Various useful lists

Adverse effects of Radiation

AO classification of fractures

Diaphyseal

  1. Simple fractures with disruption of a t least 90% bone circumfrance
  2. Multifragmentary but with some contact maintained between proximal and distal fragment
  3. complex fracture with no contact between proximal and distal framents
A,B or C 1,2 or 3 depending on basic fracture configuration
  1. Spiral fracture
  2. Oblique fracture
  3. Transverse Fracture

Articular

  1. Fractures that do not involve the joint surface (1,2 or 3 simple to comminuted)
  2. Part of the joint involved but the remainder still connected to the diaphysis
  3. Complete articular fracture with complete separartion of diaphysis

Blocks to reduction of MCP thumb dislocation

Causes lytic lesions with sclerotic rim

Causes of Benign Lytic Bone Lesions

  1. Simple bone cyst
  2. GCT
  3. ABC
  4. EG
  5. Chondroblastoma
  6. Chondro myxoid fibroma
  7. Osteoid osteoma
  8. Infection (Brodies, hydatid, chronic osteomyelitis)
  9. Subarticular cysts in OA

Causes of bone necrosis

Causes of Chondrocalcinosis

  1. Calcium Pyrophosphate Dihydrate Deposition disease
  2. Hyper-parathyroidism
  3. Haemochromatosis
  4. Acromegaly
  5. Gout
  6. Wilson's' Disease

Causes of excentric and expansile Bone Lesions

Causes of localised Sub-periosteal New Bone

Causes of lucent Lesions with no sclerotic rim

Causes of Neuropathic Arthritis

  1. Diabetes Mellitis (MTP, tarsometatarsal and inter tarsal joints)
  2. Steroid treatment (hips and knees)
  3. Syringomyelia (shoulder, elbow, wrist and cervical spine)
  4. Tabes Dorsalis (knee, hip, ankle, lumbar spine)
  5. Congenital insensitivity to pain
  6. Myelmeningoceil (ankle and inter tarsal joints)
  7. Leprosy (hands, feet and lower limbs)
  8. Chronic alcoholism (metatarso-phalangeal, inter-phalangeal joints)
  9. Heavy metal poisoning
  10. Neutritional peripheral neuropathy
  11. Neoplastic peripheral neuropathy

Causes of osteoporosis

Nutritional
Scurvey
Malnutrition
Malabsorption
Endocrine
Hyperparathyroid
Gonadal insufficiency
Cushings
Thyrotoxicosis
Drug induced
Corticosteroids
Alcohol
Heparin
Mechanical
Disuse
Immobilisation
Malignant
Carcinomatosis
Multiple myeloma
Leukaemia
Non Malignant
Rheumatoid arthritis
Ankylosing spondylitis
Tuberculosis
Chronic renal disease
Idiopathic
Juvenile
Post climateric
Haematological
Thalasaemia
Sickle cell disease

Causes of Protrusio Acetabuli

  1. Rheumatoid arthritis and JCA
  2. Osteoporosis
  3. Osteomalacia and Rickets
  4. Pagets Disease
  5. Ankylosing Spondylitis
  6. Osteoarthritis (occasionally)
  7. Acetabular fractures
  8. Familial / idiopathic
  9. Marfans syndrome (45% have protrusio, 50% of these are unilateral and 90% associated with a scoliosis)
  10. Osteogenesis Imperfecta

Causes of Sub-periosteal New Bone

  1. Periostitis: Associated with infection, osteomyelitis and subperiosteal abscess
  2. Sub-periosteal haematoma
  3. Syphilitic periostitis (diffuse or localised)
  4. Ewings sarcoma (onion skin)
  5. Osteoid osteoma (may result in localised thickening)
  6. Hypertrophic pulmonary osteodystrophy associated with COAD, clubbing, cyaotic disorders
  7. Stress fractures
  8. Venous ulcers or stasis ulcers result in periosteal thickeing beneath the ulcer
  9. Caffeys disease: Bone deposition sub-periostealy over a wide area of many bones (infantsless than6/12, often have a fever and resolves spontaneously)

