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Pilon 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 topicPosterior Malleolus — Indications for Fixation
Fix if fragment >25–30% of tibial plafond, >2 mm displacement, syndesmotic instability, or posterolateral fragment involving PITFL. CT-based morphology guides approach: posterolateral approach common; direct reduction restores incisura and syndesmotic stability. Sequence: posterior malleolus first to stabilize syndesmosis, then fibula/medial malleolus. Fixation: screws posterior‑to‑anterior or buttress plate via posterolateral approach. Restoring posterior fragment reduces need for trans-syndesm...
Open topicProximal Fibula (Maisonneuve)
Maisonneuve injury = proximal fibular fracture + syndesmotic disruption + medial injury (deltoid/medial malleolus). Mechanism: external rotation with pronation. Examine entire fibula in ankle injuries; knee pain/tenderness is a clue. Management centers on syndesmotic stabilization; proximal fibula usually non-op. Avoid missing saphenous nerve injury or peroneal nerve palsy proximally.
Open topicProximal Humerus Fractures
Neer classification (parts displaced >1 cm or >45°): guides management. Non‑operative for minimally displaced; ORIF (locking plate) for displaced 2–3 part; hemiarthroplasty/RSA for unreconstructable 3–4 part or head‑split in elderly. Assess vascularity: medial hinge, calcar length; tuberosity integrity crucial for outcomes. Complications: AVN, stiffness, tuberosity nonunion/malposition, screw perforation.
Open topicProximal Tibia Metaphyseal Fractures — Pediatrics
Occurs in ages 3–6; risk of late valgus (Cozen phenomenon) due to asymmetric overgrowth. Usually metaphyseal greenstick/complete fractures from low‑energy mechanisms (trampoline, slide). Treat with long‑leg cast in slight varus; close follow‑up for 12–18 months. Most remodel; corrective osteotomy for persistent valgus >10–15° after growth potential declines. Beware associated fibular injury and compartment syndrome (rare).
Open topicProximal Ulna/Olecranon — Tension Band Wiring (TBW)
Indication: simple, non-comminuted transverse olecranon fractures (AO 21-B1) with intact dorsal cortex. Principle: converts triceps tensile force into compression at the articular fracture line during elbow flexion. Technique: two parallel K-wires + figure-of-8 wire anterior to axis. Avoid in comminution, osteoporosis, or Monteggia — plate preferred. Complications: hardware prominence, wire migration, loss of reduction, stiffness.
Open topicRadial Head & Neck Fractures (Adults & Paediatrics)
Radial head and neck fractures are common elbow injuries caused most often by a fall on an outstretched hand that transmits axial force through the forearm to the elbow. In adults, radial head fractures are typically intra-articular and are classified using the Mason classification, with treatment ranging from early mobilization for minimally displaced fractures to open reduction, fixation, or radial head replacement for displaced or comminuted injuries. In children, fractures usually occur at t...
Open topicRadiographic Signs of Rickets
Widened physes with cupping and fraying at metaphysis; generalized osteopenia. Rachitic rosary at costochondral junction; Harrison’s sulcus due to diaphragmatic pull. Looser’s zones (pseudofractures) in osteomalacia; bowing deformities. Correct metabolic defect first; orthopedic correction after medical therapy.
Open topicRegan–Morrey Classification — Coronoid Fractures
I: tip avulsion; II: 50% height. II–III indicate elbow instability, commonly part of terrible triad → fixation required.
Open topicReverse Shoulder Arthroplasty
Indicated for cuff tear arthropathy, pseudoparalysis, massive irreparable cuff tears. Developed by Grammont: medialized & lowered center of rotation. Deltoid substitutes for deficient rotator cuff. Requires intact deltoid and axillary nerve. Complications: scapular notching, instability, acromial stress fracture.
Open topicRevision TKA — Indications & Techniques
Common indications: aseptic loosening, PJI, instability, stiffness, polyethylene wear, periprosthetic fracture, malalignment. Workup: exclude infection (ESR/CRP ± aspiration); quantify bone loss (AORI). Reconstruction: restore joint line, balance gaps; use stems, augments, cones; match constraint to ligament competence. Constraint ladder: PS → CCK → hinge; use minimum needed. Outcomes depend on accurate diagnosis and restoration of alignment/rotation/soft-tissue balance.
Open topicRheumatoid Arthritis — Hand
Autoimmune symmetric polyarthritis causing synovitis and progressive joint destruction—typical deformities in the hand: ulnar drift at MCPs, swan‑neck and boutonnière deformities, and caput ulnae syndrome. Early goal‑directed medical therapy with DMARDs/biologics is cornerstone; hand surgery addresses pain, deformity, and function (synovectomy, tendon procedures, joint arthroplasty/arthrodesis). Radiographs show periarticular osteopenia, marginal erosions, and joint space loss; ultrasound/MRI de...
Open topicRickets — Orthopaedic Sequelae
Failure of mineralization at the growth plate → metaphyseal cupping, fraying, and splaying with genu varum/valgum. Differentiate **nutritional vitamin D deficiency** from **X‑linked hypophosphatemic rickets (XLH)** and renal rickets; labs guide diagnosis. Medical therapy first: vitamin D and calcium for nutritional; **phosphate + active vitamin D** (calcitriol) for XLH; burosumab in select cases. Orthopaedic: guided growth hemiepiphysiodesis for coronal deformity; corrective osteotomy when sever...
Open topicRobotic-Assisted Joint Replacement — Current Evidence
Robotics assists bone preparation and implant positioning (mostly semi-active systems). Potential: improved accuracy, reproducibility, individualized alignment strategies. Limitations: cost, time, learning curve; uncertain long-term functional advantage. Evidence: improved radiographic accuracy; PROMs and survivorship similar in short- to mid-term. Use case: complex deformity, kinematic alignment strategies, teaching environments.
Open topicRockwood Classification — AC Joint Injuries
I: sprain; II: AC torn, CC intact; III: AC+CC torn with superior displacement. IV: posterior displacement; V: marked superior displacement; VI: inferior displacement (rare). I–II non-op; III individualized; IV–VI require surgery.
Open topicRotator Cuff Impingement — Neer and Bigliani Classification
Comprehensive guide to subacromial impingement syndrome covering Neer staging, Bigliani acromial morphology, clinical tests, conservative management, subacromial decompression and outcomes.
Open topicRotator Cuff Repair
Rotator cuff provides dynamic stability and elevation of shoulder. Tears: acute traumatic vs degenerative. Indications for repair: symptomatic full-thickness tear, acute traumatic tear in young, failed conservative treatment. Techniques: open, mini-open, arthroscopic. Complications: re-tear, stiffness, infection, deltoid detachment (open).
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