Results:At 24 months,mean reduction in IOP was 3.8 mmHg in 231patients assessed inIhe latanoprost group and

0.9 mmHg in230 patients assessed in the placebo group.Visual fieldpreservation was significantly longer in the

latanoprost group than in the placebo group.

Conclusions:There is preservation of Ihe visual field with an inlraocular-prcssurc -lowciing drug,latanoprost,in

patients with POAG.

UKGTS Lancet 2O15:385|9975):1295-304

DIABETIC RETINOPATHY

Effects of Medical Therapies on NEJM 2010:363:233-244

Retinopathy Progression InI2DM

Title:Effects of Medical Therapies on Retinopathy Progression in T 2DM

Purpose: To determine whether Intensive glyccmlc control,combination therapy for dysliprdcmia, andintensive

blood pressure control can limit the progression of DR in persons withI2DM.

Methods:Participants with T2DM at high-risk of cardiovascular disease were randomized to receive either intensive

or standard treatment for glycemia,dyslipidemia,or systolic blood-pressure control.Participants were evaluated for

Ihe effect of these interventions on Ihe progression of DR.

Results: Rales of progression of OR at 4 yr were 7.3% with intensive glycemia treatment vs.10.4% with standard

therapy;6.5% with fenofibratc for intensive dyslipidemia therapy vs.10.2% with placebo and10.4% with intensive

blood pressure therapy vs.8.8% with standard therapy.

Conclusions:Intensiveglycemic control andintensive combination treatment of dyslipidemia. but not intensive

blood pressure control,reduced the rale of DR .

Title:Risks ol progression of retinopalhy and vision loss related lo tight blood pressure control in type 2 diabetes

mellitus:UKPDS 69

Purpose:To determine the relationship between tight BP control and the different aspects of DR in patients with

T2DM.

Methods: 758 patients were allocated loa tight 8P control policy (<150/85) with angiotensin- converting enzyme

inhibitor or 3- blockers as Ihe main therapy;390 were allocated lo a less tight BP control policy (<180/105).

Results:There was a significantly higher microaneurysm count,hard exudates prevalence,and cotton wool spots in

the tight BP control group compared to the less tight BP control group.Patients with tight BP control were less likely

lo undergo photocoagulation. The cumulative incidence ofIhe end point of blindness in1eye was 18 /758 for the tight

8P control group compared with 12/390 lor Ihc less light BP control group.

Conclusions:High BP is detrimental to each aspect of diabetic retinopathy:a light BP control policy reduces Ihe risk

of clinical complications from diabetic eye disease.

UKPDS 69 ArchOphthalmol 2004;122(11):!631 40

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Trial Name Reference Clinical Trial Details

(DIRS 9 Ophthalmology 1991:98: 766 80 Title: Early photocoagulalion foi diabetic retinopathy. HORS report number 9.Early Treatment Diabetic Retinopathy

Study Research Group

Purpose: To evaluate the efficacy of argon laser photocoagulation in deterring the progression of early DR into more

advanced DR. as well as best lime to initiate treatment.

Methods:for patients with mild-to-severe non-proliferative or earlyproliferative DR in both eyes,one eye of each

patient was assigned randomly to early photocoagulation and the other to deferral of photocoagulalion (initiated as

soon as high-risk proliferative retinopathy was detected).Eyes selected for eaily photocoagulalion received one ol

four different combinations of scatter and focal treatment.

Results:Early treatment was associated witha smallreduction in the incidence of severe visual loss compared with

deferral of photocoagulation,but 5-year rates were low in both the early trealment and deferral groups|2.6%and

3.7%).Adverse effects of scatter photocoagulalion on visual acuity and visual field also were observed.

Conclusions:Scalier photocoagulalion isnot recommended lor eyes with mild or moderate nonproliferative diabetic

retinopathy but Is for more severe disease and shouldnot be delayed,focalphotocoagulalion is recommended for

eyes with macular edema,asit reduces the risk of visual loss.

NEUROPHTHALMOLOGY

Optic NeuritisTreatment trial NEJM1992: 326(9):581-8 Title:A Randomized.Controlled Trial of Corticosteroids in the Treatment of Acute Optic Neuritis

Purpose: To evaluate corticosteroids as treatment for oplic neuritis.

Methods:Patients with acute optic neuritis wererandomly assigned oral prednisone,intravenous

methylprednisolone followedby oral prednisone,or oral placebo.Visual function was assessed over a six-month

follow-up period.

