LMCC Orthopedic Review Lecture

Back to Basics

April, 2012

Dr. P.R. Thurston

LMCC Orthopedic Review Lecture
There are 10 basic topics about which questions may be
framed for medical student examinations in Orthopedics.

1) Fractures.
2) Low Back Pain.
3) Child, Painless Limp.
4) Pulmonary Fat Embolus.
5) Compartment Syndrome.
6) Metabolic Bone Disease.
7) Metastatic Disease.
8) Septic Hip / Osteomyelitis Children.
9) Dislocations.
10) Trivia.
 Definitions
Fracture:- A discontinuity in the structural
integrity of a bone.

Infraction:- An incomplete fracture.

Dislocation:- Complete loss of contact of the

articular surfaces of a joint.

Subluxation:- Non-concentric joint surfaces.

Reduction:- Returning a fracture or dislocation to an

anatomical alignment.

Comminution:- Multiple fragments.

 Fractures

Definition :- A discontinuity in the structural

integrity of a bone.

A fracture occurs because the force applied

exceeds the breaking strength of the bone so that the
Load can no longer be transferred across that zone
of the bone.
 Fractures
Mechanical Properties of Bone

Bone is a two-phase material :-

Calcium HydroxyApatite Ca10(PO4)6(OH)2 = mineral

Osteoid Collagen type I and II = fibrous

Calcium is strong in compression, but weak in tension.

Osteoid is strong in tension, but weak in compression.

 Fractures
BUT :- (for adult bone)
Calcium is stronger in compression
than Osteoid is in tension

And therefore :-

Bone always fails first in tension

 Fractures
A bone consists of three
areas :-
Each region has its own
fracture characteristics.

the Diaphysis

the Metaphysis

the Epiphysis.
 Fractures

Bending Oblique
Diaphyseal
Torque
Spiral
Direct

Metaphyseal Traction Transverse

Compression

Epiphyseal Intra-articular

Pediatric Mixed
Fracture Description

This fracture is angulated

laterally, since it points
laterally.

The distal fragment is tilted

medially
 Fracture Description

1) The distal fragment is always described with

relation to the proximal segment.
2) Displacement = Translation of bone ends.
3) Angulation = Orientation of bone ends.
4) Angulation identifies to where the fracture points.
5) For clarity, the tilt of the distal fragment is often
used to describe angulation.
 Fractures
A fracture can occur in :-
Growing Bone.
= Pediatric Deformities.
Normal bone subject to abnormal forces.
= Traumatic Fractures.
Abnormal bone subject to normal forces.
= Pathologic Fractures.
Normal bone subject to cyclic forces.
= Fatigue or Stress Fractures.
Fractures Salter-Harris Classification
I II III

IV V
 Fractures

Salter-Harris Classification

1) Fractures interfering with growing bones.

2) Worse prognosis with increasing number.

3) Probability of surgery increases with

number.
 Stress or Fatigue Fractures
Repeated loading below acute
failure threshold.

Eventual fatigue failure.

Military recruits, runners, aerobics.

Tibia, metatarsals, femoral neck.

Initial x-ray can be negative.

Bone tenderness Bone scan.

 Pathologic Fractures
Failure through abnormally
weakened bone

Minimal trauma BEWARE

Osteoporosis
Metastasis
Tumours:- Benign,
Malignant
(Multiple Myeloma).
Metabolic Bone Disease
 Pathologic Fractures
Metastases:
Lytic - Lung
- Colon
- Thyroid
- Renal
- Breast
Sclerotic - Prostate
 Pathologic Fractures

Metastases:
- require fixation to prevent fracture if they are > 1/3.
- produce pain on weight bearing in the lower limb.
- survival > 3 months.
- cannot be managed by medical therapy.
- radiotherapy after fixation (2 weeks)
(radiotherapy induced osteonecrotic fractures)
Pathologic Fractures
 Osteitis Deformans / Pagets Disease

4% of pop. Over 40
yrs.
accelerated bone
turnover
often assymptomatic
monostotic >
polyostotic
loss of stature
AV shunting
pathologic bone
 Gout

Urate crystalopathic arthritis

Crystals in periarticular tissues
Inconsistant elevated serum urate
Allopurinol and colchicine
Tophi in periarticular soft tissues
Deposits in non-articular cartilage
Juxta-articular erosions
Indications for Closed Reduction

There is significant displacement.

