Orthopaedics

Summary 2019
Topic 1
 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

The examination of patients with musculoskeletal trauma and orthopaedic

diseases

Examination
• Medical History
o When (Acute or Chronic)
o Where
o How was Trauma?
o Low/High energy Trauma

• Look à Inspection
• Skin condition (colour, temperature, innervation, inflammation)
• Position of limb
o Deformity
o Swelling
o Shortening
o Wasting

• Feel à Palpation
• !!! if you have a clear fracture on the X-Ray, skip palpitation
• Superficial – mainly for T°
o Skin o Bone
o Soft tissue o Crepitus
o Peripheral pulse o Swelling
distally to the o Severe
fracture Tenderness

• Move à Movement
• Look for movement distal from fracture side
• Check for more than one fracture
They can do themself Mechanism could be the problem
• “active” movements à objective
o Muscle problems: painful

• “passive” Movement
o Septic arthritis always painful
o Muscle problems: not painful

• Pathology
o Is the joint unstable?
o Is there movement at an old fracture site?
o Painful movement?
• Range of movement: GONIOMETRY

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Goniometry:

Hip Joint:
• Flex / 0 / Extension = 90° / 0° (neutral position) / 5°
• Abd / 0 / Add = 0° / 5° / 10° à no neutral position possible à M. Add. Contraction
• Rot.Ext / 0 / Internal Rotation
For certain joints like the knee and hip you
• Do must do it to fulfill the examination according
to the location
• Special Tests: for location (when required)
• Measurements: when required
o Muscle power grading: 0 – 5
Look for unequal muscle mass
o Wasting
o Shortening may be true or false
• Functional Tests: when required
Walking, limping, tiptoe, walk on heel

Extra Examination methods:

• X- ray (AP and lateral view)
• CT
o Impact trauma à e.g. femur head fracture
o Intraarticular fractures
• US
o Soft tissue damage

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

o Extra fluid, hematoma

o Muscle, Tendons
o Ligament à e.g. Rotator Cuff injury
• MRI
o Ligaments
o Muscle, Tendons
o Nerves
• Blood test
o In case of e.g. femur head fracture à heavy bleeding à anemia

Closed of compound (open) Fracture:

Patient à evaluate à X-Ray

• If normal: conservative, +/- extra imaging
• If fracture: describe, conservative or surgical Treatment

• No matter what you do à immobilization is the key

• If no cast can be applied à triangular external fixation
• If you can’t operate in the first 24hrs à application of skeletal traction

Immobilization

ABCDE first
• Than Immobilization
• Never fixated on the fracture itself, fixate one joint above and one below
• Splints, Cuffs
• Prepare splints e.g. on healthy side and then put on fractured site
• Check the soft tissue (nerves, muscles, blood vessels à pulse, colour)
• ALWAYS check distal pulse !!! before and after Immobilization
• Damage of nerves: check sensation, pat. should to active movements

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Examination of isolated skeletal trauma and polytrauma patients.

Shoulder Examination
• Inspection
• Palpation à to check where exactly it’s painful
• Movement
• Special test
o Muscle Testing
§ M. Teres minor
§ M. supra and infra spinatus
§ M. Supscapula
• Check for Clavicula, Scapula and Humerus

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Elbow Examination
• Also check for supination and pronation (with elbow fixed!!!)
• Check for epichondrals
o Insertion point at tendons at muscles of the lower arm
o Check for flexion + extension

Wrist Examination
• Neurological examination for special test
o Check for the medial nerve
o Press on medial nerve: ischemic pain in fingers à pathology!
o Patients presses both hands together for 1 minutes
§ If pain tingeling in first three fingers à pathology
o Radial nerve à problems with Extension

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Hip Examination
• Look at the gait
• Most common problem: Arthritis
• Hip problems often associated with back problems à always check hip in case of back
problems

Extremity measuring
• Anatomical Length: Spina iliaca anterior superior à distal point of medial malleolus
• Functional Length: Navel à Medial malleolus
• Sometimes femur fractures in femur head can also be seen in Lauenstein position
• Check abduction + adduction
• Extension + Flexion
• Internal + external rotation

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Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Knee Examination
• Inspection
o Patella fluctuation test
o Deformity
§ Genu Vagus à O-shape
§ Genu Valgus à X – shape
o Thigh and calf muscle wasting
o Swelling
o Shortening of lower limbs
o Position of lower limbs and popliteal fossa

• Feel
o Joint line

• Movement
o Flexion: (not so much)
o Extension: if you loose either Quadriceps or Patella tendon à extension not possible

• Do
o Check where it’s painful
o Lachmans Test

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

o Drawer's Test
o X-Ray:
§ Check for joint spaces
§ Check for crucial ligament sites
§ Check for position of patella

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Back Examination
• Standing position

• Schober Test à states mobility of lumbar spine (LWS)

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Ott Test à states mobility of thoracic spine (BWS)

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Definitions

• Trauma
o is defined as any body wound or shock produced by sudden physical injury, as from
accident, injury or impact.
• Trauma
o is any type of physical injury that results from action of traumatic force on the body
• Orthopaedics
o is a branch of surgery that practices on investigating and treating problems of
support and movement apparatus.
o In 1741 Nicholas Andry introduces the term orthopaedics derivating it from greek
‘orthos’- straight and ‘paideia’- growing (usually in children).

Traumatic injury
— Soft tissue injuries
o Tscherne Classification à system of categorization of soft tissue injuries

— Traumatic bone fractures

o Definition
— Fracture is a break in the bones continuity.

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

— This pathology includes cases from fractures without dislocation or so called

bone ruptures, to complicated multifragmentary or segmentary fractures.

Fractures - Classification

à Traumatic fractures (classification by the type of fracture)

• Compression fractures (Collapse of one fragment into another)
• Avulsion or bone fragment tear fracture
o Fragment pulled away by muscle or ligament
o Most common: Extensor ligament of the distal phalanx
• Seized fractures
• Impression fractures
— Stress or bone fatigue fractures
o Repeated low intensity trauma leading to bone resorption and fracture
— Pathologic fractures (Fracture through abnormal bone)
— Greenstick fractures
— Open or closed fractures
— Epiphyseal, metaepiphyseal, diaphyseal fractures (by location)
— Oblique fractures, transverse fractures, spiralform, multifragmentary, comminuted fractures
(by the fracture line)

AO classification

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Fracture Deformities

A fracture can be deformed in any one of three possible planes. Traditionally, the deformity is
described by the relative position of the distal fragment in relation to the proximal fragment.
Classic deformations are described as follows

1. Displacement is the amount of translation of the distal fragment in relation to the proximal
fragment in either the anterior/posterior or the medial/lateral planes. Displacement is the
opposite of apposition.

2. Angulation occurs when two fracture fragments are not aligned and an angular deformity is
present in either the anterior/posterior or the medial/lateral planes.

3. Alignment means that the axes of the proximal and distal fragments are parallel to each
other and the joint above and below are in the normal (anatomic) relationship. Angulation is
typically described by the direction in which the apex of the angle points – medial, lateral,
dorsal, volar, etc.

4. Rotation occurs when there is an axial change between the two fractured fragments in the
transverse plane.

5. Shortening or lengthening occurs when the distal fragment is positioned in relation to the
proximal fragment to either decrease or increase the overall length of the fractured bone.

Fracture Descriptors

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

A number of different terms are used to describe the configuration and features of any given
fracture. These general descriptors are as follows:

1. Open versus closed: A closed fracture is one in which the skin is intact over the fracture site
and an open fracture is one in which the skin is disrupted.

2. Simple versus comminuted: A simple fracture is one in which there are only two major
fragments and one fracture line. A comminuted fracture is one in which there are multiple
fragments of bone and multiple fracture lines.

3. Complete versus incomplete: A complete fracture is one in which the fracture line goes
completely across the bone. Incomplete fractures, most typically seen in children, have a
fracture line that only crosses one cortex of the bone involved.
Fracture Patterns
A number of basic fracture patterns have been described (Figs. 2.2–2.4). They include:
1. Transverse
2. Spiral
3. Oblique
4. Impacted or compressed
5. Avulsion
6. Torus(buckle)
7. Complex (multiple patterns)
8. Segmental

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Diaphyseal bone fracture types

Gustilo and Anderson open bone fracture classification

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

Dislocation

• Subluxation
o Partial loss of continuity between articulating surfaces

• Dislocation
o Complete loss of continuity between articulating surfaces

Classification
1. Type A: extra articular
2. Type B: Partial articular
3. Type C: complete disruption of the articular surface from the diaphysis

Clinical signs of fractures and dislocations

Clinical Signs of fractures

• Deformity of the bone
Frx - dislocation
• Oedema -bone fragments
• Ecchymosis: Lateral / med
Ant / post
o blue swelling, purple-blue colour Volar / dorsal
Shortening
• Loss of general function and / or mobility Rotation
Angulation
• Loss of function in the injured area (varus vs vagus)
• In open fractures, bone protruding from the skin
• Pathological movement
• Crepitation

Symptoms
• Pain
• Point tenderness over fracture site
• Increase symptoms with vibration or tapping

Evaluation of the Patient with Skeletal Trauma

1. History of injury.
The mechanism and severity of trauma are important to focus the physical exam and identify
commonly associated injuries.

2. Occupation and activity level of the patient.

Taking these into account is frequently helpful in determining surgical versus nonsurgical
treatment, as well as subsequent rehabilitation.

3. Deformity and swelling.

These must be carefully evaluated to identify fractures, joint dislocations, or soft tissue
injuries.

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 Topic 1 - The examination of patients with musculoskeletal trauma and orthopaedic diseases.

4. Joint motion. Pain on motion may indicate intraarticular joint involvement.

5. Neurovascular status. It is imperative that the neurovascular status of the extremity be

carefully evaluated to document neurologic deficits and to identify surgical emergencies such
as compartment syndrome or arterial disruption.
6. Integrity of the skin.

Classification of injured patients according to the energy assessment.

High energy trauma

Low energy trauma

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Topic 2
 TRANSPORT IMMOBILIZATION

WITH FORMABLE SPLINTS

Study material

Authors:
Krišjānis Puri š
Justas Sauka
Daniels Deksnis
Dmitrijs Grigorjevs
Linda Kalni a
Vineta Bīri a

Traumatology and Orthopaedics

student scientific interest group
Rīga Stradi š University
Faculty of Medicine

Editors:
Ruta Jakušonoka, MD PhD, Uģis Zari š, MD, Evita Rumba, MD

Rīga Stradi š University

Faculty of Medicine
Department of Orthopaedics

2019, RĪGA

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 Transport immobilization
with formable splints

In the study material ”Transport immobilization with formable splints” the immobilization, using
formable splints, is described. There are described the principles of immobilization, indications and
methodology. In the photos the immobilization techniques are pictured.
Study material is provided for students, to acquire knowledge and skills in transport immobilization,
using formable splints.

Ruta Jakušonoka
Uģis Zari š
Evita Rumba

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TABLE OF CONTENTS
INTRODUCTION ............................................................................................................................................................. 4
1.ORDER OF IMMOBILIZATION WITH FORMABLE SPLINTS ............................................................................................... 4
TRANSPORT IMMOBILIZATION OF THE UPPER EXTREMITY ....................................................................... 6
HAND TRAUMA ............................................................................................................................................................... 6
FOREARM TRAUMA ......................................................................................................................................................... 8
UPPER ARM TRAUMA ...................................................................................................................................................... 9
TRANSPORT IMMOBILIZATION OF THE LOWER EXTREMITY ................................................................... 11
FOOT TRAUMA .............................................................................................................................................................. 11
LOWER LEG TRAUMA .................................................................................................................................................... 13
FEMUR TRAUMA ............................................................................................................................................................ 15
LITERATURE ................................................................................................................................................................ 17

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 Introduction

The primary objective of splinting is to prevent movement of the fractured body part, further soft tissue
damage, haemorrhage and decrease pain. Various types of splints are available and mostly formable splints
are used, that can be moulded into various shapes and combinations, to accommodate the shape of the injured
extremity. Formable splints are mainly used for wrist, ankle and long bone injuries immobilization. In the
study material, the immobilization with formable wire-ladder (Cramer῾s) splints is described.

1.Order of immobilization with formable splints

1. Chose the necessary splint length accordingly to the healthy extremity - at least one joint above and one
joint below the injury site should be immobilized;
2. Form the splint, accordingly to the healthy extremity, using a table or another surface (Fig.1);
3. Provide analgesia and remove accessories from the extremity (jewelry etc.);
4. Ask the assistant to apply careful traction below the fracture and manually support the injured site
during the patient's limb immobilization;
5. Adjust splint to the extremity, keeping careful traction and secure the splint with a bandage (Fig.2.);
6. Check the distal pulse (before and after immobilization).
Notice:
If the splint is too long, it can be moulded, making the splint shorter (Fig. 3);
In order to make the splint longer, several splints can be connected together with a circular
bandage so that each next splint covers the previous one at least by 1/3 of it s length (Fig. 4 A,
B).

Fig.1 Fig.2

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Fig.3 Fig.4A

Fig.4B

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 Transport immobilization of the upper extremity

Hand trauma
1. The length of the splint is from the tips of the fingers to the elbow joint (Fig. 5);
2. Carefully put the splint under the injured arm (Fig. 6);
3. Put a gauze roll under the hand to provide a slight extension in the wrist joint (20º) and a slight flexion
in the metacarpophalangeal joints (40º) (Fig. 7);
4. Secure the splint, beginning from the wrist joint with a figure “8” bandage. Distal phalanges are not
covered with a bandage (Fig. 8 and 9);
5. Continue bandaging proximally with the spiral bandage to the elbow joint (Fig. 10);
6. Secure the end of the bandage under the previous layers (Fig. 11);
7. Immobilize the arm with the triangular bandage (Fig. 12 A, B, C).

Fig. 5 Fig. 6

Fig.7 Fig.8

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Fig.9 Fig.10

Fig.11 Fig.12A

Fig.12B Fig.12C

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 Forearm trauma

1. The length of the splint from the metacarpophalangeal joints to shoulder joint, elbow flexion 90º (Fig.
13 A, B);
2. Carefully put the splint under the injured arm;
3. Put a gauze roll under the hand to provide a slight extension in the wrist joint (20º) and a slight flexion
in the metacarpophalangeal joints (45º);
4. Secure the splint, beginning from the wrist joint, with a figure “8” bandage (Fig. 14);
5. Continue bandaging proximally with the spiral bandage to the shoulder joint (Fig. 15);
6. Secure the end of the bandage under the previous layers;
7. Immobilize the arm with the triangular bandage.

Fig. 13A Fig.13B

Fig.14 Fig.15

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 Upper arm trauma

1. The length of the splint from the metacarpophalangeal joints to healthy shoulder joint, elbow flexion
90º (Fig. 16);
2. Carefully put the splint under the injured arm (Fig. 17);
3. Put a gauze roll under the hand and in the axilla, to provide a slight extension in the wrist joint (20º),
flexion in the metacarpophalangeal joints (45º) and humerus abduction (40º) (Fig. 18);
4. Secure the splint, beginning from the wrist joint with a figure “8” bandage;
5. Continue bandaging proximally with the spiral bandage to the shoulder joint (Fig. 19);
6. Continue bandaging with a figure “8” bandage on the shoulders (Fig. 20 A, B, C);
7. Secure the end of the bandage under the previous layers;
8. Immobilize the arm with the triangular bandage.

Fig.16 Fig.17 Fig.18

Fig.19 Fig.20A

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Fig.20B Fig.20C

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 Transport immobilization of the lower extremity

Foot trauma
1. The length of the splint from the tips of the toes to the knee joint and form the splint, accordingly to the
healthy extremity, in the L-shape, ankle joint 90 º (Fig. 21 A, B);
2. Carefully put the splint under the injured leg (Fig. 22);
3. Secure the splint, beginning from the ankle joint with a figure “8” bandage. The toes should remain
visible (Fig. 23);
4. Continue bandaging proximally with the spiral bandage to the knee joint;
5. Secure the end of the bandage under the previous layers (Fig. 24 A, B).

Fig.21A Fig.21B

Fig.22 Fig.23

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Fig.24A Fig.24B

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 Lower leg trauma
In case of lower leg trauma, the splints should be placed under the leg, on the lateral and medial side of the
leg.

1. The length of the first splint under the leg from the tips of the toes to the hip joint, a splint is L-shaped
and should be moulded under knee joint to provide the slight flexion in the knee joint (30º) (Fig. 25 A,
B). The length of the laterally sided splint from the heal to the major trochanter. The length of the
medially sided splint from the heal to the groin (Fig. 26);
Ankle joint should be fixed in a “box”, so that there are not possible rotational movements of
the foot (Fig. 27 and 28);
2. Assistant applies careful traction below the fracture (ankle joint in 90º position) and manually supports
injured site during the patient's leg immobilization;
3. Carefully put the splint under the injured leg and from sides;
4. Secure the splint, beginning from the ankle joint with a figure “8” bandage. The toes should remain visible
(Fig. 29);
5. Continue bandaging proximally with the spiral bandage to the hip joint (Fig. 30 A, B);
6. Secure the end of the bandage under the previous layers (Fig. 31).

Fig.25A Fig.25B

Fig.26 Fig.27

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Fig.28 Fig.29

Fig.30A Fig.30B

Fig.31

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 Femur trauma

Notice:
In case of fracture of the femoral diaphysis, the most appropriate is immobilization with traction splint
accordingly to the instructions for each model of the traction splints.

If the formable splints are used in case of femur trauma, the splints should be placed under the leg, on the
lateral and medial side of the leg.

1. The length of the first splint under the leg from the tips of the toes to the angulus inferior scapulae,
the splint is L-shaped and should be moulded under knee joint to provide the slight flexion in the knee
joint (30º) (Fig. 32 A, B). The length of the laterally sided splint from the heal to the armpit (Fig. 33).
The length of the medially sided splint from the heal to the groin;
To make splints the appropriate length, connect the splints together with a bandage, if necessary
(Fig. 34);
Ankle joint should be fixed in a “box”, so that there are not possible rotational movements of
the foot (Fig. 35);
2. Assistant applies the careful traction below the fracture, ankle joint 90º, and manually supports injured
site during the patient's leg immobilization;
3. Carefully put the splint under the injured leg and from sides. Femur abduction 10 º;
4. Secure the splint, beginning from the ankle joint with a figure “8” bandage. The toes should remain
visible;
5. Continue bandaging proximally with the spiral bandage to the hip joint;
6. Continue bandaging with a figure “8” bandage around the hip joint and with the spiral bandage to the
armpits (Fig. 36 A, B);
7. Secure the end of the bandage under the previous layers.

Fig.32A Fig.32B

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Fig.33 Fig.34

Fig.35 Fig.36A

Fig.36B

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 Literature
1. Advanced Trauma Life Support for Doctors. American College of Surgeons. 10th edition. 2018.
2. Driscoll P, Skinner D (Eds). ABC of major trauma. 4th edition. BMJ Books, 2013.
3. Prehospital Trauma Life Support. Committee of the National Association of Emergency Medical
Technicians in Cooperation with the Committee on Trauma of the American College of Surgeons.
Mosby, 2018.
4. Lerner A, Soundry M (Eds.). Armed Conflict Injuries to the Extremities. A Treatment Manual. Berlin,
Heidelberg: Springer – Verlag, 2011.

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 Topic 2 - Transport immobilization and X – Ray Basics

X-Ray
Role of two

• Two views
• Two joints à above and below site for X-ray
• Two occasions à some fractures are not visible immediately after trauma
• Two limbs à comparison if required

ABCs approach

• A = adequacy, alignment
o Adequate number of views à min. 2 (at 90°, AP & Lat.), 3 views preferred,
sometimes 4
o Adequate penetration
o Alignment: anatomical relationship between bones on X-Ray (relationship in
longitudinal axis of one bone to another)
§ Fractures/ dislocations may affect alignment of X-ray
§ Angulation à deviation from normal alignment (described in °)
• B = bones
o Fracture lines, distortions
o Examine length of bone
o Be thorough, as fractures may appear subtle
• C = Cartilage
o Examination of joint spaces on X-ray (Cartilage is not seen)
o Widening of space à ligamentous injury/ fracture
• S = Soft Tissue
o Swelling, effusion à may be hidden fractures

Description of X-Ray

• Open (emergency) vs. Closed fracture

• Anatomical location of fracture
• Fracture line e.g. oblique, transverse, comminuted etc.
• Relationship of fracture fragments
• Neurovascular status

Bone

• Is the bone regular, or is there a gross abnormality? If so describe it.

• Is the cortex intact? Follow the entire cortex and look for any discontinuity.

Fractures:

• Location (Epiphysis/ Metaphysis/ Diaphysis ; Proximal, Mid or distal third)

• Pattern

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 Topic 2 - Transport immobilization and X – Ray Basics

• Deformity: All deformities are described as distal fragment relative to proximal fragment.
• Is there any change in bone density?
• Radio-lucent, thinner than surrounding bone
• Radio-opaque = thicker than surrounding bone

Joints

• Is the joint in the correct position? Is it dislocated- which direction?

• Does a fracture involve the joint?
• Are there any features of joint damage or degeneration?

Soft tissues

• Is there any evidence to suggest this is an open fracture?

• Can you see any localised swelling?

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 Topic 2 - Transport immobilization and X – Ray Basics

Transport immobilization
General

• ABC first!!
• Always assume a fracture
• Treat fracture before moving, unless safety of yourself or patient is in danger when moving
• Put Pat. in comfortable position with elevation of affected part to reduce swelling
• Support and immobilize affected area to reduce movement and control body part
o Immobilize one joint below and one above injury à protection of nerves/ muscles/
tissue
• Always check that bandages are not reducing circulation to affected part if the limb starts to
swell (capillary refill and distal pulse check)

Remember:

• Take off rings, bracelets

• If wound is open à cover with sterile dressing à stop bleeding
• Model splint according to injury à might need imagination if injury is not visible

Equipment

• Splints
o immobilise an injured arm or leg immediately after an injury.
o Apply before moving to further injury to the area
• Slings
o Slings are used to support the arm after a fracture or other injury
o used along with a splint, but sometimes used alone
o A patient can hold their own arm in a comfortable position if this is less painful.
• Traction
o method for applying tension to correct the alignment of two structures (such as two
bones) and hold them in the correct position
• Cervical Collar
o used to support the neck when there has been a suspected fracture in one of the CV
o used if potential neck or head injury.
• Spinal Board
o used in conjunction with a collar à treatment of a suspected cervical or back injury
• Vacuum Mattress
o Used in case of a neck, back, pelvis or limb trauma
o Consists of outer lining and filled with small polystyrene balls à allow the mattress
to be moulded around Patient
o Once the mattress has been moulded the air is removed with a pump

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 Topic 2 - Transport immobilization and X – Ray Basics

Application of Splints

• Choose the right splint length

• Pad it
• Mold it à use healthy limb to mold correctly
• Pad the bony prominences à on fracture site
• Hold the extremity in slight traction1
• Fix the splint to body part with bandages
• Check pulse, nerve function

Checklist - FACTS

Function

Arterial Pulsation

Capillary Refill

Temperature

Sensation

à check before applying splints as well as after

Complications

• Pressure sores
• Bullae
• Neurovascular compromise
• Compartment syndrome

Example of Splint and Bandage application:

Palm Trauma Forearm Trauma

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 Topic 2 - Transport immobilization and X – Ray Basics

Upper Arm Trauma

Clavicula Fracture Desault bandage

- Shoulder luxation

- Prox. Humerus fracture

- Shoulder girdle trauma

Treatment of Fractures/ Traumas

Conservative

• Splints/Casts Injured limb / spine

o Device to immobilize and protect body part INDICATIONS:
-Simple undisplaced fractures
§ Fractures -Closed stable fractures
-Sprain
§ Sprains -Strain
§ Dislocation -Partial rupture of ligaments /
muscles
§ Tenosynovitis -Dislocation
o Padding -Acute Inflammation
-Burns / Wounds
§ On fracture site -Additional diseases
§ Bone prominences
§ Active mobilization of muscle and joint
§ Compression on neurovascular structures
• FACTS Checklist (s.o.)

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 Topic 2 - Transport immobilization and X – Ray Basics

Surgical

• Internal Fixation
o Goals:
§ Realignment of anatomy, not compromising soft tissue INDICATIONS:
§ Stable fixation -Muscle tears
-Tendon tears
§ Quick recovery -Not successfully
conservative treatment
§ Potential faster healing -Fracture with dislocation or
displacement
-Dislocated intraarticular and
o Indications: multifragmental fractures
§ Fractures with dislocation, intraarticular fractures -Osteoarthritis
-Open fractures
§ Open fractures -Politrauma
§ Polytrauma -Compartment syndrome
-Long / Large burns
§ Neurovascular damage -Vertebral trauma
§ Unsuccessful conservative treatment

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Traction: pulling effect due to weights attached on skeletal system

o Reduces fracture/dislocation
o Reduces pain
o Prevents deformity, counteracting muscle spasm
o Small defect correction
o Costly in terms of hospital stay
o Hazards of prolonged bed rest
§ thromboembolism
§ Decubitus ulcer
§ pneumonia

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 Topic 2 - Transport immobilization and X – Ray Basics

Revision

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Topic 3
 Topic 3 – Fractures and dislocations of the upper extremity bones

Fractures and dislocations of the upper extremity bones

Clavicle Fracture

Epidemiology
• Common (account for approx. 2.6% of all fractures)
• Most commonly occurs in children and adolescents

Etiology
• Direct fall onto the shoulder, e.g., while cycling (∼85% of cases)
• Direct blow (∼5% of cases)
• Indirect trauma, like falling onto an outstretched hand (∼5% of cases)

Classification

Allman classification system

Group Location of fracture

I Midshaft fracture/middle third (∼ 69% of cases)

II Lateral/distal third

III Medial/proximal third

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 Topic 3 – Fractures and dislocations of the upper extremity bones

Clinical features
• For general symptoms, see general principles of fractures.
• Tenting of skin overlying the clavicle
o The sternocleidomastoid muscle pulls the medial segment of the
fractured clavicle upwards.
• Shortening of the clavicle
o The pectoralis major muscle pulls the scapulohumeral unit medially → medial
displacement of the lateral segment of the fractured clavicle
• Torn coracoclavicular ligaments: elevation of the acromioclavicular joint

Diagnostics
• Physical examination
• Examination for signs of fracture and concomitant injuries
• Assess for neurovascular compromise and compartment syndrome with the
6 P's: pain, pallor, pulselessness, paresthesia, paralysis and poikilothermia
• Weak pulses: possible injury of the subclavian artery
• Dysfunction of a distal nerve: possible injury of the brachial plexus
• Imaging
• Best initial test: X-ray in two projections (anteroposterior view, 45° cephalic tilt
view)
• CT/MRI when associated injuries are suspected or X-ray findings are inconclusive

• Additional tests may be necessary, e.g., arteriography and complete blood count (CBC) in the
case of suspected vascular injury, or ultrasonography in the case of
suspected clavicle fracture in children.

