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Orthopedics 1. Systemic diseases of the human skeleton (achondroplasia, osteogenesis imperfecta, arthrogryposis, rachitis)  achondroplasia o mainly metaphyses o AD, hereditary disease o disorder of cartilage growth, absence of chondral growth zone  delayed enchondral ossification  disproportionated nanosomia o fully visible on birth, no progredience o micromelia (short, ungainly extremities), thick corticalis due to normal peri- chondral ossification, trident hand, short neck, big head o delayed growth of the head  deformation with saddle nose o narrow pelvis, lordosis o normal intelligence o complication: zervico-medullar compression due to small foramen magnum, breathing disorders due to adenoid vegetations  osteogenesis imperfecta = brittle bone disease o multiple defects in the synthesis of collagen I o type I  AD, mild disease, blue sclera, dentinogenesis imperfecta, hearing loss o type IIa/b/c  genetically heterogen, lethal, congenital shortening of the long bones due to multiple fracture in utero, pseudomicromelia (buckling of long bones) o type III  mainly AR, severe course, thin, buckled bones o type IV  AD, variable course with or without dentinogenesis imperfecta o decreased function of osteoblasts  rachitis o impaired mineralization of the bone matrix due to lack of calcium and phosphate o lack of vitamin D . usually with small children, but also possible in older children . lack of calciferols . insufficient turn-over (UV light) or insufficient resorption or intake . manifestation during 2nd or 3rd month with restlessness, sweating (especially on the head), glabella on the occipital head, . 3rd or 4th month: muscular hypotension, obstipation, sometimes signs of tetany or seizures . craniotabes (abnormal softening of the skull bones), later caput quadratum . bone deformation on many skeletal sites: usually border between bone and cartilage (rips, metaphyses), pelvis, kyphosis, pectus carinatum, deformation of the lower extremity . TM: oral cholecalciferol o vitamin D resistant rachitis . chronic phosphate diabetes . hyperphosphataemic renal rachitis . no effect of calciferol therapy o renal rachitis . vitamin D resistant . impairment of renal reabsorption of Ca and phosphate in the proximal tubule due to renal acidosis or chronic renal insufficiency

1  arthrogryposis multiplex congenita stiffening of a joint in flexor position, muscle weakness o congenital, non-progredient o joint contracture on vertebral spine and extremity joints o forms . neuropathic . myopathic o either flexion or extension contracture o no skin folds seen over the joints o associated with club-foots, hip dysplasia, malpositions of wrist and fingers, scoliosis from the first year onwards o TM . physiotherapy . arthrolysis . operative treatment 2. Osteoarthritis of the hip joint  radiological signs – 4 stages o I only narrowing of joint space o II subchondral sclerosis, narrowing of the joint space o III osteophytes, pseudocysts, subchondral sclerosis o IV no joint space visible anymore  can be developed by everybody who is old enough  loss of cartilage quality, loss of elasticity, changes in cartilage matrix, free collagen fibers  reactive phenomena of adjacent tissues o bone vascular congestion (bone hypertension) o activity of osteoblasts o cartilage reparation and new bone formation (osteophytes) o worsening of synovial fluid quality o capsular fibrosis  risk factors of OA o systemic . obesity . age . gender . occupation, sports . positive family history . systemic metabolic disorders o local . dysplasia . trauma . chronic inflammation . rheumatoid diseases . chondrocalcinosis . epiphyseolysis capitis femoris . Perthes disease . idiopathic femoral head necrosis  clinical stages: o I pain on massive exercise, muscular contractures o II pain on exercise, contractures, initial pain on motion o III rest pain

2  development of axis deviation, muscular atrophy, instability of joint, up to ankylosis 3. The pathological changes of the locomotion apparatus in rheumatoid diseases and their surgical treatment  axis deformation o rheumatoid arthritis  X o osteoarthritis  O  degenerative vs. inflammatory changes  reactive muscle contractures  pain is projected to an area that is far away from the affected joint  rest pain is due to inflammation of adjacent soft tissue and bone hypertension  deformity o axial deviation o muscle atrophy o instability of joints o spontaneous ankylosis  TM o primary prevention: sports, loss of body weight o secondary prevention: treatment of prearthrotic deformities  4. Lower limb deformities  coxa vara o decrease in CCD angle ( < 120° in adults) o etiology . coxa vara capitalis/epiphysarea/cervicalis/diaphysarea . congenital . acquired  deformity due to exercise  rachitis, achondroplasia, epiphyseolysis capitis femoris, osteomalacia, osteoporosis, inflammation or tumour  misgrowth due to damage of epiphysis  Perthes disease, inflammation, tumour, trauma o clinical features . high-standing of greater trochanter, shortening of affected leg (Trendelenburg sign positive  insufficiency of abductors) . waddling in case of bilateral disease, otherwise claudication . increase in lumbal lordosis o X-ray . increased distance between coxal end of femoral head and acetabulum in newborns o TM . non-op: Thomas Schiene . op: intertrochanteric valgus osteotomy  coxa valga o increase in CCD angle (> 130° in adults, physiologically 150° in newborns) o etiology . congenital . acquired  growing disorders due to muscular disorders (paresis), unilateral shortening of the limb or epiphyseal disorders like inflammation, tumour, injuries  pathologic posture after fracture of femoral neck

3  in congenital hip dislocation in combination with increased antetorsion o clinical features . no symptoms at the beginning, later claudication, pain on exercise, arthrosis o X-ray . a-p with internal rotation (20°) . horizontal epiphysis of femoral head . sometimes subchondral sclerosis of the upper part of the acetabulum o TM . non-op: not possible, except muscle exercise . op: intertrochanteric varus osteotomy, sometimes in combination with derotation o complication . arthrosis  differences in the length of the lower extremities o relative length  o absolute length  o abduction contracture  mimics shortening of contralateral side o adduction contracture  minics shortening of ipsilateral side o TM . osteotomy . soles  protrusio acetabuli o physiologic protrusion  between 6 and 7 years of age o primary protrusion . disorders of growth, ossification, endocrine system . more common in females . first symptom usually decrease in abduction . X-ray: often in combination with coxa vara, femoral head deep in acetabulum, but still central, osteophytes . TM valgus osteotomy o secondary protrusion . osteoporosis, inflammation (tuberculosis, chronic polyarthritis, osteomyelitis), systemic skeletal diseases (e.g. M. Paget), trauma (central hip luxation) . X-ray: signs of underlying disorder . TM: according underlying disorder  congenital knee joint luxation o may present as genu recurvatum, subluxation or luxation o genu recurvatum: congenital hyperextension o subluxation: proximal tibia displaced ventrally against distal femur o luxation: may present as extension, hyperextension, slight flexion o TM: closed reposition as early as possible, cast immobilization in flexion  congenital patella luxation o lateral of lateral femoral condyle o no reposition possible, often associated with genu valgum o TM . Krogius procedure  half-moon shaped part of fibrous capsule laterally around patella

4 . Lanz tendonplastic  tendon of gracilis muscle is sutured on the patella  pulled medially by contraction of muscle .  genu varum (O) o etiology . congenital  physiologic in newborns  weakness of soft tissue  systemic disorders, e.g. dysostoses . acquired  rachitis  inflammation and neoplasia  weakness of lateral collateral ligament due to trauma or effusion o clinical features . objective data: angle between tibia and femur or distance between the inner parts of the knees . in case of unilateral deformity  development of static scoliosis possible . arthritic changes in medial compartment . Mikulicz line o TM . conservative: underlying disease (e.g. rachitis), splint immobilization at night, lateral sole heightening . op: osteotomy (supracondylar/proximal tibia wedge, pendulum)  genu valgum (X) o etiology . congenital  soft tissue disorders/weakness  bony disorders . acquired  rachitis  inflammation, tumour, trauma in the area of the epiphysis  weakness of medial collateral ligament o clinical features . most common malposition of the knee . divergence of the lower leg in closed condyles . often in combination with genu recurvatum and pes valgus . physiological valgus between 2 and 5 years of age . TM  conservative  op:  genu recurvatum o etiology . congenital  congenital knee luxation  constitutional . acquired  overstretching of the posterior part of the capsule and ligaments  trauma  epiphyseal growing disorders due to trauma, inflammation, tumour etc.  contralateral shortening of the limb

5 o clinical features . tibia and femur create an angle that is ventrally directed . pain . pre-arthrotic deformities o TM . non-op: training of flexor muscles, underlying disorders . op: osteotomy, in case of severe deformities  arthrodesis, arthroplasty  plica syndrome o  crus varum o 5. The pathological posture and scoliosis  scoliosis = fixed buckling of the vertebral spine  pathological posture = non-fixed  lateral deviation, but also rotational component due to moving of the vertebral bodies against each other but also due to torsion inside the body  etiology o primary or secondary changes in vertebral bodies, intervertebral discs or joints o 90% are idiopathic  diagnosis is usually made at the age of 10 to 12  clinical features o stages . I low-grade, but fixed buckling with slight torsion, active correction partly possible . II marked scoliosis, either S- or C-shaped, no overhang to one side . III severe scoliosis of the whole vertebral spine, overhang to one side, severe deformation of the thorax . IV severe scoliosis with rips running up into pelvis, alteration of inner organs o measurement of the scoliotic angle . Ferguson  2 neutral vertebral bodies, 2 lines running to peak point, complementary angle . Cobbs  2 neutral vertebral bodies, lines in rectangle position to the roof plates o special pathogenesis of scoliosis . congenital  asymmetrical malformations of the skeleton, e.g. synostoses of the ribs, wedge vertebral bodies  only few progression in life . scoliosis of the newborn  due to contracture  usually C-shaped . idiopathic  > 90% of all scolioses . rachitic . scoliosis of the adolescents . paralytic . reflectory . static  due to unilateral shortened limb, pelvis lop-sided . posttraumatic

6 . cicatricial  TM o swimming o corsets (Milwaukee, Boston-Brace) o operative stiffening  spondylosis o  spondylolisthesis o 6. The non-malignant tumours of the locomotion apparatus  osteoma o Gardner syndrome = polyposis intestinalis III . multiple adenomatous polyps, especially in colon and stomach, osteomas and osteofibromas, especially mandibula, and skin tumours (leiomyomas, atheromas, dermoid cysts, cutaneous fibromas) . AD, but variable penetrance . obligate precancerosis . usually lethal before 40 years of age due to colon carcinoma o very slowly growing tumour o no TM necesssary  osteoid osteoma/osteoblastoma o intracortical/epi-, meta-, apophyseal o nidus < 1cm/> 1cm o sclerotic reaction/osteolytic o night pain, ACP test/independent pain o resection/excochleation o mainly femur and tibia/vertebral spine  enchondroma o chondroma inside a bone o mainly small bones of fingers and feet o mainly diaphyseal, rarely metaphyseal part o multiple manifestation with malignant transformation in (20%) possible o first signs: swelling, pathologic fracture o Ollier´s disease . homolateral dysplasia of the long bones . shortened and deformed extremities, multiple enchondromas, sometimes haemangiomas  generalized enchondromatosis o hereditary disease, starting in the 1st decade o deformation of the extremities with multiple enchondromas, mainly on hands, platyspondyly o unknown aetiology  exostosis (cartilaginea) o MOCE – AD hereditary o malignant transformation 1% o most frequent benign disease o on long bones, metaphyseal o exchondroses that ossificate later  chondroblastoma o epiphyseal tumour (proximal humerus, distal femur, proximal tibia)

7 o joint irritation o osteolytic tumour with a tendency to necrosis and calcification  giant cell tumour o semi-malignant o metaepiphyseal o malignant transformation 1%  hemangioma  glomus tumour o 80% distal part of fingers o tenderness, response to change of temperature  lipoma  chordoma o sacrum/occipital o long anamnesis o notochordal o semi-malignant  adamantinoma = ameloblastoma o tibia o males, 30-40 years of age o semi-malignant o diaphysis 7. The malignant tumours of the locomotion apparatus  age distribution o 10-20 Ewing sarcoma o 15-25 osteosarcoma o 20-30 malignant fibrous histiocytoma o > 50 chondrosarcoma, sec. osteosarcoma o > 40 bone metastases  localization o knee joint 60% OSA, MFH o hip joint OSA, CHSA, EWSA o prox. humerus OSA, EWSA, CHSA o pelvis + scapula EWSA, CHSA o spine EWSA, met. o fingers CHSA o metaphysis OSA o diaphysis EWSA  osteosarcoma o knee, prox. femur, humerus, metaphyseal o high grade (95%)  NACHT + wide resection + ACHT (HD-MTX) o low grade  no CHT o survival 60-80% o lung metastases  surgery (good prognosis) o bone metastases  bad prognosis o radiological/histological classification with minimal clinical relevance o no radio sensitivity . histology  osteoblastic  chondroblastic

