UNIVERSITY OF

TORONTO
DIVISION OF
ORTHOPAEDIC SURGERY
MEDICAL STUDENT EDUCATION PACKAGE

Dear medical student,

Welcome to your rotation with the Division of Orthopaedic Surgery at
the University of Toronto. We hope that your time with us will be fun
and educational.
This package, developed by the Medical Student Education Committee
(Marissa Bonyun, Andrea Chan, Brandon Girardi, Ryan Katchky, Joel
Moktar, Jesse Wolfstadt, and Michael Zywiel), is meant to summarize a
few common orthopaedic topics that you will likely encounter during
your rotation, as well as during your final exams.
During your rotation, we invite you to take an active role in ward
patient care, emergency department consults, clinics, and in the
operating room. You will get the most out of your rotation if you read
around cases, familiarize yourself with this package, and supplement
your reading with journals and online resources.
Elective students should aim to complete a minimum of one call during
each week you are on service, as well as one weekend day. U of T core
residents are expected to follow the on-call requirements as outlined by
your academy. The on-call experience offers a great opportunity to get
involved in patient care. Please liaise with the site chief resident to
arrange your call shifts.

Lastly, here are some important contacts within the Division of

Orthopaedics.

Name Role Contact Information

Dr. Peter Ferguson Albert and Temmy Latner 416-586-4800 x8687
Chair, Division of pferguson@[Link]
Orthopaedic Surgery Secretary: Sherry Leal
Dr. Markku Program Director 416-967-8639
Nousiainen [Link]@[Link]
Secretary: Lovena Smith
Dr. Jeremy Hall Associate Program Director 416-864-6006
hallj@[Link]
Secretary: Ling Tung
Dr. Veronica Wadey Associate Program Director 416-967-8615
[Link]@[Link]
Secretary: Rosa Mandarano
Dr. Dan Stojimirovic Program Coordinator 416-946-7957
[Link]@[Link]

Sincerely,
The Medical Student Education Committee
OPEN FRACTURES

INTRODUCTION
 A fracture with direct communication with the external environment
 Spectrum includes poke-hole overlying the fracture to bone extruding through skin
 Typically the result of high-energy trauma
 Increased risk of infection and complications in healing due to:
 Contamination of the wound with microorganisms
 Soft tissue damage
 Compromised vascular supply

CLINICAL EVALUATION
 Assessment includes:
 Mechanism of injury
 Condition of soft tissue
 Degree of bacterial contamination
 Fracture pattern
 Must still rule out compartment syndrome

GUSTILO CLASSIFICATION
 Type I
 Wound <1cm diameter
 Type II
 Wound 1-10cm diameter
 Type IIIA
 >10cm, high energy
 Can be closed primarily without skin graft
 Extensive periosteal stripping, therefore includes a segmental or highly comminuted
fractures associated with wound <10cm
 Type IIIB
 Requires soft tissue flap for coverage
 Type IIIC
 Associated vascular injury

EMERGENCY ROOM MANAGEMENT

1. Complete trauma survey and
resuscitation
2. Early intravenous antibiotics
3. Tetanus
4. Control bleeding (direct pressure)
5. Irrigation and debridement, removal of
gross contamination
6. Assessment of neurovascular status and
compartments
7. Sterile, moist dressing
8. Closed reduction and immobilization
ANTIBIOTIC CONSIDERATIONS

 Continued for 24 hours after final wound closure

 1st generation cephalosporin (Ancef) for Gustilo Type I and II
 Can substitute Clindamycin or Vancomycin if Penicillin allergy exists
 Add an aminoglycoside (Gentamycin) for Gustilo Type III
 Add anaerobic coverage in the form of Penicillin for farm injuries or dirty wounds
 Add fluroquinolone (Ciprofloxacin) for fresh water wounds

TETANUS
 If tetanus status is unknown or not up-to-date, must give tetanus toxoid (0.5mL)
 Tetanus immune globulin should be given to patients with Gustilo Type II and III injuries if
tetanus status is unknown or not up to date
 If tetanus status is up to date, no treatment is required

OPERATIVE MANAGEMENT
 Low pressure irrigation and thorough debridement (I+D)
 Remove all devitalized bone and soft tissue in an organized fashion from outside-to-
inside
 Irrigate with 3L of normal saline for each grade
 Stabilization of fracture with internal or external fixation
 +/- Repeat debridement and irrigation in 24-48 hours
 Low threshold for repeat debridement

