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503 Cards in this Set
- Front
- Back
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Classification tibial inter condylar eminence |
Myers and McKeever 1. Minimal/no displacement 2. Elevated anteriorly with posterior hinge 3. Complete displacement
Goal: reduce fragment as well as possible
M&M recommend ORIF for 2&3 |
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Describe technique for ORIF displaced tibial eminence #'s |
Medial para patellar approach Expose tibial spine, meniscus & ACL & removal any entrapment Nonabsorbable suture or wire through distal ACL brought out distalky through holes drilled in prox tibial epiphysis avoiding physis
Arthroscopy technically challenging, use ACL guide
Account & Willis - ligament based or # based methods of fixation
Mal/non united #'s cause pain/instability & lack of extension
ORIF or femoral notch plasty |
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Complications of SH3/4 distal tibia |
Growth arrest Peripheral growth arrest from avulsion of perichondral ring Resultant angular deformity |
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What is an osteoblasts? |
Concerned with bone formation Derived from local mesenchymal precursors Form rows of cuboidal cells where new bone formed (trab/have radian systems) Rich in Alk phos Produce type 1 collagen & non village nous proteins for mineralisation bone matrix |
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What is an osteocytes? |
OB either remains as quiescent lining cell or becomes resting osteocytes In bone lacunae ? Function Osteocytic osteolysis - PThH & Ca ion transport |
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Osteoclasts? |
Principle mediators of bone resorption Large multinucleated cells derived from Mono cytic precursors Attracted by chemotaxis to prepared surfaces Ruffled border is zone of attachment to bone OC bone resorption carried out by lysosomal enzymes Resorption surfaces - how ships lacunae |
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New bone formation occurs... |
1. Endochondral ossification Ossification of proliferating cartilage Physis or bone repair 2. Membranous ossification Direct Ossification Sub periosteal new bone |
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Indications for SROM hinged prosthesis |
Severe ligamentous insufficiency Severe flexion or extension gap mismatch Recurvatum deformity Limb salvage procedures |
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What is patellar clunk syndrome? |
Patella & hypertrophied synovium on undersurface of quads tendon can bind in box & cam mechanism Hozack et al
Potential complication of PCL substituting knees |
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What is CMT ? |
Hereditary sensory and motor neuropathy |
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What is patellar clunk syndrome? |
Patella & hypertrophied synovium on undersurface of quads tendon can bind in box & cam mechanism Hozack et al
Potential complication of PCL substituting knees |
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What is CMT ? |
Hereditary sensory and motor neuropathy |
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Types of CMT |
Hypertrophic & neuronal & infantile hypertrophic
Hypertrophic Triple dose peripheral myelin protein. 22 Rep demyelinating & remyelination leads to nerve hyper trophy = onion bulb Areflexia/symmetrical distal m weakness&wasting/g&S sensory loss
Neuronal Neuropathy without demyelination Reflexes intact/n n. Conduction velocity
Infantile hypertrophic = dejerine-sottas disease |
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Definition ankylosing spondylitis |
HLA B27 seroneg spondyloarthropathy c SIJ & spine involvement |
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Definition ankylosing spondylitis |
HLA B27 seroneg spondyloarthropathy c SIJ & spine involvement |
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Pathology in ank spond |
1. Enthesitis 2. Synovitis diarthrodial synovial jnts
Enthesitis = inflammation of insertion of tendon/Lig/capsule into bone |
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Bamboo spine in which condition |
Ank spond |
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Bamboo spine in which condition |
Ank spond |
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Sero neg spondyloarthropathy |
RF & ANA neg
Reiters Ank spond Psoriatic Enteropathic |
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Bamboo spine in which condition |
Ank spond |
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Sero neg spondyloarthropathy |
RF & ANA neg
Reiters Ank spond Psoriatic Enteropathic |
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Complications of ank spond |
Spinal # (?neurol deficit - epidural haematoma) Craniocervical instability Pseudoarthrosis Cauda equina (canal stenosis) Periart arthropathy Peripheral enthesitis Extra skeletal manifestations
- ant uveitis - aortitis - pulm fibrosis - colitis - amyloidosis - sarcoidosis - prostatitis |
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X-ray features if ank spond hip/shoulder arthritis |
Concentric jnt space narrowing Osteophytes Sub sclerosis Bone ankylosis Protrusio |
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Ank spond vs RA |
Ank spond has... M Spine/SIJ/large jnt involvement Enthesopathy Aortitis Uveitis Bony fusion jnts RF neg, HLA B27 pos |
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Ank spond vs RA |
Ank spond has... M Spine/SIJ/large jnt involvement Enthesopathy Aortitis Uveitis Bony fusion jnts RF neg, HLA B27 pos |
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Osteotomy levels for ank spond |
C7/T1 Vert vsls mobile here, C8 n root most mobile, canal rel wide
L2 Localise conus Closing wedge vert osteotomy |
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Ank spond vs RA |
Ank spond has... M Spine/SIJ/large jnt involvement Enthesopathy Aortitis Uveitis Bony fusion jnts RF neg, HLA B27 pos |
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Osteotomy levels for ank spond |
C7/T1 Vert vsls mobile here, C8 n root most mobile, canal rel wide
L2 Localise conus Closing wedge vert osteotomy |
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Diagnostic criteria ank spond |
Modified New York classification
Clinical: Improved LBP w exercise 3/12 Limitation spinal movement c/s planes Decr chest expansion
Radiological: Severe unilateral sacroilitis Mild bilateral sacroilitis |
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Difference bw calcaneocavus & forefoot cavus |
Midfoot cavus 2 DF calc only Apex in tarsus
Forefoot cavus from PF 1st Ray |
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Difference bw calcaneocavus & forefoot cavus |
Midfoot cavus 2 DF calc only Apex in tarsus
Forefoot cavus from PF 1st Ray |
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Stages in Cavovarus |
1. Flex cavus & 1MT 2. HF mobile, fixed 1st MT equinus 3. Fixed HF, fixed lesser toes 4. Bony changes |
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Difference bw calcaneocavus & forefoot cavus |
Midfoot cavus 2 DF calc only Apex in tarsus
Forefoot cavus from PF 1st Ray |
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Stages in Cavovarus |
1. Flex cavus & 1MT 2. HF mobile, fixed 1st MT equinus 3. Fixed HF, fixed lesser toes 4. Bony changes |
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Coleman block test |
Tests correctibility of hind foot by eliminating forefoot deformity |
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What is Meary's angle |
Talo1st MT angle N= 0
Cavus >30 |
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What is Meary's angle |
Talo1st MT angle N= 0
Cavus >30 |
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Calc pitch |
Line be 1st MT head to inf calc and plantar surface calc
N= <20 >30 AbN Hind foot DF & Calcaneovarus |
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Describe anterior drawer for ankle instability |
Foot PF 10 Anchor foot, with other hand translate tibia anteriorly +'ve if pain or translation 3mm+
CFL plays no role
Talar tilt Tests CFL 0-23 N |
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Describe anterior drawer for ankle instability |
Foot PF 10 Anchor foot, with other hand translate tibia anteriorly +'ve if pain or translation 3mm+
CFL plays no role
Talar tilt Tests CFL 0-23 N |
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Signs of syndesmotic widening |
1. Clear space (med border fib & lay border post fib1cm above plafond) 5mm or less on AP & mortise 2. Overlap fib & ant tib tubercle 10mm AP, 1mm mortise 3. (Stress films under GA) |
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Classification for talar dome OCD |
Bernt & Hardy X-ray 1. Subchondral compression # w no visible frag 2. Partially attached osteochondral fragment 3. Fragment detached, undisplaced 4. Detached & displaced fragment
MRI 1. Undisplaced, stable 2. Undisplaced but unstable 3. Displaced, congruent with reduction 4. Displaced & incongruent with reduction
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Classification OCD knee |
Clanton & De Lee (same as B&H) 1. Stable, attached, undisplaced 2. Stable, partially detached, undisplaced 3. Unstable, completely detached, undisplaced 4. Unstable, completely detached, displaced
MRI (hefty) 1. Small signal change w'out margins 2. Clear margins, no fluid 3. Partially visible fluid 4. Completely visible fluid 5. Frag/detachment/displaced ie loose |
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Arthroscopic classification of OCD knee |
Guhl
2components - integrity of cartilage - stability
4components 1. Intact 2. Early separation 3. Partially detached 4. Crater with loose bodies |
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Poor prognostic features of OCD |
Size > 2cm Fluid behind lesion Hefti 4 Displaced Cartilage breach |
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Pathogenesis lumbar canal stenosis |
Degenerative disc disease -> rel hyper mobility of facet jnts -> ligamentous hyper trophy -> n root compression & venous congestion & HT -> intermittent neurogenic claudication |
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Define lateral recess |
Lat border dura to med border pedicle |
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Classification for bone defects |
Rand
1. Focal metaphyseal defect, intact cortical rim 2. Ext meta defect, intact rim 3. Combined meta & cortical defect |
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Differentiate bw CMF, CB, CS |
CMF & CB both neoplasms of incomplete cartilage differentiation CMF meta, no hyaline cart matrix, lack mitotic activity (<1/hpf) CB Epi, chicken wire calcification CS: hyaline cartilage matrix, Tumour permeation & mititic activity |
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Sagittal balancing principles |
Changing distal femur only affects ext Changing femiral component size only affects flexion Changing prox tibia/insert affects flex & ext |
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Classification of myelopathy |
Nurick classification
0 N or root symptoms 1 signs cord compression, N gait 2 gait difficulties, fully employed 3 gait diff prevent employment, walks unassisted 4 walks w assistance 5 WC or bed bound |
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Classification of myelopathy |
Ranawat
1 pain, no neuro deficit 2 subj weakness, hype reflexes, dyssthesias 3 obj weakness, long tract signs, ambulatory 4 + non ambulatory |
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Causes of positive trendelenburg test |
1. Pain in WB 2. Weak hip abductors 3. Shortened femoral neck 4. Subluxed/dislocated hip |
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Acquired dislocation hip after 1 yr due to |
Sepsis Muscle imbalance Persistent traumatic dislocation
Less commonly Charcot TB |
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N neck shaft angle at birth |
160 Decr to 125 later <120 = coxa vara |
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Congenital coxa vara |
Rare developmental disorder infancy/early childhood Defect endochondral ossification medial calcar When starts walking -bends into coxa vara
Hilgenreiners epi angle N 25-35 >60 -> valgus osteotomy |
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Acquired coxa valga |
'Mechanical' femoral neck shortening or overgrowth GT Causes abd m at disadvantage
Childhood: rickets , bone dystrophies, perthes Adolescence: epiphysioloysis Any age bone softening: osteomalacia, FD, path #, infection, # mal union, Paget's |
