ORTHO Booklet 427-B1 Final

Orthopedic Booklet 427-B1
427
B1
ORTHOPEDIC
BOOKLET
STYLING OF 425&426 BOOKLET + NOTES

ADDING NOTES STYLED BY


Part 1


Part-1
INDEX

= L.1: Back & Neurological Examination
= L.2: Congenital Dislocation of the Hip (CDH)
= L.3: Cerebral Palsy
= L.4: CHRONIC SPECIFIC BONE INFECTION
= L.5: COMMON HIP DISORDERS
= L.6: Common UL & LL injuries
= L.7: Congenital Talipes Equino-Varus (Congenital Clubfoot) (CTEV)
= L.8: Knee examination
= L.9: Lower Limb Fracture & Dislocation
= L.10: Mechanical Disorders of the Spine
= L.11: Metabolic Bone Disorders

L.1: Back & Neurological Examination

Dr. Saadeddin
Which Patients?
1- Back Pain ( Leg Pain).
* back with leg pain sciatica pain.
2- Back Deformity.
3- Neurological symptoms of lower limb.
4- Back Injury.
History:-
Differentiation bet. Mechanical (come with moving or certain position & its common) or non mechanical
(can come with rest)?
How much is affecting the patient? (Like in job? or pray with sitting in chair?)
Night or nocturnal pain? Can come with infection or inflammation or tumor (serious)
Coughing or sneezing? IAP intraspinal pressure back or hip pain
Does it radiate to leg? Where to?
Does it effect urination?
Acute- chronic- recurrent? Chronic more than 6 months
N.B: there are specific Qs in joints like if the knee is giving way? If the patient has limping effecting hip joint?
Examination:-
1- Examination whilst standing out of bed.
2- Gait observation.
3- Examination in supine position.
4- Examination in prone position.

Patient presenting with deformity

Patient presenting with Back & Leg Pain ((sciatica pain))
Intervertebral disc prolapse compress one or more nerve root


Check level of shoulders (alined)? Check level of scapula? Check level of iliac crest? Check asymmetrical skin
creases? Relation of upper limb to the trunk & pelvis?
* The higher the deformity the more obvious.
* Kyphosis (high antroposterior curvature of the spine).
* There is physiological kyphosis.

Back Inspection (standing)

Back Inspection (Forward Flexion)

* Have shortening in legs.
* Scolitic telt, the deformity will disappear with forward flexion.
* But if there is real deformity, will appear with forward flexion &
we measure leg length.

* It indicates the amount of pain.
* May have infection or tumor.

* Patient with scoliosis sometimes they seem to
have kyphosis because when the vertebrae rotate
they make ribs angle appear as hump.


Back Inspection in LBP: back pain mainly in
lower part opposite to deformity which
mustly inspect from occipit to meatal??
)whole back)
In inspection: whole back for deformity,
color, denting, hair, scars, rarely we see
swelling or redness
o it is rare to see inflammatory
changes (redness, swelling,
temperature) on the surface
because the structure very deep we
can detected inflammation by X ray
(like in paravertbral abscess)
Palpation:
o iliac crest in back at level of L4-L5
o We can just palpate the tip of spinous process, intraspinous ligament & paraspinous muscle
o Compress skin denting in level of S1-S2
o Middle of buttock (sciatic nerve course awe cant palpate the nerve it is cover by thick muscle like
gluteus maximus, medius, minimas)
o N.B: what are the nerves that we can palpate? 1.common peroneal nerve behind head of fibula 2.
ulnar nerve behind medial epicondyl
o we dont palpate for temperature bec. Structures are deep

Examination of forward flexion
Movement: (in all directions). Most imp. is flexion
Flexes forward extend backward - laterally to right &
left
Normally patient can bend until fingers reach 10cm from
floor (90 degree) where finger reach malleoli without
pain
Fingers reach mid of the tibia with bending 60 degree
Fingers reach knees a 45 degree
Fingers reach mid thighs a 30 degree
Hip pain less back flexion.

Examination of Lateral Flexion

Pt can bends until 30 degree laterally or reaches knee
Rotation not affected by disclination
But will affected by OA because rotation depends on facet joints


Examination of Back Extension
o Pt can extends 30 degree
Examination of Rotation
o Hold pt hand then rotate if pt is uncooperative Ask pt to sit down to fix pelvis then ask him to
rotate.
o While rotation:
There is Pain in OA.
No pain in herniation.
Standing on Heels
o Gait test:
Ask pt to Walk in tiptoe and on heel.
If he can walk in his heel, the nerve root
(L5) which is supple the three muscles
that acting to left tiptoe is intact. If he
can't he has weakness in L5.
The muscles are:
Tibilis anterior.
Extensor halluces longus.
Extensor digitorum.
In bed we examine L5 by asking the pt to left tiptoe
against resistant.
Standing on Tiptoes
B. And to walk on tiptoe we need gastrocnemius &
soleus attached to achilles tendon. the main root is S1
examine by ankle jerk if pt in bed.
N.B:
Limping in one side = Trendlenberg gait
Limping in two side = wide gait
See if the pt has analgesia gait

Back Examination in Supine Position
Does not include back inspection
SLR (straight leg raising test) and Lasague maneuver should be done
Test the sensation (Dermatomes)
Test muscle power (Mainly extensor hallouces longus)
Test Reflexes


SLR (Straight Leg Raising) Test:

Left leg with straight knee.
Very imp. For back Ex esp. in pain.
Other name is sciatic nerve stretch test.
Done actively & passively at the same time.
Start with leg that doesnt hurt or hurt less.
SLR: 0-80 degrees (ve = no pain)
For stretching in sciatic nerve.
Come with Hip pain, knee pain, infection, fracture in femur, osteomyeilitis
If pain appear in left other leg also acrossed leg pain. This indicates large disc herniation.

Lasague Maneuver:
1. Confirmatory for SLR (same angle).
2. OA, infection at hip will excluded.
3. To catch malingering pts.

Sensory Testing: Dermatomes
Thumb C6 Small finger C8
Nipple T6 Umbilicus T10
Thigh: upper (bellow inguinal ligament) L1, mid L2,
lower L3
Calf: medial L4, lateral L5 Foot: lateral S1,
medial L5
Skin between big toe & 2nd toe L5
In behind mid line upper calf and lower thigh > S2
Saddle area = Perianal area = Genital area supplied by
S3-4.
He will have problem in passing urine & stool, if he has
cauda equina compression or spinal cord compression

L4 & L5 Lesions

diffuse anesthesia indicates either
an extensive multiple roots
compression (cauda equina
syndrome) or a malingering
patient.

L5 & S1 Lesions

L5& S1 compress S1 cause
weakness of ankle jerk.
L4 & L5 disc compress L5 root
cause lower back pain extend to
lateral thigh & calf, numbness in
bet. Big toe & 2nd toe, weakness
in extensor halluces longus,
ankle jerk normal.

Investigations in Back Examination:-
Plain X rays: AP, Lateral, Oblique, Cone View &Tomograms (rarely used).
Blood Tests: CBC, ESR, Bone Biochemistry (Ca, phosphorous, alkaline phosphatase).
N.B: we found APT high in liver disease and bone destruction in newbone formation.In children we
found it high.
Ct scan.
Myelogram, Radiculogram.
MRI (golden invest. in back).
Biopsy (CT guided or Cannulated trocar under fluoroscopy).


Plain X-ray: AP & Lateral (first to do)

Plain X-ray : Oblique 45 degrees

Terry Dog & Scotty Dog appearance


Myelogram & radiculogram

Radiculogram Left L5 Root Compression

CT Scan: (Spondylolysis) = Defect in Pars Interarticularis


CT: Intervertebral Disc Protrusion

CT Myelogram
Rarely used because of infection, pain from injection.
We use instead of it MRI.

MRI Lumbar Spine: golden standard
Use in instability vertebra.
We do flexion and extension to decide how to manage


Isotope Bone Scan (Tc99m)
If there is high uptake maybe infection, fracture, tumor (10 times tan normal)
There is no uptake disc prolapse.

Closed Vertebral Biopsy
Be careful not to enter too deep we will injure anterior structure like aorta or IVC.

Muscle Power Evaluation:-
Certain muscles at lower or upper limbs.
We test Muscle Power NOT range of joint movements!
We give result by grades from 0 5:
0 paralysis.
1 fasciculation.
2 with gravity.
3 against gravity.
4 against light resistance.
5 against higher resistance (normal).

If he can flex without resistance >> at least 3
If he flex with little resistance >> at least 4
If he flex with high resistance >>at least 5


extend knee
other tests:
o hamstring muscle test >>gluteus medius >> abduction


L.2: Congenital Dislocation of the Hip (CDH)
425 Notes
Definition:
A progressive deformation of previously normally formed structures during the embryonic period.
Not a malformation arising during the period of organogenesis.
The most common disorder affecting the hip in children.
spectrum of diseases (abnormalities) of the hip with different etiologies, pathologies, and natural
histories affecting the proximal femur and acetabulum.
Initial pathology is congenital, progresses if untreated.
Does not always result in dislocation.
CDH nomenclature:
CDH congenital dislocation of the Hip
DDH Developmental Dysplasia of the Hip.
CDH Congenital Dysplasia of the Hip.
! CHD: congenital heart disease
CDH spectrum (abnormalities):
Teratologic hip:
The worst type.
There is fixed dislocation.
Occurred prenatally.
Usually associated with other major congenital anomalies.
Dislocated hip:
Head of the femur is completely out.
May or may not be reducible.
Subluxated hip:
Head of the femur is partially in.
Unstable hip:
Femoral head can be dislocated.
Acetabular dysplasia:
Shallow acetabulum.
Head of femur is subluxated or in place.
Epidemiology:
Hip instability at birth: 0.5 1 %, and 50% of them will
improve.
classic CDH: 0.1 % of infants
Mild dysplasia: substantial
Common.
Contributing to adult osteoarthritis.
Up to 50% of hip arthritis in ladies has underlying hip
dysplasia
Etiology: It is a multifactorial disease.
A. Physiologic factors:
Ligament laxity (the most important factor), due to:
Hormonal: (estrogen, relaxin) in females,oxyten.
N.B. relaxin: it's receptor are found in girls, may be that's why girls are more affected.
Familial hyperlaxity: mild- moderate- due to an inherited disease e.g. Ehlers Danlos syndrome.
(Common in SA up to 10%)
! relaxin: its receptors are found in girls, may be that's why girls are more affected & it's effect is by
increase laxity of ligament

Area Incidence per 1000
Canadian Indians 188.5
Hungary 28.7
Uppsala, Sweden 20
USA Caucasians
Blacks
15.5
4.9
Malm, Sweden 2.18
Chinese, Hong Kong 0.1
Bantus, Africa 0.0 among (16678)

B. Genetic factors:
Gender:
Female > 4 6 X more than males.
Twins:
More common in monozygotic (38 %).
Dizygotic 3 % (similar to siblings).

C. Mechanical factors:
O Prenatal: increased intrauterine pressure.
Increased intrauterine pressure
Breech position:
In utero, The knees are extended and the hip is flexed.
2-4 % of births born in breach presentation.
16 % of breech infants born with CDH.
Oligohydramnios (lack of amniotic fluid).
Primigravida (women who is pregnant for the first time).
Congenital knee recurvatum (hyperextention) or dislocation.
Metatarsus adductus.
Torticollis.
O Postnatal:
Swaddling (strapping): / /
The hip is adducted and knees extended.
It is proven experimentally and statistically.
Common in American Indians, Eskimos and Saudi Arabia.
Mechanics: hip adduction and extension.
D. Patients at risk:
Patient with positive family history increases risk 10 times more.
A baby girl increases risk 4-6 times.
Breech presentation increases risk 5-10 times.
In torticollis, 10-20 % of cases may be CDH.
Foot deformities: metatarsus adductus and calcaneovalgus (signs of intrauterine crowding).
Knees deformities: hyperextension and dislocation (associated with teratologic type).

N.B. When risk factors are
present, the infant should be
examined repeatedly and the hip
should be imaged by U/S or X-ray.

Affected At risk Risk
One sibling Siblings 1 in 17 (6%)
One parent Children 1 in 8 (12%)
One parent, one
sibling
Children 1 in 3 (33%)
2
nd
degree
relative
Nieces,
nephews
1 in 100

Clinical examination:
The infant should be quiet and comfortable.
A. Look:

- External rotation attitude.
- Contour in the both lateral
side of the hip.
Wide perineum bilaterally
when putting the legs
together
Asymmetrical thigh folds
Commonly posterior, can be
anteriorly
Shortening (not in neonates)
by Galeazzi sign (difference in
knee height)
Flex knees, heels together
B. Feel:
Empty groin.
Weak femoral pulse because can't pressed against bony part.
C. Move:
Hip instability in early infancy.
Limited hip abduction in flexion later infancy (if <60 on both sides request imaging--). (careful
in bilateral)
D. Special tests:
O Thomas test (for fixed flexion deformity):
Normally, fixed flexion deformity (FFD) is appearing in early infants and disappears later in
life.
This is because the neonate in uterus are in FFD normally
Normal FFD:
In newborns 28.
At 6 weeks 19.
At 6 months 7.
At 1 year should be completely disappear.
It is abnormal if:
There is no FFD in neonates ? CDH
There is FFD in adults.
O Instability test (Ortolani/ Barlow test):
- Ortolani test:
Feel clunk (instability), not hear click.

Flextion abduction bushing trochanter in


- Barlow test:
Reverse Ortolani.

Adduction pushdown by thumb femur
laterally
- Hamstring stretch sign:
Flex hip and knee 90 each.
Keep hip flexed and gradually extend the knee.
Normally a resistance is felt towards the end of knee
extension caused by the hamstrings which are pulled from
both ends.
In cases of CDH (also in hyperlaxity), no resistance is felt
when the hip is dislocated, the origin of the hamstrings are
not pulled by hip flexion.
- Trendelenburg test (in the walking child and adult):
Note the unilateral / bilateral (waddling).

Age Appropriate tests
Neonates
(up to 2-3 months)
Ortolani / Barlow
Thomas test
Infants (>2-3 months)
Limited abduction
Shortening (Galeazzi)
Hamstring stretch sign
Toddlers
Limited abduction
Shortening (Galeazzi)
walking
Trendelenburg


Screening program:
Clinical screening proven to be effective.
Performed by trained personnel.
Must be DYNAMIC with periodic examination till walking.
Adjunctive use of U/S -controversial-.
Incidence of hip instability declines rapidly to 50 % within the first week of neonatal life.
Better to delay u/s screening:
Older than 6 weeks.
Those at risk only by history and clinical exam:
1) Leg laxity.
2) Female.
3) Breech position.
4) Torticollosis.
5) Family history.
Investigations:
Ultrasound (u/s):
Too sensitive.
Detect a lot of hip anomalies most of which would develop normally.
Operator dependant.
U/S referral criteria:
If hip normal: no need
If hip is clearly unstable: no need
If suspicious or patient at risk: U/S is appropriate
Radiography:
Not reliable: in early infancy (because the hip still cartilaginous).
Reliable: by the age of 2-3 months.
AP view:
Neutral position.
Drew reference lines.
1) Horizontal line : at tips of iliac bone,
2) Peripendicular line : from acetabular edge to,,,,,,,,,
3) Acetabular line: angle should be < 30
4) Vertical line : b/w hip &horizontal line.
Detect acetabular index: in early infancy (if <30 normal, >40 abnormal).
<30 : normal
30 -40 : questionable
> 40 : abnormal
Von Rosen view: 45 abduction.


Treatment:
Aims:
Obtain and maintain concentric reduction in an atraumatic fashion without disrupting the blood
supply.
Method depends on age, so should be detected EARLY.in order to have good prognosis.
The earlier started, the easier the treatment the better the results.
Hip instability in the neonatal period ((1
st
two weeks))
Most hip instability improves spontaneously in early infancy, so just
observation.
Treatment modality:
observation
Double/triple diapers (often inadequate, therefore it is
ineffective)..
Pavlik harness.(( dynamic, effective,& safe): hip abducted & flexed-
-- knee flexed.

CDH in birth 6 months of age patients:
At this age, the hip instable and dislocatable and Ortolani/Barlow
test is positive, so it can be reduced by conservative manners.
Hip is dislocatable and reducible
Treatment modality:
Should be actively treated until hip is normal clinically and
radiographically
Pavlik harness (for 6 weeks at least).
Hip spica cast: cast covering trunk & limb.
Other devices:
Frejka pillow.
Craig (Ilfeld splint).
Von Rosen splint.
The splint should be not a soft abduction splint because it is not much
enough, also not a rigid splint to avoid the risk of AVN (avascular
necrosis).
CDH in 6-12 months patients:
Initially non-operative treatment by closed reduction.
The closed reduction performed under general anesthesia then
immobilization in hip spica cast.
Avoid severe abduction and frog position.
If close reduction not succeed otherwise needs open reduction.
Must be stable and concentrically reduced otherwise needs open reduction
CDH in 12-18 months patients:
Closed reduction: possible when the hip is stable and concentrically reduced.
Open reduction: probable when hip is unstable or not concentrically reduced, and arthrography is done.
CDH in patient above 18 months in age:
Open reduction with acetabuloplasty.
Also femoral shortening if it is high.
CDH in above 3 years of age patients:
Open reduction
acetabuloplasty
and femoral osteotomy for shortening

Pavlik harness
Hip abducted & flexed
Knee is flexed

CDH in patients above 8 years:
Open reduction, acetabuloplasty, cutting 3 bones and femoral osteotomy.
In Summary:
- complex multi-factorial, endemic- treatable
- Dr's awareness and health eduction
- Screening programs are needed
- Learning proper examination methods
- Identify at risk groups: repeat examination and imaging
- Efficient referral system
- Proper management in referral centers

L.3: Cerebral Palsy
Definition : non progressive insult to immature brain lead to brain damage in special area
Non-progressive cerebral damage occurring before brain maturation (1-2 years) resulting in muscle
weakness, spasticity and other symptoms e.g. mental retardation.
The incidence is about 0.5-2 per 1000 live births in premature delivaries.
The insult is non-progressive./the disease is progressive.
Causes:
Classify the causes according to the birth
Prenatal( ):
Maternal disease (toxaemia).(e.g. : Rhesus incompatibility)
Cerebral haemorrhage (due to any antibodies transmission or trauma) or infarction.
Inborn error of metabolism.
Perinatal( ):
Obstructed labour (most imp and common) which lead to respiratory complications i.e. hypoxia or
respiratory distress.
Perinatal infections.
Postnatal ( ):
Infection, e.g. meningitis (imp).
Violence i.e. trauma.
Prolonged convulsions which lead to hypoxia
N.B ( not any convulsion can causing cerebral palsy but the respiratory problem that occurring during
this convulsion lead to decrease of the O2 supply of the brain which is causing the cerebral palsy )
Classification: (imp)
A. Topographic classification:
Diplegia: ( more common )--
affection of all limbs but ( lower > upper)
Paralysis affecting symmetrical regions on both sides of the body.
Predominantly involving the legs, but the arms can be involved but to a lesser degree.
Most patients eventually walk.
Tetraplegia (quadriplegia):
Weakness or paralysis of all four limbs with trunk affection .(upper=lower)
Arms and legs are affecting equally, and the trunk also affected but to lesser degree--.
High mortality rate.
Most patients are unable to walk and their IQ is low.
Hemiplegia:
Paralysis of one side of the body ( upper Rt , upper Lt , lower Rt or lower Lt).
Upper limbs affected more than lower limbs--.
There is spasticity.
Patients eventually walk.
Bilateral hemiplegia
affection of all upper limbs But ( upper < lower)
Paraplegia.( lower limbs only is affected)
Monoplegia.(one limb is affected)
Triplegia.( 3 limbs , usually 2 lower limbs with one upper limb )
N.B. :pt with 4 limbs affected , arms more than legs bilateral hemiplegia NOT diplegia because arms are
affected more than legs.


B. Physiological classification:
Spasticity:
Commonest (50-60 % of cases).
Most important for the orthopedic
surgeon.
Increased muscle tone (Jack Knife
Spasticity)or(klasp-knife spasticity).
Slow restricted movements.
Increased reflexes.
Babinski sign is +ve.
Muscles is spasm and it can response to
surgical treatment( imp)
Athetosis:
20-25 % of cases.
Occur following kernicterus (deposition of
bilirubin in the gray matter of the brain
and spinal cord, especially the basal
ganglia, accompanied by nerve cell
degeneration).
Involuntary, uncontrolled slow
movements.(at rest)
Normal reflexes.
There is muscle rigidity or tremors.
Surgery is contraindicated. --Why??
o Because after the correction of
deformity become reversion of
deformity. e.g. (when pt has flexion
deformity of the elbow after surgery
has hyperextension deformity that is
more cribbing)
Ataxia:
1-5 % of cases.
Inability to control movement when they start(but not at rest).
Intention tremor.
Nystagmus.
Unbalanced gait.
Surgery is contraindicated.--
Rigidity:
5-7 % of cases.
Lead pipe rigidity.
Can be operate but rarely
Mixed type;: (in quadriplegia )
A combination of spasticity and athetosis with whole body involvement.
Usually can do surgery.
Can be operate but rarely


*Presentation:
Deferent from type to another according to severity of the disease and diagnosis so, there are no specific
features so, the cerebral palsy has wide results.
N.B:
Types of gaits in cerebral palsy:
1. tip toe waking = equines >> due to spasm in tendon of Achilles >>> compensate this deformity by
hyperextension of knee-recervatum-
Rx: surgical treatment
2. in toeing gait: due to internal rotation of the hip
Causes: increase of anteroverion , hip deformity, femur intorsion , tibia, foot
3. sesoring gait : due to adduction deformity
Planter flexion = flexion
dorsiflexion = extension
*Dx: By pediatrician
Deformities: (more obvious when the child attempts to stand or walk)
In general , any joint the density of deformity to ward >>
1-Flexion
2-Internal rotation ( pronation)
3-Abduction
Upper limb: (not common , no need to surgical treatment just physiotherapy )
Shoulder Adduction / flexion / internal rotation
Elbow Flexion
Forearm Pronation
Wrist and fingers Flexion
Lower limb: (MORE COMMON)
Hip Adduction / flexion / internal rotation
Knee Flexion
Feet Equinus (planter flexion; walking in tiptoe) / varus or valgus may be because of weight
bearing.-
Gait Scissoring gait,, because of adduction .
Ankle inversion ,planter fexion.
Spine Kyphoscoliosis (kyphosis = flexion , scliosis = lateral bending, lordosis= extension)
Management:
Aim of treatment:
As independent as possible.
Avoid pain (hip arthritis).
Maintain sitting posture and spinal stability.
Social benefits.
Multidisciplinary:
Orthotics before and after surgery.
Physiotherapy and Occupational therapy.
Orthopedic surgery.
Neurosurgery and pediatric neurology.
Speech therapy.
Physical(Exercise) therapy:
Start early (1
st
month) when suspected.
Qualified physiotherapist (parents).
Prevent contractures by applying splint (orthosis)>> usually during sleep-- .
Develop Coordination.
Mental exercise.
Use orthotics, plaster of Paris or casts if needed.
During follow up of pts with CP,
The most imp.
X-rays are spine x-ray


Surgery:
Best in spastic hemiplegics and severe deformities--
Contraindicated in athetoid and ataxic.
Goal of surgery:
Decrease spasm (muscle).
Release of contractures( soft tissue) if not respond to physiotherapy.
Correct deformities.
Rebalance muscles.
Stabilize the joints.by fusion through (arthrdesis)
Options of surgery:
Neurectomy (limited).
Tenotomy (cut of some of muscles tendons).
Tenoplasty (tendon elongation for tightness , usually by using Z-lengthening manner).
Muscle lengthening (recession).
Tendon transfer.
Bone surgery to correct position and stabilize joints by osteotomy (cut of bone)or fusion.
Spinal surgery.
Intramuscular botulinum toxin:
Temporarily reduces dynamic spasticity.
It is thought that its use promotes normal muscle growth and avoids the development of soft tissue
contracture.

Image:
Child with sever hip flexion with adduction and knee flexion without knee valgus
Examination :
1- Thomas test:(very imp)
- For flexion deformity of the hip
2- Asse the range of abduction and adduction):
- The pt lying dawn with hip extension then you try to abduct his legs and measure the limited range of
movement
3- Internal rotation:
- Look to the direction of the patella .
- N.B( in cerebral palsy there is no any rang of ext.rotation )
4- Popleatal test:
- Putting the hamstring muscle under tension by hip flexion 90 dgree then knee extension >> in this
case the pt can not extend the knee fully
5- Foot :
- Try to correct the equinus by dorsiflexion if corrected >> dynamic equines in the tendon of achills
A- with knee flexion ;
- If the equinus is corrected >> effect on gastrocnemius muscle (origin>> above the knee)
B- with or without knee flexion :
- the equinus is not corrected >> effect on soleus muscle
- ( origin.>> below the knee)
How to differentiate between varus and flexion deformity of the hip ??
o Put the patella in normal position (direct forward)
o If there is no varus >>> flexion deformity
How can you identify internal rotation deformity by inspection??
o Look at the patella (knee cap) >>> directed laterally
o ( )
o Intoeing


L.4: CHRONIC SPECIFIC BONE INFECTION
TUBERCULOSIS
BRUCELLOSIS
FUNGAL
SYPHILIS
TUBERCULOSIS
THE BASIC MICROSCOPIC LESION; THE TUBERCLE
FIRST DISCOVERED BY THE FRENCH PHYSICIAN LAENNEC (1781-1826) WHO DIED AT THE AGE OF
45 BY TB.
ESTIMATED 30 MILLION TB PATIENTS WORLD WIDE.
1 -3 % (300 000 1000 000) HAVE SKELETAL INVOLVEMENT
TUBERCULOSIS OF BONES AND JOINTS
TB Bacilli lived in symbiosis with mankind since time immemorial. Recorded in ancient Egyptian
mummies
Still common in developing countries
REDUCED INCIDENCE OF TB DUE
TO:
IMPROVED LIVING STANDARDS;
SANITATION, HYGIENE, NUTRITION
B.C.G. VACCINE (80% PROTECTION)
TUBERCULOSIS BACILLI -------------->

FACTORS FAVORING LOCALISATION:
1. BLOOD SUPPLY AND STAGNATION
2. LOCAL TRAUMA; HAEMATOMA?
3. LOCAL STEROIDS ?
4. Immunity infection chance
TB PATHOLOGY
Secondary to other primary TB lesions (Pulm., GL, Renal, LN)
Route of spread:
- HAEMATOGENOUS ****
- DIRECT (much less)
- bone to joint
- soft tissue to bone
THE PRIMARY LESION
QUIESCENT ( very slowly growing )
ACTIVE: (Apparent, Latent)
INFLAMMATION HYPEREMIA - OSTEOPENIA
TB FOLLICLES (TUBERCLE):
- LYPHOCYTE MONOCYTES
- ENDOTHELIAL CELLS
- LANGHANS GIANT CELLS
COALESCE
CASEATION LATER
GRANULATION TISSUE (cause joint granulatin)
BONE DISTRUCTION
SINUSES

Groups At Risk
Non affluent countries
Over growing
malnutrition, poor
Affluent countries
Immune Defficient
Steroids antica
Younger Older Age
Musculoskeletal TB
Spine 50 %
Hip 15 %
Knee 10 %
Foot 5 %
Elbow 2-5 %
Hand/Wrist 2-5 %
Shoulder 2 %

TB PATHOLOGY (JOINTS)
SYNOVIAL SWELLING because of GRANULATION TISSUE (not pus or edema)
PERIPHERAL ARTICULAR DESTRUCTION
- NO PROTEOLYTIC ENZYMES
- CENTRAL ARTICULAR WEIGHT-BEARING
AREA PRESERVED at beginning then will
be affected
RICE BODIES
- FIBRIN & ARTICULAR CARTILAGE
INCREASED BLOOD SUPPLY
- OSTEOPENIA
CLINICAL PICTURE
1. AGE
2. INSIDIOUS ONSET very slowly
3. MONO ARTICULAR
4. OTHER LESIONS (pulmonary)
5. FAMILY HISTORY CONTACT
6. GROUPS AT RISK
SYMPTOMS & SIGNS
O Constitutional
- LOW GRADE FEVER
- ANOREXIA
- WEIGHT LOSS
- NIGHT SWEATING
- TACHYCARDIA
- ANEMIA
O Local
Symptoms Signs
1. Pain
2. Night Cries( Child )
3. Swelling
4. Stiffness
5. Ultered Function

1. Wasting
2. Synovial Swelling
3. Tenderness
4. Warm
5. Stiffness
6. Limping
INVESTIGATIONS
- Leucopenia Lymphocytosis
- Anemia
- Raised Esr
- Mantoux Positive
o Not In:
Miliary Tb / Recently Vaccinated/
On Steroids / Reduced Immunity / Fever
O RADIOLOGY
Chest x-ray : all patients
Joints: phemisters triad:
1. Periartic. Osteopenia
2. Reduced joint space
3. Periph. Osseous erosions
Bones:
- Destruction
- Sequestration
- Abscess formation

Bone scan:
mono articular cf: rheumatoid arthritis( not specific)
callium scan infection specific for infection
Ct scan morphology
Mri morphology
+ First , do bone scan , if it is + ve , then do gallum scan because it is specific for infection but the
bone scan only show the abnormality and dont show the cause .