2
 Topic 3 – Fractures and dislocations of the upper extremity bones

Treatment

Midshaft (group I) fractures

• Mostly conservative treatment (e.g., simple shoulder sling) for 4–6 weeks
• Exception: excessively shortened or displaced fractures (require surgery)

Lateral (group II) fractures

• Stable fractures
• Conservative treatment (e.g., simple shoulder sling)
• Unstable fractures
• Surgical fixation (e.g., tension banding, clavicular plate) is typically indicated
• If needed, ligament repair

3
 Topic 3 – Fractures and dislocations of the upper extremity bones

Hook Plate limited contact dynamic compression plate

Sling Immobilization

Technique
• sling or figure-of-eight (prospective studies have not shown difference between sling and
figure-of-eight braces)
• after 2-3 weeks begin gentle range of motion exercises
• strengthening exercises begin at 6-8 weeks
• no attempt at reduction should be made

Open Reduction Internal Fixation

Technique
• Limited contact dynamic compression plate
o Position à beach chair or supine
o Approach
§ superior approach to AC joint
§ temporary fixation with k wires
o Equipment
§ Locking plates
§ precontoured anatomic plates
o Fixation
§ need larger distal fragment for multiple locking screws
§ >3 or 4 bicortical screws into medial fragment to reduce the risk of screw pull
out

4
 Topic 3 – Fractures and dislocations of the upper extremity bones

• Hook Plate
o Position à beach chair or supine
o Approach
§ superior approach to AC joint
§ temporary fixation with k wires
o Equipment
§ hook plates vary in hook depth and number of holes
§ proper hook depth ensures the AC joint is not over- or under-reduced
o Fixation
§ hook plates are generally used when there is insufficent bone in the distal
fragment for conventional clavicle plate fixation
§ the hook should be placed posterior to AC joint and positioned as far lateral
as possible to avoid hook escape
§ >3 or 4 bicortical screws should be placed into the proximal (medial)
fragment to reduce the risk of screw pull out

• Other types of fixation

o AC joint spanning fixation
§ usually used as an alternative to hook plates
o tension band wire
o intramedullary screw
o coracoclavicular ligament reconstruction

• Postoperative rehabilitation
o Early: sling for 7-10 days followed by active motion
o Late
§ strengthening at ~ 6 weeks when pain free motion and radiographic
evidence of union
§ full activity including sports at ~ 3 month
§ hardware removal considered usually after 3 months

Medial (group III) fractures

• Conservative treatment (similar to group I fractures)
• Displacement is uncommon due to strong ligamentous attachments.

Complications
• Malalignment with cosmetic abnormalities
• Nonunion

5
 Topic 3 – Fractures and dislocations of the upper extremity bones

Distal Humerus Fracture

Epidemiology
• Proximal humerus fractures are the most common humerus fractures
• Incidence increases with age
• Sex: ♀ > ♂

Etiology
• Direct or indirect trauma
• Falls (axial loading on an outstretched hand) from standing or falling down stairs
• Motor vehicle accidents
• Violent seizures
• Direct blow to the back of the humerus
• Pathologic fractures(e.g., Paget's disease, metastatic bone disease) are less common

Classification

1. Proximal humerus fracture (common in the elderly)

• The proximal humerus has four major segments: the anatomical neck, the humeral
shaft, the greater tuberosity, and the lesser tuberosity (the surgical neck is distal to
the lesser and greater tuberosity)
• Commonly used classification (Neer) is based on whether one or more of these four
segments have been displaced

6
 Topic 3 – Fractures and dislocations of the upper extremity bones

2. Humeral shaft fracture

• Classified according to location: proximal third, middle third (most common
location), distal third
• Or according to comminution:
• Type A (no comminution)
• Type B (butterfly fragment)
• Type C (comminution is present)

3. Distal humerus fracture

• Classification according to anatomical site
• Lateral/medial fractures
• Supracondylar fractures (supracondylar fractures are the most common
pediatric elbow fracture )

Clinical features
• Severe local pain: exacerbated during palpation or movement at shoulder or elbow
• Local swelling (edema or bleeding), deformity, or crepitus
• Shortening of the arm (associated with displacement)
• Neurovascular complications may be present

The radial nerve runs through the radial sulcu sof the upper arm and is especially at risk
in fractures of the middle third (midshaft) of the humerus!

Diagnostics
• X-ray (AP and lateral views of the humerus as well as transthoracic and axillary views of the
shoulder)
• Radiographic features of fractures
• A supracondylar fracture may also reveal:
• Positive posterior fat pad sign (not normally visible)
• Sail sign: positive anterior fat pad sign (normally visible, but not elevated)
• CT if x-ray is not diagnostic
• MRI if pathological fracture is suspected

7
 Topic 3 – Fractures and dislocations of the upper extremity bones

Treatment

Conservative therapy
• Indication: nondisplaced, closed fractures
• Procedures
• Hanging-arm cast or coaptation splint and sling for approx. one to two weeks;
subsequent follow-up X-ray and brace
• Early physical therapy to restore function

Surgical treatment

• Indication:
o open fractures
o displaced fractures that cannot be reduced
o associated injuries (nerves, blood vessels)
o floating elbow(simultaneous humerus and forearm fracture)
o Pseudarthrosis

• Procedures
o Internal fixation using plates and screws, or intramedullary
implants (especially supracondylar fractures)
o External fixation (e.g., open fracture, polytrauma)
o Arthroplasty of humeral head or elbow(complex fractures or poor quality bone),
especially in elderly patients

Open fractures require irrigation and prophylactic antibiotic therapy!

8
 Topic 3 – Fractures and dislocations of the upper extremity bones

Complications
• Proximal humerus fracture
• Adhesive capsulitis
• Avascular necrosis of humeral head (axillary artery injury)
• Heterotopic bone formation

• Humeral shaft fracture: Radial nerve palsy(common)

• Distal humerus fracture
• Malunion and varus deformity of elbow
• Brachial artery injury (common)
• Absent radial pulse suggests brachial artery entrapment (especially following
reduction!) and compartment syndrome
• → Volkmann's ischemic contracture (late complication)
• Median nerve, ulnar nerve, or radial nerve palsy

• Wrist drop à Loss of elbow, wrist, and finger extension

• Tinel sign à Tingling on percussion in carpal tunnel syndrome

Radial and Ulnar Shaft Fractures

à "Both-bone" forearm fractures

Epidemiology
• more common in men than women
• ratio of open to closed fractures is higher than for any other bone except tibia

Mechanism
• Direct trauma
o often while protecting one's head
• Indirect trauma
o motor vehicle accidents
o falls from height
o athletic competition

9
 Topic 3 – Fractures and dislocations of the upper extremity bones

Associated conditions
• Elbow injuries
o evaluate DRUJ and elbow for
§ Galeazzi fractures
§ Monteggia fractures
• Compartment syndrome
o evaluate compartment pressures if concern for compartment syndrome

Prognosis
• functional results depend on restoration of radial bow

Classification
• Descriptive
o closed versus open
o location
o comminuted, segmental, multifragmented
o displacement
o angulation
o rotational alignment

• OTA classification

• Radial and Ulna diaphyseal fractures

o Type A
§ simple fracture of ulna (A1), radius (A2), or both bones (A3)
o Type B
§ wedge fracture of ulna (B1), radius (B2), or both bones (B3)
o Type C
§ complex fractures

10
 Topic 3 – Fractures and dislocations of the upper extremity bones

Clinical Picture
• gross deformity, pain, swelling
• loss of forearm and hand function

Physical examination
• inspection
• open injuries
• check for tense forearm compartments
• neurovascular exam
• assess radial and ulnar pulses
• document median, radial, and ulnar nerve function
• pain with passive stretch of digits
• alert to impending or present compartment syndrome

Diagnostics
• Radiographs
o recommended view: AP and lateral views of the forearm
o additional views
§ oblique forearm views for further fracture definition
§ ipsilateral wrist and elbow
§ to evaluate for associated fractures or dislocation
§ radial head must be aligned with the capitellum on all views

Treatment

• Nonoperative
o Functional fx brace with good interosseous mold
§ Indications
§ isolated nondisplaced or distal 2/3 ulna shaft fx (nightstick fx) with
§ < 50% displacement and
§ < 10° of angulation
§ Outcomes
§ union rates > 96%
§ acceptable to fix surgically due to long time to union
§
• Operative
o ORIF (Open Reduction and Internal Fixation) without bone grafting
§ Indications
§ displaced distal 2/3 isolated ulna fxs
§ proximal 1/3 isolated ulna fxs
§ all radial shaft fxs (even if nondisplaced)
§ both bone fxs
§ Gustillo I, II, and IIIa open fractures may be treated with primary
ORIF
§ Outcomes

11
 Topic 3 – Fractures and dislocations of the upper extremity bones

§ most important variable in functional outcome is to restore

the radial bow

o ORIF with bone grafting

§ Indications
§ cancellous autograft is indicated in radial and ulnar fractures with
bone loss
§ bone loss that is segmental or associated with open injury (delayed
grafting in open injuries)
§ nonunions of the forearm

o External fixation
§ Indications
§ Gustillo IIIb and IIIc open fractures

o IM nailing
§ Indications
§ poor soft-tissue integrity
§ not preferred due to lack of rotational and axial stability and
difficulty maintaining radial bow (higher nonunion rate)
Complications
• Synostosis
• Infection
• Compartment syndrome
• Nonunion
• Malunion
• Neurovascular injury
o uncommon except
§ PIN injury with Monteggia fxs and Henry (volar) approach to middle and
upper third radial diaphysis
§ Type III open fxs
o observe for three months to see if nerve function returns
§ explore if no return of function after 3 months
• Refracture

12
 Topic 3 – Fractures and dislocations of the upper extremity bones

Distal Radius Fracture

Epidemiology
• Bimodal peak incidence
• 10–30 years of age; typically, due to high-energy trauma in males
• > 65 years of age; typically due to low-energy trauma in women with osteoporosis

Etiology
• Mechanism of injury
• Fall onto an outstretched hand
• Dorsiflexed wrist (a typical protective action used to break one's fall)
→ extension fracture (Colles fracture)
• Palmar-flexed wrist → flexion fracture (Smith fracture)
• Risk factors
• Osteoporosis

Classification

• Colles fracture: extension fracture; the distal fragment is

usually radially and dorsally displaced
• Smith fracture: flexion fracture; the distal fragment is radially and ventrally displaced
• Barton fracture: fracture dislocation; palmar Barton fracture involves avulsion
and volardisplacement of the radiocarpal segment; dorsal Barton fracture a radial avulsion
and dorsal displacement of the radiocarpal segment
• Hutchinson fracture: avulsion fracture of the radial styloid

13
 Topic 3 – Fractures and dislocations of the upper extremity bones

Clinical features
• Pain, tenderness, and soft tissue swelling
• Reduced range of motion at the wrist joint
• Wrist deformities based on the type of fracture:
• Colles fracture → dorsally displaced and dorsally angulated fracture (bayonet or
"dinner fork" deformity )
• Smith fracture → “garden spade” deformity

Diagnostics
• Physical examination: peripheral perfusion, motor function, and sensation
• X-ray: anterior-posterior, lateral, and oblique view of the wrist (including the carpal bones)
• See radiographic signs of a fracture.

14
 Topic 3 – Fractures and dislocations of the upper extremity bones

Treatment
• Conservative therapy
• Closed reduction while applying longitudinal traction through the fingers
• Dorsal forearm splint/casting and post-reduction x-rays
• Cast removal after 6 weeks

• Surgical therapy
• Indications
• Open, significantly displaced, intra-articular, and/or unstable fractures
• Neurovascular damage
• Postoperative immobilization of the forearm and in a dorsal forearm splint

Osteosynthesis with Kirschner wires

à The radius should be realigned to its normal position after fracture reduction!

15
 Topic 3 – Fractures and dislocations of the upper extremity bones

Radial head fracture

• Etiology
• Fall on outstretched hand with the elbow partially flexed and pronated
• Stress fracture (e.g., in throwing sports)

• Epidemiology: occurs more commonly in adults than radial head dislocation or subluxation

• Clinical presentation
• Radial head region is tender to touch
• Pronation and supination of the forearm is painful
• Effusion or hemarthrosis of the elbow joint may be present .

• Diagnostic: Elbow x-ray in two planes may show typical “fat pad sign”
• Treatment
• Nondisplaced fractures are treated conservatively with a plaster splint for approx. 2
weeks
• Complex fractures are treated surgically

• Complication: incorrect reduction can lead to cubitus valgus

Scaphoid fracture

Epidemiology
• Most common carpal bone fracture (60–70%)
• Peak incidence: 20–24 years

16
 Topic 3 – Fractures and dislocations of the upper extremity bones

Clinical features
• History of falling onto the outstretched hand with a hyperextended and radially deviated
wrist.
• Pain when applying pressure to the anatomical snuffbox and scaphoid tubercle
• Minimal reduction in the range of motion (except in dislocated fractures)
• Decreased grip strength
• Painful pinching and grasping

When pain occurs in the anatomical snuffbox after trauma, the injury should be treated as
a scaphoid fracture until proven otherwise!

Diagnostics
• Imaging
• Best initial test: X-ray of the wrist in a posteroanterior, lateral, 45° oblique, and
possibly scaphoid view
• ∼ 25% of scaphoid bone fractures are initially undetectable by x-ray
• If initial x-ray is negative, one of the following:
• If the patient is not willing for wrist immobilization: MRI of the wrist
• If the patient is willing for wrist immobilization: cast the wrist and repeat an x-
ray in 10–14 days

17
 Topic 3 – Fractures and dislocations of the upper extremity bones

• If repeat x-ray is normal but continued clinical suspicion

of scaphoid fracture: MRI wrist
à Scaphoid fractures are often overlooked on the initial x-ray!

Differential diagnoses (see “Dislocations” later on)

• Lunate dislocation
• Transscaphoid perilunate dislocation

Treatment
• Pain management: over-the-counter analgesics
• Displaced scaphoid fractures (< 1 mm): wrist immobilization via thumb spica cast for 4–6
weeks
• Surgical treatment: usually internal fixation
• Indications are complicated cases that include:
• Open fractures
• Signs of neurovascular compromise and/or osteonecrosis
• Proximal pole fracture
• Displaced fractures > 1 mm
• Nondisplaced fractures upon patient's wish for early remobilization
• Late presentation (> 3 weeks of fracture onset)
• Instability of carpal bones
• Rupture of the scapholunate ligament

Complications
• Avascular necrosis of the scaphoid bone in approx. 30–40%
• Nonunion (especially in proximal fractures) in approx. 5–10%
• Delayed union of fracture (more common in smokers)
• Instability among carpal joints
• Post-traumatic arthritis

18
 Topic 3 – Fractures and dislocations of the upper extremity bones

à Fractures in the distal third tend to heal better because of the retrograde blood supply reaching
the bone from the distal pole!

19
 Topic 3 – Fractures and dislocations of the upper extremity bones

Dislocations
Shoulder dislocation

Epidemiology
• Most common joint dislocation
• Sex: ♂ > ♀
• Peak incidence: 20–29 years

Etiology
• Anatomy: The head of the humerus is larger than the shallow glenoid fossa, which accounts
for the high incidence of shoulder dislocation.
• Trauma (e.g., falling on an outstretched arm)
• Predisposing factors for recurrent shoulder dislocation
• Loose joint capsule
• Damage to the glenohumeral ligament
• Rotator cuff tear
• Bankart's lesion and Hill-Sachs lesion
• For posterior dislocation: uncoordinated muscle contraction (e.g., seizure, electrical shock)

Classification
• > 95 % anterior (subcoracoid) and/or anterior-inferior (subglenoid)
• ∼ 4% posterior
• ∼ 1% inferior

Clinical features
• Severe shoulder pain
• Inability to move the shoulder
• Empty glenoid fossa: A palpable dent may be present at the point where the head of the
humerus is supposed to lie.
• In anterior or anterior-inferior dislocation
• The humeral head can usually be palpated below the coracoid process.
• The arm is typically held in external rotation and slight abduction.
• In posterior dislocation
• Prominence of the posterior shoulder with anterior flattening

20
 Topic 3 – Fractures and dislocations of the upper extremity bones

• Prominent coracoid process

• The arm is held in adduction and internal rotation, with the patient unable to actively
rotate it in the outward direction.
• In inferior dislocation
• The arm is held above the head, with the patient unable to actively adduct the arm.
• Neurologic dysfunction, especially with involvement of the axillary nerve, is
common.

à Posterior shoulder dislocation is frequently overlooked during clinical examination!

Diagnostics

• Physical examination
• Look for signs of fracture.
• Check for neurovascular deficits.

• Shoulder x-ray
• AP view and lateral view (Y view) to confirm dislocation and exclude fracture
• For posterior shoulder dislocation: axillary and/or scapular lateral views (Y
view)
• The lightbulb sign is diagnostic of posterior shoulder dislocation.
• Hill-Sachs lesion
• Seen in 35–40 % of patients with an anterior dislocation
• An indentation on the posterolateral surface of the humeral head caused by
the glenoid rim
• MRI
• Indicated to assess soft tissue damage or if a Hill-Sachs lesion is present
• Bankart lesion: injury of the anterior inferior lip of the glenoid labrum due to
traumatic anterior shoulder dislocation

21
 Topic 3 – Fractures and dislocations of the upper extremity bones

Treatment

The primary aim of treatment is to reposition the humeral head into the glenoid cavity and restore
full range of motion. This may be achieved by either closed reduction or surgical repair.

• Emergent management:
• Immobilization of the joint with a splint/sling
• Analgesia

• Conservative management:
• Closed reduction
• Indications:
o Inferior dislocation and most anterior dislocations (except subclavicular or
intrathoracic displacements)
o Uncomplicated posterior dislocations presenting early (< 6 weeks)
o Cases with no evidence of major arterial injury, associated injuries
(Bankart, Hill-Sachs, disruption of the labrum), or associated fractures

• Surgical management
• Indications:
o Unsuccessful closed reduction
o Concomitant dislocated fracture of humerus, clavicle, or scapula
o Displaced Bankart lesion
o Recurrent shoulder dislocations
o Young and active individuals may require early surgery to prevent
recurrent dislocations in the future.
Continuous neurovascular monitoring/evaluation before and after reduction is important for
prevention and early detection of axillary nerve and artery damage!

Complications
• Damage to the axillary nerve
• Numbness or sensory loss over the lateral surface of the shoulder
• Malfunction of the deltoid muscle, resulting in an inability to abduct the arm
• Injury to the brachial plexus, axillary artery, and/or axillary vein
• Avulsion fracture of the major and/or minor tubercles
• Shoulder joint instability
• Rotator cuff injury

Prognosis
• High rate of recurrence
• After rotator cuff repair, the rate of recurrence is significantly lower.

22
 Topic 3 – Fractures and dislocations of the upper extremity bones

Elbow dislocation

Epidemiology
• Second most frequently dislocated joint (after the shoulder joint)
• Sex: ♂ > ♀
• Peak incidence: 10–20 years

Etiology
• Trauma: typically from a fall with an outstretched hand

Classification
• Anatomical classification
• Posterior dislocation (most common: 90%)
• Anterior dislocation

Clinical features
• Pain, swelling of the elbow
• Limited range of motion: inability to flex or extend the elbow
• Elbow deformity
• Limb length discrepancy
• Nerve injury (up to 10% of cases)
• Ulnar nerve palsy
• Radial nerve palsy
• Median nerve palsy
• Brachial artery injury (very rare)

Diagnostics
• Physical examination
• Signs of fracture
• Neurovascular deficits

• X-ray of the elbow joint

• AP view and lateral view to confirm dislocation and exclude fracture
•
• Posterior fat pad sign : seen in patients with concomitant fractures (usually
of the humerus/radial head)
• CT scan of the elbow joint: indicated to evaluate the extent of associated fractures

23
 Topic 3 – Fractures and dislocations of the upper extremity bones

Treatment
• Conservative management
• Indication: simple elbow dislocation (no fracture)
• Procedure: closed reduction
• Immobilization of the relocated elbow in a posterior splint or brace

• Surgical intervention
• Indication: complex elbow dislocation (concomitant fracture); failed closed
reduction; joint instability post-reduction; vascular injury
• Procedure:
1. Closed reduction of elbow
2. Open reduction and internal fixation of the fractured segments
• Immobilization of the elbow in a posterior splint or brace

24
 Topic 3 – Fractures and dislocations of the upper extremity bones

Radial head subluxation (Nursemaid elbow)

Definition
• Subluxation of the radial head through the annular ligament: The annular ligament is
interposed and entrapped in the radiocapitellar joint

Epidemiology
• Radial head subluxation is the most common elbow injury in children under 5 years of age
and occurs exclusively in this age group.
• Age: 1–5 years, peak incidence between two and three years.
• Sex: ♀ > ♂
• Risk factors
• Previous history of radial head subluxation
• Obesity

Etiology
• Traumatic (most common)
• Sudden axial traction of the pronated and extended forearm
• Typical activities: adult quickly pulls up a falling child by the hand, swings a child by
the hands, or drags a child by the arm
• Congenital structural abnormalities (e.g., collagen abnormalities, abnormal endochondral
ossification of the growth plate and ossification sites external to the joint)[9]

Clinical features
• Child holds the arm, with the elbow slightly flexed and pronated
• Pain, aggravated by movement
• Limited extension and flexion
• No swelling

25
 Topic 3 – Fractures and dislocations of the upper extremity bones

• History and findings may be atypical, especially with children < 3 years old, who may be
unable to properly articulate their symptoms or the circumstances of the injury

Diagnostics
The condition is predominantly clinically diagnosed, with a limited role for imaging. A successfully
executed closed manual reduction is not just therapeutic, but also diagnostic
• X-ray
• Not necessary, if the patient presents with typical history and clinical signs.
• May be useful in atypical or irreducible cases to identify a displacement of the
radiocapitellar line without further disruption of the radiocapitellar joint

• Ultrasound: may be considered to prevent misdiagnosis and delayed treatment in children

too young to properly articulate their symptoms

Differential diagnoses
• Radial head fracture

Treatment

• Reduction maneuvers
o While applying pressure to the radial head, the following maneuvers are carried out
§ Supination of the forearm with the elbow in slight flexion
§ Hyperpronation of the forearm
o In successful reduction, a “click” might be heard
o Post-reduction: clinical control of normal range of motion of the elbow
o A second attempt at reduction may be necessary (by using the same or a different
approach), if normal range of motion is not achieved
o Immobilization of the arm is not required. Most children regain full mobility of
the elbow in a short time (10-30 minutes post reduction)

• Surgery: only indicated when closed manipulative reduction is unsuccessful

• Prevention: parents and caretakers should be educated about the most common
mechanisms of injury to prevent recurrence

Lunate dislocation
• Definition: disruption of perilunate ligaments and radiocarpal ligament with displacement of
the lunate bone (usually volarly) while the rest of the carpal bones remain in a normal
anatomic position
• Etiology: high-energy trauma with dorsal extension and ulnar deviation of the wrist
• Clinical features: wrist swelling, pain, and signs of median nerve injury (25% of patients)
• X-ray: the lateral radiograph shows a loss of colinearity of radius, lunate, and capitate
• Treatment: emergent closed reduction and immobilization followed by open reduction and
internal fixation

26
 Topic 3 – Fractures and dislocations of the upper extremity bones

Transscaphoid perilunate dislocation

• Definition: dorsal dislocation of the wrist around the fixated, unmoved lunate bone with a
fractured scaphoid bone
• Etiology: fall onto a hyperextended wrist, deviated toward the ulna
• Clinical features: no pain while applying pressure to the snuffbox, pain in the wrist, possibly
signs of median nerve injury
• X-ray: most commonly, metacarpal bones displaced dorsally to the lunate bone in lateral
view
• Treatment: always surgical (reposition and decompression of the median nerve;
osteosynthesis)

27
Topic 4
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Disease of the upper extremity ruptures of muscles and tendons

Acromioclavicular joint injury

Aetiology

• most common in active and young people

• contact sports, car accident -> high energy
trauma
• Direct force applied to the superior aspect of the
acromion
• Impacts the acromion inferiorly, spraining the
intraarticular acromioclavicular ligament. Extra
articular coracoclavicular ligament can be
damaged if the force is great enough
• FOOSH: indirect force -> humoral lead to
acromial process, displacing it superiorly and
stressing the acromioclavicular ligament ( not
coracoacromial ligament)

Clinical Symptoms

• Swelling
• Specific point tenderness

Classification - Rockwood

• I - Minor Sprain of the acromioclavicular ligament, intact joint capsule, intact

coracoclavicular ligament, intact deltoid and trapezius
• II - Rupture of the acromioclavicular ligament and joint capsule, sprain of coracoclavicular
ligament but intact coracoclavicular interspace, minimal detachment of the deltoid and
trapezius
• III – Rupture of acromioclavicular ligament, joints capsule and coracoclavicular ligament.
Elevated clavicle <100% displacement, detachment of the deltoid and trapezius
• IV - rupture of the acromioclavicular ligament, joint capsule and the coracoclavicular
ligament. Elevated clavicle >100% displacement, detachment of the deltoid and trapezius

1
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

• V - ( rare) Rupture of the acromioclavicular ligament, joint

capsule and the coracoclavicular ligament. The clavicula is
displaced behind the tendons of the biceps and
coracobrachialis

Physical Examination

• Standard shoulder examination

• Evaluation of range of motion
• Palpation of the bony structures
• Neurovascular status -> brachial plexus injury ( rare)
• Diagnosis
o Clavicular fracture
o Rotator cuff injury
o Shoulder dislocation
o Shoulder impingement syndrome

Soft tissue lesions of the shoulder

Types

• Subacromial impingement syndrome

• Frozen shoulder
• Calcifying tendonitis
• Bicep tendonitis

Complication

• Rotator Cuff Tear

Definition

• Soft tissue lesions of the shoulder are usually caused by the narrowing of the subacromial or
subcoracoid space and subsequent entrapment of soft tissues.
• These structural changes in the shoulder joint are often the result of overuse (e.g., engaging
in overhead activities) and degenerative or inflammatory processes.

Aetiology

• Overuse: activities involving repetitive overhead activity (e.g., basketball, volleyball)

• Degenerative processes (especially in the elderly)
• Inflammation
• Systemic diseases (e.g., diabetes mellitus )
• Iatrogenic: surgical interventions, with or without introduction of foreign bodies into the
subacromial space (e.g., surgical implants)
• Seen especially in people with concomitant alterations of anatomical structures , most
commonly of the
o Acromial bursa

2
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

o Joint capsule
o Biceps tendon
o Greater tubercle of the humorous or acromion (e.g., acromial spurs)

Subacromial impingement syndrome

Definition

• clinical syndrome caused by compression of tissues around the glenohumeral joint (e.g.,
rotator cuff, tendons, subacromial bursa) when the shoulder is elevated.
• It is a spectrum of clinical findings and can eventually result in complete rotator cuff tear.

