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A, Shoulder dislocation B. Fracture scapula C. Acromicelavicular dislocation D. Fracture clavicle (@ Velpeau bandage and Sling and Swathe splint are used in? (AlIMS Nov 08) Acromioclavicular dislocation > Shoulder dislocation Fracture of Proximal Humerus NEER's Classification: A Fractured proximal humerus, showing the four main fragments, two or more of which are seen in almost all proximal humeral fractures. 2-shaft of humerus 2-head of humerus B-greater tuberosity 4-lesser tuberosity (AIMS Nov 2037) A. Neer classification grade 4 B, Ideberg classification grade 4 ¢. Garden classification grade 3 D. Schatzker classification grad A. Neer classification grade 4 @ What is the type of Fracture shown in the X-ray of left shoulder? Damage of Nerves in the different areas injury ‘Covamon nerves involved = Anterior or inferior shoulder dislocation Axillary (cireunnflex humeral) nerve > Fracture shaft Humerus Radial nerve = Medial condyle Humerus Ulnar nerve = Elbow dislocation Ulnar nerve — Monteggia Fracture dislocation Posterior interosseous nerve ~ Supracondylar fracture Humerus AIN > Median > Radial > Ulnar (amru) = Volkman’s ischemic contracture Anterior interosseous nerve > Lunate dislocation Median nerve = Hip dislocation Sciatic nerve > Knee dislocation Common peroneal nerve = AIN (Anterior Interosseous Nerve) > Supplies Alexor of thumb (Alexor pollicis longus) and interphalangeal Joint (AIMS May 2018)Fracture Humerus R 576 + Fracture of lower 1/3% of humerus = Radial Nerve commonly involved > Alco called Holstein—Lewis fracture (AIIMS May 2016) Ossification around Elbow (Criteria) C+ Copitellum + 2 years > Radius head > 4 years 1 = internal (medial) epicondyle + & years T > Trochlea > 8 years 0 > Olecranon -> 40 years E — External (Lateral) epicondyle > 12 years Nerang aoe Carrying's Angle = Angle between arm and forearm ~ Cubitus Valgus: carrying angle is increased as distal part goes laterally, This is seen in Lateral Condyle fracture Humerus. — Cubitus Varus: carrying angle is decreased as distal part goes medially. This is seen in Supracondylar fracture humerus. Noma cat avs ‘Three bony point landmark in elbow > Formed by tip of medial epicondyle, lateral epicondyle and olecranon = Forms isosceles triangle when elbow is exes 40° = Forms transverse straight line when elbows is in extension Fracture Supracondylar Humerus. + 3 point relationship is maintained Garand type 3 supracondylar fracture humerus ~ It is the most common elbow injury, especially in children aged 5-8 years. They account for 50-70% of all elbow fractures > Most common type: Extension type (48%) > Most common type of distal Fragment displacement in extension type fracture is posteromedial displacement with internal rotation > T/t: Fixation with K~ wires Closed Reduction Complications of Supracondylar Fracture Humerus > Cubitus Varus (m/c) > Brachial artery injury = Anterior interosseous N. > Median N. > Ulnar N. injury. Neuropraxia recovers on its own. | PrepLadderElbow Dislocation: > Three point relationship is disturbed = Most common dislocation is posterior or posterolateral = Usually due to fall with forearm supinated and elbow cither extended or partially flexed. Q. Preferred treatment of Cubitus Varus is: (DNB JULY 2026) A. Medial closing wedge osteotomy B. Lateral closing wedge osteotomy C. Medial opening wedge osteotorny D. Lateral Opening wedge osteotomy Lateral closing wedge osteotomy Fracture Lateral Condyle = Late complication: Tardy Ulnar Nerve Palsy (Especially after the development of Cubitus valgus and less commonly after Cubitus Varus) > Symptoms are usually gradual in onset and may appear years after injury, > Motor loss occur first, with sensory changes developing later > Anterior transposition of ulnar nerve is most commonly used procedure. Complications of trauma > Sympathetic overactivity: Sudeck's dystrophy ~ Fracture femur complication after 48 hrs: Fat Embolisn (Worst prognosis) > H/0 injury followed by massage: Myositis ossificans + H/0 tight cast application: Compartment syndrome Compartment Syndrome > Due to tight cast, in acute injury there is increase in pressure in a close fascial space causing loss of microcirculation > M/e site: Deep posterior compartment of leg > deep flexor compartment of forearm (commonest in children) > Most commonly seen with Supracondylar fracture humerus and tibia. = Pain is not relieved by anything. (AlIMS) Clinical Features + Diagnosis is based on dramatic increase in pain (out of proportion to injury) after Fracture or any Injury (3 symptom). ~ Pain and resistance on passive stretch in distal most joint of extremity (3 sign) > Management: Paraesthesias are indication of fasciotomy ive. release of skin, superficial Fascia and deep fascia — If left untreated there will be permanent ischemic contracture of muscles causing Volkmann's ischemic Contracture.