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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OR2H OrthopaedicSurgery Toronto Notes 2023
•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
t
ri
L J
,v
© 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.
1
vswrv.jccesvdatjrdi.gcrdrwgvatldj,
do(vilat>ei/20T7.D20164s110IM.pdl
F
-
-
-
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,
pathological fracture
Exlracapsular fracture Same as femoral neck X- Ray: AP hip, AP
between the greater fracture
Closedreduction
under lluoroscopy
then dynamic Inp
screw or IM nail
OVT. varus
displacement ol
proximal fragment,
malrotation, nonunion, failure of
fixation device
Malalignment,
non-union,wound
infection
pelvis, cross table
lateral hip
area
Closed/open
reduction under
fluoroscopy, then
IM nail
X- Ray: AP pelvis. API
lateral hip and lemur
Elderly: osleopenic
femoral shaft
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OR32 Orthopaedic Surgery Toronto Notes 2023
Table 21. Garden Classification of Femoral Neck Fractures
Type Displacement Extent Alignment Trabeculae Treatment
Comparative Effectiveness of Pain Management
Interventionsfor Hip Fracture:A Systematic
He view
Ann Intern Med 20l1;155(4):234-245
Study:Randoniied contro-ed trials|BCIs|
:
nonrandoniied controlled trials|non-tCIs|
:and
cohort studies of pain management techniques in
older adults afteracute hipfracture.
Conclusions: Nerve blockade seems to be effective
i reducing acute pam after hip fracture.Low-level
evidence suggeststhat preoperabve traction does not
reduce acute pain. Evidence was insufTicent on the
benefits and harms of many other interventions.
Internal fixation to prevent displacement
(valgus impacted fracture)
Internal fixation toprevent displacement
Young:ORIF
Elderly:hemi .‘total hip arthroplasty
Young:ORIF
Elderly:hemi-.'
total hip arthroplasty
I
"
None Incomplete" Valgus or neutral Disrupted
Complete
Complete
II Aligned
Disrupted
None Neutral
III Partial Varus
IV Complete Complete Varus Disrupted
Figure 36. Garden classification of femoral neck fractures
Arthritis of the Hip
Etiology
• OA,inflammatory arthritis,post-traumatic arthritis, late effects of congenital hip disorders, or septic
arthritis
Clinical Features
• OA: pain (groin, medial thigh) and stiffness aggravated by activity, relieved with rest
• inflammatory RA: joint pain, morning stiffness >1 h, multiple jointswelling, hand nodules
• decreased ROM (internal rotation is usually lost first)
• crepitus
• leg length discrepancy (secondary to loss of cartilage and /or bone in affected joint)
• ± fixed flexion contracture leading to apparent limb shortening (Thomas test)
• ± Trendelenburg sign and/or gait (limp)
Investigations
• x-ray:W B views of affected joint
OA findings - LOSS: Loss of jointspace.Osteophytes,Subchondral sclerosis, Subchondral cysts
inflammatory (e.g.RA):osteopenia, periarticular erosions, concentric joint space narrowing
• blood work: ANA, RF
Treatment
• non-operative
• weight loss, activity modification, physiotherapy, analgesics, anti
-inflammatory medications,
walking aids
• operative
• indication: advanced disease with symptomssignificantly affecting quality of life
realign = osteotomy;replace = arthroplasty",fuse = arthrodesis
• complications with arthroplasty: component loosening, dislocation. HO, thromboembolism,
infection, neurovascular injury,limb length discrepancy, persistent limp, periprosthetic fracture
• arthroplastv isstandard of care in most patients with hip arthritis
Hip Dislocation Post-Total Hip Arthroplasty
•occurs in 1-4% of primary1HA and 10-16% of revision THAs
•common indication for early revision
•risk factors: post-traumatic arthritis, revision surgery,substance use, cognitive impairment
(dementia),spastic or neuromuscular disease,posteriorsurgical approach,spinal fusion
Mechanism