Results: Visual function recovered faster In Ihe group receivingIntravenous methylprednisolone than in Ihe placebo

group;this was particularly true for thereversal of visual-held defects.The outcome in the oral-prednisone group

did not differ from that in the placebo group.In addition,the rale of new episodes of optic neuritis ineither eye was

higher in the group receiving oralprednisone,but not Ihe group receiving intravenous methylprednisolone.than in

the placebo group.

Conclusions:Intravenous methylprednisolone followed by oral prednisone speeds the recovery of visual loss due to

optic neuritis and results in slightly better vision at six months.Oral prednisone alone,as prescribed in this study,is

an ineffective treatmentand increases therisk of new episodes of optic neuritis.

Idiopathic Intracranial JAMA. 2014;311|16):16411651

Hypertension Treatment Trial

Title: Effect of Acelazolamide on Visual Function in Patients With Idiopathic Intracranial Hypertension and Mild Visual

loss

Purpose:To determine whether acelazolamide is beneficial inimprovingvision when added to a low-sodium weight

reduction diet in patients with Idiopathic Intracranial Hypertension (IIH) and mild visual loss.

Methods:Participants with IIH and mild visual loss who received a low- sodium weight-reduction diet were randomly

assigned acelazolamide or matching placebo.

Results:The mean improvement in visual loss was greater with acelazolamide than withplacebo. Mean

improvements in papilledema grade and vision-related quality of life were also observed with acelazolamide.

Conclusions:In patients with IIH and mild visual loss, the use of acelazolamide with a low-sodium weight-reduction

diet compared with diet alone resulted in modest improvement in visual field function.

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References

ACCORD Study Group;ACCORD Eye Study Group,Chew EY,Ambrosius Wl.Davis MO.elat.Eflects ot medical therapies on retinopathy progression in type 2 diabetes.NEJM 2010;363:233-244.

Age-Related Eye Disease Study Research Group.A randomized,placebo- controlled,clinicaltrial of high-dose supplementation with vitamins C and E,beta carotene,and zinc for age-related macular degeneration

and vision loss:AREDS report no.8.Arch Ophthalmol 2001;119:1417-1436.

Anderson DR. Normal TensionGlaucoma Study. Collaborative normal tension glaucoma study. Cur r Opin Ophthalmol 2003;14:6-90.

Arthur S.Cantor 16.Update on the role of alpha-agonists in glaucoma management.Eip Eye Res 2011;93:271-283.

Atlas of ophthalmology.Available from;www.atla5ophthalmology.com/atlas/frontpage.jsf.

Bagheri N. Wajda BN.The Wills eye manual:office and emergency room diagnosis and treatmentof eye disease,7lh ed.Wolters Kluwer,2017.

Beck RW.Cleary PA.Anderson MM Jr et al.A randomized,controlled trial of corticosteroids in the treatment of acute optic neuritis. The Optic Neuritis Study Group. N Engl J Med.1992;326(9):581 8.

Bhaoot H.Nagon S. 2arbin M.Post- traumatic infectious endophthalmitis. Surv Ophthalmol 2011;96:214- 251.

Bradford C.Basic ophthalmology for medical students andprimary care residents. 7th ed.San Francisco:AmericanAcademy of Ophthalmology.1999.

Buitendijk GHS.Schauwvlieghe AME.Vmgerling JR.et al.Antiplatelet and anticoagulant drugs do not affect visual outcome inneovascular age-related macular degeneration inthe BRAMD trial.Am JOphthalmol

2018;187:130-137.

CATT Research Group.Martin DF.Maguire MG,et al.Ranibizumab and bevacizumab for neovascular age- related macular degeneration.NEJM 2011;364:1897-1908.

Elman MJ. Bicssler NM.Oin H. et al. Eipanded 2- year follow up of ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser lor diabetic macular edema.Ophthalmology 2011:118:609 614.

Friedman N. Pineda R.Kaiser P. The Massachusetts eye and ear infirmary illustratedmanual of ophthalmology. Toronto:WB Saunders.1998.

Gal RL Vedula SS.Beck R.Corticosteroids for treating optic neuritis.Cochrane Database Syst Rev 2015:8:CD00H30.

Glanville J.Patterson J.McCool R.etal.Efficacy and safety of widely used treatments for macular oedema secondary to retinal vein occlusion;a systematic review.BMC Ophthalmol 2014:14:17.

Gupta D. Chen PP.Glaucoma. American Family Physician 2016;93(8|:668-74,

Haller JA,Bandello F.Belfort R Jr.etal. Randomized,sham-controlled trial oldexamethasone intravitreal implant inpatients with macular edema dueto retinal vein occlusion.Ophthal 2010:117:1134 1146.