COMPLICATIONS
 Acute infection
 Chronic osteomyelitis
 Delayed or non-union

REFERENCES
 Rockwood and Green’s Fractures in Adults (7th Ed 2010)
 Miller’s Review of Orthopaedics (6th Ed 2012)
 Zalavras CG and Patzakis MJ, Open Fractures: Evaluation and Management. JAAOS 2003;11:212-
219
COMPARTMENT SYNDROME

INTRODUCTION
 Acute compartment syndrome is caused when the pressure within an osseofascial compartment
rises to the degree that it reduces blood supply
 It results in irreversible damage to muscles and nerves and can lead to contractures, weakness,
infections, paralysis and fracture non-union
 Rapid diagnosis and definitive treatment (fasciotomy) within 6 hrs is key to preventing
significant morbidity
 Compartment syndrome can present in the leg, thigh, forearm, arm, hand and foot
 The leg has four compartments: anterior, lateral, deep and superficial posterior
 The thigh has three compartments: Anterior, posterior and adductor
 The forearm has three compartments: volar, dorsal and the mobile wad
 The foot has nine compartments: medial, lateral, 4 interosseous and 3 central

EPIDEMIOLOGY
 Annual incidence for males is 7.1 per 100,000
and 0.7 per 100,000 per females. Mean age is
32
 Common causes of acute compartment
syndrome
o Tibial shaft fracture (36%)
o Soft tissue injury (23.2%)
o Distal radius fracture (9.8%)
o Crush injury (7.9%)
o Forearm fracture (7.9%)
o Femoral shaft fracture (3%)
o Rare causes: burns, bleeds and fluid
infusions

Figure 1: Axial cut of the leg demonstrating the four

compartments. AO Surgery Reference.

HISTORY ON PRESENTATION
 Pain is typically the chief complaint and is severe and out of proportion to the injury, the pains
may worsens despite analgesia
 High-energy injuries increase the risk of compartment syndrome, however certain low-energy
fractures (ie: tibial shaft) are at high risk as the fascial compartments remain intact
 As clinical exam is key to diagnosis, risk factors for late diagnosis of compartment syndrome are
polytrauma patients, intubated/sedated patients and children
CLINICAL EXAM
 Acute compartment syndrome is diagnosed clinically, however the sensitivity of many of the
typical findings is poor, and cannot be examined in certain patients
 Clinical findings include:
 Pain at rest that is severe and out of proportion (sensitivity of 19%, specificity of 97%)
 Pain with passive stretch
 Palpable swelling in the compartment (if superficial)
 Paraesthesia ,hypothesiaand paralysis of muscle groups are late signs
 Pulses and capillary refill should not be used in diagnosis

INVESTIGATIONS
 Intra-compartmental catheters allow for objective compartment pressure monitoring and aid in
diagnosis of clinical exam if it is equivocal
 ∆P is the difference in diastolic blood pressure and intracompartmental pressure
 If ∆P < 30mmHg for 1-2 hours fasciotomy is indicated

MANAGEMENT
 Leg: A double-incision fasciotomy releases the anterior and lateral compartments via a lateral
incision and the posterior compartment are released from a medial incision. Alternatively, a
single lateral incision can be used to release all four leg compartments.
 Thigh: A single lateral skin incision for release of both compartments
 Forearm: Single volar incision +/- dorsal incision

REFERENCES
 Rockwood and Green’s Fractures in Adults (7th Ed 2010)
 AO Surgery Reference: Compartment Syndrome.
[Link]
DISLOCATIONS

INTRODUCTION
 Spectrum from complete loss of joint congruence (dislocation) to partial loss (subluxation)
 Commonly associated with ligamentous injury
 Described by the direction of displacement of the distal bone relative to the proximal bone
 High suspicion for neurologic or vascular injury
 Simple = no associated fracture
 Complex = fracture + dislocation

PRESENTATION
 Often caused by trauma or a direct blow to the joint
 Symptoms
 Pain
 Numbness/tingling
 Signs
 Swelling and obvious deformity (although may spontaneously reduce before ED
presentation)
 Instability and limited range of motion
 +/- Abnormal neurovascular examination

