19

Chapter
OrthoPedics

“People are often unreasonable and self-centered. Forgive them anyway. If you are kind,
people may accuse you of ulterior motives. Be kind anyway. If you are honest, people may
cheat you. Be honest anyway. If you find happiness, people may be jealous. Be happy
anyway. The good you do today may be forgotten tomorrow. Do good anyway. Give the world
the best you have and it may never be enough. Give your best anyway.
For you see, in the end, it is between you and God.
It was never between you and them anyway.” Mother Teresa

Section

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SectionBasic Science, Orthopedic Anatomy and Imaging in Orthopedics
1.

1. Basic Science, Orthopedic Anatomy and Imaging in Orthopedics 373

2a. Infections

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2a. Infections 381
2b. Tuberculosis
2b. Tuberculosis 384

3. OrthoPedic
3. OrthoPedic Oncology
Oncology 387
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4. Nerve
4. Injuries
Nerve Injuries 393
20

5. General + Upper Limb Traumatology 396

5. General + Upper Limb Traumatology
6. Spine + Pelvis + Lower Limb Traumatology 402
6. Spine + Pelvis + Lower Limb Traumatology
7. Arthritis 410
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7. ArthritisDisorders of Bone
8. Metabolic 415
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9. Amputations, Sports injury and Neuromuscular Disorders 419

8. Metabolic Disorders of Bone

10. Pediatric orthopedics 424

9. Amputations, Sports injury and Neuromuscular Disorders
11. One liners 430
10. Pediatric orthopedics

11. One liners

 1
Section
Basic Science, Orthopedic Anatomy
and Imaging Orthopedic
Definition of Orthopedics Straight (Ortho) + Child (Pedics)

Father of Orthopedics (1) Nicolas Andry

Father of Orthopedics (2) H.O.Thomas

1 Thomas Test 2 Thomas Splint 3 Wrench 4 Collar 5 CTEV

shoes

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15°

Fig. 1.1 Fig. 1.2

Robert Jones (Nephew of Thomas)

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Father of Modern Orthopedics

Father of Arthroscopy Watanabe Organic – Type 1

(tensile) (O.I.) 35%
Fig. 1.3
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Fig. 1.4
Father of Arthoplasty Charnley Inorganic 65%
(Ca)10 (PO4)6 Fig. 1.5
20

(OH)2- Calcium
A B Hydroxyapatite.

Bone – type I collagen

e

Cartilage – Type II collagen

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Ossify around
1. Metaphysis: Mc site for 18 yrs of age
infection & tumors
2. Ewing’s sarcoma
diaphysis

Ossify around Fig. 1.7

16 yrs of age
Fig. 1.6
 The 20th Book Orthopedics
Epiphysis
Cartilage
Pressure Intra-articular and weight

Zone 1 Superficial Zone bearing eg. Head of humerus, lower end
Progenitor cells for articular cartilage of radius
High density chondrocytes….High water content

2
Zone Transition zone –Thickest zone Traction • Extra-articular
Chondrocytes are in Low density • K/a apophysis
• Due to pull/ of muscle attachment

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Zone
• Ossify later than pressure epiphysis
3 Middle zone
Eg. Greater trochanter of femur and
Most active chondrocytes
tubercles of humerus
Highest density proteoglycans
Lowest density water content

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Aberrant • It is an anatomical anomaly
Zone 4 Calcified cartilage • It is accessory ectopic epiphysis
Eg. Head of first metatarsal or base of fifth
metacarpal bone
Atavistic
Physis Phylogenetically independent but becomes fused.
Eg. Coracoid process of scapula
• Epiphysis
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1 Resting zone(Reserve)-Storage disorders
2 Proliferative(Growth)-Dwarfs/Giants-Laron
20

syndrome(dwarfs+truncal obesity)/Scurvy
3. Maturation Zone-Trauma
4 Provisional Calcification-Rickets
• Metaphysis
e

Salter Harris Feature

Th

types

Diaphysis I Fracture line is entirely with in Physis

Slip with causing epiphyseal slip
Metaphysis metaphysis II Fracture line extends from physis into the
fracture
Epiphysis Metaphysis (Thurston-Holland’s fragment
Split of
Slip of epiphysis sign)
epiphysis Type I Type II Type III
III Fracture line extends from physis into the
Epiphysis causing epiphyseal split
Crushing of
Split of
physis (often IV Fracture line extends across the Epiphysis,
normal x-ray
epiphysis with as physis is (articular surface), Physis, and metaphysis
Metaphyseal cartilagenous)
fracture V Crush injury of physis with initially normal
Fig. 1.8 X-rays
Type IV Type V

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 Orthopedics The 20th Book
Harmones on The Bone
Parathyroid Hormone (PTH) Green colored are drugs used in Osteoporosis

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Synovial joints:
20

Types of synovial joint Examples Types of synovial joint Examples

• Acromioclavicular • Atlanto-occipital
Plane • Intercarpal Elipsoid • Wrist (radio-carpal)
• Intertarsal • Metacarpo-phalangeal (knuckle)

• Elbow • Malleus-incus joint

Hinge • Sternoclavicular
• Interphalangeal Saddle
• First carpo-metacarpal
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• Atlanto-axial • Calcaneocuboid
Pivot (Trochoid) • Superior radio-ulnar
• Inferior radio-ulnar • Incus-stapes joint
• Shoulder
Ball and socket
Th

• Temporo-mandibular • Hip
Condylar • Talo-calcaneo-navicular
• Knee joint

Some authors consider these joints condylar: Atlanto-occipital, wrist (radio-carpal), metacarpo-phalangeal (knuckle).
Some authors consider these joints as modified hinge: Temporo-mandibular, knee joint.

A B

Fig. 1.9
IR ER
Internal rotation External rotation B
A
of hip of hip
Limitation of abduction and internal rotation
Fig. 1.10 Fig. 1.11

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 The 20th Book Orthopedics
Joint space
(Cartilage)

Cortex
Marrow
Muscle plane Soft tissue
Fat plane planes
Fig. 1.12
Fig. 1.13 Fig. 1.14
Fig. 1.15 Fig. 1.16
Genu Genu
varum =OA valgus = RA

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Fig. 1.17 Fig. 1.18
1. Clavicle –highest landmark
2. Infraclavicular region – palpable part --> corocoid
3. 4:1 is ratio of head of humerus: glenoid (golf ball on a TEE)
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C apitellum 2 yrs
20

R adial head 4 yrs

Internal epicondyle 6 yrs Fig. 1.19 Fig. 1.20

Trochlea 8 yrs

O lecranon 10 yrs
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1st Metacarpal
External epicondyle 12 yrs is anterior
S
Th

S L4 T P3
Scaphoid Lunate Triquetral Pisiform Fig. 1.21 Fig. 1.22
5 12

Sacroiliac

5
T T5 C H
Trapezium Trapezoid Capiatate Hamate
1 1
joint
↓
involved in
ankylosing
spondylitis
Fig. 1.23 Fig. 1.24

Capitate
- Largest carpal bone
- First to ossify

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 Orthopedics The 20th Book
Important views of X-rays
1. Brodens View : Subtalar joint Inversion, Eversion → To walk on
2.Von Rosen View : DDH uneven ground
3. Swimmers View : Cervicothoracic junction
4. Oblique view : Scaphoid
5. Judet View : Acetabulum (Pelvis)Tilt the pelvis →To see inside
6. Open Mouth view : Odontoid the acetabulum
7. Shentons Arch : Pelvis
Fig. 1.26

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Lesion in bone or soft tissue Joint space
(Cartilage)

*
Cortex
Glass injury X-ray Marrow
Muscle plane Soft tissue
Fat plane planes
Bony lesion Fig. 1.27

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Soft tissue lesion

Cartilage

* Calcification
MRI CSF black T1
Cortex Marrow
MRI CSF white T2

*
(water is
Stress # white on T2)
MRI
CT scan

Infection/Tumor Fig. 1.28

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MRI T1 image - anatomy
Biopsy Ewings & osteosarcoma T2 image - pathology
↓
Mimik osteomyelitis MRI:
Fig. 1.25
* Culture *Histopathology - Marrow (dark)
- Soft tissue
20

- Cartilage
3D images are seen on CT Infection Tumor

Sagittal plane
Coronal plane
e

Transverse plane
Th

Fig. 1.29 Fig. 1.30

CT scan

Body planes Fig. 1.32a Fig. 1.32b

ACL PCL
Restrict Internal rotation Restrict external Fig. 1.31
+ Hyperextension rotation MRI

• Order in which investigations become positive in OM: MRI > Bone Scan > X-ray

• Bone Tumors : MRI CT Scan Osteoid Osteoma (Cortical)

• DDH Shallowing of acetabulum. IOC MRI , Screening tool: USG (a) alpha angle decreases in DDH in USG

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 The 20th Book Orthopedics
Joint
X-ray Bone biopsy
X-ray MRI •• After clinioradiological evaluation
Aspiration (USG guided)/Arthroscopy
* MRI (Cartilage/Soft tissues) Swelling of a joint
•• Vertical incision
•• Avoid NV structure
X-M A S
•• Round/Oval hole
Effusion or suspected Old ligamentous/ Limping child / Joint swelling •• Periphery
inflammatory process Meniscal injury

* Aspiration * Arthroscopy * Latest Questions •• Multiple sites

Musculoskeletal System Stress fracture Metastasis

1. 1st investigation X ray 1. Overall MRI 1. Single MRI

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2. Next Investigation MRI 2. Unilateral MRI 2. Multiple PET scan
3. Best Investigation Biopsy 3. Bilateral Biopsy 3. Multiple (Osteoblastic) Bone scan

Stress fracture/ SHIN splints March # - Metatarsal Neck 2nd >3rd

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Periosteum : Osteosarcoma
Sunray
• Fibrous layer-Useless layer Periosteal Reaction appearance
• Cambium layer
Narrow zone Wide zone
Union-Neck of femur (Absent cambium
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layer so high chance of Non union)
Periosteal reaction-Narrow (benign), Solid
Fig. 1.34
Wide(malignant)
20

Bone tumors-Osteochondroma/
Osteosarcoma
Osteosarcoma
Codman’s D

Fig. 1.33
Periosteum → origin of tumor Fig. 1.35
e

↓ Acute OM
Should be removed
(Extra periosteal resection).
Th

GCT→ Only tumor

Ewings
to involve the joint. Non-aggressive reactions are thin, Solid, sarcoma
thick and irregular.
Aggressive reactions are Spiculated,
Onion peel
Fig. 1.37 apearance
Laminated, Hair on End, Sun burst,
disorganised, Interrupted and Codman's
Fig. 1.36
Classical Radiological features* triangle.

Ø Sun ray appearance*/Codman's triangle Osteosarcoma but can be seen in any malignant lesion
Ø Onion peel appearance* Ewing sarcoma but can be seen in any malignant lesion or chronic osteomyelitis
Ø Soap bubble appearance* GCT (Osteoclastoma) > Adamantinoma
Ø Patchy calcification* Chondrogenic tumors (Chondrosarcoma > Chondroblastoma)
Ø Homogenous calcification Osteogenic tumors (Osteosarcoma)

Calcification (CS>CB)> Osteogenic Tumor

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 Orthopedics The 20th Book
Types of Sequestrums
• Tubular or diaphyseal sequestrum is seen in acute pyogenic osteomyelitis.
• Ring sequestrum is seen in amputation stump and at Steinmann pins.
• Ivory sequestrum is seen in syphilis.
• Fine sandy sequestrum is seen in viral osteomyelitis.
• Coarse sandy sequestrum is seen in out of cavity TB (e.g., central body of vertebra)
• Flake or Feathery sequestrum is seen in the cavity tuberculosis (e.g., TB rib)
• Kissing sequestrum is seen in peridiscal TB vertebra.
• Button hole sequestrum is seen after radiation.

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• Coke sequestrum is seen in cancellous bone.
• Bombay or black sequestrum is due to H2S and pollution.
• Black sequestrum is also seen in actinomycosis.

