ORTHO NOTES BY JOACHIM & LIYANA (EDITED BY WAI WAI)

TABLE OF CONTENTS
NO.
1

TITLE

INTRODUCTION TO ORTHOPAEDICS

History-Taking
Analgesics Ladder (by WHO)
Post-Op Management (fever/oliguria/dyspnoea/shock)
Plaster Techniques
FRACTURES GENERAL PRINCIPLES***
Definitive treatment
Open Fractures
Emergency Care
Irrigation & Debridement
Stabilisation of Fracture
Wound Coverage
Delayed Union & Non-Union
Management of Bone Loss
Fracture Healing
Compartment Syndrome
Avascular Necrosis
TipBits for Fractures
SHOULDERS
Approach to Shoulder Problems
Rotator Cuff Impingement
Calcification of the Rotator Cuff
Biceps Tendonitis
Rupture of Biceps Tendon
Frozen Shoulder***
Shoulder Joint Instability & Dislocations
Other Disorders of the GH Joint
Disorders of the Scapula
Fractures of the Clavicle
Fractures of the Scapula
AC Subluxation/Dislocations
SC Dislocations
ARM
Fractures of the Proximal Humerus
Fractures of the Shaft of Humerus
Fractures Around the Elbow in Children
Fractures & Dislocations Around the Elbow in Adults

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ELBOWS & FOREARMS

Cubitus Varus (Gunstalk Deformity)

Cubitus Valgus
Rheumatoid Arthritis
Osteoarthritis
Olecranon Bursitis
Tennis Elbow (Lateral Epicondylitis)**
Golfers Elbow (Medial Epicondylitis)**
Cubital Tunnel Syndrome**
Supracondylar Fractures
Elbow Dislocations
Medial Condylar Injury
Radial Head Fracture
Radial Neck Fracture
Forearm Fracture/Dislocations
Nightstick Injury
Causes of Tardy Ulnar Nerve Palsy
HANDS & WRISTS
Types of Cases
DDx of Painful Elbow & Hand
Hands
o Acute Infections
o Skin
o Muscle/Tendon Disorders
o Lumps
Wrists
o Joint Disorders
o Lumps
o Muscle/Tendon
o Nerves
Hands & Wrists
o Rheumatoid Arthritis
o Osteoarthritis
o Bone Disorders
Colles Fracture
Smiths Fracture
Scaphoid Fracture
Complications of Wrist Fractures
Lunate Dislocation
Perilunate Dislodation
Scaphoid Dislocation
o Brachial Plexus Lesions
o Zones of the Hand

36

39

HIP

10

51
Pelvic Fractures
Approach to Hip Pain
Congenital Dislocation of the Hip (CDH) /
Developmental Dysplasia of the Hip (DDH)
Hip Dislocation
Perthes Disease (Coxa Plana)
Slipped Capital Femoral Epiphysis (SCFE)
Pyogenic Arthritis
Transient Synovitis
TB Hip
RA Hip
OA Hip
AVN of the Hip***
Proximal Femoral Fractures Summary

KNEE
Knee DDx
Common Knee Symptoms
Meniscal Tears
Meniscal Cysts
Chronic Ligamentous Instability
Osgood-Schlatter Disease
Osteochondritis Dessecans
Patellar Fracture
Recurrent Dislocation of the Patella
Patellar/Quadriceps Tendon Rupture
Dislocated Knee
Chondromalacia Patellae
OA Knees***
RA
Bakers Cyst (Popliteal Cyst)
Housemaids Knee (Prepatellar Bursitis)
Clergymans Knee (Infrapatellar Bursitis)
Semimembranous Bursa
Charcots Joint
TIBIA
Tibial Plateau Fracture
Tibial Diaphysis Fracture
ANKLE
Evaluation of Ankle Complaints

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64

12

72

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14
15
16

FOOT

SPINE

Danis Weber Classification

Lauge Hansen Classification
Ligamentous Injuries
Recurrent Knee Subluxation
Evaluation of Foot Complaints
Congenital Talipes Equinovarus (Congenital Club
Foot)
Hallux Valgus
Ruptured Tendo Archilles
Hallux Rigidus
Pes Planus
Footballers Ankle
Archilles Tendonitis
Talar Fracture
Calcaneal Fracture
Plantar Fasciitis
Bunions
Metatarsal Fracture

Approach to Back Pain

Prolapsed Intervertebral Disc (PID)
Scoliosis
Adolescent Idiopathic Scoliosis
Lumbar Spondylosis
Spinal Stenosis
Spondylolisthesis
Cauda Equina Syndrome
PID vs. Spinal Stenosis
Lumbar Spine Fractures
Cervical Myelopathy
Cervical Spondylosis
Cervical Lesions
Cervical Spine Trauma
DM FOOT (ORTHO)
POLYTRAUMA
FRACTURES
BONE & JOINT INFECTIONS
Acute Haematogenous Osteomyelitis
Subacute Haematogenous Osteomyelitis

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93
98
104
108

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21
22

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24

Post-Traumatic / Operative Osteomyelitis

Chronic Osteomyelitis
Acute Suppurative Osteomyelitis
TB
OSTEOPOROSIS***
RHEUMATOID ARTHRITIS***
ANKYLOSING SPONDYLITIS
GOUT***
BONE TUMOURS & CYSTS (OSCES-ORIENTED)
PAEDIATRIC ORTHOPAEDICS
Fractures
o Ossification Centres
o Ligamentous Laxaties
Congenital, Developmental & Physiological
Conditions
o Torticollis (wry neck)
o Approach to Limping Child
o DDH
o Clubfoot (Congenital Talipes Equinovarus)
o Flatfeet (Pes Cavus)
o LL malalignment
o Scoliosis
o Cerebral Palsy (CP)
IMPORTANT CLASSIFICATIONS FOR ORTHOPAEDICS
DISEASE MNEMONICS

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142

INTRODUCTION TO ORTHOPAEDICS

HISTORY TAKING

PRESENTING COMPLAINT
Pain
- SOCRATES
- For timing/frequency
o Early morning pain hallmark of inflammation
o Relieved at night often mechanical in nature
o Night pain indicates severity of pain, ?underlying malignancy
- For relieving factors: include analgesics & TCM
For upper limb
Activity
- Hand dominance
Loss of function for lower limb
- Washing, dressing, combing,
- Going to shops
feeding, writing
- Use of walking aids (community ambulant?)
- Use of chopsticks (assess fine
o Any lift landing?
motor skills)
- Walking distance
- Use of stairs
Also assess pre-morbid ADL status (dressing, eating, ambulating, toileting, hygiene)
Specific to lumbar spine
- History of injury
- Radiation of pain (look for dermatomal distribution)
- Associated neurological symptoms (numbness/paresthesia) & their distribution
- Any sphincter disturbance (bladder & bowel symptoms secondary to cauda equina
syndrome)

PAST MEDICAL HISTORY

- Comorbidities (fitness for op)
- Medication history
- Any drug allergies
SOCIAL HISTORY
- Alcohol/smoking
- See activity
- Any caregiver support
SYSTEMIC REVIEW
- Any recent history of trauma/falls
- The usual systemic review questions (especially to rule out extra-articular
manifestations of certain diseases such as rheumatoid arthritis)
- Red flags for lower back pain
o Metastasis: LOW, LOA, night sweats, history of malignancy, night pain
o Infection: fever, history of TB / toe gangrene
o Neurological deficits: BO, PU (continence), whether neuro deficits are
progressive
o History of trauma
o Hairy patch / cafe-au-lait spots (especially in paediatric population)

ANALGESIC LADDER (BY WORLD HEALTH ORGANISATION)

Mild pain:
Step 1: Simple analgesics (non-opioid)
o Initiate topical and/or simple oral non-opioid analgesics (e.g. paracetamol,
NSAIDs)
o + adjuvant e.g. tricyclic antidepressants, anticonvulsants (pregabalin or
gabapentin) for neuropathic pain.

Moderate pain:
Step 2: Weak opioid
o Weak opioid (e.g. tramadol, codeine phosphate or dextropropoxyphene)
o + adjuvant e.g. tricyclic antidepressants, anticonvulsants

Severe pain:
Step 3: Strong opioid
o Opioids (e.g. morphine, oxycodone)
o + adjuvant e.g. tricyclics, anticonvulsants

Specific to the hip

- Stiffness & pain arising from hip joint
- Whether patient is able to care for their feet / pedicure
Specific to the knee
- Locking (due to jamming by torn meniscus or loose body)
- Giving away (due to patellofemoral problem, loose bodies, torn flap of meniscus,
ligamentous laxity)
Specific to the feet
- Back pain (referred pain)
- Pins & needles (lumbar spine pathology/nerve entrapment/peripheral neuropathy)
- Footwear

POST-OPERATIVE MANAGEMENT
1.
2.
3.
4.
5.
6.
7.

then reabsorbed, with collapse of the supplied lung segments, usually the basal lobes.
The collapsed lung may become secondarily infected by inhaled organisms.

Life Threatening vital signs

Limb Threatening circulation
Post op pain
Post op urine output
Post op nutrition
Rehabilitation independent, dependent in ADL, WB
Discharge
Days 3-5

Postoperative Management Related to Surgery

1. Postop consciousness post sedation and anaesthesia, CVA, hypoxia,
hypovolemia
2. Post op airway aspiration, pneumonia
3. Post op circulation - Hypovolemic shock, PE/DVT
4. Local circulation - , vascular injury or compromise, Compartmental symptoms
5. Nerve compression
6. Post op GI
7. Postop urine
8. Postop fever
9. Post op wound infection

Post-Op Fever
Days 0-2

mild pyrexia
o tissue damage and necrosis
At the site of the operation
o haematoma
higher persistent pyrexia
o postoperative atelectasis
o specific infections related to the surgery

biliary infection after biliary surgery

urinary tract infection after urological surgery

Note that fever due to blood transfusion may occur in this initial post-op period.
Postoperative atelectasis generally occurs within 48 hours.
It is an extremely common post-operative complication with some degree of
pulmonary collapse occurring after almost every abdominal or trans-thoracic
procedure.
Mucus is retained in the bronchial tree, blocking the finer bronchi; the alveolar air is

Predisposing factors

obesity

smoking

wound pain

opiates and drowsiness

pregnancy

muscular weakness

nasogastric tube

abdominal distension

bronchopneumonia

developing sepsis, which may be:

o wound infection
o drip site or drain infection
o abscess formation, e.g. subphrenic or pelvic, depending on type of
surgery performed.
Indications for prophylactic antibiotics

patients at risk of subacute bacterial endocarditis, for example with mitral

valve disease or prosthetic valves

patients undergoing prosthetic joint or vascular components

operations which involve contamination to some extent, for example colon

or oesophageal resection

patients who have some other type of indwelling prosthesis, for example
total hip replacement
As a general rule prophylactic antibiotics should be given in the perioperative period
and then discontinued. It is best if the first dose can be given on induction of
anaesthesia. Prolonged administration of antibiotics is accompanied by undesirable
side effects, such as the emergence of antibiotic resistant organisms, or the
development of pseudomembranous colitis; it is for this reason that duration of therapy
should be stated.
Postoperative wound infection
Postoperative wound infection is a potentially hazardous complication of surgery. It is
important to consider the risk of it occurring, and to give prophylaxis if appropriate.
Risk factors
- senility, diabetes, ischaemia, malnutrition, vit C & Zn deficiency
- steroids and cytotoxic drugs, radiotherapy
- long preoperative hospital admission
- shaving the operative site the night prior to surgery
- rough handling of the tissue
- poor blood supply, for example sutures too tight

failure to debride devitalised tissues

large dead space
contamination of wound

Wound irrigation

removal of foreign bodies

reduction of pathogen numbers

removal of blood, clot and dead tissue

removal of free cancer cells

moistening of tissue

Days 5-7
>7 days

The solution used to irrigate may be:

physiological saline; its low osmolarity may aid in free tumour cell lysis

topical antiseptic, e.g. chlorhexidine and iodine; both may cause undesirable
cell death of host tissue. Alternatives include spraying dry povidone-iodine
spray onto the wound - this has been shown to reduce infection rates - or
local injection of antibiotic peroperatively.

venous thrombosis, in the limbs or pelvis

causes related to specific ops, e.g. failure of bowel anastomosis with fistula
formation & leakage
Causes are less likely to be directly related to the specific operation undertaken.
Causes include:
wound sepsis

distant sites of sepsis eg cerebral or hepatic abscess

thrombotic disease

postoperative atelectasis

postoperative pneumonia

wound infection

intravenous phlebitis

urinary tract infection

prostitis

gout

central line sepsis

parotitis

drug reaction

transfusion reaction
o non-haemolytic transfusion reactions
o febrile transfusion reactions

complications of specific operations, for example pericarditis after cardiac

surgery

IN SUMMARY
wind -- atelectasis within 48 hrs, aspiration, pneumonia
water -- UTI's, especially if catheterized
wound -- check for wound infection.
veins -- (OK, it's a "V") DVT, phlebitis from IV's
drugs -- drug reactions (uncommon)
Fever within 48 hours is usually atelectasis. After 48 hours, atelectasis is less likely.
After 5 days:

wound infection
intraabdominal abscess (CT abdo and pelvis)
DVT

Post-op Dyspnoea
1. Atelectasis -- usually within 48 hours, more likely in elderly, COPD, smokers, obese
patients, and those with upper abdominal incisions. Treatment is to mobilize,
encourage deep breathing and coughing, chest physiotherapy
2. Aspiration -- risk factors include GERD, food in the stomach, intestinal obstruction,
and pregnancy (delayed gastric emptying). Prevent via preoperative fasting in elective
patients, 'rapid sequence" induction in emergency patients, and those at high risk.
3. Pneumonia -- atelectasis, aspiration and copious secretions are predisposing factors.
Often gram-negative, and or polymicrobial.
4. Heart failure -- caused by fluid overload in patients with limited myocardial reserve,
post op MI, or dysrhythmias (most commonly a fib).
5. Pulmonary embolus -- most clinically significant pulmonary emboli arise from the iliac
and femoral veins.

Post-Op Oliguria
Pre-renal -- COMMONEST CAUSE OF LOW URINE OUTPUT
o external fluid loss (hemorrhage, dehydration, diarrhea)
o internal, third space loss -- bowel obstruction, pancreatitis
Renal -- nephrotoxic medications
o Untreated pre-renal causes leading to acute tubular necrosis
Post renal -- prostatic hypertrophy, blocked foley, stone in solitary kidney

Post-Op Shock
Basic haemodynamics: CO = SV x HR
Recognising shock
o Easy signs to find:
Urine output
The best CVP is if you see pee
Think Foley
Blood pressure
Skin temperature
Mental status
Drain saturation
o Lab investigations
FBC
Serial FBC for any patient with bleeding risk
Lactate
BUN / Cr
Coagulation profile
Electrolytes (specifically bicarb)
Resuscitation fluids
o No evidence to show that one type of fluid is superior to another in
resuscitation
o Ensure that you use enough crystalloid.
General principles
o Resuscitation with appropriate and
enough fluids
o Give blood if bleeding or evidence of
oxygen delivery problem
o Pressors to mitigate hypotension
o Stress dose steroids if indicated
o Intensive insulin
o Normothermia
Hypovolaemic shock
o Bleeding
Think about the surgery and everything that could go wrong
Surgical bleeding vs. postoperative oozing
Support with fluids and blood products.
Treat hypothermia

Inadequate resuscitation
Patients are NPO for several hours prior to surgery
Patients with intraabdominal processes (especially infection and SBO)
have tremendous fluid losses.
The best prevention of postoperative resuscitation problems is
preoperative resuscitation.
Post-op septic shock
o Utilize Rivers goal directed protocols (N Engl J Med 2001; 345:1368-1377,
Nov 8, 2001 )
CVP 8-12
Urine output > 0.5 cc/kg/hr
SvO2 > 70
Hgb to 10, Dobutamine
MAP>65
Norepinephrine or Dopamine
Post-op cardiogenic shock
o Patient may not complain of chest pain although there may be clues on exam.
o EKG/Echo/Swan/enzymes, etc.
o Must weigh risk of bleeding (ASA, thrombolytics, cath) vs. benefit
Usually benefit of treating heart outweighs risk
o Inotropic support
Abdominal compartment syndrome
o Post op laparotomy patients can be at risk for this as well as cirrhotics
o EASY to measure. Basically stick a foley catheter to a CVP monitor
o Abnormal is over 20 cm water. Dangerous over 30.
o Treatment is decompression
o You only find it if you THINK about it.
Summary
o Resuscitation, resuscitation.
o Think about hypovolemia
o Think about bleeding.
o Think about sepsis.
o Think about abdominal compartment syndrome
o Get an EKG in high risk patients.
o And remember The best treatment is PREVENTION
o

PLASTER TECHNIQUES
Basic Principles
1. One joint above and below the fracture
2. Cast is well molded with no pressure points
3. Always place a backslab/U slab even if patient is just admitted for pain control.
4. All hand fractures have a standard functional hand position cast
Indications
Fractures that can reduced and be stably maintained
No major soft tissue injury
No suspicion of compartment syndrome
No vascular compromise
Types of Plaster Casting
Forearm U slab: Forearm fractures
Shoulder U and O slab: Proximal and midshaft humerus fractures
Intrinsic plus hand slab: Hand fractures
Above knee cylinder slab: Knee injuries
Above knee slab: Tibia/Fibula fractures
Below knee slab: Ankle fractures

FRACTURESGENERAL PRINCIPLES
Mechanism: remember the process leading to the fracture
Traumatic
Pathologic remember O M I T: osteopenia/osteoporosis, metabolic bone
disease (hyperparathyroidism, hyperthyroidism, osteogenesis imperfecta,
rickets), infection, tumour
Stress repetitive mechanical loading, periprosthetic
CLINICAL FEATURES OF FRACTURES
Pain and tenderness
Loss of function
Deformity
Abnormal mobility and crepitus (avoid)
Altered neurovascular status (important to document)

INITIAL MANAGEMENT
ABCDEs
Limb - attend to neurovascular status (above and below)
Rule out other fractures/injuries (especially joint above and below)
Rule out open fracture
Take an AMPLE history - A llergies, M edications, P ast medical history, L ast
meal, E vents surrounding injury
Analgesia
Splint fracture - makes patient more comfortable, decreases progression of soft tissue
injury, decreases blood loss
Imaging
RADIOGRAPHIC DESCRIPTION OF FRACTURES
Rule of 2s
2 sides: bilateral
2 views: AP and lateral
2 joints: above and below the site of injury
2 times: before and after reduction
Identify view + date + patient identification (This is an AP X-ray view of the knee
joint taken on 1/12/10 for Mdm. Gee)
Anatomy
Which bone
If diaphyseal decribe by thirds : proximal/middle/distal
Type
spiral # - rotational force, low energy (# line > 2x bone width)
oblique # - angular and rotational force
transverse # - direct force, high energy
comminuted # (> 2 pieces) - direct force, high energy
compression #
avulsion # - strong muscle inserting into small bone e.g. quads to
patella, triceps to olecranon, peroneus tertius to 5th metatarsal head
butterfly # - 2 lines break out obliquely from point of contact of blow
producing a free-floating butterfly fragment
Articulation
Extra-articular: diaphysis/metaphysis
Intra-articular salter-harris classification (for children)
Apposition (% displacement) any shortening? [i.e. bayonet #]
Angulation
Apex
Associated structures (aka soft tissue): calcification, gas, foreign bodies
8

DEFINITIVE MANAGEMENT
Goals Obtain and Maintain Reduction
reduce
stabilize
rehabilitate
Attempt closed reduction
if successful
Then stabilize
if unsuccessful
Open reduction
Then stabilize-- usually internal fixation
Rehabilitate
Reduction
Is reduction necessary?
may not be for clavicle, fibula, vertebral compression fractures
reduce when amount of displacement is unacceptable
imperfect apposition may be acceptable while imperfect alignment is rarely
acceptable
Closed when possible
Closed reduction
Minimise damage to blood supply
Rely on soft tissue attachments
Rarely adequate for intraarticular #
Difficult in babies whose bones cannot see in X-ray
Open reduction: indications remember NO CAST

N - N on-union
O - O pen fracture
C - neurovascular C ompromise
A - intra- A rticular fractures (require anatomic reduction)
S - S alter-Harris III, IV, V and/or special situations depending on site
T - poly T rauma
Others
failure to reduce using closed reduction
cannot cast or apply traction due to site (e.g. hip fracture)
pathologic fractures
fractures in paraplegics for nursing access
potential for improved function with ORIF
infection
new fracture through screw holes
implant failure

Stabilization
Stabilize the fracture site but do not completely immobilize the limb if possible
External stabilization
1. splints/tape
2. casts
3. traction
4. external fixator

Non-rigid fixation risk of loss of

reduction but stimulate rapid callus
formation

Rigid fixation

Internal fixation
immediate loading but
1. percutaneous pinning (Kirschner or K-wires)
does not stimulate
callus formation
2. extramedullary fixation (screws, plates, wires)
3. intramedullary fixation (rods) - biomechanically advantageous
Rehabilitation
To avoid joint stiffness
Isometric exercises to avoid muscle atrophy
Range of motion (ROM) for adjacent joints
Continuous Passive Motion (CPM) following rigid fixation of fracture allows joint
motion to prevent stiffness for intra-articular fractures
After cast/splint removed and fracture healed resistive muscle strengthening
Evaluate bone healing (clinical, x-ray)

OPEN FRACTURES
EMERGENCY!
Definition: A fracture or its haematoma that communicates with the environment.
Gustilo-Anderson Classification of Open Fractures*****

Superficial to deep

Laceration
<1cm long

Soft tissue
Little damage,
no crush

II

1-10cm

IIIa

>10cm

Moderate
crushing, no
flap/avulsion
Extensive
damage to skin,
muscle, neurovasculature

Fracture
Usually
transverse,
short oblique,
little
comminution
Moderate
comminution

Contamination
Clean puncture
(compound
from within)

Comments
Simple #
[5% chance of amputation]

Moderate
contamination

Butterfly #
[10% chance]

Extensive
comminution
& instability

Severe
contamination

Adequate soft tissue coverage (NOT SKIN) despite

extensive laceration/flaps
- Segmental # (= # at 2 levels)
- Farm injuries / any injury occurring in a
highly-contaminated envt
- GSW
[20% chance]
IIIb
Extensive soft tissue injury/loss
Periosteal stripping & exposure of bone
[30% chance]
IIIc
Any open # a/w arterial injury that requires repair
regardless of wound size/soft tissue injury
Prophylactic fasciotomy always done to
prevent post-op compartment syndrome
[>40% chance]
NB. can only differentiate Gr III into a, b and c ONLY AFTER SURGICAL INTERVENTION
(i.e. debridement)

More energy, higher velocity trauma

Gr
I

10

EMERGENCY CARE

Sterile scrub: use scrubbing brush and scrub the site to debride all necrotic
tissues (dead muscle/fat/other tissues) --- how to tell if muscle is dead or not?
4Cs
Dead
Live muscle
muscle
Consistency
Mushy
Turgid
Colour
Pale pink
Pink/bright
red
Contraction (most important)
Absent
Present
Capillary
No bleed
Bleeding

Repair vascular injury if present (i.e. re-anastomose the vessels)

For crushed injuries involving both vascular & nerve injury amputate
Remove comminuted fragments (anything thats dead and without soft tissue
attachments discard)
Wash with 10L of saline (to dilute bacterial load)
Take wound cultures at the end of the procedure
THEN reduce
THEN maintain
External fixation preferred can be temporary (for 2/52 until youre
sure theres no infection at site, then internal fixation) or permanent
(for 3-6 months until # unites)
Disadvantage of internal fixation: must strip soft tissue :. Avoided for
grade 2 & above
Disadvantage of intramedullary nail: may spread infection (even
though in this case neednt strip soft tissue)
Wound usually left open to drain
48h later,
relook operation see if repeat I&D is necessary
Ensure soft tissue coverage over exposed area by 48th hour
exposed tendon will not survive for long... Need flap!
4-6 weeks later: bone graft/transport
THEN skin graft (after swelling subsides; if not, compartment syndrome may
occur after grafting)

Approx. 30% of patients with open fractures are polytrauma patients who have suffered
damage to 2 or more systems. Manage according to ATLS. Only manage the fracture
when the patient is stable. [In grey: for open #s]
1. ABCDE
2. Neurovascular status of the limbs (above & below)
Control any haemorrhage with direct pressure. Set IV line & start IV fluids.
Dont reduce any # unless there is apparent neurovascular compromise from
position of #.
Dressings & splints that might have been put on at the accident site should be
removed partially to assess soft tissue conditions and neuromuscular function.
All sterile wound dressings should be left in place because redressing wounds
in the emergency room increases the infection rate
3. Any other #/injuries (above & below) remove gross debris, i.e. turf, rocks
4. Rule out open #
5. Take an AMPLE Hx
6. Analgesia 75mg I/M pethidine
7. Start IV antibiotics [after wound c/s samples are taken] in all open # during the first
3-5 days (empirical NOT prophylactic!) Use broad spectrum antibiotic (e.g. 1st
generation cephalosporins); in grade 3 #, add gentamicin +/- metronidazole, and
monitor for toxicity.
8. Tetanus toxoid booster (TTB) 0.5mL
Human anti-tetanus immunoglobulin (HATI) 250 units
Simple wound
Tetanus-prone
wound
Full course + booster within
TTB
10y
Full course + booster 10y ago
TTB
TTB + HATI
Non-immunised / unknown
TTB
TTB + HATI
9. Splint to decrease pain, progression of soft tissue injury, blood loss
10. Imaging (X-rays)
11. NBM and prepare for EOT
Must get into OT within 6h (golden hours) since risk of infection increases
after this time
Done under LA/GA

11

Complications of open #s
Bone
Osteomyelitis
Mal-union (NB. healing will always take place, its only a matter of how
good the healing is)
Non-union (healing has ceased, both pieces not united by 6 months)
Certain bones are prone, e.g. tibia (due to poor muscle coverage),
scaphoid, NOF (due to poor blood supply)
Also depends on severity of injury
Types
Hypertrophic: insecure fixation / premature wt bearing
Atrophic: poor blood supply, ends osteoporotic (e.g. in
DM, vasculopathy, infection, sig tissue damage) --- Mx:
open decortications & cancellous bone graft
AVN
Arthritis
Regional
Neurovascular injury
Soft tissue blisters
Types: haemorrhagic and non-haemorrhagic
Mechanisms of injury: shearing of skin (may become infected if
operated on), ischaemia (can be due to compartment syndrome!)
Compartment syndrome*****
Complex regional pain syndrome 1
Heterotopic ossification
Joint stiffness
Systemic
Hypovolaemic shock
Fat embolism
Venous thrombo-embolism (DVT/PE) from immobility
Multi-organ dysfunction syndrome
ARDS (especially in polytrauma patients)

Local

System
-ic

Hemorrhagic shock
Sepsis
Fat embolism
DVT / PE
ARDS

Late
Malunion
Nonunion
AVN
Post-traumatic arthritis
Osteomyelitis
Heterotopic ossification
Growth disturbance in children
Joint instability
Joint stiffness
Nerve compression /entrapment
Reflex sympathetic dystrophy (RSD)
Multi-organ failure
Renal failure
Shocked lung
PTSD, depression

IRRIGATION AND DEBRIDEMENT

NB. Can also be classified as early & late complications

1

Complex Regional Pain Syndrome (CRPS): a chronic pain state induced by

Soft tissue / bone injury (CPRS I aka reflex sympathetic dystrophy aka Sudecks atrophy)
Nerve injury (CPRS II aka causalgia)
In which pain is a/w autonomic changes (e.g. sweating or vasomotor abnormalities), and/or trophic changes (e.g.
skin/bone atrophy, skin loss, joint contractures). Aetiology unknown. Treatment: no cure; pain relief only.

Early
Neurovascular injury
Swelling
Compartment syndrome
Infection
Implant failure
Soft tissue blisters (infection)

Irrigation and debridement (most important steps in treatment of open #)

To be done within 8h of the injury, otherwise wound is considered infected.
Done in the OT under LA/GA
Only now are all the splints and bandages removed
Reexamine thoroughly for neurovascular function.
Fluids are delivered under pressure and under a pulsed system to remove any blood
clots and foreign bodies.
Isotonic saline or water is used for irrigation.
Dilutes the degree of bacterial contamination. Repeat the irrigation at regular
intervals once the wound is open as there is a higher chance of removing
contaminated material.
Ensure that the whole wound is exposed to the fluids.
There is a debate as to the usefulness of adding antibiotics to the fluids. If
proper debridement is done then only vascularised tissue should remain and
adequate tissue levels can be achieved with systemic antibiotics. However,
some studies have shown lower infection rates with added antibiotics.
Ultimately, the effect of irrigation is still mechanical.
Ensure wound incision is large enough to facilitate exposure and inspection of
wound site, including the joint.
12

Meticulous removal and resection of all foreign and dead material from the wound.
All non-viable, mutilated or macerated skin removed. Dead, frayed skin edges
are excised. Skin colour is a good determinant of viability of skin. When a cut
skin edge does not bleed then it is dead.
Fasciae are expendable so it can be safely removed without fear of functional
deficit.
Difference between dead & live muscle (see emergency care)
Free fragments of bone are removed. Fractured bone ends must be exposed so
that they can be cleaned with brushes or removed.
Exposed tendon will not survive for long. Early skin coverage, skin grafting or a
muscle/skin flap may be necessary to preserve its viability.
Wound cultures should be taken at the end of the procedure.

STABILISATION OF FRACTURE

Immobilisation of the fracture is crucial for the healing of soft tissue and bone.
Stabilisation prevents further injury to the surrounding soft tissue, limits
intensity and duration of inflammatory response, diminishes spread of bacteria,
facilitates tissue perfusion and encourages early wound repair.
Should still provide free wound access for repeated debridement and placement
of local or distant flaps and bone grafts.
Should not interfere with blood supply of fracture segments and should be
sufficiently rigid to allow early joint motion and at least partial weight bearing.
Slings, splints, casts and traction may be used as definite care of simple grade I and
grade II injuries and as temporary methods for more complex fractures.
Slings can be used in fractures of humeral shaft or to provide additional support for
internally or externally stabilized forearm lesions. Splints can provide initial
stabilization of fractures below the elbow and knee.
Circular castshave no place in early Mx as they cannot accommodate swelling.
May prevent the detection of further soft tissue damage, circulatory impairment
and/or increase in compartment pressures.
Casts can be used as subsequent care of stable grade 1 and 2 tibial fractures after the
wound is closed and swelling subsided.
Can also be used as a secondary method of immobilization after removal of an
external fixator.
Traction may be indicated for pelvic fractures, acetabular lesions and femoral
fractures. But rarely used in the upper extremity.
External fixation is indicated for most contaminated grade 3b and c fractures.

Advantages: 1) No foreign material in the wound. 2) Applied without any

additional soft tissue dissection. 3) Provides easy access to the wound 4) Easily
dismantled if further debridement needed.
Disadvantages: 1) Potential for pins to injure neurovascular structures and tie
down muscle-tendon units interfering with joint motion and rehabilitation. 2)
Possible interference of the pins in reconstructive procedures as well 3) Pin
loosening 4) Secondary infection.
Usually removed or replaced by casts, braces or internal fixation as soon as soft
tissue lesions have healed.
Internal fixation provides excellent stabilization, allows early limb and patient
mobilization and facilitates fracture consolidation while preventing malalignment.
However, procedure requires additional exposure and can cause partial loss of
periosteal, cortical or intramedullary blood supply es risk of infection.
Screws are usually used in combination with a plate or external fixator for intraarticular and peri-articular fractures. Plates may be used in treatment of less severe
diaphyseal, periarticular and intraarticular fractures of the upper limb.
In the LL, plates are useful around joints. However, they must be covered well.
Intramedullary nails are used for femoral fractures. They may be used as a
secondary method after external fixation but carries a risk of infection. Therefore
contraindicated if there is a history of local or pin track infection.
Recent studies show that internal fixation for femoral shaft fractures and even tibial
shaft fractures result in faster union times as well as decreased risks of reoperation,
malunion and superficial infection. External fixation has also shown to be
associated with severe pin track infection, longer union times and a higher number
of surgical procedures to promote union.

WOUND COVERAGE

The timing of wound coverage is important.

Primary closure of wound associated with significant risk of infection.
Therefore, keep wounds open after initial debridement and decide again at the
second inspection.
Aim to close the wound within 3-5 days.
Keep moist meanwhile.
Once wound is clean and tissues are viable, delayed primary closure or skin
grafts can be done.
Aims of wound coverage: 1) Achieve a safe early closure 2) Avoid nosocomial
infection 3) Obliterate dead space 4) Facilitate future reconstruction.
Direct closure done for fresh tidy wounds free from infection and contusion.
13

Skin grafts are transplanted completely by detaching a portion of skin from a donor
site and transferring it to a raw bed-- has to achieve a new blood supply within 2-3
days to ensure viability.
Often used as in intermediary measure before a flap.
There are 2 kinds of skin grafts.
Partial/split-thickness skin graft consists of epidermis and part of the dermis.
Can tolerate less ideal conditions and less vascularity than full thickness skin
graft. The donor site must be able to heal spontaneously by epithelialisation and
if necessary, more grafts may be taken from the same place. Good for covering
large skin defects overlying viable tissue such as muscle, for large size wounds
or those of questionable circulation. Grafts contract, have poor growth in
children and have abnormal pigmentation. Partial thickness skin grafts are
taken from inner thigh or lateral buttock.
Full thickness is composed of the full thickness of the skin. Generally used for
fresh, non-contaminated wounds of small size. Full thickness skin grafts are
taken from groin or postauricular area, supraclavicular area.
Flaps contain a pedicle attachment to the body receiving its sustenance via a
network of blood vessels.
Because of their own blood supply, they can be used to reconstruct skin and
soft tissue defects irrespective of their vascularity.
Choice of flap coverage must take into account patients age & needs, location,
size & condition of the defect, likelihood of subsequent reconstructive surgery
& associated zone of injury, tissues available for the flap.
Flaps can be classified as skin, fasciocutaneous, muscle and musculocutaneous.
Used for defects with poor vascular beds such as wounds overlying the tibia,
exposed metal plates, bare bones and tendons, bone defects and open joints.
Delayed bone or soft tissue reconstruction is proposed, especially if bone graft
or tendon transfer is being planned.
An example of a local flap is the gastrocnemius. Used around the knee and
proximal third of the tibia, one of the 2 heads of the gastocnemius is used and
there must be a functional soleus. The soleus is sometimes used for mid-tibial
defects or sometimes even the distal third of the tibia
Free microvascular flap is used for large defect.
Helps prevent multiple reoperations. Provide durable coverage of the fracture
site, diminishes the infection rate and shortens the healing time. E.g. latissimus
dorsi and vertical rectus abdominis.

DELAYED UNION AND NON-UNION

Delayed union and non-union are common in open fractures.

Delayed union is when healing has not advanced at the average rate for the location
and type of fracture. I.e. reconstitution of mechanical stability but over a prolonged
period of time and with associated morbidity.
o Rx: adequate immobilization, internal fixation or even bone grafting.
In non-union, there is evidence, clinically or radiologically that healing has ceased.
I.e. failure of reconstitution of mechanical stability after appropriate time intervals.
o MCQ: commonest site = junction of distal 1/3 and proximal 2/3 of tibia
o Can be classified as hypervascular (elephant foot, horse hoof or
oligotrophic pattern) or avascular (torsion wedge, comminuted, defect or
strophic pattern).
o Treated by stable internal fixation, bone grafting, bone transport or free
composite tissue transfer.

MANAGEMENT OF BONE LOSS

Bone injury occurs during initial injury or from subsequent repeated debridement.
Any bone replacement methods should only be done after adequate soft tissue
coverage and revascularization.

Bone grafts
Work via 3 mechanisms: osteoconduction, osteoinduction and osteogenesis.
Osteoconduction is the process whereby transferred bone acts as a scaffold for new
bone to grow. (+ neovascularisation)
Osteoinduction occurs when undeveloped tissue is transformed to bone by one or
more inducing agents.
Osteogenesis is new bone formed from live osteoblasts in the transplanted autograft.
Bone transport
Used for large gaps (Ilizarovs principle of distraction osteogenesis: induction of
new bone between bone surfaces that are pulled apart in a gradual, controlled
manner. Distraction gives rise to neovascularisation hence stimulating new bone
formation.)
A segment of bone is created by corticotomy or osteotomy through normal bone in
one of the fragments of the fracture. This segment is transported by wires and new
bone forms in the gap by gradual distraction. The segment is moved by 1mm a day.
This technique of callostasis allows simultaneous restoration of a bony defect,
correction of limb length and deformity, improvement in the condition of local soft
tissues and the treatment of infection.
14

Free composite tissue transfer

Example: fibula, which is mainly a cortical bone that provides excellent strength
and length for large segmental bony defects. It is used together with muscle and
skin with its pedicle.
FRACTURE HEALING
Normal Healing
1
2

0h
Within 8h

3-6 wks
6-12 wks

4
5

6-12 mths
1-2 yrs

Hematoma formation.
Inflammatory reaction with proliferation of the cells under
periosteum and within the medullary cana. Macrophages,
undifferentiated stem cells and platelets surround fracture site.
Osteoclasts remove sharp edges (thus # more visible on
radiographs), Callus forms within hematoma
Bone forms within the callus, bridging fragments. Forming
woven bone.
Consolidationwoven bone is replaced by lamellar bone
Normal architecture is achieved through Remodelling

Evaluation of Healing - Tests of Union

Clinical - no longer tender to palpation or angulation stress
X-ray - trabeculae cross fracture site, visible callus bridging site
COMPARTMENT SYNDROME

Venous obstruction
Increased venous pressure
Constrictive dressing, cast, splint

Diagnosis
Tibial compartments (common) and forearm flexor compartment
may lead to Volkmanns ischemic contracture
Clinical signs and symptoms
Early
Pain out of proportion to injury & not relieved by analgesics**
Increases with Passive stretch of compartment muscles
Paresthesias
Pallor
Palpable tense, swollen compartment
Late
Paralysis (inability to move limb - late)
Pulses are usually still present (CRT normal)

Compartment pressure monitoring

In unresponsive or unreliable patients
Normal tissue pressure is about 0 mm Hg
Pressure increases markedly in compartment syndromes.
When intra-compartmental pressure rises to within 10-30mmHg of patient's
diastolic blood pressure, inadequate perfusion and/or ischemia results
Fasciotomy usually indicated when the tissue pressure rises to 40-45mmHg
in a patient who has any signs or symptoms of a compartment syndromeeven if distal pulses still present

Definition
Condition where pressure within an enclosed anatomical compartment rises
sufficientto occlude the microvascular circulation causing tissue ischaemia and, if
untreated, tissue necrosis.
Intracompartmental pressures over 30 mm Hg or over diastolic pressure requires
intervention

Signs of Compartment Syndrome in Anterior Leg and Forearm

Anterior leg
Volar forearm
Fracture Type
Tibial fracture
Supracondylar (humerus)
Weakness
Toe, foot extension
Finger, wrist flexion
Pain
Toe, foot flexion
Finger, wrist extension
Sensory
1st dorsal web space
Volar aspect of fingers

Etiology
Fracture, dislocation
Soft tissue damage & muscle swelling
Crush injury
Arterial compromise
Muscle anoxia

Treatment
Remove constrictive dressings
Bivalve casts down to skin and spread open
Place limb at level of heart
Emergency fasciotomy if difference between diastolic BP and compartment
pressure is greater than 30 mmHg (treat within 4-6h of onset symptoms)
15

AVASCULAR NECROSIS

TIPBITS FOR #S

Aetiology
Steroid use --- NOT dose related idiosyncratic
Alcohol
Post-traumatic fracture/dislocation
Septic arthritis
Sickle cell disease
Gauchers disease
Caissons disease deep sea diving/the bends
Perthes disease
Idiopathic

1. Arm fractures: nerves affected by humerus fracture location ARM fracture:

From superior to inferior: Axillary: head of humerus / Radial: mid shaft/ Median:
supracondular

AVN Classification
Stage Clinical Features
X-ray Features
1
Preclinical phase of No plain x-ray abnormality; may be detectable on MRI
ischemia and
necrosis; no pain
2
Painful
Early radiographic changes i.e. fragment appears dense,
normal bone contour
3
4

Painful
Very painful

Radiographic changes obvious, abnormal bone contour

Collapse of articular surface and signs of arthritis on both
sides of the joint

Mechanism
Occurs following disruption of blood supply to bone
Occurs especially in those bones extensively covered in cartilage which rely on
intra-osseous blood supply and distal to proximal blood supply, e.g. head of femur,
proximal pole of scaphoid, body of talus
Results in ischemia
Pathologic changes include resorption, subchondral fractures and loss of cartilage

2. Fractures: principles of management FRIAR: First aid, Reduction,

Immobilisation, Active Rehabilitation
3. Forearm fractures: bone in Monteggia vs. Galeazzi "Break the forearm of the
MUGR (mugger)": Monteggia=Ulna, Galeazzi=Radius
4. Salter Harris fracture classification Salter Harris, modified to SALTR:
type 1: Slipped epiphysis
type 2: Above the eiphyseal plat
type 3: Lower than the eiphyseal plate
type 4: Through both above and below eiphyseal plate
type 5: Raised epiphysis, as in a compression injury
Salter Harris classification utilises visualising long bone distal portion with
diaphysis superiorly placed and epiphysis inferiorly placed.
5. Bryant's traction: position BrYant's traction: Bent Y.
Patient's body is the stem of the Y lying on the bed, and legs are the ends of the Y
up in the air.
6. Differentials for non-union of #s --- you need a SPLINT:
Soft tissue interposition
Position of reduction (too much traction, immobilization, or movement)
Location (eg. lower third of tibia slow to heal)
Infection
Nutritional (damaged vessels or diseased bone)

Tumor (pathological fracture)

16

IMPORTANT ORTHOPAEDIC CONDITIONS IN THE SHOULDERS

APPROACH TO SHOULDER PROBLEMS

CAUSES OF SHOULDER PAIN

Tendon (rotator cuff disorders)

IMPORTANT HISTORY TO TAKE FOR SHOULDER PAIN

- Duration (time course of frozen shoulder pain and stiffness for first 6 months, less
pain but persistent stiffness for next 6 to 12 months, and recovery of joint mobility
18 months after start of symptoms).

Tendinitis
Rupture
Frozen shoulder

Joint disorders

Glenohumeral arthritis
Acromioclavicular arthritis

Any preceding trauma (frozen shoulder and rotator cuff tear often follow minor
precending injury).

Referred pain

Neck pain shoulder pain may be due to cervical pathology; shoulder pain is
typically located over the deltoid insertion and tip of shoulder, not along the
trapezius or neck.

Cervical spondylosis
Cardiac ischaemia
Mediastinal pathology

Instability

Dislocation
Subluxation

Shooting pains travelling down arm, numbness and/or weakness of hand

indicative of cervical spine pathology or nerve problem.

Bone lesions

Infection
Neoplasm

Pain on lying on shoulder while sleeping.

Nerve lesions

Suprascapular nerve entrapment

Function of shoulder (see below).

Diabetes (very important as diabetes is a cause of idiopathic frozen shoulder).

Heart disease may result in referred pain to shoulder.

FUNCTIONAL ASSESSMENT IN SHOULDER PROBLEMS

- Ability to reach for objects placed in overhead positions
- Ability to comb hair
- Ability to touch opposite shoulder and back (for personal hygiene)***
- Ability to wear top e.g. shirt, T-shirt, blouse

Think 4 Ss for Shoulder: Stiffness, Stability, Strength, Smoothness

Stiffness: Frozen Shoulder, Post-traumatic/post-surgical stiff shoulder.
Strength: Rotator cuff tears
Stability: TUBS vs AMBRII
Smoothness: Subacromial abrasion, primary degenerative joint disease, AVNs,
Recurrent dislocations, post-surgery arthritis, RA.

