ORTHOPAEDICSORTHOPEDICS > Father of Orthopedics ~ Nicolas Andry (if not in option mark H. 0. Thomas) > Father of Modern Orthopedics ~ Robert Jones > X-rays is the First investigation in orthopedics ~ Cartilage is not seen on X-ray Nicolas Andry-> Glass pieces are picked up on K — ray (AIMS 2014) + Hyaline Cartilage present in joints is seen as Joint Space in X-rays > Joint space is reduced in Arthritis > MRI is 10€ For: = Marrow Nicolas Andry + Soft tissues (Brain / Spinal cord / Ligaments / Tendons / Nerves / Vessels) + Cartilage + Avascular Necrosis / Perthe's disease (AVN of femoral epiphysis) in children = Occult Fracture — Fracture which is not easily picked up on x-ray, thus to see the resultant marrow edema IOC is MRI (a. identity the marked structure? | A. Lunate. (UIna does not form wrist joint) Osteomye! > M/C organisea involved in Open injury & Acute/Chronic/ Etiology: Sub-acute osteomyelitis is Staph. Aureus. -+ M/c organism seen in all age groups is Staph. Aureus. > Me organisnn in sickle-cell anemia patient is Salmonella. it affects diaphysis. “+ M/c organism in drug abusers and foot wounds is Pseudomonas Aeruginosa. > M/C area affected is metaphysis. | Pathology: > Hematogenous: Most common mode of infection > Earliest and most commonly involved site:- Im children — lower end fermur > Upper end tibia Im adults ~ Spine Clinical Features and Investigation: = Gold standard / Best investigation for infection: Tissue diagnosis (Frova lesion) ie. growth of organisms on culture waedia Best radiological investigation for Osteomyelitis and TB: MRI as can pick up marrow changes in snetaphysis Order of investigation in which pathology is seen: MRI > Bone Scan > X-Ray MRI (within 6 hours), Bone Sean (in 12 hours), X-rays (24-48 hours) First change seen on X-ray is loss of soft tissue planes outside the bone. First Bony change at 7 to 10 day's is Solid Periosteal Reaction NOTE In tuberculosis + no periosteal reaction is seenScenario: Reduced movement of limb, clinically toxic look and tender metaphysis (Clinical diagnosis) Osteomyelitis < 24 hours 4 hours ~ X-ray - No loss of soft tissue planes = Xray ~ loss of soft tissue planes ~ MRI — Marrow changes in metaphysis = MRI — Marrow changes in metaphysis ~ Bone Scan ~ Increased activity ~ Bone Scan ~ Increased activity ~ Treatment is started with IV antibiotics ~ Treatment is evacuation & exploration of = Once condition begins to improve or pus with antibiotics for © weeks : CRP values return to normal (usually within 2 weeks), then antibioties are given orally for another 4 weeks Complications of Acute Osteomyelitis: 2. Chronic Osteomyelitis > Most common complication + Sequestrum is selerosed dead bone seen as calcified ; bone within a lucent lesion, separating from the surrounding bone on X- ray. = Bone Scan is next in preference to MRI as it picks osteoblastic activity at the site of infection. ~ Culture and Growth of Organism > Gold standard diagnostic modality for osteomyelitis = First choice of investigation X-Ray f/b MRI f7/o Bone sca 2. Brodie's Abscess: + Lytic Lesion with Selerotie Margin = Long standing localized pyogenic abscess in bone due to strong defense mechanism — Seen in immunocompetent host = Usually involves (ong bones (metaphysis or diaphysis) eg. Upper End Tibia Negative Pressure Wound Therapy > Used to heal chronic non-healing wounds > Pressure is between 75 to £25mmHg. Air tight environment and vaceuna is applied. = It is used continuously or intermittently to help form good granulation tissue. ~ Its use is contraindicated in active infections, dead necrotic area & malignancy. Chronic Recurrent Multifocal Osteomyelitis (CRMO) ~ Diagnosis of exclusion > Autoimmune / Auto inflammatory disease involving multiple bones causing inflammation and pain APU MEHR+ Related to SAPHO Syndrome ie. 1. Synovitis 2. Aone 3. Pustulosis 4, Hyperostosis 5. Osteitis = Treatment: DMARDs & Steroids Ankylosis: Pathological fusion of bone (i) Fibrous Ankylosis (id) Bony Ankylosis (0) Fibrous Ankylosis: > Fibrous tissue in between the bone “+ Movernent of joint is painful but possible > Common cause is tubercular arthritis of hip and knee + Also Seen in Rheumatoid Arthritis (id) Bony Ankylosis > Bony union between two articular surfaces > No movement possible and joint is painless — Causes: Acute suppurative arthritis (Septic Arthritis) > Pott's Spine (TB of Spine) > NOTE: It is also seen in Ankylosing Spondylitis where it involves sacroiliac joint. ‘Tom Smith Arthrit — Septic arthritis of hip in infants = May destroy the cartilaginous femoral head rapidly and completely (chondrolysis) > Presentation: Limp, unstable gait, telescopy, shortening of limb and increased hip movement in all directions (hypermobile joint), Swelling with multiple discharging sinus: > Over mandible (or head -neck region): Actinovycosis = On foot: Madura foot/ Madura mycosis Infections of hand Infectious Tenosynovitis —> Infection of Tendon Sheath m/c by Staph. Aureus Four cardinal signs of Suppurative Tenosynovitis ~ Tenderness over the involved sheath (onost specific sign) signs of — Rigid positioning of Finger in flexed state \ Suppurative > Pain on attempting hyperextension of Finger | Tenosynovitis — Fusiform swelling of the involved part Four cardinal > Kanavel's sign is seen i.e. pain on passive extensionFelon ~ abscess in the subcutaneous tissues of distal pulp of Finger > M/e: Thumb > index finger > Me cause: Staph. Aureus Paronychia = Infection of Nail bed > M/c infection of hand + T/t + /D and antibioties Tuberculosis of Bone and Joints Tuberculosis of spine ie. Pott's spine > Mode of spread is usually secondary: Lungs > Lymphaties > M/c site of skeletal tuberculosis: spine (5O% cases) > hip (15% cases) > Knee (10% cases) > Spina Ventosa: Tuberculosis of short bones of hand > Caries Sicea (Dry): Tuberculosis of shoulder with no effusion > Poneet's disease: Tuberculosis with symmetric polyarthritis > Types of TB Spine: + Paradiscal type (most coramon type) ie. involving two consecutive vertebrae as segmental artery supplies two vertebrae thus, any infection from blood will infect both vertebrae together. * Central Type: central part of vertebral body is involved + Anterior Type: anterior surface of vertebral body is involved + Appendiceal Type: involving pedicle, lamina and less commonly transverse process ~ Least common site: spinous process (2~ least) > synovitis of facet joint (rarest) nA a) Paradiscal ) Central ©) Anterior d) Posterior Radiological Feature of TB spine: = Earliest X-ray feature is loss of curvature due to paravertebral muscle spasm ~ Best radiological investigation: MRI ~+ Gold Standard: CT guided biopsy via transpedicular route to obtain tissue From lesion.Prognostic Factor: Feature Good Prognosis | Poor Prognosis Degree of cord involvement Partial Complete (grade 'V) Duration of cord involvement Short Long (> 22 months) Speed of onset Siow Rapid Age Young Old General condition Good Poor | Vertebral disease ‘Active Healed Kyphotie deformity < 60 degree > 60 degree Cord on MRI Normal Myelomalacia / Syrinx (cord damaged Preoperative Wet lesion Dry lesion Tuberculosis of Hip > M/e site: Acetabulum > 2% m/e site: Femur (Babcock’s Triangle) ~ Stage 4: Stage of synovitis: FABER (Hexion, abduction and external rotation) with limb lengthening ‘Tt: Antibioties leading to complete resolution ~ Stage 2: Stage of early arthritis: FADIR (flexion, adduction and internal rotation). It presents with < 1 cm shortening. ~+ Stage 3: Stage of advanced arthritis: FADIR, presents with > 1 cm shortening = Stage 4: Stage of subluxation / dislocation: Wandering acetabulum or pestle and mortar appearance on X-ray > Stage 5: Stage of sequelae, ankylosis or severe arthritis Tuberculosis of Knee = Triple deformity: posterior subluxation of tibia + external rotation of tibia + flexion of knee (PERF) Causes of Triple deformity of knee: T + Tuberculosis R > Rheumatoid arthritis + Iliotibial band contracture > Polio > Low clotting power ' Pp L E Excess bleeding (hemophilia) Orthopedics Oncology| Bone Tumors ~ First investigation — X-ray (to localize the tumor) ~ CT scan is for extent of tursor and cortical lesions. = MRI is For extension to marrow, micrometastasis and soft tissue involvement MRI is radiological 1OC. > Most preferred investigation for most tumors is MRI except for Osteoid Osteoma where CT scan is first choice > PET-CT and Bone scan is for multiple lesions (multiple metastasis)= Bone Scan is used for blastic metastasis (Prostate) as can detect osteoblast activity. > Rest all metastasis PET-CT is preferred > Biopsy is