Elite

Orthopedics

mm.
•
 Introduction
Named Fractures
upper limb fractures
1. Little leaguers # 2. Piedmont # 3. Bartons #

Avulsion # of Closed # of radius at the Intra-articular #

medial epicondyle junction of the middle and of distal articular
distal 3rd’s surface of radius
of humerus
-

5. Colle’s # 6. Smith’s #
4. Chauffeurs #

# of the radius above # at the corticocalcaneal # of distal end of

junction of the distal end radius at cortico-
styloid process of radius with dorsal tilt cancellous junction

7. Galeazzi # 8. Monteggia’s # 9. Hume’s #

# of distal 3rd of radius # of proximal 3rd of # of the olecranon with an

with dislocation of distal associated anterior dislocation of
radioulnar joint ulna with dislocation of
the radial head
head
10. Moore’s # 11. Bennet’s # 12. Rolando’s #

# of distal end of
Oblique intra-articular # Old intra-articular #
radius with
of base of 1st metacarpal across the base of the
luxation of distal
with subluxation of first metacarpal
end of ulna
trapeziometacarpal joint

13. Boxer’s # 14. Essex-Lopresti #

Centrally displaced
# through neck of Comminuted # of radial
5th metacarpal head with distal radio-
ulnar joint subluxation
VERTEBRAL FRACTURES

1. Jefferson’s # 2. Hangman’s # 3. Clay shoveller’s #

Burst # of atlas C1 Traumatic spondylolisthesis # of spinous

of C2 process of T1
vertebra

Lower limb fractures

1. Unsolved # 2. Segond’s # 3. Stieda’s #

Intracapsular # neck A/w ACL tear of knee # medial epicondyle

of femur of femur

4. Masonniase’s # 5. Pilon # 6. Bumper #

Ankle injury with #

Comminuted # of tibial Comminuted depressed
neck of fibula
articular surface with # of # of lateral tibial
fibula condyle
 7. Gosselin’s # 8. Tilaux # 9. Toddler’s #

Salter type 3 # of lateral Non displaced

V shaped # of distal end part of distal tibial spiral # of tibia
of tibia epiphysis

10. Cotton’s # 11. Pott’s # 12. Wagstaffe’s #

Trimalleolar ankle # # with

Bimalleolar ankle #
displacement of
medial malleolus

13. March # 14. Jone’s #

Stress # of neck of
Avulsion # of base of 5th
2nd or 3rd metatarsal
metatarsal
Miscellaneous fractures

1. Buttonhole # 2. Cough # 3. Green stick #

crack or break on one side

of a long bone in the arm
Rib(5th or 7th) #
# with loss of bone as or leg
caused by
in gunshot wound
coughing
7. Shepherd’s # 8. Ping pong # 9. Tripod #

# of external
tubercle of talus Depressed skull # Trimalar #,

10. Malgaigne # 11. Motorcyclist #

Vertical shear # of pelvis

# of base of skull into
anterior & posterior halves
Previous Year Questions

Match the following (INICET 2021)

Name of fracture Fracture site
A.i-b,ii - a,iii - d,iv - c
i.Boxer’s fracture a.1st metacarsal B.i-b,ii - d,iii - c,iv - d
ii.Bennett’s fracture b.5th metacarpal C.i-d,ii - b,iii - c,iv - a
iii.March fracture c.5th metatarsal D.i-c,ii - b,iii - d,iv - c
iv.Jone’s fracture d.2nd metacarpal

Previous Year Questions

March fracture is seen in the ________ of IInd metatarsal (AIIMS 2017)
A. Head
B. Neck
C. Shaft
D. Base
 Anatomy and Physiology
Basic structure of bone

Growth plate
Eh .

-Increases length of bone Metaphysis

-layers of Growth plate
; ;
l Sharpey’s fires
y
l
1. Zone of Reserve cells l
l
l Periosteum
2. Zone of proliferation l l
l
Present over bone Periosteum: 2 layers
l
3. Zone of Hypertrophy (Weakest) l l except- joints & > -outer fibrous(muscle
4. Zone of Calcification (Mineralisation) 1 4 around Desmond’s attachment)
5. Zone of Ossification -inner Cambium layer(promotes
EE Epiphysis
new bone formation)

Bone- Type 1 collagen

Mnemonics
Cartilage- Type 2 collagen
Layers of Growth plate
M/C vascular area of bone- METAPHYSIS
Real
Predicted Question People
Have
Q.Most common location of bone infection?
Career
Ans- METAPHYSIS (high vascularity)
Options
Q. Which part of bone is not seen in X-RAY?

Ans- PHYSIS (made up of cartilage, cartilage is not seen on X-RAY)

Composition of Bone

Osteoid- Immature Bone(cells+proteins)

'

¥
Osteon- Mature
i. Bone(cells+proteins+minerals)

Osteoid increased in- i)Osteosarcoma

ii)Paget’s Disease

Minerals decreased in- i)Ricket’s

ii)Osteomalacia
 BONE

INORGANIC MINERALS ORGANIC MATRIX

(22-25%) WATEr
(60-70%) (5-7%)
A. Cells(5%)
a. -osteoblasts(bone forming) -more in childrens
Calcium hydroxyapatite-
-osteocytes(mature bone cells)
‘crystalline form’
-osteoclasts(macrophage or large
cells that reabsorb bone matrix)

B. Proteins(90-95%)
-Type 1 collagen- Tensile strength
-Non collagens- Osteocalcin,
Osteopontin
Osteonectin
-Enzymes- bone specific ALP

OSTEOBLASTS VS OSTEOCYTES VS OSTEOCLASTS

OSTEOBLASTS OSTEOCYTES OSTEOCLASTS

-Makes Osteoid from bone. -mature or resting osteoblas -remodel the bone.
-helps mineralisation. -most abundant cell in bone. -least abundant cell in bone
-longest lifespan in bone. -Ruffled borders present.
(Makes pits -Howship’s Lacunae)

Cell markers

BONE FORMING MARKERS BONE RESORPTION MARKERS

1. Bone specific ALP 1. N & C chains of Telppeptides

2. Procollagen Type 1C &1N 2. Deoxypyridinoline
3. Osteocalcin (protein) 3. Hydroxyproline & Hydroxylysine
4. Osteonectin 4. TRAP- Tartarate Resistant Acid Phosphatase
 Physiology of bone
Parathyroid hormone
1. Intestine- no direct effect
2. Kidney- increased conversion of vit. D
3. Bone- resorption (Ca increase and phosphate decrease)

Vit. D3
1. Kidney- increased Ca absorption, decreased phosphate
2. Intestine- increased absorption
3. bone- Ca increase, phosphate decrease

Calcitonin
1. Bone resorption inhibition(Ca decrease)

PTH

:
Acts on Bone

Receptors of Rank ligand

:
Rank ligand to Rank receptors on Osteoclast

Osteoclast stimulation (remodeling of bone)

PTH Adenoma

High level of PTH

:
Increasead stimulation of osteoblast
Increased release of RANK ligand

:
Increase osteoclast stimulation

Lysis

:
Formation of cysts(osteo-fibrosis-cystica)

Filled with blood degradation products-Brown Tumor

Development and growth of long bone

A. Enchondral ossification- Preformed cartilage —-bone

B. Intramembranous Ossification- Direct formation of Bone
eg- skull, maxilla
C. Appositional Growth- increase in width of bone—-meta/diaphysis
D. Interstitial Growth- increase in length of bone— Epiphysis

Types of bone
BONE
IMMATURE MATURE
(WOOVEN BONE) (LAMELLAR BONE)
Stronger, doesn’t break easily

Growing skeleton, healing # CORTICAL BONE/ CANCELLOUS BONE/

COMPACT BONE SPONGY BONE

Densely packed, seen Loosely packed, seen at end of

at Diaphysis Long bones

Predicted Question

Which among the following is not a function of PTH?

A. Decreases phosphate re absorption from kidney

B. Increases bone resorption
C. Increases calcium absorption from intestine
D. Increases Vit D formation
 Fractures & Healing
Fracture
-Break in continuity of cortex
MODES OF FRACTURE

TRAUMATIC PATHOLOGICAL

DIRECT INDIRECT
Causes- i) localised- infections, ischemia,
radiation exposure, cyst
Transverse # Any # pattern( oblique #, ii) systemic- Osteoporosis(M/C),
spiral #, butterfly #, metastasis, rickets, osteomalacia,
Avulsion # osteogenesis imperfects, Paget’s disease,
scurvy

OPEN # # hematoma can come out of wound( external environment)

TYPES OF FRACTURE
CLOSED #

SIGNS OF FRACTURE
1. Abnormal mobility(pathognomic sign)
2. Failure to transmit movements proximally
3. Crepitus
4. Tenderness- commonest/ consistent sign

TRANSVERSE # BUTTERFLY # OBLIQUE # SPIRAL #

② ② ② Do
'

I I I
Due to Tension Due to Bending Due to Compression Due to Twisting
fracture healing

STAGES
1. Stage of hematoma- few hours
2. Stage of inflammation & granulation- few days
3. Stage of soft callus formation/ woven bone- after 3 weeks
4. Stage of calcification(hard callus/ lamellar bone)- few months
5. Stage of Remodelling- months to years

- Callus forms only when there is movements

Microscopic movements- FORMS CONSOLIDATION
Excessive movements- leads to NON-UNION
-Bridging callus- callus formed outside the bone.

FACTORS AFFECTING FRACTURE HEALING

-Age (young>elderly)
-Nutritional status
-Associated disease- anemia, diabetes
-Intake of alcohol/smoking
-Type of bone (cancellous>cortex)
-Associated radiation exposure
-High grade injuries- Delayed healing

TYPES OF HEALING

Primary healing Secondary HEALING

Callus absent Callus present

Plate is used(absolute stability) Cast/Nail is used(relative stability)

ABNORMAL OUTCOMES OF # HEALING

1. NON-UNION
Arrest of # healing( # doesn’t heal by 9 months, there is no progress in healing for last 3 months)
X-RAY features- # line visible
- # fragments are smooth ended
- sclerosis at bone ends
 TYPES

HYPERTROPHIC OLIGOTROPHIC ATROPHIC

(Vascular) (Avascular)

Excess callus + No callus formation

Treatment- Stabilization(callus Treatment- Freshen the #
will consolidate and bone will (nibbling/rose petalling the
unite) bone segment + stabilise +
bone graft)

Bone graft- iliac crest Q

BMP(BONE MORPHOGENIC PROTEIN) - used for bone formation in NON-UNION

2. DELAYED UNION Mnemonics
# healing is present but not in time(i.e not healed by 6 months) FLUTS- # for non- union
F- Femur neck # (cambium layer absent)
Treatment- Hypertrophic- immobilise the # L- Lateral condole of Huemrus
Atrophic- bone graft U- Ulna lower 1/3rd
T- Body of Talus, lower 1/3rd of Tibia
S- Scaphoid
3.MALUNION
Biology normal, but faulty reduction( # heals at abnormal position
Occurs due to pull of muscles
Treatment- Osteotomy Mnemonics

Fractures known for Malunion

M- Malunion
I- Intertrochantric fracture femur
S- Supracondylar humerus
C- Colle’s fracture/ clavicle fracture

Classification of open fractures- gustilo Anderson

Type I- clean wound, <1 cm

Type II- wound >1cm, but without extensive soft tissue damage
Type III- Extensive soft tissue damage
a. Segmental or communities #(periosteum intact)- firearm injury
b. Contaminated injury; periosteal stripping, bone exposure
c. Vascular injury which needs surgical repair
MANAGEMENT
Type I- Treatment as closed #
Type IIIb&c- Treatment as open #
Type II & IIIa- if soft tissue is well managed- treatment of closed #
if soft tissue is not manageable- treatment as open #

SKIN TRACTION SKELETAL TRACTION

Indication Mild to moderate force Moderate to severe force

Wt used 5-6kg 15- 16 kg

Applied with Buck’s traction Steinmann pin, Dunham pins,

k-wire

MANAGEMENT OF OPEN #
-start patient on antibiotics
-wash wound with NS, P.Iodine, H2O2 Closing of wound
-wound debridement If wound is clean & < 6hrs old- close( Type I & II#)
-repeat debridement after 72 hours If wound > 6hrs old- DELAYED primary closure

STRESS #
Due to repeated activity of bone
A/k/a OCCULT # Ligamentoraxis
IOC- MRI External fixator is used to
IOC for multiple stress #- Bone scan keep the fracture ‘distracted’, so that the
Treatment- Immobilize # stretched ligaments and periosteum keep
the comminuted fragments in place

DEFINITIVE TREATMENT OF #’s

Reduction

Closed Open

Feel # & reduce under X-ray Reducing # fragment under direct visuals
Fixation

External fixation(POP) Internal fixation

 TWO TYPES OF FRACTURE

Intraarticular # Extra articular #

Open reduction + internal fixation Closed reduction + POP

(Plates & screws)
Exception: Hip # and Supracondylar If fails
humerus #
Lower limb Upper limb

Closed reduction + Open reduction +

internal fixation with rods internal fixation(plates)
& nails

Bone grafts

Autografts Iliac crest, greater trochanter, proximal metaphysis of tibia, olecranon

