7. Time- Absolute Max=3hrs.; Recovers in 5-7 days.
8. Temp- Avoid heat (eg. hot lights)
9. Document- Duration & Pressure.
10. Calibrate- against mercury manometer weekly & three monthly maintenance.
/ATechnetium- osteoblastic acivity.
3 phases: 1) Perfusion- incr. in soft tissue inflammation. 2) Equilibrium (Blood Pool)- incr. in active bone disease; decr in low perfusion areas. 3) Bone- incr. in chronic inflammation (arthritis, chr. osteomyelitis)
Gallium- inflammation.
Indium WBC- infection.
AAT1- Anatomical:
white= fat, proteinaceous fluid, bone marrow
black= other fluids, tendons, ligaments, fibrocartilage
T2- Incr. contrast betw. normal & abnormal tissue.
white= Inflammation, neoplasms, pus, all fluids
black= ligaments, tendons, fibrocartilage
Gadolinium- Incr. contrast betw. tissues in T1&T2.
A1) Bulk Forming - Bran, Fybogel, methylcellulose- few days to act, incr. fluid intake.
Admit- confusion, skull fracture, headache, vomiting, medical condition, difficult to assess, no responsible attendant.
Neurosurg- skull fracture with confuion or fit or neuro deficit, compound depressed skull fracture, base of skull #, confusion>8hrs, coma despite resus, deteriorat
*Note: No # & orientated = 1:6000 chance of ICH, # & confused = 1:4 chance of ICH.
* Hypertension: DBP 90-105mmHg= 2x risk of ischaemia
*URTI: 16x incr. risk of laryngospasm, apnoea, bronchospasm, at time of surgery; 20x incr. risk if infection 3-4wks before surgery; therefore postpone surgery for 4wks after URTI.
Dressing= Parrafin gauze & Xerofoam tied on graft with staples. Wool & crepe.
Donor site= Tegaderm/Opsite - leave to seperate itself.
Inspect Recipient site at 5days.
?Granuflex dressings.
Contraindication= Group A, B-haemolytic streptococci
^A1) Preconditions- unresponsive & ventilated, cause of coma known & irreversible.
2) Exclusions- Drug suppression, shock, metabolic, hypothermia.
3) Brainstem Reflexes- pupillary light response, corneal, vestibulo-occular, gag, motor responses. - Carried out by 2 doctors.
Apnoea Test= disconnect ventilator- no resp. attempt + incr. PCO2 to 6.65kPa.
;A1% burn= Patients palm.
fluid loss= 2-3ml/kg/%burn/day
Admit: >10% in children & elderly; >15% in adults, facial, perineum, inhalation, circumferential.
Muir & Barcley formula: Fluid(mls)= wt x %burn/2 per period; Periods(hrs)= 4,4,4,6,6,12. haemacel initially then crystalloids. 1U blood for every 10% deep burn.
2ndry intention: as above + myofibroblasts -> wound contraction.
GFs= PDGF, TGF, EGF.
Cytokines=IL1, TNF.
A= prominent posterosuperior portion of calcaneus. Associated with high heels, cavo varus. Superior calcaneal angle >75deg. Treat initially with soft heel counters & flat shoes. Surgery = excision of the bony prominence & bursa thro a medial paratendinous incision
damage. 2-point discrimination is of use.
ro FROM.
Unlock distal ball joint at 3wks, remove at 6wks.
tokines=IL1, TNF.
BDHEA is produced by the adrenal gland. Precursor of both testosterone & oestradoil. Levels fall to 20% of peak value between 35-70 years of age. Decline may be associated with an increase in disability & disease. DHEA leads to incr. androstenediol in men & incr. insulin-like growth factor of 10% in men & women. Incr. lean body mass & muscle strength. 100mg daily dose stimulated a greater incr. in androgens in women. No change in liver or thyroid function. Avoid in people with family history of hormone-sensitive tumours.
:B OA RA SepticA Gout/Pyroph.
Appear: clear turbid turbid clear
WCC/mm: 1000 30 000 100 000 10 000
Cells: mononucl Neutr. Neutr. Neutr.
Crystals: No No No Yes
Clots: No Yes Yes Yes
Viscosity: High Low Low Low
Culture: Neg. Neg. Pos. Neg.
B1) Palmar subaponeurotic space- deep to palmar aponeurosis, contains sup. palmar arch. collar-stud abscess.
2a) Ulnar & radial bursae- tendon sheaths to little finger & thumb.
2b) Tendon sheaths- drin infection thro transverse incisions over MCPJs and DIPJs, indwelling catheter for irrigation (?Jacques).
3) Midpalmar space-overlying MC's, extends to web spaces via lumbrical canals. extends under flexor retinaculum to space of Parona.
4) Thenar space- betw. thenar muscles & adductor pollicus, extends to radial side of index finger.
B1] Clear all unnecessary equipment
2] Cover operating table with polythene cover
3] Theatre personnel reduced to minimum
4] Staff with hand abrasions/lacerations excluded from theatre
5] Water resistance gowns & double gloves
6] Surgical Technique: a] Modified to limit sharps injury b] No touch technique where possible, c] Scissors & diathermy instead of scalpel, d] Scalpel not to be passed, e] Skin staples rather than sutures
7] Pt to recover in theatre and transfer to ward [Not recovery]
8] Instruments cleaned with soap & water & autoclaved
9] If needlestick injury occurs -> serial antibody testing of Pt & worker -> AZT.
BInflammatory granulomatous condition, of unknown aetiology, which causes proliferation of the synovium of joints , tendon sheaths or bursae. First described by Jaffe et al. in 1941. Synovium appears brown due to haemosiderin deposition within it. Ix: MRI, synovial biopsy. XRay=articular erosion, subchondral cysts later Rx: Total synovectomy- recurrence common with diffuse form, but not with nodular form. If found incidentally at surgery(TKR) it should not affect the decision to continue with the operation.
ANormally produce 15-20ml RBC/day (1gdl/wk)
Red cell life=120d, Platelet life=10d, WBC life=7hrs.
Albert H. Freiberg (1868-1940), Cincinnati Ohio- described infarction of 2nd MT head in 1918. He considered it to be an injury. Rx- rest, dorsiflexion osteotomy, MT head debridement, (MT head excision)
BPughs(fixed)/Bucks(sliding)
Gallows- weight to just lift buttocks
Hamilton Russell- 2 vectors, sling under knee, single cord + 3 pulleys or 2 traction cords (modified HR)
Dunlop- humeral supracondylar #, shoulder abducted 45deg, elbow flexed 45deg, weighted sling over distal humerus 0.5kg + weighted skin traction to forearm 1kg -> resultant force in line of humerus.
Halter- cervical spine spondylosis, 1.4-2.3kg
Cotrels- intermittent, for scoliosis, legs + halter
Pelvic Sling- weight just to lift pelvis (5kg), compression obtained by crossing suspension cords.
Tulloch Brown Splint- suspends leg after Girdlestone (U loop over knee + sling under calf)
$Eaudit is the systematic analysis of the quality of medical care provided in the context of prescribed targets/ standards. (to assess, evaluate & improve patient care in a systematic way)
The 'audit cycle' = -->Identify need for change --> Standard & criteria setting --> Data collection --> Assessing results against standards set --> (Implement change) --> Identify need for change
AIMS: Improve the quality of patient care.
+ educational benefit,assist in obtaining resources from the purchasers [health authority], assist in medico-legal defence, identify problems and resolve issues to implement change
The 'Elements of Health Care' should be assessed: a. Structure - availability & orginisation of resources b. Proccess - Pt. management from referral until discharge c. Outcome - Results [m&m;hospital stay;Pt.satisfaction;quality of life]
PROCEDURE:Complete & accurate medical records must be kept. Should have an audit officer & computers for collection, coding, analysis & presentation of data.
Audit meetings should be held at least once a month
All surgical staff should attend. Junior staff should present data. Consultant staff should chair meeting. A record of every meeting should be kept. Management problems should be identified, solutions sought &. Practice guidelines drawn up.
Pearson Attachment- for Thomas splint, allows knee flexion, with tibial skeletal traction, hinge centred on adductor tubercle of femur (axis knee rotation)
AAccuracy for med. meniscus 89% (93% sensitivity 84% specificity). Similar for lat. meniscus with lower sensitivity 76%. - multicentre review of2000 patients.
Myxoid Degeneration o the post. third of the med. meniscus causes high signal intensity & is commonly reported as a tear.
AAuthorship credit should be based on significant contribution to all the following:
a) Conception & design or Analysis & interpretation of data.
b) Drafting the article or revising it critically for important intellectual content.
* Dexon (polymer of glycolic acid)- Absorbed @ 60-90d.
* Maxon (copolymer of glycolic acid & trimethylene carbonate)- Absorbed by 6m; 70% strength @ 2w.
Absorption is by non-enzymatic Hydrolysis, breaking down into carbon dioxide, B-hydroxybutyric acid & glycolic acid which are excreted in the urine. (catgut & collagen are digested by proteolysis)
WAPrevents tissue adhesions after surgery or trauma. It is a membrane resembling wax paper that dissolves and is absorbed into the body. The film is comprised of two inert polysaccharides modified to form a stable membrane. In the body it turns into a gel which stays in place for 7 days, then is absorbed. Tested on ileostomies & myomectomies.
.ADorsal longit incision over distal ulna (10cm). Remove articular surfaces of DRUJ with micro saw. Remove 3cm segment of distal ulna - transverse cut distal & oblique cut prox. to avoid union. Use bone from removed segment as graft for DRUJ. Fix DRUJ with 2 K-wires. Bury K-wires under skin. Backslab.
BIncision- midline from midpatella to tibial tuberosity + 2cm. Undermine skn edges. Long lat. release down to lat edge of tibial tuberosity (down to synovium). 3 large figure-of-8 plication sutures medial collat. lig. (don't tie yet)(1 PDS). Define edges of patella tendon- defining medially down to bone & reflecting medially. Lift a 'trap door of periosteum' medial to tibial tuberosity. Divide middle of patella tendon with knife. Remove lateral half of patella tendon off insertion. Pass lateral half of patella tendon under medial half & suture to periosteal trap door with 1 PDS (may need staple). NB-Knee must be at 30deg flexion. Tie plication sutures & close in two layers.
%Afor subluxed MTPJ & PIPJ (Hammer toe)
'V-Y' Dorsal incision (over MTPJ for single toe, web spce for 2 toes); Divide extensor tendon proximally;
Remove prox.
of PP; Reduce Fat Pad with McDonald under MT head; Suture distal extensor tendon end to flexor tendon; K-wire through DIPJ-PIPJ-MTPJ.
nASteinmann pins (predrilled) thro Talus(1cm ant & inf to lat malleolus). Apply clamp for distraction. Anterior approach betw. EHL & EDL to joint. Remove articular surfaces with osteotome & save some bone for grafting. Aim for 0deg flexion & slight valgus. Bone Graft. Apply clamp & compress right down. Backslab. Retighten & compress at 3-4days. 60-80% Success Rate.
ColA2G
ColA3
BSanders Classification,(CT based): No. of fragments of posterior facet- Type 1= minimally displaced, non-operative Rx. Type 2= two major fragments. Type 3= three major fragments. Type 4= four or more pieces. ORIF recommended for types 2 & 3, primary fusion for type 4.
Indic for ORIF= post. facet displacement >2mm; Sanders type 2 & 3; young, active; reduce deformity for later subtalar fusion; lateral wall impingement. Must obtain a superior result to closed Rx.
Results of ORIF= 85% good results, preserving 50% of subtalar motion.
@Elemental fractures:
1) Post. wall, 2) Post. column, 3) Ant. wall, 4) Ant. column, 5) Transverse.
Associated types:
1) T-shaped, 2) Post. column + wall, 3) Transverse + post. wall, 4) Ant. wall/ column + post. hemitransverse, 5) Both columns.
Post. column= ischium extending up along the post. border of the ace
tabulum into the greater sciatic notch (ilio-ischial line on XR).
Ant. column= sup. pubic ramus extending along the ant. border of the acetabulum into the ilium in the region of the pelvic brim. (ilio-pectineal line on XR)
APatients Opinion; Activity Pain; Pain Rising from Chair; Rest Pain; Stairs; Walking Assistance; Walking Distance; Activity; Fixed Flexion; Flexion Range; Peri-prosthetic Radioluscency. Each scored out of 5.
Avoids combining all into one score like Harris System.
Position prone with forearm hanging over arm board.
Measure nail length & diameter with ruler. Should be 5cm from top of humeral head & take account of shortening.
Incision- form sup. edge olecranon fossa 25mm prox., triceps splitting.
Open medullary canal with 3.2mm calibrated drill bit at 30deg. angle. Overdrill with 4.5mm drill bit & enlarge hole with Conical Burr to size= 20mmx10mm.
Apply Compression Device if required to coupling.
Insert Nail under II. Nail tip should only slightly protrude into humeral head.
Prox. lock with radiolucent driver. Lock distal with insertion handle. Add 2mm to depth gauge measurement. If using Compression Device, tighten the nut after prox. locking, before distal locking. Remove Compression Device and insert end cap. Post-op Brace for 1wk.
Proximal Insertion Technique:
Position supine on broad arm board. Nail length should be at least 20mm prox. to olecranon fossa. Incise just lat. to acromion, splitting deltoid. Incise supraspinatus tendon in line with fibres. Can adduct arm. Entry point must be in line with medullary canal, at the margin of the articular surface medial to greater tuberosity. Use straight cannulated Awl to pass K-wire into medullary canal, then open canal with awl. Lock distally with radiolucent driver. Lock prox. Lat->Med.
*Reduction Tip- pass nail just thro prox. segment & use it to hitch distal segment (RM Smith).
A* insert femoral component as lateral as possible (=centre of canal) & avoid varus angulation.
* small flanged cup vs. OG cup
* J&J now using foil vacuum packing: vacuum -> less oxygen to react with UHMWPE, foil -> no hydrogen release from UHMWPE.
* position of acetabular cup should be rather closed(horizontal) & anteverted.
*Lateral position - use leg bag to put leg in when dislocated. Measure leg length at knees pre-op & later.
A>4mm depression leads to joint incongruity & valgus, 8mm depression can cause instability, therefore ORIF.
Classification:
Type 1= wedge # lat. tibial plateau.
Type 2= Lat. wedge + dpression of adjacent WBing area.
Type 3= Depression without wedge.
Type 4= medial tibial plateau (+ intercondylar eminence)
Type 5= Bicondylar
Type 6= Plateau+ # metaphysis/diaphysis junction.
NB- The result of failed open reduction is always worse than the result of failed closed reduction.
*Grd 3c may require vascular shunting prior to stabilisation. Thorough sharp debridement & pulsatile lavage. Change drapes after debridement for nailing. (Low velocity gunshot=Grd 1)
* Ext Fix: Preferable for Grd 3c, ARDS, pulm. contusion
IM Nail: Grd 1-3b, best outcome in alignment, length, joint motion.
*The shorter the interval of Ex Fix & the longer the delay betw fixator removal & nailing the less likely medullary infection will occur!
*If nailing not done in first 72hrs, wait for soft tissue envelope to close (use skeletal traction to maintain length).
*Should convert ExFix to IM Nail within 2wks, if unable to, then remove ExFix & allow pin sites to heal (can use skeletal traction for length). Usually wait 5days after pin removal for nailing (pin-sites must be 'dry') (otherwise medullary infn risk= 13%).
AFactors maintaining a stable fixation are:
1) Bone Density into which screw inserts
2) Degree of inferior comminution at # site.
3) The angle of the # line (Pauwel's angle, shaft-# line angle) - more horizontal is more stable.
4) The moment arm of the joint reaction force - which increases with a longer femoral neck & more horizontal femoral neck.
DHS: higher shaft-barrel angle & screw should be inserted as completely as possible within the barrel.
Cannulated Screws: Number does not incr. stability.
AIndic: HV angle <30deg & IMT angle <13deg. Young Pt, doesn't shorten hallux, cancellous bone cut.
'>' shaped osteotomy, central drill hole. Angle betw two cuts= 60deg.
Grip MT shaft with towel clip & push head laterally one third distance (4mm). Fix in position with 2 k-wires. Remove MT projection with saw. Bend & bury k-wires. close V-Y capsullorhaphy with swab in first web space.
Post-op: medial POP slab for 2wks, then 1-2 spacer for 4wks.
]A<1cm size; central ostepoid nidus encased in dense bone. Pt < 30yrs age. (>1.5cm= osteoblastoma)
-> pain++ relieved by aspirin.
Resembles small Brodie's Abscess (need biopsy)/ eosinophilic granuloma.
Excise nidus by burring & curretage or Radiofrequency ablation under CT guidance(Bx taken at time of trephine. Electrode heated to 90deg. for 4min)
hough only one is prominent (prevents others becoming prominent post-op).
A1) Anterolat: 25cm incision halfway betw fibular shaft & crest of tibia. Identify sup peroneal nerve just post to lateral intermuscular septum. Release ant compartment in line with tibialis anterior. Release lat compartment in line with fibular shaft.
2) Posteromed: 25cm incision 2cm behind post margin of tibia. Retract saphenous vein & nerve anterior. Release fascia over gastrosoleus. Release deep post comp. over FHL. Identify tib post- may need releasing. Use zi-zag rubber tube & staples to appose.
CPCL Retention:
*Adv: preserves proprioception, encourages femoral roll-back(incr. ROM), protects against post. subluxation, better kinematics.
*Disadv: post. laxity if too loose, 'nutcracker' effect if too tight, less conforming surface reqd. to allow roll-back & slide causing incr. contact stresses, sliding causes high subsurface stresses (delamination).
PCL Sacrifie:
*Adv: Technically easier & reproducible, greater articular interface conformity to provide ant-post. stability associated with reduced surface stresses, no sliding.
*Disadv: no roll-back causing less ROM, incr. constraint associated with the conformity increasing stresses at fixation interface, proprioception & kinematics may be affected.
Long-term follow-up reveals no difference in performance & survival.
CMETALS: High tensile strength & modulus of elasticity, medium hardness, can be ductile, poor resistance to corrosion, high electrical & thermal conductivity. Alloys- Mild steel= iron & carbon; Stainless steel- iron, chromium, carbon & manganese. Carbon improves strength. Chromium improves corrosion resistance.
POLYMERS: 1) Thermosets= decompose when heated. Bakelite. 2) Thermoplastics= soften when heated. Polythene. Low modulus of elasticity; low hardness; medium tensile strengths; ductile; low densities; high corrosion resistance; low electrical & thermal cond
uctivities; tend to creep; properties depend on temp. Can withstand high strains, not high stresses.
CERAMICS: brittle; hard; high modulus of elasticity; stronger in compression than in tension; high abrasion resistance[hard]; low electrical conductivity. Can withstand high stresses, not high strains.
COMPOSITES: two different materials bonded together. More expensive to produce.
HBMaterial Ultimate Strength(MPa) Elastic Modulus
Pure Titan. 250 100
TiAlV4 1200 110
CoCrMo 1241 240
St. Steel 515 220
Cortical Bone 205 17
PMMA 100(Compr), 24(Tens) 2.7
HMWPE 38 12
yB*Inclusion of blood- up to 70% loss of strength.
*Stress risers- Significant effect.
*Antibiotic inclusion- 5-10% strength loss.
*Radiopaque filler(BaSO4)- 5% weaker.
*Vacuum mix- 10-25% strength incr.
*Insertion delay- up to 40% strength loss.
*Pressurization- up to 20% incr. strength.
*Mixing speed- up to 20% reduction if too fast or slow.
*Constraint- stronger in compression than tension.
~F*Introduction:
-Is the study relevant & important to our practice?
-Is the work useful & original? Does it add to the fund of useful knowledge?
-Was the study setting similar enough to our working environment that, assuming the results are valid, they may be extrapolated to our practice?
*Methods:
-Was the architecture or design of the study appropriate to answer the questions posed in the introduction?
-Is the connection betw. the hypothesis & the instruments used clearly justified?
-Is the relationship betw. outcomes & measures plausible?
-Are the instrments used appropriate to the study & have they been validated previously?
-Are the population & the population sample defined & recognisably similar to that seen in practice?
-Are the recruitment definitions & inclusion/exclusion criteria clearly stated?
-Is the sample size sufficient to answer the questions posed, & has there been an attempt to estimate the required numbers in advance?
*Results:
-Is the response rate adequate? Are drop-outs well described, & is there any reason to think that they differ materially from responders?
-Are the tables & figures clear?
-Have stastistical tests been applied appropriately?
-Are p values or confidence intervals used?
-Where statistically significant differences are found, are they sufficient to be clinically important?
*Discussion:
-Does the discussion show an awareness of the methodological limitations of the study design? Are problems or difficulties acknowledged?
-Are the conclusions drawn justified by the results presented?
-Is a comparison drawn with other published work?
-Do the authors speculate too far beyond the evidence presented?
B*CCS= 1) Postexercise pressures in excess of resting pressure; 2) Pressures >15mmHg for >15min. postexercise.
*Using slit catheter (Stryker)
*Pierce fascia at 30deg. to long axis of leg. (usually Anterior compartment)
*Use non-circumferential tape to hold catheter on leg.
*Measure resting pressure.
*Treadmill Protocol= Modified Bruce:
Stage min. km/h
1 2 2.5
2 2 3.4
3 2 4.2
4 2 5
5 2 5.5
6 2 6 until symptomatic
*Measure pressures immediately & then 5min. intervals until pressure returns to resting pressure, or 20min.
C*Always inform Insurance company if planning to drive.
*Report any disability preventing driving for longer than 3 months to the DVLA.
*Below elbow casts should not proclude driving if grip and finger function is normal.
*'Doctors are advised not to say whether a patient is fit to drive, but suggest whether, or not, the patient could meet the necessary standards.' (?) 'The final recommendation about driving is made by the Medical Advisory Group at the DVLA.'
*It is the drivers responsibility to decide whether they are ready and able to drive.
*If a patient is driving against medical advice, the doctor may inform the DVLA after warning the patient.
*Disability does not necessarily proclude driving. Vehicle modifications can allow disabled to drive.
*[DVLA Medical Advice - 01792 783686]
CGold + Green
1) Stabilization wire= 3.2mm Calibrated guide wire through most suitable angle (usually 130deg) on aiming arm thro slot in dummy nail.
2)Use Miss-a-Nail jig on aiming arm & adjust.
3)->2.8mm threaded guide wire, direct measuring device, 7.3mm self drilling/self tapping cannulated screw(gold), (Or for 7.0mm Cannulated screws use 2.0mm threaded guide wire, 2.1mm cannulated drill bit & direct measuring device)
4) Remove stabilization wire & dummy nail & insert nail.
5) 5.0mm Shaft screw thro slot in nail- use 3.2mm Calibrated guide wire thro suitable angle on aiming arm, read length off wire, remove guide wire & insert screw.
6) Static locking- Use Standard Aiming Arm. Green assembly. 4.0mm Calibrated drill bit. Read length off wire. Insert 4.9mm locking bolt.
7) Green end cap.
A* For excision/replacement of radial head, removal loose bodies, synovectomy.
* Inc: 8cm proximal to joint post. to supracondylar ridge -> 6cm distal to tip of olecranon.
*Betw. triceps & brachioradialis & ECRL.
*Betw. ECRL & anconeus proximally and ECU & anconeus distally.
*Capsule now exposed.
(*Reflect anconeus subperiosteally toward triceps. Sharply release tip of olecranon, subperiosteal release of radial collat lig., dislocate joint.)
Dorsomedial incision down to bone. Remove bunion with chisel. Isolate base of PP holding PP with pointed towel clip, protecting EPL & avoiding FPL using bone levers & towel clip. Remove proximal half of PP with large bone cutters.
*Proximal percut. tenotomy of EPL for lengthening or Z lengthening thro original wound.
* Suture Interposing tissue to prevent cut surface rubbing on MT head or K-wire.
@Type A: A1- #'s not involving ring
A2- stable minimally displaced # of ring
Type B: Rotationally unstable, vertically stable.
B1- Open book
B2- Lat. compression, ipsilateral
B3- Lat. compression, contralat. (Bucket handle)
TypeC: Rotationally & vertically unstable
C1- unilateral
C2- bilateral
C3- with acetabular #
Exfix B1-C3 (controls haemorrhage in 90% of cases)
Pelvic fractures are the main cause of
death in multiple trauma patients. Mortality from pelvic Hge= 10-20%. The major blood loss is usually from the superior gluteal artery(as it passes through the sciatic notch) or ant. branches of the internal iliac artery, as well as bony surfaces.
Open pelvic #= 50% Mortality.
Ix with CT Angiography & Rx by embolisation if Hge not controlled with Exfix.
Posterior pelvic Stabilisation= Ganz Clamp[AO C-clamp] or Percutaneous ilio-sacral screw.
UA UTS(MPa) Etens.(GPa) UCS(MPa) Ecomp.(GPa)
Canc. 3-20 0.2-5 1.5-50 0.1-3
Cort. 107-146 11.4-19.1 156-212 15.1-19.7
Sawbone 172 18.6
Tufnol 120 8.0
(6F/45)
Last-A-Foam 10.2 0.354 14.7 0.36
B*Hoffmann 2 inverted 'A' frame (dedicated set)
* ideal site extends posteriorly along the iliac crest from the anterior spine for 8-10 cm. Below this area is a thick triangle of bone with its apex inferiorly.
* Transverse Incisions
* To determine the plane of the iliac crest small guide wires pass along the interior or exterior surfaces of the crest & insert the self drilling 5 mm screw along this plane. Test each one manually for security & add a third if there is any doubt.
*Reduce pelvis manually & tighten frame. Frame must be well clear of abdomen to allow for ileus & laparotomy.
*Convert 'A' to quadrilateral frame when due to mobilise.
A*90% of RA patients develope cervical spine symptoms.
1. Atlanto-Axial Subluxation: Atlas Dens Interval(ADI) >3.5mm is found in 25% of RA patients on Flexion films. >7mm indicates disruption of alar ligs. & other supports. 2. Posterior AAS = odontoid & ant. arch C2 eroded.
3. Atlantoaxial Impaction (pseudobulbar invagination): = tip of odontoid is 8mm(males) or 9.7mm(females) above McGregors Line (from post. edge of hard palate to lowest point of occiput). Caused by bone erosion betw. occiput, C1 & C2.
YA1. Passive DF of little finger >90deg.
2. Thumb touching flexor aspect of forearm
3. Elbow hyperextension >10deg.
4. Knee hyperextensiom >10deg.
5. Trunk flecion to place palms on floor
*Autosomal Dominant; Types 2&3 most common; 'cigarette paper' skin; joint dislocations; bone fragility; heterotopic calcification; vascular or visceral tears.
SAAKA- 13cm above knee (bone cut), need 11cm below stump for knee mechanism of prosthesis.
BKA- 15cm below knee (tibial cut), fibula cut 2.5cm proximal to tibial. Need 8cm below knee for adequate fit of prosthesis. Use a Burgess long posterior flap.
Post-op: Transfer to wheelchair on day 2, PAM aid day 7, measure for prosthesis at 3weeks.
ALumbar #- Duet Brace
Scoliosis <30deg.- Boston brace; >30deg- Milwaukee
Cervical #'s: Odontoid- SOMI; Other- Philadelphia, four poster, dolls collar; Halo for v. unstable #.
ensation
8C1. Atlantoaxial Instability- a)Anteroposterior- Downs Syndrome, JRA, os odontoidium, osteochondrodystrophy Fuse if >10mm. b) Rotatory- present with torticollis. CT scan with head turned Lt. & then Rt. Rx early traction & bracing, Rx late with fusion C1-C2.
2. Os Odontoidium- ununited Type2 odontoid #. >3mm translation or neurology -> C1-C2 posterior fusion.
3. Pseudosubluxation- C2 on C3 or C3 on C4. Up to 40% or 4mm is normal in children < 8yrs old. Reduces on neck extension.
4. Intervertebral Disc Calcification Syndrome- pain, decr. ROM, fever, high ESR, disc calcification without erosion. Self-limiting.
5. Basilar Impression/ Invagination- cephalad migration of odontoid into foramen magnum. Weakness, parasthaesias, hydrocephalus. Rx- transoral resection of dens, occipital laminectomy, occipitocervical fusion.
ABetween FCR & FPL. Retract FPL laterally protecting Radial artery. Retract FCR medially protecting Median nerve. Incise Pronator Quadratus along its radial border & reflect it ulnarwards. Can expose radius up to the junction of the middle & proximal thirds of radius.
unstable #.
ADiaphragmatic breathing* Flaccid limbs* warm periphery* decr. pain sensation* reduced reflexes* erection* decr. BP + decr. pulse rate* retention* decr. body temp. Return of bulbocavernosus reflex at 24hrs= end of Spinal Shock.
Treat: Depomedrone 2g IVI stat (30mg/kg), followed by infusion of 5.4mg/kg/hr for 23hrs. * Oxygen* Atropine 1mg if PR<45* Analgesia=Nefopam (no opiates) * Pressure care* prevent hypothermia* Ranitidine.
I*Dorso-medial incision at the middle of the proximal phalanx; extend it in a proximal medial direction along the medial aspect of the first metatarsal shaft, and end it 1 cm proximal to the first metatarsal-first cuneiform joint. Identify the metatarsal cuneiform joint.
*Remove medial eminence(bunion) with chisel & save for inserting into osteotomy.
