OA

"
"
"


II


II

PerthesSCFE-

II

"

"
" '

"
"
"
"
'
"
"

"
"
"
"
" '
"

'

"

"
"
"

"
"
"
"
"

1-3
3
3-5
5-8
8-12
12-14
15-16
16-17
17-19
20-23
23-24
24-27
28-31
31-34
34-38
38-39
39-40
40-41
41-44
44-46
46-47
47-49
49-51
52-53
53-54
54-58
58-59
59-61
61-62
62-64
64-67

"
2004 -

= " "
, , ,
.
-:

, CDH/DDH ,

"

) ,OM(

)(OA

) ( )(

)( )(PVD

: , , , , .
/
.
/ , .supine
/ .
Valgus , .

Varus .

( - , - )
Antecutvatum / Recurvatum
. , .
Antecurvatum .
Recurvatum .
Pes planus / cavus
pes
- Pes planus . .flat foot calcaneo-
.vaLgus
- Pes cavus . )( .
.calcaneo-vaRus
Plantar flexion ) (
Dorsi flexion .
3


- Internal rotation / External rotation .
Inversion / Eversion" , ) (.
coxa -
Anteversion / Retroversion
2:
condiles-
.1
.
.2
.
Anteversion . .
anteversion " . 12-10
. " .
" CT .
Retroversion .

.

. .
Oblique . .

Transverse . .

Spiral / , .

. ,low energy
.high enrgy ,
.
Segmental transverse .

. .
Impacted .

Avultion " .

.
:
/ :

. .
/ . "

. , , )
(.
. .green stick :

.


. ,
) (.
.
, ,
.
:
plastic deformity , .


Buckel fracture , .

Green stick fracture , .

? . ) (physis
. " -
/-
- ) (subluxation .
) (dislocation , .

AO .
. )
( . ABC .
A .
B .partial
C .
:

, .

.load bearing .

) .intra medullary nail, IMN) load shearing

IMN- .
) ( . .
load shearing .

, ,
. . .
, , .
,
. " ,
, .
.
)( ,"
)( . ) (.
Stress .
Strain . ).(load
.
Modulus of elasticity (Young's module) = stress / strain
:


. .

: , , , ,".
).(rickets

frequency of loading .

.
, .
:
.

)(

. ,
.
) , ,(.

, (.
: .

. ) , (
.

ABC- :
Alignment , , , .

Bones

Cartilage.Soft tissues-

Alignment
2 .

. ,
.
Cartilage
. "" , , ,
.
, .
:
) .(RA

:
6

:
.1
.

) ,( ,.

) ( )( ,

) ( , ) ,(BDZ , )
(.
.2 )( :

callus
o
] ) osteosarcoma(
o
) osteoid osteoma([ . .

o
(Osteoarthritis (OA .
o
.3
.
. " " . :
- - :

osteomyelitis
o
osteoid osteoma
o
hypertrophic osteoarthropathy
o
) , , ,(PBC , , .
hystiocytosis
o

o
:

o
,osteogenic sarcoma, Ewing`s ,
o
- codman`s triangle )(.
: Abnormal contour or shape .4
:

o
:

o
) /(.
o
?

."one view is no view" .

o
.
o
, .

) , (.

) (.

, .

contour

Fat pad sign 2 ) ( .

) , (
.
:
,

) stress films , (.

delayed films

. 3 .
.

= .
.
:
.1 ) .(night stick fracture .
.2 . .
.3 , ) , , ( , ,
. . , , .
:
.1 , .
.2 .
.3 = . . . , .
) ,(.habitual sub ) CP
( , , , .
:
.1 . , /.
.2 - . . .


. , ).(gas gangrene ,
:
Type I . .
Type II . . . .
, .
Type III , , ' ' , ' . A, B
.C
A . .
B .
C .
. )" 10 ( .
, ) IV (I ,.
' .
:
:transverse fracture bending , .

.
:Oblique fracture . . .bending

.
:Spiral fracture , . .

:Articular fracture . .

, .
. . .
CT . . 2
.DJD !
Impacted fracture

Avulsion fracture . . ,

.
Fracture dislocation , , .

Segmental fracture . . .

Comminuted fracture . . . .

.
:
. .
:
Intra-membranous . , ,
.1
.
anchondral , . ,
.2
'.
:
72 .1 : ) ( . .
' . .
.2 . . 6-7
. fibroucartlage ,1 .
. .
.3 . ) (.
woven bone" .
9


Remodeling .4 . )
(.
,
. .primary bone healing
:
. .
. .
. .
. ) (.
..
. ) (.
. .
. .
. . .
.
. .
:
.
.1 : 6 9.5 .
.
.2 3 .
.3 .
.4 .
.5
.6 .
.7 .
.8
compartment syndrome :
. , .
P .Pain, Paresthesia, paliour, Pressure, Pulseless, Prosthesis, Paresis, Pinkness :
.
, , , .
" ) (.
. ) ( .
- " . 60
" ) 30- ( .
) (fasciotomy .
.super.peroneal nerve .
.
!
Volkmans conctracture . .

10


, ,
.
. , .
)=( !25 . .
. 45 .
85- ," )' (.

.

: MFH . ,

. " Ewing .WBC-

.
.
. .

squamus cell carcinoma - .

'' . , .
. ,
. "" .
- . : , ,

, .
. . DD

.
, . .

" , . ,
, .low energy .
, , , ,
) (.
,

. , ,
.
-
- 1y ) (.
- 1-10 .
- 10-30 , .
- 30-40 , , ,.
40 - ,.multiple myeloma ,
-
,) CT, MRI, scintography ,(.US ,
-
- , .