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Acquired coxa valga |
'Mechanical' femoral neck shortening or overgrowth GT Causes abd m at disadvantage
Childhood: rickets , bone dystrophies, perthes Adolescence: epiphysioloysis Any age bone softening: osteomalacia, FD, path #, infection, # mal union, Paget's |
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PFFD classification |
Aitken A gap in femoral neck or subtroch region B dysplasia & shortening C absent femoral head D a genesis of entire prox femur & acet 50% have distal anomalies |
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Acquired coxa valga |
'Mechanical' femoral neck shortening or overgrowth GT Causes abd m at disadvantage
Childhood: rickets , bone dystrophies, perthes Adolescence: epiphysioloysis Any age bone softening: osteomalacia, FD, path #, infection, # mal union, Paget's |
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PFFD classification |
Aitken A gap in femoral neck or subtroch region B dysplasia & shortening C absent femoral head D a genesis of entire prox femur & acet 50% have distal anomalies |
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Treatment PFFD |
A&B - mech fn hip jnt Subtroch osteotomy Bone grafts LL
C&D Amputation Van Ness |
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Acquired coxa valga |
'Mechanical' femoral neck shortening or overgrowth GT Causes abd m at disadvantage
Childhood: rickets , bone dystrophies, perthes Adolescence: epiphysioloysis Any age bone softening: osteomalacia, FD, path #, infection, # mal union, Paget's |
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PFFD classification |
Aitken A gap in femoral neck or subtroch region B dysplasia & shortening C absent femoral head D a genesis of entire prox femur & acet 50% have distal anomalies |
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Treatment PFFD |
A&B - mech fn hip jnt Subtroch osteotomy Bone grafts LL
C&D Amputation Van Ness |
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DD transient Synovitis hip |
Perthes SCFE TB Synovitis Juvenile chronic arthritis & ank spond |
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DD of perthes |
Transient Synovitis Morquio's Cretinism MED SSD Gauchers Esp if bilateral |
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NH perthes as described by Herring 1994 |
A small % have a v diff course w recurrent loss of motion, pain, eventual poor outcome. Most children have mod prob in active phase & then improve steadily, eventually having a satisfactory outcome |
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Interpretation of positive trendelenburg |
Pain: centre over hip to decr Abd pull, decr JRF
Pivot: sub/dislocated hip, femoral neck shortening
Power: Abd weakness |
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What is Baumann's angle? |
Humeral capitellar angle Reliably predicts carrying angle after reduction N = 85-89 >5 degrees cf other side unacceptable |
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What is Baumann's angle? |
Humeral capitellar angle Reliably predicts carrying angle after reduction N = 85-89 >5 degrees cf other side unacceptable |
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Schmorls nodes |
Small radio lucent defects in subchondral bone, Central/axial disc protrusions |
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Scheuermann def |
Ant very body wedging 5 degrees in 3consecutive vertebrae Overall kyphosis angle >40 |
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Scheuermann def |
Ant very body wedging 5 degrees in 3consecutive vertebrae Overall kyphosis angle >40 |
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DD scheuermanns |
Postural Infective: discitis , OM, TB spondylitis SED: look for defects in other joints |
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Klippel feil syndrome Defn |
Multiple ABN segments cervical spine Failure of F or S 3-8 weeks gestation |
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Klippel feil syndrome Defn |
Multiple ABN segments cervical spine Failure of F or S 3-8 weeks gestation |
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Associated conditions w Klippel Feil |
Cong scoliosis Sprengels Renal aplasia Mirror motions synkinesis Cong heart disease Cong C stenosis Brainstem Basilar invagination AAI Adj level disease |
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Sprengel deformity |
In descended scapula Small, rel wide, med rotated Ass: K-F, kidney, diastematomyelia, scoliosis |
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Classification for bone stock in TKR revision |
1. Contained metaphyseal defect: BG, TKR
2. Damaged metaphysis A one condyle B both Cement <1cm, augment <2cm, BG
3. Def metaphysis +/- collaterals +/- quads 1 bulk structural allograft 2. Tumour prosthesis/custom 3. Tantalum cones meta filling 4. Mesh/impaction graft |
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What is stress shielding |
Describes phenomenon of proximal femoral bone density loss observed over time in the presence of solidly fixed implant |
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Tarsal coalition |
**** Calcaneonavicular under 12 two thirds |
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Retro peritoneal lipomas - consider what in DD? |
Adrenal myelolipoma Angio myelolipoma Liposarcoma |
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Features of lipoma to suggest malignant transformation |
Thick or nodular septations Evidence of invasion Non fatty soft tissue component
<11% have intra substance calcifications |
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Def tarsal coalition |
Congenital fibrous, cartilaginous or bony connection bw 2 + tarsal bones due to failure segmentation |
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Defn Blounts |
Progressive pathological genu Varum centred at the knee |
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Describe N bowing pattern in children from birth |
At birth- genu Varum 14m - neutral 3 - peak genu valgum approx 10 degrees 7- physiologic adult genu valgum approx 5-7 degrees |
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Features differentiating Blounts from N |
N - symmetrical flare distal F/prox T
Blounts - Often bilateral, asymmetrical Progressive Varus deformity focused at the prox tibia Often severe Sharp angular deformity Metaphyseal beaking Varus thrust |
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Angle measurement in Blounts |
Drennan angle Angle subtended by line joining metaphyseal beaks & line along lat border tibia
>16 degrees = 95% chance of progression <10 = 95% chance natural resolution |
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Aetiology of blounts |
Mechanical overload in genetically susceptible individuals
Dyschondrosis in medial prox tibial metaphysis |
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Blounts angular measurement |
Drennan angle
Line connecting metaphyseal beaks Line perpendicular to long axis tibia Angle subtended bw 2 lines |
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Findings in quadrilateral space syndrome |
Compression of axillary n (&post circumflex humeral artery) Vague pain, worse on abd/ER Deltoid & teres minor weakness/wasting
Supra scapular n compression: weak SST & IST |
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What is a lipoma |
Benign tumour of mature adipocytes which is the most common soft tissue tumour |
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What is a HAGL lesion? |
Humeral avulsion GH ligament Specifically IGH ligament |
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What is is acromiale |
Failure of fusion of adjacent ossification centres
Simulates acromion # |
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What is is acromiale |
Failure of fusion of adjacent ossification centres
Simulates acromion # |
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Acromion ossification centres |
4 Preacromion Meso Meta Basiacromion - fuses by 12 All others by 22-25
60% bilateral |
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Components in lump exam |
Site Size Consistency Margin Multiplicity Tenderness Trans illuminates |
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Diabetic ulcer classification |
Wagner 0 skin intact, foot at risk 1 superficial ulcer 2 deeper f/t extension 3 deep abscess or OM 4 partial gangrene forefoot 5 extensive gangrene |
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Operation for interdigital neuroma |
Neurectomy with nerve burial & release trans interMT ligament |
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Ankle instability study |
Kerkhoffs Cochrane 2002 meta analysis Early WB - greater % - reduced time To return to work/sports |
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Definition scheuermann's disease |
Wedging of more than 5 degrees in 3 adjacent vertebra & overall kyphosis angle >40 |
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Definition of complete spinal cord injury |
No voluntary anal contraction AND 0/5 distal motor AND 0/2 distal sensory scores ( no periianal sensation) AND intact bulbocavernosis reflex
(If BC reflex absent - could be in spinal shock) |
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Definition of complete spinal cord injury |
No voluntary anal contraction AND 0/5 distal motor AND 0/2 distal sensory scores ( no periianal sensation) AND intact bulbocavernosis reflex
(If BC reflex absent - could be in spinal shock) |
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X-ray changes childhood discitis |
Loss of lumbar lordosis 1/52 disc space narrowing 1-3/52 end plate narrowing 3/52 sawtooth erosion Longstanding: scalloping Vert Magna: resolved infections |
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Complications & incidence in laminectomy & discectomy |
10% recurrence 5% arachnoid iris 2% infection 1% DVT 0.2% cauda equina 0.1% mortality |
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Complications & incidence in laminectomy & discectomy |
10% recurrence 5% arachnoid iris 2% infection 1% DVT 0.2% cauda equina 0.1% mortality |
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Which provocative test is highly specific but not Sn for C cord compression or myelopathy |
Lhermitte provocative manouver
Electric shock like sensations that pass through extremities when neck is flexed
Also in MS |
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Neurological level of injury is |
The most caudal level of spinal cord that has N motor & sensory function
Ie c5 tetra plexus has N c5 function |
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Pt with hip flexion deformity & ank spond at increased risk of what postop THR |
Anterior dislocation |
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Definition of Sn & Sp |
Sensitivity = how good a test is at finding something if it's actually there Or how often test will correctly identify a positive amongst all positives
Specificity = how accurate a test is against false positives Or % of times test will correctly identify negative result |
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Causes of spinal canal stenosis |
Cong vert dysplasia eg achondroplasia Chronic disc protrusion Facet jnt arthritis/hyper trophy Paget's Spondylolisthesis Ligamentous flavin hypertrophy |
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Causes of spinal canal stenosis |
Cong vert dysplasia eg achondroplasia Chronic disc protrusion Facet jnt arthritis/hyper trophy Paget's Spondylolisthesis Ligamentous flavin hypertrophy |
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Canal stenosis measurements |
On CT - more accurate AP mid Sagittal <11mm Interpedicular transverse <16mm |
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Classification for freiburgs infraction |
Smillie 1. Subchondral # on MRI 2. Dorsal collapse of articular surface 3. Collapse dorsal MT head, plantar intact 4. Collapse entire head, jnt narrow 5. Severe arthritic changes |
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Classification lateral mass # |
Lamina & pedicle # Kotani A. Separation B. Comminution C. Split D. Traumatic spondylolysis |
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Diagnostic criteria for DISH |
Flowing ossification AL aspect 4 contiguous vertebrae Preservation disc height Rel absence significant degenerative changes Absence facet jnt ankylosis/SIJ ankylosis, sclerosis or intra articular Osseous fusion |
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Diagnostic criteria for DISH |
