01 1

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BASICS : HISTOLOGY AND

PHYSIOLOGY OF BONES

Introduction 00:00:09

space
Active

Orthopaedics •v4.0 •Marrow 6.0 •2022

 0^ Basics :
and Physiology c*
bones

Bone morhers.
Bone formation markers =
• Procollagen L
• Osteocalcin.
• Osteonectin.
• ALP ( Alhaiine phosphatase): iLhen a bone breahs down
the osteoblasts will act to resynthesis. As a result o? this
there will be elevated levels oV ALP.
Breakdown marhers =
• Hydroxy proline.
• Hydroxy lysine.
• M and C, telopeptide.
• TRAP (Tartrate resistant acid phosphatase).

Bone Vormation markers are elevated even when there is

bone resorption -* Bone turnover.

Parts of a long bone 00:15:14

The part that articulates with another bone is called the

articulating part.
• epiphysis.
• metaphysis.
• Diaphysis.

Orthopaedics •v4.0 •Marrow 6.0 •2022

 01 Basics
and Ph’ Leave Feedba*
bones

Periosteum
ffibrouS

(cellular layer)

Nutrition of bone 00:20:59

Mathent Voromen : naif pci arrangement o? metaphyseal artery

medullary cavity Via Ahis — epipysfi

FhetaphiySiS
foramen. Hair pin
arrangement
Once it enters, it yoes proximally
I
and distally.
vessels are arranged in a vein

hair pin loop Vashion in the artery

metaphysis.

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 01 Basics : Ftstolog Leave Feedbac
and Physiology of
bones
Bones are white -* Radio dense/Radiopaque.
Soft tissue -* Radiolucent.
Immature bone -* growth plate is visible. The physeal plate is
blach, as the cartilage lachs mineral, hence radiolucent.

Layers of growth plate

trocuth plates
Zone

-Chondrocyte
stem
m germinal

- proliferation
zone

-Zone of
maturity
and in crease
In cell

Interstitial growth/growth m length •

Physeal plate helps bone grow in length.
Direction of the growth is from epiphysis to metaphysis.
Layers :
• €»erminal layer most important.
Cells tahe rest.
• Proliferative layer ; Cells multiply.
• Hypertrophic layer : Cells start to grow m
size to accommodate calcium (Loeahest layer).
• Calc&cation layer.
• Oss’tftcaiion layer.
growth m thickness/ Appositional growth :
Osteo progenitor osteoblast cells present under the
endosteum and per iosteum grow contributing to the
thickness of the bone.

Orthopaedics •v4.0 •Manrow 6.0 •2022

 S'

Obi<que
Pasture
Orthopaedics
•
v•4.0
M6.aro0w Spira)
•
202 fractue

Active space
 mrel’s criteria
(Score > 8 suggests prophylactic fixation)
Score l a 3
Site Upper limb Louuer limb Peritrochanteric
Pain mild moderate Functional
Lesion Clastic mixed Lytic
Size < i/s 1/3 to a/3 > a/s

I? score > 8 * Prophylactic internal fixation.

most common location :

Osteoporosis Spine > Hip > Colles fracture.
metastasis Proximal ¥emur (necK o? Vernor or
subtrochanteric region) spine.
Investigation Vor metastasis ’ FD^ PCT-CT scan.

Pathological Vracture (banana Vracture pattern) =

Subtrochanteric Vracture, seen in pagers disease.

Treatment oV pathological Vracture :

• Internal Vocation.
• Treat the underlying cause.

Stress fractures :
Pain aVter fracture.
Also hnown as Vatigue Vracture. space
Fracture is due to abnormal/repetitive loading oV a normal
boneSeen in dancers, athletes, military recruits etc.,
Active
Commonly seen in the lou>er limb bones (point tenderness) >
upper limb bones.

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 02 Basics
& Heali

Shin spl ints :

medial periostitis o? the tibia (anteromedial aspect).
usually seen in marathon runners or treWers.
medial Tibial Stress Syndrome (mTSS).
clinical features Pain on the anteromedial aspect o? the ley.
X ray • Mormal.

OiWerential diagnosis :
Popliteal entrapment syndrome •
Pain in the posterior aspect o? the leg without any fracture
on x ray.
It is a congenital anamoly where popliteal artery passes
through the gastrocnemius muscle which is usually
hypertrophied m athletes, this causes compression o? the
popliteal artery causing ischemia distally.

Runner’s fracture *
Occur at the lower end o? the ^bula.

Treatment o? stress Vracture :

• Rest.
• Immobilisation.

Fracture healing 00:25:22

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 02 Basics :
& Heali

The Vracture environment is acidic before calcium depositing

alhaline a?ter calcium deposition.
First stage o? fracture healing : Hematoma.
Last stage o? Vracture healing : Bone remodelling.
=
First stage o? Vracture healing Visible radiologically Callus.
Callus visibility needs aHeast 3 ujeehs.
First stage o? the clinical union : Consolidation.

Chronological order ;
Hematoma = a to 3 days,
granulation ; a to 3 weehs.
Callus : a to 3 months.
Consolidation : a to 3 years.
Remodelling s > 3 years.

Implant removal :
There is no need to remove implants unless there is infection
or tissue irritation.
Ideally removed a?ter a years.

Callus :

Fractures a?Secting Vracture healing :

I. Patient : Age, nutrition, tobacco, alcohol
a. Type oV Vracture * Open, contamination, interposition.
=
3. Tissue Ischemia. space
4. Treatment '• Inadequate reduct ion, improper immobilization
(most common). Active

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 02 Basics : F
& Heali

Bone graVt :
most common source : Iliac crest (cancellous bone).

