Ortho Path Learning Objectives - Exam 1

Name the 3 phases of healing

inflammation, proliferation, remodeling

Describe the function of hemostasis and a blood clot after injury

body's response to stop bleeding and start healing after a blood vessel innjured

- Blood clotting- release of pro-inflammatory molecules such as cytokines and growth factors

Identify the time frame for each phase of tissue healing

Inflammatory phase - occurs immediately after

Proliferation phase - few weeks

Remodeling phase - months up to a year

Compare and contrast the difference betweeen intraarticular and extraarticular ligament healing and how this guides clinical decision making

Intra-articular - environment without supporting soft tissue vascular supply to allow healing

- ACL - within joint

Extra-articular - environment with ample surrounding microvasculature to facilitate healing

- MCL - around joint capsule

Describe the role of stress on healing tissue and a positive effect from early stress

Stress will promote adaptation and improved function

Contrast intramembranous bone formation from endochondral bone growth

Intramembranous - osteoblast differentiate from mesenchyme and form bone directly. There is no cartilaginous stage.

Endochondral - during 6th gestational week mesenchyme turn into chondrocytes. Then the chondrocytes form preliminary skeleton. Then they maturen and calcify to turn to bone.

Name a common connective tissue disorder

Ehlers Danlos Syndrome (EDS) - happens when someone has faulty collagen which leads to fragile skin and unstable joints

List 2 risk factors that lead to impaired wound and injury healing

- Age

- nutrition

- comorbidities (diabetes, cardiovascular disease, autoimmune)

- medications (anti-inflammatory and immune medications)

- lifestyle (smoking, diet, alcohol consumption)

Describe the role of proteoglycans in cartilage formation

intracellular matrix of hyaline cartilage

Proteins attach to glycosaminoglycans = proteoglycans.

combine with hyaluronic acid and water = elastic

Describe the role and importance of articular cartilage

Smooth, specialized CT that covers the end of bones in moveable joints. It provides low-friction movement and acts as a shock absorber

Name the 3 types of embryonic tissue

Ectoderm, mesoderm, endoderm

State the healing time under normal circumstances for bone healing from injury to fully remodeled

Proliferation/Repair (2-3 Weeks)

Remodeling (4-12 Weeks)

Contrast healing by primary vs secondary intention

Primary intention: Wound edges joined by fibrin plug, regrowth of basel layer of epidermins, lysis of fibrin and re-epithelialisation, restoration to intact skin

Secondary intention: Large defect filled by fibrin clot, new blood vessels and fibroblasts grow from the dermis into fibrin, collagen laid down by granulation tissue fibroblasts to restore integrity, maturation of collagen achieves structural integrity and allows regrowth of epidermis

Joints that make up the shoulder girdle

Glenohumeral joint

Acromionclavicular joint

Sternoclavicular joint

Scapulothoracic joint

Neonatal/congenital pathologies - adult and adolescent

- Shoulder dislocation

- Recurrent instability/bone loss

- Hill-Sachs Lesion

- Bankart tear

- SLAP tear

- Multi-directional instability (MDI)

- Acromioclavicular joint injury

- Clavicle fracture

- Proximal humerus fractures

- transient brachial plexus neuropraxia

- Supracondylar humerus fracture

- Neonatal brachial plexus palsy

- Symbrachydactyly

- Amniotic band syndrome

- Osteochondritis dissecans

- Parsonage-Turner Syndrome

- Sternoclavicular joint dislocations/physeal fractures

- Sternoclavicular joint injury

Describe simple elbow dislocation criteria

no fracture

- Nonoperative treatment when stable through passive range of motion after closed reduction

Describe complex elbow dislocation criteria

dislocation and associated fracture

ex: radial head, coronoid, or medial epicondyle fracture

Name the three joints that make up the elbow joint complex

Ulnohumeral, radiocapitellar, and proximal radioulnar

Name the injuries that make up the elbow "Terrible Triad"

Elbow dislocation + coronoid fracture + radial head fracture

Describe the importance of the medial epicondyle and UCL in throwing athletes

The UCL has three bands, and the anterior band is the most important for resistance to valgus movement. UCL injury is seen primarily in overhead throwing athletes and is usually chronic/attritional. Athletes may have prodromal elbow pain during activity followed by a "pop" and inability to pitch. The UCL is essential for pitching well and without pain.