Causes of symetrical Sub-periosteal New Bone

Causes of Ulnar Drift in Rheumatoid Arthritis

Anatomical

  1. Direction of pull of extensor and flexor tendons
  2. Shape of head of metacarpal (relative ulnar deficiency)
  3. Ulna collateral stronger than the radial collateral
  4. Presence of extensor indicis and digiti minimi on ulnar side of the communis tendon

Physiological (Functional)

  1. Gravity
  2. Force of opposition from thumb onto fingers
  3. Turning taps and door handles etc
  4. Pressure on radial side of hand on rising from a chair etc

Pathological

  1. Synovitis ® attrition of radial collaterals
  2. Articular cartilage erosios
  3. Extensor tendon subluxation
  4. Capsular, ligamentous and volar plate disruptions
  5. Intrinsic tendon shortening
  6. Radial deviation of wrist ® Z deformity and increased displacing force of extensor and flexor tendons
  7. Trigger finger releases ® distorted pull of flexors as well

Causes sclerotic secondary deposits

Classifiaction of Haemophilic arthropathy

Stages

  1. Soft tissue swelling
  2. Osteoporosis, epiphyseal overgrowth but joint integrity maintained
  3. Disorganisation of the joint with subchondral cysts, squaring of patella and intercondylar notch with trochlear widening
  4. Narrowing of joint space and cartilage destruction
  5. Marked narrowing and fibrou capsular contracture

Classification butonnier deformity

Types

  1. Mild deformity which is passively correctable (10 - 15o flexion)
  2. Moderate deformity (30 - 40o flexion)
  3. Severe deformity associated with joint degeneration

Classification of aneurismal bone cysts

Stages

  1. Cyst in the middle of the boe with little or no expansion
  2. Lesion substitutes the whole bone segment
  3. Eccentric inter-ossous lesion with little or no expansion
  4. Subperiosteal cyst and superficial erosion of cortex
  5. Periosteum eroded and expansion into soft tissues

Classification of Avascular necrosis (hip)

Stages

  1. Normal hip with contralateral disease
  2. Normal radiographic appearance diagnosided on MRI or bone scan
  3. Radiographic changes with no collapse and a spherical head
  4. Wedged shaped increased density, mottled osteoporosis, subchondral lucency / fracture, collapse, head no longer spherical
  5. Marked changes with secondary degeneration and collapse of subchondral bone
  6. Secondary acetabular degeneration

Classification of Avascular necrosis (lunate)

Stages

  1. Normal radiological appearance
  2. Increased density and bay be a fracture evident
  3. Collapse of the lunate with fragmentation
  4. Secondary degeneration of radio-carpal articularion

Classification of CDH

By "Type"

  1. Identified in perinatal period and respond well
  2. Secondary to neuromuscular disorder
  3. Teratologic disorders

by "Degree"

  1. Hip instability
  2. Hip subluxable
  3. Hip dislocatable
  4. Hip dislocated

Radiological

  1. Epiphysis medial to Perkins & below Helgenrieners
  2. Below Helgenrieners but lateral to Perkins
  3. Lateral to Perkins at level of acetabular margin
  4. Lateral to Perkins and above acetabulum

Also "Early" or "Late"

Classification of Cerebral palsy

  1. Spastic (defect of cerebrum & pyramidal tracts)
  2. Athetoic (defect of basal ganglia especially Kernicterus)
  3. Ataxic (defect of cerebellum)
  4. Rigid (resistance of pasive movement in all directions

