ORTHOPEDICS

TRAUMA
STRAIN An injury of the musculo-tendinous unit. Grade1 (mild): non-traumatic tightening, pain on stretching. Grade 2 (moderate): + pop/snap with spasm. Grade 3 (severe): dramatic, often with audible snap/pop, then pain. SPRAIN A ligament injury. Ligaments stabilize joints by preventing abnormal motion. Grade 1: no laxity and good end point. Grade 2: laxity, but good end point. Grade 3: no end point, needs referral for repair within 5 days. Can evaluate with stress radiographs. Rehab with isometric exercises that are begun immediately. Goal is to re-establish strength and motion while protect from re-injury. Treatment of Strain/ Sprains: NSAIDs, consider muscle relaxer. PRICEMS Protection (padding and changes in technique to avoid further injury. Rest. Ice. Compression. Elevation. Modalities (U/S, electrical stimulation, heat)/ Meds (NSAIDs, steroid injections). Support (braces). Rehab to re-establish both strength and flexibility together. FRACTURE Fracture- soft tissue injury complicated by a break in the bone Nomenclature: Fracture, [closed/open], [completeness], [configuration], [displacement], [location], [laterality] I. Closed / Open not seen radiologically a. Closed intact skin over fracture b. Open soft tissue injury in the region of the fracture with exposure to the external environment How to detect an open fracture: 1. bleeding is not proportional to the size of the wound (bleeding from the marrow) 2. wound is over the fracture 3. bone seen 4. presence of fat globules Gustilo Classification of Open Fractures Type Definition Bacteria Management I Skin opening <1cm, quite clean, minimal muscle Gram (+) Debridement + Cefazolin contusion II Laceration >1cm, extensive tissue damage, Gram (+) & (-) Debridement + Cefazolin + Gentamicin flaps, or avulsion IIIA Extensive soft tissue laceration, adequate bone Gram (+), (-), & Debridement + Cefazolin + Gentamicin + coverage anaerobes Penicillin G IIIB Extensive soft tissue injusty with periosteal Gram (+), (-), & Debridement + Cefazolin + Gentamicin + stripping and bone exposure anaerobes Penicillin G IIIC Vascular injury requiring repair Gram (+), (-), & Debridement + Cefazolin + Gentamicin + anaerobes Penicillin G + Vascular repair Sample Chart Entry NPO now D5NR 1L X 8 ATS 3000 Units IM ( ) ANST & TeAna 0.5mL IM Cefazolin 1g IV LD ( ) ANST, then 1g IV q8 thereafter Gentamicin 240mg IV OD Penicillin G 4 Million Units LD ( ) ANST then 4 M units IV q6 thereafter OR Scheduling [Debridement, Vascular repair] II. Completeness a. Complete break in 4 cortices in at least 2 views (AP and lateral) b. Incomplete III. Configuration a. Transverse fracture line perpendicular to long axis of bone; caused by tapping injury b. oblique fracture line creates an oblique angle with long axis of bone; moment force c. spiral rotational / torsional stress; e.g. child abuse

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d. segmental in different parts of the bone e. comminuted - >2 breaks in part of the bone f. torus axial loading / compression. Usually in children: perosteum not broken, buckle fracture g. longitudinal h. green stick fracture with plastic deformity less than 3 cortices are affected;bend in the long bone Type Bone Involvement Other Description Management I Transverse physis In young children, growth arrest is Closed reduction / GA Cast immobilization II Through physis & unlikely, results in malalignment metaphysis III Through physis & Intraarticular Open reduction and fixation to align growth plate epiphysis IV Through physis, Results in migration & growth arrest metaphysic & epiphysis V Crush injury of the physis Growth arrest, usually not identified earlier, with complication rate, VI Injury to perichondrium Bridging / Angular deformity cartilaginous growth plate heals ~50% of the time SALTER: S=Slide,straight through the growth plate, Type 1, A= above, Type 2, L= Low to the growth plate, Type 3, T= Through the growth plate above and below, Type 4, ER= Erasing the growth plate, Type 5

Harris-Park growth arrest line seen on late radiography of minor injuries, transversely oriented IV. Displacement a. displaced - < 50% cortical contact b. minimally displaced c. undisplaced V. Location a. anatomic: proximal third, middle third, distal third b. physiologic: epiphysis, physis, metaphysic, diaphysis VI. Laterality left or right, not seen radiologically Supracondylar Fractures a. Extension anterior fracture b. Flexion posterior fracture When fracture is undisplaced, there is bleeding which accumulates within the periosteum Fat pad sign fat / marked lucency detected anterior &/or posterior to paper-thin bone (between coronoid & olecranon fossae); indicative of a fracture Gartland classification of supracondylar fractures Type Description Management I Incomplete & undisplaced Arm sling or LAPS II Complete & undisplaced, intact Closed reduction +/- pinning, LAPS periosteum A. with rotatory component B. without rotatory component III Complete & displaced Open / closed reduction with pinning on lateral side or open fracture site with Xpinning Garden classification of Femoral Neck Fractures I impaction II complete, undisplaced III complete, displaced without contiguous trabeculations IV complete, displaced with contiguous trabeculations Lange-Hansen Classification (Initial position direction of injury) a. supination adduction b. pronation abduction c. supination external rotation d. pronation external rotation Forearm Fractures Colle distal radius, dorsal Smith distal radius, volar