INVESTIGATIONS:
No blood investigations are required usually; shoulder X-ray is the most useful invx
Important features to look out for on shoulder X-ray:
- Narrowing of subacromial space
- Bony spur on inferior aspect of acromion or acromioclavicular joint
- Calcification of supraspinatus tendon (acute calcific tendinitis)
- Narrowing of joint spaces esp. glenohumeral joint
- Osseous lesion(s) if any

17

SHOULDER PAIN likely OSCEs scenarios

Young

Instability
AC joint injuries
Impingement syndrome
Frozen shoulder (women) primary cause
Rotator cuff tears
Degenerative arthritis
Frozen shoulder primary/secondary cause

Middle-aged
Old

Rotator cuff
Elderly gentleman
S: shoulder +/- lateral aspect of
arm (confused w radiculopathy)
O: insidious/sudden after freq use
C:
R: none
A:
T: worse at night
E: cannot lie on affected arm
S:

Stem
Pain

Any preceding trauma

Past medical history + any

drug allergies
Rule out cervical pathology

Functional assessment

Frozen shoulder
Old gentleman / middle-aged lady
S: shoulder
O: <18months ago
C:
R: none
A:
T:
E: lying on shoulder while sleeping / night
pain because Im not conscious of where
my hands & arms go when Im asleep
S:

Shoulder instability
Young gentleman
S: shoulder
O:
C:
R: none
A:
T:
E:
S:

TUBS vs. AMBRII

a/w weakness
a/w shoulder stiffness
a/w stiffness if post-traumatic
If yes,
check if patient had dislocated shoulder back then
any pain before the trauma (patient may already have rotator cuff tear of which the pain was accentuated by
the trauma in which case, surgical outcome may be poorer [attaching fat to bone instead of muscle to
bone, hence no function!])
Diabetes
Have you been told by
(cause of idiopathic frozen shoulder)
doctors previously that you
have ligamentous laxities?
- Shoulder pain typically located over the deltoid insertion and tip of shoulder, not along trapezius or neck
- Shooting pains travelling down arm, numbness and/or weakness of hand indicative of cervical spine
pathology or nerve problem
Ability to reach for objects placed in overhead positions
Ability to comb hair
Ability to touch opposite shoulder and back (for personal hygiene)
Ability to wear top e.g. shirt, T-shirt, blouse
-

Occupation & hobbies, whether those are affected

OTHER DIFFERENTIALS FOR SHOULDER PAIN

Tendon (rotator cuff disorders), Joint disorders, Referred pain, Instability, Bony lesions, Nerve lesions
What are the important steps in the shoulder exam that you would like to elicit?
I would still follow the LOOK, FEEL, MOVE sequence.
Rotator cuff
Any post-traumatic/post-surgical scars
Tenderness
Painful arc (tendinitis)
Drop arm sign (tear)
Difficulty initiating abduction (tear)

LOOK
FEEL
MOVE

SPECIAL TESTS

For supraspinatus tendinitis: Jobes,

Hawkins, Neers

Frozen shoulder

Shoulder instability

Decreased active AND passive

ROM in ALL directions
but NO muscle wasting

Apprehension tests for

shoulder instability

Describe what you mean by impingement syndrome / frozen shoulder / shoulder instability.
Definition

Impingement syndrome
impingement
position
where
the
glenohumeral joint is in abduction, slight
flexion and internal rotation
-

Site of impingement is usually the

critical area of decreased vascularity
in the supraspinatus tendon 1cm
proximal to its insertion into the greater
tuberosity

Frozen shoulder
Known also as adhesive capsulitis, it is a
well-defined disorder characterised by
progressive pain and stiffness which
usually resolves spontaneously after 18
months.

Freezing 6-12 weeks

Frozen 3-4 months
Thawing up to 18 months

Shoulder instability
Shallowness of the
glenoid fossa of the
scapula & lack of support
provided by weak lig (3
GH ligamentsMedial,
Inferior, Superior;
transverse humeral lig;
coracohumeral lig) make
the GH joint unstable
strength mainly depends
on the rotator cuff
muscles

Aetiology +/risk factors

Investigations:
X-ray

Management

Repetitive rubbing of rotator cuff tendons

under coracoacromial arch (coracoacromial
ligament forms the roof, runs between
coracoid process & acromion)
Bone: OA (osteophytes)
Tendon: rotator cuff tendinitis (in
inflammatory conditions, e.g. RA, gout)
Bursa: subacromial bursitis (also in
inflamm. conditions)

PRIMARY ADHESIVE CAPSULITIS

Idiopathic in cause
a/w DM, Dupuytrens contracture,
hyperlipidaemia, hyperthyroidism,
cardiac disease
Global contracture of the shoulder
joint, but maximally in the rotator
interval area and around the
coracohumeral ligament

Pathogenesis
SECONDARY ADHESIVE CAPSULITIS
Friction leads to localised oedema and
Intrinsic causes

Chronic rotator cuff injuries

swelling (tendinitis) wear

Post-traumatic scarring following

Tendinitis is usually self-limiting but
injuries at the shoulder e.g. fracture of
with prolonged or repetitive
the surgical neck, greater tuberosity.
impingement minute tears can occur,
especially in elderly tear
Extrinsic causes

Painful disorders resulting in

Tears can be complicated by scarring,
decreased movements of the shoulder:
fibrocartilaginous metaplasia or
referred pain from cervical
calcification in the tendon
Vascular reaction occurs in an attempt
radiculopathy, post-hand, wrist or
to repair a torn tendon or to
elbow surgery, post-MI
revascularize a degenerate area. New
BVs grow in & calcium deposits are
resorbed. This vascular reaction causes
congestion & pain. Pain is caused by
wear, tear & repair of the tendons! All 3
happen in varying levels across the
ages.
Usually normal in early impingement
X-rays usually normal useful in
+/- erosion, sclerosis or cyst formation excluding other causes of painful shoulder,
at the greater tuberosity (insertion of such as infection, post-traumatic stiffness,
the supraspinatus tendon) in chronic diffuse stiffness and reflex sympathetic
tendinitis
dystrophy when patient 1st presents
May see calcification of the supraspinatus tendon (incidental and not the
cause of pain)
May see narrowing of the space
between AC joint & humeral head
May see signs of AC joint arthritis
osteophytes
Aim of conservative treatment is to relieve
TENDINITIS
pain and prevent further stiffening while
Conservative:
Eliminate aggravating activity, and waiting for recovery (since natural course
avoid impingement position
is recovery in 12-18 months)
Physiotherapy
Short courses of analgesia e.g. NSAIDs
Analgesia (NSAIDs), H&L (at shoulder
Subacromial
Hydrocortisone
& joint), local heat.
Lignocaine
/
Triamcinolone
&
Xylocaine injections at subacromial Physiotherapy:
joint for pain relief (LA takes effect Repeated circular movement of
immediately, lasts 1 day; corticosteroid
shoulder
Assisted abduction use towel or
takes effect 3-5 days later)
rope, loop it over an overhead bar like
Surgical
Open or arthroscopic subacromial
a pulley system, and hold on to each
decompression (acromioplasty)
end with one hand. Patient uses
o Excise
coracoacromial
downward pull of normal arm to
ligament & anteroinferior part
passively
abduct
painful
arm
of acromion
overhead.
o Remove
acromioclavicular Assisted internal rotation both hands
osteophytes if present
gripping either end of a towel slung
across the patients back diagonally;
TEAR
the hand on the painful side holds the
Conservative
Physiotherapy to improve strength
lower end while the hand on the
Heat therapy
normal side holds the end above the
shoulder. Patient uses hand on normal
Local anaesthesia if necessary
side to pull upwards on towel,
Surgical
If amenable to repair, open or
passively internally rotating the
arthroscopic cuff repair followed by
painful shoulder.
subacromial decompression. Especially Wall-crawling patient uses fingers
for young active individuals. With
to crawl up a wall slowly,
complete tears. Partial tears do not
increasing flexion movement.

Classification of patients with

recurrent shoulder
instability:
TUBS: Traumatic, Unidirectional (unilateral),
Bankart lesion, Surgery.
AMBRII: Atraumatic,
Multi-directional,
Bilateral,
Rehabilitation, Inferior
Capsular Shift, Interval
Closure

To see if dislocation is present

upon visit & to see if there is
Bankart lesion / Hill Sacks
lesion.

Anterior instability
For acute dislocations:
Manipulation and
reduction followed by
immobilisation in a
bandage or sling for
several wks
Recurrent dislocations:
Indications for surgery
include frequent painful
dislocation and recurrent
subluxation
Posterior instability
M. strengthening
exercises
Surgery considered when
condition is disabling &
there is no gross joint
laxity
Anterior dislocation
M & R with sedation /
GA
Hippocratic method:
increasing traction
applied to the arm with
the shoulder in slight
abduction while an
assistant applies firm
counter traction to the

19

require surgery unless persistent pain or

considerable instability.
If not amenable to repair, open or
arthroscopic debridement of degenerate
cuff
tissue
and
subacromial
decompression.

body; e.g. using a towel

slung around the chest
under the axilla
X-ray post-reduction to
check position and
exclude fracture.
Exclude an axillary nerve
injury, rotator cuff tear,
median, radial, ulnar and
musculocutaneous nerve
injuries after reduction
Rest the arm in a sling for
3 wks, 1 wk for
those>30yrs old due to
risk of stiffness
Avoid abduction and
lateral rotation for 3 wks
Elbow and finger
movements

Posterior dislocation
M & R by pulling on the
arm with shoulder in
adduction followed by
lateral rotation while
humeral head is pushed
forwards.
Immobilisation in a sling

20

ROTATOR CUFF IMPINGEMENT

AETIOLOGY
- The cuff is made of subscapularis in front, supraspinatus above and infraspinatus
and teres minor behind.
- Repeated rubbing of the rotator cuff tendons under the coracoacromial arch (the
roof of which is formed by the coracoacromial ligament running between the
coracoid tubercle anteriorly to the anterior third of the acromion posteriorly)
-

The greatest amount of wear occurs in the impingement position where the
glenohumeral joint is in abduction, slight flexion and internal rotation

Site of impingement is usually the critical area of decreased vascularity in the

supraspinatus tendon 1cm proximal to its insertion into the greater tuberosity

Vascular reaction occurs in an attempt to repair a torn tendon or to revascularize a

degenerate area. New blood vessels grow in and calcium deposits are resorbed. This
vascular reaction causes congestion and pain. Pain is caused by wear, tear and
repair of the tendons! All 3 happen in varying levels across the ages.

Contributing factors to impingement

Bone: OA thickening of AC joint, osteophytes along anterior edge of acromion
Tendon: rotator cuff swelling (in inflammatory disorders such as RA & gout)
Bursa: subacromial bursitis (in inflammatory disorders)

PATHOPHYSIOLOGY
- Pathological processes can be summed up into wear, tear and repair
- Friction leads to localised oedema and swelling (tendinitis) wear
- Tendinitis is usually self-limiting but with prolonged or repetitive impingement
minute tears can occur, especially in elderly tear
- Tears can be complicated by scarring, fibrocartilaginous metaplasia or calcification
in the tendon
- Healing is accompanied by a vascular reaction and local congestion which is
painful, and this may contribute to further impingement
- Healing is more rapid in younger patients (but also more painful) and less vigorous
in the elderly (less pain, chronic tendinitis that doesnt heal completely).
- Deposits of calcium hydroxyapatite appear in the supraspinatus tendon in acute
(calcific) tendinitis. Although these calcifications are not painful, the florid vascular
reaction which produces swelling and tension causes severe symptoms. The
calcium usually resorbs quickly and disappears in a few months.
HISTORY
(SUB)ACUTE TENDINITIS
- Patient <40 years old

Shoulder pain occurs after a bout of vigorous unaccustomed activity

Patient complains of a painful arc (60-120 deg) on abducting the arm
Complains of pain of increasing severity, reaching a climax after a few days.
After which, the pain subsides and shoulder returns to normal.

CHRONIC TENDINITIS
- Patient 40-50 years old
- Patient has a history of recurrent attacks of subacute tendinitis
- Pain settles with medications (NSAIDs) or rest but recurs when doing more
demanding activities
- Pain characteristically worse at night, and patient cannot lie on affected side
- Pain and stiffness restrict daily activities
CUFF TEAR
- Partial or full thickness tear occurs with progressive fibrosis & disruption of the
rotator cuff
- Usually >45yo with refractory shoulder pain with increasing stiffness and weakness
- Partial tears are hard to detect as they present with painful arc but still normal
motion of the shoulder. Patient can abduct the shoulder upon giving LA because
pain is the limiting factor usually. Intact tendon fibres provide continuity for
vascular ingrowth and repair.
- Complete tears occur spontaneously after a sprain or jerking injury of the shoulder,
and the patient complains of acute pain and inability to abduct the arm. To
distinguish from partial tear: No abduction despite LA. There is little or no reaction
and no repair; proxial fibres may retract and become stuck down.
PHYSICAL EXAMINATION
SIGNS OF SUPRASPINATUS TENDINITIS
- Pain at the point of insertion of the supraspinatus along the anterior border of the
acromion, best felt with the arm held in extension
- Painful arc: Pain on active abduction between 60 and 120 degrees of motion, with
disruption of scapulohumeral rhythm.
- Impingement sign: Pain elicited when affected arm is passively flexed, abducted
and internally rotated (the greater tuberosity is brought under the coracoacromial
arch impinging the supraspinatus)
- Impingement test: Pain on doing the above procedure is reduced after injection of
H&L into the subacromial space
SUPRASPINATUS TEAR
- Difficulty in initiating abduction

Ability to actively abduct the arm after passively abducting it above 90 degrees
the abduction paradox, as supraspinatus initiates abduction but deltoid can abduct
the shoulder the rest of the way
Drop sign: the abducted arm suddenly drops to the side when it is lowered past a
certain angle of abduction

INVESTIGATIONS

TEAR
Conservative

Surgical

1. X-ray

Usually normal in early impingement

May be erosion, sclerosis or cyst formation at the greater tuberosity (insertion
of the supraspinatus tendon) in chronic tendinitis
May see calcification of the supraspinatus tendon (incidental and not the cause
of pain)
May see narrowing of the space between the acromioclavicular joint and the
humeral head
May see signs of acromiclavicular joint arthritis osteophytes

May detect large tears, but operator-dependent

3. MRI

Accurate delineation of anatomy

Can help determine site and size of a tear if present

If amenable to repair, open or arthroscopic cuff repair followed by subacromial

decompression. Especially for young active individuals with complete tears. Partial
tears do not require surgery unless persistent pain or considerable instability.
If not amenable to repair, open or arthroscopic debridement of degenerate cuff
tissue and subacromial decompression.

CALCIFICATION OF THE ROTATOR CUFF

(i)
-

2. Ultrasound

Physiotherapy to improve strength

Heat therapy
Local anaesthesia if necessary

(ii)

Acute calcific tendinitis

Acute shoulder pain due to deposition of calcium hydroxyapatite crystals in the
critical zone of the supraspinatus tendon just medial to its insertion
Usually affects those btw 30-50yrs old
Investigations X-ray shoulder jt: calcification seen just above greater tuberosity
Treatment rest arm in a sling, NSAIDs, H&L and LA injection if necessary
Chronic calcification

MANAGEMENT

TENDINITIS

BICEPS TENDONITIS
- Impingement syndrome.
- Pain and tenderness sharply localised to the bicipital groove.
- Rest, local heat and deep transverse frictions. Consider a local corticosteroid

Conservative:

Eliminate aggravating activity, and avoid impingement position

Physiotherapy
Short courses of analgesia e.g. NSAIDs
Subacromial Hydrocortisone & Lignocaine / Triamcinolone & Xylocaine injections
for pain relief (LA takes effect immediately, lasts 1 day; corticosteroid takes effect
3-5 days later)

Surgical

Open or arthroscopic subacromial decompression (acromioplasty)

o Excise coracoacromial ligament & anteroinferior part of acromion
o Remove acromioclavicular osteophytes if present

common, usually asymptomatic

injection if healing is delayed.

This image cannot currently be displayed.

RUPTURE OF BICEPS TENDON

-

Patient usu >50yo, can be part of rotator cuff lesion

Presentation: upper arm becomes painful and
bruised after patient lifted something and he/she
feels something snap in the shoulder
Signs: prominent lump in the lower part of the arm
(detached belly of the long head of biceps) upon
flexion of the elbow
22

Treatment:
- No treatment in the elderly if isolated lesion.
- If part of a rotator cuff lesion esp if patient is young, may need anterior
acromioplasty with reattachment of the tendon (splint the arm with the elbow
flexed for 4 wks)
Biceps:
Origin - long head from the supraglenoid tubercle and lies in the bicipital groove, short head is from
the tip of the coracoid process of the scapula;
Insertion - posterior part of the tuberosity of the radius and deep fascia on medial aspect of forearm
via bicipital aponeurosis
Action- supinator of the forearm, flexor of the elbow jt and weak flexor of the shoulder jt]

FROZEN SHOULDER (ADHESIVE CAPSULITIS)

INVESTIGATIONS
- X-rays usually normal useful in excluding other causes of painful shoulder, such
as infection, post-traumatic stiffness, diffuse stiffness and reflex sympathetic
dystrophy when patient 1st presents
MANAGEMENT
Conservative

AETIOLOGY
The term frozen shoulder should be reserved for a well-defined disorder characterised
by progressive pain and stiffness which usually resolves spontaneously after 18 months.
PRIMARY ADHESIVE CAPSULITIS
- Idiopathic in cause
- Associated with DM, Dupuytrens contracture, hyperlipidaemia, hyperthyroidism,
cardiac disease
- Global contracture of the shoulder joint, but maximally in the rotator interval area
and around the coracohumeral ligament
SECONDARY ADHESIVE CAPSULITIS
-

Intrinsic causes

Extrinsic causes

Chronic rotator cuff injuries

Post-traumatic scarring following injuries at the shoulder e.g. fracture of the
surgical neck, greater tuberosity.
Painful disorders resulting in decreased movements of the shoulder: referred
pain from cervical radiculopathy, post-hand, wrist or elbow surgery, post-MI

CLINICAL FEATURES
- Patient aged 40-60 years
- Aching in the arms and shoulder after trauma, often trivial
- Pain gradually increases in severity and prevents sleeping on the affected side
- Subsides after several months with increasing stiffness that continues for 6-12mths
- Movement is regained gradually but may not return to normal

Physical findings: shoulder appears normal with no wasting; most marked feature is
decreased active and passive movement in all directions

Aim of conservative treatment is to relieve pain and prevent further stiffening while
waiting for recovery (since natural course is recovery in 12-18 months)
Analgesia (NSAIDs), corticosteroid injections, local heat.
Physiotherapy:
o Repeated circular movement of shoulder
o Assisted abduction use towel or rope, loop it over an overhead bar like a
pulley system, and hold on to each end with one hand. Patient uses downward
pull of normal arm to passively abduct painful arm overhead.
o Assisted internal rotation both hands gripping either end of a towel slung
across the patients back diagonally; the hand on the painful side holds the
lower end while the hand on the normal side holds the end above the shoulder.
Patient uses hand on normal side to pull upwards on towel, passively
internally rotating the painful shoulder.
o Wall-crawling patient uses fingers to crawl up a wall slowly, increasing
flexion movement.

Surgical

Poorly defined role, only for patients who fail conservative management
Manipulation under anaesthesia (least invasive) passive stretching of the capsule
while patient is under anaesthesia, but be careful of causing fractures especially in
the elderly.
Distend the joint by injecting a large volume of sterile saline under pressure
Fibrolysis/ division (open or arthroscopic) of the supraspinatus and infraspinatus
may dramatically improve ROM. Must be followed by aggressive physiotherapy
post-op.

PROGNOSIS
- Better in younger patients with post-traumatic frozen shoulder; the idiopathic frozen
shoulders that occur in diabetics tend to recur and not improve.

23

SHOULDER JOINT INSTABILITY AND DISLOCATIONS

ANATOMY OF THE SHOULDER JOINT
- Articulation: occurs btw the rounded head of the humerus and the shallow pearshaped glenoid cavity of the scapula
- Movements: flexion, extension, abduction, adduction, lateral/medial rotation,
circumduction
- Relations:
Ant: subscapularis, axillary vessels, brachial vessels
Post: infraspinatus, teres minor
Sup: supraspinatus, subacromial bursa, coracoacromial lig, deltoid
Inf: long head of triceps, axillary nerve, posterior circumflex humeral vessels
- Shallowness of the glenoid fossa of the scapula and lack of support provided by
weak ligaments(3 glenohumeral ligamentsMedial, Inferior, Superior; transverse
humeral ligament; coracohumeral ligament) make the shoulder joint an unstable
structure
- Strength mainly depends on the rotator cuff muscles
- Least supported part of the jt lies in the inferior location where it is unprotected by
the muscles
- Shoulder laxity is not equivalent to instability!!!

Bilaterally, and the instability usually responds to a Rehabilitation

program.
Surgery rarely indicated. When surgery is necessary, it involves
tightening of the Inferior capsule inferior capsular shift, or Interval
Closure.

1. ANTERIOR DISLOCATION OF THE SHOULDER

MECHANISM OF INJURY
Fall on the hand, driving humerus forwards, tearing the capsule or avulsing the glenoid
labrum
CLINICAL FEATURES
Severe pain, shoulder deformity
Lateral outline of the shoulder may be
flattened; bulge may be felt just below
the clavicle

X-RAY FEATURES
ANTERIOR SHOULDER DISLOCATION TYPES OF X-RAY VIEWS
Y-SCAPULAR (LATERAL
AP VIEW
AXILLARY VIEW
SCAPULAR) VIEW

Classification of patients with recurrent shoulder instability:

a. TUBS: Traumatic, Uni-directional (unilateral), Bankart lesion,
Surgery.
- instability related to a clear Traumatic event that presents as
Unidirectional instability, usually involves a Bankart lesion (tear in the
glenoid labrum), and frequently requires Surgery
b. AMBRII: Atraumatic, Multi-directional, Bilateral, Rehabilitation,
Inferior Capsular Shift, Interval Closure
- Instability that arises Atraumatically, occurring in patients prone to
Multidirectional instability who have excessive shoulder laxity
24

AP-overlapping shadows of the humeral head and glenoid fossa with the head lying
below and medial to the socket. Look out for Hill-sachs lesion which may indicate
recurrent anterior dislocations

Normal shoulder jt

Anterior dislocation of the shoulder

COMPLICATIONS
Early
(i)
Rotator cuff tear: occurs usu in older people, difficulty in abducting the arm
after reduction
(ii)
Axillary nerve injury: patient unable to contract the deltoid (can inititate
abduction but difficulty in abduction beyond a certain angle) and small patch of
anaesthesia over the muscle (regimental badge area); usu a neuropraxia
[course of axillary n.: arises from posterior cord of the brachial plexus (C5,6) in
the axilla, passes through quadrangular space then comes into close relationship
with the inf aspect of the capsule of the shoulder jt and medial side of the
surgical neck of the humerus] Radial n., median n., ulnar n, musculocutaneous
n. may be injured sometimes
(iii)
Axillary artery injury: examine for ischaemia before and after reduction
(iv)
Fracture-dislocation: associated fracture of the humerus-ORIF. Greater
tuberosity may be sheared off
Late
(i)
(ii)
(iii)

Shoulder stiffness
Unreduced dislocation: closed reduction can be attempted up to 6wks after
injury
Recurrent dislocation: common if the glenoid labrum is detached or the
capsule is stripped off the front of the neck of the glenoid; more common in
younger patients 90%, 50% in older patients

TREATMENT
M & R with sedation or sometimes GA
(i)
Kochers method: not recommended due to risk of nerve, vessel & bone injury
(ii)
Stimsons technique: patient lies prone with arm hanging over side of bed;

(iii)

2.
-

shoulder may reduce after 15-20mins

Hippocratic method: increasing traction applied to the arm with the shoulder
in slight abduction while an assistant applies firm counter traction to the body;
e.g. using a towel slung ard the chest under the axilla know at least this one!

X-ray post-reduction to check position and exclude fracture.

Exclude an axillary nerve injury, rotator cuff tear, median, radial, ulnar and
musculocutaneous nerve injuries after reduction
Rest the arm in a sling for 3 wks, 1 wk for those >30yrs old due to risk of stiffness
Avoid abduction and lateral rotation for 3 wks
Elbow and finger movements

ANTERIOR INSTABILITY
most common type, accounts for 95% of instability
Mechanism of injury: arm is forced into abduction, external rotation and extension
In recurrent dislocations: labrum and capsule often detached from the anterior rim
of the glenoid(Bankart lesion) and there is the presence of an indentation on the
posterolateral aspect of the humeral head (Hill-Sachs lesion)

CLINICAL FEATURES
- Patient may describe his shoulder as coming out after a sporting event in an acute
dislocation
- Complain that shoulder dislocates with relatively trivial actions and often he/she
can reduce the dislocation himself
- In recurrent subluxation: patient may describe a catching sensation followed by
numbness or weakness
- ROM full btw episodes of dislocation
- Apprehension test: examiner lifts the arm into abduction, external rotation and
then extension, patients body tautens in apprehension when he senses that the
humeral head is abt to slip anteriorly. Repeat test by applying pressure to the front
of the shoulder at the same time, patient will feel more secure now
- Drawer test: scapula is stabilised with one hand while examiner grasps the upper
arm with the other hand to manipulate the head of the humerus forwards and
backwards with the patient supine
25

Fulcrum test: patient lies supine and examiner places one hand behind the patients
shoulder to lever the humeral head forward by extending and laterally rotating the
arm, patient becomes apprehensive.

INVESTIGATIONS
- X-ray shoulder jt: AP, lateral and axillary views:
Hill Sachs lesion best shown on AP with arm internally rotated

X-RAY FEATURES
- AP view humeral head looks abnormal in shape as it is medially rotated(light bulb
sign); humeral head stands somewhat away from the glenoid fossa (empty glenoid
sign)

AP view
transcapular view
axillary view
Lat view- posterior subluxation, dislocation and sometimes deep indentation on the ant
aspect of humeral head, may have accompanying fractures of the humeral neck,
posterior glenoid rim or lesser tuberosity
-

CT shoulder
Arthroscopy
Examination under anaesthesia (EUA) to determine direction of instability

TREATMENT
- For acute dislocations: Manipulation and reduction followed by immobilisation in a
bandage or sling for several wks
- Recurrent dislocations: Indications for surgery include frequent painful dislocation
and recurrent subluxation

3. POSTERIOR DISLOCATION OF THE SHOULDER

- rare, <2% of shoulder dislocations
MECHANISM OF INJURY
- Indirect force producing internal rotation and adduction; occurs most commonly
during a epileptic fit or electric shock; can also be due to a fall on to the flexed,
adducted arm, direct blow to the front or fall on the outstretched hand.
CLINICAL FEATURES
- Arm is held in medial rotation, front of shoulder looks flat with a prominent
coracoid

COMPLICATIONS
(i)
unreduced dislocations
(ii)
recurrent dislocations
TREATMENT
- M & R by pulling on the arm with shoulder in adduction followed by lateral
rotation while humeral head is pushed forwards.
- Immobilisation in a sling

4. POSTERIOR INSTABILITY
- Recurrent instability almost always a posterior subluxation with the humeral head
riding back on the posterior lip of the glenoid
- Subluxation when the arm is in flexion and internal rotation
- Posterior drawer test positive: humeral head pushed backwards while the scapular
spine and coracoid process are held by the other hand
- Posterior apprehension test positive: forward flexion and internal rotation of the
shoulder with a posterior force on the elbow
- Treatment: muscle strengthening exercises, surgery considered when condition is
disabling and there is no gross joint laxity

26

5.
-

INFERIOR DISLOCATION OF THE SHOULDER

Occurs when the arm is hyperabducted
Humeral head is levered out of its socket and pokes into the axilla
May have severe soft tissue injury with avulsion of the capsule and surrounding
tendons, rupture of muscles, fractures of the glenoid or proximal humerus and
damage to the brachial plexus and axillary artery
Patients arm will be locked in abduction and head of the humerus may be felt in or
below the axilla

6. MULTI DIRECTIONAL INSTABILITY

- Same as AMBRII
X-RAY FEATURES
- Humeral shaft points upwards with the head sitting
below the glenoid
TREATMENT
- M&R: Pull upwards in the line of the abducted arm with
counter-traction downwards over the top of the shoulder. Examine for
neurovascular damage post-reduction. Rest arm in sling for 3 wks.
- If this doesnt work then open reduction may be needed.

DISORDERS OF THE SCAPULA

-

OTHER DISORDERS OF THE GLENOHUMERAL JOINT

-

Tuberculosis
- Uncommon
- Starts as osteitis, rarely diagnosed till arthritis supervenes.
- May proceed to abscess and sinus formation, and possibly fibrosis ankylosis.
- X-ray shows generalized rarefraction of bone in early stages with erosion of
joint surfaces. Late cases may have cystic destruction of the joint.
- Treatment: Anti-TB meds and rest the joint until acute symptoms settle.
Rheumatoid Arthritis
- AC joint, shoulder joint and various synovial pouches usually involved.
- X-ray shows progressive loss of articular space and peri-articular erosions
- Treatment: Methylprednisolone may be injected into joint & subacromial bursa.
Osteoarthritis
- Usually secondary to other fairly obvious disorders: congenital dysplasia, local
trauma, long-standing rotator cuff lesions, RA or AVN of head of humerus.
- X-rays show characteristic OA picture.
Milwaukee Shoulder

Patient presents with swelling of the shoulder and x-rays show a bizarrely
destructive form of arthritis. Similar conditions are encountered in other joints.
Largely crystal-induced rapidly progressive arthropathy; sometimes associated
with massive rotator cuff tears.
No satisfactory treatment

Congenital Elevation of the Scapula (Sprengels Shoulder)

o Scapula normally descends from neck by third month of fetal life. One
remains high in this case.
o Affected side is elevated, smaller and somewhat prominent.
o Usually painless but associated with other abnormalities like fusion of
cervical vertebrae, kyphosis/scoliosis.
Klippel-Feil Syndrome
o Bilateral failure of scapular descent and fusion of several cervical vertebrae.
Neck usually short and may be webbed, cervical mobility restricted
o Usually left untreated.
Winged Scapula
o Due to weakness of serratus anterior---which stabilizes the scapula on the
thoracic cage. Usually not apparent unless contracting the serratus anterior
against resistance. Ie push against a wall.
o Causes: Damage to Long thoracic nerve, injury or viral infxn to 5th, 6th and
7th cervical roots, certain types of muscular dystrophy
Acromioclavicular Instability
o Common condition resulting from dislocation of AC joint and rupture of
ligaments which tether the outer end of the clavicle. \
o Fairly obvious bump/step over the AC joint. If X-ray not obvious, ask
patient to carry weight on the affected arm and re-shoot the X-ray.
OA of AC joint
o Common in old people.
o Relieved by H&L injections or excision of the lateral end of the clavicle.

FRACTURES OF THE CLAVICLE

-

[MCQ] Embryology of clavicle: membranous ossification

Mechanism of injury: fall on the shoulder or outstretched hand (FOOSH)
May have a subcutaneous lump
Note: in children, clavicle fractures easily but unites rapidly w/o complications too.
X-ray features:
27

Most commonly involve the middle 1/3 of the clavicle, outer fragment will
be pulled down by the weight of the arm while inner half held up by SCM

Displacement may be severe in outer 1/3 fractures when the coracoclavicular

ligaments are torn
Complications:

Early
1. Pneumothorax
2. Damage to subclavian vessels
3. Brachial plexus injury

Late
1. Non-union, esp displaced outer 1/3 fractures
2. Malunion (healed #leaves a lump, most common Cx)
3. Shoulder stiffness
Treatment:

Middle 1/3#:Support arm in a sling for 2-3wks followed by physio; internal

fixation rarely required

Displaced outer 1/3 #: ORIF

FRACTURES OF THE SCAPULA

-

Mechanism of injury: body is fractured by a crushing force, a/w rib fractures, lung
contusion and haemo/pneumothorax, neck is fractured due to a blow or a fall on the
shoulder
Fractures of the scapula (high energy fracture) can be a/w injuries to the chest,
brachial plexus, spine, abdomen and head
Treatment:

Sling and physio for body and neck#

ORIF for fracture-dislocation(glenoid #)

Complications:

Malunion (+ crepitus)

X-ray:

Stress view may be needed to differentiate AC subluxation from dislocation

(patient is standing and holding a 5kg wt on each hand; diff in the distance
btw the coracoid process and inf border of the clavicle >50% diagnostic of
AC dislocation)

Complications:
(i)
Supraspinatus tendinitis
(ii)
Unreduced dislocation
(iii)
Ossification of the ligaments
(iv)
secondary OA
Treatment:

AC subluxation- Rest arm in a sling+physio

AC dislocation: fixation with a screw for 8wks, rest the arm for 2 wks
followed by physio; considered only for young and active patients

STERNOCLAVICULAR DISLOCATIONS
-

ACROMIOCLAVICULAR SUBLUXATION/DISLOCATIONS
-

Definitions

AC subluxation- acromioclavicular ligaments are torn with upwards

subluxation of clavicle

AC dislocation- both the acromioclavicular ligaments and coracoclavicular

ligaments may be torn, clavicle is elevated, causing a visible and palpable step
Mechanism of injury: fall on point of shoulder with arm adducted (sports injury)
Clinical manifestations: pain & swelling over AC joint; inability to ab/adduct arm

Mechanism of injury: lateral compression of the shoulders

Anterior(prominent lump over SC jt) more common than posterior dislocation
Posterior dislocation more serious as there can be pressure on the trachea and large
vessels, causing venous congestion of the neck and arm
Treatment:

Anterior dislocations: Conservative mx ( IF dangerous as large vessels are

behind the sternum)

Posterior dislocations
1. Closed reduction (sedate patient first, then pull at the shoulder)
2. If unreduced ORIF or acceptance of some degree of permanent
instability (depending on patient characteristics and functionality)

28

IMPORTANT ORTHOPAEDIC CONDITIONS IN THE ARM

4 major segments involved: head of humerus, lesser tuberosity, greater

tuberosity, shaft

One part

Two part

No matter how many

fracture lines there are,
as long as they are
undisplaced, considered
as one part
1fragment is displaced

FRACTURES OF THE PROXIMAL HUMERUS

-

Epidemiology: occurs after middle age. Most common in osteoporotic postmenopausal women
Mechanism of injury: fall on the outstretched arm (causes # in older patients,
dislocation in younger patients)
Clinical features: large bruise on upper part of arm, may have associated axillary n.
and brachial plexus injury
X- ray:

single impacted fracture extending across surgical neck

in elderly, fragments more clearly separated in younger
patients

Obtain axillary and scapular lateral views to exclude

shoulder dislocation

Inf subluxation of the humeral head as fracture heals

Three
part
Four part

2 fragments are
displaced, usu head (#
along surgical neck) and
greater tuberosity
All the major parts are
displaced

Collar & cuff for 1-2 wks

Active exercises once fracture unites (usu aft
6wks)
Cause few problems
Closed reduction, collar & cuff for 4wks
IF if reduction fails or fracture unstable after
reduction
For fractures of the anatomical neck in elderly
may need prosthesis due to high risk of AVN of
humeral head(rare); fixation in younger patients
For 2-part fracture dislocations, closed reduction
usu possible
Fracture of the greater tuberosity may be a/w ant
dislocation of shoulder while fracture of the
lesser tuberosity a/w post dislocation
ORIF
3 part fracture dislocation requires ORIF, at risk
of brachial plexus injury
A/w poor outcome, high risk of vascular injury,
brachial plexus damage, injuries of chest wall
and AVN of humeral head
Usu needs prosthetic replacement (reserved for
the elderly)

- Complications:
One part fracture involving surgical neck
1. Vascular and nerve injuries esp axillary nerve
2. Stiffness of the shoulder maximal at the outset
3. Malunion with loss of rotation
4. Avascular necrosis of the head of humerus: 10% of 3-part fractures, 20% of 4-part
fractures
-

Treatment

Neers classification: distinguishes btw no of displaced fragments(defined as

>45o angulation or >1cm separation)

Proximal humerus fractures in children

- In children, the physis can separate or there can be metaphyseal fractures,
considerable displacement and angulation is acceptable

29

Fractures may be pathological as proximal humerus is a common site of bone cysts

and tumors in children
Fractures due to bone cyst: rest the arm in a sling for 4-6 wks

FRACTURES OF THE SHAFT OF HUMERUS

Mechanism of injury:

RTA / FOOSH (fall on oustretched hand)

Fall on the hand causes a spiral fracture.

Fall on the elbow with the arm abducted causes a oblique or transverse #

Direct blow to the arm causes a transverse or comminuted fracture

Note: In the elderly, fracture may be due to mets

Clinical features:
o Painful, bruised and swollen arm
o Displacement of fragments depends on relation of the site of fracture to
the insertion of the deltoid.
- If fracture line proximal to deltoid insertion, proximal fragment adducted by
pectoralis major, lat dorsi and teres major while distal fragment abducted by deltoid
- When fracture is distal to delotoid insertion, proximal fragment is abducted by
deltoid and distal fragment pulled proximally by biceps and triceps

May have radial n. injury (radial nerve lies in the spiral

grove on the posterior surface of the humerus under to
cover of the triceps). Test radial n. function before and
after treatment by assessing active extension at MCP jt
X-ray: Look for tumors in elderly as fracture may be
pathological

Complications:
Early
1. Brachial artery injury (dx with arteriography)
2. Radial nerve injury- patient presents with wrist drop and
paralysis of the MCP extensors; common with oblique #s
at the junction of the middle and distal 1/3 of bones
Late
1. Delayed union, malunion and non-union (common in
conservatively managed patients)
2. Joint stiffness
Treatment:
- U slab Cast Brace, or
- ORIF
- Most heal readily; weight of arm with external cast enough to pull fragments
together. Hanging cast is applied from shoulder to wrist with elbow flexed and
forearm is suspended by a sling around patients neck
- Spiral fractures unite in about 6wks while other fractures take 4-6wks longer
- Cx rate after IF of humerus high (compression plate, screws, intramedullary nail,
external fixation)
Indications for surgery:
Radial n palsy
Segmental #
Open #
Pathological #
Intra-articular extension
Floating elbow (humeral + forearm #)
Non-union

30

ANATOMY OF THE ELBOW JOINT

Type of jt: Hinge jt, Stability due to the shape and fit of the bones that make up the jt
and the capsular and collateral ligaments
Articulation: Btw the trochlea and capitulum of the humerus and the trochlea notch of
the ulna and head of the radius
Ligaments:
Lateral collateral lig attached by apex to the lateral epicondyle and base to annular
ligament of radius
Medial collateral lig attached to the medial epicondyle to medial margins of olecranon
and coronoid process
Nerve supply: branch from median, ulnar, musculocutaneous, radial n.
Movements:
Flexionbrachialis, biceps brachii,, brachioradialis, pronator teres; in flexion, the bony
points form the boundaries of an equilateral triangle
Extension triceps, anconeus; in extension, the med and lat epicodyles and top of the
olecranon are in a straight line
Relations:
Ant brachialis, biceps tendon, median n., brachial artery
Post triceps, small bursa
Medulnar n. passes behind the med epicondyle and crosses medial ligament of the jt
Lat common extensor tendon, supinator
Forearm normally slightly in valgus in relation to the upper arm, average carrying angle
in children being abt 15 degrees.
In children, the secondary ossification centres can be seen on x-rays. The average ages
at which the ossific centres appear are CRITOE
C apitulum-2yrs
R adial head- 4yrs
I nternal (medial) epicondyle-6yrs
Trochlea-8yrs
O lecranon-10yrs
E xternal (lateral) epicondyle-12yrs

FRACTURES AROUND THE ELBOW IN CHILDREN

1. SUPRACONDYLAR FRACTURES
One of the commonest # in children

Mechanism of injury: Posterior displacement due to fall on outstretched hand

(hyperextension injury), distal fragment pushed backwards and twisted inwards while
proximal fragment can poke into the soft tissue anteriorly, injuring the brachial artery or
median nerve.
Anterior displacement use due to direct trauma (rare) with jt in flexion
Clinical features: S deformity in posteriorly displaced #. Examine for vascular (check
pulse and capillary return) and nerve injury.
X-ray:
Fracture best seen on lat view
Fat pad sign in undisplaced # : triangular lucency in front of distal humerus due to fat
pad being pushed forwards by a haematoma

31

cortex still in continuity

Type III #, distal fragment tilted

Both anterior and posterior fat pads
backwards visible, sail sign configuration

Baumanns angle: assess degree of medial angulation (angle is

subtended by longitudinal axis of humeral shaft and a line
through coronal axis of capitellar physis; usually <80 degrees)

Increase in Baumanns angle occur in residual varus and internal

rotation deformities

Complications:
Early
1. Brachial artery injury, can cause Volkmans ischaemia
2. Compartment syndrome pain + 1 positive sign [pain on passive extension of the
fingers, tnese and tender forearn, pulseness, blunted sensation, increased capillary refill
time], KIV angiography, vessel graft, forearm fasciotomy
3. Median n., esp anterior interosseous branch, recovery usu in 6-8wks
4. Ulnar n. damaged by careless pinning
Late
1. Malunion, causing varus deformity of the elbowgunstock deformity, rarely
valgus(may cause late ulnar n. palsy), may need correction by supracondylar osteotomy
2. Elbow stiffness
3. Myositis ossificans
Treatment
Type I

Undisplaced fracture

Type II

Angulated fracture with the posterior

Immobilize in 90o, sling x 3wks

Check x-ray 5-7days later to ensure no
displacement
Reduce under GAtraction in the

Type IIa

Less severe and merely angulated

Type IIb

More severe, both angulated and

malrotated
Increased risk of neurovascular
injury or circulatory compromise due
to swelling
Completely displaced fracture
Increased risk of neurovascular
injury or circulatory compromise due
to swelling

Type III

length of the arm with counter-traction

above elbow correct lateral shift and
tilt correct rotationcorrect
backwards shift and tilt. Check pulse!
Collar and cuff x 3wks
Reduce under GA, hold with wires

Reduce under GA, hold with wires

Open reduction if
(i) closed reduction fails
(ii) open fracture
(iii) vascular damage present
Continuous traction through a screw in
the olecranon or skin traction with the
elbow almost straight and the arm in a
small Thomas splint (Dunlop traction)

2. FRACTURES OF THE LATERAL CONDYLE

Mechanism of injury: Fall on outstretched hand with elbow extended and forced into
varus. Fragment capsized by extensor tendons. Fracture always involves joint;
fracture line usu runs along the physis and into the trochlea; fracture may damage the
growth plate
Clinical features: swollen and deformed elbow, passive flexion of the wrist (pulling on
the extensors) may be painful.
X-ray: Oblique view should be taken
Usu there is a fracture through the middle of the trochlea and the elbow is unstable and
may dislocate (Salter Harris Type II)
Less commonly, the fracture runs through lateral condyle into the trochlea, stable
fracture with no involvement of the humero-ulnar jt (Salter Harris Type IV)
Complications:
1. Non-union and malunion, causing cubitus valgus and tardy ulnar n. palsy
2. Recurrent posterolateral dislocation of elbow
Treatment:
Minimal displacement backslab
with elbow flexed & wrist extended
32

(relaxes extensor mechanism) for 2/52

Displaced # (gap of >2mm) ORIF, immobilize arm in a cast for 3-4/52

Treatment:
Displacement <30deg- collar and cuff
Displacement>30 deg- closed or open reduction. IF not necessary
Never remove radial head as it interferes with growth of the radius

3. FRACTURES OF THE MEDIAL CONDYLE

Mechanism of injury: Fall on outstretched hand, elbow forced into valgus or fall from
ht with direct blow to the elbow, medial fragment may be displaced by pull of the flexor
muscles

FRACTURES AND DISLOCATIONS AROUND THE ELBOW IN ADULTS

Clinical features: pain and swelling

1. FRACTURES OF THE DISTAL HUMERUS

X-ray: intra-articular #; in younger children, much of the medial condylar epiphysis is

cartilaginous and may not be visible on x-ray, an arthrogram may be useful in some
cases
Complications:
Early
1. Ulnar n. damage

Late
1. Stiffness of the elbow
2. Late ulnar n. palsy due to friction in roughened bony
groove

Treatment:
Undisplaced-splint and repeat x-ray
Displaced- closed reduction with percutaneous pinning or ORIF
4. PULLED ELBOW
Mechanism of injury: pull on the arm with forearm pronated, causing subluxation of
annular ligament over head of radius into radiocapitellar joint.
- Usually affects a child between 2-3yo
No x-ray findings

Type A
Extra-articular
supracondylar #
- rare in adults
- usu displaced
and unstable
ORIF

Type B

Type C
Intra-articular bicondylar# with
Intra-articular unicondylar #
varying degrees of comminution
- high energy # with soft tissue damage
- examine for vascular or nerve injury
Undisplaced #
Posterior slab with elbow flexed almost 90 deg
Check x-rays 1/52 after injury
Displaced#
ORIF, elbow held at 90 deg with arm in a sling, healing occurs
by 12wks
Skeletal traction may be considered for severely comminuted #
Elbow replacement in the elderly
Complications
Early
1.Vascular injury
2.Median n. or ulnar n. damage
Late
1. Elbow stiffness
2. Heterotopic ossification

Treatment: Supinate then flex the elbow, ligament pops back in place
5. FRACTURED NECK OF RADIUS
Mechanism of injury: Fall on outstretched hand, forcing elbow into valgus and
pushing radial head against capitulum; same injury in adult usu causes radial head #
Clinical features: pain on rotating forearm
X-ray: may have a Salter Harris II injury; proximal fragment is tilted distally, forwards
and outwards

2. FRACTURED HEAD OF RADIUS

Common in adults but rare in children
Mechanism of injury: Fall on outstretched hand with elbow extended and forearm
pronated articular cartilage of the capitulum may be bruised or chipped
Clinical features: tenderness over radial head, pain on pronation and supination
X-ray: to exclude concomitant injury of distal RUJ i.e. damage to interosseous memb.

