesion characterized by full thickness cortical
sequestration and cavitation (in this type, complete
debridement of the area will not lead to instability).
 Type IV, diffuse osteomyelitic lesions that are mechanically
unstable, either at presentation or after appropriate
treatment.
d. Treatment? (Surgery is the main line of treatment)
 Surgery for chronic osteomyelitis consists of sequestrectomy
and resection of scarred and infected bone and soft tissue.
  The goal of surgery is: Eradication of the infection by
achieving a viable and vascular environment.
 To achieve this goal.
1. Radical debridement may be required. Inadequate
debridement may be one reason for a high recurrence
rate in Chronic Osteomyelitis.
Surgery:
2. Sequestrectomy and curettage for chronic osteomyelitis.
3. Open bone grafting.
4. Polymethylmethacrylate (PMMA) antibiotic bead chains.
5. Closed suction drains.
6. Soft tissue transfer.
7. Ilizarov technique.
e. Complications?
 An acute exacerbation or ‘Alare up’ of the infection occurs
commonly. It subsides with a period of rest, and antibiotics,
either broad-spectrum or based on the pus culture and
sensitivity report.
 Growth abnormalities: Osteomyelitis may cause
 Growth disturbances at the adjacent growth plate, in one of
the following ways:
1. Shortening, when the growth plate is damaged.
2. Lengthening because of increased vascularity of the
growth plate due to the nearby Osteomyelitis.
3. Deformities may appear if a part of the growth plate is
damaged and the remaining keeps growing.
 Pathological fracture may occur through a weakened area of
the bone. Treatment is by conservative methods.
 Joint stiffness may occur because of scarring of soft tissues
around the joint or due to the joint getting secondarily
involved.
 Sinus tract malignancy is a rare complication. It occurs many
years after the onset of osteomyelitis. It is usually a
squamous cell carcinoma. The patient may need amputation.
  Amyloidosis: As with all other long standing suppurations,
this is a late complication of osteomyelitis.
10
 Pelvis fracture, classification, treatment, Complication in severe pelvis
fracture?
a. Classification?
Classification(Young Burgess):
 Anterior posterior compression APC
1. |: Symphysis pubis widening < 2.5cm
2. || : Symphysis pubis widening > 2.5cm with anterior
sacroiliac joint torn (post intact)
3. ||| : Symphysis pubis widening > 2.5cm with sacroiliac
joint displacement (both Ant + Post ) =book type
 Lateral compression LC:
1. | : Pubic ramus
2. || : Pubic ramus fracture+ ipsilateral ilium fracture
3. ||| : Pubic ramus fracture+ ipsilateral LC + contralateral
APC
 Vertical shear VS:
Pubic ramus fracture+ ipsilateral sacroiliac disruption+
innominate bone displacement
 Combination: All previous types
b. Clinical features.
 Pain and inability to bear weight.
 External rotation & limb length difference.
 Frank hematoma.
 Hematuria.
 signs of shock.
c. Treatment?
 First Aids : ABC & shock control
1. Pelvic binder
 Operative: open reduction and internal fixation
d. Complication in severe pelvic fracture?
  DVT
 PE & Fat embolism
 Infections
 Shock
 Neurological injuries (L5 root)
 Urogenital injuries
 Perth’s disease, clinical presentation, treatment, complications?
a. Perthe’s disease?
Definition:
 Non-inflammatory idiopathic AVN of the femoral Head in a
growing child produced by interruption of Blood supply to
the proximal femoral epiphysis.
 Idiopathic avascular necrosis of the proximal femoral
epiphysis in children
b. Risk factors
 Positive family history
 Low birth weight
 Abnormal birth presentation
 Second hand smoke
 Asian, Inuit, and Central European decent
c. Clinical presentation?
 Symptoms
1. Insidious onset
2. May cause painless limp
3. Intermittent knee, hip, groin or thigh pain
 Physical exam
1. Hip stiffness with loss of internal rotation and abduction
2. Gait disturbance
a. Trendelenburg gait (head collapse leads to
decreased tension of abductors)
b. Antalgic limp
3. Limb length discrepancy is a late finding
a. Hip contracture can exacerbate the apparent LLD
d. Treatment?
 Goals
1. Resolution of symptoms
a. NSAIDs, traction, crutches
2. Restoration of range of motion
a. Physical therapy (may exacerbate symptoms),
muscle lengthenings, Petrie casting
3. Containment of hip
a. Improve range of motion, bracing, proximal
femoral osteotomy, pelvic osteotomy
i. Ensure that femoral head is well seated in
acetabulum
 Non operative
Observation alone, activity restriction (non-weight
bearing), and physical therapy (ROM exercises)
1. Indications
a. Children < 8 years of age
i. (young patient do not benefit from any
surgery)
b. Children with lateral pillar A
c. Consider activity restriction and protected weight-
bearing during earlier stages until reossification is
complete
2. Technique
a. Main goals of treatment are to keep the femoral
head contained and maintain good motion
i. Containment limits deformity and
minimizes loss of sphericity and
ii. Lessen subsequent degenerative changes
b. Bracing and casting for containment have not
been found to be beneficial in a large, prospective
study
c. All patients require periodic clinical and
radiographic followup until completion of disease
process
  Operative
Operative containment
1. Indications
a. Children > 8 years of age, especially lateral pillar B
and B/C
2. Technique
a. Proximal femoral varus osteotomy
i. To provide containment
b. Pelvic osteotomy
e. Complications?
 Femoral head deformity
1. Coxa magna
a. Widened femoral head
2. Coxa plana
a. Flattened femoral head
3. Important prognostic factor
a. Stulberg classification
 Lateral hip subluxation (extrusion)
1. Associated with poor prognosis
a. Can lead to hinge abduction
 Premature physeal arrest
1. Trochanteric overgrowth
2. Coxa breva
a. Shortened femoral neck
3. Leg length discrepancy
a. Typically mild
11
 Neck femur fracture, classification, principals of treatment,
complications?
a. Neck femur fracture?
▪More common in elderly females above 50 years (due to
Postmenopausal osteoporosis).
▪ It is the commonest fracture in old age .
 Aetiology:
i. In elderly : minor trauma d.t. senile osteoporosis
ii. In young adult: severe trauma
b. Classification?
A) According to the site : Intracascular fracture or
also called high neck
Fracture includes:
a. Subcapital : immediately below the head of
femur.
b. Trancervical : in the middle of the neck of femur.
c. Basal : At the junction of neck with greater
trochanter.

B) Pauwels’ classification: Pauwels’ angle is the angle between

The fracture line and the horizontal plane .
▪ Type I: Less than 30o :Stable fracture & have
good chance to Unite .
▪ Type II : 30 – 50 o Is intermediate between
type Iand III.
 Type III: 70o or more: vertically unstable
fracture .It is under Shearing forces and
may go to non-union if it is not stabilized
By surgery.

C) Garden’s classification : According to the degree of Displacement , the fracture is

classified into :
▪ Type I : Incomplete or impacted fracture, good chance to unite.
▪ Type II : Complete undisplaced fracture in AP and lateral Views, good chance to unite.
▪ Type III : Complete with partial displacement , moderate chance to unite.
▪ Type IV: Completely displaced, more liable to non-union.