•flexion, adduction, and internal rotation (posterior dislocation),or extension and external rotation
(anterior dislocation)
r n
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OR33 Orthopaedic Surgery Toronto Notes 2023
Investigations
• x-ray: AP pelvis, AP and lateral views of the hip
DVT Prophylaxis in Elective THA
(continue 10-35d postoperative)
OOACs (e.g. rlvaroxaban), ASA,
(ondaparinux, low molecular weight
heparin,or warfarin
Treatment
• non-operative
• closed reduction and immobilization
• operative
indication: recurrent dislocations, associated polyethylene wear, malalignment, hardware failure,
or infection
revision THA
infected hip (infection can cause hip instability)
Complications
• sciatic nerve palsy in 25% (10% permanent)
• HO
• infection
Femur
Femoral Diaphysis Fracture
Mechanism
• high energy trauma (MVC, fall from height, gunshot wound)
• pathologic as a result of malignancy,osteoporosis, bisphosphonate use
• in children, can result from low energy trauma (spiral fracture)
always consider the possibility of non-accidental trauma (child abuse)
Clinical Features
• shortened, externally rotated leg (if fracture displaced)
• inability to weight-bear
• often open injury, always a Gustilo Ill (see Table 6,OR10)
• Winquist and Hansen classification
Investigations
• x-ray:AP pelvis, AP, and lateral views of the hip,femur, knee
Treatment
• non-operative (paediatric, uncommon in adults)
possible indication: non-displaced femoral shaft fractures in patients with significant
comorbidities who are non-ambulatory
most femoral shaft fractures require fixation asthis is a life-threatening injury
• operative
OKI!' with anterograde IM nail (most common) or retrograde IM nail or with plate and screw
fixation
• external fixation may be used initially (e.g. unstable patients or polytrauma patients)
early mobilization and strengthening
Complications
• blood loss
• infection
• fat embolism leading to ARDS
• VTE
• malrotation, leg length discrepancy
• malunion/nonunion
It is important to rule out ipsilateral
femoral neck fracture, asthey occur in
2-6% of femoral diaphysisfractures and
are reportedly missed in 19-31% of cases
Associated Injuries
• extensive soft tissue damage
• ipsilateral hip dislocation/fracture (2-6%)
. nerve injury
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0R31OrthopaedicSurgery Toronto Notes 2023
Distal Femoral Fracture
•fractures from articularsurface to 5 cm above metaphyseal flare
Mechanism
•direct high energy force or axial loading (may occur due to fall from standing in osteoporotic patients)
•three types:extra articular, partial articular, complete articular
Clinical Features
•extreme pain worse with knee motion
•knee effusion (hemarthrosis)
• neurovascular deficits can occur with displaced fracture
Investigations
•x-ray: AP and lateral views
•AB1 if diminished pulses or concern for vascular injury, angiography (AB1 <0.9)
•CT: to evaluate the articularsurface and degree of comminution
Supracondylar Condylar
1
2
'
Intercondylar Treatment
•non-operative (uncommon)
indication: non-displaced extra-articular fracture, poor surgical candidate
hinged knee brace
•operative
indication:displaced fracture,intra-articular fracture
« ORIT with plate or retrograde 1M nail fixation
•knee arthroplasty with distal femoral replacement prosthesis (elderly,low demand patient with
comminuted fracture)
•early mobilization
Figure 37. Distal femoral fractures
Specific Complications (seeGeneral FractureComplications,OR7)
•vascular injury
•nerve injury
•angular deformities/malunion
•post-traumatic arthritis
1. Posterior horn of lateral meniscus
2. Anterior horn of lateral meniscus
3. PCL
4. ACL
5. Posterior horn of medial meniscusij
6. Anterior horn of medial meniscus 0
^
i
L
Figure 38. Diagram of the right tibial Knee plateau
Patellar Proximal patellar
tendon .
