18- Orthopedics Explains Flashcards
1
Q
What are the different types of fractures in pediatric patients?
A
The different types of fractures in pediatric patients include complete fractures, plastic deformity fractures, greenstick fractures, buckle fractures, and growth plate fractures.
2
Q
What is a complete fracture?
A
A complete fracture is a type of fracture where both sides of the cortex are breached.
3
Q
What is a plastic deformity fracture?
A
A plastic deformity fracture occurs when there is stress on the bone resulting in deformity without cortical disruption.
4
Q
What is a greenstick fracture?
A
A greenstick fracture is a type of fracture where there is a unilateral cortical breach only.
5
Q
What is a buckle fracture?
A
A buckle fracture is an incomplete fracture with only periosteal haematoma resulting from cortical disruption.
6
Q
How are growth plate fractures classified?
A
Growth plate fractures in pediatric patients are classified according to the Salter-Harris system, which includes five types: Type I, Type II, Type III, Type IV, and Type V.
7
Q
What is a Type I growth plate fracture?
A
A Type I growth plate fracture involves a fracture through the physis only, and the X-ray may often appear normal.
8
Q
What is a Type II growth plate fracture?
A
A Type II growth plate fracture involves a fracture through the physis and metaphysis.
9
Q
What is a Type V growth plate fracture?
A
A Type V growth plate fracture is a crush injury involving the physis, and the X-ray may resemble a Type I fracture and appear normal.
9
Q
What is a Type III growth plate fracture?
A
A Type III growth plate fracture involves a fracture through the physis and epiphysis to include the joint.
10
Q
What is a Type IV growth plate fracture?
A
A Type IV growth plate fracture involves a fracture involving the physis, metaphysis, and epiphysis.
11
Q
Which types of growth plate injuries usually require surgery?
A
Injuries of Types III, IV, and V in the Salter-Harris classification system usually require surgery.
12
Q
What is often associated with Type V growth plate injuries?
A
Type V growth plate injuries are often associated with disruption to growth.
13
Q
What is osteopetrosis?
A
Osteopetrosis is a condition where the bones become harder and more dense. It is an autosomal recessive condition and is most commonly seen in young adults. Radiology reveals a lack of differentiation between the cortex and medulla, described as “marble bone.”
13
Q
What are some signs of non-accidental injury in children?
A
Signs of non-accidental injury in children may include delayed presentation, a delay in attaining milestones, lack of concordance between proposed and actual mechanism of injury, multiple injuries, injuries at sites not commonly exposed to trauma, and being on the at-risk register.
14
Q
What can cause pathological fractures in children?
A
Pathological fractures in children can be caused by genetic conditions such as osteogenesis imperfecta, which is characterized by defective osteoid formation and a failure of collagen maturation in all connective tissues.
15
Q
What are the subtypes of osteogenesis imperfecta?
A
The subtypes of osteogenesis imperfecta are: Type I (normal quality but insufficient quantity of collagen), Type II (poor quantity and quality of collagen), Type III (poorly formed collagen but normal quantity), and Type IV (sufficient quantity but poor quality of collagen).
16
Q
What is the bimodal age distribution of neck of femur (NOF) fractures?
A
Neck of femur (NOF) fractures, which are fractures in the hip, have a bimodal age distribution. They can occur as a result of high-energy trauma in young patients (e.g., road traffic accidents, horse riding), or as low-energy osteoporotic fractures in the elderly.
17
Q
What are the management aims for young patients with NOF fractures?
A
For young patients with NOF fractures, the management aims are to treat them in accordance with Advanced Trauma Life Support (ATLS) principles, retain the patient’s own anatomy, and optimize their function. These patients often have associated injuries due to high-energy trauma.
18
Q
What are the management aims for elderly patients with NOF fractures?
A
For elderly patients with NOF fractures, the management aims are to immediately regain patient mobility to avoid morbidity (infection, thromboembolic events, pressure sores) and mortality associated with prolonged bed rest. Left untreated, a neck of femur fracture can be considered a terminal event.
19
Q
What is the mortality rate associated with elderly hip fractures historically?
A
Historically, the mortality rate associated with elderly hip fractures is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff.
20
Q
What is the normal neck-shaft angle in the hip?
A
The normal neck-shaft angle in the hip is 130 +/- 7 degrees.
21
Q
What is the normal neck anteversion in the hip?
A
The normal neck anteversion in the hip is 10 +/- 7 degrees.
22
Q
What is the predominant blood supply to the femoral head and neck?
A
The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries, which are branches of the profunda femoris artery. There is also a small vascular contribution from the artery of the ligament teres.
23
What are the typical signs of a neck of femur fracture?
Typical signs of a neck of femur fracture include pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint), and the inability to straight-leg-raise. In undisplaced fractures, the signs may be more subtle.
24
What imaging modalities are used to diagnose NOF fractures?
Anteroposterior and cross-table lateral plain radiographs are usually sufficient to diagnose the majority of NOF fractures. However, if there is a high index of suspicion of fracture but plain radiographs are inconclusive, an MRI is the gold standard investigation. CT can also be used if MRI is unavailable or the patient cannot tolerate it. Full length femur views are essential to plan surgery if the fracture extends below the level of the lesser trochanter or there is a possibility of pathological fracture.
25
What are the two main types of NOF fractures?
Intra-capsular and extra-capsular fractures
26
How are extra-capsular fractures further divided?
Pertrochanteric or subtrochanteric fractures (within 5cm distal to the lesser trochanter)
27
What are the three categories used to describe fractures?
Undisplaced, minimally displaced, or displaced
28
What is the difference in blood supply disruption between intra-capsular and extra-capsular fractures?
Intra-capsular fractures commonly disrupt the blood supply to the femoral neck and head, while extracapsular fractures rarely do
29
What is the recommended treatment approach for intra-capsular fractures?
Arthroplasty (joint replacement)
30
What is the recommended treatment approach for extra-capsular fractures?
Fixation (surgical stabilization)
31
Which named classification system is commonly used for elderly intracapsular fractures?
Garden Classification
32
Which named classification system is commonly used for young intracapsular fractures?
Pauvels Classification
33
Which named classification system is commonly used for intertrochanteric fractures?
Evans Classification
34
When should surgery for NOF fractures ideally take place to minimize complications?
Within 36 hours, as a delay greater than 48 hours is associated with increased morbidity and mortality
35
How can undisplaced fractures in the elderly be treated?
Internal fixation with cannulated screws
36
What is the suggested treatment for valgus impacted subcapital fractures in the elderly?
Arthroplasty (joint replacement)
37
According to NICE guidance, which surgical option should be offered to patients who meet certain criteria?
Total hip replacement
38
What is the recommended surgical approach for intertrochanteric fractures with intact trochanter and medial calcar?
DHS (Dynamic Hip Screw)
39
What is the recommended surgical approach for intertrochanteric fractures involving the trochanter and/or medial calcar?
Intramedullary device (e.g., nail or rod)
40
What is the post-operative management for NOF fracture patients?
Full weight-bearing mobilization, multidisciplinary care involving orthogeriatrician assessment, physiotherapy, occupational therapy, and secondary prevention measures for bone health
41
What is the main difference between rickets and osteomalacia?
Rickets occurs during growth before epiphysis fusion, while osteomalacia occurs after epiphysis fusion
42
What are the common causes of vitamin D deficiency leading to osteomalacia?
Malabsorption, lack of sunlight, and inadequate diet
43
What are the types of osteomalacia?