Allografts Freeze-dried, demineralised bone matrix
Factor-based rhBMP-7

Cell based Mesenchymal stem cells

Calcium based synthetic Calcium phosphate, calcium surface, hydroxyapatite
Polytrauma
≥ 2 organ systems involved
•
Early temporary fixation is done by External fixation
DAMAGE CONTROL ORTHOPAEDICS
The patient is optimized
(Limited surgical intervention to control
•

haemorrhage & contamination) •

Definitive treatment
Done in unstable patients

Previous Year Questions

All are true about Open fracture except : (INICET 2021 JULY)
A.Tibia is commonly involved
B.Immediate debridement reduces risk of infection
C.Compartment syndrome is rarely seen in open fractures
D.Rarely associated with addition injuries

Previous Year Questions

Gustillo anderson classification type IIlb is? (AIIMS 2017)
A) Open fracture, wound more than 1 cm, less than 10 cm in length without extensive soft tissue
damage, flaps, avulsions
B) Open fracture, wound less than 1 cm in length without extensive soft tissue damage, flaps, avulsions
C) Open fracture, wound more than 10 cm in length with extensive soft tissue loss and periosteal
stripping and bone damage
D) Open facture, wound more than 10 cm in length associated with an arterial injury

Previous Year Questions

After a fracture, the growth of callus will be increased by which of the following? (AIIMS 2017)
A) Strict immobilization
B) Repeated tiny movements at the fracture site
C) Intermedullary nail
D) K wire fixation
 Previous Year Questions

Which of the following substances is used for bone formation in patients with non-union? (INICET 2020)
a. Calcium Phosphate
b. Calcium Sulphate
c. PMMA
d. Bone morphogenetic proteins

Previous Year Questions

Which of the following fractures is most prone to nonunion? (NEET PG 2019)

A) Proximal scaphoid
B) Inter-trochanteric
C) Distal radius
D) 1st metatarsal

Previous Year Questions

For hypertrophic non-union following a fracture, the most appropriate treatment would be (NEET PG 2018)
A) Stabilization
B) Bone grafting
C) Stabilization and bone grafting
D) None of the above
 Splints and Traction
Splints

Thomas splint Cockup splint- Radial nerve palsy

Dennis Brown splint- CTEV
# femur

Aeroplane splint Taylor brace

Brachial plexus injury Dorso lumbar immobilisation Milwaukee brace

Knuckle Bender splint Mermaid splint

Ulnar nerve palsy Rickets
 Previous Year Questions

A polytrauma patient with femur fracture and massive haemorrhage presents to the ER, after an RTA.
Which of the following is not an immediate treatment consideration in this patient? (AIIMS 2018)
A) Administration of IV crystalloids
B) Tranexamic acid
C) Check coagulation with thromboelastography
D) Internal fixation of femur fracture

Previous Year Questions

Identify: (AIIMS 2019)

A) Cock-up splint
B) Dynamic finger splint
C) Colle's cast
D) Knuckle bender splint
Tractions

Gallow’s traction Perkin’s traction

# shaft of femur in children #shaft femur in adult Smith’s traction
below 2 years # shaft of femur in childrens Supracondylar # of humerus

Russell’s traction- Trochanteric # Crutchfield traction- Cervical spine injuries

Agnes Hunt traction

Buck’s traction- conventional skin traction Correction of hip deformity
 Well leg traction Dunlop traction
Correction of adduction Supracondylar # of humerus
or abduction deformity

Casts

Minerva cast
Risser’s cast Turn-buckle cast
Cervical & upper
Scoliosis Scoliosis
thoracic spine disease

Shoulder spica U-slab/hanging cast Hip spica

Shoulder immobilization # humerus # femur
 Patellar tendon bearing cast Colle’s cast(hand shaking)
# tibia # lower end radius

Bachelor cast Glass holding cast

Developmental dysplasia of hip # scaphoid

Previous Year Questions

Which of the following braces is shown in the given image(INICET-2020)

a. Boston brace

b. Milwaukee brace

c. Taylor brace

d. ASHE brace
 Metabolic disorders
Bone

Osteoid Mineral

Cell Protein 1. Rickets

2. Osteomalacia
1. Paget’s disease(osteoclast ) 1. Osteogenesis imperfecta
2. Osteopetrosis(osteoclast ) 2. Scurvy
3. Brown’s tumour

Osteoporosis- Age related disorder with imbalance b/w

osteoblast & osteoclast- No lab abnormality
Osteoid abnormality- assessed by TETRACYCLINE LABELLING TEST
Osteoclastic abnormality- assessed by BONE RESORPTION MARKERS
Mineral abnormalities- assessed by levels of: S.Calcium- (Normal 9-11mg/dl)
S.Phosphate- (Normal 3-4.5mg/dl)

Rickets & Osteomalacia

Rickets
-Disorder of children occurring before physeal closure
-Causes
Nutritional deficiency Vit.D Normal: 20-40ng
Vitamin D deficiency (m/c)
EB
Malabsorption Vit.D deficiency: <20ng
Ca deficiency
EB
Liver/Renal failure
Phosphorous defiency
EB Lack of sunlight
EB Increased Renal loss

Osteoid maturation time

•
Time taken for Osteoid to become osteon
• Hypocalcaemia- increased Osteoid maturation time

Mineral apposition rate

• Speed at which mineral gets deposited on the osteoid
• Hypocalcaemia- decreased mineral apposition rate
 Vit. D Ca PTH ( 2º Hyperparathyroidism)

Kidney (DCT) Bone resorption

*¥Mh
*
Ca Boy Ca absorbed
BzhBk*••BIÑBMkaBHo
• ALP

PO4
(Excreted)

LAB FINDINGS
Hypocalcaemia
-Increased PTH(secondary hyperparathyroidism)
-Increased Alkaline phosphatase(ALP)
-Decreased PO4

CLINICAL MANIFESTATIONS
1. Skull- Craniotabes/softening of skull/ping pong skull( earliest change)- parietal/occipital bones
- Frontal bossing
-Delayed closure of fontanelle

2. Chest : Rachitic rosary- Costco chondral junction swellings, blunt, non-tender.

: Pigeon chest/Pectus carinatum- prominent sternum
: Harrison’s sulcus- depression along attachment of diaphragm at subcostal margin

3. Long bones- (shortening):

a. Diaphysis- Bowing
b. Metaphysis- Splaying(widening) & Fraying(irregular)
c. Knee- Genu valgum- Leg distal to knee goes laterally
- Genu varum- Leg distal to knee goes medially
-windswept of legs- one knee Genu valgum, other Genu varum
overall m/c/c- Rickets
in childrens- Rickets
in adults- Rheumatoid arthritis
d. Hip- Coxa vara- at proximal femur, bending of shafts of bones in legs, thigh
e. Elbow
4. Muscular flaccidity/Muscular weakness/Tetany/Protruberant abdomen
 Rickets: Disease of hypertrophic layer of growth plate

Due to lack of mineralisation, hypertrophied cells do not calcify

Continuous hypertrophy pushes the Metaphysis

Causes widening - SPLAYING/CUPPING of metaphysis

White line of frankel

-Dense line of calcification which occurs after treatment
-Indicates healing
-Best investigation to diagnose healing- XRAY

Normal Rickets

l¥ k÷÷d
Cupping of metaphysis

Fraying
Splaying of metaphysis
.

Pushed in Widening of epiphyses plate

.

Prominant sternum Rickets rosary X- ray findings

Wind swept deformity Genu valgum Genu varum

TREATMENT
Supplementation with calcium & Vit D
i
Assist healing by splint - MERMAID SPLINT
If deformity still persists- SURGICAL INTERVENTION

MONITORING
1. Radiological monitoring- Appearence of white line(can be seen within 1-1 1/2 months)
around metaphysis on X-RAY
2. Metabolic assessment- Level of Alkaline phosphatase
Initially, level of Alkaline phosphatase- High
When minerals are supplemented, there is gradual decline in ALP
As bone becomes healthy, levels of ALP- normal

- wait for skeletal maturity before doing surgery

- check serum ALP level before surgery, increased level indicates Healing(surgery not done)

HYPOPHOSPHATEMIC RICKETS
-X- Linked dominant
-PHEX gene mutation
-Normal Ca, PTH, VIT D
-Increased ALP

Previous Year Questions

A 4-year-old child was brought to the OPD with a painless deformity.
A radiograph of the child's legs is shown below. The most common cause
of this deformity is (AIIMS 2018)
A) Congenital deformity
B) Rickets
C) Scurvy
D) Trauma to growth plate
OSTEOMALACIA
Softening of bones
: Adult counterpart of Rickets
Young females
Clinical features- multiple body pain, polyathralgia, proximal myopathy

:
Deformities/XRAY- MILKMAN’S FRACTURE/LOOSER ZONE/PSEUDO FRACTURE
fracture line surrounded by sclerosis
sites- Medial aspect of neck of femur(M/C)
Clavicle, ribs, scapula, pubic ramus
PROTRUSION ACETABULI / OTTO PELVIS
CHAMPAGNE GLASS PELVIS/ TRIFOIL PELVIS
Gold standard investigation- Biopsy

STOSS Regimen Tumours a/w Osteomalacia

3 lac- 6 lac Deep IM or Oral ( stat or over 1-5 days) -fibrosarcoma
Or -osteosarcoma
Daily 2K-5K IU for 4-6 weeks -osteoblastoma
Or
Weekly 50-60K IU for 8-12 weeks -non ossifying fibroma
-hemangiopericytoma

Champagne glass pelvis Looser Zone/ Milkman #/ Pseudo # Otto pelvis

Previous Year Questions

Which tumor does not cause osteomalacia and phosphaturia? (AIIMS 2018)

A) Osteosarcoma
B) Hemangiopericytoma
C) Fibrosarcoma
D) Breast carcinoma
 Scurvy & Osteogenesis Imperfccta
FUNCTIONS OF VITAMIN C
-Required for hydroxylation of Lysine & Proline-
cross linking of collagen fibres helps in integrity of
vessels
-If no cross linking- Predisposition to hemorrhage

SCURVY

-Defective collagen due to Vit C defiency Pro collagen

-Mineralisation is normal
Hydroxylation
-Occur in knees of children Vit. C
Proline
Lysine
-Seen after 6-12 months of deprivation
i.e, scurvy not seen in neonates
Collagen

CLINICAL FEATURES
Bone

Diaphysis
Ground glass appearance: osteopenia
Pencil thin cortex
Metaphysis
Pelkan spur- projection in metaphysis

:
Scorbutic rosary- Pinful, sharp costochondral prominence
White line of Frankel- d/t failure of resorption of calcified matrix
- D/D- healing rickets, congenital syphilis, plumbism, leukemia
Epiphysis
Wimberger ring sign- sclerotic margin of epiphysis increases

Blood
Bleeding gums
Costco-chondral junction scorbutic rosary
Anemia- d/t impaired iron absorption
Subperiosteal haemorrhage causes pain- Pseudo paralysis
TREATMENT
•
Vit C supplementation

BARTONS DISEASE- Vit C& Vit D deficiency

X-ray findings

Osteogenesis imperfecta

- A/k/a Brittle bone disease

-Characterised by genetic defect in Type 1 collagen
AD- better prognosis
-AD/AR inheritence
AR- Lethal form

CLINICAL FEATURES
A. Increased tendency for #’s, but rate of # healing normal
B. Lower limb # more common
C. Growth arrest may be associated d/t repeated #
D. Hyperlaxity of ligaments with Hypermobility of joints
E. Associated problems
-Malunion/deformity
-OTTO pelvis
-Dislocations of patella, radial head
Otto pelvis
F.Occular involvement- Blue sclera
Saturn’s Ring or Arbus Juvenalis
Retinal detachment
Hyperopia
G.Auditory involvement- seen in 40-50% cases( compression of nerve d/t soft skull bone)

-When disease is severe, skull is soft & membranous

-Death occurs d/t Intracranial hemorrhage or respiratory insufficiency
INVESTIGATIONS
S.Ca & S. Ph- normal

:
Alk.PO4- Increased
X-ray- multiple # at different stages of healing
DIAGNOSIS
1. Positive family history/clinical/radiological sign
2. Electrophoresis
3. Prenatal USG- Multiple #’s

TREATMENT
Seekh kebab osteotomy or Sheffield Millar procedure

:
Splints/braces
Bisphosphonates Multiple #’s

D/D
Battered baby syndrome- metaphysical #
: Osteogenesis imperfecta- Diaphyseal #

calcium & parathyroid gland

25(OH)D3 [calcidiol]

Ca2+ Parathyroid glands PTH 1, α Hydroxylase

1, 25 (OH)2 D2 [calcitriol]

KIDNEY GUT

DCT Ca 2+ Absorption
PCT
PO4 Absorption
Ca 2+ reabsorption Ca 2+ reabsorption
PO4 Excretion PO4 Excretion
Primary Hyperparathyroidism

M/c/c- Adenoma
: Other causes- Ca/Vit D
Renal failure
Increased PTH
Liver failure

Increased Bone resorption

Skull Teeth Phalanges Bone- brown tumour

(Osteitis fibroma cystica)
Resorption of Subperiosteal resorption
lamina dura on radial side