Right carpal bone destruction and
abscess
Case of emergency ? avascular necrosis

Osteopenia + femur sublaxation
(fluid push the femur outside)
Not treated complete dislocation

The bone fused become short and stiff
Soft tissue shadow and reduction of joint
space


Complete destruction of carbal bone and also ulna
and radius
Enalrgment and thining of 5
th
metacarbal bone


DIAGNOSTIC
Aspiration: usually negative
- Afb positive
Histological
Culture : long time ( 6-8 )wks
TB SPINE (POTTS DISEASE) PERCIVAL POTT 1779:
Secondary to other primary
Hematological
- 20% other viscera
- 12% other bones/joints
Two adjacent vertebrae sometimes more than one
Skip lesions in 7%
TB SPINE SURGICAL PATHOLOGY
FIRST THREE DECADES
THORACO-LUMBAR (T12- L1 )
CENTRAL SPINE
- SPARKS POSTERIOR ELEMENTS
- SPREADEDS UP/DOWN ANT./POST. LONG. LIGS.
LESIONS COALESCE COLLAPSE
KYPHUS FORMATION
PARA VERTEBRAL ABSCESS
o CERVICAL : RETROPHARALYGEAL
o THORACIC : P.V. & ALONG RIBS
o LUMBAR : PSOAS ABSCESS
POSTERIOR:LUMBAR TRIANGLE
ANTERIOR: ILIAC FOSSA BELOW ING. LIG.
NEUROLOGICAL COMPLICATION MORE IN THORACIC (NARROWEST CANAL)

First start in the bone then ivolve the disc ( never start in the disc

TB SPINE CLINICAL FEATURES
General:
Insidious onset
Constitutional
Local: pain first indication
o Local referred
Stiffness spasm
Weakness neurological


SIGNS OF TB SPINE
MUSCLE SPASM
KHPHUS GIBBOUS
TENDERNESS
STIFFNESS
NEUROLOGICAL (WEAKNESS -
PARAPLEGIA)
TB SPINE RADIOLOGICAL FEATURES
DISC NOT INVOLVED PRIMARILY
NARROWING OF DISC SPACE
BONE DESTRUCTION
USUALLY TWO ADJACENT
VERTEBRAE
E MAY SHOW SKIP LESIONS (IMP)( YOU HAVE TO
SCAN ALL SPINE)
KHYPUS (IMP CASE)
CT/MYELOGRAM/MRI IN PARAPLEGIA


Destruction and osteopenia CT SCAN SHOW THE LESION

GIBBAUS

SCOLEOSIS

NARROWING THEN DESTRUCTION AND COLAPSE

ALL LUMBAR VERTABRE FUSED TOGETHER


PARAPLEGIA IN TB SPINE
In 10-30% of tb spine
More in thoracic region
Pressure on cord antero lateral
- Motor earlier than sensory
Signs: upper motor neuron
- May start by cord shock
Remarkable ability to recover
- Unless spine injured by trauma
PARAPLEGIA IN TB SPINE CAUSED BY EXTRADURAL PRESSURE
Granulation tissue
Pressure of abscess & caseaton
Sequestrum
Pathological fracture/disloc.
Severe kyphus
Inflammation:
- Toxic edema
- Vascular
MANAGEMENT OF TB SPINE
Usually conservative
- General
- Specific
o Rest
o Immobilise
o Chemotherapy
Surgical
- Diagnose
o Aspiration
- Drain abscess
- Debride
- Decompress
o Anterior
o Antero-lateral
- Stabilise fusion
Most cases of tb spine respond very well to conservative treatment including those with paraplegia
The need for surgical decompression of the cord is limited
When the spine is compressed you have to decompressed dont wait


BRUCELLOSIS
Milk and milk products
Back pain and stiffness
- Muscle spasm
- Fever mild
Sacro-iliac joint (commonest)
Less destructive of tb
Brucella titre (serology is diagnostic)
Antibiotics
- E.g. Septrin oxytetracycline
SYPHILIS
Spirochete
o Treponema pallidum
Congenital syphilis commonest
Chronic osteochondritis
o Periosteitis
o Osteitis
Tibia lesabre tibia
FUNGAL INFECTION
Chronic very low grade
Feet farmers thorns madura foot
Slow destruction
Sinuses granules
Secondary bacterial infection
Resistant to chemotherapy
Needs surgical debridement (at the beginning dont wait)
If advanced may need amputation

FOOT IS COMPLETELY GONE

L.5: COMMON HIP DISORDERS
Dr. Zamzami
(Pictures are not from Doctor Slides, because he refused to give them. All used pictures are from internet)
Congenital causes:
1. CDH
2. Coxa vara
O AP X-ray of the Pelvis:
Ossification center in the left is smaller
Acetabular index more than 30(45)
Shallow acetabulum
Normally the ossification center is below and medial but here is (lateral and above) thats means its
dislocated., if its below and lateral sublaxation.
Disturbed Shentons line(between the supra pupic ramus and the Femur)
CDH:
Dislocated
Adducted
Small ossification center
o crossponds to bigger head(big cartilage)
o no separation
o the head is growing without the control of the acetabulum (grows to outside)
o keeps growing
o Result ,, Coxa Magna (huge Cartilage head of femur)
o And the Acetabulum has nothing to stabilize so it
becomes shallow.
Neck-shaft angle
o Normally its between (135-150)
o Below 135 , Coxa Vara
o Above 150, Coxa Vulga
External Rotation (prominent lesser trochanter and smaller
greater trochanter ) Anteversion , If internal Rotation
(prominent Greater T. and hidden Lesser T.)RetroVersion.
Normally the Greater T. is lateral in position and Lesser T. is
postro-medially.
O Congenital Coxa Vara(since birth):
X-ray isnt obvious before the child starts walking, so they
came late and age of 2 y.o .
Abnormal gait and it gets worse as the child growing, if bilateral
(Waddeling gait)
The growth plate ,Looks like fracture of the Femur but its actually a
fibrous tissue not ossified because its in the same place not displaced.
Rx: cut the bone in certain angle to correct the varus angulation without
touching the angle
changing of the loading characteristics from shear to compression of the
femoral neck
Degenerative Causes:
1. O.A
2. R.A
X-ray features of Severe O.A :
No joint space
Scelrosis
Decrease bone density
From the Tri-radiate cartilage we
make the horizontal and vertical lines.

Osteophytic upper border of acetabulum.
Subchondrial Cyst( under the cartilage).
AP X-ray of the Left hip joint showing (post traumatic O.A):
Moderate O.A
Partialy decrease in Joint space(not complete!)
Subchondral cyst formation
Scelrosis of the Upper part of Acetabulum.
External Rotation (Lesser T. is prominent)
Extra bone Formation(Osteophyte).
AP X-ray of the hip joints Showing (R.A):
Reduced Joint space
Generalized Osteopenia (main key Feature to differentiate between R.A and O.A)
Osteophyte secondary to O.A
Rx: joint Replacement , total hip replacement(Acetabular,head and neck should change)
Perthers Disease:
Idieopathic AVN.( blood supply to the growth center of the
hip (the capital femoral epiphysis) is disturbed, causing the
bone in this area to die)
M>F
5-10 y.o
Pain,limbing.
Affect Head of femur
o Small effect , better prognosis
o Large effect, bad prognosis
o Bilateral ,is the WORSE!
X-ray features:
o Micro small flat head Femur
o Lytic lesions, Scelrosis
o Osteoblast +Osteoclast Remodelling
pahse
o weight bearing on the affected leg the
head become flat with pressure.
o Late complication: irregular flat head of femur( 2 early O.A)
Rx:
o Abduction splint
o If bilateral , worse
Wait until the head of femur heals,
o older pt. fuse the hip (surgery) ,
o bilateral cant fuse in this only case we
replace the whole hip joint.
Metabolic Causes:
1. Slipped Capital Femoral Epiphysis
2. Osteoperosis
Slipped Capital Femoral Epiphysis:
One of the causes of Coxa Vara.
The top or cap of the ball slips off the femoral head
through the growth plate.
In adolescents
M>F
Male(12-17y.o) ,Female(12-14y.o)
No known cause
75% very tall, over-weight and have small Genitalia.

25% very tall, thin and have small Genitalia.
Presents with pain after very mild trauma.
If he is lucky , he presents early to the hospitals and
treated by putting a Screw.
If late, fix it in its position now Results in coxa
vara ,Because if we move it or try to put is back in its
position(Reduce it) , it will cause AVN. , so we do
wedge Osteotomy.

Infections:
1. Septic arthritis of the hip
2. Osteomylitis of the proximal femur
In such case always think of infection and
Tumor, one of the signs of the infection is soft
tissue distruction

Fracture of the hip:
1. Neck of Femur
2. Dislocation of the hip
3. Fracture of the acetabulum.
In 70y.o pt with slight movement , osteoperotic , diabetic and fracture hemi arthroplasty.
Total hip Replacement is Contra-indicated in Traumatic Fracture.

L.6: Common UL & LL injuries
Upper Limb

Diagnosis? Fracture in mid clavicle
Clinical picture? Come with pain,&
we can feel the clavicle
Treatment? Conservative
Surgery is very rare

Figure of 8 bandge

*Diagnosis? Ant. Shoulder dislocation (commonest)
*Clinical picture?( Loss of contour )
*Treatment? Reduction as soon as possible-
immobilization - exercise

Ant. shoulder dislocation Axillary view

Luxation erecta:
Special case of inf. Dislocation
*Humerus is flexed completly

1.What is this? (post. Dislocation of
shoulder)
2.Presentation?(post. dislocation +
partial fracture)

*Bilateral post. Shoulder dislocation
Seen in 1.epilepsy or in 2.electrical shock..
*There is Impaction of head of humerus.
*Reduced under gneral anesthesia.

*Diagnosis? Fracture of neck humerus (not
dislocation) there is downward sublaxation due to
loss of the muscle ton
e
*Clinical picture? Pain, swelling, impaired function
*Treatment?
Complication? Early axillary nerve injury
How to check?
By examin. sensation over deltoid, but he cannot
abduct the shoulder. So, we ask him to te
without movement.

Comminuted fracture of neck of humerus prosthesis Esp. in elderly Hemiarthroplasty
of shoulder treatment

1.After reduction by K wire 2.Short interlocking intramedullary nail
3.Replacement by a prosthesis 4.Fixation by plate

Multiple intramedullary K-wires fixation is the ideal Tx of neck of humerus fracture

*Diagnosis? Spiral fracture of
middle & distal shaft of humerus
*Clinical picture?
*Treatment? Conservative if there
is no radial N. Inj. Otherwise we
do operation to explore.
*Complication? Radial nerve
injury wrist droop

Fracture of proximal shaft
humerus

Spiral fracture of shaft of humerus
Conservative Tx

Comminuted fracture
Treated by internal fixation (by
plate) because of radial nerve injury

U shape slab

Type of # ? segmental fracture
Treated by interlocking nail
(intermedullary nail)

When to use this? External fixator
1.Used in unhealthy skin e.g. open
fracture (most common)
Others: 2.very comminuted fracture ,
3.in critical patient as temporarily


COMPLICATION
Fracture in distal third
shaft of humerus.
this picture is for radial
nerve injury that may
caused by manipulation
Tx: surgery (open
reduction internal
fixation) to explore
the nerve

*Diagnosis? Suprachondylar
fracture of humerus. The common
type is extension (extra articular)
And it is the most around the elbow
in children.
*Clinical picture? Pain, swelling
*Treatment?
*Complications:
early brachial artery injury(most
common)
Late malunion

Tx by 2 K wire +
closed reduction

Complication of surg.
Ulnar nerve injury.


Complications of SCF
1.compartment synd.
Foleman`s synd.
2.bleeding.(artery)
3.iatrogenic injury of
ulnar nerve.

Remember the late
complication! malunion
And which is the common
bleeding
1.Cupitus varus caused by
malunion
MCQ????????
Due to: malunion of growth plate
injury as a result of SCF
2.Flexor contracture

Lateral condyle fracture.(in children) Tx:: open reduction & IF by K wire (Imp.)

1.Post. Dislocation of elbow .
Tx(most common): reduction &
immobilization by cast
2.Posteriolateral dislocation of
elbow. Tx: reduction &
immobilization for 2 day till 2 week
if longer then stifness

3.Interarticular fracture of
olecranon process
Tx: ORIF ( tension band fixation)

1.Radial head fracture
Tx: conservative treatment

2.Radial neck or radius fraction: Tx: conservative
3.Angulated fracture of radial head

Monteggia fracture . Tx: ORIF (rigid fixation by
plate for ulna & radius will spontaneously reduced
so do not touch radius


( montegea )

5.Gaelazzi fracture
Tx: ORIF (rigid fixation by plate for radius &
ulna will spontaneously reduced
6.Fracture of ulna & radius shaft (displaced)
Tx: ORIF (by plate)
If treated conservativlly it will lead to the loss of pronation of
sopination so, it is treated surgically.

Remodling of fracture in children
Tx: don`t touch the head of ulna and correct it the dislocation will be corrected
spontaneously.


*Diagnosis? Colle's fracture (non articular)(MCQ) metaphysic fracture in distal radius
with dorsal displacement
*Clinical picture?
Treatment? Closed reduction & cast or K wire

Comminuted articular fracture of distal radius
*Tx:External fixation
*Complication: osteoarthritis

*Fracture of scaphoid
*1mm displacement surgery by screw
*Not displaced cast & should include
It is difficult to heal b/c of poor vascularity.


LOWER LIMB INJURIES
Posterior dislocation of hip (most common)
If it addicated & internal rotated post. Dislocation of hip

MCQ: one vein is enough.
ant.
most common "early comp."
1.sciatica
2.drop feet
Late complication of fracture dislocation of hip
Complications: AVN, early OA
AVN: most common and late
osteonecrosis.
Dx: decrease post dislocation + fracture

Fracture of neck of femur b/c(intracapsular) so, high risk
of AVN. Tx is replacement if exracapsular then fixation
*In young pt. internal fixation
*In elderly replacement
hemiarthroplasty
Intertrochantric fracture ( extracapsular)
*Dynamic hip screw most common (no risk of AVN)
Comminuted intratrichontric fracture
Typical presentation: shortening &
external rotation
Tx: dynamic hip screw

Comminuted fracture of shaft of femur
Tx: by interlocking plate(ORIF) or IM nail
Grade 2
Classification according to size:
Grade 1 less than 1 cm (able to be close)
Grade 2 between 1-15 cm
From within # skin injury
From without # from outside
Grade 3: subtuped according ot additional injuries.
*if there is puncture wond grade I
*if the wound is larger but ,you can close itgrade II
*grade 3 (III) you can`t close it.
*Comminuted supra + intracondylar fracture
*Tx: hemorthroplasty
*Complication intraarticular #: osteoarthritis , stiffness.
*Clinical pic.: pain, swelling and morthrosis.


Fracture of tibial plateau (medial +lateral)
*In lateral #: is most common & has separation & compression at same
time.
*In medial # : more separation.
*Late complications:
1-OA
2-reduced motion

(bicondylar)Tibial plateau fracture with proximal tibial shaft
fracture Tx: ORIF by plate and screws.
Tibial shaft fracture & proximal fibula fracture
Tx: conservative.

Spiral fracture of tibia (distal shaft),
there is fracture of proximal of fibula
Tx: conservative or may need plate
fixation
Fracture of the distal tibia and fibula
Tx: T or L plate (ORIF) with screw
Called T shaped plate or patle plate???

Fracture of medial malleules ( articular fracture)
Tx: ORIF
Trimalluli fracture (type B)
Classification according to
level of fracture to dismoses
Tx: fixation lateral and medial
malloli.
Types of fracture of ankle:
a) Below syndosmosis
b) At the level of
syndosmosis.

Lateral malleulus fracture (type B)
Tx: by cast
Post.
displaced
Lateral malleulus fracture type
A(below the sendosmosis)

Type C most serious because it's associated
with rupture of sino???? Ligament instability
Tx: always treated by surgery
for fibula #:by plata
For medial malleulus # screw
Type B of fibula above syndosmosis: and
of medial M. at syndosmosis
And disrupted syndsmosis
Sendosmosis is the junction b/w tibia
and fibula.
Type B at the level sendosmosis
Type C above the sendosmosis.

Rupture of medial ligament

Injury to lateral collateral ligament
Most common injury in body
Falling from height
Late complications: 1.OA- 2. stiffness

Varus stress Anterior drawl test
?????
Calcaneal fracture
Subtalar OA after calcaneal
fracture
It one of late complication of
articular
And it is OA
Varus stress test
Type B injury + medial
collateral ligament injury

L.7: Congenital Talipes Equino-Varus
(Congenital Clubfoot)
Dr. Mohamed M. Zamzam

THE NORMAL FOOT
Complex organ that is required to be :
Stable: for supporting the body weight in standing or walking. {most imp.}
Resilient: for walking and running. (shock absorbent).
Mobile: to accommodate variations of surface. (mostly by the subtalar joint)
Cosmetic. (especially in females)
Note: in hand the most imp. is mobility.
In foot the most imp. joint is subtalar joint which make you stand vertical.

CLUB FOOT (talepes equino-virus)
Gross deformity of the foot that is giving it the stunted lumpy appearance.

Definitions:
Talipes: Talus = ankle Pes = foot
Equinus: (Latin = horse) Foot that is in a position of planter flexion at the ankle, looks like that of the
horse.
Calcaneus: Full dorsiflexion at the ankle.
Planus: flatfoot.
Cavus: highly arched foot.
Varus: heal going towards the midline.
Valgus: heel going away from the midline.
Adduction: forefoot going towards the midline.
Abduction: forefoot going away from the midline.
* ankle joint (equines, calcaneus), subtalar joint (varus,
valgus), mid tarsal joint (adduction, abduction).
* mid tarsal joint is composed of 2 joints working together
(calcaneocuboidal, talonavicular joints).


Types:
1- Postural :
Calcaneo-Valgus Equino-Varus
Look for CDH Minor, benign and fully correctable
Tx : leave it alone it will correct itself

- Usually in the children (just after birth).
- Related to abnormal position in utero.
- It is easy to treat (reassurance & mother (manipulation by the mother) hand massage when changing
diaper).
- May take few weeks of days to return to normal position.
- Diagnosed by easily modified to its normal position of the foot by the doctor.
2- Acquired, Secondary to :
- CNS Disease: Spina bifida (mostly), Poliomyelitis, cerebral palsy. {the most imp.}
- Arthrogryposis. (muscle fibrosis secondary to neurogenic problem intrauterine)
- Absent Bone : fibula / tibia.
- Syndromes.
* most important of them are (spina bifida, cerebral palsy and arthrogryposis). So, you have
to examine and do an X-ray for the back in every case.
3- Idiopathic (Unknown Etiology) :
Congenital Talipes Equino-Varus (CTEV).
Diagnosed by exclusion of the postural type (by fully correction), acquired type,
other causes.
Congenital Talipes Equino-Varus (CTEV)
Congenital clubfoot or CTEV occurs typically in an otherwise normal child.

O Etiology :
Polygenic.
Multifactorial : although many of these factors are speculative.
It has familial tendency. (imp.)
Some of these factors are (not imp.):
Abnormal intrauterine forces.
Arrested fetal development.
Abnormal muscle and tendon insertions.
Abnormal rotation of the talus in the mortise.
Germ plasm defects.
Note: examination of the spine is mandatory in any abnormal foot--.
not
correctable

O Incidence:
Occurs approximately in one of every 1000 live birth.
In affected families, clubfeet are about 30 times more frequent in offspring.
Male are affected in about 65% of cases. (opposite to CDH).
Bilateral cases are as high as 30 40 %.
One third in left foot & one third in right foot & one third bilaterally.

Best way to diagnose CTEV is clinical examination
O Geographic Distribution:
Middle East , KSA common.
Mediterranean Coast & North
Africa.
White race.
O Basic Pathology:
Abnormal Tarsal Relation :
- Congenital Dislocation
/Subluxation .
- Talo Calcaneo Navicular
Joint.
Soft Tissue Contracture :
Congenital Atresia
Position: talus in plantar flexion, calcaneus in varus, mid tarsal joint in adduction.

Note:
- primary pathology: when there is abnormal position & normal bone.
- Secondary pathology: when there is abnormality in position & bone.
- You have to treat it at delivery otherwise there will be abnormal bone with time.
- The pathology here takes:( equine inversion forfoot adduction ))
- This will affect all the soft tissue like muscle contracture or laxity &capsular change so,not
correctable.
Adaptive Changes: (10-12 months the start of walking )
Wolffs Law (not imp.)
Every change in the use of static function of bone caused a change in the internal form or architecture
as well as alteration in its external formation and function according to mechanical law
Davis Law (not imp.)
When ligaments and soft tissue are in loose or lax state; they gradually shorten
Bony : Change in the shape of tarsal and metatarsal bones especially after walking.
- bony changes include:
1- very thin navicular (wafer shaped) d.t. compression by the adduction.
2- Big cuboid.
3- Talus shape deformity.
Soft Tissue : Shortening ? Contracture in the Concave Side:
(back of the ankle, medial side of subtalar joint, medial
side of the foot [posteromedially]).
And the structures in the lateral and anterior sides are
stretched and weak.
1- Muscles 2- Tendons
3- Ligaments 4- Joints Capsule
5- Skin 6- Nerves & Vessels (medial ones may lead to neurovalscular compromise with
surgical repair).
In the convex anterior side there will be tension.


Diagnosis: first exclude postural (by correction) then you have either an idiopathic case or neurological (or
secondaries, where you have to exclude the most common cases).
General Examination: Exclude:
Neurological lesion that can cause the deformity Spina Bifida.
Other abnormalities that can explain the deformity Arthrogryposis, Myelodysplasia.
Presence of concomitant congenital anomalies : Proximal femoral focal deficiency.
Syndromatic clubfoot : Larsens syndrome, Amniotic band Syndrome.
Note |: any time the deformity is seen it is automatically called (TEV),but (CTEV) is diagnosed bu exclusion of
any other cause of (TEV).

Spina Bifida = Paralytic TEV
Characteristic Deformity: (from proximal to distal)
Hind foot:
- Equinus (Ankle joint).
- Varus (Subtalar joint). Basic deformity.
Fore foot:
- Adduction (Med tarsal joint).
- Supination fore foot.
- Cavus.
* deformities written in italic are enough.

Hind foot Fore foot

Equinus, Varus Adduction, Supination, Cavus


Findings in physical examination:

Short Achilles tendon.
High and small heel (it is not really small, it is hidden under the ankle joint).
No creases behind Heel (because of the stiff disease deformity of the joint).
Abnormal crease in middle of the foot medially (at the adduction site).
Foot is smaller in unilateral affection.
Callosities at abnormal pressure areas. (after walking usually after 1 year called { adventitions bursitis})--
Internal tibial torsion. {imp.}--
Patella is direct outward (as a compensation for the internal tibial torsion).
Calf muscles wasting d.t. tendo Achilles shortening and lack of motion (indicates the prognosis of the
joint. Severe calf wasting bad prognosis with recurrence of the condition).
Deformities dont prevent walking. {imp.}
The patient walks on the postrolateral or lateral aspect of the foot which cause adventitious
(means in abnormal site) bursa (may infected, ulcerated or calcified with time and becomes painful). This
is the case when the TEV becomes painful.
X-Ray used only for the spine (in the Dx) and to measure some angles of the foot.
Causes of in-toeing gate:-
1. Increase angle of anteversion of femur.
2. Internal femoral torsion.
3. Internal tibial torsion.
4. Metatarsus adductus (or fore foot adduction).
Treatment:
The goal of treatment for clubfoot is to obtain a normal foot (a plantigrade foot that is
functionally normal, painless, and stable over time). A cosmetically pleasing appearanceis also an important goal
sought by the surgeon and the family (sometimes it is the most imp. point for the parents).
best time for the treatment after birth.
Non surgical treatment (conservative, "Ponseti technique"): {the best} Dennis Brown splint
Gentle manipulation
Immobilization:
- Strapping (adhesive blasters) in very young infants. They stop using it
because it causes skin problems.
- POP or synthetic cast.
* POP is better because you can change the position at any time without
causing any pressure sores while with synthetic cast after applying it you
cannot mold it or change its position.
* Synthetic cast can be used after the manipulation (correction of the tibia) because of its lighter weight.
* the cast should be above the knee.

Splints to maintain correction (to support the lateral redundant muscles (peroneii), which were stretched
before the correction):
- Ankle-foot orthosis (AFO): a plastic splint molded to take the shape of the foot. From below the knee
holding the whole foot.
- Dennis Brown splint (common and the best but difficult to use by the mother)
Manipulation and serial casts
Validity, (it can't be valid) up to 1 year.
Technique Ponseti Serial manipulation and casting (weekly for 1 month then every 2 weeks)
Avoid false correction. {the worst thing could happen}by applying the teqnique proberlly.
When to stop? (fully treated in 80% of cases, residual deformity or fail of correction, respectively).
Maintaining the correction (by orthosis or splint).
Follow up to watch and avoid recurrence.
* fail of correction: after 2 or 3 visits without any achievement.

Ponseti technique (not imp.):
1. Always use long leg casts, change weekly.
2. First manipulation raises the 1st metatarsal to decrease the cavus.
3. All subsequent manipulations include pure abduction of forefoot with counter-pressure on neck of talus.
4. Never pronate !
5. Never put counter pressure on calcaneus or cuboid.
6. Cast until there is about 60 degrees of external rotation (about 4-6 casts) .
7. Percutaneous tendo Achilles tenotomy in cast room under local anesthesia, followed by final cast (3
weeks).
8. After final cast removal, apply Normal last shoes with Denis Browne bar set at 70 degrees external
rotation (40 degrees on normal side).
9. Denis Browne splint full time for two months, then night time only for two-four years.
10. 35% need Anterior Tibialis tendon transfer at age 2-3.

Surgical Treatment
Indications:
Late presentation (after 1 year of age).
Complementary to conservative treatment (most of them is tendo Achilles tomotomy)
Failure of conservative treatment.
Residual deformities after conservative treatment.
Recurrence after conservative treatment.
Types:
- Soft tissue bony operations.
Time of surgery--:
- Minimum age is 4 or 6 months.
Post operative care:
- Cast and Dennis Brown splint after the cast.
Follow up:
- To watch and avoid recurrence.
Complications:
- Growth disturbance (d.t. injury of the growth plate), infection and recurrence.

Soft tissue operations: starts before 1 year till correction of all new deformity.
1. Release of contractures (till you reache the normal bone relationship).
2. Tenotomy (cut tendo Achilles usually as complementary treatment) can be done to children less than
1 year of age. Can be done in OPD and with needle.
3. Tendon elongation (tenoplasty, Z-shaped) except in children less then 1 year of age it can't be done.
(called posteromedial release)
4. Tendon transfer.

* for important tendons (like tibialis posterior, flexor hallusis, tendo Achilles, flexor digitorum) do tenoplasty,
while for non important tendons do tenotomy.
* you have to open the capsule of all the joints in the foot (to help you in doing the correction).

* neurovascular compromise is the limiting for your correction. When that happens, do mild correction then a do
gradual correction every week till you reach the appropriate correction.

Bony operations:
Indication: when there is bony adaptation.
Usually accompanied with soft tissue operation.{imp.}
Types:
- Osteotomy, to correct foot deformity or int. tibial torsion.
- Wedge excision.
- Arthrodesis:
= fusion of the one or several joints.
It is a salvage operation to restore shape.
usually after skeletal maturity to avoid disturbance of the
The commonly used fusion of joint is "triple arthrodesis" = subtalar and mid tarsal joints.
Used when there is stiffness and pain to relieve the pain not to restore the motion.

N.B.
+ any surgery on the joint ,usually done after 4 years.
+ Triple arthrodesis usually done after 12 years.