Patella .
mtv Evaluation of Knee
<
Common Complaints
• locking, instability, and swelling
• suggests intra-articular pathology such as a torn meniscus or cruciate ligament injury
• pseudo-locking: limited ROM without mechanical block
• muscle spasm after injury, arthritis
• painful, audible clicking
• torn meniscus, cartilage injury, or floating body
ACL '
CL
hal lateral N
meniscus lomscus
LCL
U sta
patellar Special Tests of ment the Knee
• anterior and posterior drawer tests(Figure 40,OR35)
• demonstratestorn ACL and PCL,respectively
• knee flexed at 90°,foot immobilized, hamstrings relaxed
anteriorsubluxation of the tibia (anterior drawer test),suggests ACL injury
posterior subluxation of the tibia (posterior drawer test),suggests PCL injury
anterior drawer test for ACL:3.8 positive likelihood ratio, 0.30 negative likelihood ratio
posterior drawer test for PCL: 16.2 positive likelihood ratio,0.2 negative likelihood ratio
• Lachman test
• demonstrates tom ACL
hold knee in 20-30°flexion,stabilizing the distal femur with one hand
• with contralateral hand, attempt tosublux tibia anteriorly on femur
similar to anterior drawer test,more reliable due to less muscularstabilization
for ACL:25.0 positive likelihood ratio,0.1 negative likelihood ratio
• pivotshiftsign
• demonstrates tom ACL
start with the knee in extension
• requires relaxed patient, best performed in patient underspinal or general anesthesia
internally rotate foot,slowly flex knee while palpating and applying a valgus force
• if incompetent ACL, tibia will sublux anteriorly on femur at start of maneuver. During flexion, the
tibia will reduce and externally rotate about the femur (the "pivot”)
ICl iDM
'
c .- ul
C lrrm Stamshavikaya 2012 j
Figure 39. Knee ligament and
anatomy
6 Degrees of Freedom of the Knee
• Flexion and extension
• External and internalrotation
• Varus and valgus angulation
• Anterior and posterior glide
. Medial and lateral shift
. Compression and distraction n
LJ
Onphysical exam of the knee,do not
forget to evaluate the hip +
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OR35 Orthopaedic Surgery Toronto Notes 2023
reverse pivot shift (start in flexion,externally rotate, apply valgus,and extend knee) suggests
posterolateral corner injury
composite assessment for ACL:25.0 positive likelihood ratio,0.04 negative likelihood ratio
composite assessment for PCL- 21.0 positive likelihood ratio, 0.05 negative likelihood ratio
• posteriorsag sign
suggests torn PCL
• posterior tibial subluxation may lead to false positive anterior drawer sign
• flex knees and hips to 90°, hold ankles and knees
view from the lateral aspect
visible posterior tibial sag when compared to uninjured knee suggests PCL injury
• collateral ligament stress test (varus/valgus instability)
• palpate ligament for “opening"
of joint space while testing
• with knee in full extension, apply valgus force to test MCL, apply varus force to test LCL
• repeat tests with knee in 20°flexion to relax joint capsule
opening in 20°flexion suggests MCL injury (valgus force), LCL injury (varusforce)
opening in 20° of flexion and full extension suggests MCL, cruciate, and joint capsule damage
(valgus force)
• testsfor meniscal tear
• joint line tenderness
joint line pain when palpated
palpate medial and lateral joint line and observe patient for signs of pain
for meniscal tear:0.9 positive likelihood ratio, 1.1 negative likelihood ratio
crouch compression test
joint line pain when squatting (anterior pain suggests patellofemoral pathology)
McMurray’stest
with knee in flexion,palpate joint line for painful pop or click
lateral meniscustear exam:internally rotate foot,apply varusstress, and extend knee
medial meniscustear exam:externally rotate foot,apply valgusstress,and extend knee
for meniscal tear:1.3 positive likelihood ratio,0.S negative likelihood ratio
Anterior drawer test
Posterior drawer test
Figure 40.Anterior and posterior
drawer test
Examination for medial
meniscal tear
X-Rays
• AP standing, lateral
• skyline:tangential view with knees flexed at 45°to see patellofemoral joint
• 3-footstanding view:useful in evaluating leg length and varus/valgus alignment
