dr . Rami Abo Ali

1. ORTHOPEDIC SURGERY
Dr. Rami Abo Ali
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
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2. INTRODUCTION
Orthopedic
Surgery
-
Dr.
Rami
Abo
Ali
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3.  Orthopaedic surgeons deal with deformity,
diseases of bones and joints, and injuries to the
musculoskeletal system
 Despite these ancient origins, the word
‘orthopaedic’ is a recent introduction derived
from the title of a book published by a French
physician, Nicolas Andry, in 1741: Orthopaedia,
or, The Art of Correcting and Preventing
Deformities in Children
 The word itself is derived from the Greek orthos
pais and means only ‘straight child’
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

4. HISTORY AND CLINICAL EXAMINATION
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Orthopedic
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Dr.
Rami
Abo
Ali

5. SYMPTOMS
 Pain
Pain is the most common symptom in orthopedics.
Severity is even more subjective
 The following is suggested as a simpler system:
 Grade I (mild) Pain that can easily be ignored
 Grade II (moderate) Pain that cannot be ignored,
interferes with function and needs attention or
treatment from time to time
 Grade III (severe) Pain that is present most of the
time, demanding constant attention or treatment
 Grade IV (excruciating) Totally incapacitating pain
 Referred pain
 Pain arising in deep structures is more diffuse and is sometimes of
unexpected distribution; thus, hip disease may manifest with pain in the
knee
 This is not because sensory nerves connect the two sites; it is due to inability
of the cerebral cortex to differentiate clearly between sensory messages
from separate but embryologically related sites
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Orthopedic
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Dr.
Rami
Abo
Ali

6.  Stiffness
 Stiffness may be generalized (typically in systemic disorders such
as rheumatoid arthritis and ankylosing spondylitis) or localized to
a particular joint
 Locking ‘Locking’ is the term applied to the sudden inability to
complete a particular movement. It suggests a mechanical block
– for example, due to a loose body or a torn meniscus becoming
trapped between the articular surfaces of the knee
 Swelling
 Swelling may be in the soft tissues, the joint or the bone; to the
patient they are all the same. It is important to establish whether
it followed an injury, whether it appeared rapidly (think of a
haematoma or a haemarthrosis) or slowly (due to inflammation,
a joint effusion, infection or a tumour), whether it is painful
(suggestive of acute inflammation, infection or a tumour),
whether it is constant or comes and goes, and whether it is
increasing in size
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Orthopedic
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Dr.
Rami
Abo
Ali
SYMPTOMS

7. SYMPTOMS
 Deformity
 The common deformities are described by patients in terms such as
round shoulders, spinal curvature, knock knees, bow legs, pigeon
toes and flat feet. Deformity of a single bone or joint is less easily
described and the patient may simply declare that the limb is
‘crooked’.
 Weakness
 Generalized weakness is a feature of all chronic illness, and any
prolonged joint dysfunction will inevitably lead to weakness of the
associated muscles
 Instability
 The patient may complain that the joint ‘gives way’ or ‘jumps out of
place’. If this happens repeatedly, it suggests abnormal joint laxity,
capsular or ligamentous deficiency, or some type of internal
derangement such as a torn meniscus or a loose body in the joint 7
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

8. SYMPTOMS
 Change in sensibility
 Tingling or numbness signifies interference with nerve function –
pressure from a neighbouring structure (e.g. a prolapsed
intervertebral disc), local ischaemia (e.g. nerve entrapment in a
fibro-osseous tunnel) or a peripheral neuropathy.
 Loss of function
 The patient may say, ‘I can’t stand for long’ rather than ‘I have
backache’; or ‘I can’t put my socks on’ rather than ‘My hip is stiff.’
 PAST HISTORY
 FAMILY HISTORY
 SOCIAL BACKGROUND
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9. EXAMINATION
 The traditional clinical routine, inspection, palpation,
manipulation, was replaced by look, feel, move.
 Look
 Abnormalities are not always obvious at first sight. A systematic,
step-by-step process helps to avoid mistakes.
 Shape and posture
 Skin Careful attention is paid to the colour, quality and markings
of the skin. Look for bruising, wounds and ulceration. Scars are an
informative record of the past – surgical archaeology. Colour
reflects vascular status or pigmentation – for example, the pallor
of ischaemia, the blueness of cyanosis, the redness of
inflammation, or the dusky purple of an old bruise.
 Abnormal creases, unless due to fibrosis, suggest underlying
deformity which is not always obvious; tight, shiny skin with no
creases is typical of oedema or trophic change
 General survey . Attention is initially focused on the symptomatic
or most obviously abnormal area, but we must also look further
afield
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Orthopedic
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Dr.
Rami
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Ali