8  teleangiectatic  fibroblastic  chondrosarcoma o > 50 years of age o pelvis, rips, long bones, metaphyseal o secondary from enchondroma/exostosis o TM: only wide resection, high risk of implantation metastases o no sensitivity to radiation- and chemotherapy due to very slow growth o higher grade in local recurrences o grade I-II: good prognosis o lung metastases  surgery o grade III: bad prognosis  Ewing sarcoma o 10-25 years of age o femur, tibia, humerus, pelvis (>15y), diaphyseal o highly malignant Ewing sarcoma group (EWS, DNET, Askin) o prognosis: 60% survival o lung metastases  surgery o other metastases bad prognosis (LN, CNS, PNS) o NACHT (RT) + wide resection + ACHT (RT) o IFO, ADM, VCR o bone marrow transplantation (PBSC)  malignant fibrous histiocytoma o 20-35 years of age o similar to fibroblastic osteosarcoma o similar location, same TM  multiple myeloma = plasmocytoma, Kahler disease o due to malignant proliferation of plasma cells in the bone marrow or rarely extra-medullary o false negative bone scan possible o immuno EFLO o para-protein in urine o spinal tumour  angiosarcoma = haemangiosarcoma o 2 forms: . haemangiofibrosarcoma (perithelial cells) . haemangioendothelioma (endothelial cells)  secondary bone tumours (metastases) o children: Wilms tumour, retinoblastoma, neuroblastoma, leukemias o adults: clear cell renal carcinoma, NSCLC, prostatic, thyroid, breast CA, melanoma o osteoplastic mets  breast, prostatic cancer o osteoclastic/osteolytic mets  lung cancer, renal cancer, plasmocytoma, thyroid cancer o TM: . surgery or palliative radiotherapy . chemotherapy/systemic therapy for improvement of prognosis . excochleation + cement + plate (not rods) + RT . surgery  solitary metastases (cure possible)

9  pathologic fracture  life expectancy > 1 year . around joints TEP 8. The common characteristics of the tumours of the locomotion apparatus (classification, diagnostic, clinical features, laboratory and X-ray examinations, the principles of therapy)  classification: can be due to histology, radiology, clinical picture  signs on first contact with the patient: o pain o swelling o limited movement o occasional finding on X-ray o screening for metastases (bone scan)  radiological classification o inactive no sclerotic rim o active cortical bone intact o aggressive no sharp demarcation o malignant transcort. growth w/out trauma, permeative destruction  Enneking classification for benign tumours o stage grade tumour metastases o 1 inactive 0 0 0 o 2 active 0 0 0 o 3 aggressive 0 0,1 0,1  Enneking classification for malignant tumours o I o II o III  skip lesions o same compartment o high grade sarcomas o prognosis not altered  most common metastases  lung  types of resection o preserving of extremity . ablative (amputation, exarticulation) . limb sparing surgery (0, bone graft, EP, spacer) . rotation plastic o oncologic radicality . intralesional . marginal . wide . radical  surgery for benign tumours o 1 no surgery o 2 intralesional o 3 marginal/intralesional resection + local adjuvant therapy  surgery for malignant tumours o I margin wide o II margin radical/effective NACHT + wide o III margin individual

10  adjuvant treatment o local . intra-op  bone cement, phenol, cryotherapy, IORT = intra-op RT . post-op  adj. radiotherapy o systemic . pre-op  chemotherapy, NACHT . post-op  chemotherapy, ACHT 9. Congenital foot deformities  pressure mainly on calcaneus, head of I. and V. metatarsal bone  vaults o anterior cross vault o medial and lateral longitudinal vault  normal X-ray o dorsoplantar view: axis between talus and calcaneus about 30-40°. open distally o lateral view: axis between talus and calcaneus about 30-40°, open dorsally  clubfoot (pes equinovarus, excavatus et adductus) o idiopathic o congenital . etiology: genetic predisposition (AR), endo- and exogenous factors . usually bilateral . clinical features:  plantarflexion of the whole foot (pes equinus)  supination of the whole foot in combination with increased varus position of the hind-foot (pes varus)  increased adduction of the forefoot against the hind-foot (pes adductus)  greater plantarflexion of the forefoot than of the hind-foot (pes excavatus) . X-ray  parallel axis of talus and calcaneus, horizontal in lateral view  os naviculare medially and plantarly displaced  supination of cuboid, talus, calcaneus  subluxation between os naviculare, talus, calcaneus . TM  treatment as early as possible  conservative: manual redressment, first correction of adduction of forefoot, supination and varus position of hind-foot, later deepening of calcaneus  fixation in cast with knees flexed 90°  treatment for 3-4 months  operative:  soft tissue  bones  pes equinus (Spitzfuss) o very rare congenital condition o clinical features: . foot in plantarflexion . no active or passive dorsalflexion possible . increased vault . only toes touch the ground when walking . functionally increased length of the affected limb 11 . hyperextension of knee (genu recurvatum) o TM: . conservative: casting . operative: achillotenotomy, osteotomy, arthrodesis  pes calcaneus (Hackenfuss) o etiology . endogenous . decreased strength of flexors of the foot and toes . spina bifida or brain damage . intrauterine deformity o clinical features . uni- or bilateral . increased dorsiflexion in the upper ankle joint, as far as touching the anterior aspect of the lower limb, valgus position of the hind-foot, flattened longitudinal vault, slight pronation of the forefoot o X-ray . steepening of calcaneus o Tm . conservative: manual redressing, casting in flexed knee  flat-foot o etiology . endogenous or exogenous factors in utero . in combination with other malformations o clinical features . mostly unilateral . dorsalflexion of the forefoot, convexity of sole, abduction and pronation of forefoot, valgus position of hind-foot, o X-ray . steepening of the talus (in severe cases axis as tibia) . calcaneus same position as pes equinus . dorsally open angle in Chopart line . subluxation or luxation between talus and os naviculare . longitudinal axis of talus and calcaneus in lateral view between 50 and 90°, open dorsally (normal foot 30-40°) . abduction of forefoot o TM . conservative: manual redressing and casting directly after birth . operative: sagittal achillotomy  pes adductus (Sichelfuss) o usually bilateral o simple cases: only adduction of big toe (metatarsus varus) o valgus position of hind-foot o X-ray . a-p: adduction of forefoot o TM . conservative: manual redressing, casting as early as possible . operative 10. Acquired deformities of the foot and fingers  clubfoot o etiology: . muscle paresis (e.g. polio, infantile cerebral paresis, spina bifida

12 . injuries to the foot skeleton (fractures) . scar traction . imflammation of bones and joints o clinical features . uni-or bilateral o TM . arthrodesis and osteotomy  pes equinus o etiology . paresis . posttraumatic (scar traction, damage to epiphyses, fractures in malposition)  pes calcaneus excavatus o etiology . non-functioning of lower limb muscle (polio, posttraumatic paresis, disruption of Achill tendon) . scar contracture on the dorsum of the foot . ankylosis of the upper ankle joint after infection o clinical features . steepening of calcaneus, increased dorsiflexion, decreased plantarflexion, increased longitudinal vault (↔ congenital), valgus position of calcaneus, toes in plantarflexion o X-ray . pathologic posture of calcaneus, axis in extending to lower limb . talus horizontal . steepening of the metatarsalia o TM: . conservative: casting, redressing . operative  flat-foot, talipes valgus, talipes planovalgus o  talipes cavus (Hohlfuss) o  spread foot = pes transversoplanus (Spreizfuss) o etiology . weakness of soft tissue . overloading of the forefoot (high-heels, adiposity, occupational) . polyarthritis o clinical features . most common deformity . flattening of the cross vault . hallux valgus, adduction of V. toe (secondary deformities) . divergence of the metatarsal bones o X-ray . divergence of metatarsal bones . malposition of the toes, subluxation and luxation in MTP joints o TM . conservative . operative  hallux rigidus o

13  digitus quintus varus superductus o  hallux malleus (Hammerzehe) o 11. Tumorous affections of the locomotion apparatus  juvenile bone cyst = ostitis fibrosa localisata o so-called brown tumour  bleeding into the bone marrow, mesenchymal tissue o prox. femur, tibia, humerus, metaphyseal o can cause spontaneous fracture o in case of recurrent disease: malignant transformation possible  aneurysmatic bone cyst o due to intra-osseal bleeding o prox. long bones and vertebral bodies, metaphyseal  juxtacortical cyst  intra-osseal ganglion  non-ossifying fibroma  usually around knee  fibrous dysplasia  usually in long bones, in McCune-Albright-syndrome (genetic mutation of GNAS-1 for Gs-α, pubertas praecox in females, café-au-lait spots), M. Recklinghausen  histiocytosis X (eosinophilic granuloma)  myositis ossificans o muscular metaplasia with ossification due to calcification o usually due to trauma or chronic damage, rarely congenital or spontaneous development 12. The common features of the endoprothetics, the types of joint replacement  13. The artificial replacement of the knee joint  14. The artificial replacement of the hip joint  15. Preosteoarthritic state, secondary osteoarthritis  preostheoarthritic state o prevention: loss of weight, sports o axis deviation, joint incongruency o TM: varisationosteotomy  secondary osteoarthritis o overloading . joint dysplasia . axis deviation . instability . acquired disorder o trauma . fractures of the joints . luxations o inflammatory joint disorders . bacterial arthritis . chronic polyarthritis o metabolic diseases . gout . chondrocalcinosis

14 . ochronosis o endocrine diseases . hyperparathyroidism . hypothyreodism 16. Primary osteoarthritis  can be developed by everybody who is old enough  loss of cartilage quality, loss of elasticity, changes in cartilage matrix, free collagen fibers  reactive phenomena of adjacent tissues o bone vascular congestion (bone hypertension) o activity of osteoblasts o cartilage reparation and new bone formation (osteophytes) o worsening of synovial fluid quality o capsular fibrosis  risk factors of OA o systemic . obesity . age . gender . occupation, sports . positive family history . systemic metabolic disorders o local . dysplasia . trauma . chronic inflammation  clinical stages: o I pain on massive exercise, muscular contractures o II pain on exercise, contractures, initial pain on motion o III rest pain  development of axis deviation, muscular atrophy, instability of joint, up to ankylosis 17. The Scheuermann disease  other names: adolescent´s kyphosis, osteochondrosis deformans juvenilis vertebralis dorsalis sive lumbalis  can be called aseptic bone necrosis  cause: growing disorders at the borders between vertebral body and intervertebral disk due to constitutional, congenital or endocrine changes  most common spine disorder in adolescents  Schmorl´s nodes, disorder of enchondral ossification, circulation disorder in the bony epiphysis  wedge shaped vertebra  localisation o dorsal o lumbodorsal o lumbal  clinical stages o before 10 years of age: increase of dorsal kyphosis, normal movement, painlessness o between 12 and 18 years of age: stiffening of the affected area of vertebral spine (thoracal), pain only in 20% of cases

15 o round back, wedge shaped vertebra between D4 and D11 o later pain usually superior or inferior of the kyphosis  diagnosis: 3 stages after X-ray o I  very few signs of X-ray, only slight kyphosis o II  classical symptoms, pathological kyphosis, changes in the shape of several vertebral bodies, irregularities of the roof plates due to delayed bone formation, Schmorl´s nodes (parts of the discs escape into the vertebral bodies), narrowing of the disci o III  segmental fixation of the pathologic posture, osteophytes, calcification of the disci  TM: corset, increase muscle strength, operative TM 18. Amputations of the limb  amputation  setting down of parts of the body  exarticulation  amputation within a joint  indications: accidents, vascular diseases, malignant tumours, chronic osteomyelitis, congenital and acquired deformities  general amputation technique o myoplastic  suture of antagonistic muscle groups in front of the bony rest o myodesis  suture through bony canals  limb prothesis o orthopaedic shoes  toe and forefoot amputation o no amputation in Lisfranc line o in Chopart line  orthopaedic shoes  prevention of pes excavatus o hint foot amputation (Syme)  forefoot prothesis o lower limb o exarticulation in the knee joint o upper leg amputation o high upper leg o exarticulation in the hip joint 19. Osteoarthritis of the knee joint, its therapy  20. The orthopaedic prosthetics  21. Compressive syndromes of the upper extremity  thoracic-outlet syndrome o cervical rip syndrome . posterior scalenal gap . mechanic compression of the subclavian artery and brachial plexus . sensible disorders in C8/T1, arm pain, pareses of the internal hand muscles . Adson test  extension of head during deep inspiration, turning to affected side o scalenus anterior syndrome . compression of subclavian artery and brachial plexus in the scalenal gap . due to reflective hypertonus of cervical muscles in cervical spondylarthritis o costoclavicular syndrome . costoclavicular gap . compression of brachial plexus, subclavian artery and vein between the first rib and clavicule

