13rd EDITION by Anika A Alhambra

PERIPHERAL NERVE INJURY

SEDDON classification: I. NEUROPRAXIA. − Transient disorder (spontan recovery), several weeks. − EMG of the distal lession usually normal. − Caused by mechanical pressure, exp: − Crutch paralysis − Good prognosis.

II. AXONOTMESIS − A discontinuity of the axon, with intact endoneurium. − Wallerian degenration on the distal side. − There is an axon regeneration : 1 – 3 mm/day − Good prognosis

III. NEUROTMESIS − Nerve trunk has distrupted, include endoneural tube − Regeneration process Æ neuroma − Prognosis: depend on the surgery technique.

SUNDERLAND Classifications: I. Loss of axonal conduction. II. Loss of continuity of the axon, with intact endoneurium. III. Transection of nerve fiber (axon & sheath), with intact perineurium. IV. Loss of perineurium and fascicular continuity. V. Loss of continuity of entire nerve trunk.

DEGREE DISCONTINUITY DAMAGE TREATMENT PROGNOSIS 1st None, conduction block Distal nerve fibers Observation Excellent (neuroprxia) remain intact 2nd Axon (axonotmesis) Based on fibrosis Observation Good 3rd Axon & endoneurium Based on fibrosis Lysis Ok 4th Axon, Fibrotic Nerve graft Marginal endoneurium,perineurium connective tissue connects 5th Complete (neurotmesis) Complete Graft/transfer Poor

PATOPHYSIOLOGY on the nerve compression injury: 23rd EDITION by Anika A Alhambra 1. Disturb to microcirculation Æ ischemia 2. Disturb to axoplasmic transport Æ neruroaxonal transport

Intravascular edema (Increase of vascular permeability)

(Degeneration process) Proliferating fibroblast Separation nerve fiber

One week (Demyelination)

Note: compression 20-30 mmHg Æ pathology on epineurium >80 mmHg Æ completely stop 30 mmHg (8j); 50 mmHg (2j) Æ reverse after 24 hours 400 mmHg (2j) Æ reverse after 1 week ‘Tinnel sign’, is happened on injury and compression, it is sign of regeneration process (continuity sign) Pathological changes on ‘PRIMARY NERVE REPAIR’ 1. Fragmentation of axon and myelin in distal part 2. Schwan cell proliferation in distal segment, with macrophage phagocytes debris material. 3. Axonal sprouting from proximal segment 4. Axonal connection with periphery and maturation of the nerve fiber. CNS PERIFER SCHWANNCELL RESPONSIBLE FOR MYELINATING PERIPHERAL NERVES AXON - + OLIGODENDROCYTES RESPONSIBLE FOR FORMATION OF MYELIN + - ASTROCYTES SUPPORTING STRUCTURE OF THE BRAIN + -

VASKULARISASI tendon PARATENON VINCULA SYNOVIAL FEATURES - Fibrosis capsule - Synovial membrane - Fat pad - Synovial fluid - Articular cartilage

ANTIBIOTIK GAS GANGGREN: PENICILLIN & CLINDAMYSIN

PATOLOGY of peripheral neuropathy: 33rd EDITION by Anika A Alhambra - Acute interruption of axonal continuity - Axonal degeneration - Demyelination Classification *mononeuropathy & *polyneuropathy

Cause of polyneuropathy: A] Hereditary: - hereditary motor neuropathy C - Hereditary sensory neuropathy - Friedreich ataxia

B] Infection: - Herpes zoster - Leprosy

C] Inflammation: - GBS - SLE I - Sarcoidiosis - Neurologic Amyyotrophy

D] Nutritional & Metabolic: -DM - Vitamin deficiency M - Amyloidosis - Myxoedema

E] Neoplastic: - Myeloma T

F] Toxic: - Alcoholism - Lead

G] Drugs: various Others

H] IDIOPATHIC

Chief complain: ‘sensory disturbance’: - numbness, burning, shooting pain,, - Weakness, clumsiness - Loss of balance in walking - Usually, pathology on the distal part, before proximal part. - Compression Mononeuropathy: a) Median nerve : Pronator syndrome Anterior interosseus syndrome Carpal Tunnel syndrome b) Ulnar nerve : Cubital Tunnel syndrome Ulnar Tunnel syndrome c) Radial nerve : Posterior interosseous syndrome Radial Tunnel syndrome Cheiralgia paresthetica (Superficial Radial nerve syndrome) d) Others: Thoracic Outlet syndrome Suprascapular nerve syndrome Meralgia paresthetica (Lat Femoral Cut nerve) Anterior tarsal tunnel Syndrome (Deep peroneal nerve) Tarsal Tunnel syndrome (Tibial nerve) 43rd EDITION by Anika A Alhambra BRACHIAL PLEXUS INJURY

53rd EDITION by Anika A Alhambra Elbow flexion (biceps, C5 dysfunction)____ can be restored w/ latissimus dorsi flexeroplasty (ZANCOLLI) or pectoralis major & minor transfer Elbow extension ____ can be restored w/ transfer of the posterior 3rd of the deltoid to the trapezius

ANATOMIC - Root level avulsion Æ involves BOTH anterior (plexus) & posterior (dorsal sensory) region, whereas plexus injury spare posterior areas. - C4-7 nerve root WELL SECURED to their respective vertebrae & are less prone to avulsion inj. C8-T1 roots are NOT. - T1-level preganglionic inj. often includes a Horner syndrome because of disrupting the 1st sympathetic ganglion. - Traction inj are most common Æ C5 & C6 level - Proximal cord lesion Æ injure supraclavicular branches as well as the distal plexus and lead to winging of the scapula (Long thoracic nerve)

TREATMENT - Controversy - Mostly observation Æ 3 mo w/ passive ROM & bracing No improvement o Neurolysis o Grafting o Nerve transfer (usually w/ neurotization of intercostals nerve) o Muscle/ tendon transfer

LEFFERT classification I. OPEN (usually from stabbing) II. CLOSED (usually from motorcycle accident) a. SUPRACLAVICULAR i. PREGANGLIONIC _____ Avulsion of nerve roots, usually from high-speed injuries w/ o/ inj. & loss of consciousness. NO proximal stump, NO neuroma formation (negative TINEL’s sign), pseudomeningocele, denervation of dorsal neck muscles ARE common sequelae. Horner’s sign (APEM anhydrosis, ptosis, enopthalmus, miosis) ii. POSTGANGLIONIC _____ Roots remain intact; usually due to traction inj. There are proximal stump & neuroma formation (positive TINEL’s sign); deep dorsal neck muscles intact; NO pseudomeningocele (does not develop) 63rd EDITION by Anika A Alhambra b. INFRACLAVICULAR ______Usually involves branches from the trunks (Suprascapular). Function is affected based on trunk involved. Trunk injured Functional loss Upper biceps, shoulder muscles Middle wrist & finger extension Lower wrist & finger flexion III. Radiation therapy induced IV. Obstetric Injury a. ERB’s (upper root C5-6) --- waiter’s tip hand b. KLUMPKE (lower root C8-T1) c. Mixed

MOI : Open injury Close (traction injury): pre/post ganglion Radiation injury Obstetrical injury

## ] Open Injury: o Life or limb threatening vascular injury o Pro: immediate operative exploration (just markering and mapping) o After the wound has healed and no infection Æ repair o If failed Æ plan to tendon transfer.

##] Close Injury: o Caused by stretch on the elements of the plexus. o Determined there was pre or post ganglion o Post ganglion the prognosis is better. o At first treat with conservatively, if after 3-6 month no recovery Æ need operative-exploration.

Diagnose Preganglioner Postganglioner LOOK Fail arm, winged scapula, Horner-Sy Fail arm Muscle test Paralysis: Ser.ant,rhomboid,limb Limb muscle muscle Sensation Absent in involved dermatome Idem Tinnel sign Absent Present Myellografi Traumatic pseudomeningocele, and Normal obliteration of root EMG Paravertebral muscle & limb muscle Limb muscle denervation denervatio NCV Motor conduction absent ± sensory Motor & sensory conduction conduction absent Axon response Normal Absent (histamine test)

73rd EDITION by Anika A Alhambra ##] Radiation Injury: o Radiation neuropathy o Neoplastic brachial plexopathy o Prognosis is not good o Operative treatment: Neurolysis, with omentum transplant o Prevention: long term of low dose radiation

##] Birth palsy (Obstetrical Injury): o Cause: traction injury during labor. o Lesion: C 5-6 : Erb paralysis C 8-Th 1 : Klumpke palsy Entire plexus or diffuse partial involvement o Tx: conservative, after 3 month : EMG-NCV Manual muscle chart Myelogram Exercise & splinting If no contraction of biceps: need exploration-operative

o Complication : Posterior dislocation of glenohumeral. Fixed contracture Posterior subluxed of radial head Urinating contracture of the forearm

o Management: Open reduction of the joint (if any dislocation) Need astronomy prox humeri Tendon transfer (4-5 years old) Nerologic reconstruction (3 – 6 mo)

Operation Technique: − Microsurgery. Need operating microscope/loupes − Landmark of approach: mid point of the posterior border of the sternocleido- masteoid and downward to the clavicula (angle at the medial portion) − Location of plexus: between anterior and middle part of scalene muscle. − Timing of operation: more than 6 month after injury. Advantage: minimize scarring and muscle atrophy.

83rd EDITION by Anika A Alhambra Kinds of ‘NEUROLOGICAL RECONSTRUCTION’ 1. NEUROLYSIS. For distal rupture not avulsion type (per ganglion) Release neuroma & fibrotic tissue in continuity

2. NERVE GRAFTING There is a gap Source : Sural nerve / Medial coetaneous nerve

3. NEUROTIZATION Indc: a totally fail, unaesthetic limb as a result of complete avulsion. Primer: like a nerve graft Secondary: insertion as new motor end plate Source: n. intercostals /n. thoracalis longus /n. accessories /n. phrenicus

Kinds of ‘RECONSTRUCTIVE SURGERY OF IRREPAIRABLE INJURIES’ − Timing: more than 1-year post injuries, without any recovery/improvement. − Need Tendon transfer !!!!!!!!! a. SHOULDER reconstruction : • SAHA procedure: transfer of the trapezius to the proximal humerus. • L’Episcopo procedure: insertions of latissimus dorsi & teres mayor are transposed poster laterally to enhanced active lateral rotation. • If no chance for tendon transfer Î Arthrodhesis ! • Position : Abduction : 20-30o Flexion : 30o Endorotation : 30-40o

b. ELBOW Flexion restoration: 1. STEINDLER Flexorplasty. Principle: Flexor-pronator muscle arising from the medial epicondyle are transposed to a more proximal site on the anterior aspect of the humerus. Origo of : FCR, FCU, FDS, PT, PL The patient may achieve elbow flexion by flexing wrist and fingers and pronating the forearm Immobilization-position : elbow flexed 130o & forearm supinated.

2. CLARK’S transfer Principle: Sternocostal portion of the pectoralis major muscle for restoration of elbow flexion. 93rd EDITION by Anika A Alhambra Technique : muscle pedicle elevated from chestwall Æ reroute subcutaneous down the arm to be inserted to the biceps tendon at the elbow. Usually for male, not female patient (problem cosmetic) Need immobilize/splint: 4 weeks

3. Latissimus dorsi transfer. M. Latisimus dorsi Æ transferred to the arm

4. Triceps transfer Triceps brought forward and attached to the biceps tendon.

5. Sternocleoidomastoid transfer Sternocleidomastoid, reroute by bunnel technique. c. WRIST reconstruction. - Maintain the mobility of the wrist whenever possible, if not Æ arthrodhesis. But maintain the tendon must be able to glide. - JONES transfer : FCU Æ EDC PL Æ EPL PT Æ ECRB - Technique arthrodhesis (Haddad & Riordan): use illiac graft slotted between radius and the basis of MC II&III

FLAIL-ANAESTHETIC ARM’ Æ still a dilemma!!! Surgical reconstruction or amputation?? Surgical reconstruction: Arthrodhesis shoulder Posterior bone-block at the elbow Arthrodhesis & tenodhesis for the hand/wrist

“TENDON TRANSFER” 1. DEFINITION To move a functioning muscle and tendon from their normal position to a new location, in order to replace a muscle that is paralyzed. Recipient tendon is more important for the function of the limb than the donor. Tendon transfer, used to : • Substitute : for a paralyzed or a weakened muscle. • Replace : for a ruptured, avulsed, plastic tendon/muscle. • Correct : for imbalanced muscle caused by nervous disorder. 103rd EDITION by Anika A Alhambra

Disadvantages of tendon transfer: a. Loss of original function of donor muscle b. Inability of transfer to effectively perform new function c. Scarcity of available donor muscle.

2. PRE REQISITES a. Patients Educations • Understand the goals and risk of treatment. • Advise pre operative muscle educations Æthe best cooperate Æ satisfactory result. b. Timing • All swelling had subsided and all wounds had healed • Mild contracture maybe compatible • Tendon bed must glide supple, or used silicon-rods • Sensibility has returned

3. CHOICE OF DONOR MUSCLE a) Availability Potential donor maybe demonstrated b) Muscle strength. o Muscle-force : measured with dynamometer (pounds/dynes/pounds) o Physiologic cross section: o Weber & Fick : Contracted muscle force (CMF) ± 3,6 kgf/cm2 The greatest force contraction, is due to the muscle in resting length. o Viscoelastic force (VEF) : Resistance to stretch produce by cell, fascia, and connective tissue.

o Blix-curve = CMF + VEF ƒ Contracted = min + min ƒ Resting = max + min Æ best sutured (Brand) ƒ Stretched = zero + max o Work capacity: force x distance The ability of a muscle to exert its force over a distance. Its proportionate to its mass (cross sectional x length) Æ greater volume Æ greater work capacity. o Power = Force = Strength Work per unit time. 113rd EDITION by Anika A Alhambra Selections of donor muscle must be appropriate force. Each muscle had each potential force. c) Amplitudo/Excrusion. o Total excursion=excursion tendon traction + active contraction o Each muscle had each amplitudo o Effectiveness of amplitudo, influenced by: ƒ Position of the intercalary joint ƒ Freeing the soft tissue d) Direction Should pass straight from the origin to the new insertion. e) Integrity Integrity of function should be preserved; o Its must be considered on : - Multiple transfer of recipients - Multiple intercalary joints transfer f) Synergy To contract simultaneously to achieved a desired function (same action) g) Others must be considered: o Function of the transfer : Grasp must be strong Digit posture maybe relatively weak o Strength of the antagonist; avoid causing of over correction. o Mobility of the joint : acceptable mobility has been restored.

4. PLANNING TENDON TRANSVER Step I : What works? Æ Muscle testing Step II : What is available? Step III : What is needed? Step IV : Matching Step V : Alternatives Î arthrodesis/tenodhesis/capsulodhesis/releaase Step VI: Staging; dorsal or volar lies to the axis

5. SURGICAL TECHNIQUE Depend on :  Proper surgical technique o Appropriate transfer Note : a. Under tourniquet control b. Should permit free gliding transferred tendon, skin incision should not parallel to the route of the transfer. c. Should be a straight line from the origin to the new insertion. d. A traumatic handling during surgery, dressing must not be constrictive 123rd EDITION by Anika A Alhambra e. Post operative : Safe active ROM exercise after 3-4 weeks Given a schedule of manual activity Protective splint is worn until 6 weeks f. End result depend on Proper surgical technique: Preoperative planning A traumatic handling Postoperative rehabilitation Appropriate transfer

6. TEN CONDITIONS OF TENDON TRANSFER 1) Atraumatic: atraumatic handling during surgery 2) Correct : the bone had healed and no deformity 3) Good : muscle test strength minimal 4 4) Balance : action of synergism/antagonistic 5) Free : no contracture, inflammation, scarring 6) Tension : avoid of under/over correction 7) Synergy : equal of power, amplitudo, direction, action 8) Smooth : tendon bed should permit free gliding 9) Straight : from the origin to the new insertion 10) Subcutaneous

133rd EDITION by Anika A Alhambra

143rd EDITION by Anika A Alhambra ARM 1. Musculocutaneous Î BBC : biceps, brachialis, coracobrachialis 2. Radialis Î Triceps Brachii FOREARM 1. Medianus a. Medianus Î PT, FCR, PL, FDS b. AIN Î FDP, FPL, PQ 2. Radialis a. Radialis Î ECRL, ECRB, BR (Mobile web), A

b. PIN Î E3SAE3 (EDC, EDQ, ECU, S, APL, EPB, EPL, EIP) 3. Ulnaris Î FDP, FCU HAND 1. Medianus Î AFO (AbdPB, FPB, OP), L 2. Ulnaris Î PAFO (PB, AbdDQ, FDMB,ODM ), Î deep palmar branch : FPB (medial), AddP, IO, L

IO Î DAB 4 & PAD 3 L Î 2 radial o/ medianus , unipeniform , 2 ulna o/ ulnaris, multipeniform

NEUROLOGIC LEVELS IN UE

MOTORIC o C5 : shoulder abd. o C6 : elbow flexion & wrist extension o C7 : elbow extension & wrist flexion & finger extension o C8 : finger flexion o T1 : finger abd / add

SENSATION o C5 : lateral arm o C6 : lat forearm, thumb, index finger o C7 : middle finger o C8 : medial forearm, ring & small finger o T1 : medial arm

REFLEX o C5 : biceps o C6 : brachioradial o C7 : triceps

153rd EDITION by Anika A Alhambra S P I N E

I. INJURY INTODUCING : o The patient with neurology deficit, better if given IV line, because: ƒ The patient have stomach dilatation ƒ Dangerous of spinal shock ƒ Patients in starvation o Spinal shock: Means : A dysfunction of the nervous system of the spinal cord occurs after spinal cord injury ƒ Spinal shock ≠ neurogenic shock. ƒ Neurogenic shock means: A vascular hypotension with bradycardi as a result of spinal injury. It’s disruption of sympathetic outflow (T1-T2). (SYMPATETIC BLOCK) ƒ Observe until 72 hours or the recover of bulbocavernosus reflex (BCR) and anal reflex. ƒ BCR (+) its mean if the tractus is still intact. Î GOOD PROGNOSIS o Neurologic examination consist of: ƒ Motor examination (myotome)Î motor power (0-5) ƒ Sensory examination (dermatome) Î sensation (anaesthetic, hypaesthetic, normal, hyperaesthetic, dysaesthetic). ƒ Reflex, include rectal examination (BCR reflex) : loss, hypo, n, hyper. o Procedure diagnostic: ƒ Photo cervical AP/lateral (yang dinilai A, B, C, S) ƒ Photo dynamic cervical Î instability? ƒ Photo AP open mouth view Î suspect fracture C 1-2 ƒ Tomography ƒ Myellograph (if suspected a disc herniation) ƒ CT scan dan 3D-CT ƒ MRI ƒ White test’ Î by traction the cervical (3-5 kg) Î evaluate is there any widening of interdiscal (lateral projection) ƒ Electro diagnostic: • EMG Electromyography) • NCV (Nerve conduction velocity) • MEP (Motor Evoked Potential) • SSEP (Somatosensory Evoked Potential) 163rd EDITION by Anika A Alhambra

LEG TRUNK ARM

LEG TRUNK ARM

o Classification of Neurologic injury: 1. According site/part of injury: Root injury • Peripheral nerve lesion (LMN) Æ recover (prognosis good) • Motoric deficit > sensory deficit. Spinal cord injury : • Incomplete: 1) Brown – Sequard Syndrome

‰ Injury limited the either side (hemisectional injury)

‰ Ipsilateral muscle paralysis (UMN), bellow the lesion

‰ Paralysis and loss of proprioseptive sensation, vibration & light touch bellow the level on the side of cord

‰ Contra lateral hypaesthesia (pain & temperature), below the level

‰ Good prognosis to recovery.

