Short Notes in Orthopaedics

2 questions that are relevant  to ask that are allowed in short case practical  examination are (same holds true for all nerve related questions ) 1. What happened ? 2. When it happened ? if allowed ask 3. what are the difficulties for the patient ( Then introduce yourself , ask for permission to proceed and go to examination after proper examination ) Look- Scar             Wasting of triceps , forearm radial borders Feel - Temperature            tenderness - Superficial and deep          Tinel's sign - v. v.v. important         check pliability of scar and scar tenderness, check tinel's on scar           check bony union if there was a previous sign of fracture           Lymph nodes            Pulsation / Allen's test Movement            quickly assess upper extremity movements Measurement                quickly assess humerus shortening or  shortening of forearm Neurovascular examination Sensation  Autonomous zone of a

First a brief about Common Peroneal Nerve Two sensory branches  1. Lateral Sural Cutaneous Nerve       skin over lateral aspect of knee and proximal third calf 2. Branch that joins tibial anastomotic branch to form surnal nerve      skin over posterolateral aspect of calf and over lateral malleolus , lateral aspect of foot , over 4th      and 5th toes Motor Supply  1. Superficial Peroneal Nerve     Motor ;     Peroneus Longus and Brevis     Sensory;   Anterior and Lateral aspect of leg and dorsum of foot 2. Deep Peroneal Nerve     Motor; Anterior Tibialis , Extensor Digitorum longus , EHL , Peroneus Tertius , Ist dorsal         interosseus  (   Sensory; Ist web space via digital cutaneous nerve (lateral aspect of dorsum of great toe and      medial  aspect of 2nd toe ) Treatment    1.Splint   2. ROM Exercises  3. Repair - 60 - 70 % patients recover motor function .       (nerve repair techniques  already discussed in previous section . ) 4.

Supply Motor supply Tibial Component  Hamstrings , Gastocnemius , Posterior Tibialis , Long Flexor of Toes Peroneal Component  Anterior Tibialis , Long Extensor of Toes (deep peroneal nerve )  Sensory supply    Via Sural Nerve , Deep Fibular Nerve , Superficial Fibular Nerve , Medial Calcaneal Branches Affects in  Knee Flexion  Ankle - Flexion / Extension  Toe flexion / Extension  Sensation - Loss  Due to peroneal Divsion          lateral aspect of leg , dorsum of foot  Due to Tibial Division           plantar aspect of foot  Late deformities  Equinus Deformity , Clawing of Toes , Atrophy of muscles supplied by this nerve. Investigations  EMG  for the Nerve Investigation of the injury  - X-ray of the bone and joint to find out the cause.                                         Treatment  Release comrpessing Leg cast Endoneuroloysis for prolonged compression Explore for fracture and dislocation of hip, shaft of femur fract

How to proceed for the treatment ? A. Open Brachial Plexus Injury        Sharp Objects , Missiles injury   Associated vascular and mediastinal injuries are treated first. Tag plexus nerves with suture.   Document deficits    EMG after 3 -6 weeks .     Then Surgery.       For  Low velocity injury          wait and follow up in 3 and 6 weeks ,           if no improvement then surgery . B. Closed Injuries        Traction injuries         1.C5-6         2. C 5-7         3. C7 ,8,T1   Observe , Physical Therapy  for 6 - 8 weeks.     Myelography , axonal reflex evlauation   Explore at 3- 6 weeks                       if no functional recovery                       if only distal recovery                       post- ganglionic injury Surgical Goals      1. Restore elbow Flexion      2. Shoulder Abduction       3. Restore sensation to medial border of forearm and hand Techniques  Neurorraphy  Primary Repair  Neurolysis N

Losses A combined Median and Ulnar Nerve (except for FCR and Pronator Teres ) Extensive sensory loss       medial aspect of arm and hand Diagnosis Clinical examination  EMG including EMG of paraspinal muscles locates lesion in 80 % cases.

Losses  Motor Function  Subscapularis Nerve function - Subscapularis and Teres Major  Thoracodorsal Nerve - Latissimus Dorsi  Axillary Nerve - Deltoid and Teres Minor  Radial Nerve - Extensor of Elbow , Wrist fingers  Sensory loss over Deltoid  Functions affected   Shoulder IR / Abduction , Extension of elbow , Wrist and Fingers  Improvement in triceps without deltoid suggests Axillary Nerve entrapment in Quadrangular Space.

