Undergraduate

Orthopedics
 About Authors
Dr Mahmoud Massoud, MD
Lecturer Orthopedic and spine surgery
Military Medical Academy & AFCM
Dr Tharwat Eid, MD
Lecturer Orthopedic surgery Delta University
Dr Ekramy Talaat, MD
Lecturer Orthopedic surgery Delta University
Dr Diaa Elsayed, MsD
Assistant Lecturer Orthopedics Delta University
Dr Aboghoneim Muhammad, MsD
Assistant Lecturer Orthopedics Delta University
 Undergraduate
Orthopedic Introduction

3
 Bone Processors >> Failure

Osteoblast Osteoclast NB, Bone is a dynamic

• Growth >> Congenital • Defend >> Inflammatory organ under continues
build up (by Osteoblast)
• Healing >> Trauma • Contain >> Tumor and build down (by
Osteoclast ) reguraly.
So any deviation in this
Bone Regions >> Failure regular process cause
failure = Pathology.

Shoulder girdle Arm Elbow Forearm Wrist hand

Spine
Pelvic girdle Femur Knee Leg Ankle Foot

4
 Scheme diagnose Failure
• Definition & Incidence
• History: Causes Failure Complaints
.........abnormal LOOK >> Swelling , Deformity
..........abnormal FEEL >> Pain , Numbness
..........abnormal MOVE >> Stiffness, Unstability
• Examination: Region
............LOOK >> Alignment Symmetrality Skin
.............FEEL >> Tender points
............MOVE >> Joints (active and passive)
Neurovascular examination mandatory ‫الزم‬

5
 • Investigation
X-ray mandatory ‫الزم‬
......adequate: 2 views AP/Lateral 2 joints above and below 2 Occasion now and after 2 w
......Comment: OLDACID >> Open fracture..Location..Dislocation..Articular..
Internal bone quality..Displacement...>>
CT: for articular fracture
MRI: for ligaments injury
Ultrasound: for soft tissue injury
Lab: Preoperative and Inflammatory

• Classification: severity
Aim: diagnostic, prognostic, communication

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 NB, Displacement

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 X ray comment ‫امتحان‬
Plain X-ray anteroposterior view
Inadequate: no name, no age, no date, no side
no 2 joint, no 2 views, no 2 occasions
OLDACID
Open >> not in image
Location >> fracture at shaft radius and ulna
Dislocation >> no
Articular >> intact
Comminution >> no
Internal bone quality>> no osteoprosis
Displacement >> distal part both bone displaced
laterally with angulation

Comment on next page x rays as shown

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9
 • Complications
General Local
• General early: Shock: • Early ← Local → late
*Neurogenic (pain) treatment by morphia injury skin……….….......*Sepsis osteomyelitis
*Hypovolumic treatment resustation fluids injury SC…....................*Volkmanns isch.
injury muscle……….......*Myositis ossificans
• General late: prolonged bed
injury tendon………...….*Deformity
Chest: Infection, Atelectiasis, Pulm embolism
injury Nerves…….......…*Seudeuk atrophy
GIT: Gastric ulcers, Paralytic ilus, Constipation
injury Vs……….…...........*Compartement $
Urinary: UTI, stones, retention
injury growth plate…....*Gross arrest
LL: Ulcers, muscle atrophy, DVT
injury joint…….………......*Arthritis
injury bone………..….....*Delayed/Non/Malunion
injury viscera………....….*Psychoneurosis
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 • Treatment
General Local
• Polytrauma...ABCDE • Surgical or Conservative
• Shock..
*Neurogenic(pain) treatment by morphia
*Hypovol. ttt resustation fluids 1L and blood P VON U

11
 Conservative management
• Conservative..RICE protocol
........Rest..Ice..Compression..Elevation
NB Connect injured part to support Slab..Splint..Orthosis..Cast

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 Operative treatment
ORF..Open reduction and fixation Joint Prosthesis

Internal External
• On side..Ex fix • Hemi-arthroplasty
• On bone surface.. • Ring..Ilizarov • Total arthroplasty
Plate and screws
• Intramedullary..Nails
• Both..K wire

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 Follow up and rehabilitation
• Rest 1week RICE protocol (rest-ice-connection-elevation )
• Exercises...Stretching/Strenthing.

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 Undergraduate Orthopedic schedule

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 Undergraduate
Trauma

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 Trauma types
• High energy trauma accidents, Low energy trauma fall.
• Direct as hit trauma at site of injury.
Indirect as Falling on out streched hand (FOOSH) transmitted force.
• Primary by accident , Secondary by edema.
• Healing..primary direct or Secondary indirect.
• Trauma to bone or soft-tissue.