33

Complications:
1. Joint stiffness of the elbow and radioulnar jt
2. Myositis ossificans
3. Recurrent instability of the elbow if injury to the medial collateral lig and if there
is excision of the radial head
Mason classification

Type I
Vertical split in the
radial head
LA injection and
aspiration of
haematoma
Collar and cuff for
3/52

X-ray: lateral view needed, check position of radial head as it may be dislocated
Complications:
1. Stiffness
2. Non-union

3. Transient ulnar n. palsy

4. OA

Treatment:
- Comminuted # with triceps intacttreat as a bruise and rest in sling for 1/52 as
immobilization can lead to stiffness in the elderly; obtain check x-ray
- Undisplaced transverse# immoblise at 60 deg in a cast for 2-3/52
- Displaced transverse # ORIF with tension band wiring
Type II
Single fragment of lateral
portion of the head broken off
and usu displaced distally
Reduction and fixation with a
small screw

Type III
Head is comminuted
Excision of radial head

4.
-

DISLOCATION OF THE ELBOW

Posterior or posterolateral dislocation in 90% of cases; lateral shift may occur
Reduction usu stable and recurrent dislocation unlikely if there are no associated #
If there is # of the radial head, coronoid process or olecranon process, joint is more
unstable and more prone to redislocation unless # are fixed
Considerable soft tissue disruption and possible vascular and nerve injuries

Reconstruction of radial head if

there are forearm injuries,
disruption of the distal RUJ
which increases risk of
proximal migration of the
radius and instability

Fracture dislocation: reduction

and fixation, need to restore
radial pillar

Clinical features: obvious deformity, patient supports forearm with elbow

- Examine for vascular or nerve damage

**TERRIBLE TRIAD = Radial head # + coronoid process # + MCL injury **

Mechanism of injury:
- FOOSH with elbow in extension causes posterior dislocation
- Side swipe injury (driver with elbow out of the window) causes forward
dislocations usu a/w # and severe soft tissue damage

X-ray: confirms dislocation and identify associated #

3. FRACTURES OF THE OLECRANON

Mechanism of injury:
- Direct blow or fall on the elbow causing a comminuted #
- Traction when patient falls on hand with triceps contracted, causing a clean
transverse break
Clinical features:
- Bruise over the elbow in comminuted #, intact triceps
- Palpable gap and patient unable to extend elbow against resistance in transverse #
34

Complications:
Early
1. Brachial artery injury
2. Median or ulnar n. injury
Late
1. Stiffness
2. Heterotopic ossification, myositis ossificans; if bone mass restricts elbow function,
excise when mature
3. Unreduced dislocation
4. Recurrent dislocation if there is a large coronoid# or radial head #
5. Secondary OA

Line drawn down the long axis of the radius does not intersect the capitulum,
indicating radial head dislocation

Treatment:
Uncomplicated dislocation: reduce under anaesthesia
Slight flexion of elbow and traction on forearm correct lateral displacement further
flexion of elbow while pushing olecranon forwards check nerves and circulation +
check x-raycollar and cuff for 3/52 with elbow flexed>90deg
Dislocation with associated #: fix the #
Side swipe injuries repair vascular damage, skeletal stabilization
Persistent instability temporary external fixation
5.
-

RADIAL HEAD DISLOCATION

Isolated dislocation are rare
Usually a/w ulna # (Monteggia injury)
Common in children; rule out NAI

Another mechanism of injury: parents pulling kids by the hands (yanking)

Important to identify ulnar # in children as if a minor deformity allowed to persist,
may prevent full reduction of dislocation
Look for posterior interosseous nerve injury
Treatment: manipulation under anaesthesia (supination, direct pressure), cast 6/52

35

IMPORTANT ORTHOPAEDIC CONDITIONS IN ELBOWS & FOREARMS

TENNIS ELBOW (LATERAL EPICONDYLITIS)

Cause: Malunion of supracondylar #

Cause: minor trauma to origin of wrist extensors / fibrosis of extensor carpi radialis
brevis (ECRB) e.g. painting, carpenter

CUBITUS VARUS (GUNSTALK DEFORMITY)

Rx: wedge osteotomy of lower humerus
Cx: median nerve palsy

CUBITUS VALGUS
Cause: non-union of # lateral condyle (a/w bony knob on medial elbow)
Mx:
Undisplaced backslab
Moderate displacement closed reduction and backslab
Unstable K-wire and cast
Rotated Open reduction and K-wire

X-ray weekly to detect slipping

Cx: Tardy ulnar nerve palsy manage by transposing ulnar nerve anterior to elbow

RHEUMATOID ARTHRITIS
Features: pain, tenderness, swelling, stiffness, usually bilateral
X-ray: bone erosion, radial head destruction, widened trochlear notch of the ulna
Rx: splint, radial head resection, partial synovectomy, arthroplasty

OSTEOARTHRITIS
Cause: intraarticular #s, loose bodies, crystal deposition dz
Features: pain, stiffness, ROM, ulnar n palsy
X-ray: Jt space, bone sclerosis, osteophytes, loose bodies

OLECRANON BURSITIS
Causes: pressure, friction, infxn, gout (a/w tophi), RA (a/w polyarthritis & subcutaneous
nodules over the olecranon)

Features:
o Lateral epicondylar pain, aggravated by shaking hands & opening doors.
o Pain on active wrist extension with a straight elbow. Normal ROM.
o Pain reproduced by extending wrist against resistance or by passively flexing in
thus extending the tendons
Rx: rest, lifestyle modification, H&L injection, extra-corporal shockwave, excision of
fibrous mass, lengthen tendon (ECRB)

GOLFERS ELBOW (MEDIAL EPICONDYLITIS)

Similar to tennis elbow, but affecting flexor origin at medial epicondyle
Memory aid: Golfers already has L hence Medial Epicondylitis

CUBITAL TUNNEL SYNDROME

Compressive ulnar neuropathy at the elbow, in the retrocondylar groove or as ulnar
nerve passes between the 2 heads of the flexor carpi ulnaris
Caused by constriction of fascial bands, subluxation of ulnar nerve over medial
epicondyle, cubitus valgus, bony spurs, tumours, ganglions, repetitive elbow
flexion & extension
Features: paraesthesia along ulnar 1.5 fingers; weak grip strength especially when
patient rest upon or flexes the elbow; +/- nocturnal symptoms; loss of fine dexterity;
rarely, wasting of intrinsic muscles & clawing/abduction of little finger. Male> Female.
DDx: cervical spondylosis, ulnar tunnel syndrome (compression at canal of Guyon at
the wrist) preserved strength of wrist and 4th & 5th digit flexors
McGowan Grading system
1) Parasthesia in distribution, clumsiness in hand,
2) Weak interossei & muscle wasting,
3) Paralysis of interossei, marked weakeness.
Rx: Simple decompression, medial epicondylectomy if a/w non-union of epicondyle #,
anterior transposition of the ulnar nerve, injection of steroids in the cubital tunnel

36

SUPRACONDYLAR FRACTURES
Fractures in distal 1/3 of humerus proximal to the trochlea & capitulum
Epidemiology: common childhood #. Adults: More proximal, commonly with
comminution, spiraling & angulation
Mechanism of injury: FOOSH
Features: pain over elbow, swelling, deformity
Important complication: Volkmanns ischaemic contracture df: irreversible
contracture of flexor muscles of the hand due to ischaemic processes in the forearm
DDx: dislocation of elbow (equilateral by epicondyles & olecranon is disrupted)

Support

Collar & cuff for 3 wks

Sling for another 3 wks to avoid extension, but flexion is
allowed.

Cx:
1. Arterial obstruction: Brachial arterial kinking by proximal fragment. Arterial wall
damage results in Volkmanns ischaemic contracture. Symptoms = Pain, Pallor,
Paraesthesia, Paralysis, Perishing cold, swelling & bruising)
2. Median nerve injury
3. Malunion cubitus varus (may cause ulnar tunnel syndrome)

X-ray: # line across distal humerus, posterior tilt/displacement of distal fragment,

medial or lateral displacement.

ELBOW DISLOCATIONS

Mx:

Mechanism: fall on outstretched hand

Assoc injuries routinely checked for: #s of epicondyles (usually medial), lateral
condyle, coronoid & radial head & neck

Indications for
reduction

Manipulation
technique

Fixation

X-rays
Remanipulation
if reduction is
poor
Observation

Arterial obstruction
# displacement &/or angulation
<50% bony contact
Backward tilt 15%
Medial or lat tilting of 10% (may cause tardy ulnar n palsy)
Severe torsional deformity
Manipulation under GA
1. Disimpaction: Traction applied at 20o flexion with
countertraction applied to arm
2. Reduce post tilt/displacement: Flex elbow to 80o while
maintaining traction
3. Correct lat displacement/torsional deformity: manipulate
epiphyseal complex
Fix with elbow at greatest angle of flexion possible w/o
compromising circulation (check radial pulse)
Never apply a complete plaster due to risk of swelling
AP & lateral
No more than 2 remanipulations due to risk of swelling.
Employ continuous traction instead (e.g. Dunlop traction)
K-wires & plaster backslab may be used for unstable #
Overnight, esp for complications of vascular compromise

X-ray: posterolateral dislocation of elbow

Rx:
o Apply strong traction in the line of the limb under GA. Slight flexion might be
required.
o Alternative: clasp humerus from behind & push olecranon fwd & medially while
asstant applies traction in moderate flexion
o Support with sling for 3 wks.
Cx: exclude ulnar n, median n & brachial arterial injuries; elbow stiffness, myositis
ossificans.

MEDIAL CONDYLAR INJURY

Mechanism: direct violence or avulsion by ulnar collateral ligament on forceful
abduction
Mx: immobilize in plaster cast for 2-3 wks
Cx:
1. Tardy ulnar n. palsy
2. Trapping of medial epicondyle in the elbow joint

37

RADIAL HEAD FRACTURE

Monteggia

Mechanism: direct violence, or FOOSH

Features: elbow pain, swelling, bruising, restricted elbow extension
Galeazzi

X-ray: # radial head, subluxation of distal end of ulna.

(+) AP projections in mid-prone & full pronation required. Assess type of #.
Mx:
Fracture

Hairline
Undisplaced (marginal
or segmental)
Displaced (marginal or
segmental)
Comminuted

Rx

Light compression bandage & sling for 3 wks, +

backslab if pain is severe. Excellent outcome
Conservative Rx, r/v in 3 mths. Late excision of radial
head if movts are severely restricted
Radial head excision w/in 48hrs silastic prosthetic
replacement, splint for 3 wks

Mx:
o
o
o
Cx:
o
o
o
o
o
o

RADIAL NECK FRACTURE

Mechanism & Dx: Similar to radial head #
Mx:
Conservative

Minimal tilting
o

Marked tilting (>20

o
adults, >30 children)

Manipulate apply traction, pronate & supinate,

apply pressure when prominent part of radial head
presents, + K-wire if unstable

Fracture of upper ulnar (shortening & angulation) + radial head

dislocation (MUF: Monteggia Ulnar Fracture)
Mechanism: direct violence on forearm or forced pronation (eg fall
on outstretched hand with trunk rotation)
Fracture lower radius + inferior radioulnar joint dislocation with
ulnar displacement (GUD: Galeazzi Ulnar Dislocation)
More common than Monteggia.

Principle: Restore length of fractured bone, then reduce dislocation

Children: manipulation + plaster fixation <good remodeling potential>
Adults or children w displaced #s: ORIF (plate & screw), plaster fixation in 90
degrees flexion with supination
Cross union radius malunites with ulnar
Loss of pronation/supination
Loss of extension of elbow
Difficult to reduce and maintain closed. Usually requires ORIF
Shoulder to hand syndrome (frozen shoulder)
If due to persistent unreduced dislocation or late Dx:

Monteggia

Galeazzi

Anterior protrusion of radial head :. elbow ROM

Rx: excise radial head
Tardy ulnar n palsy Rx: transposition of ulnar nerve
Prominent ulna & chronic wrist pain Rx: excise distal ulna
Ligaments potentially torn :. Instability at DRUJ Rx: put in
cast, arm in supination OR use K-wires

NIGHTSTICK INJURY
FOREARM FRACTURE-DISLOCATIONS

More commonly fracture of both bones of the forearam, usually displaced.

If only one bone fractured, look for dislocation of the other.
Displaced fractures of the forearm usually treated by ORIF as non-surgical means
often result in limitation of pronation/supination.

Types: Remember, Big bone #s, small bone dislocates

Isolated fracture of the ulnar with minimal displacement.

MOI: Holding up arm to protect face from blow
Rule out fracture clinically and radiographically
Rx: Below elbow cast for 6 wks for distal one-third #. If angulation of proximal
two-thirds severe, consider ORIF.

CAUSES OF TARDY ULNAR NERVE PALSY

Medial / Lateral condylar fracture

Monteggia fracture
38

IMPORTANT ORTHOPAEDIC CONDITIONS IN THE HANDS & WRISTS

TYPES OF CASES

Ganglion
Pigmented villonodular synovitis (PVNS)
Implantation dermoid cyst
OA Heberdens & Bouchards nodes

Haemangiomas
Pseudoaneurysms
SCC
Glomus tumours

Joint

RA hands

OA hands

Vascular
Nerve

Haemangiomas
Ulnar n palsy
Median n palsy
Radial n palsy
Carpal tunnel syndrome

Lumps

Muscle /
tendon

Bones

DDX OF PAINFUL WRIST & HAND

Referred

Joint

Periarticular

Radiculopathies
Erbs palsy (C5-6)
Klumpke palsy (C8-T1)

de Quervains dz
Tenosynovitis
RA Swan neck & Boutonniere
deformities, tendon rupture

Trigger finger
Dupuytrens contracture
Mallet finger

Colles #
Smiths #
Scaphoid #
Bennetts #

Boxers #
Gamekeepers thumb
Scaphoid dislocation
Lunate dislocation

RA
OA
Infection
De Quervain
Tenosynovitis
Instability

Painful Hand
Neck
Shoulder
Mediastinum
RA
OA
Carpal tunnel
Tenosynovitis
Infection

NB. CTS, De Quervains disease and trigger finger are all tenosynovitis (i.e. same Mx)

I. HANDS
ACUTE INFECTIONS
GENERAL
-

PATHOLOGIES
1. Trauma
2. Tumour
3. Infection
4. Inflammation
5. Degeneration

Painful Wrist
Cervical spondylosis

Frequently limited to 1) Nail Fold, 2) Pulp space, 3) Subcutaneous tissues, 4)

Tendon sheath, 5) Deep Fascial spaces or joint
Cause: Almost invariably implanted Staphylococcus
Pathophysiology: Acute inflammation and suppuration in a small compartment will
result in increase in pressure leading to threatened local blood supply tissue
necrosis or a stiff and useless hand
Clinical features: Usually a hx of trauma, may be unnoticed. Painful and swollen
hand. Throbbing pain. May be a/w with fever. Exquisite tenderness, red and tense
tissues with decreased ROM.
Principals of Rx: 1) Antibioticsusually flucloxacillin, and in severe cases, fusidic
acid or a cephalosporin as well. 2) Rest and elevation. 3) Analgesics 4) Drainage
only if theres sign(s) of abscess (throbbing pain, marked tenderness and toxaemia.
5) Splintage in a the position of safe immobilisation (wrist slightly extended, MCP
in full flexion, IP joints extended and thumb abductedligaments are at greatest
length. 6) Physiotherapy

SPECIFIC TYPES
PARONYCHIA
Infection under nailfold.
39

PULP SPACE INFECTION

Usually prick or splinter of the finger tip

MUSCLE / TENDON DISORDERS

TENDON SHEATH INFECTIONS

Uncommon but dangerous. Risk of tendon necrosis and pt may end up with useless
hand. Present with painful, tender swollen hand with zero ROM (active and passive
not permitted)
Rx: As above. May require surgical drainage if no improvement over 24 hrs.

DEEP FASCIAL SPACE INFECTION

Usually infection from a web space or tendon sheath. The palm is ballooned. Loss
of normal concavity, with whole hand held still.
Rx: Incision and drainage.
JOINT INFECTION
Can be infected directly or indirectly. Clinically hard to distinguish from acute gout.
So aspirate joint.
Rx: IV antibiotics and splint. If no improvement in 24 hrs open drainage.
BITES
Animal Bites: Usual organisms Staph and strep
Human Bites: Organisms more varied and includes Anaerobes.
X-ray done to exclude fracture or foreign body.
Mx:
o Fresh wound: Examined in OT. Swab for c/s. Explore for foreign bodies such
as tooth. Splint elevate and start prophylactic antibiotics
o Infected Bites: debridement and washout. Start IV antibioticsBroad
sprectrum penicillin and cephalosporin. Consider Rabies.
o Post op: Physiotherapy. Deal with tendon lacerations when tissues are
completely healed.
SKIN
SKIN CONTRACTURES
- Cuts and burns are liable to heal with contractures, causing puckering of the palm
or fixed flexion deformities. Surgery incisions should never cross flexor creases.
- Rx: Established contractures may require excision of the scar and Zplasty of the
overlying skin.

DUPUYTRENS CONTRACTURE
Definition: nodular hypertrophy & contracture of palmar aponeurosis.
Pathogenesis: local microvessel ischaemia increased xanthine oxidase activity
superoxide free radical production stimulate myofibroblast proliferation &
type III collagen formation. Specific platelet-derived and fibroblast growth factors
also play a role in the aetiology.
o Allopurinol may help to reduce symptoms (XO inhibitor)
o The process of chronic inflammation is thought to be essential to the
subsequent fibrosis
Features: Middle-aged man.
LOOK
o Appearance of any visible cords, any pitting/tethering of skin on
palmar aspect of hand
o Scars from previous surgery
o Flexion deformities at MCPJ and PIPJ of the involved fingers
o Involvement of thumb & 1st web space (a sign of more aggressive dz)
o Garrods pads at PIPJs on dorsum of hand (thickening of s/c tissues)
FEEL
o Palpate swelling, note fixation to skin
o Compare with other palm!
MOVE
o ROM of involved fingers
o Passively move the joints with fixed deformities
OFFER
o To enquire about causes & associations
o Assess patients function, e.g. writing & dressing
o Look for other features of diffuse fibromatosis

DDx:
o Skin contracture (look for scar from previous wound)
o Tendon contracture (thickened area or cord moves on passive flexion of
involved finger)
o Congenital contracture of little finger (affects PIPJ)
o Ulnar nerve palsy (claw hand deformity)
Conditions associated with Dupuytrens contracture (DEAFEST PAIL)
o DM
o Epilepsy
o Age
o Family history (AD) / fibromatoses
o Epileptic medication (e.g. phenobarbitone)
o Smoking
o Trauma & heavy manual labour

40

Peyronies disease (fibrosis of the corpus cavernosum seen in 3% of

patients with Dupuytrens contracture)
o AIDS
o Idiopathic
o Liver disease (secondary to alcohol)
Treatment: Indicated when deformity is progressive and interferes with function
(i.e. when MCPJ or PIPJ contracture exceeds 30deg).
o Fasciotomy for prominent bands
o Partial fasciectomy (with Z-plasty to lengthen wound) in conjunction with
post-op physiotherapy (early active flexion ROM exercises for grip strength)
and night-time splintage in extension
o Dermofasciectomy (with full-thickness skin grafting) a/w lowest risk of
recurrence
o Arthrodesis/amputation for late presentations & repeated recurrences

Bone (avulsion #)
Extra-articular or involving <2/3 of joint
conservative Rx
Intra-articular or involving 2/3 of joint
surgical reduction

MUSCLE CONTRACTURE
Forearm

Intrinsic
muscles

Ischaemic contracture of forearm muscles, commonly caused by:

o Volkmanns ischaemic contracture: # causing compartment
syndrome resulting in muscle ischaemia & necrosis. Infarcted
muscles replaced by fibrous tissues. Usually follows circulatory
insufficiency due to injuries at or below the elbow.
o Tight plaster cast & limb swelling
Shortening of long flexors causing flexion deformity of fingers which
is only correctable on wrist flexion (tendodesis effect)
May be a/w ulnar and/or median nerve palsies
Treatment: If marked disability: muscle release, Excise dead muscle or
tendon transfer
MCPJ flexion, IPJ extension & thumb adduction
Causes: spasticity (eg CP), scarring (trauma and infection)
Treatment: muscle release
Aka intrinsic plus. Intinsic minus is used to describe Ulnar claw due to
paralysis of the intrinsic muscles.

MALLET FINGER

Injury to extensor tendon of terminal phalanx

Clinical features: loss of active DIPJ extension, normal
passive DIPJ extension
Types & Rx

Muscle (imbalance)
Treat with mallet splint (conservative)

RUPTURED EXTENSOR POLICIS LONGUS

Injury to long thumb extensor after fraying

Secondary to colles fracture, rheumatoid arthritis
Rx: Tendon transfer usually required

DROPPED FINGER

Rupture of extensor tendon

Patient unable to hold finger at extension at MCP joint
Rx:
(1) direct repair
(2) distal portion of the tendon attached to adjacent finger extensor

BOUTONNIERE

Flexion deformity of PIP joint due to interruption of central slip of extensor tendon
Lateral slips separate and head of proximal phalanx pops up in between
Rx: post traumatic usually repairable. Chronic deformity (in RA) usually cannot be
repaired

SWAN NECK DEFORMITY

Reverse of Boutonniere PIP hyperextended, DIP flexed

Due to imbalance of extensor vs flexor action in finger (commonly in RA)
Rx: tendon rebalancing and joint stabilisation

TRIGGER FINGER (STENOSING TENOVAGINITIS)

Epidemiology: 55- 60 years old, women > men

Causes:
o Idiopathic
o Congenital
o Overuse / Local trauma causing sheath thickening
o RA
Clinical features:
41

LOOK
FEEL
MOVE

Flexion of 1 finger; commonly affecting middle & ring fingers of

dominant hand (NB. finger doesnt need to be in fixed flexion the whole
time for it to be triggering)
Ask if theres any pain.
Palpate for small nodule overlying the tendon sheath (usually approx. at
the level of proximal transverse palmar crease).
Triggering on extension, snapping sensation, tenderness over A1 pulley

Pathology:
Most often due to formation of nodule in FDS tendon where it glides under the
A1 pulley in the region of the metacarpal head.
Flexor tendon trapped at entrance of tendon sheath; forced extension causes
opening snap. Tender nodule may be felt in front of sheath at the MCPJ

DDx:
RA
Septic arthritis
Suppurative tenosynovitis
Tumour of tendon sheath
Dislocation
Dupuytrens contracture

Staging & Mx (Greens Classification):

Stage

Pre-triggering
Triggering
Triggering &
Locking
Contracture

Features
Hx of triggering not demonstratable on PE; tenderness
Demonstrable catching, but patient can actively extend the digit
Demonstrable locking, requiring passive extension (IIIa) or inability
to actively flex (IIIb)
Fixed flexion contracture of PIP joint

Mx:
Splinting (MCP joint flexed 15; not that efficacious)
Activity modification (i.e. reduce local trauma)
H&L into tendon sheath: high rate of success in female patients, with short
duration of symptoms (<4mths), for discrete palpable nodule, single digit
involvement, no associated conditions (e.g. RA, DM)
Surgical release
o If injection therapy failed or if patient has other pathologies (e.g. RA)
which is suspected to cause triggering & cannot be treated conservatively

Divide entire A1 pulley (tendon sheath) in the midline under vision, then
ask patient to actively move the digit to confirm full release (motion
encouraged immediately following the procedure)
Complications: incising too distally cut the A2 pulley bowstringing

LUMPS
PIGMENTED VILLONODULAR SYNOVITIS (PVNS)
Definition: benign proliferative disorder of synovial lining of joint, bursa & tendon
sheaths. Produces localised/diffused nodular thickening of the synovial membrane.

Epidemiology: commonest hand lump disorder, occurs in patients 20-50yo

2 types (+ sites)
i) Diffuse form
o Affects entire synovial lining of a joint, bursa or tendon sheath; affects
large joints
o More commonly in the knee, followed by the hip; ankle; shoulder joints
ii) Localized/nodular form
o Appears in the form of a localized nodule or mass in a synovium, and the
surrounding synovium is generally normal
o Affects tendon sheaths around small jts of hands & feet (termed nodular
tenosynovitis)

Presentation: solitary, well circumscribed, tan colored, and sometimes has pale

X-ray: joint swelling, periarticular erosions, joint space narrowing, sub chondral
cyst, osteophytes formation (secondary OA changes)

Treatment: Surgical Excision. However, diffuse lesions have a high rate of

yellow regions of lipid deposition. Insidious onset, dull aching jt pain, nodular or
diffused jt swelling, ROM, locking of joint.

recurrence (>50%) If refractory to repeated surgery, may be managed with lowdose radiotherapy

IMPLANTATION DERMOID CYSTS

Usually sited along the volar surfaces of the fingers & palms
Associated with trauma to the overlying skin look for scars
GOUTY TOPHI
Relatively mobile, stuck to tendon/joint, firm, can be soft, whitish, not
transillumnant, tender in acute cases
Where: ear, ankle, elbow, finger
42

Complications: skin ulceration

DDx: PVNS

SQUAMOUS CELL CARCINOMAS

Due to burns, sunburn, Arsenic
Spread by lymphatics

ENCHONDROMA
Commonest primary bone tumor of hand
Hard, irregular, fixed swelling
MALIGNANT MELANOMA
NEUROMA

NEUROFIBROMA
Localised to digit and part of hand
4-5cm, irregular and wrinkled skin, soft, mobile with skin, a/w cafe au lait spots

GIANT CELL TUMOUR

LIPOMA

GLOMUS TUMOURS

AKA glomangioma, or nonchromaffin paraganglioma): a rare benign neoplasm,

specialized arteriovenous anastamosis and usually found in the skin of the
extremities. It arises from the glomus body (Component of the dermis layer of skin,
involved in body temperature regulation. The glomus body consists of an AV shunt
surrounded by a capsule of connective tissue. Glomus bodies are most numerous in
the fingers and toes. The role of the glomus body is to shunt blood away from skin
surface when exposed to cold temperature, thus preventing heat loss, and allowing
maximum heat flow to the skin in warm weather to allow heat to dissipate.)
Small, vascular & tender swelling, usually occuring at the region of the nail beds.
Treatment: Radiotherapy and surgery

VASCULAR TUMOURS
May have thrills and bruits
PYOGENIC GRANULOMA
Relatively common benign vascular lesion of skin and mucosa. Exact cause
unknown
Usually occurs in children and young adults as a solitary, glistening, friable,
polypoid bright red papule or nodule. Prone to bleeding and ulceration.
Ranges from few mm to several cm in size.
Regressing lesions: Appear as soft fibroma. Normally occurs at head & neck, and
distal extremities.
Typically evolves rapidly over a period of a few weeks.
Usually Hx of trauma preceding the onset of lesion may be elicited
Untreated lesions eventually atrophy, fibrose and slowly regress.

OSTEOCHONDROMA

II. WRISTS
Carpal Bones (lateral to medial):
Some Lovers Try Positions That They Cannot Handle
Scaphoid, Lunate, Triquetrium, Pisiform, Trapezium,
Trapezoid, Capitate and Hamate
Alignment in Gilulas Arc (Carpal Arc)

JOINT DISORDERS
CHRONIC CARPAL INSTABILITY
Causes:

Injury
Arthritis
Kienbcks disease (patchy lunate AVN after trauma)

Features:

Pain
Weakness
Clicking on movement
Commonest type: Scapholunate dissociation X-ray shows
Terry Thomas sign (abnormal gap between scaphoid & lunate)
43

Rx:

Acute: reduction & fixation with plaster or K-wires

Chronic: splintage, analgesics, H&L injections, arthrodesis

3. Occult
4. Interosseous
Treatment:

KIENBOCKS DISEASE

Patchy AVN secondary to post-stress/injury of the lunate.

Predisposing factor: relative shortening of ulna excessive stress on lunate
Presentation: ache and stiffness, localised to centre of dorsal wrist. Possible
limitation of wrist extension
Imaging: Earliest signs of osteonecrosis only detected by MRI. X-ray: increased
density, later irregularity and flattening of bone. Eventually OA features.
Treatment: (1) Osteotomy of distal end of radius (reduce pressure on lunate)
(2) Microrevascularisation of bone if expertise available. (3) Partial arthodesis in
late cases.

MUSCLE / TENDON
TENOSYNOVITIS/TENOVAGINITIS
-

TEARS OF TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC)

TFCC fans out from the base of ulnar styloid

process to medial edge of distal radius.
S/S: chronic pain, clicking on supination and
loss of grip strength
Dx: Arthroscopy
Rx: Arthroscopyrepair and remove fragments

Usually disappears after some months. So theres no haste to Rx

Aspiration (recurs 6-12 mths later)
Excision if recurrence: Cosmesis or if ganglion is causing pain (recurs in 20-30%)

Extensor retinaculum contains 6 compartments which transmit tendons lined with

synovium
Causes: Unaccustomed movement, overuse, repetitive minor trauma. Sometimes
spontaneous occurrence.
Pathophysiology: resulting synovial inflammation secondary thickening of the
sheath & stenosis of compartment further compresses the tendon
1st dorsal compartment (APL and EPB), and 2nd dorsal compartment (ECRL, ECRB)
most commonly affected.
3rd compartment: extensor pollicis longus
4th compartment: extensor digitorum comunis (four tendons) and extensor indicis
5th compartment: extensor digiti minimi
6th compartment: extensor carpi ulnaris

LUMPS

DE QUERVAINS DISEASE (STENOSING TENOSYNOVITIS)

GANGLION

Definition:

Cystic degeneration of joint capsule or tendon sheath.

Locations (from most to least common):
o Dorsum of wrist (at scapholunate joint)
o Volar aspect of wrist
o Volar aspect of MCP joint
o Dorsal aspect of DIPJs (termed mucous cysts)
Well defined, cystic, non-tender, positive transillumination. Contains glairy fluid
(i.e. uncooked egg-white colour & consistency). May be attached to tendon.

Entrapment tendinitis of the tendons contained within the first dorsal compartment at
the wrist (MCQs: APL & EPB); causing pain with tendon movement
Pathology

Features:

Types:

1. Simple
2. Compound chronic inflammation distends tendon sheath above & below the
flexor retinaculum ( a/w TB, RA)

Inflammation causes thickening & stenosis of synovial sheath of the 1st dorsal
compartment containing the EPB & APL
Cause: wringing out clothes, pruning roses, cutting with scissors, cradling baby

Women 30-50 YO
Pain over radial styloid process, swelling & palpable thickening of fibrous sheath
along course of tendons
Finkelsteins test +ve (exquisite pain in region of radial styloid on forced ulnar
deviation of wrist with thumb in fist); NB. This test may also be positive in CMC
degenerative joint disease, e.g. OA
44

DDx:

Arthritis thumb MCP jt, scaphoid fracture, scapholunate instability

Radiograph:

Aetiology

o
o

If diagnosis is still in doubt, obtain Roberts view in order to profile CMC joint
Treatment

Conservative
NSAIDs
Cold compression
H&L injection: inject in sheath
AND/OR
Thumb spica splint for 1 month

Surgical
Decompression of 1st compartment sheath
(tendon sheath release)
- Determine if there is any instability of
the wrist joint & correct it if present

Pathophysiology

Complications of surgical release:

Infection
Radial n palsy (+ve Tinels)
Snapping of extensor tendon (due to extreme radial release of extensor retinaculum)
APL & EPB tendon adherence (will limit thumb movements)

Extensor Carpi Radialis Brevis (most power extensor of the wrist

Second Compartment
o Pain and point of tenderness just medial to anatomical snuff box
th
Extensor Carpi Ulnaris 6 compartment
o Pain and point of tenderness immediately distal to head of ulnar
Treatment: Splintage and H&L injections usually effective.

NERVES
CARPAL TUNNEL SYNDROME

Pressure on nerve blood flow obstruction in vasa nervorum venous

congestion & oedema
With time, fibroblast proliferation occurs in the nerve inefficiency of cell
transport mechanisms and the sodium pump n. conduction impairment

Features

OTHER SITES OF EXTENSOR TENOSYNOVITIS

-

Most common cause is IDIOPATHIC! Others include

Anatomical abnormalities
Bone: previous wrist #s (e.g. Colles #), acromegaly
Soft tissues: lipomas, ganglia
Physiological abnormalities
Fluid balance alterations: pregnancy, menopause, hypothyroidism, obesity,
amyloidosis, cardiac/renal failure
Inflammatory conditions: RA, GA
Neuropathic conditions: DM, alcoholism

Symptoms may present at night or with certain activities e.g. driving, reading
newspaper. Pain, paraesthesia numbness over lateral 3.5 fingers. Burning pain &
paraesthesia over median n distribution. Usually occurs at night, waking the patient
up, relieved by shaking arm and/or hanging arm over side of bed.
Late symptoms: Wasting of thenar eminence, weak thumb abduction (autonomic
innervations by median n.), decreased sensation of lateral 3.5 fingers
Tinels & Phalens tests positive
DDx:

o
o
o

Definition

Compression ischaemia of median nerve

Epidemiology

40-50YO
Women > men

Cervical n. root lesions (e.g. cervical spondylosis of C6-7 level, or secondary

to a cervical disc herniation)
Thoracic outlet syndrome
AIN syndrome: entrapment usually at the origin of the deep head of pronator
teres; supplies FPL, pronator quadratus and radial side of FDP inability to
make OK sign but sensory INTACT
Pronator syndrome: compression of median n. by ligament of Struthers
(fibrous band arising from medial epicondyle of humerus, attaches to
supratrochlear spur on the lower anterior humerus), pronator teres muscle or
proximal arch of FDS

Investigations

Anatomical boundaries

Radial side: scaphoid & trapezium

Ulnar side: pisiform & hook of hamate
Volar aspect: trasverse carpal ligament

Nerve conduction studies (to rule out other differentials)

45

Treatment

Non-surgical
NSAIDs
Splinting of wrist in a neutral position (especially at night)
H&L injections just proximal to the carpal tunnel
Surgical
Carpal tunnel decompression (division of flexor retinaculum under tourniquet
control) either as open or endoscopic procedure
Potential complications to be explained to patient
o Scar formation (keloid/hypertrophic scars)
o Scar tenderness post-op
o Failure to relieve symptoms due to incomplete division of flexor retinaculum
o Nerve injury palmar cutaneous n. (lies supf to flexor retinaculum) and
motor branch of thenar muscles (usually leaves the radial side of median n.
towards distal extent of the standard incision) risk of n. injury can be
decreased by making the skin incision on the ulnar side of the palmar crease

X-ray: Narrowing of joint spaces, osteophytes, bone sclerosis, irregularity of carpal

bones, signs of old injuries.

Management: For CMC joint: Corticosteroid injection may help to relieve the
pain and ROM. Everything: Rest, splint, surgery if fracture or if necessary (e.g.
arthrodesis)
o

TRUE [MCQ]

OA of CMC joint of thumb can be treated conservatively / by excision

arthroplasty / by replacement arthroplasty
OA of DIPJ can be treated by arthrodesis

IV. BONE DISORDERS OF WRIST & HANDS

MCQ
Commonest complication of injury in hand fractures is tendon adhesion
But deformity in hand fractures is due to malunion!
COLLES FRACTURE

ULNAR TUNNEL SYNDROME

Compression of ulnar n. as it passes between pisiform & hook of hamate (Guyons

canal)
Clinical features: small muscle wasting, weakness of hand, sensory disturbance on
volar aspect of little finger.
Causes: ganglions, trauma, ulnar artery disease, old carpal or metacarpal #s
DDx: Cubital tunnel syndrome, cervical spondylosis

III. JOINT DISORDERS OF WRIST & HANDS

RHEUMATOID ARTHRITIS
OSTEOARTHRITIS
Primary OA: usually in DIPJ (most common) and Carpometacarpal joint of the
thumb in postmenopausal women. Usually a presentation of polyarticular disease.
Secondary OA: history of trauma or # e.g. scaphoid #, Kienbocks disease
Features: bilateral pain, swelling & tenderness. Usually starts with 1 or 2 fingers,
which usually spreads to all fingers and both hands. Bony thickening around the
DIPJ (Heberdens nodes), PIPJ (Bouchards nodes) & carpometacarpal joint of
thumb. Square hand. ROM & crepitus. In CMCJ OA, tenderness localised to 1
cm distal to radial styloid.

Fracture of radius within 2.5 cm of wrist (deformity) extra-articular #!

Dinner-fork deformity: palmar & ulnar angulation (AUA), dorsal & radial
displacement (DRD) of distal fragment, torsional deformity, DRUJ disruption
(ulnar styloid avulsion or tearing of fibrocartilage)

Mechanism: FOOSH, commonly in elderly osteoporotic women

S/S: wrist pain & tenderness over distal radius, characteristic deformity

X-ray: distal fragment is

o
o
o
o
o
o

Dorsally displaced with dorsal comminution

Dorsally tilted fragment with apex of fracture volar
Supinated
Radially deviated
Shortened
Extra-articular features:

46

Radial height from scaphoid

From head of ulna to tip of

radial styloid

Normal: 11mm
If #: <11mm

Volar tilt

Seen on lateral view

Carpal tunnel syndrome

Delayed rupture

Normal: 22
If #: <20

Reduction
method

Backslab

External
fixation
Post
reduction

Radioulnar joint subluxation

Associated scaphoid #
Comminution of radial fragment
Persisting stiffness

Normal: 11
If #: <11

Management:
Manipulation

Radial Inclination

Indicated if displaced, deformity or angulation present, joint line in

lateral X-ray tilted 10o posteriorly
1. Biers block (IV lignocaine), haematoma block (intraosseous) or GA
2. Disimpaction (distraction): apply traction in line of forearm with
countertraction applied by assistant to flexed elbow
3. Maintain traction with elbow extended
4. Correct anterior angulation & post displacement: apply pressure
anteriorly
5. Correct radial displacement: push distal fragment ulnarwards
6. Correct ulnar angulation by putting wrist in full ulnar deviation
Apply backslab w wrist in full pronation, full ulnar deviation &
slight palmar flexion
Plaster should extend from olecranon to metacarpal heads
Final moulding with pressure over post-lat aspect of distal fragment
If # is unstable

sweaty skin
Mx: physioRx, rest & splintage for pain,
chemical sympathetic blockade if severe
Most common complication
Of the extensor pollicis longus.
Mx: tendon transfer
TFCC tear
Shoulders & fingers

SMITHS FRACTURE (AKA REVERSED COLLES #)

Ant displacement & post angulation of distal fragments due to fall on back of hand
Mx: M&R, splintage with wrist extended, above elbow cast for 6 wks
BARTONS FRACTURE
Distal radial # with fracture line running into the wrist joint; anterior displacement
of distal fragment carrying the carpus with it; a/w joint subluxation (volar/dorsal)

Mx: inherently unstable, therefore require ORIF

SCAPHOID FRACTURE
Accounts for 75% of wrist #
Mechanism of injury: FOOSH with wrist extended. Combination of dorsiflexion &
radial deviation
Blood supply of scaphoid diminishes proximally [supply by dorsal and volar
branches of radial artery]
NB. Rare in the elderly osteoporotic patient [MCQ]

X-ray: Repeat to ensure adequate reduction

F/U: check circulation & assess swelling, complete plaster if swelling
is minimal
Finger, elbow & shoulder exercises

Complications

Malunion / persistent deformity

Radial drift of distal fragment

Sudecks atrophy

Pain, trophic skin changes, vasomotor

instability & osteoporosis due to sympathetic
overactivity - swelling, erythema, warmth,
changing to cyanosis with blotchy, cold &

Clinical Features:

Pain in anatomical snuffbox***

47

o
o
o

Pain over scaphoid tubercle (following course of FCR)

Restriction of thumb movement (not so much the wrist movement)
Axial loading along 1st metacarpal bone also increases the pain

X-ray: often hard to see, 4 views required (AP, lat & 2 oblique), repeat in 14 days if
unsure (# may not be seen in first few days). Usually # is through narrowest part of
bone (i.e. waist); other potential # sites include tubercle and proximal pole #.

COMPLICATIONS OF WRIST FRACTURES

Type a

Type b

Type c

Mx:
Initial Mx

Scaphoid plaster & sling, repeat X-rays in 2 wks

Scaphoid plaster for 6 wks: Fix hand in full pronation, radial

deviation & moderate dorsiflexion. Glass holding position
Plaster to extend from below elbow to just below MCP & IPJ
of thumb. Incorporate proximal phalanx of thumb.
90% should heal.
If still tender and X Ray shows no healing at 6 wks, continue
plaster cast for another 6 wks
Consider internal fixation and bone graft if non-union found
at f/u at 12 wks
Displaced #
ORIF (with compression screw)
Scaphoid tubercle # needs no splintage; treat it as wrist sprain.
Undisplaced #

Cx:

AVN of proximal pole causing secondary radiocarpal OA (X Ray at 2-3

months shows density of proximal fragment) excise scaphoid, consider
arthrodesis of carpal bones
Non-union plaster fixation, internal fixation & bone grafting. Excise radial
styloid if OA threatens
Poor blood supply at proximal part of scaphoid, hence union may take
several months.
Osteoarthritis

Most common complications are poor grip strength, stiffness and radial shortening
80% have normal function in 6-12 months
Early Cx:
O Difficult reduction +/- Loss of reduction
O Compartment syndrome
O EPL tendon rupture
O Acute carpal tunnel syndrome
O Finger swelling with venous or lymphatic block
Late Cx:
O Malunion, radial shortening
O Painful wrist secondary to ulnar prominence
O Frozen shoulder (shoulder-hand syndrome; aetiology unknown)
O Post-traumatic arthritis
O Carpal Tunnel Syndrome
O Reflex sympathetic dystrophy

LUNATE DISLOCATION
Rotation & anterior displacement of lunate
X-ray: crescent moon shape of bone becomes obvious on AP view
Cx: median n. palsy, Sudecks atrophy, AVN (& secondary OA)
Rx: closed reduction under GA + plaster fixation, open reduction if closed
reduction fails
PERILUNATE DISLOCATION
More common than Lunate dislocation
Rest of Carpus displaced backwards
Lunate vs. perilunate dislocation
The key to differentiation between both is what is
centered over the radius. If the capitate is centered over
the radius and the lunate is tilted out, it is a lunate
dislocation (left). If however the lunate centers over
the distal radius and the capitate is dorsal, we are
dealing with a perilunate dislocation (right).
Radiology Assistant, Wrist Carpal Instability

48

SCAPHOID DISLOCATION
Displacement is usually anterior
Rx: closed reduction + plaster fixation in stable position. If instability is present, fix
with K-wires
BENNETTS FRACTURE
Fracture of 1st metacarpal bone with fracture line
extending to the CMC joint
Small medial fragment of bone seen on X-ray. Proximal
& lateral subluxation of 1st metacarpal present.
Rx: closed reduction & plaster fixation
GAMEKEEPERS THUMB
Rupture of ulnar collateral ligament. Also equals to skiiers thumb
Mechanism: forced abduction of thumb (FOOSH, killing of game animals by
breaking their neck in between thumb and finger)
Progressive MCPJ subluxation and impaired grasp results, with tenderness over
medial side of MCPJ. May be a/w avulsion fracture
Rx: Scaphoid cast for 6 wks if minimally displaced. Internal fixation, Sx repair,
MCPJ fusion depending on severity of displacement / tear.
BOXERS FRACTURE
At 5th metacarpal (picture on the right)
60 degree flexion at fracture site acceptable. Dropped
knuckle deformity permanent.
METACARPAL SHAFT FRACTURE
Mostly stable and undisplaced.
If displaced, need ORIF with plates or K-wire. Make sure
that there is no rotational deformity. Otherwise will have
scissoring of fingers on flexion.
RUGGER JERSEY FINGER
Results from forceful hyperextension of DIPJ with FDP in
maximal contraction (e.g. player grasping the jersey of his
opponent during tackling) opposite MOI from mallet finger
Tendon may rupture directly from its insertion into the
bone, or it may avulse bone fragment from the base of
distal phalanx

Patient usually presents late

Ring finger most often involved (75%)
Pain & tenderness over volar distal finger, finger lies in slight extension relative to
other fingers in resting position

Acronym: ReaCTeD
H & L INJECTIONS
Common hand indications: Trigger finger, De Quervains tendosynovitis, CTS, RA
Up to 2 injections on the same digit (interval of at least 3 months)
Complications: tendon rupture
BRACHIAL PLEXUS LESIONS
Types
Lesions in continuity more than half of plexus injuries. Traction commonest
cause. Nerve roots affected postganglionic. Treatment is expectant.
Lesions with ruptured nerve roots only surgical intervention can offer any hope of
recovery
Complete avulsion lesions nerve avulsed from cord (both dorsal n ventral roots
ruptured) as opposed to brachial plexus injuries where dorsal roots are spared.
Partial avulsion dorsal roots spared thus muscle paralysis with preservation of
sensation
Long standing plexus lesions
Erbss palsy (C5 C6, sometimes c7) overweight babies with shoulder dystocia at
delivery (upper obstetrical palsy); waiters tip deformity shoulder internally
rotated, elbow extended, wrist flexed n pronated. N to rhomboids and long thoracic
N spared.
Klumpkes palsy (C8, T1) lower obstetrical palsy; intrinsic muscles wasted,
clawhand, sensory loss on medial side of forearm n wrist, commonly a/w Horners
syndrome because T1 is affected.
T1 root only wasted intrinsic muscles, sensory loss on medial side of hand,
(incomplete lower obstetrical palsy, cervical spondylosis, neurofibromatosis, CA)
Acute traumatic lesions commonest mechanisms - depression of shoulder with lat
flexion of the neck to opposite side or traction of arm will find bruise on lateral
jaw, inferior jaw and on shoulder.
o Might have subclavian artery trauma

49

SEDDONS CLASSIFICATION
1.

2.

3.

Axonotmesis: loss of the relative continuity of the axon and its covering of
myelin, but preservation of the connective tissue framework of the nerve

Distal wallerian degeneration occurs.

Loss in both motor and sensory fnx is more complete with axonotmesis
than with neuropraxia,

Usually the result of a more severe crush or contusion than neuropraxia.