- . ,
, " .
.

, .

.
" .

11


- , ,X .

:Patterns of bone lessions

, , , .
. . ,
.
, :
- Geographically well defined lesion ,

,remodeling , .
. .
- Geographically ill defined lesion , , remodeling

.
- Moth eaten lesion . .

,.
- Permeative , , .

.
, , .
. , .
Balooning remodeling . , )
( . .
fuzziness , .
, .
] '' . [.
:
- . stippling
. 40 stippling .
= ground glass .
:
, .
. OM - .
. , , .
:
- onion peel .
.1
sunburst .
.2
. .
- Codmans triangle , .
.3
.
. .

, , .
.
. ) CIS
platinum(.
) (.
CT
. . 82% '
. .
12


) CT ( , .20 ,
, " .
CT , ,
, , .
Neo adjuvant chemotherapy .
MRI
. ,CT -
. CT . .MRI-
:scintography
) 99 (:
15-25 . . 4 . .
, , ' , . 8
. . .
. .
** . .
:
, , Hawkeye (CT ,( ,) PET ,(.
- . . 64 .
.
Hawkeye .CT .
Staging :
:
. , .
, , .
: , - , .
- T=tissue :
- T0 .
- T1 , .
- T2 "
T3 ) (finger like extension , .
. .
T4 .
T6 .
, , . . ,
. .
.skip skips .
. , , .
, , !
.
G -
0G . .
1G .
2G 6 ) powerfield (.
M -
0M 1M , .
:Enneking

13


:
0G, 0T, 0M , .

0G, 0T, 0M , , ) ballooning

(.
0G, 0-1T, 0-1M ) , ( .

) . (.
:
1G, 1-2T, 0M 6 . , .

2G, 1-2T, 0M.

1-2G, 1-2T, 1M . , , .

grade .
!
.
:
:
Intralesional ) curretage ( .

/.
Marginal , . .

- wide , .

- Radical skips , .

) !( ,
' . :
3-".

50%- .CT-

. : ) (
. 95%
5- .80%
, .
, , . .
, .
, II 85% 22%- .
, .
0 ,70 1:2 !1:3

OsteoArthritis, Degenerative Joint Disease

OA ,
OA- .
.
,OA- .
OA . .
OA .-.
14


:
. .55 = . ) ,
(.
.
:
.

) (genuvarum " .
)

( . .OA
) (repeptitive joint use ,pitchers ,

) OA (.
: .OA

, , ,.
.OA -

.OA
.
:
. .:

, " .
:
. " ,"
," .
.

) OA- (.

:
. ) ,

(.
.

Subluxation

OA .
. .OA-
? .
. ,
" .
) (.
:

15


OA , 50
, . OA
. .
:

] : ! [

sub-chondral sclerosis

) sub-chondral cyst (

ankylosis .

subluxation .

, !!!
- .OA
: !
:
DDH AVM , )(.SCFE ,
20% " .
. ,
. .
. great trochanter , .
:
- .
3 :- , , . -.
) genuvarum ( .
:
).(well being
, , , .
, ) (.
:
. .

.
, .

.
,

. , ,
. .
:
NSAIDs - .

. " '
. " , .

16


) ,(

. "" .
NSAIDs .

)( . cox2 ,Viox
,GI toxicity .
DMARDs

- .OA-
o
.
o
. .NSAIDs
" .
.
ART50 .IL-1
o
. .
: .

.
. 3 .
. . .
.
, .

. .
:
) (debridement .

" . .
. OA
.
Osteotomy )

( .OA
) 20 (
.
40-35 .
.
Excisional arthroplasty ) ( .

.
.
. .
) Arthrodesis ( . 180

) ( , 30 )
( .
. )
( . .
, ) ,
(.
) Arthroplasties ( .

. "" .
17


.
.
. , ,
60 . 30
55
, 20 .
) (

:
.
) in-out fracture (.
. .
" , ' . " .
, .3a, 3b, 3c ,2 ,1
.3
.
. , .
.
/

!!!

) lavage) 10

)(debridement

:Ds 3
Dead tissue

Dead tissue

Dead space .

, " " when in doubt take it out

? : Cs 4
Colour

Consistancy

Contractility

Capacity to bleed

" .

18


" ) skin graft (
- ) free flap(.
.
, contamination - .infection - 6-
, .
MESS score-:
, .
, .
(MESS (Mengled Extremity Severity Score
.
)(4-1
.1
)(3-0
.2
)(3-0
.3
)(2-0
.4
.8-7
= 7.
MESS , .
.
!!! ! score
:Compartement syndrome
- . 30" ) 40"
(.
, . ).(limb threatening
, .
!!!
, ) (.
compartement syndrome- , ) .
, , (.
!
, !!!
:
, .
!

) (.
, !

19


, , ,
, , )
(.
!
high energy trauma .
" " .
, . ,
.
:

.1
-
.2

.3

.4

.5
"
.6
":
spinal shock .
" " C3-C5 2/3
. " " "
. , C3 ,
.
" .
. " !
" , , .
. ,
!
:
) (.
!
) (.
:
)

(.
. " ) CXR (.

. " < .US > CT

. 15

. )
" (.
)

(.
!
) ( .
) ( . ,
.

20


) ( .
. .
:
. ) (open book
. " " .
2.5" . .
" ) ( .
" .
.
, .
.