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380
 2a
Section Infection
FABER FADIR
Indications of Deformities of hip
emergency
surgery in ortho
1. Pelvic fracture
2.Vascular
3. Compartment Painless condition
syndrome - Mycetoma
4. Septic
- Charcots joint
Arthritis

Fig. 2a.1
Fig. 2a.2
Fig. 2a.2
Synovitis Posterior dislocation/Arthritis

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Infection(Septic arthritis-Misnomer)

Ilio tibial band contracture(polio)

Anterior dislocation Hip : Posterior dislocation > Anterior dislocation

Fracture neck of femur: shortening + external rotation

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Lower End Femur
Infection (Hematogenous) Knee
Staph. aureus

Osteomyelitis (Metaphysis) Septic arthritis

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Reduced movements of Limb, toxic child Joint
and metaphysis tender (Clinical Diagnosis)
FABER at Hip
20

(Flexion, Abduction and External Rotation)

*
Osteomyelitis < 24 Hours Osteomyelitis > 24 Hours
6–12 years age Non-toxic 0–5 years age Toxic
Decreased movements (Fever, ­ESR, ­CRP)
X-ray – No Loss of Soft tissue planes X-ray – Loss of Soft tissue planes
of joint Absent movement of joint

MRI – Marrow changes in metaphysis MRI – Marrow changes in metaphysis * Transient Synovitis Septic arthritis (S. aureus)
e

Bone Scan – Increased activity Bone Scan – Increased activity

* X-MAS X-MAS

Rest
Th

Surgery (Arthrotomy)+
Treatment is started with, IV antibiotics Treatment is Evacuation Antibiotics (6 weeks)
and Exploration of pus
and antibiotics for
6 weeks
Once condition begins to improve or
CRP values return to normal, Capital
(usually For 2 Weeks) then antibiotics femur
Note: Duration of antibiotics
are given orally for another 4 weeks.
is 6 week > 4 weeks
epiphysis
Fig. 2a.3
Organisms (S. Aureus)

Can cause Tom Smith Arthritis

multifocal Capital epiphysis of head of femur

IV drug abusers / Foot Human bite Animal bite Sickle cell anemia 1. __________________________

osteomyelitis Initially immobility; Later hypermobility

2. __________________________

Overall Diaphyseal Metaphyseal

 Orthopedics The 20th Book
Brodies Abscess Chronic Osteomyelitis
• Immunocompetent host If dead bone + than chronic OM
• Subacute osteomyelitis>Chronic
Osteomyelitis • Sequestrum
• Upper end tibia
Dead bone (Cause of sinus)
• Sclerotic margin
• Not seen in HIV (+ve) patients
Fig. 2a.4
• Involucrum
Reactive bone
Humerus
Femur

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Sequestrum Fig. 2a.6 • Cloacae
Skin
Normal bone Sinuses through Involucrum
Involucrum
Involucrum • Complications-Amyloidosis, Malignancy
Cloacae Involucrum

Periosteal
reaction

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Sequestrum
Cloacae
Garres OM :
Fig. 2a.5
1. Chronic OM 2. Mandible>Tibia

NPWT: /Vaccum Assisted Closure Treatment

• Remove sequestrum (PAPRIKA Sign)
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Enhances healing • Control the infection(Most important)
pressure -75 to-125 • Fill the gap(Bone graft/Bone Cement)
mm Hg • Soft tissue coverage
20

• NPWT
Fig. 2a.7

Continuous or intermittent gives good granulation

tissue C/I malignancy/Untreated OM/Necrotic
Complications
ESCHAR
- Amyloidosis
e

- Malignancy – Scc
Th

Osteomyelitis

Acute Osteomyelitis Subacute Osteomyelitis Chronic Osteomyelitis

Solid Periosteal Reaction

Femur Humerus
Sequestrum Fig. 2a.11
Skin
Normal bone Involucrum

Involucrum
Involucrum
Fig. 2a.9 Cloacae

Periosteal
reaction
Fig. 2a.8 Sequestrum
Cloacae

Fig. 2a.10

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 The 20th Book Orthopedics
1.Multifocal Osteomyelitis SAPHO Syndrome
Osteomyelitis in newborn: Synovitis Auto immune disorder
1. S. aureus > Group B Strep > Gram Negative. Acne
2. Multifocal (>50% cases) Pustulosis
3. Paucity of Clinical Signs Hyperostosis
4. Hematogenous spread, metaphyseal Osteitis
5. Poor prognosis Treatment: NSAIDS/STEROIDS/DMARD
2. Sickle Cell Anemia : Can cause multifocal osteomyelitis

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Infections of hand
1. Felon 2. Paronychia
• Pulp Space
• • Thumb >index finger • • Mc infection of hand
• Vertical incision • Infects the nail bed. To treat it sometimes
• • part of the nail has to be removed.

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• Osteomyelitis>tenosynovitis

Felon
Paronychia

Fig. 2a.12 Fig. 2a.13

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3. Infectious tenosynovitis (Kanavels sign)
20

Infection of the flexor tendon sheath of finger.

1. Pain on stretch
2. Uniform swelling
3. Flexion of finger
4. Tenderness most specific
along the sheath Index finger tendon
Fusiform
swelling
e

Pain on Slight flexion Midpalmar

extension space (2nd, 3rd
or 4th lumbrical) Thenar space
(1st lumbrical)
Th

Ulnar bursa Radial bursa

Fig. 2a.14 Fig. 2a.15

Tenderness along tendon sheath

• Mycetoma is a chronic progressive granulomatous exogenous

infection of subcutaneous tissue
• Actinomycetoma(rapid) and eumycetoma(slow)
• Thorns/soil –exogenous Multiple discharging sinuses
• Involves all structures except nerves and tendons
• Triad-Tumor like swelling(Painless) ,sinuses and granules
Fig. 2a.16
Mycetoma

383
 2b
Section Tuberculosis
1. Hematogenous spread • Lung is the most common Primary site>L.nodes

• Hematogenous spread and lesions are Paucibacillary • Caries Sicca-Shoulder

2. Paucibasillary
• TB Spine –Potts spine • Spina Ventosa-Digits
3. Spine > Hip > Knee

Potts Spine
• 2 vertebral Disease

• Vertebra and disc

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• Bone and cartilage

• Paradiscal

• Anterior disease Fig. 2b.1

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• Posterior elements and single vertebral disease is -Malignancy Rarest
- Facet joints
- Spinous process

Chronic pain, constitutional

symptoms, night pain T.B.
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Back pain Potts spine Good Prognostic Factors
1.Young age
1st Symptom: pain * 2. Early diease
20

1st sign: Tenderness

1st Neurological Sign:
Increased DTR/Clonus 3. active disease
4. slow worsening
* X-ray, MRI: 5. normal spinal cord
Paradiscal Lesion
Biopsy (CT-guided)
Gold Standard
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Treatment: Rest + ATT.

Middle path regimen If Indicated Surgery
Th

Indications of Surgery (any stage)

- Bowel/Bladder Involvement
- Increasing neurological deficit
- No improvement on
conservative management

Surgery: Transverse
Rib
Sequelae-bony Anterolateral/Anterior process
ankylosis Decompression +
Bone grafting
Pedicle
Anterior Part of
vertebral body
decompression Left side approach
as aorta safer to handle
is better
Anterolateral approach
structures removed
*Never touch posterior elements in TB spine
 The 20th Book Orthopedics

Cobra plate is used for hip arthrodesis

Arthrodesis Ankylosis Arthroplasty

Surgical fusion Pathological Fusion

Bony Fig. 2b.3 Girdlestone excision arthroplasty

Austin (For Chronic hip infections - TB)
Moore
Painless Thompson
Fig. 2b.2

Bony Fibrous
Painless Painless

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Septic arthritis >Tb Spine TB Hip and Knee
Ankylosing spondylitis Rheumatoid arthritis
Fig. 2b.4 Hemiarthoplasty

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TB Arthritis

Peripheral Spine RA (Fibrous) AS (Bony)

(Fibrous ankylosis) (Bony ankylosis)

Fig. 2b.5THR
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Complications of THR :
1. Infection c. Teratogenicity
20

4. Metal Associated

a. Hypersensitivity d. Chromosomal
2. Dislocation abnormalities Fig. 2b.6
b.Renal insufficiency e. Carcinogenesis ? Cemented THR Uncemented THR
3. Mortality –Myocardial infrarection>Cardiorespiratory 1. Elderly 1.Young
2. Cheaper 2. Normal Bone
arrest>(Pulmonary embolism-Thrombolysis) 3. Weak bone quality
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4. Cement 3. Longer ½ life

between bone & metal 4. Costly
Th

Embdic phenomenon – normal internal of 48 hours

T.B.

Chronic pain, constitutional

symptoms, night pain
Femure head migrates
in destroyed joint

Hip
C/F – Gradual pain
Fig. 2b.7 Knee
limp, flexion and synovitis

* Stage I
Synovitis
* Early
Stage II
arthritis
Stage III
Late arthritis
* Subluxation
Stage IV * Stage V TRIPLE
Excision arthroplasty Fibrous deformity
(FABER) + (FADIR + < 1 cm (FADIR + > (Wandering Ankylosis
Lengthening Shortening) 1 cm Shortening) Acetabulum)

Rest + ATT

ATT + Arthroplasty
or Arthrodesis
1. Acetabulum – Commonest site of TB Hip
2. Babcock’s D – Commonest site in head of femur Arthroplasty
Arthrodesis

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 Orthopedics The 20th Book
Hyperanemia – more blood supply – causes periarticular osteopenia.
TRIPLE

* Latest Questions
deformity
Tuberculosis
• Posterior subluxation Rheumatoid arthritis
of tibia Iliotibial band contracture
• External rotation of leg
• Flexion of knee Polio
Low clotting power
Excess bleeding (hemophilia)
PERF

TRIPLE deformity of Knee

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386
 3
Section
Biopsy cofirmatory
Onco Secrets
Benign Malignant
Geographic lesions:
IA: Well defined with sclerotic margins:
Simple Bone Cyst (SBC), Fibrous
dysplasia
Diagnosis
IB: Well defined without sclerotic rim:
Aneurysmal Bone Cyst (ABC) Giant
CB> GCT CB Cell Tumor (GCT)
Age < Part
Epiphysis + IC: Ill defined margins: Chondrosarcoma
1. 1st Decade Ewing Sarcoma Epiphysis Calcification
II Moth Eaten: Multiple Lytic lesions:

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Myeloma metastasis

2. 2nd Decade Osteosarcoma III Permeative: Poorly demarcated,

Ewing’s – maximum number numerous lytic lesions: Ewings sarcoma,
O.osteoma Myeloma, metastasis
of cases seen in 2nd decade >1 decade

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3. After Skeletal maturity GCT
(20-40 yrs) Adamantinoma

4. > 40 years Metstasis>Multiple Myeloma

E.Sarcoma

Metaphysis OS
Fig. 3.1
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Most common sites:
• Unicameral bone cyst Upper end Humerus
(Epiphyseal)
20

• Upper end humerus (Metaphyseal) UBC > CB

• Aneurysmal bone cyst
• Osteoid osteoma
• Osteoma (Ivory or
Compact or Eburnated)
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Lower limb metaphysis
(Tibia and femur)
Femur>Tibia
Skull and facial bones

