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TABLE OF CONTENTS

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1 Orthopaedic Trauma
A. Adult Fracture and Dislocation
B. Fractures in Elderly
C. Injury of Ligaments Around The Knee and Ankle
D. Injury of Knee Menisci
E. Injury to The Muscles
F. Regional Fractures and Dislocation
G. Overuse Injury of Soft Tissues
2 Orthopaedic Infections
A. Bone & Joint Infections
B. Soft Tissue Infections
3 Spinal Disorders
A. Spinal Infections
B. Spinal Degenerative Disorder
C. Spinal Malignancy
D. Spinal Trauma
E. Correlating Spinal Abnormalities
F. Correlating Nervous Tissue Presentation
4 Synovial and Osteochondral Diseases in Joint Disorders
5 Common Tendon Disorders
6 Peripheral Nerve Disorder
A. Traumatic
B. Entrapment Syndrome
7 Diabetic Foot Ulcer
8 Paediatric Orthopaedic Disorders
A. Children’s Related Anatomy
B. Trauma (fractures)
C. Hip Disorders
D. Knee Region
E. Foot
9 Musculoskeletal Tumor
10 Orthopaedic Procedures
A. Orthopaedic Immobilization
B. Principles of Surgical Amputation
C. Fracture Osteosynthesis
11 Military Related Medicine
1. ORTHOPAEDIC TRAUMA
COMMON CHIEF COMPLAINTS

PAIN JOINTS/BONE/SOFT TISSUE SX MECHANICAL SYMPTOMS


S Site of pain Pain Stiffness Locking
O Onset Swelling Movement restriction Giving way
Character of pain (compressing, Ability to weight
Deformity
C burning, heaving, stabbing, dull bear
NEUROLOGICAL SYMPTOMS
aching, pricking, throbbing) *take note on the details of the symptoms
e.g. swelling (onset, site, size, progression) Weakness
R Radiation (localized/radiating)
Numbness
Associated sx (directed to chief
Paresthesia
complaint, i.e back pain – weakness,
A
numbness, urinary or bowel
incontinence)
T Time intensity
E Exacerbating and relieving factors
Severity (pain score) – tolerable/not,
S
limitations
Progression of pain (increasing,
P
decreasing or same)
Constitutional sx (RED FLAG SX) –
C fever, night sweats, significant LOW,
LOA
F Functional status (daily activities)
A. ADULT FRACTURES AND DISLOCATIONS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): REST OF HISTORY:
FRACTURE is a break in the structural continuity of bone PMHx: comorbidities,
(discontinuity). Who – age, gender, job, hand dominance epilepsy/parkinsons/dementia/alcoholism
What happened and exactly how it happened (increase risk of falls and MVA)
Type of fracture: (mechanism of injury, force involved, DHx: anticoagulants, steroids (osteopenia),
Site Bone likelihood of other structure damage) allergies
Intra/Extra-articular When it happened SHx: smoking/alcohol (delays bone healing),
Position (proximal/middle/distal) Where it happened comprehensive SHx e.g. mobility, daily activities,
Why it happened living situations, work/drive
Obliquity Completeness (complete, incomplete)
Direction (transverse, oblique, spiral)
Skin penetration (open, closed) PHYSICAL FINDINGS: INVESTIGATIONS
Condition of bone (comminuted, Examine for swelling/tenderness/decreased FBC
B
segmental, multiple, impacted) ROM G&S
Displacement Translation (shifted sideways, Assess limb I X-ray (AP and lateral)
backwards of forwards) - # assessment (open/closed) CT scan
- Neurovascular status of limb (temp, MRI – visualize soft tissues/spinal cord, look
pulses, capillary refill, sensation, for OM
Alignment (angulation °) motor) USS – determine presence of any
Assess skin collections/radiolucent foreign bodies
Rotation (twist) - Wound and skin around # (e.g. S Swab – open wounds for culture
Length of distraction/shortening cellulitis, ulcers)
Signs of complications

MANAGEMENT: SIDE NOTES:


Resuscitate Advanced trauma life support in life Other aspects to management:
threatening wounds - For swelling: Rest, Ice, Elevation
Reduce Open reduction - Stop smoking!
Closed manipulation - Analgesia
Traction - Antibiotic prophylaxis for open #
Retain External fixation - Treat the cause of # if necessary
Internal fixation e.g. osteoporosis, fall etc.
Conservative immobilisation
Rehabilitate Physiotherapy to regain function
MODES OF BONE HEALING FRACTURE HEALING

1. Primary bone healing


 Intramembranous healing (via Haversian remodeling)
– occurs with absolute stability constructs
2. Secondary bone healing
 Involves responses in the periosteum and external soft
tissues
 Enchondral ossification – occurs with non-rigid
fixation, as # braces, external fixation, bridge plating,
intramedullary nailing etc.

FACTORS INFLUENCING OSTEOGENESIS:


1. Injury variables (extensive soft tissue injury) Stage 1: Tissue destruction and hematoma formation
o Open # Stage 2: Inflammation and cellular proliferation
o Severity of injury Stage 3: Callus formation
o Intra-articular # Stage 4: Consolidation
o Segmental # - disrupt intramedullary blood supply Stage 5: Remodelling
o Soft tissue interposition
o Damage to blood supply
2. Patient variables
o Age (rate decreases as aging)
o Excessive movement at # site PERKIN’S RULE OF # HEALING TIME (in weeks)
o Nutrition
3. Tissue variables SPIRAL TRANSVERSE (multiply by 2)
o Form of bone (cancellous faster than cortical) Union (healing) Consolidation Union (healing) Consolidation
o Bone necrosis UPPER LIMB 3 6 6 12
o Bone disease LOWER LIMB 6 12 12 24
o Infection
4. Treatment variables
o # stabilization

OPEN FRACTURE
PATHOLOGICAL FRACTURES
Fractures which occur from low energy injuries through an area of
GUSTILO CLASSIFICATION
bone weakness with a pre-existing abnormality.
GUSTILO TYPE I II IIIA IIIB IIIC
Energy Low Moderate High High High
Ddx:
Wound size <1 cm >1 cm >10 cm >10 cm >10 cm
1. Tumors
a. Primary benign – giant cell tumor, non-ossifying Soft tissue Minimal Moderate Extensive Extensive Extensive
fibroma, simple bone cyst Contamination Clean Moderate Extensive Extensive Extensive
b. Hematopoietic disorders – multiple myeloma, # pattern Simple Moderate Severe Severe Severe
leukemia, lymphoma with comm. comm. or comm. or comm. or
c. Secondary malignant – breast 50%, prostate 20%, minimal segmental segmental segmental
lungs 10%, kidney 5%, thyroid 5%, melanoma comm. # # #
2. Metabolic Periosteal No No Yes Yes Yes
a. Pagets disease stripping
b. Osteomalacia Skin coverage Local Local Local Requires Typically
c. Osteoporosis coverage coverage coverage free tissue requires
d. Hyperparathyroidism flap or flap
e. Renal osteodystrophy rotational coverage
3. Developmental flap
a. Osteogenesis imperfect coverage
b. Osteopetrosis Neurovascular Normal Normal Normal Normal Exposed #
4. Infection injury with
a. Osteomyelitis arterial
damage

GUSTILO CLASSIFICATION OF OPEN # Management of open #:


1. Admit the patient and stabilize
2. Vital sign monitoring
3. Stop bleeding
4. Immobilize # site
5. Control pain
6. Parenteral antibiotics
7. Tetanus prophylaxis
8. Nil by mouth
9. Early wound debridement and external fixation

FRACTURE COMPLICATIONS
CLOSED FRACTURE
EARLY COMPLICATIONS LATE COMPLICATIONS
LOCAL:
1. ACUTE COMPARTMENT SYNDROME – an elevation of interstitial
pressure in closed fascial compartment resulting in microvascular
compromise (5P’s)- signs of ischaemia
 Pain out of proportion
 Parasthesia 1. DELAYED UNION
 Paralysis
2. NON UNION – no signs of healing after 3 – 6 months
 Pallor
(depending on # site)
 Pulseless
a. Atrophic
2. VASCULAR INJURY causing hemorrhage, internal/external
3. VISCERAL INJURY causing damage to surrounding structures b. Hypertrophic
4. NERVE/SKIN/SURROUNDING TISSUES INJURY 3. MALUNION
4. JOINT STIFFNESS
SYSTEMIC: 5. CONTRACTURES
1. ACUTE FAT EMBOLISM SYNDROME – a syndrome caused by an 6. MYOSITIS OSSIFICANS
inflammatory response to embolized fat globules 7. AVASCULAR NECROSIS (AVN)
 Respiratory insufficiency (tachypneic) 8. GROWTH DISTURBANCE / DEFORMITY
 CNS depression (agitated, disoriented)
 Petechial rash
 Management: high flow mask, close observation, stabilize
and rehydrate
 *Gurd and Wilson criteria
2. DEEP VEIN THROMBOSIS
OPEN FRACTURE
EARLY COMPLICATIONS LATE COMPLICATIONS
1. HYPOVOLEMIC SHOCK 1. CHRONIC OSTEOMYELITIS 6. JOINT STIFFNESS
2. ACUTE FAT EMBOLISM SYNDROME 2. AVASCULAR NECROSIS (AVN) 7. CONTRACTURES
3. ACUTE COMPARTMENT SYNDROME 3. DELAYED UNION 8. MYOSITIS OSSIFICANS
4. SURROUNDING SOFT TISSUES INJURY 4. NON UNION 9. GROWTH DISTURBANCE /
5. MALUNION DEFORMITY

COMPARTMENT SYNDROMES IATROGENIC COMPLICATIONS:


 # of the limbs can cause severe ischaemia by damage to a major 1. CASTS: pressure ulcers, thermal burns, thrombophlebitis,
artery or increasing the osteofascial compartment pressure by prolonged cast immobilization may cause circulatory
swelling due to bleeding/edema disturbances, inflammation, osteoporosis, chronic edema, soft
 Decreased capillary flow  muscle ischaemia  more edema  tissue atrophy and joint stiffness
more pressure  decreased capillary flow 2. TRACTION: muscle wasting and weakness, pressure ulcers,
 Thus rapid pressure build-up, leading to muscle and nerve necrosis pneumonia/UTIs, permanent footdrop, contractures, peroneal
 Can also result from crush injuries (falling debris or simple nerve palsy, pin tract infection, thromboembolism
compression if pt unconscious for long period) or an over-tight cast 3. EXTERNAL FIXATION: pin tract infection, pin loosening or
 Any compartment, tibia # greatest risk breakage, interference with movement of joint, neurovascular
 Watch for signs of renal failure (low output uraemia with acidosis) damage due to pin placement, misalignment due to poor
placement of fixator
B. FRACTURES IN ELDERLY (OSTEOPOROSIS)
DEFINITION and DIAGNOSTIC: DEMOGRAPHICS: RISK FACTORS:
OSTEOPOROSIS:
- Ade-related decrease in bone mass 1. Male:female ratio is 1:4 – men have a
secondary to uncoupling of osteoclast- higher prevalence of secondary
osteoblast activity osteoporosis (60%) including
- Disrupted microarchitecture hypogonadism, glucocorticoid excess,
alcoholism
2. Osteoporosis
 Postmenopausal osteoporosis is highest
in women aged 50-70 years
 Senile osteoporosis begins after 70 years
 Secondary osteoporosis begins at any
age
3. Location of fractures
 Wrist # - common at age 50-60 years
 Vertebral # - common at age 60-70 years
 Hip # - common at age 70-80 years
 Vertebral body # > hip # > wrist #

HISTORY: ASSOCIATED CONDITIONS: PATHOPHYSIOLOGY:


FRAGILITY #:
- Direct relationship between degree of
1. Back pain – can be severe if fractured or
bone loss and #
collapsed vertebra
- Kyphotic deformity can arise from
2. Loss of height over time, with an
vertebral body #
accompanying stooped posture
- Pelvic ring insufficiency # most often
3. # of vertebra, wrists, hips or other bones
treated with bed rest and analgesia
- Total hip arthroplasty with constrained
components are a risk factor for fragility
#

IMAGING: MANAGEMENT: COMPLICATIONS OF TX:


1. RADIOGRAPHS Non operative treatment:
 Indications – suspicion of #, loss of 1. Biphosphonates Osteonecrosis Atypical
height, pain in thoracic/lumbar spine - First line therapy of jaw (onj) subtrochanteric
 Recommended views – lateral spine, AP - Indicated in hip/vertebral #, T-score transverse
pelvis or hip <2.5 at femoral neck or spine, low bone stress #
 Findings – thinned cortices, loss of mass Associated IV Long-term
trabecular bone, kyphosis, codfish - Mechanism: accumulate at sites of with biphosphonates biphosphonates
vertebra bone remodeling and are incorporated Incidence Rare Rare
2. DEXA SCAN (Dual Energy X-ray into bone matrix; are released into acid Mechanism Extremely low
Absorptiometry) environment once bone is resorbed and bone turnover
 Lumbar spine – measures BMD from L2 then taken up by osteoclasts; decrease rates
to L4 osteoclastic bon resorption, flattening Treatment Stop Operative
 Hip – measures BMD from femoral neck, of osteoclast ruffled border and biphosphonates fixation with
trochanter and intertrochanter region increased osteoclast apoptosis. intramedullary
3. BIOPSY 2. Calcium & Vit D nail and stop
 May be helpful to rule out osteomalacia 3. HRT biphosphonates
EXTRA NOTES:

OSTEOPENIA OSTEOPOROSIS

Decreased BMD BMD <2.5 SD from


peak bone mass
No histological Requires
requirements histological analysis
C. ACL, PCL AND COLLATERAL LIGAMENT INJURIES
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Pop sound Look
Mechanism of ACL Injury  Pain with gradual swelling  Mild swelling - loss peripatellar gutter
 Sudden stop o Pain at the side (CL)  Redness
 Sudden change of direction  Tender joint line Feel
 Direct hit  Warmth
 Discomfort during walking
 Extreme hypertension  Tender at ligament site/joint line/meniscus
 Instability (giving way) Move
Mechanism of PCL Injury  Locking (uncommon)  Normal range of motion, maybe reduce due
 Direct hit from front (dashboard injury)  Unhappy triad (MCL+ACL+meniscus to pain.
 Seizure injury)
 Twisting/hyperextension Testing for CL injury Testing for ACL and PCL
do at 0° (CrL + CL) and 30° (CL only)  Anterior and posterior drawer test
Mechanism of MCL and LCL Injury  Varus stress test (LCL) - one hand on medial  Sagging sign for PCL injury - flex knee 90°,
 Direct hit from inside to outside (LCL) or knee, grasps ankle and adduct knee. see the tibia sag ()
outside to inside (MCL)  Valgus stress test (MCL) - one hand on  Lachmann test for ACL injury - hold distal
lateral knee, grasps ankle and abduct knee. thigh one hand to stabilize, another hand
pull the tibia up-outward.
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray To exclude avulsion fracture Present or absent
MRI Can see soft tissue injury with involvement of Partial or complete tear. Normally in ACL
meniscus injury injury associated with meniscus
S Arthroscopy Visualize the extent of the injury Partial/complete ligament tear
MANAGEMENT: COMPLICATION: SIDE NOTES:
After injury - RICE  Adhesion Diagnosis is based on clinical sign and
CONSERVATIVE Off weight on affected knee  Instability symptom
by giving crutches/brace  Osteoarthritis
MEDICAL Control pain by analgesia
Physiotherapy to maintain
muscle power
SURGICAL ACL/PCL reconstruction
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Valgus Stress test (MCL test) Varus Stress test (LCL test)

Posterior Drawer Sign Sagging sign


D. KNEE MENISCUS INJURIES
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Mechanism of injury  Recurrent pain at joint Look
 Standing on semi flex knee, twist his body to  Gradual swelling  Mild swelling - loss peripatellar gutter
one side  Locking knee  Quadriceps atrophy (late)
Feel
 Clicking sound
Common site is at posterior horn.  Warmth
 Instability - giving way
 Tender at joint line
Type of tear  Reduce ROM Move
 Bucket handle tear  Full flex but reduce extension
 Radial Testing for Meniscal injury
 Longitudinal  McMurray test - fully flex hip and knee. Apply valgus force and externally rotate tibia while knee
 Anterior and posterior horn extension (medial meniscus). Vice versa
 Apley’s grinding test - prone, knee flex at 90°. Fix the leg by putting on leg on the thigh. rotate tibia
while compressing (meniscal). Then distraction test by rotate and pulling up (ligament)
 Thessaly test - patient stand with lift of one leg. Slightly flex the other leg. Twist body while holding
to something.
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I MRI To confirm the meniscal injury Meniscal tear
S Arthroscopy To visualize the meniscal injury Injury site. Bloody fluid if meniscal injury or cruciate
ligament tear. Fat globule suggest fracture
MANAGEMENT: COMPLICATION: SIDE NOTES:
After injury - RICE  Osteomyelitis Sensitivity of test (in sequence)
CONSERVATIVE Off weight on affected knee  Instability 1. Joint line palpation
by giving crutches  Chronic knee injury 2. Thessaly’s test
Back slab 3. McMurray’s test
MEDICAL Control pain by analgesia 4. Apley’s grinding test
Physiotherapy to maintain
muscle power
SURGICAL Suture the tear part via
arthroscopy
Meniscectomy
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Thessaly’s test Apley’s grinding test


E. MUSCLE INJURIES
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Type  Pain, tearing sensation Look
 Acute  Swelling  Swelling
 Chronic (overuse/repetitive)  Bruising/ecchymosis  Bruising/ecchymosis
 Deformity
 Limited ROM
 Scars (if any)
 Activity during injury - sport, exercise
Feel
stretching  Warmth and tenderness
Move
 Active and passive movement
Special
 Muscle power
 Sensory testing
 Peripheral pulses

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC Look for anemia or current infection Normal or reduce in Hb and raise in WBC
Creatinine kinase Release in muscle injury Raise
I Ultrasound To look for inflammation of the muscle Inflamed and hematoma.
MRI To look degree of injury in the muscle Partial or complete tear.
MANAGEMENT: COMPLICATION: SIDE NOTES:
After injury - RICE  Acute compartment syndrome Indications for surgical Intervention
CONSERVATIVE Immobilization  DVT • Large Intra-muscular haematoma
Rehabilitation  Myositis ossificans • Complete muscle tear (3rd Degree)
MEDICAL Pain control by analgesia  Muscle fibrosis • Partial tear (2nd degree) if more than half of
 Calcified myonecrosis muscle belly is affected)
• Scars adhesion that cause persistent pain &
SURGICAL Reattachment of muscle limited extension
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
F. REGIONAL FRACTURES & DISLOCATIONS
G. OVERUSE INJURY OF SOFT TISSUES
BURSITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Bursae is fluid filled sacs lined by synovial  Mechanical pain *PE depend on patient presenting complain. Like if
membrane.  Local swelling in elbow then examine the elbow not the gait.
 Redness
Causes Look
 Direct trauma
 Continuous pressure/repetitive use  Swelling
 Gout  History of repetitive use/athlete  Redness
 Rheumatoid arthritis  Gait
 Infection Feel
 Warmth and tender
Site of bursitis  Consistency and fluctuation
 Olecranon B (Student elbow) Move
 Trochanteric B  Active, may restricted due to pain
 Illiotibial B (illiotiial Band Syndrome - ITBS) Special
 Prepatellar B (Housemaid’s knee)  Ober’s test for ITBS - lay on unaffected side. Flex
 Intrapatellar B (Clergyman’s knee) knee 90°. Abduct and slight extend affected leg.
 Pes Anserinus B Drop the leg into adduction - positive if leg stay
 Retrocalcaneal B at level due to tight IT band.

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC To differentiate infected bursae Normal
ESR CRP Marker for inflammation Mildly raised
Uric acid To exclude gout Normal range
I MRI To ruler out tissue damage Normal
S Aspiration To investigate the fluid content, differentiating Normal
from gout and septic bursitis
MANAGEMENT: COMPLICATION: SIDE NOTES:
Rest  Sepsis
CONSERVATIVE Physiotherapy to strengthen  Osteomyelitis
the muscle  Fistula
MEDICAL Antibiotic  Chronic bursitis
Pain control - PCM, NSAIDs  Muscle atrophy

SURGICAL Aspiration
Excision

EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!


RUNNER’S KNEE
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Also known as patellar tendinitis  Pain over front of knee, under knee cap Look
 Swelling  Quadriceps wasting
Mode of injury  Crepitus  Swelling
 Mechanical overload of patella-femoral joint  Crepitus
 History of injury or recurrent
 Repetitive usage Feel
displacement
 Fluid shift
 Aggravated by climbing, standing and
Cartilage softening and fibrillation  Peripatellar tenderness
prolong siting  Mal-alignment of patellar
 History of repetitive use - athlete Move
 Active
Special
 Apprehension test - push the patellar sideway
while flexing the knee.

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X ray To visualize angle or position of the patella Abnormal tilting/subluxation
MRI To accurately measure the malalignment Malalignment
Arthroscopy To visualize cartilage Soften
MANAGEMENT: COMPLICATION: SIDE NOTES:
Activity modification  Chronic knee pain Prevention
CONSERVATIVE Physiotherapy  Osteoarthritis • Run on softer surface
• Gradually increase distance or hillwork
MEDICAL Pain control by analgesia • Wear proper shoe
• Stretching and strengthen quadriceps muscle

SURGICAL Correcting the alignment,


reduce patellar-femoral
pressure and congruence
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
SHIN SPLINT
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Injury at front outer leg causing local  Pain within lower half shin Look
inflammation  Pain at the starting of exercise but  Swelling
Nerve irritation to tendonitis to stress fracture reduce as session continue  Redness
Common in runner Feel
 Pain regress next day and worsen
Causes  Warmth and tenderness over shin
 Running on uneven terrain  Pain when plantar flex
Move
 Sudden increase speed during running  Swelling (sometime)  Normal ROM
 Sudden change of running surface  Redness (rare)
 Excessive uphill running
 Running with worn down shoe

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray To rule out fracture Normal
MANAGEMENT: COMPLICATION: SIDE NOTES:
Proper running shoe  Stress fracture Prevention
CONSERVATIVE Stretching prior to exercise  Wear proper shoe
Rest  Stretching before start exercising
Running on soft surface  Slowly increase intensity of exercise
Ice treatment
MEDICAL Anti-inflammatory
SURGICAL Nil

EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!


