1 lmcc orthopedic review lecture april, 2004 “back to basics” dr. p.r. thurston

LMCC Orthopedic Review Lecture

April, 2004

“Back to Basics”

Dr. P.R. Thurston

Syllabus

1. Diagnosis, Treatment & Complications of Fractures /Dislocations.

2. Diagnosis & Treatment of Arthritis.

3. Assessment and Management of Low Back Pain.

Fractures

Dislocations

Fractures

A discontinuity in the structural integrity of a bone.

Definition :-

A fracture occurs because the force applied exceeds the breaking strength of the bone so that the Load can no longer be transferred across that zone of the bone.

All fractures ultimately begin with kinetic energy, released by misadventure and applied to the human body.

Some of that energy is absorbed and some is transmitted to the surroundings.

Absorbed energy must be dissipated, ie. distributed, through the soft tissues and bones.

Fractures occur when the bone can not dissipate all of the energy absorbed.

Fractures

Thus :-

1 ) A fracture occurs when the energy transferred to a bone exceeds the ability of the bone to dissipate that energy.

2 ) Further energy dissipation produces :-

- comminution.

- soft tissue damage (open fractures).

- displacement.

- other fractures.

Fractures

DefinitionsFracture:- A discontinuity in the structural

integrity of a bone.

Infraction:- An incomplete fracture.

Dislocation:- Complete loss of contact of the articular surfaces of a joint.

Subluxation:- Non-concentric joint surfaces.

Reduction:- Returning a fracture or dislocation to an anatomical alignment.

Comminution:- Multiple fragments.

Bone is a two-phase material :-

Calcium HydroxyApatite Ca10(PO4)6(OH)2 = mineral

Osteoid Collagen type I and III = fibrous

Calcium is strong in compression, but weak in tension.

Osteoid is strong in tension, but weak in compression.

Mechanical Properties of BoneFractures

BUT :- (for adult bone)

Calcium is stronger in compression than Osteoid is in tension

And therefore :-

Bone always fails first in tension

Fractures

For immature bone, this effect is reversed.

The Buckle or Torus fracture occurs because the bone fails in compression first.In children, the Osteoid is stronger than the Mineral phase.

Generally, the dislocation in youth becomes the fracture in the adult.

Fractures

A bone consists of three areas :-

the Diaphysis

the Metaphysis

the Epiphysis.

Each region has its own Each region has its own fracture characteristics.fracture characteristics.

Fractures

Bending

Torque

Direct

Traction

Compression

Intra-articular

Pediatric

Diaphyseal

Metaphyseal

Epiphyseal

Oblique

Spiral

Transverse

Fractures

Bending produces a transverse fracture line, with or without a lip.

When load is added, the lip becomes a butterfly fragment.

With more loading, the fracture line becomes oblique.

BendingFractures

- Rotatory shear produces a continually changing line of failure, giving the typical “Bayonet Spikes” at the ends of the bones.

- The greater the load the longer the fracture.

- These occur only in long bones and are referred to as:-

‘Spiral Fractures’

TorqueFractures

$piral

The butterfly segment is different from the oblique bending fracture.

Torque

Fractures

If no butterfly, then the ends are Bayonet in appearance.

Fractures

“tapping fractures”.

Fractures of “dying momentum”.

Tension produced on the opposite side of the bone.

Comminution produced on the impact side of the bone.

High energy injuries.

Direct BlowFractures

Direct Blow

Transverse Fractures

Comminution on the opposite side to a bending fracture, ie. at the point of impact.

“The Nightstick Fracture”.

Fractures

The Metaphysis is subject to all of the diaphyseal patterns plus:-

1) Traction – Avulsion.

2) Compression.

Traction – Avulsion.

MetaphysealFractures

are transverse since the tension is equal on both sides of the bone.

-are caused by ligament or tendon traction.

always occur adjacent to joints.

Metaphyseal

Traction-AvulsionFractures

Traction – Avulsion.