• Enchondroma Short bones of hand

• Epithelial bone tumors Osteochondroma
Polyostotic bone lesions
a. Adamantinoma (Long bone) Tibia Enchondroma
Th

b. Ameloblastoma Mandible (SCC) GCT

Fibrous Dyslapsia
• Multiple myeloma Lumbar vertebrae
ES
• Metastasis Thoracic vertebrae
Radioresistant Bone Tumors Osteosarcoma
Chondrosarcoma
Metastatic Bone Disease
• Most common primary is Breast > Prostate > Lung
• Most common sites of primary for bone metastasis.
– In males – Prostate > Lung
– In Female – Breast > Lung Metastasis from Bone to Bone – ‘BONE’
– In Children – Neuroblastoma
• Skeletal sites most frequently involved
– Spine (Dorsal)
• Purely Osteoblastic secondaries (PCM)
– Prostate/Carcinoid/Medulloblastoma
 Orthopedics The 20th Book
General Principles for treatment of bone tumors
• Benign and cartilagenous tumors-Operated
Radical resection
• Most common surgery –Wide local excision(3cm margin)
Wide resection
• Cystic lesions –curettage -UBC
• With chemical to kill residual cells-extended curettage-
Marginal resection
Phenol/Liquid N2-ABC/CB/GCT/EC
Intralesional resection • Malignant-Neoadjuvant CT-Sx-AC
(Debulking)
• Ewings is most radiosensitive bone tumor

Tumor
Reactive zone

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Fig. 3.2 Surgical excision

Unicameral bone cyst: Single central cavity Aneurysmal Bone Cyst: Multi Loculated Eccentric
1. 1st decade, metaphyseal Fig. 3.3 1. 2nd decade, metaphyseal
2. Cortex break and fall in the cavity

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2. Fluid – fluid level on MRI – ABC
– fallen leaf sign 3. Tibia most common site
3. Trap doors sign – cortex break, 4. Rx: Extended curretage
and it moves up and down due to fluid
Rx: 1. Curettage + Bone grafting
2. Aspiration + steroids
3. Aspiration + slerosants
Fig. 3.4
th
20
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Brodie’s abscess/Brown tumor Fig. 3.5

Eosinophilic granuloma Non ossifying fibroma
Th

Enchondroma Aneurysmal bone cyst

Chondroblastoma Giant cell tumor
Hemophilia Eccentric

BEECH – Cyst NAG – Expands

(Cyst in centre) Expansile eccentric cysts
(Simple bone cyst)

Chondroblastoma Fibrous Cortical Defect / Non Ossifying Fibroma

:Codman’s tumor • Most common benign lesion

Ephiphysis + Calcification; Treatment: • 1st decade
Extended curettage • Metaphyseal
Fig. 3.6 • Self resolving
• It is not premalignant

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 The 20th Book
Osteochondroma
- Bone with cartilage cap
Diaphyseal aclasia-
Development malformation
Large to feel small on xrays
Pain • Grows away from bone
• Grows till skeletal maturity
Bursitis
Orthopedics
Exostosis
Malignancy Single - < 1% Multiple -6%
Malignant Degeneration Chondrosarcoma
• Cartilage thickness >2 cm
• Rapid increase in size
• Growth after skeletal maturity
• Loss of differentiation
Treatment :
Extraperiosteal resection
Fig. 3.7
Removal along with
periosteum

Osteoid Osteoma : Nidus : Diaphyseal

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Ivory Osteoma
Night pain relieved on salicylates • Compact Osteoma Or Eburnated Osteoma
• Skull Vault
Diaphyseal
• Requires No Treatment
Nidus(seed) in cortex -lytic lesion

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surrounded by sclerosis
Osteoblastic and Osteolytic
cells are seen
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1. Premalignant -5% cases
2. Most common tumor of bones
Enchondroma of hand and feet.
3. On biopsy hyaline cartilage seen
20

4. Rx.: Extended curettage

Olliers • OlliErs syndrome-Only

Fig. 3.8
(30% malignant) enchondromas
Mafucci
(100% malignant) • Mafucci syndrome
(Many things)-multiple
enchondroma + Fig. 3.9
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hemangiomas+phleboliths Fig. 3.10 Fig. 3.11

GCT upper end tibia ABC upper end tibia
Th

Giant Cell Tumor

Lower end Radius Upper end Tibia Upper end Femur Lower end Femur

Fig. 3.12 Fig. 3.13 Fig. 3.14 Fig. 3.15

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 Orthopedics The 20th Book
GCT Common in females
Fibrous dysplasia : Shepheral crook deformity
McCune-Albright syndrome refers to polyostotic fibrous
20-40 years Malignant component dysplasia, cutaneous pigmentation(café au lait spots), and
Lower end femur Mononuclear giant endocrine abnormalities (Precoceous puberty).
3% Mets to Lungs cells - Common in female

Treatment of Osteclastoma (GCT)

1. Extended Curettage by PMMA or phenol or liquid nitrogen

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and bone grafting it is procedure of choice for most lesions.
2. Excision
Shepherd Crook deformity
Lower end of ulna
Upper end of fibula
3. Excision and replacement by vascularized bone graft

Bo
Lower end of radius where upper end of fibula is grafted

Giant cell variants (Tumor with giant cells)

•Brown tumor of hyper parathyroidism
•Aneurysmal bone cyst (closest) and unicameral bone cyst
•Non ossifying fibroma (commonest) and Fibrous dysplasia Rind sign
•Osteoblastoma and Osteosarcoma Fig. 3.16 Fig. 3.17 Fig. 3.18
th
•Chondromyxoid fibroma and Chondroblastoma
Note: (GCT – Mononuclear & Giant cells
Both cells have identical nucleus)
LCH Hemangioma
20

• Letterer Siwe Disease-<3 years Corduroy

Fatal pattern on X-ray
• Hand Schuller Christian Disease-
Lytic skull lesions,exophthalmos and - Jail bar appearance
Diabetes Insipidus
• Eosinophilic Granuloma-Solitary Fig. 3.19 Polka dot
e

bone or lung Lesion(Pumonary on CT Scan

Histiocytosis X)-skull most
common bevelled lytic lesions CHORDOMA
Th

Biopsy-Cells with Birbeck

• Origin notochordal remnants
Granules-Tennis racket appearance
• Second common malignancy of spine after
Spontaneous Resolution
multiple myeloma
• Most commonly in sacrum
• Physaliferous cells are seen
• Treatment is surgical excision +/- radiation

Synovial Cell Sarcoma

• The term ‘synovial cell sarcoma’ is a misnomer as synovial cell sarcomas do not arise from synovium.
• Characteristic translocation (X; 18) giving rise to SYT – SSX fusion genes.
• Near the joint -bursae.
• Synovial sarcoma is biphasic tumor with epithelial and mesenchymal components
• Treatment is excision

390
 The 20th Book Orthopedics
Pulsatile bone tumors.
1. Osteosarcoma>ABC>Angioendothelioma of bone > GCT | 2. Amongst metastasis Renal and thyroid have pulsatile metastasis

Osteosarcoma
Osteosarcoma is the cancer of young • Osteitis deformans (paget’s)
• Radiation induced sarcoma
• Radioresistant bone tumor
• Matrix(OSTEOID) forming bone tumor
• Osteosarcoma and soft tissue sarcomas are
associated with germline retinoblastomas Fig. 3.20

ok
Common site: lower end femur
Pain/ Night pain : Osteosarcoma
Treatment Prognosis
T 10 protocol • Extent of disease • Systemic mets>pulmonary mets
• Etoposide-NOT used • Pulmonary mets (Mc site • Grade of lesion

Bo
• Methotrexate is very of mets) • OS is malignancy causing
important agent pneumothorax

• Origin –Marrow cells-Marrow biopsy useful to see

Ewing sarcoma the extent of the disease. Treatment
• Age-Second decade > first Decade • Pain - universal complaint Preoperative chemotherapy
• Bone-Femur Diaphysis • Presents like Osteomyelitis Wide excision (or amputation)
Chemotherapy for 1 years
Genetic Defects: Round cell tumor Subsequently radiotherapy
th
with glycogen positive cells. may be given.
• Ewing sarcoma is round cell tumor with Prognosis
glycogen positive cells Poor prognostic factors for
• The t(11;22) is the most common ewings sarcoma
20

translocation, Other diagnostic • Age>12/Male/Proximal/Fever/Anemia Fig. 3.21

translocations are - t(21;22), and t(7;22) • Increased TLC/Platelets/ESR/LDH
• Trisomy 8 ,trisomy 12 • Metastasis
• MIC2(CD99) is a specific marker • Chemoresistant
• Relapse
e
Th

Chondrosarcoma
• Chondrosarcoma - Pelvis
• Hyperglycemia
• Best prognosis amongst the malignant
tumors.
Fig. 3.22
Multiple Myeloma Plasma Cell Leukemia
• Bone Pains + high Esr + hypercalcemia Plasma cell leukemia->
• Criterion 20% plasma cells in
1) M Proteins(serum/urine) peripheral smear
2) Bone Marrow plasma cells/Plasmacytoma
3) End Organ Damage (Lesions/anemia/hypercalcemia/increased
Cr/
Hyperviscosity/Amyloidosis/bacterial Infections)
• Punched Out Lytic Lesions

391
 Orthopedics The 20th Book
Bevelled lesion - E. granulosoma
Skull Lytic Lesions
A A

M Mets

Eosinophilic granulosoma
E
Langerhans cell
L histocytosis/Lymphoma
B

T Tuberculosis (TB)
H Hyperparathyroidism

ok
Permeative lesions
O Osteomyelitis
LCH
R Radiotherapy

Bo
M Multiple Myeloma (MM) C

E Epidermoid
Fig. 3.23
Punched out
th
Lytic lesions
MM
Salt pepper skull Hyperparathyroidism
20

Note: Some other skull X-rays which are important.

D E
D1 D2
e
Th

Fig. 3.24 Fig. 3.25

Cotton wool skull Osteoporosis circumscipta Hair on end appearance

392
 4
Section Nerve Injury
Palmaris longus – hand to fingertip (graft) of Radiation n → Most common n affected
Seddon’s Classification tendon Best prognosis
Plantaris – forearm to fingertip (if need longer) No tests
Neuropraxia:Tinels Sign Negative Fracture end of humerus →Most
common cause of radial nerve injury
• Physiological block in nerve conduction /100%
Recovery/One Moment Sunderland Classification of
nerve injury and its relation
Axonotmesis:Tinels sign positive and progressive to seddon’s classification
• Damage to axon Sheath/motor march
Classifications
Sunderland Seddon’s
I Neuropraxia
Neurotmesis:Tinels sign is positive and non-progressive II, III, IV Axonotmesis
V Neurotmesis
• Complete nerve transection

ok
Fig. 4.1

Flex metacarpophalangeal
Extend interphalangeals

Bo
"Regimental Badge" area

Injury:
1. Shoulder dislocation
2. Fracture-upper end of
* Axillary Nerve Sensory Zone humerus Fig. 4.2 Fig. 4.3
(Regimental Badge Sign) 3. Injection into deltoid Lumbrical Lumbrical

Ulnar Nerve Claw hand-Ulnar/median Median Nerve

th
Claw
Test for ulnar nerve hand
20

1 Card test-palmar interossei

Pointing index-Median Nerve

Flexors (FDS+Lateral 1/2 FDP)

Oschner clasp test

Benediction test
Pen test-Median nerve
abductor pollicis brebis
e

2 Igawa test - Dorsal Interossei

3 *Book test-adductor pollicis

Th

Adductor
pollicis
(Ulnar nerve)

Negative
(Normal) Thumb in
same plane

*Froment sign Ulnar nerve palsy

as palm

Flexor pollicis

*Ape (Simian) thumb deformity

and substitutes
for adductor pollicis
longus (Anterior
interossei nerve)
Median Nerve

5 Wartenberg sign-abducted
little finger-Ulnar nerve palsy Flexion at MCP
(Knuckle bend)

Flexion
by FDP
Extension at
IP Joints
Supplied by
anterior
interossei
Flexor nerve
*Knuckle bender splint- Ulnar nerve/Median nerve pollices longus

* Latest Questions
Kiloh Nevin sign-AIN
 Orthopedics The 20th Book
Redial Nerve
Radial nerve Crutch palsy
Saturday night palsy
Honeymoon palsy

Wrist Drop

ECRL/B
BR

Dorsum of 1st Web space

Radial nerve autonomous zone

ok
Injury to Nerve

Open (Neurotmesis) Closed

Finger Drop Sunderland 5

Repair * Splint

Bo
- Radial Nerve – Cockup splint
- Ulnar/Median N. – K-nuckble
Bender Splint
(Most advise initially expectant
management)