16 . often found with pre-existing thoracic deformities, e.g. scoliosis, posttraumatic . TM: surgical resection of first rib, immobilization . test: “military exercise” o hyperabduction syndrome . compression of brachial plexus at coracoid process via pectoralis minor in case of hyperabduction  compartment syndrome  Volkmann contracture  carpal tunnel syndrome o mechanic compression of the median nerve o mainly women between 40 and 50 years of age, also in association with amyloidosis o atrophy of the thumb muscles, sensibility disorders of the palmar hand including fingers I-III and radial aspect of finger IV 22. Diseases of muscles, tendons and aponeuroses  atrophy  myogeloses  fibromyalgia  muscle contractures  myositis ossificans  myositis  progressive muscle dystrophy  myotonia  tendovaginits  rupture of aponeuroses 23. The aseptic bone necrosis  Friedrich syndrome o rare idiopathic necrosis of the epipysis of the sternal part of the clavicule o DD: Tb, osteomyelitis, Tietze syndrome  idiopathic Caisson disease o late damage, especially in femur and humerus  Hegemann syndrome o necrosis of the epiphysis in the area of the elbow (Capitulum humeri, Capitulum radii, Trochlea humeri) o thickening of the spongiosa, narrowing of the epiphysis  Panner disease (juvenile osteochondrosis) o capitulum humeri o pain on pressure, loss of function of the elbow joint due to deformation of the radius head o in early school age  Dietrich disease o only few clinical symptoms o on X-ray: clear deformation of the metacarpal heads  lunatomalacia (Kienböck disease) o necrosis of the os lunatum due to fracture or severe exertion o swelling, pain on pressure, decreased function of the wrist joint  Köhler-Freiberg disease o mainly girls between 12 and 18 years of age o deformation of the head of the second metatarsal bone (sometimes III and IV)  Köhler disease 17 o mainly boys between 3 and 8 years of age, 30% bilateral o os naviculare pedis o painful impairment of function of the middle foot and swelling  Ahlbäck disease o medial condyle of femur o in adults  Larsen-Johanson disease o ossification disorder of the patella with recurrent knee problems and intra- articular effusion  Büdinger-Ludloff-Läwen syndrome (chondromalacia patellae) o destruction of the patella core in adolescents o pain, sometimes intra-articular effusion  Pierson disease (ostitis necroticans pubis) o after sports injury and hyperextension of the tendons of M. gracilis and stretching of the symphysis o osteonecrosis on the insertion of the adductors on the inferior pubic ramus  Perthes-Calvé-Legg disease (osteochondropathia deformans coxae juvenilis) o uni- or bilateral necrosis on the area of femoral head epiphysis o especially boys between 5 and 12 years of age o clinical stages .  Kümmell-Verneuil disease o gibbus formation of a vertebral body o often after only minimal trauma 24. Specific inflammations of the locomotion apparatus  osteomyelitis o tuberculosis = spina ventosa . granulating or caseating ostitis . mainly small children . usually short bones, e.g. phalanges, metacarpals o lues o typhus  arthritis o coxitis tuberculosa . primarily synovial or primarily osseus form of tuberculosis . mainly children, adolescents . TM: tuberculostatics and synovectomy o gonitis tuberculosa . mainly males of a younger age group  spondylarthritis ancylopoetica o M. Stümpell-Pierre-Marie, M. Bechterew o much more common in males o chronic inflammatory rheumatoid disease of the axial skeleton (vertebral spine, iliosacral joints, symphysis, small vertebral joints o can be idiopathic or in association with chronic inflammatory bowel diseases, Reiter disease, psoriasis, late manifestation of reactive arthritis o chronic proliferating synovitis with capsular fibrosis and ankylosis, ossification and contraction of ligaments, visceral manifestation as iritis, aortits and disturbances in conduction o usually starts as sacroiliitis with morning stiffness and night pain

18 o Schober sign: progressive decrease in vertebral (and thoracal) mobility o finally complete stiffening of the vertebral spine in thoracolumbal kyphosis o due to genetic predisposition, HLA-B27 o manifestation usually between 15 and 30 years of age o stages due to X-ray . I bilateral sclerosis of the iliosacral joints . II usures and erosions adjacent to the joint . III usures and partial destruction . IV ankylosis  Paget disease = osteodystrophia deformans o changes in one or several bones o deformation and thickening of long bones o possible severe pain in the affected extremities o stages . I hyperaemia of the bones, loss of bone, fibrous trans formation of the bone marrow, adjacent new bone formation (mosaic structure) and tickening of the bone, but still loss of mechanical stability . II equal function of osteoblasts and osteoclasts . III sclerotic bone, cyst formation o X-ray: thickening of cortical bone, cysts, sclerosation o complication: malignant transformation (1%) into osteosarcoma 25. Metastatic tumorous affections of the bones  osteolytic metastases  NSCLC, renal cancer, plasmocytoma, thyroid cancer  osteoblastic metastases  new bone formation, in breast and prostatic cancer  mixed metastases  hypernephroma  TM o singular metastases  surgical excision possible o multiple  treatment of symptoms, e.g. pain with radiation therapy  secondary bone tumours (metastases) o children: Wilms tumour, retinoblastoma, neuroblastoma, leukemias o adults: clear cell renal carcinoma, NSCLC, prostatic, thyroid, breast CA, melanoma o osteoplastic mets  breast, prostatic cancer o osteoclastic/osteolytic mets  lung cancer, renal cancer, plasmocytoma, thyroid cancer o TM: . surgery or palliative radiotherapy . chemotherapy/systemic therapy for improvement of prognosis . excochleation + cement + plate (not rods) + RT . surgery  solitary metastases (cure possible)  pathologic fracture  life expectancy > 1 year . around joints TEP 26. Non-specific inflammations of bones and joints  osteomyelitis o chronic . primary  Brodie abscess  mainly older children or adolescents  metaphyses of long bones

19  good immunological status  osteomylitis sclerosans  diaphyses of long bones  sclerotic rim formation . secondary  after not fully treated acute haematogenous osteomyelitis or due to trauma with concurrent infection  complications: fistule carcinomas, amyloidosis, fractures  X-ray: sclerotic rim around the affected tissue  TM: mainly operative revision in combination with antibiotics  defect pseudarthrosis o acute . haematogenous  mainly metaphyses of long bones  spreading from anginas, otites, pyodermias etc.  spreading from spongiosa to corticalis and periost  subperiosteal purulent abscess formation  most common in children, rare in adults  in newborn spreading from infections of the umbilical cord  X-ray: sclerotic areas around the affected part due to new bone formation, formation of phlegmones and fistules possible  TM: antibiotics, exact immobilization . exogenous  usually posttraumatic or iatrogenic after osteosynthesis  arthritis o hydrops . inflammatory changes in the capsule, e.g. distorsion, adjacent inflammation, adjacent tumours, allergic reactions, rheumatoid diseases, arthrosis, gout, gonorrhea, tuberculosis o pyarthros . bacterial infection of the joint o haemarthros . trauma, clotting disorders, tumours o TM: immediate puncture o infectious arthritis . staphylococcus, streptococcus, pneumococcus, . direct infection (after puncture, injection, open wounds, operation) . haematogenous spreading  in children via epiphysis, in adults bacterial metastases in the capsule . from adjacent inflammations, e.g. osteomyelitis, para-articular abscesses, phlegmons . due to degree and localisation: capsular phlegmon, joint empyema, panarthritis . enzymatic destruction of the cartilage, destruction of the bony parts of the joint . complications: malpositions, dysplasia, contractures, ankylosis (fibrous, bony) . TM:  puncture  immobilization in arthrodesis position, drainage of the joint 27. Vertebral algic syndrome 

20 28. Congenital hip dysplasia  most common congenital skeletal dysplasia  can be dysplasia of the acetabulum, subluxation, luxation  etiology o combination of endo- and exogenous factors o much more common in females o usually in combination with coxa valga antetorta o luxation usually in dorsocranial direction  changes in hip structure o elongation of femoral capital ligament o damage to cartilage o capsule may at some point unite with the pelvic bone and prevent reposition o limbus cartilaginous may turn into acetabulum o insufficiency of abductors, shortening of adductors  clinical examination o loss of abduction in the hip joint (normally up to 90° in 90° flexion in newborns) o difference in the length of the limbs o asymmetry in skin folds, usually seen inguinal o Ortolani sign  intra-articular clicking, when femoral head is moved over secondary limbus o further signs . empty acetabulum . greater trochanter is shifted proximally and laterally . denting in adductors . lateralisation of the femoral head . Hilgenreiner sign, unstable hip  similar sign as Ortolani . glissement o X-ray . in case of suspicion after 4 months . Hilgenreiner line  through the 2 Y joints . Ombredann line  in 90° to above, in lateral cranial part of the acetabulum . definition of 4 quadrants  femoral head normally in lower internal quadrant . Shenton line  uninterrupted line from foramen obturatum to femoral diaphysis . acetabular angle  between Hilgenreiner line and a line running between upper part of os ileum and upper part of acetabulum (normal up to 34°)  TM o conservative . Forrester-Brown splint . Hanausek apparatus . Hoffmann-Daimler splint . Pavlik splint . over-head-extension . extension-reposition o operative . pelvis osteotomy (Chiari, Salter, Pemberton) 29. Enthesopathies (tendopathy) and tendovaginitis of the tendons

21  enthesopathy o abacterial inflammation of the tendons and their insertion sites or degenerative changes, often in combination with epicondylitis o causes: chronic overloading, microtrauma, metabolic or vascular disorders  tendovaginitis stenosans (DeQuervain) o affection of the synovial sheaths of the tendons of m. extensor pollicis longus and m. abductor pollicis brevis o pain over processus styloideus radii o TM . immobilization . corticoid injection . operative TM  tendovaginitis hypertrophicans o swelling of the extensor tendons of the forearm in radial nerve palsy  trigger finger o stenosing changes in synovial sheath of the tendons of the finger flexors or thumb flexors in the area of the proximal joints o snapping phenomenon  increasing pain preventing movement between extension and flexion 30. Dupuytren´s contracture, surgical therapy and rehabilitation  flexion contracture of the fingers, especially IV and V due to hardening and shrinking of the palmar aponeurosis, in 70-80% of cases, both hands are affected  usually males are affected (5:1), after 5th decade  cause: unknown, can be supposed to be a combination of congenital predisposition and external factors (e.g. microtraumata), sometimes in combination with rheumatoid diseases, autoimmune disorders, fibroblastic diseases (induratio penis plastica, Ledderhose disease)  patients with liver diseases, DM, epilepsy, alcoholism have a much higher incidence (30%)  staging due to extension deficiency o N none o 0 nodules or cords palpable, no deficiency o 1 0-45° o 2 45-90° o 3 90-135° o 4 > 135°  therapy: o simple fasciotomy o partial fasciotomy with resection of involved areas o complete removal of the palmar aponeurosis 31. The radial and ulnar epicondylitis of the humerus  radial epicondylitis o insertion tendopathy o more common than ulnar form o due to functional overloading in sports or profession o pain on the insertion sites of the tendons of the humerus o pain on pressure, on exercise, on passive expansion o TM: . exact immobilization, sometimes even in cast . corticoid injection

22 . acupuncture . radiotherapy . operative denervation of the affected humerus  ulnar epicondylitis o irritation of ulnar nerve possible 32. The differential diagnosis of shoulder pain  80% soft tissue disorders  acute pain o bursitis (bursa subacromialis) o ruptures of the rotator cuff o cervical disc prolaps  radicular pain o empyema of the glenohumeral joint  chronic pain o diseases of the subacromial space with or without rupture of the rotator cuff . impingement syndrome  tendon of supraspinatus muscle  pain on abduction between 60-120°  “painful arc”  tests  Hawkins and Kennedy: about 90° flexion and progressive internal rotation  Neer: fixation of scapula, progressive abduction . syndrome of the biceps tendon  inflammations or degenerative changes in sulcus intertubercularis o chronic bursitis acromialis = frozen shoulder . decrease in active and passive range of motion . fibrosis of the joint capsule . often associated with insertion tendopathy of supraspinatus muscle o tendinosis calcarea . calcifications in the muscles of rotator cuff, usually around tuberculum majus . can enter bursa . o neoplasia o rheumatoid diseases  joint stiffening o arthritis (glenohumeral or acromioclavicular joint)  instabilities o luxation  examination o clinical o X-ray o ultrasound  ruptures of rotator cuff