Fractures

Crush fractures

Impacted fractures

Usually comminuted

Usually axial skeleton

- Vertebrae

- Calcanei

Compression Fractures

The Epiphysis is subject to all of the diaphyseal and metaphyseal patterns plus:-

1) Intra-articular Fractures.

2) Pediatric Fractures about the Epiphyseal plate.

EpiphysealFractures

Intra-articular Fractures

- Always require accurate reduction.

- Usually require surgical treatment.

- Are often comminuted.

- Frequently threaten Post-traumatic Osteoarthritis.

EpiphysealFractures

Pediatric Epiphyseal Fractures

- Produce fracture patterns specific to children.

- Always require accurate reduction.

- Can produce growth abnormalities.

- Salter-Harris Classification.

EpiphysealFractures

Salter-Harris Classification

II IIII IIIIII

IVIV VV

Fractures

Salter-Harris Classification

1) Fractures interfering with growing bones.

2) Worse prognosis with increasing number.

3) Probability of surgery increases with number.

Fractures

A fracture can occur in :-

normal bone subject to abnormal forces.= Traumatic Fractures.

abnormal bone subject to normal forces. = Pathologic Fractures.

normal bone subject to cyclic forces.= Fatigue or Stress Fractures.

Fractures

Description

1) Displacement - Angulation

2 ) Closed or Open.

3 ) Simple or Comminuted.

4 ) Fracture Pattern eg. Spiral, Transverse etc.

5 ) Anatomical Area.

6 ) Mechanism.

Fractures

Fracture Description

This fracture is angulated laterally, since it points laterally.

The distal fragment is tilted medially

Description

Medially Displaced

Closed

Comminuted

Short Oblique

Fracture of the

Proximal Humerus

Caused by a direct fall

Fracture Description

1) The distal fragment is always described with relation to the proximal segment.

2) Displacement = Translation of bone ends.

3) Angulation = Orientation of bone ends.

4) Angulation identifies to where the fracture points.

5) For clarity, the tilt of the distal fragment is often used to describe angulation.

The Periosteal Bridge

The Periosteal Bridge is intact on the concave side of the fracture.

Reversal of the mechanism of the fracture tightens the bridge and stabilizes the fracture.

The Periosteal Bridge

Tightening the periosteal bridge locks the fracture together.

Holding the bridge tight requires three point fixation.

“It takes a bent cast to produce a straight bone”

J. Charnley

Treatment

Closed or Open ( Surgical ).

- Both require an understanding of fracture healing.

- Closed requires reversal of mechanism of injury.

Indications for Closed Reduction

There is significant displacement.

Reduction is possible.

The reduction, if gained, can be held.

The fracture has not been produced by a traction force.

Indications for Open Reduction

1 ) There is a significant Displacement.

2 ) Open Fractures.

3 ) Intra-articular Fractures.

4 ) Un-reducible Fractures

5 ) Reductions that cannot be maintained in a cast.

6 ) Comminuted or Segmental Fractures.

7 ) Floating Joints.

8 ) Fractures with Neurovascular damage.

Open Fractures

Classification :-

1. < 1 cm., inside-out, little soft tissue damage.

= low potential for infection.

2. 1 cm. – 10 cms., outside-in, requires debridement, but no flap or skin graft.

= moderate potential for infection.

3. > 10 cms., outside-in, high energy, devitalized muscle, comminution or bone loss, soft

tissue loss.

Open Fractures

Classification :-

3A. No loss of soft tissue cover, no flap required.

3B. Flap required due to soft tissue stripping.

3C. Associated vascular injury.

Type 1. Open Fracture = 6 mm, extend & debride

Degloving Mechanism

Type III C Injuries – Vascular Injury

Note pallor of the ankleNo pulses

Fracture Complications

1. Pulmonary Fat Emboli

2. Compartment Syndromes

3. ‘Cast Disease’

4. Stress Fractures

5. Pathologic Fractures

Pulmonary Fat Emboli :- A.R.D.S.