= M/e muscle involved: Flexor Digitorum Profundus > Flexor Pollicis Longus + M/e Nerve involved is AIN (Anterior interosseous Nerve) Myositis Ossificans > M/e around elbow > H/0 injury Followed by vnassage syste — Caleified mass with lysis in center & De 2 i nee Smcans ess dense on periphery ate | Saposte in Pulled Elbow = Dislocation of radial head by the traction applied. > Treatment is forceful supination Essex—Lopresti Fracture > Radial head fracture with oss of support around elbow & proximal migration of radius with traction in lower end of radius. = Distal radio ulnar joint gets disrupted causing wrist pain ~ Also interosseous membrane gets pulled Q What is the diagnosis of this Fracture? (AIMS may 2046) A. Monteggia Fracture type 1 B. Side swipe fracture C. Galeazzi fracture D. Monteggia Fracture type 2 A. Monteggia Fracture type 1 = Fracture of proximal third of ulna with dislocation | of proximal radioulnar joint = "Bados” classification is For Monteggia Fracture types. ~ Type | is the most common type where there is Anterior dislocation of radial head ~ M/e nerve injured: PIN (Post. interosseous Nerve) Galeazzi Fracture = Dislocation of distal radio ulnar joint with Fracture of radius & damage to interosseous membrane & triangular bro cartilage complex (TFCc)immobilization of Fracture of Forearm in cast + Fracture in upper proximal part of forearm — immobilize in Supinator position > Fracture in the middle third of forearm -> imaobilize in Mid prone position + Fracture in the lower third of forearm -> Inumobilize in pronation position Fracture in lower end radius cause S: Supination L: Lateral displacement / Lateral tilt |: tmpaction (Proxineal shite) P: Posterior displacement / Posterior tilt (Dorsal tilt) = M/e by Colles Fracture Colles Fracture: > Extra-articular injury ie. distal metaphyseal fracture of radius with dorsal displacement and angulation, especially in osteoporotic elderly causing dinner fork deformity (a). + T/t: Hand shake cast ie. Pronation + palmar angulation + Ulnar deviation > Malunited colles causes dinner fork deformity. > M/e complication is finger stiffness. > Extensor pollicis longus (EPL) may get ruptured Extensor ‘ pollicis longus over Colles may be ruptured Dinner fork deformity Smith Fracture (Reverse colles) = Anterior (volar) displacement of distal fragment of radius in distal metaphyseal fracture of radius. it causes garden spade deformity. Fracture — ih aru wo@. A young man had a fall on his outstretched hand & presented with pain on the radial side of wrist 4d swelling in anatomical snuff box. X-ray was done. What is the diagnosis? A. Seaphoid fracture rT B. Transseaphoid perilunate disruption Fracture y C. Hook of hamate Fracture 3 D. Distal radius fracture ‘A. Transscaphoid perilunate disruption fracture > Terry Thomas Sign + Scapholunate dissociation A. Normal B. Lunate dislocation C. Perilunate dislocation (M/c) D. Normal = In both Lunate & Perilunate Terry Thomae Sign dislocation median nerve is involved. Q. M/e bone to get fractured in fall on outstretched hand is: (NEET 2038) A. Lower end ulna B. Lower end radius (Colles fracture) C. 5* metacarpal Fracture D. Capitate Fracture Lower end Radius (Colles Fracture) — Fall on outstretched hand: Colles fracture (va/e overall) but in young population it is Scaphoi Game Keeper's Thumb |versy Finger > M/c injury of 2 MCP joint causing tear of |» FDP (Flexor digitorum profundus) is ulnar collateral ligament avulsed from distal phalanx Mallet Finger Zones of Flexor tendon of hand = avulsion of extensor tendon From distal | -> Zone Il: FDS (Flexor phalanx digitorum superficiality | > Avoid Surgery in this areaSpinal injury Areftexic bladder, bowel involvement and lower limbs involvement Syrmetrical involvement Asymmetrical involvernent “Conus medullaris “Cauda equina syndrome” — limmediately after injury complete loss occurs called as Spinal Shock — First reflex to come back after Spinal Shock is Bulbocavernous Reflex (Nov AIMS 2018) ¢ Dermatomes (Sensory Supply) , (Reg 8” Leg: orem Ls Most common clinically Ce Figen feet - Grea oe significant nerve root §, Sole-te> Som toe— Li Medea’ pan olieg 8 toot (System 1) Fractures of Spine Jefferson Fracture Burst Fracture of Cs Hangman’s Fracture Traumatic Spondylolisthesis of C2 (axis) over C3 with Fracture through pars-interarticularis Burst Fracture Vertical conapression injury (Total disruption of ring) Whiplash injury / Railroad — | Sprained neck due to hyperextension followed by Flexion spine / Erichsen’s disease Flexion Compression Fracture | Wedge compression Tear drop ie. bone fragment hanging from antero-inferior part of vertebra Flexion Distraction Fracture | Facet dislocation Clay-shoveler’s Fracture Avulsion Fractures of spinous process of C7 > TL Motor cyelists Fracture / Transverse fracture across base of skull leading to separation Hinge Fracture (AlIMS) into anterior and posterior half Undertakers fracture Tearing of Co-7 dise space causing subluxation Caused during handling the dead body Sciwora (spinal cord injury | Pediatrie injury without radiographic X-rays is normal but there is neural deficit