LMCC Orthopedic Review Lecture

2. LMCC Orthopedic Review Lecture �Back to Basics� April, 2012 Dr. P.R. Thurston

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

4. Fractures & Dislocations

5. Definitions Fracture:- A discontinuity in the structural integrity of a bone. Infraction:- An incomplete fracture. Dislocation:- Complete loss of contact of the articular surfaces of a joint. Subluxation:- Non-concentric joint surfaces. Reduction:- Returning a fracture or dislocation to an anatomical alignment. Comminution:- Multiple fragments.

6. Fractures

7. Fractures Bone is a two-phase material :- Calcium HydroxyApatite Ca10(PO4)6(OH)2 = mineral Osteoid Collagen type I and II = fibrous Calcium is strong in compression, but weak in tension. Osteoid is strong in tension, but weak in compression.

8. Fractures BUT :- (for adult bone) Calcium is stronger in compression than Osteoid is in tension And therefore :- Bone always fails first in tension

9. Fractures A bone consists of three areas :- the Diaphysis the Metaphysis the Epiphysis.

10. Fractures Bending Torque Direct Traction Compression Intra-articular Pediatric

11. Fracture Description This fracture is angulated laterally, since it points laterally. The distal fragment is tilted medially

12. Fracture Description 1) The distal fragment is always described with relation to the proximal segment. 2) Displacement = Translation of bone ends. 3) Angulation = Orientation of bone ends. 4) Angulation identifies to where the fracture points. 5) For clarity, the tilt of the distal fragment is often used to describe angulation.

13. Fractures A fracture can occur in :- Growing Bone. = Pediatric Deformities. Normal bone subject to abnormal forces. = Traumatic Fractures. Abnormal bone subject to normal forces. = Pathologic Fractures. Normal bone subject to cyclic forces. = Fatigue or Stress Fractures.

14. Fractures

15. Fractures

16. Stress or Fatigue Fractures

18. Pathologic Fractures Metastases: Lytic - Lung - Colon - Thyroid - Renal - Breast Sclerotic - Prostate

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

20. Pathologic Fractures

21. Osteitis Deformans / Paget�s Disease 4% of pop. Over 40 yrs. accelerated bone turnover often assymptomatic monostotic > polyostotic loss of stature AV shunting pathologic bone

22. Gout Urate crystalopathic arthritis Crystals in periarticular tissues Inconsistant elevated serum urate Allopurinol and colchicine Tophi in periarticular soft tissues Deposits in non-articular cartilage Juxta-articular erosions

23. Indications for Closed Reduction There is significant displacement. Reduction is possible. The reduction, if gained, can be held. The fracture has not been produced by a traction force.

24. Indications for Open Reduction 1 ) There is a significant Displacement. 2 ) Open Fractures. 3 ) Intra-articular Fractures. 4 ) Un-reducible Fractures 5 ) Reductions that cannot be maintained in a cast. 6 ) Comminuted or Segmental Fractures. 7 ) Floating Joints. 8 ) Fractures with Neurovascular damage.

25. Open Fractures Classification :- 1. < 1 cm., inside-out, little soft tissue damage. = low potential for infection. 2. 1 cm. � 10 cms., outside-in, requires debridement, but no flap or skin graft. = moderate potential for infection. 3. > 10 cms., outside-in, high energy, devitalized muscle, comminution or bone loss, soft tissue loss.

26. Open Fractures Classification :- 3A. No loss of soft tissue cover, no flap required. 3B. Flap required due to soft tissue stripping. 3C. Associated vascular injury.

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

28. Degloving Mechanism

29. Type III C Injuries � Vascular Injury

30. Fracture Complications 1. Pulmonary Fat Emboli 2. Compartment Syndromes

31. Pulmonary Fat Emboli :- A.R.D.S. - Long bone fractures, burns, contusions. - Interstitial pneumonitis due to free fatty acids - S.O.B. & confusion in young adults. - Axillary & Subconjunctival Petechiae. - Serum lipase elevated. - pAO2 reduced � if < 50 � 20% mortality. - Ventillatory support - Dexamethazone. - 5 day course.

32. Pulmonary Fat Emboli :- A.R.D.S. Since Pulmonary Fat Emboli occur as an on-going process, involving either repeated showers of emboli or an evolution of insults, the most effective treatment is:- Early Fracture Fixation for both prevention and management.

33. Compartment Syndromes - increased interstitial tissue pressure. - fractures, burns, tight dressings. normal pressure < 25 mm. Hg. when the tissue pressure > venous capillary pressure, but less than the arteriolar pressure. 6 P�s - pain. - pallor. - pulselessness. - paresthesias. - paralysis. - poikylothermia.

