Page created on June 1, 2020. Last updated on June 28, 2022 at 08:44

You might want to read this post regarding the order of the topics, and this post regarding my experience with the exam.

Knowledge from seminars

• Orthopaedic pain vs neuropathic pain
  • Orthopaedic
    • Stabbing characteristic
    • In the morning
  • Neuropathic
    • Radiating
    • Electrical/burning/”ants walking on skin” characteristic
    • During rest
• History taking in ortho
  • Where does it hurt?
    • 99% of orthopaedics patients have pain as main complaint
    • Acetabular (hip) pain usually manifests in inguinal area/groin
  • How much does it hurt on a scale from 0 – 10?
  • When did the pain start?
  • Did the pain start suddenly or gradually?
  • Was there any trauma at the time when the pain started?
  • Does it only hurt there?
  • Does the pain radiate anywhere?
  • What is the characteristic of the pain?
  • Does the pain occur during rest or during movement?
  • Does rest alleviate or worsen the pain?
    • Inflammatory pain typically becomes worse with rest
  • Does the pain occur during the night? In the morning?
    • Tumor pain typically occurs in the night
    • Arthritis pain typically occurs in morning and day
  • Do you have any internal diseases? DM, autoimmune, rheumatological?
  • What is your occupation?
  • Do you have any congenital conditions?
    • Scoliosis, congenital clubfoot, DDH, etc
  • Do you have any B-symptoms?
• Physical examination in ortho
  • Describe alignment of knee joints
  • Can knees extend completely (to 0 degrees)?
    • If not, there is an extension deficit/flexure contracture
  • Is there any pain upon knee/hip flexion, abduction, adduction, internal & external rotation?
  • Measure the degree of knee and hip flexion, abduction, adduction, internal & external rotation
  • Measure the limb length for any discrepancy
  • If suspicious for neuropathic pain, examine the affected area for sensory and motor abnormalities
• Physical tests
  • Lachman test
    • Tests for injury of anterior cruciate ligament (ACL)
    • Flex patient’s knee to 90 degrees
    • Your one hand should hold the patient’s thigh firmly just above the knee, with the thumb facing anteriorly
    • Your other hand should hold the patient’s calf firmly just below the knee, with the thumb facing anteriorly
    • Try pulling the tibia anteriorly
    • An intact ACL should prevent anterior movement of the tibia
  • Valgus stress test
    • Tests for injury of medial collateral ligament (MCL)
    • Flex patient’s knee to 30 degrees
    • Hold the patient’s ankle with one hand
    • Hold under and lateral to the patient’s knee with the other hand
    • With the second hand, try to push the knee in the medial direction
    • An intact MCL should prevent large movement of the knee
  • Varus stress test
    • Tests for injury of lateral collateral ligament (LCL)
    • Same procedure as the valgus stress test, but instead of pushing the knee in the medial direction you push it in the lateral direction
  • Joint line tenderness (meniscus test)
    • Tests for meniscus injuries
    • Flex the patient’s knee to 90 degrees
    • Palpate along the tibiofemoral joint line (palpate the soft spots of knee)
    • Pain indicates meniscus tears
  • Steinman test
    • Tests for meniscus injuries
    • Flex the patient’s knee to 90 degrees
    • With one hand, apply axial pressure to the knee (press down on the knee in the direction of the lower leg)
    • With the other hand, rotate the patient’s foot internally and externally
    • Pain during external rotation -> medial meniscus injury
    • Pain during internal rotation -> lateral meniscus injury
  • Patellofemoral joint test/Clarke test
    • Tests for disorder of patellofemoral joint
    • The patient should have their knee extended
    • With one hand apply pressure on the suprapatellar recess
    • With the other hand press the patella down
    • Ask the patient to contract their quadriceps muscle
    • Pain indicates patellofemoral joint disorder
  • Spurling test
    • Patient’s neck should be in full extension
    • The head should be rotated toward the painful shoulder
    • Apply an axial force on the cervical spine
    • Positive test: the pain of the shoulder becomes stronger
    • Indicates neuropathic pain
• X-ray
  • If a patient has a locomotor (musculoskeletal) problem – always take an x-ray
  • Lauenstein view = frog leg lateral view
    • Can examine antetorsion of femoral head
    • Used in DDH, etc.

1 – Introduction, gait cycle, symptoms in orthopaedic disorders

11. Gait and limping

• Gait
  • Has two phases
  • Stance phase – lasts from the moment the heel touches the ground until the foot lifts off the ground
    • Heel strike
    • Rolling
    • Lift-off
  • Swing phase – lasts from the moment of lift-off until the heel touches the ground
    • Acceleration
    • Swing-through
    • Deceleration
  • What to assess in a patient’s gait
    • The character
    • The step length
    • The width
    • Whether there is limping
    • Whether the pelvis remains level during walking
    • Whether the shoulders remain level during walking
• Limping
  • = the movement of the lower limbs is no longer symmetrical, or the phases of the two lower limbs differ
  • Potential causes of limping
    • Limb length discrepancy (discrepancy gait)
      • Normal 1 – 1,5 cm
    • Contractures (range of movement restrictions) or ankylosis (contracture gait)
    • Muscle atrophy/weakness or paralysis (paralytic gait)
    • Pain (antalgic gait)
    • Joint instability
  • Discrepancy gait
    • Causes lateral pelvic tilt
    • Due to discrepancies in limb length
  • Antalgic gait
    • Patient limps to avoid pain
    • The stance phase on the painful side or limb is shortened
  • Paralytic gait
    • Due to muscle weakness or paralysis
    • Trendelenburg limping
      • A special form of paralytic gait
      • Due to weakness of gluteus medius, often due to superior gluteal nerve lesion
      • Pelvis tilts toward the contralateral side during the stance phase
  • Contracture gait
    • Due to contractures in muscle, skin, or joints

15. Ultrasound imaging in orthopaedics

• Used to investigate soft tissues
  • Tendons
  • Muscles
  • Ligaments
  • etc.
• Can be used for functional and dynamic examination
  • I.e., muscle movement can be detected
• Used for examination of
  • Soft tissue cysts
  • Tendons
  • Soft tissue tumours
• Can also be used therapeutically
  • Used in physiotherapy
  • US provides heat, etc. to deep tissues
  • Speeds up healing of muscles, tendons, ligaments, etc.

27. Joint movements, contractures, ankylosis, measurement methods in orthopaedics

• Joint movements
  • The passive movements of the affected/painful joint and the contralateral joint should be examined for contractures (range of motion), pain and crepitation
  • Joints should physiologically not extend beyond 0° – if so, it’s called hyperextension
  • If the examination of the joint movements is limited by pain they should be re-examined during anaesthesia before the surgery
• Contractures
  • = decrease of range of motion of a certain movement
  • Any joint can experience contracture in any movement
  • If a knee cannot be flexed as much as much as normal, the patient has a knee extension contracture
    • The knee motion stops in extension, before it reaches complete flexion
  • If an elbow cannot be extended as much as normal, the patient has an elbow flexure contracture
    • The elbow motion stops in flexion, before it reaches complete extension
  • General causes
    • Scarring of the skin
    • Muscle paralysis or constriction
      • Neuromuscular diseases, like Heine-Medin disease or infantile cerebral paresis
    • Changes in the joint and capsule
      • Very common in osteoarthritis, developmental dysplasia of the hip
      • Can be due to inflammation, trauma or repeated surgeries
  • Thomas test
    • A test which tests for hip flexion contracture
    • Patient is supine on table
    • Passively flex the hip and knee of the unaffected leg
    • Positive test: The patient will reflexively lift the thigh of the other, affected leg
    • Negative test: The affected leg remains on the table
• Increased range of motion of joints
  • Opposite of contracture
  • Often a symptom of a connective tissue disease like Marfan
• Ankylosis
  • = Total loss of joint motion due to bony or fibrous jusion
  • Causes
    • Ankylosing spondylitis (Bechterev disease)
    • Psoriatic arthritis
    • Rheumatoid arthritis
    • Postoperative arthrofibrosis
• Limb length discrepancy
  • Measurement
    • Performed with limbs in extension and parallel position
    • Measured between easily palpable bony surfaces, or easily visible structure
    • For upper limbs: length between acromion and styloid process of radius
    • For lower limbs: length between anterior iliac spine OR umbilicus, and the medial malleolus
    • Length must always be compared between limbs
  • Is best measured by x-ray or CT
  • Normal length discrepancy: 1,0 – 1,5 cm
  • Causes
    • Idiopathic
    • Osteoarthritis
    • Tumour
    • Trauma
    • Developmental dysplasia of the hip
  • Clinical features
    • Limping
    • Lower back pain
    • Scoliosis
  • Treatment
    • Orthopaedic shoes – see topic 55
    • Limb equalization – see topic 25

50. Joint motions, measurement of muscle strength

• Joint motions
  • Shoulder
    • Abduction 90 degrees
      • Elevation another 90 degrees
    • Flexion 90 degrees
      • Elevation another 90 degrees
    • Internal rotation 90 degrees
    • External rotation 50 degrees
  • Elbow
    • Flexion 150 degrees
    • Extension 10 degrees
    • Supination 90 degrees
    • Pronation 90 degrees
  • Wrist
    • Palmarflexion 50 degrees
    • Dorsiflexion 40 degrees
    • Ulnar deviation 30 degrees
    • Radial deviation 30 degrees
  • Hip
    • Flexion 130 degrees
    • Abduction 30 degrees (when standing)
    • Adduction 30 degrees (when standing)
    • Internal rotation 40 degrees (when flexed)
    • External rotation 30 degrees (when flexed)
  • Knee
    • Flexion 130 degrees
    • Extension 10 degrees
    • Slight internal and external rotation in flexed position
  • Ankle
    • Dorsiflexion 30 degrees
    • Palmarflexion 40 degrees
    • Eversion, inversion
    • Pronation, supination
• Measurement of muscle strength
  • Determined by physical examination or EMG
  • Scale:
    • 5 – Normal strength (full function even against great resistance)
    • 4 – Muscle function only against limited resistance
    • 3 – Muscle function against the action of gravity
    • 2 – Muscle function only in the absence of gravity
    • 1 – Only muscle fibrillation is visible
    • 0 – Total paralysis

2 – Congenital dislocation of the hip

7. DDH (developmental dysplasia of the hip), etiology and pathology of

• DDH is the most common congenital musculoskeletal deformity
  • Affects approx. 2 out of 100 000 newborns in Europe
• Left hip is slightly more often affected than the right
  • Bilateral DDH is rare
• Etiology
  • Girls > boys
  • Breech position during delivery
    • Causes abnormal flexion of the hip
  • Firstborn children > later-born children
  • Family history
  • Oligohydramnios
• Pathology
  • The acetabulum is dysplastic and shallow
    • Normally the acetabulum contains 2/3 of the femoral head
    • In DDH the acetabulum contains less than 2/3
    • This increases the pressure on the surface of the hip
  • Subluxation / dislocation of the femoral head
    • Due to the shallow acetabulum
• Secondary changes
  • Occurs in untreated DDH -> secondary changes develop in the femoral head and acetabulum
  • These secondary changes make hip reduction more and more difficult
  • Bony changes
    • Delayed ossification of femoral head
    • Increased femoral antetorsion
      • = the shaft of the femur has a torsion, causing the femoral neck to rotate anteriorly
      • This increases the angle between the femoral neck and the condylar axis
    • Increased collodiaphyseal angle
    • Coxa valga
      • Due to increased collodiaphysal angle
  • Soft tissue
    • Loose capsule
    • Abnormal position of iliopsoas
      • The iliopsoas normally runs in front of the head of the femur
      • In DDH the tendon of the iliopsoas comes between the cavity of the acetabulum and the head of the femur
      • This makes it difficult to reduce the head of the femur through the narrowed opening