*Adductor Release: can be performed thro same incision or thro another over the first web space. The adductor hallucis adheres to the lateral capsule as it courses to its insertion on the base of the proximal phalanx. Slide a small probe down the base of the proximal phalanx, and then turn it laterally to lift the adductor tendon away from the capsule. Adducting the hallux away from the midline to apply tension on the adductor also may be helpful in locating the adductor insertion. Make the releasing incision parallel to the lateral border of the lateral sesamoid, extending the cut proximal and distal for 3 to 4 mm and carefully preserving the underlying neurovascular bundle. Although the adductor tendon is dorsal to the deep transverse intermetatarsal ligament, this ligament is usually divided when fully mobilizing the adductor. If not, divide it to allow repositioning of the sesamoids. This mobilization should proceed from a distal to a proximal direction along the medial side of the adductor. Note: Dissection on the lateral side of the adductor may transect the small transverse head of the adductor hallucis and not release the primary deforming force, which is the oblique head of the adductor hallucis
*Using a power saw with a small blade, begin the osteotomy at a point 1 cm distal to the TMTJl. The osteotomy is at right angles to the metatarsal and should go to, but not through, the lateral cortex. Complete the osteotomy by manipulating the metatarsal laterally.
*Next, contour the resected exostosis to fit snugly into the osteotomy, as the first metatarsal is pushed laterally by squeezing the metatarsal heads together, thereby opening the basal osteotomy. Be careful that the distal fragment does not tilt dorsally and thereby raise the metatarsal head, which might predispose to transfer metatarsalgia. If the osteotomy is now stable, no internal fixation is needed. If it is not stable, insert one or two small Kirschner wires obliquely across the osteotomy from distal-medial to proximal-lateral and cut them off beneath the skin.
Close with a 'Y-V' capsulorrhaphy
WB*Central Cord: Sacral sensory sparing. Greater weakness in upper limbs than lower limbs. Occurs in cervical spine.
*Anterior Cord: Variable loss of motor & sensation to pain & temp, preserving proprioception.
*Brown-Sequard: Ipsilateral proprioceptive & motor loss with contralateral loss of pain & temp. sensation.
*Conus Medullaris: Injury to sacral cord (conus), resulting in an areflexic bladder, bowel & lower limbs. Sacral segments may show preserved bulbocavernosus & micturition reflexes.
*Cauda Equina: Injury to lumbosacral nerve roots resulting in areflexic bladder, bowel & lower limbs.
A1) Wedge Compression- ant. column
2) Stable Burst- ant. & middle column.
3) Unstable Burst- ant., middle, & post. columns.
4) Chance #- Horizontal vertebral avulsion injury with centre of rotation ant. to vertebral body.
5) Flexion-distraction- compressive falure of ant. column, tensile failure of post. column. Centre of rotation post. to ant. longit. lig.
6) Translational- Disruption of spinal canal alignment in transverse plane, sheer mech common.
BNon-structural= postural, nerve root irritation, short leg, hysterical.
BStart with 2kg for high fracture, 3-5kg for low .
Dislocation- Incr. by 4kg every 30-60min (max 25kg). Insert tongs slightly post. if flexion reqd. & ant. if extension reqd. Excessive distraction -> paralysis of Abducens nerve (6) with nystagmus.
1) Crutchfield calipers- incise 5-6cm from midline in the plane of EAM, nearer the vertex.
2) Cone - incise 6cm above EAM, drill/awl 1mm impressions in outer table, close with turnbuckle spanner.
3) Gardner-Wells - No incision, insert 2.5cm above pinna, screw in.
4) Halo - 1cm above eyebrows & ears, Pt should not be able to see ring looking up, torque wrench 6lbs/inch. Recheck head pin torque 48hrly. (Vest torque 30lb/in) Halo->50% less c-spine mobility.
tC*Jefferson #= ant. & post. rings of C1 compressed/ burst. >7mm diastasis= complete tear transverse lig. Vertebral-cerebellar artery damage -> Wallenberg S
. Rx: stable- SOMI, unstable- halo.
*Hangman #= pars interarticularis C2 (traumatic spondylolisthesis). Axial load + extension. Rx- Reduce with traction & apply halo vest immediately. Halo vest for 8wks then moulded collar for 4-8wks.
*Odontoid #= Types1 to 3 - sup. to inf.(Anderson & D'Alonzo). Type2 -> 36% non-union due to 'Watershed area'. Physis fuses at 12yrs age. 25% have #'s elsewhere in cervical spine. Rx= halo reduction & traction for 6wk, then halo vest for 6wk. Posterior C1-C2 fusion if union slow, cannot tolerate halo, atlas #.
*Clay-Shoveller #= Avulsion # spinous process C7 (need to exclude intraspinous & capsular lig. tears)
*Rotatory Subluxation C1-C2- 'cock robin' head position. Rx- halter traction.
ADiamorphine 0.5mg/ml/24hrs, oral dose to start
Cyclizine 150mg/24hrs or Haloperidol 5-10mg/24hrs
Methotrimiprazine 200mg/24hrs to decr. agitation
(Hyoscine 1.2-1.8mg/24hrs)
Or- Fentanyl Transdermal patches dose according to previous 24hr opiod requirements.
AType1- ACJ sprain (undispl.)
Type2- Complete AC tear, but intact coracoclavic. ligs.
Type3- AC & CC tears with coracoclavicular distance 125-200% of opp. shoulder.
Type4- Buttonhole of clavicle thro Trapezius (overlap on AP XR)
Type5- Superior displacement >2x opp. side.
Type6- Inferior displacement below coracoid.
*Types 4-6 should be reduced & stabilised (= modified Weaver-Dunn proc. [= transfer of CC lig. into the resected end of the distal clavicle])
A[A] Arthritides: rheumatoid, juvenile, ankylosing sponylitis, OA (primary).
Surgery: 1) Chevron osteotomy- young, high demand, no shortening. 2) Wilsons- shortening. 3) Mitchells- shortening. 4) Kellers- Low demand, MTPJ arthritis. 5)Basal Dome osteotomy- IM angle >16deg. 6) Lapidus- first MT cuneiform arthrodesis for severe IM angle.
A*Types:
1. Dysplastic(20%)- superior sacral facets are congenitally defective. Often with spina bifida occulta.
2. Isthmic(50%)- Relating to pars interarticularis
[a] Lytic- separation of pars due to fatigue # (spondylolysis). [b] Elongation of pars. [c] Acute #.
3. Degenerative(25%)- facet jt. OA. & long standing intersegmental instability.
4. Post-Traumatic- # not in pars.
5. Pathological- TB or neoplasm.
6. Postoperative
AGRL- Galeazzi, Radius #, Lower DRUJ subluxation.
Mx.- Anatomical reduction of radius (MUA in children, volar DCP in adults). Check reduction with XR on-table & test for stability. Simple/ easily reducible DRUJ -> immobilise in supination for 6w. Complex/ irreducible -> explore DRUJ thro dorsal incision, ECU may be preventing reduction, reduce & test stability, transfix with K-wires proximal to DRUJ, fix ulnar styloid # wth K-wire if large & suture TFCC if torn, immobilise in supination.
-> screws had lower ultimate AXIAL load to failure, No difference betw. 3 groups in lat. bend & torsion.
-> Screw+DHS = no benefit after DHS insertion, but will control rotation at time of DHS insertion.
@ base of thumb metacarpal articulates w/ saddle shaped trapezium; saddle shaped articulation provides inherent stability; radial lateral ligament, which is covered by APL tendon, inserts into the thumb metacarpal; anterior oblique ligament originates on the tuberosity of the trapezium & insertes on ulnar - volar edge of metacarpal base; anterior oblique ligament provides mobility but prevents dislocation; ligament maintains volar stability of saddle joint; anchors volar lip of first metacarpal to trapezium and second metacarpal; maximum tension occurs in this ligament with the metacarpal in flexion, abduction, and supination; dorsal capsular ligaments are covered by EPB & EPL;
- ulnar ligament; limits range of abduction & extension of thumb; if this ligament is torn unopposed pull of M
D- Reduction: - accomplished w/ longitudinal traction on end of thumb, in addition to abduction and extension of thumb metacarpal; thumb is pronated to bring it into opposition w/ non-displaced palmar fragment;
- Fixation:
- less than 3 mm of displacement: - consider closed reduction and percutaneous pin fixation; use 0.45 inch K-wires to maintain reduction but do not attempt to spear small volar lip fragment with the wires; pins stabilize first metacarpal to trapezium or second metacarpal; may accept slight joint incongruity; if reduction not possible ORIF w/ AO cortical screw; spica cast for 4-6 weeks;
- greater than 3 mm of displacement: - consider open reduction and internal fixation;
- Open Reduction: 2.5 cm transverse incision is made over radial base of thumb metacarpal; dorsal sensory branches of radial nerve are identified & protected; EPB & APL are identified and retracted; radial artery is protected and retracted ulnarly; by traction of thumb metacarpal, trapezial frx is visualized & reduced; frx reduction is provisionally secured w/ K-wire;
- if radial fragment of adequate size, 2.0-mm cortical lag screw is used; if only 0.028-inch K-wires are used to secure trapezial frx, additional immobilization is reqd for 6w.
*Lateral Inc.- superior to lat. epicondyle to 6cm across joint, betw. ECU & anconeus. Not >3 fingerbreadths distal to elbow joint to avoid post. interosseous nerve.
*incise annular lig. transversely.
*Osteotomize radius just prox. to biceps tuberosity. Reassemble fragments to ensure complete excision & XRay.
* fashion medullary canal with burrs or rasps & insert trial & then implant.
*Ensure good contact with capitellum, not too tight.
*Reapproximate anuular lig., drain & close. Immobilise for 3wks.
*Complic- loosening, failure, disloc., infection. 90% faile in 7yrs, 20% reqd. revision. thus replacement best used only when elbow is unstable without radial head.
?APoor Prognosis:
*Clinical-
1) progressive loss of movement
2)Adduction contracture
3) Flexion w/ abduction
4)Heavy child
*Radiological-
1) lateral calcification to the epiphysis
2) Gage's sign (V-shaped defect at lateral physis)
3) lateral subluxation
4) metaphyseal cyst formation/ reaction
5) horizontal growth plate
A= Time Dependent response of a material to a constant load or constant deformation. Can be modeled as a combination of a viscous fluid & an elastic solid.
*Response = Creep or stress relaxation.
*Creep= constant load -> variable deformation (rapid initial; then slow progressive, time dep. until equilibrium).
*Stress Relaxation= response to constant deformation (responds w/ high initial stress; then slow progressive, time dep. stress required to maintain deformation).
[A- Class I: islands of bone w/in soft tissues about hip
- Class II: bone spurs in pelvis or prox. end of femur leaving > 1cm betw the opposing bone surfaces.
- Class III: bone spurs that extend from pelvis or the prox. end of femur, which reduce the space betw. the opposing bone surfaces to < 1cm;
- Class IV: radiographic ankylosis of the hip.
&A*Strap incision, slightly more medial.
*Excise lateral end of clavicle.
*No. 5 sutures thro coracoid & over clavicle.
*Coraco-acromial lig. removed from acromion & passed thro end of clavicle & then thro drill holes in clavicle cortex.
Note- screws betw. clavicle & corocoid not strong enough.
insics or RA.
4AEach correct answer score one point:
1. Age; 2. Time(to nearest hour); 3. Address; 4. Year; 5. Name of Hospital; 6. Recognise two people; 7. DOB; 8. Year of First World War; 9. Name of present Monarch; 10. Count backwards from 20.
Be aware of deafness, dysarthria, dysphasia, depression, dysphonia, dialect.
or fibrosis of intrinsics or RA.
E - described in 1882 by Dr. Edward Bennet.
- oblique intraarticular metacarpal frx & thumb CMC dislocation;
- Mechanism of Frx: - results from axial blow directed against the partially flexed metacarpal (ie. from fist fights); frx starts at ulnar base of thumb metacarpal; palmar ulnar aspect of thumb is normally stabilized by strong ligaments; disruption of the ulnar fragment destabilizes thumb; volar frx fragment remains attached to CMC by volar anterior oblique lig; anterior oblique ligament anchors volar lip of metacarpal to tubercle of the trapezium; hence, small volar lip fragment remains attached to anterior oblique ligament which is attached to trapezium;
- distal metacarpal fragment (containing most of articular surface) is displaced proximally, radially, & dorsally by pull of APL; displaced metacarpal is also rotated in supination by the pull of APL; metacarpal head is also displaced into palm by pull of ADP;
- Radiographs: oblique frx line with a triangluar fragment at ulnar base of metacarpal; triangular fragment remains attached to trapezium w/ proximal displacement of the metacarpal; note size of the volar lip fragment and the amount of displacement of shaft;
- Prognositic Features: location and displacement of the fracture; extent of crush or impaction at the metacarpal; presence or absence of shearing or impaction injury to radial side of articular surface of the trapezium;
AUnar Nerve: 1cm prox. to pisiform/ wrist crease. Medial to ulnar artery. Deep to radial border of FCU. 7ml 0.25% Bupivicaine(Marcaine). Inject 4ml 1cm deep to skin & then withdraw to subcutaneous tissue injecting 3ml to block the palmar cutaneous branc.
Median Nerve: Just lateral to Palmaris Longus tendon or 1cm medial to FCR tendon. Insert needle until resistance of flexor retinaculum felt, then advance 2mm. Inject 4ml, then withdraw to subcutaneous tissue & inject 3,l to block palmar cutaneous branch.
JC-also known as Forestier's disease;
-disease involves non-marginal syndesmophytes present at at three successive vertebral levels;
-No disc & joint narrowing & no OA.
-differentiated from AS by marginal syndesmophytes;
-more common in elderly men; ass w/ DM & gout.
-Ass. w/ low back pain.
-prevelance of DISH may be as high as 28%;
-Ass. w/ extraspinal ossification in large joints
-osteophytes are seen at extravertebral sites, esp margins of large joints.
-increased risk of hetertopic ossification following THR.
-Location of Syndesmophytes: can occur anywhere in the spine, most common in thoracic spine, more often seen on the right side;
-cervical spine frequently involved, characterized by thick, wavy ossification of ant. longit. lig.; relative preservation of the disk spaces; no vaccum phenomena or vertebral end plate sclerosis
CSupine, w/ shoulder abducted 90deg. & elbow flexed 90deg. Palpate axillary artery at the lateral border of Pec Major & fix the artery with the palpating finger. Insert a 3.5cm 22G short bevel needle through an intradermal skin weal, just superior to the artery until the resistance of the fascial sheath is felt & a 'pop' indicates penetration of sheath. Aspirate, inject 30ml 0.5% Bupivicaine(Marcaine) using DIGITAL PRESSRE distal to needle to encourage proximal spread. When injection complete, maintain digital pressure whilst adducting arm so humeral head doesn't obstruct prox. spread. If blood is aspirated -> use a transarterial technique, pushing needle out opp. side of artery. The Musculocutaneous nerve may not be blocked adequately, thus withdraw needle from sheath & redirect it 90deg to skin & superior to artery (or block it seperately at elbow).
BSkin inc: from middle of iliac crest to ASIS then distally & slightly laterally 12cm. Free attachments of gluteus medius & TFL from iliac crest. Strip periosteum w/ attachments of gluteus medius & minimus off lat. surface of ilium w/ periosteal elevator. Distally enter betw. TFL laterally & sartorius, rectus femoris medially. Ligate Ascending branch of lat. femoral cutaneous artery, lying 5cm distal to hip joint. Lat. fem cutaneous nerve lies on sartorius 2.5cm distal to ASIS, retract it medially. Expose & incise capsule transversely.
Swiss
Swiss
Swiss
orocoid not strong enough.
a, dialect.
AAnteromedial approach; Reduce #; Provisionally hold w/ K-wires; Fix w/ two 3.5mm lag screws passed retrograde from talar neck to body; preferable to use Titanium screws for possible MRI scans for AVN in the future; post-op NWB for 8-12wks.; Passing screws from neck to body can be difficult so can pass them from back to front.
* Hawkins Line (lucent subchondral line 12wk after injury)= indicator that AVN will NOT occur.
B* Trochlea is wider at front than back; Blood supply via sinus tarsi vessels from dorsalis pedis artery.
1] Avulsion #s: ass. w/ ankle sprain, non-op. Rx.
2] Talar Neck #s: 'aviators astralgus'
Hawkins classification= type 1- undisplaced # (AVN 3%, nonunion 1.5%, subtalar arthrosis 24%), type 2- displaced # w/ subtalar jt. disloc. (AVN 37%, nonunion 7%, subtalar arthrosis 66%), type 3- displaced # w/ both subtalar & ankle jt. disloc. (AVN 77%, nonunion 11%, subtalar arthrosis 63%)
Mx= type1- POP for 8-12wks. type 2&3- ORIF.
Hawkins Line (lucent subchondral line 12wk after injury)= indicator that AVN will NOT occur.
3] Talar Body #s: high incidence of ankle arthrosis & AVN; ORIF needs fibular or medial malleolar osteotomy.
vB*Shorten by7mm. fix w/ DCP plate (5 hole).
*Incision over subcutaneous border.
*Three 2mm dril holes in coronal plane, marking ends & midpoint of longitudinal cut; Drill 3.5mm hole on ventral surface (distal step) for lag screw, which will pass thro screw hole on plate, check position with plate; Make transverse cuts w/ removing 7mm segments for step at the same time; insert 10mm screw thro screw hole in plate & predrilled hole to hold plate onto bone; Reduce w/ bone holders, ay need to adjusst steps for good fit; Compression screws thro proximal holes; May need to explore DRUJ for soft tissue release to allow shortening.
B*Results of non-op. Mx: undispl- 90% good result, displaced 20% & comminuted 0%. Problems of surg.= failure of reduction, failure of fixation, soft tissue.
*Types= Tongue vs joint depression.
*Axial XR gives idea of loss of height & subtalar jt.
*Coronal CT -> 3 major fragments: medial(sust tali), lat, body. Axial CT (horiz)= sust. tali, CCJt.
*Lat jt frag- rotates, usually not depressed. Body frag- displaced up & lat.
*Aims of Surg= Heel height, width & length (joint congruity will follow. Key to reduction is correction of body frag.
Misoprostol (prostaglandin E2 analogue) is indicated for previous gastric ulceration.
Enteric coated tablets reduce mucosal damage.
Low initial doses allow adaptive mucosal protection to develop.
'An arthritic patient should never be denied the benefits of NSAIDs, even if they have a peptic ulcer.'
[Misoprostol can promote cartilage healing by effecting IL-2 & TNF in synovium]
K1] For injuries less than 2-3 weeks old:
- skin incision begins on mid-lateral aspect of the ulnar side of the thumb, is curved
over the MP joint, & extends proximally just ulnar to the EPL tendon; identify branches of the superficial radial nerve at prox. aspect of the incision; identify the EPL, its extensor hood, & adductor aponeurosis; if a Stener lesion is present, it should be visible at this point, & can be seen as a mass of tissue just prox. to the adductor aponeurosis; longitudinal incision is made thru aponeurosis volar to edge of EPL, leaving rim of tissue on tendon to be used later for closure; take care to preserve the underlying MP joint capsule; alternatively, the deep dissection can procedure thru the attachment of the adductor tendon to the extensor hood; again, take care to avoid damage to the capsule; the adductor tendon is retracted volarly; note presence of transverse tear in the dorsal capsule & identify ligament tear; dorsal capsule is reflected, which permits a clear view of joint & inside portion of the collateral lig.; in a minority of cases, the tear occurs thru the mid-substance, which allows for direct tendon repair; in vast majority of cases (90%), ligament ruptures at its insertion into phalanx; prior to ligament fixation, some surgeons will hold the joint reduced with a K wire; w/ distal rupture consider fixation w/ small bone anchors or w/ pull out suture; UCL flap is partially dissected & mobilised off of the metacarpal to permit advancement; its essential that the bone anchors in the proximal phalanx be placed volar to the mid-axial line; the volar position of the bone anchor will prevent volar subluxation of the joint; alternatively the ligament can be anchored down w/ sutures tied down over a button; volar ulnar edge of proximal phalanx is debrided of soft tissue; drill 2 parallel holes distally & dorsally to exit on the far side of the cortex; - take care to avoid the N/V bundle; pass a 2-0 PDS suture thru the distal ligament using a short Bunnel Weave (which will allow the suture to be pulled out postoperatively); sutures are pulled thru the drill holes & tied over a padded button with the joint in slight flexion; closure should include re-approximation of the attachment of adductor tendon to the dorsal extensor hood;
2] Chronic Gamekeepers:
Proximal phalanx tends to volarly subluxate & rotate; deformity develops as a result of damage to ulnar collateral ligament & dorsal capsule; in addition to dorsal joint support provided by capsule & EPB, EPL tendon also contributes to the dorsal stability of MP joint; when ulnar collateral ligament ruptures, ulnar side of phalanx tends to displace volarly & rotate into supination; w/ repeated radial stress, dorsal expansion may attenuate & allow EPL to shift ulnarly, compromising its extension effect on the joint;
*Warn Pt about above + leg length diff. + post-op pain + sciatic n. injury (<1%)
*10% of all THR are unhappy w/ result overall.
C*Abductor Lever Arm- incr. with centralisation of head & lateralisation of greater trochanter -> decr. strength reqd. of abductors to resist body weight & decr. joint reaction force. Biological advantages of preserving pelvic subchondral bone & avoiding troch. osteotomy vs. biomechanical advantages of decr. joint forces & wear.
*Varus-> lengthens abductor lever arm(good), but incr. bending moment & decr. axial loading of stem, also incr. risk of loosening & shortens femur (-> disloc.)
Valgus-> mild valgus preferable, but it decr. abductor lever arm, lengthens femur & can dislocate superiorly.
Neck-femoral shaft angle should not exceed 140deg.
*Wear- influenced by: 1)Coefficients of friction & finish of surfaces, 2)boundary lubrication, 3)load, 4)distance travelled for each cycle (depends on head diameter), 5)number of cycles, 6)hardness of materials. Wear is abrasive (vs. adhesive or corrosive).
QC*FUNCTIONS:
1] Grout, 2] Load transfer, 3] Osseointegration.
* CURING:
Dough Time(won't stick to gloves): 2-3min.
Setting Time(surface temp. is half max. temp ): 8-10min.
Working Time: Setting Time - Dough Time.
Rapid mixing -> incr. dough time & weaker, porous.
Incr. Temp. -> decr. dough & setting times.
Humidity -> decr. setting time.
*Dry component= polymerized microspheric(10-30
m) powder of PMMA, BaSO4(radio-opaque), benzoyl peroxide(free radical source to be acted on by initiator)
*Polymerization forms linear long-chain polymers with no cross-linking. Designed to cure with no volume change, but do get initial shrinking followed by expansion over 30days with water & lipid absorption.
*Less porosity -> incr. tensile strength & ? fatigue life.
.2-1.8mg/24hrs)
Or- Fentanyl Transdermal patches dose according to previous 24hr opiod requirements.
A*Mechanical axis of lower limb extends from center of femoral head to center of ankle joint & passes almost thro. center of knee. It is in 3deg. valgus from vertical.
*Anatomic axis of Femur is in 6deg. valgus from mechanical axis & 9deg. valgus from vertical axis.
*Anatomic axis of Tibia is in 3deg. varus from vertical axis.
*Femoral component should be inserted in 9
2deg. of valgus from vertical axis & Tibial component should be 2-3deg. varus from vertical axis.
AAdv: 1) Less stress in underlying bone; 2) Stresses more evenly distributed; 3) Contained polyethylene -> less cold-flow & bending of polyethylene; 4) Permits modularity; 5) Prevents 'wing-up' phenomenon.
Disadv: 1] Thinner plastic -> incr. stress in UHMWPE; 2] Eccentric loading may -> tilting; 3] Stress shielding of underlying bone; 4] More expensive.
*There may be a place for all-plastic tibial components in the elderly.
aC1. In sagittal plane the resultant of the Quads tendon muscle force(Q) & Patella tendon muscle force(P) = Joint reaction force(R) of PFJ. This force pushes patella against femur. With increasing knee flexion the angle betw. Q & R becomes more acute -> incr. magnitude of R causing ant. knee pain on squating & ascending stairs. By doing an Anterior Tibial Tubercle Transposition the direction of P is more vertical -> Decr. R.
2. Children w/ ant. knee pain walk w/ bent knee gait due to tight hamstrings & calf muscles (test by SLR w/ hand under lumbar spine). Compensation for tight calfs is foot pronation. This twists the patella tendon laterally, moving R laterally -> pressure of patella on LFC. Rx w/ hamstring & calf stretching & supination shoes. A valgus knee requires reinforcing of VMO, = strapping/ Goldthwaite-Roux/ Lat. release/ tibial transposition.
1] Bifocal Lengthening= for shortening with metaphyseal deformity/ short >6cm.
2] Compression-Distraction= for shortening with diaphyseal deformity/ short<3cm
compress fracture gap, callus formed, then distract.
3] Bone Transport= proximal osteotomy, then distract -> Docking, bone graft.
oLInfantile Blounts Disease: (pathologic tibia vara) - most common form of disease; usually bilateral, infantile tibia vara is seen between 2-4 years of age; ass. w/ internal tibial torsion; growth disorder of medial portion of proximal tibial physis; medial angulation & internal rotation of proximal tibia; aetiology is related to repetitive trauma to posteromedial proximal tibia physis from ambulating on a knee with varus alignment; children w/ tibia vara are usually in upper percentiles of weight (for age)& began walking early; this contrasts w/ dysplastic children who present w/ bow legs but who are in the lower percentiles for ht and wt; gait is= painless varus thrust in stance phase; normal knee alignment progresses from 10-15 deg of varus at birth to max or peak valgus angulation of 10-15 deg at age of 3 to 3.5 yrs; neutral femoral-tibial alignment is achieved when pts are 12-14 months old; Greene: neutral femoral-tibial alignment at 14 months old; Radiographs: show metaphyseal diaphyseal angle of >11 deg early (this angle is formed by lines between metaphyseal beaks& perpendicular to the longitudinal axis of the tibia); radiographs show a localized deformity at proximal tibial level w/ a medial metaphyseal lesion; in contrast, the common physiologic bowlegs involves both the tibia &distal femur (during 2nd year); Treatment: Mild Case: - mild cases occuring before pt is 2 yrs old may spontaneously regress; Orthotic Management includes long-leg, locked-knee braces w/ pelvic band to control rotation, worn while child is wt bearing; nighttime bracing doesn't address pathophysiology (ineffective); Surgical Indications: if deformity does not correct before age 4-5 yrs, surgery is indicated - osteotomy of proximal tibia and fibula should also include lateral rotation to produce a +10-degree thigh-foot angle.; if surgery is delayed beyond ages of 6-8, recurrence is expected; consider tibial osteotomy when medial physeal slope is > 60 deg; w/ medial physeal slope of 50 to 60 degrees, orthotic treatment is consider if there are risk factors; obesity, female gender, and a poor social situation are poor prognostic signs for successful bracing; example of proximal tibial osteotomy: - Physeal Arrest:prior to development of a physeal arrest, rx consists of proximal tibial osteotomy; once a medial physeal arrest occurs, rx becomes more difficult; considerations for treatment would be tibial osteotomy w/ or w/o completion of fusion of the physeal plate; physeal bar resection & interposition is an unproven technique. if physeal bridge of bone is identified,then resection of osseous bar with interposition of fat, methylmethacrylate, or medical-grade elastomer should be considered; physeal bar resection in infantile tibia vara is difficult and results are unpredictable; osseous bridge > 50% of width of growth plate is usually listed as contraindication to physeal bar excision;
Age Stage Treatment
< 18 mo I-II None
18-24 mo I-II A frame/Blount brace (night)
2-3 yr I-II Modified locked KAFO
3-8 yr III-IV Valgus rotation osteotomy
3-8 yr VI Resection of bony bridge.
fD*Kyphosis= failure in one plane, Scoliosis= failure in 3 planes (essential deformity is lordosis).
*The axis of spinal rotation (determined b the orientation of the facet joints) lies behind the cervical & lumbar curves & in front of the thoracic curve. The centre of gravity lies in front of the whole spine. Therefore lordoses are unstable in forward flexion, tending to rotate. The cervical & lumbar lordoses are protected by the shape of the vertebrae being broader anteriorly & powerful stabilising muscles & ligaments. Thoracic vertebrae are narrower anteriorly & wedged asymmetricaly by aorta. Thus any loss of kyphosis -> rotational buckling.
*Spine can be modelled as an elastic cantilever -> Eulers law of column buckling.
*Therefore, in scoliosis the essential deformity is lordosis, w/ the spinous processes being directed to the concavity of the lateral curve. As rotation progresses the load on the epiphysis on the side of the body which is more anterior increases (Heuter Volkmann law) -> lateral deformation -> rib hump.
*Scoliosis= triplanar deformity of lordosis, rotation & lateral wedging of vertebrae.
Level 2: fibrils arranged into sheets (= lamellae) w/ a preferred orientation.
Level 3: lamellae arranged into tubular osteons, which have a central Haversion canal & form the basic structure of cortical & trabecular bone. Alternatively, the lamellae may be arranged in sheets for plexiform bones.
Arial
Arial
Arial
Arial
orocoid not strong enough.