Loosening of teeth
Salt & pepper/
pepper pot

-Brown tumour is a/k/a VON RECKLING HAUSEN Disease of bone

LAB FINDINGS
Ca & ALP
Phosphate

Renal osteodystrophy

Occurs in Renal failure

-

Hypocalcemia(secondary hyperparathyroidism)
PTH
÷ ALPI

X-ray- Rugger Jersey Spine

 Paget’s disease & Osteopetrosis
PAGETS DISEASE

Increased bone turnover

•o•o•

•
A/k/a - Osteitis deformans
•
M/C in males > females
M/C site- Pelvis > tibia
: M/c symptom- Pain
Etiology- idiopathic
: Can be a/w - SQSTM I gene mutation
- Paramyxovirus infection
X-ray : Mosaic pattern

PATHOLOGY : Increased osteoclastic activity LAB FINDINGS

ar
•
S. Ca & PO4- Normal
Increased bone resorption • Increased bone turn over- ALP T
1
Increased compensatory bone formation A
ALP
Immature weak, woven bone formed

1. LYTIC PHASE- increased osteoclastic activity

a. Blade of grass appearence/ candle flame appearence- Brim sign
b. Osteoporosis circumscripta
7

2. MIXED PHASE- osteoclastic & osteoblastic activity

PHASES a. Picture frame/ Ivory vertebra

: b. Cotton wool skull

3. BLASTIC PHASE- increased osteoblastic activity

a. Tom ‘o’ shatter sign
b. Banana #

COMPLICATIONS
A. Pathological # : Banana # Causes of IVORY VERTEBRA
B. Cranial nerve palsies : II, V, VII, VIII L-Lymphoma
C. Osteosarcoma I-Infections
Paraparesis or paraplegia in association
D. Steal syndrome with Paget's disease of the spine not due to M-Medulloblastoma
E. Cardiac failure cord compression but due to spinal artery P-Pagets
steal syndrome
F. Osteoarthritis H-Hemangioma
G. Otosclerosis(d/t nerve compression by bone) O-Osteosarcoma
TREATMENT
-DOC- Bisphosphonates
-Calcitonin for pain control

Picture frame
Banana # Blade of grass Ivory vertebra

Osteoporosis circumscripta Cotton wool skull Tom ‘o’ shatter skull

osteopetrosis
-Decrease in osteoclastic activity
-A.k.a Alber’s schanberg disease, Marble bone disease
-Decreased functional activity of osteoclasts(Qualitative defect)- Carbonic Anhydrase II protein pump is
defective
-Increased bone formation- Thick, sclerotic, hard bone but not strong

-Pathological #
-Deafness d/t nerve compression by bone
AD dominant AR Dominant
In adults Infantile
C/F- pain, pathological # Sever form, poor prognosis
Healing- normal Increased bone formation
bone markers raised(resorption &
formation)

Osteomyelitis of mandible
Rugger jersey spine
TREATMENT
•
Bone marrow transplant

Erlenmeyer flask deformity Endobones(bone in bone)

Osteoporosis

- Porous bone disease

- Quantitative defect, all the constituents are decreased in proportionate manner
- Peak bone mass attained at 30 years
- Estrogen protects against osteoporosis, after menopause bone density rapidly decreases.
- M/c/c # neck of femur
ETIOLOGY
Sedentary lifestyle
: Smoking, Alcohol
• Post menopausal
•
High salt intake, low calcium intake
•
Hypogonadal state
•
Endocrine disorders
•
Drugs- steroids, Antiepileptics, Antacids, Methotrexate

CLINICAL FEATURES
- Backpain(earliest)
- U.L > L.L
- Proximal humerus shows maximum osteoporosis in hemiplegic patients
- Severe form : # vertebra > # hip > colles #
- Kyphosis d/t vertebral compression : Dowager hump
INVESTIGATIONS
1. S.Minerals- normal
2. X-ray-Compression vertebral #
Cod fish vertebrae/ fish mouth vertebrae- bones bend around the disc
3. Quantitative CT scan
4. Single photon emission absorption entry
5. IOC for bone density- DEXA Scan : T score : 0 to -1SD = Normal
-1 to -2.5SD = Osteopenia
< -2.5SD = Osteoporosis
< -2.5 SD + # = Severe Osteoporosis

Screening National osteoporosis foundation

•
Females of age 65 or older
• Males of age 70 or older
• # after 50 yrs of age COD FISH VERTEBRA
• Females of menopausal age with risk factors Sickle cell disease
• Post menopausal females under the age of 65 with risk factors Renal osteodystrophy
Hereditary spherocytosis
•
Males aged 50-69 with risk factors
Osteogenesis imperfecta

TREATMENT

L V
S

Decrease bone resorption Increase bone formation Decrease bone resorption &
increase bone formation
Bisphosphonates Calcium
1. Risedronate- once weekly Teriparatide(synthetic PTH) Strontium Ranelate
2. Ebandronate- once monthly
Intermittent PTH
3. Zolendronate- once yearly
Osteoblastic activity
Calcitonin
Estrogen
DOC- Bisphosphonates (inhibits osteoclastic activity)
SERM- Raloxifen
Denosumab (Rank-L inhibitor)
Treatment for fractures
Newer drugs Vertebroplasty
•• Balloon kyphoblasty- PMMA
Romosuzumab(sclerotic inhibitor)
•

Abaloparatide
on
 Prolonged use of bisphosphonates

Osteonecrosis of Jaw- follows dental procedure

: Atypical # femur: XRAY taken
Cod fish vertebrae
(Biconcave app. of vertebral body)
Previous Year Questions

A 75-year-old lady falls in the bathroom. On examination, she has a fractured

neck of the femur. This occurs due to: (AIIMS 2019)
A) Osteoporosis
B) Osteopetrosis
C) Paget's disease
D) Metastasis

Previous Year Questions

Which of the following tests are not commonly used in osteoporosis: (INICET 2020)
A. DEXA
B. Bone scan
C. Quantitative CT
D. Chemical analysis
E. X-ray
a.A,B,and C
b.AandB
c.B,C and D
d.A,C,D and E

Previous Year Questions

In Osteoporosis,levels of Calcium and ALP :(INICET 2021 JULY)

A.Both are normal
B.Calcium is increased,ALP is decreased
C.Both are increased.
D.Calcium is decreased and ALP is increased

Previous Year Questions

Among the following drugs, which promotes Bone formation? (INICET 2020)
a. Bisphosphonates
b. Teriparatide
c. Calcitonin
d. Raloxifene

Previous Year Questions

A 60yr old female with previous history of Colle's fracture is complaining of backache.DEXA Score is
- 2.6. Which of the following given statement is wrong in relation to treatment of this patient. ?
A. Teriparatide should be started before supplementing bisphosphonates
B. Bisphosphonates not given for more than a year.
C. Calcium required is 1200mg per day
D. Oral Vit D3 given along with Oral calcium
 Previous Year Questions

Time for checking the bone mineral density in women is(AIIMS 2019)
A) At 50 years
B) At 55 years
C) At 60 years
D) At 65 years

Previous Year Questions

A 55 year old female complains of lower backache. The radiographic image of her
lumbosacral spine is given below. What is the probable diagnosis? (NEET PG 2019,2020)
A) Osteoporosis
B) Ankylosing spondylitis
C) Osteomalacia
D) Renal osteodystrophy

BONE DISEASE CALCIUM PTH PHOSPHATE ALP

RICKETS/ OSTEOMALACIA HM 1 In A

PRIMARY HYPERPARATHYROIDISM t * I 1

SECONDARY HYPERPARATHYROIDISM Is A t, A

OSTEOPOROSIS N N N N

PAGET’S DISEASE N N N M

OSTEOPETROSIS HM HM Hm N

Osteosclerosis
Abnormal hardening & elevation in bone density
Seen in
Renal osteodystrophy
Fluorosis
Paget’s disease of bone
Hypervitaminosis D
Ostgenic bone mets from Carcinoma Prostate & Breast
 Paediatric deformities & fractures
Paediatric bone - features
-increased water content in bone
-soft & flexible
-resilient to stress
-thick periosteum
-good potential for Remodelling- especially metaphyseal end

TERMINOLOGIES
1. Melia- Limb
2.Amelia- Absence of limb
3.Hemimelia- one of the 2 paired bones is absent(radius/ulna, tibia/fibula)
4.Phacomelia- Seal like limb
5.Syndactyly- Conjoined digits
6.Camptodactyly- Bent fingers- flexion of PIP joint usually of little finger
7.Synostosis- Failure of embryological separation of skeletal components
8.Duplication of digits- Polydactyly- Extra digits
Macrodactyly- Overgrowth
Brachydactyly- Under growth

M/c # in children- Green stick #

M/c # in forearm- radius > ulna
M/c # at birth- clavicle #
M/c # in a child following a fall on outstretched hand-Supracondylar # humerus
M/c # overall- clavicle #
M/C muscle a/w congenital absence- Pectoralis

Pseudoarthrosis Previous Year Questions

Causes Most common bone to be fractured in

Idiopathic(m/c/c) children is(NEET PG 2018)
Congenital- m/c bone: Tibia A) Distal forearm bones
Non- union B) Humerus
Post surgical C) Clavicle
Neurofibromatosis D) Carpals
Toddlers #
In children following an accident, spiral # of tibia: Undisplaced #
: CLINICAL FEATURES : Pain on walking
# line usually missed of X-ray
r
TREATMENT- POP

Battered baby syndrome

-Multiple # at different stages of healing
-Metaphyseal # (m/c)
-Advice whole body scan to detect all the #’s

Growth plate

PHYSIS: Growth plate

-Interstitial growth
-Radiolucent
-Direction of growth- Epi to Metaphysis

Hypertrophic layer- weakest layer

If Germinal is injured- No Growth

Classification for growth plate injuries- “SALTER HARIS”

Type I- Physis only
Type II- Physis + Metaphysis
Type III- Physis + Epiphysis
Type IV- Epiphysis + Physis+ Metaphysis
Type V- Physis only(worst outcome)
Type VI- Perichondrial ring injury

M/C type of Salter Harris : Type II

Best prognosis: Type I
Madelung deformity
- Females > male
- Defect: Distal end of radius Growth plate fuses early, but ulna continues to Grow
- 50% cases- B/L
Ulna is more prominent than radius: “Vickers Ligament”
Velar subluxation of hand: Dinner fork deformity
-TREATMENT: Darrach’s procedure(respect excessively grown ulna)

Congenital muscular torticollis

Primary/ Congenital- m/c
- A/k/a Wry neck
Secondary/ acquired ( eye problems)

PRIMARY
Birth injury

÷
Temproray ischemia of sternocleidomastoid
Compartment syndrome

:
Fibrosis & contracture
COCK - ROBIN appearance

Right side more than left

a/k/a STERNOCLEIDOMASTOID TUMOR
Self resolving by 1 yr of age; if not will lead to PHAGIOCEPHALY

TREATMENT
Conservative stretching (<1 yr of age)
Surgery(1-3 yrs of age): Release the contracture

SPRENGEL SHOULDER
Congenital undescended Hypoplastic Scapula
Restriction of Upper limb function
: Occurs d/t persistent OMOVERTEBRAL BAR
Klippel feel syndrome(m/c)
: Scoliosis
ASSOCIATED WITH:
Genitouriary abnormalities
: Spina bifilar & Diastematomyelia
Treatment
WOODWARD operation (Done at 3-8 yrs of age)

Surgical release of Omvertebral bar

Previous Year Questions

All of the following are associated with Sprengel shoulder except? (AIIMS 2017, NEET PG 2018)

A) Diastematomyelia
B) Klippelfeil syndrome
C) Dextrocardia
D) Congenital scoliosis
 Paediatric Hip
Hip joint
Type- Ball & socket
: Neck-shaft angle EB
Normal: 120-130 degree
Children: 140 degree
If angle is less: COXA VARA
If angle is more: COXA VALGA
COXA NORMA COXA VALGA COXA VARA

Below head of femur CAPITAL FEMORAL EPIPHYSIS

CHILDREN Hip has 2 Growth Plates
Below Greater tochanter
Paediatric hip problems

At birth CDH
2-5 yrs Septic arthritis(Tom Smith Arthritis)
4-8 yrs Perthes’s disease
5-12 yrs Transient synovitis
10-12 yrs SCFE(slipped capital femoral epiphysis)

CAUSES OF LIMP
PAINLESS PAINFUL
-CDH/DDH -Perthe’s
-Congenital Coxa vara -SCFE
-Limb length discrepancy -TB synovitis
-Septic arthritis
COXA VARA
EB Neck-Shaft angle: < 120 degree

CLASSIFICATION =→
Congenital Acquired

Congenital femoral deficiency SCFE

Developmental Perthe’s
Skeletal dysplasia
# neck of femur
Traumatic hip of CDH
Osteogenesis imperfecta

Osteopetrosis
 CLINICAL FEATURES
Pain
EB

Shortening < 3cm

EA

Limitation of abduction and Internal rotation

EA

X-ray
Increased Hilgenreiner's epiphyseal angle (normal <25 degrees)
i Fairbanks triangle: separate triangle of bone seen at infermedial part of metaphysis
TREATMENT
H-E angle >40 degree, <60 degree: observe

:
>60 degree or if shortening is progressive- Subtrochanteric valgus osteotomy

PERTHE’S DISEASE

Vascular insult to head of femur Doesn’t grow properly Softened leading to COXA VARA

Age: 4- 8 yrs
Male > Female
ETIOLOGY
Idiopathic(m/c/c)
••

Trauma(m/c known cause)

••

Hereditary factors
••

Coagulopathy
••

Collagenopathy
••

Passive smoking
••

Clinical features
-Painful limp
-unilateral (10-12% B/L)
-Trendelenberg gait/Antalgic gait
-Synovitis : Abduction, ER