38. DDH, clinical and X-ray features of

• Clinical features
  • Limited motion of the limb
    • Especially abduction (adduction contracture)
  • Asymmetric skin folds on the thigh and gluteal region
  • Positive Barlow sign
    • A click is heard and felt when pressure is applied to dislocate the hip
    • This test shows that the hip can be dislocated, but is not currently dislocated
  • Positive Ortolani sign
    • A click is heard and felt when pressure is applied to reduce the hip
    • This test shows that the hip is reduceable and therefore currently dislocated
    • Positive Ortolani sign is the only definitive sign of DDH
  • Late
    • Limb length difference
    • Trendelenburg gait
• Diagnosis
  • Screening at birth, 3 weeks, 3 months, 6 months
    • Only in those with risk factors or if there is clinical suspicion
    • US or X-ray
  • Ultrasound
    • Used for infants < 4 months
    • Can detect clinically silent DDH
  • X-ray
    • Used for infants > 4 months
    • In AP and Lauenstein view
    • Shows acetabular dysplasia and hip location
    • Femoral head is above the Hilgenreiner line
    • Femoral head is lateral to the Perkin line

41. Conservative treatment of DDH

• If patient is < 6 months
• Baby must use a so-called Pavlik harness or an abduction splint, which secures the baby’s hips in a stable “frog-leg” position, allowing them to develop normally
  • Pavlik harness fixes the femoral head in the correct position
  • Over the time acetabulum will be deepened
  • Abnormal use of the Pavlik harness can cause osteonecrosis of the femoral head
• Pavlik harness rapidly becomes ineffective after 4 months of age -> abduction splint or plaster cast
• Has high success rate when used correctly

52. Surgical treatment of DDH (developmental dysplasia of the hip)

• If patient is already > 6 months old OR conservative treatment didn’t work
• The specific surgical treatment depends on the exact pathology, but it always involves open reduction of the joint
• Other procedures which may be necessary
  • Soft tissue procedures
    • Adductor and/or iliopsoas muscles may need operation because they adapt to the dislocated joint, causing contracture
  • Femur osteotomy (= varus de-rotational osteotomy)
    • Corrects collodiaphyseal angle and antetorsion
  • Pelvic osteotomy (= acetabulum-plasty)
    • Dega osteotomy
      • Done when socket is too wide and too shallow
    • Salter osteotomy
      • Done when the socket doesn’t sit properly on the femoral head
• Patient must wear spica cast afterwards

3 – Congenital foot deformities

Basics of foot

• DDH is the most common congenital problem of the musculoskeletal system
• Congenital foot deformities are the second
• Foot = everything distal to tibiotalar joint
• Arches of the foot
  • Soft tissues like muscles, tendons and ligaments are important in maintaining the arches of the foot
  • The three arches form a triangle under the foot
  • Transverse arch
  • Lateral longitudinal arch
  • Medial longitudinal arch
• Characteristics of healthy foot
  • Pain free
  • Good muscle balance
  • No contractures
  • Heel in physiological position (no varus or valgus)
  • Toes without deformity
• Parts of foot
  • The forefoot is comprised of the metatarsal bones and the phalanges
  • The midfoot is comprised of the navicular, the cuboid, and the cuneiform bones
  • The hindfoot is comprised of the talus and calcaneus
• Function
  • Dynamic functions
    • The medial structures (talus, navicular, cuneiform and first three metatarsal bones)
    • Provide shock absorption when walking
  • Static functions
    • The lateral structures (calcaneus, cuboid, fourth and fifth metatarsal bones)
    • Provide stability
• The majority of the pressure is on the calcaneus and the first two metatarsal bones
• Forefoot deformities
  • Pes adductus (skew-foot)
  • Pes supinatus
• Hindfoot deformities
  • Often have associated forefoot deformities
  • Clubfoot (talipes equinovarus)
  • Vertical talus (rocker-bottom foot)

22. Clubfoot, etiology and pathology of

• Clubfoot is one of the two hindfoot deformities (the other being rocker-bottom foot)
  • It is a hindfoot deformity, but it also has associated forefoot deformities
• Clubfoot is also called congenital talipes equinovarus (CTEV)
• The clinical appearance involves
  • Concave medial side and convex lateral side
    • Think banana pointing medially
  • Heel varus
  • Adducted and supinated forefoot
  • Can be unilateral or bilateral
• Congenital clubfoot
  • Common
    • The 2^nd most common congenital deformity
  • Incidence depends on race
  • Etiology: Neuromuscular problem
    • Dominant posterior musculature
    • Weak peroneus muscles
    • Shortened Achilles tendon
  • For management of congenital clubfoot: see topic 24
• Acquired clubfoot
  • Rare
  • Etiology of acquired clubfoot
    • Paralytic causes
      • Paralysis of muscles can cause clubfoot
    • Teratologic (tibia hypoplasia)
    • Syndromic (Larsen/Marfan syndrome)
    • Secondary (arthrogryposis)
    • Postural (mechanical)
      • Due to abnormal intrauterine position of feet
• Pathology of clubfoot
  • Heel varus and equinus
  • Forefoot adductus and supinatus
  • Concave medial side
  • Convex lateral side
  • The long axis of the talus and calcaneus run parallel to each other in the AP and lateral views

24. Congenital clubfoot, management of

• See topic 22 for more general information about clubfoot
• Conservative treatment
  • The conservative technique for treating congenital clubfoot is called the Ponseti method
  • This method is the standard of care, and is successful in almost 100% of cases
  • The Ponseti method takes 4 – 6 weeks
  • Begins as soon as the baby’s skin is ready (can be even after 2 days after birth)
  • Procedure
    • The foot is manually manipulated into a more correct position
      • This type of manipulation is called talus derotation
      • Talus derotation creates an angle between talus and calcaneus
    • The foot is then casted in that position
    • After some days the cast is removed, the foot is once again manipulated and re-casted
    • This procedure is repeated multiple times until the deformity is confirmed corrected by x-ray
    • Achilles tenotomy is finally performed
• Operative treatment
  • Needed if conservative treatment is unsuccessful
  • Surgical treatment should finish before 12 months of age
• Aftercare
  • Exercises
  • Follow-up (with x-ray)
    • Taking x-rays is important to determine that the bones are being corrected and not just the soft tissue is being moved
  • Splinting – important to keep the foot in normal position

59. Rocker bottom foot (vertical talus)

• Rocker-bottom foot (vertical talus) is one of the two hindfoot deformities (the other being clubfoot)
  • Despite being a hindfoot deformity, vertical talus has associated forefoot deformities
• It is a congenital disorder
• The clinical appearance involves
  • Concave lateral side and convex medial side
    • Think banana pointing laterally
  • Concave dorsal side and convex plantar side
  • A prominent calcaneus
• Vertical talus and clubfoot have opposite macroscopic appearance (they’re opposite deformities)
• Etiology
  • Structural (genetic)
  • Paralytic (neurologic)
  • Teratologic (fibula hypoplasia)
  • Symptomatic (Larsen/Marfan syndrome)
  • Postural (mechanical)
• Pathology
  • The talus sits vertically instead of normally
  • The angle between the long axis of the talus and calcaneus in the AP view is > 32 degrees
  • The angle between the long axis of the talus and tibia in the lateral view is > 120 degrees
• Treatment
  • Start with conservative treatment
    • Manipulation + cast (similar to Ponseti method, but in the opposite direction)
    • Check result with X-ray
  • Perform surgery before 1 year of age if results are not satisfactory
    • Surgery of congenital foot abnormalities must be finished before 1 year (before the child will stand)

4 – Spine deformities

Basics of spine

• Curvatures
  • Lordosis – concave (inward)
  • Kyphosis – convex (outward)
  • Scoliosis – deformity in all 3 planes (not just sideways)
    • Lateral curvature in the coronal plane
    • Lordotic deviation in the sagittal plane
    • Vertebral rotation in the horizontal plane
  • Normal:
    • Cervical lordosis
    • Thoracic kyphosis
    • Lumbar lordosis

Basics of scoliosis

• Scoliosis – deformity in all 3 planes (not just sideways)
  • Lateral curvature in the coronal plane
  • Lordotic deviation in the sagittal plane
  • Vertebral rotation in the horizontal plane
• Most patients with scoliosis have small curves without progression
• Scoliosis causes a characteristic “rib hump” when bending over
  • Due to the rotation of the vertebrae the ribs will be pushed posteriorly
• Scoliosis is a dynamic deformity – annual (or more frequent) follow-ups are mandatory until bony maturation
• Categorization of scoliosis based on onset
  • Congenital (due to vertebral malformations)
  • Early onset (< 9 years)
    • Infantile (< 3 years)
      • Boys > girls
      • 80% spontaneously resolve
    • Juvenile (3 – 9 years)
      • Boys = girls
  • Adolescent (11 – 18 years) (= adolescent idiopathic scoliosis, AIS)
    • Boys < girls (1:7)
  • Adult
    • Rare
    • Due to degenerative disease, trauma, etc.
• Categorization of scoliosis based on vertebral rotation
  • Structural scoliosis – with vertebral rotation
  • Functional scoliosis – without vertebral rotation
    • See topic 30
• Diagnosis
  • Scoliometer
    • = a tool which measures the angle of trunk rotation
  • Coronal balance
    • Patients with scoliosis will compensate in the coronal plane by laterally moving their head or pelvis
    • Computers measure the degree of compensation of scoliosis based on x-ray
    • If the straight line from C7 does not land between the buttocks, the scoliosis is decompensated to one side
    • During treatment the goal is to put the spine into normal coronal and sagittal balance
  • Sagittal balance
    • Patients with scoliosis will compensate in the sagittal plane by anteriorly or posteriorly moving their head or pelvis
    • Computers measure this as well
  • X-ray
    • Of full spine (base of skull to pelvis)
      • To check the pelvic compensation as well
    • AP and lateral views
    • While standing and while bending laterally
    • TRuGA (traction x-ray under general anaesthesia)
      • X-ray while the head and pelvis are pulled in opposite directions
      • Shows how rigid the curve is
  • MRI
    • Only if red flags (like unusual curve) are suspected
    • Can detect tethered cord, syringomyelia, dyasthematomyelia, Chiari malformation
    • If these conditions are not detected before scoliosis surgery paralysis or severe complications can develop
  • 3D CT
    • If congenital vertebral malformations are suspected
• How to measure scoliosis -> measure Cobb angle
  • Cobbs angle is the angle between the following two lines:
    • A line parallel to the superior endplate of the highest affected vertebra
    • A line parallel to the inferior endplate of the lowest affected vertebra
  • A Cobb angle of > 90 degrees has high risk of cardiac or respiratory disease, so surgery is always indicated
    • Depending on the type of scoliosis surgery may be indicated at smaller degrees too

18. Scheuermann’s Disease

• = Scheuermann kyphosis
• Epidemiology
  • Male > female (2:1)
  • Prevalence 4 – 8%
  • Starts around puberty
• Pathology
  • Avascular necrosis of the vertebral body apophysis
• Clinical features
  • Usually affects thoracic spine
  • Rigid, progressive, and painful hyperkyphosis
  • Kyphosis increases when bending forward
  • Subacute back pain
• Signs on X-ray
  • Regular hyperkyphosis (Cobb angle > 40 degrees)
  • Wedging of vertebral bodies
  • Irregular endplates
  • Schmorl herniation
  • Long and narrow vertebral bodies (compared to normal cube shape)
• Treatment
  • Cobb angle 40 – 70 degrees
    • Schroth therapy and Gschwend brace
  • Cobb angle 70 – 80 degrees
    • Surgery if pain is dominant
  • Cobb angle > 80 degrees
    • Surgery

30. Functional scoliosis, postural deformities

• Functional scoliosis = A structurally normal spine that appears to have a lateral curve
  • The spine appears scoliotic due to an underlying problem like:
    • Limb length discrepancy
    • Antalgic posture
      • Disc herniation
      • Sacroiliitis
      • Appendicitis
      • Etc.
    • Hysteriform scoliosis
      • Very rare
      • Some kind of psychosomatic problem in young females?
  • There is NO rotation of the vertebral bodies, unlike in structural (normal) scoliosis
    • -> No rib hump when bending over
    • -> Scoliosis disappears in supine position or when bending to the side
• Postural deformities
  • Normal posture of spine
    • Cervical lordosis
    • Thoracic kyphosis
    • Lumbar lordosis
    • Lumbosacral kyphosis
  • Postural deformities
    • Excessive thoracic kyphosis
    • Excessive lumbar lordosis
  • Treatment
    • By physiotherapy and exercise
    • Surgery not required