34. Compartment Syndrome

35. Rx Compartment Syndrome

37. Compartment Syndrome

38. Back Pain

39. Classification of MechanicalBack Pain  (MacKenzie) Postural syndrome normal tissues become painful by the application of prolonged stresses (sitting, bending etc) Dysfunction syndrome soft tissues are shortened and stiff. Usually >30 year old, poor posture, under exercised, reduced mobility Derangement syndrome Disc derangement (tears and herniation)

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

41. Anatomy

42. Three joint complex (Kirkaldy Willis)

43. Non operative Treatment of Back Pain Do nothing Activity modification Medications Exercise and physiotherapy Braces Manipulation Massage therapy Traction/inversion therapy Vitamins/Supplements/Diets Weight control Every Suzanne Summers sponsored abs exerciser

44. Disc herniation

45. Cauda Equina Syndrome Sciatica associated with bowel or bladder dysfunction. Perineal numbness. Low or Sequestrated Lumbar Disc. Pressure on S1, S2 and/or S3 nerve roots. Requires immediate Decompression to avoid permanent disability.

46. Spinal stenosis Symptoms: unilateral radicular pain bilateral claudication better with forward flexion of trunk better walking uphill rare bowel/bladder involvement Signs: usually no neuro signs look for pulses stress test Investigations: XR CT Myelo-CT MRI

47. Developmental Dysplasia of the Hip An in utero Anterior Subluxation of the hip. Growth in this position produces excessive Anteversion / Adduction. Classification: Positional 2/1000 Hereditary 2 x more likely if mother Teratologic Arthrogryphosis 50% bilateral, F > M 8:1 Test ALL newborns at birth Conservative Rx at birth � Pavlik, D.diaper Surgical Rx if resistant

48. Legg-Perthe�s Disease Osteochondrosis (avascular necrosis) Proximal Femoral Epiphysis Necrosis, revascularization, fragmentation, healing 3 � 11 yrs., M > F 4:1, 15% bilat. Subluxation laterally, Coxa plana, Coxa magna Osteoarthritis 50 yrs.

49. Slipped Capital Femoral Epiphysis Weakness of the physis of the femoral head allows medial and inferior slip during the last phase of growth. Shortening of the leg, adduction, painless limp and external rotation contracture. Observation if mild, fixation if severe Surgery risks Avascular Necrosis of femoral head

50. Ages for Hip Disease D.D.H. Birth Septic Hip Birth � 11 Legg-Perthes 3 � 11 Transient Synovitis 3 � 11 S.C.F.E. 11 - 16

51. Osteomyelitis Acute infection, metaphyseal 90% Staph., 20% mortality 100% growth abnormality Periosteal elevation, osteolysis Sequestrum, Involucrum

52. Dislocations The articular surfaces are no longer in contact. Commonly affects - Shoulders > PIP joints > Elbows > Ankles. Often associated with fractures. Occasionally associated with neurologic injuries

53. Shoulder Dislocations 95 % anterior 1 % posterior Luxatio erecta Medial Axillary nerve injury Rapid reduction

54. Shoulder Dislocations Conscious sedation. Traction reduction. Immobilization. Recurrent. Voluntary Habitual. Multiaxial instability.

55. Elbow Dislocation Posterolateral. Median nerve injury. Ulnar nerve injury. Rapid reduction. Early mobilization.

56. Time for a 10 minute break!

57. 1. Talipes Equinovarus is the proper name for :- a. Flat feet b. In-toeing c. Club feet d. Knock knees e. Wry neck

58. Talipes Equinovarus congenital deformity of the foot Equinus, Inversion, Adduction, Supination 2 per 1000 live births 50% bilateral M >F 2:1 Serial corrective casts at birth Surgery if resistant EARLY TREATMENT IS ESSENTIAL

59. 2. A Trendelenburg sign refers to :- a. Leg length discrepancy b. Gait abnormality c. Knee recurvatum d. Scoliosis e. Hip Contracture f. Abductor weakness

60. 3. All of these are signs of D.D.H. except :- a. Limited Abduction b. Ortolani Sign c. Asymmetric Skin Folds d. Galeazzi�s Sign e. McMurray Sign

63. 4. The most common congenital spinal abnormality is :- a. Scoliosis b. Spina Bifida c. Torticolis d. Klippel � Feil Syndrome e. Multiple Hereditary Osteochondroma

64. Spinal Bifida defect of neural tube closure Lumbar spine, commonly low 2 per 1000 myelodysplasia Mild to complete paraplegia Occulta, meningocoele, Myelomeningocoele Bowel and bladder dysfunction

73. 8. A 6 year old boy with delayed physical development, convulsions, tetany, weakness, blue sclera and bony deformities is most likely suffering from :- a. Physical Abuse b. Ehlers � Danlos Syndrome c. Osteogenesis Imperfecta d. Multiple Hereditary Exostoses e. Myositis Ossificans

74. 9. A 6 year old boy with delayed physical development, a rachitic rosary, weakness  and bony deformities is most likely  suffering from :- a. Physical Abuse b. Rickets c. Scurvy d. Osteitis Deformans e. Myositis Ossificans

