< Back Adolescent Idiopathic Scoliosis Previous Next

< Back Scaphoid Fractures scaphoid-fractures Previous Next

< Back Orthoses Spot Knowledge Orthoses Purpose: Support function, control deformity, reduce pain Types: Static: Stabilize joint Dynamic: Facilitate movement Design principles: Simplicity, lightness, durability, aesthetics; consider rigidity/flexibility and tissue tolerance Orthoses Orthoses are devices used to provide functional support, control deformities, and reduce pain in joint, muscle, or nervous system disorders. Static types stabilize the joint, whereas dynamic types facilitate movement. In their design, simplicity, lightness, durability, and aesthetics are important. When prescribing orthoses, considerations include the three-point pressure system, static or dynamic stabilization, tissue tolerance, and whether the deformity is rigid or flexible. Foot orthoses include shoes as the basic form, providing accommodation for deformities or support for walking. Insole orthoses , such as heel cups, UCBL, or Arizona orthoses, are particularly useful in flexible pes planus . Medial and lateral wedges influence varus-valgus loading at the knee, and rocker-bottom shoes facilitate weight transfer during gait. Ankle-foot orthoses (AFOs) are used in cases of ankle muscle weakness or overactivity. The ankle angle indirectly affects knee stability. Non-articulated AFOs are rigid and aesthetically acceptable, creating a knee flexion moment during the early stance phase. Articulated AFOs allow a more natural gait pattern while providing dorsiflexion assistance and motion-limiting options. Different joint-locking mechanisms are applied in the presence of knee flexion contracture or quadriceps weakness . Supramalleolar orthoses (SMO) are suitable for mild deformities. Knee-ankle-foot orthoses (KAFOs) are indicated in quadriceps paralysis, knee instability, or genu varum/valgum. They can be constructed from metal or plastic. The Scott-Craig orthosis allows paraplegic patients to stand and walk. Knee joints in KAFOs may be single-axis, polycentric, or posterior offset, and locking mechanisms such as drop ring, pawl lock, or adjustable locks provide additional stability. Knee orthoses are employed for patellofemoral disorders, genu recurvatum, or sports injuries. Devices such as infrapatellar straps or the Swedish knee cage provide sagittal plane control, and polycentric joints mimic natural knee motion. Hip-knee-ankle-foot orthoses (HKAFOs) consist of a metal frame with mechanical hip and knee joints. These orthoses are used in hip instability, especially after total hip arthroplasty , to maintain approximately 15° abduction and limited flexion. Single or double-axis hip joints provide motion control, but the device increases energy expenditure and may be challenging to use. Trunk-hip-knee-ankle-foot orthoses (THKAFOs) are used in paraplegic patients to control the trunk and align the spine. Walking with a reciprocating gait orthosis is achieved through weight transfer. Lower Extremity Prostheses Lower extremity prostheses aim to provide comfort, function, lightness, and aesthetic integration. Modern developments include energy-storing feet, computer-assisted fabrication, and microprocessor-controlled knees . The main components of a prosthesis include the socket , which interfaces with the residual limb, the suspension system, the knee joint, the pylon, and the terminal device. Sockets are generally patellar tendon-bearing , and suspensions may be either classic suction or silicone-based. Microprocessor-controlled knees adjust to walking speed and provide control during ramp or stair descent, although they do not actively extend the knee. The foot component provides stability, shock absorption, compensation for muscle function, and aesthetics. The SACH foot is a low-cost option, whereas energy-storing dynamic response feet are suitable for running and sports. Functional levels are classified according to mobility, ranging from Level 1, which involves transfers and walking on flat surfaces, to Level 4, which includes high-energy activities. Rehabilitation training includes donning and doffing the prosthesis, daily skin inspection, and performing safe transfers. Complications may include choke syndrome, dermatologic reactions, residual limb pain, and gait difficulties. Energy expenditure increases by 10–20% in transtibial amputees and 60–70% in transfemoral amputees. Upper Extremity Prostheses The selection of upper extremity prostheses depends on the level of amputation, expected function, aesthetic requirements, and cost. Body-powered prostheses are durable, low-cost, and provide good sensory feedback, but they are less aesthetically appealing. Myoelectric prostheses detect muscle activity through electrodes, offering superior aesthetics, though they tend to be heavier and more expensive. Terminal devices may be passive, focusing on appearance, or active, offering functional grasp such as hooks or hand types. Grasping mechanisms include pinch, tripod, key, spherical, and power grasps. Myoelectric hands provide stronger grip but are sensitive to environmental conditions. Joint units include quick-change wrists, locked or flexion wrists, and rigid or flexible elbow hinges. Shoulder-level amputations have limited function, and some patients may prefer prostheses solely for aesthetic purposes. Complications of upper limb prostheses include contact dermatitis, excessive sweating, pain due to poorly fitting sockets, and neuroma formation. References 1. Nouri A, Ensafi V, Sigari E, Maalek SS. Materials and manufacturing for ankle–foot orthoses: A review. Advanced Engineering Materials . 2023;25(7):2300238. doi:10.1002/adem.202300238 2. Gunaratne PN, Tillekeratne K, Kottegoda NJ, Rathnayake L, Jayasekara R. Developments in hardware systems of active ankle orthoses. Sensors (Basel) . 2024;24(24):8153. doi:10.3390/s24248153 Previous Next

