OSTEOLOGY OBEGroup 4Banares, BrendonCarvajal, ElyzaDel Castillo, RoyJusto, KatrinaPatam, Kasandra Christina A.Zape, JosselBaylosis, Eloisa

1. Pelvis

Duverneys fracture is an isolated pelvic fracture involving only the iliac wing. It is caused by direct trauma to the iliac wing, and it is regarded as a stable injury as they do not disrupt the weight bearing pelvic ring.

Malgaignes fractureis an unstable type of pelvic fracture which involves both pubic rami and sacro-iliac complex or sacrum. Injury characterized by rupture of entire pelvic floor, including posterior sacro-iliac complex as well as sacrospinous and sacrotuberous ligaments. It results from vertical shear energy vectors like falling from height then landing on lower limbs.It comprises of two ipsilateral pelvic ring fractures, which are vertically orientated: anterior to acetabulum posterior to acetabulum

Pipkin fracture is a fracture of femoral head in association with posterior dislocation of hip. It results from the impact to the knee with the hip flexed (dashboard injury). Classification Type I: fracture distal to the fovea capitis, a small fracture not involving the weight bearing surface Type II:fracture proximal to the fovea capitis, a large fracture involving the weight bearing surface Type III: type I or II fracture with a fracture of the femoral neck, has an increased risk of avascular necrosis Type IV:type I or II fracture with a fracture of the acetabular wall, usually the posterior wall

Clinical Significance of Symphysis Pubis PregnancyDuring pregnancy in the human, hormones such as relaxin remodel this ligamentous capsule allowing the pelvic bones to be more flexible for delivery. The gap of the symphysis pubis, normally is 45mm but during pregnancy there will be an increase of at least 23mm, therefore, it is considered that a total width of up to 9mm between the two bones is normal for a pregnant woman. The symphysis pubis separates to some degree during childbirth. In some women this separation can become a diastasis of the symphysis pubis. The diastasis could be the result of a rapid birth or a forceps delivery or maybe even be prenatal. A diastasis of the symphysis pubis is a symptom of pelvic girdle pain.SymphysiotomySymphysiotomy is a surgical procedure in which the cartilage of the pubic symphysis is divided to widen the pelvis allowing childbirth when there is a mechanical problem. It allows the safe delivery of the fetus where cesarean section is not an option especially suggested on woman in isolated areas experiencing obstructed labor.InjuryThe pubic symphysis widens slightly whenever the legs are stretched far apart. In sports where these movements are often performed, the risk of a pubic symphysis blockage is high, in which case, after completion of the movement, the bones at the symphysis do not realign correctly and can get jammed in a dislocated position. DiseaseRenal osteodystrophy, produce widening, while ochronosis results in calcific deposits in the symphysis. Ankylosing spondylitis, result in bony fusion of the symphysis. Osteitis pubis, the most common inflammatory disease in symphysis pubis. Degenerative joint disease of the symphysis, which can cause groin pain, results from instability or from abnormal pelvic mechanics.Symphysiolysis is separation or slipping of the symphysis. It has been estimated to occur in 0.2% of pregnancies.

Ischial Spine during Pudendal BlockThe ischial spines are boney landmarks palpable to the examining finger, and located deep, lateral and a little posterior to the vagina. The spine can be felt as a distinct boney "bump" quite separate from the rest of the pelvic sidewall. It is used in as landmark for transvaginal approach of pudendal block. The perineum is innervated by the pudendal nerves that originate from S3-S4, and pass close to the ischial spine as it traverses the pelvic sidewall. Running from the ischial spine to the sacrum is the sacrospinous ligament, a tough band of tissue that can be felt with the examining fingers. This ligament is important because the pudendal nerve runs just underneath it and next to the ischial spine. The perineum is innervated by the pudendal nerves that originate from S3-S4, and pass close to the ischial spine as it traverses the pelvic sidewall.The block is performed with the patient in the lithotomy position.