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Barton fracture/dislocation or subluxation in which the rim of the distal radius, dorsally or volarly, is displaced with the hand & carpus Chauffeur fracture radial styloid Monteggia proximal half of ulnar shaft & dislocation of radial head Galeazzi - dislocation of distal radioulnar joint Nightstick Fracture - fracture of ulnar diaphysis alone from a direct blow Management of Fractures A. Casting / Splinting Immobilize one joint above & one joint below Deforming forces in radio-ulnar fractures (fractures of necessity operate because closed reduction wont work) Location Deforming Forces Cast in Proximal third Supinator Supinated position Middle third Supinator + pronator teres Neutral (raise your hand position) Distal third Supinator + pronator teres + pronator Pronated position quadratus B. Debridement 4Cs of proper debridement 1. color beefy red 2. consistency firm 3. contractility 4. capacity of bleed C. Reduction should hold ragments in place 1. Closed reduction (under vocal anesthetic) 2. Open reduction a. Plating more rigid, load sparing: plates carries axial load, sparing the bone leads to delayed healing b. Intramedullary (IM) nailing w/ or w/o screws Nailing more stable & better biomechanically, load sharing: nail shares load with bone better healing; enhances blood supply by centripetal circulation Screws prevents rotation & tilting of nail; bone closer to joint is cancellous, hence requiring screws with bigger threads c. External fixation preferred if with open wound & infected d. Pinning also in closed reduction Acceptable reduction of supracondylar fractures: a. anterior humeral line should bisect or lie posterior to the capitulum b. intact figure of eight c. >30 angel of capitellum with humeral line at lateral view d. angle between humeral line & base of humerus (Bowmans angle) 82 5 at AP view D. Correction of malrotation with regard to radial fractures, check the following: a. radial styloid should be in the same plane as the radial tuberosity, but on opposite directions b. proper interdigitation at the fracture site c. no difference in the diameters of the apposed bone d. presence of the radial bow Fracture Healing Requires 8-12 weeks of healing Stages: a. Inflammatory 1-5 days b. Proliferative 5 days to 2 weeks c. Remodelling 2 weeks to 6 months Motion in joints squeezes synovial fluid during flexion Pt should do partial weight bearing activities after 1 day of open reduction if the pt is stable. Weight bearing is important in bone formation because disuse can lead toosteoporosis. Long bone fractures predispose pt to fat embolism Tibia has poor capacity to heal because it is subcutaneous with high chances of malunion Full weight bearing started at 6 weeks specially if patient is young Possible complications a. Limb length discrepancy b. Malunion (Fx not in the right position) c. Non-union (not healed at the specified amount of time) Hypertrophic ends of bone are broad Atrophic ends of bone are sharp e.g. penciling d. Post-traumatic arthritis e. Fat embolism (in long bone fractures may present as dyspnea) Golden period of surgical intervention Open long hand injury within 6-8 hours Hand injury within 12 hours Tendon repair within 10-14 days

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COMPARTMENT SYNDROME Sxs usually begin within a few hours of injury, may be delayed up to 64 hrs (6 Ps) a. Pulselessness (unreliable pulses, late sign) b. Pain (with passive stretching is an early sign, yet diminishes secondary to pressure ischemia) c. Pallor (if any arterial injury or in affected compartment) d. Paresthesias (discomfort out of proportion to injury and unrelenting, late sign) e. Paralysis (secondary to ischemia, late sign) f. Poikilothermy Causes: a. compartment size (crush, closure of fascial defect, application of exessive traction to fractured limb) b. contents (swelling, bleeding, extensive use of muscles in sz/ exercise/ tetany/ eclampsia, burns, venous obstruction) c. Externally applied pressure (tight cast/ dressing, lying on limb, pneumatic anti-shock garment, congenital bands) Leg a. Anterior tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tersius. Deep peroneal nerve sensory loss at 1st web space. Weakness of toe extensors, tibialis anterior. Pain on passive toe flexion. b. Lateral peroneus longus, peroneus brevis. Pain of active or passive eversion and inversion of the foot, superficial peroneal nerve (hypesthesia of lateral foot). c. Superficial Posterior gastrocnemius, soleus. Weakened soleus/ gastroc, pain with foot dorsiflexion. d. Deep Posterior tibialis posterior, flexor digitorum longus, flexor hallucis longus, poplitus. Posterior tibial nerve sensory loss (plantar surface), weakness of toe flexors and tibialis posterior. Pain on passive toe extension. Upper arm: a. Flexor/ Anterior Compartment sensory loss of ulnar & median nerves, weak biceps and distal flexors, pain on passive elbow extension. b. Extensor/ Posterior sensory loss of radial nerve (dorsum of hand), weakened triceps and forearm extensors. Pain with passive elbow flexion. Forearm: a. Dorsal Compartment weakened digital extensors, pain of passive digital flexion. 1. Abductor pollicis longus (APOL) Extensor pollicis brevis (EPB) 2. Extensor carpi radialis longus (ECRL) Extensor carpi radialis brevis (ECRB) 3. Extensor pollicis longus (EPL) 4. Extensor digitorum communis (EDC) Extensor indicis proprious (EIP) 5. Extensor digiti minimi (EDM) 6. Extensor carpi ulnaris (ECU) b. Volar Compartment sensory loss of ulnar/ median nerves (palm of hand), weakened digital flexors, pain on digital extension. Compartment Pressures: normal: <10mmHg from DBP. Abnormal: 10-30mmHg. Compartment Syndrome: >30mmHg or MAPCP <30-40mm. Tx: Fasciotomy if unequivocally positive clinical findings. If pt has an altered MS, is unreliable due to intoxication or has polytrauma with inconclusive physical findings--> check pressures. Fasciotomy if >30-40mmHg or if pressure 20mmHg below DBP or worsening clinical signs. If <30, monitor pressures serially along with clinical eval. MANGLED EXTREMITY SEVERITY SCORE (100% specific) Skeletal / soft-tissue injury 1 Low energy (stab; simple fracture; pistol gunshot wound) 2 Medium energy (open or multiple fractures, dislocation) 3 High energy (high speed MVA or rifle GSW) 4 Very high energy (high speed trauma + gross contamination) Limb ischemia (* Score doubled for ischemia > 6 hours) 1* Pulse reduced or absent but perfusion normal 2 Pulseless; paresthesias, diminished capillary refill 3* Cool, paralyzed, insensate, numb Shock 0 Systolic BP always > 90 mm Hg 1 Hypotensive but responsive to fluid challenge 2 Hypotensive not responsive to fluid challenge Age (years) 0 <30 1 30-50 2 >50 0-6 Probable viable limb, > 6 Increased risk of amputation

