Table of Contents

Page created on June 1, 2020. Last updated on December 18, 2024 at 16:57

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

Knowledge from seminars

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

1 – Introduction, gait cycle, symptoms in orthopaedic disorders

11. Gait and limping

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

15. Ultrasound imaging in orthopaedics

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

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

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

50. Joint motions, measurement of muscle strength

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

2 – Congenital dislocation of the hip

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

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

38. DDH, clinical and X-ray features of

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

41. Conservative treatment of DDH

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

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

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

3 – Congenital foot deformities

Basics of foot

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

22. Clubfoot, etiology and pathology of

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

24. Congenital clubfoot, management of

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

59. Rocker bottom foot (vertical talus)

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

4 – Spine deformities

Basics of spine

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

Basics of scoliosis

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

18. Scheuermann’s Disease

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

30. Functional scoliosis, postural deformities

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

42. Scoliosis with known etiology, treatment of

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

51. Idiopathic structural scoliosis

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

5 – Cerebral palsy

17. Infantile cerebral palsy

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

6 – Paediatric hip diseases (Perthes, epiphyseolysis)

13. Juvenile slipped upper femoral epiphysis

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

26. Perthes’s Disease

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

54. Transitory coxitis, coxa saltans

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

7 – Shoulder disorders + upper extremity

Basics

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

14. Rheumatoid arthritis, surgical aspects of

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

21. Tennis elbow (humerus epicondylitis)

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

28. Recurrent dislocation of the shoulder

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

34. Periarthritis of the shoulder, frozen shoulder

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

39. Cervical rib, thoracic outlet syndrome (TOS)

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

Rotator cuff tear

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

Wrist osteoarthritis

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

Dupuytren contracture

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

Osteoarthritis of the fingers

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

8 – Prearthritic conditions, osteoarthritis

Osteoarthritis (OA)

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

2. Prearthritic conditions

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

9 – Joint arthroplasty + hip osteoarthritis + bone substitution

16. Hip osteoarthritis, clinical features, conservative management of

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

35. Surgical options for degenerative joint diseases

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

58. Joint prothesis types and fixation methods

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

61. Bone substitution, bone transplantation

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

10 – Complications of joint replacement and revision arthroplasty

57. Complications of joint replacements

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

11 – Adult foot deformities + static disorders of the foot

Basics of adult foot deformities

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

3. Flat foot (pes planovalgus)

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

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

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

32. Sterile necrosis of the foot bones

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

12 – Acute injuries and degenerative diseases of the knee joint

Basics of knee

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

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

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

46. Knee ligament injuries

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

48. Meniscus injuries

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

63. Arthroscopy

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

Knee deformities

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

13 – Low back pain

Basics of spine

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

20. Spondylolysis, spondylolisthesis, sacralisation, lumbarization

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

29. Spondylarthritis ankylopoetica (ankylosing spondylitis)

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

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

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

66. Discus hernia, sciatica

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

14 – Bone tumours

Basics of bone tumours

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

62. Diagnostic and treatment principles of bone tumors

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

4. Benign bone tumours

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

8. Ewing’s Sarcoma

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

37. Osteoclastoma (giant cell tumor)

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

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

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

Topics which weren’t covered in lecture

1. Obstetrical brachial plexus injuries

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

5. Acetabular Protrusion

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

6. Tendovaginites, types and management

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

10. Knee effusion, popliteal cysts

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

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

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

19. Congenital torticollis (wry neck)

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

23. Congenital Coxa Vara

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

25. Limb Equalisation

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

31. Posttraumatic dystrophy (algodystrophy) of the bone

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

33. Osteoarthritis of the elbow

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

40. Cervicobrachial syndrome

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

43. Recurrent dislocation of the patella

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

45. Prognostic significance of septic hip conditions in newborn

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

47. Femoral head necrosis

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

49. Tuberculous arthritis

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

53. Chondromalacia patellae

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

55. Rehabilitation following limb amputation, orthoses, orthopaedic shoes

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

56. Acute osteomyelitis

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

60. Orthopaedic aspects of osteoporosis

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

65. Closure abnormalities of the spinal cord

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

67. Aseptic bone necroses

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

Previous page:
Immunology and Rheumatology MRTs

Next page:
Urology

Parent page:
Fourth year

4 thoughts on “Orthopaedics”