L.8: Knee examination
Prof. Salem
Look- feel- move
Each time compare to other knee
Look:
We must look for 3 thing in the knee:
1- deformity: genovarus or genovalgus, flexion deformity .
((N.B. : normally , knee has 7 valgus, if it is < 7 it is varus, if it is 7.7 valgus. ))
2- effusion : large fluid collection is seen as swelling above the patella, but small effusion will only fill the
hollows either side of the patella.
3- m. wasting: here the 1
st
m. wasted is vastus medialis
then we inspect for skin scar, color ..etc
one or more of them must be present in any knee injury
* ! don't forget the posterior side of knee (popliteal fossa) for backer cyst swelling .-

feel:
superficial: temperature and sever tenderness
deep: tenderness, crepitus, bone prominence, joint line, and soft tissue contour (ligament), fluid collection .

move:
start with active then passive
we must know the ZERO point which is not same in all patient by comparing the two knee together
in SA, varus is common about 6
0
is acceptable
passive movement: flextion idealy till reach thigh around(0-150
0
) measuer it by genometry and extention

Special test:
You must differentiate between special test of joint and special test of disease

Stability : all ligaments
Normal function of each lig:
MCL: restrain valgus stress, and prevent medial open
LCL: restrain varus , and prevent lateral open
Meniscus : shock absorpant, as torpant to distribution of synovial fluid
ACL: prevent translation of tibia anteriorly
PCL: prevent translation of tibia posteriorly

Stability examination of the Ligament when the leg
is Extended, if the knee wobbles ,there is an injury
to the LCL
Stability examination of LCL
The knee held bent at an angle Of 20 -30 .


Effusion
Measurement
Test of ligament for stability: we do tension against function of lig.
1) varus, valgus test: concider it +ve if there is pain or opening
we do it first in 25degree flexion to unlock joint then if +ve, we repeat it at 0 degree why?
If it is isolated injury to collateral lig. ONLY, the test is ve at zero degree but if it is also +ve at zero degree i.e. the
injury involve also the posterior capsule (ACL, MCL, MM(medial meniscus)=dislocated knee
2) anterior drawer test:
excessive movement of the tibia Forward in relation to the femur , indicates injury to medial Collateral
ligament and/or ACL .
knee is at 90 degree, relax hamstring m., & your thumb below tibial tuberosity then pull tibia forward, it is
+ve if movement at 5mm or above


3) Posterior drawer test:
for PCL, same mechanism of anterior drawar test but posteriorly.(( Is the excessive backward
Movement of the tibia in Relation to the femur.))

4) lachman's test : for ACL
The anterior drawer test with the knee joint bent to an angle 10 -20 . This test is used to examine the
integrity of ACL Hold the thigh on lateral side with one hand and hold the upper Part of the leg on the medial
side.The lower leg id lifted forward and an anterior drawer sign Can then be both seen and felt.

5) sagging sign:
It is important to compare both Knees in flexion in the injured Knee the upper end tibia is displaced
Backwards in compare to the other Side.
90 degree flex knee, we see sagging of leg posterioly with out do anything, diagnostic for PCL.


6) Meniscus Examination:

Med Meniscus
in flexed knee we do: compression externally rotation ,abduct the leg then translate leg from full flexion
to full extension to avoid false negative in any degree -
Lateral Meniscus
in flexed knee we do: compression internally rotation then translate leg from full flexion to full
extension to avoid false negative in any degree
NB,
- Remember, 3 forces ,heal directed medially when you examine medial meniscus
And verse versa
- it +ve ONLY if it produce pain OR click

! clinical examination is more accurate than MRI
McMurrays test:
- If there is torn meniscus , the fragment can some times be displaced Into the joint space by rotating the
tibia on the femur in flexion Producing a distinct and painful click.
- The test can repeated alternately to decide which meniscus is torn.

Injury to the lateral meniscus
Pain can occur if the knee
Is over extended.--
Injury to the medial meniscus;
Tenderness can occur over the
Medial synovial cavity.

Effusion:
Examination of an effusion in the knee joint By moving the hands towards each other you will compress
The fluid in the knee.Then by pressing the thumb against the patella ,it will make Dance against the bone
underneath if an effusion is present.

Pulge test = melting test: knee extention, empty medial pouch, press suprapattellar pouch, we see pulge
Fluctuating test: fluctuate medial side and see pulge on lateral side and vas versa
Pattelar tabe , ballottement: usually huge fluid

Measurement:
The important measure here is measurement of m. wasting
20cm above tibial tuberosity and measure by the circumstance

Special test for disease:
Apprehension test: for dislocated patella
dislocate the patella (push it laterally)
Then ask pt to bend his / her knee
It is + when pt can not bend the knee

Friction test: : for condromalacia or retropatellar pain & OA:
move patella laterally, then ask pt to contract Qaudercipes muscle
it is + if it painfull


L.9: Lower Limb Fracture & Dislocation
Dr. Bakarman
Mechanism of fractures
+ Lower limb fracture is a result of a high energy trauma except in elderly
people or diseased bones
+ Types of fracture are depend on position of limb during impaction and magnitude of forces applied.
Management
- The proper way to treat a patient with high energy trauma is to look at the patient as whole ,not to
injured limb alone!
So the aim to treat such patient is to save life first, then save limb ,finally to save function.
A.B.C.D

Pelvic Fractures
Pelvic fracture is a high energy trauma , as a result of MVA, fall from hight .

Classifications. ( Tile)
Type A. Stable(no need for external fixation becuz it's stable)
A 1. fractures of the pelvic not involving the Ring
A 2 . Stable , minimally displaced fracture of the Ring .
N.B: by conservative treatment (bed rest &analgesic)

Type B. Rotationally Unstable ,Vertically
Stable
B1. Open Book
B2 . Lateral Compression : Ipsilateral
B3. Lateral Compression :Contra lateral


Type C. Rotationally and Vertically Unstable
(most severe it's unstable horizentaly &
vertically (
C1 . Unilateral
C2 . Bilateral
C3 . Associated with Acetabular Fracture

MOST SERIOUS COMPLICATION IS BLEEDING
MANEGEMENT:
Aggressive treatment . By A.B.C.D.
Obtain X-Ray: AP pelvic, Inlet ,outlet ,Ct Scan.
Think in systemic approach.
Specific treatment:
Type A . symptomatic treatment
Ttype B .ORIF with plates& screws ,External Fix.
Type C . ORIF with plates & screws. Both AP.

Type A
Because the symphesis pubis intact.


Type B after correction with ORIF Type C after correction with ORIF

N.B the most common complication is post traumatic arthritis.it is late but the early complication is
bleeding.

Acetabular fracture
Usually it is a result of high-
energy trauma .
The acetabulum is divided
into 4 segmentsan anterior
column and wall (rim) and a
posterior column and wall
(rim). Fractures of the
acetabulum are classified
based on their involvement
of these structures .


Classification Letournel And Judet

From A-E Simple ( fracture of one part )
From F-J Complex ( more than one part )
Investigation
AP pelvis.
Judat views ( Internal Oblique,Obturator view)
C T scan (unstable).: usefull in :
1- Amount of post. Wall fracture. 2- intaarticular fragment impact 3- subblaxation
External oblique ,iliac view post. Column + ant. Wall .

Posterior wall fracture ( obturator view).:
Gives an idea about ant. Column &ant.wall.

Posterior column fracture from iliac view.
Post column &ant wall

Posterior column fracture

TREATMENT
Indications for Nonoperative Treatment
1. Nondisplaced and Minimally Displaced Fractures.
2. Fractures with Significant Displacement but in Which the Region of the Joint Involved Is Judged To
Be Unimportant Prognostically
3. Secondary Congruence in Displaced Both-Column Fractures
- Medical Contraindications to Surgery
- Local Soft Tissue Problems, Such as Infection, Wounds, and Soft Tissue Lesions from Blunt Trauma.
- Elderly Patients with Osteoporotic Bone in Whom Open Reduction May Not Be Feasible.
skeletal traction for 4-6 weeks. And then start physiotherapy in bed , PWB (partial wt bearing) ,FWBAT
(full wt bearing as tolerated) .
Operative Treatment
Indications for Operative Treatment.
1. An acetabular fracture with 2 mm or more displacement in the dome of the acetabulum.
2. any subluxation of the femoral head from a displaced acetabular fracture noted on any of the
three standard roentgen graphic views
More than 50% involvement of the articular surface of the posterior wall or clinical instability with hip
flexion to 90 degrees in posterior wall fractures .
Incarcerated Fragments in the Acetabulum after Closed Reduction of a Hip Dislocation.
Need ORIF By Blate & Screws


High risk of AVN

complications
posttraumatic arthritis in 17%.( most common )
a vascular necrosis after posterior dislocation was 7.5%.
Infections are reported to occur in 1% to 5%
Sciatic nerve palsies as a result of the initial injury occur in approximately 10% to 15%.
Heterotopic ossification (HO) occurs after most extensile approaches
N.B. : ALWAYS examine the neurovascular .

HIP Dislocations

N.B posterior type is the most common .


The typical position is of post dislocation :
Hip flexed, adducted, internally rotated


Post sagging.

Proximal femoral fracture.
Fractures of the proximal femur are classified first according to their anatomical location.
Femoral neck fractures and intertrochanteric fractures occur with about the same frequency.
They are both more common in women than in men by a margin of three to one.
it is a result of MVA, Fall,

N.B. Intracapsular fracture associated with more risk of AVN.

It will be affect blood
supply :
1- Obterator artery.
2- Medial &
3- Lateral circumflex
artery.

1- Age 2- activity 3- state of acetabulum

Treatment neck of femur
Nondisplaced fracture of neck of femur can be treat
with canulated screws.
Displaced fracture ----------DHS in patient less than
60 years.
> than 65 years look for.
. Level of activities.
. Status of the acetabulum.
then chose THR vs. hemi arthoplasty.
Intertrochantaric fracture-------DHS(dynamic hip
screw) . DCP(dynamic condyler plate).--
Subtrochantaric fracture---------DHS.ABP(angle blade
plate).DCP. ---
Combination of both------- IM (intramedullary )Nail
with Canulated srews.-



In bicondylar type there is a high risk of post traumatic OA--

Type A
Not dynamic
-Need surgery
-Most worst

Type B need fixation with screw.


Need internal fixation.ORIF Comminuted fracture

Bipartite patella= failure of
fusion of osteochondral
plate of patella.
Comminuted
Use also
screw.

A . transverse fracture.
B tention band fixation with figure of 8
N.B. patellar dislocation is common in young adults.


Of patellar dislocation.
If there is no pulse.
According the
distal segment we
know the direction


Tx : is plate &screw ,fixation with open reduction.

Lesarouf repair ( ext.
fixation)
In casse of severe
comminuted fracture .

Common site of open fracture.
Very important ---

High risk of soft tissue injury.
(transverse fracture)
Due to direct force ,more than
spiral due to twisting force.
Tx : intramedullary nail
IM nail.

Most important fracture in adult.

NWB BK cast=Not weight bearing
below
knee cast.

NEED ORIF.

Type B

Complication:
Post traumatic arthritis (COMMONEST).
Stiffness.
Skin necrosis.
Malunion or nonunion.
Wound infection.
Regional complex pain syndrome.


L.10: Mechanical Disorders of the Spine
Dr. Saadedeen
Low back pain in society:
It is now generally accepted that between 60% & 80% of general population will suffer from low back pain
someday, & between 20% & 30% (one third of population) are sffering from it at any given time.
Important of the back & spine are ranked as the most frequent cause of limitation of activity in people
younger than 45 years of age.
Back pain ancient curse is now appearing as a modern international epidemics.
Back pain is a major cause of impairment especially in the industrial societies.
Disorders of Intervertebral Disc:
Are thought to be the cause of most cases of low back pain
Are common at middle age
Result from loss of hydration of the Annulus Pulposis or major trauma to disc
Function of Intervertebral Disc:
It functions as a cushioning structure (like menisci)
It is a structure of shock absorption
The amount of pressure inside the disc varies according to posture of human
Normally it does not encroach on spinal canal posteriorly (when disc compressed it will expand
laterally but should not go into spinal canal posteriorly)
Anatomy of Intervertebral Disc:

The disc is a biconvex structure
It consists of outer layer of Interlaced fibers called Annulus Fibrosis and central layer called Nucleolus
Pulposis
The Nucleolus is soft, elastic and well hydrated structure at young
age
Usually bean (kidney) shaped, when compressed become circular.
Fibers of annulus fibrosis is interlacing with compression, but it will
return to normal shape with decompression ( which is better than
circular that if compressed will elongate, then it will not return to
normal shape)
If annulus fibrosis loss its elasticity with dehydration, it will not
return to normal shape & also with age or with high force.
Pressure inside the Disc:
Least pressure is when person is lying flat
Pressure increases 3 folds on twisting in bed
Pressure increases 4 folds when standing
Pressure increases 6 folds on forward bending
Pressure increases 10 folds on bending and lifting

This explains the most common cause for rupture of
intervertebral disc
We could ask patient about

Pressure= 185 with abnormal sitting
Pressure= 275 with person lifting heavy object

Circumferential Tear in Annulus:
it occurs with elasticity
repeated of pressure on dehydrated disc
produce tears especially postereo-laterally
nucleus is still inside not go outside (no
protrusion)
patient feels deep seated back pain

Radial Tears of Disc: --------------------------------------------->
Radial tears are more serious than circumferential tears
Circumferential tears cause deep seated backache but radial tears may lead
to bulge in the annulus inside the spinal canal or protrusion of nucleolus
inside the canal (herniation) like in sciatica .
Protrusion of Intervertebral Disc:
Usually it is posterolateral as the posterior longitudinal ligament resist
central posterior protrusions
Most common .
Central protrusions are usually small, but large protrusions are more serious
as they may cause Cauda Equina Syndrome (compress many nerve roots)
Protrusion of Disc, if large sequestrated disc -


Nerve Root compression by PID:
Protrusion of Intervertebral disc may compress the nerve root exiting spinal canal at that level and
may cause inflammatory change
Protrusion at L4-L5 compresses L5
Protrusion at L5-S1 compresses S1
PID: mostly affects L5 & S1 due to:
o they are most mobile segments which are present at lower back (area of most pressure)
N.B. if there was a central protrusion it will compress S2,S3. That innervates the bladder &anus .so, there will
be incontinence.

Central Disc Protrusions:
May compress More than one nerve root
It does compress central roots like S2 S3 / S4
This leads to compression of nerve roots to bladder (retention or
incontinence) and rectum (Cauda Equina Syndrome)

Clinical Picture of PID:

A middle age male (more common)
May present with LBP and or Sciatica (Though sciatica in Arabic is referred to as painful leg in women )
Sometimes follows clear incident of heavy lifting or back straining
Frequently NO history of any cause is present

May present as : Acute , Recurrent or Chronic
In Acute cases patient may report that he felt a tear or a click at his back-
This may be followed by immediate radiation of pain to leg or not-
Pt. present with lateral flexion to opposite side of PID & muscle wasting at side of protrusion with
prolong, chronic cases .
Radiation to leg may appear later
(if only tear without radiation to legs it is only deep seated pain
But if tear+radiation deep seated pain with sciatica)
This is NOT a systemic disease
There is NO fever or weight loss
PAIN IS MECHANICAL i.e. : it follows some posture which increases the intervertebral disc pressure
Constant pain or nocturnal (night) pain is a sinister sign (night pain means dangerous problem like tumor
or infection more than PID)
Pain is increased by coughing and relieved by lying in bed
Usually it is the lower back
Commonly there is Para vertebral muscle spasm
We palpate the level of Iliac Crest = level of L4-L5
Palpation in Back Examination:
We can palpate the Para Spinal muscles ,tips of spinous
processes and the inter spinal ligament
We cannot palpate the lamina , the disc or vertebral body
We start by identifying the level of Iliac Crest
This corresponds to L4-L5
Almost 5 cm below is L5-S1
Below on the sides there is a dimple which corresponds
to upper S.I. Joint
Lesions at L4-L5 will produce tenderness at L4-L5 level
Lesions at L5-S1 will produce tenderness at L5-S1 level
Palpation at site of PID cause mild tenderness not severe
We can palpate for tenderness at Sciatic Nerve course as well
Examination of Back Movements:
1. Forward Flexion:
Forward flexion is 90 degrees or when tips of fingers reach level of
malleoli
Flexion to level of mid-tibia is 60 degrees
Flexion to knees is 45 degrees
Flexion to mid-Thigh is 30 degrees
2. Back Extension:
From straight to 30 degrees
Some people can do much more (Gymnastics or people with ligament
laxity )
Back extension is reduced or lost in people with acute PID ( It may be
even Minus extension as they may walk with flexed back )
3. Lateral Flexion:
Lateral flexion is 30 degrees to right or left
Lateral flexion to the same side of pain is always restricted (except in case of axial disc herniation)
4. Rotation:
Rotation is not affected by PID, (only in older & osteoarthritic pt.)
May be done in EITHER standing or sitting positions
In standing position examiner has to immobilise the pelvis of the patient to make sure than there is
no rotation of whole body
In sitting position body weight immobilises the pelvis and probably more accurate


Walking on Heels = L5:
Asking the patient to stand and walk on his heels elicit if
there is any weakness at L5

(which is main nerve root for All 3 muscles of dorsiflexion = Tibialis Anterior , Extensor Digitorum and Extensor
Hallucis Longus)

Walking on Tip Toes = S1:
Asking the patient to stand and walk on tip toes elicit if there is
any weakness of S1 (which is the main nerve root for muscles
of plantar flexion = Gastocnemius and Soleus

Examination in Supine position:
Once we ask patient to lie down in bed we start examining
certain tests
This does NOT include inspection of the back
Most important is SLR test ( Straight Leg Raising Test ) and Neurological assessment for the condition

Straight Leg Raising Test:

It is a Sciatic Nerve Stretch Test
Normally it is Painless
Is done in supine position
Normal from 0-90 degrees
Reliable test is between 30-80
Lasague Maneuver:
Lasague Maneuver is a modified SLR test ( bend the hip
90 &the knee 90 then extend )
It has 3 advantages:
It is a confirmatory test for SLR (angle obtained from SLR
test = angle obtained from lasague test)
It excludes hip or knee pain as a cause for the pain on SLR
(this test is painful with hip &knee diseases &painless with
PID)
It excludes malingering patients ()


Lesions of L3-4 and L4-5:

Lesions of L4-5 and L5-S1:

Investigations of Backache:
1. blood analysis: CBC-ESR
2. Ca, alkaline phosphatase, phosphorus
3. x rays Plain:
X Rays are useful
AP, Lateral and Oblique may be done(for density, alignment, narrowing of
intervertebral space.)
On this lateral view there is obvious sign = Loss of normal lordosis =straitening
of lumbar spine

Lateral view or cone view demonstrate narrowed disc space
Also this view demonstrates gas shadow in disc space= chronicity= Knotts sign =
vacuum phenomenon (air in the disc space not from bowel)

2. Myelography and radiculography:
Used to be the most important test for eliciting disc protrusions
NOT used these days for the above diagnosis
Still used for investigating certain intra spinal and instability
conditions
Detect space occupying lesion (filling defect) caused by infection, tumor, PID
Inject dye at L3-L4

3. C.T. Scan Disc Protrusion:
Useful but MRI is better

4. C.T. Myelography: 5. MRI(golden tool):

Management of PID:
Essentially conservative (except quada equina syndrome)
Almost 85% respond to conservative treatment
Up to 15% surgical treatment is indicated
Severity of symptoms does not indicate severity of disease (severe back pain dose not mean surgical RX)
1.Conservative Treatment:
Should be tried initially in most cases
Short period of Bed Rest (< 1 week ) should be tried in ACUTE cases-
Bed rest is NOT indicated in chronic cases
NSAIDs and muscle relaxants are used ( Drugs to protect against G.I. effects especially in the elderly=2
nd

generation but it may affect on the heart )-
Avoids narcotics like morphine.


2.Physiotherapy and Exercises:
Are the most important tools in management
Always should be part of treatment
Weight reduction and back care education
Heat therapy especially Short Wave diathermy and Ultrasound important types of treatments
Heat & cold muscles spasm
Exercises to strengthen back and abdominal muscles should be done
3.Chiropractic Therapy ( ) & Acupuncture:
Recently gaining popularity
Chiropractics means re-alignment of bones and joints to normal structure (However once we understand
the pathology of PID, it is difficult to see how can a disc be put back in place!)
Acupuncture is by stimulating specific points by needles and is helpful in some patients
4.Steroid Injections In PID(in acute & semi acute cases)
In selected cases they are valuable adjuvant to other modalities of treatment
They are injected in the Extradural space by lumbar or caudal route
It is believed they work by reducing the inflammatory changes in the nerve root associated with PID (but
notpressure on N. root)
5.Surgery:
Radiological evidence MUST be obtained prior to surgery
Theses radiological changes MUST correspond with the clinical picture
We have to remember that NOT every bulging disc should be operated on
MRI is the golden standard in diagnosis
Indications for Surgery for PID:
There are Five indications
Only one definite and urgent indication in CAUDA EQUINA syndrome (not conservative)
Three valid and correct indications (will be explained soon )
One controversial and personal indication
Valid Indications for Surgery in PID:
Failure of conservative treatment ( for at least 6 weeks ) and continuation of pain
Progression of neurological deficit (but initial deficit is not an absolute indication )
Recurrent and disturbing attacks with conservative Rx
Controversial indications in PID:
Time Factor : Patient is not prepared to complete a full period of conservative treatment ( 6 weeks ) to
see if it will succeed
Patients preference
Surgeons preference

Exclude a psychological causes:


Operative procedures for PID:
At least 15% of cases of PID end up having surgery
At USA : at least 250 000 cases are operated on annually
At USA : there are 7 million individuals who had back surgery
Still at USA : there are 21 million people with disability certificate due to backache !
Aim of surgery for PID:
To relieve patient of his pain
Leg pain can be relieved by removing pressure on nerve root ( Decompression of nerve root )
This is done by removing the bulged or protruded part of the disc and any other part which can be
curetted out
Back pain can be relieved by stabilising that intervertebral disc segment
Other surgical modalities: orthodesis, disc replacement.
Position for surgery for PID:
Usually it is Chest-Knee position
This is to avoid any pressure on abdomen
Avoidance of pressure on abdomen reduces intra
abdominal pressure and consequently reduces intra
spinal pressure = reduction of venous bleeding from
dural veins
1.Open Disc Surgery:
3-5 cm for each disc level
Lamina above and lamina below are exposed with the
part of Ligamentum Flavum between
Part of Ligamentum Flavum and lamina

removed to get access to spinal canal


Exposure of Dura and Nerve Root
Excision of protruded PID

Dura is retracted with the nerve root to expose
the protruded PID
Once protrusion is exposed it is incised in 5x5
mm cruciate incision
Occasionally nucleolus is already penetrated
through the annuulus

Excision of PID
Protruded or extruded disc is removed and
disc space curetted
Nerve root should be Free from any
compression and Free from tension
If any bone was involved it should be removed
2.Endoscopic Micro- Discectomy:

Relatively New method of
Disc Surgery
Minimally traumatic in
experienced hands
Minimal scar and blood loss
Requires high quality surgical
tools
Fluoroscopy pre and during
surgery is necessary
Nerve root injury may be as
high or even higher than with
other methods

3.Percutaneous Discectomy:

Is done through a cannula inserted lateral to
midline into disc space under G.A. or L.A. and
nucleolus is sucked with shaver
Initially was thought to be easy and simple
Has not proved to be very successful
Reported success rate is 70%
Patient and surgeon are exposed to repeated
radiation
Works by suction


4.Laser Discectomy:
May become the golden standard for managing PID in the future ( especially when open MRI machines
are available )
Route of entry is similar to Percutaneous Discectomy
Can be done under local or general anesthesia
Not perfect at present
Works by evaporation.

L.11: Metabolic Bone Disorders
+ Calcium Homeostasis
Bone is not only for support
Bone formation & bone resorption
Hydroxyapatite crystals
Calcium & phosphate control:
a. Intestinal absorption
b. Renal excretion
c. Bone
+ Vitamin D
Sources:
a. Diet
b. Ultraviolet rays on skin
Cholecalciferol activation:
a. PTH
b. Phosphate concentration
Action :
a. Intestinal absorption of Ca
b. Bone resorption
+ Parathyroid Hormone
Fine regulator of Ca exchange
Serum Ca regulate its secretion
Action:
1) Increase phosphate excretion
2) Increase Ca reabsorption
3) Vitamin D activation
+ Calcitonin:
C cells of thyroid gland
Serum Ca regulates its secretion
Action
* Rapid hypocalcaemic effect by
inhibiting
bone resorption
+ Secondary rule
Other Hormones Non-hormonal Factors
- Estrogen - Mechanical stress
- Corticosteroids - Prostaglandin E
- Thyroxin - Acid-base balance


Rickets & Osteomalacia:
Different expressions of the same disease.
Inadequate mineralization. (normal matrix deficied)
Rickets : Areas of endochondral growth
Osteomalacia : All skeleton is incompletely calcified
Causes:
Calcium deficiency
Hypophosphataemia
Defect in Vitamin D metabolism:
1)nutritional
2)underexposure to sunlight
3)intestinal malabsorption
4)liver & kidney diseases
Symptoms & Signs
Rickets
- Tetany or convulsions ?(due to
hypocalcemia )
- Carbo-pedal spasm is the type of
convulsion .-
- Failure to thrive , muscle flaccidity
- Craniotabes , joint thickening
- Pigeon chest , rickety rosary ((
thickening of all costochodral joint)),
Harrisons sulcus
- Deformities

Osteomalacia
- Bone pain , backache
- Muscle weakness
- Vertebral collapse kyphosis and loss of height. b/c of high stress on it.
- Deformities & stress fractures
Biochemistry:
Hypocalcaemia, Hypocalcuria
High alkaline phosphatase --
X-rays
Rickets
- Growth plate widening & thickening
- Metaphyseal cupping to accumulate the growth plate widening.
- Diaphyseal deformities
Osteomalacia
- Looser zone , biconcave vertebra , protrusio acetabuli
- Spontaneous fractures . {stress fracture}
Signs of secondary hyperparathyroidism : due to prolonged hypocalcemia.


Treatment
- Vitamin D deficiency
- Rickets:
1)controlled Vitamin D
2)sun exposure
3)correct residual deformities
- Osteomalacia:
1. Vit. D + Ca
2. fracture management
3. correct deformity if needed

Hyperparathyroidism
+ Primary
hyperplasia - adenoma - carcinoma
+ Secondary
persistent hypocalcaemia
+ Tertiary
secondary leads to hyperplasia
Pathology
- PTH overproduction
- Increased renal tubular absorption , intestinal absorption and bone resorption of Ca
- Hypercalcaemia and hypercalciuria
- Suppressed phosphate tubular reabsorption
- Hypophosphataemia and hyperphosphaturia
- Hypercalcaemia:

- calcinosis , stone formation , recurrent infection and soft tissue calcification
- Bone resorption
- loss of bone substance , subperiosteal erosion osteitis fibrosa cystica and brown tumors
Symptoms & Signs
- Hypercalcaemia
anorexia , nausea , depression and polyuria
- Bone rarefaction
pain , pathological fractures and deformities
- Biochemistry
hypercalcaemia , hypophosphataemia , high alk. Phosphatase and serum PTH


X-rays
- Subperiosteal bone resorption
- Generalized decrease in bone density
- Brown tumors
- Chondrocalcinosis : knee , wrist and shoulder

Treatment
Surgical excision of adenoma or hyperplastic parathyroid tissue
Hungry bone syndrome treated by vitamin D
Osteoporosis:
Normal mineralization
Decrease bone mass (amount of bone per unit volume) {deficient matrix}
Age related
Associated or manifestation of other conditions, like osteopenia or other metabolic bone disease.
Causes
1) Idiopathic
2) Nutritional
3) Endocrine disorders
4) Drug induced
5) Malignant diseases
6) Miscellaneous


Idiopathic osteoporosis - normal investigations
In old patients we have to role out malignancy and multiple myeloma
Younger patients must be fully investigated
Several causes may be involved
Osteoporosis can be associated with osteomalacia-

Symptoms & Signs
Bony aches
Easy fractures
spine - lower radius - femoral neck-
Rib fracture , chest pain
Normal biochemistry -
X-rays
Decrease bone density (osteopenia)
Wedging or biconcave vertebrae
Thin cortex and deformities in long bones.
Dexa Scan
Biopsy



Treatment
E Treat underlying cause
E Idiopathic , extremely difficult
E Calcium and vitamin D
E Fluoride and triple therapy
E Calcitonin( ), Diphosphonate (ed bone density)
E Treat fractures, it's pathological fracture so, we treat it by ORIF to avoid malunion.

