Orthopedics - Brodno: Traumatology

Review of Orthopedics – 2012/2013 – Brodno Szpital 1.0.
Orthopedics – Brodno
TRAUMATOLOGY Treatment:
– Hypertrophic nonunions: Stimulation of osteogenesis by
1. Non-unions external forces:
1. Mechanical forces: (external support) – also by surgical
means: placement of rod/compression plating. Usually used
Definition and Risk Factors/Prevention: for elephant’s foot
– It is a fracture that fails to unite in 4-6 months 2. Electrical stimulation: stimulate dormant chondrocytes &
– Nonunions happen when the bone lacks adequate stability mesenchymal cells: Usually in combination w/ mechanical
and/or blood flow. Factors that can increase the risk of 3. Biological enhancement: autogenous cancelous bone graft
nonunion include: smoking, older age, severe anemia, diabetes, (mostly from iliac crest) = potent stimulator of fracture
anti-inflammatory drugs (e.g. aspirin, prednisone), healing.
malreduction, and infection. – Atrophic nonunions: surgically ‘freshen up’ the avascular
– Nonunions are more likely to happen if the injured bone has bone ends and rigid internal fixation and autogenous bone
a limited blood supply. They are also more likely if the bone grafting.
suffers severe trauma, even if it has an adequate blood supply. – Complex A/H: Ilizarov method – in combination with
– Often occurs when a fracture is ‘missed’ on x-ray and thus autogenous bone grafting: enables bony union, treatment of
the correct treatment is not administered (e.g. immobilization any accompanying deformity, segmental bone loss, or
in a cast). shortening.
– Nonunions with more blood supply and some degree of
micromotion will produce more callus and nonunions with no Complications:
or excess motion and poorer blood supply will produces less – If left untreated: a pseudoarthrosis (false joint) with an actual
callus. synovial-lined capsule enveloping the bone ends (with fluid
left in the cleft) may form. Thus formation of a joint between
the two ends will need surgical intervention.
2. Mal-union
Definition:
– A malunion is a fractured bone that has healed in an
unacceptable position that causes significant impairment. This
Classification (Weber and Cech): can happen in almost any bone after fracture.
– Hypertrophic: viable bone ends: possess the biology but lack
the stability to unite:
1. Elephant’s foot: laying down exuberant callus
2. Horse foot
3. Oligotrophic: no callus
– Atrophic: nonviable ends, they lack the biology to heal.
Clinical Feature:
– Swelling, pain, tenderness, deformity, and difficulty bearing
weight. Mechanism and Cause:
– Patients with nonunions usually feel pain at the site of the – Is a fracture that is healed with an unacceptable amount of
break long after the initial pain of the fracture disappears. This angulation, rotation, or overriding that has resulted in
pain may last months, or even years. It may be constant, or it shortening of the limb.
may occur only when the broken arm or leg is used. – A Mal-union may be caused by inadequate immobilization of
the fracture, misalignment at the time of immobilization, or
Diagnosis: premature removal of the cast or other immobilizer.
– If union has not occurred by 6 months, then it is unlikely to – In general, a shortening and angulatory deformities are
do so without intervention. Typically a diagnosis of non-union better tolerated in upper than in the lower limb. More than 2,5
requires an x-ray (or CT) at >6 months demonstrating non- cm is poorly tolerated in the lower extremity.
union of the fractured ends of the bone.
– One should evaluate joints above/below nonunion; degree Diagnosis:
of shortening/deformity of affected limb must also be – History: History is of a fracture that may or may not have
determined. been treated by a physician. The individual may report pain,
Edited By: Marsel Toplić 1

Review of Orthopedics – 2012/2013 – Brodno Szpital 1.0.0
swelling (edema), instability, or deformity at the site of a Diagnosis and Treatment:
previously broken bone. If the fracture was in a lower – There is a localized pain and tenderness over the involved
extremity, the individual may report difficulty bearing weight bone.
through the limb. – X-ray films may not show fracture for 2 weeks
– Physical exam: The exam reveals the deformity of a – On x-ray it may look like Ewing/bone-forming sarcoma.
malunion or the instability of a nonunion. Touching with the – Bone scan is positive in 12-15 days
hands (palpation) may reveal tenderness. – Treatment is rest from strenuous activities (stop physical
– Tests: Plain x-rays demonstrate the fracture malunion or stress) to allow remodeling (for 4 weeks)
nonunion. CT scan, MRI, or bone scan may help further – Differential diagnosis: sarcomas, nonossifying fibroma,
define the condition. fibrous cortical defect
Treatment:
– Smaller discrepancies: use a shoe lift
– Indication for surgery: when the deformity is sufficient to
cause pain/impairs fixation.
Surgical Procedure:
– Osteotomy: closing wedge (wedge of bone removed);
opening wedge (wedge of autogenous/allograft bone is added)
= alters limb length
– Limb-lengthening
– Proper fixation and usually autogenous cancellous bone
grafting to ensure that the osteotomy heals.
3. Stress fractures
4. Dislocations
Definition and Mechanism:

General about Dislocations:
– These are fractures resulting from repetitive loading – each
– Complete loss of articular contact between two bones in a
load being below the endurance limit, but through
joint
accumulated stress creates a level of force that causes a bone
– There is a severe injury to ligaments and capsular tissues;
to fail. These injuries are typical in the proximal tibia, the
distal piece described in relation to the proximal joint/bone
second metatarsal, and the femoral neck.
Most require urgent reduction to prevent complications – with
– They are common in young (<30yrs) athletes.
general anesthesia/IV sedation
– May be due to: – On physical examination there is pain, loss of motion,
1. Insufficiency fracture: stress applied to a weak or shortening of extremity, sometimes neuronal or vascular injury
structurally deficient bone. – Nursemaid's elbow is a partial dislocation common in
2. Fatigue fracture: repetitive, excessive force applied to toddlers. – The main symptom is refusal to use the arm.
normal bone Nursemaid's elbow can be easily treated in a doctor's office.
– It is most common in adolescent athletes
– Tibia is most common site Shoulder Dislocation:
– Usually occurs several weeks after a sudden increase of – Background: The shoulder is the most frequently dislocated
physical activity for which the patient is not properly joint. It moves almost without restriction but pays the price of
conditioned.
stability. The shoulder's integrity is maintained by the
glenohumeral joint capsule, the cartilaginous glenoid labrum
Types:
(which extends the shallow glenoid fossa), and muscles of the
– March fracture: common in soldiers/pilgrims; found in
rotator cuff.
metatarsal bones of the foot; x-ray may not show injury until
– Types:
3-4wks after onset of pain; common in weight bearing bones
1. Anterior dislocations occur in as many as 98% of cases.
(i.e.: tibia); caused when the bones are under too much stress;
Anterior displacement of the humeral head is the most
rest is best and only treatment.
common dislocation seen by emergency physicians and is
– Metaphyseal-diaphyseal areas of long weight-bearing bones:
depicted in the image below.
Early x-rays look normal before periosteal new bone begins to
2. Posterior displacement is the next most frequently
form; most-sensitive DEXA scan (bone scan).
occurring dislocation.
– Post-menopausal women: can occur with minimal physical
3. Inferior (luxatio erecta), superior, and intrathoracic
activity; i.e.: osteoporotic stress fractures in the sacrum
dislocations are rare and are usually associated with
complications.

– Etiology: peak incidence in men aged 20-30 years (with a seen with elbow dislocations.
male-to-female ratio of 9:1) = sports-related; women aged 61- 2. Anterior dislocation: is usually the result of a direct
80 years (with a female-to-male ratio of 3:1) = collagen fibers posterior blow to a flexed elbow. Associated fractures of the
have fewer cross-links, making the joint capsule and olecranon are commonly seen.
supporting tendons and ligaments weaker and dislocation 3. Divergent dislocations: very rare injury which is
more likely; fall-related; sports, assaults, falls, seizures, associated with significant high-energy trauma to the elbow.
throwing an object, reaching to catch an object, forceful In children, radial head subluxations often occur when the arm
pulling on the arm, reaching for an object, turning over in bed, is pulled. The child commonly holds the arm pronated, mildly
or combing hair; tend to recur flexed, and abducted against the body and refuses or fights any
– Clinical features: severe shoulder pain and limited ROM manipulation of the affected arm.
– Diagnosis: imaging: Anteroposterior (AP) and axillary or – Diagnosis:
scapular "Y" views 1. History: early diagnosis is important to prevent loss of
1. Anterior dislocation: is characterized by subcoracoid function or neurovascular compromise. Essential elements of
position of the humeral head in the AP view. The dislocation the dislocation history include the mechanism of the injury,
is often more obvious in a scapular "Y" view, where the the time between the injury and presentation, functioning,
humeral head lies anterior to the "Y." In an axillary view, the previous attempts at reduction/manipulation, swelling,
"golf ball" (ie, humeral head) is said to have fallen anterior to location, and the type of pain.; neurovascular compromise
the "tee" (ie, glenoid). must be assessed.
2. Posterior dislocation: the AP view may show a normal 2. Imaging: AP & lateral X-rays
walking stick contour of the humeral head, or it may resemble – Treatment: closed reduction: prone position with the
a light bulb or ice cream cone, depending upon the degree of affected elbow flexed at 90° and the humerus supported by
rotation. The scapular "Y" view reveals the humeral head the table (see the image below). The hand of the affected arm
behind the glenoid (the center of the "Y"). In an axillary view, should be pointing toward the ground. Apply downward
the "golf ball" falls posteriorly off the "tee." traction to the forearm, which is held in slight pronation, while
3. Inferior dislocation (luxatio erecta): the AP view may using the other hand to grasp the humerus, and apply pressure
show the arm raised over the head with the radial head inferior to the olecranon in a downward motion to facilitate reduction
to the glenoid Physical therapy; surgery if chronic residual instability
4. Arteriography, angiography, and Doppler flow studies Complications: brachial/radial a compromise & median n;
may be used to evaluate suspected vascular injury. compartment syndrome
– Treatment: Kocher's original method: Bend the arm at the
elbow, press it against the body, rotate outwards until Hip Dislocation:
resistance is felt. Lift the externally rotated upper part of the – Symptoms: inability to bear full weight and there is an
arm in the sagittal plane as far as possible forwards and finally excessive mobility of the limb with crepitus.
turn inwards slowly. – Types:
1. Procedural sedation and analgesia (PSA) protocols, intra- 1. Anterior:
articular lidocaine, and ultrasound-guided brachial plexus A. Etiology: force to the posterior part of the knee when
nerve block assist in making reduction an easier and more hip is abducted
comfortable procedure. Using US-guided interscalene block B. Diagnosis: shortened, ABducted, external rotated limb
reduces time spent in the ED and lessens one-on-one health C. Treatment: closed reduction & post-reduction CT
care provider time compared to procedural sedation.[8] 2. Posterior:
Immobilize the shoulder after reduction. A. Etiology: severe force to the knee when hip is flexed &
Perform careful prereduction and postreduction neurovascular Adducted
exam B. XX: knee into dashboard in MVA
C. Diagnosis: shortened, ADDucted & internally rotated
Elbow Dislocation: limb
– Background: it is most common in children. 50% are sports D. Treatment: closed reduction & post reduction CT,
related. Posterior dislocation accounts for 90%. ORIF if unstable
– Types: 2. Central (rare): traumatic injury where femoral head is
1. Posterior elbow dislocations: the patient often describes pushed into pelvic cavity
falling on an outstretched hand (ie, the FOOSH injury) as the – Complications: avascular necrosis, post-traumatic arthritis,
mechanism of injury. Some clinicians speculate that the elbow fracture of femoral head/shaft; sciatic neural palsy (25%),
is more likely to dislocate when it is slightly abducted and thromboembolism, heterotrophic ossification
flexed. When compressive forces are directed on to the
outstretched hand, the radius and ulna, along with the valgus Patellar Dislocation:
force at the elbow, suffer the common posterolateral – Definition: Lateral displacement of patella after contraction
dislocation. These forces also contribute to associated of quadriceps against flexed knee
fractures. In addition, hyperextension at the elbow has been