• Ottawa Knee Rules (see hmergencv Medicine. LR16)
Examination for lateral
meniscal tear
Cruciate Ligament Tears Figure 41. McMurraytest
• ACL tear much more common than PCL tear
Table 22. Comparison of ACL and PCL Injuries
Anterior Cruciate Ligament PosteriorCruciate Ligament
Originates from medial wall of lateral femoral condyle,
inserts at the anteromedial and posterolateral
intercondyloideminence of the tibialplateau
Non contact (more commoa):sudden deceleration with
change of direction or landingmaneuver (anterior tibial
translation with valgus knee stress)
Contact:direct blow tolateral aspect of knee
Audible "
pop"
Immediate swelling
Knee"giving way"
Inability to continueactivity
Effusion (bemarthrosis)
Posterolateral joint line tenderness
Positive anterior drawer
Positive lachmann
Pivot shift
lest for collateral ligament andmeniscal injuries
look for second fracture on stay (commonly associated
with ACL injuries)
Stable knee with minimal functional impairment:
immobilization 2-4 wk with early ROM and strengthen ng reconstruction
Nigh demandlifestyle:ligament reconstruction
Originates at the lateral wall of medial femoral condyle,inserts
at the posterior intercondyloid eminence of the tibial plateau
Anatomy
Mechanism Non contact (less common):hyperflexion or hyperextension
Contact:sudden posterior displacement ol tibia when knee is
fleied or hyperextended|e.g.dashboard MVC injury)
History Audible'pop- Figure 42. T1MRI of torn ACL and
immediate swelling
Pain withpush off
Cannot descend stairs
Effusion (hemarthrosis)
Anteromedial jointline tenderness
Positive posterior drawer
Reverse pivot shift
Other ligamentous,bony injuries
PCL
Physical
Treatment Unstable knee or young person/highdemand lifestyle: ligament
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OR36 OrthopaedicSurgery Toronto Notes 2023
Collateral Ligament Tears
Mechanism
• valgusforce to knee = MCL tear
• varusforce to knee = LCL tear
O’Donoghue'5 Unhappy Triad
• ACL rupture
• MCL rupture
• Meniscal damage (medial andor
lateral)
Clinical Features
• stvelling/effusion
• tenderness above and below joint line medially (MCL) orlaterally (LCL)
• joint laxity with varus(LCL) or valgus (MCL) stresstests
• laxity with endpoint suggests partial tear
• laxity with no endpoint suggests a complete tear
• test for other injuries (e.g. O'Donoghue'
s unhappy triad), common peroneal nerve injury
Investigations
• x-ray:AP and lateral views of the knee;MR1
Treatment
• non-operative
partial tear:immobilization x 2-4 wk with early ROM and strengthening
complete tear:immobilization at 30“ flexion
• operative
indication:multiple ligamentousinjuries
• surgical repair of ligaments
Meniscal Tears
•medial tear much more common than lateral tear
Mechanism
•twisting force on knee when it is partially flexed (e.g.stepping down and turning)
•requires moderate trauma in young person, but only mild trauma in elderly due to degeneration
Clinical Features
•immediate pain,difficulty WB, instability,and clicking
•increased pain with squatting and/or twisting
•effusion (hemarthrosis) with insidious onset (24-48 h after injury)
•joint line tenderness medially or laterally
•locking of knee (if portion of meniscus mechanically obstructing extension)
Investigations
•MR1,arthroscopy
Treatment
•non-operative
indication:not locked, degenerative tearin the presence of osteoarthritis
ROM and strengthening (NSAIDs)
•operative
indication:locked knee is a surgical emergency (i.e.patient cannotfully extend knee,due to
mechanical block) or failed non-operative treatment
arthroscopic repair/partial meniscectomy generally indicated for younger patients with
traumatic/non-degenerative meniscus pathology
Meniscal repair may be performed in
select patientsif tear is peripheral with
good vascularsupply is a longitudinal
tear, and1-4 cm in length
Partial meniscectomy may be performed
when tears are not amenable to repair
(complex,degenerative,radial)
Tissue Sourcesfor ACL Reconstruction
• Hamstring autograft
• Middle1/3 patellar tendon (bonepatellar-bone autograft)
• Allograft (e.g.cadaver)
Popliteal Cysts