Prevention
* Good diet
* Exercise
* Exposure to sun light
* Ca supplement
* Hormone therapy



Part 2


Part-2
INDEX
L.12: Orthopedic investigation
L.13: Principle of fractures
L.14: EXAMINATION OF THE FOOT AND ANKLE
L.15: Hip Examination
L.16: Presentation & DDx in Orthopedics
L.17: Peripheral nerve injury
L.18: OSTEO-ARTHROSIS
L.19: TRACTION IN ORTHOPEDIC
L.20: Upper Limb Examination
L.21: Fractures & Dislocations of the Upper Limb
L.22: Operative Treatment of Fractures & Dislocations
L.23: Pyogneic Bone & Joint Infection
L.24: Orthotics & Prosthetics
L.25: Soft Tissue Injury
L.26: Spinal Deformity
L.27: Spinal Injuries

L.12: Orthopedic investigation
Blood :
1-CBC :
U/E
Hb( if it less than 7 cotraindication of OR)
RBC
WBC (IF high acute infection )
Platlets
2- ESR
3-C-reactive protein Those 3 are important in case of infection
4-blood culture
+ ESR: (advantage : 1- is more sensitive 2- simple to do ) ( disadvantage : need 72 hrs to respond to
treatment )
+ C-reactive protein: ( advantage : 1- more specific 2- faster in response )
(disadvantage : 1- expensive 2- dye is not always available)
+ Blood culture: to know the exact organism always do it before Rx
Note : in septic arthritis we need : 1- CBC 2- joint aspiration .
Joint aspiration (( taking a sample from synovial fluid))
Indication : swelling monoarthritis .
Disadvantage : may lead to infection .
- If the the patient has infection :
Febrile CBC
Sign : investigation : ESR
Swelling WBC
- TO exclude we always do:
1
st
: X-ray
2
nd
: blood test
3
rd
: joint aspiration if the joint is knee we can do it in ER but if it is hip do it in OR.
Synovial fluid : is a viscous, non-Newtonian fluid found in the cavities of synovial joints. With its yolk-like
consistency ("synovial" partially derives from ovum, Latin for egg), the principal role of synovial fluid is to
reduce friction between the articular cartilage of synovial joints during movement.
1- Gelatinous (viscous),yellowish, clear, like yolk normal
2- Turbid : if WBC,ESR,febrile patient we do arthrotomy
If not we don't do it
3- Thick cheesy that means there is pus so, we have to do arthrotomy to drain it
Biobsy : taking a sample from tissue to reach to Dx
Indication : 1-infection 2- tumor i.e ( if there is a lytic lesion )
Types :
1- incisional ( we take a sample from tissue then we close )
2- excisional : (we take all the mass with borderline )
3-FNA
4-core

Arthroscopy : visualize the joint from inside by a scope
Diagnostic ( for anterior cruciate ligament ACL as a substitute of
MRI )
Therapeutic ( meniscal tear )

L.13: Principle of fractures
A Fracture is a Break in the continuity of bone
It could be complete or incomplete (green-stick fracture)
o complete usually in old people .
o incomplete usually in pediatric due to high water content in the bone .

Classification of fracture:
It may classify in different ways:
Depend on amount of force ; it is classified into :
1- Pathological : Fracture abnormal bone Cyst, Tumor, Infection
2-Traumatic fracture .

Depending on communication with external environment :
1- Simple (closed): Does NOT communicate with external environment
2- Compound (open ): Communicate with external environment,,, Infection !!orthopedic
emergency.

Depending on the presence or absence of soft tissue
(viscera,nerve,blood vessel )damage:
1- Complicated : Associated with damage to
nerves, vessels or internal organs
2- Non-complicated .


Other special classification e.g: fracture around the hip , ankle,etc.

Dislocation : Complete separation of the articular surface . Distal to proximal fragment
Anterior, Posterior, Inferior, Superior .can't move.

Subluxation:-Incomplete separation. Joint Function in Anatomical position Only, can be moved!!

Mechanism of injury :
The line and extent of the fracture are determined by:
1- Amount of physical force .
Trivial force = Pathological
Magnitude = Non-pathological
2- Direction of physical force (direct or indirect)
A-direct force :
The bone fractured at the point of impact.
Usually associated with complicated fracture.-
3 types:
1- Trapping force : lead to transverse fracture.
2- Crushing force ; lead to comminuted fracture .
3- Penetrating force; lead to comminuted fracture .
N.B. comminuted fracture : one in which the bone is splintered or crushed.
B- indirect force :
Is a force which is exerted at a distance from the site of the fracture .
Less chance to association with complicated fracture .-
5 types:
1- Twisting force;lead to spiral fracture .
2- Angulation force; lead to transverse fracture .(may need ORIF or 3weeks casting)
3- Angulation +axial compression force ;lead to partial
transverse fracture +butterfly(a separate triangular
fragment).-
N.B. The axial fracture in spine occur at:
thoracolumbar.
4- Twisting + angulation + axial compression ;lead to
short oblique fracture.90%need surgery.Mxtakes
time if conservative .


5- Vertical compression force ;lead to comminuted
fracture
Direction of Force On Cancellous Bones:- Direct OR
Indirect Comminuted Pattern Burst

Force due to Resisted Muscle Action: - Avulsion Transverse pattern

Diagnosis :
A. History :
+ Ask about history of trauma; to exclude pathological fractures .
* Pathological (trivial)
* Non-pathological ( magnitude)
+ Mechanism of trauma to suspect:( ask about: Fall from height, RTA, pedestrian, Driver.?)
1- the possible injury
2- the association with soft tissue injury
3- help in management (by reverse the force during reduction ).
+ Complaints :
-Pain: sharp, sudden in onset , aggravated by movement , relived by rest,
usually not refferd.(localized ).
-Lose of function . commonest
- Deformity. presentation
- Symptom related to complications.
+ Ask about other systems especially in head ,chest and abdominal injuries.
+ Past medical, surgical history.
+ Past drug history ( important in pathological fracture).-
B. Examination :
+ General examination :
- Sign due to fracture or trauma :
Vital signs, Shock A,B,C
Any associated injury to head ,chest, or abdomen .
- Sign related to the cause fracture(especially to the pathological fracture) eor example ;cancesr of
lung or prostate .
+ Local examination :(always compare)
Look Feel Move Do
Simple Vs
compound
fracture
Localized
Tenderness
Active Vs passive movement Special test:
a) Circulation
b) Nerves
Any deformity

Abnormal movement Measurement:
shortening
Hematoma

Creptus

Skin lesion

Swelling


C. X-rays:
Essential requirements:
+ Two views:
Antero-posterior(AP view)and lateral view.
It is need for 2 reasons:
Some fracture may show in one view only , e.g: undisplaced fracture of the neck of the
femur .
To determine the degree of displacement at the fracture site .
+ Two joints:
Joints above and below the site of fracture.
It is needed for two reasons:
To detect any associated injury.
To determine the angulation at the fracture site.
Pre and post reduction .
Occasional requirements:
Two limbs for comparsion ,especially in children.
Repeat the X-ray after 1-2 weeks(Two Occasions ):
Indication if the X-ray doesnt show a fracture .
Applied most commomnly in suspected fracture to the scaphoid .-
Special X-ray ,e.g. stress films to ligamentous injuries (decrease it use nowadays since the MRI
has taken the job) .

Description of the fracture on X-ray :
Situation :
Side (right or left)
Site( upper, middle , or lower ).
Pattern :Line of the fracture ( transverse ,spiral ,or comminuted )
Displacement which could be :
Shift (lateral ,medial, anterior, or posterior)
Tilt (angulation )
Twist (rotation ).(internal or external )
Shortening (over riding or impaction )


Management :
Repair of the fracture :
a- Primary repair:
With Rigid Internal Fixation
No Callus formation
Active Haversian remolding
Long time to heal
b- Secondary Repair:
Without rigid fixation
Commonest type even
with I.F.
Fast healing
Callus formation
Stages as in figure below:

Time Factor- Perkins formula

Union Consolidation (remodeling )
Upper
limb
Spiral: 3 weeks
Transverse : 6 weeks
Spiral=6 weeks
Transverse =12 weeks
Lower
Limb
Spiral:6 weeks
Transverse:12 weeks
Spiral =12 weeks
Transverse =24 weeks
N.B. Remodeling take double the time of union .AND the children take the the half of the period .
Aim of management :
General aim : To Save the Life of Patient
Local aim: : Rapid Recovery of Injured Part and Its Function.
O General aim (save the life ) by :
- Full general examination.
- Treat life threating injury :
1- Head,chest,or abdominal injury.
2- Shock
O Local aim :
- Save the limb:
- By early detection and treatment of:
- Ischemia
- Infection
- Save the function :
1) REDUCTION
2) IMMOBILISATION
3) SOFT TISSUE TREATMENT
4) FUNCTIONAL ACTIVITY & REHABILITATION
1) Reduction :
Should be Under Anesthesia
Closed or Open
Study X-Ray and direction of force
The basic Maneuvers :
Traction
Reverse mechanism of Inj
Direct pressure

+ Standards of reduction :
Anatomical Reduction is Ideal for all type of fracture.
Anatomical Reduction is a MUST be achieved in-- :
- Dislocation
- Intra-articular fractures(displaced fracture involve the joints especially in young
patient.
- Fractures Both bones Forearm, to avoid loss of pronation and supination.
X-Ray Image Intensifier help control reduction
Remember to Assess Reduction after 10 Days-- !
Reduction can be Acceptable if :-
Alignment will NOT affect Function, so some loss of opposition and slight degree of angulation (less than
10 degree ) are acceptable.
Remolding CAN correct deformity
Remolding can correct :-
Angular deformities NOT Rotational deformities -
Children MORE than Adults
+ Time of reduction:
Immediate Reduction is a MUST in:
* Vascular Inj ( risk of ischemia)
* Spinal Cord or Nerve Inj (risk of para or quadric plegia )
Urgent R. in:
OPEN fractures ; Save Limb
Dislocations Need Urgent reduction for Pain and pressure on surrounding pressure.
CLOSED fractures CAN wait If Facilities do not permit Urgent management.
+ Method :
First , obtain acareful study of :
X-ray to identify where the fragment lie.
The direction of force
Shiuld be under anesthesia .
Achieved either by:
Closed manipulation.
Open reduction.
The basic maneuvers are :
1- Traction
2- Reverse direction of injury
3- Direct pressure to reduce side to side shift or tilt .
N.B. X-rays image intensifier help to confirm the reduction of fragment .
+ Immobilization
Life is Movement, and Movement is Life
Do NOT Immobilize Any Joint Unnecessarily-
Applied after fracture reduction until union.
Can be achived by:
Plaster of Paris
Traction
Internal Fixation
External Fixator

absolute
reduction

Healing of fracture :
Factor that affect the rate and effictiveness of healing process:
Age
Line of fracture
Systemic or local disease.
A.fracture healing without rigid fixation :
+ Stge I :hematoma formation : Clot formation
+ Stage II : traumatic inflammation :
More fibrin will accumulate to already present clot.
Increase blood flow and infiltration of leukocyte.
+ Stage III : Demolition:
Macrophage will take place through removal of inflammatory exudates ,fibrin ,RBC's and debris.
Remove any bone fragment undergoes necrosis by macrophage and osteoclasts.
+ Stage IV : formation of granulation tissue.
+ stageV : woven bone and cartilage formation :
by the activity of osteoblasts.
Formation of external intermediate and internal callus ( callus : unorganized network of woven
bone ,which is absorbed as healing is completed ,and ultimately replaced by true bone ).
+ Stage VI : Formation of lamellar bone : Form over the woven bone and cartilage .
+ Stage VII . Remodelling:
Continuation of osteoclastic removal and osteoblastic laying down of bone .
External callus will removed slowly ,intermediate callus converted to compact bone while the
internal callus will hollowed into narrow cavity which contain cancellous bone .
B. Fracture healing with rigid internal fixation :
The bone heals by primary vascular bone formation .
No formation of external or internal callus .-
Complication:
general complication-- :
Immediate Early Late
Shock
Crush syndrome
Association of internal
organ injury
DVT Gas gangrene
Pulmonary embolism hypostatic pneumonia
Fat embolism bed sore
Tetanus
Accident neurosis

Local complication --:
Immediate Early Late
OSkin loss
OVascular
gangrene
ONerve
damage
OSkin
1-fracture blisters
2-plaster sores
O Nerve
compression
OBONE
1-Delayed union
2-Nonunion
3-malunion
4-Avascular atrophy
O JOINT
1-stiffness
2-instability
3- post traumatic
osteoarthrosis
OVascular
1-Volkman's
ischemia
2-compartment
syndrome
O Muscle &tendon
1 - Tom fibers
2 - Tendon rupture
3 - Disuse atrophy
O others
1 -Late tendon
rupture
2 -Late neuritis

E Delayed Union:-
Healing Slow but still Active, Remove the cause!
Fracture Site Tender
X- Ray: little Callus, Medulla Open
Smoking is one of the causes of delayed union

E Non- Union:-
Reparative process Stopped, Need Intervention
Painless, with Abnormal Movement, formation of Psudoarthrosis(false joint)!
X- Ray: Sclerosis, Blocked Medulla.
+ Delayed Union & Nonunion Causes:-
Local :-
1. Poor Blood Supply
2. Soft Tissue Interposition
3. Infection
4. Inadequate Immobilization
5. Over-Distraction
6. Pathology, Tumors
General:-
1- Nutrition
2- Bone Disease
3- Old Age
4- Smoking
5- Hypothyroidism
E Malunion:-
1- Primary,i.e: Neglected fracture .
2- After Reduction! Watch X-Ray After 10 Days--.
3- secondary ,i.e. unavoidable deformity E.g. crushing
injury to Epiphyseal Growth plates Cause
Deformitiesfracture with extensive bone loss.

E Avascular Necrosis:-
Death of Bone from; Impairment or Loss of blood Supply.
In X-ray , it appears as sclerosing area ((bad sign ,mean dead
bone ))
The most common sites are-:
- Scaphoid bone
- Neck of the femur
- Talus
- Anatomical snuff box.

E Myositis Ossificans:-
Not myo! or itis! that mean no iflamation no muscle movement"--
It is ossification of te connective tissue ,not the muscle
It is a Heterotopic Ossification in soft tissue
May follow minor trauma
Elbow ; Knee; Hip are the commonest site affected- .


Diagnosis:
There is Pain & Limitation of movement
On X-Ray, initially appears cloudy ( Calcification)and later appears as Ossification.
After sever Head Injuries
Prevention :
Avoid Passive Massage
Rest Susceptible site( elbow ,knee,and hip) after injury
Treatment :
May Need Excision When Mature
- There is Primary Congenital Form !
- Myositis Ossificans Progressiva
- Ossification : formation of or conversion
into bone or a bony substance .
E Reflex Sympathetic Dystrophy
Sudecks Acute Bone Atrophy
Commonest Hand and foot # Arm or Leg--!
Cause iatrogenic .
- Diagnosis:
History : Pain, Swelling, Restriction Movement
Examination : Skin :Glossy, Smooth, Stretched with increase in local temperature (due to increase
blood flow in the limb )
X-rays: show osteoporosis .
- Treatment :
Physiotherapy
Sympathetic Block
- Medical : Drugs,
- Surgical: Regional Block Sympathectomy
E Compartment Syndrome :
elevation of the interstitial pressure in a
closed osseofascial compartment that results
in microvascular compromise.
Normally the the interstitial pressure =
0mm/Hg until 20-25 mm/Hg is acceptable.
- The most common causes of acute compartment
syndrome are:
1. fractures,( even open fracture)
2. soft tissue trauma,
3. arterial injury,
4. limb compression during altered consciousness,
5. burns.
6. Other causes include intravenous fluid extravasation and anticoagulants
- Diagnosis:
Symptom : 5 P's pain , pulsless, paras thysia ,paralysis, pallor .
Level of leg as the level of heart for 20 minutes , if the pain goes that good ,if not measure
the pressure if high do fasciotomy
- Treatment:
Fasciotomy .. N.B. Do not give narcotic.

Pathological fracture :
It is a break of the continuity of bone within an abnormal bone structure .-
Abnormal bone structure could be due to :
1) Congenital disease (osteogenesis imperfect).(defect in type II collgen)
2) Infection (osteomyelitis ).
3) Fracture through a cyst.
4) Metabolic disease ( osteoporosis ,osteomalacia, paget's disease).
5) Primary bone tumors.(rare)
6) Metastatic bone tumors . (more common) especially from:
(Kidney thyroid- lung prostate breastcancer's )
+ Diagnosis :
- History :
Insignificant amount of trauma-.
Constitutional symptoms.
History of malignancy .
- Examination :
E General :
a) Sign of malignancy ,e.g.: weight loss
b) Sign of infection .
E Local:
a) Tenderness ,pain , swelling.
b) Muscle spasm and deformity is minimal
- Investigation :
Radiology :
1) X-rays ,MRI,CT scan of the lesion site(are essential ).
2) CRX and CT-chest to detect pulmonary metastasis .b/c the sarcomas of the bone metastasis to the
lung.
3) Bone scan ,Pet scan.
Laboratory :
1) Specific tests e.g. raised acid phosphatase in prostatic cancer ,and positive bence jones protein
(BJP)IN multiple myeloma .
2) Non-specific tests e.g. CBC,ESR,CRP, and LDH.
+ Management :
Aim : to make patient more functional and pain free for the remaining life span .(saving life,limb,it's
function).
Early operative stability (e.g. by internal fixation ) should be carried out .
Other methods in advanced cancer such as chemotherapy ,radiation ,hormonal.
Indication for prophylactic internal fixation (metastasis)-:
1) Involvement of the cortex
2) Increased pain
3) Pure lysis
4) Weight bearing area.


Fractures in children :
Fracture in children has a special consideration for the following reasons:
1) Healing is more rapid .
2) Open reduction is rarely indicated ,except in cases of fracture into joints- .
3) High remolding rate. Especially in angular deformities not in rotation deformities.
4) Growth distribution in epiphyseal injuries.
5) Often missed due to poor communication with the child .b/c the child often tend to cry.
6) X-rays of both limbs for comparison are required .especially if it is near joints.
Children differ than adult in:
1) Children bones are more malleable, allowing a plastic type of bowing injury.
2) The periosteum is thicker than adult &usually remain intact on one side of fracture-.
3) Usually incomplete so,green stick fracture is common .
Fracture caused by child abuse :
Multiple areas of large ecchymosis in different stages of resolution ( from black &blue to brown
&green) Also are pathognomic of child abuse .
Mostly occurs between birth and 2 years of age.
Most commonly occure in long bones (humerus , tibia , femur )
bone scan or a skeletal survey generally is indicated
It may be diagnose d by excludition :
1-Heamophelia 2- metabolic bone disease
E N.B. multiple fracture in different stage of healing are almost indicative of abuse.
E N.B. growth plate b/w metaphyseal & epiphyseal .
A. Physeal injuries :
Represent 30% of fractures.-
Occurred twice as often in the upper extremities as in the lower extremities .
Commonly used classification is that of salter and harris , which is based on the roentgenographic
appearance of the fracture .
N.B. before applying the salter &harris classification you should note the open growth plate .

Salter &Harris classification for physeal injury
Type Features Treatment Prognosis

Epiphysis is completely
separated.
No fractured through
bone.
By closed reduction
Excellent
No growth disturbance

Commonest type (70%)-
Small fracture through
metaphysic.
By closed reduction
Excellent
No growth disturbance

It is intra articular
fracture .(only in
epiphysis)
Accurate reduction is
essential .

Open reduction may be
necessary.
Good

It is intra articular
fracture (in epiphysis
+metaphysic)
Open reduction is
almost always
necessary.
Can be favorable if
anatomically reduced.

Due to severe crushing
force.

No epiphyseal
displacement .
No reduction

Just immobilization by
plaster of paris cast .
Poor.
Cessation of growth
Angular deformity
often occur .-

B. Birth fracture:
Generally it is iatrogenic .
These fractures occur most commonly in the clavicle ''most common -'' ,humerus ,hip ,and
femur .(long bones)
They rarely require surgery .
It is frequently diagnosed as pseudopalsy ,infection, or dislocation.
It may be present as a mass or deformities (length deformity is a common)
Treatment : conservative .

Open fractures (compound fracture ):
Fracture site communicate with the external environment-
Emergency management
Infection will occur with delayed or inadequate treatment-
N.B. periosteom is rich in blood supply ,, thick in children faster healing.
O Management :
A . general care :
Aim: (save life, save limb, then save function (.
Antibiotics directed against staphylococci (most common), and as needed-.
Tetanus prophylaxis.
In ER:
1) Splint to prevent further damage.
2) Check for tetanus.
3) Start with antibiotic.
4) If there is gross contaminated remove .
5) Put wet spong &send to OR.
N.B. don't irrigate , depride, or clean in ER.
B . local care:
Aim : save the limb and function .
Steps of operative procedure:
1. Clean:
Fracture site is covered; Sterile Gauze
Skin shaved, Limb Cleaned Betadiene


2. Irrigation: Plenty of Saline or Water Dilution is the Solution For pollution
3. Debridement(Excise Wound):
Deride = Unleash tight structures
Skin: Excise edges, incise to explore!
Deep Fascia: open widely, Dont Suture!
Dead Muscles: Excise Liberally
4. Decontamination of the bone:
Curette ends, remove dirt
Remove small detached fragments
Keep large pieces
Reduce Fracture, Avoid Internal Fixation
5. Closure???.
Primary Closure Ideal ! Skin Best Dressing
Avoid Wound Tension
Avoid primary suture of Nerves & tendons Except *Clean wounds *< 6 hours +*Expert
Be aware of exception of closure in-:
1) Wound over 6 hrs.
2) High velocity missle injuries (e.g. gun shot wound)
3) Highly contaminated wounds.
4) If closure cause tension of skin edges.
6. Immobilize.
2
nd
: look a patient after 48 hrs???

L.14: EXAMINATION OF THE FOOT AND ANKLE
Anatomy
+ Bone and joints:
Hind foot:1- calcaneus. 2-talus
Mid foot
forefoot
+ Soft tissues
Ligaments
muscles : 1-intrinsic 2- extrinsic .
Examination:
+ Inspection:
1- INSPECTION OF THE PATIENTS GAIT:
Evaluation of the walking cycle:
A. Stance phase 60%
B. Swing phase 40%
2- Inspection in standing position
3- Any asymmetry of length, rotational problem, or mal alignment of the lower limbs.
4- POSTERIOR HEEL STANDING:
Valgus ((eversion )): heel is to the outside of the midline.
Varus (inversion )): heel is to inside of the midline.
5- Deformity, swelling, skin changes, muscle wasting, asymmetry of length, abnormal position.
Note : INSPECT ALL ARROUND
In vagus : to compensate for being longer than the left leg .
In varus: to compensate for being shorter than the right leg.
N.B. the multiple bony projection give us the DDX of Osteoarthritis with Osteophyte .
6- PLANTAR PLANES: Abnormal planes are not parallel.
7- PLANTAR SKIN:Like callosity: over thickening of skin due to overpressure on it i.e. callosities
on side of foot from over pressure during sitting in prayers. But normally (the skin is thick not
over thick b/c of w.t bearing )
8- FOOT SHAPE:

+ Palpation
Bone and joints
Soft tissues
Tenderness, swelling, deformity.
N .B. while inspection &palpation don't forget the planter fascia.
- Anatomical landmarks:
Medial malleolus, lateral malleolus, Achilles tendon, calcaneal tuberosity, peroneal tendon,
tibialis posterior tendon, tibialis anterior tendon, plantar fascia, base of 5th metatarsal, 1st
MP joint, metatarsal heads..etc
N.B. Tibialis posterior tendon found posterior to medial malleolus.
It's easier to feel the depression of the ankle joint line during dorsiflexion &lateral to the
extensor group of bendens-- .
Useful for arthroscopy & aspiration .


+ Movements
Ankle: -dorsiflexion -plantar flexion.
10 degree of ankle dorsiflection is the minimal amount necessary for normal gait. if
not COMPENSATION BY SUBTALAR VALGUS--.
During eversion there is slight dorsiflexion that's why patients with a short tendon
get valgus to compensate to reach the 10 degrees of normal gait.
If tendon is very short Tip-toe walking.
Subtalar: -inversion -eversion.
MOVE THE HEEL:
Inversion---eversion
N.B. subtalar : doesn't move the fore foot-.
Inversion have longer range than eversion .

Midtarsal: -pronation -supination
Midtarsal supinationMove the metatarsals one by one.
N.B. the most rigid metatarsal joint is the second .
Tarso-metatarsals: move the metatarsals one by one.
Toes: especially big toe.
ALL THE TOES SHOULD BE IN GROUND CONTACT IN Weight Bearing.(stability of the
foot on the ground)
65 degree of big toe dorsiflection is the minimal range necessary for normal gait--.
IMPORTANCE OF THE BIG TOE (running, jumping)
Problem of hallux rigidus: b/c of loss of this type of movement due to pain.
EVALUATION BY PODOSCOPE:

1+2+3= pes cavus (high arched- varus result from high arched foot)
EXAMINATION OF THE SHOES:
BAD SHOES:(Too lax-Too loose(wide) -Too flat)--
+ Special problems
1- Pes planus: common 20%
Pain with activity, ugly gait.
INSPECTION STANDING: HEEL, ARCH, FOREFOOT&heel valgus.
LIGAMENT LAXITY: generalized or regional .
EXAMIN THE TENDO ACHILLES
move the heel and the 1
st
metatarsal .
May be asymptomatic
these could be pain and fatigue during walking corrected by foot insoles with rising
the heel- .
Note: tibialis posterior is the main dynamic protector of the medial arch- .
2- Pes cavus (High arch-Varus)
3- ACHILLES TENDON:
Tight: equinus when the foot is fixed in planter flexion due to tight Achilles tendon .
RUPTURE: (signs in prone position)
o depression.
o absence of rest plantar flexion.

o no plantar flexion by squeezing the calf muscles but can do active planter
flexion during standing.
-TENDONITIS: -body. -insertion.

4- TARSAL COALSION:
Painful stiff flat foot Usually bilateral, can be unilateral due to fusion of calcaneus and
navicular or due to a stiff subtaller bone.
Calcaneonavicular stiffness can be seen on x-ray.
-Stiff subtalar.seen only on CT.
MORE COMMON:calcaneo-navicular and
subtalar.
Symptom appear in adulthood.
5- Ligaments injuries:
a) Lateral collateral ligament of the ankle: is
the most common ligament in the body to
be injured (mostly anterior part), varus
stress view AP--.
b) Subtalar ligaments: increased valgus by
standing on one leg-.
c) Syndosmosis lig. inj.: X.Ray AP WB
6- Ankle sprain:
Lateral ligament (special test ):1-Stress view.
2-Anterior drawer
Varus stress: put the foot in inversion
position ,if :
a) Parallel articular surface normal
b) Not parallel with more than 10 degree angulationlateral collateral
ligament injury.
Anterior drawer : pull foot forward while holding leg .
7- INTOING GAIT:
Very common .
Problem could be in any one of these:
a) Internal femoral torsion: exaggerated
anteversion(normally :anteversion 10-15
degree)
b) Internal tibial torsion.(patella &foot are not
alined)
c) Forefoot adduction.(metatarsal varus):
treated by cast in children.
8- PLANTAR FASCIITIS(heel pain syndrome):inflammation
of calcaneal insertion of planter fascia.
a) Any tightness of Achilles tendon.

b) Any mechanical foot disorder.
c) Any use of bad shoes.
Calcaneal spear (as aresult of the disease not a cause)
Treatment :
a) correct the mechanical problem
b) Treat inflammation
c) Physiotherapy

9- Metatarsalgia
Pain of metatarsal head.
Most common on 2
nd
metatarsal(b/c it is the most rigid one )
10- Hallux valgus
3 deformities:
a) Medial deviation of the 1
st
metatarsal joint .
b) Lateral deviation of big toe .
c) Bunion (prominent head of 1
st
metatarsal )
Treat when it is symptomatic .
11- Hallux rigidus:
It is an O.A in 1
st
MPJ cause limited dorsiflexion of the 1
st
metatarsal joint especially
while walking
Treated by give the patient rigid shoes with curved front and back .
Epidemiology :
In K.S.A: OA is common in knee then 1
st
metatarsal.
In west: OAis common in hip.
12- The toes
1- Hummer toes : flexion of proximal &distal IPJ.
2- Clawing toes: flexion in proximal IPJ &extension of metatarsaophalengeal joints
(MPJ).
3- IN GROWN TOE NAIL
4- Hallus valgus deformity.
5- Mallet of flexion of distal IPJ.