Flowing ossification AL aspect 4 contiguous vertebrae Preservation disc height Rel absence significant degenerative changes Absence facet jnt ankylosis/SIJ ankylosis, sclerosis or intra articular Osseous fusion |
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Associated conditions DISH |
L spinal stenosis C spine: dysphasia/hoarseness/sleep apnoea/myelopathy # & instability |
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Genetic link in CTEV |
PITX1 |
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Genetic link in CTEV |
PITX1 |
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Associated conditions with CTEV |
Hand (Streeter dysplasia) Diastrophic dysplasia Arthrogryposis Tibia hemimelia Myelodysplasia Prune belly syndrome |
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Genetic link in CTEV |
PITX1 |
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Associated conditions with CTEV |
Hand (Streeter dysplasia) Diastrophic dysplasia Arthrogryposis Tibia hemimelia Myelodysplasia Prune belly syndrome |
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CTEV contractures: |
CAVE MF Cavus FF Adductus Hindfoot varus HF equinus |
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Defn disc protrusion & extrusion |
Protrusion: dist bw edges of herniation less than edges of base
Extrusion: dist bw edges of disc material >dist at base |
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Classification CP spine deformity |
Weinstein
GP 1: dble curves, minimal pelvic obliquity GP 2: large TL/L curve w marked pelvic obliquity |
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What is Botox? |
Competitive inhibitor of presynaptic cholinergic Rc with a finite lifetime (usually 2-3m) |
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What is Botox? |
Competitive inhibitor of presynaptic cholinergic Rc with a finite lifetime (usually 2-3m) |
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Goal of CP spinal surgery |
Obtain painless, solid fusion w well corrected well balanced spine w level pelvis
Careful assessment of family goals & risk/benefit analysis |
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Pelvic surgical fixation techniques in CP spinal fusion |
Galveston technique Stability, truncal balance, level pelvis Lamina S1 to PSIS & bw tables of ileum just ant sciatic notch |
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Definition HO |
Formation of bone in atypical, extraskeletal tissues Occurring spontaneously or after trauma, or within 2 m of neurological injury |
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Classification for HO |
Brooker 1. Bone islands 2. Bone spurs with >1cm gap bw opposing surfaces 3. Bone spurs w <1cm gap 4. Apparent bony ankylosis |
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Definition DISH |
Common spinal disorder of unknown origin characterised by back pain & stiffness Flowing ossification along AL margins at least 4 contiguous vertebrae & no changes spondyloarthropathy or degenerative spondylosis Almost universally along R side thoracic vertebrae due to protection from aorta |
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Stable TL burst # with no neurological deficits Op vs nonop |
Operative Rx provided no long term benefits Does have increased complication rate |
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Definition of protrusio |
Diagnosis made on the bases of AP pelvis X-ray demonstrating CEA > 40 & medialisation medial wall acetabulum past ilioischial line |
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What is pelvic incidence |
Correlates most strongly with isthmic spondylolisthesis grade
PI = PT + PS
Angle subtended by the initial line from COFH to midpt sacral endplate& a line perp to centre of sacral endplate |
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PI angles |
Constant in childhood 47 degrees Incr in adolescence Constant in adulthood 57 |
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What is diastematomyelia |
Fibrous/cartilaginous/bony bar creating longitudinal cleft in spinal cord
If cord does not reunite distally = diplomyelia (true cord duplication) |
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Define a complete spinal injury |
A complete injury has no sparing of motor or sensory function below the affected level and must have recovered from spinal shock (ie intact bulbocavernosis reflex intact) before diagnosis can be made
ASIA A |
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Difference bw neurogenic shock & spinal shock |
Neurogenic: hypotension & rel brady in acute spinal cord injury Circ collapse from loss of sympathetic tone
Spinal: temp loss spinal cord fn & reflex activity below level of injury - flaccid areflexic paralysis - Brady & hypo - absent bulbocavernosis reflex |
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Difference bw neurogenic shock & spinal shock |
Neurogenic: hypotension & rel brady in acute spinal cord injury Circ collapse from loss of sympathetic tone
Spinal: temp loss spinal cord fn & reflex activity below level of injury - flaccid areflexic paralysis - Brady & hypo - absent bulbocavernosis reflex |
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Variables which correspond to short life expectancy in or with CA mets |
Multiple spinal mets Multiple extra spinal mets Unresectable organ mets Critically ill SCI (c or I/c) Aggressive CA eg lung, osteosarc |
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Cervical stenosis |
Absolute <10mm Relative <13mm canal diameter |
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Defn cervical spondylosis |
Chronic disc degeneration & facet arthropathy that can lead to Radiculopathy Myelopathy Discogenic neck pain |
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Aetiological classification of lumbar canal stenosis |
Cong or acquired
Congenital: Achondroplasia SED Osteopetrosis
Acquired: Degenerative: ddd, spondyl,kyphosis, scoliosis Iatrogenic: fusion Misc: Paget's, DISH, ank spond Tumour Infection Trauma |
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Defn spinal instability w spondy |
4mm translation or >10 degrees angulation compared to adjacent segment motion |
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OI vertebra called |
Codfish vertebrae w compression # Kyphoscoliosus |
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Rickets defn |
Decr in Ca (+/- PO4) affecting mineralisation at epiphysis of long bones
Brittle bones Physeal cupping/widening LLax Skull flat Rachitic rosary Dorsal kyphosis (cat back) Long bone bowing
Gross distortion maturation zone &poorly defined zone of prov Ca |
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Defn rickets |
Disorder of mineralisation of osteoid matrix caused by inadequate Ca & PO4 |
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Defn rickets |
Disorder of mineralisation of osteoid matrix caused by inadequate Ca & PO4 |
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Types of rickets |
Vit D def (nutritional) Vit D dependent (type 1&2) Renal osteodystrophy Hypophosphatasia Familial hypophosphatemic (Vit D Rs) |
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Defn rickets |
Disorder of mineralisation of osteoid matrix caused by inadequate Ca & PO4 |
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Types of rickets |
Vit D def (nutritional) Vit D dependent (type 1&2) Renal osteodystrophy Hypophosphatasia Familial hypophosphatemic (Vit D Rs) |
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Defn osteopetrosis |
Metabolic bone disease caused by defective osteoclastic resorption of immature bone |
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Pathophys of osteopetrosis |
Inability to cause acidification in clear zone & therefore preventing bone resorption |
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Osteopetrosis 2 types |
AR - lethal AD - Albers Schonberg disease Deactivation of 3 genes: CA 2 Alpha3 subunit of vacuolar pump Cl Chnl 7 |
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Osteopetrosis 2 types |
AR - lethal AD - Albers Schonberg disease Deactivation of 3 genes: CA 2 Alpha3 subunit of vacuolar pump Cl Chnl 7 |
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Associated conditions osteopetrosis |
# long bones Coxa vara CN palsies: blind & deaf OM - impaired WBC fn
Erlenmeyer flask Rugger Jersey spine Bone within a bone Block femoral metaphysis
Give IF gamma 1 beta for AD form |
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Disproportionate dwarfism |
Achondroplasia SED MED Diastrophic dysplasia Kniests dysplasia Metaphyseal chondrodysplasia |
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Disproportionate dwarfism |
Achondroplasia SED MED Diastrophic dysplasia Kniests dysplasia Metaphyseal chondrodysplasia |
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Proportionate dwarfism |
Cleidocranial dysplasia (dysostosis) Mucopolysaccharidoses |
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Defn MED |
A form of disproportionate dwarfism characterised by irregular delayed ossification of multiple epiphyses
Failure of formation of secondary ossification centre (epiphysis) AD COMP defect ch19 Type IX collagen COL9A1/2/3 causing defect in type 2 collagen (9 is the link protein ) |
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Defn MED |
A form of disproportionate dwarfism characterised by irregular delayed ossification of multiple epiphyses
Failure of formation of secondary ossification centre (epiphysis) AD COMP defect ch19 Type IX collagen COL9A1/2/3 causing defect in type 2 collagen (9 is the link protein ) |
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Difference bw MED & perthes |
MED: Bilateral & symmetrical No metaphyseal cysts Early acetabular changes |
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Defn SED |
Form of disproportionate dwarfism characterised by short trunk and caused by defect in secondary ossification centre epiphysis |
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Paed forearm # Acceptable... |
<9 yr Complete displacement 15 angulation 45 malrotation
>9 yr 30 malrotation 10 angulation prox 15 angulation distally |
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Defn DMD |
DMD is an x linked rc disease of dystrophin causing progressive prox m wasting
Scoliosis behaves like NM curves w rapid progression <2 degrees/mnth -> restrictive cardiopulmonary fn Most advocate fusion at 20-30 |
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Defn sequestrum |
Necrotic bone which has been walked off from its blood supply & presents as a nidus for chronic OM |
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Defn DMD |
DMD is an x linked rc disease of dystrophin causing progressive prox m wasting
Scoliosis behaves like NM curves w rapid progression <2 degrees/mnth -> restrictive cardiopulmonary fn Most advocate fusion at 20-30 |
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Defn sequestrum |
Necrotic bone which has been walked off from its blood supply & presents as a nidus for chronic OM |
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Defn involucrum |
Layer of new bone formation outside the existing bone of OM |
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Subacute OM radio graphic classification |
1A&B lucency 2 metaphyseal w cortical bone loss 3 diaphyseal 4 onion 5 epi 6 spinal |
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Joints with intra articular metaphysis |
Shoulder Hip Elbow Ankle |
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Poor prognostic indicators in Paeds septic arthritis |
Age <6 m OM Hip jnt Delay >4 days to presentation |
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Indicators in septic arthritis to differentiate bw transient Synovitis |
90% chance if 3/4 WCC >12,000 Inability to WB Fever >38.5 ESR>40 CRP>2.0
Temp then CRP best predictors |
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Septic arthritis is a surgical emerg bc... |
Chondrolytic effect from pus Pressure effect from fluid contributing to risk of AVN |
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Action of Botox |
Botulinum toxin A decr Ach levels in synaptic cleft by blocking presynaptic release of Ach peripherally |
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Action of Botox |
Botulinum toxin A decr Ach levels in synaptic cleft by blocking presynaptic release of Ach peripherally |
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Action of baclofen |
Acts as GABA agonist Effects more centrally as an agonist at presynaptic GABA B away from NMJ Primarily at spinal cord level to block mono & poly synaptic reflexes |