Clinical features

• Pain on movement which is worsened by overhead activities.

• Nocturnal exacerbation of pain, especially when lying on the affected shoulder
• Movement restriction depending on the muscle involved
• Most common symptoms are due to supraspinatus injury or subacromial bursitis
• Painful arc → pain-related restriction of movement and strength with abduction of the arm
between 60–120°
• Can progress to rotator cuff tendinitis and rotator cuff tear

• Stage 1 – irritation of the rotator cuff and bursa

• Stage 2 – involves fibrosis of the structures, leading to restricted function
• Stage 3 – involves the painful, rupture of the rotator cuff, intermittent bursitis, pseudo
paralysis of the arm

3
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Frozen shoulder (adhesive capsulitis)

Definition

• inflammation and fibrosis of the joint capsule leading to contracture of the joint

Clinical features

• Severe restriction and limitation of both active and passive range of movement of the
glenohumeral joint in all planes ( especially external rotation)
• Dull shoulder pain
• Self-limiting course; however, improvement may take more than a year

• Stage 1 ( Freezing stage) minimal synovitis with pain and limitation of motion
• Stage 2 ( frozen stage) proliferative synovitis with contraction of the capsule and adhesion of
the axillary recess
• Stage 3 ( thawing stage) contracted capsule following the end of inflammation

Calcification tendonitis
Definition

• Calcium deposits of unknown aetiology; mostly in the area of insertion of the supraspinatus
muscle tendon

Clinical features

• Often no or mild pain, intermittent flares possible

• Limited range of motion if large calcium deposits occur

Diagnosis

• Evidence of calcium deposits on x-rays

4
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Complications

Calcific bursitis resulting in pain and stiffness of the shoulder; radiologic evidence of calcium deposits
in the subacromial bursa

Biceps tendonitis
Definition

• inflammation of the proximal long head of the biceps tendon as it’s insertion on the glenoid

Clinical features

• Anterior shoulder pain that becomes worse with lifting

• Tenderness along the anterior humorous

Complications

• Biceps tendon tear or rupture

• Associate conditions: rotator cuff tears

Rotator cuff tear

Aetiology

• Chronic degenerative tear seen in older adults (> 50 years)

• Acute injury seen mostly in athletes
• Inflammatory: complication of rotator cuff syndrome

Clinical features

• Most commonly affects the supraspinatus tendon

• Acute ruptures: acute severe pain and loss of strength
• Degenerative ruptures: chronic pain; loss of strength less pronounced

5
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

• Restriction of ROM (depending on which muscle is involved)

Diagnostics

• Clinical examination
• X-ray: superior displacement of the humeral head (high-riding humeral head)
• Ultrasound and MRI to evaluate the extent and location of the rupture

Treatment

• Treatment of degenerative rupture, especially in elderly, inactive patients, can

be conservative

• Surgical repair of the rotator cuff is recommended in cases of traumatic rupture, especially
in physically active patients, or treatment-refractory cases.

Soft tissue lesions of the shoulder

Clinical Examination

• Pain and limited movement

• Subacromial pain triggered by manual exertion of pressure below the acromion
• Painful active and/or passive abduction, possibly aggravated by internal and/or external
rotation
• Signs of narrowed subacromial space and of impingement
• Painful arc: pain with abduction of the arm between 60–120°
• Neer test: The internally rotated and outstretched arm is passively elevated, while the
scapula is simultaneously stabilized; the movement causes pain.
• Signs of muscular involvement: See examination of the rotator cuff

Instrumental diagnostics

• Subacromial lidocaine injection test: The test may be helpful in distinguishing between
subacromial impingement syndrome (including subacromial bursitis, rotator cuff tendinitis)
and other causes of shoulder pain and restriction (e.g., complete rotator cuff tear, frozen
shoulder, glenohumeral joint arthritis).
o It is not very specific, as it can improve pain in a variety of conditions, but it does
improve the specificity of the Neer test.

• X-ray to evaluate for:

o Degenerative changes or narrowing of the subacromial space (e.g., through atypical
configuration of the acromion)

• Calcification of the supraspinatus tendon in calcifying tendinitis

• Ultrasound and MRI: to evaluate the soft tissue structures (bursa, rotator cuff, and tendons)

6
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Treatment

• Conservative treatment
o Acute
§ Avoid activities involving overhead movements
§ Anti-inflammatory and analgesic medications (NSAIDs)
§ Physical therapy
o Chronic cases may require subacromial glucocorticoid injections
• Surgical treatment
• Impingement
o arthroscopic decompression, possibly open acromioplasty if evidence of acromion
narrowing is apparent
• Rotator cuff tear
o arthroscopic or open rotator cuff repair
• Removal of calcium deposits with needling or extracorporeal shock wave therapy

Tenosynovitis ( Stenosing Tenosynovitis + DeQuaveine tendonitis)

Definition

• Tenosynovitis is the inflammation of a tendon (tendinitis) and its synovial sheath

(synovitis).
• This inflammation is often due to tendon overuse (e.g., texting, typing), but can also be
due to systemic diseases (e.g., rheumatoid arthritis, sarcoidosis) or infection following a
penetrating injury (e.g., animal/human bites, thorn prick injury

Aetiology

• Non-infectious tenosynovitis (most common)

o Overuse tendinitis: repetitive use of the involved tendon (e.g., texting, typing,
gaming)
o Systemic diseases (e.g., rheumatoid arthritis, sarcoidosis, diabetes mellitus)
• Infectious tenosynovitis
o Direct inoculation following penetrating trauma
o Animal/human bites
o IV drug use
o Thorn prick injuries
• Hematogenous spread of infection
o Neisseria gonorrhoeae
o Mycobacterium tuberculosis

7
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Clinical Features

• Tendons of fingers and wrist are commonly affected

• First sign: pain on passive extension of the affected tendon, finger slightly flexed at rest
• Swelling, also fever and erythema in bacterial infections
• Palpable crepitation
• Late sign : tenderness along the affected tendon; sharp, stabbing pain worsened by
activity, followed by constant dull ache at rest

Stenosing Tenosynovitis (Trigger finger)

Epidemiology

• Male: female 6:1

• Age: > 40 years

Aetiology
• usually idiopathic

Pathophysiology

• fibrocartilaginous metaplasia of the tendon sheath of the A1 annular pulley

→ loss of smooth gliding of the finger flexor tendons under the annular pulley
→ finger gets locked in flexed position

Clinical features

• Trigger finger: painful locking of a finger in flexed position; releases suddenly with a
snap/pop on extension
• Often associated with tenderness and a palpable nodule at the base of
the metacarpophalangeal joint
o Mostly affects thumbs and ring fingers
o Diagnostics: clinical diagnosis
o Treatment: see below

Diagnostics

• Tenosynovitis is a clinical diagnosis with specific tests used to establish the etiology.
• Laboratory tests in infectious synovitis
• CBC (leukocytosis), CRP , ESR
• Aspiration and analysis of synovial fluid (WBC count, Gram stain, culture)
• X-ray: assessment of possible bone involvement, detection of a foreign body in cases of
penetrating trauma

8
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

• Tests for underlying disease if one is suspected (e.g., RA factor measurement,

gonococcal cultures)

Treatment

• Treatment of non-infectious tenosynovitis

o Conservative management
§ NSAIDs, CS
§ Splinting (immobilization) of the affected finger for 6 weeks
o Physiotherapy (stretching exercise)
o ICE, Rest or splint
o Interventions
§ Single (ultrasound-guided) glucocorticoid injection into the tendon sheath
(effective in 90% cases, esp. if the tenosynovitis has been present for less
than 6 months) .
o Splitting of the constricting retinaculum/ligament

• Treatment of infectious tenosynovitis

o Analgesics and broad spectrum IV antibiotics (e.g., cephalosporins, clindamycin )
o Splinting and elevation of the affected finger (to decrease the edema)
o Surgery: incision and drainage + saline irrigation, open debridement of
necrotic/infected tissue

DeQuaveine tendonitis
Definition

• Thickening of the abductor pollicis longus

and extensor pollicis brevis due to myxoid
degeneration

Epidemiology

• Sex: male > female

• Age: 30–50 years

Aetiology

• Repetitive/prolonged abduction and

extension of the thumb
• Rheumatoid arthritis

Specific Clinical features

• Pain with or without swelling of the radial styloid; pain may radiate to thumb or elbow,
exacerbated on movement/grasping objects
• Positive Finkelstein test: examiner grasps the affected thumb and exerts longitudinal
traction towards the ulnar side → pain

9
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Cubital tunnel syndrome

Definition

• Ulnar nerve entrapment occurs when ulnar nerve is compressed, typically at the elbow.
Compression causes paraesthesia, numbness, and/ or pain in the ulnar nerve
distribution

Aetiology

• Leaning on the elbow or prolonged elbow flexion during occupational activities (e.g.,
leaning on a desk), athletic activities, or surgical procedures (e.g., during general
anaesthesia)
• Blunt trauma
• Masses (e.g., tumours, hematomas)
• Metabolic abnormalities (i.e., diabetes)

Clinical Features

• Muscle weakness and atrophy

o Claw hand deformity
o Wartenberg sign
o Froment sign

• Sensory loss
§ Loss of sensation over the hypothenar eminence
§ Lesion at the elbow: positive Tinel test
§ Lesion at the wrist
• Pain: Elbow lesions typically present with referred pain in the forearm

10
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Ganglion cysts

• Benign trans illuminating liquid/gel-filled nodules that develop along tendons or joints
(usually the dorsal wrists). May be asymptomatic or cause pain that may self-resolve or
become chronic. Large cysts can cause numbness, weakness, or tingling if the nerve is
being compressed.
• unknown aetiology
• occurs in the presence of irritation or mechanical changes.

Tennis elbow (lateral epicondyle)

Definition

• Overuse injury of the hand and finger extensor

tendons that originate the lateral humeral
epicondyle

Aetiology

• Repeated or excessive pronation/supination

and extension of the wrist( e.g in racquet
sports)

Clinical features

• Pain and tenderness over the lateral epicondyle and along extensor muscles
• Thickening of the tendons
• Inflammation and Rupture of the tendon
• Normally Aseptic inflammation (signs: less redness, but oedema, swelling, ROM
decreased)

Diagnostics

• 1st: Clinical Symptoms and subjective evaluation (ROM, Provocation Tests, Palpation)
• 2nd: objective Evaluation
§ Ultra Sound
§
• Examiner holds the patient’s hand with the thumb placed over the lateral epicondyle.
• The patient makes a fist, supinates the forearm, deviates radially and extends the fist
against the examiner’s resistance -> pain over the lateral epicondyle

Treatment

• Rest, Splinting
• NASIDs
• Ice

11
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

• RICE
• Physiotherapy: US Therapy with Hydrocortisone
• Surgical treatment

Golfers Elbow (medial epicondyle)

Definition

• Overload injury of the hand and finger flexor

tendons that originate the medial humoral
epicondyle

Aetiology

• Repeated wrist flexion and forearm pronation

( e.g while playing golf)

Clinical Features

• Pain over the medial epicondyle and along flexor muscles, increases with activity,
thickening of the tendons
• Test: Pain is elicited on asking the patient to flex the wrist against resistance, with the
elbow held in extension
• For rotator cuff tendinitis, see soft tissue lesions of the shoulder

Diagnostics:

• History
• Physical examination with ROM and pain dirstribution
• MRI and US
• E-Ray to exclude other pathologies

Treatment

• Counterforce brace
• NSAID and CS
• R.I.C.E
• Surgical intervention such as tendon debridment or tendon release might be required
• Ulnar nerve should be protected in those manipulations

12
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Students Elbow (Olecranon Bursitis)

Definition

• Inflammation of a bursa

Aetiology

• Local trauma: fall on the joint, overuse injury ( e.g

excessive kneeling or leaning on the elbows for a
long period of time whilst working at desk)
• Systemic disease (RA, Gout)
• Infection as a complication

Main types/localisation

• Olecranon bursitis: inflammation of the bursa of the elbow joint ( localised at proximal
ulna) that is often caused by leaning on the elbow for the long periods of time .

Clinical features

• Local joint swelling

• Pain limited mobility
• Erythema and warmth

Diagnostics

• Usually, clinical diagnosis is sufficient

• Aspiration of superficial bursas to rule out infection or gout
• S ray may be considered to exclude bone involvement if suspected

Complications

• Septic bursitis usually caused by S.aureus

Treatment

• Rest, ice or heat, elevation and NSAIDS

• Antibiotics if septic
• Operative measures may become necessary ( drainage of pus, bursectomy) for recurrent
bursitis that fails to respond to conservative management

13
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Carpel Tunnel Syndrome

Definition

• CTS is a peripheral neuropathy caused by either chronic or

acute compression of the median nerve by the transverse
carpal ligament (all flexor muscle tendons + N. medialis)

Epidemiology

• USA 1-3 cases per 1000 subjects per year

• In certain high risk groups incidence greater than 150 cases
per 1000 subjects per year
• UK 70-160 cases per 1000 subjects
• Female-to-male ratio is 3-10:1
• Peak age range 45-60
• Most common entrapment neuropathy in the upper
extremity ( 90%)

Aetiology

• Previous fracture (à hematoma à compresses nerve) of the distal radius (most

important)
• Inflammation of muscle tendons due to overuse
• Idiopathic
• Traumatic dislocation of the lunate
• Manual work ( increase vibration from tools, forceful and repetitive flexion and
extension of wrists
• Rheumatoid arthritis + chronic inflammation of the tendon sheaths
• Pregnancy and puerperium: CTS affect 60% of women
• Obesity
• Osteoarthritis
• Diabetes with peripheral polyneuropathy
• Hypothyroidism

Clinical Feature

• Mild to moderate
o Sensory symptoms on the palmar surface of the thumb, index and middle finger;
radial half of the ring finger
§ burning sensation
§ Loss of sensation
o Symptoms worsen at night

14
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

o N.B palmar surface of the thenar eminence is not affected as it is innervated by the
superficial branch of the median nerve which is 7cm proximal to the carpel tunnel
and therefore NOT compressed
• Moderate to Severe
o Motor symptoms
§ Weakened pinch and grip (N-medialis motor branch is the only nerve which
is responsible for entire hand flex of all fingers
§ Patients can often lose grasp of certain objects
o Rare: thenar atrophy a with muscle flattening and impaired thumb opposition
o Thenar atrophy secondary to median nerve injury. Atrophy of the left and right
thenars ( abductor pollicis brevis and opponens pollicis muscles) secondary to
bilateral carpal tunnel syndrome

Diagnostics

• Provocative tests
o Hand elevation test
o Capral compression test
§ Sensitivity 75%-90%
§ Specificity 00%-93%
§ Direct Pressure over transverse ligament for 30 seconds

o Phalen’s test

15
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

o Tinel’s sign à provocation for N.medianus

• Electrophysiological tests ( Gold Standard)

o Nerve conduction studies

o Electromyogram

Treatment

• Mild to moderate symptoms

o Conservative treatment
§ Immobilization of the wrist with a padded, volar splint worn during the night
§ Steroid injection ( triamcinolone)
§ Short term treatment with NSAIDS
• Moderate to severe symptoms
o Open or endoscopic release of transverse carpal ligament

16
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Dupuytren Syndrome
Definition

• Common fibroproliferative disorders affecting the palmar fascia mainly of the 4th and 5th
fingers, in males.

Aetiology

• Exact aetiology is unknown

• Genetic predisposition
• Risk Factors
o Cigarette smoking
o Recurrent trauma
o Alcohol abuse
o Liver cirrhosis
o AI ( autoimmunity)

Pathophysiology

• Dupuytrens contracture (palmar fibromatosis) is a fibroproliferative disorders of the

palmar fascia = aponeurosis)
• Injury (trauma/ischemia) to the palmar fascia
à triggers myofibroblasts
à fibroblast proliferation and collagen (Type III) deposition
à thickening of the palmar fascia
à formation of nodules in the palmar fascia
• Nodules are adherent to the overlying dermis à characteristic puckering of palmar skin
• Nodules progress to form cords in the palmar fascia à flexion contractures of the
palmar fascia

Clinical features

• 4th and 5th fingers are most commonly involved

• Skin puckering near the proximal flexor crease: earliest sign
• Palmar nodule
• Palmar cords
• Flexion contracture of affected fingers
• Signs of aggressive disease: knuckle pads ( Garrod nodes) Plantar fibromatosis(
ledderhose disease)
• Peyronie’s disease

Diagnostics

• Usually clinical
• Ultrasound of palm can demonstrate nodules and cords of the palmar fascia
• Fasting blood sugar level

17
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

Differential diagnosis

• Palmar fasciitis
o all fingers bilaterally affected
• Claw hand deformity
o extension of the MCP
o flexions of PIP and DIP
o Numbness of ulnar aspect
• Stenosing tenosynovitis
o Painful locking of a finger in flexed position
o Mostly affects thumbs and ring fingers

Treatment

• Conservative therapy
o Observation
o Physiotherapy
o Hand splint/brace

• Intralesional injections
o Indicated in patients with rapidly progressing disease or painful nodules
§ Corticosteroids
§ Collagenase

• Surgery: indicated in patients with functional disability due to contractures

o Fasiotomy
o Fasciectomy

• Prognosis
o Variable prognosis
o Recurrence rates are high, even after surgery ( 60%)

Ruptured biceps tendon

• A biceps tendon rupture occurs when the biceps muscle is torn from the bone at the
point of attachment (tendon) to the shoulder or elbow.
• Most commonly, the biceps tendon is torn at the shoulder.
• These tears occur in men more than women; most injuries occur at 40 to 60 years of
age due to chronic wear of the biceps tendon.
• In younger individuals, the tear is usually the result of trauma (such as an auto accident
or fall).
• Biceps tendon ruptures can also occur at any age in individuals who perform repetitive
overhead lifting or work in occupations that require heavy lifting, and in athletes who lift
weights or participate in aggressive contact sports.
• Most commonly, the biceps tendon will tear at the long head of the biceps at the upper-
arm bone, leaving the second attachment at the shoulder blade intact.

18
 Topic 4 - Disease of the upper extremity ruptures of muscles and tendons

• The arm can still be used after this type of rupture, yet weakness will be present in the
shoulder and upper arm.
• A tear can either be partial, when part of the tendon remains intact and only a portion is
torn away from the bone, or complete, where the entire tendon is torn away from the
bone.

Osteoarthritis (Shoulder Osteoarthritis + Elbow Osteoarthritis à check summary for Topic 12)

19
Topic 5
 Topic 5 – Spine injuries

Spine Injuries
Spine anatomy

• 32 vertebrae – ensure body kept vertical

• C1-7, T1-12, L1-5, S-1-5,C-3
• Ligaments
o Posterior longitudinal ligament
o Anterior longitudinal ligament
o Supraspinous ligament
o Interspinous ligament
o Ligamentum Flavum
• Joints found between two vertebral bodies
• Intervertebral discs
• Muscles Central point of body is sacrum

Spine Functions

• Support- movement of trunk, head, body, flexion, extension

• Movement
• Protection- spinal cord, caudate equina

Injury

• Injury or bodily injury is damage or harm caused by to the structure or function of the body
caused by an outside agent or force which may be physical or chemical, and either by
accident or intentional. A severe and life-threatening injury is referred to as a physical
trauma.
• Spinal trauma often results in a complex interaction of injuries to the musculoskeletal and
nervous systems. This combination of biochemical and neurological considerations provides
a unique challenge to those dealing with the spinally injured patient.

Incidents and leading cases of spinal injury

• Vehicular accidents ( 45%)

• Falls (20 %)
• Sports Related Injuries ( 15%)
• Acts of violence ( 15%)
• Miscellaneous causes (5%)

Definitions

Fracture: present when there is a loss of continuity in the substance of a bone

The therm covers all bony disruptions, ranging from hairline fractures at one end of the scale to
multi fragmentary fractures at the other

Fractures of vertebrae ( vertebral body)

1
 Topic 5 – Spine injuries

• vertebral body is compressed and becomes lowered

• Lines of fracture are not very visible (upper arrow)
• Although easier to see fracture lines if there is a fracture of other vertebral parts. ( lower
arrow) i.e in joints, spinal process, transvere process

Fracture

• Present when there is a loss of continuity in the substance of a bone

• Losing substance of bone

Dislocations- complete loss of contact between articulating surfaces of joint

Subluxations- articulating surfaces of a joint are no longer congruous, but loss of contact is not
complete

• Left photo- C5 vertebral compression fractures

• Middle photo- C3 vertebral dislocation

2
 Topic 5 – Spine injuries

• Right photo- C6 dislocation + fracture of spinal process

• Subluxation- not totally closed joint, not congruent

Classification

• Spinal injuries (fracture, dislocation, contusion, sprain)

o Spinal cord injury
§ Pain or an intense stinging sensation caused by damage to the nerve fibres
in your spinal cord.
§ Loss of movement
§ Loss of sensation, including the ability to feel heat, cold and touch
§ Loss of bowel or bladder control
§ Exaggerated reflex activities of spasms
§ Changes in sexual function. Sexual sensitivity and fetility
§ Difficult breathing, coughing or clearing secretions from lungs

o Spinal injury

Differences between plegia and paresis in Spinal cord injury

• Plegia
o Complete motor and sensory loss below the level of injury
• Paresis
o Weakness with some preservation of motor function and expanded sensory
function below the level of injury
• Paraplegia is an impairment in motor and/or sensory function of the lower extremities
• If the arms are also affected by the paralysis, tetraplegia is the proper terminology
• Paraparesis: weakness of the lower extremities
• Tetraparesis: muscular weakness affecting all four extremities
• Bladder and bowel dysfunction: retention or incontinency constipations

3
 Topic 5 – Spine injuries

First Aid

• Contact
• ABC
• Immobilisation ( specifically of neck)
• Analgesics
• I/V solution of NaCl 0.9%
• oxygen
• in case of spinal cord injury -> sol.solumedroli ( 30mg/1kg body weight) also
methylprednisolone
• transport in horizontal position

Associated injuries

• associated injuries may occur in up to 50% of patients

• intra-abdominal bleeding from liver and splenic injuries
• arterial and venous vessel disruption
• pulmonary injuries
o haemothorax
o pulmonary contusion

Goals in treating a patient with spinal injury

• maintenance of airway, breathing and circulation

• accurate identification and classification of spinal injury
• identification of associated injuries ( head, pulmonary, abdominal, long bone, pelvis injuries)
• fracture - could be loss of blood, not visual till upto 1.5 litres

4
 Topic 5 – Spine injuries

Detailed examination of the spine

• patient is log rolled, and the spine is inspected and palpated

• one should note:
o localised tenderness
o bruising
o interspinous widening or displacement
o palpable step
o hematoma

• palpate and listen to sound abdomen, auscultate lungs, measure BP, feelings, reflexes and
pathological reflexes

ASIA Impairment Scale

• A grade has no motor or sensory function at the level of S4-S5 sacral segments
• B has some sensory function below the neurological level, including S4-S5, but no motor
function
• C has some motor function below the neurological level, but more than half of the key
muscles involved have a muscle strength score that is less than 3
• D has motor function below the neurological level but more than half of the key muscles
have a muscle grade of 3 or more
• E indicated normal motor and sensory function

Guidelines for spinal cord injury (SCI) as developed by the ICCP panel

• Complete and incomplete SCI are other terms used to describe overall severity of SCI
• Technically, SCI is classified as complete if there is no motor or sensory function
• Preservation in the sacral (most caudal) spinal segments
• Thus, incomplete SCI is when there is some preserved motor or sensory function at the
lowest sacral spinal level (S4-S5) There can be extensive variability in the degree of
preserved function after incomplete SCI

First guidelines for SCI

• How spinal cord injuries are managed- especially in the critical early stages has a profound
effect on a patient’s outcome

Imaging

5
 Topic 5 – Spine injuries

Rules

• See 7 cervical vertebrae in both projections

• Thoracic vertebrae fracture- 92% combines with rib fractures (pneumothorax, haemothorax)
• Fall from height may mean spine, pelvic and foot fractures!

Pathophysiology
Primary SCI

o Initial physical deformation forces that may result in severing of axons and
subsequent cellular death
o Secondary injury is more complicated and refers to the cellular mechanisms that
occur in the minutes to weeks to years following the initial injury
Secondary injury

o Ischemia
o Vasospasm 1. Fracture on
o Delayed axonal loss the left
o Apoptosis 2. Spinal cord is
o Ion mediated cell damage squeezed by
o Excitotoxicity hematoma
o Neuroinflammation and bones.
o Mitochondrial dysfunction
o Oxidative cell damage

• Use of steroids in the management of acute SCI is controversial. Consensus option

recommends steroids in acute treatment of SCI only as an option with little clinical benefit
e.g methylprednisolone

Contraindications to steroid administration

• Patients presenting SCI more than 8 hours following injury

• Injuries limited to the cauda equina or individual nerve roots
• Gunshot wounds
• Age < 13 years
• Pregnancy
• Uncontrolled diabetes
• Patients on steroid maintenance

• Primary goals of treatment are prevention and limitation of neurological injury as well as
restoration of spinal stability, regardless of whether operative or non-operative therapy is
chosen.