%BA subject who flexes the elbow to 90deg. with the arm fully elevated, so the forearm is is held over the head, then lowers the arm in the sagittal plane without attempting to rotate the humerus, finishes holding the forearm across the body w/ the humerus in internal rotation. If the elevated limb is lowered in the coronal plane the forearm will come to lie w/ the humerus in external rotation. Explained by the rolling die analogy. (The order in which the rotations of the die occur results in a different face despite starting w/ the same face.)
+C*Glenohumeral movement = glide + roll.
*Scapulohumeral Rhythm= combined motion of glenohumeral & scapulothoracic jt.s for arm elevation.
*Scapulohumeral Balance= the scapula acts to position the glenohumeral jt. such that the resultant force of activity is directed into the glenoid.
*The humeral head glides upwards on the glenoid by 3mm during the first 30-60deg. of abduction.
*Rotator cuff muscles act to centre the humeral head in the glenoid during movement. All the rotator cuff muscles are involved in elevation, particularly in the early stages. Infraspinatus & Teres minor may be able to compensate for the loss of supraspinatus.
*The resultant force acting at the glenohumeral joint = 0.89xBodyweight at 90deg. abduction.
*Shear forces at the glenohumeral jiont peak at 0.42xBW at 60deg. abduction.
A* Total shoulder arthroplasty in patients w/ large rotator cuff defects early loosening of the glenoid component is ass. w/ the upward migration of the humeral head. (Franklin, 1988, 10yr FU of 50 Pt.s)
* Need sufficient bone stock on scapula to support a glenoid component.
* Glenoid deformed/ diseased -> replace.
* No long term follow-up studies & insufficient numbers to make adequate recommendations.
* Aim for a non-constrained & conforming construct.
fDA] Abnormal Loads:
- articular cartilage can withstand loads of up to 25MPa without damage. Loads exceeding this -> chondrocyte death & cartilage fissures.
- single impact loads or less intense multiple impact loads can cause articular damage.
- impact loading -> loss of proteoglycans from matrix -> decr. cartilage stiffness, incr. hydraulic permeability & disrupt collagen meshwork.
- animal studies: limited periods of repetitive impact loading developed degenerative changes.
- Human studies: distance runners do not develope more OA than controls, but footballers & baseball players do.
- if repair cannot keep up w/ damage -> degeneration.
B] Abnormal Joints:
- Instability -> altered congruence & regions of contact of opposing surfaces -> incr. the number & intensity of impact loadings, & incr. shear & compression forces on specific regions of the cartilage.
- Partial loss of joint sensory innervation accelerates joint degeneration (in dogs, following ganglionectomy).
- Forced activity following joint injury or ACL transection -> joint degeneration, whereas immobilisation after injury prevents degeneration.
sCI. Conforming= concave tibial component surface; prevents excessive slide & contact stresses; maximum stability; but ->less flexion by limiting 'roll-back'.
II. Non-conforming= flattened tibial surfaces; allows rotational + AP movement & roll-back; but ->line & point loading in extension.
A] Unicompartmental/condylar: for patients <60y, w/ lat. comp. OA where valgus deform. is mild.
B] Bicompartmental: historical.
C] Tricompartmental:
1) Unconstrained- depend on soft tissues for stability; mobile meniscal-bearing surfaces of tibial component (=LCS prosthesis)
2) Semiconstrained- most prostheses.
3) Fully Constrained- hinge/ link mechanisms; for knees w/ instabilities & deformities too severe for adequate correction w/ semiconstrained type; Because movement in one or more planes is restricted -> high stresses in implant & interfaces -> wear & loosening.
A MATERIAL PROPERTIES
Stainless steel cheap, easy fabrication
(316L)
Titanium expensive, low density, low modulus,
biocompatable, good osseointegration
CoCr alloys expensive, high density, high modulus, (wrought) difficult to fabricate
CoCr alloys expensive, high density, high modulus, (wrought) difficult to fabricate
C*Zones: subchondral bone- tidemark - calcified zone - deep zone - middle zone - superficial tangential zone -surface.
*organic matrix= collagen type 2 (10-30%) + proteoglycans (3-10%) + water (60-87%).
*Proteoglacan(PG) looks like test tube brush w/ keratan & chondroitin sulphate chains(=GAGs) bound to a protein core molecule monomer. The monomer is attached via a link protein to hyaluronic acid.
*Aging-> decr. water content, decr. carbohydrate: protein ratio, decr. chondroitin sulphate, incr. keratan sulphate.
*PG gel is trapped in the collagen network enabling it to resist compression.
*Creep occurs when a viscoelastic tissue, like cartilage, is subjected to a constant load.
*Stress Relaxation occurs with constant deformation.
*In contrast to bone, articular cartilage tends to stiffen w/ increasing strain.
*Disruption of the collagen network is a key factor in the developement of OA.
OP-1 is equivlent to autograft in tibial non-unions.
Can create bone in non-bony sites where mesenchymal cells can differentiate (animal models).
NNB. vascularity & ST envelope.
Amazing slides shown of new bone formed in gap filled w/ OP-1 in rabbit.
The 'Run out' is the transitional sres
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J- compression syndrome of the tibial nerve in the tarsal tunnel; tarsal tunnel is formed by the flexor retinaculum behind and distal to the medial malleolus; an accessory flexor digitorum longus muscle is a common cause; Exam findings:pain, paresthesias, & atrophy of foot intrinsics; pain radiates along the plantar side of the foot; +ve Tinel sign behind medial malleolus; manual compression for 30 sec. may reproduce symptoms; EMG can be useful when the operator has experience w/ this condition Diff dx: 1)stress fractures (identified on 45 deg medial oblique view), 2)inflammatory arthritides, 3)plantar fasciitis, 4)PID.
Surgery: Extend the incision from 1 cm plantar to the navicular tuberosity in a proximal direction, bisecting the area between the medial malleolus and the medial tubercle of the calcaneus and ending 1 cm anterior to the tendo calcaneus. With the foot in gravity equinus, this is almost a straight line. Do not undermine the incision. Coagulate or tie the superficial veins connecting the plantar and saphenous systems, and deepen the incision through the investing fascia of the calf proximally and the medial side of the foot distally. This will allow identification of the proximal and distal (posterior and anterior) borders of the flexor retinaculum and the neurovascular bundle before it disappears beneath it. Occasionally the nerve will be enlarged at the upper border of the retinaculum. Release the retinaculum from a proximal to a distal direction until the muscle fibers of the abductor hallucis are reached. Sometimes a medial calcaneal branch will penetrate the retinaculum, and care must be taken to avoid severing one or more branches of this nerve (medial calcaneal) to avoid a painful neuroma. The tibial nerve divides beneath the flexor retinaculum into the medial and lateral plantar branches. The medial calcaneal branch may arise from the main tibial nerve or its lateral calcaneal branch. An excellent anatomic study by Havel et al. showed the tibial nerve to bifurcate into its medial and lateral components beneath the lacinate ligament in 93% of 68 foot dissections. Once the medial and lateral plantar nerves reach the medial border of the abductor hallucis, they turn plantarward and lateral deep to this muscle. Trace each nerve well distal to the inferior edge of the flexor retinaculum until it is certain that no tethering by the fascial origin of the abductor hallucis exists. This is facilitated by releasing part of the origin of the abductor hallucis. If the epineurium appears thickened, it should be incised. Removal of a section of the flexor retinaculum over the neurovascular bundle is recommended. Remove the tourniquet and secure hemostasis before closing the wound (skin and subcutaneous tissue only). Apply a sterile compression dressing.
>C*Arthroscopy pre-op.
*5cm strap incision betw. tip of acromion & ACJ, allowing access to ACJ & rotator cuff.
*coronally orientated incision of delto-trapezial fascia w/ diathermy. Lift it as 2 flaps off acromion cutting thro bursa anterolat., exposing underlying rotator cuff. Coagulate acromial branch of thoracoacromial artery. (excise the Coracoacromial ligament to expose undersurface of acromion)
*Acromioplasty in two cuts w/ saw: 1. coronal vertical, 2. oblique cut removing undersurface of acromion. Should be able to insert thumb under acromion.
*Repair rotator cuff: remove small area of cortex using gouge. Insert 2 size 2 Dacron Mitek anchors into this area & suture to proximal oart of tendon tear. Will need to externally rotate shoulder for access.
*Post-op: polysling, Neer rehab. program (PROM day2; AROM 4-6w).
E- autosomal dominant disorder with hyperextensibility of "cigarette paper" skin, joint hypermobility & dislocation, soft tissue/bony fragility, & soft
tissue calcification;
- failure of other supporting connective tissue can lead to vascular & visceral tears as well;
- types II & II (of XI) are most common & least disabling;
- joint effusions & arthralgias are common, & children are often
misdiagnosed with forms of arthritis;
- Ehlers-Danlos syndrome is characterized by joint hypermobility & skin
changes such as thinness, hyperextensibility, & fragility;
- some forms are produced by mutations in genes for Type I or
Type III procollagens, but others are produced by defects
in enzymes required for the assembly or processing of procollagens;
cutaneous manifestations are present in all forms;- skin is soft, velvety, & may be abundant over h&s & feet; - it is hyperextensible, but returns immediately to normal
configuration when released;
- it may be extremely fragile, splitting after insignificant trauma;
- wounds are characterized by minor bleeding & dehiscence;
- sutures may pull out of surgical wounds;
- Type IV:
- defect of Type III procollagen in Ehlers-Danlos syndrome;
- is rare but very severe form of syndrome in that it frequently
produces rupture of large arteries & hollow organs;
- all pts studied to date have had defect in Type III procollagen;
- Treatment:
- consists of PT, orthotics, & arthrodesis;
soft tissue procedures fail;
/AAspirin- inhibits the aggregation of platelets & inhibits cyclooxygenase.
Heparin- binds to & enhances the activity of Antithrombin III. -> inhibits thrombin, factors IXa & Xa. (reversed w/ Protamine)
Warfarin- inhibits production of Vit. K dependent factors (II, VII, IX, X).
LMWH- inhibits factor Xa.
ing slides shown of new bone formed in gap filled w/ OP-1 in rabbit.
* Ix: Tch Bone Scan- segmental diffuse pattern of tracer uptake (sensitive, Triphasic scan= specific). Diagnostic Sympathetic Block (stellate ganglion).
* Rx: Rx cause, active ROM exercises, sympathetic blockade, TCA's, vasodilators, steroids.
HStatistical tests are either Parametric (ie. assume that the data were sampled from a particular form of distribution, such as a normal distribution) or Non-Parametric (makes no such assumption). Parametric tests are more powerful. Non-parametric tests look at the rank order of the values (from smallest to largest).
Parametric tests & their non-parametric equivalents:
1. 2 Sample (unpaired) t-test: Mann-Whitney U test; Compares 2 independent samples drawn from the same population; To compare girls heights w/ boys heights.
2. One sample (paired) t-test: Wilcoxon matched pairs test; Compares 2 sets of observations on a single sample; to compare weights of infants before & after a feed.
3. One way analysis of variance (F test) using total sum of squares; Kruksall-Wallis analysis of variance by ranks; Effectively, a generalisation of the parallel t or Wilcoxon matched pairs test where 3 or more sets of observations are made on a single sample; To determine whether plasma glucose level is higher one, two or three hours after a meal.
4. Two way analysis of variance: Purpose as above but tests the influence (& interaction) of two different covariates; Plasma glucose levels as above, but tests if the results differ betw. male & female subjects.
test: Fishers exact test; tests the null hypothesis that the distribution of a discontinuous variable is the same in two (or more) independent samples; to assess whether acceptance into medical school is more likely if you are born in Britian.
6. Product moment correlation coefficient (Pearsons r): Spearmans rank correlation coefficient; assesses the strength of the straight line association betw. two continuous variables; to assess whether & to what extent plasma HbA levles is related to plasma triglyceride level in DM.
7. Regression by least squares method: non-parametric regression; describes the numerrical relation betw. two quantitative variables, allowing one value to be predicted from the other; to see how PEFR varies w/ age.
8. Multiple regression by least squares method: non-parametric regression; describes the numerical relation betw. a dependent variable & several predictor variables (covariates); to determine whether & to what extent a persons age, body fat & Na intake determine their BP.
* Compressive strength incr. w/in minutes. Healing time as normal.
* Counters compressive forces in regions of compromised cancellous bone.
* No adverse biological host response.
* Vascular infiltration & remodelling
* But: fails w/ repeated cyclical loading, thus the osteoinduction is most NB. 60% soft tissue extrusion at insertion -> no adverse results. Infection potential problem.
KD*Compression allows for load sharing & stability.
A]DHS- allows sliding & impaction. Resists shear by impaction. Bending moment is counteracted by component contact at inferior region of # surface. Screw sliding depends on: 1) angle betw. barrel & sideplate. For a larger barrel/plate angle the screw is more closely aligned to the applied joint force -> incr. ratio of sliding:shear. 2) Ratio of length of screw within barrel to length of screw extending out of barrel. Higher ratio= less friction betw. screw & barrel -> more slide.
B] Lag/Cannulated Screws- similar fixation stiffness & strength as DHS. Fail at higher load than DHS, & fail by bending. Screws more perpendicular to # yields greater impaction.
C] IMHS/Recon nail- 1) the bending moment transferred to IM Nail is less than DHS, because the moment arm from joint load is less. 2) The greater length of IM Nail produces a larger counteracting moment arm -> reducing force across nail-bone interface. 3) Force is distributed along length of nail in contact w/ endosteal surface vs. discrete load transfer points of DHS plate screws.
D*Ankle works as 2nd order lever w/ ratio 3:1. Just lifting heel off ground -> 3x BW thro joint
*The talar body is a Frustrum; broader ant>post & med>lat.. DF= upwards & outwards.
*1/6 of load thro ankle passes thro lat facet to lat malleolus.
*Shentons line of ankle gives idea of fibula length
*% joint congruence= area of contact x 100/ total contact area. Ankle relies on congruety (unlike knee which is incongruent & has thick articular cartilage [from stress=F/A]) Disturbing congruety -> Incr stress (from decr A)
2mm lateral shift -> halves contact area -> doubles stress.
inversion injury in running person -> ext rotation of talus, but tib & fib don't follow.
AO Type C: pronation/ eversion -> rotational injury (not abduction injury), ant TF lig fails first then interosseous then post TF. Ant. tibial tubercle (att. of ant TF lig may be avulsed (Tilaux).
Discussion on B1.1-
Latta: Loading & muscle action -> corrects minor incongruiety.
Colton: must look at # gap in lat. view & fibula length.
Pt age & activity most NB
qAPosition: Seated, trunk rotated 30deg. towards affected side, so that blade of scapula is parallel to the edge of the cassette; The casette is placed horizontally behind the humerus and in contact with the arm; X-Ray tube angled 30deg. to vertical, so that the central ray passes from just lateral and superior to the coracoid process, through the gleno-humeral joint.
Pelvic Fractures
Open Fractures
Pelvic Fractures
Tile Classification & Management
Peripheral Nerve Injuries
Upper Limb Myotomes (Brachial Plexus)
Fracture Healing
Interfragmentary Strain Hypothesis
Glascow Coma Scale - GCS
Extensor Tendon Groups (3's)
Motor Neurone Disease
Spinal Muscular Atrophy
Myotonias
Non-steroidal anti-inflammatories (
NSAID)
Femoral Shaft Fractures
Open (compound)
Fitness to Drive after Trauma or Surgery
Fluid & Electrolytes
Fluid Compartments
Surgery
Upper Limb
Volar Appr
Sutures
Absorbable
Talus/Talar Fracures
Statistics
Meta-Analysis
Surgery
Acromioclavicular(ACJ) dislocations
Weaver-Dun
Surgery
Ankle Fracture ORIF
Antidepressants
ASA Classification
American Society of Anaesthesiologists
Authorship of Research
Vancouver Guidelines
Radiology
Radio isotope Scans
Research Article Critique Checklist
Salter-Harris Type 1 Proximal Humeral Fractures in Children
Spine
Prolapse Intervertebral Disc (PID)
Discectomy
Spine
Rheumatoid Arthritis
Spine
Sheuermann's Disease/ Idiopathic Kyphosis
Bone Investigations
Investigation of Bone Metastases for Primary
0Bone Substitutes
Osteogenic Protein-1 (OP-1) (BMP7) ('Novos')
Bone Tumours
Age Predilection
Ulnar Collateral Ligament(UCL) Injury of Thumb (Gamekeeper's/ Skiier's)
Surgery
Heterotopic Ossification (of Hip)
Brooker Classification (based on AP XR)
Approach for THR & Hemiarthroplasty
Surgical a
Spine
Prolapse Intervertebral Disc (PID)
Chemonucle
Spine
Spinal Cord Injury
Incomplete
Spine
Spondylolisthesis
0Anaesthesia, Regional
Ankle Block
Anaesthesia, Regional
Nerve Block Dosages
Anaphylaxis
Biomaterials
Polymethylmethacrylate (PMMA) Bone Cement
Biomaterials
Titanium
Biomaterials
Viscoelastic
Biomaterials
Failure of Internal Fixation Devices
Biomaterials
Titanium
Bone Tumours
Benign
Enchondrom
Asegmental defect = segmental transport
ST condition is the Factor in decision making
Defect < 2.5cm: BG or Shorten- best. or ?Bone transport.
Defect 2.5-5cm: shorten then lengthen later
Defect >5cm: Bone transport
Antegrade (prox.) transport better (avoids scarring to compt.
Good docking contact -> compress; Poor contact -> BG.
B* Sural Neve: 5ml 0.5% Bupiv., subcut. 'sausage' behind lateral malleolus towards lat. border of Achilles tendon.
* Saphenous Nerve: 5ml 0.5% Bupiv., 1cm prox. & 1cm ant. to medial malleolus around long saphenous vein.
* Deep Peroneal Nerve: 5ml 0.5% Bupiv., just medial to the dorsalis pedis artery at ankle level, betw. EHL & EDL.
* Superficial Peroneal Nerve: 5ml 0.5% Bupiv., after completing deep peroneal n. block withdraw needle to surface & inject 5ml 'sausage' laterally along line betw. the malleoli.
* Tibial Nerve: 5ml 0.5% Bupiv., place leg in 'figure-of-four' position. Inject from a point just behind the medial malleolus towards the os calcis distally, underneath the post. tibial artery.
5CValgus Intertrochanteric Osteotomy:
- places the hip in an Adducted position.
- Indic.= 1) Dysplasia w/ a mushroom cap deformity w/ comfort in adduction & improved XR appearance in adduction. 2) post-Perthes hinged abduction w/ discomfort & resistance to abduction. 3) Non-union of femoral neck # [reduces shear forces & incr. compressive forces]. 4) acquired varus deformity.
- valgus osteotomy lengthens femur, thus resect a block wedge.
Varus Intertrochanteric Osteotomy:
- effectively abducts the hip.
- Indic.= 1) coxa valga subluxans. 2) dysplasia w/ round femoral head, w/ improved comfort & XR in abduction.
- shortens femur.
Angulation osteotomies for OA 2ndry to dysplasia -> 80% good results at 10yrs. At 2-3yrs one third reported good results, one third had satisfactory result, & one third were failures.
EDFEMORAL COMPONENT:
* high strength super-alloy(stainless steel).
*Head- ceramic hardest (more scratch resistent, less three-body wear) & least friction, followed by steel then titanium.
* Broad medial border & broader lat. border to load prox. cement mantle in compression.
* No sharp edges which may initiate # of cement mantle.
* A Collar aids in determining depth of insertion & may diminish resorption of bone in the medial neck.
*Stem should occupy 80% of the cross-section of femoral canal w/ a 4mm mantle proximally.
* Head size= 0.5xexternal cup diameter. Usually 22-28mm. (larger= volumetric wear, smaller= point wear).
B4.5mm cortical screw passed across syndesmosis under Image Intensifier.
Place foot on towels on radioluscent table. Reduce under II & hold with large pointed reduction clamps over skin. Drill with 3.2mm drill bit aiming 30deg. anterior across 3 cortices. Insert screw. If medial side not closing, explore (with screw slightly loosened). Release trapped deltoid ligament & Tib. Post. tendon. Repair Lig. Tighten screw (Not too tight)
7ATapping => 1] Allows precision placement when placing screw obliquely (lag); 2] Less torque lost in overcoming friction at the bone-screw interface.; 3] Less force reqd. = less likelihood of losing # position.
Self-Tapping Screws => quicker, less instruments, tight fit, same holding power as pre-tapped screw.
APeople over 65yrs have approx. 700mg calcium in normal diet & Vit D blood levels of 200IU. Adding 500mg calcium & 700IU reduced fractures by 50% over 3yrs of taking supplements.(double blind, placebo study of 176 men & 213 women over 65yrs.)
RDA Calcium = 1400mg
RDA Vit. D = 600-800IU.
A1) Patellofemoral overload (Chondromalacia)
2) Patellofemoral Subluxation/ Instability
3) Plica Syndrome
4) 'Jump' knee (enthesitis of patella tendon origin)
5) Torn Meniscus
6) Discoid Meniscus
7) Osteochondritis Dissecans
8) Patella Bursitis
9) Bipartite Patella
10) Patella cysts or tumours
11) Johansson-Larsen's disease (traction tendinitis at lower pole of patella, w/ calcification)
-AThe type of tissue formed in a fracture gap depends on the strain(motion). Strain= elongation of the gap
length of gap.
If Strain 10-100% granulation tissue forms, 2-10% forms fibrocartilage, <2% forms bone. Formation of fibrocartilage reduces interfragmentary strain such that bone may form (<2%).
BBone is the only tissue which heals without a scar
Osteogenic induction potential of mesenchymal cells of muscle (fibroblasts). Callus picks up its vessels from surrounding muscle.
# Personality determines fixation (low energy -> rigid fix, high energy -> biological fix)
* NB- entire venous drainage of bone is Periosteal.
Movement at # site is directly proportional to the working length.
Chair demonstration of exfix, plate & IMNail
Smoking incr. union time.
FAPlain XRays:
- Cannot see medullary bone
- Cannot see deformity (eg. rotation of spine in scoliosis)
- Can miss pathology due to plane of incident beam (eg. # line, Hill-sack lesion)
- Not dynamic (static view of injury, tendon avulsion ass w/ dislocation) [Small bits of Bone = Major Injury]
- Dead Bone looks Normal on XR.
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Swiss
{I*malignant tumor of plasma cells arising from a single clone;
*accounts for > 40% of primary malignant tumors of bone.
* w/ chemotherapy, survival time of 3-5 years is not uncommon
* 50-70 yrs at presentation; constitutional symptoms, anemia, thrombocytopenia, and renal failure; approx 80% of pts have chief complaint of bone pain w/ diffuse bone tenderness, particularly over the sternum and pelvis. path. # of spine or femur may be heralding event.
* Serum Electrophoresis: finding of abnormal protein peak migrating w/ IgA or IgG fraction is diagnostic; an protein migrating w/ IgG or IgA bond in about 90 % of pts; major criteria for dx: monoclonal globulin spike > 3.5 g for IgG; monoclonal globulin spike > 2.0 g per 100 ml for IgA.
* Bence Jones Proteinuria: <50% of patients, urinary immunoelectrophoresis may have substantially higher yield for IgG light chains excreted in the urine. dx: monoclonal globulin spike > 1.0 g / 24 hrs for urinary light chains.
* Serology: incr. ESR; Hypercalcaemia in 20-40% of Pt.'s (doesn't correlate w/ the amount of bony destruction), combo of calcitonin & steroids is usually effective esp. when there is renal insufficiency, agents that are nephrotoxic such as plicamycin (mithramycin) should be avoided; parental pamidronate (biphosphonate) is effective but should be used w/ caution in renal insufficiency; Alk Phos: is a marker of osteoblast activity, usually not increased in myeloma since there is little new bone formation, which explains why bone scans appear cold; Anaemia (normocytic, normochromic);
* Renal F(x): lambda light chains, are nephrotoxic, & light-chain myeloma is commonly complicated by renal failure;
* Bone Scans: may appear cold; bone-scanning, although likely to show incr activity at site of frx, shows no incr even at site of discrete lesion in 25 % of patients;
* Histology: normal marrow biopsy may show upto 8 % plasma cells; between 10-20 % suggest myeloma; greater > 20-30 % plasma cells on bx is diagnostic of myeloma;
* immunohistochemical studies: may reveal lambda light chains or heavy chains and kappa light chains
* XRT: myeloma is sensitive to XRT, & reossification of tumor defects may ocurr within several months. XRT is recommended for intractable bone pain, esp if pain is localized; it can be dramatically effective in relieving symptoms;
* Chemo: when dz is disseminated, chemo is indicated 5 year survival remains under 30%.
fHEPIDEMIOLOGY:
male(13-14y) > female(11-12y); higher weight & height centile; Bilateral in 25% w/ the opp. side usually asymptomatic.
CLASSIFICATIONS:
1. Acute= < 3wks symptoms; 2. Chronic= > 3wks symptoms; 3. Acute on Chronic= sudden incr. in pain preceded by a period of lesser symptoms.
XR: Grade 1- preslip (may see epiphyseal widening & rarefaction); Grade 2- displaced < one third of femoral neck; Grade 3- displaced one third to one half femoral neck; Grade 4- >50% femoral neck slip.
Incr. physeal height is due to a widened zone of hypertrophy, = region of slippage. chondrocytes are disorganised. The perichondral fibrocartilagenous complex, which provides shear strength, thins w/ age, so that by adolescence this complex contributes less to stability.
TREATMENT:
Complication rate w/ more than one screw increases by 10-fold, vs. a 33% increase in resistance to shear forces w/ a 2nd screw.
Screw position = centre of head. Higher incidence of AVN w/ superior & anterior screw placement. Screw end should be 5mm from the subchondral bone. NB- check screw position by rotating hip under I.I. Forceful reduction incr. risk of AVN.
Femoral osteotomy: For loss of movement & pain 2ndry to osseous deformity where physes are closed. Southwick subtrochanteric biplanar (45deg. valgus & extension) has lowest risk of osteonecrosis, but high incidence of chondrolysis.
COMPLICATIONS:
Chondrolysis- acute cartilage necrosis. Onset within 3 months & max. w/in 1y. Follows all types of Rx. Risk Factors= 1) pin penetration, 2) cast immobilisation, 3) duration of symptoms & severity of slip. Genetic susceptibility. XR: joint space narrowing, demineralisation, osteophytes, protrusio. Rx= symptomatic. May improve spontaneously over 3 years.
* Osteonecrosis- Risk Factors= 1) severity of slip, 2) reduction attempts, 3) multiple screws, & 4) high osteotomies.
6. Lish nodules- >1 iris lesions by slit-lamp exam.
7. Family Hx
8. Pencilling ribs, scalloping, scoliosis,
9. Tibial pseudoarthrosis
10. 10% risk of malignancy
B*Bone is weakest in Shear, followed by tension & compression.
*Transverse # indicates failure in pure tension. Debonding of osteons, crack propogates across weak interface betw. osteons, so a transverse # is a series of steps. On the compression side # surfaces are oblique to the applied load = failure by shear/slippage. => butterfly/wedge fragments on compression side.
*# cracks initiate from a stress riser, eg. osteocyte lacuna or blood vessel channel.
* Torsion -> # line oriented 45deg. to the axis about which the torque is applied. (proven using Mohr's circle)
*Compression -> metaphyseal #s since cancellous bone is weaker than cortical bone.
l thinning
5. Optic glioma
6. Lish nodules- >1 iris lesions by slit-lamp exam.
7. Family Hx
8. Pencilling ribs, scalloping, scoliosis,
9. Tibial pseudoarthrosis
10. 10% risk of malignancy
ts, 3) multiple screws, & 4) high osteotomies.
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@1) Compression Plate(DCP): Applied to the tensile surface(extreme fibre) under compression -> tension within plate & compression on bone. # edges resorb after 72hrs -> decr. stresses in plate & bone -> improved apposition. Plate resists bending moment by acting in tension.
2) Neutralisation Plate: applied at right angles to the above. If apposition is poor this arrangement is more rigid. But screws are subject to bending & torsional forces. Plate is centred at the neutral axis rather than the extreme fibre.
3) 2 plates -> incr. torsional rigidity.
4) Spiral #: Interfragmentary screws perpendicular to # line (not > 20deg. from perpendicular) -> torsonal control; Neutralisation plate -> prevents bending. or can use locked IM Nail.
5) Screw Purchase is improved by: smaller root diameter, not tapping, increasing the length of thread engagement, not using cannulated screws, placing screw in most dense bone.
7) Prebending plates -> prevents gapping of cortex opp. to plate -> more uniform compression.
8) LC-DCP (Titanium)- less distH
urbance of periosteal blood supply, reduces bone resorption under plate
A* Titanium-aluminium-vanadium alloy (ASTM F-1366) (Ti6Al4V) used for implants.
* Ninth most common element in eart's crust. Pure element v. reactive. Only element that burns in nitrogen.
* Stable passive surface layer of titanium oxide -> v. resistant to corrosion.
IATYPE FEATURES COMPLIC.
1 Undisplaced, no sublux. AVN v. rare
2 Displaced, subtalar sublux. AVN 30-40%
3 Displaced, subtalar & ankle sublux. AVN almost 100%
Bulb tip guide + smooth guide alongside & pull bulb tip rod out w/ nail (NB align #)
Proximal break: use cork screw
Solid Nails: Don:t use them. Drive out from below
Should have long Graspers & Kuntsher Cap
ATo reduce bleeding: 1) stop NSAIDs 1wk pre-op. 2) Position with no pressure on abdomen (reduces backflow from IVC to Batson's plexus). 3) Hypotensive anaesthetic. 4) Tamponade frquently & bipolar diathermy occasionaly. 5) Adrenaline into incision site & cutting diathermy tho muscle.