Traumatology 33. Bone fractures and types of dislocations  causes: o direct fracture  on the place of effect o indirect fracture  leverage

23 o fatigue/stress fracture  repeated micro-traumata o pathologic fracture  pre-existing damage of the affected bone o greenstick fracture  children  clinic o closed fracture (without injury of soft tissue and skin) o open fracture . I piercing of the skin from in- to outside . II rupture of the skin from the outside, no soft tissue . III big rupture of skin, soft tissue affected . IV total or sub-total amputation  diagnosis o certain fracture signs . malposition . abnormal movements . crepitation . visible bone fragments o uncertain fracture signs . swelling . haematoma . pain . decreased function o X-ray  complete fracture  incomplete fracture  types of dislocations o dislocatio ad axim (along a vertical axis) . frontal plane varosity, valgosity . sagittal plane  antecurvation, recurvation o dislocatio ad latus (lateral movement) o dislocatio ad longitudinem cum contractione/cum distractione (longitudinal movement with shortening/lengthening) o dislocatio ad peripheriam (distorsion along a longitudinal axis) 34. Fractures of the distal forearm  Montegii fracture  Galeazzi fracture  radial fracture loco typico o Smith fracture  fall on palmarly flexed hand o Colles fracture  fall on dorsally extended hand . bajonette deformity 35. Fractures of children age and epiphysiolysis  epiphyseolysis  disruption of epiphyseal disk with or without dislocation from the bone, Salter-Harris classification type I  possible causes: o osteochondritis o osteomyelitis o aseptic bone necrosis o trauma  epiphyseolysis capitis femoris o proximal femoral epiphysis is affected o only rarely traumatic cause, in 50% bilateral

24 o between 9 years of age and epiphysial closure, f:m = 1:3 o hormonal factors have to be taken into consideration (obese children or extremely tall) o two forms: . acute  complete dislocation of the epiphysis, vascular compromise of femoral head, up to 80% necrosis of femoral head . lenta  broadening of the epiphyseal disk, femoral neck moves ventrocraniallly, can stop at every stage, but acute dislocation is also always possible o usually pain in knee joint and on the anterior aspect of the upper leg o leg is held in external rotation, slight shortening of the limb and claudication in hip joint o Drehmann sign  on flexed hip: ability of internal rotation is markedly decreased o X-ray for diagnosis o TM . acute  immediate reduction and reposition, removal of haematoma . lenta  from 30° onwards, valgisation and flexion osteotomy (Imhäuser) o complications  Waldenström disease (= chondrolysis, joint space narrowing) 36. Open fractures  consequences: o contamination o crushing, stripping, devascularization o destruction/loss of soft tissue  compartment syndrome still possible (!)  Gustilo and Andersen classification o I clean skin, opening of < 1cm, usually from inside to outside, minimal muscle contusion, simple transverse or short oblique fracture o II laceration > 1cm long, extensive soft tissue damage, minimal to moderate crushing, simple transverse/oblique fracture with minimal comminution o III extensive soft tissue damage, including muscles, skin, neurovascular structures . A extensive soft tissue laceration, adequate bone coverage, segmental fracture, gunshot injury, minimal periosteal stipping . B extensive soft tissue injury, periosteal stripping and bone exposure requiring soft tissue flap closure, usually massive contamination . C vascular injury requiring repair  Tscherne classification o I small puncture wound without associated contusion, negligible bacterial contamination, low energy mechanism of fracture o II small laceration, skin and soft tissue contusion, moderate bacterial contamination, variable mechanism of injury o III large laceration with heavy bacterial contamination, extensive soft tissue damage, frequent associated arterial or neural injury o IV (in)complete amputation, variable prognosis based on laceration and nature of injury  Tscherne classification of closed fractures o O injury from indirect forces and negligible soft tissue damage

25 o I low to moderate energy mechanisms, superficial abrasions/contusions of soft tissue overlying fracture o II closed fracture with significant muscle contusion, possible deep contaminated skin abrasions, associated with moderate to severe energy mechanisms and skeletal injury, high risk of compartment syndrome o III extensive crushing of soft tissue, subcutaneous degloving or avulsion, arterial disruption or established compartment syndrome 37. Types of traumatic lesions of the joints and their basic therapy  bony lesions (fractures) o  soft tissue injuries o  luxations o open/closed reduction o immobilization o further treatment: depending on associated injuries  subluxations 38. Changes of fracture healing  primary healing o primarily cortical healing o only in case of ideal adaption of the fragments  secondary healing o primary callus formation o formation of bridging callus o formation of medullary callus  phases o removal of the haematoma associated with the fracture, starts about 8 hours later o callus formation  during the first 2 weeks, fibrous-cartiligenous bone tissue, so-called connective tissue callus . primary callus formation . bridging callus  in case of some distance between the fragments or interposed structures, growing from the periost (periosteal bone callus) . medullary callus  extremely rigid connection between the fragments, growing from the connective tissue cells of the bone marrow, mainly fibrous callus between the fragments, less cartilage o callus mineralization  similar to enchondral ossification o definitive formation of bony callus  restructurization, formation of spongiosa and compacta 39. Pseudoarthrosis and the bones and their therapy  in fractures: no bony connection between the fragments after 6 months  can also be congenital disorder  etiology o biological factors  compromised vascularization of the bony fragments or adjacent soft tissue, sequestrum formation, age, drugs, radiation o mechanical factors  local instability due to insufficient immobilization, shearing forces  more common on lower extremity than on upper  classification o biological reactive pseudarthrosis  hypertrophic form

26 . instability of the fragments . increased periosteal callus formation, but no healing o biological nonreactive pseudarthrosis  atrophic form . further classification: infected vs. non-infected . no callus formation, avascular fragments  pathologic mobility or pain, swelling and exercise intolerance  TM o hypertrophic  stabilisation, osteosynthesis o atrophic  autologous bone graft, external fixator with removal of infected tissue in case of infected pseudarthrosis 40. The principles of osteosynthesis  types: o internal vs. external o ablative vs. stable  materials o cortical bone screws  AO, pre-drill . lag screw principle  clearage hole in the nearest fragment, tightening the screw draws fragments together  right angles to plane of fracture . to neutralize torsional and bending stresses  plates o plates . should be applied on convex surface of bone . dynamic compression plate  specially contoured slots (no plain round holes), inserted eccentrically after using offset drill guide; when screws are tightened  heads pinch the plate  compression of fracture . types:  low-contact dynamic compression plate  reconstruction plates  V-cuts  T- and L-buttress plates  cloverleaf  distal tibia  hook plates (Zuelzer, AO)  lateral tibial head (hockey stick) plate  carbon fibre plate o cancellous bone screw o self-tapping screw o blade plates  plate portion fixed on shaft of bone, blade/spine inserted into bone, fixed with cancellous bone screws o dynamic hip screw/dynamic condylar screw o intramedullary nails . Rush pins  hooked ends . Nancy nails . tubular, solid cloverleaf pattern nails . interlocking nails o tension band wiring  e.g. olecranon, patella o external fixators . Ilizarow fixator  Kirschner wires through bones, ring encircling the limb . hybrid fixator  metaphyseal fractures 41. The algodystrophical syndrome of Sudeck  other names: reflex sympathetic dystrophy, complex regional pain syndrome (CRPS)  dystrophy and atrophy of soft tissue and bones  etiology:

27 o multifactorial cause o disorders of vegetative innervation o after trauma, infections, operations, nerve damages o no relation between primary and secondary lesions  stages o I inflammation, increase in metabolic turnover, livid discoloration of the skin, oedema, loss of function of the joints o II dystrophy, no more swelling, but atrophy of the tissues with loss of calcification of the affected bones and fibrous stiffening of joints, trophic skin disorders, loss of function o III atrophy, end stage with generalized atrophy of skin, subcutis, muscles, bones, severe loss of function and stiffening of the joints, later either involution of atrophy or persistence  TM o I immobilization, analgetics, blockage of sympathetic pathway o II physiotherapy o III active and passive mobilization 42. Volkmann´s ischemic contracture and compartment syndrome  Volkmann´s contracture o other names: ischemic muscular contracture o irreversible ischemic muscle contracture of the deep forearm flexors, flexion in wrist joints and IPJs, extension in MCPJs o when children are affected  no more growth of the affected extremity o TM: desinsertion o very common in supracondylar fractures o prophylaxis!  compartment syndrome o mainly on lower leg o increase in tissue pressure in a closed compartment o causes: . external compression of the compartment . oedema (posttraumatic after fracture, contusion, burns, postischemic, postoperative) or haematoma . elevation of the extremity in case of hypotension o symptoms: . acute increasing pain . hard swelling with pain on pressure . muscle weakness . pain on passive stretch o therapy: decompression 43. Fractures of the wrist and hand  wrist o distal radius  scaphoid, lunate; ulna (via sigmoid notch) o triangular fibrocartilage complex o carpal bones . proximal: scaphoid, lunate, triquetrum, pisiform . distal: trapezium, trapezoid, capitate, hamate o dorsal ligaments are weaker than volars o space of Poirier: ligament-free area in capitolunate space o mechanisms . fall on outstretched hand 28 . wrist in hyperextension o OTA . A common carpal fracture-dislocation  1.1 transscaphoid, perilunate dislocation  1.2 transscaphoid, perilunate dislocation and associated carpal fractures  1.3 perilunate dislocation and associated other fracture except scaphoid . B carpal fracture  1 vertical  2 oblique  3 transverse . C scaphoid fracture, isolated  1 avulsion  2 horizontal, transverse, oblique  2.1 distal third  2.2 middle third  2.3 proximal third  3 vertical/multifragmentary o scaphoid . most common . scaphoid lift test  pain on dorsal-volar shifting . Watson test  ulnar to radial deviation . classification  fracture pattern (Russe)  horizontal oblique  transverse  vertical oblique  stability  stable: non-displaced, no step-off  unstable: > 1mm displacement  location  distal third  middle third (waist): most common  proximal third . TM  thumb spica cast  long-arm thumb spica cast: neutral position  displaced fractures: ORIF . complications  non-/malunion  osteonecrosis (proximal pole) o lunate . second most common . osteonecrosis  Kienböck disease . Stahl and Lichtman classification  I normal appearance or linear or compression seen on tomogram  II sclerosis, slight collapse of radial border  III fragmentation, collapse, cystic degeneration, loss of carpal height, proximal migration of capitate, scaphoid rotation (scaphoidlunate dissocation)  IV advanced collapse, scaphoid rotation, sclerosis, radiocarpal osteophytes 29 . TM  short-arm cast, splint  ORIF, external fixation . complications  osteonecrosis o triquetrum . direct trauma o pisiform o trapezoid . rarely fractured . tenderness proximal to base of MCB II o capitate . uncommon . closed/open reduction because of risk for osteoporosis o hamate . distal articular fracture, fracture of body of hamate, hook of hamate . complications  symptomatic non-union  rupture of flexor tendon to small finger  ulnar or median neuropathy o perilunate dislocations/fracture-dislocations . greater arc injury  through scaphoid, capitate, triquetrum  A1.1-1.2 . lesser arc injury  radial styloid, midcarpal joint, lunatotriquetral space  perilunate/lunate dislocation . tenderness distal to Lister tubercle . classification  perilunate instability ↑: scapholunate joint (radioscapholunate ligament)  midcarpal joint (radioscaphocapitate ligament) dorsal radiolunatotriquetral ligament  volar dislocation of lunate  I disruption of scapholunate joint, disruption of radioscapholunate ligament and interosseus scapholunate ligament  II disruption of midcarpal joint, disruption of radioscaphocapitate ligament  III disruption of lunatotriquetral joint, distal limb of radiolunatotriquetral ligament  IV disruption of radiolunate joint, dorsal radiolunatotriquetral ligament, volar dislocation of lunate . TM  ORIF (Kirschner wire) . complications  median neuropathy  OA  chronic perilunate injury o carpal dislocations . midcarpal stress test  dorsal-palmar  pathologic clunk . dynamic test for midcarpal instability . TM

30  closed reduction  ORIF (Kirschner wire) . complications  OA  recurrent instability o scapholunate dissociation .  I . X-ray:  “Terry-Thomas-sign”  widening of scapholunate space  “cortical ring sign”  rotation of scaphoid over trapezoid . complications  recurrent instability o lunatriquetral dissociation . Ballottement test  dorsal-volar displacement o ulnocarpal dissociation . TFCC rupture or avulsion . complication  recurrent instability  ulnar neuropathy  hand o maintenance of joint motion, protection of underlying structures o TM . fracture reduction . elevation of entire extremity  limit oedema . immobilization . early finger mobilization o descriptive classification . open/closed . bone involvement . location within bone . fracture pattern: comminuted, transverse, spiral, vertical split . displacement . deformity (rotation, angulation) . extra-/intraarticular . (un)stable o Swanson, Szabo and Anderson classification . I clean wound, no significant contamination . II one or more of following  contamination  delay in TM > 24h  significant systemic illness o OTA (metacarpal fractures) . A extraarticular  1 metacarpal head  1.1 simple  1.2 metphyseal wedge  1.3 metaphyseal complex  2 no classification  3 metacarpal base  3.1 simple  3.2 metaphyseal multifragmentary . B articular