– Physical Examination: knee catches/gives way w/walking; 3. Imaging: A cervical spine series usually includes
severe pain, tenderness anterior medial from rupture of anteroposterior (AP), lateral, oblique, and odontoid views.[10]
capsule, weak knee extension/inability to extend leg unless All 7 vertebrae must be visualized, and the disc spaces should
patella reduced; positive patellar apprehension test (patient is be approximately equal throughout the cervical spine.
apprehensive when examiner laterally displaces patella); often CT scanning is performed in patients who have abnormal
recurrent, self-reducing plain radiographs or in whom there is a strong clinical
– Imaging: X-rays: X-Rays (A/P, Lateral, skyline – suspicion of a fracture with inconclusive radiographs
patellofemoral joint; check for fracture of medial patella & MRI is usually indicated in athletes with neurologic deficits
lateral femoral condyle) and when plain radiographic films and CT scans do not
– Treatment: provide enough information for definitive management.
1. Non-operative: done first; knee immobilization 4-6wks, – Classification: Quebec taskforce of whiplash association
progressive weight bearing & isometric quadriceps disorders:
strengthening 0 – no neck pain, no physical signs
2. Surgery: tightening of medial capsule & release of lateral 1 – neck pain, stiffness/tenderness, no other physical
retinaculum, possible tibial tuberosity transfer, proximal tibial symptoms
osteotomy 2 – neck complaints & musculoskeletal signs (<ROM and
patient tenderness)
5. Sprain/Strain 3 – neck complaints & neurologic signs (weakness, sensory
& reflex changes)
Sprain: 4 – neck complaints w/fracture +/or dislocation
– Definition: a partial/full tearing of a ligament away from its
bone attachment – Treatment: NSAIDs, m. relaxants, soft cervical collar (2-
– Types/subtypes: 3wks) physical therapy, electrical stim, chiropractic care; if not
1. First degree: little/no swelling; minimal pain improving = rigger point injections, typically along the medial
border of the scapula, may help decrease trigger zones and
2. Second degree: localized swelling without tenderness,
referred pain and help improve muscular flexibility
moderate-severe pain, abnormal motion and deformity, unable
to bear weight
3. Third degree: total disruption of ligament; loud ‘snap’ or Ankle Sprain (twisted ankle):
– Definition: 1 or more ligaments are torn. The anterior
‘pop’, sever pain, abnormal motion, deformity, unable to bear
weight talofibular ligament is most commonly involved. 85% of ankle
sprains involve the lateral aspect.
Strain: – Etiology: happens when foot is rolled/turned beyond
normal motion – sports or walking on uneven surface; Lack of
– Definition: a ‘pull’ in a tendon, ligament/m caused by
excessive stretch/force; twist/tear of tendons; over- conditioning/warming up/stretching, previous history,
stretching/pulling the muscle or tendon inadequate shoes
– Symptoms: redness, inflammation, swelling, n become more
– Symptoms: Pain (may radiate), spasms, loss of fixation,
sensitive (throbbing pain), warmth
severe weakness, disfigurement
– Treatment: RICES: Rest Ice Compression Elevation Support – Classifications:
Grade 1 – slight stretching w/minimal damage to ligament
Grade 2 – tearing & ankle jt moves in abnormal ways
Cervical Sprain:
– A strain refers to an injury to a muscle, occurring when a Grade 3 – severe injuries; complete tears
muscle-tendon unit is stretched or overloaded. Cervical – Treatment: RICE, ankle brace
muscles that are commonly strained include the
sternocleidomastoid (SCM), the trapezius, the rhomboids, the 6. Fracture
erector spinae, the scalene, and the levator scapulae.
– Etiology: 1ary MVA: predominantly = whiplash; 2ary = Definition and Mechanism:
sports-related (e.g. American football (e.g. linemen); wrestlers, – Structural break in bone continuity.
etc). – A fracture may be due to trauma, pathology (tumor,
– Diagnosis: osteopenia, infection), stress (reparative mechanical loading).
1. History: Mechanism of injury; how, when, and where the
injury took place, with particular attention regarding the Complications of Treatment:
position of the head and neck at the time of the injury; – Infection, painful implants (i.e.: internal fixators), non-
Location of the pain; Aggravating and relieving factors (eg, healing fractures (nonunion/malunion), decreased
sneezing, coughing, traction); Presence, location, and duration ROM/function as before fracture.
of any neurologic symptoms;
2. Physical Examination: full neurological exam, cervical ROM

Clinical Feature: 7. Pathologic fracture (PF)
– Pain, tenderness, loss of fixation, deformity, muscle
guarding, swelling and bruising, abnormal motility and Definition and Etiology:
crepitus, altered neuronal or vascular status. – A PF is a broken bone caused by disease, most commonly
osteoporosis but also cancer, osteomalacia, Paget’s disease (i.e.
Evaluation: tumors, infections, and other disorders)
– Vascular function (pulse, capillary refill) and neurologic – PFs are due to an underlying disease process that weakens
function (sensation and motor function) the bone to the point of fracture (with normal daily activities)
– Fragility fracture: results from a fall from standing
Characteristics: height/less: this may be vertebral fractures, neck of femur, and
– Classifications: fractures may be open/closed, Colles fracture of the wrist
transverse/oblique/spiral/butterfly/green-stick, simple (two
parts)/comminuted (>2 parts), proximal/middle/distal, Treatment:
extra/intra-articular, – The treatment include: treatment of both the fracture itself
angulation/displacement/rotation/shortening/apposition and the underlying process that weakened the bone, e.g.
– Integrity of skin/soft tissue: infection.
1. Closed fracture: skin/soft tissue over and near fracture is
intact.
Pathologic Hip Fracture:
2. Open fracture: skin/soft tissue over and near fracture is
lacerated/abraded. There might be continuous bleeding from – Related to hyperparathyroidism (fracture of femoral neck in
the puncture site. Fat droplets in the blood may suggest elderly); metastatic disease (Tx: cemented solid stem or total
communication with the fracture. hip arthroplasty); Pagets Disease (disorder of problem with
– Location: bone remodeling = enlarged & misshapen bones; The
1. Epiphyseal (end of bone), metaphyseal (flared portion of excessive breakdown and formation of bone tissue causes
bone at the ends of the shaft), diaphyseal (shaft of long bone), affected bone to weaken, resulting in pain, misshapen bones,
and physis (growth plate) fractures, and arthritis in the joints near the affected bones;
– Orientation:
– Treatment: non-displaced fractures may be treated with
1. Transverse, oblique, butterfly, segmental, spiral,
internal fixation); neurologic disease; Parkinson’s disease –
comminuted/multi-fragmenary, intra-articular (fracture line
crosses articular cartilage & enters joint), femoral neck fracture (related to 6 month mortality of 60%);
compression/impacted (i.e.: vertebrae, proximal tibia) spastic hemiplegia (stroke) – fraction tends to occur on
2. Greenstick: incomplete fracture of one cortex (often in hemiplegic side w/ varying degrees of flexion & adduction
children) contracture associated w/hypertonicity of muscles)
3. Pathologic: fracture through bone is weakened by a
disease or tumor.
8. External fixation
Diagnosis – Plain X-Rays:
– Rule of 2’s: Definition:
1. Two sides: bilateral – External fixation is a surgical treatment used to set bone
2. Two views: AP and lateral fractures in which a cast would not allow proper alignment of
3. Two joints: above and below the site of injury fracture; immobilization for a fracture to heal.
4. Two times: before and after reduction.
– Site: which bone, if extra-articular (diaphysis/metaphysis), Definition:
if diaphyseal decribe by thirds (proximal/middle/distal), or if it – Holes are drilled into uninjured areas of bones around the
is intra-articular. fracture and special bolts/wires are screwed into the holes
– Outside the body a rod or curved piece of metal with special
Management: ball - and - socket joints joins the bolts to make a rigid support
– Limb: attend to neurovascular status (above and below) and (clamps & rods form the external frame)
rule out other fractures/injuries (especially joint above and – The fracture can be set in the proper anatomical
below). configuration by adjusting the ball & socket joints
– Rule out open fracture – External fixator is used in OR under general anesthesia;
– AMPLE history: Allergies, Medications, Past medical remove = special wrenches with no anesthesia!
history, Last meal, Events surrounding injury – Used ONLY when internal fixation is contraindicated for
– Analgesia open-fractures, limb lengthening
– Splint fracture: makes patient more comfortable, decreases
progression of soft tissue injury, decreases blood loss
– Imaging

9. ORIF (Open Reduction Internal Fixation)
Usually associated with massive contamination. Will often need
Indications: further soft-tissue coverage

– NO CAST: Non-union; Open Fracture, neurovascular
Compromise, intro-Articular fracture, Salter-Hariis 3,4,5, procedure (i.e. free or ratational flap)
multiple trauma
– Serious fractures such as comminuted/displaced fractures or Type III fracture associated with an arterial injury requiring repair,
in cases where the bone would not heal correctly in
cast/splinting alone irrespective of degree of
IIIC
Definition: soft-tissue injury.

– Implementation of implants and open reduction (setting) of
the bone:
1. Open reduction: open surgery to set bones Complications:
2. Internal fixation = uses of screws, plates, intramedullary – Bacterial colonization of bone, infection, stiffness and loss
bone nails) to enable/facilitate healing of range of motion, non-union, mal-union, damage to muscles,
A. Rigid fixation prevents micro-motion across lines of neuronal damage & palsy, arthritis, tendonitis, chronic pain
fracture to enable healing & prevent infection which happens associated with plates, screws, pins, compartment syndrome,
when implants (like plates) are used
deformity, audible popping and snapping
Internal Fixation:
10. CRIF (Closed Reduction Internal Fixation)
– Internal fixation: involves the surgical implementation of
implants for repairing a bone (internal fixator = stainless
steel/titanium; consist of bone screws, metal plats, pins, rods, Definition and Indication:
Kirschner wires, intramedullary devices like Kuntscher & – CRIF is a reduction (setting of bone) without any open
interlocking nails). surgery followed by internal fixation.
– It is an acceptable alternative in unstable displaced lateral
condylar fractures of humerus in children, but if fracture
Open Fracture: Gustillo Classification displacement after closed reduction >2mm, ORIF is
recommended.
I Open fracture, clean wound, wound <1 cm in length
11. Scaphoid fractures
Open fracture, wound > 1 cm in length without extensive soft-tissue
II Epidemiology and Etiology:
damage, flaps, avulsions
– A transverse fracture that is common in young men, not
common in children or patients beyond middle age.
Open fracture with extensive soft-tissue laceration, damage, or loss – Most commonly occur in patients who fall on an
outstretched or extended hand (FOOSH) where the wrist is
or an open segmental
bent backwards, resulting in a transverse fracture through the
waist (middle) of the Scaphoid. The fracture is usually
fracture. This type also includes open fractures caused by farm
III
undisplaced.
injuries, fractures requiring
Clinical Features:
vascular repair, or fractures that have been open for 8 h prior to – Pain on wrist movement
– Tenderness in scaphoid region: Anatomical “snuff box”
treatment – Some patients have obvious fractures on day one and in
some cases the fractures can be significantly displaced.
Type III fracture with adequate periosteal coverage of the fracture
Diagnosis:
bone despite the extensive
IIIA – X-ray may not show anything until 2 weeks after pain started
– A patient presenting with wrist pain, a negative X-ray and
soft-tissue laceration or damage
tenderness over the thumb side of the wrist should be
considered to have a scaphoid fracture until proven otherwise.
Type III fracture with extensive soft-tissue loss and periosteal – Secondary X-rays 2 weeks later, or MRI on occasions can
IIIB
confirm diagnosis.
stripping and bone damage.

Treatment: 14. Fractures of the distal radius (ex. Colles fr)
– Non-displaced: long-arm thumb spica cast for 4-6 weeks
followed by short arm cast until radiographic evidence of Definition:
healing is seen (2-3 months). – Fractures of the distal radius account for approximately 14%
– Displaced: Open (percutaneous) screw fixation. of all fractures.
– Most of the non-displaced fractures will heal with – Bimodal distribution: In young (18-25) it is mainly due to
appropriate casting. The problem is that they are very slow to trauma and in older (>65) it is due to falls.
heal, making patients feel the casts are intolerable. “I have to – The fractures are due to: FOOSH, sports injury, etc.;
be able to work!”
Classification:
Complications: – The AO classification emphasizes the location as extra-
– Avascular necrosis, delayed union, non-union, osteoarthritis articular, partial articular, and completely articular.
12. Thumb fractures (incl. I metacarpal) Subtypes:

– Colles fracture: involves the distal metaphysis of the radius.
He described the resulting volar angulation, dorsal
Definition: displacement, loss of radial inclination and resultant radial
– Fracture involves the distal/proximal phalange, 1st shortening as a "silver fork deformity."
metacarpal bone: 2 types – Smith's fracture, or reverse Colles' fracture, is a dorsally
1. Transverse or short oblique fracture across the base of the angulated fracture of the distal radius, with the hand and wrist
metacarpal displaced volarly with respect to the forearm. The fracture may
2. “Bennett’s fracture-subluxation”: Oblique fracture be extraarticular, intraarticular, or a part of a fracture-
dislocation involving the wrist. It is reduced by closed
entering the CMC joint at about the middle of the articulate manipulation, underarm plaster with hand in dorsiflexion and
surface. This type is intra-articular. complete supination for 6 weeks, checking for displacement
with x-ray meanwhile.
Symptoms: – Barton's fracture is a fracture-dislocation with an
– Pain, swelling, decreased ROM, extreme tenderness, intraarticular fracture in which the carpus and a rim of the
deformity, numbness/coldness distal radius are displaced together. Reduction isoften
imperfect and is therefore operated with attachment of a plate
with screws.
Treatment: – The Chauffeur's fracture is a radial styloid fracture,
– Reduction of displacement under anesthesia. It can be described initially in car drivers operating automobiles, which
difficult to maintain reduction in the case of Bennet fracture. required hand cranking to start. When the engine engaged, the
Use a plaster including forearm and wrist, keeping thump crank would "kick back," and the Chauffeur's fracture would
result.
extended at CMC joint. Check with x-ray if there is a good
position.
– Screws or a percutaneous Kirschenner wire (obliquely
through base of metacarpal into trapezium) can be used to
fixate the thumb, later a plaster should be used for 4-6 weeks.
13. Boxer’s fracture
Definition:
– 2nd/3rd metacarpal transverse neck fracture that is more
likely to occur from a straight punch (absorb most of force);
‘Bar room fracture’: metacarpal neck (knuckles) fracture
particularly involving the 4th/5th due to fighting.
– Can be prevented with hand wraps and boxing gloves.
Treatment:
– Surgical with Kirschenner wire (<12w) if > 40 degrees tilt,
otherwise reduction of the displacement which is easy to do
but hard to maintain. Often the function remains but may
leave a cosmetic deformity.
– Initial: Jahss maneuver: MCP & PIP jts are flexed to 90*;
usually full rehabilitation takes 3-4 months in minor fractures.

