1) List of Important Orthopaedic Classifications
Fracture types
Simple / § Transverse (<30o)§ Oblique (>30o)
§ Spiral
Comminuted / § Spiral wedge – torsional forces
§ Bending wedge – characteristic butterfly fragment
§ Comminuted wedge – bending wedge # with fragmented butterfly fragment
§ Complex spiral – >1 spiral fragments
§ Complex segmental – double #
§ Complex irregular – bone lying btwn main elements is fragmented
Hairline / If not detected on XR initially:
§ Do oblique XR
§ Repeat film after 7-10 days
Greenstick / § Children
§ Elastic spring of periosteum may cause recurrence of angulation, hence plaster fixation must be well done.
§ Rapid healing
Compression / Common sites
§ Vertebral bodies
§ Heels
Avulsion / Common sites
§ Base of 5th metatarsal (peroneus brevis)
§ Tibial tuberosity (quadriceps) (Osgood-Schlatter’s disease)
§ Lower pole of patella (Johansson-Larsen’s disease)
§ Upper pole of patella (quadriceps)
§ Lesser trochanters (iliopsoas)
Impacted / One fragment driven into another
Describing Fractures
1. Level / § Anatomical – epiphysis, epiphyseal plate, metaphysic, diaphysis OR§ Thirds – proximal, middle, distal
2. Displacement / § Direction of displacement in terms of movt of distal fragment
§ Degree of displacement in % of # surfaces in contact
3. Angulation / § Described in terms of the direction the point of # angulation is pointing towards (eg anterior angulation in Colles’ #)
4. Axial rotation / § Easily missed, hence always examine the joints above & below the #
5. Open / Close / Open
§ Gustilo Classification
§ Open from within or without – latter has risk of infxn, hemorrhage & injury to muscles, nerves or bld vessles. Also usually comminuted & more difficult to manage.
Open Fractures: Gustilo Classification
Type I / § <1cm AND cleanType II / § >1cm AND no extensive soft tissue damage, avulsions or flaps
Type IIIA / § Extensive soft tissue damage, avulsions or flaps but adequate soft tissue coverage of bone OR
§ High-energy trauma cause irregardless of size of wound
Type IIIB / § Extensive soft tissue loss with periosteal stripping and exposure of bone.
§ Massive contamination common
Type IIIC / § Arterial injury requiring repair
Haemorrhage in Fractures
Close # of femoral shaft / 2-3LHaemothorax / 3-5L
Pelvic # / 3-5L
Epiphyseal Plate Injuries: Salter-Harris Classification
Type 1 / § Whole epiphysis separated from shaftType 2 / § Epiphysis is displaced together with a metaphyseal fragment
Type 3 / § Separation of part of the epiphysis
Type 4 / § Separation of part of the epiphysis with a metaphyseal fragment
Type 5 / § Crushing of part or all of the epiphysis
*Cxs: avascular necrosis, growth arrest
Upper limb
Colles’ # / # distal radius w/in 2.5 cm of wrist (aka dinner-fork #)Anterior & ulnar angulation
Dorsal & radial displacement of distal fragment
Impaction of fragments.
Smith’s # / # distal radius w posterior angulation ± anterior displacement (aka reversed Colles’ #)
Galeazzi #-dislocation / # of radius, inferior radioulnar joint dislocation (GUD)
Monteggia #-dislocation / Ulna fracture + anterior dislocation of head of radius (MUF)
Trigger Finger
Stage / Features / MxPre-triggering / Pain, no trigger / NSAIDs
Triggering / Correctable by active extension / H&L
Triggering & Lock / Correctable by passive extension / H&L, Sx sheath incision
Contracture / Fixed flexion deformity / Sx release
Pelvic Fractures: Tile classification
Type A / Stable #s / A1 / No involvement of pelvic ringA2 / Stable, minimally displaced # of the pelvic ring
Type B / Rotationally unstable, vertically stable / B1 / AP compression # (“open book” #)
B2 / Lateral compression #, ipsilateral
B3 / Lateral compression #, contralateral
Type C / Rotationally & vertically unstable / C1 / Unilateral
C2 / Bilateral
C3 / Associated acetabular #
Perthes’ Disease
Catterall grading– according to degree of femoral head involvement
Grade / Severity / Px1 / involve anterior portion of epiphysis only. No collapse or sequestrum / Revascularisation may be complete w/o bone collapse
2 / £ 50 % involvement with a sequestrum / Bony collapse inevitable
3 / ~75% involved, with collapse & sequestrum / Bony collapse inevitable. Poor Px
4 / whole epiphysis involved
Fracture of Neck of Femur:
Garden Classification
Type 1 / Incomplete fracture (Inferior cortex not broken)No displacement
Abduction #
Trabeculae are angulated / Fixation by:
§ Cannulated screws / pins
§ DHS / Risk of AVN (%) / 10
Type 2 / Complete fracture line (inf. cortex broken)
No displacement
Trabecular lines interrupted but not angulated / 20
Type 3 / Complete fracture line
Slight-moderate displacement
Rotation of femoral head – prox frag abducted & int. rotated / § >65YO – hemiarthroplasty.