Regeneration requires a number of weeks.

Neurotmesis:

Occurs on severe contusion, stretch, lacerations.

Surgical repair essential and quality of recovery always imperfect. For

neurotmesis is better to use a new, more complete classification, , called
Sunderland System

Wallerian Degeneration: degeneration

of axons distal to sight of transection
(resorbed by phagocytes)

SUNDERLAND SYSTEM

Neuropraxia: mildest for nerve injury. an interruption in conduction of the impulse

1.
down the nerve fiber with axonal continuity conserved
2.

Likely a biochemical lesion caused by concussion /shock-like injuries to the fibres.

3.

Recovery takes place without wallerian degeneration.

Temporary loss of function reversible within hours to months of the injury (the
average is 6-8 weeks). (not the 1mm/day rule).
Nerve

Frequently greater involvement of motor than sensory function with

autonomic function being retained.
Brachial plexus

First-degree: "Seddons neuropraxia"

Second-degree: "Seddons axonotmesis"
Third-degree: endoneurium disruptured, epineurium & perineurium intact

Thus, when the axons regenerate, they may enter an incorrect nerve sheath,
resulting in abnormal regeneration.
Site of Entrapment

Provocative Test

Supra/infraclavicular

Arm elevation
Pressure between the scalene muscles

Radial nerve

Distal forearm

Forearm pronation + wrist ulnar deviation

Pressure over tendinous junction of ECR and brachioradialis

Ulnar nerve

Median nerve

Cubital tunnel

Elbow flexion + pressure on cubital tunnel region

Guyon's canal

Pressure at Guyon's canal

Proximal forearm

Forearm supination + pressure on pronator teres

Carpal tunnel

Wrist flexion and/or extension with pressure proximal to carpal tunnel

Accompanying the loss of the nerve sheath is intraneural scarring, which further
obstructs axonal regrowth through the site of injury.

Recovery may range from poor to complete and depends on degree of

intrafascicular fibrosis;
Fourth-degree: interruption of all neural and supporting elements; epineurium intact; the
nerve is usually enlarged.
Fifth-degree: complete transection with loss of continuity. Grade V corresponds to
Seddon's classification of a neurotmesis lesion

MCQ: Worst nerve injury (after surgical intervention) traction injury

4.
5.

ZONES OF THE HAND

Zone 2 is no mans land.

Return of function is difficult in Zone I because of short stump of FDP

50

IMPORTANT ORTHOPAEDIC CONDITIONS IN THE HIP

PELVIC FRACTURES

Most common fracture involves pubic rami, followed by ilial, ischial, acetabular,

coccygeal and sacral bones

Tile Classification

Type A

Type B

Type C

Type A: stable, minimally displaced, includes avulsion fractures and fractures not
involving pelvic ring, e.g. rami fracture
Type B: partially unstable, rotationally unstable, but vertically stable, e.g. open
book fracture from external rotational force to pelvis
Type C: unstable, rotationally and vertically unstable, associated with rupture of
ipsilateral ligaments, e.g. vertical shear fracture

Treatment
ABCs
Assess genitourinary injury (rectal
exam/vaginal exam mandatory)
Type A - bedrest and mobilization
w walking aids
Type B/C - external or internal
fixation
Complications
Hemorrhage - life threatening
Fat embolism
Bladder/bowel injuries
Neurological damage
Obstetrical difficulties
Persistent sacro-iliac (SI) joint pain
Post-traumatic arthritis of the hip with acetabular fractures
[MCQ] Trendelenburg test is a test of stability of pelvis on femur

APPROACH TO HIP PAIN

Diagnosis
History of injury, high energy trauma
Examination reveals local swelling, tenderness; if
unstable, may have
Deformity of the hips and instability of pelvis with
palpation
X-rays (i.e. AP, inlet, and outlet views) judet view
for acetabular fractures

CAUSES OF PAINFUL HIP

6 lines to look for in a pelvic X-ray specifically

looking for acetabular fracture
1. Iliopectineal line anterior column of pelvis
2. Ilioischial line posterior column
3. Acetabular teardrop should in line with
ilioischial line
4. Dome superior weight bearing area costing
of both ant and post column
5. Ant wall of acetabulum
6. Post wall of acetabulum

1. Site of pathology

Referred pain
Joint disorders

Periarticular
disorders

Discogenic dz
Infection Perthes dz
OA
Osteonecrosis
RA
Hernia
Tendinitis

Slipped capital femoral epiphysis

Bursitis / synovitis

HISTORY AND PHYSICAL EXAMINATION:

- Hip pain (anterior) usually at groin
- Pain at gluteal region (posterior) usually lumbar pathology

2. Cause of pathology

Vascular:
Infection:
Trauma:
Autoimmune:
M
I

Perthes disease, AVN

OM, TB, Transient synovitis
OA, dislocation, fracture
RA

51

- N
- Congenital:

SCFE, CDH

3. Look for predisposing factors e.g. Osteoporosis and fall risk

4. Look for complications of pathology
5. Assess premorbid status (goal for mgmt is to regain premorbid status)

Medial gap the greater the gap, the greater the possibility of dislocation
Neck/shaft angle (normal 120-135; <120 coxa varus, >135 coxa valgus)
4. Other neighbouring structures
Acetabular margins
Sacroiliac joint
Joint space
Ischium

6. Assess carer support

COMMON HIP DISORDERS BY AGE

<1YO
1-5YO
5-10YO
10-20YO
Adults

CDH
Transient synovitis (commonest cause of hip pain in child)
Septic arthritis
Perthes disease
Juvenile Chronic Arthritis
SCFE
OA, AVN, RA

FEATURES OF AP HIP X-RAY TO NOTE

1. Any fractures
Neck of femur (subcapital, transcervical, base of neck)
Intertrochanteric
Subtrochanteric
2. Quality of bone
Bone texture
Density of femoral head
3. Lines
Shentons line broken in

Congenital dislocation of hip

Posterior dislocation of hip

Pathological dislocation of hip

Tom-Smith arthritis (septic arthritis of the hip in infants which destroys

the whole head of femur)
Not broken in impacted NOF #
Perkins line (line drawn along lateralmost aspect of acetabular roof) &
Hilgrenreihners line (line drawn horizontally through superior aspect of the
triradiate cartilages) both lines are perpendicular to one another. Femoral
head should be in the inner lower quadrant of both these lines.
Acetabular index should be low (want acetabulum to hug femoral head)

GAIT ANALYSIS
Normal Gait
1. Stance phase = heel strike + mid stance + push off
2. Swing phase = acceleration + initial swing + midswing + deceleration
Type of gait
Antalgic
Trendelenburg

Notes
Short stance phase
Sound side sags

Short leg

Ipsilateral hip
drops when weight
is on short leg

Adductor lurch
Toe to heel
High steppage
Broad based
Parkinsonian /
festinant
Spastic
(scissoring)

Foot lands flat or

on ball instead
Small shuffling
steps
Jerky, feet in
quinus, hips
adducted

Causes
Pain (infxn, inflammation, transient synovitis)
Contralateral abductor weakness, hip
dislocation/ subluxation, short NOF, hip pain
Previous # or congenital shortening
Hip dysplasia, CP
CP, club foot, idiopathic
Proprioception loss, foot drop (damage to L5;
common peroneal n. palsy)
Ataxia (cerebellar lesions)
Parkinsons disease
UMN lesion e.g. cord compression, multiple
sclerosis or CP

52

CONGENITAL DISLOCATION OF
DYSPLASIA OF THE HIP (DDH)

THE

HIP (CDH) / DEVELOPMENTAL

Features

Easily dislocatable hip secondary to shallow acetabulum usually posterior &

superior dislocation
1 per 1000 live births (common enough for it to be screened by neonatologists)
Girls > boys
Bilateral in 30%
Risk factors
o 1st female child
o Family history
o Breech delivery
o Condition predisposing to crowding of uterus (multiple pregnancies,
oligohydramnios, fibroids, baby too big, mother too small)

U/S not done at birth because laxity of hip joint, may get spurious reading
at birth (in order for baby to come out of birth canal) hence earliest U/S
is at 6 weeks
When to do U/S
For high-risk cases (e.g. positive family history / extended breech delivery)
/ hip laxity / hip clicks
To ensure concentric stable reduction after treatment
Weekly after with splint to ensure reduction and correct
application of splints
Every 6 weeks after once hip reduced
Most effective <3 months old (3 months onwards: X-rays; must
ensure concentric reduction with good acetabular cover, if not
mechanical forces of hip not evenly distributed may get OA)

Mx

1. Watch

Possible causes:

Intrauterine malposition
(a/w breech presentatn)
Tight iliopsoas

Postnatal posture (hip

extension)
Hypertrophic lig teres
Hourglass capsule

Shallow acetabulum
(acetabular dysplasia)
Fibrous tissue in
acetabulum

Repeat U/S at 4-6 weeks

If hips reduced and stable, no further Rx
Otherwise treat as DDH

Physical examination:

Assymetrical skin creases, short limb, internally rotated, hip abduction ROM
Ortolanis test (tests reducibility) impeded hip abduction + clunk as dislocation
reduces
Barlows test (tests dislocatability) dislocate the hip by flexing the hip joint and
adducting it followed by posterior force in the line of the shaft of femur.
Trendelenburgs test positive
Ix

U/S Hip

Abnormal acetabular shape and femoral head position

X-ray

Abnormal sloping of acetabular roof

shallow acetabulum
small underdevted femoral head
femoral head displaced upwards & outwards

Diagnosis is CLINICAL
U/S or X-rays can be used but both are NOT used to diagnose at birth
X-ray: radiation + hip is not ossified

Observe if
Hip laxity only
Hip clicks

2. Abduction
splint /
Pavlik
harness

When to watch instead of intervening for DDH?

When you are not sure of the diagnosis.
0 to 6 months
Abduction splint (old mtd) or Pavlik Harness
Repeat U/S in harness after 1/52 and out of harness at 6/52
Worn for at least 3 months until 1st X-rays
If X-rays show concentric hips with good acetabular cover,
then wean off splints

For Pavlik harness:

- Human position: 50deg of abduction of each side and 100deg of
flexion (preferred position)
- Frog position: entire hip down at 90deg, can cause AVN (femoral
head very sensitive to tension)
53

3. Close
reduction
& hip
spica

0 to 6 months
If unable to achieve stable reduction with splints then closed
reduction and hip spica attempted

BEFORE

4. Open
reduction
& hip
spica

Acetabular surgery (Salter osteotomy)

- Done at 2yo
- In Salters osteotomy the entire acetabulum, together with the pubis and ischium, is
rotated anteriorly and laterally as a unit, with the symphysis pubis acting as a hinge.
The osteotomy is held open anterolaterally by a wedge of full thickness bone graft,
usually taken from the anterior part of the iliac crest
- Osteotomy redirects entire acetabulum so that its roof covers femoral head both
anteriorly and superiorly
- In young children, the acetabular deficiency is usually anterior, and therfore the
Salter Osteotomy is designed to provide coverage anteriorly at the expense of
posterior coverage;
- Success of procedure depends to some extent on the flexibility of the symphysis
pubis (which decreases w/ age)
- Importance of screening so as to intervene earlier

AFTER

Decreased joint space after reduction

6 to 12 months
Closed reduction can still be attempted but more difficult to
achieve stability
Open reduction then done
12 to 18 months
Child is already weight bearing
Open reduction usually involves femoral derotation and
shortening
Acceptable is thought to remodel accordingly
Above 18 months
Potential for acetabular remodeling is less
Both acetabular and proximal femoral surgery will be required.

Prognosis

Good results if treated <6yo

For chronic neglected dislocations: reductions usually not attempted if
o >8yo for unilateral (no more remodelling past 8yo :. reduction may cause OA)
o >5yo for bilateral
Consequences of not reducing
o Partially dislocated (formation of false joint) progressive deformity,
disability & secondary OA hip
o Completely dislocated will have Trendelenburg gait, cost of energy to walk
will be high hence not ideal (have to sit on side back pain, will get
scoliosis
o Bilateral: waddling gait, hips dislocated behind so nothing to hold pelvis in
between, would get lordosis
o ALL will walk assuming muscles and nerves are functional
54

DISLOCATION OF THE HIP

Mainly seen in artificial hips
Cause

Pyogenic arthritis

X-ray

Absent femoral head

Management

Traction, open reduction, varus

osteotomy of femur

Muscle imbalance

Valgus femoral head

As for CDH + muscle rebalancing

operation

Trauma

Look for associated

acetabular rim #

Reduction, ORIF if rim # present

Myositis ossificans
Knee injury
Coxa magna (occurs in up to 50% of children after a hip dislocation)

PERTHES DISEASE (COXA PLANA)

Features

Femoral head necrosis secondary to disturbance in blood supply

4-8YO, boys:girls = 4:1, 5-10% bilat
DDx: non-specific transient synovitis
Precipitant: effusion, trauma or synovitis occluding blood supply to femoral head

Dislocation after Total Hip Arthroplasty (THA)

Stages (similar to AVN classification)

Posture

Stage 2: revascularisation & repair. X-ray shows bone density

Stage 3: distortion & remodelling. Epiphyseal collapse, flattening or enlargement
may result.

Anterior dislocation: hip flexion, abduction and external rotation [MCQ]

Posterior dislocation: hip flexion, abduction & internal rotation, shortened leg. X-ray
shows smaller femoral head and less prominent trochanter because leg adducted and
internally rotated. [MCQ: AVN is a distinct possibility]

Hip pain & irritation

Limp, shortened leg
Decreased abduction & internal rotation

Treatment

X-ray:

Occurs in 1-4% of primary THA and 16% in revision cases

About 74% are posterior dislocations, 16% anterior and 8% central
THA are unstable in the position of flexion and internal rotation

1. Muscle relaxtion is keyconscious sedation (IV fentanyl) or spinal or GA

2. Assistant applies downward pressure to pelvis
3. Reduction for posterior dislocation Fully flex hip, abduct and externally rotate
hip, apply upward traction on femur
(i)
Known as Bigelows manoeuvre
(ii)
Maintained until patient is pain-free (approx. 2 weeks)
4. Reduction for anterior dislocation Fully flex hip, adduct and internally rotate hip,
apply downward pressure on femur (Barlows equivalent)
Complications

Post-traumatic arthritis due to cartilage injury or intra-articular loose bodies

# femoral head, NOF, femoral shaft
Slipped upper femoral epiphysis
AVN femoral head
Sciatic nerve palsy (esp when rim # is present)
Femoral vein compression causing thrombosis & embolism
Secondary OA hip
Recurrent dislocation

Stage 1: ischaemia causing femoral head bone death. Normal X-ray

Clinical features:

Apparent widening of joint space

epiphyseal density healing & reossification
Flattening, fragmentation & lat displacement of epiphysis
Subchondral fracture
Metaphyseal rarefaction & broadening

Small dense
capital epiphysis

Catterall grading

According to degree of femoral head involvement

Grade

Severity

Prognosis

50 % involvement with a sequestrum

Bony collapse inevitable

~75% involved, with collapse & sequestrum

whole epiphysis involved

Bony collapse inevitable.

Poor prognosis

Involves anterior portion of epiphysis only.

No collapse or sequestrum

Revascularisation may be
complete w/o bone collapse

55

Mx:
Initial

Skin traction until pain resolves

Definitive

Good prognosis:
Onset <6YO
Partial fem head involvement
No metaphyseal rarefaction
Normal fem head shape

No Rx needed

Poor prognosis:
Onset >6YO
Complete fem head involvement
Severe metaphyseal rarefaction
Lateral fem head displacement

Containment of femoral head

Abduction splint OR
varus osteotomy of femur OR
innominate osteotomy of
pelvis

AVN
Coxa vara Rx: osteotomy to prevent secondary OA
Secondary OA
Bilat SCFE: 1/3 of cases

Mx

Manipulation is contraindicated!!!
Displacement <1/3 of
epiphyseal width

Accept position
Epiphyseal fixation with pins

Displacement 1/3 to half

of epiphyseal width

Epiphyseal fixation with pins

Osteotomy: if residual deformity is present even
after remodelling

Displacement >half of
epiphyseal width

Epiphyseal fixation with pins +/- osteotomy

OR Epiphyseal replacement & fixation with pins

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

Epidemiology:

Usually occurs in very tall, fat pubertal (11-15yo)

boys with delayed gonadal development.
Boys > girls
History:

Pain in groin radiation to anterior thigh or knee

(referred)
Limp
Hx of trauma
Physical Examination:

Coxa vara deformity

Externally rotated short leg
Decreased abduction & internal rotation
Pain on movement

X-ray:

Wide & woolly epiphyseal plate

Trethowans sign: femoral head falls below line
drawn along superior surface of femoral neck
(normally cuts through fem head) ice-cream
falling off cone
Complications

PYOGENIC/SEPTIC ARTHRITIS
Epidemiology:

Children <2yo, usually Staph by haematogenous or local spread (from femoral OM)
*** True clinical emergency; if undiagnosed, may result in complications such as
complete destruction of the articular cartilage and the underlying epiphysis, loss of the
adjacent growth plate, and dislocation of the joint ***
Investigations:

Culture blood & joint aspirates

Choice of ABx depending on Gram stain results & culture sensitivities

Management:

Medical
o IV antibiotics (penicillin for strep; and cloxacillin for staph)
o ESR and CRP levels are valuable indicators of clinical response. The CRP is
generally more sensitive than the ESR, and antibiotics should be continued at
least until this measure has normalized.
o Switching to oral antibiotics is also acceptable, provided that adequate blood
levels of the antibiotic are demonstrated, the patients parents are reliable, and
the antibiotic does not cause a gastrointestinal disturbance that would interfere
with its absorption.
Surgical
o Consider septic joint to be a closed abscess :. Dont expect ABx alone to work
56

Perform repeated percutaneous joint aspirations in cases of involvement of an

easily accessible peripheral joint; a clinical course shorter than 6 days; and no
evidence of an associated OM, immune deficiency, or other chronic illness
o If the patient's condition fails to improve, perform open drainage in OT
Definitely indicated in the hip and the shoulder and in peripheral joints
that do not respond to percutaneous aspiration.
Indicated in patients who are systemically ill, and it should be given
greater consideration when the suspected organism is S aureus or a
gram-negative bacterium that produces cartilage-damaging enzymes.
(Gonococcal arthritis less likely to rapidly damage a joint :. may be
managed with repeated aspirations if the joints involved are peripheral.
Open drainage should still be performed in cases of gonococcal
arthritis of the hip.)
o If treatment was significantly delayed, substantial capsular damage may have
occurred. If instability is suspected, immobilize the patient for a longer period.
A neglected septic hip with radiographic instability requires a spica cast, and an
unstable shoulder requires a sling and swathe.
Follow-up (at least up to 1 year after surgery)
o Whether joint function has returned to normal
o No radiographic evidence suggestive of loss of joint space, AVN of the
epiphysis, joint instability, or damage to the growth plate
o

TB HIP
Groin / thigh pain, limp, muscle wasting, limb shortening, hip deformity, ROM
X-ray:

General rarefaction
Femoral epiphyseal enlargement
Bone abscess
Articular destruction
Healing by fibrous ankylosis

Management:

Anti-TB drugs
Skin traction
Evacuate abscess, joint debridement
Arthrodesis or joint replacement if joint is destroyed

RA HIP
Multiple joint involvement, groin pain, limp, & painful movement
X-ray:

TRANSIENT SYNOVITIS
Epidemiology: boys 2x more than girls, 3-10yo; commonest cause of irritable hip
History
o Unilateral groin/hip pain
o Very young children: no other symptoms except crying at night
o Recent Hx of URTI, pharyngitis, bronchitis or otitis media (in >50% of cases)
o No definitive cause known
Physical examination
o Antalgic gait
o Tenderness during palpation even during passive movement
o Mild restriction of motion (in 2/3 of patients)
o Log roll (most sensitive test): detect involuntary muscle guarding of one side
compared to the other
Treatment
o Apply heat & massage
o Bed rest for 7-10 days in a position of comfort
o Medications: NSAIDs (naproxen/ibuprofen)

Osteoporosis
Decreased joint space
Periarticular erosion and bone destruction
Management:

Total hip replacement

OA HIP
Causes:

Young adults

Congenital subluxation
Perthes disease
SCFE Coxa vara,
Acetabular deformities / injury

Older adults

RA,
AVN,
Pagets dz,
Primary OA
57

Clinical features:

More common in Caucasians (in Caucasians, OA hip > OA knee; in Asians, OA knee
> OA hip)
Groin pain radiation to knee
Joint stiffness due to synovial hypertrophy & capsular fibrosis
Limp, Trendelenburg positive
Fixed flexion deformity
Leg in ext rotation & adduction posture
Decreased ROM
X-ray:

Decreased joint space

Subarticular sclerosis
Cyst formation
Osteophytes (elephant trunk osteophytes)

Management:

Analgesics
Physiotherapy
Walking aids
Surgery: Osteotomy, arthroplasty

AVASCULAR NECROSIS OF THE HIP

AETIOLOGY / PREDISPOSING FACTORS:
Traumatic
Atraumatic

Neck of femur fracture

Fracture-dislocation or dislocation of the hip joint
Iatrogenic
Glucocorticoid use, including TCM (causes two things: 1) changes in
circulating lipids microemboli; 2) changes in venous endothelium
stasis increased intraosseous pressure necrosis)
Alcohol
Congenital
Perthes disease
SCFE-associated AVN
Inherited thrombophilia e.g. Factor V Leiden
Immunocompromised states
Systemic lupus erythematosus (3-30% of SLE patients get AVN;
SLE+steroids highest risk)
HIV

Transplant surgery
Others
Antiphospholipid antibodies
Gaucher disease (hereditary, autosomal recessive disease of
glucocerebroside metabolism, results in accumulation of cerebrosidefilled cells in bone marrow)
Decompression disease (Caisson disease) nitrogen bubbles
Sickle cell disease

PATHOGENESIS
Multifactorial, involving
(a) Metabolic factors
(b) Local factors affecting blood supply to bone
- Vascular damage
- Increased intraosseous pressure
- Mechanical stresses
Summary of various pathogenetic mechanisms
1) Arterial supply interruption:
- Fracture
- Dislocation
- Infection
2) Arterial occlusion:
(intra-vascular occlusion / venous stasis & regrograde arteriolar stoppage)
- Sickle cell disease
- Vasculitis
- Caisson disease
3) Capillary compression: (by marrow swelling)
- Steroids
- Gauchers disease
Begins with interruption of blood supply hyperaemia of surrounding area
demineralisation, trabecular thinning collapse of bone with mild stress
CLINICAL FEATURES
Usually affects anterolateral femoral head
Other bones that can be affected: humeral head, femoral condyles, proximal tibia,
vertebrae, small bones of hands and feet scaphoid, talus
Commonly presents with pain
- Weight-bearing and motion-induced pain in most cases
- Rest pain occurs in two-thirds of patients, and night pain in one-third
58

Surgery

IMAGING
(a) Plain films

Earliest findings are mild density changes (plain XR may be normal for months
after symptoms begin)
Sclerosis, cysts in subsequent part of disease
Pathognomonic crescent sign subchondral lucency (evidence of subchondral
collapse)
Later stages: Loss of sphericity or collapse of femoral head
Ultimately joint space narrowing, degenerative changes in the acetabulum result

(b) MRI

98% sensitivity for diagnosis

Changes can be seen early in the disease when other investigations are negative
Earliest finding is a single low-density line on T1 weighted scan that represents
the separation between normal and ischaemic bone
A high-intensity line on T2 weighted images represents hypervascular
granulation tissue pathognomonic double-line sign (low-density line plus
high-density line)

DIAGNOSIS
Clinical, based on typical symptoms with compatible findings on imaging
Rule out other causes of pain and bony abnormalities
FICAT-ARLET STAGING
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4

Hip-at-risk
CT scan and XR normal
Positive findings on MRI or biopsy
XR changes seen but no collapse
Early flattening of dome crescent sign
Flattening of femoral head with joint space narrowing
Signs of early OA

TREATMENT
Conservative (ineffective at halting progression)

Bed rest
Partial weightbearing with crutches
NSAIDs or other analgesics
Bisphosphanates slows resorption of necrotic bone

(a) Core decompression with or without bone grafting

Centre of head of femur is excavated
Fibular graft or other formed graft is used to fill up the cavity
Used in stage 0 to 2 disease in young and active patients best chance of
preserving femoral head
(b) Osteotomy
Joint-sparing redistributes weight-bearing forces to articular cartilage which is
supported by healthy bone
For late stage 2 disease with cyst formation, and stage 3 disease
(c) Resurfacing arthroplasty
(d) Total hip replacement
For stage 4 disease and in older sedentary patients with not so severe disease

PROXIMAL FEMORAL FRACTURES SUMMARY

DDX OF HIP FRACTURES:
Pubic ramus fracture
Acetabular fracture
Isolated fracture of greater trochanter
Trochanteric bursitis/ contusion
BLOOD SUPPLY OF FEMORAL NECK***

Extent of dz:
A: <15%
B: 15-30%
C: >30%

Nutrient artery of femur

Retinacular Arteries (from medial and lateral circumflex arteries)
Artery through ligamentum teres (from obturator artery)
In NOF fracture
- Nutrient artery severed
- If significant displacement, retinacular vessels severed AVN
- Only ligamentum teres vessels remain

PREDISPOSING FACTORS
Nonmodifiable

Old Age
Early menopause
Female Sex
Nulliparity
Caucasian
Family/Personal History of fractures
59

Modifiable

Anything that causes increased risk of falls, e.g.

Poor vision, vestibular dysfunction
LL weakness
Hazards at home
Significant co-morbitidies e.g. CCF, CVA
Reduction of bone strength
Osteoporosis, low Ca intake
Steroids, alcohol, smoking, thyroxine, increased/decreased T4
Physical immobility
Pathological bone conditions
Chronic liver and renal failure

HISTORY
Fall

How pt fell e.g. landed on bum

Pain, tenderness, deformity
Can walk? (If yes impacted [Garden 1] fracture, which

is undisplaced need to admit to prevent progression to

displaced fracture which has poorer prognosis)

What happened
before fall

[hazards at home]

Predisposing
factors to fracture

Modifiable
Non-modifiable

Comorbidities
Premorbid functional status
Osetoporotic Risk Factors

Radiological
Preop

Analgesia
Antibiotics if infection suspected
Pre-op traction for pain relief and to ensure union takes place in a good position
Thromboembolism prophylaxis (SC heparin 5000 units BD)

TYPES OF FRACTURES ACCORDING TO SITE

Intracapsular

NOF
Other

Extracapsular

INVESTIGATIONS
Confirm diagnosis, determine severity
Pre-operative investigations

Subcapital
Transcervical
Basal
Intertrochanteric
Pertrochanteric
Involves the trochanter(s) which are themselves
fractured

GARDEN CLASSIFICATION OF NOF FRACTURES

Undisplaced

PHYSICAL EXAMINATION
Shortened
Externally rotated
[MCQ] # of proximal half: flexion & abduction
Bruising (suggest extra capsular #)
Tenderness over femoral neck
Painful limited hip movements

AP Pelvis (not hip)

Lateral XR of affected hip joint
FBC
U/E/Cr
PT/aPTT
urinalysis
GXM
CXR
ECG

INITIAL MANAGEMENT

2
3

Displaced

Inferior cortex not completely broken

Fracture line not complete
May have some angulation of trabeculae
Inferior cortex completely broken
Fracture line complete
Minimal displacement
Inferior cortex completely broken
Fracture line complete
Significant displacement
Head internally rotated, abducted (distal fragment externally rotated)
Inferior cortex completely broken
Fracture line complete
Complete displacement
Head retains neutral position in acetabulum
60

WHO FRACTURE RISK ASSESSMENT TOOL (FRAX)

-

Developed by WHO to evaluate fracture risk for patients

Gives 10-year probability of hip fracture and the 10-year probability of a major
osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture).
o For local Chinese: use Hong Kong Chinese
o For local Indians: use US (Asian)
Disadvantages
o Cannot calculate for patients <40yo
o Does not take into account type of fractures, number of fractures
o Does not tell you who to treat still rely on clinical judgement
Website: http://www.shef.ac.uk/FRAX/faq.jsp
Risk factors used:

MANAGEMENT
-

Conservative: if undisplaced, clinically stable & ROM is full and painless

Total hip replacement: for OA hips, pathological #, acetabular involvement, or
revision hip

For NOF #:

<60yo
>60yo

Gardens 1, 2
Gardens 3, 4
Cancellous bone screw [PRESERVE HEAD]
Cancellous bone screw (~65yo)
Hemiarthroplasty
Hemiarthroplasty (uni/bipolar) (~90yo)
Total hip replacement

Ultimately depends on patients pre-morbid ADL status & his/her aims, probability of
successful op & risks of requiring a 2nd operation
-

Sample of questionnaire:

For Intertrochanteric / Pertrochanteric

Internal fixation with a dynamic hip screw will suffice usually. Unless it is a
reverse oblique fracture.
[MCQ] If treated conservatively, will result in MALUNION

61

NOTE: Total Hip Replacement involves replacement of the acetabulum also, usually
reserved for patients with OA, pathological fracture, revision of implant will see on
X-ray that acetabulum is metal as well, with screws going into hip bone

Physiotherapy

Preserve joint movement

Restore muscle power
Assess what type of mobility aids needed

Treat osteoporosis and comorbidities

Thompson
(has neck, no holes,
needs cement)

DHS Plate
and Screw

Austin Moore
(has 2 holes, no neck,
doesnt need cement)

Moores has a short neck, thus used for subcapital and mid-neck fractures; Thompson
has longer neck, used for fractures near base of NOF
Thompson better for osteoporotic patients
Lifespan: about 10 yrs [must explain to patients before and after op that lifespan varies
between patients if you have no symptoms past 10 years, you need not replace it
immediately]
Material: ultra high molecular wt polyethylene and surgical grade stainless steel
HIP ARTHROPLASTY
Hip Arthoplasty

Hemi arthroplasty
(Only femoral component)
Total Hip replacement (THR)
(Femoral & acetabular component)

COMPLICATIONS OF TOTAL HIP REPLACEMENT

Intraoperative
Immediate
(within 24h)
Early (within
30 days)

Bipolar arthroplasty
Unipolar arthroplasty
(Moores & Thompson)

AFTER-CARE:
Weight
bearing

COMPLICATIONS OF FEMORAL FRACTURES

Non-union in 30%
Redisplacement
AVN in intracapsular NOF #, rarely occurs in intertrochanteric
- Undisplaced 10-30%
- Displaced 50-80%
- Rx: total hip replacement
Erosion of femoral head in unstable IT fractures causing coxa vara
Complications: delayed union, non-union, malunion (coxa vara), OA

Implant
Try and get pt to sit up by 24h, walk by 72h
Internal fixation
Sit up by 24h
Encourage mobility with non-wtbearing (wheelchair)by 72h
Do not weight bear until healing of # occurs, if not high risk of
cutout

Late
(>30 days)

Perforation/# of the acetabulum or femur

Dislocation (due to incorrect placement of the prosthetic
components)
Infection
DVT (most common complication) / PE
Fat embolism
Sciatic n. palsy (more common in the posterior surgical approach
to the hip joint)
Infection
Heterotopic ossification
Disuse osteoporosis
Tissue atrophy
Implant failure
Wearing of articular surfaces (esp acetabulum for unipolars)
Loosening
Erosion, cut-out etc
Peri-prosthetic #

POST-OP MANAGEMENT
Use GS principles
Ask about relevant social history & family support
Management of post-op DVT
62

o
o
o

Pre-op: thromboembolic deterrent (TED) stockings fitted pre-op

Peri-op: TED stockings, minimize duration of surgery, use compression boots
& foot pumps
Post-op: low dose of LMWH, early mobilization of patients with the help of
physiotherapists

OUTCOME OF NOF FRACTURES

25% mortality at one year
10% bedbound
33% wheelchair bound
33% ambulating + walking aid
Union takes about 3 months

SUBTRONCHANTERIC FRACTURES
least common hip fracture, seen in younger population with high energy injuries
highly unstable
transverse, spiral or oblique fracture passes below lesser trochanter
x-rays show flexed and abducted proximal fragment, from pull of iliopsoas on lesser
trochanter, gluteus medius and minimus on greater trochanter
Treatment
a. obtain a good closed reduction under fluoroscopy on the fracture table
b. internal fixation with intramedullary nail
FEMORAL DIAPHYSIS FRACTURES
high energy (MVA, fall from height, gunshot wounds)
low energy (spiral fracture in children)
high morbidity/mortality (hemorrhage, fat embolism, ARDS, MODS)
blood replacement often required
frequently comminuted with soft tissue trauma
Clinical
a. leg is shortened, externally rotated
b. unable to weight bear
c. assess neurovascular status
d. r/o: open fracture, soft tissue compromise
e. r/o: child abuse with spiral fractures in children
Treatment
o ABCs of trauma are essential

o
o
o
o

Immobilize leg with Thomas Splint

Adequate analgesia
Surgical fixation (intramedullary nail) within 24 hours
high rate of surgical union after 6 to 12 weeks
Early mobilization of hip and knee

SUPRACONDYLAR FEMORAL FRACTURE

high energy, multiple trauma
knee joint is disrupted severely with bicondylar fracture
distal fragment moves posteriorly due to pull of gastrocnemius
poor prognosis with comminuted fractures
can be intra or extra articular
high incidence of post-traumatic arthritis
Treatment
o internal fixation and early knee ROM
o if conservative treatment need pearson knee piece to allow flexion and
thus decrease pull and prevent flexion deformity.
o quadriceps strengthening
INTERTROCHANTERIC FRACTURE OF THE FEMUR
Evans- Jensen Classification
I
2 fragments, undisplaced
II
2 fragments, displaced
III
3 fragments w/o posterolateral support (ie # of the greater trochanters)
IV 3 fragments w/o medial support (ie # of the lesser trochanter)
V
4 fragments
R
Reversed oblique # (prone to displacement)
*Alternative classification: according to number of fragments + reversed oblique #

63

IMPORTANT ORTHOPAEDIC CONDITIONS IN THE KNEE

KNEE DDX
Lump

Pain
Generalised
OA
RA

Deformity

Instability

Anterior
Posterior
Lateral
Osgood-Schlatter dz
Bakers cyst
Meniscal cyst
Housemaids knee
Popliteal cyst
Clergymans knee
Popliteal aneurysm
Chondromalacia
Meniscal tear
patellae (CMP)
(med & lat)
Patellofemoral OA
Osteochondritis
dissecans (OCD)
Meniscal disorders
Tendinitis
Bursitis
Osgood-Schlatters dz
RA
TB
Recurrent dislocation of patella
Genu varum / valgum
Charcot jt: DM, perineuropathy, tertiary syphilis, tabes dorsalis,
syringomyelia, myelomeningocele
Ligamentous instability (ACL, PCL, med & lat collateral ligs)
Recurrent dislocation of patella
Osteochondritis dissecans
RA

DIFFERENTIALS FOR POPLITEAL FOSSA SWELLINGS (OSCES)

Tissue type
Skin &
subcutaneous
tissues

Pathology
Lipoma

Sebaceous cyst

Artery

Popliteal artery
aneurysm

PE & Comments
- Soft to firm; smooth/lobulated surface
- If large & soft elicit fluctuation
- slip sign
- Elicit which layer lipoma is in e.g. S/C or I/M
(in the latter, the lipoma disappears on m.
contraction)
- Soft to firm; smooth surface
- +/- punctum (present in 50%)
- Attached to the skin, hence does not move
independently from the skin
- 50% bilateral; expansile pulsation
- Comment on diameter (2cm diameter)
- Palpate all LL pulses (distal pulses may not be
palpable if aneurysm is thrombosed)

Vein

Nerve
Enlarged bursae

Cysts

Saphena varix (@
saphenopopliteal
junction)

DVT
Neuroma

Bakers cyst
Popliteal cyst

Gaiter area: look for complications of varicose v.

- Venous eczema
- Lipodermatosclerosis
- Ulceration: active & healed (latter causes
white patch called atrophie blanche)
- Peripheral oedema
Look for varicosities along long saphenous v.
Tourniquet test, Trendelenburg test, Perthes test
E.g. tibial n.
- Above the joint line
- a/w semimembranosus and medial head of
gastrocnemius medially & with popliteus and
lateral head of gastrocnemius laterally
- Below the joint line & deep to gastrocnemius
- a/w degenerative changes in knee joint
Enlargement of popliteal bursa
Knee joint is normal

COMMON KNEE SYMPTOMS

-

locking = spontaneous block to extension

torn meniscus, loose body
pseudo-locking = restricted ROM without mechanical block
arthritis (effusion, pain), muscle spasm following injury
instability = giving out
torn ACL, patellar subluxation, torn meniscus, loose body
traumatic knee swelling
effusion, usually represents hemarthrosis
ligamentous injury with hemarthrosis
meniscal injury
traumatic synovitis
non-traumatic knee swelling without trauma
septic or crystal-induced arthritis
seronegative arthritis (P-A-I-R: Psoriatic, AS, IBD, Reiter's)
seropositive arthritis (RA, SLE)
avascular necrosis (rare)
sickle cell disease

History
- ligamentous injuries require high energy force
- meniscal injury in young & old person requires moderate & mild force respectively
64

X-Rays of the Knee

AP, lateral
weight-bearing
Skyline view
with knees in flexion, beam is aimed from anterior tibia to
anterior femur
allows for view of patellofemoral joint
Tunnel view
Knee bent, can see the hollow between 2 articular surfaces
Oblique
For intra-articular fractures
Erect-leg full- radiograph from hip to foot with patient in standing position
length view
useful in evaluating limb length discrepancies and genu varus /
valgus
Rosemberg
30-40 deg flexed weight bearing view with the x-ray beam
view
tilted caudal to profile the joint line
Best view to visualise loss of medial joint space
MENISCAL TEARS
History & PE:
Mechanism: twisting injury, usually during sports (esp football)
Locking of knee in partial flexion: torn portion of menisci jammed between femur
& tibia, blocking extension. Unlocks with flexion. Suggestive of bucket-handle type
meniscal tear.
Pain, swelling, effusion.
Tenderness: medial meniscal tear (well localized med joint line tenderness); lateral
meniscal tear (ill-defined joint line tenderness)
Course: Symptoms resolves, recurs periodically w twists/strains. Sometimes, knee
gives way spontaneously.
McMurrays & Apleys grinding test positive
Ix:
Arthrography
MRI
Prognosis & Mx:
Outer 1/3 Good vascular supply, good healing.
Attempt operative repair
Mid 1/3
Intermediate vascular supply & healing
Inner 1/3
Avascular, poor healing. Excision required

Cx:
Recurrent synovial effusion & articular cartilage damage due to loose meniscal tag
swelling, OA
MENISCAL CYSTS
Tender & tense swelling arising from outer part of meniscus along the joint line
(usu lateral)
Hx of joint injury may be present
Rx: if symptomatic, arthroscopic decompression or removal
CHRONIC LIGAMENTOUS INSTABILITY
Chronic instability sense of joint wanting to or actually giving way
pain & recurrent swelling
ODonahues triad (aka unhappy triad): ACL tear + med meniscus tear + med
collateral lig tear
ACL injury more common than PCL injury
History

PE
Rx

Post-op physio
impt in all cases

ACL Tear
PCL Tear
o indirect varus blow to knee
o fall onto flexed knee
o hyperextended knee + internal rotation
with plantar flexed foot
o hit anterior tibia on
o audible pop, knee instability
o giving way
dashboard in MVA
o immediate swelling
(dashboard injury)
o hyperflexion
or
o inability to continue activity
o patients with greater Q-angle got
hyperextension
with
greater chance of ACL tear
anterior tibial force
Anterior drawer +
Sag sign +
Lachmans + (falsely +ve in PCL tears)
Posterior drawer +
Apleys distraction test +
Apleys distraction test +
Conservative hamstring & quadriceps ex., physio, external brace
Stabilization / Reconstruction
o Reattachment (tightening of loose lig / capsule),
o Reinforcement (diversion of healthy muscles or tendons to
strengthen weak structures), using hamstrings, patellar,
quadriceps
o Replacement (rerouting living structures or inserting synthetic
material)

65

History

PE

MCL Tear
o valgus force to knee
o +/ "pop" heard
o severe pain with partial tears
o complete tear may be painless

Rx

LCL Tear
o varus force to knee
o similar history to MCL
o rule out common peroneal n.
injury (difficult dorsiflexion
and decreased sensation at the
top of the foot)

swelling
tender above and below medial joint line
Medial & Lateral collateral ligament tears: Valgus & Varus stress
tests + respectively
assess joint space opening with valgus force
o pain
o Laxity with end point - partial tear
o absence of end point - complete tear
o rule out ACL and medial meniscus tear
minor
o immobilize briefly, early ROM and strengthening
moderate
o knee immobilizer or cast (NB. Ligaments take 3/52 to heal)
o early physiotherapy with ROM and strengthening
severe or combined
o surgical repair of associated injuries
o surgical repair of isolated MCL/LCL tear is controversial

OSGOOD-SCHLATTER DISEASE
Traction injury of apophysis which patellar ligament inserts into (partial avulsion of
tibial tuberosity cos of unequal growth rate between patellar ligament and bone)
Tender lump over tibial tuberosity
Pain after activity, usually on active knee extension
Usually young adolescent
X-ray: fragmentation/displacement of tibial apophysis
Rx: Restrict activities especially sports. Spontaneous recovery.
[MCQ] patient doesnt present with loose bodies in knee joint because it is extraarticular!
OSTEOCHONDRITIS DESSECANS
Separation of small osteocartilaginous fragment of condyle articular
usually a/w hx of trauma

PATELLAR FRACTURE
History
Direct - blow to patella (Usually comminuted)
Indirect - sudden strong contraction of the quadriceps femoris against resistance
(Usually a transverse #)
Immediate pain
Physical
Swelling & bruising of knee joint +/- abrasions
Marked tenderness at knee joint
Patellar deformity (+/- palpable gap)
Inability to extend knee
Proximal displacement of patella
X-Ray
AP, lateral (need to exclude bipartite patella - common congenital fragmentation of
the patella)
Treatment
Isolated vertical fractures - non-operative treatment - plaster cast 6/52, early ROM
Transverse displaced fracture ORIF with wires.
Comminuted fracture - ORIF; may require complete or partial patellectomy
Indications for surgical tx
o sig articular step-off > 2mm
o loss of extensor mechanism with displacement > 3mm
o open #
RECURRENT DISLOCATION OF THE PATELLA

surface,

Intermittent ache or swelling, locking, giving way, effusion

15-20yo, Bilateral in 50%, male > female
X-ray tunnel view: Loose fragment in joint, crater on the medial femoral condyle
Rx: removal of small fragments, fixation of larger fragments, cast for 6 wks.