Segmental sensory and motor deficits - C8 , T 1        Motor loss - Intrinsic hand functions                             Wrist and Finger flexors        Sensory loss - over C8 , T1 dermatomes ( arm, forearm and hand ) Horner Syndrome   Investigations          Myelography     EMG Lateral Cord Injury   Motor  Musculocuataneous Nerve - Biceps weakness  Lateral Root - Median Nerve - FCR , Pronator Teres weakness Lateral Pectoral Nerve - Pectoralis Major Glenohumeral Subluxation Sensory Deficit   anterolateral aspect of Forearm

After examination of brachial plexus  through our previous scheme of examining Brachial Plexus , students have to know further detail about diagnosis and  management of different Brachial Plexus Injuries. Its discussed below. Upper Plexus Palsy (Erb's Palsy )  C5-6     +/-  C7 Injury Typical Position and  attitude of upper limb          Elbow extended , shoulder Internally rotated , and adducted          flacid rt side of trunk Movement of Upper Limbs impairment                  Shoulder ROM - Abduction not possible                                             due to paralysis of Deltoid and Supraspinatus                                       External Rotation not  possible                                             due to paralysis of Infraspinatus and Teres Minor                                        Flexion  not possible                                               due to paralysis of Biceps , Brachialis , Brachioradialis             Forearm  

Factors influencing regeneration after Neurorraphy 1.Age - higher chances of failing in elderly. Higher rate of success in children. 2.Gap between nerves - managed by nerve mobilization, transposition , joint flexion , grafting and     bone shortening . 3. Delay in repair - upto 12 months - satisfactory results. 4. Level of injury - proximal muscles - good recovery.                                proximal injury - incomplete motor and sensory recovery. 5. Conduction of nerve ends - for this expose fascicular bundles 6. Time of surgery -                    primary repair - best done within 6-8 hours                    delayed repair - best done in 7- 18 days. Instruments required for neurorraphy     Pneumatic tourniquet      suction apparratus       electrocautery        Gelfoam and thrombin at nerve ends to control bleeding        sutures ; 8-0 , 9-0 , 10-0 monofilament         Epineural repairs ; 8-0 , 9-0

Following points to be included in one's scheme . A. Detailed Clinical History                1.      Particular detatils of patient                             Hand dominance                              Profession             2.    C/C            3.   History of Present illness                   Regarding                  Site of Injury                   mechanism of injury -blast , crush , tractrion ,                                                      open wound with contamination                                                       weakness , progressing or improving                                                      consequences of weakness on daily life                                                     abilities related to the organ affected                                                                  constitutional symptoms                        Any other injuries on body        4. Treatment history -                    

Anaesthesia over entire hand on palmar surfaace Clawing of hand Tr Availability of Donor tendons for treatment     Brachioradialis      ECRL , ECRB, ECU , EIP Omer  1. Thumb arthrodesis   2. Fingers - Zancoli capuslodesis - MCP joint of all fingers  3. Release tendon sheath of flexor tendons   4. ECRL to FDP (on radial border )   5. Bachilradialis to FPL   6. ECU to EPB on Ulnar side   7. Amputate IF and fold radiallyinnervated dorsal flap into palm for sensation.

Complete anaesthesia over palm loss of all intrinsics loss of thumb functions clawing - fixed if untreated Tr 1. PT - to supple joints and skin 2. Finger intrinsics                 Brand transfer , ECRB (extended )                 Clawing  - Brown                                    ECRL (extended ) to restore MCP as Brand .   3.Thumb adduction           EIP / FDS           Omer                     FDS LF- 4 tails / ECRL for adductor    4. Opposition           ECU extended by EPB or PL     5. Fusion of Thumb for stability           Options - ECRL for clawing , EIP for thumb adduction, ECU for thumb opposition to           memorize for exam .