Reduction is possible.
The reduction, if gained, can be held.

The fracture has not been produced by a traction

force.
Indications for Open Reduction

1) There is a significant Displacement.

2) Open Fractures.
3) Intra-articular Fractures.
4) Un-reducible Fractures
5) Reductions that cannot be maintained in a cast.
6) Comminuted or Segmental Fractures.
7) Floating Joints.
8) Fractures with Neurovascular damage.
 Open Fractures
Classification :-

1. < 1 cm., inside-out, little soft tissue damage.

= low potential for infection.

2. 1 cm. 10 cms., outside-in, requires debridement, but

no flap or skin graft.
= moderate potential for infection.

3. > 10 cms., outside-in, high energy, devitalized muscle,

comminution or bone loss, soft tissue loss.
 Open Fractures

Classification :-

3A. No loss of soft tissue cover, no flap required.

3B. Flap required due to soft tissue stripping.

3C. Associated vascular injury.

Type 1. Open Fracture = 6 mm, extend & debride
Degloving Mechanism

Degloving Mechanism
Type III C Injuries Vascular Injury

Note pallor of the ankle

No pulses
Fracture Complications

1. Pulmonary Fat Emboli

2. Compartment Syndromes
Pulmonary Fat Emboli :- A.R.D.S.
- Long bone fractures, burns, contusions.

- Interstitial pneumonitis due to free fatty acids

- S.O.B. & confusion in young adults.

- Axillary & Subconjunctival Petechiae.

- Serum lipase elevated.

- pAO2 reduced if < 50 20% mortality.

- Ventillatory support

- Dexamethazone.

- 5 day course.
Pulmonary Fat Emboli :- A.R.D.S.

Since Pulmonary Fat Emboli occur as an on-going

process, involving either repeated showers of emboli or
an evolution of insults, the most effective treatment is:-

Early Fracture Fixation

for both prevention and management.

 Compartment Syndromes
- increased interstitial tissue pressure.
- fractures, burns, tight dressings.
- normal pressure < 25 mm. Hg.
- when the tissue pressure > venous capillary pressure, but less
than the arteriolar pressure.
- 6 Ps
- pain.
- pallor.
- pulselessness.
- paresthesias.
- paralysis.
- poikylothermia.
 Compartment Syndrome
Symptom: Pain out of proportion to that
expected for the injury.

Signs: 1. Loss of function of muscle due to

ischemia within the compartment.
2. Pain with passive stretch
3. Numbness etc. are LATE findings!
4. If neuro symptoms present, potential
for full neuro recovery is only 10 %.
Rx Compartment Syndrome

Release all compressive

dressings / plaster.

Elevate extremity to
heart level.

Fasciotomies.
4compartment
fasciotomy
 Compartment Syndrome

Careful monitoring.
Recognise it - 5 Ps
Call Orthopaedic
Surgeon
Pressure measurements
Back Pain
 Classification of MechanicalBack
Pain
Postural syndrome (MacKenzie)
normal tissues become painful by the application of
prolonged stresses (sitting, bending etc)

Dysfunction syndrome
soft tissues are shortened and stiff. Usually >30 year
old, poor posture, under exercised, reduced mobility

Derangement syndrome
Disc derangement (tears and herniation)
Causes and Classification of Back Pain: McNab
Spondylogenic
Viscerogenic Osseus:
Trauma
Vasculogenic Infection
Neoplasms
Neurogenic Inflammatory
Metabolic (eg.Pagets)
Psychogenic Deformities
Soft tissues:
Spondylogenic
Muscles
SI joints
Disc
Facets
Anatomy

Extension Flexion
 Three joint complex (Kirkaldy Willis)
R e c u r r e n t r o t a t io n a l s t r a in

S y n o v ia l r e a c t io n fa c e t jo in t D is c c ir c u m fe r e n c ia l t e a r s

C a r t ila g e d e s t r u c t io n
r a d ia l t e a r

O s t e o p h y t e fo r m a t io n D is c h e r n ia t io n

C a p s u la r la x it y Instability I n t e r n a l d is c d is r u p t io n

S u b lu x a t io n Lateral N. Ent d e c r e a s e d is c h e ig h t

E n la r g e m e n t o f a r t ic u la r p r o c e s s Central Stenosis o s te o p h y te s
Non operative Treatment of Back Pain
Do nothing

Activity modification

Medications

Exercise and physiotherapy

Braces

Manipulation

Massage therapy

Traction/inversion therapy

Vitamins/Supplements/Diets

Weight control

Every Suzanne Summers sponsored abs

exerciser
 Disc herniation

Ms J.H. 25 y.o. female presented with cauda equina syndrome

 Cauda Equina Syndrome

Sciatica associated with bowel or bladder dysfunction.