Girls > Boys

Usually bilateral
Apprehension test +: Lateral dislocation of patella if quadriceps contract when knee
is in flexion. Results in pain and inability to extend knee.
Predisposing factors: lax ligaments, abnormalities of patella (high, low or lateral) or
lat fem condyle, genu valgus, tibial tubercle mal-alignment

66

Mx
Reduction & backslab
Quadriceps strengthening exercise
Operation: repair of torn medial structures / soft-tissue realignment / transposing
patellar ligament medially (realignment procedure)
PATELLAR/QUADRICEPS TENDON RUPTURE

Low energy injury, sudden forceful contraction during attempt to stop fall
Partial or complete
More common in patients with DM, SLE, RA, steroid use
History
o fall onto flexed knee
o inability to extend knee
Physical
o palpable gap between patella and quadriceps
o may have hemarthrosis / effusion of knee
Investigations
o knee radiographs to rule out patellar fracture
o joint aspirate may show hemarthrosis
Treatment
o surgical repair of tendon

DISLOCATED KNEE

Bad high energy injury

Can be anterior (most common), posterior, rotatory or lateral
Associated injuries
o popliteal artery (immobile due to geniculate arteries and the anterior tibial
artery going thru hiatus in interosseous membrane) intimal tear or disruption
in 35-50%
o capsular, ligamentous and common peroneal nerve injury
Investigations
o Angiogram, doppler
Treatment
o closed reduction, above knee cast x 4 weeks
o alternately, external fixation especially if vascular repair
o surgical repair of all ligaments if high demand patient
Cx : ischemia, peroneal nerve injury, compartment syndrome, reperfusion injury,
stiffness

CHONDROMALACIA PATELLAE
Anterior knee pain in adolescent girls worse on climbing stairs
Retropatellar tenderness, friction test +, effusion
Chronic / recurrent overload of patellar articular surface due to malcongruence of
patellofemoral surfaces OR abnormal tracking of patella during flexion/extension.
A/w development of OA
Ix: skyline views of patella, CT, arthroscopy
Rx:
Conservative: analgesics, reduce activities, physioRx, quadriceps-strengthening
exercises
Operative: shaving of articular cartilage, arthroscopy lavage, realignment of patella,
patellectomy
RHEUMATOID ARTHRITIS
Stage 1 (synovitis) pain, chronic swelling, large effusion, thickened synovium
Stage 2 (articular erosion) joint instability, ROM. X-ray: loss of jt space &
marginal erosion, but lack of osteophytes c.f. OA
Stage 3 (deformity) pain, deformity, instability & disability. X-ray: bone
destruction
Rx:
Conservative splintage, intraarticular steroid injection
Operative osteotomy, TKR
BAKERS CYST
Definition
o Posterior herniation of knee joint capsule
o Leading to escape of synovial fluid into the posterior bursae, stiffness &
knee swelling (fluid distention of the gastrocnemio-semimembranous bursa)
o Common in children, occurring more often in boys
o Often a/w OA and Charcots joints
o Important to rule out DVT, but the two can co-exist
Diagnosis
o PE: swelling usually below the joint
Fluctuant
Transillumination possible
Non-tender
Positive slip sign it is a deep structure.
67

Reducible only if connected to knee joints which not all bakers cysts
are especially in children.
o U/S: fluid between semimenbranosus & medial gastronemius tendons in
communication with posterior knee cyst (100% accuracy)
Because of their anatomic location, Bakers cysts can increase risk of DVT
o Most commonly, the Baker cyst is located between tendons of the medial
head of the gastrocnemius and the semimembranous bursa. Occasionally,
the Baker cyst can be found between the heads of the gastrocnemius
muscles. This can result in a lateral deviation of the popliteal vein, and a
compression of the popliteal vein-predisposing to venous stasis and DVT
Treatment
o In children, surgical excision of popliteal cysts is rarely indicated
Usually spontaneous resolution of cysts in 10-20 months;
A prolonged period of observation is strongly recommended before
surgical excision is considered.
In protracted cases, cysts may respond to aspiration and steroid
injection, (note that unlike adults, the cyst may not be intra-articular
and therefore may respond to aspiration
o In adults: reoccurrence is common, even following surgical removal, and
therefore treatment is directed toward intra-articular pathology;

POPLITEAL CYST
Definition
o Cyst located on the medial side of popliteal fossa, just distal to flexion
crease of the knee, under medial head of gastrocnemius
Epidemiology
o Found in children & young adults
o 2x more common in boys
o Usually unilateral
Diagnosis
o More prominent during knee extension & vice versa
o If cyst is not found in medial part of popliteal fossa or has a solid
component (on U/S), rule out tumour with CT/MRI scan
Treatment
o Asymptomatic ones can be treated non-surgically with good results
o Though spontaneous remission is not to be expected in all cases

CLERGYMANS KNEE (INFRAPATELLAR BURSITIS)

Swelling superficial to patellar ligament & distal to the patella
Rx: firm bandaging, avoid kneeling, aspiration, excision if chronic
SEMIMEMBRANOUSUS BURSA
Painless fluctuant swelling in medial part of popliteal fossa
Enlargement of bursa between semimembranousus & medial head of gastrocnemius
Rx: excision if symptomatic (pain)
CHARCOTS JOINT
Causes:
- Peripheral neuropathy
- DM
- Tertiary syphilis
- Tabes dorsalis
- Syringomyelia
- Myelomeningocele
- Cauda equina lesion
Rapidly progressive OA
Gross jt deformity, but painless
Unstable jt, effusion, no warmth
Mx: Rest, immobilize
Stabilize with cast/ calipers
Surgical arthrodesis

Popliteal Fossa Boundaries (right)

- roof: fascia lata
- floor: (prox to distal) popliteal
surface of femur, capsule of
knee joint, popliteus m. covered
by its fascia

HOUSEMAIDS KNEE (PREPATELLAR BURSITIS)

Swelling over patella due to friction between skin & patella
Rx: firm bandaging; avoid kneeling; aspiration; excision if chronic
68

Osteoarthritis (Knees)

Most common joint disease in the world

Degenerative joint disease
Morphological changes
Cartilage degeneration
o Fissuring
o Pitting
o Eburnation as joint motion polishes surface
Bone Hypertrophy
o Osteophyte formation
Mild synovitis
Two types
Primary
- Senile (old-age)
- Post-menopausal

Secondary
Trauma acute or chronic
Rheumato RA
Infections Syphilis
Metabolic Hyper PTH

Joints affected:
PIPJs of hands (Bouchards nodes)
DIPJs of hands (Heberdens nodes)
Thumb joints
MTPJ of big toe
Cervical and lumbar spine
Hip
Knee
* frequency of OA: Asians: knees > hips; Caucasians: hip > kness
OA of knees and hands F>M ; OA hip- M> F
Other risk factors
Hereditary
Obesity
Competitive contact sport
Deformities e..g genu valgus/varum
Recreational running is NOT a risk factor

Differentials need to exclude other DDx of hip/knee pain from history

Referred pain from hip, back
VITAMIN

Vascular AVN

Infections warmth, fever, inoculation e.g. intra-articular injection by GP

Traumatic

Autoimmune/ inflammatory PMHx

Metabolic Gout, tophi

Neoplastic LOW/LOA, SOB, goiter, urinary, GIT

History
NO systemic involvement
Joint pain
o The usual 6 points about pain
o Which joints?
o Insidious onset
o Morning stiffness not prominent (<30mins)
o Worsened by activity
o Alleviated by rest
ASK ABOUT BACK PAIN, HIP PAIN WHICH CAN BE REFERRED TO THE KNEE
Precipitating causes
o Trauma
o History of contact sports / occupation
o Associated conditions RA, syphilis
o BMI of patient
Functional Loss
o Job scope
o Recreational activity restriction
o Premorbid status: function & mobility
Social hx ask about housing (floor, lift landing)
Treatments tried (TCM?)
GI bleed risk
o History of ulcer disease and/or GI bleeding

69

o
o
o

High dose or multiple NSAIDs

Concomitant use of corticosteroids and/or warfarin
Age >60 yrs

Physical Examination
Genu varum/valgus predisposes to OA usually genu varum
Fixed flexion deformity
Externally rotated
If joint swelling, is MILD
Joint line tenderness
Crepitus
Decreased ROM
Patellofemoral OA (5%)
Examine other joints as well
Note absence of rheumatoid nodules / tophi / rashes / Sjogrens
Examine HIP, BACK
Neuro exam SMART sensory, motor, autonomic, reflexes, trophic changes
Investigations
To confirm diagnosis and exclude differentials
To look for causes (not applicable usually)
To look for complications (not applicable usually)
Radiological

AP weight bearing (so that even small degrees of articular cartilage thinning can be seen)
Lateral
Skyline (tangential) view
Long film (to see degree of varus/valgus)

To view all 3 compartments medial, lateral, patellofemoral compartment

Mechanical axis centre of hip to centre of ankle
Anatomical axis line of femur to line of tibia (normally 4-6 valgus)

L-O-S-S findings
Loss of joint space
Loose bodies
Osteophytes
Subchondral sclerosis
Subchondral cyst

Management
Nonpharmacological
Physiotherapy
Preservation and improvement of joint mobility
Exercise
Range of motion and muscle strengthening exercises
Load reduction
Body weight reduction if obese
Use of walking aids
Avoid kneeling and squatting.
Pharmacological
Paracetamol
NSAIDs

Should be first line drug; effective in a proportion of patients

Must be used with special care in
>60y
previous history of GI bleed
concurrent warfarin/ steroid medications
renal dysfunction

COX-2 inhibitors acorxia

Glucosamine with
chondroitin
Tramadol
Intraarticular injections of
corticosteroids
Intraarticular hyaluronic acid
injections (e.g. Synvisc)
Surgical
Minimally
invasive
(Arthroscopic)

Prescribe with PPI/H2RA in patients with increased likelihood of GI bleeding

Vioxx a/w increased risk of stroke and cardiac events.
Glucosamine has anti-inflammatory properties
Chondroitin inhibits cartilage breakdown and stimulate cartilage repair
Have been found to be at least as effective as NSAIDS, with the added advantage of fewer side effects
Consider in patients with highly-resistant pain
Consider is patients with highly resistant pain. It is recommended that no more than 4 glucocorticoid
injections be administered to a single joint per year because of the concerns with long-term damage to
cartilage
Marketed as joint replacement substances; expensive, no evidence to support its efficacy

For early degenerative arthritis

Alternative to osteotomy and TKR if the patient is reluctant to have more aggressive surgery
Techniques include
Washout and debridement
Cartilage regeneration procedures
o Chondrocyte transplant
o Microfracture of subchondral bone
o Mosaicplasty
Arthroscopic surgery may defer definitive operation by up to 5 years

70

High tibial
osteotomy

Knee replacement

Only in certain cases e.g. unicompartmental involvement. Osteotomy permits redistribution of weight
Contraindications
Inflammatory arthritis
Severe flexion deformity >15o
Varus/ valgus >15o
>5mm loss of subchondral bone
lateral thrust while walking
When symptoms are severe
Try to avoid doing in patients <60 as TKRs usu last only ~10y
Types
o Unicompartmental
o Total +/- preservation of PCL; PCL preservation preserves proprioception function but wear of prosthesis

For PFOA

Complications
Intraop GA, # of tibia or femur
Immediate vascular injury to superficial femoral, popliteal and genicular vessel
Early DVT/PE, fat embolism, infection, peroneal nerve palsy (1%)
Late loosening, patellar instability, #, disruptn of extensor mechanism, periprosthetic #, wear of polythene surfaces
Arthroscopy to confirm diagnosis
Rx
- Realignment procedures
- Cartilage transplantation (still under research)
- Patellectomy (problems a/w it include loss of normal knee power and function, quadriceps weakness, and failure to
resolve anterior knee pain, may eventually require total knee arthroplasty for knee arthritis)
- Patellofemoral arthroplasty
- Total knee arthroplasty

Cartilage regeneration procedures

Chondrocyte transplant
Harvest condrocytes from non weight-bearing sites, e.g. patellofemoral surface, culture, reimplant
Microfracture
Subchondral penetration of bone, inducing regrowth of fibrocartilage
Mosaicplasty
Cylindrical cartilage taken from non-weight bearing areas, implanted on knee joint surface to form a
new layer of cartilage, comprised of the intact original cartilage and the transplanted grafts
Post-surgical
Physiotherapy
Continuous Passive Movement (CPM)

To maintain joint ROM & muscle power

Approach to OA knee
1) Confirm Dx of OA knee: pain and its characteristics
2) Exclude other sites of pathology
a) back pain, PU claudication
b) hip
c) ischaemic pain or neuropathic pain
Ischaemic pain
Neuropathic pain
Fixed claudication distance
Variable claudication distance
Better walking downslope
Better walking upslope
Recovers quickly with rest
Recovers slowly with rest
Pain present at night
Pt usu sleep in kyphosed
position with no pain
3) Exclude DDx
a) malignancy other bone pain, LOW, LOA etc.
b) septic arthritis fever, tenderness, swelling, trauma, intraarticular injectn
c) RA other jts, morning stiffness, pain
d) gout precipitant, inflammation

71

IMPORTANT ORTHOPAEDIC CONDITIONS IN TIBIA

TIBIAL PLATEAU FRACTURE
Results from femoral condyle(s) being driven into the proximal tibia often due to a
valgus (eg. Bumper # from getting hit by a car from the side) or varus force
Lateral > medial
Associated injuries / complications: popliteal artery injury, compartment syndrome,
ligament tear, meniscal tear, malunion
Schatzker classification
I lateral split
II lateral split with depression (the force
may have been greater or underlying bone
may be osteoporotic & unable to resist
depression)
III pure lateral depression
IV pure medial depression
V bicondylar
VI split extends to metadiaphysis
Treatment
Fracture displacement ranging from 4-10 mm can be
treated nonoperatively
if depression is < 3 mm
o Sarmiento program of functional cast
bracing, NWB x 2 months
if depression > 3 mm, displaced or comminuted
o ORIF +/- bone graft to elevate fragment
Absolute indications for surgery:
Open plateau fractures
Fractures with an associated compartment syndrome
Fractures associated with a vascular injury
Relative indications for surgery:
Most displaced bicondylar fractures
Displaced medial condylar fractures
Lateral plateau fractures that result in joint instability
Contraindications for surgery
1. Presence of a compromised soft-tissue envelope (for immediate open reduction)

2. Fractures that do not result in joint instability or deformity and can therefore be
treated with nonoperative modalities.
TIBIAL DIAPHYSIS FRACTURE
Most common long bone #.
Commonly open #
High intensity injury
o associated with crush injuries and MVAs
Soft tissue, nerve and vessel injury common
o assess neurovascular status
o rule out open fracture
Displacement is difficult to control
Good reduction is required
o minimal shortening and angulation
Healing time: 16 weeks on average
Treatment
ATLS principles first
Conservative managemenet
o For closed injuries (= closed reduction)
o Long leg cast x 4-6/52
o Followed by below-knee cast until healed
Surgical management
o For open injuries
ORIF with external fixator
wounds on anterior surface heal poorly and may necrose
o For unstable injuries or failed closed reduction require IM nail
o For patients with high risk of compartment syndrome

Closed reduction and cast; admit and observe for compartment

syndrome; prophylactic fasciotomy if operating on tibia fracture
Indications for surgery
Associated intra-articular and shaft fractures, open fractures,
Definitive indications
Relative indications

Delayed indications

major bone loss, neurovascular injury, limb reimplantation,

compartment syndrome, and a floating knee.
Associated intra-articular and shaft fractures, unstable fractures,
an inability to maintain reduction, relative shortening of
segmental fractures, a tibial fracture with an intact fibula, a
transition zone fracture, and polytrauma.
Failure to maintain reduction, unacceptable reduction,
complications
72

PILON FRACTURE OF DISTAL TIBIA

Combination of talar # & distal tibial metaphyseal #, usually with intra-articular

comminution
Vertical loading drives talus into tibial plafond. The cortical bone shatters; the
softer metaphyseal bone can also be affected.
20-25% of these will be open #
Associated injuries / complications:
30% will have ipsilateral injuries and 5-10% will have bilateral injuries;
- compartment syndrome
- compression # of vertebral column, particularly L1;
- contralateral # of: os calcis, tibial plateau, pelvis, or acetabulum (vertical
shear injuries)
- vascular injuries
Treatment
o Conservative
Pain relief
Antibiotic prophylaxis (open # / internal fixations)
Splint cast immobilisation if # is undisplaced
o Surgical
Preliminary stabilisation with external fixator +/- fibular # fixation
Definitive surgery after condition of soft tissues is optimised (blisters
have epithelised, skin is wrinkled)
Types: ORIF, external fixation, limited internal fixation with external
fixation, percutaneous pinning
Indications for surgery include the following:
o Open fracture
o Displaced fracture
Articular fragments with a gap of >2 mm or step of >1 mm
Rotational malalignment
o Vascular compromise
o Compartment syndrome

73

IMPORTANT ORTHOPAEDIC CONDITIONS IN THE ANKLE

EVALUATION OF ANKLE COMPLAINTS
Most common dislocation of ankle joint is subtalar joint must reduce before X-ray!
History
Ask about pain, swelling, mechanism of injury, effect on standing/walking
PE

avulsion fractures are transverse

shear fractures are oblique if pure inversion / eversion
shear fractures are spiral if rotational force
DANIS WEBER CLASSIFICATION
Based on level of fibular fracture relative to syndesmosis

neurovascular status
look, feel, move (dorsiflexion, plantarflexion)
assess for tenderness at knee (Maisonneuve), lateral and medial malleoli
special test: anterior draw (for ankle), talar tilt, squeeze test, Thompson test

X-ray
views
o AP, Lateral and Mortise (15 degrees internal rotation)
o Mortise gives true view of talus in tibiotalar joint
o space between talus > tibia and talus > fibula
o space should be symmetric and < 4 mm with no talar tilt
o disrupted space signifies ligamentous or bony injury
When to x-ray - Ottawa ankle rules
Ankle x-ray is only required with
o pain in malleolar zone AND
o bony tenderness over posterior aspect of the distal 6 cm of medial or lateral
malleolus OR inability to weight bear both immediately and in E.R.
Foot x-ray series is only required with
o pain in midfoot zone AND
o bony tenderness over navicular or base of fifth metatarsal OR inability to
weight bear both immediately and in E.R.
Ring Principle of the Ankle
The ankle can be thought of as a ring comprising of
a: lateral malleolus
d: deltoid ligament
b: medial malleolus
e: syndesmotic ligament
c: posterior (medial) malleolus
(syndesmosis)
f: calcaneofibular ligament
Fractures of the ankle involve
ipsilateral ligamentous tears or bony avulsion
contralateral shear fractures

(Types A C = increased risk of syndesmotic injury)

Type A (infra-syndesmotic)
avulsion of lateral malleolus below plafond or torn calcaneofibular ligament
+/ shear fracture of medial malleolus
Type B (trans-syndesmotic)
avulsion of medial malleolus or rupture of deltoid ligament
spiral fracture of lateral malleolus starting at plafond
Type C (supra-syndesmotic)
avulsion of medial malleolus or torn deltoid ligament
fibular fracture is above plafond
frequently tears syndesmosis
Maisonneuve fracture if at proximal fibula
posterior malleolus avulsed with posterior tibio-fibular ligament
LAUGE HANSEN CLASSIFICATION
Based on mechanism of injury;
First word= position of foot,
Second word = direction of movement of the talus in relation to the leg
NB. supination = inversion, pronation = eversion of the foot
Supination-External Rotation (Weber B)
most common (45-65%)
supination and external rotation oblique fracture at level of the sydesmosis

Pattern of fracture
determined by mechanism of injury
74

Pronation-Abduction (Weber B/C)

sequence of injury:
1) avulsion fracture of medial malleolus or rupture of deltoid ligament;
2) abduction force then either ruptures the syndesmosis or avulses its bony
attachment sites;
3) lateral force from talus impacts and fractures fibula at or above level of
syndesmosis and ruptures interosseous membrane

Lauge Hansen classification

SA
SE
PA
PE

In Summary...
Corresponds to Danis Weber type...
A
B
C

Pronation-External Rotation (Weber C)

sequence of injury:
1. transverse fracture of the medial malleolus or disruption of deltoid ligament;
2. external rotation then results in rupture of the anterior tibiofibular ligament or its
bony insertion;
3. oblique or spiral fracture of fibula above the level of the joint;
4. posterior injury with tibiofibular ligament rupture or avulsion of posterior
malleolus
fibular fracture may be proximal (i.e., Maisonneuve fracture 2)
1F

Supination-Adduction (Weber A)
sequence of injury:
1. supination force may rupture portions of lateral collateral ligaments or may
avulse distal fibula, resulting in transverse fracture below the level of intact
syndesmosis;
2. adduction forces talus against the medial side of the joint, resulting in vertical
fracture of the medial malleolus
Treatment
Undisplaced fractures: NWB BK cast
Displaced fractures: reduce ASAP
Indications for ORlF
all fracture-dislocations
all type C fractures
trimalleolar (lateral, medial, posterior) fractures
talar shift or tilt
failure to achieve or maintain closed reduction
Prognosis dependent upon anatomic reduction
high incidence of post-traumatic arthritis
2

Maisonneuve fracture: spiral fracture of the proximal third of the fibula associated with a tear of the
distal tibiofibular syndesmosis and the interosseous membrane

75

- Crutches are only necessary for a few days.

- Physiotherapy
- Usually return to play within 2-3 weeks

LIGAMENTOUS INJURIES
Medial Ligament Complex (deltoid ligament)
Responsible for medial stability
Usually avulses medial or posterior malleolus
usually a/w syndesmotic or lateral ankle sprain
Lateral Ligament Complex (ATFL, CFL, PTFL)
Responsible for lateral stability
Makes up for >90% of ankle ligament injuries
Clinical: swelling and discoloration, pop sound,
giving way
Diagnosis: stress x-rays and mortise view
o talar inversion produces joint separation exceeding the unaffected side by
six degrees (talar tilt test)
Frequncy of injury: ATFL > CFL > PTFL
Anterior Talofibular Ligament (ATFL)
Most common ligamentous ankle injury
Sprained by inversion and while ankle is in plantar flexion
Swelling and tenderness anterior to lateral malleolus, ++ ecchymoses
Anterior draw test for ankle positive with Grade III ATFL injury
attempt to sublux talus anteriorly
if positive then stress other lateral ligaments
Talar tilt test for integrity of other ligaments
Grading and Treatment of Ligamentous Ankle Injuries
Initial treatment of all sprains follows the RICE protocol (Rest, Ice, Compression,
Elevation). Protective weight-bearing is instituted with crutches. This is continued until
normal gait is restored.

Grade III sprains are treated non-operatively nowadays

- Bracing with a hinged knee orthosis (in the past: BK walking cast for 3 weeks)
- Crutches for 1-2 weeks
- Physiotherapy
- Usually return to play after 6 weeks
Focus of rehabilitation (NB. Allow sufficient healing of ligament first = 3wks)
Restore full ROM at the knee
Controlled strengthening. Often in the knee, the functional strength of the
quadriceps muscle, especially the medial VMO muscle, is weak and atrophied.
Sport-specific or function-based training. Upon achieving full strength and
pain-free ROM in the lower extremity, the athlete can be cleared to return to
their sport, most often without any brace or external support.
RECURRENT ANKLE SUBLUXATION

Aetiology
ligamentous laxity
Joint (loss of normal proprioception)
internal derangement of anatomy
intra-articular loose body
Treatment depends on cause
Strengthening and balance training for neuropathic joint
ligament reconstruction for lateral laxity and talar tilt

arthroscopy / arthrotomy for internal derangement

Goal of therapy: decrease pain, restore ROM & regain strength

Grade I microscopic stretch/tear (pain)
Grade II macroscopic tear (pain on motion)
Grade III complete tear (unstable ankle, talar tilt apparent on mortise view)
Grade I and II sprains are routinely treated nonoperatively.
- Ankle brace, usually in dorsiflexion & eversion (individualized to the patient's
discomfort).
76

IMPORTANT ORTHOPAEDIC CONDITIONS IN THE FOOT

EVALUATION OF FOOT COMPLAINTS
History

Physical

X-rays

pain, swelling, loss of function, sensory changes, deformity,

mechanism of injury, activity level of patient
inspection, palpation, active and passive ROM, weight bearing status
neurovascular status
AP, lateral, oblique (as a minimum)

LOOK

FEEL
MOVE
OFFER
Non-surg Rx
Surgical Rx

Hammer toe
Mallet toe
Claw toe
More common in Females, Elderly, with RA
Imbalance between intrinsic (lumbricals & interossei) and extrinsic (long
flexors & extensors) muscles of the lesser toes
For claw toe: may be 2 to neurological disorders e.g. peripheral
neuropathy (Charcot-Marie-Tooth disease, DM), LMN disease (polio),
UMN disease (CP, stroke, multiple sclerosis)
Affects lesser toes, most commonly 2nd toe
Usu all 4 lesser toes
involved; may be B/L
Flexion deformity at Flexion deformity
Flexion deformity
PIPJ
at DIPJ
at PIPJ and DIPJ
+/- DIPJ extension
NO
MTPJ/PIPJ + hyperextension of
+/- MTPJ extension
involvement
MTPJ
Any callosities
Any tenderness
Is the deformity fixed or mobile
Watch the patient walk
Examine patients shoes
Ask questions to assess effect of the condition on his/her life
Appropriate footwear (usually unhelpful for mallet toe)
Mobile deformity
Mobile deformity
Mobile deformity
Flexor-to-extensor
Flexor digitorum
Flexor-to-extensor
tendon transfer
longus tenotomy
tendon transfer
Fixed deformity
Resection of
proximal phalangeal
H&N +/- flexor &
extensor release
Proximal
phalangectomy
PIPJ arthrodesis

Fixed deformity
Resection of
middle phalangeal
H&N +/- flexor
tenotomy
DIPJ arthrodesis
Amputation of
distal of distal

Fixed deformity
Resection of
proximal
phalangeal H&N
+/- flexor &
extensor release
Extensor tenotomy
for MTPJ

phalanx (to
include nail &
matrix)

contractures
Resection of
metatarsal heads
of the lesser toes

Hammer toe

Mallet toe

HAMMER/MALLET/CLAW TOE
Epidemiology
Aetiology

Painful callosities:
Terminal
phalangectomy

Claw toe

HALLUX VALGUS
Definition: valgus angulation of 1st metatarsal (i.e. lateral angulation of big toe)
Epidemiology: most common disorder involving the 1st MTP joint
Causes: idiopathic; hereditary, loss of muscle tone, RA; increased incidence in those
who wear enclosed footwear
Associated deformities: inflamed bunion, hammer toe, metatarsalgia, secondary OA
of 1st MTP jt
Ix: do a plain weight-bearing X-ray to assess
1) degree of valgus deformity
2) presence of OA of the first MTPJ
Rx:
- Non-surgical: appropriate footwear & physiotherapy
- Surgical: depending on patients wishes, level of activity & state of peripheral
vascular system
Bunionectomy
1st metatarsal realignment osteotomy
Excision arthroplasty (Kellers procedure) essentially a proximal
hemiphalangectomy
Fusion for degenerative joint disease

77

HALLUX RIDGDUS

Definition: literally means stiff great toe; however, limited ROM is only one of
the symptoms that constitute this diagnosis
Epidemiology: second most common disorder involving the 1st MTP joint (the first
being hallux valgus). Seen in adolescents & in adults.
Causes: Primary OA of MPJ of great toe.
Diagnosis
Symptoms: pain on top of great toe +/- diffuse, lateral forefoot pain
resulting from increased weight-bearing on lateral foot to offload the hallux.
Pain is worse with certain activities and with certain footwear.
Signs: tender dorsal osteophyte at 1st MTP joint (usually confirms this dx);
slightly antalgic gait; limited plantarflexion & dorsiflexion a/w pain
especially at the end of ROM
Treatment
Conservative
- Activity modification: use of in-sole orthotics, avoid extreme DF of
great toe (e.g. kneeling/squatting with toes in great extension)
- Pharmacological: paracetamol, NSAIDs
Surgical
- Cheilectomy: excision of all irregular bony spurs that limit motion
- MT osteotomy: based on the premise that metatarsus elevatus or a
long first MT are the underlying causes of hallux rigidus
- Joint arthroplasty (commonly known as Keller technique): involves
the excision of the base of the proximal phalanx; indicated in
moderate to severe cases of hallux rigidus in individuals with low
functional demands who desire the maintenance of joint motion;
however, complications are common such as hallux weakness,
elevation, floppiness, a short hallux, and development of transfer
lesions under the second MTP joint
- Arthrodesis: salvage procedure should other surgical interventions fail
& hallux rigidius is severe enough

RUPTURED TENDO ARCHILLES

Degenerate tendon ruptures during pushing off (jumping/ running)
>40 years old (i.e. middle-aged), a/w long term steroid use
Rupture at musculous tendinous junction occurs most often in young people, but
ruptures near the calcaneus also occur
Mechanism usually involves eccentric loading on a dorsiflexed ankle with the knee
extended (soleus and gastroc on maximal stretch)

Unable to tip toe

Gap felt 5cm above insertion of tendon
Weak plantar flexion, not a/w tautening of tendon
Thompson aka Simmonds test: lack of plantar flexion on squeezing calf
Mx: Acute plaster cast with foot in equines to approximate tendon ends + shoes
with raised heels for 6 wks
Operative repair to equinus, plaster and raised heels for 8 wks

PES PLANUS (AKA FLATFOOT)

Definition:

= flat foot
Condition whereby the arch of the foot collapses with the entire sole of
the foot coming into complete / near complete contact with the ground.

Epidemiology: very common

Aetiology:
Young
Flexible
Functional
Hypermobile lig laxity
Tibialis post tendon dysfunction

Rigid
Tarsal coalition
Inflammatory jt dz
Neurogenic disorders

Adult
Acquired

Diagnosis:
Physical Examination (see picture)
o Abducted forefoot
o Valgus hindfoot
o Flexible flatfoot: arch appears when patient dorsiflexes (not a true
collapsed arch because medial longitudinal arch is still present)
Treatment:
When to treat: (1) if patient has rigid flatfeet, (2) if there is associated foot or
lower leg pain, or if the condition affects the knees or the lower back
Use of orthotics (arch support to be used for the rest of patients life;
exercises recommended by podiatrist)
Surgery as last resort (usually time-consuming & costly)
78


FOOTBALLERS ANKLE
Anterior ankle impingement syndrome
- Definition of ankle impingement syndrome: painful mechanical limitation of full
ankle ROM secondary to an osseous or soft-tissue abnormality
Repeated forced dorsiflexion tearing of anterior capsule of ankle joint subsequent
bone spur formation (osteophytes) aka anterior exostoses of the tibia subsequent pain
+ limited ROM
Treatment:
Acute phase
Conservative: NSAIDs, physiotherapy, orthotics, bracing
Surgical: arthroscopic excision & debridement
Recovery phase
Posterior splinting for 1/52 with supportive brace & compression stocking
Physiotherapy for 2/52 for strengthening, ROM, proprioception and sportsspecific rehabilitation

CALCANEAL FRACTURE

ACHILLES TENDONITIS
-

Chronic inflammation from running and shoe-wear (high heels)

May develop heel bumps (Haglunds deformity: prominence of the posterior
superior calcaneus where the Achilles tendon laterally inserts into calcaneus)

Diagnosis
pain, aggravated by passive stretching
tenderness, swelling
crepitus on plantar flexion
Treatment
rest, gentle stretching, NSAIDs
proper footwear +/- orthotics
do NOT inject steroids (prone to rupture)
TALAR FRACTURE (RARE)

60% of talus covered by articular surface (7 articular facets!)

Decreased surface area for vascular perforation
Blood supply to talus: distal to proximal
Fractures of the neck at risk of AVN

Mechanism: MVA or fall from height

axial loading or hyper-plantar flexion injury
talar neck driven into tibial margin
Rule out potential associated injuries
spinal injuries, femoral neck fractures, tibial plateau fractures
X-Rays
AP/lateral films with CT scan of talus
Treatment (aims: revsacularisation & fracture healing)
BK cast, NWB x 6 months
ORIF: to reduce displacement and prevent AVN or non-union
Complications
undisplaced: 0-10% risk of AVN
displaced: 100% risk of AVN

Mechanism: axial loading (fall from a height onto heels)

Rule out potential associated injuries
Spinal injuries (10%)
Femoral neck fractures
Tibial plateau fractures
Knee ligamentous injuries
Physical
Heel viewed from behind is wider, shorter, flatter,
varus tilt
May be swollen, with bruising on soles
X-Rays
Brodens views (oblique views of subtalar joint)
Bohler's Angle decreased (normal: 20 - 40 degrees)
Bohler's Angle
Treatment
Goal is to prevent widened heel and maintain subtalar joint congruency
NWB, early ROM
ORIF if depressed centrally or tongue-type fracture
Closed vs. open treatment is controversial (open: potential vascular
complications)
Primary arthrodesis if severe
Cx : malunion, subtalar arthritis, chronic heel pad pain, calcaneal widening (
increase in shoe size)

79

PLANTAR FASCIITIS

Repetitive strain injury of plantar fascia

Most common cause of heel pain [MCQ]
Epidemiology: common in runners, jumpers, ballet dancers, obese individuals
Pathogenesis: chronic inflammation due to microtears of plantar fascia
History
Intense pain on waking or after rest
Subsides as patient walks
May be associated with systemic diseases
Diabetes mellitus
Enthesopathies including seronegative and seropositive arthritis
Physical
Swelling, local tenderness over plantar fascia
mostly at medial calcaneal tubercle
Pain with toe dorsiflexion (stretches plantar fascia)
X-Ray
Sometimes show heel spur at insertion of fascia into medial calcaneal
tubercle
Note: spur is reactive, not the cause of pain
Treatment
Non-operative (90% resolve)
Rest and NSAIDs x 4-6 months
Stretching exercises
Supportive shoes with heel cup
Steroid injection
Surgical in refractory cases (rule out nerve entrapment as cause of pain first)
Release of plantar fascia--50% effective at pain relief
Spur removal not required
Can be done endoscopically

BUNIONS

Definition: localised painful swelling at the base of the big toe

Joint is enlarged, toe is often malaligned
Frequenly associated with inflammation
Can be a/w degenerative joint disease (OA) or bursitis
Epidemiology: 10x more frequent in women
Two primary causes: heriditary, shoewear
Diagnosis & pathogenesis: a/w hallux valgus deformity
valgus alignment of MTP joint is aggravated by eccentric pull of EHL and

intrinsics
secondary exostosis forms with bursa and thick skin creating the bunion
Treatment: (1) cosmetic reasons, (2) for pain with shoes
Conservative: properly fitted shoes and toe spacer
Surgical: removal of bunion with realignment of 1st MTP joint

METATARSAL FRACTURE
As with the hand, 1st, 4th, 5th metatarsals (MT) are relatively mobile, while the 2nd and
3rd are fixed
Types of Metatarsal #s

Fracture

Avulsion of base of
5th MT
Jones Fracture midshaft 5th MT

March Fracture shaft 2nd, 3rd MT

Mechanism

Sudden inversion
followed by
contraction of peroneus
brevis
Stress injury

Stress injury

Clinical

Treatment

Tenderness along shaft

of 5th MT
Tends to displace b/c
of peroneus brevis and
tilting
Painful shaft of 2nd or
3rd MT

NWB BK cast x 6/52

ORIF if athlete

Tenderness at base of
5th MT
X-ray foot

Requires ORIF if
displaced

Symptomatic

80

1st MT Fracture

Trauma

Painful 1st MT

Lisfranc Fracture
2nd Tarso-MT
fracture- dislocation

Fall onto plantar flexed

foot or direct crush
injury

Shortened forefoot
prominent base

ORIF if displaced
otherwise NWB BK
cast x 3 weeks then
walking cast x 2 weeks
ORIF

Kohlers disease AVN of navicular bone

MCQ --- Stress fractures: common sites

a. head of femur
b. 2nd metatarsal
c. distal end of femur
d. tibia

81

IMPORTANT ORTHOPAEDIC CONDITIONS IN THE SPINE

APPROACH TO LOWER BACK PAIN

Axial

Diagnosis

Hx

Tx

Facet
Spondylosis (OA)

Epidemiology
Pain
dominance
Worse with
Onset
Duration

Old
Back

Other aspects
of history

NB. Patient is usually

asymptomatic. Lumbar
spondylosis is hence
not found unless a
complication ensues,
e.g. nerve root
compression from
posterior osteophytes
with superimposed
spinal stenosis

PE

Normal

Ix
Conservative

MRI
NSAIDs
Activity modification
Exercise/physiotherapy
Lumbar corset

Surgical
(all under GA)

Fuse

Extension
Short (days to weeks)

LOWER BACK PAIN

Discogenic
Degenerative
disc disease
Back
Flexion
Gradual
Long (weeks to
months)

Leg Pain
Radicular
PID (commonly L5, S1 S1
affected)
Young
Old
Leg
Leg

Claudication
Spinal stenosis

Flexion

Extension
Congenital/acquired
Short episode attacks (minutes)
Acute or
chronic (weeks to months)
Symptoms of radiculopathy
Neurogenic claudication
Sciatica (+/- cross sciatica)
Pain, weakness and/or
numbness in the legs
Shooting pain down calf
while walking (ask for
a/w m. weakness, tingling /
segmental sensory
numbness
deficits)
Cough impulse positive
Rule out cauda equina syndrome Variable claudication
distance
(impt complication)
Pain even on standing
Urinary retention
Park bench to park
Saddle anaesthesia (loss of
bench relieved with
sensation over the buttocks
flexion
& the perineum)
No pain at night (patient
LL weakness
sleeps on lateral
decubitus foetal
position)
Rule out vascular claudn
1. Listing (to relieve n. root
Same as radicular
compression), paravertebral
(+) 4. Pulses
m. spasm, restricted ROM
2. SLR, Bowstringing,
Laseague tests +ve
3. Tone, Reflex, Power
4. Sensation
X-ray (to exclude bone disease) & MRI
NSAIDs
Back care education
Bed rest
Epidural steroid injection
Physiotherapy
Back care education
Discectomy
Nerve decompression
Indication: failure of 3
months of conservative mx,
cauda equina syndrome
Usually only alleviate
symptoms of radiculopathy,
not of LBP
& fuse
(Transforaminal Lumbar Interbody Fusion, or TLIF)

Caveats
Sciatica (df): leg pain localised in the distribution of one/more lumbosacral nerve roots, typically L4-S2, with or
without neurological deficit. [when the dermatomal distribution is unclear, please describe it as non-specific
radicular pattern]
Both spondylosis and degenerative disc disease may occur at the same time (chicken & egg phenomenon)
Can have 2 or more concurrent pathologies, e.g. lumbar spondylosis with spinal stenosis (spinal stenosis increases
with age but the symptoms may be exacerbated by further compression due to spondylosis)
Causes of spinal stenosis can also cause radiculopathy as well
Give the other as differential, e.g. PID ddx spinal stenosis

82

Other differentials
Cauda Equina syndrome
Neoplastic (primary, metastatic)
Trauma - fracture (compression, distraction, translation, rotation)
Spondyloarthropathies (e.g. ankylosing spondylitis)
Referred pain - aorta, renal, ureter, pancreas
Important Red flags (rule out malignancy, infection, trauma)
- Age (<20 or >50 increased risk of conditions listed above)
- LOW, LOA
- Hx of malignancy
- Night pain
- Fever, chills, rigors
- Hx of trauma
- Any bladder/bowel symptoms

How to read Spine X-rays

Lateral view

Lateral view of spine

1) anterior vertebral line
2) posterior vertebral line
3) spinolaminar line
4) interspinous line
Also look out for soft tissue
(prevertebral fat stripe)
should be
<6mm at C2
<2mm at C6

X-Ray
Oblique views: look for "Scottie Dog" sign (= spondylolysis)
S superior facet
N transverse process
I inferior facet
P pars interarticularis

83

PROLAPSED INTERVERTEBRAL DISC (USUALLY YOUNGER PTS)

- Fenestration & discectomy OR microdiscectomy

- Usually only alleviate symptoms of radiculopathy, but not of LBP

Surgical

- Acute posterior or post-lateral herniation of nucleus pulposus causing pressure on

nerve root (traversing nerve root, not exiting nerve root)
- Young adult
- DDx: AS, TB spine, vertebral tumours, nerve tumours
- L4/5 commonest (a/w L5 radiculopathy) followed by L5/S1(a/w S1 radiculopathy)
Symptoms

- Backache (pressure on post longitudinal ligaments)

- Sciatica (pressure on dural envelope or nerve root)
- Radiculopathy (usu L5 or S1): Numbness, paraesthesia & muscle weakness in leg or
foot (compression of nerve root) relieved by flexion to 1 side (listing)
- Aggravated by coughing, straining, lifting, flexion of spine

- Indications: failure of 3 months of conservative management (i.e.

progressive neurological deficit, persistent pain), cauda equina
syndrome

SCOLIOSIS
Causes
Nonstructural
Structural

Signs

- Listing (to relieve compression on nerve root), paravertebral muscle spasm,

protective scoliosis, loss of lumbar lordosis
- Restricted ROM
- SLR limited, + bowstringing / sciatic nerve stretch test
- Cross sciatic tension +
- Segmental myotomal/ dermatomal deficits sensory deficits, power, reflexes
Lumbar Radiculopathy/Neuropathy
Root
L4
Quadriceps, tibialis anterior
motor
sensory
reflex
test

posteromedial
knee reflex
limitation of femoral stretch

L5
ankle dorsiflexion, great toe
extensor, hip abductor
lateral calf or 1st web space
hamstring reflex
limitation of SLR

Complications:

S1
ankle plantar flexion
lateral aspect of foot
ankle reflex
limitation bowstring

- Cauda equina syndrome urinary retention, saddle anaesthesia, lower limb weakness
Investigations:

- X-rays: AP, lat, oblique to exclude bone disease

- CT/MRI/myelogram
Management

Conservative

Bed rest
NSAID
Epidural steroid injection
Physiotherapy
Back care education

- Limb length discrepancy (apparent or true shortening of one leg)

- Hip contracture
- Muscle spasm eg 2o to PID
-

Adolescent idiopathic (commonest, 80%)

Infantile idiopathic may resolve or progress
Osteopathic due to congenital vertebral anomalies
Neuropathic eg 2o to polio or CP. Causing asymmetrical muscle
weakness
- Myopathic due to muscular dystrophies
- Neurofibromatosis

ADOLESCENT IDIOPATHIC SCOLIOSIS

- Progression: greatest during pubertal growth spurt, minimal progress post-puberty.
- Deformity:
Fixed 1o curve may be in thoracic or lumbar spine.
Vertebrae are rotated w spinous processes pointing to the concavity of the curve.
Ribs on the convex side are carried around to form a prominent hump
Shoulder is elevated on side of convexity, hip sticks out on side of concavity
Mobile 2o curves may develop above &/or below 1o
curve to maintain normal head & pelvic position
X-ray:

- full length AP spine X-ray (measure Cobbs angle sup & inf
extent of scoliosis is where both sides of the intervertebral
space is of equal height)
- lateral flexion X-rays,
- X-ray pelvis (look for Risser sign)

84

Definition: Risser sign is defined by the

amount of calcification present in the iliac
apophysis and measures the progressive
ossification
from
anterolaterally
to
posteromedially. Measure of skeletal maturity
(Risser III patient has past peak of growth
spurt, a period of rapid spinal growth during
which scoliosis curvatures can increase
rapidly)
Grade I: 25% ossification action of the iliac
apophysis
Grade II: 50%
Grade III: 75%
Grade IV: 100%
Grade V: means the iliac apophysis has fused
to the iliac crest after 100% ossification
Complications:

Pulmonary TLC & FVC due to thoracic lordosis deformity (Cobbs angle >70o)
Cardiac Right heart dz causing pulm HPT. ( Cobbs angle >80o)
Listing
Limb length discrepancy
Backache
Radiculopathies

Mx:
Age
Prepubertal/
Pubertal
Postpubertal

Cobbs
Angle

<20

20-40o
>40o
>50o

S/S

- Backache intermittent; aggravated by standing, walking & prolonged sitting;

relieved by lying down
- Pain referred to buttocks and sometimes extends down leg
- Acute incidents of pain, locking or giving way
- Reduced lumbar ROM
X-rays narrowed disc space, osteophytes
Mx:

- Conservative modify activities, exercise, manipulation, NSAIDs, lumbar corset

- Surgical spinal fusion

SPINAL STENOSIS (USU OLDER PTS)

- Causes: disc degeneration, OA & hypertrophy of post disc margin & facet joint,
degenerative spondylolisthesis (usually L4/5 level), spondylolytic spondylolisthesis
(usually L4/5 or L5/S1)
- Causes of spinal stenosis can cause radiculopathy as well
S/S:

- Neurogenic claudication: Thigh aches, numbness, paraesthesia after standing upright

/ walking. Claudication distance is variable
- Relieved by spine flexion / sitting
Patient stands in slight flexion
- Limited spinal extension
- Segmental sensory deficits, power, reflexes

Mx
Neurogenic claudication

4mthly F/U & full length spine X-ray to check for

progression of scoliosis
Supports (e.g. Milwaukee brace)
Spinal fusion + supports post-op to prevent recurrence
Spinal fusion

LUMBAR SPONDYLOSIS
Definition:

Flattening of disc & displacement of posterior facet joints, due to 2o OA facet joint

- Variable claudication distance

- Better walking uphill due to spine
flexion. Worse on walking downhill
- Pain even on standing
- park bench to park bench pain
requires spine flexion to be relieved.
- No pain at night PT sleeps on lateral
decubitus fetal position

Vascular claudication

- Constant claudication distance

- Better walking downhill as effort is
less. Worse on walking uphill
- Shop window to shop window pain
relieve simply by resting, even if
standing up
- Pain at night
Also ask for PMHx of peripheral
vascular disease, hx of smoking...

Invx: lat X-ray, CT myelogram (waisting of dye column, posterior indentation, partial

or complete block)

Epidemiology:

Usually >40YO, males > females

85

CAUDA EQUINA SYNDROME

Mx:
Conservative

Education on spinal posture

Surgical

Nerve root compression

Decompression

Nerve root compression & spinal

instability

Decompression & spinal fusion

SPONDYLOLISTHESIS
Forward translation of upper vertebral body over the lower vertebral body, usually at
L4/5 or L5/S1 level
Causes

1.
2.
3.
4.
5.
6.

Dysplasia congenital lumbosacral facet jt dysplasia

Isthmic (spondylolytic) break in the pars interarticularis
Elderly (degenerative) OA degeneration of facet joints
Trauma
Suspicious (pathological) neoplasm
Post-op due to laminectomy for decompression

Spondylolytic
Pathological
Operative
Trauma
Elderly
Dysplastic

S/S

- Backache intermittent, worse on exercise or straining

- Stepping of spine
- Stiffness (for degenerative type)
X-ray:

- Fwd shift of upper spinal column

- Elongation of the archs / defective facets
- Gap in the pars interarticularis on oblique view (Scotty dog sign)
Meyerding classification
Grade % translation of VB

I
II
III
IV

0-25
25-50
50-75
75-100

Mx

Conservative bed rest & supporting corset

Operative spinal fusion

Old patients, non-disabling symptoms

Disabling symptoms, young adult,
neurological compression

Definition
Cauda equina syndrome (CES) has been defined as low back pain, unilateral or usually
bilateral sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and
variable lower extremity motor and sensory loss usually due to mechanical compression
of the cauda equina.
Aetiology
V
Spinal epidural hematoma
Spinal anaesthesia
IVC thrombosis
I
Abscess
T
Traumatic injury
A
M
I
Idiopathic
N
Tumour (primary/metastatic)
Lymphoma
Others
Spinal anaesthesia
Lumbar disk herniation
Late-stage ankylosing spondylitis
History
Low back pain - This pain may have some characteristic that suggests something
different from the far more common lumbar strain. Patients may report severity or a
trigger, such as head turning that seem unusual.
Radiating pain
o Acute or chronic
Unilateral or bilateral lower extremity motor and/or sensory abnormality
Bowel and/or bladder dysfunction
o Initial presentation may be of difficulty starting or stopping a stream of
urine that may be followed by frank incontinence first of urine then of
stool. Urinary incontinence is on the basis of overflow.
o Usually with associated saddle (perineal) anaesthesia (Examiner can ask if
toilet paper feels different when wiping.)