•synovial fluid-filled masslocated in the popliteal fossa (i.e. Baker’s cyst)
Etiology
•classified as primary (distension of the bursa with no communication to joint) orsecondary
(communication between bursa and joint, bursa fills with articular fluid)
•primary cysts are usually congenital in children,while secondary are acquired from traumatic injury
or degenerative/inflammatory joint disease in adults
Clinical Features
•usually asymptomatic bulge on the posterior aspect of the knee
•usually located between the semimembranosus and medial head of gastrocnemius
•may cause local tightness, restricted range of motion, or posterior knee pain
•symptoms may worsen with physical activity
•for secondary
- popliteal cysts,symptoms are more associated with the underlying condition of the
knee
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OR37 Orthopaedic Surgery Toronto Notes 2023
Investigations
• clinical diagnosis is often sufficient
• ultrasonography can be used to identify'cyst and its relation to adjacent soft tissue structures
• knee x-ray to assess for joint abnormalities that may be associated with the cyst
• MRI allows for clearest visualization but this is only indicated to plan for surgery, when an underlying
knee pathology such as a meniscal tear issuspected,or when the diagnosisis uncertain after
ultrasonography
Treatment
• asymptomatic cysts do not require treatment
• non-operative
indication:initial treatment forsymptomatic secondary popliteal cysts
identify and treat underlying cause
• rest, NSAlDs, cold packsfor symptomatic treatment
image guided aspiration and intra-articularsteroid injection may offer temporary relief
Quadriceps/Patellar Tendon Rupture
Mechanism
• sudden forceful contraction of quadriceps during an attempt to decelerate
• eccentric loading of the extensor mechanism, usually with the foot planted and the knee slightly bent
• DM,SLK,RA,steroid use, renal failure on dialysis
• more common in obese patients with pre-existing degenerative changes in tendon
Clinical Features
• inability to extend knee or weight-bear
• tenderness and/or palpable gap at rupture site
• possible audible “pop"
• patella in lower or higher position with palpable gap above or below patella, respectively
• may have an effusion
Patella alta -
high riding patella
Patella baja -
low riding patella
investigations
• ask patient to perform straight leg raise (unable to with complete rupture, although may be inhibited
by pain,if unclear, can reassessin 10 d)
• knee x-ray to rule out patellar fracture,MRI to distinguish between complete and partial tears
• lateral view:patella alta with patellar tendon rupture, patella baja with quadriceps tendon rupture
Treatment
• non-operative
indication:incomplete tears with preserved extension of knee
immobilization in brace, followed by progressive physiotherapy
• operative
indication:complete ruptures with loss of extensor mechanism function
• early surgical repair: better outcomes compared with delayed repair (>6 wk post-injury)
• delayed repair complicated by quadriceps contracture, patella migration, and adhesions
Dislocated Knee
Mechanism
• high energy trauma more common (i.e. MVC), low energy (sport-related), or ultra-low velocity
(obesity)
• by definition, caused by tears of multiple ligaments Schenck Classification
Typel
Singe cruciate (ACl or PCL) and single
collateral (MCLorPLC)
Type 2
Injury to ACL and PCL
Type 3-M
Injury to ACL. PCL. and MCL
Type 3-L
Injury to ACL,PCL. and PLC
Type 4
Injury to ACL PCL. MCL. LCL
Type 5
Multiliqamcnlous injury associated with
fracture/dislocation of knee
Clinical Features
• knee instability
• effusion
• pain
• ischemic limb, neurological deficit, or compartment syndrome
Classification
• Kennedy classification (based on direction of tibial displacement) classified by relation of tibia with
respect to femur
• anterior, posterior,lateral,medial, rotary
• Schenck classification (based on pattern of ligamentous injury)
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Investigations
• x-ray: AP and lateral
associated radiographic findings may include extensor mechanism injury, tibial plateau fracture
