Orthopedics 2

fractures of bone

reduction and internal fixation of fracture to allow intramembranous healing

• used in fractures around joints as adjuvent 
• maintain alignement 
• do not resist rotation or bending

thicker than kirschner wires

• fractures of long bones
• minimally invasive 
• allows compressive forces to stimulate bone healing

• used in articular fractures 
• maintain alignement 
• transmit forces bypassing fracture site

• prevent axial displacement of fracture fragments 
• e.g. malleuolus

have oval shaped screw holes so that when screw in the ends are brought together

transmit forces bypassing fracture site

used when there are multiple fragments in the fracture

• placed perpendicular to a fracture
• screws ends of fracture back together

Less invasive stabilization system

minimally invasive percutaneous plate osteosynthesis

scaphoid fracture

intertrochanter neck of femur

pertrochanter neck of femur

proximal humerus

distal femur

distal tibia

condylar fracture of tibia

intertrochanter

condylar fracture of femur

lower tibia

• 1. hematoma – fibrin clot
• 2. inflammation – granulation tissue
• 3. soft callus – within 2 weeks
• 4. hard callus – type 2 collagen (cartilage) --> type 1 collagen (bone)
• 5. remodelling

• small amount of strain – internal fixation
• intramembranous healing / haversian remodeling

• higher amount of strain – cast, rod, external fixation
• endochondral ossification (healing through cartilage formation)
• initial periosteal callus
• later medullary callus

• decreased strain on fracture site + healing tissue 
• stability 
• diminished fracture gap 
• allows primary / direct bone healing (no callus)

• open reduction internal fixation 
• serious fractures

• closed reduction internal fixation 
• condylar fracture of humerus in children

• infection 
• stiffness / loss of range of motion
• non union / mal union 
• damage to muscles / nerves 
• arthritis / tendonitis 
• chronic pain 
• compartment syndrome 
• deformity

• bone implants + external bearing frame 
• load is transfered from bone to fixation frame 
• when callus begins to consolidate transfer load back onto bone

• open fractures 
• soft tissue damage 
• ustabel fractures 
• pelvic fractures 
• fractures complicated by infection / non union
• arthrodesis

• artificial induction of joint ossification so that it will no longer move 
• used in untreatable joint pain

• pins into bone
• external rings stabilized between each other 
• can also be used to lengthen by increasing distance between rings
• use 3D computer modeling to determine placement of pins etc.

• pins into bone
• external rings stabilized between each other 
• can also be used to lengthen by increasing distance between rings

• pin tract infections 
• pin lossening / breakage 
• poor placement of fixator

• no casting - inspection 
• miantains length 
• stabilized distantly from fracture

• chronic, intermittent pain affecting joints and connective tissue 
• systemic inflammatory disorders

occurs when articular cartilage is worn down / damaged

• autoimmune disease of the joints
• RF

• bamboo spine - ossification of intervertebral discs 
• ANCA

• multiorgan autoimmune disease
• ANA

• remission + maintenance - steroids + NSAIDs
• preserve joint function + prevent deformities - physiotherapy + splinting 
• repair damage - surgery

synovectomy - pain releif + decreases inflammation

• tendon lengthening 
• tendon repair 
• arthrodesis

arthroplasty - reconstruction / replacement of joint

• extensive debridement of femoral head 
• complications - bone shortening + disturbances in gait

reshape joint + add prosthetic disc

replace with prosthetic

• routine blood tests 
• X ray 
• ECG
• prophylaxis of venous thrombosis 
• antibiotics 
• autologous blood transfusions

• cosmetic or functional
• dental 
• facial 
• larynx / trachea 
• breast 
• amputation 
• disarticulation

artificial device that replaces a missing body part from trauma, infection, congenital or surgery

hold patients limb like glove

• hydraulic cylinders control knee flexion 
• microprocessors measure speed psoition etc.

direct structural and functional connection to existing bone

• device that supports / corrects function of a limb or torso
• cannot correct deformity - joint must be able to be positioned passively

device used to control, limit or immobilize a body segment

• restrict movement 
• assist movement 
• decrease weight bearing
• protect from injury