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ADULT
CHRONIC OSTEOMYELITIS Mostly hematogenous vs. direct spread Locus of minora resistencia blood goes to the area of low resistance Acute - ~2 weeks; presents as pain, fever, malaise Chronic - ~6 weeks; sudden drop of pressure, decreased pain, fever, malaise.Do serieal ESR (sEnsitive measures inflammation not infection) & CRP (sPecific) monitoring Etiology: Staphylococcus aureus most common organism in all age patients (90%). Direct trauma: Staph, Strep; Trauma to foot through shoe: P. aeruginosa; Hematogenous: Strep pneumo, H. influ type B, Hgb SS: Salmonella Risks: smoking, DM, extremes of age , chronic hypoxia, immune def, malignancy, malnutrition, RF, liver failure, alcohol abuse, corticosteroid therapy, arteritis, chronic lymphedema, extensive scarring, radiation fibrosis, venous stasis, major vessel compromise. S/s: warmth, swelling, pain, +fever, dec ROM, limp, h/o trauma. Draining sinus, open wound. Continuous bone pain, point tenderness and well-localized. +Pain at infection site with percussion of the bone away from the area of tenderness. Possible sympathetic effusion. Pathophysiology: Stasis Accumulation Acute Increase in pressure gets walled off (radio-opaque) abscess Rupture of cortex (cloaca) Periosteum (sudden drop of pressure, decreased pain) Sequestrum (dead bone with infection that is devoid of blood supply) Involucrum (shell of new bone formed by the peiostum that surrounds the sequestrum Draining sinus Types Type 1 (medullary): limited to the endosteum. Most hematogenous cases. Tx: Abx alone effective in 85%, if recalcitrant, then to surgery. Often can tx for 2-4weeks with PO Quinolones unless a child (need initial IV Abx). Type 2 (superficial): involves the bone surface. Decubital ulcers, venous stasis sores, skin breakdown (burns, trauma). Can progress to Type 3&4 in compromised host. Type 3: localized, but have medullary and superficial characteristic resulting in full thickness cortical sequestration, which requires removal of the nidus. Type 4: diffuse with unstable bone/limb. Often from infected nonunion, endoprosthetic infection, chronic sepsis, or progression of other types. SEPTIC ARTHRITIS Pus would adhere to the cartilage Emergency Endotoxins released by bacteria causes the inflammation Gold standard for diadnosis: Arthrocentesis (+) result in Gram staining Treatment: Debridment (joint kept in fixation, very sever pain in any movement within any range); for TB arthritis: fusion, splint, antiKochs NEOPLASMS Principal Questions 1. Where is the mass? 2. What is the size of the mass? Compare the lesion relative to the size of the affected bone 3. What is the tumor doing to the bone? Lytic, sclerotic, blastic 4. What is the bone doing to the tumor? Margins Permeative ill-defined bordersl aggressive Geographic bone walls off the tumor; slow-growing 5. What is the matrix? Osteoid radiologically: cloudlike or ill-defined amorphous densities with haphazard mineralization. This pattern is seen in osteosarcoma. Mature osteoid, or organized bone, shows more orderly, trabecular pattern of ossification. This is characteristic of the benign bone-forming lesions such as osteoblastoma. Mixed Chondroid - Radiologically, it is usually easier to recognize cartilage as opposed to osteoid by the presence of focal stippled or flocculent densities, or in lobulated areas as rings or arcs of calcifications. They are best demonstrated by CT. Whatever the pattern, it only suggests the histologic nature of the tissue (cartilage) but does not reliably differentiate between benign and malignant processes. 6. Is there a cortical break? If with soft tissue injury, then there is cortical break 7. Is there soft tissue involvement?