< Back Dr. İlkay TOSUN What the Pathologist Needs Accurate pathological diagnosis is the cornerstone of musculoskeletal tumor management. Even the most advanced imaging cannot replace high-quality, representative tissue and precise clinical context. The pathologist’s ability to deliver an accurate diagnosis depends not only on tissue quality but also on the quality of information provided by the surgeon. Effective communication between the surgical, radiologic, and pathology teams is therefore essential. Essential Clinical Information When submitting a biopsy or resection specimen, the following details must be clearly documented on the pathology request form and discussed, ideally in a multidisciplinary setting: Patient demographics: Age, sex, and relevant medical history (especially prior malignancy or radiation). Clinical presentation: Duration of symptoms, pain, swelling, growth rate, trauma history. Anatomical location: Specific bone, side (right/left), and compartment (intramedullary, cortical, soft-tissue). Radiologic findings: Summary of MRI, CT, and X-ray features (matrix pattern, cortical involvement, soft-tissue extension). Suspected diagnosis or differential diagnosis: To guide appropriate sampling and staining. Previous procedures: Any prior biopsy, curettage, or surgery must be mentioned, as they may alter histologic appearance. Tissue Handling and Labelling Mark orientation: Use sutures or ink to identify margins and anatomical orientation. Avoid crush or cautery artifact: Handle tissue gently to preserve architecture. Separate samples: If both soft-tissue and bone are present, send them in separate containers. Include imaging correlation: Providing printed or digital images helps the pathologist select representative areas for sectioning. Communication During Intraoperative Consultation In frozen-section or intraoperative evaluation, the pathologist must be informed of: The surgical goal (diagnosis confirmation vs. margin assessment). The area of interest (solid vs. necrotic, viable vs. cystic). Whether margin evaluation is required, and from which site. Surgeons should ensure timely specimen delivery to prevent desiccation or thermal artifact. The pathologist’s main intraoperative contribution is to confirm tissue adequacy and margin status , rather than to provide an immediate tumor type. Accurate diagnosis relies on a combination of clinical, radiologic, and histologic data — emphasizing the importance of multidisciplinary tumor board discussions. Frozen Section Limitations Frozen section (intraoperative consultation) is not suitable for diagnosing bone and soft-tissue tumors. Soft-tissue tumors are inherently heterogeneous , and frozen sections may not reflect the entire lesion. Bone tumors require decalcification for accurate evaluation, which is a time-dependent process and cannot be performed during frozen examination. Therefore, definitive diagnosis should not be expected from frozen sections in musculoskeletal oncology. However, frozen sections may be useful for assessing surgical margins , especially in wide resections or recurrent cases. Sampling and Biopsy Considerations Small or limited biopsies (e.g., tru-cut or core biopsies ) may not always provide a definitive diagnosis because large tumors are often heterogeneous. Extensive sampling is essential — ideally at least one tissue block per centimetre of tumor diameter — to capture representative areas, including viable, necrotic, and atypical regions. Close coordination between the surgeon and pathologist ensures correct orientation, adequate fixation, and avoidance of crush artefacts. Common Challenges Non-representative sampling: Necrotic or hemorrhagic areas yield non-diagnostic results. Lack of clinical context: Leads to misclassification (e.g., distinguishing infection from neoplasm). Improper fixation: Inadequate formalin volume (should be 10× tissue volume) affects morphology. Delayed transport: Causes autolysis and RNA degradation, limiting molecular studies. Key Points The pathologist needs context as much as tissue — imaging findings, clinical suspicion, and surgical notes are indispensable. Always coordinate with pathology before biopsy for specimen handling and ancillary test planning. Representative, well-oriented, and fresh tissue improves diagnostic accuracy. Successful diagnosis in MSK oncology is a team process , not a laboratory event. References Mankin HJ, Hornicek FJ. Diagnosis, Classification, and Management of Bone Tumors: The Importance of Multidisciplinary Communication. J Am Acad Orthop Surg. 2017;25(8):540–551. Bridge JA, et al. Molecular Diagnostics of Bone and Soft Tissue Tumors: Evolving Role in Classification and Therapeutics. Mod Pathol. 2020;33(S1):27–44. O’Donnell P, Tirabosco R, Saifuddin A. What the Pathologist Needs from the Radiologist in Bone Tumour Diagnosis. Skeletal Radiol. 2018;47(10):1321–1332. Fletcher CDM, et al. WHO Classification of Soft Tissue and Bone Tumours, 5th Edition. IARC Press, 2020. Previous Next