L.15: Hip Examination
Look
1- General on patient
Lying comfortably in bed, not in pain.
Lying in bed in pain holding the R thigh in flexion.
Sitting in a chair uncomfortably with the R hip extended.
Sitting uncomfortably in a wheelchair with hips adducted (scissoring) and L hip extended.
Lying uncomfortable in bed.
Lying supine in bed with R hip adducted and internally rotated, L hip abducted and externally
rotated.
2- General local hip, thigh, lower limb
- Position
a. Abduction
b. Adduction
c. Flexion
E.g. Lumbar lordosis
- Major deformity- swelling
a) Lateralised contour
b) Wide perineum
c) Masses
d) Asymmetrical skin folds
- Extra cast, splint, traction, dressing
3- Anatomic local
a. Skin : swelling, scars, colour, hair, dryness
b. Subcut. : LN, veins, nerves, tendons .
c. Muscles : bulk, wasting, twitches .
d. Bones : landmarks, swelling, angulation and deformity.
e. Joints : position, swelling, redness.. ( hip too deep to see swelling )
( Do Not Forget The Posterior Aspect ! )
4- Important Considerations:
o Amount of exposure.
o Duration of exposure.
o Persons present during exposure.
o Place of exposure.
o Attitude and behavior during exposure.
Feel
Tenderness :
generalised
specific
Temperature : compare distal/proximal, R/L
Anatomic :
Skin : dryness, hyper/hypothesia, scars
Subcut. : LN, nerves, vessels, tendons, nodules
Muscle : tone, bulk, twitches, gaps, tenderness
Bone : landmarks ( ASIS, Gr Tr. , Isch. Tub. ) tenderness, mass, crepitus
Joint : swelling, effusion, crepitation, synovial thickening, joint line tenderness ( hip joint too deep
to elicit except in 1- pediatric 2- infants.)
Move
Must differentiate between true hip joint motion and pelvic motion
Must stabilize the pelvis in neutral position
Flexion / Extension
Position of rest could only be determined by a special test : Thomas Test

Extension
In presence of fixed flexion deformity, extension is already in minus
no need to assess !
we have 2 ways:
1-In Lateral Position
2-In Prone Position
Abduction / Adduction
Must stabilize and prevent pelvic motion
Performing abduction / adduction on BOTH hips simultaneously.
Stabilizing one hip at the edge of couch.
Holding ASIS to assess beginning of pelvic motion.
abduction / adduction on BOTH hips simultaneously

Stabilizing the other hip at the edge of couch

Holding ASIS to assess beginning of pelvic motion

Internal / External Rotation
Must stabilize and prevent pelvic motion
Performing Internal / External Rotation on BOTH hips simultaneously:
1) Supine Extended
2) Supine Flexed
3) Prone

Special Tests
Thomas test
Precaution : When knee has fixed flexion deformity
Solution : Keep knee outside edge of couch
Trendelenburgh test

You are testing the hip the patient is standing on !
Normally the pelvis tilts down on the weight-bearing hip.
This is performed by the hip abductors.
Positive Trendelenburgh is when:
the pelvis on the non weight-bearing hip tilts down, and
the trunk has to tilt to the weight-bearing side.
Causes of Positive Trendelenburgh :-
1) Weak hip abductors : paralyzed / wasted
2) Mechanically inefficient hip abductors :
3) distance between origin & insertion reduced : coxa vara
4) Unstable pivot of motion : hip subluxation / dislocation
5) Inhibited hip abductors : painful to move joint
6) trauma (sprains) / infection / irritation / tumor
7) Reduced range of motion : hip incongruent / stiffness / OA

Leg length assessment
Galleizzi

Both heels have to be at the same level


O Apparent Length E True Length
Midpoint to Medial Malleolus ASIS to Medial Malleolus

Neonatal Examination for CDH:
1- Ortolani. 2- Barlow.
Remember (Feel Clunk - Not hear click !)
Gait - walking
Gait walking Gait cycle :
Normal gait.
Antalgic gait.
Lurch.
Circumduction gait.
High-step gait.
Tip-toe walking.
Stance phase:
Heel strike.
Mid-stance.
Push off.
Swing phase:

L.16: Presentation & DDx in Orthopedics
Dr. Hazem
1- Pain:
- Shoulder:
a. Systemic
b. Referred from:
GB,
heart,
diaphragm,
Ms. Skeletal (cervical spine=redicualr pain)
-Radiculated pain points at C
4
(spine of scapula)
-differs from shoulder pain which could be infront or back (angle of acromion)

c. Local
acromioclavicular Top
glenohumeral Anterior
3-Rotators think of nerve supply
(the ptn feels it at deltoid insertion)
C5,C6 rotators
C5 deltoid
C5
Rotators : presented with pin point pain anterior.
Cervical : sharp pain .
- Back pain: Middle back pain (Lumbosacral) :
Between L4-5 usually:
1-hip
2-sacroiliac joint: more common, sacral place (L4,5-S1)
Could be dye to :
1- Disc disease: (Root is compressed in chronic disc pain
setting worse than walking--> worse than standing
lumbosacral & radiation to back (postrolateral thing) supply of sciatic could reach
to foot & toes
disc pain associated with (numbness-weakness)
2-Spinal stenosis
The spinal cord is compressed (in the cord, not the root)
*The canal could be stenosed by anything: e.g. Osteoarthrosis, Thick
ligamentum flavum, central disc
The presentation is the same whatever is the cause
Typically: pain in the back of the thigh after a period of walking, this pain relieves
immediately with : bending forward & setting immediate relief Neurologiacal
Claudication -no numpness-
(While vascular claudication occurs in calf muscle & needs time to relief)


- Hip & Knee
- Refer to each other
- Whats common?
- hip & knee sharing in L3 in( dermatom & joint suppply)
- Think of myotomes:
Hip Flx. 2-3
Ex of knee 3-4
Both has 3 reffered to each other
Ex of ankle 4-5

Ex of hip 4-5
Flx of knee 5-1
Flx of ankle 1-2

inversion 4-5
eversion 1
Hip pain
* Point to groin (Anteriorly) referred to knee in Medial side
Pain in the same area but other than hip:
if posteriorly--> sacroiliac
if lateral--> bursitis
Knee pain
Anterior knee pain refers to hip in the same area usually pattellar & mainly patellofemoral joint
e.g OA
Posterior knee pain (from popleteal structure) e.g. torn meniscus posteriorly & with flexion
Medial & lateral knee: Osteoarthrosis mainly

2- Swelling:
* Dont forget to auscultate for bruit & to palpate for thrill, especially if you are suspecting a tumor.
Mass depth: with muscle contraction: it will be smaller if its below the muscle but if it is above the
muscle, contraction will make it more obvious& nothing will happen if it is from muscle.
Tenderness, consistency, discharge, is it pulsating

3- Deformities:
Knee: varus is important, valgus (in Rhumatoid), recurvatum (=hyperextension, is also common in
Rhumatoid), flexion.
Hip: FFD, abduction & adduction instead of valgus & varus
Fixed flextion deformity: To compensate:
he will hyperlordose the back by tilting (the most common)
or equines if it for little deformity-
Or flex the other knee
abduction & adduction in hip:
usually d.t. ms. contraction
adduction: the pelvis will be tilted & higher in the affected side
abduction: pelvis is lower in the affected side
- So (dont forget to examine for shortening)


4- Limping:
- 2 types are IMP :
1-antalegic gate (painfull gate)
shortening in stance phase

2- Trendelengburg:
Test: examine abductors (Gluteus medius & minimus ) of weight bearing
e.g. Ptn who has abduction weakness in Rt, if he stands on it, the trunk will tilt to Rt
although the pelvis is more lower in the left side
if bilateral we called it (waddling) .
5- Instability:
Knee
a. ACL: the most severe if occurs on flat ground (gives: giving away)
b. Quad: weakness ex. feel as if something is going out (you need it in extension to do locking) (gives:
Pseudogiving way)
c. PF: PF subluxation (gives: Pseudogiving way)
Do apperhention test & axial x-ray of (sky line) patellofemoral joint on flx 45
0
degree & take the image you
will see (Shifed or tilted patella)

6- Clicking:
In adult if painful injury of meniscus
Is painless chronic meniscal injury or habitual

7- locking:
- Deformity: loss of extension
- Causes:
Menisci, cruciates, ostephytes, foreign body

8- Crepetus
Mainly in osteoartharosis

L.17: Peripheral nerve injury
Dr. Al-Harby
What is peripheral nerve?
It is a nerve which connect between CNS & periphery.
When it is damage, there is chance of regeneration unlike of CNS.
It is composed of: cell body, axon & nerve end.
Always mixed (contain both sensory & motor fibers).
If the cell body is motor: it is located in ant. Horn cell (motor end plate).
If axon is sensory: it is located in post. Horn cell .
Rehab. Is very important in peripheral nerve injury.
Definition:
Partial or complete interruption of normal physiology of nerves (nerve conduction is affected).
Types:
1-Neuropraxia:
E.g: when you set for long time you feel numbness.
Commonest & easiest in recovery
Reversible failure propagation of electrical impulses across the affected nerve segment.
No anatomical change of the nerve structure (anatomy is intact).
Duration: usually: sec-min.
Rare: hrs-days.
e.g:
Saturday night palsy :alcoholicsradial nerve palsy
Honeymooners syndrome.
Wheel chair bound persons.
2-Axontemesis:
Complete absence of sensory & motor activity of that nerve
Associated with accident & trauma:
-fracture of humeral shaft radial N. injury
-fracture of medial epicondyle ulnar N. injury.
- fracture of proximal fibula peroneal N. injury.
-fracture of acetabulum & post. Dislocation of femoral headsciatic N. injury.
No sensation or motion (loss of N. function).
Axon+myline sheath are damaged (histological changes).
The cell body losses its continuity with N.
Endo, epi, perineum are intact (fascia is intact).
Anatomy is intact.
There is wallerian degeneration.
Good prognosis.
3- Neurotemesis:
Anatomical damaged in the nerve (N. ends are not in continuity)complete disturbance of activity
of that N. + loss of supporting tissues.
There is wallerian degeneration.
Prognosis is poor& worst without surgical repair.
Wallerian degeneration:
It is a process of proximal part regeneration &distal part degeneration of the N. regarding to the damage
site.
Length of regeneration:1mm/day . e.g: if the length of sciatic N. injury is 50cmit needs 500 days to
recover.
During the period of regeneration, if the distal part is not stimulated from outside lead to atrophy of
motor end plate & loss its function. So, you have to stimulate motor end plate by rehab to prevent
degeneration of it ((it is not reversible))--.

If the anatomy is intact (axontemesis) no need to repair.
If the anatomy is disturbed (neurotemesis) you have to repair. Then wait for regeneration.
N.B: if the tunnel is not in continuity that is mean there is no stimulus for regeneration which may cause
neuroma (group of N. tissue which dose not have any function).
Rehab.
Pain control by simple analgesia.
N. & muscle stimulation.
Dynamic splints to avoid stiffness. (you have to prevent pressure sores).
Nearby joints range of motion by doing passive movement to prevent muscle stiffness.
It takes months-years (long time) to recover.
Remember:
Pressure sores developes due to the pressure of splibt in case of complete loss of sensation of the
splinted limb.
You can prevent pressure sores by padding the splint with cotton between splint & limb.
Etiology:
Acute:
Fractures (the commonest)axontmesis.
Wrong position (Saturday night syndrome, handicap){ neuropraxia}.
Surgery.{neurotmesis}
Electrical burn (the worst) because it damages everything.
Chronic:
Tight N. passage (e.g: carpal tunnel syndrome, tarsal tunnel syndrome).
Tumors which compress the N.
Presentation:
Hx of trauma.
Loss of sensation.
Loss of motion
Loss of power.
Loss of reflexes.
Muscle wasting.
Contractures (deformity).
Tropic changes: loss of normal well being of limb due to disuse (shiny skin, hair disturbance..).
Dx: Confirmed by:
X-ray: in trauma.
EMG: study of muscle electrical activity.
NCS (N. conduction study): study of activity of electricity in the N. itself.
MRI. ( like in brachial plexus injury so, we use it in special cases).
Erbs palsy:
birth injury (difficult labor e.g: shoulder dystocia & breech presentation).
Traction often on N. roots C5-C6 but may occure on C4-C7-C8.
Stretch or rupture or avulsion the worst.
Upper limb in extension + internal rotation waiter phenomena.
Mother notice no motion in the affected limb.
90% good recovery.
Remember: rehab. Is important.
Role of surgery after 3 months of life: explore & repair.
Fracture of clavicle does not cause Erb,s palsy.--


Carpal Tunnel Syndrome:
Median N. entrapment due to thickening of flexor retinaculum.
Presentation:
-Pain, numbness, worse at night & wakes pt. from sleep.
-Weakness + burning sensation: with bending the wrist forward.
-It affects:
-lateral 3 fingers
-thenar area is wasting.
Female > male: with pregnancy & hypothyroidism no explanation.
in manual workers.
Dx:
-clinical.
-needs NCS to confirm the Dx.
Rx:
-conservative (not helpful).
-no role of medical Rx.
-surgical (main procedure for this condition) just open the flexor retinaculum.
-immediate recovery post-operatively.
Radial N. injury:
The common cause: humeral shaft fracture at the junction between middle & lower third.
Presentation:
-Wrist drop (cannot extend).
-Loss of sensation in snuff box area (numbness).
Rarely disturbed anatomically.
Rx:
-conservative (dynamic splint).
-if no improvement within 3 months surgical intervention.
N.B: dynamic splint= splint with joint movement but static splint= splint with no joint movement.
Ulnar N. injury:
Associated with elbow injury + tight compartment-.
Usually in children with supracondylar fracture-.
Presentation:
-numbness in medial 1 fingers.
-wasting of hypothener muscle.
-in late stage: CLAW hand (extention of MCP +flexion of IPJ) due to loss of lumbrical & interosseous
action.
Rx: as in radial N.
Sciatic N. injury:
With trauma or post. Dislocation of the hip + distal injury to its branches ( post. Tibial + common
peroneal).
Presentation:
-loss of sensation & motion below the knee level.
- loss of all activities (flexion, extention.) below the knee level.
- extention of the knee is not lost.
Long period of recovery.


Peroneal N. injury:
Presentation:
-foot drop no heel strike= inability to extend the foot.
-loss of sensation.
-leg weakness.
Causes:
-Direct injury is rare.
-tight splint without proper cotton padding.
-skeletal traction.
Rx: -skeletal traction.
-dynamic splint.

Quiz:
Px for neuropraxia is poor. X
Wallerian degeneration typically dose not occur in neuropraxia.
Wallerian degeneration dose not occur in neurotemesis. X
Surgical reconstruction is necessary in neurotemesis.
Ligamentous structure can cause neuropraxia.
Axon degeneration happens in mild compression. X
Axontemesis is generally caused separation of cell body from the neuron. X

L.18: OSTEO-ARTHROSIS
INTRODUCTION
Osteoarthrosis (OA) is non-inflammatory degenerative(defect in cartilage, then after that, inflammation as a
secondary response) disorder of synovial joints, affecting the articular cartilage (N.B. The changes in the synovium
in OA are secondary to articular cartilage lesions, in contrast to Rheumatoid Arthritis, where the primary lesion is
in the synovium).
N.B. in Rheumatoid Arthritis it starts first with an inflammation in the synovium.
OA has two types:
1) Primary OA: like congenital defect in the cartilage.
No obvious predisposing factor can be identified idiopathic
Possible intrinsic factors include: mechanical, vascular, & cartilaginous factors.
Usually bilateral and commonly seen in old ages.
2) Secondary OA:
Local or systemic causes are present. E.g. trauma, infection, congenital disorders, bleeding disorders,Wt.
load, etc..
Note:
Secondary OA is more common in our community than western countries.
OA of hip or knee is often secondary OA.
Obesity is considered to be a cause of secondary OA.
Whatever the cause, the final pathway of changes in articular cartilage is identical.
It is usually a mono-arthritis, but in the knee it may be bilateral.
Predisposing Factors:
1. Increased loude.g. Obesity (N.B. the hips & knees takes 3.5 times the body weight each, with each step). In
jogging and squatting the cartilage take a high stress.
2. Trauma e.g. Intra-articular fracture. Malunited fracture in the proximity of a joint & sport injuries in
athletes, the good muscle bulk delay the presentation(This is why there is increased tendency nowadays
toward surgical intervention in sport injuries) Also, Direct injury to the cartilage.
3. Congenital Disorderse.g. congenital dislocation of the hip &multiple epiphyseal dysplasia. CDH cause earlier
presentation at 20 years.
4. Infections e.g. Septic Arthritis.
5. Inflammation e.g. Rheumatoid Arthritis.
6. Necrosis e.g. Perthes disease, steroid-induced & other types of Osteonecrosis.
7. Hematological Disorders e.g. Hemophilia (due to recurrent Hemarthrosis) &Sickle Cell disease (most
commonly in the hip & shoulder due to arteriolar occlusion).
8. Metabolic disorders e.g. crystal deposition diseases {such as Gout(in small joints, also the knee may be
affected, especially in the lower limb)&Calcium Pyro-Phosphate Di-hydrate (CPPD) deposition
disease}&Pagets disease.
9. Endocrine disorders e.g. Diabetes Mellitus&Acromegaly.
In DM, the exact relation is unknown, but the increased incidence of capsulitis, tendonitis & other soft
tissue & joint diseases among diabetics may play an important role in addition to diabetic
neuropathy.
In Acromegaly, OA is possibly due to joint incongruity following cartilage overgrowth, or because of
mechanically defective matrix resulting from the endocrine disturbance.
10. Neuropathy, Examples in the lower limb include: DM, Syphilis&TabesDorsalis; while in the upper limb it is
usually due to Syringomyelia.


Note:
Neuropathic OA is a rapidly progressive degeneration in a joint which lacks proprioceptive &
protective pain sensations, leading to completely unorganized destroyed painless joint Charcots
Joint.Charcots Joint destruction of the joint & early healing with repetition.
11. Hereditary factors e.g. Multiple Skeletal Dysplasia& Primary Generalized OA.
Note:
Primary Generalized OA has two types: nodal & non-nodal
Nodal type characteristically affects, in addition to other joints, distal and/or proximal inter-
phalangeal joints of the hand, with the development of gelatinous cyst or bony outgrowths on the
dorsal aspects of these joints (Heberdens nodes are in DIP joints, while Bouchards nodes are in PIP
joints).
Occupations that commonly predispose to trauma as in manual workers.
Epidemiology:
Common in our community especially in the knees (most common site in our community).
In western countries, 90% of individuals over 40 years have degeneration of weight bearing joints
(though asymptomatic).
In western countries, males are more commonly affected than females before 50 years of age, but
after that females become more commonly affected. In KSA, females are the most commonly
affected in all age groups.
In our community, OA is seen in younger ages more than other countries.
Some studies have shown that obese people have more degenerative changes in weight
bearingjoints than non-obese.
Most of the people have a degenerative changes orthoscopic finding after the age of 40s.
Common Affected Joints:
1- Knee
2- Hip
3- Cervical & Lumbar spine.
4- 1
st
Carpometacarpal Joint (CMJ).
5- 1
st
Metatarsophalangeal Joint (MTPJ).
6- Interphalangeal Joints (IPJ) of the hand.
N.B. Shoulder OA is not commonly seen except in case of secondary OA, especially due to Rheumatoid
Arthritis &Sickle Cell disease.
PATHOLOGY
Cellular Changes:Normally 80% of the cartilage is water.
The first initiating event is possibly fatigue fracture of the collagen fiber network in the cartilage
matrix (N.B. The collagen matrix consists of collagen fibers embedded in a firm, hydrated gel of
proteoglycans & structural glycoproteins).
Swelling and softening of the cartilage follows. (due to increased water content).
Then, gradual depletion of proteoglycans in the matrix happens.
Because of proteoglycan depletion, there will be abnormal distribution of body weight over articular
cartilage, leading to chondrocyte damage.
The damaged chondrocyte release proteolytic enzymes resulting in more destruction of collagen
fibers (N.B. Secondary inflammatory response will happen at this time, but remember that it is never
the primary factor in OA).
Then, fibrillation on weight bearing surfaces of the cartilage ensues.

Synovial fluid will be pumped into sub-chondral bone through fissures in the articular cartilage cyst
formation especially in areas of greater stress.
After the exposure of the underlying bone, there will be attempts to repair & counteract the
increased load resulting in sub-chondral vascular congestion, bone sclerosis & eburnation (Ivory-like
polished areas).
Note:
Due to injury to secreting cells & increased water content, the produced synovial fluid will be thin &
therefore will be less able to act as a lubricant & shock absorber.
Sequence of events:
1- Cellular changes of articular cartilage leading to flaking and fibrillation.
2- Cartilage erosion and decreased joint space.
3- In the attempts to strengthen the articular cartilage, peripheral unstressed areas of the cartilage
proliferates & ossifies producing weak bony outgrowths Osteophytes that may form loose bodies if
separated resulting in locking of the joint.
4- Synovial and capsular thickening.
5- Progressive weakening of sub-chondral bone leading to bone collapse & deformity.
6- In addition to the above changes, distortion of the ligaments may happen, leading eventually to mal-
alignment and subluxation of the joint.
N.B. - In the knee, the most common deformity in Osteoathrosis is Varysdue to ligament laxity.
- Lateral Thrust Is a clinical presentation of the patient with OA.

CLINICAL FEATURES
Symptoms:P.I.N.S.D
1) Pain:
It is the main presenting symptom. (MCQ)
It is also the main indication for surgery.(MCQ) The indications for surgery: (MCQ)
1- Pain (90%)
2- Sub-laxation
3- Severe bone erosion
Site
Radiation: pain in the back, hip & knee can be referred to each other.
Nature: it is aggravated by activity and relieved by rest, although ,with time, relief is less & less
complete (at advanced stage, night pain waking the patient up may be present).
Relation of pain to stairs, praying & sitting.
2) Stiffness:
At early stage, stiffness will be in the morning & after prolonged rest because of stasis &
congestion around the joint capsule. Later on, stiffness will be more severe & may become
continuous.
3) Deformity:
Fixed flexion deformity.
Varus or valgus in the knee (the usual deformity is varus; if it is valgus, you have to think about
associated Rheumatoid Arthritis, or history lateral meniscal injury).
Abduction or adduction deformity in the hip (remember: coxavara&valga describe the
relationship between the head & neck of femur, but not the hip joint deformity; therefore they
should not be used here).
4) Instability: giving away
E.g. instability of the knee due to degeneration and rupture of the anterior cruciate ligament, or
quadriceps weakness.
5) Nodules:
In the hand (Heberdens& Bouchards nodes).

Signs:E.M.T.I.C.D.N
1) Swelling (due to effusion, synovial & capsular thickening and/or Osteophytes).
2) Painful movement.
3) Decreased range of movement (active & passive).
4) Crepitus (due to rough articular surfaces).
5) Instability.
6) Deformity (see above).
7) Nodules.
8) Positive Trendelenburgs test (hip OA)
9) Painful Straight Leg Raising test (hip or back OA)

INVESTIGATIONS
No specific investigation for OA is available except X-ray.
Secondary causes should be excluded.
Synovial fluid analysis is requested if there is suspected infection especially with suddenly painful,
red & swollen joint.
Blood tests are normal especially in primary OA.
X-Ray:
AP & Lateral standing views are needed especially in case of hip or knee OA.
Skyline (or Axial) view should be obtained in knee OA to show patello-femoral joint.
(All three must be done to the knee)
X-ray features of OA:
1) Narrowing of joint space.
2) Subchondral sclerosis.
3) Bone cysts.
4) Osteophytes.
5) Mal-alignment (e.g. Varus deformity).
6) At the end stage:
- Subluxation.
- Bone erosion.
- Loose bodies.
- Tilting of the patella.
7) Evidence of primary cause in secondary OA may be present e.g. old fracture, Rheumatoid
Arthritis, etc.
- Sometimes, you may find Migration of hip joint or Subluxation of knee joint.
N.B. In positive SLR, there are two ways to differentiate between back & hip disease:
a) In active SLR, there will be pain in the first 20-30 if the hip is affected.
b) Lasegue test.
N.B. Pain in deep flexion indicates patella-femoral abnormality as well as pain on climbing
stairs.


TREATMENT
Aims of treatment:
1- Relieve pain.
2- Increase range of movement.
3- Reduce load.
Available measures of treatment:
A) Conservative treatment.
B) Surgical treatment:
1- Arthroscopic debridement.
2- Osteotomy.
3- Arthrodesis.
4- Arthroplasty.
A) CONSERVATIVE TREATMENT
Weight reduction in obese patients.
Load reduction especially in obese patients: can be achieved by using walking stick[external support.
Used by the opposite hand to the affected leg (strengthen the muscle)] (used in moderate to severe
OA) and the avoidance of prolonged, stressful activities.
Physiotherapy the most effective conservative(including muscle & range of movement exercises&
modify the activities) this is aimed at:
1) Strengthening the muscles around the joint to take off some load from the affected joint,
therefore decreasing the pain and slowing the progression of the disease.
2) Increasing the range of movement of the diseased joint.
Medications:
Systemic drugs: at first, Paracetamol is used as an analgesic, if not effective NSAIDs can be used.
Local injections:
1- Hyaluronic acid injections:
- Hyaluronic acid is a major constituent of synovial fluid and serves as a lubricant & shock
absorber.
- These injections are effective in patients with mild to moderate X-ray changes (no bone
erosion, subluxation nor many osteophytes).
- A course of 3 injections are given (1 injection/week).
- Adverse effects include:
1- Hypersensitivity especially if derived from birds.
2- Local reaction at the injection site.
Hyaluronic acid injection is not given in:
o RA
o ACL?
o Instability
(MCQ) Dont give it in acute exacerbation (..?) disease.
Not steroid
+ Steroid is given only in OA in acute stage, because the steroid will only relief the
inflammation, but not on the bone erosion.
+ Before using steroids or other injection we have to drain the effusion?
2-Steroid injections:
- Always try to avoid them except in case of very acute exacerbation of pain & other
signs of OA (because steroids can accelerate the progression of the disease by causing
osteonecrosis in the affected joint).
We usually use the COX-2 selective drugs to avoid the adverse effect.

B) SURGICAL TREATMENT
1) Arthroscopic Debridement:join lavage
Consists of washing the joint, diluting the proteolytic enzymes, removing osteophytes &
shaving irregular surfaces.
Used in moderate OA (bone is not exposed yet).
It usually provides temporary symptom relief for about 6 months up to 1 year.
In OA, this method is applied only in the knee. (MCQ)
N.B. If Hyaluronic acid is not working well then mostly the lavage will not work
2) Osteotomy:
Aimed at overrealigning the deformed joint (e.g. varus/valgus in the knee (10 valgus instead of
7 valgus), abduction/adduction in the hip) in order to decrease pain & slow the progress of the
disease by:
o Redistribution of body weight to less damaged parts of the joint.
o Vascular decompression of subchondral bone.
Used mainly in:
o Hip
o Knee
Indications:
1- Very narrow joint space but not complete loss of the space, many osteophytes and/or severe
night pain.
2- Failed arthroscopic debridement.
The patient must be:
- Young (< 55 years).
- Thin to reduce the post-surgical complications such as bone collapse, in addition to the
problems of prolonged rehabilitations).
- Active.
The joint must be: (MCQ)
- Mobile.
- Stable.
- Minimally deformed.
Note: There must be overcorrection of the deformity in order to decrease the load on the damaged part of the
articular cartilage. For example, the knee is normally in slight physiological valgus (about 7) and therefore about
60% of the weight is on the medial side of the knee, while 40% is on the lateral side. In case of 10varus deformity
of the knee, the amount of correction should be 10 + 7 + 3. Overcorrection = 20 (now, 40% of the weight will
be on the damaged medial side & 60% on the lateral side)
According to the (functional?) axis of the knee center of hip & center of the ankle..the center of the knee..
3) Arthrodesis:for youngers as theyre more active, because total replacement will
fail in such a patient.
It is surgical fusion of a joint aimed at:
o Conversion of painful stiff joint to painless stiff joint.
o Stabilizing a joint in a functional position.
Used in:
o Wrist
o Ankle
o Hand

o Cervical & Lumbar spine
o Hip & Knee (uncommon because this will lead to secondary OA in the ankle joint)
All are primary treatment except for the hip and knee which is usually secondary and
rarely primary, unless patient with infection we do to him arthrodesis for hip & knee
Indications:
1- Failed total joint replacement.
2- Neuropathic OA (total joint replacement has given bad results with this type) so the best
treatment here is Arthrodesis. The problem here is that it was bilateral so do one joint &
think of another solution for the other one.
3- Stiff, painful joint (MCQ). like in (sicklar?) patient, not replacement!
4- Loss of quadriceps action (due to paralysis or rupture). Like due to polio
5- Flail joint.
Contraindications (applied to lower limb OA):
1- Bilateral disease.
2- Ipsilateral joint problem (e.g. diseased hip & knee on the same side).
3- The presence of lumbar spine OA in addition to the affected joint (N.B. lumbar spine OA alone
can be treated by arthrodesis).
4- Contralateral hip problem.
Disadvantages: It transfers the load to the most distal joint leading to secondary OA of that joint.
4) Arthroplasty:
There are 3 types:
- Excisional arthroplasty.used as a mode of treatment of small joint of the hand and foot
& in large joint hip & knee if theres infection.
- Partial replacement.
- Total replacement.
A) Excisional arthroplasty: It gives a good range of motion.
Means removing part of a joint to create a gap at which movement can occur. It is aimed
at allowing painless movement at the expense of stability (pseudoarthrosis).
Used in:
- 1
st
Carpo-Metacarpal Joint (CMJ).
- Metatarso-Phalangeal Joint (MTPJ).
- Post infection in the hip GirdlestonesArthroplasty & the knee.
Indications:
1- Severely stiff & painful joint especially in hand & foot. Like RA
2- Post infection in the hip & knee. selected
Disadvantages:
1- Weakening the joint (unstable joint)
2- Shortening.
3- Need of walking aid. So, not weight bearing
B) Partial replacement Hemiarthroplasty: In general, not for
inflammatory, nor infection
o Means replacing part of the joint (either one articular surface as in the hip, or one
joint compartment as in the knee).
o Used in:
Hip (not in OA) (MCQ)
Shoulder.
Knee.

