Quick Reference Illustrations

💡 Treat as you find - don't move to B until A is secured

💡 Clinical diagnosis - do NOT wait for all 6 P's!

💡 Timeline: Days 1-7, Weeks 1-3, Weeks 3-12, Months-Years

💡 Key timeframes: Antibiotics ASAP, debridement early, flap ideally <72hrs

💡 Articular = absolute stability, Diaphyseal = relative stability

💡 Unstable patient = DCO, Stable = ETC

💡 Petechiae in upper body distribution - pathognomonic

💡 Resuscitate BEFORE tourniquet release - hyperkalaemia kills

💡 Score is predictive not prescriptive - clinical judgement essential

💡 Factors affecting: Diabetes, Smoking, Infection, Nutrition

💡 Call MTP early - don't wait for lab results

💡 Communicate time to team - reperfusion injury risk

💡 A=Complete, B=Sensory incomplete, C/D=Motor incomplete, E=Normal

💡 Smoking cessation critical for fusion success

💡 PLC injury drives decision - assess on MRI

💡 Ask about bladder function in EVERY spine patient

💡 Progression is insidious - most need surgery once diagnosed

💡 Know the clinical patterns - commonly tested

💡 Don't remove collar until formally cleared

💡 Most resolve - surgery for red flags or failed conservative

💡 CoC for young/active, MoP for elderly, avoid MoM

💡 Posterior has highest dislocation risk - repair capsule!

💡 Know indications for each - not one size fits all

💡 Test stability in ALL positions before closure

💡 CULTURE BEFORE ANTIBIOTICS

💡 Plan for worst case scenario

💡 Always assess stem stability - guides treatment

💡 Reduced LOS, lower complications, better satisfaction

💡 Anatomic types I-IV, Host types A-C

💡 SINGLE dose, within 60 mins of incision

💡 CULTURE BEFORE ANTIBIOTICS

💡 Aspiration is DIAGNOSTIC - joint washout is TREATMENT

💡 Clinical diagnosis - DO NOT wait for imaging

💡 Antibiotics are ADJUNCT to surgery - don't delay debridement

💡 Identify organism BEFORE antibiotics

💡 Type II most common, Type V worst prognosis

💡 Rotation and angular deformity ⊥ to joint motion DO NOT remodel

💡 If you suspect NAI - DOCUMENT and REFER

💡 Pavlik contraindicated if irreducible or >6 months

💡 Any adolescent with knee pain - EXAMINE THE HIP

💡 Herring lateral pillar classification determines prognosis

💡 DOCUMENT before and after manipulation

💡 Equinus corrected LAST - before risks rocker-bottom

💡 Know the 3 S's: Sacrifice, Synergy, Sufficient excursion

💡 Regeneration: 1mm/day = 1 inch/month

💡 Zone II requires meticulous repair + early mobilisation

💡 Zone I = Mallet, Zone III = Boutonniere risk

💡 Thumb any level, children any digit, multiple digits always

💡 Blood supply distal to proximal - proximal pole high AVN risk

💡 Treatment decision individualised - both are valid

💡 Fibula is the key - restore length and rotation first

💡 MDT essential - Endo, ID, Vascular, Podiatry

💡 High index of suspicion - easy to miss on non-WB films

💡 REFER TO SPECIALIST CENTER - biopsy by operating surgeon

💡 A poorly planned biopsy can compromise definitive surgery

💡 Fix + XRT preferred over XRT alone for impending fracture

💡 Good amputation > Bad limb salvage - discuss with patient

💡 Avoid allograft in young athletes - higher failure

💡 Always compare to opposite knee

💡 Popliteal artery injury in up to 30% - check ABI on ALL

💡 Save meniscus when possible - meniscectomy accelerates OA

💡 Irreparable doesn't mean non-operative - consider alternatives

💡 Quantify bone loss - it determines procedure choice

💡 Hip/fracture: 28-35 days, Knee: 10-14 days

💡 Material risk = what THIS patient would want to know

💡 Match graft type to clinical scenario

💡 Balance bleeding vs thromboembolic risk - individualise

💡 Type I below fovea (non-WB), Type II above fovea = ORIF if displaced

💡 COUNT displaced segments (>1cm or 45°) - determines treatment

💡 Key = posterior ring - vertically unstable = C-type

💡 Learn the 5 elementary patterns first - associated are combinations

💡 Fix/replace radial head + fix coronoid + repair LCL = restore stability

💡 Always check DRUJ with radial head fractures - miss = disaster

💡 Never treat isolated forearm fracture without checking joints!

