inflammation of the common flexor tendon as it inserts into

the medial epicondyle

Tennis Elbow = laTeral epicondylitis; pain

associated with extension of wrist

Mechanism

• repeated orsustained contraction of the forearm musdes/chronic overuse

Clinical Features

• point tenderness over humeral epicondyle and/or distal to it over forearm musculature

• pain upon resisted wrist extension (lateral epicondylitis) or wrist flexion (medial epicondylitis)

• generally a self-limited condition, but may take 6-18 mo to resolve

Treatment

• non-operative (vert'good outcomes)

rest,ice, NSAlDs

use brace/strap

physiotherapy,stretching, and strengthening

activity modification/ergonomics

• corticosteroid injection

• operative

• indication:failed 6-12 mo conservative therapy

• percutaneous or open release of common tendon from epicondyle

Elbow Joint Injection

Inject at the centre of the triangle

formed by the lateral epicondyle, radial

head, and olecranon

Forearm

Radius and Ulna Shaft Fractures

Mechanism

• high-energy direct or indirect (MVA, fall from height,sports) trauma

• fractures usually accompanied by displacement due to high energy mechanism

Clinical Features

• deformity, pain,swelling

• loss of function in hand and forearm

rT

L J

Investigations

• x-ray:AP and lateral of forearm ± oblique of elbow and wrist

• CT if fracture is close to joint +

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OR22 Orthopaedic Surgery Toronto Notes 2023

Treatment

• goal is anatomic reduction since imperfect alignment significantly limitsforearm pronation and

supination

• ORIT with plates and screws;closed reduction with immobilization usually yields poor results for

displaced forearm fractures(except in children)

Specific Complications (seeGeneral FractureComplications, OR7)

- compartmentsyndrome

• soft tissue contracture resulting in limited forearm rotation -surgical release of tissue may be

warranted

Monteggia Fracture

• fracture of the proximal ulna with radial head dislocation and proximal radioulnar joint injury

- more common and better prognosisin the paediatric age group when compared to adults

Mechanism

• direct blow to the posterior aspect of the forearm

• hvperpronation

• fall on the hyperextended elbow Figure 19. Monteggia fracture

Clinical Features

• pain,swelling, decreased rotation of forearm ± palpable lump at the radial head

• ulna angled apex anterior and radial head dislocated anteriorly (rarely the reverse deformity occurs)

Investigations

• x-ray:AT and lateral views of the elbow, wrist,and forearm

In all isolated ulna fractures,assess

proximal radiusto rule out a Monteggia

fracture

Treatment

• adults (if stable):splint and early postoperative ROM if elbow completely stable,otherwise

immobilization in plaster with elbow flexed for 2-3wk

• adults (if unstable):OR1F of ulna with indirect reduction of radiocapitellar joint in 90% of patients

(open reduction of radiocapitellar joint if unsuccessful)

• paediatrics:attempt closed reduction and immobilization in plaster with elbow flexed for Bado Type

1-111,surgery for Type IV

Specific Complications ( seeGeneral Fracture Complications, OR7)

• PIN injury: most common nerve injury;observe for 3 mo as most resolve spontaneously

• radial head instabilitv/redislocation

• radioulnar synostosis

Bado Type Classification of Monteggia

Fractures

Based on the direction of displacement

of the dislocated radial head,generally

the same direction astheapexofthe

ulnar fracture

Type b anterior dislocation of radial

head and proximal/middle third ukiar

fracture (60%)

Type II:posterior dislocation of radial

head and proximal/middle third ulnar

fracture (15%)

Type III:lateral dislocation of radial

head and metaphyseal ulnar fracture

(20%)

Type IV-combined: proximal fracture

of the ulna and radius,dislocation of the

radial head in any direction (<5%)

Nightstick Fracture

•isolated fracture of ulna without dislocation of radial head

Mechanism

•direct downward blow to upward block forearm (e.g.holding arm up to protect face)

Treatment

•non-operative

indication: non-displaced

below elbow cast (x 10 d),followed by forearm brace (~8 wk)

