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

+

Activate Windows

Go to Settings to activate Win

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

L J

+

Activate Windows

Go to Settingsto activate Windows.

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

ri

+

Activate Windows

Go to Settings to activate Windows.

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 +

Activate Windows

Go to Settingsto activate Windows.

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

iJ

+

Activate Windows

Go to Settings to activate Windows.

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

ri

L J

+

Activate Windows

Go to Settingsto activate Windows.

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)

j

+

Activate Windows

Go to Setting!

OR.lx Orthopaedic Surgery Toronto Notes 2023

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

ri

L J

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

Activate Windows

Go to Setttngsto activate Windows-

OR39 Orthopaedic Surgery Toronto Notes 2023

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

r n

L J

+

Activate Windows

Go to Settings to activate Windows.

OR10 Orthopaedic Surgery Toronto Notes 2023

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

Activate Windows

Go to Settings to activate Windows.

OR II Orthopaedic Surgery Toronto Notes 2023

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

+

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)