- Long bone fractures, burns, contusions.

- Interstitial pneumonitis due to free fatty acids

- S.O.B. & confusion in young adults.

- Axillary & Subconjunctival Petechiae.

- Serum lipase elevated.

- pAO2 reduced – if < 50 – 20% mortality.

- Ventillatory support

- Dexamethazone.

- 5 day course.

Compartment Syndromes

- increased interstitial tissue pressure.- fractures, burns, tight dressings.

- normal pressure < 25 mm. Hg.- when the tissue pressure > venous capillary

pressure, but less than the arteriolar pressure.- 5 P’s

- pain.- pallor.- pulselessness.- paresthesias.- paralysis.

Compartment Syndrome

Symptom: Pain out of proportion to that

expected for the injury.

Signs: 1. Loss of function of muscle due to

ischemia within the compartment.

2. Pain with passive stretch

3. Numbness etc. are LATE findings!

4. If neuro symptoms present, potential

for full neuro recovery is only 10 %

Rx Compartment Syndrome

Release all compressive dressings / plaster.

Elevate extremity to heart level.

Fasciotomies.

Rx Compartment Syndrome

Increased girth.

Pallor of the foot.

Recent surgery.

4 compartment fasciotomy

Careful monitoring.

Recognise it - 5 P’s

Call Orthopaedic Surgeon

Pressure measurements

Stress or Fatigue Fracture

Repeated loading below acute failure threshold.

Eventual fatigue failure.

Military recruits, runners, aerobics.

Tibia, metatarsals, femoral neck.

Initial x-ray can be negative.

Bone tenderness – Bone scan.

Pathologic Fractures

Failure through abnormally weakened bone

Minimal trauma – BEWARE

Osteoporosis Metastasis Tumour:- Benign,

Malignant (Myeloma).

Metabolic Bone Disease

Pathologic Fractures

Fractures

an understanding of the mechanism that produces them,

Ultimately, the treatment of fractures requires

An understanding of the diagnostic tools available,

Fractures

And the current technologies used in their treatment

Fractures

Dislocations

The articular surfaces are no longer in contact.

Commonly affects -

Shoulders > PIP joints > Elbows > Ankles.

Often associated with fractures.

Often associated with neurologic injuries

Shoulder Dislocations95 % anterior

1 % posterior

Luxatio erecta

Medial

Axillary nerve injury

Rapid reduction

Shoulder Dislocations

Conscious sedation.

Traction reduction.

Immobilization.

Recurrent.

Voluntary

Habitual.

Multiaxial instability.

Elbow Dislocation

Posterolateral.

Median nerve injury.

Ulnar nerve injury.

Rapid reduction.

Early mobilization.

Back Pain

Classification: Mechanical (MacKenzie)

Postural syndromenormal tissues become painful by the application of

prolonged stresses (sitting, bending etc)

Dysfunction syndromesoft tissues are shortened and stiff. Usually >30 year

old, poor posture, under exercised, reduced mobility

Derangement syndromeDisc derangement (tears and herniation)

Causes and Classification of Back Pain: McNab

Viscerogenic Vasculogenic Neurogenic Psychogenic Spondylogenic

SpondylogenicOsseus:

Trauma Infection Neoplasms Inflammatory Metabolic (eg.Pagets) Deformities

– Soft tissues: Muscles SI joints Disc Facets

Non operative Treatment of Back Pain

Do nothing

Activity modification

Medications

Exercise and physiotherapy

Braces

Manipulation

Massage therapy

Traction/inversion therapy

Vitamins/Supplements/Diets

Weight control

Every Suzanne Summers sponsored abs exerciser

Degenerative Conditions of the Lumbar Spine

Congenital

Disc herniation

Degenerative Disc Disease

Spinal Stenosis

Degenerative Spondylolisthesis

Degenerative Scoliosis

“And when did you first notice that your back had gone out?”