Losses   pronation of forearm   flexion - IF, LF (Long Finger ) , thumb flexion   opposition of thumb   sensation over median nerve Treatment IF , LF -      side to side anastomosis           FDP 4th and 5 th finger     or ECRL to FDP 2nd and 3rd finger Thumb Flexion        Brachioradialis Opposition        EIP Sensation        Neurovascular Island flap

Deficits Opposition of thumb sensation over sensibility distribution paralysis of 2 radial lumbrical muscles - little consequences with intact ulnar nerve Functional requirement Opposition of thumb  Sensation on first web space - ? island flap thumb Synergestic Muscles Wrist Extensors  FDS

Same loss as low Ulnar Nerve palsy + FDP - RF and LF (additionally) . Treatment  Same as in low Ulnar Nerve Palsy but not to take FDS RF for treatment.  FDP - 4th and 5th Finger          side to side anastomosis with FDP 2nd and 3 rd finger  Available  - wrist extensor , FDS , EIP.

Clawing 1.Stiles and Forrester - Brown FDS - detach , split and transfer to dorsum of fingers to extensors  No f/u 2. Bunnel FDS - detach , split    one slip to each of extensor aponeurosis by way of lumbricals    effective when intrinsic only weak but not paralyzed , 3. Fowler's modification    FDS - splitted into 4 slips     passed through volar side of deep transverse metacarpal ligaments , attached to radial side of extensor aponeurosis of each finger effective if wrist is flexed. 4.Brand ECRL / ECRB passed through volar side of forearm , to carpal tunnel and extended by 4 tailed grafts Plantaris / Palmaris Longus ) and through lumbrical canal to extensor aponeurosis. 5. Riordan FCR passed through dorsum of wrist, extended with 4 tailed graft , each tail passed volar to deep transverse metacarpal ligament and attached to radial side of extensor aponeurosis . 6.Zancoli Arthrodesis  capsulodesis , joint supple , no muscles for transfe

Adduction of Thumb 1. Boyes Brachioradialis throgh 3rd interosseous space to dorsum  to thumb adductor tubercle along with tendon graft of Palmaris Longus (PL ) or  Plantaris Post-operatively - cast removal at 3 weeks and active exercises 2. Royle Thompson transfer (modified ) FDS ring finger transferred dorsoradially like Riordan , divided into two slips . Distal one - appeoneurosis with EPL Proximal slip - MCP joint capsule and Adductor Pollicis Abduction of IF 1.EIP transfer 2. Abduction Pollicis Longus transfer

A. Arthrodesis   15 degrees IR , slightly flexed    if no tendons for transfer , at 20 degrees flexion , IP joint for a IP joint flexion contracture . B. Tendon transfers  1 . Riorddan    FDS RF through loop of FCU to thenar region to apponeurosis of EPL and Abductor Pollicis .  Post - operatively - 3/52 dressing, then splint remove and active motion intermmitantly        thumb splint in opposition for 6 weeks , teach opposition with RF. 2. Brand transfer  FDS RF to thenar region  then split into two slips.           1st  passed to ulnar side of thumb IP joint proximally           2nd passed to Abductor Pollicis and EPL . 3. Bulkhalter         EIP taken to subcutaneuos tissue and ulnar border of wrist to palm to thumb to MP capule          thumb , Abductor Pollicis Brevis and EPL . 4. Grooves and Goldner      FCU and Sublimus       FCU - proximal portion alongwith sublimus passed and loop created by distal portion of FCU        with ECU .

Skin and joints supple No bony malalignment Restore sensation before tendon transfer Polio - wait at least 18 months before surgery otherwise it may recur          Meadin Nerve - wait for four months Technical considerations - Donor tendon should be pink and red Poor nutrition - Pink and pale ; smaller than normal tendons.