Ilium

Lumbar—
vertebra

Characteristics o? ideal bone gra?t :

I. Osteogenesis : e^raVt rtsel? Vorms bone with the help o¥
osteoblasts.

bone on it as a sca^old on its surface.

examples include *
Calcium phosphate.
Calcium sulVate.
PmmA.
3. Osteoinduction :
Something that stimulates the host to Vorm bone.
These are recombinant growth
factors. space
example :
Bone morphogenic proteins.
Active
used to coat the implants used
in Vracture ftxation.

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 02 Basics : F Cure
& Healing Leave Feedba^

management oV Vracture :
I. Displacement s
Relationship o? movement o? the
bone distal to the Vracture site.
They displace due to the pall o?
muscular Vorce.
Reduction :
Bringing the Vracture fragment bach to the normal
anatomy by application o? Vorce to counter the pull o?
muscle.
3. Traction :
Application o? Vorce to counter the muscular Vorce
causing the displacement (applied with counter
traction).
4. Fixation :
To Keep the Vracture in reduced position till it heals.

SKin traction SKeletal traction

Indication mild to moderate moderate to severe Vorce.
Vorce.
uJeight StofoKg. IS to Ifo Kg.
used
Applied Buck’s traction. Steinmann pin or
with Denham pins or IK wire or
Crutchfteld’s tong.

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 02 Basics :
& Healir Leave Feedba,

Steinmonn pins ;
Smooth.
used in normal young healthy adult bones.
Tibial/Vernoral traction.

Steps :
• Preparation o? the site.
• Localisation o? location oV insertion o? skeletal traction pin.
• Local anesthetic is injected A.S cm below behind the
tubercle.
• using surgical blade Mo ll, stab incision is made.
• Dilating using artery Vorceps, to conVirm that there is no
presence o? so¥t tissue along the way.
• Pin is inserted into drill and the bone is drilled Vrom lateral
to medial side.
• Removal o? drill application o? dressing.
• Bohler stirrups mounted over the traction pin.
• R.ing o? the bohler stirrups is attached to sheletal traction
rope attached with weights.

Splints to reduce pain 01:03:52

Purpose o? splinting Vracture =

To support Vracture to minimise pain.

Father o? British orthpedics H O Thomas.

Father o? Orthopedics : Miholas andrey. i
Father o? modem Orthopedics : Sir RobertJones 8
I
I. Bohler Braun splint »
A thin steel rod penetrates the shin bone to which the stirrup
is attached

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 02 Basics :
& Healin Leave Feedbai

measuring for a Thomas splint :

Fixed traction device, two rods one ring ,ideal in mobile
situation.
I. measure the oblique circumference of the thigh
immediately below the gluteal fold of buttock and ischial
tuberosity.This may be too painful on the affected
leg ,so measure the unaffected leg add S to to cm to
accomodate for swelling.
a. This measurement should correspond with the internal
circumference of Thomas’s splint ring.
3. measure the distance from the grom to the heel add IS
to as cm to allow plantar flexion of the foot.
4. This distance should correspond to the medial (inner side
bar of the splint).

Russel traction :
conservative management of Inter
trochanteric fracture of femur.

Definitive management of fracture 01:08:36

Reduction

Closed
Feel for fracture Reduction of fracture
reduction under x ray fragments carried under
direct Visualisation

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 02 Basics
& Heali Leave Feedba

Closed reduction uuith internal ftxation using intramedullary

interlocking nail :
Pre operative Post operative

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 02 Basics : F jre

& Healing Leave Feedbai

Olecranon fracture *
Open reduction +• internal fixation with tension band wiring.

Tension band uoirirg

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 Open Fractures. Leave Feedbacl
Amputations and
Polytrauma
Type HI A • Wound > 10 cm long or lesser shin lesions with
gross contamination and or high energy fracture patterns.
6one coverage adequate.
Fracture occurred in a contaminated area Farm, flrearm,
sewage.
Type III 6 s Extensive so¥t tissue stripping that typically needs
some type o? so¥t tissue flap Vor coverage.
Periosteal stripping.
Type III C : Large wound with major arterial artery.
Associated with vascular injury.

Type I Type II Type III A Type III 6 Type III C

management o? open flracture : Emergency.

Wound :
6road spectrum antibiotics.
Debridement.
Wash the wound with normal saline or
Sterile normal saline.
Povidone iodine.
Hydrogen peroxide.
Wound closure :
Delayed Vor second loots i? :
I? more than (o hours (golden period o? wound) Delay
pr imary closure.
Associated neurovascular injury.
Edges cannot be approximated
When you are not satisfled with the debridement.
Fracture : Stabilisation with external flxation.
And its modiflcations.
management o¥ open flracture : Emergency.

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 Amputations and
Polytrauma

Illizarov ring fixator 00:09:48

Instead o? rods and pins, there are rings and pins.

Distraction osteogenesis/callotaxis :
In the case o¥ an open fracture, i? a bone piece is missing it
can be replaced by growing a new bone.
This is done by ftrst cutting the bone (corticotomy) and
placing theVrame.
Once this is done, distraction is applied at the corticotomy Site
at the rate o? imm/day (physiological limit) . Rs a result there
o? which new bone formation tabes place. This is called
distraction osteogenesis.

