Short Notes in Orthopaedics

 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

 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

 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                      

 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 humeru

  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 posit

 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

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.        Secon

 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 h

 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.                         

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