SHOULDER
 Most common dislocated joint
 Must obtain AP, lateral, and axillary views of glenohumeral joint to make diagnosis
 Velpeau view can be substituted for an axillary view if the arm cannot be abducted
 Axial nerve neuropraxia = most common complication

Anterior (95%) Externally rotated and abducted position

Posterior (5%) Internally rotated and adducted position

Caused by seizures, electrocution, or
inebriation
Frequently missed for extended periods of
time
Inferior Arm held overhead in full abduction with
(Luxatio erecta, elbow flexed
rare)

ELBOW
 Second most common dislocation
 Posterolateral is most common direction
 Terrible triad = posterolateral elbow dislocation with associated radial head fracture,
lateral ulnar collateral ligament injury, and coronoid tip fracture
HIP
 Rare, but potentially devastating injury
 Caused by high-energy trauma
 Must follow ATLS protocols and search for other injuries (head injury, abdominal trauma,
femoral shaft fracture)
 May be associated with sciatic nerve injury, acetabular fracture, femoral head, neck, or shaft
fracture, or knee injuries
 Major complication is osteonecrosis of femoral head

Posterior (90%) Results from axial load with hip

flexed, adducted, and internally
rotated (i.e. dashboard injury)

Anterior (10%) Results from hip abduction and

external rotation

KNEE
 Caused by high-energy trauma (MVCs) or low-energy trauma (athletic injury)
 Vascular injury in 5-15%, common peroneal nerve injury in 25%
 Classified as anterior (30-50%), posterior (25%), lateral, medial, or posterolateral dislocations
 Multiple ligaments involved
 Evaluate vascular status with serial clinical examination, ankle-brachial index (ABI), and CT
angiogram if ABI<0.9
 Evaluate compartments, as frequently associated with compartment syndrome

INITIAL MANAGEMENT
 Thorough neurovascular examination
 Must be documented clearly in patient’s chart
 Urgent closed reduction under conscious sedation
 Immobilization to maintain reduction, reduce pain, limit swelling, and protect neurovascular
structures
 Repeat neurovascular examination and diagnostic imaging
 Referral to an orthopaedic surgeon for evaluation of ligamentous structures and definitive
management

REFERENCES
 Miller’s Review of Orthopaedics (6th Ed. 2012)
 AAOS Comprehensive Review (1st Ed. 2009)
SEPTIC ARTHRITIS
INTRODUCTION
 Definition: Purulent infection of a joint
 Three etiologies of bacterial seeding into a joint
1. Hematogenous spread secondary to bacteremia
2. Direct inoculation secondary to trauma or surgery
3. Contiguous spread from adjacent osteomyelitis
 Presents differently in native and prosthetic joints
 Can cause irreversible damage to articular cartilage via release of proteolytic enzymes by PMNs
 Septic arthritis of a native joint should be treated with irrigation and debridement on an urgent
basis

EPIDEMIOLOGY
 Most common joints are knee, hip, elbow and ankle
 Most common organisms include
 Staph Aureus (MSSA or MRSA)
 Staph Epidermidis
 Neisseria Gonorrhea (in young, healthy, sexually active patients)
 Streptococcus
 Salmonella (in patients with Sickle Cell Disease)
 More common in patients with diabetes, history of IV drug use, immunocompromised patients
 Infection tends to seed in prosthetic joints

HISTORY ON PRESENTATION
 Pain
 Fevers/Sweats/Chills
 Inability to bear weight
 Often report preceding UTIs, pneumonias, gastroenteritis or other infections

PHYSICAL EXAM
 Vital signs
 Temp >38.3 or <36
 HR>90 beats/min
 RR>20 breaths/min
 Hypotension (sBP <90mmHg)
 Altered LOC
 Inspection – swelling, erythema, evidence of trauma, inoculation or impaired wound healing
 Palpation – warmth, tenderness
 Inability to weight bear
 Poor tolerance to active and passive ROM
 Distal neurovascular exam

Investigations
 Bloodwork: WBC > 10, ESR > 30, CRP > 5 (most specific)
 Imaging – XR, MRI, u/s may show an effusion or collection
 Joint Aspiration – gold standard for diagnosis
 Specimen sent for cell count, C+S, Gram Stain and crystals
 Cell count provides most rapid and most reliable results (see table below)