Be able to name the order of elbow apoptosis ossification

Capitellum → Radial head → Internal/medial condyle → Trochlea → Olecranon → External/lateral condyle. o After age 1, a new ossification center appears every 2 years.

Describe the importance of the lateral ulnar collateral ligament in elbow stability

The LUCL =varus ulnohumeral stability

without= posterolateral rotary instability

first structure to fail in elbow dislocation.

Describe the mechanism of compression for carpal tunnel and cubical tunnel syndrome

- Carpal tunnel: compression of the median nerve

roof = transverse carpal ligamen

floor =proximal carpal row

radial boundaries= scaphoid tubercle/trapezium

ulnar boundaries = hook of hamate/pisiform.

Night splinting prevents passive wrist flexion and compression.

- Cubital tunnel: compression of the ulnar nerve

between the two heads of FCU distally,

within the arcade of Struthers proximally, or between the UCL and Osborne's fascia.

Describe the location of scaphoid fractures and associated risks of missed or undertreated injuries

proximal pole, waist, and distal pole

blood enters distally.

Nondisplaced distal-pole fractures =good healing

waist and proximal-pole fractures= operative

Missed or nonhealing fractures = malunion/nonunion, avascular necrosis

Describe treatment options for scaphoid fracture based on location

Nondisplaced distal-pole fractures have a good chance of healing. Nondisplaced waist fractures can be treated nonoperatively in young patients. The slides list casting options including long-arm thumb spica, short-arm thumb spica, and short-arm cast. Waist and proximal-pole fractures, especially when displaced, are considered operative. Vascularized bone grafting is identified as a treatment for complex nonunion/AVN problems.

Describe the mechanism for "Gamekeepers thumb"

Gamekeeper's (Skier's) thumb is a first MCP medial collateral ligament sprain caused by acute traumatic abduction/valgus of the first MCP joint. The slides also describe chronic attritional injury

Describe an associated injury that requires operative intervention in treating thumb UCL injuries

A Stener lesion: the thumb UCL avulses and displaces above the aponeurosis and will not heal without surgery. The slides also state operative treatment when valgus motion is >20° compared with the other side.

Describe normal developmental milestones

- head control — 3 months

- sit — 6 months

- stand with support — 12 months

- walk unsupported — 15 months

- Infant gait is less stable and efficient, with a wide base, irregular cadence, instability, and poor energy efficiency due to a high center of gravity, low muscle-to-body-weight ratio, and immature nervous/postural control.

Define metatarsus adductus

- A medial deviation of the forefoot

- It is secondary to intrauterine positioning and/or genetics, is noted at birth, has a convex lateral border and a normal-to-high arch, and the majority resolve with growth.

Describe normal patterns of growth in the tibia

- Torsional

o internal tibial torsion- by the foot-thigh angle.

corrects over time age 3, by up to 10-15°

- Varus/Valgus

10-15° of varus at birth

maximum valgus of 10-15° at 3-4 years.

Describe normal femoral growth patterns

- The slides state that upper-limb growth occurs earlier than lower-limb growth

- the foot grows earlier than the rest of the lower limb

- during childhood the trunk grows most rapidly

- during adolescence the lower limbs grow the fastest

- For the femur specifically, the slides discuss femoral anteversion: newborn femoral anteversion is 45-50° and normal adult anteversion is 15°

Describe components of a rotational profile

- determine the foot progression angle during gait

- assess hip rotation

- assess tibial rotation

- determine the alignment of the foot

- hip rotation is measured with the child prone and includes internal and external rotation

Define anteversion and retroversion

- Femoral anteversion = forward angulation of the femoral neck

o It is usually noted after age 3

o the slides list easy W-sitting and kissing patellas as observations.