10. EXAMINATION
 Feel
 Feeling is exploring, not groping aimlessly. Know your anatomy
and you will know where to feel for the landmarks; find the
landmarks and you can construct a virtual anatomical picture in
your mind’s eye
 The skin
 Is it warm or cold; moist or dry; and is sensation normal?
 The soft tissues
 Can you feel a lump; if so, what are its characteristics? Are the pulses
normal?
 The bones and joints
 Are the outlines normal?
 Is the synovium thickened? Is there excessive joint fluid?
 Tenderness
 Once you have a clear idea of the structural features in the affected
area, feel gently for tendernessKeep your eyes on the patient’s face; a
grimace will tell you as much as a grunt. Try to localize any tenderness to
a particular structure; if you know precisely where the trouble is, you
are halfway to knowing what it is.
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Orthopedic
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Dr.
Rami
Abo
Ali

11. EXAMINATION
 Move
 ‘Movement’ covers several different activities: active movement,
passive movement, abnormal or unstable movement, and
provocative movement
 Active movement
 Ask the patient to move without your assistance. This will give you an idea
of the degree of mobility and whether it is painful or not. Active
movement is also used to assess muscle power.
 Passive movement
 Here it is the examiner who moves the joint in each anatomical plane.
Note whether there is any difference between the range of active and
passive movement.
 Range of movementis recorded in degrees, starting from zero
which, by convention, is the neutral or anatomical position of the
joint, and finishing where movement stops, due either to pain or to
anatomical limitation
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Orthopedic
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Dr.
Rami
Abo
Ali

12. EXAMINATION
 Test
 Several clinical tests are used to elicit suspected
abnormalities: some examples are Thomas’ test for
flexion deformity of the hip, Trendelenburg’s test for
instability of the hip, McMurray’s test for a torn
meniscus of the knee, Lachman’s test for cruciate
ligament instability and various tests for intra-articular
fluid.
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Ali

13.  Muscle tone
 Increased tone (spasticity) is characteristic of upper motor
neuron disorders such as cerebral palsy and stroke.
 It must not be confused with rigidity (the ‘lead-pipe’ or
‘cogwheel’ effect) which is seen in Parkinson’s disease.
 Decreased tone (flaccidity) is found in lower motor neuron
lesions
 Power
 Muscle power is usually graded on the Medical Research Council
scale:
 Grade 0 No movement
 Grade 1 Only a flicker of movement
 Grade 2 Movement with gravity eliminated
 Grade 3 Movement against gravity
 Grade 4 Movement against resistance
 Grade 5 Normal power
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14. JOINT LAXITY
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15. EXAMINING INFANTS AND CHILDREN
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16. TERMINOLOGY
 The principal planes of the body are
named sagittal, coronal and
transverse; they define the direction
across which the body (or body part)
is viewed in any description
 Anterior and posterior
 Ventral and dorsal
 Dorsal and plantar
 Proximal and distal
 Medial and lateral
 Axial alignment
 Valgus and varus
 Rotational alignment
 Flexion and extension
 Abduction and adduction
 Lateral rotation and medial rotation
 Pronation and supination
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Orthopedic
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Ali

17. DEFORMITY
 Specific terms are used to describe the ‘position’ and ‘shape’ of
the bones and joints.
 Varus and valgus
 Kyphosis and lordosis
 Scoliosis
 Postural deformity is one which the patient can, if properly
instructed, correct voluntarily: e.g. thoracic ‘kyphosis’ due to
slumped shoulders. Postural deformity may also be caused by
temporary muscle spasm.
 Structural deformity A deformity which results from a
permanent change in anatomical structure cannot be voluntarily
corrected
 ‘Fixed deformity’ means that one particular movement cannot be
completed. Thus the knee may be able to flex fully but not extend
fully – at the limit of its extension it is still ‘fixed’ in a certain
amount of flexion. This would be called a ‘fixed flexion deformity’.
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Dr.
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Ali