.
. ) long tissue hinge
( . ,
. , , .
) (circumferantial .
) (physis : 70% - "
30%-" ," 40% " 15% -"
, 55% .
:

(buckle (torus


) (
. .
) (bend .
Buckle , .
) (greenstick .
- Transitional fractures .
.
- juvenile tillaux fracture , ) (tibia fibular lig
, , . .
.
- Triplane fracture . .triplane
.
,AP : , ) PA ,
(.
tillaux .

21


- long tissue hinge ,
" . " ,
) ( .
. 3 - ,
- )(.
:
, .


.


:(heterotrophic ossification (HO .
. .
:Remodeling remodelling- ) ,(,
. ,
" .
, , . -
remodelling .
remodelling- .
:Child abuse .
.
.
, ".
:
: , , ; ; .
: .
: , .
Salter & Harris classification Physis fractures
.
:I . . , .
.I
:II . . .triplane-
:III . .tillaux-
:IV .
Crush V: . .
, .
-:
, ) .(5
.
Bony bars . .
. bony bar ,
) .(radial deviation
bony bar .

22


OA- :
. OA- .
:
, .
LLD 2.5-" ) (.
LLD 2.5-5cm = .
Mosley LLD- .
Epiphysiodesis , " staples .
.bony bar
.
: . .
.
.
:
'.
, , , , .
supracondylar fracture
, .
Supracondylar fracture , " .
- extension type ,) flexion type- 5%(.
) ( . fat pad sign
) ( . "
) .(K wires - )
( Volkmanns contracture .
, AVN . . " :Delbet
:1 . .AVN
:2 .
:3
:4 inter trochanteric
# .

, ,
.

23


,
. .necrotising fasciitis
:Osteomyelitis
.
, .M:F 3-4:1 "
.
)\ ( , "
.
. , U-
) turn ( .
. , "
.

. "
.

.1 8 , "
, .
.
.2 , "
) , , , (
, .
, .
-
.
.sequestrum .involucrum
)=( , - ,
.
OM- , ,
, ) . < (") . "(.
OM , .
, , , ) ""(

) (

)" (
.
, , !!!

"

) (.
) ( !
. )( , )
( ) (.
24


" , !

, 7-14
.1
. .
) (.
.
OM . 48-24
.2
. )
( , 6 . FN .FP-
.30-40%
US- .
.3
) .(29 !!! , E.
.coli
, , ,TB , , ,.
OM ! .
17 IV.
DD
)(
)(eosinophilic granuloma, Ewing`s

RA
RF
" .
ABX.
ABX IV 3 ," PO 3
.
.
)?( 24-48 ,
, ) ( ,
. .
. .
) OM , (.





OM- host
"
50% -
) (
OM 3 , OM

"
, IV ABX-

25


:Septic Arthritis

.OM- 2-3 , .M:F 2-3:1"
.
) , , ( , )
( .
, ,PMN
, , . ,
.
, .
\ .
, .AVN
.
) ( , , , , ,.
.
!
,

,
" OM-

.
.
"
"
.66-75% -
-
- , , ,
.1
/ . - .AP
US .
.2
. !
,OM
.3
SPECT
) .(51" ) .OM (multifocal
, ,TB , , ,.
) DD transient synovitis ( 1

JRA
RF
) , (
) Perthes ,8-6 (
,ABX
ABX IV 2-3 " PO 2-3

, ) ( ,

26


.
.
) , ,
(.
, , ,OM .
OM
AVN
LLD
)(

:Transient Synovitis
DD- 1 .septic arthritis
. .SA ,
.
) (.
) (.
) ,
( ,
.
:
OM/ SA. 50% " , .
) (.
. . "
. , ALL -
, .
, ) (.
:Discitis
, .
" " ) .(TB . ESR .
.
, ) .(TB-
.
:Perthes disease
. AVN - )
(.
.8-6 . .
) ( .
. -
.2

.
:

27

Anal Tone & Bulbocavernosus Reflex
-Extensor Hallucis Longus ( L5 ), Tibialis Anterior ( L4 ), Peroneus Brevis & :
Longus ( 1S Eversion ), Quadriceps Femoris ( 3-4L (Iliopsoas ,
.( ( 2-3L
:
3L . .
:
) ( L3,4 ) .( 1S
:
, , , , .
- ) ,(Axillary Nerve C4,5
.Musculocutaneous Nerve C5,6 ,Ulnar Nerve C8-T1
,Median Nerve C7,8-T1 .Radial Nerve C6-8
,C4,5 ,C7 .T1,2
.C5,6

. , , .
, LLD .Pelvic Obliquity Plumb Line ,
,C7 " " , .Scoliosis ,Scoliotic Posture
.Sciatic List Kyphosis ".
,Spinous Processes . ,
.
" , .Lateral Bending ," ,Lateral ,
.Rotation, Lateral Bending
" Straight Leg Raising , ,
Bowstring Sign , .

(Low Back Pain (LBP

:Acute LBP
65-35 .
. acute low back pain muscular
.pain ) ( LBP .
.
!
:Chronic LBP
, , 3.
, . "
) (.

28


" .
,L5-S1
)" ( " )(.

