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ميحرلا نمحرلا هللا مسب

Orthopedics: is the branch of surgery concerned with

conditions involving the musculoskeletal system and

associated muscles, bones and joints.

- The purpose of this lecture is to convince you that orthopaedics is important!

The man in this picture, who is a famous old French surgeon called "Nicholas

Andry", was the first person who used the word

"orthopaedics" for the first time.

"Orthopaedics" is derived from the Greek words:

Ortho means → Straight.

Paedis means → Child, the same root as pediatrics.

So, Orthopaedics could be translated as "Straight child".

- In the earliest days of orthopaedics specialty, originally French

Orthopedic surgeons dealt with bone deformities and

- Nicholas Andry put a "Crooked tree" as a symbol of

Orthopaedics

-The crooked tree was used to symbolize a bone (living tissue),

where by binding the tree to a straight pole (dead tissue) with a

piece of rope, the tree will grow in a straight manner.

You can treat living things !

Orthopaedics is related to:

1] Quality of life:

some specialties other than Orthopaedics are related to life and death, for

example:

▪ If someone's appendix had to be removed, but the doctor didn't remove it, the

patient may die !

This lecture is

not included in

midterm exam.

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A patient with a stroke, if the doctor didn't do anything for him, definitely

he will die !

Orthopaedics, on the other hand, is related to the Quality of life, that is the

general well-being of individuals and societies. Like cars, mobile phones, clothes,

etc … !

2] Pain:

▪ pain is something pathological, normally you shouldn't feel pain, so you should

think of this pain as an underlying pathologic like Inflammation (inflammation signs

are redness, heat, swelling, pain and loss of function)

3] Deformity:

▪ Femur bone is a curved bone, if it becomes straight bone, it will be deformed.

▪ Radius has a radial bow, if this bone becomes straight, it will be deformed, so no

more pronation and supination.

▪ Deformity means deviation from normal anatomy, So you should know the normal

anatomy in the beginning to recognize the deformity.

4] Loss of function

** This is a longitudinal section of a child's femur: trabeculum

Articular surface

Growth plate

cortex

medulla

Pain, deformity and loss of function

are the major complaints of patients.

Epiphysis

Diaphysis

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**This slide shows Haversian system using

special stain.

Osteocyte

Connections between osteocytes are called:

Canaliculi.

As you saw in the previous picture, Orthopaedics is concerned to histology also, any

defect at the level of histology of tissues could be responsible for many metabolic

disorders such as; (osteoporosis, osteomalacia, osteogenesis imperfecta, etc…),as

well as, enzyme defects, mitochondrial defects, cell type defects, increasing

function, decreasing function or abnormal function.

The primary function of bone is Calcium reservoir.

- Calcium homeostasis is extremely important for the body: for contractility

of muscles, heart function, complement immunity, platelet function, cAMP,

secondary messenger in the brain. So, calcium homeostasis in the body (ionic

calcium in the plasma Not bound Calcium) is extremely important, and any

defects in calcium would lead to major loss of function at the expense of

bones.

Disability or discomfort may result from many reasons, so we have to think of

the anatomy of the bone (structure, fracture, movement, support and

protection problem), as well as the metabolism of bones, and that's why we

should study the physiology of them.

**This picture shows "Scanning electron

micrograph of Osteoclasts"

▪Osteoclasts are multinucleated giant

cells that are formed by the process

of conjoining of numerous mononuclear

cells derived from bone marrow.

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▪ Osteoclasts reabsorb calcium of the bones, on the other hand,

osteoblasts build bones, so bones are dynamic tissues.

▪ Enzymes are secreted from Ruffled border to destroy organic and

inorganic contents of bone matrix

Osteoclasts are found in pits in the bone

surface which are called Howship lacunae

Ruffled border

Nucleolus of Osteoclast

▪The strongest bone in the body is the proximal femur, When you are lying down

and raising your leg up, it will bear weight equal to your body weight multiplied by 4 !

Slide (12)

"layers of growth plate"

▪ each layer could have a disease such

as excessive or less function.

Examples of such diseases:

1) Chondroplasia: people with chondroplasia have

short stature.

2) Marfan syndrome: people with Marfan syndrome

are usually tall with long, thin arms and legs.

- These are two defects at the same level.

Slides (13-16)

Examination of (Joints, bones, muscles):

1] Look (Inspection):

▪ Deformity. ▪ Muscle wasting. ▪ Scars.