due to lax abnormality) ligaments permitting traction injury to cord. Cervical spine is most commonly affected Lordosis inward curvature of spine seen at cervical and lumbar spine [)PrepLadder> mia conical Lordosis: —> Thoracic kyphosis ¥ = = % fe = | z Thoracle Curve > Lumbar lordosie TT Lorosis v Normal curvature of spine Pathological Lombar Curve © Pave Curve Causes of increased lumbar lordosis Mnemonic: SOAP S > Spondylolisthesis (slip of one vertebra over another) 0 > Obesity / Osteoporesis A» Achondroplasia P > Postural e = — sacrum Pelvis and Hip Injury ‘Trendelenburg Test > To check hip stability > Affected in injuries involving Superior gluteal nerve Thus affecting Gluteus medius and Minimus. > Pathology is related to hip joint and femur neck. ‘Thomas Test Shenton’'s Arch Hip Flexion deformity is assessed by it = Formed by: Inferior border of superior pubie rami, head and neck of ferur Maintained shentons intact mesial aspect of femoral neck head ang inferior border ‘of supenor pubse rami) Broken shentons aren due ton subluxationRadiographic factors indicating unstable pelvis ~ Posterior sacroiliac complex displacement > 1. cm ~ Avulsion Fracture of sacral or ischial end of the sacrospinous ligament > Avulsion Fracture of the LS transverse process ~+ Disruption of pubic symphysis with pubic diastasis of 2 cm = Presence of gap rather than impaction in the posterior pelvic ring Spur Sign > Seen in Bicolumnar Fracture of acetabulum Classification and Criteria for Fracture Acetabulum: Judet Femur Neck Fracture Garden's Classification for Fernur Neck Fracture (incomplete (Partally displaced fracture) gardens) All trabeculae Displacea Be 7 1, wy / ‘abeculae of acetabulum ~ & head aligned but neck not aligned / Complete fracture) All wabecuiae Stage! Stage Il aligned Stage it Stage IV > The limb will be shortened and externally rotated Pauwels Classification: Angle between fracture and horizontal plane Intertrochanterie Fracture > Increased shortening & ‘| Panett increased external rotation > Treatment: 1. Proximal femoral nail 2. Dynamic hip screw / \ — | APU MEHDashboard injury = M/e is Posterior dislocation of hip with fracture posterior lip of acetabulum. = 2™ mde is PCL (Posterior cruciate ligament) injury, Posterior Dislocation of Hip > FADIR: Flexion, adduction and internal rotation of lower limb along with shortening. Flexed & adducted thigh Internal rotation of lower limb = Pipkin's Type IV Fracture Dislocation (Variety of posterior dislocation of hip) > This is a fracture dislocation of unusual type. FADIR will not be seen here Position of hip at time of Injury Pattern of Injury Flexion, adduction, internal rotation [FADIR] Pure posterior dislocation Hyperabduction, Rexion & external rotation [FABER] | Anterior dislocation Anterior Dislocation of hip = Flexion, abduction and external rotation with lengthening of limb is thereLower Limb Traumatology Gallows traction <) ~ Fracture shaft femur = Use for child less than 2 years of age or 22 kg body weight ae Floating Knee > Fracture of femur, tibia and fibula near the joint making the joint unstable > Me: Surgery Thomas Splint ~ Used to immobilize lower linab ~> Classically given for Tuberculosis of knee joint. Q. What is method of fixation of this Fracture? (AlIMS May 27, Nov 26) A. Plating B. Nailing C. Screws D. Tension Band Wiring A. Tension Band Wiring (also done for Olecranon / Medial Malleolus) ‘Normal X-ray ankle: | Pott’s Fracture ‘ > Bimalleolar Fracture > medial and lateral | Poser tee. | malleole Fractured Cotton's Fracture TTillaux Fracture = Trimalleolar Fracture > Avulsion of antero-lateral part of lower > medial, lateral and posterior malleoles | tibial epiphysis due to pull of syndesmotic 585 SR aPuRy weaFracture Caleaneum Bohler's Angle ~ decreases in fracture by 20-40" Angle of Gissane (Normal: 45 - 105°) = increases in Fracture Eponym Fractures 20-40 deyroe decreases 95-105 egree increase in cacaneum) Bumper Fracture Comminuted depressed Fracture of the lateral tibial condyle Pilon Fracture (Plafond) Comminuted intra-articular fracture of distal tibial end Maisonnewve's Fracture ‘Ankle Fracture with associated spiral Fracture of neck of fibula Aviator’s Fracture Fracture neck of talus Lisfrane’s Fracture Dislocation fracture dislocation via tarsometatarsal joint ‘Chopart’s Fracture Dislocation fracture dislocation via intertarsal joint ‘Malgaigne’s Fracture = Fracture pelvis with combination of Fracture of ipsilateral publie rami anteriorly and sacroiliac joint disruption posteriorly. ~ Supracondylar Fracture humerus Mallet Finger (AIMS 2038) ‘Avulsion of extensor tendon From base of distal phalanx Straddle Fracture Bilateral superior and inferior pubie vari fracture of the pelvis Barton's Fracture Fracture through the articular surface of distal radius with subluxation of wrist Chauffeur's Fracture (I/A Fracture) ‘Oblique Fracture of styloid process of radius Night Stick Fracture Isolated fracture of shaft ulna Fracture) Bennett's Fracture Dislocation (I/A Partial