Orthopaedics Flashcards
Commonest malignant primary bone tumour
Oseosarcoma
50% around the knee
Complications of colle’s fracture
Compression on median nerve
Rupture of extensor pollicis longus tendon
Imaging for scaphoid fractures
If first x-ray NAD
Fix for two weeks then re-x-ray
If still NAD –> MRI
Lasègue’s straight leg raise test
Increases tension along the sciatic nerve (L5 and S1 nerve roots)
97% sensitive for disc prolapse
Intrinsic muscle wasting of the hand
Ulnar nerve palsy T1
Thenar wasting
Median nerve palsy C8
Hypothenar wasting
Ulnar nerve palsy T1
Medial epicondylitis
Golfer’s elbow
Lateral epicomdylitis
Tennis elbow
Morton’s neuroma
Thickening of the tissue that surrounds the digital nerve leading to the toes as the nerve passes under the ligament connecting the metatarsals in the forefoot
It is most frequent between the third and fourth toes.
A neuroma presents with burning pain in the ball of the foot that radiates to the involved toes.
Palpate in the web space between the symptomatic toes for a mass.
Compression of the metatarsals may elicit a ‘click’ betwee the bones (Molders’ click).
Sites of tendon injury with age
Adolescents: tendon insertions
Adults: musculotendinous junction
Grading ligamentous injuries 0-3
0 = Normal ligament
1 No increase in joint laxity but there is tenderness around the injured ligament
2 Partial disruption of the ligament fibres with increased joint laxity, and a soft end point
3 Complete disruption of the ligament; there is a marked increase in joint laxity with no end point clinically
Management of ligamentous injuries
Grade 1 + 2: splinting, anaglesia and fraded mobilisation
Garde 3: surgical repair
Posterior impingement of the ankle and tendinopathy of the flexor hallucis longus tendon
Ballet dancers
Ottawa ankle rules
Bone tenderness along the distal 6 cm of the posterior margin or at the tip of the lateral malleolus
Bone tenderness along the distal 6 cm of the posterior margin or at the tip of the medial malleolus
Inability to bear weight at the time of the accident or at the time of examination
Cervical lordosis
35-45 ‘
Lumbar lordosis
40 - 80’
Mostly occurs L4 - S1
Thoracic kyphosis
20 - 50’ (mean 35’)
Increases with age
Radicular artery of Adamkiewicz
Largest anterior segmental medullary artery
Arises left posterior intercostal artery at the level of the T9 - T12 intercostal artery, which branches from the aorta, and supplies the lower two thirds of the spinal cord via the anterior spinal artery
Ligation –> ischaemia of the spinal column
During anterior approaches to the spine, segmental division is performed to avoid ligating this influental vessel
Cauda equina
Low back pain
Uni- or bilateral sciatica
Saddle anaesthesia
Motor weakness in the lower extremities
Variable rectal and urinary symptoms
Lasègue’s sign
Denotes radicular pain aggravated by ankle dorsiflexion during straight leg raise
Provocative discography
3.5 mL of radio-opaque contrast agent is injected into the disc
The contrast pattern will allow the discrimination of different degrees of disc degeneration; cottonball or lobular would be considered normal
Whereas irregular, fissured or ruptured would be considered degenerate
Indication for surgical intervention in cervical radiculopathy
Intractible pain
OR
Functional neurological deficit
Surgical management of cervical radiculopathy
Anterior cervical discectomy and fusion (using a cage packed with bone graft and plate)
Cervical total disc replacement
Posterior laminoforaminotomy
Cervical myelopathy
LMN signs AT level of lesion
UMN signs below level of lesion
Commonest cause of cauda equina syndrome
Massive central lumbar disc protrusion at L4/5
Lumb disc herniation
90% at L4/L5 or L5/S1 levels
Posterolateral disc protrusion will affect the traversing root, e.g. an L4/5 disc protrusion will affect the
L5 nerve root.