Ischial Tuberosity during Pudendal BlockIschial tuberosity is used as a landmark for perineal approach of pudendal block. The perineal approach is considered valuable when the engaged head of the fetus makes vaginal palpation difficult. The ischial tuberosity is located by palpation. The needle is introduced slightly medial to this point, for a distance of 2.5 cm. The nerve is usually encountered without eliciting paraesthesia. Up to 8 mL of solution is infiltrated at this point. The needle is then withdrawn and directed into the deep and superficial tissue of the vulva along its anterior margin in order to block the ilioinguinal and genitofemoral component. The block is repeated on the other side.

Diagonal ConjugateIt is an oblique line that extends from the inferior border of the symphysis pubis to the promontory and is measure through the vagina. It is approximately 13 cm and it is where the obstetric conjugate deduced. Obstetric Conjugate (True Conjugate)The shortest pelvic diameter through which the fetal head must pass during birth, measured from the middle of sacral promontory to posterosuperior margin (closest point) of symphysis pubis. The obstetric conjugate cannot be measured directly due to the presence of the bladder. It is computed by subtracting 1.5 to 2.0 cm, depending on the height and inclination of the symphysis pubis. Normally the obstetrical conjugate measures 11 cm or more.Anatomical ConjugateIt is the line between the upper boarder symphysis pubis and the middle of the sacral promontory. It is approximately 12 cm.

Transverse Diameter of Pelvic InletIt extends across the greatest width of the superior aperture, from the middle of the brim on one side to the same point on the opposite. It is bounded by the inferior border of the walls of the iliac bones and is measured at the widest point. It is normally close to 13.5 cm but may be less in the small gynecoid pelvis and anthropoid pelvis.Transverse Diameter of Pelvic OutletThe transverse diameter of the outlet is between the two ischial tuberosities. It is approximately 10-11 cm.

Anteroposterior Diameter of Pelvic OutletIt is the distance between the middle of the pubic symphysis and the tip of coccyx. Its measurement varies from 9.5-11.5 cm due to the mobility of coccyx.

Oblique Diameter of Pelvic InletOblique Diameter I is the distance between the right sacroiliac joint and the opposite iliopubic eminence. It is approximately 12-12.5 cm.Oblique diameter II is the distance between the left sacroiliac joint and the iliopubic eminence on the opposite side. It is approximately 11.5-12 cm.

Ortolanis Click and Balows Maneuver (For congenital hip dysplasia)Ortolani test or Ortolani Maneuver (abducting) is a physical examination for congenital hip dysplasia or developmental hip dysplasia. The maneuver is performed by abducting the infants hip an assessing for a clicking sound. Ortolanis click is a positive sign when performing Ortolanis test. It is a distinctive click or clunk sound heard in the test for a congenital dislocated hip. It is noted in infancy when the hip slips into or out of the socket. Ortolani maneuver is performed before 2-3 months of age. The maneuver is done in early infancy because after 2-3 months the development of soft tissue contracture prevents the hip from being relocated, thus, no clicking or clunking sound will be assessed in children with congenital hip dysplasia.Barlow test (adducting) is a maneuver performed by bringing the thigh towards the midline of the body while applying light pressure on the knee, directing the force posteriorly. Feeling of femoral head slipping out of the socket postolaterally, is considered as a positive Barlows sign.The Ortolani test is then used to confirm that the hip is actually dislocated.

Charley-horseIt is another name for a painful muscle spasm or cramps. Charley horses can occur in virtually any muscle, but they are most common in the legs. These spasms are marked by extremely uncomfortable muscle contractions. The muscles dont relax for several seconds or more, and the pain can be quite severe.It can also refer to a bruise on an arm or leg and a bruising of the quadriceps muscle of the anterior or lateral thigh, or contusion of the femur, that commonly results in a hematoma and sometimes several weeks of pain and disability.

2. FEMURAnatomy

1. Radiograph

The laterality of the femur is determined by the head. It must face IN and the lesser trochanter must be on the BACK side of the bone so hold the bone so that the head is on top and the trochanters are on the BACK surface of the bone. If the head faces left it is a left femur when you are facing the bone. But if it is determined in anatomical position, the left femur has its head facing the right.