Deficits Pinch - aadductor Pollicis             - Ist dorsal interossei Grip - finger intrinsics Treatment Claw A. Tendon Transfer 1.  RF/LF intrinsic paralysis              EIP - 2 slips passed volar to deep transverse ligament , and passed to radial side of each                          finger extensor finger aponeurosis               Zancoli capsulodesis 2. Omer MCP thumb arthrodesed                FDS RF 2 Slips made..                                                       1 slip passed across palm to fibres of adductor pollicis                                               2nd slip further divided into 2                                                      1  passed through lumbrical canal to radial side of extensor                                                           aponeurosis RF                                                      other to LF                        other technique                                        Omer - Brac

Look - Overlying skin             Deltoid conotour             muscles on supraspinatus and infraspinatus fossae ,             inferior angle of scapula level same or not Feel   temperature  Clavicle medial end , laterally , AC Joint , Acromion process , Spine of scapula ; medial border / inferior angle and lateral bodrder of scapula , glenoid and humerus Movement  Flexion , abduction , extension , ER/IR both active and passive measure the angle affected Special Tests Drop arm test on flexion and abduction Cross arm adduction test Adson's test Hawkin's test Neer's Impingement Test Cuff Muscles     Supraspinatus test       Infraspinatus test       Teres Minor test       Subscapularis test Apprenhension sign , Sulcus test Tinel's sign on ulnar nerve and median Nerve Radial , Ulnar ,Median Nerve  sensation test Radial and ulnar artry pulsation Test for ligamentous Laxity D/D C- spine pathology

Not to miss following points during the examination Attitute of the limb or hand cascade of fingers Look -            any scars on arm , forarm        guttering on the dorsum of hand , wasting on hypothenar region Feel - temperature            any soft tissue or bony tenderness            tinel's sign ,scar tenderness , scar pliability Movement           active and passive Measurement if any angulation or bony deformity Neurovvascular examination sensation of autonomous zones of hand and  direct the examination to the nerve affected Power of muscles - Examine both the weaker muscles and donor group of muscles   Elbow - Brachioradialis               Wrist      FCU Hand       FDP - 4th and 5th finger , FDS Ring Finger , FDP 2nd and 3rd finger                Lumbricals               Opponens Digiti Minimi               Abductor Digiti Minimi              Adductor Pollicis              FPB Special tests to know the names .     Card

Not to miss following points during the examination Attitute of the limb Look - Wrist Drop              Elbow semiflexed            any scars on arm , forarm           any muscles wasting Feel - temperature            any soft tissue or bony tenderness            tinel's sign ,scar tenderness , scar pliability Movement           active and passive Measurement if any angulation or bony deformity Neurovvascular examination sensation of autonomous zones of hands and  direct the examination to the nerve affected Power of muscles - Examine both the weaker muscles and donor group of muscles           Arm - Triceps function   Elbow - Brachioradialis               Pronator Teres              Supinator Wrist      ECRL              ECRB            ECU            PL / FCU / FCR Reflexes Pulsation Special tests - ligament laxity How do you confirm that its radial nerve injury ? Humerus shaft fracture or dorsoradial fracture

Atttitude of the joint Look - Around Joint and extremity for the skin , any muscles wasting on arm , forearm and hand Feel - Soft tissue , any bony tenderness on medial condyle , tinel's sign on ulnar nerve , nerve palpation , Olecranon process , lateral condyle , pulsation of brachial artery Feel axillary lymy nodes Done all if history suggestive of Insatbility or old lateral condyle fracture otherwise a quick valgus / varus stress test done Joint Stability test - Valgus stress test Varus stress test -  with shoulder on internal rotaion                                force varus done similar to valgus stress ,                                avoid rotating limb when performing test PLRI (Pivot shift test ) Lateral Ulnar collateral ligament insufficiency manifestation - episodes of subluxation or dislocation Position - UL -  Patient lies supine , shoulder flexed sothat limb lies above patient's head                           examiner grasps  pa

Detailed history and Physical Examination Investigations PT - for supple skin , with good  ROM of joints Splinting Neutotropic medications Surgery  not good after 9 months .