Far-lateral disc protrusion (extraforaminal) will affect the exiting nerve root, e.g. a far-lateral L5/S1 disc protrusion will affect the L5 nerve root
Spinal stenosis
Classic symptoms: back, buttock, thigh and calf pain
Provoked by walking and extended posture
Relieved by flexed posture
Symptoms progress in up to one-third of untreated patients
Spondylolysis
Unilateral or bilateral defect in the pars interarticularis without vertebral slippage
Incidence in athletic population 15–47%
May be completely asymptomatic/incidental finding on
radiograph
Difficult to image, but MRI proving more useful
Conservative treatment: activity modification, antilordotic brace
Surgical treatment: direct repair preserving motion or spinal fusion if associated disc degeneration
Spondylolisthesis
Forward slippage of the vertebral body caused by a break in in the continuity of pars interarticularis
Wiltse classification of spondylolisthesis identifies the CAUSE = 6 types
Meyerding classification grades severity = 4 grades
Low grade slip I - II –> fusion-in-situ
High grade slips III - IV–> decompression and fusion
Commonest metatastic malignancy to spine
Breast 21%
Lung 14%
Benign primary spine tumours
Osteoid osteoma
Osteoblastoma
Chondroma
Chondroblastoma
Chondromyoixod fibroma
Giant cell tumous
Haemangioma
Lymphangioma
Lipoma
Benign tumours tend to occur in the posterior elements
Intermediate spinal pimaries
Aggressive osteoblastoma
Haemangiopericytoma
Haemangioendothelioma
Chordoma
Malignant spinal pimaries
Osteosarcoma
Chondrosarcoma
Ewing’s sarcoma
Neuroectodermal tumours
Malignant lymphoma
Myeloma
Angiosarcoma
Fibrosarcoma
Liposarcoma
Malignant tumours tend to involve the entire vertebral column
Neurofibroma
Benign tumours arising from the nerve sheath
Three types:
- Cutaneous
- Spinal
- Plexiform
90% of cases they present as solitary lesions,
Multiple = patients with neurofibromatosis type 1 (NF1), -autosomal dominant
Neurofibromatosis Type 1
Referred to as peripheral neurofibromatosis or von Recklinghausen disease
1 in 3000
Diagnosis of NF1 (2 or more of the following):
- At least 6 cafe au lait spots >5mm pre-puberty
- At least 6 cafe au lait spots >15mm post-puberty
- Two or more neurofibromas (any type)
- Presence of plexiform neurofibroma
- Multiple freckles in the axillary or inguinal regions,
- Distinctive bone abnormality involving the eye socket or arm/leg bones
- Optic glioma in the brain
- Two or more Lisch nodules in the eye,
-Parent, sibling or child with NF1
Neurofibromatosis Type II
Central
1 in 40,000
Schwannomas on both 8th cranial (vestibular) nerves
Parent, sibling or child with NF2 plus:
-One vestibular schwannoma in a person less than 30 years of age
-Any two of the following: meningioma, glioma,
schwannoma, juvenile cataracts
Epidural abscess
Surgical emergency
Majority of cases occur within the thoracic spine.
Without treatment –> neurological deficit including paralysis may develop.
Indications for surgery in atlanto-axis subluxation in rheumatoid arthritis
AAS with a PADI of 14 mm or less
AAS with at least 5 mm of basilar invagination
Subaxial subluxation with a sagittal canal diameter of 14 mm or less
(PADI= posterior atlantodental interval)
Cobb angle of 10° or more
= Scoliosis
Early onset idiopathic scoliosis
Cause disruption to lug development
After 8 years, late onset scoliosis, the alveoli are developed
Early onset may cause cor pulmonale and RHF
Management of idiopathic scoliosis
Idiopathic curves of less than 25° are monitored with clinical and radiographic examination
In growing children (premenarchal) with curves between 20° and 29°, a brace may be indicated. Bracing is used to prevent curve progression
Curves beyond 45° are not amenable to brace treatment.
Surgery in the form of corrective instrumentation and
spinal fusion is indicated for curve progression beyond 40°, truncal imbalance and unacceptable cosmesis.
During surgery, continuous spinal cord monitoring is used in the form of somatosensory evoked potentials (SSEP), motor-evoked potentials (MEP) and free-run and stimulated electromyographic (EMG) activity to minimise the risk of neurological damage. The risk of neurological injury is 0.4% (1 in 250).