•operative

• indication:significantly displaced

ORIT if >50% shaft displacement or >10°angulation

Galeazzi Fracture Figure 20. Nightstick fracture

•fracture of the distal radial shaft with disruption of the DRU|

•most commonly in the distal 1/3of radius near junction of metaphysis/diaphysis

For all isolated radiusfractures assess

Mechanism DRUJ to rule out a Galeazzi fracture

•FOOSH with axial loading of pronated forearm or direct wrist trauma

•forceful axial loading of radial shaft (e.g. direct trauma to distal 1/3 of radius)

Clinical Features

•pain,swelling, deformity,and point tenderness at fracture site

r h

L J

(§)

Monteggia vs. Galeazzi Fractures

Remember the mnemonic 'MUGGER'

:

Monteggia

Ulnar fracture

Galeazz

Radialfracture

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Investigations

• x-ray: AP, and lateral views of the elbow, wrist, and forearm

shortening of distal radius >5 mm relative to the distal ulna

• widening of the OKU ) space on AP

• dislocation of radius with respect to ulna on true lateral

Fracluro ol distal radius

Treatment

• all cases are operative (“fracture of necessity")

OR1P of radius; afterwards, assess DRU|stability by balloting distal ulna relative to distal radius

if DRU) is stable and reduced,splint for 10-14 d with early ROM encouraged

if DRU) is unstable, OR1P or percutaneous pinning with long arm cast in supination x 2-3wk

Wrist Dislocation of ulna

Figure 21. Galeazzifracture

Colles’ Fracture

Indications for Direct Surgical

Management of Codes' Fracture

• Displaced intra-articular fracture

• Comminuted

• Severe osteoporosis

• Dorsal angulation >5‘or volar tilt

>20"

• >5 mm radlal shortening

• extra-articular transverse distal radius fracture (~2 cm proximal to the radiocarpal joint) with dorsal

displacement ± ulnar styloid fracture

• most common fracture in those >40 yr, especially in women and those with osteoporotic bone

Mechanism

. KOOSH

Clinical Features

• “dinner fork" deformity

• swelling, ecchymosis, tenderness Features of Inadequate Closed

Reduction that Require ORIF

- Radial shortening >3 mm or

- Dorsal tilt >10“ or

- Intra-articular displacement/step-off

>2mm

Investigations

• x-ray:AP and lateral ± oblique views of wrist

Treatment

• goal is to restore radial height (13 mm), radial inclination (22°), volar tilt (11°), as well as DRU)

stability and useful forearm rotation

• non-operative

closed reduction (think opposite of the deformity)

hematoma block (sterile prep and drape,local anesthetic injection directly into fracture site) or

conscious sedation

• closed reduction:traction with extension (exaggerate injury); traction with ulnar deviation,

pronation, flexion (of distal fragment- not at wrist)

• dorsal slab/below elbow cast for 5-6 wk

obtain post

-reduction Aims immediately; repeat reduction if necessary

• x-ray at 1 wk, 3 wk, and at cessation of immobilization to ensure reduction is maintained

• operative

indication: failed closed reduction,or loss of reduction

percutaneous pinning, external fixation, or ORIF

Lateral View

Smith’s Fracture

• volar displacement of the distal radius(i.e.reverseColies’fracture)

AP View

Mechanism 1. Dorsal tilt

• fall onto the back of the flexed hand 2. Dorsal displacement

3.Radial shortening

4. Ulnar styl

5 Radial tilt

old fracture Investigations

• x-ray: AP and lateral ± oblique views of wrist

Treatment

• if non-displaced/stable: closed reduction and splinting in wrist extension with hematoma or regional

nerve block;long arm cast in supination x6 wk

• if displaced/unstable: ORIF

6. Radial displacement

Figure 22. Colles’ fracture and

associated bony deformity

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0R21Orthopaedic Surgery Toronto Notes 2023

Complications of Wrist Fractures

• most common complications are poor grip strength,stiffness, and radialshortening

• distal radiusfractures in individuals <40 yr of age are frequently high energy/comminuted and are

more likely to require ORU-

'