Diagnosis and Treatment:
– X-ray is the main diagnostic tool. Diagnosis and Treatment:
– Nonsurgical treatment: (many can be treated this way): – Diagnosis: Patients history, physical examination, a
casting if bone in good position (non-displaced) for 6w; long radiograph and possible CT scan can further identify the
casts only needed if ulna is unstable
extent of the damage and area of instability. Axial CT scans are
– Surgical treatment: if radius is displaced, irreducible, or
pathognomonic. Diagnostic arthroscopy may also be used.
reducible but unstable
– Treatment: If a DRUJ injury occurred as the result of a
– Indications for surgery:
fracture, the associated fracture is first addressed. Depending
1) intra-articular displacement of 1mm or more
on the level of joint instability, additional fixation of the joint
2) dorsal tilt: no more than 0-10*
3) Radial length shortening of more than 2mm may also be required.
15. Colles fracture 17. Nightstick fracture
Definition and Epidemiology: Definition, Symptoms, and Treatment:

– It is the most common fracture in those >40 years, especially – Isolated fracture of Ulna often caused by a direct blow to the
in women and those with osteoporotic bone. arm (holding up arm to protect face)
– It is a transverse distal radius fracture (about 2,5 cm – Symptoms: pain, deformity and swelling of forearm.
proximal to the radiocarpal joint) with dorsal displacement – Treatment:
with or without ulnar styloid fracture (60%). 1. Nondisplaced: below-elbow cast (distal 2/3 of forearm)
for 10 days and the forearm brace (8 weeks)
Mechanism: 2. Displaced: ORIF if> 50% shaft displacement or >10
– The fractures are due to: FOOSH. degrees angulation
– In elderly: extra-articular; in younger = intra-articular
because of higher force needed to break the bone. 18. Monteggia fracture
– The risk increases with osteoporosis.
Clinical Feature: – Fracture of the proximal 1/3 of Ulna with anterior
– There is acute pain, tenderness, bruising (eccymosis), carpal dislocation of radial by:
tunnel syndrome, and swelling. 1. Direct blow to posterior arm
– Frequently, the wrist hangs in an odd or bent way 2. Hyperpronation
(deformity): “dinner fork” deformity 3. Fall on the hyperextended elbow
– Median nerve may be compressed: check via OK sign with – Types: there are 4 types of Monteggia fractures. First type is
fingers. the most common: extension (60%): anterior dislocation of
radial head and fracture of ulnar diaphysis with anterior
Diagnosis and Treatment: angulation
– X-ray is the main diagnostic tool.
– Non-displaced fracture: cast Clinical Features:
– Volar forearm splint: temporary immobilization of forearm, – Decreased rotation of forearm and palpation lump at radial
wrist and hand fractures head
– Mild angulation and displacement: closed reduction
– Significant angulation and deformity: open reduction & – Ulna angled apex anteriorly and radial head displaced
internal/external fixation anteriorly.
Complications: Diagnosis:
– Mal-union, compression of the median nerve – AP, lateral, and oblique X-rays of elbow
– Also rule out: annular ligament tear, nerve injury (radial
16. Injury of the distal radio-ulnar joint (DRUJ) nerve)
Treatment:
Definition and Risk Factors: Treatment = ORIF of Ulna with indirect radius reduction in
– DRUJ injury may be the result of ligamentous disruption or
90%. If elbow is completely stable use a splint and early post-
fracture, which compromises joint stability.
op ROM, otherwise immobilization in plaster w. elbow flexed
– DRUJ injuries can occur in isolation or in association with
(6 weeks).
distal radius fractures, Galeazzi fractures, Essex-Lopresti
injuries, and both-bone forearm fractures.
– Risk factors: activities, sports, osteoarthirits, RA

19. Fractures of distal humerus Complications:
Complications = Non-unions (can lead to deformity of elbow
Epidemiology and Definition: and osteoarthritis)
– Most common in children (~7 years), unusual in adults Deformity ( by persistent upward displacement of fractured
– Usually due to high-energy injury; these fractures can lead to condyle or by damage to growing epiphyseal
significant functional impairment. cartilage)
– Distal humerus fractures most commonly involve both the Frictional neuritis of the Ulnar nerve (If cubitus valgus
medial and lateral columns. =deformity of lateral condyle)
– Classified by AO Osteoarthritis
Clinical Feature: Epidemiology, Diagnosis, and Complications:

– Anterior Interosseous nerve injury is common – Affects adolescence; lateral condyle more than medial
– POTENTIALLY DANGEROUS: damage to Brachial – Diagnosis: assess radial (finger extension), median (finger
Artery flexion) and ulnar (finger abduction) nerves.
96% = extension injury via FOOSH (= Fall On an Out – Complications: nonunion, mal-union, valgus angulation,
Stretched hand), the lower fragment of humerus is often avascular necrosis
displaced backwards and tilted backwards.
Lateral Condyle:
Diagnosis: – Etiology: peak in 6 yr olds
– AP and lateral x-rays; CT is further info needed – Type: Saltar-Harris IV
– Duplex Doppler studies or angiography should be – Symptoms: FOOSH, pain, swelling, crepitus
performed if there is a suspicion of brachial artery injury. – Treatment: if displaced: Surgical (ORIF) reduction should be
performed within 48hrs; open reduction for type II and type
Treatment: III fractures, Type I is, 2mm of displacement
– Non-operative: if non-diplaced with cast in 90 degrees
flexion for 3 weeks Medial Condyle:
– Operative: if displaced, vascular injury or open fracture. – There is a fracture line through medial metaphysis and
Percutaneous pinning followed by limb cast w elbow flexed> epicondyle; fracture line involves the trochlear surface; Saltar
90 degrees. ORIF in adults. Harris IV which crosses the physeal plate; <15mm
– Elderly patients with poor bone quality: total elbow displacement may be treated nonoperatively
arthroplasty (TEA). Specifics: FOOSH, elbow forced into valgus, fall on apex on
flexed elbow, olecranon creating the fracture. Avulsions by
Complications: flexor and pronator muscles (arm wrestling)
– Arterial occlusion: Nerves may get ischemic: Volkmann’s Tx: Saltar Harris IV with ORIF
Ischemic contracture (= muscles become fibrous tissue when
ischemic o contracts, causing hand and wrist into flexion) 21. Olecranon fracture
– Median nerve damage
– Deformity from mal-union Mechanism and Epidemiology:
– By direct trauma to posterior part of elbow (fall onto the
20. Fractures of humeral condyles point of the elbow fall on point of elbow with avulsion by
triceps or fall on outstretched arm).
Definition: – It is fractured rather frequently in adults (rarely in children:
– Uncommon, serious, mainly children, from a fall mostly. because olecranon is short, thick and strong; instead there are
= Intra-articular, Lateral condylar fracture which extends supracondylar fractures of the humerus).
obliquely upwards and laterally from the capitular surface. – There may be a loss of active extension due to triceps
adolescence; lateral more common tendon avulsion.
Treatment: Types – Mayo Classification:

1. Simple crack fracture: plaster for a few weeks + mobilizing – Type I: Undisplaced – stable to flexion & extension, early
mobilization
exercises
– Type II: Displaced fragments but collateral ligaments are
2. Displaced fracture: A) Reduce displacement under
intact
anesthesia + plaster in 90 degrees
– Type III: Displaced, unstable forearm in relation to
B) If reduction fails: Surgery, Condyle attached w. small screw
humerus’ fracture-dislocation

Diagnosis and Treatment: Types:
– Diagnosis: AP and lateral X-ray. – Posterior elbow dislocations: patients FOOSH (probably
– Treatment: slightly abducted and flexed).
1. Undisplaced: above elbow cast immobilization at 40 – Anterior elbow dislocations: result of a direct posterior blow
degrees of flexion for 2 weeks, early ROM; full flexion after 6 to a flexed elbow. Associated fractures of the olecranon are
weeks commonly seen.
2. Displaced (more than 2 mm of articular displacement): – Divergent dislocations: are very rare injuries and are
ORIF (plate, band wire), above elbow slab x 1 week, early associated with significant high-energy trauma to the elbow.
ROM
Clinical Features and Diagnosis:
22. Radial head fracture (proximal radius) – There is an elbow pain, swelling, and deformity
– Might also be a flexion contracture
Mechanism and Epidemiology: – There might be an absence of radial or ulnar pulses
– Due to: FOOSH with elbow extended and forearm – AP and lateral radiographs
pronated.
– It is a common fracture of the upper limb in young adults Treatment:
– Closed reduction under anesthesia (post-reduction x-rays
Clinical Features: required)
– There is progressive pain due to hemarthrosis with loss of – Long-arm splint with forearm in neutral rotation and elbow
ROM and pain on lateral side of elbow aggravated by forearm in 90º flexion
pronation or supination. – Early ROM (<2 weeks)
Diagnosis: Complications:
– Stiff elbow (loss of extension)
– X-ray: may not be seen: anterior or posterior fat pad sign
”sail sign”. – Neurovascular injury to ulnar or median nerve, brachial
– Mason classification: artery
1. Undisplaced fracture: usually normal ROM – Entrapment of bone fragments within the joint space
2. Displaced segmental fracture: ROM is compromised – Compartment syndrome
3. Comminuted (more than 2 fragments) fracture
4. Comminuted with posterior elbow dislocation 24. Fractures of the proximal humerus
Treatment: Epidemiology and Mechanism:

– ORIF is performed if angulation is >30°, 3-mm – Young: High energy trauma: MVA
displacement, or depression greater than one third of the – Older (primary): FOOSH from standing height in
articular surface osteoporotic individuals; major cause of morbidity in the
– Early excision can be performed for severely comminuted elderly population.
fractures – Accounts for 4-5% of all fractures and F:M:3:1
– Type 1: elbow slab, sling 3-5 days, early ROM
– Type 2: ORIF radial head Symptoms:
– Type 3/4: excision of radial head +/– prosthesis – Pain, swelling and tenderness around the shoulder (especially
around greater tuberosity)
Complications: – Fracture involves: proximal humeral diaphysis (surgical
– Joint stiffness; recurrent instability if medial collateral neck); +/– greater tuberosity; +/– lesser tuberosity
ligament is injured and radial head excised; Myositis ossificans – Classified into 2, 3, and 4 part fractures
23. Elbow dislocation Classification:

– The Neer classification system is based on displacement
criteria of 1 cm or fragment angulation of 45°. The type of
Epidemiology and Mechanism:
fracture then is divided into segments. Four segments are
– Usually affects young people in sporting events or high
possible: articular segment, the lesser tuberosity, the greater
speed Motor vehicular accidents (MVA).
tuberosity, and the surgical neck.
– > 90% are posterior or posterior-lateral
– It is the third most common joint dislocation after shoulder
Diagnosis:
and patella
– Test axillary nerve function
– Mechanism: FOOSH: rule out concurrent radial head or
– X-rays: AP, trans-scapular and axillary
coracoid process fractures

– CT scan (this is a fracture where you could argue that you Complications:
should be generous with CT scan) – Radial nerve injury (up to 18%): expect spontaneous
recovery in 3-4 months, otherwise send for EMG: Holstein-
Treatment: Lewis fracture is more associated with radial nerve palsy than
– Non-operative: other types of humeral shaft fractures.
1. Sling immobilization (nondisplaced): begin ROM in 7-10 – Non-union/mal-union
days to prevent stiffness – Compartment syndrome
2. Closed reduction (minimally displaced)
– Operative: 26. Shoulder dislocation
1. ORIF (anatomic neck fractures, displaced, dislocated)
2. Hemiarthroplasty: three-part (elderly, poor bone stock) Background and Types:
and four-part (except: older debilitated patient and severe
– The gleno-humeral joint is the most commonly dislocated
diabetic).
joint in the body (since stability is sacrificed for motion).
– Types:
Complications: 1. Anterior dislocations: >90% of cases.
– AVN, axillary nerve palsy, malunion, post-traumatic arthritis 2. Posterior dislocation (up to 5%):
3. Inferior (luxatio erecta), superior, and intrathoracic
25. Humeral shaft fracture dislocations are rare and are usually associated with
complications.
Mechanisms and Clinical Feature: Anterior Dislocation:

– Direct blows and high energy trauma is most common, – Mechanism: abducted and externally rotated arm or blow to
FOOSH, twisting injuries and metastases (in the elderly). posterior shoulder
– Different Types of shaft fractures: – Clinical feature: pain
1. Bending force produces transverse fracture of the shaft – Diagnosis:
2. Torsion force will result in a spiral fracture 1. X-rays: AP, trans-scapular, axillary: dislocation (Mercedes-
3. Combination of bending and torsion produce oblique Benz sign), Hill-Sachs lesion, bony Bankart lesion
fracture (Holstein-Lewis: oblique distal third) with or without 2. Neurovascular exam including: axillary nerve (sensory
a butterfly fragment patch over deltoid and deltoid contraction); musculocutaneous
4. Compression forces will fracture either proximal or distal nerve (sensory patch on lateral forearm and biceps
ends (distal third) of humerus contraction).
– There is arm pain, deformity, and swelling. The arm is – General Treatment: closed reduction with IV sedation and
shortened, with motion and crepitus on manipulation. muscle relaxation; 2 methods:
1. Traction-Countertraction:
Diagnosis: 2. Stimson: Patient lies prone with arm over table edge with
– Rule out radial nerve function (before and after treatment) a weight for 15-20 min.
– X-rays: AP and lateral including shoulder and elbow joints – Other Treatment:
(Doppler and Compartment pressures) 1. Check post reduction X-rays and neurovascular status.
2. Sling for 3 weeks followed by shoulder rehabilitation
Treatment: 3. Surgery reserved for patients with recurrent instability
– Clinical Signs used:
– Non-operative (most common): deformity can be accepted
1. Positive apprehension test: apprehension with shoulder
due to compensatory range of motion of shoulder hanging
abduction and external rotation to 90 degrees since humeral
cast (weight of arm in cast provides traction across fracture
head is pushed anteriorly and recreates feeling of anterior
site) with sling immobilization x 7-10 days, then Sarmiento
dislocation
functional brace
2. Positive relocation test: a posteriorly directed force applied
– Operative:
during the apprehension test relieves apprehension since
1. Indications: open fracture, neurovascular injury,
anterior subluxation is prevented.
unacceptable fracture alignment, polytrauma, segmental
3. Sulcus sign: presence of subacromial indentation with
fracture, pathological fracture, “floating elbow” (simultaneous
distal traction on humerus indicates inferior shoulder
unstable humeral and forearm fractures), intra-articular
instability.
2. Procedure: compression plating (most common),
intramedullary rod (nail) insertion, external fixation
Procedure: Compression plating, intramedullary rod or
Posterior Dislocation:
external fixation. – Mechanism: adducted, internally rotated, flexed arm;
FOOSH; 3 E’s (epileptic seizure, EtOH, electrocution); or
blow to anterior shoulder