42. Scoliosis with known etiology, treatment of

• Structural scoliosis is secondary in 20% of cases
• Compared to idiopathic scoliosis, neuromuscular scoliosis involves
  • Pelvic deformities in addition to the spinal deformities
  • Risk of progression independent of growth (after skeletal maturity)
  • Several comorbidities
  • Neurological problems
  • Problems while sitting
• Etiology
  • Neuromuscular
    • = causing muscle weakness or asymmetry
    • Spinal muscular atrophy
    • Cerebral palsy
    • Duchenne muscular dystrophy
  • Congenital (abnormal vertebrae)
    • Wedge vertebrae
    • Block vertebrae
    • Hemiblock vertebrae
  • Syndromic
    • Neurofibromatosis
      • MRI should be performed to look for neurofibromas
    • Marfan syndrome
    • Ehlers-Danlos syndrome
• Treatment
  • Neuromuscular scoliosis
    • Growing rods until growth is finished
    • Spinal fusion surgery (of Luque)
  • Congenital scoliosis
    • Surgery to correct the congenital abnormality
  • Syndromic scoliosis
    • Same as for adolescent idiopathic scoliosis

51. Idiopathic structural scoliosis

• Structural scoliosis is idiopathic in 80% of cases
• Adolescent idiopathic scoliosis (AIS)
  • 11 – 18 years
  • Lenke classification system
    • The gold standard for classification of AIS
    • Helps plan surgeries
  • Risser sign
    • = degree of ossification of the iliac apophysis across the iliac crest
    • Is used to estimate the skeletal maturity of the vertebral column and to guide treatment
      • -> more mature = less risk of scoliosis progressing
      • -> less mature = more risk of scoliosis progressing
      • Spinal fusion surgery can only be performed on those with mature skeleton
        • If Risser 2 or lower -> conservative treatment
        • If Risser 3 or higher -> spinal fusion surgery
    • Risser 1 = 25% of the iliac crest is ossified
    • Risser 2 = 50%
    • Risser 3 = 75%
    • Risser 4 = 100% of the iliac crest is ossified
    • Risser 5 = the iliac crest is fused to ileum
  • Skeletal maturity can also be planned based on menarche
    • We say that 2 years after menarche the skeleton is mature enough for spinal fusion surgery
  • Poor prognostic factors (factors which increase risk of curve progression)
    • These factors are important to determine how often a check-up should be performed
    • Female
    • Age of onset
    • Greater Cobb angle
    • Scoliosis of upper spine
    • Bigger vertebral rotation
    • Bigger rib-vertebral angle difference (RVAD)
  • Treatment
    • Conservative
      • Used for Risser 2 and below while waiting for skeletal maturity, and for < 50 degree Cobb
      • Schroth therapy
        • = special 3D training exercises
        • These exercises not only stops progression but can cause regression of curve
      • Cheneau brace
        • Should be worn for 20 hours per day
        • Must be combined with physical exercise
        • The brace helps stopping the progression but does not cause regression
    • Surgery
      • Posterior instrumented fusion with direct vertebral rotation
        • A form of spinal fusion surgery
        • Gold standard
        • Involves placement of screws and rods
      • Osteotomies
        • On rigid spines
    • Cobb angle 15 – 20 degrees
      • Night-time brace + Schroth therapy
      • Only observation (if non-progressive curve)
    • Cobb angle 20 – 40 degrees
      • Cheneau brace + Schroth therapy
    • Cobb angle 50 – 65 degrees -> Surgery
      • Surgery at this stage corrects the cosmetic problem and prevents later back pain
    • Cobb angle > 65 degrees -> Surgery
      • Surgery at this stage not only corrects the cosmetic problem and prevents later back pain, but also prevents severe cardiorespiratory complications
• Early onset scoliosis
  • Treatment is not based on fusion (as in AIS) but rather uses unilateral growing rods
  • Many cases resolve spontaneously

5 – Cerebral palsy

17. Infantile cerebral palsy

• Risk factors
  • Preterm birth
  • TORCH
  • Brain damage
  • Alcohol
• Types of CP
  • Spastic CP
    • Most common
    • Spastic paralysis occurs
  • Ataxic CP
  • Athetoid CP
• Clinical features
  • Hyperlordosis
  • Knee joint
    • Flexion contracture
  • Hip joint
    • Hip dislocation
    • Flexion contracture
    • Adduction contracture
  • Equinovarus and planovalgus deformity of feet
  • Scissor gait (legs cross while walking)
• Treatment
  • Conservative
    • Physiotherapy
    • Bracing
    • Intramuscular botox – reduces spasticity
    • Spasmolytics
  • Surgery
    • In case of severe contractures
    • Various orthopaedic procedures

6 – Paediatric hip diseases (Perthes, epiphyseolysis)

13. Juvenile slipped upper femoral epiphysis

• = slipped capital femoral epiphysis
• Epidemiology
  • Most common hip disorder in adolescents
  • Males > females
  • 6 – 16 years
• Etiology
  • Unknown cause
  • GH and sex hormone imbalance may be involved
  • Obesity and family history are risk factors
• Pathology
  • The femoral head (epiphysis) slips off the neck (metaphysis) in the line of the growth plate
  • Can be acute or chronic
• Clinical features
  • Often bilateral
  • Acute type
    • Sudden onset pain
  • Chronic type
    • Nagging groin/thigh/knee pain
    • Antalgic gait
  • Flexion, abduction, and internal rotation contracture
  • Features of sex hormone imbalance
    • Fat
    • No pubic hair
    • Delayed sexual development
• Diagnosis
  • X-ray
  • MRI
• Treatment
  • Always surgical – there is no conservative treatment
  • Urgent surgical internal fixation with screwing of the femoral head
    • Percutaneous procedure
    • Screw can be removed when child is done growing

26. Perthes’s Disease

• = idiopathic avascular necrosis of the femoral head
• Epidemiology
  • 3 – 16 years
  • Boys > girls
• Etiology: Idiopathic by definition
• Pathomechanism
  • The femoral epiphysis grows quickly and is therefore highly dependent on adequate blood supply
  • Inadequate blood supply can be due to compression of the arteries (for example from transient coxitis)
• Clinical features
  • Usually unilateral
  • Antalgic gait
  • Pain in groin, thigh, or knee
  • Limited internal rotation and abduction
• Diagnosis
  • X-ray
    • Often shows nothing the first 3 – 6 months
    • Shows flat, collapsed femoral head
  • MRI
    • If x-ray is negative but clinical suspicion persists
• Treatment
  • The primary aim of treatment of Perthes disease is containment (= holding the femoral head in the acetabulum)
    • Can be achieved by conservative therapies or by surgery
  • Conservative
    • Non-weightbearing activities
      • To allow re-ossification
      • Swimming is excellent
    • Pain management
    • Physical therapy
  • Surgical
    • Generally only for children > 8 years
      • Younger children generally don’t benefit from surgery
    • Surgical containment by femoral or pelvic osteotomy
• Complications
  • The younger the patient, the better prognosis
  • Heals in 3 – 5 years
  • May lead to late osteoarthritis (Perthes is a prearthritic condition)

54. Transitory coxitis, coxa saltans

• Transitory coxitis (= transitory synovitis of the hip = irritable hip)
  • Epidemiology
    • Most common cause of acute hip pain in children 3 – 8 years
    • Boys > girls
  • Etiology
    • Occurs without precipitating cause in most cases
    • May follow upper respiratory tract infections or trauma
  • Pathology
    • Synovitis of the hip
  • Clinical features
    • Almost always unilateral
    • After upper respiratory tract infections
      • This may give transitory coxitis a season appearance
    • Often recurs
    • Antalgic limp
    • Thigh/knee pain
    • Flexion contracture
    • Limited internal rotation
    • No fever
  • Diagnosis
    • ESR, CRP, WBC slightly raised
    • US/MRI show hip joint effusion
    • X-ray shows nothing
  • Treatment
    • The condition is self-limiting after a few weeks in most cases
    • Rest
    • NSAIDs
    • Joint fluid aspiration
      • This can also exclude septic arthritis, which may cause similar symptoms
  • Complications
    • The pressure caused by the effusion can cause avascular necrosis of the femoral head
• Coxa saltans (= snapping hip)
  • A condition characterised by a snapping sensation felt in the hip
  • May or may not be audible, may or may not cause pain
  • Three types
    • External snapping hip
      • Caused by iliotibial tract sliding over greater trochanter
      • Often visible
    • Internal snapping hip
      • Caused by iliopsoas tendon sliding over femoral head or other structures
      • Often not visible, but is audible
    • Intra-articular snapping hip
      • Caused by loose bodies in the hip joint
  • Treatment
    • Internal and external types usually don’t require treatment
      • If painful, the anatomic structure which causes the snapping can be incised
    • Intra-articular type can be repaired by hip arthroscopy

7 – Shoulder disorders + upper extremity

Basics

• From an orthopaedic point of view the upper extremity starts from the neck and the heart
  • This is because upper extremity symptoms may come from the neck (nerves) or heart (vessels)
  • Nerve roots of the brachial plexus innervates the dermatomes of the upper extremity
• Upper extremity consists of three joints – shoulder, elbow, and hand
  • Only full function of all three joints allow normal movement of upper extremity
• Pain can radiate up or down the upper extremity
  • The area which is painful can be far away from the diseased area
• DD of shoulder problems or pain
  • Adhesive capsulitis (frozen shoulder)
    • Negative x-ray
    • Severely restricted movement
  • Osteoarthritis of the shoulder
    • X-ray findings like in any OA
  • Rotator cuff tear
  • Problems in the neck, heart (AMI), A/C joint, tumours in the region
• We use only 15% of the ROM of the shoulder during daily activity
  • -> try using the whole ROM to prevent problems

14. Rheumatoid arthritis, surgical aspects of

• In cases of severe joint destruction causing severe pain or unacceptable dysfunction
• Mainly joint replacement
  • Mainly shoulder, hip, knee, PIP, MCP
• In some cases: joint fusion
  • Mainly wrist, ankle

21. Tennis elbow (humerus epicondylitis)

• Tennis elbow = lateral humerus epicondylitis
  • Overuse of extensor muscles causes chronic periostitis
    • The extensors originate from the lateral epicondyle
  • Very common cause of elbow pain
  • Etiology
    • Many small repeating movements without rest
    • Excessive computer use
    • Racquet sports
  • Clinical features
    • Pain over lateral epicondyle and the extensors
  • Treatment
    • Conservative
      • The primary treatment is conservative
      • Rest
      • Lifestyle changes
      • NSAIDs
      • Physiotherapy
    • Surgical
      • Injection of local anaesthetics and steroids
        • Less and less used because of local steroid side effects (like skin atrophy)
      • Surgery
        • Detachment of muscles and excision of periosteum
        • Only in recurring cases
• Golf elbow = medial humerus epicondylitis
  • Overuse of flexor muscles causes chronic periostitis
    • The flexors originate from the medial epicondyle
  • Very common cause of elbow pain
  • Etiology
    • Many small repeating movements without rest
    • Golfing
    • Excessive computer use
  • Clinical features
    • Pain over medial epicondyle and the flexors
  • Treatment
    • Same as for tennis elbow

28. Recurrent dislocation of the shoulder

• Chronic/recurrent dislocation of the shoulder
• Etiology
  • Untreated or poorly treated previous trauma
    • Most common cause
    • After one traumatic dislocation the joint capsule is torn, which predisposes to recurrent dislocation
    • After a dislocated shoulder has been reduced, further dislocations must be prevented by immobilizing the shoulder
    • Immobilizing allows the joint capsule to heal back to its normal and tight position
    • No immobilization causes the joint capsule to heal into a looser position
  • Dysplasia (underdevelopment of the glenoid fossa)
  • Voluntary dislocation
    • Due to psychiatric problems
• Types according to direction
  • Antero-inferior dislocation (most common)
  • Posterior dislocation
    • Mostly only occurs in epilepsy or electric shock, especially if bilateral
• Treatment of recurrent dislocation
  • Surgical stabilization