fracture of 1% metacarpal base with trapezium -metacarpal joint dislocation Rolando’s Fracture Comminuted intraarticular Fracture of base of 1* vactacarpal, without dislocation. one’s Fracture Fracture of base of s* metatarsal Boxer's Fracture Fracture through the neck of 5% metacarpal [P) PrepLadderClassifications Allrman’s: Fracture clavicle Campbells / Rockwood: AC joint Neers: Proximal Humerus fracture Gartland: Supracondylar Humerus Milch: Lateral condyle Humerus Masons: Head Radius Bados: Monteggia Fracture Frykmanns / Fernandez: Colles Dennis: 3 columns of spine . Young and Burges / Tiles: Pelvis . Judet and Lectournel: Acetabulum . Thompson and Epstein: Posterior dislocation Pipkins: Head of femur Gardens / Pauwels / Anatomical: Neck femur Boyd and Griffith / Evans: Intertrochanterie fracture - Winquist and Hansen's: Shaft femur Schatzkers: Proximal tibia Ruedi and Allgower: Distal tibia Hawkins: Neck talus Essex Lopresti (x-ray) / Sanders (CT sca Gustilo Anderson: Open fracture Tacherne: Soft tissue injury in closed fracture geese nawEes Fracture Management Plaster casts and their uses Minerva Cast Cervical and upper thoracic spine disease Risser’s Cast Scoliosis Turn=buckle Cast Scoliosis Shoulder Spica ‘Shoulder inamobilization U-slab / hanging cast Fracture humerus Hip spica Fracture femur Cylinder cast / tube cast Fracture patella Patellar tendon bearing Cast (PTB) Fracture tibia Colle’s east (Hand shaking) Fracture lower end radius Glass holding cast Fracture seaphoidCommon splints & brace and their uses Upper Limb Crammmer- wire spliné Emergency ivmobilization Alumninurn Splint Immobilization of fingers Cock—up splint Radial nerve palsy Knuckle bender Splint Ulnar nerve palsy / median nerve palsy Volkrann’s splint or Turn Buckle splint Volkmann's Ischemic contracture (VIC) Aeroplane splint Brachial plexus injury Dunlop traction, Smith's traction Supracondylar fracture of humerus Figure of eight bandage Clavicle Gutter splint Phalangeal and metacarpal fractures Thumb spica splint ‘Scaphoid fracture / metacarpal fracture 7 Game keepers thumb Sugar tong Humeral fracture Distal sugar tong / reverse sugar tong Distal forearm fracture Double sugar tong Elbow fracture Buddy strapping Phalangeal fracture Lower Limb Thomas splint Fracture femur, knee immobilization Bohler-Braun splint Fracture femur, Knee and tibia Dennis Brown splint cTev Toe=raising splint Foot drop splint Bryant's traction, Fracture shaft of femur in child <2. gears Russells traction (skin) inter trochanteric fractures Buck's traction ‘Conventional skin traction Perkin’s traction Fracture shaft femur in adults 90 degree—90 degrees traction Fracture shaft of femur in children ‘Agnes—Hunt traction (JIPMER) Correction of flexion deformity of hip Well-leg traction Correct abduction deformity of hip Pavlik harness, Von Rosen splint, llfeld / Craig splint or Bachelor Cast Developmental dysplasia of hip (DDH) Broom stick (petrie) cast Legg Calve — Perthes diseaseSpine Four-post collar Neck immobilization SOMI brace (Sternal occipital mandibular ivamobilization brace), Head-halter traction, Crutchfield traction Cervical spine injury ASHE (Anterior spinal hyper extension) brace Taylor's brace Milwaukee brace, Boston brace, Halo-pelvic traction, Rissen’s Cast, Boston brace Dorsolunabar spinal injury Dorsolumbar immobilization Scoliosis (usually idiopathic or dorsal) Lumbar corset Backache Goldthwaite brace Lumbar spine (TB) Minerva cast, Halo device Cervical spine Crutchfield Traction = applied on skull Fracture Neck Femur > Reduction & fixation with screw ( (A) Combi hole = (B) Locking screw (the threads in head of serew lock with the threads of hole in plate) > Used in Osteoporotic patients, metaphyseal fractures, non-union, and around periprosthetic space ‘RAPURY weBone cutter +» Used for cutting bone Bone nibbler > Nibbling of the bone Bone holding forceps > Always have dentations (AIIMS May 201.7) Bone plate holding forceps > Smooth surface for plate and dentations for bone holding forceps ~~, T a : Fergusson bone holding forceps Lane bone holding forceps Dynamic compression Plate (DCP) x Locking compression plate (LCP): Most commonly used now a days Limited contact Dynamic compression Plate (LC-DCP): Developed to preserve bone vascularity aT eA Aa cesses eeaoceses Bone curette: To curettage cavity and for bone grafting Osteotome: Cutting edge on both sides LS eeeAraputations Type Level OF Amputation Lisfrane | Tarsometatarsal joint Chopart _| intertarsal joint Pirogoff | Caleaneum is rotated forward to fuse it to tibia after vertical section | through its middle Ankle / Hindfoot Amputation Type Level of amputation Syme ‘Amputation of tibia and fibula 0.6 cm proximal to the periphery of ankle joint and passing through the dome of ankle centrally. Sarmiento | Transection of tibia and fibula 4.3 cm proximal to the ankle joint and excision of the medial and lateral malleoli. Boyd Arthrodesis between distal tibia & the tuber of calcaneus after talectomy Type of Sequestrum