Figure 46. Ring principle of the ankle

and Danis-Weber classification

Activate Windows

Go to Settings to activate Windows.

0R‘

I2 Orthopaedic Surgery Toronto Notes 2023

Ankle Ligamentous Injuries

Medial Ligament Complex (deltoid ligament)

• eversion injury

• usually avulses medial or posterior malleolus and strainssyndesmosis

Lateral Ligament Complex

(anterior talofibular, calcaneofibular, posterior talofibular)

• inversion injury, >90% of all ankle sprains

• anterior talofibular (ATT-) most commonly and severely injured if ankle is plantarflexed

• swelling and tenderness anterior to lateral malleolus

• + + ecchymosis

• positive ankle anterior drawer

• may have significant medial talar tilt on inversion stress x-ray

Treatment

• non-operative

microscopic tear (tirade I)

rest, ice, compression, elevation

macroscopic tear (Grade 11)

strap ankle/aircast for up to a few weeks,should not interfere with early rehabilitation;

NSAlDs

physiotherapy:strengthening and proprioceptive retraining

complete tear (Grade 111)

below knee walking boot x 4-6 wk (controversial and variable); NSAlDs

physiotherapy:strengthening and proprioceptive retraining

surgical intervention may be required if chronic symptomatic instability develops

Legend

PTF: Posterior talofibular

CF: Calcaneotibular

ATF: Anterior talofibular

PTT:Posterior tibiotalar

TC: Tibiocalcaneal

ATT:Anterior tibiotalar

TN: Tibionavicular

Figure 47. Ankle ligament complexes

With a history of significant trauma

from axial loading of lower limb, always

consider spinal injuries and talar/

calcaneal fractures

Foot

Talar Fracture

Mechanism

• forced dorsiflexion with axial load, commonly from MVC or fall from height

• 60% of talus covered by articular cartilage;fractures often intra-articular

• talar neck is most common fracture of talus(50%)

• non- neck talus fractures are rare, and can include talar body (15-25%), process (10%), or head

fractures

• tenuous blood supply runs distal to proximal along talar neck

high-risk of AV N with displaced fractures

Investigations

• x-ray:AP, lateral, and Canale views (maximum equinus, 15° pronated) of the foot

• CT to better characterize fracture and assess for ipsilateral foot injuries (up to 88% incidence)

• MRI not helpful acutely, but can clearly define extent of AVN during follow up

Treatment

• non-operative

indication: non-displaced

emergent reduction in ER, below-knee cast 8-12 wk (NWB first 6 wk)

• operative

indication:displaced

• OR1F

Complications

• AVN (

—30% risk of osteonecrosis)

• malunion/nonunion

• post-traumatic arthritis(subtalar most common)

Calcaneal Fracture L J

Calcaneal Fracture Treatment

Principles

• Avoid wound complications (10-25%)

• Restore articular congruity

• Restore normal calcaneal width and

height

• Maximum functional recovery may

take longer than 12 mo

•most common tarsal fracture

Mechanism

•high energy axial loading:fall from height onto heels, MVA

•75% are intra-articular and 10% are bilateral

•10% of fractures associated with compression fractures of thoracic or lumbar spine (rule out spine

injury)

+

Activate Windows

Go toSettings to activateWindows.

AL GRAWANY

0R13Orthopaedic Surgery Toronto Notes 2023

Clinical Features

• marked swelling, pain, inability to weight bear,bruising on heel/sole

• wider,shorter,flatter heel when viewed from behind

may have apparent varus deformity

Investigations

• x-rays:AP,lateral, and oblique foot (mandator)'views);Broden view, Harris view,or AP ankle

(optional)

loss of Bohler’s angle, double-density sign

• CT:gold-standard, assess intra-articular extension

Haglund Deformity:an enlargement of

the posterior-superior tuberosity of the

calcaneus

Treatment

• dosed vs.open reduction is controversial

• N \VB cast x 6-12 wk with early ROM and strengthening

Complications

• wound complications

• subtalar arthritis

• compartmentsyndrome

• malunion The most common site of Achillestendon

rupture is 2-6cm from itsinsertion

where the blood supply isthe poorest Achilles Tendonitis

•Achilles:largest tendon in the body

• formed by confluence ofsoleus and gastrocnemiustendons

Mechanism

•chronic inflammation from activity or poor-fitting footwear

•may develop painful heel bumps (i.e.retrocalcaneal bursitis or Haglund deformity)

