4_5881836056923341743.pdf

FRCS Trauma and OrthopaedicsExam
A guide to clinicals and vivas
Edited by
Mansoor Kassim
D Orth, FRCS (Tr and Orth)
Senior Clinical Fellow
Maidstone and Tunbridge Wells Hospital
Prof Nicola Maffulli
MD, MS, PhD, FRCP, FRCS(Orth), FFSEM
Professor of Sports and Exercise Medicine, Consultant Trauma and Orthopaedic Surgeon
Queen Mary University of London
Barts and the London School of Medicine, London, England
Professor of Musculoskeletal Medicine and Surgery, Consultant Trauma and Orthopaedic Surgeon
University of Salerno, Salerno, Italy

Preface
The exam to obtain the Fellowship of the Royal Colleges of Surgeons in Trauma and Orthopaedics
(FRCS Tr and Orth) is a tough test of the knowledge of trainees close to the end of their trauma and
orthopaedic training. It is considered a most difficult exam, where the candidates are tested on a wide
range of orthopaedic problems. Routine reading from journal and textbooks, and accurate preparation
in a clinical setting may not be enough to pass the examination.
The concept for this book arose when Mr Kassim was preparing for his FRCS(Tr and Orth) exam:Mr
Kassim understood how necessary it was to go through many textbooks and guidelines to find what
exactly was needed in viva and clinical stations.
There is very little guidance on the best way to proceed with vivas and clinicals, and confusion over
what the best approach in answering vivas and clinical examination is. This book aims to help
candidates to prepare for the exam as in a real exam scenario. The book contains common viva and
clinical stations at be basis of the FRCS(Tr and Orth).
Each chapter is written by an expert in their field. We hope that this book will help pre-FRCS(Tr and
Orth) candidates to approach the exams with confidence, and will help them pass!
Mansoor Kassim
Nicola Maffulli

Acknowledgements
The book will not have been produced without he guidance and wisdom of many individuals.
We especially thank Mr Peter Rosenfeld, Professor Roger Emery, Mr Ahmed Hussain, Mr Katik
Hariharan and Professor Fares Haddad
Our greatest thanks to all the contributors who employed their precious time write world class
chapters.
Mansoor Kassim
Nicola Maffulli

CONTENTS
A. VIVA
Section 1
1. Hand
2. Paediatric orthopaedics
Section 2
Adult orthopaedics and Pathology
Section 3
Trauma
Section 4
Basic sciences
B. CLINICAL EXAMINATION
Section 1
Short cases
-Upper limb
-Lowerlimb
Section 2
Lowerlimb short cases
Section 3
Intermediate cases

Contributers
Paediatric Orthopaedics
Mathew Barry
Andreas Rehm
Hand
Maxine Horwitz
Elliot Sorene
Alistair Hunter
Adult Orthopaedics and pathology
Paul Allen
Sathish Kutty
Peter Reilly
AndrewSanky
Mansoor Kassim
Trauma
Mamoun Al Rashid
Mansoor Kassim
Basic Sciences
Shibu P Krishnan
Dennis Kosuge
Clinicals
Mansoor Kassim
Mr Mathew Barry
Clinical lead and Consultant in Orthopaedics
Royal London hospital
Mr Andrew Rehm
Consultant in Paediatric Orthopaedics
Addenbrookes hospital
Mr Maxine Horwitz
Consultant Hand Surgeon
Chelsea and Westminster
Mr Elliote Sorene

Consultant Hand Surgeon
UCLH
Mr Alistair Hunter
Senior Registrar, UCLH rotation
Mr Peter Reilly
Consultant Shoulder Surgeon
St Marys hospital
Mr AndrewSankey
Consultant Shoulder Surgeon
Chelsea and Westminster Hospital
Mr Paul Allen
Clinical lead and Consultant Knee Surgeon
Princess Alexandra Hospital
Mr Satish Kutty
Consultant Hip Surgeon
Princess Alexandra Hospital
Mr Kartik Hariharan
Consultant in Orthopaedics, and Foot and Ankle Lead
Royal Gwent and Ysbyty Ystrad Fawr Hospital
Mr Mamoun Al Rashid
Orthopaedic Fellow
Harward Medical School, Boston, USA
Mr Shibu P Krishnan
Locum Consultant in Orthopaedics
Buckinghamshire NHS trust
Mr Dennis Kosuge
Senior Registrar, Royal London Hospital
Mr Mansoor Kassim
Senior Clinical Fellow
Maidstone and Tunbridge hospital
B. Clinical examination
Short cases
1. Hand

2. Paediatrics
3. Hip
4. Knee
5. Foot and ankle
6. Shoulder and elbow
7. Trauma
Intermediate cases
1. Hip
2. Knee
3. Shoulder and elbow
4. Spine

Hand Viva
Alistair Hunter, Elliot Sorene and Max Horwitz

1. Clinical picture of a swan neck deformity.
Describe the deformity, the underlying pathology and its classification.
How will you manage this patient?
Describe:
- Hyperextension at the PIPJ
- Flexion of the DIPJ
Pathoanatomy:
One of the common primary lesions is a lax volar plate, allowing producing hyperextension at the
PIPJ from
- Trauma
- Rheumatoid arthritis
- Generalised joint laxity
Secondary lesions arise from an imbalance of forces at the PIPJ, from
- volar subluxation of the MCPJ
- Laceration or transfer of FDS (unopposed extension at PIPJ)
- Intrinsic contracture (excessive extensor forces through the PIPJ), assess with Bunnell test
- Mallet finger (extension of DIPJ extension force to the PIPJ)
Classification (Nalebuff) and Treatment:
Type Description Treatment options
I PIPJ completely flexible
Splinting with double ring splints
DIPJ fusion if mallet deformity significant
Consider spiral oblique retinacular
ligament reconstruction (SORL)
II
PIPJ flexion limited in certain positions
Lateral band translocation (Littler)
Intrinsic release if necessary +/- MCPJ

(tight intrinsics) reconstruction
III PIPJ flexion limited in all positions
Dorsal release FDS tenodesis or lateral
band translocation
IV PIPJ stiff with radiographic changes
Arthrodesis – consider for index and
middle finfers if stablitiy is important
Arthroplasty

2. Clinical picture of a hand of a patient with Dupuytren’s. The ring and little fingers are
involved.
Describe the deformity: what is the diagnosis?
What are the associations?
Name the different types of cord.
How would you manage this patient, and which incision(s) would you use?
Clinical picture of Dupuytren’s:
- Describe deformities, bands and cords
Epidemiology/associations:
- Northern European and Celtic descent (likely autosomal dominant with variable penetrance)
- Diabetes mellitus
- Epilepsy: controversial
- Alcoholic/smoker (controversial)
- Hypercholesterolemia
- HIV
Aetiological theories and associations:
- Genetic- increased incidence in relatives
- Traumatic: micro trauma
- Neoplastic
- Inflammatory
Associations:
- Ledderhose disease (plantar fascia, 5% of patients)
- Peyronie’s disease (Dartos fascia of the penis, 3% of patients)
- Garrod’s disease (knuckle pads)
- Dupuytren’s diathesis relates to certain features of Dupuytren’s disease and indicates an aggressive
form. These factors are patient aged below 50 years, positive family history, bilateral disease, and

-
-
ectopic lesions.
Anatomy:
- Core of pathology is central palmar aponeurosis thickening
- Fascial involvement (bands) become pathologic cords
- Myofibroblast is the offending cell
- Increased levels of cytokines- IL/TGF/PDGF/FGF etc seen
Cords:
- Pre-tendinous cord: flexes MCPJ
- Central cord
- Lateral cord
- Spiral cord: from pre-tendinous band/spiral band/lateral digital sheet/Greyson’s ligament (pass
deep to NV bundle- chance of injury during surgery, it displaces the neurovascular bundle)
- Natatory cord: cause web space contractures
- Abductor digiti minimi cord
- Commisural cords: dorsal/palmar- 1st web contractures
Clinical features:
- Cords – MCP flexed by pretendinous cord, PIP by central, spiral and lat cord
- Pits
- Nodules
- Garrod’s pads dorsally
- MC in ring and little fingers
- Inability to lay hand flat on a table i.e. failure of Huestons table top test.
Management:
Non-operative:
Observe if good function or minimal contracture
Nice Guidelines from 2010 have described radiotherapy but this is not a common treatment
method
Operative:
Indications:
- Reduced function
- MCP >30 degrees
- PIP >15 degrees
Treatment of choice:
Partial fasciectomy
- 15% recurrence
- PIP not as successful as MCP
- Can result in residual contracture or fixed flexion deformity
- If >70 degree – very unlikely to achive full correction, and may need variable releases
- Incisions: Brunner, longitudinal with a Z-plasty

- Wounds in the palm can be left open: McCash open palm technique
Complications:
- Infection
- Delayed wound healing
- Incomplete correction
- Recurrence (30-50% at 10 years, (Bulstrode et al., 2005, Tonkin 1984)
- Neurovasular injury
- CRPS
- Amputation
Postoperative Management:
- Carefully applied bulky dressing providing compression
- Elevation
- Some advocate avoiding finger extension immediately from excessive tension on the wound
- Early wound check and initiation of active range of movement exercises
- May need extension splint at night
- Follow up for recurrence or involvement of other digits
Other procedures:
- Collagenase injections - sited directly into the cord and manipulation takes place the following day
- Percutaneous fasciotomy - in simple pretendinous palmar cord (45% recur)
- Segmental fasciectomy
- Total fasciectomy - not advocated at present
- Dermofasciectomy + skin graft - if recurrence with skin involvement. The full thickness skin graft is
taken from the forearm or the groin (hair free) after excision of the diseased tissue and skin (‘fire-
break’). Some surgeons advocate this as their main method of treatment.
- McCash open palm technique - the wound is left open and allowed to heal by second intention

3. Clinical picture of tendon transfer
What are the underlying principles of tendon transfer?
What are the transfers for ulnar, radial and median nerve injuries?
Principles:
1) Full passive joint range of movement of the joint
2) Sensation should be intact distally
3) Normal or near normal (grade 5) power in the donor
4) The donor should have good excursion
5) Synergistic muscle activity in the donor
6) No scar tissue in the operative field
7) The tendon lost should be expendable
Tendon Transfers
There are many tendon transfer procedures described for each pathology. Those mentioned below are
a few of the most common.
Ulnar claw
- Aim to prevent hyper-extension at the MCPJs, thus allowing the extrinsic extensors to extend DIPJs
and PIPJs
- One of the methods of bringing the MCPJ into flexion is by passing the FDS volar to the A1 pulley
and suturing it back on itself (Zancolli Lasso proceure)
- MCPJ capsulodesis
Ulnar nerve palsy
- Thumb adduction: split insertion of middle finger FDS/BR to adductor pollicis brevis
- Index abduction: EIP or AbPL to first dorsal interosseus
- Wartenberg deformity: EIP to EDM
High ulnar lesion (loss of FCU and FDP)
- Suture FDPs to functioning index and middle FDP
- In addition, transfers for low lesion
Radial nerve palsy
- Wrist extension: pronator teres to ECRB/ERCL
- Finger extension: FCR or FCU to EDC
- Thumb extension: Palmaris longus to EPL
Median nerve palsy
Low lesion:
- Aim to regain opposition (loss of APB)- FDS ring/Abductor digiti minimi/PL to AbPB
High lesion:
- Thumb IP flexion (loss of FPL) – BR to FPL
- Index and middle flexion – side to side tenodesis of FDP to functioning FDP ring and little
- In addition, transfers for low lesion