Congenital Anomalies

Congenital scoliosis

Arthrogryposis

Congenital anomalies

Spina bifida

Anatomy

Extension Flexion

Three joint complex(Kirkaldy Willis, Farfan)

C ap su la r laxity

E n la rg em en t o f a rt icu la r p rocess

S u b lu xa tion

O s teop h yte fo rm ation

C artilag e d es tru c tion

S yn ovia l reac tion face t jo in t

D isc h ern ia tion

os teop h ytes

d ec rease d isc h e ig h t

In te rn a l d isc d is ru p tion

rad ia l tea r

D isc c ircu m feren c ia l tea rs

R ecu rren t ro ta tion a l s tra in

Instability

Lateral n. ent

Central stenosis

Disc herniation

Ms J.H. 25 y.o. female presented with cauda equina syndrome

Spinal stenosis

Symptoms:– unilateral radicular

pain– bilateral claudication– better with forward

flexion of trunk– better walking uphill– rare bowel/bladder

involvement

Signs:– usually no neuro signs– look for pulses– stress test

Investigations:– XR– CT– Myelo-CT– MRI

Spinal stenosis

lateral AP

myelogram

Post myelogram CT

Degenerative Spondylolisthesis

Most common cause of spinal stenosis

More common in women, hemisacralization of L5, diabetics and women with BSO

OA of hip also in 11-17%

Isthmic spondylolisthesis

Severe spondylolisthesis

Time for a 10 minute break!

Pediatric Orthopedics

1. Developmental Dysplasia of the Hip.

2. Legg-Perthes Disease.

3. Slipped Capital Femoral Epiphysis.

4. Club Feet.

5. Osteomyelitis.

6. Septic Hip.

1. Talipes Equinovarus is the proper name for :-

a. Flat feet

b. In-toeing

c. Club feet

d. Knock knees

e. Wry neck

c. Club feet

a. Flat feet

b. In-toeing

c. Club feet

d. Knock knees

e. Wry neck

Pes Planus

Metatarsus Adductus

Genu Valgus

Torticolis

Talipes Equinovarus

congenital deformity of the footEquinus, Inversion, Adduction, Supination2 per 1000 live births50% bilateralM >F 2:1Serial corrective casts at birthSurgery if resistant

EARLY TREATMENT IS ESSENTIAL

2. Trendelenburg refers to :-

a. Leg length discrepancy

b. Gait abnormality

c. Knee recurvatum

d. Scoliosis

e. Hip Contracture

b. Gait abnormality

a. Leg length discrepancy – Apparent vs Real

b. Gait abnormality

c. Knee recurvatum – straightens past 1800

d. Scoliosis – lateral curvature, lordosis, kyphosis

e. Hip Contracture – Thomas test

3. All of these are signs of D.D.H. except :-

a. Limited Abduction

b. Ortolani Sign

c. Asymmetric Skin Folds

d. Galeazzi’s Sign

e. McMurray Sign

a. Limited Abduction

b. Ortolani Sign

c. Asymmetric Skin Folds

d. Galeazzi’s Sign

e. McMurray Sign

DislocatedReducible

Knee heightTorn Meniscus

Dislocated

Developmental Dysplasia of the Hip

Acetabular dysplasia

Femoral anteversion

Adduction Contracture

50% bilateral, F > M 8:1

Test ALL newborns at birth

Conservative Rx at birth – Pavlik, D.diaper

Surgical Rx if resistant

4. The most common congenital Spinal abnormality is :-

a. Scoliosis

b. Spina Bifida

c. Torticolis

d. Klippel – Feil Syndrome

e. Multiple Hereditary Osteochondroma

b. Spina Bifida

a. Scoliosis

b. Spina Bifida

c. Torticolis – ‘Wry Neck’