Perineal numbness.
Low or Sequestrated Lumbar Disc.
Pressure on S1, S2 and/or S3 nerve roots.

Requires immediate Decompression to

avoid permanent disability.
 Spinal stenosis

Symptoms: Signs:
usually no neuro signs
unilateral radicular pain
look for pulses
bilateral claudication
stress test
better with forward flexion of trunk
better walking uphill Investigations:
rare bowel/bladder involvement XR
CT
Myelo-CT
MRI
 Developmental Dysplasia of the Hip
An in utero Anterior Subluxation of the hip.
Growth in this position produces excessive Anteversion /
Adduction.
Classification: Positional 2/1000
Hereditary 2 x more likely if
mother
Teratologic Arthrogryphosis
50% bilateral, F > M 8:1
Test ALL newborns at birth

Conservative Rx at birth Pavlik, D.diaper

Surgical Rx if resistant
 Legg-Perthes Disease

Osteochondrosis (avascular necrosis)

Proximal Femoral Epiphysis
Necrosis, revascularization, fragmentation, healing
3 11 yrs., M > F 4:1, 15% bilat.
Subluxation laterally, Coxa plana, Coxa magna
Osteoarthritis 50 yrs.
Slipped Capital Femoral Epiphysis

Weakness of the physis of the femoral head allows

medial and inferior slip during the last phase of
growth.
Shortening of the leg, adduction, painless limp and
external rotation contracture.
Observation if mild, fixation if severe
Surgery risks Avascular Necrosis of femoral head
 Ages for Hip Disease

D.D.H. Birth
Septic Hip Birth 11
Legg-Perthes 3 11
Transient Synovitis 3 11
S.C.F.E. 11 - 16
 Osteomyelitis
Acute infection, metaphyseal

90% Staph., 20% mortality

100% growth abnormality

Periosteal elevation, osteolysis

Sequestrum, Involucrum
 Dislocations

The articular surfaces are no longer in contact.

Commonly affects -

Shoulders > PIP joints > Elbows > Ankles.

Often associated with fractures.

Occasionally associated with neurologic injuries

Shoulder Dislocations

95 % anterior

1 % posterior

Luxatio erecta

Medial

Axillary nerve injury

Rapid reduction
Shoulder Dislocations

Conscious sedation.
Traction reduction.
Immobilization.

Recurrent.
Voluntary
Habitual.

Multiaxial instability.
Elbow Dislocation
Posterolateral.

Median nerve injury.

Ulnar nerve injury.

Rapid reduction.

Early mobilization.
Time for a 10 minute break!
1. Talipes Equinovarus is the proper name for :-

a. Flat feet Pes Planus

b. In-toeing Metatarsus Adductus
c. Club feet
d. Knock knees Genu Valgus
e. Wry neck Torticolis
Talipes Equinovarus
congenital deformity of the foot
Equinus, Inversion, Adduction, Supination
2 per 1000 live births
50% bilateral
M >F 2:1
Serial corrective casts at birth
Surgery if resistant

EARLY TREATMENT IS ESSENTIAL

2. A Trendelenburg sign refers to :-

a. Leg length discrepancy

b. Gait abnormality Trendelenberg Gait
c. Knee recurvatum
d. Scoliosis
e. Hip Contracture
f. Abductor weakness
3. All of these are signs of D.D.H.
except :-

a. Limited Abduction
b. Ortolani Sign
c. Asymmetric Skin Folds
d. Galeazzis Sign
e. McMurray Sign Knee Meniscal Tear