ADx: Positive Hx + anterior drawer of 10mm & talar tilt of 9deg on stress X-Rays
Rx: Evans Procedure= section a portion of peroneus brevis tendon proximally. Direct tendon thro drill hole in fibula from ant to post & suture back on itself. 30% incidence of restricted inversion.
may form (<2%).
P Guhl recommends arthroscopic evaluation and treatment of all patients who are 12 years of age or older as determined by bone age roentgenograms, and who have lesions larger than 1 cm in diameter located primarily in a weight-bearing area. Lesions that are massive (over 3 cm in diameter), lesions having large or multiple loose bodies that are thought to be replaceable, or lesions that are inaccessible to arthroscopic techniques are best treated by open arthrotomy.
Treatment of the lesion is based on the arthroscopic examination. The lesions are classified into one of the following groups: (1) intact lesions, (2) lesions showing signs of early separation, (3) partially detached lesions, and (4) craters with loose bodies (salvageable or unsalvageable).
Early separated or partially detached lesions may be secured in their beds using Kirschner wires introduced under arthroscopic control.
After thorough diagnostic arthroscopy to rule out other pathologic conditions and removal of any loose bodies, insert the 30-degree viewing arthroscope through the anterolateral portal and a probe through the anteromedial portal. Carefully probe the area of osteochondritis dissecans involving the medial femoral condyle. If the surface is basically smooth, with only an area along the margin of the lesion fissured and loose, the disorder is classified as an early separated lesion. Pushing on the lesion with the arthroscope or probe will reveal only minor movement of the fragment where the articular surface defect is present. Carefully debride this defect in the articular surface with basket forceps or a small curet through the anteromedial portal.
Technique for pinning lesion of osteochondritis dissecans: A, Probing lesion of medial femoral condyle showing early detachment. B, Insertion of multiple Kirschner wires for fixation of early separated lesion of medial femoral condyle.
Pass a 0.062 inch Kirschner wire through a small cannula (to prevent winding up the soft tissues on the wire). Place the tip of the cannula and the Kirschner wire through the capsule and into the joint at an optimal position, so that the direction of the Kirschner wire is perpendicular to the surface of the fragment and directed superiorly and medially so that it will ultimately exit through the posteromedial aspect of the femoral condyle in the epicondylar area. To locate accessory puncture holes, insert an 18-gauge spinal needle through various locations until the proper location and direction are achieved. Make a small portal, and push the small cannula and sharp obturator through the capsule and into the joint under direct view of the viewing arthroscope. Remove the sharp obturator from the sheath and insert a 0.062-inch Kirschner wire through the cannula. Push the tip of the Kirschner wire into and through the articular cartilage layer by hand. When the desired position is achieved, gently tap the Kirschner wire with an instrument to seat it in the fragment. Apply a power drill to the distal end of the wire and drill the wire out through the medial femoral condyle, exiting in the epicondylar area. When the tip of the wire is palpated under the skin in the epicondylar area, make a small skin incision over it and advance the wire. Remove the drill from the distal end of the wire and apply it to the proximal end. Then withdraw the wire retrograde until only a few millimeters of its tip remain within the joint. Observe the lesion and the tip of the wire through the arthroscope as the wire is slowly withdrawn until its tip is flush or slightly below the articular cartilage surface. One to three wires usually are required, depending on the size of the lesion. The Kirschner wires should be slightly divergent, if possible, through the femoral condyle. Alternate the viewing arthroscope and cannula and wire portal sites to allow perpendicular insertion of the wires through the fragment as necessary. Cut off the proximal ends of the wires so that they are prominent beneath the skin surface for easy location and removal 4 to 8 weeks later. Smooth 0.062- inch Kirschner wires are most often used. Kirschner wires with only the distal 3 cm having raised threads probably are more desirable, however.
CDeckchair(/supine) & sandbag under shoulder. Incise vertically from coracoid to axillary fold. Develope interval betw pec major & deltoid with blunt dissec., reflect cephalic vein laterally. Expose coracoid process with the origins of short head of biceps, coracobrachialis & pec minor (=conjoined tendon). Divide conjoined tendon 2cm from coracoid & hold with stay suture (may need to osteotomize coracoid).
Divide subscapularis 2.5cm medial to its insertion vertically & hold with stay sutures, followed by capsule. Inspect joint. Repair (0. PDS)= 1) Suture the free end of lat. part subscapularis to soft tissue/labrum along ant. rim of glenoid. Sutures tied with internally rotated shoulder. [Optional-2) suture the medial part of the capsule over the lat. part of subscapularis with arm in neutral]. 3) Suture medial edge of subscapul. to the rotator cuff at the greater tuberosity, arm neutral. 3wks in sling in internal rotation.
D**Puno et. al. Clin Orth, 212: 113-121; 1986;
- 201 tibial fractures: AO type reamed slotted tibial nail w/ closed technique versus closed reduction w/ Cast application; - IM nail: 98% union rate (no malunions),- 3.3% infection rate. Cast immobilzation: 90.1% unions, 4.3% malunions, 1.4% infections, initially 13% of fractures lost the reduction and required operation.
**Bone and Johnson:
- 76 primary fractures and 36 2ndary fractures (exfix/closed failures) using AO or Grosse-Kemph IM Nailing - union rate: 97% for both groups; time to union: primary group: av 17.8w, secondary group: av 21.6w; infection: 9% - mostly pts rx'ed w/ open procedures or open frx.
**Keating et al. (JBSJS, 1997 MAr, 79A:334):
- RTN(GK) vs UTN(RT): Time to union= 30 v 29wks; Non-union= 9% v 12%; Infn= 4% v 2%; Nail breakage= 4% v 2%; Screw breakage= 9% v 29%.
**Blachut et al. (JBJS, May 1997, 79A'640):
- 154 #'s randomised
- UTN 11min faster.
- RTN(GK) v UTN(RT): Malunion= 4% v 3%, Non-union= 4% v 11%; Infn= 0% v 2%; Nail breakage= 1% v 0%; Screw breakage= 3% v 16%.
**Court-Brown et al (JBJS, July 1996, 78B:580):
- 50 randomised #'s
- RTN(GK) v UTN(AO): Time to union= 16 v 23wks; Renailing= 0% v 20%; Malunion= 0% v 16%; Nail breakage= 0% v 4%; Screw breakage= 4% v 52%.
B*on the acetabular side the compressive stress decreases as it radiates from the joint, while on the femoral side stresses increase as the larger area of the femoral head narrows to the smaller diameter neck.
*the resultant force acting on the femoral head is not parallel to the axis of the neck (159deg.) -> Bending moment with compession medially & tension laterally. Abductor muscle force applies compression laterally & tension medially. Abductor muscle force has a lever arm one third that of the body weight -> abductor force= 3xBW.
A*Aspirate
*Try closed reduction on traction table under II.
*Lat. incision, reflect Vastus Lateralis anteriorly, Charnley retractor, enter medial to Gluteus medius, inverted 'T' incision in capsule, Hohmann over ant. acetabulum -> exposes # & head.
*Reduce by ext. rotation & disimpaction -> int. rotate & traction to reduce. Put neck on head, not head on neck.
*Pass AO screws.
*Note: main blood supply of femoral head is posterior.
A- Midline incision
- Elevate articular fragments from below with an underlying thick 'skin' of cancellous bone. Slightly overcorrect. NB- lat tibial plateau is convex & angled 10deg inferior from ant. to post.
- Always contour 'L' buttres plate to fit snugly to avoid any tension on plate
- Apply 'L' buttress plate starting w/ most distal screw & moving proximally. Insert prox. screws last.
- Post-op: Immediate CPM & keep NWBing for 10-12wks in FCB.
D Seventy tibial shaft fractures treated by intramedullary nailing using two different techniques were compared. The first group (35 cases) was treated with a Herzog intramedullary nail following hand reaming and minimal traction. The second group (35 cases) had a Grosse and Kempf or AO nail inserted following power reaming and skeletal traction. Fracture patterns were similar in both groups. In the hand-reamed group, the mean time to union was 15.2 weeks with two delayed unions and no non-unions. In the power-reamed group, the mean time to union was 19.9 weeks with 10 delayed unions and two non-unions. These differences were statistically significant. Complications in the hand-reamed group included a Sudecks atrophy and one mal-union. In the power-reamed group, there were three transient foot drops, two compartment syndromes and one pulmonary embolus. This difference was not statistically significant. Our findings suggest that surgical technique has an important effect on the healing rates of nailed tibial shaft fractures. When intramedullary nailing is performed, minimal reaming is required and skeletal traction should be avoided if possible.
ws last.
- Post-op: Immediate CPM & keep NWBing for 10-12wks in FCB.
E*The principal factor that alters bending stiffness is nail diameter.
*The Slot has little effect on nail bending stiffness, but a non-slotted nail is 40 times more stiff in Torsion. *A slot reduces torsional stiffness by 98% -> quicker healing with callus. Defined by Polar Moment of Area(J).
*For a fracture located within 5cm of the most proximal distal locking screw, the peak stress around the hole may exceed the endurance limit of the metal. The nail is loaded as a Cantilever beam.
*Hoop stresses in the femur can be reduced by overreaming by 0.5mm and making entry hole slightly posterior(to account for bend in nail).
*Axial loading increases the femoral bow, forcing the nail into contact with the medullary wall, and shortening the working, thus increasing torsional stiffness.
*'Springback Angle' is the angle of recovery from torsional deformity. (Thimsen et al).
*Locked nails, wich rely on cortical purchase of the screws, are less affected by osteoporosis.
*Tubes with a wall thickness:radius ratio of less than one eighth tend to behave as curved sheets rather than tubes. These thin-walled tubes are subject to buckling. (Bone is thick-walled).
*A wider diameter hollow tube is stiffer than a solid smaller diameter tube with the same amount of material. And the outer fibre stress for a given bending moment is reduced. (This is why bones have a medullary canal). This is more Efficient. -Defined by the 'Second Moment of Area'(I).
Radioluscent table, supine & hip bump, leg to bend over side of tble (like arthroscopy). Percutaneous insertion under II (align w/ distal fragment, not prox) Can use AO UFN.
OBlongit. incision over olecranon, curved laterally around elbow point -> 10cm distal, down to bone. Pennybecker to clean edges. Reduce with pointed reduction forceps. Drill a transverse 2mm hole for wire in ulna 5-7,5cm below olecranon. Pass 1,6mm wire thro hole. Insert two parallel K-wires down olecranon, parallel to post. cortex of ulna (Avoid elbow joint & coronoid process). Pass wire around K-wires in figure-of-8 under Triceps. Twist loop in wire opposite wire ends & tighten both together. Tighten until shine goes. Check XRay. Withdraw K-wires 5mm & then bend over ends and bury.
A*@ 21d sufficient strength to tolerate active contraction of muscle.
greater than cold-worked Stainless Steel. But Elastic Modulus is 12
less.
* Bone is a Composite material= a ceramic phase (calcium hydroxyapetite), dispersed in a collagen-based matrix.
@*Radiolucent table, Supine. Large wedge/assistant under knee.
*Through patella tendon
*Flex knee, assistant supporting under thigh
*Pass guide wire 15cm, ceZ
ntral- check on II AP & Lat. with knee extended & rotating leg rather than II.
*Apple Core.
*measure nail size.
*Pass nail with knee flexed to #, checking on II with knee extended. Exceed # by 2cm & try hitch distal fragment - Correct ROTATION & ANGULATION- pass nail through.
*Follow nail distally making sure it is CENTRAL !!
*Proximal lock
*Distal locking: use all 3 holes- determine site with Steinmann pin & II, tap an indent, position drill point & align drill direction with II direction (use sleeve). For lat. holes bend knee & ext rotate hip.
*NB- CENTRAL (controls angul.), ROTATION, LENGTH.
BComplic: malunion 10%, delayed union 8%, non-union 2%, refracture 3%, iatrogenic radial n. palsy
Union time: 10-23wks depending on severity of #.
Probs of non-op Rx: pain, speed of rehab., delayed union.
Indic for fix: multiple trauma, floating elbow, unacceptable # position (> 20 deg), oppen #, pain control, faster rehab.
unlocked nail -> migration in 33%
locked nail -> migration in 13% (osteoporotic bone)
Retrograde: 5deg. loss of elbow movement, heterotopic ossification.
humeral nails are just scaled down tibial nails (too rigid for UL).
Preferred Rx: Non-op. usually, ORIF if fixation reqd.
B IM NAIL PLATE & SCREWS
decr endosteal circ. decr. periosteal circ.
Indirect reduction direct reduction
Preserves soft tissue destroys soft tissue
Allows # motion rigid fixation
Early union-callus slow union- no callus
rare anat. reduction frequent anat. red.
failure at crossbolts failure at plate
for segmental #'s for intraarticular #'s
for shaft #'s for juxtaarticular #'s
uC*Supine on breakable, radiolucent table. Tourniquet.
*Check it is reducible with II first.
*Prep with steridrape around foot.
*Break table so knee flexed to
70deg. so that II fits under perpendicular to leg.
*Medial parapatella approach. Apple core at 11deg to vertical
*Hand ream (to stimulate healing).
*Measure nail size.
*Pass nail under II. -NB: Central in AP & Lat., ROTATION.
*Can use small incisions either side of # & reduce # with pointed reduction clamps prior to nailing.
*Prox. lock with jig.
*Distal lock by levelling out table & elevating foot. Pass II under table for lateral view. Use swab holders to centre over hole for incision. Drill tip over hole. Drill in line of II. First cortex-stop-hole-stop & check on II-far cortex- enlarge hole with drill. Depth gauge & bolt.
*NB bevel on nail holes makes drilling easier but must be straight across, not angled much.
Aosteoid osteoma: Brodie's abscess
Expand bone= Giant cell tumour/ ABC/ Simple bone cyst
7. Stainless steel has a slow, but finite, rate of corrosion & poss. toxic effects of nickel ions.
Complic: 1) Nerve damage-30% in forearm
2) Refracture-4%, 3) Infection-7%
4) Reduced local bone strength by 50% post-op.
B1841 - Diffenbach drove ivory pegs through holes, drilled in the shaft of the fractured bone
1889 - Senn used "aseptic iron" for fixation of fractures.
1897 - Nicolaysen nailed the first femoral neck fracture.
1916 - Hey Groves treated shaft fractures of long bones with intramedullar nail. 1930 - Rush rods were presented.
1931 - Smith-Petersen in Boston used stainless steel for femoral neck fractures.
1939 - K
ntscher in Kiel reintroduced intramedullary nailing for shaft fractures of femur.
1942 - K
ntscher developed techniques for nailing fractures of tibia, humerus, radius and ulna.
1967 - K
ntscher's interlocking nail and image intensification
DE* For femoral neck #, reduction & provisional fixation is essential prior to reaming & nail insertion. Thus use the 'Blunt Medullary Reamer' as a 'nail blank' in the metaphyseal canal, and insert guide wires anteriorly & posteriorly around it & into the femoral head to stabilize the neck # during reaming & nail insertion.
* Where the prox. fragment is in flexion: pass the guide wire into the prox. fragment only & ream to 10mm. Reduce the prox. fragment to the distal fragment using the 'Internal Fracture Alignment Device'.
* Ream the prox. fragment to 15mm for the expanded prox. portion of the Recon Nail. 13mm for the Delta Recon Nail.
* NB- The prox. femur sags because the buttock is unsupported on the # table, this causesthe direction of the head screws and femoral head to point towards the ceiling. This is corrected by pushing the buttock towards the ceiling.
(* Recon Nail ONLY- The Prox. Drill Guide/ Jig needs to be flush w/ the greater trochanter for correct nail depth. It should also lie below the horizontal to avoid posterior screw placement in femoral head.)
* Screws:
Proximal: 3.2mm Guide wires
4.8mm Drill bit (cannulated)
6.4mm screw
Distal: 4.0mm drill bit (3.5mm Delta II)
5.0mm screw (4.5mm Delta II)
* Diameters: 10 & 11mm Delta
8 & 9 mm Delta II
AAntibiotic, Tourniquet
Midline longit. incision. Don't open # site. Reduce with pointed reduction forceps. 2 parallel K-wires from prox to distal using guide to space them. Incise medial & lat retinaculae to palpate articular surface of patella for a step. Wire figure-of-8, using 14G venflon to go under K-wires. Cerclage wire as anterior as possible, under retinaculum & behind K-wires. Check X-Rays on table. Bury wire ends (ensure distal K-wire ends not protruding too far).
AD1. Mineral:Collagen ratio: Decalcification -> decr. yield & ultimate tensile strengths & modulus; Hypermineralisation -> incr. stiffness(modulus); Collagen mainly responsible for deformation after yield & toughness(ability to absorb energy before failure).
2. Bone Porosity & Density: incr. density -> incr. compressive strength.
3. Osteon Structure: -> anisotropic properties.
4. Trabecular Orientation: aligned parallel & perpendicular to compressive loads & at 45deg. to shear loads.
5. Loading Rate: Bone is stronger at higher load rate.
6. Age: Greenstick #s= plastic deformation; Bending strength & modulus of bone incr. to adulthood then decr. w/ aging; With aging bone becomes hypermineralised -> more brittle; Bone density also decr. w/ aging; Endosteal thinning-> decr. second moment of area->weaker.
7. Use & Disuse: Cyclic loading -> hypertrophy.
8. Defect/holes: For a hole whose diameter is 20% of bone diameter torsional strength decr. by 67%.
*Cancellous bone is less stiff & less strong than cortical bone in compression.
*Compromise betw. stiffness & energy absorption.
_B*12 000 000 working days lost per year due to LBP
30% are referred to Ortho; 3% admitted; 0.5% operated.
*Chemonucleolysis - chymopapaine (hyaluronidase), 70% success rate, not for sequestration/spinal stenosis; Anaphylaxis=0.14% (cannot give it twice cos patients become sensitized to it)
*Percutaneous discectomy- same success rate, higher complication rate than chemo.
NAPrevalence of disc herniations (PID) in Asymptomatic subjects: CT=20%, MRI=28%, Myelogram=24%, Discogram=37%.
CT - % incidence of disc prolapse = patient age
MRI is the Imaging of choice. It identifies: level, site, size, side, bony encroachment.
CT misses intrathecal lesions & large disc hernias. CT useful in showing sponylolysis.
Acetabulum Fractures
Judet & Letournel Classification
Achilles Tendon Rupture
Operative Treatment
AIDS in Surgery
Theatre Precautions
BChymopapain hydrolyses proteoglycans (cementing protein of nucleus palposis). Superior to placebo injection. dose=2000U. Acts within 1hr. Can re-expand narrow disc space.
INDIC: As for discectomy, except: Cauda Equina or Sequestrated discs.
CONTRAINDIC: As above, Allergy, Previous failure, ?previous Sx, ?spondylolysis.
TECHNIQUE: Pt. in lateral, across two trolleys. Using image intensifier insert spinal needle into disc space from posterolat. Inject radio-opaque dye(discogram) and then chymopapain (2000U). Post-op wear support corset for 6wks. Lower complication rate than surgery and as good results. Should not repeat chymopapain in view of anaphylaxis.
Anabolic Steroids
Hormone Re
Anatomy
Compartments of the Lower Leg
Ankle Fractures
ORIF vs MUA
Anticoagulation
DVT/ PE Treatment
INR(warfar
Biomechanics
Wolff's Law
Brain Stem Death
Bone Graft
Iliac Crest Complications
Bone Investigations
Bone Investigations
Investigation of Bone Metastases for Primary
Spine
Prolapse Intervertebral Disc (PID)
Diagnosis
Spine
Prolapse Intervertebral Disc (PID)
Discectomy
Spine
Prolapse Intervertebral Disc (PID)
Discectomy
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
equina 0.2%, death 0.1%.
matrix.
Sketch
<??33
&Paint.app
Anticoagulation
DVT/ PE Treatment6INR(warfarin)= 2.0-4.5; APTT(Heparin)= 1.5-2.5 x Norm.
NEW - Innohep: 175U/kg/day until INR >2
Heparin: Bolus 5000U or 70U/kg then 1500U/hr (20-30U/kg/hr), check APTT after 4-6hrs.
*Complic- reduce strength of knee extension, incr. tibiofemoral joint loading, OA, ant. instability lat. sublux. of tendon, poor cosmesis, loss of full extension, Boutonniere-type deformity due to tear from abrasion of quad tendon against femoral condyle.
2. Occult Talar Lesions- tarsal coalition, osteoid osteoma, PVNS, eosinophilic granuloma, avulsion # of inferolateral or posterolateral process of talus.
3. Sinus Tarsi Syndrome- follows ankle strain
4. Anterior Impingement Syndrome- osteophytes- sport
5. Osteochondritis Dissecans of Talus.
CD*Predisposing: 70% arise from UTI, chronically ill, steroids.
*Dx: long delay, wrong Dx.
*Path- organisms in metaphyseal region, toxins cause thrombosis, infarct, abscess, blocks nutrition.
*Batsons venous plexus= communication betw. pelvic & vertebral plexus.(NB surgically)
*OM- Triad= fever+pain+tender. radicular pain.
*L1= commonest site for TB, T10 commonest site for TB paralysis.
*Ix- ASOT, anti-staph. titres. skin tests for TB.
*Rx- IV ABs for 2w oral for 3m. Sx if neurology or not settling o instability.
*SX= ant. decompression & strut graft.
*subacute presentation
more bone destruction, more sequestra, larger abscess, gaseous pus, kyphosis, more neurological signs.
*cause of paralysis- abscess, sequestra, kyphosis, reduced cord blood supply.
*Rx- Rifampicin.
*Indic for Sx=Large abscess, neurology, instability, no response.
Post-op disc infn:
end plate erosion/sclerosis, S. aureus, E. coli. Very rarely require Sx.
Juvenile Discitis:
*rigid hyperlordosis, triad.
*Probably autoimmune (Bianco), no sepsis to be found
* Rx w/ antibiotis altho may not make a diff.
D*78% of late deaths from trauma are due to sepsis.
*60% deaths from femur # due to pulm. infn.
*Incr corticosteroid -> protein catabolism, immunosuppression.
*Heyman Herndon Epiphysiodesis- w/ removal of anterior 'bump' of femoral head to improve ROM.
*Dennis-Dunn open femoral neck osteotomy.
*10% risk of AVN if not.
therefore should do open osteotomy for severe slips, because restore normal anatomy for subsequent THR. If develope early AVN the can do temporary arthrodesis until adult age then take down fusion & do THR.
*30-40% risk of AVN if closed reduction is done, rather 'allow reduction to occur' on # table.
Ankle
Ankle Sprain Rehabilitation
Ankle
Chronic Ankle Pain
Ankle
Chronic Lateral Ankle Instability
OBTrue Lateral of wrist= radial styloid is seen as a triangle in centre of radius.
Scapholunate distance >4mm = lig. tear
Ulnar translocation= lunate overlaps ulnar border of radius by >50%
radial deviation of wrist -> incr volar angulation of scaphoid on lat view. Differentiate from VISI by seeing capitate in line w/ radius.
Step in 'Shenton's line' of wrist at triquetrolunate joint. (NB compare to opp. side)
Lig injury= scapholunate dissociation, rotatory subluxation, VISI, DISI, other
NB ligs = S-L & triquetro-lunate
Instability= static/ dynamic (determined by static/ dynamic films)
BPatella is centred in trochlear groove at 30deg flexion. Insall-Salvati index- length of patella to length of patella tendon, normal=1.
Blackburne-Peel index- length of patella articular surface to the distance of its inferior margin from the tibial plateau w/ knee in 30deg. flexion. normal=0.8-1.1. More accurate.
Q-angle is unreliable, the centre of the trochlear groove is better.
Arthroscopy- suprapatella portal watch patella centre in trochlear groove betw. 30-60deg.
*Treatment: 1) Distal realignments to transpose the tibial tubercle. 2) Prox. realignments to alter the tension of tissues attached to the patella.(Lat release & med. reefing)
Kinesiology2
Patellofem
Patellectomy
Screw-home mechanism
Anterior Knee Pain
Patellofem
Anterior Knee Pain
Patellofem
Kinesiology1
FEMOROTIBI
AMERCHANT
AXIAL/ SKYLINE
= w/ the patient on their back w/ the knee flexed 45deg. over the end of the table & w/ the XR cassette resting on the shin & at 90deg. to the XR beam which is angled at 30deg. to the horizontal.
From This:-> 1) Sulcus angle of Brattstr
m: N=126-150deg. (avg. 142deg.). 2) Congruence angle: betw. a line bisecting the sulcus angle & a line thro the lowest point of the patella articular ridge. = -ve on the medial side, +ve on lateral side. N= -17 to +16deg.
ACL Reconstruction
Anterior Knee Pain
Biomechani
Intramedullary Nails (IMNails)
Reamed vs Unreamed
0Intramedullary Nails (IMNails)
Retrograde/ Supracondylar nails
Anterior Knee Pain
Biomechani
BTech: Pt. lies on XR table, on affected side, w/ affected knee flexed 20deg. & supported by a small radioluscent pad so that the tibia is parallel to the table surface. Feet should be at the end of the table. XR tube at end of bed. Cassette is supported w/ sandbag. Use centering light to center central beam almost parallel to tibia thro posterior aspect of the patella.
ffd= >90cm, fod= as close to knee as possible, Exposure=
Adv: Quadriceps relaxed, XR beam not directed at gonads, film not held by Pt., easier for Pt. to maintain position, easier to demonstrate the joint space.
BFlex hip to 90deg with knee at 90deg- traction & slight adduction- internally rotate 45deg-slowly cicumduct & extend & abduct.
* Idea is that when the hip is flexed 90deg. all surrounding muscles are maximally relaxed, further internal rotation also relaxes the 'Y' ligament. By having these relaxed reduction is possible. Full flexion & adduction 'books open' the # site. The leg is slowly abducted & fully extended whilst maintaining internal rotation.
Heel-Palm Test: Surgeon holds both heels internally rotated & abducted. Int rotation is released. If the #ed side externally rotates more than the other side -> Reduction is not satisfactory.
_BAim: Determine whether low dose aspirin reduces mortality & major morbidity in #NOF patients.
Eligible: All #NOF, except those with clear indication for aspirin (recent MI, CVA) & those with c/i for aspirin (recent PUD, bleeding diathesis, anaphylaxis).
Method: Can continue other forms of prophylaxis. Telephone randomisation. Written consent. Start tablet pre-op. 2 tablets once daily w/ food. Vigilance for vascular complic. (PE, MI, CVA, Bleeding, etc.). Complete form after discharge/ death/ 35d.
Outcomes: All vascular deaths during days 0-35. Non-fatal vascular events <35d. Bleeding complic. <35d.
Femoral Neck Fractures
Singh Index for Osteoporosis
Femoral Neck Fractures (NOF)
Biomechanics
Femoral Neck Fractures
Basicervical #'s Mx
'Basicervi
Femoral Neck Fractures
Leadbetter Manouevre & Heel-Palm Test
for closed
Femoral Neck Fractures
PEP Trial (Pulmonary Embolism Prevention)
]B*Fracture rate doubles each decade after age 50.
20-40% of NOFs die within 6mnths.
*5-10% die post-op from cardiovascular & PE complic.
*Garden 1/2: Non-union 5% at 1yr, AVN 16% at 3yrs.
Garden 3/4: Non-union 50% at 1yr, AVN 30% at 3yrs (>80% overall).
* 1/3 of Pt.s w/ AVN require further Sx, while
of non-union Pt.s require further Sx.
*Conservative vs Operative: similar complication rate & mortality, but operative treated has 26 days less hospital stay, increased patient comfort, easier nursing, better anatomical result and cheaper.
* one third of all dislocated Thompsons hemi's are infected.
(CA prospective, randomized trial of 104 consecutive patients with
displaced fractures of the femoral neck treated with either a sliding screw plate (DHS) or four AO cancellous cannulated screws (CHS) was performed to study the
influence of the fixation device and the fixation procedure on the
vascularity of the femoral head. The vitality of the femoral head was
determined by 99mTc-MDP scintigraphy performed 2-3 months after the
operation. The two treatment groups were comparable with regard to age,
degree of primary displacement and quality of reduction. There were
significantly more (P less than 0.01) avascular femoral heads or femoral
heads with reduced vascularity in the sliding screw plate group (14/40,
35 per cent) than in the four AO cancellous bone screw group (5/47, 11 per cent).
@wires= 1.5mm in aduls & children; 1.8mm in adult femur.
Aim for wires at 90deg. to each other & 4-5 wires per segment
Bring the ring to the wire- Not the wire to ring
Tether through muscles in joint extension
e Tension= 1.2mm-90kg; 1.5mm-110kg; 1.8mm-150kg
Paediatrics
Chromosomal Disorders
Downs S
Paediatrics
Chromosomal Disorders
Noonan S
Times New Roman
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Paediatrics
Appearance of epiphyses of Elbow/ Secondary ossification centres
Paediatrics
Child Abuse (NAI)
Paediatrics
Chromosomal Disorders
Noonan S
Paediatrics
Fibular Hemimelia
Paediatrics
Heuter-Volkmann Law
Paediatrics
Legg-Calv
-Perthes Disease
Catterall'
Paediatrics
Club Foot/ Talipes Equinovarus (CTEV)
Surgery
Paediatrics
Management
Paediatrics
Heuter-Volkmann Law
fAI - Extraarticular, no # of ulna
II - Extraarticular, # of ulna
III - Intraarticular radiocarpal, no # of ulna
IV - Intraarticular radiocarpal, # of ulna
V - Intraarticular radioulnar, no # of ulna
VI - Intraarticular radioulnar, # of ulna
VII- Intraarticular radioulnar & radiocarpal, no ulna #
VIII- Intraarticular radioulnar & radiocarpal, # of ulna
A= The ability to model structures of complex geometry as an assemblage of simple elements. The main requirement is to have, for a range of elements of varying shapes, solutions of the governing differential equations for arbitrary boundary conditions.