Necrosis : Abduction, ER

Healing

Disease starting at early age: settles early

Disease occurs after 9 yrs of Age: worst outcome
STAGING
STAGE CLINICAL FINDINGS RADIOGRAPHY

A. DENSITY STAGE Limp, pain: mild - intermittent Density of femoral head

without any subchondral #

B. FRAGMENTATION STAGE Worsening of pain & limp Head shows fragmentation,

may show lateralisation

C. REOSSIFICATION STAGE Pain/ limp start resolving Femoral head gradually ossifies

D. HEALED STAGE Occasional limp Osteochondral lesions

XRAY

Sagging Rope sign

Legg-Calve-Perthes Rope like radiodense line along the
Both femoral epiphyses show extensive intertrochanteric line, represents edge of
destruction, the acetabula are deformed. enlarged femoral head: COXA MAGNA

Catterall classification

X-ray classifications Salter-Thomson classification

Lateral Pillar classification

MRI- Most accurate investigation for perthes’s
Scintigraphy-Tc scan is highly sensitive
Arthroscopy- Not commonly done
USG- can be done in initial stage. For joint effusion
CT- Not routinely done

Petrie Brace
NON-SURGICAL: Braces Scottish Rite Brace
TREATMENT
SURGICAL Osteotomy
SLIPPED CAPITAL FEMORAL EPIPHYSIS
- Males > Females
- 60% are a/w Endocrinopathy

PATHOPHYSIOLOGY

Phase of rapid development of Bone

Increased Stress d/t increased weight

Epiphysis doesn’t slip
Anterior & upward movement of femoral Head of femur remains in acetabulum, but
neck slips
neck on epiphysis

Increased GH(growth of Growth plate)

Decreased Sex hormones(sex hormones strengthens Growth plate)

ETIOLOGY
Majority- idiopathic -Thinning of perichondrial ring complex
-Retroversion of femoral neck
Mechanical factors -Change in inclination of adolescent proximal physis in
relation to neck & shaft
Endocrinal factors
-Thyroid growth
-Imbalances -Sex hormone
-

-Chronic renal failure

-Kleinfelter syndrome
-Turner syndrome
-Primary hypoparathyroidism

CLINICAL FEATURES
-Adolescent over wt child(10-15 yrs of age)
-Antalgic /Trendelenburg gait
-Restricted abduction & IR

ooo
Prodromal symptoms for < 3 weeks
CLASSIFICATION
-

•
Presents with sudden # like episode after minor trauma
ACUTE SCFE
•
SALTER-HARIS type I injuries
v8

Most frequent form

CHRONIC SCFE Adolescent patient presenting with vague groin pain

ACUTE ON CHRONIC SCFE : Prodromal symptoms >3 weeks: sudden onset pain
 INVESTIGATIONS
XRAY

i
Trethowan sign: Klein’s line (line drawn parallel to superior femoral neck),
doesn’t intersect head of femur as neck is slipped
CT Scan : Not usually done
Tc 99 Scan : increased uptake in capital femoral epiphysis

USG : detection of early slip

MRI : Early SCFE can be diagnosed

TREATMENT : Closed reduction with Insitu pinning

COMPLICATION : Avascular necrosis

DDH - developmental dysplasia of hip

Idiopathic spontaneous subluxation of femoral head
Female > male
•
Left side > B/L > right side
@
M/c in frank breech presentation with extended knees
ETIOLOGY

Ligamentous laxity of hip capsule (F>M)

•
Prenatal positioning - Breech
•
Postnatal posturing
•
Primary acetabular dysplasia
••

More in western countries > asian

CLINICAL FEATURES
Female child with Asymmetrical thigh/ Gluteal folds, widened perineum

On abduction of hip, On abduction of hip,

Dysplastic hip will dislocate relocation of dislocated hip
 ALLIS/ GALEAZZI sign KLISIC Test: for B/L DDH

Toe walk
Walking Trendelenburg gait in U/L DDH
Waddling gait in B/L DDH

Affected limb at lower level

on flexion of Hip & Knee

INVESTIGATIONS
USG- IOC for screening
: MRI- IOC for diagnosis

Normally, femoral head located DDH, head of femur- lateral to

medial to PERKIN’s line & PERKIN’s line & superior to
inferior to HILGENREINER’s line HILGENREINER’s line

TREATMENT
Age Treatment

0-6 months Pavlik harness

Von Rosen splint

6-18 months Reduction f/b cast in abduction

Bachelor cast
Smith Peterson approach : open reduction

> 18 months Femoral osteotomy

> 3 yrs Varum derotation osteotomy(VDRO) + Pelvic osteotomy

>10 yrs Total Hip replacement, only after skeletal maturity

 Paediatric knee & foot
Physiological & pathological varuS & valguM

Haqqani
GENU VARUS GENU VALGUM

Baby will have Physiological varus

Corrects itself by 2 yrs

Physiological valgus(maximum at 4 yrs)

Corrects overtime by 7-10 yrs

Residual valgus of 5-7 degree

PATHOLOGICAL VARUS & VALGUS

Injury to medial Growth plate Injury to lateral Growth plate

Lateral condyle continues to grow Medial condyle continues to grow

Genu varus Genu valgum

CAUSES
B/L Genu Varum B/L Genu Valgum Windswept deformity
Child Rickets > Idiopathic Idiopathic > Rickets Rickets
Adult OA > RA RA > OA RA

MANAGEMENT
EPIPHYSIODESIS
Young child Growth plate can still grow (Fuse healthy Growth plate)
1. Closing wedge Osteotomy
Older child No potential of Growth
2. Open wedge osteotomy
Congenital dislocation of knee
M/c - HYPEREXTENSION of knee : GENU RECURVATUM
Congenital muscular torticollis

A/W intrauterine packaging defects: Developmental dysplasia of Hip

Metatarsal Addction

Blounts disease
a
Abnormality of proximal medial tibial physis TIBIAL VARUM

Infantile Late onset

Triad (<3yrs)
1. B/L idiopathic Genu Varum Juvenile Adolescent
2. Genu Recurvatum ( HYPEREXTENSION) Blounts disease (4-10 yrs) (>10 yrs)
3. Internal rotation of Tibia

Clinical sign : SIFFERT KATZ SIGN(unstable knee on flexion)

X-ray : METAPHYSEAL BREAKING SIGN

Foot deformities

EQUINUS: Foot is flexed in plantar-flexion

CALCANEOUS: Foot is fixed in dorsiflexion

VALGUS: Foot is everted & abducted at the mid-tarsal

joints so that the sole faces outwards
VARUS: Foot is inverted& addicted at the mid-tarsal
joints so that the sole faces inwards

CAVUS: Longitudinal arch of foot is exaggerated

Congenital talipes equinus varus (Ctev)

Congenital abnormality of Leg, Ankle, Foot

50% B/L
1:1000 live births
Males>Females
A/W Breech & oligohydramnios

ETIOLOGY
Idiopathic(m/c/c)- primary CTEV
Other congenital causes: Spina bifilar & Arthrogryposis multiplex
congenita(AMC)
Secondary causes: Acquired TEV: POLIO

PATHO-ANATOMY
Tendoachilles Plantar flexion EQUINUS
Hypoplastic/ Small Talus- leads
CTEV
to dislocation of
TALONAVICULAR JOINT Tibialis posterior Inversion VARUS

DEFORMITIES
CAVUS Exaggeration of medial longitudinal arch.
ADDUCTION Talonavicular/ midtarsal joint
VARUS Talocalcaneal/ Subtalar joint
EQUINUS Ankle joint
INTERNAL ROTATION of Tibia

XRAY
Talocaneal ankle (normal): KITE’S ANGLE
-AP View: 30-55 degree CTEV: 0 degree(parallel)- varus
-Lateral view: 25-50 degree
Tibia-calcaneum:10-40 degree(normal)
Increase in angle- S/O EQUINUS
Talus- 1st metatarsal: AP View- 5-15 degree (normal) Negative- ADDUCTION deformity

Lateral view- MEARY ANGLE Angle > 4 degree- PES CAVUS

Normal: 0 degree
Angle turns Negative: PES PLANUS
TREATMENT
Started preferably in 1st week of life
PONSETI METHOD Serial manipulation & POP casting for a period of 1 yr

Order of correction: CAVE Cavus > Adduction > Varus > Equinus
By 7-8 weeks, deformity is corrected in 90% of cases
Rules of POP 1.Apply cast above the knee
2.Remove & reapply cast every week
Adduction & Varus are corrected together
Fulcrum of correction: TALAR head

Equinus is always last to be corrected, Can lead to breakage of

if equinus is corrected 1st & the order midtarsal joint
is not followed ROCKET BOTTOM FOOT

AGE WISE MANAGEMENT OF CTEV

Once deformity is corrected,

0-1 Yr PONSETI Technique
DENNIS BROWN Splint is applied
Combined duration of usage of
CTEV shoe for walking shoes & splint- not less than
After 1 yr & DENNIS BROWN 23hrs/day
Splint at night
Continued till 3-5 yrs of age

Structures released:
1. Tendo Achilles
1-3 yrs POSTEROMEDIAL SOFT TISSUE RELEASE(PMSTR) 2. Tibialis posterior
A/k/a TURCO’S procedure 3. Flexor hallucinating longus
4. Flexor digitorum longus

3-5 yrs PMSTR + Bony procedure to correct adduction deformity

lateral column shortening

DILLWYN EVANS procedure - procedure done by
Calcaneocuboidal fusion

PMSTR + DILLWYN Evan procedure + Bony procedure to correct

5-8 yrs deformity : DWYER OSTEOTOMY
 8-10 Yrs Removal of multiple tarsal bone in wedge form: WEDGE TARSECTOMY

Talonavicular joint
1. Triple arthrodesis(joints fused) Calcaneocuboidal joint
Talocalcaneal joint
> 10 yrs M/c complication: Pseudo arthrodesis of
Talonavicular joint(if done in < 10 yrs of age)

2. Ilizarov / Joshi’s External stabilization System (JESS)

ACHONDROPLASIA
AD disorder
: M/c form of Dwarfism
Mutation in FGFR3 gene on chromosome 4

:
PATHOPHYSIOLOGY
Failure of ENDOCHONDRAL OSSIFICATION- Bones remains
short, intramembranous & periosteal ossification is normal Starfish hand

CLINICAL FEATURES
-Short stature
-Trunk height is normal
-Arm span & height: reduced
-Saddle nose
-Frontal bossing of skull
-Rhizomelic shortening: Shortening is more in proximal bones
-Normal IQ & sexual developments
-Hands are short/ broad- central 3 fingers may be of equal length, star fish hand app
-Trident hand app

RADIOGRAPHY
-Champagne glass app
-Scalloping of vertebra/ Bullet shaped vertebra

Bullet shaped vertebra

 Infections
M/C organism involved in bone infections: Staphylococcus aureus
-Infection in joints: Septic arthritis
-Infections in medullary cavity: Osteomyelitis

Osteomyelitis
ACUTE < 2 weeks
TYPES SUBACUTE 2-4 weeks
CHRONIC > 4 weeks

Acute osteomyelitis
s
M/c type of bone infection
In metaphysis, blood vessels are in hairpin loop fashion
Males > Females
: M/c joint affected in young: HIP
Femur is more affected than tibia Sluggish flow
: Route of spread- hematogenous(m/c)
M/c site in adults: Vertebrae Ischemia & hypoxia
: M/c site in childrens: Metaphysis
Venous stasis
M/C ORGANISMS
Overall Organisms thrive
: Acute
sed Phagocytic activity
Chronic
: Developed countries
HIV
: Immunocompromised Staphylococcus aureus

Open #
: After surgery

IV drug abusers- Pseudomonas

Sickle cell disease- Salmonella(in diaphysis)
Prolonged parental therapy- Fungal infections
Human bite- Eikenella
Animal bites- Pasteurella
Infants- Steptococcus Group B
PATHOLOGY

Infection at metaphysis

Local inflammatory response

Pathological hallmark:ABSCESS
Local ischaemic necrosis of bone

Abscess formation

Increase in intramedullary pressure

Cortical ischaemic & breach

Spread of abscess in Subperiosteal space

CLINICAL FEATURES
High grade Fever
: Bony tenderness(localised)
Swelling
: Local rise of temperature
Joint stiffness; child doesn’t move limb d/t pain- PSEUDOPARALYSIS

:
Investigations
1. ESR
Peak elevation in 3-5 days & returns to normal after almost 3 weeks of starting
treatment
2. CRP
CRP better than ESR
: Raised within 6 hrs & returns to normal by end of 1st week
3. Local aspiration
Best way to diagnose the infection
: Culture & sensitivity of aspirate
4. Serum procalcitonin: most sensitive & specific marker for acute osteomyelitis

5. Tissue Biopsy- GOLD STANDARD

6. Radiology
Initially negative
X-ray 1st - 3rd day: soft tissue swelling
Bone changes can be seen on 10th-12th day

Helps in differentiating acute hematogenous osteomyelitis from soft

USG
tissue conditions like cellulitis

Changes within 24 hrs

MRI
Marrow edema

Bone scan Isotopes used: Technetium 99 Diagnose in 24-48 hrs after onset
Gallium
Indium

TREATMENT
s

Antibiotics Surgery
-

Supportive treatment Correct dehydration/ splint of affected part of limb

< 24 hrs Antibiotics 2 weeks (IV) f/b 4 weeks oral

After 24 hrs Drainage under antibiotic coverage

COMPLICATIONS OF ACUTE OSTEOMYELITIS

Chronic osteomyelitis (M/C)
s
Pathological #
Septicaemia
: Septic arthritis
Altered growth

:
Subacute Osteomyelitis
Signs & Symptoms are minimal
Increased host resistance
Reasons: Decreased bacterial resistance

: Administration of antibiotics before onset of symptoms

Causative organisms: S.Aureus, S.Epidemidis
Clinical features
Consistent, mild to moderate pain
: Fever

Investigations
XRAY : Lytic area with surrounding sclerosis
: Diagnosis: Biopsy & Culture
Abscess may not be present but granulation tissue is present
Treatment
Curettage
: I/V antibiotics f/b oral antibiotics: 6 weeks

Brodies Abscess
-Localised form of subacute osteomyelitis
Treatment
-Involves long bones in lower limbs
Curettage & antibiotics
-Intermittent pain will be there
-No abscess in cavity: diagnosis is confirmed by culture of adjacent soft tissue.