Heijl A.Leske MC,Bengtsson B,et al.Reduction of intraocular pressure and glaucoma progression:results from theearly manifest glaucoma trial.Arch Opthalmol 2002:120:1268-1279.

Kanski JJ.Clinical Ophthalmology:Asystematic approach.6th ed.Oxford:Butterworth-Heinemann.2007.

Koland|ian NA. Wei C. Patel SP, et al.Delayed systemic recurrence of uveal melanoma.Am J Clin Oncol 2013:36:443 449.

lichlcr PR.Musch DC.Gilcspie 6W.cl al.Interimclinical outcomes in the collaborative initial glaucoma treatment study comparing initial treatment landomized to medications or surgery.Ophthal 2001:108:1943

1953.

lim CH.Turner A,lim BX.Patching for corneal abrasion.Cochrane Oatabase SystRev 2016;7:CD004764.

Maguire AM.High KA.Auricchio A,et al.Age-dependent effectsof RPE65 gene therapy for leber's congenital amaurosis:a phase1dose-escalation trial.Lancet 2009;374:1597-1605.

Mintz-Hrltncr HA. Kennedy KA.Chuang A2;BEAT ROP Cooperative Group.Efficacy olintravitreal bevacizumab lor stage 3*

retinopathy of prematurity. NEJM 2011;364|7):603 615.

Moore Dl. MacDonald HE.Canadian Paediatric Society, clal.Preventing ophthalmia neonatorum.Paediatr ChildHealth 2015:20:93 96.

Phulke S.Kaushik S,Kaur S,et al.Steroid induced glaucoma:an avoidable irreversible blindness. J Curr Glaucoma Prac 2017;11|2):67.

Plateroti P,Plateroti AM.Abdolrahimzadeh S,et al.Pseudoexfoliation syndrome and pseudoexfoliation glaucoma:a review of the literature with updates on surgical management.J.Ophthalmol.2015.

Pushker N. Tejwani LK.Bajaj MS,et al.Role of oral corticosteroids in orbital cellulitis.Am J Ophthalmol 2013:156:178-183.

Rayapudi S.Schwartz SG.Wang X.olal.Vitamin A and fish oils lor retinitis pigmentosa.Cochrane Oatabase Syst Rev 2013:12X0008428.

Sankar MJ.Sankar J.Chandra P.Anti vascular endothelial growth factor (VEGF) drugs for treatment olretinopathy of piematurity.Cochrane Database Syst Rev 2016:1X0009734.

Scuderi G,Contestabile MT.Scuderi Letal.Pigment dispersion syndrome and pigmentary glaucoma:a review and update.Int Ophthalmol 2019:39(7):1651-62.

Sheikh A.Hurwitz B,vanSchayck CP.el al.Antibiotics vs.placebo for acute bacterial conjunctivitis.Cochrane DatabaseSyst Rev 2012;9:CD001211.

Solomon SO.Lindsley K8.Krzystolrk MG.etal.Intravitreal Bevacizumab vs.Ranibizumab for treatment of neovascular age-related macular degeneration:findings from a Cochrane Systematic Review.

Ophthalmology 2016:123:70-77.

Stahl A.Lepore D,Fielder A. et al.Ranibizumab vs.laser therapy for the treatment of very low birlhweight Infants with retinopathy of prematurity (RAINBOW):an open-label randomised controlled trial,lancet

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Stein R.Stein H.Management of ocular emergencies.4th ed.Montreal:Mediconcept.2006.

Tasman W. Jaegar EA.Duane's ophthalmology, 2011ed. Philadelphia:lippincolt WilliamsiWilkins.2010.

University of Michigan Kellogg EyeCentre. Available from: www.kellogg.uinich.edu/lheeyeshavcit/indcx.html.

Vass C.Him C.SychaI.et al.Medical interventions for primary open-angle glaucoma and ocular hypertension.Cochrane Database Syst Rev 2007:4:CD003167.

Vedula SS.Krzystolik MG.Antiangiogenrc therapy with anti-vascular endothelial growth factor modalities for neovascular age-related macular degeneration.Cochrane Database Syst Rev 2008:2:CD005139.

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Weisbrod DJ,Fclfcli T.El-Delrawy SR . TorontoGuide to ClinicalOphthalmology for Physicians and Medical Trainees.1st ed.Edmonton:Brush Education.2019.

Wells JA. Glassman AR.Ayala AR.et al.Allibercepl.bevacizumab.or ranibizumab for diabetic macular edema: 2 year result froma comparative effectiveness randomized clinicalInal.Ophthal 2016:123:1351 1359.