💡 Fix clavicle first - often restores glenoid alignment

💡 Angiogram mandatory - vascular injury very common

💡 Prevention easier than treatment - start within 72 hours

💡 Centre over greater trochanters NOT iliac crests

💡 Hypertrophic = needs stability, Atrophic = needs biology + stability

💡 Day 2-4 is danger zone - avoid major procedures

💡 Early soft tissue coverage (72-120hrs) reduces infection

💡 Pink pulseless = reduce urgently. White pulseless = surgical emergency

💡 Fracture crosses physis - rigid fixation needed or nonunion

💡 Sharp metaphyseal beaking distinguishes from physiologic varus

💡 Address all levels simultaneously - avoid birthday syndrome

💡 Type I most common, Type II lethal, Type III worst surviving

💡 Structural curve = doesn't correct on bending films

💡 Get CT if >2mm displacement - essential for planning

💡 Epiphysiodesis timing critical - use growth charts

💡 Screen for renal anomalies with USS - commonly associated

💡 Resorption fast (weeks), Formation slow (months)

💡 Osteoblast = Builds (mesenchymal), Osteoclast = Chews (haematopoietic)

💡 Type I = bone, Type II = cartilage, Type III = early healing

💡 Superficial zone degenerates first in OA

💡 R-P-H-C mnemonic. Hypertrophic zone weakest = fracture plane

💡 Titanium closer to bone modulus - less stress shielding

💡 Area under curve = toughness, Slope = stiffness

💡 Once mature biofilm forms - antibiotics alone won't work

💡 GRADE system = quality of evidence + strength of recommendation

💡 Non-parametric = ranked data, not normal distribution

💡 Soft callus visible on XR ~2-3 weeks, Hard callus ~6 weeks

💡 Proximal injuries = worse prognosis (longer distance)

💡 Early controlled motion improves tendon gliding and strength

💡 Clavicle = only long bone with intramembranous ossification

💡 Fatigue failure at screw holes - most common mechanism

💡 Lateral cutaneous nerve of thigh most commonly injured

💡 Greater sciatic notch dissection = risk to superior gluteal vessels

💡 Cephalic vein lateral - protects from injury with deltoid retraction

💡 Supinate to protect PIN - moves it medially

💡 FCR tendon is key landmark - work ulnar to radial artery

💡 Stay within 5cm of GT tip to protect superior gluteal nerve

💡 Stay medial to avoid patellar tracking issues

💡 Left side preferred - RLN more consistent course

💡 Ulnar nerve identification is mandatory - transpose if needed

💡 NVB between EHL and EDL - retract together to avoid stretch

💡 Goal: restore hip center, leg length, offset - template on BOTH hips

💡 MoM largely abandoned - ALVAL concerns. CoC best wear but fracture risk

💡 Know all 3 femoral rotation landmarks - TEA most reliable

💡 Reverse requires functional deltoid - recruits deltoid for abduction

💡 Return to cutting sports: 9-12 months, LSI >90%, psychological readiness

💡 Isolated Grade I-II: non-operative with quad strengthening

💡 Match treatment to lesion size: <2cm microfracture, 2-4cm ACI

💡 Alpha angle >55° = CAM. <2mm joint space = poor outcome

💡 Type II most common needing repair. Age >40 consider biceps tenotomy

💡 Stage I-II flexible = osteotomy/reconstruction. Stage III-IV = fusion

💡 Position: neutral DF, 5° valgus, slight ER, posterior translation

💡 Eccentric exercises (Alfredson) first-line. AVOID steroid injection

💡 RED FLAG - document bladder function. Surgery <48hrs for best outcomes

💡 C6 and C7 most common. Know dermatome, myotome, reflex for each

💡 Neurogenic claudication relieved by flexion (shopping cart position)