Stener lesion
Occurs due to gamekeepers thumb
Aponeurosis of ABductor pollicis longus interposed between the ruptured ulnar collateral ligament (UCL) of the thumb and its site of insertion at the base of the proximal phalanx
No longer in contact with its insertion site, the UCL cannot spontaneously heal
Mx: surgicalk attachment
Scheuermann’s kyphosis
Wedging og T7 - T10 vertebrae
Apical pain and lower back pain
–> attempts by lumbar musculature to compensate for the thoracic hyperkyphosis
Mx
Physiotherapy
Bracing in skeletally immature
Surgical:
-Pain (apical or low back pain produced by
compensatory hyperlordosis)
-Progressive deformity greater than 70°,
-Unacceptable cosmesis and neurological and/or cardiopulmonary compromise
Anterior release followed by posterior correction and
fusion.
Posterior chevron osteotomies carried out at the time of posterior instrumentation may prevent the need for the initial anterior release
Diastematomyelia
An abnormal bony or cartilaginous spur projecting across the middle of the vertebral canal
–> dividing the dural tube and spinal cord in two
Between 50% and 70% of patients are seen to have a skin naevus, dimple or hairy patch when the spine is examined
Management of osteoporotic spinal fractures
Providing no neural comprimise
Bed rest
Analgesia
If painful
- -> Kyphoplasty
- ->Vertebroplasty
Sprengel’s shoulder
Abnormal descent of the scapular from its embryonic mid-cervical position
High, small, rotated scapular that remains attached to the cervical spine by a:
- bony bar, or
- fibrous band, or
- omovertebral body
Klippel-Feil syndrome
Congenital abnormality involving fusion of at least two cervical vertebrae
–> short neck and reduced mobility, causes apparent low hair-line
Risk factors for frozen shoulder
Diabetes
Cardiovascular disease
Thyroid disease
Female gender
Age
Treatment of calcific tendonitis
Acute pain with restricted movement around the shoulder due to subacromial calcific deposits
BUT external rotation possible
Tx:
Corticosteroid injections
Barbotage: aspiration and flushing
Surgical decompression if persistent
Changes in rheumatoid arthritis
Osteoporosis
Destruction of articular cartilage
Synovial proliferation
Pannus formation
Rupture of the long head of the biceps
Tends to be proximal tendon rupture in elderly patients due to abrasion under the anterior acromion
- -> bulge appears in arm
- ->sometimes pain of biceps tendonitis is relived by rupture
In elderly it doesn’t alter function –> conservative management
Types of shoulder instability
Traumatic
Atraumatic
Habitual
Types of shoulder instability
Traumatic
-Surgery
Atraumatic
-Surgery
Habitual
-Not for surgery
Bankart’s lesion
Detachment of the anteroinferior labrum
Hill-Sach’s lesion
Damage to the humeral head
Cortical depression on posterolateral humeral head
Management of traumatic recurrent shoulder instability
Repair of labrum
Tightening of anterior capsule
+/- graft of Hill-Sachs
Posterior shoulder dislocation
Forced internal rotation
- Electrocution
- Seizure
- Restraint
Rheumatoid elbow
Radial head excision
Elbow arthroplasty
Points of ulnar compression
Within the cubital tunnel (behind medial epicondyle)
Junction of arcade of Struthers
Medial intermuscular septum as nerve passes into posterior compartment of distal humerus
Between heads of flexor carpi ulnaris
Froment’s sign
Weakness of adductor pollicis
= ulnar nerve palsy
Edinburgh position of safety
Hand splinting position to prevent collateral ligament shortening and deformity during times of immobiliation
= Wrist extension
=MCP flexion
=IPJ extension
Thumb ulnar collateral ligament injury
= Gamekeepers thumb
Chronic overuse –> stretching of ulnar collateral ligament of thumb
Skier’s thumb = forceful abduction causing acute tear
Surgical Mx: pollicis abbductor tendon slips between two ends and prevents healing
Triangular fibrocartilage complex injuries
Triangular fibrocartilage complex:
- Ulnocarpal ligaments
- Extensor carpi ulnaris tendon
- Meniscus-like structure between distal ulna and carpus
Stabilises distal radio-ulnar joint
Injury –> ulna wrist pain and instability
Mx: arthroscopic / open repair