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 Classification of fractures

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 Bone healing
• Stages >> Hematoma ..Granulation tissue..1ry Callus .. 2nd Callus
• PREREQUISITES >> Vascularity + Mechanical Stability
• Types >> 1ry.. No stages direct bone to bone contact eg anatomic reduction by plates
>> 2nd ..Stages with Callus formation eg cast or ex fixation
>> Non Union.. Inadequate vascularity or Stability >> treated by surgical adequate
stabilization and bone graft
>> Malunion..Union but with Deformity >> Surgical osteotomy

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 Soft tissue trauma
• Contusion: Small amount blood collection
• Hematoma: Huge amount blood collection Treatment by
• Edema : Excess fluid collection conservative
RICE protocol
• Bullae: Massive fluid collection

• Tenting: Fracture pointed into skin

• Skin avulsion: Exposed bone Treatment by
surgery to save
• Crushed limb: Mushed muscles the limb from
Amputation
• Open fractures >>

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 Open fractures
• Definition: Skin cut with fracture hematoma continues with outside
• Management: Scheme+ operative depridment according
• Classification
I < 1 cm Wash with saline
II 1-10 cm and betadine
III > 10 cm Give antibiotics

Wound >> Clean Quiry Infected.....................

Fixation >> Internal wait and see Ex fixation
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 Compartment syndrome
• Definition: Increased pressure within one of the body's anatomical compartments results in
insufficient blood supply to tissue (stop tissue perfusion) within that space contained in its fascia.
• Clinical: Acute Pain out of proportion, Paresthesia, Paralysis ,Pallor and Pulselessness is the end.
• Investigation: Intracompartment pressure higher than 30 mmHg of the diastolic pressure.
• Treatment: Removal of the external compression + Scheme
Surgical decompress the compartments (fasciotomy urgent).

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 Clavicle fracture
• Definition: Discontinuity clavicle bone surface.
• Classification and Incidence: A. Group I: Middle third (80%) Most common,
B. Group II: Distal Third (10-15%) , C. Group III: Medial Third (5%).
• Mechanism injury: FOOSH
• Clinical: Scheme
• Management : Scheme+
>> Conservative treatment 90% (arm sling + RICE protocol)
>> Operative treatment for PVONU + skin tenting (ORIF)
• NB. Neurovascular injury associated >> Brachial plexus
Subclavian artery
• NB. Most common complication is malunion ,
other in Scheme

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 Shoulder dislocation
• Definition: Discontinuity in gleno-humeral articulation
• Classification and Incidence: Anterior Dislocation, Posterior Dislocation
• Mechanism injury: FOOSH
• Clinical: Scheme
• Management : Scheme+ urgent reduction ( by traction and counter traction)
>> Conservative treatment 90% (arm sling + RICE protocol)
>> Operative treatment for recurrent shoulder dislocation arthroscopy ‫منظار‬
• NB. Neurovascular injury associated >> Axillary nerve injury
• NB. Most common complication is recurrent shoulder dislocation, other in Scheme.

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 Proximal Humerus fracture
• Definition: Discontinuity in bone surface of head humerus.
• Classification and Incidence: Articular and Tuberosities in old age
• Mechanism injury: FOOSH
• Clinical: Scheme
• Management : Scheme+
>> Conservative treatment 90% (arm sling + RICE protocol)
>> Operative for Displaced # (ORIF),
Comminuted Articular (arthroplasty)
• NB. Neurovascular injury
>> Axillary nerve injury

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 Humerus shaft fracture
• Definition: Discontinuity in humeral shaft surface .
• Classification and Incidence: Proximal, Mid shaft, Distal
• Mechanism injury: Direct (Car window seat injury)
• Clinical: Scheme
• Management : Scheme+ Neurovascular
>> Conservative treatment 90% (arm brace + RICE protocol)
>> Operative treatment for PVONU (ORIF)
• NB. Neurovascular injury associated >> radial nerve injury
• NB. Most common complication is malunion, other iScheme

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 Elbow dislocation
• Definition: Discontinuity in humero-ulnar articulation.
• Classification and Incidence: Anterior dislocation, Posterior dislocation
• Mechanism injury: FOOSH
• Clinical: Scheme
• Management : Scheme+ urgent reduction ( by traction and counter traction)
>> Conservative treatment 90% (above elbow splint + RICE protocol)
>> Operative treatment for recurrent elbow dislocation arthroscopy ‫منظار‬
• NB. Neurovascular injury associated >> median, ulnar nerve injury, Brachial a.
• NB. Most common complication is recurrent dislocation, other Schemeee.

