Apley - and - Solomon's - System - of Orthopaedics - LT PDF

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pelvic ring or acetabular fractures,
pelvis account for less than 5% of

all skeletal injuries,
important due to the potential risk of

severe blood loss.
pelvic ring is made up of the two

innominate bones and the sacrum,
articulating in front at the symphysis
pubis and posteriorly at the sacroiliac
joints.
transmits weight from the trunk to

the lower limbs
no inherent bony stability of

the pelvis.
three segments together
anteriorly
symphysis pubis
sacroiliac joints posteriorly.
stability of the pelvic ring depends

upon the integrity of the strong
ligaments
posterior stability by the posterior

anterior stability is provided by the anterior sacroiliac ligaments the sacrococcygeal
sacroiliac ligaments and the iliolumbar liga- ligaments, and the sacrotuberous and
ments sacrospinous ligaments
internal iliac vessels supply the

pelvic viscera,
external iliac vessels continue in their

journey to supply the lower limbs
rich low-pressure venous plexus

posteriorly
It is bleeding from this plexus that

comprises the major blood loss in
pelvic haemorrhage.
lumbosacral plexus is at risk with

posterior pelvic injuries.
The L5 and S1 nerve roots
pelvic ring injuries
sciatic nerve
acetabular fractures.
urethra is much more mobile and

shorter in females, and it is less prone
to injury.
male urethra
commonest urogenital organ to

be damaged
severe pelvic injuries the
membranous urethra
pelvic colon, with its mesentery, is

a mobile
not readily injured
rectum and anal canal
more firmly tethered
therefore vulnerable
Nowadays, the application of a pel-

vic binder at the scene of the accident
is mandatory in any suspected pelvic
injury
Guarding or tenderness suggests the

possibil- ity of intraperitoneal bleeding
binder applied
X-rays should be taken following the

removal of the binder to ensure no
displacement of the pelvis has
binder removed. occurred
Neurological examination is very

important; there may be damage to
the lumbosacral plexus.
1 The sacroiliac joint area is

inspected for any diastasis or sacral
fracture.
2 The ilium is inspected for

any fracture.
a radiological feature which

correlates to the non-articular floor of
the acetabulum, and close inspection
in this area will reveal any acetabular
fracture.
a radiological feature which
correlates to the non-articular floor of
Page 4 (row 4, column 1) the acetabulum, and close inspection
in this area will reveal any acetabular
fracture.
systematically look at each line to

see which is broken.
4 The obturator foramen is inspected
for any fracture of the superior or helps to interpret the Letournel
inferior pubic ramus. classification
symphysis pubis is examined for

any fracture or diastasis.
Specialized radiographs
pelvic inlet and outlet views
30–40 degrees in a caudal and

cephalic angle and are used to assess
the pelvic ring.
(b) outlet view.
(a) Inlet view;
sacrum and sacroiliac joints, provides a true anteroposterior view

of the sacrum and pubic symphysis
areas
Judet views (taken at

30 degrees obliquely)
obturator oblique iliac oblique view
anterior column of
the acetabulum posterior column and anterior wall
of the acetabulum.
CT scans can be reformatted to
provide Judet views,
a full ‘trauma CT scan’.
head, neck, chest, abdomen

and pelvis.
excluding a bladder rupture or

urethral injury
Avulsion fractures
most common avulsion injuries
anterior inferior iliac spine (rectus ischial tuberosity (hamstring origin)

femoris origin)
violent muscle con- traction;
adductor longus a piece of

the pubis
sartorius
anterior superior iliac spine
Stress fractures
common in osteoporotic bone

the most common cause of chronic

inflammatory joint disease.
most typical features
symmetrical polyarthritis
tenosynovitis,
morning stiffness,
elevation of the erythrocyte

sedimentation rate (ESR)
autoantibodies (rheumatoid factor

(RF) and anti-citrullinated peptide
antibodies (ACPAs))
Individuals with RA tend to