2. ORTHOPAEDIC INFECTIONS
Infection (pathogenic organisms multiply and spread within the body injuries)  acute / chronic inflammatory reaction  redness, swelling, heat, pain and
loss of function

BONE & JOINT INFECTION

OSTEOMYELITIS SEPTIC ARTHRITIS

SOFT TISSUE INFECTION

GAS GANGRENE
NECROTIZING FASCITIS
CELLULITIS
HAND INFECTION (PARONYCHIA, FELON, SUPPURATIVE TENOSYNOVITIS, WEB SPACE INFECTION, DEEP PALMAR ABCESS)
A. BONE & JOINT INFECTIONS
OSTEOMYELITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
An inflammation of bone caused by an infecting Risk factors : Acute :
organism, usually affect long bones of the leg Diabetes mellitus LOOK – Febrile and dehydrated, classic signs of
IV drug use inflammation – redness, heat localized to the
Can be acute or chronic metaphyseal area of the bone
Acute – formation of pus, localized in an abcess Acute : Abscess in the muscle or subcutaneous plane
Chronic – formation of granulation tissue, leading - High grade fever FEEL– Swelling of the adjacent joint
to fibrosis - Severe pain MOVE – Pseudoparalysis (restricted)
- Local redness, swelling, warmth, edema
Spread : Chronic:
Hematogenous (previous infection) Chronic: LOOK – Chronic discharging sinus
Lymphatics (lymphangitis, lymphadenopathy) - Chronic discharging sinus (sero-purulent FEEL – Thickened, irregular bone. Tenderness
Exogenous (injection, open fractures, surgery) thick pus) MOVE – Stiff adjacent joint
- Minimal pain and tenderness
- Pyrexia or fever
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B Full blood count Evaluating leukocytosis or anaemia Polymorphonuclear leukocytosis
ESR Inflammatory activity in body Elevated
CRP Sensitive marker for monitoring progress Elevated
Blood C&S To detect the microorganism Presence of microorganisms
I X-rays Reveal damage to the bone Acute: Periosteal new bone deposition
Chronic : Cortical thickening, sclerosis and
irregularity, Loss of trabecular architecture,
osteolysis, Sequestrum – devitalized bone that
serve as a site of infection, Involucrum – new
bone formation around area of bone necrosis
CT Scan For preoperative planning to detect osseous Abnormal thickening of the affected cortical
abnormalities, foreign bodies, or necrotic bone bone, with sclerotic changes, encroachment of
and soft tissue. the medullary cavity, and chronic draining sinus.
MRI Early detection of osteomyelitis and assessment MRI findings are different depending on the
of the extent of involvement and the activity of pulse sequences used (T1-weighted or T2-
the disease in cases of chronic bone infection weighted) and on the disease stage
Bone scan In early stage, when x-ray shows normal findings Abnormal/ tumor/infection – increased
concentration in specific area eg: metaphysis
S Bone biopsy Gold standard for diagnosing osteomyelitis, Microbiologic diagnosis of osteomyelitis
because it can also reveal what particular type of
germ has infected your bone
MANAGEMENT: COMPLICATION: SIDE NOTES:
- Splinting or cast for - Recurrence of bone infection and chronic Common microorganism:
CONSERVATIVE immobilization – allow osteomyelitis Infant – Staphyloccocus aureus
healing and avoid further - Bone abscess Children – Haemophillus influenza
trauma - Septic arthritis Young adult – Nesseria gonnorhea
MEDICAL - Antipyretic and analgesic - Septicemia Adult – Staphylococcus aureus / Streptococcus /
– reduce fever and pain - Growth arrest or impaired bone growth Gram bacilli
- IV or oral antibiotic - Non union fracture IVDU – Pseudomonas
therapy, based on - Deep vein thrombosis and pulmonary Elderly – Polymicrobial / salmonella
aspiration and biopsy embolism
SURGICAL - Drainage of infected fluid
or pus by needle
aspiration
- Wound irrigation and
debridement followed by
organism specific
antibiotic
- Amputation if worsens
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Pathogenesis

1) Bacterial seeding favorable in the metaphyseal region. Why Metaphysis???


- Lack phagocytic activity
- Slow flow and more turbulent
- Highly vascularize
- U-shaped small end arteries favors trapping of infected embolus

2) Acute inflammatory response (edema + pus formation) will increase intramedullary pressure, this will lead to
- Vascular collapse
- Eventually causing tissue necrosis and bone breakdown
- Forming acute osteomyelitis

3) Poor management and prolong condition (>6 weeks), will cause more destruction and obstruction of blood supply, leading to
- Avascular necrosis, so more death of bone tissue
- Formation of a piece of dead bone tissue separated from the bone structure (sequestrum) – hallmark for chronic osteomyelitis

4) New bone formation (Involucrum) will occur


- Has multiple openings or sinuses, which exudates (pus) and debris from sequestrum pass through to external environment
- Forming chronic osteomyelitis
SEPTIC ARTHRITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Inflammation of a joint that’s caused infection, Acute joint swelling LOOK – Redness, swelling of the joint
usually affects one large joint in the body, such as Swollen and tender joint FEEL – Tenderness at the joint
knee or hip Erythema MOVE – limitation of active and passive range of
Fever motion
Impaired range of motion actively and passively

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC To determine the presence and number of red Increase white blood cell count
and white blood cells that would indicate
reaction to an infection in order to help evaluate
and monitor the condition
ESR Inflammatory activity in body Elevated
CRP Sensitive marker for monitoring progress Elevated
Blood C&S To determine if a microorganism is present in the Presence of microorganisms
blood
I X-ray Establish a baseline and may detect fractures, Reveal the linear deposition of calcium
chondrocalcinosis, or inflammatory arthritis. pyrophosphate
Ultrasonography Detect early effusions, and guide joint aspiration Presence of effusion
and drainage procedures.
MRI Suggest an acute intraarticular infection Combination of bone erosions with marrow
edema
S Synovial fluid analysis To detect the presence of inflammatory cells or Presence of microoerganisms
crystals that may indicate either an infectious or
non-infectious cause (just as gout) for joint pain
and symptoms
Arthrocentesis identify the causative infectious agent

MANAGEMENT: COMPLICATION: SIDE NOTES:


- Physical therapy consists Joint degeneration and permanent damage Microorganisms involve:
CONSERVATIVE of maintaining the joint in Infant – Staphyloccocus aureus
its functional position and Children – Haemophillus influenza
providing passive range- Young adult – Nesseria gonnorhea
of-motion exercises Adult – Staphylococcus aureus / Streptococcus /
MEDICAL - Appropriate antimicrobial Gram bacilli
therapy, which may IVDU – Pseudomonas
require intravenous Elderly – Polymicrobial / salmonella
antibiotics.
- Treated for inflammation
and pain with a
nonsteroidal anti-
inflammatory drug
(NSAID)
SURGICAL - **Primary treatment –
Joint drainage
- Surgical drainage may be
required in any infected
joint which does not
respond to medical
treatment
B. SOFT TISSUE INFECTIONS
GAS GANGRENE
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Complication of necrosis characterised by the Posttraumatic gas gangrene – sustained serious LOOK – Blisters with foul smelling brownish
decay of body tissues caused by Clostridium injury to the skin or soft tissues or have discharge, Pale skin that quickly turns gray, dark
species. A life-threatening bacterial infection experienced open fractures red, purple, or black
with gangrene which has the following three Postoperative gas gangrene – frequently FEEL – Intense pain and swelling around the
features: undergone recent surgery of the GI or biliary wound. Crepitus follows gas production
tract MOVE – Reduce movement
- Muscle necrosis A sudden onset of pain. The pain gradually
- Sepsis worsens but spreads only as the underlying
- Gas production - usually a mixture of infection spreads.
hydrogen, carbon dioxide, nitrogen and
oxygen
-
These can rapidly lead to septicaemia, septic
shock and death.
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC To determine the presence and number of red Hemolytic anaemia, leukocytosis, increase LDH
and white blood cells that would indicate
reaction to an infection in order to help evaluate
and monitor the condition
CRP Suggestive of necrotising soft-tissue infections Elevated
Skin cultures To test for the presence Presence of microoerganisms
of Clostridium perfringens and other bacteria
I X-ray Can help delineate the typical feathering pattern May demonstrate gas in the soft tissues and/or
of gas in soft tissue indicate underlying osteomyelitis
CT Scan Detect necrotizing soft tissue infections
MRI To view interior body structures and assess the
extent to which gas has spread.
MANAGEMENT: COMPLICATION: SIDE NOTES:
Fluid replacement Multi-organ failure
CONSERVATIVE (intravenous fluids) and good Spread to involve bone marrow
nourishment. Disseminated intravascular coagulation
Hyperbaric oxygen therapy -
kills anaerobic C. perfringens
MEDICAL Cover Gram-negative, Gram-
positive and anaerobes - eg,
combination of penicillin,
gentamicin and
metronidazole.
SURGICAL Radical debridement of
necrotic tissue (may require
amputation if a limb is
involved)
Damaged tissues can also be
treated with skin graft
NECROTIZING FASCIITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Infections of any of the layers within the soft - Due to antecedent trauma or surgery LOOK – Oedema extending beyond the area of
tissue compartment (dermis, subcutaneous - Intense pain and tenderness over the erythema, skin vesicles, and crepitus
tissue, superficial fascia, deep fascia, or muscle) involved skin and underlying muscle Rapid spread of infection
that are associated with necrotizing changes - May begin at a site distant from the Bullae appearance
initial traumatic insult FEEL – Pain disproportionate to appearance
Etiology – Group A beta haemolytic - History of cormorbid status MOVE – Crepitus
streptococcus - Fever – high grade + chill + rigor

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC A low WBC count may be a sign of severe sepsis. abnormally high or low WBC count with or
If a spreading soft-tissue infection is present, without a left shift (elevated percentage of
necrotising fasciitis should be suspected. polymorphonuclear leukocytes and/or bands)
CRP non-specific finding that may be seen in a range Elevated
of systemic infections
I Plain radiography Help to identify subcutaneous gas
CT Scan Identify other causes of infection, particularly Increased thickness of the fascia layer with or
deep abscesses without enhancement can be associated with
NSTI.
S Finger test Lack of resistance to finger dissection in normally Lack of bleeding, malodorous 'dishwater pus'
adherent tissues and lack of normal tissue resistance to blunt
finger dissection
Tissue biopsy Gram stain and culture of affected tissues Histological findings: Obliterative vasculitis of
the subcutaneous vessels, acute inflammation,
and subcutaneous tissue necrosis
Excisional deep skin biopsy Helpful in diagnosing and identifying the
causative organisms
MANAGEMENT: COMPLICATION: SIDE NOTES:
Fluid and nutritional support - NF carries a significant mortality rate,
CONSERVATIVE particularly if marine organisms are
involved.
MEDICAL Immediate empirical - Septic or toxic shock (the latter due to
antibiotic therapy streptococcal endotoxin production).
- The deep tissue infection may lead to
SURGICAL Surgical emergency, arrange vascular occlusion, ischaemia and tissue
for prompt regimen surgical necrosis. There may be nerve damage
debridement or amputation if and muscle necrosis.
necessary - Large areas of tissue loss may require
skin grafting, reconstructive surgery or
amputation.
CELLULITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Cellulitis is a bacterial infection of the deepest - Area of skin redness or swelling that LOOK – Red, swelling, glossy look
layer of your skin. gets larger FEEL – Tenderness
Bacteria can enter your body through a break in - Tight, glossy look to skin MOVE – Muscle aches
the skin - from a cut, scratch, or bite. - Mild pain or tenderness
- Skin rash that happens suddenly and
grows quickly
- Signs of infection including fever, chills
and muscle aches

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B Full blood count Evaluating leukocytosis or anaemia Leukocytosis, leukopenia
ESR Inflammatory activity in body Elevated
CRP Sensitive marker for monitoring progress Elevated
I Ultrasonography Detection of occult abscess and direction of care fluid collection seen if abscess is present
CT scan Indicated if abscess is suspected (e.g., if tender fluid collection seen if abscess is present; orbital
fluctuance is present on examination or if there or preseptal (periorbital) cellulitis
is an incomplete response to antimicrobial
therapy). Also indicated in evaluation of orbital
and preseptal (periorbital) cellulitis.
S Aspiration and culture Growth of typical pathogen (e.g., Streptococcus
pyogenes)
MANAGEMENT: COMPLICATION: SIDE NOTES:
Elevation of the Sometimes cellulitis can spread entering the
CONSERVATIVE affected leg can assist with lymph nodes and bloodstream causing:
the edema and inflammation, - Sepsis
thus help in the recovery. - Bone infection
- Inflammation of the lymph vessels
- Gangrene
MEDICAL Antibiotics - Necrotizing fascitis
If disease widespread,
antibiotic should be given
intravenously.
Pain reliever in severe pain
Treat any underlying causes
HAND INFECTION

(PARONYCHIA, FELON, SUPPURATIVE TENOSYNOVITIS, WEB SPACE INFECTION, DEEP PALMAR ABCESS)
Paronychia Felon Suppurative Web space infection Deep palmar abcess
tenosynovitis
Definition Soft tissue infection Closed-space inflammation of a Infection of the web Purulent infection of
around a fingernail infections of the tendon and its sheath space deep spaces in the
that begins as cellulitis fingertip pulp palm
but that may progress
to a definite abscess
Management - Frequent hot soaks - Incision and - Pain relief - Drainage of the - Close
- Short course of drainage - Antibiotic therapy multiloculated observation
antibiotics - Elevating and abscess - Antibiotics
- If pus is present, immobilizing the - Drainage and
drainage and hand debridement
dressing is required - Consulting an - Rehabilitation
experienced hand
surgeon
DIFFERENTIAL DIAGNOSIS HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
- An insect bite or sting (which can closely History of trauma LOOK – Red, swollen, exquisitely tender over the
mimic a subcutaneous infection) - Superficial abrasion site of tension
- A thorn prick (which, itself, can become - Laceration FEEL – Tender over the site of tension
secondarily infected), - Penetrating wound MOVE –
- Acute tendon rupture (which may resemble a -Superficial infection  able to flex the finger
septic tenosynovitis) Predisposing conditions -Deep infection  active flexion of the finger is
- Diabetes mellitus not possible
- Drug abuse
- Immunosuppression

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
U Radiography Useful in excluding fractures and retained
foreign bodies if they are radiopaque.
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
3. SPINAL DISORDERS
A. SPINAL INFECTIONS
1. Predisposing factors:
 Diabetes mellitus
 Malnutrition
 Substance abuse
 Human immunodeficiency virus (HIV) infection
 Malignancy
 Long-term use of steroids
 Renal failure
 Septicemia
Common chief complaint

Localized pain of the Muscle spasm of back Restricted movement


back

2. Differential diagnosis of spinal infection:


 Spinal osteomyelitis
 Discitis
 Tuberculosis
PYOGENIC OSTEOMYELITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Pathology:  Localized, dull back pain *cardinal symptom 1. General Examination:
 Most common pathogen involved:  Often intense, unremitting, worsens  Ill-looking
 Staphylococcus aureus upon straining  Increased pulse rate (tachycardia)
 Escherichia coli and  Muscle spasm  Feverish
Pseudomonas in  Restricted movement
immunosuppressed patients  Non-specific symptoms: chills, low-grade 2. Focus Examination:
 Sources of infection: fever and malaise
 Haematogenous spread  History of some invasive spinal procedure LOOK – redness at the back region
 Inoculation during invasive  History of distant infection during the
procedures (spinal injections and preceding few weeks FEEL – tenderness on palpation of the involved
disc operations) spinal segment, paraspinal spasm
 Infection begins in vertebral end plate
spread to  disc and adjacent vertebra MOVE – limitation of motion
 May spread from;
 Along the ant. longitudinal lig.  3. Assess patient’s neurological function
adjacent vertebra or,
 Outwards  paravertebral soft 4. Examine patient’s skin, ENT, chest and pelvis
tissues (from thoracic spine  to exclude a focus of infection
along psoas  groin) / (from
lumbar region  buttock, * In children, they have an awkward gait with a
sacroiliac joint or, hip) stiff spine, or if the lumbar spine is involved they
can present with abdominal symptoms and signs

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B Full blood count Increased in white cell count indicates infection Elevated white cell count (leukocytosis)
ESR/CRP To detect any infection/inflammation Elevated
Blood culture Essential in patients who are febrile though it is Positive
often negative in the early stages of infection
U Urinalysis
I X-rays/plain radiograph of affected area Early signs:
 Loss of disc height
 Irregularity of the disc space
 Erosion of the vertebral end-plate
 Reactive new bone formation
 Soft tissue swelling
MRI May show characteristics changes in the
vertebral end-plates, intervertebral disc and
paravertebral tissues
S Radionuclide scanning Increased activity at the site
MANAGEMENT: COMPLICATION: SIDE NOTES:
CONSERVATIVE  Bed rest

MEDICAL  Pain relief


 IV antibiotic
administration for 4-6
weeks (vancomycin or
linezolid as MRSA has
become a common
infecting agent)
 Continue with oral
antibiotic for 6-8 weeks if
there is;
 Clinical
improvement
 A falling CRP and
ESR
 A normal white
cell count
* Duration of antibiotic
treatment depends on the
clinical, haematological and
radiological findings
SURGICAL Seldom needed.

1. Open biopsy and


decompression
 Indication for an open
biopsy and
decompression are:
 Failure to obtain
a +ve yield from a
closed needle
biopsy and a poor
response to
conservative
treatment
 The presence of
neurological signs
 The need to drain
a soft tissue
abscess
 Anterior approach is
preferred; necrotic and
infected material is
removed and the cord is
decompressed
 Rib or iliac grafts to
reconstruct anterior
column defect
 If the spine is unstable,
posterior fixation may be
necessary
 Postoperatively, spine is
supported in a brace until
healing occurs
2. Posterolateral
extrapleural /
retroperitoneal
decompression and
instrumentation (in the
elderly and
immunocompromised
patients)
3. Laminectomy (for a
primary epidural abscess)
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
DISCITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Infection limited to the intervertebral disc is
rare  Acute back pain MOVE – Severe limitation of movement
 Occur usually due to direct inoculation  Muscle spasm
following discography, chemonucleolysis or  History of some invasive procedure
discectomy
 Vertebral end-plates are rapidly attacked and * In children, there may be history of flu-like
the infection then spreads into the vertebral illness followed by back pain, muscle spasm and
body severe limitation of movement

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B Full blood count Increased in white cell count indicates infection Elevated white cell count (leukocytosis)
ESR/CRP To detect infection/inflammation Elevated
I X-rays/plain radiograph of affected area
MRI
S Radionuclide scanning Increased activity at the site
MANAGEMENT: COMPLICATION: SIDE NOTES:
CONSERVATIVE  Bed rest

MEDICAL  Analgesics
 Broad-spectrum
antibiotic following any
injection into the disc
SURGICAL  Surgical evacuation or
decompression indicated
if there are signs of;
 Abscess
formation
 Cord or nerve
root pressure
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
SPINAL TUBERCULOSIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Most common site of skeletal tuberculosis  Long history of ill health and backache 1. Back Examination
 Blood-borne infection  Paraesthesiae and weakness of the legs
 Settles in vertebral body adjacent to the LOOK – cold abscess pointing to the groin,
intervertebral disc  followed by bone gibbus deformity in late cases
destruction and caseation, with infection
spreading to the disc space and adjacent FEEL – local tenderness in the back
vertebrae
 Paravertebral abscess may form, and then track MOVE – spinal movements are restricted
along muscle plane  sacro-iliac or hip joint, or
along the psoas muscle  thigh 2. Neurological Examination
 As the vertebral body collapse into each other,
a sharp angulation (gibbus or kyphos) develops Motor and/or sensory changes in the lower
 Major risk of cord damage due to: limbs
 Pressure by the abscess
 Granulation tissue ** Spinal TB is found mostly in the thoracic
 Sequestra or displaced bone spine, spastic paraparesis is a common
 Ischaemia from spinal artery presentation in adults.
thrombosis
 With healing, vertebrae re-calcify and bony
fusion may occur
 If there has been much angulation, spine is
usually ‘unsound’, and flares are common
 With progressive kyphosis  risk of cord
compression

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B Full blood count Increased in white cell count indicates infection Elevated white cell count (leukocytosis)
ESR Raised in acute stage
I X-rays/plain radiograph of entire spine  Earliest signs of infection:
 Local osteoporosis of two adjacent
vertebrae
 Narrowing of intervertebral disc
space, with fuzziness of the ned-
plates
 Progressive disease is associated with signs
of:
 Bone destruction and collapse of
adjacent vertebral bodies into each
other
 Paraspinal soft-tissue shadow (due to
either oedema or a paravertebral abscess)
Chest X-ray
MRI and CT scan May reveal:
 Hidden lesions
 Paravertebral abscess
 Epidural abscess
 Cord compression
S Mantoux test To diagnose tuberculosis May be positive
Needle biopsy Recommended in patients with no neurological
signs to confirm the diagnosis by histological
and microbiological investigation
Open operation To obtain tissue if needle biopsy does not
provide firm diagnosis
MANAGEMENT: COMPLICATION: SIDE NOTES:
AIM OF  To eradicate or arrest the Pott’s paraplegia
TREATMENT OF infection
SPINAL TB  To prevent or correct 1. Early-onset paresis (usually within 2years of
deformity disease onset)
 To prevent or treat the  Due to pressure by inflammatory oedema,
major complication - an abscess, caseous material, granulation
paraplegia tissue or sequestra
 Patient presents with LL weakness, UMN
CONSERVATIVE  Ambulant chemotherapy signs, sensory dysfunction and
/ MEDICAL alone (for early or limited incontinence
disease with no abscess  Diagnosis confirmed by MRI or
formation or neurological myelography
deficit)  Treatment: early anterior decompression
 Rifampicin 600mg and debridement followed by spinal fusion
daily + isoniazid  Prognosis for neurological recovery
300mg daily + following surgery is good
pyrazinamide 2g
daily (given in 2. Late-onset paresis
combination for 6-  Due to direct cord compression from
12 months or until
x-ray shows increasing deformity, or vascular
resolution of bone insufficiency of the cord
changes)  If MRI or myelography reveals direct cord
 Ethionamide and decompression  operative removal of
streptomycin may necrotic tissue
substitute isoniazid
(if resistant
mycobacteria)
 Continuous bed rest and
chemotherapy (for more
advanced disease)
SURGICAL Operative treatment is
indicated:
 When there is an abscess
that can readily be drained
 For advanced disease with
marked bone destruction
and threatened or actual
severe kyphosis
 Neurological deficit,
including paraparesis, that
has not responded to drug
therapy