".
:LBP-
)(

spondylolysis, spondylolythiasis

spinal stenosis

:
5 .L1-L5 L1 "
) ( . " ."
L1" ," .cauda equina-
AP lateral. CT-
.
MRI , , .
:IV disc-
Anulus . .1 120
. .
.
Nucleus pulposus . ).(compression
. - .
:
:
.
o
skin markings hairy patches- , .spina bifida-
o


o
spinous process
o
o -.
o !!! -
." , , .
":
Plumb line C7- .
o
Pelvic oblequity
o
(Leg length discripancy (LLD
o
:
o
o

o
:
T4
o
T7
o

29


T10
o
pubis T12
o
:nerve root tension signs
(Straight leg raise (SLR
o
, .L4-L5
o ,
.
Femoral strech test
o
. ,iliopsoas L1-L2-L3
:
L4 L4- drop foot .tibialis anterior
drop foot steppage .
L4 ) (.
L4 .
L5 .EHL
, .
.L5
S1 " ' '".
.
S1 .
:
GAG- )( .
, . .
, . ,
.
" .
- .
.
. ) (list
) . CL( . "" .
, . ,
. ) (
.
.
:
) , (.
) (
) , , , ,,
(hypernephroma, multiple myeloma
, B signs , .
) ( cauda equina
.syndrome cauda equina-
. , L4-L5 S1
- , ) retention" ,overflow
( ) saddle shape (.
30


:
L4-L5 L4 ,exiting root-
. ,L5 .traversing root-
Foraminal disc - .
L4-L5 .L4 ,exiting root- .
:
prutrusion .
prolapse " .PLL-
extrusion .PLL-
sequestered .
:
"
. GAG .
. 6- .
, . 30% MRI
. 2% .
:
) , , ,( .
6 6 .
outcome- .
:
-
. 8 decompression .cauda equina 6
.
dysfunction .
.
.
:Disc degeneration
90% , chondroitan sulfate
.
" ,
. ).(dessication
) (facet joint .
.
, ) black disc disease.(MRI-
discogenic LBP , , )
.(activity related ) ( , .
!
? outcome- .
)) (ADL
( , .
" ) (arthrodesis .
) (.
:Lumbar spinal stenosis

31


Spinal stenosis / -
.caude equina-
:spinal stenosis
degenerative disc disease
.1
. ) (.
congenital ) (.
.2
:
) .(intermittent claudication -
. ) (
) (IV foramina .
DD- spinal stenosis .vascular claudication:
.
.
) (.
.
, '.
.
:Spondylolysthesis
" , .
) L4-L5 L5-S1 (.
:" ,facet .
.

"
" . 10 .
, , .
- Lump line C1 .L5-S1
Scoliosis 10 . .
45 " , " .
" , " .
: , .
: , .
.
)- " , ,( ,
) , ,(MMC .
.
:

Cobb angel ) 10-5 ( .

) (.

32


2 ,
.
.
Moe & Nash classification : pedicles -
.AP pedicles- ,
) pedicle (.
Risser sign .iliac crest- ,

.

:
:
80%.

:CHIPs -

,Compensatory LLD
o
- Hysterical
o
- Irritable ) !( , ,
o
Postural . .
o
:
Infantile 0 3

Juvenile 10-3

Adolescent .20-10

Adult .20 .

Idiopathic scoliosis - Adolescent type

.20-10 ) 2-3%( . . .
" ) ( . )
(.
4 ," apex- :
.
.1
.
.2
double curve ).($
.3
- !
.4
:

) (

" .

:
) 25-( .

45-30 5 .

33


40-

) ( . ,
] . - ) TLSO ( , )
( , ) ( [.
) (traction " .

:
50 ) (

40 .

, balanced spine
.
:

:
" , .
.1
.
.2
)( " bne graft .
.3
" ." )
( . " .
.100%
:
" )

"( . .1:1000 " spinal cord monitoring"

wake up test .
Pseudoarthrosis , ,

.
deep wound infection 1%.

- .

:Infantile type Idiopathic Scoliosis

3-0 . . )
.(adolescent type- !
:
20

30

40 . "

) ( , " "
, . 10
) ( crunk shaft phenomena

.
:Juvenile type Idiopathic scoliosis
10-4 . 20% . = 70% .
) ( .
.MRI
34


:
.

, .

:Congenital Scoliosis
hemivertebra .

) ,block vertebrae

( bony block
.
Mixed type .

. -
, " .
:
mixed .

: , ) ( ,
:
fusion ".

Posterior spinal fusion .

hemivertebrae 0 .

:Neuromuscular Scoliosis

,UMN CP
o
LMN "
o
-
o

" .100% , , ,.
:
long C type " ) .

(.
.

, , .

" ) , ( ,

.
:
75% . = .
) ( . .idiopathic scoliosis
:Pathologic Kyphosis
Postural kyphosis . . 75.
Scheuermamm`s
35


." . ) .(0.5-8%
,10 ) (.
,aseptic necrosis ,.
) 50( , , ) 75(.

"
,thoracolumbar junction .T11-L2 : "
)( " )( 50% . " 40% ,
.(spinal cord injury (SCI
" " ) (.
" .
fusion.decompression-
":
Axial compression T12

. " .
burst fracture . retropultion
" .
Flexion .

posterior wall- .
Lateral compression

Flexion-rotation

Shear

Flexion-distruction . )(trunk

" .distruction .
Extension

(Bulbo-Cavernosus Reflex (BCR

, . -
LMN- L4 , .
BCR " ) ( , !!! spinal shock
:Spinal shock " , complete cord dysfunction ,
, . 48-24 ) ( .
.
:Neurogenic shock ,
cardiac output-" .
. " . "
.
# BCR
") . (.
:
.10T
: ," , .
) .CT MRI 40(.
Complete spinal cord injury
36


.
.
.
:
contusion-.compression-
. / .
6 . .
" . 30"/"
, 5.4mg/kg/hr 23 .
, ".
2-1 " )
C3 .(C4-" .
" :
A .
B .
C .
D .
E .
, A-C .
,(ASIA (american spinalcord injury association , .
:Conus Medullaris syndrome
spinal shock .BCR .T12-L1
.
:Denis Spinal Stability classification -
" 3-:
2/3 ALL +

1/3 + PLL +

spinous process -.facets-

" , compression .(distraction (burst-

,
.
Compression fracture
.
50% .
. , .
Burst fracture
, .
.
- .burst
? burst
40-50% .

