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) 4 # Surgical neck humerus • 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 needs urgent referra l to an orthopaedi 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 destroy 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 dfdefect ive, the pelilvis will sikink 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 tdtrapped btbetween 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