86

Physical Examination
Local tenderness to palpation over the lower back
Pain radiating to the legs
Loss or decreased reflexes
o Hyperactive reflexes may signal cord involvement, hence ruling out CES
o Similarly, Babinski sign / other signs of UMN involvement rule out CES
Sensory loss/abnormality in perineal area or lower extremities
o Test light touch
o Anaesthetic areas may show skin breakdown
Muscle weakness
o +/- muscle wasting (if chronic)
Alteration in bladder function may be assessed empirically by obtaining urine via
catheterization. A significant volume with little or no urge to void, or as a post-void
residual, may indicate bladder dysfunction. Bedside ultrasonography may be also
used to estimate or measure post-void residual bladder volume.

Management

Other Problems to Be Considered

Conus medullaris syndrome
Spinal cord compression
Lumbosacral plexopathy
Peripheral nerve disorder

Remember, it is a SURGICAL EMERGENCY! It will cause permanent urinary/bowel

incontinence if untreated. Must operate on patient within 48h.

Investigations
Imaging
o Plain radiography - Unlikely to be helpful in cauda equina syndrome but
may be performed in cases of traumatic injury or in search of destructive
changes, disk-space narrowing, or spondylolysis
o CT with and/or without contrast - Lumbar myelogram followed by CT
o MRI - Superiority of MRI over CT only suggested by case reports (Early
consultation with the appropriate subspecialty is encouraged to guide
imaging studies.)7
o Ultrasonography may be used to estimate or measure post-void residual
volume.
Other Tests
o Catheterization for residual urine volume may reveal urinary retention
suggesting a neurogenic bladder.

Prehospital care should focus on associated symptoms related to the pain (ie, what
besides the pain is different).
Stabilize acute life-threatening conditions.
Immobilize the spine if traumatic.
Emergency Department Care
No proven medical treatment exists, and therapy generally is directed at the
underlying cause of cauda equina syndrome (CES).
For mechanical compression of the cauda due to disk herniation, surgical
intervention may be indicated.
Admit patients to appropriate service (usually neurology, neurosurgery, or
orthopedic surgery) with frequent neurologic checks.
Complications: Residual weakness, incontinence, impotence, and/or sensory
abnormalities are potential problems if therapy is delayed

LUMBAR SPINE FRACTURES

Elements of 3 Column Spine***
Anterior Column
Ant longitudinal ligament
Ant annulus fibrosis
Ant 1/2 of vertebral body

Middle Column
Post longitudinal ligament
Post annulus fibrosis
Post 1/2 of vertebral body

Posterior Column
Post body elements
Supra- & intraspinous lig.
Facet joints
Ligamentum flavum

87

Basic Types of Spine Fractures and their Mechanisms

Type
Mechanism
Compression
Flexion
Anterior
Anterior flexion
Lateral
Lateral flexion
Burst
Axial load +/- flexion/rotation
Flexion Flexion, distraction, common in lap-belted motor vehicle
Distraction
collision (Chance)
Fracture
Flexion-Rotation, Shear, Flexion Distraction
dislocation
Chance Fracture of the Spine
- Hyperflexion injury
- Fracture extends through all 3 columns!
- Most commonly seen in MVC lap-belted passenger
- CT scan to assist with diagnosis

Relieved by
Neuro
symptoms
Inspection
Straight leg
raise

Neurological
signs

Younger
- Increase in abdominal pressure
(laughing, coughing, lifting,
straining)
- Spine flexion, prolonged sitting
Listing to 1 side
Pain, numbness, paraesthesia,
weakness
Listing, scoliosis, loss of lumbar
lordosis, paravertebral spasm
- SLR elicits nerve root
compression (i.e.
radiculopathy)
- SLR, SNST, Bowstring and
cross SLR positive
Radiculopathy (usu L5 &/or S1)

(NEUROLOGICAL DISEASE WITH POSSIBLE ORTHO CAUSE)

Site

- C5-6 > C4-5 > C3-4 > C6-7

-

Cervical spondylosis due to bony spurs & thickened ligament

Infection
Vascular disease
Trauma
Degenerative conditions
- Demyelinating disorders
- Tumours

PID VS SPINAL STENOSIS***

PID

CERVICAL MYELOPATHY

Causes of cervical myelopathy

Insert notes from Spine Trauma slides from CGH

Patient age
LBP
aggravating
factors

variable depending on severity

of stenosis)
- Radiculopathy(if n. root is
compressed by underlying
spinal stenosis)

Spinal stenosis

Causes of compression

Older (unless cause is PID)

Neurogenic claudication
symptoms

Spine flexion

Symptoms

Pain, numbness, paraesthesia,

weakness
Pt stands in flexion
SLR, SNST, Bowstring and cross
SLR may or may not be positive
(depending on whether nerve root
is compressed by underlying
cause of spinal stenosis)
- Spinal stenosis: LMN signs at
level of compression, UMN
signs downwards (but signs are

Anterior: protruding disc or posterior osteophytes

Anterolateral: jts of Luschka (uncovertebral jt)
Lateral: cervical facets (thickening / bony spurs)
Posterior: ligamentum flavum
Weakness and clumsiness of the hands, paraesthesias in the hand
Tightness, hot or cold sensations in the trunk
Tingling in the legs
Gait disturbances (ataxic, broad based, clumsy, shuffling)
May have symptoms associated with malignancy LOA, LOW, malaise, etc.

Signs

- Lower motor neuron findings at the level of the lesion

- Upper motor neuron findings below the level of the lesion/cord compression
- Upper limbs usually show a mix of UMN & LMN signs, while lower limbs usually
show UMN signs only
- Skipping of the face & head
- Clonus, Lhermitte's sign (electric shock-like, radiating down body on neck flexion),
Babinski and Hoffman's pathologic reflexes
88

- "Finger escape sign" (the patient is asked to hold out their hand with fingers
extended and the medial fingers drift into flexion)
- Urinary retention (rare)
Investigations

Exclude tumour!
Plain X-rays
CT (bony spurs & ligament ossification)
MRI (disc prolapse & cord compression)
Pavlov's Ratio: ratio of the distance from the
posterior aspect of the vertebral body to the
anterior aspect of the lamina (i.e. space allowed
for the cord at the same level) to the AP width of
the vertebral body. Normal: 1 Abnormal:
0.85

Management

- As for cervical spondylosis

CERVICAL SPONDYLOSIS
(ORTHOPAEDIC DEGENERATIVE DISEASE OF THE C-SPINE)
Features

- IV disc degenerate & flatten + bony spurs on ant & post margins of vertebral bodies
- Posterior spurs may encroach upon the IV foramina compressing nerve roots
- >40YO, male > female, usually C5/6
DDx

- Thoracic outlet syndrome (look for signs of limb ischaemia; perform Roos test and
Adsons manoeuvre) (a/w ulnar n. palsy)
- Carpal tunnel syndrome
- Rotator cuff lesions (abnormal shoulder movements, no neurological signs)
- Cervical tumour (symptoms are constant)
Risk factors

- Smoking
- Drinking
- Excessive driving

Radiation: occiput (headache), scapular muscles, down one or both arms.

Paraesthesia, weakness, clumsiness
Periods of exacerbation & quiescence
Posterior neck & scapular tenderness
neck ROM throughout with pain
Limb numbness, weakness, reflexes

Investigations

- X-ray: narrowed IV disc space, bony spurs (osteophytes), encroachment of IV

foramina in oblique view
Management

Conservative:
- Heat & massage, NSAIDs, cervical collar, physioRx
Surgical:
- Discectomy anterior fusion
- Corpectomy (removing part of vertebral body; latin corpus vertebrae)
- Laminoplasty
- Laminectomy foraminectomy.
- Indications: progressive neurological deficits, multiple levels of cord compression

CERVICAL LESIONS
TORTICOLLIS
Causes

Acquired
Acute - muscular damage caused by inflammatory diseases, such as myositis,
lymphadenitis, or tuberculosis (TB); from cervical spinal injuries that produce scar
tissue contracture; and, less commonly, from tumor or medication
Spasmodic - organic central nervous system disorder, probably due to irritation of
the nerve root by arthritis or osteomyelitis. Benign paroxysmal torticollis might
be migraine variant.
Ocular torticollis - compensatory mechanism enacted by patients with trochlear
nerve palsy or superior oblique muscle weakness
Hysterical

Presentation

- Neck pain & stiffness, worse in the morning

89

Congenital
Traumatic infants after difficult delivery - breech presentation (delivery buttocks
first instead of heads first)
Skeletal anomalies, atlantoaxial instability
Klippel-Feil syndrome

The presence of craniofacial asymmetry (e.g. hypoplasia of the face including the small
left eye) indicates congenital or long-standing torticollis.
Management

- Pre-hospital care: ensure patent airway, perform C-spine immobilisation / precaution

for patients with history of trauma
- A&E: ABCDEs, give antibiotics if infection suspected
- Definitive treatment
Generally supportive; includes analgesics, benzodiazepines, anti-cholinergics,
heat, massage, stretching exercises
Drug-induced torticollis: treated with diphenhyrdramine, benztropine, or
benzodiazepines
Surgical Rx: SCM release (>1yo: dont need to wait or try conservative Rx)

THORACIC OUTLET SYNDROME

1. Lower trunk of brachial plexus n subclavian artery pass btw the ant n middle
scalene muscles and over the 1st rib.
2. Compression maybe due to cervical rib (rare), fibrous bands or abnormalities of
scalene attachments, or by a pancoast tumour
3. Symptoms increase with increasing age as shoulders sag
4. Typically woman in her 30s complains of pain n paraesthesia extending down from
her shoulder down the ulnar aspect of her arm to the medial two fingers
5. Worse at night, agg by bracing shoulders or raising arms above shoulder height

ACUTE PROLAPSED INTERVETEBRAL DISC (PID)

Precipitated by local sprain or injury, usually underlying pathology already present

e.g. intervertebral disc pressure
Leads to compression of
o Post intervertebral lig pain, stiffness, from back of neck to scapula, occiput

N root pain, paraesthesia in one / both (rare) arms. Radiating to outer elbow,
dorsum of wrist, middle n index finger. Weakness is rare. Prolapse usually
above/below C6 vertebrae so C6 & C7 N roots commonly affected
Acute torticollis may be present
X-ray shows disc space. MRI to confirm.
Ddx
o Soft tissue sprain neurological S&S absent.
o Neurological amyotrophy (acute brachial neuritis) sudden, severe pain @
back or shoulder. Multiple neurological sites affected & might have winging
of scapula. Pain followed by flaccid paralysis a few days later.
o Cervical spine infection unrelenting & local spasm with severe pain. X-ray:
erosion of bone
o Cervical tumors neurological signs progressive. X-ray/MRI shows bone
destruction. Primary tumors rare, secondary more common. Of primary,
sarcoma & multiple myeloma most common.
Treatment
o Heat, analgesics
o Rest with collar (in 75% of patients symptoms will resolve with non-operative
measures)
o Reduce: traction intermittently placed for 30 mins @ a time. Up to 8kg
o Remove: anterior approach discectomy fuse affected area / maintain height
using bone grafts.
o

CERVICAL SPINE TRAUMA

Neuro examination by levels (check dermatome for each of them)
C4 spontaneous respiration
C5 biceps reflex, deltoid strength
C6 wrist extension, brachioradialis reflex
C7 - wrist flexion, triceps reflex
C8 finger flexion
T1 interossei
L1, L2 hip flexion (femoral n.)
L2, L3 hip adduction (obturator n.)
L3, L4 knee extension (femoral n.) knee jerk
L4 dorsiflexion (deep peroneal n.)
L4, L5 hip abduction (superior gluteal n.)
L5, S1 hip extension (inferior gluteal n.)
S1 knee flexion (sciatic n.)
S1, S2 plantarflexion (tibial n.) ankle jerk (S1)
90

Pathologic reflexes (UMNL) Hoffmans sign, Babinskis reflex, Oppenheims sign

(dorsiflexion of big toe elicited by downward irritation of medial side of tibia)
Sacral sparing: incomplete injury - perianal sensation, rectal motor function, great toe
flexor activity
Frankel Score
A Complete Motor / Sensory
B Complete Motor / Incomplete Sensory
C Incomplete Motor < 3 / Incomplete Sensory
D Incomplete Motor > 3 / Incomplete Sensory
E Normal
Spinal shock - state of complete spinal areflexia.
over in 24-48 hours - Bulbocavernosus reflex signifies the end of spinal shock
Treatment of Spinal Cord Injury
o attributed to contusion and/or compression - Microvasculature disruption
o Treatment: Methylprednisolone- bolus 30mg/kg followed by 5.4 mg/kg/hr
over 23 hours. Patients treated within 8 hours respond best.

TRAUMA C-SPINE SERIES AP, lateral, open mouth odontoid

Who needs C-spine X-ray?
Midline cervical tenderness
History of neck/distracting injury
Have focal neurological deficits
Intoxicated / not response to person, time, place and event

NB. Pure dislocation of the spine is commonest in the cervical region

Lateral
adequate exposure - must see occiput to T1, need to be able to see soft tissue
shadows, Swimmers view or CT if unable to see to T1
Specific things to look for
1. anatomic lines -> 4 parallel lines

1)
2)
3)
4)

Anterior vertebral line

Posterior vertebral line
Spinolaminal line
Interspinous line

Also look for soft tissue swelling

(prevertebral fat stripe) which should be
- <6mm at C2 level
- <2mm at C6 level

2. Step deformity of >3.5mm anywhere

Anterior subluxation of 1 vertebra on another indicates facet dislocation
Less than 50% of the width of a vertebral body implies unifacet
dislocation
Greater than 50% implies bilateral facet dislocation
This is usually accompanied by widening of the interspinous and
interlaminar spaces
3. Atlantodens interval (ADI) distance between odontoid process and posterior
border of arch anterior of atlas atlantoaxial instability (AAI) present if
>3mm in adults
>5mm in children
4. Uniformity of shape & height of IV disc (all the same except C1 & C2)
Compression #: anterior wedging of vertebral body or teardrop fractures
of antero-inferior portion of body
Burst #: anterior compression of greater than 40% of normal vertebral
body height (with retropulsion of fragments of the vertebral body into
the spinal canal)
Loss of height disc herniation
5. Angulation 11 greater than contiguous segments (Disruption of the PLL,
Subluxation of C3 on C4)
6. Anterior Occipitoatlantal Dislocation (Powers Ratio)

91

Odontoid view
Shows C1 burst fractures, C1-2 alignment, Dens fractures
C1 Ring Fracture Classification - Posterior Arch - 28%, Jefferson Burst Fx,
Anterior Arch Blow Out, Lateral Mass Fx, Transverse Process Fx
Jefferson Fracture - Axial loading. Open Mouth View - Lateral Mass Spreading, >
6.9 mm = Transverse Lig Avulsion.
C1 Burst Fracture Treatment
1. Stable (Intact Transverse Ligament) - Rx - Halo 10 - 12 wks.
2. Unstable - Traction Reduction, Halo 12 - 16 wks,
Late Instability: C1-2 Fusion
Odontoid Fracture Classification
1. Type 1 - Tip Avulsion, Type 2 Waist (worst),
Type 3 Body
2. Type 2 Unstable, Easily Missed, 10% Spinal
Cord Injury due to translation, Poor Prognosis,
Assoc Fx 20 - 30%
3. Type 3 - Good prognosis, Reduction, Brace (halo
device) vs fixation, heals easily
AP view
Spinous processes should line up and have equal gaps
sagital plane fractures
lateral mass fractures
facet fractures / dislocations (below)

Complete the exam

If films negative remove collar and complete exam.
Palpation- one person supports the head with axial traction while the other palpates
from occiput to T1. Check for tenderness, swelling, stepoff. cannot rely on clinical
exam if decreased mental status or distracting injury.
If symptomatic replace collar.
If negative then proceed to ROM.
Active ROM only. Should be full and pain free.
If exam completely negative and films negative at this point may remove collar. Write
order that C-spine is clear
If unable to perform ROM but the rest of exam is negative: replace collar and have
patient return in 10-14 days for flexion and extension views. If done acutely muscle
spasm or guarding may hide a ligamentous injury.
Obtunded patient with normal films - Leave the collar on. Dynamic Fluoroscopy.
MRI
Hangmans Fracture of C2
Flexion Tear drop fracture of ant-inf part of vertebral body. Unstable fracture.
Treatment gardner-wells traction tongs, halo device

LEFT: Unilateral facet dislocation. (A) Lateral view

of this fracture caused by a flexion-rotation
mechanism shows that it is stable. Anterior
displacement of spine is less than one half of the
diameter of a vertebral body. (B) Anteroposterior
view shows disruption of a line connecting spinous
processes at the level of the dislocation. (C) Oblique
view shows that the expected tiling of the laminae is
disrupted, and the dislocated superior articulating
facet of the lower vertebra is seen projecting within
the neural foramina.

92

DM FOOT (ORTHO)
EPIDEMIOLOGY
- Prevalence of DM is 8.2% (28.4% in 60-69 age group)
- 5% of all Diabetics develop foot ulcers
- In Spore, 2 amputations done daily
o Foot ulcers commonly become infected gangrene result in Major Lower
Limb Amputation
- Mortality: 10% at time of amputation, 30% within a year, 70% within 5 years

Osteomyelitis / septic arthritis

Gangrene (dry/wet)
Charcots osteoarthropathy
Necrotising fasciitis

HISTORY:
PATIENT PROFILE (include OCCUPATION! nature of job)

2. VASCULOPATHY:
o Microangiopathy:
terminal arterioles
thickening of basement membrance of endothelium
o Atherosclerosis: middle-sized and large arteries

PRESENTING COMPLAINT: ulcer/abscess/gangrene, pain/swollen/infection

When did you sustain the injury? How was it sustained? What were you doing at
that time?

Footwear at point of injury?

When did you discover it? How did you realize it?

If not discovered at point of injury reason? Numbness/weakness

Precipitating injuries: trauma, rusty nails, pressure

Type of wound: open/closed, bleeding?

Progression of injury: grew bigger, more painful, discharge, gangrene

1st episode? Any previous injuries of similar nature?

Ask for poor wound healing

3. IMMUNOPATHY
o Defects in leukocyte function (phagocytosis, chemotaxis, adherence,
neutrophil dysfxn)

PAIN:

SOCRATES

Localised to toe/heel?

PATHOGENESIS OF DM FOOT
1. NEUROPATHY (20-40% of all diabetics)
o Sensory
o Motor
o Autonomic

Inherent susceptibility to infections

Mild monomicrobial
Severe polymicrobial, a/w ostemyelitis
Prior use of ABx predisposes to MRSA & Pseudomonas

Vascular claudication
1) Pain in muscle (usu described as cramp)
2) Only on exercise (ask abt claudication distance: quantify in eg. no. of bus stops)
3) Disappears on rest

Predominantly Gm positive cocci (Staph aureus, coagulase ve staph eg.

epidermidis, Group B Strep, Enterococci, Corynebacterium)
All forms of Staphylocci a/w increased risk of mortality

Followed by Gram negative rods (eg. Pseudomonas (rotten fruit smell, green
discharge), Proteus, E. coli) and anaerobes eg. Bacteroides (faecal smell)

Rest pain (present at rest throughout day and night)

o Continuous severe aching pain bad enough to stop sleep and use of limb;
o Usu in most distal part of limb (toes and forefoot)
o A/w gangrene pain at border of living and dead tissue
o Relieved by hanging leg over side of bed; prefer to sleep sitting in chair
o May be so bad (unremitting, progressively worse) that beg for amputation
NB: Critical limb ischaemia (rest pain and ulceration/gangrene)
o ? Night pain

MODES OF PRESENTATION:

Cellulitis
Abscess (supf/deep)
Ulcer (decubitus / vascular / neuropathic)
93

ULCER:

Site:
Plantar (sole) neuropathic
Heel/toes vascular (ischaemic)

Size

Any discharge? Colour? (green Pseudomonas)

Foul-smelling? (eg. fish, rotten fruit smell)

Pain?

Recent trauma / foreign body penetration eg. rusty nail (even seemingly
insignificant)

Footwear (ill-fitting shoes, slippers, barefeet)

SWELLING:

Acute onset

Pain

Erythematous, warmth

Discharge? colour, odour, pus

Fever chills rigors

SWOLLEN JOINT

Symptoms of inflammation red, hot, swollen, pain, loss of function think

septic arthritis

Weakness, difficulty walking, deformity think Charcots arthropathy

GANGRENE:

Toe/ heel/ foot

Dry/ wet?

Other symptoms of ischaemia claudication, rest pain, cold extremities,

discolouration
HISTORY OF SELF-MEDICATION

Seek medical help from doctors?

Sinseh : skin burns ulceration sepsis

Self-medicate : nail digging, self cutting callosity

DIABETES HISTORY (DETERMINE TYPE 1 OR 2):

How long? How was it diagnosed?

Treatment: Diet/OHGAs/Insulin/Combination? Dosage/med changes, compliance

Control: Symptoms of poor control to ask: 1) polyuria, 2) polydipsia, 3) polyphagia

Monitoring of DM: hypocount, HbA1c; what are the usual values? How often
follow-up? Did doctor say good control?
Previous hospitalizations for DM, any surgery done? DKA, HHNK, abscess, ulcer,
gangrene etc
Complications:
o Microvascular

Retinopathy blurring of vision, cataracts, previous laser PRP

Nephropathy bubbly urine (?microalbuminuria), 24hr urine test CCT,

UTP

Neuropathy Sensory: numbness, paraesthesia, loss of proprioception

Motor: weakness
Autonomic: postural hypotension, gastroparesis,
diarrhoea, impotence
o Macrovascular

CAD IHD (CP, SOB), h/o AMI, cardiomyopathy

CVA TIA, major stroke

PVD paraesthesia, intermittent claudication, pallor, poor wound healing

Co-morbidities HTN, IHD, CVA, CRF (worst combination with DM),
Other risk factors smoking, HTN, HCL (aggravates atherosclerosis)
Functional status community walker / housebound / unable to walk (stroke), can
do household chores? ADL independent? How does the current orthopaedic
problem affect the pts function in general?
Care-giver?
Family history of DM

Determine if Foot ulcer is: Vascular

- punched out
- gangrene
- ischemic limb sympts

Neurogenic
- painless
- deformed joints
- loss of sensation (vibration,
proprioception)

PHYSICAL EXAMINATION:
GENERAL:

Well / ill / toxic

Acidotic breathing (Kussmaul)

Alert, oriented / drowsy (hypoglycaemia)

Pallor / sallow appearance (renal failure)

Dehydration: furred tongue, dry mucosa, sunken eyes

Fundoscopy diabetic retinopathy

94

VITALS

BP (both sides, postural)

Palpate ALL pulses carotids (thrill, bruit), UL, LL

SYSTEMIC REVIEW: Heart, lungs, abdomen
LOCAL EXAMINATION:
Inspection:

Skin:
o Scars, Sinus, Healed wounds
Signs of PVD (chronic ischaemia):

Shiny

Loss of hair

Dusky discolouration, pale

Trophic nail changes

Pigmented skin

NO varicose veins (good negative to mention)

o Signs of DM neuropathy

Sensory:
Joint deformity (charcots jt, claw toe, hammer toe)

Motor:
Muscle wasting

Autonomic:
Dry skin, Fissuring, Callosity
Ulcer:
o Site interdigital web space, dorsum, sole, heel
o Size
o Shape
o Floor: pus, slough, necrotic tissue, granulation tissue
o Edge: punched-out vascular; irregular
o Any foreign body in ulcer?
o Surrounding skin : erythematous, necrotic, warm, tender
Swelling
Cellulitis
Gangrene dry / wet?

Popliteal pulse
Femoral pulse
o NB: Vasculopathy assessment: (prognostic significance for distal amputation)

2 pulses palpable v good chance of success

1 pulse fairly good

0 pulses NO chance
Ulcer:
o Tenderness, bogginess around ulcer
o Squeeze surrounding skin for discharge quantity, colour, odour
Tenderness of each individual metatarsal bone / joint (OM, SA):
o dorsal surface
o deep palpation of SOLE (pus tends to be dependent)
Sensation:
o Semmes-Weinstein monofilament (5.07 gauge applies 10g of force test 9
points on sole and 1 point in 1st web space if pt cannot feel means high risk!!!
o Vibration
o Propioception
o Pin prick
o Light touch
Motor (usually not required): test ankle reflexes.
Test upper limb for glove and stocking distribution too!

Move:

Palpation:

Temp warm (normal?) / hot (infected) / cold (ischaemia)

Capillary refill time (<2sec)
Pulses DP (midpt of 2 malleoli, 1/3 way down to 1st digital cleft)
PT (hip in ER, knee flexed, foot dorsiflexed, 1/3 way down line from med
malleolus to TA)
95

Buergers test (2 components):

o Pt supine, raise LL, look for pallor of sole and toes, record vascular angle
Normal: 90deg pink
Ischaemia: 15-30deg pallor
Critical Ischemia: <20deg
o Pt sitting with legs hanging over side of bed, note time of reactive hyperemia
Normal: remain pink
Ischaemia: white to pink
CAPILLARY FILLING TIME >15-30 secs = severe ischaemia
ABI:
o Doppler ultrasound probe used to measure ankle systolic pressure (should have
3 waveforms systolic, diastolic, recoil. If only 2 means already partial
obstruction.)
o ABI = Ankle systolic press/Brachial systolic press
Normal
> 1.0
Ischaemia
<0.8
Min to mod dz
0.5 0.9
Severe dz
<0.5
Critical ischemia <0.3
o Digital pressure index
Normal >0.7
Abnormal <0.7

INVESTIGATIONS:
BLOODS

FBC anaemia, TWC with differential count for infx ( leukocytosis, polymorphic
neutrophils)

ESR, CRP (acute phase reactants)

U/E/Cr nephropathy

Venous bld glucose (fasting >8mmol/l, random> 11mmol/L)

Hypocount (TDS including 10pm)

HBA1c normal 4-7%

Urinalysis glycosuria, ketonuria (DKA), proteinuria (nephropathy)

Blood c/s if septic

(For medical case, please include urine dipstix, lipid profile)

CULTURES

Wound swab of ulcer take pus and from deepest possible part to increase yield
o Gram stain
o C/s (aerobic and anaerobic)
IMAGING

ECG cardiac status

CXR anaesthesia fitness

X-ray foot (AP, Lat):

1. Osteomyelitis rarefaction / osteopaenic, erosions, periosteal reaction (early),
cortical sclerosis (chronic)
2. Septic arthritis widening of jt space, periarticular osteoporosis (early), jt
space narrowed (+/- erosions) (late)
3. GAS gangrene Clostridium, Strep. Microaerophiles excl NECROTISING
FASCIITIS if theres gas present
4. Bony destruction (Charcots/ LisFranc jt) neuropathic changes
5. Calcification of vessels
6. Foreign body

Duplex scan arterial insufficiency

Angiogram, femoral (if vascular reconstruction needed) localize areas of

occlusion amenable to bypass Sx or angioplasty

MANAGEMENT:
WAGNER CLASSIFICATION of DM foot ulcers: This determines management. In
general, lower grades respond to ABs and debridement. Higher grades (2-5) require
amputation.
Grade

Description

Superficial ulcer, no penetration

into deeper tissue, no infection
Deep ulcer extending to muscle,
tendon, bone, ligament

Foot at risk, No open wound

Infection of deep tissue with pus,

Treatment

Patient education
Accommodative footwear
Regular clinical, podiatry exam
Offloading with total contact cast
Walking brace/special footwear
Surgical debridement
Wound care
Offloading
Culture-specific Antibiotics
Debridement or partial amputation
96

gangrene (e.g. tendinitis,

osteomyelitis, deep abscess)
Forefoot gangrene

Whole foot gangrene

Offloading
Culture-specific antibiotics
Lower extremity amputation
Vascular consultation
Major extremity amputation
Vascular consultation
o

KINGS CLASSIFICATION
Clinical Condition
Normal
High-risk
Ulcerated
Cellulitic
Necrotic
Major Amputation

Stage
1
2
3
4
5
6

General measures:

IV Line for DS/NS at least 1.5L/day to prevent DEHYDRATION

Intake/output charts urine output monitoring
Diabetic chart Hypocount TDS including 10pm (watch out for
HYPOGLYCAEMIA)
IV antibiotics (broad spectrum: Augmentin (Gm positive cocci, Gm negative
rods, anaerobes) or Clindamycin (Gm positive, anaerobes, esp for necrotising
fasciitis) + Ciprofloxacin (Gm negative), ONCE c/s results obtained change to
culture-specific antibiotics
Daily wound dressing Chlorhexidine, flush with H202, saline then
Chlorhexidine dressing
Elevate leg if swollen
Topical antibiotics:
BNP (bacitracin, neomycin, polymycin) powder for Pseudomonas
Bactroban cream for MRSA

Surgery:

I&D for ABSCESS

Radical debridement for ULCER all slough excised, exposed tendons
excised (or else become necrotic), in heel whole part of TA exposed must be
excised (desloughing)
Heel ulcer / gangrene unless successfully resurfaced = BKA

Dry gangrene:

Gangrene dry / wet determines

management options
If vascular cause consider whether
amenable to bypass or not

Pulses usually v bad

Clean with ethanol, splint and dressing
Prophylactic antibiotics (sides usually get infected)
Toe may auto-amputate
Ray amputation can be considered in young pt (in older pts better to leave it
alone after all its quite easy to care for dry gangrene)
+/- Hyperbaric Oxygen Therapy (HBOT)

Wet gangrene: AMPUTATE

Ray amputation (open/closed)

Amputation of digit through metatarsal removing large part of 1 ray
Open ray for adequate drainage of pus involving 1 ray, upon healing
with health granulation tissue, split skin graft is used
Closed ray if after debridement all infectious tissue has been removed,
close wound by tagging

Disarticulation at joint (PIP, DIP)

Ray amputation (through metatarsal)
Forefoot
Lisfranc (Tarsometatarsal)
Chopards (Midtarsal)
Symes (through ankle) rare, requires good PT pulse [MCQ]
BKA require 30% more energy to walk; bilateral BKA 40%
Through knee (Stokes-Gritti)
AKA require 40% more energy to walk
Hip disarticulation
Hindquarter amputation (hemipelvectomy)

Multidisciplinary approach

Orthopaedic surgeon, vascular surgeon

Endocrinologist
Infectious Disease Specialist
Podiatrist
Diabetic Nurses, Wound-Care Nurses
Dietician
PT/OT
MSW
Amputation support group
97

POLYTRAUMA
Definition of polytrauma

Injury to several (>1) physical regions or organ systems where at least 1 injury or a
combination of several injuries is life threatening

Different from multiple injuries not life threatening or a severe life-threatening

single injury (barytrauma)
Trimodal peak of trauma mortality:
- 1st hour after injury: most patients die
- 1-4 hours after injury: golden hour Death usually caused by hypovolemic shock
- Several weeks later: late complications & multiple organ failure
Mechanism of accident
Deceleration trauma
Fall trauma
Trauma resulting from being run over
Crush trauma
Avulsion trauma
Penetrating injury
Explosion injury
Thermal injury
Chemical injury
Radiation injury

Important to break the figure down into its components, such as E3V3M5 = GCS 11.
A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate
injury and 8 or less a severe brain injury.
Abbreviated Injury Scale
An anatomical scoring system.
Injuries are ranked on a scale of 1 to 6, with 1 being minor, 5 severe and 6 an
unsurvivable injury.

Suspect Polytrauma when:

- Fall from height > 3m
- Ejection from vehicle
- Death of fellow passenger
- Pedestrian/Motorcyclist and car
- High speed accident
- Entrapment, Pinning or Burial
- Explosion

Glasgow Coma Scale

Eye Response (4)
Eyes open spontaneously 4
Eyes open on verbal command 3
Eyes open to pain 2
No eye opening 1

Motor Response (6)

Obeys commands 6
Localising to pain 5
Withdrawing from pain 4
Flexion to pain 3
Extension to pain 2
No motor response 1

Verbal Response (5)

Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No verbal response 1

AIS Score Injury

Injury Severity Score
Each injury is assigned an AIS score and is
1
Minor
allocated to one of six body regions (Head,
2
Moderate
Face, Chest, Abdomen, Extremities (including
3
Serious
Pelvis), External). Only the highest AIS score
4
Severe
in each body region is used. The 3 most
Critical
severely injured body regions have their score 5
squared and added together to produce the ISS 6
Unsurvivable
score.
The ISS score takes values from 0 to 75. If an injury is assigned an AIS of 6
(unsurvivable injury), the ISS score is automatically assigned to 75.
The only anatomical scoring system in use and correlates slinearly with
mortality, morbidity, hospital stay and other measures of severity.
weaknesses
o any error in AIS scoring increases the ISS error,
o many different injury patterns can yield the same ISS score and
injuries to different body regions are not weighted.
o the ISS (along with other anatomical scoring systems) is not useful as a
triage tool.

98

Example

Region

Injury Description

AIS

Square Top Three

Chest

Cerebral Contusion

Head & Neck

No Injury

Face

Flail Chest

16

Abdomen

Minor Contusion of Liver

Complex Rupture Spleen

2
5

25

Extremity

Fractured femur

External

No Injury

Injury severity

o
50

Physiological response to polytrauma

Mediated mainly by:
Tissue damage
Hypovolaemia
Manifested by
Changes in cardiovascular system
Inflammatory reaction
SIRS ARDS MOF
immune suppresion
Changes in metabolic status
Closely interlinked by the neuroendocrine system.
Hypovolaemia 1
Systemic compensation by

sympathetic activation

Renin-angiotensin-aldosterone activation

Anti-diuretic hormone secretion

o Reduced right heart filling pressure reduced oxygen uptake
o Reduced left heart filling pressure 2 reduced pulmonary venous return
reduced cardiac output

Less inhibitory stimulation of baroceptors in aortic arch & carotid sinus

reflex inhibition of vagal activity + sympathetic stimulation to heart & vessels
CO & SVR
o (cerebral & myocardial vessels not involved; peripheral
vasoconstriction in cutaneous, skeletal & visceral tissue, preserving
circulation to important organs (brain, heart & kidneys)
Further intravascular loss distortion of incompletely filled chambers
stimulates cardiac C fibres reflex vagal slowing of heart rate + vasodilation
circulatory collapse
Chemoceptors of carotid sinus & aortic arch becomes more sensitive to PaO2
at PaCO2 (pH) tachypnea, vagal slowing of HR, sympathetic
vasoconstriction in skeletal muscles
High sympathetic drive causes catecholamine release from adrenals
activation of renin-angiotensin-aldosterone system further release of
corticosteriod, antidiuretic hormone, glucagon, insulin & human growth
hormone Na & water retention to incr circulating blood volume & maintain
BP
Cellular compensation by anaerobic respiration
o compensatory anaerobic metabolism lactic acidosis

Classification of shock
(% of blood
Class I
loss)
<15%
Pulse pressure
Resp Rate
14-20
Urine outpt
>30
Mental status -

Class II
15-30%

20-30
20-30
Mild anxiety

Class III
30-40%
(SPB)
30-35
5-15
Confused

Class IV
>40%

>35
Neg
Lethargic/
obtunded

Inflammatory response 1,2

Any tissue injury generates a local inflammatory response
(with/without pre-existing infection) directed at elimination of dead
tissue, foreign invaders & healing
Greater trauma causes more inflammatory reaction

Cellular mediators: PMNs, macrophages & fibroblasts

Cytokines: esp IL-1 & TNF-
Complement system: esp C3 (anaphylactoid reaction) & C5 (PMN
stimulator)
Prostaglandins: thromboxane, prostacyclins etc
99

 Acute-phase reactants Liver synthesis of acute phase reactants such as

opsonins (CRP), protease inhibitor, haemostatic agents (fibrinogen) &
transporters (transferin)
Stress hormones: adrenaline, cortisol release Insulin secretion
suppressed, glucagon enhances glycogenolysis overall hyperglycaemia

Overwhelming inflammatory response

Both pro-inflammatory + anti-inflammatory cytokines are generated in an
inflammatory response
Major trauma causes systemic release of inflammatory agents
Spillover of such inflammatory agents systemically can occur with major trauma
Systemic inflammatory response syndrome (SIRS)
ARDS /MOF
In severe states, SIRS can evolve into acute respiratory distress syndrome
(ARDS) or multi-organ failure (MOF)
SIRS can occur in a non-septic state
ARDS or lung failure is usually the first to occur followed by other organ
systems damage with hypoxia(MOF).
MOF can occur in without SIRS
SIRS can be precipitated by a 2nd time injurious event (eg: surgery or secondary
infection) after the initial trauma 2-hit theory of SIRS

Liver Glycogenolysis & gluconeogenesis

Anaerobic metabolism lactic acidosis
Skeletal muscle catabolism (-ve nitrogen balance) substrate for liver
gluconeogenesis (negative nitrogen balance)
Lipolysis release of FFA & glycerol (TG & LDL)
High resting energy expenditure - General catabolic state
body temperature
Convalescent state
Insulin secretion resumes, insulin resistance decreases
Aerobic respiration reestablished

Clinical manifestation of SIRS

Defined as presence of 2 of the following signs:
Hyperthermia >38C or hypothermia <36C
Tachycardia >90bpm
Tachypnea >20breaths/min or PaCO2<32mmHg
Elevated/depressed white cell count [>12,000/uL or <4000/uL] or 10%
immature band forms
Initial hypermetabolism

Early hyperglycaemia

Plasma cortisol increases in proportion to injury with corresponding sympathoadrenal response (until adrenal perfusion fails)
Early hyperglycaemia occurs with increased sympatho-adrenal activity
Peripheral insulin resistance & depressed insulin secretion with high circulating
catecholamines & glucagon release
Skeletal glycogenolysis
100

Life and Limb Threatening Conditions

Life Threatening Conditions:
Airway
1. Facial fractures
a. major fractures of maxilla and mandible
b. nasal intubation not recommended
2. Larynx injuries
a. presents with stridor, hoarseness, crepitus in the neck and rapid respiratory
obstruction
b. do tracheostomy to secure airway
Breathing
1. Spinal injury
a) always assume cervical injury until proven otherwise
b) high cervical cord transection paralyses intercostal muscles and diaphragm,
c) resulting in apnoea in minutes to hours
d) steroids useful if administered within first 8 hrs
2. Chest injuries
a) Rib fracture: presents with tenderness and crepitus
b) Tension pneumothorax: accumulation of air under pressure in the pleural
space. This develops when the injured tissue forms a one-way valve,
allowing air to enter the pleural space & preventing the air from escaping
naturally.
i. Air trapped pushes heart and mediastinal structures to the
contralateral side, impinging on the contralateral lung.
ii. Hypoxia decreases venous return and cardiac output, causing
hypotension.
iii. Haemodynamic collapse leads to death.
c) Haemothorax
d) Pulmonary contusion: parenchymal damage leads to impaired gaseous
exchange.
e) Flail chest: paradoxical movement of a segment of chest wall, usually
caused by fracture of 3 or more ribs, resulting in injury to heart and lungs,
leading to pulmonary contusion, VQ mismatch and respiratory distress.
3. Fat embolism
- Results when embolic marrow fat macroglobules damage small vessel
perfusion leading to endothelial damage in pulmonary capillary beds
- Risk factors
Long bone # [note that the risk is especially high with femoral shaft
fracture and concomitant head injury]

Risk is higher w/ non-operative therapy but is also higher w/ overzealous reaming of femoral canal
Multiple trauma w/ major visceral injuries and blood loss (incidence may
be as high as 5-10%)
- Cause of death on 3rd day after pelvic fracture is due to fat embolism
- NB. Complications of skeletal traction do not include fat embolism
- Clinical manifestations
Symptoms usually begin 24-48 hours after injury
Major criteria
Hypoxia
Altered mental status
Petechial rash
Minor criteria
Tachycardia (>110/min)
Tachypnoea
Hypotention
Fever (>38.5 C)
Retinal changes of fat globules or petechiae
Renal dysfunction
Jaundice
Acute drop in hemoglobin and/or platelets
Elevated ESR
1 major and 4 minor criteria, plus fat microglobulinemia, must be
present to formally diagnose fat embolism syndrome
- Treat the hypoxaemia
4. Thromboembolism (DVT)
- develops 5-7 days later, worried about pulmonary embolism
5. Tetanus
- develops 7 days later
- administer tetanus toxoid as prophylaxis, especially with lacerations, abrasions,
dirty wounds and open fractures
Circulation
1. Posterior dislocation of sternoclavicular joint
2. Abdominal injuries: liver injuries and splenic rupture
3. Pelvic ring fracture
4. Hip injuries: may sustain internal bleeding and neuropathies as well. Usually
caused by dislocations and fractures.
5. Femoral shaft fractures: femoral artery involved

101

Limb Threatening Conditions:

Vascular Impairment
- Haemorrahge: visible or occult
- Ischaemia: acute interruption of flow of blood to a limb or organ.
Anaerobic respiration predominates, leading to lactic acidosis and
eventually cell death.
- Causes: Dislocations or fractures
- Arteries involved: Axillary, brachial, femoral, popliteal

Mangled Extremity
- High energy transfer or crush resulting in some combination of injuries to
arteries, bones, tendons, nerves and/or soft tissue
- Scored using MESS (Mangled Extremity Severity Score)
A) Skeletal/ Soft Tissue Injury
Low energy (stab: simple fracture; pistol/ gunshot wound)
Medium energy (open or multiple fractures; dislocation)
High energy (high speed MVA or rifle GSW)
Very high energy (high speed trauma + gross contamination)
B) Limb Ischemia
Pulse reduced or absent but perfusion normal
Pulseless; paresthesia, diminished capillary refill
Cool, paralysed, insensate, numb
C) Shock
Systolic BP always > 90mmHg
Hypotensive transiently
Persistent hypotension
D) Age (years)
<30
30-50
>50
* Score doubled for ischaemia > 6hrs
- Acutely differentiates salvageable and unsalvageable limbs
- MESS 7 carries a 100% predictive value for amputation
Acute Compartment Syndrome
- pressure within a closed muscle compartment exceeds the perfusion
pressure
- tissue pressure exceeds venous pressure and impairs blood outflow

1
2
3
4
1*
2
3*
0
1
2
0
1
2

lack of oxygenated blood and lack of waste product removal results in pain
and decreased peripheral sensation secondary to nerve irritation
caused by either external restriction of compartment (eg. tight splints, casts,
dressings) or internal increase in compartment volume (eg. haemorrhage,
post-ischaemic swelling)
5Ps: Pain, paresthesia, pallor, paralysis, pulselessness
Complications: muscle necrosis, Volkmann contracture
Treatment: Fasciotomy

Necrotizing Fasciitis
- insidious soft tissue infection characterized by tissue necrosis
- organisms spread from subcutaneous tissue along superficial and deep
tissue planes, of which the latter causes vascular occlusion, ischaemia and
tissue necrosis.
- less seen in multiple trauma
- 3 types of NF: Type 1 Polymicrobial NF
Type 2 Grp A Strep NF (Flesh-eating bacterial infection)
Type 3 Gas gangrene
- presents with fever, chills, erythema and painless bullae formation
- treatment: antibiotics and surgical debridement
Gas Gangrene
- onset: 12-24hrs after injury
- commonly Clostridial infection, but may be caused by other organisms
- decreased oxidation reduction potential promotes advance of a highly
lethal condition
- less seen in multiple trauma
- present with intense pain and swelling around the wound
- associated with a brownish discharge and bronze discolouration of wound
- gas (with a musty odour) formation usually not marked
- important to distinguish from anaerobic cellulitis, which presents with
abundant gas formation that is foul smelling in nature
- distinction between the 2 made by doing a Gram stain of the exudate
- management: fluid & electrolyte replacement, antibiotics, multiple
incisions & fasciotomy, hyperbaric oxygen
Osteomyelitis
- infection of bone and bone marrow
- difficult to treat, can be life threatening as well due to septicaemia
- routes of spread: haematogenous, contiguous from a focus of infection
- bacteria can be inoculated at the time of trauma
102

present with fever, headache, vomiting, severe bone pain

treatment: antibiotics and extensive debridement of necrotic tissue

Principles in management of orthopaedic injuries in polytrauma

Polytrauma is defined as the presence of 2 long bones# plus 1 visceral injury OR 2
visceral injuries OR 3 #
In polytrauma patients, limb injuries are the commonest and this can take the form of
long bone # or soft tissue injuries. However it is the head and visceral injuries that are
most lethal.
Management

Primary survey

Acute or resuscitation period (1-3 hrs after trauma)

Primary or stabilization period (<24hrs)
Secondary or re generation period (3-8 days)
Tertiary or rehabilitation period (>8 days)

Continued haemodynamic and resp stability

Debridement of soft tissue necrosis
Eliminate septic foci
Wound closure
Joint reconstruction

Tertiary period

Secondary survey

4 different periods in orthopaedic management of trauma injuries

Secondary period (3-8 days)

Patient weaned off intensive care

Physiotherapy initiated
If patient has developed multiple organ failure, no further operative procedures
can be considered at this stage.