D) According to the position of the distal fragment after trauma :

4. Adduction fracture: 80% of cases.
5. Abduction fracture: 20% of cases.

c. Principles of treatment?
• Relieve of pain and treatment of osteoporosis ( increase bone
density , Increase strength of bones & improve healing of bones
).
• Prophylaxis to prevent complications of prolonged be rest .
• Emergency surgery is usually recommended as soon as
possible for High femoral neck fractures to relieve pain, restore
mobility and the Proximal fragment cannot be fixed by
conservative measures.
• Post-operative early mobilization of the patient as soon as the
General condition allows with physiotherapy to avoid
complications of Prolonged bed rest .
 d. Complications
General complications :
• Complications of prolonged bed rest
a. DVT, PE
b. Bed sores
c. Hypostatic pneumonia
d. Traumatic anuria (in crushing injury).
e. UTI, calculi
f. Muscle weakness & constipation .
g. Osteoporosis
h. Tetanus in compound fracture.
i. Psychological
• Mortality rate is 20 % in the first 3 months after the
fracture in Elderly patients .
Local complications :
1. Avascular necrosis
2. Delayed union & non-union
3. Mal-union
4. Osteoarthritis of hip.
5. Sciatic or femoral nerve injury.
6. Myocytis ossificans
 Talipes equinovarus (Club foot) treatment and complication?
a. Treatment?
i. Goals
1. Resolution of symptoms
a. NSAIDs, traction, crutches
2. Restoration of range of motion
a. Physical therapy (may exacerbate symptoms),
muscle lengthenings, Petrie casting
3. Containment of hip
a. Improve range of motion, bracing, proximal
femoral osteotomy, pelvic osteotomy
 I) Ensure that femoral head is well seated
in acetabulum
ii. Non operative
Observation alone, activity restriction (non-weight
bearing), and physical therapy (ROM exercises)
1. Indications
a. Children < 8 years of age
I) (young patient do not benefit from any
surgery)
b. Children with lateral pillar A
c. Consider activity restriction and protected weight-
bearing during earlier stages until reossification is
complete
2. Technique
a. Main goals of treatment are to keep the femoral
head contained and maintain good motion
I) Containment limits deformity and
minimizes loss of sphericity and
II) Lessen subsequent degenerative
changes
b. Bracing and casting for containment have not
been found to be beneficial in a large, prospective
study
c. All patients require periodic clinical and
radiographic followup until completion of disease
process
iii. Operative
Operative containment
1. Indications
a. Children > 8 years of age, especially lateral pillar B
and B/C
2. Technique
a. Proximal femoral varus osteotomy
I) To provide containment
b. Pelvic osteotomy
b. Complications?
i. Femoral head deformity
1. Coxa magna
a. Widened femoral head
2. Coxa plana
a. Flattened femoral head
3. Important prognostic factor
a. Stulberg classification
ii. Lateral hip subluxation (extrusion)
1. Associated with poor prognosis
a. Can lead to hinge abduction
iii. Premature physeal arrest
iv. Trochanteric overgrowth
v. Coxa breva
1. Shortened femoral neck
vi. Leg length discrepancy
1. Typically mild
vii. Acetabular dysplasia
1. Poor development secondary to deformed femoral head
2. Can alter hip congruency
viii. Labral injury
1. Secondary to femoral head deformity
a. Femoroacetabular impingement
ix. Osteochondritis dissecans
1. Can lead to loose fragments
x. Degenerative arthritis
1. Stulberg I and most Stulberg II hips perform well for the
lifetime of the patient
 12
 Gleazzi and Monteggia fractures definition, principles of treatment in adult
complication?
a. Definition?
o Monteggia fracture dislocation : It is a fracture upper 1/3 of
shaft of ulna with dislocation of superior radio-ulnar joint . 4
types :
 Type I : Fracture upper 1/3 of shaft of ulna with anterior
dislocation of head of radius .
 Type II : Fracture upper 1/3 of shaft of ulna with
posterior dislocation of head of radius .
 Type III : Fracture ulna just below the coronoid process
with lateral dislocation of head of radius .
 Type IV : Fracture upper 1/3 of shaft of ulna and radius
with anterior dislocation of head of radius

o Galeazzi fracture dislocation : It is a

fracture lower 1/3 of shaft of radius
with dislocation of inferior radio-ulnar
joint . 2 types :
 Type I : Posterior displacement
of shaft of radius and anterior
dislocation of head of ulna .
 Type II : anterior displacement
of shaft of radius and posterior
dislocation of head of ulna .
 b. Principles of treatment?
i. Closed reduction of the dislocated joint is performed
first followed by
ii. open reduction and internal fixation of the fractured
bones by plate & screws .
a. Complications?
a.
 Vertical talus as congenital anomaly clinical presentation, treatment,
complications?
a. Congenital vertical talus?
i. This rare condition is seen in infants, usually affecting
both feet. Superficially it resembles other types of valgus
foot, but the deformity is more severe; the medial arch is
not only flat, it is the most prominent part of the sole,
producing the appearance of a rocker-bottom foot (Figure
21.11).
 ii. The hindfoot is in equinus and valgus and the talus points
almost vertically towards the sole; the forefoot is
abducted, pronated and dorsiflexed, with subluxation or
dislocation of the talonavicular joint. Passive correction is
impossible.
b. Clinical presentation?
i. The infant’s foot is in marked valgus and has a rocker-
bottom shape.
ii. X-ray shows the vertical talus pointing downwards
towards the sole and the other tarsal bones rotated
around the head of the talus.
a. Treatment?
Serial casting using a so-called ‘reverse Ponseti’ technique
followed by stabilization of the talonavicular joint with an open
approach, to confirm that the joint is reduced and then held with
a K-wire, together with an Achilles tenotomy has been shown to
be very effective. For some resistant feet, open reduction in full
may be required.
b. Complications?
 Untreated, it will result in multiple bony deformities with a
rocker-bottom appearance. It also results in callosities
formation and difficulty in wearing shoes. Other complications
are mainly due to associated disorders or surgery related if
needed.
 Complications of nontreatment include callus, skin breakdown,
and poor push-off, while
 Complications of treatment include: stiffness, residual varus or
valgus, and the need for additional surgery
  Patients should be monitored periodically even after surgery to
verify normal growth
13
treatment of humerus fracture in adult
 Proximal
 Nonoperative
sling immobilization followed by progressive rehab
 Operative
CRPP (closed reduction percutaneous pinning)
ORIF
arthroplasty
 Shaft of humerus
 Nonoperative
coaptation splint followed by functional brace
 Operative
open reduction and internal fixation
 Distal Humerus Fractures
Nonoperative
cast immobilization
 Operative
closed reduction and percutaneous pinning
indications
Children's complications of fracture indication for ORIF?
o fracture associated with vacscular injury or complex fracture
o failure to acheive adequete reduction with non operative meatures
similar to adult

Osteoarthritis
degenerative disease of synovial joints that causes progressive loss of
articular cartilage
Symptoms
 function-limiting knee pain
effect on walking distancespain at night or restactivity induced
 swelling knee stiffnessmechanical instability, locking, catching
sensation
Differential diagnoses
1. Rheumatoid arthritis (RA
2. Osteoarthritis
3. Psoriatic arthritis
4. Gout
5. Pseudogout