2) Central cord syndrome.

‰ Caused of whiplash injury, no bony damage in elderly

‰ The most common incomplete cord injury.

‰ Compressed between bony osteophyte anteriorly and bulging the lig flavum posteriorly

‰ Flaccid LMN paralysis (ext sup)

‰ Spastic UMN paralysis (trunk & lower extremity)

‰ Variable of sensory loss

‰ Bladder dysfunction Æ injury retention. 173rd EDITION by Anika A Alhambra

‰ Disproportionately greater loss of motor power in the upper extremities as compared to the lower extremities. Bladder dysfunction & varying degree of sensory loss below the lesion

‰ Prognosis : poor recovery of hand function good recovery for motoric & sensory for LE

3) Anterior cord syndrome:

‰ Caused by hyperflexion injury

‰ Complete motor paralysis sensory anaesthesia at level below the lesion (pain & temperature)

‰ Proprioseptive sensation, vibration & light touch Æ intact

‰ Prognosis is good, if in 24 hours there is any evident.

4) Posterior cord syndrome

‰ Caused by hyperextension injury

‰ Loss of proprioceptive sensation (position, vibration, light touch, deep pressure).

5) Complete Transection SCI

‰ Complete anaesthesia below the injury of level.

‰ Complete absence of voluntary motor power distal the level. (total flaccid paralysis)

‰ Deep tendon reflex (-), babynski sign (-), BCR&cremaster (+)

‰ Usually irreversible.

6) Conus medullaris syndrome

‰ Flaccid paralysis of the lower extremities (LMN) and spincter dysfunction, in chronic phase Æ UMN

‰ Sensory deficits are variable

‰ Fracture disloc & burst fr are common at the T11 to T12 & T12 to L1, because the change in spinal anatomy from the stiff thoracic spine to move mobile lumbar spine 7) Cauda Equina Syndrome

‰ Proximal anesthesia Æ numbness of: buttocks, back of leg, soles of feet

‰ Spinchter dysfunction Æ paralysis bladder & bowel

‰ Normal leg strength Æ

‰ Absence of radicular pain Æ pain in back of thigh & leg

‰ Atrophy Æ calves 183rd EDITION by Anika A Alhambra

‰ Urgent surgical decompression

2. According cause of injury: PRIMARY : 1. Contusion : - Irreversible neuronal death Î poor prognosis - Associated with vascular injury & intramedular haemorhage. 2. Compression : - Direct neuronal dysfunction - Spinal vasculatory problem - Good prognosis 3. Stretch : - Flexion distraction injury - Cappilary & axonal collapse - Good prognosis 4. Laceration : - Retropulsed bone fragment In fracture – dislocation - Poor prognosis

SECONDARY : Caused by edema, haemorhage, and ischemia

PATOPHYSIOLOGY Of “ SCI ” Theory :

‰ Free radical theory. :Rapid depletion of antioxidant, oxygen free radical accumulate in injured central nervous system tissue and attack membrane lipid protein, and nucleic acid.

‰ Calcium theory : Influx of extra cellular Ca into nerve cells in the propagation of secondary injury. Ca activates phospholipase, protease, and phosphates, resulting in both interruption of mitochondria activity and disruption of the cell membrane.

‰ Opiate receptor theory : Endogenous opiate maybe involved in the propagation of secondary spinal cord injury.

‰ Inflammatory theory : Inflammatory substance (prostaglandin, leukotrine, PAF, serotinin) accumulates in acutely injured spinal cord tissue and are mediator of secondary tissue damage.

Stability of the spine. 1. The three column C spine” of Dennis Anterior Column : ALL, Anterior annulus fibrous, Anterior half of vertebral body Middle Column: PLL, Posterior annulus fibrous, Posterior half of vertebral body 193rd EDITION by Anika A Alhambra Posterior column: Supraspinosus lig, Infraspinosus lig, Facet joint capsule

2. Coefficient stability” by Renee Louis Corpus : 1 Facet R/L : each 1 instable ≥ 2 Ligamentous : each ½ Î Stable means : able to resist a physiological load, without any progressive deformity or any neurological injury. ÎInstability : Ligamentous instability: permanent, absolutely need operation. Bony instability: transient/temporary, healed 2-3 month, except: vertical fr/burst.

MOI in spinal trauma : Flexion Æ - Fracture of vertebral bodies - Acute disc rupture Extension Æ - Fracture of part bony element, (tear drop) - Rupture of ALL & PLL Axial-compression Æ - Burst fracture of vertebral body - Rupture of lig Rotational Æ - rupture of ligament

Goal of treatment :”painless stable spine”: ¾ Presume the life ¾ Prevent complications & further spinal cord injury ¾ Restore alignment & stability ¾ Provide maximum functional & early immobilization ¾ Minimize residual deformity, by doing: o Reduction of fracture o Stabilization of the fracture o Decompression o Fusion/spinal arthrodesis ¾ The method of stabilization is depend on the biomechanics feature of the injury and the most logical procedure is to approach at that lesion site of the spine injury

Modalities of treatment: 1. Physiotherapy : target for ADL 2. Psychotherapy : “Consultation-Liaison Psychiatry” acceptability to the new condition without stress. 203rd EDITION by Anika A Alhambra 3. Nursing : respiratory care, prevent ulcer sore, CIC/bowel training 4. Dietary : early enteral feeding (high protein) 5. Surgery : painless stable spine (posterior/anterior stabilization)

Complications after spine injury: a. Ulcus decubitus b. Spasticity Æ joint contracture c. CV system : o Hypotension orthostatic o Autonomic Hyperreflexia (injury above Th 6 level) = “SYMPATHETIC BLOC” Îhypertension, headache, hyperhydrosis, hyperemia, bradicardi. o DVT (Deep Vein Thrombosis) d. Respiratory system : Pneumonia e. Back pain f. Metabolic problem : osteoporosis disuse g. Bladder problem : UTI h. Bowel problem : constipation and diarrhea i. CNS Î Indwelling catheters is Contra Indication BECAUSE : Bladder constriction Lead of renal calculi Early renal failure

213rd EDITION by Anika A Alhambra CERVICAL INJURY

Suspect to cervical injury: ‰ Impaired consciousness ‰ Head and facial/supra clavicula injury ‰ Localized deformity &swelling in the neck ‰ Un explained hypotension

Criteria of cervical instability: 1. Upper Cervical:

‰ ADI > 3mm (AP sublux)

‰ Ranawat vallue < 13mm (vertical sublux)

‰ Power ratio : > 1 mm

‰ Widening body mass 2. Lower cervical o ‰ VBA > 11 on flexion position (vertebra Body Angle)

‰ Anterior/posterior translation > 3,5 mm (20%)

‰ Facet dislocation >50%

‰ Loss parallelism of facet joints

‰ Widening of interspinosus space

FLEXION INJURY: ¾ Clay-Soveler fracture: Avulsion fracture of processes spinosus (C6-C7-Th1) Stable, caused by blunt trauma. Tx: collar brace, bedrest, analgetic.

223rd EDITION by Anika A Alhambra

¾ Unilateral facet dislocation: MOI: flexion & rotation force Potential unstable Gx: neck pain and torticollis (chin pointing the opposite) Ro: anteriorly displaced of VB ± 25%

¾ Bilateral facet dislocation: MOI: hyper flexion Common site : VC 5-7 Complete disrupt of posterior lig complex Æ unstable! Gx: neck pain, stiffness, instability rotated the head, quadriplegia. Tx: Cervical traction with crutchfield Æ ORIF posterior stabilization. Sublaminar wiring + b graft, plate & screw fixation

¾ Flexion tear-drop fracture: MOI : flexion Fracture of anterior-inferior corner, triangular shape, of VB ¨ unstable. Gx: Anterior cord syndrome Tx: crutchfield Æ ORIF (anterior stabilization)

EXTENSION INJURY

‰ Pillar fracture MOI: hyperextension & rotation Æ Tear of anterior long lig, vertical fracture line

‰ Hangman’s fracture (Traumatic spondylolysthesis of axis): o MOI: hyperextension & axial compression o Vertical fr of pedicle C2, displacement/angulations of C 1-2 Æ Potentially unstable. o Type: stable Æ I : bilateral pedicle fr, little displace (translation < 3mm), no angulations. Pot.unstÆ II : bi-pedicular fr, anterior translation >3mm, angulations of C2, ALL intact. IIa : minimal translation but severe angulations Æ unstable UnstableÆ III: type II & and disruption of ALL Severe angulations & displacement or bilateral facet disloc at C2-C3 o Gx: occipital neuralgia o Tx: conservative: crutchfield Æ minerva cast/halo traction Operative: posterior stabilization. (type III) 233rd EDITION by Anika A Alhambra

AXIAL INJURY • Jefferson fracture (VC 1) MOI : axial loading Lateral mass fracture Æ stable Four each fracture Æ potentially unstable Gx : neck pain, and on the vertex, torticolis, occipital neuralgia Ro: prevertebral soft tissue swelling & ADI (lat projection) Need AP open mouth view : displacement of body lateral masses < 7mm : stable > 7mm : potentially unstable (rupt. of lig. transversum) Tx: conservative: halo traction Operative: posterior fussion (occipital-C1-C2)

• Anderson fracture (Odontoid fr) Type : I : avulsion fr of the tip of dens, at site of attachment alar ligament Æstable II: transverse fr of the base of odontoid Æ unstable & nonunion (60%) III: fr throught the body of axis Æ stable / unstable Gx : Occipital / suboccipital pain / neuralgia ~ ∆ n. occipitalis major, sense of Instability, torticolis Brown Squard syndrome (rare) RO : Retropharygeal tissue swelling & ADI (lat) AP open mouth view Need tomography Tx : conservative: crutchfield Æ minerva cast Operative : -altanto-axial fusion or Odontoid screw fixation

• Burst fracture (lower C spine) MOI : axial loading Ro: fr comminutive of VB, decrease of disc spaceÆ potentially unstable Gx: neck pain and on vertex Need CT scan ¨ canal encroachment?? Tx : Posterior technique: Wiring (Rogers technique) or Brook technique Lateral mass plate (Roy Camille) Reconstruction plate, Louis plate Anterior technique: - plate : - CSLP or S plate Orogco/Lieman

243rd EDITION by Anika A Alhambra

• OTHERS o Atlanto-occipital disruption: Always fatal, comatose Ro: retropharyngeal soft tissue swelling Displacement of the occipital condyle from facet C1 Horizontal displace ≥ 1mm Æ unstable Vertical distance (basion-tip of dens) > 5mm Æ unstable. Tx: Occipito-cervical fussion: Anterior technique Posterior technique: - Y plate - Reconstruction plate o Atlanto-axial disruption: MOI: - Anterior disloc + rupture transverse lig - Anterior disloc + fr base of odontoid - Posterior disloc - Rotatory sublux Ro : ADI, if 3-5mm : transverse lig disruption > 5mm : rupture transverse & alar lig Pada open mouth view : “wink-sign” (narrowing of joint space C1-C2) Tx: C1-2 posterior procedure : Gallie procedure Brooks & Jenkins proc Sontag modification Gallie modification (Sby)

NECK SPRAIN ¾ Injury of soft tissue in cervical region (muscle, ligament, disc, nerve, vasa) ¾ MOI: Hyperextension (whiplash) : Mild (spasm, tenderness, restriction) Moderate (referred pain) Severe (spasm, weakness of neck, inability control position of the head) Ro : retropharyngeal soft tissue swelling Hyperflexion: mild/moderate/severe Common site : C5-T1 Ro : - Prevertebral soft tissue swelling - Widening of inter spinosus Cervical disc disorder: acute/chronic 253rd EDITION by Anika A Alhambra Need: discography/myelography/CT myello

¾ Tx: Immobilization : cervical collar (6 weeks) Bed rest Medicamentosa (NSAID/analgetic) Physiotherapy In cervical disc disorder: need immediate decompression

SCIWORA (Spinal Cord Injury With Out Radiology Abnormality Principal of management: 1. Supportive: - 02 saturation 100% (nasal canule) - Maintenance of systolic blood pressure > 90 mmHg 2. Drugs: Methylprednisolene: 30mg/kg BB (bolus) Æ dilanjutkan infusion at rate 5,4 mg/kg/hours (24-48 hours) 3. Immediate traction immobilization 4. Surgery, indicated if : Residual cord compression Permanent instability

THORACO LUMBAL NEUROLOGIC LEVELS IN LOWER EXTREMITY MOTORIK L1-2 : hip flexion (m. iliopsoas) L3 : knee extension (m. quadriceps Î rectus femoris, vastus lateralis, vastus medialis, vastus intermedius) L4 : foot inversion (m.tibialis anterior) L5 : toe extensor / foot dorsoflexion (m. ext hallucis longus) S1 : foot eversion / foot plantar flexion (m.peroneus longus & brevis)

SENSATION REFLEX T12 : lower abd L4 : KPR L1 : upper thigh L5 : - L2 : mid thigh S1 : ATR L3 : lower thigh L4 : medial leg Æ medial side foot L5 : lateral leg Æ dorsum of foot S1 : lateral side of foot S2 : posterior thigh S3-4-5 : perineum

263rd EDITION by Anika A Alhambra

Criteria of thoracal instability: Criteria of lumbal instability: o o ‰ VBA (sagital plane angulations) > 5 ■ VBA > 22

‰ Sagital plane displacement > 2,5mm ■ Sagital plane translation > 4,5m m

Indication of operation in TL spinal fracture (King): − Problem of instability (coef instab ≥ 2) − Problem static/biomechanics : Kyphotic > 300 Compression wedge > 50% − Canal encroachment > 30% − Progressive deficit neurology

Type of fracture : Frans Dennis & Fergusson MOI Compressive (anterior/lateral) : flexion Burst (A, B,C,D,E) : axial loading Fracture dislocation − Flexion rotation : flexion rotation − Shear/translation : shearing − Flexion distraction : flexion distraction Seat belt (Chance) : flexion distraction Tear drop : extension distraction Burst A : BOTH ENDPLATE B :ONLY SUPERIOR ENDPLATE C : ONLY INFERIOR ENDPLATE D : INVOLVED ROTATION E : WITH LATERAL WEDGING

DENNIS ƒ Compression fr ƒ Burst fr ƒ Flexion distraction injury : seat belt / change fr ƒ Fracture dislocation

Principle management of specific fracture : Compression : Stable Æ hyperextension orthosis Unstable :Æ Conservative : hyperextension cast Operative : posterior stabilization Burst : Stable Æ hyperextension cast Unstable Æ Anterior stabilization + graft Posterior stabilization by distraction system Fracture dislocation: Posterior stabilization Chance: Conservative Æ Hyperextension cast 273rd EDITION by Anika A Alhambra Operative Æ Posterior spinal fusion by compression system

Type of instrumentation: A. For posterior instrumentation principle: Tension band system ƒ Rod : Harrington roads (flexible) Jacobs’s roads (rigid) Cortel-Duboussete rods (very flexible) ƒ Plate : Pedicle Screw Plate system (by Roy Cammile / Rene Louis) ƒ Sublaminar wiring: Segmental Spine Instrumentation (by Luque) Modified SSI w/ K-Nail B. For anterior instrumentation : ƒ Dunn device ƒ Kaneda device ƒ Dwyer instrumentation ƒ Zielke instrumentation ƒ Louis plate

Note :

‰ On burst Fr, neurological grading Frankle A, is caused by, ƒ Spinal shock ƒ Flexion distraction injury

‰ Constipation on TL cause ‘Sympathetic-dysreflexia’, so need Æ bowel training Æ and compressed the plexus Aurbach Æ for stimulates the gastrocolic reflex.

‰ Cause of DYSREFLEXIA • Full of bladder • Cysts or calculi • Pressure sore Æ infection • Constipation

‰ Sign of DYSREFLEXIA • Headache • Sweating on the head/scull • Dyspnea • Bradicardi • Hypertension • ……………… 283rd EDITION by Anika A Alhambra

NOTE : L2-3-4 Æ N. FEMORALIS M. Rectus Femoris M. Sartorius QUADRICEPS M. Vastus Lateralis M. Pectineus FEMORIS M. Vastus Medialis M. Vastus Intermedius L2-3-4 Æ N. OBURATOR M. Adductor Longus M. Gracillis M. Adductor Brevis M. Obturator Externus M. Adductor Magnus M. Oburator Internus L4-5 Æ N. COMMON PERONEAL N. SUPERFICIAL PERONEAL M. Peroneus Brevis M. Peroneus Longus

SCIATIC N. DEEP PERONEAL NERVE M. Tibialis Anterior M. Peroneus Tertius M. Extensor Digitorum Longus M. Extensor Digitorum Brevis M. Extensor Hallucis Longus N. TIBIALIS M. Gastrocnemius M. Plantaris M. Flexor Hallucis Longus M. Soleous M. Tibialis Posterior M. Popliteus M. Flexor Digitorum 293rd EDITION by Anika A Alhambra HIP FLEXOR : Iliopsoas, Pectineus HIP EXTENSION : gluteus maximus HIP EXOROTATOR (short) : PGOGQ (Piriformis, Gamelli Superior, Obturator Int & Obturator Ext, Gamelli Inferior, Quadratus femoris) HIP ADDUCTION : Adductors (4) + Gracillis HIP ABDUCTION : Gluteus Medius, Gluteus Minimus, TFL KNEE FLEXION : HAMSTRING (biceps femoris, semimembranosus, semitendinosus, Æ N.Ischiadicus L5-S1) KNEE EXTENSION : QUA DRICEPS FEMORIS + sartorius FOOT DORSO FLEXION : Tibialis anterior, Ext.dig.longus, Ext.hallucis longus FOOT PLANTAR FLEXION : Gastrocnemius, Soleus, Flex.dig longus, Flex. Hallucis longus, Tibialis posterior

PES ANSERINUS: GSS ( Gracillis, Sartorius, Semitendinosus)

THORACOLUMBAL SPINAL STABILITY 1. HOLDSWORTH: posterior ligamnetous complex as the major structure providing stability. Only fracture-dislocations and shear injuries as unstable.

2. DENIS : three columns a) Anterior column: anterior longitudinal ligament, anterior annulus fibrous and anterior half of the vertebral body b) Middle column: Posterior longitudinal ligament, posterior annulus fibrosis and posterior half of the vertebral body. c) Posterior column: pedicles, facet joint, lamina, spinous processes and interspinous & supraspinous ligament Unstable if: • Loss of greater than 50% of vertebral body height • Angulations greater than 20o • Failure of at least two of Denis three columns

3. WHITE and PANJABI: under normal physiological loading, the spinal column is capable of maintaining its pattern without displacement, no additional neurological deficit, no major deformity and no incapacitating pain.

