Orthopedic Instruction

Upper

extremity
Lower extremity

SHOULDER JOINT
Bone
Clavicle
Scapula
Humerus
Joint
Acrominoclavical
joint
Glenohumeral joint

A-P view
Clavicle
Acromion
Coracoid process
Humeral head
Glenoid

Scapula

Axial View
Clavicle
Coracoid Process
Humeral head
Acromion
Glenoid
Scapula

Rotator Cuff
Supra-Spinatous
Infra-Spinatous
Subscapularis
Teres

minor
Function
Depress humeral head
Stabilize joint

Acrominoclavical
Dislocation

Trapezoid ligament
Coracoacrominal ligament

Conoid Ligament

Acrominoclavical
dislocation

Acrominoclavical
dislocation
Treatment
Type

I, II

Conservative

Type

III, IV, V, VI

Open

reduction
C-C Reconstruction

Rotator Cuff tear

Mechanism
Intrinsic

Factor

Blood

supply
Degeneration
Extrinsic

Factor

Impingement

Multiple

syndrome

Factor

Intrinsic

+ Extrinsic

Impingement syndrome

Physical Examination
Impingement test

Hawking sign

Drop arm test

Unable to drop the arm slowly

Treatment
Conservative

management

Rest

and protection
Medication
NSAID
Subacrominal
Local

injection

analgesic + Steroid

Treatment
Operative
Open

management

repair

Arthroscopic

repair

Carpal Tunnel Syndrome

Tinel

sign , Phalens testcarpal tunnel

compression test
Phalens test , 90
,

Cubital Tunnel Syndrome

Tardy ulnar palsy , medial epicondyle

.
Cubitus valgum

Pitcher valgus stress

medial epicndylitis
Ulna nerve, Tinel sign

Scaphoid Fracture

,
(dorsiflexed
& radial deviated )
X-ulnar deviation view
(snuff box)
(non-union )
( AVN )SLAC (scapholunate advanced collapse)

de-Qervains Disease
abductor

pollicis longus
extensor pollicis brevis radial styloid
process tenosynovitis
: Finkelstein test
, ,

The Hip

Osteonecrosis of Femoral
Head
Avascular

necrosis
Osteonecrosis
Ischemic necrosis
Aseptic necrosis
Male > female
Bilaterality: > 50%

ONFH- Etiology
Use

of corticosteroid
Alcohol use
Traumatic
Radiation
Metabolic disorders

ONFH- staging (Steinberg)

Stage I
Normal X-ray

Stage II
Irregular

Stage III
Crescent sign

ONFH- staging

Stage III
Head collapse

Stage IV
Early OA

Stage IV
Advanced OA

ONFH- Treatment
Conservative

treatment
Bisphosphonate
Shockwave
Head preserving surgery
Core decompression
Bone grafting
Osteotomy
Arthroplasty

ONFH- Treatment
Core

decompression

ONFH- Treatment
Bone

grafting

ONFH- Treatment
Rotational

Osteotomy

ONFH- Treatment
Arthroplasty

OA Hip- primary (Rare in Taiwan)

Age

related change (rarely <50 y/o)

Female > Male
Activity, Occupation
Obesity
Genetic differences
Developmental abnormalities
Idiopathic

OA Hip- secondary (> 90%)

Developmental

Hip dysplasia
Legg-Calv-Perthes disease
Slipped capital femoral epiphysis
Trauma

Fracture
Radiation damage
Metabolic

disease)

diseases (gout, crystal deposition

Legg-Calv-Perthes disease

Slipped capital femoral epiphysis

Dysplasia: the most common

underlying cause of OA hip
Definition:
-Head coverage
<75%
-Acetabular angle
>42*
-CE angle <20*
-Roof angle positive

Tear drop
Shentons line
Ant/post wall
Ilioischial line
Iliopectineal line
Acetabular angle
Coverage
Roof angle
Depth
CE angle

Treatment: Correct
deformity

Treatment: Arthroplasty

Arthroplasty complications
Dislocation
Loosening
Wear
Osteolysis
Fracture
Infection

Hip Fracture
Subcapital fracture
Cervical fracture
Basal neck fracture
Intertrochanteric
fracture

FN fracture
Garden

classification
Incomplete

<->

Complete
Non-displaced

> displaced

<-

Hip fracture: treatment

Non-displaced
Displaced

Pinning
Dynamic

hip
compression
screw
Hemi-Arthroplasty

Knee

Anatomy
3 compartments
Hyaline cartilage
Soft tissues

MCL / LCL
ACL / PCL
Meniscus
Muscles & tendons

Anatomy: alignment
Varus
Valgus

Anterior Drawer Test (ACL)

Lachman Test (ACL)

Pivot Shift Test (ACL)

Posterior Drawer Test (PCL)

Meniscus Examinations

Chondromalacia
Excessive

load on the

PF joint
Most common in young
ladies

Chondromalacia: Treatment
Non-OP

- Q muscle exercise
- reduced strenuous activities
OP
- Lateral retinacular release
- Re-alignment surgery

Anterior Cruciate Ligament

Anteromedial bundle
Posterolateral bundle
Provides 86% of anterior restraint of the
knee
Average length 313 mm
Type I collagen

Mechanism of injury---ACL
Soccer
Basketball
Skiing
Others

75% occurred in non-contact injuries

90% occurred during games

Indications for surgery of ACL

tear
Life

style and activity level are the keys

to formulate Tx plan
Surgery for high risk/high demand
patient
Age and sex are not predictor factor
Chronic ACL injuries
Combined ACL and other ligament or
meniscus injuries

Osteoarthritis
Gradual

processes of
knee joint destruction &
regeneration
Age related
- Cartilage
- Subchondral bone
- Cysts - Osteophytes
- Synovium
Irreversible process

Pathogenesis of OA
Biomechanical
Chondrocytes
Matrix
Matrix
degradation
synthesis
Cytokines
IGF-1
Enzymes
TGF-
Nitric oxide
Genetic
Metabolic
Loss of matrix integrity
OA

Treatment: Conservative
BW

reduction
Physiotherapy
NSAIDs
Glucosamine
Viscosupplementation

Uni-compartmental knee
arthroplasty
Medial

compartment
Lateral compartment
Patellofemoral
compartment

Total knee arthroplasty

Standard

procedure nowadays
>15,000 procedures per year in Taiwan
Start form early 1980s
Multiple technique modified and
prostheses choices

TKA complications
Wear

Loosening
Infection

Osteolysis
Periprosthetic fracture

Any Questions?