Ring sequestrum At end of amputation stumps and around pin tracts (external fixation) Tubular sequestrum Hematogenous osteomyelitis and segmental fractures (middle segment) Rice grain sequestrum / Coke Tuberculosis sequestrum / Feathery sequestrum [Button sequestrunn Pheochromocytoma Black sequestrum Gunshot Bombay sequestrum Overiying skin loss Coloured sequestrurn Fungal Linear / Flake sequestrum Only one cortex involved Reimplatation of Amputated Limb = Mnemonic for order of repair: “BE FAN of VS" B= Bone E> Extensor tendon F + Flexor tendon A Arteries N= Nerves Vv > Veins S > SkinSports injury MRI Knee Sagittal View O! Donoghue Triad cones Pee ee Poor Prognosis as injury to tM: medial collateral ligament aay A: ACL Ms mail meniscus Anterior Drawer Test: Lachman’s Test > ACL injury: to perform do 90" knee Alexion| > ACL injury: to perform do 20° knee flexion pass Us, Pivot Shift Test Dial Test > ACL injury (also Lelli Test done) > Done for postero-lateral corner injury of PCL knee Anterior to posterior structures in knee (Anterior to Posterior) > Mnemonic: MCL-LMC Anterior cu (Medical College Lucknow - Lucknow Medical College) M > Anterior horn of Medial meniscus C= Anterior eruciate ligament L = Anterior horn of lateral meniscus L + Posterior horn of lateral meniscus M = Posterior horn of middle meniscus C > Posterior cruciate ligament meniscotem nf ‘Attaching foe Poplteus. Antenor meniscofemora i 92Neuromuscular Diseases MRI Lumbosacral Spine Disectomy > T/¢ of choice for dise prolapse Spondyolyss = break in pars EULESS | = Slip of one vertebra interartiularis over other + M/C involved o> M/e site: LoS Le vertebral + Beheaded Scottish terrier sign. ‘Spondyloisthesis Q. X-ray is of a SOyr old female with chronic backache. What is the most likely diagnosis? A. Spondylolysis B. Spondylosis C. Spondyfolisthesis D. Prolapsed inter- vertebral disc A. Spondylolisthesis | Tennis Elbow > Inflarnmation involving lateral epicondyle (lateral epicondylitis) De Quervain's Tenosynovitis = Inflaramation of abductor pollicis longus (APL) and extensor pollicis brevis (EPB) = Finkelstein’s test is used to diagnosis it Dupuytren’s Contracture = Involves ring and little finger + Palmar aponeurosis contracture is seen commonly is diabetics, alcoholics > M/e site: MCP > DIP > PIP “Trigger Finger ~ catching or locking of the involved finger > Name is $0 due to the popping sound made by the affected finger when moved > M/c finger affected: ring Finger or thurabBursitis Tennis elbow Lateral Epicondilitis (ECRB > ECRL) Golfer's elbow Medial Epicondi Student's elbow / Miners elbow Olecranon bursitis Housernaid’s knee Prepattelar bursitis (commonest) Clergyman’s knee Infrapatellar bursitis (superficial bursa) Weaver's bottom ischial bursitis Tailors ankle Lateral malleolus bursitis Bunion Medial side of great toe: 4 metatarsal head bursitis Bunionette ‘5 toe of foot: 5 metatarsal head bursitis Order of Nerve Injuries ‘Seddon's Classification > 3 stages N > Neuropraxia (200% recovery) A> Axonotmesis (progressively recovering) N > Neurotmesis (surgery required for recovery) Sunderland. classification of Nerve injuries 75 stages > Tinets Sign (Recora’s regeneration rate) tells about nerve injury recovery > By tapping on the nerve course from distal to proximal direction tingling is felt at the sprouting nerve ends till the distal course of the nerve (law of projection) and it disappears as myelination takes place. — Rate of recovery of nerve is 2mm / day. > Tinel’ is positive and progressive in axonotmesis and Sunderland stage 2 and 5. ~ Usually, sural nerve is used as gratt for nerve repair. Good Prognostic Factors For Nerve Injury Mnemonic: Good Nerve G ~ Growing age / Good repair © - Only motor involvement © - Only sensory involvement D ~ Distal lesion N = Neuropraxia E ~ Early repair R ~ Radial Nerve injury (M/e nerve damaged during Fracture shaft humerus) V = Vascularity maintained E ~ End to end repair Erb’s Palsy (Policeman / Waiter's tip hand) | Klurnpke's Palsy (Claw Hand) ~ Involves upper part of C, 4 ogg | > involves lower part of C, , nerve roots of brachial T,nerve of brachial lexus plexus It has better prognosis than klumpke's palsy.Median nerve palsy (Pointing Index) + aka benediction attitude > Ochsner's Clasping test is positive Sensory distribution of median nerve rtoat vere Excanne seo Stiwmedan nee Pen Test for median nerve injury Check abduction of thumb Ape thumb deformity for median nerve injury Kiloh-Nevin sign AIN (branch of median nerve) is paralysed 1 9 VA Flexion! / A+] by FOP supplies by mo anterior interosest ene - 32 Flexor polices longus a Ulnar nerve palsy Card Test > Patient is asked to hold a card between the fingers and if patient can't do so, test is positive > Palmar interossei of Fingers are involved > Adduction is lost here (Igawa Test > IF no movement of middle finger occurs means test is positive. > Dorsal interossei of fingers are involved. ~ Abduction is lost here Wartenberg's sign > Failure of adduction of little fingerBook