Treatment
Nonoperative
non-steroidal anti-inflammatory drugs indications first line treatment for all
patients with symptomatic arthritis tramadol rehabilitation, education and
wellness activity indications first line treatment for all patients with
symptomatic arthritis technique self-management and education programs
combination of supervised exercises and home program have shown the
best resultsthese benefits lost after 6 months if exercises are stopped
weight loss programs indications patients with symptomatic arthritis and
BMI > 25techniquediet and low-impact aerobic exercise controversial
treatments
acupuncture viscoelastic joint injections glucosamine and chondroitin
needle lavagelateral wedge insoles
Operative
high-tibial osteotomy indications younger patients with medial
unicompartmental OA technique valgus producing proximal tibial oseotomy
unicompartmental arthroplasty (knee) indications isolated
unicompartmental diseasetotal knee arthroplasty indications symptomatic
knee osteoarthritis failed non-operative treatments controversial
treatments arthroscopic debridement or lavagearthroscopic meniscal
debridement
 14
 Complications of sever pelvis fracture ,prevention of this
complicatins
1. DVT
2. PE & Fat embolism
3. Infections
4. Shock
5. Neurological injuries (L5 root)
6. Urogenital injuries
Prevention of complication
Prevention by immediate admession and by pain mangement
follow up care, blood transfusion if blood loss
RICKETS

Pathophysiology

 Vitamin D and PTH play an important role in calcium

homeostasis
 disruption of calcium/phosphate homeostasis
 poor calcification of cartilage matrix of growing long bones
 occurs at zone of provisional calcification
 eads to increased physeal width and cortical
thinning/bowing
Clinical presentations Child is restless, babies cry without obvious reason
In severe cases with very low calcium: tetany or convulsions

Treatment
Nonoperative
a. calcitriol20-30 mg/kg/day split into 2-3 doses in children 0.5-0.75 μg/day
split into 2 doses in adult
1. Vitamin D-resistant (familial hypophosphatemic) Rickets
2. type I Vitamin D-dependent rickets
b. phosphate replacement
20-40 mg/kg/day split into 3-5 doses in children
ii. 750-1000 mg/day split into 3-4 doses in adults
1. Vitamin D-resistant (familial hypophosphatemic)rickets
c. Vitamin D: 5000 IU/day for 6-10 weeks
1. Vitamin D-deficient (nutritional) rickets
2. type II Vitamin D-dependent rickets
Surgery
Multilevel osteotomy
Complications

16
Hip disclocation
 Types
 anterior
 posterior
 centeral
 Clinical presentarion
 Hip pain which radiates to the knee
 In anterior dislocation Lengthened, externally rotated leg
 In posterior disloxation Shortened, internally rotated (adducted) hip
 Types of anterior hip dislocation

 Types of anterior hip dislocation

Types of anterior dislocation

DDH
 DDH definition
A disorder of abnormal development resulting in dysplasia and possible
subluxation or dislocation of the hip
 diagnosis
 Present of Risk factors ( +ve family history, breech
presentation, Leg or Knee Deformity (
 Physical examination
o Neonates: upto 3 months
 Instability
 Positive Ortolani test : dislocate dislocatable hip
by adduction and depression of the flexed femur)
 Positive Barlow test : reduces a dislocated hip by
elevation and abduction of the flexed femur
o Infants : > 3 months
 Limited Abduction
 Positive Galeazzi test (Shortening) : apparent limb
length discrepancy due to unilateral dislocated hip
with hip and knee flexed at 90 degree
 Femur appears shortened on dislocated sided
o Toddler
 Limited Abduction
 Positive Galeazzi test
o Walking child : > 1 year
 Pelvic obliquity
 Lumber lordosis (due to hip contracture resulting
from the dislocation)
 Trendelenburg gait : result from abductor
insufficiency
 Tow walking: compensate for relative shortening
of affected side
 Imaging
 o US :
 Useful before femoral head ossification <4-6
months
 Too sensitive: detects a lot of hip anomalies
 Operator dependent
o X-ray :
 Early infancy: Not reliable
 Infancy 2-3 months: Reliable
 AP Veiw:
o Draw reference lines
o Acetabular index :
 Less 30° : Normal
 30-40° :Questional
 More 40° : Abnormal
 Von Rosen Veiw:
 45° Abduction

 Clinical features
• Neonate (up to 2-3 months) :
- Instability/ Ortolani-Barlow
• Infant ( > 2-3 months) :
- Limited abduction
- Shortening ( Galeazzi )
• Toddler : - Limited abduction
- Shortening ( Galeazzi )
• Walking : - Trendelenburgh
 Treatment

 Complications

• AVN - growth plate injury

• Redislocation :
• Stiffness : - AVN and increased pressure
- mucky surgery – fibrosis
- too much immobilization
• Pathological fractures : - supracondylar femur
- around femoral plate
• Osteoarthritis : - does not occur in all untreated cases
- not seen in high posterior DDH
17
Forearm fracture in adult
 Treatment.
1:FRACTURE OF BOTH BONES:
 IN ADULTS:- open reduction and internal fixation (ORIF), the
fragments are held by plates and screws.After operation the arm kept
elevated until the swelling subsides, with active exercises of hand.
2: Fractures of the shaft of the radius or the ulna with radio ulnar
joint disruption:
MONTEGGIA FRACTURE:
1:coservativeClose reduction and arm immoblizationIn long elbow
flexed 902:operativeInternal fixation and reduction of the radial head
Galeazzi
In adultReduction is best by open operation and plating of radius

 Complications
early
 Vascular injury
 Nerve injury
 Compartment syndrome

Late
 delay union or non uoin
 Infection
 Decreased range of motion
 Posttraumatic arthritis

Chronic osteomyelitis
 Classification
Anatomical criteria consist of four types: Type I, an endosteal or medullary
lesion.Type II, superficial osteomyelitis, limited to the surface of bone.Type
III, a localized infection involving a stable, well-demarcated lesion
characterized by full-thickness cortical sequestration and cavitation (in this
type, complete debridement of the area will not lead to instability).Type IV,
diffuse osteomyelitic lesions that are mechanically unstable, either at
presentation or after appropriate treatment.

 treatment
Surgery for chronic osteomyelitis consists of sequestrectomy and resection
of scarred and infected bone and soft tissue. The goal of surgery is:
Eradication of the infection by achieving a viable and vascular environment.
To achieve this goal. Radical debridement may be required. Inadequate
debridement may be one reason for a high recurrence rate in chronic
osteomyelitis.Surgery Sequestrectomy and curettage for chronic
osteomyelitis.Open bone grafting
 complications

18
Shoulder dislocation types, diagnosis methods of reduction?
 Types
Anterior dislocation
o Sub coracoid
o Sub glenoid
o Sub clavicular.
Posterior dislocation
Inferior dislocation
  diagnosis
 Clinical
 X-ray

 Methods of ttt?
Ant dislocation
Stimon’s technique.
The patient is left prone with the arm hanging over the Side of the bed.
After 15 or 20 minutes the shoulder May reduce.
Hippocratic methods
 Traction is applied to the arm with the shoulder is slight Abduction
while an assistant applied firm counter-Traction to the body.
 The heel of the foot is placed against the Humeral head in the axilla
And longitudinal traction is applied to The arm
Kocher’s method
The elbow is bent to 90 and hold close to the Body. No traction should be
applied .The arm is slowly rotated 75 laterally. The Point of the elbow is
lefted forward and The arm is rotated medially.
Dr. Saeed said: apply abduction + ext rotation + pull the arm to down →
then adduction + int rotation + pull the arm down