Vitamin D deficiency, renal failure, drug-induced (e.g., anticonvulsants), vitamin D resistant (inherited), and liver disease (e.g., cirrhosis)
44
What are the features of rickets?
Knock-knee, bow leg, and features of hypocalcemia
45
What are the features of osteomalacia?
Bone pain, fractures, muscle tenderness, and proximal myopathy
46
What are the typical findings in the investigation of osteomalacia?
Low levels of calcium, phosphate, and 25(OH) vitamin D; raised alkaline phosphatase; and x-ray findings of cupped, ragged metaphyseal surfaces in children and translucent bands (Looser's zones or pseudofractures) in adults
47
What is the treatment for osteomalacia?
Calcium with vitamin D tablets
48
What is the mechanism and presentation of a ruptured anterior cruciate ligament?
Mechanism: high twisting force applied to a bent knee. Presentation: loud crack, pain, and rapid joint swelling (haemarthrosis)
48
How is a ruptured anterior cruciate ligament managed?
Intense physiotherapy or surgery
49
What is the mechanism and clinical finding of a ruptured posterior cruciate ligament?
Mechanism: hyperextension injuries with the tibia lying back on the femur. Clinical finding: paradoxical anterior draw test
50
What is the mechanism and instability associated with a rupture of the medial collateral ligament?
Mechanism: leg forced into valgus via force outside the leg. Instability: knee unstable when put into valgus position
51
What are the characteristics and symptoms of a meniscal tear?
Characteristics: rotational sporting injuries. Symptoms: delayed knee swelling, joint locking, and recurrent episodes of pain and effusions
52
Who is commonly affected by chondromalacia patellae and what are the typical symptoms?
Teenage girls, following an injury to the knee (e.g., dislocation of the patella). Typical symptoms: pain when going downstairs or at rest, tenderness, and quadriceps wasting
53
What are the risk factors and clinical features of a dislocation of the patella?
Risk factors: genu valgum, tibial torsion, and high riding patella. Clinical features: traumatic primary event, valgus and external rotation of the knee, skyline x-ray views required, and 20% recurrence rate
54
What are the two types of fractured patella and how do they occur?
i. Direct blow to the patella causing undisplaced fragments. ii. Avulsion fracture
55
Who is commonly affected by tibial plateau fractures and what is the mechanism of injury?
Elderly individuals or following significant trauma in the young. Mechanism: knee forced into valgus or varus, resulting in knee fracture before ligament rupture
56
How are tibial plateau fractures classified?
Using the Schatzker system
57
What is the Schatzker Classification system used for?
Classification of tibial plateau fractures
58
What are the features and characteristics of a Type 1 tibial plateau fracture?
Anatomical description: Vertical split of lateral condyle. Features: Fracture through dense bone, may be undisplaced or condylar fragment pushed inferiorly and tilted
58
What are the features and characteristics of a Type 2 tibial plateau fracture?
Anatomical description: Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle. Features: Wedge fragment displaced laterally, widened joint. Untreated cases may develop a valgus deformity
59
What are the features and characteristics of a Type 3 tibial plateau fracture?
Anatomical description: Depression of the articular surface with intact condylar rim. Features: The split does not extend to the edge of the plateau, depressed fragments embedded in subchondral bone, stable joint
60
What are the features and characteristics of a Type 4 tibial plateau fracture?
Anatomical description: Fragment of the medial tibial condyle. Features: Two injuries seen - depressed fracture in osteoporotic bone in the elderly, or high-energy fracture with a condylar split from the intercondylar eminence to the medial cortex. Associated severe ligamentous injury may be present
61
What are the features and characteristics of a Type 5 tibial plateau fracture?
Anatomical description: Fracture of both condyles. Features: Both condyles fractured, but the column of the metaphysis remains in continuity with the tibial shaft
62
What are the features and characteristics of a Type 6 tibial plateau fracture?
Anatomical description: Combined condylar and subcondylar fractures. Features: High-energy fracture with marked comminution
63
What is avascular necrosis?
Cellular death of bone components due to interruption of the blood supply, causing bone destruction
64
Is avascular necrosis the same as non-union?
No, avascular necrosis is different from non-union. In avascular necrosis, the fracture has usually united
64
Which are the main joints commonly affected by avascular necrosis?
Hip, scaphoid, lunate, and talus
65
What can occur in the affected bone in avascular necrosis in terms of vascular ingrowth?
Vascular ingrowth into the affected bone may occur, but many joints will develop secondary osteoarthritis
65
What is the typical appearance of avascular necrosis on radiological imaging?
Radiological evidence is slow to appear
66
What are some causes of avascular necrosis?
Pancreatitis, lupus, alcohol, steroids, trauma, idiopathic factors, infection, caisson disease, collagen vascular disease, radiation, rheumatoid arthritis, amyloid, Gaucher disease, sickle cell disease
67
What is the usual presentation of avascular necrosis?
Pain, often despite apparent fracture union
68
Which imaging modality can show changes in avascular necrosis earlier than plain films?
MRI scanning
69
What is the key in the treatment of fractures at high-risk sites in avascular necrosis?
Early, prompt, and accurate reduction
70
How can non-weight bearing help in avascular necrosis?
Non-weight bearing may help facilitate vascular regeneration
71
In some cases, what may be necessary or preferred as a treatment option for avascular necrosis, especially in the elderly?
Joint replacement, for example, hip replacement in the elderly
72
What are the risk factors associated with pseudogout?
Hyperparathyroidism, hypothyroidism, haemochromatosis, acromegaly, low magnesium, low phosphate, and Wilson's disease.
73
What is pseudogout?
Pseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synovium.
74
What can be observed during joint aspiration in pseudogout?
Weakly-positive birefringent rhomboid-shaped crystals can be seen.
75
Which joints are commonly affected by pseudogout?
Knee, wrist, and shoulders are the most commonly affected joints.
76
What can be seen on x-ray in pseudogout?
Chondrocalcinosis, which refers to the presence of calcium deposits in the joint cartilage, can be seen on x-ray.
77
What are the management options for pseudogout?
Joint fluid aspiration is performed to exclude septic arthritis. NSAIDs or intra-articular, intra-muscular, or oral steroids can be used, similar to the treatment approach for gout.
78
What is Colles' fracture?
Colles' fracture is a fracture of the distal radius characterized by a transverse fracture located 1 inch proximal to the radio-carpal joint, resulting in dorsal displacement and angulation. It is often associated with a "dinner fork deformity."
79
How is Colles' fracture typically caused?
Colles' fracture is commonly caused by a fall onto an extended outstretched hand.
80
What is Smith's fracture?
Smith's fracture, also known as a reverse Colles' fracture, is a fracture of the distal radius characterized by volar angulation of the distal radius fragment, resulting in a "Garden spade deformity." It is typically caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed.
81
What is Monteggia's fracture?
Monteggia's fracture is characterized by a dislocation of the proximal radioulnar joint associated with an ulna fracture. It is typically caused by a fall on an outstretched hand with forced pronation. Prompt diagnosis is crucial to prevent disability.
81
What is Bennett's fracture?
Bennett's fracture is an intra-articular fracture of the first carpometacarpal joint. It is caused by an impact on a flexed metacarpal, commonly seen in fist fights. On an x-ray, a triangular fragment can be observed at the ulnar base of the metacarpal.
82
What is Galeazzi fracture?
Galeazzi fracture is a radial shaft fracture associated with a dislocation of the distal radioulnar joint. It is caused by a direct blow.