d. Klippel – Feil Syndrome – Congenital Fusion

e. Multiple Hereditary Osteochondroma

Spinal Bifida

defect of neural tube closure

Lumbar spine, commonly low

2 per 1000

myelodysplasia

Mild to complete paraplegia

Occulta, meningocoele, Myelomeningocoele

Bowel and bladder dysfunction

5. Polydactyly

6. Syndactyly

100100

101101

Sprengel’s Deformity

Omovertebral Bone

8. A 6 year old boy with delayed physical development, convulsions, tetany, weakness, blue sclera and bony deformities is most likely suffering from :-

a. Physical Abuse

b. Ehlers – Danlos Syndrome

c. Osteogenesis Imperfecta

d. Multiple Hereditary Exostoses

e. Myositis Ossificans

a. Physical Abuse

b. Ehlers – Danlos Syndrome

d. Multiple Hereditary Exostoses

9. A 6 year old boy with delayed physical development, a rachitic rosary, weakness and bony deformities is most likely suffering from :-

a. Physical Abuse

b. Rickets

c. Scurvy

d. Osteitis Deformans

9. A 6 year old boy with delayed physical development, a rachitic rosary, weakness and bony deformities is most likely suffering from :-

b. Rickets

107107

108108

109109

Etiology Alkaline Calcium Phosphate Urea Phosphatase

Vitamin D Up Down Normal NormalDeficiencyRickets

Renal Up Down Up UpInsufficiency(Renal Rickets)

Renal Up Down Down NormalTubular Insufficiency(HypoPhosphatemia)

110110

10. This is :-

a. Osteomyelitis

b. Osteomalacia

c. Osteoporosis

e. Leprosy

111111

10. This is :-

112112

10. This is :-

a. Osteomyelitis

b. Osteomalacia

c. Osteoporosis

e. Leprosy

Osteitis DeformansPaget’s Disease

4% of pop. Over 40 yrs.

accelerated bone turnover

often assymptomatic

monostotic > polyostotic

loss of stature

AV shunting

pathologic bone

11. A child with knee pain has a ____ problem until proven otherwise.

a. Knee

b. Femoral

c. Tibial

d. Hip

e. Patella

11. A child with knee pain has a ____ problem until proven otherwise.

d. Hip Obdurator Nerve

11. All of the following are part of the differential of hip pain in a 6 year old, except :-

a. Femoral Osteomyelitis

b. Septic Hip

c. Transient Synovitis

d. Legg-Perthes Osteochondritis

e. Slipped Capital Femoral Epiphysis

a. Femoral Osteomyelitis

b. Septic Hip

c. Transient Synovitis

d. Legg-Perthes Osteochondritis

Ages for Hip Disease

D.D.H. Birth

Septic Hip Birth – 11

Legg-Perthes 3 – 11

Transient Synovitis 3 – 11

S.C.F.E. 11 - 16

12. Osteomyelitis in children is produced by what route of infection?

a. Direct extension from another focus

b. Hematogenous spread

c. Perforating wounds

d. Lymphatic spread

e. Septic hip

12. Osteomyelitis in children is produced by what route of infection?

b. Hematogenous spread

Osteomyelitis

Acute infection,metaphyseal

90% Staph.,20% mortality

100% growth abnormality

Periosteal elevation, osteolysis

Sequestrum, Involucrum

123123

124124

Paronychia

125125

126126

15. All of these are findings of a Herniated L5-S1 disc, except :-

a. Absent Achilles reflex

b. Lateral foot numbness

c. Sciatica

d. Low back pain

e. Extensor Hallucis Longus weakness

a. Absent Achilles reflex S1

b. Lateral foot numbness S1

c. Sciatica S1

d. Low back pain

e. Extensor Hallucis Longus weakness L5

f. Knee jerk L4

16. Avascular necrosis of the femoral head is associated with all of the following except :-

a. Steroid use

b. Alcohol

c. Deep sea diving

d. Lipid storage disease

e. Diabetes

a. Steroid use

b. Alcohol

c. Deep sea diving

d. Lipid storage disease

e. Diabetes

133133

8 year old boy

What is the Diagnosis?