die younger
result of the effects of chronic

inflammation
early ischaemic heart disease
prevalence of RA in most popu-

lations is 1–2%,
peak incidence in the fourth or

fifth decades.
Women are affected three times
Important factors in the evolution

of RA
(1) genetic susceptibility

(2) an immunological reaction
focused on synovial tissue
(3) an inflammatory reaction in joints

and tendon sheaths
(4) the appearance of rheumatoid

factors (RF)
(anti-CCP or ACPA
(5) perpetuation of the

inflammatory process
(6) articular cartilage destruction
Genetic susceptibility
first-degree relatives of patients
(HLA) DR4
HLA-DR4 is encoded in the major

histocompatibility complex (MHC)
region on chromosome 6
HLA-DR4 binding groove called the

‘shared epitope’
HLA Class II molecules appear
(B lymphocytes, macrophages,
dendritic cells), which can act as anti-
gen-presenting cells (APCs)
T-cell immune reactions, the

process is initiated only when the anti-
genic peptide is presented
no such antigen has been

discovered.
The inflammatory reaction
Once the APC/T-cell interaction

is initiated,
marked proliferation of
synovium,
appearance of new blood vessel

formation. Immune cells
action by the use of ‘short-range

hormones’ (cytokines)
activate inflammatory cells such as

macrophages and B cells.
chemokines, attract other

inflammatory cells to the area.
cytokines are important in RA
tumour
necrosis factor
(IL-6) (TNF),
interleukin-1
(IL-1)
resulting synovitis, both in joints and in tendon

sheath linings, is the hallmark of early RA.
Rheumatoid factor
B-cell activation
production of anti-IgG
autoantibodies
detected
as ‘rheumatoid factor’ (RF)
Low levels of RF many ‘normal’ individuals
high, an inflammatory disease

is likely
Other autoimmune conditions
(SLE) and Sjögren’s
associated with the presence

of RF.
Other autoimmune conditions
(SLE) and Sjögren’s
associated with the presence

of RF.
associated with RA
presence of anti-CCP is
very specific
Chronic synovitis and joint

destruction
Chronic rheumatoid synovitis
associated with
proteolytic enzymes, prostaglandins

and the cytokines TNF and IL-1
Immune complexes
in synovial joints
leads to depletion of the cartilage
Vascular proliferation and

osteoclastic activity
further to cartilage destruction and

periarticular bone erosion.
most characteristic lesions
the synovium or within rheumatoid

nodules. Th
four stages
In any one joint, features of different

stages can be occurring
simultaneously
Stage 1: Pre-clinical Stage 2: Synovitis

Stage 3: Destruction Stage 4: Deformity
RA becomes clinically apparent, new blood vessel formation,

causes joint and tendon articular destruction,
destruction
Raised ESR, C-reactive protein (CRP)
and RF proliferation of synoviocytes and capsular stretching
infiltration of the subsynovial layers
Articular cartilage is eroded
by polymorphs, lymphocytes and
detectable years before the plasma cells tendon rupture leads
first diagnosis.
direct invasion of the cartilage by a
thickening of the capsular structures pan- nus of granulation tissue creeping progressive instability
over the articular surface
villous formation of the synovium deformity of the joints.
bone is eroded by tissue invasion

cell-rich effusion into the joints and and osteoclastic resorption
tendon sheaths.
Similar changes occur in

reversible. tendon sheaths,
causing tenosynovitis,
partial or complete rupture

of tendons
EXTRA-ARTICULAR TISSUES LymphadenopathY Vasculitis Muscle weakness

Visceral disease
Rheumatoid nodules Not only the nodes draining life-threatening

generalized myopathy or
inflamed joints, Ischaemic heart disease and
neuropathy,
osteoporosis are common
small granulomatous lesion complications.
skin exclude spinal cord disease or cord
mediastinal nodes, can compression
cen- tral necrotic zone be affected
nailfold infarcts,
(atlantoaxial subluxation)
splenomegaly can also be
palisade of local histiocytes
associated with neutropaenia
Sensory changes
beyond that by inflammatory Felty’s syndrome.
granulation tissue.
a neuropathy
(especially over bony
prominences)
tendons result from nerve compression by