 Anterior approach
 All infected and
necrotic material is
evacuated or
excised and the gap
is filled with iliac
crest or rib grafts
Anterior and posterior
fixation and fusion may be
needed for additional
stability
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
B. SPINAL DEGENERATIVE DISORDERS
1. Common chief complaint  back pain
2. Differential diagnosis (three groups of disorders to be excluded):
 Inflammatory disorders
- Such as ankylosing spondylitis, cause severe and more generalized stiffness and typical x-ray changes
 Vertebral tumours
- Cause constant pain and x-rays show bone destruction or a pathological fracture
 Nerve tumours
- May cause sciatica but pain is continuous, CT or MRI may delineate the lesions
CERVICAL SPONDYLOSIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Degenerative condition of the cervical spine  Pain and stiffness LOOK – loss of normal cervical lordosis
 Occur in individual >50 years of age  Initially intermittent but later
 Men > women persistent FEEL – tenderness over the lower cervical spine
 Occurs early in persons pursuing ‘white collar  Occipital headache if upper half of or in the muscles of the paravertebral region
jobs’ or those susceptible to neck strain cervical spine is affected
(because keeping neck constantly in one  Radiating pain MOVE –
position while reading, writing etc.)  To shoulder or downwards on outer  UL may have signs of nerve root
 Pathology begins in IV disc: aspect of the forearm and hand compression (C6 root involvement)
 Degeneration of disc results in   May be paraesthesia in the region of  LL must be examined for signs of early cord
reduction of disc space & peripheral nerve root, commonly over base of compression (e.g. +ve Babinski reflex)
osteophyte formation thumb (along C6 nerve root)  Muscle weakness is uncommon
 Posterior intervertebral joints get  Muscle weakness is uncommon
secondarily involved  generate  Giddiness
pain in neck  Episodes of giddiness because of
 Osteophytes impinged on the nerve vertebro-basilar syndrome
roots  radicular pain in the UL
 Osteophytes press on spinal cord 
signs of cord compression
 Cervical spondylosis occurs most commonly
in the lowest three cervical intervertebral
joints (commonest at C5-C6)

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X- ray of cervical spine (AP and lateral  Narrowing of IV disc spaces (most
views) commonly between C5-C6)
 Osteophytes at the vertebral margins,
anteriorly and posteriorly
 Narrowing of the intervertebral foramen in
cases presenting with radicular symptoms
(best seen in oblique view)
MANAGEMENT: COMPLICATION: SIDE NOTES:
During period of remission:
CONSERVATIVE  Proper neck posture:
/ MEDICAL avoid situations where
patient has to keep the
neck in one position for a
long time. Only a thin
pillow should be used at
night
 Neck muscle exercise:
help in improving neck
posture
During episode of acute
exacerbation:
 Analgesics
 Hot fomentation
 Rest neck in cervical
collar

Traction to the neck if
there is stiffness
 Anti-emetics if there is
giddiness
SURGICAL Surgical decompression (in
exceptional case where the
spinal cord is compressed by
osteophytes)
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
LUMBAR SPONDYLOSIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Degenerative disorder of the spine  Begin as low backache (initially worst during
characterized clinically by an insidious onset activity, but later present almost all the FEEL – muscle spasm
of pain and stiffness and radiologically by time)
osteophyte formation  A feeling of ‘a catch’ while getting up from a MOVE – spinal movements are limited terminally
 Causes: sitting position and improves when walking
 Bad posture and chronic back strain a few step SPECIAL TEST – Straight leg raising (SLR) test
(commonest cause)  Pain may radiate down the limb up to the positive if nerve root compression is present
 Previous injury to the spine calf (sciatica)
 Previous disease of the spine  Transient numbness and paraesthesia in the
 Birth defects dermatome of a nerve root, commonly on
 Intervertebral disc prolapse the lateral side of leg or foot (L5, S1 roots)
 Degeneration begins in intervertebral joints respectively
 followed by a reduction in the disc space
and marginal osteophyte formation
 Degenerative changes develop in the
posterior facet joints
 Osteophytes around the intervertebral
foramen may encroach upon the nerve root
canal  interfere with the functioning of the
emerging nerve

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X- ray of lumbo-sacral spine (AP and  Reduction of disc space
lateral views)  Osteophyte formation
 Narrowing of joint space of the facet joints
 Subluxation of one vertebra over another
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Treatment is essentially
CONSERVATIVE similar to cervical
/ MEDICAL spondylosis.
 As the symptoms subside,
spinal exercises are
advised
 In some resistant cases,
lumbar corset may have
to be used at all times
SURGICAL  Spinal fusion may
occasionally be necessary
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
DEGENERATIVE DISC DISEASE
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 With ageing disc properties change (gradual  Varies from person to person
loss of proteoglycans and the disc becomes  Depends on the location of affected disc: FEEL – tenderness over the affected spinal
somewhat dehydrated and degenerate)   Affected disc in the neck area may region
decreased mechanical properties result in neck or arm pain
 Ligaments/facets assume greater load  can  Affected disc in the lower back may MOVE – reduced range of motion
be source of pain result in pain in the back, buttock or
leg
 Pain often gets worse with movements such
as bending over, reaching up or twisting
 In some cases, may have numbness or
tingling in the leg or arm

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X- ray  Flattening of the ‘disc spaces’
 Spur formation at the borders of the
vertebral bodies, often accompanied by
characteristics features of osteoarthritis in
the small facet joints
MRI  Bulging of one or more discs in both sagittal
and axial projections
 Diminished thickness and reduced signal
intensity, or small tears and fissures in the
disc
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Postural and muscle In long-term progress, patient may develop any
CONSERVATIVE strengthening exercises associated features such as;
/ MEDICAL  Daily activities  Degenerative spondylolisthesis
modification  Facet joint osteoarthritis
 Analgesics  Spinal stenosis
SURGICAL In some cases, surgery may
be recommended (lumbar
fusion or disc replacement
are options)
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
C. SPINAL MALIGNANCY
1. Differential diagnosis of a solitary bone lesion

FEATURES GIANT CELL TUMOUR SIMPLE BONE CYST ANEURYSMAL BONE CYST FIBROUS DYSPLASIA
AGE 20 – 40 years < 20 years 10 – 40 years 20 – 30 years
COMMON BONES Lower femur, upper tibia, Upper humerus, upper femur Tibia, humerus Neck of the femur, tibia
lower radius
LOCATION Epiphysis Metaphysis Metaphysis Metaphysis
X-RAY Soap-bubble appearance, Maximum width less than Distending lesion, Multi-loculated, ground
eccentrically placed width of growth plate ‘ballooning’ the bone glass appearance,
trabeculations +++
TREATMENT Excision Curettage and bone graft Curettage and bone graft Curettage and bone graft
PREFERRED
GIANT CELL TUMOUR (OSTEOCLASTOMA)
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Common bone tumour with variable growth
potential  Swelling and vague pain (common LOOK – swelling located eccentrically at the end
 Pathology: presenting complaint) of the bone, deformed limb if pathological
 Cell origin is uncertain fracture has occurred
 Microscopically, consists of
undifferentiated spindle cells, FEEL – smooth surface of bony swelling located
profusely interspersed with multi- eccentrically at the end of the bone, tenderness
nucleate giant cells on firm palpation
 Tumour stroma is highly vascular

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-Ray Characteristics radiological features:
 Solitary, may be loculated, lytic lesion
 Eccentric location, often subchondral
 Expansion of overlying cortex
 ‘Soap-bubble’ appearance
 Cortex may be thinned out, or perforated at
places
 No calcification within the tumour
 None or minimal reactive sclerosis around
the tumour
 Tumour usually does not enter adjacent
joints

MANAGEMENT: COMPLICATION: SIDE NOTES:


SURGICAL  Wherever possible,  Recurrence following treatment is a serious
excision of the tumour is problem
the best treatment.  With every subsequent recurrence, the
 However, for sites like tumour becomes more aggressive
the spine, where excision
is sometimes technically
not possible,
radiotherapy is done
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
MULTIPLE MYELOMA
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 A malignant neoplasm derived from plasma  Multiple site involvement GENERAL EXAMINATION – Patient looks weak
cells  Increasingly severe pain in the thoracic and
 Pathology: lumbar spine LOOK – no swelling or deformity unless a
 Affects flat bones (the pelvis, vertebrae,  Loss of weight pathological fracture occurs
skull and ribs)
 May occur as a solitary lesion FEEL – local tenderness over the affected bones
(plasmacytoma), multiple lesion
(multiple myeloma), extra-medullary ** Neurological symptoms may result if the
myelomatosis or diffuse myelomatosis tumour presses on the spinal cord or the nerves
 Lesions are mostly small and in the spinal canal
circumscribed
 Bone is simply replaced by tumour
tissue and there is no reactive new
bone formation
 Grossly, the tumour is soft, grey and
friable
 Microscopically, it consists of sheets of
closely packed cells
 Typically have and eccentric nucleus
with clumped chromatin
 Affects adults > 40 years of age
 Men > women

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
Full blood count (FBC) Low haemoglobin
ESR High ESR
B To support diagnosis of multiple myeloma  Increase total protein
Liver function test (LFT)
 A/G ratio reversed
Serum calcium Increased
Bence Jones proteins are found in 30 per cent
U Urine To support diagnosis of multiple myeloma
of cases
I X-Ray Characteristics radiological features:
 Multiple punched out lesions in the skull
and other flat bones
 Pathological wedge collapse of the
vertebra, usually more than one,
commonly in the thoracic spine. The
pedicles are usually spared
S Serum electrophoresis Abnormal spike in the region of gamma
globulin (myeloma spike) is present in 90
percent of cases
Sternal puncture Myeloma cells may be seen
Bone biopsy from iliac crest, or CT guided To support diagnosis of multiple myeloma May show features suggestive of multiple
needle biopsy from vertebral lesion myeloma
Bone scan May be required in cases presenting as solitary
bone lesion, where lesions at other sites may
be detected on bone scan
Open biopsy Required sometimes, to confirm the diagnosis
MANAGEMENT: COMPLICATION: SIDE NOTES:
Consists of control of the Pathological fractures
CONSERVATIVE tumour:
/ MEDICAL  Chemotherapy
 Melphalan (drug of
choice) given in
combination with
Vincristine,
Prednisolone, and
sometimes
Cyclophosphamide
 Cycles are repeated
every 3-4 weeks for
6-12 cycles
 Splintage to the diseased
part by POP, brace etc.
 Radiotherapy which are
useful in cases with:
 Neurological
compression
 Localized painful
lesions
 Fractures
 Soft tissue masses
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
METASTASIS IN BONE
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Commoner than the primary bone tumours  Patient with known primary malignancy,
 Tumours most commonly metastasizing to who presents with symptoms suggestive of
bone are: secondaries in the bone, which are:
 Carcinoma of the lung in the male  Bone pain
 Carcinoma of breast in the female  Pathological fracture
 Other malignancies are:  Patient who is not a known case of primary
 Carcinoma of prostate malignancy, who presents with:
 Carcinoma of thyroid  Bone pain (diagnosed by
investigation due to destructive
lesion in the bone)
 Pathological fracture

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR Indication of bony secondaries High ESR
I X-Ray In a case with known primary:
 Metastatic deposits
In a case presenting first time with bony
secondaries:
 Sclerotic secondaries in the bone
MANAGEMENT: COMPLICATION: SIDE NOTES:
Consists of:
CONSERVATIVE  Symptomatic relief of
/ MEDICAL pain
 Prevention of any
pathological fracture
 Control of secondaries by
chemotherapy or
radiotherapy
SURGICAL Limited, mostly to the
management of pathological
fracture
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
D. SPINAL TRAUMA
ACUTE INTERVERTEBRAL DISC PROLAPSED
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 ‘Prolapsed disc’ means the protrusion or  Low backache
extrusion of the nucleus pulposus through a  Acute: LOOK – posture
rent in the annulus fibrosus  Severe with spine held rigid by  Patient stand with a rigid, flattened
 It is a sequence of changes in the disc, which muscle spasm lumbar spine
ultimately leads to its prolapse  Any movement at spine is  The whole trunk is shifted forwards
 These changes consist of the following: painful in the hips
 Nucleus degeneration  Chronic:  Trunk is tilted to one side (scitatic tilt
 Softening of the nucleus and  Dull and diffuse or scoliosis)
its fragmentation  Made worse by exertion,  The sideways tilt tends to exaggerate
 Weakening and disintegration forward bending, sitting or on attempted bending forwards
of the posterior part of the standing in one position for a
annulus long time
 Nucleus displacement  Relieved by rest
 Disc protrusion  Sciatic pain
 Disc extrusion  Pain radiates to gluteal region, back of
 Once extruded, disc does not the thigh and leg
go back  In S1 root compression  radiates to
 Extruded disc may lost its posterolateral calf and heel
contact with the parent disc  In L5 root compression  radiates to
 this is called sequestrated anterolateral aspect of leg and ankle
disc  In a disc prolapse at higher level (L2,
 Stage of fibrosis L3)  radiates to the front of thigh
 The stage of repair  Radiation often begin on walking, is
 Site of exit of the nucleus is usually relieved on rest (neurological FEEL – tenderness
posterolateral claudication)  Diffuse tenderness in the lumbo-
 Commonest level of disc prolapse is between  Neurological symptoms sacral region
L4-L5 or C5-C6  Paraesthesias (pins and needles)  Localized tenderness in the midline
 Numbness in the leg or foot or lateral to the spinous process
 Weakness of the muscles
 In cases with large disc material MOVE – unable to bend forward
compressing the theca and roots:
 Irregular LMN type paralysis in SPECIAL TEST –
the lower limbs  Straight leg raising test (positive SLR
 Bilateral absent ankle jerks test at 40 o
̊ r less is suggestive of root
 Hypoaesthesia in the region of compression
L5 to S4  Lasegue test (pain in the back of
 Urinary and bowel thigh or leg)
incontinence
NEUROLOGICAL EXAMINATION –
 Motor weakness
 Sensory loss
 Loss of reflex
* corresponding to the affected nerve root (L4, L5
and S1 more commonly affected)
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I Plain x-ray To rule out bony pathology such as infection  Does not show any positive signs of acute
disc prolapse
 In chronic disc prolapse,
 Affected disc may be narrowed
 Lipping of the vertebral margins
posteriorly
Myelography  Perform in cases where precise localization of  Complete or incomplete block to the flow of
the neurological signs is not possible dye at the level of a disc
 Used in cases where facilities for a CT scan are  An indentation of the dye column
not available  Root cut off sign: appears on x-ray as an
abrupt blunting of the dye column filling the
root sheath

CT scan  Disc appears flat or convex


 Loss of pre-thecal fat shadow normally seen
between the posterior margin of the disc and
theca
 Herniated disc material can be seen within
spinal canal, pressing on the nerve roots or
theca
MRI scan Investigation of choice  Shows prolapsed disc, theca and nerve roots
very clearly
Electromyography Helps in localizing the offending disc in cases with  Findings of denervation, localized to the
multiple disc prolapse. distribution of a particular nerve roots
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Rest: on a hard bed is safdf Secondary changes associated with disc prolapse:
CONSERVATIVE necessary for not more  Changes in structures occupying spinal
/ MEDICAL than 2 – 4 days canal
 Drugs: analgesics and  Changes in intervertebral joints
muscle relaxants
 Physiotherapy: hot
fomentation, gentle
arching exercises
 Others: lumbar traction,
transcutaneous electrical
nerve stimulation (TENS)

SURGICAL Indications of operative


treatment:
 Failure of conservative
treatment
 Cauda equina syndrome
 Severe sciatic tilt
Disc is removed by the
following techniques:
 Fenestration: ligamentum
flavum bridging between
two adjacent laminae
excised and the spinal
canal at the affected level
exposed
 Laminotomy: in addition
to fenestration, a hole is
made in the lamina for
wider exposure
 Hemi-laminectomy:
whole of lamina in one
side is removed
 Laminectomy: laminae on
both sides, with the
spinous process are
removed

Chemonucleosis
 An enzyme
(chymopapain) is injected
into the disc, which leads
to dissolution and fibrosis
of the disc and thus relief
symptoms
 Done through few
puncture wounds

Percutaneous discectomy
 Disc is removed by using
an endoscope
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
VERTEBRAL FRACTURES
1. Thoracolumbar
 Burst fracture (axial compression injury)
 Chance’s fracture (flexion-distraction / Jack-knife injury)
2. Pars interarticularis (traumatic spondylosis)

STABLE INJURY UNSTABLE INJURY


 The vertebral components will not be displaced by normal  There is a significant risk of displacement and consequent damage,
movements or further damage, to the neural tissues
 If neural elements are undamaged, there is little risk of them
becoming damaged

3. In assessing spinal stability, three structural elements must be considered:


 Posterior osseoligamentous complex (or posterior column)  pedicles, facet joints, posterior bony arch, interspinous and supraspinous
ligament
 Middle column  posterior half of the vertebral body, posterior part of intervertebral disc and posterior longitudinal ligament
 Anterior column  anterior half of vertebral body, anterior part of intervertebral disc and anterior longitudinal ligament
4. All fractures involving middle column and at least one other column should be regarded as UNSTABLE
5. Pathophysiology:
 Primary changes
 May be limited to vertebral column
 Spinal cord and/or nerve roots may be injured
 Secondary changes
 More gradual cellular disruption and extension of the initial neurological damage
THORACOLUMBAR FRACTURES
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
1. Axial compression or burst injury  Pain +/- numbness or weakness 1. SPINE EXAMINATION
 Usually caused by severe trauma or extreme  History of high energy trauma
force LOOK – bruising over the back region following
 The term implies that the vertebra has been injury
crushed in all directions and the space for the
spinal cord and nerves is compromised FEEL – tenderness over the back region
 Vertebra is crushed completely  bony following injury
fragments spread out  spinal cord injury
 Severe axial compression may ‘explode’ the 2. NEUROLOGICAL EXAMINATION
vertebral body  failure both ant. and mid.
columns Motor, sensory and reflexes
 Considered unstable and requires immediate
medical attention 3. RECTAL EXAMINATION
2. Flexion-distraction fracture / Jack-knife injury
(Chance’s fracture) To assess sphincter tone
 Vertebra is literally pulled apart (distraction)
 Occur in a head-on car collision when the
upper body is thrown forward while the pelvis
is stabilized by a lap seat belt
 There is little or no crushing of the vertebral
body, but the post. and mid. columns fail in
distraction, thus this fracture is unstable in
flexion
 Neurological damage is uncommon

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray (AP and lateral views) 1. Burst injury
 AP x-ray shows spreading of the
vertebral body with an increase of the
interpedicular distance
2. Chance’s fracture
 Horizontal fractures in the pedicles or
transverse processes
 In AP view, the apparent height of the
vertebral body may be increased
 In lateral view, there may be opening
up of the disc space posteriorly
CT scan 1. Burst injury
 Posterior displacement of bone into
spinal canal (retropulsion)
MANAGEMENT: COMPLICATION: SIDE NOTES:
1. Burst injury NEUROLOGICAL:
CONSERVATIVE  If there is minimal ant.  Spinal cord/cauda equina injury
/ MEDICAL / wedging and # is stable with
SURGICAL no neurological damage; IMMOBILIZATION:
 Kept in bed until  Deep venous thrombosis (DVT)
acute symptoms  Pulmonary embolism
settle (usually a
week) SURGICAL:
 Then, mobilized in a  Infection
thoracolumbar  Dural tears
brace or body cast
(worn for 12 weeks)
 If there are signs of present
or impending neurological
compromise (tingling,
weakness or alteration of
bladder or bowel function);
 Anterior
decompression and
stabilization
2. Chance’s fracture
 Posterior spinal fusion
 Heals rapidly and requires 3
months in a body cast or
well-fitting brace

EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!


PARS INTERARTICULARIS (TRAUMATIC SPONDYLOSIS)
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Occur in young athletes involved in repetitive  Pain (sharp at first then more dull and achy) 1. SPINE EXAMINATION
bending and straightening of the spine  Aggravated by standing, bending backward
or repetitively and forcefully extending the LOOK – bruising over the back region following
spine injury

FEEL – tenderness over the back region following


injury

2. NEUROLOGICAL EXAMINATION

Motor, sensory and reflexes


INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray (oblique view) Thin fracture line at the pars interarticularis

S Isotope bone scan May show the ‘hot’ spot


MANAGEMENT: COMPLICATION: SIDE NOTES:
 Stop the activity or sport
CONSERVATIVE that evokes the back pain
for up to 12 weeks
 May need brace if pain is
not adequately relieved
 Fracture usually heals
spontaneously

EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!