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How is poly manufactured? |
Addition polymerisation occurs when a free radical added to monomer that contains C-C bond. Free radical breaks the dble C bond & occupies one of the sites. This results in another C having a free bonding site which then reacts with another free radical, and the reaction progresses |
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How do you improve wear characteristics of poly? |
Irradiate material to increase cross linking to improve wear |
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How do you improve wear characteristics of poly? |
Irradiate material to increase cross linking to improve wear |
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Creep |
Time dependent deformation in response to a constant load |
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Stress relaxation |
Time dependent decr in load reqd to maintain a material at a constant strain |
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American Rheumatism association criteria for Dx RA |
5 out of following must be present for >6 weeks 1. Morning stiffness 2. Pain on motion or tenderness in at least 1 jnt 3. Swelling at least 1 jnt 4. Swelling of at least 1 other jnt 5. Poor mucin ppt from synovial fluid 6. Characteristic histo changes in synovium 7. Characteristic changes in nodules |
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Bearing surface in young F with DDH needing THR |
C on C V smooth, hard, strong, stiff, biocompatible, bioinert, does not corrode & has v low friction & wear Linear wear rates minimal cf M on P |
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Classification systems of DR # |
Fernandez AO Frykman Melone
Fernandez: defines # according to mech of injury & useful for surgical planning |
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How to treat a comminuted intra articular DR # |
Treat this operatively via ORIF utilising a volar Henry's approach through the bed of FCR using a variable angle locking locking plate to achieve anatomical reduction & stable fixation of the fracture fragments |
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What is Tinels sign |
Tinels reported this eponymous sign in 1915 Repetitive percussion over the nerve causes tingling sensation in the cutaneous distribution of that nerve And reproduces patients symptoms |
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What would be expected in NCS in CTS? |
Incr latency Decr amplitude & velocity |
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Classification of causes in CTS |
Szabo classification
Anatomical: decr size, once contents
Physiological: neuropathic, inflammatory, altered fluid balance
Patterns of use: repetitive, WB w wrist extended, vibration |
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Classification of causes in CTS |
Szabo classification
Anatomical: decr size, once contents
Physiological: neuropathic, inflammatory, altered fluid balance
Patterns of use: repetitive, WB w wrist extended, vibration |
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Defn blounts |
Growth disorder of proximal PM tibial epiphysis secondary to combination of hereditary & developmental factors
Repetitive trauma to knee in overwt children when ambulating may overload growth plate (heuter volkmann principle) |
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Classification of causes in CTS |
Szabo classification
Anatomical: decr size, once contents
Physiological: neuropathic, inflammatory, altered fluid balance
Patterns of use: repetitive, WB w wrist extended, vibration |
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Defn blounts |
Growth disorder of proximal PM tibial epiphysis secondary to combination of hereditary & developmental factors
Repetitive trauma to knee in overwt children when ambulating may overload growth plate (heuter volkmann principle) |
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What constitutes a skeletal survey |
Skull Pelvis Chest C/t/L spine Tubular bones one side AP only Lat if asymmetry H&F |
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Thurston Hollands sign? |
SH2 injury with metaphyseal extension |
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Defn nonunion |
Nonunion is the arrest of the bone healing process
US FDA # that has failed to show progressive evidence of healing by 4-6 m after the injury |
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Defn nonunion |
Nonunion is the arrest of the bone healing process
US FDA # that has failed to show progressive evidence of healing by 4-6 m after the injury |
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Delayed union |
# taking longer to show progression of healing than would normally be expected
Failure of # to unite within the expected time |
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Atrophic nonunion |
Needs: Apposition of biologically viable bone ends Mechanically stable # fixation Autologous osteoinductive bone graft application (crest is gold standard) Healthy viable soft tissue envelope |
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# healing stages |
McKibbin JBJS 1978 Haematoma Inflammation Neoangiogenesis Soft callus Hard callus |
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Callus |
Woven bone formed by mineralisation of fibrocartilage matrix |
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Bone remodelling |
In response to local stress/strain in accordance to Wolfs law |
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Creeping substitution |
Primary bone healing Advancing front OC Followed by OB laying down bone matrix N bone turnover mechanism |
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Healing of drill holes |
Late medullary callus |
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Healing of drill holes |
Late medullary callus |
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Inter fragmentary strain |
Strain (motion) inversely proportional to # gap
Small gap & small motion = large strain Large gap + small motion = small strain |
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Pulsed US in # healing |
US is acoustic radiation at freq above human hearing. Mech energy transmitted to body as high freq pressure waves Wolfs law
Multiple studies suggest efficacy w accelerated # healing
Heckman JBJS 1994 R DB RCT Tibial dia # Incr healing |
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Intra membranous bone formation |
Essential in -fetal development -Fracture healing
Occurs without cartilage model
Embryonic flat bone( skull, max, mandible, clavicle, pelvis, subperiosteal long bone) Distraction osteogenesis Blastem bone (kids w amputations) # healing w rigid fixation compression plating) 1 component of healing w IMN
Conditions w defects in IMO: Cleidocranial dysplasia CBFA1 (runx2) on chmm 6 |
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Enchondral bone |
Long physeal growth Embryonic long bone formation Non rigid # healing
Cartilage model Chondrocytes produce cartilage Absorbed by OC, bone replaces cartilage by OB Occurs on metaphyseal side Collagen X
Sox-9: regulates chondrogenesis PTHrP- delays diff chondro in z of H
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Hueter volkmann law |
Compression across growth plate slows longitudinal growth
Tension accelerates |
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Groove of ranvier |
Osteochondroma
Ring incr mech strength of physis |
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NSAIDs & # healing |
Inhibit via prevent calcification of osteoid matrix
JBJS Br 2000 - significant - 2/3 tibia # nonunion |
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Biofilm bacteria complex |
Entity comprising bacteria in an extracellular matrix with a glycocalyx
Matrix is a vascular |
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Enchondral bone |
Long physeal growth Embryonic long bone formation Non rigid # healing
Cartilage model Chondrocytes produce cartilage Absorbed by OC, bone replaces cartilage by OB Occurs on metaphyseal side Collagen X
Sox-9: regulates chondrogenesis PTHrP- delays diff chondro in z of H
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Hueter volkmann law |
Compression across growth plate slows longitudinal growth
Tension accelerates |
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Groove of ranvier |
Osteochondroma
Ring incr mech strength of physis |
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NSAIDs & # healing |
Inhibit via prevent calcification of osteoid matrix
JBJS Br 2000 - significant - 2/3 tibia # nonunion |
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Biofilm bacteria complex |
Entity comprising bacteria in an extracellular matrix with a glycocalyx
Matrix is a vascular |
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Osteomyelitis |
Cierny-mader system
Anatomy of bone involvement the subclassifies according to physiologic status of host Define lesion & hosts ability to deal with it Prognosis well correlated
1. IM 2. Superficial 3. Invasive localised w IM involvement 4. Invasive diffuse |
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General treatment of OM |
Surgical debridement Skeletal stabilisation Soft tissue Mx Space - dead space Mx AB's
Goal: complete eradication of infection w preserved soft tissue envelope, healed bone segment, preserved LL & fn |
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Pathogenesis OM patterns with age |
Truetas patterns 1. Infants: transphyseal vsls 1yr 2. Children: nutrient A meta, subperiosteal infection 3. Adult: infection spreads along shaft |
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Enchondral bone |
Long physeal growth Embryonic long bone formation Non rigid # healing
Cartilage model Chondrocytes produce cartilage Absorbed by OC, bone replaces cartilage by OB Occurs on metaphyseal side Collagen X
Sox-9: regulates chondrogenesis PTHrP- delays diff chondro in z of H
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Hueter volkmann law |
Compression across growth plate slows longitudinal growth
Tension accelerates |
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Groove of ranvier |
Osteochondroma
Ring incr mech strength of physis |
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NSAIDs & # healing |
Inhibit via prevent calcification of osteoid matrix
JBJS Br 2000 - significant - 2/3 tibia # nonunion |
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Biofilm bacteria complex |
Entity comprising bacteria in an extracellular matrix with a glycocalyx
Matrix is a vascular |
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Osteomyelitis |
Cierny-mader system
Anatomy of bone involvement the subclassifies according to physiologic status of host Define lesion & hosts ability to deal with it Prognosis well correlated
1. IM 2. Superficial 3. Invasive localised w IM involvement 4. Invasive diffuse |
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General treatment of OM |
Surgical debridement Skeletal stabilisation Soft tissue Mx Space - dead space Mx AB's
Goal: complete eradication of infection w preserved soft tissue envelope, healed bone segment, preserved LL & fn |
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Pathogenesis OM patterns with age |
Truetas patterns 1. Infants: transphyseal vsls 1yr 2. Children: nutrient A meta, subperiosteal infection 3. Adult: infection spreads along shaft |
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Principles of Mx of intra articular # |
Anatomical reduction Early mobilisation |
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Conditions causing lumbrical plus |
FDP avulsion FDP transection Too long tendon graft Amputation through middle phalanx |
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Quadrigia effect |
Characterised by active flexion lag in fingers adjacent to a digit with a previously injured or repaired FDP tendon
Most commonly due functional shortening of FDP >1cm |
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Quadrigia effect |
Characterised by active flexion lag in fingers adjacent to a digit with a previously injured or repaired FDP tendon
Most commonly due functional shortening of FDP >1cm |
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Hook of hamate pull test |
Hand in ulnar deviation Flex DIPJ of RF & LF Flexor tendons act as deforming forces on # site Positive test = pain |
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Kaplans lesion |
Most common IF Complex irreducible dorsal dislocation MCPJ MC head buttonholes into palm Volar plate interposed bw base P1 & MC head |