Previous Year Questions

A 12-year-old boy presents with a gradually progressing swelling and pain for 6 months over the upper tibia.
His radiographic image is shown below. The most likely diagnosis is: (NEET PG 2019)

A) Osteosarcoma
B) Osteoclastoma
C) Brodie's abscess
D) Ewing's sarcoma

Chronic Osteomyelitis

Hallmark
1. Sequestrum: Dead bone surrounded by Granulation tissue
Dense as compared to normal bone as there is no demineralisation
2. Involucrum: Reactive new bone formation
Seen around sequestrum
3. Cloaca: Aperture in involucrum
 Types of Sequestrum
Tubular: Pyogenic osteomyelitis
Annular: Amputation stump
Feathery/ coarse sandy: TB
Fine sandy: viral
Bombay: H2S inhalation
Ivory: syphills
Black/ coke: Fungal, actinomycosis
Ring: Pin tract infection

Clinical features
-Tenderness is almost always present
-Chronic discharging sinu: commonest presentation
-Bone is irregularly thickened
-Adjacent joint can become stiff

Gold standard investigation: TISSUE BIOPSY

TREATMENT
•
Antibiotics cover Previous Year Questions

•
Sinus tract excision
Ring sequestrum is seen in? (AIIMS
•

Sequestrectomy 2020)
•
Debridement A) Salmonella infection
•
Curettage- till fresh bleed seen(PAPRIKA sign) B) TB osteomyelitis
•
Saucerization C) Pin tract infection
•
Close the dead space with bone graft or cement D) Chronic osteomyelitis
•

Cover with skin or muscle - MYOPLASTY

•

VAC/NPWT - negative pressure wound therapy

COMPLICATIONS
•
Acute exacerbation of osteomyelitis- m/c
•

Pathological #
•

Growth abnormalities in childrens- deformity/ shortening

•
Amyloidosis
•

Joint stiffness
•

Squamous cell carcinoma(sinus tract malignancy)

 Previous Year Questions

Identify the following marked structures (AIIMS 2018)

A) a - Sequestrum, b - Involucrum, c - Cloacae
B) a - Sequestrum, b - Cloacae, c- Involucrum
C) a - Involucrum, b - Cloacae, c - Sequestrum
D) a- Cloacae, b - Sequestrum, c - Involucrum

A patient has a history of a road traffic accident 2 years back, and has developed pain and swelling now at the
same site. His X-ray image is shown in the image given below. What is the probable diagnosis? (NEET PG 2018)
A) Osteogenic sarcoma
B) Ewing's sarcoma
C) Chronic osteomyelitis
D) Multiple myeloma

Garees Osteomyelitis
Sclerosing form osteomyelitis of Garres
: Non-suppuration- Marked sclerosis & cortical thickening and distension of bone.

Clinical features
Age group: 8-10 yrs/ young adults
: Intermittent complaints TREATMENT
Swelling and tenderness over localised area -No treatment is completely helpful
: Increased ESR -Antibiotics
XRAY - Generalised sclerosis
: Culture are usually negative

Chronic Multifocal Non Suppurative Osteomyelitis

Chronic, non bacterial osteomyelitis
: Rare disease
Auto inflammatory disease Affects childrens & adolescents
: Multifocal, recurrent lesions Metaphysis of long bones
Clavicle
Rib cage
Sternoclavicular joint
TREATMENT
•
Palliative
•
Antibiotics usually have no role
 Tuberculosis of Bones
M/c site of TB: lungs
: M/c site of TB in skeletal system: AXIAL system > APPENDAGES
(Spine) (Hip>Knee)

TB-Spondylitis TB-Arthritis
M/c spine affected: Thoracic-lumbar vertebrae
M/c spine affected in children: Cervical spine
Rarest involved joint in TB: TMJ
Rarest musculoskeletal-skeletal structure involved in TB: Bursa
If bursa involved: Trochanteric Bursa
Causative organism: Mycobacterium TB
Etiology
Always secondary to some primary focus : lungs/ lymph nodes

Route of spread: Hematogenous or from surrounding tissues

Pott’s spine
8
M/c skeletal site: vertebra > Hip > Knee

Type of involvement of vertebra

Paradisal M/C, 1st radiological sign seen: narrowing of IV disc space

Anterior/ wet/ exudative M/C in childrens

Central

Posterior/ appendicular Least common, Facet > spinous process

Clinical features
Low grade fever

Constitutional symptoms: Night pain

Decreased appetite
Weight loss

Pain-earliest symptom
Paraspinal muscle spasm/tenderness-earliest sign
Local findings:
Cautious gait
Military attitude
Cold abscess

Cold abscess
Due to exudative reaction
No signs of inflammation
Composed of WBC, Serum, Caseous material, bone
debris, TB bacilli

Abscess formed can travel to other sites

Abscess of thoracic spine may Reach to anterior chest wall in Lower dorsal or lumbar region
rupture into mediastinum parasternal area through intercostal Abscess can go to Iliac fossa(psoas
(Bird’s nest appearence) vessels abscess), lumbar triangle, below
inguinal ligament, knee joint

DEFORMITY
Knuckle 1 bony prominence felt
Gibbus 2-3 bony prominence felt
Angular kyphosis > 3 bony prominence felt

Spine is stiff; spasm of vertebral muscles

During sleep, muscles get relaxed so they allow movement b/w inflamed surfaces: ‘NIGHT CRIES’

M/c/c of kyphosis in males (India)- TB

M/c/c of kyphosis- Osteoporosis
INVESTIGATIONS
1. XRAY: Decrease in I.V disc space
Destruction of vertebra
Soft tissue shadow may be seen
2. CT scan: Small paravertebral abscess
3.MRI: IOC
4.CT guided biopsy: Gold standard

TREATMENT
Indications of surgery in TB spine
1. ATT
• No improvement with conservative treatment/drug resistance
2. Rest/ Immobilization of affected part • Tissue sampling in case of doubtful diagnosis
3. High protein diet/ improve anemia • Evolving neurological deficit
• Instability of spine
• Presence of severe deformity
• Neurological symptoms
• Severe kyphosis/progressive kyphosis
• Recurrence of disease
• Progressive impairment of pulmonary function

Previous Year Questions

All of the following are indications of surgery in a patient of Potts' spine except? (AIIMS 2020)
A) Cold abscess without neurological complication
B) Doubtful diagnosis
C) Drug resistant TB
D) Progressive cauda equina syndrome/conus medullaris syndrome

Pott’s Paraplegia

Compression of spinal cord because of disease process resulting in neurological symptoms

: M/C: upper thoracic TB
Early onset paraplegia Late onset paraplegia
< 2yrs of onset of symptoms/disease >2yrs of onset of symptoms
-Inflammatory edema -TB debris
-TB granulation tissue -Sequestra from vertebral bodies
-TB abscess -Mechanical compressions
-Caseous tissue (knuckle, gibbus, angular kyphosis)
-Vascular thrombosis
-Ischemia
Clinical features
•

Spastic paraplegia(initially)
•

Ankle clonus/DTR++ (most prominent sign)

•

Extensor plantar
•

Flaccid paralysis(later stage)

STAGE’S OF POTT’S PARAPLEGIA
Stage I : Walks normally/ no motor weakness
Ankle clonus is present
Extensor plantar response with or without brisk tendon reflex
Stage II : Patient manages to walk with or without support
Spasticity of limbs+

Stage III : Patient is bedridden

Spastic paraplegia in extension

Stage IV : Patient with flexor spasm/ Paraplegia in flexion

PROGNOSTIC FACTOR’S OF POTT’S SPINE

FEATURE BETTER PROGNOSIS POOR PROGNOSIS
Degree of cord involvement Partial(only sensory/ motor) Complete(grade IV)

Duration of cord involvement Shorter Longer(>12 months)

Speed of onset Slow Rapid

Type Early onset Late onset

Age Younger Older

General condition Good Poor

Vertebral condition Active Healed

Kyphotic deformity <60 degree >60 degree

Cord on MRI Normal Myelomalacia/ syrinx

Intra-operative Wet lesion Dry lesions

TREATMENT
MIDDLE PATH REGIMNE ATT + Braces & Resting - Taylors brace
Isoniazid
5-6 months
Intensive phase Rifampicin (Bactericidal)
Ofloxacin

Isoniazid 3-4 months

Pyrazinamide
Continuation phase F/b
Isoniazid 4-5 months
Rifampicin

Isoniazid
Prophylactic phase 4-5 months
Ethambutol

Indications for Surgical management

-If no improvement in 3-6 weeks of treatment initiation
-Advanced disease with marked bone destruction with threatened actue kyphosis
-Bowel & bladder involvement
-For mechanical stability of spine
-Recurrence in neural complications

SURGERIES (Decompress spine & remove the debris)

••

Anterior/ Anterolateral decompression of spine (best)

Remove rib, transverse process, pedicel, vertebral body
Costo-transversectomy(temporary decompression)

: Arthrodesis of spine
Laminectomy

TB Hip Joint

2nd m/c skeletal TB site after vertebra

Route: Hematogenous spread
In Hip: M/c site - Acetabulum > Femur
M/c site involved in Femur: Babcock Triangle

Has least amount of macrophages & monocytes

 STAGES OF TB HIP
I. Synovitis -capsular distension +
-pain
-hip at position of ease- flexion, abduction, external rotation

Apparent lengthening

II. Early arthritis Flexion, adduction, internal rotation

(Muscle spasm)
(cartilage destroyed)
Apparent shortening(<1cm)

III. Late arthritis Flexion, adduction, Internal rotation

(Joint destroyed)
True shortening

IV. Advanced arthritis Flexion, adduction, Internal rotation

(Dislocation/
Wandering acetabulum
subluxation)
Pestle & mortar deformity

-Constitutional symptoms
V. Fibrous ankylosis
-Painful limb/ Antalgic gait
-Shortening
-Deformities

Investigations
X-ray: Juxta articular osteopenia , osteoporosis
Juxta articular osteopenia
PHEMISTER TRIAD in TB arthropathy Peripheral Osteoid erosions
Gradual narrowing of joint space

TREATMENT
Early stage: ATT + Rest + Traction + general care
Limb in functioning position Apply POP
Later stage of disease
(Deformity +)
Limb in unacceptable position

Griddle stone excision all arthroplasty

Head & neck of femur removed &
interposed with muscle
Arthrodesis

Arthroplasty: Best
(Done only after disease disappears)
TB Knee Joint

PATHOLOGY
Hematogenous spread

Dissemination in synovium

TB synovitis

Synovial membrane becomes

congested & studded with tubercles

Joint fluid increase

Granulation tissue & pannus formation

Damage to articular margin, destruction

of bones & liagemnts

Clinical features
C
Generalised weakness
C
Weight loss
C
Evening rise of temperature
C
Low grade fever
C
Spasm of hamstrings
Early stage: Synovitis
Position of knee- flexion
Posterior subluxation
Later stages: TRIPLE DEFORMITY External rotation
Flexion
Iliotibial band contracture
(Test-ober’s test / abduction contracture)

Septic Arthritis
•
Infection of joints
•
M/c in childrens
•
M/c site: Knee(adults), Hip(infants)
•
Route: Hematogenous
•
Causative organism: Overall- Staphylococcus aureus
Sexually active individuals- Gonococcus
I.V drug abuser- Pseudomonas
Clinical features
Fever
i Toxic child with inflammatory signs
No joint movement

÷Patellar tap sign +

Position of ease -Hip : flexion, abduction, external rotation
-Knee : Flexion

INVESTIGATIONS
Blood counts
: X-ray: increased joint space
USG: Athrocentesis(aspiration)
: MRI

TREATMENT
Arthrotomy
If Treatment delayed
Enzymes released Bony ankylosis
-collagenase Destroys articular
-elastase cartilage within 4-6 hrs
-metalloproteinases

Tom Smith Arthritis

•

Septic arthritis of hip in infancy

•
Hyper mobile HIP
•
Capital femoral epiphysis
•

Telescopy +
 Infections of Hand
Paronychia
M/c organism: Staphylococcus aureus
: Infection of soft tissue fold around the fingernail
Clinical features: Pain/tenderness/swelling