Posterior and inferior as q 7

Septic arthritis
 Patogenesis
the relatively avascular joint space serve as excellent culture medium.The
presence of bacteria or their products within a joint incites an intense local
reaction. This is followed by hyperemia, vascular congestion, exudation of
synovial proliferation. Destruction of articular cartilage may occur
Secondary to interference with chondrocyte nutrition.Direct pressure
necrosis,It may result from exposure to proteolytic enzymes and other
products released during phagocytosis of bacteria.Finally, proliferating
synovia promotes the enzymatic digestion of the articular cartilage and
invades the matrix.
 Clinical presentation
Acute onset
 Classical triad of fever, joint pain, and restricted range of motion
 Arthritis
 Usually monoarticular
 Most commonly affected joints: knees (followed by hip, wrists,
shoulders, and ankles)
 Joints are swollen, red, warm, and painful
 Treatment
 General supportive
 Measures Antibiotics
 Surgical drainage

 Complications
1. Joint destruction
2. Osteomyelitis
3. Sepsis
4. Children: growth arrest

20
Fracture around elbow, supracondyler fracture in children ,complication
and management?

These are among the most common fractures in children

Cause/
Fall on outstretched hand, hyperextension
Classification of gartland

• Type I an undisplaced fracture

• Type II an angulated fracture with the posterior
cortex still intact
– IIA: a less severe injury with the distal fragment
merely angulated
– IIB: a severe injury; the fragment is both angulated and malrotated
• Type III a completely displaced fracture (although
the posterior periosteum is usually preserved,
which will assist surgical reduction)
• Type IV an anteriorly displaced fracture
Clinical picture
History of falling ,pain ,swelling , deformity,
Diagnosis
History
X ray
fat bad sign in undisplaced fracture
complication
1_brachial artry injury lead to ischemia and Volkmann's contracture or
gangrenous
2-radial nerve injury
3 malunion lead to cubitus varus and or vulgus
Elbow stiffness_ 4
Treatment
According to classification
In type 1/
The elbow is immobilized at 90 degrees and neutral rotation in a
lightweight splint or cast and the arm is supported by a sling
 The splint is retained for 3 weeks and
 supervised movement is then allowed.

TYPE IIA: POSTERIORLY ANGULATEd

FRACTURES – MILD
fracture can be reduced
under general anaesthesia by the following stepwise
manoeuvre): (1) trction for 2-3 minutes in the length of the arm with
countertraction above the elbow;
(2) correction of any sideways tilt or shift and rotation (in comparison with
the other arm);
(3) gradual flexion of the elbow to 120 degrees, and pronation of the
forearm, while maintaining traction and exerting finger pressure on the
olecranon to correct the posterior tilt. Then feel the pulse and check the
capillary return: if the distal circulation is suspect, immediately relax the
amount of elbow flexion until it improve
Following reduction, the arm is held in a collar and cuff; the circulation
should be checked

TYPES IIB AND III: ANGULATED AND MALROTATED

OR POSTERIORLY DISPLACED FRACTURE
As type II A then held with percutaneous smooth K-wire
Open reduction and internal fixation
1) a fracture that
simply cannot be reduced closed;
(2) an open fracture; or
(3) a fracture associated with vascular damage. The fracture is exposed
from the lateral side, the hematoma evacuated, the fracture reduce and
held by 2 k wire
In ANTERIORLY DISPLACED FRACTURES
Closed reduction and external fixation under general anaesthesia and x ray
by traction to distal fragment
with the elbow semi-flexed, applying thumb pressure over the front of the
distal fragment and then
extending the elbow fully,then percutaneous pins,post slap
 Etiology, Pathology, Diagnosis and treatment of acute
hematogenous osteomyelitis?
a. Etiology?
 90% → Staphylococcus Aureus
 10%
1. Streptococcus Hemolyticus
2. Pnumococcus,
3. Hoemphilus influenze
4. Typhoid.
5. E.coli.
6. Others
 Source Of Infection
1. Infected umbilical cord in infants
 2. Boils, tonsilitis, skin abrasions
3. In adults UTI.
b. Pathology?
 Starts at metaphysis
 Trauma ? → stimulation of edema+ irritation
 Vascular stasis
 Acute inflammation
 Suppuration
 Necrosis
 New bone formation
 Resolution
c. Diagnosis?
 History & Clinical features
1. Severe Pain.
2. May be unable to move the affected extremity
(pseudoparalysis)
3. Fever.
4. General malaise.
5. History of a recent upper respiratory infection or
other infection that offers a clue as to the source of
bacteremia.
6. A history of previous trauma is quite common in
children with bone or joint sepsis.
 Laboratory:
1. FBC (full blood count), with diff.count.
2. B.C.(Identification of the pathogen, sensitive to
antibiotic)
 3. ESR (elevated has been traditionally monitored but
not sensitive) ‫يتغير بعد يومين ثالث‬
4. CRP (more sensitive index of infection.) ‫يتغير بسرعة‬
 Imaging:
1. X-ray
2. CT (has limited application in the diagnosis or
management of osteoarticular infection.)
3. MRI (best for soft tissue pathology) → more
acurate.
4. U/S (is most useful in demonstrating of fluid
collection; whether the collection in the hip joint or
in a subperiosteal location. It can serve as an aid
when performing aspiration.)
d. Treatment? → must do culture because we will give the pt
antibiotics for long period.
 Aspiration appropriate cultures have been obtained.
 Supportive treatment for pain and dehydration.
 Splintage and bed rest.
 Antibiotics IV administration of antibiotics should be
started. Empirical antibiotic coverage usually is best
begun with first-generation Cephalosporin.
However the choice of antibiotics should provide
coverage for any specific pathogens that the patient's
history suggests may be present, recently with a short
course of IV antibiotics (average of 4 days), followed
by Oral antibiotic for a total of 3 to 4 weeks of
antimicrobial therapy. And the patient clinical course
CRP, and ESR were closely followed.
 Surgery:
When? Indications?
1. If the response to antibiotic therapy is not rapid .
 2. If any signs of abscess appear
3. Open drainage
 After surgical drainage the wound may be left open to
heal by secondary intention.
 Or may be the wound closed over suction drains or
suction -irrigation system.
e. Complications
 Systemic sepsis
 Growth deformity (physeal arrest or stimulation)
 Pathologic fracture
 Osteonecrosis.
 Chronic infection.
 Although there have been reports of cardiopulmonary
complications secondary to osteomyelitis (e.g.
bronchopneumonia, cardiac failure from septic
pricardaitis, septic pneumonia).