Clinical Correlation

STIEDA FRACTURE

It is the fracture of the internal condyle of the femur. While the long-term effects of avulsion of the medial collateral ligament from its femoral attachment, causing local pain and heterotopic ossification, comprise the Pellegrini-Stieda lesion. Pellegrini-Stieda Disease is post-traumatic ossification in or near the medial collateral ligament near the margin of the medial femoral condyle. One presumed mechanism of injury is a Stieda fracture.The injury is generally sustained as the result of a strike or unnatural stretch in the area where the medial collateral ligament joins to the thigh bone (femur). A significant direct blow can often be sufficient to provoke the condition. High speed impact from a cricket ball, football or other projectile is a common cause, as is a severe tackle or similar strike during a contact sport. Pellegrini-Stieda syndrome can also be caused by stretching the muscle incorrectly, especially due to a specific fall. With the foot remaining in position, the falling person drops over their own knee with the result of inward bending; this provokes a damaging overstretching of the ligament. Such a fall can occur in sports as diverse as basketball, rugby, gymnastics, football, and cycling.

GARDEN'S CLASSIFICATION OF FEMORAL NECK FRACTUREThe Garden classification of subcapital femoral fractures is the most widely used today. This system is used to describe fractures on the basis of the distortions of the principal (medial) compressive trabeculae before reduction. Garden stage I : undisplaced incomplete, including valgus impacted fractures. Garden stage II : undisplaced complete Garden stage III : complete fracture, incompletely displaced Garden stage IV : complete fracture, completely displacedA stage I Garden fracture is an incomplete subcapital fracture. The femoral shaft is twisted externally. The alignment of the trabeculations of the distal femoral neck relative to the femoral head (which itself is adducted) causes the fracture to be in a valgus configuration. In other words, the trabecular markings in the femoral neck are displaced away from the midline relative to those in the femoral head. The altered angle of the trabeculations is greater than 180 when viewed on the AP projection (normally 160). Such fractures are inherently stable.

A stage II Garden fracture is a complete, but nondisplaced, fracture. The femoral head is abducted, but the femoral neck has moved in such a way as to maintain normal alignment with the femoral head. These fractures are considered stable and have a favorable prognosis.

A stage III Garden fracture is a complete, partially displaced subcapital fracture. The femoral shaft is externally rotated. The femoral head is abducted and axially rotated such that its superior surface resides more anteriorly. The alignment of the femoral neck relative to the head is in varus deformity.

A stage IV Garden fracture is a complete and fully displaced fracture. The femur is externally rotated and superiorly displaced relative to the femoral head. The head, now completely detached from the neck, remains in anatomic position relative to the acetabulum. This fracture is considered unstable with a poor prognosis.

BAKER'S CYST

A Bakers cyst is a swelling on the back of the knee caused by the build-up of fluid inside sacs called bursae between the two heads of the gastrocnemius (calf muscle). The symptoms are mild unless the cyst bursts or extends down into the calf muscles. Common causes of Bakers cyst include arthritis, infection, torn knee cartilage and other knee injuries. Bakers cyst is also known as a popliteal cyst.Often a Baker's cyst causes no pain. When symptoms occur, they may include: Tightness or stiffness behind the knee. Swelling behind the knee that may get worse when you stand. Slight pain behind the knee and into the upper calf. You are most likely to feel this when you bend your knee or straighten it all the way.Sometimes the pocket of fluid behind the knee can tear open and drain into the tissues of the lower leg. This can cause swelling and redness in that part of the leg.