Management
 Surgical emergency
 Prevent and treat systemic sepsis
 Decrease bacterial load within joint to prevent cartilage damage
 Obtain tissue diagnosis for targeted antibiotic treatment
 Open or arthroscopic irrigation and debridement (I+D)
 Obtain tissue cultures
 Post-operatively, patients require careful monitoring for recurrence and prolonged IV antibiotics
(>6 weeks)

Special Cases
 Neisseria Gonorrhea Septic arthritis
 Usually a migratory polyarthritis
 May be managed with IV antibiotics and serial aspirations rather than I+D
 Prosthetic Joint Infections (PJI)
 Consider PJI in any patient with unexplained pain following joint replacement
 Physical exam findings such as ROM and weight bearing less reliable
 Lower threshold for infection on cell count (> 1800 WBCs)
 Requires 2-stage revision arthroplasty
 Less urgent due to inability to damage cartilage
 Paediatric Septic Hip
 Distinguish from Transient Synovitis using Kocher Criteria
 Fever>38.5
90% likelihood of septic
 WBC >12
arthritis if 3 or more of
 ESR>40 above present
 Inability to bear weight
 CRP>2 later added as additional criterion

Resources
 Miller’s Review of Orthopaedics (6th Ed. 2012)
HIP FRACTURES

INTRODUCTION
 The term ‘hip fracture’ typically refers to fractures of the proximal femur (from the femoral head
to 5cm below the lesser trochanter)
 Fracture types can be subdivided into those that are intra-capsular and extra-capsular, with a
number of different subtypes for each
 Furthermore, fractures can be subdivided into those that are displaced or undisplaced

EPIDEMIOLOGY
 Hip fractures typically occur as a consequence of a low-
energy fall (from standing height or less) in older
patients (typically 65 years of age and over)
 Most important risk factors are decreased bone density
(which is associated with female sex) and older age
 Hip fractures are among the most common underlying
diagnosis for unplanned orthopaedic admissions to
hospital (approximately 30,000 patients/year in Canada)
 <5% of hip fractures can also occur secondary to high-
energy mechanisms (e.g. car crashes, falls from height),
more often in younger patients

CLINICAL EXAMINATION
 Patients with a hip fracture present with inability to ambulate
 Inspection: The classic deformity is a shortened, externally rotated leg
 Palpation: Pain with attempted movement of affected hip
 Must check neurovascular status and skin integrity to rule out open injuries or
neurovascular injury

MANAGEMENT
 Goals: Pain control, early mobilization, and facilitating return to pre-injury level of independence
 Work-up: AP pelvis and AP/lateral hip x-ray, CXR + ECG, CBC, lytes + Cr, INR/PTT, group +
screen, vit. D
 Achieved through early surgical intervention to allow immediate, full weight bearing
 Typical goal: surgery within 48 hours of injury
 Non-operative treatment: Patients with impacted fractures who are able to bear weight through
them or palliative patients with life expectancy measured in weeks
 Associated with extremely high risk of immobility-related medical complications (bed
sores, infections, DVT/PE) and failure to regain mobility
 Most patients who experience fragility hip fractures have one or more
major medical comorbidities, and these should not delay surgery unless
they are unstable
 Displaced intra-capsular fractures are treated with hip replacement
because of high risk of disruption of blood supply and consequent
osteonecrosis of the femoral head
 Undisplaced intra-capsular, intertrochanteric, and subtrochanteric hip
fractures are typically treated with surgical reduction and internal fixation

OUTCOMES
 Despite aggressive surgical management, patients with hip fractures have high morbidity (in-
hospital complications such as delirium, cardiac events, UTIs; failure to regain pre-injury level of
function), and mortality (around 30% at 1 year)
 Primary prevention efforts (assessment [DEXA scan] and treatment of bone mineral density
[calcium, vitamin D, bisphosphonates, anabolic agents]; falls prevention programs) have been
instrumental in reducing age-adjusted incidence of hip fractures, and the associated adverse
impact of these injuries on patients’ quality of life

REFERENCES
 Rockwood and Green’s Fractures in Adults (7th Ed 2010)
 Miller’s Review of Orthopaedics (6th Ed 2012)
DISTAL RADIUS FRACTURES

