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< Back Dr. Natig VELI He graduated from Istanbul University, Istanbul Faculty of Medicine in 2008. Between 2009 and 2014, he completed his residency training in Orthopaedics and Traumatology at the same institution. Since obtaining his specialist degree, he has been actively involved in the field of orthopaedic oncology. Oncologic Orthopaedics natigvaliyev@gmail.com Previous Next

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< Back Clavicle Fractures Clavicle fractures are common shoulder injuries, especially in young active individuals, typically caused by a fall onto the shoulder or an outstretched hand. Overview 2–5% of all fractures, ~40% of shoulder girdle injuries Most common: middle third (~80%) Bimodal distribution: young active (sports, traffic) + elderly (falls) Mechanism: fall on shoulder, direct blow, FOOSH (less common) Clinical Presentation Local pain, swelling, tenderness Visible deformity or step-off in displaced cases Reduced shoulder motion due to pain Skin tenting → risk of open fracture Always check neurovascular status Imaging X-ray: AP + 15° cephalic tilt view (Zanca view) CT: distal (AC joint) or medial end (SC joint) fractures Classification Allman Classification I: Middle third (nearly %80) II: Distal third III: Medial third AO/OTA Classification (Clavicle, Distal) Type A – Nondisplaced, CC ligaments intact A1 : Extra-articular fracture A2 : Intra-articular fracture Typical management : Nonoperative Type B – Displaced, CC ligaments intact B1 : Extra-articular fracture B2 : Comminuted fracture Management : Can be treated nonoperatively or with surgery depending on symptoms and patient factors Type C – Displaced, CC ligaments disrupted C1 : Extra-articular fracture C2 : Intra-articular fracture Management : Operative fixation usually required Neer Classification (distal) : Type I Stable fracture pattern, usually managed non-operatively Fracture line lies lateral to the coracoclavicular (CC) ligaments Trapezoid and/or conoid ligament remains intact Type IIA Unstable injury, often requiring surgical fixation Fracture is medial to the CC ligaments with significant displacement of the medial fragment Conoid ligament preserved Trapezoid ligament intact Type IIB Unstable fracture, high risk of nonunion, usually surgical Fracture occurs between the CC ligaments Conoid ligament torn, trapezoid ligament intact Medial clavicle fragment displaced Type III Stable fracture, generally treated non-operatively Intra-articular extension into the acromioclavicular joint Both conoid and trapezoid ligaments intact Type IV Pediatric pattern, Salter-Harris type I physeal injury, usually stable Medial clavicle fragment displaced superiorly Periosteal sleeve avulsed from the inferior cortex Conoid and trapezoid ligaments intact Type V Unstable comminuted fracture, typically surgical Medial clavicle fragment displaced Inferior fragment remains attached to CC ligaments Conoid and trapezoid ligaments intact Robinson (Edinburgh) Classification: Considers location (medial, middle, distal), displacement, and comminution More comprehensive, useful for research/epidemiology Treatment Nonoperative Sling or figure-of-eight bandage Analgesia, early motion Indication: minimally displaced, <2 cm shortening Operative Indications Open fracture / threatened skin Neurovascular compromise 2 cm shortening or marked displacement Comminution in active/high-demand patients Symptomatic nonunion Techniques Plate fixation (superior or anteroinferior) Intramedullary devices (elastic nail, pin) for midshaft Distal: hook plate, locking plate, CC fixation Complications Nonunion (esp. distal, smokers, comminuted) Malunion (cosmetic, functional deficit) Hardware irritation, infection Rare: neurovascular injury Key Pearls Most middle-third fractures heal well nonoperatively Distal type II fractures = higher nonunion risk → surgery often indicated 2 cm shortening in young/active = consider fixation Look for associated injuries: ribs, pneumothorax, scapula clavicle-fractures Previous Next