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Features of aggressive tumours Cellular atypia Frequent mitoses Extensive necrosis Significant vascularity Small amounts of immature matrix Grade (assessment of biological aggressiveness) G0 Histologically benign (well differentiated and low cell to matrix ratio). May be latent , active or aggressive benign lesions G1 Low grade malignant (few mitoses, moderate differentiation and local spread only) G2 High grade malignancy (frequent mitoses, poorly differentiated and frequent mitoses) Site (anatomic setting of the lesion) T0 Confined within its capsule (does not extend beyond the bounds of the compartment of origin, may be distorted but remains intact) T1 Extra capsular extension but contained within the anatomic compartment (eg cortical bone, joint capsule or fascia) T2 Extending beyond compartmental barriers (spreads beyond fascial plane without longitudinal containment) Metastasis (nodal or blood borne tumour spread) M0 No evidence of regional or distant metastases M1 Regional or distant metastases evident Age Most common benign lesions Most common malignant tumors 0 - 10 10 - 20 simple bone cyst, eosinophilic granuloma non-ossifying fibroma, fibrous dysplasia, simple bone cyst, aneurysmal bone cyst, osteochondroma (exostosis), osteoid osteoma, osteoblastoma, chondroblastoma, chondromyxoid fibroma enchondroma, giant cell tumor Osteoma Ewing's sarcoma, leukemic involvement, metastatic neuroblastoma osteosarcoma, Ewing's sarcoma, adamantinoma

20 - 40 40 & above

chondrosarcoma metastatic tumors, myeloma, leukemic involvement, chondrosarcoma, osteosarcoma (Paget's associated), MFH, chordoma

Diagnostics 1. ESR sensitive measure of inflammation; goes up later, decreases in 2-3 weeks but does not decrease with improvement of infection 2. CRP specific measure of acute inflammation; peaks in 2-3 days, decreases in 10 days with resolution of inflammation 3. Alkaline phosphatase measure of bone formation, significant if 3-4X elevated 4. MRI important for staging 5. Bone scan or skeletal survey for metastasis 6. Biopsy aspiration, tru-cut, open Therapeutics 1. Excision of mass a. Intralesional - leaves macroscopic tumour, not therapeutic; within the bounds of the mass, for benign lesions, curette the mass b. Marginal through the reactive zone pseudo-capsule of tumour, residual extensions or satellites, controls non-invasive benign tumours c. Wide - excise tumour, reactive zone and cuff of normal tissue, skip lesions left; with 2-3 cm cuff of normal tissue d. Radical - removal of entire compartment or compartments, distant metastases left; disarticulation 2. Limb salvage involves excision & reconstruction (autograft, allograft, isograft, xenograft) 3. Amputation 4. Post-op chemotherapy methotrexate, doxorubicin, cisplatin OSTEOSARCOMA Primary tumor arising from bone and producing bone with variants depending on the appearance of the prominent cell type Male : Female 2:1 Peak incidence 10 - 20 years, with a second peak at 50 - 70 years (80% less than 30 and those more than 40 years usually secondary to Pagets) Commonly seen at the axial skeleton proximal to the knees and elbow joints Location: Distal femur (32%), proximal tibia (16%), proximal humerus Codmans triangle, sunburst pattern EWINGS SARCOMA Lytic lesion with calcified periosteal layering (onion skin) TKO: Twenty years or younger, Knee, Onion Skin MULTIPLE MYELOMA Most common primary malignant bone tumor METASTASIS Usual primaries: Breast in women, lung, thyroid, prostate, kidney

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FEMORAL NECK FRACTURES Usually in the elderly Parts of the femur from proximal to distal 1. femoral head 2. femoral neck a. subcapital b. transcervical c. basicervical if fractured, has best prognosis 3. greater trochanter 4. lesser trochanter 5. subtrochanteric area (5cm below the superior margin of the lesser trochanter) isthmus narrowest portion of the femoral canal intertrochanteric fracture extracapsular femoral neck fracture intracapsular test for pelvic obliquity TLL and ALL Synovial Ring Blood Supply 1. medial circumflex artery (from deep femoral artery) 2. lateral circumflex artery (from deep femoral artery) 3. medial epiphyseal artery supplies inferior part of femoral head 4. lateral epiphyseal artery supplies superior & anterior part of femoral head Management Apply traction then pinning if <65 y.o.; do arthroplasty if >80 y.o. May save femoral head by using pins / screws / plates / bone cement / antibiotic-laden spacer (40g bone cement: 2.4g heatstable and water-soluble antibiotic) Replacement: a. Total hip arthroplasty replace head & acetabulum b. Partial hip arthroplasty replace head only Complications: avascular necrosis, poor healing, non-union OSTEOPOROSIS Seen as radiolucency with thinning out of the cortices Medical treatment 1. Calcium supplements 2. Estrogen prevents bone resorption of calcium by osteoblastic stimulation 3. Low-dose parathyroid hormone induces negative feedback ( transfer of calcium from bone to blood) to restimulate bone formation PATHOLOGIC FRACTURE Caused by normal stresses applied to normal bone; with predisposing factor CRP, ESR, Alk phos