34. Periarthritis of the shoulder, frozen shoulder

• Adhesive capsulitis (= periarthritis of the shoulder)
  • = inflammation of the joint capsule which shrinks it and makes movement painful
  • Can be idiopathic (primary) or secondary to diabetes, thyroid disease, etc.
  • Pathomechanism
    • Inflammation of the joint capsule makes movement of the shoulder painful
    • Pain causes the shoulder to be less frequently used
    • Lack of use and inflammation causes the shoulder capsule to thicken and adhere to itself and the humerus -> the symptoms become progressively worse
    • In the “end-stage” adhesive capsulitis the shoulder cannot be moved at all -> frozen shoulder
  • Stages
    • Freezing stage – pain and limited motion
    • Frozen stage (frozen shoulder) – less pain, no motion
    • Thawing stage – symptoms improve
  • Clinical features
    • Restricted and painful movements of shoulder
      • Especially internal and external rotation
  • Diagnosis
    • Adhesive capsulitis is a clinical diagnosis based on decreased movement without underlying disease
    • Negative X-ray
    • MRI may show soft tissue inflammation
  • Treatment
    • It’s usually self-limiting
    • Conservative
      • NSAIDs
      • Physiotherapy
    • Surgical
      • Manipulation under anaesthesia (MUA)
        • (Not so much used anymore)

39. Cervical rib, thoracic outlet syndrome (TOS)

• TOS – see also surgery 1, topic 13
  • Etiology
    • Descending shoulder girdle due to weak muscles
      • This stretches the scalenus muscles, narrowing the triangular space
    • Rigid vessels (due to aging)
    • Strong (hypertrophic) scalenus muscles
  • Pathology
    • Subclavian artery, subclavian vein and brachial plexus run through a narrow triangular space called the thoracic outlet
    • The thoracic outlet is comprised of the clavicula, the first rib and the anterior and medial scalenus muscles
    • If the thoracic outlet becomes narrower some or all of the neurovascular structures may be compressed
  • Symptoms
    • Arm or hand tingling or weakness
  • Diagnosis
    • If there is a pulse deficit in the hand -> subclavian artery is compressed
    • If not -> most likely the symptoms are caused by compression of brachial plexus
  • Treatment
    • Conservative
      • Strengthen muscles (if TOS was due to weak muscles)
    • Surgical
      • Surgical decompression
• Cervical rib
  • Some people have a congenital extra rib before the first rib called the cervical rib
    • The first rib starts at Th1
    • The cervical rib starts at C7
  • This cervical rib compresses the thoracic outlet, causing TOS
  • The treatment is surgical resection of the cervical rib

Rotator cuff tear

• = tear in the tendon of one or more muscles of the rotator cuff
  • Most commonly affects supraspinatus tendon
• Rotator cuff
  • = supraspinatus, infraspinatus, teres minor, and subscapularis
  • These muscles attach to the greater tubercle of the humerus
  • Function is to stabilize the shoulder and allow for normal shoulder motion
• Clinical features
  • Painful/weak/impossible elevation of shoulder
• Imaging
  • US or MRI
• Differential diagnosis
  • OA
  • Frozen shoulder
  • Cervical problems
• Treatment
  • Surgical reinsertion of tendon with arthroscopy (not open surgery)

Wrist osteoarthritis

• Epidemiology
  • Usually affects people in working age, unlike other OA
• Etiology
  • Vibration work
    • Miners, roadworkers, etc.
  • Fracture of distal radius
  • Scaphoid fracture
    • In that case: fix the scaphoid fracture with a screw
• Clinical symptoms
  • Pain
  • Restricted ROM
• Treatment
  • Wrist arthrodesis with plate and screws
    • Unlike arthrodesis for knee and hip joint (which is never performed anymore), wrist arthrodesis is still performed
    • This is because wrist prosthetic replacement is not as good as hip or knee replacement
  • Wrist prosthetic replacement
    • Good only for mild movements and light lifting
    • For these reasons, wrist replacement is not good for non-elderly

Dupuytren contracture

• Idiopathic
• Pathology
  • Hypertrophy/metaplasia of palmar aponeurosis -> shrinkage of palmar aponeurosis -> the affected finger gets pulled -> flexion contracture
• Clinical features
  • Painless
    • The patient does not complain of pain but rather of the deformity
  • Most commonly affects the 4^th finger, but can affect any finger
  • Flexion contracture of MCP and PIP joint
• Treatment
  • Surgical removal of the aponeurosis

Osteoarthritis of the fingers

• May occur in physical workers
• Treatment:
  • Conservative
  • Surgical: joint replacement

8 – Prearthritic conditions, osteoarthritis

Osteoarthritis (OA)

• = the degeneration of articular cartilage in the joint, causing friction and inflammation between bones
  • Not a primary inflammatory process, rather a degenerative process
• It’s a progressive disease
• Can affect all joints, but most commonly weight-bearing joints
• Risk factors
  • Pre-arthritic conditions
  • Old age
  • Overweight
  • Excessive joint loading
• Pathomechanism
  • Stress -> cartilage damage -> cartilage degeneration -> loss of joint space and bony surface -> subchondral bone becomes sclerotic
• Clinical features
  • Pain and stiffness
    • Patient can hardly move joint in the morning
    • Patient needs a certain time to get the joint mobile and for the pain to disappear
      • As the osteoarthritis progresses this takes longer and longer time
    • Stiffness and pain return in the evening
      • As the osteoarthritis progresses the stiffness and pain return earlier and earlier in the evening
    • The symptom-free period during the day becomes smaller and smaller as the disease progresses
  • Limited ROM (contractures)
    • Occurs in any arthritis
    • Is more and more limited as the disease progresses
  • Swelling
    • Due to osteophytes and free fluid
    • When the synovial membrane gets irritated due to osteoarthritis it starts to produce too much fluid -> fluid can’t drain anywhere -> swelling
• Diagnosis
  • X-ray
    • Loss of joint space
      • Hyaline cartilage is translucent on x-ray, making it look like there is a space between the joint
      • When there is loss of hyaline cartilage it looks like the joint “space” becomes smaller
    • Subchondral cysts
    • Subchondral sclerosis
    • Osteophytes
  • X-ray severity does not correlate with symptom severity!
    • A patient may have severe symptoms with just a few signs on the x-ray, or opposite
• Prevention
  • Much easier to prevent than to treat
  • Eliminate risk factors (prearthritic conditions)
  • Exercise
    • Reduces pain
    • Maintains ROM
    • Maintains muscle power
• Treatment
  • NSAIDs – for pain
  • Joint replacement
  • See individual topics

2. Prearthritic conditions

• = mechanical problems which leads to earlier osteoarthritis than normal
  • Any abnormal alignment, function, usage of joint
• Prearthritic conditions of all joints
  • Abnormal joint alignment – causes abnormal weight loading on the joints
    • Varus deformity
    • Valgus deformity
  • Excessive weight loading – obesity, joint overuse
  • Trauma involving intraarticular fractures
  • Inflammatory prearthritic conditions
    • RA
    • Gout
    • Autoimmune arthritis
  • According to a comment, RA and gout can cause early osteoarthritis but are not considered prearthritic conditions
• Prearthritic conditions of the hip
  • Developmental dysplasia of the hip – see topic 7
  • Femoroacetabular impingement
    • Abnormal contact between the acetabular rim and proximal femur
    • This leads to damage of the acetabular labrum and the acetabular chondrum
  • Slipped capital femoral epiphysis – see topic 13
  • Perthes disease – see topic 26
  • Acetabular labral tear
  • Coxa valga
  • Coxa vara
• Prearthritic conditions of the knee
  • Genu valgum
  • Genu varum
• Prearthritic conditions of the foot
  • Flatfoot
  • Hallux valgus
• Prevention
  • Surgical correction of poor joint alignment (osteotomy)
  • Treatment of underlying disease

9 – Joint arthroplasty + hip osteoarthritis + bone substitution

16. Hip osteoarthritis, clinical features, conservative management of

• Clinical features
  • Morning stiffness
  • Inguinal pain or pain above greater trochanter
    • Can refer to the thigh and knee
  • Contractures (reduced ROM)
    • First movement affected: internal rotation
  • Limp
  • Muscle atrophy around hip and thigh
  • Limb length difference
• Diagnosis
  • By conventional x-ray
  • AP view and Lauenstein (frog-leg) view x-ray
    • Narrow joint line
    • Subchondral sclerosis
    • Subchondral cysts
    • Osteophytes
• Treatment
  • Conservative
    • Frequent exercise
      • Especially joint-friendly exercises, like swimming, cycling
    • Weight loss
    • Physical therapy
    • NSAIDs
    • Orthopaedic shoes
    • Crutch on affected side
  • Surgical
    • Only if conservative treatment isn’t sufficient (late stage)
    • Total hip replacement
    • See topic 35

35. Surgical options for degenerative joint diseases

• Surgical treatment of hip osteoarthritis
  • Hip arthroplasty is one of the most successful orthopaedic operations
    • > 90% satisfaction rate
    • 1,5 million procedures every year
  • Can be used in any joint destruction
    • Mostly in osteoarthritis or osteonecrosis of hip joint
    • But contraindicated in case of ongoing local or systemic infection
      • The prosthesis has no blood supply and antibiotics therefore can’t reach it -> provides good base for infection
  • (Partial hip replacement)
    • NOT used in orthopaedics -> only used in treatment of hip fractures
    • Femoral head is replaced with prosthesis
    • Acetabulum is preserved
  • Total hip replacement (THR)
    • Used in orthopaedics
    • Femoral head is replaced with prosthesis
    • Acetabulum is replaced with prosthesis
  • Postoperative DVT prophylaxis
• Surgical treatment of knee osteoarthritis
  • The procedure is called knee replacement, but the name is misleading – only the joint surfaces are replaced
    • It should rather be called joint resurfacing
  • Most knee replacements are fixed by bone cement
  • Not replaced:
    • The collateral ligaments
    • The posterior cruciate ligament
    • The joint capsule
  • Total knee replacement
    • The joint surfaces of both condyles are replaced
    • If both condyles are affected by OA
  • Knee hemiarthroplasty (= partial knee replacement)
    • The joint surface of only one of the condyles is replaced
    • If only one of the condyles are affected by OA

58. Joint prothesis types and fixation methods

• Joint prosthesis
  • They are used to replace damaged joints
• Total hip replacement (THR)
  • Surgical technique
    • The acetabulum is opened and reamed (hollowed out)
      • This removes any residual cartilage and leaves only the bony surface
    • The neck of the femur is cut with a saw
    • The medullary cavity is reamed to make space for the femoral stem
    • If bone cement is used, bone cement is applied to the medullary cavity of the femur and the acetabulum to fix the femoral stem and the acetabular parts, respectively
    • If bone cement is not used the femoral stem and acetabular parts are banged in
  • Components
    • Acetabular component
      • Polyethylene insert or liner
        • A special kind of plastic
        • Provides the mobile part of the joint
      • Acetabular shell
        • Made of metal
    • Femoral head
    • Femoral stem – goes into medullary canal of femur
  • Types
    • Cemented THR
      • Both femoral component and acetabular component are fixed to the bone with bone cement
      • Bone cement dries after 15 minutes, meaning that the prosthesis can (in theory) be walked on and used immediately after the procedure
        • However, no patient can walk immediately after any major surgery
      • Bone cement is created by mixing a powder with a solution -> then applied with a cement gun
      • The bone cement will enter the lacunae of the bone, fixing the prosthesis to the bone
    • Uncemented THR
      • Does not use bone cement – instead, the prosthesis is fixed by force
        • This is called “press fit”
      • The acetabular part is banged into the acetabulum
      • The femoral stem is banged into the medullary cavity of the femur
      • The prosthesis has a porous coating and the bony part is rough, which creates a lot of friction between the prosthesis and the bone
        • This is called primary fixation
        • If the friction itself is not enough the prosthesis can be further fixed with screws
      • After some weeks the bone will grow into the porous surface of the prosthesis
        • This is called secondary or final fixation
        • This takes time, and the patient must not be weightbearing during this time
  • Indications
    • Cemented THR
      • For elderly
      • For less active patients
      • For those with poor bone quality
    • Uncemented THR
      • For young, active patients
      • For those with good bone quality