6
 Topic 5 – Spine injuries

Treatment

• Immobilisation- from injured spine, less time, and need to improve comfort
• Pharmacotherapy – reduce pain, improve comfort
• Physiotherapy – restore patients mobility/functions
• Surgery

Immobilisation

Pharmacotherapy

Spinal Cord Injury (SCI)

• Analgesics
• Sedative
• Sol. Solumedroli
• Sol.Na
• Sol.HES
• Sol Mannitol
• Antibiotics ( for hematoma)
• Proton Pump Inhibitors
• HEI
• Vitamin B

Spinal Injury ( SI)

• Analgesics
• Sedative

Physiotherapy

Spinal cord injury (SCI)

• Breathing exercises
• Positioning- every 2 hour turning patient from one side to another
• Active exercises
• Passive exercise in paralysed limbs
• Exercises for spine muscles
• Orthoses, verticalization
• Self-control

Spinal Injury

• Breathing exercises
• Exercises for spine muscles
• Swimming

Indications for spine surgery

• Fracture, dislocation with SCI (emergency)

• Unstable fracture
• Dislocation

7
 Topic 5 – Spine injuries

Goal of spine surgery

• Restore normal anatomical relationships

• Stabilize + Decompress spinal cord (in case of SCI)

Stability of the spine

• Spinal instability is defined as the inability of the spine to bear weight without anatomic
deformation of pain
• Stable spinal vertebral injuries
o Teardrop avulsion fractures of the cervical vertebral bodies
o Clay shovelers (C6) or other spinal process fractures
o Compression fractures of <50% of the vertebral height
o Unilateral laminar, facet, or pedicle fractures

Unstable fracture

• Clinical examination
o Coughing makes pain worse
o Difficulty turning in bed
o Feel gap between spinal processes
• X-ray
o >50% of vertebral collapse
o 30 degrees angulation
o 30 degrees kyphosis

AO Spine fracture classification

A- Fracture
B- Fracture + ligament rupture
C- Fracture + ligament rupture + rotation
• Spine stability - A>B>C
• Unstable fracture = bone fracture + ligaments
rupture

SCI Complications

• SC oedema (sudden death)

o Sol.Solumedrol 30ml/1kg body weight
• Breathing problems( diaphragm palsy bronchitis, pneumonia, abscess sepsis)
o Breathing exercises, antibiotics, bronchoscopy, tracheostomy
• Stress ulcers (bleeding)
o PPI (omeprazole)
• Urinary tract infection (sepsis)
o Long term catheter à Intermittent catheterisation, mictuation, antibiotics
• Bed sores à sepsis
o Best treatment is prophylaxis i.e turning every 2 hours, skin examination, Skin self-
control, pillow
o 4 grades
§ Grade 1- part of the skin

8
 Topic 5 – Spine injuries

§ Grade 2 - deeper
§ Grade 3 – to subcutaneous tissue
§ Grade 4 – to the bone
o Grade 1 + 2 able to treat conservatively
o Grade 3 + 4 able to treat with surgery

Treatment

• Dressing
• Anaemia and fluid disbalance correction
• Protein disbalance correction
• Antibiotics
• Surgical
o Necrotomy
o Plastic surgery
• Bed sores best treatment- prophylaxis
• Patients positioning ever 2 hours
• Complications
o Contractures
o Heterotopic ossification ( unknown reason but activates phosphatases)

Special Fractures

• Special fracture (C1,C2 fractures)

o Head rotation
o 50% death on accident place= SCI or MO (medulla oblongata)damage
o Clinically
§ Pain in neck
§ Difficulties to turn head
§ Very hard to change position
§ Patient supports head with their arms
o Aim- restore normal anatomical relationship and consolidate fracture
o C2 fracture – reposition with HALO

• C1 fracture – red arrows indicate the lateral masses

go to the side
• C2 fracture

• C2 Dens fracture- takes place in 3 different places. Apex middle and body. Possible
displacement either anteriorly or posteriorly
• C2 arcus fracture- hangman fracture, also found in car accidents

9
 Topic 5 – Spine injuries

• C1 and C2 fracture treatment aim is to restore anatomical

relationship and consolidate fracture
• HALO metallic ring + local anaesthesia to treat cervical fracture
• 4 Screws introduced into skull. Fixed with brace rods
•

Spine Dislocations

• Localisation
o Joint - Cervical part
• Treatment
o Reposition
o Fixation

Special fracture ( Processes transversus fracture)

• Result of direct injury • Treatment: bed rest-3d ,analgesics,

• Pain, impossible to move straight leg brace, physiotherapy
• Hospitalisation, Kidney contusion,
rupture

Special fracture (os coccyx fracture)

• Result of direct injury • Surgery as a last resort (Ectomy)

• Treatment: analgesics in suppository
form

Summary of main points:

• Classification
o Spinal injury
§ SCI – paraplegia, paresis, radiculopathy, bladder and bowel dysfunction
§ SI

Algorithm

Treatment: immobilisation, pharmacotherapy, physiotherapy and surgery

10
Topic 6
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Management of Polytrauma patients with orthopaedic injuries

Definitions
Trauma
• Trauma is an injury characterized by a structural alteration or physiologic imbalance that
results when energy is imparted during interaction with physical or chemical agents

Polytrauma
• Syndrome of multiple injuries exceeding a defined severity (Injury Severity Score (ISS) > 17)
with sequential systemic reactions that may lead to dysfunction or failure of remote organs
and vital systems, which have not themselves been directly injured.

Abbreviated Injury scale (AIS)

• AIS (1-6 severity code)
o 1 – minor
o 2 – moderate
o 3 – severe but not life threatening
o 4 – severe and life threatening
o 5 – critical, survival uncertain
o 6 – unsurvivable
• Anatomic scoring system
• Classifies individual injuries

Injury severity score (ISS)

Sum of squares of highest AIS scores in three different ISS body regions
• 6 ISS body regions:
o Head or neck
o Face
o Chest
o Abdominal or pelvic contents
o Extremities or pelvic girdle
o External
• Classifies multiple injuries
• ISS 1 – 75
o 75 (three AIS 5 Scores injuries or at least one AIS 6 scores injury)

New injury severity score (NISS)

• Sum pf squares of three highest AIS scores anywhere in body
• Assessment of injury severity of polytrauma patients with orthopaedic injuries

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 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

ISS = take the 3 most severe injuries from DIFFERENT Regions, square them and add them together
NISS = take the 3 most severe injuries from different or ONE Region, square them and add them
together

Assessment of Polytrauma is important for à Damage control Orthopedics (DCO)

Mechanisms of injury

• High Energy blunt trauma

o Road traffic accidents
o All from height
o Crush injuries

• Penetrating Trauma
o Gunshot wounds

• Miscellaneous trauma
o Explosion trauma

Motor vehicle crashes

• Speed (Major killer)
• Type of crash
o Frontal impact
o Lateral impact
• Position of patient
• Safety belts, car deformity, extrication time

Fall from Height

• Fractures of the bones of lower extremities
• Spine compression fractures

2
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Management of Trauma Patients

1. Primary survey with simultaneous resuscitation

• In advanced:
o medical bag & long backboard or scoop stretcher
o Assess situation and safety on scene

• cABCDE
o Before: life threatening bleeding control
§ Look, feel for life threatening bleeding
§ Pressure bandages, Tourniquet
§ Topical hemostatic agents

o A – Airway with restriction of cervical spine motion

§ Speak to patient
§ Jaw thrust
§ Check breathing
§ Breathing is
• Secure airway (O-F or N-F), reassess
§ Secure C – spine (cervical collar)
§ Check the neck: tracheal deviation, Distended jugular veins?
o B – Breathing and Ventilation
§ Chest Assessment:
• Inspect: immediately check back after dressing applied or
injury found
• Auscultation
o Lungs
o Heart apex
• Palpation
• Percussion
o If dull sound à haemothorax
• Check the back
• Reassess airways!!!

o C – Circulation with hemorrhage control

§ Check hemorrhage
• Head, arms, radial pulse, Abdomen, Pelvis, Iliac crests
and pubis

3
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

• Buttocks
• Legs
§ I/v access
§ Bandage all wounds, convert tourniquet to bandage, if necessary
§ If the life threatening injuries à immobilize and transport to
hospital
§ Reassess: Airway and breathing

o D – Disability (neurologic evaluation)

§ Glasgow Coma scale or AVPU (Alert, verbal response, Pain
response and unresponsiveness)
§ PERRL (Pupils, equal, round, reaction to light)
§ Record
§ Reassess: airway, breathing, radial pulse, I/v access,
Bandages/treatment

o E – Exposure and environmental control

§ Exposure casualty, take off shoes
§ Assess from head to toe (look, palpate !!!)
§ Assess distal pulse
§ Immobilize fractures
§ Longroll a patient, Assesses back
§ Insulate patient
§ Immobilize on long backboard
§ AMPLE
• Allergies
• Medications currently used
• Past Illnessess/pregnancy
• Last meal
• Events/environment related to injury
§ Record
§ Reassess: airway breathing, radial pulse, I/v access, bandages /
treatment
§ Oxygen
§ Monitore
§ Information in admission of Hospital (MIST)
• M – Mechanism
• I – Injuries
• S – Signs
• T – Treatment
o Reassess after every step!

• Assessment of patient and establishment of treatment priorities, based on

injuries, vital signs and the injury mechanism
• Aim:

4
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

o To identify life threatening conditions and stabilize trauma patient till

next step of treatment

5
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Haemorrhagic Shock

Result of acute blood loss with a reduction in circulating intravascular volume

Classification:

Class 1 à blood loss up to 15%

• Minimal clinical symptoms
• Treatment
• Body compensates or crystalloid solutions

Class 2 à blood loss 15 – 30%

• Clinical symptoms
o Tachycardia (100-120)
o BPs – N
• Treatment
o Mostly – crystalloid solutions

Class 3 à blood loss 30-40%

• Clinical symptoms
o Tachycardia (120-140)
o Tachypnoe
o BPs decreased
o Anxoius, confused
• Treatment
o Crystalloid solutions and blood transfusions

Class 4 à blood loss > 40%

• Clinical symptoms
o Tachycardia (> 140)
o Tachypnoe
o BPs highly decreased
o Confused, lethargic
o Urinary output – negligible
• Treatment
o Rapid crystalloid and blood transfusion, FFP, pRBC
o Immediate surgical intervention

Evaluation response and therapeutic decisions:

• Vital signs improve after initial electrolyte solution bolus

• Vital Signs improve after electrolyte solution bolus, but them deteriorate
o Blood products and blood, operation
• Vital signs not improve after crystalloid and blood administration à immediate surgery

6
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Blood loss in orthopedic trauma

• Femur 1-2L
• Pelvis 0.5 - >3L
• Tibia 0.5 – 1L
• Humerus 0.5 – 1L

Blood loss from extremities can be significant, but fractures of extremities usually are not
responsible for hypovolemia

Lethal Triad

Damage control resuscitation (DCR)

• Hemostatic and hypotensive resuscitation focused on prevention of lethal triad
• Lyophilized dry plasma
• Tranexamic acid

Internal Haemorrhage: immediate surgery, TAs 90-100 mmHg!

2. Adjuncts to the primary survey with resuscitation

• In hospital resuscitation area
o EKG, pulse oximetry, Carbon dioxide, ventilatory rate, Arterial blood gas,
blood lactate
o Gastric and urinary catheter
o X – Ray: E.g. Thorax, pelvis
o Focused assessment sonography in Trauma (FAST), eFAST, or DPL

3. Secondary survey and adjuncts

• Secondary survey does not begin until primary survey is completed, resuscitative
efforts are underway and normalization of vital functions has been demonstrated
o Examine patient from head to toe
o Take complete medical history, including AMPLE
o Reassess vital signs

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 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

• Adjuncts to secondary survey – laboratory and radiological (additional X-Rays, CT,

Contrast Angiography) examination and other diagnostic procedures

4. Reevaluation
5. Definitive care
• Formulate management plan for the Patient

Orthopaedic Trauma
• Severe limb injuries must not distract team from priorities of cABCDE
• Careful examination of extremities after resuscitation, because even minor injuries
may result in long term disability !!!

Potentially life-threatening extremity injuries

• Major arterial haemorrhage
• Crush syndrome

If Polytrauma à Damage control Orthopedics (DCO)

• Limited early surgical intervention for stabilization of musculoskeletal injuries in the unstable
polytrauma patient
• External fixation of unstable fractures
• Internal fixation – when patient is stable à BUT NEVER in dirty open fractures e.g. accidents
outside on the streets, because of high risk of Infection (Osteomyelitis)
• Remember! – internal fixation for patient is second severe trauma

Orthopaedic injuries
• Debridement of wounds (until 10L of Saline Solution)
• Primary external fixation of long bones / pelvic fractures
o Compartment syndrome – Faciotomy (including open Fractures)
• I/v antibacterial therapy
• Tetanus prophylaxis

8
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Pelvic injuries
• Fix pelvis to prevent hemorrhage
• Either internal (screws and plates) or external fixation

Mechanism
• High energy mechanisms
o motor vehicle crashes
o collisions with pedestrians
o falls from height

• Major haemorrhage, which can be difficult to control

• Other major injuries

o Intra-abdominal organs (28%), including aortic injury
o Hollow viscus injury (13%)
o Rectal injury (up to 5%)

• High morbidity and mortality (overall mortality is 10-30%; up to 50% if shocked)

9
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Classifications
• Tile classification
o based on pelvic stability and useful for guiding pelvic reconstruction

• Young-Burgess classification
o more useful in the ED as it is based on mechanism and also indicates stability (I to III
subclassification)

Tile Classification
• Tile A
o Rotationally and vertically stable
o pubic ramus fracture, iliac wing fracture, pubic stasis diastasis <2.5 cm
• Tile B
o Rotationally unstable, vertically stable
§ B1: pubic symphysis diastasis >2.5 cm and widening of the sacroiliac joints
(open book fracture due to external rotation forces on the hemipelvises)
§ B2: pubic symphysis overriding (internal rotation force on hemipelvises)
• Tile C
o Rotationally and vertically unstable
o disruption of SI joints due to vertical shear forces
§ C1: unilateral
§ C2: bilateral
§ C3: involves acetabulum

AO Classification

A = Stable
B = partial stable
C = unstable

Posterior Arch = Sacroiliac joint disruption or iliac wing fracture

Anterioir Arch = symphysis rupture, Fractures of Rami superior / inferior

10
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Young Burgess Classification

• Anteroposterior compression (APC)
o common feature is diastasis of the pubic symphysis or vertical fracture of the pubic
rami
§ APC I: Pubic symphyseal diastasis, <2.5 cm, no significant posterior ring injury
(stable
§ APC II: Pubic symphyseal diastasis >2.5 cm, tearing of anterior sacral
ligaments (rotationally unstable, vertically stable
§ APC III: Hemipelvis separation with complete disruption of pubic symphysis
and posterior ligament complexes (completely unstable)

• Lateral compression (LC)

o common feature is a transverse fracture of the pubic ram
§ LC I: Posterior compression of sacroiliac (SI) joint without ligament disruption
(stable)
§ LC II: Posterior SI ligament rupture, sacral crush injury or iliac wing fracture
(rotationally unstable, vertically stable)
§ LC III: LC II, with open book (APC) injury to contralateral pelvis (completely
unstable)

• Vertical shear injuries (VS)

o common feature is a vertical fracture of the pubic rami
o displaced fractures of the anterior rami and posterior columns, including SI
dislocation (completely unstable)

• Combined mechanism (CM) fractures

o massive pelvic injuries that don’t fit the other categories (completely unstable)

Stable fracture. In this type of fracture, there is often only one break in the pelvic ring and the
broken ends of the bones line up adequately. Low-energy fractures are often stable fractures.
Stable pelvic fracture patterns include:

11
Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

12
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Unstable fracture. In this type of fracture, there are usually two or more breaks in the pelvic ring and
the ends of the broken bones do not line up correctly (displacement). This type of fracture is more
likely to occur due to a high-energy event.
Unstable pelvic fracture patterns include:

Hemorrhage from pelvis fractures

4 potential sources:
• Surfaces of fractured bones
• Pelvic venous plexus
• Pelvic arterial injury
• Extra-pelvic sources (present in 30% of pelvic fractures)

à Classically venous hemorrhage is said to account for 90% of bleeding from pelvic fractures, and
arterial only 10%.

Clinical Assessment
Before Hospital:
1. I/V line for fluids and pain medication
2. Immobilization
3. Transport to Hospital

à Assessment for pelvic trauma should be part of a coordinated, structured assessment for multiple
traumatic injuries (e.g. ATLS approach)

• Assessment of the pelvis should be performed with extreme care

13
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

• Inspect:
o Local signs
§ Swelling
§ Ecchymosis,
§ Deformity
§ Asymmetry
§ Wounds

• Palpate the skeletal structures:

o pubic symphysis, iliac crests, the posterior sacroiliac joints, ischial tuberosities as well
as the the spine extending inferiorly to the sacrum and coccyx

• Assess for mobility:

o Gently compress the iliac crests to fell for instability
o If there is no pain or movement felt on compression, gently distract the iliac crests
(some experts, such as Scott Weingart, advise against distraction)
o A gentle technique and cautious approach is important to avoid aggravating
haemorrhage if the pelvis is fractured
o This maneuver should only be performed once, ideally by the most senior trauma
doctor present.
o Do not ‘rock’ the pelvis!

• Patients with suspected pelvis fractures also need careful examination of:
o Rectum — digital rectal exam to palpate for rectal injury (e.g. blood, wounds), bony
fragments, sphincter function and a boggy or high-riding prostate
o Perineum and genitalia — check for coexistent genital trauma, blood at the meatus,
and scrotal or other perineal hematomas. Perform a vaginal exam in women for
vaginal tears.
o Lower limb length discrepancy and malrotation, and neurology
o The abdomen, e.g. tenderness, distention, external signs of trauma

Normal examination in an alert adult patient effectively rules out significant pelvic injury (93-100%
sensitivity) unless there are distracting injuries. Any injuries missed in this circumstance tend to
be clinically insignificant or only require managed conservatively.

Associated injuries

1. Abdominal and gastrointestinal injuries

• Rectal injury is common (up to 5%), other intestinal injury may also occur (up to 5%)
• signifies an open fracture — which are more likely to be hemodynamically unstable
• may require fecal diversion, pre-sacral drainage and perineal debridement
• Risk of death from secondary sepsis
• In addition, there may be injury to spleen and liver (12%)

14
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

2. Genitourinary injuries
• Bladder and urethral injury (5-20%)
• urethral
o posterior urethra with pelvic fractures
anterior urethra with straddle injuries
• bladder: intra- and/or extraperitoneal
• vaginal tears (<5% in females; signifies and open fracture)

Other injuries (e.g. head, chest) may also be present, especially as the presence of pelvic fractures
implies a high energy mechanism of injury.

Complications

Acute
• Haemorrhagic Shock up to >2L blood loss (Class 3) (leading mechanism of death)
o laceration of venous structures
o arterial injury (e.g. branches of internal iliac)

• Visceral and soft tissue injury:

o fractures may be compound into the perineum or vagina
o lacerations into bladder
o urethral injuries common in males

• Nerve injury
o Sacral plexus injury; e.g. S2-5 sacral nerve root injuries with sacral fractures
o Injuries to L4/5 or S1 nerve roots
o N. ischiadicus damage

• Ileus
• Fat embolization (Pelvic and Femur Trauma)
• Acute Respiratory Distress Syndrome
• Venous thromboembolism
• Abdominal compartment syndrome

Late
• Infection (second most common mechanism of death)
• Fracture complications (e.g. osteoarthritis, malunion)
• Disability and immobility
• Incontinence
• Sexual dysfunction
• Dystocia following subsequent pregnancy

15
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Management

16
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Systemic inflammatory response syndrome

• Major Trauma triggers RNA, DNA, dead cells fragments release, that acts as Danger –
Associated molecular patterns (DAMPs) and pathogen-associated molecular patterns
(PAMPs)
• Severe injury (including unappropriated surgery) can cause uncontrolled release of cytokines,
neuromediators, proteins which contribute to development of SIRS and Multiple organ
dysfunction Syndrome (MODS) or sepsis (if inflammation Is caused by infection)

Trauma Team

Resuscitation area
• Trauma team – group of medical personal
o At least 2 doctors (one of them is Team leader)
o 2-3 nurses
o Additional staff
o Every team member has defined task
• Early recognition of problems
• Treatment of symptoms

Rehabilitation of polytrauma patients

• Early rehabilitation
o Bed positioning
o Pulmonary exercise
o Immobilization
o Range of motion exercises
o Physical therapy
o Occupational therapy

Clinical Case
• Car accident
• Multifragmented Fracture of distal 1/3 of left femur
• Open multifragmented fractures of distal 1/3 right tibia and fibula
• Fracture of diaphysis of left humerus
• Fractures of left os pubis superior and inferior ramus
• Fractures of 8.-10. Ribs of left side
• Pulmonary contusion
• Fracture of Th12, L2, L4, L5 left proc. Transversus
• Hypovolemic shock III-IV.
• ARDS
à Fixateur Externa

17
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Crush Injuries

Definition
• Syndrome resulting from skeletal muscle injury and resultant release of uscle cell contents
into circulation

Mechanism of injury
• Collapse of buildings (earthquakes, terror acts)
• Major traffic accidents
• Fire
• Military operations
• Works in mine caves, forest etc

Pathogenesis

Local clinical sign

• Limb swollen, tense, hard, blisters
• Dital pulse tend to disappear
• Crush injuries of trunk and buttocks can be overlooked, if complete physical examination is
NOT performed
• High risk of major blood vessel injury!!!

18
 Topic 6 – High Energy Trauma. Trauma of the pelvis. Polytrauma

Prehospital emergency treatment

• Primary survey (cABCDE)
• I/V normal saline solution immediately (even when casualty is still trapped (1000 – 1500
ml/H)
o *Sodium bicarbonate 50mEq and mannitol 10g on each liter of fluid during
extrication may decrease risk of renal failure
• O2
• Immobilization
• No unnecessary movements of limb
• Continue I/v normal saline solution till 1000ml/h (and sodium bicarbonate 50mEq per
liter, if possible) to ensure renal output of 150-200ml/h

Hospital emergency treatment

• If signs of compartment syndrome à fasciotomy
o Indications for fasciotomy
§ Increasing swelling, limb tense, hard
§ Increasing pain
§ Paresthesia
o Disadvantages
§ High bleeding risk
§ High infection risk

• If fracture à external fixation

• Debrided wounds and fasciotomy incisions do not close primarily
• Mentioned fluid therapy until à myoglobin disappears from urine (about 60h)
• The earlier i/v therapy, the better chance prevents acute renal failure
o If renal failure à reduction of fluid and hemodialysis
• Infection prevention à wide spectrum antibiotics, metronidazole
• Tetanus prophylaxis

Tscherne classification of closed fractures

à proper assessment of soft tissue damage in closed Fractures

0 – injury from indirect forces, simple fracture

I – moderate energy, contusion of soft tissue
II – severe energy, significant muscle contusion, high risk of compartment syndrome
III –
• extensive, crushing of soft tissues
• subcutaneous avulsion
• fragmented fracture
• arterial disruption
• or established compartment
syndrome

19
Topic 7
 Topic 7 - Colloquium

1. Orthopaedics Tests (only two skills tested)

1. Patella ballottement test (Patella Tap Test)

• The patellar tap is a technique used in an examination of the knee to test for knee
effusion or "water-on-the-knee"
• With the examinee lying on their back, the examiner extends the knee and presses the
area above the kneecap with the palm of one hand.
• This pushes fluid under the kneecap and lifts it.
• While keeping the pressure on with the first hand, the examiner uses the fingers of their
other hand to press down on the kneecap.
• If a knee effusion is present, the kneecap will move down and "tap" the bone beneath

2. Piano Key Test Fresh complete fracture, dislocation of acromial end of clavicula

• Patient Position: Subjects sits with the involved limb relaxed at the side, or stands facing
Dislocation =
only in joints, the examiner.
there is no
contact • Action: Apply pressure to the subject's distal clavicle in an inferior direction.
between • Test result “+”:
articulating
surfaces o Instability of the AC joint on the involved side
Subluxation = o Depression of the clavicle when pressure is applied and elevation
still contact but o of the clavicle when pressure is released
not like
dislocation • Positive Test Implications: Instability of the acromioclavicular joint

1
 Topic 7 - Colloquium

3. Thompson Test
• squeezing the calf (i.e., gastrocnemius muscle) of the patient, in prone position with legs
extended
• Normal: results in passive plantar flexion
• Rupture: absent passive plantar flexion

4. Lachmann Test. The anterior and posterior drawer Test

• Lachmann Test
o The patient lies on his/her back and flexes the knee by 20–30°.
o The femur is stabilized, while the proximal calf is moved anteriorly.
o Asymmetry in side-to-side laxity or a soft endpoint indicates an ACL tear

2
 Topic 7 - Colloquium

• Posterior drawer Test

o The patient lies on his/her back and flexes the knee by 90°.
o The foot is fixed in place by the examiner and the patient is asked to relax.
o The proximal end of the tibia is then pushed posteriorly. Thumbs in tuberositas
Tibiae !!!!
o A firm endpoint along with the absence of posterior tibial movement implies that
the PCLis intact.

• Anterior drawer test

o The patient lies on his/her back and flexes the knee by 90°.
o The foot is fixed in place by the examiner and the patient is asked to relax.
o The proximal end of the tibia is then pulled forward.
o Thumbs in tuberositas Tibiae !!!!
o A firm endpoint along with the absence of anterior tibial movement implies that the
ACL is intact.
o This test is the least reliable, because a hamstring spasm may also present with
a positive anterior drawer test.

3
 Topic 7 - Colloquium

2. Transport immobilization and Bandages (only one skill is tested)

• Desault bandage
• Spindle shape bandage for joints
• Finger bandage
• Figure of “eight” bandage for joints
• Amputation trunk bandage
• Transport Immobilization – upper and lower extremity

3. Extremity measurements of length, girth, range of Motion (ROM) (only one skill tested)

Range of Motion

o Upper extremity
§ Spine
• Flex/Ext.: 80° / 0 / 30°
• Lateral Flex 30° / 0 / 30°
• Rotation 40° / 0 / 40°

§ Neck:
• Flex/Ext. 90° / 0 / 55°
• Lateral Flex.: 45° / 0 / 45°
• Rotation: 70°

§ Shoulder:
• Flex/Ext.: 150°- 170° / 0 / 40° (or 70°/0/70° from 0 Position)
• Abd/Add: 170° - 180° / 0 / 20-40°
• Rot. Ext / int: 40-60° / 0 / 95°

§ Elbow
• Flex/Ext.: 150° / 0 / 0° (10°)
• Sup. / Pron. 90° / 0 / 90°

§ Wrist
• Dorsal Flex/ Palmar Flex.: 35 – 60° / 0 / 50°-60°
• Sup. / Pron. 80° / 0 / 80°

4
 Topic 7 - Colloquium

o Lower Extremity
§ Hip
• Flex/Ext.: 130°-140° / 0 / 30°
• Abd/Add: 30°-45° / 0 / 20°-30°
• Rot. Ext / int: 30°-45° / 0 / °

§ Knee
• Flex/Ext.: 120° - 150° / 0 / 0° (5°-10°)

§ Ankle
• Dorsi Flex/Plantar Flex: 20° / 0 / 50°

Extremities length measurements

Lower Extremity
• Entire Leg
o Anatomical Length: Spina iliaca anterior superior à distal point of medial malleolus
o Functional Length: Navel à Medial malleolus
• Upper Leg
o Tip of Trochanter major à lateral knee joint space
• Lower Leg
o lateral knee joint space à Malleolus lateralis

5
 Topic 7 - Colloquium

Girth of leg

• Upper leg
o 15 and 20cm above of medial knee joint space (Kids 6 and 10cm above)
• Lower leg
o 15 cm below of medial joint space

Upper Extremity – Length

• Entire Arm:
o Lateral tip of acromion à Proc. Styloideus radii (hanging arm in standing position)
• Upper arm
o Lateral tip of acromion à Epicondylus humeri lateralis
• Lower Arm
o Epicondylus humeri lateralis à Proc. Styloideus radii in maximum supination

6
Topic 8
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

Diaphyseal fractures of the lower extremity bones

Femur diaphyseal (shaft) fracture

rotational forces are not well sustained by the femur
Epidemiology
• Age: bimodal distribution, based on exposure to causative force
• High-energy trauma associated: common in younger population (< 25 years)
• Low-energy trauma associated: common in older population (> 65 years)
• Sex: ♂ > ♀

Etiology
A fracture in the diaphysis (shaft) of the femur caused by:
• High-impact trauma:
o motor vehicle accidents
o pedestrian-versus-vehicle accidents
o Falls
o gunshot wounds
• Low-impact injuries associated with pathological fractures : fall from standing (height > 1 m)
• Stress fractures (rare): seen in long distance runners

Clinical features
• Painfully swollen, tense thigh
• Restricted range of motion
• Signs of fracture (e.g., shortening, deformity à leg shortening, int./ext. Rotation)
• Blood loss in closed fractures 0.5 – 1.2L
• Crepitus and distal neurovascular deficits (check finger movements) could be present.
• Check A. dorsalis pedis and A. tibialis posterior pulse
• Beware of symptoms associated with fat emboli: change in mental
status, dyspnoea, hypoxia, petechiae, or fever!
• Open fractures are almost always associated with multiple injuries!