In order to carry out such analysis it is necessary to define: Geometry(nodal coordinates, connectivity information), Element Properties(Youngs modulus, cross-sectional area) and Loads(boundary conditions).
Biomechanics
Stress Shielding
Biomechanics
Wolff's Law
Biomechanics
Finite Element Modelling/Analysis (FEM)
Biomechanics
Hip Joint/ Femoral neck (NOF)
Biomechanics
Wolff's Law
Implants
Furlong LOL HAC Hip Hemiarthroplasty
Implants
Furlong, uncemented, HAC
Implants
Ilizarov External Fixator
yBBASIC LAG DCP CANCELLOUS
Drill 3.2 & 4.5 3.2 3.2/4.5
Tap 4.5 4.5 6.5
Screw 4.5 4.5cort. 6.5 spong.
SMALL LAG DCP/Tub. CANCELLOUS
Drill 2.5 & 3.5 2.5 2.5
Tap 3.5 3.5 4.0
Screw 3.5 3.5 4.0
Max. Screw-Plate Angle: DCP=25deg in horizontal plane & 7deg in transverse plane, Tubular=50deg.
DCP exerts 80kp compressive force.
Wound Healing
Scars
Wound Management/ Dressings
Wrist
Colles Distal Radius Fractures (Colles)
X-Rays/ Ra
/A*Robert Keinbock, Viennese radiologist, 1910.
*Aetiology:
1] Mechanical- ulna minus more common in Keinbocks(75-90%) vs. 35-50% in normal people. Short ulna -> incr. loading of lunate. Smaller lunates more susceptible, as well as incr. ulna inclination of distal radius articular surface.
2] Vascular-
ATreatment depends on: age, displacement & stability.
Age 1-5: require some apposition, <70deg. angulation .
Age 5-12: require 50% apposition, <40de angulation.
Age >12: require more accurate reduction.
Reduction: Apply longit. traction with distal fragment flexed 90deg & abducted 90deg. If reduction is stable apply collar & cuff. May require spica POP in 'salute' position. If unstable use percutaneous, retrograde K-wires or Steinmann pin.
Intraarticular #: Distal ball joint in line with capitate-lunate joint. First screw=base of 2nd MC & 10deg to horizontal.
Mould joint by moving it thro FROM.
Unlock distal ball joint at 3wks, remove at 6wks.
FA*Occur when falling onto a wrist dorsiflexed >95deg.
*The prox. pole is stabilised betw. the radius & capitate & palmar carpal ligs.(radiolnate & radioscapholunate), while the distal pole is relatively free (& radial collat. lig. is lax in dorsiflexion) -> cantilever beam type loading -> waist #(narrowest & weakest region).
-Neurofibromatosis/ Von Recklinghausen Disease
Spine
Diastomatomyelia
Spine)Sheuermann's Disease/ Idiopathic Kyphosis
V=Thoracic kyphosis with 5deg. or more anterior wedging of three sequential vertebrae.
Arises 5cm prox. to wrist jt. & runs down along ulna border of FCR tendon before crossing flexor retinaculum (-> curve incision to ulna side distally)
Surgery Tension Band Wiring of Olecranon
Surgery
Lower Limb3Unreamed Tibial IMNail (UTN) without traction table
Malcom Smith (SJUH)
Surgery
Hallux Valgus (HV)-Keller's Excision Arthroplasty of MTPJ Hallux
Biomaterials$Composite Bone Mechanical Properties
Pelvic Fractures
External Fixation
RM Smith
Bone Tumours
Age Predilection
Edeiken
Spine
Rheumatoid Arthritis
Dee, Mango & Hurstr
OPertinent Anatomy: - radial nerve & profunda vessels pass across medial head of triceps; beneath long & lateral heads which then continues distally to lateral humerus to pass into lateral intermuscular septum to enter flexor compartment; the nerve crosses the posterior aspect of the humerus at 20-21 cm proximal to the medial epicondyle and 14-15 cm proximal to the lateral epicondyle; - nerve gives four branches to triceps, which arise in order: - nerve to long head; - nerve to medial head (#1); - nerve to lateral head; - lateral head arises just above the spiral groove (containing the radial nerve); - nerve to medial heads (#2); - medial head arises just below the spiral groove; - nerves to long & medial heads will lie medial to incision line, & nerves to the lateral & medial (#2) heads to lateral side; - ulnar nerve & brachial vessels will be seen above medial side of medial head of triceps if long head is retracted medially; - note that the ulnar nerve supplies the medial head of the triceps, which allows the medial head to be split down the mid-line, w/o resultant denervation;
Position: lateral position, injured side up;
Formal Posterior Approach: - triceps splitting approach allows exposure upto 15-16 cm proximal to the lateral epicondyle (at which point the radial nerve crosses the posterior humerus); - additional mobilization of the radial nerve will allow an additional 6 cm of exposure; - longitudinal incision is made posterior from a point 8 cm distal to the acromion down to the olecranon fossa; - deep fascia is split in line with the incision; - partial elevation of the triceps insertion on the olecranon is only necessary for fracture extension into the humeral condyles; - exposure involves splitting fascia between long & lateral heads of triceps; - frequently these two muscles will have a common tendon distally; - identification of the proper interval is better identified proximally; - the tendinous interval between these muscles is split, and the long head of triceps is retracted medially and lateral head is retracted laterally; - radial nerve should then be visible, lying deep in the spiral groove (along w/ profunda brachii vessels) just above insertion of medial (deep) triceps; - typically the radial nerve runs 15 cm above the lateral epicondyle; - alternatively, the lateral head can be elevated laterally, which then allows the the radial nerve to be elevated in a superior direction; - the superior dissection is limited by the branch of the radial nerve to the medial head of the triceps; - this approach may allow upto 21 cm of safe dissection as measured from the lateral epicondyle;-
Modified Posterior Approach: (from Gerwin et al, JBJS 1996) - allows exposure of upto 75-94% of the posterior humeral shaft or 26 cm of exposure above the lateral epicondyle; - triceps is retracted medially to expose the lower lateral brachial cutaneous nerve; - this nerve branches off the radial nerve on the posterior aspect of the lateral intermuscular septum; - the branch is then traced to the main trunk of the radial nerve; - divide the intermuscular septum around the nerve, to permit mobilization of the radial nerve; - the medial and lateral heads of the triceps are then elevated off the humerus and then retracted medially; - the radial nerve is retracted medially along with the triceps; - this exposure can be carried a distance of 26 cm above the lateral epicondyle; - as the radial nerve course around posterior aspect of the humerus one will find multiple branches to the lateral head of the triceps, but there are no branches to the medial head of the triceps; - as the nerve reaches the lateral aspect of the humerus, it divides into 3 branches, including one branch to the medial triceps; - disadvantages: - this approach may injure the variable brach of the radial nerve to the brachialis muscle;
ABone Density= the weight of bone material per unit volume.
Bone Porosity= % of mineralised tissue in a given volume.
*Incr. density -> incr. compressive strength.
*Incr. density -> incr. holding power of fixation devices.
*Incr. porosity -> decr. elastic modulus
Spine
Anatomy
Spine
Caudal Epidural
Spine
Cervical Spine Disorders
ASpiral Blade- for subtroch. #'s. Reduces risk of rotational or varus collapse; blade orients axially within nail slot for max. bending strength; extra wide weight bearing surface.
Ti-6AI-7Nb alloy (TAN):
1] Modulus of Elasticity- TAN(100GPa) > cortical bone(20GPa), and < 316L stainless steel(180GPa) or CoCrMo(250GPa) = Flexible.
ATaken from the first set of recordings on the patient.
Value GCS SBP RR
4 13-15 >89 10-29
3 9-12 76-89 >29
2 6-8 50-75 6-9
1 4-5 1-49 1-5
0 3 0 0
RTS= 0.9386.GCS + 0.7326.SBP + 0.2908.RR
RTS values lie betw. 0 and 7.8408.
RTS correlates well w/ the Probability of Survival. (RTS of 4 = approx. 60% PoS)
RTS<4 should be in a Trauma Centre
Upper Limb
Throwing Mechanics
Wound Healing
Wound Healing
Upper Limb
Shoulder fusion/ arthrodesis
Upper Limb
Thoracic Outlet Compression Syndrome (TOCS)
Wound Healing
lA= A congenital abnormality that is often the localized manifestation of a systemic syndrome caused by a growth disturbance of the ulnopalmar portions of the distal radius epiphysis and physis.
Madelung described this in 1878.
Rx= Ulna shortening, Darrach procedure, Milch cuff resection in children, biplanar radial opening wedge osteotomy with trapezoidal graft.
Bush fits groove over cam & cam dot faces ball joint.
Screw Insertion: self tapping & tapered. Insert most difficult first then use template. Insert under II control -2mm beyond opp. cortex. NB- Leave a space on male-female join on template to allow for dynamization.
Fixator: 1cm from skin. Tighten screws & manipulate #. Tighten central body nut. Tighten cams only with torque wrench.
Dynamization: Stable #'s= 2-4wks, unstable= 5-8wks. Weight-bearing: stable #'s= PWB up to 3-6wks then FWB. unstable #= N/PWB up to 8wks, dynamize & FWB at 8wks.
Pin-site care: Saline on cotton buds daily, showers, skin massage.
Delayed Union: Compress # with silver 'compression distraction attachment'.
<A= SH4 # of anterolateral epiphysis in older adolescents; avulsion # caused by external rotation force thro ant. tibiofibular lig.; lat. physeal plate closes later than medial.
Rx= closed MUA & POP or ORIF if MUA fails
ORIF: 6cm anterolat. incision, reduce w/ bone holder, fix with 4mm cancellous screw or 2 K-wires.
Spine
Thoracic Spine Fractures
YSignificant=1) ant. vertebral body height 25% shorter than post. 2) Kyphosis >30deg.
Tourniquet
Bruner's Ten Rules
Knee Arthroscopy
Without Tourniquet
Droitwich Knee Clinic
- Adrenaline in drip 1:300 000 (1ml in 3L)
- Slight Trendelenburg
- Inflate knee prior to introducing trochar
- Illuminate veins for siting 2nd portal
Note: early arthroscopy can cause Arthrofibrosis.
Radiology
Radio isotope Scans
Radiology
Magnetic Resonance Scans (MRI)
Implants
Ilizarov External Fixator
Bradish<
Femoral Neck Fractures
Raymond Newman5'Orthogeriatrics (Butterworth Heinneman)
High velocity bullet= 1000m/s(Temporary cavitation, shock wave); Bomb shrapnel=2000m/s
Bullets yaw (cos centr of gravity behind centre of bullet). Bullets become unstable in body & fragment in tissue.
Damage depends on tissue density & elasticity -> mechanical & functional damage -> cavitation, fragmentation, contamination.
NB- Every wound is contaminated, Good Resus & early surgery, Surgery is Two-Stage process.
Surgery= Antibiotics(Magnapen & Flagyl) & anti-tetanus(Ig in war wounds); incise generously- layer by layer (time consuming); excise damaged fascia, incise intact fascia; Remove ALL devitalised tissues(dead muscle doesn't bleed or conrtract to diathermy); Do not repair tendons & nerves initially; Do not remove bone; Leave wound open(except face, joints); No tight packing; Photo/draw; Inspect 48hrs.
Implants
Orthofix External Fixator
Implants
Russell-Taylor Humeral IMNailing
Implants
Screws
Self Drill
Magnetic Resonance Imaging (MRI)
Massive Blood Transfusion & Complications
Motor Neurone Disease
Spinal Muscular Atrophy
APhase 1: RICE (immobilze in POP for 2-3wks)
Phase 2: Strengthening of peroneal & dorsiflexor mucles, stretching of TA. Isometric exercises using furniture or rubber bands.
In severe strains protect ankle with pneumatic brace or taping for sports for 3-6mnths.
Surgery
Repair Achilles tendon rupture
*Prone position; *Posteromedial incision
*Longit. incision of paratenon
*Repair tendon with 0 Ethibond Krackow/ Kessler
*Paratenon repair with 2/0 Vicryl
*BK POP
Anaphylaxis
Airway, O2, Vent.
Adrenaline IM 0.5ml of 1 in 1000
IV 1ml boluses of 1 in 1000
crystalloid
IV chlorpheniramine 10mg
IV hydrocortisone 200mg
Salbutamol Nebs 5mg
Paediatrics
Child Abuse (NAI)
* Hx does not correlate with injury, Hx varies, Delayed presentation, Frequent attendances, Withdrawn apathetic child, Bruising uncommon sites (pinna, centre of back), Long bone #'s in infants or toddlers, bite, slap or grip marks, Unusual burns.
Tibial Fractures
Minimum Acceptable:
`1. varus/valgus <5deg.
2. AP angle <10deg.
3. Apposition= 50%
4. Shortening =1cm
5. No Rotation
Femoral Neck Fractures%Leadbetter Manouevre & Heel-Palm Test
for closed reduction of NOF #'s!Guy Whitman Leadbetter(1893-1945)4
)Femoral Neck Fractures- Intertrochanteric
Kyle & Gustilo Classification
Type 1- 2 part undispl., stable
Type 2- 3 part with lesser troch. #, stable
Type 3- 4 part with greater troch. #, unstable, posteromed. comminution.
Type 4- 4 part with subtrochanteric #, highly unstable.
Biomechanics'Finite Element Modelling/Analysis (FEM)
Intramedullary Nails (IMNails)
Biomechanics
Wrist
Madelung's Deformity
Patellectomy
Gunal et al.
JBJS, 79B(1):13-16.g
Achilles Tendon Rupture
"Am J Sports Med; 21(6): 791, 1993.
Bone Tumours
Benign
Osteoid Osteoma
Surgery
Maissonueve #
Malcom Smith, SJUHm
Paediatrics
Heuter-Volkmann Law
Pressure on an epiphysis retards the rate of growth whilst tension increases the rate. Thus the 'leading edge' of a deformity grows more rapidly than the 'trailing edge', increasing the rate of progression.(eg. Scoliosis)
Paediatrics
Fibular Hemimelia
Wound Management/ Dressings
FA1) Baumanns angle: between physeal line & long axis of humerus. compare to opp. side.
2) Metaphyseal-Diaphyseal angle: between long axis of humerus & line betw widest points of distal humeral metaphysis.
3) Humeral-Ulnar angle = carrying angle.
4) Lateral: angle betw. long axis of humerus & long axis of lat. condyle= 40deg.
Terminal Care
Subcut. Infusion
Spine"Prolapse Intervertebral Disc (PID)
Chemonucleolysis R Deutman
"Current Orthopaedics, 9(2):106-109j
Spine"Prolapse Intervertebral Disc (PID)
Discectomy- Complications
Simmons & Wilber (1978)
Dural Tear- 2-4%
Nerve Root Damage- 0.5%
Cauda Equina Lesion- 0.2%
Infection- 0.1%
Death- 0.1%
Types= protrusion-extrusion-sequestration.
Spine"Prolapse Intervertebral Disc (PID)
Discectomy - Tips
AIDS in Surgery
Theatre Precautions
'Pigmented Villonodular Synovitis (PVNS)
Pelvic Fractures
AO C-clamp/ Ganz Clamp
Application
PF Heini, J Witt, R Ganz
Injury, 1996, Vol 27, Suppl 1
Stab incision- Intersection of a line joining ant & post superior iliac spines & the elongation of the dorsal border of the femur. i.e. into iliac wing.
Anaesthesia
The First Anaesthetic
Harold Ellis
Famous Operations
William Morton, a dentist, gave sulphuric ether on 16 Oct. 1846 for the removal of a benign neck tumour at Massachosetts General Hospital.
Intramedullary Nails (IMNails)ZIntramedullary nailing technique and its effect on union rates of tibial shaft fractures.4 O'Dwyer KJ. Chakravarty RD. Esler CN. (Worcester)
Injury. 25(7):461-4, 1994 Sep.t
Trauma
Chest Trauma
Life Threatening: Tension Pneumo., Cardiac tamponade, Open chest wound(sucking), Massive haemothorax, Flail segment. (=Trauma Clinicians Often Miss Fractures)
*CXR: Wide mediastinum = >8cm superior mediastinum (?PA film).
Studies have -> best result in #s fixed at 2-4d after injury (!?).
1/3 of serious HI have 2ndry brain injury, thus better doing IMNail >24hrs after injury (to avoid hypotension during time of 2ndry BI).
6A1) With the MCPJ in extension, try to flex the PIPJ. If it doesn't flex= tight intrinsics or joint capsule contracture. 2) With MCPJ in flexion the intrinsics are relaxed. Thus if unable to flex PIPJ= tight capsule.
*Tight intrinsics: 'Instrinsic Plus' hands due to ischaemia or fibrosis of intrinsics or RA.
Antibiotics
Rationale for Open Fractures
Anticoagulation
Drug Mechanism of Action
Anticoagulation
DVT/ PE Treatment
INR(warfar
Consultant Tips
*Complications record (on wards) (RPH)
*Acute Admissions record (junior doctors) (SJUH)
*See all outpatients every 3rd visit (RF Brown)
*Trauma list day after on-call.
Os Calcis/ Calcaneus Fractures
"Deborah Eastwood, Royal Free Hosp.
)Non-steroidal anti-inflammatories (NSAID)
)Massive Blood Transfusion & Complications
Ankle Fractures
Tillaux Fracture of Ankle
Campbell]
Upper Limb
Proximal Humeral Fractures
Neer Classification
N= 2, 3, or 4 parts (fragments).
A fragment must be separated by 5mm or 45deg.
Spine
Low Back Pain & PID
Biomechanics
Hip Joint/ Femoral neck (NOF)
Radin et al.
+'Practical Biomech. for the Ortho. Surgeon'V
Knee
Activity Score (IKDC)
1- Strenous activity (jumping, pivoting, hard cutting)
* The mobility of the lat. meniscus varies from person to person, but a meniscus which stays dislocated when the hook is removed must be considered pathological.
*Lachman & pivot shift = Posterolat. band tear
* Anterior Drawer = Anteromedial band tear
Paediatrics
Chromosomal Disorders
Turner S
(45XO)
*Females, short stature, sexual infantilism, web neck, cubitus valgus, scoliosis, short 4&5 metacarpals.
*renal anomilies(66%), cardiac anomilies(33%)
*malignant hyperthermia !
Screw-home mechanism
= combination of extension & external tibial rotation.
*occurs because MFC is 1.7cm longer than LFC in vertical plane & LFC > MFC in horizontal plane -> as knee extends the tibia is rotated externally.
THR
Complications
Blounts Disease
Benign Tumours
1. Implantation Dermoids: volar surface of finger/palm.
2. Glomus Tumours: vascular, v. tender, nail bed region.
FDrill hole laterally thro one cortex & insert double wire with clip (
Surgery
'Seprafilm'
Hospital Doctor, 18/7/96.4
Surgery
Tendon Repair Technique
Krackow, Thomas & Jonesm
Campbell's, pg. 11
Suited for Flat tendons. It allows application of tension, resists pull-out & avoids 'bunching up'. Twice as strong as staple fixation to bone. Method: over-through-around side- under loop-over-
Reflexes
Reinforcement= Jendrassik's manoeuvre.
S2/S3=1) anal sphincter reflex= contraction of internal sphincter around examining finger. 2) Bulbocavernosus reflex= contraction of bulbocavernosus on pinching glans penis.
Achilles Tendon Rupture
Operative Treatment
Landvater & Renstrom
'Clin. Sports Med.; 11(4):741, Oct. 1992eMedial incision to avoid Sural nerve. PDS suture. Krackow method. Can augment with plantaris tendon.
Type 3: high risk of neurovascular problems & instability, therefore K-wire.
Open Approach=1) Lateral if there is no NVD, incision centred over distal humerus betw triceps & extensor origin. the distal humerus buttonholes thro brachialis & muscle needs to be released. Cannot extend incision proximal because of radial nerve.
2) Antero-medial Approach if the median nerve & brachial artery are thought to be entrapped.
Statistics
Common Tests
Statistics
Meta-Analysis
Stroke
Knee Arthroscopy"Classification of Articular Damage
Insall
1 - Swelling & softening of cartilage
2 - Deep fissures extending to subchondral bone
3 - Fibrillation
4 - Erosive changes & exposure of subchondral bone
Knee Arthroscopy+Classification of Articular Carilage Damage
Frund & Outerbridge
/'Arthroscopy of the Knee' by Aigner & Gillquist
Grade1- softening & oedematous swelling
Grade2- cartilage clefts not down to bone
Grade3- clefts down to bone with partialy expsed bone
Audit
Spine"Prolapse Intervertebral Disc (PID)
Diagnosis w/ Radiology
SD Boden
JBJS 78-A, 1:114, Jan 1996
Traction
Classification
Isobel Taylor
#Ward Manual of Orthopaedic Traction
Manual - Skin - Skeletal.
Sliding/Balanced: weights & pulleys apply & direct traction pull.
Fixed: traction & countertraction provided by two fixed points. (Thomas splint)
Operative steps: 1) fibula length, 2) tibia articular recon., 3) bone graft, 4) support of fragments.
Best fixed within 12hrs, or wait for swelling to resolve.
Wrist3Frykman's Classification of Distal radius Fractures
Bone Cysts
Aneurysmal (ABC)
spine & metaphyseal. Eccentric. paraneoplastic
Expands cortex & thins cortex.
Young adults
Resembles Giant Cell Tumour, except it doesn't extend to articular surface.
Curettage & bone graft.
Filled with blood.
Bone Cysts&Simple Bone Cyst (unicameral/solitary)
metaphyseal, central
children, humerus
# -> cyst obliteration
aching -> excise, curettage & bone graft./ inject with vent needle to decompress & inject steroid.
Trauma
Missile Injuries
Technical Tips
Femoral Shaft Fractures
Open (compound)
Lhowe
Orth Clin N Am, 25(4), Oct 1994 C
Femoral Shaft Fractures
Winquist & Hansen
1- Transverse/ <25% butterfly
2- Transverse 25-50% butterfly
3- >50%, comminution - unstable
4- Extensive comminution, no cortical contact- unstable
5- Segmental bone loss- unstable
Tibial Plafond/Pilon Fractures
Ruedi & Allgower Classification
F1- Minimally displaced
2- Incongruous articular surface
3- Comminuted
Tibial Plateau Fractures
Schatzker Classification
Humerus
Fractures - Proximal
Humerus
Supracondylar Fractures
Children M
Humerus
Supracondylar Fractures
Gartland C
Hand
Flexor Tendon Repair/ Graft
Duran Prot
Metacarpal & Phalangeal Fractures
Palmar Cutaneous Branch of Median Nerve
ADorsal transverse incision across 2-4 MTPJ's. Blunt dissection down to metatarsii. Oblique osteotomies with mini-saw=
30-45deg. from dorso-prox. to plantar-distal, made 3mm proximal to neck. Break plantar periosteum with osteotome & slide distal fragment dorsal. Apply booty POP with moulded anterior arch.
Note- Do 2nd, 3rd & 4th metatarsii, even though only one is prominent (prevents others becoming prominent post-op).
Tibial Fractures - Proximal
Associated Injuries of knee
Rosen (AO)DCruciates- 40%
Art. Cartilage- 36%
Meniscal- 32%
Collat. Ligs- 8%
Open/Compound Fractures
Gustilo & Anderson
JBJS 58-A:453, 1976F
Tibial Fractures
Intramedullary Nails (IMNail)
Indications
1) Segmental
2) multiple injuries
3) delayed/ non-unions
4) Unstable shaft fractures
5) Loss of position in POP
Open #'s- infection rate is equivalent to external fixation, but nailing after external fix leads to high infection rates.
Actylcholine vasodilates bone vaculature (noradr. doesn't)
#: marked incr. flow in first to weeks, but uptake is not increased. Nitric oxide increases uptake (capillary permeability & increases surface area).
Callus is largely independent of endosteal blood supply.
Reaming -> incr. periosteal bld flow. (not dependent on nutrient artery), -> decr. endosteal bld flow. At 6wks flow in cortical bone recovers to normal & periosteal bld flow still high. Reason= centrifugal flow is reversed. (undescribed law of compensation [Treute])
Compartment pressures: incr. in bone (up to 300mmHg), but no change in blood flow in the muscle compartments.
At 6wks: lower bone mineral density in reamed vs. unreamed; & Lower torsional stiffness in reamed !
[Reichert et al JBJS 77B, 1995., Rhinelander; Klein]
Kessler: new bone formation occurs over reamings on subperiosteal surface. Tydings: new bone formed on reamings placed over bone surface.
Hooper(1991): unin quicker in reamed group.
Blachut: no difference in non-union rate betw. reamed & unreamed nailing.
DPatent foramen ovale in heart (25% of people) -> fat emboli to brain as well as lung (post-op confusion), using trans-oesophageal doppler echocardiogram. Occurs w/in 5-10sec after starting reaming.
Reduce pressures: saline dripping (lower viscosity), short head length, deep flutes, push reamer down slowly (velocity). from eq. P ~ viscosity. L. velocity
Fat embolism doesn't occur in low energy trauma. Hb drop, coagulopathy, drop platelet count.
Thinks the cause of embolisation is an altered coagulability rather than purely pressure. cos it is more common when reaming for tumour. Rarely see 'echogenic showers' in # patients, more commonly seen in tumour & THR. Call this 'Pulmonary DIC'.
During reaming the coagulation system is activated. PF 1&2 >3 = DIC. Levels of 9 reached w/ reaming.
Now doing PA
catheter studies.
Timing of Nailing- >10hrs after injury led to incr. risk of fat embolism. (Keating). Day 1-3 seem to do worst. Should check PO2 pre-op. Fat embolism developes 4hrs-5d. after injury.
Keating uses 11mm nails for most tibias & 12-13mm nails for femurs.
Bone Substitutes,Osteogenic Protein-1 (OP-1) (BMP7) ('Novos')5.Friedlaender, Edinburgh Trauma Symposium, 19971
BSkin: surface marking = from lat. to biceps tendon to radial styloid.
Find plane between- lat: Brachioradialis & medial: FCR[dist.]. Sup. Br. of Radial nerve runs under Brachioradialis.
Proximal third- ligate recurrent radial art. & vein, then reflect supinator off radius (will need to supinate). Post interosseous nerve lies within supinator- NB avoid forceful retraction of supinator & don't place retractors around radial neck (cos in 25% of people the post. interosseous n. is in direct contact w/ the neck).
Middle third- pronate to detach PT (& FDS) insertion off radius
Distal third- reflect reflect FPL & pronator quadratus off radius from anterolat. to medial side.
Intramedullary Nails (IMNails)
Reamed vs Unreamed
Bone Tumours
Benign
Differential Diagnosisd_
Traumatic Boutonierre
Capner splint for 6wks
Pellegrini-Steida's disease
p= heterotopic calcification at the attachment of the MCL on the medial femoral condyle. Seen 4-5wks post injury
Adson's Test: Hyperabduct & externally rotate arm squeezing fingers intermittently for 3 min. to reproduce symptoms.
Test2: turn head towards Affected side & take deep breath & hold it. Radial pulse obliterated = +ve.
Auscultate Subclavian artery.
Indications
Paediatrics$Ossification of Carpal Bones (wrist)
2m - Capitate, Hamate
6m- radius epiphysis
10m- Triquetrum
2y- Lunate
2.5y- Trapezium
3y- Trapezoid, Scaphoid
4.5y- Ulna epiphysis
@* Bites- Co-amoxiclav 2 tds for 5d. OR Erythromycin stearate 500mg bd + metroni+
dazole 400mg tds for 5d.
* Osteomyelitis- Peniciilin + Fluclox. OR Clindamycin + sodium fusidate. (Children = Fluclox + Amoxycillin IV for at least 5d, then po. OR Erythromycin + sodium fusidate po for penicillin allergy)
* Cellulitis in children- Fluclox + Amoxycillin IV until improving then po).
ATianium, rectangular troch. area, keel acts like stopper on bottle.
Coating is applied in a vacuum. 50 microns of pure titanium is applied then a 150 micron layer of HAC. Tit is oxygen hungry & HAC supplies the oxygen.
Engh calculations of stress shielding-> diameter of femoral shaft should not be too large (narrower diameter= less stiff)
Preservation of bone stock vs. bone destruction w/ charnley
Furlong c/i for Paget's & Infection.
Swiss
Swiss
Swiss
Swiss
Swiss
Swiss
Swiss
Swiss
Swiss
Swiss
Swiss
Swiss
Swiss
CIn view of the increasing popularity of the direct lateral approach to the hip joint for hemi- or total hip arthroplasty, the location of the superior gluteal nerve (SGN) was studied. This nerve is in danger when using a transgluteal incision. In 20 embalmed specimens the relation of the SGN to the tip of the greater trochanter (TT) was studied as well as the relation to the iliac crest. For this purpose macroscopy, microscopy and CT were used. In 13 hips a so-called most inferior branch was found at an average of 1 cm distal to the inferior branch, the main trunk of the nerve. There was substantial variation in the course of both the inferior and the most inferior branch of the SGN. In order to prevent nerve damage, proximal extension of the transgluteal incision should be limited to 3 cm cranial to TT. Furthermore the incision has to be confined to the distal one third of the distance TT-iliac crest. In tall people extra care should be taken.
