1. Introduction to Orthopaedics

2. Orthopedic Surgery = Not only Bone Surgery Orthopedic specialty is the branch of Surgery which manage trauma and disease of Musculoskeletal system It includes : bones, muscles, tendons, ligaments, joints, peripheral nerves, vertebral column and spinal cord and its nerves

3. Orthopedic Specialty Sub-Specialties in orthopedic include :  General  Pediatric Orthopedic  Sport and Reconstructive Orthopedic  Orthopedic Trauma  Arthroplasty (Joint Replacement)  Spinal Surgery  Foot and Ankle surgery  Oncology  Hand Surgery  Upper Limb

4. Red Flags Red Flags = Warning Symptom or Sign Red flags should always be looked for and remembered Presence of a red flag means the necessity for urgent or different action/intervention

5. Examples of Red Flags Open Fractures : more serious and very high possibility of infection and complications Complicated Fractures : fracture with injury to major blood vessel, nerve or nearby structure Compartment Syndrome : increase in intra- compartment pressure which endangers the blood circulation of the limb and may affect nerve supply Cauda Equina Syndrome : compression of the nerve roots of the Cauda Equina at the spinal canal which affect motor and nerve supply to lower limbs and bladder (also saddle or peri-anal area)

6. Examples of Red Flags Infection of Bone, Joint and Soft Tissue Osteomyelitis : Infection of the bone Septic Arthritis :Infection of the joint Cellulitis :spreading Infection of the soft tissue May cause septicemia or irreversible damage. Multiple Trauma or Pelvic Injury: more than one fracture or injury sustained at the same time consider massive blood loss and associated injuries. Acute joint Dislocations : requires urgent reduction or may cause serious complications

7. Othropaedic Terminology

8. Descriptive Orthopaedic Terms Valgus: part of body distal to joint directed away from midline Varus: Part of body distal to joint directed toward midline Hallus Genu varus Genu valgus pes varus metatarus valgus metatarus varus

9. Hallus valgus Which foot has a valgus deformity? How do you describe this foot deformity?

10. Alignment terminology

11. Alignment Terminology: Cubitus Varus

12. Alignment terminology: Cubitus Valgus

13. Orthopaedic History A good general orthopaedic history contains:  Onset, Duration, and Location of a problem  Limitations and debilitation attributed to the problem  Good surgical history, especially with regards to orthopaedic surgeries and prior anesthesia  Co-morbid conditions that contribute to the problem or will preclude healing in some manner

14. Physical Exam Basics Inspect and Palpate everything- start with normal structures and move to abnormal Range of motion in all planes Strength Sensation Reflexes Gait Stability

15. Physical Exam Basics NVI What does this mean? 1. Neurologic exam- Always document the neurologic status. Some fractures are associated with nerve injuries and knowing the status of the nerve is critical 2. Vascular exam- Always check for pulses distal to the fracture sight. Missed vascular injuries can be devastating

16. Physical Exam NEVER trust someone else’s exam. ALWAYS put your hands on the patient and see for yourself Always trust your exam- you WILL pick up something that someone else has missed at some point

17. Acquired or Congenital Acquired conditions include :  Trauma  Developmental  Inflammation  Infection  Neuromuscular  Degenerative  Metabolic  Tumor

18. Traumatic Injuries Fractures Dislocations Soft tissues injuries: ligaments, tendons Nerve injuries Epiphyseal injuries

19. Congenital Anomaly : Talipes Equino Varus TEV

20. Fractures: Break in the continuity of bone

21. Dislocations Complete separation of the articular surface Distal to proximal fragment Anterior, Posterior, Inferior, Superior

22. Dislocation with fracture of the bone Always X-Ray Joint Above and Below Fracture Dislocation

23. Force due to Resisted Muscle Action:- “Avulsion” Transverse pattern Avulsion Fracture

24. Intra-articular Fractures If displaced ; should always be treated by ORIF= Open Reduction and Internal Fixation failure to reduce and fix such fracture results in loss of function, deformity and early degenerative changes

25. Soft tissue injuries of the knee

26. (Developmental Dislocation of Hip) DDH

27. Developmental Foot deformity: Hallux Valgus

28. Developmental: SCFE (Slipped Capital Femoral Epiphysis)

29. Spinal Deformities: Kyphosis or Hyperlordosis

30. Spinal Deformity: Scoliosis

31. Degenerative Disorders Occur at any joint Knee & hip most common sites Can be primary or secondary Can lead to pain and/or deformity and/or loss of function