18.  CAUSES OF JOINT DEFORMITY
 There are six basic causes of joint deformity.
1. Contracture of the overlying skin
2. Contracture of the subcutaneous fascia
3. Muscle contracture
4. Muscle imbalance
5. Joint instability
6. Joint destruction
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Orthopedic
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Dr.
Rami
Abo
Ali

19. BONY LUMPS
 A bony lump may be due to faulty development, injury,
inflammation or a tumour. Although X-ray examination is
essential, the clinical features can be highly informative
 Size : A large lump attached to bone, or a lump that is
getting bigger, is nearly always a tumour.
 Site :A lump near a joint is most likely to be a tumour
(benign or malignant); a lump in the shaft may be
fracture callus, inflammatory new bone or a tumour. A
benign tumour has a well-defined margin; malignant
tumours, inflammatory lumps and callus have a vague
edge.
 Consistency : A benign tumour feels bony and hard;
malignant tumours often give the impression that they
can be indented.
 Tenderness : Lumps due to active inflammation, recent
callus or a rapidly growing sarcoma are tender.
 Multiplicity : Multiple bony lumps are uncommon: they
occur in hereditary multiple exostosis and in Ollier’s
disease.
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Orthopedic
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Dr.
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Abo
Ali

20. BASICS
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21. CLASSIFICATION OF JOINTS
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 Fibrous – bones connected
by fibrous tissue.
 Cartilaginous – bones
connected by cartilage.
 Synovial – articulating
surfaces enclosed within
fluid-filled joint capsule.
 Synarthrosis – immovable.
 Amphiarthrosis – slightly
moveable.
 Diarthrosis – freely moveable.
Classification by type of tissue:
Classification by degree of
movement:

22. FIBROUS JOINTS
 A fibrous joint is where the bones are bound by a tough, fibrous tissue.
These are typically joints that require strength and stability over range
of movement.
 Fibrous joints can be further sub-classified into sutures, gomphoses and
syndesmoses.
 Sutures are immovable joints (synarthrosis), and are only found
between the flat, plate-like bones of the skull.
 There is limited movement until about 20 years of age, after which
they become fixed and immobile. They are most important in birth, as
at that stage the joints are not fused, allowing deformation of the skull
as it passes through the birth canal.
 Gomphoses are also immovable joints. They are found where the teeth
articulate with their sockets in the maxilla (upper teeth) or the
mandible (lower teeth).
 The tooth is bound into its socket by the strong periodontal ligament.
 Syndesmoses are slightly movable joints (amphiarthroses).
 They are comprised of bones held together by an interosseous
membrane. The middle radioulnar joint and middle tibiofibular joint
are examples of a syndesmosis joint.
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24. CARTILAGINOUS JOINTS
 In a cartilaginous joint, the bones are united by fibrocartilage
or hyaline cartilage
 There are two main types: synchondroses (primary
cartilaginous) and symphyses (secondary cartilaginous).
 Synchondroses
 In a synchondrosis, the bones are connected by hyaline
cartilage. These joints are immovable (synarthrosis).
 An example of a synchondrosis is the joint between
the diaphysis and epiphysis of a growing long bone.
 Symphyses
 Symphysial joints are where the bones are united by a layer
of fibrocartilage. They are slightly movable (amphiarthrosis).
 Examples include the pubic symphysis, and the joints
between vertebral bodies.
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Orthopedic
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Dr.
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Abo
Ali