WARD'S TRIANGLE

Ward's triangle is not a true anatomic area but is generated by the DEXA scan as the area having thelowest BMD in the femoral head.It refers to a radiolucent area between principle compressive, secondary compressive and primary tensile trabeculae in the neck of femur. Contains thin, loosely packed trabeculae. The measurement of BMD in Ward's triangle should not be used to diagnose osteoporosis. One should use the femoral neck BMD, trochanter BMD, or total hip BMD as determined by the DEXA scan to diagnose osteoporosis.It is seen in x-rays and DEXA bone scan as a radiolucent area. Area of the femoral neck formed by the intersection of 3 bundles of trabeculae primary compressive trabeculae medially, primary tensile and, secondary compressive trabeculae laterally

2. TIBIA

Segond fracture-avulsion fracture of the knee that involves the lateral part of the tibial plateau-often associated with tear of the anterior cruciate ligament-usually occurs from falls and sports such as basketball and skiing

bumper fracture-aka fender or tibial plateau fracture-usually result from fall from a height, splitting, and impact with automobile bumper

Tillaux fracture-fractures through the anterolateral aspect of the distal tibial epiphysis, with displacement

3. Patella

Clinical:Turner Kieser Syndrome absence of patella

4. FIBU:LA

FibulaRadiograph (Ankle Mortise)

Clinical Correlation:Anatomical Strucure InvolvedDefinitionPicture

Potts Fracture(aka Dupuytren Fracture)Medial and Lateral MalleolusStrained sturdy medial (deltoid) ligament of the ankle, tearing off the medial malleoulus due to its strong attachment. The talus will move laterally, tearing of the lateral malleolus

Bosworth FractureDistal FibulaFracture of distal fibula with posterior dislocation of the proximal fibular ligament then becomes trapped behind the posterior tibial tubercle

LeFortes Fracture of the AnkleDistal FibulaVertical fracture of the antero-medial part of the distal fibula with avulsion of the anterior tibiofibula ligament and the internal malleolus of the ankle

Maisonneuve FractureProximal third of fibulaSpiral fracture of the proximal third of the fibula with an avulsion of the distal tibiofibular joint and the interosseous membrane

Runners Fracture(aka Hairline Fracture)Weight bearing bones (Tibia or metatarsals)Incomplete fracture of bones due to repeated or unusual strain or heavy weight being put on the ankle or leg.

Top 1Top 2Top 3

Specimen-of-choice for bone grafting (Top 3 from most common to least common)PelvisFibular ShaftTibia

TIBIAA. Gosselin fracture

The Gosselin fracture is a V-shaped fracture of the distal tibia which extends into the ankle joint and fractures the tibial plafond into anterior and posterior fragments.B. Segond fracture

Segond fracture is an avulsion fracture of the knee which involves the lateral aspect of the tibial plateau. It is frequently (75% of cases) associated with disruption of the anterior cruciate ligament.The classical appearance: curvilinear or elliptic bone fragment projected parallel to the lateral aspect of the tibial plateau (referred to as lateral capsular sign that is best seen on the straight anteroposterior view of the knee).C. Potts fracture

Archaic term loosely applied to a variety of bimalleolar ankle fractures. In other words, it is a fracture to the lateral, medial or posterior malleoli or bony parts on the outside and inside of the ankle which is caused by a combined abduction external rotation from an eversion force.

D. Tillaux fracture to include Salter-Harris Classification

Tillaux fractures are Salter-Harris III fractures through the anterolateral aspect of the distal tibial epiphysis, with variable amounts of displacement..

There are nine types of SalterHarris fractures; types I to V as described by Robert B Salter and W Robert Harris in 1963, and the rarer types VI to IX which have been added subsequently: Type I A transverse fracture through the growth plate (also referred to as the "physis"): 6% incidence Type II A fracture through the growth plate and the metaphysis, sparing the epiphysis: 75% incidence Type III A fracture through growth plate and epiphysis, sparing the metaphysis: 8% incidence (Tillaux fractures) Type IV A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis: 10% incidence Type V A compression fracture of the growth plate(resulting in a decrease in the perceived space between the epiphysis and diaphysis on x-ray): 1% incidence Type VI Injury to the peripheral portion of the physis and a resultant bony bridge formation which may produce an angular deformity (added in 1969 by Mercer Rang) Type VII Isolated injury of the epiphyseal plate (VIIIX added in 1982 by JA Ogden) Type VIII Isolated injury of the metaphysis with possible impairment of endochondral ossification Type IX Injury of the periosteum which may impaired intramembranous ossification