134134

8 year old boy

Legg – Perthes

Osteochondosis

Legg-Perthe’s Disease

Osteochondrosis (avascular necrosis)

Proximal Femoral Epiphysis

Necrosis, revascularization, fragmentation, healing

3 – 11 yrs., M > F 4:1, 15% bilat.

Subluxation laterally, Coxa plana, Coxa magna

Osteoarthritis 50 yrs.

Osteochondroses

Freiberg’s Disease

Osgoode-Sclatter’s

Scheuermann’s

Kienbock’s

Osteochondritis Disecans

2nd Metatarsal Head

Tibial TubercleSpineCarpal Lunate

Lateral Femoral Condyle

137137

19. Diagnosis?

138138

19. Gout

Urate crystalopathic arthritis

Crystals in periarticular tissues

Inconsistant elevated serum urate

Allopurinol and colchicine

Tophi in periarticular soft tissues

Deposits in non-articular cartilage

Juxta-articular erosions

140140

Spondylolytic Spondylolisthesis

Spondylolisthesis

Lumbosacral junction defect

Spondylolysis of Pars Interarticularis

Traumatic or congenital

Acute – immobilize

Chronic - surgery

21. The Salter- Harris Classification is used to assess the severity of :-

a. Epiphyseal Fractures

b. Developmental Dysplasia of the Hip

c. Legg – Perthe’s Disease

d. Club Foot

e. Osteomyelitis

21. The Salter- Harris Classification is used to assess the severity of :-

a. Epiphyseal Fractures

144144

I II III

145145

22. What is this deformity?

146146

22. A Diner Fork Deformity

Probable Diagnosis?