INTRODUCTION
 Main goal: optimize the anatomy, restore function
 Most can be treated non-surgically with closed reduction and splint application if acceptable
reduction is obtained

EPIDEMIOLOGY
 One of the most common fractures see in the emergency department
 Bimodal distribution:
 Younger patients = high energy
 Older patients = low energy (falls)
 Fracture pattern is related to the mechanism of injury
 The most commonly seen DR fracture is the Colles’ fracture from a fall on outstretched hand (FOOSH)

CLASSIFICATION

HISTORY ON PRESENTATION
 General:
 Follow ‘AMPLE’ history:
 Allergies
 Medications
 Past medical history (specifically any history of osteoporosis; include social history -
smoking, EtOH, handedness, occupation)
 Last meal (timing)
 Events prior (mechanism of injury - specifically how did they fall - especially in elderly
patients - were there any pre-syncopal or cardiac prodromal symptoms or was it purely
mechanical?)
 History of presenting illness:
 Pain (OPQRST)
 Neurological symptoms?
 Any bleeding at the time of injury?
 Timing of the injury (when did it happen)?
 Any other injuries?

PHYSICAL EXAM
 ATLS protocol (if unstable trauma patient)
 Inspection (open wound, skin blistering, deformity, swelling, general skin quality, any obvious
hematoma)
 Palpation (compartments soft, pain on passive stretch, effusion, snuffbox tenderness)
 Active and Passive ROM (painful, limitations)
 Distal neurovascular examination
 Radial +/- ulnar pulses palpable
 Hand warm, well perfused (i.e. cap refill)?
 Allen’s test
 Motor exam:
 Median nerve:
 Recurrent motor branch: palmar abduction of thumb
 Anterior interosseous branch (AIN): flexion of thumb IP and index DIP
(“OK” sign)
 Radial nerve: thumb IP joint extension against resistance (“thumbs up”), wrist
extension
 Ulnar nerve: cross-fingers +/- abduct fingers against resistance (“spread fingers
apart”)
 Sensory exam:
 Median: radial 3 1/2 digits on palmar side (sensation along distal radial side of index
finger)
 Radial: dorsal aspect of base of thumb
 Ulnar: ulnar side of distal aspect of 5th digit
 Joints above and below - elbow +/- shoulder (depending on severity of injury), carpal bones, including
anatomic snuffbox (scaphoid fractures)
 Must rule out compartment syndrome, open fracture, and
neurovascular injury

ANATOMY
 80% axial load supported by DR, 20% by ulna and
triangular fibrocartilage complex (TFCC)
 Many ligaments attached to DR - often remain intact in
fractures and therefore can help to reduce fractures by
“ligamentotaxis”
 Volar ligaments are stronger, confer more stability

INVESTIGATIONS
 X-Ray: AP, lateral of forearm
 Include joints above (elbow +/- shoulder) and below (carpus) in X-rays
 Consider contralateral joint for comparison
 CT: for help to clarify intra-articular involvement
DESCRIPTION OF INJURY
 “This is a [AGE]-year old [SEX] who sustained a [RIGHT vs. LEFT], [OPEN vs. CLOSED] distal radius
fracture. The fracture is [VOLAR/DORSAL] displaced, with [ANGULATION], [+/- COMMINUTION], and
[HOW MUCH] loss of radial length.”

MANAGEMENT
 NOTE: ALL fractures should undergo closed reduction even if they will likely need surgical
management
 Limits swelling
 Provides pain relief
 Relieves median nerve compression

Options for definitive management:

1) CLOSED REDUCTION + SPLINT/CAST IMMOBILIZATION
 Non-displaced or minimally displaced fractures
 Stable fracture pattern expected to unite within parameters
 Low-demand where future functional impairment is less of a priority than operative risks

2) CLOSED REDUCTION + PERCUTANEOUS PINNING +/- EXTERNAL FIXATION

3) OPEN REDUCTION INTERNAL FIXATION

The choice to manage a DR fracture surgically depends on:

 Age of patient
 Functional demands (lifestyle, occupation, hand dominance)
 Tolerance of deformity
 Patient preference
 Radiographic alignment parameters

Indications for surgical treatment:

 Loss of reduction acceptable parameters
 Articular gap ≥2mm
 Unstable volar extra-articular fractures (“Smith fracture”)
 Intra-articular volar shear fracture (“Barton fracture”)
 Open fractures
 Fracture with NV injury
 Fractures with associated intercarpal ligament injury
 Polytrauma/need to use crutches