Debridement if chronic damage
Felon
Abscess of specialised fibrous septae in finger pulp
Can cause DIP osteomyelitis
Mx: I&D
Paronchyia
Nail bed infection
Incision, drainage and Abx
+/- partial removal of nail to allow drainage
Flexor tendon sheath infection
Kanavel’s cardinal signs
- held in flexion
- swelling over tendon and digit
- tender
- pain on passive extension
Mx: tendon sheath irrigation and IV Abx
Untreated: adhesions, necrosis, +/- proximal spread
Hand signs of Rheumatoid
Boutonniere
Swan-neck
Flexor tendon synovitis
Radial deviation of wrist + prominent ulnar head
Flexion, subluxation and ulnar deviation of MCPs
Dupuytren’s
Autosomal dominant
Palmar nodules Skin puckering Cords Flexion contractures Garrods knuckle pads over dorsal of PIPs
Associated with: Smoking Trauma Epilepsy AIDS Hypothyroidism Alcohol liver cirrhosis
Mx: when patient can't put hand flat on table OR Flexion develops in the PIP joint --> surgery Z-plasties Digital nerves at-risk
Proceed to amputation if finger restricting useful movements
Trigger finger
Tendon size mismatch between flexor tendon sheath pulley A1 and size of flexor tendon
- -> locking / snapping of finger
- -> pain
Mx:
Corticosteroid injection
Proceed to pulley release
In thumb in children –> resolved spontaneosuly
De Quervain’s
Tenosynovitis of abductor pollicis longus and extensor pollicis brevis within first dorsal extensor compartment
1st EC
Associated:
Female patients during pregnancy (New mother’s wrist)
Inflammatory arthritis
Test: Finkelstein’s
Associations with carpal tunnel syndrome
Majority idiopathic
BUT... Diabetes Thyroid disease Alcoholism Amyloidosis Inflammatory arthritis Pregnancy Obesity
Tests for carpal tunnel syndrome
Phalen’s test: flexion of wrist
Tinnel’s test: tap on carpal tunnel
Durkin’s test: press on carpal tunnel
Management of carpal tunnel syndrome
Night splinting of wrist in extension
Surgical decompression
-Transverse carpal ligament
Guyon’s tunnel syndrome
Ulnar nerve compression in Guyon’s tunnel
Tingling and numbness in little and ring finger
Hypothenar wasting
Dorsal branches don’t pass through so dorsal sensation intact
Causes:
Ganglion
Ulnar artery aneurysm
Hook of hamate fracture
Kienbock’s disease
Idiopathic avascular necrosis of the lunate
Preiser’s disease
Idiopathic avascular necrosis of the scaphoid
Blood supply to femoral head
Retinacular branches of medial circumflex femoral artery
Small contribution from ligament teres
Causes of avascular necrosis of the femoral head
Avascular of the femoral head can be idiopathic (Perthe’s) or secondary
- -> collapse of femoral head
- ->secondary osteoarthritis
Causes:
- Sickle cell disease
- Haemoglobinopathies
- Hypercoaguable states (protein C and S deficiency)
- Caisson disease (the bends in divers)
- Hyperlipidaemia
- SLE
- Gaucher’s disease
- Antiphospholipid syndrome
- Radiotherapy
- Chemotherapy
- HIV
- Steroids
- Chronic liver disease
- Alcoholism
Presentation of AVN of femoral head
Men aged 35-45
Bilateral in >50%
Asymptomatic initially
Ache in groin
Limp
Limitation of movement
Radiographic changes in avascular necrosis of the femoral head
Initially normal, request an MRI
Early: sclerosis
Crescent sign –> subchondral bone resorption
Flattening –> femoral collapse
Graded I - IV
Management of AVN of femoral head
Pre-collapsed stage –> surgical decompression using core decompression +/- inserting vascular bone graft
Collapsed –> femoral osteotomy to shift WB or replacement
Causes of secondary osteoarthritis of hip
Trauma
Avascular necrosis / Perthe’s
Slipped capital femoral epiphysis
Dysplasia
Inflammatory arthtropathy = Rheumatoid
Developmental dysplasia of hip
Septic arthritis
Femeroaectabular impingement
Posterior approach to hip replacement
Along the fibres of gluteus maximus, dividing short external rotators of the hip
Anterolateral approach to hip replacement
=Hardinge
Parts of the gluteus medius and minimus are reflected off the greater trochanter
Medial meniscus tears
Three times more common than lateral meniscus tears
Outer third of the meniscus is vascular and so tears can be repaired with the prospect of healing
Bundles of the ACL
Two bundles
