Special thanks to Waleed Abu Lubbad for no specific reason

PBL 1

Done by: Ali Alabbadi

Corrected by: AbdelRahman Al

Orthopedics:

Means “straight child” in Greek

Deal with treating diseases of bones and muscles

Diseases that affect bones and muscles tend to fall into 3 different categories:

1. Congenital

a. Genetic, drugs, radiation

2. Developmental

a. Developmental dislocation of hip (DDH), tendon abnormalities,

compressive neuropathy (nerve having pressure applied abnormally)

3. Acquired

a. Trauma, infection, paralysis, arthritis, neoplasm

Genetic:

in this picture, notice how the patients left leg is

smaller than his right, called hemi atrophy or hemi

hypertrophy

This example shows the following; if a patient comes in

complaining of knee pain, it is important to fully expose

the entire area in order to compare the contralateral

side.

Here, we see that the patient is shorter than normal, and he

has a joint deformity that is called genu valgum. It also called

“knock knees”.

This example we all know, typical dwarfism caused by

achondroplasia. His trunk and head are normal, but his

limbs are short.

This is another form of dysplasia, called

macrodactyly. It means one digit is larger

compared to the rest.

This is called lobster feet, because the

feet look like lobster claws.

Other forms of genetic abnormalities involving the peripheries include syndactyly,

polydactyly, craniosynostosis, and blue sclera caused by OI. (remember patho)

Defects that affect the spine:

Scoliosis; the spine is deviated to the left or right (coronal or

AP view).

Kyphosis; the spine has an exaggerated hump

Here the patients’ shoulders are

pushed together, in a disease

called clavicle dysostosis, they

have no clavicle, allowing the

medial deviation of their

shoulders.

Drugs and Radiation:

In the 50s pregnant women were prescribed

thalidomide for morning sickness, this caused their

babies to be born with malformed limbs.

Developmental:

Carpal Tunnel syndrome, caused by pressure on the carpal

tunnel and is painful for patient while affecting distribution

of the median nerve in hand.

DDH is a dislocation of

the femoral head in

newborns.

Genu varum, opposite of genu valgum, in which the

knees are bowed outward.

Acquired:

Infection with sinus drainage. This

infection is iatrogenic, because it was

caused by improper aseptic technique by

hospital staff (notice surgical scar).

Claw hand, caused by damage to the ulnar nerve

in the hand, also called ulnar nerve palsy.

Here, you can see the muscles of the thumb (thenars)

are wasting, meaning this patient has his median nerve

compressed (carpal tunnel), although to reach this stage

it must be chronic.

This is a case of osteosarcoma.

Osteoarthritis

X-ray

Gross

Severe cases can need

replacement surgery

Here is another case of arthritis,

but in the hip. Hip replacement

surgery may be required.

Trauma and Infection:

Can be soft tissue, bone or both, and it is the bread and butter of orthopedics.

Here is a simple cut wound. When it comes to

trauma of limbs, the most important things that

need to be worried about are nerves and vessels.

In trauma cases there is a very important list that we all need to know:

1. Life; make sure the patient will not die.

2. Limb; save the limb by saving vascularity, no vascularity = no limb

3. Wound; prevent infection

4. Fracture; treatment can be delayed

In the picture above, the trauma is not life threatening, so you should check on

the functionality of the nerves and vessels that may be damaged, such as the

radial nerve, and axillary artery.

Here we see a small puncture wound in the

patients arm, caused by a skewer. The patient

later came in with swelling, pain and a tingling

sensation.

From anatomy, we remember in the limbs there are some major structures; bone,

muscle, nerves, vessels, and fascia. In a wound such as this, the fascia is

penetrated, but not to a degree that allows free bleeding. This means that blood

will continue to pool in the compartment, causing even more swelling (other than

natural inflammation). If this swelling is ignored, it can cause extravascular

compression which can close major arteries and veins. This can lead to an

infarction and necrosis of large portions of the arm (no vascularity = no limb). This

also compresses nerves, which causes the pain and tingling sensation the patient

complained about. This is called compartment syndrome.

For major cases of compartment symptom, the

treatment is to drain the compartment, in this case

with an operation called a fasciotomy. This relieves the

pressure, saving the limb.

Another common form of acquired soft

tissue ailments is infection. Here we

see a large portion of the skin is

necrotic, which we call eschar.

Treatment for necrotic tissue is

debridement and drainage of the pus.

The most common pathology of bone

is fractures, here we have a fracture of

the diaphysis (a little patho review,

this is a transverse, displaced, simple

fracture).

Here is another fracture, but in this case, the

trauma also caused a dislocation of the

t tibiotalar joint. This trauma will most likely

have long term effects.

Treatment can vary from simple immobilization, to reduction (putting bone back

in place), to major surgeries requiring prostheses.

In cases with open fracture like this, your

main cause of concern is not the fracture

itself or any soft tissue damage, but

infection. Major traumas have a list of

treatment and support methods in order to

help the patient survive, recover limb

functionality, and be comfortable (relieve

pain).

This list is as follows:

Advanced Trauma Life Support (ATLS)

Analgesia

Antibiotics

ATS (??)

Adequate irrigation and splinting

ATLS has yet another checklist in order to deal with the trauma, abbreviated as

ABCDE:

1. A – airway

2. B – breathing

3. C – Circulation

4. D – disability (unconsciousness)

5. E – exposure (full physical examination of patient)

These were put in this specific order based on their mortality rates.

This patient has a fracture, and it

also caused compartment

syndrome, and the surgery he

had performed fixed the fracture,

as well as draining the

compartment.

The shoulder is the most mobile

joint in the body, meaning it is

also the least stable, and is

commonly dislocated. The

shoulder can be dislocated

anteriorly or posteriorly.

Posterior dislocations are much

less common, and happen in 2

situations; seizures or electric

shocks. The dislocation happens

due to a loss of control of the

muscles, allowing the stronger

internal rotators of the shoulder to

take control and pop the humerus

out of its socket.

The scary thing about shoulder dislocations is its proximity to the axillary nerve.

Some people are hyper lax, meaning they are very flexible and can voluntarily

dislocate joints in their body. There is pathologic hyper laxity which is usually

involved with genetic or developmental defects. You should not attempt to treat

these people.

Finally, the last case we are familiar with, and it is ACL injuries. The ACL is located

in the knee joint and normally it prevents anterior displacement of the tibia on

the humerus. This can happen due to being hit on the leg, or it can happen due to

pivoting of the leg when landing from a jump. Surgery is a must in this injury, and

it is performed by grafting a part of the hamstring in place of the ACL.

Hamstring graft