Posterior Approach Charnley
Radiological follow up
Technical Tips
TGeneral Points
The signing of a consent form is of secondary significance, but provides invaluable evidence that consent has been obtained.
Express Consent (i.e. written or oral) should be obtained for any procedure that carries a material risk (see below).
Consent could be obtained during the out-patient consultation and then again on admssion.
Person obtaining Consent
Should, whenever possible, be the person who will carry out the procedure.
If not, it should be obtained by someone who is appropriately qualified and familiar with all the details and risks of the proposed procedure.
Material Risks
Defined as those to which a reasonable person in the patient' position would be likely to attach significance.
Bolam test = A practitioner can expect to avoid liability if the court finds that a reasonably competent practitioner in a similar position would not have mentioned the risk, and that such a decision was supported by a responsible body of relevant professional opinion.
Sidaway case (1985) -> In some cases a practitioner may reasonably omit to mention a material risk if, after proper consideration of the patient's condition, he believes that a warning would be harmful to the patient's health (Therapeutic Privilege).
The practitioner must be mindful of the severity and likelihood of the risk compared with the need for the procedure. It may be appropriate to warn of a relatively rare risk for a non-therapeutic procedure, such as sterilisation or a screening test. Whereas a similar risk for an important therapeutic procedure may not require specific warning because of the possibility of deterring a patient inappropriately from a necessary treatment.
Rogers v Whitaker (Court of Australia)(1992) -> A risk is material if a reasonable person in the patient's position, if warned of the risk, would be likely to attach significance to it.
Finlay CJ, Irish courts (1995) -> 'If a medical practitioner charged with negligence defends his conduct by establishing that he followed a practice which was general and which was approved of by his colleagues of similar specialisations and skill, he cannot escape liability if in reply the plaintiff establishes that such practice has inherent defects which ought to be obvious to any person giving the matter due consideration.'
Alterations & Abbreviations
No alterations should be made to the consent form after it has been signed by the patient.
No abbreviations should be used, especially for 'left' and 'right'.
Competent Adult
Criteria for a patient to make treatment decisions:
1. Comprehend and retain the information.
2. Believe the information.
3. Weigh the information in the balance and arrive at a choice.
Minors
Family Law Reform Act, 1969:
Legal age of consent = 16 years & older.
At age 16 and 17 years it is wise to discuss treatment with the parents.
Parents and others can act in loco parentis in authorising treatment for a child. A competent child cannot always veto treatment which his parents have authorised.
The Gillick Judgement, 1985:
Arised from consent for contraception, but applies generally.
The doctor can proceed without the parent's consent or knowledge if:
1. The patient understands the advice.
2. The practitioner cannot persuade the patient to inform her parents.
3. She is likely to continue with sexual intercourse without contraception.
4. Her physical or mental healt are likely to suffer without treatment.
5. It is in the patient's best interests to proceed without parental consent.
This produced the concept of 'Gillick competence' = children under 16 can truly consent to treatment only if they understand its nature, purpose and hazards.
Children in Care:
When a child is subject of a care order, the local authority can authorise treatment on behalf of a child, since it has 'parental responsibility'. Social workers must inform parents, where practicible. However, if a child is being accomodated on a voluntary basis, the local authority does not have parental responsibility.
Incompetent Adults
F v West, Berkshire, 1989
Where a patient temporarily, or permanently, lacks the capacity to give or to express consent to treatment, it is axiomatic that treatment necessary to preserve the life, health or well-being of the patient, may be given without consent.
The doctor must act in accordance with a responsible body of relevant professional opinion (Bolam).
It is good practice to involve others in the decision-making process, such as relatives and others concerned with the care of the patient.
This applies to unconscious patients, also.
'Do Not Resuscitate' Decisions
The overall responsibility for a 'do not resuscitate' decision rests with the Consultant in charge of the patient's care.
The perspectives of other medical and nursing staff members, as well as the patient's relatives and close friends, may be valuable in forming the consultant's decision.
Any decision should be reviewed periodically.
Clinical Research - Participation should be noted in the patient's clinical records. Written consent should be obtained.
Photographs or video - Consent is necessary. The precise nature and intended use sould be explained to the patient. Plans for disposal of the material should be discussed with, and approved by, the patient.
Taken w/ knee in 20deg. flexion. Lateral PF angle= betw. a line across the tops of the femoral condyles & a line along the lat. facet of patella. If the lines are parallel or open medially = AbN.
Radiology
New Skyline XR Viewe&Vivienne Horsfall, 'Synergy'- Jan 1998
Surgery
Posterior Approach to Humerus
Wheeless
Femoral Neck Fractures
AVN following # NOF Fixation2Linde-F; Andersen-E; Hvass-I; Madsen-F; Pallesen-R
Injury.17(3):159-63, May 19865
Shoulder
Scapula Fractures
Associated Injuries:
*Rib/ Pulmonary Injury- 25%
*Clavicle # - 23%
*Brachial Plexus Injury - 10%
Indications for Surgery:
*Glenohumeral joint involvement
*v. displaced
*significantly angulated neck #
*impinging # of acromion
Humerus
Fractures - Proximal
* Must have AP + Axillary + Lateral views
* 90% are stable injuries in elderly
* AVN of humeral head may not lead to significant functional impairment (not WBing jt.)
* TBW = if head & Greater tuberosity are in one piece.
Hand!Metacarpal & Phalangeal Fractures
OKU 5
**USE LEAST INVASIVE TECHNIQUE CONSISTENT WITH NECESSARY STABILITY **
Consider ORIF if: 1) Closed reduction fails, 2) Percutaneous Fix cannot be achieved, 3) # is unstable d.t. segmental bone loss or comminution.
Antibiotics
Guidelines
Dr Derek Johnstone
Scarborough-
Implants
Furlong, uncemented, HAC
John Bradley
Consent to Treatment
Dr John Gilberthorpe
MDU Booklet, 1998.
Hip#Approach for THR & Hemiarthroplasty[Surgical anatomy of the superior gluteal nerve & ... the direct lateral approach to the hip\
K frx tends to occur in older children, about one year prior to eiphyseal closure;
- Two Part Frx: type of SH type IV frx; occurs when the medial portion of of the distal tibial epiphysis is closed; lateral view: shows Salter type IV frx; posterior plafond fragment extends across epiphyseal plate to involve metaphysis of the tibia; may be comminuted w/ separation of posterior half from lateral three fourths;
- Three Part Frx: combination of SH types II & III frx; occurs when only the middle portion of the distal tibial epiphysis is closed; appears as SH type III frx on AP view & type II on lateral; frx of anterolateral portion of epiphysis of distal tibia (similar to Tillaux frx); frx of large posterior fragment comprised of posterior & medial portions of tibial epiphysis plus a large metaphyseal fragment of variable size; medial one fourth of plafond and medial malleolus are left intact; fibula may also be fractured;
- Mech: occurs due to external rotation forces; anterior part of frx begins intra-articularly in saggital plane, when frx reaches epiphyseal plate, it courses laterally in horizontal plane, and the posterior portion changes direction upward in saggital plane;
- Non Operative Rx: most two part triplane frx, can be treated by closed reduction under GEA; closed reduction is successful when frxs is displaced < 2 mm & when joint surface is congruous; closed reduction is achieved by internal rotation of foot & long leg cast for 4 weeks followed by short leg casting for 2-3 weeks; these frxs are often assoc w/ significant soft-tissue swelling, which makes maintenance of reduction w/ cast somewhat difficult;
- Indic. for ORIF: displacement > 3mm; most often, 3 part frx will require ORIF;
- Surgical Technique: because of complex frx pattern, adequate reduction may be difficult; wide dissection may be necessary to achieve reduction; surgical technique depends on whether frx is two part or three part frx; screws used to provide fixation should not cross growth plate, unless patient is nearing the end of growth.
- technique for 3 part frx: open reduction of both SH type II & type III components is necessary & requires adequate exposure; stabilization w/ two screws, placed percut., obliquely through the anterolateral epiphyseal fragment, & an AP screw to stabilize post. metaphyseal fragment; incision: anterolateral incision; anterolateral fragment is identified and displaced to allow for visualization of posteromedial fragment; reduction of posteromedial fragment is achieved under direct vision thru internal rotation and dorsiflexion of foot; posteromedial fragment is fixed w/ K-wire or cancellous screws in an AP direction from anterior aspect of distal tibia into post. fragment; fibular frx is subsequently reduced and fixed; at this point, the frx has been essential converted to a Tillaux frx; anterolateral fragment is reduced and fixed w/ K wires or cancellous screw;
-Complic.: growth deformities are uncommon cos frx occurs at end period of skeletal maturity
DLPXB
Hallux Valgus.
Paediatrics
Legg-Calv
-Perthes Disease
Management
Lacertus Fibrosis
J= An aponeurotic band fromthe biceps tendon to the fascia of the forearm.
Spine
Spondylolisthesis
Surgery
Galeazzi Fractures
Internet
World Wide Web Sites
Bennett's Fracture Treatment
Hand 1st CMCJ
Anatomy
!Tibial Shaft/Diaphyseal Fractures
Intramedullary Nailing (IMNail)
Outcome Literature
Ankle Fractures
Triplanar Fracture
Screw Design
Spine
Spinal Cord
Femoral Neck Fractures
Basicervical #'s Mxa'Basicervical #'s of the proximal femur. A biomechanical study of 3 internal fixation techniques.
Blair et al. (New York)
CORR. (306):256-63. 1994 Sep.
Surgery!Radial Head Excision/ Replacement
Swanson
Campbells
Surgery1Open reduction of intracapsular #NOF in young Pt.
SJ Matthews
Bone Tumours
Benign
Enchondroma
multiple= Ollier's disease
on tubular bones (usually small bones)
-> fracture.
cks of calcification.
Excise & curettage & bone graft.
NB exclude chondrosarcoma in adult + long bone.
*Maffucci S
= enchondromatosis + haemangiomas
Hydroxy-apatite Coatings (HAC)
Ten years
Hydroxy-apatite Coatings (HAC)
The applic
Technical Tips
jCHA is osteo-conductive.
Experimental Evidence: High susceptibility to bone ingrowth, gap filling, micromotion during ingrowth & sealing of the implant-bone interface against polyethylene particle induced osteolysis.
Clinical Evidence:
* Nine year survival rate of 96% for cup & 98% for stem.
* Revisions only for malposition/ recc. disloc. or sepsis.
* Stable Harris hip score of 97.
* Mechanical failure rate & osteolysis rate for mid/distal femoral stem of Zero up to 10 years.
* Scalloping lesions of 2-3mm diameter only visible along the calcar of the stem, probably caused by PE wear effects. This points to the sealing (gasket) effect of the HAC in the proximal femur.
* DEXA showed 30% BMD loss only in the proximal medial stem area (Greun zone 7).
* Retrieval studies show excellent osseo-integration.
These are all proof of the OSTEO-CONDUCTIVE properties of HAC.
COSTEOTROPISM = The ability of HAC to attract bone to its surface like a uniting fracture. Once a fracture is united it remains so.
Fixation:
1. Primary Mechanical Fixation for a finite time. Obtained by using a cone, which transfers force from the metal to bone without differential movement. The femur can withstand high hoop stresses, allowing a firm fix which will only loosen after 3 months.
2. Secondary Absolute Fixation of the HAC to metal for an infinite time. This involves:
1) Chemical Bonding - Involves a simple chemical reaction betw. oxygen hungry titanium & an oxygen radicle. Calcium titanate is a stable chemical compound & thus bonds the HAC to the prosthesis.
2) Energy - Kinetic energy imparted to the partially melted granules by the vacuum spraying process ensures adherence to the metal substrate.
3) Interference fit - Coating the metal w/ HAC to cover all surface irregularities.
Shoulder
Motion
Shoulder
Scapula Fractures
Shoulder Instability/ Recurrent Dislocations
Putti-Platt Procedure
Shoulder
Codman's Pivotal Paradox
Shoulder
Codman's Pivotal Paradox
Shoulder
Scapula Fractures
MIndications
Diagnostic
Provide information regarding shoulder instability
In place of or in addition to radiographic methods
Assess rotator cuff
Glenohumeral side
Subacromial side
Investigate cause of pain or other symptoms
Therapeutic
Shoulder stabilisation
Acromioplasty
Synovectomy
Technique
Preparation
Place patient in lateral position
Tilt posteriorly 30o so that glenoid is parallel with bed
Stabilise patient with beanbag or lateral rests
Apply skin traction to forearm
Place traction pole at foot of table opposite surgeon
Suspend arm with 5-10 lb weight
Abduction 45-60o
Forward flexion of 20o
Outline bony landmarks
Prep and drape patient
Posterior portal
Identify posterolateral corner of acromion
Identify soft-spot
1 cm medial and 2 cm inferior
Insert spinal needle into glenohumeral joint
Direct tip towards coracoid
Inject small amount of saline
Confirm position by backflow
Distend joint with 50 ml saline
Make stab wound at posterior portal
Introduce cannula and trocar
Confirm position with back-flow
Introduce arthroscope
Examination
Initial orientation is (for right shoulder)
Biceps tendon to left 10-15o from vertical)
Glenoid to right inferiorly
Humeral head to right superiorly
Biceps tendon and groove
Trace tendon
From superior attachment to glenoid
To where enters bicipital groove
Rotator cuff
Supraspinatus tendon is seen upwards above tendon
Glenoid
Is seen posteriorly below tendon
Inspect surface and labral rim
Inferior recess
Revealed by continued inferior rotation of scope
Humeral head
Can see all but anterior part of head
May see bare patch posteriorly between articular surface and capsular insertion
Anterior labrum
Scope passed anteriorly
Brings anterior labrum into view
Anterior portal
Direct scope into intra-articular triangle
Biceps tendon
Head of humerus
Glenoid labrum
Advance until rests aginst anterior capsule
Light transilluminates skin at site of portal
Remove scope from sheath
Insert rod through sheath
Make stab incision
Advance rod
Use portal for probe and instruments
Subacromial portal
Pass blunt obturator through posterior portal
Direct it superiorly immediately below acromion
Introduce arthroscope
Neurological complications
Uncommon (0.1%)
Direct injury
Posterior portal
Passes between infraspinatus and teres minor
Is 3-4 cm superior to quadrangular space
Anterior portal
Pierces deltoid
Enters between subscapularis and supraspinatus
Is lateral to coracoid
Structures at risk
Musculocutaneous nerve
Subscapular nerves
Structures at risk if portal incorrectly placed medially
Brachial plexus
Axillary artery and vein
Other portals
Suprascapular fossa portal
Suprascapular nerve at risk
Lateral portal
Axillary nerve at risk
Procedures
Bankart repair
Suture through drillhole from anterior glenoid into infraspinatus fossa
Suprascapular nerve may be injured by drill or suture passer
Debridement of AC jt
Brachial plexus may be injured if debridement carried too far medially
Trapezius and serratus ant control scapula in all phases
Allows stable glenoid
Takes < 1 second
Acceleration accounts for 2 %
Arm IR 7000 degrees per second
Ball 0 - 90 mph in 80 ms
Kinetic energy 27 000 in-lb ( 4x kicking leg KE)
( due to 2x angular velocity and KE varies with square of ang. Vel. )
Rotator cuff disipate energy in follow through
@Physical Principles
Obtains image contrast information by the reaction of various tissues when stimulated by a radio frequency (RF) pulse while in a strong magnetic field.
An RF coil is used to generatet a pulsed signal directed at a body part, and the same or another coil recieves the response from the stimulated nucleus.
The basic principle is that nuclei with an odd number of protrons or neutrons exhibit spin. As they spin they precess, at a particular frequency, about an axis much like a spinning top.
Because the nucleus is charged it acts like a magnet.
Hydrogen is the nucleus most commonly used for imaging because it is abundant and has favourable magnetic characteristics.
Normally the hydrogen nuclei precess about randomly orientated axis, however when placed in a strong magnetic field they precess at a frequency determined by the magnetic field, and align themselves parallel to the external field.
If a pulsed RF signal resonant to the precessing frequency is applied then it causes deflection of the nuclear magnetic moment proportional to the strength of the RF signal. If the nuclear magnetic moment is deflected 90 degrees to lie perpendicular to the external field then it can induce an AC current in an external coil.
When the RF pulse stops the nuclei return to the previous alignment.
Definitions
Resonance
the synchronising of the RF signal with the precessing frequency of the hydrogen nuclei.
enables the axis of precession to be deflected.
the precession frequency is a function of the strength of the magnetic field and the gyro-magnetic ratio of each nucleus.
Pulse Sequence
schedule of RF signals used to characterise the imaged tissue.
way of manipulating the relaxation properties (the return of the nuclei to the previous alignment).
Pulse sequences commonly used
spin echo
inversion recovery
chemical shift
small flip angle
Spin echo sequence is a 90 deg. signal followed by a 180 deg. signal.
The 90 deg pulse aligns the nuclei, but they start to dephase because of the local influence of neighbouring atoms. The 180 deg. pulse rephases them, and the AC current developed is read as a signal.
TE or echo time is the time between the 90 deg. and the peak signal (or echo) developed from the tissue.
TR or repitition time ie the time between the 90 deg. signals.
Spin echo sequences with short TE and TR times are T1 weighted and those with long TE and TR times are T2 weighted.
Transverse and Longitudinal Relaxation Times
T1 and T2 are tissue related characteristic time constants.
T1 is known as the longitudinal relaxation time (also the spin lattice relaxation time). It is related to the time taken for the nuclei to realign with the external magnetic field after they have been deflected by the 90 deg pulse.
T2 is the transverse relaxation time (aka spin spin relaxation time). It is related to the time taken for the signal generated by the nuclei orientated 90 deg to the external magnetic field to be lost because of dephasing.
In general T1 demonstrates anatomy and T2 demonstrates pathology.
Basic Signal Intensities.
Low signal intensity appears dark.
Tissues with a short T1 have a high signal intensity.
Tissues with a long T1 have a low signal intensity.
and vice versa.
Inflammed tissues appears darker on T1 images and brighter on T2 images because the T1 and T2 are increased relative to normal tissue.
This is probably due to increased water content.
Neoplastic Tissue usually has increased relaxation times relative to normal tissue, hence the T1 is darker (or isointence) and the T2 is brighter.
Fibrous tissue has a prolonged T1 and therefore appears dark on T1 images. The T2 time is reduced so it is dark on T2 scans.
Haematoma varies depending on its age and degradation products. Generally there is an increase in the T1 and T2 times (dark on T1, bright on T2).
Blood flow appears dark on both T1and T2 scans.
MR Scanning in Trauma
Muscle haematomas
acute haematomas are dark on T1 (long T1) and bright on T2 (long T2).
this pattern changes as the haematoma becomes older.
Spinal Injuries
Allows visualization of the spinal cord and canal in the sagital plane.
MR can often differentiate between cord haematoma and oedema.
Retropulsed bone fragments and haematoma impinging on the thecal sac are well seen.
Intra-articular Knee Injuries
PCL well visulised in sagital plane appearing as a low signal band on T1 and T2.
ACL less well seen because of its small size and orientation.
Appears grey/black on T1 rather than the black appearing PCL.
Menisci well seen
but chemical changes within the meniscus maybe interpreted as tears.
Criterea for MR scan diagnosis of a tear
alteration in contour of meniscus.
high signal intensity extending to articular surface of meniscus.
Proving to be useful in the diagnosis of discoid meniscus, especially in children (diagnosed on sagital images by "bowtie" configuration appearing in 3 contiguous 5mm cuts).
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Ossification Centres
Osteoarthritis
Os Calcis/ Calcaneus Fractures
Os Calcis/ Calcaneus Fractures
Osteoarthritis
Patient Controlled Analgesia (PCA)
Pellegrini-Steida's disease
Pelvic Fractures
AO C-clamp/ Ganz Clamp
Applicatio
SAnt Longit Lig
Attaches to the discs
Starts C1 ant tubercle
Post Longit Lig
Attaches to bodies to allow escape of basilar vertebral veins.
Starts at C2, but cont above as Tectorial Membrabne.
Lig Flava
Attaches to lamina below at back and lamina above at front
Relations of Intervertebral Foramina
Thoracic and Lumbar
1 In front lower part of body and disc
1 Behind facet joint and capsule
Cervical
2 As the pedicle arises lower from the body, the body below is also a relation
Movements
3 Free flex/ ext at alanto-occipital joint and lumbar vert.
4 Restricted flex at T Spine
5 Rotation- Thoracic region above T9 and alanto-axial joint
6 Very little rotation at lumbar.
7 C Spine C3-7 pure rotation is impossible as the facets are not on a circle. Hence abduction is really a rotary movement.
Atlas
8 No centrum
9 Short ant arch = ossifeid hypochordal bow. Ant alanto -occipital lig connects it to the occiput. C1 and vertebral artery escape between the two.
10 Long post arch with no spine. Post alanto-occipital lig connects it with the occiput
11 Upper facet is concave and kidney shaped. No rotation at alanto-occipital joint.
12 Lower facet is round and flat
13 The facets are in line with the uncovertebral joints and hence the C1 and C2 nerve roots goes behind them.
14 Dens is not centrum of C1, but development in own right
15 Median alantoaxial joint is where dens articulates with back of ant arch C1, held in place by transverse limb of the cruciform ligament.
16 Bifid spinous process.
17 Superior articulation is via uncovertebral type flat joint. Allows good rotation.
18 Inferior articulation is ordinary facet.
Tectorial Membrane
19 Cont of post longit lig
20 Attaches from Axis to Ant foramen magnum
Cruciform Ligament
Transverse and Longit parts
21 Tranverse articulates with back of dens
22 Longit part attaches to foramen mag in front tectorial membrane.
Apical Ligament
23 Weak, notocord rem. in front cruciform lig
Alar lig
24 Obliquely slopeup to foramen
25 Strong
Ant alanto -occipital lig in front of all these ligaments
Venous Drainage
Body via basivertebral vein to internal vertebral plexus
Arch and muscles to external vertebral plexus (Intramuscular)
Muscles
Flexors
Prevertebral Rectus (Ant rami supplied and derived from innermost layer body wall))
26 Lonus capitis
27 Longus colli
28 Psoas
Rectus abdominus and obliques are the main flexors
Extensors
Derived from outer layer body wall and supplied by post rami
Three layers
1. Interspinales join adjacent SP
1. Intertransverslaes join adjacent TP
Transversospinalis (Intermediate)
1. Rotatores rotate are horizontal and are only in T Spine and connect the bases of SP to TP
1. Multifidus slope up to laminae, TP and mamillary process of vertebrae 2 or 3 above. Start sacrum to neck
1. Semispinalis lies on multifidus and extends from TP to SP in the loew T Spine to skull.
1. Semispinalis thoracis TP to SP 6 or more above
1. Semispinalis cervicis arise in continuity and inserts into C2 bifid SP
1. Semispinalis capitis. From upper 6 T spine TP and lower 4 C Spine TP into occiput between sup and inf nuchal lines. It covers semispinalis cervicis and sits deep to splenius and trapezius. Ascending branch superficial cervical artery passes deep and deep cervical artery (ascending branch of the costocervical trunk) passes superficial.
Erector Spinae (Superficial Layer)
Three main groups
1. Iliocostalis (Lateral)
29 Start on sacrum and iliac crest
30 Insert into 6 lowest ribs angles.
31 From their insert into 6th rib above ie 11th F 5th.
32 Then insert into lowest 4 C spine TP
1. Longissimus (Medial)
33 Longissimus thoracis arise sacrum/ ilium and inserts into gutter of ribs and SP.
34 Then Longissimus cervicis arises on ots medial side in the gutter and passes to the TP of the lower Cspine.
35 Longissimus capitis arises from this insertion and inserts into mastoid process.
1. Spinalis
36 Weak medial part
37 Runs next to semispinalis
Splenius
Flat sheet which binds down extensor muscles and arising from upper thoracic spines, lig nuchae and supraspinous ligaments. Deep to Trapezius and SCM. Inserts into sup nuchal line and mastoid process (splenius capitis) and TP of upper three C Spine.
Ligamentum Nuchae
Triangular sheet midline of firius tissue.
Attaches to C2 SP and Ext. occipital crest and deep cervical fascia.
Suboccipital Triangle
Formed by (All post rami C1)
1. Rectus capitius posterior major (C2 SP F inf nuchal line)
1. Sup oblique (Lateral mass AtlasF lat occiput)
1. Inf Oblique (C2 SP F Lateral mass Atlas)
Suboccipital n (C1) runs thru it
Vert artey reuns across floor
Floor is post alanto-occipital membrane and post arch Atlat
Over roof runs Gr occipital n (C2) and occipital artery
Rectus Capitis post minor
Post arch Atlas to Inf Nuc Line
Vertebral Artery
Second part runs vertically thru foramin of TP anterior to spinal nerves
Between Axis and Atlas runs laterally to give out slack
Gives off spinal br. C6 F C2
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
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Arial
@Normal Gait
Cycle begins when foot strikes the ground and ends when it strikes the ground again
Stance phase:
Heel strike to toe off
60% gait cycle
2 periods of double stance 10% each
-at these times the body's centre of mass (COM) is at its lowest
-divided into 5 phases:
Initial contact
Loading response
Midstance
Terminal stance
Pre-swing
Swing phase 40% gait cycle
Initial swing
Mid-swing
Terminal swing
Running; the two periods of double support are replaced by perriods of double float
.: Stance time now less than swing time
Step length; longtitudinal distance between 2 feet
Stride length; distance covered during 1 cycle= 2 by step lengths or R + L length
Velocity= cm/s or m/min
Cadence= steps /minute
STANCE PHASE
1. Initial Contact
Position foot correctly as it comes into contact with the floor
GRF: post to ankle, at or just in front of the knee, ant to hip
Beginning of first rocker
Hamstrings active and aid in hip extension
Hip abductors act eccentrically to resist adduction moment created by body's mass acting on hip joint
2. Loading Response
To maintain smooth progression while decelerating the body's mass as it travells downwards from its zenith at midstance
Deceleration 20-30% body weight with normal gait
GRF 130% BW (mass + inertia)
Decelleration controlled by; rate of knee flexion (3 vasti) and ankle plantarflexion
At end knee flexion 15', ankle plantarflexed 10' and second rocker begins
GRF moves anterior to ankle; TA ceases, tib post, triceps and peroneals begin
GRF passes through hip; hip extensors relax, hip abductors required as weight transferred to stance limb
GRF to foot is lateral to ankle joint-> eversion moment of the heel ->calcaneus everts, head of talus rotates medially,
IR tibia and fibula by traction on ligaments
IR femur controlled by adductors, medial hamstrings and anterior gluteals
All act to bring pelvis foward on contralateral side as it moves through pre-swing to toe-off
3. Mid-Stance
Utilize momentum to maintain stability over hip and knee while advancing body over stationary foot
-10-30% cycle
-onset marked by opposite toeoff
-knee fully extended and extension continuing at hip
-COM at zenith
-foward velocity at minimum
Sagital plane;
GRF moves along the length of the foot
Anterior to knee and posterior to hip (extension of both joints)
Eccentric contraction of soleus limiting plantarflexion stabilizes all 3 joints
Coronal plane
Pelvis drops 5' on unsupported side; hip abductors and TFL active
Ankle tib post and peroneals stabilize the foot as GRF progresses along its lateral side
Transverse plane
IR shank continues
Thigh IR until full knee extension
Midstance- pelvis reaches neutral
Shoulders also neutral but rotating in opposite directions as upper trunk acts to counteract the weight
4. Terminal Stance
Provide acceleration and ensure adequate step length
Acceleration from;
Foward fall of COM
Concentric action of triceps generates 80-85% energy
COM falls in front of base of support, anteriorly and towards unsupported side
Sagital plane;
Gastroc joins soleus to stop further dorsiflexion
Triceps concentric contraction and heel leaves groung
Onset of 3rd rocker
Fulcrum of rotation is metatarsal heads (axis 30' to coronal)
Rotation; inversion of hindfoot which locks ST joint
Knee and hip fully extended (GRF ant to knee and post to hip
5. Preswing
Prepares limb for swing
Begins with opposite heel strike
Hip flexors act concentrically firing as accelerators
Stance limb moves forards
Weight unload onto contralateral limb
GRF passes behing knee -> knee flexion
Ankle plantarflexors contribute
At toe off; ankle plantarflexed 27', knee flexed 45' and hip flexed 5'
Coronal plane;
Hip abductors inactive as weight transfers
Gracillis and adductor longus become active and assist hip flexion
Transverse plane
Maximum rotation of pelvis at end of terminal stance
Onset of preswing, it rotates foward with trailing limb
Thigh rotates ext. Relative to the pelvis
Foot centre of pressure under MT 2 & 3 heads
SWING PHASE
1. Initial Swing
50%- 70%
Allows foot clearance
Variable cadence via control and precise timing of 2 joint muscles- ability lost in neuromuscular conditions
Sagital plane
Pre-tibial muscles dorsiflex foot
Knee flexes to 62'
Hip flexes secondary to iliopsoas
Coronal plane
Adductors assist flexors in advancing the limb
Swing side pelvis drops 5'
Reduces vertical excursion and COM and conserves energy but increases the amount of knee flexion required
Transverse- pelvis rotates foward
2. Midswing
70-85%
Maintain foot clearance
Knee extends, must maintain level pelvis, hip flexion and ankle dorsiflexion
Normal gait- foot clearance 0.87cm in midswing
3. Terminal Swing
Deceleration of shank and correct positioning of foot for contact (85% - 100%)
Need full knee extension and neutral position of foot
Sagital;
Hamstrings decelerate thigh and shank ( max activity in this phase)
Hip extensors, quads, pretibial muscles all prepare to resist GRF
Coronal
Hip abductors act just before initial contact to resist impeding large adductor moment
Transverse
Maximum forard rotation of pelvis
ER of limb continues secondary to inertia
Necessities of Normal Gait
Stability in stance
-body is top heavy
-C of G is anterior to S2
-walking continually alters segment alignment- body must constantly balance trunk over base support
Means of Progression
-progression results from foward fall of body from its high point at mid-stance to its low point at double support P.E. = K.E.