E. CORRELATING SPINAL ABNORMALITIES
SPONDYLOLISTHESIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Forward displacement a vertebra over the one below
it LOOK – visible ‘step’ above the sacral crest,
 Commonly occurs between L5-S1, and between L4-L5 increased lumbar lordosis
 Occasionally, the displacement is backwards
(retrolisthesis) FEEL – palpable ‘step’ above the sacral crest d/t
 Pathology:  Backache with or without sciatica forward displacement of the spinal column
 Divided into the following types:  Aggravated by standing or walking
 Isthmic: commonest, lesion in pars  Neurological symptoms in the LL SPECIAL TEST – positive straight leg raising test
interarticularis (sometimes) (SLR)
 Lytic: fatigue fracture of the  In large number of cases,
pars interarticularis abnormality is symptomless
 Intact but elongated pars
interarticularis
 Acute fracture of the pars
interartcularis
 Dysplastic: least common, congenital
abnormality
 Degenerative: common in elderly
people
 Pathological: results from a
generalized or localized bone disease
 Traumatic: rare, following an injury
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray (lateral and oblique views)  Anterior displacement of one vertebra over
other on lateral view
 Oblique view may show defect of the pars
interarticularis
 Scotty dog appearance

Scotty dog

MANAGEMENT: COMPLICATION: SIDE NOTES:


CONSERVATIVE  Rest
 External support
 Flexion exercises
 Lifestyle change (change
job)
SURGICAL  Decompression of
compressed nerves if any by
fusion of the affected
segments (intertransverse
fusion)
 Internal fixation devices
(pedicular screws and rods)
 helped in early
mobilization of the patient
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
SPINAL STENOSIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Narrowing of spinal canal results in cord/root 1. SPINAL EXAMINATION
compression  Pain
 Causes: hypertrophy of facet capsule or  relieved by sitting / forward leaning MOVE – pain with back extension
ligamentum flavum, bulging disc, (neurogenic claudication)
DDD/osteophytes  Paraesthesia 2. NEUROLOGICAL EXAMINATION
3. PERIPHERAL PULSE
 Intact pedal pulses would confirm
the claudication as spinal rather
than arterial
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray  Shows features of disc degeneration and
proliferative osteoarthritis or degenerative
spondylolisthesis
CT scan  Canal narrowing
MRI To evaluate cord/root compression

MANAGEMENT: COMPLICATION: SIDE NOTES:


 Activity modification
CONSERVATIVE  Flexion exercises
 Nerve root
blocks/epidural injection

MEDICAL  NSAIDs

SURGICAL  Decompression
(laminectomy +/- partial
facetectomy)
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
F. CORRELATING NERVOUS TISSUE PRESENTATION (SPINAL CORD AND ROOT)
1. Acute and chronic myelopathy and radiculopathy
2. Spinal shock and neurogenic shock
3. Cauda equina syndrome
4. Incomplete cord lesions (anterior cord syndrome and central cord syndrome)
5. Neurogenic bladder
MYELOPATHY AND RADICULOPATHY
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
MYELOPATHY MYELOPATHY MYELOPATHY
 Any neurologic deficit related to the spinal  Insidious onset (symptoms over 1 – 2 years)  Gait: slow, broad-based ataxic gait
cord  Axial neck pain (often times absent),  Finger escape sign positive
 Pathology: compression of the spinal cord by occipital headache common  small finger spontaneously abducts
osteophyte or extruded disc material in the  Diffused non-dermatomal numbness and when patient holds finger extended
spine tingling and adduct d/t weakness of intrinsic
 Weakness and decrease manual dexterity muscle
 Loss of balance, weakness walking up and  Grip and release test positive
down the stairs  failure to make a fist and release 20
 Urinary retention (rare and only occur in late times in 10 seconds
disease progression)  UMN lesion signs
RADICULOPATHY  spastic weakness
 A sharp aching pain in the neck and shoulder  increased tone and hyperreflexia
 Radiating down on one or both arms (arms > legs)
 Precipitated by sudden neck  sustained clonus
 Older patients typically men > 50 years old movement on awakening  Babinski test positive
RADICULOPATHY  Stiffness of neck with limitation of RADICULOPATHY
 A condition characterized by involvement of movement  Neurological examination
a single or group of nerves  Nocturnal pain, waking patient at night  sensation, strength and reflexes of
 Pathology: compression (e.g. from an  Unilateral dermatomal numbness and the lower extremities
intervertebral disc or osteophytes) or tingling  Musculoskeletal examination
irritation of the nerve root as it exits and  numbness/tingling in thumb (C6)  assessment of the lower extremity
emerges from the spinal cord  numbness/tingling in middle finger joints, as pain referral pattern may
(C4) be confused with focal peripheral
 Unilateral weakness involvement
 difficulty with overhead activities
(C7)
 difficulty with grip strength (C7)
 Radiculopathy in roots L1-L3, refers pain to
ant. aspect of thigh and typically does not
radiate below knee

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I Plain radiographs (AP, Lateral and  In lateral view, look for:
Oblique views)  disc space narrowing, comparing
the level above and below
 subchondral sclerosis
 osteophyte formation
 In oblique view, look for:
 foraminal stenosis
MRI  Demonstrates the spinal cord and soft tissue
structure
 Helps to exclude other causes of similar
neurological dysfunction
S Nerve conduction studies  To distinguish peripheral from central
process
MANAGEMENT: COMPLICATION: SIDE NOTES:
MYELOPATHY
CONSERVATIVE  physical therapy for neck
strengthening, balance
and gait training
RADICULOPATHY
 immobilization (decrease
inflammation and muscle
spasm)
 rehabilitation via moist
heat, cervical isometric
exercise
MEDICAL  NSAIDs
 Muscle relaxants for
radiculopathy
SURGICAL MYELOPATHY
 Ant. cervical discectomy /
corpectomy and fusion
 Post. laminectomy and
fusion
 Cervical disc arthroplasty
RADICULOPATHY
 Ant. cervical discectomy
 Post. foraminotomy
 Cervical total disc
replacement
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
CAUDA EQUINA SYNDROME
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 compression of cauda equine
 bilateral leg pain
 usually from large midline disc herniation or INSPECTION – lower extremity muscle atrophy
 weakness of lower limb
extrusion with insidious presentation
 reduce perianal sensation (Saddle
 surgical emergency
anaesthesia) PALPATION – palpation of the bladder (for
 urge incontinence urinary retention)

NEUROLOGICAL EXAMINATION –
 bilateral lower extremity weakness and
sensory disturbances
 decreased or absent lower extremity
reflexes

RECTAL/GENITAL EXAMINATION –
 Reduced or absent sensation in the perianal
region (S2-S4 dermatomes), perineum and
post. thigh
 decreased rectal tone or voluntary
contracture
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray Normal or disc space narrowing
MRI Compression of cauda equina
MANAGEMENT: COMPLICATION: SIDE NOTES:
SURGICAL Emergency surgical
decompression:
 laminectomy
 discectomy

EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!


SPINAL SHOCK AND NEUROGENIC SHOCK
SPINAL SHOCK NEUROGENIC SHOCK
A temporary condition following transection of the spinal cord A type of shock that is caused by the sudden loss of signals from the
characterized by: sympathetic nervous system
 muscular flaccidity and,
 loss of motor reflexes in all parts of the body below the point
of transection
SPINAL SHOCK NEUROGENIC SHOCK
MECHANISM Peripheral neurons become temporarily unresponsive Loss of sympathetic tone  decrease systemic vascular
to brain stimuli resistance (vasodilation)
BP Hypotension Hypotension
PULSE Tachycardia Tachycardia
MOTOR Flaccid paralysis Variable
REFLEXES Absent Variable
MANAGEMENT  Immobilization  Monitoring for careful fluid management
 Neurological charting until return of  Vasopressors
bulbocavernous reflex
 Early surgical inervention
INCOMPLETE CORD LESIONS
CENTRAL CORD SYNDROME ANTERIOR CORD SYNDROME
Commonest Less common
 Initial flaccid weakness  LMN paralysis of the UL with UMN  Complete paralysis and anaesthesia but deep pressure and
(spastic) paralysis of LL, and intact perianal sensation position sense are retained in the LL (dorsal column sparing)
 Bladder control may or may not be preserved from an early stage
SCOLIOSIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Scoliosis is the sideways curvature of the spine. In most cases, visible deformity is the only Trunk should be completely exposed and the
symptom. Pain is occasionally a feature in adults patient examined from in front, from the back
Two types: with a long-standing deformity. and from the side.
non-structural (transient) and
structural (permanent). In structural scoliosis, the In exceptional cases of severe long-standing Skin pigmentation and congenital anomalies
vertebrae, in addition to sideways tilt, are rotated scoliosis, sharp angulation of the spinal cord over such as sacral dimples or hair tufts are sought.
along their long axis; in non-structural scoliosis the apex of the curve may result in interference
they are not. with cord functions, leading to a neurological The spine may be obviously deviated from the
deficit. midline, or this may become apparent only when
*Non-structural scoliosis: the patient bends forward (the Adams test). The
This is a mobile or transient scoliosis. It has three level and direction of the major curve convexity
subtypes: are noted.

Postural scoliosis: It is the commonest overall The hip (pelvis) sticks out on the concave side and
type, often seen in adolescent girls. The the scapula on the convex.
curve is mild and convex, usually to the left.
The main diagnostic feature is that the curve The breasts and shoulders also may be
straightens completely when the patient bends asymmetrical.
forwards.
With thoracic scoliosis, rotation causes the rib
Compensatory scoliosis: In this type, the scoliosis angles to protrude, thus producing an
is a compensatory phenomenon, occurring in asymmetrical rib hump on the convex side of the
order to compensate for the tilt of the pelvis (e.g., curve. In balanced deformities the occiput is over
in a hip disease or for a short leg). The scoliosis the midline; in unbalanced (or decompensated)
disappears when the patient is examined in a curves it is not.
sitting position (in case the leg is short) or when
the causative factor is removed. Side-on posture should also be observed.
Sciatic scoliosis: This is as a result of unilateral Neurological examination
painful spasm of the paraspinal muscles, as may Leg length is measured. If one side is short, the
occur in a case of prolapsed intervertebral disc. pelvis is levelled by standing the patient on
wooden blocks and the spine is re-examined.
General examination includes a search for the
possible cause and an assessment of
cardiopulmonary function (which is reduced in
severe curves)
INVESTIGATION
For proper assessment of
scoliosis, a full antero-posterior X-ray of the spine
in supine and erect positions, plus a lateral view
are necessary.

Severity of the curve is measured


by Cobb's angle – an angle between the line passing
through the margins of the vertebrae at the ends
of the curve.

Radiological assessment regarding the likelihood


of progress of the curve can be made by looking at
the iliac apophysis (b). It fuses with the
iliac bone at maturity and
indicates the completion of growth, and thus no
possibility of the curve worsening. This is called
Reisser's sign.

MANAGEMENT: COMPLICATION: SIDE NOTES:


 Breathing problems (in severe scoliosis)
 Low back pain.
 Lower self-esteem.
Non Operative These consist of  Persistent pain if there is wear and tear of
exercises to tone up the spinal the spine bones.
muscles and give  Spinal infection after surgery.
support to the spine.  Spine or nerve damage from an
Following supports are uncorrected curve or spinal surgery.
commonly used:
Milwaukee brace: This is
named after the city of
Milwaukee where it was
designed
Boston brace: It is
cosmetically more acceptable.

Reisser's turn-buckle cast:


This is a body cast with
a turn-buckle in between.
Tightening of the turn- buckle
stretches the concave side of
the curve, thus correcting the
deformity.

Localiser cast: This is a body


cast applied with the spine in
traction. A special localiser
table is required for this.

Operative Operative methods comprise


of fusion of the spine.

In congenital scoliosis,
simple fusion is sufficient. In
idiopathic scoliosis,
the spine is fused after
achieving some correction
by stretching the spine.

Stretching could be done


pre-operatively by traction
(Cotrel traction), localiser cast,
or halo-pelvic distraction
system. It could be achieved
per-operatively by
Harrington's distraction
system, Dwyer's compression
assembly and Luque-Hartshill
systems.

KYPHOSIS
Excessive backward convexity of the spine. It is of two types; round or angular.
Round Angular
means a gentle backward curvature of the spinal column. It is caused means a sharp backward prominence of the spinal column. It may be prominence
by diseases affecting a number of vertebrae (e.g., senile kyphosis). of only one spinous process because of the collapse of only one vertebral body: as
Such a kyphosis may be localised to a segment of the spine, or it may may occur in a compression fracture of a vertebra. This is called as knuckle. There
be diffuse. may be a kyphosis localized to a few vertebrae, and is called as gibbus. It is seen
commonly in tuberculosis where usually two or more vertebrae are affected.
Causes:
Postural Compensatory Scheurmann's disease Ankylosing spondylitis
This is the commonest type, seen If there is an exaggerated lumbar It is a common type. There is a The disease produces a stiff and kyphotic
in tall individuals, especially in lordosis due to some disease, the gentle round kyphosis in the spine. It begins in young
some tall women, because of thoracic spine develops lower thoracic spine. It is due to men as low backache, which gradually
their tendency to stand with a compensatory kyphosis. osteochondritis affecting the ring spreads to affect the whole spine.
forward stoop. epiphyses of the vertebral bodies.
Chest expansion is reduced because of the
It occurs in the upper dorsal On X-rays, the vertebral bodies limitation of movements at the costo-
spine, and can be corrected by appear wedge-shaped, narrower vertebral joints. In a few cases, hips and
postural training and in front. shoulders are also affected.
physiotherapy.
There may be a dull constant pain
during early stages of the disease,
but later, only kyphosis remains.

Conservative treatment is
adequate for most patients with
pain as the complaint. If the
deformity is severe, especially if it
is compromising the activities in
any way, surgical intervention
may be required.
4. SYNOVIAL AND OSTEOCHODRAL DISEASES IN JOINT DISORDERS
RHEUMATOID ARTHRITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
RA is an autoimmune disease associated with  Age 30 - 50 y/o Look
autoantibodies to Fc portion of Ig G (RF) and to  Slowly progressive, symmetrical,  Swelling
CCP peripheral polyarthritis  Redness
 Joint pain  Muscle wasting
Characterize by  Deformity - ulnar deviation, Boutonniere, swan
 Persistent synovitis  Morning stiffness > 30 min
neck, hammer toe deformity, genu varus and
 Hyperplastic synovium (pannus)  Fatigue and sleep disturbance valgus.
 Vascular proliferation  Deformities  Subcutaneous nodule
 Joint effusion  Family history  Ulcer and callus of foot dorsally
 Symmetrical polyarthritis  Popliteal cyst
 Systemic inflammation Feel
 Warmth
Causes Move
 Women > men  Reduce ROM - hand, elbow, feet.
 Family history - first degree
 Genetic
 Smoking
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC To look at Hb and WBC for anemia and infection Normochromic normocytic anemia
ESR and CRP To look for current inflammation and progress of disease raise
I X ray Bone involvement Soft tissue swelling with possible bone
erosion/effusion
MRI Extend of disease Synovitis and erosion
S Sr ACPA, RF, ANA Prognosis and early manifestation Raised
Joint aspiration To distinguish type of arthritis Cloudy owing to white cell
MANAGEMENT: COMPLICATION: SIDE NOTES:
Rest  Tendon ruptured Common site of joint involvement
CONSERVATIVE Physiotherapy  Joint rupture (Baker’s cyst) • Proximal interphalangeal
 Septic arthritis • Shoulder
MEDICAL Analgesia - NSAIds  Secodary OA of knee and hip • Elbow
Corticosteroid  Spinal cord compression • Hip
DMARDs -  Amyloidosis • Acromioclavicular
Sulfasalazine, • Cervical
Methotrexate, • Temporomandibular
hydroxychloroquine. • Sternoclavicular
Anti-TNF therapy or • Wrist
rifuximab (last choice)
SURGICAL Synovectomy
Total replacement
arthroplasty
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
OSTEOARTHRITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
OA is a degenerative disorder of the joint which  Old age/repetitive usage Look
normally seen in weight bearing (wear and tear)  Joint pain  Swelling
joint (articular cartilage).  Relieve by rest  Deformity - genu varus
 Swelling of the joint  Quadriceps muscle wasting
Type 
 1° OA - old age  Stiffness
Feel
 2° OA  Joint instability  Warmth and tender
o AVN  Locking  Crepitus
o Coxa vara  Irregular joint line due to ostephyte
o CDH Move
o Acetabulum fracture  Reduce ROM
o Obesity
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B Sr uric acid To rule out gout Normal
I X-ray To rule out fracture and extend of the OA Loss/reduce joint space, Osteophyte, Subchondral
cyst, sclerosis, loss bodies, joint deformit
S Rh factor To rule out rheumatoid arthritis Normal
Arthroscopy To see for any loose body Present or maybe absent
MANAGEMENT: COMPLICATION: SIDE NOTES:
Weight reduction  Capsular herniation
CONSERVATIVE Avoid stress  Loose bodies ↑water and proteoglycan depletion → fibrillation →
Local heat  Rotator cuff dysfunction eburnation (when bone exposed) → bone
Exercise to strengthen muscle  Spinal stenosis hypertrophy (osteophyte) → subchondral cyst and
and stability sclerosis → synovial inflamed and thickened →
MEDICAL Control pain by analgesia  Spondylolisthesis deformity and stiffness
Chondroprotective agent -
glucosamine, chondroitin
sulphate
Viscosuplementation -
sodium hylarunon
SURGICAL Osteotomy
Total/partial arthroplasty
Joint debridement
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
GOUT AND PSEUDOGOUT
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Gout is a purine metabolism disorder.  Men over 30 y/o Look
 Severe joint pain, weeks, resolve  Swelling
Characteristic: spontaneously  Redness
 Hyperuricemia  Deformity
 Recurrent attack (chronic)
 Deposition of monosodium urate  Ulcer
 Joint stiffness
monohydrate crystal in joints/periarticular Feel
 Ulcer over the swelling
tissues  Warmth and tender
 Recurrent synovitis  Family history of gout Move
(late)  Reduce ROM of the affected joint .
 Cartilage degeneration
 Renal dysfunction
 Uric acid stone

Risk factor:
 Old, male
 Hyperparathyroidism
 Genetic enzyme defect
 Hemolytic disorder
 Obesity, DM and HPT
 Chronic inflammatory disease
 Alcohol abuse
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC To exclude sign of infection Normal
Sr Uric acid To diagnose gout Markedly raised
I X-ray To look the extent of the disease and condition Joint space narrowing, tophi (punch out cyst/deep
of the bone. erosion), bone destruction
S Rh Factor To exclude rheumatoid arthritis Normal
Joint aspiration To exclude septic arthritis Crystal deposition
MANAGEMENT: COMPLICATION: SIDE NOTES:
Apply ice  Tendon deformity Common site:
CONSERVATIVE Reduce weight , stop taking  Ulceration • MTP joint of big toe
alcohol  Osteoarthritis • Archilles tendons
MEDICAL Control pain by NSAIDs  Infection of the joint • Olecranon bursae
Intraarticular steroid injection  Renal calculi • Ear pinnae
Allopurinol Pseudogout:
Probenecid • Same presentation as gout. Common in
SURGICAL Aspiration hyperparathyroidism and haemochromatosis
Curettage tophi if doesn’t • Pyrophosphate crystal deposition
resolve • Larger joint
• Meniscal calcification on X-ray
• Treated with NSAIDs
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

OSTEOCHONDRITIS DESSICANS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
OD is when a bone underneath the cartilage die  Young male adult Look
due to ischemic necrosis  Intermittent pain  Swelling
 Mild swelling Feel
Pathogenesis was unclear.  Tenderness
 Locking of the joint (floating fragment)
Trauma  edema  capillary compression  Move
localized ischemia  necrosis  Giving way  Reduce ROM, may experience locking

Common site
 Medial surface of media femoral condyle of
knee
 Anteromedial corner of talus of ankle
 Superiomedial femoral head
 Humeral capitulum
 Head of second metatarsal bone
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray Abnormalities of the bone Bone fragment, demarcation of dissecting fragment
MRI To detect early changes. Decrease signal intensity at affected area
MANAGEMENT: COMPLICATION: SIDE NOTES:
Off load on affected side  Osteoarthritis Risk factor
CONSERVATIVE Restriction of activity • Common in children and adolescents (10 to
20 y/o)
MEDICAL Control pain by analgesia
• Active in sports
SURGICAL Arthroscopy to pin the
detached fragment or
remove
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
FROZEN SHOULDER
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Frozen shoulder is characterized by  History of trauma Look
progressive pain and stiffness of glenohumeral  Pain over shoulder joint  Muscle wasting
joint.  Worsen during night time Feel
 Capsule thicken and become tight  Tenderness
 Avoid sleeping on affected side
 Unknown etiology Move
 Stiffness
 Self-limiting disease (after about 18 months)  Reduce active and passive movement of all
 Also known as adhesive capsulitis  Limited abduction and internal rotation motion.
Special test
Stages  Scratch test - scratch from front and back of the
1. Freezing - painful, progressive reduce ROM opposite scapula. Negative if he can do it
2. Frozen - less pain, but stiff remain (joint/tendon not affected)
3. Thawing - improving, normal strength and
motion

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X ray To look for any possible fracture Normal or some degree of arthritis
MRI To look for any affected structure Rotator cuff tear, inflamed tendon
MANAGEMENT: COMPLICATION: SIDE NOTES:
Hot pad  Stiffness and pain perceive Diagnostic
CONSERVATIVE Physiotherapy (pendulum  Fracture when forcefully move • Painful restriction movement
exercise) • Normal X-ray
MEDICAL Control pain by analgesia • Progressive
Intra-articular steroid
injection
SURGICAL Arthroscopy capsular release
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
Normal shoulder joint lining (left) and an inflamed joint lining of frozen
shoulder.
HEMOPHILIC ARTHROPATHY
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Occur due to Hemophilia  Male Look
Recurrent haemarthrosis leading to chronic  Begin when child start to walk  Swelling
synovitis and progressive articular destruction  Bruising  Bruising
 Joint swelling  Instable gait
Hemophilia (plasma con., N=40%) Feel
 Mild - >5%  Difficulty to stay upright
 Effusion
 Moderate - 1% - 5%  Weakness of the limb (nerve Move
 Severe - <1% compression)  Reduce ROM

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC Sign of anemia and platelet count Reduce
I X-ray To look extent of the disease and staging Bone resorption, cyst formation, osteoporosis,
widening of intercondylar notch
S Clotting factor Type of Hemophilia and its severity Reduce Factor 8 or 9
MANAGEMENT: COMPLICATION: SIDE NOTES:
Immobilized the limb (short  Compartment syndrome Arnold and Hilgartner staging
CONSERVATIVE time) • Stage I – soft-tissue swelling;
Physiotherapy • Stage II – osteoporosis and epiphyseal
overgrowth;
MEDICAL Clotting factor • Stage III – slight narrowing of the articular
Control pain by analgesia space and squaring of the bone ends;
• Stage IV – marked narrowing of the articular
SURGICAL Aspiration if very severe space;
Tendon lengthening • Stage V – joint disintegration.
Osteotomy
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
CHARCOT ARTHROPATHY
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Also known as neuropathic arthritis.  Pain Look
 Instability  Swelling
Characteristic:  Swollen joint with deformity  Redness
 Loss of pain sensitivity and proprioception  Deformity - collapse of midfoot arch (rocker
 Destruction of articular surface and bone bottom foot)
 Mass of hypertrophic synovium and bone Feel
fragments  Warmth
 Capsule stretch and increase laxity Move
 Unstable joint  Reduce ROM - hand, elbow, feet.