4. Plain radiograph of scaphoid fracture 8 weeks old
How would you manage a non union?
Management:
- History for patient’s age, handedness, mechanism of injury, activity level, expectations, is there a
delayed presentation?
- Assess the stability (Herbert classification, Herbert and Fischer, 1984)
- If there is doubt as to the configuration of a fracture or the presence of displacement, a CT scan
should be requested.
- A displaced fracture is defined as more than 1 mm of displacement, >60 degrees of scapholunate, or
15 degrees of lunocapitate angulation
Herbert Classification
A Acute, Stable
A1 Tuberosity
A2 Incomplete fracture through waist
B Acute, Unstable
B1 Distal oblique fracture
B2 Displaced fracture through waist
B3 Proximal pole fracture
B4
Trans-scaphoid perilunate fracture dislocation
of the carpus
B5 Comminuted fractures
C Delayed Union
Widening of the fracture line, cyst development
and density of proximal fragment
Fibrous unionRelatively stable with little or no

D Non-union
D1 deformity, likely to progress to pseudarthrosis,
surgery is normally required
D2
Sclerotic non union (pseudarthrosis)Usually
unstable, progressive deformity, leading to
development of OA, surgery is normally
required
Non operative Management:
- If stable at plain radiography, apply short arm thumb spica for further 4 weeks explaining risks and
benefits. If no signs of union at 12 weeks, operative intervention should be considered
Operative Management:
- If unstable fracture pattern
- If there is a delayed presentation
- Dias et al. (2005) advised early aggressive conservative management, whereby fracture healing is
assessed by plain radiographs or CT at 6 to 8 weeks, and internal fixation with or without bone
grafting if a gap is identified at the fracture site (95% union rate). They did not find any clear overall
benefit in early operative intervention for non-displaced or minimally displaced fractures.
- McQueen et al. (2008) showed in a randomised controlled trial comparing conservative
management versus percutaneous screw fixation for acute undisplaced fractures, that operative
management gave significantly better results with lower rate of non-union and short times to return to
work.
Difficult to come to firm conclusions given the wide variety of defining a non-union.
Percutaneous Technique:
- Dorsal approach requires a small open incision from risk to tendons and nerves. The wrist must be
in flexion which can displace the fracture. Used in proximal pole fractures
- Volar approach can lead to increased prevalence of later scapho-trapezial degenerative joint
disease, though usually asymptomatic
Non-union:
- Define the pathology with imaging (CT or MRI)
- Is there a Scaphoid Non-Union Advanced Collapse (SNAC)?
Techniques:
- Historically the Inlay (Russe) bone graft was indicated if there was no adjacent carpal collapse or
humpback (flexion) deformity of the scaphoid (92% union rate). Otherwise, the Interposition (Fisk)
graft was designed to restore scaphoid length and angulation when there was adjacent collapse or a
humpback deformity of the scaphoid (72-95% union rates).
The modern approach uses a corticocancellous wedge graft from the iliac crest and a compression
screw

- The wrist is extended and the two fracture fragments are gently distracted with spreaders
- The fracture surfaces are prepared with an osteotome or curette.
- The size of the graft can be calculated on the preoperative CT scan
- The graft is taken from the iliac crest with an osteotome (not an oscillating saw to avoid thermal
necrosis of the graft)
- The graft is inserted on the palmar surface and the compression screw inserted, avoiding rotation of
the graft with a supplementary K-wire
- Punctate bleeding at the proximal pole fracture site is the most reliable sign for a vascular proximal
pole. If bleeding is obvious, the union rate is 92%, but if there is no bleeding the rate is 0%.
- Vascularised bone graft from the radius is harvested from the dorsal aspect of the distal radius,
based on the 1,2 intercompartmental supraretinacular artery. Can be used when treating non-union in
the face of AVN or revisions.
- A wrist denervation is a useful adjunct to treatment
- A limited radial styloidectomy can be added to the reconstruction if secondary radiocarpal OA has
ocurred.
- Salvage procedures for advanved non union with collapse (SNAC) include a four corner fusion,
proximal row carpectomy and wrist arthrodesis

5. Clinical picture of finger tip injury.
Discuss the options for soft tissue flaps.
The principle is to provide a sensate, well healed tip, and to preserve length (allowing bony support
for the nail).
Can be divided into:
1) Soft tissue loss without bone exposure:
- Fingertip lacerations or avulsions of the substance smaller than 1 cm2 will heal by second intention,
especially good in children. Some argue that wound contraction will lead to a hook nail deformity,
but tight primary closure wound closure (drawing the nail bed over the tip) will lead to the same
outcome and must be avoided.
- For wounds extending for more than 1 cm2, a local flap may be needed to cover the defect
2) Soft tissue loss with bone exposure:
- Exposed bone is not a satisfactory bed for healing. Even if they heal, skin at the tip is poor quality
and easily broken down, leading to a chronic ulcer.
- If bone is exposed, the prominence must be shortened with excision back to rounded edges and
primary, tension free, soft tissue closure performed. Bear in mind the need for bony support of the
nail bed.
- If excessive bony debridement is required to achieve closure, soft tissue coverage is indicated.
Soft Tissue Coverage Choices:
Local flap coverage:
- Advancement flap from the same finger has the advantages of rapid healing, maintenance of
sensation and limited morbidity.

- The aim is to free the skin from the septae anchoring it to bone, whilst retaining the nerves and
vessels, allowing a tension free advancement.
1) Options for straight or more dorsal tissue loss:
- Volar V-Y advancement (Atasoy)
- Double lateral V-Y advancement flap (Kutler)
2) Options for more volar tissue loss:
- Cross finger flap, but scars the adjacent finger
- A rectangular flap is raised from the three sides of the dorsal surface of the middle phalanx of the
adjacent digit.
- The flap is normally based on the lateral side of the adjacent digit and swung on its pedicle and
sutured in place.
- The flap is divided within two weeks to avoid stiffness of the fingers.
- Thenar flaps can be considered, are well tolerated in children, but can lead to PIP joint stiffness in
adults.
3) There are more complex advancement flaps but these should be performed by experienced
surgeons
Terminalisation:
- Indicated for a severely crushed distal phalanx
- The level is through the DIPJ, trimming the condyles of the middle phalanx
- Aim to preserve the FDS and achieve tension free primary closure
- Digital nerves are transected as proximally as possible
- A volar skin flap is created and the wound is closed dorsally

6. Plain radiographs of Madelung deformity of the distal radius.
What is the diagnosis, and how does the condition arise?
Discuss the management of this condition.
The deformity results from premature fusion of the ulnar and volar aspect of the distal radial
epiphysis. As the child grows, the distal radius develops increased radial inclination and volar tilt,
and ulnar-carpal impaction.
Presents more frequent in females, those with a positive family history and is often bilateral.
Causes:
- Usually idiopathic
- Congenital dysvhondrosis
- Post traumatic
- Dysplastic (Ollier’s disease, achondroplasia, multiple epiphyseal dysplasias)
- Genetic (association with Turner’s syndrome and Leri-Weill dyschondrosteosis).
Clinical manifestations:
- Insidious onset of wrist pain (radioulnar impaction)
- Development of prominence of the dorsal ulnar head
- Bowing of the distal radius
- Limitation of forearm rotation.
Management:
- Determined by the degree of deformity, the degree of closure of the growth plate (? progressive) and
the severity of the symptoms.

Nonoperative management:
Monitor patients without pain
Operative management:
Aims to either correct deformity or relieve pain and improve function (or both):
- Prevent further deformity if the growth plate is open, with epiphysiodesis, and a closing wedge
osteotomy to correct the deformity
- Release of the Vickers Ligament, a tethering structure
- Include ulnar shortening if it is long and sypmtomatic and distal ulnar epiphysiodesis if the growth
plate is open
- Alternatively one can include radial lengthening.
- For symptomatic relief, a Sauve-Kapandji procedure will decrease ulnar sided wrist pain and
increase range of movement, or consider Darrach’s procedure (though risks instability).
- For adults with severe pain and instability, a wrist arthrodesis is suitable.

7. Plain radiographs of fractures of the 4th and 5th metacarpal shafts.
What is the management of these fractures?
How will you undertake open reduction and internal fixation?
What is your approach?
- The displacement of metacarpal fractures is normally reduced by the intermetacaral ligaments, the
intrinsic muscles and the adjacent metacarpal, but the border metacarpals are not supported as stably
as the middle and ring metacarpals.
- This anatomical splinting is lost in this fracture pattern; therefore, there is a lower threshold for
fracture fixation.
- In addition, with shortening of the metacarpals comes loss of extension (with each 2 mm of
shortening there is a 7 degree extensor lag at the MCPJ (Strauch et al., 1998) from changes in the
relationship between flexors and extensors.
Ensure:
- There are no associated soft tissue injuries (fight bite) that need to be addressed
- The soft tissues overlying the fractures are intact
- Any rotational deformity is noted preoperatively
- There is no dislocation of the 4th or 5th CMCJs, clinically or radiologically
- There is no other associated phalangeal fracture
Management:
Open reduction and internal fixation with dorsal plating is the method of choice:
- Dorsal longitudinal incision between 4th and 5th metacarpals
- Soft tissue dissection; avoid the dorsal cutaneous branch of the ulnar nerve, then through the
juncturae tendinum interconnecting the common extensor tendons.

- Retract the tendons over either fracture
- Decide whether a lag screw (1.7 mm) with a neutralisation plate is appropriate or amini-fragment
DCP (2.0 mm). Hand locking plates are also available.
- For screw only fixation, the ratio of the length of the oblique or spiral to the diameter of the bone
must be at least 2:1. The screw must also pass though the spike in an area that is more than 3 times the
width of the screw to avoid comminution
- Plate fixation on the dorsal side of the metacarpal allows a tension band effect.
- Prebending the plate just beyond the normal metacarpal bow avoids opening of the volar apect of
the fracture
- At least six cortices proximally and distally
- Always re-evaluate rotation one final time before closure
- Postoperatively, early active motion to avoid finger stiffness and tendon adhesions to the plate
(though less frequent than in phalangeal fractures).

8. Draw incisions for the hand and explain the underlying principles.
Surgical scars contract and in the palm can cause fixed flexion deformities of the fingers.
A good incision should:
- allow for extensile exposure
- provide well vascularised skin flaps
- allow for lengthening of the wound
- should cross flexion creases transversely or obliquely
Three incisions commonly used in the hand give excellent exposure.
The Z-plasty:
- A straight, midline, longitudinal incision is made
- When z-plasty flaps are transposed, there is lengthening in the longitudinal axis and shortening in the
transverse axis (McGregor, 1967)
- Increasing the Z-plasty angle increases the amount of lengthing
- A standard Z-plasty of 60 degrees gives a longitudinal lengthening of 75%.
- When planning, the transverse limb after transposition should lie in a flexure line, both in the digit
and the palm
- A continuous multiple Z-plasty should be planned for longer incisions
Drawing the Z-plasty:
1. Draw the longitudinal incision
2. Draw a perpendicular dotted line perpendicular to the incsion at the skin crease
3. Draw two parallel lines at 60 degrees to the incision that meet at each of the lateral borders of the
dotted line
4. The flaps marked then cross over, with the parallel lines then meeting at the dotted line
Brunner Incision (Brunner, 1967):
- A zig-zag volar incision with the apex at the finger flexor crease

- The skin flaps are full thickness
- The angle should be no less than 60 degrees to avoid necrosis at the apex
- The neurovascular bundle is vulnerable at the apex of the incisions
The Mid-axial Incision:
- The site for the midaxial incision is marked by flexing the finger and marking the point at each joint
where the flexion crease ends. The dots are then connected.
- The digital artery and nerve lie approximately 2 mm volar to the margin of incision, so preserve the
fat on the volar flap
- On the radial side of the index and middle and the ulnar side of the ring and little fingers there is a
dorsal branch of the digital nerve that should be preserved

9. Plain radiographs of osteoarthritis of the CMC joint.
What is the management of this condition?
What is the evidence for excision vs arthrodesis vs arthroplasty?
Non-operative Management:
- For mild symptoms this is the first line treatment
- Splints can be used (thumb spica)
- NSAIDS
- Activity modification
- Injections – Heyworth (2008) showed in a prospective, randomised, double blinded trial that
steroid, hylan and saline were all equally effective at reducing pain and increasing thumb function at
three months
Trapeziectomy +/- further procedure:
-Trapeziectomy (excision arthroplasty)
Concerns with thumb weakness from shortening
Modifications to this technique were developed:
-Trapeziectomy with palmaris longus interposition (interposition arthroplasty)
-Trapeziectomy with ligament reconstruction and tendon interposition (50% FCR) (LRTI). The aim is
to support the base of the first metacarpal and prevent thumb shortening.
The evidence:
- Davis et al. (2004) radomised 162 women with 183 procedures over 9 years with Eaton Grade II to
IV to one of the above three procedures.
- Three months postoperatively, pain had significantly improved in all groups, with further
improvement by one year, with no difference between groups.
- No difference in thumb-key and tip-pinch strength or grip strength between groups
- However, all patients were immobilised with a K-wire for four weeks, which is not standard
practice, and may have increased the stability of the pseudarthrosis in the trapeziectomy alone group.
- Longer term outcomes may be different.