Ortolani, Barlow & Galeazzi Signs

4. The most common congenital
spinal abnormality is :-

a. Scoliosis
b. Spina Bifida
c. Torticolis
d. Klippel Feil Syndrome
e. Multiple Hereditary Osteochondroma
 Spinal Bifida

defect of neural tube closure

Lumbar spine, commonly low
2 per 1000
myelodysplasia
Mild to complete paraplegia
Occulta, meningocoele, Myelomeningocoele
Bowel and bladder dysfunction
5. ?
5. Polydactyly
6. ?
6. Syndactyly
7. ?
7. Sprengels Deformity

Omovertebral Bone
8. A 6 year old boy with delayed physical
development, convulsions, tetany,
weakness, blue sclera and bony deformities
is most likely suffering from :-

a. Physical Abuse
b. Ehlers Danlos Syndrome
c. Osteogenesis Imperfecta
d. Multiple Hereditary Exostoses
e. Myositis Ossificans
9. A 6 year old boy with delayed physical
development, a rachitic rosary, weakness
and bony deformities is most likely
suffering from :-

a. Physical Abuse
b. Rickets
c. Scurvy
d. Osteitis Deformans
e. Myositis Ossificans
9. Rachitic Rosary
9. Delayed Ossification
 10. This is :-

a. Osteomyelitis
b. Osteomalacia
c. Osteoporosis
d. Osteitis Deformans
e. Leprosy
11. A child with knee pain has a ____
problem until proven otherwise.

a. Knee
b. Femoral
c. Tibial
d. Hip
e. Patella
12. All of the following are part of the
differential of hip pain in a 6 year old,
except :-

a. Femoral Osteomyelitis
b. Septic Hip
c. Transient Synovitis
d. Legg-Perthes Osteochondritis
e. Slipped Capital Femoral Epiphysis
13. Osteomyelitis in children is
produced by what route of infection?

a. Direct extension from another focus

b. Hematogenous spread
c. Perforating wounds
d. Lymphatic spread
e. Septic hip
14.

Paronychia

An infection of the base

of the nail plate
15.

Felon

A pulp space infection

16. All of these are findings of a
herniated L5-S1 disc, except :-

a. Absent Achilles reflex

b. Lateral foot numbness
S1 Nerve Root
c. Sciatica
d. Low back pain
e. Extensor Hallucis Longus weakness

L5 nerve root
17. Avascular necrosis of the femoral
head is associated with all of the
following except :-

a. Steroid use
b. Alcohol
c. Deep sea diving
d. Lipid storage disease
e. Diabetes
18.

8 year old boy

What is the
Diagnosis?

Legg Perthes
Osteochondosis
19. Diagnosis?

Gout
20. What is this deformity?

A Diner Fork Deformity

21. Probable Diagnosis?

A Colles Fracture
21. Colles
Fracture
 21. Colles Fracture

distal radial fracture

FOOSH
occurs at all ages
commonly 60 yrs. +
osteoporosis
intra-articular
CR & K-Wires
External vs Internal Fixation
22. Diagnosis? :-
22. Diagnosis? :- A Scaphoid Fracture
23. The common complication
of this fracture is :-
23. Proximal pole Avascular Necrosis
due to a Scaphoid Fracture
24. This is a :-

a. Buckle Fracture
b. Greenstick Fracture
c. Stress Fracture
d. Pathologic Fracture
e. Growth Arrest line
 24.
This is a :-
a. Buckle Fracture
b. Greenstick Fracture
c. Stress Fracture
d. Pathologic Fracture
e. Growth Arrest line
25. Is this fracture treated by Closed or
Open Reduction?
25.

ORIF
25. Fractures of Necessity
26. What is the Diagnosis?
26. Posterolateral Dislocation of the Elbow
26. Reduction by traction.

TRACTION
27. What is the Diagnosis?
27. Anterior Dislocation of the Shoulder
27. Reduction by traction

Traction
28.

This is a :-

a. Supracondylar #
b. Olecranon #
c. Dislocation
d. Forearm #
e. Radial Head #
28. Supracondylar Fracture
29. The complications of a
Supracondylar fracture in children
include all of the following except :-

a. Malunion
b. Volkmanns Ischemic Contracture
c. Compartment Syndrome
d. Cubitus Varus
e. Peripheral Nerve Injuries
f. Pulmonary Fat Embolus
30. The only sign of a Compartment
Syndrome that is always present
is :-

a. Pain
b. Pallor
c. Pulselessness
d. Paresthesias
e. Paralysis
31. Compartment pressures
indicating the need for fasciotomy :-