• 80% have normal function in 6-12 mo

Table 13.Early and Late Complications of Wrist Fractures

Early Late

Difficult reduction tloss olreduction

Compartment syndrome

Extensor pollicis longus tendon rupture

Acute carpal tunnel syndrome

Finger swelling with venous block

Complications ot a tight cast/splinl

Malunion,radial shortening

Painful wrist secondary to ulnar prominence

Froren shoulder (“shoulder-hand syndrome")

Post-traumatic arthritis

Carpal tunnel syndrome

CRPS/RSD

AP view

A.Radial inclination

B.Radial length

Scaphoid Fracture

Epidemiology

• most common carpal bone injured

• common in young men; not common in children or in patients beyond middle age

• may be associated with other carpal or wrist injuries (e.g. Colies’

fracture)

Mechanism

• FOOSH: impaction of scaphoid on distal radius, most commonly resulting in a transverse fracture

through the waist (65%), distal (10%), or proximal (25%)scaphoid

Clinical Features

• pain with resisted pronation

• tenderness in the anatomical “snuffbox”, over scaphoid tubercle, and pain with long axis compression

into scaphoid

• usually nondisplaced

Lateral view

C. Volar tilt

1

o

Effect ol Colics’Iracturo

on distal radius

Figure 23.Normal wrist angles

*

wrist angles in Codes’fracture

Note the relative shortening of the

radius relative to the ulna on AP

view in Codes’fracture

Investigations

• x-ray: AP, lateral, and scaphoid views with wrist extension and ulnar deviation

• ± Q’

or MRI:detect occult fracture and prevent AVN

• bone scan rarely used

• note: a fracture may not be radiologically evident up to 2 wk after acute injury,so if a patient

complains of wrist pain and has anatomical snuffbox tenderness but a negative x-ray, treat as

if positive for a scaphoid fracture and repeat x-ray 2 wk later to rule out a fracture:if x-ray still

negative,order CT or MR1

Scaphoid Fracture Special Tests

Tender snuff box:100% sensitivity,but

29%specific,asit is also positive with

many other injuries of radial aspect of

Treatment wrist with FOOSH

• early treatment critical for improving outcomes

• non-operative

• non-displaced (<1 mm displacement/

^

5° angulation): long-arm thumb spica cast x 4 wk, then

short arm cast until radiographic evidence of healing isseen (2-3 mo) The proximal pole of the scaphoid

receives as much as100% of its arterial

blood supply from the radial artery that

enters at the distal pole.A fracture

through the proximal third disrupts

this blood supply and results In a high

incidence of AVN/nonunion

• operative

• displaced: ORIt with headless/countersink compression screw is the mainstay treatment

Specific Complications (seeGeneral FractureComplications,OR7)

• most common: nonunion/malunion (use bone graft from iliac crest or distal radius with fixation to

heal)

• AVN of the proximal fragment

• delayed union (recommend surgical fixation)

• scaphoid nonunion advanced collapse (SNAC) -chronic nonunion leading to advanced collapse and

arthritis of wrist

Prognosis

• proximal pole:proximal fifth fracture,AVN rate 100%; proximal third fracture:AVN rate 33%

• waist:middle of the scaphoid fractures have healing rates of 80-90%

• distal pole:distal third fractures have healing rates close to 100% n

L J

Figure 24. ORIF left scaphoid

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OR25 Orthopaedic Surgery Toronto Notes 2023

Hand Ulna Radius

'

Scaphoid

Trapezium

•Trapezoid

**Capitate

Lunate

• sec Plastic Surperv. PL24

Triquetrum

Pisiform ^

Hamate

^

Spine

3

; n

Spinous

process Metacarpal

bones(1-5)

.-1

Lamina Transverse

process Pedicle Neural arch Superior

articular

process

u- u

©Hisheva Merci

Figure 25. Carpal bones

1/

/

V- •

V- iVertebral '

y

body

Order of Carpal Bones

So Long To Pinky. HereComes The

Thumb

Proximal Row:Scaphoid. Lunate.

Triquetrum. Pisiform (Lateral to Medial)

Distal Row:Hamate.Capitate.

Trapezoid.Trapezium (Medial to Lateral)

Transverse

-

•

- -ri:

Pedicli

ir

-

1M

Vertebral

foramen

8

Inferior

articular process

Spinous Vertebral

process

s

'J*

.