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Classification dorsal PIP #/D |
Hastings Based on amt P2 articular surface involvement
1-stable. <30% Dorsally based ext block splint 2. Tenuous. 30-50% If reducible in flex, dorsally based ext block splint 3. Unstable. >50% ORIF,hamate autograft or volar plate arthroplasty |
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Features Diastrophic dysplasia |
Hitch hikers thumb Club feet Cleft palate Cauliflower ears Joint contractures Dislocations Scoliosis, C kyphosis,SBO, AAI Quadriplegia |
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Femoral rollback |
Progressive posterior change in the femoral-tibial contact point as the knee moves into flexion |
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Spot weld |
Indicates stable osteointegration of an extensively porous coated implant |
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Bony pedestal |
Bone accumulation within the canal below the tip of a mechanically loose stem
Keeps loose stem from subsiding further |
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Load relaxation |
Time dependent Non linear Decrease in load |
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Spot weld |
Indicates stable osteointegration of an extensively porous coated implant |
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Bony pedestal |
Bone accumulation within the canal below the tip of a mechanically loose stem
Keeps loose stem from subsiding further |
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Load relaxation |
Time dependent Non linear Decrease in load |
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Stress relaxation |
Decrease in stress as tendon is subjected to constant strain over extended period |
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Prerequisite for efficient gait |
Stable stance phase Step length adequate Sufficient foot clearance in swing Swing phase foot prepositioning Energy conservation |
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Planovalgus foot |
Physiological Pathological - cong - acquired
Cong: TACS Tarsal coalition/acc Nav/CVT/skew foot
Acq: TRANC Tib post/RA/arthritis/Neuro(CP,polio)/Charcot |
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Cavovarus foot |
RINT
Residual club foot Idiopathic Neuro (CVA/CMT/CP/PNS/spinal cord/Spina bifida/polio) Traumatic (tib ant rupture/mal United talar neck/compartment syndrome) |
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Concept of effective joint space |
Well fixed cementless sockets causes expansile pattern of osteolysis
Radio lucent area starts at implant bone interface and expands
Joint fluid & wear particles flow according to pressure gradients & follow path of least resistance |
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Polio |
Viral disease affecting anterior horn cells |
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Polio |
Viral disease affecting anterior horn cells |
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Postpolio syndrome |
Not a re activation Aging phenomenon by which more nerve cells become inactive. Occurs after middle age |
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Treatment postpolio |
When deformity overcomes functional capacity utilise standard polio surgeries: contracture release, arthrodesis & tendon transfer |
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Nonunion |
US FDA # occurred minimum 9 m prev & has no radio graphic signs of progression towards healing for 3 consecutive m |
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Tumours of vertebral body |
Histiocytosis X GCT Chordoma Osteosarcoma Haemangioma Mets Marrow cell tumours |
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Tumours of vertebral body |
Histiocytosis X GCT Chordoma Osteosarcoma Haemangioma Mets Marrow cell tumours |
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Tumours of posterior elements |
OO OB ABC |
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Ranawat's guidelines for protrusio |
1. <5mm protrusio -> no BG 2. >5mm protrusio & intact medial wall -> BG (no augmentation) 3. Uncontainable defect -> augmentation device |
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Frozen shoulder |
Global reduction in shoulder motion associated with inflammation of capsule
No inflammatory cells Active fibroblastic proliferation |
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Frozen shoulder |
Global reduction in shoulder motion associated with inflammation of capsule
No inflammatory cells Active fibroblastic proliferation |
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Frozen shoulder classification |
Nevasier - freezing (most painful) - frozen - thawed
Each 4-8 months |
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How do OC resorb bone? |
Bind to surface of bone using integrin anchor proteins Secrete protons & carbonic anhydrase system which dissolves HA mineral matrix Also secrete proteolytic lysosomal enzymes which hydrolyse organic cellular components |
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Fixation of displaced sub capital NOF in child |
Transphyseal # fixation provides the most reliable fracture stability and recommended in hip # >6 yrs despite risk of premature physeal closure |
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Acceptable alignment paed tibial shaft # |
Children <10 any direction Adolescent <5 in all planes |
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Name of curve describing physiologic LL alignment |
Selenius curve Birth 15 g varum 2 0 3-4 10 7 it's 7 degrees gvalgum |
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Angles in Paeds genu varum & valgum |
Selenius curve tibiofenoral angle Drennan angle >16 abN (N <11) Meta/epi angle (N <20) |
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Main objectives THR |
Pain relief Stability Mobility Equal LL |
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Definition of anteversion of acetabulum |
The angle the axis of acetabulum makes with the coronal plane of the body
Campbell's |
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Safe range in acetabular cup positioning |
Lewinnek Anteversion 15 +/- 10 Abd/inclination 40 +/- 10 |
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Am Coll Rh arth defn |
MAX RANS Morning stiffness 1hr Arthritis >3 areas >6/52 X-ray changes RF Arthritis hand >6/52 Nodules Symmetrical arthritis |
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Defn strain |
Deformation of a material when a given force is applied |
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AAOS recommendation for use of nuclear medicine imaging in Dx PJI |
Nuclear imaging is an option in whom Dx has not been made & are not scheduled for Surg WBC & Tc bone scan is most specific scanning method |
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Blood supply to bone |
3 sources 1. High pressure nutrient arteries (endosteal circulation) 2. Meta-epiphyseal system 3. Periosteum (low pressure) |
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Causes acetabular dysplasia |
DDH Perthes SCFE NMD eg CP Skeletal dysplasia eg MED, SED Trauma Infection |
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Symptomatic dydplasia |
Asymptomatic - NH unknown Symptomatic - poor prognosis Untreated DDH 50% have oa at 50yrs |
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X-ray measurements acetabular dysplasia |
Shentons line (cooperman- best prognostic line) AI: N<20 paed Sharps AA: adults N<42 CEA: N20-40 Sourcil/tonnis: N<10 Weinstein extrusion index: head covered/total width N<75
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Tonnis angle |
Measures inclination of WB zone >10 AbN |
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Treatment options young symptomatic hip dysplasia |
Supportive Arthroscopy PAO +/- femoral: congruous jnt, concentrically reduces hip Salvage: unreduced hip & incongruent jnt THA: established OA |
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Shelf |
Incr WB surface by applying extra articular buttress of bone lat over Subluxed femoral head Fibrocartilage cover |
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Sharps angle |
N 33-38 |
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Acet dysplasia angles |
Tonnis N <10 Sharps N 33-38 (AI paeds) CEA N 20-40 Ant CEA Lequesne (ant coverage femoral head) N>20 (<20 instability) Weinstein extrusion index N>75 |
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Principles of Mx of # |
Obtain & maintain length, alignment & rotation |
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Sites of ulnar nerve compression |
Cubital tunnel & guyons canal 2heads FCU/aponeurosis Arcade of struthers Bw osbornes Lig &MCL
Also: med head triceps, MIS, med epicondyle, fascial bands FCU, anconeus epitrochlearis, apon FDS EXternal sources: #, med epicondyle nonunion, osteophytes, HO, tumours, ganglions |
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Gauchers disease |
AR deficiency in B glucocerebrosidase Accumulation sphingolipids |
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DDx for cubital tunnel |
Local & systemic Local: epicondylitis, R/m n entrapment, arthropathy, brachial plexus (pancoast), cervical radiculopathy Systemic: peripheral neuropathy, mono neuritis multiplex, MS, leprosy |
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Larsens syndrome |
Hypermobility Multiple joint dislocations Extra bones wrist & feet Double ossification centre calc |
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Aspirin, heparin, warfarin |
Aspirin irreversibly blocks TXA2 in plts, inhibiting aggregation LMWH bind antithrombin which leads to conformational change & accelerates - thrombin (IIa) & + FXa Warfarin - vitK dependent synthesis of Ca dep clotting factors 2,7,9,10 |
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Lapland Cardinal line |
Transverse line from 1st web space to hook of hamate, parallel to prox palmar crease Just prox to sup palmar arch |
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Blood supply femoral head |
Extra capsular arterial ring (MFCA, LFCA, sup & inf gluteal a) Ascending cervical br - most impt Lat epiphyseal a Intracapsular sub synovial ring of Chung
Also a of Lig teres, epi & meta supply |
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Classification subtroch # |
Russell Taylor 1A- no piriformus exam, LT intact 1B- LT # 2A- piriformis ext 2B- LT # |
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Classification of FDP tendon avulsion |
Leddy & packer 1 retraction to Palm 2 retraction to PIP 3 avulsion & # base distal phalanx |
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Creeping substitution |
Process by which cancellous BG is incorporated. OB lay down new bone over old graft bone, which is subsequently reabsorbed |
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Osteoinductive |
Recruit host mesenchymal cells to diff into OB for new bone formation |
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Osteoconductive |
Form scaffold for new blood vsl ingrowth & new bone formation |
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The endurance limit is |
The max stress under which a material will not fail regardless of how many cycles are applied to it |
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Osteogenic |
Ability of cellular elements within graft to make new bone |
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X-ray features psoriatic arthritis |
Pencil in cup Jnt space narrowing Peri articular erosions Osteolysis PIP/DIP ankylosis Morningstar appearance Asymmetric, oligoarticular Carpus/MCPJ/PIPJ/DIPJ |
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Gout |
Mono sodium irate crystal deposition disorder Punched out peri articular erosions with sclerotic overhanging margins |
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Gout treatment |
Acute: Indomethacin 50mg tds Colchicine (if PUD) Or steroids if can't take above Chronic: Allopurinol (x oxidase inh) Colchicine prophylaxis after recurrent attacks |
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Bone infarct |
Interruption blood supply: intrinsic or extrinsic factors RF's- like osteonecrosis Smoke up a chimney MRI central signal remains N marrow Observe |
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FD |
Developmental abN caused by failure of prod N bone Associated: McCune Albright (Coast of Maine) Mazabraud OFD 1% risk osteosarc or fibrosarcoma change |
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OFD |
DDx adamantinoma Rare form FD which prinarily affects ant cortex diaphyseal tibia, no periosteal rn Osteoblastic rimming Bowing, pseudarthrosis <30% Usually regress |