💡 Myelopathy does NOT improve spontaneously - surgery indicated

💡 Type II most common, highest nonunion. Risk factors: age >50, displacement >5mm

💡 Type IIA - do NOT apply traction! Use gentle extension

💡 Tabletop test positive = indication for treatment

💡 Steroid injection 60-90% success - try before surgery (max 2 injections)

💡 Acute (<6 weeks) = direct repair. Chronic = reconstruction or salvage

💡 Splinting works even weeks late - 6-8 weeks continuous extension

💡 Elson test: rigid DIP with PIP extension = central slip rupture

💡 NEVER biopsy before imaging. Biopsy by OR in consultation with treating surgeon

💡 Know portal placement and nerve at risk for each portal

💡 Age <25 at first dislocation = highest recurrence risk

💡 Peripheral = repair. Central = partial meniscectomy. Preserve if possible

💡 Weight-bearing CT for subtle injuries. Miss = arthritis

💡 Match osteotomy to IMA: mild = distal, moderate = proximal, severe = basal

💡 ALWAYS check DRUJ with radial head fracture - rule out Essex-Lopresti

💡 Dual plate 90-90 configuration for rigid fixation and early motion

💡 TBW for simple transverse. Plate for comminuted or Mayo III

💡 TLICS <4 non-op, >4 surgery. MRI for PLC assessment

💡 Unstable SCFE = emergency. High AVN risk. Single screw perpendicular to physis

💡 Age >8 at onset = poor prognosis. Lateral pillar classification guides treatment

💡 Treatment by age: 0-6mo Pavlik, 6-18mo closed reduction, >18mo open reduction

💡 Ponseti gold standard. Most need tenotomy. Boots/bar for 4 years

💡 Check AIN (FPL, FDP to index). Pink pulseless hand needs assessment

💡 Elbow flexion test positive = ulnar nerve compression

💡 Transfer loses 1 MRC grade. Joint must be supple. Straight line of pull

💡 Displaced in young = urgent ORIF <6hrs. Elderly = consider hemi/THA

💡 Unstable = IM nail. Tip-apex distance <25mm for cut-out prevention

💡 MRI most sensitive. Early (pre-collapse) = core decompression option

💡 CT essential for planning. Restore articular surface. Soft tissue window 7-14 days

💡 Staged protocol: 1) ExFix, 2) Wait for soft tissues, 3) Definitive ORIF

💡 Bohler angle <20° = significant depression. Check spine (10% associated)

💡 Hawkins sign at 6-8 weeks = revascularization = good prognosis

💡 Pelvic binder first. Hemodynamic instability = angio or PPP

💡 Know 3 X-ray views: AP, Obturator oblique, Iliac oblique

💡 Elderly 3-4 part = consider reverse shoulder. Valgus-impacted = better prognosis

💡 Surgical indications: shortening >2cm, skin tenting, polytrauma

💡 90% have associated injuries. Think of floating shoulder concept

💡 Radial nerve palsy: 90% recover - observe 3-4 months before surgery

💡 Know radial height (11mm), inclination (22°), volar tilt (11°)