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 Fracture Ulna and Radius
• Definition: Discontinuity in bone surface of radius and ulna.
• Classification and Incidence: Proximal, Mid, Distal
• Mechanism injury: Direct trauma (Night stick fracture)
• Clinical: Scheme
• Management : Scheme+
>> Conservative only for fissures (above elbow cast)
>> Operative for Displaced # (ORIF),
• NB. Neurovascular injury
>> Posterior interosseous nerve injury

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 Moon & Ground

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 Distal end radius fracture
• Definition: Discontinuity in bone surface of distal radius.
• Classification : Posterior (Colles), Anterior (Smith)
• Incidence: Common in old age osteoporosis
• Mechanism injury: FOOSH
• Clinical: Scheme
• Management : Scheme+ Dinner Fork Deformity
>> Conservative Colles (below elbow cast)
>> Operative for Displaced #, Smith (unstable)(ORIF),
• NB. Neurovascular injury
>> Median nerve injury

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 Scaphoid fracture
• Definition: Discontinuity in bone surface of scaphoid bone.
• Classification : Non displaced, Displaced
• Incidence: Common in young age
• Mechanism injury: FOOSH
• Clinical: Scheme
• Management : Scheme+
>> Conservative non displaced (scaphioid below elbow cast)
>> Operative for Displaced # (ORIF >> Screw)
• NB. Common complication is Non union then Avascular necrosis
due to relevant poor blood supply.

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 Pelvic fracture
• Definition: Discontinuity in bone surface of pelvic bones.
• Classification: Compression>> AP or lateral..Shear
• Incidence: Common in young age accidents
• Mechanism injury: High energy trauma
• Clinical: Scheme +shock
• Management : Scheme+ ABCDE
>> Emergency Pelvic binder
>> Conservative non displaced
>> Operative for Displaced #
(ORIF >> Plate & Screw)

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 Hip dislocation
• Definition: Discontinuity in acetabulum and head femur articulation.
• Classification : Anterior dislocation, Posterior dislocation
• Incidence: Common posterior dislocation
• Mechanism injury: High energy trauma (Car dash board injury)
• Clinical: Scheme
• Management : Scheme+ urgent reduction ( by traction and counter traction)
>> Conservative treatment 90% (+ RICE protocol)
>> Operative treatment for associted acetabulum fractures
• NB. Neurovascular injury associated >> Sciatica nerve injury

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 Proximal Femur fracture
• Definition: Discontinuity in bone surface of proximal femur
• Classification : Neck femur..Intertrochanteric..Subtrochantric
• Incidence: Common in old age osteoporosis
• Mechanism injury: falling down ground
• Clinical: Scheme
• Management : Scheme+
>> Operative for all >> young ..ORIF Old...arthroplasty
• NB. Common complication is non union then Avascular necrosis
due to relevant poor blood supply cut with the fracture.

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 Femoral shaft fracture
• Definition: Discontinuity in bone surface of shaft femur.
• Classification : Proximal, middle, Distal
• Incidence: Common in young age accidents
• Mechanism injury: High energy trauma
• Clinical: Scheme + shock
• Management : Scheme+ ABCDE
>> Operative for all..ORIF
• NB. Common use of intramedullary nail

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 Knee Dislocation
• Definition: Discontinuity in tibial and femur articulation.
• Classification : Anterior dislocation, Posterior dislocation
• Incidence: Common posterior dislocation
• Mechanism injury: High energy trauma (car dash board)
• Clinical: Scheme
• Management : Scheme+ urgent reduction ( by traction and counter traction)
>> Conservative treatment 90% (+ RICE protocol) + knee brace
>> Operative treatment for associted fractures ORIF, ligaments injury arthroscope
• NB. Neurovascular injury associated >> sciatica nerve injury, popliteal artery

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 Tibia fracture
• Definition: Discontinuity in bone surface of shaft tibia.
• Classification : Open or Closed fracture
• Incidence: Common in young age accidents
• Mechanism injury: High energy trauma
• Clinical: Scheme + shock + open fracture
• Management : Scheme+ ABCDE
>> Operative for all >> closed ..ORIF open .. Ex fix
• NB. Common use of intramedullary nail
• Complications :Scheme + compartment syndrome

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 Ankle fracture
• Definition: Discontinuity in bone surface of lateral malleolus.
• Classification : At, Below, Above joint line
• Incidence: Common in young age Sport
• Mechanism injury: Low energy trauma
• Clinical: Scheme
• Management : Scheme
>> Operative for above and at joint line ..ORIF
below..Conservative below knee cast
NB. Common use of plate and screws