Distraction osteogenesis

i
i

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 03 Open Fractures, Leave Feedbac
Amputations and
Polytrauma

Amputation OsarhcuiatiOG

To increase the stability o? external fixators s

Increase the number oV in uniplanar pins < rods < planes,
nnultiplanar : e.rg and pins (most stable).

In cases where the bone is damaged and contaminated :

Amputation : It is cutting o? the limb through the bane.
Disarticulation : Cutting o? the limb at the joint.

Decision o? amputation is based on the Vollowing scoring

mess (mangled Extremity Sever ity Score),

velocity o? injury or soft tissue coverage.
Ischemia time (most important parameter).
Score doubles & time more than (o hrs.
Shoch of blood pressure.
Age o? the patient.
I? the score is >1, amputation is carried out.
Limb salvage Index.

Amputations 00:18:35

Crush injury due to road tragic accident is the most common

cause in India.
Peripheral vascular diseases lihe diabetes mellitus most I
$
common tn the world.
Frost bite, gas gangrene, malignant tumour.
Congenital deficiency o? limb/abnormal limb/neuromuscular
disease lihe polio that has rendered the limb Vunctionless.

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 Amputations an
Polytrauma
muscle is sutured to muscles.
uohen the indication o? amputation is ischemia.

Cuttirg the bone »

6one is cut Scm shorter than the so¥t tissue to be able to
close the uuound

Closure oV the flap •

Symmetrical method : Suture line is on the
mid coronal plane.
Advantage : Easy.
-
Disadvantage ulhen the prosthesis is applied,
it will be on the suture causing pain and
uuound dehiscence.

SKeuued method : The posterior flap is longer

than the anterior flap.
It is approximated anterior to the mid coronal plane
Advantage • Decreased the problems o? application o? limb
prosthesis and uuound dehiscence.

Sheuuedflap

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 Open Fractures. Leave Feedbac
Amputationsand
Polytrauma
Amputations oV the Voot :
midVoot *
Chopart = At the intertarsal joint between the
talonavicular and the calcaneocuboid

LisVranc Between the tarsal and metatarsal bones.

Symes O.G cm above the dome o? talus (wide base).
Sarmientos L3 cm proximal to the anKle with both malleoli,
(narrow base).
Boyd : filter taiectomy Vuse calcaneum to tibia
PirogoV^ : AVter taiectomy calcaneus is cut and rotated then
Vused to tibia

Length rf amputations stump/energy expenditure

relationship :
Length o? the stump should be Kept as long as possible.
It is better Vor prosthetic fitting.
It reduces energy expenditure.
Hip disarticulation require IOO51 more energy to perform
same.
Knee disarticulation require soft more energy to perform
same action.

Complications o? amputation ! i
Infection.
Bleeding.
Flap necrosis 5 Too tight suturing.

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 03 Open Fractures, Leave Feedbacl
Amputations and
Polytrauma
SAFb : Stationary Attachment Flexible bndosKeleton, similar to
Jaipur Voot.
heel is the connection between prosthesis and the terminal
device.

Sach ?oot The Jaipur Voot

Sola arwe boo Ldooden Keel

Con^xesstte heel

Prosthesis SACH Jaipur foot

Appearance Does not looK normal LOOXS normal

WaKmq barefoot Mot possible Possible

mobility Restricted. Allowed
Dorsiflexion Absent Present
Inversion/ Absent Present
eversion

Squattinq Mot possible Possible

Cost Hiqh LOU)

imputation in children :
Save as much as possible.
disarticulation is preferred over amputation as it does not
disturb growth o? bone by protecting the growth plate.
multiple revisions o? stump is required.
Children adapt well to prosthesis.

Reimplantation of limb :
Only in clean wound with low mtSS score.
Transportation of the appendage.
Clean in sterile ms/rl.
uJrap in sterile gauze piece soahed
in MS or RL.
Keep in a plastic bag, seal it.
Then Keep it in the ice box (this increased
the ischemia time to 151-3.4 hours).

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 Open Fractures. Leave Feedbacl
Amputations and
Polytrauma
Occurs days -to uueehs later.
Cause : sepsis.

ATLS 00:46:11

Simultaneous diagnostic and therapeutic activities

intended to identify and treat limb and liVe threatening
injuries beginning with the most immediate.

It is Vor non-cardiac arrest patient, he is a trauma patient.

To prevent death in the golden hour oV trauma
Haemothorax.
Pneumothorax.
Cardiac tamponade.

Order o? evaluation *
Airway with restriction o? cervical spine motion.
Cervical spine can be stabilised by a Philadelphia collar.
Breathing : Ensure there is expansion o? the chest.
Circulation : Stop the bleeding (internal or external).
Pelvis and Vemur Vracture are the most common cause o?
bleeding in polytrauma patients.

Pelvic fracture management :

Pelvis is a $at bone (cancellous), it has many vessels. In the
event o? a fracture, the plexus around the pelvis ruptures
and cause bleeding along with the cancellous bone.
I
Pelvic binders : To tamponade the blood loss 0.5-a L o? blood
is less, ue., 4-8 units).
I
IVF : EL > MS, theoretically can control acidosis with release o?
pyruvated and bicarbonate Vrom lactate.

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 Open Fractures, Feedbacl
Amputations and
Polytrauma
Log roll technique : Turning the patient without twisting the
spine and slide the stretcher, placing him in the supine
position.
Other fractures are not o¥ immediate concerns except Vor
fractures that can cause further contamination or bleedirg.
(Semur fracture » l-LS L o? blood is lost).
In such cases, Vemur fractures are stabilised temporarily.