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Causes of bowing/deformity |
Congenital Soft bone Dysplasia Physeal injury # mal union Pagets |
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DDx for lump at joint line |
Meniscal cyst Ganglion Calcific deposits in collateral ligament Meniscal extrusion Tumours (s: lipoma, fibroma, b:OC |
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Principles of recurrent patella dislocation |
Repair/strengthen MPFL Realign extensor mechanism |
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Ultimate tensile strength is |
Highest stress observed on s-s curve Represents highest load/stress before material fails |
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Nora lesion characterised by |
Florid reactive periostitis Cartilage cap component |
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Secondary chondrosarcoma |
Paget's FD Enchondromatosis- olliers & maffuccis MHE |
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Signs of malignant change of enchondroma |
Pain in absence trauma Older age Extension into soft tissue |
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Associations w spondylolisthesis |
SBOcculta T hyper Kyphosis Scheuermann |
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RF for progression spondyl |
Young age at presentation F, slip angle >10 High grade slip Done shaped or sacrum >30 |
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Classification adult scoliosis |
DINIT Deg Idiopathic - non treated AIS NM Iatrogenic Traumatic |
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Bone scan Dx pattern in sacral insuff # |
H shaped |
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Criteria for surgical Mx nonunion lat condyle # |
Flynn Large metaphyseal fragment Displacement <1cm from jnt surface Open viable lat condylar physis
SC closing wedge w ulnar n transposition |
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Aseptic loosening of m on m articulations |
Characterised by perivasc infiltrate of lymphocytes and accumulation of plasma cells |
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Friction |
Rs to sliding motion bw 2 bodies in contact |
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Knee dislocation classification |
Schenck 1. D w ACL or PCL intact 2. ACL & PCL torn 3. ACL, PCL & either PLC or PMC 4. ACL, PCL, PLC, PMC 5. #/dislocation knee |
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Excursion distance in THR |
Distance the head must travel to dislocate after primary impingement has occurred Usually half width of femoral head |
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Large femoral heads in THR have |
Greater primary arc motion and greater excursion distance Once head/neck ratio Incr volumetric wear |
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Indications for ORIF med epi # |
Incarcerated epi within jnt Associated dislocation High demand w high valgus stress eg pitcher |
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Mucopolysaccharidoses |
GP of metabolic syndromes characterised by absence/malfunctioning of lysosomal enzymes which break down GAG's
Morquio - incr keratin sulfate |
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Features of morquio syndrome |
Spine: hyperL lordosis, T kyphosis, odo ihypo w instability Hip dysplasia, coxa vara Genu valgum LL N intelligence & facies Proportionate dwarfism |
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Features of morquio syndrome |
Spine: hyperL lordosis, T kyphosis, odo ihypo w instability Hip dysplasia, coxa vara Genu valgum LL N intelligence & facies Proportionate dwarfism |
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Dorsal PIPJ #/ D |
Hastings <30% stable 30-50% tenuous >50% unstable ORIF/volar plate arthroplasty/dynamic ext splint/hemi hamate osteochondral reconstruction |
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Features of morquio syndrome |
Spine: hyperL lordosis, T kyphosis, odo ihypo w instability Hip dysplasia, coxa vara Genu valgum LL N intelligence & facies Proportionate dwarfism |
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Dorsal PIPJ #/ D |
Hastings <30% stable 30-50% tenuous >50% unstable ORIF/volar plate arthroplasty/dynamic ext splint/hemi hamate osteochondral reconstruction |
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Describe hemi hamate recon |
Volar approach, shot gun jnt # prepared, measure defect, matching graft harvested from hamate, fixed to base w appropriate length screws |
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Classification of Glenoid # |
Ideberg 1-nonangulated/displaced 2A-short/displaced >1cm 2B- angulated >40degrees |
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Dupuytrens classification |
Woodruff 1. Early palmar disease, no contracture 2. 1 finger, MCPJ contr 3. 2 + PIPJ 4. 3+ >1 finger 5. Finger in palm |
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Complications dupuytrens 20 yr rv |
5% CRPS 3% digital n 2% dig a/infection/haem Wound healing probs 23% |
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1st CMC OA Rationale for Rx |
Current evidence supports simple traoeziectomy over more complex procedures secondary to low complication rate & similar clinical outcome |
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Priorities for RA hand |
Fireman: save my beer (relieve pain) dog (improve fn) remote (slow progression) & wife (improve appearance) & address compressive neuropathy |
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What is sauve kapandji |
Creates a distal R/U arthrodesis w ulnar pseudarthrosis prox to the fusion site to allow rotation |
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X-ray features RA wrist |
Extensive pannus Intra carpal supination Volar subluxation Ulnar translation Caput ulnae SLAC Carpal collapse |
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Causes of swan neck |
Primarily-lax volar plate (trauma, RA, LL) Secondary-imbalanced forces PIPJ ie ext>fl (Mallet/FDS rupture/intrinsic contracture/MCPJ volar sub |
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Treatment swan neck |
Non op - dble ring splint Op - volar plate advancement & PIPJ balancing w central slip tenotomy(fowler) or FDS tenodesis or SORL |
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Freidrichs ataxia |
Progressive AR syndrome of early onset w decr or absent reflexes & predominant spine cerebellar in coordination |
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THR dislocation |
3% primary 10-15% revision
Early >1 yr - surgical factors Late >5 yrs - Mayo 0.8% |
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THR dislocation |
3% primary 10-15% revision
Early >1 yr - surgical factors Late >5 yrs - Mayo 0.8% |
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RF for dislocation THR |
F, age >70 Less experienced surgeon NM disorder, alcohol, DDH, Rev, AVN, takedown arthrodesis, rev # NOF, troch migration |
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Soft tissue injury classification |
Tscherne & Gotz 0. Min ST damage, indirect, simple # 1. Sup abrasion, direct, mild-mod # 2. Deep contaminated, impending Comp.syndrome, severe # 3. Ext skin contusion/crush, cmpt syndrome, Severe # |
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Biofilm def |
Complex aggregation of micro orgs which adhere to each other on a solid substrate |
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Stages of biofilm |
Initial attachment Irreversible attachment Initial maturation Further maturation Dispersion |
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Causes of irreducibility of complex dislocation MCPJ |
MC head Buttonhole bw flexor tendon (ulnar) & lumbrical (radial) Volar plate Sup trans MC Lig Natatory Lig Sesamoids |
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Classification for swan neck |
Nalebuff (treatment options) 1. Flex hyperextension PIPJ 2. Hyperextension + intrinsic tightness 3. Limited flex PIPJ in all positions MCPJ (permanent lat band dorsal subluxation) 4. Destruction PIPJ |
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Radial club hand associations |
Sonic hedgehog 1:100,000 bilateral 50-72% Associations: VACTERL, VATER, TAR, Fanconi, Holt-Oram |
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Diastematomyelia |
Cong anomaly caused by persistence in neuro enteric canal by Osseous/cartilaginous or fibrous tissue causing Sagittal division of spinal cord or cauda equina |
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Cauda equina |
Constellation of symptoms that result from compression of terminal spinal nerve roots in LS region Bilateral leg pain/B&B dysf/saddle anaesthesia/LL sensorimotor dysfn |
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RF for OM/infections |
Start with all the 'I' Infection - recent haematogenous IVDU/Inflammatory (RA)/immunocompromised(DM,smoker, malnutrition, obesity Trauma |
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Acute Ptolemaic OM Rule of 50's |
50yrs 50% in L spine 50% staph aureus 50% w epidural abscess have neurological compromise 50% elevated WCC
90% ESR/CRP elevated |
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Ank spond |
Systemic chronic autoimmune seroneg spondyloarthropathy Characterised by HLAB27, RF neg, primarily affecting axial spine
S: syndesmophytes, spinal apo physeal jnts, SIJ, symphysis pubis, entheSitis |
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Causes of nonunion |
MAGI Motion A vascularity Infection Gap
Motion- inadequate stability Avascularity-open#, stripping during surg Infection #gap-bone loss, nailed in distraction |
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Causes of nonunion |
MAGI Motion A vascularity Infection Gap
Motion- inadequate stability Avascularity-open#, stripping during surg Infection #gap-bone loss, nailed in distraction |
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Components of tibial nonunion exam |
Union Infection Deformity Joint above & below NV exam |
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Signs of infection on xray |
Harris & barrack jbjs96 Radio lucent lines Focal osteolysis & endosteal scalloping Periosteal new bone formation
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Signs of infection on xray |
Harris & barrack jbjs96 Radio lucent lines Focal osteolysis & endosteal scalloping Periosteal new bone formation
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Signs of loosening on xray |
Oneill & Harris jbjs84 RL lines >2mm bone/cement Cement/prosthesis RL line Cement #, prosthesis migration, bone destruction, femoral stem # |
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FD Underlying prob |
Shepherd crook Think cAMP looking wrist |
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FD Underlying prob |
Shepherd crook Think cAMP looking wrist |
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Carpal coalitions |
<0.2% Associated w tarsal coalitions & UL FofF def: - arthro multiplex cong - bird headed dwarfism - hand foot uterus - FAS - Diastrophic dwarfism - turners |
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Synovial chondromatosis |
Rare, benign met aplasia of synovial membrane resulting in formation of multiple intra articular cartilaginous bodies that may/not calcify, self limiting, non aggressive most common in knee & hip 3-5th decade, M3:1 Extremely rare in children 1 & 2 forms |
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Synovial chondromatosis |
Rare, benign met aplasia of synovial membrane resulting in formation of multiple intra articular cartilaginous bodies that may/not calcify, self limiting, non aggressive most common in knee & hip 3-5th decade, M3:1 Extremely rare in children 1 & 2 forms |
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Synovial osteochondromatosis Diff bw 1 & 2nd forms |
Primary- less common Secondary- setting if pre existing OA/RA/Osteonecrosis/OCD/neuropathic osteoarthropathy/TB/osteochondral # |
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Clinical tests for TFCC |
Fovea tenderness Axial compression test Piano key test |
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Clinical tests for TFCC |
Fovea tenderness Axial compression test Piano key test |
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TFCC classification |
Palmer 1. Traumatic 2. Degenerative Each have A/B/C/D |
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Classification of multiply injured ligaments knee |
Schenck - KD KD 1 ACL +MCL/LCL KD2 ACL + PCL KD3M ACL + PCL +MCL KD3L ACL + PCL +LCL KD 4 all |
