Genu Valgum

 Find out age , family history positive if any(Heridatiary Multiple Exostosis/HME, Hypophosphatemic Rickets, Bony Dysplasia ) 

https://www.medicalnewstoday.com/articles/319894

Physical Examination

    Gait 

    Squatting

    Standing - Quadriceps , Patella forward, forefoot , Obvious Genu Valgum Deformity

    Side -        Any scars 

                     Knee in extension

    Back -       Popliteal swelling, comment on calf muscles

                     Heel varus 

Ask patient to lie down 

    Feel -         Temperature normal, no bony/ soft tissue tenderness

                    scar - non-tender , mobile

                    Patella- non-tender, Gliding, Clarke test, Apprehension

    Movement - Knee - Flexion and Extension

                         does deformity disappear with knee flexion

    Measure the deformity 

                        Genu Valgum and Q-angle (knee in 20 degree flexion ? )

     Special tests - LCL, MCL, Obers test 

    Neurovascular tests 

    Lymh node as a routine check up 

    quickly comment on frontal bossing, teeth, ligament and laxity. 

Investigations 

     Standing leg Alignment X-ray

     Tibiofemoral angle as per Saelenius curve

    

Treatment 

    Observe 

    Bracing -still practiced for  mild deformity. 

    Guided Growth - Physeal Staples (advantage -reversible )

    Osteotomy when else fail.

Pes Cavus Deformity (Theory )

 Pes Cavus 

https://thetagoeclinic.co.uk/pes-cavus/

Important Causes

A. Heriditary Motor Sensory Neuropathy

  Also called as Charcot-Marie-Tooth Neuropathy 

   Characterized by motor and sensory neuropathy.

    

         1)           Weak Tibialis Anterior (TA)

                                &

                Normal Peroneus Longus 

                         leads to 

                    Ist Metatarsal Drop

    

           2)     Weak Peroneus Brevis and Varus Hindfoot leads to Varus Hindfoot (Normal TP )

                            leads to 

                            Varus hindfoot

            3) overactive extensors to compensate weak TA to clear ground leads to clawing leading to further tightening of Plantar fascia (windlass effect ) and hence worsening cavus deformity.

    

Clinical findings 

     Painless Polyneuropathy

     Muscle weakness, atrophy, sensory loss with involvement of CPN

    Sensorineural Hearing loss 

    

B .Spina Bifida / Poliomyelitis

    weak triceps surae lead to calcaneal deformity owing to unopposed DF and reciprocally PF forefoot.

     Varus Heel (subtalar inversion ) locks midtarsal joints making a rigid foot.

    Excessive pressure forms Callosities.

    Questions to be considered 

            when did the symptoms start, other family members affected, any neurological disease if present, are the symptoms progressing, any change in vision or hearing 

    Physical examination    

            Look

            Toes- deformities
                      callosities under MT head,              callosities on lateral border of foot

                      Ist ray - Plantar flexion

            Foot drop, leg muscles wasting 

                    Foot wear problems 

            Heel - varus/valgus, equinus, 

             Foot- Plantaris 

           Feel 

                tenderness, deformities correctable or.                  normal

                Sensation

             Movement 

                Active / Passive 

            Special Tests 

                Varus deformity- Coleman Block test

                Equinus Deformity- Silverskiold test

            Measure the deformity

            Neurological tests 

            Check lymph nodes, Vascularity, back 

        Investigations 

            X-ray - weight bearing lateral -                                 Calcaneus pitch

   https://www.nature.com/articles/s41598-022-16995-6      

    (Normal < 30 degrees) and lateral.                      Meary's angle (Normal 0-5   degrees)

                       PA -Meary's angle (N - 0 -5degrees)

            MRI - Muscle enzymes 

                        Genetic Screening

            Neurophysiology for underlying                              Neurology 

    Treatment 

            Conservative

                  Operation for symptomatic. 

                 Orthotics fail.

            Release of Plantar Fascia.

            DF osteotomy for Ist ray +/- 2nd ray.

            Calcaneum sliding and closing wedge.                    osteotomy 

            Transfer Peroneus Longus to Peroneus.                 Brevis at level of distal fibula.

            Clawing of toes - flexor transfer to.                         extensor aponeurosis 

            Jones Procedure 

https://musculoskeletalkey.com/47-transfer-of-the-long-toe-extensors-to-the-heads-of-the-metatarsals-jones-transfer/

             Triple Arthrodesis

                        

 http://www.boneschool.com/lower-limb/foot-and-ankle/foot-arthrodesis/triple-arthodesis

                

            

Monteggia Fracture Dislocation

 Classification 

    Bado -   Anterior - 75 - 80 %

                  Posterior - 5 % , common in adults

                  Lateral     -   15-25 %

            Any type associated with radial shaft.         fracture , rare. 

https://rayorthos.com/bado-classification-of-monteggia-fractures/

Management 

    ATLS review 

    Full history

    Examination - r/o other injuries , open wounds, compartment syndrome, DNVS

    Further radigraphs    

    Urgent reduction and fixation

    Direct approach to ulna 

            Internervous plane - ; ECU (PIN) and FCU (UN)

            Fixation using 3.5 mm DCP using AO principle

    How does DCP work ?