Log Holl technique

Damage control orthopaedics (OCO) ;

It is that modality o? management where you thinh & the
patient $rst rather than the fracture.
Limited surgical intervention in a patient who is grossly
injured, to control haemorrhage and contamination,
early temporary ftxation is done by external fixation.
Patient is shifted to ICU for optimisation.
De^nrtive treatment.
Example : Fat embolism syndrome, chest injury, coagulopathy,
hypothermia, severe acidosis.
Crush syndrome 00:51:14

Limb is compressed for a prolonged per iod.

Hypoperfusion and myonecrosis of the crushed limb,
ulhen the limb is released from the compression, toxic
metabolites get released to cause reperfusion injury,
liesuit in a systemic reaction due to tissue necrosis.

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 Q3 Open Fl ires.
Amputations ai
Polytrauma
fill are true about fracture healing except
nutrition affects healing
b. Stable fixation promotes healing.
Compression at fracture sites causes non-union.
d. Hormonal status may affect healing.

The correct order of priorities in the initial management of a

patient with head injury is ?
Airway, breathing circulation treatment of extracrani¬
al injures.
b. Treatment of extracranial injures, Airway, breathing
circulation.
Circulation, Airway, breathing treatment of extracra¬
nial injures.
d Airway, circulation, breathing treatment of extracra¬
nial injures.

In an unconscious severely injured patient of multiple frac¬

tures and an open bleeding wound on the r ight thgh, the $rst
thirg to be done is ?
Secureairway.
b. Blood transfusion and treat shocK.
Tourniquet and splinting
d. &CS scoring

A vascular repair is warranted in which type of Qustilo

Anderson injury ?
IUC
b. I
n
d. 1116

Tarsometatarsal amputation is also Known as ?

Choparts amputation. I
b. Lisfranc’s amputation. *
Pirogoff’s amputation.
d. Syme’s amputation.

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 03 Open Fractures, Leave Feedbacl
Amputations and
Polytrauma
S. Bohler’s stirrup.
fa. Bohler brown splint / frame.
a 3,4,1.
b. 3,5,fa.
c. a,I,fa.
d. 4,fa,I.
upper -tibial pin -traction :
l. Steinman’s pin or Denham’s pin.
a. Drill.
3. Artery Vorceps.
4. Blade noli
S. Local anesthetic.
fa.Bohler’s stirrup.
The pin is placed a.5 cm behind and below the tibial
tuberosity.
Enter Vrom the lateral side and go towards the medial
side.

UJhich oV the Vollowing is true about an open Vracture ?

I. Tibia and phalanges are most involved.
a. usually, no co-existing injuries.
3. Compartment syndrome does not occur in open
Vractures.
4. Early debridement should be done.
I and 4.
I and a.
a and 4.
a and 3.
Compartment syndrome • > SOmmHg.
PitValls :
l. The incidence o? compartment syndrome associated
with high and low energy injuries is nearly equal
a. Compartment syndrome can occur in open Vractures.
3. Have a high index o? suspicion and be particularly
vyilant in patients with an altered level oV conscious¬
ness.
*
Mormal pressure ’ < lOmmHg.

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 04 Metabolj£_Bor 4Q
Disease : Part Leave Feedba

Secondary hyperparathyroidism :
Hypocalcemia is the trgger Vor PTH secretion
(hyperparathyroidism).
PTH restores the serum Cof bach to normal.
This results in inhibition o? the secretion o? PTH due to the
negative Veedbach mechanism.

Primary hyperparathyroidism :
This is due to the disease in the PTH gland which results in
secretion o? excessive amounts oV PTH.
It has no triggers.
Serum Caa’ is increased beyond the normal levels.

mechanism o? action o? PTH :

Decrease in Ca
negative Veedbacb
Increase in PTH negative VeedbacK

Kidneys VeedbacK Kidneys Bone

Activation o? I a Osteoblasts
Absorption o? Ca“'
excretion o? phosphate
£AMK L
Vrom ur ine
Activate Vorm o?
Vitamin D Osteoclasts

Absorption O? Caa+ desorption oV

and phosphate bone (increase
Vrom GOT in ALP)

PTH receptors are present on the osteoblasts.

Denosumab : QAMK Igand inhibitor.
Bone resorption leads to activation o¥ osteoblasts and causes
resynthesis o? bone (elevation o? serum ALP).

Lab Endings in secondary hyperparathyroidism *

• Co3* 5 Decreased/normal

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 04 Metabolic,
Disease : Part Leave Feedbai

Rickets 00:26:23

RicKets occurs before skeletal matur rty (in children).

Osteomalacia occurs aVter skeletal maturity (in adults).
Causes’
• Decrease in vitamin D ’ Hypocalcemia
i. Nutritional (m/c).
A. malabsorption.
3. Lach o? sunlyht exposure (sunscreens > SPF 30).
4. Liver and Kidney diseases.
S. Drays
• Decrease in calcium.
• Decrease in phosphate

Teanindoyies ’
Osteoid maturation time Time tahen by the osteoid to
’
become osteon.
Hypocalcemia increases the osteoid maturation time,
mineral apposition time : Speed at which the mineral yets
deposited on the osteoid.
Hypocalcemia decreases the mineral apposition time.

Lab ^ndinys :
• Ca'“ 5 Deereased/nor mal.
• PTH : Increased (secondary hyperparathyroidism).
• Phosphate ’ Decreased.
• ALP : Increased (bone turnover).