21
Indication of internal fixation, complications?
Fractures in patients with multiple injuries.
Patients with severely mutilated or amputated limbs undergoing
reimplantation in whom external fixation is impractical.
Intra-articular fractures or physial .
Open fractures of the major long bones, in elderly patients.
Major vascular injuries requiring repair that accompany open fractures
and
where external fixation is not the best choice.
 Selected fractures of the hand, forearm, and foot
Complications
Mostly due to poor technique
post-surgical infection, malunion, nonunion, ,refracture , compartment
syndrome
2_complication of anaesthesia
3_pseudoarthrosis-failure of healing
4-implant breakage ,loosing

Ewing sarcoma ,clinical presentation, diagnosis, treatmen

Ewing's sarcoma is a highly malignant tumor that is found in the lower
extremity more than the upper extremity, but any long tubular bone may
be affected.
The most common sites are the metaphysis and diaphysis of the femur
followed by the tibia and humerus.
sarcoma is most common in the first and second decade.
Clinical presentation
Pain,swelling in diaphysis,
tenderness,fever,headache,anorexia,maliaise,wormth,erythema on this
area

Diagnosis
1_cbc show increase ESR, leukocytosis,decrease Hb
2 plain xray show diaphyseal bone distruction.periosteal reaction(lamelated
or onion like)
Ct ,MRI for extension_3
Treatment
Sensitive for chemo and radiotherapy
So 1_preoperative chemotherapy for shrinkage
2_complete surgical resection with adjavant radiotherapy
3-radiotherapy can sensitive without surgical resection

22
External fixation indication and complication?
Indications
1_fracture associated with severe tissue damage or contaminated wound
2-fracture around joint with soft tissue swelling
3 infected fracture that can't do by internal fixation
4 multiple injury
5-ununited fracture that can be exiced or recompressed
Complication
1damage to soft tissue
2_over distraction

3_pin track infection classified into

 Grade 1_serius drainage
 Grade II-Superficial cellulitis
 Grade III-Deep infection
 Grade IV-Osteomyelitis.
4_limition of joint movement
5_malalignement,malunion,ununion
Types
1_external skeleton fixator(simple)
2_cast brace to allow movement of knee
3. Ellizurov external fixator
4_orthofix external fixator
5-ring fixator
6-clamp pin
Types occurding to plan ‫هذا المهم‬
1-uniplanner external fixator
2_biplanner external fixator
3_triangulated or multiplanner
‫من أنواع ال‬external fixation ‫تذكر‬plaster of paris ,orthosis
‫بس بأكثر األسئلة يقصد ب‬external fixation ‫الجهاز نفسه‬
External fixator

Osteosarcoma diagnosis and treatment?

Osteosarcoma is the most common primary malignant tumor of bone,
characterized by the direct formation of bone or osteoid by tumor cells.
The incidence of osteosarcoma peaks in those aged 10-20 years;
(maximum period of skeletal growth).
Osteosarcoma occurs most commonly in the metaphyses of long tubular
bones, particularly around the knee joint (distal femur, proximal tibia). The
proximal humeral metaphysis is another common site. The disease
commonly extends from the metaphysis into the adjacent diaphysis or
epiphysis.
Clinical picture
Patients complain of worsening
pain and swelling, particularly suffering night pain,
non-mechanical pain or joint restriction. Pathological
fracture is rare
Diagnosis/
History +clinical picture (as above)
2_increase ALP,LDH
3_the main investigation ,X ray
Radiographic appearances shows a mixture of lytic and sclerotic areas. Soft
tissue extension of osteosarcoma is common and seen on radiographs as a
soft-tissue mass.
Cloudlike areas of sclerosis due to malignant osteoid production and
calcification may be seen within the mass.
Periosteal reactions are commonly seen once the tumor extends through
the cortex (Codman triangles and multilaminated, spiculated, and
reactions).
4- MRI for the whole bone will
delineate the medullary and extra-osseous extent of tumer
5_nuclear medicine(isotope)for metastasis

Treatment
I) Early cases: (No lung metasuses)
a. Pre-operative (neo- adjuvant) chemotherapy.
b. Surgery :Local control of the tumour by one of the followings:
1) Limb salvage surgery :
Method: Wide local resection with replacement of the defect by prosthesis.
Indication : If the tumor can be removed with adequate safety margin and
the resulting limb has satisfactory function.
After resection , histopathology for analysis if wide margin achived,
judgement to chemotherapy by degree of necrosis
2)Amputation: Proximal to the joint above the tumor.
4 Indication: reverse of number 1
c.Post-operative adjuvant chemotherapy
II) Advanced cases: palliative amputation, palliative choand radiotherapy

23
Gaint cell tumer diagnosis and treatment?
Although benign, GCTs show a tendency for significant bone destruction,
local recurrence, and occasionally metastasis.
* Frequency: GCTs represent 5% of all primary bone tumors and 18-21%
of all benign bone tumors. The most common bone tumor in the young
adults aged 25 to 40 years, GCTs occur most commonly in the third decade
of life.
The common site ,distal femur,proximal tibia,proximal humerus,distal
radius
Classification of gaint cell tumer by companancii/
Stage 1 Completely intraosseous
Stage 2 Demonstrates cortical erosion without distruction
Stage 3 Characterized by cortical destruction with a soft-tissue component
Clinical picture/
Swelling the main symptom,slow growing ,hard in consistency
Pain ,in late stage

Diagnosis/
1_x ray :
*The lesions are expansile, osteolytic, radiolucent without sclerotic margins
and usually without a periosteal reaction and eccentrically located within
the bone.

There is a well-defined defect in the metaphysis and epiphysis, with

destruction of the medullary cavity and adjacent cortex. The destruction
may stop just short of the joint.
2_in CT gives an accurate estimation of cortical
bone involvement, and MRI demonstrates low signal
on T1 and intermediate to high signal on T2 with
areas of heterogeneity
Treatment)curettage
Various treatment options are advocated in the current literature, including
the following: (1) curettage, (2) curettage and bone grafting, (3) curettage
and insertion of polymethylmethacrylate (PMMA), (4) cryotherapy after
curettage of the cavity, (5) curettage and a chemical adjuvant (phenol, zinc
chloride, alcohol, and H202) prior to the insertion of PMMA or à bone graft,
in stage 1,III (6) resection in stage III, (7) radiation therapy, and (8)
embolization of the feeding vessels
8/RANKLe AB(denosumab) in stage III
Note /in any tumer during surgery must take biobsya soft-tissue
component
Bone cyst diagnosis, treatment?
I_simple cyst
2_aneursmal cyst

I-simple cyst/
_Occur before 15 years
50%developed in proximal humerus
Other common site,proximal and distal tibia,proximal femur,illiac
wing,calcenous
Clinical features/. Asymptomatic , discovered accidentally,or by
pathological feacture after minor trauma
Appear solitary cyst contain serous fluid ,some times hemorrage in fracture

Diagnosis
On pathological fracture when discove accedently by radiology
1_x ray, symmetric radiolucent well demarcated, expancile cyst at
metaphysis,may extend to physeal plate and cortex thin
(Fallen leaf sign) _seperate of thin cortex and fall in cavity in pathological
fracture
2_on histopathology exam/cyst contain serous fluid,, the cyst lining
demonstrates connective tissue with reactive bone

3,MRI will demonstrate the homogeneous fluid-filled cavity.

