Review of the Common Orthopaedic Problems
Review of the Common Orthopaedic problems • Upper limb – fractures – dislocations – ligament/tendon injuries • Lower limb – fractures – dislocations – ligament/tendon injuries
2 Fractures
bones have rich blood supply & heal well provided fractured bone ends are adeqqyuately aligned (reduced) and immobilized assess for damage to related structures ! – especially nerves & vessels
3 Fracture Clavicle
• common in both adults & children • usually middle third • almost invariably heal with some deformity
check pulses in arm to assess subclavian artery (rare complication)
• common in elderly (usually impacted) • reduce if ggyrossly displaced (more likely in adolescents) • hold with collar & cuff • exercise the shoulder joint ASAP!
assess axillary nerve
5 Dislocated shoulder
• common injury • usually inferiorly displaced (rotator cuff weakest here) • test for nerve (axillary) & vessel injjyury • reduce • exercise – stability of shoulder joint primarily due to rotator cuff muscles
6 Reduction dislocated shoulder
usually inferiorly & antildilteriorly displaced 7 Painful arc syndrome
• painful abduction typically at around 90 degrees • due to impingement in sub‐ acromial space:
– supraspinatus tendon – sub‐acromial bursitis – anterior rotator cuff (subscapularis) – posterior rotator cuff
8 Painful arc syndrome
9 Painful arc syndrome
10 # Shaft of humerus
• any age due to fllfall or heavy blow to arm • reduction seldom necessary • hold in collar & cuff + supporting brace • exercise joints above & below the #
assess radial nerve function
11 Supracondylar # humerus
` common, especially in children (endangers epihyseal growth plate) ` assess brachial artery & median nerve ` reduce & hldhold in flex ion with collar & cuff +/‐ pop slab ` exercise shoulder & hand/fingers
assess radial pulse & median nerve status
12 vip # Head of radius
• due to fall on outstretched hand • may be easily missed • suspect if: – tender over radial head – pain on pronation/supination
13 # Head of radius any fracture involving articular surface is complicated and nee ds urgen t re ferra l to an orth opaedi c surgeon !
#’s involving an articular surfaces prone to develop OA in long term
14 # Olecranon
• caused by direct blow on olecranon • ? status of extensor mechanism • ‐‐> conservative if intact; open reduction & repair if disrupted
15 # Olecranon
16 Dislocated elbow
• usually olecranon process of ulna displaced posteriorly • important to exclude damage to vessels &/or nerves • hold in collar & cuff • exercise after 1/52
17 18 ‘Tennis elbow’
• lateral epicondylitis at extensor tendon origin • usually NOT seen in tennis players! • ? synovial membrane/articular cartilage impingement as intra‐articular injection of local anaesthetic often gives excellent results
19 Bursitis ‐ student’ s elbow
‘student’s elbow’ • inflammation of a bursa due to prolonged friction/irritation • prone to infection - especially difbitdangerous if bursa communicates with joint • (infections can comppyletely destro y a joint) however this bursa does not communicate with elbow joint • ttbtreat by: – drainage – antibiotics
20 Bursal communication do not communicate with do communicate with joint: joint:
` subacromial ` suprapatellar ` olecranon ` popliteus & medial head of ` prepatellar gastrocnemius ` infrapatellar ` semimembranosus ` sublbscapular
communication with joint very important in spread of infection ...