thickened synovium
sclera
3.2 Rheumatoid synovitis (a) The macroscopic
appearance of rheumatoid synovitis with fibrinoid mate- carpal tunnel syndrome
rial oozing through a rent in the capsule. (b) Histology
viscera.
shows proliferating synovium with round-cell infiltration
and fibrinoid particles in the joint cavity (×120).
usually insidious,
In the early stages In the later stages
polysynovitis, with soft-tissue

swelling and stiffness deformity becomes increas-
ingly apparent
Typically, a woman of 30–

40 years combination of joint instability and
tendon rupture produces the typical
‘rheumatoid’ deformities:
pain, swelling and loss of mobility in
the proximal joints of the fingers
ulnar deviation of the fingers

history of ‘muscle pain’, tiredness
radial and volar displacement of

the wrists
As time passes, the symptoms
‘spread’ to other joint
valgus knees
wrists, feet, knees and shoulders

valgus feet and clawed toes
order of frequency
stiffness in the cervical spine
generalized stiffness
early morning
stiffness typically lasts longer than

30 minutes.
symmetrically distributed swelling

and tenderness of the
metacarpophalangeal joints
Tenosynovitis
extensor compartments of
the wrist
flexor sheaths of the fingers;
thickening,
crepitation over the back of the

wrist or the palm while passively mov-
ing the fingers
If the larger joints are involved,
local warmth, synovial hypertrophy
appearance of nodules Less specific features include
small subcutaneous lumps muscle wasting
rubbery in consistency, lymphadenopathy
elbows, scleritis,
tendons (where they may cause nerve entrapment syndromes,

‘triggering’ or rupture
skin atrophy
vasculitis
peripheral sensory neuropathy
X-rays
Early later stages
soft-tissue swelling and periarticular marginal bony erosions

osteoporosis and narrowing
especially in the proximal joints
hands and feet
Flexion and extension views of the cervical spine often show subluxation at the atlantoaxial or mid-cervical levels;
Ultrasound scanning and MRI
Ultrasound
synovitis and early erosions.
Blood investigations
Normocytic, hypochromic
anaemia
aggravated by
non-steroidal anti-
inflammatory drugs
In active phases the ESR and CRP

concentration are usually raised
anti-CCP antibodies have added

much greater specificity
Synovial biopsy
needle biopsy
non-specific
persisting for at least 6 weeks.
subcutaneous nodules or X-ray signs

of periarticular erosions, the diagnosis
is certain
chief value of the RF tests
prognosis:
Atypical forms of presentation
rapid appearance of severe joint pain

and stiffness
disease starts with chronic pain and

swelling of a single large joint
presence of
all metacarpophalangeal
all metacarpophalangeal
early morning stiffness
at least 30 minutes
raised ESR
diagnosis of rheumatoid arthritis.
Calcium pyrophosphate
differential diagnosis deposition disease
older people
Seronegative inflammatory Ankylosing spondylitis
polyarthritis
psoriatic arthritis affects large joints

sacroiliac and intervertebral joints
Still’s disease, X-ray signs

causing back pain
systemic lupus erythematosus characteristic
Polyarticular gout
Reiter’s disease/reactive arthritis
Tophaceous gout
conjunctivitis.
erosions are quite different from
urethritis or colitis
those of rheumatoid arthritis
lumbosacral spine are the

the diagnosis is clinched by
main targets
identifying typical birefringent urate
crystals
Sarcoid disease
symmetrical small-joint
polyarthritis
large joint s
knee or ankle
Erythema nodo- sum and hilar

lymphadenopathy on chest X-ray are
clues to the diagnosis.
Sarcoid disease
Acute sarcoidosi Chronic sarcoidosis
subsides spontaneously within