o Unipolar (Moore’s or Thompson’s)
o Bipolar – for younger PTs
§ <65YO – attempt joint salvage / 30
Type 4 / Severe displacement / 40
Anatomical Classification
A / Subcapitate / Intracapsular – risk of severing retinacular vessels resulting in AVN (12-33% of all #NOFB / Transcervical
C / Basilar / Extracapsular
Phases of AVN
I / Only head involvementII / Progress to secondary OA & acetabulum is affected as well
Intertrochanteric Fracture of the Femur
Evans’ Classification
I / 2 fragments, undisplacedII / 2 fragments, displaced
III / 3 fragments w/o posterolateral support (ie # of the greater trochanters)
IV / 3 fragments w/o medial support (ie # of the lesser trochanter)
V / 4 fragments
R / Reversed oblique # - prone to displacement
*Alternative classification: according to number of fragments + reversed oblique #
Ankle Fractures
Weber’s classification
Type / Level of fibular #A / Distal to syndesmosis
B / Involve the syndesmosis
C / Proximal to syndesmosis
Pott’s Classification
First degree / # of a single malleolus (medial or lateral)Second degree / # of both medial & lateral malleoli
Third degree / # of medial, lateral & posterior malleoli
Scoliosis
List of Causes
Non-structural / § Limb length discrepancy (apparent or true shortening of one leg)§ Hip contracture
§ Muscle spasm – eg 2o to PID
Structural / § Adolescent idiopathic (commonest, 80%)
§ Infantile idiopathic – may resolve or progress
§ Osteopathic – due to congenital vertebral anomalies
§ Neuropathic – eg 2o to polio or CP. Due to asymmetrical muscle weakness
§ Myopathic – due to muscular dystrophies
§ Neurofibromatosis
Spondylolisthesis
§ Causes
1. Dysplasia – congenital lumbosacral facet jt dysplasia Spondylolytic
2. Isthmic (spondylolytic) – break in the pars interarticularis Pathological
3. Elderly (degenerative) – OA degeneration of facet joints Operative
4. Trauma Trauma
5. Suspicious (pathological) – neoplasm Elderly(degenerative)
6. Post-op – due to laminectomy for decompression Dysplastic
§ Meyerding classification
Grade / % translation of VBI / 0-25
II / 25-50
III / 50-75
IV / 75-100
Bone Tumours
Enneking’s Classification
Grade (surgical) / G0 / BenignG1 / Low grade malignant
G2 / High grade malignant
Site / T0 / Benign Intracapsular & intracompartmental
T1 (A) / Intracompartmental
T2 (B) / Extracompartmental
Metastasis / M0 / No regional / distant mets
M1 / Regional / distant mets
Staging for Malignant Neoplasia
IA / G1 / T1 / M0
IB / G1 / T2 / M0
IIA / G2 / T1 / M0
IIB / G2 / T2 / M0
IIIA / G1 or 2 / T1 / M1
IIIB / G1 or 2 / T2 / M1
Staging for Benign Neoplasia
1 / Latent / G0 / T0 / M0
2 / Active / G0 / T0 / M0
3 / Aggressive / G0 / T1 or 2 / M0 or 1 (giant cell tumour)
Osteoporosis
BMD T-score / Definition>-1 / Normal
-1 to -2.5 / Oteopenia
<-2.5 / Osteoporosis
<-2.5 + fragility fracture / Severe osteoporosis
Rheumatoid Arthritis
§ Stage 1 (synovitis) – pain, chronic swelling, large effusion, thickened synovium
§ Stage 2 (articular erosion) – joint instability, ¯ROM. X-ray: loss of jt space & marginal erosion, but lack of osteophytes c.f. OA
§ Stage 3 (deformity) – pain, deformity, instability & disability. X-ray: bone destruction
2) Orthopedics Short Cases
Brachial Plexus Injury
‘Examine the arms of this patient’
Inspect:
Horner’s syndrome
§ Suggests proximal BP injury
Bruises at neck, arm
§ Suggests brachial plexus injury
Posture
§ Waiter’s tip – arm adducted, shoulder internally rotated, wrist and fingers flexed
o Erb’s palsy (C5,6,7)
§ Arm flail, hanging loose – suspect complete brachial plexus palsy
Muscle Wasting
§ Deltoid Muscle (C5,6,7)—axillary nerve
§ Intrinsic muscles of Hand (C8, T1. C5,6,7 also)
Examine power, reflexes
§ Standard neuro exam
§ Reflexes, likely LMN; if UMN suspect motor neurone disease
Determine level of brachial plexus lesion
§ Push against wall – serratus anterior supplied by long thoracic nerve (C5,6,7)
§ Horner’s syndrome – T1 carries cervical sympathetic
o Others:
§ Ask pt to put hand on hip, ask pt to push elbow back, feel rhomboid contraction which is medial to scapula – rhomboid
§ Put hand above spine of scapula, ask patient to abduct, feel contraction of supraspinatus
§ If any of these shows weakness, it suggests BP injury is proximal
This patient has brachial plexus injury, lesion is:
§ Supraganglionic – if Horner’s positive
§ At roots – if winging of scapula
§ Distal to roots – i.e. trunks, divisions, cords
Causes
§ BP injury – avulsion from motorcycle accident, congenital
§ CA spread – breast, osteosarcoma
§ Radiotherapy
Peripheral Nerves
‘Examine the hands of this patient’
Is it:
§ High or low median,or carpal tunnel syndrome?