Classification of Compund Fractures

Types

  1. Woundless than1cm and compound from within out (0 - 2% infection)
  2. Woundsmore than1cm clean with little or no devitalised tissue (2 - 7% infection)
  3. Moderate to massive wound, high velocity injuries and those with significant contamination
    1. Adequate soft tissue cover (7% infection)
    2. Extnsive soft tissue injury bone exposed (10 - 50% infection)
    3. Associated with vascular injury needing repair (25 - 50% infection)
Amputation indicated if
Type IIIC with division of posterior tibial nerve
Type IIIC with extensive muscle loss and tissue damage resulting in poor functional expectation
Warm ischaemia ofmore than8 hours

Classification of fractures around THR stem

Types

  1. Comminuted fracture about the stem (requires revision)
  2. Oblique fracture about the stem (treatment depends on fixation of component)
  3. Fracture at the tip of the stem (treatment depends of fixation of component)
  4. Fracture distal to implant

Classification of giant cell tumours of bone

Stages

  1. Contined within bone
  2. Lesion expanding cortex
  3. Lesion breaching cortex
    Ci Joint involvement
    Cii Distant metastasis

Classification of Growth plate fractures

SH I
Cleavage through physis
SH II
Cleavage through physis with an attached metaphyseal fragment
SH III
Cleavage through physis with an attached epiphyseal fragment (fracture exits into joint)
SH IV
Fracture extending from the metaphysis to epiphysis across the growth plate
SH V
Crush fracture of the physis
Ogden VI
Peripheral fracture across the physis remaining extra-articular
Ogden VII
Fracture of the epiphysis
Ogden VIII
Fracture of the metaphysis with disruption of the blood supply to the physis
Ogden IX
Periosteal damage affecting later growth

Classification of heterotopic calcification

Classes

  1. Islands of bone within soft tissue
  2. Bone spurs from pelvis and femur withmore than1cm between surfaces
  3. Bone spurs withless than1cm between surfaces
  4. Apparent bony ankylosis

Classification of JCA

Classification of Non-unions

"Vital" bone ends
Hypertrophic
Oligotrophic
Avascular bone ends
Dystrophic (partial union of butterfly
Neuretic (avascular segment)
Gap (missing segment)
Pseudarthrosis (synovial like lining and fluid between ends)

Classification of Osteogenesis Imperfecta

Types I & IV
Autosomal dominant +/- dentinogenesis imperfecta
Types II & III
Autosomal recessive
Types I & II
Blue sclera

Classification of Osteomyelitis

Types

  1. Medullary infection only
  2. Superficial infection limited to cortical surface
  3. Localised full thickness cortical sequestra
  4. Diffuse multiple sequestra, and excision would result in loss of structureal integrity

Classification of Perthes Disease

Cateral

Stage 1
Anteromedial portion of head and no collapse
Stage 2
More head involved and may be fragmentation but uninvolved pillars of bone limit collapse
Stage 3
More head involved and metaphyseal reaction with increased collapse
Stage 4
Whole head involved with severe collapse and metaphyseal reaction

Salter-Thompson

  1. Lateral portion of femoral capital epiphysis intact
  2. Lateral portion of femoral capital epiphysis collapsed

Herring

  1. Normal height of the lateral pillar of the femoral capital epiphysis
  2. Less than 50% reduction in height of the lateral pillar
  3. More than 50% reduction in height of the lateral pillar

Classification of PFFD

Types

  1. Femoral head present and adequate acetabulum and subtrochanteric pseudarthrosis but with bony connection of neck and shaft at maturity
  2. Femoral head present and adequate acetabulum but there is no connection between head and shaft at maturity
  3. Dysplastic acetabulum, no femoral head and femur short
  4. Absence of femoral head and acetabulum, marked deformity and shortening of femoral shaft

Classification of RSD (Langford)

Minor causalgia
Purely sensory nerve to distal portion of limb
Minor Tramatic dystrophy
Most common type
Shoulder hand syndrome
Proximal trauma or painful visceral lesion (shoulder or neck injury, cervical disc, PU, MI, pancost tumour etc)
Major traumatic dystrophy
Trauma that produces swelling, redess, dysfunction eg crush injuries and colles fractures head the list
Major causalgia
Partial injury to a major mixed nerve in the proximal part of the extremity