Treatment: Remove soft tissue & nail

Chronic Paronychia
Occurs when nails are having long exposure to water
: Eponychium is thickened
Treatment: Methyl prednisolone

Felon
Whitlow
: Thumb more affected than index finger
Organism- Staphylococcus aureus
: M/c complications: Osteomyelitis of distal phalanx,
tenosynovitis of flexor tendon
Treatment: Vertical incision & antibiotics

Tenosynovitis
Inflammation of tendon sheath
: Due to spread of adjacent pulp infection
Causative organism: Staphylococcus aureus

:
Clinical features
Kanavel’s sign
-Tenderness over involved sheath
-Rigid position of finger in flexion
-Pain on attempting Hyperextension of fingers
-Swelling of involved part of hand
-Pain on percussion

Treatment
Antibiotics
Splint
: Decompression(if needed)
 Soft tissue conditions
Frozen shoulder

0
Adhesive capsulises/ Periarthritis of shoulder
Clinical feature
-Pain & restriction of all movements of shoulder- Global stiffness
-1st movement affected: external rotation
-B/L in 30% cases
-Self limiting

Associated with DM(m/c)

: Hyperlipidemia
Cardiac problems
Hypo & Hyperthyroidism
: Hemiplegia
Following injury / surgery to shoulder

STAGES
1. FREEZING stage: increasing pain at night
2. FROZEN stage: increasing stiffness, decreased ROM, pain
3.THAWING stage: decrease in pain & stiffness and increase in ROM

DIAGNOSIS
Clinical
:
X-ray- normal
MRI- capsulitis

TREATMENT
Physiotherapy
O

Pain & anti inflammatory medications

O

Steroid injections
O

Manipulation under anaesthesia

O

Arthroscopic capsular release

O

Painful arc syndrome

Pain during mid range of abduction: 60-120 degree
: Due to rotator cuff muscle impingement -tendinitis
-calcifications
-partial tear
Causes
1. Supraspinatous
2. Subacromial bursitis
3. # greater tuberosity

Neers test
:Passive elevation of the internally rotated arm in sagittal plane(shoulder foreword flexion)
Hawkin’s test
:With elbow flexed to 90 degree, shoulder passively flexed to 90 degree and IR

TREATMENT
•
Avoid painful & overhead activities
Physiotherapy
: NSAID’s
Steroid injection into subacromial space
: Arthroscopic subacromial decompression

On injecting anaesthetic agents into subacromial space, Pain reduces & ROM increases.

Previous Year Questions

Painful arc syndrome is seen in all except: (NEET PG 2019)
A) Complete tear of supraspinatus
B) Fracture greater tuberosity
C) Subacromial bursitis
D) Supraspinatus tendinitis

Tennis elbow & Golfers elbow

Tennis elbow Golfer’s elbow/ swimmer elbow

Lateral epicondylitis(m/c) •
Medial epicondylitis

•
Common extensor origin •

Common flexor orgin

•

Extensor carpi radialis brevis

•

Flexor carpi radialis

Test: extension of wrist against resistance •

Flexion of wrist against resistance

(Cozens test) (Reverse cozens test)
TREATMENT
Rest
: Brace- counter force
NSAIDS
: Physiotherapy
Steroids
: Ortho biological- Platelet rich plasma
Blood
Stem cells

Previous Year Questions

A counterforce brace is used in? (AIIMS 2020)

A) Tennis elbow
B) Ankle sprain
C) Ulnar claw hand
D) Foot drop

Rotator cuff tear

CAUSE
Young- Trauma
O
O
M/c tendon to rupture : SUPRASPINATUS
Elderly- Degeneration
O
O
2nd m/c tendon to rupture : TENDO ACHILLES

CLINICAL FEATURES
O
Pain in shoulder
TESTS
Subscapularis Lift off test, belly press test, bear hug/Gerber test
Supraspinatus Beer can/ empty can test/ jobe’s test
Infraspinatus/ trees minor Horn blower’s test

Forgotten tendon of rotator cuff: subscapularis

On injecting anaesthetic agents into subacromial space- no effect on ROM

TREATMENT
Avoid painful & overhead activities
O

Physiotherapy
O

NSAIDS O

Steroid injection
O

If repairable- Arthroscopic repair

O

If irrepairable- young- Tendon transfer(latismus dorsi)

O

Elderly- Reverse shoulder arthroplasty

BICEPS TENDON RUPTURE

O Rupture of long head of biceps
O
Sign: popeye sign

BASEBALL/PITCHER’S ELBOW
O
Hypertrophy of the lower humerus, loose bodies/ arthritic changes

JAVELIN THROWERS ELBOW

O
Overarm action causing Avulsion of olecrenon
O
Medial collateral ligament & ulnar nerve involved
DE QUERVAIN’S DISEASE
O
Stenosis tenosynovitis of APL & EPB
O
Cause: overuse, RA
O
Females > males
O
Tests: FINKEL STEIN TEST
Grasp the thump & perform ulnar deviation Results in pain
EICKHOFF TEST
TREATMENT
Immobilisation with splints
O

NSAID’s O

Local injection of steroids

O

Previous Year Questions

De Quervain's disease classically affects (NEET PG 2018)
A) Extensor pollicis longus and abductor pollicis longus
B) Extensor pollicis longus and abductor pollicis brevis
C) Extensor pollicis brevis and abductor pollicis brevis
D) Extensor pollicis brevis and abductor pollicis longus
DUPUYTREN’S CONTRACTURE
O
Abnormal fibrosis of palmar aponeurosis in the form of nodule/ cord
O
M/c/c: idiopathic
O
M/c affected finger: Ring finger > Little finger
O
M/c affected joint: MCP joint
O M/c presentation: Nodular swelling Palm- Garrod’s pads
TREATMENT Sole- Ledderhose disease
Conservative
Penis- Peyronie’s disease
O

Fasciectomy
O

O Collagenases
O Amputation

TRIGGER FINGER
O
Stenosis of A1 pulley located on MCP
O
Females > Males
M/c/c- Trauma

: M/c Tendon involved- FDP

M/c affected finger- Ring finger
BOWLER’S THUMB

Ulnar digital nerve neuroma of thumb

: Cause: Repeated bowling activities which leads to PERINEURAL FIBROSIS

TREATMENT- Stop bowling

GAMEKEEPER’S THUMB/ SKIER’S THUMB

0 Avulsion of ulnar collateral ligament(UCL) of thumb at 1st MCP joint
TREATMENT- Thumb spica cast: for 4-6 weeks

STENER LESION

: Entrapment of adductor policies muscle b/w UCL

TREATMENT- Surgical repair
MALLET FINGER/ BASEBALL FINGER
Avulsion of extensor digitorum communis

: C/F :Flexion deformity of DIP joint/ inability to extend

TREATMENT: Mallet splint/ Frog splint

JERSEY FINGER
0
Avulsion of flexor digitorum profundus
0
CLINICAL FEATURES- extended DIP/ inability to flex
TREATMENT: Frog splint

:
Bursitis & Hallux valgus

BURSITIS :Inflammation of Bursa

Students elbow Olecranon bursitis

Housemaid’s knee Prepatellar bursitis

Clergyman’s knee Infrapatellar bursitis

Weaver’s bottom Ischial tuberosity bursitis

Haglund/ pump bump deformity Retrocalcaneal bursitis

Tailor’s ankle Lateral aspect of 5th metatarsal

Bunion Medial aspect of great toe

HALLUX VALGUS
Lateral deviation of great toe
Overcrowding/ overriding of fingers
TREATMENT -Conservative- fillers b/w fingers
Surgery- chevron / Keller osteotomy
GANGLION

M/c/c of mass/ swelling in hand/ wrist

: Unilocular cystic swelling arising from synovium/ tendon sheath

Dorsal side > ventral side
TREATMENT-Aspirate the contents & injection of sclerosants/ steroids
Surgical removal
COMPOUND PALMAR GANGLION
Chronic inflammation of common flexor sheath in TB, RA
: Hourglass appearance

CHONDROMALACIA PATELLAE
Anterior knee pain/ Patellofemoral syndrome
: Young females
Idiopathic cause
: C/F- Anterior knee pain on standing up after prolonged sitting (Movie sign)
BAKER’S CYST
A/k/a popliteal/ mordant baker cyst
: Pressure, pulse on diverticulum
Swelling becomes prominent on knee extension

i
Causes: Osteoarthritis, RA
Pigmented villonodular synovitis
Diagnosis: USG
Treatment: excision

Previous Year Questions

A 25 year old man involved in a fight, injured his finger and the deformity is
shown in the following image. X-ray is normal. The most appropriate
management at this stage is: (AIIMS 2018)
A) Splint the finger in flexion
B) Buddy strapping
C) Surgical repair of the flexor tendon
D) Splint the finger in hyperextension
 Oncology
g
Father of orthopaedic oncology: WILLIAM ENNEKING

ENNEKING CLASSIFICATION
BENIGN MALIGNANT

Latent: Well defined margin of thick rim of reactive bone I A- Intracompartmental

Resolves spontaneously Low grade
I B- Extracompartmental
Eg: non-ossifying fibroma
II A- Intracompartmental
Active: Intracapsular but actively growing High grade
Thin cortex & well defined margins IIB- Extracompartmental

Extended curettage required Metastasis III

Eg: Aneurysmal bone cyst(ABC)

Aggressive: Extracapsular, aggressively growing & lesion comes out of cortex Intracompartmental- Tumour limited to bone
Extended curettage & marginal excision required Extracompartmental- Tumour beyond bone
Eg: Giant cell tumor

1.FIBROUS DYSPLASIA
TUMOUR LIKE LESIONS 2.FIIBROUS CORTICAL DEFECT/ NON-OSSIFYING FIBROMA
3.BONE CYSTS: SIMPLE/ ANEURYSMAL

BENIGN MALIGNANT
CHONDROBLASTOMA
CHONDROCYTES CHONDROSARCOMA
ENCHONDROMA

OSTEOID OSTEOMA
WHO CLASSIFICATION TRUE TUMOURS -

OSTEOBLASTS OSTEOSARCOMA
OSTEOBLASTOMA

OSTEOCLASTS GIANT CELL TUMOUR <5% CAN BE MALIGNANT

BENIGN HAEMANGIOMA From Endothelium of vasculature

MISCELLANEOUS
MALIGNANT EWING SARCOMA From Endothelium of Bone marrow

OSTECHONDROMA Lies b/w tumour like & true tumour

PULSATILE BONE TUMOURS

1. Osteosarcoma
2. Giant cell tumour
3. Aneurysm all bone cyst
4. Angioendothelioma
5. Renal & thyroid metastasis
LOCATION OF TUMOURS
-Ewing’s sarcoma
-Osteoid osteoma
DIAPHYSIS -Adamantinoma(soap bubble)
-Fibrous dysplasia(diaphysis> metaphysis)

-Osteosarcoma
-Osteochondroma
METAPHYSIS -ABC
-UBC
-Non Ossifying fibroma

-GCT
EPIPHYSIS -Chondroblastoma

PREDICTION OF PATHOLOGICAL FRACTURE: MIREL’S CRITERIA

Variable 1 2 3

Site Upper limb Lower limb Peritrochanter

Pain Mild Moderate Severe Score >8 : prophylactic internal fixation

Size <1/3 1/3 - 2/3 >2/3

Lesion Blastic Mixed Lytic

PERIOSTEAL REACTIONS
-Reaction of periosteum to insult of bone 1. Onion peel Ewing’s sarcoma
-Leads to formation of new bone 2. Sunburst Osteosarcoma
-Non-specific
3. Codman’s triangle Osteosarcoma

POLYOSTOTIC LESIONS FIBROUS CORTICAL DEFECT

(Multicentric lesions)
A/k/a NON-OSSIFYING FIBROMA
1. Fibrous dysplasia
g

Part of cortex replaced by fibrous tissue

2. GCT : Eccentric in lesion
3. Enchondroma M/c lesion of bone
4. Osteochondroma : Usually occurs in first decade
Metaphysis
: Self-resolving
Treatment: curettage + bone graft
FIBROUS DYSPLASIA
g
Developmental anomaly
Bone tissue replaced by fibrous tissue & woven bone

:
Monostotic (femur)
TYPE
Polyostotic (maxilla > femur)

INVESTIGATIONS
X-ray: Dense sclerotic rim- RIND SIGN
Ground glass appearance
Biopsy: Chinese letter pattern appearance

:
BONE CYSTS

SIMPLE/UNICAMERAL

Benign, unilocular
ANEURYSMAL

Benign, multiloculated
: Asymmetrical expansion/ ballooning
°
Symmetrical expansion
g
Centric ,
Eccentric
"
Metaphyseal g
Metaphyseal
°
10-20 yrs ,
10-20 yrs
Proximal humerus Around knee
: Clear/ straw coloured fluid
,

g
Treatment g
Treatment
Aspiration
I I
Extended curettage
Excision curettage + ABG
g g
Embolization(pelvis)

In extended curettage, remove the whole lesion & destroy residual cells inside the cavity with
g
Liquid nitrogen
Bone cement
: Phenol
 Benign tumours
OSTEOCHONDROMA/ EXOSTOSIS
•
M/c benign bone tumour
•
Developmental anomaly( not a true tumour)
⑥
Metaphysis -Grows with skeleton
-Stops growing after skeletal maturity
•
Sessile, pedunculated: Stalk grows away from growth plate/joint
&
Large to feel, small on xray
•
Overlying Cartilage < 2cm
If >2cm: malignant transformation
•
M/c site: Distal Femur

