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Peri-implant fracture
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Open topicPeri-implant Fractures
Definition: fracture adjacent to fixation device or prosthesis. Differentiate peri-implant vs periprosthetic. Causes: stress risers, osteopenia, trauma. Management: depends on implant stability, bone stock, fracture pattern. Principle: retain stable implant, revise/replace if loose.
Open topicPeri-implant fractures - Case Based Discussion
Case Presentation A 68-year-old female presented to the emergency department following a trivial fall at home with severe pain and inability to bear weight on the left lower limb. The patient had previously undergone fixation of an intertrochanteric fracture with a Proximal Femoral Nail (PFN) two years earlier. She reported sudden pain around the distal thigh following the fall. Pain and deformity of distal thigh Inability to bear weight Previous surgical scar over proximal femur Localized tende...
Open topicPerilunate Dislocation
Perilunate dislocations and fracture-dislocations are high-energy carpal injuries in which the lunate loses its normal articulation with the surrounding carpal bones — the capitate, scaphoid, triquetrum, and hamate are displaced dorsally while the lunate remains (at least initially) in the lunate fossa of the distal radius. They result from a fall onto an outstretched hand in hyperextension, ulnar deviation, and intercarpal supination, and are classified by the Mayfield progressive perilunar ins...
Open topicPerilunate dislocation - Case Based Learning
Case Presentation A young male presented with severe wrist pain following a motorcycle accident 3 days ago. The mechanism involved a fall on an outstretched hand with the wrist in dorsiflexion. Severe wrist pain and swelling Reduced wrist movements Difficulty gripping objects Tenderness over carpal region No distal neurovascular deficit initially X-ray reveals disruption of carpal alignment suggestive of perilunate dislocation. Mechanism of Injury Perilunate dislocation typically occurs due to h...
Open topicPeriosteal Reaction
Periosteal reactions are one of the most underrated signs on a plain X-ray. One look at the pattern tells you whether you're dealing with something benign and slow — or aggressive and urgent.
Open topicPeripheral Nerve Injury — Sunderland Classification
Seddon: neuropraxia, axonotmesis, neurotmesis; Sunderland expands to 5 degrees based on structural disruption. Degree I: conduction block; II: axonal disruption intact endoneurium; III: endoneurial disruption; IV: perineurial disruption intact epineurium; V: complete transection. Prognosis worsens with increasing degree; surgical exploration/grafting typically for IV–V. EMG/NCS guide prognosis and timing; Tinel’s progression marks regeneration (~1–3 mm/day).
Open topicPeriprosthetic Distal Femur Fracture
Lewis–Rorabeck and Su classifications guide treatment; stability of the femoral component is the key decision point. Stable TKA → fixation (locking plate or retrograde nail if intercondylar box permits). Loose TKA → revision arthroplasty with long stem or distal femur replacement in poor bone stock. Biologic fixation with long, locked constructs reduces nonunion/varus collapse. Early ROM; weight‑bearing tailored to construct stability.
Open topicPeriprosthetic Fractures — Classification & Management
Classification guides treatment by considering fracture location, implant stability, and bone stock. THA femur: **Vancouver** (A: trochanteric; B1: around stem-stable; B2: around stem-unstable; B3: poor bone stock; C: distal). TKA periprosthetic femur: **Lewis–Rorabeck** (I: nondisplaced, stable; II: displaced, stable; III: loose component). Principles: fix stable implants; revise loose stems; restore alignment and biology with locking plates/cables/strut grafts or long-stem revision. Risk...
Open topicPeriprosthetic Fractures after TKA — Classification & Management
Incidence rising with aging population and expanding TKA volumes. Common sites: distal femur (supracondylar), tibia (around keel/stem), patella (resurfaced patella). Classifications: Lewis–Rorabeck & Su (femur), Felix (tibia), Ortiguera–Berry (patella). Stable components → fixation; loose components/poor bone → revision with stems/augments ± megaprosthesis. Avoid iatrogenic risk factors (anterior femoral notching, malalignment, osteolysis).
Open topicPeriprosthetic Joint Infection — Principles
Diagnosis uses consensus criteria (MSIS/ICM) combining major and minor criteria. Classify by timing: early (24 mo) — guides biofilm maturity and strategy. Treatment options: DAIR (debridement, antibiotics, implant retention), one‑stage or two‑stage revision; chronic suppression in poor hosts. Principles: radical debridement, exchange modular parts, biofilm‑active antibiotics (e.g., rifampicin combinations for staph). Prevention bundle: laminar flow, antibiotic prophylaxis, skin prep, glycemic co...
Open topicPeriprosthetic Osteolysis — Imaging & Management
Periprosthetic osteolysis = bone loss from wear particle-induced inflammation. Detected on radiographs as radiolucencies, cystic defects; CT useful for mapping, MRI (MARS) for soft tissue. Must exclude infection before labeling aseptic osteolysis. Management: debridement of granuloma, bone grafting, bearing exchange, revision arthroplasty if components loose. Prevention: use of HXLPE, ceramics, optimal component position.