-to raise it back to level of midstance need K.E.
-inertia of swinging limb
-energy for accelerators- 85% plantarflexors; 15% hip flexors
-foward momentum is not constant, accelerates and decelerates as COM passes over base of
support
Conservation of energy by;
a. Minimizing excursion of COM
-normal vertical excursion 4.4cm if stiff limb then 9.5 cm
-AKA energy cost of walking is doubled
Controlling momentum
-maintain GRF in front of knee in last 1/2 of stance .: Extension moment of knee and quads not needed
-muscles acting across 2 joints transfer energy between segments
Pathological Gait
4 basic types of physical impairment
1. Contractures
Rigid
Elastic
2. Muscle weakness
3. Pain
Position joint with minimum pressure in joint
Ankle 15' plantarflexion
Knee 30' flexion
Hip 30' flexion
Spasticity
Premature, prolonged and unco-ordinated muscle action
*metatarsus primus varus, pes planus, atlantoaxial instability, scoliosis, spondylolisthesis, hip instability, SUFE, patella disloc., planovalgus feet.
*Atlantoaxial instability- evaluated with flex-ext. XR's. Asymptomatic child should avoid contact sports, diving & gymnastics. Fusion for progressive instability & instability >10mm or neurological symptoms.
*NB- preop cardiac assesment.
NERVE CONDUCTION STUDIES
Tested by stimulating a peripheral nerve at one point and recording the response at another.
Pathological Processes
Two posible types of injury
Myelin sheath
Axonal Damage
affected in an all or none fashion.
Transection of a nerve or avulsion of a root cause complete disruption to conduction , whilst lesser injuries may be electrophysiologically inapparent.
Myelin Sheath Damage
results in a graded slowing of conduction.
Conduction is slowed in proportion to the length of nerve demylinated until ultimately conduction stops.
Compressive lesions tend to cause demylination in the largest fibres at the site of compression
this leads to slowing of conduction locally.
Useful in localising entrapments.
Technique
Nerve stimulated by a pair of electrodes applied to the skin.
generally a square wave pulse of up to 500 mV and 0.1 - 1 mS duration.
stimulation increased until all axons in nerve are depolarised producing a plateau in the recorded amplitude.
this stimulus intensity is used for the NCS.
Surface electrode records response over the distal part of the nerve or the muscle.
muscle signal up to 1000 times stronger (because of intrinsic amplification).
Nerve potential ~ 5 - 10 micro V.
Represents the summated activity of many axons.
Response Amplitude and Latency
Amplitude
proportional to number of functional axons
loss of axons causes decrease in response amplitude.
Amplitude is a measure of the total number of functioning axons in the nerve.
Conduction Velocity
calculated from the latency values.
reflects only the function of the fastest conducting fibres.
fortunately most compressive or traumatic disorders affect the largest fibres.
Calculated by dividing the latency by the distance between the stimulating and recording electrodes.
If the response is measured over the muscle then the delay at the motor end plate must be considered.
Conduction slowed by the small, unmyelinated terminal branches of the motor axon and by the time taken for release of Ach.
Typically ~1 mS.
Because of this delay terminal latencies cannot be used to calculate a meaningful conduction velocity, however because the delay is fairly constant the terminal latency
HaemaneticsMReplaces saline + RBC's only. Need to check clotting after replacing 4units.
Implants
Unreamed Femoral Nail (UFN)
Surgery
Unreamed Femoral Nail (UFN) AO
Miss-a-Nail
Paediatrics%Club Foot/ Talipes Equinovarus (CTEV)
820% recurrence after Sx vs. 20% success of non-surg Mx.
Surgery
Segmental Chemical Ablation
for Ingrown Toenail
Ring Block & Jacques Catheter tourniquet.
divide nail plate with scalpel & remove nail segment.
Apply aqueous 80% Phenol for 3min.
Wash with alcohol solution (Hibitane)
Surgery*Kocher Approach to Elbow (Postero-lateral)
+BTransduction
long acting local anaesthetics
Transmission
Neural blockade with local anaesthetics which inhibit transmission by binding to sodium ion channels via epidural or intrathecal routes
Modulation
perispinal application of opioids (epidural or intrathecal) can provide intense analgesia without autonomic or motor blockade as they act directly on the dorsal horn
degree of lipophillicity determines rate of diffusion across the dura (onset and duration of effects)
Transcutaneous electrical nerve stimulation
based upon gate control theory
rEDefinition
Acute pain may be defined as an unpleasant localized sensation in response to a noxious stimulus (trigger) that appears to be capable of producing tissue damage.
Acute Pain Physiology
effect of acute pain produces an individually varied emotional response that depends on the;
physiologic
psychologic
cultural
socioeconomic factors
Adverse psychologic or physiologic effects of pain
alter early response to treatment or rehabilitation
all substances further stimulate and sensitize the nociceptors
Central factors influencing pain perception
noxious impulses via afferents stimulate
midbrain
thalamus
frontal cortex
origin of suprasegmental and cortical responses
segmental and suprasegmental responses result in physiological changes
CVS, GIT, GUT, Endocrine & immunological systems
Cortical contribution
less well understood
begins with individuals perception of pain
emotional responses (anxiety)
measurable changes in circulating catecholamines, cortisol, clotting time, fibrinolysis and T & B lymphocyte function
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Postoperative Analgesia
Postoperative Pain Relief
Psychology of Pain & Dysfunction
ADysfunction
psychologic component of pain dysfunction syndrome often pronounced, frequently dominant clinical feature
Often categorized as having psychogenic disorder;
hysterical, unstable, depressed
most frequently seen changes are
persistent anxiety
reactive depression
dependency
somatic preoccupation
Important to be aware of socioeconomic factors
sick role positively reinforced until workers compensation claim settled
sFNSAIDs
Used extensively to control the pain of arthritic and musculotendinous inflammatory processes
Act via decreasing the levels and effects of inflammatory mediators produced at the site of the injury
Good synergistic effect when used in combination with opioids
Keterolac similar efficacy to opioids in post-op. analgesia for musculoskeletal surgery
Epidural Analgesia
significant increase in use for surgery of lower extremities
benefits especially in the elderly;
decreased postoperative sedation
earlier mobilization (CPM)
more effective than parenteral narcotics
other sideline benefits (DVTs)
clinical trials with patient controlled epidural analgesia encouraging
Regional anaesthesia
gaining wider acceptance for upper limb surgery
advantages;
earlier mobilization
improved vascular flow
prolonged sympathetic block
Axillary, interscalene blocks
Parenteral Narcotics
50% insufficient analgesia
may meet or exceed the minimal analgesic concentration for only 35% of dosage interval
Small frequent intravenous doses of opioids;
rapid onset
achieved on-demand with patient controlled analgesic devices (PCAs)
-programmable computerized dosage delivery
-bolus loading dose followed by predetermined on demand IV dose
-morphine sulfate and meperidine used
-lock-out time interval before subsequent dose allowed
-record of patient requests informative
-high degree of patient acceptability
-decreased complications; respiratory depression and sedation
-reduces nursing staff demands
Transdermal narcotics (fentanyl)
of use in elderly and debilitated patients
requires systemic loading dose followed by transdermal patch
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Definition
: Pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage
Gate Control Theory of Pain
Attributes transmission through the dorsal horn to the interplay between myelinated and unmyelinated inputs
hypothesized that both myelinated and unmyelinated primary afferents directly excited cells in substancia gelatinosa and that interneurones presynaptically inhibited afferent input by inhibition of transmitter release
useful theory to explain modification and modulation of afferent pain sensation
Neural Pathways
Transduction is the process by which noxious stimuli cause electrical activity at the nerve endings
nociceptors are primary afferent neurones whose periphery selectively respond to noxious stimuli; chemical, thermal, mechanical
Sensitization of the receptors can be accomplished by the release of chemical mediators.
-may leak out of damaged cells (K+, histamine, serotonin, ATP) or enzymatically synthesized (bradykinin, prostoglandins, leukotrienes)
-release substances that enhance transduction (Substance P)
Transmission refers to the propagation of impulses throughout the sensory system
there are three neuronal components to the transmission system
primary sensory afferent nerves carrying information to the spinal cord
-most numerous axonal fibre in peripheral nerve C fibre
-small unmyelinated, slow, cell bodies in DRGs
a series of ascending relay neurons between the spinal cord, brain stem and thalamus
-smaller A-d & C fibres take venterolateral position in the dorsal horn
-ascend in Lissauers tracts for short distance then into grey matter
-larger A-a & A-b fibres straight into dorsal columns
-neurotransmitters synthesized in DRG responsible for excitation of spinal neur.
Modulation refers to the process of controlling the amount of afferent activity transmitted from the periphery to the CNS
transmission may be selectively facillitated or inhibited at the level of the dorsal horns through distinct pathways containing noradrenalin, serotonin and endogenous opioids
Endogenous Opioids:
-contributes to pain modulation
-3 main groups: prokephalin-A, prokephalin-B and pro-opiomelanocortin
-found in high concentrations in areas important for nociception
-show characteristic properties of opioid family of compounds
-microinjection of opioids into areas containing endogenous opioids can
give rise to profound analgesia
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KDefinition
Dysfunctional pain disorder may be considered after elimination of all plausible functional causes when a patients reported pain is judged extreme with respect to the known degree of the tissue damage
Chronic Pain Disorders
Causalgia
Mimocausalgia
Sympathetic dystrophy
Algoneurodystrophy
Chronic traumatic oedema
Posttraumatic pain syndrome
Shoulder- hand syndrome
Sudeks Atrophy
Sympathalgia
Posttraumatic spreading neuralgia
Posttraumatic osteoporosis
Neurodystrophy
Reflex sympathetic dystrophy
confusing conglomeration of terms
all characterized by an abnormal pain response and dysfunction of the affected extremity
use of term "pain dysfunction syndrome" as a clinically descriptive label
Abnormal persistence of pain may be caused by unrecognized disease process;
Cartilage loss, subchondral cysts, structural collapse of the articular surface, intraarticular crystals
Differential Diagnoses;
Hyperparathyroidism
X-rays show subperiosteal erosions, blood tests show hypercalcemia and inc. Se PTH
Ochronosis
Inborn error of metabolism; absence of homogentisic acid oxygenase
Homogentisic acid deposited as a dark brown pigment in connective tissue, hyaline and fibrocartilage
Clinically presents in 4th decade with pain & stiffness in spine and larger joints
Xray show calcification of intervertebral discs, progressing to obliteration of the disc space and bony ankylosis
Excretion of homogentisic acid causes the urine to turn dark on standing
Haemochromatosis
Characteristic progressive degenerative arthritis of finger joints
Xray shows calcification of multiple joints and discs
Serum iron and iron binding capacity are raised
*gout strikes the small joints, pseudogout the large joints and ochronosis the spine
Haemochromatosis
Disorder where iron deposied in many tissues
, including articular cartilage
Concominantly get cirrhosis of the liver, heart failure, diabetes & bronze skin
Arthropathy very similar to CPPD
Chondrocalcinosis often a prominent feature
Adult onset hypophosphatasia
Hereditary metabolic disturbance characterized by low levels of serum alkaline phosphatase
Ochronosis
Alkaptonuria is an inborn error of metabolism in the tyrosine pathway
Homogentisic acid oxidase is absent and homogentisic acid accumulates in the tissues
Its deposition causes black pigmentation, termed ochronosis
Pigmented articular cartilage and vertebral discs become brittle and undergo early severe degeneration
X-ray;
Narrow calcified intervertebral discs, subchondral sclerosis with vacum phenomenon
Severe destruction present in shoulders, hips, knees
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FDefinition
Collecyion of disorders characterized by the degeneration of anterior horn cells and sometimes the bulbar motor neurone
Aetiology
Most autosomal recessive , some inherited as dominant trait.
Neurochemical subclassification complicated
Classification
Dubowutz
Severe
Unable to sit unsupported
2. Moderate oe intermeddiate
Able to sit unsupported
3. Unable to walk or stand unaided
Able to stand and walk
Clinical
Severe ( Werding - Hoffman Disease )
Weak at birth or in first few months
Decreased DTR's
Tongue fasciculations
Generalized hypotonia , poor head control and swallowing and recurrent URTI's
Survival beyond 1 yr. unusual
Intermediate
Develop normally in first few months
Learn to sit but never crawl or walk
DTR's decreasedd and tongue fasciculations comman
Develop progressive scoliosis
Survive into teenage yrs. or early adulthood
Mild ( Kuge lberg - Welander )
Reach early milestones
Late first decade , early second decade have trouble keeping up with peers
Grower's sign frequently present
Some may have normal DTR's but usually depressed
Many in wheelchair by mid thirties
Diagnosis
Werdnig - Hoffman Disease
Muscle Biopsy shows hypertrophy of Type 1 fibres in a uniform manner
Stain using Atpase histochemical technique
CPK levels may be normal
EMG difficult to interpret, fibrillation potentials comman
Kugelburg - Welender Disease
Biopsy shows fibre grouping typical of neurogenic atrophy
Instead of usual mosiac arrangement of motor units there is a tendency for muscle fibres to group tpgether
Type 1 fibres predominate
CPK levels may be mildly elevated
EMG consistant with the biopsy showing a mixed pattern of denervation and reinervation
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BIncidence
Presents in 5th - 7th decade Men : Women 2:1
Aetiology
Unknown
POssibly Viral ( resemblence to polio )
Pathology
Progressive degeneration of anterior horn cells and nuclei of cranial neura ( 10, 11,12 )
Combined with demylination and gliosis of anterior and lateral columns of the cord
Clinical
Progression may confine patient to a wheelchair in 1 yr.
Patient ends up bed ridden
In early stages may be mistaken for orthopaedic condition
Myopathy due to cervical disc or stenosis
Diagnosis
Concentric needle EMG shows fibrillation and sharp waves
This is evidence of degeneration
Motor unit potentials are long and often of increased amplitude
Indicates reinveration
Fasciculations are common
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A* 100 ASA Ektachrome, or Kodachrome, 100 ASA, on a tripod or
copy-stand with a view box on the easel.
* Adding an FL-D filter gets things away from most of the blue, at only a little cost regarding exposure values.
* For automatic cameras you set the
mode to aperture priority. The light meter then gives you the shutter speed
to compare to the following chart:
Reading Exposure Time
8 60
15 45
30 30
60 20
125 10
Introduction
Acute viral infection.
Anterior horn cells of the spinal cord. Certain brainstem motor nuclei. Hallmark is muscle weakness with normal sensation
Epidemiology
Peak incidence in 5-14 age group.
Since the use of vaccines, only sporadic cases in developed countries. Still a problem in third-world countries (usually in children < age 5)
Infection is common but only a few develop paralysis (1-2%)
Immunization
Oral attenuated trivalent vaccine (sabin) used. At 2, 4, 6 and 18 months, & school entry.
Killed vaccine also exists (salk)
Regular boosters required
Pathology
Usually caused by one of three types of poliomyelitis virus
= RNA enteroviruses (brunhilde, lansing and leon)
Humans are sole natural reservoir
Transmitted by oropharyngeal route. Spread by infected food or faecal matter. Multiplies in alimentary tract lymph nodes & spleen. Spreads through blood. Reaches CNS. Involves
Anterior horn cells of spinal cord, esp. Cervical & lumbar, Medulla, cerebellum and midbrain. Spares
remainder of spinal cord, Sacral roots, entire cerebral cortex.
Damage to anterior horn cells occurs due to
Direct viral multiplication, Toxic by-products of virus & results of inflammation in the surrounding glial cells. Inflammation settles and ganglion cells dissolved by neutrophils and macrophages.
Changes largely complete at 4 months.
Involved motor unit skeletal muscle grossly atrophies. Flaccid paralysis results. Clinical weakness proportional to number of lost motor units.
Clinically detectable weakness present when 60% or more muscle units destroyed.
Paralysis twice as common in lower extremities than upper extremities.
Most commonly affected muscles in lower extremity are: Quadriceps, Glutei, Tibialis anterior, Medial hamstrings, Hip flexors.
Most commonly affected muscles in upper extremity are: Deltoid, Triceps, Pectoralis major.
Sacral roots spared. Characteristic sparing of intrinsic muscles of foot
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Poliomyelitis
Clinical & Management
Post- Splenectomy Management
Plantar Fasciitis
Poliomyelitis
Aetiology & Pathology
Post- Splenectomy Management
2T1. ACUTE
STAGE
Clinical features
Variable incubation period (6-20 days)
Reflects virus ingestion and multiplication
Increased physical activity late in the incubation period leads to poorer prognosis
Acute disease reflects viraemia
Symptoms vary from mild malaise to generalised encephalomyelitis and widespread paralysis
Is a clinical diagnosis (no laboratory tests)
In young children, there is initial malaise and fever. Then several days of well-being
Prodrome usually not present in older children and adults
Then after 3-4 days, fevers recur. Associated headache, sore throat and features of meningism
Acute phase lasts 7-10 days
Spinal
Onset of patchy asymmetric paralysis
There is spasm of opposing muscles causing pain
Tendon reflexes disappear
Characteristic flexor posturing
Muscles tender to palpation
Attempts at stretching increase reflex muscle spasm
No sensory changes
Bulbar
Fullminant encephalitis with bulbar involvment may occur
Leads to speech and swallowing problems
May be sudden respiratory failure from involvement of respiratory centre
Treatment
Bed rest, Analgaesia
Correct anatomical positioning of limbs: Hip 250 flexion, Knee 200 flexion, Ankle plantigrade.
Gentle passive range of movement, Regular muscle charting, May require respiratory support
Differential diagnosis
1 Guillain-barre syndrome
2 Other forms of encephalomyelitis
2. CONVALESCENT
STAGE
Clinical features
Starts 2 days after normal temperature and cessation of paralytic disease. Continues for 2 years. Spontaneous improvement in muscle power occurs. Occurs rapidly through 1st 4 months. More gradually after that. Almost complete after 6th month. Average improvement is: 2 grades above assessment at 1 month, 1 grade above assessment at 6 months
Treatment
Gradual increase in physical therapy programme when muscles lose sensitivity
Physiotherapy very important
Train co-ordination of recovering muscles. Maintain joint mobility. Hydrotherapy very useful. Orthoses used sparingly to prevent deformity
No place for surgery
3. CHRONIC
STAGE
Clinical features
After 2 years, No further recovery
Characteristic features:
1. Limb bluish, wasted and deformed
If disease occurred in childhood, limb may be shortened
3. Limb has floppy feel
4. Normal sensation
5. If trunk affected, may be scoliosis and/or respiratory insufficiency
Problems are:
1. Deformity due to unbalanced paralysis
2. Instability from balanced paralysis
3. Deformity contributed to by growth
4. Worse if disease occurs early
Treatment aimed at managing consequences
Treatment
Principles
1. Prevent deformity
2. Physiotherapy
3. Splintage
4. Stabilise flail joints
5. Tenodesis
6. Arthrodesis
7. Balance imbalance
8. Tendon division
9. Tendon lengthening
10. Tendon transfer
11. Osteotomy
Orthoses
1. Improve functional ability (eg. Walking)
2. Prevent paretic muscles from overstretching
3. Augment action of weak muscles
Surgery
Aims=
Prevent deformity, Improve function, Eliminate or reduce orthosis requirement
Truisms:
1. Tendon transfer cannot overcome deformity
2. Deforming forces can overcome arthrodesis
Guidelines
1. Soft tissue procedures (esp. Tendon transfers) indicated in young child
2. Bony procedures postponed until skeletal growth adequate
Tendon transfers
: Performed when Dynamic muscle imbalance sufficient to produce deformity, Orthotic managemment required. Performed to:
Provide active motor power to replace function of paralysed muscle
Eliminate deforming effect of muscle when its antagonists are paralysed
Produce stability through better muscle balance
Adequate strength
To perform desired function.
Muscles of subnormal strength may be transferred if
They are factors in dynamic instability & They are combined with other muscles of subnormal strength. One grade of power is lost
Similar strength and range of motion
: To muscle being replaced
Phasic (cf. Antagonistic) transfers preferable
Expendable
Loss of original function must balanced against potential gain. Must remember strength of antagonist of removed muscle
Free passive ROM At joint to be moved by transferred tendon
Predictive factors of recurrence= 1. Late onset (age >10 yrs)
2. Four-extremity involvement
3. Ventilator dependence
4. Hospitalisation during preceding acute illness
May affect 20-80% of surviving patients
Diagnostic criteria
1. Confirmed history of polio
2. Partial to complete recovery
3. Period of neurological stability for at least 15 yrs
4. Onset of 2 or more of: Fatigue, Muscle pain New weakness, Functional loss, Cold intolerance, New atrophy
5. No other cause
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QSCAPULA
body forms primary centre : present fron K8
secondary centres
- coracoid centre appears first year and fuses at 15 yrs
- subcoracoid centre (including superior glenoid), inferior
glenoid rim, 2 acromial centres, inferior angle and medial border
appear at puberty and are fused by 20 years
CLAVICLE
first bone to ossify : intramembranous ossification of medial and lateral primary ossification centres which appear at K5-6 and fuse one week later
secondary centres at sternal and acromial ends which appear in late teens and fuse rapidly via endochondral ossification
HUMERUS
primary centre at K8
7 secondary centres
- humeral head present at birth in 20% : remainder by 6/12
- greater and lesser tuberosities in 2nd and 5th years respectively
- head and tuberosities fuse in 6th year and join to shaft at 19-20 yrs
- centres for capitellum (1st yr), trochlea (9th yr) and lateral
epicondyle (12th yr) unite at puberty and fuse to the shaft at 14-16
years
- centre for the medial epicondyle is extracapsular and separated
from the other distal centres by a extension of shaft : ossifies 4th
yr and fuses 20th yr
RADIUS
primary centre K8
2 secondary centres
- radial head ossifies 4th-5th yr and fuses 14th-17th yr
- distal centre ossifies 1st yr and fuses 17th-19th yr
- variable centre for tuberosity appears 14th-15th yr
primary centre K8
3 secondary centres
- distal centre ossifies 5th-6th yr and fuses 17th-18th yr
- 2 centres in olecranon (proximal end and trochlear groove
- ossifying 9th-11th yr and fusing with shaft 14th-16th year
- order of ossification of centres about the elbow given by
CRITOE:-
Capitellum
Radial head
Internal epicondyle
Trochlea
Olecranon
External epicondyle
CARPUS
capitate first and pisiform last
one centre foe each of the carpus
capitate and hamate may be ossified at birth and by 1 and 3 months respectively if not
triquetral 3rd yr
lunate 4th yr
scaphoid, trapezium and trapezoid 4th-5th yr
pisiform 9th-12th yr
METACARPALS
primary centres K9
secondary centres in the base of the first and heads of the remainder
- centres for index to little ossify in that order in 2nd yr and fuse
15th-18th yr
- centre for thumb ossifies 1st-2nd yr and fuses 15th-17th yr
PHALANGES
primary centres ossify:-
- distal phalanges K8
- proximal phalanges K10
- middle phalanges K11
secondary centres in bases
- ossify proximodistally 2nd and 3rd yrs
- fuse 15th-17th yrs
PELVIS
3 primary centres separated by triradiate cartilage
- ilium ossifies above greater sciatic notch at K9
- ischium ossifies in it's body 4th mo
- pubis in the superior ramus 4th-5th mo
- (crest, IP ramus and acetabulum remain cartilage )
- ischiopubic synchondrosis fuses 7th yr
secondary centres
- 3 acetabular centres ossify 8th yr and fuse with their respective
primary centres
- triradiate cartilage fuses 16th-18th yr
- centres for crest, AIIS and ischial tuberosity ossify at puberty
and fuse 15th-20th yr
FEMUR
primary centre ossifies K7
2nd long bone to ossify after clavicle
secondary centres
- distal centre ossifies 9th prenatal month and fuses 16th-18th yr
- head ossifies by 6th mo and fuses 14th-17th yr
- greater trochanter ossifies 4th yr and fuses shortly after puberty
- lesser trochanter ossifies 12th-14th yr and fuses shortly after
puberty
TIBIA
primary centre ossifies K7
proximal secondary centre usually present at birth and fuses 16th-18th yr with small accessory centre for tuberosity developing 10th-12th yr which rapidly fuses with the epiphyseal centre
distal centre appears early in first yr and fuses 15th-17th year
medial malleolus usually forms as an extension of the distal centre in 7th yr but may have a separate centre
FIBULA
primary centre K8
distal centre ossifies in first year and fuses 15th-17th year
proximal centre ossifies 3rd-4th yr and fuses 17th-19th yr
TARSUS
all form from single centre except calcaneum which has a posterior secondary centre ossifying 6th-8th yr and fusing 14th-16th yr
calcaneum (3rd prenatal mo) , talus (6th prenatal mo) and sometimes the cuboid (by 6th postnatal month) ossifying at birth
lteral cuneiform first yr, medial cuneiform 2nd yr and intermediate cuneiform and navicular third yr
posterior process of talus may have a separate centre which may not fuse (os trigonum)
patterns for metatarsals and phalanges similar to that for hand
Arial
Arial
YANeuropraxia- Transient lesion, axons intact. Recovers in few weeks.
Transverse incision palmar aspect over MCPJ (palpable nodule). Blunt dissection down to thickened A1 pulley. Excise segment of pulley. Check FROM free. NB- digital nerve more palmar in thumb.
Implants
Orthofix External Fixator
Surgery
Pennig Wrist External Fixator
Fracture Fixation
IMNail vs ORIF
Split Skin Graft (SSG)
Palmar Spaces
Bone Tumours
Benign!Giant Cell Tumour (osteoclastoma)
Subarticular, mature bones
'Soap-bubble' appearance.
one third remain benign, one third invade locally, one third metastasize.
Sokoloff characterised it as a noninflammatory remodelling of movable joints.
It is the common pathway leading to joint changes characterised by degeneration of articular cartilage, erosion and thickening of subchondral bone, formation of marginal osteophytes and subchondral cysts, and eburnation and remodelling of bone.
INCIDENCE
More than 80% over 55 years age have XR changes of OA, but only 25% will have significant disease.
AETIOLOGY
1. Abnormal Forces
1 subluxation
1 coxa vara
2 Coxa magna
3 Weight
4 angular deformity
2. Abnormal Cartilage
5 infection
6 chondrolysis
7 storage diseases
3. Abnormal Bone
8 fracture
9 pagets
10 avascular necrosis
OKU 3; 2 main groups: 1. excessive stress on normal tissues
2. inadequate chondrocyte response to normal forces
Normal age related changes (sokoloff)
Reduplication of the tidemark at the osteochondral junction.
Focal surface fibrilation, and the formation of some bone spurs.
Bone spurs related to vascular invasion of the calcified layer of the cartilage.
Decreased protein synthesis, with a decrease in the ratio of chondroitin sulfate to keratan sulfate.
Increase in the collagen fibre diameter, but no change in the elastic properties of normal cartilage.
May be primary or secondary.
Primary
Idiopathic
Generalised
Erosive
secondary
Mechanical
Trauma
Instability
Post meniscectomy
Genu varum/valgum
Congenital or Developmental
Hip dysplasia
Morquio syndrome
Perthes disease
Ehlers Danlos syndrome
Inflammatory
Septic
Psoriatic
Reiter's
Endocrine
Acromegaly
Diabetes
Hypothyroidism
Hyperparathyroidism
Oestrogen excess
Metabolic
Hyperuricaemia
Haemochromatosis
Ochronosis
Chondrocalcinosis
Pagets disease
Haemophilia
Wilson's disease
Gaucher disease
Miscellaneus
Neuropathic
AVN,OCD
aetiology
Expirimental models for creating OA involve maximal joint loading, joint instability, and articular damage with cyclic loading.
A purely mechanical basis of OA is untenable since inflammatory changes coexist with chemical factors to produce the disease.
There is an inverse relationship between OA and osteopenia.
OA patients tend to be heavier and more muscled, with greater bone mass, and have fewer fractures.
Osteopenic patients tend to be the opposite, and do not develop degenerative changes.
? bone in OA is stiffer and thus absorbs impact loading poorly.
primary O.A.
In some cases there is a genetic component.
Generalised inflammatory form;
Involvement of IPj's
Commonly episodic, associated with a raised ESR.
Dominant trait in women and recessive trait in men.
Erosive subtype;
Diffuse cartilage destruction with bony erosions and synovitis.