147147

22. Colles Fracture

22. Colle’s Fracture

distal radial fracture

occurs at all ages

commonly 60 yrs. +

osteoporosis

intra-articular

149149

CR & K-Wires

150150

External vs Internal Fixation

151151

23. The common complication of this fracture is :-

152152

23. Proximal pole Avascular Necrosis

153153

154154

24. This is a :-

a. Buckle Fracture

b. Greenstick Fracture

c. Stress Fracture

d. Pathologic Fracture

e. Growth Arrest line

155155

24. This is a :-

a. Buckle Fracture

156156

This is a :-

a. Buckle Fracture

b. Greenstick Fracture

c. Stress Fracture

d. Pathologic Fracture

e. Growth Arrest line

157157

Greenstick Fractures

158158

25. Is this fracture treated by Closed or Open Reduction?

159159

160160

25. Fractures of Necessity

161161

26. What is the Diagnosis?

162162

26. Posterolateral Dislocation of the Elbow

163163

26. Reduction by traction.

TRACTION

164164

165165

27. Anterior Dislocation of the Shoulder

166166

27. Reduction by traction

167167

This is a :-

a. Supracondylar #

b. Olecranon #

c. Dislocation

d. Forearm #

e. Radial Head #

168168

This is a :-

a. Supracondylar #

169169

28. Supracondylar Fracture

29. The complications of a Supracondylar fracture in children include all of the following except :-

a. Malunion

b. Volkmann’s Ischemic Contracture

c. Compartment Syndrome

d. Cubitus Varus

e. Peripheral Nerve Injuries

f. Pulmonary Fat Embolus

a. Malunion

b. Volkmann’s Ischemic Contracture

c. Compartment Syndrome

d. Cubitus Varus

e. Peripheral Nerve Injuries

30. The only sign of a Compartment Syndrome that is always

present is :-

a. Pain

b. Pallor

c. Pulselessness

d. Paresthesias

e. Paralysis

present is :-

a. Pain

present is :-

a. Pain

b. Pallor

c. Pulselessness

d. Paresthesias

e. Paralysis

31. Compartment pressures indicating the need for fasciotomy :-

a. 0 – 15 mms. Hg

b. 15 – 25 mms. Hg

c. > 25 mms. Hg

d. > 50 mms. Hg

e. > 75 mms. Hg

31. Compartment pressures indicating the need for fasciotomy :-

c. > 25 mms. Hg

fractures, crush injuries, burns

collapse of venous return compartment pressure > 25 mms. Hg

engorgement of muscle within

necrosis of muscle tissue

Volkmann’s Ischemic Contracture

Fasciotomy

179179

32. A 20 yr. old male with a fractured femur has findings of confusion,

tachypnea and conjunctival petechia. The most likely diagnosis is :-

a. Pneumonia

b. Pulmonary Fat Emboli

c. Cerebral Contusion

d. Cardiac Contusion

e. Transient Stress Reaction

180180

32. A 20 yr. old male with a fractured femur has findings of confusion,

tachypnea and conjunctival petechia. The most likely diagnosis is :-

b. Pulmonary Fat Emboli

32. Pulmonary Fat Embolus

2% - long bone #’s 10% - multiple #’s

tissue thromboplastin ---> extrinsic cascade VII

A.R.D.S. - aterial hypoxemia

petechia across chest, in axillae and conjunctiva

early fixation decreases PFE, but increases infection rates

no current lab tests or treatment protocol

182182

33. Name the Fracture :-

183183

33. Monteggia Fracture

184184

185185

186186

34. Name this fracture :-

187187

34. Name the fracture :-

Galeazzi Fracture

188188

GaleazziFracture

189189

35. The commonest complication of this fracture is :-

190190

35. A Radial Nerve Palsy

191191

36. Does this fracture require surgery?

192192

193193

194194

195195

38. This patient most likely

has a fracture of the --------.

196196

has a fracture of the --------.

197197

has a fracture of the hip.

External Rotation

Shortening

Hip Flexion

198198

199199

39. What’s the Diagnosis?

200200

39. Sub-Capital Hip Fracture.

201201

40. All of the following are complications of this fracture except :-

a. Malunion

b. Avascular necrosis

c. Fat emboli

d. Non-union

e. Thrombophlebitis

202202

40. All of the following are complications of this fracture except :-

c. Fat emboli

203203

40. Blood Supply of Femoral Head

204204

40. Save Head versus Replacement

205205

40. Subcapital Hip Fractures

1. Abduction

2. Minimally displaced

3. 50% Displaced

4. Completely Displaced

Garden Classification

206206

40. Subcapital Hip Fractures

1. Avascular Necrosis - 30%

2. Malunion - 30%

3. Non-union - 30%

4. Surgery required

5. Older population

6. Pathologic - Osteoporotic

Properties

207207

41. What’s the Diagnosis?

208208

41. Intertrochanteric Hip Fracture

209209

41. Intertrochanteric Fractures

210210

41. Intertrochanteric Fractures

Properties

1. Varus deformity

2. Well - Healing

3. Traumatic + Osteoporosis

4. Surgery required

5. Mid-range Age population

211211

212212

Subtrochanteric Hip Fracture

213213

42. Subtrochanteric Fractures

Properties

1. Non-union

2. Traumatic

3. Surgery required

214214

Surgery or not?

215215

Surgery or not?

216216

44. Surgery or not?

217217

44. Surgery or not?

218218

44. Ankle Fractures Eversion Injuries

219219

44. Ankle Fractures

Inversion

Injuries

220220

23 y.o. male

Basketball injury

Open fracture

Numbness dorsum toes

45. What is the approach to this fracture?

221221

Reduce dislocation

Sterile dressing

Splint extremity

Re-check NV status

IV Antibiotics

Tetanus

Surgery

222222

46. Surgery or not?

223223

46. Surgery or not?

224224

47. Surgery or not?

225225

47. Surgery or not?

226226

47. Surgery or not?

227227

48. A 45 yr. old male, who was previously in good health, has sudden onset of transverse low back pain and right sided sciatica to his foot, after chopping wood at the cottage. Upon arising the following morning, he notices numbness on the outer border of his right foot and

some weakness in the right leg. He has no bowel or bladder problems.

