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Degenerative disease of spine

Cervical spondylosis

-                   Cause

• Degeneration of disc, facet joint

-                   Clinical presentation

• Neck pain
• Radiculopathy
• Myelopathy
• Vertebrobasilar insufficiency

-                   Investigation

• X ray
  • Osteophyte
  • Subluxation
• MRI
  • Disc
  • Spinal cord
  • Spinal nerve root
• EMG ,NCV

-                   Differential Diagnosis

• nerve entrapment syndrome
• rotation cuff lesion
• cervical tumors
• Thoracic outlet syndrome

-                   Treatment

• Supportive treatment
• Surgical treatment
  • anterior discectomy and fusion
  • foraminotomy
  • laminoplasty

Lumbar spondylosis

-                   Cause and and Pathology

• Intervertebral disc degeneration
• Facet hypertrophy
• Ligamentum flavum hypertrophy
• Segmental instability

-                   Clinical presentation

• LBP
• radiculopathy
• neurogenic claudication

-                   Investigation

• X ray
  • Narrow disc space
  • Marginal osteophyte
  • Facet joint osteoarthritis
  • Vertebral displacement (spondylolisthesis)
• MRI
  • bulgingannulus fibrosus
  • Decrease disc height of intervertebral disc
  • Decrease signal intensity of intervertebral disc

Spinal stenosis

-                   Cause

• degeneration

-                   Pathophysiology

• Degenerated interverteral disc and facet joint

-                   Clinical presentation

• LBP
• radiculopathy
• neurogenic claudication

-                   Investigation

• X ray
• MRI
• Computerized Tomography
• Melography

-                   Differential Diagnosis

• vascular claudication

-                   Treatment

• Conservative treatment
  • Medication
  • Life style modification
• Operative treatment
  • Decompression

Degenertive Joint disease

Osteoarthriris

-          Normal articular cartilage

• Chondrocyte
• Extracellular matrix

-          Pathophysiology

-          Cause of Osteoarthriris

• Primary OA
• Secondary OA
  • Trauma
  • infection
  • repetitive overload

-          Pathology

• Progressive cartilage destruction
• Sclerosis of the surrounding bone
• subarticular cyst formation
• Capsular fibrosis

-          Clinical presentation

• Natural history
• Symptoms : Pain Swelling, Deformity, Loss of motion
• Sign: Joint swelling ,Joint deformity, Local tenderness, Crepitation, Limited movement, Muscle wasting, Instability

Investigation

-          Plain film

• joint space narrowing
• subchrondal sclerosis
• subchondral cyst

-          MRI

Differential Diagnosis

-          Joint infection

-          Crystal induced arthritis

-          Lesion from remote areas

-          Inflammatory arthropathy

-          Neuropathic arthropathy

Treatment

-          Supportive treatment

• Relieve pain
• Maintain joint mobility
• Muscle strengthening
• Modify daily activities
• Viscosupplementation

Surgical treatment

-          Cartilage repair

-          Joint debridement

-          Corrective osteotomy

-          Joint replacement (arthroplasty)

Foot and ankle Injury

Ankle sprain

-Lateral ankle sprain

-                   Lateral ligament complex

• anterior talofibular ligament (ATFL)
• calcaneofibular ligament (CFL)
• posterior talofibular ligament (PTFL)

-                   Cause

• forceful inversion

-                   Pathology

-                   Clinical presentation

• Pain
• swelling
• Ecchymosis

-                   Investigation

• X ray : Ankle(AP, Lat, mortise)
• MRI
• Computerized Tomography

-                   Treatment

• Conservative treatment
  • RICE method (Rest, Ice, Compression & Elevation)
• Operative treatment
  • Ligament repair

Medial ankle sprain

-                   Cause

-                   Pathology

• Superficial deltoid ligament 
• Deep deltoid (tibiotalar) ligament 

-                   Clinical presentation

• Pain, swelling
• Ecchymosis

-                   Investigation : X ray, MRI,Computerized Tomography

-                   Treatment

• Conservative treatment
  • short-leg walking cast (plantigrade)
• Operative treatment
  • Surgical exploration and repair