303rd EDITION by Anika A Alhambra 4. RENE LOUIS : three vertical and one horizontal Three vertical : a. One anterior column : - vertebral body (1) - Intervertebral disc (1) b. Two posterior column : Right facet joint (1) Left facet joint (1) One horizontal : a. Pedicles (R + L) (1/2) b. Lamina (R + L) (1/2) Unstable if : Coefficient os instability ≥ 2

Surgical approach of the spine: • Anterior approach: Advantages: Disadvantages: Directly through the effected vertebra A major surgery Perform a short stabilization Need ICU for post operative care

• Posterior approach: Advantages: Disadvantages: Technically easier Need more long stabilization than anterior

II. INFECTION “SPONDILYTIS TUBERCULOUSIS” (Pott’s disease)

Deff : is a chronic Granulomatous infections cause by specific bacteria, which attack the spinal column

ETIO-PATHOLOGY • Cause by Mycobacterium tuberculosis (bovine, africanum/ levine) • Spreading by: hematogenous, limphogenous, direct extension • Predisposition Factor : - IV drug abuse - Intraarticular steroid injections - Chronic systemic disease - Systemic use of immunosupresent • The common site: Lower thoracal & upper lumbal. Î BATSON PLEXUS • Specific pathology Æ destruction of the anterior vertebral body Æ Kyphotic

313rd EDITION by Anika A Alhambra • Stadium of Spondylitis TB: Stadium I (implantation) Stadium II (early destruction) : 5-6 weeks Stadium III (late destruction) : 8-12 weeks Stadium IV (neurological deficit) Stadium V (permanent deformity) : 3-5 years

7 PROBLEMS 1. Eradical infection 2. Instability 3. Kyphotic deformity 4. Deficit neurology 5. Fracture pathologies 6. Spasm 7. Social Control

SIGN & SYMPTOM: General : Anorexia – malaise – weight loss – night sweating Local : Back pain – Gibbus – Cold abscess – parasthesia – weakness. Laboratory : increase of ESR Hypoalbuminemia < 5 mm : - Slight anemia Mantoux test (+) Î 5 – 9 mm : ? Diff countÎ shift to the left >10 mm : + ICT Infection test Urine : sediment & culture & pulasan Bilas Lambung

RADIOLOGY: • Plain radiography: Destruction of anterior vertebral body (anterior wedging) Collapse/compressed vertebrae (60%) Lytic lesion (40%) Sclerotic vertebrae edge (30%) Narrowing of discuss intervertebral. Paravertebral abscesses (30%) : Trigonum of Petit Lig Pauparti Illiac crest Abnormal chest X-ray (60%) • USG : good for distinguish the abscess 323rd EDITION by Anika A Alhambra • MRI : good for examine compression cord by abscess or other material

HYSTOPATOLOGY: Î FNAB / Open Numerous of Langerhans giant cells with nodular collections of hystiocytes and infiltration of chronic inflammatory cells (granulornatous-tissue)

TREATMENT: Goal Î Eradicated the disease Prevent or correct deformity Prevent or treat the complication Sembuh Î klinis membaik : nafsu makan meningkat, BB naik, keringat malam hilang, ESR normal RO : resolution, fusion a. Conservative : • Drugs : Tuberculostatica (start 2 weeks before operation) EHRZ (SHRZ) : 2 months according HE : 6 months (bila KP + ) WHO If no KP, regiment is 7H3R3 Bactericide: Isoniasid (INH) : 5-10 mg/KgBW/day Rifampicin : 10 - 15 mg/kgBW/day (max 600 mg) Pyrazinamide : 20-25 mg/kgBW/day Streptomycin : 15 mg/kgBW/day Bacteriostat: Ethambutol : 15 – 20 mg/kgBW/day Second line of tuberculostatica: Ethionamide : 3 x 250 mg Para aminosalicylic acid (PAS): 10-20 gr Aminoglycoside (Amikasin, kanamycin, Capreomycin) Quinolon (Ofloxacin, Ciprofloxacin) Rifabutin (derivat Rifampicin) Clofazimin Thioacetazone (T) : 2,5 mg/KgBB/day

• Immobilization : Cervical Æ minerva cast, 3-4 month T-L Æ Body jacket, 3-4 month

b. Operative : debridement & bone grafting (ribs, illiac, fibular) or allograft 333rd EDITION by Anika A Alhambra ADSF (Anterior Decompression Spinal Fusion) Indication: Evidence of progressive neurological deficit (acute/chronic) Evidence of cold abscess (large) Back-pain Æ intractable Problem static : Kyphotic deformity > 40o COMPLICATIONS: Paraplegia, acute: caused by: Edema/absencesÆ compressed to SC Vascular thrombosis Æ ischemia of SC Granulomatous, inflammation of the arachnoid (patchy meningitis) Psoas abscess Spine deformity : Kyphotic-scoliosis

III. SPONDYLOARTHROPATHY DISEASE A. OPLL (Ossification of the Posterior Longitudinal Ligament) • Cause : unclear, suspected: Decrease of absorption of Ca in the gut Insufficient metabolic-hormone for vit D Autosomal dominant inheritance trait. • Pathology : As a heterotrophic bone ossification as a response to the mechanical stressÆ enchondral ossification Æ canal encroachment Æ Nerve compression Spinal cord compression • Sign & Symptom: Asymptomatis or neck stiffness & pain, paresthesia, spastic gait. Need : JOA SCORE ⇔ myellopathy : - Upper ext function - Lower ext function - Sensory function - Bladder function Total point: 17, means : < 7 : severe myellopathy 8-12 : moderate myellopathy >13 : mild myelopathy • Diagnosis: - Ro cervical lateral : type : - continuous - segmental - mixed - localized

- Tomograph - CT-scan 343rd EDITION by Anika A Alhambra - Myellography or CT-myello - MRI - Electro diagnostic (EMG, NCV, SSEP)

• Treatment: o Conservative: collar brace, NSAID o Operative, bila: - Score JOA: 6-12 point (moderate - severe) - Canal stenosis >50% Æ Decompression: Anterior : decompression + fussion Posterior : laminectomy (bilateral laminar excision) laminoplasty : expansive lamina Z-plasty open-door laminoplasty Combined posterior-anterior

B. SPINAL CANAL STENOSIIS Def: Narrowing of the bony spinal canal Æ irritation of the nerve root Sign & Symptom: LBP + radiation down to both legs (posterior aspect of the thigh) Æ radicular Pain, equal w/ dermatome, claudication Increase with: walking/ standing/extend position Decrease with: sitting, slight flexion/raclining chair. Tenderness at the site of the affected lumbar spine (not always) ROM of the spine Æ decrease (mild, moderate, severe) Diagnosis: - Ro photo of lumbosacral AP/Lat: Narrowed & hypertrophy of the facet joints Osteophytes on anterior/posterior of vert bodies - CT scan : mid sagital diameter <12 mm - Myellography Æ ‘apple core lession’ - MRI Treatment: Conservative: - NSAID - Back exercise Operative: Laminectomy – decompression

353rd EDITION by Anika A Alhambra C. HNP (HERNIATED OF NUCLEUS PULPOSUS) Deff: Herniation of the disc material into surrounding tissue. Machnab’s classification: Grade I : protrusion Grade II : prolapsed (sub ligamentous extrusion) Grade III : extrusion (transligamentous extrusion) Grade IV : sequestration o Sign & Symptom : Specific radiculat pain (irritation on the nerve root as its exist the spinal canal), pain radiate downward to the lower extremity and below knee. • Increase by : sneezing, coughing, lifting, bending, jumping, sitting, straining. • Decrease by : lying down in the supinatine position. Lasseque test/straight leg raising test (+)/ Bragard’s test o Diagnosis : Myelography MRI o Treatment : Conservative : - bedrest (2 weeks), with flexion hip & knee, lay down 6 wk on firm matras - Inj. Methylpredisolone (Medrol) : 5 days - Lumbar traction (controversial?) Operative : disectomy if : Motor weakness Reflex changes Sensory changes Loss of ladder & bowel control Persistent severe pain after conservative treatment (3 wk) Î NEUROLOGICAL DEFICIT

D. SPONDYLOLYSIS & SPONDYLOLYSTHESIS Spondylolysis : defect on pars articularis of the VB without displacement Spondylolysthesis : displacement to the anterior portion of the affected segment of the body vertebra, common site : - L 4-5, L5-S1

Six type Spondylitis: 1. Lytic (isthmic) : 50% Æ Defect at interarticularis region Increase with aging Cause suspected by repeated stress 2. Degenerative (25%) Æ Generalized OA 3. Dysplastic (20%) Æ Defect congenital 363rd EDITION by Anika A Alhambra 4. Traumatic 5. Pathologic (tumor) Æ Any bone destruction 6. Iatrogenic Æ post operative instability

Pathology: It can due to pressure of : durameter, nerve root, cauda equina or disc prolapsed.

Sign & symptom : asimptomatic (painless) : in children Intermittent LBP (exp after exercise/strain) Sciatica Pecular/spondylolythic gait : Limited hip flexion Short stride length Wide base support Protruding abdomen Square buttock/sweetheart pelvis Palpable ‘step’ Hamstring tightness Neurologic sign (paresthesia, weakness, incontinent bladder & bowel)

Diagnostic: X-ray Lumbosacral (AP/Lat/Oblique and dynamic) Lat : Forward shift (Meyerding) : Grade I : 25% Grade II : 25-50% Grade III : 50-75% Grade IV : > 75% (Meschant) : ≤ 10o = slight 11-20o = moderate > 20o = severe (Marique) percentage of AP shift Lumbar index Slip angle/LS Kyphotic angle (L5-S1) AP : - elongation Oblique : broken neck of Scotty dog Scotty dog : Nose : transverse process Ear : superior facet Body : lamina 373rd EDITION by Anika A Alhambra Tail : superior facet Eye : pedicle Neck : pars intrarticularis Fore & hind leg : inferior facet

CT scan Caudography or MRI : to examine nerve involvement

Treatment: Conservative : Activity modification Muscle strengthening / back exercise Antilordotic brace NSAID Weight reduction

Operation : if, Persistence or recurrence symptom Symptom increase with mild activity Slip ≥ 50% Slip angle 40-50o (in growing child) Progressive neurological deficit Goals: Reduction of back & leg pain Prevention of further slip/further neurological deficit Stabilization of normal spine mechanic, posture and gait Technique : Fussion in situ ± laminectomy (decompression) ALIF (Anterior Lumbar Interbody Fussion) PLIF (Posterior Lumbar Interbody Fussion) Combined PALIF On severe case (Spondyloptosis) Resection of VL 5 Reduction & fussion of VL 4 to sacrum

E. ANKYLOSING SPONDYLITIS Def: A from of spinal arthritis, with end result calcify bridging of intervertebral spaces, cause stiffness the spine (bamboo-spine) Pathology Î Inflammatory process (RA) in the pelvic joints & costovertebral articulations.

383rd EDITION by Anika A Alhambra The differences : Predominance in young man (17-35 years) Absence of rheumatoid nodules Absence of rheumatoid factor Presence of chronic inflammatory cells & granulations tissue. Occurrence of perispinosus calcifications (fibrous tissue ossify Æ bony ankylosis). Inflammation Æ erosion Æ ossification MARIE – STRUMPELL downÆup MORBUS – BACTHEREW upÆ down

Sign & symptom: • LBP (morning stiffness & pain), extend: buttock, hip, and thigh. • Palpable tenderness of Sarco illiac joint & lumbar spine. • Flattening of the normal lumbar lordosis • Motions are lost Æ Schober test (+) • Pain : chest wall, neck • Severe: iritis, aortitis, carditis, atlanto-axial instability • The patient can heard his/her steps

Laboratory: • HLA B 27 Ag (+) • ESR increase • Mild anemia

Radiology : defect after 3-6 months First : S I J : ill defined margins Æ widening of joint space Æ irregular bridging Æ obliteration Æ bony ankylosis Spine : Spur formations : Osteophyte Marginal syndesmophyte Erossion Æ sclerosis Ossification of the anterior long lig Æ bamboo spine ! Atlanto-axial instability : dynamic cervical Æ ADI ?

Treatment: Conservative: NSAID: Phenylbutazone or Indomethacin Corticosteroid (severe case) Exercise program: breathing & NBW exercise Avoid Kyphotic activity Surgical intervention is uncommon 393rd EDITION by Anika A Alhambra IV. CONGENITAL “SCOLIOSIS”

A. Definition: Lateral bending deformity of the spine (abnormal curve > 10o) B. Type of scoliosis: I. Non structural/functional/compensator/postural II. Structural: a. Idiopathic (65%) : Infantile : 0-3 years Juvenile : 4-14 years Adolescent : 15-mature Adult : after mature b. Congenital (15%) : Defect of formation Æ Hemivertebra Wedge vertebra Sacral agenesis Defect of segmentation Æ Unilat unsegmented bar c. Neuromuscular (10%) : UMN : CP LMN : Poliomyelitis, syringomelia, spina bifida, SMA Myopathy : DMP - EDS - AMC - Marfan Sy d. Others : Neurofibromatosis (5%) Post injury (mechanical, radiation, post operative) Tumor Infection Metabolic : rickets, osteoporosis, OI Arthritides disease C. Diagnosis Include : Severity - location - Direction - Etiology

Anamnesis : Chief complaint Associated symptom Age of first present Family history Menarche status

Sign & symptom: Cosmesis? Back pain? Respiratory impairment?

Px: Standing: From anterior : Shoulder level Pelvic obliquity --. Block test From posterior : plumb line & body arm distance 403rd EDITION by Anika A Alhambra From lateral : Lordosis/Kyphotic Forward bending: Rib-hump : measure with scoliometer Others : distraction test Æ flexibility? LLD Joint hyperlaxity? Neurologic examination? Lung function? In severe cases X-ray: - (AP, lat, R/L bending) Measurement: 1. Cobb-Lipman angle 2. Reisser-Fergusson angle 3. Nash & Moe (rotation) : 0-4 4. Risser sign : 1-5 Stagnara view

D. Treatment : Key of treatment : “Early diagnosis & treatment to prevent progression of deformity” Principle: 0-20o : observation 20-40o : brace (worn at least 23 hours/day) 40-50o : borderline, if still mobile ¨ trial with bracing > 50o : operative a. Conservative : Observation Electric simulation (not effective) Bracing: No for correction, just prevent the progressive of curve Indication : Risser >4 Long flexible curve, without structural changes. Milwaukee (apex above Th IX) Boston (apex bellow Th IX) Traction : Non skeletal: Cotrell traction Skeletal : Cranio/halo – femoral Cranio/halo pelvic Cranio/halo gravity Exercise Æ without brace : Postural training Crawling, sit up, push up EDFL (Extension, Derotation, Flexion, Lateral) Bending Curve stretching 413rd EDITION by Anika A Alhambra With brace : Pulling away of pad Body – shifting Casting : Risser localizer cast Cotrell EDF plaster

b. Operative: Goal of operation: Minimize deformity Limitation stress on vertical column To keep the curve <50o by the end of adolescent Indication : Curve >50o in idiopathic – adolescent Curve >40o, progressive during bracing Curve >40o, neglected, not flexible.

Kind of instrumentation: 1. Posterior instrumentation: Harrington rods Luque rods Cirorth rod & hook 2. Anterior instrumentation: - Dwyer system 3. Combined: Herrington – Luque Dwyer – Herrington 4. In congenital scoliosis: Epiphsiodhesis (convex growth arrest) Hemivertebra excision Vertebrectomy Combined procedure

Note: • Progressively of curve, depend on: o Weight action force above the apex level o Bowstring effect of the muscle at concave side Without adequate treatment, curve progressively: 1o/year In lumbal scoliosis more severe, because no tension like ribs in thoracal region. In congenital scoliosis, progressively is more than idiopathic (2-5o/year) • Associated anomalies, in congenital scoliosis: ‘VATER syndrome” (Vertebral Anomalies, Anal malformations’ Cardiac defect, Tracheo Esophageal fistula, Renal & Radial (limb) anomalies) • CRANKSHAFT phenomenon : deformity caused by operation only posterior fusion and the anterior side still growth

423rd EDITION by Anika A Alhambra DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) Definition: A developmental abnormality of the hip joint, in which the capsule, the proximal femur, and the acetabulum are all defective.

Incidence: 1-2/100 (Male: Female = 1:7)

Classification: I. Teratologic/teratogenic : - It develops early in uterus with severe contracture. - At birth, the dislocated hip can’t be reduced by Ortholanni maneuver. II. Typical: a. Dislocated hip: The femoral head is completely outside of the acetabulum b. Dislocatable hip : The femoral head is in the acetabulum, but can easily displaced out of it, by Barlow’s provocative test. c. Subluxatable hip: The femoral head can be passively displaced partially out of acetabulum not completely dislocated.

Etiology: A. Prenatal : Ligamentous hyperlaxity (hormonal-imbalance) Intra uterine malposture Mechanical force resulting from anatomic instability Genetic influence. B. Postnatal : Environmental factors

Pathology : The capsule is very stretched out and very loose

‰ The lig teres is elongated

‰ The labrum is everted

‰ The femoral head is spherical

‰ Excessive antetorsion of the proximal femur

‰ The acetabulum has become shallower

Sign (Symptom: A. 1 months : Ortholani test (+) : clunk of entry sign Barlow’s test (+) : clunk of exit sign

B. 1-3 months

‰ Asymetrical gluteal/thigh fold

‰ Limitation of hip abduction 433rd EDITION by Anika A Alhambra

‰ Relative shortening of the femur (Galleazi sign (+))

‰ Ortholani test present, but soft.

C. 3-6 months

‰ Contracture of the hip (Thomas test post)

‰ Limitation of abduction

‰ Galleazi sign (+)

‰ Telescoping sign (+)

‰ Ortholani sign decrease (no reduction is possible)

D. After walking age

‰ Waddling gait/Sailor gait

‰ Trendellenburg test (+)

‰ Widened of perineal space

‰ Greater trochanter are prominent

‰ Buttocks are broad & flat

‰ Hyperlordosis

Radiographic Findings 1. X-ray of the hip AP view : ƒ Hilgenreiner’s line/ Y line ƒ Perkin’s line/Onbredonne’s vertical line ƒ Shenton’s or Menard’s line ƒ Von Rossen line ƒ Acetabular index/acetabuler roof angle ƒ Y coordinate of Ponseti ƒ C – E angle of Wilberg Æ 5 –8 y : 19O 9 – 12 y : 12 - 25° 13 – 20 y : 26 - 30° 2. USG

Treatment (depend on : age, stage, type) Goal: Stable concentric reduction Principle: To create a normal upper end of the femur To provide adequate acetabular coverage of the femoral-head To establish normal biomechanics of the hip

443rd EDITION by Anika A Alhambra

a. At birth – 3 months. - Closed reduction of the hip - Maintain the reduction with : Pavlik Harness Frejka Pillow Von Rossen splint (On the save zone concept : 30-65°) - Duration : twice of the age (in weeks) of the infant when the PH is first applied. (min 6 week). b. 3 months – 3 years • Preliminary traction • Close reduction • Retained of the reduction with hip spica cast • After removal cast followed by : night splint with : Pavlik Harness Dennis Brown hip abduction splint Scottish Rite brace

453rd EDITION by Anika A Alhambra c. Above 4 years • Prelimenary traction • Open reduction : medial or anterolateral approach • If needed, combined with: Femoral osteotomy : - intertrochanter/subtrochanter Innominate osteotomy : salter or pemberton Lateral transfer of the greater trochanter d. Adolescent • Indication of surgery : hip instability severe OA (abn bone condensation in acetabular roof).