• decrease weight bearing 
• knee arthritis

restrict movement to prevent injury

severe arthritis / osteoarthritis

cervical brace

• back brace - scoliosis, kyphosis 
• cervico - thoraco - lumbo - sacral

• back brace - scoliosis, kyphosis
• thoraco - lumbo - sacral

• 15-30° dorsiflexion 
• except in carpal tunnel syndrome - neutral

90° ventro-medial flexion

• abduction 
• 15-30° dorsiflexion
• thumbs up kind of position

• static brace
• prevent / correct contractures 
• promote soft tissue stretching 
• passive ROM

• static brace
• immobilization

• static brace 
• immobilization
• recent surgery / inflammation

• maintain joint in semiflexion 
• allows more flexion but not extension
• contractures, burns, fractures

• shoulder straddle suspends forearm 
• arm weakness (SCL etc.)

• prevents flexion 
• spasticity

system of springs that assist in finger extension but allow finger flexion (against spring force)

• bichannel adjustable ankle locking 
• like a sock that has artifical ankle joint that can be set to certain flexion
• stroke, head trauma, spinal injury etc.

• ankle foot orthosis 
• plastic moulded sock like shell that maintains foot from plantarflexion (footdrop)

• knee ankle foot orthosis 
• like thigh length sock with adjustable knee and ankle joints 
• maintains foot from plantarflexion 
• quadriceps weakness, hamstring spasticity

• inject fluid into joint to allow better visualisation 
• insertion of small camera through small incision 
• insertion of small specialized equipment through separate small incision

• knee
• hip 
• shoulder
• wrist
• spine

• not osteoarthritis
• meniscal repair
• chondral defects

femoro-acetubular impingement

• subacromial decompression 
• acromioclavicular osteoarthritis
• rotator cuff tears
• frozen shoulder (adhesive capsulitis)
• chronic tendonitis
• removal of loose bodies and partial tears of the long biceps tendon
• SLAP lesions
• shoulder instability

• repetitive strain injury 
• fracture of the wrist

• best modality for joint visualization 
• minimally invasive 
• one day surgeries 
• little time imbolised / in physiotherapy 
• barely visible scars 
• can be done under local anesthesia

• teres minor
• supraspinatus 
• infraspinatus 
• subscapularis

• abduction - 180°
• external rotation - 90°
• internal rotation - 100-120°

• gleno-humeral joint (scapula + humerus) - ball and socket 
• sterno-clavicular joint - gliding joint 
• acromio-clavicular joint (scapula + clavicle) - diathroidal joint 
• scapulo-thoracic joint

irritation and pain when arm is raised over 90° (acromion rubs on tendon / bursa)

• stages of shoulder impingement 
• stage 1 - under 25 years old, acute inflammation, reversible 
• stage 2 - 25-40 ears old, tendon fibosis, operation 
• stage 3 - over 40 years old, osteophytes on acromion, surgery

• superior labrum, anterior to posterior
• tear of the shoulder joint above middle of socket
• usually after dislocation

• tear of the shoulder joint below middle of socket 
• usually after dislocation

• SLAP classification I-IV
• I - labrum + biceps frayed 
• II - detached biceps 
• III - bucket handle tear in labrum 
• IV - bucket handle tear with detached biceps

• SLAP lesion types V-VII
• V - bankart lesion 
• VI - superior tear 
• VII - capsular injury

• head of humerus forced out of shoulder socket 
• once dislocation happens once, the shoulder is vulnerable to repeat

• red-red - in highly vascularized area at periphery (meniscal suturing)
• red-white - in less vascularized area 
• white-white - no vessels in this area (meniscotomy)

• outside in 
• inside out 
• all inside (absorbable pins)

cracks form in the articular cartilage and the underlying bone

• drilling / microfracturing - remove small defects 
• autologous chondrocyte implantation 
• mosaic plasty (take from non weight bearing parts)- not in children

• repairing defects using allotransplants 
• uses synthetic materials

• excision of joint surfaces --> gap formed 
• place deep fascia / plastic lamina in gap for better mobility 
• gap closes with fibrous tissue

only one joint surface is replaced with a synthetic material

• completely replace both joint surfaces 
• increased risk of sepsis

• usually in hip and knee 
• after fracture of head of femur 
• for pain releif

• fills free space between prosthesis and bone 
• absorbed forces so it doesnt detroy bone underneith it 
• made from plexiglass powder + ATB + liquid --> dough --> solid in 24 hours