82
What is Holstein Lewis fracture?
Holstein Lewis fracture is a fracture of the distal third of the humerus that results in entrapment of the radial nerve. The radial nerve innervates the muscles in the extensor compartments of the arm. Conservative treatment includes reduction and use of a functional brace. Vascular injury may require open surgery.
83
What is Pott's fracture?
Pott's fracture is a bimalleolar ankle fracture caused by forced foot eversion.
84
What is Barton's fracture?
Barton's fracture is a distal radius fracture (Colles' or Smith's fracture) associated with radiocarpal dislocation. It is caused by a fall onto an extended and pronated wrist. Involvement of the joint is a defining feature.
85
What are the symptoms of a dorsal column lesion?
Loss of vibration and proprioception
86
What are the characteristics of Tabes dorsalis (SACD)?
Lesion in the spinothalamic tract resulting in the loss of pain, sensation, and temperature
87
What are the symptoms of a central cord lesion?
Flaccid paralysis of the upper limbs
88
Which region of the spine is commonly affected by osteomyelitis in intravenous drug users (IVDU)?
Cervical region
89
Which region of the spine is typically affected by tuberculosis (TB)?
Thoracic region
90
Thoracic region
Dorsal column signs, such as loss of proprioception and fine discrimination
91
What are the signs of Brown-Sequard syndrome?
Hemisection of the spinal cord results in ipsilateral paralysis and loss of proprioception and fine discrimination, as well as contralateral loss of pain and temperature.
92
What areas does the C2 dermatome cover?
The C2 dermatome covers the occiput and the top part of the neck.
93
Which area does the C3 dermatome cover?
The C3 dermatome covers the lower part of the neck to the clavicle.
94
What area does the C4 dermatome cover?
The C4 dermatome covers the area just below the clavicle.
95
Which areas are innervated by the C5 to T1 dermatomes?
The C5 dermatome covers the lateral arm at and above the elbow. The C6 dermatome covers the forearm and the radial (thumb) side of the hand. The C7 dermatome represents the middle finger. The C8 dermatome covers the medial aspect of the hand. The T1 dermatome covers the medial side of the forearm.
96
Which area is innervated by the L1 dermatome?
The L1 dermatome represents the hip girdle and groin area.
97
What areas are covered by the thoracic dermatomes (T2 to T12)?
The T2 to T12 dermatomes cover the axillary and chest region. T3 to T12 cover the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is located at the umbilicus. T12 ends just above the hip girdle.
98
Which areas are covered by the L2 and L3 dermatomes?
The L2 and L3 dermatomes cover the front part of the thighs.
99
Which areas are innervated by the S1 dermatome?
The S1 dermatome covers the heel and the middle back of the leg.
100
Which area is innervated by the S2, S3, and S4-5 dermatomes?
The S2 dermatome covers the back of the thighs. The S3 dermatome covers the medial side of the buttocks. The S4-5 dermatomes cover the perineal region.
101
Which dermatome innervates the anal sphincter?
The anal sphincter is innervated by the S2, S3, and S4 dermatomes.
102
Which myotome is responsible for elbow flexion (biceps)?
Elbow flexion (biceps) is controlled by the C5 myotome.
103
Which myotome is responsible for wrist extension?
Wrist extension is controlled by the C6 myotome.
104
Which myotome is responsible for knee extension (quadriceps)?
Knee extension (quadriceps) is controlled by the L3 myotome.
104
Which myotome is responsible for elbow extension (triceps)?
Elbow extension (triceps) is controlled by the C7 myotome.
105
Which myotome is responsible for long finger flexion?
Long finger flexion is controlled by the C8 myotome.
106
Which myotome is responsible for small finger abduction?
Small finger abduction is controlled by the T1 myotome.
107
Which myotomes are responsible for hip flexion (psoas)?
Hip flexion (psoas) is controlled by the L1 and L2 myotomes.
108
Which myotomes are responsible for ankle dorsiflexion (tibialis anterior)?
Ankle dorsiflexion (tibialis anterior) is controlled by the L4 and L5 myotomes.
109
Which myotome is responsible for toe extension (hallucis longus)?
Toe extension (hallucis longus) is controlled by the L5 myotome.
110
Which myotome is responsible for ankle plantar flexion (gastrocnemius)?
Ankle plantar flexion (gastrocnemius) is controlled by the S1 myotome.
111
What is the common location for proximal humerus fractures?
Proximal humerus fractures usually occur through the surgical neck.
fractures through the anatomical neck are rare.
112
What is the risk associated with displaced anatomical neck fractures?
Displaced anatomical neck fractures (>1cm displacement) carry a risk of avascular necrosis to the humeral head.
113
What is the common injury pattern in children with proximal humerus fractures?
The commonest injury pattern in children is a greenstick fracture through the surgical neck.
114
How are impacted fractures of the surgical neck usually managed?
Impacted fractures of the surgical neck are usually managed with a collar and cuff for 3 weeks followed by physiotherapy.
115
What treatment options may be required for more significant displaced fractures?
More significant displaced fractures may require open reduction and fixation or the use of an intramedullary device.
116
What are the three possible causes of bony fractures?
Bony fractures can result from trauma (excessive forces applied to bone), stress-related injuries (repetitive low-velocity injury), or pathological fractures (abnormal bone that fractures during normal use or minimal trauma).
117
What are the different types of fractures?
The different types of fractures include oblique fractures (fracture lying obliquely to the long axis of the bone), comminuted fractures (more than two fragments), segmental fractures (multiple fractures along a bone), transverse fractures (perpendicular to the long axis of the bone), and spiral fractures (severe oblique fracture with rotation along the long axis of the bone).
118
Aside from evaluating the fracture itself, what other factors should be considered in the diagnosis of a fracture?
In addition to evaluating the fracture site and type of injury, other factors to consider in the diagnosis include associated injuries and distal neurovascular deficits. This may require clinical examination and radiographs of proximal and distal joints.
119
How is developmental dysplasia of the hip usually diagnosed?
Developmental dysplasia of the hip is usually diagnosed in infancy through screening tests.
120
What is the classification system used for open fractures?
The Gustilo and Anderson classification system is commonly used for open fractures. It includes three grades: Grade 1 (low-energy wound <1cm), Grade 2 (wound >1cm with moderate soft tissue damage), and Grade 3 (high-energy wound >10cm with extensive soft tissue damage). Grade 3 further divides into subgroups: 3A (adequate soft tissue coverage), 3B (inadequate soft tissue coverage), and 3C (associated arterial injury).
121
What are some key points in the management of fractures?
Some key points in fracture management include immobilizing the fracture and adjacent joints, carefully monitoring and documenting neurovascular status (especially after reduction and immobilization), managing infection (including tetanus prophylaxis and IV broad-spectrum antibiotics for open injuries), and ensuring timely debridement and lavage for open fractures (within 6 hours of injury).
122
What are the treatment options for developmental dysplasia of the hip?
Treatment options for developmental dysplasia of the hip include splints, harnesses, or traction. In later years, osteotomy and hip realignment procedures may be needed. In cases of arthritis, a joint replacement may be necessary. However, it is best to defer this if possible, as it will likely require revision.
123
What radiological findings should be observed in developmental dysplasia of the hip?
Initially, there may be no obvious changes on plain films, and ultrasound (USS) provides the best resolution until 3 months of age. On plain films, Shenton's line should form a smooth arc.
124
What is the typical age range for Perthes Disease?