§ High or low radial?
§ High or low ulnar?
Inspect
Wasting of small muscles of hand
§ Suggests either ulnar nerve lesion, OR C8-T1
§ To differentiate, test abductor pollicis – supplied by C8T1 component in median nerve
o thus will be weak in root lesion BUT NOT in ulnar nerve lesion
Claw hand – ulnar nerve palsy
Thenar (Median n. palsy) &/or Hypothenar (Ulnar n. palsy) wasting
Screen
§ Extend wrist and fingers
o Both cannot – high radial nerve
§ Common sites of injury – axilla, spiral groove
o Wrist can extend, finger cannot extend – posterior interosseous branch (=deep branch) of radial nerve affected, hence it is low radial nerve
§ Common sites of injury – fracture of proximal head of radius, dislocation of radial head
§ Close hand
o Benediction sign – median nerve
§ If Benediction sign present, test flexion of IPJ of thumb
· If weak flexion, suggests a high median nerve lesion
o Supracondylar fracture of elbow
· If strong flexion, test for sensation over lateral palmar surface, and do Tinel’s
o No sensation
§ Injury at wrist
o Sensation intact
§ Carpal tunnel
· Place hands on pillow, abduct against resistance
o If weak – ulnar nerve
§ Then test little finger flexion at DIPJ
· If no little finger DIPJ flexion, high elbow ulnar
o Distal brachial plexus lesion
o Cubitus valgus causing tardy ulnar nerve palsy
· If DIPJ flexion present, low ulnar
o Wrist injury
Detailed examination of relevant nerve
Ulnar (C7,C8, T1)
‘patient has ulnar nerve palsy, lesion is above/below the elbow as evidenced by weakness/ strength of the flexor digitorum profundus’
supplies all interossei, medial 2 lumbricals, adductor pollicis, hypothenar eminence, medial half of flexor digitorum profundus, flexor carpi ulnaris, palmar dorsal sensory of medial 1.5 fingers
§ Abduct fingers against resistance – test little finger
§ Adduct fingers with paper – hold paper betw little & ring finger
§ Adduct thumb – Froment’s sign
§ Little finger flexion at DIPJ – differentiate betw high & low lesion
§ Sensory distribution (medial 1.5 fingers)
Causes of ulnar nerve palsy
§ Distal brachial plexus injury
§ At medial epicondyle – check for cubitus valgus
§ At wrist
Median (C6,7,8,T1)
‘Benediction sign is present suggesting median nerve palsy’, I would like to test the muscles supplied by median nerve and sensation
§ Lateral 2 lumbricals
§ Opponens pollicis
§ Abductor pollicis – IPJ flexion of thumb (‘OK’ sign)
§ lateral half of Flexor digitorum profundus – DIPJ flexion of index finger
§ sensation palmar lateral 3.5 digits
Press wrist for 30s for parasthesia
Phalen’s test – flexion of wrist for 2 minutes for parasthesia
Tinel’s test – tap wrist repeatedly for parasthesia
§ if any of these 3 positive, suggests carpal tunnel syndrome
Radial (C5,6,7,8)
Test muscles distal to proximal
§ test fingers and wrist extension
§ supinator strength
§ brachioradialis – flex arm in semipronated position
§ triceps – extension (weak in high lesion)
§ Extensor lollicis longus (thumb extension at IP jt) & brevis (extension at MCP jt)
§ test sensation – variable, over posterior arm, and over dorsal aspect of skin proximal to lateral 3.5 fingers
Shoulder Joint
‘Examine the shoulder joint’
Inspect
§ sternoclavicular joint
§ clavicle
§ acromioclavicular
§ deltoid wasting
§ scapula
o small scapula and webbing of neck (Klippel-Feil)
o winging of scapula (C5,6,7 radiculopathy or long thoracic n inj)
Palpate
§ sternoclav joint ® clavicle ® acroclav ® deltoid
Screening movements
§ Abduct, adduct, flex, extend, external/internal rotate in 90o abduction
If abduction restricted
§ Cannot initiate – rotator cuff injury
§ Painful arc – tendonitis/ rotator cuff impingement
§ Restricted movements – fix scapula; if after fixing scapula cannot abduct at all it suggests fixed glenohumeral joint with previous movements entirely scapular
§ Apprehension test
§ Ganz and Gerber drawer test
§ Biceps tendon test
§ Job’s sign
§ Neurological exam – power/reflexes/sensation
§ Pulses
§ Offer to examine the neck
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