Intra-articular fracture of the femur.
o Indications:
1- Necrosis.
2- Trauma.
3- Degeneration.
4- Inflammation (only for the shoulder; because total replacement of the shoulder
easily ends with loosening).
o Contraindications:
1- Infection.
2- Inflammation e.g. Rheumatoid Arthritis (except the shoulder non-weight
bearing) (MCQ)
3- Young patients (especially in the weight bearing hips & knees; because the
prostheses need to be changed later due to their relatively long life expectancy,
also young people are usually active & therefore the prostheses will last less than
expected).
Note: acetabulum &glenoid should be in good condition before considering
hemiarthroplasty in the hip or shoulder. Similarly, one compartment should be normal
in the knee joint. Therefore, hemiarthroplasty cannot be used in case of hip OA,
because both joint surfaces are affected, also should not be used in the knee if both
compartments are affected. (MCQ)
C) Total replacement:
o Means replacing both surfaces of a joint. It is aimed at realigning the joint in order
to decrease pain & increase movement.
o Used in:
- Hip & Knee (most common joints).
- Shoulder (not advisable; see above).
- Elbow.
- Ankle.
o Indications:
1- Pain.
2- Stiffness.
3- Deformity (with pain & stiffness).
4- Old patients (> 50 years).
o Contraindications:
1- Infection (Acute T.B.)
2- Neuropathic OA (see above).
3- Loss of extensor mechanism. (Paralytic)
4- Relative contraindications (i.e. you have to look for other options before
considering total replacement):
a) Young patients (see above).
b) Active & athletic patients.
Note:
- Consider goals of the patient, his/her occupation & lifestyle.
- Loosening, mal-alignment & bone erosion are the end stage to be reached by all prostheses
(when to reach this stage depends on the patients activity, lifestyle, etc.).
- Exclude infection in any case of loosening of the prosthesis.
- The patient should not overstress the prosthesis by participating in contact sports or other
stressful activities.
COMMON SHORT NOTE QUESTION:
Discuss the clinical features and treatment of osteo-arthrosis of the knee joint in an elderly patient.
A patient 1
st
time comes to you with night pain, complete loss of joint space & no benefit from NSAIDs, Whats
the best Px?
Total knee replacement
A.S.A.

OSTEO-ARTHROSIS NOTES
Degenerative not inflammatory.
Affects the cartilage.
Rheumatoid is inflammatory.
Primary causes:
- Aging.
- Intrinsic defect (mechanical, vascular & cartilaginous factors.
- Idiopathic.
Secondary causes: (Extrinsic)
- Infection.
- Inflammatory (Rheumatoid).
- Instability (lig. Injury).
- load (obesity).
- Trauma (# intra-articular)
- Hematological (sickle cell, hemophilia)
Predisposing factors:
- load (obesity). N.B. Hips & knees takes 3.5 times the body weight each, with each step.
w/ jogging .
- Trauma. Direct, mal-union, sport injury.
- Dysplasia (congenital).
- Necrosis (e.g. Pethes disease).
- Metabolic (gout).
- Endocrine (DM, Acromegaly)
- Neuropathic (Syphilis, DM)
Epidemiology:
- Strong relationship between obesity &Osteo-Arthrosis.
- M > F ; < 50 years
- F > m ; > 50 years
- Here (in KSA) F > M in all age groups.
Common joints:
- Knees (sicklers?, CDH).
- Hips.
- Cervical spine (30 years), Lumbar spine.
- (CMJ).
- (MTPJ).
- (IPJ).
Pathology:
- Water in the cartilage matrix.
- Proteoglycan load on cells
- Chondrocyte damage &synovitis.
- Proteo-lytic enzyme release.
- Collagen disruption.
- Underlying bone is exposed Sclerosis sub-chondral sclerosis
- Fissures in the cartilage pumping of synovial fluid sub-chondral cysts.
- Hyper-vascularity of sub-chondral bone en-chondral ossification ossification of the
cartilage on the periphery.
- Osteophytes
- Bony collapse weak bone
- Loose bodies.

- Mal-alignment.
Symptoms:
- Pain (imp.) main indication of surgery.
-
-
-
- Valgus is common in inflammatory disease.
Investigation:
DDx: (to exclude)
- Septic Arthr. (acute).
- Sicklers. (acute).
- Rheumatoid. (chronic).
- Hemophilia. (chronic)
3 X-ray views (standing):
- AP
- Lat.
- Skyline
Sub-laxation:
- Of tibia Lat. Because of laxity (stretch).
- Of LCL & tight MCL (relaxed).
Erosions are posterior-superior in the hip then medially.
Rx:
o Early:
- Weight.
- Paracetamol.
- Physiotherapy.
o Then:
- Weight (10 15 Kg).
- NSAIDs.
- Local injection:
Steroids if acute.
Vesico-Supplementation (do not give in effusion) by erosion of bone in
mild & moderate disease
- load by stick.
Then Surgery
1- Joint lavage & Debridement
- In knee only!
- 60 70 % success rate
2- Osteotomy:
- In mobile & stable joints & young, thin, active patients
- Normal valgus 7 + Abnormal varus + 3 50 lat. 50 med.
3- Arthrodesis:
Where? (Small joints)
- Wrist & hand.
- Ankle.
- Cervical spine.
- Hip & knee (less common)
Why?
- Converts painful joints to painless joints.
- Stabilizing a joint.

3 in hip 2 (osteo?) in knee due to increased load on knee
Indications:
- Failed TKR (Total Knee) due to infection.
- Neuropathic (Charcots).
- Stiff, painful joint.
- Loss of quadriceps action.
- Flail joint.
Containdications:
- Bilateral disease.
- Epsilateral joint problem.
- Lumbar OA.
- Contralateral hip problem.
4- Arthroplasty:
a) Excision
Why? allow movement in severe painful joint.
Where?
- Hand & foot.
- Hip (Gridlestones) after failed THR.
Not TB old.
b) Joint replacement:
1) Partial (hemiarthroplasty)
Where?
- Hip (#).
- Shoulder (Rheumatoid Arthritis).
- Knee (OA).
Contraindications:
- Infection.
- R.A. (excluding shoulder).
- Young
2) Total replacement:
Why?
- Relieve pain.
- Improve movement.
- Realign.
Where?
In any joint, but commonly hip & knee
Indications:
- Pain.
- Stiffness.
- Deformity (w/ pain & stiffness).
- Old patient (> 60 years) not necessarily.
Contraindications:
- Infection.
- Neuropathy.
- Loss of extensor mechanism.
- Young patient (relative).
- Active/Athletic patients.


L.19: TRACTION IN ORTHOPEDIC
DR. TARIF AL-AKHRAS
Introduction:
Traction treatment involves the use of puling force to a part of the body to overcome muscle spasm,
shortening and some time the effect of gravity. As well as acting on limbs, traction can be applied to the
pelvis and spine. By controlling movement of the injured part, traction enables bone and soft tissue to heal
and can be used as a method of treatment (in inflamed limb always put it in rest position).
Indications :
Restoring and maintaining of bone alignment following fracture.
Resting inflamed joint and maintaining them in functional position (e.g. elbow in 90 flexion , wrist in mid
dorsiflexion , hip 15 flexion , knee 15 flexion , ankle: in a man neutral but in a lady in equines

Gradually correcting deformity due to contracted soft tissue (it is one of the ways to correct fixed flexion
deformity in rheumatoid patient)
Relieving pain due to muscle spasm.
Types of traction :
1. Manual traction.
2. Skin traction.
3. Skeletal traction.
4. Traction by gravity (hanging) : used only in fracture of proximal humerus & apply cast below fracture site.

1. Manual traction (closed reduction):
Exerted directly when the physician pulls on the part during manipulation to obtain closed reduction of a fracture or
dislocation e.g. hip dislocation.
2. Skin traction:
It is most commonly used in lower limb # putted distal to the # site , connect it to a bulley with weights.
In children ( cuz conservative treatment is better for them).
In temporary ( as first aid when they are not ready for theatre) management in adult ( femoral
fracture or dislocation cuz their main treatment is surgical (internal fixation) , we want mobilize
them & discharge them as early as possible.
Contraindication to skin traction:
E Pre-existing health problem which predisposes the skin to damage and poor healing (DM,
varicose ulcers and use steroid drug , fragile skin ).
E Any wounds, sores or rush in the area where traction to be applied (friction burn).
E Marked swelling in the area : we fear of vascular compression & compartment syndrome.
E A history of hypersensitive skin ( allergy).
E Any suspicion of circulation problem.
Advantages of skin traction:
Easy to apply.
No hazard of bone infection or epiphyseal
plate injury.
Types of skin traction:
1-gallows traction:
Skin traction for both limbs (for balance) & use
countertraction of body & buttoks should not touch bed used in children & contraindicated in
whom above 3 years or above 16 kg weight , but why this C.I. ? cuz it will affect the circulation
& may predispose the child to arteriosclerosis & regional osteoporosis (it was used in past for
CDH ).
2-fixed traction ( Thomas splint):
Used to transfer patient from hospital to hospital ( not permanent cuz it may cause pressure
sores) ; found in ER & ambulance.

3. Skeletal traction :
Achieved by inserting Kirschner wire or Steinman pin directly into the bone , it is done in OR
under sterile condition , its set is composed of : Steinman pin , bohler braum , hand drill ,
T-handle , K-wire (needs to be tensed to become stronger) , cratch field for skull traction.
The most commonly used sites for pin insertion are :
- Upper tibia ( choose 2 points which are 2cm below &2cm medial & lateral to tibial
tuberosity , do criss cross incision to locally anesthesize the periosteum & skin then
insert the pin or wire from one side to reach the other side then tense it by bohler &
immobilize it & put a bulley with weight which is 1/10 of body wt. for skeletal
traction but not exceeding 5-6 kg. for adult in skin traction) for short time & average
wt..
- Femoral condyle (under GA cuz it is deep & we apply a heavy wt. for long time e.g
dislocation of hip & acetabular # )
- Calcaneum.
- Olecranon.
- Skull .

Complication of skletal traction :
1. Infection :
predisposing factors :
o Poor insertion technique (non-sterile).
o Loosening of the pin called pin tract infection.
o Tension of the skin and subcutaneous tissues leading to necrosis traction which
lead to infection so , we do criss cross incision to prevent pressure on skin.
2. Over distraction of the bone fragments if you apply heavy wt. & to overcome it x-ray pt.
regularly every day
3. Nerve damage : can result from the use of heavy traction forces.
4. Breaking of the pins (rarely) or wire (more common but it is very thin so low risk of infection)
N.B. use the same principle of elizarov & to made the weak K- wires to become strong

Plaster of Paris
E POP was first used in orthopedics by Mathysen, a Dutch surgeon in 1852.
E It commercially available since 1931.

Chemical Formula :
(CaSO4)
2
H
2
O+3H
2
O heat

2(CaSO4H
2
O)+heat
Hemihydrated calcium Hydrated calcium
sulfate Sulfate
( plaster of Paris) (gypsum)


Plaster of Paris
It used in four forms:
1. Slab. which can be volar or dorsal.
2. Cast.
3. Spica.
4. Functional cast brace. stiffness
1. Slab :
It is a temporary splint made up of half by POP and half by bandage ( cotton ) roll.
Used in the initial stages of fracture treatment ( as first aid ), during first aid and to immobilize
the limbs postoperatively. Why postop ? to decrease incidence of compartment syndrome then
replaced by cast.
2. Cast :
The POP roll completely encircles the limb.
It is used as definitive form of fracture treatment and also to correct deformity.
3. Spica :
This is encircles apart of the body, e.g. hip spica( for CDH ) and thumb spica ( scaphoid fracture).
Rules of application of POP :
Choose the correct size of the roll.
A joint above and joint below should be included e.g.# tibia (knee & ankle) , femur(hip &knee) , forearm
(wrist & elbow).
The joint should be immobilized in functional positions.
The plaster should not be too tight or too loose.

Complications of Plaster of Paris :
Due to tight fit:
E Pain.
E Pressure sore .
E Compartmental syndrome.
E Peripheral nerve injury.

Due to improper application:
E Joint stifnes ( common in adult but children can tolerate it with full ROM )
E Blisters and sores d.t. pressure.
E Breakage of cast.
Due to plaster allergy:
E Allergic dermatitis.

N.B.
1. In scaphoid fracture cast should cover the knuckles : include MPJ ( this is a exception i.e knuckles
should be free cuz stiffness in finger is a very serious complication).
2. Sarmiento plaster or patellar tendon bearing (PTB): After doing above knee cast then x-ray it
after 3-4 weeks & found to be STABLE , TRANSVERSE # , START TO BE STICKY (NOT FRESH #) then:
Do a cast above knee anteriorly & below knee posteriorly (dorsally) (this is a good way to prevent
stiffness).
3. Plaster cylinder : A full cast not including ankle joint ( exception of joint above & below) in
patellar fracture cuz it is not affected by movement of ankle.
4. U shape slap for # of humerus.
5. Colles fracture : below elbow cast (considered stable & will not cause stiffness in EUROPE but in
USA it is like smith : unstable & need above elbow cast).

6. Cervical collar : in disc prolapse of neck.
7. Re-enforce : put another roll of POP if the old one get contact with water & get soft.
8. Trim. : cut the cast if long ( remember the knuckles & exception ..)
9. Split (it is an ER ) : if you get compartment syndrome with early sign of pain with passive
extension of finger . Late signs are pain , swell , pale , numbness , pulseless , cold ( those too
late ).
So , split the cast by a saw (remove cast & even cotton bandage) to get a bivalve shape ( convert
a cast to a slab) DONT remove the whole cast cuz u dont wanna loose the operation .
10. If a pt. Come after 5 days with fever : Open a window in the cast to see the wound & treat it.

Thomas splint gallows traction

Skull traction


L.20: Upper Limb Examination
Dr.Hazem Alkhawashki
SHOULDER EXAMINATION
Complex joint
SHOULDER GIRDLE :
Sternoclavicular joint
Clavicle
Acromioclavicular joint
Glenohumeral joint
Scapula
Scapulothorasic
Shoulder is a very shallow joint , it is not a true bone & socket & the stability of the shoulder comes from the
ligaments around it.

This is synovial capsule but there is another structure which is the subacromion bursa , it is important in presentation of
shoulder pain. It is a very big bursa , & in the elbow there is ((the olecranon bursa)) the two may got swollen & they can
occupy the whole arm posteriorly.

LOOK
Front
Back
Side
Up
skin ,swelling
Muscle
Contoure
deformity
Clavicle, scapula, neck

The examination should done either the patient standing or sitting to give a free movement , because
shoulder examination is shoulder girdle examination.
Front:
clavicle: deformities , fracture , edema , tumors.
Sternoclavicular joint: dislocation:
Anterior ((most common)).
Posterior
Acromioclavicular joint: more commonly injured than sternoclavicular joint, it dislocates
superiorly & so it is obvious by examination from the anterior side.
Muscles: deltoid bulk anteriorly, it decrease in:
axillary nerve injury.
Also in recurrent dislocation that cause disuse atrophy.

Side:
You see effusions , swelling & it points anteriorly, because posteriorly there is muscle bulk so the
swelling points anteriorly &(( we look at it from the side)) .
Sternoclavicular joint swelling also will be clear from the side.
Back:
Scapula & the spines ((if there is scoliosis or hump , lumbar scoliosis, high scapula)).

Look at the axilla to see e.g. tumors..
But in feeling more important, & the doctor said that he prefer to examine it at the end of the examination.

FEEL
Have a system, start from one point &end in another.
. .
Sternoclavic., clavicle, ac.cl. coracoid process, humeral head ,G.tub., subacromial space & scapula.

DO NOT FORGET AXILLA

DO NOT FORGET SCAPULAR ANGLE &SPINE

Feel joint ant. &lat.
Lateral view for:
Swelling
Sternoclavicular joint.
Coracoid process you
dont see it but you feel it.
See also the head of the
humorous.
Angle of scapula at
the level of T 7 .
Back view:
Supraspinatous muscle bulk.
Infraspinatous muscle bulk.
Level of scapula.
Winged scapula ((serratous anterior)).
Scoliosis & hump of scapula.
Infra & supra spinatous supplied by dorsal scapular nerve.

Test effusion ant.

Palpate subacromion lat.&post.
Inf. Angle & parascap.

- You have to have a system in your mind. Either from front of the patient or from the back of the patient.
The doctor likes to do it from the back.
- Disadvantages of examining the patient from the back:
- You cant see his facial expressions , so you have to tell him please tell me if there is pain.
- But from front you can judge by seeing his face.
- Start with the sternoclavicular joint then clavicle, acromion, the acromion is very wide ((2-2.5 cm wide)) ,
so you palpate the acromion then the acromioclavicular joint ((important in osteoarthrosis)) , then take
your hand to the subacromion bursa , the subacromion bursa is just at the tip of the acromion, then feel
the spine of the scapula.
- There is 2 places that I can feel the subacromion bursa:
Just at the tip of the acromion ((the most common place)).
Inferior to the angle of the acromion at the back.
- Palpate the spines , edges, & the muscles.
- Shoulder pain is muscular. The shoulder is where you get referral pain from cervical spines, so cervical
spine problems can cause pain at the shoulder.
- Why do we palpate the scapular spine?
- Because there is tenderness in some conditions like : entrapment of dorsal scapular nerve ,which supplies
supra & infra spinatous muscles.
- Scapular spine towards the edge distally there is a small opening where the dorsal scapular nerve after
gives its supply to the supraspinatous then comes down through the opening to supply the infraspinatous
& entrapment of the nerve may occur here ((as in carpel tunnel ))& the patient comes with pain mainly at
the shoulder , at the back of the shoulder, & there is also wasting .
- *Pressing on the spine of the scapula , check for tenderness , indicate nerve injury.
- There are muscles around the shoulder from anterior & lateral ((rotators)) & they are:
Supraspinatous.
Infraspinatous.
Subscapularis.
Teres minor.
- Subscapularis is attached to the lesser tuberousity anteriorly but the rest of the muscles is attached to
the greater tuberousity.
- So I palpate the :sternoclavicular joint, clavicle, acromioclavicular joint, acromion, subacromion bursa
,spine , edge of scapula, muscles, then palpate the coracoid process((feel rather than see)), & the tendon
which attached to the coracoid process is conjoint tendon
- (( coracobrachialis +short head of the biceps)).
- Usually there is no tendonitis but it could be , & the patient may have fracture also in this area. & the land
mark of the coracoid is about 1 inch below the distal third of the clavicle.

- What is the tendon which has intra articular attachment ?
- ((long head of the biceps)).
- The palpation of the tendon of the long head of the biceps :
o It is not very sensitive because , if the patient has osteoarthrosis he will have pain at the same
area because of capsulaitis. & if the patient diabetic & has frozen shoulder he may also have
tenderness.

- The advantage of palpating the inferior angle of the scapula is to assess the movement , the movement of
the shoulder is complex , all of the joints share on it from the sternoclavicular up to the scapula.
- If a patient comes with osteoarthrosis or rheumatoid & we want to asses how much of the movement
comes from the glenohumoural joint & how much comes from the scapula. So on movement ((passively
or actively no matter)) we differentiate between the 2 movements by putting the hand on the inferior

angle of the scapula. So if the patient move the scapula you will feel this & you will know how much of
the movement is glenohumoural & how much is scapulothoracic.
- Also feel the greater tuberousity ((anterolateral structure)) but with extension of arm it becomes most
anterior structure.

Acromion Acromioclavicular joint is at the
top.
Trapezoid
ligament.
Supraspinatous.
Palpate biceps
tendon
(intraarticular)
Palpation of the
axilla.
To check at
which angle
the scapula
start to
move.

MOVE
((the explanation of the slides is at the end dont worry))
Compare sides
Active &passive
Notice painful move
Range of motion(GH &Scap.) (
)
FLEXION,
- Forward, to full elevation
- Horizontal
- NEER Impingement test with forward flexion(passive) ( ) ( )

EXTENTION,
Backward to 60 degrees 60

EXTENTION,
Horizontal
ABDUCTION,
- From side of body to full (with ext. rotation)
- ARC TEST(active), ( )
Mid arc
End of arc

End arc pain >> problem in
acromioclavicular joint e.g.((
osteoarthrosis >>>capsulitis &
osteophytes)).
No pain >> no pain>>pain when reach
the joint.

Mid arc pain >> problem in bursa or
greater tuberousity tendons
((tendonitis , bursitis))
((60 -120 )).
No pain >>pain>>no pain.

Neers impingement test:
((passive)).
Impingement of tendons between
acromion & humorous.
To check if there is problem with the
greater tuberousity or bursa.
60
0
but it
decrease with age.
Full flexion.
During extension , the greater
tuberousity becomes the most
anterior process.

ADDUCTION,
To reach opposite shoulder
FUNCTIONAL ABD./ADD.
- Abduction + ext.rota.
-
- Adduction + int.rota.
-

ROTATION,
- External ,in add.&abd.
- Internal ,in add.&abd.
SURRASPINATUS, power & impingement ( )
INFRASPINATUS, power

Supra spinatous >> initiation of abduction 1
st

30
Deltoid >>abduction at 60
Subscapularis >> internal rotation
Infra spinatous >>external rotation

- To check for supra spinatous :
o elbow flexed >> internal rotation >>
abduction.
- If drops means may be tear in supra spinatous.
ROTATION,
Apprehension test

Abduction & external rotation.
Functional abd /add : not noted in degrees.
Pain only with external rotation>>
problem in infra spinatous tendon.
Impingement of supra
spinatous.
Injury of serratous anterior ((long thoracic
nerve)) >>winging of scapula.

Special tests
+ Apprehension test:
Recurrent dislocation
+ Rotator cuff,
- impingement,
- supraspinatus,
- infraspinatus,
- subscapularis
+ Biceps tendon

+ Acromio-clavicular
dislocation:
Grade 1 2 3 Fr
Definition, causes
+ Frozen shoulder:
Definition, causes
+ Axillary Nerve:
Sensitive motor

Explanation of slides:
Shoulder is very mobile :
We dont test circumduction but we test flexion ,adduction, rotation of the shoulder.
Always in all movements we do active & passive . ( )
& we want to see the range of motion & the pain with motion.
So we start with flexion & extension:
Always compare between 2 limbs .
Extension usually is limited around 60 & it gets more limited in older age group.
- One of the special tests which we do it with flexion is Neers test ;Neer is an orthopedic surgeon, how we apply
Neers test? The patient is standing with pronation of his limbs , then passively I put my hand in the top of
shoulder & with the other hand I do flexion fore the patient.
- If I rotate the arm , what will happen to the greater tuburousity? It will become under the acromion & this is
normal.(( the greater tuberousity is anterolateral structure but with extension of arm it becomes most anterior
structure )).
- Suppose that there is tendonitis of the rotators or there is bursitis then the patient will have pain at certain
degree, usually is after 90 .which is after entering of the greater tuberousity under the acromion . ((so with
entering of the greater tuberousity under the acromion & the patient has pain this may indicate tendonitis or
bursitis .
- Neers impingement test ( ( ) ) impingement of tendons between acromion & head of humorous.
There is 2 impingement tests one of them is general & dont tell which muscle is affected.
Adduction & abduction:
o The trunk may limit the adduction.
o Do actively & passively.
Apprehension test: for recurrent dislocation
of shoulder.
(( abduction , external rotation , extension))
Frozen shoulder: ( ( ) )
mild pain >>patient immobilizes shoulder >>
pain goes away >> shoulder still stiff.
Recommended treatment: manipulation under
G.A >> steroid injection.
Axillary nerve:
sensory: over deltoid muscle.
Motor: deltoid.

o With abduction we do arc test ( ( ) )
& this is active test (( remember Neers test is passive)). #there is angles written in the book for arc test.
The importance of arc test is to know when the patient feels the pain.
If I do abduction & at certain degree there will be contact between the acromion & the greater tuberousity.
If the patient has bursitis :
o At the beginning of abduction he will not feel any pain , but he will feel pain at the moment of
contact between the greater tuberousity & the acromion, & then the greater tuberousity enter in
a wider area & here the pain disappear .
o So on arc test if there is tendonitis or bursitis there will be ((mid arc pain )) : ((important))
o No pain >>pain>>no pain.
The doctor said in the book they said it is between 60 & 120 degrees .
If there is a problem in the wider area (( which is near the acromioclavicular joint )) if there is osteoarthrosis in
that joint leading to capsulitis & osteophytes so the patient will feel the pain at this area only. (( end arc pain)):
o No pain >>no pain>>pain.
So the arc test give us an idea about the pathology, & the patient can have mid arc pain with end arc pain
depending on his pathology.

Adduction:
The patient should be able to touch the opposite scapula, & opposite angle of the scapula.

Functional (add / abd):
There is functional movement & we dont measure it by angle , but we measure it by range of movement. ( (
) )
Which means I want to know if the patient can reach his face, or his forehead , or to his occipit , or to his parietal
bone ,or to the opposite scapula.
& this is important for surgery (( I want to make his functional movement better , not the movement which I
examine it )).
Functional movements are 2 movements actually:
o Abduction + external rotation .
o Adduction + internal rotation .
Rotation:
o I can test rotation in abduction or in adduction.
o With internal & external rotation there is special tests.
o Supra spinatous abducts the arm in the 1
st
30 degree of abduction ((beginning of abduction is
done by supraspinatous)).
o Which muscle is the external rotator of the shoulder? Infra spinatous.
o Subscapularis is the internal rotator.
o When you want to test infra spinatous muscle you test the external rotation against resistance.
The doctor prefers to do it from behind: from behind put your hand in the elbow to stabilize it &
do abduction with external rotation against resistance (( you test for 2 things power & pain)). If
the patient has pain means tendonitis which I test it already by Neers test , now this means that
the tendonitis is from the infra spinatous muscle.((when the patient has pain only with external
rotation)).
o The function of supra spinatous is initiation of abduction so test the power of it at 30 , & then
test deltoid at 60 .There is test we do it specifically for supra spinatous muscle , supra spinatous
is the 1
st
muscle comes to the greater tuberousity, so if I do abduction , flexion, internal rotation I
stretch the muscle so I cause pain if the patient has tendonitis of this muscle.
With abduction & flexion the greater tuberousity becomes under the acromion , then I increase the
problem by doing internal rotation so I stretch the muscle & it if there is tendonitis of the muscle this
cause pain .
This test can be done in another way & it is important for the power or rupture of the muscle((supra
spinatous is the muscle which hold the shoulder in its position not the deltoid)) . Patient who comes
with sports injury (( e.g. basket ball players)) ( ( ) )
They might tear their supra spinatous & the test which I do passively (( abduction , flexion , internal
rotation)) then I remove my hand , if the arm falls down so this is supra spinatous injury or weakness.

So this is a test of ((power)).patient do it passively then actively when I remove my hand (( it is
combination passive & active)).

Apprehension test:
It is a very important test in the shoulder , & it is a test of recurrent dislocation (( like apprehension test of
the knee )). Shoulder dislocation occur with abduction & external rotation , so I do abduction & external
rotation ; So one hand on the shoulder from behind (( the thumb on the angle of the acromion & fingers
anterior )), then I hold the arm with the other hand I do external rotation & it is already in abduction & then
extension (( like I want to push it out)) & I dont go further the patient will stop me because he feels like it will
dislocate.
Winging of scapula:
Examine winging of scapula which occur with injury of ((serratous anterior)) (( long thoracic nerve)).
Axillary nerve:
It supplies the deltoid muscle +sensory supply in the area over the deltoid ((upper arm)).