most specific investigation for tissue diagnosis Classical Radiological Features Sunray appearance/ Codman’s triangle Osteosarcovna but can be seen in any raalignant lesion Onion peel appearance Ewing sarcoma but can be seen in any malignant lesion or chronic osteomyelitis Soap bubble appearance Osteoclastoma (GCT), Adamantinoma Ground glass appearance Fibrous Dysplasia Patchy calcification Chondrogenic tumors (chondrosarcoma > chondroblastonna) Homogenous caleification Osteogenic tumors (osteosarcoma) Most Common Site | + Unicameral bone cyst Upper end Humerus (METAPHYSIS) = Ancurysmal bone cyst Lower limb metaphysis (Tibia and feraur) = Osteochondroma Distal fernur = Osteoid osteoma Femur > Tibia — Osteoblastoma Vertebrae > Osteoma (ivory/Covapact/Eburnated) Skull and Facial bones > Enchondroma Short bones of hand > Chordoma Sacrum (most common) > Sphenoccipital region (clivus) > anterior vertebral body i.e. involves only axial skeleton Adamantinoraa (Long bone) Tibia Ameloblastoma Mandible Osteoclastoma (GCT) Lower end of Femur Fibrous dysplasia Upper fermur- monoostotic (common) craniofacial region— Polyostotic Multiple myeloma Lumbar vertebrae Osteosarcoma (GCT) Lower end of femur Ewing's sarcoma Feraur Chondrosarconna Pelvis Secondary tumors Dorsal vertebrae (Secondaries in bone are commonest from breast > prostate > lung > kidney)+ M/C tumor of hand — SCC > M/C BONE tumor of Hand + ENCHONDROMA + Tumors that go from one bone to other Mnemonic: BONE B — Bone to bone 0 ~ Osteosarcoma N = Neuroblastonsa E — Ewing's Sarcoma ~ Patient >40 years age, with new & painful bone lesion, most probably has Metastatic carcinoma > Multiple Myeloma. > Two most common primary source of bone metastases: Breast cancer and Prostate cancer ~ If patient has unknown primary, then most likely sources ave Lung cancer and Renal eell carcinorma Unicameral or Simple Bone Cyst ~+ Single cyst, seen in 2" decade in center of bone & usually at upper end. > Sometimes cortex breaks from the margin and falls inside cavity, thus called fallen Fragment sign or Fallen leaf sign (**) Aneurysmal Bone Cyst ~ Maltiple septae (Multiloculated) > More vascular > Aggressive > M/C Area: Tibia (metaphysis) = Occurs before skeletal maturity Exostosis / Osteochondroma (aka ACLASIAS) > Bony growth covered with cartilage cap which can't be Seen on X-ray & grows away From joint > They go towards diaphysis, although they arise from metaphysis thus called Diaphysis Aclasia or Exostosis (overgrowth). Osteoid Osteoma: (seen in cortex) ~ Diaphyseal tumor which formas lytic cavity with surrounding sclerosis in the cortex > Characteristic: night pain, relieved by ASPIRIN = Rare tumor with CT sean as IOC.> Most common bone tumor of hand ~ Ollier's Syndrome: Multiple enchondromas > Mafucci Syndrome: Multiple Enchondroma + hemangioma + calcified superficial veins (pheloboliths) Epipyseal lesign with cartiage = Epiphyseal tumor with calcification ~ Treatment: Extended curettage + Only turnor which can involve joint surface > Seen after skeletal maturity » Sites: t) Lower End of Radius ii) Upper End Tibia (AIMS 2015) ill) Upper End Feewur iv) Lower End Femur > Lower end femur is m/e site for: = Giant cell tumor ~ Osteosarcoma Osteomyelitis + Tumor in lower end radius till other diagnosis proved is GCT (Most probably).Fiorous Dysplasia + Shepherd Crook Deformity > Present in upper end of femur > Bone is replaced by fibrous tissue > Ground glass appearance and bone looks hazy, ~ Rind Sign (lytic cavity with Selerotic Margins in upper end Fermur (<—) > associated with McCune—Albright syndrome Mnemonic: PPP + Polyostotie Fibrous dysplasia Precocious puberty = Pigmentation: coffee colored spots Osteosaréorna (Codman's Triangle) = Present in lower end femur metaphysis = Seen in 2 decade of life more cormonly = Codman Triangle (a): Triangular bony growth seen at angle of lifting of periosteum. It is seen in other malignant lesions too. = It also shows Sunray/Sunburst/Speculated appearance (b). + Calcification along the sharpey's fibers is seen (can be seen in other malignant lesions too) Ewing's Sarcoma = Occur in diaphysis of long bones = It is the most common tumor of 2° decade but no. of cases are more seen in 2% decade. = Onion Peel or Lamellated Appearance is seen ~ Also seen in other