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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 Dr.Ahmet SALDUZ Chondrosarcoma Chondrosarcoma is a malignant cartilage-forming tumor of bone that primarily affects adults and demonstrates a wide biological spectrum from indolent low-grade to highly aggressive dedifferentiated forms. It most often arises in the pelvis, ribs, and proximal long bones. The tumor typically presents with chronic pain, swelling, and functional limitation. Diagnosis relies on a combination of radiographic features — including endosteal scalloping, cortical thinning, and “rings-and-arcs” calcifications — and histologic grading. 1. Definition and General Features Chondrosarcoma is a malignant bone tumor composed of cartilage-forming cells (chondrocytes) . It primarily affects adults and older individuals , and is rare in children . The tumor typically arises in the medullary cavity (central/intramedullary) of the bone. Depending on its grade, the neoplastic cells may produce hyaline, myxoid, or fibromyxoid cartilage matrix . The disease presents a wide biological spectrum , ranging from indolent low-grade lesions to highly aggressive high-grade and dedifferentiated variants . Chondrosarcoma is resistant to chemotherapy and radiation therapy ; therefore, surgical management is the cornerstone of treatment. 2. Epidemiology and Clinical Presentation Most common between the third and seventh decades of life. Predominantly involves the axial skeleton (pelvis, ribs, sacrum) and proximal long bones (femur, humerus). Distal limb and hand/foot involvement is extremely rare. Typically presents with chronic pain , mild swelling, and functional impairment . High-grade lesions may cause severe, persistent pain , rapid growth, and occasionally pathologic fractures . Palpable masses are more common in pelvic or axial lesions . 3. Histologic Grading Grade 1 (Low-grade): Slow-growing, minimal metastatic potential (<1%). Histology shows hyaline cartilage , mild nuclear atypia, occasional binucleation. Grade 2 (Intermediate-grade): Displays increased cellularity , myxoid stroma , and nuclear pleomorphism . Locally aggressive behavior with cortical involvement. Grade 3 (High-grade): Highly pleomorphic , anaplastic cells with frequent mitoses and little to no cartilage matrix. Metastatic rate >30% 4. Variants and Subtypes Juxtacortical chondrosarcoma: Arises from the periosteal surface of the bone; may be palpable even when low-grade. Mesenchymal chondrosarcoma: Rare, high-grade tumor with a small round-cell component; highly aggressive. Clear cell chondrosarcoma: Rare, epiphyseal lesion; low-grade, often contains giant cells . Secondary chondrosarcoma: Malignant transformation from a pre-existing benign cartilage tumor (osteochondroma or enchondroma). Dedifferentiated chondrosarcoma: Low-grade tumor transforms into a high-grade sarcoma after a latent period; carries poor prognosis. 5. Imaging and Diagnostic Workup Accurate diagnosis requires clinical, radiographic, and histopathologic correlation . Plain radiographs (X-rays): First-line and most informative modality. Characteristic findings: rings-and-arcs calcification , endosteal scalloping , and cortical thinning . CT Scan: Superior for assessing cortical integrity and endosteal erosion . Helps distinguish enchondroma from low-grade chondrosarcoma. MRI: Best for evaluating marrow and soft-tissue extension . May overestimate aggressiveness due to high water content in cartilage. PET/CT: Useful for detecting recurrence or metastasis in higher-grade cases. Biopsy: Often limited by tumor heterogeneity —needle biopsy may miss high-grade areas. Final diagnosis should be based on multidisciplinary consensus. 6. Differential Diagnosis Enchondroma: Usually asymptomatic, minimal endosteal scalloping (<50% of cortical thickness). No cortical breach or soft-tissue extension. Osteosarcoma: Distinguished by presence of osteoid matrix production. Ewing sarcoma / Fibrosarcoma: More aggressive growth, round-cell morphology. 7. Treatment Algorithm A. General Principles Surgery is the mainstay of therapy. Chondrosarcoma is chemoresistant and radioresistant , except for mesenchymal or dedifferentiated subtypes. Treatment strategy depends on grade, anatomical location, and resectability . B. Grade 1 (Low-grade) Treated only if symptomatic or radiographically aggressive . Extremity lesions: Managed by intralesional curettage using high-speed burring , followed by bone graft or cement filling . Adjuvant use of phenol, cryotherapy, or thermal ablation is optional but not essential. Pelvic and axial lesions: Require wide excision due to higher recurrence and metastatic potential. Local recurrence rate: 5–15%; metastasis is extremely rare . C. Grade 2 (Intermediate-grade) Typically treated by wide or marginal excision ; intralesional curettage is insufficient. Chemotherapy: Generally ineffective; may be considered for mesenchymal variants . Local recurrence: ~15%; metastasis rate: 5–15%. Complete en bloc removal offers best oncologic outcome. D. Grade 3 and Dedifferentiated Types Treatment: Wide surgical resection (en bloc) with negative margins whenever feasible. Proton beam radiation may be used for positive or close margins , especially near vital structures. Chemotherapy: Controversial; occasionally used in mesenchymal chondrosarcoma with modest benefit. Largely ineffective in other subtypes. Local recurrence rate: ~25%; metastasis rate: >30%. Strong correlation between local recurrence and distant metastasis. 