E. bumper fracture

Fracture of the lateral tibial plateau caused by a forced valgus applied to the knee. This causes the lateral part of the distal femur and the lateral tibial plateau to come into contact, compressing the tibial plateau and causing the tibia to fracture. The name of the injury is because it was described as being caused by the impact of a car bumper on the lateral side of the knee while the foot is planted on the ground

F. toddlers fracture

Minimally or undisplaced spiral fractures usually of the tibia, typically encountered in (you guessed it) toddlers.Toddler fractures typically occur between 9 months and 3 years of age, and are believed to be the result of new stresses placed on the bone due to recent and increasing ambulation. Although early reports suggested that tibial toddler fractures where indicative of non-accidental injury, subsequent work has suggested that this is not the case, and that the vast majority are not suspicious

G. Osgood-Schlatter disease

Disease thought to be due to chronic, repeated microtrauma to the insertion of the patellar ligament onto the tibial tuberosity. It is seen is active adolescents, especially those who jump and kick, and is therefore seen more frequently in boys. It is bilateral in up to 50% of patients. Occasionally the clinical and imaging findings will persist into adulthood, when it is referred to as unresolved OSD. Clinically there will be pain and swelling over the tibial tuberosity.

H. ACL (Anterior Cruciate Ligament) Tear

Athletes who participate in high demand sports like soccer, football, and basketball are more likely to injure their anterior cruciate ligaments.

I. PCL (Posterior Cruciate Ligament) Tear

The posterior cruciate ligament is located in the back of the knee. It is one of several ligaments that connect the femur (thighbone) to the tibia (shinbone). The posterior cruciate ligament keeps the tibia from moving backwards too far.An injury to the posterior cruciate ligament requires a powerful force. A common cause of injury is a bent knee hitting a dashboard in a car accident or a football player falling on a knee that is bent.

J. housemaids knee

Housemaids Knee also known as prepatellar bursitis or knee bursitis is a swelling of the bursa or small sack of fluid at the front of the knee. It more commonly occurs in people who spend long periods of time kneeling.The primary symptom of prepatellar bursitis is the swelling of the area around the kneecap. It generally does not produce a significant amount of pain unless pressure is applied directly to the swelling. The area of swelling may be red (erythema), warm to the touch, or surrounded by cellulitis, particularly if the area has become infected. In such cases, the bursitis is ofteaccompanied by fever. Unlike arthritis, prepatellar bursitis generally does not affect the range of motion of the knee, though it may cause some discomfort when the knee is completely flexed.

K. clergymans knee

Infrapatellar bursitis is the inflammation of the infrapatellar bursa, which is located just below the kneecap. It is a common cause of knee pain and swelling among persons whose work involves kneeling on hard surfaces. It can be caused by friction between the skin and the bursa.

L. ODonoghue Injury (a.k.a The Unhappy Triad and blown-knee)

TheO'Donoghue unhappy triadcomprises of a 3 types of pathology that frequently tend to occur simultaneously in knee injuries. They are:1. anterior cruciate ligament (ACL) tear2. medial collateral ligament (MCL) tear/strain3. (medial) meniscal tear (lateral compartment bone bruise)

M. Medial and Lateral Meniscis Locations and Usual Shapes

N. ACL and PCL osseous positions/attachments

O. Pimentas point

Pimenta's Point is an anatomical landmark for easy location of the posterior tibial artery or tibialis posterior artery (a peripheral pulse on the inside of your ankle). An imagined line is drawn between the bony prominence of the medial malleolus and the insertion of the achilles tendon. At the exact midpoint of this line place three fingers parallel to the leg and you will either feel the posterior tibial pulsation (normal) or will not (peripheral vascular disease or calcification, anatomical variant).