Skeletal manifestations OO:31:31

SKull :
• Craniotobes/piny pony sKull : SoVteniny o? the sKuli
(earliest chanye).
• Frontal bossiny.
• Delayed closure o? Vontanelle. I
Chest ’
• Rachitic rosary ! Costochondral junction swellinys (blunt and
non-tender).

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 04 Metabolic Bor
Disease : Part Leave Feedbai

Clinical Endings :
In Knee »
• bilateral etenu valgum (KnocK Knees).
• Bilateral e^enu varum (bow Knees).
• uJind swept deformity (varus on one side and valgus on the
other side).
I. mcc overall » RicKets.
a. mcc in children « RicKets.
-
3. mcC in adults Rheumatoid arthritis.

Cow Knees KnocK Knees uJind swept

deformity
bilateral Bilateral ulind Swept
e^enu Varum Qenu Valgum OeVormity
(Bow Legs) (KnocK Knees)

mcc in RicKets > Idiopathic > RicKets

§
Children Idiopathic RicKets
mCC in adults Osteoarthritis Rheumatoid Rheumatoid
> Rheumatoid Arthritis > Arthritis
Arthritis Osteoarthritis

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 04 Metabolic Bon
Disease : Part Leave Feedbac

Healing rickets 00:45:33

Dense mineralization of growth plate :

Healing octets.
uJhiteline of Franhel ; Thich band of
calc&cation on the metaphysis.
best method to assess the healirg of
rickets is x-ray > serum ALP.

Treatment of deformity in rickets 00:46:55

mermaid splint and vitamin D therapy.

Surgery for deformity correction.
I. young lOart for
remodelling.
a. Older child : Osteotomy after the bone activity is
reduced which is assessed by bone turnover (normal
Serum ALP).

Osteomalacia 00:49:44

Occurs after skeletal maturity.

Female > male.
Voung people.
Presentation • Polyarthralgia, bone pains, proximal myopathy.

Deformities/x-rays :
milkman’s fractures/looser zone/pseudo
fractures :
AhA cortical infarctions.
Pulsations from the arteries around the
bone can cause stress fractures which
heal by the callus which is descent in
mineral.
These appear as transverse bands of raref o^^r^w^ic^Tare I
perpendicular to long axis of bone. 5
me sites : Meeh of femur, clavicle, ribs, scapula, pubic ramus.

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 04 Metabolic Bor
Disease : Part Leave Feedbai

Scurvy 00:54:29

Collagen maturity defect because of vtamin C deftciency.

Laboratory values are normal as mineralisation is normal.
Problem is in endothelium/shin/gums.
Clinical manifestations of scurvy

Cone Blood vessels

Diaphysis • Bleeding gums.
• ground glass appearance. Costochondral junction :
• Pencil thin cortex. • Scorbutic rosary.
metaphysis : • Tender and sharp.
• uJhiteline of Franhel. Bone s
• Scorbutic zone. Subperiosteal hemorrhage.
(Trummerfeld zone)
• PelKan’s spur.
epiphysis :
• uJimberger ring sign
(sclerotic r im around the

epiphysis).

o/o of whrteline of Frenhel »

• Healing rickets.
• Congenital syphilis.
• Plumbism.
• LeuKemia.

Conditions which can present with pseudoparalysis (due to

pain on movement)

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 04
There is no feedback to the PTH secretion leading to =
• excessive bone breakdown.
• excess accumulation of S Caa\
manifestations due to increased S. Caa*: (mnemonic Bones,
stones, groans, fatigue, psychiatric overtones) :

Panful bones Painful bone condition (classically osteitis fbrosa

cystica)
Penal stones Kidney stones (can ultimately lead to renal
failure
Abdominal groans gastrointestinal symptoms, nausea, vomiting,
constipation
Psychiatric moans effects on nervous system-, lethargy, fatigue,
memory loss, psychosis, depression

Laboratory findings =
• PTH • Increased
• Calcium Increased
• Phosphate Decreased
• ALP : Increased
Brown tumor :
Accumulation of blood in the cavities
formed due to bone reorption
where hemoglobin breahs down into
hemosiderin (brown colored fluid).
AKA osteitis fibrosa cystica.
AhA von IZecKlinghausen disease of the
bone.

Treatment of primary hyperparathyroidism : Surgical excision

of the adenoma.

Renal osteodystrophy 01:03:57

Seen in renal failure patients which leads to :

Deficiency of vitamin D : Hypocalcemu I
Penal failure leads to excess excretion of calcium.
Phosphate levels are high.

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 05 R1
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METABOLIC BONE DISEASE : PART 2

Osteoporosis 00:00:31

volume/ mass/ density o? bone decreases

Quantitative defect.
Porous bone disease
Mormal bone qualrtu.

Qualitative versus quantitative defect :

QuatatNe A

cesser <**antdy of osteod rrwwrats

*Jor maJ OSteOid * mTWraK

Osteoblast 6one Vormation.

=
Osteoclast Bone resorption.
In young age, the balance shifts towards osteoblast In old
age shifts towards osteoclast.

space
Active

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 05 Metabolic Bon
Disease : Part Leave Feedbai

Laboratory investigations : Normal .

m/c complication :
-
Fragility Vracture Spine,necK o? Vemur/hip, Colles Vracture.
—
Spine fracture » Deformity : Kyphosis.
Kyphosis is due to vetrebral compression.
Height reduces and patient bends Vorward.

Cod^sh / ^sh mouth vertebrae •

soVt vetrebrae end plates compresses around
inter-vertebra) disc,
Evident aVter 30^ loss o¥ bone.