💡 Galeazzi = radius fracture + DRUJ. Monteggia = ulna + radial head

💡 Check for ipsilateral neck fracture (3-6%). Fat embolism risk

💡 High compartment syndrome risk. IM nail preferred for unstable

💡 B1 = stable stem ORIF. B2 = loose stem revision. B3 = revision + graft

💡 Zone II most challenging. Preserve A2 and A4 pulleys. Early active motion

💡 Zone I = mallet (splint 6-8 weeks). Zone III = boutonniere mechanism

💡 EDX: distal motor latency >4.5ms. Recurrent motor branch at risk

💡 SL angle >60° = DISI. Know Mayfield progression of perilunate injury

💡 Match reconstruction to amputation level. Toe transfer for proximal

💡 Upper trunk = waiter's tip. Horner syndrome = T1 avulsion

💡 Central cord = elderly hyperextension. Anterior cord = worst prognosis

💡 SLIC <4 non-op, >4 surgery. MRI for disc herniation before reduction

💡 L5-S1 isthmic. L4-5 degenerative. Progressive slip = fusion

💡 Medical optimization first. Vaughan-Jackson = EDC rupture small finger first

💡 Bone biopsy gold standard. Antibiotics 6 weeks. Dead space management crucial

💡 Pediatric hip emergency. WBC >50k suggests infection. Washout + antibiotics

💡 Acute <4 weeks = DAIR. Chronic = 2-stage revision with spacer

💡 Exhaust conservative before surgery. Joint space narrowing, osteophytes, sclerosis, cysts

💡 Grade I-II = conservative. Grade III/combined = reconstruction

💡 Vascular injury 20-40%. ABI mandatory. Early reconstruction 2-3 weeks

💡 HTO for varus, DFO for valgus. Young active patient with unicompartment OA

💡 Constraint ladder: CR → PS → CCK → Hinge. Address bone loss first

💡 Know Paprosky for acetabulum and femur. Match reconstruction to bone loss

💡 Longitudinal biopsy incision. Wide margin 1-2cm. MRI for local staging

💡 Mirels >8 = prophylactic fixation. Biopsy unknown primary

💡 Osteoid osteoma: nocturnal pain relieved by aspirin. GCT = soap bubble epiphyseal

💡 Peak 10-20 years. Neoadjuvant chemo → surgery → adjuvant. Response = prognosis

💡 Peak 10-15 years. Diaphyseal. Very chemo-sensitive. t(11;22) translocation

💡 T-score <-2.5 = osteoporosis. Atypical femur fracture with long-term bisphosphonates

💡 Know Ca, PO4, ALP, PTH, Vit D patterns. Paget: isolated elevated ALP

💡 Age >8 = worse prognosis. Herring lateral pillar for prognosis. Containment treatment

💡 Unstable = 50% AVN. Single screw central placement. Endocrine workup if young/bilateral

💡 Correct CAVE in order: Cavus first, Equinus last. Tenotomy 95%. FAO bracing 4 years

💡 AIN most common nerve injured. Type II-III = closed reduction and K-wires

💡 C-R-I-T-O-E ages 1-3-5-7-9-11. Medial epicondyle avulsion trap

💡 ATFL most commonly injured. Brostrom-Gould for chronic instability

💡 Thompson test: no plantarflexion = rupture. Risk: FQ antibiotics, steroids

💡 90% resolve with conservative. First-step pain classical. Differential: tarsal tunnel

💡 Mild = Chevron. Moderate = Scarf. Severe = Lapidus (1st TMT fusion)

💡 Bone loss >20% = Latarjet. ISIS score predicts recurrence

💡 Peripheral = repair, central = partial meniscectomy. Root tears = meniscectomy kinematically

💡 <2cm² = microfracture. 2-4cm² = OATS. >4cm² = MACI/OCA

💡 Alpha angle >55° = cam. Contraindicated: advanced OA, dysplasia

💡 ECRB origin most common. 90% resolve conservative. Nirschl debridement surgical

💡 Hook test for distal rupture. Young = repair, older = tenotomy/tenodesis proximal

💡 C7 most common. C5 = deltoid. C6 = biceps. C7 = triceps

💡 Cauda equina = emergency (bowel/bladder, saddle). 90% resolve conservative

💡 Shopping cart sign. Distinguish from vascular claudication. When to add fusion

💡 TLICS <4 non-op, >4 surgery. PLC integrity key. MRI for PLC assessment

💡 Type II = highest nonunion. Elderly considerations. Screw vs fusion

💡 Retrograde blood supply → proximal pole AVN. Waist most common

💡 Ring > small. Hueston table top test. Northern European, alcohol, family history

💡 A1 pulley at MCP level. Diabetics have higher injection failure

💡 EPB subcompartment. Radial sensory nerve at risk in surgery

💡 Cubital most common. Froment sign. Ulnar paradox explained

💡 Lethal triad: hypothermia, acidosis, coagulopathy. Convert when lactate normalizes