Perthes Disease typically occurs between 5 and 12 years of age.
125
What are the recommended treatments for Perthes Disease?
The recommended treatments for Perthes Disease include removing pressure from the joint to allow normal development, as well as physiotherapy. It is usually self-limiting if diagnosed and treated promptly.
126
What radiological findings are associated with Perthes Disease?
X-rays will show a flattened femoral head, and in untreated cases, the femoral head will eventually fragment.
127
Who is typically affected by slipped upper femoral epiphysis?
Slipped upper femoral epiphysis is typically seen in obese male adolescents.
127
What radiological findings are associated with slipped upper femoral epiphysis?
X-rays will show the displaced femoral head falling inferolaterally, resembling a melting ice cream cone. The Southwick angle gives an indication of disease severity.
128
What symptoms are commonly experienced with slipped upper femoral epiphysis?
Common symptoms of slipped upper femoral epiphysis include knee pain and limitation to internal rotation.
129
What are the treatment options for slipped upper femoral epiphysis?
Treatment options for slipped upper femoral epiphysis include bed rest and non-weight bearing to avoid avascular necrosis. In severe cases or cases with a high risk of slipping, percutaneous pinning of the hip may be required.
130
What are the key features of talipes equinovarus?
The key features of talipes equinovarus include equinus of the hindfoot, adduction and varus of the midfoot, and a high arch.
more common in males.
131
What are some key anatomical deformities associated with talipes equinovarus?
Key anatomical deformities associated with talipes equinovarus include adducted and inverted calcaneus, wedge-shaped distal calcaneal articular surface, severe tibio-talar plantar flexion, medial talar neck inclination, displacement of the navicular bone (medially), wedge-shaped head of talus, and displacement of the cuboid (medially).
132
What is the initial management approach for talipes equinovarus?
The initial management approach for talipes equinovarus is conservative, with the Ponseti method being the preferred technique. This method involves serial casting to mold the foot into the correct shape.
Around 90% of patients will require an Achilles tenotomy after casting in the Ponseti method.
132
What is the next phase of treatment after an Achilles tenotomy in the Ponseti method?
After an Achilles tenotomy, a phase of walking braces is used to maintain the correction.
133
What are the surgical procedures involved in correcting talipes equinovarus?
Surgical procedures for correcting talipes equinovarus involve multiple tenotomies and lengthening procedures. In cases that do not respond to surgery, an Ilizarov frame reconstruction may be attempted, which has shown good results.
134
What is an ankle fracture?
An ankle fracture refers to a fracture around the tibio-talar joint, involving the lateral, medial, and/or posterior malleolus. Pilon and Tillaux fractures are also considered ankle fractures, but are not covered here.
135
Who is affected by ankle fractures?
Ankle fractures are common and affect both men and women. However, men have a higher rate of ankle fractures as young adults due to sports and contact injuries, while women have a higher rate post-menopausal due to fragility type fractures.
136
What are the components of the ankle joint?
The ankle joint, also known as the mortise joint, consists of the distal tibia (tibial plafond and posterior malleolus), the distal fibula (lateral malleolus), and the talus. The main movement at the ankle joint is plantar and dorsiflexion.
137
What are the ligaments involved in ankle stability?
On the medial side, the deltoid ligament (superficial and deep portions) acts as the primary restraint to valgus tilting of the talus. On the lateral side, the lateral ligament complex consists of the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). Together, they resist valgus stress and anterior translation of the talus within the mortise joint. The syndesmosis, a ligament complex between the distal tibia and fibula, is fundamental to ankle joint integrity and consists of the anterior-inferior tibiofibular ligament (AITFL), transverse tibiofibular ligament (TTFL), interosseous membrane, and posterior-inferior tibiofibular ligament (PITFL).
138
What is the initial management approach for ankle fractures?
In high-energy injuries, management should follow ATLS principles to identify more significant injuries first. The neurovascular status of the foot should be documented, and open injuries should be excluded. If an open injury is present, it should be managed according to BOAST 4 principles. If there is an obvious deformity, it should be reduced as soon as possible with appropriate analgesia or conscious sedation. Radiographs are not necessary for clearly deformed or dislocated joints, as the priority is to relieve pressure on the surrounding soft tissues from the bony deformity. If the fracture pattern is not clinically obvious, plain radiographs can be taken to guide subsequent manipulation during plaster-of-paris below knee backslab application.
139
What imaging modalities are used to evaluate ankle fractures?
AP, lateral, and mortise views (with 20 degrees internal rotation) are essential to evaluate fracture displacement and syndesmotic injury. Decreased tibiofibular overlap, medial joint clear space, and lateral talar shift indicate a syndesmotic injury. In cases where there is suspicion of syndesmosis involvement without radiographic evidence, stress radiographs can be diagnostic. Complex fracture patterns, including posterior malleolar fractures, are best defined using CT.
140
What are the two commonly used classifications for ankle fractures?
The two commonly used classifications for ankle fractures are Lauge-Hansen and Danis-Weber.
141
What does the Lauge-Hansen classification consist of?
The Lauge-Hansen classification consists of two parts: the foot position and the force applied. It helps understand the forces involved and predict ligamentous or bony injuries. There are four injury patterns: Supination - Adduction (SA), Supination - External rotation (SER), Pronation - Abduction (PA), and Pronation - External rotation (PER).
142
What are the percentages associated with each Lauge-Hansen injury pattern?
The percentages associated with each Lauge-Hansen injury pattern are: SA (Supination - Adduction) - 10-20%, SER (Supination - External rotation) - 40-75%, PA (Pronation - Abduction) - 5-20%, PER (Pronation - External rotation) - 5-20%.
143
How does the Danis-Weber classification work?
The Danis-Weber classification is commonly used and is based on the level of the fibula fracture in relation to the syndesmosis. It helps determine the risk of syndesmotic injury and fracture instability. There are three types: A (fracture below the level of the syndesmosis), B (fracture at the level of the syndesmosis or tibial plafond), and C (fracture above the level of the syndesmosis, including Maisonneuve fractures).
144
Besides the lateral side, what other factors can dictate fracture stability?
In addition to the lateral side, a medial or posterior bony or ligamentous injury can also dictate fracture stability. Bimalleolar and trimalleolar fractures are generally more unstable.
145
What is the treatment approach for Weber A fractures?
Weber A fractures are stable and can be fully weight-bearing in an ankle boot. They do not typically require operative fixation.
146
What is the treatment approach for Weber C fractures?
Weber C fractures usually involve syndesmotic disruption and are typically bimalleolar. They are unstable and often require operative fixation. In addition to fracture fixation, the syndesmosis usually requires reconstruction or augmentation with screws to restore joint integrity and function.
147
What are the commonly used fixation methods for operative treatment of ankle fractures?
Operative fixation for ankle fractures usually involves open reduction and internal fixation using plates and screws. Fibula nails, external fixation, or hindfoot nails may also be used in specific cases where soft tissue or bone quality is poor.
148
What is the treatment approach for Weber B fractures?
Weber B fractures can vary greatly. They can be part of a trimalleolar injury, which is extremely unstable and requires fixation. However, a unimalleolar Weber B fracture can be stable and can be mobilized immediately in an ankle boot. Determining stability may involve stress radiographs or a trial of mobilization and repeat radiographs.
149
How long does it generally take for ankle fractures to unite enough to prevent displacement?
Ankle fractures generally take 6 weeks to unite enough to prevent secondary displacement. During this time, a cast is typically kept on for conservatively managed patients.