• examine newborn at 
• 0 minutes 
• 3 minutes 
• 6 minutes 
• 1 week 
• every 2 months for first year 
• 12 months 
• 18 months 
• 3 years 
• every 2 years afterwards

• passive and active movement 
• neurological examination
• spine 
• legs 
• feet 
• arms
• hands

• confirmation of subluxation 
• dysplasia of cartilagenous acetubulum

• examine quiet and relaxed newborn 
• subluxation or dislocation of hips 
• asymmetry - skin fold, length, position of knee

• congenital hip dysplasia 
• sign of dislocation 
• feet flat on table, knees and hips bent 
• one knee looks higher than the other

• congenital hip dysplasia 
• dislocation of femur 
• flex hips and slowly abduct
• limited abduction / asymetry

• congenital hip dysplasia 
• unstable hips, NOT dislocated hips 
• thumb on lesser trochanter and fingers on greater trochanter (grab head of femur), adduct and push backwards, slowly abduct 
• feel subluxation

• congenital hip dysplasia 
• dislocated hip 
• flex knee and grab head of femur, abduct and lift femur
• feel sliding in acetubulum

• congenital hip dysplasia 
• bowing of legs 
• talipes equinovarus (club foot)
• calcaneo-valgus 
• metatarsus adductus

• Madelung deformity - deformity of radius + dislocation of ulna 
• Clavicle fracture - birth trauma 
• Brachial plexus injury
• numerical abnormalitis in digits

• hyper-kyphosis 
• hyper-lordosis 
• scoliosis 
• free movement 
• herniation of disc at L5 --> radiating pain

• herniation of L5 intervertebral disc 
• lie on back, passively lift straight leg 
• pain

• cation when walking - pain 
• limping 
• trendelenburg gait (hips)

• weakness of abductors of hip (gluteus medius + minimus)
• stand on one foot 
• see fall of opposite hip

• anterior iliac spine + malleolus 
• umbilicus + medial malleolus 
• indirect - level of pelvis (use lift block)

• inspection - flat / swollen / muscle wasting 
• attitude - arm held to chest
• palpation 
• movement

• abduction - 180°
• extension - 45°

• shoulder examination 
• 1. touch opposite shoulder 
• 2. touch upper back + stretch 
• 3. touch lower back + stretch

• inspection 
• attitude 
• palpation
• motion 
• Pattelo-femoral examination
• anterior cruciate ligament 
• posterior cruciate ligament
• collateral ligaments - valgus / varus
• meniscus

• flexion - 135°
• extension - 10°

• Quadriceps femoris muscle angle 
• valgus or varus 
• slight knee flexion (so not locked)
• angle between anterior iliac spine to patella and tibial tubercle and patella

increased fluid in supra-patellar pouch

• test anterior cruciate ligament 
• push knee anteriorly and posteriorly (up and back)

• test anterior cruciate ligament
• patient lies on back with knee half bent and foot flat on table 
• pull knee towards self

• test anterior cruciate ligament 
• patient lies on back 
• start with knee straight, internally rotate, then bend knee

• posterior cruciate ligament
• patient lies on back with knee half bent and foot flat on table 
• push knee towards patient

• posterior cruciate ligament
• patient lies on back, doctor lifts legs to 90° and compares tibial tuberocities of both knees

• patient lies on back 
• doctor lifts leg with bent knee and turns leg inwards (varus force - lateral meniscus) or outwards (valgus force - medial meniscus)
• doctor extends knee slowly and feels for any popping etc.