¾ Classification: Grade I : stable, congruous, but dysplastic Grade II : Un stable, sub luxated Grade III: subluxated, slightly uncongruous, reducible Grade IV: subluxated, marked uncongruity, irreducible.

Grade I : observe (Conservative) II-IV Î realignment osteotomy of prox femur

(CONTAINMENT) Innomiate osteotomy: Chiari (is the best) Shelf Triple innomiate Salter Wagner Sutherlands (double)

Resume

3 months 3 months – 3 years Above 3 years Adolescent Close reduction Preliminary traction Preliminary traction Open reduction close reduction ¨ Close reduction Femoral osteotomy ↓ open reduction: Innominate Palvik Harness ↓ Femoral osteotomy osteotomy: Frejka Pillow Hip spica cast Innominate osteot Chiari Von Rossen splint ↓ Salter Shelf Night splint Pemberton Salter Palvik Harness Lat transfer of the Sutherlands Dennis Brown splint greater trochanter Scottie rite brace

463rd EDITION by Anika A Alhambra Limping Child with pain on the hip

I. IRRITABLE – HIP (TRANSIENT SYNOVITIS) ¾ Def: Syndrome of transient hip pain and restriction of movement. ¾ Etiology : unknown (trauma, allergic) ¾ Most common : 6-12 years. ¾ Sign & symptom: o Pain & limp (intermittent & following activity) o All movement are restricted o Long lasting : 1-2 weeks ¾ Lab : all normal ¾ Roentgen: normal ¾ USG : small joint effusion ¾ Treatment : Bedrest with immobilize under traction Analgetic/NSAID Follow up until 1 – 1,5 y (early Perthes)

II. SEPTIC/PYOGENIC ARTHRITIS ¾ Note : - common age : < 2 years ¾ Cause : Staphylococcus Î Destruction the joint by proteolytic enzyme of bacteria. ¾ Sign & symptom: ƒ ill & pain ƒ All movement of the hip are restricted ƒ Soft tissue swelling ƒ Sign of dislocation of the femoral head ƒ Aspirating pus of the joint : (+) ¾ Lab: Leucositosis & slight anemia ¾ Roentgen : widening of joint space ¾ USG : joint effusion !!! ¾ Treatment : Cito arthrotomy, with Antibiotic installed locally Decrease intraarticular pressure Evacuation the pannus Antibiotic depend on culture Immobilization the joint by traction or splinting. ¾ Complications: o Pathological dislocation o Necrotic of the head

473rd EDITION by Anika A Alhambra III. TUBERCULOUS ARTHRITIS (Early stage) ¾ Cause : Mycobacterium Tuberculosis ¾ Sign & Symptom: • Soft tissue swelling • Mild pain & limping • Mantoux test (+) ¾ Lab : Increase of ESR Slight anemia Leukocyte : normal/decrease ¾ Roentgen: Cartilage & cortical destruction Subchondoral osteoporosis ¾ Treatment: Chemotherapy: Triple drugs Operative: Synovectomy debridement ± arthrodesis.

IV. SLIPPED CAPITAL FEMORAL EPIPHSIOLYSIS (SCFE) ¾ Def: Displacement of the proximal femoral epiphysis ¾ Common age : - pubertal growth spurt (14-16 years), Boy > girls ¾ Cause : Hormonal imbalance pituitary hormone Æ physis unable to resist the shearing stress impossed by the increase of body weight. Exp: Hypogonadal Frohlich type child Juvenile hypothyroidism Craniopharyingioma Trauma (30%): mechanical stress. ¾ Pathology: Disruption occur at the hypertropic zone of the physisÆ premature fussion Æ permanent exorotation coxa vara ¾ Sign & symptom : o pain in the groin, thigh, or knee o limping, the leg is ‘turning-out’ o exorotation and 1-2 cm short of normal limb o all movement are limited ¾ Roentgen: o AP view : - widen of epiphseal plate o Trethowan’ s sign (+) o Lat view: femoral epiphyseal angle with neck femur < 90o) ¾ Complications: Slipping at the opposite site Avascular necrosis 483rd EDITION by Anika A Alhambra Coxa vara Articular chondrolysis ¾ Treatment : Depend on the degree of slips !!! Minor slip (AP : < 1/3 of width; Lat < 20o of tilt) Î grade I Needs no correction Fussion in situ with 2-3 threaded pins Moderate slip (AP: 1/3 - 2/3 of width; Lat 20-40o of tilt) Î grade II Fussion in situ and then wait. 1-2 years later ¨ corrective osteotomy Severe slip (AP: > 2/3 of width; lat > 40o of tilt) Î grade III (acute stage) close reduction under immage intensifier open reduction by Dunn’s method

V. LEGG-CALVE PERTHES DISEASE ¾ Def: Painful disorder of childhood characterized by avascular necrosis of the femoral head. ¾ Common age: 4-8 years (boys > girl) ¾ Pathogenesis : unknown Maybe: Vascular theory : Block off the arterial flow Venous stasis Growth arrest theory Effusion following trauma Æ avascular tamponade Inflammation theory Æ non specific synovitis Viscosity theory (Bleck) Æ coagulation abnormality ¾ Pathology: takes 2-4 years (3 stages) 1. Ischemia & bone death 2. Revascularization & repair 3. Distortion & remodeling ¾ Sign & symptom: • Pain & limping • All movements are diminished • Muscle atrophy

493rd EDITION by Anika A Alhambra Classification 1. CATTERALL: I. Epiphysis has retained, half of nucleus is sclerotic., such widening of joint space II. Up to half the nucleus is sclerotic, any fragmentation & some collapse of central portion III. Most of the nucleus is involved, sclerosis, collapse of the head, metaphseal resorption IV. The whole head is involved, metaphyseal resorption is marked.

2. SALTER-THOMSON Type A = Caterall I / II Type B = Catteral III / IV

3. LATERAL PILLAR (HERRING) Î height of lateral of the epiphysis Type A : Normal height of the lateral pillar is maintained Type B : More than 50% height of lat pillar is maintained Type C: Less than 50% height of lat pillar is maintained Note : head at risk : Lateral calcification Gage’s sign Lateral subluxation Metaphyseal cyst formation Horizontal growth plate X-ray after healing: Mushroom shaped of the head Dysplastic acetabular socket Larger than normal & laterally displaced Sagging rope sign

4. CONWAY – DIAS (1997) Æ Bone Scintigrafi for prognostic value A pathway : 4 stages x- ray modified Waldenstorm B pathway : 4 stages A1 whole head involved B1 idem Waldenstorm 1 : n A2 early lateral B2 base filling Waldenstorm 2 :subchondral collapse A3 medial extension B3 mushroom Waldenstorm 3 : fragmentation A4 complete revascular B4 idem Waldenstorm 4 : remolding

A : potential form B : true form (head at risk 90%) Treatment : According the age and stage !!! 503rd EDITION by Anika A Alhambra

Goal : Painless hip Full ROM Round head - NSAID 5/6 years : all types : symptomatic : - Traction (2 weeks) - NWB (crutch) - Decrease activity Îfollow up every 1-3 monthsÆ good response Æ healing Æ poor response Æ containment

AGE ‘BENTY’

Lat pillar (A) : symptomatis : same above Caterral I - III

> 5/6 years ` Abd.brace/cast

Lat Pillar B/C type B/C : Containment: Caterral IV (head at risk)

Operative Add release VDRO Psoas release Salter Osteotomy

Residual after healing epihyseal extrusion index KLISIC ¾ Coax magna SALTER ¾ Coax brevis IF > 20% Æ Need COAPTATION ¾ Hinge abduction ¾ Osteochodritis dissecans ¾ Step acetabulum ¾ Non spherical head

513rd EDITION by Anika A Alhambra VI. JUVENILE RHEUMATHOID ARTHRITIS Def: A systemic disease, with fever, lymphadenopathy, and a progressive bone destruction of both side of the joints without any reactive osteophyte formation. Cause: • Autoimmune disease (abN immunology response) • Heredity (genetic factor HLADRA) • Climatic factor (environment) • Stress reaction (physiological) • Dietary factor

Classification • Pauciarticular < 3 joint • Polyarticular > 3 joint • Polyarticular + systemic sign

Pathology: Not specific : Synovitis & joint changes Bone & cartilage change Specific : Rheumatoid nodule (rare) Other inflammation : pleura, pericardium, iris, sclera, etc

Sign & symptom : (Pauciarticular : ≤ 3 joints) − Pain in the groin & limp. − All movement are restricted & painful. − Limb usually : exorotated & fixed flexion

Laboratory : no pathognomonic !!

‰ DL normal / slight anemia, eosinophilia

‰ RA factor : pos (10% in child) CRP (+)

‰ IgG & IgM (increase) ANA (+)

Roentgen: ƒ Acute/early stage : no specific Æ acute synovitis Articular space narrowing Destruction of articular cartilage ↔ pannus ƒ Late stage : Acetabulum & femoral head are eroded Protrusio acetabuli Articular space (-) Æ fibrous/bony ankylosis 523rd EDITION by Anika A Alhambra

Treatment : depend of stage/severity of the disease 1. Rest in acute stage : immobilization in traction Bivalve cast, plastic splint, etc. But still need exercise/physiotherapy 2. Drugs : NSAID 3. Operative (rare !!) Soft tissue procedure : synovectomy, Tenotomy, Capsulotomy Bone & joints procedure : Osteotomy, Arthrodesis, Arthroplasty Salvage procedure

The CHILD w/ COXA VARA Î DECREASE OF THE NECK SHAFT ANGLE

1. DEVELOPMENTAL COXA VARA

2. METAPHYSEAL DYSPLASIA

3. MORQUIO SYNDROME

4. PFFD

5. MALUNION FRACTURE

6. OI

7. TUMOR Æ FIBROUS DYSPLASIA PAINLESS LIMP 8. SCFE WADDLING GAIT LUMBAR LORDOSIS

INTERTROCHANTER/SUBT IN GENERAL SYMPTOM AND SIGN ROCHANTER OSTEOTOMY

HIP PROBLEM Delayed milestone

Limp

Pain & stiff

LLD

Complain at birth

Eosinophilic grnulomatosus Tumor w/ pain at hip in children Î Lytic process Î Leucemia

533rd EDITION by Anika A Alhambra LIMPING GAIT IN CHILDREN

UPS

A limp: Î ASYMMETRIC DEVIATION FROM THE NORMAL GAIT DD/ Trauma Infection Inflammatory Congenital Neuromuscular Developmental disorders Neoplasm

Normal gait: SWING PHASE Î 40% STANCE PHASE Î 60%

Disturbance Gait: ƒ ANTALGIC GAIT o Pain related o Stance phase ↓ o DD/ Diskitis o Walks slowly or refuse ƒ TRENDELENBURG GAIT o Weakness of abductor muscle o Common in DDH o Pelvis tilts away from the affected o Stance phase Æ N ƒ SHORT LIMB GAIT o Walks on the toes o LLD > longer extremity may remain flexed at the hip and knee (stance phase) ƒ SPASTIC GAIT o Hypertonicity and Muscle group o Imbalance between the muscle HYSTORY ƒ Onset and duration ƒ Association w/ pain ƒ Getting better or worse ƒ Older patient ƒ Worse in the morning Î rheumatologic ƒ Night pain Æ malignancy ƒ Growing pain, 3 critea : o Bilateral • Occurs only at night o No symptom at the day • Self limited unknown reason 543rd EDITION by Anika A Alhambra ƒ Sign of infection Î fever +/- ƒ Family history of : Rheumatologic Inherited Neuromuscular disease

PHYSICAL EXAMINATION ¾ Stance phase ¾ Stiffness +/- ¾ Trendelenburg Gait Î Torso shift over the pathologic limb ¾ Neurologic examination : Walk on the toe and heel Test for reflexes and clonus ¾ Spine examination : Bending forward Spondylolysis & Spondylolisthesis Æ Bending Backward ¾ Sacroiliac joint : Faber test ¾ Hip examination : o Most important o Fluid production in the joint capsule ↑ Î transient synovitis o Abduction and external rotation and flexion Î↓ o Extension and internal rotationÎpressure↑ o Asymmetry abduction hip Î DDH Î Galleazy test o SCFE Î external rotation o DD/ Transient synovitis HIP ROTATION Septic arthritis ¾ All joint examination ¾ Active & passive ROM ¾ Palpated tenderness and warm ¾ Lost of ROM Æ Localized pathological site ¾ Patellar ballottement Æ effusion ¾ Pain the extreme flexion & extension Æ sign of meniscus pathology ¾ Ankle joint examination Æ include careful palpation

LABORATORY FINDINGS

‰ BLOOD : White cell Î >>> ESR & CRP Î monitor improvement AB therapy CRP more sensitive & earlier elevated

‰ ASPIRATE JOINT Î gram stain + culture Î protein and glucose analysis - Serum Rheumatoid anti nuclear antibody - HLA typing (Human Leucocytes Antigen) usually (-) 553rd EDITION by Anika A Alhambra RADIOLOGICAL : • Plain film AP & Lateral • Pelvic X- Ray : Fragmentation in perthes disease Joint space widening in perthes and sepsis Structural ab n in hip dysplasia • Hip lesion Æ special position • In non verbal patient Æ x – ray from the hip to the feet, detect fracture through the growth plate • Hip infection (septic arthritis ) o USG more sensitive for identify the effusion fluid in the soft tissue o Bone scan if physical examination history (-) o CT scan bone structure o MRI best highlight for soft tissue lesion

Need For Immediate Attention 1. Septic arthritis : intra articular pressure ↑ Î poor blood supply femoral head ÎAVN 2. Bone tumor rare but should Be Ruled Out 3. Leukemia 4. Multiple fracture Æ possibility of child abuse

DILLEMA If no constitutional symptoms, no localized abnormalities (by history and physical examination) Î plain film to rule out fracture Î observation & reevaluation in a few days (depending on the severity and family situation)Î if symptom not resolve / localized after 2 –4 weeks Î bone scan

DIFFERENTIAL DIAGNOSIS OF THE ACUTELY LIMPING CHILD • TRAUMA o Fracture o Stress Fracture o Toddler’s Fracture (minimally displaced spiral fracture of tibia) o Soft tissue contusion o Ankle sprain • INFECTION o Cellulites o Osteomyelities o Septic arthritis o Lyme disease o TBC of bone 563rd EDITION by Anika A Alhambra o Gonorrhea o Post infection of reactive arthritis • TUMOR o Spinal cord tumors o Tumor of bone o Benign : osteoid osteoma, osteoblastoma o Malignant : osteosarcoma, Ewing’s sarcoma o Lymphoma o Leukemia • INFLAMMATORY o Juvenile Rheumatoid Synovitis o Transient Synovitis o Systemic Lupus Erythematosus • CONGENITAL o DDH o Sickle cell o Congenitally short femur o Clubfoot • DEVELOPMENTAL o LCP o SCFE o Tarsal coalitions o Osteochondritis dissecans (knee, talus) • NEUROLOGIC o CP, especially mild hemidiplegic o Hereditary Sensory Motor Neuropathies • ALL AGES o Septic arthritis o Osteomylitis o Cellulites o Stress fracture o Neoplasm (including leukemia) o Neuromuscular DD/ OF THE ACUTELY LIMPING CHILD BY AGE

‰ TODDLER (ages 1 to 3) • Septic hip • DDH • Occult fractures • LLD 573rd EDITION by Anika A Alhambra

‰ CHILD (ages 4 to 10) • LCP • Transient synovitis • Juvenile Rheumatoid Arthritis

‰ ADOLESCENT • SCFE • AVN of femoral head • Overuse syndromes • Tarsal coalitions • Gonococcal Septic Arthritis

CORRELATING HISTORY EXAMINATION & DIAGNOSTIC STUDIES

Category History Physical Laboratory Radiology examination studies may show TRAUMATIC Fall Localized pain, None unless Plain film, bone swelling. Loss of infection is scan motion possible INFECTIONS Fever, chills, Rigid guarding, CBC, ESR, CRP, Plain film, MRI, erythema warmth, erythema joint aspirate bone scan NEOPLASM Night pain which Mass CBC, ESR, CRP, Plain film, unrelated to AFP, calcium, MRI/CT, bone activity electrolytes, joint scan, staging aspiration work-up CONGENITAL Problem since Deformity, LLD, None Plain film birth loss of ROM NEUROLOGIC Ataxia, loss of High/low muscle Creatine kinase (if Plain film balance, tone, deep tendon DMD is in DD/) disorganized gait reflex ↑ / ↓, cavus foot or claw toes INFLAMMATORY Pain > 6 mo, Warmth/erythema, Plain film family history of 1 / more joints rheumatoid arthritis DEVELOPMENTAL Painless limp Loss of ROM in None Plain film (LCP), Knee pain joints, asymmetric (LCP, SCFE) ROM, pain w/ ROM

583rd EDITION by Anika A Alhambra THE CHILD WITH BOW LEGS

Physiologic (Î 4 years, wait until 10 years for correction) Pathologic (trauma, metabolic, congenital, tumor, infections)

I. RICKETS Def: Inadequate mineralization of bone in child Cause : 1). Dietary Rickets (Ca deficiency) Nutritional lack Intestinal malabsorbtion (fat malabsorbtion) 2). Renal Rickets (tubular / glomerular) Renal disease (decrease of 1α hydroxylase) 3). Familial rickets (Hypophosphatemic) = Vit D resistant Others predisposing factor: ƒ Under exposure of sun ligt ƒ Liver disease

“defect metabolic pathway of vit D”

METABOLIC PATHWAY OF VIT D

Diet (Vit D2)

Sign & Symptom: ƒ craniotabes ƒ ricket rosary (enlargement of costo-chondral junction) ƒ Harrison sulcus (lateral indentation of the chest) ƒ spinal curvature ƒ coxa vara 593rd EDITION by Anika A Alhambra ƒ Frontal broasing ƒ Tibia bowing ƒ Bending & fracture of the long bone ƒ Muscular flaccidity ƒ Tetani/convulsi

Laboratory: ƒ Ca (serum & urine) decrease, except: Renal rickets ƒ ALP (serum) increase ƒ 25. OHCC (serum) decrease

Treatment: depend on the cause If caused by deficiency of Vit D Æ dietary rickets Vit D: 400 – 1000 IU.day Ca supplement

II. BLOUNT DISEASE Def: A progressive bowleg deformity associated with abnormal growth of the posteromedial part of the proximal tibia physis.

Sign & Symptom: ƒ Bowing leg bilateral & internal rotation of tibia ƒ Common in obese male

Roentgen: Langenskioid I. Irregularity of ossification zone of metaphysis, with medial beaking, II. Sharp medial beaking, posteromedial depression in ossification line of the metaphysis III. Depending of the depression in the metaphseal beak, with small area of calcification. IV. Thickening of the epiphseal plate and bony epiphysis enlarges V. Partially double epiphseal plate VI. Ossify of the double medial part of the epiphyseal late (metaphyseal-epiphseal bony bridge).

603rd EDITION by Anika A Alhambra Treatment : depend on age & stage !!!

