Short Notes in Orthopaedics

De-Quervan's tenosynovitis   based on clinical scenario , diagnose this  what test do you do ? , they ask.   most important clinical test - Finketstein test   ,  how do you treat ?      always explain role of immobilization     pain management   steroid injection   surgery - tell what you do ?  Ricket's   x-ray diagnosis   investigations  treatment  tumor x-ray   Osteosarcoma , GCT , Metastasis , Ewing's  sarcoma are very frequent , master them. Osteomyelitis   diagnosis  investigation  treatment            needs to be mastered in every portion of bone .  GCT - histopathology slide was tested during our time . have a look .  Ankylosing Spondylitis   a very favorite topic of CPSP Pakistan.  recognise on X-ray  Treatment of the condition - Flexion contracutre of both hips  Preoperative preparation  caution during surgery to be taken 

Club foot  identify in photo  councelling to parents about this condition  meaning of familial condition  treatment Cerebral Palsy  adductor tightness, equinus defomity  its diagnosis  types  treatment SCFE  diagnosis on a photo  x-ray elaboration of SCFE Classify it what lab investigations to be sent will be asked managment AMC  diagnosis on photo x-ray of hip and knee which shows both dislocated its treatment surgical steps for flexion contracutre release of knee was asked during our time Scoliosis diagnosis risk factors for scoliosis progression measure the deformity on X-ray its management DDH X-RAY recognition different lines to be known    Hilgenreiners , Perkin lines  acetabular angle and centre edge angle importance Approach to management  ( i remember exactly the same question , long ago. ) Congenital pseudoarthrosis of tibia its a very important question , diagnosis in x-ray classification v

Acetabular fracture       diagnosis on plain x-ray       classification     approach to management     about corona mortis Compartment syndrome management of forearm  (equllay important in foot and hand )   diagnosis on plain x-ray       based on soft tissue shadow enlargement   approach to management  AC joint dislocation        diagnosis on x-ray          type          approach to management   Lisfranc Injury     classification        types        management  Supracondylar fracture     classification      types     management         they also ask if no pulsation distally on radial and ulnar arteries approach to management ACL injury    X-RAY FEATURES        segond sign importance Neck of femur fracture both in adults and paediatric cases  diagnosis  blood supply peculiarity  chances of AVN  approach to treatment Thompsons and Austin-Moore prosthesis  identify   tell hip approaches  Disadvvantage of lat

Shuck test  Ist MCP joint stability  > 2 mm translations +ve Grind test     Ist MCP          axial load and make round Watson test    From DF and ulnar deviation to palmar flexion and radial deviation     thumb on scaphoid tubercle (just proximal to thenar region )   S-L Ballotment   (scaphoid shuck and S-L Ballotment )  L- T ballotment TFCC compression      axial compression      radial to ulnar deviation Piano key test - press with thumb on ulnar head Other tests - DRUJ compression test             hold distal radius and ulnar with 2 fingers and pronate and supinate them            midcarpal instability               TFCC like 

Gait , Romberg sign Sitting         Look - Head , neck , sides and face         feel temperature feel - soft tissues - anterior / posterior , deeper structures movement Tests  Spurling  Axial compression  Hyperabduction   Sensation   myotome    reflexes   Lhermitte's  Lying position        Reflexes        Clonus         Babinski's      Upper limb tension signs for brahial plexus tension tests               ULT1 - patient supine                           examines axilla , hand on shoulder not to let elevate shoulder                           shoulder abduction to 90 degrees , forearm supination , wrist and fingers extended                            head same side - relief ; head opposite side - pain on antecubital region               UL 2 - Median nerve variant                           examiner on head end , thigh depresses shoulder                          pain if illicited suggestive of Compression                   radi

Calcium hydroxyappatite crystals , supraspinatus tendon 1.5-2 cm away from insertion Investigations  X-ray  Ultrasound - more sensitive for diagnosis and treatment Treatment  Ist line - non-operative  needling and lavage under USG guidance  ESWL  Surgery for symptoms progressing , absence of conservative treatment 

ROM Restriction , no initiating factor , global stiffness , affects external rotation Plain X-ray normal Stages  1. Painful Freezing  2. Progressive stiffness  3. Resolution O/e  diffuse tenderness  motion - active / passive both restricted Investigations  X-ray - to differentiate primary and secondary frozen syndrome Bone scan - to differentiate from Reflex Sympathetic dystrophy MRI - to rule out other pathology Arthrosocopy - It has both therpeutic and diagnostic value. Management Analgesics USG , TENS Steroids -Intra-articular Stretching exercises Manipulation under anaestheisa    sequence - flexion , extension , abduction , adduction ,external rotation , internal rotation Arthroscopic Release  rotator interval , MGHL , coracohumeral ligament , Rehabilitation supervised ROM exercise