Wilhelmus KR.Antiviral treatment and other therapeutic intervenbons for herpes simplex virusepithelial keratitis.Cochrane Database Syst Rev 2010;T2:CD002898.

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Wong AM.New concepts concerningthe neural mechanisms of amblyopia and their clinical implications.Can J Opthalmol 2012;47:399-409.

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Orthopaedic Surgery

John-Peter Bonello, Kalter Hali, Robert Koucheki, and Marc Manzo, chapter editors

Chunyi Christie Tan and Vrati Mehra, associate editors

Arjan S. Dhoot, HBM editor

Dr.Jeremy Hall, Dr. Paul Kuzyk, and Dr. )esse Wolfstadt,start'

editors

Acronyms

Basic Anatomy Review

Fractures -General Principles.

Fracture Description

Approach to Fractures

Fracture Healing

General Fracture Complications

Articular Cartilage

Orthopaedic X-Ray Imaging

Orthopaedic Emergencies

Trauma Patient Workup

Open Fractures

Cauda Equina Syndrome

Compartment Syndrome

Osteomyelitis

Septic Arthritis

Shoulder

Shoulder Dislocation

Rotator Curt Disease

Acromioclavicular Joint Pathology

Clavicle Fracture

Frozen Shoulder (Adhesive Capsulitis)

Humerus

Proximal Humeral Fracture

Humeral Shaft Fracture

Distal Humeral Fracture

Elbow.

Supracondylar Fracture

Radial Head Fracture

Olecranon Fracture

Elbow Dislocation

Epicondylitis

Forearm

Radius and Ulna Shaft Fractures

Monteggia Fracture

Nightstick Fracture

Galeazzi Fracture

Wrist

Colles'Fracture

Smith's Fracture

Complications of Wrist Fractures

Scaphoid Fracture

Hand

Spine

Fractures of the Spine

Cervical Spine

Thoracolumbar Spine

Pelvis

Pelvic Fracture

OR2 Knee

Evaluation of Knee

Cruciate Ligament Tears

Collateral Ligament Tears

Meniscal Tears

Popliteal Cysts

Quadriceps/Patellar Tendon Rupture

Dislocated Knee

Patella

Patellar Fracture

Patellar Dislocation

Patellofemoral Syndrome

Tibia

Tibial Plateau Fracture

Tibial Shaft Fracture

Ankle

Evaluation of Ankle and Foot Complaints

Ankle Fracture

Ankle Ligamentous Injuries

Foot

Talar Fracture

Calcaneal Fracture

Achilles Tendonitis

Achilles Tendon Rupture

Plantar Fasciitis

Bunions (Hallux Valgus)

Metatarsal Fracture

Paediatric Orthopaedics

Fractures in Children

Stress Fractures

Physeal Injury

Slipped Capital Femoral Epiphysis

Developmental Dysplasia of the Hip

Legg-Calve-Perthes Disease (Coxa Plana)

Osgood-Schlatter Disease

Congenital Talipes Equinovarus (Club Foot)

Scoliosis

Bone Tumours

Benign Active Bone Tumours

Benign Aggressive Bone Tumours

Malignant Bone Tumours

Common Medications

Landmark Orthopaedic Trials

References

OR34

OR2

OR5

,OR7 OR38

OR8

OR9

OR40

OR41

OR12

OR42

OR17

OR45 OR19

OR21

OR50

OR23

OR53

OR54

OR25 , OR54

OR25

OR29

Hip., OR30

Hip Dislocation

Hip Fracture

Arthritis of the Hip

Hip Dislocation Post-Total Hip Arthroplasty

Femur

Femoral Diaphysis Fracture

Distal Femoral Fracture

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0R2 Orthopaedic Surgery Toronto Notes 2023

Acronyms

DDH developmental dysplasia of the MCL medial collateral ligament

metatarsal

metatarsophalangeal

motor vehicle collision

neurovascular status

non-weight bearing

osteoarthritis

open reduction internal fixation

posterior cruciate ligament

pulmonary embolism

posterior interosseous nerve

posterolateral corner

RA rheumatoid arthritis

rotator cuff disease

range of motion

reflex sympathetic dystrophy

slipped capital femoral epiphysis

superior labrum,anterior

posterior

sensitivity

totalhiparthroplasty

total shoulder arthroplasty

weight-bearing

fracture

ABI ankle brachial index

AC acromioclavicular

ACL anterior cruciateligament

anterior interosseous nerve

anteroposterior

ARDS acute respiratory distress

syndrome

AVN avascular necrosis

CA coracoacromial

CC coracoclavicular

CRPS complex regional pain syndrome IM

C&S culture and sensitivity

r 3 M RCD

DRUJ distal radioulnar joint ROM

DVT deep veinthrombosis

EtOH ethanol/alcohol

FAI femoroacetabular impingement NWB

FOOSH fall on outstretched hand

GA general anesthetic

HO heterotopic ossification

l&D incision and drainage

intramedullary

LCL lateral collateral ligament

MTP

All. MVC RSD

AP NVS SCFE

SLAP

OA

ORIF SN

PCI THA

PE TSA

PIN WB

PIC t

Basic Anatomy Review

C5 ,oC7

C6 28

C7

'