32. Osteoarthritis of Hip

33. Osteoarthritis of Knee

34. Metabolic Disorders (Rickets): Bow Legs

35. Osteoporosis: Hip Fracture

36. Osteoporosis: Colles fracture

37. Bone Tumor

38. Bone tumors

39. Neurological Evaluation : Sensory & Motor

40. Nerve Injury: Muscle wasting

41. Spinal Cord Injury Often results from fracture dislocation of spine When injury is at cervical spine it may result in Tetraplegia Injury at dorsal spine may result in Paraplegia

42. Neuromuscular disorder: Polio

43. Chronic Osteomyelitis : discharging sinus

44. Chronic Osteomyelitis : Sequestrum

45. Physiotherapy for Orthopaedic Patients Physiotherapy is an important part of recovery It is used for : pain relief, prevention of stiffness, muscle strengthening, mobilization of stiff joint or spine, training non-weight bearing or partial weight bearing Physiotherapy modalities include: heat, cold, exercise, ultrasound, traction, electrical stimulation

46. Clinical Skill: Cast application

47. Clinical Skills: Knee Aspiration

48. SPINAL DEFORMITIES

49. NORMAL SPINE ALLIGNMENT FRONTAL PLANE STRAIGHT LATERAL PLANE 20-40 DEGREE THORACIC KYPHOSIS 30-60 DEGREE LUMBAR LORDOSIS

50. SCOLIOSIS Def. Lat. deviation of the spine from midline with rotation

51. Rotation in scoliosis

52. SCOLIOSIS Types :  Congenital (structural abn. In vertebrae or ribs )  Neuromuscular (eg. Cerebral palsy, spinal muscular atrophy…)  Idiopathic (most common )  Others

53. CONGENITAL CLASSIFICATION Wedge vertebrae Hemi- vertebrae Unilateral Bar vertebrae Block vertebrae

55. IDIOPATHIC SCOLIOSIS TYPES  Infantile (0-4 yrs )  Juvenile (4-9 yrs )  Adolescent (> 10 yrs ) [most common]

56. IDIOPATHIC SCOLIOSIS  Incidence  More in female  Rt thoracic curve is the most common  ? Family Hx  More in twins

57. IDIOPATHIC SCOLIOSIS Complications :  Loss of self image  Family observation  Pain  Early fatigue  Cardio-pulmonary dysfunction ( if curve > 90 )

58. IDIOPATHIC SCOLIOSIS On Examination :  Shoulder level inequality  Waist line asymmetry  Spinal deformity  Rib hump  Adam foreword flexion test  Full neurological exam

59. Adam’s Forward Bend Tet

60. clinically

61. IDIOPATHIC SCOLIOSIS Radiological exam :  X-rays :  AP – LAT standing long film  AP supine  AP Pelvis  LAT spine

62. IDIOPATHIC SCOLIOSIS  MRI : If abnormal curve suspected  Ct scan : If congenital scoliosis suspected

63. X-ray 71 ْ 53 ْ

64. Cobb and Lippmann  Determine end vertebrae Those most tilted from horizontal  Line along upper end plate prox. & lower endplate distally  Measure formed angle Transitional vertebrae

65. Treatment Based on : 1. Maturity of the pt.  Menarche  Risser’s sign 2. Magnitude of deformity 3. Curve progression

66. Risser’s stage eg.

67. Treatment Options 1. Observation 2. Bracing 3. Surgery ? Physical therapy & exercise

68. Treatment ( protocol )  Mature pt.  < 50 ْ observation progression ~ 1 ْ / year  > 50 ْ surgery  Immature pt.  0-25 ْ Observation every 4-6 months clinically & radiologically  25-40 ْ Bracing  > 40 ْ Surgery

69. Braces eg.

70. Treatment  Braces :  Did not correct the deformity  Might stop the progression of the curve (or slow it down)  Effect is dose related (more worn better effect)  Best 23 hours / day  If curve apex above T7 Milwaukee brace  If curve apex bellow T8 Boston brace

71. Milwaukee brace

72. Boston brace

74. Treatment  Surgery :  Anterior spinal fusion  severe curve  young pt. < 10 years  Post spinal fusion & instrumentation The gold standard treatment for most of cases  Both For selected cases

75. Treatment  Complications of surgery  Neurological deficit  Bleeding  Infection  Pseudoarthrosis  Crank shaft phenomena

77. Examples

84. What is a herniated disc?  The spine is made up of a series of connected bones called "vertebrae.“  The disc is a combination of strong connective tissues which hold one vertebra to the next and acts as a cushion between the vertebrae.  The disc is made of a tough outer layer called the "annulus fibrosus" and a gel-like center called the "nucleus pulposus."  As you get older, the center of the disc may start to lose water content, making the disc less effective as a cushion.