     It words in different modes.

    Compression - Placing screws eccentrically in combihole to allow sliding compression at fracture                                 site ( simple unstable two piece fractures )

    Neutralization    - provides interfragmentary compression achieved by lag screw fixation as in                                             fracture with a butterfly fragment .

    Buttress or Briding Plate  - prevents fracture collapse in non-reducible communited fractures )

     Post operatively - protect soft tissues in backslab for four weeks to prevent lateral subluxation of             radial head.

    Physiotherapy to regain elbow ROM. 

Shaft of Humerus fracture with Radial Nerve Palsy

 How do you approach a patient with shaft of himerus fracture with radial nerve palsy?

    Approach based on ATLS. 

    Exclude other injuries - NV, Open wounds, compartment syndrome 

    AMPLE History

    Analgesia

    Splinting 

    Collar and Cuff with gravity traction

    Fracture can be managed non-operative or operatively based on fracture displacement and fracture             geometry 

https://nerveclinic.co.uk/nerve-injuries/nerve-injury-after-fracture-or-dislocation

    Early Immediate Exploration Criteria for Radial Nerve Injury

    (https://www.aofoundation.org/trauma/about-aotrauma/blog/2023_03-      blog-moharram-lambert-radial-nerve-palsy)

    Open Fractures with Radial Nerve Palsy 

     High velocity injuries - Gunshot wounds, Penetrating wounds, Severe soft tissue damage

    Neurotemesis (complete transection ) signalled by loss of Brachioradialis function, finger and wrist        drop

    There is no need of exploring the nerve nerve while fixing the humerus if there are no indications. 

     Otherwise we manage the  Radial Nerve expectantly. 

    90 % - Neuropraxia and recover within 3-4 months.

    Wrist splint( in extension ) for wrist drop 

    Physiotherapy - to maintain range of motion. 

If radial nerve palsy does not improve after 4 months, what will you do ?

    Nerve conduction , EMG studies.

    If neuroproaxia - continue to monitor expectantly.

    If muscle denervated, action potential - Fibrillation potential on EMGs.

    Refer to local peripheral nerve injury specialist.

 Principles of tendon transfer 

    1. Supple joint with full ROM

    2. Donor should be healthy and expendable.

        Grade 5 , MRC Power

        Adequate Excursion    

        Synergist

        Straight line of pull

   3. Recipient - tendon of paralyzed muscle 

    4. Common transfer 

        ECRB to supplement by Pronator Teres 

        Palmaris longus (PL) by EPL

        Flexor Carpi Radialis (FCR) by ED 

Cervical Spine Dislocation

 

C5 displacement over C6 , (displacement > 50 % , it's a Bifacet dislocation )

Delayed Diagnosis of B/l facet dislocation :a case report.Julie O Shaughnessy et. al.

Only shows C7 and is inadequate for trauma C-spine lateral radiograph. 

Management 

    - ATLS guideline -remove helmet visor to gain access to eyes , nose and mouth.

    - Exclude other injuries.

    - Full imaging of spine / full neurological examination - ensure this is isolated injury.    

    - Spine surgery consultation for reduction 

                    Close or Open 

    - Exclude a prolapsed disc which damages cord during reduction.

    

         If no MRI scanner, can we reduce with patient awake ?

        Yes, we can reduce. We can monitor patient awake, alert .Serial neurological examination is also             possible.

         Gardner-Wells-Tong / Crutchfield skull traction is applied on skull and then adding sequential                 weights to traction cord.

        Patient positioned on supine, under C-arm guidance, after each addition of weight load, image                 taken and assessed. Initially 10 pounds then 5 pounds added. Once neck is fully stretched, facets             unlocked then neck is fully extended to complete the reduction and traction reduced. 

        How do we apply a Halo traction Jacket?

        Take the consent.

        Four pins using local anaesthesia applied on skull, tightened with a torque limiter (6 pins for                     children)

        Placement carried out as follows - 

         1. Anterior - 1 cm above lateral outer 1/3rd of eyebrow

         2. Posterior - Behind earlobe above mastoid 

        Three Person Job- one holding head and two applying Halo.

        Apply Jacket of approximate size.

        Check radiograph of spine to ensure correct reduction.