Frozen shoulder: ( ( ) )
((adhesive capsulitis)) no movement , it is more in the older aged group & specially in diabetics. Diabetes is
one of systemic diseases which cause tendonitis , capsulitis because diabetes affects small vessels , capillaries
, so it affects the microcirculation around the joint & capsule so it causes inflammation. Patient with frozen
shoulder has natural history of trauma then pain ((not necessary fracture)). With pain the patient will protect
him self by restriction of movement. Old age or diabetics or (( could be small fracture undisplaced)) over
protect him self & dont move , then after 2-3 weeks the pain disappear & the restriction of movement
remains, then with physiotherapy the restriction of motion becomes better.
((pain >>pain + restriction of motion >> restriction of motion without pain >> improve)).
It will take 2 years naturally to improve with physiotherapy , nowadays we take these patients to theater &
we do manipulation under anesthesia & we give them steroid injection through shoulder , & it is much better
than if we leave the patient to improve by himself. Recurrence may occur if the pathology persist & without
physiotherapy but at least this manipulation remove the adhesions & decrease the inflammation by the
injection.

Elbow
Elbow is a superficial joint .
Look , feel & move.
+ Inspection:
All around, swelling, deformity, muscle wasting, skin changes, abnormal position,
alignment: (varus, valgus)

Triangle
between
lateral
+medial
epicondyls+
olecranon.
Carrying angle larger in
females.

+ Palpation
- Lateral epicondyle
- Medial epicondyle
- Olecranon
- Radial head
- Ulnar nerve
- Biceps tendon

+ Movements
- Active, passive:
- Extension: 0 to 10 deg., ligament laxity.
- Flexion: 145 deg., obese thin, restriction.
- Pronation Supination:
75 80 deg. Hold a pencil.

- Tennis elbow.
- Golfers elbow.

+ Olecranon Bursitis
+ Ulnar nerve neuritis
+ Cubitus varus

Inspection:
Relation from posterior :
between 2 epicondyles posteriorly & olecranon. It is a triangular relationship & it is important
clinically to differentiate between dislocation of elbow & supracondylar fracture of elbow.
In supracondylar fracture the triangular relation preserved.
But when we have dislocation of elbow((dislocation of olecranon posteriorly)) this triangular
relation is lost. ((with dislocation the olecranon & epicondyles becomes in one straight line)).
See is there any deformities (( varus or valgus deformity)) or not.
Carrying angle of the elbow maintained or not : it is the angle between the humorous & the axis
of the forearm , average is 7 & it is more in females.
Varus deformity occurs as complication of supracondylar fractures.
Radial head: flexion of elbow on trunk, 1 cm
distal to lateral epicondyle, on rotation we
can feel it.
Remember short tendon of biceps
inserted in femur.
Fix shoulder joint then ask to pronate &
supinate.

Which is more difficult varus or valgus?
In varus: only the shape is the problem.
But in valgus: it is a problem because of the position of ulnar nerve & with valgus there is neuritis
& ulnar nerve problems.
So valgus is more difficult.

Palpation:
Palpate bony prominences & attachments of tendons so you palpate the epicondyles , olecranon ,
anteriorly palpate the biceps tendon for tendonitis.
Palpate lateral epicondyle then go 1 cm distally , rotate the arm , now your hand is on the head of radius ,
& this is important because lateral compartment of elbow is the place in which usually arthritis or
rheumatoid starts.
Ulnar nerve: you can palpate it but it is painful for the patient , so you dont palpate it unless there is a
reason for it. ((easy to palpate it posterior to epicondyl but it is painful )).
When I palpate the epicondyles , there is 2 problems of presentations of elbow:
o Tennis elbow:
Actually it is more common in ordinary people than in tennis players but it is described in the past in
tennis players , it is tendonitis in the lateral epicondyle ((extensors)) , these tennis players have to do
extension of the wrist , patients complains of pain when they try to open the door or open a can.
o Golfers elbow:
Less than tennis elbow, ((medial epicondylitis)) ,((flexors)), so it is with flexion movements.

Movements:
Extension of elbow can go to -10 (( in the knee -5 )) but in elbow it has more hyperextension.
Flexion is limited by the bulk , in the usual life we need how much of elbow function to do daily activities?
90 to 100 degrees.((normal flexion is from -10 to 140 )).which is more important flexion or extension?
Flexion.
Supination & pronation :they are from the movements of shoulder & we test them by giving the patient
2 pens & adduct the arm , then ask the patient to do supination & pronation. Why do I give him pens? To
measure the angle by goniometer between humorous & the pen. you can supinate 90 & pronate 80 &
this is important in manual workers. We dont really need full pronation or supination for daily activities
we need something between the 2 ((a range of 80 to 90 in combination of pronation & supination)), ((45
degrees from pronation & 45 degrees from supination)).

When we do palpation there is tests we do for:
o Tennis elbow: patient usually complains that he feels pain in the arm when he wake up in the
morning, & the pain usually because the patient extending his arm & sleep on it ((he put his hand
under the pillow)).This position when you get tennis elbow pain ((pain with extension)), so test it
with extension mainly & 20 flexion & the arm is pronated & test extension against resistance &
the patient will have pain ((against resistance I will activate the muscle & cause pain)).
Other way: ( ( ) )
Stretch the muscle passively but this is not usually used a lot.
To test for tennis elbow pronate the arm & test the extension of wrist against resistance. And
look for tenderness also.
o Golfers elbow: ((opposite of tennis elbow))
Supinate the arm & test flexion of wrist against resistance. And look for tenderness also.

Ulnar nerve neuritis:
Ulnar nerve is on the medial side, so I test ulnar nerve on flexion in about 60 & I stabilize the arm &
I stretch the nerve on valgus of forearm.
Ulnar nerve neuritis increase with flexion because it will stretch it. Patients with ulnar nerve problem
usually sit for a long time & press on it & comes with pain & numbness.


L.21: Fractures & Dislocations of the Upper Limb
Upper Limb include:
Clavicle.
Scapula.
Shoulder Joint.
Humerus.
Elbow Joint.
Forearm Bones.
Wrist Joint.
Scaphoid Bone.

Mechanism of Injuries of the Upper Limb:
- Mostly Indirect.
- Commonly described as " a fall on outstretched hand ".
- Type of injury depends on position of the upper limb at the time of impact : Flexed, Extended, adducted,
abducted, pronated or supinated.

Fracture of the clavicle in Adults :
- Common especially in children and elderly.
- Commonest site is the middle one third.
- Mainly due to indirect injury.
- Direct injury leads to comminuted fracture (comminuted if we have more than 1 piece)

Treatment :
E Conservative by an arm sling or figure of eight bandage.
E Operative fixation is indicated if there is an open fracture, neurovascular injury or nonunion or tenting of
skin (cuz any time it can be OPEN fracture)


N.B. the most common joints to be dislocated are shoulder, elbow and hip joints respectively--.
Dislocation of the Shoulder:
Mostly Anterior > 95 % of dislocations.
Posterior Dislocation occurs < 5 %. (difficult to diagnose). Occur mainly with major(painfull)trauma.
True Inferior dislocation (luxatio erecta) occurs < 1%.
Habitual Non traumatic dislocation may present as Multi directional dislocation due to generalized
ligamentous laxity and is Painless, which is common in females.
N.B :hip joint is stable by bony configuration.
Mechanism of anterior shoulder dislocation:
Usually Indirect fall on Abducted and extended shoulder.
May be direct when there is a blow on the shoulder from behind
while it is in a throwing motion.
Anterior Shoulder dislocation:
Usually also inferior.
Bankarts Lesion: detachment of ANTERIOR labrum (soft tissue)
from its place in humeral head.
Recurrent.
Clinical Picture:
Patient is in pain.
Holds the injured limb with other hand close to the trunk.
The shoulder is abducted and the elbow is kept flexed.
There is loss of the normal contour of the shoulder.
Loss of the contour of the shoulder may appear as a step.
Anterior bulge of head of humerus may be visible or palpable in
lateral side of chest.
A gap can be palpated above the dislocated head of the humerus.
The definite diagnosis is by X-ray.

X Ray anterior Dislocation of Shoulder (see Mercedes sign) but in inferior dislocation patient will come like

Associated injuries of anterior Shoulder Dislocation:
Injury to the neuro vascular bundle in axilla ( rare ) .
Injury of the Axillary or Circumflex Nerve ( Usually stretching leading to temporary neuropraxia ) which is
the commonest.
Neuropraxia: Numbness in the area supplied with intact nerve.
Associated fracture.
Brachial plexus traction & axillary artery damage.
Axillary Nerve Injury (most of its injuries are neuropraxium i.e.temporary)
Also called circumflex nerve.
It is a branch from posterior cord of Brachial plexus.
It hooks close round neck of humerus from posterior
to anterior.
It pierces the deep surface of deltoid and supply it
and the part of skin over it.
Function of deltoid is one of abductor.
Symptom & sign: 1-loss of sensation over the deltoid
muscle. 2-partial loss of abduction.

Management of Anterior Shoulder Dislocation :
Is an Emergency (so you want to minimize further damage d.t. traction on brachial plexus & on vascular
supply of humeral head i.e. ischemia)
It should be reduced in less than 24 hours or there may be Avascular Necrosis of head of humerus--.
Following reduction the shoulder should be immobilised strapped to the trunk for 3-4 weeks and rested in
a collar and cuff
If recurrent dislocation (2 or more) do bankert repair i.e. re-attach labrum to its place done by open
method or arthroscope.

Methods of Reduction of anterior shoulder Dislocation :

Hippocrates
Method (A form of
anesthesia or pain
abolishing is
required ) principle
is by traction
&countertraction.
Stimpsons technique
for 30 min. ( some
sedation and analgesia
are used but No
anesthesia is required )
it does not work all the
time , good only in
muscular guy & the
head wont come back.

Kochers technique is the method used in hospitals under
general anesthesia and muscle relaxation .applying some
tension then traction then external rotation then internal
rotation and finally confirmatory X-ray.


Complications of anterior Shoulder Dislocation : Early
Neuro vascular injury ( rare ).
Axillary nerve injury.
Associated Fracture of neck of humerus or greater or lesser tuberosities .
CAUSES OF POSTERIOR DISLOCATION:
3 E: epilepsy , electric shock , ethanol &bilateral dislocation is more with this type.
Complications of anterior shoulder Dislocation: Late
Avascular necrosis of the head of the Humerus (high risk with delayed reduction).
Heterotopic calcification ( used to be called Myositis Ossificans ): new bone formation in joint, commonly
in the elbow joint--.
Recurrent dislocation which is the commonest complication-.
The younger the patient the higher the risk of getting recurrence.
Fractures of The Humerus:
Proximal Humerus (includes surgical (most common) and anatomical neck (high risk of
avascular necrosis).
Shaft of Humerus.
Distal humerus ( includes Supra Condylar fracture which is most common in children ).
Management of proximal fracture:
1- Conservative (closed reduction &arm sling),generally ,if not displaced.
2- Plating if unstable.
3- K wires (rush roads) it is thinner than IM nail with no opening.

Proximal Humerus Fracture

Fracture Proximal Humerus : Plating or Rush Nail insertion

Intra-medullary K wire fixation

Fractures Shaft of the Humerus :
Commonly Indirect injury.
Indirect injury results in Spiral(which heals faster &more stable) or
Oblique fractures.
Direct injuries results in transverse or comminuted fracture.
May be associated with Radial Nerve injury(cuz radial nerve go
posteriorly in radial (spiral) groove)
Radial Nerve Injury:
Results in Wrist drop ( cuz all extensors are supplied by it . patient can
move his fingers but not dorsiflex the wrist)
Associated with fracture humerus in up to 12% of fractures.
2/3 (8%) of Radial injury are Neuropraxia ( will take 3-5 month to heal) with same prognosis
1/3 (4%) are nerve lacerations or transection ( neurotemesis).
Management of Radial Nerve Injury:
When present in open fractures; immediate exploration and repair.
In closed injuries treated conservatively; initial management is doing Nerve Conduction Studies (NCS) and
Electromyography (EMG) and awaiting for spontaneous recovery.
Recovery usually starts after few days but may take up to 9 months for full recovery.
If No spontaneous recovery occurs in 12 weeks confirmed by NCS and EMG ;then exploration of the nerve
should be carried out ( NCS & EMG are useless in first day)
Management of Fracture Shaft of the Humerus:
Most of the time is Conservative.
Closed Reduction in upright position followed by application of U shaped Slab(back slap) of POP or
Cylinder cast ( as initial treatment)
Few weeks later or initially in stable fractures Functional Brace may be used.

Shaped slab of POP(why?)to stay away from swelling&compartment syndrome.

Functional brace Fracture Shaft of Humerus
Indications for ORIF Fracture Shaft of Humerus
Failure to reduce fracture conservatively.
Bilateral humeral fractures.
Open fracture with or without radial nerve Injury.
Unconscious patient.
Delayed-Union, Non-Union (more than 6 month not healed) and Mal-Union.

Plating fracture Shaft of humerus

- Supra- condylar Fracture of Humerus (d.t. fall on out-stretched hand) in 3-8 years commonly--.
- On out stretched Supra-condyler area is weak:
- 1
st
we do X-ray.
- On lateral view we divide it to 3 types:
o Type 1: undisplaced with fracture line.
o Type 2: anterior cortex is broken but the posterior is intact.
o Type 3:both cortex are open.


Pediatric Supra-Condylar Humeral fracture (95% of displacements are posterior)-
Types--:
1-no displacement only the outer cortex is involved w/o angulation treated by cast.
2-disruption of only anterior cortex not posterior with posterior angulation treated in OR as 3.
3-disruption of both cortices treated by close reduction under GA with percutaneus 2 K wire medial&lateral
for 3 weeks with back slap.
Reduction of supra-condylar Fracture:
Absolute Emergency.
Should de done under G A by experienced doctor as soon as possible.
In the past the arm was held in flexed elbow position in back-slab POP after reduction.
At present time Percutaneous K wire fixation is ALWAYS carried out after reduction--.
IN adult supracondylar fracture treat by ORIF(but in dislocation use CRIF) or plating urgently & no worry
much about compartment syndrome like kids--.

Pediatric Supra-condylar fracture
Complications Supra-Condylar Fractures :
A. Early= - Compartment syndrome (commonest problem in children so it is ER--) lead to muscle ischemia ,
fibrosis & flexor contracture.
- Brachial Artery injury ( Acute Volkmann's Ischemia ).
- Nerve Injury : Median(the commonest esp. ant. Interosseus), Ulnar or Radial.
B. Late= Stiffness
E Volkmann's Ischemic contracture.
E Heterotopic Calcification.
E Mal-Union ( Cubitus(elbow) Valgus or varus){commonest}-. N.B. HIP IS COXA.knee is geno


Volkmann's Ischemic Contracture Supracondylar fracture.(in adult)

FOREARM:

Fracture dislocation (treated surgically ORIF)

MONTEGGIA FRACTURE-DISLOCATION

Montaggia fracture-dislocation:-
- fracture of proximal ulnar shaft & dislocation of radial head.
- it is 4 types :
1- commonest:fractured ulna , ant. Dislocation of radial head .
2- frac. Ulna , post. dis. Of radius.
3- with lateral dis.
4- with ant. Dis. &radial shaft fracture.
- Treated by closed reduction of radial head & plating ulnar shaft ,if not 1ry open reduction .
- Generally it is worse than below cuz difficult to treat & missed easily otherwise it end up in stiffnes &pain.


GALEAZZI FRACTURE-DISLOCATION
Galeazzi fracture-dislocation:-
- fracture of distal third of radius & dislocation of ulnar head at distal radioulnar joint.
- treated by closed reduction & plating.

DISTAL RADIUS FRACTURE
Distal radius fracture:-
- Very common esp. Elderly d.t. Fall on out-stretched hand.& mainly women becuz of
osteoporosis.
- Types:
1- Colles fracture: fracture of distal radius, dorsal(post.) Angulation in an osteoporotic
bone extra articularely.
2- Smith (revers colles): exactly same but with volar (ant.) Angulation.
- Treated by closed reduction & casting. Or in or by closed reduction with external fixator by k wire
or plating.--
- Follow up here is one week.-
Types of treatment:- external fixator


Scaphoid fractures:-

- Scaphoid is the biggest bone in the wrist.
- It is composed of 3 parts: proximal pole (common to have avn), waist and distal pole.
- Its fracture can be missed easily.
- Cause of the fracture: fall on an out-stretched hand & patient come with pain in anatomical
snuff box -.
- Complications:
1- avn cuz its blood supply from distal to proximal not by radial artery--.
2- non-union (most common)take to or & screw with bone graft from iliac crest to stimulate
healing.
3- arthritis
4- stiffiness
- Treatment: depends on fracture displacement if more than 1mm (rest of body <2mm) so treat
in thumb spica & include thumb. Or orif by screw &take long time to heal if it displaced.

* in general if a patient come (pain ) & no visible fracture on x-ray put a cast for 2 week then come back
& remove &examine if no pain discharge but if tender x-ray again if you see fracture treat but if you
dont see fracture investigate more & mri is best but you can use bone scan or CT.

L.22: Operative Treatment of Fractures & Dislocations
Dr. Bakarman

Open fracture:
Types for: 1- to choose proper anti biotics 2- to choose method of fixation .
Type 1 < 1cm + clean (no dead tissue)
Type 2 > 1cm with moderate contamination.
Type 3 severe tissue injury , and this type divide into A- degloving injury(superfacial).
B- Injury extend to periosteum.
C- associated w\ vascular injury
Treatment:
In open fracture you have to treat the patient in the :
A- ER treatment :
Save the life, limb & function ( ABC)
Remove any gross debridement \ Irrigation.
Give the pt anti tetanus & antibiotics.
In type 1 give the pt Abx that cover staphylococcus as: 1
st
generation cephalosporine.
In type 2 give the pt Abx that cover both gram +ve & -ve as: 2
nd
generation cephalosporine or
aminoglycoside.
In type 3 give the broad spectrum Abx which cover Anaerobs, gram
+ve & -ve as: 3
rd
generation cephalosporine or ampicillin.
Cover the bone with sterile gauze.
Immobilize the pt.
B- OR treatment:
Thorough debridement
Take swab \ culture.
Then fix the limb accordingly.
Internal fixation with open reduction for type 1,2.
External fixation for type 3 .
High energy trauma treatment: as above.


Need ORIF
Proximal femur fracture need IF
with intramedullary nail
Galleazzi fracture dislocation

Fracture of both radius & ulna need fixation

Principles:
1. Surgical indications
2. Timing for Surgical intervention .
3. Principles of Surgical treatment .
4. Methods of fixation

Surgical Indications
1. Displace intraarticular # > 2mm to prevent post traumatic OA
2. unstable # with failed N.O.R (non operative treatment
3. Major Avulsion # e.g. patellar tendon, olecranon fracture, greater trochanter .
4. Pathological # to prevent :
1- Painful early mobilization.
2- Fracture.
5. Fractures of necessity e.g. galeazzi # ,lateral & medial epicondyle #, displaced medial maleollus # in adult
b/c there is risk of malunion.
6. Displaced physeal injures ( growth plate injury). To maintain aligment and growth.
7. Fractures with Compartment Syndrome e.g. forearm # & tibia #.
8. Fractures with vascular injury e.g. supracondylar injury.
9. Fractures with neurological deterioration as in the spinal # & humeral # with radial nerve palsy.
10. Polytrauma patient to improve pulmonary function.


Timing for intervention
E The timing of the surgical intervention
1. Emergency (6 hours).
Open #.
Compound #.
Fracture w\ vascular injury,neurological.
Neck of femur #.
Failed closed reduction of dislocation.
Compartment syndrome.
2. Urgent ( 24 hours).
Long bone # in adult to improve the pulmonary function ( fat embolism)
3. Elective ( delay).
Simple #
Ankle # with massive swelling wait until swelling subside then interfere.
Principles of Surgical Treatment
1. anatomical reduction of the fracture fragments, especially in joint fractures,to:
1- prevent post-traumatic osteoarthritis.
2- Start active range of motion. ROM.
2. stable internal fixation to fulfill the local biomechanical demands.
3. preservation of blood supply to the injured area of the extremity.
4. active, pain-free mobilization of adjacent muscles and joints to prevent the development of fracture
disease.
Methods of Fixation
Methods of fixation Indications Advantages Disadvantages
K-wires fixation Mainly for children
but it can be used in
adults.
Less trauma to soft
tissue.

Relative stability so you
have to stabilize the
patient by complete
cast if there is no
swelling , if there is a
swelling paxlab only.
External fixation 1- open fracture
particularly type 3
2- comminuted #
3- Poly trauma.
4- Unhealthy soft
tissue & vascular
injury.
5- Infected
nonunion.
6- for lengthening.
7- Massive swelling.
Complication :
1- pen tract infection
(most common). If
infected do culture, do
daily dressing & give
antibiotic, if still remove
to prevent osteomylitis.
2- Injury to
neurovascular bundle
during fix.
3- delay union \ non
union \ mal union.
4-discomfort
5- growth arrested

Plates & screws
( N.B. In UL for
ever bcs of risk of
refracture unless it
cause pain or
infection then it
should be removed.
In LL remove it
after 2 yrs).
1- long bone #.
2- Intra-articular #.
3- compound #.
Absolute stability.
Early ROM.
Less stiffness.
Soft tissue dissection.
High risk of infection.
NBW for 6 wks
Healing problems.
Bone necrosis.
Intramedullary nail
(( contraindicated in
children--)) .
Long bone #. Early WB.
Restore limb &
rotation.
Anterior Knee pain in
50% of pts.
Healing defect ( mal-,
non-, delay-\ union).
Not used in pediatric
age group coz it will
affect blood supply to
femoral head.
Antegrade direction in
fix. Not used in
shoulder coz it will
affect the rotator cuff.

N.B. : skin traction 10% of body w.t in bound
Skeletal traction complication : 1- malignant 2- cut through or distraction of bone (delay union).
Plates of the femur:
Dynamic hip screw (DHS):
Used in Intertrochantric # & subtrochantric #.
Dynamic condylar screw:
Used in subtrochantric # or supracondylar # of the distal femur.
Angle blade plate:
Used in subtrochantric # or supracondylar # of the distal femur or corrective osteotomy.
Hemiarthroplasty:
- 3 types:
Ostenmoore hemiarthroplasty
Bipolar hemiarthroplasty.
Total hip replacement .
- Used usually in 65 yrs or above .
- The way to choose the type depend on 3 questions:
The age
The level of activity, if the pt active bipolar. If not ( bed ridden) ostenmoore .
The status of acetabulum , if it diseased total hip replacement. If not according to the
previous 2 parameters .
Practices:
Low grade energy trauma:
In ER:
Stabilize (ABC).
1
st
generation cephalosporine.
Remove gross contamination.
Sterile gauze.
Antitetanus
Immobilze.

In OR:
Thorough debridement & irrigation.
Take swab & culture.
Fix the limb ( internal fix.)
There is a role of closed reduction w\ complete cast above and below the joint unless there is a swelling.

Intercondylar fracture
Treat the pt w\ ORIF (fixation w\ plates & screws).

AP & lateral view of wrist joint showing sallter-harris fracture type II in pediatric age group.

Type I complete separation of the epiphyseal.
Type II part of the metaphyseal.
Type III extend to the joint.
Type IV
Type V there is a compression.

Rx closed reduction w\ K-wire fix.


Displaced Scaphoid fracture.
- Rx thumb spika cast for 2 wks then repeat the X-ray then look to the fracture if there is a
fracture cont. on spika cast if not remove it.
- If it is displaced need ORIF w\ screw
- If not thumb spika cast.
- Most common complication AVN in the proximal pole.

Neck femur fracture type III .
Rx
- If the pt < 65 yrs reduce it & fix it
w\ cannulated screw
- If the pt > 65 yrs ask your self
three Qs : (principle of
hemiarthroplasty).
1- Age . 2- acetabulum
stability. 3- activity.

Fracture of the femural neck .
Rx the pt is 70 yrs old w\
signs of OA so , total hip
replacement is the Rx.

Intertrochantric fracture.
Rx Dynamic hip screw.

Short oblique Fracture of the
femoral shaft in child.
Rx reduction w\ elastic nail ,
Hip spika cast for 6 wks.
K-wire.
Plate & screw.
Traction for 2 wks until callus
form then put the pt in hip spika.
Ext. Fix.

a- Segmental fracture of the
femural shaft
Rx Reduction & IF w\
Intramedullary nail.
b- Sub trochantric fracture:
Rx: ORIF by hip screw.

Displaced Patellar fracture.
Rx
displaced : OR w\ tension
band.
Non-displaced : slinder cast.

Patellar dislocation
Rx closed reduction.

Knee dislocation.
Rx: closed reduction with
external fixation.

Short oblique fracture of the shaft
of tibia.
Rx closed reduction and above
knee cast bcs of good aligenment
for 6 wks then BK cast for 6 wks
until healing .
The best method is to fix it w\
intramedullary nail.

Fracture of both istal tibia &
fibula
Rx fix it w\ intramedullary
nail.

Fracture of proximal tibia
Rx fix it w\ plate & screw coz
it extend to intra-articular.

Salter-haris type II of the distal
femur. Complication =
genvarus-
Rx closed reduction & K-wirs
fixation + cast.

Supracondylar fracture.
The most common nerve to be
injured is the anterior
interosseous nerve so you
have to assess it by asking the
pt to do (OK-sign) flexor
polices longus + flexor
digitorum longus.
Rx closed reduction & K-wire
fixation + cast or paxlab.

Medial maleollus fracture
Rx ORIF either tension band or
screw.

Salter-haris type III fracture
Rx cannulated screw + K-
wire + screw.

Weber type B fracture
Rx ORIF w\ plate & screw.

Suprasydinsmotic fracture:
Rx ORIF w\ plate & screw.

Salter-haris type I fracture.
Complication = shortening
+varus deformity.
Rx closed reduction & IF.

Intercondylar Intra-articular
fracture
Rx fix it w\ plate & screw.


Salter-haris type IV
Rx cannulated screw , DON`T
put any plate in the groeth
plate affect the growth--

Weber type B fracture
Rx plate & screw

After Rx w\ plate & screw.

Comminuted intra-articular
fracture
Rx K-wire w\ rigid fixation as
paxlab.

After healing and removing the
wire.
The most problem is stiffness.

Shaft femur fracture in the
children
Rx plate & screw.

Both bone fracture in the
pediatric age group
Rx closed reduction & K-wire
+ cast.

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Radius fracture in children
Rx elastic nail + cast.

Fracture of the femoral neck .
Rx DHS.

Both bone fracture in adult ,
Rx plate & screw.

Mid shaft tibia fracture
Rx Intramedullary nail
Most common complication is
anterior knee pain.

Supracondylar fracture in
children type II ,
Rx closed reduction+K-
wire+cast.

L.23: Pyogneic Bone & Joint Infection
Dr. Al-Ahaideb
Classification based on
Duration:
- Acute (within the first 2 weeks).
- Subacute (2 6 weeks).
- Chronic (> 6 weeks).
Route of infection:
- Hematogenous (through the blood) {vast majority} or
- Exogenous (through communication with external
environment) e.g. following open fracture or a foreign body
went to a bone or a joint.
Host response:
- Pyogenic (pus forming) e.g. osteomyeilitis septic arthritis. or
- Granuolmatous (forming granulation tissue) e.g. TB, brucellosis.

.. Osteomyelitis ..
Definition:
- An infection of bone involving the periosteum (cortical bone) and the medullary cavity.
* periosteum (peri = around, osteum = bone) in pediatric is a thick layer of double bone while in adults it is a (not
well identified) thinner layer which is the remnants.

Organism:
- Neonates: strep group B and A, staph aureus, E. coli.
- Children: Staph aureus, E coli, serratia, pseudomonas (not common Hem. Infl < 4 years).
- Sicklers: staph aureus (most common), salmonella (most unique for them).
- Drug addicts: staph aureus (the commonest), pseudomonas (most unique for them).
* The commonest by far and for all ages is staph. Aureus.
Person who are not vaccinated against heamophilus you should suspect but the final Dx is by culture.
Pathology:
Hematogenous colonization of the bones by bacteria.
Stage of inflammation.
Spread of infection with pus formation.
Formation of subperiosteal abscess (if it stayed for long time).
Pus tracks towards skin (tract between the skin and the bone which always oozing some pus) to form a
sinus (in chronic osteomyeilitis)
With chronic osteomyeilitis, Bone infarction or necrosis (Sequestrum = dead bone inside the bone, which
looks in the X-ray as a white area- within a black area. The black area is the infection while the white
area is the necrotic bone).


With chronic osteomyeilitis Subperiosteal new bone formation (Involucrum --, which looks in the X-ray
as if the cortex of the bone is doubled with a black space separates the 2 layers). Body always tries to fight
the infection, the infection is destroying the bone, the body is trying to form new bone, to replace the
destroyed bone.
* in acute you don't see any thing in the x-rays for weeks before he develop these things.