- Femoral retroversion = backward angulation of the femoral neck

Gait pattern of anteversion and retroversion

anteversion - feet inward during walking

retroversion - feet point outward during walking

Define vara and valgum

- Vara - bowed leg alignment

o measured by intercondylar distance or the femoral-tibial angle

- Valgum - knock-knee alignment

o measured by intermalleolar distance

Describe the changes in genu varus/valgum as a child ages

Normal alignment progresses from 10-15° of varus at birth to a maximum of 10-15° of valgus at 3-4 years

What are the possible contributors of in/out toeing?

Femoral anteversion, internal tibial torsion and metatarsus adductus can all contribute to in/out toeing

Describe diseases that can lead to pathologic bowing/knockknees

- Rickets - radiologic growth-plate changes, vitamin D problem, include inherited rickets

- blount disease - pathologic abnormallity of the proximal medial metaphysis, the medial growth plate slows or stops while the lateral growth plate continues

Joints of the ankle

- subtalar

- talocrural

- talocalcaneonavicular (midtarsal)

- calcaneocuboid (midtarsal)

How they correspond to motion and function

Subtalar - allows pronation, supination, rotation

o diagonal axis makes pronation/supinaton triplanar

Midtarsal

o During pronation, their axes are parallel, unlocking the foot and making it hypermobile for shock absorption.

o During supination, the axes are nonparallel and the joint becomes locked for efficient force transmission.

Normal development of the foot in terms of arch development

Infant feet = flat - of joint laxity/ abundant subcutaneous fat Adult foot length = earlier than the rest 1/2 by 12-18 months.

Be familiar with deformities of the toes and forefoot

- Hallux valgus

- Hallux varus

- Cleft foot

- Polydactyly

- microdactyly

- turf toe

- mallet toe

- hammer toe

- claw toe

Hallux valgus

- bunions

- proximal joint creates deformity

Hallux varus

- medial deviation of the big toe

- daylight sign

cleft foot

Lobster claw deformity

Polydactyly

extra digits

microdactyly

overly small digits

Turf toe

hyperextension of first MTP joint

Mallet toe

the part of the toe that should be in contact with the ground isn't

- distal phalanx bent

Hammer toe

- middle joint of a smaller toe bends upward and curls downward

Claw toe

mtp bends upward pip and dip joints curl downward

Vertical talus

- congenital deformity and the most severe/serious pathologic flatfoot, with flattening and convexity of the sole.

- It is normally associated with myelodysplasia or arthrogryposis.

- Surgical treatment includes anterior release to reduce the contracted ankle capsule/talus, posterior release to allow the foot to dorsiflex to neutral, and immobilization with casting.

Clubfoot

- congenital deformity occurring in about 1 in 1,000 births.

- Components are equinus, cavus, adductus, varus, and internal rotation.

- Clinical position: hindfoot equinus/varus, forefoot adductus/supination, and cavus.

- The foot may be small with a skinny calf and short leg ("clubleg").

- Types include postural, congenital idiopathic, and syndromic/teratologic.

- The standard approach is the Ponseti method

Ponseti method

Correction in order:

- cavus

- rotate foot from under talus

- then equinus

- serial casting is followed by bracing/stretching

- with a foot-abduction brace worn until 3-5 years.

Cavus

- increased height of the longitudinal arch, often associated with clawing of the toes and heel varus.

- physiologic cavus representing the extreme end of normal variability of longitudinal arch shape

joints that make of the shoulder girdle

glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic joints

Describe the shoulder and upper extremity anatomy and pathology

- The glenoid is the articular surface on the lateral scapula

- the labrum deepens the socket and increases stability

- the humeral head is covered with articular cartilage. - The GHJ is described as a "golf ball on a tee."

Describe Neonatal/congenital pathologies

neonatal brachial plexus palsy

adolescent and adult pathologies

shoulder dislocation

bankart tear

hill-sachs lesion

recurrent shoulder instability

SLAP tear

Multidirectional Instability (MDI)

AC joint injury

clavicle fracture

Parsonage-Turner syndrome

Sternoclavicular joint injury

Shoulder dislocation

anteroinferior dislocation caused by= forced abduction and external rotation

injure the labrum, ligaments, and bone/cartilage.