dislocations, proximal fibular fractures, and/or avulsion of fibular head
• assessment of NVS:
AB1(abnormal if <0.9)
arteriogram or CT angiogram if abnormal vascular exam (such as abnormal pedal pulses or
abnormal AB1)
detailed neurologic assessment, paying close attention to the peroneal nerve (foot drop is
common)
Treatment
• urgent closed reduction and immobilization
can be complicated by interposed soft tissue (posterolateral variant)
• assessment and management of neurovascular injuries and compartment syndrome
• emergent operative repair if vascular injury, open injury,irreducible or grossly unstable dislocation,
or compartmentsyndrome
• ligament reconstruction to restore knee stability is typically performed in a delayed fashion
• early, comprehensive physiotherapy
Specific Complications
• high incidence of associated injuries (tibia/fibula fracture, extensor mechanism injury)
• popliteal artery injury
• peroneal nerve injury
• chronic: instability,stiffness, post-traumatic arthritis
Patella
Patellar Fracture Undisplaced
Mechanism
• direct impact injury:fall, MVC (e.g. dashboard)
• indirect trauma: rapid knee flexion against contracted quadriceps (rare)
Lowor/upper pole Comminuted
displaced © ‘QiClinical Features
• marked tenderness
• inability to extend knee orstraight leg raise
• proximal displacement of patella
• patellar deformity
• ± effusion/hemarthrosis
Transverse Osteochondral
Figure 43. Types of patellar fractures
Investigations
• x-rays: AP, lateral,skyline
• do not confuse with bipartite patella: congenitally unfused ossification centers with smooth margins
on x-ray at superolateral corner (most often)
Treatment
• non-operative
• indication:
non or minimally displaced (step-off <2-3 mm and fracture gap <1-4 mm)
intact extensor mechanism
• straight leg immobilization 1-4 wk with removable brace/splint, WB as tolerated
• progress in flexion after 2-3 wk
• physiotherapy: quadriceps strengthening when pain hassubsided
• operative
indication:
>2 mm articular step-off, >3 mm fragment separation, comminuted, disrupted extensor
mechanism,open fracture
GRIP, if comminuted may require partial/complete patellectomy
- goal:restore extensor mechanism with maximal articular congruency
Complications
• Symptomatic hardware
• Loss of reduction
• Osteonecrosis
• Hardware failure
• Knee stiffness
• Nonunion
• Infection
• Post
-traumatic arthritis
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Patellar Dislocation
Mechanism
• usually a non-contact twisting injury with knee extended, externally rotated tibia and fixed foot
• lateral displacement of patella after contraction of quadriceps at the start of knee flexion in an almost
straight knee joint
• direct blow (e.g. knee/helmet to knee collision)
J
Increased
-sign:Associated
lateral translation
with patella alta; + in extension
which pops into the patcllofcmoral
groove as the patella engages the
trochlea early in flexion
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Risk Factors
• 2nd-3rd decade of life, female
• Q-angle (quadriceps angle) S15°(males), >20° (females)
• miserable malalignment syndrome:femoral anteversion,genu valgum, external tibia) torsion/
pronated feet
• high-riding patella (patella alta)
• weak vastus medialis
• ligamentouslaxity (eg. Ehlers-Danlos, Marfan Syndrome)
ASIS
Clinical Features
• knee catches or gives way with walking
• severe pain, tenderness anteromedially from rupture of capsule
• weak knee extension or inability to extend leg unless patella reduced
• positive patellar apprehension test
• passive lateral translation results in guarding and patient apprehension
• often recurrent, self-reducing
• concomitant MCL injury
• J-sign
Investigations
• x-rays:AP, lateral, and skyline views of the knee
• check for fracture of medial patella (most common) and lateral femoral condyle
• consider M It I in young patient if concerned for osteochondral injury/loose body
Q-angle
Central
patella I -
/
<3
'
Tibial I
tuberosity ®
Treatment
• non-operative first
closed reduction
NSAlDs,activity modification, and physical therapy
short-term immobilization for comfort, then 6 wk controlled motion