61. Bone substitution, bone transplantation

• Bone substitution/transplantation = replacing bone with something (called a bone graft)
• As the native bone grows it will generally replace the graft material with normal bone
• Needed in
  • Alignment correction
    • A wedge of bone graft may be inserted into a gap made by an osteotomy to correct alignment
  • Tumour surgery
    • Significant amounts of bone are removed and should be replaced
    • Tumour in diaphysis -> part of the diaphysis is removed and must be replaced
  • Revision joint replacement (replacing the previously implanted prosthesis with a new one)
  • Bone cyst removal
  • Congenital bone defects
  • Post-traumatic bone defects
• Properties of an ideal bone graft
  • Sterility
  • Good mechanical properties
    • Loadability
    • Fixation – must be fixable by plate or screw
  • Good healing properties
    • Osteoconduction – the grafts ability to connect the resected bone surfaces of host bone
    • Osteoinduction – the grafts ability to induce host osteogenesis
    • Osteogenesis – the grafts ability to produce bone by itself
      • Some grafts contain living osteoblasts, or a protein called BMP which stimulates host osteoblasts
  • Good availability
• Types of grafts according to material
  • Bone grafts
    • Solid (tubular) bone grafts
      • To replace bone after tumour removal, etc.
    • Morselized bone (= bone chips)
      • To replace bone inside a bone cyst
  • Artificial grafts
    • Metal grafts
    • Bone cement grafts
• Types of grafts according to origin
  • Autologous (from the patient)
    • Best graft
    • Osteogenesis + osteoinduction + osteoconduction
    • Patient needs an extra surgery to acquire the bone graft
    • Limited amount
  • Allogenic
    • From a human donor
      • Cadaver
      • Brain dead
      • From another patient who had bone removed as part of joint replacement, etc.
    • Osteoinduction + osteoconduction
    • Contains BMP
    • May contain transmittable diseases (hepatitis, HIV)
    • Expensive
  • Xenogenic (from another species)
    • Only used after deprotonation, so only the inorganic bone remains
    • No BMP or transmittable diseases
    • No osteoinduction or osteogenesis, only osteoconduction
    • Grafts from sea corrals
      • Sea corrals are comprised of hydroxyapatite with similar properties as human bone
• Conclusion
  • The choice of graft depends on the patient
  • A modern orthopaedic department should have all different types of bone graft available
  • There is no single “best” graft or material

10 – Complications of joint replacement and revision arthroplasty

57. Complications of joint replacements

• Complications of joint replacements are relatively rare
  • THR has an expected survival of more than 15 years
  • Complications rate is < 3%
  • Satisfaction rate > 90%
• Intraoperative complications
  • Fracture
  • Nerve damage
  • Vessel damage
  • Bleeding
  • Complications related to anaesthesia
• Early postoperative complications
  • Infection
    • Patients receive antibiotic prophylaxis, but the risk is not eliminated
  • Dislocation
  • DVT
    • Patients receive anticoagulation prophylaxis, but the risk is not eliminated
• Late complications
  • Particle disease (= particulum disease)
    • Friction between the prosthetic femoral head and the polyethylene liner causes polyethylene particles to come off
    • These particles increase osteoclastic activity, loosening the prosthesis
      • This is visible as osteolytic lesions around the prosthesis
    • The more active the patient, the higher risk for particle disease
    • Prevention
      • Use different surfaces
        • Ceramic surfaces create less friction than metal surfaces, but are more expensive
      • Keep normal bodyweight
• Revision arthroplasty (= revision surgery)
  • Removing the old prosthesis and replacing it with a new
  • Done if the implant is weary or loosening, most commonly due to particle disease
  • Younger patients who get joint replacement may “outlive” their replacement and may therefore need a revision

11 – Adult foot deformities + static disorders of the foot

Basics of adult foot deformities

• Most common foot conditions
  • Forefoot
    • Hallux valgus
    • Hallux rigidus
    • Metatarsalgia
    • Morton neuroma
    • Tailors bunion
  • Flatfoot
  • Hindfoot
    • Ankle joint osteoarthritis
    • Subtalar joint osteoarthritis
    • Heel spur
    • Plantar fasciitis
    • Haglund’s heel
    • Achilles tendon problems

3. Flat foot (pes planovalgus)

• Flat foot occurs due to flattening of one or more of the arches of the foot
  • Due to muscle insufficiency or failing capsules and ligaments
• Flat foot can occur in children and in adults
• The arches of the feet develop a while after birth – flatfoot in newborns is normal
• Etiology
  • Increased bodyweight
  • Being forced to stand early as a baby (too early walking age)
  • Standing all day at work
  • Bad shoes
  • Old age
• Types of flat foot
  • Pes transversoplanus – flat transverse arch
  • Pes planus – flat longitudinal arch
• Clinical features
  • In children
    • Pain in muscles of the thigh and calf after activity
    • Due to the muscles actively working to correct the flatfoot
  • In adults
    • Pain in the area of the flat arch during activity
    • In adults the muscles have given up trying to correct the flatfoot
  • Heel valgus
  • Pes transversoplanus -> wide forefoot
  • When tip-toeing a non-fixed flatfoot will gain back the arch
• Prevention
  • Don’t let your child walk too early (before 1 year)
  • Preventative muscle exercises
  • Tickle baby feet
  • Prevent obesity
• Treatment
  • Conservative
    • Heel wedge – corrects heel valgus
    • Arch support
      • Arch support is not treatment – they will cause do the job of the muscles, causing them to get weaker
      • Arch support can prevent pain but does not treat the underlying flatfoot
  • Surgical: Calcaneo-stop procedure
    • A screw is drilled into the calcaneus
    • The screw causes discomfort to the patient -> this forces the patient to use their muscles to correct their foot
• Complications:
  • Pes planus fixatus (= fixed flatfoot)
    • Due to tarsal coalition (fusion of tarsal bones), which occurs secondary to untreated flatfoot or as a developmental malformation
    • When tip-toeing a fixed flatfoot will not gain back the arch
    • Tarsal coalitions can be resected surgically
  • Hallux valgus
  • Bunion
  • Hammertoe
  • Osteoarthritis

9. Hallux valgus, mallet finger, digitus V. varus, bunion

• Hallux valgus
  • Etiology
    • Genetics
    • Shoe wear
    • Anatomical variations
  • Pathology
    • Valgus deformity of big toe
    • Flexor tendons are dislocated laterally
    • Extensor tendon slips down
  • Diagnosis
    • X-ray
    • Hallux valgus angle (HVA) > 15 degrees
      • Angle between the long axis of the first metatarsal and the long axis of the first phalanx
    • Intermetatarsal angle (IMA) > 9 degrees
      • Angle between first and second metatarsal
    • Distal metatarsal articular angle (DMAA) > 10 degrees
    • Dislocation of sesamoid bone
  • Stages
    • Light
      • HVA 15 – 30 degrees
      • IMA 9 – 13 degrees
    • Moderate
      • HVA 30 – 40 degrees
      • IMA 13 – 20 degrees
    • Severe
      • HVA > 40 degrees
      • IMA > 20 degrees
  • Treatment
    • Conservative treatment
      • Not very effective
      • Involves using hallux valgus splints
    • Surgical treatment
      • Preoperative
        • Antibiotic prophylaxis
        • 350 mmHg tourniquet to prevent bleeding
      • Operative techniques
        • Lateral release
          • The adductor tendon and lateral capsule are cut (released)
        • Distal chevron metatarsal osteotomy (DCMO)
          • A wedge-shaped part of the first metatarsal is slipped laterally and then fixed in the correct position
        • Scarf osteotomy
        • Lapidus operation
          • Involves osteodesis of medial cuneiform and first metatarsal bone
          • Used for severe deformities
    • Postoperative management
      • RICE
      • LMWH
      • Lymph drainage
      • Special shoe wear which prevents weightbearing on the forefoot
        • Worn for 4 – 6 weeks
      • Later – orthopaedic insoles
• Hammer toe (= digitus malleus)
  • (It says hammer finger in the topic name, but they mean hammer toe)
  • Toe deformity with PIP flexion + DIP extension + neutral MTP
  • Most commonly affects 2^nd and the other lesser toes
  • Etiology
    • Poorly fitting shoes
    • Polyneuropathy
    • Rheumatoid arthritis
    • Trauma
  • Treatment: remove head of proximal phalanx
• Bunion
  • = exostosis on the side of the foot
  • Most commonly on the medial side, in connection with hallux valgus
  • Treatment: bunionectomy (removal of the exostosis)
• Tailor’s bunion (= bunionette)
  • = digitus V. varus (varus of the fifth digit)
  • Prominence on lateral side of foot (fifth metatarsal joint)
  • Treatment: Scarf-like osteotomy
• (Mallet finger)
  • Trauma to extensor digitorum tendon
  • Due to trauma of the finger in extended position, which causes sudden forced flexion
    • Often occurs when trying to catch a ball, so it’s also called baseball finger
  • Often occurs in fingers 3, 4 and 5
  • Can cause fracture or subluxation
  • Treatment
    • Conservative
      • Extension splinting of DIP joint
    • Surgical
      • In severe cases

Other adult foot deformities and problems

• Hallux rigidus
  • = osteoarthritis of the MTP joint of the hallux causes the joint to become stiff and painful
  • Treatment: MTP joint fusion
• Metatarsalgia
  • = Pain under the MTP joint line, most commonly of the 2^nd and 3^rd toes (the toe-ball)
  • Can be due to pes transversoplanus
  • Treatment
    • Conservative – orthopaedic insoles or shoes
    • Surgical – Weil-osteotomy
• Morton’s neuroma
  • A benign growth of perineural tissue which causes pain under the toe-ball
• Plantar fasciitis
  • Very common cause of heel pain
  • Most frequent in women and obese patients
  • Common with other foot deformities (flat foot, cavus deformity)
  • Symptoms
    • Morning pain
    • Typical pain localization
  • Diagnosis
    • Pain point pressure
    • X-ray
    • MRI
  • Treatment
    • Conservative
      • First choice
      • Insoles
      • RICE
      • Physical therapy
    • Surgery – fasciotomy
• Haglund heel/deformity
  • Bony protrusion on the back of the calcaneus
  • Causes pain when wearing shoes

32. Sterile necrosis of the foot bones

• = avascular necrosis or osteonecrosis of the foot
• Most commonly affects talus, navicular and the first and second metatarsal bones
• Köhler disease
  • = osteonecrosis of the navicular bone
  • Rare
  • In young children (5 – 10)
  • Boys > girls
  • Presents with pain on dorsal and medial surface of foot
  • It’s self-limiting, so conservative treatment with NSAIDs and immobilization is the only treatment
    • No role for surgery
• Osteonecrosis of the 2^nd metatarsal head (Freiberg disease)
  • In adolescents (13 – 18)
  • Girls > boys
  • Presents with pain on forefoot
  • Treatment
    • Conservative
      • NSAIDs
      • Immobilization
    • Surgery
      • Rarely needed (only in severe disease)
      • Osteotomy/arthrotomy
• Sever disease
  • = osteonecrosis of calcaneal apophysis (the tuberosity of the calcaneus)
    • Sever disease is also called calcaneal apophysitis
  • Often occurs in young athletes (8 – 12)
  • Pain in the area of the calcaneal apophysis
  • It’s self-limiting, so conservative treatment with NSAIDs and immobilization is the only treatment
    • A soft heel pad decreases the pressure on the calcaneus
    • No role for surgery