1a.

body

Left Lateral View Superior View

Figure 27. Schematic diagram of vertebral anatomy

Adapted fron:Moore KL Agi.r AMR.Essential Clinical Anatomy,3rd ed. Philadelphia:Lippincott Williams and Wilkins.2007.p274

Fractures of the Spine

• see Neurosurgery. NS39

Compression Cervical Spine

General Principles

• Cl (atlas): no vertebral body, no spinous process

• C2 (axis):odontoid = dens

• 7 cervical vertebrae; 8 cervical nerve roots

• nerve root exits above vertebra (i.e. C4 nerve root exits above C4 vertebra), C8 nerve root exits below

C7 vertebra

• radiculopathy = impingement of nerve root

• myelopathy = impingement of spinal cord Burst

Special Testing

• compression test: pressure on head worsens radicular pain

• distraction test: traction on head relieves radicular symptoms

• Valsalva test: Valsalva maneuver increases intrathecal pressure and causes radicular pain

• Lhermitte Sign: electric shock sensation radiating to back upon forward flexion of the neck,some

etiologies include multiple sclerosis, cervical myelopathy, and B12 deficiency

• occiput-wall distance (OW'

D):patient stands against a wall with erect posture and distance between

the occiput and the wall is measured, value greater than 2 cm is abnormal, indicative of thoracic

hyper-kvphosis

Fracture-dislocation

Figure 26. Compression, burst, and

dislocation fractures of the spine

Table 14. Cervical Radiculopathy/Neuropathy

Root C5 C6 a C8

Deltoid

Biceps

Biceps

Brachioradialis

Wrist extension

triceps

Wrist flexion

Finger extension

Index and middle finger Bing and little finger

Motor Interossei

Digital flexors

Sensory Axillary nerve (patch over thumb

lateral deltoid)

Reflex Biceps Biceps

Brachioradialis

triceps Finger jerk

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OR26 Orthopaedic Surgery Toronto Notes 2023

X-Rays for C-Spine

• AP spine:alignment

• AP odontoid:atlantoaxial articulation

• lateral

vertebral alignment: posterior vertebral bodiesshould be aligned (translation >3.5 mm is

abnormal)

• angulation:between adjacent vertebral bodies(>11° is abnormal)

disc or facet joint widening

anterior soft tissue space (at C3 should be S3 mm:at C4 should be <8-10 mm)

• oblique:evaluate pedicles and intervertebral foramen

• ± swimmer’

s view:lateral view with arm abducted 180“ to evaluate C7-T1 junction if lateral view is

inadequate

• ± lateral flexion/extension view: evaluate subluxation of cervical vertebrae

Differential Diagnosis of C-Spine Pain

• neck muscle strain, cervical spondylosis, cervical stenosis, RA (spondylitis), traumatic injury,

whiplash, myofascial pain syndrome, acute discogenic nerve root entrapment, infection, fracture,

neoplasm, pain from soft tissue structure

C-SPINE INJURY

• see Neurosurgery. NS38

Thoracolumbar Spine

General Principles

• spinal cord terminates at conus medullaris (Ll /2)

• individual nerve roots exit below pedicle of vertebra (i.e. L4 nerve root exits below L4 pedicle)

Special Tests

• straight leg raise: passive lifting of leg (30-70“

) reproduces radicular symptoms of pain radiating down

posterior/lateral leg to knee ± into foot

• Lasegue maneuver: dorsillexion of foot during straight leg raise makessymptoms worse, or if leg is

less elevated, dorsillexion will bring on symptoms

• femoral stretch test: with patient prone. Hexing the knee of the affected side and passively extending

the hip results in radicular symptoms of unilateral pain in anterior thigh

Table 15. Lumbar Radiculopathy/Neuropathy

Root L4 L5 S1

Motor Ouadnceps (knee extension hip

adduction)

Tibialis anterior (ankle Inversion •

dorsillexion)

Medial malleolus

Squat and rise

Knee (patellar)

Femoralstretch

Extensor hallucis longus

Gluteus medlus(hip abduction)

Peroneuslongus brevis (ankle eversion)

Gastrocnemius soleus (plantar (lesion)