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 Ankle sprain
• Definition: Twisting injury to ankle ligament .
• Classification : Medial and lateral injury
>> Grade I one side, II two sides, III three sides + foot
• Incidence: Common in young age Sport
• Mechanism injury: Low energy trauma twist
• Clinical: Scheme
• Management : Scheme
Conservative treatment RISE protocol
>> Grade I ..Bandage 1 week ‫رباط ضاغط‬
>> Grade II...Below knee splint 2 weeks
>> Grade III...Below knee cast 4 weeks

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 Spine fractures: Cervical and Lumbar
• Definition: Discontinuity in bone surface of vertebrae,
• Classification : 3 Column ..Anterior Middle Posterior
• Incidence: Common in young age accidents
• Mechanism injury: High energy trauma
• Clinical: Scheme + Neurovascular
• Management : Scheme+
>> Conservative for one column
without neurologic insult (brace or collar)
>> Operative for Displaced # or 2 columns
decompression and fixation
• NB >>

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 NB, Notes on Spine fractures

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 Pediatric fractures

Shaft Growth plate

• Usually incomplete fractures ?
• Dangerous Fracture that involves the
• Distinct fracture patterns due to the unique epiphyseal plate or growth plate that may
properties of growing bones. The periosteum cause deformity
in growing bones is thicker and stronger than
in adult bones, which is why children are
more prone to more incomplete fractures eg.
greenstick and torus or buckle .

Conservative Operative reduction and

43 Cast fixation by K wire
 Fissure fracture ‫شرخ‬

Stress fracture Fatigue fracture

• Tiny cracks in a bone. They're caused by • Develop from normal use of a bone that's
repetitive force, often from overuse — such weakened by a condition such as
as repeatedly jumping up and down or osteoporosis, tumor, infection
running long distances
• Treatment underlying cause.
• Treatment conservative cast.

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 Undergraduate
Congenital bone diseases

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 Congenital bone diseases
• Congenital bone disorders are a group of various types of diseases that affect regular bone
growth.
• Aetiology could be idiopathic, genetic, medication, viral induced.
• Symptoms usually deformity.
• Management usually needs multidisciplinary team of orthopedic surgeon, physiotherapist,
neurologist, family support .
>> Surgical treatment age dependant includes ideally one procedure in order to stabilize the bone
and therefore increase the level of mobility.

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 Upperlimb Congenital

Winging scapula Arm shortening

• Usually due to damage or impaired
• Limb-length discrepancy is when one
innervation to the serratus anterior muscle. leg or arm is shorter than the other leg
or arm.

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 Elbow stiffness Absent Radius or Ulna
• Congenital elbow contracture is a rare upper-
extremity disorder. Arthrogryposis (multi joint
stiffness)is the main etiology of congenital
elbow stiffness.

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 Syndactyly Polydactyly: extrafingers
Fused skin of fingers

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 Spine and Pelvis congenital

Scoliosis : S twist of spine DDH

• Developmental dysplasia of the hip, means
that the hip joint of a newborn baby is
dislocated or about to dislocate.

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 Lower limb congenital

Femoral shortening Varus knee valgus knee

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 Intoe: internal rotation of the limb Dwarf: short stature

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 Flatfoot Talipus equino varus
Foot planterflxion and internal
rotation

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 Undergraduate
Inflammatory bone
diseases

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 Osteomyelitis
• Definition: infection of bone and bone marrow inside .
• Classification :Acute, Chronic
• Incidence : Common in children after trauma
• Mostly by staph aureus
• Predisposing factors..DM, HIV, immune compromise
• Clinical: General fever ...Local hot, red, tender, swallen
• Investigation: Lab high ESR, CRP, CBC..leukocytosis
>> X ray no changes early ..in chronic cavity with remenants
• Management : Scheme+ Antibiotic ( by Aspirate C/S)
>> Conservative treatment 90% (+ RICE protocol) + brace
>> Operative treatment for evacuate acute abcess, depridment chronic

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 Septic arthritis
• Definition: Bacterial infection of synovial membrane and synovial fluid .
• Classification: Acute, Chronic
• Incidence : Common in drug abuser or post surgical
• Mostly by staph aureus
• Predisposing factors..DM, HIV, immune compromised
• Clinical: General fever ...Local hot, red, tender, swallen
• Investigation: Lab high ESR, CRP, CBC..leukocytosis, synovial fluid analysis
>> X ray no changes early ..in chronic cavity with remenants
• Management : Scheme+ Antibiotic ( after aspirate C/S)
>> RICE protocol + brace
>> Operative urgent for evacuate pus from the joint
• Complications degeneration of articular cartilage with early osteoarthritis ...Stiff joint
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 DD. Synovial fluid aspirate

• Inflammatory..like rheumatoid arthritis causing synovitis affect mainly hand.