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray To look extent of disease Subluxation, bone destruction, irregular calcified
masses
MANAGEMENT: COMPLICATION: SIDE NOTES:
Molded splint  Severe foot deformity Stages
CONSERVATIVE Orthosis or cast  Ulceration • Stage 1 (acute, development-fragmentation):
MEDICAL Control pain by analgesia  Nonunion heal lead to floppy foot • marked redness, swelling, warmth; early
radiographs show soft tissue swelling, and bony
SURGICAL Open reduction and internal fragmentation and joint dislocation may be noted
fixation several weeks after onset
Fusion of joint • Stage 2 (subacute, coalescence)
• decreased redness, swelling and warmth;
radiographs show early bony healing
• Stage 3 (chronic, reconstruction-consolidation)
• redness, swelling, warmth resolved; bony healing
or nonunion and residual deformity are frequently
present.
EXTRA NOTES: Acronyms/tables/pictures/anything. Be
creative!
5. COMMON TENDON DISORDERS
TENDINOPATHY
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Tendinopathy
 Disease of a tendon LOOK
 Most affected joint areas  red and swollen area (inflammation)
o Shoulder, elbow, wrist, hip, knee,  erythema
ankle  asymmetry
 muscle atrophy
1. Tendinitis/tendonitis FEEL
 Inflammation of a tendon (redness,  tenderness on the affected area
swelling, heat, soresness) that
1. pain  warm on touch (inflammation)
occurs when the body’s immune MOVE
 get worse when it is used
system detects an injury and
 worse at night and getting up in the  limited range of motion in affected side
responds.
morning
 Body increases blood flow and
2. stiffness
infection-fighting substances to the
3. loss of strength in the affected area
injured tendon
4. tender, red, warm and swollen (if there is
inflammation)
2. Tendinosis
5. crepitus or crunchy sound during the use of
 Degenerative injury to a tendon that
the tendon
does not provoke an immune
response
 It occurs when repetitive,
unrelenting stress over time causes
breakdown of collagen, growth of
abnormal blood vessels and
thickening of tendon’s sheath
(covering)

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC To exclude and identify sign of infection  Increase in the white cell count,
neurtophils
ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint  calcification in tendons or joint
related problem structure
MRI To detect soft tissue injury  small tears on the tendon, ligament,
cartilage or muscle injury
Ultrasound To detect soft tissue injury  thickening, swelling or tears of the
bursae and tendons
MANAGEMENT: COMPLICATION: SIDE NOTES:
 rest and reduce
CONSERVATIVE activity level  Tendon rupture
 ice for the first 24 to  tendinosis
48 hours
 splinting and
immobilization, sling
for rotator cuff
tendonitis
 strengthening and
stretching exercises

MEDICAL  Nonsteroidal anti-


inflammatory drugs
(NSAIDS) or
analgesics – relieve
pain
 Corticosteroid
injection combined
with local anesthesia
SURGICAL  Arthroscopic
 Open surgical
treatment for tendon
decompression and
tenodesis
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Tendinosis Subject Tendinitis


Degeneration Cause Inflammation
Very common Prevalence Rare
6-10 weeks (acute presentation) Recovery period days-2 weeks (acute presentation)
3-6 months (chronic presentation) 4-6 weeks (chronic presentation)

Longer time to heal Quick to heal


Encouragement of collagen synthesis Conservative theraphy Anti-inflammatory modalities and drugs
maturation and strength
Feels better after proper training Presentation Painful when there is movement
QUADRICEPS TENDON TEAR
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Quadriceps Tendon Tear
 Rupture of the quadriceps tendon 1. Tearing and or popping sensation LOOK
leading to distruption in extensor 2. Acute knee pain, swelling and functional  Obese patient
mechanism, at insertion of tendon to the
loss  Suprapatellar swelling
patella  Ecchymosis
3. Inability to straighten the knee
 More common than patella tendon tear  laceration
4. Indentation at the top of kneecap where
 Usually affecting people >40 years old, FEEL
the tendon tore
males>females, more on non dominant  tenderness on the affected area
limb usually unilateral 5. Bruising  warm on touch (inflammation)
6. Cramping  palpable defect in suprapateallar area
Classification: 7. Sagging or drooping kneecap/patella  low lying patella
1. Partial tears 8. Difficulty in walking because knee  swelling
 Not disrupt the soft tissue buckling of giving way MOVE
2. Complete tears  difficulty in ambulating or moving
 Splitting of soft tissue into 2 pieces  limited range of motion in affected side
 lag in extension of the knee
Quadriceps muscle:  patient may extend the knee fully in
1. Rectus femoris supine position but not in flexed
2. Vastus lateralis position, if it is incomplete rupture
3. Vastus intermedius
4. Vastus medialis

Pathophysiology:
1. Eccentric loading of knee extensor (more
load on area other than the center)
2. When foot is planted and knee is slightly
bent
3. In younger patient, the mechanism is usually
direct trauma
4. Various systemic condition that disrupt
tendon vascular supply and tendon structure
 Diabetes mellitus – arteriosclerotic
changes
 Fibrinoid necrosis in chronic synovitis
 Hyperparathyroidism – dystrophic
calcifications and subperiosteal bone
resorption at tendon insertion
 Obesity – fatty degeneration and
increases the load
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC To exclude and identify sign of infection  Increase in the white cell count,
neurtophils
ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint Lateral radiographs
related problem  Obliteration of quadriceps tendon
shadow
 Suprapatellar mass
 Suprapatellar calcific densities
 Spurring of anterior superior patella
 Joint effusion
 Patella baja
 Anterior tilting of superior patella
Axial view
 Tooth sign, vertical ridging of
osteophytes at the quadriceps insertion
on anterior patella

MANAGEMENT: COMPLICATION: SIDE NOTES:


Indicated for partial tear
CONSERVATIVE  Immobilize knee in  Loss of motion and extensor mechanism
full extension for 3 to weakness
6 weeks  Infection, wound compromise and skin
 Range of motion breakdown
exercise  Malalignment of patella, patella alta,
 Quadriceps patellar tilt, patellar subluxation
strengthening until  stiffness
injured leg is in same
length with the
contralateral leg

SURGICAL Indicated for complete tear


 Direct repair of
tenson to patella
 Scuderi technique for
acute tears
 Codivilla tendon
lengthening and
repair technique for
chronic rupture
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
PATELLAR TENDON TEAR
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Patella Tendon Tear
 Disruption of a tendon attaching the LOOK
patella to the tibial tubercle (patella is a  Large hemarthrosis and echymosis
sesamoid bone), usually at the  Elevation of patella height (patella alta)
osseotendinous junction or high riding patella
 Male>female  Diffuse swelling anterior knee
 3 patterns of injury FEEL
 Avulsion with or without bone  Localized tenderness on anterior knee
from inferior pole of patella  Palpable gap between the inferior pole
(most common) of the patella
 Midsubstance  Patella is proximally displaced as
 Distal avulsion from tibial 1. Intermediate, disabling pain compared to contralateral side
tubercle a. Infrapatellar pain MOVE
 Rupture usually due to end stage or long 2. Sudden quadriceps contraction with knee  Unable to perform active straight leg
standing chronic tendon degeneration raise or maintain passively extended
in flexed position
3. Pop or tearing sensation knee
Pathophysiology:  Reduced ROM of knee due to pain
1. Tensile overload of the extensor mechanism 4. Immediate swelling
2. Most ruptures occur with knee in flexed 5. Difficulty with rising and bearing weight
position, >60 degrees
3. When a violent contraction of quadriceps is
resisted by the flexed knee (during landing
after a jump), patellar tendon sustains
greater stress than the quadriceps tendon,
tensile load much higher at the insertion
sites than in midsubstance of tendon, thus
patellar tendon most commonly rupture near
its proximal end, off the inferior pole of the
patella
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint Lateral radiographs
related problem  Patella alta
 Calcification (chronic patella
tendinosis), usually on inferior pole of
patella
Axial view
 Preexisting patellofemoral arthritis
Ultrasonography To diagnose acute and chronic patellar tendon  Hypoechogenicity – acute tears
ruptures  Thickening of tendon at rupture site
and disruption of normal echo pattern
– chronic tears
Magnetic Resonance Imaging To identify patella tendon rupture  Discontinuity of tendon fibers with
adjacent hemorrhage or edema
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Cast or brace
CONSERVATIVE immobilization in full  Reduced quadriceps strength and loss of
extension for 6 weeks full knee flexion
 Therapy program to  Stiffness
regain motion and  Patella baja, when tendon is relatively
strength shortened after repair
 Strengthening  Rerupture
exercise, progressive  Patellafemoral pain
weight bearing
exercise
SURGICAL Primary repair
 End to end repair
 Transosseous tendon
repair
 Suture anchor tendon
repair
Tendon reconstruction
 Semitendinosus or
gracilis tendon
autograft
 Central quadriceps
tendon patellar bone
autograft
 Contralateral bone
patellar tendon bone
autograft
 allograft
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
SHOULDER IMPINGEMENT SYNDROME
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:

Shoulder Impingement Syndrome LOOK


 also known subacromial  Scapular winging
impingement, painful arc syndrome,  Muscle mass or bone
supraspinatus syndrome, swimmer’s asymmetry/atrophy
shoulder and thrower’s shoulder FEEL
 Occurs when the rotator cuff 1. Difficulty reaching up behind the back  Bony tenderness over anterior
tendons, long head of biceps tendon, 2. Gradual increase of shoulder pain with overhead use portion of acromion
glenohumeral joint capsule, of arm/activities (refers to deltoid region)  Shoulder girdle tenderness,
subacromial bursa become impinged  Lateral deformities and atrophy
between the humeral head and MOVE
 Superior
anterior acromion  Stiffness with external and
 clinical syndrome in which the bursa
 Anterior shoulder
internal rotation with arm in 90
or tendons of rotator cuff muscles 3. Weakness of shoulder muscle degrees of abduction
become irritated and inflamed as 4. Difficulty in elevation of arm  Increased external rotation and
they pass through subacromial 5. Stiffness, numbness, paresthesias, clicking, decreases internal rotation in
space, beneath the acromion due to weakness, crepitus of instability and neck pitching arm compared to
impingement by the bones syndromes nonpitching arm
 usually from repeated overhead  Painful arc motion with elevation
activity above the shoulder level
o paper hanging, painting,
repetitive lifting, swimming,
tennis, baseball
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint related problem  Axillary view – glenoid avulsion
and Hill Sachs lesion (rule out
subtle signs of instability)
 Supraspinatus outlet view – to
assess supraspinatus outlet
space (if less than 7 mm, means
has increased risk for
impingement syndrome), hooked
acromion (risk of impingement)
Arthrography To assess integrity of glenohumeral joint and evaluating  If the injected dye escapes out of
rotator cuff tears the joint into subacromial space,
thus indicates full thickness
rotator cuff tear
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Avoid repetitive
CONSERVATIVE overhead  Rotator cuff degeneration and tear
activities with  Biceps tendinitis
affected arm  Frozen shoulder (adhesive capsulitis)
 Do stretching  Reflex sympathetic dystrophy
exercise
MEDICAL Oral anti-inflammatory
medications
 Aspirin,
naproxen,
ibuprofen
 6 to 8 weeks
 Monitor stomach
irritation and
bleeding]
Cortisone type injection
 Potent anti-
inflammatory
medication
 Use when
necessary
SURGICAL  Rotator cuff
repair
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
ROTATOR CUFF TEAR/INJURY
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
LOOK
Rotator Cuff Tear  Shoulder – swelling, atrophy,
 Common cause of shoulder pain asymmetry
 May involves individual or combination of tendons,  Suprapsinatus and infraspinatus –
which often associated with AC joint pathology atrophy (in massive rotator cuff tear
 Ranging from acute reversible tendinitis to massive and entrapment of suprascapular
tears of nerver)
 Supraspinatus 1. Insidious onset of pain by overhead  Scapular winging – rare
 Infraspinatus activities  ST motion abnormalities
 Teres minor  Night pain
 Subscapularis FEEL
2. Weakness
 Function of rotator cuff or SITS is  Tenderness localized to greater
3. Instability
 To provide stability by balancing force tuberosity and subacromial bursa
4. Loss or limited ROM
couples about the glenohumeral joint in  Palpated biceps tendon anteriorly on
both coronal and transverse plane 5. Swelling the bicipital groove – can be inflamed
6. Numbness or painful
Mechanism of tear 7. Catching or popping shoulder
 Chronic degenerative tear – seen in older patients, MOVE
involves the SIT, may extend anteriorly to superior  Reduced Glenohumeral motion and
margin of subscapularis tendon increased in ST motion during active
shoulder elevation
 Acute avulsion injuries – seen in younger patients,  Reduced active elevation with normal
involves acute subscapularis tears, acute SIT tears passive ROM
seen in patients above 40 years old with a shoulder
dislocation  Both active and passive ROM reduced –
adhesive capsulitis
 Excess external rotation and loss of
 Iatrogenic injuries - due to failure of surgical internal rotation on the same side – in
repair, seen in repair failure of subscapularis overhand throwers
tendon following open anterior shoulder surgery
SPECIAL TESTS
 Drop arm test
 Neer Impingement test
 Hawkins-kennedy impingement test
 Apprehension test
 Relocation test
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint True AP view
related problem  Narrowed acromiohumeral distance
 Sclerosis, reactive changes at the
insertion site on the greater tuberosity
(sclerosis, cyst formation) and spurring
of acromion
Supraspinatus outlet view
 Abnormalities in acromion shape and
slope
MRI Diagnostic of rotator cuff pathology  Evaluate muscle quality - size, shape,
degree of retraction of tear, degree of
muscle fatty atrophy (best seen in
sagittal image)
 Medial biceps tendon subluxation –
indicates subscapularis tear
S EMG and nerve conduction testing To evaluate possible suprascapular nerve  Cervical radiculopathhy - shoulder pain
impingement and weakness
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Physical therapy
CONSERVATIVE  Allow patient to sleep with a  Recurrence
pillow between the trunk and  Deltoid detachment
arm – to reduce tension on  AC pain
supraspinatus tendon and to  Axillary nerve injury
prevent blood flow  Suprascapular nerve injury
compromise in its watershed  Infection
region  stiffness
MEDICAL  Pain management –
ibuprofen, acetaminophen
 Inflammation reduction –
NSAID
 Corticosteroid injection into
subacromial space
SURGICAL  Arthroscopic or open rotator
cuff repair
 Tendon transfer
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
ACHILLES TENDON RUPTURE
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Achilles Tendon Rupture
 Rupture of Achilles tendon, usually 4 to 6 LOOK
cm above the calcaneal insertion in  Swelling on the calf
hypovascular region  Wide flat dorsal ankle
 Often misdiagnosed as ankle sprain  Achilles tendon not obvious in
 Anatomy – largest tendon in body comparison with the contralateral side
formed by confluence of soleus muscle 1. Sudden pop or snap sound FEEL
tendon, medial and lateral 2. Weakness and difficulty in walking  Swelling
gastronecmius tendons, blood supply 3. Acute severe pain in the heel  Palpable void, depression or gap
from posterior tibial artery  Shot-like pain MOVE
 Risk factors – episodic athletes,  Loss of plantar flexion of foot
flouroquinolone antibiotics, steroid (Thompson test)
injection  Hyperdorsiflexion
 Mechanism – due to sudden and violent
dorsiflexion in a plantar flexed foot

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint  Bone may be normal but soft tissue
related problem swelling may be the evident
 Tendon calcification
 Spurs at the calcaneal insertion site
Ultrasonography To see any abnormalities of tendons, muscles and  Deep venous thrombosis
joints  Baker cyst
Magnetic Resonance Imaging To see any abnormalities of tendons, muscles and  Partial tear of achilles tendon
joints
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Functional bracing or  Rereupture
CONSERVATIVE casting in resting  Wound healing complication
equinus  Sural nerve injury
SURGICAL  End to end Achilles
tendon repair
 Percutaneous Achilles
tendon repair
 Reconstruction with
VY advancement
 Flexor hallucis longus
transfer with VY
advancement of
gastrocnemius
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

TIBIALIS POSTERIOR TENDON RUPTURE


DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
LOOK
Tibialis posterior muscle  Loss of foot arch or flat foot (pes
 Responsible for moving foot ankle towards planus)
the midline of body (inversion), pointing foot  Hindfoot valgus deformity
and ankle down (plantarflexion) and
1. Medial ankle or foot pain and weakness  Pain and swelling on the medial site of
maintain normal arch of the foot the ankle
2. Pregressive loss of arch
 Forefoot abduction
3. Unable to raise the heel in standing
Tibialis posterior tendon rupture  Forefoot varus
 aka Posterior Tibial Tendon Insufficiency 4. Visible swelling or thickening of medial FEEL
site of lower leg or ankle
(PTTI)  Tenderness over midfoot
 Most common cause of adult-acquired 5. Lateral ankle pain (subfibular  Tenderness at the posterior tip of
flatfoot deformity impingement) as a late presentation medial malleolus
 Risk factors/causes – women over 40, MOVE
overuse, degeneration, trauma, being  Weakness in inversion of foot
overweight, steroid injection  Inability in heel elevation

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint AP foot
related problem  Increased talonavicular uncoverage
 Increased talo-first metatarsal angle
Lateral foot
 Increased talo-first metatarsal angle
 Decreased calcaneal pitch
 Decreased medial cuneiform floor
height
Ankle mortise
 Talar tilt (deltoid insufficiency)

Magnetic Resonance Imaging To see any abnormalities of tendons, muscles and  Tendo degeneration
joints  Arthritic changes in talonavicular,
subtalar and tibiotalar joints

MANAGEMENT: COMPLICATION: SIDE NOTES:


 Rest from aggravating
CONSERVATIVE activities  Pain that is not completely relieved
 Regular icing  Nonunion with both osteotomies and
 Use of a compression fusion
bandage  Wound infection
 ankle foot orthosis
 Elevation of affected limb
MEDICAL  NSAIDS (ibuprofen cannot
be given to asthma
patient) - to reduce pain
and inflammation
SURGICAL  Reconstruction of tibialis
posterior tendon
 FDL transfer
 Calcaneal osteotomy
 Gastrocnemius recession
 tenosynovectomy
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Hind foot valgus deformity Flat foot or pes planus forefoot abduction Position of tibialis posterior tendon

PERONEAL TENDON INJURY


DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Peroneal tendonitis
Peroneal tendon
1. pain behind and distal to the LOOK
 the 2 peroneal tendon in the foot run  swelling just below lateral malleolus
lateral malleolus
side by side behind the outer ankle bone  bruising on lateral side of the ankle
or lateral malleolus
2. swelling just below the lateral
FEEL
 one peroneal tendon attaches to the melleolus  Tenderness at the back and lateral of
outer part of the midfoot, another one 3. inability to turn the foot inward the foot
peroneal tendon runs under the foot and  Swelling on posterolateral aspect of the
attaches near the inside of the foot arch Peroneal tendon rupture ankle
 function – to stabilize foot and ankle and 1. audible snap or tearing sound at MOVE
protect from the sprains the time of injury  Difficulty in turning the foot inward
2. pain and swelling on the lateral (inversion) and outward (eversion) due
Peroneal tendonitis side of the foot or ankle to the pain
 common cause of pain around back and  Stiffness
3. unable to bear weight
lateral region of the foot  Lateral ankle instability
4. bruising and stiffness – late
 usually due to inflammation, irritation or
degeneration of the tendons presentation
 Causes – mcirotrauma from repetitive 5. weakness on moving the foot and
tension, abnormal foot position ankle away from the midline of
(hindfoot varus, high arches), ankle the body (eversion)
sprain, muscle imbalance (tigh calf
muscle and weak peroneal muscle), Peroneal tendon subluxation
excessive eversion or rolling out of foot 1. painful snapping sensation along
lateral ankle
Peroneal tendon rupture 2. weakness, swelling and pain over
 Causes – severe ankle sprains, excessive posterolateral aspect of the ankle
turning of foot inwards (inversion) during 3. pain with toe walking or cutting
weight bearing, rapid change of
laterally
direction, following awkward landing
from a jump or height 4. lateral ankle instability

Peroneal tendon subluxation or dislocation


 Torn of the peroneal retinaculum will
cause the peroneal tendon to be no
longer held in place, therefore may slip
out of position and flick over the bony
prominence on the lateral side of the
ankle
 Once dislocated, peroneal tendon may
remain in the dislocated position or can
return back to their original position
(peroneal tendon prone to recurrent
subluxation and dislocation)

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint  Fractures of lateral malleolus or
related problem calcaneus
 Arthritis
 Loose bodies
 Migration of os perineum in a
perineum longus tendon rupture
 Rim fracture – avulsion of superior
peroneal retinaculum from the lateral
malleolus
 Talar stress – more than 15 degrees of
tilt, talar instability
Ultrasonography To identify all type of peroneal lesion and to  Peroneal tendon lesion
assess dynamic stability
Magnetic Resonance Imaging To identify peroneal tendon injury  High signal intensity on the affected
tendon
 Presence of circumferential fluid
greater than 3 mm in maximal width
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Rest
CONSERVATIVE  Apply ice or cold therapy  Instability of gait that leads to fall and
 Ankle sprain taping further injury of the ankle
 Elevation of the leg  Sural nerve injury
 Change training structure  Continuation of symtoms
 Orthotics  Chronic lateral ankle pain
 Acupuncture – to reduce  Restricted range of motion
pain
 Physical therapy
MEDICAL  NSAID - to reduce the
pain and inflammation
 Injection of corticosteroid
is not recommended –
peroneal tendons are
very superficial and are in
close approximation with
the sural nerve, injecting
this area can cause fat
necrosis and sural
neuroma
SURGICAL  Groove deepening
 Superior peroneal
retinaculum repairing
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
STENOSING TENOSYNOVITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:

Stenosing tenosynovitis LOOK


 Aka trigger finger or trigger thumb 1. popping sensation or  finger or thumb in flexed position
 Refers to bend of the pulleys and tendons in locking/catching feelling in the FEEL
the finger finger or thumb  Tenderness on palpation over A1 pulley
 Causes 2. discomfort at the base of the  Palpable bump over A1 pulley
o pulley at the base of the fingers MOVE
finger or thumb
becomes too thick and constricting  Difficulty in straighten or extend the
3. finger clicking
around the tendon, making it hard finger or thumb
for the tendon to move freely 4. finger nodules
through the pulley 5. pain at distal palm near A1 pulley
o tendon develops a nodule (knot) or 6. finger becoming locked in flexed
swelling at its lining, because, thus position
increased resistance to the gliding of
the tendon through the pulley
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray To check for bone related problems or joint  Abnormal sesamoid bone, loose bodies
related problem in the MCP joint, osteoarthritic spurs
on metacarpal head, avulsion injury of
collateral ligaments
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Night splinting
CONSERVATIVE  Activity modification  Radial digital nerve injury Green’s classification
 Grade I (pretriggering) - Pain; history of
MEDICAL  NSAID – reduce pain catching that is not demonstrable on clinical
and inflammation examination; tenderness over the A1 pulley
 Steroid injections
SURGICAL  Surgical debridement  Grade II (active) - Demonstrable catching,
and release of the A1 but with the ability to actively extend the
pulley digit maintained
 Release of A1 pulley
and 1 slip of FDS  Grade III (passive) - Demonstrable locking in
(ulnar slip usually) which passive extension is required (grade
IIIA) or in which the patient is unable to
actively flex (grade IIIB)

 Grade IV (contracture) - Demonstrable


catching, with a fixed flexion contracture of
the proximal interphalangeal (PIP) joint
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
JUMPER’S KNEE
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:

Jumper’s Knee LOOK


 Aka patellar tendinopathy, patellar  Intra-articular effusion of the knee
tendinosis or patellar tendinitis (insertioanl (rare)
tendinopathy)  Swelling over tendon
 Refers to functional stress overload due to FEEL
jumping, activity related anterior knee pain  Point tenderness at the inferior pole,
associated with focal patellar tendon 1. Insidious onset of anterior knee pain at superior patellar pole or tibial
tenderness inferior border of patella tuberosity
 Affects  Pain following activity  Hamstring and quadriceps tightness
o the attachment of patellar tendon to  Then pain during activity and  Basset’s sign – tenderness to
inferior patellar pole pain with prolonged flexion palpation at distal ple of patella in
o attachment of quadriceps tendon to full extension, no tenderness to
superior patellar pole palpation at distal pole of patella in
o attachment of patellar tendon to the full flexion
anterior tuberosity of the tibia MOVE
 Risk factor  Normal knee range of motion
o Repetitive, forceful, eccentric
contraction of the extensor muscle
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
I X-ray To check for bone related problems or joint  Radiolucency at or elongation of the
related problem involved pole
 Inferior traction spur (enthesophyte)
inchronic cases
Ultrasonography To detect tendon abnormalities  Thicknening and hypoechogenicity of
tendon fibers
 Signs of hypervascularity
 Peritendinos neovascularization
Magnetic resonance imaging To detect tendon abnormalities  Tendon thickening
 Loss of posterior border of fat pad in
chronic cases

MANAGEMENT: COMPLICATION: SIDE NOTES:


 Physical therapy Blazina classification system
CONSERVATIVE  Activity modification  stiffness  Stage 1 – Pain only after activity, without
 Cyrotherapy  muscle or joint contracture functional impairment
 Stretching  Stage 2 – Pain during and after activity,
 strengthening although the patient is still able to
MEDICAL  Cortisone injection perform satisfactorily in his or her sport
 Stage 3 – Prolonged pain during and after
SURGICAL  Drilling of the involved pole activity, with increasing difficulty in
o To increase vascular performing at a satisfactory level
supply to the affected  Stage 4 – Complete tendon tear requiring
side, allow healing, surgical repair
improve pain and
tenderness
 Longitudinal tendon excision
with subsequent restructuring
of the residual tendon
 Resection of the involved pole
o Reattachment and
reinforcement of
medial patellar
retinaculum

EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!