21 Mechanism of # forearm
22 Compound # forearm
Obvious problems • nerves • vessels • tendons • muscles
plus the real risk of serious bone infection ‘osteomyelitis’
compound #’s have great risk of infection 23 ##s’s lower radius & ulna
• due to fall on dorsiflexed hand • characteristic ‘dinner fork’ deformity • 3 stage reduction necessary • hold in ‘pop’ • exercise upper limb
24 Colles’ # lower end radius
25 # Scaphoid • endangered in falls on outstretched hand • # easily missed initially • check for tenderness in anatomical ‘snuff‐box’ & re x‐ray in 2‐3 weeks if unsure • common complication of avascular necrosis of proximal segment
26 # Scaphoid secondary avascular necrosis due to disruption of blood supply ... Scaphoid arterial supply
28 lateral ligament
scaphidhoid triquetral medial lunate ligament
ulna radius
Triangular articular disc (fibrocartilage)
29 ‘Mallet finger’
• avulsion of extensor tendon of terminal phalanx • occurs if finger forcibly bent during active extension (eg. catching a ball) • may ‐‐> fixed flexion deformity of terminal joint
30 position of ‘rest’ for hand
• position of rest for the hand ‐ ligaments & tendons at most relaxed position • index finger is less flexed than the other fingers • cf immobilization position to avoid excessive shortening
31 Infection in fingers
• x3 volar pulp spaces in the fingers • distal & middle spaces are confined (proximal communicates flfreely with web space) • when infected, pressure build‐up may lead to necrosis if unrelieved
32 Infection in fingers
33 33 Infection in fingers
34 34 35 1/20/2011 # Neck of femur ‘NOF’ common injury in elderly
36 36 # NOF
leg typically shortened & externally rotated
37 37 Garden’s classification
38 39 40 1/20/2011 Blood supply to hip
41 42 1/20/2011 blood supply to femoral head
vessels at risk
collec tive ly they may be regar de d sole blood supply of femoral head (in an adult) is via retinacular vessels along the neck - as ‘end arteries’ so blood supply to from capsule which attaches at its base the femoral head is endangered - especially with proximal ##s’s
43 Intertrochanteric #
44 DHS
45 Posterior hip dislocation
what is the mechanism and structure endangered in posterior dislocation?
46 Posterior hip dislocation
• traumatic dislocation (which requires considerable force ‐ eg MVA where knee hits dashboard) usually displaces the femur posteriorly • the sciatic nerve is endangered (affected in around 10% of cases)
47 Posterior hip dislocation
48 Posterior hip dislocation
49 50 51 DDH
• what is the mechanism and diagnosis of DDH ? • what is Trendelenberg’s test and how is it interpreted ?
52 DDH
• a common birth defect, routinely tested for in the clinical examination of the newborn (Ortolani’s test) • early diagnosis & treatment essential for full development of acetabulum • weight‐bearing may result in permanent deformity & resultan t arthr itic change
53 DDH ‐‐ untreated
54 Trendelenberg’s test
` stability of the hip joint when a person stands on one leg depends on three factors: ◦ gluteus medius & minimus are functioning normally ◦ head of femur enlocated (within acetabulum) ◦ neck of femur intact & have normal angle with shfhaft of femur ` if one of these factors is ddfefect ive, the pelilvis will siiknk downward on the opposite, unsupported side ‐ this is a positive Tdlb’Trendelenberg’s sign
55 Trendelenberg test
56 Hip joint pathology
why may perceived “pain in the knee” sometimes be due to hip joint pathology ?
57 # Shaft of femur
what is the major life threatening effect of a fractured shaft of femur ?
58 59 Fracture shaft of femur
• shock from profuse bleeding into the very large compartments of the thigh • particularly with laceration of profunda femoris artery which is endangered because it lies along the shaft of the femur
60 # distal femur
61 DDx for knee pain
• pain oriiigina ting from the hip jitjoint may be referred to the knee • review Hilton’s Law!
62 Examination of knee joint
in clin ica l examiiination of the knee joint, what is the significance of: • wasting of quadriceps muscles ? (in particular vastus medialis) • swelling of suprapatellar bursa ?
63 Examination of knee joint
• almost any knee joint pathology will lead to wasting of the quadriceps muscles ‐ especially noticeable in VM • injjyury to the knee may result in a large accumulation of synovial fluid in the suprapatellar bursa as well as the knee joint itself (because the bursa communicates freely with the knee joint)
64 Knee injuries
65 soft tissue knee injuries
what is the mechanism & effects of injury to each of the following: • medial &lateral collateral ligaments ? • anterior & posterior cruciate ligaments ? • medial &lateral menisci ?