Langenskiold I-II Langenskiold Langenskiold III-V VI < 2 years 2-4 years Observe Bracing Valgus Derotation Resection of the (Modf KAFO) Osteotomy (VDRO) bony-bridge MD angle MD ANGLE > 11°

III. OSTEOGENESIS IMPERFECTA (Brittle-bones) Cause : defective in synthesis of collagen type I Î defect in : bones, teeth, ligament, skin, sclera Sign & symptom: - Osteopenia - blue sclera - Prominent to fracture - crimbling teeth (dentigenous-imperfecta) - Bowing of the long bone ` - humpti-dumpty face (broad forehead) - Laxity of joints

Inheritance sclera age Classification : by Sillence et all Î Depend on: joint laxity teeth hearing impairment

Defect I II III IV Inheritance Autos-dom Autos-res Autos-res Autos-dom Fracture (+) with Multiple fracture Multiple Less frequent minor fracture of fracture trauma Joint laxity (+) No identify (+) Less frequent Sclera Deep-blue Normal Blue-gray Pale-blue Other (-) Large scull * Large scull Hearing abnormality impairment Respiratory Difficulty Prognosis Mild/quite Worst Æ lethal !! Bad Best/good good Note : - Type B = as above with crimbling teeth - Fracture can heal as a normal

Goal of treatment: 1. Gentle nursing during infants (to prevent fracture) 2. Mobilization (to prevent osteoporosis) 3. Prompt splinting (to prevent deformity) 4. Corrective osteotomy Î realignment Æ IM rod fixation 5. Reposition & immobilization to treat the fracture 6. No specific treatment 613rd EDITION by Anika A Alhambra The Child with KNOCK-KNEE

Physiologic Pathologic Until 4 years Renal rickets (renal osteodystrophy) Tumors (osteochondroma) Infections Injury

Indication of operation: on age 10 years. Valgus > 15o Î need hemiepiphsiodhesis (physeal stapling) on medial side

623rd EDITION by Anika A Alhambra Patient with (Anterior) Knee Pain

DD: 1. Chondromalacia patella 2. Trauma : Î Soft tissue injury : # Torn meniscus # Torn of ligament Î Fracture/dislocation : # Fr of the tibia spine # Patelo-femoral sublux 3. Osteochondritis dissecans 4. Pre patellar bursitis 5. Arthritis (RA, OA, HA) 6. Patellar cyst or tumor

1. CHONDROMALACIA PATELLA Deff: Î Softening and fibrillation of the articular surface of the patella.

Cause Î mechanical overload of the patellofemoral joint.

Physical examination Î - malcongruence of patella femoral surface - Malaligntment of the extensor mechanism - Weakness of the vastus med Æ patella tilt or subluxate

Sign & symptom Î - Pain (increase by climbing stairs, standing after sitting) - Malalignment or squinting of patella (Q angle, N < 20o) - Qwasting, effusion (squeeze test + Æ ballottement of patella), crepitus (friction test +)

Roentgen : Genu : AP, Lat, Skyline (Merchant’s) view Sulcus angle Congruent angle CT scan

Treatment: Conservative : Education Physiotherapy : Q strengthening Drugs : NSAID SMOAD Operative : Æ improve patellar alignment & patello femoral congruence !! Soft tissue procedure : - Lateral release & medial plication - Proximal realignment 633rd EDITION by Anika A Alhambra

Bony procedure : - Excision of diseased area

• Shaving (by scope) • Maquet’s procedure Æ tibia tubercle alignment • Hauser operationÆ release & transfer of entire extensor insertion • Goldthwait operationÆ release & transfer part of lig. patella • Patellectomy

2. TORN MENISCUS Cause: Injury with weight is being taken on the flexed knee and there is a twisting strain Note: Usually in young adult Medial > lateral Type: • Vertical tear (75%) • Bucket handle tear • Anterior/posterior horn tear • Horizontal tear Sign & symptom: • Pain & tenderness • Locking (inability extend the knee fully) • Swelling (effusion) Special test Î Mc. Murray test or Apiey’s grinding test Imaging Î Arthrography & MRI & Arthroscopy (dx & tx) Treatment Æ Conservative: backslap in straight position for 3-4 weeks mobilizing with crutch & QE Operative: Indication • The joint is locked • Recurrent symptom • Periphery tear, have capacity to heal (red-Zone) ¨ should be sutured. If no capacity to heal (white-zone) Æshould be excise (meniscectomy), by open or arthroscopic procedure.

643rd EDITION by Anika A Alhambra 3. OSTEOCHONDRITIS DISSECANS Def: A small well demarcated, avascular fragment of bone and overlying the cartilage Æ loose body Cause: trauma (single impact or repetitive microtrauma) Common site : lateral part of the medial femoral condyle. Sign & symptom: • Intermittent pain or swelling • Given way or locking • Q wasted, small joint effusion • Localized tenderness • Wilson’s sign Imaging:

‰ Genu AP/Lat/Tunnel view

‰ MRI: low signal intensity in T1 weight image

‰ Bone scan: increased activity around the lession

‰ Arthroscopy Treatment: ¾ Early stage : no treatment is needed, activity decreased (6-12 months) ¾ Late stage : - small fragment Æ removed by scope - big fragment: fixed with pins or Herbert screw.

4. PRE PATELAR BURSITIS (HOUSEMAID’S KNEE) Def: An uninfected bursitis is caused by constant friction between skin and patella. Sign & symptom: ♥ Swelling is circumscription & fluctuant ♥ Secondary infection Æ warm, pain/tenderness Treatment:Î ♣ Aspirated & bandaging ♣ Kneeling is avoided ♣ Lump is best excised ♣ If infection Æ antibiotic

653rd EDITION by Anika A Alhambra 5. ARTHRITIS A. RHEUMATHOID ARTHRITIS Def: A type of chronic inflammatory disease in which abnormal immunological reactions are prominent. Cause: Abnormal immunological reactions Î synovial inflammation (T-cell infiltration & B cell reactivity). Physical examination : Ψ Genetic factor (HLA –DR4) Ψ Environmental trigger factor Ψ Others factors (multiple) : Ω Hormones Ω Diet Ω Psychological stress

1. Synovitis Pathology : 3 stages 2. Destruction 3. Deformity Sign & symptom: ¾ Intra articular o Early stages : sign of synovitis: swelling & pain & ROM ↓ Joint stiffness is morning/inactivity Local warm, joint effusion o Late stage : Joint deformity: valgus knee Restricted of joint motions & painful ¾ Extra articular features : o Sub cutaneous nodules (25%) o Lymphadenopathy o Iridocyclitis o Vasculitis X-ray : Early : sign of synovitis : soft-tissue swelling & peri articular osteoporosis. Later : marginal bony erosions & narrowing joint spaceÆ articular destructions & joint deformity.

Laboratory: • Normocytic hypochromic anemia • ESR increased • CRP (+); RF (+) : 80% ; ANA (+) : 30% Diagnose : - Clinical features - Laboratory (not specific) - Biopsy (close/open): not specific 663rd EDITION by Anika A Alhambra

Treatment: ♣Conservative: NSAID, local splintage, steroid in severe ♣Operative : if conservative treatment has failed ♦ Synovectomy ♦ Supra condyler osteotomy (valgus knee) ♦ Arthroplasty

B. OSTEOARTHRITIS Def: A degenerative joint disease (DJD) non inflammation, with specific process, hypertropic of hyaline cartilage, bone, and soft tissue around the joint. Pathogenesis: 1. Biomechanics theory Structural weakness of joint supporter, cause by aging, trauma, matrix changes Mean Î normal stress mechanic - abnormal cartilage (structure) 2. Homeostasis theory Disorder of synthesis & degradation matrix balance 3. Stress (extra-articular) theory Abnormal stress mechanic, normal cartilage. (structure)

Predisposing Factor : Unchanged Change 1. Genetic 1. Obesity 2. Gender 2. Overuse/trauma 3. Ethnic 3. Hormonal 4. Age 4. Diet (Fusarium) 5. Metabolic (Gout) 6. Muscle weakness 7. Congenital dis (DDH) Classification: MOSKOWITZ : A. Primary (idiopathic) B. Secondary: Trauma, Metab, Endocrine, Charcot joint, Dysplasia, Others MOLL (the stage of OA by radiologically) Grade 1 : Doubtful OA : Osteophyte minimal Grade 2 : Mild OA : Osteophytes at two points Subchondoral sclerosis Good joint space & no deformity 673rd EDITION by Anika A Alhambra Grade 3 : Moderate OA : - moderate Osteophytes - Narrowing of joint space - Some deformity of bone ends Grade 4 : Severe OA : - Large Osteophytes - Loss of joint space - Sclerosis & subchondoral cyst - Deformity of bone ends

KELLGREN LAWRANCE’S criteria : Grade 0 : normal Grade 1 : narrowing of joints space Grade 2 : osteophyte & sclerosis subchondral Grade 3 : postural deformity Grade 4 : large osteophyte & joints destruction

ALTMAN criteria

AHLBACK criteria 1. Rongga sendi normal 2. Rongga sendi menyempit > 3mm pada satu sisi dan tdp osteophyte 3. Rongga sendi menyempit shg condylus dan tibia plateu bertemu 4. Tdp destruksi sendi yg jelas shg tdp perubahan alignment baik varus/valgus

683rd EDITION by Anika A Alhambra OUTERBRIDEGE criteria Grade I : tdp pelunakan lapisan sendi rawan Grade II : adanya borok / Ulcus yg luasnya < 2 cm Grade III : borok dg ukuran 2 5 cm Grade IV : adanya lapisan rawan sendi yg telepas eburnated

Sign & symptom: • Usually over 50 years old & over-weight. • Dull pain (during WB) • Swelling, Q wasted • Patello-femoral crepitus with pressure pain • Giving way or locking, ROM is decreased • Joint stiffness (in the morning & after rest) • Deformity • Loss of function: limping, difficult climbing stairs • Deformity • Loss of function: limping, difficult climbing stairs Treatment: goals Î Pain relieve & prevention of deformity Correction the deformity to restore function 1. Conservative : • Education : control of BW • Drugs : NSAID with specific COX-2 inhibitor ƒ SMOAD (Structural Modifying OA Drugs): ƒ Glucosamine sulfate, Chondroitin sulfate • Physiotherapy: QE, TENS, USD, SWD, JRR, etc 2. Operative: Indications : a. Persistent pain with conservative tx (3months) b. Progressive deformity & instability Consist of : Open a. Abrasioplasty (lavage & debridement) Scope b. Pridie procedure (Drilling) c. Microfracture d. Osteochondral autograft : Mozaic-plasty” e. Osteochondoral allograft f. Autologous chondrocyte implamation (A C I) g. Osteotomy (for distributing of load) : HTO/SCFO h. Artificial joint arthroplasty TKR & THR i. Arthrodhesis 693rd EDITION by Anika A Alhambra

INDICATION OF HTO • Age < 60 (young patient w/ good bone stock) • Active • Varus deformity < 15 ° Æ if > 15 ° SCFO • ROM is good • No joint laxity

Complication THR/TKR • Osteolysis • Loosening • Implant failure • Dislocation • Heterotopic bone • Thromboemboli disease • Infections • Other : nerve injury

C. HAEMOPHILIC ARTHRITIS Def: Chronic synovitis & progressive articular destruction cause by recurrent intra articular bleeding. Cause: • Deficiency of factor VIII (hemophilia A-classic), if platelet dysfunction Æ “Von Willbrand” • Deficiency of factor IX (Haem B/Christmas disease)

Pathogenesis: Hemorrhage in the joint Æ synovial irritation, inflammation and sub synovial fibrosis & pigmented. Æ avascular pannus & produce cartilage degrading enzyme Æjoint destruction sub periosteal hematoma Æ cystic resorbtion

Sign & symptom: Pain, warm, swelling, limited movement Temporary loss of power & sensation (nerve pressure)

703rd EDITION by Anika A Alhambra Radiography (Arnold-Hilgartner) I. Soft-tissue swelling II. I + Osteoporosis + squaring III. II + Narrowing of joint space & squaring of P-F joint IV. III + Joint disorganization V. IV + Joint disintegration

Treatment: In acute bleed: Immediate factor replacement Analgesic Immobilization Chronic stage: Continuous factor replacement Intermittent splintage Physiotherapy Operative : Release contracture Realignment osteotomy Arthrodesis Synovectomy is rare Aspiration, just only in tension hemarthrosis and one week after conservative treatment failed

713rd EDITION by Anika A Alhambra

The Patients With Intoing Gait

1. METATARSUS ADDUCTUS Def : Forefoot is adducted at the tarsal metatarsal joint. Age : 1 year Treatment : - Passive stretching - Serial casting (LLC) - Operative ( > 1 year, resistant case ) : Medial release if need with MT osteotomy.

2. TIBIAL TORSION The most common cause of intoeing, cause of excessive medical ligamentous tightness. Age : 2 years Treatment : - Dennis Brown night splint - In severe case need : supramaleollar osteotomy 3. FEMORAL ANTEVERSION Def : Internal rotation of the femur Age : 3 – 6 years Cause : television sitting position / sit in W position Treatment : - Observe until 10 years - If still < 100 of internal rotation Î FDRO in intertrochanteric.

Pemeriksaan pada intoeing gait 1. Foot Progression Angle (FPA) Î The angle between footstep w/ the straight line 2. Medial / endorotation 3. Lateral / exorotation 4. Thigh – foot angle (TFA) Î The angle between foot axis w/ femoral axis

723rd EDITION by Anika A Alhambra 4. CLUBFOOT Definition: A congenital anomaly with deformity, ankle equinus, varus heel (sub talar, and abduction forefoot.

Classification: I. Non rigid/postural clubfoot: packing syndrome II. Rigid (true congenital): moderate ¨ severe III. Resistant rigid/secondary clubfoot: ec/ Spina bifida, Arthrogryposis Constriction band syndrome STREETER DISEASE Etiology: • Chromosome theory : hereditary germ plasma defect • Embrionyc theory : defect during fertilized germ cell • Otogenic theory : arrest of foetal development • Foetal theory : abnormal intra uterine force/packing • Neurologic theory : defect on nerve fiber • Myogenic theory : abnormal of muscle and tendon

Pathoanatomi: Î Abnormal rotation on joints: - Talocalcaneus - Talonaviculare - Calcaneocuboid Posterior displacement of lateral malleoli Contracture of plantaris and spring ligament Æpes cavus Paralellism axis of talus and calcaneus Shortened and contracture of triceps sure, tom-dig-herry, Collateral lig and post capsule. Navicular and calcis displace & rotate medially Fore foot adducted & supinated Poor prognosis if Æ Small high heel Deep plantar mid foot creases Thin calf “Coleman Block Test”Î rigidity

Radiographic examination At last the age 3 months View: AP Æ Talocalcaneal (Kite) angle : 20-40o Calcaneo-second metatarsal angle 15-20o 733rd EDITION by Anika A Alhambra Talo-first metatarsal angle 0-20o Naviculare positioned centrally TMT angle 45o Lateral Æ Talocalcaneal angle 35-50o Tibio-talar angle: Dorsoflexion : 70-100° Plantar flexion : 120-180o

Treatment Goal : ♣ Reposition of pathologic structure to perform plantigrade foot ♣ Restore alignment of the joints to near anatomical structure ♣ To get a normal muscle balance ♣ To perform pain free, mobile, and stable foot A. Conservative: ♥ Stretching and gentle manipulation ♥ Serial plastering ♥ Adhesive strapping physiotherapy The manipulation is done as soon as possible, shortly after birth, it is better if still in “golden period” (three weeks after birth). Complications: pressure necrosis, rocker bottom foot, flattening of talus, cavus deformity, joints-stiffness, longitudinal breach. B. Operative Indication Î Rigid type & resistant rigid Failed after 3 months conservative treatment Recurrent deformity Neglected cases

Time of surgery : 6-12 months (before the patients walked) Because : - Clear anatomical structure - Weight bearing after surgery promote the correction

Technique: Posteromedial release (Cordovillia) Æ Turco • Subtalar release (Cincinnati) • Bensahel suggest that operation on CTEV is “a la carte approach” • Illizarov technique 743rd EDITION by Anika A Alhambra • After 8 years: need addition procedure: Lichtblau : resection of distal calcaneus/anterior end of calcis Simon : resection of lateral calcaneo-cuboid Evans Æ resection of calcaneo-cuboid Dwyer Æ open medial osteotomy of the calcis Cuboid decancellation • Plastering (LLC) 10-12 weeks, after open the cast perform night splint:Î Dennis-Brown splint • Passive stretching (Physiotherapy) • Correction shoes follow up the patients until nature age • In adolescent patients: need triple arthrodhesis or telectomy.

Complications: Infections, skin necrosis, joint stiff, over/under correction, flattening or beaking of talar head, talar/calcis/navicular, skew foot.

CTEV, important AMC, important Definition Definition Classification Classification Etiology Etiology Pathoanatomy Pathoanatomy Diagnostic: clinical & RO Diagnostic: clinical,EMG/NCV, biopsy, Management: Î goal Lab : CPK Principle Management: Î goal Complication Principle Technique Complication Technique 753rd EDITION by Anika A Alhambra 5. ARTHROGRYPOSIS MULTIPLEX CONGENITAL (AMC) Definition: A non progressive disorder with multiple congenital rigid of many joints. Incidence : 3/10.000 Etiology: Multifactor I. Intrinsic : defect of collagen II. Extrinsic : Mutagenic agent Drugs Chemical agent Hypothermic Neuromuscular blocking agent Intra-uterine immobilization Infections (virus)

Defect of “Cranio spinal-motored axis”

Foetal Hypo/akinesia

AMC

Classification : A. Myogenic : congenital muscular dystrophya B. Neurologic : defect of lower motor neuron

Sign/symptom : • Normal facies, normal intelligence, normal sensory • Multiple joints contracture • Absence of skin crease, cylindrical shape of extremities • Muscle atrophy • Absence of deep tendon reflex • UE: add & int. rot of humerus, elbow ext, wrist flex ulnar dev. • LE: hip disloc, knee contracture, rigid clubfeet • Spine: scoliosis, torticollis

763rd EDITION by Anika A Alhambra Laboratorry: ƒ CPK ƒ Chromosome analysis ƒ Electrophysiology (EMG-NCV) ƒ Muscle biopsy

Treatment : Goal independent self ambulation and have optimal limbs functions. Principle: Release the contracture as soon as possible Restore the result by physiotherapy Promote during ambulation with orthosis For muscle balance need tendon transfer Modalities: 1. Physiotherapy Î passive stretching Æ plastering Æ night splinting 2. Surgery Î ƒ Foot & ankle : soft tissue release & bony procedure if needed Æ planti grade feet ƒ Knee : ♥ Flexion deformity ∞ Hamstring lengthening ∞ Posterior capsulotomy ∞ Shortening of the femur ♥ Extension deformity : Quadriceplasty ƒ Hip: if dislocated Æ need open reduction/containment if contracture: release illiotibial band, illiopsoas, tensor in flexion fascia lata (all hip flexor) ƒ Elbow: extension position Æ tendon transfer for flexion ƒ Wrist: flexion position Æ tendon transfer for dorsoflexion ƒ Fingers: need volar release, web space plasty, etc ƒ Antebrachii: pronation contracture ¨ release insertion of PT ƒ Spine: need spinal fusion & instrumentation (curve > 40) 773rd EDITION by Anika A Alhambra Patients With Kyphotic Deformity Def : Excessive dorsal curvature of the spine. DD : 1. Compensatory Kyphotic (cause other deformity) 2. Congenital Kyphotic (missing/fused anterior segment) 3. Adolescent Kyphotic (Scheuermann’s disease) 4. Ankylosing Spondylitis 5. Tuberculosis Spondylitis 6. Osteoporosis Kyphotic 7. Fracture (post traumatic) Æ pathologies (tumor/etc) Adequate trauma Note : Gibbus / kyphos is a sharp posterior angulations due to localized collapse or wedging of one or more vertebrae.