        Tighten pins after 24 hours. 

    https://www.slideserve.com/taber/critical-          care-of-spinal-cord-injury-dr-amr-el-said-       professor-of-anaesthesia-intensive-care-      faculty-     of-medicine.

  Complications 

        Loss of reduction 

        Pin site infection and Loosening 

        Pain

        Nerve Injury 

        

        

        

Subtrochanteric Fractures

 Subtrochanteric Fractures 

    Common in elderly people.

    Causes - simple fall from standing. 

                            Fragility or Pathological fractures 

                   High energy fractures

    Russel Taylor Classification    

                  1. Intact Pyriformis fossa

                                A. Lesser trochanter intact

                                B. Lesser trochanter detached

                  2. Pyriformis fossa involved 

                                A. Intact posteromedial buttress

                                B. Communition of posteromedial buttress

        Seinsheimer Classification - offers guideline for management and prognosis.More distal the                 primary fracture line is , the higher the incidence of complications. 

https://www.slideserve.com/mairi/subtrochanteric-fractures

       Management in Preoperative phase 

                 Assess medical condition, Past Co-illnesses, r/o metastasis, 

                Exclude other injuries

                NV status

                Analgesia    

                Immobilize in Thomas Splint

                X-ray - Whole Femur 

                Routine blood inv. 

                Arrange Blood 

     Fixation of this fracture

                No any gold standard method.

                Historically , plating used to be done. 95 degrees condylar screw plate is a good recent option.It gives a good proximal and distal control. It permits at least two cortical screws in proximal fragment into proximal fragement. 

                Recent option - Nailing 

                All methods have sizable failure rate. 

                Massive biomechanical loads transmitted through this area.

Deforming forces 

                If lesser trochanter attached to proximal fragment, Psoas tendon causes flexion and abduction                 of proximal fragment. 

                Medial group of adductor muscles pull the distal fragment medially. 

   https://www.researchgate.net/figure/A-B-C-A-      comminuted-subtrochanteric-fracture-was-         treated-by-MIPO-minimally-   invasive_fig1_287961100

When to expect healing in this fracture ?
Around four months.

There is always a race between union and implant failure due to fatigue.

 Non-union chance is 5-10 %.

Fat Embolism and Damage Control Orthopaedics

A young  pedestrian was hit by a car and sustained Mid shaft of tibia fracture of her left leg. After 24 hours, he suffered from shortness of breath. Chest X-ray is shown as below. What may be the cause. 

Fat Embolism in Pulmonary Artery

Upright portable AP chest x-ray showing hypovolemia secondary to a pulmonary embolism, knowns as Westermark sign. Image courtesy

https://emergencymedicinecases.com/wp-content/uploads/2012/03/015-15-Figure-1.jpg

Radiographic other findings

PA chest xray in a patient with a PE. Arrow denotes the area of pulmonary infarction, known as Hampton hump. 

Image courtesy  http://www.imagingpathways.health.wa.gov.au/images/pe/ham.jpg

 Sometimes Atelectasis is found.

What is Damage Control Orthopaedics (DCO) ?

    

    Planned and staged surgical strategy in management of polytrauma patients to minimize effects of            second hit on already limited physiological response. 

     First Hit - from injury and body's response to this injury. 

     Second Hit - surgery

    Studies suggest that primary ex-fixator and secondary nailing improves outcome. It decreases                     incidence of MODS and ARDS.

How to decide which patient requires DCO and what are its alternative ?

      Alternative to DCO 

            -Early total care, early treatment of all fractures 

     DCO indications - 

                Injury Severity Scale (ISS)> 20

                Abdominal or pelvic trauma in hypovolaemic shock (SBP < 90 mmHg)

                Anyone with bilateral lung contusion

What is ISS ?

       Based on Abbreviated Injury Scale (AIS)

        Each body system gives on AIS of 1-6 with 6 most serious .

        ISS is Dervied from adding squares of 3 most severely injured body system.

        Score > 16 is considered injured. 

When to expect to operate on a DCO ?
        Made in conjunction with anaesthetist and intensivist.

        At least after four days.

        BP, HR, T  - Normal

        ABG- Corrected

        Convert Ex-fixator to a Nail in 10 days to avoid risk of fractures.

                 

Hip Dislocations and its management

 Approach to patient  with a hip dislocation

  AP radiograph showing a posterior hip.      dislocation

    ATLS Protocol is followed. Don't miss to say X-ray pelvis, C-spine lateral view and CXR-AP view                        to r/o other injuries

                document NV status of limb along with findings on hip

                additional view of Hip Lateral and CT-Hip joint incase there is a acetabulum fracture

                adequate analgesia 

                pelvic specialist consultation 

  How to treat this injury ?