.. Acute Osteomyeilitis ..
Organism:
The commonest is staph. Aureus.
Source of infection:
- Hematogenous (almost always),
- Direct extension,
- Direct from outside.
Incidence:
- Age: more in children.
- Sex: boys > girls.
- Site of infection: most commonly metaphysis (because the blood supply in the metaphysis is high. So
if the blood colonized with bacteria, most of it will go to the metaphysis).
- The commonest bone to be affected is tibia.
Pathology and age variation:
The blood supply to the epiphysis and the diaphysis (shaft) is from the metaphysis. So, if the infection
reaches the metaphysis, it will spread to the epiphysis (and may to the shaft because of its poor blood
supply) causing septic arthritis along with osteomyeilitis.
In children the epiphyseal plates work as an infection barrier.
Although neonates have epiphyseal plates but they also have an epiphysio-metaphyseal vascular
connection which allows the infection to spread to the epiphysis making the neonates the most in risk age
groups.
Osteomyeilits can be eradicted, if it's discovered early, with antibiotics while septic arthritis may destroy
the cartilage even if you discovered it early and the patient has a chance to get early osteoarthritis.
* osteomyeiltis can cause septic arthritis and vise versa.
Neonates:
- Extensive bone necrosis.
- Increased ability to absorb large sequestrum.
- Increased ability to remodel.
- Epiphysio-metaphyseal vascular connection. Bypass the growth plate so, may be secondary septic
arthritis .
- Secondary septic arthritis (which might destroy the cartilage).

Adults:
- No subperiosteal abscess --.
- Adherent periosteum (not defined and well apparent).
- Soft tissue abscess.
- Vascular connection with the joint.
- Secondary septic arthritis (through direct spread) (closed growth plate ).
- No physeal plate so increase the risk to develop septic arthritis.
* higher risk age group to develop septic arthritis:- (respectively)
1) neonates.
2) adults.
3) children. (are the least group to develop septic arthritis).
Clinical picture:
+ History:
- Skin lesion.
- Sore throat.
- Trauma to the joint or anterior?? bone, open facture.
- Any source of infection (URTI, UTI ).
* sometimes the family don't remeber a history of an URTI but in most of the time there is a source.
+ Symptoms:
- Sometimes mild or absent (neonates)--.
- Pain (main and cardinal symptom).
- Fever (helps in making differential diagnosis).
- Restlessness (in neonates and young children).
- Vomiting (when gets septicemia).
- The limb is held still (pseudoparalysis because of pain).
- Malaise.
+ General signs:
- Looks ill.
- Fever.
- Tachycardia.
- Dehydration.
+ Local signs:
- Look for: redness, swelling
- Feel for: high temperature, tenderness
- Move: limited degree of motion, because of the pain the patient will not allow you.
+ Laboratory tests:
- CBC: high WBC.
- ESR: high (very important test for diagnosis and monitoring of patient's response to treatment).
- C-reactive protein (most sensitive).
- Blood cultures (positive up to 50%), you should take 3 samples.
- Aspiration (if there is swelling. To detect the pus and send it for culture).
* normal WBC count in adults = 11
But in neonates = 16
* normal ESR = up to 20
+ Radiography:
- first line. Plain X-rays (normal in the first ten days, after that resorption of affected bone and sub-
periosteal new bone formation). So, it will not help in the diagnosis of osteoarthritis or
osteomyeilitis. diagnosed by exclusion in this time.
- Bone scan (very sensitive but not specific because it will not tell you if the increase in uptake is d.t.
infection or trauma to the bone, contusion ).
- Gallium scan (more specific).
- Ultrasound (shows fluid collection which may or may not be an infection).
- CT scan to show bone (not used unless you want to rule out trauma).

- MRI to show soft tissue (the most sensitive for infection because it will show you the pus and the
inflammation).
+ Differential Diagnosis:
- Acute septic arthritis.
- Cellulitis (superficial infection).
- Ewing's sarcoma (behaves like acute osteomylitis).
- Sickle cell bone crisis.
- Acute rheumatoid arthritis (juvenile rheumatoid arthritis).
Treatment:
+ General
1. Admission.
2. Hydration (important). b/c it may kill the p.t.
3. Correction of electrolyte imbalance.
4. Analgesics.
5. Immobilization (the best way to control the pain, like in fractures).
+ Surgical treatment (the first treatment)
Drainage:
- Indications? Not in acute osteomyeilitis unless MRI shows pus but with septic arthritis there
is always a need for surgical draining.
- Drilling?
e.g. a child came with septic arthritis in the hip and the MRI shows acute osteomyeilits in the
proximal femur (at the neck) and we are already gone to the OR for draining the septic hip
while we are there some people recommend to make small drill holes in the proximal neck
just to allow draining of any pus there might be non but if it forms there will away for it to go
out.
- Skin closure? Close the skin over the drain because the initial irrigation is not enough.
- Second look? Sometimes you need more than 1 irritation.
+ Antibiotics:
- Type? Broad spectrum till the culture results come.
- Route? 3 6 weeks( IV then oral).
- When to start? After taking the aspiration in ER.
* aspiration can be taken from the knee in the ER but hip joint must be aspirated in OR.
- When to stop?
- Monitoring? Clinical, CBC, ESR, CRP.
.. Septic arthritis ..
- May affect any age and any joint.
- The hip and knee are the most affected--.
- Pathology: hematogenous or from the bone.
in neonates: transphyseal vessels.
In joints where the metaphysic is intracapsular (hip, shoulder, proximal radius and distal fibula).
- Symptoms: like AO.
- Signs: hot swollen joint which is painful to any motion, inability to bear weight.
- Investigations: CBC, ESR and CRP. similar
- Organisms: similar to AO.
- Rx: arthroscopy or arthrotomy (in case of a very small child and there is no small scopes) is a must
(irrigation and washout + antibiotics) (similar to AO).
- Main DDx: transient synovitis of the hip (viral infection , no need for treatment).
Chronic Osteomylitis :
+ Ignored acute stage.
+ May be after surgery.
+ There may be since for pus to drain out.
+ It is hardly to eradicate.
+ Also, it may complicate internal hard near.

+ L.24: Orthotics & Prosthetics
Definitions:
(A) Orthotics: ( )
The subject dealing with orthosis

+ Orthosis:
A device or appliance prescribed by doctors for specific conditions affecting the limbs or trunk.
+ Orthotist:
The person who manufacture the orthosis (many orthoses come redy-made these days, as there are
large companies specialized in manufacturing orthosis
(B) Prosthetics:( )
The subject dealing with prosthesis
+ Prosthesis:
A device or appliance prescribed and used to replace a removed, absent or amputaed part of the
body
+ Prostheticst:
The person who makes the prosthesis

(A) Orthoses:
Are used on limbs and trunk in a variety of conditions affecting the musculoskeletal system:
- congenital
- traumatic
- inflammatory
- degenerative
- neurological

orthotics = calipers
- traditionally calipers were the most known form of orthosis
- caliper is a device which is applied to lower limb to give support or control a joint
functions of orthosis:
1- prevent deformity
2- correct deformity
3- maintain correction
4- controls instability
5- relives weight bearing
6- facilities ambulation
7- relives pain
Orthosis prescription:
the doctor ordering or prescribing an orthosis should understand the functional needs of the patient and
to provide the orthotist with an exact prescription that specific the material, the joints, joint position and
range of motion to be allowed.
Old and new terminology:
Old terminology is still commonly used
- Rigid hip abduction splint Von Rosen
- Surgical corest lumber orthosis
- Surgical shoes foot orthosis
- Below knee caliper AFO (anke foot orthosis)
- Above knee caliper KAFO (knee ankle foot orthosis)


1) Prevention of deformity:
examples: AFO
- used in paralytic drop foot (following polio or sciatic nerve injury) to prevent development of
equines
- dynamic fingers- wrist splint in dropped wrist following radial nerver palsy to prevent
development of fingers and wrist flexion deformity

- drop wrist in radial n. palsy:
seen in fractures junction of mid and lower 1/3
rd
humerus
radial n. palsy makes loss of wrist and MCP joints dorsiflexion
nerve function recovers with passage of time (if not cut)
prevention of deformity is important .
dynamic wrist splint= wrist & MCP joints orthosis in radial n. palsy .
note : motor nerve recovery higher than sensory recovery.

- Brachial plexus palsy:
Brachial plexus palsy usually leads to loss of shoulder abduction and external rotation . If not treated it
leads to adduction and internal retation deformity (taking a tip position) .
Abduction orthosis is used to prevent this deformity
Brachial plexus injury is usually a stretching injury
Shoulder should be splinted in functional position awaiting nerve recovery .
Also Active and Passive exercises and electrical nerve stimulation should be done .
2) Correction of deformity:
FO:
-Foot orthosis:
Shoe raise to compensate for shortness
-Spinal orthosis:
Cervico-dorso-lumbar orthosis (Milwakee) to prevent increase of deformity and correct
deformity during growth .
-An orthosis will not correct a fixed bony deformity or fixed joint contracture .

Foot orthosis :
Shoe Raise is a simple orthosis which corrects limb length asymmetry
Heel cups inserted into shoes may prevent development of varus or valgus heel deformity .
Spinal orthosis :
Are used in deformities in excess of 25 degrees of cobs angle .
Are used in Growing individuals .
To be effective they have to be used for 23 hours daily .
They have to be used till bone growth cease i.e. in growing child (18yrs).
Many types :
Can be Rigid or Semi-Rigid .
Most comprehensive form is Milwaukee Brace= Cervico- Dorso - Lumbosacral Orthosis CDLS .
Boston brace or Jewett brace is a type of rigid Dorso-lumbosacral orthosis .
DLS :
May be concealed under the clothes
Can control deformities or injuries at lumbar spine as well as dorsal spine up to level D6-
Can control scoliotic or kyphotic deformities
Cervico-dorso-lumbar orthosis (Milwaukee brace) can control all spinal deformities .


Milwaukee brace :
It consists of three basic component :
- the pelivic girdle .
- the vertical bars .
- the mandibulo-occipital assembly .
the three components are individually made for the patient. When filled first it should not be stretched too
much .
DISADVANTAGE:
May be cause mandibular deformity.
3) Maintenance of correction of deformity:
* Club foot orthosis
Plaster of Paris is a type of Temporary Orthosis following surgical correction of club foot .
Later it is replaced by backslap foot-ankle orthosis or Dennis brown night boots .
They are used to maintain correction AT NIGHT following surgical correction and removal of Plaster of
Paris .
Once the child is walking his body weight will maintain correction .

4) Instability control :
Most important function for permanent orthosis:
In cases of polio and other muscle paralysis (AFO) flail ankle, guadriceps paralysis (KAFO) .
- HKAFO in paraplegics with or without trunk control ..
Temporary use:
- patellar orhtosis (brace)
- ankle orhtosis
- aircast orhtosis
knee orhtosis :
Knee Orthosis is a knee brace which controls of knee instability following Ligaments injuries like collateral
ligaments or cruciate ligaments
They stop lateral instability and control knee movements between certain degrees
E.g. Perth's disease : avascular necrosis of femur head.
Thomas splint :
It is an orthosis which transmits the weight from the ground to Ischial Tuberosity (so
weight is relived from affecting the hip
In Perth's disease a similar orthosis has to be used for up to 2 years--
5) Weight relief function of orhtosis :
Weight relief Foot-Ankle orthosis may be used following comminuted fractures of lower
tibia ( Pylon Fractures)due to compression at the foot secondary to fall from high.
Weight is transmitted from the ground to patellar tendon and upper flare of tibia
6) Pain relief function of orhtosis :
Lumbar corset, Lumbar brace or soft, semi-rigid or rigid Lumbar or Lumbo sacral orthosis is
commonly used for acute pain or following injury
E.g. Cervical collar or cervical orthosis
7) Facilitates mobilization:
Paralysed or weak limbs Will be able to support weight bearing if fitted
with suitable orthosis
This is very important in cases of Polio or other paralytic disorders
Paraplegic patients may be able to mobilise if fitted with adequate
Orthosis and received the necessary training


(B) Prosthesis
Functions of prosthesis:
Restores function (Weight Bearing)
Restores Shape ( Cosmetic )
Stump..
Is the part of the limb remaining following amputation-
Weight bearing is normally NOT at the end of the stump-
In Above Knee amputation (30%) weight bearing is at Ischial Tuberosity-
In Below Knee amputation (70%) weight bearing is at Patellar Tendon and upper flare of tibia-

The socket..--
The socket is the immediate part the stump has to be placed
It is usually made of plastic material and padded at pressure points
A venting opening is made at the end to ease getting stump in

Lower limb prosthesis:
May be Below knee or Above knee
It consists of the socket and the additional part
Picture shows above knee artificial limb ( Above Knee Prosthesis)
Weight bearing is at the Ischial Tuberosity

Ideal orhtosis/ prosthesis
-Functional
-Fits well
-Light in weight
-Easy to use
-Cosmetically acceptable
-Easily maintained/repaired
-Ideally locally manufactured

*Sacralization :
Lumber vertibrea fused with sacrum, may completely fused or cause psudoarthrosis

*Lumberilization :
-Opposite to sacralization
-They are painless due to congenital anomalies

*Spondylolysis : ( (
- Detect in pars-interarticularis .

*Spondylolithesis: ( (
- Decapitated dog .


+ L.25: Soft Tissue Injury
Prof. Al-Zahrany
Sport Medicine:
Treating the sport injury or athletes injury regardless of age or sex or professionalism of athletes in sport .
It is not a one man work, it is a team work.
Injury of the athletes are minor not that serious but we shouldn't underestimate it and majority of the
injury in athletes is knee injury 60% .
Most of them are meniscal and ACL injury 10% of them after treatment lose the chance to play again.

Main ligaments That injured in knee :
Meniscal Injury
ACL anterior cruciate ligament
PCL posterior cruciate ligament
MCL medial collateral ligament
LCL lateral collateral ligament

How to manage the knee injury?
* In acute knee injury of the athletes what should we do?
1- Out of the field of play ground, NOT return to play to prevent
further injury !
2- Very quick history and examination (mainly we are
concerned about neurovascular injury and sever instability) .
Don't underestimate the neurovascular injury ,it may lead to
amputation !
N.B. sign of severe injury : immediate swelling. hemorrhage
3- Conservative management : RICE (Rest to prevent further injury and decrease pain and swelling , Ice
packs (change it every 20 min to decrease pain and swelling ) , Compression , Elevation (to decrease pain
and tear)) .
4- Start the rehabilitation immediately muscle exercise to prevent loss of muscle power .
5- Urgent surgery if-- :
1-Avulsion fracture ..
2- Locked knee >> (lack of extension = flexion deformity) ..
3- Neurovascular injury ..
4- Sever instability ..
* In general , we do conservative management in all knee injury except the 4 thing which mentioned above .

* Diagnosis:
- Reevaluation .
- Proper Hx and Ex .
- X-ray .

* Should we do MRI to all patient?
- It is very expensive, not done to all patients
- Should do it in very professional athletes
- In Australia, they do knee aspiration to decrease the cost of MRI
* By 2 weeks you have to reach proper diagnosis , if you excluded the 4 serious injury which we have to concern
about (neurovascular, )

* If diagnosed as isolated ACL or isolated PCL injury
what should we do?
if young pt. active and sporty surgery .
if not much active or old physiotherapy (conservative) .

* In general, we do conservative first unless otherwise reason .
N.B. : ACL , correction surgery is much easier than PCL.
Surgery:
- Not repair but reconstruction from hamstring tendon or patellar tendon; we have to do it after physiotherapy
(2-4w) until full movement of joint occur to prevent stiffness that occur due to surgery. --
* If patient have stiffness or pain due to previous injury , we do arthroscopy to joint to wash out all the remnants
in the joint before physiotherapy- .
- in LCL you have to check the common peroneal nerve, droped feet-.

** MCL & LCL (extra-articular ligaments ) :

Grades: I- 0-5 mm
II- 5-10 mm
III- >10 mm

* Grade I & II Pt. may present with pain and tenderness only without tearing of ligament Treatment here is
conservative ONLY
* Grade III Pt. have pain , surgical (by repair NOT reconstruction)
Miniscal Tears :
>80% of the tears treated conservatively up to 6 weeks.
The medial menisci is more prone to be injured b/c it's more fixed.
Aiming to eliminate :
1- Pain,
2- Effusion, all by conservative Rx
3- Locking ( the most imp.)
If one of these 3 symptoms was not eliminated surgeryaiming to preserve the menisci.
* Acute swelling is not due to miniscal injury , but due to hemarthrosis in MCL, LCL, ACL, or PCL .

We have two roles in surgical treatment :
The Surgical treatment sholud be :
Stable tears = 5-10 mm in length =>
* In the White zone (the central avascular part of meniscus) leave it alone ( manage conservatively ) .
* In the Red zone (peripheral vascular part of meniscus)
leave it alone .

Unstable tears= >10 mm length , or probe to movement between meniscal tear is >5mm =>
* In the White zone remove the tear part .
* In the Red zone repair surgically .

What do we use for repair ? :
- Meniscus arrow inserted by special gun , that way , the two part of tear will come in contact to each
other. The procedure could be done under local anesthesia.
- It is indicated when conservative management fail , regardless that the injury is stable or unstable .
- For compined (ACL,PCL) or (ACL,MCL):
1- In surgery start first with (PCL) then (ACL) b/c of anatomy.
2- In MCL/ACL injury start 1
st
with (ACL ) &after 2 weeks start with (MCL).
3- IN meniscial injury fix of them together .

L.26: Spinal Deformity
+ NORMAL SPINE ALLIGNMENT
FRONTAL PLANE STRAIGHT
LATERAL PLANE 20-40 DEGREE THORACIC KYPHOSIS
30-60 DEGREE LUMBAR LORDOSIS
+ SCOLIOSIS
Is Lateral deviation of the spine from midline
with rotation .
N.B. there is no rotation in postural scoliosis- .

+ Types :
1. Congenital (structural abn. In vertebrae
or ribs )
2. Neuromuscular (eg. cp,mmc,sma)
3. Idiopathic (most common )--
4. Others tumors ,trauma & infection.

1. CONGENITAL CLASSIFICATION

Block vertebrae Unilateral bar
vertebrae
Hemi vertebrae Wedge vertebrae


2. IDIOPATHIC SCOLIOSIS
Spinal deformity in a spine which was normal
+ Causes :
? Properioception disorders.
Brain stem.
Melatonin hormones.
UNKNOWN .
+ TYPES:
Infantile (0-4 yrs )
Juvenile (4-9 yrs )
Adolescent (> 10 yrs ) [most common]-
+ Incidence:
More in female
Right thoracic curve is the most common -
? Family Hx
More in twins
+ C/O :
Loss of self image: in front of merrier (one breast is higher than the other.)
Family observation
Pain : usually is not associated with idiopathic scoliosis-.
Early fatigue
Cardio-pulmonary dysfunction ( if curve > 90 )
Neurological dysfunction (if curve 100 )
+ O/E :
Shoulder level inequality
Waist line asymmetry
Spinal deformity
Rib hump
Adam foreword flexion test
Full neurological exam
+ Radiological exam :
X-rays :
AP LAT standing long film
AP supine
AP Pelvis to see the maturity of patient .
LAT L-S spine (l s= lumbosacral)
MRI :
If abnormal curve suspected ( any curve other than
rt. thoracic curve in young female ).
We can use the MRI in each case except in: R.t
thoracic adolcent female patients.-
Ct scan :
If congenital scoliosis suspected

+ Cobb and Lippmann :
Determine end vertebrae( Those most tilted from
horizontal).
Line along upper end plate prox. & lower endplate
distally.
Measure formed angle.
for double curves the lower end vertebrae of the
upper curve= upper end vertebrae of the lower curve
(transition vertebrae)

+ Treatment
Based on :
1. Maturity of the pt. :
Menarche
Rissors stage(4&5 ARE MATURE)
2. Magnitude of deformity
3. Curve progression (( ESPICIALLY AFTER 2 YRS OF
MENARCHE)).

+ Options OF TREATMENT :
1. Observation
2. Bracing
3. Surgery
? Physical therapy & exercise
+ Treatment ( protocol )
Mature pt.
< 50 observation
progression ~ 1 / year
> 50 surgery
Immature pt.
0-25 Observation every 4-6 month
clinically & radiologically
25-40 Bracing
> 40 Surgery


+ Braces :--
Did not correct the deformity-
Might stop the progression of the curve (or slow it down)
Effect is dose related (more worn better effect)
Best 23 hours / day
If curve apex above T7 Milwaukee brace
If curve apex bellow T8 Boston brace

+ Surgery :
o Anterior spinal fusion
severe curve
young pt. < 10 years
o Post spinal fusion & instrumentation
The gold standard treatment for most of cases-
o Both
For selected cases
+ Complications of surgery :
Neurological deficit
Bleeding
Infection
Pseudoarthrosis
Crank shaft phenomena
+ Examples



please be careful when you deal with any case of
Spinal deformity
specially
scoliosis


L.27: Spinal Injuries
May be serious Injuries
May be Stable or Unstable
May result in Tetraplegia ( at cervical spine )or paraplegia( below cervical spine)
Requires special handling of patients, especially unstable patient.
Stability of Spinal Column
Depends on Posterior Ligamentous Complex:
1) Supraspinous Ligament
2) Interspinous Ligament
3) Facet Joints and their ligaments
4) Ligamentum flavum
5) Posterior 1/3 of Vertebral Body
Posterior Ligamentous complex

Mostly result of RTA
May be associated with other serious injuries Like Brain, Face, thorax, Abdomen or Pelvis
Management begins at the site of accident
Correct method of patient transfer is more important than speed of transfer-
+ Mechanism Of Spinal Injuries
Hyper flexion
Hyperextension
Compression
Shearing (usually with rotation).


+ Mechanisms and pathology:
Force
Segment
affected
Type of fracture Stability Spinal cord injury
Flexion
Cervical
Dorsal
Lumbar
Wedge Stable Usually not affected
Hyperextension Cervical Many forms Mostly stable May be sffected
Compression
Cervical
Lumbar
Burst Stable
May be affected by
backward displacement
of bone
Shearing
Cervical
Dorsal
Lumbar
Body :slice of bone .
Facets: fracture or
dislocation
Unstable Usually affected

1- Flexion Injuries
Stable Injury
Affects Cervical, dorsal and Lumbar spine
Wedge # Superior Anterior of vertebra
Spinal cord injury unlikely

Wedge # L1


2- Hyperextension Injury

Stable injury(most common).
Affects mainly cervical spine, but may affect other area.
Anterior Longitudinal Ligament damage ? Whiplash injury
possibly rupture of intervertebral disc may cause cord compression

broken rib 8 torn mediastinal viscera ( e.g. esophagus, aorta)


3- Compression Injury

Stable injury
Affects cervical or lumbar spine
Retro pulsed bony fragment may compress the cord
Burst injury. ) )
4- Shearing injury:

Shearing = tearing
Usually with rotation
Unstable
Affects any segment of the spine
Leads to Dislocation or # Dislocation
Spinal cord injury is common
Shearing Injury Damages Posterior Ligamentous complex


+ Dislocation of vertebra:
Unstable Shearing injury
May cause cord compression or even transection
Not always clear on x rays
Unilateral facet dislocation may happen (Locked Spine).


+ Fracture Dislocation:
Injury Slices the top anterior part of vertebra
Facet joints dislocate
Cord commonly transected
Most dangerous injury.b/c it cause sharp edge which may cause((cord-transection))
Fracture Dislocation Dorsal Spine

Method of Transfer of Patient:


Neurological Evaluation: Sensory

N.B. IN CERVICAL INJURY patient lose all sensation.
When sensation is lost around the perianal area , it means : complete spinal cord transaction.
+ Neurological evaluation: High Inj
Unstable injury at level of C1 or C2 results in immediate death due to crushing of Medulla
Oblongata.
Unstable injury at Level C3 means Tetraplegic patient who has to be ventilated artificially due to
paralysis of diaphragm and intercostal muscles.

+ Management of Spinal Injuries:
1. Correct method of patient Resuscitation at site of accident.
2. Correct method of patient Transfer to hospital.
3. Careful Neurological and Radiological Assessment of the patient in hospital to determine the
extent and site of injury.
4. Management of Spinal Shock & Paralysis.

+ Spinal Shock:
o Follows injury to the Spinal Cord
o Characterised by Flaccid paralysis
o Loss of Sensation ,Power ,Reflexes below the level of cord injury
o Loss of the Bladder function :Urinary Retention. So, we use the catheter at any level of cervical
spin injury.
o Lasts up to 24 hours
o Recovery may begin immediately
o It convete to septic paralysis it mean teared spine.
o N.B.b/w T1,T2 vertebrae leads to injury to the nerve root not the cord.
+ Medical management of Paralysis:
o Immediate catheterisation to prevent overflow incontinence of bladder which follows the urinary
retention

o Prevention of pressure (bed )sores by regular turning of patient every <6 hours
o Prevention of DVT by all known measures
o Prevention of joints stiffness and deformities by physio and functional joint postures
o Medical management of Paralysis
o Prevention of Pulmonary complication
o Maintenance of fluid, electrolytes and protein balance
o Immediate attention to any possible infection
o Be aware of incidence of Heterotopic Calcification which may follow head or spinal injuries
o Anticoagulant drugs to prevent DVTor pulmonary embolism.
+ Religious, social and Psychological counseling:
o Patients develop SEVERE depression following spinal injuries especially if it was complete
paralysis
o Some patients may wish to die or even commit suicide
o Proper counseling and offer of available help affects patient favorably
+ Surgical (Local) management
o Accurate Diagnosis
o Dislocation or Fracture-Dislocation should be reduced and immobilised as soon as possible
o If there is Cord Transection (division) NO further surgical benefit can be obtained by exploring the
spinal cord
o If there is Cord Compression it should be decompressed
o If dislocation + cord transaction correct the dislocation .
+ Halter Traction of Cervical Spine:

Is a method of applying traction on the cervical spine
May be used during patient transfer to hospital
Sometimes it is used to treat severe neck pain
+ Reduction of Unstable Cervical Spine Injury
Usually done gradually by skull skeletal traction
Sometimes it should be combined with Surgery when there is failure of reduction (due to
locked facet in unilateral dislocation for example)--


+ Skull skeletal traction:
1- Parietal bone (Crutchfield )

2- Temporal Bone (Blackburn Or Barton)


+ Reduction By Gradual Skeletal Traction
o No GA required
o Initial traction with neck flexed as found after injury
o Traction weight is increased and reduction checked by x rays, followed Gradual extension
o Once reduced traction weight is lowered

+ Immobilisation: Rigid Cervical Orthosis


+ Posterior Spinal Fusion by Wire fixation

+ Anterior Spinal Fusion By H Plate & Bone graft

+ Unstable Dorsal & Lumbar Injuries
o Usually results in Paraplegia
o Principles of current management is similar to unstable cervical injuries with Tetraplegia
o Dislocation or fracture-Dislocation should be reduced and stabilised by internal fixation &fusion
with bone graft
o Paralysis is addressed afterwards
o Reduction & Fixation by Harrington Rods
o Reduction & fixation by pedicular Screws and Rods.


o Reduction and Fixation by Posterior Instrumentation
+ Management of Cord Compression
o IF paralysis was due to cord compression ( NOT transection), this compression should be removed
if patient is to improve
o Removal of cord compression is usually done through Anterior Approaches
o Whole of fractured vertebra is excised and replaced by bone graft
o Attention is given to remove bony fragments from inside spinal canal
o Also we may use titanium cages & till it with bony graft.(support)
Residual Cord Compression after stabilisation with rods


Method of Removal of Bone fragment from Spinal Canal

Mobilisation of Paraplegic Patient

+ Rehabilitation of Paralysed Patient
o The Aim is to return the patient to be a useful, self supporting possibly independent member of
the society
1) Prevention of complications
2) Stabilisation of injury
3) Fitting with Orthosis if necessary
4) Gait training
5) Social help
6) Housing help
7) Financial help

+ Spinal Cord Repair ?
At present time ,if spinal cord is transected IT WILL NOT BE POSSIBLE TO REPAIR IT IN
HUMANS
Research and experiments on repair in animals and humans are going on
Implanting electrodes which are stimulated by remote computer in certain muscles of gait
may allow walking (but this is VERY limited)
+ Special Types of Spinal Injury
1) Fractures of C1
2) Fractures of Odontoid Process of C2
3) Fractures of the body of C2
4) Fractures of Spinous process of C7
1- Fractures of C1
Unstable fracture may lead to immediate death
Comminuted but Stable Body fracture of C1 is called Jeffersons Fracture
2- Fractures of C2
Fractures of the Odontoid Process
Fractures of the body
Fractures of the Odontoid process
Fractures of the tip: short Immobilisation is adequate
Fractures of the base: will heal well by adequate Immobilisation
Fractures at middle require internal fixation
3- Hangmanss Fracture
Fracture of the Body of C2
Separates the body from posterior elements
IF displaced leads to immediate death by compression of Medulla Oblongata
This is the method of death in hanging and NOT by suffocation which takes more time

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