Median Nerve Entrapment (Pronator Syndrome ) Injury proximal to Elbow - Involvement of  Wrist , Fingers and Thumb  Injury on proximal forearm -- Wrists spared  Injury on Wrist - thenar group of muscles involved  Benediction sigh - High median nerve injuries .  D/D  1. Bicipital Tendinitis       resisted elbow flexion illicits pain  2. Resisted Pronation    with a finger 3 finger breadth below elbow crease illicits pain  Radial Tunnel Syndrome  PIN compression at Arcade of Forhse  4 fingers below lateral epicondyle illicits tenderness.  Resisted long finger  extension test  - finger and wrist at 30 degrees extension - give pressure to flex MCP passively.  a severe PIN compression , ECU doesnot function and wrist goes into radial  deviation.   Note  Brachioradialis , ,ECRB , ECRL lie proximal to radial tunnel .  ECU , EDC , EPL and EPB lie distal to Radial tunnel .  Anterior Interosseous Nerve (AIN ) - 

Brachial Plexus Its a complex structure . Rembering all of its branches is difficult. Rembering further down to all muscles supplied by each nerve is even more difficult.Finally the Brachial plexus site of injury can be pin pointed just by examination .  Best way is to reharse with friends in the same order mentioned as below. It makes examination fast , easy and simple. Look  Front              Head at centre                no ptosis , myosis , anhydrosis on forehead              Shoulders - any scars  on shoulder ?                                         normal axillary folds             Chest - wasting of Pectoralis Major              No any fixed attitude of Upper extremities  Side -     Normal overlying skin on shoulder, describe scars if present , UE                  Normal Deltoid contour , Biceps , triceps , forearm muscles ,                no guttering on dorsum of hand , normal thenar and hypothenar muscles               axilla clear Back

Look - from front side and back             Alignment of Upper Extremity - Normal             No fixed attitude             Fullness anterior shoulder            skin normal            muscule wasting around shoudler - anteriorly , deltoid contour and supraspinatus and             infraspinartus fossae Feeling           Temperature normal           tenderness on anterior shoulder            palpate axilla -axillary artry , lymph node palpable or not Movement           Abduction           Adduction          Felxion          Extension          ER           IR Special Tests           Sitting position                                 Apprehension ,                                                           anterior drawer test                                 Sulcus test           Lying  Position                                  Jobe's relocation test                                  Laxity test - Load and shift - anterior and posterior

Examination from Examination starts after consent and order from the examiner. Expoure requires upto umbilicus . Front   bent on lt side ,     chin deviated to  rt side  decreased head shoulder distance on lt side  oral cavity looks normal /abnormal  no squinting  facial asymmetry - normal ?  lt side sternocleidomastoid - taut chest - no muscle wasting Side    Ear almost touching shoulder  ,      Deltoid contour normal     elbow fully extended Back      b/l shoulder symmetrical , hairline      scapula at same level      occiput flat      Thoracic and lumbar curvature maintained with no scoliosis Gait and Squating - normal  Feel - lt sternocleidomastoid taut , thick            no tenderness on mastoid, sternum , clavice, AC joint , scapula , humerus and C-spine           No palpable lymph nodes, no tenderness on supra / infraspinatus fossa         Movement           Flexion / Extension , Rotation , Lateral Flexion both active and

Rigidity of Ist MTP joint  Gait - Altered  Grerat toe straight , callus on medial side of distal phalanx  MTP - Knobby , tender dorsal bunion  outer side of sole - worn on footwears  Treatement  Not interfering activites - leave alone  Intermittant pain         I/A injection , Local anaesthetics + corticosteroids         rock soled shoes        full length insole  Surgery            chilectomy          Extension Osteotomy - PP          Arthrodesis                            10 degrees valgus and DF , 10 mm clearance         Arthroplasty         Interposition Arthroplasty        Capsular Arthroplasty           Metal implant better           silicone implant  note - Taylor's Bunion oberlies 5th MT head. 

Claw Toes - MTP - Hyperextension                     PIP -   Flexion                     DIP -   Flexion Hammer Toes - MTP - Extension                           PIP - Acute Flexion                           DIP - Straight Mallet Toes -     MTP - Neutral                             PIP -  Neutral                            DIP - Flexion

Attitude Gait Calf wasting Clawing of  toes , swollen MTPs Corns on dosum , plantar callosities Skin - warm and tenderness Non-fluctuant puffy swelling around ankle movement restricted Comment on adjacent joints Lymph nodes - Popliteal and groin Also comment on other joints on hands DNVS X-RAY  - Regional Osteoporosis Blood Inv. - CBC ,ESR , RA - Factor , Anti- CCP antibodies Biopsy Treatement - Special Shoes to accomodate toes DMARDs Synovitis - Corticosteroids , Operative Synovevtomy Similar case may be present for Toe deformities Note Surgery for claw toes Excision Arthroplasty for Hallux Valgus