Superior Labral Anteroposterior Tears Associated with glenohumeral instability and rotator cuff tears Investigations  MR Arhtrography Treatment  Repair or resect Arthroscopically

Klippel-Feil Syndrome Clinical Examination Short webbed neck , no neck appearance  , head on top of shoulder with restricted ROM Spinal Examination  Sprenge'ls deforomity  Torticollis ,  Scoliosis , kyphosis  Congenital heart disease ( Risk of atlantoaxial instability ) Not to forget Neurological examination Sprengel's deformity  Trapezius , Rhomboids, Levator Scapulae may be absent Pseudoarthrosis of Clavicle Inspection           swelling on shoulder           mobile end , painless           shoulder motion        X-ray - sclerosed ends      managent - conservative Gunsotck Deformity Scars lumps of HMEs Abduction , thumb up - clearly seen  Measure carrying angle  ROM Able to reach his face or not Instability Treatment Painless  mass present posteriorly around lateral epicondyle  Attitude - pronated ROM - both restricted supination and loss of  full extension Radial Head Dislocation Posterior - always c

Pain on anterior shoulder Investigations  Plain radiography to see bicipital groove and outlet view USG , MRI with Gadolinium with enhanced arthrography to identify SLAP tears  Arthroscopy Treatment  PT   strengthening rotator cuff muscles Intra-articular tendinosis          Debridement - 25-50 %           Tenotomy or tenodesis for > 50 % Subluxation / dislocation         tenotomy or tenodesis 

Suprascapular Nerve (C5,6 ) Injury Compression      due to Ganglion , Labral tears    Above spinoglenoid notch - Supra/infra-scapular muscles    Below spinoglenoid notch with infracspinatus muscle Clinical features     Lateral shoulder pain      Wasting of supraspinatus /infraspinatus muscles       Loss of abduction and external rotation Management     EMGs     NCS Treatment      Trapezius muscle splitting approach        decompress notch      arthroscopic debridement of notch Long Thoracic Nerve (C5-7 )            Neuorolysis            Pectoralis Major transfer Spinal Accessory Nerve Injury     Mx         Non-operative after more than 12 months with good compensation         Options - Neurolysis ,direct repair with nerve grafting , muscle transfer ,scapulothoracic fusion Thoracic Outlet Syndrome    Causes           Cervical rib, anomalous scalenius Types         Neurogenic - Upper Plexus Type                

Principles of treatment  structural instability - traumatic or atraumatic                    operative management   non-structural instability - muscles patterning                  non -operative management Structural abnormality   Anatomical repair          Bankart repair              reattachment of bankart lesion to margin of glenoid by open or arhtroscopic technique           if Hill-sach lesion , transfer infraspinatus to fill defect to prevent redislocation  Non anatomical repairs            Laterjet procedure                 coracoid transfer to anterior glenoid rim with conjoined tendon             Magnuson -stock - advancement of subscsapularis            Putti - Platt - imbrication and shortening of subscapularis             Glenoid or humeral osteotomies - if there's excessive anteversion of GH joint. Strucutral posterior instability             Reverse Bankart procedure and capsular shift             Reverse Putti-platt    

Swelling Head palpable position of extremity Anterior test       Duga's test       Ruler test       Callaway test Neurological impairment Instability       Fulcrum test      apprehension       Jobe's relocation test       Jerk test       Drawer test        Sulcus test Investigations       AP view       Scapular view        lateral view                        information about direction of dislocation , fracture , blocks for relocation      Stryker notch view - for humeral head defects            West point axillary view - shows notch defects        CT scan - shows detailed anatomy        MRI - associated rotator cuff tear and labral tears         Arhtroscopy -  invasive                                 difficult atraumatic structural and muscle pattern in non structural cases         EMG - atraumatic complex instability situation Treatment  Urgent reduction  1. Stimson method - prone , downward traction  2. Koch

Thomas and Masten in 1989 TUBS - traumatic unidirectional Bankart lesion treated with surgery AMBRI - atraumatic multidirectional bilateral                 bilateral treated with rehabilitation               responds with inferior capsular shift and closure of rotator cuff interval Stanmore classification Type I - true TUBS , structural Type II- true AMBRI , strucutral Type III - muscular patterning

Investigations                     Zanca view to show AC joint                     Lignocaine injection inside the joint Treatment                    Open /Arthroscopic excision                     (5 -1 cm lateral end of clavicle excision done )