Screening options :
• Quantitative CT Scan :
Expensive more radiation exposure.
Single photon emission absorptionmetry :
Do not give generalised picture.
DEXA Scan - IOC
Dual energy Xray absorptiometry.
alas invented to measure body Vat.
DEXA Scan results are compared between two population. 2
Z-Score *
Same sex race o? same age.
Not used Vor diagnosis o? osteoporosis.
Example ! In elderly, even reference will have low density.

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 05 Metabolic Bone Leave Feedbacl
Disease : Part -

Supplements Dosage
Calcium 8OO-lalOOmg/dag
VitO 400-800 lu/dag

Vith 300-400 lu/dag

Calcitonin -
Bisphosphonates :
Drug o? choice.
Inhibit bone resorption.
=
E.isedronaie Once a weeh dosage.
Ibandronate Once a month dosage.
Zolendronate •
Once a year dosage.
Qood compliance.
Complication ’
3-5 years o? intahe o? bisphosphonates leads to
~
Atypical fracture ocurring in hip (in 5%) .

subtrochanteric
Vracture at lateral
cortex

Prevention oV atypical fracture :

Drug holiday '• Patient ashed to stop intahe aVter 3-5 years
-
o¥ use ?or Veu) months I year.
Alternate drugs prescribed.
Later bisphosphonates can be given.

Teriparatide •
Synthetic parathormone (acts as anabolic drug).
Parathormone acts on osteoblast and latter releases
Receptor activator oV nuclear factor Kappa-6 ligand
feAMhL.) causing bone resorption.
1
$
But in small doses, e.AMhL is not released but increases
osteoblast.

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 05 Metabol
Dise

LocKmg plate ’
Instruments for $xing in osteoporotic soft bones.
Plate with threaded holes screw which loch on bone .
uieight of screw fallirg on plate prevents cutting of bone.

Paget's disease 00:34:14

Also called as Osteitis deformans.

Abnormal activity of osteoclasts.
Stages :
Lytt
mixed.
blastic.
male > female
mainly in elderly patient (sth decade)
m/c cause : Idiopathic
m/c manifestation = Pain
Association •
SQSTrni gene mutation.
Paramyxovirus.
Pelvis > tibia
Pathology s
Increased osteoclastic activity.

increase the bone resorption.

Increased bone formation by osteoblast.

Increased bone turnover hence increase in ALP

( may be upto ao times).
S.calcium phosphate : Normal 3
Qualitative defect that is =
Immature, weaK, vascular woven bone (poor bone
quality)

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 05 Metabolic Bor RQ
Disease : Part Leave Feedba,

Diagnosis :
dincally
Biopsy o? bone = mosaic pattern.
Eadiologically :
• Lytic phase •
Osteoporosis circumscripta
flame shaped / Blade o? grass appearance

• mixed phase =
Picture Vrame vertebrae
ivory vertebrae
Cotton wool shull

Picture frame vertebrae

• Blastic Phase
Tam O Shanter Shull /Diploic swelling (thichening o? Shull)

Orthopaedics •v4.0 •Marrow 6.0 •2022

Treatment :
multidisciplinary approach for fracture prevention with
bisphosphonates, fracture management when present, and
realignment osteotomies for long bone deformities

Realignment osteotomy
The bent part removed and cut into fragments.
Rod called Duboin rod is inserted and bone is put in
fragments .
Also called as SeeKh hebab/scoff ield miller operation.
Calcium PTH Phosphate OLP
RicKets/om/
Sec Hyper PTH
/M T I T
Renal
Osteodystrophy
u T TTT T
Osteoporosis KJ KJ Kl KJ

Primary Hyper
PTH
TTT TTT T
Paget’s KJ KJ KI
TTT S
Disease

MCQs 00:50:07

Q. Osteomalacia is associated with which one of the following?

A. Decrease osteoid volume osteoblastic activity

Orthopaedics •v4.0 •Marrow 6.0 •2022

 05

supplements Vor treatment When should the patient referred

Vor surgical correction o? the deformity?
A. When vitamin D levels return to normal
6. When growth plate heeding is seen radiographically.
C. When bone specific alKaline phosphatase is normal.
D. When serum calcium becomes normal

Q. A child comes to you with Bichets and has genu varum o?

the right Knee. vitamin O was given Vor 3 months, and growth
plates healed on xray. But deformity has persisted. What will
be best time to refer this patient to the Orthopedic surgeon
for a corrective osteotomy?
A. When serum Vitamin D levels become normal
6. When serum AIKaline phosphatase levels become normal
C. When Femoro-tibial angle > IS® on X-ray
O. When serum calcium phosphorous levels become normal

are True regarding scurvy Except?

Q. All
A. Vitamin C deficiency leading to defective collagen
osteoid formation.
6. Defective elastic fibres bone mineralization.
C. King sgn and metaphyseal fractures.
D. Dense line between epiphysis metaphysis.
Q. Which of the following is not a feature 0? osteitis fibrosa
cystica?
A. Fracture
6. Tetany
C. Increased serum calcium
D. Increased alKaline phosphatase
Q. Trueregarding Paget’s disease is All Except?
A. Deafness is d/t otosclerosis
6. Heart failure is a dreaded complication
C. Pain best relieved by MSAIDS
D. Elevated serum alKaline phosphatase is a common lab 5
finding. I
Q. Which of the Vollowing is seen in Osteoporosis ?
A. Low Ca, Hgh PO4, Hgh AIKaline Phosphatase
B. Low Co, Low PO4, Low AIKaline Phosphatase