Arthrodesis:
- A choice in younger patients and manual workers with isolated CMCJ arthrosis
- The aim is to provide good pain relief, stability of the thumb and maintenance of thumb length
- The thumb is fused in a clenched fist position to allow maintenance of better grip strength.
However, the operation is technically difficult with only a small area for bony union
- In addition there is loss of movement and the procedure does not address STT symptoms.
The evidence:
- It is difficult to assess whether arthrodesis is superior to other methods given lack of good quality
evidence
- In a systematic review, the non-union rates ranged between 8 and 21%, with are high rate of
complications and revision operations with this procedure (Vermeulen, 2011).
Joint Replacement Arthroplasty:
The evidence:
- Total joint replacement has shown in one study to have faster convalescence, better strength and
patient comfort compared to trapeziectomy and LRTI, but the follow up was only one year (Ulrich-
Vinther et al, 2008)
- There are concerns about longer term survival with loosening and dislocation.
Osteotomy:
The evidence:
- Abduction-extension osteotomy can provide good results for early disease (Stage I and II OA), but
patients with Stage III did better with an LRTI in a retrospective study (Atroshi et al., 1998).
Overall:
- There is no hard evidence that one technique is superior to another in a systematic review
(Vermeulen et al., 2011)
- A good result is achieved in 80-90% of patients
- The stage of the disease, the rehabilitation time, the daily demands of the patient and the surgeon’s
experience are considerations in chosing the technique.

10. Clinical picture of flexor tendon injury in zone 2.
Describe the flexor tendon zones.
How would you manage this injury and what are the post operative regimes.
Draw the flexor pulleys. How will you reconstruct them?
An injury to the flexor tendons is described according to the the Zone of Injury:
Zone Site Description of Injury
Zone I
Distal to FDS tendon
insertion
Rugby-jersey finger
Zone II FDS insertion to A1 pulley
Bunnell’s ‘No man’s land. This zone is unique in
that FDP and FDS are enclosed in the same
tendon sheath
Zone III Palm
Often associated with a neurovascular injury,
carrying a worse prognosis
Zone IV Carpal tunnel Often complicated by adhesions
Zone V Proximal to carpal tunnel
Often associated with a neurovascular injury,
which carries a worse prognosis
Thumb
T I
FPL insertion to A2 pulley Outcome is different to finger flexor tendon
repairs. Early range of motion protocols do not
improve long term outcomes
There is a higher re-rupture rate than in finger
flexor tendon repairs
T II
A2 pulley to distal A1
pulley
T III A1 pulley to carpal tunnel
Principles:
- Repair if laceration greater than 60% of tendon width (Al-Qattan, 2000)
- Repair as early as possible, definitely within three weeks, as tendon retraction complicates the
procedure
- Incision should allow lengthening and cross flexion creases obliquely or transversely

The technique:
- The strength of the repair is dependent upon the number of core strands crossing the repair site in a
linear relationship
- Four core strands are required for early active motion (Strickland, 1995)
- Use a 3,0 non-absorbable suture
- Circumferential suture uses a 6,0 non absorbable suture that reduces tendon gapping
- It is essential to preserve the A2 and A4 pulleys
Postoperative Regime:
Principles:
- Mobilize early to prevent adhesions and to allow increased tendon excursion
- Postoperative controlled mobilisation has been the major factor in improved outcomes
- Tendon healing has three phases (inflammatory, fibroblastic and remodelling) and the repair is
weakest at Days 6-12 postoperatively
- Active (Belfast) and Passive (Kleinert, Duran, Mayo) protocols
- Children are immobilized postoperatively
Belfast:
- Dorsal blocking splint is used with the wrist in 20 degrees and MCPJ in 70 degrees of flexion.
- ‘Place and hold’ exercises
Kleinert:
- Elastic bands allow attached to distal phalanx crossing the volar aspect of the wrist allow dynamic
splint assisted passive flexion but active extension.
Draw the pulleys:
- Odd numbers are at the level of the joints
- Even numbers are at the level of the phalanx
Pulley Level
A1 MCPJ
A2 Proximal phalanx
A3 PIPJ
A4 Middle phalanx
A5 DIPJ
Reconstruction of Flexor Pulleys:
-A2 and A4 pulleys are essential to prevent bowstringing of the flexor tendons
-Reconstruction may be necessary after flexor tendon rupture or surgical damage
-Technique involves using a portion of FDS as a free graft
- Many methods, including anchoring the graft to bone using bone anchors on either side of the
phalanx
- Accurate tensioning of the pulleys is difficult and sometimes requires revision

- Reconstruction of the pulleys should not be undertaken at the same time as a direct repair, tendon
grafting or tenolysis as early active motion may stretch the reconstruction

11. Plain radiograph of mallet finger.
What is the management of this injury?
-The mallet finger deformity is caused by loss of extension at the DIPJ.
- The mechanism of injury is forced flexion of the extended DIPJ and is often a sporting injury
(netball, basketball)
-The disruption to the extensor mechanism may be tendinous or bony
Tendinous:
- The vast majority of acute injuries (<12 weeks) should be treated conservatively
- The DIPJ is splinted continuously for six to eight weeks, but allow PIPJ movement
- An off the shelf Stack splint can be used, but be wary of dorsal skin maceration (a short Zimmer
splint is an alternative)
- Strict instructions should be given for how to clean the finger out of the splint without flexion.
- Begin progressive flexion exercises at 6 weeks
- Usually maintain night splintage for another six weeks
- Surgery can lead to a loss of flexion and is avoided if possible
- An extensor lag after treatment is common, with around 30-40% of patients regaining full flexion
Bony Mallet:
The mechanism of the injury is a bony avulsion at the insertion of the extensor tendon.
Non operative management:
- As per tendinous mallet
- If there is displacement, get a plain radiographin a mallet splint to observe if it reduces.

- Check for fracture displacement at one week post injury with a good quality lateral radiographs.
- Is reserved for subluxed DIPJs or large or displaced bony fragments
- Absolute indication – volar subluxation of the distal phalanx
- Relative indications – the bony fragment >40% of the articular surface, or there is >2 mm
displacement
Techniques:
- For subluxation include reducing and holding with a K-wire across the joint for 4 weeks.
- The bony fragment can be difficult to control given its size. Fixation methods include a single screw,
or a dorsal blocking K-wire
Chronic patients:
- Look for an associated Swan-neck deformity
- Treatment in a mallet splint for 6 weeks, or reconstruction of the terminal tendon (tendon
advancement or Fowler central slip tenotomy if Swan neck deformity is present).
- Consider tenodermodesis (Sorene and Goodwin, 2004)
- Consider DIPJ fusion if the joint is painful, stiff or has post-traumatic OA

1.
2.
3.
4.
5.
12. Clinical picture of a mangled hand.
What approach will you use and what are your priorities?
What are the principles of management of traumatic amputation at fingers What are the
prognostic factors?
Maintain a structured approach:
- Manage the patient according to ATLS guidelines
- May require multidisciplinary approach with support from Plastic/Vascular surgery team
Decision making for any hand injury relies on:
Evaluation of the patient – mechanism, past medical history, site and pattern of injury. ATLS
protocol must be followed
Priorities include recognition of nerve/vessel/ tendon/muscular injuries
Plan treatment and discuss the options with the patient
Restore bony anatomy and provide stability
Soft tissue care with good debridement +/- reconstruction
Early mobilisation
The principles of wound coverage:
Early coverage of traumatic wounds is important:
- Leads to to reduced flap failure rates, reduced effects of fibrosis, easier surgery for flap planning
and vascular anastomoses, less vascular spasm, lower infection rate and fewer returns to theatre
- Wounds covered within 6 days had fewer infections than those covered between 6 days and 3
months (0.7% vs 17.5%).
The reconstructive ladder guides management using the simplest effective methods whilst restoring
the hand to useful function and reducing morbidity.
- From simple to complex – primary wound closure, secondary wound closure, skin graft, local flap,

regional flap, free flap. The flap treatment options are determined in part by the location of the lesion.
Principles of traumatic amputation at the fingers:
- Discuss with local centre - ? for replantation
- Care of the patient: nil by mouth, intravenous antibiotics, adequate analgesia, clean and dress the
stump, plain radiographof amputated part
- Care of amputated finger: wrap in saline moistened gauze, place in a sealed plastic bag, and place
the bag in a container with ice and normosaline
Is the digit(s) suitable for replantation?
Indications for replantation:
- Thumb
- Multiple digits
- Individual digits distal to insertion of FDS
- Children do well with most parts
Contraindications for replantation (Pederson, 2001):
- Single digit Zone II
- Mangled parts
- Multiple levels
- Prologued ischaemic time (for digit cold ischaemic time <24 hours, warm ischaemic time <12
hours).
Complications from replanted digits include infection, cold intolerance and stiffness.
If replantation is not possible, then the principles of phalangeal ampuation are:
- A mid-axial skin incision on both sides of the digit
- Sharp proximal transection of nerves
- If the tendon insertion site is absent, debride tendon and allow it to retract
- Do not suture flexors to extensors
- Volar flaps rather than dorsal

13. Plain radiograph of enchondroma proximal phalanx with fracture.
Define the lesion:
- An enchondroma is a benign lesion caused by an abnormality of chondroblast function in the physis
- It is the second most common benign cartilage tumour after osteochondroma
- They are solitary intramedullary tumours (diaphysis and metaphysis)
- The hand is the most common site (60%), with the proximal phalanges most common, followed by
the metacarpals and middle phalanges
- Often present as pathological fractures
- Radiographic appearance of a well defined lucent lesion with a short zone of transition, a lobulated
contour, thinning of the cortices and can have an area of ‘pop-corn’ calcification
- Malignant transformation is rare (around 1%)
- Differential diagnosis for this lesion includes bone infarct, chondrosarcoma and chondroblastoma.
Management (Review - O’Connor and Bancroft, 2004):
- Further imaging is seldom required for these lesions in the hand
- Allow the fracture to heal with a period of immobilization
- Surgical management then follows with open biopsy through a small incision removing tissue for
frozen section. If the diagnosis is confirmed, the surgeon can proceed with enlargement of the bony
lesion and curettage of the lesion. - - The margin of the excsion can be extended with a high speed
burr where sufficient bone exists.
- Chemical cauterisation of the cavity can be made with phenol. The defect can then be packed with
bone graft.
- Follow up of the patient with surveillance radiographs is at 6 months, 1 year and 2 years. The