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Classification of multiply injured ligaments knee |
Schenck - KD KD 1 ACL +MCL/LCL KD2 ACL + PCL KD3M ACL + PCL +MCL KD3L ACL + PCL +LCL KD 4 all |
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Classification SNAC wrist & treatment |
Watson 1 radial styloid beaking 2 radio scaphoid arthritis 3 mid carpal arthritis: SC & CL
SLAC wrist arthritis develops @4yrs 75% had RS changes @9yrs 60% had midcarpal ie grade 3 changes
Nonop Op: 4CF- better strength & ROM PRC (min age 35-40) risk of subsequent OA higher Wrist arthrodesis |
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Functions of the meniscus |
Transmit load across knee Enhance articular conformity Distribute synovial fluid across articular surface Prevent soft tissue impingement AP stabilisation of knee |
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Effect of partial meniscectomy |
Resect <35% meniscus Increases contact pressure 350% |
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Factors influencing meniscal repair |
Location: red red Tear pattern: long >1cm or radial to periphery Quality: repair not indicated in macerated or degenerative tears |
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Causes of medial scapular winging |
Based on direction top corner scapular - up & med Med more common; usual young athlete Serratus anterior deficit - LTN - iatrogenic from anaesthetic, surgery - trauma scapular # - repetitive stretch eg weightlifter - compression - brachial plexus injury - v rarely due to rhomboid dysfunction DSN injury
Can be mistaken for Parsonage Turner Syndrome in absence of trauma |
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Causes of medial scapular winging |
Based on direction top corner scapular - up & med Med more common; usual young athlete Serratus anterior deficit - LTN - iatrogenic from anaesthetic, surgery - trauma scapular # - repetitive stretch eg weightlifter - compression - brachial plexus injury - v rarely due to rhomboid dysfunction DSN injury
Can be mistaken for Parsonage Turner Syndrome in absence of trauma |
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Causes of lateral scapular winging |
Deficit in trapezius due to spinal acc nerve injury Eg iatrogenic-LN dissection in post neck
Eden-Lange transfer |
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Causes of medial scapular winging |
Based on direction top corner scapular - up & med Med more common; usual young athlete Serratus anterior deficit - LTN - iatrogenic from anaesthetic, surgery - trauma scapular # - repetitive stretch eg weightlifter - compression - brachial plexus injury - v rarely due to rhomboid dysfunction DSN injury
Can be mistaken for Parsonage Turner Syndrome in absence of trauma |
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Causes of lateral scapular winging |
Deficit in trapezius due to spinal acc nerve injury Eg iatrogenic-LN dissection in post neck
Eden-Lange transfer |
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Prognostic indicators of functional outcome following DR intra articular # |
3/12: quality of reduction <2mm step off,within 2mm height, restore carpal alignment 1yr:age&income Michigan hand Qu scores |
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Blood supply to capitellum |
Recurrent radial Collateral radial Recurrent interosseous |
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Flexor tendon repair |
4 strand adelaide repair with 3.0 Ticron with 6.0 vicryl epi tendinous repair |
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Early passive motion protocols in |
No op details Soft tissue loss 2 strand repair |
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Early passive motion protocols in |
No op details Soft tissue loss 2 strand repair |
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Early active motion protocols flexor tendon repairs |
Enhanced strength with reduced loss of fn 4 strand repair etc |
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Features of rickets |
Defect in mineralisation of osteoid matrix caused by inadequate ca & phos
Rachitic rosary, codfish vert, bowing, retarded growth, dental disease, path #, waddling gait
Think hillbilly with bowed, waddling gait, poor teeth going cod fishing |
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Dorsal approach for foot fasciotomy |
Double incision Immediately medial to 2nd MT, immediately lateral to 4th MT |
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Incidence sciatic n palsy in THR |
1-2% primary THR 3-4% Rev THR 5-6% DDH |
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Radio ulnar synostosis |
Defect in longitudinal segmentation in 7th week AD & sporadic, bilateral 60% Associated general sk abN eg hip dysplasia, CTEV, LL, madelungs Also syndromes: carpenter, apert, arthrogryposis, multiple exostosis |
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Theories for pain production in disc disease |
Directly due to annulus micro tears Nerve compression Mechanical - incr load on post elements Cytokines IL-1 |
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Which approach Transtectal trans w impacted roof # |
Ext iliofemoral |
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Which approach Transtectal trans w impacted roof # |
Ext iliofemoral |
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Kocher langenbeck approach |
Comm post wall # PW & PC # Simple PW# |
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Which approach Transtectal trans w impacted roof # |
Ext iliofemoral |
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Kocher langenbeck approach |
Comm post wall # PW & PC # Simple PW# |
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Ant Column post hemiT |
II approach |
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Pedowitz diagnostic criteria CECS |
Preexercise pressure 15mmHg 1min post exercise pressure 30mmHg 5min PEP 20mmHg |
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Medial epicondyle # |
Min displaced - slab then AROM 1/52 Irred incarceration & open # - Surg CR: sup/valgus/WE ORIF with ulnar n protection |
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Osteolysis |
End result of a biological process when number of wear particles following joint replacement overwhelms body's capacity to clear them from circulation. Residual particles phagocytosis by Macrophages, release cytokines/inflamm that recruit OC to resorb bone |
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Blood supply patella |
Desc genicular Ant genicular Sup/inf med & lat genicular Form prepatellar arterial network + trans infrapatellar artery = extraosseous Also intraosseous from peripatellar anastomoses & trans infrapatellar a |
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Defn arthrogryposis |
Generalised term for congenital Jon progressive limitation of joint movement due to soft tissue contractures affecting 2 or more joints |
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DD for Larsens |
E-D syndrome
Larsens is similar to amyloplasia but instead of rigid joints, gross LL
This has multiple joint dislocations Double ossification centre in calc is diagnostic |
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Defn arthrogryposis |
Generalised term for congenital Jon progressive limitation of joint movement due to soft tissue contractures affecting 2 or more joints |
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DD for Larsens |
E-D syndrome
Larsens is similar to amyloplasia but instead of rigid joints, gross LL
This has multiple joint dislocations Double ossification centre in calc is diagnostic |
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Double ossification centre in calc is diagnostic of what |
Larsens |
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Defn arthrogryposis |
Generalised term for congenital Jon progressive limitation of joint movement due to soft tissue contractures affecting 2 or more joints |
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DD for Larsens |
E-D syndrome
Larsens is similar to amyloplasia but instead of rigid joints, gross LL
This has multiple joint dislocations Double ossification centre in calc is diagnostic |
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Double ossification centre in calc is diagnostic of what |
Larsens |
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Defn arthrogryposis |
General term for congenital, non progressive limitation in joint movement secondary to soft tissue contraction affecting 2+ joints |
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Defn CP |
Non progressive injury to the immature brain incurred within first 2 yrs resulting in disorder of movement or posture |
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Ortho manifestations of CP |
Contractures # Deformity Hip subluxation/dislocation Spine deformity Foot deformity Gait disorders |
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Ortho manifestations of CP |
Contractures # Deformity Hip subluxation/dislocation Spine deformity Foot deformity Gait disorders |
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Classification CP |
Type of motor disorder MAARS Mixed Athetoid Ataxic Rigid Spastic |
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Classification CP according to limbs |
Mono Di Tri Hemi Quad Spastic pentaplegia
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Cong knee dislocation |
Associated: DDH, CTEV, CVT, breech Arthrogryposis, Larsens, downs, myelodysplasia- Ie LLax/m imbalance |
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Classification coxa vara |
Cong Dev Dysplastic Acq Physeal Sub physeal |
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Classification coxa vara |
Cong Dev Dysplastic Acq Physeal Sub physeal |
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Causes of dysplastic coxa vara |
OI Rickets Pagets Renal FD Osteopetrosis Hypothyr Sk dysplasia: CCD, SED, Jansen Schmidt |
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Mode of action of cephalosporins |
Bactericidal Disrupt synthesis of peptidoglycan layer forming bacterial cell wall |
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Complications THR |
Death 0.5-1% at 3/12 DVT Rx 10-30% Fatal PE 0.2% Infection 1%/3% rev Dislocation 3%/10% rev Sciatic n 0.5% femoral 0.1% Vasc 0.25% HO symptomatic 3-10% LLD 10-20% |
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Complications THR |
Death 0.5-1% at 3/12 DVT Rx 10-30% Fatal PE 0.2% Infection 1%/3% rev Dislocation 3%/10% rev Sciatic n 0.5% femoral 0.1% Vasc 0.25% HO symptomatic 3-10% LLD 10-20% |
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Pedicle screw fixation starting point |
Vary from level to level, pt to pt Confluence of midpt of trans process, lat edge sup articular facet & superomed edge of mammillary process is approx entry point |
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AAOS clinical practice guidelines for surgical fixation DR# |
Post red radial shortening >3mm Dorsal tilt >10 Intra art stepoff >2mm |
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AAOS clinical practice guidelines for surgical fixation DR# |
Post red radial shortening >3mm Dorsal tilt >10 Intra art stepoff >2mm |
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?vit C post op ORIF DR# |
Mod recommendation 500mg p/day 6/52 |
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Extra capsular supply to femoral head |
Desc br MCFA Desc br LCFA Asc br Sup gluteal Inf epi gastric a
MCFA & LCFA br form extracapsular ring -> Asc cervical a most impt lat epiphyseal a -> sub synovial intra articular ring |
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Blood supply femoral head |
Extracapsular Medullary Lig teres
Extracap: Desc Br MCFA/LCFA Asc br sup gluteal, inf epi gastric a |
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Causes AVN hip |
Traumatic A traumatic - steroids/Alcohol
AS IT GRIPS 3C
Also: IT (idio, trauma) GRIPS (gaucher, gout , RTx, RA, infection, inflamm, pancreatitis, pregnancy, SLE, ScD, smoking CRF, chemo, caisson |
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Bone graft in protrusio |
Ranawat recommendations <5mm no BG >5mm + iliac med wall BG Med wall def BG + cage augment/screws |
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Technical issues in THR in protrusio |
Dislocation (insitu neck cut) Med wall defect: rim fit, mesh & BG Acetabular fixation: cup/cage Femoral offset: needs incr LL: incr Sciatic n: often close |
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Teardrop |