– Diagnosis: – 2 main ligaments attach clavicle to scapula: acromioclavicular
1. X-rays: AP, trans-scapular, axillary: dislocation (Mercedes- (AC) and coracoclavicular (CC) ligaments.
Benz sign), reverse Hill-Sachs lesion, reverse bony Bankart
lesion Diagnosis and Treatment:
2. Up to 60-80% are missed on initial presentation due to – X-rays: AP, Zanca view, axillary
poor physical exam and radiographs – Treatment:
– Clinical feature: 1. Non-operative (most-common): sling 1-3 weeks, ice,
1. Arm is held in adduction and internal rotation; external analgesia
rotation is blocked 2. Operative:
2. Anterior shoulder is flattening; there is a prominent A. Indications: AC and CC ligaments are both torn and/or
coracoid and a palpable mass posterior to shoulder. clavicle displaced posteriorly
3. Posterior apprehension (“jerk”) test: with patient supine, B. Procedure: excision of lateral clavicle with AC/CC
flex elbow 90º and adduct, internally rotate the arm while ligament reconstruction
applying a posterior force to the shoulder; patient will “jerk”
back with the sensation of subluxation. 29. Metatarsal fractures
– Treatment:
1. Closed reduction: inferior traction on a flexed elbow with
pressure on the back of the humeral head
– Classified into acute fractures or stress fractures.
2. Obtain post-reduction x-rays
– Seen in: dancers, runners, military, etc;
3. Check post-reduction neurovascular status
– More stress is placed on the second and third metatarsals
4. Sling x 3 weeks, followed by shoulder rehabilitation
during ambulation; thus, these bones are at increased risk for
stress fractures.
27. Clavicle fractures
Symptoms, Diagnosis, and Treatment:
Epidemiology and Mechanism: – Symptoms: pain with exercise: pain with rest; tenderness,
– It is common in children (unites rapidly without redness, swelling
complications) – Diagnosis: test for RA (ESR and rheumatoid panel); x-ray
– Mechanism: it may be due to fall on shoulder (87%), direct may be negative at first, bone scanning (very sensitive), MRI
trauma to clavicle (7%), or FOOSH (6%). Clavicle fracture is – Treatment: ice, stop exercise, orthotics, rare to need surgery;
associated with rib fractures, scapula fractures, other fractures rehabilitation & physical therapy
about the shoulder, pulmonary contusion etc.
Fracture Mechanism Clinical Treatment
Classification – Allman with Neer Modification: Type
– Group I fractures: are middle third injuries (80%) Avulsion of Sudden Tender base Requires ORIF
base of 5th inversion of 5th MT if displaced
– Group II fractures: are lateral (distal) third injuries (15%)
MT followed by
– Group III fractures: are medial (medial) third injuries (5%) contraction of
peroneus brevis
Treatment: Midshaft 5th Stress injury Painful shaft Non weight
MT of 5th MT bearing, below
– Proximal and middle third clavicular fractures: sling for 1-2 (Jones knee cast (NWB
weeks; early ROM and strengthening once pain subsides; if fracture) BK) for 6w
ends overlap >2 cm, consider ORIF ORIF if athlete
– Distal third clavicular fractures: undisplaced (with ligaments Shaft 2nd, Stress injury Painful shaft Symptomatic
3rd MT of 2nd or 3rd
intact): sling for 1-2 weeks; displaced (Coracoclavicular (March MT
ligament injury): ORIF fracture)
1st MT Trauma Painful 1st ORIF if
MT displaced
28. Injuries of the acromio-clavicular joint otherwise
NWB BK cast x
3 wks then
Mechanism and Clinical Feature: walking cast x 2
– May be due to fall onto shoulder with adducted arm (fall wks
onto tip of shoulder): after bicycle wrecks, contact sports, and Tarso-MT Fall onto Shortened ORIF
car accidents. fracture – plantar flexed forefoot (Lisfranc
dislocation foot or prominent fracture)
– There is a palpate step deformity between distal clavicle and direct crush base
acromion (with dislocation) injury
– There is pain with adduction of shoulder and/or palpation
over AC joint; there is also limited ROM

30. Lisfranc injuries 32. Calcaneus fracture
Anatomy and Incidence: General about Fractures of Calcaneus:

– Lisfranc joint: is the point at which the metatarsal bones & – Mechanism: axial loading: fall from a height onto heels (fall
tarsal bones connect; or jump from height.).
– Lisfranc ligament: is a tough band of tissue that joins the 2 – Incidence: 5 % bilateral, 10 % associated with compression
of these bones fracture of lumbar or thoracic spine.
– Incidence: Lisfranc injuries may be seen in MVA, military – Types: based on sub-talar joint involvement:
personnel, runners, horseback riders, football players, and 1) Intra-articular:
contact sports/missing a step on a staircase 2) Extra-articular
– Symptoms: pain over heal, tenderness, inability to bear
Types of Injuries and Mechanism: weight, swelling, redness, hematoma
– Sprains: Lisfranc ligament and other ligament of bottom of – Diagnosis:
midfoot are stronger than those on the top of the midfoot; 1. X-rays: AP, lateral, oblique (Broden’s view)
weakened through a spring (stretching of a ligament), patients 2. Loss of Bohler’s angle
experience instability of joint in the middle of the foot 3. CT: assess intraarticular extension
– Fractures: break in bone in the Lisfranc joint can be either – Treatment:
an avulsion fracture (small piece of bone is pulled off) or break 1. Non-surgical: extra-articular when calcaneal weight-
through the bone/bones of midfoot bearing surface and foot function are not compromised:
– Dislocation: bones may be forced from their natural closed reduction with or without fixation; 2-3mo of reduced
positions movement with gradual build-up
2. Surgical: intra-articular with displacement; closed
Symptoms, Diagnosis, Treatment, Complications: reduction with percutaneous fixation: associated with less
– Symptoms: swelling, pain, bruising, inability to bear weight, wound complications, better soft tissue healing; ORIF
abnormal widening
– Diagnosis: mistaken for sprains, how it occurred, X-ray 33. Ankle fractures
– Treatment: elevate, ice, immobilize (cast), NSAIDs, physical
therapy (post-swelling) Mechanism and Classification System:
1. Non-operative: dislocation < 2mm, casting 6 wk, – Pattern of fracture depends on the position of the ankle
immobilize and no weight bearing. when trauma occurs
2. Operative: internal fixation with screws, no weight bearing – Generally involves: ipsilateral ligamentous tears or transverse
for 6-12 wk. bony avulsion and contralateral shear fractures (oblique or
– Complications: compartment syndrome, arthritis spiral).
– Classification systems:
31. Fractures of the talus 1. Danis-Weber
2. Lauge-Hansen: based on foot’s position and motion
General about Fractures of Talus: relative to leg
– Mechanism: axial loading or hyperdorsiflexion due to MVA,
snowboarding (soft boot, not rigid enough), falls: 50 % of Classification – Danis-Weber:
fractures occur at talar neck. – Based on level of fibular fracture relative to syndesmosis
– Symptoms: acute pain, inability to bear weight, swelling, – Type A: infra-syndesmotic: subtypes
tenderness 1. Pure inversion injury
– Diagnosis: x-ray, CT (if x-ray not enough) 2. Avulsion of lateral malleolus below plafond (plafond: an
– Treatment: predominantly surgery; unless bones still aligned anatomical part/surface that is farthest from midline of body
= just cast; post-surgery = cast for 6-8 weeks esp the articular surface of the distal end of the tibia) or torn
– Complications: osteonecrosis or AVN. calcaneofibular ligament
– Treatment: 3. May include shear fracture of medial malleolus
1. Undisplaced: non-weight bearing below knee cast x 20-24 – Type B: trans-syndesmotic
weeks 1. External rotation & eversion
2. Displaced: ORIF (high rate of nonunion, AVN) 2. +/- avulsion of medial malleolus OR rupture of deltoid
ligament
3. Spiral fracture of lateral mallelous starting at plafond
– Type C: supra-syndesmotic
1. Pure external rotation
2. Avulsion of medial malleolus OR torn deltoid ligament
3. +/- posterior malleolus may be avulsed

4. Maisonneuve fracture: if proximal fibula is fractured Clinical Feature:
5. Frequently tears syndesmosis – There is a sudden pain (“pop”) after a push-off movement,
– The patients is able to do dorsiflexion of toes and there is
Treatment: swelling above heel.
– Undisplaced: non-weight bearing below knee cast
– Indications for ORIF: all fracture-dislocations; most of type Diagnosis:
B, and all of type C; trimalleolar (medial, posterior, lateral) – Based on clinical history (felt like being ‘kicked or shot
fractures; talar tilt >10º; medial clear space on XR greater than behind the ankle’), usually palable gab, there is a positive
superior clear space; open fracture/open joint injury Thompson test
– There is an audible pop, sudden pain with push off
34. Ankle sprain (Twisted Ankle) movement; sensation of being kicked in heel when trying to
plantar flex; palpable gap; apprehensive toe off when walking;
Definition and Mechanism: weak plantar flexion;
– Most common musculoskeletal injury: 1 or more ligaments – Thompson Test: with patient in prone position, squeeze calf
are torn; anterior talofibular ligament is most commonly ->passive plantar flexion = intact Achilles tendon; +ive = no
involved; passive plantar flexion (no movement of ankle) = ruptured
– Lateral aspect accounts for 85% of ankle sprains tendon.
– Happens when ankle placed into abnormal position and – To rule out any avulsion fracture: do MRI, US, X-ray.
overstretching of ligaments. Occur with side-to side motion,
during sports. Treatment:
– Non-surgical: ’low demand’/elderly: cast foot in plantar
Symptoms and Classification: flexion (relax tendon) = 8-12 weeks
– Surgical: ‘high-demand’/younger and older active patients:
– Symptoms: redness, inflammation, swelling, nerves become
more sensitive (throbbing pain), warmth surgical repair, then cast as above = 6-8wks
– Diagnosis: X-ray; MRI; Anterior drawer test
– Classification: 36. Pilon fractures
1. Grade 1: slight stretching with minimal damage to
ligament Definition and Mechanism:
2. Grade 2: tearing and ankle joint moves in abnormal ways – When a bone breaks and hits another one which breaks;
3. Grade 3: severe injuries; complete tears usually intra-articular fracture of distal tibia.
– It may be due to axial force during MVA or fall from a
Treatment: height on feet.
– Microscopic tear (Grade I): rest, ice, compression, elevation
(RICE) Diagnosis and Treatment:
– Macroscopic tear (Grade II): strap ankle in dorsiflexion and – Diagnosis: X-ray, CT
eversion x 4-6 weeks; PT: strengthening and proprioceptive – Treatment:
retraining 1. Type 1 and 2: non-operative. Splint and plaster cast.
– Complete tear (Grade III): below knee walking cast 4-6 2. Type 3: require surgical treatment: external fixation,
weeks; PT: strengthening and proprioceptive retraining; ƒ internal fixation, and ankle fusion
surgical intervention may be required if chronic symptomatic
instability develops 37. Ligamentous injuries around the knee
35. Achilles tendon rupture Anatomy and Incidence:

– There are 4 major ligaments around knee:
Epidemiology and Etiology: 1. Medial and lateral collateral ligament (MCL, LCL)
– Peak age: 30-50y 2. Anterior and posterior cruciate ligament (ACL, PCL)
– It occurs with loading activity; stop-and-go sports (squash, – The MCL is the most commonly injured ligament.
tennis, basketball): eccentric contraction of gastrocnemius- – ACL tear much more common than PCL tear
soleus muscles; it is also secondary to chronic tendonitis, and
steroid injection. Symptoms:
– The rupture occurs at 3-6 cm proximal to the insertion on – CLIPS: Clicking, Locking, Instability, Pain, Swelling
the calcaneus where blood supply is poor.
Tests:
– Ant/post drawer test: Tibia sublux ant (ACL may be torn);
Tibia sublux post (PCL may be torn)

– Lachmann test: torn ACL – hold knee in 10-20 degree 38. Meniscal injuries
flexion, stabilizing femur; try to sublux tibia ant on femur
– Posterior sag sign: torn PCL; may give a false positive Incidence and Mechanism:
anterior draw sign; flex knees and hips to 90 degrees, hold
– Medial tears more common than lateral.
ankles and knees; view from lateral aspect; if one tibia sags
– Peak age: 30-40 y, after 50 y of age tears are more commonly
post compared to other, its PCL is torn due to arthritis than trauma.
– Pivot shift sign: torn ACL, start with knee in extension, – Mechanism: twisting force on knee when it is partially flexed
internally rotate foot, slowly flex knee while palpating and
(e.g.: stepping down and turning); requires moderate trauma in
applying a valgus force; normal knee will flex smoothly; if young but only mild in elderly due to degeneration
incompentent ACL -> tibia will sublux ant on femur at start of
maneuver. During flexion, the tibia will reduce and externally
– Lateral tears may be associated with ACL tears and sports
rotate abt the femur (the ‘pivot’); reverse pivot shift (start in
injuries.
flexion, externally rotate, apply valgus, and extend knee) ->
suggests torn PCL
Clinical Features and Diagnosis:
– Collateral ligament stress test: palpate ligament for ‘opening’
– Clinical Feature: immediate pain, difficulty weight-bearing,
of joint space while testing; with knee in full extension, apply
instability and clicking; increased pain w/ squatting/twisting;
valgus force to test MCL, apply valgus force to test LCL
effusion -> insidious onset 24-48hrs after injury; joint line
tenderness medially or laterally; locking of knee (= torn
Anterior Cruciate Ligament:
meniscus – also very painful)
– Mechanism: Sudden deceleration; Hyperextension and
– Tests: McMurray’s test: with knee in flexion, palpate the
internal rotation of tibia on femur joint line for painful ‘pop/click’
– History: Audible “pop”; swelling; Inability to continue
1. Lateral meniscus: internally rotate foot, varus stress &
activity
extend knee
– Physical Examination: Effusion (hemarthrosis); 2. Medial meniscus: externally rotate foot, valgus test, &
Posterolateral joint line tenderness
extend knee
Positive anterior drawer test, Positive Lachmann, Pivot shift – Diagnosis: MRI, arthroscopy
– Treatment: Stable knee with minimal functional impairment: – Treatment:
immobilization 2-4 weeks with early ROM and strengthening
1. If not locked: ROM and strengthening
2. If locked or failed above: arthroscopic repair/partial
Posterior Cruciate Ligament: meniscectomy
– Mechanism: Sudden posterior displacement of tibia when
knee is flexed or hyperextended (dashboard MVA injury) 39. Tibial plateau fractures
– History: Audible “pop”; swelling; Cannot descend stairs
– Physical Examination: Effusion (hemarthrosis);
Anteromedial joint line tenderness Mechanism and Incidence:
Positive posterior drawer test, Reverse Pivot shift – Axial loading (e.g. fall from height)
– Treatment: Unstable knee or young person/high-demand – Femoral condyles driven into proximal tibia
lifestyle: ligament reconstruction – Can result from minor trauma in osteoporotics
– Lateral fractures more common than medial
Collateral Ligaments: – Peak age: 30-40 y in men, 60-70 y in women.
– Can be classified with Schatzker classification (I-VI):
– Mechanism:
1. Valgus force to knee: medial collateral ligament (MCL)
2. Varus force to knee: lateral collateral ligament (LCL) Diagnosis, Treatment, and Complications:
– Clinical Features: – Diagnosis: X-rays: AP and lateral
1. Swelling/effusion – Treatment:
2. Tenderness above and below joint line medially (MCL) or 1. If depression on x-ray is <3 mm: straight leg
laterally (LCL) immobilization x 4-6 weeks with progressive ROM weight
– Treatment: bearing
1. Partial tear: immobilization x 2-4 weeks with early ROM 2. If depression is >3 mm: ORIF often requiring bone
and strengthening grafting to elevate depressed fragment
2. Complete tear or multiple ligamentous injuries: surgical – Complications: ligamentous injuries, meniscal lesions,
repair of ligaments – not for MCL or delayed union, AVN (bone infarction);
LCL on their own