.50% complete cord injury

" . ".
.incomplete

37


20-25% .
".
: , .
] ??? [
:Flexion-Distraction injury
.seat-belt type injury
. ,
spinous process-.
ALL- ) .(compression pressure
.
) (10% distraction- " ,
.
, , . ) Chance
( . .
Fracture dislocation , .
:
Allen Fergusson classification
Compression

Flexion

Compression-flexion .

Flexion, distraction, rotation .chance .

Torsion .

Tension & Torsion

- Vertiacl compression .A , . .burst .

.
) AO :(Gertzbein
.A Compression . .
.B - Distraction / Burst 50% ..
.C - Flexion, Distraction, Rotation .
" .
":
ABC

CT-

- ) ,(IVC filter ,

:
TLSO .thoraco lumbo sacral orthosis .T7-
OCTO .occipito cervical thoraco orthosis .C7
. B
" .
:
72-48 .
.
):(early decompression
38



.1
" .
.2
) (
.

"
:

- -.

80% " 3 . -
,Urosepsis , , .
".
:
.year/29-50:100,000 39.8 , ) .(82% :",
, , ,.
:
(Spinal Cord Injury (SCI
" ) .(C , ,
, .
".
.
C4 .C4
. , L1
.L3-L4
".
3 . ) 4 .(5
outcome- .
" .

" 5 .
:
= C5
.1
C6
.2
C7
.3
C8
.4
)( T1
.5
:
L2
.1
L3
.2
39


Dorsiflexion L4
.3
Extensor halluxis longus L5
.4
plantar flexion L5
.5
" 100 ) 20 * .(5

." 56 112
0 ; 1 2 ,
-
T4
T10
L1
:ASIA impairment scale
A , .
S4-S5 " .
B
S4-S5
C ,
.3-
D ,
.3
E .
# ".
":
:
ABC

"

, .

:

.1

.2

.3
)(ADL
.4
":

GI

DVTPE-

Autonomic dysreflexia

heterotopic ossification

40


syringomyalia

neurogenic bladder & bowel

:
.
= psy ,S2-S4 ,detrusos- .
sy T11-L2 )(.
sy- psy- .
psy- sy- .
hyper-reflexia .bladder dysinerrgia
150" .
, reflux- .
)( psy- .
.
, .
.
: 4.
" .
- -
.
"
) (.
, ,
. 100 -" " US
3- . .UTI
: paralytic ileus -
"
. " , ' .
"
.
.
"
' .
:
1 " . ,2
) . 6-4 , 8-6
(.
.
" .
, .
.
,malleoli ,.
? ! - .
)( , , " ,
.

41


,
.
:Heterotopic Ossification
, ) (.
, , ) (.
: , , ,ROM.
: ,alkaline phosphatase .
: , , DVT .
.
.
:Autonomic Dysreflexia
" T6 . !
) ,
( splanchnic sympathetic autflow T5-L5
".
" , , , ,.
.
, , )
( ) (.
: . ,
.
"
) .(spinal anasthesia " .
:Syringomyelia
.
" ) (cavity .
: , , ,
MRI, CT- " . .
" , .
:
.entrapement ,

, .

, .
:
.
.
, , .
.
,.
":
:C1-C4
.

42


, .
.
.
:C5
.
elbow flexion )(
.
elbow flexion , .
:C6
extension .
, .
.
,.
:C7
.
,grooming , , .
, .
.
:C8
.
)
(.
. .
:
.
, ,
. .
) ( .
:
.
. .
.
= .ankle foot orthosis .
:
" . ,
33 . 13.
" .
:
:
,

43

-.

, ,
.
.
:

.
:
)
( .
) ACh" , .(NE
, , S2-S4" ,pudendal- .psy
" . "
T8-T12 , .
, .
" .
:
. .

,papaverine ,E.
o
Myus PGE .urethra-"
o
.
PGE5 ACh 4 ."
o
,dilated cardiomyopathy .
, 20- )
o
( . .
surrogate therapy

" , ) 4 ,
( , , corpus cavernosus - )
,peronie (.
:
) T6 (.
" .vibratoty penile ,
stimulation- .
,
'.
# .
/ .
.

44

,
3 , ,
- - . .Y
, . .
) -( " , "
) (.
15- ,
- . .
:
: .
.1
. .
:rotator cuff- .AC ligaments -
.2
:
)(look
.1
) (feel
.2
) (move
.3
- . , ,
.a
) ( . ,screening -
.
3 .

.b
. 6
)( , )( , )( , ) ( ,
) (.
- : , , ,.
.4
:
.5
:
.a

.i
sulcus sign
.ii
apperehension test
.iii
: rotator cuff
.b
painfull arch
.i
) (.
.ii
Impingement signs and test "
.iii
0bursa
biceps-
.c
Speed`s test
.i
Yergason`s test
.ii

II
Basic shoulder Anatomy
: , ,.