TENNIS ELBOW
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:

Tennis elbow LOOK


 Aka lateral epicondylitis 
 Overuse injury involving eccentric 1. Pain with resisted wrist extension FEEL
overload at origin of common extensor 2. Pain with gripping activities,  Point tenderness at ERCB insertion into
tendon, that leads to tendinosis and lateral epicondyle, lateral side of elbow
shaking hands or squeezing object
inflammation at origin of extensor carpi MOVE
3. Pain on lateral side of the elbow,
radialis brevis  Pain on resisted wrist extension with
 Mechanism of injury gradually increasing elbow fully extended or resisted
o Repetitive pronation and 4. Decreased grip strength extension of long fingers or maximal
supination with elbow in flexion of wrist
extension, common in tennis
players (backhand implicated)
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint  Usually normal
related problem  Osteophytes, degenerative joint diease
Ultrasonography To detect tendon abnormalities  Tendinosis, partial tearing or
calcifications
Magnetic Resonance Imaging To detect tendon abnormalities  Increased signal intensity at ERCB
tendon
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Rest and avoid
CONSERVATIVE activity that causes  Iatrogenic LUCL injury
the pain  Missed radial nerve entrapment
 Apply ice to the syndrome
affected area  Iatrogenic neurovascular injury
MEDICAL  NSAIDS – to reduce
the pain and
inflammation
 Topical or injection of
cortisone
SURGICAL  Release and
debridement of ECRB
origin
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
GOLFER ELBOW
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:

Golfer elbow
 Aka medial epicondylitis FEEL
 Due to overuse of muscle in the forearm that 1. Pain over medial epicondyle  Tenderness over origin of PT and FCR at
allow medial epicondyle
a. Worse with wrist and
o Gripping, rotating of arm, flexing of MOVE
forearm motion
wrist, winging, pronation – cause  Pain with resisted forearm pronation
pulls or tiny tears to insertion of
2. Stiffness and wrist flexion
flexor pronator mass (pronator teres, 3. Weakness
flexor carpi radialis) 4. Numbness or tingling
 Risky sports
o Golf, racket sports, throwing sports,
weight training
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint  Unremarkable
related problem  Sign of fracture or arthritis

Magnetic Resonance Imaging To check tendon abnormalities  Tendinosis of PT and FCR

MANAGEMENT: COMPLICATION: SIDE NOTES:


 Rest
CONSERVATIVE  Ice  Chronic elbow pain
 Brace  Limited range of motion
 Stretching  A lasting, fixed bend (contracture in
 Reduce load on elbow)
affected limb  Medial antebrachial cutaneous nerve
neuropathy
MEDICAL  NSAID (ibuprofen,
acetaminophen) –
reduce pain and
inflammation
SURGICAL  Open debridement
and reattachment of
flexor pronator mass
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
CALCIFYING TENDINITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
1. Symptoms of subacromial
Calcifying tendinitis impingement LOOK
 Calcification and tendon degeneration  Pain during elevation at  Supraspinatus fossa muscle atrophy
near the rotator cuff insertion – anterolateral shoulder MOVE
associated with subacromial  Reduced active range of motion
 Pain with overhead
impingement  Scapular dyskinesia
activities
 Supraspinatus tendon mostly affected  Decreased in rotator cuff strength
  Weakness
 Altered normal range of
motion
2. Atraumatic pain
3. Catching, crepitus
4. Mechanical block
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint  Supraspinatus calcification on AP,
related problem supraspinatus outlet and axillary views
 Infraspinatus and teres minor
calcification (int rotation)
 Subscapularis calcification (ext
rotation)
Ultrasonography To quantify extent of calcification and guidance  Hyperechoic deposits
during needle decompression and injection

Magnetic Resonance Imaging To detect tendon abnormalities  Calcific deposits with low signal
intensity on all sequences

MANAGEMENT: COMPLICATION: SIDE NOTES:


 Physical therapy
CONSERVATIVE  Stretching and  Recurrence
strengthening  Persistent shoulder pain
MEDICAL  NSAIDS – to reduce  Shoulder stiffness
pain and  Iatrogenic injury to rotator cuff with
inflammation operative treatment
 Steroid injections
SURGICAL  Extracorporeal shock
waze therapy
 Ultrasound guided
needle lavage
 Surgical
decompression of
calcium deposit
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

BICEP TENDINITIS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Bicep tendinitis LOOK
 Inflammation or irritation of upper  popeye deformity
biceps tendon (proximal – long head of FEEL
biceps tendon) 1. Pain in the front of shoulder or  Tenderness on palpation over biceps
 Recognized as a pain generator in the anterior shoulder pain groove
shoulder 2. Pain if achiness that moves down MOVE
 Associated with the upper arm bone  Pain on internal rotation about 10
o Subacromial impingement 3. Weakness degrees
o Stenosis of bicipital groove 4. Occasional snapping sound or  Pain on forward elevate shoulder
o Rotator cuff tears (esp sensation in the shoulder against examiner resistance while
subscapularis pathology) elbow extended and forearm supinated
 Pain on active supination against
examiner resistance with elbow flexed
to 90 degress and forearm pronated
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B ESR To detect and monitor inflammation  Increase ESR
CRP To detect and monitor inflammation  Increase CRP
I X-ray To check for bone related problems or joint 
related problem
Ultrasonography To detect tendon abnormalities  Thickened tendon within bicipital
groove
Magnetic Resonance Imaging To detect tendon abnormalities  Thickening and tenosynovitis of
proximal biceps tendon
 Increased T2 signal around biceps
tendon
MANAGEMENT: COMPLICATION: SIDE NOTES:
 Rest  Rupture of proximal bicep tendon
CONSERVATIVE  Ice (popeye deformity)
 Physical therapy
MEDICAL  NSAIDS (ibuprofen and
naproxen) – to reduce
pain and inflammation
 Steroid injection
SURGICAL  Biceps tenodesis
 Arthroscopic tenodesis
 tenotomy
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!
6. PERIPHERAL NERVE INJURY
UPPER LIMB
Course Branches and Supply Injury Special Test
Axillary nerve -Branch of posterior cord Motor: Motor:
Supplies deltoid and Loss of supply to deltoid + teres
(C. 5, 6) teres minor minor
Flat shoulder
Sensory:
C. 5, 6 Sensory:
Small area of numbness over the
deltoid (the ‘sergeant’s patch)

Median nerve Arm: Arm: NO BRANCHES Hand of Benediction


-Descends lateral to the third part of axillary a.
Origin: and upper part of brachial a. Forearm: Motor: loss of all flexors of forarm
Lateral root -At middle of arm, crosses in front of brachial Motor > ant. comp. exc. FCU and medial half of FDP.
(C.5, 6, 7) a. and continues medial side of arm, reaching ***upper pt of
Medial root cubittal fossa median n. branches Ape hand d/t flat thenar eminence
(C.8, T.1) -Enters forearm by passing between the 2 out into anterior
heads of pronator teres interosseous n. which
supplies Flexor pollicis
Forearm: longus, Flexor
-Lower part of forearm, becomes superficial digitorum profundus
(covered by skin, sup. + deep fascia) (lat 1/2 ), Pronator
-Enters hand by passing deep to flexor quadratus
retinaculum
Ulnar nerve Arm: Arm: NO BRANCHES Ulnar claw hand 1. Paper test
-Descends medial to the third part of axiallry 2. Book test
Origin: a. and upper part of brachial a. *Ulnar paradox
-At middle of arm, pierces medial
intermuscular septum to reach post.
Compartment and descends till it reaches the
back of med. epicondyle

Forearm:
Radial -Descends post. To 3rd part of axillary a. and Arm: Wrist drop
upper part of brachial a. Motor > Triceps
Origin: -Passes thru the lower triangular space, Sensory (C.5,6,7,8, T.
Posterior cord leading to spiral groove (accompanied by 1)
(C.5, 6, 7, 8, profunda brachii a.)
T.1) -Pierces lat. Intermuscular septumat lower Forearm:
arm Motor > supplies
-Terminates in front of lateral epicondyle brachioradialis, ECRL

NO BRANCHES IN
FOREARM

Hand:
Terminal branch-
1. Superficial terminal
branch (sensory)
2. Deep terminal
branch (posterior
interosseous nerve)
>> supplies the rest of
post. compartment

Posterior -Deep terminal branch of radial nerve Supplies post. Motor:


interosseous compartment of Only paralysis of finger extensors.
nerve forearm exc. –
Extension of wrist is
Brachioradialis, ECRL normal due to
normal extensor
carpi radialis longus.
Deformity – Finger drop only.

No sensory loss because this deep


branch of radial nerve is entirely
muscular.

LOWER LIMB
Course Branches and Supply Injury
Sciatic nerve -Passes from pelvis and runs on closed capsule Divides into CPN and tibial n. E.g. MOI: Hip dislocation
(L.4, 5, S.1, 2, (post. Part) of hip joint
3) -Reaches gluteal region by passing through Motor: Motor:
greater sciatic foramen below piriformis -Supplies hamstrings + ischial part of -Loss of hip ext., knee flexion,
adductor magnus dorsi+plantar flexion, foot eversion
Termination:
-At mid thigh, terminates by dividing into Sensory: Sensory:
Common peroneal n. and Tibial n. L.4, 5, S.1, 2, 3 Loss of L.4, 5, S.1, 2, 3

Common -Enters popliteal fossa, runs downwards and Divides into Superficial peroneal nerve and E.g. MOI: # neck of fibula
peroneal laterally, leaves fossa to the lateral side of Deep peroneal nerve
nerve neck of fibula. Motor:
(L.4, 5, S.1, 2, Deep peroneal n.- supplies ant. Loss of ankle extension, foot eversion
3) compartment of leg *High-stepping gait
(action: dorsiflexion, foot eversion)
Sensory:
Sup. peroneal n.- supplies peroneus longus Loss of L.4, 5, S.1, 2, 3
and brevis (action: plantar flexion, foot
eversion)

Posterior -Enters popliteal fossa, runs vertically -Gives a branch, called sural nerve Motor:
tibial nerve downwards, and goes to post. compartment Loss of plantar flexion
(L.4, 5, S.1, 2, of leg Motor: Clawing of toes
3) Supplies the posterior compartment of the
leg Sensory:
(action: plantar flexion) Loss of L.4, 5, S.1, 2, 3

Sensory:
(L.4, 5, S.1, 2, 3)
Extra notes:

Nerve injury
NERVE ENTRAPMENT SYNDROME
CARPAL TUNNEL SYNDROME
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
-Wherever peripheral nerves traverse fibro-
osseous tunnels, are at risk of entrapment and LOOK:
compression. Alignment, deformity, clawing, site of thenar and hypothenar
-Nerve compression impairs epineural blood flow musles (wasting), scar over flexor retinaculum,
and axonal conduction > s/s: numbness, palmar/dorsum wasting
-Pain and paraesthesia @ dist. of
paraesthesia, muscle weakness
median nerve.
FEEL:
-Woken up at night d/t burning pain,
RISK FACTORS: Bulk of thenar muscles (wasting in severe chronic case)
tingling and numbness (flexed hand at
1. women Sensory dulling in median nerve territory (lateral 3 ½ fingers)
night)
2. 40-50 yo
-Pain relieved by hanging arm over
MOVE:
side of bed or shaking the arm.
***CLINICAL DIAGNOSIS however must identify Weak thumb abduction, flexion
-Clumsiness and weakness (fine
underlying systemic ds (if have)
movements, fastening buttons) -
SPECIAL TEST:
advanced cases
Acromegaly- d/t fibrosis of flexor retinaculum 1. Compression test
Hypothyroidism- d/t fat deposition 2. Tinel’s sign
Rheumatoid arthritis 3. Phalen’s test
Pregnancy
Social (occupation)- overuse syndrome
MANAGEMENT: COMPLICATIONS: SIDE NOTE:
1. CONSERVATIVE Prolonged/ severe decompression Electromyography and nerve conduction tests:
-Light splints that prevent wrist flexion (help with leads to: -Help to confirm diagnosis
night pain) -segmental demyelination -Establish level of compression
-target muscle atrophy -Estimate degree of nerve damage
2. MEDICAL -nerve fibrosis
-Steroid injections into carpal canal < temporary Conduction Test: slowed down across the compressed
relief segment

3. SURGICAL EMG:
-Open surgical division of transverse carpal -abnormal action potentials in muscles that are not
ligament obviously weak/wasted
-fibrillations seen in severe cases
ROLE OF CONDUCTION NERVE STUDY

1. MOTOR NERVE CONDUCTION 2. SENSORY NERVE CONDUCTION

or or

Compound Muscle Action Potential (CMAP) Sensory Nerve Action Potential (SNAP)

The nerve under study (usually a mixed motor and sensory nerve) is Recorded by stimulating a suitable subcutaneous sensory nerve and
stimulated electrically at an easily accessible subcutaneous site (e.g. recording with sur- face electrodes on the skin over a measured
the forearm or wrist for the median nerve or behind the medial distance along the same sensory nerve, e.g. from the index and middle
malleolus for the posterior tibial nerve), until it propagates an action
fingers of the median nerve.
potential which travels to the innervated muscle where a surface
electrode records the response.
Smaller in amplitude than CMAP and is measured in microvolts.
In practice it is and more accurate to stimulate the nerve at two points,
first at a distal site and then at a proximal site, and subtract the distal
latency from the proximal latency to obtain a truer measurement for
the intervening segment of the nerve.

Common investigations are measurement of the NCV for the median


nerve at the wrist or the ulnar nerve at the elbow in suspected cases of
carpal tunnel syndrome or cubital tunnel syndrome respectively. In a
focal entrapment neuropathy one will find focal slowing with normal
velocities on either side of the lesion.

Conduction slowing of uniform degree along the whole length of the


nerve suggests a demyelinating neuropathy, e.g. Charcot–Marie–Tooth
syndrome.
7. DIABETIC FOOT ULCER
PATHOPHYSIOLOGY OF DIABETIC FOOT
ASSESSMENT OF DIABETIC COMPLICATION

HISTORY TAKING

- Age
- Gender
- Duration of having Diabetes Mellitus
- Compliance towards medication
- Social history

NEUROPATHIC

• Regarding sensory impairment, diabetic foot can lead to loss of vibration and joint sense position and diminished temperature discrimination in the
feet

• Symptoms of diabetic foot occur mainly due to sensory impairment; symmetrical numbness and paraesthesia, dryness and blistering of the of the
skin, superficial burns and skin cracks or ulceration

• Motor loss in diabetic foot usually manifests as claw toes with high arches, and highly predisposed to plantar ulceration

• Patients of diabetic foot may also get ‘charcot joints’ (neuropathic joint disease) which mainly occur at the mid-tarsal joints

VASCULAR

• High blood glucose levels can contribute to the formation of fatty deposits in blood vessel walls. Over time, that can restrict blood flow and increase
the risk of hardening of the blood vessels (atherosclerosis). Lack of blood flow can affect your hands and feet.

• One of the long term complications of diabetes mellitus is atherosclerosis, which affects mainly the medium-sized blood vessels

IMMUNODEFICIENCY
• Another complication of diabetes mellitus is immunodeficiency. This is due to the deleterious effect towards the white blood cell

• This immunodeficiency effect, combined with local ischeamia, insensitivity to skin injury and localized pressure due to deformity, cause a high risk
of sepsis

• Because of this altered immune function, diabetic patients have an 80% increased risk of cellulitis, a four times risk of osteomyelitis, and double the
risk of sepsis and death from infection.

MANAGEMENT OF COMPLICATIONS

PRESSURE ULCER (INFECTED OR NON-INFECTED)

 Regular inspection & examination of foot & foot wear


 More focus on high risk patient
 Education of patient, family & health care providers
 Appropriate foot wear
 Treatment of non ulcerative pathology

ROLE OF OFF-LOADING ORTHOSIS

 Ankle foot orthosis (AFO) is a prefabricated foot and ankle brace that fully suspends the foot and ankle, allowing a patient to walk while being
completely non-weight bearing
 Indicated for conditions that require offloading and protection of the foot and/or ankle, such as arthritis, skin ulcerations, and fractures of the foot
and ankle
 The foot is offloaded each time the brace is applied, thereby reducing the risk of further foot damage
DIABETIC FOOT ULCER
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
An open sore or wound that occurs in History of diabetes mellitus INSPECTION –
approximately 15 percent of patients with Presence of risk factors (sensory Foot ulcers
diabetes and is commonly located on the bottom neuropathy, previous history of foot ulcer, • Site
of the foot. Charcot’s foot deformity, chronic kidney • Size
• Shape
disease)
• Surrounding
Malaise
• Base
Oedema of foot, ankle or calf • Edge
Foot erythema • Depth
Absent pedal pulses • Smell
• Discharge
– Loss of hair
Pigmentation of the skin over the shin (diabetic
dermopathy)
Muscle wasting (diabetic amyopathy)
Trophic changes
Check for Charcot’s joint at the ankle and knee
Any other foot deformity (claw toes, high arch
foot)

PALPATION –
Warmth
CRT
Pulse of dorsalis pedis and posterior tibial artery.
Sensation (monofilament)

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC Suggest the presence of an infection Leukocytosis with left-shift
blood glucose level Baseline guidance Elevated
CRP/ESR Suggestive of infection Elevated
I X-ray foot Screen for osteomyelitis, fractures, joint stability, May show hypolucencies, cortical
and other deformities destruction/osteolysis, and/or joint subluxation
MRI Foot More accurate in setting of adequate arterial Hypo-intense areas of bone on t1 sequences;
perfusion hyper-intense areas of bone on t2 sequences;
soft-tissue fluid collections (if osteomyelitis
present)
S Angiography Best test for diagnosing peripheral artery disease Haemodynamically significant (i.e., >50%)
stenosis or occlusions between the aorta and
the foot (if peripheral artery disease present)

MANAGEMENT: COMPLICATION: SIDE NOTES:


Regular check-up Peripheral neuropathy
CONSERVATIVE Maintenance blood glucose Peripheral vascular disease
level Foot ulceration
Foot infection and osteomyelitis
MEDICAL Amputation
Charcot’s neuroarthropathy

SURGICAL Surgical bypass and/or


endovascular intervention
Amputation if necessary
EXTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

WAGNER- MEGGITT’S CLASSIFICATION (grading system for lesions of the diabetic foot)

Grade Denomination Description


0 Foot at risk Thick calluses, bone deformities, clawed toes, and
prominent metatarsian heads
1 Superficial ulcers Total destruction of the thickness of the skin
2 Deep ulcers Penetrates through skin, fat and ligaments, but does
not affect bone
3 Abscessed deep ulcers Deep ulcer with abscess, osteomyelitis or joint sepsis
4 Limited gangrene Limited necrosis in toes or the foot
5 Extensive gangrene Necrosis of the complete foot, with systemic effect
8. PAEDIATRIC ORTHOPAEDIC DISORDERS
Paediatric Orthopaedic Disorders

B. Traumatic Fractures

i. Physeal fracture (Salter-Harris)

Type 1
 separation of the epiphysis.
 A transverse fracture through the hypertrophic or calcified zone of the plate.
 Even if the fracture is quite alarmingly displaced, the growing zone of the physis is usually not injured
and growth disturbance is uncommon

Type 2
 fracture through the physis and metaphysis – is the commonest; it occurs in older children and seldom
results in abnormal growth
 This is essentially similar to type 1, but towards the edge the fracture deviates away from the physis and
splits off a triangular metaphyseal fragment of bone (sometimes referred to as the Thurston – Holland
fragment).

Type 3
 A fracture that splits the epiphysis and then veers off transversely to one or the other side, through the
hypertrophic layer of the physis.
 Inevitably it damages the ‘reproductive’ layers of the physis (as these layers are closer to the epiphysis
than the metaphysis) and may result in growth disturbance.

Type 4
 As with type 3, the fracture splits the epiphysis, but it extends into the metaphysis.
 These fractures are liable to displacement and a consequent misfit between the separated parts of the
physis, resulting in asymmetrical growth.

Type 5
 crushing of the physis – may look benign but ends in arrested growth.
 A longitudinal compression injury of the physis. There is no visible fracture but the growth plate is
crushed and this may result in growth arrest.

Investigation

 X-Ray

Treatment
 Undisplaced fractures may be treated by splinting the part in a cast or a close-fitting plaster slab for 2–4 weeks (depending on the site of
injury and the age of the child).
 with undisplaced types 3 and 4 fractures, a check x-ray after 4 days and again at about 10 days is mandatory in order not to miss late
displacement.
 Displaced fractures should be reduced as soon as possible. With types 1 and 2 this can usually be done closed.
 If a type 3 or 4 fracture cannot be reduced accurately by closed manipulation, immediate open reduction and internal fixation with smooth K-
wires is essential.