Anteromedial bundle: tight in flexion
Posterolateral bundle: tight in extension
Bundles of the PCL
Two bundles:
Anterolateral bundle: tight in flexion
Posteromedial bundle: tight in extension
Lisfranc’s Injury
Disruption to the cornerstone second metatarsal
2nd metatarsal is recessive in relation to 1st and 3rd
–> Loss of transverse arch and flat foot
Superficial posterior compartment of leg
Gastrocnemius
Soleus
Plantaris
Deep posterior compartment of leg
Tibialis posterior
Flexor digotorium longus
Flexor hallucis longus
Lateral compartment of leg
Peroneus longus
Peroneus brevis
Anterior compartment of leg
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Peroneus tertius
Morton’s neuroma
Pain in the second or third web space
Compression of common digital nerve between third and fourth metatarsal
–> pain
Usually secondary to other foot deformities
Freiberg’s disease
Avascular necrosis of epiphysis of metatarsal
–> re-shaping osteotomy
Management of Charcot
Immediate off-loading and casting to correct deformity
Plasmacytoma
= solitary mass of myeloma
Osteosarcoma
Osteogenic tumours
Two peaks: Adolescence
Second in elderly patients with Paget’s disease or post radiotherapy treatment
Onion-skinning
= Ewing’s sarcoma
Familial conditions with high risk of bone and cartilage cancers
Maffuci syndrome
-Enchondromatosis and soft tissue angiomas
Ollier disease
-Enchondromatosis
Familial retinoblastoma syndrome
Ollier disease
Nonhereditary sporadic disorder where intraosseous benign cartilaginous tumors (enchondroma) develop close to growth plate cartilage
Maffuci syndrome
Maffucci syndrome is a sporadic disease characterized by the presence of multiple enchondromas associated with multiple cavernous hemangioma and phlebolith.
Conditions associated with moderate risk of cancerous transformation
Hereditary multiple exocytoses
Polyostotic Paget’s
Radiation osteitis
Low risk of malignant change
Osteomyelitis
Osteonecrosis
Fibrous dysplasia
Osteogenesis imperfecta
Osteoblastoma
Chondroblastoma
Batson’s venous plexus
Retroperitoneal veins with no valves that allow haematgenous mets to the spine + proximal long bones
Sclerotic bone mets
Pancreatic metastasis
Osteoid osteoma
Bening bone-forming lesion
-Usually occur in children and adolescents
Small but very painful
Pain occurs at night
Responds to NSAIDs
Commonly in proximal femur, and cause a dense cortical reaction in the centre of which is a nidus
Osteomablastoma
Larger version of osteoid osteoma - still benign
> 2cm
More aggressive counterpart of osteoid osteoma that more typically occurs in the spine.
Osteosarcoma
Malignant bone-forming tumour
Most common site: distal femur
Classification:
- Sclerotic
- Chondroblastic
- Telangiectatic
Usually intraosseous
Osteoid tumours
Osteoid osteoma – small, painful; produce dense cortical reaction
Osteoblastoma – larger and more aggressive than osteoid osteoma
Osteosarcoma – malignant; commonest in lower femur and upper tibia
Osteochondroma
Benign cartilage-capped bony projection
Continuity between cortex of bone and frowth - characteristic finding
Bony projection always grows away from the joint towards the diaphyseal region of the bone.
Osteochondromas can be pedunculated with a stalk or sessile (without a stalk)
Usually solitary, but some patients have multiple osteochondromas (hereditary multiple exostoses, autosomal dominant inheritance)
Cause compressive symptoms: nerve impingement, vascular pseudoaneurysm, fracture and infarction
Hereditary multiple exostoses
Autosomal dominant
Enchondroma
Benign cartilagenous neoplasm
Within the intramedullary cavity of bone
50% are in the hands and feet: enchondromas are the most common bone tumours in the hand. A
Pain, swelling or pathological fracture, many are
asymptomatic
Patchy calcification, expansion and scalloping can be visible on radiographs
Ollier disease is a developmental condition characterised by multiple enchondromas
Maffucci syndrome, multiple enchondromas are associated with multiple angiomas
Malignant transformation to chondrosarcoma can occur in approximately 20% of patients with Ollier disease and is almost inevitable in patients with Maffucci syndrome.