P. shin-splint

Shin splints or in medicine referred to as Medial tibial stress syndrome (MTSS) is defined by the American Academy of Orthopaedic Surgeons as "pain along the inner edge of the tibia. Shin splints are a common injury affecting athletes who engage in running sports or other forms of physical activity, including running and jumping. They are characterized by general pain in the lower region of the leg: between knee and ankle. Shin splints injuries are specifically located in the middle to lower thirds of the inside or medial side of the tibia, which is the larger of two bones comprising the lower leg.

Q. ski-boot syndrome

Compression of the nerve beneath the extensor retinaculum (deep fibular nerve). This commonly occurs with wearing tight ski boots (referred to as ski boot syndrome). The patient will experience pain in the dorsum of the foot.

R. foot-drop

Foot drop is a gait abnormality in which the dropping of the forefoot happens due to weakness, irritation or damage to the common fibular nerve including the sciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. It is usually a symptom of a greater problem, not a disease in itself. It is characterized by inability or impaired ability to raise the toes or raise the foot from the ankle (dorsiflexion

TARSAL TARSAL BONES

Choparts Fracture-DislocationChoparts Fracture-Dislocation is a fracture/dislocation of the mid-tarsal joint, or Chopart jointtalonavicular and calclcaneocuboid joints. Commonly, the calcaneus, cuboid and navicular are fractured. The foot is usually dislocated medially and superiorly as it is plantar flexed and inverted, as in landing from a fall or as in a motor vehicle accident.

Shepherds FractureA Shepherds fracture is one of the talar posterior process caused by sudden flexion of the foot or repetitive motion.

Calcaneal SpurCalcium deposits on the underside of the heel bone can form a protrusion, or calcaneal spur. They can be painless. Treatment includes exercise, orthotics, or surgical removal.

Os TrigonumThe os trigonum is an extra small bone, or ossicle, that sits posterior to the talus. It is found in 7% of adults. Os Trigonum Syndrome occurs from repeated pointing of the toecommon in ballet dancers and soccer players. A nutcracker fracture can occur when the os trigunum is crushed between the ankle and heel bones.

Lisfranc FractureA Lisfranc Fracture occurs at the mid foot when one or more metatarsal bones are displaced from the tarsus.

JONES FRACTURE- involves frx at base of fifth metatarsal at metaphyseal-diaphyseal junction, which typically extends into the 4-5 intermetatarsal facet;- Jones frx is located w/in 1.5 cm distal to tuberosity of 5th metatarsal & should not be confused w/ more commonavulsion frxof 5 th metatarsal styloid;- this fracture is usually proximal to the metatarsal cuboid joint; - in addition, the acute Jones frx must be distinguished from the chronic Jones frx the later of which may represent astress frxw/ poor prognosis for healing; - hence, strictly speaking a Jones frx is an acute injury

PSEUDO-JONES FRACTURE-also known as dancers fracture-fracture of the proximal 5th metatarsal reaching the articular surface. This is located too proximal and reaches the articular surface, and is therefore not aJones fracture

MORTON'S NEUROMA-also known asMorton's metatarsalgia,Morton's neuralgia,plantar neuromaandintermetatarsal neuroma- is abenignneuromaof an intermetatarsalplantar nerve, most commonly of the second and third intermetatarsal spaces (between 2nd3rd and 3rd4th metatarsal heads).- not actually a tumor, but a thickening of the tissue that surrounds the digital nerve leading to the toes.

BUNION

-also referred to as hallux valgus or hallux abducto valgus-is often described as a bump on the side of the big toe that actually reflects changes in the bony framework of the front part of the foot. -bunions are a progressive disorder. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which becomes increasingly prominent. Symptoms usually appear at later stages, although some people never have symptoms.

PSEUDOAINHUM ringlikeconstrictionsaroundthedigits,limbs,ortrunk,occurringbothcongenitallyandinassociationwithawidevarietyofhereditaryandnonhereditarydisorders.Themostseverecasesofcongenitalpseudoainhumresultinautoamputationinutero.