     Consenting , explain risk of fracture

      CR of hip 

       Bigelow Procedure

                        Patient on supine , assistant stabilizes Pelvis via ASIS 

                        Surgeon - traction ,Adduction and IR 

     If CR fails, OR via Posterior approach.

What are precautions after Reduction we take  ?

        Confirm under C-arm

         EUA - to assess stability

         Distal femoral pin to maintain hip reduction for traction

          Post-operative CT scan to confirm concentric reduction, r/o fracture fragments inside jts,  characterize posterior wall #s.

        NV examination when patients recover from anesthesia

Indications for fixing posterior wall fractures 

        Lack of joint congruity

        Instability ( 20 % wall involved - joint stable, 20-40 % wall involved -joint unstable)

        Fracture > 30 % of the wall to maintain the reduction

  How to fix posterior wall fractures ?
        Posteior approach

        Screw fixation / Butress Plating

https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/acetabulum/posterior-wall/orif-through-kocher-langenbeck

        Counselling - Early complications     

                                        Infection

                                        Sciatic Nerve Injury

                              Long term complications

                                         Heterotopic ossification    

                                         AVN

                                        OA 

Indomethacin is routinely used to minimize risk of heterotopic ossification.

LMWH to reduce risk of DVT and PE. 

              

        

          

Knee Dislocation and its management

 Like any other joint dislocation, its a surgical emergency.

                            https://www.orthobullets.com/trauma/1043/knee-dislocation

Causes 

     Motor Vehicle Collision

     Sports related injuries

     Falls

Initial Assessment

    - NV status before and after reduction

    - If any vascular injury ,exploration and angiography 

    - Normal pulse does not rule out vascular injury , measure ABPI (< 0.9 - ABNORMAL )

Classification 

 Based on direction of dislocation of tibia in relation to femur 

        Anterior - dislocation most common.

    upto 20 % spontaneously relocate and dont fit into classification.

            https://emedicine.medscape.com/article/823589-clinical?form=fpf

    Association

        Ligaments injury

        Arterial Injury - as high as 40 % 

                       how to proceed ?

                        arrange for patient to go urgently  to a theatre where plastic surgeons will be available.

                        prompt reconstruction with interposition vein grafting

                        knee stabilized with a spanning ex-fixator. 

                        lower limb fasciotomy done

        Nerve Injury - CPN Involvement - 20-30 % 

                        treat expectantly , large proportion dont recover fully

    Definite treatment of unstable knee ? 

                    MRI - to characterize ligament structures    

                    EUA 

                    Repair / Reconstruct ligament structures 

   Treatment 

            If no Arterial injury , relocate knee dislocation under IV sedation at ER then treat other                            associated injuries ,  

            Early reconstruction of PLC and PCL 

            Delayed ACL reconstruction

            Early Bracing, Rehab with late reconstruction

            If associated with arterial injury , treat as mentioned above. 

Pilon Fracture

Result of high energy trauma resulting with a heavy axial force of talus which bursts tibial plafond over  talus 

AP radiograph of Ankle shows a multifragmentary Pilon fracture.

                                        https://ota.org/for-patients/find-info-body-part/4687

How do you approach ?

    ATLS review

    R/o concomitant injuries

    R/o compartment syndrome

    NV status , observe signs of open injury or degloving injury

    temporary splinting, analgesia, obtain AP/Lateral views and  CT -study

     plan and do  definitive management 

Classification of Pilon Fractures 

        Type 1 - essentially non-displaced

                 2 - displaced with communition

                3  - metaphyseal or articular communition

What is the primary treatment for this fracture ?

        monitor signs of compartment syndrome

        transfer to theatre

        place an ex-fixator - damage control surgery

                    keep limb out to length

                    maintain alignment to avoid further insult to soft tissues

         +/- fix fibula at the same setting to restore length

What is the definitive treatment ?

        CT-scan -preoperative planning

         Wait 7-10 days for soft tissues to be in appropriate condition for surgery

        Openly reduce and fix along AO (Arbeitsgemeinschaft fur Osteosynthesefragen ) principles

          Non-surgical treatment - an option but gives a poor result

          Surgical Treatment - Ex fixator such as fine wire Ilizarov frame.

                                            ORIF with Plating

                                            Goals - 

                                                    anatomical reconstruction of articular surfaces 

                                                     restoration of correct rotational alignment

                                                    

                            https://journals.sagepub.com/doi/10.1177/0036933015569159

Complications to warn the patients 

    Short term 

                Wound break down

                Infection

                Compartment syndrome    

                Complex Regional Pain Syndrome(CRPS)

    Mid  Term

                Non-union

                Mal-union

      Long term

                Limitations of ankle movement

                Post-traumatic OA - 80 %