Clinical Features

•posterior heel pain,swelling, burning,stiffness

•thickened tendon, palpable bump

Investigations

•x-rav:lateral,evaluate bone spur and calcification

•U/S,MRI can assess degenerative change

Treatment

•non-operative

• rest, NSAlDs, activity and shoe wear modification (orthotics, open back shoes)

• heel sleeves and pads are mainstay of non-operative treatment

gentle gastrocnemius-soleusstretching,eccentric training with physical therapy,deep tissue calf

massage

• shockwave therapy in chronic tendonitis

avoid steroid injections (risk of Achillestendon rupture)

•operative

open or arthroscopic debridement of Hagelung lesion

Achilles Tendon Rupture

Mechanism

• sudden forced plantar flexion, violent dorsiflexion when plantar flexed

• loading activity,stop-and-go sports(e.g.squash, tennis, basketball)

• secondary to chronic tendonitis,steroid injection,fluoroquinolone antibiotics

Complications of Achilles Tendon

Rupture

. Infection/wound healing

complications (operative

management)

• Sural nerve injury (operative

management)

Clinical Features

• audible “pop,

" sudden pain with push-off movement

• pain or weakness/inability to plantarfiex

• palpable gap

• apprehensive toe off when walking

• Thompson test:with patient prone,squeeze calf, normal response is plantar flexion

no passive plantarflexion is positive test= ruptured tendon

n

LJ

Investigations

• x-rav:rule out other pathology

• U/Sor MRI:differentiate between partial vs.complete ruptures +

Activate Windows

Go to Settings to-actfvate-Windowsr

OR'I I Orthopaedic Surgery Toronto Notes 2023

Treatment

• non-operative

• indication:low functional demand (level I evidence suggests no difference in re-rupture rates

between operative and non-operative management with functional rehabilitation)

• functional bracing/casting in resting equinus(plantar flexion), with functional rehabilitation x

12 wk

• operative

indication: high functional demand (e.g.professional athlete)

surgical repair,followed by functional rehabilitation x 12 wk

Plantar Fasciitis

Definition

• inflammation of plantar aponeurosis at calcaneal origin

• common in athletes (especially runners, dancers)

• also associated with obesity, DM, inflammatory arthropathies

Mechanism

• repetitive strain injury causing microtears and inflammation of plantar fascia

Clinical Features

• insidious onset of heel pain, often when getting out of bed, and stiffness

• intense pain when walking from rest thatsubsides with ambulation;worse at end of day after

prolonged standing

• tendernessto palpation at medial tuberosity of calcaneus

• pain with toe dorsiflexion (stretchesfascia) and palpation of fascia from heel to forefoot

Bone spur Calcaneus

Figure 48.X-ray of bony heel spur

Surgical vs. Nonsurgical Methodsfor Acute

Achilles Tendon Rupture:AMeta-Ana lysis of

R andomited Controlled Trials

J Foot Ankle Surg Am 2018 Nov •Dec;57(6):1I9M1M

Purpose: To compare surgical treatment and

conservative treatment olacuteAchileslendoo

rupture.

Methods: A meta -analysis was performed looking

at randomned trials comparing surgical with

nonsurgical treatment or comparing different surgical

Irealments ol Achilleslendoo rupture.

Results:10 randomiied cinical trialsw<th a total of

934 randomited patients were included.Fatients

in the non-surgical group had a higher re-rupture

rate than patients in the surgical group.Howeier.

re-rupture rateswere equiralentfP*.08)if an early

range of motion eie rcises protocol was performed,

lower incidence of complications (eicbdtng rerupture) wasfou nd in non-surgical patients.

Conclusions: Non-surgical treatment for acute

Achiles tendon rupture is preferred if a functional

rehabilitation protocol with early range of motion

is possible.If not,surgical treatmentshould he

considered because of the lower rate of re-rupture.