Ankle fracture

-       Anatomy

-       Mechanism

• Rotational force
• Axial compression

-       Clinical Feature

• low VS high-energy injury
• Pain, swelling
• Ecchymosis
• Tenderness

-       Classification

• Lauge-Hansen, Danis-Weber
  • Supination-Adduction (SA)
  • Supination-External Rotation (SER)
  • Pronation-Abduction (PA)
  • Pronation-External Rotation (PER)
  • Danis-Weber
    • Type A (infrasyndesmotic) เกิดจากsupination-adduction force
    • Type B (transsyndesmotic) เกิดจากsupination-external rotation force
    • Type C (suprasyndesmotic) เกิดจากpronation-external rotation force

-       Investigation

• X ray : Ankle(AP, Lat, mortise)
  • Medial clear space 
  • Tibiofibular clear space
  • MRI
  • Computerized Tomography

-       Treatment

• Isolated fracture of medial malleolus
  • Non-displaced และminimally displaced fracture
    • SLC
    • Displaced fracture(> 2 mms.)
      • ORIF
      • Isolated fracture of lateral malleolus
        • Non-displaced และminimally displaced fracture
          • SLC
          • Displaced fracture(> 2 mms.)
            • ORIF

Bimalleolar fracture

-           ORIF

Trimalleolar fracture

-           ORIF

-           Posterior malleolus fixation when More than 25% fragment with displacement

Pilon fractures

-       Non-displaced fracture

• closed reduction & casting

-       Displaced fracture

• ORIF
• External fixation when severe soft tissue injury

Foot fractures

-       Talus Fracture

• MCM: neck of talus

• Mechanism: ankle hyperextension injury

• Clinical
  • Beware Skin necrosis

• Investigation
  • X ray : Ankle(AP, Lat, Oblique)
  • CT scan
    • fracture displacement , osteochondral fragment
    • MRI ใ
      • chondral fracture ,osteonecrosis

• Classifications: Hawkin’s classification
  • Type I: non-displaced fracture
  • Type II: displaced fracture with subtalar subluxation or dislocation
  • Type III: displaced fracture with subtalar and ankle dislocation
  • Type IV: displaced fracture with talonavicular dislocation
  • Treatment
    • Type I: SLC 8-12 wks
    • Type II: CR with SLC8-12 wks
    • Type III, IV: urgent ORIF with K-wire , lag screws

• Complications
  • avascular necrosis, malunion, post-traumatic osteoarthritis

Calcaneus fracture

-       Anatomy : Largest tarsal bone

-       Mechanism

• Axial compression force
• Avulsion force

-       Clinical Feature

• low VS high-energy injury
• Pain, swelling
• Ecchymosis
• Tenderness

-       Investigation

• Plain film
  • Lateral: Bohler’s angle
  • axial views : width
  • CT scan : Intraarticular fracture

-       Classification

• Intra-articular fracture
  • joint depression type
  • tongue type
  • Extra-articular fracture
    • anterior process
    • sustentaculum tali
    • calcaneal tuberosity
    • inferomedial process

-       Treatment

• Extraarticular fracture 
  • non‐
  • Intra-articular fracture
    • Non displace : non operative
    • Displace: ORIF
      • Tongue type : close reduction with large pin fixation (Essex-Lopresti technique)
      • Joint depression type : ORIF with plate and screw fixation

-       Complications 

• Early complications
  • compartment syndrome, infection
  • Late complications
    • malunion, peroneal tendon impingement, Achilles tendon insufficiency

Metatarsal fractures

-       Mechanism of injury 

• Direct blow เกิดcomminuted fracture
• Twisting injury เกิดspiral fracture
• Avulsion fractures : 5 metatarsal base
• Repetitive trauma ทำาให้เกิดinsufficiency fractures