PEDIATRICS
Difference between pediatric & adult patients Bone still growing in children In children, ligaments are stronger than bones Children have hyperlaxity of joints For elbow injuries: elbow dislocation in adults, supracondylar in children Pediatric Milestones 4 months turn around 6 months crawl 9-10 months stand on their own 12 months first step, broad-based gait Closure of Physis in Different Bones C Capitellum 2 y.o. R Radial head 4 y.o. I Internal epicondyle 6 y.o. T Trochlea 8 y.o. O Olecranon 10 y.o. E External epicondyle 12 y.o. Collagen Type I skin, tendon, ligaments & bone Collagen Type II Hyaline cartilage

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Congenital abrupt disruption in embryonal development Developmental partial disruption; progressive defect ORahilly 1. Terminal distal parts, e.g. aphalangia 2. Intercalary before the distal, e.g. phocomelia (flipper limbs 3. Para-axial 2-bone portions, as in radio-ulna, congenital absence of the tibia Most common polydactyly, syndactyly Growth plates A. Physis horizontal, stress-riser B. Epiphysis spiral Epiphyseal Growth Plate 1. Zone of reserve cartilage - Typical hyaline cartilage with chondrocytes Cartilage would store lipid (proteoglycans) Lysosomal storage Gauchers disease 2. Zone of proliferation - Cartilage cells undergo successive mitotic divisions to form columns of chrondocytes Matrix: Inorganic (calcium hydroxyapatite) and Organic (Collagen tensile strength, Proteoglycans compressive strength) Longitudinal growth 3. Zone of maturation - Cell division stopped, chondrocytes increase in size 4. Zone of hypertrophy Chondrocytes greatly enlarged and vacuolated; Matrix becomes calcified Cartilage Bone Cartilage would store lipid (proteoglycans) a. Zone of provisional calcification b. Zone of cartilage degeneration chondrocytes degenerate & lacunae of calcified matrix invaded by ostogenic cells & capillaries Fractures which are absolute indications of surgery for children 1. Supracondylar 2. Medial condyle 3. Lateral condyle 4. Medial head 5. Femoral neck CLUB FOOT Talipes equinovarus Clubfoot can be classified as (1) postural or positional or (2) fixed or rigid. Postural or positional clubfeet are not true clubfeet. Fixed or rigid clubfeet are either flexible (ie, correctable without surgery) or resistant (ie, require surgical release). Measurement Normal Foot Clubfoot Tibiocalcaneal angle 60-90 on lateral view >90 (hindfoot equinus) on lateral view <25 (hindfoot varus) on lateral view, Talocalcaneal angle 25-45 on lateral view, 15-40 on DP view <15 (hindfoot varus) on DP view None (forefoot supination) on lateral view, Metatarsal convergence Slight on lateral view, slight on DP view increased (forefoot supination) on DP view DEVELOPMENTAL DYSPLASIA OF THE HIPS broad spectrum of conditions characterised by instability of the hip with subluxation or dislocation due to acetabular or femoral dysplasia. Females more than Males, Siblings of affected children: 10 times increased risk of DDH, 60% left, 20% right and 20% bilateral Ortolanis test - the contralateral hip is held still while the thigh of the hip being tested is adducted and gently pulled anteriorly. +if get the sensation of instability or hear a clunk (due to a dislocated hip reducing into the acetabulum). High pitched clicks are normal. (Out = Ortolani) Barlows test - adducting the hip while pushing the thigh posteriorly. (+) if the hip dislocates out of socket and confirmed by doing the Ortolani to reduce the dislocation (push Back = Barlow) Galleazzi sign - the affected limb short in the thigh when the knee is flexed to 90o with the hips flexed to 45o and the heels at the same level LEGG-CALVE-PERTHES DISEASE Osteonecrosis of the proximal femoral epiphysis in a growing child caused by poorly understood non genetic factors Male : Female 4:1; Onset usually 2 - 12 (the majority are 4 - 8 and mean 7 years); ~ 10 - 12% are bilateral Birth weight usually lower than normal children; Skeletal age often delayed Pathophysiology: Alteration in blood supply to femoral head with fetal supply from metaphyseal vessels, lateral epiphyseal vessels running in the retinaculum up the neck and small supply from the ligamentum teres. Metaphyseal supply gradually decreases (by the age of 4) vessels in the ligamentum teres are not developed until about the age of 7 and between the age of 4 and 7 blood supply to the head may depend solely on lateral epiphyseal vessels which are susceptible to external pressure from an effusion