Investigations

• x-ray to rule out fractures, may shosv plantar heel spur

• spur issecondary to inflammation, not the cause of pain

Treatment

• non-operative

• pain control and stretching programs are first

-line

• rest, ice, NSAlDs,steroid injection

physiotherapy: Achilles tendon and plantar fascia stretching, extracorporeal shockwave therapy

• orthotics with heel cup -to counteract pronation and disperse heel strike forces

• operative

very rarely indicated

when performed,includes endoscopic release of fascia

Bunions (Hallux Valgus)

Definition

• bony deformity characterized by medial displacement of first metatarsal and lateral deviation of

hallux

Normal angle <15“

Hallux Valgus angle >15

“

Mechanism

• valgus alignment of 1st MTP (hallux valgus), loose medial and tight lateral joint capsule,

hallucis becomes a deforming force

• formation of a reactive exostosis and thickening of the skin creates a bunion

• associated with poor-fitting footwear (high heel and narrow toe box)

• can be hereditary (70% have family history)

• more frequent in women

adductor

Clinical Features

• painful bursa over medial eminence of 1st MT head

• pronation (rotation inward) of great toe

• numbness over medial aspect of great toe

Investigations

• x-ray:standing AP, lateral, and oblique views;sesamoid can be helpful

Figure 49. Hallux valgus

Treatment

• indications: painful corn or bunion, overriding 2nd toe

• non-operative (first-line)

properly fitted shoes (low heel) and toe spacer

• operative: persistent symptoms, goal is to restore normal anatomy, not cosmetic reasons alone

osteotomy with realignment of 1st MTP joint

arthrodesis

+

Activate Windows

-Go to Settings to activate Windowsr

0RI5 Orthopaedic Surgery Toronto Notes 2023

Metatarsal Fracture

• use Ottawa l-

'

oot Rules to determine need for x-ray

Ottawa Ankle and Foot Rules

(seeEmergency Medicine. ERIE)

X-rays only required if;

Pain in the midfoot zone AND any of:

bony tenderness over the navicular or

base of the fifth metatarsal;OR inability

to weight bear both immediately after

injury and in the ER

Table 23. Types of Metatarsal Fractures

Fracture Type Mechanism Clinical Features Treatment

Avulsion of Base of 5th MT Sudden inversion followed by lender base of 5th MT Conservative management

contraction of peroneus brevis

ProximalShaft of 5th MT (Jones Stress injury

Fracture)

Shaft 2nd. 3rd MT ( March

Fracture)

1st MT

Painful over base of 5th MT •NWBBK cast x 6-8 wk

ORIF if athlete, displacement, or Painful shaft ol 2nd or 3rd MI

skin tenting

Trauma

Symptomatic (protected weight

bearing, pain management)

ORIF if displaced otherwise *NW 6

BK caslx 3wk then walking cast

x 2 vrk

ORIF or arthrodesis if displaced

Cast immobilization if undisplaced

x8-12 wk

Painful1st Ml

Tarso-MT Fracture - Dislocation Forceful axial load on a plantar

(Lisfranc Fracture)

Pain over base of 2nd MT

flexed footor direct crush injury Swelling over midfoot

Inability to bear weight

Bruising on plantar aspect of

midfoot

’NWB BK = Non weight beating, below knee

Paediatric Orthopaedics

Fractures in Children

• type of fracture

thicker, more active periosteum results in paediatric-specific fractures; greenstick (one cortex),

torus (i.e.‘buckle’, impacted cortex) and plastic (bossing)

distal radiusfracture most common in children (phalangessecond), the majority are treated ssith

closed reduction and casting

• epiphyseal growth plate

weaker part of bone,susceptible to injuries

growth plate often mistaken for fracture on x-ray and vice versa (x-ray opposite limb for

comparison), especially in elbow

tensile strength of bone < ligaments in children, therefore clinician must be confident that

fracture and/or growth plate injury have been ruled out before diagnosing a sprain

intra-articular fractures ha\re worse consequences in children because they usually involve the

growth plate, and may affect future bone growth

• anatomic reduction

gold standard with adults

may accept greater angular deformity in children as remodeling minimizes deformity at skeletal

maturity

• time to heal

shorter in children

• always he aware of the possibility of child abuse ( non-accidental injury, NAI)

ensure stated mechanism is compatible with injury presentation

• high index of suspicion with fractures in non-ambulating children (<l yr); look for other signs,

including x-ray evidence of healing fractures at different sites and different stages of healing

common suspicious fractures in children:metaphyseal corner fracture (hallmark of nonaccidental trauma),femur fracture <1 y/o, humeral shaft <3 y/o,sternal fractures, posterior rib