Sensory

Screening Test

Reflex

lateral foot

Walking on toes

Ankle (Achilles)

Straight leg raise

1st dorsal webspace and lateral leg

Heel walking

Medial hamstring*

Test Straight leg raise

Differential Diagnosis of Back Pain

1.mechanical or nerve compression (>90%)

• degenerative (disc,facet,ligament)

• nerve root compression (e.g. disc herniation)

spinal stenosis (congenital, osteophyte, central disc)

2.others(<10%)

• neoplastic (primary, metastatic, multiple myeloma)

• infectious(osteomyelitis,TB)

• metabolic (osteoporosis)

traumatic fracture (compression,distraction, translation,rotation)

• spondyloarthropathies (ankylosing spondylitis)

referred (aorta,renal,ureter, pancreas)

DEGENERATIVE DISC DISEASE

• loss of vertebral disc height with age resulting in:

bulging and tears of annulusfibrosus

change in alignment of facet joints

osteophyte formation

n

c j

Mechanism

• compression and dehydration of disc material over time with age

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OR27 Orthopaedic Surgery Toronto Notes 2023

Clinical Features

• axial back pain

• pain worse with axial loading and flexion

• negative straight leg raise

Investigations

• x-ray,MRI,provocative discography

• imaging only indicated ifsymptoms persist greater than 6 wk or if red flag symptoms are present

Treatment

• non-operative

• staying active with modified activity

back strengthening

• NSAlDs

do NOT treat with opioids; no proven efficacy ofspinal traction or manipulation

• operative -rarely indicated

decompression ± fusion (in cases ofsevere or progressive neurological deficit;refractory cases

with impaired quality oflife)

SPINAL STENOSIS

• narrowing ofspinal canal

• congenital (idiopathic,osteopetrosis, achondroplasia) or acquired (degenerative, iatrogenic - post

spinalsurgery, ankylosing spondylosis, Paget'

s disease, trauma)

Clinical Features

• ± bilateral back and leg pain

• neurogenic claudication

• ± motor weakness

Investigations

• CT/MR1 reveals narrowing ofspinal canal

Treatment

• non-operative

physiotherapy (flexion exercises,stretch/strength exercises), NSAlDs,lumbar epiduralsteroids

* operative

indication:non-operative failure >6 mo

decompressive surgery

Table 16.Differentiating Claudication

Neurogenic Vascular

Aggravation With slandinglwalking

Walking distance variable

Change inposition (usually flexion.sitting. Stop walkingleaercise

lyingdown)

Relief in "10 min

Walking/exercise (reproducible)

Alleviation

Time Relief in -2 min

MECHANICAL BACK PAIN

• back dominant pain that does not involve nerve impingement

Clinical Features

• dull backache aggravated by activity and prolonged standing (orsitting,depending on cause and

pathology')

• morning stiffness (e.g.if facet OA)

• no neurological signs

Treatment

• symptomatic (analgesics, physiotherapy, weight loss, and exercise program)

• prognosis:symptoms may resolve in 4-6 wk, others become chronic

i

Cauda equina syndrome and ruptured

aorticaneurysms are causes of low

back pain that are considered surgical

emergencies

Disc Prolapse

Annulus librusjs

\ Nucleus

NYpulposus

'

/ / 1 Nerve

//root

LUMBAR DISC HERNIATION

• tear in annulus fibrosus allows protrusion of nucleus pulposus,causing either a central, posterolateral,

or lateral disc herniation,most commonly at L5-S1 > L4-5 > L3-4

• M:F=3:1

• only 5% become symptomatic

• usually a history of flexion-type injury

1 r i

,£ LJ

Vertebra |

Clinical Features

• back dominant pain (central herniation) orleg dominant pain (lateral herniation)

• tenderness between spinous processes at affected level

• muscle spasm iloss of normal lumbar lordosis

+

Figure 28.Disc herniation causing

nerve root compression

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•neurological disturbance is segmental and varies with level of central herniation

• motor weakness ( L4, L5, SI)

• diminished rellexes (1.4, SI)

• diminished sensation (1.4, L5,SI)