Bankart tear

anterior band of the IGHL pulls anteroinferior labrum away from the glenoid

instability

Hill-Sachs lesion

An injury to the articular surface of the humeral head that occurs during shoulder dislocation

Recurrent Instability

Repeated shoulder instability can cause labral injury and loss of glenoid bone, sometimes requiring a Latarjet procedure to increase articular surface.

SLAP tear

A tear of the superior labrum

anterior to posterior

athletes and involves long head of the biceps attachment

MDI

Shoulder instability in multiple directions is distinguished from simple hyperlaxity by the presence of pain, with the sulcus sign being a classic finding.

AC joint injury

Usually occurs from a fall onto the lateral shoulder with the arm adducted and can range from no deformity to obvious deformity.

Clavicle fracture

The most commonly fractured bone, which generally has strong healing potential and can often tolerate some deformity without functional loss.

Parsonage-Turner syndrome

An acute brachial plexus neuropathy causing sudden shoulder/upper-extremity pain followed by weakness, numbness, and eventual muscle wasting.

Sternoclavicular joint injury

anterior or posterior displacement

posterior = subclavian artery.

Neonatal brachial plexus palsy

injury to brachial plexus in delivery= weakness

improves by 3 months

Horner syndrome can occur

Compare and contrast of soft tissue injury vs bone and/or cartilage injury

- Soft tissue injuries involve labrum and ligament

o Bankart tear - where the anterior band of the IGHL tears the anteroinferior labrum from the glenoid

- Bone and/or cartilage injuries involve glenoid, humeral head, or articular cartilage

o Hill-Sachs lesion - which is an injury to the articular surface of the humeral head that occurs during dislocation

Describe the proximal humeral physis on growth and development

- The proximal humeral growth plate provides approximately 90% of humeral growth

- Proximal humerus fractures frequently involve the growth plate in pediatric patients and have tremendous healing and remodeling potential.

Define the Function of the AC joint

The AC joint allows motion in three planes:

- anterior-to-posterior gliding of the clavicle

- rotation of the clavicle

- tilting of the acromion during GHJ abduction/adduction

AC ligament and coracoclavicular (CC) ligaments

- AC joint's stabilizing structures

CC ligaments as the coracoclavicular stabilizers

Describe Mechanism of injuries for brachial plexus

Brachial plexus injuries occur when the nerves of the brachial plexus are damaged by traction, stretching, or compression, causing weakness, numbness, or loss of movement in the upper limb.

Neonatal vs trauma

Neonatal - Usually occurs from traction on the brachial plexus during delivery, especially with high birth weight, shoulder dystocia, prolonged labor, or maternal obesity.

o occurs during delivery

Trauma - Can occur from traction or compression of the brachial plexus, such as during a traumatic event or collision.

o traction/compression from an injury or accident

Describe Upper limb deficiency causes and types

- Causes - Vascular ingrowth and timing of vascular injury/disruption dictates the type and severity of deficiency.

- types: Symrachdyactyly, amniotic bands, trauma, and resection from malignant processes

Describe Mechanism of amniotic band syndrome

- The amnion is the lining inside the uterus during fetal development

- Injury to the amnion can cause a sheet or band to form, which can entangle parts of the fetus and disrupt development

- Severity is determined by blood flow distal to the amniotic band.

Describe of osteochondritis dissecans

occur in any joint - vascular phenomenon

- Diseased subchondral bone loses blood supply and turns into fibrous scar tissue;

adjacent articular cartilage cracks and fails- leaving an osteochondral defect / early arthritis / dysfunction.

- Articular cartilage does not have a direct blood supply

• it receives nutrition from synovial fluid and joint compression.