31  1 metacarpal head  1.1 oblique/spiral  1.2 sagittal  1.3 coronal  2 metacarpal diaphyseal  2.1 oblique/spiral  2.2 transverse  2.3 simple wedge  3 metacarpal base  3.1 avulsion  3.2 depression  3.3 split/depression . C articular/extraarticular  1 metacarpal head  1.1 articular simple, metaphyseal simple  1.2 articular simple, metaphyseal multifragmentary  1.3 articular and metaphyseal multifragmentary  2 no classification  3 metacarpal base  3.1 articular simple, metaphyseal simple  3.2 articular simple, metaphyseal multifragmentary  3.3 articular multifagmentary, metaphyseal simple  3.4 articular and metaphyseal multifragmentary o OTA (phalangeal fractures) . A extraarticular  1 proximal aspect  1.1 simple  1.2 multifragmentary  2 diaphyseal  2.1 spiral/oblique  2.2 transverse  2.3 simple wedge  2.4 multifragmentary  3 distal aspect  3.1 simple  3.2 multifragmentary . B articular and diaphyseal  1 proximal partial articular  1.1 unicondylar  1.2 bicondylar  2 no classification  3 distal partial articular  3.1 unicondylar  3.2 bicondylar . C complete articular  1 proximal complete articular  1.1 articular simple, metaphyseal simple  1.2 articular simple, metaphyseal multifragmentary  1.3 articular and metaphyseal multifragmentary  2 no classification  3 distal complete articular  3.1 simple  3.2 complex 32 o intraarticular fracture of thumb . Bennett fracture  volar lip fragment, first metacarpal pulled proximal . Rolando fracture  “Y” or “T” fracture o complications . mal-/non-union . infection . MCPJ extension contracture . loss of motion . OA 44. Fractures of the forearm  olecranon o Schatzker classification . transverse  apex of sigmoid notch . transverse impacted  comminution and depression of articular surface . oblique  hyperextension injury, midpoint of sigmoid displaced distally . comminuted fracture . oblique distal  extending distally to coronoid . fracture-dislocation o Calton classification . non-displaced  < 2mm, no increase with 90° flexion, ability to extend actively against gravity . displaced  avulsion fracture, common in elderly due to indirect trauma . oblique and transverse fracture  due to indirect trauma . comminuted fracture  direct trauma . fracture-dislocation  severe injury o OTA (proximal radial/ulna fractures) . A extraarticular  1 ulna only  2 radius only  3 ulna and radius . B articular involvement of either radius or ulna  1 ulna fractured, radius intact  2 radius fractured, ulna intact  3 articular fracture of either radius or ulna, extraarticular fracture of other . C articular involvement of both  1 simple fracture of radius and ulna  2 simple fracture of radius or ulna, multifragmentary fracture of other  3 multifragmentary fracture of radius and ulna o TM . non-op  long arm cast, immobilization, 45-90° of flexion . op  no internal suture  intramedullary fixation: 6.5mm intracancellous lag screw fixation  bicortical screw fixation  tension band wiring + 2 parallel Ki wires  plate and screw fixation  excision o complications . decrease in range of motion . arthritis

33 . non-union . ulnar nerve symptoms . decrease in power of extension  radial head o injury to ligamenteous structures of elbow o valgus stability o Essex-Lopresti lesion: radial head fracture-dislocation and disruption of interosseus ligament o Mason classification . I non-displaced . II marginal fracture and displacement (impaction, depression, angulation) . III comminuted fracture involving entire head . IV associated with elbow dislocation (Johnston) o Schatzker classification . I wedge fracture  simple wedge fracture, non-displaced . II impaction fracture  part of head and neck intact, variable comminution . III severely comminuted fracture o OTA of proximal radius and ulnar fractures (see above) o TM . Mason I  sling, aspiration of joint . II  aspiration, if no mechanical block  see I . III  excision, repair of interosseus ligament . IV  excision if comminuted . radial head excision: proximal to annular ligament . radial head prothesis o complications . contracture . chronic wrist pain . OA . reflex sympathetic dystrophy  forearm o many open fractures o fractures of both radial and ulnar diaphyses . descriptive classification  open/closed  location  comminuted, segmental, multifragmented  displacement  angulation  rotational alignment . OTA  A simple, diaphyseal  1 ulna simple, radius intact  2 radius simple, ulna intact  3 radius and ulna simple  B wedge fracture, diaphyseal  1 ulna wedge, radius intact  2 radius wedge, ulna intact  3 wedge of radius and ulna, simple or wedge of other  C complex, diaphyseal

34  1 ulna complex, simple or wedge of radius  2 radius complex, simple or wedge of ulna  3 complex of both . TM  non-op: long arm cast, neutral position, 90° flexion (only for nondisplaced fractures)  op:  open reduction and internal fixation  compression plate (3.5mm dynamic compression plate DCP) with or without autogenous bone grafting  external fixation: severe bone or soft tissue loss  intramedullary fixation . complications  infection  Volkmann contracture  posttraumatic radioulnar synostosis o fractures of ulnar diaphysis . nightstick, Monteggia, stress fractures . Bodo classification of Monteggia factures  I anterior dislocation of radial head, fracture of ulnar diaphysis at any level, anterior angulation; due to forced pronation  II posterior/posterolateral dislocation, fracture of ulnar diaphyses and posterior angulation; due to axial loading with flexed elbow  III lateral/anterolateral dislocation, fracture of ulnar metaphysis  IV anterior dislocation, fracture of both ulna and radius with abduction of elbow in proximal third at same level; type I mechanism . TM  nightstick fractures  plaster immobilization, 3.5mm DCP  Monteggia fracture  3.5mm DCP, closed reduction of radial head . complications  radial/median nerves injury  radial head instability o fractures of radial diaphysis . Galeazzi/Piedmont fracture = fracture of radial diaphysis at junction of middle and distal thirds and associated disruption of the distal radioulnar joint . reverse Galeazzi fracture =fracture of distal ulna and associated disruption of distal radioulnar joint . TM  proximal radius: long-arm cast, neutral position or supination; open reduction and plate fixation  Galeazzi fracture: plate and screw fixation . complications:  malunion/non-union  compartment syndrome  radioulnar synostosis  recurrent dislocation 45. Fractures of the elbow, traumatic dislocations of the elbow  ulnohumeral (hinge), radiohumeral (rotation), proximal radioulnar (rotation)  neurovascular injury (!)

35  descriptive classification o chronology  acute, chronic (unreduced), recurrent o relationship of radius/ulna to humerus . posterior  posterolateral (> 90%)  posteromedial . anterior . medial . lateral . divergent (rare)  posterior dislocation  most common  fracture dislocations: elbow dislocation with associated fracture about the elbow o radial head o medial/lateral epicondyle o coronoid process  instability scale (Morrey) o I posterolateral rotatory instability, positive pivot shift test, disruption of lateral ulnar collateral ligament o II perched condyles, varus instability, disruption of lateral ulnar collateral ligament, anterior and posterior capsule o IIIA posterior dislocation, valgus instability, disruption of lateral ulnar collateral ligament, anterior and posterior capsule, posterior medial collateral ligament o IIIB posterior dislocation, grossly unstable, disruption of lateral ulnar collateral ligament, anterior and posterior capsule, anterior and posterior medial collateral ligament  TM: o posterior dislocation . non-op  closed reduction and anaesthesia (elbow flexed), posterior splint at 90° . op  soft tissue/bony entrapment  Morrey dynamic external fixator (disruption of medial collateral ligament)  grossly unstable o anterior dislocation . closed reduction and analgesia, distal traction  dorsally directed pressure o medial/lateral dislocation . closed reduction, often greater soft tissue injury o divergent dislocation . a-p-type (radius-ulna)  see posterior dislocation . mediolateral (transverse) type  direct distal traction, elbow extended  complications o loss of motion (extension) o neurologic compromise o vascular injury o Volkmann contracture o instability/re-dislocation o heterotopic bone/myositis ossificans 46. Fractures of the humerus  proximal humerus o most common humeral fractures (45%) o glenoid fossa 25% of humeral head

36 o 4 segments according to Neer . humeral head . greater tuberosity . lesser tuberosity . humeral shaft o blood supply: anterior and posterior humeral circumflex artery o displacement: . greater tuberosity  superiorly and posteriorly (supraspinatus, external rotators) . lesser tuberosity  medially (subscapularis) . shaft  medially (pectoralis major) . deltoid: abduction of proximal fragment o mechanisms of injury . high energy trauma . fall on outstretched upper extremity o Neer classification . 4 parts . displacement: >1cm or more than 45° of angulation o OTA . A extraarticular, unifocal fracture  1 avulsion of tuberosity  2 impacted metaphysis  3 non-impacted metaphysis . B extraarticular, bifocal fracture  1 and metaphyseal impaction  2 without metaphyseal impaction  3 with glenohumeral dislocation . C articular fractures  1 slight displacement, impacted valgus fracture  2 marked displacement, impacted  3 with glenohumeral dislocation o TM . minimally displaced fractures  sling immobilization . two-part fractures  anatomic neck  open reduction and internal fixation, prothesis (hemiarthroplasty) in the elderly  surgical neck  < 45°: sling immobilization; > 45°: closed/open reduction and internal fixation  irreducible fractures  open reduction and internal fixation with pins, flexible nails and tension banding, plate and screws  greater tuberosity  displaced: open reduction, internal fixation and rotator cuff repair  lesser tuberosity  closed reduction unless a displaced fragment blocks internal rotation . three-part fracture  unstable: open reduction and internal fixation  elderly: prosthetics (hemiarthroplasty) . four-part fractures:  fixation with multiple Kirschner wires/screw fixation (younger patients)  elderly: prosthetics (hemiarthroplasty) o complications

37 . vascular injury (arteria axillaries): infrequent . neural injury:  brachial plexus (6%)  axillary nerve: anterior fracture-dislocation . stiffness . myositis ossificans: uncommon . osteonecrosis . non-/malunion  humeral shaft o from insertion of pectoralis major to supracondylar ridge o position of fragments . above pectoralis major insertion  proximal fragment abducted, rotated externally by rotator cuff  distal fragment medially, proximally by deltoid and pectoralis major . between pectoralis major and deltoid tuberosity  proximal fragment medially by pectoralis major, latissimus dorsi  distal fragment laterally and proximally by deltoid . distal to deltoid tuberosity  proximal fragment abducted by deltoid  distal fragment medially and proximally by biceps and triceps o descriptive classification . open/closed . location: proximal, middle distal third . degree: (in)complete . direction and character: transverse, oblique, spiral, segmental, comminuted . intrinsic condition of bone . articular extension o OTA . A simple fracture  1 spiral  2 oblique (> 30°)  3 transverse (< 30°) . B wedge fracture  1 spiral wedge  2 bending wedge  3 fragmented wedge . C complex fracture  1 spiral  2 segmented  3 irregular (significant comminution) o TM . non-op  > 90% can heal without surgical treatment  hanging cast  traction from weight of cast  coaptation splint: stabilization, forearm in collar and cuff . op  indication: multiple trauma, inadequate closed reduction position, non-union, pathologic fracture, associated vascular injury, progressive radial nerve palsy after fracture manipulation,

38 “floating” elbow, segmental fracture, intraarticular extension, bilateral fracture, open fracture  approaches:  anterolateral: proximal third  anterior: between biceps and brachialis muscles  posterior: between lateral and longitudinal head of triceps  open reduction  plate fixation and lag screw  best functional results  no violation of rotator cuff  in proximal and distal shaft fractures, intraarticular extension, pre-existing deformity, nonunions  4.5mm dynamic compression plate and fixation of 8-10 cortices  intramedullary fixation  in osteopenic bone fractures, pathological fractures  Ender nails, Rush rods, Hackenthal nails  external fixation  in infected nonunion, bone defect/loss, burn patient, open fracture with extensive soft tissue injury o complications . radial nerve injury (18%)  middle third . non-union, malunion . vascular injury: uncommon  distal humerus o extension-type (>80%) o flexion-type (2-4%) o OTA . A extraarticular fracture  1 apophyseal avulsion  2 metaphyseal simple  3 metaphyseal multifragmentary . B partial articular  1 lateral sagittal  2 medial sagittal  3 frontal . C complete articular  1 articular simple, metaphyseal simple  2 articular simple, metaphyseal multifragmentary  3 articular, metaphyseal multifragmentary o supracondylar fractures . extension-type  neurovascular injury: brachial artery, median nerve, radial nerve  Volkmann ischemia  fracture line from anterodistal to posteroproximal  TM  non-op: posterior long arm splint in at least 90° flexion for 6 weeks  op: open reduction and internal fixation, one plate in each column, parallel or 90°; in elderly: total elbow replacement  complications