•
Orthopaedics •v4.0 Marrow 6.0 •2022
 Q5 Metaboli^^.Qna
Disease Leave Feedba

C. CabxiVene
O. Calcitonin

Q. which o? theVollowing s the best method to assess healing

in a case o¥ fcicKets?
A. Serum vitamin O levels
6. Serum AlKaline phosphatase levels
C. Xray
O. Serum calcium phosphorous levels
Q. UJhat is the Diagnosis in the given
X-ray?
A. Scaphoid Vracture
6. Colles fracture
C. 2-ichets
O. Osteoporosis
Q. A S-year-old child was brought to the pediatrician with
complaints o? bilateral Knee pain. His bone mineral density is
normal. X-ray image oV the joints is given below. uJhat is the
most liKely diagnosis?
A. E-icKets
6.
metaphyseal dysplasia
O. PyKnodysotosis

Q. UJhat will be the Mext step in

management when the girl in
the given image presents to you in your OPO ?
A. uS^hnee
6. CT Knee
c. X-ray Scanogram
o. me.1

Q. A SS year old ?emale

complains o? lower bacKache.
The radiographic image o? her
lumbosacral spine is given below. 1
UJhat is the probable diagnosis?
A. Osteoporosis
6. AnKybsing spondylitis

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 06 77
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UPPER LIMB TRAUMA : CLAVICLE

AND SHOULDER

upper limb trauma usually occurs due to falling on an

outstretched hand.

Clavicle 00:02:34

Only long bone arranged

horizontally in the body
ossi^es in the membrane.
First bone to ossify (s'b
intrauterine ween) the last
bone to complete ossification
(ao-as yrs). medial a/srd

Only long bone that has a primary centres of ossification.

Curved S-shaped bone.
medial is tubular while lateral l/3rd is flat leading to
vulnerability at the junction.
me fracture occurs at middle i/s^ (junction of lateral l/3rd
medial a/3r<) or (junction of lateral a/s medial b/s).

me bone fracture at the time of birth/diff icult birth/birth

extraction : Clavicle fracture. osptaong forces o cla.vJe

me. fracture in new born : Clavicle.

me fracture overall : Clavicle.

Displacements of clavicle fracture :

UJeight of the limb.
Pectoralis muscle.

me complication of clavicle fracture space

malunion.
Other complications :
Active
Meurovascular injury » branchial
plexus, subclavian vessels.
Mon-union (very rare).

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 06 Upper Limb
Trauma : Cla Leave Feedbai
& Shoulder
Shoulder joint 00:13:41

Head o? humerous is 4 times larger than the glenoid

It is a mobile joint, therefore less stable joint.
me. dislocated joint.

Stabilizers s OynajTw: stabilisers State stabilisers

Static stabilizers •
I. Capsule.
a. Labrum (^brocartilagenous rim around glenoid).
3. Qleno humeral ligaments s Superior glenohumeral, middle
glenohumeral, inferior glenohumeral (most important).

Shoulder joint is uieaKest : ln?eriorlg.

But dislocation is me Anter iorig.
2
&

Shoulder dislocation : 5
most mobile me dislocatedjoint <50% o? ail joint dislocations),
me disclocation s Anterior (90-98%) > Posterior > Inferior
(rare).

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 06 Upper Limb
Trauma : Cie
& Shoulder
Axillary nerve is quite uoell protected,
however can be injured by :
Proximal shoulder Vracture.
Dislocation o? shoulder joint.
Axillary nerve examination :
Deltoid teres minor.
Regimental badge area : Pain,
paresthesia, tenderness.

Confirm with X-ray :

AP.
Lateral/axillary view. Cutaneous Enervation o? upper Imb
flnteror aspect Posterior aspect

median nerve
median nerve
cschas

modifted Kocher’s technique T&Am.

Traction is applied,
txtemal rotation.
Adduction.
medial rotation/internal rotation.

Stimson’s technique :
Patient prone on table with aWected
limb hanging Vreely over edge,
lO-iS-lb weight is suspended Vrom wrist,
overcomes muscle
gradual traction
spasm and in most cases achieves
reduction in ao-as minutes.

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 06 Upper L QQ

Trauma Leave Feedbac

& Shouh

me complication of shoulder dislocation : Reccurent shoulder

dislocation.
me early complication of shoulder dislocation : Axillary nerve
injury.
me late complication of shoulder dislocation : Reccurent
shoulder dislocation.
me nerve injured in shoulder dislocation : Axillary nerve,
me type of shoulder dislocation s Anterior dislocation,
me sub type of shoulder dislocation : Subcoracoid
=
uJeahest part of the shoulder joint Inferior.
Rarest type of shoulder dislocation » Inferior dislocation.

Posterior dislocation :
Posterior Dislocation
mechanism of injury : High voltaye Clavicle

electric shoch, 6CT, seizure,

fall on outstretched hand, direct
trauma.
Attitude : Adducted internally
rotated.
Shoulder contour is not lost.
Inability to abduct or externally rotate.
Liyht bulb siyn seen on x ray.
Lesions :
Reverse ftanhart =
Postero-inferior.
Reverse Hill Sach’s :
Antero-medial.

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 07 QC

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UPPER LIMB TRAUMA

ARM AND ELBOW

Proximal Humerus Fractures 00:00:08

TWo nechs o? proximo) humerus :

Anatomical nech is located just under -the articular surface.
Surgical necks goes through the greater and lesser tuberosity,
most common location oV Vracture o? proximal humerus.

Axillary nerve injury :

Fracture o¥ proximal humerus invariably causes axillary
nerve injury due to it’s proximity.