* Cock-up splint-Radial nerve Direct repair Repair with graft

e.g. Sural nerve
Modified Jones Transfer
Progression EMG (2-3 wks) *Neuropraxia Sunderland 1
100% Recovery
th
• Pronator Teres to Extensor carpi
radialis longus/Extensor carpi Defibrillation
radialis brevis Satisfactory Unsatisfactory
• Flexor carpi ulnaris to Extensor
digitorum communis
• Flexor carpi radialis to Extensor
20

pollicis longus (Extensor pollicis

brevis and Abductor pollicis
longus)

Flexion of elbow
e

Abduction of shoulder
External rotation at shoulder
Th

Supination of forearm

Erbs palsy Klumpke’s palsy

C5,C6 Nerve root C8 T1 nerve root

Policeman or Waiter More common

Claw hand
tip deformity Waiter tip deformity +
Horner’s syndrome
Better prognosis

Fig. 4.4

394
 The 20th Book Orthopedics
NERVE ENTRAPMENT SYNDROMES / COMPRESSION NEUROPATHY

– Phalen’s / Reverse Phalen’s Test

1. Adsons test
2. Wrights test

ok
3. Roos test

Thoracic outlet syndrome Allens test

Bo
Associated with
Thoracic outlet
syndrome

Fig. 4.5
Cervical rib
Adson’s Test Roos Test Wright Test Fig. 4.9
th
Plan A
Rest + NSAIDs
↓
Local steroids → Surgery
20

Fig. 4.6 Fig. 4.7 Fig. 4.8

e
Th

395
 5 General +
Extra articular fracture – close reduced
Intra articular fracture – open reduced

Section Upper Limb Traumatology

Fracture Break in the cortex Consistent sign - Tenderness

Surest sign
• Abnormal mobility
• Failure to transmit movements proximally
• Crepitus

Most Common Most common tendon – Supra spiratans > Biceps > Tendoachilles
Facture at Birth Clavicle
Facture in Children Forearm (R>U)

ok
Dislocation Shoulder (Anterior)
Dislocation in Children Elbow (post)
Rarest Dislocation Ankle
Sprain - Lateral Sprain – Anterior Talofibular ligament/
- Medial On medial side : - Deltoid ligament

Bo
Tendon injury
Markers of bone resorption Markers of bone formation
• Hydroxyproline/Pyridinoline/deoxypyridinoline/ • Osteocalcin/ALP/Serum procollagen
Telopeptides (N and C terminal) Type 1(N and C terminal)
th
Stages of Bone Union
• Hematoma – blood –from marrow + with cells
• Granulation tissue
20

• Callus -3 weeks-Micromovements allows callus formation

• Consolidation
Fig. 5.1
• Remodelling

Non union – Bone not united at 9 months

e

Primary SeCoNdary Hypertrophic NU Atrophic NU

Excess callus Avascular bone ends.
Callus Absent Present
Th

formation Rx Freshen the margin

Biological Rx Stabilization +
healing No Yes
Bone grafting +
Examples Plating Nailing/Casts Stabiliazation

Cubitus Valgus

Cubitus Varus

Fig. 5.3
Fig. 5.2
 The 20th Book Orthopedics
Swimmers – Most common joint damaged – shoulder
Gustilo and Anderson Classification is used for open fracture Treatment of open fracture – Debridement + external fixation

ok
Shoulder Dislocation

Anterior Inferior Posterior

Down and Out Dugas Test Luxatio

Bo
Erecta Up and In

Callaway test

Electric Empty
Hamilton Ruler test bulb glenoid
sign sign

Fig. 5.4a Fig. 5.4b

Bryant’s test
th
Anterior Dislocation Posterior Dislocation
In anterior dislocation Reduction Kochers In posterior dislocation
Arm – abducted Head at level of
Head – below the joint joint, adduction
20

Epilepsy / Electric Shock

Recurrent Shoulder Dislocation

Anterior Posterior
e
Th

Anteriomedial
defect
in humeral head
seen in posterior
dislocation

Fig. 5.6

Fig. 5.5

Test anterior instability

Test for Shoulder Instability Matsen's classification for recurrent
instability of shoulder Surgery for Instability
•• Anterior: Anterior Drawer / Apprehension test /
Fulcrum / Crank TUBS AMBRII • Bankarts repair
T: Traumatic A: Atraumatic • Putti plat-Double
•• Posterior: Jerk test U: Unidirectional M: Multidirectional breasting of
•• Inferior: Sulcus test B: Bankart's B: Bilateral Subscapularis
S: Surgery R: Rehabilitationa • Bristow Latarjet-
I: Inferior capsular
Better prognosis shift procedure Coracoid transfer
I: Internal closure to anterior glenoid

Good prognosis Poor prognosis

Fig. 5.5 397
 Orthopedics The 20th Book

“FOOSH” (Fracture due to fall on outstretched hand)

Anterior of inferior Axillary, (circumflex humeral) Fracture clavicle

shoulder dislocation
Fracture surgical neck
humerus
Fracture shaft humerus
Fracture supracondylar
humerus
Medial condyle humerus
Cubitus valgus
Monteggia fracture dislocation
Volkman’s ischemic contracture
nerve Holstein lewis fracture
Surgical neck of humerus fracture
lower 1/3rd humerus
Axillary nerve fracture can damage
Supracondylar fracture humerus
radial nerve
Lateral condyle fracture humerus
Radial nerve Head and neck fracture of radius
AIN > Median > Radial >Ulnar Galeazzi fracture dislocation
(AMRU) Colle's fracture (Most common)
Ulnar nerve
Fig. 5.7 Radial styloid fracture
Trady Unar Narve Palsy Fracture scaphoid
Posterior interosseous nerve
Anterior interosseous nerve

ok
Lunate dislocation Median nerve
Hip dislocation Sciatic nerve Foot drop Fractures of necessity (requiring surgery)
Knee dislocation C. Peroneal nerve Fig. 5.8 • Galeazzi fracture dislocation
• Lateral condyle fracture humerus
• Displaced fracture olecranon and patella
Humerus (Indications of surgery of # in humerus) • Fracture neck femur

Bo
• Vascular injury • Monteggia fracture in adults
• Articular fractures
• Multiple fracture
• Pathological fracture Clavicle
• Radial nerve involvement after reduction • Most common bone to fracture
• Middle 1/3rd (Mc)
• At junction of Medial 2/3rd and Lateral 1/3rd
th
• Observation/sling/figure of 8 bandage
Three point relationship at Elbow In 90° flexion of elbow.
• Operative indications are increasing
Lateral Epi, Medial Epi + Olecranon make a triangle
20

Fracture Supracondylar Humerus

• Undisplaced fracture fat pad sign
• Displaced fracture- Posteromedial displacement
e

• Treatment: Reduction + K wire

• Complication : Cubitus varus
Th

(Gun stock deformity)

Fig. 5.9
Brachial artery injury can cause Valgus – lateral
pulselessness. (closed reduction and look for Cubitus varus – medial
reappearance of pulse Carrying angle – due to trochlea lower in female
↓
Smith & Dunlop tractions used for it More in female

Fracture Lateral condyle Humerus

Most common complication – Gun stock Intra-articular

deformity, open reduction + K wire fixation
(Cubitus varus) Cubitus valgus deformity
Treatment: Lateral closing, Wedge osteotomy

398
 The 20th Book Orthopedics
Fig. 5.10 Monteggia fracture Anterior Fig. 5.12 Galeazzi Fracture

Commonest Triangular
I II fibrocartilage
Posterior complex
damage

Lateral
Interosseous
membrane
damage
Fractures of necessity
(requiring surgery)
Fracture ulna + dislocation III Both bones fracture monteggia
classification — Bado
IV • Galeazzi fracture dislocation
radial head • Lateral condyle fracture
Fig. 5.11 Bado Classification humerus
Rx. Surgery: Bell Tawse • Displaced fracture olecranon
procedure and patella

ok
• Fracture neck femur
• Monteggia fracture in adults
• Articular fractures

Bo
Extra-articular - Distal end radius fracture

PC AS
th
20

Explain to the rule of splintage

e

Fig. 5.15 Normal

Th

Dinner fork deformity

Fig. 5.17 - Smith
Fig. 5.16
Fig. 5.13 Fig. 5.14 Garden spade deformity

Complications of Colles Fracture:

1.Finger stiffness (Mc) 4. Carpal tunnel syndrome
2. Dinner fork deformity 5. Sudeck’s dystrophy
3. Rupture of EPL (Extensor pollicis longus)

399
 Orthopedics The 20th Book

Pulled Elbow
• Nursemaids elbow

• Radial head out of Annular ligament

• Age 1 to 4 years
• Pronation
• Forceful supination is treatment to position the head
Barton fracture - Intra-articular back

Intra-articular fracture lower radius with wrist subluxation.

ok
Terry thomas sign/David Letterman sign

Scaphoid Fracture Scapholunate Dislocation

Bo
• Anatomical Snuffbox tenderness
• Most common carpal bone to fracture
• Fractures at the waist
• Distal pole fracture in children
• Blood supply distal to proximal
• Glass holding cast
Fig. 5.18
th
Bennett's Rolando
Bennetts fracture Rolando fracture
20

dislocation Pull by
adductor pollicis
Most important
Intra-articular
pull is by Intra-articular
fracture
abductor Comminuted
Base of 1st pollicis longus
metacarpal pull fracture of Base
by abductor of 1st metacarpal
pollicis longus
Fig. 5.19
Fig. 5.20

Wrist Dislocation Phalanx

e

L Capitate
1. Perilunate (Mc): Lunate in
R Lunate
place other carpal bones
Th

dislocate Radius

2. Lunate dislocation :Lunate

dislocates
Fig. 5.21
Fig. 5.22
PIE sign Spilled
Normal Lunate Perilunate Teapot/cup sign

Articular Non-articular

Restricted Active and Active

movements passive

400
 The 20th Book Orthopedics

Compartment Syndrome - Capillary Network Volkmann’s Ischaemic Contracture (VIC)

Most common area-Deep posterior compartment of leg>deep
Area Area • Deep Flexor compartment Forearm
Flexor forearm

Pain out of proportion to injury

Symptom Muscle • FDP>FPL

Pain on passive stretch at distal most joint of extremity • AIN>MEDIAN>ULNAR

Sign Nerve

ok
Pulse is not a reliable indicator-as microcirculation is affected
Pressure <11 mm Hg Calf Pressure during walking-200-300 mm Hg • TURN BUCKLE SPLINT
Normal Pressure Splint
Fasciotomy(Release upto deep fascia)
Treatment Surgery • Maxpage Muscle Sliding Operation
Pressure >30 mmHg Neurovascular Compromise

Bo
Indications
Pulse is not reliable indicator – as microcirculation is
Sudecks Dystrophy
affected
• Crps-Complex Regional Pain Syndrome
Myositis Ossificans
• Type 1 Traumatic(colles)
• History of Massage often present Stimulus
• Unilateral • Type 2 Nerve Injury(median)
th
• Elbow most common area involved
• Sympathetic Overactivity
• Brachialis>Biceps
• Immobilization 1st 3 weeks • Red hot shiny skin- Response
• Only Active Exercises No Passive Exercises-3 weeks to 1 year • Patchy Osteopenia- Response
20

• >1 year-Surgery
• Lankfort’s Triad(stimulus, activity, response)
• Exercises To Continue
• Results Poor
e
Th

401
 6 Spine + Pelvis +
Section
Lower Limb Traumatology
Scoliosis Congenital Upper border
of scoliosis
Cervical curve
Perpendiculars
Idiopathic 58°
Cobb's angle
Thoracic curve used to
management
Perpendiculars

A B C
Lumbar curve

Lower border of scoliosis

Pelvic curve Cobb's angle
Fig. 6.1

ok
Wedge
Semisegmented Fully segmented vertebrae Block Unsegmented Unsegmented bar
hemivertebrae vertebrae bar with hemivertebrae
Fig. 6.2