CLINICAL FEATURES
Usually Asymptomatic, painless
: Causes of pain
Bursitis(m/c)
: Nerve compression
Pathological #
: Aneurysm
Malignant transformation, If cartilage cap >2cm

:
Heavy calcification
Persistence of growth

TREVOR’S disease: Intra-articular epiphyseal osteochondroma

TREATMENT

Extra periosteal excision( after skeletal maturity)

OSTEOID OSTEOMA
M/c true benign bone tumour
: Childrens; <30 yrs
Males > Females

÷
Any bone can be involved, except skull
Eccentric/ cortical lesion
Never becomes malignant
Night pain; responds to Aspirin
INVESTIGATIONS
XRAY
&
Central nidus(<2cm)
&
Dense sclerosis around central nidus
&
Dilated blood vessels Central nidus releases prostaglandins
&
Osteoblasts, osteoclasts & woven bone
CT SCAN
Nidus < 1.5 cm
&

Tc99
Increased uptake
&

TREATMENT
NSAIDS
: Radio-frequency ablation- pelvis/ long bones
Enblock resection/ curettage

:
CHONDROMA
Tumour of Hyaline cartilage
Enchondroma

: - If phalanges
- M/c tumour of hand & feet
Islands of hyaline cartilage
Metaphysis of long bones (enchondral ossification)
: Syndromic relations:
Ollier’s disease: Multiple enchondromatoses with deformity & growth stunting
: (3-5 % malignancy risk)
Maffauti syndrome: Multiple enchondromatoses with multiple hemangioma
(100% malignancy risk)
INVESTIGATIONS
XRAY: -Centrally placed radiolucent area at junction of metaphysis & diaphysis
-Popcorn calcification/Ring & Arc calcification/ stippled calcification
(Fan like metaphyseal septation)

TREATMENT
Enblock resection
: Extended curettage + grafting
Fibrous dysplasia

Bone/ Marrow replaced by fibrous tissue

: 1st - 3rd decade
Developmental anomaly
: Malignant transformation is rare
Hypophosphatemia may be associated
: Diaphysis > Meta/Epi
Proximal femur/ tibia > ribs > maxila

:
HISTOLOGY
Chinese letter pattern appearence Shepherd crook deformity
(Irregular woven bone spicules with fibrous stroma)
X-ray
Shepherd crook deformity
: Ground glass appearence

Syndromic associations
1. McCune Albright syndrome: Polyostotic fibrous dysplasia with cutaneous pigmentation &
endocrine abnormalities
2. Mazabraud syndrome: Polyostotic fibrous dysplasia with intramuscular myxomas
TREATMENT
For extensive disease : Bisphosphonate
: For pain/deformity/pathological #: osteotomy + internal fixation

Non ossifying fibroma

&
Fibrous cortical defect
&
Developmental anomaly
&
Seen in 30-35 % childrens
&
M/c benign bone lesion
&
Not a true tumour

HISTOLOGY
&
Defect is filled with spindle shaped cells distributed in whorled or store form pattern
&
Giant cells & form cells always present
XRAY
&
Well defined, lobulated lesion
&
Eccentrically located at metaphysis

TREATMENT
&
Dissolve spontaneously with skeletal maturity
Curettage + bone grafting

:
Unicameral bone cyst

Developmental / Reactive lesion

First 2 decades
Males > Females
Metaphysis
&
Proximal humerus > Femur (m/c)
&
Adults: Ilium, Calcaneum (m/c)
&
Fluid contains PGE2
Active form: Distance b/w cyst & physis <1cm
Latent form: Distance b/w cyst & physis >1 cm
Aspirate
XRAY
Cyst is eccentric to central, lytic
&
Clear serous fluid
Well marginated
& If H/O trauma + : blood
Fallen fragment sign
&

TREATMENT
Aspiration F/b Steroids
i
Sclerosants
Curettage + Bone graft

Previous Year Questions

The pathognomonic sign of a simple bone cyst is (NEET PG 2018)

A) Fallen fragment sign
B) Scalloping of cortex
C) Never breaches physis
D) Central radiolucent lesion
Aneurysmal bone cyst
Locally destructive, blood filled, reactive lesion
&

Not true tumours

&

5-20 yrs
&

Mild - moderate pain for weeks to months

&

Proximal humerus > Distal femur

&

Metaphysis
&

Gross appearence:
Expansive lesion with blood filled septate spaces with thin layer of bone covered by periosteum
&

TREATMENT
&
Extended curettage + Grafting
&
If lesion is in large bone like pelvis: PRE-EMBOLIZATION

Hemangioma
-Benign, asymptomatic, vascular tumour of bone
-Spine>skull>pelvis
-Elderly population
Investigations
X-ray:
Vertical striations (Jail-bar/jail house/corduroy appearance)
Vertical striations
&

CT Scan : POLKA DOT appearance

TREATMENT
Conservative + Radiotherapy
: Vertebroplasty

POLKA DOT appearance

Predicted Question

Which of the following suggests malignant degeneration in an osteochondroma?

A) Fracture
B) Obstruction to joint movement
C) Weight loss
D) Thickness of cartilage cap >2cm
 Benign aggressive tumours
Chondroblastoma

A/k/a CODMAN’S Tumour

÷
10-25 yrs
Males > Females
.
Epiphyseal in orgin
M/c region: Knee> Distal femur > proximal tibia > proximal humerus
Investigations
XRAY: Well circumscribed lesion, central with surrounding reactive rim

÷
CT Scan (for calcification) : Punctate calcification
MRI: for surrounding edema
Biopsy: chicken wire/ Picket fence calcification
TREATMENT
Excision curettage f/b bone grafting

Giant cell tumour/ Osteoclastoma

Clinical features
Clinical finding: Egg shell crackling
20-40yrs
&
More common in Females
&
Locally aggressive
&
Epiphysis-metaphyseal (Can grow up to cartilage or joint)
&
Sometimes, pulsatile
&
Rate of malignant transformation: <5-10%
Soap bubble app
M/c bone tumour of distal end of radius
Location: Distal femur > proximal tibia > distal end of radius D/D
Non ossifying fibroma
Investigations Aneurysmal bone cyst
HISTOLOGY Mononuclear stromal cells
•
Chondromyxoid fibroma
Multinuclear giant cells
•
Chondroblastoma
Soap bubble appearance Fibrous dysplasia
XRAY •

Bone cyst
TREATMENT :Extended curettage + autograft Brown tumour
Osteosarcoma
 Previous Year Questions
What is your diagnosis from the below XRAY image? (AIIMS 2018)
A) Solitary bone cyst
B) Aneurysmal bone cyst
C) Giant cell tumor
D) Osteoblastoma

30 yr old male complains of gradual swelling around wrist for 3 months,clinical photo and X Ray is
given below. What is the most likely diagnosis? (NEET-PG 2021)

A. Ewing s sarcoma
B. Osteoclastoma
C. Pycnodysostosis
D. Osteochondroma

A child presents with difficulty walking. On biopsy of hip, some osteoclasts and grooved nuclei with
eosinophilic cytoplasm are present. Which investigation would you order next? (AIIMS 2019)
A) MRI
B) Serum Calcium
C) Serum PTH
D) CD1a marker

The following X-ray shows a lytic lesion of the lower limb. The biopsy shows fibroblastic
proliferation, osteoclast and inflammatory cells. From the given options, the most likely diagnosis
that can be inferred from the above clinical picture is? (AIIMS 2019)
A) Aneurysmal bone cyst
B) Giant cell tumor
C) Chondroblastoma
D) Langerhan cell histiocytosis

The treatment for the condition given below is:(AIIMS 2019, NEET PG 2019)
A) Extended curettage with allograft
B) Bone biopsy
C) Curettage
D) Extended curettage with autograft

A 30-year-old female developed a tumor at the knee joint. Biopsy-image is given below. What is the most
likely condition? (NEET PG 2020)
A) Osteosarcoma
B) Ewing's sarcoma
C) Giant cell tumour
D) Osteoblastoma
Osteoblastoma
&
Rare bone forming tumour
&
M/c presentation: Pain (painful scoliosis)
&
Classical appearance: Mineralised central nidus with surrounding halo & reactive sclerosis
Nidus > 1.5cm
&
Long bones: Diaphyseal/Metaphyseal
TREATMENT :Extended curettage & Resection

Ameloblastoma
&
Epithelial tumour: Ameloblast(enamel forming cells)
&
M/c site- Posterior part of mandible in the region of molar teeth
&
Rarely metasatsize
XRAY- Honeycomb/ Bubble appearance
&
Chemotherapy & radiotherapy- has no role
Enamel forming
Malignant tumours
Osteosarcoma

&
Osteoid production by malignant cells Bone forming tumour
&
M/c non haematological malignancy of bones

Primary Osteosarcoma -M/c bone tumour in children

-2nd decade of life
-Occurs in older population
-Patients with Paget’s disease
Secondary Osteosarcoma
-Post radiation
-Fibrous dysplasia

Metaphyseal tumour: Distal end of femur

: Gross appearance: Fleshy appearance
M/c radio-resistant tumour

i 15% develop micro metastasis to lungs: Pneumothorax

Pulsatille
Primary Osteosarcoma- Types
A. Conventional intramedullary osteosarcoma
Most common form
Classical osteosarcoma
Can break cortex & present as soft tissue mass
B. High grade surface osteosarcoma
Least common form
Aggressive
Arises on outer aspect of cortex
C. Low grade intramedullary osteosarcoma
Mimics benign lesion(osteoblastoma, fibrous dysplasia)
D. Parosteal osteosarcoma
Rare
Low grade osteosarcoma- arises from bone surface & intramedullary cavity is involved late
E. Telangectatic osteosarcoma
Ballooned appearence on radiography
F. Periosteal osteosarcoma
Arise from surface of bone- Diaphysis
G. Small cell osteosarcoma
Rare form

Investigations
XRAY Permeative lesion around metaphysis

: Sunray/ sunburst appearence (Due to stretching of sharpey’s fibres perpendicular to bone)

Codman’s triangle
MRI: Extent of tumour

CT Scan: Metastasis at lungs

TREATMENT
Neoadjuvant chemotherapy to control metastasis

Surgery/ limb ablation

Adjuvant chemotherapy

Chemotherapeutic agents - T10 protocol

1. A B C - Actinomycin/ Bleomycin/ Cyclophosphamide/ Doxirubicin
2. Vincristine
3. Crisp Latin
4. High dose Methotrexate
 5 yr survival rate: 70% -Does’nt respond well to Radiotherapy
-Skip lesions are seen

Previous Year Questions

A 10 year old male child presents with pain around the left knee joint. On X ray,
there is a lesion at the distal femur. Following are the clinical images. What is
the most probable diagnosis?(INICET 2020)
a. Giant cell tumour
b. Osteosarcoma
c. Osteoblastoma
d Chondrosarcoma

EWINGS SARCOMA
M/c tumour in 1st decade
: 2nd m/c malignancy in < 30 yrs of age
3rd m/c non haematological malignancy of bone
: 5-25 yrs
Males > Females
: Metaphyseal tumour extending into diaphysis
Ewing's sarcoma arises from
PROGNOSTIC FACTORS the bone marrow
Metastasis
: Size of lesion
Fever, anemia
: Leucocytosis
Mesodermal tumour but biopsy is ectodermal
Male, age>12 yrs
: Raised ESR
Chemoresistance Trisomy 8 & trisomy 21 are seen in patients with Ewing’s sarcoma
: Relapse

ROUND CELLS
<5yrs - Neuroblastoma
5-10 yrs - Eosinophilia granuloma
5-30yrs - Ewing’s sarcoma
>30yrs - Lymphoma
>50yrs - Multiple myeloma
INVESTIGATIONS
XRAY: Onion peel appearence

: Lamellated appearence
MRI: To find extend
CT scan, Bone scan : Metastasis
: Biopsy:
-Small blue round cells with pseudo rosette
-M1C2 gene mutation- CD99 marker positive
-PAS positive & reticulum negative
-Variable consistency
Cytogenetic: t(11:22)- m/c

:
t(21:22), t(7:22)

TREATMENT
Neo adjuvant/ Adjuvant chemotherapy
Radiotherapy: melts like snow
: Surgery
CHONDROSARCOMA
2nd m/c non haematological malignancy of bone
: Primary chondrosarcoma: 40-60 yrs
Secondary chondrosarcoma: 25-45 yrs
: Sites: Pelvis, Proximal femur, Proximal humerus
M/c presentation: Pain/Swelling
: A/w Hyperglycemia
INVESTIGATIONS
XRAY: Popcorn calcification

:
(Single lesion arising in medullary cavity with irregular matrix calcification)
TREATMENT
Low grade: Extended curettage
High grade: wide/ Radical resection
: Resistant to radiotherapy/ chemotherapy
CHORDOMA
Vacuolated physalliferous cells of primitive notocord
: 2nd m/c primary malignancy of spine after myeloma
-
M/c site: sacrum> base of skull> Vertebrae

TREATMENT -
Wide excision, radiotherapy
ADAMANTINOMA

2nd-3rd decade

: Very rare tumour

Arise from epithelial cell
M/c bone involved: Tibia(subcutaneous bone)
: M/c presentation- Pain
XRAY
Multiple radiolucent
: Lesions- honey comb/ soap bubble appearance in Diaphysis
SYNOVIAL SARCOMA
Arises from joint capsule, bursa, tendon
: t(X:18) gives rise to SYT:SSX fusion genes
AMELOBLASTOMA
Benign tumour in mandible caused by Aberrant epithelial cells