Diagnostics
• Plain x-ray: AP of Hip, AP lateral view of knee à always include one joint above + below of
original fracture side
• CT and MRI if a tumour, infection, or other pathological process is suspected, open fractures
• Arteriography/Angiography if vascular injury is suspected

Treatment
• Stabilization, analgesia, (Fentanyl, Tramadol) and open fracture management
• Splinting and traction
• Surgery (definitive treatment)
gold standard • Intramedullary rod via an interlocking nail (antegrade nailing): treatment of choice
• External fixation with conversion to intramedullary nail within 2–3 weeks
• Indications:
• All pat with femoral shaft fractures except those not fit definitive surgery
1
Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

o Isolated fracture
o Closed fracture
o Gustilo types I and II open and clean IIIA fractures
o Polytrauma patients in stable condition

• Temoporary External Fixation

o Open fracture / Polytrauma
• Conversion to a nail or plate within a week or two before site
can become infected
• Mobilization on post op day 1
• Partial weight bearing
• Plates

2
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

• Non-operative treatment is undertaken only temporally à skeletal traction

o The patient will be in some form of traction for at least 6-8 weeks , often 10-12
weeks
o It requires great skill of application and constant monitoring throughout the whole
treatment period
o The initial Treatment is usually skin traction, later skeletal traction
o Local anaesthesia, long wire through the tuberositas tibiae
o 10% - 15% of patients own body weight used for Traction weight (around 6kgs)
o Drill from the lateral side to prevent Peroneus Nerve damage

Complications
• See also complications of fractures (especially vascular injury and fat embolization)
• Posttraumatic deformity
• Rotational error
• Osteoarthritis of the knee
• DVT and pulmonary embolism due to immobilization
3
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

Classifications
• Anatomical Classification (in which region the diaphysis is fractured)
o Proximal 1/3
o Middle 1/3
o Distal 1/3
• AO Classification

4
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

Tibial diaphyseal fracture

Classification: à Fracture + Soft tissue Damage

• Isolated fibula fracture
• Isolated tibia fracture
• Open or closed
• Displaced or non-displaced
• Proximal or shaft (Shaft fractures are the most common fracture sides)
• Combined tibia and fibula fracture (85% both bones , 15 % only tibia)
• Tibial plateau fracture

Clinical features

Fracture signs
• Pain, redness, and swelling at the site of injury
• Deformity and axis deviation
• Bone fragments penetrating the skin
• Palpable step-off or gap
• Bone crepitus
• Concomitant soft tissue injuries
• Neurovascular compromise below site of injury

• High risk of open fracture (and consequently infection) given minimal soft tissue surrounding
the tibia and fibula

5
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

Diagnostics
• Clinical examination: peripheral perfusion, motor function, and sensation
• X-rays: knee and ankle (anteroposterior and lateral views)
• Even when no obvious fracture is detected, tibial plateau fractures may cause
lipohemarthrosis. This is visible as a fat-fluid level on x-ray.
• MRI: can be useful to assess injuries to the meniscus and the ligaments associated with tibial
plateau fractures.
• Joint aspiration: can be performed
• Bloody effusion (hemarthrosis) with fatty spots indicates an osteochondral fracture

Treatment
• Conservative treatment
• Isolated fibula fractures
• Splinting and partial weight bearing
• Non-displaced proximal tibial fractures
• Hinged knee brace and no weight bearing for 6 weeks
• Non-displaced tibial shaft fractures
• Long leg cast (if the long leg cast fails to ensure proper healing, then surgical
treatment is indicated)

• Long leg cast 4-6 weeks

• Then Sarmiento or PTB (Patella tendon bearing) cast
• Cast fir at least 12 weeks
• The average healing time is 16-24 weeks

• Calcaneus Traction
• Drill the wire from the medial side, to prevent A. tibialis posterior damage
• 4 – 6 kg for tibia traction

• Surgical treatment
• Indication: open or displaced tibial shaft fractures
• Open fractures require urgent irrigation and debridement
• Open reduction and internal fixation with plate, screw, or intramedullary nail
• External fixation may be used, especially for complex fractures and compartment
syndrome, polytrauma, severe comorbidities

6
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

Complications
• Patients with tibial fractures should be monitored for:
• High risk of compartment syndrome in any of the compartments, given that
the tibia is surrounded by the anterior, lateral, and deep posterior compartments of
the lower leg
• Fat embolism
• Peroneal nerve injury (foot drop)
• Deep vein thrombosis
• Nonunion à incomplete healing of a fracture
• Clinical features: pain, swelling, limited weight-bearing capacity, and
reduced range of motion persisting after the normal duration of healing
(usually 6–9 months)
• Treatment: debridement and resection, osteosynthesis
(fixation), antibiotics in the case of infected nonunion

Compartment Syndrome

Classification
• Acute compartment syndrome: predominantly trauma-induced; a surgical emergency!
• Chronic compartment syndrome: also known as exertional compartment syndrome; usually
not a medical emergency

Pathophysiology
• External or internal forces as initiating event
→ increased compartment pressure
→ decreased tissue perfusion
→ lower oxygen supply to muscles
→ irreversible tissue damage to muscles and nerves after 4–6 hours of ischemia

à Clinical signs (within 4-6hrs treatment)

Clinical features
• Compartment syndrome may occur in any enclosed muscle compartment inside the body.
• The most common sites are the lower legs and arms.
• Less common sites include the feet, hands, thighs, and gluteal region.

Acute compartment syndrome

Typically presents with a rapid progression of symptoms.

Early presentation
• Pain
• Often out of proportion to the extent of injury
• Worse with passive stretching or extension of muscles
• Very tight, “wood-like” muscles that are extremely tender to touch
7
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

• Paresthesia (e.g., pins and needles)

• Soft tissue swelling
• Initially, peripheral circulation and distal pulses are maintained.

Late presentation
• Muscle weakness to paralysis
• Absent (or weak) distal pulses
• Cold peripheries
• Pallor or cyanosis
• Worsened pain and swelling

6 P's of acute limb ischemia: Pain, Pallor, Paresthesias, Poikilothermia, Pulselessness, and Paralysis!

Arterial pulse is usually still palpable; pulselessness is a sign of very severe compartment syndrome!

Diagnostics
• Compartment pressure measurement is necessary to confirm the diagnosis.
• Further laboratory tests are unnecessary but should be performed in trauma-
related compartment syndrome to assess for rhabdomyolysis.
• Imaging may be useful to identify an underlying etiology.

• Compartment pressures (initial and confirmatory test): measurement of tissue pressure

with a manometer and calculation of delta pressures (delta pressure = diastolic -
(compartment) tissue pressure)
• Delta pressure in manifest compartment syndrome: ≤ 30 mm Hg

• Laboratory tests specific for rhabdomyolysis

• Imaging
• X-rays
• Pulse oximetry: not diagnostic but can help identify limb hypoperfusion
Differential diagnoses
• Deep vein thrombosis • Cellulitis
• Acute limb ischemia • Peripheral artery disease
• Rhabdomyolysis (often also a
complication of compartment
syndrome)

Treatment
• Surgical treatment: required for all cases of acute compartment syndrome!
• Also indicated if conservative treatment fails in chronic compartment syndrome.
• Fasciotomy (tissue and fascia incisions): relieves the pressure, thus restoring
perfusion
• Should be conducted within 6 hours after the onset of the condition to
prevent necrosis

8
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

• Followed by open wound treatment

• Fibulectomy: if fasciotomy fails; to decompress all compartments of the lower leg
• Escharotomy: In the case of circumferential compression by a burn eschar
• Last resort: amputation

• Supportive treatment
• Indicated as perioperative care
• Eliminate any underlying cause, e.g., remove restrictive cast/dressing
• Cooling and positioning of the limb at heart level to relieve pressure
• Close monitoring
• Correct any fluid imbalances
• Supplemental oxygen
• Analgesia
Elevated positioning may worsen ischemia by reducing blood flow!
Acute compartment syndrome is a surgical emergency and requires an early fasciotomy!

Complications
• Muscle and soft tissue necrosis with a higher risk of infection
• Nerve lesions (esp. the tibial nerve and peroneal nerve) with sensory and motor deficits or
paralysis
• Fracture malalignment
• Rhabdomyolysis with potential Crush syndrome
• Muscle contractures
• Rebound compartment syndrome
• Occurs 6–12 hours after surgical reperfusion
• Etiology: increased capillary permeability and edema, often due to
insufficient fasciotomy incisions
• Volkmann contracture
• Permanent flexion contracture due to shortening of forearm muscles (“claw-
like deformity” of the hand, fingers, and wrist)
• Direct complication of insufficient treatment or undiagnosed compartment
syndrome

9
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

Fibula Shaft Fracture

Causes
• direct blow to the bone
• a twisting injury.

Risk Factors
Playing high impact sports, such as skiing or soccer, may increase your risk of a fibula shaft fracture.

Symptoms
• Tenderness or pain in the lower leg, especially pain that worsens with movement
• Inability to walk or bear weight
• Deformity of the lower leg

Treatment

• Isolated fibular fractures in the absence of an associated ankle injury can be managed with
appropriate pain control and weight bearing as tolerated.
• Immobilization for a brief period may be appropriate if it improves comfort.
• Operative stabilization of the fibula may be indicated for fractures that have associated ankle
injuries in which the mortise or syndesmosis are unstable.

Complications

• Compartment syndrome
• Nonunion
• Malunion

Tibial/fibular fractures

• 85% both bones, 15% only tibia

• Compartment syndrome
o 4 compartments, covered by fascia
§ Swelling or bleeding in compartment
§ Fascia does not expand
§ Increases pressure in compartment, decreased blood flow
o 4-6h for treatment à otherwise pat. Might loose foot
o Surgery à fasciotomy
o Symptoms
§ Pain § No distal pulse
§ Blue/ pale § No sensation
• Non operative treatment
10
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

o Minimal displacement after reduction <1cm shortening, <5-10% angling

§ Long leg cast 4-6 weeks
§ Sarmentio or PTB cast
§ Cast for 12 weeks (average healing time is 16-24 weeks)
• Control x-rays necessary

Ruptures of muscles and tendons

Achilles Tendon Rupture

Epidemiology
• Peak incidence: 30–50 years
• Sex: ♂ > ♀
• Most common in people that are active in sports or recreational activity
• Felt that someone kicked him from behind

Etiology
• Anatomy of the Achilles tendon
• Largest tendon in the human body
• Provides the attachment of the converged soleus and gastrocnemius muscles to
the calcaneus

• Mechanism of injury
• Indirect trauma from physical activities (e.g., tennis, basketball)
• Rarely, direct trauma or longstanding paratenonitis (possibly with tendinosis)

• Risk factors
• Pre-existing degenerative conditions (including polyarthritis)
• ↓ Physical conditioning (poor physical condition)
• Medication
• Local injections of glucocorticoids
• Systemic glucocorticoids
• Immunosuppressants

Classification
• Complete rupture (most common)
• Less common:
• Partial rupture
• Avulsion of the bony insertion of the Achilles tendon at the calcaneus

11
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

1. inspection
2. palpation
3. movement
4. functional tests

Clinical features
• Popping or snapping sound/sensation when the injury occurs
• Sudden, severe pain in the Achilles tendon
• Difficulty mobilizing: loss of plantar flexion power on the affected side
• Deformity: calf swelling (i.e., hematoma) and/or palpable interruption of the affected
Achille's tendon

• Clinical test
• Thompson test: squeezing the calf (i.e., gastrocnemius muscle) of the patient,
in prone position with legs extended
• Normal: results in passive plantar flexion
• Rupture: absent passive plantar flexion
à Normal plantar flexion does not rule out a suspected Achille's tendon tear!
à Always compare the symptomatic side with the opposite normal side!

Diagnostics
• Mainly a clinical diagnosis
• Imaging is indicated to evaluate the extent of the injury and/or to exclude other suspected
pathologies.
• Ultrasound (best initial test)
• X-ray: mainly to rule out suspected bone fractures
• MRI (confirmatory test): only imaging modality that can distinguish between a partial
and complete rupture

12

if ultrasound is not available at night, perform X-ray to exclude bone fracture

 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

Treatment
Both conservative and surgical approaches are recommended, but the indications for conservative vs
surgical treatment are controversial.
• Conservative therapy
1. Rest, analgesia, serial casting
2. Rehabilitation

• Surgical therapy
1. Open or percutaneous tendon repair percutaneous we don’t do it
2. Casting until the knee in plantar flexion for 1 month, then orthosis
3. Rehabilitation

Complications
• Re-rupture
• Contractures and/or scarring → permanent limited range of motion

Prognosis
• Excellent prognosis with early treatment
• Repair of complicated cases (e.g., following re-rupture) has a poorer outcome

neglected Achille’s tendon rupture = not diagnosed and not cured

Quadriceps Tendon Tear

Etiology
• Commonly a result of eccentric contraction of the quadriceps muscle when the knee is partly
flexed and the foot planted (e.g., during falls)
• Sports trauma, motor vehicle crashes
• Trauma (e.g., direct blow) to the suprapatellar region (rare)
• Risk factors: hyperparathyroidism, gout, SLE, diabetes, rheumatoid arthritis,
and glucocorticoid therapy

Clinical features
• Pain and swelling of the knee joint, (mostly localised above the patella)
• A palpable gap in the quadriceps tendon
• Inability to extend the knee
• Inability to extend the knee against resistance

Diagnostics
• X-ray(AP and lateral view): lack of quadriceps shadow, suprapatellar mass present
• Ultrasound: hypoechogenic section seen across the tendon
• MRI: used if other techniques are inconclusive; will show tear across all three layers of the
tendon

13
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

Treatment:
• surgical repair (suturing) of the quadriceps tendon with follow-up physical therapy
• After 6 weeks, strengthening begins à after 10-12 weeks injury has healed
• Pat may resume normal activity after full ROM is reached
• Always surgery
o Incision in front of knee à strong sutures into tendon, tying it back down to patella
(suture anchor)
o Knee immobilizer after surgery to keep knee straight for 6 weeks
o Full weight bearing after 1-2 weeks
o Physical therapy needed to renew muscle strength

Patellar tendon rupture

Etiology
• Trauma to the infrapatellar region (common)
• Rarely as a result of contraction of the quadriceps muscle with the foot planted (e.g., due to
a fall)
• Chronic tendon degeneration

• Risk factors
• Weakening of collagen structure
• Systemic (SLE , RA , Chronic renal disease, DM)

Clinical features
• Pain and swelling of the knee joint
• A palpable gap in the quadriceps tendon
• Inability to extend the knee
• A high-riding patella

Diagnostics
• X-ray (AP, lateral, axial): a high-riding patella; calcification seen in chronic causes
• Ultrasound: hypoechogenic section seen across the tendon (suggests an acute tear)
• MRI: used if other techniques are inconclusive; shows disrupted tendon fibers with adjacent
hemorrhage or edema

Treatment 4-6 weeks immobilization then rheabilitation

• Partial tears: immobilization
• Complete tears: surgical end-to-end suturing of the patellar tendon

• Two main types: partial or complete tears

• Partial tears can sometimes be treated non operatively

14
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

• Complete tears, as well as partial tears when the patient is unable to perform a straight leg
raise are always treated with surgery

• Incision on the front of the knee.

• Then strong sutures are placed into the tendon and tied back down to the top of the
patella.
• The patient is then placed into a knee immobilizer keeping the knee straight after
surgery for 6 weeks, taking it off for physical therapy.
• Full weight bearing after 1-2 weeks

• Fix it through the patella

Hamstring Tear harmstring muscles ( muscoli ischiocrurali),

from medial to lateral: semimembranosus,
Etiology semitendinosus and biceps femoris)
• High energy trauma:
o MVA, falls from heights, crush injuries
• Low energy Trauma:
o Elderly
• Pathological fractures:
o Tumors, MTS, osteomyelitis
• Athletic injury
o Running, basketball, tennis etc.
• Overuse of muscle
• Rapid acceleration
• Risk Factors
o muscle tightness
o muscle imbalance
o muscle weakness
o muscle fatigue

Clinical features

• Blood loss 0,5-1,2l

• Deformation (shortening, int./ext. rotation)
• Can’t put weight on it
• immediate pain
• unable to continue activity
• pain while walking or no walking possible
• Hamstrings:
o Spasm
o Tightness
15
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

o Tenderness
o If complete rupture, muscle might bulge under skin
• Bruising

Diagnostics
• Ask Patient about injury
• Palpation
• Imaging
o X-ray
o MRI
• Classification:
o Grade I à minor strain (heals fast)
o Grade II à tears / partial tears
o Grade III à complete rupture/ tear (takes months to heal)

Transport immobilization
• Traction splints
• Vacuum mattress à polytrauma

Treatment
• Intramedullary nailing
• Strongest mechanical fixation and early immobilization
• Non operative treatment: traction for 6-8 weeks (10-12 weeks)
• Constant monitoring
• First skin traction, later skeletal traction (10-15% of pat. Body weight in femoral diaphyseal
fractures)
• Temporary external fixation
o Open fracture
§ Conversion to a nail or plate within a week or two before site can become
infected
§ Mobilization on post op day 1
§ Partial weight bearing

• Non-surgical
o RICE
o No sports
o Physiotherapy
§ Strength training
§ Stretching
§ ROM rehabilitation
o Pain management à NSAID’s

16
 Topic 8 – Diaphyseal fractures of the lower extremity bones. Ruptures of muscles and tendons

• Surgical
o Only for avulsion injury (complete rupture & ischiadic bone broken)
§ Suture/staples to reattach muscle

• Platelet rich plasma

o Taken from Patients own blood
o Injected into muscle
o Still investigated treatment method

17
Topic 9
 Topic 9 - Low energy trauma. Fractures of proximal femur. Geriatric trauma.

Low energy trauma. Fractures of proximal femur. Geriatric trauma.

Low energy trauma

• Simple injuries caused by low velocity trauma

• indirect impact (fall, twist injuries, sports, stab wound etc.) à angular, rotational, cotorsion,
axial loading
• Low energy fractures can be challenging to treat due to weakened bone strength and low
healing potential
• these fractures must be accurately reduced and fixed with enough stability to obtain
favourable outcomes through the maintenance of appropriate alignment and early
rehabilitation

In the trochanteric region, if the blood supplu to the

Medication for low energy trauma and geriatrics: head is unharmed, the treatment = reduction +
enoxaparin osteosynthesis
• LMWH à Clexane, etc.
• NSAIDs + Tramadol + Fentanyl
• Laxatives
• Fluids à Divide doses
• Omeprazole 20mg/d The blood supply to the femoral
• Antibiotics à 3 days ceftriaxone post-op head comes up from the circumflex
artery.

In intertrochanteric femoral fractures

Fractures of proximal femur the femoral head blood supply is
AO classification: preserved and the fracture can be
Proximal femur Anatomy revision - femur —> 3 fixed.
- proximal —> 31

When transcervical fractures the

blood supply is at risk with necrosis
of the femoral head as
consequence. The surgical
treatment will be hemiarthrosplasty
or head replacement.

1
 Topic 9 - Low energy trauma. Fractures of proximal femur. Geriatric trauma.

Femur fracture sites

• Majority of proximal femur fractures (90%) in Pat. >50 years

• 2-3x higher in females
• Spiral or oblique fractures heal better than transverse fractures à larger fracture site grows
together easier

Fracture healing

• Indirect:
1. Callus
2. Micromovements between fragments
• Direct:
1. No Callus
2. No micromovements

2
 Topic 9 - Low energy trauma. Fractures of proximal femur. Geriatric trauma.

Classification

• Classified on basis of location:

o Neck of femur fracture
o Inter trochanteric fracture
o Subtrochanteric fracture
Pertrochanteric
• Classified into:
o Intracapsular fractures
§ Femoral head fractures
§ Femoral neck fractures (subcapital fracture, transcervical fracture, basicervial
fracture) à loss of blood supply

o Extracapsular fractures
§ Intertrochanteric fractures
§ Subtrochanteric fractures

à each fracture type requires special treatment method

1) Neck of femur fracture

• Occurs in region between head of femur and inter trochanteric region
o Prone to non-union:
§ Intracapsular à synovial fluid impedes healing process
Due to the fact that blood supply coming from
above is terminated after 60s § Blood supply loss of head and neck due to disruption of branches of a.
circumflexa femoris medialis
§ Absence of cambium layer of periosteum in this region

DHS screw
• Treatment: surgically Parallel screw

• Classifications: all have similar outcome/ complication predicting value, hence most
physicians classify fracture as undisplaced or displaced

1. Garden’s Classification (most widely used)

Type I: incomplete fracture (impacted valgus fracture)

Type II: complete fracture without displacement
Type III: complete fracture with partial displacement
Type IV: complete fracture with complete displacement

3
 Topic 9 - Low energy trauma. Fractures of proximal femur. Geriatric trauma.

2. Powel’s Classification (based on obliquity of fracture line, limited use due to

subtypes)

Type 1: with obliquity of 0–30°.

Type 2: with obliquity of 30–50°.
Type 3: with obliquity of 70° or more

3. AO classification (complicated and low prognostic significance)

31B1: subcapital fractures with minimal displacement

31B2: transcervical fractures
31B3: displaced subcapital fractures

• Young adults:
o Rare
o high energy trauma
o Treatment principle: anatomic reduction and fixation

• Elderly age group

o Majority of cases
o Low energy trauma
o Associated with high mortality
o Retraction leads to further complications
o Surgery within 48h, if no comorbidities exist
o Surgery within 4 days if comorbidities exist
o Preferred treatment: replacement of femur neck
o Fast remobilization necessary

2) Inter Trochanteric femur fracture

The fracture line passes between the two trochanters,

above the lesser trochanter medially and below the crest
of the vastus lateralis laterally. Both femoral cortices are
involved. 4
 Topic 9 - Low energy trauma. Fractures of proximal femur. Geriatric trauma.