Spinal Fractures
1. Jefferson fracture: Burst fracture of C1
2. Hangman's fracture: Traumatic spondylolisthesis of

Bo
C2(axis) over C3
3. Burst fracture:Vertical compression injuries
4. Whiplash injury: Sprained neck.
Easier were called as railroad spine/ Erichsen's disease
Hyperextension followed by flexion.
5. Flexion – Compression:
th
a. Wedge compression
b. Tear drop (may have bone fragment from antero-
inferior part of vertebra).
Anterior
column 6. Flexion – distraction: Facet dislocation
20

Posterior 7. Clay- Shoveler's fracture: Avulsion fractures of spinous

Posterior column
column
process of C7 > D1 Vertebra
Fig. 6.3 8. Motor Cyclists fracture (Hinged fracture): Transverse
Columns of acetabulum fracture across base of skull leading to separation into
anterior – posterior.
9. Undertakers fracture: Tearing of C6-7 disc space causing
Spur Sign → Both column fracture subluxation, caused by Undertaker's handling the dead
e

of acetabulum body.
Spinal Cord Injury Without Obvious Radiological
Abnormality (SCIWORA): Pediatric injury (<8yrs). X-
Th

rays are normal but there is neural deficit. This is due to

lax ligaments permitting traction injury to cord. Cervical
spine is most commonly affected.
Fig. 6.4

Spur sign
TRENDELENBERG TEST-DROP
Normal hip abductors Weak hip abductors
Trendelenburg's test Thomas test
Normal hip
Hip abductors-gluteus medius and Drop of pelvis
Thomas test
gluteus minimus on normal side
on bearing weight
for hip flexion
Superior gluteal nerve on diseased hip
deformity

Positive means drop of pelvis on

opposite(normal)side
15°
Bilateral –waddling gait
Fig. 6.6: Spur Sign Fig. 6.5
Fig. 6.6
Normal is Negative (No drop)
 The 20th Book Orthopedics

Fracture Neck of Femur Fracture Intertrochanteric Femur

60/f 80/M
Intracapsular More common
60/F Extra pain
↓Pain Extra shortening
↓Shortening Extra external rotation
↓External (Lateral border of foot
rotation touches
Fig 6.7 : Garden Classification the bed)

• Proximal femoral nail >

ok
Dynamic hip screw
30° Horizontal

70° Fracture Neck of Femur – Treatment

A Fracture 1. <65 years, £ 3 week
line
• Closed reduction and internal fixation with multiple screw
C

Bo
50° is the treatment of choice. In basicarvical fracture Dynamic
Hip Screw can be done.
– If closed reduction is not possible open reduction and
B
screw fixation is indicated.
According to the angle the 2. <65 years, > 3 week fracture,
Fig 6.8 : Pauwels Classification fracture makes with the osteotomy/Bone grafting + fixation.
horizontal line 3. ³ 65 years
Anatomical (level of fracture)
• No pre-existing arthritis – hemiarthroplasty
th
Risk of AVN Subcapital > Transcervical > Intertrochanteric
4 Pre-existing arthritis (any age) — total hip replacement
Complication are Osteonecrosis(AVN) > Nonunion > arthritis

Delbert Classification for Pediatric fracture

20

neck femur
Type
1. Transepiphyseal
2. Transcervical
3. Cervicotrochanteric
Fig. 6.10 DHS
4. Intertrochanteric
e

Incidence 2 > 3 > 4 > 1.

Fig. 6.11
Th

Fig. 6.9 PFN Ring (Most trabblesome part)

Diagnostic Criterion for Fat Embolism – Gurd's Minor Criteria (8)

Gurd's Major Criteria (4) Ÿ Tachycardia
Ÿ Axillary or subconjunctival petechia Ÿ Pyrexia Thomas Splint
Ÿ PaO2 below 60 mmHg Ÿ ANEMIA Fig. 6.12
Ÿ CNS depression Ÿ Thrombocytopenia
Ÿ Pulmonary oedema Ÿ Fat globules present in sputum
Ÿ Fat present in urine (GURD TEST)

1 major + 4 minor = fat embolism

Ÿ Increasing ESR Age wise treatment of SoF (Shaft of Femur)
Ÿ Emboli present in retina

spica TENS (Titanium I/L Nail ≥10 yr

<5 yr Elastic Nail System) (Interlock)
5-10yr

403
 Orthopedics The 20th Book
Hip dislocation

Pure dislocation Fracture dislocation

without fracture (Atypical Positions)

Anterior Posterior (90%)

Anterior
*+Head
Lengthening
anterior
* Shortening
Typical positions + Head posterior (Gluteal)
Central Posterior Fracture dislocation

dislocation
Usually posterior
Flexion, abduction and Flexion, adduction and
Head in pelvis - Head gluteal (posterior)
external rotation (FABER) internal rotation (FADIR)
(per rectal) - Shortening

ok
- Clinical presentation
of FADIR or FABER lost
in fracture dislocations
Flexed &
adducted

*
thigh
shortening
Pipkins type IV:
Dislocation with fracture
femur head & acetabulum

Bo
Internal
rotation
of lower
limb NOTE : “Any mass that moves with rotation of thigh is femoral head.”

Floating
Knee
th
Anterior dislocation Closed reduction of dislocation

Posterior dislocation of hip Floating Knee Fig. 6.13

20

Principle bones
Vascular sign narath positive above & below
(Pulsation not felt) is positive
lose contact
Normally—Negative
Ottawa Ankle Rules
The Ottawa Ankle Rules were developed to assist in making the decision to order an xray in a patient with ankle injury. X-ray examination is called
for if there is:
1. Pain around the malleolus
e

2. Inability to take weight on the ankle immedialtely after the injury

3. Inability to take four steps in Emergency Department
4. Bone tenderness at the posterior edge or tip of the medial or lateral malleolus or the base of the fifth metatarsal bone.
Th

If x-ray examination is considered necessary, antero-posterior, lateral and 'mortise (30 degree oblique) views of the ankle should be obtained.

Angles in orthopedics

Normal is 20-40 degree, decreases

1. Q angle →→ measure around knee joint
in fracture calcaneusm
→ increased in patellar subluxation/ dislocation
Fig. 6.14
2. Cobb’s angle → Scoliosis

Normal 3. Kites angle → CTEV

95-105
degree
(increase in
fracture
calcaneum)

404
 The 20th Book Orthopedics
Plaster casts and their uses:
Fig. 6.17
Name Use

Minerva cast Cervical spine disease Fig. 6.16

Risser’s cast Scoliosis
Turn-buckle cast Scoliosis
Shoulder spica* Shoulder immobilization Fig. 6.15 Cylinder cast
PTB cast
U-slab Hanging cast
U-Slab/hanging cast Fracture of the humerus
Hip spica Fracture of the femur
Common Splints/Braces and their Users:
Cylinder cast/tube cast Fracture of the patella
Patellar tendon bearing Fracture of the tibia

ok
Cast (PTB cast)
Colle’s cast (Hand shaking) Fracture lower end radius
• Cock-up splint
Glass holding cast Fracture scaphoidQ
• Knuckle bender splint

Bo
Extra articular
fracture of
distal end radius
• Dunlop trac on
• Smith’s trac on
Hand shaking
cast

Hand

Fig. 6.19
shaking
to reduce

Fig. 6.18 Glass holding cast

Hand shaking
th
20

• Thomas splint
• Bohler-Braun splint
• Dennis Brown splint

Fig. 6.20 Fig. 6.21 Clavicle figure 8 • Gallow’s trac on

Dunlops

• Russell’s trac on
e

a
b
w
Th

• Agnes- Hunt trac on

w • Palvic harness, Von Rosen splint Ilfeld or Craig

Fig. 6.22 Fig. 6.23 BB splint w splint or Bachelor cast
Mallet-finger-splint

• Milwaukee brace

Fig. 6.25
Russells traction Milwaukee brace • Minnerva cast. Halo device
Fig. 6.24
• Risser’s cast. Milwaukee brace, Boston brace

405
 Runner’s fracture – involves lower part of fibula
Lauge Hansen classification → for ankle fracture
Orthopedics The 20th Book
I = fracture which involves the joint
surface or have concomitant joint injuries

* Jefferson # -atlas (C1)

* Hangman's # -axis (C2)
Hangman's fracture
Jefferson's fracture

ok
* Night stick # shaft ulna
*Colles # -extra-articular Chauffers Colles fracture
radius with dorsal
displacement and smith

Bo
(Reverse colles)

(I) Chauffers #
-radial styloid

Bucket handle open book pelvic fracture

th
(I) Bartons # -intra-articular
radius with subluxation
of wrist
*(I) Crescent # -iliac
blade with SI
20

Straddle # -bilateral
pubic rami
Malgaigne
Straddle
(I) Malgaigne # -ipsilateral pubic and SI

(I) Maisonneuve # -spiral fracture

neck of fibula with medial malleolus
e

* (I) Pilon # -intra-articular

Th

Pilon fracture
fracture tibial end Classification
1. Allman's: Fracture clavicle
2. Campbells/ Rockwood: AC Joint

* (I) Aviators # -neck of the talus 3.

4.
Neers: Proximal Humerus
Gartland: Supracondylar Humerus
5. Milch: Lateral Condyle Humerus
6. Masons: Head Radius
Jones # -base of 5th metatarsal 7. Bados: Monteggia
Aviators fracture 8. Frykmanns/ Fernandez: Colles
9. Dennis: 3 Columns of spine
10. Young & Burges/Tiles: Pelvis
11. Judet & Lectournel: Acetabulum
12. Thompson & Epstein: Posterior dislocation
13. Pipkins: Head of femur
Jones
14. Gardens/Pauwels/Anatomical: Neck femur
fracture 15. Boyd & Griffith/ Evans: Intertrochanteric fracture
Pseudo-Jones 16. Winquist & Hansen's: Shaft femur
fracture
17. Schatzkers: Proximal tibia
(I) Lover’s # -calcaneum fracture 18. Ruedi and Allgower : Distal tibia
19. Hawkins : Neck talus
20. Essex Lopresti (X-ray)/ Sanders(CT Scan):
Calcaneum
Left foot
21. Gustilo Anderson: Open fracture
Jones - pseudo jones 22. Tscherne: Soft tissue injury in closed fracture

406
 The 20th Book Orthopedics

I = fracture which involves the joint

surface or have concomitant joint injuries

Supracondylar fracture Clay-shoveller’s # -spinous process

lower cervical vertebrae

Proximal humerus fractures

Monteggia
Malgaigne # -supracondylar

ok
(I) Monteggia # -upper ulnar *
with dislocation of
proximal radioulnar joint

(I) Galeazzi # -lower radius with

Galeazzi fracture dislocation of distal radioulnar

Bo
(I) Rolando # -intra *
articular first
metacarpal base

(I) Bennets # -1st *

metacarpal base
Boxers fracture with dislocation
th
Mallet Finger # -avulsion *
of extensor tendon from
distal phalanx

Boxers # -5th metacarpal neck

20

Bumper fracture (I) Dashboard # -posterior dislocation

with acetabulum fracture

(I) Bumper # -lateral tibial condyle

e

Cotton fracture (I) Cottons # -trimalleolar *

Th

(I) Potts # -bimalleolar *

Potts fracture (I) Choparts # -dislocation
through intertarsal joints

March # -2nd and 3rd metatarsal neck *

Choparts fracture
Lisfrancs fracture

(I) Lisfranc # -tarsometatarsal joints *

*Latest Questions

March fracture

407
 1. Open injuries- external fixator
2. Tension band wiring: Fracture patella or olecranon
3. Upper limb bones plating
4. lower limb nails
Orthopedics The 20th Book
Treatment of Fractures
• Extraarticular Fractures CR
• Intrarticular Fractures OR
• Small Bone Fractures Screws/K Wires
• Children Non Operative Except Periarticular
Fractures
• Children K(Kirschner) Wires