The most likely diagnosis would be:-

a. Lumbar Muscular Strain.b. Herniated Lumbar Disc.c. Herniated Lumbosacral Disc.d. Cauda Equina Syndrome.e. Spinal Stenosis.

228228

48. A 45 yr. old male, who was previously in good health, has sudden onset of transverse low back pain and right sided sciatica to his foot, after chopping wood at the cottage. Upon arising the following morning, he notices numbness on the outer border of his right foot and

some weakness in the right leg. He has no bowel or bladder problems.

The most likely diagnosis would be:-

c. Herniated Lumbosacral Disc.

229229

49. Your initial approach to this problem would

include some or all of the following:-

a. Bedrest.

b. Anti-inflammatories.

c. Muscle Relaxants.

d. Spinal X-rays.

e. Physiotherapy.

f. Orthopedic/Neurosurgical referral.

g. CT-Myelogram or MRI

h. Discectomy

230230

49. Your initial approach to this problem would

include some or all of the following:-

a. Bedrest.

b. Anti-inflammatories.

c. Muscle Relaxants.

d. Spinal X-rays.

e. Physiotherapy.

f. Orthopedic/Neurosurgical referral.

g. CT-Myelogram or MRI

h. Discectomy??

231231

50. During the work-up for this problem, the patient complains that he has unaccountably soiled his underwear, without knowing it. Your response to this would be to:-

a. Reassure the patient that this is not serious

b. Order an urgent MRI

c. Get an urgent referral to Neuro/Orthopedics

d. Place the patient on immediate bedrest.

232232

233233

a. Reassure the patient that this is not serious

b. Order an urgent MRI

d. Place the patient on immediate bedrest.

234234

51. A lumberjack felling a tree is unfortunately struck on the back by the tree, knocking him to the ground and injuring his left lower extremity. In the ER, his left hip is in flexion, adduction and internal rotation. The most likely diagnosis is:-

a. Fracture of the Hip.b. Fracture of the Femur.c. Anterior Hip Dislocation.d. Posterior Hip Dislocation.e. Fracture of Pelvis.

235235

51. A lumberjack felling a tree is unfortunately struck on the back by the tree, knocking him to the ground and injuring his left lower extremity. In the ER, his left hip is in flexion, adduction and internal rotation. The most likely diagnosis is:-

d. Posterior Hip Dislocation.

236236

52. Which of the following signs and symptoms are consistent with a torn medial meniscus of the knee:-

a. Inability to squat

b. Pain on descending stairs

c. Locking

d. Recurrent effusions

e. All of the above.

237237

52. Which of the following signs and symptoms are consistent with a torn medial meniscus of the knee:-

a. Inability to squat

b. Pain on descending stairs

c. Locking

d. Recurrent effusions

e. All of the above.

238238

53. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle.

Your response to this situation would be to:-

a. Re-X-ray the ankle.

b. Remove the cast.

c. Measure the compartment pressures.

d. Instruct the patient to elevate the limb and prescribe an anti-inflamatory.

239239

53.. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle.

b. Remove the cast.

240240

53. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle.

a. Re-X-ray the ankle.

b. Remove the cast.

c. Measure the compartment pressures.

d. Instruct the patient to elevate the limb and prescribe an anti-inflamatory.

241241

54. The most common dislocations of the shoulder are:-

a. Medial.

b. Posterior.

c. Luxatio Erecta.

d. Anterior.

242242

54. The most common dislocations of the shoulder are:-

d. Anterior.

243243

55. Metastatic lesions to bone, of the following tumours, usually produce lytic defects except:-

a. Thyroid.

b. Pancreas.

c. Prostate.

d. Kidney.

e. Lung.

244244

c. Prostate.

245245

a. Thyroid.

b. Pancreas.

c. Prostate.

d. Kidney.

e. Lung.

246246

Th - Tha – That’s all folks!

1 lmcc orthopedic review lecture april, 2004 “back to basics” dr. p.r. thurston

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