Orthopaedics

Last updated on July 14, 2020 at 16:23

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 2nd 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 4th 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
  • 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 2nd 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 2nd and 3rd 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 2nd 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
  • 3rd 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

Previous page:
Immunology and Rheumatology MRTs

Next page:
Urology

Leave a Reply

Your email address will not be published.