TYPES OF PLATE
1. Dynamic compression plates: These are used to fix the

ok
diaphyseal region and can be used as neutralization
A B C
Buttress mode or compression mode.
2. LCDCP: Limited contact–DCP It decreases the contact Fig. 6.27 Nail
with bone surface hence preserving bone vascularity.
3. Locking Compression plate -The Screw locks in screw Distraction Histiogenesis

Bo
holes of the plates hence the name – locking plates.
Indications of locking plates : Tibia
(shin bone)
External
Ÿ Osteopenic bone fixator
Fracture
Ÿ Metaphyseal areas
Ÿ Periprosthetic fractures
Ÿ Failed fixation (nonunion)
External
th
fixation
20

Fig. 6.28: Ilizarov Fixator

e
Th

Fig. 6.29Tension Band Wiring Fig. 6.30 Fig. 6.31

Osteotome Bone Curette

Screw threads
Cortical screw Cancellous screw Locking head screw

Fig. 6.32 Screws & Plates Fixation Fig. 6.33 DCP Fig. 6.34 LCDCP Fig. 6.35 LCP

408
 The 20th Book Orthopedics

Fig. 6.36 Bone Cutter Fig. 6.37 Bone Nibbler Double Action Fig. 6.38 Bone Holding Forceps

ok
Bo
Fig. 6.39 Bone Plate Holding Forceps Fig. 6.40 Fergusson Bone Holding Forceps
th Fig. 6.41 Lane Bone Holding Forceps
20
e
Th

409
 7
Section
Arthritis

RA involves upper cervical spine

OA

RA

Fig. 7.1

Fig. 7.2

ok
Osteoarthritis Rheumatoid Arthritis Psoriatic Arthritis (Caspar Criterion)

Involved PIP, DIP and 1 CMC PIP, MCP, Wrist DIP, PIP and any joint
st

Spared
Clinical cases and senarios
Bo
(Carpometacarpal) Joints
MCP (Metacarpo phalangeal), DIP joint usually
Wrist and Ankle

Ankylosing spondylitis* Sacro iliac joint

Rheumatoid arthritis Metacarpophalangeal joint

th
Pseudogout* Knee

Gout* MTP joint of Great Toe

20

Septic Knee

Syphilitic arthritis* Knee

Gonococcal arthritis* Knee

Diabetic charcot joint* Foot joint (midtarsals)

e

Senile Osteoporosis* Vertebra

Pagets disease* Pelvic bones > Femur > Skull > Tibia
Th

Osteochondritis dessicans* Knee > Elbow

Actinomycosis* Mandible

Haemophilic arthritis* Knee (Children-Ankle)

Acute Osteomyeltiis* Lower end of femur (Metaphysis)

Brodies Abscess* Upper end of Tibia

 The 20th Book Orthopedics

Fig. 7.3 OA: Fig. 7.4 Fig. 7.5

Genu Varus
Involves
Wedge to 2/3rds
Medial across tibial
plateau width MCL

compartment laxity

Quadriceps Lateral
Wasted closing
and medial
opening
wedge Re-tensioned
MCL

A B
Osteoarthritis – Management: 2.Young 3. Elderly
1. Initial • Surgery for young –HTO(High • 60 or More-TKR (Total Knee

ok
• Initial treatment conservative Tibial Osteotomy) (upto 20 Replacement)(Movement
• If activities of daily living are degrees deformity) normal,proprioception good and
affected-surgery mild insignificant Sensory loss)

Bo
The 1987 Revised Criteria For Diagnosis of RA
OA Knee RA Knee
Varus arthritis Valgus synovitis 1. Guidelines for classification 4 of 7 criterion are
sclerosis Oeteopenia required to classify a patient as having RA Patients
with 2 or more criteria are not excluded.
Classification Criteria for Rheumatoid Arthritis -2010 Score
2. Criteria (a - d must be present for at least 6
weeks and b- e must be observed by physician)
Joint involvement 1 large joint (shoulder, elbow, hip, knee, ankle) 0
th
2–10 large joints 1 a. Morning stiffness, in and around joint lasting 1
1–3 small joints (MCP, PIP, Thumb IP, MTP, wrists) 2 hour before maximal improvement.
4–10 small joints 3 b. Arthritis of 3 or more joint areas, observed by a
>10 joints (at least 1 small joint) 5 physician simultaneously, have soft tissue swelling
20

Serology Negative RF and negative ACPA 0 or joint effusion, not just bony over growth.The
Low-positive RF or low-positive anti-CCP antibodies (3 times ULN) 2 14 possible joint areas involved are right or left
High-positive RF or high-positive anti-CCP antibodies (>3 times ULN) 3 proximal interphalangeal (PIP),
Acute-phase reactants Normal CRP and normal ESR 0
metacarpophalangeal (MCP), wrist, elbow, knee,
Abnormal CRP or abnormal ESR 1 ankle and metatarsophalangeal joints (MTP).
Duration of symptoms <6 weeks 0 c. Arthritis of hand joints eg. wrist, MP or PIP joints.
e

>6 weeks 1 d. Symmetrical arthritis i.e. simultaneous involvement

Total Score 10 Score ≥ 6 indicates – R.A of same joint area on both sides of body.
e. Rheumatoid nodules: subcutaneous nodules over
Th

bony prominences, extensor surfaces or juxta

Extensor articular region. (PATHOGNOMIC)
defect
(at PIP)
f. Serum rheumatoid factor .
g. Radiological changes: bony erosion or unequivocal
Flexor
bony decalcification, periarticular osteoporosis and
Fig. 7.7 defect of PIP narrowing of articular (joint) space.

Ulnar deviation
of fingers

Fig. 7.6

411
 Orthopedics The 20th Book
Akylosing Spondylitis : HLA B 27 positive

Fig. 7.8 Pencil in Cup Fig. 7.9 Acro-osteolysis Fig. 7.10 Arthritis Mutilans
Psoriasis Scleroderma RA

ok
Diagnostic Criteria – Modified NewYork Criterion
Essential criteria is definite radiographic sacroilitis- (SI Joint (more on iliac side of joint)-
Ÿ
• Enthositis
Never diagnose ANKYLOSING SPONDYLITIS WITHOUT SACROILITIS
• Peripheral jts involved in 30% cases Ÿ Supporting criteria: one of these three
1. Inflammatory back pain

Bo
• Anterior uveitis is most common
2. Limited chest expansion (<5 cm at 4thICS) not a reliable criterion in elderly because of
extra articular manifestation (30%) pulmonary disorders
• Cardiac defects are seen 3. Limited lumbar spine motion in both saggital and frontal plane
(Schober test /Modified Schober test)
th
Psoriatic arthritis SI joint Tests

Enteropathic arthritis
20

• Gaenslen test
Ankylosing spondylitis (>90%) • Patrick test
Reitter’s syndrome/reactive arthritis • Figure of 4
SAPHO syndrome • FABER test
-Spine
-lesion on
e

-soles & palm

Fig. 7.11
PEARS (HLA B27 Postive) Sacroilitis – AS Image
Th

A B

Fig. 7.14
Fig. 7.13 Dagger Sign
Fig. 7.12 Bamboo Spine Trolley Track Sign

- Bony ankylosis Calcification of Calcification of

- Fusion of vertebra interspinous ligament interspinous ligament
and facet joints.

412
 Most common cause
Multiple loose bodies

The 20th Book Orthopedics

Elderly

Fig. 7.15
Synovial chondromatosis

Feature Gout Pseudogout

ok
Fluid analysis Uric acid Crysals, Needle Calcium Pyro PO4 Crystals, Rhomboid

Joint Involved 1st MTP Great toe Knee

Bo
Association Protein + Alcohol Hypothyroidism

Charcots Joint

Totally deranged
th
anatomy and
destroyed joint
20

Fig. 7.16 Hemophiliac Arthropathy PENIA

• Periarticular osteopenia
1. Neuropathic Joints (painless) • Squaring of patella
• Epiphyseal Enlargement
- Loss of proprioceptive fibres • Widened notch
e

• Decreased joint space

- Joint is totally destroyed • Subarticular cyst
• Arnold Hilgartner
Th

- Treatment – Arthrodesis – surgical fusion of joint classification

Fig. 7.17

Cause of widening of notch

- Hemophilia
- RA
- JRA (Juvenile Rheumatid
arthritis)
Fig. 7.19

Fig. 7.18

413
 Orthopedics The 20th Book
Synovial Fluid Analysis
• Normal synovial fluid is clear, WBC count ≤ 200/ uL
• Non-inflammatory synovial fluid is clear, viscous, amber colored with a WBC 200/ul-2000/uL and a predominance of mononuclear
cell.
• Inflammatory fluid is turbid, yellow, with an increased WBC count 2,000 to 50,000/uL and a polymorphonuclear leukocytic
predominance.
• Inflammatory fluid has reduced viscosity, diminished hyaluronic acid.
• Infections (pyogenic) is purulent, WBC count > 50,000/uL, PMN > 90% .
• Infections (Tuberculosis/granulomatous) is yellow, turbid, WBC count 10,000–20,000/uL, PMN 60% and presence of lymphocytes,
plasma cells and histiocytes.

ok
CHARACTERISTIC DEFORMITIES OF HAND AND FOOT IN RA
'Z-deformity', i.e. radial deviation of the wrist with ulnar deviation of the digits, often with palmar subluxation of proximal phalanges.

Bo
'Swan-neck deformity', i.e. hyperextension of PIP joints with compensatory flexion of the DIP joints.
Boutonniere deformity, i.e. flexion contracture of PIP joints and hyperextension of DIP joints. It is due to rupture of extensor tendon.
Hyperextension of 1st interphalangeal joint and flexion of MP joint with a consequent loss of thumb mobility and pinch—Swan Neck
deformity of thumb.
Eversion at hindfoot (subtalar joint), plantar subluxation of metatarsal heads, widening of forefoot, hallux valgus, and lateral deviation and
dorsal subluxation of toes; hammer toe (flexion of PIP).
th
Wind swept deformities of toes, i.e. valgus deformities of toes in one foot and varus in other (as wind sweeps all the structure in one
direction).
20
e
Th

414
 8
Section
Metabolic Disorders of Bone-
THE BENDS!
Rickets:
1. N to ↓ Ca+2
2. ↓ PO43+ (Except CRF) → have↑PO43+
NOTE: 3. ↑ALP,↑PTH
• Rickets: Lack of adequate mineralization of growing bones.
• Osteo malacia: Lack of adequate mineralization of trabecular bone.
• Osteoporosis: Proportionate loss of bone volume and mineral.
• Scurvy: Defect in osteoid formation
Fig. 8.3

Widening Whitening

ok
Bo
Cupping, splaying
and flaring of
radius and ulna
Fig. 8.1 Fig. 8.2
X-ray Knee Rickets
Rickets Fig. 8.4 X-ray knee Scurvy
A–Abdomen protuberant
th
B–Bowing of bones (on weight bearing)
C–Costochondral Junction prominent - (Rosary), Craniotabes (open fontanelles) • Wimberger ring sign-Sclerotic margin of
D–Diaphragm pull - Harrisons groove (lateral indentation of chest due to epiphysis-Scurvy
pull of diaphragm on ribs)/Double malleolus • Wimberger corner sign-metaphyseal
20

E–Enamel defect of teeth and delayed dentition defect in Congenital Syphilis

F–Forward sternum - Pigeon chest (Pectus carinatum) • White line of frankel; Scurvy; Heating
G–Growth plate - widening Rickets; Lead poisioning methotrexate
H–Hypocalcemia causing Hyper PtH therapy
I–Irritability
J–Joint deformities - Genu valgum/genu varum/coxa vara
e

(reduced neck shaft angle of femur)

K–Kyphosis
L–Loosers zones Osteotomy correction only
Frankels/Fracture (metaphysis)
Th