14. Clinical picture of Boutonniere deformity.
What is the underlying pathology?
What is the classification and the management of this condition?
This is an aquired deformity of the extensor mechanism characterised by a flexion deformity at the
PIPJ and an extension deformity at the DIPJ
They are caused by:
- Rupture of the central slip of the extensor mechanism, from attenuation (eg. secondary to capsular
distension in rheumatoid arthritis), laceration or traumatic disruption
- Volar subluxation of the lateral bands because of to disruption or incompetence of the triangular
ligament
- The lateral bands fall volar to the axis of rotation of the PIPJ, becoming a flexor of the PIPJ.
- The lateral bands then transmit their force to extension of the DIPJ
Classification into four stages:
Stage Description
I
The deformity is totally correctable passively, and there is full flexion of the DIP
joint when the PIP joint is fully extended
II Flexion of the DIP joint is limited when the PIP joint is passively corrected.
III Stiffness of the PIP joint without joint destruction.
IV Stiffness of the PIP joint with joint destruction
Management:
Nonoperative:
- Splint the PIPJ in extension for 6 weeks if the injury is less than 4 weeks old
- Encourage active DIPJ flexion and extension to avoid contraction of the oblique retinacular

ligamemt
Operative (Stanley, 2004):
Choosing the most appropriate surgical procedure will depend on the severity of the anatomical
deformities which need to be corrected:
- Improving passive PIPJ extension with serial casting or a Capner splint is worthwhile before
surgery commenced
- Lateral band relocation - correction of PIPJ flexion with mobilization of the lateral bands posterior
to the axis of rotation of the PIPJ
- Improving active DIPJ flexion with lengthening of the conjoined lateral bands over the middle
phalanx
- PIPJ arthroplasty if the joint is destroyed but movement maintained
- Arthrodesis if there is gross uncorrectible deformity of the DIPJ or PIPJ

15. Plain radiograph of malnuited distal radius fracture. The patient has reduced range of
movement and rotation with pain.
Clinical evaluation:
- Full history: age, occupation, handedness, daily activities, restrictions in daily life from the
malunion, and in particular the expectations of the patient (symptomatic and functional)
- Examination noting the extent of the deformity, whether they had previous operative management and
range of movement compared to the contralateral side.
- Radiology:
Ask for bilateral wrist views to compare to the normal side.
Comment on fracture configuration, radial height, radial inclination and dorsal/volar angulation, intra-
articular components and size of any steps, presence of healing/callus, congruency of the DRUJ,
presence of degenerative changes at radioulnar or DRUJ.
Malunion of the radius results in alterations to the:
- Radiocarpal joint
- Distal radioulnar joint
- Midcarpal joints
These changes can lead to immediate functional impairment (lack of flexion and supination) or later
degenerative changes from increased contact stresses.
The exact indications for corrective osteotomy remain unknown, but most surgeons would reserve the
procedure for patients with symptomatic malunion, with DRUJ pain being amongst the commonest
symptoms (McQueen, 2008).

Management:
Pre-operative planning:
- An osteotomy may be performed when there is an agreement between the surgeon and the patient that
there is a plateau in the patient’s clinical improvement.
- One can wait until the fracture callus has incorporated, but this may not be necessary, as taking
down the callus and internally fixing before the fracture has healed may be technically easier than
bone grafting and corrective osteotomy (Jupiter, 2001).
- Ensure the patient has had appropriate non-operative mangement including physiotherapy if the
patient has been monitored or the patient has presented late
- Plan the osteotomy with standard PA and lateral plain radiographs of both wrists.
- A low threshold for a CT scan to gain further information on the planes of the deformity and any
rotational components, and on the DRUJ and its salvagability.
- Discuss the donor site morbidity for an iliac crest graft
Operative Management (Rockwood and Green, 2010):
1) An opening wedge osteotomy when the DRUJ can be salvaged:
- The deformity is usually approached from the collapsed side.
- This is dorsal in most patients, and can allow for intraoperative assessment of DRUJ articular
changes directly.
- On the lateral view on image intensifier one pin is inserted proximally perpendicular to the shaft
and one distally in the metaphysis parallel to the articular surface.
- The osteotomy is performed and the correction made. Bone graft is harvested from the iliac crest
and inserted into the defect and the correction is held with a dorsal plate.
- A volar approach may also be used, with a volar locking plate for fixation.
2) A closing wedge osteotomy with associated hemiresection of the ulna when the DRUJ cannot be
reconstructed
3) An ulnar shortening osteotomy when there is shortening of the radius without loss of palmar tilt or
radiocarpal incongruity

16. Clinical picture of nail bed injury.
How will you manage this injury?
- Nail bed injuries, especially crushing injuries, may seem innocuous but must be treated with care to
avoid later nail deformities
- Examine for a visible nail bed laceration. If present this will require repair
- Determine whether there is an underlying distal phalanx fracture with a plain AP and lateral
radiographs
Management:
Preoperative planning:
- Consider photographs for documentation
- Discuss with the patient the possibility of long term nail deformity
Technique:
- Ring block of the digit with local anaesthetic (without adrenaline)
- Apply a finger tourniquet and mark it appropriately to avoid leaving it in situ
- Perform irrigation and debridement
- Remove any residual nail and repair with a 6-0 absorbable suture
- Replace the nail plate if available, or a synthetic alternative, to maintain the eponychial fold
- Look for a nail bed avulsion – if this is present then a free nail bed graft is required
Distal phalanx fractures:
- Small tuft fractures do not require treatment, but diaphyseal fractures can cause deformity with
angulation and malalignment
- Ensure there is no flexor or extensor tendon avulsion
- K-wiring of the more unstable fractures can be required
- Ensure there is no soft tissue or nail bed entrapment in the fracture site, as non union may result
- Avoid immobilisation of the joint for more than three weeks: this will lead to stiffness with a worse
outcome

17. Plain radiograph of sclerotic lunate (Kienbock’s disease)
Name the diagnosis.
What is the classification of this condition? How would you manage this patient?
Discuss carpal height.
Kienbock’s disease is avascular necrosis of the lunate, first described in 1910.
Classification is radiological (Lichtman):
Stage Description Treatment
I
No changes on plain radiographs, changes
only on MRI
NSAIDs and a period of immobilisation
II Sclerosis of the lunate
Joint levelling procedure (radial shortening
or ulnar
IIIA
Fragmentation of the lunate with carpal
collapse without fixed scaphoid rotation
lengthening) if ulnar negativeRadial wedge
osteotomy if ulnar neutralVascularised
bone grafts (2,3 intercompartmental
supraretinacular artery)
IIIB
Fragmentation of the lunate with carpal
collapse and fixed scaphoid rotation
STT fusion to maintain carpal height and
transfer the load to the scaphoid fossa.
Proximal row carpectomy may not be as
good because of damage of surrounding
joint surfaces
IV Degenerated adjacent intercarpal joints
Total wrist fusion if other methods have
failed

Diagnosis:
- History of wrist pain that radiates up the forearm. Assess the patient’s disability carefully. The
exact aetiology is unknown, but they may have experienced a single forgotten traumatic incident or
repetitive microtrauma.
- Examination findings of tenderness at the lunate, stiffness in dorsiflexion, pain on passive
dorsiflexion of middle finger and weakness of grip
- Radiological diagnosis with plain PA and lateral radiographs as above. MRI if no changes evident
on plain radiographs.
Treatment:
- It is important to recognise that the radiographic appearances do not correlate well with the syptoms
of the patient, the natural history of the disease is not clear, and there is no strong evidence to support
on treatment over another (Review Schuind et al., 2008)
Non-operative:
- Initial management can include splintage and analgesia
- If conservative management fails, consider operative managment
Operative:
Reconstruction
- Ulnar shortening osteotomy
Salvage
- Proximal row carpectomy
- Wrist fusion
The choice of procedure is guided by
- The severity of the symptoms
- The ulnar variance
- The stage of the disease
- Carpal height
- Careful counselling of the patient
Along with careful counselling of the patient, this will guide the choice of operative management.
Carpal height:
- The measurement of carpal height is useful in following the progression or the extent of
degenerative disease, carpal instability or osteonecrosis
- In Kienbock’s disease, it relates to the radiographic staging
- Carpal height is the distance between the distal articular surface of the capitate and the distal
articular surface of the radius
- The carpal height ratio is the carpal height/length of 3rd metacarpal
- The average ratio is 0.53, with a range between 0.45 and 0.6

18. Plain radiographs of comminuted distal radius fracture.
Describe theradiographs.
How would you manage this patient?
What is the evidence for ORIF vs percutaneous K-wiring vs External fixation?
This is an AP and lateral radiographof the wrist in a skeletally mature patient. There is a comminuted,
intra-articular distal radius fracture involving the radiocarpal joint and the distal radioulnar joint.
There is dorsal translation and angulation of the metaphyseal fragments, with extension of the fracture
proximally into the radial shaft.
Management:
- History to include age, occupation, handedness, mechanism of injury (low vs high energy) and
activities of daily living
- Examination to assess skin quality and integrity, distal neurovascular status (in particular median
and ulnar nerves), clinical deformity and continuity of extrinsic extensor and flexor tendons
(especially EPL).
- Radiological Assessment:
View Measurement Normal
Acceptable healed position
(Rockwood and Green,
2010)
Lateral Volar tilt 11 degrees Neutral
AP Radial height 22 mm
Within 2-3 mm of
contralateral wrist
Radial inclination 11 degrees <5 degrees loss
Articular congruence No step <2 mm step-off
Non-operative management:

- Closed reduction and a below elbow cast if the patient is medically unfit for surgery or previously
severely limited in completing ADLs.
1) Open reduction internal fixation:
Benefits:
- Accurate fracture reduction, volar locking plates allow direct fixation of comminuted fractures,
bone grafting possible if bone loss or depressed fractures and early wrist mobilisation is possible.
- A prospective randomised trial of 144 intra-articular fractures found internal fixation produced
superior results to bridging external fixation supplemented with percutaneous pinning, both
radiographically and clinially (Leung et al., 2008).
Disadvantages:
- Risks of infection, nerve and tendon injury
2) Closed reduction and percutaneous K-wiring:
Benefits:
- Simple, minimally invasive and inexpensive
- Evidence to show that younger patients with extra-articular and simple articular fractures with little
dorsal comminution can be treated successfully (Trumble et al., 1998)
Disadvantages:
- in patients with osteoporosis, a randomised controlled trial showed no advantage using
percutaneous pins over cast alone (Stoffelen and Broos, 1999)
- Concerns about loss of position in a fracture with dorsal comminution with this technique
- Risk of infection of the pin sites and continued treatment in a cast causing stiffness.
3) External Fixation:
- Includes bridging for intra-articular fractures (static or dynamic) or non-bridging for extra-articular
fractures.
- Adjunctive fixation with K-wires for intra-articular fragments may be required.
- Non-bridging external fixation requires at least 1cm of intact volar cortex for the distal pins so
would not be possible in this fracture
- Bridging external fixation relies on ligamentotaxis for fracture reduction. Studies have shown that
this technique alone may not be sufficiently rigid to prevent some collapse and some loss of volar tilt
during healing (McQueen, 1998)
Benefits:
- Avoiding the zone of injury and damage control fixation
Disadvantages:
- Loss of reduction, stiffness if a bridging fixator is used, and possibility of superficial radial nerve
injury
On this basis:
- The treatment of choice for this fracture is open reduction and internal fixation (ORIF) with a volar

locking plate using a modified Henry’s approach.
- For more borderline fractures, despite an increasing trend towards ORIF, there is no strong
evidence to indicate that ORIF is superior to conservative management.