40. Distal femur fractures 2. If recurrent: surgical tightening of medial capsule and
release of lateral retinaculum, possible tibial tuberosity transfer,
General about Distal Femur Fractures: or proximal tibial osteotomy
– Mechanism: Direct high energy force (young, low energy in
older women)/axial loading 43. Fracture of the femoral shaft (Diaphysis)
– Types: supracondylar, condylar, intercondylar
– Physical Examination: extreme pain, effusion, shortened, Mechanism:
externally rotated leg is displaced – High energy trauma (MVA, fall from height, gunshot
– Treatment: ORIF, early mobilization & strengthening wound);
– Complications: femoral a. tear, extensive soft tissue injury, – In children, can result from low energy trauma (spiral
angulation deformities, post-traumatic arthritis, n. injury fracture)
41. Patellar fractures Clinical Features and Diagnosis:

– Shortened, externally rotated leg (if fracture displaced)
Mechanism and Clinical Features: – Inability to weight-bear
– Mechanism: – There is usually blood loss: 0,5-1,5l
1. Direct blow to the patella – Often open injury, always a Gustilo III
2. Indirect trauma by sudden flexion of knee against – Diagnosis: AP pelvis, AP/lateral hip, femur, knee
contracted quadriceps
– Clinical Feature: marked tenderness, inability to extend knee Treatment and Complications:
or straight leg raise, proximal displacement of patella, patellar – Stabilize patient and immobilize leg early
deformity, effusion – ORIF with intramedullary nail, external fixator, or plate and
screws within 24 hours
Diagnosis and Treatment: – Complications: hemorrhage requiring transfusion, fat
embolism leading to ARDS, extensive soft tissue damage,
– Diagnosis:
ipsilateral hip dislocation/fracture, and nerve injury
1. X-rays: AP, lateral, skyline
2. Consider bipartite patella: congenitally unfused
ossification centres with smooth margins on x-ray 44. Subtrochanteric fracture
– Treatment:
1. Non-displaced (<2 mm): straight leg immobilization 6-8 Mechanism and Incidence:
weeks; PT: quadriceps strengthening – Seen in osteopenic elderly with low-impact fall and in young
2. Displaced: ORIF (>2 mm) patients with high-trauma cases
3. Comminuted: ORIF; may require partial/complete – It is seen under lesser trochanter to 5cm distal from it
patellectomy
Clinical Feature, Diagnosis, and Treatment:
42. Patellar dislocation (acute) – There is shortening of the extremity, swelling tenderness,
inability to flex hip/abduct leg, and hemorrhage.
General: – Diagnosis: AP X-ray; Seinsheimer: (Grades) classification
– Mechanism: lateral displacement of patella after contraction – Treatment: predominantly surgical – external fixation, open
of quadriceps against flexed knee reduction, intramedullary fixation (1ary choice)
– Clinical Feature: knee catches/gives way with walking; severe
pain, tenderness anteriormedially from rupture of capsule, wk 45. Femoral neck fractures
knee extension/inability to extend leg unless patella reduced;
1. Positive patellar apprehension test: patients apprehensive Mechanism and Diagnosis:
when examiner laterally displaces patella; often recurrent, self- – Mechanism:
reducing 1. Young patients: car accident/fall from height;
– Imaging: X-rays: X-Rays (A/P, Lateral, skyline – 2. Old patients (>60): a simple fall onto the hip: fatigue
patellofemoral joint; check for fracture of medial patella & fracture
lateral femoral condyle) – Diagnosis: acute onset of hip pain, unable to bear weight,
– Treatment: shortened, externally-rotated leg, painful range of motion
1. Non-operative first: knee immobilization x 4-6 weeks; ƒ x-ray: A/P, lateral hip, A/P pelvis
progressive weight bearing and isometric quadriceps
strengthening Mechanism and Diagnosis:
– Treatment:
1. Garden I/II: internal fixation

2. Garden III/IV: depends on age of patient and function; 1. Causes:
older/low function: hemiarthroplasty; young/high function: A. Isolated injuries (rare): forceful contractions (force
reduction w/internal fixation avulsion) of the iliopsoas muscle in adolescents or by benign
– Complications: DVT, non-union & avascular necrosis or malignant bone tumors in the elderly.
– One of commonest causes of morbidity due to increasing B. Combination with other fracture types (most common):
component of intertrochanteric fracture
incidence in the ageing population. – Greater Trochanter fracture:
– Whenever possible surgery should be done within 24-48h. 1. Causes:
A. Isolated injuries (rare): usually occurs in elderly patients
46. Hip dislocation due to a direct trauma to the outside of the hip or indirectly
due to contraction of the gluteus medius and gluteus minimus
muscles.
Clinical Feature: B. Combination with other fracture types (most common):
– Inability to bear full weight, excessive mobility of the limb component of intertrochanteric fracture
and crepitus at joint
Treatment:
Types: – Bedrest, stretches to regain hip function, and if bone
– Anterior Dislocation: fragment > 1cm, ORIF - wires
1. Etiology: force to the posterior part of the knee when hip
is abducted: Forced abduction and lateral rotation of limb 48. Pelvic fractures
2. Diagnosis: shortened, ABducted, external rotated limb
3. Treatment: closed reduction and post-reduction CT
Incidence and Mechanism:
– Posterior Dislocation – Most Common:
– Young: high energy trauma, either direct/by force
1. Etiology: severe force to the knee when hip is flexed and
transmitted longitudinally through the femur
adducted: knee into dashboard in MVA
– Elderly: fall from standing height, low energy trauma
2. Diagnosis: shortened (2-3cm), ADDucted and internally
– Classifications: Tiles and Young&Burgess
(medially) rotated limb
3. Treatment: closed reduction and& post reduction CT,
Clinical Feature and Diagnosis:
ORIF if unstable
– Clinical: local swelling, tenderness, deformity of lower
– Central Dislocation - Rare:
extremity, pelvic instability
1. Etiology: traumatic injury where femoral head is pushed
– Diagnosis:
through the medial wall of acetabulum toward pelvic cavity, by
1. X-ray: AP pelvis, inlet and outlet for pelvic fracture; Judet
a heavy lateral blow upon the femur.
films (obturator and iliac oblique) for acetabular fracture
2. CT scan: posterior pelvic injury and acetabular fracture
Treatment:
– Notes:
– Posterior dislocation: Use general anesthesia; reduce by
1. Acetabular fractures: lead to early coxarthrosis
longitudinally (vertically) pulling the femur while hip and knee
2. Femoral head dislocations: lead to AVN
is flexed to a right angle and rotated laterally.
3. Anterior and posterior column: classified into simple and
– Hip reductions should be reduced as soon as possible, i.e.
complex fractures
within 6hrs to decrease the risk of avascular necrosis of the
femoral head).
Treatment and Complications:
– Up to 50% of patients with hip dislocations suffer fractures
– Stable fractures: nonoperative treatment, protected weight
elsewhere at the time of injury.
bearing
– Examine for neurovascular injury prior to open/closed
– Indications for operative treatment: unstable pelvic ring
reduction
injury; disruption of anterior and posterior SI ligament; ƒ
– Hip precautions for 6wks post-reduction (no extreme hip
symphysis diastasis >2.5 cm; vertical instability of the
flexion, adduction, internal/external rotation)
posterior pelvis; CREF or ORIF or total hip arthroplasty
– Complications:
Complications:
1. Hemorrhage (life-threatening): 1500-3000 ml blood loss
– AVN, post-traumatic arthritis (osteoarthritis), fracture of
2. Injury to rectum or urogenital structures
femoral head/shaft; sciatic nerve palsy (25%),
3. DVT/PE risk
thromboembolism, heterotrophic ossification
49. Cervical sprain (Whiplash)
47. Trochanteric fractures

Incidence and Mechanism:
– A strain refers to an injury to a muscle, occurring when a
– It often affects older people (75-85y)
muscle-tendon unit is stretched or overloaded.
– Lesser Trochanter fracture:

– Cervical muscles that are commonly strained include the ORTHOPEDICS
SCM, the trapezius, the rhomboids, the erector spinae, the
scalenes, and the levator scapulae. 1. Arthrodesis (artificial ankylosis/joint fusion)
– Causes include:
1. MVA: whiplash (Occupants of cars stuck violently from Definition:
behind.) – Most common – It is an artificial induction of joint ossification
2. Sports-related (ankylosis/syndesis) between two bones via surgery.
Clinical Feature and Diagnosis: Use:

– Clinical Feature: pain, stiffness, headache, or decreased – It relieves joint pain in patients which cannot be managed by
cervical ROM. pain medication, splints, etc. The causes of such pain are
– Physical Examination: neurological exam, cervical ROM fractures which disrupt the joint and in arthritis e.g.
– Imaging: osteoarthiritis.
1. X-ray: AP, lateral, oblique, and odontoid views. – Most commonly performed on joints of spine, hand, ankle
2. CT scanning: abnormal X-ray or suspicion of fracture. and foot.
3. MRI: in athletes with neurologic deficits
Procedures:
Treatment: – 1. Autograft (bone from elsewhere in patient’s body) or
– NSAIDs, muscle relaxants, soft cervical collar (2-3wks) allograft (donor bone) used to create a bone graft between 2
physical therapy, electrical stimulation, chiropractic care bones; autograft is preferred
– 2. Metal implants can be used to attach the 2 bones in a
50. Fractures of the lumbar spine position that favours bone growth
– 3. Synthetic bone that mimics the bone, can also be used
– 4. Combo of 1-3
Mechanism and Types of Fractures:
– Mechanism: may be caused by: MVA, fall from height, sport
2. Synovectomy
accidents, gunshot wound, osteoporosis (crush fractures od
the vertebral body), or tumors
– Types: Definition and Use:
1. Compression fracture: – The surgical removal of a part/all of an inflamed lining of
2. Axial burst fracture: fall from height the synovial membrane of a synovial joint. This leaves the
3. Flexion/distraction fracture: vertebrae is pulled apart capsule intact. It is indicated before cartilage damage.
4. Transverse process fracture: from rotation/extreme – It will reduce local pain and swelling.
sideways bending – Used in certain diseases involving the synovium: RA,
juvenile idiopathic arthiritis, hemarthrosis, pigmented
Clinical Feature and Diagnosis: villonodular synovitis, and synovial osteochondromatosis.
– Clinical Feature: moderate to severe back pain (worse by – Procedure: conducted arthroscopically or classic arthrotomy.
movement), numbness, tingling, weakness, or bowel/bladder – Complications: infection, neural palsy, phlebitis
dysfunction.
– Diagnosis: Emergency stabilization, neurological tests, 3. Instability of the knee
imaging (X-rays, CT, MRI)
Etiology and Classification:
Treatment and Complications: – It is due to acute/chronic injury of:
– Treatment: brace for 6-12wks (most compression injuries 1. Anterior cruciate ligament (ACL): probably by twisting,
like compression and burst fractures), surgery for unstable pivoting, or turning
burst fractures that have: significant comminution, severe loss 2. Posterior cruciate ligament (PCL): probably due to probls
of vertebral body height, excessive forward going down stairs/slopes
bending/angulation, significant n. injury due to parts of the 3. Medial collateral ligament (MCL): Injury that abducts the
vertebral body/disk pinching the spinal cord tibia upon the femur (subluxation). Wide abduction of tibia
– Complications: DVT, PE, pneumonia, pressure sores, upon femur cannot occur unless the cruciate and capsule are
bleeding, infection, spinal fluid leak, nonunion also torn in the injury.
4. Lateral collateral ligament (LCL): less common, there is an
adduction of the tibia upon femur
Diagnosis:
. – General:

1. The timing of an effusion (acute hemarthrosis usually – If ankle ligament do not heal adequately
occurs within 2 hours) and hearing or feeling a “pop” (highly – Complete rupture of the talo-fibular and calcaneo-fibular
suggestive of an ACL injury) are significant events. ligaments with consequent tilting and subluxation of the talus.
2. Chronic instabilities: present with mechanical symptoms – May be mistaken for simple strain of the ligaments.
such as locking, catching, clicking, or giving way, particularly
with twisting movements. Clinical Features and Diagnosis:
– According to injury: – Clinical Feature: swelling and edema, tenderness over the
1. MCL injury: AP X-rays are taken while an abduction stress lateral ligaments.
is applied to the tibia. – Diagnosis: AP radiographs while an adduction stress is
2. ACL injury: Anterior drawer test applied to the heel. (tilting of talus is not seen in strain)
3. PCL injury: Posterior shift when backward force applied
below patella. Treatment:
– If treated as a simple strain with early exercises and activity,
Terms: the torn ligaments may fail to heal and recurrent subluxation
– Laxity: is the measured amplitude of joint movement within of the ankle may occur.
the constraints of its ligaments. – Conservative treatment: ligament protected by a below-knee
– Physiological Laxity: implies no ligament is stretched plaster for at least 8 weeks.
pathologically. – If disability is slight, it may be sufficient to strengthen the
– Pathological Laxity: means a ligament has been stretched by evertor (peroneus longus) muscles with exercise. Severe
injury. disability may require surgery: new tendon inserted taken from
– Instability: is a complaint by a patient that they lose single peroneus brevis/tertius.
leg stance because the joint – Strengthening peroneal m may help control ankle joint and
subluxates due to pathological laxity. improve joint stability; surgery to tighten ligaments around
– Disability: is instability that interferes with the required ankle
function of the knee.
5. Glenohumeral (shoulder) joint instability
Treatment:
– General: Definition and Classification:
1. Grade 1-2 (incomplete tear): no surgery needed:
– Definition:
mobilization, physiotherapy, and reevaluation in about 2 weeks
1. Instability: of the shoulder is deﬁned as abnormal or
may be adopted.
symptomatic motion, usually translocation of the humeral
2. Grade 3 (complete tear): need surgical
head with respect to the glenoid.
repair/reconstruction.
2. Laxity: describes the passive motion characteristics of the
– According to injury:
joint.
1. MCL injury: – Classification: Can be traumatic or non-traumatic; anterior,
A. Conservative: Aspiration of blood stained effusion.
posterior or multidirectional. Anterior and posterior instability
Knee is afterwards supported in a long-leg plaster (reatined
refers to shoulder dislocation (question 26; traumatology).
after 6 weeks).
B. Operative: sutured ligaments with 6 weeks support in
Multidirectional Joint Instability (MDI):
plaster.
– MDI is a common condition that may be a bilateral
2. ACL injury: Most surgeons prefer to await events and to
occurrence and is usually atraumatic in nature.
reconstruct the ligament secondarily if significant disability
– MDI is characterized by diffuse capsular laxity due to
persists after a long period of rehabilitation. (ligament
inadequate ligament structures. This laxity is referred to as
reconstruction seldom restores full stability; may also
MDI because of the increase in mobility of the glenohumeral
deteriorate with time due to stretching)
joint (ball and socket of shoulder) in all directions.
3. PCL injury: reconstruction, only when disability justifies it.
– Clinical features: pain (sore shoulder that worsens with
In case of reconstruction: By substitution of a strip of
activity or specific arm movements – overhead activities,
aponeurosis or tendon (usually patellar tendon). Important
carrying items, overuse, injury), dislocations (subluxation)
with intensive exercises to redevelop the quadriceps muscle.
– Diagnosis: symmetrical finders, hyperlaxity may be shown
through a positive sulcus sign (inferior laxity), anterior and
4. Instability of the ankle posterior capsule testing. Routine x-rays may be obtained but
are most often negative. MRI evaluation may demonstrate
Definition and Etiology: abnormalities of the labrum (cartilage that encircles the cup of
– Rupture of the lateral ligament of the ankle the shoulder) and generalized capsular laxity.
– Strains can also cause instability – Treatment:
– In cases of sever adduction injury 1. Initial: supportive care, NSAIDs, ice;

2. Arthoscopic surgery: shoulder capsule is tightened by in wrist, pain on outside of elbow when hand is extended at
electrothermal or suture technique; then rehabilitation and wrist, pain on outside of elbow when trying to straighten
physical therapy fingers.
Treatment:
6. Glenoid labrum injury – Generally a self-limited condition, but may take 6-18 months
to resolve.
Anatomy, Definition and Etiology: – Combination of therapy:
– Anatomy: Glenoid labrum increases depth of should cavity 1. Apply ice/cryotherapy to elbow (15mins up to 6x/day):
making the shoulder joint more stable; glenohumeral ligaments this will reduce pain and inflammation if present;
and shoulder capsule attach to glenoid labrum. 2. Rest;
– Etiology: repetitive overhead throwing, lifting heavy objects 3. NSAIDs; or corticosteroid injections
below shoulder height/catching heavy objects and FOOSH. 4. Use brace/strap;
5. Surgery: percutaneous or open release of common tendon
Classification: from epicondyle (only after 6-12 months of conservative
– Glenoid labrum injuries are classed as either superior or therapy)
inferior towards the bottom of the glenoid socket.
– Superior injury: is known as a SLAP lesion (superior labrum, 8. Benign tumors of the musculoskeletal system
anterior (front) to posterior (back) and is a tear of the rim
above the middle of the socket that may also involve the General about Benign Tumors:
biceps tendon. – Minimal trauma may precipitate pathologic fractures; if there
– Inferoir injury: is a tear of the rim below the middle of the were no symptoms prior to time of fracture, chances are
glenoid socket is called a Bankart lesion and also involves the that tumor is benign. On other hand, if fracture has been
inferior glenohumeral ligament. preceded by dull, aching pain, possibility of malignant primary
bone tumor or metastasis is likely.
Clinical Feature: – Example of benign tumors:
– Clinical Feature: shoulder pain which cannot be localized to 1. Osteoid Osteoma
a specific point, pain is made worse by overhead 2. Osteochondroma
activities/when arm is held behind the back, weakness, 3. Enchondroma
instability in shoulder, pain on resisted flexion of biceps and 4. Cystic Lesions
tenderness over front of shoulder. 5. Giant Cell Tumors/Aneurysmal Bone
Cyst/Osteoblastoma
Treatment:
– Treatment: Characteristics of Benign Bone Tumors:
1. Rest – Benign bone tumors generally do not extend beyond the
2. Cold therapy: reduce pain and inflammation cortex of bone;
3. NSAIDs – Often these tumors are surrounded by a radiodense margin
4. Rehab to restore full function of bone;
5. Unstable injuries: surgery to re-attach labrum to glenoid; – Whereas metaphyseal tumors are common, diaphyseal
following surgery the shoulder will usually be kept in a sling tumors are uncommon;
for 3-4wks
Osteoid Osteoma:
7. Tennis elbow (Lateral Epicondylitis) – Incidence: 2nd and 3rd decades, M>F.
– Affects: tibia and femur mostly
Definition, Mechanism, and Clinical Feature: – Clinical Feature: produces severe intermittent pain, mostly at
night (diurnal prostaglandin production)
– Definition: inflammation of the common extensor tendon
– Treatment and complications: characteristically relieved by
(extensor carpi radialis brevis muscle tendon) as it inserts into
NSAIDs (treatment only necessary if symptomatic) and it is
the lateral epicondyle.
not known to metastasize.
– Mechanism: it is due to repeated or sustained contraction of
the forearm muscles: overuse/repetitive strain caused by
repeated extension of the wrist (e.g. tennis, Osteochondroma:
badminton/squash) but also common after periods of – Incidence: 2nd and 3rd decades, M>F. It accounts for 45%
excessive wrist use in day-to-day life. Inflammation is rare but of all benign bone tumors.
increased pain receptors in the area makes the region – Affects: the metaphysis of long bone (distal ends of
extremely tender. femur/proximal ends of humerus). (“mushroom” on x-ray)
– Clinical Feature: pain about 1-2cm down from bony area at – Clinical Feature: generally very slow growing and
the outside of the elbow (lateral epicondyle), there is weakness asymptomatic unless impinging on neurovascular structure.

– Treatment: resection Multiple Myeloma:
– Complications: malignant degeneration occurs in 1-2% – Incidence: most common primary malignant tumor of bone
(becomes painful or rapidly grows). in adults; 90% occur in people >40 years old
– Pathology:
Enchondroma: – Clinical Feature: anemia, anorexia, renal failure, nephritis,
– Incidence: 2nd and 3rd decades increased ESR, bone pain (cardinal early symptom),
– Affects: 50% occur in the small tubular bones of the hand compression fractures, hypercalcemia; high incidence of
and foot; others in femur, humerus, ribs infections (e.g. pyelonephritis/pneumonia)
– Treatment: treatment only necessary if symptomatic – Diagnosis: CT-guided biopsy of lytic lesions
– Complications: malignant degeneration occurs in 1-2% (pain – Treatment: chemotherapy, radiation, surgery for
in absence of pathologic fracture is an important clue) symptomatic lesions or impending fractures
Cystic Lesions: Bone Metastasis:

– Incidence: children and young adults – Incidence: 2/3 from breast or prostate; also consider
– Pathology: includes unicameral/solitary bone cyst (most thyroid, lung, kidney
common), fibrous cortical defect – Pathology: usually osteolytic; prostate occasionally
– Clinical Feature: local pain, pathological fracture (50% osteoblastic
presentations) or incidental detection – Clinical Feature:
– Treatment: treatment of unicameral bone cyst with steroid – Diagnosis: bone scan for musculoskeletal (MSK)
injections ± bone graft; curettage and bone graft involvement, MRI for spinal involvement may be helpful
– Treatment: stabilization of impending fractures: internal
9. Malignant tumors of the musculoskeletal system fixation, IM rods; bone cement
Osteosarcoma: 10. Osteoporosis

– Incidence: 2nd decade of life (60%); history of Paget’s disease
radiation. Definition and Etiology:
– Affects: distal femur (45%), proximal tibia (20%) and – Definition: “porous bones," causes bones to become weak
proximal humerus (15%) and brittle. There is thinning of bone tissue and loss of bone
– Clinical Feature: painful, poorly defined swelling, decreased density over time (reduction of total bone mass). A common
ROM ; metastasis to lung, result of osteoporosis is fractures, most of them occur in the
– Diagnosis: x-ray shows Codman’s triangle spine, hip or wrist.
– Treatment: complete resection (limb salvage, rarely – Etiological risk factors: post-menopausal female (estrogen
amputation), neo-adjuvant chemotherapy; survival: 70% deficiency), increasing age, Vitamin D deficiency, low dietary
Ca intake, smoking, alcohol abuse, glucocorticoid therapy,
Chondrosarcoma: drugs, anticonvulsants, endocrine disease (Cushing’s,
– Incidence: hyperthyroidism, hyperparathyroidism), MM
1. Primary (67%): normal bone; patient over 40 – Pathogenesis: there is an increased bone breakdown by
2. Secondary (33%): malignant degeneration of pre-existing osteoclasts and decreased bone formation by osteoblast.
cartilage tumour such as enchondroma or osteochondroma,
younger age group and better prognosis than primary Clinical Feature:
chondrosarcoma – There is an sudden onset of back pain in spine often
– Affects: most commonly occurs in pelvis, femur, ribs, radiating around to the front: suggests vertebral crush
scapula, humerus (with metastasis to the lung) syndrome (but only 1/3 of vertebral ractures are symptomatic)
– Clinical Feature: pain, pathological fracture, flecks of – There is a loss of height over time and a stooped posture
calcification (Kyphosis).
– Treatment: unresponsive to chemotherapy, treat with – Fractures: of the vertebra, wrist (Colles fracture), hip or
aggressive surgical resection + reconstruction other bone
– Fracture of proximal femur: due to falling on side/back
Ewing’s Sarcoma:
– Incidence: most occur between 5-20 years old Diagnosis:
– Clinical Feature: affects diaphysis of long bone; metastases – Dual energy X-ray absorptiometry (DEXA) scan: measures
frequent without treatment area in bone density usually of lumbar spine and proximal
– Diagnosis: mild fever, anemia, leukocytosis and increased femur. If patient >75: DEXA not needed.
ESR/LDH – Bone density less than 2.5 standard deviations below young
– Treatment: resection, chemotherapy, radiation adult mean value
– X-ray: fracture and asymptomatic vertebral deformities