45


,Biceps ,Bicipital Groove -
.pectoralis minor
.radial tuberosity - , .
) rottator cuff (SITS.
, , greater tuberosity .
.
: . , .
, , .
, . ) . ,
. ( .
Sulcus sign , . , .
rotator cuff gap , ' .'
.
AC Dissociation , .
: , Spine , , .
, ) Subacromial Bursitis Rotator Cuff
.( Tear , , , .
: X X , , .
.FROM , -
, ,
. ,
, ,
.
.frozen shoulder . SITS .
, . , ,MUA Manipulation Under Anesthesia
.
Axillary Nerve & Vessels
.
:
Impingement sign , .Near Test ,
, Impingement Test.
SITS .painful arch 45-90.
Apprehension test )
( ) ,
( . , ,
.
)
(.
) ( .
Winding scapula . Subscapularis Serratus
. Anterior
, . Sulcus Sign .
Biceps Tendinitis Speed , ,
Yergasons Test . ,
Long Head Of Biceps Bicipital Groove.

46


AP ,.Lat ,Glenoid
) ( . , ,
-Transscapular Lateral View . Y
) ( ) ,Y ,
Spine (.

. "
)(.
) rotator cuff- (SITS
Supra spinatous
Infra spinatous
Teres minor
Sub-scapular
external rotation .internal rotation
, " .C3-C4
. .
.
:Clavicle -
.S " 2
sterno-clavicularclaviculo-acromial-
= ; 1 = ; 2 = .3
)" ( , .
)" ( . " "
, .
" ,
.
.
.
.
: . ,
. , ,.
6.
, .
:
.
.
4 ) 3 (greater & lesser tuberosity ,
AVN ) ( . ,
.
.
.compression
:
AC joint- .1
47


.2
Dislocation 3.
90% " ) ( ."
.
.
) .(5
# .
.
:Rotator Cuff -
- - ) (.
rotator cuff- .
Insertion tear Substance tear .
Impingement sign . internal rotation
. .
" .US .

.
.
) .(tendinosis"
.
:
)
(.
) rotator cuff- ( .
:
,
) (.
US ,rotator cuff- )
US( . US- )
" ( . US- .
MRI ) , 2000 "( .
.
US ? MRI
: ,40 !
, .
:
rotator cuff- .
,
.
.
) ( .
. .
?
60-

3
) (.
48


:
95% .
5% ) , (.
2 : ) , (
) ( . .
0.5% .
: . )
, (.
" ) , (.
" ) (

) ( .
" .
" .aprehenssion test external rotation
90 . .
sulcus sign- ) ( .
hyper-luxity " .
.
Torn Labrium .
) ( .
.
" , .
:Calcific Tendonitis
, ) .(70 30-40%
, .
.
:
US , 35 . 75%-.
Shock wave therapy . 75%- .
Needling 75% .
.
, . .
.sinovitis .
) delto-pectoral groove- .(coracoid-
.
, .
:Stiff Shoulder
- ) ( .
) ( ) ( . "
osteoarthrosis . .
.
adherance - .rotator cuff-
.
. .
Idiopathic frozen shoulder

49


, ) IDDM 36% " ,
NIDDM ,(20% , , .
: freezing .
. " ) ( .
.
, .
.
: " .

- ,
. .20
. .
. 250
".
# .
:
:
Antalgic . . - .
Spastic .scissoring .
adductors- rotators- .
Trandelenburg , ) abductors-,
, ( . DDH false acetabulum
. .
# .
:
, , ,open sinus drainage ,.
Pelvic obliquity
ASIS - .medial maleolus- ,
.medial maleolus -
.
" .
Lumbar hyperlordosis "
" , .
Assymetric gluteal folds , " .US
:
:

ASIS ASIS- .L4-L5

o
iliac crest
o
greater trochanter .
o
pubic tubercle
o
:

50


PSIS " .skin dimples
o
ischial tuberosity
o
sacro-iliac spine 1" PSIS-
o
greater trochanter
o
3 , .
3 ." .
, .
" , .
:
.inguinal ligament, adductor magnus, sartorius

, .
4 . .
.iliopsoas, adductors, abductors

greater trochanter & trochanteric bursa bursitis

" .NSAIDs
sciatic nerve

: circumflex arteries -
.
.
. aseptic necrosis ,
. ,

. ) hemi-arthroplasty ,total hip replacement
(.

. 30%- . 15-10
) (.
: . lumbar plexus - -
.drop foot )(
, .
. -
NSAIDs .
. .
: .
20 .
).(straight leg testing
:
100 ) 90 (

20-10.

50-45

30-20

external rotation 90- .

internal rotation" .

51


. , , quad-

.hamstrings
. L4-L5 ,

L5-S1 .
.

:
, . .

(Limb Length discrapency (LLD . -

.apperant .
Ober test liotibial band-

.
, .
.
Thomas test

. .

. .
" .
FABER test .sacroiliac joint

.
- , .
CDH .

II
. .
: , , ,Antalgic, Spastic , , . ,Pelvic Obliquity
, , ' ,Fixed Flexion Deformity , , ,
.
,
non displaced , .Garden

.
: ,ASIS Iliac Crest, PSIS, Ischial ,
,Tuberosty SI ,PSIS .
, .
.Psoas Bursitis, Adductor Tendinitis
OA , .
" , .trochanteric bursitis
.
.
52


tuberosity .
: , 20-30 .
) ( ) log rolling ( .
. .Log Rolling
Snapping Psoas Tendon .
, :
swing . .
Fixed flexion deformity . ) ( ,

. OA - CP .
) ( .
.Ruptured Achilles Tendon
- Iliotibial Tract Ober ,
tract .
Faber .sacro iliac joint 4
) ( . FABER = flexion, abduction and external .
.rotation
DDH .Barlow & Ortholani
.false ASIS .true
.pelvic obliquity -
45 .
) ( . , .C7 S1

. .
. , ,
- ) - , (.
.
. 3
.subcapital, midcervical, base of neck - -
.
)( .low energy
- ) ( .
- .
] high energy [
.
) , ( ,
. 1 )( -
.