19. Plain radiographs of a dorsal PIPJ fracture-dislocation.
Describe the radiographic appearance.
What is your immediate assessment and treatment?
How would you splint the patient? How would you follow up this patient?
This is fracture dislocation of the base of the middle phalanx. The fracture involves more than 50% of
the volar joint surface, with dorsal subluxation of the phalanx at the PIPJ. The fracture is not
multifragmentary.
Immediate Assessment:
- History including age, occupation, handedness, mechanism of injury
- Examination including neurovasular and soft tissue status
Management:
- Reduce the fracture with traction and flexion at the PIPJ, then splintage in an extension block splint
at 40 degrees flexion with a repeat radiograph to check the position of the reduction
- Follow up in fracture clinic on a weekly basis, with reduction in the extension block by 10 to 15
degrees each week for the first three weeks
- The greater the proportion of the joint surface involved, the higher the angle of flexion that the
extension blocking must begin, and the longer it takes to reach full extension. There is a greater risk of
a permanent fixed flexion deformity in these patients.
- With more than 40% of the joint surface involved, the instability precludes non-operative
management. ORIF or a dynamic fixator may be needed.

20. Plain radiograph of Bennett fracture.
What is the management of this injury?
Bennett’s fracture is an intra-articular fracture dislocation of the base of the 1st metacarpal.
The configuration of the fracture:
- A small volar fragment continues to articulate with the trapezium from the strong volar anterior
oblique ligament (palmar beak ligament)
- Lateral retraction of the rest of the metacarpal because of the pull of abductor pollicis longus. The
metacarpal head is displaced into the palm by the action of the adductor pollicis
Management:
Non-operative:
- The fracture can be reduced using thumb traction, abduction and extension with pronation
- The fracture can be held in position with a Bennett’s cast (hitchhiker position) with moulding at the
fracture site to maintain the position
- Accept up to 2 mm of fracture displacement (well tolerated at this joint
Operative:
1) Closed reduction and percutaneous K-wire fixation:
- Consider when there is less than 3 mm displacement and volar fragment occupies less than 50% of
the articular surface
- The wires stabilise the 1st metacarpal to the trazepium or 2nd metacarpal, and do not attempt to fix
the volar fragment
- Complete in a spica cast for 6 weeks

2) Open reduction and internal fixation:
- Consider when there is more than 3 mm fracture displacement
- Use a limited incision to control the fracture fragments then stabilise with K-wires or, rarely, lag
screw fixation and a T-shaped neutralisation plate with early mobilisation.

21. Clinical picture of a thumb with stress of the MCPJ in flexion.
What is the diagnosis?
How would you manage this injury?
What is a Stener lesion and where does it get stuck?
Diagnosis:
- This is a stress view radiograph of the thumb MCPJ. The opening at the ulnar aspect of the joint
indicates an ulnar collateral ligament (UCL) injury. There is no associated avulsion fracture of the
base of the proximal phalanx.
Management:
History:
- Includes age, occupation, handedness, mechanism of injury and chronicity of the injury.
Examination:
- Reveals swelling and tenderness over the ulnar apect of the MCPJ
- The clinical stress examination of the joint in flexion and extension, with laxity and no end point, is
the gold standard for diagnosis (Tsiouri, 2009).
- Laxity in flexion of over 35 degrees (or 15 degrees more than the other side) indicates a rupture of
the proper collateral ligament; laxity in extension indicates a rupture of the accessory collateral
ligament. If the diagnosis of instability is uncertain, stress radiographs can be performed (Tsiouri,
2009).
Anatomical basis:
- In acute, unstable injuries, acute repair is advocated because of the high likelihood of a Stener

lesion (Stener, 1962)
- A Stener lesion can prevent healing of the ulnar collateral ligament and can lead to chronic
collateral ligament instability if treated non-operatively
- The anatomic basis of the Stener lesion is the proximal edge of the adductor aponeurosis
- The UCL usually tears at its attachment to the base of the proximal phalanx, and the torn stump
comes to lie dorsal to the aponeurosis
- It is therefore prevented from healing back to its anatomic insertion at the volar, ulnar base of the
proximal phalanx
Acute repair of the UCL:
A ‘lazy-S’ incision is made over the ulnar aspect of the base of the thumb.
- Care is taken to identify and protect the dorsal branches of the superficial radial nerve
- The adductor aponeurosis is identified and incised longitudinally, and the dorsal capsule and
collateral ligaments are assessed
- The most common method of repair is the use of bone anchors, which give good results of loss of
only 10 degrees of MCPJ and 15 degrees of IPJ motion (Weiland, 1997).
- Care must be taken in tensioning the repair to avoid stiffness

22. Plain radiograph showing an increased scapho-lunate gap.
What are the causes of this appearance?
How would you confirm the diagnosis?
Discuss SLAC wrist and its treatment?
Causes:
- Scapholunate (SL) dissociation because of a scapholunate ligament rupture
- Differential diagnosis of ulnar translocation, a reduced perilunate dislocation or a physiological
scapholunate separation in lunotriquetral coalition
Radiological signs of scapholunate dissociation:
- SL gap of >3 mm on a clenched fist view (Terry Thomas sign)
- Cortical ring sign (given by cortical outline of the distal pole of the scaphoid in volar flexion)
- Scapholunate angle of >70 degrees from dorsal tilt of lunate and flexion of the scaphoid (normally
around 45 degrees) on the lateral view
Confirm the diagnosis:
- History of fall onto outstretched hand with stress loading onto carpus in extension
- Examination findings of tenderness just distal to Lister’s tubercle and a positive Watson’s test (with
the elbow resting on a tabletop and the forearm raised, with pressure over volar aspect of scaphoid
and deviating the wrist from ulnar to radial, a clunk secondary to dorsal subluxation of the scaphoid
over the doral rim of the radius is produced)
Investigations:
- MRI has low sensitivity but good specificity
- Wrist arthroscopy is the gold standard for diagnosis

Management:
Non-operative:
- In medically unfit patients or those who are not self-caring
Operative:
The options are divided into reconstructive and salvage
Acute:
- Scapholunate ligament repair is undertaken either directly or with bone anchors. The repair is
protected with K-wires to the scapholunate and scaphocapitate joints
Chronic:
- Soft tissue procedures include a modified Brunelli (FCR tenodesis)
- Bony (salvage) procedures include a stabilisation with wrist fusion (e.g. STT) for rigid and
irreducible dorsal intercalated segment instability (DISI)
SLAC wrist
- SLAC stands for ‘scapholunate advanced collapse’, with progressive instability causing arthritis of
the radiocarpal and midcarpal joints from chronic dissociation between the scaphoid and the lunate
Management:
Non-operative:
- If symptoms are minor then advice, analgesia and splintage may be suitable
Operative:
Watson classification of SLAC wrist (radiographic appearance)
Type Description Operative Management
I
Arthritis between scaphoid and radial
styloid
Radial styloidectomy and scaphoid
stablisation (STT fusion) +/- PIN
denervation
PIN = posterior interosseous nerve
II
Arthritis between scaphoid and entire
scaphoid fossa of the distal radius
Scaphoid excision and four corner fusion or
proximal row carpectomy for relative
preservation of strength and motion
III
Stage II + arthritis between lunate and
capitate (eventually with proximal
migration of the capitate)
Scaphoid excision and four corner fusion or
wrist fusion (better pain relief and grip
stregth at the expense of motion)

References
Al-Qattan. Conservative management of zone II partial flexor tendon lacerations greater than half the
width of the tendon. J Hand Surg 2000;25A:1118-1121.
Atroshi I, Axelsson G, Nilsson EL. Osteotomy versus tendon arthroplasty in trapeziometacarpal
arthrosis: 17 patients followed for 1year Acta Orthop Scand. 1998 Jun;69(3):287-90
Brunner J.M. The zig-zag volar-digital incision for flexon tendon surgery. J Plast Recon Surg 1967;
40:571-574.
Bulstrode NM, Jemec B, Smith PJ. The complications of Dupuytren’s contracture surgery. J Hand
Surg 2005; 30:1021-1025
Davis T, Brady O, Dias J. Excision of the Trapezium for Osteoarthritis of the Trapeziometacarpal
Joint: A study of the Benefit of Ligament Reconstruction or Tendon Interposition. J Hand Surg (Am)
2004;29-A:1069-77.
Herbert TJ, Fischer WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint
Surg 1984;66B:114-123.
Heyworth BE, Lee JH, Kim PD, et al. Hylan versus corticosteroid versus placebo for treatment of
basal joint arthritis: A prospective, randomized, double-blinded clinical trial. J Hand Surg Am
2008;33:40-48
Jupiter JB, Fenrnandez DL. Complications following distal radius fractures. J Bone Joint Surg Am
2001; 83:1244-1265
Leung F, Tu YK, Chew WY, et al. Comparison of external and percutaneous pin fixation with plate
fixation for intra-articular distal radial fractures. A randomised study. J Bone Joint Surg Am 2008;
90:16-22
McGregor I.A. The Z-Plasty in Hand Surgery. JBJS Br 1967;49: 448-457
McQueen MM. Redisplaced fractures of the distal radius: A randomised prospective study of
bridging versus non-bridging external fixation. J Bone Joint Surg Br 1998; 80:665-669.
McQueen MM, Wakefield A. Distal radial osteotomy for malunion using non-bridging external
fixation: good results in 23 patients. Acta Orthop 2008; 79:390-395
McQueen MM, Gelbke MK, Wakefield A et al. Percutaneous screw fixation versus conservative
treatment for fractures of the waist of the scaphoid. A prospective randomised study. J Bone Joint
Surg Br 2008;90:66-71.
O'Connor MI, Bancroft LW. Benign and malignant cartilage tumors of the hand. Hand Clin. 2004
Aug;20(3):317-23, vi. Review

Pederson WC. Replantation. Plast Reconstr Surg. 2001 Mar;107(3):823-41
Rockwood and Green (ed) Fractures in Adults (7th Ed) p839
Schuind F, Eslami S, Ledoux P. Kienbock's disease. J Bone Joint Surg Br. 2008 Feb;90(2):133-9.
Sorene ED, Goodwin DR. Tenodermodesis for established mallet finger deformity. Scandinavian
Journal of Plastic and Reconstructive Surgery and Hand Surgery 2004; 38(1): 43-45.
Stanley J J Bone Joint Surg Br 2004 vol. 86-B no. SUPP III
Stener B. Displacement of the ruptures ulnar collateral ligament of the metacarpophalangeal joint of
the thumb. J Bone Joint Surg Br 1962;44-B:869–79.
Stoffelen DV, Broos PL. Closed reduction versus Kapandji pinning for extra-articular distal radius
fractures. J Hand Surg Br 1999; 24:89-91
Strauch RJ, Rosenwasser MP, Lunt JG. Metacarpal shaft fractures: the effect of shortening on the
extensor tendon mechanism. J Hand Surg Am 1998;23:519-523.
Strickland JW. Flexor Tendon Injuries: II. Operative Technique. J Am Acad Orthop Surg. 1995
Jan;3(1):55-62.
Trumble TE, Wagner W, Hanel DP et al. Intrafocal (Kapandji) pinning of distal radius fractures with
and without external fixation. J Hand Surg Am 1998; 23: 381-394
Tsiouri C, Hayton MJ, Baratz M. Injury to the Ulnar Collateral Ligament of the Thumb. Hand
2009;4:12-18
Ulrich-Vinther M, Puggaard H, Lange B. Prospective 1-year follow-up study comparing joint
prosthesis with tendon interposition arthroplasty in treatment of trapeziometacarpal osteoarthritis. J
Hand Surg Am. 2008 Oct;33(8):1369-77.
Vermeulen GM, Slijper H, Feitz R, Hovius SE, Moojen TM, Selles RW. Surgical management of
primary thumb carpometacarpal osteoarthritis: a systematic review J Hand Surg Am. 2011
Jan;36(1):157-69
Weiland AJ, Berner SH, Hotchkiss RN, McCormack RR, Gerwin M. Repair of acute ulnar collateral
ligament injuries of the thumb metacarpophalangeal joint with an intraosseous suture anchor. J Hand
Surg 1997;22A:585-591.