fractures,spinous process fractures

if concerned for NAI, admit child to hospital, contact appropriate authorities, engage allied health

such associal work, and treat injuries as normal

I

i

<

I

*

froximal Radius Proximal Radius ,

Figure 50. Greenstick (left) and torus

(right) fractures

Greenstick fractures are easy to reduce

but can redisplace while in cast due to

intact periosteum

Stress Fractures

Mechanism

• insufficiency fracture

normal or physiologic stress applied to a weak or structurally deficient bone

• fatigue fracture

repetitive, excessive force applied to normal hone

• most common in adolescent athletes

• common in tibia, calcaneus, and metatarsals

r T

L J

+

Activate Windows

Go to Settings to activate Windows.

OR46 Orthopaedic Surgery Toronto Notes 2023

Diagnosis

• localized pain and tenderness over the involved bone

• plain films may notshow fracture initially

• bone scan positive in 12-15 d, MR1 demonstrates abnormal edema

Treatment

• rest from strenuous activitiesto allow remodeling (can take several months)

• protected weight bearing

• splinting/Aircast optional

Physeal Injury ^Typo I

Table 24.Salter-Harris Classification of Epiphyseal Injury

SALT(E)R-Harris Type Description Treatment

Closed reduction and cast immobilization; healswell.

95%do nol affect growth

through metaphysis and along growth plate Closed reduction and cast if anatomic; otherwise closed t

open reduction, internal fixation

Through epiphysis to plate and along growth Anatomic reduebon by ORIF to preventgrowth arrest.

avoid fixation across growth plate

Closed reduction and cast if anatomic; otherwise ORIF

Cast immobilization (operative management is rarely

indicated):high Incidence ol growth arrest

I (Straight through;Stable) Transverse through growth plate

It (Above)

III (Below)’

plate

Through epiphysis and metaphysis

Crush injury of growth plate

IV (Through and through)’

V (Ram)’

Typo III

’TypesIII

- V are more likely to cause growth arrest and progressive delormity

Slipped Capital Femoral Epiphysis Typo IV

•most common adolescent hip disorder, peak incidence at pubertal growth spurt

Definition

•type 1 Salter-Harris epiphyseal injury at proximal hip with anterosuperior displacement of the

metaphysis relative to the epiphysis (remains in the acetabulum)

Etiology 5

•multifactorial

• genetic:autosomal dominant, Black children at highest risk

cartilaginous physis hypertrophies too rapidly under gr

overweight:mechanicalstress

• trauma: causes acute slip

•risk factors: obesity (No.l factor), male, hypothyroid, growth hormone deficiency, previous radiation

to hip region,renal osteodystrophy, Down Syndrome

|

=

owth hormone effects

Figure 51. Salter-Harris classification

of epiphyseal injury

Clinical Features

•acute:sudden,severe pain with limp, less than 3 wk duration

•chronic: typically groin and anterior thigh pain, may present with knee pain

• positive T rendelenburg sign on affected side, due to weakened gluteal muscles

•can be associated with knee pain due to activation of the medial obturator nerve

•restricted internal rotation, abduction, flexion

Drehmann sign:obligator)'external rotation during passive flexion of hip

•Loder classification:stable vs. unstable (provides prognostic information)

• stable = able to bear weight, with or without crutches (risk of osteonecrosis <10%)

• unstable = unable to ambulate even with crutches (high-risk of osteonecrosis, between 24-47%)

Bilateral involvement occurs In about

25%

Klein's Line

On AP view, line drawn along superolateral border of femoral neck should

cross at least a portion of the femora!

epiphysis. If it does not.suspect SCFE

Investigations

•x-ray: AP, frog-leg lateral radiographs both hips

• posterior and medial slip of epiphysis

disruption of Klein's line

AP view may be normal or show widened/lucent growth plate compared with opposite side

Treatment

•operative: percutaneous in-situ fixation without reduction (reduction is highly controversial)

•consider prophylactic fixation of contralateral hip in high-risk patients

Complications

•z\VN, chondrolysis (loss of articular cartilage,resulting in narrowing of jointspace), pin penetration,

premature OA, loss of ROM, contralateral SCFE

ri

L J

+

Activate Windows

Go to Settings to activate Windows.