• In area between greater and lesser trochanter or involve those structures

• 45% of all hip fractures

o Treatment:
§ Surgical fixation Cephalomedullary nail

§ With intramedullary nail or plate à unstable fracture

§ Dynamic hip screw à stable fracture

o Arthroplasty in elderly patients, pathological fractures, or if other surgical modalities

fail

• Classification:
o Evan’s Classification

o AO Classification
o Jenson’s Classification

5
 Topic 9 - Low energy trauma. Fractures of proximal femur. Geriatric trauma.

à All divide fracture into stable vs. unstable fractures (reverse oblique and coronal split fractures)

• Diagnostics

o X-ray (AP view with maximal internal rotation and lateral view):
proximal femur fracture between the greater and lesser trochanters
o MRI if a pathological fracture is suspected

3) Subtrochanteric Fracture
o Fracture between lesser trochanter and isthmus of femur shaft
o Lowest incidence of hip fractures (10-30%)
o Fracture deformity due to several muscles pulling on broken off
piece

• Classification:

• Treatment:
o Surgery à reduction of fracture

6
 Topic 9 - Low energy trauma. Fractures of proximal femur. Geriatric trauma.

In General

Clinical Picture

• Varies depending on type, severity, cause of fracture

o Displaced fracture: standing is not possible
o Non-displaced fracture: minimal pain, ambulatory
• Thigh/ groin pain
• Displaced fracture: externally rotated leg, shortened leg, tenderness on palpation,
ecchymosis may be present Shortened leg
• Low range of motion in hip à painful
glued heel symptom —> femoral neck

Diagnostics

• Imaging
o X-Ray
o MRI (if not seen in X-ray)
o Bone Scan (same as MRI, may take 2-3 days after injury before visible)
• Lab Tests
o Complete blood count
o Electrolyte count
o Blood urea nitrogen and creatinine Femoral neck fracture: if
blood supply to head is
o Arterial gas analysis (in pat. With pulmonary disorder) compromised —> treatment =
o ECG osteosynthesis/arthroplasty

Treatment

• Surgery
• Perioperative medical management - no partial weight-bearing for 6- 8
weeks
• Rehabilitation - early activation: sitting, exercises
already starting from next day
- follow up after 6-8 weeks —> gradual
weight-bearing —> full weight bearing
Geriatric Trauma

• Traumatic injury occurring to an elderly person

o Mostly defined as 65 years or older
o Consideration of overall health as well as age to determine risk
• difficult to accurately identify the severity of injury and the degree of physiologic
derangement because of age-related differences in biology
• Main traumatic deaths in elderly:
1. Falls (40% of deaths)
2. Traffic collisions
3. Burns

à Traumatic injuries occur less frequent as in younger people, but mortality and complication rate is
significantly higher

• Differences to younger individuals:

o Decline in NS function à loss of proprioception, balance/ unsteady gait, motor
coordination, reaction time
o Osteoarthritis à loss of range of motion

7
 Topic 9 - Low energy trauma. Fractures of proximal femur. Geriatric trauma.

o Osteoporosis à easier to break bones

o Medication side effects à e.g.: warfarin à life threatening hemorrhages

General Challenges in Geriatrics:

• Inactivity
• Neurological
• Osteoporosis
• Gender
• Drink/ Eating habits
• Pre-existing conditions

Evaluation of Elderly Patients: Treatment of Elderly Patients:

Femoral head fractures:

C = intaarticular fractures of the femoral head, may

be associated with hip dislocations, acetabular
fractures, femoral neck fractures

31-C1: Split (Pipkin) —> fragment which has split off

from the femoral head
31-C2 with depression
31-C3 with neck fracture —> worst prognosis
because in most cases the main fragment of the
femoral head looses its vascular supply
8
Topic 10
 Topic 10 - Fractures of Bones around the Knee joint.
The lesions of meniscus and ligaments

Fractures of bones around the knee joint

& lesions of meniscus and ligaments

Knee Joint
• Type of joint: a complex hinge type of synovial joint made up of two components
o The tibiofemoral articulation
§ Between the condyles of the tibia and femur
§ Weight-bearing
o The patellofemoral articulation
§ Between the anterior surface of the femoral condyles and the posterior
surface of the patella
§ Not weight-bearing
o The tibiofibular articulation

• Movements
o Flexion: hamstrings, sartorius, gracilis, popliteus
o Extension: quadriceps femoris
o External rotation of the flexed knee: biceps femoris and sartorius
o Internal rotation of the flexed knee: semimembranosus, semitendinosus, gracilis

• Blood supply:
o anastomosis around the knee joint between branches of the femoral and popliteal
vessels (genicular anastomosis)

• Innervation
o genicular branches of the femoral, obturator, tibial, and common peroneal nerves

Knee Structures

• Cruciate ligament
o ACL
o PCL
• Collateral ligament
o MCL
o LCL
• Other ligaments of the knee:
o Patellar ligament
o Popliteofibular ligament
o Menisci ( semilunar cartilages)
• Lateral Meniscus

1
 Topic 10 - Fractures of Bones around the Knee joint.
The lesions of meniscus and ligaments

ACL injury (Anterior Cruciate Ligament Injury)

à Higher incidence in females

Mechanism of injury

• Low-energy noncontact: sports injuries with a twisting mechanism, e.g., football, soccer,
basketball, baseball, alpine skiing, and gymnastics
• High-velocity contact injuries (less common):
o direct blows to the knee causing forced hyperextension or valgus deformity of the
knee

Clinical features

• Audible pop followed by knee swelling (e.g., hemarthrosis), pain, and instability
• Positive Lachman test (most sensitive test)
• Positive anterior drawer test
• Positive pivot shift test
• Features of other ligamentous or meniscal injuries

• The unhappy triad includes

o tears of the anterior cruciate ligament
o medial collateral ligament
o and the medial meniscus (i.e., tender joint line, poor knee extension)

Diagnosis

• Joint aspiration (in the case of severe joint effusion): hemarthrosis

• MRI (confirmatory test)

Treatment

• Conservative treatment for mild knee instability, less physically demanding occupations, or
premorbid inactivity
o RICE protocol
o Analgesia
o Physical therapy

2
 Topic 10 - Fractures of Bones around the Knee joint.
The lesions of meniscus and ligaments

• Arthroscopic surgery for multi ligament injuries, chronic knee instability, and for highly
competitive athletes
o Allograft from Achilles or patellar tendon
o Postoperative care: knee brace, crutches, physical therapy
o Double-bundle ACL graft using the semitendinosus and/or gracilis tendons
(hamstring muscles)
o ACL graft from the patellar tendon

Complications

• Meniscal degeneration
• Osteoarthritis
• Patella fracture
• Patella tendon rupture
• Reflex sympathetic dystrophy
• Postoperatively: graft failure, graft impingement
• The anterior cruciate ligament is injured more commonly than the posterior cruciate
ligament

PCL injury (Posterior Cruciate Ligament injury)

Mechanism of injury

• Noncontact injury involving hyperflexion of the knee with a plantarflexed foot (seen in
athletes)
• Direct posterior blow to a flexed knee, seen in motor vehicle accidents (dashboard injury) or
athletic contact injury

Clinical features

• Initially vague symptoms: minimal (or absent) posterior knee pain, swelling,
functional range of motion
• Positive posterior drawer test
• Positive posterior sag sign
• Positive quadriceps active test
• Positive posterolateral drawer test

Diagnosis

• X-rays initially: bony avulsions and posterior sag of

the tibia
• MRI (confirmatory test)

Treatment

• Conservative therapy for isolated injuries

• Surgery for multiligament injuries, chronic knee instability, and for highly competitive
athletes

3
 Topic 10 - Fractures of Bones around the Knee joint.
The lesions of meniscus and ligaments

Collateral Ligament Injury ( MCL and LCL)

MCL Injury (Medical Collateral Ligament injury)

à Most commonly injured knee ligament

Mechanism of injury: valgus stress with possible external rotation

Clinical features

• Knee swelling with ecchymosis (e.g., hemarthrosis), pain, deformity, and instability
• Medial joint line tenderness
• Valgus stress test
• Medial joint laxity
• Frequently associated with medial meniscal tear

Diagnosis

• An isolated MCL tear is a clinical diagnosis but x-rays and MRI can be used to rule out
associated injuries

Treatment

o Conservative (functional brace and physical therapy) for isolated MCL tears
o Surgery if multi ligament injury is present

LCL Injury (Lateral Collateral Ligament injury)

• Isolated LCL injury is very rare;
• it is usually associated with a tear of the anterior and/or posterior cruciate ligaments, as well
as the posterolateral corner (PLC)

Mechanism of injury: varus stress with possible external rotation

Clinical features

• Knee swelling with ecchymosis, pain, deformity, and instability

• Lateral joint line tenderness
• Varus stress test
• Lateral joint laxity

4
 Topic 10 - Fractures of Bones around the Knee joint.
The lesions of meniscus and ligaments

Diagnosis

• An isolated LCL tear is a clinical diagnosis, but x-rays and MRI can be used to assess for
associated injuries.

Treatment

• Conservative treatment (including a functional brace) for isolated LCL tears

• Surgery for PLC disruption

Osteoarthritis of the Knee

Etiology

• genu valgum
• genu varum
• cruciate ligament rupture
• meniscal tear

Clinical Features

• Function-limiting knee pain

• Knee swelling which increases on activity
• Mechanical instability, locking, catching sensation
• In case of patello-femoral osteoarthritis: positive Patellar grind
test (pain on movement of the patella

Diagnostics

• Conventional x-ray
o radiological signs of osteoarthritis
o Indirect evidence of knee osteoarthritis through uneven pressure distribution
o Patella lateralization
o Genu valgum, genu varum

Meniscus Tear
Definition

• Two wedge-shaped pieces of cartilage act as "shock absorbers" between your

thighbone and shinbone à are called meniscus.
• They are tough and rubbery to help cushion the joint and keep it stable.
• A meniscal tear can be caused by trauma or degenerative changes in the knee joint.

Etiology

• Young, active patients: traumatic (i.e., axial loading and rotation action with a fixed foot
during physical activity)

5
 Topic 10 - Fractures of Bones around the Knee joint.
The lesions of meniscus and ligaments

• Older patients: degenerative (e.g., continuous work in a squatting position)

Classification à A meniscus tear may be medial or lateral

• Location of the tear

o White zone: inner third, avascular area
o Red-white zone: middle third, poorly vascularized area
o Red zone: outer/peripheral third, vascularized area

• Type of tear
o Longitudinal tear (vertical tear): perpendicular to the tibial plateau
o Radial tear: perpendicular to the tibial plateau and the longer axis of the meniscus
o Horizontal tear: parallel to the tibial plateau
o Displaced tears

§ Bucket handle tear

• displaced and extensive longitudinal tear that splits the meniscus
into two parts that remain connected at the anterior and posterior
ends

§ Parrot beak tear displaced radial tear

• Flap/oblique tear: displaced longitudinal or horizontal tear

o Tears may also be simple or complex.

• Knee pain: exacerbated by weight-bearing or physical activity

• Joint line tenderness (medial or lateral)
• Restricted knee extension with knee instability
o Locked knee may occur if the torn meniscus obstructs knee movement.
o May hear clicking sound or have a popping or locking sensation

6
 Topic 10 - Fractures of Bones around the Knee joint.
The lesions of meniscus and ligaments

• Intermittent joint effusions (see dancing patella sign)

o Tears in the red zone near the base of the meniscus → bloody effusion
(hemarthrosis)
o Tears in the medial, white zone → serous effusion

Signs of meniscus injury

• McMurray Test à pain on palpitation or audible pop with manoeuvres

• Apley grind Test à pain during external/internal rotation.
• Thessaly Test à medial or lateral line pain with rotation
• Steinman Test à Pain during external rotation and internal rotation
• Payr test à Knee pain à posterior horn lesion of the medial meniscus

Diagnostics

• X-ray : to exclude degenerative joint changes

• MRI (imaging modality of choice): identifies the location and extent of meniscal tears
o Hyperintense line in meniscus with distorted meniscal morphology
o Empty groove in the case of bucket handle tears

• Arthroscopy: both diagnostic and therapeutic with a sensitivity and specificity of ∼ 100%
o Diagnostic step of choice if MRI is contraindicated (e.g., patient with metal
prostheses

Treatment

• Conservative treatment
o Indications: pre-existing degenerative changes in the knee joint (especially among
older patients)
o Approach
§ Rest, ice, and elevation of affected limb
§ Analgesia (NSAIDs)
§ Physical therapy (e.g., strengthening the quadriceps)

• Surgical treatment
o Indication: persistent disabling symptoms/effusions, functional limitations, complex
tears
o Procedure
§ Arthroscopy
§ Meniscus transplantation

7
 Topic 10 - Fractures of Bones around the Knee joint.
The lesions of meniscus and ligaments

Examination Methods

• Patella ballottement test- Positive if accumulation of fluid

• Lachman Test
o Patient lies supine
o Leg in 30° flexion
o Slight external rotation
o The injured leg moves 3 (mm) more
than is normal for its range of
motion, compared to the other leg.

• Anterior Drawer Test

o The patient lies on his/her back and flexes the
knee by 90°.
o The foot is fixed in place by the examiner and
the patient is asked to relax.
o The proximal end of the tibia is then pulled
forward.
o A firm endpoint along with the absence of
anterior tibial movement implies that the ACL
is intact.
o This test is the least reliable, because a
hamstring spasm may also present with
a positive anterior drawer test.

• Posterior Drawer Test

o The patient lies on his/her back and flexes the
knee by 90°.
o The foot is fixed in place by the examiner and
the patient is asked to relax.
o The proximal end of the tibia is then pushed
posteriorly.
o A firm endpoint along with the absence of
posterior tibial 3movement implies that
the PCL is intact.

8
Topic 11
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

Intraarticular fracture of the lower extremity bones.

Orthopaedic diseases of the foot.
Intraarticular fracture of the lower extremity bones
• Intraarticular fractures are the fractures where the fracture line crosses into the surface of a
joint resulting in some degree of cartilage damage.
• The fractures can vary from hairline fractures to displaced fractures
• Intraarticular fractures ideally should be reduced anatomically and fixed securely so that
early joint movement can be allowed
• If this cannot be achieved, some permanent loss of motion is to be expected and the joint
may develop degenerative arthritis as a result of the injury
• Other problems: bony prominence, deformity, numbness, weakness, reflex sympathetic
dystrophy and others

Two mechanisms:

1. Indirect Forces
• force that leads to a bending moment is resisted by ligaments and that resistance
converts the eccentric load to direct axial overload Fracture of bone shaft
• usually partial articular fracture
• Loading one side of the joint usually produces a split or shearing fracture
• a pull on the ligamentous insertions on the opposite side results in an avulsion fracture
or torn ligament
2. Direct Forces
• axial loading force, which allows one component to act as a hammer on the other,
producing an impaction of the articular surface
• if more severe, an impaction with a fracture of the metaphysis or even diaphysis
• bone quality, the position of the limb, and the exact vector of the force will determine
the fracture patter

Evaluation of Intraarticular fracture

• complete neurovascular examination

• associated musculoskeletal and non-orthopedic injuries
• multiple bones involved
• examine for compartment syndrome

Diagnostics

• X-Ray (AP, lateral view)

• CT

Treatment

• Restoration of articular surface

• Stable fixation with intra fragmentary compression
• Anatomical reduction to avoid stiffness
• Early motion
• Basic principles, surgical:
o Plaster cast immobilization of intraarticular fractures results in joint stiffness.

1
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

o Plaster cast immobilization of intraarticular fractures combined with open reduction

and internal fixation results in much greater stiffness.
o Depressed articular fragments are impacted and will not be reduced by closed
manipulation and traction.
o Major articular depressions do not fill with fibrocartilage and thus instability, which
results from their displacement, is permanent.
o Anatomical reduction and stable fixation of articular fragments is necessary to
restore joint congruity.
o Metaphyseal defects beneath reduced articular segments must be filled with
structural bone graft or substitute to prevent displacement of the articular fragment.
o Metaphyseal and diaphyseal displacement must be reduced to obtain proper limb
alignment and prevent joint overload.
o Immediate motion is necessary to prevent joint stiffness and to ensure articular
healing and recovery. This requires stable internal fixation

Immediate surgical intervention if: Open fractures

o Irreducible fracture dislocations

o Associated with neurovascular injuries
o Articular fractures associated with compartment syndromes
• Conservative treatment (less common)
o For undisplaced fracture
§ Immobilization with early remobilisation
• Treatment procedures may be delayed due to soft tissue damage external fixation required

Fractures of the Foot

Anatomy Revision

2
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

Ankle Fracture (Malleolar fracture)

• Supination or pronation trauma (“twisted ankle”)

Classification

Symptoms

• Local pain, swelling and hematoma

• Tenderness, especially in the area of the malleoli, the syndesmosis, and the posterior aspect
of the ankle joint
• Restricted range of movement
• Skin abnormalities (lacerations, discolorations, tenting, or blistering)
• In some cases, accompanying injury (e.g., fracture of the proximal fibula, knee, or foot)

Diagnostics

• Physical examination: Check for neurovascular deficits

• 3-view plain x-ray: Anteroposterior (AP), lateral and oblique view
• MRI
• USS

3
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

Treatment

• Initial management: rest, ice, compression, and elevation

• Conservative treatment
o Indications: stable fractures (isolated/nondisplaced malleolar fractures)
o Short leg cast for 4–6 weeks
• Surgical treatment: to ensure normal alignment of bone and cartilage to prevent ankle
arthritis and to regain functionality
o Indications: unstable/displaced fractures, open ankle fractures, and cases of
neurovascular damage
o Technique: reposition and internal or external fixation with metal plates and/or
screws, osteosynthesis

à depends on location and type of fracture

Recovery

• Toe: 4-8 weeks of healing

• Metatarsal: 6-8 weeks, maybe longer
o Follow up X-Rays
o Swollen for several months

Talar fractures
• Uncommon injury
• High energy Trauma à Sports
• Location
o talar head fractures
o talar neck fractures
o talar body fractures
o talar dome osteochondral fracture
o posterior talar process fracture
o lateral talar process fracture
• Fractures occur in all parts of bone
• Minimally displaced fracture / stable fracture
o Conservative treatment
• Displaced fracture
o Surgery required
• Open fracture
o Take longer to heel, high risk of complication
• Symptoms
o Acute pain
o Inability to walk or bear weight on the foot
o Considerable swelling, bruising, and tenderness

Diagnostics

• Physical examination
• X-Rays
• CT

4
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

Treatment

• First Aid à padded splint, elevating leg

• Pain medication NSAID’s
• Conservative à elderly patient, stable fractures
o Cast à 6-8 weeks, limited weight bearing
o Rehabilitation à
• Surgical à displaces unstable fracture
o Internal fixation with screws, reduction
o Cast splint up to 6 weeks after surgery
• Bone grafting
• Physical therapy

Calcaneus fracture
• High energy trauma examine as polytrauma —> ABCDE
• 2% of fractures
• Severity depends on:
o The number of fractures
o The amount and size of the broken bone fragments
o The amount each piece is out of place (displaced) — In some cases, the broken ends
of bones line up almost correctly; in more severe fractures, there may be a large gap
between the broken pieces, or the fragments may overlap each other
o The injury to the cartilage surfaces in the subtalar joint
o The injury to surrounding soft tissues, such as muscle, tendons, and skin

Cause

• Fall from a height

• Twisting injury to the ankle
• Motor vehicle collision

Symptoms

• Pain • Heel deformity

• Bruising • Inability to put weight on the heel or
• Swelling walk

Diagnostics

• Bohler’s angle (20-40°)

• X-ray
• CT scan
• Physical examination à Skin, pulse, feeling, movement, other areas of body

Treatment

• Goal is to restore normal anatomy and function

• Conservative
o Immobilization with splint, brace, cast à 6-8 weeks (no weight on foot)
• Surgical (if displacement)

5
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

o Percutaneous screw fixation

o Open reduction and internal fixation
• Pain management (NSAID’s, local anaesthetics)
• Rehabilitation
o Early movement
o Physical therapy
o Weight bearing

Tibial/fibular Syndesmosis
• A syndesmosis is a fibrous joint between two bones and linked by ligaments and a
strong membrane.

• formed between the distal tibia and fibula and it is attached by the
o interosseous ligament (IOL)
o anterior-inferior tibiofibular ligament (AITFL)
o posterior-inferior tibiofibular ligament (PITFL)
o transverse tibiofibular ligament (TTFL)

• Approximately 5% (range 1-11%) of all ankle injuries involve the distal tibiofibular
syndesmosis, which may lead to chronic instability and pain

Type of injury

• High ankle sprain or syndesmotic ankle sprain (syndesmosis injury)

o AITFL injury is normally combined with a tear of the IOL.
• Tibiofibular Diastasis (separation of tibia and fibula)
• Ankle fracture
• Syndesmotic Impingement (anterolateral soft tissue impingement)
o A fatty synovial fringe (small bundle of adipose tissue) moves during ankle
movement. It rises during dorsiflexion and thus retracts between the tibia and the
fibula and descends during plantar flexion thus lowering towards the ankle joint.
o May cause chronic pain after an ankle sprain

Treatment

• acute stable injuries à conservatively

• unstable injuries à surgically by syndesmotic screw fixation, suture-button dynamic fixation
or direct repair of the anterior inferior tibiofibular ligament

6
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

Toe and Forefoot

Fractures of the toes and forefoot are quite common. Fractures can result from a direct blow to the
foot—such as accidentally kicking something hard or dropping a heavy object on your toes

Symptoms

• pain and swelling

• Bruising or discoloration that extends to nearby parts of the foot
• Pain with walking and weight bearing

Diagnostics

• Physical examination:
o Swelling
o Tenderness over the fracture site
o Bruising or discoloration—your foot may be red or ecchymotic ("black and blue")
o Deformity
o Skin abrasions or open wounds
o Loss of sensation—an indication of nerve injury
• Imaging:
o X-ray
o MRI

Treatment

• First aid
o Apply ice to help reduce swelling.
o Elevate your foot as much as possible.
o Limit weight bearing.
o Lightly wrap your foot in a soft compressive dressing
• Mostly symptomatically
• Pain medication (NSAID’s)
• Taping toe to neighbouring one
• Fracture reduction if misplaced

Metatarsal fracture

Anatomy

• Head—which makes a joint with the base of the toe

• Neck—the narrow area between the head and the shaft
• Shaft—the long part of the bone
• Base—which makes a joint with the midfoot

Etiology

• Twisting injury
• Blow to forefoot
• Stress fractures from repetitive activity à runner/ athlete

7
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

Treatment

• Elevation
• Limited weight bearing
• Cast/walking boot
• Unstable fracture à surgery à internal fixation
• 1st and 5th surgical, others conservative

5th Metatarsal fracture

• Most commonly affected at base of bone

• Mostly avulsion fracture
• Jonas fracture à horizontal or transverse fracture od base or shaft à difficult healing due to
poor blood supply

Treatment

• Walking boot and weight bearing

• Displaced fracture à reduction and internal fixation
• Non-union after spontaneous healing à surgery

Plantar metatarsalgia/ Morton’s neuroma

• painful foot condition in the metatarsal region

• a common inflammatory condition occuring most frequently in the second, third and/or
fourth metatarsophalangeal joints, or isolated in the first metatarsophalangeal joints
• often accompanied by excessive callus formation over a bony protrusion, with severe pain
and pressure sensitivity around the callus
• benign neuroma of intermetatarsal plantar nerve
• tenderness between heads

Diagnostics

• MRI
• X-ray

Treatment

• Conservative
• Surgery à excision

Etiology

• deformity à overload

8
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

Distal femur fracture

Etiology

• High energy injuries à fall from heights, motorcycle injuries

• Elderly pat. à low energy trauma

Symptoms

• Pain
• Swelling
• Hematosis
• deformity

Diagnosis

• Aspiration à fat droplets from bone marrow

• X-ray
• CT
• CT angiography à A. poplitea damage
• Physical examination

Treatment

• Conservative
o Skeletal traction
o Cast/ brace
• Surgical
o Ext. fix. à 10-15% traction
o Int. fix. à plates and screws, intramedullary nail
o Knee replacement
o Weight bearing à none/ minimal for 6 weeks à increase after
• Pain management
• Early mobilization
• Weightbearing à after 3 months
• Physical therapy/ Physiotherapy

9
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

Patellar type fractures

Same symptoms as distal femur fracture

Treatment

• Conservative à cylinder cast, weight possible

• Surgical à screws, tension bands
• After 1 week sutures out
• For 6 weeks minimal weight bearing
• X-Ray
• CT scan

Proximal Tibial fracture

• Different types of fractures

o Transverse fracture
o Comminuted fracture
• Stress fractures
• Trauma

Symptoms

• Pain that is worse when weight is placed on the

affected leg
• Swelling around the knee and limited bending of
the joint
• Deformity — The knee may look "out of place"
• Pale, cool foot — A pale appearance or cool
feeling to the foot may suggest that the blood
supply is in some way impaired.
• Numbness around the foot — Numbness, or "pins and needles," around the foot raises
concern about nerve injury or excessive swelling within the leg

Diagnostics

• Physical Examination • CT
• X-ray • MRI

Treatment

• Conservative
o Cast/ brace o Low weight bearing
o Less movement

• Surgical
o Internal fixation
§ Angular staple plates
§ Plates and screws
o External fixation if needed

10
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

• Pain management
• Weight bearing
• Early mobilization

Pilon fracture

• fracture of the distal tibia that involves the tibial part of the talocrural joint and is frequently
associated with fibular fractures
• High energy trauma: Fall from height, motor cycle accidents etc. à femur impact onto tibia
• The severity depends on:
o The number of fractures
o The amount and size of the broken bone fragments
o The amount each piece is out of place (displaced)—In some cases, the broken ends
of bones line up almost correctly; in more severe fractures, there may be a large gap
between the broken pieces, or the fragments may overlap each other.
o The injury to the surrounding soft tissues, such as muscle, tendons, and skin

Symptoms

• Same symptoms as prox. Tibial fracture

o Swelling o Inability to bear weight on the
o Bruising injured leg
o Tenderness o Deformity—your ankle may
look angled or crooked

Diagnostics

• X-ray
• CT
• Physical Examination
o Lower leg and ankle
o Toe feeling and movement
o Pulse

Treatment

• Conservative
o Splints/ casts
o Monitoring à follow up X-ray
• Surgical treatment (unstable fractures)
o Reduction and internal fixation with screws and plates
o External fixation in case internal fixation is not yet indicated
• Pain Management
• Low weight bearing
• Physical therapy

Complications

• Posttraumatic Arthritis • Infection

• Stiffness • Bone healing problems

11
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

Plantar fasciitis

• Pain in heel

Risk factors

• Tighter calf muscles that make it difficult to flex your foot and bring your toes up toward your
shin
• Obesity
• Very high arch
• Repetitive impact activity (running/sports)
• New or increased activity

Symptoms

• Pain on the bottom of the foot near the heel

• Pain with the first few steps after getting out of bed in the morning, or after a long period of
rest, such as after a long car ride. The pain subsides after a few minutes of walking
• Greater pain after (not during) exercise or activity

Diagnostics

• Physical examination
o A high arch
o An area of maximum tenderness on the bottom of your foot, just in front of your
heel bone
o Pain that gets worse when you flex your foot and the doctor pushes on the plantar
fascia. The pain improves when you point your toes down
o Limited "up" motion of your ankle
• X-ray
• MRI/ US (not routinely)

Treatment

• Conservative (90%)
o Physiotherapy o Rest
o Othotics o Ice
o Casts o Exercise e.g. calf stretch,
o Night splints plantar fascia stretch
o NSAID’S o Extracorporal shockwave
o Steroid injections/ cortisone therapy

• Surgical (only after 1 year of unsuccessful aggressive treatment)

o Gastrocnemius recession à lengthening of calf muscle
o Plantar fascia release

12
 Topic 11 - Intraarticular fracture of the lower extremity bones. Orthopaedic diseases of the foot.

Hallux valgus deformity/ Bunions

• Lateral deviation of toe at MTP joint

• Most commonly in women
• Develop slowly
• Often inflammation in joint
• Worsens over time
• Painful while walking

Etiology

• Poorly fitted shoes

• High-heels
• Heredity
• Inflammatory conditions (RA)

Symptoms

• Pain and tenderness

• Redness and inflammation
• Hardened skin on the bottom of the foot
• A callus or corn on the bump
• Stiffness and restricted motion in the big toe, which may lead to difficulty in walking

Diagnostics

• Physical examination
• X-Ray

Treatment

• Conservative treatment mostly

o padding, wide shoes, spacers btw. toes, orthotics insoles
o icing
o NSAID’s
• Surgery à if pain persists over long time period and conservative treatment does not work

Claw toes

• MTP hyperextension à bent toes à toes are bent downward (flexion) at the middle joints
toward the sole of your shoe
• Rule out neurological problems/disorders

Treatment

• Toe spacer, splint, taping, pads to distribute weight

• Surgery
• Soft shoes, no high-heels
• Stretching toes towards normal position
• Exercise toes

13
Topic 12
 Topic 12 – Osteoarthritis

Osteoarthritis
In General

Definition

• Slowly progressive chronic disease

• Risk factors: obsity, lack of excersise, higher bone mass, muscle strength, gender à more
affected: females: after menopause, because Chondrocytes are not stimulated by estrogen
anymore
• common form of Arthritis – non-inflammatiory
• Cartilage (and bone) degeneration in joints
• Pain during exercise, which may become chronic
• Swelling of joints, reduced range of motion
• Most commonly involved joints: knee and DIP, then hip, neck, lower back
• Symptom management, but underlying causes cannot be reversed
• Primary (unknown cause) and secondary (known cause) Osteoarthritis

Epidemiology

• 43.4 mio. people globally à moderate to severe disability

• 250 mio. people à knee Osteoarthritis
• 52.2 mio. people in USA affected

Pathogenesis

• Primary: „wear and tear”, very common

• Loss of cartilage and damage to bone (when sitting on one another)
o Bone sclerosis where cartilage used to be
o Pain due to nerves in bones
• Ligaments of joint thicken, become fibrotic
• Damaged menisci
• Osteophytes develope (bone outgrowth) à natural ankylosis of joint
• Biochemical changes in cartilage à collagen matrix becomes disorganized
à Decrease in proteoglycan (decrease in osmotic pull)
à Increased water content due to broken down cartilage
à Inflammation of synovium and joint capsule due to removal attempt of cartilage
breakdown products