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LIMB LENGTH DISCREPANCY Eval: pt supine, fully extend the lower extremities keeping the pelvis level and note the relative relationship of the medial malleoli. If any abnormality measure the limbs from the ASIS and then remeasure as standing on blocks placed under the shorter limb to level the pelvis. Observe the pts gait w/o shoes. Leg length discrepancy: check pelvic tilt, secondary to scoliosis. True leg length discrepancy measured from the ASIS to the medial of the lateral malleoli Apparent leg length discrepancy measured from the umbilicus to the medial or lateral malleoli Tx: No tx if <2cm difference. Shoe lift if 2-5cm.Surgery if disparity exceeds 5-6cm. CEREBRAL PALSY Non-progressive motor dysfunction due to hypoxia during vertebral development (1-3 y.o. myelinization) Types: spastic, athetoid, flaccid, hypotonic

HAND
Zones of the hand Extensor zone 7 zones, bony prominences are the odd zones; Zone 1 at DIP joint, Zone 7 at the wrist Flexor zone: Zone 1: Middle phalanx - From middle of middle phalanx distally (only the tendon of FDP) Zone 2: Proximal phalanx - From MCP joint to the middle of the middle phalanx (Tendons of FDS and FDP) Zone 3: Distal palmar - From the distal end of the flexor retinaculum to the MCP joints (Tendons of FDS & FDP with the origin of the lumbricals) Zone 4: Thenar - Tendons beneath the flexor retinaculum Zone 5: Wrist - Tendons proximal to the flexor retinaculum No Mans Land the zone extending from the distal palmar crease to just beyond the PIP joint (Zone 2). Flexor tendon injuries here have a poor prognosis. Wrist Bones: Some lovers try positions that they cant handle Proximal Row: Scaphoid, Lunate, Triquetrum, Pisiform. Distal Row: Trapezium, Trapezoid, Capitate, Hamate. ?ALLENClassification of Fingertip Injuries I Tip with no involvement of the nailbed II <50% involvement of the nailbed III >50% involvement of the nailbed IV Entire nailbed involved

Primary wound closure Advancement flaps V to Y advancement using Atasol or Kutler procedure: Make A V-shaped incision at palmar distal phalanx & pull distally for wound coverage; suture proximally Completion amputation with shortening & primary wound closure

Felon abscess on finger pulp Paronychia abscess under nailbed Collar button web space abscess Paronas space continuity between hypothenar and thenar eminences. Hence abscess may spread. Cardinal Signs of Kanavel for Tendon Sheath Infection 1. Fingers held in flexion 2. Uniform swelling of fingers 3. Intense pain on finger extension 4. Sensitivity upon palpation Tendons and Nerves and Functional Testing: Median Nerve (M): lay hand of dorsal surface, hold radial border of thenar eminence and resist pts palmar abduction of the thumb. Intact TIP-TIP Vs pulp-pulp pinch (if ant interosseous nerve is damaged). Ulnar Nerve (U): abduct fingers or pinch paper between thumbs and fingers. Radial Nerve (R): extend fingers and wrist against resistance. Interossei: (U) spread hand (dorsal), hold paper btwn fingers (ventral). Lumbrical: (M,U) extend wrist and DIP/PIP as fingertips held. Flexor Dig Profundus (FDP): (M,U) flex DIP while MCP and PIP extended. Flexor Dig. Superficialis (FDS): (M), flex PIP all other digits are extended, have thumb and index finger pinch. Flexor carpi radialis (FCR): (M), flex and radial deviate the wrist. Flexor carpi ulnaris (FRU): (U), flex and ulnar deviate the wrist. Abductor pollicis longus (APL): (R), ext and abd thumb. Extensor pollicis brevis (EPB): (R), ext and abd thumb. Ext carpi radialis brevis (ECRB): (R), make fist while extending wrist. Ext carpi radialis longus (ECRL): (R), make fist while extending wrist. Ext pollicis longus (EPL): (R), lift thumb off flat surface while palm flat. Ext. Digitorum communis (EDC): (R), extension of fingers at MCP joint. Ext. indicis proprius (EIP): (R) ext of index finger at MCP as others in fist. Ext digiti minimi (EDM): (R), ext of 5th digit while making a fist. Ext carpi ulnaris (ECU): (R), ext and ulnar deviation of wrist. Page 9 of 9 Orthopedics /epcapul UPCM09

Management of Hand Injuries 1. Repair tendon & nerves 2. Replantation depends on muscle metabolism 3. Revascularization limb: 4-6 hours ischemia time

SPINE
Motor C2 C3 C4 C5 C6 C7 C8 T1 L2 L3 L4 L5 S1 Radial nerve Ulnar nerve Median nerve Muscle Sensory Back of head Front of neck lat and inf over clavicles down to 2nd interspace Lateral arm Lateral forearm Middle finger Medial forearm Medial arm Distal third of thigh Middle third of thigh Medial maleolus Dorsum of foot Sole Snuff box Small finger Index finger

Pt diapragmatically Arm abduction Elbow flexion Wrist extension Elbow extension Finger flexion Finger abduction Finger adduction Hip flexion Knee extension Ankle dorsiflexion Big toe extension Plantar flexion Thumbs up Apposition

breaths Deltoid Biceps brachialis Extensor carpi radialis longus & brevis Triceps Flexor digitorum profundus Intrinsics Intrinsics

