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Orthopedics Rapid Revision Lecture

Jul 20, 2024

Orthopedics Rapid Revision Lecture 🦴

Lecture Plan

  • Duration: 4 hours
  • Structure: 2 hours lecture, short break, another 2 hours lecture
  • Focus: Rapid revision of Orthopedics
  • Share notes and one-liners within the lecture

Important Topics

Basic Terms and Anatomy

  • Orthopedics Terminology: Prefix used for deformities (cubitus, coxa, genu, Manus, helex, PES)
  • Important facts:
    • Father of Orthopedics: Nicholas Andre
    • Important anatomical lines (e.g., midline for deformity identification)
    • Deformities identification: valgum (away) and varum (towards midline)
  • Bone Identification: Hip joint, Knee joint, etc.

Specific Deformities

  • Cubitus: At the elbow joint
    • Cubitus valgus: Away from midline
    • Cubitus varus: Towards midline
  • Genu: At the knee joint
    • Genu valgum: Knock knees – feet away from midline
    • Genu varum: Bow legs – feet towards midline
  • Coxa: At the hip joint
    • Coxa valgum: Away from midline
    • Coxa varum: Towards midline
  • Manus varus: Problem at the wrist joint, hands going inwards
  • Foot Deformities: Pes valgus, Pes varus, Helux valgus, Helux varus
  • Wind Sweep Deformity: Valgus in one limb and varus in another

Skeletal System Basics

  • Axial Skeleton: 80 bones (includes hyoid bone and ear ossicles)
  • Appendicular Skeleton: 126 bones (incl. clavicle)
  • Bone Composition:
    • Organic part: Osteocytes, Osteoblast, Osteoclast, Collagen (Type 1), Non-collagenous proteins
    • Inorganic part: Hydroxyapatite
    • Osteoid (growing bone), Osteon (mature bone)

Pediatric Conditions

  • Rickets: Vitamin D, Calcium, and Phosphate deficiency
    • Clinical features: Craniotabes, Frontal bossing, Harrison sulcus, Rachitic rosary, Deformities (e.g., genu valgum, genu varum)
    • Diagnosis and Treatment: Radiological signs (cupping, fraying, splaying), Vitamin D dosage
  • Osteomalacia: Malabsorption of vitamin D in adults
    • Clinical features: Low back pain, Pseudofractures (Milkman’s fractures)
    • Diagnosis and Treatment: Bone biopsy, Vitamin D supplementation

Osteoporosis

  • Definitions:
    • Primary: Post-menopausal, senile
    • Secondary: Due to medications or other conditions (e.g., glucocorticoids, rheumatoid arthritis)
  • Investigation: DEXA scan, T-score, Z-score
  • Treatment: Bisphosphonates, Calcitonin, HRT, SERMs, Denosumab

Genetic Bone Diseases

  • Osteogenesis Imperfecta: Brittle bone disease (genetic defect COL1A1, COL1A2)
    • Clinical features: Multiple fractures, Blue sclera, Hearing impairment
    • Treatment: Bisphosphonates, Surgical (Sofield-Miller operation)
  • Achondroplasia: Most common cause of dwarfism (FGFR3 mutation)
    • Clinical features: Short height, Trident hand, Champagne glass pelvis
    • Treatment: Symptomatic; no definitive cure
  • Paget’s Disease: Skeletal disorder causing enlarged and misshapen bones (SQSTM1 mutation)
    • Clinical features: Increased bone turnover, Deformities
    • Treatment: Bisphosphonates, Surgery (osteotomy)