M–Milestone delayed once radiological healing takes place

Ring sign (Wimberger Ring Sign)
Muscle weakness In healing rickets – white line of Frankel
Osteopenia
R–Rickets
Cleft ~Corner SiGn
Osteomalacia Scurvy line (Trummer feld zone)
Pelkan spur

Females FROGS like Posture

Triradiate Pelvis (FROGS LIKE posture in scurvy)
Fig. 8.5 Protrusio acetabuli-Otto Pelvis Coxa vara
(Bilateral) Hypophosphatemic Rickets
Osteoid/osteon>1 • X Linked Dominant
• PHEX gene mutation
Tetracycline labelling • Normal Ca,PTH,Vit D
Biopsy gold standard • High ALP • Increase incidence of skeletal deformities
 Orthopedics The 20th Book

Pseudo Fracture
Pseudo Fracture /Milkman Fracture/ Loosers Zones
Arterial indentations on softened bone
Osteomalacia/HyperPTH/Neurofibromatosis
Neck Femur/Pubic Rami
Rest /Treat Primary Cause

Hyperparathyroidism
• Subperiosteal resorption • Salt pepper skull

ok
• Osteitis fibrosa cystica • Loss of lamina dura
• Rotting fence post appearance • Very rarely AVN
• Brown tumor

Bo
Achondroplasia

• Enchondral ossification defect

• Normal intelligence
• Limb dwarfism
th
• Trident or starfish hand
• Champagne glass pelvis
20

Fig. 8.6 Fig. 8.7 Achondroplasia

Bullet shaped vertebra

Cleidocranial Disorder
• Autosomal Dominant Normal collarbone CCD

• Intramembranous ossification defect Partly missing

e

Collarbone collarbone

• Absent clavicle-Shoulders can meet in midline

• Squashed face
Th

• Delayed dentition Fig. 8.8 Fig. 8.8 Fig. 8.8

• Scoliosis and coxa vara

Osteopetrosis

• Carbonic anhydrase II Proton pump Genetically defective-Bone resorption

• Marble Bone
• Functional Deficiency Osteoclasts
• Pancytopenia/Anemia/Infection
• Hepatosplenomegaly
Fig. 8.9
• Blindness/Deafness–2/7/8 Marble Bone
Fig. 8.10
• Bone healing delayed but few studies claim normal healing Rugger Jersey spine
• Marrow Transplant

416
 The 20th Book Orthopedics
Pagets Disease
• Osteoclast Larger Irregular
• Excessive Disorganised Bone Turnover
• Age > 50 years,Males
• Pelvis Commonest
• Pain Most Common Symptom
• Ca And P Normal
• Alp Raised
• The diagnostic histological feature of pagets disease is cement lines.
• Ivory Vertebra/Cotton Wool Skull
• Osteosarcoma(1%)

ok
• Bisphosphonates Most Potent
• Calcitonin Good For Pain Control Fig. 8.11 Fig. 8.12 Fig. 8.13
Ivory Vertebra Picture frame vertebra Cotton wool skull

Bo
Osteoporosis : Singh Index

• Bone mineral density –DEXA SCAN • Hemiplegic-Humerus maximum loss of bone mineral
• T SCORE density
• O to -1-Normal Drugs
• -1 to -2.5-Osteopenia • Estrogen
• <-2.5 –Osteoporosis • Bisphosphonates–Increases hip fracture
th
• Severe osteoporosis Osteoporosis with fractures • Calcitonin
(vertebra>Hip>Colles) • Low dose PTH –stimulates osteoblasts Fig. 8.14
• Normal Ca,PO4,Alp Codfish Vertebrae
20

Osteogenesis imperfecta
• Defect in type I collagen formation. • Deafness
• Autosomal dominant (AD) • Dentinogenesis imperfecta
• Osteopenia causing repeated propensity to • Sillence classification
fracture. Fractures heal at a normal rate. • Gene therapy
e

• Lower Limb,Femur • Path#-Bailey Dubow rods(adjust nail length with

• Hyper laxity,DDH growth)
Th

• Blue Sclera Fig. 8.15

1. 2. 3. Osteopathia
Melorheostosis Osteopoikilosis
Fig. 8.16 striata
Ivory Vertebra Fig. 8.17
Candle dripping Spotted bone Striated bone
disease disease disease
417
 Orthopedics The 20th Book

CRF > Osteopetrosis

Pagets

Fig. 8.18 Fig. 8.19

ok
Bo
Ankylosing
Fig. 8.20
Spondylitis

Achondroplasia

Fig. 8.21
th
20

Fig. 8.23

Osteoporosis >Osteomalacia

Fig. 8.22
e
Th

418
 9
Section
Amputations, Sports injury and
Neuromuscular Disorders –THE PAIN!
Mangled Extremity Severity Score (MESS)

MESS Score:Total Score is 11, Six or less consistent with a salvageable limb. Seven
or greater amputation is generally the eventual result.

Jaipur foot
(Natural Looking)

Amputation neuroma
Rx:

ok
1. Surgery
2. Transcutaneous electrical
nerve stimulation (TENS)
inhibits pain gate pathway Fig. 9.1 Fig. 9.2

Bo
(Dr. P.K. Sethi)
th
Amputation Reimplantation

• Bone BE FAN VS
• Choparts Inter-tarsal • Extensor tendon
20

• Flexor tendon
• Lisfranc's Tarso-metatarsal • Arteries
• Nerves
• Syme's 0.6 cm above the talar dome • Veins
• Skin coverage.
e
Th

Arthroscope:
1. 4 mm diameter Portals of Knee Arthrscopy
2. 30 degree

Anterolateral portal Anteromedial portal Superolateral portal Posteromedial portal Gillquist portal
(Trans Patellar
portal )
• Most common approach • Additional viewing of • Patello femoral • Repair of posterior horn
• 1 cm above joint line and lateral compartment articulation and excision meniscal tears
1cm lateral to patellar tendon • Instrumentation of medial plicae • Removal of posterior
• Universally see all structures loose bodies
except
i. PCL
ii. Anterior part lateral
meniscus
iii. Posterior horn medial
meniscus
 Anterolateral Corner:ACL + LCL + Lateral half of Joint Capsule
Posterolateral Corner: LCL + Popliteus (Most important) PCL – restrict external rotation
ACL – restrict internal rotation and hyper extension

Traumatic Knee ACL PCL

ok
* Postero-lateral Antero-lateral Posterior Force Varus Force Valgus Force * Home
Bounce
Test
Flexion

Corner Injury Corner Injury

Bo
Dial Test Pivot Shift Test PCL LCL MCL
Extension

Difficulty going Varus Stress Test *Valgus Stress Test

downhill in 30° flexion in 30° flexion
Feel compared

* Knee extension from flexed position

Normal feel-Hard/Firm
Torn structure-Rubbery/Spongy Feel
Torsion, Flexed Knee + (Empty feel not seen)
Torsion + Flexed Knee Valgus Force
th
* (Medial
Meniscal Tear
> Lateral)
ACL Tear

* Lachman Test Positive

20

McMurrays Test Positive/

Apleys Grinding Test
Thessaly Test/ Ege’s Test MATE
*
90 degrees knee
Rehabilitate + Arthroscopic
C f pu
lin ll flexion required
o

ic
ACL Reconstruction to perform the test
ia
n'
s
lin

* Peripheral 1/3rd Tear * Inner 2/3rd Tear

e H
am

Repair Arthroscopic
st
e

rin

Excision
g'
s
lin
e
of
pu
ll
Th

Patella Femur
Anterior drawer test-ACL
Posterior
cruciate
ligament Knee joint
Anterior
cruciate
ligament
Rotatory
movement

Arthroscope

Another Meniscus
arthroscopic
instrument Meniscal ligament Tibia

Mcmurray test-Menisci
(Medial > Lateral)
* Latest Questions
PLeAD:
ACL
Lachman Anterior drawer test
test Lelli test
Pivot shift test Anteromedial part Posterolateral part

Flexion stability Extension stability

420
 The 20th Book Orthopedics
Disc prolapse

Flexor tendon injuries • Clinical presentation-lower

back ache radiating to lower CSF
Distal to sublimis white so
Zones of flexor tendon limb T2 image
• Mri investigation of choice
Pulley 5 Forearm
Zone I • LUMBAR –DEHYDRATED
A5
4 Carpal tunnel • L4-L5>L5-S1
A4

A3 3 Lumbrical • LOWER NERVE ROOT

No man's land
A2
COMPRESSED-L5
2 FDS
Zone II
A1
Treatment:
• Rest +NSAIDS

ok
Lumbrical No Man's Land • Local Steroids
Zone III origin
1 FDP • Surgical Fig. 9.4

Carpal
Decompression
Zone IV tunnel
a. Laminotomy
b. Laminectomy

Bo
Proximal to
Zone V carpal tunnel
c. Hemilaminectomy
Fig. 9.3

Yellow flag signs – no further work up and management required Red flag signs of back ache – indicative of further work up
and management
Ÿ Pyschosocial factors shown to be indicative of long term Ÿ Thoracic pain
th
chronicity and disability: Ÿ Fever and unexplained weight loss
Ÿ A negative attitude that back pain is harmful or potentially Ÿ Bladder or bowel dysfunction
severely disabling Ÿ History of carcinoma
20

Ÿ Fear avoidance behaviour and reduced activity levels Ÿ Ill health or presence of other medical illness
Ÿ An expectation that passive, rather than active, treatment will Ÿ Progressive neurological deficit
be beneficial Ÿ Disturbed gait, saddle anaesthesia
Ÿ A tendency to depression, low morale, and social withdrawal Ÿ Age of onset <20 years or >55 years
Ÿ Prolonged steroid intake
Ÿ Radicular impingement
Nerve Muscle group used for motor grading in
e

Root ASIA system

C5 Elbow flexion (Biceps, Brachialis) + Shoulder Abduction
Th

C4 C4
C6 Wrist extension (extensor carpiradialis longus C6: Thumb and
C7: index finger *
and brevis) (Middle finger) C5 T2
C7 Elbow extensor (triceps) C3
T2
C7 C4
C8: (Ring and C6 C5
T2 C5
C8 Finger flexors (flexor digitorum profundus) little finger) C8 T1
3
4
5
4
T1 Hand intrisics (interossei) Finger abduction L5: Lateral part of
5
7
6

leg, + dorsum of 8 T1
L2 Hip flexors (iliopsoas) foot + great toe
9
10 T1
11
C6
L3 Knee extensor (quadriceps) S1 L2
L1 12 C6
L3
S1: Sole L5 L4 S3
L4 Ankle dorsiflex or (tibialis anterior) and 5th toe C8
C6
L5 Great toe extensors (extensor hallucis longus) EHL L4: Medical part C7
C7
of leg and foot
S1 Ankle plantar flexors (gastrocnemius and soleus)/
Disc Prolapse (System 1)
FHL (Flexor Hallucis Longus) Preffered (System 2)
Fig. 9.5

421
 Orthopedics The 20th Book
Superior
articular process Haglund Deformity Prominent calcaneal tuberosity
(cor of scotic dog)

Pedicle (eye)

Pars inter-articularis
(Neck of dog)
Dog Break-spondyloysis
-dog with Collar in neck

Transverse
process (Head)
Fig. 9.7 Rx: Plan A
Isthmus (Neck)

Lamina and spinous

process (Body)

ok
Inferior articular Dupuytren’s Contacture
process (forolog)
Opposite inferior Diabetes mellitus
articular process
(hind leg)
Fig. 9.6
Palmar Aponeurosis-Flexion deformity

Bo
Slip of one vertebra over other-spondylolisthesis
-Beheaded Dog or Beheaded Scottish Terrier Sign • MCP>PIP>DIP Fig. 9.8
• Ring Finger>Little Finger
• Wait and watch
Game Keepers Thumb
• If more than 30 degrees deformity at MCP
Forced radial deviation or more than 15 degrees at PIP-Subtotal
Fasciectomy
Torn ulnar collateral ligament at
• Collagenase has also been used
th
MCP of thumb.
Rx Cast application
• Mallet Finger Avulsion of extensor
tendon from distal phalanx
Rx: Splint
20

• Jersey Finger Avulsion of FDP from distal phalanx Fig. 9.9

Rx surgery
1. Tennis Elbow Lateral Epicondylitis (ECRB>ECRL)
• Bowlers Thumb Compression of ulnar digital nerve of
2. Golfers Elbow Medial Epicondylitis thumb Rx: Plan A
3.