85.  A herniated lumbar disc can press on the nerves in the spine and may cause pain, numbness, tingling or weakness of the leg called "sciatica." Sciatica affects about 1-2% of all people, usually between the ages of 30 and 50.  A herniated lumbar disc may also cause back pain, although back pain alone (without leg pain) can have many causes other than a herniated disc.

87. Anatomy - Normal Lumbar Disc  In between each of the five lumbar vertebrae (bones) is a disc, a tough fibrous shock-absorbing pad.  Endplates line the ends of each vertebra and help hold individual discs in place.  Each disc contains a tire-like outer band (called the annulus fibrosus) that encases a gel-like substance (called the nucleus pulposus).

88.  Nerve roots exit the spinal canal through small passageways between the vertebrae and discs.  Pain and other symptoms can develop when the damaged disc pushes into the spinal canal or nerve roots

89.  Disc herniation occurs when the annulus fibrous breaks open or cracks, allowing the nucleus pulposus to escape.  This is called a Herniated Nucleus Pulposus (HNP) or herniated disc herniated disc

90. Signs and Symptoms  The lumbar spine consists of the five vertebrae in the lower part of the spine, each separated by a disc, also called a lumbar disc.  The discs in this part of the spine can be injured by certain movements, bad posture, being overweight and disc dehydration that occurs with age.

91. Signs and Symptoms  Although the lumbar vertebrae are the biggest and strongest of the spinal bones, risk of lumbar injury increases with each vertebrae down the spinal column because this part of the back has to support more weight and stress than the upper spinal bones.

92. Signs and Symptoms  The lumbar disc is the most frequent site of injury in several sports including gymnastics, weightlifting, swimming and golf, although athletes in general have a reduced risk of disc herniation and back problems.

93. Signs and Symptoms Symptoms of disc herniation in the lower back are slightly different from symptoms in the cervical or thoracic parts of the spine.cervicalthoracic The spinal cord ends near the top lumbar vertebrae but the lumbar and sacral nerve roots continue through these spinal bones. lumbar disc herniation may cause:  Lower back pain  Pain, weakness or tingling in the legs, buttocks and feet  Difficulty moving your lower back  Problems with bowel, bladder or erectile function, in severe cases

94.  L4  Quads/Tibialis Anterior  Patellar reflex  Sensory Great toe and medial leg

95.  L5  Strength of Ankle and great toe dorsiflexion  Extensor Hallucis Longus  Sensory to dorsum of foot

96.  S1  Ankle reflexes and sensation of posterior calf and lateral foot  Peroneals/Gastroc  Achilles reflex  Sensory to lateral and plantar foot

97. Diagnosis Initial diagnosis of lumbar herniation generally is based on the symptoms of lower back pain. Your doctor will examine your sensation, reflexes, gait and strength. Your doctor also may suggest the following tests:  X-ray -- High-energy radiation is used to take pictures of the spine. X-ray  Magnetic Resonance Imaging (MRI) -- An MRI provides detailed pictures of the spine that are produced with a powerful magnet linked to a computer. Magnetic Resonance Imaging (MRI)  Computed Tomography (CT) Scan -- A CT scan uses a thin X-ray beam that rotates around the spine area. A computer processes data to construct a three-dimensional, cross-sectional image. Computed Tomography (CT) Scan  Electromyography (EMG) -- This test measures muscle response to nervous stimulation. Electromyography (EMG)

98. Treatment Conservative treatment of lower disc pain usually is successful over time. It includes:  Pain medication or pain therapies such as ultrasound, massage or transcutaneous electrical nerve stimulation  Anti-inflammatory medication such as aspirin, ibuprofen and acetaminophen  Physical therapy  Steroid injections  Education in proper stretching and posture  Rest

99. Treatment  However, if your pain doesn't respond to conservative treatment in two to four weeks, your condition affects your bowel or bladder function, or if it threatens permanent nerve damage, your doctor may suggest surgery.  Modern methods of surgery allow some spine operations to be performed through tiny incisions using miniature instruments while a microimaging instrument called an endoscope is used to view the surgery site

100. Treatment  The surgery usually includes removing the part of the disc that has squeezed outside its proper place, called a discectomy.  The surgeon also may want to remove the back part of the vertebrae, called the lamina, in a laminectomy; or to surgically open the foramen, the holes on the side of the vertebrae through which the nerves exit, in a foramenotomy.  Only about 10 percent of adult lumbar disc patients require surgery and even fewer children and adolescents

101. THAN YOU