Patchy calcification, expansion and scalloping can be visible on radiographs
Enchondroma
Chrondroblastoma
Benign cartilage-producing tumour
Occurs in EPIPHYSES of bones in CHILDREN
Commonly knee
Presents: severe pain and knee effusion
Radiograph often missed lytic lesion in centre of epiphyses
-Isotope bone scan can help identify the lesion
Chondrosarcoma
Malignant tumour with cartilagenous differentiation
Low- grade –> aggressive
Pain + welling
Many arise from enchondromas or osteochondromas
Clear cell chondrosarcoma is a rare form of chondrosarcoma that occurs in the epiphysis
Tumours of cartilage differentiation
Osteochondroma – cartilage capped; grows away from physis
Enchondroma – inside bone; commonest in hands and feet
Chondroblastoma – in epiphyses of adolescents
Chondrosarcoma – of varying malignancy
Eosinophilic granuloma
Eosinophilic granuloma is a rare neoplasm of Langerhans cells
Unifocal (eosinophilic granuloma)
Multifocal (Hand–Schuller–Christian disease)
Disseminated (Letterer–Siwe disease).
–> Skull and the diaphyses of long bone
In the spine it can present with collapse, known as vertebra plana
Radiographs can appear aggressive and similar to Ewing’s sarcoma
-often expansion and a ground glass appearance, sometimes with cystic change
Ewing’s Sarcoma
Malignant round cell sarcoma
T11:22
Arises diaphysis long bone or pelvis
Painful mass and may have systemic symptoms including fever, anaemia and increased erythrocyte sedimentation rate (ESR)
Radiologically the bone appears moth-eaten and may show an ‘onion-skin’ periosteal reaction
Bone tumours misc
Simple bone cyst – proximal long bones of children
Aneurysmal bone cyst – more aggressive, expanding
Giant cell tumour – found in epiphyses around the knee
Fibrous dysplasia – may be multiple; long bones, ribs and skull
Ewing’s – round cell sarcoma; patients may have fever and anaemia
Enneking staging system
Staging primary bone cancers
If breached cortex = 2B
Trojani system
Staging for malignant sodt tissue tumours
Based on tumour differentiation, mitotic count and tumour necrosis,
Relief with non-steroidal anti-inflammatory drugs may suggest
an osteoid osteoma
Red flags for soft mass
Painful
Increasing in size
More than 5 cm in diameter
Biopsy for ?sarcoma
Only biopsy once staging is completed
Biopsy should be performed at the institution undertaking the main surgery
Imaging-guided biopsy is more reliable
he biopsy track must be excised at definitive surgery
Jamshidi needles for bone, Trucut needles for soft tissues
CT-guided thermocoagulation
Used in treatment of osteoid osteoma
Many recgress spontaneously
Neoadjuvant chemotherapy
Pre-op chemotherapy used for:
- Osteosarcoma
- Ewing’s sarcoma
Insensitive to radio or chemotherapy
Chondrosarcomas
Mirel’s scoring system
Used to predict risk of pathological fracture
Larger, more painful, lytic lesions carry a higher risk
Lower limb higher risk vs upper limb
Soft tissue sarcomas
Complete excision with biopsy tract
Not senitive to chemotherapy
Pre-op and post-op radiotherapy can be useful but can impair wound healing
Involucrum
Pathological feature of osteomyelitis in which new bone is constructed around dead bone forming many sinuses
Debridement, antibiotics and implant retention, ‘DAIR’
Can only be undertaken if the prosthesis is well-fixed
The surrounding infected soft tissue and bone must be
fully excised and modular components exchanged
This cannot be achieved by arthroscopic surgery
Good soft tissue cover is essential. Following debridement, the patient is treated with long-term antibiotics (frequently 6 weeks of intravenous therapy followed by 6 months or more of oral antibiotics).
Prolonged infection-free intervals will be achieved in 80% of patients but success with this strategy may be lower in infections caused by Staphylococcus aureus.
Two-stage joint revision surgery
Thorough excision is undertaken and all cement and loose foreign material is removed.