66 Medial aspect
media l meniscus
medial ligament
67 Lateral aspect
ltlatera l meniscus
lllateral ligament
68 68 Collateral lig. injuries
` the strong collateral ligaments of the knee are taut in full extension ` the medial collateral ligament may be ruptured stressing by fdforced abduc tion (valgus strain) lateral ligament ` the lateral collateral stressing ligament by forced medial adduction (varus strain) ligament
69 Cruciate lig. injury • the cruciate ligaments are intracapsular but extrasynovial ‐ they have a very poor blood supply • however associdiated tearing of the surrounding membrane may lead to haemarthrosis (an accumulilation of bloo d wihiithin the jijoint cavi)ity)
70 ACL rupture
during weight-bearing the ACL normally prevents the tibia slipping forward
71 71 PCL rupture
• the posterior cruciate ligament normally prevents the tibia slipping backwards • particularly under stress while downhill skiing • note contribution of quadriceps mechanism in joint stablbility
72 Role of menisci
• act as shock absorbers to spread the load of the body over a larger area • help to deepen slightly the tibial articular surfaces • help to spread synovial fluid
73 Meniscal injuries
• may be ttdrapped bbtetween the condyles of the femur & tibia, and split longitudinally between their horns of attachment (‘bucket‐handle’ tear)
• media l meniscus is more commonly injured because: – it is longer – its horns are further apart – is less mobile
74 Medial meniscal damage 76 Medial meniscus more commonly injured • the medial meniscus is tethered to the MCL and is much less mobile than the lateral meniscus
• the LM which with its attachment to the popliteus and to the femur by the menisco‐femoral ligaments, can get ‘pulled out of the way’ so it is not surprizing that the MM is torn some 20 times more often than the LM
77 ‘locking’ mechanism of knee
• what is the mechanism of locking & unlocking in the normal knee ? • what is pathological ‘locking’ which may occur after injury ?
78 Normal ‘locking’ of knee `as knee moves into extension the ACL becomes taught, extension of the lateral condyle of the femur is thus terminated `further extension of medial condyle is made possible by passive rotation of lateral condyle around radius of taught ACL, this forces medial condyle to glide backwards into its own full extension
79 Normal ‘locking’ of knee
• this medial rotation of the femur on the tibial plateau tightens the oblique popliteal ligament ‐ the MCL & LCL are set slightly obliquely and are tightened simultaneously • all three become taut and limit further rotation ‐ this ‘screw home’ mechanism is said to lock the joint
80 normal ‘locking’ of knee
`in this posiiition the jjioint is slig ht ly hyperextended and all four ligaments are taut `the ACL preventing further extension and the other three preventing further rotation
81 normal ‘unlocking’ of knee
• from the ‘screw home’ or ‘locked’ position lateral rotation of the femur must precede flexion; this lateral rotation is produced by the popliteus muscle • the untwisted knee can now be flexed by the hamstrings • note flexion/extension takes place above the menisci, in the upper compartment, whereas rotation takes place below the menisci, in the lower compartment
82 Pathological ‘locking’ of knee
`due to intra‐artilicular fragment of bone or cartilage becoming wedged between the femoral & tibial condyles `results in the joint being unable to be fully extended (fixed flexion deformity)
83 Patella fracture
84 84 Dislocation of patella
whthat is the mechhianism & effect of dislocation of the patlltella ? – including the factors tending to provoke & prevent recurrence
85 Dislocation of patella
• occurs laterally due to the action of quadriceps pulling along the line of the femur ‐ which is at an angle to the tibia – & also provoked by tight lateral patellar retinaculum
• young females are more prone due to a tendency towards genu valgum (wider angle) and a relatively smaller patella
• stability due to prominent lateral condyle of femur; medial patellar retinaculum & medial pull of vastus medialis Patellar dislocation ‐‐ adult
87 Bursitis of the knee
• what is the site & structure involved in prepatellar bursitis ? (‘housemaid’s knee’) • what is the site & structure involved in ifinfrapa tlltellar bbitiursitis ? (‘clergyman’s knee’)
88 Prepatellar bursitis
` situated over lower half of patella & upper half of patellar ligament ` due to friction between skin & patella ` liable to infection ` seen in coal miners & military personnel
89 infrapatellar bursitis
• situated over tibial tuberosities
• especillially seen in roof tilers & carpet layers
• ddx patellar tendopathology & Osgood‐Schlatter syndrome
90 Patellar ‘tendonitis’
• inflammation of the patellar ligament • due to excessive load on the patellar ligament or ‘tendon’ • seen not just with jumping sports ! • often co‐exitists with patlltello‐flfemoral syndrome
91 Fracture to shaft tibia
` why is a fractured shaft of tibia often a compound fracture? ` entire medial surface of tibia is subcutaneous and skin is under tension (and associated with poor healing) ` note that a compound fracture exposes bone to air (also other environmental contaminants) and therefore prone to infection
92 Fracture to shaft fibula
why is a fracture of the shaft of fibula not usually a serious injury ? (compared to that of the tibia)
93 fracture to shaft fibula
• shaft surrounded by muscles on all sides (except at upper & lower ends) • protects skin from laceration • prevents displacement of bone by acting as a splint
• what is the mechanism & diagnosis of ankle ‘sprains’ ? • why is the lateral ligament complex more commonly injured than the medial ?