granulomatous infiltration of lungs,
6 months
bone, synovium
X-ray features
punched-out ‘cysts’ and cortical

erosions in the bones of the hands
and feet
ESR and serum angiotensin

converting enzyme (SACE) RAISED
typical noncaseating granulo- mas.
(NSAIDs)
Treatment
corticosteroids
Lyme disease Viral arthritis
flu-like symptoms

transient polyarthralgia
Treatment with doxycycline

typically parvovirus B19
spreads to multiple organs
flu-like illness
asymmetrical inflammatory
polyarthritis
early morning stiffness,
larger joints
absence of ‘rheumatoid’ X-ray

features and subcutaneous nodules
Polyarticular osteoarthritis (OA)
involves the finger joints,
whereas RA affects the proximal

OA always involves the distal joints of the hand and predominantly
interphalangeal joints erosive features
causes a nodular arthritis
radiologically obvious
osteophytes,
Polyarticular osteoarthritis (OA)
involves the finger joints,
whereas RA affects the proximal

OA always involves the distal joints of the hand and predominantly
interphalangeal joints erosive features
causes a nodular arthritis
radiologically obvious
osteophytes,
confusion may arise
later stages, is associated with loss

of articular cartilage and secondary
OA.
Rheumatoid arthritis –
differential diagnosis
mainly the proximal joints were affected

(rheumatoid arthritis); the distal joints were the worst (Heberden’s were asymmetrical nodular swellings around the
osteoarthritis) joints (gouty tophi).
Treatment
no cure for rheumatoid arthritis
multidisciplinary approach
include a rheumatologist, orthopae-

dic surgeon, physiotherapist,
occupational therapist,
Poor prognosis
female sex,
multiple joint involvement
high ESR
CRP,
positive RF
anti-CCP,
younger age,
high BMI
the presence of erosions

at diagnosis.
smoking
aimed at controlling inflammation

as rapidly as possible.
corticosteroids for their rapid onset

(initially oral doses of 30 mg of
prednisolone o
Steroids should be rapidly tapered

to prevent significant side effects.

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Page 1 (row 1, column 1)

pelvic ring or ace- tabular fractures,

pelvis account for less than 5% of

important due to the potential risk of

pelvic ring is made up of the two

transmits weight from the trunk to

no inherent bony stability of

three segments together

sacroiliac joints posteriorly.

stability of the pelvic ring depends

posterior stability by the posterior

internal iliac vessels supply the

external iliac vessels continue in their

rich low-pressure venous plexus

It is bleeding from this plexus that

lumbosacral plexus is at risk with

The L5 and S1 nerve roots

pelvic ring injuries

urethra is much more mobile and

commonest urogenital organ to

pelvic colon, with its mesentery, is

not readily injured

rectum and anal canal

more firmly tethered

Nowadays, the application of a pel-

Guarding or tenderness suggests the

X-rays should be taken following the

Neurological examination is very

1 The sacroiliac joint area is

2 The ilium is inspected for

a radiological feature which

systematically look at each line to

symphysis pubis is examined for

pelvic inlet and outlet views

30–40 degrees in a caudal and

sacrum and sacroiliac joints, provides a true anteroposterior view

Judet views (taken at

obturator oblique iliac oblique view

a full ‘trauma CT scan’.

head, neck, chest, abdomen

excluding a bladder rupture or

most common avulsion injuries

anterior inferior iliac spine (rectus ischial tuberosity (hamstring origin)

violent muscle con- traction;

adductor longus a piece of

anterior superior iliac spine

common in osteoporotic bone

the most common cause of chronic

most typical features

elevation of the erythrocyte

autoantibodies (rheumatoid factor

Individuals with RA tend to

result of the eﬀects of chronic

early ischaemic heart disease

prevalence of RA in most popu-

peak incidence in the fourth or

Women are aﬀected three times

Important factors in the evolution

(1) genetic susceptibility

(2) an immunological reaction

focused on synovial tissue

(3) an inflammatory reaction in joints