Tibialis anterior Extensor hallucis longus Peroneus

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Spinal Reflexes (D-deep; S-superficial) Reflexes Methods of elicitation Corneal (S) Pharyngeal (S) Palatal (S) Biceps (D) Triceps (D) Bracioradial (D) Finger flexion (D) Scapular (S) Abdominal muscle stretch reflexes (D) Epigastric (S) Abdominal skin-muscle reflexes (S) Cremasteric Adductor (D) Quadriceps (D) Gluteal (S) Triceps surae (D) Plantar (S) Clitorocavernous (S) Bulbocabernous (S) Touching cornea with cotton Touching posterior wall of pharynx Touching soft palate Tab biceps tendon Tap triceps tendon Tap styloid process of the radius, with forearm held in semipronation Flick palmar surface of the tip of the finger Stroking skin between scapulae Tap lowermost rib, tap finger placed on rectus abdominis or tap symphysis pubis Stroking downward from nipples Stroke skin of the upper and lower abdominal quadrants Stroke skin of the upper and inner thigh Tap medial condyle of the tibia Tap tendon of the quadriceps femoris Stroking skin of buttock Tap Achilles tendon Stroke sole of the foot Pinching clitoris Prick skin of the glans penis (dorsum of glans) Prick skin of the perianal region

Normal results Contraction of orbicularis oris Contraction of pharynx Elevation of palate Flexion of the forearm at the elbow Extension of the forearm at the elbow Flexion of the forearm at the elbow Flexion of the fingers Contraction of scapular muscles Contraction of the abdominal wall or, when the symphysis is tapped, adduction of the legs Dimpling of epigastrium ipsilaterally Contraction of the abdominal muscles andretraction of the umbilicus to the stimulated side Upward movement of the testicle Adduction of the leg Extension of the lower leg Contraction of glutei Plantar flexion of the foot Plantar flexion of the toes Insert gloved finger to palpate anal contraction Insert gloved finger to palpate anal contraction; Contraction of the bulbocavernosus muscle and constrictor urethrae Constriction of the anal sphincter anal wink

Segment(s) traversed Pons Medulla Medulla C5-C6 C6-C7 C5-C6 C7-T1 C5-T1 T8-T12

T7-T9 T8-T12

L1-L2 L2-L4 L2-L4 L4-L5 L5-S2 S1-S2 S3-S4 S3-S4

Anal (S)

S4-Coccygeal

SPINAL CORD INJURY Incomplete spinal cord lesions Any sparing distal to the injury = incomplete lesion= possible recovery The greater the sparing the greater the prognosis a. Brown- Sequard - an injury to either side of the cord (hemisection) ipsilateral: muscle paralysis and jt position/ vibration loss contralateral: pain and temperature loss good prognosis, 90% regain bladder / bowel function + walk b. Central cord syndrome - most common incomplete cord injury, assoc with extension injury to Cx spine in middle aged pt Impact direct to the central grey matter severe flaccid LMN paralysis of the upper limbs Damage to the central portion of the corticospinal and spinothalamic long tracts in the white matter UMN spastic paralysis of the lower limbs and trunk The sacral tracts are peripheral and are usually spared and the pt has sacral sparing Prognosis : 50-60% have progressive return of motor and sensory function to lower limbs- but poor recovery of hand function due to irreversible damage to the central grey matter c. Anterior cord syndrome - complete motor and sensory loss apart from dorsal column sparing with deep pressure/ proprioception/ vibration as only remaining modality Prognosis : good if recovery progressive within 24 hrs ; after 24 hrs prognosis poor; 10-15% have recovery d. Posterior cord syndrome - loss of deep pressure/ proprioception/ vibration only e. Conus Lesion - involves long tract and anterior horn cell damage of varying degree with a mixed LMN and UMN paralysis in the lower limbs. If complete loss of bladder contraction, bladder reflex, bulbo-cavernous reflex and anal wink, loss of voluntary anal tone and absent sensation. Often incomplete however with normal peri-anal sensation and variable bladder tone ASIA Impairment Scale A Complete. No motor or sensory function is preserved in the sacral segments S4-S5 B Incomplete. Sensory but no motor function is preserved below the neurological level and includes the sacral segments S4-S5 C Incomplete. Motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade less than 3 D Incomplete. Motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade of 3 or more E Normal. Motor & sensory functions are normal