150
What is the approximate time frame for returning to activities after an ankle fracture?
Returning to activities after an ankle fracture typically takes approximately three months. This process may require the assistance of a physiotherapist to improve range of motion and muscle strengthening.
151
What is an open fracture?
An open fracture refers to a fracture where there is a break in the bony cortex along with a breach in the overlying skin. Any wound present in the same limb as a fracture should be suspected as an open fracture.
152
What are the main problems associated with open fractures?
One of the main problems with open fractures is the accompanying injuries to the surrounding soft tissues. While the skin is usually resistant to trauma, the underlying muscle, nerves, blood vessels, and periosteum can be damaged or disrupted. The severity of these injuries correlates with the severity of the fracture and can impact the outcome.
153
How are open fractures graded?
Open fractures can be graded using the Gustilo and Anderson system. Grade 1 refers to a low-energy wound less than 1 cm, Grade 2 refers to a wound greater than 1 cm with moderate soft tissue damage, and Grade 3 refers to a high-energy wound greater than 1 cm with extensive soft tissue damage. Grade 3 can further be classified as 3A (adequate soft tissue coverage), 3B (inadequate soft tissue coverage), or 3C (associated arterial injury).
154
What is the initial management approach for open fractures?
Initial management of open fractures involves careful patient examination to check for associated injuries, control of hemorrhage, and assessment of the extent of the injury. Imaging should be performed, and distal neurovascular status should be established. The wound should be covered with a dressing, and antibiotics should be administered. Early debridement, which involves the removal of foreign material and devitalized tissue, is a cornerstone of open fracture management. In most cases, the wound is left open.
155
How should the open fracture wound be irrigated?
The open fracture wound should be irrigated, typically using 6 liters of saline solution.
156
What is the recommended method for stabilizing the fracture in open fracture management?
In open fracture management, an external fixator is often used initially to stabilize the fracture.
157
Why is the blood supply to the scaphoid a concern in fractures?
The surface of the scaphoid is covered by articular cartilage, leaving only a small area for blood vessels. This puts the blood supply at risk in case of a fracture.
158
What imaging technique is required for visualizing the scaphoid?
To visualize the scaphoid, an ulnar deviation anteroposterior (AP) view is often necessary.
159
What is the management approach for non-displaced scaphoid fractures?
Non-displaced scaphoid fractures can be managed with casts or splints.
160
What is the surgical fixation method for displaced scaphoid fractures?
Displaced scaphoid fractures usually require surgical fixation, commonly with a screw.
161
What are the potential complications of scaphoid fractures?
Complications of scaphoid fractures can include nonunion (failure of the fracture to heal), avascular necrosis of the scaphoid (loss of blood supply leading to bone death), scapholunate disruption and wrist collapse, and degenerative changes in the adjacent joint.
162
What is the background information about proximal humerus fractures?
Proximal humerus fractures are the third most common fragility fracture in the elderly. They usually result from low-energy falls in elderly females or high-energy trauma in young males. These fractures can be associated with nerve injuries, particularly axillary nerve injury, and fracture-dislocation of the humeral head. A detailed neurological assessment is necessary for all upper limb injuries.
163
What is the anatomy of the proximal humerus?
The proximal humerus consists of the articular head, greater tuberosity, lesser tuberosity, metaphysis, and diaphysis. The anatomical neck is the area between the articular head and the tuberosities, and the surgical neck is the area between the tuberosities and the metaphysis. The greater tuberosity is where the supraspinatus, infraspinatus, and teres minor muscles attach, while the lesser tuberosity is where the subscapularis muscle attaches.
164
What is the conservative management approach for minimally displaced proximal humeral fractures?
Minimally displaced proximal humeral fractures, which make up the majority of cases, can be managed conservatively. This involves immobilization in a polysling and progressive mobilization. Pendular exercises can begin at 14 days, and active abduction exercises can start at 4-6 weeks.
164
What is the vascular supply to the humeral head?
The humeral head is supplied by the anterior and posterior humeral circumflex arteries. Fractures involving the anatomical neck are at the greatest risk of osteonecrosis (loss of blood supply leading to bone death).
164
What imaging techniques are used for shoulder fractures?
Radiographs, including true anteroposterior (AP), axillary lateral, and/or scapula Y views, are used to delineate the fracture pattern and confirm or exclude the presence of an associated dislocation. CT scans may be indicated to better define intra-articular involvement and aid in preoperative planning. MRI is not useful for fracture imaging.
165
What is the Neer Classification used for?
The Neer Classification is the most commonly used classification system for proximal humerus fractures. It describes the fracture as two, three, or four parts depending on the number of main fragments. It also comments on the degree of displacement. The main fragments described in the classification are the greater tuberosity, lesser tuberosity, articular surface, and shaft. Displacement is defined as greater than 1cm or angulation greater than 45 degrees. Attention should also be paid to humeral alignment, fracture displacement, and the position of the greater tuberosity, as malunion can cause impingement problems.
166
When is operative management indicated for proximal humeral fractures?
Operative management is indicated in cases of irreducible fracture dislocation, large displacement, younger patients, and head splitting fractures (intra-articular fractures). However, the recent PROFHER trial has suggested that operative intervention does not provide significant benefit to patient outcomes, especially in elderly patients with extra-articular fractures. Surgical management options include ORIF (plate and screw fixation), intramedullary nail fixation for extra-articular fractures, hemiarthroplasty for un-reconstructable fractures in older patients with good glenoid quality, total shoulder arthroplasty for un-reconstructable fractures where high functioning shoulder is required, and reverse shoulder arthroplasty for better functional outcomes compared to conventional total shoulder replacement.
167
What are the characteristics of scapula fractures?
Scapula fractures are uncommon and are usually associated with high-energy trauma. The most commonly involved areas are the scapula body or spine (50%), glenoid fossa, and glenoid neck. It is important to exclude any associated life-threatening injuries.
168
What imaging techniques are used for scapula fractures?
Plain radiographs, including true anteroposterior (AP), axillary lateral, and/or scapula Y views, are used for initial evaluation. CT scanning is useful for defining intra-articular involvement, displacement, and three-dimensional reconstruction.
168
How are scapula fractures classified?
Scapula fractures are classified based on the location of the fracture, which can involve the coracoid, acromion, glenoid neck, glenoid fossa, or scapula body. In cases of ipsilateral glenoid neck and clavicle fracture, it is referred to as a "floating shoulder," where the limb is effectively dissociated from the axial skeleton.
169
What is the conservative management approach for scapula fractures?
The vast majority of scapula fractures can be managed conservatively. This involves sling immobilization for two weeks followed by early rehabilitation. However, floating shoulder fractures will usually require fixation. Intra-articular fractures and displaced/angulated glenoid fractures should also be considered for surgical management.
170
What are the different types of dislocations around the shoulder joint?
Dislocations around the shoulder joint include glenohumeral dislocation, acromioclavicular joint disruption, and sternoclavicular dislocation.
171
What is the initial management approach for glenohumeral dislocation?
The initial management of glenohumeral dislocation requires emergent reduction to prevent lasting chondral damage. It is important to assess and document the neurovascular status of the limb, particularly the axillary nerve. Radiographs should be taken to confirm the direction of dislocation. The dislocation is then reduced through emergent closed reduction under entonox and analgesia, often requiring conscious sedation. The arm should be immobilized in a polysling, and follow-up radiographs should confirm relocation.
171
What are the types of glenohumeral dislocation?