Describe treatment options of osteochondritis dissecans of capitellum of humerus

- Osteochondral allograft - replaces bone and articular cartilage - donor tissue

Define the cause and symptoms of Parsonage-Turner syndrome

- an acute brachial plexus neuropathy

- sudden acute shoulder and upper-extremity pain, weakness, numbness, and wasting

- Supraspinatus and infraspinatus wasting , with suprascapular nerve involvement in 97% of cases

- Onset can coincide with recent viral illness; the slides describe an autoimmune component, possible recurrence, spontaneous resolution, and a duration of 18-24 months

Describe clavicle fracture management principle

- Clavicle fractures have tremendous healing potential, and deformity can often be tolerated without functional loss

- Surgical indications listed are greater than 100% displacement, shortening greater than 2 cm, open fractures or fractures threatening the skin, and comminution.

Describe a systematic approach to understanding evaluation of the shoulder

The physical exam begins with inspection for swelling, deformity, discoloration, and wounds, followed by range of motion.

- Special tests include:

o apprehension/relocation for anteroinferior GHJ instability

o O'Brien's for SLAP

o clunk for labral tear/crepitance

o load-and-shift for degree of instability

o sulcus sign for inferior GHJ instability

o cross-arm testing for ACJ pain.

- A neurovascular exam is critical:

o distal motor testing includes radial/PIN (thumbs up)

o median/AIN ("OK" sign)

o ulnar nerve finger abduction/adduction.

Describe knee anatomy and functional anatomy

- The knee is primarily made up of the femur, tibia, and patella.

- The knee includes the tibiofemoral joint and patellofemoral joint.

- The knee primarily allows flexion and extension, with a small amount of rotation when the knee is flexed.

- The menisci, ligaments, muscles, and articular cartilage provide stability and help distribute forces through the knee.

Ligaments - location and function

- ACL (anterior cruciate ligament): prevents excessive anterior translation of the tibia and helps control rotational movement.

- PCL (posterior cruciate ligament): prevents excessive posterior translation of the tibia.

- MCL (medial collateral ligament): resists valgus forces at the knee.

- LCL (lateral collateral ligament): resists varus forces at the knee.

meniscus - function

- Help distribute load across the knee.

- Increase joint congruency.

- Provide shock absorption.

- Contribute to joint stability.

- Assist with lubrication and nutrition of the joint.

Articular cartilage

- Articular cartilage covers the ends of the bones within the knee joint.

- It provides a smooth, low-friction surface for movement.

- It helps distribute forces and absorb some of the stress placed on the joint.

- It has a limited ability to heal because it has poor blood supply.

Compartments of the knee

- Medial compartment - medial femoral condyle and medial tibial plateau.

- Lateral compartment - lateral femoral condyle and lateral tibial plateau.

- Patellofemoral compartment - patella and trochlea of the femur.

Quadriceps

Extends the knee.

Helps stabilize the patella and knee.

Hamstrings

Flex the knee.

Can assist with rotation of the tibia.

Gastrocnemius

Assists with knee flexion.

Also contributes to plantarflexion of the ankle.

Popliteus

Helps initiate knee flexion.

Assists with rotation of the tibia/femur.

Sartorius

Assists with knee flexion and rotation.

ACL injury

- Sudden deceleration.

- Cutting or changing direction.

- Landing from a jump.

- Knee moving into valgus with rotation.

- Hyperextension.

MCL injury

- valgus force applied to the knee.

- lateral side of the knee hit

PCL injury

- Often caused by a force pushing the tibia posteriorly.

- Example: dashboard injury in a motor-vehicle accident.

- Can also occur from a fall onto a flexed knee.

LCL injury

- Usually caused by a varus force applied to the knee.

- Often involves a force directed toward the medial side of the knee.

Meniscus injury

- Twisting or rotation of the knee.

- A planted foot combined with knee rotation.

- Acute trauma or degenerative changes.

Discoid meniscus

- A discoid meniscus is an abnormally shaped meniscus, most commonly involving the lateral meniscus.

- It is thicker and more disk-shaped than a normal meniscus.

- It may become symptomatic because of tearing, instability, or mechanical symptoms.

ACL treatment - graft type

- Patellar tendon autograft

- Hamstring tendon autograft

- Quadriceps tendon autograft

- Allograft