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26. SYNOVIAL JOINT
 A synovial joint is defined by the presence of a fluid-filled joint cavity contained
within a fibrous capsule.
 They are freely movable (diarthrosis) and are the most common type of joint found
in the body.
 Synovial joints can be sub-classified into several different types, depending on the
shape of their articular surfaces and the movements permitted:
 Hinge – permits movement in one plane – usually flexion and extension.
 E.g. elbow joint, ankle joint, knee joint.
 Saddle – named due to its resemblance to a saddle on a horse’s back. It is
characterised by opposing articular surfaces with a reciprocal concave-convex shape.
 E.g. carpometacarpal joints.
 Plane – the articular surfaces are relatively flat, allowing the bones to glide over one
another.
 E.g. acromioclavicular joint, subtalar joint.
 Pivot – allows for rotation only. It is formed by a central bony pivot, which is
surrounded by a bony-ligamentous ring
 E.g. proximal and distal radioulnar joints, atlantoaxial joint.
 Condyloid – contains a convex surface which articulates with a concave elliptical
cavity. They are also known as ellipsoid joints.
 E.g. wrist joint, metacarpophalangeal joint, metatarsophalangeal joint.
 Ball and Socket – where the ball-shaped surface of one rounded bone fits into the
cup-like depression of another bone. It permits free movement in numerous axes.
 E.g. hip joint, shoulder joint.
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Ali

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28. TYPES OF BONE
 Long bones
 The epiphysis in a growing long bone is separated
from the hollow shaft, or diaphysis, by the epiphyseal plate, or
physis. The part of the diaphysis next to the physis is the
metaphysis. Any bone arranged like this is called a long bone,
even if it is quite short– the phalanges of the fingers and toes
are ‘long’ bones in structure. Damage to a growing epiphysis
causes deformity.
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Ali

29. TYPES OF BONE
 Flat bones
 Flat bones, such as the skull, pelvis and ribs, form
in condensations of fibrous tissue and are often
called membrane bones. Their function is the
protection of soft viscera such as the brain and
lungs.
 Short bones
Short square bones like those of the tarsus and
carpus form in blocks of cartilage and ossify from
the centre. They do not have epiphyses
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Ali