There are four types of glenohumeral dislocation: anterior, posterior, inferior, and superior. Each type has specific features, causes, examination findings, and reduction techniques.
172
What is a Bankart lesion?
A Bankart lesion refers to the avulsion of the anterior glenoid labrum, which occurs with an anterior shoulder dislocation. In posterior dislocation, the posterior labrum can be involved, known as reverse Bankart lesion.
173
What is the most common type of glenohumeral dislocation?
The most common type of glenohumeral dislocation is the anterior dislocation, which accounts for over 90% of cases. It is usually caused by a traumatic force on the arm when the shoulder is abducted and externally rotated. Examination findings include a loss of shoulder contour (sulcus sign) and anteriorly palpable humeral head. Reduction techniques include the Hippocratic, Milch, Stimson, and Kocher (not advised due to the risk of fracture complications).
174
What is a Hill Sachs defect?
A Hill Sachs defect is a chondral impaction on the posteriosuperior humeral head caused by contact with the glenoid rim. In some cases, the defect can be large enough to lock the shoulder, requiring open reduction. In posterior dislocation, it is referred to as reverse Hill Sachs defect.
175
What is the association between rotator cuff tear and age?
Rotator cuff tears are known to increase with age.
Greater or lesser tuberosity fractures also increase with age.
176
What is the association between humeral neck fracture and shoulder fracture dislocation?
Humeral neck fractures are commonly seen in shoulder fracture dislocation, especially in cases of high-energy trauma and elderly patients. It is important to discuss these fractures with orthopaedics prior to any attempted reduction.
176
What is the anatomy of the rotator cuff?
The rotator cuff is a group of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles play a crucial role in shoulder movements and maintaining glenohumeral stability. Each muscle has specific scapular and humeral attachments, actions, and innervation.
177
Which muscle is responsible for external rotation of the humerus?
The infraspinatus muscle is responsible for external rotation of the humerus. It is attached to the infraspinatus fossa of the scapula and the posterior facet of the greater tuberosity of the humerus. Its innervation is provided by the suprascapular nerve.
178
Which muscle is involved in external rotation of the humerus?
The teres minor muscle is involved in external rotation of the humerus. It is attached to the lateral border of the scapula and the inferior facet of the greater tuberosity of the humerus. Its innervation is provided by the axillary nerve.
179
Which muscle is responsible for internal rotation of the humerus?
The subscapularis muscle is responsible for internal rotation of the humerus. It is attached to the subscapular fossa of the scapula and the lesser tuberosity of the humerus. Its innervation is provided by the upper and lower subscapular nerves.
180
What is the most common cause of shoulder pain?
Subacromial impingement
180
How are the anterior and posterior muscles of the rotator cuff balanced?
The anterior muscle, subscapularis, is balanced with the posterior muscles, infraspinatus and teres minor. This balance helps maintain shoulder stability and proper movement.
180
What happens when there is an injury or tear in the inferior rotator cuff muscles?
Injury or tear in the inferior rotator cuff muscles, including infraspinatus, teres minor, and subscapularis, can result in upward migration of the humeral head on the glenoid. This can be seen on an anteroposterior radiograph.
181
What causes subacromial impingement?
Subacromial impingement is caused by the impingement of the superior cuff on the undersurface of the acromion, along with an inflammatory bursitis.
182
What is the most common type of tear in the rotator cuff?
The majority of tears in the rotator cuff involve the superior cuff, which includes the supraspinatus, infraspinatus, and teres minor.
182
What is rotator cuff arthropathy?
Rotator cuff arthropathy refers to shoulder arthritis that develops in the presence of rotator cuff dysfunction. It occurs due to superior migration of the humeral head caused by the loss of rotator cuff function and integrity.
183
What imaging modality is best for assessing cuff pathology?
MRI is the best imaging modality for assessing cuff pathology. It provides detailed visualization of the rotator cuff and the rest of the shoulder.
183
What factors are considered when deciding to repair a rotator cuff tear?
When considering repair of a rotator cuff tear, factors such as the age and activity level of the patient, the nature of the tear (degenerative vs. acute traumatic), and the size and retraction of the tear are taken into consideration when making a surgical plan.
184
What treatment options are available for subacromial impingement?
Subacromial impingement can be managed with physiotherapy, oral anti-inflammatory medication, and subacromial steroid injections. In some cases, arthroscopic subacromial decompression may be performed to create more space for the rotator cuff.
185
What is calcific tendonitis?
Calcific tendonitis is the presence of calcific deposits within tendons, commonly seen in the rotator cuff, particularly the supraspinatus tendon. It is associated with subacromial impingement and pain in the shoulder.
186
Who is more commonly affected by calcific tendonitis?
Calcific tendonitis is more common in women aged 30-60 years.
187
What are some associations of calcific tendonitis?
Calcific tendonitis is associated with diabetes and hypothyroidism.
187
What are the three stages of calcification in calcific tendonitis?
The three stages of calcification in calcific tendonitis are the formative phase, resting phase, and resorptive phase.
188
What is the formative phase of calcific tendonitis characterized by?
The formative phase of calcific tendonitis is characterized by the presence of calcific deposits.
188
Which phase of calcific tendonitis is the most painful?
The resorptive phase of calcific tendonitis is the most painful stage.
189
What imaging modality is usually sufficient for diagnosing calcific tendonitis?
Plain radiographs are usually sufficient for diagnosing calcific tendonitis. They show calcification of the rotator cuff, typically within 1.5 cm of its insertion on the humerus.
189
What are the common symptoms of calcific tendonitis?
Calcific tendonitis presents similarly to subacromial impingement, with pain, especially during overhead activities. It is atraumatic in nature.
190
What are the treatment options for calcific tendonitis?
Non-operative treatment options for calcific tendonitis include NSAIDs, steroid injections, and physiotherapy. In some cases, ultrasound-guided or surgical needle barbotage can be performed to break down the deposits. Surgical excision may be required in rare cases.
190
What is adhesive capsulitis, also known as frozen shoulder?
Adhesive capsulitis, or frozen shoulder, is a condition characterized by pain and loss of movement in the shoulder joint. It involves fibroplastic proliferation of capsular tissue, leading to soft tissue scarring and contracture.
191
What are some associations of adhesive capsulitis?
Adhesive capsulitis is associated with prolonged immobilization, previous surgery, thyroid disorders, such as hypothyroidism, and diabetes.
192
What are the three stages of adhesive capsulitis?
The three stages of adhesive capsulitis are the freezing and painful stage, the frozen and stiff stage, and the thawing stage, where shoulder movement slowly improves.
193
What imaging modality is often used to diagnose adhesive capsulitis?
Plain radiographs are used to exclude other causes of a painful shoulder. MRI arthrogram may show capsular contracture and can be used to exclude cuff pathology, although it is often not performed since the diagnosis is largely clinical.
194
What are the treatment options for adhesive capsulitis?
Non-operative treatment options for adhesive capsulitis include NSAIDs, steroid injections, and physiotherapy. The condition can take up to 2 years to improve. In some cases, operative manipulation under anesthesia or arthroscopic adhesiolysis (release of adhesions) may be performed to expedite recovery, followed by intensive physiotherapy.
194
What are the possible causes of glenohumeral arthritis?
Glenohumeral arthritis can be caused by osteoarthritis (primary or secondary to cuff tear or trauma), rheumatoid arthritis, or as part of a spondyloarthropathy. Majority of those with rheumatoid arthritis will develop symptoms.