Can be seen by other radiology
Treatment
1_healed spontaneously ;by skeletal growth and maturation
2. Callus of pathological fracture prompot healing of cyst
3_observition and restrictions of movement until cyst completely healing in
asymptomatic patient
4_currtage and bone graft in active lesion
5-percutanous injection of steroids

Aneursmal cyst
Is a skeletal osteolytic lesion
Cause/reactive to hemorrage with preexisting trauma
Common site/in metaphysis of long bone of lower bone
It is eccentric but may come central
Clinical picture/pain,swelling
Diagnosis
On pathology/marked expansion of involved bone(balloning),with cystic
bone distruction, periosteal new bone formation
2_radiology ,well defined radiolucent osteolytic subperiosteal lesion
eleveting the periosteal and eroding cortex
Perosteal reaction as egg shell
3_MRI demonstrates the typical cystic features
with multiple intralesional septations and fluid levels
4_Angiography demonstrates persistence of
contrast and a blush of flow within the lesion

Treatment/cuuratage and autogenous grafting

 24
1. 0pen fracture definition, classifications ,emergency care,
treatment, complications
a) Definition?
It is a fracture associated with overlying skin wound
communicating the fracture hematoma with the external
environment.
b) Classification

c) Emergency care?
In prehospital care
The fractures should be aligned and splinted, and
sterile dressings should be applied to the wound
1_primary survey
A -airway and cevical immobilization
B-breathing
C_circulation and hemorrage control by dirct pressure or pneumatic
turniqate ,fluid resuscitation,and consult vasculer surger
D-disability
E_exposure and environment
2_secondory survey when patient stable(AMPle)
3_fracture stabilization
4_antibiotic (cephalosporins, gentamicin),anti tetanous
5_local preparation
After satisfactory anesthesia,and Application of a pneumatic
tourniquet when feasible.
Shave and Cleanse the skin around the wound or the whole
extremity by antiseptic and saline..
Then remove the sterile dressing from the wound and
Obtain cultures.
Then thoroughly irrigate the wound with copious amounts of
isotonic saline
During irrigation expose all parts of the wound, including the
ends of the bone fragments, and gently massage them to wash away
as much foreign material as possible
6-Remove with sterile instruments obviously devitalized tissue,
foreign
material, and small bone fragments devoid of soft tissue attachment.
For exposed soft tissues thorough irrigation with large amounts of
saline is preferable to scrubbing.
Once all obviously devitalized tissue has been excised and thorough
irrigation has been carried out, place a sterile dressing over the
wound
and perform a surgical preparation and draping of the entire field as
for a clean surgical procedure

‫تفصيل ال‬surgical treatment

i. 2) Definitive surgical treatment under general anesthesia

1. Profuse irrigation to remove dirt and reduce
contamination
2. Debridement (excision) of devitalized tissues
Debridement:
Exploration of the wound
Excision of devitalized tissue
Removal of foreign material.
-Small fragments of bone completely devoid of soft
tissue attachment and therefore avascular are removed.
Removal of large avascular fragments is controversial. It
generally is best to remove any avascular bone and plan
on later replacement with autogenous bone grafting

3. Reduction and fixation of fractures 1

a. Gustilo I & II: No risk of infection
Therefore open reduction and internal fiction
are allowed:
i. -Intra-medullary nail for fracture shaft
of Femur or tibia
ii. -Screws or plate and screws for
fractures other long bones Or fracture
near a joint.
b. Gustilo 3: High risk of infection,
i. -Therefore closed reduction and external
fixation by external skeletal fixator
(internal fixation is contraindicated to
avoid infection).
ii. After proper management of soft tissue
problems and subside of Infection,
external fixation is better converted into
internal fixation.
ii. Amputation is indicated in
1. -Severe crushes involving main vessels or nerves
2. -In fractures complicated by ischaemic or gas
gangrene.
‫باختصار‬definitive management of open wound

1_stabilization , debridement and irrigation in emergency

2_antitetanous , antibiotics
3_formal irrigation and depridement through 6hours
4_fracture stablization by circuler cast and window if wound
minimum,traction, skeletal fixator,internal fixation (if there is indication
d) Complications?
i. Infection → 2nd hemorrhage, osteomyelitis, tetanus & gas
gangrene.
ii. Compartment syndrome
iii. Delayed union and non-union.
iv. Neurovascular injury
v. DVT
vi. Post traumatic Osteoarthritis

2. Meniscal injury, clinical picture diagnosis treatment?

a) CP?
i. Pain is often severe and further activity is avoided;
ii. Swelling appears some hours later
iii. The knee is ‘locked’ in partial flexion.
iv. The main complaint is of recurrent ‘giving way’ or ‘a
catch in the knee’. ‘Locking’ – i.e. the sudden inability
to extend the knee fully – suggests a bucket- handle tear
v. On examination the joint may be held slightly flexed and
there is often an effusion. In long- standing cases the
quadriceps will be wasted. Tenderness is localized to the
joint line, in the vast majority of cases on the medial side.
 Flexion is usually full but extension is often slightly
limited.
Between attacks of pain and effusion there is a
disconcerting paucity of signs. The history is helpful, and
McMurray’s test, Apley’s grinding test or the Thessaly test
may be positive
b) Dx?
i. Plain X-rays are usually normal, but MRI is a reliable
method of confirming the clinical diagnosis, and it may
even reveal tears that are missed by arthroscopy.
ii. Diagnostic knee arthroscopy is now infrequently
performed due to the increased use of MRI scanning.
c) TTT?
i. DEALING WITH THE LOCKED KNEE
Usually the knee ‘unlocks’ spontaneously; if not, gentle
passive flexion and rotation may do the trick. Forceful
manipulation is unwise (it may do more damage) and is
usually unnecessary; after a few days’ rest the knee may
well unlock itself. However, if the knee does not unlock,
or if attempts to unlock it cause severe pain,
arthroscopy is indicated. If symptoms are not marked,
it may be better to wait a week or two and let the
synovitis settle down, thus making the operation easier; if
the tear is confirmed, the offending fragment is removed
or repaired if possible.
ii. CONSERVATIVE TREATMENT
If the joint is not locked, MRI scanning now plays a
critical role in planning further treatment. If a
peripheral tear has been identified and the lesion may
be repairable, then arthroscopy and suture repair of the
meniscus can be employed, particularly in the younger
patient. However, other unstable or potentially unstable
tears, identified on MRI, often present with infrequent
 symptoms that are not disabling. Non-operative care
should be instigated as many patients will settle, with
resolution of the acute flare of pain and swelling,
despite the continued presence of the meniscal tear.
iii. OPERATIVE TREATMENT
Surgery is indicated (1) if the joint cannot be unlocked
and (2) if mechanical symptoms (locking or catching)
are recurrent and non-operative treatment has failed. In
most cases, if available, an MRI scan should be
obtained to determine the pattern of tear and to plan
treatment with the patient. As a result ‘diagnostic’
arthroscopy is now infrequently performed. Tears close to
the periphery, which have the capacity to heal, can be
sutured; at least one edge of the tear should be red
In appropriate cases the success rate for both open and
arthroscopic repair can be high.
Tears other than those in the peripheral third are dealt
with by excising the torn portion (or the bucket handle
Total meniscectomy is thought to cause more instability
and so predispose to late secondary osteoarthritis;
certainly in the short term it causes greater morbidity
than partial meniscectomy and has no obvious
advantages. Arthroscopic meniscectomy has distinct
advantages over open meniscectomy: shorter hospital
stay, lower costs and more rapid return to function.
However, it is by no means free of complications.
Postoperative pain and stiffness are reduced by
prophylactic non-steroidal anti-inflammatory drugs. In
some patients a flare of pain can occur, which can
persist for a number of months. In some cases there is a
rapid progression of articular cartilage damage and
the development of arthritis.
Conservative treatment of fracture ,type ,indication , complication?
Type/
I-Immibolization by plaster or cast or brace with or without closed
reduction
II-closed reduction
III_traction (skeletal or skin) to immobilization

GENERAL INDICATIONS FOR conservative TREATMENT

I_CHILDREN'S FRACTURES.
II-UNDISPLACED FRACTURES.
III-POOR BONE QUALITY.
IV-UNFIXABLE FRACTURES
V-SYSTEMIC CONTRAINDICATIONS TO SURGERY
VI-LOCAL CONTRAINDICATIONS TO SURGERY
VII-PSYCHOSOCIAL PROBLEMS
Complication of conservative treatment?
Complications od cast and plaster and traction
1_Plaster Sores.
2-The Tight Cast
3_Thermal Effects of Plaster.
4_Thrombophlebitis and Equinus Position
5_The Cast Syndrome
6_Infection Secondary to Cast Application.
7_Allergic Reactions
8_Traction Hazard(pin site infection, circulatory embarrassment,nerve
injury)
Complication of reduction
1_malaignement and malunion,non union ,injury to nerve ,vessels durinf
reduction
Countraindication of closed reduction?
when:
. 1.There is no significant displacement
2.The displacement is of little concern (eg, humeral shaft).
3.No reduction is possible (eg, comminuted fracture of the head and
neck of humerus).
4.The reduction, if gained, cannot be held (eg, compression fracture
of the vertebral body).
5.The fracture has been produced by a traction force (eg, displaced
fracture of the patella).