a. 0 15 mms. Hg
b. 15 25 mms. Hg
c. > 25 mms. Hg
d. > 50 mms. Hg
e. > 75 mms. Hg
32. A 20 yr. old male with a fractured
femur has findings of confusion,
tachypnea and conjunctival petechia.
The most likely diagnosis is :-
a. Pneumonia

b. Pulmonary Fat Emboli

c. Cerebral Contusion

d. Cardiac Contusion

e. Transient Stress Reaction

35. What fracture is this?

A Fracture of the Humerus

35. The commonest complication of this
fracture is :-
35. A Radial Nerve Palsy
36. Does this fracture require surgery?

Yes, it is a Traction
Injury and cannot be
reduced and held
closed.
37. This patient
most likely has a
fracture of the
.?

Right Hip Fracture

External rotation
Shortening
Flexion
A Sub-capital Hip Fracture
38. All of the following are complications
of this fracture except :-
a. Malunion
b. Avascular
necrosis
c. Fat emboli
d. Non-union
e. Thrombophlebitis
38. Blood Supply of Femoral Head
38. Save Head versus Replacement
 38. Subcapital Hip Fractures
Garden Classification
Properties

1. Avascular Necrosis - 30%

2. Malunion - 30%
3. Non-union - 30%
4. Surgery required
5. Older population
6. Pathologic - Osteoporotic
39. Whats the Diagnosis?
39. Intertrochanteric Hip Fracture
39. Intertrochanteric Fractures

Properties

1. Varus deformity
2. Well - Healing
3. Traumatic + Osteoporosis
4. Surgery required
5. Mid-range Age population
40.

Surgery
or not?

Yes, Subluxation of
the Talus due to
rupture of the Distal
Tibio-fibular
Syndesmosis.
41. Surgery or not?

Yes, Unstable
Bimalleolar
Ankle Fracture
42. What is the approach to this fracture?

23 y.o. male
Basketball injury
Open fracture
Numbness
dorsum of toes
42.

Reduce dislocation
Sterile dressing
Splint extremity
Re-check NV status
IV Antibiotics
Tetanus
Surgery
43. A 45 yr. old male, who was previously in good
health, has sudden onset of transverse low back pain
and right sided sciatica to his foot, after chopping
wood at the cottage. Upon arising the following morning,
he notices numbness on the outer border of his
right foot and some weakness in the right leg. He
has no bowel or bladder problems.

The most likely diagnosis would be:-

a. Lumbar Muscular Strain.

b. Herniated Lumbar Disc.
c. Herniated Lumbosacral Disc.
d. Cauda Equina Syndrome.
e. Spinal Stenosis.
44. Your initial approach to this problem
would include some or all of the following:-

a. Bedrest.
b. Anti-inflammatories.
c. Muscle Relaxants.
d. Spinal X-rays.
e. Physiotherapy.
f. Orthopedic/Neurosurgical referral.
g. CT-Myelogram or MRI
h. Discectomy
45. During the work-up for this problem, the
patient complains that he has unaccountably soiled
his underwear, without knowing it. Your response to
this would be to:-

a. Reassure the patient that this is not serious

b. Order an urgent MRI
c. Get an urgent referral to Neuro/Orthopedics
d. Place the patient on immediate bedrest.
46. Which of the following signs and
symptoms are consistent with a torn
medial meniscus of the knee:-

a. Inability to squat

b. Pain on descending stairs

c. Locking

d. Recurrent effusions

e. All of the above.

47. A 35 yr. old male falls jogging and sustains an
undisplaced lateral malleolar fracture of the ankle. He is
treated in a Below-knee Walking cast, but returns to the
ER 24 hrs. later complaining of increased, persistent, burning
pain at the ankle.
Your initial response to this situation would be :-

a. Re-X-ray the ankle.

b. Remove the cast.

c. Measure the compartment pressures.

d. Instruct the patient to elevate the limb and prescribe an

anti-inflamatory.
48. The most common dislocations of
the shoulder are:-

a. Medial.

b. Posterior.

c. Luxatio Erecta.

d. Anterior.
49. Metastatic lesions to bone, of
the following tumours, usually
produce lytic defects except:-
a. Thyroid.

b. Pancreas.

c. Prostate.

d. Kidney.

e. Lung.
Th - Tha Thats all folks!