• patient lies on stomach with knee up at 90°
• compression test - doctor pushes down on foot and rotates leg 
• distraction test - doctor pulls on foot and rotates leg

• inspection - length, symmetry, allignement, swlling 
• movements

• flexion 
• extension 
• abduction 
• adduction 
• internal rotation
• external rotation

• weakness of abductors of hip (gluteus medius + minimus)
• stand on one foot 
• see fall of opposite hip

• psoas syndrome / hip flexion contractures 
• patient lies on back and brings one knee to chest while keeping other leg straight 
• other hip flexes without straight leg - iliopsoas 
• hip comes into abduction - tensor fasciae latae 
• knee extension - rectus femoris 
• lateral rotation of tibia - biceps femoris

• iliotibial band tightness
• patient lies on side, support knee and bring hip into extension with knee still bent 
• let go of knee, it should drop

• sacroiliac joint 
• patient lies on back then bring leg into FABER - flexion, abduction, external rotation (like ballet stand)

• genetic 
• drugs during pregnancy and early development 
• infections during pregnancy and early development 
• trauma during birth and afterwards 
• anoxia / compresion in utero

• oligodactyly - fewer digits 
• polydactyly - more digits
• polysyndactyly - when digits are fused

24-36 days

• lacking / shrunken limbs
• thalidomide famous for it

• partial / total absence of a bone 
• fibular - short deformed leg + club foot 
• tibial - short extremity in supination + dislocation of femur 
• radial - shorter forearm + deviated wrist

• hands + feet attached to abbreviated arms + legs 
• caused by thalidomide

• rhizomelia - proximal shortening 
• mesomelia - central shortening 
• acromelia - distal shortening

complete / partial amputation due to constriction by amniotic sac

• multiple contractures + muscle fibrosis 
• unable to perform flexion / extension

• long fingers, toes and limbs 
• abnormal spine curvature + protrusion of sternum 
• increased flexibility 
• early osteoarthritis

• severe dorsiflexion of foot (upwards) 
• forefoot abducted (outwards)
• common

• intrauterine positioning 
• muscle imbalance (meningocele)

• stretching 
• casting 8-10 weeks

• flexible flat foot 
• seen when child first starts to walk (14-18 months)

• compensation in posture for flat foot 
• scoliosis
• valgus knees (+ osteoarthritis)

• within first decade spontaneously develop normal arch 
• casting 
• Grice procedure

allows arthrodesis (fusion) of subtalar joint

• rigid flat foot - neonate with foot almost turned inwards 
• dorsiflexion of forefoot (up)
• equinus position of hindfoot (like horse) 
• abduction of foot (outwards)

• surgery before child starts to walk 
• soft tissue release
• tendon lengthening 
• reduction of talo-navicular joint

• rigid and painful flat foot in older children 
• fusion of tarsal bones 
• talo-calcaneal 
• calcaneo-navicular

triple arthrodesis

• fusion of joints 
• talo-calcaneal
• talo-navicular
• calcaneo-cuboid

increased arch in foot

• plantar release 
• osteotomy - cutting bones 
• tendon transfers 
• triple arthrodesis - fusing bones

• diagnosis of pes cavus 
• mark angle of foot to ankle 
• place a block on lateral aspect of foot to see if the angle becomes more straight

congenital club foot

• more common in boys 
• mechanical theory - increased intrauterine pressure 
• ischemic theory - ishcemia of calf muscle 
• genetic theory 
• secondary causes - polio, spina bifida, muscle imbalance

• 1. plantar flexion of ankle - equines 
• 2. subtalar joint inverted inwards - varus 
• 3. forefoot adduction - inwards 
• 4. internal rotation of tibia 
• 5. pes cavus - increased arch

• lateral view - talocalcaneal angles <35°
• anterior posterior view - talocalcaneal angle <20°

• splinting 2-3 days after birth 
• 1. forefoot adduction 
• 2. forefoot suppination 
• 3. equinus

• method of correcting club foot 
• series of long term leg plasters 
• achilles tendon release 
• external rotation of feet ins pecial boots for 2-3 years 
• 1. cavus 
• 2. adductus 
• 3. varus 
• 4. equinus

• soft tissues release 
• tendon lengthening at 6-9 months 
• talectomy - remove 
• calcaneal osteotomy - split 
• triple arthrodesis

• flat foot - abducted forefoot + valgus hindfoot 
• congenital / aquired 
• flexible / rigid

• posterior tibial tendon dysfunction 
• hypovascularity 
• overload (obesity) 
• inflammatory disorders 
• trauma 
• neuropathy 
• tindinosis