Complication

 Types 1 and 2 injuries, if properly reduced, have an excellent prognosis and bone growth is not adversely affected.
 Complications such as malunion or non-union may also occur if the diagnosis is missed and the fracture remains unreduced (e.g. fracture
separation of the medial humeral epicondyle).
 Types 3 and 4 injuries may result in premature fusion of part of the growth plate or asymmetrical growth of the bone end.
 Types 5 and 6 fractures cause premature fusion and retardation of growth.
 Established deformity should be treated by corrective osteotomy. If further growth is abnormal, the osteotomy may have to be repeat
DYSPLASTIC DEVELOPMENT OF HIP (DDH)

DEFINITION and DIAGNOSTIC : HISTORY PHYSICAL FINDINGS:


 Breech positioning
• DDH refers to any manifestation of LOOK-
 Family history
subluxation, dislocation or dysplasia  Hip flexion contracture / Lumbar Lordosis
•  DDH
Dislocated  Walks on one toe or with long knee bent
• Dislocatable  Ligamentous Laxity
 Trendelenberg
• Subluxatable  Infantile muscular torticollis FEEL-
• Dysplastic acetabulum  Postnatal positioning  Trochanter / ASIS
• Not Teratologic / Neurogenic  Walking age MOVE-
 Gait abnormality  Limited abduction
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
Imaging:- • The ossified capital femoral epiphysis should lie
 X-ray Hilgenreiners line entirely within the inner lower quadrant
established by Hilgenreiner's and Perkins' lines.

• In subluxation or dislocation the medial aspect of


the ossified proximal femoral metaphysis
typically lies within the superolateral quadrant

horizontal line is drawn connecting the


superior margins of the triradiate
cartilages

Perkins line

is vertical to this line and is drawn


through the most superolateral margin
of the ossified acetabulum.

Acetabular Angle
Angle between Hilgenreiner's line and a
line drawn from the most superolateral
margin of the ossified acetabulum to
the superolateral margin of the
triradiate cartilage  estimate
acetabular development

In the neonate the angle of intersection


is normally less than 30°

MANAGEMENT: COMPLICATION: SIDE NOTES:


Management is depend on age:  Dislocation
 Under 6 months of age  AVN
 6 months to 6 years
 after the age of 6 years

XTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Atieology:
 Unknown for certain
 Many factors
 Balance between ligamentous laxity, maternal hormones, and positional factors.
 There is also some undefined genetic factor
 Family history
 Breech positioning
 Female sex
 Oligohydramnios
 Calcaneovalgus

Detail of management:
LEG CALVES PERTHES DISEASE

DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:


• Idiopathic avascular insult(s) to developing
• Limp
femoral head • Limited ROM
• Mild groin pain or
• Age range 4 to 8 years commonly, has been – Internal rotation
anteromedial thigh or knee
reported 2 to 15 years – Abduction
• Usually activity related,
• Male : Female = 5:1 – Fixed flexion present
relieved by rest
• Bilateral 10% • Positive Trendelenburg
• History of trauma ~20%
• Limb length inequality

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
Imaging:-  To see the hip joint  Increased density of bony epiphysis
 X-ray  Widening of the joint space
Flattening, fragmentation and lateral
displacement of epiphysis
 Broadening of the metaphysis

MANAGEMENT: COMPLICATION: SIDE NOTES:


 Skin Traction in bed if pain Differential Diagnosis:
CONSERVATIVE  Rehabilitation • Primary bone dysplasia (bilateral)
 encouraged to walk with • DDH sequelae
crutches and participate in • Sickle cell, Gauchers
physical therapy • Traumatic AVN
 Splintage • Transient Synovitis
 Petrie cast ( at least 1 year) • Sepsis
MEDICAL  Anti-inflammatory
medications Stages:
Stage 1 – Bone death
SURGICAL • Following one or more episodes of
• Varus osteotomy ischaemia
– May stay varus in • Necrosis of bony femoral head
older child • Looks normal on x-ray but stops enlarging
– Adds to LLD
– Changed Stage 2 - Revascularization and repair
mechanical axis • New blood vessels enter necrotic area
• Salter osteotomy • New bone laid down on dead trabeculae
– ?Enough coverage • X-ray : increased density
– Restores some leg
length Stage 3 - Distortion and Remodelling
• If large part of bony epiphysis damaged or
repair is slow  epiphysis may collapse
and subsequent growth at head and neck
will be distorted
• Epiphysis flattened  coxa plana
• Epiphysis enlarged  coxa magna
• Femoral head incompletely covered by
acetabulum
XTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Ateiology:
• Current theories:
– Idiopathic
– Trauma
– SUFE
– DDH
– Venous hypertension
– Activated protein C resistance
– Proteins C and S deficiency
– Steroid
SLIP UPPER FEMORAL EPIPHYSIS (SUFE)

DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:


 Definition
o Posteromedial displacement of the • Externally rotated extremity
proximal femoral epiphysis in • Shortening
relation to the neck • Muscle wasting
o Anterolateral displacement of • ROM limited by pain
femoral neck in relation to proximal • Classic sign – tendency to external
femoral epiphysis rotate as hip flexed
 Histology :
- Inflammatory changes in synovium • Groin, thigh or knee pain
- Separation through widened ‘Zone of – Sudden or insidious
Hypertrophy’ onset
o normally 15-30% of width of physis • Traumatic episode (25%)
o in SCFE up to 80% • Antalgic gait
Southwick recommended measuring the femoral • Out-toeing
head–shaft angle on AP or from leg lateral views
 mild slips (< 30° from the normal
contralateral side)
 moderate slips (30° - 60°)
 severe slips (> 60°)

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
Imaging: - To see Hip Joint - Trethowan’s line not straight
- X-ray - To see Trethowan’s line
- CT Scan

MANAGEMENT: COMPLICATION: SIDE NOTES:


Aims of treatment:
• Prevent further slippage  Avascular necrosis of femoral head • Early diagnosis leads to simple
– stabilisation  Articular chondrolysis (Cartillage effective treatment
– physeal arrest loss) • Late diagnosis leads to more
• Correction of severe deformity  Degenerative arthritis deformity and therefore more OA
• Avoidance of complications • Acute slips have a bad prognosis
regardless of treatment
Surgical treatment:
• cannulated screw in centre of head Risk Factor:
• Adolescence
• Weight
– 49% over 95th percentile
(weight for age)
– 73% boys over 90th
percentile (weight for height)
• Trauma
• Endocrinopathy- hormonal imbalance

Classify into two:


 Stable - walking & weightbearing
possible
• Unstable - walking not possible, even
with crutches

XTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Atieology
• Multifactorial
– increased shear forces
• obesity
• decreased femoral anteversion
• increased physeal obliquity
– altered growth plate physiology
• hormonal balance
– hereditary influences
• 2 - 7% incidence of genetic transmission
– endocrinopathies
 Hypothyroidism
 1° or 2°
 Panhypopituitarism
 Hypogonadal conditions
 Growth hormone therapy
 Renal osteodystrophy
GENU VARUS

(Infantile Blount’s disease)


DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Progressive bow leg deformity/pathological
genu varum, associated with abnormal • Genu varum deformity which is bilateral in infants
growth of the posteromedial part of the • Exhibit positive cover up test
proximal tibia • Internal rotation of tibia. Child walks with an outward
thurst of the knee. Lateral subluxation of the tibia.

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
Imaging:  To see the knee joint • Proximal tibial epiphysis is flattened medially
 X-Ray • Adjacent metaphysis is beak shaped.
• Medial cortex of the proximal tibia is
thickened(illusionary effect of internal rotation of tibia)
• Tibial epiphysis looks fragmented
• Late stages : bony bar forms across medial half of tibial
physis. varus focused at proximal tibia
• Degree of proximal tibia vara can be measured using
metaphyseo-diaphyseal angle
MANAGEMENT: COMPLICATION: SIDE NOTES:
Differential diagnosis
CONSERVATIVE Brace treatment with KAFO osteogenesis imperfecta
 Indication : stage I and osteochondromas
II in children less than trauma
3 years old various dysplasia
 Technique : Bracing
must continue for 2
years
 Outcomes : improve if
unilateral, poor if
bilateral and obese.

MEDICAL
SURGICAL
Proximal tibial fibula valgus
osteotomy

XTRA NOTES: Acronyms/tables/pictures/anything. Be creative!


CONGENITAL TALIPES EQUINUS VARUS (CTEV)

DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:

Known as Club Foot Look on the foot:


 The deformity is usually obvious at (CAVE)
birth; the foot is both turned and • Cavus
twisted inwards so that the sole face • Adductus (forefoot)
posteromedially. • Varus (hindfoot)
• Equinus (hindfoot)

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
Imaging:  Plain x-rays are unhelpful in
 X-Ray young infant because the tarsal
 CT Scan are incompletely ossified and
difficult to define.
 In older children, the severity of
the deformity is obtained from
the talocalcaneal angle (normal=
20-40 degrees) in the AP and
lateral views.

MANAGEMENT: COMPLICATION: SIDE NOTES:

CONSERVATIVE  Conservative manupulation


– Ponsetti method
 Casting/Bracing
MEDICAL
SURGICAL  Comprehensive release
Cincinnati incision
 Ilizarov

XTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Atielogy:
• Embryonic arrest
• Retractive fibrotic response (like Dupuytren’s contracture)
• Primary germ plasm defect
• Localised neuromyogenic imbalance
• A/w DDH & torticollis
Multifactorial, exact cause remains unknown

Algorithm for management:


CTEV

Serial casting

Successful Unsuccessful

1
Splint Surgery
2

Splint
Remain Relapse
corrected
Recurs Successful

F/U Revision surgery : bony/ soft


tissue/ Ilizarov F/U
OSTEOGENESIS IMPERFECTA
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
• A rare inherited disease that can present as trauma fractures in • Osteopenia
babies and children. • Proneness to fracture (w/o INSPECTION –
• Due to defective synthesis of type I collagen pain/swelling) PALPATION –
lead to weakening of connective tissues and imperfect ossification in all • Laxity of ligaments PERCUSSION –
types of bone. • Blue sclerae AUSCULTATION –
• Generalized involvement of bones, teeth, ligaments, sclerae • Dentinogenesis imperfecta
and skin. (crumbling teeth)
• Fractures occur less frequently after puberty. • Bone deformity
• Hearing impariment

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
Imaging  To see the bone  Bone deformities
 X-Ray deformities and bone  Mini-fracture
density

MANAGEMENT: COMPLICATION: SIDE NOTES:


• Aim of management is directed
CONSERVATIVE • Fractures are treated conservatively, at preventing fractures
but immobilization must be kept to a
minimum

MEDICAL • Children with severe OI may be


treated medically with cyclical
bisphosphonates to increase bone
mineral density and reduce the
tendency to fracture.
SURGICAL • Malunion of complete fractures or
breaking of recurrent incomplete
fractures may require operative
correction

XTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Sillence Classification:
RICKETS
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
• Inadequate mineralisation of the bone • The infant with rickets
in children effects on physeal growth may present with
and ossification, resulting in tetany or convulsions.
deformities of the endochondral • Later the parents may
skeleton (rickets). notice that there is a
• In adults, osteoid throughout the failure to thrive,
skeleton is incompletely calcified, and listlessness (lacking of
the bone is therefore ‘softened’ energy) and muscular
(osteomalacia). flaccidity.
• Early bone changes are
deformity of the skull
(craniotabes) and
thickening of the knees,
ankles and wrists from
physeal overgrowth.
• Enlargement of the
costochondral junctions
(‘rickety rosary’) and
lateral indentation of
the chest (Harrison’s
sulcus) may also
appear.
• Distal tibial bowing has
been attributed to
sitting or lying cross-
legged.
• Once the child stands,
lower limb deformities
increase, and stunting
of growth may be
obvious.
• In severe rickets there
may be spinal
curvature, coxa vara
and bending or
fractures of the long
bones.

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
Imaging:  To see the deformity of • Children In active rickets there is thickening and widening
 X-Ray the bone of the growth plate, cupping of the metaphysis and,
sometimes, bowing of the diaphysis.
• The metaphysis may remain abnormally wide even after
healing has occurred.

MANAGEMENT: COMPLICATION: SIDE NOTES:


Some of these problems Inadequate mineralization may be due to defects anywhere along
CONSERVATIVE can be corrected by the metabolic pathway for vitamin D:
simple social adjustments. • Nutritional lack
(E.g: diet and sunlight • Underexposure to sunlight
exposure) • Intestinal malabsorption
• ↓ 25-hydroxylation (liver disease, anticonvulsants)
• ↓ 1α-hydroxylation (renal disease, nephrectomy, 1α-
MEDICAL Treatment with vitamin D hydroxylase deficiency)
(400–1000 IU per day) The pathological changes may also be caused by calcium deficiency
and calcium supplements or hypophosphataemia.
is usually effective.
SURGICAL
Surgery Established long-
bone deformities may
need bracing or operative
correction once the
metabolic disorder has
been treated.

XTRA NOTES: Acronyms/tables/pictures/anything. Be creative!

Pathology:
• The characteristic pathological changes in rickets arise from the inability to calcify the intercellular matrix in the deeper layers of the physis.
• The proliferative zone is as active as ever, but the cells, instead of arranging themselves in orderly columns, pile up irregularly; the entire
physeal plate increases in thickness, the zone of calcification is poorly mineralized and bone formation is sparse in the zone of ossification.
• The new trabeculae are thin and weak, and with joint loading the juxta-epiphyseal metaphysis becomes broad and cup shaped.

Hypophosphataemic rickets
• Chronic hypophosphataemia occurs in a number of disorders in which there is impaired renal tubular reabsorption of phosphate.
• Calcium levels are normal and there are no signs of hyperparathyroidism, but bone mineralization is defective.
• Familial hypophosphataemic rickets (commonest form of rickets seen today.)
• It is an X-linked genetic disorder with dominant inheritance, starting in infancy or soon after and causing bony deformity of the lower limbs if it
is not recognized and treated.
RENAL OSTEDYSTROPHY
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
• Patients with chronic renal failure and • Children are more severely affected
lowered glomerular filtration rate are liable than adults.
to develop diffuse bone changes which • They are usually stunted, pasty-faced
resemble those of other conditions that and have marked rachitic deformities
affect bone formation and mineralization. associated with myopathy.
• Renal abnormalities usually precede the • In all patients signs of secondary
bone changes by several years. hyperparathyroidism may be
• widespread and severe.

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
Imaging: • Widened and irregular epiphyseal
 X-Ray plates.
• In older children with longstanding
disease there may be displacement of
the epiphyses (epiphyseolysis).
• Osteosclerosis is seen mainly in the
axial skeleton and is more common in
young patients: it may produce a
‘rugger jersey’ appearance in lateral x-
rays of the spine, due to alternating
bands of increased and decreased
bone density.

Blood: • Features are ↓serum calcium, ↑


 Serum Calcium, Phosphate serum phosphate and ↑alkaline
 ALP phosphatase levels. Urinary excretion
 PTH of calcium and phosphate is
diminished.
• Plasma PTH levels may be raised.

MANAGEMENT: COMPLICATION: SIDE NOTES:


• Renal failure, if irreversible, may
CONSERVATIVE require haemodialysis or renal
transplantation.
MEDICAL Hyperphosphataemia and
secondary
hyperparathyroidism can be
treated by restricting the
intake of phosphorus (e.g. by
taking phosphate binders)
and administering vitamin D
or one of its analogues.

More recently a calcimimetic


drug, cinacalcet, has been
introduced; this acts directly
on the parathyroid glands
increasing the sensitivity of
calcium receptors and
inducing a reduction in
serum PTH levels.

SURGICAL
Epiphyseolysis may need
internal fixation and residual
deformities can be corrected
once the disease is under
control.

XTRA NOTES: Acronyms/tables/pictures/anything. Be creative!


9. MUSCULOSKELETAL TUMOUR
OSTEOCHONDROMA
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
A benign chondrogenic lesion derived from  most lesions are asymptomatic  palpable mass
aberrant cartilage from the perichondral ring  usually present with painless  may have mechanical symptoms secondary to
that may take the form of mass mass
 solitary ostoechondroma  may have mechanical symptoms
 Multiple Hereditary Exostosis (MHE) or symptoms of neurovascular
compression
 they continue to grow until
skeletal maturity

INVESTIGATION
I Radiograph sessile (broad base) or pedunculated (narrow stalk) lesions found on the surface of bones
 higher risk of malignant degeneration in sessile lesions
 pedunculated lesions point away from the joint
continuity with native tissue
 cortex of the lesion continuous with cortex of the native bone
 medullary cavity of lesion continuous with medullary cavity of native bone
 cartilage cap is usually radiolucent and involutes at skeletal maturity
 nodules of metaplastic cartilage can occur within the bursa over cartilage caps

CT/MRI used to better characterize lesions


MANAGEMENT: COMPLICATION: SIDE NOTES:
Pseudoaneurysm of the popliteal artery in Recurrence
observation alone the popliteal fossa  2-5% of cases after resection
indications Nerve compression  Short-term X-ray surveillance is adequate unless
-asymptomatic or minimally symptomatic  sciatic nerve symptomatic later
cases  common peroneal nerve
 atrophy of anterior and lateral
compartment muscles of the leg
OPERATIVE marginal resection at base  radial nerve
of stalk, including cartilage Tendon compression
cap lesions around the shoulder can give rise to
indications  rotator cuff impingement
-symptomatic lesions  subscapularis tear
-lesion may cause  bicipital tendinitis
inflammation to Chondrosarcoma
surrounding tissue
-lesion may be cosmetically
displeasing
-try to delay surgery until
skeletal maturity

Wide surgical resection


(*2nd Osteochondroma)
OSTEOSARCOMA
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
 Most common non-haematological rapidly progressive pain, fever, and Palpable mass
primary malignant neoplasm of bone in swelling
children and adolescents.
 Pain and swelling are the most common
presenting symptoms.
 Although it can occur at any age, it
usually affects patients in the second and
third decade of life with a peak incidence
between 13 and 16 years of age. It is
more common in males than females.
 Chemotherapy combined with surgery is
the standard of care.
 Prognosis of patients with localised
disease has improved substantially
following the introduction of
chemotherapy, with 75% to 80% 5-year
survival rates.

INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B Sr Alkaline Phosphatase Although it is common, an elevated serum level usually elevated
is not diagnostic of osteosarcoma. Serum values
tend to normalise after tumour ablation and
resurge with local recurrence or metastatic
disease.
Sr LDH Levels are frequently elevated but are not
diagnostic of osteosarcoma. However, elevated
levels in combination with typical signs and
symptoms increases the suspicion of a bone
lesion.
I Radiograph Conventional radiographs in 2 planes should be radiolucent lesion with areas of mottled radiodensity
ordered in patients suspected of possible and ill-defined margins; neoplasm is usually located
osteosarcoma at the first or second visit. in the metaphysis of long bone; periosteal reaction in
the form of Codman's triangle or a sunburst
appearance is common; sometimes soft tissue mass
can be appreciated on conventional radiographs
CT primary tumour Matrix production by the tumour and the findings vary with exact type of tumour; shows dense
extent of cortical destruction are best bony mass; may show central calcification, cortical
appreciated on CT scans destruction
CT thorax High-resolution spiral CT of the thorax forms may indicate lung or rib metastases
part of the systemic staging of osteosarcoma.
The lungs (along with the skeleton) are the
primary sites of metastasis.
S Bone biopsy Histological examination of biopsy sample highly pleomorphic spindle cell neoplasm producing
confirms a diagnosis of osteosarcoma. osteoid or immature bone; osteoid typically has a
lace-like appearance; neoplastic cells and osteoid
show a permeative growth pattern with invasion of
the native bone trabeculae; neoplastic cartilage can
also be produced by the tumour cells; mitotic activity
is high and composed of atypical mitotic figures
MANAGEMENT: SIDE NOTES:
SURGICAL multi-agent chemotherapy
and limb salvage resection
indications
-high grade osteosarcoma
chemotherapy
-preoperative chemotherapy
given for 8-12 weeks followed
by maintenance
chemotherapy for 6-12
months after surgical
resection
-98% necrosis after neo-
adjuvant chemotherapy is
good prognostic sign
-expression of multi-drug
resistance (MDR) gene tends
to have a poor prognosis
tumor cells can pump
chemotherapy out of cell with
MDR expression
present in 25% of primary
lesions and 50% of metastatic
lesions
surgical technique
-trend towards limb salvage
whenever possible
-overall survival in
osteosarcoma is equal after
limb salvage vs. amputation
to deal with local extent of
disease
-rotationplasty is a great
surgical option which
optimizes the patient's
function, and most commonly
done in a pediatric population
EWING’S SARCOMA
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
A distinctive small round cell sarcoma pain often accompanied by fever swelling and local tenderness
often mimics an infection
Epidemiology
 typically found in patients from 5-25 years
of age
 second most common malignant bone
tumor in children
locations
 ~50% are found in the diaphysis of long
bones
 the most common locations include pelvis,
distal femur, proximal tibia, femoral
diaphysis, and proximal humerus
INVESTIGATION
TEST WHY ORDER EXPECTED FINDINGS
B FBC, ESR Routine ix ESR is elevated
WBC is elevated
anemia is common
I Radiographs Identify site of lesion large destructive lesion in the diaphysis or
metaphysis with a moth-eaten appearance
lesion may be purely lytic or have variable
amounts of reactive new bone formation
periosteal reaction may give "onion skin" or
"sunburst" appearance
Bone Scan required as part of staging workup will show very "hot" lesion
MRI necessary to identify soft-tissue extension and often shows a large soft tissue component
marrow involvement
CT chest is required for appropriate staging to look for -
pulmonary metastasis
S Bone marrow biopsy required as part of workup for Ewing's to rule out
metastasis to the marrow
Histology To know the morphology Gross appearance
may have liquid consistency mimicking pus
Characteristic findings
sheets of monotonous small round blue cells
prominent nuclei and minimal cytoplasm
may have pseudo-rosettes (circle of cells with
necrosis in center)
MANAGEMENT: SIDE NOTES:
Prognosis
survival
-60-70% long term survival with isolated extremity disease at presentation and appropriate
treatment/tumor response to chemotherapy
-40% long term survival with pelvis lesions
-15% long term survival if patient presents with metastatic disease
SURGICAL chemotherapy and limb
salvage resection poor prognostic factors
indications -spine and pelvic tumors
standard of care in most -tumors greater than 100cm3
patients -< 90% necrosis with chemotherapy
chemotherapy -elevated lactic dehydrogenase levels
preoperative chemotherapy -p53 mutation in addition to t(11:22) translocation
given for 8-12 weeks followed
by surgical resection and
maintenance chemotherapy
for 6-12 months
irradiation
-current trend is towards
surgical resection and away
from irradiation due to long
term morbidity associated
with radiation
-increased risk of secondary
malignancies
-adjuvant radiation may be
helpful in these situations:
-non-resectable tumors (eg.
large spinal tumors)
-positive post-resection
surgical margins
-patients who present with
widely metastatic disease
OSTEOID OSTEOMA
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
It is the commonest true benign tumour of the The tumour is seen commonly between the There are minimal or no clinical signs, except for
bone. ages of 5-25 years. The bones of the lower mild tenderness at the site of the lesion, and a
Pathologically, it consists of a nidus of tangled extremity are more commonly affected; tibia palpable swelling if it is a superficial lesion
arrays of partially mineralised osteoid trabeculae being the commonest. The tumour is
surrounded by dense sclerotic bone.
generally located in the diaphysis of long
bones. Posterior elements of the vertebrae
are a common site. The presenting complaint
is a nagging pain, worst at night, and is
relieved by salicylates..
INVESTIGATION
It is generally confirmed on X-ray. The
tumour is visible as a zone of sclerosis surrounding
a radiolucent nidus, usually less than 1 cm in size
In some cases, the nidus may not be seen
on a plain X-ray because of extensive surrounding
sclerosis, and may be detected on a CT scan.
MANAGEMENT: SIDE NOTES:
Complete excision of the nidus along -
with the sclerotic bone is done. Prognosis is good.
It is not a pre-malignant condition.
OSTEOCLASTOMA
DEFINITION and DIAGNOSTIC : HISTORY (SYMPTOMS): PHYSICAL FINDINGS:
Giant cell tumour (GCT) is a common bone tumour Examination reveal a bony swelling, eccentrically
with variable growth potential. Though generally Common presenting complaints are swelling located at the end of the bone.
classified as benign*, it tends to recur after local and vague pain. Sometimes, the patient,
removal. Frankly malignant variants are also unaware of the lesion, presents for the first Surface of the swelling is smooth. There may be
known. tenderness on firm palpation. A characteristic
time with a pathological fracture through the
‘egg-shell crackling’ is often not elicited. The
lesion.
The tumour is seen commonly in the age group of limb may be deformed if a pathological fracture
20-40 years i.e., after epiphyseal fusion. The bones has occurred.
affected commonly are those around the knee i.e.,
lower-end of the femur and upper-end of the tibia.
Lower-end of the radius is another common site.
The tumour is located at the epiphysis**.
It often reaches almost up to the joint surface.