2 .
:
" .
.

53


.
.
.
:
- ) ( ,
" . , .
, " .
. -
) AVN
(.
:
100 , . 20-
.
) subcapital, midcervical (base of neck
" :
impacted valgus , .
.1
non displaced , .
.2
partially displaced
.3
completely displaced .
.4
) ,(2+1 ).(4+3
:
, .FN

FN

MRI .

. .
) 8 ( -.
, .
.AVN
,
, . ,
.
, , AVN
.
- hemi arthroplasty , .
garden ,
.
. -
.
: , , ,
15-10 ) (.
) Unipolar prothesis (Austin Moore .
. " . ,
.
Bipolar prothesis ,
. 2 ,
. -
54


. total hip replacement -
. .
) (.
:Inter-Trochanteric Fractures
" , .
" :Evans
) A :(B- - .
) C :(D- .
) Reverse Obliquity (E - . .
, .
:
" " .(dynamic compression hip screw (DHS -
, .
" " " .
reverse obliquity .
) (IMN, intra medullary nail load shearing
)" ( . .
PCCP ,DHS- 2 .
,percutaneous" 2 2" . .

PerthesSCFE-
:Perthes
AVN .
AVN -
.
:
. ,
.1
)
) . (.
(resorption (fraagmentation .
.2
. )( .
reossification .
.3
.
remodelling " .
.4
, .
:
) 8-4 ,13-2 (.
.1:1500
) 4( .
.
10-15%"
, !
:
55


.
.10
Synovitis
4 :DD- ,transiant ,
synovitis .JRA US -
.AVN ,
transiant synovitis
.
:

" .
, .
:

o

o
) (
o
) ,
o
(.

:


MRI
" :Pillar-Herring
)( .
A . .
B .50% " .
C .50% , )
( OA . .
,
. , 3 .
Salter Thompson
:
- A subchondral .50%-
- B subchondral .50%-
:Catterall . , 4-:
.I 25%
.II 50%
75%
.III
75%
.IV
:Head at Risk signs
.
.

Gage`s sign "" .
56



physis-

2 . .
,self limitted 80% . 20%
. OA , )
(.
Outcome :
.
.1
.
.2
, OA .20-18
.3
incongrous congruency ,
.4
.
. OA .40
) . incongrous congruency (.
:
.

containment . .

?
50% )(Catrall 3-4

2 .head at risk

Salter B . C .
:containment
.

.impigement

:containment
containment .internal rotation-
Brace , .

,
. , .
.
(Varus Dilatation Osteotomy (VDO

. .
, .AVN-
Inominate (pelvic) osteotomy

. .
# ) .(35-29
Arthrodiasthasis .
.
, .
Stalberg :

57


1 ,2 . .OA
3 ,4 . OA .
5 . OA .
." "
, , .
woven bone ) (.
.
.
] :SCFE [
Slipped Capital Femoral Epiphysis .
SCFE SCFE ,
.
:
Klein`s line ,
. .slipped capita
Metaphyseal blanch sign
.
Scham`s sign
. SCFE ".
Acute 3- . .

:
, ) 20
20" (.
, "- " . ,
) , (.
? , .
? .
? " .
L3-L4 .

:
:
, .
Valgus- 7 .
Recurvatum , .
) (.
.pre-patellar bursitis .
.
quadriceps- , .
.
58


:
:
: .recurvatum
o
, .
o . 140.
.
: )( .
) 15-10"( .
) (.
.
) (SAG .PCL
:
) ( )
( ) , (.
? " .medial meniscus
? .
. .
? )
(hemarthrosis , - )
( . 12-8 anterior cruciate-
.(ligament (ACL .
. 90%- .ACL
.
? ,ACL

.
. 75 .
. .
ACL- .osteoarthritis
:
ACL
" " - 20
.1
. .
. .
" " 90- ,
.2
, . ,
) ( .
(Pivot shift (PS 30-0 ,"
.3
. ACL -
. , . : ,
. ,
.ACL-
PCL
.
PCL.

59


Active quadriceps test quad- -
.1
PCL ) (.
Reversed pivot shift external rotation ,
.2
. .
:Meniscus-
.
.
.1
external rotation , .
.
.internal rotation
:Aplley .
.2
. .
.
.
:Patelofemoral
) (anterior knee pain .
malelignment .
- .
.quad- .

II
: , ) .
( , , , ,
, , ) ,( Diurnal / Activity Variation'.
: , , ,Fixed Flexion Deformity , , ,
.
: , tibial tuberosity , ..patellar lig
, . .
" .Superficial and Deep Peroneal Nerves
, ) " ( ,
,RA , Gutters .
, , Patellar Tap Sign / Patellar
.Ballottment
ROM : .
, ,
, .

:
ACL Lachman 30 - .
. . Anterior Drawer Sign ,
Hamstrings , .
, Pos. Sag. Pivot shift , ,internal rotation
, . ACL , .
PCL posterior sag - . 45 ,
Quad. Active test . ,Quadriceps Femoris
60


, , . .Posterior Drawer Sign
, Reversed Pivot Shift , .
Collateral Ligaments )( )
( ) ( ) (.
: . 90 .ankle
, . , .,
.
Patellar Grinding Test ,
. ," .