Bone Tumors

  • Osteochondroma: Most common benign bone tumor
    • Radiographic features: Metaphyseal origin, “Exostosis”, Sessile or pedunculated
    • Treatment: Excision if symptomatic
  • Giant Cell Tumor: Common in adults (20-40 years)
    • Location: Epiphysis
    • Radiographic features: Soap bubble appearance
    • Treatment: Curettage, Bone grafting
  • Osteosarcoma: Common primary malignant bone tumor
    • Age: Adolescents and young adults
    • Location: Metaphysis, usually around knee
    • Radiographic features: Sunburst pattern, Codman's triangle
    • Treatment: Chemotherapy followed by surgical resection
  • Ewing’s Sarcoma: Highly malignant bone tumor
    • Age: Children and adolescents
    • Location: Diaphysis of long bones, pelvis
    • Radiographic features: Onion skin appearance
    • Treatment: Chemotherapy, radiotherapy, surgical excision
  • Chondrosarcoma: Malignant tumor of cartilage
    • Age: Adults (30-60 years)
    • Radiographic features: “Popcorn” mineralization
    • Treatment: Surgical resection

Knee Joint Injuries

  • Ligament Injuries: ACL, PCL, MCL, LCL
    • Tests: Anterior drawer test, Lachman test, Pivot shift test
    • Treatment: Non-operative (brace), Surgical (graft)
  • Meniscus Injuries: Medial more commonly injured
    • Clinical features: Locking, pain after 24-48 hours
    • Tests: McMurray test
    • Treatment: Meniscectomy or meniscal repair
  • Patella Fractures: Displaced vs. non-displaced
    • Treatment: Tension band wiring or partial/total patellectomy

Spinal Conditions

  • Spondylolysis: Stress fracture in pars interarticularis
    • Symptoms: Lower back pain
    • Treatment: Conservative (bracing), Surgical if refractory
  • Spondylolisthesis: Vertebra slips over the one below it
    • Grades: I to IV based on percentage slippage
    • Investigation: X-ray (Scotty dog appearance)
    • Treatment: Bracing, Surgical (fusion)
  • Prolapsed Intervertebral Disc (PID): Commonly L5-S1
    • Symptoms: Radicular pain, positive straight leg raise (SLR)
    • Treatment: Conservative initially, Surgery (microdiscectomy) if needed

Miscellaneous Conditions

  • Carpal Tunnel Syndrome: Compression of median nerve
    • Symptoms: Numbness, tingling in hand
    • Tests: Phalen’s, Tinel’s sign
    • Treatment: Splinting, Surgery (release)
  • Congenital Talipes Equinovarus (Clubfoot)
    • Deformity: C.A.V.E (Cavus, Adductus, Varus, Equinus)
    • Treatment: Ponseti method (serial casting), Bracing

Tenosynovitis

  • Trigger Finger: Stenosing tenosynovitis of flexor tendons
    • Symptoms: Triggering, locking of finger
    • Treatment: Splinting, Steroid injection, Surgery
  • DeQuervain’s Tenosynovitis: Inflammation of first dorsal compartment
    • Clinical test: Finkelstein test
    • Treatment: Thumb spica splint, NSAIDs, Steroid injection
  • Dupuytren's Contracture: Palmar fibromatosis leading to finger flexion contracture
    • Treatment: Needle aponeurotomy, Collagenase injection, Fasciectomy if severe

Common Fractures and Treatments

  • Colles' Fracture: Distal radius fracture with dorsal displacement
    • Treatment: Closed reduction and casting, ORIF if displaced
  • Smith’s Fracture: Distal radius fracture with volar displacement
    • Treatment: Closed reduction and casting, ORIF if needed
  • Scaphoid Fracture: Common in young adults, FOOSH injury
    • Tenderness in anatomical snuffbox
    • Treatment: Thumb spica cast, ORIF if displaced
  • Boxer’s Fracture: Fifth metacarpal neck fracture
    • Treatment: Closed reduction and casting, ORIF if severely displaced

Key Surgical Procedures and Devices

  • Fracture Treatments: ORIF, CRIF, Intramedullary nailing, External fixation
  • Joint Replacement: Total hip/knee replacement for severe arthritis or trauma
  • Spinal Surgery: Discectomy, Fusion, Laminectomy
  • Common Orthopedic Devices: Plates, Screws, Intramedullary rods, External fixators

These notes capture the overarching principles and essential details covered in the lecture. Further review of specific images and clinical cases will complement this summary.

Full transcript