INVESTIGATION
GCT is one of the common cause of a solitary lytic
lesion of the bone, and must be differentiated from
other such lesions (Table–28.3). Following are some
of the characteristic radiological features of this
tumour:
• A solitary, may be loculated, lytic lesion.
• Eccentric location, often subchondral (Fig-28.2a).
• Expansion of the overlying cortex (expansile
lesion).
• ‘Soap-bubble’ appearance – the tumour is
homogeneously lytic with trabeculae of the
remnants of bone traversing it, giving rise to a
loculated appearance.
• No calcification within the tumour (Fig-28.2b).
• None or minimal reactive sclerosis around the
tumour.
• Cortex may be thinned out, or perforated at
places.
• Tumour usually does not enter the adjacent joint.
MANAGEMENT: SIDE NOTES:
1) Well – defined lesion
-through curettage or ‘stripping’ of the cavity with
burrs and gouges -> swabbing with hydrogen
peroxide of by the application of liquid nitrogen

2) More aggressive tumors


- excision/ bone grafting or prosthetic
replacement
OSTEOBLASTOMA CHONDROBLASTOMA HAEMANGIOMA OF THE BONE
This is a benign tumour consisting of vascular This is a cartilaginous tumour containing This is a benign tumour of angiomatous origin,
osteoid and new bone. characteristic multiple calcium deposits. commonly affecting the vertebrae and the
skull. It occurs in young adults.
It occurs in the jaw and the spine. If in long It occurs in young adults, and is located
bones, it occurs in the diaphysis or aroundthe epiphyseal plate. Bones around the Common presenting symptoms are persistent
metaphysis, but never in the epiphysis. knee are commonly affected. pain and features of cord compression. At
times thelesion is asymptomatic. Typically,
It occurs in patients in their 2nd decade of life. Radiologically, there is a well-defined lytic one of the lumbar vertebrae is affected.
lesion surrounded by a zone of sclerosis.
The patient presents with an aching pain. Radiologically, it appears as loss of horizontal
Areas of calcification within the tumour striations and prominence of vertical striations
Radiologically, it is a well-defined radiolucent substance give rise to a mottled appearance of the affected vertebral body
expansile bone lesion 2-12 cm in size. There is
minimal reactive new bone formation.

Treatment is by curettage.

The importance of this tumour lies in


differentiating it from commoner diseases like
TB spine or metastatic bone disease of the
spine.

Treatment is by radiotherapy.
GLOMUS TUMOR RHABDOMYOMA GANGLION CYST
This rare tumour usually occurs around fine  Rhabdomyoma is a rare cause of a The ganglion cyst is the most common
peripheral neurovascular structures, and lump in the muscle. swelling in the wrist. It arises from leakage of
especially in the nail beds of fingers or toes.  It is occasionally confused with the synovial fluid from a joint or tendon sheath
‘lump’ that appears after muscle and contains a glairy, viscous fluid.
A young adult presents with recurrent rupture: both are in the line of a
episodes of intense pain in the fingertip. A muscle, can be moved across but not Although it can appear anywhere around the
small bluish nodule may be seen under the along it, and harden with muscle carpus, it usually develops on the dorsal
nail; the area is sensitive to cold and contraction. surface of the scapho-lunate ligament. Palmar
exquisitely tender. X-rays sometimes show  However, with muscle rupture wrist ganglia usually arise from the scapho-
erosion of the underlying phalanx. symptoms appear quite suddenly, lunate or scapho-trapeziotrapezoid joint.
there is a depression proximal or
Treatment is excision; the tumour, never distal to the lump and the swelling Clinical Features
larger than a pea, is easily shelled out of its does not grow any bigger. The patient, often a young adult, presents
fibrous capsule.  If a tumour is suspected, early with a painless lump, though occasionally
exploration and biopsy are advisable there is slight ache and weakness. The lump is
because malignant change may occur. well defined, cystic and not tender; it can
If the diagnosis is confirmed, the sometimes be transilluminated. It does not
tumour should be excised. move with the tendons. The back of the wrist
is the commonest site; less frequently a
ganglion emerges alongside the radial artery
on the volar aspect. Occasionally a small,
hidden ganglion is found to be the cause of
compression of the deep (muscular) branch of
the ulnar nerve.

Treatment is usually unnecessary. The lump


can safely be left alone; it often disappears
spontaneously. However, it can be aspirated
to reassure the patient. If it becomes
troublesome – and certainly if there is any
pressure on a nerve – operative removal is
justified.Even then it may recur with
embarrassing persistence; it is not easy to
ensure that every shred of abnormal tissue is
removed.
RHABDOMYOSARCOMA PIGMENTED VILLONODULAR SYNOVITIS SYNOVIAL SARCOMA (MALIGNANT
SYNOVIOMA)
Malignant tumours are occasionally seen in Pigmented villonodular synovitis (PVNS) presents as This malignant tumour usually develops near
the muscles around the shoulder or hip. a longstanding boggy swelling of the joint – usually synovial joints in adolescents and young
the hip, knee or ankle – in an adolescent or young adults. However, only about 20 % involve the
The patient(young adult) presents with ache adult. joint itself.
and an enlarging, ill-defined lump that moves
with the affected muscle. Xray may show excavations in the juxta- articular The patient usually complains of rapid
bone on either side of the joint. When the joint is enlargement of a lump around one of the
CT and MRI show that the mass is in the opened, the synovium is swollen and hyperplastic, larger joints – the hip, the knee or the
muscle, but the edge may be poorly often covered with villi and golden-brown in colour shoulder.
demarcated because the tumour tends to – the effect of haemosiderin deposition.
spread along the fascial planes. At biopsy the The juxta-articular excavations contain clumps of Occasionally the tumour presents as a small
tissue looks and feels different from normal friable synovial material. swelling in the hand or foot and the
muscle and microscopic examination shows histological diagnosis comes as a complete
clusters of highly abnormal muscle cells. surprise.

This is a high-grade lesion which requires Pain is a common feature and many lesions
radical resection of the affected muscle, i.e. are present for years before they are
from its origin to its insertion. diagnosed.

If this cannot be assured or if the tumour has X-rays show a soft-tissue mass, sometimes
spread beyond the fascial sheath, amputation with extensive calcification. MRI will help to
is advisable. Recurrent lesions are also treated outline the tumour. Biopsy reveals a fleshy
by amputation. lesion composed of prolifera- tive ‘synovial’
cells and fibroblastic tissue; characteristically
If complete removal is impossible, adjunctive the cellular areas are punctured by vacant slits
radiotherapy may lessen the risk of that give the tissue an acinar appearance.
recurrence. Cellular abnormality and mitoses reflect the
degree of malignancy.

Small, well-defined lesions can be treated by


wide excision. High-grade lesions, which
usually have illdefined margins, require radical
resection – and this may mean radical
amputation. Resection may be combined
with radiotherapy and occasionally
chemotherapy.
10. ORTHOPAEDIC PROCEDURES
A. ORTHOPAEDIC IMMOBILIZATION – TRACTION
DEFINITION: FUNCTIONS: SKIN VS SKELETAL TRACTION:
- A method of restoring alignment to a
fracture through gradual neutralization
of muscular forces SKIN SKELETAL
a. Reduction of fractures and dislocations TRACTION TRACTION
- Traction is applied to the limb distal to
b. Reduce/relieve pain AGE Children and Adults
the #, so as to exert a continuous pull in
c. Preventing deformities adults
the long axis of the bone
d. Correction of soft tissue contractures APPLIED Adhesive Pin, wire
Types of traction based on mechanism:
- Fixed traction: by applying force against e. Ensure immobilization WITH plaster
fixed point of body f. Minimize muscle spasms APPLIED ON Skin Bone
FORCE TO <5 kgs >5 kgs
- Traction by gravity: only apply to # of UL
PRINCIPLES: Counter traction (force acting in MAINTAIN
- Balanced traction: the pull is exerted
opposite direction REDUCTION
against an opposing force, provided by
DURATION Short Long
the weight of body when foot of bed is
raised
SKIN TRACTION: COMPLICATIONS: SKELETAL TRACTION:
INDICATIONS: SKIN TRACTION: INDICATIONS:
1. Temporary management of # of neck of 1. Allergic reactions 1. For those cases in which skin traction is
femur and intertrochenteric # 2. Excoriation of skin contraindicated
2. Management of femoral shaft # 3. Pressure sores 2. Patients with external fixator in situ
3. Undisplaced # of acetabulum 4. Common peroneal nerve palsy 3. Weight required for traction is >5 kgs
4. After reduction of dislocation of hip
5. To correct minor fixed flexion deformity SKELETAL TRACTION COMMON SITES:
of hip and knee  Olecranon (supracondylar and distal
SKELETAL TRACTION: humerus #)
CONTRAINDICATIONS: 1. Mal-union  Greater trochanter (medial/anterior force
1. Abrasion and lacerations of skin in the 2. Deformities acetabular #)
area to which traction is to be applied 3. Ligmentous damage  Distal end of femur (superior force
2. Disturbance in blood circulation such as 4. Introduction of infection into bone acetabular # and femoral shaft #)
varicose vein or impending gangrene 5. Damage to epiphyseal growth plates  Proximal end of tibia (distal femoral #)
3. Dermatitis 6. Nerve injuries  Distal end of tibia (certain tibial plateau #)
 Calcaneum (tibial shaft # and calcaneal #)
CARE OF PATIENT IN TRACTION
 Traction should be made comfortable
 Proper functioning of traction unit must be ensured
 Sensations over toes and fingers should be normal
 Proper position of # ensured by taking check x-rays in
traction
 Physiotherapy of limb should be continued to minimize
muscle wasting

SKIN TRACTION

SKELETAL TRACTION!

SKIN TRACTION!
ORTHOPAEDIC IMMOBILIZATION – CAST IMMOBILIZATION
DEFINITION

CAST – A hard circular dressing with soft padding inside of it used to immobilize body parts. It immobilizes and protects until healing occurs. It is usually made from Plaster
of Paris or fiberglass materials

SPLINT - A half cast used to temporarily immobilize and protect body parts. It consists of a deep layer of soft padding next to the skin, a middle layer of rigid fiberglass or
Plaster of Paris, and a superficial layer of compression wrap securing it to the patient. Also, an orthotic used to immobilize and protect a body part.

PURPOSES OF CASTING

 Provide immobilization
 Protect the injury
 Prevent further injury
 Decrease pain

CONDITIONS THAT BENEFIT FROM CAST IMMOBILIZATION

 Fractures
 Sprains
 Severe soft-tissue injuries
 Reduced joint dislocations
 Inflammatory conditions: arthritis, tendinopathy, tenosynovitis
 Deep laceration repairs across joints
 Tendon lacerations

COMPLICATIONS OF CAST OR SPLINT IMMOBILIZATION

 Compartment syndrome
o Most serious complication
o Increased pressure within closed space that compromises blood flow and tissue perfusion and causes ischemia and potentially irreversible damage to the
soft tissue within that space
o May experience worsening pain, tingling, numbness, severe swelling, delayed capillary refill or dusky appearance of exposed estremities
 Heat injury
o Result of casting or splinting process
 Pressure sores and skin breakdown
o Caused by focal pressure from a wrinkled, unpadded area over a bony prominence
 Infection
o Bacterial and fungal infections due to moist, warm environment of a cast (common in open wound)
 Joint stiffness

GUIDELINES FOR PROPER CAST AND SPLINT APPLICATION

 Use appropriate amount and type of padding


 Properly pad bony prominences and high-pressure areas
 Properly position the extremity before, during, and after application of materials
 Avoid tension and wrinkles on padding, plaster, and fiberglass
 Avoid excessive molding and indentations

COMPARISON OF PLASTER VS. FIBERGLASS FOR SPLINTS AND CASTS

PLASTER FIBERGLASS
Cost lower Higher
Moldability excellent Average
Strength average Excellent
Weight heavier Lighter
Curing period 48-72 hours Under 30 minutes
Radiolucency poor Good
Water resistance poor Excellent
Skin complications Easily washes off skin and clothes Gloves are mandatory, resin stains clothes and
bonds to skin for days
Allergic reaction Very low Slightly higher
Monovalve Spreads easily Spreads but recoils; needs a wedge to
maintain opening
TYPES OF CASTS

Type of cast Location Uses

Applied below the elbow to the hand. Forearm or wrist fractures. Also used to hold the forearm or wrist muscles and tendons in place after
Short arm cast
surgery.

Applied from the upper arm to the hand. Upper arm, elbow, or forearm fractures. Also used to hold the arm or elbow muscles and tendons in
Long arm cast
place after surgery.

Arm cylinder Applied from the upper arm to the wrist. To hold the elbow muscles and tendons in place after a dislocation or surgery.
cast

Shoulder spica Applied around the trunk of the body to the Shoulder dislocations or after surgery on the shoulder area.
cast shoulder, arm, and hand.

Applied around the neck and trunk of the After surgery on the neck or upper back area.
Minerva cast
body.

Applied to the area below the knee to the Lower leg fractures, severe ankle sprains/strains, or fractures. Also used to hold the leg or foot
Short leg cast
foot. muscles and tendons in place after surgery to allow healing.

Leg cylinder Applied from the upper thigh to the ankle. Knee, or lower leg fractures, knee dislocations, or after surgery on the leg or knee area.
cast
Unilateral hip spica Applied from the chest to the foot on one leg. Thigh fractures. Also used to hold the hip or thigh muscles
cast and tendons in place after surgery to allow healing.

Applied from the chest to the foot on one leg to the knee of the other Thigh fracture. Also used to hold the hip or thigh muscles
One and one-half
leg. A bar is placed between both legs to keep the hips and legs and tendons in place after surgery to allow healing.
hip spica cast
immobilized.

Applied from the chest to the feet. A bar is placed between both legs to Pelvis, hip, or thigh fractures. Also used to hold the hip or
Bilateral long leg
keep the hips and legs immobilized. thigh muscles and tendons in place after surgery to allow
hip spica cast
healing.

Short leg hip spica Applied from the chest to the thighs or knees. To hold the hip muscles and tendons in place after surgery to
cast allow healing.

Abduction boot Applied from the upper thighs to the feet. A bar is placed between both To hold the hip muscles and tendons in place after surgery to
cast legs to keep the hips and legs immobilized. allow healing.
ORTHOPAEDIC IMMOBILIZATION – BRACING
FUNCTIONAL BRACING
 One way of preventing joint stiffness while permitting fracture splintage and loading
 Using either plaster of Paris (POP) or one of the lighter thermoplastic materials
 Segments of a cast are applied only over the shafts of the bones, leaving the joints free; the cast segments ae connected by metal or
plastic hinges that allow movement in one plane
 Used mostly for fractures of:
 femur
 tibia
 Since the brace is not very rigid, applied only when the fracture is beginning to unite (after 3-6 weeks of traction or conventional
plaster)
 Four basic requirements of functional bracing:
 the fractures can be held reasonably well
 joints can be moved
 the fracture joins at normal speed (or perhaps slightly quicker) without keeping patient in the hospital
 method is safe
 Techniques:
 fracture is stabilized
 a hinged cast or splint is applied
 Unlike internal fixation, functional bracing holds the fracture through compression of soft tissue
 Small amount of movement that occurs at the fracture site through using the limb encourages vascular proliferation and callus
formation
B. PRINCIPLES OF SURGICAL AMPUTATION
Amputation is a procedure removing part of the through one or more bones.
Disarticulation is a part removed through a joint.

Indication
Dead
 Dead limb like in PVD, severe trauma, burns and frostbite
Dangerous
 Malignant tumour, lethal sepsis, crush injury
Damned nuisance
 If retain the limb it get worse
 Due to pain, gross malformation, recurrent sepsis and loss of function
Type
Open or Guillotine (open due to unhealthy wound)
 2°closure
 Plastic repair - soft tissue
 Revision of stump - reconstructed
 Reamputation - higher level
Closed
Myodesis
 Skin is closed
o Tourniquet - not in ischemic limb
o Ex-sanguination - squish limb by Esmarch bandage. Contraindication in infection and malignancy.
o Level of amputation
The traditional sites of election; the scar is made
 Extent of the disease/trauma terminal because these are not end bearing stumps.
 Anatomical principle - save joint as far as possible.
 Suitability for the efficient functioning of the limb –
too long below knee amputation, not suit for prosthetic.

Procedure
Skin flaps: mobile and sensitive skin.
Muscles: cut distally to the bone
• Myoplasty - opposite muscle are sutured together
• Myodesis - muscle suture to stump.
Nerves
 Pull into the wound distally, and divided with a sharp knife (cut end retracts well proximal to bone section).
 Large nerve ligated before divided.
Major blood
 Ligated using non-absorbable sutures.
 Tourniquet released before skin closure.
 Secure haemostasis
Bone level
 Excessive periosteal stripping proximally may lead to the formation of 'ring sequestrum'.
 Bony prominences that not well padded must be resected.
 Smoothen sharp edges.
Drain: A corrugated rubber drain should be used for 48-72 hours post-operatively.
After treatment
 Dressing and wrapping
 Positioning and elevation of the stump
 Exercise
 Prosthetic fitting and gait training (final treatment)

Complication
Hematoma - inadequate hemostasis
Infection - wound break
Skin flap necrosis
Deformities of the joint - due to contracture
Neuroma - form at end of cut nerve
Phantom sensation

Esmarch bandage
FRACTURE OSTEOSYNTHESIS
INTERNAL FIXATION – PLATING
INTERNAL FIXATION – K-WIRING
INTERNAL FIXATION – INTERLOCKING NAILING
EXTERNAL FIXATION – ILIZAROV
ILIZAROV'S TECHNIQUE (Ring fixator)
The basic premise of Ilizarov’s technique is that osteogenesis requires dynamic state. The dynamic state means that the site of osteogenesis
(e.g., a fracture) requires either a controlled distraction or a controlled compression. This dynamic force, when properly applied, causes the
dormant mesenchymal cells at the non-union site to differentiate into functioning osteoblasts. This results in bone synthesis and fracture
healing.

According to his theory in wider perspective, any living tissue when subjected to constant stretch under biological conditions, can grow to any
extent. The biological conditions are provided by:
(i) aligning the fracture with minimal damage to its vascularity,
(ii) performing an ‘osteotomy’ of the bone (e.g., in limb lengthening surgeries), without damaging its periosteal and endosteal blood
supply. Such an ‘osteotomy’ was termed corticotomy by Ilizarov.

The whole segment of the limb is stabilized by a specially designed fixation system called ring fixator. This protects the growing tissues from
bending or shearing forces, but permits loading in the long axis of the limb. Distraction or compression can be applied at the fracture or
corticotomy site by twisting nuts on the fixation system.
Advantages Disadvantages
 Immediate load bearing  Inconvenience, as the external fixator hampers normal activity
 A healthy viable bone in place of devascularized bone  Long duration of treatment
 Correction of more than one problems by one stage operation.  Pin tract infection
 Nerve palsy by pin insertion or traction
 Joint stiffness caused by transfixation of the soft tissues by the
external fixator.
11. MILITARY RELATED MEDICINE
GUNSHOT INJURY TO EXTREMITY
Severity of the injury depends on:
- Velocity
- Presenting area
- Mechanical properties

PRIMARY SURVEY

A – Airway  cervical spine injury


B – Breathing Diaphgram, intercostal muscle, multiple fracture of the ribs
C – Circulation  Hypovolemic shock
D – Disability
E – Exposure

PRESENTATION

Symptoms

- Pain, deformity

Physical exam

- Perform careful neurovascular exam


- Clinical suspicion for compartment syndrome
- Secondary to increased muscle edema from higher velocity wounds
- Examine and document all associated wounds
- Massive bone and soft tissue injuries occur even with low velocity weapons
-

INVESTIGATION

Radiographs

- obtain to identify bone involvement and/or fracture pattern

CT scan
- identify potential intra-articular missile
- detect hollow viscus injury that may communicate with fracture
- high index of suspicion for pelvis or spine fractures given increased risk of associated bowel injury

MANAGEMENT

Nonoperative

- Local wound care


- Tetanus +/-
- Short course of oral antibiotics

Operative

- Trans-abdominal trajectories  laparotomy takes precedence over arthrotomy


- ORIF/external fixation
- Arthrotomy
INJURY INDUCED BY MARCHING ACTIVITY
A metatarsal stress fracture is a hairline break in a bone, caused by repetitive stress.

Seen in soldiers who marched for long periods of time.

SYMPTOMS

- Pain in the foot during exercise


- Relieved by rest but after a while, the pain become continuous
- Localised to the area of the fracture
- Swelling but no bruising

INVESTIGATION

- X-ray – Metatarsal fractures


- Bone scan

MANAGEMENT

- Avoid any exercise or activity that caused stress fracture


- Elevating foot help to relieve the pain
- Special shoes to immobilise the fracture
- Below-knee plaster cast