A. SCHEURMANN’S DISEASE Def : A growth disorder of the spine which the vertebrae become slightly wedge shape. Cause : Unknown Sign & symptom : ♥ Backache & fatigue ♥ Smooth thoracic Kyphotic & compensatory lumbar lordosis ♥ Tight hamstring Æ limit SLR ♥ If severe Æ cardiopulmonary dysfunction Radiography : ψ TL lat Î ∞ Irregular/ fragmentation of endplate (T 6-10) ∞ One/more w/ wedge shaped of vertebrae ∞ School nodes ∞ Measure Kyphotic angel Æ abnormal if : Wedging individual segment > 5° Overall Kyphotic angle > 40° Treatment ♣ Conservative Æ back exercise & postural Kyphotic in skeletal mature bracing ♣ Operative : indication : ♦ Rigid curve >60°, in young adult ♦ Painful severe Kyphotic in skeletal mature ♦ Impending spastic paresis

Î CORRECTION & FUSION using : “HARRINGTON COMPRESSION ROD”

783rd EDITION by Anika A Alhambra B. OSTEOPOROTIC KYPHOSIS Cause : 1. postmenopausal Age : 60 –70 years (5 year after menopause) Chief complain Æ LBP Treatment : hormone replacement Symptomatic

3. Senile 4. Age 75 years (15 years after menopause) 5. Chief complain : back pain & spinal deformity

- X ray : multiple vertebral fracture - Treatment : - symptomatic - spinal bracing

793rd EDITION by Anika A Alhambra

Patients With Joint Laxity

DD : 1. Marfan’s Syndrome 2. Ehlers – Danlos Syndrome 3. Larsen’s Syndrome 4. Osteogenesis imperfecta 5. Generalized (familial) joint laxity 6. Muscular dystrophia

SIGN : • Hyperextend of elbow • Hyperextend of thumb • Hyperextend fingers • Genu recurvatum • Flat foot • Palm on the floor

CHIEF COMPLAINT • Recurrent dislocation of the joints • Frequent fall & • Rapid fatigue • Flat feet

803rd EDITION by Anika A Alhambra Patients with Wryneek

ƒ Pterygeum colli ƒ Unilateral absemce of

m. sternocleido Congenital (wryneck) ƒ Postural torticolis Soft tissue Acquired (wryneck) Æ Atlantoaxial Sublux/trauma - JRA - Grisel’s disease - Cervical adenitis - Syringomyelia Ocular dysfunction - Bulbar palsy “ WRYNECK “

Kleiple Feil Sy Occipitocervical anomaly Æ Fam Cervical dyspl Unilat absence facet

Osseous

Tumor Osteoid osteoma Aneurismal bone cyst

813rd EDITION by Anika A Alhambra EMERGENCY IN ORTHOPAEDIC Î CRITICAL CARE

I . COMPARTEMEN SYNDROME Definition : A complex symptom in which caused by elevated pressure in an enclosed osseofacial space, can damage irreversibly the contents of the space. Volkmann’s Ischemia Volkmann’s contracture

Cause : a. Decrease size of compartment : - Tightened fascia - Tight dressing - Local compression

b. Increase the contain of the space : - Primary edema - Blood accumulation - Combined

Patophysiology : Vascular congestion Æ capillary beds occludedÆ muscle & nerve Ischemia Æ transudation of colloid plasma into the surrounding tissues increase of tissue pressure Æ arterial flow impaired The worst on the central portions : (Ellipsoid theory) Diagnosis: (7P) : - Pain on passive stretching - Pallor - Pain at rest - Uselessness - Paresthesia - Paoikilothermia - Paralysis

Gold standard for measurement : - Wick catheter technique - Slit catheter technique normal : 20 – 30 mmHg - Stic catheter technique > 30 mmHg need fasciotomy - Continuous infusion technique - Needle manometer technique Necrosis of the muscle happened, 8 hours in 30 mmHg intra compartment pressure. Others examinations: • Blood: CPK, BUN, creatinine, aldolase, SGOT, LDH. • Urine: myoglobinuria, oligouria • EMG • SSEP

823rd EDITION by Anika A Alhambra Proper initial management: - Constrictive dressing should be removed or split. - Circumferential cast should be bivalved - Limb should be placed at the level of the heart

Definitive treatment: Fasciotomy, skin and fascia are left open; skin is grafted at a later date.

Prophylactic fasciotomy should be performed on : - Tibia osteotomy - Leg lengthening - Arterial repair - Open tibia fractured

II. FAT EMBOLISM Definition: A syndrome due to the entry of neutral fat into the vascular system. The syndrome usually develops 24 – 48 hours.

Pathophysiologi: Fat in the myellum Î into vascular system Î obliterated vascular in lungs and brain ventilator distress & brain function disorder. Theory: 1. Mechanical (marrow globular) : Bauss 1924. It is caused : damage of the adipose tissue damage of venous system higher pressure in the bone marrow than in the venous system. 2. Biochemistry Disorder of the stability chylomicron – emulsion emboli of microglobules 3. Cathecolamine – adrenal steroid pathway stress Î mobilization of fat from the depot Î increase of FFA & triglyceride.

Clinical Symptoms: Sevitt a. Major (min 1) :Î Respiratory disorder Ptechie Brain (CNS) disorder b. Minor (min 2) : Î Pyrexia Icterus Tachicardi Retina disorder Renal disturbance

833rd EDITION by Anika A Alhambra c. Laboratory (min 1) Î Fat macroglobulin Anemia Thrombocytopenia blood Urine Increase of ESR

Radiology: fluffy infiltrate of the lungs (snow – storm) ECG : Cardiac failure, Abnormal T – wave Î cause of ischemia

Base of treatment : 1. Proper and adequate of fracture management 2. Adequate shock management 3. Adequate pain control with analgetic 4. Respiratory support 5. Corticosteroid administration: - Decrease of cerebral edema - Anti aggregation of thrombosis - Decrease of FFA in plasma - Prevent decrease of pa O2 6. Restore of fluid and electrolyte balance 7. Others : - Antibiotic prophylaxis - Digitalis - Bronchodilator

III. OPEN FRACTURE Definition: Fracture with open wound, which the bone fragment had been exposed with the other space. Classification: Gustillo Anderson : depend on :- Mode of injury - Soft tissue damage - Bone comminution Grade I : 1 cm wounds or less Grade II : > 1 cm wound with moderate soft tissue damage Grade III : Extensive soft tissue damage and crushing due to high velocity trauma. Type III is further subdivided into three subtypes : A : Adequate coverage B : Bone exposed with periosteal stripping C : Circulation distrupted, arterial repair required

Management: Principal: - Prevent infection - Restore the limb functions - Bone and soft tissue healing 843rd EDITION by Anika A Alhambra Consist of: 1. Ensure the ABCs are stable 2. Complete examination include all of system organ 3. Close the wounds with the clean gauze 4. Immobilization the fracture 5. Recognition the fracture by the X-ray 6. Determined the vascular status 7. Preoperative debridement : - Fluid replacement - Anti tetanus - Antibiotic prophylaxis - Debridement & Irrigation 8. Reposition & fixation to secure the stability 9. Closure the wounds: - Grade I & II Î Primary closure - Grade III Î Delayed primary closure (3 – 5 days) or early free-flap 10. Early bone grafting if necessary (1 – 6 weeks) 11. Recognize and treat the complications adequately

Note : • If there is with vascular involvement :

‰ < 4 hours : Stabilization fracture first than vascular repair

‰ > 4 hours : repair vascular first than stabilize the fracture • To determine the vascular by: clinical / Doppler / arteriography Muscle fibers edema Î 4 – 8 H Muscle fibers die Î 6 – 12 H

IV. MULTIPLE TRAUMAS Definition: Patients with more than one organ system had been injured and they influenced to life threatening. Steps of ATLS (INITIAL ASSESMENT) 1. Preparation: pre hospital & in hospital phase 2. Triage: sorting the patients 3. Primary survey: - Airway maintenance with cervical spine control. Alert Verbal - Breathing and ventilation Pain - Circulation with hemorrhage control. Unresponsive - Disability and neurological status : - Level of conscious: AVPU - Pupil size & reaction

853rd EDITION by Anika A Alhambra - Exposure / environmental control : - completely undressed - warmed environment 4. Resuscitation. 5. Roentgenogram 6. Secondary survey - “ a head to toe evaluation - GCS scoring - peritoneal lavage - Other radiologic evaluation Allergies - Laboratory Medication Past illness - “ AMPLE “ history Last meal 7. Re – evaluation Environment 8. Definitive care.

RULE OF PRIMARY AND SECONDARY SURVEY 1. Used of personal protections apparatus (gloves, goggles, mask, head cover, shoe cover, gowns or aprons) 2. Examine the airway with cervical control, if : obs (-) or obs (+) chin lift / jaw thrust Î oropharyngeal (unconscious) Free nasopharyngeal (conscious)

Apply the collar brace endotracheal intubations or cricothyroidotomy

3. Oxygenation - Evaluation: Blood pressure, pulses, Respiratory rate - Evaluation: breathing sound, heart beat sound. if none Î * Tension pneumothorax: contraventile * Hematothorax : chest tube * Cardiac tamponade : pericardiocentesis

4. IV line administration: - 2 (two) IV line with big and short needle, by taking blood sample (cross match, pregnancy test for female, others) - Bolus 1-2 liters of ringer lactate - If need with venasection - Rule: 2LÎev Î 2L Î ev Î type spes with cross match Î ev Î PRCO 863rd EDITION by Anika A Alhambra 5. Re-evaluation: I – P – P – A, completely with: - ECG observation - Pulse oxymetry - RT Î DC & MS - Evaluate: AVPU and pupils 6. Open all of dress (undress), find the all source of external bleeding, Stop the bleeding with clean / sterile gauze. Remember, preventing iatrogenic hypothermia by coverage the patients. 7. Re-evaluation again : - All the vital sign - Blood gas analysis - Urine output

V. ACUTE HEMATOGENOUS OSTEOMYELITIS Definition : acute infection of the bone (metaphysis) & marrow Cause : - Staphylococcus aureus !!! - Streptococcus pyogenes / pneumoniae (infant) - Haemophylus influenza (child < 4 years) - E.coli, Pseudomonas, Proteus (gram neg) - Bactericides (an aerobe) - Salmonella

Predisposing Factor: - DM, malnutrition, drug addict, very elderly, debility - Immunosuppressive therapy, immunodeficiency.

Site or infection: “ metaphysis area “ because: - Area of growth cells - Rich of vascular - Thin cortex - Slow blood flow

Pathology: depend on :- Age - Host response - Site of infection - Immune system - Virulence of organism - Malnutrition

Stage of infection Pathology (Hobo ‘ s theory) 1. INFLAMATION (72 hours) Î Vascular congestion Exudation Infiltration by PMN 873rd EDITION by Anika A Alhambra 2. SUPPURATION Î Sub periosteal abscess 3. NECROSIS Î Sequester: pieces of dead bone separated 4. REACTIVE NEW BONE REACTION Involucrum : new bone thickened surrounding the sequester Cloacae : perforated area from the infolucrum 5. RESOLUTION - Sclerosis and thickening of the bone - Remodeling Stage of clinical (Trueta, 1968) * Stage I : process in the bone : tenderness * Stage II : pus in medullar cavity & sub periostealÎ malaise, fever, pain, headache * Stage III : pus in the soft tissue (abscess) with inflammation sign (calor, dolor, tumor, rubor, functionless) Sign & Symptom : - Pain, malaise, fever, tenderness - Local redness, warmth - Swelling / edema - Restrict of joint motions (refuse to move the limb) - Lymphadenopathy

Roentgen : - Swelling of subcutaneous tissue & muscle - Periosteal reaction / bone formation / thickening of periosteum - Patchy rarefaction of the metaphysis - Bone destruction / destroy bone trabecullae - Osteoporosis bone - Small crack epiphyseal plate

Laboratory: - Leucositosis, increased of ESR - Blood culture (+) - Antistaphylococcal – ab

Treatment: A. General supportive treatment: - IV line (dehydration?) - Analgetic B. Immobilization affected part: - splintage - Skin traction C. Eradication infection: Antibiotic, depend on culture & sensitivity test • Adult / child: - Flucloxacillin 3 – 4 days ( IV ) Îcontinued with 3 – 6 weeks (PO) • < 4 years: Cephalosporin 2nd generation ÎAmoxicillin & clavulanic acid 883rd EDITION by Anika A Alhambra D. Drainage Must be done, if in 36 hours without better improvement with antibiotic. (Monitoring Î LED, temperature, CRP). Drained by open operation under GA (drilling into the medullar cavity)

Complications: - Suppurative arthritis - Altered bone growth - Chronic osteomyellitis

VI. GAS GANGRENE Def : Septic condition caused by microorganism producing gas due to damage soft tissue during the open fracture of bones.

Causes : Clostridium perfringen / welchii Clostridium septicum Clostridium tertium

Pathogenesis: Contaminated of tissue with (spores / vegetative forms) of Clostridia sp & transient hypoxia (low tissue oxygen tension)

Bacterial growth

Toxin produce : (enz hyalluronidase & collagens )

(Clostridia – myositis) ƒ Local edema ƒ Tissue destruction ƒ Thrombosis local vessels ƒ Gas produced (H2S & CO2)

Distant spread (More edema & more thrombosis) 32 – 48 hours

Moribund state

893rd EDITION by Anika A Alhambra Sign & symptom: - General : toxic, irrational, mild shock - Local : ‘bronze – color’ until black discoloration blebs & bulla (sero – sanguineous ), crepitating. Laboratory: - Hemolysis of bloodÎ droop in hemoglobin ( 12 – 24 hours ) - Hemoglobinuria - ATN (decrease of RFT) - Leucocytes - Spore / in gram stain

X – Ray Î gas in soft tissue

Treatment : - Secure ABC (life saving ) - Surgical debridements, irrigation, leave the wound open/amputation - Antibiotic (triple drug) Æ penicillin/ metronidazole - Antitoxin ( β globulin – modified polyvalent ) - HBO Î increase of oxygen content in the soft tissue.

Complication : pneumothorax / air embolism

Note : “ Gas producing microorganism “ * An aerob : - Gram ( - ) : - Bactericides sp - Gram ( + ) : - bacilli : Clostridium sp - coccus : Peptostreptococcus * aerob : - Gram ( - ) :- E.coli - Proteus - Klebsiella - Enterobacter - Gram ( + ) : - Streptococcus pyogenes - Staphylococcus aureus 903rd EDITION by Anika A Alhambra DIAGNOSTIC PROCEDURE (INVESTIGATION)

I. MAGNETIC RESONANCE IMAGING Principle: * Magnet field * Transmitter cell nuclei (proton / neutron) (ion Hydrogen) * Receifer * Computer dysplay

Electrical signal Signal intensity depend on strength of radio wave of soft tissue

Degree of brightness of the structures

High signal intensity low signal intensity (Bright / white) (Dark / black)

The intensity depend on concentration of ion hydrogen (State of tissue water molecule)

Weighted

T 1 T2 Longitudinal relax time transversal relax time (No pulse) (Application of pulse) Î Good anatomical detail Î Good contrast

Note: contrast of MRI : Gadolinium Magnet field force TESLA: HIGH : 1 – 1,5 T MODERATE : 0,5 – 1 T LOW : < 0,5 T

No Structure T 1 T 2 1 Fat & bone marrow High signal Intermediate 2 Hematoma High signal High signal 3 Cortex bone, lig/tendon, fibro cartilage, Low signal Low signal air 4 Muscle, nerve, hyaline cartilage Intermediate Intermediate 5 Fluid Intermediate High signal T 1 Æ FAT IMAGING T 2 Æ WATER IMAGING 913rd EDITION by Anika A Alhambra II. CRP A kind of protein is produced by hepatocyte as a response of body to an acute Condition such on : - trauma - ischemia stage - Inflammation - neoplasm

It’s showed there is a tissue injury. Peak level: 24 – 48 hours after trauma, and rapidly change 24 – 48 hours after better clinical condition.

III. PCR Amplification method for synthesis a specific DNA sequence in vivo.

IV. Various technique of bone mass measurement (Bone densitometry) : SPA : Single photon absorbtiometry Î site: forearm & heel DEXA : Dual Energy X-ray Absorbtiomtry Î site: lumbar & femur QCT: Qualitative Computed Tomography Î site: spine

V. BONE SCAN Principle : - Rate of production of new hydroxyapatite ( osteoblastic activity ) - The blood flow to the certain area - Photon emission by radionuclides taken up in specific tissue can be recorder by either a simple rectilinear scanner or a gamma camera

Isotope: - Technetium – 99m - Gallium –67 : specific for inflammation - Indium –111: specific for infection

Stages of isotopes: Blood pool phase: shortly after injection Bone phase: 3 hours later

Types of abnormality: Increase activity in the perfusion phase: Î Inflammation Decrease activity in the Perfusion phase: local vasc insufficient Increase activity in the bone phase: Î newly forming bone (Fracture, injection, tumor, healing after necrosis) Decrease activity in the bone phase: absent blood supply

923rd EDITION by Anika A Alhambra Indication: 1. Early detection of bone metastases 2. Confirmation of equivocal lession (stress fr, small bone abscess) 3. Assessment of the extent of disease (loosening of prosthesis) 4. Monitoring the progression or regression of active disease 5. Diagnosis of changes caused by metabolic disease.

VI. SYNOVIAL FLUID ANALYSIS Indications: - Acute joint swelling after injury - Suspected joint infection - Synovitis (acute / chronic) Technique : joints aspirated under aseptic conditions. Examination : - Macroscopic / Gross : appearance & viscosity ? - Microscopic : Cells & crystals & Bacteriology ? - Biochemistry : Glucose, K, Na, etc

VII. ARTHROSCOPY Indication: - Diagnostic - Therapeutic Technique: • By a rigid telescope fitted with fibreoptic illumination. • Tube diameter : - 2 mm (small joints) - 4 – 5 mm (big joint) • Carried out under general anaesthesia, guided by image. • The joints is distended with fluid (paraffin fluid, Nacl, Rl) • Use various instruments (probes, curettes, forceps)

Complications: • Haemarthrosis • Thrombophlebitis • Infection • Joint stiffness

933rd EDITION by Anika A Alhambra VIII. ELECTRODIAGNOSIS Electro diagnostic testing is an objective method to assess for neurogenic lesion. The goal: to identify and ultimately localize the neurogenic lesions (demyelination Or axonal loss ) Note: Clinical expression of peripheral nerve dysfunctional: - Muscle atrophy - paresthesia - Muscle weakness - pain - Sensory loss - dysesthesia

A. ELECTROMYOGRAPHY (EMG) A diagnostic procedure is used to record motor unit activity at rest and when attempts are made to contract the muscle. - At rest: normally there is no electrical activity - On voluntary contraction: determined of: number, shape, amplitude, and duration of the muscle – action potential

The EMG examination parameter for diagnosis include: 1. Insertional activity: decrease / normal / increase 2. Spontaneous activity: * Fibrillation, positive sharp wave; means denervation * Fasciculation Î - anterior horn cell disease (ALS) - Radiculopathy - Nerve entrapment - Cervical Spondylitis myelopathy - Metabolic disease: tetany, thyrotoxicosis, and anticholinesterase intox * Complex retetttive discharge: Muscular dystrophia, myositis, chronic denervating, polyneuropathy 3. Motor unit morphology 4. Interference pattern

Can to distinguish: * Myopathy : small action – potential on contractions, silent / increase spontaneous activity at rest. Both amplitudo and duration are diminished.