Clinical Picture

• Deep, achy Pain in joints during or after movement à worsens during prolonged activity,
relieved during rest
• Tenderness of joint
• DIP joints are the most often affected
• Hands’ joints, great toes, spine, knees and hips are often involved
• Minimal morning stiffness (less than 30 minutes) or stiffness after inactivity
• Loss of flexibility, reduced range of motion à Pain
• „crepitus“ when joint is moved

1
 Topic 12 – Osteoarthritis

• Joint locking, instability

• Osteophytes
• PIP joints and CMC joints at the base of the thumb are also typically involved
• Heberden nodes (palpable osteophytes in DIP joints) are more characteristic in women
• Inflammatory changes are typically absent, less pronounced or go unnoticed

Classification criteria

Used scores:

• WOMAC scale à pain, stiffness and functional limitation

o The WOMAC measures
§ 5 items for pain (score range 0–20)
§ 2 for stiffness (score range 0–8)
§ 17 for functional limitation (score range 0–68).
§ Physical functioning questions cover everyday activities

• Kellgren-Lawrence grading scale à osteoarthritis of the knee (uses only projectional

radiography features)

• Tönnis classification à osteoarthritis of the hip joint (using only projectional radiography
features)

àHip joint:
Grade Kellgren-Lawrence Classification Tönnis Classification

0 No radiographic features of OA No OA signs

1 Possible joint space narrowing & osteophyte formation

Mild: Osteosclerosis, minor joint space narrowing

2 Def. Osteophyte formation & possible joint space narrowing Moderate: small bony cyst, moderate joint narrowing/loss
of head sphericity

3 Multiple osteophytes, def. Joint space narrowing, sclerosis, possible bony Severe: large bony cyst, moderate joint space
deform. narrowing/loss of head sphericity

4 Large osteophytes, joint space narrowing, severe sclerosis, bone deform. --

2
 Topic 12 – Osteoarthritis

• Knee injury and Osteoarthritis Outcome Score (KOOS) and Hip disability and Osteoarthritis
Outcome Score (HOOS)
• Can be classified by affected joints:
o Hand: Trapeziometacarpal OA
o Wrist: Wrist OA
o Vertebral column: Spondylosis, Facet joint Arthrosis
o Hip: Hip OA
o Knee: Knee OA

Osteoarthritis of the Hand (1990)

1) Classification using history and physical examination
Hard tissue enlargment of 2 or more of the following joints – 2nd
and 3rd DIP, 2nd and 3rd PIP and 1st carpometacarpal joints of
both hands*
Pain, aching + 3 of the
or stiffness following Hard tissue enlargment of 2 or more DIP joints
Less than 3 swollen MCP joints

Deformity of at least one of the joints listed above*

OA of the Hip (1991)

1) Using history, physical examination and laboratory findings
Internal hip rotation >15⁰

Pain associated with internal hip

and
Morning stiffness of hip <60 min
Pain in the
Over 50 years of age
hip
or

Internal hip rotation <15⁰

and
ESR <45 mm/hour or hip flexion <115⁰ if ESR unavailable

2) Using history, physical examination, laboratory and radiographic findings

ESR < 20mm/hour

Pain in hip + 2 of the following Radiographic femoral and/or acetabular osteophytes

Radiographic joint space narrowing

3
 Topic 12 – Osteoarthritis

OA of the Knee (1986)

1) Using history and physical examination
Over 50 years of age

Less than 30min of morning stiffness

Crepitus on active motion

Pain in knee + 3 of the following
Bony tenderness

Bony enlargment

No palpable warmth of synovium

Treatment

• to reduce pain, maintain or improve joint mobility, limit functional disability and improve
self-management.
• No immunosuppressive medication (no inflammation)
• The 4 pillars of treatment are:
1. patient education
2. rehabilition
3. medication (non-pharmacological and pharmacological approaches)
4. referrals (surgery and non-surgical)

Conservative Treatment

• Pain medication àstart with less agressive treatment

o COX-2 selective inhibitors
o PCM (1.line)
o NSAIDs (2.line) + PPI
o Tramadol (3.line)
o Acetamoniphen
o Topical capsaicin (Hand OA)
o Opioids

• Intraarticular injections
o Glucocorticoid joint injection (last few weeks-months, short term treatment)
§ Second line therapy, when active joint inflammation is present or 1st line is
not enough
§ Decreases acute episodes of pain
§ Has rare side effects
• Increase risk of infection
§ No more than 3 injections a year
o Hyaluronic acid joint injection (may just be placebo)
o Platelet rich plasma

4
 Topic 12 – Osteoarthritis

• Oral glucocorticoids – can help relieve pain but should not be given chronically. Also a strong
placebo effect has been noticed in trials

• Glucosamine
o Relieve pain and improve joint mobility
o glucosamine may lubricate joints, help cartilage retain water and prevent its
breakdown
o side effects: cause mild stomach upset, nausea, heartburn, diarrhea and
constipation, as well as increased blood glucose, cholesterol, triglyceride and blood
pressure.

• Muscle relaxants
• Acupuncture
• Mesenchymal stem cell therapy continues to be a promising investigational approach to knee
arthritis

• Pain management additional therapy:

o Exercise:
§ combination of exercises to strengthen your muscles and exercises to
improve your general fitness
§ builds up muscle and strengthens the joints
§ stretching techniques to keep joints flexible

o Weight loss:
§ can take some of the increased strain in your joints off
§ e.g.: swimming, cycling

o Physiotherapy/ Occupational therapy:

§ Learning to use joints properly
§ Assistive devices
§ Manual therapy (stretching of joints)

o Cryotherapy (Heat/cold therapy):

§ Pain reduction

o Transcutaneous electrical nerve stimulation (TENS):

§ Electrical impulses sent through electrodes to skin
§ Numbing nerve endings in your spinal cord to control pain

o US/ Magnetic therapy

o Nutritional supplements (may not help):
§ Chondroitin and glucosamine
§ Acupuncture: lack of medical evidence, but some find it helpful

5
 Topic 12 – Osteoarthritis

Surgery
• Joint replacement
o Cemented
o Uncemented
o Hybrid type
o Resurfacing
o Short stem
o Hemiarthroplasty
• Osteotomy
• Arthroscopic debridement
• Joint denervation
• Arthrodesis

Side Effects of Medication

• Gastrointestinal bleeding (NSAID)

• Gastric ulcers
• Liver and Kidney damage (NSAID)
• Cardiovascular disease (COX-2 inhib.) à BP, edema
• Chondrodegeneration

Radiology and Laboratory Tests: (Tests done for differential diagnoses)

• X-ray
o Direct
§ Irregular Joint space narrowing
§ Subchondral sclerosis
§ Osteophytes
§ Subchondral cysts
o Indirect evidence of knee osteoarthritis through uneven pressure distribution
§ Patella lateralization
§ Genu valgum (x-shape), genu varum (o-shape)

• US (diff. Diagnosis) à ability to detect synovial pathology, very informative for finger OA
o Ultrasound imaging enables real time, multiplanar imaging at relatively low cost
o For inflammatory arthritis: Doppler US shows vasodilation of BV
o Shows
§ Inflammatory and structural abnormalities
o useful for evaluation of cortical erosive changes and synovitis in inflammatory
arthritis

• MRI (rarely used à expensive)

o Visualizing
§ Articular cartilage
§ Menisci
§ Ligaments
6
 Topic 12 – Osteoarthritis

§ Synovium
§ Capsular structures
§ Fluid collections
§ Bone marrow
§ Osteophytes and subchondral cysts

o MRI isn't commonly needed to diagnose osteoarthritis but may help provide more
information in complex cases
o MRI has become a key-imaging tool for OA research
o with MRI à OA can be classified into
§ Hypertrophic & Atrophic phenotypes, according to the size of osteophytes

• CT à for better visualisation for bony structures

o has an established role in assessing facet joint OA of the spine
o Shows
§ Osteophytes
§ Cortical bone
§ Soft tissue calcifications

• Bone scintigraphy à to rule out infections

o contrast media accumulates in places with high active metabolism (infections, RA,
oncology)
o enables imaging of
§ Active metabolism
§ Visualization of bone turnover changes seen with
• Osteophyte formation
• Subchondral sclerosis
• Subchondral cyst formation
• Bone marrow lesions
• Sites of synovitis

o Scintigraphy with 99mTc-hydroxymethane diphosphonate

o can provide a full-body survey that helps to discriminate between soft tissues and bone
origin of pain
o Nuclear medicine imaging is not commonly applied to imaging of OA in a routine clinical
setting

Blood tests à ruling out other causes for pain, like RA, not very helpful

1. Rheumatoid factor (RF) and Cyclic citrullinated peptide antibody (CCP)

§ to help diagnose rheumatoid arthritis (RA) and differentiate it from osteoarthritis;
both tests are positive with RA and generally negative in OA.

2. Synovial fluid analysis

7
 Topic 12 – Osteoarthritis

§ to look for signs of joint infection and to detect monosodium urate (uric acid) crystals
that could indicate gout or calcium pyrophosphate crystals that may contribute to
joint damage in osteoarthritis

3. Erythrocyte sedimentation rate (ESR)

§ to detect inflammation in the body; ESR will be increased in RA but not in
osteoarthritis.

4. C-reactive protein (CRP)

§ to detect inflammation and test for the activity of the disease;
§ may be used to help differentiate osteoarthritis and RA;
§ an increased level of CRP occurs in RA but not in osteoarthritis
§ Could be a little increased in OA as well

5. Complete blood count (CBC)

§ to help evaluate red and white blood cells and hemoglobin; may be ordered to
monitor the side effects of some OA treatments

6. Comprehensive metabolic panel (CMP)

§ to help evaluate and monitor kidney and liver function
7. Blood test for Coagulopathies

• Blood sugar levels à Diabetes Mellitus

• Joint fluid analysis à inflammation or gout

Risk factors

• Increased Weight
• Osteoporosis
• Connective tissue disorders
• Genetics
• Hard physical weight
• Smoking

8
 Topic 12 – Osteoarthritis

Hip Joint Osteoarthritis

Primary or idiopathic (wear or tear)

• Affects middle aged and older patients

• Mostly overweight patients
• Pain initially starts from inguinal, lateral or posterior hip joint regions, radiates to the knee
• Difficulty getting around, putting on footwear (leg length reduction, contracture)
• Sleeping disorders due the pain

Secondary

• Evolves as a consequence after hip joint pathologic processes (external)

o LCC, DCC
o Coxa vara
o Perthes disease
o Juvenile epiphysiolysis
o TBC, coxitis
o Femur head aseptic necrosis
o After femural neck, head and acetabular fractures
o Tumors
o Infections
o Septic arthritis

Essential Aspects in Patient care

• Preoperative period

o Clinical examination
§ Primary or idiopathic
§ Affects middle aged and older patients
§ Mostly overweight patients
§ Pain initially starts from inguinal, lateral or posterior hip joint regions, radiates to
the knee
§ Difficulty getting around, putting on footwear (leg length reduction, contracture)
§ Sleeping disorders due the pain

o Preoperative preparation
§ Primary or idiopathic
§ Affects middle aged and older patients
§ Mostly overweight patients
§ Pain initially starts from inguinal, lateral or posterior hip joint regions, radiates to
the knee
§ Difficulty getting around, putting on footwear (leg length reduction, contracture)
§ Sleeping disorders due the pain

• Postoperative Period
9
 Topic 12 – Osteoarthritis

o Primary or idiopathic
o Affects middle aged and older patients
o Mostly overweight patients
o Pain initially starts from inguinal, lateral or posterior hip joint regions, radiates to the
knee
o Difficulty getting around, putting on footwear (leg length reduction, contracture)
o Sleeping disorders due the pain

Complications

Vancouver Classification

10
 Topic 12 – Osteoarthritis

Arthroplasty

Total hip replacement

• Description: total hip joint replacement with replacement of the

femoral head and the acetabulum with a prosthesis
• Indications
o Primary arthritis with total joint destruction and exhausted
conservative measures
o Femoral neck fracture with concomitant hip osteoarthritis
1. Cemented (acetabulum and femur prosthesis cemented into bone)
2. Non-cemented (press-fit-method)

Components of hip implants:

Hip hemiarthroplasty

• Description: only femoral prosthesis is implanted, with

preservation of the native acetabulum
• Indications
o Femoral neck fractures in older patients without
concomitant hip osteoarthritis
o Primary arthritis with complete joint destruction in older
patients

Postoperative deep venous thrombosis prophylaxis is needed for hip

replacement and any surgery to correct a fracture close to the hip joint.

o Perioperative start
o For 28– 35 days postoperatively

11
 Topic 12 – Osteoarthritis

Knee Osteoarthritis

Risk factors

• Excessive weight
• Degenerative changes in knee joint
• Hard work, athletes
• Post traumatic and post knee joint illness
• Osteoporosis
• Connective Tissue disorders

Treatment

• Conservative
• Surgical à knee replacement (full, partial)

Post-Op Complications

• Cardiopulmonary complications
• Venous complications (vein thrombosis, TE)
• Fat embolism
• Allergic reactions
• Bleeding
• Mechanical complications
• Infection

Classification

12
 Topic 12 – Osteoarthritis

Knee joint replacement

1. Nonconstrained prosthesis

• Unicondylar knee replacement

o Description
§ unicompartmental prosthesis of the femoral and tibial articular surface
§ insertion of a plastic sliding surface (mainly polyethylene) between both
prosthetic components

o Indication
§ unilateral osteoarthritis of the inner and outer surface of the joint
§ more frequently internal in varus gonarthrosis

• Bicondylar knee replacement (total knee replacement)

o Description
§ Both condyles of the femur and the joint surface of the articular surface
of the tibial head are replaced.
§ Insertion of a plastic sliding surface (mainly polyethylene) between both
prosthetic components
§ If necessary, additional replacement of the posterior surface of the
patella (tricondylar knee replacement)

o Indication
§ knee osteoarthritis, which is nonresponsive to conservative treatment
and severely restricts the patient's quality of life

13
 Topic 12 – Osteoarthritis

• Patellofemoral joint replacement

o Description
§ prosthetic replacement of the femoral trochlear (= patella condyle) and
the rear surface of the patella
o Indication
§ mainly isolated degenerative alterations of the femoropatellar joint

2. Constrained prosthesis: rotating hinge knee prosthesis

o Indication
§ severe knee osteoarthritis with ligament insufficiency and femorotibial
rotational malalignment
o Description
§ analogous to the bicondylar knee prosthesis
§ but: femoral and tibial components are larger shaft prostheses that are
more deeply anchored and are connected via a movable axis

3. Postoperative deep venous thrombosis prophylaxis

• is to be administered for knee replacement and any surgery to correct a fracture located
close to the knee joint
o Perioperative start
o For 11–14 days postoperatively

14
Topic 13
 Topic 13 – Osteomyelitis and purulent Arthritis

Osteomyelitis

Osteomyelitis
• Osteon - bone
• Mielo - marrow
• In literal translation bone marrow inflammation
• Infectious inflammation process that affects all layers of the bone
o Bone marrow
o Cortical layer of the bone
o Periosteum

Aetiology
• Staphylococcus aureus 60%
• Other microflora 30%
• Combined microflora 10%
o Streptococcus haemolyticus
o Enterobacter
o Pseudomonas aeruginosa,
o Haemophilus influenzae,
o Salmonella,fungal infection etc.

Aetiopathopathogenic Classification

1. Acute Osteomyelitis
• Haemtogenous Osteomyelitis
• Post Traumatic Osteomyelitis

2. Chronic Osteomyelitis
• Secondary chronic osteomyelitis
• Primary chronic osteomyelitis
o Brody’s abscess
o Ollier’s albuminous osteomyelitis
o Garre’s sclerosing osteomyelitis

Cierney Classification of Osteomyelitis (Anatomical Staging)

1. Medullary Osteomyelitis
2. Superficial Osteomyelitis
3. Localized Osteomyelitis
4. Diffuse Osteomyelitis

Pathogenesis
• Usually affects long bones, less frequent flat bones
• Usually affects young people, haematogenous osteomyelitis – more often in children
• Usually affects metaphysis of the bone
• Microbes reach the bone in exogenous or endogenous way

1
 Topic 13 – Osteomyelitis and purulent Arthritis

• Coefficient factors:
o Lowered body’s immune resistance
o Trauma

Bone blood supply

Osteomyelitis: Stages

2
 Topic 13 – Osteomyelitis and purulent Arthritis

1. Acute Haematogenous Osteomyelitis

Clinical outlook
• Pain
• High temperature
• Fever
• Weakness
• Intoxication (headache, nausea, vomiting)
• Dry, coated tongue, tachycardia
• Local swelling
• Locally skin cyanotical reddish
• Fluctuation
• Fistula
• Leukocytosis, left shift

2. Acute Post-traumatic Osteomyelitis

• Develops after open fractures with soft tissue damage or after surgical manipulations
• Exogenous infection

Acute Traumatic Osteomyelitis

Clinical outlook
• Usually developes slowly
• Infected hematoma
• Soft tissue defects, secondary wound healing
• Granulation tissue in the wound, swelling, reddish, fistulas
• Subfebrile temperature, raises in dynamics
• Small leukocytosis, raises in dynamics
• Slow fracture coalescence

3
 Topic 13 – Osteomyelitis and purulent Arthritis

Osteomyelitis Diagnostics

Clinical Display: Tumor, Dolor, Color, Functio laesa

• CRP ↑
• Blood bacterial culture
• Bone punctate- microflora
• Antibiotic sensitivity

• Blood analysis- lekocytosis, ESR↑

Acute Osteomyelitis

X – Ray outlook
• Appears after 14-16 days
• Periostal reaction (layering)
• Cortical layer delamination
• Bone usuration
• Infectious osteoporisis scene
• Endostal sclerosis
• Sekvestration

+ Sceletal Scintigraphy

Differential Diagnosis
• Acute lymphangioitis
• Acute phlebitis
• Deep phlegmone
• Several other infectious diseases

4
 Topic 13 – Osteomyelitis and purulent Arthritis

Prophylaxis of osteomyelitis
• Open fractures – primary wound surgical management with debridement and rinsing and
fracture immobilisation- method of choice Ex Fix
• Closed fractures - fixed with osteosynthesis – sterility, perioperative antibiotic prophylaxis
• Risk factors
o Diabetes
o Immunodeficency
o Osteoporosis
o Prolonged hormonal therapy

5
 Topic 13 – Osteomyelitis and purulent Arthritis

Treatment of Osteomyelitis

Conservative
• Bed rest and immobilization of the affected extremity
• Antibiotic treatment

6
 Topic 13 – Osteomyelitis and purulent Arthritis

!!! Treatment of osteomyelitis should not be delayed, especially in children! Osteomyelitis can have
detrimental effects on bone development, resulting in severe long-term complications !!!

Surgical

Indication
• Osteomyelitis refractory to antibiotic treatment → debridement of necrotic bone and tissue
• Abscess → drainage
• Post-traumatic osteomyelitis → debridement and fracture management (e.g., external
fixator)
• Infected prosthetic joint or foreign body → removal
• Revascularization in case of poor wound healing due to Peripheral artery disease

Haematogenous osteomyelitis:
1. bone Trepanation + drainage + rinsing
2. Antibacterial therapy (extended!)
3. Immobilisation

7
 Topic 13 – Osteomyelitis and purulent Arthritis

Cierny-Mader Biological Classification of Adult Osteomyelitis

1st Type
• medullary OM
• haematologically infected fractures and pseudarthroses

2nd Type
• superficial OM
• developes on the bone surface that has not been closed adequatelly with soft tissue

3rd Type
• local infection- sequestrum, cavity formation- stable bone

4th Type
• diffuse OM- circular bone laesion- unstable bone

1st Type: drainage, curettage + antibiotics

2nd Type: drainage, curettage + antibiotics. Proper wound closage- rotated skin flaps
3rd Type: drainage, curettage, elimination of sequestrum, proper wound closage, + antibiotics
4th Type: drainage, curettage, bone transplantation, bone stabilisation + antibiotics

8
 Topic 13 – Osteomyelitis and purulent Arthritis

Vertebrae osteomyelitis = Spondilytis

• Intervertebral disk and vertebrae inflammation

• Causes - 40 % TBC, 60% mixed microflora
• Getting infected- haematologically or after jatrogenic interference- blockade, anaestehsia,
operation

Spondylitis
• Pain when standing up vertically • High temperature
o Chief complaint: back/neck pain • Highly limited movements
o Not relieved with rest • Kyphosis
o Worse with activity and at • ESR elevated (> 25)
nights • Rtg - ,,kissing vertebrae“

9
 Topic 13 – Osteomyelitis and purulent Arthritis

Diagnostics
• Assess patient for clinical features and history suggestive of vertebral osteomyelitis
• Initial work-up:
• Blood cultures
• Inflammatory markers
• X-ray imaging (anterior-posterior and lateral views)
• Often inconclusive in the first 2 weeks of infection
• Initial narrowing of intervertebral spaces and end plate sclerosis
• Progressive kyphosis, vertebral body squaring, and development of block
vertebra

• Contrast-enhanced MRI: the most sensitive diagnostic study for vertebral osteomyelitis
• Findings
• Disruption of vertebral structure, fusion of vertebral bodies and discs
• Contrast enhancement

• Gallium bone scan if MRI is contraindicated (metal foreign body implants) → detects sites of
infection

• CT-guided needle aspiration biopsy (confirmatory test): culture and histology

• Indicated if clinical and radiographic tests support the diagnosis but blood
cultures are negative
• Enables appropriate antibiotic selection based on the culture results.
• Not recommended in patients with neurologic compromise or sepsis.

Treatment
1. Stationary
2. Surgical – liquidate inflammation process- drainage, curretage + bone plastics
3. Antibacterial
4. Long-lasting

10
 Topic 13 – Osteomyelitis and purulent Arthritis

• Bed rest and immobilization of the affected vertebral segment; spinal orthosis required in
severe cases
• Antibiotic treatment (IV administration, for weeks or months)
• Immediate empiric therapy if the patient presents with signs of neurologic
compromise and/or sepsis
• Pathogen-directed therapy once blood culture results are available (see “Treatment”
below)
• Tuberculosis treatment: if mycobacterium tuberculosis is the underlying pathogen
• CT-guided catheter drainage of paravertebral abscess
• Surgery
• Indications: spinal instability, neurological deficits, cord compression, large epidural
or paravertebral abscess, refractory osteomyelitis
• Debridement; stabilization of collapsed vertebrae/spinal instabilities with or without
interbody fusion

Complications of osteomyelitis

• Systemic
o Sepsis à Amputation
o Septic arthritis
o Amyloidosis
o Ankylosis
o Thromboembolism

• Infectious
o Abscess
o Sequestrum (à a piece of dead bone that has become separated during the process of
necrosis from normal bone)
o Pyarthrosis: infiltration of nearby joints

• Mechanical
o Progressive destruction
o Pathological fractures and complications → pseudarthrosis, abnormal bone healing

• Course: recurring/chronic cases

• In children: growth impairment
11
 Topic 13 – Osteomyelitis and purulent Arthritis

Secondary Chronic Osteomyelitis

à As a consequence of a non-treated acute osteomyelitis.

X-Ray outlook
• Bone cavities
• Sequestrum
• Periostal reaction
• Sclerotic changes of the cortical layer of the bone

Primary Chronic Osteomyelitis

• Brody’s abscess (Abscessus Brodie)
o In bone metaphysis
o Cavity filled with pus, surrounded with capsule
o Minimal complains
o Surgical treatment

• Osteomyelitis albuminosa Ollier

o In cortical layer of the bone
o Cream consistency exudate delaminates periosteum
o Complains about pain, subfebrile temperature, swelling
o Surgical treatment

• Sclerotizing osteomyelitis (Osteomyelitis scleroticans Garre)

o Bone sclerosis and periosteal layering
o No sequestrum made

12
 Topic 13 – Osteomyelitis and purulent Arthritis

Septic Arthritis

• Acute inflammatory process

• Usually caused by bacterial infection
• Causes cartilage destruction
• Older children and adults usually affected in knee joint
• Newborns- hip joint

Incident
• Knee joint
• Hip joint
• Tarsal joints
• Elbow
• Shoulder joint
• Palm joints
• Other joints (till 10%)

Aetiology
• Penetrating wounds
• Haematogenous
• From metaphyseal or diaphyseal infections
• Jatrogenic (i/art injections)
• Implants

Risk factors
• RA
• Diabetes mellitus
• I/V drugs use
• HIV
• Glucocorticoid usage

13
 Topic 13 – Osteomyelitis and purulent Arthritis

Pathohistology
• Inflammatory reactions
• Neutrophils migrate outside of the blood vessels (extravasation) into the joint cavity
• Release of proteolytic enzymes that damage joint cartilage
• Swelling increases and synovial blood circulation lowers
• Synovium bursts and forms abscesses

Clinical outlook
• Systemic inflammatory manifestations
• Pain in the affected joint
• Movement limitations and pain
• Swelling, redness and increased temperature in the joint

Examinations
• Joint punction (50,000-60,000/mL , 80% - NEU, ↓ glucose)
• Bacterial culture, antibiotic sensitivity
• Inflammatory mediators (CRP, Ley, ESR)
• Rtg
• CT

Treatment

14
 Topic 13 – Osteomyelitis and purulent Arthritis

First of all: à Following arthrocentesis and culture, simultaneous empiric antibiotic therapy (based
on the Gram stain) and evacuation of purulent material should be performed.