Familial diseases: raised in families, usually because of environmental connected. reasons.

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2] Feel (Palpation):

▪ Temperature ▪ Tenderness ▪ Masses ▪ Anatomical landmarks

3] Move:

▪ Active ▪ Passive

Slide (17) Very important slide

" Causes of orthopedic diseases"

▪ Orthopaedic diseases are divided into 3 categories, and here are some examples:

1] Congenital means acquired before birth, and caused by:

Genetic disorders: the underlying cause is a genetic defect such as

Down syndrome. Genetic disorders may be recognized at birth or after

birth but it is acquired before birth.

Drugs.

Radiation.

2] Developmental means developed over a period of time, usually with slight

destruction ↓

- a man started to lose his hair, then after a period of time he became bald !

3] Acquired diseases: caused by:

Trauma infection: Here, it is extremely important to know the anatomy of

the body, because your goals are to restore function, correct deformity and

restore normal anatomy.

Congenital diseases

• Intrauterine infection.

• dislocation.

Developmental diseases Acquired diseases

Tendon injuries.

DDH "Developmental

dysplasia of the hip":

dislocation of the hip joint.

CTS, carpal tunnel syndrome.

Acquired

Immunodeficiency

Syndrome (AIDS).

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Paralysis.

Infection.

Arthritis.

Neoplasm: and it is divided into:

1) Primary neoplasia: originates in the bone, and can be divided into

benign tumors and cancers.

2) Secondary neoplasia: originates in other sites and spread (metastasize)

to the bones to become easily fractured.

Slide (18)

This slide shows examples of congenital

diseases.

▪ The photo on the upper left side shows a

hand with an extra digit beside the

pathological (abnormal) thumb, this disorder

is known as "polydactyly".

Slide (20)

▪ An abnormal hand fitted with a prosthesis.

- This limb reduction, which is caused by a faulty gene, may be as a result of:

1] Thalidomide:

Thalidomide was a widely used drug in 1960s as an oral contraceptive. Later on, it

became apparent that thalidomide resulted in severe birth defects in thousands of

children, though it was banned in most countries at that time.

2] Chernobyl disaster:

Chernobyl disaster is an explosion released

large quantities of radioactive particles into the

atmosphere reached Russia ! Long-term cancers

and deformities are still being accounted for.

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Slide (21)

X-ray of femur, you can identify the (ischium, pubis, head of femur inside the

socket "acetabulum", etc…) the first picture shows the normal anatomy whereas;

the second shows dislocation of the head as a result of either congenital or

developmental problem.

Slide (22)

Unilateral problem, with a normal right side:

You know that, there are three dimensions regarding to

the body; (proximal – distal), (anterior – posterior), and,

(medial – lateral).

X-ray picture is a two dimensional plane >>>

- If it was Coronal: we can identify both

(Superior – inferior) and (medial – lateral) dimensions.

-If it was Sagittal: we can identify both

(Superior – inferior) and (anterior – posterior)

dimensions.

-If it was Axial: we can identify both

(Anterior – posterior) and (medial – lateral) dimensions.

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Because of this, we have to mention the type of section in the x- ray picture.

another important point is, to take the permission from the patient if you want

to use his/her photo, or you have to delete all his/her information.

Slide (23)

The clinical examination reviles an abnormal

anatomy for a baby female, having a limited

abduction + short leg syndrome

Your job is trying to restore the normal

anatomy. You have to know the normal size of

each organ, in order to distinguish normal from

abnormal.

Slide (24)

Femur neck fracture, very common case.

Doctors usually try to do reduction, fixation and

electrolyte balance in an attempt to restore the

normal anatomy.

- You should know the history of your patient i.e. if

she has diabetes, CDV disease, and so on.

Slide (25)

Painful deformity, an acquired (neither developmental

nor congenital) case, referred to as scoliosis, a

painful benign tumor.

This case is characterized by bow legs, and usually,

we need surgery in order to treat such cases.

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Fracture

Here the pt has fracture & bleeding >>

inflammation (swelling, loss of function

/she can't move her arm, ecchymosis)

here the color was red>> blue >> black >>

green>> yellow then disappears, this change

is due to bilirubin & other RBCs

components.

When you learn this normal bone healing, you can answer your pt's questions,

about how many weeks does it need to heal (2, 4, or 6 wks …) & you also give

instructions to your pt such as:

....ممنوع تسوق سيارة , بعد أسبوعين بتفّك الجبصين, بعد أسبوعين بتفّك الغرز

you can't provide your pt with these answers, unless you know the underlying

anatomy, physiology & pathology very well.