Mormal

X-ray shouis fracture o?

surgical nech oV humerus
Dislocated shoulder

Proximal humerus Vracture *

• Seen in post menopausal, elderly osteoporotic females.

• Less dense other bones as density decreases in ul > ll
and proximal > distal
-
• me complication StiV^ness o? shoulder
• me injured nerve Axillary nerve.

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 Q7 Upper limb
Trauma Arm & Leave Feedbacl
Elbow
Complication : Radial Merve Injury
Os radial nerve runs in close proximity to shaVt o? humerus.

U slab Hanyiny cast

Open reduction internal Nation o? fracture sha?t o? sha?t.

Holstein Lewis Vracture :
Fracture o? the distal third 0? the humerus resultiny in
entrapment o? the radial nerve.

I
*
I

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 07 upp^11
Trauma Leave Feedba
Elbow

Qx o? Open # : 0C2.IF worth exploration o? nerve.

Case : A patient presented worth shaVt o? humerus # worth no
recovery a^ter (o months.

Posterior approach to humerus, a vertical incision is made.

Qadial nerve passes Vrom medial side and yoes laterally.

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 07 Upper liqjU 91
Trauma Arm & Leave Feedba
Elbow

Lateral condylar humerus fractures 00:20:55

Fracture o? a condyle above the radial head.

=
Salter Harris’s type IV Injury o? physeal plate Involves all 3
-
layers metaphysis, physis and epiphysis.
Intra articular « / Fracture o? necessity : Necessitates
surgery, no rote o? conservative management.
3 Point bony relationship is disturbed
Fractures o¥ necessity :
• Intra articular fracture
Lateral condylar humerus
monteggia/ Galeazzi
Nech o? Vemur

Complications s
Sti^Jness o? elbow.
Non-union, due to :
• Pull o? common extensor group o?
muscles.
Intracapsular, hence washed by synovial fluid, which
prevents healing.

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me trocture around the elbow in children.
rrc Vracture Vollowing a Vail on outstreatched hand (FOOSH)
in a child
me mode o? injury FOOSH.
me mechanism ot injury : Hyper extension.
Reason :
geometry oV bone changes Vrom
triangular superiorly to a Slat bone
interiorly.
There are a tossae, olecranon coronoid
Vossa at the distal end oV humerus.
Fossae mahe the bone thin and weaK
Hence , high risK o? tracture.
The Vracture passes through the olecranon tossa
SaRer Harris type I or type II $ /extra-articular.

Types:
l.rrc : extension type /
distal fragment goes
posteriorly, due to pull o?

Postero-medial type
Postero-lateral type. extension type Rexion type

a. Rexion type /distal fragment goes anteriorly.

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 07 Upper lirgb
Trauma Lea'
Elbow
Type I diagnosed by indirect signs.
Fatpad sign Fai pushed by the
fracture haematoma appears as lucency
around the bone
Or Sail sign.

Type HI
Baumann’s angle (Helps in assessment o¥ reduction)
Angle between
A line parallel to the longitudinal axis oV the humeral shafr.
And a line alona the lateral condular qrowth plate.

used to assess the medial tilt.

Mormal Baumann’s angle Valls between ^10° 75° -
As the Baumann’s angle increases the carrying angle
decreases, leading to cubitus varus.
Rsh tail sign
Helps asses the Internal rotation o? the distal fragment

AP view.

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 07 Upper limb Q7
Trauma Arm & Leave Feedbai
Elbow
This is -type III Wture showing reduction and fixation with K
wire.

me injured vessel ftrochial artery

me injured nerve AIM /Anterior
interosseous nerve > median.
injury o? these structures ©occur
due to proximal fragment.

Dunlop traction

Compartment syndrome
As a complication o? suprachondylar humerus Vracture.
The proximal fragment injures the brachial artery.
Distal blood flow is compromised > Flexor group o? muscles
are ejected flrst.
The largest muscle oV the flexor group • Flexor digitorum
profundus has high metabolic requirement.
Hence it is the earliest muscle to be aV^ected in ischemia.

Fracture swelling leads to decreased venous return/venous

congestion
ischemia. oV muscles (FOP) » Inflammation » Swelling o?
muscle inside the Vascial compartment » Compression o?
capillaries providing blood to the muscles, this leads to vicious
cycle o? further ischemia, and compression o? vessels.
This leads to muscle necrosis —
» Fibrosis > Contracture
o? muscles.

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 07 Upper limb
Trauma
Elbow
Case scenar io
Patient with tense swelling in right lower limb, Vollowing
proximal tibial fracture which was neglected, presented with
tense swelling in the leg, and pain on passive stretch. Patient
also shows blisters which are perforated over shin of leg (due
to superficial shin being necrosed by compartment pressure).
This is a case of acute compartment
syndrome of lower limb.
It is treated by decompression of all
4 compartments Anterior, lateral,
posterior superficial and posterior deep
compartments.

to reach the posterior superficial and

deep compartments.
To access the lateral and anterior part
the leg, incision made over the lateral part of the leg.
is

Shin, superficial fascia and deep fascia are incised.

Low blood pressure following a trauma •

=
Differential pressure/AP Difference between diastolic
pressure and compartment pressure.
If absolute pressure > 30mmHg or AP < 30 mmHg : Diagnosis
of compartment syndrome.

Volhmana’s ischemic contracture !

§
• Ischemia &
• Fibrosis of forearm muscle.
• Rexion contracture of wrist fingers.
• Sensory loss motor paralysis in the forearm hand

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