Synovium resembles Rh. but the ESR is normal and Rh factor negative.
More common in women, prediliction for the hands.
Family history in 70%.
15% subsequently develop Rh arthritis.
Secondary O.A.
Mechanical factors appear to be the major contributing factors.
Static or dynamic abnormalities in alignment, geometry, stability or forces.
Inflammatory and crystaline deposits may also play a significant part.
1. crystal deposition in o.a.
Age dependent and relatively common.
The disease produces the crystals which then may contribute to the disease process.
Intra-articular Particles
calcium pyrophosphate (pseudogout)
basic calcium phosphates (eg. hydroxyapatite)
monosodium urate monohydrate (gout)
cholesterol
fragments of cartilage and bone (wear particles)
fibrin/fibronectin aggregates (rice bodies)
Crystals have been identified in;
Post meniscectomy
Chondrocalcinosis
Ochronosis
Haemochromatosis
Charcot's joints
The normal proteoglycan matrix inhibits hydroxyapatite crystal formation.
In haemochromatosis chondrocalcinosis is found in 30%, the crystal is calcium pyrophosphate dihydrate.
In ochronosis the crystal homogentisic acid is deposited in the matrix of the cartilage.
role of enzymes
Chondrocyte derived:
Neutral proteases
Latent proteoglycanases
Latent collagenases
are present in areas of erosion.
Activation of the latent enzymes occurs by serine proteases.
In myxoedema there is synovial thickening and effusion, with deposition of hyaluronic acid in joint tissue.
Thought to be due to TSH which affects the ligaments and articular cartilage properties.
In hyperparathyroidism, arthropathy has been associated with erosive lesions.
In acromegally, excess hGH results in excessive chondrocyte and bony proliferation. Leads to osteophytes and 2' degenerative changes.
3. Neuropathic Joints
Impairment of efferent sensory input from the joint leads to characteristic changes.
Seen in,
Diabetes
Syrinx
Congenital indifference to pain
Tabes dorsalis
Fragmentation of the cartilage with displacement into the synovial lining is a prominent feature.
Possible mechanisms
Damage to the mechanoreceptors with loss of appreciation of static joint angles and dynamic joint movement.
Loss of protective sensation.
Combination of trauma and deafferentiation.
Sympathetic neuropathy leads to increased blood flow in subchondral bone and increased osteoclastic activity with erosions.
PATHOLOGY
Discrete pathological process.
Deterioration and loss of the bearing surface.
Exaggerated proliferation of new osteoarticular tissue at the joint margins.
Breakdown of the osteochondral junction.
Combination of loss of articular cartilage and subchondral microfracture exposes the joint to the underlying bone marrow.
The surface irregularity is always focal with normal areas of adjacent cartilage. Histologically the cartilage is alteratively hyper and hypo cellular.
Diminished metachromasia parallels the loss of proteoglycan.
The tidemark reduplicates and becomes irregular with extension into the uncalcified cartilage.
Antiangiogenesis factors and protease inhibitors normally prevent capillary ingrowth into cartilage.
These become defective or absent in OA
The ingrowth is an intergral part of the endochondral ossification and bony remodelling.
There is increased thickness of the calcified cartilage with extension into the uncalcified zone.
Vertical fissures alter the collagen fibril arrangement and its properties. There is increased interfibrillar distance.
Cartilage is eroded leaving denuded subchondral bone. Clusters of chondrocytes appear near fibrillated areas, but the overall chondrocyte population is decreased.
There are areas of hyperaemia and venestasis along the subchondral bone.
Later changes involve thickening of the subchondral bone with cyst formation. Subchondral changes may be of fibrous, fibrocartilagenous, cartilagenous, or bone foci.
biochemical changes
Proteoglycan subunit synthesis and glucosamine incorporation into hyaluronate increase and these changes probably precede gross disruption of the surface.
Proteoglycan content decreases in the affected regions.
The proteoglycan aggregates appear as smaller and shorter chondroitin sulfate chains.
This may represent changes in link protein synthesis, or increased degradation of GAG's.
There is some controversy regarding these biochemical changes, probably due to sampling dificulties in what is a focal disease.
In samples taken from the knee with early fibrillation there is increased water content in the superficial layers, but no change in the content or synthesis of GAG's.
In deeper fibrillated cartilage there is increased water content throughout the entire thickness, and a loss of GAG's.
In the hip these changes are more diffuse and may also occur in cartilage not visually involved.
This suggests that OA in the knee is more mechanical than metabolic in nature, because of its focal involvement, as apposed to the hip.
The synthetic cells continue functioning normally until there is serious depletion of GAG's.
CLASSIFICATION
primary or secondary
PRESENTATION
INVESTIGATIONS
MANAGEMENT
steroid injection
Particularly useful where there is associated inflammation as in crystal deposition.
Harmful effects on chondrocyte function have been reported in expirimental models.
Minimum of 4 - 8 weeks between injections and no more than 3 in 6 months.
COMPLICATIONS
PROGNOSIS
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Necrotizing Fasciitis
Necrotizing Fasciitis
Antibiotics
Neurofibromatosis 2
Motor Neurone Disease
Motor Neurone Disease ( Amyotrophic lateral sclerosis )
Myotonias
Neurofibromatosis 2
BPosition- Prone w/ arm on armboard.
Incision- Longit. centred over medial epicondyle.
Procedure- mobilise ulnar nerve from prox. to distal (where small muscle branch arises & nerve runs deep to muscle). Divide the intermuscular septum. Incise Flexor origin muscle 1cm distal to origin, down to bone - perpendicular to fibres. Bury nerve deep in muscle incision & suture muscle fascia to bury nerve.
NB- nerve should lie in a straight line, it should not 'catch' on any tissue.
Closure- 2/0 vicryl to fat, skin closure.
Chronic Pain Syndromes
Physiology
Paediatrics
Stickler Syndrome
Acute Pain Management
Physiology
!B*Adhesive wear occurs at the surface.
*Volumetric wear is proportional to the force acting times the sliding distance.
Medial longit. incision over PP down to bone; lift periosteum & retract w/ bone levers; varus wedge osteotomy at level of PP neck; transfix w/ 2 parrallel medial K-wires across # from disto-med. to proximo-lat.; short medial POP slab.
B1] 95% OA rate at 5yrs (Ruby, Max-1980's) [only includes non-unions presenting to hosp.]
2] Rx of Asymptomatic non-unions is a dilemma.
3] Often see elderly people with scaphoid non-union + OA, who have never been symptomatic.
Union Rate: 70% if have OA or DISI. 95% if done at 12-16wks.
Failure: is seen by a luscent area around implant (screw).
Complic: Hypertrophic scar. Wrist stiffness.
EVOLAR APPROACH
Surface: Scaphoid tubercle & FCR tendon.
Inc: Longit. along FCR radial border to scaphoid tubercle, then angle radially along the direction of APB.
Dissect thro the bed of FCR tendon sheath. Incise & reflect the capsule & the radioscapoid & radioscapholunate ligaments. Define the scaphotrapezoid joint by reflecting the scaphotrapezoid lig. radially.
Proc: Check Herbert jig. Correct side should be showing on jig. Check long drill bit lies in correct position to spike.
Insert jig by putting spike as far dorsally behind prox. pole as possible. Jig should lie 45deg. to surface & 45deg. to long axis of forearm. Check position w/ Image Intensifier.
Prepare # & bone graft from iliac crest.
-> Long drill right down.-> Short drill.-> Tap-> Screw as per length on jig. Avoid Scapholunate joint!
If too difficult, use an AO cancellous screw or K-wires.
DORSAL APPROACH
For proximal pole fractures.
Inc: Longit. over Lister's tubercle. Incise extensor retinaculum & compt. 4. Reflect ECRB & EPL radially. 'L' incision of dorsal ligament reflecting flap to radial side, entering joint. Flex wrist 90deg. to expose prox. pole & #.
Prepare & bone graft.
Long drill in parallel with dorsal scaphoid ridge (prominent ridge on dorsum of scapoid- expose it).
Check w/ II. short drill- etc.
Wrist
Scaphoid Fractures
Fixation
Wrist
Scaphoid Fractures
Herbert Sc
Wrist
Wartenburg Syndome
Wrist
Madelung's Deformity
Wrist
Radiology
Wrist
Scaphoid Fractures
AInc: over ulnar nerve
Proc: Release nerve prox. & distally. Dissect the periosteum off the medial epicondyle w/ longit. incision, to repair et end. Using an osteotome, remove the rounded posterior edge of epicondyle so it lies flush w/ the floor of the cubital tunnel. The ulnar nerve should slip into this flattened area when flexing the elbow (i.e. not 'stretching' in the groove). Close the periosteum.
= 48% success rate vs. 27% for transposition.
Surgery
Medial Epicondylectomy
Surgery
Open Acromioplasty & Rotator Cuff Repair(RCR)
Surgery
Lower Limb
Unreamed T
Surgery
Maissonueve #
Surgery
Open Acromioplasty & Rotator Cuff Repair(RCR)
IPlace the patient in the lateral position with the affected hip uppermost. If a fracture table and a supracondylar femoral traction pin are used, keep the knee joint in at least 45 degrees of flexion to prevent excessive traction on the sciatic nerve. (RMS- Place foot on sterile Mayo table with knee flexed, Sciatic nerve monitoring essential)
Begin the skin incision over the greater trochanter, and extend it proximally to within 6 cm of the posterosuperior iliac spine. The incision can be extended distally over the lateral surface of the thigh for approximately 10 cm as necessary. Divide the fascia lata in line with the skin incision and bluntly split the gluteus maximus in line with its muscle fibers. Protect the branch of the inferior gluteal nerve to the anterosuperior portion of the gluteus maximus to avoid denervating that part of the muscle. Identify and protect the sciatic nerve overlying the quadratus femoris. Incise the short external rotators at their tendinous insertions on the greater trochanter and reflect them medially to further protect the sciatic nerve. Leave the quadratus femoris intact to protect the underlying ascending branch of the medial circumflex femoral artery. The tendinous insertion of the gluteus maximus on the femur can be incised to increase exposure. Next, elevate the gluteus medius and minimus superiosteally from the posterior and lateral ilium. These muscles can be held retracted by inserting two smooth Steinmann pins into the ilium above the greater sciatic notch. Identify and protect the superior gluteal nerve and vessels as they exit the greater sciatic notch. The entire posterior acetabulum and posterior column are now exposed. Further exposure can be gained by an osteotomy of the greater trochanter and reflection of the origins of the hamstrings from the ischial tuberosity. Reattach the greater trochanter with two 6.5 mm lag screws during wound closure.
SUMMARY: A, Skin incision. B, Incision of fascia lata and splitting of gluteus maximus outlined. C, Gluteus maximus has been retracted exposing short external rotators, sciatic nerve, and superior gluteal vessels. Ascending branch of medial circumflex femoral artery underlies quadratus femoris. D, Hip joint capsule has been exposed by division and posterior reflection of short external rotators. Quadratus femoris is left intact. E, Osteotomy of greater trochanter and reflection of hamstring origins from ischial tuberosity have enlarged exposure.
Burns
Callotasis (stretching of callus) & Bone Transport
CEPOD Classification of Operations
Paediatrics
Morquio Syndrome
Paediatrics
Chromosomal Disorders
Downs S
(Trisomy 21)
Paediatrics
Chromosomal Disorders Noonan S
C*short stature, web neck, cubitus valgus
*malignant hyperthermia !
Paediatrics
Chromosomal Disorders
Prader-Willi S
*Chromosome 15 abnormality.
*hypotonic infant, mental impairment, obese adult with large appetite, growth retardation, DDH, hypoplastic genitals, scoliosis.
Implants
Acutrak Bone Screw System
/Merck Biomaterial, (Tel: 01420 543511) (Acumed)
Biomechanics
Wolff's Law
Wolff, 1892
A= Bone is laid down where needed and resorbed where not needed.
* If tight in extension or extension block preop -> remove more off distal femoral cut.
@*= Hereditary arthroophthalmopathy
*Autosomal Dominant disorder of connective tissue.
* Also one of the osteochondrodysplasias.
* Incidence probably 1:10 000 births.
* Characterized by skeletal, orofacial & ocular abnormalities.
* The most c
ommon specific roentgenographic findings include coxa valga and widening of the femoral neck. Acetabular protrusio, chondrolysis, avascular necrosis & vertebral changes.
* Premature arthritic changes are to be expected.
* Congenital myopia & micrognathia are the most common nonskeletal findings.
* This syndrome should be considered when patients have unexplained coxa valga, especially with concomitant acetabular protrusio.
CLinical Musculoskeletal Manifestations:
1. Bony enlargement of large joints
2. Articular Hypermobility
3. Ankle joint instability
4. Planovalgus feet/ Pes planus
5. Genu valgum
6. OA of large joints- starts in teens
7. Intraarticular loose bodies
8. Kyphosis & scoliosis
9. Incr. lumbar lordosis
10. Fibrositis/ Fibromyalgia
11. Marfan-like body habitus
12. Arachnodactily
13. Pectus Excavatum
Radiological Manifestations:
as above plus:
1. protrusio acetabuli
2. flattening of epiphyses
3. thoracic disc herniation
4. spondylolisthesis
5. Posterior SUFE
6. Broad femoral neck & coxa valga.
7. slender tubular bones
#B*Lateral Compression(LC):
I - ipsilat or contralat ramii (transverse) & ipsilat sacral compression.
II - ipsilat or contralat ramii & ipsilat post. iliac
III - ipsilat or contralat ramii & LC I/II & contralat. APC
*AP Compression(APC):
I - symphysis (<2cm) or ramii (vertical) & ant. SI lig. stretched
II - symphysis or ramii & ant. SI lig. torn
III - symphysis or ramii & ant & post SI lig. torn
*Vertical Shear(VS): ant & post vertical displacement.
*Combined Mechanical(CM): combination of other injuries.
1. Morrison JB. Mechanics of the knee joint in relation to normal walking. J Biomech. 3:51-61. 1970.
2. Seireg A & Arvikar RJ. The prediction of muscular load sharing & joint forces in the lower extremeties during walking. J Biomech. 8:89-102. 1975.
C* Virchow's triad -> DVT formation. The femoral vein is distorted/ obstructed during THR by: hip adduction, flexion & internal/external rotation; use of bone lever retraction; anterolateral=posterior approach. (Gallus's study which showed lower incidence w/ post. approach was not randomized).
Early Mobilisation
- Foot movement for 1 min. -> incr. venous outflow for 30min.
Compression Stockings (TED)
- -> Reduce diameter of vessels -> incr. velocity of venous blood.
- Decr. incidence of DVT from 54% to 20%.
- Another study showed no effect of AK TEDs in THR & TKR, but significant decr. DVT rate w/ BK TEDs following TKR.!
Pneumatic Pumps
- A-V Impulse foot pump reduced DVT rate from 40%(no prophylaxis) to 5% following THR.
- A-V Impulse foot pump + LMWH = 6.6% following THR, vs. 27.3% LMWH alone (Bradley).
- The extent of +ve DVT's are also less w/ foot pumps.
- Lower requirement for blood transfusion post-op.
A*= Compress each leg w/ USS probe at 3 sites: Femoral vein at femoral lig., Popliteal vein at fossa, Trifurcation 8cm distal to fossa.
*Repeat test next day & then 1 week in normal scans.
*Miss <1% (0.7%) of all DVT's.
*Use of distal site -> picks up an additional 6.3% of DVT's, But also -> incr. false positives (positive predictive value of femoral & popliteal vein is 98.5%, but 79% for the distal site)
*A further 3% of DVT's are picked up at the repeat 1 wk scan.
2. Arcuate complex (the fabellofibular lig., deep portions of the capsule, a meniscotibial linkage)
3. Popliteus muscle
4. Gastrocnemius muscle
NB for stability
Tibial Plateau Fractures
Surgery
Mark Andrews?
Statistics
Meta-Analysis
BMJ, 315:1371-4; 22 Nov. 1997
Defn by Haque = 'A statistical analysis that combine or integrates the results of several independent clinical trials considered by the analyst to be 'combinable'.'
Antibiotics
Rationale for Open Fractures
1. Cephalosporin or Flucloxacillin- for Staphylococci.
2. Benzylpenicillin- for Clostridia & Beta-haemolytic Streptococci (particularly gunshot wounds)
E"Anticoagulation-Thromboprophylaxis
Compression Ultrasonography
Cogo et el.
BMJ, 316:17-20. 3 Jan 1998U
Bone Cysts
Differential Diagnosis
Differential Diagnosis Mnemonic
zVINDICATE:
Vascular
Infection
Neoplastic
Drugs
Inflammatory/ Idiopathic
Congenital
Autoimmune
Trauma
Endocrine/ Metabolic
Biomaterials
Titanium
*Adv: Resistant to fatigue & corrosion, Easily worked
= Radial nerve trapped under fibrous arch as it arises from under Brachioradialis.
Dx: parathesia on dorsoradial surface of hand when dorsiflex wrist.
Wrist
Dorsal Wrist Ganglion
Frank Burke (Derby)
EAlmost always arise from scapholunate ligament.
20% recurrence rate.
Surgery
EIP->EPL Tendon Transfer
Frank Burke (Derby)
Don't list Pt. immediately when Dx'ed, but review them 6wks later. 50% will be coping well despite EPL rupture
Post-op: Early active mobilisation.
Surgery- Technical Tips
Mark Andrews
Furlong HAC uncemented
Tibial cut should be at least 8mm.
Femoral cut: Insert 'doggy bone' w/ knee flexed, if it is 21mm then distal femoral cut = 21-8=13mm.
K- Discussion:
- frx of proximal tibial metaphysis are rare;
- valgus greenstick fractures usually occur between 3-6 yrs of age;
- cortex is slightly opened on the medial side;
- distal fragment is angulated lateralward;
- Non Operative Treatment:
- usually treated with closed methods;
- frx is reduced before immobilization in cast;
- place leg in long leg cast in extension for 6 weeks;
- ensure that valgus angulation is not present w/ knee in extension (either clinically or radiographically);
- any valgus angulation must be corrected by closed manipulation under anesthesia and a long leg cast w/ knee in extension for 6 weeks;
- inform patient's family of possibility of delayed vaglus angulation;
- Operative Treatment:
- if closed reduction is impossible because of soft-tissue interposition, open anatomical
reduction rarely may be indicated.
- Delayed Valgus Angulation:
- one complication unique to frxs of proximal metaphysis is valgus angulation;
- frx may appear benign, with little or no angulation, but after healing occurrs, limb may drift into progressive valgus angulation;
- proposed causes of this angulation:
- unrecognized valgus at time of original injury or overgrowth;
- angulation may result from overgrowth of tibia w/o overgrowth of fibula;
- presence greenstick fracture of proximal tibia w/ slight medial opening may contribute to progressive valgus deformity;
- interposition of flap of fibrous tissue consisting of periosteum, MCL, & pes anserinus results in failure of medial gap to close;
- normal growth may occur after removal of offending tissue;
- increased vascular response resulting in asymmetrical growth stimulation of medial portion of the proximal tibial physis;
- treatment of delayed valgus angulation:
- spontaneous correction usually occurs with time;
- therefore, it is generally advised to continue w/ non operative treatment, until natural history is clear;
- increase in valgus angulation may occur for as long as 17 mo followed by spontaneous improvement w/ in 1-2 years;
- deformity may improve over 5-10 years;
- surgical indications:
- failure to reduce fully any medial tibial cortical gap mandates surgical exploration and removal of interposed soft-tissue flap;
- if deformity is not sufficiently corrected by age of ten to twelve yrs, tibial osteotomy or hemiepiphyseodesis can then be performed if necessary;
- surgical treatment:
- fibular stapling of medial portion of physis or proximal tibial osteotomy;
- note that recurrence of valgus deformity is frequent after osteotomy in skeletally immature patients;
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
@0 - 4 weeks:
Postoperative Dressing:
Wrist extended 45 degrees, MCP's in 0 to 5 degrees of flexion, interphalangeal joints are free. Active range of motion of the interphalangeal joints is initiated immediately. The patient may be immobilized in a forearm based cast or splint. If the patient is splinted, sutures are generally removed at two weeks and scar massage is initiated.
4 - 6 weeks:
Gentle Active Flexion of the metacarpal phalangeal joints with interphalangeal extension and wrist extension is allowed. At four weeks, the wrist component of the splint is discontinued.
7 - 12 weeks:
Passive range of motion, dynamic splinting and electrical stimulation is institu
ted for metacarpal phalangeal stiffness and tendon adhesions. Progressive strengthening is started at eight weeks anticipating a return to work at 12 weeks.
Hand
Extensor Tendon Repair Rehabilitation Post-op.
Flexor Tendon Healing & Post-Op Care
Extensor Compartments
Extensor Tendon Groups (3's)
Flexor Tendon Healing & Post-Op Care
G0 - 5 days: Postoperative dressing.
3 - 5 days: The postoperative dressing is removed. A light dressing and edema control are applied as needed.
A full Dorsal Blocking splint is fitted to the wrist and digits for controlling wear in the following position:
Wrist: 20 degrees of flexion - MCP's: 45 degrees of flexion - PIP/DIP: full extension
Controlled passive mobilization is initiated 2 x day (Modified Duran program) with the splint on as follows:
8 repetitions of passive flexion and active extension of the PIP joint.
8 repetitions of passive flexion and active extension to the DIP joint.
Optional: Controlled active mobilization is initiated 2 x day with the splint on as follows:
8 repetitions of active unresisted composite flexion and extension of the PIP and DIP joints with the wrist and MCP joints supported in flexion.
4 weeks: The Dorsal Blocking splint is removed every 2 hours for the following exercises:
10 repetitions of active flexion and extension to the wrist.
10 repetitions of active flexion and extension to the digits.
Passive exercises are continued as needed.
The Dorsal Blocking splint is re-applied.
Electrical stimulation of the muscle may be used with the splint on, to increase tendon excursion.
5 weeks: The Dorsal Blocking splint is discontinued. Active exercises are done hourly as follows:
12 repetitions of PIP blocking.
12 repetitions of DIP blocking.
12 repetitions of active composite flexion and extension.
Continue passive flexion as needed.
6 weeks: Passive extension exercises are initiated to the wrist and digits. Dynamic extension splinting may be applied as indicated.
8 weeks: Gentle strengthening is initiated beginning with foam, then putty and hand helper. Light grasping is allowed. No lifting or heavy use of the hand is allowed.
10 - 12 weeks: May return to work with full use of hand, including sports. NOTE: Generally the greatest achievement in total motion is seen by this period.
E= Radial head frx plus dislocation of distal RU joint (& interosseous membrane disruption);
- mechanism: fall from height;
- in this type of frx, radius will also migrate proximally if radial head is excised;
- if injury is not found when it is acute, pt may develop severe wrist pain from radial migration and subluxation, of upto 5-6 mm;
- there may be loss of forearm pronation, supination, & extension;
- late reconstruction( > 4 weeks) of radial instability yields poor results;
- Exam: distal radio-ulnar joint tenderness is most sensitive test to diagnose injury;
- Radiographs: lateral view of pronated wrist may show ulna to be dorsally subluxated;
- Management
1) RU joint:
- full supination of the forearm usually results in reduction of RU joint dislocation;
- in order to maintain inadequate radial length & RU joint reduction, consider pinning of RU joint for 6 weeks to allow for anatomic healing of interosseous membrane;
2) radial head:
- ORIF is indicated unless comminution precludes adequate fixation;
- type III radial head fracture;
- Kocher approach
- radial head implants:
- indicated when ORIF is not possible;
- avoid radial head excision: excision of radial head will result in proximal migration of radius, along w/ severe wrist pain (ulnacarpal impingement) as well as elbow pain;
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Arial
Corticosteroid Dosages
Crystal Arthropathies
Chondrocalcinosis (Pseudogout)
Crystal Arthropathies
Hydroxy-apatite Coatings (HAC)!Ten years of HA, what do we know?
Geesink5
JBJS 80B(Suppl1):31. 1998
Hydroxy-apatite Coatings (HAC)VThe application & clinical behaviour of Hydroxy-apatite Ceramic in Prosthetic Coatings R Furlong
JBJS 80B(Suppl1):31. 1998
Shoulder
Arthroscopy
Crystal Arthropathies
Chondrocalcinosis (Pseudogout)C
Arial
Electrophysiologial tests
Motor Neurone Disease
Spinal Muscular Atrophy[
Arial
Arial
Myotonias
Neurofibromatosis 2
Osteoarthritis
Poliomyelitis
Aetiology & Pathology
!Spina Bifida (Meningomyelocoele)3
Spinal Muscular Atrophy3
Spine
Tetraplegia3
Kinesiolgy
Kinesiology1
FEMOROTIBIAL JOINTA
Arial
Kinesiology2
Patellofemoral Joint4
Ankle
Kinesiology4
Kinesiology
Upper Limb
Throwing Mechanics4$
DUsually the approach is developed between the extensor hallucis longus and extensor digitorum longus tendons, but Nicola advises developing it between the tibialis anterior and extensor hallucis longus tendons. In his approach the neurovascular bundle is retracted laterally with the long extensor tendons of the toes, and the tibialis anterior tendon is retracted medially.
Extensor hallucis longus and tibialis anterior tendons, along with neurovascular bundle, are retracted medially. Tendons of extensor digitorum longus muscle are retracted laterally. (Modified from Colonna PC and Ralston EL: Am J Surg 82:44, 1951.)
TECHNIQUE
Begin the incision on the anterior aspect of the leg 7.5 to 10 cm proximal to the ankle and extend it distally to about 5 cm distal to the joint. Its length will vary with the surgical indication. Divide the deep fascia in line with the skin incision. Isolate, ligate, and divide the anterolateral malleolar and lateral tarsal arteries, and carefully expose the neurovascular bundle and retract it medially. Incise the periosteum, capsule, and synovium in line with the skin incision. Expose the full width of the ankle joint anteriorly by subcapsular and subperiosteal dissection.
Flexor Tendon Repair/ GraftBDuran Protocol- Early passive mobilization therapy/ rehabilitation
Upper Limb
Essex Lopresti FractureU
Arial
Necrotising Fasciitis
Antibiotics
QBenzylpenicillin - 2.4g QDS
+ Flucloxacillin - 500mg QDS
+ Clindamycin - 1.2g BD
Surgery Anterior Approach to Ankle Joint4
Arial
Arial
Surgery'Dorsal Approach to wrist/ distal radius
Wheeless
Surgery
Anterior Approach to Ankle Joint
Surgery
Dorsal Approach to wrist/ distal radius
Surgery
Fasciotomy of lower leg
Compartmen
*MThe recent worldwide appearance of invasive group A streptococcal infections has again called attention to streptococcal necrotizing fasciitis. However, in contrast to polymicrobial necrotizing fasciitis, the streptococcal form has not been thoroughly studied clinically. The objective of the study was to elucidate the characteristic features of recent cases of necrotizing fasciitis due exclusively to pure group A streptococci. We encountered six patients with these criteria at a single hospital in Japan during the last 12 years. A clinicopathological analysis was performed in these six patients. In three patients, the clinical signs and the laboratory findings were characteristic of systemic toxicity. In this group, the clinical presentation was a pale or blue-gray lesion associated with severe intravascular coagulation histologically involving the vessels in the lesion. In the three patients without signs of systemic toxicity, a swollen, erythematous skin lesion persisted for as long as one week; histologically, the intravascular coagulation within these lesions was mild. In clinicopathological terms, the entity in these six patients could be clearly classified as either fulminant or subacute. In the fulminant type, immediate surgical debridement of necrotic fascia is required; in the subacute type, incision and drainage alone are sufficient. (Misago N. Narisawa Y. Ryu S. Gotoh Y. Tanaka T. Yokoyama M. Kohda H . Journal of Dermatology. 23(12):876-82, 1996 Dec.)
Twelve cases of necrotizing fasciitis were identified retrospectively over a 5-year period. All were associated with a history of substance abuse by injection or with diabetes. Eleven of the 12 infections were associated with beta-hemolytic Streptococcus, a mixed anaerobic aerobic infection, or both. Three of five patients tested for human immunodeficiency virus had positive test results. A wide extensile approach was used to debride necrotic fascia. An average of 3 debridements were necessary, with a range of 1-6 debridements. Two patients under-went shoulder disarticulation because of uncontrollable infection. The rapid and destructive nature of this disease makes early recognition, aggressive debridement, and antibiotic therapy necessary to minimize morbidity. (Gonzalez MH. Kay T. Weinzweig N. Brown A. Pulvirenti J . Journal of Hand Surgery - American Volume. 21(4):689-92, 1996 Jul.)
NF caused by hemolytic streptococci is a highly lethal disease (over 70% in literature). It starts typically with a purple lesion of the skin, followed by necrotizing fascial infection with secondary necrosis of the overlying skin and rapid progression to septic shock and multiorgan failure. This development is characteristic for NF and allows, together with microbiological results, to distinguish NF from other necrotizing soft tissue infections. Early recognition and aggressive surgical debridement are the mainstays of successful management. Antibiotics and intensive care therapy are indispensable. Hyperbaric oxygen or other supportive therapies do not lower death rate. There was a trend towards polymicrobial infection and many were resistant to standard antimicrobial therapy. The mortality rate was 21.1%. Our results are comparable to many earlier series. (Li YH. Toh CL. Khoo C. Low YP . Annals of the Academy of Medicine, Singapore. 26(2):175-8, 1997 Mar.)
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