Rheumatoid Arthritis (RA)

This pt has RA, where she complains of

deformity in fingers.

>> which is a pathological process involving the

synovial structures, so any part in the body

has a synovial sheath will be affected by inflammation, swelling, pain,

subluxation & deformities …

& in the foot, they'll have difficulty in walking (loss of function).

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Ankylosing Spondylitis "تشّمـع المفاصل"

this is called "bamboo sign"(مثل القصيب), where

there is a fusion in the pt's spin (pt moves as

one peice).

Knowing that the underlying pathology doesn't

involve the nerves, we can reassure the pt &

advise him/her to do physiotherapy & standing

posture (because otherwise the pt may

develop bended posture).

Then when the disease reaches & destroys

the hips, we'll replace both of them.

You should know anatomy very well to avoid

causing injury to the surrounding structures

(sciatic nerve, or femoral artery ...).

This is a lateral X-ray for the same pt.

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This is a Cadaver, where we may have multiple

fractures and diseased factors (spongy bone, cortical

bone, inter-vertebral disc, lamina, pedicle, spinous

process, dimifacet joint, nerve root canal, neural

foramina, anterior & posterior longitudinal ligament …)

If you know the anatomy very well, you can interpret

problems & pathologies.

Osteogenesis Imperfecta

Systemic disease with multiple deformities (legs, hips, chest …).

Trauma

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The pt in the previous picture has both:

Patellar Dislocation &

Gamekeeper's thumb, where we've an unstable joint,,, you fix it, so it'll

heal, improve & restore the normal function.

Shoulder Dislocation,

as a result of excessive movement.

Here, you can see the glenoid & humerus

head in a normal relation on the top.

Treatment: relocate the dislocated joint.

This is the hip joint. When it's completely destructed

the pt can't move, can't tie his/her shoes, & can't

sleep … then he/she needs surgery to improve.

- In this case: the pt has DDH ended by hip

destruction.

This pt has severe knee destruction

due to septic arthritis (SA).

You've to know that in SA we have

abnormal osmolaLity & osmolaRity of

the synovial fluid & a subsequent

cartilage destruction ending with a

completely destructed joint.

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here, in total knee replacement surgery, one

of our important objectives is not to have

infections, so we provide a sterile condition

during this surgery, we give prophylactic, IV

antibiotics, & so many things to prevernt

infection.

Infected joint equals a disaster!

This is post surgery (post total knee

replacement).

Here the pt had bilateral hip joint

replacement. But as you can see it's

dislocated on the left side, because this pt

had a stroke & a subsequent abductor

muscles weakness (gluteus maximus, medius

and minimus). So pt will have difficulty in

walking.

This young pt had arthrodesis >> we removed

the cartilage & there'll be a fusion between

the two … complete loss of movement &

complete loss of pain! (شيء على حسب شيء).

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This is ankle replacement

you can see the tibia, calcaneus, prosthetic joint.

Hip joint replacement: Is defined by WHO as the

best operation ever invented by Man! :) With a 90%

satisfaction rate, while ankle replacement for instance has a high failure rate

(60% of the best of these ankles survive 5 years, after that they're

damaged) & 8% post-operative infection rate (we still don't know exact

biomechanics of the ankle joint so we still unable to do ankle replacement

with a high success rate).

This is shoulder replacement; it's a successful surgery, we do it here in our

hospital, we should have intact muscles, otherwise it'll dislocate again

(empagement).

This is a pathological fracture, this is a

primary benign bone tumor

(osteochondroma), from its appearance you

can reassure the pt & his/her family that

it's simple; we hang it 6 weeks & it'll resolve

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While

This pt is totally different! This is

osteosarcoma ("sun burst

appearance">> malignant tumor >>

amputations >> life & death)

Here, the humerus, scapula, thoracic muscles & … all were

removed to save the life of the pt.

You'll learn all these things & then you'll be able to

council pts & their families :)

A major surgery, removing all

distal femur with the knee,

connecting tibiae with proximal

femur.

This is a diabetic pt, she had a "below-knee"

amputation (due to diabetes >> decreased blood

supply >> ischemia >> amputation). & you should know

that pt may die because of ischemia & subsequent

infection.

Best wishes

Asmaa Al-Bitar & Abeer Odeh.