💡 Life first. Vascular injury 6h, compartment 4h, open fracture 6h

💡 Antibiotics within 1 hour. Soft tissue coverage by day 7

💡 Binder first. FAST+ → laparotomy. FAST- → angio or packing

💡 Type III collagen in early healing → Type I in remodeling (2 years)

💡 Autograft = gold standard (all 3 properties). BMP = osteoinductive only

💡 Titanium = closest elastic modulus to bone. CoCr = hardest for bearings

💡 Younger, closer to physis, in plane of motion = better remodeling. Rotation never remodels

💡 Neurapraxia = full recovery. Regeneration 1mm/day. EMG at 3 weeks

💡 Within 60 min before incision. Redose every 2 half-lives. Stop at 24h

💡 THR/TKR = high risk, 14-35 days prophylaxis. LMWH or DOAC

💡 Capacity: understand, retain, weigh, communicate. Material risks disclosure

💡 Time out before incision: identity, procedure, site, antibiotics, imaging

💡 3-step ladder: non-opioid → weak opioid → strong opioid + adjuvants

💡 BTB = bone-to-bone healing. Allograft higher failure in young athletes

💡 Partial → debride vs complete and repair. Massive irreparable → SCR, transfer, reverse

💡 RTS criteria: strength >90%, hop tests passed, psychological readiness, 9-12 months

💡 MAP >85-90 for 7 days. Steroids no longer recommended. Early decompression <24h

💡 Red flags: saddle anesthesia, bowel/bladder, bilateral. Decompression <48h

💡 0-6mo Pavlik. 6-18mo closed reduction. >18mo open reduction + osteotomy

💡 FEVER = urgent workup for septic arthritis. Age-based: toddler, child, adolescent

💡 Infection workup first (aspirate, CRP, ESR). Then component position/alignment

💡 First = closed reduction, brace. Recurrent = investigate and revise

💡 Precollapse (I-II) = core decompression. Collapsed (IV) = THA

💡 Flexor tenosynovitis = emergency I&D. Herpetic whitlow = DON'T incise

💡 Wrong biopsy = amputation. Longitudinal incision in line with definitive surgery

💡 Narrow transition = benign. Wide/permeative = malignant. Age matters

💡 Red flags: >5cm, deep, rapid growth, painful. MDT discussion essential

💡 Unknown primary = biopsy. Mirels >8 = prophylactic fixation

💡 Bone loss >25% = Latarjet. ISIS score for decision making

💡 Self-limiting 1-3 years. Freezing = pain, Frozen = stiffness

💡 Intact cuff = anatomic TSA. Cuff deficient = reverse TSA

💡 Functional arc 30-130°. Wait 3-6 months stable before surgery

💡 Hypertrophic = add stability. Atrophic = add biology

💡 Medial clear space >4mm = unstable. Always assess syndesmosis

💡 MDT essential. Offload is key. ABI may be falsely elevated in diabetics

💡 No surgery in active phase. TCC for offloading. Surgery for instability only

💡 Major criteria: 2 positive cultures or sinus tract. Off antibiotics 2 weeks before aspirate

💡 Acute <4 weeks = DAIR possible. Chronic = 2-stage gold standard

💡 Fuse for instability, deformity, failed decompression. Anterior vs posterior by pathology

💡 Progressive = surgery. Anterior vs posterior by number of levels and lordosis

💡 Less than 25 = observe. 25-40 with growth = brace. Greater than 40 = surgery

💡 Hard signs = immediate surgery. 4-6 hour ischemia limit. Shunt before ortho fixation

💡 Most distal viable. BKA preferred if possible. Energy doubles with each proximal level

💡 Surgery within 36 hours. Cemented if needed. Mobilize day 1. Orthogeriatric reduces mortality

💡 Unstable: dorsal tilt greater than 20, shortening greater than 5mm, articular step greater than 2mm

💡 ACL = recon in young active. MCL = brace. PCL = most non-op. Multiligament = check vascular

💡 More core strands = stronger repair. Zone 2 = 6 strands + early active motion

💡 Stable = single screw in-situ. Unstable = urgent, higher AVN risk

💡 Younger than 6 = good prognosis. At-risk signs need containment surgery

💡 CAVE order: Cavus, Adductus, Varus, Equinus. 80% need tenotomy. FAB until age 4