TB Arthritis Attitude Gait Calf wasting Skin - wasrm and tenderness Comment on adjacent joints movement restricted Lymph nodes - Popliteal and groin DNVS X-RAY  - Regional Osteoporosis , bone abscess , narrowing , irregularity of joint space Blood Inv. - CBC ,ESR , Mantoux test Joint fluid analysis Biopsy Treatement - ATT NWB in a caliper 

According to  MEHTA AND BHOJRAJ  Group A - Paradiscal and Central Involvement                      transpleural debridement with fusion (no instrumentation ) note - if Arthrodesis also required , then use transpleural approach instead of costotranseversectomy) Group B - Group A + Deformity                      mx A + Instrumentation  Group C  - to ill to undergo transpleural surgery                      transpedicular decompression and posterior instrumentation  Group D - Posterior involvement only                   posterior decomression only 

If Deformity and disease activity both present then treat deformity as well as medically. In general , Treatment  Rest, Nutrition  Chemotherapy  Traction   Surgery Thoracic Spine -  Approach - A bit ambiguous, many options are there. Anterior Transpleural ,Anterolateral  extrapleural and posterolateral Posterolateral approach (Martin 1970 ) -Dura exposed by hemilaminectomy first and then operation extended  laterally to remove posterior ends of 2-4 ribs, corresponding transevese process and pedicles. He thinks anterolateral approach risky. Approach to Atlanto-occipital and Atlanto-axial joint  - numerous structures on the way anteriorly. -supine - 5 to 10 degrees hyperextension , tracheostomy done . Transoral Anterior Approach - uvula, soft palate , bissected hypopharynx packed, 5 cm incision given and flaps raised. Apply stay    sutures. Then anterior arch of atlas , body of axis and atlantoaxial joint exposed . Anterior approach to spine  Dorsa

Name - Muhammad Ashad                         Age / Sex - 9 yrs / m  wt. - 20 kgs Gr II stduent , Lahore,  Pakistan               History Teller - Father Site of taking history  - Orthopaedic Dept., XYZ Hospital , Lahore , Pakistan Date of examination - 1 July, 2017 C/C - Pus discharge left leg with limping gait for 18 months HOPI - M. Ashad was involved in RTAin Jan 1 , 2016. He was a pilon rider  and  hit by a bus from the side and fell down. He had a shear injury on the leg and foot. Bike rider did not have any major injury and walked immediately. Ashad had unbearable pain on foot and leg with a large wound on dorsum of the foot, shin and lateral side of the leg.Leg was deformed with bone exposed on the shin. He was soon taken to Emergency Dept., ABC Hospital in Gujrawala,Lahore within 45 minutes in a taxi with leg wrapped using a handkerchif. He was in shock when they reached the hospital.He had no LOC, ENT bleeding and vomiting . Left leg was bandaged to con

Different Options Free Functional Transfer lateral dorsi or Nerve to  Pec Major to lateral extensor mass Extraplexal transfer         Cross C 7 to Suprascapular nerve       Phrenic Nerve to  c 5,6        Intercostal to C 7 Management priorities   Elbow flexion     shoulder abduction

Age 6- 10 years common in boys. Fall on outstretched hand (FOOSH) - common mechanism of injury. Break in periosteum anteriorly , hinge force posteriorly. Extension fracture in 95 % of cases Flexion type fracture in 5 % of cases . Extension type fracture classification of Gartland and Wilkin's 1. Undisplaced fracture 2.Displaced fractures , posterior cortex intact 3.Displaced fracture , posterior cortex breaks Flexion type direct injury on elbow on flexed position. Patient presentation 1. history of trauma 2.pain , swelling , deformity , bruises on arm 3.Deformity - S-shaped , puckering , 4.compratment syndrome ( It may be due to vessel spasm , contusion , tear , thrombosis If capillary refill present , hand arm Dunlop traction given. ) 5.Nerve injuries  proximal fragment spike hits the nerve. type 3a posteromedial displacement - radial nerve injured  type 3b with posterolateral displacement -  ulnar nerve affected. flexion type injur