•positive straight leg raise

•positive contralateral SLU

•positive Lasegue and Bowstring sign

•cauda equina syndrome (present in l-10%):surgical emergency

Neurogenic claudication Is position

dependent; vascular claudication is

exercise dependent

Investigations

•x-ray,MRI, consider a post-void residual volume to check for urinary retention; post-void >100 mL

should heighten suspicion for cauda equina syndrome

Treatment

•non-operative

symptomatic

extension protocol physiotherapy program

NSAlDs

MRI abnormalities (e.g. spinal stenosis,

disc herniation) are quite common in

both asymptomatic and symptomatic

individuals and are not necessarily

an indication for intervention without

•operative clinical correlation

• indication; progressive neurological deficit, failure of symptoms to resolve within 3 mo, or cauda

equina syndrome due to central disc herniation

• surgical discectomy

•prognosis

90% of patients improve in 3 mo with non-operative treatment

Table 17. Types of Low Back Pain

Mechanical Back Pain Direct Nerve Root Compression Red Flags for

Disc Origin Facet Origin Spinal Stenosis Root Compression

BACK PAIN

Bowel or bladder dysfunction

Anesthesia (saddle)

Constitutional symptoms/malignancy

Khronic disease

Paresthesias

Age >50 yr

IV drug use

Neuromotor deficits

Pain Dominance

Aggravation

Back Back Leg Leg

Flexion Extension,standing,

walking

More sudden

Shorter (days,v/eeks)

Exercise,extension,

v/alking,standing

Congenital or acquired

Acute or chronichistory

(weeks to months)

Belief of strain,

physiotherapy (flexion

back program), surgical

decompression if

progressive or severe

deficit. NSAlDs.

acetaminophen

flexion

Gradual

Long (weeks, months)

Acute leg tback pain

Constant and severe pain,

lasting weeks)

Relief of strain,

physiotherapy (extension

back program for disc

herniation), surgical

decompression il

progressive or severe

delieit. NSAlDs.

acetaminophen

Onset

Duration

Relief of strain,

physiotherapy and

exercise, weighlloss.

NSAlDs,acetaminophen

Relief of strain,

physiotherapy and

exercise,weighlloss.

NSAlDs. acetaminophen

Treatment

Sciatica

• Most common symptom of

radiculopathy (L4-S3)

• Log dominant, constant, burning pain

• Pain radiates down legifoot

Back Pain • Most common cause - disc herniation

Back Dominant

*

Ley Dominant

*

T

Constant

Disc Herniation (lateral)

Constant

Inflammatory

Mechanical

Intermittent Intermittent

Spinal Stenosis

T

Disc Herniation (central) Facet Joint

Figure 29. Approach to back pain

f.- K

i SPONDYLOLYSIS

[Spondylolysis

Definition

• defect in the pars interarticularis with no movement of the vertebral bodies

Mechanism

• trauma; gymnasts, weightlifters, backpackers, loggers,labourers

,

h

t

Spondylolisthesis

(anterioi displacement)

Clinical Features

• activity-related back pain, pain with unilateral extension (Michelis"

test)

Investigations

• oblique x-ray; “collar” break in the “Scottie dog’

s

" neck

• bone scan

• CTscan

f*

.

8

:

V ) a

V 1 +

y

Figure 30. Spondylolysis,

Spondylolisthesis

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OR29 Orthopaedic Surgery Toronto Notes 2023

Treatment

• non-operative

activity restriction, brace,stretching exercise

Superior articular

process (ear) Fracture

> I

ADULT ISTHMIC SPONDYLOLISTHESIS

1 A '

* v

^

f Inferior articular

Definition

• defect in pars interarticularis causing a forward translation or slippage of one vertebra on another,

usually at L5-S1, less commonly at L4-5

Mechanism

• degenerative (adults), traumatic, pathological, teratogenic

Transverse process process (nose) Eg

Figure 31. “Scottie dog” fracture

Clinical Features

• lower back pain radiating to buttocks relieved with sitting

• neurogenic claudication

• L5 radiculopathy

• Meyerding Classification (percentage of slip)