Optimal timing of long bone # stabilization in trauma patients in the primary period
divided into 3 groups of patients:
* Early stabilisation (within 48h) does not improve
Polytrauma
survival but it will benefit some patients, e.g. reduces
without brain
the number of days of mechanical ventilation
and chest injury
(? Improves morbidity)
* Hence it is preferable to perform long bone
stabilisation in polytrauma patients
* No evidence that early stabilisation (within 48h)
Brain injury
improves survival compared to late stabilisation
Chest injury
0B

1B

2B

Acute period

Decompression of organ cavities (tension pnemothorax, cardiac tamponade)

Haemorrhage control

Decision on temporary and definitive fixation of fractures

articular congruity
stable fixation
axial alignment with the rest of the extremity
restoration of full range of motion

Limb salvage v.s. amputation (many scoring systems i.e. mangled extremity
scores/Hannover fracture scale)

Special considerations

If pelvis is fractured, early stabilisation with pelvic clamp is crucial

Primary period(<24 hrs): stabilization of fractures

In definitive treatment of #, in order to preserve normal function, there should be

Pelvis
Spine
103

Long bones

Pelvic #
Ensure that theres no need for general surgical intervention e.g. intra-abdominal
or retroperitoneal haemorrhage
Haemorrhage control with pelvic packing and temporary stabilisation with external
fixators and pelvic clamps
Spine #

Urgent spinal stabilisation required (urgent = within 24h of injury)

Long bones #

Pts with # shaft of femur can lose up to 1L of blood. Femoral shaft fractures
should undergo immediate stabilization of the fracture within 24h of injury

Immediate stabilization of long bone fractures has many advantages in the

multiply injured patient, such as improved long-term function, prevention of
deep venous thrombosis and decubitus ulcer, decreased need for analgesia, and
reduction in the incidence of adult respiratory distress syndrome and fat
emboli19
Recommendations for staged treatment of femoral shaft fractures

FRACTURES
General Mx of #
ABCDE
- Assess neurovascular status, beware of compartment syndrome
- If hypovolaemic IV fluids, packed cells, whole blood
Analgesics
Preliminary skin traction to relieve pain, minimize further displacement
How to determine if # is displaced or not: compare continuity of trabeculae lines
Traction: things to note
Traction can be skin or skeletal
Skeletal traction can be with Thomass splint or pulley frame or both
Traction care
Ring pressure (Thomass splint)
Pressure sores: Buttocks, Tendo Achilles, under heel
Common peroneal palsy weakness of dorsi flexion
Loosening of Steinmann pin
Upper limb fractures dislocations by Lee Yizhi
Fracture
Clavicle

Method

Remarks
Malunion in adults
Excellent remodeling in
children

Sling 3/52
Scapula body:
Scapula neck:

Physio

Sling & physio

ORIF if # dislocat
n

AC subluxat :
n
AC dislocat :

Sling ~1/52 & physio

young and active : Arthrodesis, 3/52

rest, physio
Inactive: Sling & physio
Late OA: excision outer 1/3 clavicle
Sternoclavicular
n
dislocat
n
Anterior dislocat :

Anterior: conservative
Posterior: ORIF
Reduction under GA
Hippocrates/Kochers

Associated with 1)rib #

2)lung contusion
3)hemo/pneumothorax
Body # by crushing force
n
Partial dislocat : AC
ligaments torn
Complete dislocation: CC
ligaments torn (conoid &
trapezoid)
Tenting of skin may cause
necrosis
n
Post dislocat : Tracheal and
n
vascular compress
X-ray to exclude #
Axillary n often damaged
n
95% of shoulder dislocat s

104

Sling 3/52

dislocation
Pulled elbow

pressure), cast 6/52

Sling 3/7 or
Supinate + flex elbow

Radius and ulnar

in adults:
in
children:
Single forearm
bone
Monteggias:

ORIF (plates/screws/rods)
Long arm cast 6/52, check x-ray at 2/52

Physio
Posterior
n
dislocat :
Prox humerus:

# prox humerus: ORIF

Recurrent: Surgery
n
GA Reduct
Same as ant dislocatn

Neers 1: Sling 6/52

Neers 2: Collar cuff 6/52
Neers 3: ORIF/HemiA
Neers 4: HemiA
All followed by physio

Shaft of humerus

Supracondylar

U-slab 3-6/52 + sling

If very unstable, plate/nail

n
Closed reduct ASAP
C&C 3/52 then sling 3/52
ORIF (dbl plating) in adult for early f(x)
GENTLE physio

Lateral condyle
Proximal radius
in adults:

In children:
Olecranon

Elbow dislocation

Radial head

Undisplaced: C&C 3/52

Displaced: ORIF (Kwire)
Mason 1: C&C 3/52, gentle physio
Mason 2: ORIF plate & screw
Mason 3: Excision in 48hrs
Mason 3 with Essex L: Prosthesis, splint
2/52, physio
o
<20 : C&C 2/52
o
>20 : MUA, if fail OR. If unstable, IF (Kwire)
Stable & undisplaced (<2mm + no
change in flexion + extend against grav):
C&C 3/52
Displaced: tension band wiring
Displaced + comminuted: plate & screw
n
MUA (tract , flexion, push olecranon)
then C&C 3/52 or above elbow backslab

trauma: MUA (supination, direct

Commonly missed!
4% of shoulder dislocatns
Usually seen in osteoporotic
pple >50yrs
Try to conserve head in
young pts even with Neers
3/4
Suspect mets in elderly!

Galeazzis:
Cx: Shortening, angular
deformity (gunstock),
decreased ROM
Acute: Brachial A inj,
compartment sx, volkmanns
ischaemia
Myositis ossificans
Cubitus valgus, tardy ulnar
palsy: corrective osteotomy

Posterolateral most common

Cx= brachial A, median
(AIN)/ulnar, stiffness,
myositis ossificans,
associated #s
Monteggia #, PI Nerve inj

Both in children:
Colles

ORIF or long arm cast 12/52

ORIF (ulnar plating, reduce radial head),
o
n
long arm cast 90 flexion, partial supinat
ORIF (radial plating, reduce ulnar head),
long arm cast in supination 6-8/52
Reduction under GA, immobilisatn 6/52

Undisplaced: Splintage in plaster slab

Displaced: MUA (Biers/ hematoma
block), below elbow backslab 6/52 in
neutral or slight flexion, xray @ 2/52

Smiths (reverse
Colles)
Bartons
Radial styloid/
Chauffeurs
Undisplaced
scaphoid
Displaced
scaphoid
Trans-scaphoid
perilunate
dislocation

As for Colles but with wrist extension

Peri-lunate
dislocation

Closed reduction, cast 6/52

If irreducible, OR with IF of scaphoid # if
present, CTR and ligamental + capsular
repair
Undisplaced: Crepe bandage 3/52 and
finger exercises
Displaced: Closed reduction, plaster
slab 3/52, finger exercises
Displaced + unstable: ORIF with K-wire

Metacarpal

ORIF with buttress plate

Percut K-wire/ lag screw
Below elbow cast (exclude PIPJ) 10/52

Pain, lateral tenderness,

refusal to move arm
9m-6yrs
No X-ray findings
Radial head slips out of
annular lig
Compartment sx, PIN/ AIN
inj, delayed/non/mal-union,
PIN
Non-union!
Cross-union
Radial/ PIN palsy (Mont),
ECU & EDM inj (Gal)
myositis Ossificans, nonunion, missed dislocation

EPL rupture, malunion,

median n compression,
Sudecks atrophy, DRUJ
n
subluxat , hand shoulder
stiffness

A/w lunate dislocat

AVN, non-union, scaphoid

collapse, OA

ORIF, cast 3/52

Chronic carpal instability

Median n compression
Lunate AVN leading to OA

Rotational malunion,
stiffness

105

Bennets (intraart # dislocation

@ base of CMCJ
of thumb)
Phalangeal

Mallet finger
Game-keepers
thumb

CRIF with precut kwires

Undisplaced: buddy splintage 3/52

Displaced: MUA, plasterslab 3/52 or IF
with Kwires
Splinting in extension 6/52
Partial tear: short arm cast w thumb
spica
Gross instability: ligamental repair

Treat open wounds first!!

Impt Hip & Lower Limb #s and Ds (plus impt tendon ruptures)
Type
Acetabulum, #

Hip, post. D
-- Hip is flexed, add & int rot

Hip, ant. D
-- Hip is abd, ext rot

Fem epiphysis, slipped

-- fem shaft move up & ext rot on
epiphysis
Neck of Fem (intracap) #
-- shortened, ext rot
-- 1. subcapital, 2. transcervical
-- osteoporosis impt factor
Garden Classification
o Typ 1: incomplete #,
trabeculae angulated
o Typ 2: complete #, trabeculae
disrupted but NOT angulated
o Typ 3: complete #, fem head
rotated, trabeculae disturbed,

Treatment
o minimal displc/ highly frag
Traction, Hamilton-Russell
o main part intact, fem head displc
ORIF w cancellous screws &
plates
o Muscle relaxant + Reduce, flex
knee, hip 900, correct add & int
rot, lift fem head into
acetabulum
o OR if irreducible
o ORIF if a/w #s elsewhere
o Muscle relaxant + Reduce, flex
knee, hip 900, correct abd & ext
rot, push down, convert to post.
D, lift fem head into acetabulum
o IF w screws + Manipulate if slip
> 30% + epiphyseal closure
o Subtroch Osteotomy if
epiphysis closed (chronic)
o Undisplc --> CRIF
o Displc --> Arthroplasty
o unfit for multiple Sx or badly
displc, typ 4, avn & non-union
likely --> Hemiarthroplasty/
Total hip replacement w/o
tryring CRIF

Remarks & specific Cxs

Cxs
o Hemorrhage > 5L
o Ruptured urethra, bladder
o Bowel injury
Cxs
o Irreducible due to in-turned
labrum or bony frags in
acetabulum
o # (fem head, NOF, patellar,
fem shaft)
o Sciatic nerve palsy
o AVN due to tearing of
capsule
o 20 OA
o Recurrent D
o Myositis Ossifcans (post
exploration or D a/w head
injury)

displc
o Typ 4: complete #, totally
displc
Neck of fem, basal (extracap) #
-- shortened, ext rot
Intertroch #
-- shortened, ext rot
Types:
1) # line thru mass of Great
Troch,
2) (1) + separation of Less
Troch,
3) separation of Great & Less
Troch,
4) 4. w a spiral # down prox
fem shaft
Fem shaft #
-- leg is shortened, ext rot, abd
due to pull of quds & hams

o AVN
o Involvement of Other Hip
Tx principles
o Young (< 50 y.o.) CRIF
o Elderly --> arthroplasty
Cxs
o AVN disruption of
arterial ring @ base of neck
o Non-union typ 3 & 4,
bone graft (young),
arthroplasty (elderly)

Fem Supra, Uni, T & Y

condylar #

Patellar D

o Displc/ Undisplc --> ORIF w

DHS or Gamma Nail, fixation
not removed unless pat < 45 y.o
or pain
o Stable, little frag DHS w
long plate
o Unstable DHS w long plate
or Gamma Nail, then nonweight bear crutches after 48 hrs
to 16 weeks
o Alt -->Traction +/- Thomass
splint

Cxs
o AVN & non-union NOT
common

Cxs
o Failure of fixation (cutting
out of fixation device)
coxa vara*
*if early, bedrest & skeletal
traction

o Traction to overcome pull of

quads & hams
o Intramed Nail
o Alt --> Traction, EF (Ilizarov),
Plating
o Fem & Tib # Cx rate high,
early mobilisation by Intramed
Nail
o Metastatic # Intramed Nail
+ packed cement to relieve pain
& give support
o Fem shaft # w nerve palsy
exploration w repair + IF
o Fem neck & prox shaft #
DHS + long Plate
o Fem shaft & patellar # close
nailing for both, mobilise knee
early
o Open # deribement + IF
o Open #, IIIB,C conservative
or EF
o Child supracondylar plaster
o Others IF for good reduction
& permit early mobilisation
o If displc, grossly comminuted
conservative w traction
o CR, plaster backslab x 3/52,
knee exercise

Cxs
o Hypovolemic shock
o Fat embolism
o Delayed Union, Non-union
esp. conservative
o Mal-union lat. Angulation
Tx = osteotomy
o Limb Shortening
o Knee stiffness due to
quads tethering, knee jt
invovlement or prolonged
immobilisation
o Infection

Remarks

106

Patellar #

Tibial tubercle, avulsion

Quads tendon, rupture

Patellar ligament, rupture

Tibial plateau, #
o all involve articular surface
o key is to get knee f(x) vs pretty
x-ray
o knee exercises ASAP
o bumper #
o commonly lat. tibial condyle

Tibia & Fibula, #

o Usu. # both, esp. adult
o commonly open
o usu. spiral #

o vertical # --> cylinder cast 6/52

w crutches during first 2/52,
physio after cast removal
o horizontal, undisplc # --> as of
above
o horizontal, displc # --> 1. sight
communition: ORIF, 2. limited
damage to patellar: partial
patellectomy, 3. major damage:
patellectomy, repair quads
insertion & lateral expansions
o CRIF (w screw)
o ORIF (risk of premature
epiphyseal fusion in child)
o Tendon reattachment, plaster
cast, quads exercises at 2nd
week, weight bear at 4th week,
felxion at 6th week
o As of above
o minimally displc --> aspirate
hemarthrosis, compression
bandage, CPM & active
exercise, weight bear after 6/52
o comminuted--> aspirate,
compression bandage, sk
traction, CPM & exercise
crutches after 6/52
o depressed # --> CR or ORIF,
active exercises ASAP, castbrace after 2/52
o closed, minimally displc --> full
cast x 12/52 (upper thigh to MT
necks, knee slight flexion, ankle
at 900), exercise foot, ankle,
knee ASAP
o closed, displc --> MUA (IF
when CR fails), full cast x
12/52, exercise ASAP
o comminuted --> EF x 6/52 +
partial weight-bear, then f(x)al
brace
o open --> Ab ASAP, debride,
clean, leave open (above grd II),
EF to stabilise, WI, suture or
graft when granulate

Injuries to patellar & extensor

apparatus of knee
(patellar #, rupture of quads
tendon, rupture of patellar
ligament, avulsion of tibial
tubercle) due to:
1) direct force on knee
2) violent contraction of quads
Every knee injury, exclude:
o damage to extensor
apparatus
o lateral D of patellar w
spontaneous reduction
o torn ligaments
o torn mensici

Cxs
o Compartment syndrome
o Valgus deformity
o Joint stiffness

Cxs
o Infection
o Vascular injury (prox #
damage pop artery)
o Compartment Syndrome
o Delayed, Non-union -->
Intramed Nail + bone graft
indicated
o Malunion --> angulated -->
osteotomy

Ankle, ligament injury

o partial/ complete tear of lateral
ligament
o bruising, swelling, tenderness
o painful passive inversion
o complete tear --> excessive
movement
Ankle #
o normally talus seated in
mortise
o one or both mall can be #
o eversion + ext rot = oblique #
of lat mall (pushed off),
transverse # of med mall
(pulled off); vice-versa for
inversion
Distal tibial & fibular
epiphyses, #-separation
o physeal injury

Calcaneum #
o fall from height
o calcaneum driven up against
talus
o flattened Bohlers angle
o check hip, pelvis, spine for #
o extra-art --> involve posterior
part, calcaneal processes
o intra-art --> oblique # line, run
to superior articular surface

o partial --> crepe bandage,

activity ASAP
o complete --> plaster
immobilisation or operative
repair
o 1 mall # --> reduce, cast x 6/52
(below knee), IF with screw if
frag large
o 2 mall #, below tibiofibular jt -> CR, +/- IF ,cast
o 2 mall #, above tibiofibular jt -->
unstable, IF with screw for frag
& plate for fibula, +/- transverse
screws between tibia & fibula
o Salter-Harris 1,2 --> MUA, full
cast x 3/52, below knee cast x
next 3/52
o Salter-Harris 3,4 (undisplc) -->
as above, re x-ray 5d after to
ensure good reduction
o Salter-Harris 3,4 (displc) -->
ORIF, below knee cast x 6/52
o undisplc --> exercise ASAP,
bandage after swell subside,
nwb crutches x 6/52
o displc, avulsed tuberosity -->
CRIF, immobilise in equinus
(relieve tension of tendon Ach),
wb after 6/52
o displc, intra-art --> ORIF +
bone grafts, splint & elevate,
exercises ASAP, nwb crutches
after 3/52, wb after 12/52

Cxs
o Adhesions
o Recurrent subluxation

Tx principles
o reduce to restore shape of
mortise
o plaster x 8/52
Cxs
o Joint stiffness
o OA (not common)
Cxs
o Mal-union (valgus)
o Asymmetrical growth (# thru
epiphysis may cause fusion
of physis)
o Shortening of leg
Tx principles
o elevate leg + ice packs -->
decrease swelling
o x-rays, CT scans (better
views)
Cxs
o Broadening of foot
o Talocalcaneal stiffness -->
subtalar arthrodesis or triple
arthrodesis

107

Chronic OM: pus discharges through cloacae (perforations) in the involucrum

BONE & JOINT INFECTIONS

Types:

Clinical features

1.
2.
3.
4.
5.
6.

Acute haematogenous osteomyelitis

Subacute haematogenous osteomyelitis
Post-traumatic/operative osteomyelitis
Chronic osteomyelitis
Acute suppurative arthritis
TB infxns of bone & joints

Investigations

Waldvagel Classification:

A haematological spread
B a/w wound
C contiguous spread from local infection
1) type of organism
2) site of infection
3) host response (immunocompromised?)
Principles of treatment

Rest affected part

Provide analgesia & general supportive measures
Initiate antibiotic treatment
Surgical debridement (of pus & necrotic tissue)

A = sound bone
B = new bone
C = involucrum
D = cloaca
E = sequestrum

ACUTE HAEMATOGENOUS OSTEOMYELITIS

Common organisms:

Adults: Staph. Aureus

Children <4YO: H. influenzae
Hx of sickle cell anaemia: salm onella

<1YO: GBS, Staph A, E Coli

1-16YO: Hib, Staph A, Strep, Enterobacter
Adults: Staph, Strep, Pseudomonas, E Coli

Site:

X-ray: normal in first 10 days. Later, rarefaction of metaphysis & periosteal new
bone formation. Sclerosis when healing occurs
FBC: leukocytosis
ESR
Blood C/S
Bone scan (usu. technetium or gallium radioisotopes used): turns + before x-ray
changes appear. For doubtful cases.

Complications

3 things to consider:

5.
6.
7.
8.

Pain, malaise, fever, toxaemia

Cellulitis, swelling, oedema, erythema, warmth, tenderness, ROM

Adults: anywhere, esp thoracolumbar spine. Adults are usu immunocompromised

Children: usu. metaphysis of growing long bone. Growth plate limits spread
towards epiphysis.
Infants: risk of epiphyseal extension, jt involvement & growth disturbance.

Spread septic arthritis, metastatic OM (i.e. to other bones)

Growth disturbance shortening / deformity if physis is damaged
Chronic OM

Management

Empirical antibiotics first, changing when C/S returns

Adults/older children flucloxacillin & fusidic acid (IV 3/7, PO 3-6/52)
Children <4YO or G negative organisms cultured Cephalosporin
Analgesia
CRIB & splintage (+ traction in upper femur OM to prevent hip dislocation)
Drainage for subperiosteal abscess or persistent pyrexia & local tenderness of >24h

SUBACUTE HAEMATOGENOUS OSTEOMYELITIS

Milder form of acute OM less virulent organism or better patient resistance

Common sites: distal femur, prox & distal tibia
PT: child/adolescent
X-ray: Brodies abscess (small oval cavity surrounded by sclerotic bone) (DDx:
osteoid osteoma)
Management: drainage & ABx cover

Pathology

Infection spreads to form subperiosteal abscess

Bone dies, forming a sequestra encased by the involucrum (periosteal new bone)
108

POST-TRAUMATIC / OPERATIVE OSTEOMYELITIS

Risk factors: DM, old age, immunosuppressed, steroid Rx, chronic disease, obese,

Organism: Staph. Aureus

Opley classification:
A
Early 1 mth
B
Intermediate 1mth to 1 yr
C
Late >1 yr

multiple ops at same site, difficult / long ops, haematoma formation, tight dressings,
wound tension

Management:

Clean surgical technique

Thorough debridement
Drainage
Antibiotic cover
External fixation of unstable/unfixed #

CHRONIC OSTEOMYELITIS

Sequelae of acute haematogenous, post-traumatic & post-op OM

Recurrent flares of acute infxns pain, pyrexia, erythema, tenderness, discharging
sinus, non-healing ulcer

Investigations:

X-ray: bone rarefaction surrounded by sclerosis sequestra

Bone scan: to reveal hidden foci of infxn

Management:

Incise abscess, remove necrotic bone, fill with bone chips

Antibiotics fusidic acid or cephalosporins
Sequestrectomy

Investigations

Blood C/S
Joint aspiration, pus microscopy & C/S
X-ray: widened joint space & soft tissue swelling; subarticular bone destruction if
late stage
U/S: joint effusion

Complications:

Dislocation
Epiphyseal destruction & pseudoarthrosis
Growth disturbance shortening or deformity if physis is damaged
Ankylosis if articular cartilage is eroded
Sepsis 25% if untreated

Management:

Joint aspiration
Systemic antibiotics
Splintage
Drainage and joint washout
Rehab: increasing movement when joint is not inflamed. If cartilage has been
destroyed, keep immobile to allow ankylosis to occur

TUBERCULOSIS
Main TB entities in orthopaedics

Common sites (wt bearing joints)

TB spondylitis
TB osteomyelitis
TB arthritis
TB tenosynovitis
TB myositis

Pathology

Spreads to skeleton by haematogenous seeding

May spread to articular surfaces causing jt destruction and fibrosing ankylosis
May spread to soft tissue to form subacute abscess, which may form a chronic
discharging sinus

Common organisms:

Clinical features

ACUTE SUPPURATIVE ARTHRITIS

Adults: Staph. Aureus
Children <4YO: H. influenzae

Clinical features

Acute monoarthropathy usu. hip in children & knee in adults

Swelling, erythema, warmth, tenderness, fluctuation, ROM, pain, spasm

Spine (50%)
Hip
Knees

TB symptoms: fever, wt loss, night sweats etc

Joint symptoms: chronic course, pain, swelling, wasting, synovial thickening,
ROM, joint stiffness and deformity
109

Spine: vertebrae may collapse causing a Potts gibbus (usu. thoracic)

Investigations:

X-ray: soft tissue swelling, rarefaction of bone, joint space narrowing &
irregularities w bone erosion on both sides of joint, periarticular osteoperosis
Synovial biopsy
ESR , Mantoux test +

Management:

Anti-TB drugs as for pulmonary TB (isoniazid, rifampicin, pyrazinamide - RHZ)

Rest, traction, splintage, operation
If articular surfaces are destroyed Immobilize joint
Long term Joint arthrodesis or replacement

110

OSTEOPOROSIS

If both Z & T-scores are abnormal, it means patient has secondary osteoporosis

DEFINITION
A bone disease characterized by

o Decreased bone mass

o Weakening of microarchitectural structure of bone
Leading to
o Increase in bone fragility and hence fractures, commonly at
1. Distal radius (Colles)
2. Spine (compression fracture)
3. Hip fracture (NOF or intertrochanteric)
4. Head of humerus
5. Pubic rami
Little of normal bone Prof S Das De
PATHOGENESIS
Loss of balance between bone resorption and bone formation.
Bone matrix manufactured by osteoblasts. Bone resorption by osteoclasts.
Each cyle of remodelling takes abt 4-6 months. Annual rate of turnover is abt 4% for

cortical and 25% for trabecular bone. [bone loss occurs within 2wks; bone formation
takes 3 mths]
Bone size increases from childhood to adolescence and peaks at ard 35 yrs. From then
on, decrease at 0.3%/yr for men and 0.5%/yr for women till 50 yrs old. Menopause
for women (50-60 yr old) causes decrease at 3%/year due to decrease in oestrogen; it
subsequently normalises again at 0.5%/yr.
Wolffs law - Bone is deposited and resorbed in accordance with the stresses placed
upon it.

INDICATIONS FOR BMD SCREENING OF OSTEOPOROSIS:

Previous fragility fracture

Patients with strong risk factors
High risk postmenopausal women as categorized by OSTA
Radiological evidence of osteopaenia / vertebral deformity
Women who are considering prevention therapy for osteoporosis
Monitoring of treatment

RISK FACTORS
Osteoporosis Selfassessment Tool
for Asians (OSTA)

Nonmodifiable
Modifiable

Use age weight = x

If x >20, measure BMD
If x = 0-20, measure if other risk factors present
If x <-20, low risk, no need to measure unless positive
history of fragility fracture
Previous adult fracture history
Previous family history fracture
Weight (lean people predisposed to osteoporosis)
Drugs smoking, alcohol (both a/w nutritional def),
steroids, thyroxine, anticonvulsts
Early menopause (<45YO)
Comorbidities hyperthyroidism, hyperPTHism, Cushing
syndrome, liver disease, COPD, CRF, RA, organ
transplant etc.
Immobilization
Lack of physical exercise

LAB DEFINITION, BY BONE MARROW DENSITY AT THE HIP

BMD T-score
>-1
-1 to -2.5
<-2.5
<-2.5 + fragility fracture

Definition
Normal
Osteopaenia
Osteoporosis
Severe osteoporosis

T-score is the number of s.d. below the average for a young adult at peak bone
density (based on BMD of 25yo Caucasian females)
Z-score is the number of s.d. below an average person of the same age.
If Z-score is normal but T-score is not, it means patient has primary osteoporosis
(i.e. senile or post-menopausal osteoporosis)

INVESTIGATIONS
X-Ray if applicable

Vertical trabeculae bears the most weight of stress hence disappear last.
Osteoporosis got prominent vertical trabeculae but no horizontal.
o Picture-framing of vertebrae accentuation of cortical outline
o Codfish appearnace of vertebrae due to concave end-plates
o Pathologic fractures vertebral compression fracture (ant height of vertebrae is
80% or less of the posterior height) if multiple of spine -> Dowagers hump
o Singhs index for trabeculae at hip jnt grade I (only one present) to grade VI
(all present)
Ca/ PO4 to exclude osteomalacia (normal in osteoporosis, low in osteomalacia)
o

111

 FBC, ESR, U/E/Cr, Vit D

Others if suspect underlying associated disease

TFT; LFT; tumor markers and myeloma screen (FBC, ESR, bone marrow
aspiration, urine electrophoresis, skull X-ray)
Measurement of BMD
o Dual energy X Ray absorptiometry (DEXA) of hip for diagnosis, spine for
monitoring of treatment is the investigation of choice
Rationale for dual energy: to take X-ray of soft tissues and of bone at
different penetrance levels
o Other rarely done investigations include U/S heel/ tibia, quantitative CT scan
o

Selective Estrogen
Receptor
Modulators (SERMs)

Synthetic Steroid

Others

Raloxifene
(EVista)

Agonist in bone; antagonist in breast & uterine cells

Induces osteoclast apoptosis
Hot flushes, sweating, leg cramps
oral
Increased risk of clots e.g. DVT, PE
Teratogenic
Has also been shown to be protective against breast ca
Tibolone
Has progestogenic and some androgenic properties as
(Livial)
well as oestrogenic effects
Also has value in controlling hot flushes
Calcitonin
Intermittent PTH Rx
Calcium & Vit D
Cyclical etidronate

MANAGEMENT:

BMD T-score
>+1
1 to -1
-1 to -2.5
< -2.5 + fragility fracture

Action
Re-BMD in 5y
Re-BMD in 2y
Medical prevention, F/U BMD @ >1yr
Medical treatment, F/U BMD @ >1yr

Lifestyle measures, to be encouraged in everyone

Nutrition
Age
Calcium
Vitamin D
11-18
1000mg
400IU
18-65
800mg
400IU
>65
800mg
800IU
Exercise
Weight bearing exercises (3x30min/wk)
Smoking, alcohol
cessation
Fall prevention

Remove hazards (+ install bars, anti-slippery mats etc.)

Treat comorbidities predisposing to fall e.g. cataracts
Correct postural hypotension

Medications available
HRT

Bisphosphonates

Aledronate
(Fosamax)

Not to be used if osteoporosis is the only problem

Use only if other indications e.g. unbearable hot flushes
Switch to other treatments when symptoms abate
Similar in structure to pyrophosphate; osteoclasts
ingest it apoptosis
Hypersensitivity
Oesophageal reaction e.g. heartburn
Take medicine sitting up, keep upright for 30min after
swallowing, wkly dosing
Overuse will result in SSBT (severe suppression of
bone turnover) --- bone would hence be brittle

112

RHEUMATOID ARTHRITIS
DEFINITION

PATHOLOGY

Systemic chronic inflammatory disorder of unknown cause that affects the

3 stages: Synovitis, Destruction, Deformity

peripheral joints in a symmetrical fashion

EPIDEMIOLOGY
-

Prevalence:
Gender:
Age of onset:
Morbidity:
Mortality:

0.8% of adult population

3x more common in females
80% of patients develop it b/w 35 to 50 years old
High level of functional impairment
If untreated, 20-30% will become permanently work-disabled
within 3 yrs
Related mainly to extra-articular manifestations

- Synovial cell hyperplasia

& proliferation
- Dense perivascular
inflammatory infiltrates
- vascularity
(angiogenesis)
- Neutrophils &
aggregates of organizing
fibrin on synovial surface
- P/E: Fusiform swelling @
PIP jts

PATHOGENESIS
-

- Erosion of articular
cartilage and
subarticular bone
o Direct invasion by
pannus
o Degradative
enzymes secreted by
neutrophils
o osteoclastic
activity in
underlying bone
- Tendons, ligaments, jt
capsule also destroyed

- Deformity and loss of

function
o Fibrosis/Ca2+ of pannus
o Fibrous/Bony Ankylosis
o Destruction of articular
cartilage, subarticular
bone, tendon, ligaments,
capsule
- P/E:
o Z-deformity of thumb
o Swan-neck deformity
o Boutonneires deformity
o Ulnar deviation @ MCP
jts

Cause unknown
Postulated to be response of a genetically susceptible host to an infectious agent
CLINICAL PRESENTATION
SYMPTOMS / HISTORY TAKING
- HLA-DR4, HLA-DR1
- Twin studies
o Monozygotic twins: 30%
concordance rate
o Dizygotic twins: 3%

- Persistent infection of articular

structures/retention of microbial
pdts in synovial tissues
- Alterations of jt components by
microorganism/response to
microorganism
- Molecular mimicry

1. Joint involvement: typically affects PIP, MCP, wrist, elbow, shoulders, knees,

ankles, feet
- Pain
- Stiffness:
- Swelling
- Deformity
- ROM

Insidious onset
Early morning stiffness at jt, last for >1hr before improvement
Symmetrical, Red inflamed, warm to touch
Progressive in nature

Usually periods of relative quiescence with periods of flare

2. Extra-articular manifestations (occurs later in the course of the disease)

3. Constitutional symptoms

Fever
Fatigue, malaise
Weight Loss

113

4. Associated with

Sjogrens Syndrome:
Feltys Syndrome:

Palm
Palmar erythema
Dorsum
Wasting of the interossei, best
seen in 1st dorsal web space

Dry eyes, Dry mouth, Recurrent chest infection

Splenomegaly, Leg ulcers, Recurrent infections, LN,
Wt loss

5. Loss of function

Class 1: Normal functional ability

Class 2: Normal functional ability despite discomfort
Class 3: can only perform a few tasks of work/self care
Class 4: Complete/ Almost complete incapacity

FEEL

6. Previous treatment history

Medications: Anti-inflammatory drugs, Steroids (assess for adverse SEs)

Intraarticular injections
Previous operations

MOVE

7. Family history
8. Social History

OFFER

Occupation
Family setup
Caregiver

PHYSICAL EXAMINATION
LOOK

Wrist
-

Volar subluxation
Radial deviation
Piano key sign subluxation of DRUJ causing head of ulna to
pop up on dorsum of the wrist where it can be jogged up & down

Thumb
Z-thumb deformity (flexion of IPJ and hyperextension of MCPJ)

Fingers
Ulnar deviation of the fingers, involving the more lateral digits in
the more advanced cases
Volar subluxation at MCPJ, most commonly over index & middle
fingers
Swelling of PIPJ
Swan-neck deformity (flexion of DIPJ, hyperextension of PIPJ)
Boutonniere deformity (hyperextension of DIPJ, flexion of PIPJ)

Palpate over swollen joints to detect warmth & tenderness of

acutely inflamed joints
Palpate the elbows for rheumatoid nodules (present in 25% of
patients). You may also find rheumatoid nodules at other pressure
areas, e.g. pulp of the fingers & radial side of index finger
Functional assessment
Unbutton a shirt
Write with a pen
Hand exam (median n. for any carpal tunnel syndrome**)
Examine other joints in the body that are affected by RA
MCPJ,PIP,thumb, wrist, elbow, knee, ankle, mtpj [CERVICAL NECK]
Examine the rest of the patient for extra-articular manifestations of RA
Ask patient how the condition affects his/her life
-

Extra-articular manifestations:
Ophthalmic
Sleritis
Episcleritis
Keroconjunctivitis sicca
Respiratory
Pulmonary effusion
Pulmonary fibrosis
Cardiac
Pericarditis
Vascular
Vasculitis
Reticulo-endothelial
Lymphadenopathy
Splenomegaly
Feltys syndrome
Neurological
Multifocal neuropathies
Carpal tunnel syndrome

114

American College of Rheumatology Diagnostic Criteria

(fulfill 5 out of 7 criteria)
1. Morning stiffness >1 hr
2. Affects at least 3 out of 14 joints with soft tissue swelling or
fluid (PIP, MCP, Wrist, Elbow, Knees, ankles, MTP)
3. Arthritis of hand joints
4. Symmetrical joint swelling
5. Subcutaneous nodules
6. Positive Rheumatoid factor test
7. Radiological changes consistent with RA

First 4 must be
present
continuously
for 6 weeks

INVESTIGATIONS
BLOODS
1. FBC

Anemia, Thrombocytosis, WBC & D/C: eosinophilia, exclude

infection

2. U/E/Cr

Assess renal function before starting treatment

3. LFT

Assess liver function before starting treatment

4. ESR,CRP Inflammatory markers = indicate active disease

Used for disease progression monitoring, treatment response

5. RF

Anti-IgG autoantibodies (65-85% of patients)

- Not diagnostic (present in healthy pple, SBE, TB, Viral infections)
- Prognostic: high titre = poor prognosis

6. ANA

Positive in autoimmune disease

- Not diagnostic (present in SLE, Scleroderma, Sjogrens,
Raynauds disease)

JOINT ASPIRATION
1. Analysis of synovial fluid: Straw coloured, cloudy, flecks of fibrin

Large numbers of WBCs , esp neutrophils

2. Biopsy: Histological features non-specific and not diagnostic

IMAGING
X-rays: disease monitoring, treatment response

Early: Periarticular osteopenia

Later: Marginal bone erosions
Advanced: Articular destruction, Joint deformities

C-spine: Atlanto-axial subluxation

MANAGEMENT

Goals:

Control disease activity

Prevent/ control joint damage
Prevent Loss of function
Control Pain
Maximise quality of life

CONSERVATIVE MANAGEMENT
1. Non-pharmacological:

Rest
Patient education
Physiotherapy
Occupational therapy

2. Pharmacological: (early aggressive treatment, Esp those w poor prognostic

factors)
NSAIDs: Indomethacin, Diclofenac, Naproxen
o Symptomatic treatment: anti-inflammatory, analgesia
o Does not alter disease progression
o ADRs: PUD
o Contraindication: Renal impairment
Steroids: Prednisolone
o Symptomatic treatment: anti-inflammatory
o May help slow disease progression/joint damage
Disease modifying anti-rheumatic drugs (DMARDs): Methotrexate, Gold,
Hydroxychloroquine (See Table)
o Slow down disease progression of bone & cartilage destruction
o Take 1-6 months to be effective
o Monotherapy/Combination
Anti-TNF :
Etanercept, Abcliximab, Infliximab

SURGICAL MANAGEMENT
1. Surgical Release for nerve entrapment syndromes (eg. Trigger finger, CTS, De
Quervains)
2. Synovectomy
For persistent synovitis > 6 mths
115

 Symptomatic relief of pain and swelling

Restore ROM
3. Arthroplasty
Mainly for knees, can also be done for hip, shoulder, elbow
Pain relief, correction of deformity, Stability and alignment, Preserve ROM
4. Others:
Tendon repair
Osteotomy:
genu valgum
Arthrodesis: mainly triple arthodesis of ankle
o surgical fusion of joint to give stability, pain relief, deformity correction
DMARDS SUMMARY TABLE
DMARDs

Methotrexate

Pharmacology

- Recommended as initial
DMARD
- Rapid onset of action (12mths)
- Retards progression of
radiological erosions

Hydroxychloroquine

Toxicity

Investigations

- Rash
- Abdominal cramps
- Diarrhoea
- Retinal pigmentation

- Eye
examination (612 mthly)

- N+V
- Mucosal ulcers
- Liver cirrhosis, LFTs
- Interstitial pneumonitis
- Severe BM suppression

- Baseline FBCs,
U/E/Cr
- LFTs, Hep B/C
status
- CXR

Sulfasalazine

- Faster onset (1-3 mths)

- Retard Radiographic
progression

- N+V
- Headache
- Rash
- BM suppression

- FBC, LFTs

Gold

- Oral: Slow onset (6mths)

- IM: Faster onset (weekly
injection of 22 wks)

- Rash
- Ulceration, mucositis
- Nephrotic syndrome
- Pancytopenia

- FBC
- UFEME,
U/E/Cr (at
every injection)

Leflunomide

- Alternative to MTX
- Slows radiographic
progression

- Diarrhoea
- Alopecia
- Headache
- Immunosuppression
- LFTs

- FBC, U/E/Cr

*Blue boxes: teratogenic

- LFTs, Hep B/C

status

116

ANKYLOSING SPONDYLITIS
Definition: chronic, multi-systemic inflammatory disorder of the sacroiliac joints and
axial skeleton (characterised as a seronegative spondyloarthropathy)

Predilection for SI joints & spine progressive stiffening & fusion of axial skeleton

EPIDEMIOLOGY
15-25 YO
Male : Female = 4:1
Mnemonic: P-A-I-R
HLA-B27
First degree relatives at risk of psoriatic arthritis, IBD & Reiters syndrome
PATHOLOGY
Enthesitis: subchondral granulation tissue that erodes the joint & is replaced
gradually by fibrocartilage and then ossification (occurs in ligamentous capsular
attachment sites to bone)
In the spine, this occurs at junction between vertebral bodies and annulus fibrosus
of IV discs. Outer fibres of the discs eventually undergo ossification
syndesmophyte is formed progresses to the characteristic bamboo spine
SIGNS
Decreased lumbar lordosis
Kyphosis
Restricted lumbar spine movement in all planes
Restricted chest expansion : <5cm at 4th intercostal space
Extra-articular manifestations Iritis, uveitis, myelopathy, AR, arrhythmia,
pulmonary fibrosis
SYMPTOMS
Recurrent lower back pain
o Insiduous onset
o For >3 months
o Often begins unilaterally & intermittently
As the disease persists, it becomes more persistent & bilateral &
progresses more proximally
o Dull character
o Poorly localised to the buttock/thighs
o Symptoms worse in the morning & after periods of inactivity, relieved with
exercise

o a/w loss of spine extension

Costovertebral & costotransverse joint involvement: difficulty breathing / chest
tightness
Temporomandibular joint involvement: decreased ROM / jaw pain
Extra-articular manifestations
Eye

Acute anterior uveitis

Iritis

2C

Cauda equina syndrome

Cardiac conduction defects

Spinal
cord

Myelopathy due to atlantoaxial

subluxation
Cauda euina syndrome

6A

Heart

Aortic regurgitation
Cardiac conduction defects

Lung

Apical pulmonary fibrosis

Anterior uveitis
Atlantoaxial subluxation
Aortic regurgitation
Apical lung fibrosis
Amyloidosis
Archilles tendonitis

Systemic

Amyloidosis
Osteoporosis

INVESTIGATIONS
ESR
Rh factor
FBC
ECG

Raised
Negative
Normochromic anaemia
Conduction defects

Synovial fluid
complement
X-ray

Not depressed, decreased viscosity, leukocytosis

Bone scan

Squaring of vertebrae
Vertebral fusion
Romanus lesion: shiny corners of vertebrae due to sclerosis
Bamboo spine due to syndesmophyte formation
Erosion & sclerosis at anterior corners of vertebrae
Facet joint fusion
Atlantoaxial dislocation
SI joint bony erosion, marginal sclerosis, +/- fusion
Whiskering calcification of tendons attached to ischial tuberosity
Osteoporosis / OA changes ( jt space, sclerosis, ossified bone
cysts)
Apical lung fibrosis
Costovertebral jt involvement
Sacroilitis & spinal involvement

117

GOUT

GRADES OF SACROILITIS
I
II
III
IV

Widening of joint
Joint erosion
Sclerosis on both sides
Ankylosis

Inflammatory arthritis caused by cellular reaction to uric acid crystal deposition

(monosodium urate)

Rome criteria

Bilateral sacrolitis > grade I + any of the

following:
LBP + stiffness > 3 mths not
relieved by rest
Thoracic pain or stiffness
lumbar spine ROM
chest expansion
Hx of uveitis

NY criteria

Bilat Sacroilitis > grade I

OR Unilat Sacroilitis > grade II
AND any of the following:
LBP of inflammatory nature
lumbar spine movt in sagittal &
frontal planes
chest expansion

MANAGEMENT
Aims:

Relieve pain & stiffness

Maximise skeletal mobility
Avoid development of deformities

CONSERVATIVE
Lifestyle modification
Pharmacotherapy
- NSAIDs (usually
indomethacin)
- Sulphasalazine
Radiotherapy
Local corticosteroid injection
Systemic steroids
SURGICAL
Hip stiffness
Spine flexion deformity

Exercise, ensure good posture

Pain relief (ask abt renal function, hx of GI bld,
coagulant Rx)
For persistent peripheral arthritis. Not useful for
axial disease
If drug therapy is ineffective
For plantar fasciitis & enthesopathy
For acute iritis
Total hip replacement
Vertebral osteotomy

Pathophysiology accumulation of uric acid/urate in blood and tissues.

Supersaturation of tissues urate crystals precipitate into crystals.
Causes Hyperuricemia (incl renal impairment) Alcohol ingestion. Dietary excess
(especially sardines, kidney, liver, meat extracts). Thiazide diuretics. Salicylates.
Lead poisoning.
Acute changes in the level of uric acid cause gout (not high levels)
Hyperuricemia is found in 90% in individuals with gout, but also found in patients
taking diuretics and even in those taking low doses of aspirin
Most individuals with hyperuricemia do not have gout, but if high uric acid are not
treated, 90% develop gout in 30 yrs
Epidemiology 90% male predominance; men > 20yo & post-menopausal women
Presentation
Redness, swelling, heat, tenderness and interference with range of movement
typically most intense in 24 hrs, tenderness exquisite.
Monoarticular, 1st MTP jnt most commonly affected podagra. Knee and ankle jnts
next most commonly affected.
Tophus deposit may exist in the antihelix of the ear or subcut regions e.g.
olecranon, archilles tendon, fingertips, cornea
Other findings fever, chills, carpal tunnel syndrome
May progress to chronic arthritis or even present as chronic arthritis
DDx: septic arthritis, pseudogout (tends to affect larger jnts and women more), bursitis,
RA if polyarticular gout affecting finger, haemarthrosis
Lab studies Identification of causative crystals or classic radiographic findings
Joint Aspiration: Negatively birefringent needle shaped urate crystals on polarising
examination. Synovial fluid WBC count usually elevated. (pseudogout rhomboid
shaped crystals)
Blood Investigations:
o FBC: WCC often elevated, with left shift during acute attacks
o ESR elevated during acute attacks.
o Hyperuricemia present in 95% of cases but not diagnostic.
Once acute gout episode controlled, 24-hr urine uric acid lvl also assessed for
choosing medication to control the associated hyperuricemia

118

Imaging
o Punched out lesions / rat-bitten / lytic areas with overhanging edges(after 1st
year of disease)
o Erosion with joint space preservation is typical.

Treatment to relieve pain, prevent disease progression and prevent tissue

deposition of uric acid

Treatment of the acute attack

o NSAID (e.g. naproxen 500mg twice daily or indomethacin 50mg three times
daily) at full dosage (2-5 days), reduce to1/2 or 1/4 once attack controlled
o Low dose NSAIDs for the 1st 6-18 mnts Mx of underlying hyperuricemia - ppt
gouts in up to 50% of patients
o Avoid aspirin paradoxical(increases urate absorption)
o Oral colchicine (anti-inflammatory) frequently causes unpleasant side-effects
Treatment of underlying hyperuricemia most untreated pts with gout will
experience a recurrent episode in 2 yrs
o Pharmacologial
Allopurinol (antihyperuricaemic) once daily
Frequent and disabling attacks,Signs of chronic gouty joint disease,
Tophi, Renal insufficiency, Recurrent nephrolithiasis, or Urinary uric
acid excretion > 1100 mg/day
Probenicid, Sulphinpyrazone (urocosuric) multiple times daily
Initial therapy < 60 who excrete <800 mg of uricacid perday, no renal
insufficiency, hx of urolithiasis or tophi
Colchicine
Low dose prophylaxis during the initiation of anti hyperuricemic therapy.
NSAIDs if cannot tolerate colchicine.
o Non-pharmacological
Dietary:
caloric restriction ( protein low fat dairy not meat/fish, replace refined
with complex carbos, saturated fat)
Limit intake of alcohol.
Surgery:
Complications of trophaceous disease infection, nerve compression, jnt
deformity and intractable pain, cosmetic reasons

119

c.