malignant lesions & chronic lesions (Eg. chronic osteomyelitis) Q.A 5 year child with pain and swelling over tibia, x-ray done shows periosteal reaction, most probable diagnosis? (Al 2016) A. Osteosarcoma B.GcT C. Ewing's sarcoma D. Chondrosarcoma A. Ewing's sarcoma RaPuny werHemangioma 572, = X-ray: Corduroy appearance or Jail Bar Pattern ie. vertical striations in vertebrae + Polka dot appearance in CT scan («—) Causes of Lytie Lesions in Skull > Metastasis ~ Eosinophilic granuloma (a) > Langerhans Cell Histioeytosis (b) / Lymphoma > Tuberculosis > Hyperparathyroidisen (rare) © = Radiation = Osteomyelitis = Multiple myeloma: punched out lesions (d) * Epidermoid Milking Position Age of Ossification = 3 joints which are up: Wrist, shoulder & knee > Ossify at 18 years Ossity around 4B yrs of age > 3 joints which are down: Elbow, Hip & Ankle > Ossify at 16 years Ossity around Fracture Healing: Given by “Frost” tEymsicee Stages of Fracture Healing = Stage of hematoma > Stage of granulation tissue > Stage of callus (Earliest seen at > weeks) ** > Stage of consolidation: woven bone is seen (clinically bone is united) + Stage of remodelingNOTE: In open fracture hematoma is last to appear, thus causing problem in fracture healing. Gustilo and Anderson Classification for Open Fracture (Aims Nov 2017) Grade Characteristic Features Clean wound of < + em length Wound > 2 em in length without extensive soft tissue damage, skin lap or avulsion Wound associated with extensive soft tissue damage, comminution, contamination or segmental fractures ‘Adequate periosteal coverage is there Significant periosteal stripping and it requires secondary bone coverage procedure like skin grafting or fla (Open fracture with vascular injury that requires vascular repair ‘Stress Fracture > 10¢ is MRI ~> Lower extremity: March Fracture: Fracture of 2nd metatarsal neck > 3 metatarsal neck > Upper extremity: Olecranon (most common site of upper limb stress fracture) + Pelvis and spine: Pars interarticularis of 5 lumbar vertebra (causing spondylolysis) is commonest site in spine ‘Advanced Trauma Life Support (ATLS) ~ Airway maintenance with cervical spine stabilization (3* step) f/b breathing f/b circulation > Order OF Resuscitation: ATIS=A->B->C ACLS => A->B Upper Limb Traumatology S — Supraspinatus (Most commonly damaged) 1 ~ tnfraspinatus t ~ Teves Minor S — Subscapularis (Forgotten tendon as inserted on Lesser Tubercle & rest all at Greater Tubercle) Shoulder dislocation: > M/C complication: recurrent shoulder dislocation (due to damage of structure) > Lesions: AruBankart Lesion: Tear in Antero-inferior part of glenoid labrum > M/C lesion Hill-Sachs Lesion: Tear in postero-lateral part of glenoid labrum Tear in anterior part (Most common lesion associated wth recurrent anterior dislocation) — Position of Arm in Shoulder Dislocation «Anterior Dislocation (Subcoracoid > Preglenoid > Subelavicular type) ‘ Slight abduction and external rotation «Posterior Dislocation : Difficult to diagnose as the patient may have normal contour of shoulder. Holds injured shoulder in internal rotation and examiner cannot rotate it externally + Inferior Dislocation (Luxatio erecta / Subglenoid) Locked in full abduction & fixed by the side of head > Test for shoulder dislocation B — Bryant's (Marked lowering of axillary fold) D ~ Dugas test (Inability to touch opposite shoulder tip) © ~ Callaway's test (Circumference of axilla is increased) H — Hamilton ruler test (place ruler on Acromian process and lateral epicondyle, if ruler touches both at the same time indicates positive test) Anterior Shoulder Dislocation A ~ Lost contour of shoulder B - Abducted arm Maneuvers for Reduction of Anterior Dislocation K = Kocher's method (usually done) | 5 = Stimpson's gravity method (use of gravity) i H — Hippocrates method (Not usually done) Surgeries for Recurrent Dislocation OF Shoulder ~ Bankart's operation: Detached anterior structures are fixed to glenoid vin with sutures ~ Putti Platt's Operation: Subscapularis tendon and capsule ave overlapped and tightened L — Bristow Latarjet Operation: Transplantation of coracoid process with its attachments to the anterior rin of glenoid Posterior Shoulder Dislocation = Electric bulb sign Bee > Empty glenoid sign — > Common in electric shock / epilepsy