Treatment: Clinical Feature, Diagnosis, and Treatment:
– New vertebral fractures: bed rest for 1-2wks, strong – Clinical Feature: pain in thoracic spine in active state;
analgesia, muscle relaxants. Slouching posture or hunchback. Back pain may subside then
– Therapy against osteoporosis: and come back later in life with OA. There is also spinal
1. Subcutaneous calcitonin (salmon calcitonin) stiffness or tenderness.
2. Physiotherapy, Exercise – Diagnosis: physical exam. Forward bend test. Patient bend
3. Calcium and Vitamin D forward from the waist while the spine is viewed from the
4. Smoking and alcohol abuse cessation side. With kyphosis, the rounding of the upper back may
5. Bisphosphonates: become more obvious in this position. Spinal imaging tests, X-
6. Selective estrogen receptor modulators (SERM): ray, MRI.
raloxifene – Treatment: Mild case no treatment. Pain: brace or plaster
jacket. Exercise for back muscles. Worst cases: surgery,
11. Scoliosis excision of intervertebral discs with grafting, spinal fusion
instrumentation.
Definition, Epidemiology, and Etiology:
– Definition: Lateral curvature of spine with vertebral rotation 13. Legg-Calve-Perthes disease (LCPD)
– Epidemiology: just before puberty: affects 10-14 year olds;
F>M Definition, Epidemiology, and Etiology:
– Etiology: – Definition and incidence: LCPD is avascular necrosis (AVN)
1. Idiopathic: most common (90%) of the proximal femoral head epiphysis resulting from
2. Ccongenital: vertebrae fail to form or segment compromise of the tenuous blood supply to this area.
3. Neuromuscular: Upper motor neuron (UMN) or lower – LCPD usually occurs in children aged 4-10 years. M>F.
motor neuron lesion (LMN) lesion, myopathy – Etiology: idiopathic (unknown); it is associated with family
4. Other: osteochondrodystrophies, neoplastic, traumatic history, low birth weight, abnormal pregnancy, and hip
5. Postural: leg length discrepancy, muscle spasm trauma.
Clinical Feature, Diagnosis, and Treatment: Clinical Feature, Diagnosis, and Treatment:
– Clinical Feature: – Clinical Feature: the child has hip pain and intermittent limp
1. Might be back pain: usually adults (abductor lurch); there is tenderness and pain over the anterior
2. Asymmetric shoulder height when bent forward; thigh (atrophy of muscles), and there is a flexion contracture
prominent scapulae, creased flank, and asymmetric pelvis (decreased internal rotation and abduction of hip).
3. Adam’s test: rib hump when bent forward – Diagnosis: X-rays may be negative early, but eventually there
4. Non-idiopathic scoliosis: is associated with café-au-lait is a characteristic collapse of the femoral head (diagnostic)
spots, dimples, neurofibromas which appears widened and flattened (coxa plana). Bone scans
5. There is a primary curve with secondary compensatory – Treatment: the therapy goal is to preserve ROM and
curves above and below preserve femoral head in acetabulum.
– Diagnosis: x-ray: measure curvature (Cobb’s angle); might 1. ROM exercises and minimal weight bearing
also be an associated kyphosis; CT; MRI 2. Brace in flexion and abduction for 2-3 years
– Treatment – Based on degree of curvature: 3. Femoral or pelvic osteotomy
1. <20º: observe for changes – Complications: early onset osteoarthritis and decreased
2. >20º or progressive: bracing (many types) that halt/slow ROM.
curve progression but do NOT reverse deformity
3. >40º: cosmetically unacceptable or respiratory problems: 14. Developmental dysplasia of the hip joint (DDH)
surgical correction (spinal fusion)
Definition and Etiology:
12. Scheuermann’s disease (Juvenile Kyphosis) – Definition: DDH is seen in patients who are born with (or
during or after birth) dislocation or instability of the hip,
Definition and Etiology: which may then result in hip dysplasia. DDH was called
– Diagnosis and Incidence: is a deformity (kyphosis) in the congenital dysplasia of the hip (CDH).
thoracic or thoracolumbar spine in children (esp. boys 13-16). – Etiology: due to ligamentous laxity, muscular
This means that there is a forward rounding (>50deg) of your underdevelopment, and abnormal development of acetabulum
upper back (Hunchback). There is osteochondrosis of the (roof), proximal femur, labrum, capsule and other soft tissues.
secondary ossification centers of the vertebral bodies – Risk factors: family history, breech position, female, first
– Etiology: Osteoporosis, degenerative arthritis of spine, born, and left hip.
ankylosing spondylitis, CT disorders, tuberculosis, or cancer.

Clinical Feature: Clinical Feature and Diagnosis:
– Terms and Tests: – Clinical Feature:
1. Subluxation: incomplete contact between the articular 1. Head twisting: in a variety of directions (Chin toward
surfaces of the femoral head and acetabulum. shoulder (most common), Ear toward shoulder, Chin straight
2. Dislocation: complete loss of contact between the articular up, Chin straight down).
surface of the femoral head and acetabulum. 2. Neck pain that can radiate into the shoulders
3. Instability: consists of the ability to subluxate or dislocate 3. Headaches.
the hip with passive manipulation. – Diagnosis: Physical exam. MRI. EMG.
4. Ortolani test: palpable "clunk" is present when the hip is
reduced in and out of the acetabulum Treatment:
5. Barlow’s test (for dislocatable hip): flex hips and knees to – There is no cure: only symptomatic relieve: Botulinum toxin,
90º and grasp thigh then fully adduct hips, push posteriorly to Parkinsons drugs, Muscle relaxants, Pain medications,
try to dislocate hips exercises that improve neck strength and flexibility.
6. Galeazzi’s Sign: knees at unequal heights when hips and – Surgery: muscle and nerve cutting if nothing helps.
knees are flexed; dislocated hip on side of lower knee; difficult
test if child <1 year 16. Low back pain syndrome
– Clinical Features:
1. Dislocation: early manifestation seen with Ortolani test
Definition, Classification, and Etiology:
2. Asymmetry of the gluteal thigh or labral skin folds.
– Definition: it is a symptom that affects about 90% of
3. Decreased abduction on the affected side.
persons aged 18-55 years in their lifetime.
4. Affected leg shortening
– Classification:
1. Acute: <6 weeks
Diagnosis:
2. Subacute: 6-12 weeks
– Physical examination: diagnosis is clinical:
3. Chronic: >12 weeks
– Investigation: USG (view cartilage), x-ray after 3 months
– Etiology: soft tissue sprain/strain during loading of back
– Investigations: USG (view cartilage), x-ray after 3 months
(99%); sciatic nerve entrapment (compression of sciatic nerve),
herniated nucleus pulposus, direct trauma, muscle spasm due
Treatment and Complications: to chronic overuse injury or muscle strain or sprain, or
– Treatment: piriformis syndrome, osteoporosis, spinal degeneration,
1. 0-6 months: reduce hip using Pavlik harness to maintain lumbar spinal stenosis.
abduction and flexion
2. 6-18 months: reduction under GA, hip spica cast for 2-3 Clinical Feature and Diagnosis:
months (if Pavlik harness fails) – Symptoms: Chronic pain in the buttocks. This pain may
3. >18 months: open reduction; pelvic and/or femoral
radiate to the lower leg and worsens with walking or squatting.
osteotomy
There might be pain when getting up from bed and the pain is
– Complications: redislocation, inadequate reduction, stiffness;
exacerbated by hip adduction and internal rotation. Patients
AVN of femoral head
have an intolerance to sitting.
– Diagnosis: CT and MRI to exclude herniated disc, spinal
15. Torticollis (spasmodic torticollis) tumor, or abscess. Electromyography.
Definition: Treatment:
– Definition and Incidence: head and neck dystonias that are – Conservative: application of heat/cold; physical therapy,
painful. In this condition the neck muscles contract continued activity within limits of pain; exercise (prevention).
involuntarily, causing head to twist or turn to one side. It is a – Acute back pain: NSAIDs/paracetamol, muscle relaxants,
rare disorder that can occur at any age, even infancy (types: physical activity
congenital or aquired) and F>M. – Chronic non-specific back pain: physical activity, TCA,
acupunture, intensive multidisplinary Tx programs,
Types: behavioural therapy, spinal manipulation
– Congenital torticollis: Congenital muscular torticollis is rare – Surgery: especially with development of neurologic
(< 2%) and is believed to be caused by local trauma to the soft symptoms (e.g.: leg weakness, bladder/bowel incontinence as
tissues (SCM) of the neck just before or during delivery. seen in severe central lumbar disc herniation): microdisectomy,
– Acquired torticollis: any injury or inflammation of the discectomy, laminectomy, formainotomy, spinal fusion, spinal
cervical muscles or cranial nerves from different disease cord stimulator; lumbar artificial replacement.
processes.

Piriformis syndrome: – Risk Factors: chemotherapy, alcoholism, excessive steroid
– General: is characterized by pain and instability. The use, post trauma, (decompression sickness), vascular
location of the pain is often imprecise, but it is often present compression, hypertension, vasculitis, arterial embolism and
in the hip, coccyx, buttock, groin, or distal part of the leg. The thrombosis
female-to-male incidence ratio is 6:1. – Symptoms: depend on affected joint; pain (may be at rest
and night); restricted ROM; may be asymptomatic and is
17. Spondylolisthesis occasionally discovered incidentally on x-ray.
– Diagnosis: Xray. MRI. Bone scan. CT.
– Treatment: No medical treatment has proven effective in
General:
preventing or arresting the disease. Pain medications.
– Definition: defect in pars interarticularis causing a forward
Immobilization may be helpful in some cases. Limit stress and
slip of one vertebrae on another usually at L5-S1, less
weight bearing on affected joints. (Crutches). Surgery: Core
commonly at L4-5
decompression, Osteotomy, Total hip arthroplasty, Bone
– Etiology: congenital (articular processes; children),
grafts.
degenerative (osteoarthritis; adults), traumatic, pathological,
teratogenic, stress fracture
20. Osteochondritis dissecans
– Clinical features: lower back pain radiating to buttocks
– Diagnosis: X-ray. CT, MRI.
– Treatment: NSAIDs; physical therapy, corset. If it is severe, General:
surgery can be performed with internal brace of screws and – Definition: Localized disorder of convex joint surfaces in
pins to hold together the vertebra. which a segment of subchondral bone becomes avascular and,
– Complications: Cauda equina syndrome with the cartilage that covers it, may slowly separate and form
a loose body. This may occur from repetitive trauma.
18. De Quervain's disease – Symptoms: pain; joint popping or locking (due to loose
body); joint weakness; decreased ROM; swelling and
tenderness. Commonly seen in knee and elbow
Definition:
– Diagnosis: X-ray (still attached with a line of demarcation, or
– Other names: Also called De Quervain's tendinitis,
loose in the joint with a cavity in articular surface). CT. MRI.
washerwomans sprain, radial styloid tenosynovitis, and De
– Treatment: restore the normal functioning of the affected
Quervain tenosynovatis.
joint and to relieve pain, as well as reduce the risk of
– Definition: idiopathic inflammation in 1st extensor
osteoarthritis: physical therapy; surgery, if conservative
compartment (abductor pollicis longus (APL) and extensor
treatments don’t help, patients may need surgery to remove
pollicis brevis (EPB)). This means that it is an entrapment
loose fragments or to reattach fragments to the bone.
tendinitis.
21. Ganglion cyst

Clinical Features:
– Positive Finkelstein’s test: pain over the radial styloid
induced by making fist, with thumb in palm, and ulnar General:
deviation of wrist. – Definition: the most common soft tissue tumor of hand and
– Pain localized to the 1st extensor compartment wrist (60% of masses). It is a fluid-filled synovial lining that
– Tenderness and crepitation over radial styloid may be protrudes between carpal bones or from a tendon sheath; it is
present most commonly carpal in origin.
– Clinical features:
Treatment: 1. It is most common around scapholunate ligament junction
– Mild: NSAIDs, splinting and steroid injection into the 2. More common in younger persons; F>M:3:1.
tendon sheath (successful in over 60% of cases) 3. It is often non-tender although tenderness increased when
– Severe: surgical release of stenotic tendon sheaths (APL and cyst smaller (from increased pressure within smaller cyst sac)
EPB); remember there may be 2 or more sheaths 4. There might be pain, limitation of activity, and
compression of the median nerve.
19. Avascular bone necrosis – Treatment:
1. Conservative treatment: watch and wait (can compressed
until it bursts in the early stages).
General: 2. Aspiration (recurrence rate 65%)
– Definition: cellular death of bone components due to 3. Consider operative excision of cyst and stalk (recurrence is
interruption of the blood supply. The bone structures collapse, possible)
resulting in bone destruction, pain, and loss of joint function. 4. Steroids if painful
– Affects: bones with a single terminal blood supply, such as
the femoral head, carpals, talus, and humerus.

22. Meniscal injuries 25. Dupuytren's contracture
General: Definition:
– SEE QUESTION 38 - TRAUMATOLOGY – Flexion contraction of/from thickening and shortening
longitudinal palmar fascia (aponeurosis), forming nodules
23. Chondromalacia Patellae (Patellofemoral (usually painless), fibrous cords and eventually flexion
Syndrome) – Runners Knee contractures at the metacarpophalangeal (MCP) and
interphalangeal joints.
– Flexor tendons are not involved
Mechanism and Incidence:
– Dupuytren’s diathesis: early age of onset, strong family
– Softening, erosion and fragmentation of articular cartilage,
history, and involvement of sites other than palmar aspect of
predominantly medial aspect of patella
hand.
– It is commonly seen in active young females (15-18)
– Risk factors: post-trauma, deformity of patella or femoral
groove, excessive knee strain (athletes.
Epidemiology:
– It is a genetic disorder with high incidence in northern
Europeans. It affects men > women and often presents in 5th-
Clinical Features, Diagnosis:
7th decade of life.
– Clinical Features:
– It is associated with but not caused by alcohol use and
1. There is a deep, aching anterior knee pain which is
diabetes.
exacerbated by prolonged sitting (theatre sign), strenuous
Mostly Ulnar part of aponeurosis affected (ring and little
athletic activities, stair climbing, and squatting.
finger)
2. There is also a sensation of instability, pseudolocking, and
tenderness to palpation of underside of medially displaced
Clinical Features:
patella.
– It mostly affects the ulnar part of the aponeurosis: ring >
– Diagnosis: X-ray: AP, lateral; arthroscopy
little > long > thumb > index
– Treatment:
– It may also involve feet (Lederhosen’s) and penis
1. Non-operative: RICE (Rest, Ice, Compression, Elevation);
continue non-impact activities; NSAIDs (Peyronie’s)
2. Surgical with refractory patients: tibial tubercle elevation;
arthroscopic shaving/debridement; lateral release of Treatment:
retinaculum – Intra-lesional steroids may help in early stages
– Surgery, only effective treatment
24. Golfer's elbow (Medial Epicondylitis) – If slow progressing, better to let be, especially in the elderly
– It may recur, especially in Dupuytren’s diathesis
Definition, Etiology, and Clinical Feature: 26. Shoulder joint instability

– Definition: inflammation of the common flexor tendon as it
inserts into the medial epicondyle
– Etiology: repeated or sustained contraction of the forearm General:
muscles – If the shoulder joint dislocates more than 1-2 times or is
– Clinical Feature: frequently partially slipping out and then returning into its
1. Point tenderness over humeral epicondyle place.
2. Pain upon resisted wrist or wrist flexion (medial – Joints: Glenohumeral, Acromioclavicular, Sternoclavicular,
epicondylitis) Scapulothoracic
– SEE QUESTION 26 - TRAUMATOLOGY
Treatment:
– Generally a self-limited condition, but may take 6-18 months 27. Rotator cuff injury
to resolve.
– Combination of therapy: Anatomy:
1. Apply ice/cryotherapy to elbow (15mins up to 6x/day): – The rotator cuff is a series of 4 muscles and tendons that act
this will reduce pain and inflammation if present; to stabilize humeral head within the glenoid fossa:
2. Rest; Supraspinatus, Infraspinatus, Teres minor and Subscapularis.
3. NSAIDs; or corticosteroid injections
4. Use brace/strap; Epidemiology, Definition, Etiology:
5. Surgery: percutaneous or open release of common tendon – Epidemiology: Rotator cuff disease can occur in any age
from epicondyle (only after 6-12 months of conservative group but occurs predominantly in ages 50-70.
therapy)