OR-17 Orthopaedic Surgery Toronto Notes 2023

Developmental Dysplasia of the Hip

Definition

• abnormal development of hip, resulting in shallow acetabulum (dysplasia), displacement with some

remaining contact between the articularsurfaces (subluxation), or complete displacement of the joint

(dislocation)

• most common orthopaedic disorder in newborns

• all newborns require screening with physical exam

Etiology

• due to ligamentous laxity, muscular underdevelopment, and abnormal shallow slope of acetabular

roof

• spectrum of conditions

• dysplastic acetabulum, more shallow, and more vertical than normal

head subluxates out of joint when provoked

• dislocatable head in socket

dislocated femoral head completely out of acetabulum

Physical Exam

• diagnosis is clinical

limited abduction of the flexed hip (<60°)

affected leg shortening results in asymmetry in skin folds and gluteal muscles, wide perineum

Barlow’

s test demonstrates whether hips are dislocatable

flex hips and kneesto 90° and grasp thigh

fully adduct hips, push posteriorly to try to dislocate hips,feeling for a distinct clunk

Ortolani’s test demonstrates whether hips are reducible

initial position as above but try to reduce hip with fingertips during abduction

positive test: palpable clunk is felt (not heard) if hip is reduced

T rendelenburg test and gait useful if older (>2 yr)

Cialeazzi'

s sign

knees at unequal heights when hips and knees flexed

appearance of a shorter femur (lower knee) on affected side

difficult test if child <1 yr

Investigations

• perform screening U/S at 4-6 weeks in patients with risk factors and positive physical findings to view

cartilage (bone is not calcified in newborns until 4-6 mo)

• follow-up radiograph after 3 mo

• x-ray signs (at 4-6 mo):false acetabulum, acetabular index >25°, broken Shenton’

sline,femoral neck

above Hilgenreiner’

s line (horizontal line through right and left triradiate cartilage),ossification

centre outside of inner lower quadrant (quadrantsformed by intersection of Hilgenreiner’

s and

Perkin’

slines)

Barlow'

stest

lv\

i

®

Ortolani'

s tost

Figure 52. Barlow’s test and

Ortolani's test

(

*3

5 Fs that Predispose to Developmental

Dysplasia of the Hip

Fanily history

Female

Frank breech

First born

LeFt hip Treatment

• 0-6 mo:reduce hip using Pavlik harness to maintain abduction and flexion

• 6-18 mo: reduction under GA, hip spica cast x 2-3 mo (if Pavlik harness fails)

• 18 nio-2 yr: open reduction with spica casting

• >2 yr: pelvic and /or femoral osteotomy

Complications

• redislocation, inadequate reduction,stiffness

• AVN of femoral head may be seen at any point in treatment; due to impingement of medial circumflex

femoral artery with severe abduction and flexion secondary to prolonged Pavlik harness or spica cast

treatment

Legg-Calve-Perthes Disease (Coxa Plana)

Most common in adolescent athletes,

especially jumping/sprinting sports

Definition

• idiopathic AVN of femoral head, presents at 4-8 yr of age

. 12% bilateral, M:P=5:1, 1/1200 children

• associations

family history of Legg-Calve-Perthes Disease

low birth weight

abnormal pregnancy/delivery

• ADHD in 33% of cases, delayed bone age in 89%

second-hand smoke exposure

• key features

» AVN of proximal femoral epiphysis, abnormal growth of the physis, and eventual remodeling of

regenerated bone

r »

L J

Children diagnosed with coxa plana

<6 yr of age have improved prognosis

+

Activate Windows

Go to-Settings-to activate Windows,-

0R18 Orthopaedic Surgery Toronto Notes 2023

Clinical Features

• child tvith antalgic or T rendelenburg gait ± pain

• intermittent knee, hip, groin, or thigh pain

• flexion contracture (stiff hip)

• decreased internal rotation and abduction of hip

• limb length discrepancy (late)

Investigations

• x-ray: AP pelvis,frog leg lateral

• initially, may be negative; if high index of suspicion, obtain bone scan or MR1

• eventually, collapse of femoral head will be seen (diagnostic)