An antibiotic-impregnated spacer may be implanted (which may be articulating)
This is a temporary measure and cannot withstand full weight bearing.
The patient is treated with oral or intravenous antibiotics, most commonly for 6 weeks.
New prosthesis is implanted after the course of antibiotics has been completed.
Rerevision surgery for infection has a higher failure rate than a first revision, and so early referral to a specialist centre should be considered.
Single-stage joint revision surgery
Removal and reimplantation are undertaken in the same operating session.
Healthy soft tissues around the new implant are essential to prevent reinfection. Some centres consider single-stage revisions when less florid signs of infection are present (i.e. absence of collections or sinus tracts), or for frail patients for whom the risk of a second operation is higher.
There are no adequate trial data comparing outcomes with the two-stage approach.
Commonest site of acute osteomyelitis in adults
Vertebral column
Children: long bones
Cierny and Mader classification
Classification for chronic osteomyelitis
Four stages of infection
Stage 1: medullary
- just cancellous bone
- ream bone and pack with Abx pellets
Stage 2: superficial
-Only the cortical bone is involved and this requires excision.
- follows skin ulceration and there may be large skin
defects which require complete excision and local or free muscle flaps
Stage 3: localised
-limited area of dead cortical bone with medullary
infection.
-staged reconstruction after excisio n
Stage 4: diffuse
- Involves the entire circumference of the bone and surrounding soft tissue
- All infected non-unions are Stage 4.
- Resection must be segmental and stabilisation in an external fixator will be required. Reconstruction will involve the introduction of new bone and healthy soft tissue
- Ilizarov method, which uses distraction osteogenesis to fill bone defects
Three host groups A- C
A, no active concurrent disease
B, compromised host
C,severe comorbidity preventing surgery
Stages of chronic osteomyelitis
Stage 1: medullary
Stage 2: superficial
Stage 3: localised
Stage 4: diffuse
Occurence of congenital limb abnormalities
Usually occur within 2 motnhs of fertilisation
The upper limb bud forms on the lateral wall of the embryo 4 weeks after fertilisation, followed promptly by the lower limb bud
AER controls proximal to distal differentiation and interdigital necrosis
ZPA directs posterior to anterior differentiation
Wnt influences dorsal to ventral differentiation
Heuter-Volkmann principles
Compressibe forces inhibit growth
Tensile forces stimulate growth
Wolff’s law
Bone deposition and resorption depend on the stresses applied
Apical ectodermal ridge
Guides mesordermal proliferation in the progress zone in proximal –> distal direction
Controls digit formation
Zone of polarising activity
Mesodermal zone of polarising activity directs anteroposterior limb development via the sonic hedgehog protein
Ectodermal driven wingless- type (Wnt) signalling centre
Ectodermal driven wingless- type (Wnt) signalling centre develops dorsoventral axis configuration and limb alignment.
Cause of persistent in-toeing gait
Femur/hip: Persistent femoral neck anteversion
Tibia: Internal tibial torsion
Foot: Metatarsus adductus
Internal tibial torsion
Internal tibial torsion is assessed by the thigh–foot angle
Commonly associated with physiological tibia vara
in infants
Spontaneous correction can be expected by age 4, as the tibia also rotates as it grows.
Normal variants of early gait
Children’s legs are often bowed until age 2 years and then knock-kneed until age 6 or 7 years
Neuromuscular pathology must be excluded in toe walkers, particularly when the onset is late
Intoeing or extoeing may be caused by excessive femoral or tibial torsion or foot deformity
Flexible, pain-free flat feet do not need treatment
Flat foot
Flexible vs rigid
Flexible:
On tiptoe the arch is restored and the heel corrects into varus; subtalar joint movements are full and pain free
Rigid:
On tiptoe the arch fails to return and the heel remains in valgus; subtalar joint movements are restricted and often painful
=inflammation or a tarsal coalition (calcaneonavicular bar)
Achondroplasia
Gain in function mutation in fibroblast growth factor receptor 3 (FGFR3)
Short arm chromosome 4
Autosomal dominant
Disproportionate short stature where the limbs are shorter than the trunk
Radiograph features: -Splaying metaphysis -Over-long fibula -Slight bowing -Horzontal acetabulum -Square pelvic wings Underdevelopment of the foramen magnum and spinal stenosis can cause neurological difficulties
McCune Albright’s
Precoious puverty
Cafe-au-lait spots
Fibrous dysplasia
ground glass’ appearance
Fibrous dysplasia
Developmental dysplasia of the hip screenig test
DDH defines the spectrum of hip instability, ranging from the hip that is in joint but has a shallow (dysplastic) acetabulum
‘pushed out’ (Barlow positive) to the dislocated hip
Irreducible (Ortolani negative).