39  Volkmann ischemic contracture  aggressive elevation and traction, serial neurovascular examination  stiffness . flexion type  frequently open lesion  sharp proximal fragment  force against proximal aspect of flexed elbow  olecranon, medial and lateral epicondyles remain in their normal spatial relationship  triangular plane shifted anterior the humeral shaft  fracture line runs obliquely from anteroproximal to posterodistal  TM  non-op: posterior elbow splint; long arm cast placed in stages (Soltanpur), flexed elbow, 6 weeks  op: open reduction and internal fixation with 3.5mm reconstruction plate on each column, parallel or 90° o transcondylar fractures . traverse both condyles, within joint capsule . posadas fracture  transcondylar and anterior displacement of distal fragment and dislocation of radial head and proximal ulna . TM  non-op: posterior splinting  op:  closed reduction, percutaneous pinning  open reduction and internal fixation  elderly: total elbow arthroplasty . complications  excessive callus production  pseudarthrosis  ankylosis o intercondylar fractures . most common, comminution common . distorted spacial relationship between olecranon, medial and lateral condyles . Riseborough and Rodin classification  I non-displaced  II slight displacement, no rotation between condylar fragments on frontal plane  III displacement and rotation  IV severe comminution of articular surface . TM  non-op (elderly): cast immobilization; traction – olecranon pin  op:  open reduction and internal fixation  interfragmentary screws, dual plate fixation  total elbow arthroplasty . complications  arthritis  failure of fixation  loss of motion (extension) o condylar fractures . mainly children, lateral > medial . medial condylar fracture  medial epicondyle and trochlea . lateral condylar fracture  lateral epicondyle and capitellum 40 . Milch classification (2 types for medial and lateral , key = lateral trochlear ridge)  I lateral trochlear ridge left intact  II lateral trochlear ridge is part of condylar fragment (medial or lateral), less stable, radioulnar translocation possible . Jupiter classification  proximal extension of fracture line  low: Milch I  high: Milch II . TM:  non-op: posterior splinting, elbow flexed 90°  lateral condylar fracture  supination  medial condylar fragment  pronation  op: screw fixation with or without collateral ligament repair . complications  lateral  cubitus valgus  tardy ulnar nerve palsy  medial  cubitus varus  post-traumatic arthritis o capitellum fractures . in coronal plane with shear fracture parallel to anterior humerus . block of flexion: anterior displacement of articular fragment into coronoid/radial fossae . classification  I (Hahn-Steinthal fragment): large osseus component of capitellum, sometimes with trochlear involvement  II (Kocher-Lorenz fragment): articular cartilage with minimal subchondral bone  III markedly comminuted . TM  non-op: immobilisation in posterior splint (3 weeks)  op:  I p-a screws, a-p headless screw  excision most type II . complications:  osteonecrosis  posttraumatic arthritis  cubital valgus  loss of motion (flexion) o trochlea fractures (Laugier fracture) . associated with elbow dislocation . TM  non-op: posterior splint immobilization (3 weeks)  op: Kirschner wire/screw fixation . complications:  arthritis  range of motion↓ o lateral epicondylar fractures . extremely rare . resisted wrist extension . TM: symptomatic immobilization . complications: excision/relief o medial epicondylar fractures . more common than lateral 41 . entrapment of ulnar nerve . pain on active flexion of wrist or forearm pronation . TM:  short-term immobilization up to 2 weeks  displaced fragments:  manipulation and immobilization  fibrous union  open reduction and internal fixation  screw or Ki wire  excision . complications  arthritis  weakness of flexor mass o fracture of supracondylar process . anteromedial surface of distal humerus . ligament of Struthers  medial epicondyle . median nerve/brachial artery transverse . TM: non-op splint immobilization in posterior elbow splint . complications  myositis ossificans  recurrent spur formation 47. Shoulder dislocations (glenohumeral dislocation)  anterior > posterior > inferior/superior  stability o passive: . joint conformity . vacuum effect of limited joint volume . adhesion/cohesion  synovial fluid . scapular inclination (≠ inferior dislocation) . joint capsule . superior glenohumeral ligament . middle glenohumeral ligament . inferior glenohumeral ligament . glenoid labrum . bones: acromion, coracoid, glenoid fossa o active: . biceps, long head . rotator cuff (supra-, infraspinatus, subscapularis, teres minor)  anterior dislocation (84%) o mechanism: impact to posterior shoulder o shoulder held in slight abduction and external rotation o Hill-Sachs lesion: posterolateral head defect  impression fracture on glenoid rim o classification . degree of instability  dislocation vs. subluxation . chronology  congenital, acute/chronic, locked (fixed), recurrent, acquired (repeated minor injuries, capsular laxity) . force:  atraumatic  congenital laxity, usually self-reducing  traumatic  often detachment of anterior/inferior labrum (Bankart lesion) . pat. contribution  (in)voluntary . direction  subcoracoid, subglenoid, intrathoracic o TM

42 . non-op: traction-countertraction  Hippocratic: gentle internal/external rotation and axial traction  Stimson: analgesia, patient prone on stretcher, affected extremity hanging free, gentle manual traction  Milch: patient supine, upper extremity abduced and externally rotated, thumb pressure  Kocher: humeral head levered on anterior glenoid  then immobilization for 2-5 weeks . op: soft tissue interposition, displaced greater trochanter o complications: . recurrent dislocation . osseus lesions (Hill-Sachs, Bankart) . soft tissue injuries (rotator cuff, tendons) . axillary artery injury . elderly: injury of musculocutaneous and axillary nerve  posterior dislocation o no external rotation possible, limited anterior elevation o classification . etiology  traumatic: sprain, subluxation, dislocation, recurrent, fixed  atraumatic: voluntary, congenital, acquired ( recurrent microtrauma) . anatomic  subacromial (98%)  subglenoid (posteriorly and inferiorly to glenoid)  subspinosus (medial to acromion, inferior to spine) o TM . non-op:  full muscle relaxation, sedation/analgesia, pain > anterior dislocation  patient supine, traction to adducted arm, no external rotation  immobilization 3-6 weeks . op:  in large posterior glenoid fragment, major displacement of associated lesser tuberosity fracture, open dislocation, irreducible dislocation, reverse Hill Sachs lesion  infraspinatus muscle/tendon placation (reverse Putti-Platt procedure)  transfer of tendon of long head of biceps to posterior glenoid margin (Boyd-Sisk procedure) o complications: . fracture . recurrent dislocation . neurovascular injury . anterior subluxation  inferior dislocation (luxatio erecta) o hyperabduction force o common associated injures: . rotator cuff avulsion/tear . pectoralis injury . proximal humeral fracture . injury to axillary artery/brachial plexus

43 o humerus locked in 110-160° of abduction and forward elevation o TM . non-op: traction-countertraction and immobilization for 3-6 weeks . op: “buttonholes” through inferior capsule/soft tissue  superior dislocation 48. The pelvis fractures  due to direct injury or longitudinally by femur  isolated fracture  pelvic ring remains intact o fracture of superior ischio-pubic ramus o fracture of inferior ischio-pubic ramus o fracture entering acetabulum o fracture of wing of ilium o avulsion of anterior inferior spine  fractures with disruption of the pelvic ring o injuries in anterior and posterior half of the ring o mechanisms . anterior-posterior crushing . compression from side to side . vertical shearing forces  treatment o in case of slight displacement  bed rest for 4-6 weeks o in disruption of symphysis pubis  external pelvic fixation o in upward displacement of half of the pelvis  heavy weight traction by femoral or tibial pin  complications o rupture of bladder/urethra o injury of rectum/vagina o injury of a major blood vessel o injury of nerves (lumbo-sacral plexus) o involvement of acetabulum  osteoarthritis  high energy trauma  innominate bone  triradiate cartilage at dome of acetabulum  Young and Burgess classification o 1 lateral compression (LC) . I sacral impaction on side of impact, transverse fracture of pubic rami, stable . II posterior iliac wing fracture (crescent) on side of impact and variable disruption of posterior ligamentous structures  variable mobility of anterior fragment (internal rotational stress), maintains vertical and external rotational stability, with or without anterior sacral crush injury . III LC-I or II on side of impact, contralateral hemipelvis: external rotational injury (“windswept pelvis”)  sacroiliac, sacrotuberous, sacrospinous ligaments rupture o 2 anterior-posterior compression (AP) external rotational injury, symphyseal diastasis, longitudinal rami fractures . I symphyseal diastasis < 2.5cm, vertical fracture of one or both pubis rami, intact posterior ligament . II symphyseal diastasis > 2.5cm, widening of sacroiliac joint  anterior sacroiliac ligament disruption, intact posterior sacroiliac ligament, disruption of sacrotuberous, sacrospinous ligaments, “open book” injury, internal and external rotational stability, vertical stability intact 44 . III complete abruption of symphysis and ligaments, external rotational instability, lateral displacement, no cephaloposterior displacement, completely unstable o 3 vertical compression (VC)  complete disruption of symphysis and ligaments, extremely unstable in cephaloposterior direction, inclination of pelvis o 4 combined mechanisms  Tile classification o A stable . 1 fracture of pelvis, pelvic ring intact, avulsion injury . 2 stable, minimal displacement of ring o B rotationally unstable, vertically stable . 1 external rotation instable, open book injury . 2 lateral compression injury, internal rotation unstable, ipsilateral only . 3 lateral compression injury, bilateral rotation unstable, bucket-handle o C rotationally and vertically unstable . 1 unilateral . 2 bilateral, one side rotationally unstable, other vertically unstable . 3 bilateral, both sides roarionally unstable  OTA o A fractures of pelvic ring, stable . 1 fracture of innominate bone, avulsion . 2 fracture of innominate bone, direct impact . 3 transverse fracture of sacrum and coccyx o B fractures of pelvic ring, partially unstable . 1 unilateral, partial disruption of posterior arch, external rotation (open book) . 2 unilateral, partial disruption of posterior arch, internal rotation (lateral compression) . 3 bilateral, partial lesion of posterior arch, o C fractures of pelvis ring, unstable disruption of posterior arch . 1 unilateral, complete . 2 bilateral, ipsilateral complete, contralateral incomplete . 3 bilateral, complete  TM o Tile stabilizing options . 1  A1/2: protected weight-bearing and symptomatic treatment . 2  B1: if diastasis < 2cm  see above; otherwise external fixation and symphyseal plate . 3  B2/3:  ipsilateral: elastic recoil  contralateral: external fixation or ORIF ( in case of leg discrepancy) o external fixation: rectangular construct mounted on 2-3 5mm pins spaced 1cm apart along anterior iliac crest o internal fixation  complications o infection o thrombembolism o mal-/nonunion 49. Fractures of the vertebral body

45  Denis classification o I compression fractures . usually stable . only anterior ligament . anterior/lateral wedging (hyperflexion of spine) . height of posterior part maintained o II burst fractures . axial loading of spine . failure of anterior and middle columns . one or both endplates involved . bone fragments may be extruded into spinal canal . loss of height . laminar fractures . separation of pedicles o III seat-belt injury . rapid deceleration . failure of posterior and middle columns . instable in flexion . through bone (Chance fracture), ligaments or both o IV fracture dislocations  failure of all 3 columns . flexion-rotation-fracture-dislocation  fracture of articular process on one side or slicing fracture through vertebral body, rotation and subluxation of spine . shear types of fracture-dislocation  posterior-anterior type  upper segment shears forwards, often with fracture of posterior arch  anterior-posterior type  complete ligamentous disruption, often no fracture  flexion-distraction type  anterior annular tear, stripping of anterior longitudinal ligament, anterior subluxation  TM o IMMOBILIZATION o Halo vest o Minerva plast 50. Fractures of the foot  talar neck fractures o classification . I fracture without displacement . II fracture and subtalar subluxation, proximal portion in plantar flexion . III tibia between the fragments, posterior fragment extruded backwards and medially, main portion displaced laterally . IV head of talus dislocates from navicular + type II/III  other talar injuries o dome fractures  upper articular surface of talus, shearing injury o avulsion fracture o fracture of lateral process of talus o fracture of body of talus  after comminution o compression of head of talus  calcaneal fractures o valgus tilt o vertical fracture of tuberosity  no subtalar joint involvement