195
Who is more commonly affected by glenohumeral arthritis?
Glenohumeral arthritis is more common in the elderly.
196
What are the common symptoms of glenohumeral arthritis?
Glenohumeral arthritis presents with pain at night and with movement, similar to other forms of arthritis.
197
What imaging modalities are useful for diagnosing and assessing glenohumeral arthritis?
AP and axillary radiographs can show features of arthritis. CT or MRI may be useful to classify the shape of the glenoid and extent of bone loss, especially when considering arthroplasty. MRI is also essential for assessing the integrity of the rotator cuff if shoulder replacement is being considered.
198
What are the initial treatment measures for glenohumeral arthritis?
Initial treatment measures for glenohumeral arthritis include NSAIDs, management of rheumatoid arthritis (if applicable), physiotherapy, and steroid injection.
199
What are the advantages of total shoulder replacement compared to hemiarthroplasty?
Total shoulder replacement has shown superior outcomes in terms of pain relief, function, and implant survival compared to hemiarthroplasty.
199
What are the surgical treatment options for glenohumeral arthritis?
Surgical treatment options for glenohumeral arthritis include hemiarthroplasty, arthroscopic debridement (for isolated ACJ arthritis), and total shoulder replacement. Total shoulder replacement has been shown to produce superior outcomes in terms of pain relief, function, and implant survival compared to hemiarthroplasty. There are two types of total shoulder replacement: anatomical (ball on humerus, with cup on glenoid) and reverse geometry (ball on glenoid, with cup on humerus). Anatomical total shoulder replacement requires an intact rotator cuff, so reverse total shoulder replacement is preferable when the cuff's integrity is questionable.
200
When is arthroscopic debridement useful for glenohumeral arthritis?
Arthroscopic debridement is useful for glenohumeral arthritis when the patient has isolated ACJ arthritis, but it is rarely used for glenohumeral arthritis.
200
What are the two types of total shoulder replacement?
The two types of total shoulder replacement are anatomical (ball on humerus, with cup on glenoid) and reverse geometry (ball on glenoid, with cup on humerus).
201
How can osteoporosis be detected on imaging?
Osteoporosis is visible on plain films when the calcium content is approximately halved. More subtle changes can be detected using DEXA scanning.
201
Which type of total shoulder replacement is preferable when the rotator cuff's integrity is questionable?
Reverse total shoulder replacement is preferable when the rotator cuff's integrity is questionable.
202
What is an important factor to consider when opting for reverse total shoulder replacement?
When opting for reverse total shoulder replacement, it is important to consider the integrity of the rotator cuff.
203
What is osteoporosis?
Osteoporosis is a condition characterized by bone atrophy, where the volume of bone tissue per unit volume of anatomical bone is reduced. It can be generalized or localized, and it is distinguished by a reduction in the amount of osteoid matrix while still maintaining normal mineralization.
204
What medications can be prescribed to prevent fragility fractures in osteoporosis?
Medications that can be prescribed to prevent fragility fractures in osteoporosis include bisphosphonates (alendronate, ibandronate, risedronate, and zoledronic acid) as well as non-bisphosphonates (raloxifene, denosumab, teriparatide, calcitriol, and hormone replacement therapy).
204
What supplements are administered in the treatment of osteoporosis?
Calcium and vitamin D supplements are also administered in the treatment of osteoporosis.
205
What are the common causes of osteomyelitis?
The common causes of osteomyelitis include Staphylococcus aureus, occasionally Enterobacter or Streptococcus species. In individuals with sickle cell disease, Salmonella species may be the cause.
206
What diagnostic procedure is performed to confirm osteomyelitis?
A bone biopsy and culture are typically performed to confirm the diagnosis of osteomyelitis.
206
What are the clinical features of osteomyelitis?
The clinical features of osteomyelitis include erythema (redness), pain, and fever.
206
What imaging technique can be used to investigate osteomyelitis?
X-ray imaging can reveal a lytic center with a ring of sclerosis, which is characteristic of osteomyelitis.
207
What is the treatment for osteomyelitis?
The treatment for osteomyelitis involves prolonged antibiotic therapy. In some cases, surgical removal of sequestra (dead bone tissue) may be necessary.
208
How is sacro-ilitis related to ankylosing spondylitis?
Sacro-ilitis, which is inflammation of the sacroiliac joint, is typically visible on plain films and is commonly associated with ankylosing spondylitis.
208
What is ankylosing spondylitis?
Ankylosing spondylitis is a chronic inflammatory disorder that affects the axial skeleton.
209
What percentage of individuals who are HLA B27 positive develop ankylosing spondylitis?
Up to 20% of individuals who are HLA B27 positive will develop ankylosing spondylitis.
210
What is Scheuermann's disease?
Scheuermann's disease is a condition characterized by epiphysitis of the vertebral joints, mainly affecting adolescents. Symptoms include back pain and stiffness. X-ray changes may show disturbance in the epiphyseal plate and anterior wedging. Progressive kyphosis involving at least 3 vertebrae is a common clinical feature. Minor cases may be managed with physiotherapy and analgesia, while more severe cases may require bracing or surgical stabilization.
211
What is scoliosis?
Scoliosis refers to the curvature of the spine in the coronal plane. It can be divided into structural and non-structural types. Non-structural scoliosis is more common in adolescent females and is typically related to minor postural changes that can be corrected with maneuvers like bending forwards. Structural scoliosis affects more than one vertebral body and can be idiopathic, congenital, or neuromuscular in origin. It cannot be corrected by alterations in posture. Idiopathic structural scoliosis is the most common type. Severe or progressive structural scoliosis is often managed surgically with bilateral rod stabilization of the spine.
212
What is spina bifida?
Spina bifida is a condition characterized by the non-fusion of the vertebral arches during embryonic development. It can be categorized into three types: myelomeningocele, spina bifida occulta, and meningocele. Myelomeningocele is the most severe type and is associated with neurological defects that may persist even after anatomical closure of the defect.
213
What diagnostic tests can be used to diagnose septic arthritis in pediatric patients?
Diagnostic tests for septic arthritis in pediatric patients include plain x-rays and consideration of joint aspiration. The Kocher criteria can also be utilized.
214
What is septic arthritis?
Septic arthritis is a condition characterized by a joint infection, with Staphylococcus aureus being the most common organism involved.
214
What are the Kocher criteria for septic arthritis diagnosis?
The Kocher criteria Kocher's 'WIFE' for septic arthritis diagnosis include: non-weight bearing on the affected side, erythrocyte sedimentation rate (ESR) > 40 mm/hr, fever, and white blood cell (WBC) count >12,000 mm³. If all four criteria are met, there is a 99% chance that the child has septic arthritis.
215
What is the recommended treatment for septic arthritis?
The recommended treatment for septic arthritis involves surgical drainage of the affected joint as soon as possible to prevent permanent joint damage. In some cases, repeated procedures may be necessary. Additionally, appropriate intravenous antibiotics should be administered.
216
What is Paget's disease of bone?
Paget's disease of bone is characterized by focal bone resorption followed by excessive and chaotic bone deposition. It typically affects the spine, skull, pelvis, and femur in that order. Serum alkaline phosphatase levels are elevated, while other parameters remain normal. X-rays show abnormal thickened and sclerotic bone. There is a risk of cardiac failure with more than 15% bony involvement, as well as a small risk of sarcomatous change.
217
What is the treatment for Paget's disease of bone?
The treatment for Paget's disease of bone involves the use of bisphosphonates.