• assesed with single limb heel rise 
• 1. pain with minimal / no loss of tendon strength 
• 2. dynamic deformity visible 
• 3. chronic dysfunction + lengthening of posterior tibial tendon + calcaneal subluxation 
• 4. fibro-talar arthrosis

use light box to asses points of load bearing on foot

• casting / orthosis - corrective shoes with arch support 
• NSAIDs 
• physio

• arthrodesis - subtalar / triple 
• osteotomy - calcaneal 
• soft tissue procedures - lengthen achilles tendon / lateral collumn

long standing pes planus

• caused by high energy mechanism 
• medial (75%) - locked in supination 
• lateral (25%) - locked in pronation

• closed reduction 
• non weight bearing caste 4-6 weeks

• actual - different bone lengths (after fracture, damage, growth plate, congenital)
• virtual - problem in pelvis / upper leg means it looks a different length

• prosthetics - heel / shoe 
• surgical prolongation (calo-taxis prolonges at a healing callus)
• surgical abbreviation

• coxa vara 
• coxa valga

• neck of femur angle smaller than 120°
• leg appears shorter 
• brings legs inwards together 
• trendelenburg gait + increased lumbar lordosis 
• therapy - osteotomy

• neck of femur angle greater than 135°
• usually slipped epiphyesis of femoral head

• varus - bow leg (boys)
• valgus - knock-knee (girls)

• bow legged (boys)
• also see internal rotation + pes planus 
• premature arthritis in medial compartment 
• surgical therapy

• dysarthosis + growth impairment of proximal tibia 
• rare

• knock-knee (girls) 
• physiological until age 10 
• lateral compartment osteoarthritis 
• surgical therapy

• disease of hip joint causing instability 
• present at birth 
• due to excess stretching of posterior hip capsule 
• usually on left 
• more common in breach births

• galaezzi test - feet flat on tabel knees bent 
• passive hip abduction test 
• barlow test - hold hips and push backwards (subluxation) 
• ortolani test - hold hip and lift (luxation)
• ultrasound

• not before 3 months (femur not ossified yet) 
• good after 6 months 
• arthrogram - inject contrast into joint

• used before 6 months (before ossification) 
• 2 weeks, 3 months, 6 months 
• alpha angle - between acetubular roof line and mid femur 
• beta angle - between inclination line (perpendicular to acetubular roof line) and mid femur

• acetubular dysplasia 
• subluxation - incomplete contact between articular surfaces 
• luxation / dislocation

• 1. normal hip - nothing 
• 2. mild acetubular instability - treat if still present after 6 months 
• 3. unstable with possible dislocation - pavlik's harness 
• 4. reducible luxation of hip - Byrant's traction 
• 5. non-reducible luxation of hip - fmeoral osteotomy + triangle acetubular osteotomy

• forces abduction + flexion of hip 
• not used anymore

special nappies causing abduction + flexion of hips

• worn 2-3 weeks 
• hip flexion at 100° + unable to adduct 
• low risk of avascular necrosis

• method of closed reduction in luxation of hip 
• gently stretches soft tissue around hip and decreases forces in joint

• method of closed reduction in luxation of hip 
• 20 days 
• 1. hips flexed with straight legs (up) 
• 2. abduction to 50° (side)
• 3. casting for 3 months

• general anesthesia 
• flexion over 90°
• abduction 30-40°
• slight internal rotation

• immobilizes hips and thighs
• changed every 6 weeks 
• kept for 3-6 months

• older children 
• severe dysplasia with limping 
• severe leg shortening 
• high valgus of hip 
• subluxation of femoral head

• open reduction 
• femoral shortening osteotomy 
• suturing capsule tears

• cut shaft of femur + rotate + plate --> reduction 
• remove piece of iliac crest + place into pelvis above hip joint - salter osteotomy

• newborn coxitis --> pathological luxation 
• epiphysiolysis of femur in delivery 
• teratogenic luxation

• spica cast --> atrophy of muscles 
• pavlik harness --> skin irritation 
• forceful reduction / tension in soft tissue --> avascular necrosis of femoral head

• avascular necrosis 
• osteo-necrosis 
• bone infarction 
• ischemic bone necrosis 
• occurs in people under 50 years old