< Back Talus C A talus Previous Next

< Back Leg Length Discrepancy in THA Previous Next

Core Orthopedic Topics Key points about the subject, serving as a guide for orthopedic doctors. Basic Science Trauma Spine Shoulder & Elbow Knee & Sports Deformity Correction Pediatrics Arthroplasty Orthoplastic Approach Hand Foot & Ankle Oncologic Orthopaedics Oncologic Orthopaedics

< Back DISH (Diffuse Idiopathic Skeletal Hyperostosis) Previous Next

< Back Alper DUNKI Professionalism and Ethical Principles Spot Knowledge Coagulation Basics Intrinsic pathway (XII → XIIa): PTT Extrinsic pathway (tissue factor): PT Fibrinolysis: Plasmin breaks down fibrin Tranexamic acid: Antifibrinolytic, reduces blood loss in orthopaedics Professionalism and Ethical Principles In modern medicine, professionalism is based on updated versions of the Hippocratic Oath . The principle of “first, do no harm” requires the physician to act carefully in surgical, pharmacological, or diagnostic decisions . The physician must prioritize the patient’s benefit in all situations. Confidentiality, accurate record-keeping, respect for patient privacy, and informed consent are fundamental components of modern professionalism. Informed Consent Consent is based on an individual’s right to autonomous decision-making . The patient must be provided with sufficient information, including risks and alternatives , explained in a clear, non-technical language . For most procedures, verbal explanation is sufficient; however, for invasive procedures , written consent is essential. True informed consent requires adequate information , the patient’s understanding , and voluntariness . The patient has the right to make their own decisions, even if they are contrary to the physician’s recommendation. Complications and Peer Review Surgical complications are inevitable but should be rare . Honest disclosure of errors to patients or their families reduces litigation risk . The possibility of complications must be discussed during the consent process . Peer review is an educational process to evaluate physician errors, which should be informative and developmental rather than punitive. Industry Relations Physician–industry relationships are not inherently negative; however, financial interests may increase bias risk . Research contracts between academic institutions and companies generally safeguard publication and intellectual property rights . NIH projects require declaration of financial interests. Since 2013, the Sunshine Act mandates public disclosure of all payments made to physicians. Ethics Committees (IRB) Research involving human subjects is evaluated by committees for scientific validity and ethical standards . In the U.S., the Common Rule and FDA regulations apply. The Belmont Report codifies the principles of respect, beneficence, and justice . All studies involving human subjects must be approved by an institutional review board (IRB) . Cultural Competency Medical decisions are influenced by cultural values . Physicians should respect diverse cultures and help patients make informed decisions . In cases of language barriers , a professional interpreter should be used. Awareness of the power imbalance between physician and patient is essential to ensure voluntary consent . Elder and Child Abuse Physicians are obligated to report suspected abuse to social services. Legal protections cover such reports; malicious reporting carries liability. Failure to report is considered neglect . End-of-Life Decisions In most states, advance directives (living wills) are recognized. These documents indicate the patient’s treatment preferences if they lose consciousness. Their legal binding is limited, and unforeseen clinical scenarios may lead to discussion. Appointment of a proxy decision-maker is important. Care of Uninsured Patients Physicians are not obligated to provide care to uninsured patients; however, emergency departments must provide emergency care under EMTALA . For patients unable to pay, discharge planning must be careful, and referral to appropriate institutions should be arranged. Treatment should continue until a new physician is available. Sports Medicine Issues Team physicians may face conflicts of interest between player and club . Confidentiality rules may be unclear; since HIPAA may not apply, professional ethics become paramount. Players must make decisions with awareness of risks and have the right to a second opinion . Return-to-play decisions , especially after head trauma , should be made with caution. References 1. Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract . 2021;30(1):17-28. doi:10.1159/000509119 2. Desai MK, Dilipkumar J. Medical professionalism and ethics: an overview. J Med Ethical Hist J . 2022; Previous Next

Hand General Principles Hand Anatomy & Biomechanics Tendon Zones & Repair Principles Nerve Anatomy (Median, Ulnar, Radial) Vascular Supply of the Hand Physical Examination & Special Tests Fractures & Injuries Phalangeal Fractures Metacarpal Fractures Thumb Injuries (UCL, Bennett, Rolando) Scaphoid Fractures Perilunate & Lunate Dislocations Carpal Fractures Distal Radius & Ulna Fractures (Wrist) Tendon, Nerve & Ligament Injuries Flexor Tendon Injuries Extensor Tendon Injuries Mallet Finger, Boutonnière Deformity Nerve Injuries (Median, Ulnar, Radial) Ligament Injuries Special Considerations Complex Regional Pain Syndrome (CRPS) Congenital Hand Problems Dupuytren's Disease Infections Carpal Tunnel Kienböck's Disease

< Back Ankylosing Spondylitis & DISH Fractures d Previous Next