Classification of slipped epiphysis

Extent

Minimal
less than 1/3 or 30o slip angle
Moderate
1/3 - 2/3 slip or 30o - 50o slip angle
Severe
more than 2/3 slip or slip angle greater than 50o

Onset

Acute
symptoms less than 2/52 & sudden onset
Chronic
symptoms existing more than 2/52
Acute on Chronic
symptoms more than 1/12 with acute exacerbations
Pre slip
contralateral slip with widening of the physis

Classification of tibial pseudartrosis

Types

  1. Anterior bowing and defect in the tibia associated with other congenital anomalies
  2. Anterior bowing & hour glass contriction leading to spontaneous fracture usually by 2 years and often recurrent (most common)
  3. Pseudarthrosis develops through a congenital cyst
  4. Pseudarthrosis develops in a sclerotic segment without narrowing (stress fracture)
  5. Occurs in association with a dysplastic fibula and results in pseudarthrosis of one or both bones
  6. Pseudarthrosis occurs in association with an intra-osseous neurofibroma or schwanoma

Classificaton of spondylolisthesis

  • Congenital or dysplastic 20%
  • Isthmic 50%
  • Degenerative 25%
  • Other (trauma, pathological) 5%

    Classification Swan neck deformity

    Types

    1. No limitation of PIP movement in any position of the MCP joint
    2. Limitation of PIP movement when the MCP is extended
    3. Limitaiton of PIP movement in all positions of the MCP
    4. Limitation in movement associated with joint degeneration

    Classification thumb deformities

    Types

    1. Flexed and subluxed MCP with extension of IP joint
    2. Fixed dislocation of subluxation of MCP with IP extension
    3. Swan neck deformity secondary to CMC pathology (metacarpal adducted, MCP extended and IP flexed
    4. Game keeper thumb with ulna collateral ligaement laxity

    Complications of pagets disease

    Skeletal
    Pathological fracture
    Sarcomatous transformation
    Arthritis of affected joints & loosening of TJRs
    Extra-skeletal
    Nerve compression (deafness, blindness)
    Spinal canal stenosis
    High output cardiac failure
    Hypercalcaemia

    Conditions associated with slipped epiphysis

    Endocrine
    Hypothyroidism
    Hyperparathyroidism
    Pan-hypopitutarism
    Pituitary tumours
    Adiposogenital syndrome
    Acromegally
    Hypo-oestrogen states
    Cryptochidism
    Genetic
    Kleinfelters syndrome
    Downs syndrome
    Marfans syndrome
    Iatrogenic
    Radiation therapy
    Chemotherapy
    Growth hormone therapy
    Metabolic
    Rickets
    Renal disease
    Osteodystropy
    Other
    Coxa vara
    Inracranial tumours

    Congenital Malformations

    Contraindications to dvt prophylaxis

    Absolute
    Acute bleeding disorder
    Acute peptic ulceration
    Stroke in the last 6/12
    Platelet countless than100,000
    Malignant hypertension
    Relative
    Concomitant aspirin or NSAID therapy
    Lack of compliance of the patient
    Lack of suitable laboratory fascilities

    Eneking classification tumours:

    Grade: (assessment of biological aggressiveness)

    G0
    Histologically benign (well differentiated and low cell to matrix ratio)
    May be latent , active or aggressive benign lesions
    G1
    Low grade malignant (few mitoses, moderate differentiation and local spread only)
    G2
    High grade malignancy (frequent mitoses, poorly differentiated and frequent mitoses)

    Site: (anatomic setting of the lesion)

    T0
    Confined within its capsule (does not extend beyond the bounds of the compartment of origin, may be distorted but remains intact)
    T1
    Extra capsular extension but contained within the anatomic compartment (eg cortical bone, joint capsule or fascia)
    T2
    Extending beyond compartmental barriers (spreads beyond fascial plane without longitudinal containment)