Hallux Valgus Lateral deviation of great toe

e

ROTATOR CUFF SYNDROME INCLUDES

Th

Rx: Plan A
i. Subacute tendonitis (Painful arc syndrome-painful
abduction between 60º–120º)
ii. Chronic tendonitis (Impingement syndrome; Neer's test is used
for it )
iii. Rotator cuff tears.
Dequervains tenosynovitis
Treatment:
DeQuervains TS • Physiotherapy + NSAIDS
• Local injection of steroids Fig. 9.11
Abductor Pollicis Longus
• Surgery if required for impingement syndrome or rotator
Extensor Pollicis brevis
cuff tears (especially in young individuals)
Fig. 9.10
Frankeistein test Frozen shoulder
Rx: Plan A Common in DM
limitation of IR(Internal rotation) + abduction Rx Plan A

422
 The 20th Book Orthopedics

Avascular necrosis and Osteochondritis

Osteochondritis
1. Keinbock -lunate
2. Kohler - navicular
3. Panners - Capitulum
4. Perthes - femur head
5. Scheurmann - ring epiphysis of vertebrae
6. Calves - central bony nucleas of vertebrae
7. Frieberg- 2nd metatarsal head
8. Islene- 5th metatarsal base

ok
9. Osgood shattler's -tibial tuberocity
10. Sever's - calcaneum
11. Johanson-Larsens - lower pole of patella
12. Osteochondritis Dissecans-
Fig. 9.12

Bo
Snow cap sign: AVN of Humeral head
Lateral epiphyseal Most
arterial group important group
Subsynovial
intracapsular Distal pole
arterial ring
Ascending
cervical
arteries Blood supply is
th
distal to proximal

Medial femoral Extracapsular

circumflex artery arterial ring Proximal pole undergoes avascular
necrosis more proximal the fracture
more avascular necrosis
20

Most important group

Fig. 9.13 Fig. 9.14
Blood supply to femur head (posterior aspect)

Anterolateral
aspect of
Head is involved
e
Th

Fig. 9.15 Fig. 9.16 (MRI-IOC)

Area of necrosis
Fibular graft

Fig. 9.17 Fig. 9.18

Muscle Pedicle Graft Fig. 9.19
Core Decompression
THR

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 10
Section
Pediatric orthopedics-
The big guys area !
Altered shape of femoral head – limitation of abduction and M:F
Disease B/L
internal rotation
Normal axis – clavicle
DDH 1:6 20%
Axis deviation – Axilla (In case of destroyed femoral head)
IOC – MRI
Perthes 3:1 20%
TOC – Maintain hip reduced

SCFE 3:1 40%

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Fig. 10.2: DDH

Bo
Fig. 10.1
IR ER
ER Fig. 10.3

DDH
• Small epiphysis Rx:
• Superolateral displacement of femur epiphysis
th
• Pavlik Harness
• Vascular sign of Narath Positive
• Von Rosen Splint
• Shenton’s arch is broken
Tests: Ortolani & Barlow’s • Bachelors cast
20

Allis or Galleazzi test

Klisic test
RISK FACTORS DDH
• Oligohydramnios
• Metatarsus adductus
DAD Abduction to
• Congenital Muscular Torticollis adduction reduce (RAB)
e

to dislocate
• Talipes Calcaneovalgus > Ctev
• Family history
Th

• Breech Barlow maneuver Ortolani maneuver

Rx:
• Females Fig. 10.4
• Pavlik Harness
• First born child
• Von Rosen Splint
• Left
• Bachelors cast
• Twin pregnancy is not a risk factor

Perthe’s disease - MRI IOC

Avascular necrosis of femoral epiphysis.Age 4-8 yrs, 20% B/L

B/L more common in males, Classically painless may be self
resolving.Radiological signs: Gage’s , Sagging Rope sign,
Crescent sign Rx.: Maintain abduction

Fig. 10.5
 The 20th Book Orthopedics

Slipped Capital Femoral Epiphysis

• Age 11-20
Trethowan sign
• CAUSE- Endocrinopathies and Growth spurt. (In SCFE due to
• A classical sign is Axis deviation Kleiins line–along slip line passes
neck of femur cuts superior to it.)
• DIAGNOSIS-MRI VERY SENSITIVE a part of epiphysis
• Flexion restricted
Kleins line

Normal
Rx Fixation Fig. 10.6

DMD Normal Skull

ok
Mastoid
CMT process
1. X-linked Recessive (Xp 21)
2. Dystrophin gene mutation is seen • It is associated with Sternum Sterno-
cleidomastoid
muscle
3. Boys (more common) breech delivery,
Clavicle

Bo
4. Average age of presentation is 4 years Fig. 10.7 shoulder
5. Patient is Unable to walk by 12 years of dystocia, birth Sternum

age injury and SCM Torticollis

6. Average life span is 26 years ischemia/tumor.

7. Proximal muscle weakness is seen • Associated with
8. Pseudohypertrophy of calf Fig. 10.7 and Metatarsus
adductus,DDH,CTEV
tongue is seen
th
• The head is tilted Fig. 10.9
9. Gait—patient is usually a toe walker toward the involved SCM
10. Scoliosis is seen and the
11. Gower’s sign (patient climbs chin is rotated towards the contralateral shoulder,
20

on himself)Fig. 10.8 producing the ‘Cock robin’ appearance.

12. Cardiomyopathy and congestive • SCM on involved side may feel tight and hard and a
heart failure is seen mass or knot can be detected in the body of SCM in
first 3 months of life.
13. There is increase in Creatine Kinase
• It can disappear spontaneously
and EMG shows Muscle damage.
• There may be asymmetrical development of face
Definitive diagnosis is by Muscle biopsy (plagiocephaly).
e

and genetic studies • Treatment: Unipolar (one head of SCM) or bipolar

(two heads of SCM) release, Optimum age: 1–4
Th

years.
Fig. 10.8

KFS
• Classical triad of Short ‘web’ neck (prominence of trapezius muscle),Low hair line, and
Restricted neck movements.
• It is associated with congenital osseous fusions (synostosis) due to failure of segmentation
of the cervical spine, involving two or more vertebrae.
• Scoliosis (~60%)
• Sprengel’s deformity (~50%) it is congenital elevated or undescended scapula
(Omovertebral bone bridges the cervical spine to the scapula and limits the neck and shoulder
Fig. 10.10
motion)

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 Orthopedics The 20th Book
Blounts Disease Genu Varum

• The abnormality is
characterized by Blounts Disease Physiological Genu Varum
• varus (Tibia>genu)
• Genu recurvatum and
• Internal torsion of
the tibia

Fig. 10.11

ok
Vertical

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talus

Rocker Bottom foot

Causes: 1. Incorrect correction of CTEV
Fig. 10.12 Fig. 10.13 2.Vertical talus Fig. 10.14

Pes Planus
th
• Flat foot refers to obliterated medial longitudinal arch.
• Heel is often in valgus called as planovalgus
20

• Pes Planus is of 2 types (Jacks test)

• Flexible : Disappears on non-weight bearing. Management is conservative
• Rigid : Due to Congenital Vertical talus or RA or Infection or tarsal coalition(AD-Talocalcaneal and calcaneonavicular) or
tibialis posterior dysfunction. They often require surgical intervention
e

CTEV
Th

Kites method –followed earlier Ponsetti method now preferred

At birth Manipulation by mother initial weeks Manipulation and cast
Change of cast Every 2 weeks Weekly
Correction order C-A-V-E C-AV-E
Fulcrum while manipulating Calcaneocuboid joint Head of talus
Duration of treatment 6–9 months 6–8 weeks

Aim: Equalize
both borders

Small
medical Large lateral
border border

Fig. 10.15

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 The 20th Book Orthopedics

Pirani scoring (6 parameters) Evans

(Calcaneocuboid Wedge)
Talar head Lat border curvature
Heel Medial crease
Equinus Posterior crease

Fig. 10.17
To Score CTEV severity

Age wise treatment of CTEV

ok
3 to 5 Years 5 to 8 Years
Calcaneocuboid wedge Soft tissue release
+ +
<1 cast
Soft tissue release Evans
Above knee cast:
As rule of splintage
+

Bo
immobilize one joint Dwyers
above one joint below
and to correct ankle
equinus knee has to
be immobilized thus
above knee cast

Fig. 10.16
th
Posteromedial soft
tissue release
20

Post. Post. Med CSTR

Complete
Fig. 10.18 subtalar release Lateral based
wedge of calcaneum Fig. 10.19
e

Dwyers Osteotomy
CTEV
1. <1 year cast (starting from birth), Ponsetti method (tenotomy of tendoachilles is carried out).
2. 1–3 years Soft tissue release-Posteromedial soft tissue release (Turcos)
Th

3. But in children older than 3 years of age lateral column shortening procedures are often performed in conjunction with posteromedial
soft tissue release.
4. 3–8 years
a. Soft tissue release together with shortening of lateral side of foot by Evan - Dillwyn Procedure (i.e. resection and fusion of calcaneo
cuboid joint)
b. Dwyer’s osteotomy of calcaneum is done to correct calcaneal varus in > 5 years.
5. 8–10 years Wedge Tarsectomy is done as deformity is more and requires multiple bones to be removed.
6. ³ 10 years
Triple arthrodesis is necessary for recurrent or persistent clubfoot deformity in older children (chronic cases). It is best done at > 10
years of age when foot growth is complete and the bones are ossified to achieve good fusion. It involves fusion of three joints: TN:Talo-
Navicular;TC:Talo-Calcaneal; CC: Calcaneo-Cuboid
7. Thomas designed CTEV Shoes (straight Inner Border, Outer Shoe Raise & No Heel) Fig. 10.20
8. Dennis Brown splint is used and it encourages
abduction and dorsiflexion of foot
9. Parallelism of talus and calcaneum in A.P as well as lateral views is seen in CTEV

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 Orthopedics The 20th Book

BBS Pediatric fracture

1. A classic finding is a 1. Torus # - Buckling of cortex at
chip fracture in which a metaphysio diaphysis junction
corner of the metaphysis 2. Plastic deformation: Bend in
of a long bone is torn off the bone
with damage to epiphysis
3. Green stick fracture one
and periosteum.
cortex breaks.
2. Metaphyseal bucket handle fractures are seen. Fig. 10.21
3. Fractures are spiral femur > humerus >tibia. Fig. 10.22
4. Sub epiphyseal micro fractures are seen (not seen on X-rays—seen on Greenstick
MRI).
fracture

ok
5. Nobbing fractures are seen in the ribs due to shaking of the child.
6. Skull has egg shell fractures, occipital impression fractures and fractures
crossing the suture line.
7. Good quality skeletal survey. Baby gram is not preferred

Bo
The defects in tibia or fibula

Fig. 10.23
Radial club hand
(radial hemimelia)
Absent radius and all
th
radial components of
upper limb (radial artery
Postero-medial + thumb)
Congenital Fibular bowing
Tibial
20

pseudo hemimelia hemimelia

arthrosis
of tibia
e
Th

Fig. 10.24

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 The 20th Book Orthopedics

Madelung Deformity :Deformity in lower end radius Polio

• Lower limb>UL
More common in females
• The most common muscle to be affected is Quadriceps
• ♀50% B/L Femoris(Partial)-Hand knee gait
• Associated with • The most common completely paralyzed muscle in polio
Turner’s syndrome is tibialis anterior.
• Functions are excellent • Upper limb -Deltoid
• Hand muscles(Very rare)-Opponens Pollicis
• Acute fatality is due to involvement of the respiratory
muscles

ok
Fig. 10.25

Bo
th
20
e
Th

429