Radiological landmark that delineates the true floor of the pelvis Lat limb: inf aspect ant wall acetabulum Med limb: jn obt canal + a/inf portion quad plate |
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Classify bipartate patella |
Saupe 50% bilateral Ass N-P syndrome |
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Causes of paed equinovarus foot |
CP spastic hemi Duchenne Residual CTEV Tibial hemimelia |
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Classify tibial tubercle # |
Ogden 1. # secondary oss centre near PT insertion 2. Propagates to prox jn with primary oss centre 3. Extends post to cross primary odd centre 4. Entire prox tib physis 5. Periosteal avulsion of ext mech from SOC |
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Prox tibia physeal closure order |
Post to ant Prox to distal |
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At risk w prox tibial tubercle # |
Recurrent ant Tib artery |
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Classification met adductus |
Bleck HBL 2/3 Then 3/4 The 4/5 & unable to abduct forefoot beyond ML |
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Secondary causes CVT |
Primary Secondary: Arthrogryposis Myelomeningocoele Sacral agenesis DDH Multiple pterygium syndrome |
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Small separated fragment of bone from growth plate in SH2 |
Thurston holland sign |
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McCune Albright |
Unilat polyostotic FD Cafe au lait (CofMaine) Precocious puberty Oncogenic osteomalacia FGF23 |
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Indications for surgery in DM Charcot foot |
RIP Recurrent ulcerations Infection Pain |
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Osteoinductive BG |
Ability of graft to induce or recruit pluripotent mesenchymal stem cells that differentiate into bone forming OB & chondroblasts |
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Osteoinductive BG |
Ability of graft to induce or recruit pluripotent mesenchymal stem cells that differentiate into bone forming OB & chondroblasts |
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Osteoconductive BG |
Refers to scaffolding Provides environment for new bone apposition by supporting host cap ingrowth, perivasc tissue, OPG cells |
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Osteoinductive BG |
Ability of graft to induce or recruit pluripotent mesenchymal stem cells that differentiate into bone forming OB & chondroblasts |
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Osteoconductive BG |
Refers to scaffolding Provides environment for new bone apposition by supporting host cap ingrowth, perivasc tissue, OPG cells |
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Osteogenic BG |
By fresh cancellous BG contains viable donor Osteocytes or precursors which promote primary bone formation |
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Creeping substitution |
Cancellous BG Concomitant OB deposition of new bone osteoid & Osteoclast resorption of necrotic donor trabeculae |
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Standard surgical procedure for degenerative spondylolisthesis |
Decompression laminectomy and partial medial facetectomy & instrumented fusion |
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CP is a non progressive permanent disorder of movement & posture sustained from a brain injury before the age of 2 yrs |
Most common Spastic diplegia or hemiplegia 65% Higher in premature & Low birth Wt children |
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Aetiology of CP |
Prenatal 44% TORCH infections Drugs/ETOH Perinatal 27% Hypoxia/prematurity/LBW Postnatal 5% Meningitis/head inj/immersion |
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Mercer Rangs stages of CP |
1. Dynamic contracture 2. Fixed musculotendinous contractures 3. Bone & jnt involvement |
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NF |
Inherited AD disorder of neural crest origin with skeletal/skin/ophthal abN |
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NF2 |
Acoustic schwannoma |
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Diagnostic criteria NF1 |
NIH: 2+/7 (62AO2LO1st) 6+ cafe au lait 2+ NF or 1 plexiform NF Axillary/inguinal freckling Optic glioma 2+ lisch nodules Osseous lesion 1st degree relative |
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Treatment options tibia pseudarthrosis |
IMN & BG Vasc BG Distraction osteogenesis Rarely amputation |
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DD hemihypertrophy |
Idiopathic NF1 Beckwith Weidemann syndrome (cong o'growth syndrome) Klippel- |
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Causes of hemihypertrophy |
Idiopathic Proteus Beck with Weidemann Klippel trenaunay weber syndrome NF1 |
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Causes of torticollis |
CINB Congenital muscular torticollis 80% Inflammatory Neurogenic eg Klippel feil Bony malformation |
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Clinical test for glom us tumour |
Love test Application pinhead pressure over suspected area resulting in exquisite tenderness |
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Frozen shoukder |
Idiopathic inflammatory condition characterised by progressive shoulder pain & dysfunctipn due to tightening capsulligamentous structures which spontaneously resolves |
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Frozen shoulder classification |
Freezing: painful, capsular adhesions Frozen: decr pain inc stiffness, capsular contractures Thawing: decr stiffness |
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Frozen shoulder classification |
Freezing: painful, capsular adhesions Frozen: decr pain inc stiffness, capsular contractures Thawing: decr stiffness |
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ER typically decr in Frozen shoulder DD |
Frozen shoulder OA Unreduced posterior dislocation |
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Most Sn indicator of Frozen shoukder |
Pain on forced ER |
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Is Frozen shoulder inflammatory |
Yes Clear progression from perivasc at mono inflammatory infiltrates to reactive capsular fibrosis |
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5 main components of revision hip Surg |
Previous Surg info Classify bone defects Extraction equipment Implantation equipment BG |
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Pulm effects of IMN |
Pulm failure from pulm injury not from method of fracture fixation |
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Indications shoulder arthrodesis |
Chronic infection GHJ Stabilisation in paralytic disorders Post traumatic brachial plexus palsy Salvage failed GHJA Arthritic disease unsuitable for Arthroplasty/young pt Stabilisation after resection for neoplasia |
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Indications shoulder arthrodesis |
Chronic infection GHJ Stabilisation in paralytic disorders Post traumatic brachial plexus palsy Salvage failed GHJA Arthritic disease unsuitable for Arthroplasty/young pt Stabilisation after resection for neoplasia |
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CI shoulder arthrodesis |
I elbow arthrodesis C shoulder arthrodesis Paralysis scapular stabilisers Charcot arthropathy |
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Position of shoulder arthrodesis |
10-15 FF & Abd 45 IR |
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Goals in treatment calc # |
1. Restore congruency post facet 2. Restore height (Bohler) 3. Reduction width calc 4. Decompress subfib space for perineal tendons 5. Realignment tub into valgus 6. Reduction CCJ if # |
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Goals in treatment calc # |
1. Restore congruency post facet 2. Restore height (Bohler) 3. Reduction width calc 4. Decompress subfib space for perineal tendons 5. Realignment tub into valgus 6. Reduction CCJ if # |
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Checks for post femoral IMN |
Occult neck # Symmetry of lower limb lengths & limb segments length Symmetry of rotation: passive & active Examine knee ligs for concomitant injury Palpate thigh/calf - ensure soft
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How to make AB impregnated cement nail |
40F chest tube for 10mm nail Humeral nail guide wire 2.5mm ball tip 2bags PMMA cement 2g Vanc + 2.4g tobra |
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DR # acceptable |
AAOS clinical guidelines 2009 - radial height N11mm Loss <3mm - radial inclination N 22 deg >10 degrees - volar tilt N 11 <10 dorsal tilt - articular surface <2mm step -DRUJ stability & congruence |
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Screw home |
IR femur in last 15 degrees extension |
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At vertical, r'ship of mech vs anatomical axis |
Mech is 3 deg Valgus Ana is 9 deg Valgus So ANA is 6 deg Valgus rel to mech axis |
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Qangle N values |
15 ext 8 flex |
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Discoid meniscus classification |
Watanabe 1. Incomplete coverage 2. Complete coverage 3. Wrisberg variant |
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Discoid meniscus classification |
Watanabe 1. Incomplete coverage 2. Complete coverage 3. Wrisberg variant |
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Diff bw Weisberg variant discoid meniscus |
1&2 have intact meniscotibial ligs Wrisberg doesn't therefore moves abN & often symptomatic even if not torn |
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6 general indications for meniscal repair |
Complete long tear >10mm Tear w/in peripheral 1/3 or <3mm meniscocapsular jn Unstable tear displaced by probe Tear without secondary deg/deformity Tear in active pt Tear identified during Lig stab procedure |
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MRI appearance bloody effusion |
High T1 Low T2 |
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Criteria for Dx exercise induced CCS |
>30mmHg at 1 min post exercise >20 at 5 mins >15 at 15 mins |
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4 risk factors for infection in TKR |
RA M Inc INR Compromised skin |
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Risk factors peri prosthetic # in TKR |
Osteoporosis Osteonecrosis Osteolysis Notching Stress shielding |
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Classification distal femoral peri prosthetic # |
Lewis & Rorabeck 1. Undisplaced, stable prosthesis 2. Displ, stable 3. Displ, loose prosthesis |
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Classification distal femoral peri prosthetic # |
Lewis & Rorabeck 1. Undisplaced, stable prosthesis 2. Displ, stable 3. Displ, loose prosthesis |
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Prox tibial peri prosthetic # |
Felix, Stuart & hanssen 1. Plateau 2. Adj stem 3. Dist to prosthesis 4. Tib tub Subclassify A-C desc rel stability of prosthesis
Like Vanc... |
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3 ways to protect ext mech |
Quads snip V Y quadricepsplasty Tub osteotomy |
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Salvage options for disrupted ext mech |
SemiT autograft Allograft |
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3 Surg indications for constrained hinge |
All ligs gone Knee resection Hyperextension instability eg polio |
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Atlas/axis space occupied by cord |
Steele's rule of thirds 1/3 cord 1/3 dens 1/3 space |
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Treatment acute sag band rupture |
MCPJ ext splint |
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Treatment acute sag band rupture |
MCPJ ext splint |
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Sag band rupture >2/52 treatment |
Ext centralisation procedure |
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Therapeutic measures for perthes |
3 primary obj - improved mobility - weight relief - improved containment |
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5 causes kyphosis |
SANTI Scheuermanns Ank spond NF Trauma eg compression # Iatrogenic (post laminectomy) |
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Indications for Surg in TL burst # |
Unstable >50% Loh >50% canal compromise >30 degrees kyphosis Incomplete/prog neuro deficit |
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Arthrofibrosis |
The excessive fibroblastic tissue healing response that results in loss of motion esp after knee trauma or surgery |