• trauma - femoral head 
• embolism 
• caisson disease - nitrogen bubbles in arteries 
• metabolic disorders 
• autoimmune 
• smoking - hip 
• alcohol
• pregnancy 
• idiopathic

• decreased blood suply 
• 12 hours - death of hematopoetic cells 
• 12-48 hours - death of bone cells 
• 5 days - death of fat cells 
• reperfusion --> osteoblasts + fibroblasts 
• causes bone collapse

• slow onset 
• limping / restriction of movement 
• local pain eventually 
• no outward visible signs

• I - demineralization + osteoporosis 
• II - fragmentation (fracture) 
• III - reparation - remodeling of necrotic area (in child)
• IV - definitive changes - shape and structure of bone

debridement + joint replacement

• osteonecrosis of head of humerus (shoulder)
• caused by corticosteroids, alcohol, radiotherapy

• osteonecrosis of capitulum of humerus (elbow)
• caused by trauma

• osteonecrosis of lunate (wrist) 
• caused by repetitive microtrauma in manual labor

osteonecrosis of proximal femural epiphysis (thigh)

• osteonecrosis of tibial tuberosity (shin) 
• caused in sports by overload of insertion of patellar ligament

• medial tibial condyl (knee)
• common in sickle cell disease

osteonecrosis of tarsal navicular (foot)

• osteonecrosis of calcaneal apophysis (heel)
• caused by overloading

• osteonecrosis of vertebral body 
• caused by trauma (elderly)

juvenile osteochondrosis of the spine

• morbus perthes / coxa plana 
• osteonecrosis of epiphysis of femoral head

• boys 4-10 years old 
• multifactorial 
• genetic influences 
• second hand smoking 
• low birth weight

• X ray 
• bone scan 
• MRI 
• arthrography

• mild intermittent groin pain 
• limp in child 
• limited hip motion 
• trendelenburg positive

• 1. non-specific effusion of joint + slight widening of joint space 
• 2. metaphyseal demineralisation + periarticular swelling 
• 3. dense necrotic ossification center 
• 4. collapse of head + increased width of neck 

varus deformity of head

• waldenstrom staging 
• catterall classification 
• herring classification

• initial 
• fragmentation 
• re-ossification 
• healing + remodelling

• 1. anterior epiphysis only 
• 2. anterior epiphysis + sclerosis 
• 3. most of epiphysis affected + loss fo structural integrity of head 
• 4. total head involvement + loss of structural integrity of head + socket

• height of lateral pillar of femoral head on AP x ray 
• A - full height 
• B - over 50% of height 
• C - less than 50% of height

• prevent epiphyseal collapse + miantain spherical head 
• 1. maintain femoral abduction 
• 2. maintain internal rotation

• looks like pavlik straps for adults 
• miantain hip in abduction

• can be with traction 
• pulls leg straight outwards

• performed when head of femur is at risk 
• pelvic osteotomy 
• femoral osteotomy 
• abduction rotation femoral osteotomy 
• cheilotomy - reshape femoral head

• slip of proximal femoral epiphysis (hip) 
• head of femur is held at more of an angle 
• dorsal + medial dislocation
• usually in left hip

• adolescent females 11-14 years old 
• adolescent males 13-16 years old (more common)
• mutlifactorial 
• genetics 
• testosterone --> epiphyseal closure 
• estrogen --> hyperlax joints 
• obesity - increased forces on femur

• prodromal symptoms - lower limb joint pain increased on walking, decreased range of motion
• affected hip in external rotation
• prefer legs crossed 
• abnormal gait - external rotation / trendelenburg 
• decreased hip motion 
• loss of internal rotation

• 1. <30° angle of neck of femur 
• 2. 30-60°
• 3. >60°

always surgical treatment

• fix with kirschner wire to prevent farther slipping 
• correction osteotomy - southwick, imhauser

• correction osteotomy for coxa vara 
• via small trochanter

• correction surgery for coxa vara 
• via interhumeral area

lateral curve of the spine

• congenital scoliosis - associated with malformation 
• idiopathic - infantile, juvenile, adolescent

• 0-10° - normal 
• 10-20° - rehabilitation 
• 20-40° - corset 
• >40° - surgery