,
, . ,
.
, .
, - .
, .
" - ,
.
.

:
. "
. - " .
" ) ( .
:
. .
, "
. )
( . .
.
. )
(.
.
,
. .
: .
quadriceps- " quadriceps ligament pattela- patellar
.tendon " ) ( ."
,
- . .
Osgood-Schlatter ,tibial tuberosity -
) (14-12 .
.

61


. quadriceps-
) ( .
, .
.
,
, hamstrings-- .
. . ,
, , .
.
: .
,midstance , )( . toe off
) heel strike -( . ,
,
.
, -
. , ,
. ,
.

:
.1 :
: .
- - )

< ( . ) ( ,
. )
genuvarum .(genuvalgus .
. .

(OCD (osteo-chondritis oseans-

) (.
Traction epiphysaitis .

,sliped capital femoral epiphysis

o
.
.
L3-L4 . scheurman
o
.
: osteogenic

sarcoma ,
) ( . , "
) ( . ,
. "
.
. " "
, ) (.
:
, .

62

- ) STD ,( .

) . " ,
,
(.
,RA, IBD .

,DJD (degenerative joint disease (osteoarthritis

.
(AVN (avascular necrosis AVN .

(
.degenerative meniscus tear

.2 :
Feels wrong

"" ) (giving away . -

,quadriceps- .pre-patellar bursitiss ,

:Looks wrong

:Moves wrong

."
o
. )
( . " .
.
) (.
o
) , (.

.3 :
? .
, , .
) , (
.
.
:ACL- . .
: ,Hemarthrosis , .
.4 :

63

, .
o
.
o
) (
o
)( ,UTI , , )

( . .
- Pain severity score .

, .10-1
?

. .
patellar tendinitis (1) : - ;
) infra-patellar tendinitis (2 ; ) Housmade knee (3 pre-patellar
.bursisit .
; lateral colateral ligament ; (2) medial colateral ligament (1) :
) (3 .
: ) (reflex sympathetic dystrophy .

, , ,.
, ,.
,.hyperextension, fixed flexion ,
Alignmnet
.
o
Q angle quadriceps- . 15
o
.
)
o
(.

o
reflex sympathetic dystrophy
o
, .
:

synovitis "" )
o
.(patellar tap sign
.RA
effusion .
o

o
:" .

. )(meniscal cyst
, .
.baker`s cyst

,

64

) ,aplley test ( .
:
) patellar grinding test ,(
o
patellar aprehension test
o
) J sign- (.
o
/
- , .Pivot shift, quadriceps active test ,

:
4 :
AP .1
.2
skyline .3 -.
tunnel - AP .4 .
,CT ,MRI ,.
# .

.
adduction
.1
plantar felexion
.2
inversion
.3
.
abduction
.1
dorsi flexion
.2
eversion
.3
:Gait cycle
heel strike .1
) " , ( . .swinging
- (Full weight bearing (FWB .2
. 1 2- 0.6-
. , )
" " (
heel off .3 .
, .
= .
4 .
, .
" . ,
abductory twist ) 1st metatarsal- (
.
:
,padget`s disease .calcaneous-

65


"" . . .

:
.
) (.
, , ) ( . ,US- .
:
,
.1
. ,
)(.
) (post static dyskenesia
.2
, ,
, " .
) heel spur " "( .
. tuberosity- .
, .
"":
) ( , )(.
. .plantar fascia-
plantar fascia- . tuberosity-
. insertion -
. ) (fasciaitis . .
,bursa .
.bursitis
posterior tibial nerve-
.nerve entrapement
fascitis & bursitis & nerve entrapement . ?
,
. .
"":
. .plantar fascia-
." .
" NSAIDs .
60% .NSAIDs-
)( .
. 3 )
(.
95% .

66


- ."
.
, .
:
, inversion

) (

- Rocker , .

, .

:Hallux Valgus
. . ,
.
: ) metatarsus primum varum (
) abductor hallucis- ( .
. EHL - FHL- . overriding toe
.
.
, , .
) (modified McBride ,
insertion- abductor- )( .
) ( . 15%-
.
. ,
. " .
:Stiff Big Toe Joint
MPJ- . .
, .toe off - hallux
.limitous .hallux rigidous
:Stone procedure . 3-2
. , , )
(.
:Hammer toe
.
. .
.high toe box shoe
) ( .
, ,
, . .PIP fusion
:Metatarsalgia
, .
, ,.

67


: , ) ,(pes cavus , , ,
, , , ) ,
( , ) AVN ,
, ,30- (.
,.
: , web- . -
web . )
( . . .
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68


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69


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70


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71


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72

.1
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73

.Ischiopubic Ramus ,
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.
Pubis Corona Mortis External Iliac
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, ) ,Secondary Intention
74

Flap ( . ,
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Amputation 4. Transmetatarsal 5. Toe Amputaton 6. Ray Amputation
.

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: 100"
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, Radial
,.N ,.Pronator Teres Median N ,Medial Epicondyle
.Anconeus Ulnar N.. 4 ..CTS Median N., Guyons Canal Ulnar N -

75

Carpal Tunnel Syndrome CT ,.Trans. Carpal Lig ,

, . ? ) ( ,.Median N
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.
THR ,
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Lerisches Triad , , .
,Common Iliac Artery " , Saddle Thrombus
.

76