25
1-Olecranon and Radial head fractures of the elbow , Types, Treatment and
Complications
2-Anterior Cruciate ligament injury, mechanism of injury, clinical picture,
diagnosis & treatment
Radial head fractures
Types : ) Mason’s Classification (
 Type I: Undisplaced fracture.
 Type II: Marginal fracture with displacement.
 Type III: Comminuted fractures.
 Type IV: Radial head fracture with posterior dislocation of elbow.
Treatment :
 Type 1
1. Decrease the pain byAspiration of elbow within 24h
2. Early mobilization within 24h
 Type 2
1. Excision head of radius
2. (MacLaughlin's criteria for immediate excision: Angulation >30° ,
Depression >3mm, Involvement of >⅓ of head)
 Type 3
1. Radial head excision is indicated within first 24h
2. Excision head is replaced with prosthesis
 Type 4
1. Prompt reduction of the dislocation is a must
2. Asses status of head. If it's meets the criteria do it within 24h
Complications :
1. Injury to the posterior interosseous nerve
2. osteoarthritis and elbow stiffness is the common
Olecranon fractures
Types : (Mayo classification (
1. Undisplaced
2. Displaced stable (communited or non communited)
3. Displaced unstable (communited or non communited)
Treatment
 Undisplaced: Analgesia and mobilization with above elbow cast for
6 weeks
 Displaced :open reduction and internal fixation with plate, screw
or wires
Complications
1. Stiffness
2. Ulnar nerve symptoms
 3. Osteoarthritis
Anterior Cruciate ligament injury
Mechanism
1. External rotation with abduction of the flexed knee
2. Hyperextension of knee in internal rotation.
Clinical picture
1. Popping sensation felt or heard at the time of injury
2. Swelling of the knee
Diagnosis
1. X-ray: (AP) view, lateral view, intercondylar notch view, sunrise views
a. Usually normal in ACL tear, but If Avulsion fracture of tibial spine
present it indicates ACL tear.
2. MRI: This is the best
3. KT-1000 arthometer:
a. Device measuring anteroposterior tibial displacement by
tracking the tibial tubercle in rotation to the patella.
b. More than 3 mm anterior displacement at 20 lbs predicts an ACL
tear with 94 percent accuracy.
Treatment
 Conservative :
o For Grade I and II tears and consists of rest, long leg casts for 4-6
weeks, NSAIDs, physiotherapy, etc.
 Surgical
o Primary repair )by sutures)
o Reinforcements (additional support by body graft)
o Reconstruction Arthroscopically assisted (total replaced by body
graft)
 26
Polytrauma pt pre hospital emergency and assessment, treatment of pt with
massive pelvic fractures
Methods of diagnosis and treatment of orthopaedic surgery
Polytrauma pt pre hospital emergency and assessment :
Primary survey:ABCDE
1. Air way maintenance with cervical spine protection
2. Breathing and Ventilation
3. Circulation and hemorrhage control
4. Disability: neurological status
5. Exposure/Environmental control: completely undress the pt ,
but prevent hypothermia
Secondary survey:
 Includes reassessment of all vital signs
 Head to toe evaluation of the trauma pt (brief history) :
Allergies, Medications currently used , Past illnesses , Pregnancy,
Last meat , Environment related to the injury
Hemorrhage control (major arterial bleeding):
1. Application of direct pressure , pneumatic Tourniquet
2. Aggressive fluid resuscitation
3. Vascular surgery consult
Fracture Stabilization (to reduce risk of) :
1. Neurovascular compromise , Reduce pain, Decrease blood loss,
Cartilage sparing, Fat emboli

Treatment of pt with massive pelvic fractures :

 After excluding associated trauma, the only life threatening aspect of
pelvic fracture is exsanguinating hemorrhage that can be treated by 5
basic modalities:
 1. PELVIC BINDERS ) external fixation )
2. Fluid resuscitation
3. Pneumatic Antishock garments
4. Angiographic embolization
5. Direct transmission to operating room and Internal fixation
Methods of diagnosis and treatment of orthopaedic surgery :
Diagnosis
1. History and physical examination (orthopaedic tests)
2. Radiological investigation (X-ray , CT, MRI , Us, IV imaging)
3. Laboratory investigation (Heamatology, Microbiology,
Biochemistry, Histology & Cytology)
Treatment
 Non surgical
1. Medication ) Analgesic, Anti inflammatory, Antibiotics,
Chemotherapy
2. Physiotherapy ) Thermal, massage, Exercise )
3. Immobilization ( casts , splinter )
 Surgical
Open surgery
Minimally invasive (orthoscopic treatment)
 Rehabilitation
27
Ankle fracture, mechanism of injury , classification , treatment and
Complications
Osteoporosis, definition, treatment and Complications
Ankle fracture, mechanism of injury , classification , treatment and
Complications
Mechanism
 Addiction , Abduction, External rotation.& Vertical loading
 Classification ) Danis-Weber classification ):
 Weber A : Avulsion fracture below tibiofibular joint line
 Weber B : Oblique fracture arising from the joint line
 Weber C : More proximal fracture of the fibula associated with
syndesmotic injury
Treatment
o NON-OPERATIVE TREATEMENT :
 Closed reduction & PRICER
 Protection (crutches, splint or brace)
 Rest , Ice, Compression, Elevation, Rehabilitation
 NSAID topical or systemic (the same effect)
o OPERATIVE TREATMENT:
 Open reduction and internal fixation
Complications
 Ankle pain, swelling, instability and stiffness,
 Sensation of instability or giving way and intermittent swelling
are suggestive of cartilage damage
Osteoporosis, definition, treatment and Complications
Definition
IS a skeletal condition characterized by loss of bone mineral density
(BMD) leads to decreased bone strength and increased
susceptibility to fractures.
Treatment
Optimize bone health:
1. Optimize calcium and vitamin D intake.
2. Treat vitamin D deficiency.
3. Encourage physical activity, including strength
(resistance) and balance training.
Pharmacotherapy for osteoporosis :
 a. Bisphosphonates for osteoporosis:
i. Mechanism of action: inhibition of osteoclasts, which
are involved in bone resorption
ii. Agents: Alendronate, Risedronate , Ibandronate ,
Zoledronic acid.
b. Nonbisphosphonates :
i. Hormonal therapy: Estrogen and Testosterone
ii. Calcitonin
iii. Parathyroid hormone
iv. Denosumab: Patients with impaired renal function.
v. Romosozumab :postmenopausal women with multiple
vertebral fractures or very high fracture risk.
vi. Teriparatide: Treatment of glucocorticoid-induced
osteoporosis.
Complications
1. Fractures: most common in the vertebres, spine, and Wrist
2. Chronic pain & Decreased mobility
3. Kyphosis: due to spine fractures
28
Fractures of growth plate in children, classification, principles of
treatment And Complications
Compartment syndrome as orthopaedic surgery, clinical picture,
treatment & complications