218
What is pes anserinus bursitis?
Pes anserinus bursitis refers to the symptomatic inflammation of the pes anserinus bursa, which is located at the medial aspect of the knee, deep to the pes anserinus tendons.
218
What is osteoporosis?
Osteoporosis is a condition characterized by excessive bone resorption resulting in demineralized bone. It is more common in old age and often asymptomatic, except for an increased risk of pathological fractures. Alkaline phosphatase and calcium levels are usually normal. Treatment for osteoporosis includes bisphosphonates, calcium, and vitamin D supplementation.
219
What are secondary bone tumors?
Secondary bone tumors refer to bone destruction and tumor infiltration that occur as a result of cancer spreading to the bone from a primary site. The appearance of the tumors on imaging depends on the primary cancer, with sclerotic appearances seen in prostate cancer and lytic appearances seen in breast cancer. Elevated serum calcium and alkaline phosphatase levels may be observed. Treatment for secondary bone tumors includes radiotherapy, prophylactic fixation (surgical stabilization), and analgesia for pain management.
220
What are the clinical symptoms of pes anserinus bursitis?
The classic symptoms of pes anserinus bursitis include pain and swelling along the proximal medial tibia. These symptoms may be exacerbated by specific activities such as ascending and descending stairs.
221
How is pes anserinus bursitis typically treated?
Most cases of pes anserinus bursitis resolve with physiotherapy.
221
What are the stages of bone fracture healing?
Bone fracture healing involves several stages:
1. Bleeding vessels in the bone and periosteum
2. Clot and hematoma formation
3. The clot organizes over a week, leading to improved structure and collagen
4. Osteoblasts in the periosteum produce new bone
5. Mesenchymal cells produce cartilage (fibrocartilage and hyaline cartilage) in the soft tissue around the fracture
6. Connective tissue and hyaline cartilage combine to form a callus
7. Endochondral ossification occurs as the new bone approaches the new cartilage to bridge the gap
8. Trabecular bone forms
9. Trabecular bone is resorbed by osteoclasts and replaced with compact bone
222
What are the factors that can affect fracture healing?
Several factors can affect fracture healing, including:
- Age
- Malnutrition
- Bone disorders such as osteoporosis
- Systemic disorders like diabetes, Marfan's syndrome, and Ehlers-Danlos syndrome, which can cause abnormal musculoskeletal healing
- Drugs such as steroids and non-steroidal anti-inflammatory agents
- Type of bone: Cancellous (spongy) bone fractures are usually more stable, involve greater surface areas, and have a better blood supply than cortical (compact) bone fractures
- Degree of trauma: The more extensive the injury to the bone and surrounding soft tissue, the poorer the outcome
- Vascular injury, especially in the femoral head, talus, and scaphoid bones
- Degree of immobilization
- Intra-articular fractures, which communicate with synovial fluid containing collagenases that can retard bone healing
- Separation of bone ends: Normal apposition of fracture fragments is necessary for union to occur. Inadequate reduction, excessive traction, or interposition of soft tissue can prevent healing.
- Infection
223
What is Perthes disease?
Perthes disease is an idiopathic avascular necrosis of the femoral epiphysis of the femoral head. It is characterized by impaired blood supply to the femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone may either heal or a subchondral fracture may occur.
224
What are the clinical features of Perthes disease?
The clinical features of Perthes disease include:
- Males are affected 4 times more often than females.
- It typically occurs between the ages of 2-12 years, with younger age of onset associated with better prognosis.
- Limp
- Hip pain
- It can be bilateral in 20% of cases.
225
How is Perthes disease diagnosed?
Perthes disease is diagnosed through plain x-ray, technetium bone scan, or magnetic resonance imaging (MRI) if the x-ray is normal and symptoms persist.
226
What is the prognosis of Perthes disease?
Most cases of Perthes disease will resolve with conservative management. Early diagnosis improves outcomes.
226
What are the stages of Perthes disease according to Catterall staging?
Perthes disease is staged according to Catterall staging, which includes the following stages:
Stage 1: Clinical and histological features only.
Stage 2: Sclerosis with or without cystic changes and preservation of the articular surface.
Stage 3: Loss of structural integrity of the femoral head.
Stage 4: Loss of acetabular integrity.
227
What are the management options for Perthes disease?
The management of Perthes disease includes:
- To keep the femoral head within the acetabulum: casting or braces.
- Observation for children younger than 6 years.
- Surgical management for older children, with moderate results. Severe deformities may require surgery.
228
What are stress fractures?
Stress fractures are small hairline fractures that occur due to repetitive activity and loading of normal bone.
229
Is there usually surrounding soft tissue injury with stress fractures?
No, surrounding soft tissue injury is unusual with stress fractures.
230
What can be identified on radiographs in cases of late-presenting stress fractures?
In cases of late-presenting stress fractures, callus formation may be identified on radiographs.
231
Is formal immobilization always necessary for stress fractures?
No, not all stress fractures require formal immobilization.
232
What is the anatomy of the tibial collateral ligament?
The tibial collateral ligament is a broad, flat band that attaches to the medial epicondyle of the femur. Some of its fibers extend onto the adductor magnus tendon. It passes downwards and forwards to the medial side of the tibia, with its deepest fibers fused with the medial meniscus.
233
What is the anatomy of the fibular collateral ligament?
The fibular collateral ligament is round and cord-like. It stands clear of the lateral part of the fibrous capsule and is enclosed within the fascia lata. It extends from the lateral epicondyle of the femur to the head of the fibula, in front of its highest point. It splits the tendon of the biceps femoris. On the lateral side of the joint, the fibers are short and weak, bridging the interval between the femoral and tibial condyles. The popliteus tendon intervenes between the lateral meniscus and the capsule.
233
What is the function of the tibial and fibular collateral ligaments?
The tibial and fibular collateral ligaments prevent disruption of the knee joint at the sides. They are most tightly stretched in extension. The fibular ligament prevents rotation of the tibia laterally, while the tibial ligament prevents rotation of the femur medially.
234
Which collateral ligament is most often affected by injury?
The medial collateral ligament is most often affected by injury.
235
What are the grading and treatment options for collateral ligament injuries?
Collateral ligament injuries are graded and treated as follows:
Grade 1: Minor tearing of ligament fibers, negative instability tests. Treatment involves conservative management with analgesia and physiotherapy.
Grade 2: Ligament laxity seen with the knee in 30 degrees of flexion, knee stable when joint extended. Usually treated with splinting or casting for 4-6 weeks.
Grade 3: Ligament completely torn, joint instability. Surgical ligament reconstruction is typically required.
236
How are fractures involving the growth plate classified in children?
Fractures involving the growth plate in children are classified using the Salter-Harris system.
237
What are the five main types of fractures in the Salter-Harris classification?
The five main types of fractures in the Salter-Harris classification are:
Type 1: Transverse fracture through the growth plate.
Type 2: Fracture through the growth plate to the metaphysis (most common type).
Type 3: Fracture through the growth plate and the epiphysis with the metaphysis spared.
Type 4: Fracture involving the growth plate, metaphysis, and epiphysis.
Type 5: Compression fracture of the growth plate (worst outcome).
238
How are non-displaced type 1 injuries usually managed?
Non-displaced type 1 injuries can generally be managed conservatively.
239
What is the management approach for unstable or more extensive growth plate fractures?
Unstable or more extensive growth plate fractures will usually require surgical reduction and/or fixation. Proper alignment is crucial in these cases.