progressive WB and isometric quadricepsstrengthening
• operative
indication: if recurrent or loose bodies present
• chronic instability:surgical tightening of medial capsule and release of lateral retinaculum,
possible medial patcllofemoral ligament (MPl'
L) reconstruction
patellar dislocation associated with congenital deformity: tibial tuberosity transfer
Figure 44.0-angle
The angle between a vertical line
through the patella and tibial
tuberosity and a line from the ASIS
to the middle patella;the larger the
angle,the greater the amount of
lateral force on the knee (normal
<20')
Patellofemoral Syndrome
•syndrome of anterior knee pain associated with idiopathic articular changes of patella
Risk Factors
•malalignment causing patellar maltracking (Q-angle S20g
,genu valgus)
•female > male, physically active, <40 y/o
•excessive knee strain (athletes, especially running and weight training)
•recurrent patellar dislocation,ligamentous laxity, post-trauma
•deformity of patella or femoral groove
Mechanism
•softening, erosion, and fragmentation of articular cartilage, predominantly medial aspect of patella
Clinical Features
•diffuse pain in peri- or retropatellar area of knee (major symptom)
exacerbated by prolonged sitting (theatre sign),strenuous athletic activities,stair climbing,
squatting,or kneeling
•insidious onset and vague in nature
•sensation of instability, pseudolocking
•pain with compression of patella with knee ROM or with resisted knee extension
•swelling rare, minimal if present
•palpable crepitus
Investigations
•x-ray:AP, lateral, and skyline views of the knee - may find chondrosis, lateral patellar tilt, patella alta/
baja,orshallow sulcus
•CT:patellofemoral alignment, rule out fracture
•MR1:best to assess articular cartilage
Pain with firm compression of
patella into medial femoral groove
is pathognomonic of patellofemoral
syndrome
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Treatment
• non-operative
• continue non-impact activities; rest and rehabilitation
NSAlDs
• physiotherapy: vastus medialis, core, and hip strengthening
• operative
indication:failed non-operative treatment
« arthroscopic debridement
lateral release of retinaculum
patellar realignment (e.g. anterior tubercle elevation)
Tibia
Tibial Plateau Fracture
Mechanism
• varus/valgusload ± axial loading (e.g. fall from height)
• femoral condyles driven into proximal tibia
• can result from minor trauma in those with osteoporosis Schatzker Classification
Type Description Clinical Features
I lateral plateau split fracture
II lateral split-depressed fracture
III Lateral pure depression fracture
IV Medial plateau fracture
V Bicondylar plateau fracture
VI Bicondylar with metaphincaVdidpljseal
disassociate
• frequency:lateral > bicondylar > medial
• medial fractures require higher energy - often have concomitant vascular injuries
• knee effusion,swelling
• inability to bear weight
• risk of compartment syndrome, meniscal tears, and neurovascular injuries
• Schatzker classification
Investigations
• x-ray: AH, lateral, and oblique views
• CT: preoperative planning, identify articular depression and comminution
• ABI if any differences in pulses between extremities
Treatment
• non-operative
indication:# depression is <3 mm
protected WB with immobilization in a splint for 6-12 wk with early progressive ROM
• operative
indication:articularstep-off >3 mm, condylar widening >5 mm, open #s, neurovascular injury,
significant varus/valgus instability (>15°)
• OR11-
'
often requiring bone grafting to elevate depressed fragment
Specific Complications (seeGeneral l-
'
nactiire Complications, OR7)
• post-traumatic OA
• meniscal lesions
Tibial Shaft Fracture
•most common long bone fracture and open fracture
Mechanism
•low energy'pattern:torsional injury
•high energy:including MVC,falls,sporting injuries
Clinical Features
•pain, inability to weight-bear, deformity
•open vs. closed
• neurovascular compromise
•compartment syndrome
Investigations
•x-ray:full length AH and lateral views
AF,lateral, and oblique views of ipsilateral knee and ankle