Primary degenerative Glenohumeral Arthritis  - capsular contracture            Anterior / Posterior subluxation , Posterior glenoid wear  Secondary Degenerative Glenohumeral Arthritis           Inflammatory arthritis           Cuff tear arthropathy           Capsulorraphy arthropathy                    opposite side arthritis            Neulpathic arthritis Investigations           X-ray - AP , Axillary views          CT -glenoid bone stoks and zone of wear and orientation           USG/  MRI - squality of rotator cuff repair Treatment          Non operative             ROM , Strengthening exercises , NSAIDs, analgesics, steroid injections        Shoulder Arthroplasty

Partial thickness tear based on location  Bursal side tear  Intratendinous tear  Articular side based on depth ; E'l Man's  3 mm   3-6 mm   > half of tendon Anatomical classification  C - shaped  U-shaped  L-shaped  Longitudinal Pain at deltoid  side Investigations  Plain radiographs     sclerosis on undersurface of acromion      Traction spurs in coracoacromial line      upward displaced humeral head     acetabularized coracoid , acromion and glenoid     degenerative calcification of cuff Cuff tendon imaging    USG - dynamic evaluation of cuff    MRI - detects cuff tear and assesses cuff vasculature   Treatment      Partial thickness tear  Non - operative    activity modification     stretching and  strengthening     anti-inflammatory medications    Surgery - Principles                 > 50 % tears (large )              failure of conservative management from 3 -6 months   during surgery  ,      

1. Subacromial Impingement     Intrinsic - Degneration tendinopathy     Extrinsic - Due to coracoacromial arch Acromion types Type I - Acromion flat         II - Curved        III - Hooked Types ; Neer Calssification Stage1 - Edema and haemorrhage ; < 25 years          2- fibrosis ; 25-40 years           3 - tendon rupture > 40 years Treatment     Antiinflammation    Steroids    PT    Strengthening exercises   2. Subcoracoid Impingement    contact between subscapularis and coracoid    Treatment - Arthroscopic or open coracoplasty 3. Internal Impingement  contact of posterior rotator cuff with posterosuperior glenoid when ar mabducted extended and      externally rotated.  Treatment       PT - Rotator cuff strengthening exercises       Surgery -  Removal of posterosuperior glenoid osteophytes and posterior release

Posterior (Viewing )  2 cm medial and posterior to posterolateral corner of Acromion Anterior  lateral and inferior to coracoid process Lateral  anterior 1/3rd of lateral border of acromion and 2 cm inferior Additional - Naeviser                     Anterolateral                     Posterolateral                    Anteroinferior                   Posteroinferior 

Most common bone tumor in children Solitary or Multiple Aberrant cortical overgrowth adjacent to growth plate leading to eccentric bony growth disturbances of growth plate development or localized bone disturbances     First type            HME - AD inheritance           MED - AD inheritance            Dsyplasia Epiphysealis Hemimelica (Trevor Disease ) occurs in infants and young children              second type            Fibrous dysplasia Management         X-ray characteristic        CT scan - of pelvis , shoulder and spine        MRI          1.  assessing continuity of parent bone with cortical and medullary bone in an             osteochondroma          2.   catiliage cap size ,          3.   impingement syndrome ,           4. and arterial and venous   compromise Angiogram        AV compression Treatment      Solitary - Symptomatic            very large - avoid in skeletally immature (restricts growth  )            

Normal IQ , co-operative Head and face             large head , frontal bossing             mid face hypoplasia            dental malocclusion Skeletal features            disproportionate short stature                                       normal trunk length with rhizomelic shortening of proximal limbs with                                       redundant skin folds           brachydactyly and trident hands           lumbar lordosis           hyperextension knees            limited elbow extension and rotation          bowed legs Radiologically         1. small skull base          2.progressive interpedicular narrowing L-S spine         3.short pedicles leading to spinal stenosis         4.short femoral neck and metaphyseal flaring with inverted V-shape distal physis          5. small sacrosciatic notch , flat roofed acetabulum Orthopaedic problems           1.craniocervical junction abnormailities           cord compression            

Curved joints Classical Arthrogryposis multiplex congenita                limbs involved , muscles absent or deficient  Arhtrogryposis  associated with neuropathic (brain, spinal cord, perpheral nervous system - nerves )                                                      or myopathic (congenital muscular dystrophy ) Arthrogryposis associated with other syndromes or anomalies such as diastrophic dysplasia ,  Aetiology - Unknown                      Fetal Akinesia                     Hereditary On examination   Involved limbs - tubular shape, thin subcuatneous tissue absent skin crease                                symmetrical , severe distally typically hands and feet                             dislocated hip joints , ocasionally knees                              trunk - rarely affected , scoliosis                              muscle groups absent    Normal  IQ  Management       Paediatrician , Orthopaedic s