Cold Paediatrics
Mr Andreas Rehm
Paediatric Orthopaedic Surgeon

1. Perthes Disease (Legg- Calvé-Perthes; Legg:Boston, USA; Calvé: Berck sur Mer, France;
Perthes: Tübingen, Germany)
1. What are the X ray findings?
-Deformity of the right femoral head
-Subchondral fracture with collapse of the articular surface
-Lateral subluxation of the femoral head
-Break in Shenton’s line
-leg is held in adduction
2. What is Perthes Disease?
It is an idiopathic avascular necrosis of the femoral capital epiphysis. The cause is unknown. It is
thought to be multifactorial.
3. Epidemiology
It occurs between about 18 months of age and skeletal maturity.
Most children are between 5 and 10 years of age at the time of onset.
It is bilateral in 10 to 12% of children. Boys are affected 4 to 5 times more frequently than girls. Girls
have a worse prognosis.
4. Etiology
The cause is uncertain. It is probably mulifactorial. Haematologic and clotting abnormalities (e.g.

deficiencies of protein C and S) have been suggested by some but have not been confirmed by others.
The main arterial supply to the femoral head comes from the lateral ascending cervical artery which
is the terminal branch of the medial circumflex femoral artery and lies within the hip joint capsule.
The terminal branch runs through a narrow passage between the greater trochanter and the capsule
where it can become constricted. The blood supply can be occluded by abducting and internally
rotating the hip.
Inoue et al concluded from their research that at least two femoral head infarcts are required to cause
Legg-Calvé-Perthes disease.
Inoue A, Freeman MA, Vernon-Roberts B. The pathogenesis of Perthes disease. J Bone Joint Surg Br
1976; 58:453.
5. Most common symptoms and signs?
Symptoms are pain in the groin, around the hip and/or knee. Signs are:
-child walks with a limp
-limited range of hip movements affecting generally abduction and internal rotation.
6. What is the lateral Pillar classification (Herring)?
Group A
No involvement of the lateral pillar. No density change. No loss of height.
Group B
Mild density change in lateral pillar. Height ≥ 50% of original height. Central pillar collapse.
Group B/C
Very narrow lateral pillar (2-3 mm wide) with 50% of the original height that is depressed relative to
the central pillar.
Group C
Lateral pillar with <50% of original height.
It has superseded the Catterall classification and has become the most commonly used classification.
Park et al evaluated the inter- and intra-rater reliability of the Herring lateral pillar, Catterall and
Salter-Thompson classification and concluded that the Herring classification showed the greatest
reliability.
Herring JA, Neustadt JB, Williams JJ, Early JS, Browne RH. The lateral pillar classification of
Legg-Calve-Perthes disease. J Pediatr Orthop 1992;12:143-150.
Herring JA. Legg-Calvé-Perthes disease. In:Tachdjian’s Pediatric Orthopaedics, Vol. 2, Fourth ed.
Philadelphia: Saunders Elsevier, 2008:1044-1045.

Herring JA. Tachdjian’s Pediatric Orthopaedics, Vol. 3, Fourth ed. Philadelphia: Saunders Elsevier,
2008:2519.
Park MS, Chung CY, Lee KM, Kim TW, Sung KH. Reliability and stability of three common
classifications for Legg-Calvé-Perthes disease. Clin Orthop Relat Res 2012 Mar 20 (Epub ahead of
print).
7. What is the Catterall classification?
Group I: Only anterior portion of the epiphysis affected. Up to 25% head involvement.
Group II:
More of the anterior portion is involved and a central segment is present. Up
to 50% head involvement.
Group III:
Most of the epiphysis involved with the unaffected portions located medial
and lateral to the central segment. Up to 75% head involvement.
Group IV: Total head involvement.
According to Catterall, groups I and II have a benign prognosis.
Several interobserver studies have shown a low degree of reproducibility.
Christensen F, Soballe K, Ejsted R. The Catterall classification of Perthes’ disease: An assessment of
reliability. J Bone Joint Surg Br 1986; 68:614.
Hardcastle PH, Ross R, Hamalainen M. Catterall grouping of Perthes’ disease: An assessment of
observer error and prognosis using the Catterall classification. J Bone Joint Surg Br 1980;62:428.
8. What are Catterall’s Head at risk signs?
1) Gage sign (V shape lucency at lateral epiphysis)
2) Horizontal growth plate
3) Lateral calcification
4) Subluxation
5) Metaphyseal cystic changes
Forster et al reported poor inter- and intra-observer reliability for head at risk signs.
Forster MC, Kumar S, Rajan RA, Atherton WG, Asirvatham R, Thava VR. Head-at-risk signs in
Legg-Calvé-Perthes disease: poor inter-and intra-observer reliability. Acta Orthop 2006;77(3):413-
417.
9. What are the 4 radiographic stages described by Waldenström?
1) initial / ischaemic
2) fragmentation/resorbtion
3) reossification/healing
4) residual/remodelling

Waldenström H. The definite form of coxa plana. Acta Radiol 1922;1:384.
Initial phase: The blood supply of the femoral head is compromised. The articular cartilage still
grows as it is nourished by the joint fluid resulting in increased joint space and apparent mild joint
subluxation on plain radiographs (Waldenstrom’s sign). The head ceases to enlarge. An increased
density in the femoral head is the result of new bone accumulation on the dead trabeculae. At the end
of this phase lucencies occur within the ossific nucleus and cysts within the metaphysis. Plain
radiographs may show a subchondral fracture.
Fragmentation phase: More new bone is laid down on the dead trabeculae causing increased bone
density. Subchondral fractures may occur causing a black subchondral line (Crescent sign). The
hyperaemia and revascularisation causes bone lysis and rarefication giving a fragmented appearance
on the plain radiographs.
Reossification phase: New subchondral bone is laid down in the femoral head until the entire head
has re-ossified. The head is plastic and if it is not concentrically contained within the acetabulum, it
will become deformed.
Residual phase: There are no further changes in the density of the femoral head. The shape of the
femoral head may remodel. The shape of the acetabulum and greater trochanter may be affected. The
plasticity is lost and the femoral head shape will remain. The normal internal architecture will return,
but within an altered shape if this has occurred. Deformity will lead to arthritis.
10. Treatment
This is very controversial with there being no national and no international agreement. Annamalai et
al (2007) showed a great deal of variability in the UK in the decision-making process and treatment.
In the early onset group under the age of 8 years, children are mostly managed non-operatively.
Herring et al conducted the largest multicentre centre study in America by comparing non-operative
management with operative management (either femoral varus or pelvic osteotomy) for early and late
onset groups. It was reported that there was no difference in outcome between non-operative
management, femoral varus or pelvic osteotomy in the early onset group.
In the late onset group, they found an improved outcome for lateral pillar groups B and B/C with
either femoral varus or pelvic osteotomy over the non-operative group. There was no difference for
groups A and C.
Herring JA, Kim HT, Browne R. Legg-Calvé-Perthes Disease. Part I: Classification of radiographs
with the use of the modified lateral pillar and Stulberg classifications. J Bone Joint Surg Am 2004
;86-A:2103-2120.
Herring JA, Kim HT, Browne R. Legg-Calvé-Perthes Disease. Part II: Prospective multicenter study
of the effect of treatment on outcome. J Bone Joint Surg Am 2004. 86-A:2121-2134.

Containment surgery has been advocated by others when the femoral head extrudes from the
acetabulum irrespective of age (the femoral head is maintained within the depth of the acetabulum
with femoral osteotomy, pelvic osteotomy or both combined).
Staheli and Catterral have popularised the shelf procedure to create a pelvic shelf providing
resistance to further subluxation of the femoral head. Abduction bracing/casting can be used, but is
generally not longer used by most paediatric orthopaedic surgeons.
In the late healed stage a femoral valgus osteotomy is used if there is hinge abduction. Combination of
femoral and pelvic osteotomy have been described to improve the acetabular roof alignment in the
healed stage.
Hip distraction using a hip joint spanning external fixator has been described for the late onset group
to unload the femoral head by distracting the hip joint.
Stulberg classification describes the end stage of the disease at skeletal maturity. I: normal spherical
femoral head; II: round femoral head and fitting within 2 mm of a circle on both anteroposterior and
lateral radiograph; III: out of round by more than 2 mm on either radiograph; IV: flat head and
matching flat acetabulum (aspherical congruency); V: flat head with non-matching acetabulum
(aspherical incongruency).
11. Prognosis
This is related to the congruency of the hip joint and the spericity of the femoral head.
Patients with Stulberg class V develop severe arthritis before the age of 50 years.
Stulberg reported that children presenting on or before their 8th birthday had a 59% rate of good
results and only an 8% rate of poor results. Those presenting after their 8th birthday had a 39% rate of
good outcomes and a 26% rate of poor outcomes using the Stulberg classification.
StulbergSD, Cooperman DR, Wallensten R. The natural history of Legg-Calvé-Perthes disease. J
Bone Joint Surg Am 1981;63:1095.

2. Congenital Taliped Equino Varus (CTEV)
Which are the deformities?
Deformities
1. Hindfoot equinus
2. Hindfoot varus
3. Midfoot/forefoot cavus
4. Forefoot adduction

CAVE = CavusAdductusVarusEquinus
The forefoot looks supinated but it is in a pronated position in relation to the midfoot. The calf and
foot are smaller which is obvious in the unilateral deformity.
What is the Pirani classification.
This is a system to score the severity of a clubfoot deformity. It consists of A) a hindfoot score,
assessing the posterior heel/ankle crease, the position of the calcaneum in the heel and the rigidity of
the equinus and B) a midfoot score, assessing the medial crease, the lateral curvature of the foot and
the lateral coverage of the head of the talus by the navicular.
Each component scores 0, 0.5 or 1 giving a maximum of 6 points for the most severe deformity.
Posterior heel/ankle crease: 0=normal (multiple fine creases which do not change the contour of the
heel); 0.5=one or two deep creases which do not appreciably change the contour of the heel; 1=one or
two deep creases which appreciably change the contour of the heel.
Position of the calcaneum in the heel: 0=calcaneum easily palpable; 0.5=calcaneum palpable deep
inside the heel; 1=not palpable.
Rigidity of equinus: 0=foot comes up to a dorsiflexed position of more than 5°; 0.5=range between
5° of plantar flexion and 5° of dorsi flexion; 1=fixed equinus of more than 5°.
Medial crease: 0=normal (multiple fine creases which do not change the contour of the arch); 0.5=
one or two deep creases which do not appreciably change the contour of the arch; 1= one or two deep

creases which appreciably change the contour of the arch.
Curvature of lateral foot border: 0=straight lateral border from the heel to the 5th metatarsal head;
0.5=mildly curved lateral border (the curvature appears to be in the distal part of the foot in the area
of the metatarsals; 1=pronounced curvature (it appears to be at the level of the calcaneo-cuboid
joint).
Lateral talar head coverage: 0=complete reduction of the navicular onto the talar head; 0.5=partial
reduction of the navicular onto the talar head; 1=easily palpable talar head because of fixed medial
subluxation of navicular.
Pirani S, Outerbridge HK, Sawatzky B, Stothers K. A reliable method of clinically evaluating a
virgin clubfoot evaluation. 21st SICOT Congress 1999.
www.global-help.org
How will you manage- at birth and late stage.
The Ponseti method is the preferred treatment. It starts soon after birth and consists of:
1. Weekly serial casting with above knee plasters for about 6
weeks.
2. Percutaneous Achilles tendon release in about 80% of
patients at about 6 weeks.
3. Further post-operative casting for about 3 weeks (a cast
change during this period might be necessary).
4. Boots on a bar 23 hours a day for 3 months.
5. Boots on a bar for during the night up to the age of 4/5 years.
Ponseti treatment is also effective in older children in correcting all or part of the deformity.
Depending on the severity of the deformity additional surgery is required.
Ponsetti method
Order of correction
1. Simultaneous correction of cavus, fore/midfoot adduction (aim for 60°-70° abduction) and hindfoot
varus.
2. Equinus correction once cavus, fore/midfoot adduction and hindfoot varus are corrected.
About 20% of patients need a tibialis anterior tendon transfer for dynamic supination deformity
between the age of 3 to 5 years. Transfer is into the lateral cuneiform (the ossification centre must be
visible).
Outcome of ponseti?