12 – Acute injuries and degenerative diseases of the knee joint

Basics of knee

• Anatomy
  • 1 lateral and 1 medial meniscus
    • The meniscus is cartilage
  • 3 bones (femur, tibia, patella)
  • 4 ligaments
    • ACL – anterior cruciate ligament
      • Intraarticular
      • Connects the femur to the tibia
    • PCL – posterior cruciate ligament
      • Intraarticular
      • Connects the femur to the tibia
    • LCL – lateral collateral ligament
      • Connects the femur to the fibula
      • Does not merge with the joint capsule of the knee
    • MCL – medial collateral ligament
      • Connects the femur to the tibia
      • Merges with the joint capsule of the knee
  • The hyaline cartilage of the joint
  • Muscles
    • Quadriceps
    • Hamstrings
• The knee does not only do flexion and extension – in flexed position it also does rotation
  • For a long time, it was difficult to create a prosthesis which could mimic this function
  • A prosthesis which would only do flexion and extension would loosen early

44. Early and late symptoms of knee arthritis, conservative treatment options

• Osteoarthritis of the knee
• Clinical features
  • Same as for hip OA
  • Morning stiffness
  • Pain
  • Limping
  • Restricted range of motion (Flexion contracture)
  • Crepitation
  • Alignment deformities (Varus, valgus)
• Diagnosis
  • Same as for hip OA
  • X-ray
  • Joint space narrowing
  • Subchondral sclerosis
  • Osteophytes
  • Subchondral cysts
• Treatment
  • Conservative
    • Weight loss
    • Regular moderate exercise
    • Orthopaedic shoes and other walking aids
    • Physiotherapy
    • NSAIDs
  • Surgical
    • Total knee replacement
    • See topic 35

46. Knee ligament injuries

• Anterior cruciate ligament injury
  • Typical sport injury
  • Etiology
    • Sudden twisting of the leg
    • Osteoarthritis of knee (osteophytes can damage ligament)
  • Clinical features
    • Swollen leg (haemarthrosis)
      • Due to bleeding from the ACL
    • Acute pain
    • Knee instability
  • Diagnosis
    • Positive Lachman test
    • Positive anterior drawer test
    • MRI
      • Gold standard
    • Not visible on x-ray
  • Treatment
    • Conservative
      • Stabilize the knee, by:
      • Strengthen muscles
      • Wear a brace
    • Surgery
      • Arthroscopic surgery
        • Not in the acute setting
        • Only if knee instability remains after a long time and after trying conservative therapy
      • An artificial ligament or a bone-tendon-bone (BTB) graft is used to replace the ACL
      • Patient can return to activity soon
• Posterior cruciate ligament injury
  • Less frequent than ACL injury
  • Occurs due to posterior injury to a flexed knee
  • Clinical features
    • Same symptoms as for ACL injury, but much less intense/significant
  • Diagnosis
    • MRI
      • Gold standard
    • Positive posterior drawer test
  • Treatment – Same as for ACL injury
• Medial collateral ligament injury
  • Most commonly injured knee ligament
  • Caused by valgus stress to the knee
  • Clinical features
    • Knee swelling
    • Pain
    • Knee instability
  • Diagnosis
    • Positive valgus stress test
    • MRI not needed
  • Treatment
    • Conservative – for isolated MCL injury
    • Surgery – if multi-ligament injury is present
• Lateral collateral ligament injury
  • Isolated LCL injury is rare
  • Clinical features
    • Knee swelling
    • Pain
    • Knee instability
  • Diagnosis
    • Positive varus stress test
    • MRI not needed
  • Treatment
    • Needs surgery

48. Meniscus injuries

• The menisci equalise the weight load on the joints, and stabilizes the joint
• Medial meniscus is more commonly injured than the lateral
• Etiology
  • Trauma (in young people)
    • Axial loading of the knee + rotation
  • Degenerative disease
• Location of tear
  • White zone
    • The inner third
    • Avascular part of meniscus
  • Red-white zone
    • Middle third
    • Poorly vascularized
  • Red zone
    • Outer third
    • Well vascularized
• Types of tear
  • Bucket handle tear
  • Flap tear
  • Transverse tear
  • Torn horn tear
• Clinical features
  • Pain on lateral or medial side
  • Tenderness on the joint line
  • Knee instability
  • Popping or clicking with movement
  • Slowly developing knee effusion
• Diagnosis
  • MRI
    • Gold standard
  • McMurray test
  • Steinman test
  • Apley test
• Treatment
  • Conservative
  • Surgical repair with arthroscopy

63. Arthroscopy

• Small tube with a light and camera is pushed into the joint through a hole
  • A cannula is pushed through a second hole to provide irrigation fluid
  • A third hole is opened for entry of tools, like forceps, shavers, scalpel, etc.
• Was developed to diagnose intraarticular knee injuries without opening the joint
• Was originally used for diagnostic purposes – nowadays not used for diagnosis
  • We use MRI instead
• Widely used today for minimally therapeutic purposes
  • Gives more rapid recovery than open joint surgery
• Indications
  • Meniscotomy
  • ACL reconstruction
  • Foreign body removal
  • Repair of rotator cuff tear
• Can be used for all joints which are not very small
  • Mostly used for knee and shoulder

Knee deformities

• Etiology
  • Rickets (vitamin D deficiency)
  • Post-traumatic
  • Disease of growth plate
• Types
  • Genu varum
  • Genu valgum
  • Recurvate knee (hyperextended knee)
• Complications
  • All knee deformities are prearthritic conditions
• Treatment
  • Vitamin D – in case of rickets
  • Surgical
    • Wedge osteotomy
    • Blocking the growth plate in childhood

13 – Low back pain

Basics of spine

• Intervertebral discs
  • They lie between the vertebral bodies
  • They consist of the outer annulus fibrosus and the inner nucleus pulposus
  • The discs have no blood supply, they’re instead supplied by diffusion
    • Moving of the spine causes changes in compression of the discs, which creates a “pumping” effect which facilitates diffusion of nutrients
  • Annulus fibrosus
    • = concentric collagen fibres
    • Protects against distraction
  • Nucleus pulposus
    • Gelatinous core
    • Consists of mostly water
    • Protects against compression
  • As the patient ages the water content of the discs decreases, which puts more of the compression forces on the vertebral bodies

20. Spondylolysis, spondylolisthesis, sacralisation, lumbarization

• Spondylolysis
  • = defect of the neural arch (pars interarticularis) of the vertebrae
    • This allows the vertebra lying superiorly to slip anteriorly
  • More common in certain territories
  • Diagnosis: oblique x-ray
  • Most commonly between L5-S1
• Spondylolisthesis
  • = refers to anterior slipping of a vertebra compared to the one below it
  • Etiology
    • Spondylolysis
    • Fracture
    • Congenital malformation
    • Tumour
  • Clinical features
    • Many cases are asymptomatic
    • Low back pain
    • Palpable “step off” at the area of slippage
    • Pain may radiate
  • Severe (grave V) spondylolisthesis is called spondyloptosis
    • The vertebra has slipped so far with respect to the vertebra below that the two endplates are no longer congruent
• Sacralisation and lumbarisation
  • Sacralisation = fusion of L5 to S1
  • Lumbarisation = non-fusion of S1 and S2, which causes the S1 to appear as a sixth lumbar vertebra
  • These are congenital abnormalities
  • Due to abnormal weight bearing -> problems with the rest of the spine
  • May cause lumbago in adult years

29. Spondylarthritis ankylopoetica (ankylosing spondylitis)

• Also called Bektherev disease
• Epidemiology
  • Males > females
  • 15 – 40
• Etiology
  • HLA-B27 positivity
  • Inflammatory bowel disease
• Pathology
  • Ankylosis = fusion of articular surfaces
  • Spondylitis = inflammation of the vertebrae
• Clinical features
  • Back pain
  • Neck pain
  • Morning stiffness
  • Limited spinal mobility
  • Anterior uveitis
• Diagnosis
  • Schober test
  • X-ray
    • Shows ankylosis and sacroilitis
• Treatment
  • Conservative
    • Physical therapy
    • NSAIDs
    • Biological therapy (TNF inhibitors)
  • Surgery
    • Osteotomy
    • Nerve decompression
    • Spinal fusion

36. The degenerative spine (spondylosis, low back pain)

• Low back pain (LBP)
  • Low back pain is very common
  • LBP can generally take on one of two major forms
    • Lumbago (mechanical low back pain)
    • Sciatica (neurological low back pain)
      • See topic 66
  • LBP can occur in a healthy spine, often due to stretching or microscopic tears of muscles or ligaments
• Lumbago
  • = mechanical low back pain
  • (Some sources, like this year’s lecture, reserve the term “lumbago” for idiopathic LBP)
  • Can have many causes
    • Mechanical disorders
    • Congenital malformations
    • Lumbar instability
    • Degenerative diseases
  • Can be acute or chronic
    • Lasts less than 1 month – acute
    • Lasts more than 6 months – chronic
  • Clinical features
    • Low back pain
    • Decreased lumbar lordosis
    • Antalgic gait
    • Paravertebral muscle spasm
    • Restricted lumbar movements
    • No neurological signs (radiation, paraesthesia, etc.)
  • Treatment
    • Analgesia
    • For acute lumbago – rest
    • For chronic lumbago – mobilization
• Spondylosis
  • = age-related degenerative changes in vertebrae
  • Most commonly due to spinal osteoarthritis
  • May cause compression of the spinal cord

66. Discus hernia, sciatica

• Sciatica (= lumbo-ischialgia)
  • = neurologic back pain caused by compression of spinal roots
  • Most commonly due to herniated disc
  • Clinical features
    • Low back pain
    • Decreased lumbar lordosis
    • Antalgic gait
    • Paravertebral muscle spasm
    • Restricted lumbar movements
    • Neurological symptoms
      • Pain radiating to the legs
      • Paraesthesia in the legs
• Disc hernia
  • Disc protrusion = the intervertebral disc protrudes onto spinal nerves or the spinal cord
  • Disc herniation = disc prolapse = the nucleus pulposus extrudes out of the disc through a tear in the annulus fibrosus -> compresses spinal nerves or spinal cord
  • Disc sequestration = disc hernia, but a part of the nucleus pulposus is torn off as a fragment
  • Neurologically affected areas and functions according to affected spinal root
    • L4
      • Motor: Tibialis anterior muscle
      • Reflex: Patellar reflex
      • Sensory: Medial part of feet
    • L5
      • Motor: Extensor hallucis longus muscle
      • Reflex: Ankle reflex
      • Sensory: Middle part of feet
    • S1
      • Motor: Peroneus muscle
      • Reflex: Achilles reflex
      • Sensory: Lateral part of feet
    • Cauda equina syndrome
      • A medical emergency due to compression of the cauda equina (L2 and below)
      • Motor: Flaccid paralysis of legs
      • Sensory: The saddle area (inner thigh, anus, genitalia)
      • Visceral: Urinary retention, faecal incontinence, erectile dysfunction
  • Diagnosis
    • Physical examination
    • Straight leg-raise test (Lasegue test)
    • MRI
      • Gold standard
  • Treatment
    • Most cases are self-limiting!
    • Conservative
      • Physiotherapy
      • Local heat
      • NSAIDs
    • Herniectomy or discectomy
      • If conservative treatment fails or in case of cauda equina syndrome

14 – Bone tumours

Basics of bone tumours

• Most common bone tumours according to age group
  • Childhood
    • Osteosarcoma
    • Ewing sarcoma
    • Benign cysts
    • Fibrous dysplasia
  • Young and middle age
    • Chondrosarcoma
    • Malignant fibrotic histiocytoma
    • Osteoclastoma (giant cell tumour)
  • Elderly
    • Metastasis
    • Myelomas