46 o horizontal fracture . posterior superior angle . avulsion fracture, involving Achilles tendon o avulsion fracture of sustentaculum tali o anterior calcaneal fracture  articulation with cuboid  peritalar dislocation o disruption of lateral ligament of ankle, talocalcaneal ligaments, medial displacement  total dislocation of talus o disruption of all ligaments  acute rupture of tendocalcaneus  midtarsal dislocations  isolated fracture of navicular o body o tuberosity (traction of posterior tibial muscle)  tarsometatarsal dislocations o Myerson classification  3 columns o common patterns . medial column . all 3 columns  dorsal dislocation of all joints . all 3 columns  dislocation of all, fracture of base of II. metatarsal bone . lateral column  fracture of fifth metatarsal bone o Jones fracture  distal to intermetatarsal joint  metatarsal shaft and neck fracture  first metatarsal fracture  march fracture  stress fracture, usually neck/shaft of 2nd metatarsal bone  phalangeal fracture 51. Malleolar fractures  pilon o mechanisms of injury . axial compression . shear forces . combined o Ruedi-Allgower classification . 1 no significant articular incongruity, cleavage fracture, no displacement of bony fragments . 2 significant articular incongruity and minimal impaction/incongruity . 3 significant articular incongruity and metaphyseal impaction o Mast classification . A malleolar fracture and significant posterior lip involvement . B spiral fracture of distal tibia and extension into articular surface . C “central impaction injury”  talar impaction, extension into articular surface with or without fibular fracture, subtypes 1-2 according Ruedi- Allgower o OTA . A extraarticular distal tibial fracture  1 metaphyseal simple  2 metaphyseal wedge  3 metaphyseal complex . B partial articular distal tibial fracture 47  1 pure split  2 split depression  3 multifragmentary depression . C complete articular distal tibial fracture  1 articular simple, metaphyseal simple  2 articular simple, metaphyseal multifragmentary  3 articular multifragmentary o TM . non-op: long-leg cast (6 weeks) . op:  internal fixation: only if no comminution, low profile anterior/medial buttress plate  external fixation:  in combination with external fixation  hybrid external fixation  articulating/non-articulating  calcaneal pin  arthrodesis o complications . soft tissue slough . necrosis . haematomas . non-/malunion . infection . posttraumatic arthritis . tibial shortening  ankle o Lauge-Hansen classification . SA (supination-adduction)  10-20%  associated with medial displacement of talus  stage I: transverse avulsion-type fracture of fibula or rupture of lateral collateral ligament  stage II: vertical-medial malleolar fracture . SER (supination-external rotation)  40-75%  I disruption of anterior tibiofibular ligament with or without avulsion fracture at tibial/fibular attachment  II spiral fracture of distal fibula, from anteroinferior to posterosuperior  III disruption of posterior tibiofibular ligament or fracture of posterior malleolus  IV transverse avulsion-type fracture of medial malleolus or rupture of deltoid ligament . PA (pronation-abduction)  5-20%  I transverse fracture of medial malleolus or rupture of deltoid ligament  II rupture of syndesmotic ligament or avulsion fracture at insertion sites  III transverse/short oblique fracture of distal fibula, lateral comminution or butterfly fragment . PER (pronation-external rotation) 48  5-20%  I transverse fracture of medial malleolus or rupture of deltoid ligament  II disruption of anterior tibiofibular ligament with or without avulsion fracture at insertion sites  III spiral fracture of distal fibula, from anterosuperior to posteroinferior  IV rupture of posterior tibiofibular ligament or avulsion fracture of posterolateral tibia o Danis-Weber classification . A fibular fracture below level of tibial plafond, oblique/vertical fracture of medial malleolus (SA) . B oblique/spiral fibular fracture at level of syndesmosis, caused by external rotation, disruption of anterior (and posterior) syndesmotic ligament (SE) . C above syndesmosis, associated with medial injury (PE, PA III) o Tile classification o OTA . A infrasyndesmotic lesion  1 infrasyndesmotic lateral malleolus, isolated  2 infrasyndesmotic lateral malleolus, associated medial malleolus fracture  3 infrasyndesmotic lateral malleolus and posterior medial tibial fracture . B transsyndesmotic lesion  1 transsyndesmotic lesion of lateral malleolus, isolated  2 transsyndesmotic lesion of lateral malleolus and associated medial lesion  3 transsyndesmotic lesion, medial lesion and fracture of posterolateral rim of tibia (Volkmann fracture) . C supradesmotic lesion  1 simple diaphyseal fibular fracture  2 complex (multifragmentary) fracture and associated medial injury  3 proximal fibular fracture and associated medial injury o TM . non-op: long-leg cast and posterior splint with U-shaped component . op  open reduction and internal fixation  lateral malleolar fracture: lag screw/Kirschner wire and tension banding  medial malleolar fracture: cancellous screw or figure- of-eight tension banding o complications . non-/malunion . wound problems . infection . arthritis . reflex sympathetic dystrophy . compartment syndrome of foot . tibiofibular synostosis 52. Traumatic lesions of the soft tissue of the knee

49  ligaments o tear of medial ligament . abduction of tibia upon femur . medial meniscus may also be torn . wide abduction on clinical examination only when cruciate ligaments and capsule are also torn . anterior draw test  90° flexion, quadriceps relaxed . Lachman test  10-20° flexion, moving upper end of tibia forwards . TM  conservative: aspiration of effusion, long-leg plaster for 6 weeks  operative: medial/anteromedial incision, plaster for 6 weeks o tear of lateral ligament . adduction of tibia upon femur . common associated injury: common peroneal nerve o tears of the cruciate ligaments . anterior (from anterior tibial intercondylar area to internal aspect of lateral femoral condyle): hyperextension, upper end of tibia forwards . posterior (from posterior tibial intercondylar area to internal aspect of medial condyle): upper end of tibia backwards . anterior draw test . Lachman test . TM:  anterior: delayed surgery  posterior: reconstruction if necessary o strain of medial or lateral ligaments . clinical features similar to torn meniscus o Pellegrini-Stieda´s-disease  menisci o sports injury, twisting force with (semi-)flexed knee o types  all begin as longitudinal split . “bucket-handle” tear  still attachment on both ends, most common, displacement towards middle of joint, full extension limited = “locking” sign . posterior horn tear  remains attached at posterior horn . anterior horn tear . transverse tear  usually artefact at time of operation o torn medial meniscus . pain on anteromedial aspect of joint . no full extension o torn lateral meniscus . clinical picture similar but less well-defined . pain often poorly localized o TM: excision of displaced fragment o horizontal tear of degenerate medial meniscus 53. Fractures of the tibia and fibula  most common long-bone fractures  mechanisms of injury o direct  high energy ( soft tissue), penetrating injury, bending, fibular shaft: direct trauma to lateral leg o indirect  tensional mechanisms, stress fracture  descriptive classification

50 o open/closed o localization: proximal, middle, distal thirds o fragment number and position: comminution, butterfly fragment o configuration: transverse, spiral, oblique o angulation: varus/valgus, ant/post, shortening o rotation o associated injuries  OTA o A simple . 1 spiral . 2 oblique (>30°) . 3 transverse (<30°) o B wedge (butterfly) . 1 spiral . 2 bending . 3 fragmented o C complex (comminuted) . 1 spiral . 2 segmented . 3 irregular  TM o acceptable reduction . <5° of varus/valgus angulation . <10° of a-p angulation . <10° of rotational deformity, external better than internal . < 1cm of shortening . >50% cortical contact o non-op . long-leg cast and progressive weight-bearing . time to union 16 +/- 4 weeks; delayed > 20 weeks . tibial stress fracture: cessation of offending activity, short-leg cast . fibular shaft fracture: weight-bearing as tolerated o op . fasciotomy (anterior, lateral, superficial posterior, deep posterior) . external fixation: open, unstable closed, complicated closed fractures . plates and screws: fractures extending into meta-/epiphyses . flexible nails: Enders nails, Rush rods  multiple curved intramedullary pins – angulation and rotation ↓, only stable fractures . intramedullary nailing  locked nails  healing↓  unlocked nails  rotation↑  reamed nails  closed fractures  unreamed nails  open fractures, I, II, IIIA  tibia fractures with intact fibula  long-leg casting  complications o mal-/non-union o soft tissue loss o stiffness o Sudeck atrophy o compartment syndrome o neurovascular injury

51 o fat embolism o claw toe deformity 54. Fractures of the distal femur, of the patella and upper tibia  distal femur o distal 9 cm of femur measured from the articular surface of the condyles o 5-7° physiological valgus of femur o descriptive classification . open vs. closed . localization: supra-, inter-, condylar . pattern: spiral, oblique, transverse . articular involvement . angulation: varus, valgus, rotational deformity . displacement: shortening, translation . comminuted, segmental, butterfly fragment o Neer classification . I minimal displacement . IIA condyles displaced medially . IIB condyles displaced laterally . III conjoined supracondylar and shaft fractures o Seinsheimer classification . I non-displaced fractures, < 2mm of displacement . II only distal metaphyses, no intraarticular extension  A two-part  B comminuted . III involving intercondylar notch in which one or both condyles are separate fragments  A medial separate  B lateral separate  C both . IV extending through articular surface of a condyle  A medial condyle (two-part/comminuted)  B lateral condyle (two-part/comminuted)  C complex and comminuted o OTA . A extraarticular  1 simple  2 metaphyseal wedge  3 metaphyseal complex . B unicondylar, partial articular  1 lateral condyle, sagittal  2 medial condyle, sagittal  3 frontal . C inter-/bicondylar, complete articular  1 articular simple, metaphyseal simple  2 articular simple, metaphyseal complex  3 multifragmentary articular fracture o treatment . non-op  longitudinal traction, early cast brace . op  indicated in open fracture, neurovascular injury, ipsilateral lower extremity fracture, displaced intraarticular fracture, irreducible fracture

52  relative indication: displaced extraarticular supracondylar fracture, peri-prosthetic fracture, marked obesity  95° condylar blade plate  dynamic condylar screw  condylar buttress plate  locked antegrade intramedullary nail  supracondylar nails  Zickel supracondylar device  no Enders nails, no Rush rods  external fixation: IIIb, IIIc  debridement with or without external fixation  internal fixation: I, II, IIIa  bone graft: autogenous corticocancellous and cancellous bone, allograft, substitutes o complications . malunion, non-union . post-tr. OA . infection . loss of knee motion  patella o mechanism of injury . direct  retinacula often still intact . indirect  retinacula often disrupted . combined o descriptive classification . open/closed . displacement . pattern: stellate, comminuted, transverse, vertical (marginal), polar . osteochondral o OTA . A extraarticular  1 avulsion  2 isolated body fracture . B partial articular  1 vertical, lateral  2 vertical, medial  3 multifragmentary (stellate) . C complete articular  1 transverse  2 transverse, second fragment  3 complex o TM . non-op  intact extensor mechanism, nondisplaced or minimally displaced (<3mm)  cylinder cast . op  open reduction and external fixation  tension banding with Kirschner wires or cancellous lag screw  split after op  patellectomy

53  partial: large salvageable fragment and smaller comminuted polar fragments  total: extensive comminution  then: long-leg cast 10° flexion, 3-6 weeks o complication . infection . fixation failure . refracture . non-union . avascular necrosis (prox. fragment) . posttraumatic OA . loss of knee range of motion . painful retained hardware . ↓ extensor strength and extensor lag . patellar instability  patellar dislocation o dislocation: patella alta, congenital, abnormalities of patella or trochlea, ↓ vastus medialis, ↑ lateral retinaculum o mechanism of injury . lateral: internal rotation of femur, on externally and planted tibia, knee flexed . medial instability: iatrogenic, congenital, traumatic . intraarticular . superior: forced hyperextension o descriptive classification . reduced/unreduced . congenital/acquired . acute (traumatic)/chronic (recurrent) . lateral, medial, intraarticular, superior o TM . non-op  reduction and extension casting/bracing with or without arthrodesis . op  lateral release  medial plication  proximal patellar realignment  distal patellar realignment o complications . redislocation . loss of range of motion of knee . patellofemoral pain  knee dislocations o uncommon injury o ginglymoid (hinge joint): patellofemoral, tibiofemoral, tibiofibular 10-0-140 o requires significant soft tissue injury o additionally: vascular injury – popliteal artery disruption (20-60%); neurologic injury – peroneal nerve (10-35%) o immediate reduction before radiographic evaluation – limb-threatening condition o descriptive classification