Boden et al reported a significant reduction in the need for radical surgical release with the Ponseti
technique in comparison to a stretch and strap technique. Gray et al performed a metaanalysis of the
literature to evaluate interventions for clubfeet. Evidence was limited because of limited use of
outcome measures and lack of available raw data. From the data available they concluded that the
Ponseti technique may produce better short-term outcomes compared with the Kite technique. Jowett
et al performed a systematic review of the literature of the results of the Ponseti method and
concluded that the original Ponseti method is the current best practice for the treatment of clubfeet
with an initial correction rate of around 90%. Halanski et al performed a prospective comparative
study comparing the Ponseti method with below knee casting followed by surgical release. They
concluded that both had a relatively high recurrence rate but that the Ponseti cohort had significantly
less operative interventions and required less revision surgery. Therefore they adopted the Ponseti
method as their primary treatment for clubfeet.
Morcuende et al reported that 86% of 157 clubfoot patients treated with the Ponseti method
underwent a percutaneous Achilles tendon release. The need for surgical releases was avoided in
98% of their cohort.
Boden RA, Nuttall GH, Paton RW. A 14-year longitudinal comparison study of two treatment
methods in clubfoot: Ponseti versus traditional. Acta Orthop Belg 2011. 77(4):522-8.
Gray K, Pacey V, Gibbons P, Little D, Frost C, Burns J. Interventions for congenital talipes
equinovarus (clubfoot). Cochrane Database Syst Rev 2012.18;4.
Jowett CR, Morcuende JA, Ramachandran M. Management of congenital talipes equinovarus using
the Ponseti method: a systematic review. J Bone Joint Surg Br 2011. 93(9):1160-4.
Halanski MA, Davison JE, Huang JC, Walker CG, Walsh SJ, Crawford HA. Ponseti method
compared with surgical treatment of clubfoot: a prospective comparison. J Bone Joint Surg Am 2010.
92(2):270-8.
Morcuende JA, Dolan LA, Dietz FR, Ponseti. Radical reduction in the rate of extensive corrective
surgery for clubfoot using the Ponseti method. Pediatrics 2004. 113(2):376-80.
Other treatments:
A minority of patients will need extensive soft tissue releases. The majority of these are thought to be
the result of non-compliance with the Ponseti treatment by parents/carers. Teratologic clubfeet
generally also need surgical releases. Residual deformities might require osteotomies and/or fusions
at a later stage. This is preferably delayed until the end of growth (girls ~14 years, boys ~16 years).
Etiology
The etiology is unknown. It is thought to be multifactorial with genetic and extrinsic factors being
involved. The incidence is about 1-2 (0.39 – 7) in 1000 but there are racial differences. There is a
~4% chance of a child to have a clubfoot deformity if one parent had a clubfoot deformity. There is a
~15% chance of a child to have a clubfoot deformity if both parents had a clubfoot deformity.

Pathology
The talus is the primary defect.
Thickening and contracture of tendon sheaths and ligaments, denervation and neuromyogenic changes
of muscles, shortened musculotendinous units, fibrosis of tissues and deficiencies of arteries have
been described.

3. Developmental Dysplasia of the Hip (DDH)
Dislocated hip in 3 years old girl.
What would be the clinical findings?
1) Apparent shortening and external rotation of the leg.
2) Reduced abduction of the affected hip.
3) There might be asymmetry of the thigh and/or buttock skin creases (dislocated hips can have
symmetric looking creases and many normal hips have asymmetric creases).
4) The femoral head is most likely palpable in the buttock.
5) Barlow and Ortolani test are most likely negative since dislocated hips in older patients are
usually irreducible. It is most likely possible to feel the femoral head moving within the buttock.
Describe Barlow and Ortolani test
Barlow test (described 1962, T.G. Barlow, Manchester): The hips are flexed to 90°. The thigh is held
between index finger and thumb with the index finger on the greater trochanter and the thumb on the
medial side of the thigh. The middle-, ring- and little fingers are at the back of the hip joint. The leg is
adducted towards the midline whilst pressure is applied on the knee, directing the force posteriorly.
If the hip is dislocatable you will feel the femoral head coming out into the buttock (positive test).
Ortolani test (described 1937, M. Ortolani, Italian Paediatrician): From the above position the leg is
abducted slowly and the greater trochanter is pushed anteriorly. A positive sign is an obvious
clunking sensation when the femoral head reduces into the acetabulum.
Which lines and angles do you assess on the antero-posterior X ray?

1. Shentons line (Radiologist, London, 1872-1955): This is a smooth curved line drawn along the
inferior aspect of the superior pubic ramus and the inferiormedial aspect of the femoral neck.
2. Hilgenreiner line (German surgeon and orthopaedist), Prague, 1870-1954): This is a straight line
drawn through the upper aspect of both triradiate cartilages.
3. Perkins line (Orthopaedic Surgeon, Oxford, 1892-1979): Drawn perpendicular to Hilgenreiner’s
line through the supero-lateral aspect of the acetabulum.
Perkins and Hilgenreiner line divide the hip joint into 4 quadrants. The proximal medial femur or the
ossification centre of the femoral head lies within the lower medial quadrant in a normal hip.
4. Acetabular index: This is the angle between Hilgenreiner’s line and a line drawn from the
triradiate cartilage to the lateral edge of the acetabulum. It should measure less than 20° by the age of
2 years.
What is the normal Graf ultrasound alpha angle?
Graf type I = normal = ≥60 degrees
Graf type
IIa = alpha angle 50-59°, up to the age of 3 months
IIb= alpha angle 50-59°, over the age of 3 months
IIc=alpha angle 43-49°, beta angle <77°
IId =alpha angle 43-49°, beta angle >77°
Graf type III =alpha angle <43°, everted labrum.
Graf type IV =alpha angle <43°, the femoral head is dislocated with the labrum interposed between
femoral head and acetabulum (inverted labrum).
Treatment
1) 0-6 months of age
All babies have their hips examined clinically after birth using Barlow and Ortolani test. Most hips
with a positive Barlow test at birth stabilise within 2 to 3 weeks without treatment. An ultrasound
(US) should be done to confirm the clinical diagnosis. These hips need to be followed up with
ultrasounds to assure normal development. Treatment with a Pavlik harness is indicated if the hips do
not stabilise after 2 to 3 weeks. If Ortolani test (relocate dislocation) is positive at birth with the hip
in a dislocated position at the beginning of the clinical examination, then this is again confirmed by
US. Even some of these hips reduce spontaneously within 2 weeks without treatment. Therefore
treatment can be held off for the first 2 weeks. Harness treatment is started if the hips do not reduce
during this period.
In the harness the hips are flexed to 90° to 100° and allowed to abduct to 65°.
Those children with risk factors for hip dysplasia but normal neonatal hip examination have hip

ultrasounds at about 6 weeks of age. Pavlik harness treatment is started if the ultrasound shows hip
dysplasia with instability.
Treatment is continued until the US shows normal development of the hips. Most harness treatments
go over 2 to 4 months. The harness is left on full time until the hip stabilises. The harness can be taken
off for daily bath times thereafter. It is not used for children above the age of 6 months.
Pavlik harness treatment is abandoned if a hip does not reduce within 4 weeks of treatment. This also
applies to bilateral dislocations where one hip remains dislocated at 4 weeks. Damage to the
acetabulum occurs by directing the femoral head into the wrong position if treatment is continued. In
these cases, an arthrogram is performed followed by closed reduction and spica immobilisation in
most cases. An adductor longus release is sometimes added. Some surgeons replace the spica with a
harness after one month when the hip has stabilised and continue with the harness until the hip looks
normal. An open reduction is occasionally necessary.
Treatments and timings vary between orthopaedic surgeons. The hip development in the harness is
monitored with regular US according to the surgeons preference.
Harness treatment is associated with an avascular necrosis rate of about 2% (up to about 8% has been
reported). Femoral nerve palsy is rare.
2. 6 to 18 months of age
Patients are brought to theatre were an arthrogram of the hip joint is performed followed by either
closed or open reduction with adductor longus release if it is contracted and hip spica application.
Some surgeons perform an additional iliopsoas release. A CT or MRI scan is performed after
reduction to confirm the position. The spica period is 3-4 months with a change half way through
followed by immobilisation with a removable abduction brace for a further about 3 months.
The timing of the reduction is controversial. Some surgeons wait with the reduction for up to about
one year.
A femoral derotation osteotomy is performed at times for those cases with excessive femoral neck
anteversion.
3. Older than 18 months
Patients who present after the age of 18 months usually require an open reduction and hip realignment
surgery. This includes femoral derotation osteotomy, pelvic osteotomy or both combined. An
adductor longus release is generally necessary. Post-operative immobilisation is with a hip spica for
3 months. Bracing is usually not necessary after the spica period after realignment surgery.
The open reduction is either performed through an anterior ilioinguinal approach (Smith Peterson) or
medial approach. The anterior approach allows reefing of the hip joint capsule. The approach
depends on the surgeons preference.
The femur is derotated to reduce excessive femoral neck anteversion. It needs to be shortened if there

is too much pressure on the acetabulum after reduction and varus needs to be incorporated if the
femoral neck is in too much valgus.
The pelvic osteotomy most commonly performed is the Salter osteotomy but a Dega osteotomy is also
an option.
Other pelvic reconstruction osteotomies used in older patients with DDH and other hip pathologies
are: triple pelvic osteotomy (Steel, Tönnis), Ganz periacetabular osteotomy (Bernese). Pelvic
salvage osteotomies are Chiari and Shelf procedure.
30 months old girl at first presentation.
Risk factors for DDH
NIPE = NHS Newborn and Infant Physical Examination programme
NIPE recommends:
A hip ultrasound should be performed when one or both of the following risk factors are present:
1) first degree family history of hip problems in early life
2) breech presentation at or after 36 completed weeks of pregnancy, irrespective of presentation at
delivery; breech presentation at delivery if this is earlier than 36 weeks.
There is also an association between DDH and talipes calcaneovalgus, metatarsus adductus,
torticollis, oligohydramnios and high female birth weight.
There is no association between clubfoot deformity and DDH.
NIPE states that the emphasis should be on the two risk factors listed above. Others should only be
introduced if there is the capacity to do so.
DDH is 4 to 8 times more common in females and slightly higher in first born infants. It is 3 times
more common on the left side.
Norton KI, Mitre SA. Developmental Dysplasia of the hip. E-Medicine, 2002. Available at
www.emedicine.com/radio/topic212.htm. Accessed December 12, 2002.
American Academy of Pediatrics. Clinical Practice Guideline: early detection of developmental

dysplasia of the hip. Pediatrics 2000; 105:896-905.
Aronsson DD, Goldberg MJ, Kling TF, Roy DR. Developmental dysplasia of the hip. Pediatrics
1994; 94:201-208.