Test _ 596 | + Adductor pollicis holds book between thumb and palin. fa > Fromont's sign (ie. the thumb flexes to hold the book) is / present if ulnar nerve is injured. =——— Flexion at Claw Hand joint Loss of Fexion at MCP and extension at IP Paralyzed Joint done by the lumbricals normally ee + Median claw hand: Involvernent of first (lateral part) Hyperextension and second lumbricals + Ulnar claw hand: Involvement of ulnar lumbricals. = Total Claw Hand: involvement of both lumbricals frcarbest + Ulnar claw hand is more common. > Knuckle bender splint is given extension at + Ulnar nerve injury paradox is that it causes less clawing IPjeints of hand when injured proximally as compare to distally. LOA. Flexion Extension . Adduction Abduction A. Flexion |e Action of lumbricals at this joint is? (NEET 2018) | | Radial Nerve Injury > High Radial nerve palsy: Brachioradialis paralyzed + wrist drop + Finger drop + Sensory loss — Low radial nerve palsy: Wrist drop + Finger drop + Sensory loss > Posterior interosseous nerve (Motor Branch of RN): Finger drop + No sensory loss > Superficial nerve: Sensory loss = Note: In low radial nerve palsy brachioradialis is spared. Coek- Up Splint: Wrist drop Se 4 f Bs? ‘Area of symptoms in Carpal Tunnel Syndrome = Compressions of median nerve, patient will experience night pain and tingling > Most common compression neuropathy > M/C/C is Idiopathic = Phalen's Test & reverse phalen's test (opposite of phalen’s) f ‘Area of syriploms in carpal tune!. Winging of scapula is due to palsy of? (Neet 2022) al A. Long thoracie nerve B. Nerve to latissimus dorsi C. Spinal accessory nerve D. Nerve to rhomboid ‘A. Long thoracie nerve Joint Disorders Diagnosing Arthritis DIP OA psonatie reactive PIP-OA SLE RA psonate NGP_RA. pseudogout 1st CMC OA. Wast RA, pseudogout gonocaccal artis vende aris, carpal tune! syndrome De Quenain's tenosynovitis “> Upper cervical spine: commonly involved in RA Total knee Replacement (TKR) Unicondylar Knee Replacement} / + Only done in cases of 44, Mono-compartmental Osteoarthritis, Total Hip Replacement Hemiarthroplasty > Fracture at neck of Femur >65yrs we replace only head of Femur. = THR: Cemented Replacement is done in elderly patient as they have poor bone stock & Un-Cemented Replacement is done in young adults as they have good bone stock. APU EHHigh Tibial Osteotomy ~ Done to correct the Varus deformity, in age Herberden's nodes: DIP = Bouchard's nodes: PIP = Metacarpophalangeal joints are not involved in OA. > 2° carpornetacarpal joint is commonly involved in OA + Wrist is not involved in OA tate age) Osteoarthritis Knee = Reduced joint space > Cartilage damage (Arthritis) ~ Subchondral sclerosis seen as whitening in the subchondral area of tibia (early sign of OA) — First sign of OA: Joint space reduction NOTE: RA knee: Genu valgus (A) OA knee: Genu varus (B) Rheumatoid Arthritis > Deformities in hand:Ulnar deviation of fingers (A) Arthritis mutilans (B)+ Deformities in fingers Swan Neck Deformity Flexion of DIP and hyperextension of PIP Boutonniere Deformity Flexion of PIP and. hyperextension of DIP Saan neck detoerty PIP (ntyperentension Classification Criteria for Rheumatoid Arthritis Score [Joint involvement 2 large joint (shoulder, elbow, hip, knee, ankle) 2-40 large joints 2-3 small joints (MCP, PIP, Thumb IP, MTP, wrists) 4-20 small joints >40 joints (at least 4 small joint) Negative RF and negative ACPA Low-positive RF or low-positive anti-CCP antibodies (3 times ULN) High-positive RF or low-positive anti-CCP antibodies (73 times ULN) ‘Acute-phase reactants Normal CRP and normal ESR ‘Abnormal CRP or abnormal ESR Duration of symptoms <6 weeks >6 weeks Total Score 40 Score > 6 indicates RA > The 1987 Revised Criteria for Diagnosis of RA requires 4 of 7 criterions to classy a patient as having RA. Patient with 2 or more criteria are not excluded. ~ Criteria (and roust be present for at least 6 weeks and b- ¢ must be observed by physician) a. Morning stiffness in and around joint lasting 1 hour before maxinnal improvement. 6. Arthritis of 3 or more joint areas observed by a physician with simultaneously, have soft tissue swelling or joint effusion, not just bony over growth. The 14 possible joint areas involved are right or left PIP, MCP, wrist, elbow, knee, ankle and MTP. (PrepLadderor juxtaarticular region Serum rheumatoid Factor narrowing of articular (joint) space. | A. Rheumatoid arthritis | B. Fracture distal phalanx of great toe | 6 Bunion |B. Osteochondtitis JA. Rheumatoid arthritis Arthvitis of hand joints eg. — wrist, MCP or PIP joints [ 2. Hammer toe deformity is seen in? (Al Dec 25) d. Symmetrical arthritis ie. simultaneous involvement of same joint area on both sides of body. Rheumatoid nodules (pathognomonic): subcutaneous nodules over bony prominences, extensor surfaces 4g Radiological changes: bony erosion or unequivocal bony decalcification, periarticular osteoporosis and “Ankglesing Spondyliti:Peabures Sacroilitis Psoriasis Pencil in cup deformity Slerodarma > Acro-osteolysis Hemophiliac Arthropathy = Epiphysis enlarged = Squaring of patella > Wide notch between Joint > Arthritis + Osteopenia Charcot Ankle ~ painless canton seen in DM (on/e cause) = Never replace but cause Fusion of pintGout > Polavising microscopy shows negatively birefringent needle shaped rie acid crystals. + Martels Sign: Overhanging bony edgesseen Metabolic Disorders of Bone Rickets > Cupping, splaying and flaring of bones occurs. > White line of Frenkel seen in healing rickets. > Te: Vit-D and Calcium Osteomalacia + Protrusio Acetabull aka ‘Otto pelvié (G/L disease) gk SORTER = Triradiate pelvis > Coxa Vara occurs Hyperparathyroidism ~ 1PTH causes Iytic lesion in bone k/a Brown Tumor (A) > Loss of Lamina Dura ie. tooth = Salt pepper skull (C) ket(B) Chronie Renal Failure 7 [scurvy > Rugger-ersy spine ie | Sclerosis around alternate bands if epiphysis osteosclerosis and radiolucency winberger’s ring + Also seen osteopetrosis Sign White line of Frenkal present Osteoporosis > Codfish vertebrae (Biconcave Vertebrae) + Diagnosis: BMD (Bone Mineral Density) by Dexa San, T score: Normal is 0 to ~1 IF < -2.5 then it is osteoporosis. > Osteoporosis with fracture: severe osteoporosis = commonly seen in vertebrae _— PrepLadderPaget: Disease > Blade of grass (>) Candle bone disease (Melorheostosis) | Osteopoikiloss ~ Sclerosis over the bone + Looks like dripping of wax. ~ periarticular, symmetrical and uniform size bony spots skeleton Wares lOseteopathia striata > Striations over entire Pediatries Orthopedies Perthes Disease > Destruction of epiphysis of femur, due to AVN = 10C: MRI > Age group: 4-8 years Slipped capital femoral epiphysis > Movement of epiphysis over metaphysis, due to metaphysic movement postero-medially = Age group: 14 20 years ~> associated with hormonal disorders like increased GH, hypothyroidism ete Normat Developmental dysplasia of hip (DDH) + Displacement occurs in supero-laterally > 10C: MRI = T/t - Pavlile Harness Tretnowan sgn UnSCFE due to sto ane passes ; ‘ pelvs Fated acta cavty >) _ displaces (P»_ sont Patrology 's shalow Noemat positon —> iaplatee He otfemur> Test: Ortolani test: Reduction by abduction. Barlow test: adduction dislocates the hip joint we Blounts Disease Rocker Bottorn Foot Defect in posteromedial aspect of upper end of tibia ipnene of CTEV nau ~ Vertical talus = Causes: - incorrect correction Convex sole like rocker bottom cTev Sequence of correction Kites method: Ponsetti method: C > Cavus (Preferred) A> Adduction C+ Cavus V> Varus AV Adduction and Varus E > Equinus E > Equinus Age wise treatment > At birth: Apply above knee cast ~ If age <1 years: Apply above knee cast = tf.age 2 years: TURCO's soft tissue release (STR). IP age 3-5 years: Caleaneocuboid wedge + STR (Page 5-8 years: STR + Evan's (shortening lateral side of foot) + Dwyer's Osteotomy IP age 8-20 years: Wedge tarsectomy (f age >20 years: Triple arthrodesis ie. fusion of joints 4) Talonavicular Fusion (onost difficult to Fuse) 6) Talocaleaneal Fusion ©) Caleaneo-cuboid Fusion ~ Dennis Brown splint “+ CTEV shoes: Outer shoe raise, straight medial border and no heel (designed by Thomas)Bilateral radial club hand = Associated with TAR (thrombocytopenia with absent radius) syndrome & Holt Oram syndrome + Tt: Pollicization Index bnger rotated and reconstructed as thumb Torus Fracture Greenstick Fracture Q. Madelung's deformity involves? (NEET Pattern 2013) A. Humerus Proximal ulna Distal radius Carpals A. Distal Radius — Distal radius joint surface is inclined anteriorly and towards ulna. There is deficiency of volar and ulnar part of distal radius. The ulnar head becores prominent. The deformity is more conmon in females and is often bilateral (50%). The functions are good and usually don't require intervention. Salter- Harris Classification For Epiphyseal Injury “Type | + Slip of epiphysis Type Il > Slip of epiphysis along with metaphysis Fracture Z (Thurston Holland Sign >) Type Ill > Split of epiphysis into two parts “Type IV — Split of epiphysis with metaphyseal fracture along the same line Type V > Crushing of physis (often normal X-ray as physis is cartilaginous) Most severe and poor prognosis Klippel—Feil Syndrome = Synostosis (congenital osseous fusion) due to lack of cervical vertebrae fragmentation ~ Short webbed neck, low posterior hair line and restricted neck movements‘Sprengef's shoulder Torticolis Congenital pseudo-arthrosis of tibia Contracted sternocleidomastoid due to ischernia during birth > Head tlt: towards affected rausele = congenital undescended @ + Anterolateral bowing of tibia > Chin points away from contracted muscle = Aka ‘Wry Neck? Vertebra Plana = Aka pancake/ silver dollar/ coin on edge vertebra > causes 1. Metastasis 2. Tuberculosis z 4. Lymphoma Eosinophilic granuloma Duchenne Muscular Dystrophy > Pseudo hypertrophy of calf muscle seen Osteochondritis: Fragmentation of bone with overlying cartilage. Kienbock Disease > Involves lunate Kohler Disease = Involves navicular bone Miscellansous Haglund’s deformity ~ prominent calcaneal tuberosity with overlying bursitis (retro-calcaneal) ™~ > Weak proximal wuscles + Mutated ‘Dystrophin gene’ Osteochondritis Dissecans > Involves lateral " surface of . medial fernoral ‘= condyle Seaphoid Blood Supply + Blood supply is distal to proximal > Gower’s Sign present AVN Avascular Necrosis OF Humeral Head ~> Snow cap sign: dense sclerosis over the head of humerusBlood Supply to Femur Head (Posterior Aspect) 7a pene 608 > AVN (Avaseular Necrosis) occurs at the Head of Femur, aoe in neck of Femur Fracture due to the damage of medial acto Femoral circumflex Artery ‘ascending > Involves anterolateral aspect of head eer > Sectoral sign is seen. Medial femora ‘oreuronortey, Avascular necrosis of hip = Abduction & internal rotation affected — Crescent sign & area of lucency is seen 10C: MRI: Double line sign seen =e C AD fers need Tie bone ao Crescent san + T/t: Core decompression to decrease intraosseous pressure and then take muscle pedicle graft along with its blood supply. ~ M/e: Meyer's graft (Quadratus femoris) is taken. oudar grat Muscle pedicle sutured with capsule Quadratus femoris muscle pedicle gral placed in siot Insertion of quadratus femoris= Rotational Osteotomy is also done = Total hip replacement (preferred now) — Damages temoral heas sn weight beanng reg Normal sector of femur heat nce Rotated and placed in woight beanng area Questions based on NEET pattern Qi. Identify the nerve supply of the marked muscle? A. Radial nerve B. Median nerve C. Ulnar nerve D. Anterior Interosseous Nerve At. Median Nerve Lateral Lumbricals ie. first 2 are supplied by Median Nerve Medial Lurabricals are supplied by Ulnar Nerve 2. Regarding synovial tenosynovitis of flexor tendon choose correct option? A. The affected finger is extended at all joints B. It has to be conservatively managed C. Little finger infection can spread to thumb but not to index finger | D. Patient present with minimal pain 2. Little finger infection can spread to thumb but not to index finger |+ Tenosynovitis shows Kanavel’s signs a) Flexion of Finger 6) Swelling of Finger ©) Pain on stretch of finger 4) Percussion tenderness Index finger tendon ~ Little finger infection can spread to thumb as "Rnd radial & ulnar bursa join in Forearm ‘space of Parona’ > Thenar space has index finger tendon iv. 1 lumbrical Jin in forearm Space of Parona ~ Midpalmer space has middle, ring and little fingers 2, 3% and 4% lumbricals. ~> Treatment: conservative management but if not resolved then surgery.(Q3. 22 years boy came with swelling of lower end tibia which is surrounded by rim of reactive bone. What is most likely diagnosis? A GCT B. Brodie's abscess ©. Hyper PTH D. Osteomyelitis Az, Brodie's abscess is present only in immunocompetent individuals. (Q4. Vihich of the Following is false about GCT? A. Epiphyseo-metaphyseal location B. Eccentric C. Defined margins D. Chemotherapy is the mainstay of treatment Ad. GCT occurs in 20 — 40 year age group and it is epiphysio-metaphyseal. Extended curettage is the treatment of choice. 5. 75yr female has chronic backache. X-ray spine is shown. What is the likely diagnosis? A. Pott’s spine B. Osteoporosis CC. Spondylolisthesis D. Spondylodiscitis AS. Osteoporosis 6. A 7oyr male patient has single well defined lytic lesion of skull with no other complaint and normal urine examination. What is the most likely diagnosis? A. LGH (Langerhans Cell Histiocytosis) cam} B. Localized Myeloproliferative disorder > * C. Generalized Myeloproliferative disorder D. Tumor of Osteoblast AG. L.CH (Langerhans cell histiocytosis) - Multiple rayelorna Langerhans cell histiocytosis Q7. Foot drop is caused due to injury to? A. Common peroneal nerve B. Tibial nerve C. Femoral nerve D. Obturator nerve AT. Common peroneal nerve takes the turn near the neck of fibula where itis prone to get injured causing loss of dorsiflexion of foot.[@8. Which nerve gives sensory supply to this region? A. PIN B. Radial C. Medial D. Ulnar As. Radial 99. In scaphoid Fracture which area has maxinum chances of AVN / Nonunion / Malunion? Proximal 2/3 Middle 1/3 Distal 4/3 Scaphoid tubercular fracture Aa. Proximal 4/3 as blood supply of scaphoid distal to proximal Q20. Which movement is painful in painful are syndrome? A. Initial abduction B. Terminal abduction C. Mid abduction D. Full range of abduction A420. Mid abduction [60° to 120°] ~ It 5a subacute inflammation of rotator cuff tendons > Treatment: Rest, NSAIDS, physiotherapy f/b Steroids F/b Surgery. | @22. The most likely diagnosis for the tumor at upper end of tibia is? A. Get B. UBC c. aBe D. cB ALL. GCT as it goes up till joint Q42. Left-Right movenent of skull occurs at? A. Atlanto-oecipital joint B. Atlanto-axial joint c cae D. ce-c7 |A12, Atlanto—axial joint Q23. What is treatment for a 24 years old child with naive Rheumatoid Arthritis? ‘A. DMARDS after initial 3 months of NSAID's B. Only NSAID C._DMARDS with short course of steroids D. Monotherapy with TNF drugs ‘A13. DMARDS with short course of steroids