Examination in order General  presence of wheelchair  , walking aid , communication devices  , orthosis e.g. AFO , KAFO , Wrist Splint , Spinal Brace Look at trunk for gastroscopy or a baclofen pump Pattern of involvement  Anatomical     monoplegic     diplegic     hemiplegic      quadriplegic      movement disorder      spastic      ataxic      dyskinetic                  athetoid - slow writhing movement of fingers , hand or lower limb                  dystonic - involuntary sustained contraction                   chorea - random movement of limbs more on rest position                   ballismus and hemiballismus                                            infrequent jerky movements , purposeless                     mixed Standing -            posture - UL ,                           scoliosis - C-curve neck to LS junction                     (      idiopathic curve with a rib hump )                   walking                

At birth or during childhood cosmetic deformity pressure problems , caught on with socks on Memorandum   5th toe MTP - hyperextended                IP joints flexion                Deviation - medially , overrides 4th toe , nail laterally facing , hypoplastic skin - dorsum contracted , MTP - Subluxed dorsomedailly , +/- bunionette Management             strapping              stretching               Surgery - Butler Procedure                                 Rocket incision over little digit centred over ED . derotate toe Contracted tendon and capsule released.

know is it painful or not ? and where is pain ?          Talocalaneal coalition - medial side pain          Calcaneonavicular Coalition - lateral side pain Look -            Standing - forefoot abducted , adducted - skew foot )           hind foot - valgus               bottom of foot - conved plantar surface - in rocker bottom foot         shoulde be able to pass 2 fingers on medial arch.         quickley see on lower back to see if there are any tell-tale signs. Gait  Tip toeing - flexible - heel varus ; medial arch prominent  Tarsal Coalition - arch doesnot form , heel valgus Sit - legs dangling        check shoes        more wear on medial side; if no wear ask if they are new. Check Achilles tendon tightness -- stiff flat foot ROM - Ankle and subtalar joint             subtalar joint stiffness - difficult to illicit - patients will have ball and socket joint by                remodelling  use IF/ Thumb to stabilize or at least to check t

After proper exposure from umbilicus to toes with an inner  wear Check height and weight which might clue bony displasia or metabolic diseases Gait - see foot progression angle (Angle between foot print and line of walking )            normal angle is -5 to +20 degrees           -5 to -10 mild , -10 to - 15 moderate            > -15 degrees severe Look - Leg length discrepancy , any noticeable deformities or muscles wasting            Check Trendelenburg test during standing position Feel - any tenderness on soft tissue or bony tenderness Movement Special test on prone position with a pillow on chest  Hip rotation           Knee in 90 degree flexion , check Hip IR and ER       Normally Hip IR < 70 degrees , ER < 30 degrees          meausre Anteversion angle             Birth ; 40 degrees             9 years  ; 20 degrees            16 years ; 16 degrees     Thigh foot angle       normally ; 0-20 degrees       measure tibial and hi

It depends on quality of bone , gemoetry of fracture and type of implant used. Wight bearing not allowed immediately in   Uncemented THR   Plate fixation   Locking Plate Wight bearing allowed immediately   Nailing   TBW    External Fixator application    Cemented THR    Pedicle Screw fixation    Dissectomy Note - THR Prosthetic dislocation - skin traction role             gives splintage to soft tissues strain  .

Examination depends on the question given. May be examination of the whole extremity or just the hand . Be careful ! Exaimination begins after asking 2 questions as allowed . Relevant questions might be after your  own  introduction .  1. what happened ?  2.when did it happen ? one can ask hand dominance and profession during examination to be clever . Then get permission from patients If command is to examine the whole upper extremity go as below Look - Normal alignment of Right Upper extremity             shoulder at slight abduction            elbow flexed, forearm supinated with palm facing up             cascade of fingers not maintained , index finger is extended while others are in flexion            no wasting of muscles on arm , forearm , hand on volar and dorsum side           on hand , there is a transverse scar around 1 cm proximal to metacarpophalangeal joint ,            healed.            color of all fingers look pink on finger tips as

 Joint                                       Muscle Imbalance                                                             Deformity Ankle                                      Triceps Surae - Strong                                                                                                     TA weak                                                                           Equinovarus                                                      Reverse                                                                              Calcaneovarus Subtalar Joint                       Invertors strong/Evertors weak                                            Cavovarus                                               Reverse                                                                                Cavovalgus