62. Diagnostic and treatment principles of bone tumors

• If it’s unclear whether the patient has a bone tumour or not – treat as is they have one!
• When to think of bone tumours
  • Night pain
  • “Growing pain”
    • What’s known as “growing pain” is not related to growth
  • Patients with history of cancer
  • Atypical symptoms
  • Pathological fracture
  • Lytic or sclerotic bone lesions on x-ray
  • Negative X-ray when patient has symptoms
  • Unexplained weight loss
• Differentiating between bone tumours and infection can be difficult
  • Most studies can’t differentiate the two
    • Labs
    • X-ray
      • X-rays have low sensitivity and specificity for bone tumours
    • CT
      • CT has high sensitivity but low specificity
      • Not good for diagnosis
      • Good for planning surgery
    • MRI
      • MRI has high sensitivity but low specificity
    • Bone scan
      • Bone scan has high sensitivity but low specificity
  • Only biopsy can give the final answer
    • All suspicious cases should take a biopsy
    • Done under general anaesthesia
      • Local or regional anaesthesia are not used
    • When taking biopsy we go through the muscle to reach the bone
      • This is to prevent spreading of tumour cells while taking biopsy
      • During surgery we go between the muscles
• Typical image features of malignant bone tumour
  • Positive bone scan
  • Codman triangle
  • Soft tissue expansion
• Typical image features of benign bone tumour
  • Clear margin between normal tissue and tumour
  • No periosteal reaction
  • No Codman triangle
• Treatment of bone tumours
  • Recent advances in oncology have increased the 5-year survival rate of malignant tumours from 20 to 80%
    • Advances in cytostatic treatment allows for the treatment of micro-metastases, which allows for the use of
  • Benign tumours are generally treated with just surgery
  • Malignant tumours are generally treated with neoadjuvant chemo, surgery, and adjuvant chemo
  • Amputation
    • Previously amputation used to be the mainstay of treatment of bone tumours
  • Limb-sparing surgery (= limb-salvage surgery)
    • Nowadays, with improved oncological treatment (like neoadjuvant and adjuvant chemo) limb-sparing surgery has become sufficient
    • The tumor is removed, along with bone and tissue around it
    • The bone is replaced by a prosthesis, allograft bone, or both

4. Benign bone tumours

• Osteoid osteoma
  • Small tumour in cortical bone
  • Contains a radiolucent nidus with a sclerotic margin
  • 10 – 30 years
  • Causes intense pain, especially at night
    • Pain is responsive to NSAIDs
  • Treatment
    • Surgical en-bloc resection
• Cartilaginous exostosis (= osteochondroma)
  • = exostosis covered with cartilage
  • Most commonly solitary
    • Can be multiple in multiple hereditary osteochondromas
  • 10 – 20 years
  • Usually not painful, but causes bump
  • Have a mushroom-look on x-ray
  • Occurs on the metaphysis of long bones
  • Typical places:
    • Distal femur
    • Proximal tibia
• Bone cysts and cyst-like conditions
  • Not true tumours
  • MRI is best for diagnosis
  • Simple bone cyst
    • = serous fluid-filled lesion
    • Usually found in young people
  • Aneurysmal bone cyst (ABC)
    • Shows multiple fluid lines (niveau) on MRI or CT
    • Because it contains multiple liquids of different density
  • Non-ossifying fibroma
    • Due to dysfunctional ossification
    • Located in metaphysis of long bones of the lower extremity
    • Has such a characteristic x-ray appearance that MRI or biopsy is not necessary
      • “Bubbly” lytic lesion with sclerotic outline on x-ray

8. Ewing’s Sarcoma

• Epidemiology
  • Children, adolescents
  • Boys > girls
• Clinical features
  • Can occur in any bone
    • Most often in diaphysis of long bones
  • Highly malignant
  • Night pain
  • B symptoms
• Diagnosis
  • Resembles osteomyelitis on x-ray, MRI and histology
  • Immunohistological staining or PCR helps to differentiate
• Treatment
  • Neoadjuvant polychemo + limb-sparing surgery + adjuvant polychemo
  • Radiation may also be used

37. Osteoclastoma (giant cell tumor)

• Epidemiology
  • 20 – 40 years
• Clinical features
  • Locally aggressive tumour (borderline between benign and malignant)
  • Most commonly in distal femur or proximal tibia, close to the knee
  • High recurrence rate
  • Deep persistent pain
  • Pathological fractures
• Diagnosis
  • X-ray: Multi-cystic osteolytic lesions
• Treatment
  • Curettage and filling of the tumour with bone cement

64. Clinical and radiological features of osteogenic sarcoma, treatment options

• Osteogenic sarcoma = osteosarcoma
• Epidemiology
  • Children + teenagers
  • Boys > girls
  • Osteosarcoma is the most common primary bone tumour
• Clinical features
  • Occurs in metaphysis of long bones
    • Especially distal femur and proximal tibia
  • Night pain
  • B symptoms
• Diagnosis
  • X-ray
  • Codman triangle
  • Sunburst appearance
• Treatment
  • Neoadjuvant chemo + limb-sparing surgery + adjuvant chemo

Topics which weren’t covered in lecture

1. Obstetrical brachial plexus injuries

• Also called neonatal brachial plexus palsy
• During birth the brachial plexus or its roots may be damaged
  • Especially if lateral traction (pulling) is applied to the foetus’ head (shoulder dystocia)
  • The condition is uncommon
• The result is paralysis
• Three types exist
  • Erb’s type – the upper arm is paralyzed
    • This is the most common
    • The superior trunk of the brachial plexus is affected
  • Klumpke’s type – the forearm is paralyzed
    • The inferior trunk of the brachial plexus is affected
  • Full brachial plexus palsy
    • The whole upper limb is paralyzed
    • The whole brachial plexus is affected
• Clinical features
  • Initially, regardless of type
    • The affected upper limb is internally rotated and flappy
  • Later
    • The affected part experiences paralysis, anaesthesia
  • In older children and adults the humerus is shorter
• Treatment
  • Many cases resolve spontaneously
  • Conservative
    • Shoulder is positioned in abducted position to prevent contractures
  • Surgery
    • Nerve graft
    • Muscle transfer

5. Acetabular Protrusion

• = the acetabular socket is so deep that the femoral head may protrude into the pelvis
• This is a prearthritic condition
• Epidemiology
  • In adolescents and in elderly
  • Women > men
• Clinical features
  • Hip pain
  • Limited ROM
• Diagnosis: x-ray
• Treatment
  • Arthroscopic or open joint surgery
  • Total hip replacement

6. Tendovaginites, types and management

• Tendovaginitis = tenosynovitis = inflammation of a tendon and its synovial sheath
• Females > males
• Etiology
  • Repetitive use of tendon
  • Rheumatological diseases
  • Bacterial infection
• Tendons of the fingers and wrist are most commonly affected
• Clinical features
  • Pain on passive extension of affected tendon
  • Finger slightly flexed at rest
• Special types
  • Stenosing tenosynovitis (trigger finger)
    • Thickening of one of the annular pulleys causes the finger to be locked in a flexed position
    • Idiopathic
    • Mostly affect ring finger or thumb (trigger thumb)
  • De Quervain tenosynovitis
    • Thickening of the abductor pollicis longus and extensor pollicis brevis
    • Due to repetitive abduction and extension of the thumb
    • Causes swelling of radial styloid process
• Treatment
  • Surgical incision of the affected tendon

10. Knee effusion, popliteal cysts

• Knee effusion
  • = fluid accumulation in the intra-articular space of the knee
  • May be serous, bloody, or purulent
  • Etiology
    • Osteoarthritis
    • Trauma
    • Crystal arthritis (gout)
    • Rheumatoid arthritis
    • Septic arthritis (infection)
    • Ligament injuries
    • Meniscus injuries
  • Clinical features
    • Swelling around and above patella
    • Decreased ROM
    • Patellar ballottement
  • Diagnosis
    • Swift diagnosis of septic arthritis is important to reduce complication
    • X-ray
      • Check for OA or fracture
    • Joint aspiration
      • Detect bacteria, crystals, blood
    • MRI
      • Check for ligament injuries
  • Treatment
    • RICE
    • NSAIDs
    • Depends on underlying cause
    • Septic arthritis -> IV antibiotics
• Popliteal cyst
  • Also called a Baker cyst
  • = a cyst in the popliteal fossa, between the semimembranosus and gastrocnemius
    • The cyst consists of a gel-like material
    • The cyst communicates with the synovium of the knee, so it’s not a true cyst
  • Etiology
    • It forms on the basis of a chronic inflammation of the knee
    • Osteoarthritis
    • Meniscus injury
    • Rheumatoid arthritis
  • Clinical features
    • Often asymptomatic
    • Pain
    • Locking and clicking during movement
  • Diagnosis
    • MRI
      • To look for meniscal problem
    • X-ray
      • Osteoarthritis
  • Treatment
    • Treat underlying conditions
    • Surgical removal if there are complaints

12. Chronic osteomyelitis (Garre, Brodie’s abscess)

• Chronic osteomyelitis
  • Develops insidiously over months or years
  • Usually related to bone ischaemia or necrosis
    • Ischaemic or necrotic bone is not reached by antibiotics and the immune system, proving grounds for a chronic infection
  • Results in bone destruction and sequestrum formation
  • Main symptom is pain
  • Difficult to treat; often recurs
    • Can recur many years later
• Brodie abscess
  • = a cystic region of pus and necrosis encapsulated by a rim of sclerotic bone
  • Occurs in the setting of chronic osteomyelitis in the metaphysis of long bones
    • Especially the distal tibia
  • Most common in younger patients
  • Treatment: Surgical opening, antibiotics, and autologous bone implantation
• Garré’s sclerosing osteomyelitis
  • = causes sclerosis and bony proliferation in metaphysis or diaphysis of long bones
  • Can also infect the mandible by spreading from dental caries
  • Most common in younger patients
  • Cancer should be ruled out
  • Treatment: Surgical opening

19. Congenital torticollis (wry neck)

• Torticollis = wry neck = a deformity causing the neck to be stiff and the head to be turned or tilted to one side
• 3^rd most common congenital musculoskeletal disorder (after DDH and clubfoot)
• Most commonly due to fibrotic and/or hypertrophic sternocleidomastoid
• Clinical features
  • Tilted and rotated head
  • Limited range of motion
  • Prominent and tense sternocleidomastoid
• Treatment
  • Conservative
    • Physiotherapy
    • Stretching of SCM
  • Surgery
    • At 1 – 2 years if conservative was insufficient

23. Congenital Coxa Vara

• A rare congenital condition
• The condition is present at birth but usually isn’t discovered until 3 – 4 years
• Pathology
  • Malfunction of the ossification of the femoral neck
  • The collodiaphyseal angle gradually decreases
• Diagnosis: x-ray
• Clinical features
  • 1/3 are bilateral
  • Coxa vara
  • Fold asymmetry
  • Abduction contracture
  • Limping
• Treatment: Valgus osteotomy

25. Limb Equalisation

• Performed when correction with shoes is inadequate, often at > 2,5 cm discrepancy
• Multiple surgical procedures are available to correct limb length
  • Some are complex, but by combining two or more of them we can reduce the complexity and the number of operations required
• Temporary epiphysiodesis – using screws or staples across the epiphyseal plate
  • Can only be used in skeletally immature patients, of course
  • This prevents further growth of the longer limb until the short limb has “caught up”
• Permanent epiphysiodesis – the surgical destruction of the epiphyseal plate
  • Can only be used in skeletally immature patients, of course
  • The epiphysis of the longer limb is removed (then turned 90° and re-inserted)
  • If timed correctly, the shorter limb will continue to grow but stop growing when it reaches the length of the operated limb
• Limb shortening
  • By osteotomy
  • Is less complex and has faster healing period than limb lengthening
  • Femoral osteotomy is preferred over tibial osteotomy
  • The ends are fixated together
• Limb lengthening by callotasis (= distraction osteogenesis)
  • First, a part of the bone is removed by osteotomy
  • A distracting device is used to distract the area of the bony callus
    • The distracting device may be external or internal
    • Internal rods are often used
  • The distraction is adjusted multiple times daily and for very small lengths each time
    • New bone will fill the gap
  • After the target length has been reached, the patient must gradually put more and more weight on the bone to strengthen the new bone
• Monitoring and post-operative
  • During distraction, x-ray is routinely taken to monitor
  • 3 – 4 weeks after distraction is complete the distraction device is left in place to provide stabilization
  • Weight-bearing is recommended to mature the bone
• Complications
  • Infections
  • Angular deformities like varus or valgus due to non-axial weight-bearing
  • Joint contractures due to muscle imbalances