CLOSED-REDUCTION
 Analgesia: Hematoma block or conscious sedation
 Reduction technique
 Reduction technique guided by the fracture pattern
 Exaggerate the fracture, apply traction
 Restore anatomic alignment
 Example: For Colles’/dorsal distal radius fracture
 Hyperextend distal fragment
 Traction to reduce distal fragment to proximal fragment
 Short arm splint (below elbow) for all except intra-articular solar shear fracture (“Barton fracture”)
which requires above elbow splint, with forearm supinated and elbow at 90 degrees to avoid further
shear from flexors
 Total length of immobilization ≈ 6 weeks
 Return to use to avoid stiffness, limit swelling
REFERENCES
1. Ch. 22: Distal Radius fractures (pg. 269) in Egol, K. A., Koval, K. J., and Zuckerman, J. D., Handbook of
th
Fractures (4 Edition).
2. Ch. 35: Wrist Fractures and Dislocations, Carpal Instability and Distal Radius Fractures (pg. 355) in
Boyer, M. I. (Ed.) AAOS Comprehensive Orthopaedic Review (2014).
ANKLE FRACTURES

INTRODUCTION
 Result from direct or indirect forces
 Rotational, translational, and axial forces
 Fractures to the malleoli are considered intra-articular
 Goals of management include:
1. Restoring and maintaining normal joint anatomy
2. Early range of motion
3. Respecting the soft-tissue envelope

EPIDEMIOLOGY
 Rotational fractures of the ankle are among the most common injuries requiring care:
 2/3 = isolated malleolar fractures
 1/4 = bimalleolar fractures
 5-10% = trimalleolar fractures
 Rates of surgery depend on fracture type:
 11% isolated lateral malleolar #s managed surgically
 74% of trimalleolar #s managed surgically

HISTORY ON PRESENTATION
 General:
 Follow ‘AMPLE’ history:
 Allergies
 Medications
 Past medical history (especially peripheral vascular disease, diabetes mellitus, smoking,
EtOH, baseline ambulation status, occupation)
 Last meal (timing)
 Events prior (mechanism of injury)
 History of presenting illness:
 Pain (OPQRST)
 Neurological symptoms?
 Joint-related symptoms (instability, swelling, weakness, stiffness, locking/catching)
 Any bleeding at the time of injury?
 Mechanism?
 Any other injuries?

PHYSICAL EXAM
 ATLS protocol (if presents as unstable patient)
 Inspection – Is the patient ambulatory or limping, open wounds, skin blistering, deformity, swelling,
skin quality
 Palpation – Compartments soft, pain on passive stretch, areas of maximal tenderness, effusion
 Active and passive range of motion (painful? limitations?)
 Distal neurovascular examination
 Dorsalis pedis and posterior tibialis pulses palpable
 5 cardinal sensory regions intact? (superficial peroneal nerve, deep peroneal nerve,
posterior tibial nerve, saphenous nerve, sural nerve)
 Motor intact? (ankle dorsiflexion and plantarflexion, large toe extension, foot eversion)
 Examine joints above and below
 Special tests
 “Wrinkle” sign – Ability to wrinkle or pinch skin is indicative that skin is supple enough to
withstand surgical wound closure
 Syndesmosis “squeeze” test – squeeze ankle ~ 5cm proximal to joint; tenderness may be
indicative of syndesmosis injury
 Must rule out compartment syndrome, open fracture, and neurovascular injury

ANATOMY

CLASSIFICATION

Danis-Weber
 Staging and degree of instability depends on the level of the fibular fracture:
 Plafond – root of the ankle joint/articular surface of the distal tibia
 Type A: below the level of the plafond (least unstable)
 Type B: at the level of the plafond
 Type C: above the level of the plafond (usually unstable)
Lauge-Hansen
 Staging is based on 2 variables:
1. Foot position at time of injury (1st word);
2. Applied stress/force to talus relative to leg (2nd word)
 The initial position of the foot determines which structures are tight at onset of deformation, and
likely to fail first:
 When foot is supinated, the lateral structures are under tension & fail first
 When foot is pronated, the medial structures are under tension & fail first