If same problem in family runs , think of some neurological diseases, Also ask if its progressive .Ask if they have any vision problem . Look   Back   Toes callsities under metatarsal heads , lateral border of foot    Exagerrated Cavus   Foot drop   leg muscles wasting   hindfoot varus /valgus , equinus,forefoot plantaris , Ist ray PF   footwear problems   Feel - temperature, tenderness , deformity correctible or not   Neurovascular examination      sensation     motor - tone , power , reflexes .  Movement       Active and passive  Special tests      Varus Coleman block test       Silfverskiold test for Equinus deformity   How to proceed ?  X-ray - Weight bearing lateral x-ray            to see calcaneal pitch (N< 30 degrees ) and lateral Meary's (N 0-5T degrees )               normal - 20-30 degrees                low - Pes Planus                high - Pes Cavus  PA - meary'

Posteromedial Bowing - Physiological Anteromedial Bowing -     Fibular Hemimelia      Ankle Instability     Foot - Equinovarus +/- absence of lateral rays    Tarsal Coalition    Ball and socket ankle joint     Femoral shortening Treatment      Bracing            Amputation     Ankle Recontruction         depends on LLD , Foot and ankle involvement   Anterolateral Bowing       50 % - Neurofibromattosis , Ehlers-Danlos syndrome , and amniotic band syndrome

Positive Family history  Late childhood or early adulthood knee pain or recurrent dislocation of patella Features  Finger nail dysplasia  Hypoplastic patella  Presence of conical iliac horns  hypoplasia of radial head  40 percents have immune related nephropathy Clinically  tenderness on patella , features of early arthritis at younger age  impression - Chonromalacia Patella                                             Naile Patella Syndrome                         (Elbow ROM -restricted )                       

Perform the examination as in Genu Valgum Key findings  Look - Swelling on anterior tibial tuberosity Feel - Temperature            Bony hard in consistency           tenderness Movement       Tightness of quadriceps and patellar tendon Distal  neurovascular structures      Sensory , motor examination - normal     DPA, PTA - normal Examine -Ankle and Hip Shoes exmination Investigation  X-ray Knee - Fragmentation of Tibial Tuberosity. Management       Reassure    Non operative        Cast  Why this happens ?  Growt spurt in this age causes bone to grow longer than soft tissues such as quadriceps . 

  Important imformation from the patients in the short case might be     Age of the patient    Family History                 HME , Rickets and bony dysplasias might run in family .    Deformity O/e    after exposure of both lower extremities from umbilicus to toes with an underwear Gait  and Squatting - comment .They may have circumduction gait. Standing - Genu Vlagum deformity                   Quadriceps normal                   Patella facing forward , forefoot normal Side - any scars or not around knee           knee in extension           hip,  thigh , leg , ankle and foot normal alignment Back             Popliteal swelling ,             thigh and calf normal looking normal             heel in normal varus               dont forget to measure Intermalleolar distance               and Genu Valgum in standing           After Lying down Palpation           normal temperature compared to opposite side           no soft tissu

Interphalangeal joint of thumb flexed , b/l No other anomalies Extension limited At base , node mobile with flexion / extension of the joint Treatment  Surgical release of A1 pulley Infants - - stretching

Coxa Vara  Painless limp , LLD - gradually worsening  Unilateral or B/l in 30 -50 % cases  Prominent trochanters  Pelvic tilt - LLD  Trendelenburg test or delayed trendelenburg  Waddling B/l  High GT - supratrochanteric shortening  Decreased abduction   (decreased articular trochanteric distance ) Decreased IR ( due to decreased antversion ) may have out -toeing rule out cervical instability causing limping Types                         Pathology                                   Site                                                   Progression Congenital               Dysgenesis                             Subtrochanteric                                        progresses Developmental        Growth abnromality                physological                                           resolves Acquired             Dysplastic;Fibrous dysplasia            metaphysis                                         progresses                           metabolic ;

Not to miss following points during the examination Attitute of the limb or hand cascade of fingers Look -            any scars on arm , forarm        wasting on forearm and thenar region Feel - temperature            any soft tissue or bony tenderness            tinel's sign ,scar tenderness , scar pliability            lymph nodes Movement           active and passive -rapidly test it Measurement if any angulation or bony deformity or bony shortening Neurovascular 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 Forearms - Brachioradialis , Pronator Teres , Supinator             Wrist      FCU, FCR , PL,Pronator Quadratus , ECRL Hand       FDS                 FDP , FPL                Lumbricals               Opponens Pollicis               Abductor Pollicis Brevis              FPB Reflexes Pulsa