Open topicPerthes Disease — Management
Idiopathic avascular necrosis of femoral head in children 4–10 yrs. More common in boys; often unilateral. Clinical: limp, hip/knee pain, limited abduction/internal rotation. Imaging: X-ray shows increased density, fragmentation, collapse, reossification (Waldenström stages). Management: containment (bracing, osteotomy) to keep femoral head within acetabulum.
Open topicPes Planus - Flat foot
Pes planus (flatfoot) is a deformity characterized by loss or reduction of the medial longitudinal arch of the foot, resulting in hindfoot valgus, forefoot abduction, and altered biomechanics. It may be flexible or rigid, congenital or acquired, and can occur in both children and adults. Most pediatric flexible flatfeet are physiological and asymptomatic, whereas adult-acquired flatfoot is commonly associated with posterior tibial tendon dysfunction (PTTD). Diagnosis is based on clinical examina...
Open topicPhyseal Injuries — Salter–Harris & Ogden
Physis has zonal architecture; hypertrophic zone is weakest and fails in most injuries. Salter–Harris I–V (Slip, Above, Lower, Through, Rammed) with Ogden’s extension (VI–IX). Aim for **anatomic reduction**, especially for SH III–IV to prevent joint incongruity and growth arrest. Consider percutaneous reduction techniques to minimize physeal damage; avoid repeated forceful attempts. Long‑term surveillance for growth disturbance with Park–Harris lines and contralateral comparison.
Open topicPigmented Villonodular Synovitis (PVNS) / Tenosynovial Giant Cell Tumor (TGCT)
Benign proliferative synovial lesion; localized or diffuse type. Common in knee (80%) and hip; presents with pain, swelling, recurrent effusion. MRI: low-signal intensity on T2 due to hemosiderin deposition. Treatment: synovectomy (arthroscopic/open); recurrence common in diffuse type. Targeted therapy: CSF1R inhibitors (pexidartinib) for unresectable cases.
Open topicPilon Fractures — Strategy
High‑energy axial load injures distal tibial plafond with severe soft‑tissue compromise. Standard of care is staged protocol: **span → scan → settle → ORIF**. Restore length and alignment initially with spanning external fixation; obtain CT with ex‑fix in situ. Definitive fixation addresses articular fragments (anterolateral/posteromedial approaches) and metaphyseal voids. Complications remain common: wound issues, infection, post‑traumatic arthritis.
Open topicPipkin Classification — Femoral Head
I: inferior to fovea (non–weight-bearing); II: superior to fovea (weight-bearing). III: I/II with femoral neck fracture; IV: I/II with acetabular fracture. II–IV worse prognosis; urgent reduction and fixation as indicated.
Open topicPisiform Fractures
The pisiform is a sesamoid bone located within the flexor carpi ulnaris (FCU) tendon on the medial side of the wrist, articulating with the triquetrum at the pisiotriquetral joint. Pisiform fractures are uncommon injuries, typically caused by a direct blow to the hypothenar eminence or a fall onto the outstretched hand. They account for less than 2% of all carpal fractures and are frequently missed on standard PA and lateral wrist radiographs, requiring a carpal tunnel view or a supinated obliqu...
Open topicPlantar Fasciitis
Degenerative fasciosis (not true 'itis') of the plantar fascia origin at the medial calcaneal tubercle due to repetitive micro‑trauma. Classic history: sharp 'first‑step' pain on arising or after rest; eases with a few minutes of walking, recurs after prolonged standing. Risk factors: tight gastrocnemius–soleus, cavus or planus foot, prolonged standing, obesity, running/sudden training change. Exam: point tenderness at medial calcaneal tubercle; positive Windlass test (pain with 1st MTP dorsifle...
Open topicPolyethylene Wear in TKA
Primary driver of late osteolysis and aseptic loosening in TKA. Wear modes: adhesive/abrasive; delamination & pitting with high contact stress/oxidation in older PE. Risk factors: malalignment/malrotation, thin inserts, tibial backside micromotion, third-body debris. Prevention: HXLPE, polished tibial trays, correct alignment, adequate insert thickness. Management: exclude PJI; bearing exchange + synovectomy vs full revision depending on fixation and bone loss.
Open topicPolytrauma — Damage Control Orthopaedics
Concept: balance early fixation vs systemic insult. ETC = early total care in stable patients; DCO = staged for unstable. Indicators for DCO: ISS >40, hypothermia, acidosis, coagulopathy. DCO: temporary ex-fix → definitive fixation after stabilization. Goal: prevent ‘second hit’ phenomenon.
Open topicPolytrauma — Damage Control vs Early Total Care
ETC: definitive fixation within 24 h for stable patients. DCO: temporary stabilization in unstable patients; definitive fixation after stabilization. Second hit phenomenon: surgery can worsen SIRS/ARDS in unstable patients. DCO techniques: external fixation, splinting, traction. Completion after normalization of lactate, coagulation, and temperature.
Open topicPolytrauma Scores — ISS, RTS
ISS: anatomical score using AIS; 1–75; >15 = major trauma. RTS: physiological score (GCS, SBP, RR);
Open topic