    Metastasis: (nodal or blood borne tumour spread)

    M0
    No evidence of regional or distant metastases
    M1
    Regional or distant metastases evident

    Surgical Margins

    1. Intra capsular (leaves macroscopic tumour, not therapeutic)
    2. Marginal (through pseudo-capsule of tumour, residual extensions or satellites, controls non-invasive benign tumours)
    3. Wide (excise tumour, reactive zone and cuff of normal tissue, skip lesions left)
    4. Radical (removal of entire compartment or compartments, distant metastases left)

    Factors affecting fracture healing

    1. Blood Supply
    Soft tissue injury
    Radiation
    Chemical or thermal burns
    Infection
    Anaemia and hypoxia
    Denervation
    Excessive compression (more than 30lbs)
    Age
    2. Excessive Movement
    Inadequate immobilisation
    Inadequate fixation or compliance
    3. Gap
    Intact fellow bone
    Interposed soft tissue
    Distraction of bones
    4. Other
    Nutrition (Vit C required for normal collagen)
    Drugs (corticosteriods inhibit osteoblast differentiation

    Factors Affecting wound healing

    1. Systemic
    Hypoprotinaemia
    Hypoxia and poor tissue perfusion
    Deficiency of Vit C & Zinc
    Diabetes, jaundice & ureamia
    Increased age
    2. Local
    Impaired local circulation
    Infection and foriegn bodies
    3. Exogenous Chemicals
    Corticosteriods
    NSAIDs (reversed by Vit A)
    Oestrogns retard healing
    Androgens enhace healing
    4. Physical factors
    Physical stress
    Emotional stress
    5. Surgical factors
    Poor tissue handling
    Poor haemostatis
    Avoid drains exiting through wounds
    Encourage early mobilisation

    Giant cells seen in

    Grades of muscle function

    1. No muscle activity
    2. Flicker or twitch without movement of the joint
    3. Movement with gravity eliminated but unable to move against gravity
    4. Movement against gravity but not against resistance
    5. Able to move against gravity and some resistance
    6. Normal power

    Groups of NSAIDs

    Harrington Classification spine 2o deposits

    Grades

    1. No neurological loss or bone involvement
    2. Involvement of bone without collapse or instability or neurological involvement
    3. Neurological involvement without bone involvement
    4. Vertebral collapse or instability without neurological compromise
    5. Vertebral collapse or instability with neurological compromise

    Indications for ORIF of fractures

    Absolute

    1. Unable to obtain an adequate reduction
    2. Displaced intra-articular fractures
    3. Certain types of displaced epiphyseal fractures
    4. Major avulsion fractures where there is loss of function of a joint or muscle group
    5. Non-unions
    6. Re- implantations of limbs or extremities

    Relative

    1. Delayed unions
    2. Multiple fractures to assist in care and general management
    3. Unable to maintain a reduction
    4. Pathological fractures
    5. To assist in nursing care
    6. To reduce morbidity due to prolonged immobilisation
    7. For fractures in which closed methods are known to be ineffective

    Questionable

    1. Fractures accompanying nerve of vessel injury
    2. Open fractures
    3. Cosmetic considerations
    4. Economic considerations

    Indications for ORIF of metastatic lesions

    1. Life expectancy greater than 1 - 2 months
    2. Continued pain after radiotherapy
    3. Lesion greater than 2.5 cm diameter (described for the femur)
    4. Destruction of 50% or more of the cortex of a long bone
    5. Adequate bone quality
    6. Procedure would ® mobilisation and independence
    less than 50% cortical erosion ® 60% go on to fracture
    greater than 50% cortical erosion ® 4% go on to fracture (Filder 1981)

    Indicators or spinal instability

    Methods of sterilisation

    Neurofibromatosis diagnostic criteria

    1. Cafe au lait patches (6 or more and more than1.5cm diameter)
    2. Two or more neurofibroma or one plexiform neurofibroma
    3. Optic glioma
    4. Two or more iris hamartomas (Lisch nodules)
    5. Defective osseous lesions (eg pseudarthrosis)
    6. 1st degree relative with the condition