Investigations

• x-ray (AP, lateral, oblique flexion-extension views), MRI

Treatment

• non-operative

activity restriction, bracing, NSAIDs

• operative

Table 18. Classification and Treatment of Spondylolisthesis

Class Percentage of Slip Treatment

0-25\ Symptomatic operative lesion only lor intractable pain

Same ns above

Decompression lorspondylolisthesis end spinal fusion

Same as above

Same as above

1

2 2S SO

3 sore

4 re-ioo

s »100

Specific Complications

• may present as cauda equina syndrome due to roots being stretched over the edge of L5 orsacrum

Pelvis

Pelvic Fracture

Mechanism

• young: high energy trauma, either direct or by force transmitted longitudinally through the femur

• elderly: low energy trauma,fall from standing height

• lateral compression, vertical shear,or anteroposterior compression fractures

-Anterior Clinical column Features

• pain,inability to bear weight

• local swelling, tenderness

• abnormal lower extremity positioning: external rotation of one or both extremities,limb-length

discrepancy

• pelvic instability

i Posterior

-pr.

column S

3.

A

V

Investigations

• x-ray:AP pelvis,inlet and outlet views,)udet views (visualizes obturator and iliac oblique when

acetabular fracture suspected)

6 cardinal radiographic landmarks of the acetabulum:ilioischial line, iliopectineal line,teardrop,

weight bearing roof, posterior rim,anterior rim

CT scan useful for evaluating posterior pelvic injury and acetabular fracture (if stable)

may see contrast blush (indicating active bleeding)

• assess genitourinary injury (rectal exam,vaginal exam, hematuria, blood at urethral meatus)

if involved, the fracture is considered an open fracture

©

Figure 32. Pelvic columns

n

i j

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OR30 Orthopaedic Surgery Toronto Notes 2023

Classification

Table 19. Tile Classification of Pelvic Fractures Possible Radiological Findings

• Pubic rami fractures: superior/inferior

• Pubic symphysis diastasis:common

in AP compression (N

_

5 mm)

• Sacral fractures: common in lateral

compression

• SI joint diastasis: common in AP

compression (N*M mm)

• Disrupted anterior column

(iliopectineal line) or posterior

column (ilioischial line)

• “Teardrop" displacement: acetabular

fracture

• Iliac,ischial avulsion fractures

• Displacement of the major fragment

superior (VS), open book (APC).

bucket handle (LC)

Type Stability Description

Rotationally stable

Vertically stable

A1:fracture not involving pelvic ring|i.e.avulsion or iliac wing fracture)

A2: minimally displaced fracture of pelvic ring je.g.ramus fracture)

A3:transverse sacral or coccygeal fracture

B1:open book (external rotation)

62: lateral compression

-ipsilateral

62 1:with anterior ring rolation/displacemenl through ipsilateral rami

62-2: with anterior ring rolation/displacemenl through non ipsilateral rami (bucket-handle )

63: bilateral

Cl:unilateral

C1-1:iliac fracture

C1-2:sacroiliac fracture-dislocation

C1-3:sacral fracture

C2: bilateral with 1side type 8 and1side type C

C3:bilateral both sides type C

A

Rotationally unstable

Vertically stable

6

C Rotationally unstable

Vertically unstable

Treatment

• ABCDEs

• emergency management

IV fluids/blood

pelvic binder/sheet

± pre-peritoneal packing

externa] fixation vs. emergent angiography/embolization

± laparotomy (if EAST/DHL positive)

• non-operative treatment: protected \VB

indication:stable fracture (e.g. elderly patient with fracture sustained in fall from standing)

• operative treatment: OKIE

• indications

unstable pelvic ring injury

symphysis diastasis >2.5 cm

open fracture

Specific Complications (seeGeneral FractureComplications, 0R7 )

• hemorrhage (life-threatening)

• injury to rectum or urogenital structures

• obstetrical difficulties,sexual and voiding dysfunctions

• persistent SI joint pain

• post

-traumatic arthritis of the hip with acetabular fractures

• high-risk of DVT/PE

Stable avulsion fracture

Open book fracture

Hip

Hip Dislocation Typo C

Unstable vertical fracture -

•full trauma survey (see Emergency Medicine. Patient Asscssmcnt/Managemcnt, FR2)