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Key Muscles: 1. Elbow flexors 2. Wrist extensors 3. Elbow extensors 4. Finger flexor ( distal phalanx of middle finger) 5. Finger abductors (little finger) 6. Hip flexors 7. Knee extensors 8. Ankle dorsiflexors 9. Long toe extensors 10. Ankle plantar flexors SPINAL SHOCK Physiologic period of areflexia, flaccidity, loss of sensation & autonomic dysfunction below the level of lesion immediately following spinal cord injury May last for several hours to several weeks but typically subsides within 24 hours. Within 48 hours, 90% are already (+) for bulbocavernous reflex spinal shock has terminated Early resolution of spinal shock is an important prognostic sign AUTONOMIC HYPERREFLEXIA Medical emergency seen in pts with SCI lesions above T6 Characterized by mass sympathetic & selected parasympathetic response Triggering stimuli: filled bladder (most common), filled colon, pregnant SCI pt in labor, ingrown toenails, decubitus ulcers, pressure sores, urinary tract infection Symptoms: 1. Hypertension (most common & life threatening) 2. Headache 3. Nasal stuffiness 4. Above the lesion: sweating & flushing 5. Below the lesion: piloerection, dry, pallor, cold & clammy skin SCOLIOSIS F>M, idiopathic Cobbes angle Functional Curves: due to leg length differences, painful conditions, resolve when problem is remedied. Structural Curves: Idiopathic scoliosis the most common type. Also seen with congenital spinal abnormalities, NM dz (polio, CP, MD, spinal bifida), Marfans, neurofibromatosis, dwarfism. Forward bending test: most sensitive (arms hanging with palms together, feet together, knees straight. Best viewed standing in front of pt. Look for elevation of rib cage/ paravertebral muscles on one side and depression on other or asymmetry. If any asymmetry >5-7 deg --> get x-rays. Check AP of thoracolumbar spine. Use Cobb method (draw lines parallel to the two most angled vertebra and drop a perpendicular, measure the angle at the intersection) to measure magnitude. 2-3% of pop has a curve of 10 deg. LOW-BACK PAIN Types: 1. Discogenic back pain herniation of nucleus pulposus 2. Radicular nerve root irritated, (+) straight lef test 3. Referred may be secondary to UTI, PID, aortic aneurysm, infection , hip arthritis Management 1. Conservative NSAIDs, bed rest for 1-2 days, physical therapy 2. Surgical Laminectomy, Laminotomy CLAUDICATION Neurogenic Claudication (Lumbar Spinal Stenosis) Vascular (Intermittent) Claudication Most in elderly (60-70yo) with severe DJD-osteophytes (usually Due to ischemia in exercising muscles. Pain is sclerotomal at L4-5 or L3-4), bulging annuli decrease the cross-sectional (vascular supply distribution), occurs with a fixed amount of area of spinal canal spinal stenosis leg pain with activity, may occur with standing alone resolves almost commonly bilateral sciatic, insidious onset neuro deficit immediately with rest. Not improved with grocery shopping with (dermatomal weak/ numb). Worse with any activity that cart Vs shopping mall (neurogenic claudication is). extends the spine, walking down-hills, variable amount of Atherosclerotic dz of iliofemoral vessels, often with impotence, walking, prolonged stand, back extension, lift/bend, cough. dystrophic skin changes (nail atrophy, alopecia), foot pallor, Able to walk longer at grocery store Vs mall, can lean on cart decreased pulses, arterial bruits. Check: ABI and Doppler if suspect. and flex spine. SPONDYLOSIS Non specific degenerative process of the spine, in cervical region it is synonymous with stenosis. Usually seen in age >50, presents as dull nagging LBP, morning stiffness, worse with activity, relief with gentle exercise, hydrotherapy. All movements restricted. Tends to cause spinal stenosis with neurogenic claudication. Tx: analgesics, exercise, TENS.

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SPONDYLOLISTHESIS Anterior subluxation of one vertebral body on another, usually L5 on S1. Grade 1-4 (<25-75%). 5% pop. Pain with extreme stretching of the interspinous ligaments. Risk for progression if early onset (10-15yo), female, recurrent sxs, postural deformity. Tx: strict flexion exercise program for at least 3 mo (avoid hyperextension). If have <25% slippage: counsel on avoiding vocation that necessitates heavy lifting or strenuous activity. If >50%: avoid contact sports. SPONDYLOLYSIS A failure of the neural arch, manifesting as a defect in the pars interarticularis (neck of the Scotty Dog seen on oblique L spine). May be congenital, degenerative, traumatic, pathologic. 6% men, 9% females, many asymptomatic. Presents with dull, nagging LBP in age >50, AM stiffness, worse with activity, Dec ROM. Tx: NSAIDs, exercise, hydrotherapy, TENS, acupuncture. LBP In Children: Age <10yo: infection, tumor, psychogenic. Age >10yo: spondylolysis, spondylolisthesis, Schaumanns dz, overuse, postural, HNP, tumor/infection, spinal dysraphism. NEOPLASM Spine metastasis most common CA of the spine Faster progression of symptoms means worse prognosis Signs & symptoms: 1. night pain 2. instability of spine most painful 3. stretch of the periosteum 4. motor weakness, then sensory loss, then bladder & bowel incontinence Radiologic features 1. collapse of the vertebral body requires 30-50% destruction before this is detected radiographically 2. owl wink sign destruction of the pedicle, usually seen posteriorly Indications for surgery 1. Rapid onset that you can decompress right away a. anterior decompression preferred b. posterior decompression with instrumentation c. laminotomy / laminectomy not indicated for unstable spine 2. Intractable pain 3. Impending fracture

References: Class 2005. Orthopedics Reviewer. DeMyer, W. Technique of the Neurologic Examination eMedicine Ryu, R. Orthopedics. http://www.wheelessonline.com http://www.umdnj.edu/tutorweb/pdf/bone_tumors.pdf

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