Anonymous says:

June 25, 2022 at 21:35

Hello! About topic 2, my teacher said that RA and Gout can cause early osteoarthritis but we should never say they are pre-arthritic conditions in an exam. He made a big deal out of it
1. Nikolas says:
  
  June 28, 2022 at 08:44
  
  THank you
Anonymous says:

May 24, 2021 at 13:59

Hello!
You said that the cause for medial collateral ligament injury is due to valgus stress to the knee, what do you mean by this?
1. Nikolas says:
  
  May 24, 2021 at 14:33
  
  Valgus stress is a force applied to the external surface of the knee, like seen in this picture: https://www.physio-pedia.com/images/d/d7/MCL_%26_ACL_Injury.jpeg

Comments are closed.

Knowledge from seminars

1 – Introduction, gait cycle, symptoms in orthopaedic disorders

11. Gait and limping

15. Ultrasound imaging in orthopaedics

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

50. Joint motions, measurement of muscle strength

2 – Congenital dislocation of the hip

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

38. DDH, clinical and X-ray features of

41. Conservative treatment of DDH

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

3 – Congenital foot deformities

Basics of foot

22. Clubfoot, etiology and pathology of

24. Congenital clubfoot, management of

59. Rocker bottom foot (vertical talus)

4 – Spine deformities

Basics of spine

Basics of scoliosis

18. Scheuermann’s Disease

30. Functional scoliosis, postural deformities

42. Scoliosis with known etiology, treatment of

51. Idiopathic structural scoliosis

5 – Cerebral palsy

17. Infantile cerebral palsy

6 – Paediatric hip diseases (Perthes, epiphyseolysis)

13. Juvenile slipped upper femoral epiphysis

26. Perthes’s Disease

54. Transitory coxitis, coxa saltans

7 – Shoulder disorders + upper extremity

Basics

14. Rheumatoid arthritis, surgical aspects of

21. Tennis elbow (humerus epicondylitis)

28. Recurrent dislocation of the shoulder

34. Periarthritis of the shoulder, frozen shoulder

39. Cervical rib, thoracic outlet syndrome (TOS)

Rotator cuff tear

Wrist osteoarthritis

Dupuytren contracture

Osteoarthritis of the fingers

8 – Prearthritic conditions, osteoarthritis

Osteoarthritis (OA)

2. Prearthritic conditions

9 – Joint arthroplasty + hip osteoarthritis + bone substitution

16. Hip osteoarthritis, clinical features, conservative management of

35. Surgical options for degenerative joint diseases

58. Joint prothesis types and fixation methods

61. Bone substitution, bone transplantation

10 – Complications of joint replacement and revision arthroplasty

57. Complications of joint replacements

11 – Adult foot deformities + static disorders of the foot

Basics of adult foot deformities

3. Flat foot (pes planovalgus)

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

Other adult foot deformities and problems

32. Sterile necrosis of the foot bones

12 – Acute injuries and degenerative diseases of the knee joint

Basics of knee

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

46. Knee ligament injuries

48. Meniscus injuries

63. Arthroscopy

Knee deformities

13 – Low back pain

Basics of spine

20. Spondylolysis, spondylolisthesis, sacralisation, lumbarization

29. Spondylarthritis ankylopoetica (ankylosing spondylitis)

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

66. Discus hernia, sciatica

14 – Bone tumours

Basics of bone tumours

62. Diagnostic and treatment principles of bone tumors

4. Benign bone tumours

8. Ewing’s Sarcoma

37. Osteoclastoma (giant cell tumor)

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

Topics which weren’t covered in lecture

1. Obstetrical brachial plexus injuries

5. Acetabular Protrusion

6. Tendovaginites, types and management