•examine for neurovascular injury prior to open or closed reduction

•high index of suspicion for associated injuries

•reduce hip dislocations within 6 h to decrease risk of AVN of the femoral head

•hip precautions (no extreme hip flexion, adduction, internal or external rotation) for 6 wk postreduction

•see Hip Dislocation Post-Total Hip Arthroplasty, OR32

Figure 33. Tile classification of pelvic

fractures

Up to 50% of patients with hip

dislocations suffer fractures elsewhere

at the time of injury ANTERIOR HIP DISLOCATION

•mechanism: posteriorly directed axial loading of the femur with hip widely abducted and externally

rotated

•classified into inferior (flexion, abduction, external rotation ) and superior (extension and external

rotation)

•clinical features:shortened, abducted, externally rotated limb

•treatment

closed reduction under conscioussedation/GA

post-reduction Cl to assess joint congruity

3. External rotation

2. Internal rotation

!raction

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L J

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© Janet SM Chan 2009

Figure 34. Rochester method +

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0R31 Orthopaedic Surgery Toronto Notes 2023

POSTERIOR HIP DISLOCATION

• most frequent type of hip dislocation (90%)

• mechanism:severe axial load to knee with hip flexed and adducted

• e.g. knee into dashboard in MVC

• clinical features:shortened, adducted,internally rotated limb

• x-ray:affected femoral head will appear smaller than unaffected femoral head

• Thompson and Hpstein classification - posterior dislocation:

I -with no or minor posterior acetabular wall fracture

II -with large posterior acetabular wall fracture

III - with comminuted acetabular fracture

IV -with acetabular floor fracture

V - with fracture of femoral head

• treatment

• closed reduction under conscious sedation/GA only if no associated femoral neck fracture or

ipsilateral displacement

• GRIT if unstable, intra-articular fragments, orsignificant displacement

post-reduction CT to assess joint congruity and fractures

COMPLICATIONS FOR ALL HIP DISLOCATIONS

• post-traumatic OA

• AVN of femoral head

• associated fractures(e.g. femoral head, neck, or shaft)

• sciatic nerve palsy in 25% (10% permanent)

• HO

• thromboembolism - DVT/PH

Hip Fracture

General Features

• acute onset of hip pain after a fall

• unable to weight-bear

• shortened and externally-rotated leg

• painful ROM

X-Ray Features of Subcapital Hip

Fractures

• Disruption of Shenton’s line (a

radiographic line drawn along

the upper margin of the obturator

foramen,extending along the

inferomedial side of the femoral

neck)

• Altered neck-shaft angle (normal is

120-130")

I

DVT Prophylaxis in Hip Fractures

LMWH (i.e. enoxaparin 40 mg SC once

daily), fondaparinux,low dose heparin

on admission,do not give <12 h before

surgery

Source:UptoDat*

•Prevention ol venous

Ihrcmbcefnbcfam inadult orthopedic surgical pitienb.

tnouparin(IOYHMM)US FIX approved product

information https.

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Cl Intertrochanteric m

fracture

Subtrochanteric

fracture

Normal joint Subcapital fracture 0

Figure 35. Subcapital,intertrochanteric, and subtrochanteric hip fractures

Table 20. Overview of Hip Fractures

Fracture Type Definition Mechanism Investigations Treatment Complications

Young: MVC, fall from X- Ray: AP hip, AP

height pelvis, cross fable

Elderly: fall from lateral hip

standing,rotational

force

Femoral Neck See table 21. OH 32

(Subcapital)

Intracapsulat DV1. non- union. AVN.

dislocation

AVN of Femoral Head

• Distal to proximal blood supply along

femoral neck to head (medial and

lateral femoral circumflex arteries)

• Susceptible to AVN If blood supply

disrupted

• Etiology:femoral neck fracture,

chronic systemic steroid use, SCFE.

Legg-Calvd-Perthes. SLE,RA

Intertrochanteric

Stable:intact

posteromedial cortex and lesser trochanters Oirect or indirect

Unstable: non- inlacl and transitional bone force transmitted to

posteromedial cortex between the neck the intertrochanteric

and shall

Subtrochanteric Fracture begins at Young: high energy

or below the lesser trauma

trochanter and

involves the proximal bone *

fall,