INVESTIGATIONS
 Radiographs: AP, lateral, mortise view (15° internal rotation) +/- stress view (15° external rotation in
ankle dorsiflexion)
 CT scan - to better characterize joint if significant comminution exists
 MRI - soft tissue/ligamentous injuries
MANAGEMENT
 Goal: stable, anatomical reduction of talus in ankle mortise

Nonsurgical: short leg walking boot or cast

 Indications:
 Isolated undisplaced medial malleolus fracture or avulsion fracture
 Isolated lateral malleolus with <3mm of displacement and NO talar shift
 Posterior malleolus fracture with <2mm articular surface step-off and involving <25% of the
joint surface

Surgical: open reduction and internal fixation

 Indications:
 Open
 Fracture-dislocations
 Vascular injury
 Any talar shift
 Isolated medial or lateral malleolus with displacement not meeting above criteria
 Bimalleolar fractures (both medial and lateral malleoli)
 Bimalleolar equivalent fractures (lateral malleolus fracture with medial widening)
 Posterior malleolus fracture with >2mm articular step-off or >25% of joint surface involved
 Syndesmosis widening/instability

Surgical options:
 Medial malleolus:
 Lag screw fixation
 Antiglide plate
 Tension band wire
 Lateral malleolus:
 Lag screw fixation + neutralization plate
 Bridge plate
 Intramedullary screw/k-wire placement
 Isolated lag screw fixation
 Posterior malleolus:
 Antiglide plate
 Lag screw fixation
 Syndesmosis:
 1 or 2 screws; 3 or 4 cortices

REFERENCES
 Miller’s Review of Orthopaedics (6th Ed. 2012)
 AAOS Comprehensive Review (1st Ed. 2009)
CAUDA EQUINA SYNDROME

INTRODUCTION
 Cauda Equina = “horses tail” – represents the terminal nerve roots in the lumbosacral area of
the spine below the end of the spinal cord (L1-S5 nerve roots)
 Compression of the cauda equina from any source is termed “Cauda Equina Syndrome”
 leads to impaired function of the nerve roots and a constellation of symptoms
 a medical emergency because ongoing compression will lead to permanent loss of
nerve function and paralysis

ANATOMY
 The spinal cord ends around the first lumbar vertebrae (L1-2) as the conus medullaris
 Cauda equina (L1-S5 nerve roots) supply motor and sensory innervation to the lower
extremities and perineal region; they also control emptying of the bladder

PATHOPHYSIOLOGY
 Any space-occupying lesion in the lumbosacral spinal canal can cause compression of the cauda
equina.
 Central intervertebral disc herniation (most common cause)
 Tumour
 Spinal Stenosis
 Infection – spinal epidural abscess
 Trauma
 Epidural Hematoma – post-op from spinal surgery

HISTORY ON PRESENTATION
 Timing of onset related to diagnosis:
 Acute – disc herniation/trauma
 Insidious – tumour/stenosis
 Pain - radiating bilateral leg pain (similar to sciatica)
 Neurological (motor/sensory) deficits of lower extremities
 “Saddle” anaesthesia – decreased sensation perineal region
 Initially presents with urinary retention (secondary to loss of bladder innervation) followed by
overflow incontinence
 Bowel incontinence (rare, but also associated)
PHYSICAL EXAM
 Vital signs
 Lower motor neuron disorder:
 Examine for bilateral lower extremity motor and sensory loss
 Decreased deep tendon reflexes
 Perineal Examination:
 Decreased perineal sensation
 Loss of rectal tone

INVESTIGATIONS
 MRI is the gold standard investigation to assess for compression of the cauda equina
 If infection or tumour is suspected MRI should include gadolinium dye for enhancement.

MANAGEMENT
 Cauda Equina syndrome is a surgical emergency.
 Treatment involves urgent decompression of the nerve roots of the cauda equina
 Ongoing compression leads to progressive loss of neural function
 Decompression within 48 hrs associated with better outcomes
 Majority require urgent surgical decompression via removal of the vertebral
lamina/compressive material
 In some cases, caused by tumour, external beam radiation therapy may be indicated
 Larger decompressions may require additional spinal stabilization through instrumentation and
fusion

REFERENCES
 Miller’s Review of Orthopaedics (6th Ed. 2012)
 AAOS Comprehensive Review (1st Ed. 2009)