Figure 53.Pelvic x-ray and reference

lines and angles for assessment of

DDH

TriradiateCartilage

y-shaped epiphyseal plate at junction

of ilium,ischium,and pubis

Hilgenreiner’sLine

Line running between triradiate

cartilages

Perkin's Line

Line through lateral margin of

acetabulum,perpendicular to

Hilgenreiner's Line

Shenton’sLine

Arced line along Inferior border of

femoral neck and superior margin of

obturator foramen

Acetabular Index

Angle between Hilgenreiner's Line

and line from triradiate cartilage to

point on lateral margin of acetabulum

Treatment

• goal is to keep femoral head contained in acetabulum and maintain ROM (contain and maintain)

• non-operative

physiotherapy: ROM exercises

restricted weightbearing

• operative

« femoral or pelvic osteotomy (>8yr of age orsevere)

prognosis better in males, <6 yr, <50% of femoral head involved, abduction >30°

• 60% of involved hips do not require operative intervention

• natural history is early onset OA and decreased ROM

Osgood-Schlatter Disease

Definition

• inflammation of patellar ligament at insertion point on tibial tuberosity

. M>F; boys 12-15 yr;girls 8-12 yr

Mechanism

• repetitive tensile stress on insertion of patellar tendon over the tibial tuberosity causes minor avulsion

at the site and subsequent inflammatory reaction (tibial tubercle apophysitis)

Clinical Features

• tender lump over tibial tuberosity

• pain on resisted leg extension

• anterior knee pain exacerbated by jumping or kneeling, relieved by rest

Investigations

• x-ray lateral knee:fragmentation of the tibial tubercle,± ossicles in patellar tendon

Treatment

• benign,self-limited condition, does not resolve until growth halts

• non-operative (majority)

• avoid aggravating activitiessuch as basketball or cycling

NSAJDs, rest, flexibility, isometric strengthening exercises

casting ifsymptoms do not resolve with conservative management

• operative:ossicle excision in refractory cases (patient is skeletally mature with persistent symptoms)

Congenital Talipes Equinovarus (Club Foot)

Definition

• congenital foot deformity

• muscle contractures resulting in CAVE deformity

• bony deformity: talar neck medial and plantar deviated;varus calcaneus and rotated medially around

talus; navicular and cuboid medially displaced

Etiology

• intrinsic causes (neurologic, muscular, or connective tissue diseases) vs. extrinsic (intrauterine

growth restriction);maybe idiopathic, neurogenic,orsyndrome-associated

• fixed deformity

• 1-2 in 1000 newborns, 50% bilateral, M>F-2:1,severity 1

;

>M

Physical Exam

• examine for CAVE deformity

• examine hips for associated DDH

• examine knees for deformity

• examine back for dysraphism (unfused vertebral bodies)

• diagnosis is often from physical exam findings alone, radiographs unnecessary

<§> n

L J

CAVE deformity

Midfoot Cavu (tight intrinsics, FHL,FDL)

Forefoot Adductus (tight tibialis

posterior)

Hindfoot Varus tight Achilles tendon,

tibialis posterior,tibialis anterior)

Hindfoot Equinus (Hindfoot Equinus

(tight Achilles tendon)

+

Activate Windows

Go to Settings to activate Windows.

OR-19 Orthopaedic Surgery Toronto Notes 2023

Treatment

• largely non-operative via Ponseti Technique (serial manipulation and casting)

• correct deformities in CAVE order

change strapping/cast ql-2 wk

typically requires percutaneous Achilles tendon release after ~ 2 months of casting with

another 3 weeks of casting in maximal dorsiflexion

surgical release in refractory case (rare)

• delayed until age 3-4 mo

• 3 yr recurrence rate = 5-10%

• mild recurrence common;affected foot is permanently smaller/stiffer than normal foot with calf

muscle atrophy

' Plantar flexion

of ankle joint

Talus in equinus

and varusI

v, I

0

[0

/

-j

I1

Forefoot

bones in

varus,

Inversion of i

calcaneus Scoliosis

Figure 54.Club foot

- depicting the

Definition gross and bony deformity

• lateral curvature ofspine with vertebral rotation

• age:10-14 yr

• more frequent and more severe in females

Etiology

• idiopathic: most common (90%)

• congenital:vertebrae fail to form orsegment

• neuromuscular: UMN or LMN lesion, myopathy

• postural:leg length discrepancy, muscle spasm

• other: osteochondrodystrophies, neoplastic, traumatic

Clinical Features

• cosmetic concern ± back pain

• primary curve where several vertebrae affected

• secondary compensatory curves above and below fixed primary curve to try to maintain normal

position of head and pelvis

• asymmetric shoulder height when bent forward

• Adam’

s test: thoracic or lumbar prominence on affected side with forward bend at the waist