Management of DDH
Many hips that are unstable in the first few days/weeks of life do not need treatment as they improve spontaneously
Up to age 4–6 months, a harness or splint is effective
treatment
In older babies, closed reduction is often possible and
preferable to an open reduction
For failed closed treatment, open surgical reduction is
required
Avascular necrosis eponymous conditiosn
Kienbock’s disease Lunate
Perthe’s: Hip
Panner’s disease Capitellum of the humerus
Freiberg’s disease Metatarsal head – usually the second
Köhler’s disease Navicular
Hilton’s law
Hilton’s law, which states that a joint is supplied
by the same nerves as the muscles that move the joint,
Osteochondritis dissecans
Mostly commonly affects medial epicondyle of distal femur
Osteochondral fragment becomes partially or totally separated
If partial: rest and conservative managment
Complete or mechanical symptoms: fixation or removal of loose bodies
Osgood-Schlatter disease
Traction apophysitis of patellar tendon insertion
Pain, tenderness and swelling at the tibial tubercle, exacerbated by exercise, are diagnostic
Radiographs are unnecessary if bilateral, if unilateral ?maliganncy so imaging required
Mx: relative rest and analgesia, and the condition
resolves once the apophysis has fused
Fibular hemilemi
Congenital failure of formation of the lateral ‘column’ of the lower leg
Blount’s disease
Disordered growth in the posteromedial proximal tibial physis
Presents with porgressive and severe tibia vera + intoeing
Surgical management necessary
Congenital pseudoarthrosis of the tibia
Rare condition presents clinically with an anterolateral
bow of the tibia with or without a fracture.
Congenital pseudoarthrosis of the tibia
Rare condition presents clinically with an anterolateral
bow of the tibia with or without a fracture
50% are associated with neurofibromatosis
Paediatric knee and tibial conditons
Osteochondritis dissecans – better prognosis in children than adults
Discoid meniscus – usually lateral, may require surgery
Anterior knee pain – treatment almost always conservative
Fibular hemimelia – associated with abnormalities from the foot proximally (foot worse than hip), the tibial bow has an anteromedial apex
Blount’s disease – clinically, a sharp proximal tibial angulation
Congenital pseudarthrosis of the tibia – the tibial bow has an anterolateral apex
Posteromedial apex tibial bow – largely physiological, the bow improves with time but the limb may be short
Congenital talipes equinovarus
Deformed in three planes
- Hindfoot is in equinus and varus
- Midfoot cavus and
- Forefoot lies adducted and apparently supinated, although actually pronated relative to the hindfoot.
M > F
50% bilateral
Most cases are idiopathic but neuromuscular causes include spina bifida and arthrogryposis
Scoring systems (Pirani/Dimeglio), are used to assess the severity
Radial club hand
Associated with VACTERL syndrome
-abnormal vertebrae, anus, cardiovascular system, trachea, oesophagus, renal system and limb buds
- short radius
- deformed ulna
- +/- an absent thumb
Mx: balance of conservative measures, including physiotherapy and splinting, and judicious surgery to centralise and stabilise the hand and wrist on the single bone forearm
Radioulnar synostosis
Presents with a fixed forearm position in childhood
Congenital radial head dislocation
Usually posterolateral vs traditional traumatic anterior
Congenital toricollis
Usually caused by moulding but may present with fixed sternocleidomastoid contracture or with a palpable ‘tumour’ within the muscle.
There is a strong correlation with DDH
Most cases resolve with stretching
Persistent cases develop facial asymmetry and require surgical release of the sternocleidomastoid at one or both ends.
Kocher et al. Septic arthritis
Fever > 38.5
Non-weight bearing
ESR >40
WCC >12
0: 2%
1: 9.5%
2: 35%
3: 72.8%
4: 93%
Tibial metaphyseal corner injuries
= Non-accidental injury