30. TYPES OF BONE
 Accessory ossicles
In addition to the normal bones, accessory ossicles occur as variants
of normal. These are entirely innocent structures but can be mistaken
for fractures andtreated as such.
 The os trigonum behind the talus and the accessory navicular are
among the most common
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31. STRUCTURAL BONE TYPES
 Cortical (compact)
 Strong, dense bone, makes up 80% of the skeleton
 Composed of multiple osteons (haversian systems) with intervening
interstitial lamellae
 Osteons are made up of concentric bone lamellae with a central canal
(haversian canal) containing osteoblasts (new bone formation) and an
arteriole supplying the osteon. Lamellae are connected by canaliculi.
Cement lines mark outer limit of osteon (bone resorption ended).
 Volkmann’s canals: radially oriented, have arteriole, and connect
adjacent osteons
 Thick cortical bone is found in the diaphysis of long bones
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32. STRUCTURAL BONE TYPES
 Cancellous (spongy/trabecular)
 Crossed lattice structure, makes up 20% of the skeleton
 High bone turnover rate.
 Bone is resorbed by osteoclasts in Howship’s lacunae and formed on
the opposite side of the trabeculae by osteoblasts.
 Osteoporosis is common in cancellous bone, making it susceptible to
fractures (e.g., vertebral bodies, femoral neck, distal radius, tibial
plateau).
 Commonly found in the metaphysis and epiphysis of long bones
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34. MICROSCOPIC BONE TYPES
 Woven
 Immature or pathologic bone; poorly organized, not stress
oriented
 Randomly oriented collagen fibers
 Examples: Immature—bones in infants, fracture callus;
Pathologic—tumors
 Lamellar
 Mature bone; highly organized with stress orientation
 Collagen fibers arranged in parallel layers
 Cortical and cancellous bone are both made up of lamellar
bone
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35. BONE COMPOSITION
 Bone is made up of
 organic component 40% of dry weight
 inorganic component 60% of dry weight
 Cells
 Osteocytes
 Osteoblasts
 Osteoclasts
 Extracellular Matrix
 Organic (40%)
 Collagen (type I) 90%
 Osteocalcin, osteonectin, proteoglycans, glycosaminoglycans,
lipids (ground substance)
 Inorganic (60%)
 Primarily hydroxyapatite Ca5(PO4)3(OH)2
 osteocalcium phosphate 35
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36. BONE CELL TYPES
 Osteoblasts
 • Function : produce bone matrix (“osteoid”). Make type 1 collagen and other
matrix proteins
 • Line new bone surfaces and follow osteoclasts in cutting cones
 • Receptors: PTH(parathyroid hormone), vitamin D, glucosteroids, estrogen,
PGs, ILs
 Osteocytes
 • Osteoblast surrounded by bone matrix. Represent 90% of all bone cells
 • Function: maintain & preserve bone. Long cell processes communicate via
canaliculi.
 • Receptors: PTH(release calcium), calcitonin(do not release calcium)
 Osteoclasts
 • Large, multinucleated cells derived from the same line of cells as monocytes
& macrophages
 • Function: when active, use a “ruffl ed border” to resorb bone; found in
Howship’s lacunae
 • Receptors: calcitonin , estrogen, IL-1, RANK L. Inhibited by bisphosphonates
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37. BONE FORMATION
 Bone formation (ossifi cation) occurs in 3 different ways:
enchondral, intramembranous, appositional
 Enchondral
 • Bone replaces a cartilage anlage (template). Osteoclasts
remove the cartilage, and osteoblasts
 make the new bone matrix, which is then mineralized.
 • Typical in long bones (except clavicle).
 • Primary ossification centers (in shaft) typically develop in
prenatal period.
 • Secondary ossification centers occur at various times after
birth, usually in the epiphysis.
 • Longitudinal growth at the physis also occurs by enchondral
ossification.
 • Also found in fracture callus
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38. BONE FORMATION
 Intramembranous
 • Bone develops directly from mesenchymal cells
without a cartilage anlage.
 • Mesenchymal cells differentiate into osteoblasts,
which produce bone.
 • Examples: flat bones (e.g., the cranium) and clavicle
 Appositional
 • Osteoblasts make new matrix/bone on top of existing
bone.
 • Example: periosteal-mediated bone diameter (width)
growth in long bones 38
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39. BLOOD SUPPLY
 Bone receives 5-10% of cardiac
output
 • Bones that receive tenous
blood supply
 scaphoid
 talus
 femoral head
 odontoid
 Long bones have three blood
supplies
 Nutrient artery (intramedullary)
supplies the inner 2/3 of mature
bone via the haversion system
 Periosteal vesselssupplies the
outer 1/3 of bone
 Metaphyseal vessels
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40. ANATOMY OF PERIOSTEUM
 Periosteum consists of two layers outer fibrous and inner
cambium layer.
 • The fibrous layer contains fibroblasts
 • The cambium layer contains progenitor cells that develop
into osteoblasts.
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41. TYPES OF CARTILAGE
 Hyaline
 Found in articular cartilage of synovial joints and cartilage
in physes
 Contains type II collagen
 Fibrocartilage
 Found in meniscus, Triangular fibrocartilage complex TFCC,
vertebral disc, articular disc (e.g., acromioclavicular joint)
 Contains type I collagen
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42. INVESTIGATIONS
PLAIN FILM RADIOGRAPHY
 Radiographs are essential in
orthopaedics, not only
to recognize fractures and other bone
lesions but also to determine the best
way to treat a fracture, the accuracy
of reduction and the state of union.
 Orthopaedic radiographs must always
be taken in at least two planes
because lesions can be missed if one
shadow is superimposed upon
another, particularly with fractures,
where one view may show gross
displacement while the other is
anatomical.
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43.  All radiographs are eventually examined by a radiologist, but the
orthopaedic surgeon has to make a decision on management before
the report is available and must therefore examine the films correctly.
 This is especially true in the accident department, a place rich in
pitfalls for the unwary
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45.  ABCs APPROACH
 A Adequacy, Alignment
 B Bones
 C Cartilage
 S Soft Tissues
 Apply ABCs approach to every orthopedic film you evaluate
 All x-rays should have an adequate number of views.
◦ Minimum of 2 views—AP and lateral
◦ 3 views preferred
◦ Some bones require 4 views
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Ali