-       Treatment

• Non-displaced fractures
  • short leg cast
  • Displaced fractures
    • 1^st metatarsal : ORIF
    • 2^nd-5^th metatarsal : close reduction withshort leg cast
    • Multiple metatarsal fractures : ORIF

Fracture of Fifth metatarsal base (Jones’ fracture)

-       Insertion of Peroneus brevis

-       Mechanism

• Forceful inversion

-       Treatment

• Non-displaced fracture : short walking cast
• Displaced fracture : ORIF with TBW or screw fixation

Fracture and dislocation of the spine

Cervical spine injury

-                    Neck sprain

• Treatment
  • Rest
  • heat, soft collar
  • NSAIDs, muscle relaxant analgesic

-                    Whiplash injury

• Mechanism of injury : hyper extension
• Clinical feature
  • Neck pain
  • Neck tenderness
• Investigation
• Plain radiograph: C-spine AP, lateral
• MRI
• Treatment
  • Medication: NSAIDs, muscle relaxant, analgesics
  • Physiotherapy: isometric ,ROM exercise

-                    C1 burst fracture (Jefferson’s fracture)

• Mechanism of injury
  • axial load
• Clinical feature
• Investigation
  • Open mount: overhanging lateral mass > 7 mms.
  • CT scan
• Treatment
  • Conservative treatment
    • Stable type :semi-rigid collar
    • Unstable type : halo vest
  • Surgical treatment: posterior C1-C2 fusion

-                    Odontoid Fracture

• Mechanism of injury
  • forced flexion injury
  • hyperextension
• Clinical feature
  • Neck pain
  • Neuro deficit
• Classification
  • Type I fracture tip of odontoid
  • Type II junction between odontoid and C2 body
  • Type III C2 body
• Investigation
• Treatment
  • Type I : Rigid collar
  • Type II : reduction withposterior fusion

: anterior screw fixation

• Type III : Halo Vest

-                    Traumatic Spondylolithesis of C2 (Hangman’s fracture)

• Mechanism of injury
  • extension, compression and flexion
• Clinical feature
  • Neck pain
  • Neck tenderness
  • neurodeficit
• Investigation
  • C- spine AP, Lateral Flexion Extension
  • CT scan
• Treatment
  • Stable fracture : semi-rigid collar
  • Unstable fracture : reduction àhalo vest
• Mechanism of injury
  • Flexion และflexion-rotation
  • Axial compression
  • Hyperextension
• Clinical feature
  • Neck pain
  • Neck tenderness
  • neurodeficit
• Investigation
  • X ray
  • CT scan
• Treatment
  • Wedge compression fracture : Collar 6-12 weeks
  • Burst fracture
    • No neurodeficit: bed rest with skull traction
    • Neurodeficit: anterior corpectomy with bone graft & plate fixation
  • Fracture-dislocation
    • Reduction with skull traction
    • posterior open reduction & fusion

Lower cervical spine fracture

Thoracolumbar Spine Injury

-                    3 column theory

• Anterior column
• Middle column
• Posterior column ( Posterior ligamentous complex)

-                    Mechanism of injury

• Low-energy fracture
  • Transverse process fracture (avulsion fracture)
  • Pars interarticularis fracture (traumatic spondylolysis)
• High-energy fracture
  • Compression fracture
  • Axial compression (burst fracture)
  • Flexion-distraction
  • Fracture-dislocation

-                    Investigation

• Plain X-ray :AP,lateral
  • Loss of vertebral height/wedging
  • Widening of interpedicular distance
  • Widening of interspinous distance
  • Kyphotic angle
• CT scan
• MRI

-                    Treatment

• Stable fracture(compression fracture ที่anterior height loss < , burst fracture ที่ไม่มี neurodeficit และChance fracture
  • thoracolumbar brace หรือbody cast ในท่าextension

• Unstable fracture(burst fracture ที่มีneurodeficit, flexion-distraction injury และ
  • Operative treatment

• Fracture with spinal cord injury
  • Operative treatment