4. Slipped Upper Femoral Epiphysis
Radiograph A
1. Describe the radiograph
-Antero-posterior radiograph of the pelvis. Abnormal
alignment of the right proximal femoral epiphysis.
-irregularity and widening of the physis.
-Reduced height of the epiphysis.
-The joint space might be increased inferiorly as seen on the radiograph.
-Klein’s line: line drawn along the superior surface of the neck. It should dissect the epiphysis. In this
case it does not, which indicates a slip = Trethowan’s sign.
-Metaphyseal blanch sign of Steel: The epiphysis slips
posteriorly in relation to the femoral neck. The posterior
portion of the femoral head is therefore seen on the antero-
posterior radiograph as a crescent-shaped area of increased density overlying the metaphysis
adjacent to the physis.
(J Bone Joint Surg Am 1986. 68:920-922)
-Which other Radiograph do you request? – Lateral view of the hip (always request radiographs in 2
planes-antero-posterior and lateral).
In chronic slips the edges will show new bone formation and rounding off of the edges as signs of
remodelling.
Radiograph B

The above radiographs show a preslip on the right side with widening of the physis.
2. How do you manage the patient with the radiographic appearance shown in A?
Immediate admission into hospital and bedrest. Plan cannulated screw fixation on the next available
list.
3. How many screws do you use for fixation?
Fixation with one cannulated screw is the preferred technique in the UK. Fixation with two screws,
Steinmann pins and Kirschner wires have been reported from other countries.
4. Would you perform prophylactic screw fixation of the normal hip.
This is controversial. Most colleagues in the UK would not perform prophylactic pinning. However,
Woelfle et al reported that prophylactic pinning of the normal hip is a safe procedure and Seller et al
recommended prophylactic pinning of the normal side in all patients.
Hurley et al reported that a contralateral slip developed in 61 (36%) patients out of 169. Therefore if
prophylactic pinning would be done for every patient, 64% of patients would undergo one
unnecessary operation and two unnecessary operations if the surgeon would remove the metal at a
later stage.
Prophylactic pinning is recommended for patients with chronic renal insufficiency because of a
prevalence of bilateral slips of 95% and patients with endocrinopathies (hypothyroidism, growth
hormone deficiency,…).

Woelfle JV, Fraitzl CR, Reichel H, Nelitz M. The asymptomatic hip in unilateral slipped capital
femoral epiphysis: morbidity of prophylactic fixation. J pediatr Orthop B 2012;21(3):226-9.
Seller K, Raab P, Wild A, Krauspe R. Risk-benefit analysis of prophylactic pinning in slipped
capital femoral epiphysis. J Pediatr Orthop B 2001;10(3):192-6.
Hurley JM, Betz RR, Loder RT. Slipped capital femoral epiphysis: The prevalence of late
contralateral slip. J Bone Joint Surg Am 1996;78:226.
5. How do you manage the patient after surgery?
Management will vary between colleagues. Most colleagues will mobilise patients touch
weightbearing for the first 6 weeks and then start partial weightbearing increasing to full
weightbearing over a further 6 weeks.
6. What are potential complications?
Avascular necrosis (AVN) of the femoral head:
-The reported AVN rate ranges from about 7% to 60% for unstable slips. Sankar et al reviewed 70
patients who presented with an unstable slip. The treatment was by a) in situ screw fixation, b) closed
reduction and screw fixation or c) open reduction and internal fixation. 14 patients (20%) developed
AVN. 3 (19%) of 16 patients in group a, 10 (26%) of 38 patients in group b and 1 (6%) of 16 patients
in group c. Seller et al reported on 29 patients with unstable slips who underwent fixation with 3 or 4
Kirschner wires. The chondrolysis rate was 0% and the AVN rate 6.8%. Kennedy et al reported on
212 patients (299 hips). AVN occurred in 4 of 27 unstable hips and in none of 272 stable hips. Uglow
and Clarke reported that an acute unstable slip should either be managed surgically within 24 hours of
onset or after about 3 weeks on traction if presentation is later than 24 hours to reduce the AVN rate.
Chondrolysis of the hip joint:
- The etiology is not known. Some authors reported a association between implant penetration into the
cartilage space of the hip joint and chondrolysis but others did not find a association. Kennedy et al
reported an incidence of 1.5%. Arnold et al reported that none of 65 patients who had pinning in situ
of a chronic slip developed chondrolysis.
Rached et al reported a chondrolysis rate of 3.6% in 26 patients who underwent reduction and
pinning in situ with one screw or multiple wires.
Kennedy JP, Weiner DS. Results of slipped capital femoral epiphysis in the black population. J
Pediatr Orthop 1990;10:224.
Arnold P, Jani L, Scheller G, Herrwerth V. Results of treating slipped capital femoral epiphysis by
pinning in situ. Orthopade 2002;31(9):880-7.
Rached E, Akkari M, Braga SR, Minutti MF, Santili C. Slipped capital femoral epiphysis: reduction
as a risk factor for avascular necrosis. J Pediatr Orthop B 2012; 21(4):331-4.
Sankar WN, McPartland TG, Millis MB, Kim YJ. The unstable slipped capital femoral epiphysis:
risk factors for osteonecrosis. J Pediatr Orthop 2010;30(6):544-8.

Seller K, Wild A, Westhoff B, Raab P, Krauspe R. Clinical outcome after transfixation of the
epiphysis with Kirschner wires in unstable slipped capital femoral epiphysis. Int Orthop
2006;30(5):342-7.
Kennedy JG, Hresko MT, Kasser JR, Shrock KB, Zurakowski D, Waters PM, Millis MB.
Osteonecrosis of the femoral head associated with slipped capital femoral epiphysis.
Uglow MG, Clarke NMP. The management of slipped capital femoral epiphysis. J Bone Joint Surg B
2004;86-B(5):631-5.
3. Epidemiology
-incidence 2-10 per 100000 per year
-2.5 male to 1 female
-50-75% of patients are over the 95th centile
-Boys 10 – 16 years
-Girls 10 – 14 years
4. Etiology of SUFE
a: idiopathic, b: mechanical/anatomical, c: endocrine, d:traumatic
Three mechanical factors of the adolescent hip may contribute: a) thinning of the perichondrial ring,
b) relative or absolute retroversion of the femoral neck and c) a change in the inclination of the
proximal femoral physis with there being an increased slope of the physis.
An underlying endocrinologic etiology with hormonal imbalance is also suspected with many
children being obese and hypogonadal features frequently seen in boys. However, a generalised
endocrine abnormality has not been found. Vitamin D deficiency has also been reported.
5. Pathology
-the displacement occurs through the hypertrophic zone.
6. Classifications
-based on onset of symptoms: acute (10%), acute on chronic (30%), chronic (60%) = symptoms for
more than 3 weeks.
-Loder (functional) classification: stable, unstable (unable to tolerate any kind of mobilisation not
even with crutches).
No AVN in stable slips. AVN between about 7% and 60% reported in unstable slips.
-Southwick head neck angle:
3 lines are drawn on lateral hip radiograph. 1: line connecting the two corners of the epiphysis; 2:
perpendicular line drawn to 1 through the middle of the neck; 3: line drawn along the axis of the
femoral shaft. The angle between line 2 and 3 is measured. Mild slip (grade 1): <30°; moderate
(grade 2): 30-50°; severe (grade 3): >50°. The normal angle is 0 to 12°.
-Wilson uncovered physis:

Severity (assessed on lateral hip radiograph): Pre-slip (widening of physis might be visible); mild
slip: up to one third of metaphysis uncovered; moderate slip: up to two thirds uncovered; severe slip:
more than two thirds uncovered.
7. Treatment
The aim of the treatment is to prevent further slippage of the epiphysis. The preferred technique for
grade 1 and 2 slips in the UK is pinning in situ using one screw.
In severe slips (>60°), a gentle repositioning manoeuvre can be attempted within 24 hours of onset of
symptoms, bringing the leg into about 10°-15° of internal rotation and 20° of abduction. If no
improvement is achieved, then the surgeon must decide if a pinning in situ is possible or if a femoral
neck osteotomy needs to be performed.
The preferred femoral neck osteotomy is a cuneiform osteotomy (Fish). Biring et al reported a 3.5%
AVN rate and an 11% chondrolysis rate associated with this osteotomy. Ziebarth et al eported no
AVN and no chondrolysis after open reduction of 40 moderate and severe slips.
Inter- (Kramer) and sub-trochanteric (Southwick) osteotomies can be used to correct residual
deformities. Dunn popularised a trapezoidal neck osteotomy in the past.
Uglow and Clark recommended to wait with the definite treatment for 3 weeks if presentation is later
than 24 hours since the onset of symptoms and to immobilise the patient with traction until surgery.
Biring GS, Hashemi-Nejad A, Catterall A. Outcomes of subcapital cuneiform osteotomy for treatment
of severe slipped capital femoral epiphysis after skeletal maturity. JBJS Br 2006;88(10):1379-1384.
Ziebarth K, Zilkens C, Spencer S, Leunig M, Ganz R, Kim YJ. Capital realignment for moderate and
severe SCFE using a modified Dunn procedure. Clin Orthop Relat Res 2009;467(3):704-16.

5. Picture of intoeing in 3 yr old.
Differential diagnosis of intoeing:
-foot deformity (metatarsus adductus, clubfoot)
-internal tibial torsion (normal in newborns [average of 4t
internal rotation], usually better by 2 years of age and
generally corrects by the age of 4 years). The medial and
lateral malleolus lie in the same plane.
-femoral anteversion (adult angle of 10° to 20°).
-cerebral palsy
-hip dysplasia
Clinical examination
-Staheli rotational profile
1. Foot progression angle
-out-toeing = +
-in-toeing = -
-4 to 16 years: -8° t0 +16°
Lösel S, Burgess-Milliron M, Micheli L, Edington C. A simplified technique for determining foot

progression angle in children 4 to 16 years of age. J Pediatr Orthop 1996;16(5):570-574.
2. Hip/femoral rotation.
Test for femoral neck anteversion:patient positioned prone, one knee flexed to 90° at a time. Lower
leg rotated from side to side. The examiner’s other hand feels the greater trochanter. The prominence
of the greater trochanter changes on the lateral side with the position of the lower leg. The leg is
stopped in the position where the greater trochanter feels the most prominent. The angle between the
vertical and the axis of the lower leg is the amount of femoral neck anteversion.
Age (years) Anteversion (degrees)
Birth – 1 year 30-50
2 30
3-5 25
6-12 20
12-15 17
16-20 11
Internal rotation of >70° and limited external rotation are suggestive of increased femoral neck
anteversion.
3. Thigh foot angle
Age 1: -27 to +20°
Age 3: -15 to +25°
Age 5: -5 to +30°
Age 7: 0 to +30°
Age 9: +3 to +33°

The angle changes very little after the age of 8 years.
4. Bleck grades for metatarsus adductus:
-based on heel bisector line.
-mild: line lies along 3rd toe.
-moderate: line lies between 3rd and 4th toe.
-severe: line lies between 4th and 5th toe.
Bleck EE. Metatarsus aductus: classification and relationship to outcomes of treatment. J Pediatr
Orthop 1983;3(1):2-9.
Metatarsus adductus angle:
-angle between longitudinal axis of the lesser tarsus (cuboid,
navicular, cuneiforms) and axis of 2nd metatarsal
-mild deformity: 15-20°
-moderate deformity: 21-25°
-severe deformity: >25°
Investigations
CT scanogram:
-horizontal cuts through the hips, knees and ankles.

4_5881836056923341743.pdf

Recommended

Recommended

More Related Content

Similar to 4_5881836056923341743.pdf

Similar to 4_5881836056923341743.pdf (20)

Recently uploaded

Recently uploaded (20)

4_5881836056923341743.pdf