77. 10. This is :- a. Osteomyelitis b. Osteomalacia c. Osteoporosis d. Osteitis Deformans e. Leprosy

78. 11. A child with knee pain has a ____ problem until proven otherwise. a. Knee b. Femoral c. Tibial d. Hip e. Patella

79. 12. All of the following are part of the differential of hip pain in a 6 year old, except :- a. Femoral Osteomyelitis b. Septic Hip c. Transient Synovitis d. Legg-Perthes Osteochondritis e. Slipped Capital Femoral Epiphysis

80. 13. Osteomyelitis in children is produced by what route of infection? a. Direct extension from another focus b. Hematogenous spread c. Perforating wounds d. Lymphatic spread e. Septic hip

83. 16. All of these are findings of a herniated L5-S1 disc, except :- a. Absent Achilles reflex b. Lateral foot numbness c. Sciatica d. Low back pain e. Extensor Hallucis Longus weakness

84. 17. Avascular necrosis of the femoral head is associated with all of the following except :- a. Steroid use b. Alcohol c. Deep sea diving d. Lipid storage disease e. Diabetes

90. 21. Colle�s Fracture distal radial fracture FOOSH occurs at all ages commonly 60 yrs. + osteoporosis intra-articular

91. CR & K-Wires

92. External vs Internal Fixation

101. ORIF

105. 26. Reduction by traction.

106. 27. What is the Diagnosis?

107. 27. Anterior Dislocation of the Shoulder

111. 29. The complications of a Supracondylar fracture in children include all of the following except :- a. Malunion b. Volkmann�s Ischemic Contracture c. Compartment Syndrome d. Cubitus Varus e. Peripheral Nerve Injuries f. Pulmonary Fat Embolus

112. 30. The only sign of a Compartment Syndrome that is always present  is :- a. Pain b. Pallor c. Pulselessness d. Paresthesias e. Paralysis

113. 31. Compartment pressures indicating the need for fasciotomy :- a. 0 � 15 mms. Hg b. 15 � 25 mms. Hg c. > 25 mms. Hg d. > 50 mms. Hg e. > 75 mms. Hg

114. 32. A 20 yr. old male with a fractured femur has findings of confusion, tachypnea and conjunctival petechia. The most likely diagnosis is :- a. Pneumonia b. Pulmonary Fat Emboli c. Cerebral Contusion d. Cardiac Contusion e. Transient Stress Reaction

115. 35. What fracture is this?

116. 35. The commonest complication of this fracture is :-

117. 35. A Radial Nerve Palsy

119. 37. This patient most likely has a fracture of the �.?

121. 38. All of the following are complications of this fracture except :-

122. 38. Blood Supply of Femoral Head

123. 38. Save Head versus Replacement

124. 38. Subcapital Hip Fractures

125. 39. What�s the Diagnosis?

126. 39. Intertrochanteric Hip Fracture

127. 39. Intertrochanteric Fractures

128. 40.Surgery or not?

129. 41. Surgery or not?

132. 43. A 45 yr. old male, who was previously in good health, has sudden onset of transverse low back pain and right sided sciatica to his foot, after chopping wood at the cottage. Upon arising the following morning, he notices numbness on the outer border of his right foot and some weakness in the right leg. He has no bowel or bladder problems.  The most likely diagnosis would be:- a. Lumbar Muscular Strain. b. Herniated Lumbar Disc. c. Herniated Lumbosacral Disc. d. Cauda Equina Syndrome. e. Spinal Stenosis.

133. 44. Your initial approach to this problem would include some or all of the following:- a. Bedrest. b. Anti-inflammatories. c. Muscle Relaxants. d. Spinal X-rays. e. Physiotherapy. f. Orthopedic/Neurosurgical referral. g. CT-Myelogram or MRI h. Discectomy

134. 45. During the work-up for this problem, the patient complains that he has unaccountably soiled his underwear, without knowing it. Your response to this would be to:- a. Reassure the patient that this is not serious b. Order an urgent MRI c. Get an urgent referral to Neuro/Orthopedics d. Place the patient on immediate bedrest.

135. 46. Which of the following signs and symptoms are consistent with a torn medial meniscus of the knee:- a. Inability to squat b. Pain on descending stairs c. Locking d. Recurrent effusions e. All of the above.

136. 47. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle.  Your initial response to this situation would be :- a. Re-X-ray the ankle. b. Remove the cast. c. Measure the compartment pressures. d. Instruct the patient to elevate the limb and prescribe an anti-inflamatory.

137. 48. The most common dislocations of the shoulder are:- a. Medial. b. Posterior. c. Luxatio Erecta. d. Anterior.

138. 49. Metastatic lesions to bone, of the following tumours, usually produce lytic defects except:- a. Thyroid. b. Pancreas. c. Prostate. d. Kidney. e. Lung.