46.  Stress Views
 Stress views are important in
evaluating ligamentous tears and
joint stability
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47. C-ARM X-RAY
FLUOROSCOPY
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48. COMPUTED TOMOGRAPHY (CT)
 Like plain tomography, CT produces sectional images through
selected tissue planes – but with much greater resolution
 New multislice CT scanners provide images of high quality from
which multiplanar reconstructions in all three orthogonal planes
can be produced.
 Three-dimensional surface rendered reconstructions and volume
rendered reconstructions may help in demonstrating anatomical
contours, but fine detail is lost in this process.
 It is ideal for evaluating acute trauma to the head, spine, chest,
abdomen and pelvis. It is better than MRI for demonstrating fine
bone detail and soft-tissue calcification or ossification.
 Great rule in preoperative planning in secondary fracture
management
 It is also useful in the assessment of bone tumour size and spread,
even if it is unable to characterize the tumour type. It can be
employed for guiding soft- tissue and bone biopsies.
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50. MAGNETIC RESONANCE IMAGING(MRI)
 It yields superb soft-tissue contrast, allowing different soft tissues to
be clearly distinguished, e.g. ligaments, tendons, muscle and hyaline
cartilage.
 Another big advantage of MRI is that it does not use ionizing
radiation.
 It is, however, contraindicated in patients with pacemakers and
possible metallic foreign bodies in the eye or brain, as these could
potentially move when the patient is introduced into the scanner’s
strong magnetic field.
 Approximately 5% of patients cannot tolerate the scan due to
claustrophobia, but newer scanners are being developed to be more
‘open
 Its excellent anatomical detail, soft-tissue contrast and multiplanar
capability make it ideal for non-invasive imaging of the
musculoskeletal system
 In orthopaedic surgery, MRI of the hip, knee, ankle, shoulder and
wrist is now fairly commonplace. It can detect the early changes of
bone marrow oedema and osteonecrosis before any other imaging
modality.
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51.  In the knee, MRI is as accurate as arthroscopy in diagnosing
meniscal tears and cruciate ligament injuries.
 Bone and soft-tissue tumours should be routinely examined by
MRI as the intraosseous and extraosseous extent and spread of
disease, as well as the compartmental anatomy, can be
accurately assessed.
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ewing sarcoma in a 10-year-old boy

54. RADIONUCLIDE BONE IMAGING
 Skeletal scintigraphy helps to diagnose and evaluate a variety of bone
diseases and conditions using small amounts of radioactive materials
such as Technetium-99m, Gallium-67, Indium-111
 ADVANTAGES
 Whole-bodyevaluation in one test/ same radiation exposure.
 Low radiation exposure
 Sensitive evaluation
 DISADVANTAGES
 Needs radiopharms &gamma camera not widely available
 Radiation exists
 Low specificity
 COST
 Oncological indications
 Primary tumours (e.g. Ewing’s sarcoma, osteosarcoma)
 Staging, evaluation of response to therapy and follow up of primary
bone tumors
 Secondary tumours (metastases)
 Staging and follow-up of neoplastic diseases
 Distribution of osteoblastic activity prior to radiometabolic therapy
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55. RADIONUCLIDE BONE IMAGING
 Non-neoplastic diseases
 Whenever there is an increase in blood flow to a lesion or there
is an alteration in osteoblastic activity.
 Stress and/or occult fractures.
 Trauma
 Musculoskeletal inflammation and infection
 Bone viability (grafts, infarcts, osteonecrosis).
 Metabolic bone disease.
 Arthritis
 Complications of hardware/prosthetic joint replacement, loose
or infected joint prosthesis.
 Heterotopic ossification.
 Complex regional pain syndrome (CRPS)
 Other bone disease, such as Paget disease, Langerhans cell
histiocytosis, or fibrous dysplasia.
 Congenital or developmental anomalies.
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57. ARTHROSCOPY
 Diagnostic and therapeutic
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58. OTHER INVESTIGATIONS
 Ultrasound ( mass , DDH , effusions ..)
 Examination under anaesthetic
 Laboratory investigations
 Electrical studies (Nerve conduction studies,
Electromyogram (EMG) )
 Bacteriology (Culture and sensitivity of synovial fluid or
wound swap ..)
 Bone mineral density (BMD) (osteoporosis, osteomalacia
..)
 Bone and soft tissue biopsy
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