💡 Red zone = repair. White zone = partial meniscectomy. Root tear = must repair

💡 High-risk sites: anterior tibia, navicular, FN tension side, 5th MT Jones = may need surgery

💡 Prior fragility fracture = treat regardless of T-score. Drug holiday after 5 years

💡 Debride all dead bone. Culture-directed antibiotics 6+ weeks. Dead space management critical

💡 Pain on passive stretch = earliest sign. Pulselessness = late/unreliable. Delta P <30 = fasciotomy

💡 Type III = urgent reduction. Pink pulseless = reduce immediately. AIN = median nerve

💡 Severe (thenar wasting, axonal loss) = direct to surgery. Mild/moderate = trial splinting

💡 Neurogenic improves with flexion. Vascular same in all positions. Decompress +/- fuse for instability

💡 Biopsy by tumor surgeon. Neoadjuvant chemo 10-12 weeks. Response = % necrosis

💡 Trial 1-3 injections. Diabetics higher recurrence. Thumb - protect radial digital nerve

💡 Similar re-rupture rate with functional rehab protocol. Non-op = quicker recovery, less complications

💡 Type I = early motion. Type III = replace if comminuted. Check for Essex-Lopresti syndrome

💡 Operate if displaced >3mm or step >2mm. Non-op if can SLR. Avoid total patellectomy if possible

💡 Operate if >100% displacement or >2cm shortening. Middle third plate preferred

💡 Most treated with brace. Radial nerve palsy - observe 3-4 months unless open

💡 Adults = IM nail standard. Pediatric by age group. Damage control in polytrauma

💡 Simple transverse = TBW. Comminuted = plate. Elderly comminuted = excision + triceps advance

💡 Simple = early motion. Terrible triad = radial head + coronoid + LUCL. Stability test at 30/90°

💡 Most (80%) non-op. Young + displaced = fix. Elderly + poor bone = consider arthroplasty

💡 Snuffbox tender + XR negative = MRI or treat as fracture. Proximal = higher AVN risk

💡 Both bones adult = operative. Check elbow and wrist for associated injuries

💡 Check for open injury and compartment syndrome. Nail vs plate by location and soft tissue

💡 Check for rotational deformity. Rotation = operate. Stable = buddy tape and early motion

💡 Younger = faster healing + more remodeling. Accept more angulation near growth plate

💡 Ottawa rules exclude fracture. Functional treatment for most. Surgery if chronic instability

💡 Conservative failed first. Optimize weight, smoking, medical. Early mobilization post-op

💡 Screen red flags first. Most acute = conservative. Image if red flags or failed treatment

💡 Neuropraxia = quick recovery. Axonotmesis = 1mm/day. No recovery by expected time = investigate

💡 Day 0-2 = atelectasis. Day 3-5 = UTI/pneumonia. Day 5+ = SSI/DVT. Inspect wound!

💡 All patients = mechanical. Chemical by risk. Major joint = high risk. Regional = timing matters

💡 Bladder dysfunction + bilateral legs + saddle = emergency MRI. Decompress within 48h

💡 Hot swollen joint = aspirate. Kocher for pediatric hip. Urgent washout + IV antibiotics

💡 Pain out of proportion + systemic toxicity. Dont delay for LRINEC. Immediate debridement

💡 Reduce within 6 hours = reduce AVN. Check sciatic. Post-reduction CT for concentricity

💡 Risks (general + specific), non-op option, who operates, questions encouraged

💡 Phases: Immediate pain/mob, Early ROM, Middle strength, Late sport-specific

💡 Smoking 4 weeks. HbA1c optimization. Bridging anticoag. Iron for anaemia

💡 Clean + within 6-8h = primary. Contaminated = leave open. VAC for soft tissue loss

💡 Locking = meniscus or loose body. Giving way = ligament. Large effusion = haemarthrosis

💡 Night pain + weight loss = cancer. Bladder + bilateral = cauda equina. ALWAYS check red flags