As little as possible of the tumour is exposed; block of tissue is removed

ideally in the boundary zone, so as to include normal tissue, pseudocapsule
and abnormal tissue
d. Frozen section examined; several samples taken if necessary
e. If bone removed, the raw area is covered with bone wax or
methylmethacrylate cement
f. Drains should be avoided to minimise risk of tumour seeding
g. For tumours that are almost certainly benign: excisional biopsy can be
done (remove entire lesion)
h. For cysts: careful curettage to remove representative tissue

BONE TUMOURS & CYSTS (OSCE ORIENTED)

DX OF BONE TUMOURS & CYSTS:
Impt differentiating features
Site of lesion
Patients age
Special x-ray features
Diagnosis of Musculoskeletal Tumours
1. Imaging
a. Plain X-rays
i. Site of lesion
ii. Solitary or multiple
iii. Well-defined or ill-defined (i.e. narrow / widened zone of transition)
iv. Any cortical thickening
v. Any periosteal new bone formation & extension of tumour into
soft tissues (malignant!)
- Periosteal hypertrophy may also mean infection, stress
fracture, soft tissue bruising
vi. NB. stippled calcification inside a vacant area is characteristic of
cartilage tumours
b. CT & MRI
i. Useful to assess true extent of tumour & its relationship to
surrounding structures
ii. Assuming that there are no metastases, the local extent of the
tumour is the most important factor in deciding how much tissue
has to be removed
c. Radionuclide scanning with technetium
i. Shows non-specific reactive changes in the bone
ii. Useful to reveal site of small tumour (e.g. osteoid osteoma) or the
presence of skip lesions / silent secondary deposits.
2. Biopsy --- essential for diagnosis & planning of treatment
a. Open Bx more reliable
b. Site is selected so that it can be included in any subsequent ablative
operation

Differential diagnoses for tumours

1. Chronic osteomyelitis
a. Systemic features may have been suppressed by antibiotics
b. Submit tissue for histological & bacteriological examination
2. Stress fracture (young adult with localised pain near a large joint)
Management
Grade \ Compartment
Low
High

Intra-compartmental
Wide excision
(w/o exposing tumour)

Extra-compartmental
- Radical incision
- +/- bone graft OR prosthetic
replacement
- Radical
incision
and
prosthetic replacement OR
amputation
- +/- chemo to risk of mets

120

BONE TUMOUR CLASSIFICATIONS

Malignant Bone tumours by frequency
1. Metastatic
Common Pri site of metastatic tumours:
2. Multiple Myeloma
Thyroid GI (except *Midline & paired
rectum)
NPC
structures
3. Osteosarcoma

Renal
*Most are osteolytic
Breasts
4. Chondrosarcoma
Prostate
except prostatic (blastic)
Lungs
5. Ewings sarcoma
Testes
& breast (blastic & lytic)

Others

Red marrow populated areas

Cartilage cap of osteochondroma OR
Central medullary
Pelvis

Fibrous tissue
Marrow

Benign
Osteoid osteoma
Chondroma
Osteochondroma
Fibroma
Eosinophilic granuloma

Children/Adolescents (<20YO)

Chondroma (arise @ puberty, presents ~30YO)

Osteochondroma
Osteosarcoma
Osteoid osteoma (<30YO)
Non-ossifying fibroma
Ewings tumour
Simple bone cyst

Young Adults (20-40YO)

Aneurysmal bone cyst

Giant cell tumour
Chondroma (arise @ puberty, presents ~30YO)
Osteoid osteoma (<30YO)

Vascular
Uncertain

Haemangioma
Giant-cell tumour

Bone tumours by Site

Long bones
Metaphysis

Middle age / Elderly (>40YO)

Chondrosarcoma
Multiple myeloma
Osteosarcoma (~50YO)
Metastatic tumours

Spine

Hands / feet

Malignant
Osteosarcoma
Chondrosarcoma

Fibrosarcoma
Ewings sarcoma
Myeloma
Angiosarcoma
Malignant giant-cell tumour

Osteochondroma
Simple bone cyst
Aneurysmal bone cyst
Giant cell tumour (proximal tibia, distal radius,
distal femur)
Non-ossifying fibroma (cortex)
Osteosarcoma (esp knee & proximal humerus)
Chondrosarcoma

Diaphysis

Ewings tumour

Non-specific

Osteoid osteoma
Chondroma
Metastatic
Aneurysmal bone cyst
Giant cell tumours
Multiple myeloma
Metastatic
Chondroma
Giant cell tumours (calcaneum)

Metastatic

Bone tumours by Patient age

Bone tumours by cell type

Cell type
Bone
Cartilage

Multiple myeloma
Metastatic
Chondrosarcoma

[MCQ] Mets to spine: disc space not eroded!

[MCQ] Ewings and osteomyelitis can be confused by all of the following:
1. Swelling
2. Diaphyseal location
3. Periosteal bone formation
4. Exploration reveals liquefied material like pus
[MCQ] child with cystic lesion at epiphysis of lnog bone, most likely diagnosis:
osteoblastoma

121

FEATURES OF BONE TUMOURS & CYSTS

Bone tumour

X-ray findings

Site

Age

Others

Osteoid osteoma

Small round/oval radiolucent area surrounded by dense

sclerosis
DDx: Brodies abscess
May be single or multiple
o Multiple exostosis has AD inheritance & low rates of
malignant change
2 main types:
i)conical (well defined)
ii)cauliflower with partial calcification of cartilage cap
Well defined rarefied area in medulla
Characteristic speckles of calcification w/in area of
rarefaction

Femur, tibia

<30

Aspirin (pain relief)

Excision

Edge of epiphyseal plate

Long bone metaphysis

Adolescence

Bony hard lump pain or disturbed tendon

fxn
Excise if symptomatic or growing (risk of
malign change)

Tubular bones of hands &

foot
Long bones

Excise / curette & replace w bone graft

Risk of malig change, esp if multiple
lesions are present

Translucent areas on shaft side of growth disc

Bone expansion with cortical thinning
Fallen fragment sign
Well defined margins around a rare area
Eccentrically placed
Bone expansion with cortical thinning
Confined to metaphyseal side of growth plate (c.f. Giant cell
tumour which extends to articular surface)
Diameter of cyst usu > diameter of bone
Cortex
Well defined sclerosed margins

Prox ends of humerus,

femur, tibia.
Usually in the metaphysis
Spine
Metaphysis of long bones

Arises at puberty,
presents ~30YO.
Need to rule out
chondrosarc if >30y/o
Children up to puberty
Young adults

Curette & filled w bone chips

Metaphysis of long bones

Child

No Rx unless #ed.

Rarefied area situated asymmetrically

Extends to articular surface (MUST, otherwise excluded)
Soap bubble appearance
Cortex is thinned, may be ballooned / perforated

End of long bones (prox

tibia, distal radius, distal
femur)
Vertebral body
Calcaneum

20-40YO

Sunray appearance
Bone areas of rarefaction in medulla
Subperiosteal new bone formation
Codmans triangle = lifting of periosteum prox to tumor @
the edge of the sunray
Central medullary type: initially appears like a chondroma.
Destructive medullary tumour with flecks of calcification

Metaphysis of long bones

Knee & prox humerus

Bimodal distribution:
10-20YO; ~50YO
(a/w Pagets dz)

Central medullary tumour

OR

>40YO

Hx of patho #
High rate of recurrence if not completely
excised
Curette & fill with bone chips
Excision & bone graft/ prosthetic
replacement
Metastasize readily esp to lungs
ALP by 3-4X
Biopsy to confirm dx
ChemoRx RT
Resection / amputation
Tend to metastasize late

Osteochondroma

Chondroma
(enchondroma)
Simple (solitary)
bone cyst
Aneurysmal bone
cyst

Non-ossifying
fibroma (fibrous
cortical defect)
Giant cell tumour

Osteosarcoma

Chondrosarcoma

Intralesional steroid injection

Curette & filled w bone chips

122

 Malig change in cartilage cap of osteochondroma type: large

exostosis surrounded by flecks of calcification in the
cartilage cap
Bone destruction
Overlying onion-skin layers of periosteal new bone

malignant change in
cartilage cap of
osteochondroma
Diaphysis of long bone

Multiple
myeloma (single
tumor =
plasmacytoma)

Overall reduction in bone density

Multiple punched out defects (skull XR is often shown)

Metastatic
tumours

Usually osteolytic EXCEPT prostatic CA mets which are

osteosclerotic
Moth eaten appearance
Generalised osteoporosis
Look for lung metastases

Ewings tumour
(primitive neuroectodermal
tumour, PNET)

Enneking Classification
Grade
G0
Benign
(surgical)
G1
Low grade malignant
G2
High grade malignant
Site
T0
Benign Intracapsular &
intracompartmental
T1 (A) Intracompartmental
T2 (B)
Extracompartmental
Metastasis M0
No regional / distant mets
M1
Regional / distant mets

10-20YO

Rare, arise from vascular endothelium

Amputation, RT, adjuvant chemoRx

Areas containing red

marrow. Esp skull and
vertebrae

45-65YO

Areas containing red

marrow
Esp axial & long bones

50-70YO

Osteoporosis + high ESR

Urinalysis Bence-Jones proteins
Serum/urine electrophoresis monoclonal
Ig band
ChemoRx & RT, int fixation of #, brace for
spinal #
Other problems
o Nchormic Ncytic anaemia
o Hyperviscosity syndrome
o Renal stones
o Gout & hyperuricaemia
o Abnormal globulin: albumin ratio
Palliative ChemoRx & RT
Int fixation of #s
Sx decompression & fusion of vertebrae to
prevent neuro deficit

Staging for Malignant Neoplasia

IA
G1
T1
M0
IB
G1
T2
M0
IIA
G2
T1
M0
IIB
G2
T2
M0
IIIA
G1 or 2
T1
M1
IIIB
G1 or 2
T2
M1

Staging for Benign Neoplasia

1
Latent
G0 T0
2
Active
G0 T0
3
Aggressive G0 T1 or 2

M0
M0
M0 or 1 (giant cell tumour)

123

Salter Harris Classification examples

ORTHOPAEDIATRICS

FRACTURES

Prevalence in Singapore
Bimodal distribution
Modal peaks:
7 and 11 years old
Median age: 7.64 0.05 years old
By Gender
Male modal peaks: 7 yrs & 11 yrs
Female modal peaks: 5 yrs & 10 yrs

Type
I
II
III
IV

Male median: 8.18 0.06 yrs

Female median: 6.66 0.07 yrs

Basic Principles
Presence of growth plate which gets injured before ligaments ( avulsion #s)
Presence of secondary ossification centers CRITOE
Potential for remodeling in those less than 10 years of age
Less likely for joint stiffness due to casting
Treatment is usually non surgical
Greenstick and Buckle #s
Plastic deformation
Pathological fractures
Non-accidental Injuries
Growth plate

Example

11yo with ankle inversion injury

Distal fibula #

Distal radius #

13yo with ankle injury

Tillaux #

5yo with elbow injury

Lateral condylar # of humerus

Basic Mx principles of physeal #s

Extra articular #s usually treated
with M&R

Intra articular extension

Requires anatomical reduction
Usually involves ORIF

All dislocation must be stably reduced ASAP.

Aim for acceptable alignment based on
o Age
o Potential for remodeling
o Plane of motion
o Fractured bone
o Fracture site epiphysis, metaphysis and diaphysis
o Fracture personality spiral, oblique, transverse, ,buckle, greenstick,
Bayonet and Salter Harris
Reduction maintained with plaster as children are less likely to get joint stiffness

If surgery is required...
Minimal dissection to ensure no damage to growth plate
Usually smooth pins used instead of plate and screws as smooth pins produce
minimal growth plate damage and periosteum
Usually combined with casting postoperative for added stability to fixation
Pins inserted percutanoeusly where possible.
Remodelling
- Remodelling occurs 75% at the physis, 25% at the fracture site
- Physeal remodelling
Once physis is aligned, it resumes symmetrical growth
- Diaphyseal remodelling
Follows Wolffs law form follows function.
- The closer the fracture to an active physis, the greater the remodelling potential

124

vi.
vii.

Common types of #s in children

5. Clavicle #s
a. Very common amongst the very young after falling off the sofa at home.
b. Also as a result of birth trauma
c. Almost never treated with surgery
d. Arm sling will usually suffice
e. ONLY # ACCEPTABLE AS NON-NAI IN THE VERY YOUNG

iii. Grade IIB (with rotation component to the #) closed reduction &
percutaneous pinning (CRPP)
iv. Grade III M & R and CRPP
Brachial artery & median nerve may kink (not rupture)
Presents as pulseless hand
Ulnar n. usually not affected (if affected, usually iatrogenic)
Management closed reduction (right)
Complications
i. Cubitus varus (increased extension but reduced flexion)

Axial force to correct varus alignment

6. Proximal humeral #s
i.
Has great potential remodeling due to the fact that the shoulder is one most
mobile joint in the body.
ii.
Usually treated with collar and cuff OR an O slab.
7. Supracondylar #s
iii.
In Singapore, the typical child who has a supracondylar fracture is a
7yo boy falling off a monkey bar with his non dominant hand
iv.
Most common fracture in KKH requiring surgery
v.
Classification
i. Grade I (posterior fat pad sign seen) Cast Immobilisation
ii. Grade IIA (Baumann angle = 75, anterior humeral line bisects
capitulum) M & R

Flexion to correct the extension of fragment

8. Lateral condylar #s
a. Important because its a SH IV fracture with joint extension
b. Displacements >2mm needs ORIF
125

c.

Even if undisplaced, need close surveillance to intervene if there any

further displacement (by muscles)
d. Can lead to non union, elbow deformity and instability if untreated
9. Radius/ulnar #s
a. Unlike in adults radius/ulna can usually be treated by M&R
o Immobilize with U Slab of sugar tong slab
b. Surgery indicated if unable to achieve stable acceptable alignment e.g.
o In older children/teenagers
o Excessive rotation
o Excessive angulations (>200)
c. Surgery if indicated done with minimal disturbance of growth plate and
periosteum
d. Also think of Monteggia/Galeazzi #s
e. Radial neck MUST bisect the capitulum of humerus in all views
10. Distal radius #s
a. Can be different varieties
b. Salter Harris II involving the distal radius epiphysis
o Below elbow cast after M&R
c. Distal 1/3 fracture of the radius ulna which is the most unstable.
o Above elbow cast after M &R
o Bayonet acceptable for those < 10 years old if delayed presentation
d. Buckle fractures due to buckling of the periosteum
o Very stable
o No M&R required
o May treat with Brace only
11. Femur #s
a. General Concerns
o Adequate pain relieve
o ATLS for multiply Injured
b. Be aware of possible Non Accidental Injuries NAI
o In those not ambulating
o Mentally retarded
o Non communicative yet

c. Be aware of pathological fractures

d. Treatment
o Gallows traction for those less than 2 years or 20 lbs
o Russells traction for others till next elective list
o Early 1 leg hip spica. Allows for sitting. Better accepted.
12. Tibial #s
a. Most common type of #s in children
b. Aim is to achieve acceptable alignment
o No varus or recurvatum
o Angulation < 100.
o No rotation
c. Above knee cast backslab.
d. Admit if
o Concerns of Compartment syndrome
Flexor hallucis longus pain on stretching of ischaemic muscle --extend the childs toe (small movement but great pain)
o Good alignment cannot be achieved
o Open fracture.
Tibia is superficial therefore predisposes to osteomyelitis and nonunion (a/w poor blood supply for tibia unlike femur :. Vicious cycle)
e. Beware of the Toddlers fracture (Refuses to walk, keeps on falling)
Fractures in Adolescents
5. Tibial spine #s
a. In older children / adults, more likely ACL tear.
b. But since ligament is stronger than bone, more likely avulsion # of tibial
spine (site of attachment still has cartilaginous contact, not bone)
c. Classification Meyers & McKeever
i.
Type I minimal or no displacement
ii.
Type II angular elevation of anterior portion with intact posterior
hinge
iii.
Type III - complete displacement with or without rotation

126

6. Tillaux #s
a. Growth plate not completely closed yet and lig > bone :. Tillauxs fracture

b. More growth plate = more # parts (e.g. triplane # in a 12yo girl)

Imbalance of muscle and bone growth cause tension in unfused apophysis

7. Tibial tuberosity (Osgood Schlater Disease)
8. Inferior pole of patella (Sindig Johanssen Larsen)
9. Apophysis of calcaneum (Severs syndrome)
Tension can convert to fracture during sporting activity especially in those who are
heavy for their age

Refer early
Brachial Plexus Injuries
Clavicle fracture

No intervention

Reassure family

Ensure no pressure on fracture site

Exclude Brachial Plexus Injury

If the infant initially demonstrates discomfort with the fracture, the long arm
sleeve of the infant's shirt can be pinned to the shirt for 7 to 10 days to provide
adequate immobilization.
Humerus fracture

Mechanism of injury -- -- -- -- -- -- -->

Femur Fracture

Rx: pavlik harness

Specificity of Skeletal Trauma for Abuse

High Specificity
Moderate Specificity
- Classic metaphyseal lesions - Multiple fractures, especially bilateral
- Posterior rib fracture
- Fractures in various stages of healing
- Scapular fracture
- Epiphyseal separation
- Vertebral body fracture or subluxation
- Spinous process fracture
- Digital fracture
- Sternal fracture
- Complex skull fractureLow specificity
- Clavicular fracture
- Long-bone shaft fracture
- Linear skull fracture

Traumatic Birth Injuries

- Osteogenesis imperfecta

Life-threatening condition
127

Able to hyperextend the elbow (beyond 10 degrees)

Left
Right
Able to put hands flat on the floor with knees straight
Able to hyperextend knees (beyond 10 degrees)
Left
Right

1
1
1
1
1

CONGENITAL, DEVELOPMENTAL AND PHYSIOLOGICAL CONDITIONS

TORTICOLLIS (AKA WRY NECK)
Classification
Primary/Muscular/idiopathic tight SCM
Secondary always exclude & treat this first since this is the underlying cause
Squint
Hearing problems
Flat head (plagiocephaly)
Bony fusion of cervical spine (Klippel Feil)
Tumours and infections in the neck
Trauma
OSSIFICATION CENTRES

Clinical Features
Childs tilts or looks to the sides opposite to the tight SCM
Facial asymmetry on the side of the torticollis
Limited lateral rotation on the same side of torticollis
Limited lateral flexion on the opp side of torticollis

CRITOE ossification starts at

1. capitalium (1yo),
2. internal/medial epicondyle (3yo),
3. trochlea (5yo),
4. olecranon (7yo),
5. external/lateral epicondyle (9yo)
LIGAMENTOUS LAXITIES
Assessed using Beighton scoring (out of 9)
Test

Able to bend thumb backwards to touch volar forearm

Left
Right
Able to bend little finger back (beyond 90 degrees)
Left
Right

Points
1
1

Management
Exclude secondary causes
If under 1 year can be treated effectively with stretching (physio)
Surgery usually needed for those above 1 year old.
Release of the SCM is done with or without a reconstruction of the sternal head
Post op aggressive physiotherapy with use of custom made cervical collar for
immediate post op period.

1
1
128

APPROACH TO LIMPING CHILD

Presentation: limping child / delayed walking / abnormal gait
Things to consider
1) Site/location
2) Painful versus painless
3) Age (NB. regardless of age, must always include trauma & infection [septic
arthritis, OM, synovitis] under painful causes)
<3yo

3yo to
schoolgoing

Painful
Most commonly due to infection
Trauma (exclude NAI)
Toddlers # (1-4yo): distal tibial #
Transient synovitis
DX OF EXCLUSION
Inability to bear weight
a/w excessive running
May be related to upper respiratory
infection
Gets better with rest
Growing pain
Diagnosis of exclusion
Usually between 4-5yo and during
puberty
Bone growth rate faster than rate of
increase in length of muscle &
tendon
Pain occurs usually at the end of the
day, often relieved with massage /
after a good nights rest
Leukaemia (4-10yo)

Schoolgoing
through
adolescence

Perthes disease (4-8yo)

Loss of blood supply to the hip
Unknown cause
Can cause early degenerative disease

Painless
Limb length discrepancies
Bone: femur versus tibia
shortening
Joint: commonly DDH
Generalised
o Muscle hypertrophy on
one side; causes: nerves
(NF), vessels
(haemangiomas)
o Polio infection
Physiological
o Metatarsal adductors
o Tibial torsion
o Femoral anteversion
o Flat foot
Biggest concern: undiagnosed
dislocated hip ( DDH)
Significant limb length
discrepancy
Asymmetrical thigh crease
Hip clicks
Limited/asymmetrical
abduction

Adolescents

Transient synovitis
Commonest cause of irritable hip
Epidemiology: boys 2x more than
girls, 3-10yo
History
o Unilateral groin/hip pain
o Antalgic limp
o Very young children: no other
symptoms except crying at
night
o Recent Hx of URTI,
pharyngitis, bronchitis or otitis
media (in >50% of cases)
o No definitive cause known
Slipped Upper Femoral Epiphysis
(~15yo)
Thought to be due to excessive
weight on a predisposed hip
Maybe due to an endocrine
abnormalities (Pituitary, growth,
thyroid and parathyroids, gonadal
hormones)
Diagnosis delayed because they can
present with knee pain
Always need surgery to stop
progression
Growing pain (see above)

129

DDH

Incidence
1:1000 live births
Common enough for the condition to be screened by the neonatologists
Risk factors
1st female child
Family history
Breech
Condition predisposing to crowding of uterus (multiple pregnancies,
oligohydramnios, fibroids, baby too big, mother too small)
Diagnosis:
Diagnosis is CLINICAL
Barlow maneuver test of dislocatability
see if hip can come out or not, test positive when it goes
back in on the way
Ortolani maneuver test of reducibility
pushing a hip that is already out; clunk only when it
moves over labrum
U/S or X-rays can be used but not to diagnose at birth
X-ray: radiation PLUS hip is not ossified
U/S not done at birth because laxity of hip joint, may get spurious
reading at birth (in order for baby to come out of birth canal)
hence earliest U/S is at 6 weeks
When to do U/S
For high-risk cases (e.g. breech) / hip laxity / hip clicks
To ensure concentric stable reduction after treatment
Weekly after with splint to ensure reduction and correct
application of splints
Every 6 weeks after once hip reduced
Most effect <3 months old (3 months onwards :X-rays; must
ensure concentric reduction with good acetabular cover, if not
mechanical forces of hip not evenly distributed may get OA)
When to do X-rays
3 months onwards

Each Xray must show concentric reduction with good acetabular

cover

Management
Goals

CONCENTRICALLY REDUCED AND STABLE HIPS WITH

GOOD ACETABULAR COVER
To Avoid Early Degenerative Disease of the Hips
Treatment
WATCH observe if
Hip laxity only
Hip clicks
Repeat U/S at 4-6 weeks
If hips reduced and stable, no further tx
Otherwise treat as DDH
ABDUCTION SPLINT
0 to 6 months
Abduction splint (old mtd) or Pavlik Harness
Repeat U/S in harness after 1 week and out of harness at 6
weeks
Worn for at least 3 months until 1st Xrays
If Xrays show concentric hips with good acetabular cover,
then wean off splints
In Human position: 50deg of abduction of each side and 100deg
of flexion

130

CLOSED REDUCTION & HIP SPICA

0 to 6 months
If unable to achieve stable reduction with splints then
closed reduction and hip spica attempted
OPEN REDUCTION & HIP SPICA
6 to 12 months
Closed reduction can still be attempted but more difficult
to achieve stability
Open reduction then done
12 to 18 months
Child is already weight bearing
Open reduction usually involves femoral derotation and
shortening
Acceptable is thought to remodel accordingly
Above 18 months
Potential for acetabular remodeling is less
Both acetabular and proximal femoral surgery will be
required.
Acetabular surgery (Salter osteotomy)
FOR CHRONICALLY NEGLECTED CONDITIONS (RARE)
Reductions not usually attempted if
> 8 years for unilateral (no more remodelling past 8yo, so
reduction would cause OA)
> 5 years for bilateral
Consequences of not reducing
Partially dislocated (formation of false joint)
Completely dislocated will have Trendelenburg gait,
cost of energy to walk will be high hence not ideal (have
to sit on side back pain, will get scoliosis
Bilateral: waddling gait, hips dislocated behind so
nothing to hold pelvis in between, would get lordosis
Will ALL will walk assuming muscles and nerves are
functional

CLUBFOOT (CONGENITAL TALIPES EQUINOVARUS)

Incidence
1:1000
2x more common in males, bilateral in 1/3 of patients
a/w spina bifida & arthrogryposis (non-progressive condition characterized by
multiple joint contractures found throughout the body at birth)
Also screened at birth by neonatologist
Types
- Structural
o Something wrong with the structure, intervention required
o Mainly Idiopathic
o Neuromuscular [muscle imbalance peroneals not working (S1)]
o Syndromic e.g.
- Positional (if able to dorsiflex foot then positional)
o When you examine the feet flexible, due to position in the womb
Clinical Features

Hindfoot equinovarus

Forefoot supination

Forefoot adduction

Cavus
131

Management
I) Ponseti casting
- Serial casting and manipulations soon after birth.
- Foot corrected distal to proximal
o Weekly for 4 weeks
o Fortnightly for 4 weeks until external rotation of 60 achieved
o Then assess need for TA tenotomy if hindfoot still uncorrected.
#1
#2

#5

SUMMARY:
External rotation: tilt toe and turn out
60deg in relation to the knee
Principle: serial casting & manipulation
FOREFOOT: casting (forefoot corrected
first then hindfoot!)
HINDFOOT: cut the tendon (if force into
casting, will cause vertical talus)
Then BOOTS & BARS

II) Boots & Bars

- 23hrs/ day for 3 months
- Then wean till child being to cruise
- Then night and nap till 4 years old.
#3
FLATFEET (PES CAVUS)

#4

Classification
Two diagnostic groups
Dynamic
Due to generalised ligamentous laxity
All children have this till about 7yo
Ask patient to tip toe tightening of plantar fascia
arches indicative of ligamental problems
Jacks Test (reverse of tip-toe; pull toe up arch appears)
Due to tight TA
Growth spurts creates muscle tightness esp TA due
to imbalance of muscle and bone growth
Due to collagen tissue disorders, e.g. Marfans
Fixed Flatfeet
Neuromuscular e.g. CP
Idiopathic
Tarsal coalition with/without peroneal spasm
132

Calcaneo Navicular
9 to 12 years
Do an oblique x-ray
Talo - calcaneum
12 to 15 years; 50% bilateral
Do a CT

Management
Dynamic with no tight TA
Dynamic with tight TA
Fixed
- Tarsal coalition

Watch and Masterly Inactivity

Stretching, Good Shoeing and Medial Arch Support
Treat underlying problem - usually needs surgery
- Treat if < 30% involved, with soft tissue interposition
(fat & extensor digitorum brevis)

LOWER LIMB MALALIGNMENT

At birth: all children will have varus up to 2yo

4yo: maximal valgus occurs (reassure parents & monitor childs inter-malleolar
distance every 6 months to record progress)
7yo: resolves spontaneously; should a marked deformity persist past 10yo,
operative correction should be advised
Normal adults/teens: Slight valgus, about 6deg or so

Importance of aligning early:

Accept valgus till about 5-7yo
If valgus <7yo, mechanical axis will be lateral (i.e. pressure at lateral portion of
growth plate) inhibition of lateral growth plate compared to medial
OA of lateral compartment (about 30-40yo)
Causes
Child
Toddler
Infant

HIP: Medial femoral torsion (femoral anteversion)

- Usually bilateral
LEG: Medial tibial torsion (commonest cause of bow-leggedness in 1yos)
FOOT: Metatarsus adductus
1. Metatarsus deviate medially
2. Kidney-shaped sole
3. Splaying of first webbed space
4. Inverted sole

SCOLIOSIS
Classification
- Idiopathic
- Neuromuscular
CP
SMA
Myelomeningocoele
Muscular dystrophies
- Congenital
Hemivertebrae
Block vertebrae
- Syndromic
Ehler-Danlos
Marfans
Neurofibromatosis
VACTERL

133

Clinical Assessment
- General assessment + height
- Back examination
Scoliometer (in clinic)
Spinal balance: plumbline
Screening test: Adams Forward Bending Test

Why positive?

Idiopathic scoliosis: important points in history-taking

- Chronological age
- Menarche
- Family history
-

Neurological examination
Cobbs angle (X-ray)

Time of diagnosis
Severity of first X-ray
Any previous treatment
Associated symptoms
Back Pain
Neurological: clumsiness/weakness, bowel/bladder function

Red flags that scoliosis may NOT be idiopathic

History
- Back pain that is well-localised and constant
- Pain that is becoming progressively worse over time
- Feelings of weakness or clumsiness
- Episodes of bowel or bladder incontinence
- Ejaculation problems
134

Physical Examination
- Foot deformity, particularly unilateral
- A lack of rotational deformity on Adams forward bending test
- Hyperkyphosis
- Tight hamstrings (popliteal angle > 5060 deg)
- Abnormal curve pattern : Not R thoracic and/or L lumbar
- Unequal or abnormal reflexes
X-rays
- Widened pedicles
- Kyphosis
- Atypical curve pattern
- Lack of vertebral rotation
- Rapid curve progression (>1 degree / month)
- Absent pedicles (`winking owl)
- Limb length discrepancy
MRI
When to order
o Neurologic abnormalities on physical exam (dont forget the feet)
o Structural (congential) abnormalities on plain film
o Excessive kyphosis
o Apex left thoracic or thoracolumbar curves
o Early onset scoliosis
o Syndromic features present
What to look for
Syringomyelia
Chiari malformations
Tethered cord
Diastematomyelia
Treatment

CEREBRAL PALSY
Definition
Non progressive insult on a developing brain
The brain lesion is permanent and non progressive, but the natural history of
cerebral palsy is not static.
If non-progressive insult on a developed brain = stroke
Aetiology
About 10 to 15% of patients documented perinatal hypoxia.
Cerebral palsy is not solely the result of prematurity because 60 to 65% of
afflicted children were born at full term
Although only approximately 10% of cerebral palsy patients weigh less than
1,500 grams at birth, in this low birth weight group the risk of having cerebral
palsy is 90 per 1,000, compared with 3 per 1,000 if weighing more than 2,500
grams and appropriate for gestational age
Low birth weight for gestational age & prematurity are commonly
associated with the development of spastic diplegia
Types
Neuropathic Types***
Spastic
Overactive Golgi
apparatus
The only one in which
Ortho team can intervene
Ataxic
Athetoid
Hypotonic
Mixed

Anatomic Patterns***
Hemiplegic
Diplegic
Quadriplegic
Total body
Others
Triplegic
Monoplegic

135

Management is dependent on functional assessment of the child! (See right)

Type
Functional Aim
Hemiplegic

Diplegic

Quadriplegic

Walker

Efficient Walking

Supple Hamstrings
Supple TA
Upper Limb is the best position for function

Efficient walking

No crouch/jump gait

No tiptoeing

Feet in neutral position

No scissoring

Consider need for assistance if power and control poor

Dietary control (optimal BMI; too heavy, patient cannot bear weight)

All should walk !! (if not, could be due to poor parental support, laziness
[rehab into society would be even more difficult])
Non Walker

Investigate reason

If reason for inability to walk is neurological then aims same as

quadriplegic sitter

Painless seating

Seating Clinic

Spine fairly straight and stable

Hips painless and reduced

No pelvic tilt

Adequate abduction for hygiene care

Adequate knee flexion

136

Botulinum A Toxin
intramuscular injection of a neurotoxin produced by Clostridia bacteria.
It is delivered into or near sites of nerve arborization, and blocks the release of
acetylcholine from presynaptic vesicles at the myoneural junction.
Recovery of tone results from the sprouting of new nerve terminals, which
peaks at about 60 days
The agent is injected using a 23- or 25-gauge needle, usually without local or
general anesthesia
The muscles are located by palpation.
To reach muscles that are deep or difficult to localize, electromyographic
guidance and electrical stimulation have been used
BTX diffuses readily, so the injection should be placed in the muscle belly

Done percutaneously in very young

Hamstring release
In those with very severe crouch gait and popliteal angles usually
exceeding 45o
Release of semitendinosus
Fractional lengthening of semimembranosus and biceps femoris

Adductor release
Done for significant scissoring in walker
Uncorrectable tight adductor in non- walker such that perineal hygiene
is compromised
Painful subluxed hips

Soft tissue surgery: basic principles

Surgery only done when deformity progresses to contracture and is not
dynamic anymore (not dynamic = passive ROM still possible)
Surgery is CONTRAINDICATED in joints with correctible deformity
Surgery done with functional aim in view
Cosmesis only a consideration in Upper Limb
Tendo-Achilles Lengthening
Indicated when ankle cannot be dorsiflexed to neutral in walker
137

Bony surgery: basic principles

Usually in older children
When soft tissue surgery had failed with recurrence of deformity
[aka once joints are stuck/immobile]
In areas where soft tissue surgery alone inadequate
Spine
Unstable hips
Severely deformed feet due to uncorrected muscle imbalance.
Spine
Paralytic scoliosis due to muscle imbalance
Not treatable with bracing
Seating is difficult for Quadriplegics if uncorrected
Unstable hips
Hips need to be reduced because
Pain
Severe pelvic tilt causing 2o scoliosis
Pressure sores due to unequal pressure when sitting
Not the same as DDH
Usually needs Open Reduction
With or without femoral and/or acetabular osteotomy
Feet
Usually done in older age group
Many methods described
Principle is to correct the foot alignment
Indicated in walkers with passively uncorrectable deformities
Valgus feet
Calcaneal Shift, Grice Extra-articular Fusion

Tendon Transfers
Split Posterior Tibialis Tendon Transfer

Triple Arthrodesis
Salvage procedure

138

IMPORTANT CLASSIFICATIONS FOR ORTHOPAEDICS

FRACTURE TYPES
Simple

Comminuted

Hairline
Greenstick

Compression
Avulsion

Impacted

Transverse (<30o)
Oblique (>30o)
Spiral
Spiral wedge torsional forces
Bending wedge characteristic butterfly fragment
Comminuted wedge bending wedge # with fragmented butterfly
fragment
Complex spiral >1 spiral fragments
Complex segmental double #
Complex irregular bone lying btw main elements is fragmented
If not detected on XR initially:
Do oblique XR
Repeat film after 7-10 days
Children
Elastic spring of periosteum may cause recurrence of angulation, hence
plaster fixation must be well done.
Rapid healing
Common sites
Vertebral bodies
Heels
Common sites
Base of 5th metatarsal (peroneus brevis)
Tibial tuberosity (quadriceps) (Osgood-Schlatters disease)
Lower pole of patella (Johansson-Larsens disease)
Upper pole of patella (quadriceps)
Lesser trochanters (iliopsoas)
One fragment driven into another

DESCRIBING FRACTURES
1. Level
Anatomical epiphysis, epiphyseal plate, metaphysic, diaphysis
OR
Thirds proximal, middle, distal
2. Displacement
Direction of displacement in terms of movt of distal fragment
Degree of displacement in % of # surfaces in contact
3. Angulation
Described in terms of the direction the point of # angulation is
pointing towards (eg anterior angulation in Colles #)
4. Axial rotation Easily missed, examine the joints above & below the #
5. Open / Close
Open

Gustilo Classification
Open from within or without latter has risk of infxn,
hemorrhage & injury to muscles, nerves or bld vessles. Also
usually comminuted & more difficult to manage.

OPEN FRACTURES: Gustilo Classification

Type I
<1cm AND clean
Type II
>1cm AND no extensive soft tissue damage, avulsions or flaps
Type IIIA
Extensive soft tissue damage, avulsions or flaps but adequate soft tissue
coverage of bone OR
High-energy trauma cause irregardless of size of wound
Type IIIB
Extensive soft tissue loss + periosteal stripping + bone exposure
Massive contamination common
Type IIIC
Arterial injury requiring repair
HAEMORRHAGE IN FRACTURES
Close # of femoral shaft
Haemothorax
Pelvic #

2-3L
3-5L
3-5L

EPIPHYSEAL PLATE INJURIES: Salter-Harris Classification

Type 1 Whole epiphysis separated from shaft
Type 2 Epiphysis is displaced together with a metaphyseal fragment
Type 3 Separation of part of the epiphysis
Type 4 Separation of part of the epiphysis with a metaphyseal fragment
Type 5 Crushing of part or all of the epiphysis
*Cxs: avascular necrosis, growth arrest
UPPER LIMB
Colles #

Smiths #
Galeazzi #dislocation
Monteggia #dislocation

# distal radius w/in 2.5 cm of wrist (aka dinner-fork #)

Anterior & ulnar angulation
Dorsal & radial displacement of distal fragment
Impaction of fragments.
# distal radius w posterior angulation anterior displacement (aka
reversed Colles #)
# of radius, inferior radioulnar joint dislocation (GUD)
Ulna fracture + anterior dislocation of head of radius (MUF)
139

Features
Pain, no trigger
Correctable by active extension
Correctable by passive extension
Fixed flexion deformity

Mx
NSAIDs
H&L
H&L, Sx sheath
incision
Sx release

PELVIC FRACTURES: Tile classification

Type
Stable #s
A
No involvement of pelvic ring
A
1
A
Stable, minimally displaced # of pelvic ring
2
Type B Rotationally
B1 AP compression # (open book #)
unstable,
B2 Lateral compression #, ipsilateral
vertically stable
B3 Lateral compression #, contralateral
Type C Rotationally &
C1 Unilateral
vertically
C2 Bilateral
unstable
C3 Associated acetabular #
PERTHES DISEASE
Catterall grading according to degree of femoral head involvement
Grade
Severity
Px
1
involve anterior portion of epiphysis
Revascularisation may be
only. No collapse or sequestrum
complete w/o bone collapse
2
50 % involvement with a sequestrum Bony collapse inevitable
3
~75% involved, with collapse &
Bony collapse inevitable. Poor
sequestrum
Px
4
whole epiphysis involved
INTERTROCHANTERIC FRACTURE OF THE FEMUR
Evans Classification
I
2 fragments, undisplaced
II
2 fragments, displaced
III
3 fragments w/o posterolateral support (ie # of the greater trochanters)
IV
3 fragments w/o medial support (ie # of the lesser trochanter)
V
4 fragments
R
Reversed oblique # - prone to displacement
*Alternative classification: according to number of fragments + reversed oblique #

FRACTURE OF NECK OF FEMUR:

(A) Gardens Classification
Type Incomplete fracture (Inferior cortex
1
not broken)
No displacement
Abduction #
Trabeculae are angulated
Type Complete fracture line (inf. cortex
2
broken)
No displacement
Trabecular lines interrupted but not
angulated
Type Complete fracture line
3
Slight-moderate displacement
Rotation of femoral head prox frag
abducted & int. rotated
Type Severe displacement
4

(B) Anatomical Classification

A Subcapitate
B Transcervical
C Basilar

10
Fixation by:
Cannulated screws /
pins
DHS

>65YO
hemiarthroplasty.
o
Unipolar (Moores
or Thompsons)
o
Bipolar for
younger PTs
<65YO attempt joint
salvage

20
Risk of AVN (%)

TRIGGER FINGER
Stage
Pre-triggering
Triggering
Triggering &
Lock
Contracture

30

40

Intracapsular risk of severing retinacular vessels

resulting in AVN (12-33% of all #NOF
Extracapsular

(C) Phases of AVN

I
Only head involvement
II Progress to secondary OA & acetabulum is affected as well
ANKLE FRACTURES
Webers classification
Type
Level of fibular #
A
Distal to syndesmosis
B
Involve the syndesmosis
C
Proximal to syndesmosis

140

Potts Classification
First degree
# of a single malleolus (medial or lateral)
Second degree
# of both medial & lateral malleoli
Third degree
# of medial, lateral & posterior malleoli
SCOLIOSIS
List of Causes
Non
structural

Structural

Limb length discrepancy (apparent or true shortening of one leg)

Hip contracture
Muscle spasm eg 2o to PID
Adolescent idiopathic (commonest, 80%)
Infantile idiopathic may resolve or progress
Osteopathic due to congenital vertebral anomalies
Neuropathic eg 2o to polio or CP. Due to asymmetrical muscle
weakness
Myopathic due to muscular dystrophies
Neurofibromatosis

SPONDYLOLISTHESIS
Causes
1. Dysplasia congenital lumbosacral facet jt dysplasia
2. Isthmic (spondylolytic) break in the pars interarticularis
3. Elderly (degenerative) OA degeneration of facet joints
4. Trauma
5. Suspicious (pathological) neoplasm
6. Post-op due to laminectomy for decompression

Meyerding classification
Grade % translation of
VB
I
0-25
II
25-50
III
50-75
IV
75-100

BONE TUMOURS
Ennekings Classification
Grade
G0
Benign
(surgical)
G1
Low grade malignant
G2
High grade malignant
Site
T0
Benign Intracapsular & intracompartmental
T1 (A)
Intracompartmental
T2 (B)
Extracompartmental
Metastasis
M0
No regional / distant mets
M1
Regional / distant mets
Staging for Malignant Neoplasia
IA
G1
T1 M0
IB
G1
T2 M0
IIA
G2
T1 M0
IIB
G2
T2 M0
IIIA
G1 or 2 T1 M1
IIIB
G1 or 2 T2 M1
Staging for Benign Neoplasia
1
Latent
G0 T0
2
Active
G0 T0
3
Aggressi
G0 T1 or 2
ve
OSTEOPOROSIS
BMD T-score
>-1
-1 to -2.5
<-2.5
<-2.5 + fragility
fracture

M0
M0
M0 or 1 (giant cell
tumour)

Definition
Normal
Oteopenia
Osteoporosis
Severe osteoporosis

RHEUMATOID ARTHRITIS
Stage 1 (synovitis) pain, chronic swelling, large effusion, thickened synovium
Stage 2 (articular erosion) joint instability, ROM. X-ray: loss of jt space & marginal
erosion, but lack of osteophytes c.f. OA
Stage 3 (deformity) pain, deformity, instability & disability. X-ray: bone destruction
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DISEASES MNEOMONICS

1. Osteosarcoma: risk factors PRIMARY:

Paget's, Radiation, Infaction of bone, Male, Alcohol, poor diet, sedentary lifestyle
[adults only] Retinoblastoma, Li-Fraumeni syndrome, Young [10-20 yrs].
Osteosarcoma is the most common primary malignant tumor of bone.
2. Osteosarcoma: features PEARL HARBOR:
Paget's disease (10-20%)*, Early age (10-20 yrs), Around knee, Raised periosteum
by expanding tumor: "sunburst pattern", Lace-like architecture, Hyaline
arteoriosclerosis, Alkaline phosphatase increased, Retinoblastoma*, Boys,
predominantly, Osteomyelitis DDx, Radiation*
Sunburst pattern was Japanese Navy emblem during WWII.
*: Predisposing factors.

8. Deep tendon reflexes: root supply "1,2,3,4,5,6,7,8":

S1-2: ankle, L3-4: knee, C5-6: biceps, supinator, C7-8: triceps
9.

Monoarthritis differential GHOST:

Gout, Haemarthrosis, Osteoarthritis, Sepsis, Trauma

10. Can H&L (hydrocortisone and lignocaine) everything except plantar fascitis and
archilles tendonitis

3. Sacroiliitis: causes PUB CAR: seronegative arthropathies + Bechets

Psoriasis, Ulcerative colitis, Behcet's disease, Crohn's disease, Ankylosing
spondylitis, Reiter's disease
4. Rheumatoid arthritis: features RHEUMATOID:
Ragocytes/ Rheumatoid factor (anti-IgG), HLA-DR4/ HLA-Dw4, ESR increase/
Extra-articular features (restrictive lung disease, subcutaneous nodules), Ulnar
deviation, Morning stiffness/ MCP joint, Ankylosis/ Atlantoaxial joint subluxation/
Autoimmune/ ANA, T-cells (CD4)/ TNF, Osteopenia
Inflammatory synovial tissue/ Idiopathic/ IL-1, Deformities (swan-neck,
boutonniere)
5. Seronegative spondyloarthopathy: diseases PAIR:
Psoriatic arthitis, Ankylosing spondylitis, IBD, Reiter's syndrome
6. Osteomalacia: features "Vit-D deficiency in ADULT":
Acetabuli protrusio, Decresed bone density, Under mineralization of osteoid,
Looser's zone (pseudofracture), Triradiate pelvis (females)
7. Osteomyelitis: complications FIBRES:
Fractures, Intraosseous (broidie) abscesses, Bacteremi/ Brodie abscess, Reactive
amyloidosis, Endocarditis, Sinus tracts/ Squamous cell CA

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