8. Prognosis and Follow-up Prognosis depends on tumor grade, location, and margin status . Axial lesions (pelvic/spinal) have worse outcomes than appendicular ones. 5-year survival rates: Grade 1–2: 70–80% Grade 3: <40% Mesenchymal: 48% Clear cell: 100% Dedifferentiated: 0% Follow-up: Every 3–6 months during the first 2 years, then annually. Chest CT scans recommended for detecting pulmonary metastasis. 9. Recent Advances and Future Directions Proton beam radiotherapy: Effective for microscopically positive margins or unresectable lesions . Targeted molecular therapies under investigation: Angiogenesis-related pathways (VEGF, HIF-1α, HDAC4, Runx2, Beclin-1) are upregulated in aggressive tumors. Isocitrate dehydrogenase (IDH1/2) mutations found in ~50% of patients; associated with abnormal DNA methylation and oncogenic transformation. IDH inhibitors and immune checkpoint therapies (anti–PD-1 agents such as pembrolizumab) show preliminary promise. Surgical innovation and improved reconstructive techniques in the pelvis and spine have significantly enhanced local control and survival. 10. Key Takeaways Chondrosarcoma is a heterogeneous, primarily surgical malignancy requiring multidisciplinary management . Accurate diagnosis depends on integrating clinical, imaging, and pathological data . Low-grade tumors can often be managed conservatively with intralesional techniques , while high-grade and axial lesions necessitate wide, sometimes radical excision . Emerging molecular and immunotherapeutic strategies represent hopeful developments for advanced or unresectable disease. References: 1. Gazendam A, Popović S, Parasu N, Ghert M. Chondrosarcoma: A Clinical Review. J Clin Med. 2023;12(7):2506. doi:10.3390/jcm12072506. 2. Kim JH, Park HK, Lee Y-J, et al. Classification of Chondrosarcoma: From Characteristic to Challenging. Int J Mol Sci. 2023;24(6):4425. doi:10.3390/ijms24064425. PMC 3. Duan H, Li J, Ma J, Chen T, Zhang H, Shang G. Global research development of chondrosarcoma from 2003 to 2022: a bibliometric analysis. Front Pharmacol. 2024;15:1431958. doi:10.3389/fphar.2024.1431958. 4. Yin J, et al. New advances in the treatment of chondrosarcoma under the PD-1/PD-L1 pathway. J Cancer Res Ther. 2024;20(2):522-530. doi:10.4103/jcrt.JCRT_2024_20. Section Key Information Definition Malignant bone tumor composed of cartilage-forming cells. Most common in adults, typically arising in pelvis, ribs, and proximal long bones. Resistant to chemotherapy and radiotherapy — surgery is the primary treatment. Epidemiology & Sites Occurs mainly between ages 30–70. Common sites: pelvis, femur, humerus, ribs, and sacrum. Rare in distal extremities and hands/feet. Clinical Presentation Chronic pain, swelling, functional limitation; high-grade lesions show rapid growth and pathologic fracture. Radiologic Features X-ray: “rings-and-arcs” calcification, cortical thinning, endosteal scalloping. CT: defines cortical erosion. MRI: shows marrow and soft-tissue extension. PET/CT useful for recurrence/metastasis. Histologic Grading Grade 1: mild atypia, rare metastasis. Grade 2: increased cellularity, cortical invasion. Grade 3: anaplastic cells, >30% metastasis rate. Subtypes Juxtacortical, Mesenchymal, Clear Cell, Secondary (from enchondroma/osteochondroma), Dedifferentiated. Differential Diagnosis Enchondroma (benign, <50% scalloping, no soft-tissue invasion), Osteosarcoma (osteoid production), Ewing Sarcoma (round-cell morphology). Treatment Low-grade : Intralesional curettage with graft or cement. Intermediate/High-grade : Wide resection with negative margins. Adjuvant : Limited role of chemo/radiotherapy except for mesenchymal or dedifferentiated types. Prognosis Depends on grade and location. 5-year survival: Grade 1–2 (70–80%), Grade 3 (<40%), Dedifferentiated (0%). Axial tumors have poorer outcomes. Recent Advances Proton beam radiotherapy, 3D surgical planning, and targeted molecular therapy (IDH inhibitors, PD-1 blockade) are emerging for unresectable or recurrent disease. Chondrosarcoma pathology Chondrosarcoma Grade 2-3 Chondrosarcoma Grade 2-3 Postoperative 3d CT 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

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