* Neuropathy : no action – potential on contraction, fibrillations and positive sharp waves at rest. Both amplitudo and duration are increased (Earliest sign usually after 4 weeks)

943rd EDITION by Anika A Alhambra B. NERVE CONDUCTION STUDIES A diagnostic procedure to determine the nerve conduction velocity. Normally: about 40 – 60 m/s Nerve impulse are stimulated & recorded by electronic surface electrodes. Latency is the time between the onset of the stimulus and response Note: - Neuropathy : latency increase Î conduction N / ↓ - Myopathy: latency / conduction normal - Anterior horn cell disease: latency / conduction normal - Neuropraxia : Pox to lesionÆabsent, Distal to lesion Æ N

C. SOMATOSENSORY EVOKED POTENTIALS (SSEP) A diagnostic procedure by measuring sensory nerve conduction velocity. The response can be electrodes placed on the spinal cord, on the skin over one of the vertebrae on the scalp over the cerebral cortex.

SEP technique has the advantage in evaluating: * Proximal neuropathies: GBS, CIDP (Chronic inflammatory Demyelinating Polyneuropathy, Brachial & Lumbosacralplexopathy * Proximal sciatic nerve lesions * Thoracic outlet syndrome * Cervical Spondylitis myelopathy Disadvantage Î can be used for identified level of radiculopathy

IX. BIOPSY The goal of biopsy is to confirm the diagnosis by histological examination. Divided : - Open Biopsy - Close biopsy: - Core Needle biopsy - FNAB Technique of open biopsy : - Done in operating theatre with GA - Incision longitudinal, located in line with operation plan - Don’t use tourniquet - Make a little window by curretaged at metaphysic area - Take a viable tissue, don’t the necrotic area - Good hemostasis - Avoid: neurovascular structure, through more one compartment, Codman triangle, post radiation area, drainage. - Close the wound with edge uninterrupted suture.

953rd EDITION by Anika A Alhambra Advantage of close biopsy: - Less of contamination - Less risk of infection & fracture - Relative cheaper - Able perform in difficult and deep location (use imaging guide) - Radiation can be perform early after FNA

Note: Specimen must be sent immediately without any fixation

963rd EDITION by Anika A Alhambra REHABILITATION

I. DEFINITION A. Rehabilitation: • The restoration of an individual handicapped to the fullest physical, mental, social, vocational and economic, which he or she was capable. • The process of restoring a persons ability to live and work as normally as possible after a disabling injury or illness

B. Impairment : Any loss or abnormality of anatomical structure physiological or psychological of function

C. Disability : Any lack or restriction as the result of the impairment of ability to perform an activity as abnormal function

D. Handicap : A disadvantage for a specific individual as the result of an impairment or a disability that limit the achievement of a role that is normal milieu (depend on the environment)

E. Orthotics : A device applied externally to the patients’ body used to supporting, correcting, protecting or compensating for an anatomical deformity or weakness of the body part.

F. Prosthesis : A device used to replace a missing part of the body

Note: Used of a splint / appliances / device: 1. To provide immobilization and local rest 2. To provide fixed traction (Thomas splint) 3. To prevent deformity / retain correction / correct mild deformity 4. To stabilize joints and to protect weak muscle 5. To maintain extension (spine, hip, knee)

973rd EDITION by Anika A Alhambra II. ORTHOTIC and PROSTHETIC A. According the law / dictum: OP must be prescribed properly, it must be rationally. * Appropriate indication * Appropriate patients * Appropriate device * Appropriate dose * Beware of adverse reactions

B. Conditions for Prescription: ♥ Material: strong, light, durable, available and non traumatic * Metals : iron, duralumin ( aluminum and steel ) * Non metals : leather, rubber, wood, foam, plastic, polypropylene ♥ Easy for maintenance ♥ Accepted by the patients / community ♥ Technology, which we have: low, medium, high ♥ Price

C. Purpose of OP : ♣ Protection / immobilization: fracture, RA ♣ Correction (by three point compression / pressure ) : CTEV, Scoliosis ♣ Supportive / Stabilization: paresis / paralysis, Myopathy ♣ Motorization / Functional: drop foot ♣ Substitution: after amputation

D. How to prescription ? Consist of : ♥ The name of device ♥ Specification in detail

Steps / Stages of make a prosthesis : A. Pre Surgical Stage. ♠ Explanation about: ♦ INFORMED CONCERN ♦ Phantom limb/sensation ♦ Phantom pain (immature psychology) ♦ Kind of amputation ♦ Stump amputation ♠ Strengthened the upper-ext muscle for preparing mobilization with crutch. 983rd EDITION by Anika A Alhambra B. Post Surgical Stage. Ω Temporary prosthesis ( Pillon Leg ) ω Immediate after surgery (in the Op Theatre) ω For proprioceptive sense Ω Pre prosthetic phase ω Shaping of the stump, with proper bandaging ω Exercise all of the important muscle. ω Exercise the entire joint to prevent contacture Ω Prosthetic phase ( Fabricating of prosthesis ) ω Measurement and making negative model with plaster cast. ω Making the positive model. ω Fabrication of the soft insert (leather, rubber, polyethylene foam). ω Making a socket system ω Make alignment with BK adjustable shank ω Shaping and finishing Ω Post prosthetic phase ω Initial checkout ω OP training ω Final checkout and evaluation ω Vocational training ω Placement

III. ORTHOSIS Upper extremity : ∝ Very complicated, because to promote the function of the hand ( grasping, pinching, hooking ) ∝ Divided in static and dynamic. ∝ Principle : Φ Place the wrist joint in appropriate position ( 450 dorsoflexion ) Φ Flexion MCP and PIP joint Φ Apposition of the thumb with II and III Exp : “ Knuckle bender “ use for loss of ulnar and medianus nerve, ( intrinsic muscle palsy intrinsic minus )

Note : intrinsic muscle : 14 1/2 ( 3/4 ) innervated by ulnar 4 1/2 ( 1/4 ) innervated by median ∞ 2 lumbrical : index & middle ∞ 2 1/2 thenar : 993rd EDITION by Anika A Alhambra ∝ Abductor pollicis brevis ∝ Opponens pollicis ∝ Flexor pollicis brevis ( superficial head )

Lower Extremity : For support the body and ambulation not so complicated 1. Anatomy of the SHOE - Sole - shank - heel - Counter - toe box - quarter - Vamp - hole - throat and tongue - Closer system Purpose of the shoes : - to protect ( strong counter ) - to correct ( promote normal gait ) Depend to purposes : * short quarter : oxford type * high quarter : cover the malleoli * very high : lars 2. Anatomy of AFO Î Control alignment and motions of the foot & ankle joint. ♦ Shoe / foot attachment, consist of: - shoe insert - Caliper - Stirrup ♦ Ankle joint mechanism: - ankle joint - Ankle stop ( plantar or dorsal stop ) - Correction T strap ( valgus / varus ) ♦ Calf band ♦ Up right ( single / double )

3. Anatomy of KAFO. ► AFO ► Knee joint mechanism ■ Single axis ■ Extension stopÆ * Drop ring lock * Adjustable lock * Pawi lock ■ Correction strap ■ Kneecap ■ Thigh band ■ Upright : single / double

1003rd EDITION by Anika A Alhambra 4. Anatomy of HKAFO ∆ KAFO ∆ Hip joint mechanismÆ  Single axis with hyperextension stop  Double axis ∆ Pelvic bandÆ ♥ unilateral ♥ bilateral ♥ pelvic girdle ( double pelvic bands )

Spine : 1. Cervical collar : ♥ Soft : ↔ no correction , just reminding ↔ for minor injury. ♥ Semi rigid : Thomas cervical collar Îsome protection for flexion /ext/lateral but NO rotation ♥ Rigid : two/three/ four poster SOMI ( Sternal Occipital Mandibular Immobilization ) Philadelphia brace 2. SIO ( Sacro llilac orthosis ) Î To stabilize SIJ in Ankylosing Spondylitis or Sacroilliitis.

3. LSO ( Lumbo Sacral Orthosis ) Î ‘ Knight brace ‘ ----> for FEL control

4. TLSO ( Thoraco Lumbo Sacral Orthosis ) General anatomy , consist of : - pelvic band - thoracic band - abdominal support - up right (anterior / posterior / lateral) ♣ ‘ Jewet Brace ‘ Î for F control ♣ ‘ Taylor Brace ‘ Î for FER control ♣ ‘ Knight Taylor Brace ‘ Î for FEL control ♣ Combined Î for FELR control ♣ ‘ Boston Brace ‘ Îfor scoliosis, apex bellow Vth IX

5. CTLSO ( Cervico Thoraco Lumbo Sacral Orthosis ) ♦‘ Milwaukee Brace ‘ Indication : Scoliosis , apex above Vth IX Resist : FE some L no R Correction pad is on the just bellow the apex To be used 23 hours, every day until bone mature 1013rd EDITION by Anika A Alhambra Most routinely exercise in side the brace ( day time ) - Ask the patient avoid the pressure of the pad Just only some correction to the curve Need ADF Ex ( Alongation Derotation Flexion Exercise ) KLEP Ex

Special Orthosis : 1. Dennis Brown Splint Indc : angular & rotation deformity : CTEV, pronated foot, abnormal tibia torsion. 2. A-framed orthosis 3. Torsion shaft orthosis, for : - mild scissor gait - Spastic hemiplegia - abn toe in / toe out 4. Von Rossen Splint 5. Palvik Harness 6. Ilfeld splint 7. Scottish – Rite orthosis, Toronto orthosis, Trilateral orthosis for LCP 8. Severe paralytic disorder, used : - DHJ ( Detachable Hip Joint ) - Standing frame orthosis - Parapodium - Reciprocation Gait orthosis

IV. PROSTHESIS ♣ Upper Extremity: Î Elections depend on functional or cosmetic reason. ♣ Functionally but cosmetic is bad: hook prosthesis * Voluntary closing, by APRL (Army Prosthesis Research Lab) * Voluntary opening, by DORRANCE ♣ Cosmetic good but functional is bad (semi mobile). ♣ The latest generation is ‘ myoellectric – hand ‘ ÎElectrode influenced with bio – feedback through the oscilloscope in the scene.

♣ Lower Extremity . to support the body weight and mobilization. ♥ FOOT # Non articulated : - SACH ( Solid Ankle Cushioned Heel ) The cushioned replace the ankle joint by altering the body weight - SAFE ( Stationary Attachment & Flexible Endoskeleton ) 1023rd EDITION by Anika A Alhambra - STEN ( Stored Energy ) - Seattle foot - Special : Jaipoor - foot # Articulated : Single axis or double axis

♥ Anatomy of BK Prosthesis. - FA - assembly - Shank : ♥ Endoskeleteal ( metal or plastic tube ) ♥ Exoskeletal ( plastic foam ) - Socket : containment of the stump & transmission of body weight PTB socket = “muenster socket” in LE prosthesis Î hard on ISNY ( Icelandic Swedish New York ) - Suspension : ♥ Cuff system ♥ Supracondylar system ♥ Supracondylar / Supracondylar system ♥ With tight corset

♥ Anatomy of AK Prosthesis. ♥ FA - Assembly ♥ Shank ♥ Knee – Ass : * axis : singe or polycentric * extension stop : internal or external aid * knee block * friction device : - Sliding system : constant / variable - Fluid control : hydraulic / pneumatic ♥ Thigh piece ♥ Socket : ♦ Quadrilateral ♦ Ischial containment ♥ Suspension device Î suction alone (negative pressure) partial suction + silessian bandage no suction ( using pelvic belt )

♦ SYME prosthesis (James Syme) The kinds : •OSP ( Original Syme Prosthesis ) •CSP ( Canadian Syme Prosthesis ) •VAPC Syme Prosthesis ( Veterans Administration Prosthetics Center )

1033rd EDITION by Anika A Alhambra ♦ STUBBY prosthesis Î for bilateral above knee amputee

♥ Hip Disarticulation Prosthesis Î “ Canadian hip disarticulation type “ • Characteristics: • Socket design Î to provide total contact * Basic socket: extensive socket waistband * Diagonal socket * Hemipelvictomy socket • Added with: * Hip extension stop * Stride – length control strap

V. WALKING APPARATUS CRUTCH Handgrip on the level of major throchanter Elbow mild flexion ( 300 ) Axillary pad : 2 – 3 finger-breadth below axillary fold Long Î 15 cm lateral of the foot 10 cm in front of the foot Kind of walking : two point gait three point gait four point gait swing to swing through ( the pathologic level not higher than V th XII )

1043rd EDITION by Anika A Alhambra MACAM – MACAM 4 R Î Recognition 5 R Î Receive Reduction Review Retain Revive Rehabilitation Re-Review – Revive Rehabilitation

Bryant triangle Î fracture femur proximal

MPS

PROPORTIONATE Diastrophic dysplasia Cleidocranial dysplasia

SHORT STATURE (DWARFISM) Short trunk Î spondyloepiphyseal dysplasia DISPROPOTIONATE Rhizomelic Æ Achondroplasia Short limb Mesomelic Acromelic

1053rd EDITION by Anika A Alhambra ORTHOSIS

1063rd EDITION by Anika A Alhambra

1073rd EDITION by Anika A Alhambra

1083rd EDITION by Anika A Alhambra PROTHESE

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1123rd EDITION by Anika A Alhambra

EMERGENCY ORTHOPAEDICS THE SPINE

Actual injury to the cord resulting in neurologic dysfunction rarely occurs from transection. The cord and tough meninges remain intact. Injury occurs from compression of the cord & disruption of the blood supply. Experimental studies demonstrate that trauma inflicted on spinal cord will produce an initial increase in blood flow that latter falls to 70 to 80% of he pre trauma flow. It is felt that this relative cord ischemia results in neurologic cell death. Although the mechanism for these blood flow changes is unknown, present investigation show release of vasoconstrictive substance and improving mean arterial pressure. Since cell death occurs within 4 hours of the original injury, future hope of reversing permanent neurologic dysfunction will require prompt & definite action on the part of emergency personnel.

¾ The sections of vertebra column that have the greatest mobility are also the areas of most frequent injury ¾ Cervical spine is the most flexible, ___ bounded above by relatively heavy head and below by the more fixed thoracic spinal column Î the most common SCI occurs between C5 – C6, but at this level the spinal canal is 30 % larger than the cord itself ¾ Thoracic spine requires significant force to disrupt or dislocate and if it occur will result thoracic cord injuries that are usually complete & irreversible. ¾ Lumbar spine, ______the canal is relatively large and the spinal cord narrows & end opposite the L2 vertebra. The cauda equina loosely fills the reminder of the spinal cord and tolerates compression better than the cord itself. Although T12 to L1 SCI at the interface of the fixed thoracic and more mobile lumbar spine in the 2nd most common injury ___ incomplete lesions of the cord at this level and below are common

Prehospital treatment a Initial scene at scene is crucial Æ primary survey ABCD a Primary importance is an assessment of the scene of the accident to determine the extent of possible further danger to the patient or to the rescuer.Î If the Px/ should be moved, do it w/ extreme care. 1133rd EDITION by Anika A Alhambra a Emergency medical technicians & paramedic should: 1. Assess ABC 2. Assess vital sign 3. Question the px/ w/ regard to pain or numbness 4. Palpate the neck for sign of injury, record any paralysis, motor weakness, or sensory deficit 5. Assess for impaired level of consciousness 6. Check pupil size, equality, and reactivity to light 7. Examine the eyes and ears for sign of injury 8. Palpate the head, arms, legs chest and abdomen for injuries a Respiratory insufficiency should be expected in the px/ w/ CCI Î The C4 LEVEL, n. PHRENICUS innervated the diaphragm, injured at this level will result hypoventilation due to paralyses of the intercostals muscles Æ abdominal breathing. CCI above C4 will cause complete respiratory paralysis Æ ventilator a Hypotensive ÆHypovolemic shock : rapid heart rate and cool & clammy skin a Hypotensive ÆSC shock : Loss of sympathetic nerve function (vasodilatation, vascular collapse which will lead to hypotension, but w/ a normal or slow heart rate and the skin warm & dry) a Î 2 large IV line & MAST

Fractures, Dislocations & Subluxations CLASSIFICATION

1143rd EDITION by Anika A Alhambra

1153rd EDITION by Anika A Alhambra

STABILITY Suspicion of rupture of transverse ligament CI doing flexion-extension views. PX w/ greater than 3 to 5 mm separation between the dens and the anterior ring of the atlas should be suspect of a transverse rupture until proven otherwise.