    Pathological Fractures

    Principles of Tendon Transfer

    1. No fixed deformity
    2. Adequate power of donor muscle (will loose 1 grade)
    3. Adequate excursion and length of donor tendon
    4. Expendable function of donor muscle
    5. Suitable position and direct line of pull
    6. Good soft tissue bed for transfer
    7. Synergistic muscle (not antagonist)
    8. Control of associated joint mobility & stability of proximal joints
    9. Suture under correct / physiological tension
    10. Suitable insertion technique and firm fixation
    11. Avoid construction of pulleys
    12. Reasonable expectations (simple and specific aims)

    Principles of Tumour Biopsy

    Open

    1. Longitudinal incision
    2. Sharp dissection should proceed directly to the tumour, through muscle not between muscle planes
    3. Uninvolved anatomic compartments should not be exposed
    4. Avoid all major neurovascular structures to prevent contamination
    5. Excise block of reactive tissue, pseudo capsule, capsule, and block of tumour ® formalin +/- frozen section
    6. Windows in bone should be as small as possible and oval to avoid stress risers and pathological fracture
    7. Release tourniquet prior to closure ® haemostasis
    8. Close with a sub cuticular stich
    9. Drains should come out through the wound
    10. If proceed following biopsy ® new instruments and drapes to stop seeding

    Needle

    1. As for open biopsy
    2. Place the biopsy tract where it can be excised

    Rheumatoid arthritis radiological classification

    Grades

    1. Osteoporosis and soft tissue swelling
    2. Marginal errosions & very slight narrowing of joint space
    3. Joint space narrowing becomes marked
    4. Punced out errosions through subchondral plate
    5. Normal anatomical contours of articular surface destroyed

    Rheumatoid Diagnostic Criteria:

    1. Bilateral, symmetrical poly arthritis
    2. Involvement / swelling of wrist, MTP or PIP joints for at least 6/52
    3. Rheumatoid nodules
    4. Rheumatoid factor in serum
    5. X-Ray changes typical of RA (peri articular erosions & peri articular decalcification)
    6. Morning stiffnessmore than60 mins and present for at least 6/52
    7. Swelling of at least 3 joints for at least 6/52
    8. Poor mucin clot formation
    9. Synovial histology consistent with RA
    Need at least three of the above to lead to diagnosis

    Rheumatoid extensor tendon rupture differential

    Rheumatoid extra-articular manifestations

    Risk factors for DVT & PE

    Scoliosis Aetiology

    1. Idiopathic
        Infantile
        Juvenile
        Adolescent
    2. Osteopathic or congenital
    3. Neuropathic (Polio, Cerebral Palsy, dysraphism etc)
    4. Myopathic (Dystrophies)
    5. Mesenchymal (Marphans, Ehlers Danlos etc)
    6. Miscellaneous (metabolic disorders, trauma, soft tissue contracture, infection etc)

    Surgical Sift

    1. Congenital and developmental abnormalities
    2. Infection
    3. Inflammatory conditions
    4. Degenerative disorders
    5. Trauma and mechanical derangement
    6. Neoplastic contitions and lesions that mimic them
      Benign
      Malignant
      1o
      2o
    7. Metabolic and endocrine dysfunction and degeneration
    8. Neurological or 1o muscle disorder
    9. Iatrogenic
    10. Idiopathic

    Tumours more common in Females

    Zones of the growth plate

    Generalised increase in bone density

    1. Osteopetrosis
    2. Engelmanns disease
    3. Melorheostosis
    4. osteopoikilosis

    Wormian bones

    1. Osteogenesis Imperfecta
    2. Cleidocranial Dysplasia

    Erlenmeyer flask appearance of the Distal Femur/ Proximal tibia

    1. Metaphyseal dysplasia (Pyles disease)