• Gout..uric acid crystals deposited in joint cause synovitis affect commonly big toe.
• Hemophilia..bleeding disorder cause hemorrhage inside the joint affect commonly knee.

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 Osteoarthritis
• Definition: Degerative disease of the joints
• Classification: Stages
• Incidence : Common in old age in knee joints
• Predisposing factors: genetic, familial, racial, previous fracture
• Clinical: pain , swallen, stiffness
• X ray Stages
• Management : Scheme+
>> Conservative treatment 90% (+ RICE protocol) + brace
>> Operative treatment for advanced cases by arthroplasty

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 Osteoporosis
• Definition: Metabolic bone disease in old age
causing decrease bone density.
• Classification: stages Osteopenia then early, late Osteoporosis
• Incidence: Common in old age, in spine, hip, end radius
• Predisposing factors: Decreases calcium and vitamin D intake
• Clinical: pain, fatigue fracture
• X ray rarefaction, best DEXA scan
• Management : Scheme+ sport strengthing
>> Conservative treatment 90% (calcium + vit D)+ bone forming drugs + brace
>> Operative treatment for advanced deformity cases by correction osteotomy .

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 Rickets
• Definition: Metabolic bone disease in children soften the bone.
• Classification: Stages Active..Healing..Healed..Deformity
• Incidence : Common in children age , no sun exposure
• Predisposing factors: Decreases calcium and vitamin D intake
• Clinical: Deformity Genu valgus varus, bossing skull, rosary beades
• X ray stages Active..Healing..Healed..Deformity
• Management : Scheme+
>> Conservative treatment 90% (calcium + vit D) + brace
>> Operative treatment for advanced deformity cases by correction osteotomy .

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 DEXA scan
• The investigation of choice to diagnose osteoporosis by comparing bone density of the patient to
bone intensity of normal person.

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 Painful Conditions
• Carpal tunnel syndrome: Compression on median nerve by wrist flexor
retinaculum, causing pain and numbness at hand.
• Trigger finger:Chronic inflammatory tenosynovitis causing nodule
restricting tendon movement.
• Tenosynovitis: Acute Inflammation of tendon sheath causing pain on
movement .
• Tennis & Golfer elbow: Inflamation of the muscle origin.
• Bursitis: Inflammation of bursa sac cover outside joints.
• Planter fascitis: Inflammation of planter fascia causing heal pain.

• Treatment
>> Conservative mainly, RICE protocol
+ Local injection steroid
>> Operative in resistance cases
release of compression
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 Undergraduate
Musculoskeletal Tumors

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 Benign Msk Tumors • Latent ..No complaint, very
slow growing , stop at adult
• Active..patient complaints
with observed growing but
stop at adult
• Aggressive... complaints with
rapid growth even after adult

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 Malignant Msk Tumors
• Stages
I.. Intracompartement
II..Extracompartement
III..Distant metastasis
• Grades
Low grade ..good
High grade..bad

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 Diagnostic
• Patient complaints of swelling or mass, pathological fracture

• X-ray most common is metastasis

• A..age
<30 (a.e.i.o.u) Anurismal bone cyst/Ewing Sarcoma/Infection/Osteosarcoma/Unicameral bone cyst
>30 (MACRO) Metastases/Adult lymphoma/Chondrosarcoma/Round cell multiplemyloma
/Osteosarcoma
• B..bone
Which bone? (Sacrum >> chordoma/ Hand >> Chondroma/.....)
Which part? Epiphysis>> Giant cell tumor ‫ كبير‬Chhondroblastoma ‫طفل‬

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67
 • C..content = matrix
Osteogenic (flafy cotton)..
Chondrogenic (calcification)..
Fibrous ( ground glass).

• D..delineation

• E..extension to tissue surround infiltrates / Bone morrow/joint/

vasular invasion

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 Management
• If suspect tumor & pre-operative.... CT & MRI whole limb
• Benign..
>> Latent ..Conserve
>> Active... Currtage
>> Aggressive... Excision

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 Undergraduate
Examination

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 General
• Identification ‫سالم عليكم انا د محمود‬
• Excuse ‫استاذنك افحصك لالمتحان‬
• Exposure Upper limb..bared till cervical spine , Lower limb..bared till cervical and lumbar spine

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 Special
Tests of
Upper-
limb

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 Special
Tests of
Lower-
limb

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