31. Posttraumatic dystrophy (algodystrophy) of the bone

• Also known as complex regional pain syndrome, Sudeck atrophy, or reflex sympathetic dystrophy
• Refers to a condition where painful sensations in a limb are more prolonged or more severe than would be expected
• Classically occurs after trauma, but can occur after other conditions as well
• Clinical features
  • Excessive pain
  • Hyperesthesia
  • Vasomotor problems (hypo/hyperthermia, hypo/hyperpigmentation)
• Stages
  • Acute stage (stage I) (within a few weeks of trauma)
  • Subacute stage (stage II) (within a few months)
  • Chronic stage (stage III) (for years)
    • Skin and muscle atrophy
    • Constant pain
• Diagnosis
  • Triple-phase bone scintigraphy
• Treatment
  • Rest/immobilization
  • NSAIDs
  • Steroids
  • Physiotherapy

33. Osteoarthritis of the elbow

• Much less frequent than OA of the hip and knee
• Related to manual labour and overuse
• Symptoms like any OA
• Treatment
  • Conservative
  • Surgical: Joint replacement

40. Cervicobrachial syndrome

• Pain syndrome involving neck pain which radiates to the upper limbs
• Idiopathic etiology
  • Most common among workers who perform repetitive tasks
• Differential diagnosis
  • Cervical radiculopathy
  • Rheumatological diseases
  • Thoracic outlet syndrome
• Treatment
  • Only conservative
  • NSAIDs
  • Steroid injection
  • Physical therapy

43. Recurrent dislocation of the patella

• = lateral dislocation or subluxation of the patella which occurs occasionally
  • A specific movement will cause dislocation
  • Due to loosening of the joint capsule due to previous trauma
• Epidemiology
  • Adolescents
  • Girls > boys
• When the dislocation occurs, the knee becomes swollen and painful
• Treatment
  • Conservative
    • Quadriceps exercises
    • Special orthoses
  • Surgery

45. Prognostic significance of septic hip conditions in newborn

• Neonatal septic arthritis of the hip
• Epidemiology
  • 50% occur in children < 2 years
  • Hip is involved in 1/3 of all neonatal septic arthritides
• It’s a surgical emergency
• Risk factors
  • Prematurity
  • C-section
  • Trauma
  • Infection
• Clinical features
  • Acute pain
  • Fever
  • Limping
  • Swelling
• Prognosis
  • Delayed diagnosis and treatment will cause permanent joint damage
  • Femoral head destruction
  • Joint contracture
  • Gait abnormalities
• Treatment
  • Emergency surgical incision and drainage, followed by IV antibiotics

47. Femoral head necrosis

• = osteonecrosis of the hip
• The femoral head is the most frequent area of osteonecrosis, most probably due to the intricate blood supply
• Etiology
  • Idiopathic (Perthes disease)
  • Trauma
    • Femoral head fracture
  • Chronic steroid
  • Alcoholism
  • Radiation
• Clinical features
  • Insidious onset of pain
  • Affects both hips most of the time
• Diagnosis: MRI
• Treatment
  • Conservative
    • Bisphosphonates
    • Exercise
  • Surgery

49. Tuberculous arthritis

• Epidemiology
  • Rare
  • More common in developing countries
• Most commonly affects spine, hip, and knee
• Clinical features
  • Pain during activity
  • Subfebrility
  • Night sweats
• Diagnosis
  • Synovial mycobacterial culture
  • X-ray
• Treatment
  • Conservative
    • Antimycobacterial treatment
  • Surgical
    • In advanced cases

53. Chondromalacia patellae

• = softening of the cartilage on the posterior articular cartilagenous surface of the patella
• Due to overuse, inflammation, or injury
• Epidemiology
  • Adolescents
  • Girls > boys
• Clinical features
  • Diffuse pain around or behind the patella
  • Insidious onset of symptoms
  • Pain worsens when walking in stairs or sitting for a long time
• Treatment
  • Conservative
    • Main treatment is conservative
    • Rest
    • Physical therapy
    • NSAIDs
  • Surgical

55. Rehabilitation following limb amputation, orthoses, orthopaedic shoes

• Rehabilitation after amputation
  • Aims of rehabilitation
    • Teach the patient how to use prosthesis
    • Improve balance, endurance and strength
      • After amputation the amount of energy necessary for walking increases a lot, so endurance and strength are important
    • Prevents secondary disabilities
      • Contractures, especially flexion contracture
    • Reduces phantom pain
    • Hasten stump conditioning
      • After amputation the stump is oedematous
      • The oedema gradually and naturally shrinks, a process called stump conditioning
      • Stump conditioning must finish before a permanent prosthesis can be designed, otherwise the prosthesis may not fit perfectly, causing problems
  • Components of rehabilitation
    • Strength exercises
    • Balancing exercises
    • Stretching
    • Patient education
      • The patient must learn to take care of the stump and the prosthesis
    • Patient counselling
• Orthoses (orthosis in singular)
  • Orthoses are externally fitted devices which support the musculoskeletal system
  • They’re often used temporarily, but in some conditions permanent orthoses are necessary
  • Uses
    • After operation or injury, to promote recovery until full recovery is achieved
    • Reduce weight-bearing forces on the limb
    • Restrict movement in a certain direction
    • Immobilize an extremity or joint
    • Correct abnormal shape or function of an extremity or joint
    • Offloading of a region of a pressure ulcer
  • Naming
    • Orthoses are named after the joints they contain or their function
    • An ankle-foot orthosis (AFO) is applied to the foot and ankle
    • An ulcer-healing orthosis offloads the region of a foot ulcer, allowing for healing
  • Foot orthoses – see orthopaedic shoes
  • Ankle-foot orthoses
    • For temporary fixation of the ankle
    • Used after trauma and operations
  • Knee orthoses
    • For temporary fixation of the knee
    • Used to prevent lateral instability or hyperextension
  • Knee-ankle-foot orthoses
    • Used in muscle weakness, knee instability, genu valgum or genu varum
  • Hip orthoses
    • Used in DDH (Pavlik harness)
    • Also used in infantine cerebral palsy and after trauma
  • Hip-knee-ankle-foot orthoses
    • Transfer weight-bearing to the sciatic tuber
    • Used in Perthes disease
  • Spinal orthoses
    • Used in degenerative spinal disorders, vertebral fractures, scoliosis, etc.
  • Wrist orthoses
    • Used in carpal tunnel syndrome
• Orthopaedic shoes and insoles
  • Custom-made shoes or insoles used to compensate for orthopaedic conditions
  • Uses
    • To equalize limb length discrepancies
    • To remove pressure from some parts of the foot
      • In metatarsalgia, RA
    • To distribute pressure across the whole foot
      • In diabetes, other neuropathies
    • To prevent deformities of the foot
    • To soften the impact of the heel-strike
    • To compensate for valgus or varus of the ankle

56. Acute osteomyelitis

• Acute osteomyelitis develops within days or weeks
• Most common in children < 5 years
• Pathology
  • Haematogenous spreading is most common in children and adolescents
    • Most commonly S. aureus
  • Exogenous osteomyelitis is most common in adults
    • Multibacterial
    • From trauma, ulcer, IV drug use
• Clinical features
  • Local pain
    • Gradual onset
  • Fever, malaise
• Diagnosis
  • Inflammatory markers
  • Blood culture
  • X-ray
  • MRI
  • Biopsy
    • Confirmatory test
• Treatment
  • Conservative
    • Rest
    • IV antibiotics
  • Surgery
    • In refractory cases, or if there’s abscess
• Prognosis
  • 95% of children resolve completely
  • Acute osteomyelitis in adults often becomes chronic

60. Orthopaedic aspects of osteoporosis

• Osteoporosis = decrease in bone mineral density
• Orthopaedic surgeons are involved in the treatment of osteoporotic vertebral fractures
  • The trauma department handles the treatment of osteoporotic hip and wrist fractures
• Osteoporotic vertebral fractures
  • Clinical features
    • Loss of height
    • Local pain on percussion
    • Progressive kyphosis
  • Stable fractures
    • Most osteoporotic vertebral fractures are stable
    • Most develop slowly over time and are therefore asymptomatic
    • The structural stability of the spine remains intact
    • No neurological problems
    • Treated conservatively
      • Anti-osteoporotic medication
      • NSAIDs or calcitonin nasal spray
      • Physical therapy
      • External bracing or orthotics
    • If pain remains despite conservative treatment -> vertebral augmentation
  • Unstable fractures
    • Osteoporotic vertebral fractures are rarely unstable
      • Unstable fractures are most commonly traumatic in origin
    • The structural stability of the spine is compromised
      • This may cause spinal cord injury and neurological problems
    • Unstable fractures must be treated urgently to prevent permanent neurological injury
    • Treated surgically
      • Mostly with vertebral augmentation (vertebroplasty or kyphoplasty)
      • Alternative: spinal fusion surgery
  • Diagnosis
    • X-ray

65. Closure abnormalities of the spinal cord

• = spinal dysraphism = spina bifida
• Spinal dysraphism is an umbrella term for conditions caused by abnormal closure of the neural plate
• The most important cause is maternal folic acid deficiency during pregnancy
• Types
  • Closed spinal dysraphism (spina bifida occulta)
    • Asymptomatic
    • Due to incomplete closure of vertebrae
  • Open spinal dysraphism (spina bifida cystica)
    • Meningocele – herniation of meninges
    • Myelomeningocele – herniation of meninges and spinal cord
• Treatment
  • Antibiotic prophylaxis from birth to surgery
  • Surgical closure
    • Within 72 hours of birth
  • Postoperative monitoring for hydrocephalus
    • If it develops, place a ventriculoperitoneal shunt
  • Regular follow-ups throughout life
• Prognosis
  • Nearly all patients with myelomeningocele develop neurogenic bladder and faecal incontinence
  • Many develop orthopaedic problems like scoliosis, foot deformities, hip deformities, pathologic fractures due to osteopaenia, etc.

67. Aseptic bone necroses

• = avascular necrosis = osteonecrosis
• Epidemiology
  • Most common in children and adolescents
• Etiology
  • In children
    • Idiopathic
    • Overuse
  • In adults
    • Alcoholism
    • Chronic steroid treatment
    • Radiotherapy
    • Trauma
    • Sickle cell disease
• Pathology
  • There is ischaemia of bone which leads to necrosis
  • In children the condition mostly resolves spontaneously, as the bone can still repair itself
  • In adults the condition is generally irreversible, as bone can no longer repair itself as well
• Special types of avascular necrosis in children and adolescents
  • Osgood-Schlatter disease
    • Avascular necrosis of the tibial tuberosity (the insertion of the quadriceps)
    • Occurs in adolescents, male > female
    • A characteristic lump forms on the tibia
    • Related to overuse
  • Perthes disease
    • Avascular necrosis of the femoral head
    • Occurs in children, male > female
    • Idiopathic
  • Kohler disease
    • Avascular necrosis of the navicular bone of the foot
    • Occurs in children, male > female
    • Idiopathic
• Special types of avascular necrosis in adults
  • Ahlback disease
    • Avascular necrosis of the medial femoral condyle
    • Occurs in elderly, female > male
  • Avascular necrosis of the hip
    • Occurs in middle-aged, male > female
    • A common cause of total hip replacement
• Clinical features
  • Pain
    • Usually of insidious onset
    • Exacerbated by use
  • Loss of function (in late stages)
• Diagnosis
  • X-ray
  • MRI
• Treatment
  • Treatment depends on localization, extent, and age
  • In children – generally conservative
    • RICE
    • NSAIDs
  • In adults – conservative or surgical