• prominent scapulae, creased flank, asymmetric pelvis

• associated posterior midline skin lesions in neuromuscular scoliosis

• cafe-au-lait spots, dimples, neurofibromas

• axillary freckling, hemangiomas, hair patches

• associated pes cavus or leg atrophy

• apparent leg length discrepancy

• Scoliosis Lenke Classification: guide to select curves to be included within the fusion construct

Figure 55.Cobb angle -

used to monitor the progression of

the scoliotic curve

Investigations

• x-ray:3-footstanding, AP, lateral

measure curvature:Cobb angle

• may have associated kyphosis

Scoliosisscreening is not recommended

in Canada (Grieg A,et al.2010; Health

Canada.1994)

Treatment

• based on Cobb angle

• <25°: observe for changes with serial radiographs

• >25° or progressive:bracing (many types, controversial) that halt/slow curve progression but do

not reverse deformity

• >45°, cosmetically unacceptable, or respiratory problems:surgical correction (spinal fusion)

In structural or fixed scoliosis, bending

forwards makesthe curve more obvious

Postural scoliosis can be corrected by

correcting the underlying etiology

r

+

Activate Windows

Go to Settings to activate Windows.

OR50 Orthopaedic Surgery Toronto Notes 2023

Bone Tumours

•primary bone tumours are rare after 3rd decade

•metastasesto bone are relatively common after 3rd decade

Clinical Features

•malignant (primary'or metastasic):local pain and swelling (weeks to months), worse on exertion and

at night, ± soft tissue mass

•minor trauma can be the initiating event that calls attention to lesion

Red Flags

• Persistentskeletal pain

• Localized tenderness

• Spontaneousfracture

• Enlarging mass

-soft tissue swelling

Table 25. Distinguishing Benign from Malignant Bone Lesions on X-Ray

©

Benign Malignant

No periostealreaction or benign appearing reaction (e.g.uniform

smooth periosteal thickening as seen ina healing fracture)

Acute periosteal reaction

•Codman’s triangle

•"Onion skin"

•"Sunburst”

Poorly defined borders,with a wide zone of transition,orinfiltrative

(suggesting fast-growing lesion)

Varied bone formation

Eitraosseousand irregular calcification

Soft tissue mass present

Aggressive cortical destruction or tumour infiltration without cortical

destruction

Describing Bone Tumours on X-rays

1 Location (which bone and whether

it isin the diaphysis.metaphysis.or

epiphysis)

Sharp,well-demarcated borders,narrow zone of transition (between

lesion andnormal bone,suggesting slow-growing lesion)

Well-developed bone formation

Intraosseous and even calcification

No soft tissue mass

No cortical destruction or uniform cortical destruction in some low

grade and locally aggressive benign lesions

2 Size

3 Solitary vs.multifocal

4 Morphology:geographic,permeative,

or moth-eaten margins

5 Presence of periosteal reaction

6 Presence of bony remodeling

7 Cortical involvement

8 Matrix:osteoid (cumulus cloud),

chondroid (punctate or popcorn

calcification),or fibrous (ground glass

appearance)

9 Presence of soft-tissue mass

10 Associated pathological fracture

Adapted from Bucktioltz RW. Heckman JD.Rockwood and Green'

s Fractures in Adults.Volume1. Philadelphia: Uppincotl Williams & Wilkins.2001.

p558

Diagnosis

• malignancy issuggested by rapid growth, warmth, tenderness, aggressive features on imaging

• may be associated with constitutional symptomssuch as fevers, night sweats, weight loss,or loss of

appetite

• staging should include:

• local

full length radiographs of the affected bone

± CT and/or MR1 of affected bone

biopsy

should be referred to specialized centre for biopsy

• systemic

blood work (CBC, electrolytes,liver function assays, inflammatory markers,bone profile,

extended electrolytes including calcium)

serum electrophoresis for older patients ± Bence )ones protein

CT chest/abdo/pelvis

Bone scan or bone marrow biopsy depending on preliminary diagnosis

Neoplasi

Periosteum

Benign Active Bone Tumours

Codman'

s