Fractures of growth plate in children, classification, principles of

treatment And Complications
Classification (Salter and Harris classification) :
1. Type 1 – separation of the epiphysis
2. Type 2 – fracture through the physis and metaphysis – is the
commonest
3. Type 3 – an intra-articular fracture of the epiphysis –
 4. Type 4 – splitting of the physis and epiphysis
5. Type 5 – crushing of the physis – may look benign but ends in
arrested growth.
Treatment
a. Undisplaced fractures
i. Splinting the part in a cast or a close-fitting plaster slab
for 2–4 weeks
b. Displaced fractures
i. Type 1 &2  closed reduction , then splinted securely
for 3–6 weeks.
ii. Type 3 & 4 closed reduction, if failure  Open
reduction & internal fixation , then splinted for 4–6
weeks
Complications
Malunion or non-union (type 1 &2)
Asymmetrical growth of the bone end (type 3&4)
Premature fusion and retardation of growth (type 5)
Compartment syndrome as orthopaedic surgery, clinical picture, treatment &
complications
Clinical picture 4P:
Pain
Paresthesia
Paralysis
Pulselessness
Treatment
 Initial Decomposition
by immediate splitting or removal of the casts or other
compromising circular dressing
 Decompressive FASCIOTOMY
 Complications
1. Nerve damage
2. Muscle and soft tissue damage
3. Secondary Infection
4. Volkmann's contracture
5. Acute kidney injury
29
Femoral shaft fractures classification, principles of treatment jn children
Discuss knee injury menisci and ligament injury
Femoral shaft fractures classification, principles of treatment jn children
Classification
 Type 1 there is only a tiny cortical fragment.
 Type 2 the ‘butterfly fragment’ is larger but there is still at least
50% cortical contact between the main fragments.
 Type 3 the butterfly fragment involves more than 50% of the
bone width
 Type 4 is essentially a segmental fracture.
Treatment
NON OPERATIVE TREATMENT
 Balance traction followed by spica cast for infants and
children
 Skeletal traction for younger adolescents
OPERATIVE TREATMENT fixation with :
 Flexible intramedullary nails
 Trochanteric entry-point rigid nails with interlocking screws.
 Plates and screw inserted by the MIPO technique
 External fixation.
Discuss knee injury menisci and ligament injury
A-Menisci injury
Types
Medial meniscus injury
Lateral meniscus injury
Mechanism of injury
Rotational force when a flexed knee extends.
Clinical picture
Pain on the inner aspect of the knee.
Knee locking
Feeling of something moving within the joint
Knee Swelling
Treatment
Conservative:
Rest, ice packs, compressive bandage, Buck's skin traction, Joint
aspiration, Quadriceps exercises.
Surgical :
Arthroscopic menisci repai or Meniscal transplant
Closed partial meniscectomy via an arthroscopy

B-Knee ligament injury

Types
The knee joint is stabilized by four main ligaments:
1. The anterior cruciate ligament (ACACL)
2. Posterior cruciate ligament (PCL)
 3. Medial collateral ligament (MCL)
4. Lateral collateral ligament (LCL)
ligament injuries often occur during sports activities that involve sudden
stops, changes in direction, or direct blows to the knee.
Mechanism of injury
 Direct valgus force.
 Rotational or twisting forces.
Clinical picture
 Pain , swelling, tenderness
 Popping sensation(knee "gave away")
Treatment
 Conservative : Rest, long leg casts for 4-6 weeks, NSAIDs,
physiotherapy,
 Surgical: primary repair, reinforcements or reconstruction

30
Polytrauma pt pre hospital and emergency assessment, treatment of pt with
cervical injury
Discuss Volkmann's contraction prevention & treatment
Polytrauma pt pre hospital emergency and assessment:
Primary survey:ABCDE
 Air way maintenance with cervical spine protection
 Breathing and Ventilation
 Circulation and hemorrhage control
 Disability: neurological status
 Exposure/Environmental control: completely undress the pt ,
but prevent hypothermia
 Secondary survey:
• Includes reassessment of all vital signs
• Head to toe evaluation of the trauma pt (brief history) :
Allergies, Medications currently used , Past illnesses , Pregnancy,
Last meat , Environment related to the injury
Hemorrhage control (major arterial bleeding):
1. Application of direct pressure , pneumatic Tourniquet
2. Aggressive fluid resuscitation
3. Vascular surgery consult
Fracture Stabilization (to reduce risk of) :
• Neurovascular compromise , Reduce pain,
Decrease blood loss, Cartilage sparing, Fat emboli
Treatment of pt with cervical injury
At the site of Accident:
Fixation of neck movement
Primary survey and resuscitation if needed but with great tension
Transfer to the hospital
At the hospital:
Stable cervical spine
Fixation with ( halo vest, four postcervical collars, Minerva
jacket, cervical collars ) for 8-12 weeks
Unstable cervical spine
Non surgical
Skeletal traction for 3-6 weeks then collar or jacket.
Surgical
 Open reduction and internal fixation with plate and
screw
Anterior approach decompression by disk
removal in disk prolapse
Posterior approach  for ligamentous instability
fixation
Discuss Volkmann's contraction prevention & treatment
Definition
Is a permanent flexion contracture of the hand at the wrist, resulting in a
claw-like deformity of the hand and fingers. Passive extension of fingers is
restricted and painful.
Etiology
 Tight cast
 Trauma  rupture or thrombosis of brachial artery
 Embolism or prolonged tourniquet
Pathology
Ischemia collateral blood supply fibrosis  contracture 
shortening
Clinical picture
1. 5P) Pain, paraesthesia, pale , pulselessness of Radial Artery,
Passive extension of fingers is Painful)
2. Claw hand
3. Flexion of the Elbow , wrist & interphalangeal joints
4. Hyperextension of metacarpophalangeal joints
5. Muscle wasting
Prevention:
In any injury around the elbow look for the radial pulse & if absent
do the following:
2. Reduce the fracture if not reduced.
 3. Avoid kinking of arteries after reduction.
4. Remove any tight cast or tourniquet if present.
5. If there is a compression haematoma incision &
evacuation.
6. If suspicious for vascular injury Dopplex ultrasound.
7. If the circulation not return within 30 minutes exploration
→ open reduction & internal fixation prior to vascular
repair.
8. If the artery is thrombosed arterial reconstruction.
Treatment
1- In mild cases: Gradual extension of the fingers & physiotherapy.
2- In severe cases:
a. Muscle sliding operation: The common flexor origin is
detached and fixed in a lower position.
b. Arthrodesis of the wrist in extension with transfer of the
extensor tendons.
c. Tenoplasty to elongate the tendons.

‫مالحظة‬
‫ غير‬19 ‫ و‬15 ‫األسئلة رقم‬
‫مواجيد‬