Clinical instability Æ the loss of the ability of spine under physiologic loads to maintain relationships between in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve roots, and in addition, no development of deformity w/ excessive pain a Upper Cervical Spine o Fracture of the ring atlas C1 can be stable or unstable depend on the integrity of transverse ligament & alar ligament o RÖ: open mouth view Î simple Displacement of the lateral masses fr. C1 will exhibit minimal lateral displacement of the lateral mass o Displacement of the lateral masses of the atlas ƒ Displacement of the lateral masses overriding C2 < 5,7 mm: indicate that the transverse ligament is intact ƒ > 7 mm is evidence of a ruptured transverse ligament. o Unstable injury: allowing odontoid process to compress the cord and cause neurologic damage, Fr. Base Prc. Odontoid o Atlantoaxial instability occurs w/ rupture of the transverse lig. alone Æ can be detected w/ lateral cervical spine film. ƒ Normal distance between dens & the anterior ring of the atlas should between 0 –3 mm ƒ 3 – 5 mm : suggest rupture of the transverse lig. ƒ > 5 mm : strongly suggest rupture of the transverse & alar lig. 1163rd EDITION by Anika A Alhambra o Traumatic spondylolisthesis of the axis (hangman’s fr) is manifested by a fr. Through the posterior arch

a Lower Cervical Spine ƒ Instability should be suspected when there is > 3,5 mm distance between the adjacent vertebral bodies ƒ Instability should be suspected when angular measurement between vertebra is > 11º ƒ Injury to both anterior & posterior elements should be presumed unstable

Excessive angulations of the cervical spine

ƒ Instability in the lower spine, faced w/ an overriding vertebraÆ measurement between the posterior – inferior corner of the upper vertebral body and posterior – superior corner of the inferior vertebral body should < 3,5 mm ƒ > 3,5 cm Æ suspect instability ƒ > 7mm Æ bilateral faced dislocation 1173rd EDITION by Anika A Alhambra

ƒ Overriding of the superior vertebral body by a distance equal to or > ½ of its AP diameter ƒ If no associated neurologic damageÆ under supervise do flexion-extension views to assess instability

NEUROLOGIC INJURY

TREATMENT

1183rd EDITION by Anika A Alhambra FLEXION

1. Hyperflexion Sprain Stable Injury

2. Simple wedge (Compression) fracture Potentially Unstable injury

3. Clay – Shoveler Fracture Stable Injury

4. Bilateral Facet Dislocation Very Unstable Injury

1193rd EDITION by Anika A Alhambra

5. Flexion Teardrop Fracture Extremely Unstable Injury

FLEXION – ROTATION Unilateral Facet Dislocation Generally Stable Injury ______Potentially Unstable if Chronic

1203rd EDITION by Anika A Alhambra EXTENSION – ROTATION Pillar Fracture

VERTICAL COMPRESSION 1. Jefferson Burst Fracture Stable, Rarely Unstable Injury

2. Burst Fracture Potentially Unstable Injury

1213rd EDITION by Anika A Alhambra EXTENSION 1. Hyperextension Sprain Stable, Potentially Unstable Injury

2. Avulsion of the Anterior Arch of the Atlas Potentially Unstable Injury

3. Extension Teardrop Fracture of the Axis Potentially Unstable Injury

1223rd EDITION by Anika A Alhambra 4. Fracture of the Posterior Arch of the Atlas Stable Injury

5. Laminar Fracture Stable Injury

6. Traumatic Spondylolisthesis of the Axis (Hangman’s Fracture) Potentially Unstable Injury

1233rd EDITION by Anika A Alhambra 7. Hyperextension Fracture – Dislocation Unstable Injury

LATERAL FLEXION Uncinate Process Fracture Stable Injury

DIVERSE MECHANISMS 1. Atlanto – Occipital Disruption Extremely Unstable Injury

2. Atlanto Disruption, C1 and C2 Potentially Unstable Injury

1243rd EDITION by Anika A Alhambra 3. Odontoid Fracture Potentially Unstable Injury

PEDIATRIC CERVICAL SPINE

1253rd EDITION by Anika A Alhambra

1263rd EDITION by Anika A Alhambra

1273rd EDITION by Anika A Alhambra

1283rd EDITION by Anika A Alhambra

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1303rd EDITION by Anika A Alhambra

1313rd EDITION by Anika A Alhambra Fractures, Dislocations & Major Ligamentous Injuries of the Back

FLEXION 1. Pure Flexion Stable Injury a. Anterior Wedge Fracture

2. Flexion with Rotation Unstable Injury a. “Slice Fracture”

b. Fracture – dislocation through disc

c. Posterior ligamentous disruption wo/ wedge fracture

d. Posterior ligamentous disruption w/ wedge fracture

1323rd EDITION by Anika A Alhambra DISTRACTION (TENSION) Unstable Injury a. “CHANCE” Fracture b. Ligamentous Disruption c. Ligamentous Disruption With Posterior and/or Element Fracture

1333rd EDITION by Anika A Alhambra AXIAL LOAD 1. Pure Axial Load Unstable Injury a. Burst Fracture wo/ Posterior Element b. Burst Fracture w/ Posterior Element

2. Axial load w/ Rotation Unstable Injury a. Sagital Slice Fracture

1343rd EDITION by Anika A Alhambra EXTENSION Unstable Injury Extension Injury

SHEARING Type A Shear Fracture

Type B Shear Fracture

Type C Shear Dislocation

1353rd EDITION by Anika A Alhambra LATERAL BENDING Pure Lateral Bending Stable Injury a. Lateral Wedge Fracture

Lateral Bending w/ Axial Load Unstable Injury a. Lateral Burst Fracture

MINOR FRACTURES

PENETRATING INJURY

1363rd EDITION by Anika A Alhambra

TYPES OF SYMES PROSTHESES

A. CANADIAN SYME PROSTHESIS

B. REMOVABLE-WINDOW DESIGN

C. FLEXIBLE POSTERIOR BUID-UP PROSTHESIS

1373rd EDITION by Anika A Alhambra

FOOT – ANKLE ASSEMBLY FOR LOWER LIMB PROSTHESES

A – B Î Nonenergy storing nonarticulated prosthetic feet A. SACH Æ Solid Ankle Cushion Heel B. SAFE Æ Stationary Attachment Flexible Endoskeleton foot

C – H Î Energy storing nonarticulated prosthetic feet C. Seattle foot D. STEN Æ STored ENergy E. Carbon copy II foot

F. Quantum modular foot G. Flex – foot H. Flex - walk

1383rd EDITION by Anika A Alhambra

I – J Î Articulated prosthetic feet I. Single – axis prosthetic foot J. Multiple – axis prosthetic foot

1393rd EDITION by Anika A Alhambra ENDO- VS EXOSKELETAL LOWER LIMB PROSTHESIS A. Endoskeletal transtibial prosrhesis

B. Exoskeletal transtibial prosthesis

C. Endoskeletal transfemoral prosthesis (covered w/ soft rubber foam)

D. Exoskeletal transfemoral prosthesis

1403rd EDITION by Anika A Alhambra TRANSTIBIAL SOCKET

A. Patellar tendon-bearing ( PTB ) socket

B. Icelandic – Swedish – New York University ( ISNY )

Pressure tolerant (A – C) & Pressure relief (D – F) areas in PTB socket 1413rd EDITION by Anika A Alhambra

1423rd EDITION by Anika A Alhambra Narrow mediolateral (narrow ML) or Ischial Containment (IC) socket a Mediolateral dimension narrower than AP measurement a The ischial tuberosity (which lies lies outside the socket in the quadrilateral design) is contained within narrow ML/IC socket a Weight bearing Î focused primarily through the medial aspect of the ischium and the ischial ramus instead of the ischial tuberosity a The ischial tuberosity is locked in the socket and resulting “bony block” between ischium, trochanter, and lateral distal aspect of the femur gives more stable mechanism for acceptance of perineal biomechanical forces Î thus providing increased comfort in the groin and better control of pelvis and trunk. a The narrow ML design is intended to maintain the femur in adduction although this may not always be feasible if the amputae has uncorrectable deformity because of poor surgical technique Î by keeping the femur in relative adduction during the stance phase, the hip abductors are kept more stretched and efficient position. a The narrow ML socket can decrease NV bundle compression and can be fitted to short residual limb Î more expensive difficult to fabricate than Quadrilateral socket Transfemoral socket A & B Æ Quadrilateral transfemoral socket

A B

C & D Æ Ischial containment or Narrow ML transfemoral socket The ischial containment socket has bony block

C D

1433rd EDITION by Anika A Alhambra

ELECTIVE CASES 1443rd EDITION by Anika A Alhambra THORACOLUMBAR FRACTURES FRACTURE CONFERENCE OCTOBER 31, 1990 JOSEPH B. SCARCELLA, M.D

I. ANATOMY, THORACOLUMBAR SPINE

A. Posterior of vertebral body with attached posterior bony complex ( attached via pedicles ) is the border of vertebral canal

B. Can be arranged in a column type fashion

C. Holdsworth proposed 2 column theory :

Anterior - body and disc Posterior - posterior bone - ligamentous complex

Rupture of posterior column created instability.

D. Denis proposes 3 column :

Anterior - anterior longitudinal ligament - anterior one half of body and annulus fibrosis

Middle - posterior longitudinal ligament, posterior one half of annulus and body posterior bone / ligamentous complex

Rupture of 2 or 3 creates instability.

II. FRACTURE CLASSIFICATION

A. Minor - articular process fractures transverse process fractures spinous process fractures pars interarticularis fractures

B. Major

1. Compression fractures ( anterior or lateral ) 1453rd EDITION by Anika A Alhambra

- failure under compression - anterior end plate most often involved - L-1 most common

Radiographic sign : - posterior height unchanged - posterior cortex intact - no subluxation of bodies - interspinous distances increased - CT scan shows middle and posterior columns intact

2. Burst

- failure under axial load of interior and middle columns - can also affect posterior column Radiographic signs : - lateral film shows fracture of posterior wall of body, loss of posterior height tilting and retropulsion of bone fragments - AP shows increase in interpedicular distance may have vertical lamina fracture with splaying of posterior joints - CT characteristic break in posterior wall with expulsion of fragment into joints

Five sub types : - Fracture both end plates - Fracture superior end plates ( most common ) - Fracture inferior end plate - burst rotation - burst lateral flexion

3. Seat Belt Type

- failure of posterior and middle columns by tension

Radiographic signs : - increase interspinous distance - horizontal split transverse process - horizontal split pedicles 1463rd EDITION by Anika A Alhambra - pars fracture - tomos are best to delineate

4. Fracture Dislocation

- failure of all columns under tension, rotation compression or shear

Three sub types :

- Flexion rotation most common - posterior and middle column fail under tension and rotation - anterior fails under compression and rotation

- Shear type - all columns distrupted including A.L.L.

- Fracture dislocation of flexion distraction type - similar to seat belt type but annulus is also completely ruptured - A.L.L. is intact but stripped

III. ASSOCIATION WITH NEUROLOGIC IMPAIRMENT

Compression type - no association

Seat belt type - no association

Burst - 53% no neurological sequelae ; 47% partial impairment

Fracture dislocation rotation - 52% complete, 25% intact

Fracture dislocation shear - all complete

Fracture dislocation distraction - 3/4 were incomplete IV. TREATMENT

A. Denis - Three degrees of instability

1473rd EDITION by Anika A Alhambra 1. First degree ( mechanical instability ) - compression and seat belt fractures - neural elements not acutely threatened - nonoperative

2. Second degree ( neurological instability ) - burst fractures despite initial presentation are at risk - treatment still controversial

3. Third degree ( first and second ) - fracture - dislocation - burst with neurological injury - needs decompression and stabilization

B. Operative Options :

- laminectomy with “ posterior decompression “ does not address anterior component of injury

- posterior instrumentation with fusion without anterior decompression has no improvement in neurological function compared to nonoperative reduction and external support

- anterior decompression has shown improvement in ultimate neurological functioning

PATELLA FRACTURES

FRACTURES CONFERENCE FEBRUARY 13, 1991

I. General :

- Patella fractures constitute about 1% of all skeletal injuries - Mean age is reported between 40 and 50 years of age

II. Function :

- to increase the mechanical advantage of the quadriceps tendon 1483rd EDITION by Anika A Alhambra - to aid in nourishment of the articular cartilage of the femur - to protect the femoral condyless from injury

III. Anatomy :

- The patella is the largest sesamoid bone in the body - It lies within the quadriceps tendon - The ossification center usually appears at age 2 –3 - An anomaly of ossification can occur and when it does, it usually is supero – lateral bipartite patella - Superior border receives the rectus femoris, vastus medialis, vastus lateralis and vastus intermedius - The apex of the patella is directed distally and provides the origin of the patellar tendon - A thin layer of quad tendon passes anteriorly to the surface of the patella and joins the patellar tendon distally - With the knee extended, the lower portion of the cartilaginous surface articulates with the interior surface of the femoral condyles - With increase in flexion, lst the middle then upper portion comes in contact with the femur - There are 7 articular facets with a longitudinal ridge dividing the patella into medial and lateral. There are then the upper, middle and lower facets. The 7th is a thin longitudinal strip in the medial aspect of the patella - The medial and lateral retinaculum insert directly into upper tibia and are fibers of the vastus medialis litelilis, and fascia lata that bypass the patella - Patellar plexus : branches of superior, medial, inferior genicular arteries. The 10 blood supply enters the patella centrally and distally and thus transverse fractures may lead to AVN of proximal pole.

IV. Mechanism of Injury - Indirect : this occurs when the intrinsic strenght is exceeded by the pull of the musculotendinous units attaching to it. ( typically occurs with stumbling ) falling usually follows with tearing of the retinacula as the quadriceps continues to pull. - Direct : e.g. striking a dashboard 1493rd EDITION by Anika A Alhambra - These fractures are stellate, in complete or undisplaced as retinaculum usually doesn’t tear. ( maybe able to extend againts gravity )

V. Classification : 50 – 80% transverse or oblique 30 – 35% stellate or comminuted 12 – 27% longitudinal

VI. Signs and Symptoms : diagnosis made by hx, P.E. and confirmed with X – ray - palpable defect may be present - hemarthrosis - presence or absense of active extension

VII. Radiography : AP & Lateral views. - laminograms may be helpful - skyline or axial view if AP and lateral don’t slow the fracture

VIII. Treatment : Goal : To restore quadriceps mechanism to provide strenght and function to knee.

Historically : 1) up until 1870 ‘s – splint extremity with hip flexed and knee extended, Fibrous union resulted with some degree of disability. 2) Loops of metal or leather to hold fragments together 3) 1877, sir Hector Cameron og Glasgow Scotland performed the 1 st open reduction by inserting silver thread through drill holes 4) Late 1800’s early 1900’s cerclage wiring and wiring through longitudinal holes became popular 5) 1935 Thompson introduced partial patellectomy

Current Concepts : 1) Nonoperative treatment : Recommended for nondisplanced fracture with preserved extensor mechanism and minimal disruption of articular surface (2 – 4 mm) Cylinder cast 4 – 6 weeks. Straight leg raising to begin 2 days post injury 1503rd EDITION by Anika A Alhambra 2) Operative treatment : Recommended for fracture separation >4mm, comminuted fractures with displaced articular surface, osteochondral fractures with displacement into the joint, longitudinal fractures with displacement. a) Cerclage b) hemicerclage c) wire through drill holes d) screw fixation e) tension band wiring f) partial or complete patellectomy

The principal of tension band wiring for transverse fractures involves placing wires anteriorly ( tension side ) through insertions of quadriceps and patellar tendons. The gap that exists posteriorly will close down by compressive forces of quadriceps. 3) jhjj

IX. Prognosis : - Full flexion usually returns except in total patellectomy - extensor leg may be present - full function of knee after fracture should occur within 6 – 12 months - post traumatic arthritis may occur - weakness climbing stairs, walking downhill, and kneeling - refracture incidence 1 – 5% - AVN is rare ( radiographically seen 1 – 2 months post fracture and generally revascularizes within 2 years ) 1513rd EDITION by Anika A Alhambra EXTENSOR MECHANISM RUPTURE OF THE KNEE Barry Cromer M.D.

I. Quadriceps tendon rupture A. Occurrence 1. Age – 90% . 40 Y/o a) Peak age : 60 – 70 Y/o b) bilateral rupture : > 70 Y/o 2. Predisposing factors a) obesity, gout, hyperparathyroid, DM, syphylis, nephritis, arterioscerosis b) Bx local degenerative changes 3. Mechanism = sudden forceful contracture of quads with knee in semi – flexed position ; direct trauma 4. Location a) most common @ central portion of tendon, @ superior pole of patella b) may be 4 – 5 cm proximal to patella c) aponeurotic expansions of vastus medialis and vastis leteralis may not be involved = partial rupture B. Diagnosis 1. Symptoms = inability to extend @ knee with minimal suprapatellar pain or tenderness 2. Complete disruption a) profuse hemarthrosis secondary to tearing of synovial lining in suprapatellar pouch; subcutaneous extension of hematoma into rupture b) patellar easily mobile ; patella baja c) x – ray: bilateral knees show patella baja d) quad deformity = with active contraction of quad a bulge proximal to rupture and a void area @ rupture site ; hematoma may obscure bulge acutely 3. Incomplete rupture a) display weakness of incomplete extension of leg b) palpable continuity of fibers without rigidity of proximal muscle mass with medial and lateral margins of quad tendon c) less patellar freedom d) may not develop hemarthrosis 1523rd EDITION by Anika A Alhambra C. Surgical indication D. Late repair ( > 2 wks ) 1. direct reopposition if contracture < 5cm a) reapproximate b) Scuderi flap c) retention bands with iliobital tract fascia or dacron tape = reinforce from base of scuderi flap through drill holes across proximal patella 2. Codivilla technique - > 5cm gap

3. Anterior hamstring transfer a) indicated for elderly or debilitated pt.

E. Post – operative management 1. cylinder cast with drop lock joint or bledsoe brace 2. WBAT in full extension 3. passive ROM after 1 wk 4. active assist ROM after 3 wks 1533rd EDITION by Anika A Alhambra F. Results 1. acute repair – excellent in majority 2. late repair – lack FROM

TIBIAL NON-UNION

September 12, 1990 FRACTURE CONFERENCE C. Callewart

DEFENITION :

Non – union = failure to unite after 8 months or failure to progress tward union after a prolonged period of time.

Delayed Union = failure tu unite after 20 – 26 weeks

CLASSIFICATION :

Hypertrophic - good blood supply, abundant callus, good healing potential Atrophic - poor vascularity, little callus, minimal healing potential

Serial radiographs, bone scan used to differentiate

Initial Management and Evaluation Fracture Conf. of July 18, 1990 Cervical Spine Injuries B. Brackett, MD

Approximately 8000 to 10.000 acute cervical spine injuries are sustained each year. Of all spinal cord injuries, 82% affects males ; 66% of these injuries involve patients 30 years of age or younger. MVAs, falls, sports, and violence account for almost all cases of spinal injury. Quadriplegia is the outcome in greater than 50% of spinal injuries. C4, C5 and C6 are the most commonly involved sites.

ATLS protocol – ABCs. “ AMPLE “ history – Allergies, Medications, Past illnesses, Last meal, Event preceding injury. 1543rd EDITION by Anika A Alhambra

History Mechanism of injury Sensory and motor deficits, pain and its radiation. High velocity. Windshield injury, hx of transient paralysis.

Physical Exam – Facial / head trauma. Voluntary movementof the extremities. Cervical rigidity. The spine should be immobilized during this exam. Perianal sensation.

Neurological Exam – A brief motor / sensory exam will help isolate the level of the injury Radiographic Examination – Cross – table lateral with the collar in place should be the initial evaluation. If one was suspicious enough to obtain a lateral, AP and adontoid views should be obtained.

Chech list for the lateral C – spine : 1. A smooth line should be able to be drawn along the anterior / posterior vertebra body border. A 0 to 3.5 mm anterior subluxation may be normal (Fig. 1). Soft tissue swelling is an important indication of an occult fracture. The retropharyngeal space at C3 should be no greater than 3mm and no greater than 5 – 6mm at C6. 2.

CALCANEUS FRACTURES

8 / 8 / 90 Fracture Conference Callewart

ANATOMY

Identify : - Anterior 1/2 articular, posterior Achilles insertion - Medial and lateral processes on plantar surface - Sustentaculum tali, 3 facets, interosseous ligament - Tarsal sinus, canal - Flat lateral surface, peroneal groove, tarsal sinus - Medial concavity, T.A. , FDL, FHL grooves - Radiographically - - - - thalmic portion, Critical angle of posterior facet, Crucial angle of Gissane, Bohler angle 25 – 400 1553rd EDITION by Anika A Alhambra

MECHANISM

Falls from height, causing talus to wedge into calcaneus and / or avulsion of tubercle from posterior 1/2. 5% - 10% bilateral, 10% assoc with D/L spine compression fractures, 25% - 50% assoc with other L.E. fractures.

CLASSIFICATION (Essex - Lopresti )

Extra – articular 25% - subtypes : anterior process tuberosity medial process, sustentaculum

Intra – articular 75% - subtypes : Tongue joint depression comminuted

FADIOGRAOHIC FINDINGS

1563rd EDITION by Anika A Alhambra

EXTRA – ARTICULAR

Most can be treated closed, compressive dressing & elevation for 720, followed by 6 wks. NWB ambulation in plaster. Essex – Lopresti technique may be helpful ( p. 1730, Chapman )

INTRA – ARTICULAR

Untreated fractures cause a wide hindfoot, inpingement of peroneal tendons, and pain upon ambulation. This is due to limited subtalar motion. Most pronounced on uneven ground.

Indication for surgical treatment is a displaced posterior facet fracture. Generally speaking, anatomic ORIF produces greater motion, active patients. Good results in – 75%