consider dedicated ankle x-rays or CTscan to rule out intra-articular extension of middle third or
distal tibia shaft fractures
n
L
Flgure 45. Tibial shaft fracture
treated with IM nail and screws
$ +
Tibial shaft fractures have high incidence
of compartment syndrome and are often
associated with soft tissue injuries
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Treatment
• non-operative
indication: closed and minimally displaced or adequate closed reduction
• long leg cast x 6-8 wk, convert to functional (patellar tendon hearing) brace for another 6 wk with
progressive W B
Danis-Weber Classification
• Based on level of fibular fracture
relative to syndesmosis
• Type A (infra-syndesmotic)
• Pure inversion injury, tibiofibular
syndesmosis remainsintact
• Avulsion of lateral malleolus below
plafond or torn calcaneofibular
ligament
• ± shear fracture of medial malleolus
• Type B (trans-syndesmotic)
• External rotation and eversion (most
common)
• ± avulsion of medial malleolus or
rupture of deltoid ligament
• Spiral fracture of lateral malleolus
starting at plafond
• Type C (supra-syndesmotk)
• Pure external rotation
• Avulsion of medial malleolus or torn
deltoid ligament
• t posterior malleolus avulsion with
posterior tibio fibular ligament
• Fibular fracture is above plafond
• Frequently tearssyndesmosis
• operative
• indication: displaced or open
if displaced and closed:ORIF with IM nail, plate and screws, or external fixator
if open: antibiotics,18,D, external fixation or IM nail, and vascularized coverage of massive soft
tissue defects
Specific Complications (seeGeneral Fracture Complications,OR7)
• significant incidence of compartmentsyndrome
• knee pain associated with infrapatellar IM nailing (>50% anterior knee pain)
• malunion, nonunion
• lack of soft tissue coverage secondary to open fracture may require furthersurgery for muscle flap
coverage
Ankle
Evaluation of Ankle and Foot Complaints
Special Tests
• anterior drawer: examinerstabilizes the tibia with one hand and attempts to displace the foot
anteriorly with the contralateral hand with the ankle held in neutral or plantar flexion
• talar tilt:foot isstressed in inversion and angle of talar rotation is evaluated
Ottawa Ankle and Foot Rules
(see Emergency Medicine. ER16)
X-rays are only required if:
Pain in the malleolar zone AND any of:
bony tenderness over posterior or tip of
lateral malleolus; OR bony tenderness
over posterior or tip of medial malleolus;
OR inability to weight bear both
immediately after injury and in the ER
X-Ray
• AP, mortise, and lateral views
• mortise view: ankle at 15° of internal rotation
gives true view of ankle joint
joint space should be symmetric with no talar tilt
• Ottawa Ankle and Foot Rules should guide x-ray use (see Emergency Medicine, ER16); nearly 100%
sensitivity
• ± CT to better characterize fractures
Ankle Fracture
Mechanism
• pattern of fracture depends on the position of the foot when trauma occurs
• classification systems
• Danis-Weber: based on location of main fibular fracture line relative to the syndesmosis
Lauge-Hansen: based on foot position and direction of applied stress/force
Norma ank e
Treatment
• non-operative
indication: non-displaced, Danis-Weber Type A, and some isolated undisplaced Danis-Weber
Type B
early protected WB in walking boot
• operative
• indications
fracture-dislocation
most Danis
-Weber Type B, and all T ype C
any talar displacement
displaced isolated medial or lateral malleolar fracture
trimalleolar (medial, posterior, lateral) fractures
displaced and large posterior malleolar fractures
« persistent medial clear space widening despite attempt at closed reduction and
immobilization 1. Posterior malleolus
2. Medial malleolus
open fracture/open joint injury
ORIF with plates and screws
ri
3. Deltoid ligament L J
4. Syndesmosis
5. Lateral malleolus
Complications
• risk of poor wound healing and deep infections (up to 20%) in patients with DM, particularly if
concomitant peripheral neuropathy
• postoperative stiffness
• malunion, nonunion
• post-traumatic arthritis
6. Calcaneofibular
ligament Type C
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