T1

C8

iT1

Coracobrachialis

Musculocutaneous

nerve

Bleeps brachii

-Ulnar

nerve

Median

nerve

-Medial cutaneous

nerve of the arm

(sensory)

Brachialis Lateral cutaneous

nerve of forearm

(sensory)

Pronator teres

Pronator teres

Flexor carpi radiaiis

—Rexor carpi

ulnaris

Medial cutaneous

nerve ot the forearm

(sensory)

Rexor digitorum

profundus

Imedial 4.5 digits)

Palmaris longus

Rexor pollicis

longus Flexor digitorum

superficialis

Dorsal cutaneous

Flexor digitorum branch (sensory)

profundus

{lateral 2,3 digits)

Pronator

quadrates '

I Palmar cutaneous

/ branch (sensory)

Palmar interossei

'

almaris brevis

lypothenar muscles

Adductor Thenar pollicis ,

muscles

2.3 lumbricals

Dorsal/

interossei 4,5

r “i

lumbricals Palmar sensory

branches of median

nerve

i.J

r

CM

i

Superficial terminal

branches (sensory)

s

3

i

@

+

ANTERIOR VIEW

Figure1. Median,musculocutaneous, and ulnar nerves:innervation of upper limb muscles

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0R3 Orthopaedic Surgery Toronto Notes 2023

15

LC

C7

Axillary C8

Subclavian

Subscapularis Deltoids , Posterior [

Circumflex

humeral .Teres major Thoracoacromial

Anterior

Axillary norvo lateral thoracic

\

'

latissimus \ dorsl

Radial nerve

'

Triceps brachii Hong head!

Subscapular

Brachial

artery

Upper cutaneous,

norvo of the arm

(sensory!

Profundi

brachii

SSuperior ulnar

collateral

Inferior ulnar

collateral

Triceps brachii (medial head)

Brachioradialh

Extensor carpi J.

radialis longus (I

Extensor carpi

radialis brevis//

Radial

-recurrent

Anterior and posterior

ulnar recurrent

iSupinator

Posterior-^

interosseous

nerve

Radial,

Ulnar f AExtensor carpi ulnaris

[

'

Extensor digit! minimi

Extensor digitorum

'Extensor indicis

Abductor,

^

'"'

pollicis longus

Abductor^

^

pollicis brevis ,

Anterior interosseous

Superficialradial nerve

(sensory)

Deep palmar arch

Superficial palmar arch

I

5

J

*

ANTERIOR VIEW POSTERIOR VIEW

Figure 2. (Left) Blood supply to the upper limb, (Right) Axillary and radial nerves: innervation of the upper

limb

Table1Sensory and Motor Innervation of the Nerves in the Upper and Lower Extremities

Nerve Motor Sensory Nerve Roots

Dcltoidlferes Minor/Tiiceps (long Lateral upper arm (Sergeant's

head)

Biceps/Grachialis

Triceps (medial andlateral heads) Lateral dorsum of the hand

Wrist/ thumb/finger Extensors Medial upper lorcarm

Wrist abductors

Wrist flexors

Flexion of1st-3rddigits

Axillary C5. C6

Pilch)

Musculocutaneous

Radial

Lateral lorcarm C 5.C6

C5. C6.CJ. C8

Median Palmar thumb lo radialhall ol 4th C6, C 7

digit,and the dorsal lips of digits t

to radialhall ol digit 4

Medial palm and dorsum ol hand C8.T1

5th digit and medial half ol 4th

Ulnar Wrist flexors and adductors

flexion of 4th-5lh digits

digit

Tibial Ankle plantar flexion

Knee flexion

Great toe flexion

Ankle eversion

Sole of foot LS. St

Superficial Peroneal

Deep Peroneal

Dorsum of foot L5.S1

Ankle dorsiflexion and Inversion

Great toe extension

1st web space L5. S1 ( n\

Sural Lateral foot S1,S2

Saphenous Anteromedial ankle L3,L4

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