95 Ankle ‘sprains’
• forced inversion strain may tear or rupture the lateral collateral ligament complex of the ankle • forced eversion strain may tear or rupture the medial collateral ligament
96 Ankle ‘sprains’
“a ligament is more vulnerable to injury if it is in the form of discrete parts”
– therefore lateral collateral ligaments of ankle (in three discrete parts) more commonly injured than the stronger medldial (‘del toi d’) ligament (two adjoining parts)
97 collateral ligaments of ankle
`all ligament s have poor blood supply (therefore heal slowly) `but a rich nerve supply (pain & proprioception)
98 Lateral ligssankleankle
99 Medial ligs ankle
100 Tenosynovitis
“injury/inflammation of a tendon or tendon sheath occurs when the load applied to a tendon either in a single episode, or more often, over a period of time, exceeds its ability to withstand that load”
the very poor blood supply of tendons leads to prolonged healing times
101 Tenosynovitis
• predisposing factors – increase in activity – decrease in recovery time – poor muscle flexibility – decreased joint ROM • note – inflammatory exudate may lead to fibrous adhes ions and chihronic pai/tiffin/stiffness
102 Achilles tendon
• what is the site & structure involved in Achilles tendonitis ? • what is the effect of a complete rupture of the Achilles tendon ?
103 Achilles tendonitis
• injury occurs when the load applied to the tendon either in a single episode, or more often, over a period of time, exceeds its ability to withstand that load • note: very poor blood supply leads to prolonged healing times • ddx Achilles paratendonitis & retrocalcaneal or Achilles bursitis on examination ...
• silingle iiidtncident • patient feels (()hears) sudden snap in tendon • immediate pain, weakness & disability • ? related to degeneration or corticosteroid injection!
106 Special testing ... Stress # 2nd metatarsal
• fracture of a shaft of a metatarsal – in particular the 2nd which is the longest, narrowest & has its base wedged between the cuneiform bones may occur with minimal trauma (‘stress fracture’) • due to repeat ‘micro‐trauma’
108 Hallux valgus
` what is the mechanism and effects of hallux valgus ? ` a common deformity where the proximal phalanx of the big toe forms an acute angle with the 1st metatarsal ` particularly seen in the elder ly ` often associated with an overlying bursa (‘bunion’)
109 Hallux valgus & ‘bunions’ ‘flat foot’ ‐ pes planus
• what is the mechanism & effects of ‘flat foot’ ? • the medial & lateral longitudinal arches of the foot (and transverse arch) are maintained by the shape of the bones, plantar aponeurosis, ligaments, long tendons and intrinsic muscles • weakness of one or more of these links leads to collapse of these arches and a ‘flat foot’ results!
111 112 Arch supports
113 Arch supports
114 Plantar fasciitis
• what is the site & structure involved in plantar fasciitis ? • inflammation of the plantar fascia ‐ usually at its attachment to the calcaneus • ? due to excessive pronation
115 Plantar fasciitis
• x‐ray may show calcaneal spur ‐ but this is rarely the actual cause of the patient’s pain (? result of the plantar fifascia pathhlology )
• treatment consists mainly of stretching plantar fascia & orthotics to correct pronation (+/‐ corticosteroid injection or operation in dffdifficu lt cases)
116