– Definition: A rotator cuff tear occur more often gradually, – The discriminative touch is often lost first
chronic over time than as a concequence of trauma. Early – Patients are usually awakened at night with numb/painful
signs of rotator cuff diseases is things like tendonitis or bursitis hand, relieved by shaking/dangling/rubbing
or any muscle weakness that narrow subacromial space, – There is a decreased light touch, 2-point discrimination,
eventually progressing on to become a partial or full tear. especially fingertips
– Etiology: compression of tendons (primary supraspinatus) – In advanced cases there is thenar wasting and weakness
and subacromial bursa, result is bursitis, tendonitis, and rotator
cuff thinning and tearing; narrowing of the subacromial space. Diagnosis:
– Tests – CTS is a clinical diagnosis:
Clinical Features: 1. Tinel’s sign: tingling sensation on percussion of nerve
– Night pain or difficulty sleeping on affected side 2. Phalen’s sign: wrist flexion induces symptom
– Pain worse with active motion (eg trouble with overhead 3. Durkan test: direct compression of median nerve in carpal
activities), loss of range of motion and weakness tunnel for 30 seconds reproduces numbness and tingeling in
– Tenderness to palpation over greater tuberosity one or more of the radial digits.
– Investigations: nerve conduction velocities (NCV) and EMG
Diagnosis: may confirm, but do not exclude, the diagnosis
– Jobe’s test: Supraspinatus tear
– Posterior cuff test: Infraspinatus och Teres minor tear Treatment:
– Lift-off test: Subscapularis tear – Avoid repetitive wrist and hand motion, wrist splints when
– Neer’s test: Rotator cuff impingement repetitive wrist motion required
– Hawkins-Kennedy test: Rotator cuff impingement – Conservative: night time splinting to keep wrist in neutral
– Painful arc test: Tendinopathy position
– X-rays: AP view of humerus relative to glenoid, high riding – Medical: NSAIDs, local corticosteroids injection, oral
humerus may be sign of tendonitis corticosteroids
– MRI – Surgical decompression: transverse carpal ligament incision
– Arthrogram: Geyser sign: Injected dye leaks out of joint to decompress median nerve
through rotator cuff tear – Indications for surgery: numbness and tingling ± sensory
loss, weakness ± muscle atrophy, unresponsive to conservative
Treatment: measures
– Mild: “wear”: Non-operative: physiotherapy and NSAIDs – Complications: injury to median motor branch, palmar
– Moderate: “tear”: Non-operative but maybe steroid injection cutaneous branch or superficial transverse vascular arch, local
– Severe: “repair”: May require surgical repair: rotator cuff pain (pilar pain), scar
repair or acromioplasty
29. Stenosing Tenosynovitis (Trigger finger)
28. Carpal tunnel syndrome (CTS)
General:
Definition, Etiology, Epidemiology: – Definition: inflammation (not main feature) of synovium
– Definition: median nerve compressed by nearby anatomic causes size discrepancy between tendon and sheath/pulley
structures as it passes through the transverse carpal ligament (most commonly at A-1 pulley): locking of thumb or finger in
(flexor retinaculum). flexion/extension: thickening of the fibrous sheath at the base
– Etiology: of a finger or thumb leads to interference with “gliding of the
1. There is a median nerve entrapment at wrist where the tendon” and hence, inability to extend digit.
primary cause is idiopathic. – Etiology: idiopathic or associated with RA, diabetes,
2. Secondary causes: space occupying lesions (tumors, hypothyroidism and gout
hypertrophic synovial tissue, fracture callus, and osteophytes), – Clinical Feature:
metabolic and physiological (pregnancy, hypothyroidism, and 1. Thumb, ring and long fingers most commonly affected
RA), infections, neuropathies (associated with diabetes mellitus 2. Patient complains of catching, snapping or locking of
or alcoholism), and familial disorders affected finger
3. CTS may also be due to job/hobby related repetitive 3. Tenderness to palpation/nodule at palmar aspect of MCP
trauma, especially forced wrist flexion over A1 pulley
– Epidemiology: CTS affects females more than men (4:1) and 4. Women are 4 times more likely than men to be affected
it is the most common entrapment neuropathy. – Conservative treatment: NSAIDs, steroid injection, ƒ
surgical flexor tendon release, injections less likely to be
Clinical Features: successful in patients with DM or symptoms greater than 6
– There is a sensory loss in median nerve distribution i.e. radial months
3.5 digits

– Surgical treatment: incise A-1 flexor tendon pulley to permit Treatment:
unrestricted, full active finger motion – Rest, ice, NSAIDs, steroid injection
– PT: stretching, ultrasound
30. Hallux valgus (Bunions) – Orthotics with heel cup: to counteract pronation and
disperse heel strike forces
Mechanism and Epidemiology: – Endoscopic surgical release of fascia in refractory cases: spur
– Valgus alignment on 1st Metatarsophalangeal (MTP) (hallux removal is not required
valgus) causes eccentric pull of extensor and intrinsic muscles:
the great toe is deviated laterally at the metatarso-phalangeal 32. Achilles tendinopathy (Tendonitis)
joint.
– Reactive exostosis forms with thickening of the skin creating General:
a bunion – Mechanism: it is due to chronic inflammation (more due to
– Most often associated with poor-fitting footwear (high- degeneration) from activity or poor-fitting footwear. There
heels) but can be hereditary might also be a development of heel bumps
– It is 10 times more frequent in women (retrocalcaneobursitis).
– Physical Examination: pain, stiffness and crepitus with
Clinical Feature: ROM. There is also a thickened tendon and a palpable bump.
– Painful bursa over medial eminence of 1st metatarsal head – Treatment: rest, NSAIDs, gentle stretching, deep tissue calf
– Pronation (rotation inward) of great toe massage, orthotics, and open back shoes. Steroids should
– Numbness over medial aspect of great toe NOT be injected due to the risk of tendon rupture.
– Complications: Achilles tendon rupture (severe pain)
Treatment:
– Cosmetic and to relieve pain 33. Rheumatoid arthritis (RA)
– Non-operative first: properly fitted shoes (low heel) and toe
spacer Definition and Epidemiology:
– Surgical: osteotomy with realignment of 1st MTP joint – Definition: chronic, symmetric, autoimmune, systemic
inflammatory disorder that may affect many tissues and
31. Plantar fasciitis (Heel Spur Syndrome) organs, mainly synovial (synovitis with pannus formation)
joints: erosive synovitis of peripheral joints (i.e. wrists, MCPs,
Mechanism and Epidemiology: MTPs).
– It is due to repetitive strain injury causing microtears and – Epidemiology: RA affects 1% of adult population (F>M).
inflammation of plantar fascia: causing an inflammatory The age of onset is 20-40 years. It is associated with HLA-
process at the plantar fascia, the connective tissue at the DR4/DR1 association (93% of patients have either HLA type)
bottom of the foot (anterior part of calcaneus).
– It affects mostly females Etiology and Pathophysiology:
– Plantar fasciitis is common in athletes (especially runners) – RA is an autoimmune disorder with unknown etiology.
but it is also associated with obesity, DM, seronegative and – The hallmark of RA is hypertrophy of the synovial
seropositive arthritis. membrane. There is an activated rheumatoid synovium
(pannus) that grows into and over the articular surface
Clinical Feature: resulting in destruction of articular cartilage and subchondral
– There is morning pain and stiffness and an intense pain bone.
when walking from rest that subsides as patient continues to
walk. Diagnostic Criteria – ARA: 4 must be met:
– Other findings include swelling and tenderness over the sole – Morning stiffness
– The spur is greatest at medial calcaneal tubercle and 1-2 cm – At least 3 joints involved
distal along plantar fascia – Hand – at least one area in wrist, metacarpal or PIP
– Pain is also seen with toe dorsiflexion (stretches fascia) – Symmetrical
– Rheumatoid nodules
Diagnosis: – Rheumatoid factor
– Plain radiographs should be taken to rule out fractures – Radiological changes typical for RA
– Exostoses (heel spurs) can often be seen at the insertion of – Destruction of joint cartilage and narrowing cartilage space,
fascia into medial calcaneal tubercle sometimes localized erosion in bone ends
– The spur is reactive to inflammation, but does not cause the
pain

Clinical Feature: Diagnosis:
– Joints become swollen, tender, warm, and there is morning – Biopsy: monosodium urate crystals in synovial fluid/tophus
stiffness greater >1hr. with polarized light microscopy;
– There is usually a polyarthritis (symmetrical), primarily in – Blood tests: hyperuricemia, ESR, WBC
– X-rays: may show tophi as soft tissue swelling, punched-out
small joints of hands, feet, and cervical spine (larger joints like
lesions
shoulder and knee can also be involved).
– The joint involvment can lead to loss of movement and
erosion of joint surface causing deformity and loss of function. Treatment:
– Specific deformities: ulnar deviation, boutonniere deformity, – Acute gout: NSAIDs: high dose, then taper as symptoms
swan neck deformity, and Z-thumb improve; corticosteroids (intra-articular, oral or intra-muscular)
– Systemic: rheumatoid nodule over olecranon, calcaneal if renal, cardiovascular or GI disease and/or if NSAIDs
tuberosity & MCP jointss; fibrosis of lungs, renal amyloidosis, contraindicated or failed; colchicine within first 24;
atherosclerosis, MI, stroke, episcleritis, and anemia allopurinol can worsen an acute attack (therefore do not start
during acute flare)
Diagnosis: – Chronic gout: avoid foods with high purine content (e.g.
– X-ray, USG for synovium (color Doppler shows vascular visceral meats, sardines, shellfish, beans, peas); allopurinol.
signs in synovitis),
– MRI;
– Blood tests: rheumatoid factor, ESR, CRP, CBC, renal
function, liver enzymes, ANA Clinical Tests
1. Clinical Tests in Orthopedics – Not All Though

Treatment:
– Goals: alleviate current symptoms and prevent future
destruction of joints Ott Test:
– NSAIDs, steroids, –
– Disease modifying anti-rheumatic drugs (DMARDs):
methotrexate; antiTNF (etanercept), monoclonal antibiodies
Bragard’s Test:
–
– Other: weight loss and orthotics
Thomas’ Test:
34. Gout (Podagra/Rich Mans Disease) –
Definition, Etiology, and Pathogenesis: McMurray’s Test:

– Definition: derangement in purine metabolism resulting in –
hyperuricemia; monosodium urate crystal deposits in tissues
(tophi) and synovium (microtophi). Big toe (1st metatarsal Appley’s Test:
phalangeal at base) is commonly the first place to be affected. –
– Etiology and Pathogenesis: sources of uric acid: diet and
Derbolowsky Sign:
endogenous sources; overproduction, renal undersecretion
–
(most common), genetics, medical conditions (obesity, DM,
hypertriglyceridemia, and hyperthyroidism), drugs (diuretics). Schober’s Test:
–
Epidemiology and Clinical Feature:
– Epidemiology: Gout is most common in males >45 years Mennel’s Test:
old. It is extremely rare in premenopausal female. –
– Signs and Symptoms:
1. Recurrent episodes of acute inflammatory arthritis Valsalva Test:
2. Acute gouty arthritis: severe pain, redness, and joint –
swelling, usually involving lower extremities: attack will
subside spontaneously within several days to weeks; may recur Trendelenburg-Duschenne Sign:
3. Tophi: urate deposits on cartilage, tendons, bursae, soft –
tissues, and synovial membranes: common sites: first MTP, ear
helix, olecranon bursae, tendon insertions (common in
Lasegue Sign:
Achilles tendon) –
4. Kidney: gouty nephropathy and uric acid calculi
Soto-Hall Test:
–

Neer’s Test: References:
– – The Toronto Notes for Medical Students 2011
– Wheeless' Textbook of Orthopaedics
Lachmann’s Test: – Current Diagnosis and Treatment in Orthopedics, 4th
– – Slides
Anterior Draw Test:

–
Pivot-shift Test:
–
Golfer Sign:
–
Anvil Test:
–
Patrick’s Sign:
–
Posterior Draw Test:

–
Thompson Squeezed Test:

–
References
1. Reference List

Orthopedics - Brodno: Traumatology

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Review of Orthopedics – 2012/2013 – Brodno Szpital 1.0.

Edited By: Marsel Toplić 1

Definition and Mechanism:

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Indications: further soft-tissue coverage

Definition: soft-tissue injury.

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12. Thumb fractures (incl. I metacarpal) Subtypes:

13. Boxer’s fracture

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15. Colles fracture 17. Nightstick fracture

Definition and Epidemiology: Definition, Symptoms, and Treatment:

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Clinical Feature: Epidemiology, Diagnosis, and Complications:

Treatment: Types – Mayo Classification:

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Treatment: Epidemiology and Mechanism:

23. Elbow dislocation Classification:

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Mechanisms and Clinical Feature: Anterior Dislocation:

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Anatomy and Incidence: General about Fractures of Calcaneus:

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35. Achilles tendon rupture Anatomy and Incidence:

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41. Patellar fractures Clinical Features and Diagnosis:

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Definition and Mechanism:

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Clinical Feature and Diagnosis: Use:

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Cystic Lesions: Bone Metastasis:

Osteosarcoma: 10. Osteoporosis

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21. Ganglion cyst

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Definition, Etiology, and Clinical Feature: 26. Shoulder joint instability

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1. Clinical Tests in Orthopedics – Not All Though

Definition, Etiology, and Pathogenesis: McMurray’s Test:

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Anterior Draw Test:

Posterior Draw Test:

Thompson Squeezed Test:

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