Antibacterial therapy
• In the beginning empirically using the most likely one
• After receiving microbiological test results - make corrections if needed
• Length - approximately 6 weeks

Surgical treatment
• Joint lavage and drainage, Arthroscopy
• Urgent operation
• 1-5 times
• 6-9 liters 0,9% Sol.NaCl
• Every 2nd-3rd day
• Drainage?
• Early movements

Purulent Arthritis

Etiology
• Mechanism of infection
• Hematogenous spread (most common)
• From a distant site (e.g., abscesses, wound infection, septicemia)
• Disseminated infection (e.g., gonorrhea)
• Direct contamination
• Iatrogenic (e.g., joint injection, arthrocentesis, arthroscopy)
• Trauma (e.g., open wounds around the joint, penetrating trauma)

• Risk factors
• Prosthetic implant • Immunosuppressed state
• Interventions (e.g., intra- • Diabetes mellitus
articular injections) • Age > 80 years
• Underlying joint disease, • Chronic skin infections
especially rheumatoid • IV drug
arthritis

15
 Topic 13 – Osteomyelitis and purulent Arthritis

Causative organisms
• Staphylococcus aureus - most common, in adults and children > 2 years and arthritis
caused by invasive procedures
• Streptococci
• S. epidermidis
• H. influenzae
• N. gonorrhea
• Gram-negative rods esp. E. coli and P. aeruginosa
• M. tuberculosis and atypical mycobacteria
• B. burgdorferi (Lyme disease)

Clinical features
• Acute onset
• Joint involvement
• Usually monoarticular
• Most commonly affected joints: knees; followed by hip, wrists, shoulders, and ankles
• Classical triad of fever, joint pain, and restricted range of motion
• Joint may be swollen, red, and warm

Subtypes and variants

Prosthetic joint infection

• Etiology
• Early onset (< 3 months of placement) : most commonly S. aureus
• Delayed onset (3–24 months of placement) : coagulase-
negative staphylococci, particularly S. epidermidis
• Late onset (> 24 months of placement) : most commonly S. aureus

• Clinical findings
• Usually prolonged, low-grade course
• Minimal swelling, with or without a sinus that drains pus
• Can present acutely

• Diagnostic findings
• Conventional x-ray: loosening of the prosthesis, periosteal reactions
• For other diagnostic tests see “Diagnostics” below

• Therapy
• Removal of the prosthesis (usually) and administer IV antibiotics for 6–8 weeks
• Reimplantation of the prosthesis following antibiotic treatment

In order to avoid infection, strict sterile techniques should be ensured in any procedure that involves
penetration of the joint space

16
 Topic 13 – Osteomyelitis and purulent Arthritis

Bacterial coxitis (septic arthritis of the hip)

• Uncommon condition that requires urgent treatment to avoid destruction of the joint
• Etiology: S. aureus and group A streptococcus account for the majority of cases
• Clinical findings
• Joint pain (may be referred to the groin or knee); patients present with flexion and
external rotation of the hip → alleviates pain by decreasing intraarticular pressure
• See also “Clinical features” above
• For diagnostics and therapy, see respective sections below.
à Bacterial coxitis is an orthopedic emergency!

• Gonococcal arthritis
• Gonococcal arthritis is the most common form of arthritis in sexually active young adults!
• In a young, sexually active adult presenting with classic symptoms
of septic arthritis, gonococcal infection must be ruled out!
Lyme disease

Diagnostics

• If septic arthritis is suspected, arthrocentesis should be conducted for synovial fluid

analysis. Imaging (e.g., X-ray, MRI) may be indicated to assess potential underlying diseases
or differential diagnoses.

• Ultrasound-guided arthrocentesis: Definitive diagnosis requires detection of bacteria in

the synovial fluid.
• To conduct synovial fluid analysis, gram stain, and culture
• ↑ Synovial fluid WBC and dominance of polymorphonuclear (PMN) cells
• Cell count: > 50,000 WBC/μl (neutrophil predominant) points
to septic arthritis (can be as low as > 10,000 in early disease).
• Fluid appears yellowish-green and turbid
• Synovial fluid culture and gram stain is positive in most patients with bacterial
arthritis.
• Also alleviates pain by decreasing intraarticular pressure

• Laboratory tests
• ↑ CRP/ESR
• Blood culture: at least 2 sets of blood cultures to rule out a bacteremic origin

• Imaging: to look for signs of underlying osteomyelitis and concurrent joint disease and rule
out possible differential diagnoses (see “Differential diagnosis” below)
• Ultrasound: effusion, edema of the surrounding soft tissue, possible empyema
• X-ray: unremarkable early in the course of septic arthritis; osteolysis usually becomes
visible after 2–3 weeks.
• MRI or scintigraphy for early detection
• MRI provides early evidence of infectious involvement of the surrounding
soft tissue
• Scintigraphy is used for detection or exclusion of polyarticular involvement

17
 Topic 13 – Osteomyelitis and purulent Arthritis

à Suspected septic arthritis requires aspiration of synovial fluid for analysis!

Treatment

Initial management

Following arthrocentesis and culture, simultaneous empiric antibiotic therapy (based on the Gram
stain) and evacuation of purulent material should be performed.
• Empiric antibiotic regimens
• Gram-positive cocci: Vancomycin
• Gram-negative cocci: Ceftriaxone
• Gram-negative bacilli: 3rd generation
cephalosporin (e.g., ceftazidime), cefepime, piperacillin-tazobactam, or carbapenem
• Suspected pseudomonas infection (e.g., IV drug users): IV ceftazidime plus
an IV aminoglycoside (e.g., gentamicin)
• No organism on gram stain but strong suspicion for bacterial septic arthritis:
IV vancomycin plus either ceftazidime, cefepime, or an aminoglycoside
• Start serial drainage with lavage
• Sometimes debridement (arthroscopic or open approach) is necessary

Further management
• Tailor antibiotics to gram stain, culture and susceptibility results when available (see table
below)
• Continue antibiotic therapy at least ≥ 2 weeks
• Continue serial drainage as needed
• Immobilization + NSAIDs for pain relief and to reduce inflammation
• Follow-up: Physiotherapy should be initiated early to prevent contracture of both the joint
and its capsule

18
 Topic 13 – Osteomyelitis and purulent Arthritis

Treatment of children
• ≤ 3 months: oxacillin + gentamicin
• If high risk of MRSA (i.e., prolonged ICU stay) → replace oxacillin with vancomycin
• > 3 months: nafcillin + cefazolin
• If high risk of MRSA + signs of sepsis → replace nafcillin with vancomycin
• If high risk of MRSA without signs of sepsis → replace nafcillin with clindamycin

Complications
• Joint destruction
• Osteomyelitis
• Sepsis

19
Topic 13 – Osteomyelitis and purulent Arthritis

20
Topic 13 – Osteomyelitis and purulent Arthritis

21
Topic 14
 Topic 14 - Thermic Trauma

Thermic Trauma
• Injury to skin or other organic tissue primarily caused
o Heat
o Radiation
o Radioactivity
o Electricity
o Friction
o Contact with chemical
• 265,000 deaths / year
• 96% fatal fire related burns occur in low- and middle- income countries

Severity of burns depends on

• Area
• Depth
• Allocation
• Age of patient
• Comorbidities

Classification of burns

• By cause
• By localization (genitals, face etc.)
• By area
• By depth

Causes of burns

• Thermal trauma
o Flame flash burn vs. prolonged exposition)
o Scaled (Hot water + steam)
o Contact burn (Hot object)
o Dependent on the heat of the heat source and exposition time

• Chemical
o Diluted/Concentrated
o Acid/Alkaline
o Exposure time/concentration/amount
o Clean boarders of wounds

o Electrical burns

1
 Topic 14 - Thermic Trauma

o Monitor in ICU 24h, ECG every day, CT if headache is present (Electricity may
coagulate blood in brain) check patient entirely, electrical entry wound normally
only one big wound, but exit wounds are often up to 6 wounds
o High/low voltage
o Severe burns
o Entrance/exit wounds
o Associated trauma (head, spine injuries, fractures)
o Headache à minimally coagulated zone in the brain à CT immediately
o Arrythmias
o Rhabdomyolysis (kidney failure)

• Radiation
o Sunburns
o Exposure to UV light
o Nuclear radiation

First Aid

• Stop the burning process

• Removing from danger
• Remove all clothing
• Your safety first
• Cool the burn wounds
• 15-degree water (8 degrees – 25 degrees), when using snow à exposure is less minute wise
• First 3 hours
• Keep the rest of the body warn
• Running water for chemicals (20-30min)
• Cover the wounds ( plastic wrap/ clean linen)
• Call for help

Acute Management

• A – Airways
• B- Breathing
• C – circulation
• D – Disability: neurological status
• E – Exposure with environmental control

Airways

• When to suspect airway injuries

o Face and or neck burns
o Singing of the eyebrows and nasal vibrissae
o Carbon deposits in the mouth and or/nose and carbonaceous sputum
o Acute inflammatory changes in the oropharynx
o Hoarseness
o History of impair mentation/conferment in a burning environment

2
 Topic 14 - Thermic Trauma

o Explosion with burns to head and torso

o Carboxyhaemoglobin level greater than 10%
§ Consider Intubation

Breathing

• Administer oxygen
• Expose the chest- beware circumferential deep dermal or full thickness chest burns- is
escharotomy required
• Consider CO (Carbon Monoxide) poisoning

Circulation and Haemorrhage control

• Inspect for any obvious bleeding

• Apply capillary blanching test (Centrally and peripherally to burnt and non burnt areas)
o Prolonged indicated poor perfusion due to hypotension, hypovolaemia or need for
escharotomy on that limb; check another limb.
• Monitor circulation of peripheries if there is a circumferential burn present - is there a need
for escharotomy?

Escharotomies

• Any circular/semi-circular full thickness burn to a limb with compromise of blood flow
• Full thickness burns to thorax if breathing compromised

Disability: Neurological status

• Establish level of consciousness;

• A - Alert
• V - Response to Vocal stimuli
• P - Responds to Painful stimuli
• U – Unresponsive

• Be alert for restlessness and decreased levels of consciousness – hypoxaemia, CO

intoxication, shock, alcohol, drugs and analgesia influence levels of consciousness

Exposure with environmental control

• Remove all clothing and jewellery

• Keep patient warm, avoid hypothermia
• Remove wet sheets and examine posterior surfaces for burns and other injuries

3
 Topic 14 - Thermic Trauma

Fluids Resuscitation

• > 15%-20% TBA adults

• > 10% TBA for children
• Fluid loss is proportional to affected area
• First 24 hours – 4ml x weight ( kg) x burned surface area(%)
• Next 24 hours- 2ml x weight ( kg) x burned surface area( %)

• Infusion rate is guided by urine output

• 0.3-0.5ml/kg/h- adults
• 0.1 ml/kg/h- children

Calculating area of burn

TBSA = total burned surface area

• Rule of nine (different for adults and

children)
o Divide human body into areas
o For wider burns
o Picture for adults’ patients
o Entire arm = both sides (9%)
o Just one side = 4-5%
o Both arms = 18%
o Entire trunk = 36%

• Palm method
o Scattered burns
o use patients’ hand
o Palm area = 1%
o In small wounds

Correct diagnosis
à Mechanism, allocation, area, depth

Example: Chemical burn of right forearm and right thigh 8%, IIA – IIB, III

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 Topic 14 - Thermic Trauma

Determining the burn degree

1st degree (superficial, epidermal)

• Sunburn, scald, flash, burn;

• Skin intact;
• Redness, swelling, pain;
• Brisk capillary refill;
• Heals spontaneously in 3-7 days
• Minimal protective dressing/moistening creams
(Bepanthen cream) + analgesia + 2-3L of H2O
• Patient most often don’t have to go to hospital
• Drink lots of water à up to 3 Litres

2nd A degree (superficial dermal)

• Scalds, flesh burns, chemicals, hot objects;

• Oozing blisters/denuded areas
• Underneath - bright red/pink, smooth
• Swelling, pain
• Brisk capillary refill
• Heals spontaneously in 14-21 days
• Minimal dressing requirements
• Don’t open the blisters à high infection risk
• Treatment:
o Painkiller
o Bepanthen
o Fluid intake, per os (home) or i/v (500ml)
o Right after burn happened: Panthenol Foam à burns (analgesia + antiseptic)

2nd B degree (deep dermal)

• Contact with flame, hot surface, hot liquids,

chemical, electrical
• Mid to full thickness dermal burn
• Heterogenous, variable depths
• Pale pink/blotchy red/violet/white blisters
• Sluggish to no capillary refill
• Surgical treatment required – debridement
• Black necrosis à only seen 4 - 5 days AFTER the burn

5
 Topic 14 - Thermic Trauma

3rd degree (full thickness)

• Contact with flame, hot surface, hot liquids,

chemical, electric
• Full thickness skin burns
• Extends to underlying tissue (
muscles/tendons/bone etc)
• Pale white/brownish/grey or black
(charred)/ blotchy red
• No capillary refill
• Rigid, leathery, no elasticity
• Surgical treatment required (Necrotomy)
• Brown necrosis à in 3rd degree (black necrosis = 2nd B°)
• Grey necrosis and sharp borders à chemical burn

Necrosis

In 4-5 days IIB and III degree burns form necrosis

• IIB = back, thick, leathery

• III = brown, hard, spider web pattern

Complications

• Compartment syndrome
• Look for further peripheral pulses e.g. doralis pedis, tibilias posterior, means certain
extremities can be preserved instead of immediate amputation
• Electrical trauma can reach heart and brain (full head to toe physical examination is needed)

6
 Topic 14 - Thermic Trauma

Treatment

Medication

• Adequate analgesia • Symptomatic treatment

à ask Pat. about stomach ulcers o Patients comorbidities
• Also prescribe PPI o High BP?, Heart diseases?
• Anticoagulation (Fragin) • Infection prophylaxis
• Sedation (Perfusor i/v fentanyl, • Prophylaxis against tetanus
tramadol)

Local treatment

• Dependent on the hospital / country e.g. chlorohexidine

• Follow principles

Surgical Treatment

• Escharotomies / Fasciotomies
• Debridement – cheaper
• Skin grafting – 0.2-0.5mm
• Full thickness grafting
• Amputations
• Appropriate dressing

Burns wound treatment

Principles

• Ensure adequate perfusion

• Minimise bacterial contamination
• Management of exudate
• Providing optimal environment for the wound
• Stimulate epithelisation process

Method Appropriate dressing

• Cleanse (exudate, haematomas, • Good coverage

slough) • Sustains optimal moisture level
• Debride ( devitalised tissue) • Appropriate exudate absorbency
• Appropriate dressing • Appropriate pressure

7
 Topic 14 - Thermic Trauma

Burn wound treatment based on different types of wound;

• Excessive exudation
o Foam (Mepilex, Allevyyn)
o Alginates
o Parafine based dressings

• Moderate/minimal exudation
o Silicone based (Mepitel, Mepilex)
o Non sticking dressings
o Hydrocolloids

• Hydration of the wound

o Cream gels
o Sheet gels

• Infected/contaminated wound- silver or antimicrobial dressing

• IIB or III degree burn

o Surgical wound closure ONLY if these 3 criteria are fulfilled…
§ Wound is well debrided
§ Good granulation tissue
§ No infection
o Surgical treatment (skin grafting)
o Full thickness grafting
o Microsurgeons/plastic surgeons
o Amputations

Rehabilitation

o Burns cause a serious physical and psychosocial morbidity

o Early mobilisation, physio and ergotherapy are crucial
o Long term rehabilitation

Knowledge for OSCE Exam 2019:

1. Burn degree (recognize from picture)

2. TBSA in %
3. Calculate fluid substitution with formula (ml)
a. Calculate for 8h

8
Topic 15
 Topic 15 - Decision making in Spinal Care

Decision making in Spinal Care Lumbalization 6 L

Sacralisation 4 L
Spine functions
Spondyloarthrosis - osteoarthritis of
• Transmit load (support) – faccia joints
o posture and gait
Spondylosis - degenerative change
• Allows movement (movement of the spine (age related)
o range of motion, goniometry, Schober
• Protects the spinal cord (protection)
o Reflexes, skin sensation, muscle power
o Babinski reflex
§ occurs after the sole of the foot has been firmly stroked.
§ The big toe then moves upward or toward the top surface of the foot.
§ The other toes fan out. This is due to spinal cord being squeezed

o Straight leg raising test:

§ Doctor is raising patients’ straight leg
§ If the patient experiences sciatic pain when the straight leg is at an angle of
between 30 and 70 degrees, then the test is positive

o Spurling test
§ assess nerve root pain.
§ The examiner turns the patient's head to the affected side while extending
and applying downward pressure to the top of the patient's head.
§ A positive Spurling's sign is when the pain arising in the neck radiates in the
direction of the corresponding dermatome ipsilaterally

à Lower back pain is a symptom (LBP Algorithm on last page)

Lower Back Pain Epidemiology

• 15-20% incidence in the population

• Majority of acute and chronic back pain are benign
• Lifetime prevalence 80%, mosts lasts less than 6 weeks
• Each year 3-4% of the population is temporarily disabled, and 1% of the working age
population is totally disabled from low back problem

History of the benign self-limited back pain

• 90% recover spontaneously in 4-6 weeks

• Tendency to recur
• Factors promoting transition to chronic pain not clear
• Imaging: disk degeneration and protrusion can be seen in over 60% of asymptomatic adults

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 Topic 15 - Decision making in Spinal Care

Relative age dependence of certain clinical syndromes Most commonly seen spinal disorders
(95%):
• First 10 years à Torticollis, Klippel-Feil syndrome Stenosis
• 20s - 30s à Scoliosis, Scheuermann disease Spondylolisthesis
Disc hernia
• 20s - 40s à Ankylosing spondylitis
• 30s - 50s à Discogenic disorders
• 50s - 80s à Spinal stenosis

Spinal disorder clinical symptoms

• Prolapsed disk
o Pain increased by coughing, sneezing and pressing
o Segmental radiation
o Neurologic deficits

• Facet syndrome
o Pain in small segment of the back with pseudo radicular radiation

• Spinal stenosis
o Intermittent spinal claudication
o Improves when the spine is moved out of lordosis

• Ankylosing spondylitis
o Deep-seated night-time pain in the small segment of the back
o Morning stiffness
o Extra vertebral findings
o Hyperkyphosis
o Kyphosis of cervical region
o Beginning of disease -> thoracic expansions ( <1.5cm means a possibility of
)
ankylosing sp. )

Differential diagnosis of low back pain

• Spinal
• Discogenic
• Arthrogenous
• Spondylolisthesis
• Fracture
• Spondylitis
• Tumour, metastases
• Ankylosing spondylitis
• Psychological causes
• Spinal stenosis
• Coccygodynia

2
 Topic 15 - Decision making in Spinal Care

• Extraspinal
o Urologic causes (urolithiasis, cystitis, Prostatitis, prostate tumour)
o Gynaecologic causes ( pregnancy, prolapsed uterus and vagina, myomatosis, ovarian
tumours, endometriosis)
o Neurological causes (Borrelia, zoster infection, angioma, intradural and extradural
tumours
o Intra-abdominal causes (gastric ulcer, pancreatitis, cholecystitis, hepatitis,
pyelonephritis, diverticulitis, visceral tumour
o Aneurysm of abdominal aorta
o Psychological causes

Work Up

• History
• Physical examination
o Posture
o Gait
o Range of motion
o Palpation
o Neurological examination (motor, sensor and reflex testing)
o Shoulder, hip and knee examination
• Diagnostics: X ray, blood count, urine analysis

Back Pain in a primary care setting, causes other than a benign self-limited back pain

o 4% compression fracture
o 3% from spondylolisthesis
o 0.7% from malignancy
o 0.3% from ankylosing spondylitis
o 0.1% from vertebral osteomyelitis

Potential Red flags in Low Back Pain: Diagnostic testing may be indicated early on

• Past History
o Cancer, unexplained weight loss
o Immunosuppression, including prolonged steroid use
o IV drug use
o History of recent urinary infection
o Fever or constitutional symptoms
o Coagulopathy; low platelet, anticoagulant
o Older patient with new onset of back pain
o Metabolic bone disorder

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 Topic 15 - Decision making in Spinal Care

• Present History
o Significant trauma
§ Fall from height or severe injury in young adult
§ Minor injury or lifting in osteoporotic patient
o Pain worse at night, supine position or not relieved by any position
o Suspected cauda equina syndrome or spinal cord compression
§ Bladder dysfunction
§ Saddle anaesthesia or sensory level
§ Major limb motor weakness
o Progressive neurologic deficit
o Physical examination and laboratory findings:
§ Pulsatile abdominal mass
§ Fever
§ Neurologic deficit not explained by single radiculopathy
§ Increased ESR, CRP
§ Unexplained anaemia
o Pattern not compactable with benign mechanical back pain
o Lack of response to conservative measures

Causes of Low Back Pain

o Mechanical causes (Lumbar spinal stenosis + lumbar disc herniation)
o Paraspinal muscles
o Sacroiliac joint
o Spondylolysis/spondylolisthesis
o Nonspecific back pain
o Rheumatologic
o Neoplastic disease
o Metastatic spinal disease
o Infections: acute or chronic
o Vascular or hematologic
o Endocrine/Metabolic
o Referred Pain
o Other nonmechanical causes
o Psychological factors

1. Mechanical causes

Mechanical causes 98% of low back pain, sitting produces the highest load on the spine, typically
worsens pain;

o Intervertebral disc herniations

o Facet: commonly describes as lateralised pain, referring to the gluteal region and the
thigh
o Extension, with lateral flexion or rotation towards the painful side, may increase the pain

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 Topic 15 - Decision making in Spinal Care

• Lumbar disk syndrome à Clinical symptoms

o Sudden onset
o Erratic development
o Position dependent
o Pain increasing by coughing, sneezing and pressing
o Kyphotic spine
o Flexed knee and hip

o Top blue dots à antalgic position (not straight spine)

o Middle photos blue test (straight leg rising test positive on right side 20 degrees, left side
negative)
o Top Right photo X rays - antalgic position (not straight spine)
o Bottom Right photo - large L4 + L5 disk herniation

o L5 + S1 disk herniation

5
 Topic 15 - Decision making in Spinal Care

• Lumbar spinal stenosis

o Sometimes known as pseudoclaudication
o Aching pain, paraesthesia & heaviness in legs that progress with walking
o Relived by trunk flexion, stooping or sitting

o Patient forward flex- suffering from pain amps paresthesia related to walking
o Bent hips and knees are characteristic
o Spinal stenosis – hypertrophic joints, hypertrophic yellow ligament and spinal canal is
squeezed

6
 Topic 15 - Decision making in Spinal Care

L4 + L5 spinal stenosis (right photo)

2. Paraspinal muscles
3. Sacroiliac joint
• Pain is worsened by extensive use at the leg, such as walking
• May be reproduced by stressing the joint such as forced flexion of one lower extremity
coupled with extension and abduction of other

4. Non-Specific back pain

5. Spondylolysis/spondylolisthesis

o Spondylo = spine, Listhesis = slippage

o Spondylolisthesis is a forward slip of one vertebra ( i.e. one of the 33 bones of the
spinal column) relative to another
o Spondylolisthesis usually occurs towards the base of spine in lumbar area

• Clinical Symptoms
o Hyperlordosis
o Pain in lower back
o Thighs and buttocks stiffness

7
 Topic 15 - Decision making in Spinal Care

o Muscle tightness
o Tenderness in slipped area
o Pressure on nerve roots may cause changes in sensation
o Pain radiating down the legs
o Lower back pain

• Treatment
o Conservative
o NSAIDS
o Exercises
o Surgery

6. Rheumatologic: pain in frequently worst in the morning with constitutional symptoms

• Seronegative spondyloarthropathies:
o Ankylosing spondylitis (more common)
§ Spinal looks like bamboo tree and ankylosis of SI joint
o Psoriatic arthritis, Reactive spondylarthropaty
o Reiters syndrome
• 10: 1(m:f)
• Lumbar spine # and lower extremities involvement
• Urethritis in 93% of cases
• Constitutional symptoms, musculocutaneous lesions of the moth,
genitals, palms soles and nails
o Rheumatoid arthritis
o Polymyalgia rheumatic
o Nonarticular rheumatic disorders
§ Myofascial pain
§ Fibromyalgia syndrome

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 Topic 15 - Decision making in Spinal Care

7. Neoplastic disease
• Primary tumours of the spine
o Multiple myeloma: rare, back pain
(present 35%)
o Bone or cartilage tumour: Osteoid
osteoma

8. Metastatic spinal disease

• Most common:
§ Breast
§ Lung
§ Prostate
§ Kidney
§ Lymphoma
§ melanoma
§ GI tract
• Back pain (90% of patients of who have spinal metastasis)
• Early metastasis not visualised on
§ plain radiographs
§ bone scans +ve 85%
o MRI may identify spinal metastasis in patients who present with
§ Normal radiographs
§ Bone scans

• Left photo: pathologic fracture T12

• Right photo: post surgery

9
 Topic 15 - Decision making in Spinal Care

9. Infections: acute or chronic

• Osteomyelitis (spondylitis)
• Discitis
• Epidural abscess

Spondylitis- vertebral osteomyelitis

• Epidemiology
o Approximately 2-7% of all osteomyelitis
o Lumbar > Thoracic > Cervical
o Males > Females (2:1)
o More common after 5th Decade (>50% of cases)
o Common in patients who are
§ Young I/V drug abusers
§ Diabetic
§ Immunocompromised (chronic steroids, HIV, malnutrition)

• Etiology
o Hematogenous spread is the most common route for vertebral osteomyelitis
o Urinary tract is most common source
o Soft tissue infections
o Respiratory infections
o Unidentified source
o Direct inoculation (penetrating trauma, invasive spinal procedure)

10. Vascular or Hematologic

• Abdominal aortic aneurysm (atherosclerotic or inflammatory) rupture, erosion of
adjacent structures of Dissection
• Epidural hematoma
• Retroperitoneal hematoma while on anticoagulant therapy: severe pain on extension of
the hip
• Hemoglobinopathy: painful bone infarcts, become susceptible to osteomyelitis

11. Endocrine/Metabolic
• Osteoporosis: Primary or secondary

10
 Topic 15 - Decision making in Spinal Care

• Paget’s disease

12. Referred Pain

• Pelvic disorders
o Endometriosis; pain associated with periods
o Torsio of a mass, cyst or fibroid
o Pelvic inflammatory disease
o Prostatis, Cystitis
• Abdominal disorders
o Pancreas, pain worst with supine position
o Posterior duodenal ulcers
o Renal
• Other nonmechanical causes
o Hip joints or trochanteric bursa
o Guillain- Barre syndrome
o Meningeal irritation

13. Psychological factors

• Signs suggestive of nonorganic back pain

Treatment of LBP

Bed Rest

o Appropriate for acute low back pain

o Two days as effective as seven
o Prolonged bedrest has deleterious effects on physical and psychological condition
o Not recommended for chronic pain

Medications

14. NSAID
• Anti-inflammatory + analgesic effect

11
 Topic 15 - Decision making in Spinal Care

• Side effects: GI, renal, more profound in elderly, history of GI events, concomitant
steroids, diuretics
• Regular dosing needed
• COX2 inhibitors may prove safer
• Muscle relaxants
§ Mainly used in acute pain
§ Sedative side effects limit daytime use, may help with sleep

Exercise

o Stretching
o Yoga
o Different position

DISH syndrome

o Diffuse idiopathic skeletal hyperostosis (DISH; also called Forestier's disease or hyperostotic
spondylosis)
o Definition:

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 Topic 15 - Decision making in Spinal Care

§ degenerative disease of the vertebral column (especially the thoracic and

lumbar spine), which is characterized by calcification and ossification of spinal
ligaments and enthese

Scheuermann disease

o Scheuermann kyphosis is a growth-related disorder of the thoracic spine that leads to

hyperkyphosis.

o The condition is typically diagnosed in early adolescence following a referral to the physician
because of
§ poor posture
§ or a spinal deformity discovered in a school screening program.

13
 Topic 15 - Decision making in Spinal Care

o Subacute back pain is present in some cases. Conventional lateral spine x-rays showing > 40°
of kyphosis (normal: 20–40°) and anterior vertebral wedging of > 5° of three or more
adjacent vertebrae confirm the diagnosis

14