54 . anterior  forceful knee hyperextension >-30°, most common (30-50%), associated with posterior and possible anterior cruciate ligament tear . posterior  “dashboard injury”, anterior and posterior ligament rupture . lateral  valgus force, medial supporting structure disrupted, often tears of both cruciate ligaments . medial  varus force, lateral and posterolateral structures disrupted . rotational  varus, valgus and rotational component, buttonholing of femoral condyle through capsule o TM . non-op:  immediate closed reduction  ant.: axial limb traction and anteriorly directed force on distal femur  post.: axial limb traction and extension and anteriorly directed force on upper tibia  med./lat.: axial limb traction and lateral/medial translation of tibia  rotational: axial limb traction and derotation of tibia  then splinted at 20-30° of flexion . op:  in residual soft tissue interposition, open injuries, vascular injuries, unsuccessful closed reduction o complications . limited range of motion . ligamenteous laxity  instability . vascular compromise . nerve traction injury  upper tibia = tibial plateau o lateral > medial o mechanism of injury: violent varus/valgus force o neurovascular injury (!), hemarthrosis, compartment syndrome (V, VI) o associated injuries  meniscal tears (50%), ligamentous disruptions (collateral, cruciate) o Schatzker classification . I lateral plateau, split fracture . II lateral plateau, split depression fracture . III lateral plateau, depression fracture . IV medial plateau fracture . V bicondylar fracture . VI plateau fracture and metaphyseal-diaphyseal dissociation o OTA . A extraarticular fractures . B partial articular fractures  1 pure split  2 pure depression  3 split depression . C complete articular fracture  1 articular simple, metaphyseal simple  2 articular simple, metaphyseal multifragmentary  3 articular and metaphyseal multifragmentary o TM . non-op

55  reduction via distal supramalleolar skeletal traction and ligamentotaxis  immobilization in fracture brace, no weight-bearing . op  in displacement, instability, open fracture, compartment syndrome, vascular injury  I  IV: percutaneous screws/lateral “L” plate, otherwise open reduction and internal fixation, in depressed fragments: elevation via bone tamp  V + VI: ring or hybrid fixator  weight-bearing:  I  III: started at 4-8 weeks (until 12 weeks)  IV  VI: started at 8-12 weeks o complications . knee stiffness . infection . compartment syndrome . malunion/non-union . OA . peroneal nerve injury . popliteal artery laceration . avascular necrosis 55. Diaphyseal femoral fractures (femoral shaft fractures)  between 5 cm below lesser trochanter and 5 cm proximal to adductor tubercle  usually due to high energy trauma  blood loss!!!  descriptive classification o open vs. closed o localization: proximal, middle, distal third, supra-/infraisthmal o pattern: spiral, oblique, transverse o angulation: varus, valgus, rotation deformity o displacement: shortening, translation o comminuted, segmental, butterfly fragment  Winquist and Hansen classification o I minimal, no comminution o II cortices of both fragments at least 50% intact o III 50-100% cortical comminution o IV circumferential comminution, no cortical contact at fracture site  OTA o A simple fracture . 1 spiral . 2 oblique (>30%) . 3 transverse (<30%) o B wedge fracture . 1 spiral . 2 bending . 3 fragmented o C complex fracture . 1 spiral . 2 segmented . 3 irregular

56  treatment o non-operative . skin traction: only young children . skeletal traction: in patients too sick for surgery . cast brace o operative . intramedullary nailing: Enders nails, Rush rods  3 point fixation  better: reamed locked nails  unreamed locked nails (in I, II, IIIA)  retrograde intramedullary nails . external fixation  method of choice for IIIB/C open fractures  compression plating  complications o nerve injury: uncommon o femoral artery injury  compartment syndrome o infection o refracture o non-union, delayed union o mal-union o fixation device failure 56. Fractures of the upper femur  fractures of the femoral head o usually in combination with hip dislocation o blood supply of the femoral head: medial and lateral femoral circumflex artery, artery of ligamentum teres o Pipkin classification . I  hip dislocation and fracture of the femoral head caudad to fovea capitis femoris . II  hip dislocation and fracture of the femoral head cephaldad to fovea capitis femoris . III  I/II + fracture of femoral neck . IV  I/II + fracture of acetabular rim o orthopaedic trauma association classification of femoral head fractures . C1 femoral head split fracture  1.1 avulsion of lig. teres  1.2 rupture of lig. teres  1.3 large fragment . C2 femoral head depression fracture  2.1 posterior and superior  2.2 anterior and superior  2.3 split depression . C3 femoral head fracture + femoral neck fracture  3.1 split + transcervical neck fracture  3.2 split + subcapital neck fracture  3.3 depression + neck fracture o treatment according to Pipkin classification . I  closed TM if reduction adequate (<1mm step-off), otherwise open reduction and internal fixation with small cancellous screws or Herbert screws, anterior approach . II  open reduction and internal fixation

57 . III  young patient: open reduction and internal fixation (neck and head), anterolateral approach (Watson-Jones); older patients: prosthetic replacement . IV  dependent on acetabular fracture o complications: . osteonecrosis . post-traumatic osteoarthritis  fractures of the neck of the femur o close of epiphysis: 16 years of age o angles: neck-shaft 130° +/- 6°; femoral anteversion 10° +/- 6° o capsule: anteriorly intertrochanteric line, posteriorly 1-1.5 cm proximal o common > 60 years of age, more common in women (general osteoporosis), due to fall or stumble (rotational force), 84% of patients have mild to severe osteoporosis o in 95% marked displacement (laterally and upwards), 5% impacted fragments o displaced fracture: lateral rotation up to 90°, limb shortened 2-3 cm, severe pain on movement o impacted abduction fracture: no shortening, no rotation o mechanisms of injury . low energy – direct/indirect . high energy . cyclical loading o lateral and anterior-posterior X-ray o anatomic location: . subcapital . transcervical . basicervical o Pauwels classification . I 30° . II 50° . III 70° o Garden classification . I  incomplete/impacted . II  complete/non-displaced on a-p and lateral views . III  complete/partial displacement . IV  completely displaced o OTA . B1 subcapital and slight displacement  1.1 impacted in valgus > 15°  1.2 impacted in valgus < 15°  1.3 non-impacted . B2 transcervical  2.1 basicervical  2.2 midcervical adduction  2.3 midcervical shear . B3 subcapital, non-impacted displaced  3.1 moderate displacement in varus and external rotation  3.2 moderate displacement, vertical translation, external rotation  3.3 marked displacement o current classification . non-displaced and impacted valgus fracture  good prognosis . displaced 58 o TM: . aims of TM: no additional damage, decrease discomfort, restore hip function, rapid mobilization . in displaced fracture  rigid immobilisation or metal prothesis of femoral head; three flanged Smith-Petersen nail or its modifications; three parallel screws or compression screw plate (dynamic hip screw)  open reduction and internal fixation and capsulotomy (young patients) . in impacted abduction fracture . operative TM  reduction  internal fixation  prosthetic replacement (elderly)  hemiarthroplasty o complications . non-union . osteonecrosis . fixation failure . thrombembolism  intertrochanteric fractures o 50% of all proximal femoral fractures o between greater and lesser trochanter  extracapsular fracture o shortening, external rotation, varus position o displacement: . greater trochanter: laterally and proximally . lesser trochanter: medially and proximally o Bayd and Griffin classification . I single fracture, along intertrochanteric line, stable, easily reducible . II major fracture line along intertrochanteric line and comminution in coronal plane . III at level of lesser trochanter, variable comminution, reverse obliquity = extension . IV extending into proximal femoral shaft in at least 2 planes o Evans classification . I primary fracture line from lesser trochanter proximally and laterally, subdivision: initial stability, stability after reduction . II reverse obliquity fracture: inherently unstable o Kyle classification . I non-displaced, stable . II displaced into varus and small lesser trochanter fragment, stable . III displaced into varus, comminution, greater trochanter fracture, unstable . IV III + subtrochanteric extension o OTA o TM . non-op  hip deformity . op  sliding hip screw  intramedullary hip screw (sliding hip screw + intramedullary nail)  prosthetic replacement o complications . loss of fixation

59 . non-union/mal-union . malrotation deformity . osteonecrosis of femoral head . lag screw-sideplate separation . lag screw migration  pelvis  trochanteric fractures o greater trochanter . 7-17 years of age: avulsion of epiphysis . elderly: trauma . descriptive classification  associated fractures  displacement  angulation  rotation  comminution . treatment  non-op  analgesics  assisted weight-bearing  op  displacement > 1cm  lateral incision  operative fixation via screws, wires, heavy sutures (tension bad wiring of fragment and attached abductor) . complications  malunion  non-union o lesser trochanter  subtrochanteric fractures o between lesser trochanter and 5 cm below o Fielding classification . I level of lesser trochanter . II < 2.5cm below level of lesser trochanter . III > 2.5cm below level of lesser trochanter o Seinsheimer classification . I non-displaced/ less than 2 mm displacement . II two-part fracture  A transverse femoral facture  B spiral fracture, lesser trochanter attached to proximal fragment  C spiral fracture, lesser trochanter attached to distal fragment . III three-part fracture  A lesser trochanter part pf 3rd fragment, which has inferior spike of cortex of varying length  B spiral fracture of proximal third of femur, 3rd part = butterfly fragment . IV comminuted fracture with at least 4 fragments . V subtrochanteric-intertrochanteric fracture o Russell-Taylor classification o OTA o treatment . non-op  skeletal traction in 90°/90° position  spica casting/cast bracing

60 . op  interlocking nails: centromedullary, cephalomedullary  95°fixed angle plates  sliding hip screw  Zickel nail  condylocephalic nails  bone grafting o complications . loss of fixation . non-union, malunion 57. Traumatic dislocations of the hip joint and acetabular fractures  posterior dislocation and fracture dislocation o femoral head forced out of the back of the acetabulum by violence applied along the shaft of the femur while the hip is flexed or semi-flexed o fracture dislocation: bony fragment from rim of acetabulum displaced backwards o clinical features: femur rotated medially, displaced upwards, new vertical axis through greater trochanter o treatment: . reduction by pulling longitudinally upon femur while hip is flexed to a right angle and rotated laterally  support from beam for 3-6 weeks . operation for large acetabular fragment o complications . injury to sciatic nerve . damage to femoral head . avascular necrosis of femoral head . post-traumatic ossification . osteoarthritis  anterior dislocation o due to forced abduction and lateral rotation  central fracture-dislocation o femoral head driven through the medial wall of the acetabulum towards pelvic cavity, capsule remains intact o heavy lateral blow upon femur, longitudinal force upon femur in abduced hip o treatment: restoration of acetabular surface if possible  2 columns o anterior (iliopubic component) o posterior (ilioischial component)  Judet-Letournel classification o elementary patterns . posterior wall  inferior to acetabular dome  “marginal impaction” in posterior fracture dislocation . posterior column  detaches entire posterior column in 1 fragment with or without central femoral head dislocation . anterior wall  associated with disruption of iliopectineal line with or without associated anterocentral displacement of femoral head . anterior column  disruption of iliopectineal line  associated with anteromedial displacement of femoral head 61 . transverse  transtectal (through acetabular dome)  juxtatectal ( between acetabular domeand foaas acetabuli)  infratectal (fossa acetabuli) o associated patterns . T-shaped . posterior wall and posterior column . transverse and posterior wall . anterior column and posterior or hemitransverse . both columns  OTA o A partial articular, one column . 1 posterior wall . 2 posterior column . 3 anterior o B partial articular, transverse . 1 transverse . 2 T-shaped . 3 anterior column, posterior hemitransverse o C complete articular, both columns . 1 high . 2 low . 3 sacroiliacal joint involvement  complications o wound infection o nerve injury (sciatic, femoral, superior gluteal) o heterotopic ossification o avascular necrosis o chondrolysis

 comminution fracture = Splitterfraktur, Trümmerbruch  reduction = Einrenkung  varus = nach innen gekrümmt, O-Stellung  valgus = nach lateral konkav, X-Stellung  arthrodesis = operative Gelenkversteifung  reamed = erweitert, ausgebohrt  butterfly fragment =  meta-, dia-, apo-, epiphysis o metaphysis = Längenwachstumszone, zwischen Diaphyse und Epiphyse o diaphysis = Mittelstück o apophysis = Ossifikation von Nebenkernen, später Verschmelzung mit dem Hauptknochenkern, meist Knochenfortsätze o epiphysis = Endstück  cleavage fracture = Spaltungsfraktur  rods = Stab, Stange  nightstick fracture = Schlagstock  bending fracture = Biegungsfraktur  buttress = Stütze 62  trident hand = Dreizackhand  cancellous =   cleavage = Spaltung

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