:
ONE LINERS IN ONCOLOGY
M/c malignant bone tumour: metastasis
M/c primary malignant bone tumour: Multiple myeloma > Osteosarcoma
: M/c non Hematological malignancy: Osteosarcoma > chondrosarcoma
M/c benign bone tumour: OSTEOCHONDROMA
: M/c true benign bone tumour: Osteoid osteoma
M/c site for bone metastasis : Breast > Prostate > Lungs
: In childrens - Neuroblastoma
M/c Blastic metastasis: Prostate > Medulloblastoma > Carcinoids

Predicted Question

A 19 year-old man presented with progressive swelling of lower end of femur. X ray shows codman triangle
and CT scan of the chest reveals osteoblastic metastases. What is the most probable diagnosis?
A) Giant cell tumor
B) Ewing's sarcoma
C) Osteosarcoma
D) Secondary metastasis
 Trauma
Upper limb Trauma
Clavicle
-Only horizontally arranged long bone
-Medial 2/3rd: Tubular
-Lateral 1/3rd: Flat
-M/c site of #: Junction of medial 2/3rd & lateral 1/3rd
-M/c bone # at birth
-Only long bone to ossify in membrane
Clinical features
-Medial fragment: pulled up by SCM
-Lateral fragment: pulled down d/t gravity & wt of pectoralis muscle

Complications
-Malunion(m/c)
-Injury to subclavian vessels, Brachial plexus
-Shoulder stiffness

Treatment
1. Conservative -Arm sling/ Arm pouch
-Figure of 8 bandage
FIGURE OF 8 BANDAGE
2. Indications for surgery
A. Open clavicle #
B. Massive displacement(tenting of skin)
C. Clavicle involving acromioclavicular joint
D. # with neuromuscular injury
E. Floating shoulder: # clavicle + # glenoid

Acromio-clavicular Injury

-Due to fal on shoulder

TREATMENT
-Triangular sling
-Velpeau bandage

Velpeau bandage
 Shoulder Joint
Rotator cuff injury
Grades of injury Treatment
Grade I Tear < 50 % articular surface

Tear > 50 % articular surface

Grades I, II, III - Arthroscopic repair ± Acromioplasty
Grade II
Grade IV - Open/ Arthroscopic repair
Grade III Small to medium tear < 3cm; 1 tendon involved Grade V - Tendon transfer/ Partial repair
Grade VI - Reverse total shoulder arthroplasty
Grade IV Large, massive tear = 3cm; Repairable; 2-3 tendons involved

Grade V Large, massive tear = 3cm; not repairable

Grade VI Retracted massively; irreparable; intra-articular pathology

Dislocation of shoulder

SHOULDER JOINT: -Ball (head of humerus) & socket(glenoid) joint

-M/c dislocated joint

Stabilisers of Shoulder Joint

STATIC DYNAMIC
Capsule •

Rotator cuff muscles

•

Labrum •

Supraspinatus
•

Glenohumeral •
Infraspinatus
•

Ligaments- Superior •

There’s minor
Middle Subscapularis
Inferior
: Deltoid
Biceps-long head
•

M/c type of shoulder dislocation: Anterior > Posterior > Inferior

Anterior shoulder dislocation

A. Per-glenoid
B. Sub-coracoid(m/c)
Subtypes
C. Subclavicular
D. Intrathoracic
Clinical features
Attitude of limb: Arm by the side of body
Abducted & externally rotated
Shoulder contour is lost
TESTS
1. Hamilton’s ruler test Ruler over lateral aspect of arm, check for
touching the acromion & lateral epicondyle of
humerus
2. Dumas test Touch opposite shoulder

3. Calloway’s test Measure girth of affected shoulder & compare to

unaffected, increased girth indicates dislocation

4. Bryants test Vertical axillary circumference increases

Investigations

XRAY: AP VIEW- Head is dislocated

Lateral/Axillary view- to confirm if anterior or posterior dislocation

Management
Reduce the dislocation

A. Modified kocher’s technique(m/c)

-Traction
-External rotation
-Abduction
-Medial rotation
B. Stimson maneuver: Traction of dislocated limb
C. Hippocrates method

Posterior dislocation of shoulder

MECHANISM OF INJURY
-High voltage electric shock, seizure
-Fall on outstretched hand
-Direct trauma
XRAY LESIONS:
Light bulb sign/ Empty glenoid sign Reverse Bankart (posterior inferior)
Reverse Hill Sach’s (anteromedial)

Inferior dislocation of shoulder

A/k/a LUXATIO ERECTA

: Rare
MECHANISM OF INJURY: Hyperabduction injury
Salute posture seen
Sulcus sign seen

Tests for shoulder instability

Fulcrum test
1. ANTERIOR Crank test
Apprehension test: Abduct & external rotate the shoulder

2. POSTERIOR Jerk test

3. INFERIOR Sulcus test

Surgeries for shoulder instability

1. Putti-platt procedure: double breasting the subscapularis using capsule

2. Bristol-Latarjet procedure: cut Coracoid & reposition it in the anterior surface of
glenoid to prevent dislocation

Complications of shoulder dislocation

1. Bankart’s lesion
-Lesion of the anterior part of the glenoid labrum of the shoulder
-This injury is caused by repeated anterior shoulder subluxations
-M/c lesion a/w shoulder dislocation

2. Hill Sach’s lesion

-Occurs due to recurrent shoulder dislocation
-Head of humerus hits the glenoid repeatedly

Indentation on the posterolateral head of humerus

 M/c complication shoulde dislocation: Recurrent shoulder dislocation

M/c early complication: Axillary nerve injury

Previous Year Questions

The most common sequela of traumatic dislocation of the shoulder in young adults is (2017 AIIMS)
A) Subscapular tendinitis
B) Rotator cuff injury
C) Recurrent dislocation of shoulder
D) Frozen shoulder
Which muscle is not involved in overhead abduction of the arm?(INICET 2020)
a. Serrated anterior
b. Deltoid
c. Trapezius
d. Pectolaris major

Arm & Elbow

Proximal humerus fracture
•

Seen in postmenopausal, osteoporotic females

•

M/c at surgical neck of humerus

•

M/c complication - stiffness

•

M/c injured nerve - Axillary nerve

•

Mechanism- Fall on outstretched hand

NEERS classification
Type I - Undisplaced #
Type II - 2 parts #
Type III - 3 parts #
Type IV - 4 parts # (worst prognosis)

Treatment
-Sling support / Shoulder immobilizer
 Previous Year Questions
Which is the classification system used for the fracture depicted in the below X-ray? (AIIMS 2017)
A) Schatzker classification
B) Ideberg classification
C) Neer classification
D) Garland classification

Shaft Humerus fracture

•

Fracture of humerus below the surgical neck till the Supracondylar region
•

M/c site : Distal 1/3rd of Humerus

•

M/c involves Radial nerve

Management
•
Closed reduction + POP(U slab > hanging cast)

Indication of surgical management(ORIF):

-If close reduction fails
-Iatrogenic injury to nerve
- Open #

Holstein Lewis fracture

Recover fully within 3 months
-Oblique # of distal 1/3rd of humerus
If not recovering
-Results in entrapment of radial nerve
Nerve conduction study
MANAGEMENT
No radial nerve injury- Conservative Recovering Not recovering
Radial nerve injury - usually neuropraxia Wait & watch Surgical exploration

Fracture around elbow

3 point bony relationship
-Tip of olecranon
-Tip of medial epicondyle
-Tip of lateral epicondyle

Broken Maintained Reversed

1. Medial condyle # Supracondylar humerus # Posterior dislocation of elbow

2. Lateral condyle #
3. Olecranon #
4. Inter condylar #
Lateral condyle fracture
•

Intra-articular #
•

Type IV salter Hari’s #

•

Fracture of necessity

complication
Fracture of necessity
Non- union(m/c) (Surgical fixation required)
(strong muscular attachment, intra articular, low vascularity)
# lateral condyle
Cubits valgus # neck of femur
# Galeazzi
Tardy ulnar nerve palsy # monteggia

Management -ORIF

Supracondylar fracture
•

M/c # around elbow in children

•

M/c # following fall on outstretched hand in childrens

•

Salter Harris type II >I

•

2 types: extension(m/c)/ Flexion

•

Mechanism of injury- Hyper extension

Displacement
Proximal migration
•

Medial tilt(assessed by baumann’s angle)

go

Medial shift
•

Internal rotation(Fish tail sign in XRAY)

•

Posterior tilt
•

Posterior shift
•

Fish tail sign is also seen in # of lateral part of distal humerus

GARTLAND’S CLASSIFICATION

TYPE I TYPE II TYPE III TYPE IV

Undisplaced # Partially displaced Complete # Complete loss of anterior
Fat pad sign seen Incomplete #
& posterior hinge

Unstable (extension
+ flexion)

Management
Type I- POP
: Type II - Reduce & POP
Type III, IV - ORIF with K wire
: Dunlop traction has been used in case treatment is delayed

Complications
Early complications
-Brachial artery injury
-Nerve injury (Anterior interosseous > Median nerve > Radial > ulnar)
-Volkmmann ischemia
_Compartment syndrome
-Volkmann ischemia contracture

Late complications
-Malunion(m/c)- Cubits varum/ Gunstock deformity/ decrease in carrying angle
Treatment- French/Modified French osteotomy
-Myositis ossificans

Previous Year Questions

A 10 year old came to OPD with following deformity of his left
upper limb, most likely fracture causing it is? (AIIMS 2018)

A) Supracondylar Fracture
B) Olecranon Fracture
C) Radial Head fracture
D) Triad of elbow
 Previous Year Questions
A 5 year old boy fell on outstretched hand, X ray is as shown below. Which of the following
vessel is most commonly affected? (AIIMS 2017)

A) Radial artery
B) Brachial artery
C) Ulnar artery
D) Cubital vein

Previous Year Questions

Fishtail deformity is seen in the fracture of (AIIMS 2020)

A) Distal end of radius
B) Distal end of humerus
C) Distal end of tibia
D) Distal end of femur

Pulled Elbow
-a/k/a Nursemaid elbow
-Distal subluxation of radial head out of annular ligament
-Age group: 2-5 yrs
MECHANISM: when axial force applied on extended & pronated elbow

Clinical features
Child crying
: Attitude- Elbow extended, Forearm pronated
Treatment
9
Flex the elbow & forearm is supinated

Previous Year Questions

A maid is playing with the child by spinning out the child by holding hands. A few hours later, the child starts
crying, does not use his arm and does not let anybody touch. What is the possible diagnosis? (NEET PG 2020)
A) Pulled elbow
B) Olecranon fracture
C) Fracture head of radius
D) Elbow dislocation
Elbow dislocation

-Anterior/ Posterior(m/c)/ Medial/Lateral

-M/c dislocation in childrens
-Attitude: Flexion at elbow
-M/c nerve involved: Ulnar nerve
Investigation
9
XRAY: Coronoid process behind the humerus
3 point bony relationship- Disturbed(reversed)
: Bowstring sing
TERRIBLE TRIAD OF ELBOW
1. Posterior elbow dislocation
2. Coronoid #
3. Radial head #

Forearm, Wrist & Arm

Monteggia Fracture

Fracture of upper 1/3rd ulnar diaphysis + radial head dislocation

•
Nerve involved- Posterior interosseus nerve(PIN)
•

PIN palsy- finger drop(no sensory loss)

BADO CLASSIFICATION OF MONTEGGIA FRACTURE

Type I Ulna fractured with radial head dislocating anteriorly(m/c)

Type II Ulna fractured with radial head dislocating posteriorly

Type III Ulna fractured with radial head dislocating laterally

Type IV Both radius + ulna fractured with radial head dislocating anteriorly
Galeazzi fracture
A/k/a piedmont fracture/ reverse monteggia fracture
- Fracture of the lower 1/3rd of radius diaphysis with distal radioulnar joint disruption
- Piano key sign

Previous Year Questions

A patient presents to the emergency department after he fell on his outstretched hand. An X-ray was
performed and is given below. What is the diagnosis? (AIIMS 2019)
A) Colle's fracture
B) Rolando's fracture
C) Galeazzi fracture
D) Monte gia fracture

True regarding Galeazzi fracture-dislocation:(AIIMS 2017)

A) Radial collateral ligament tear with interosseous membrane tear with radial shaft fracture
B) Interosseous membrane tear with ulnar shaft fracture
C) Interosseous membrane tear with triangular fibrocartilage complex (FCC) tear and radial shaft fracture
D) Interosseous membrane tear with triangular fibrocartilage complex (FCC) tear and ulnar shaft fracture

Essex Lopresti fracture

Occurs due to axial loading causing radial head fracture with disruption of distal radioulnar

:
joint, leading to tear interosseous membrane

Colle’s fracture

Fracture of distal end of radius at cortico-cancellous junction

Extra articular
: Common in post menopausal women
MECHANISM- Occurs due to fall on out stretched hand, with wrist in extension
Clinical features
• Dinner-fork’ deformity, with prominence on the back of the wrist and a depression in front.
• In less deformity there may only be local tenderness and pain on wrist movements.
Investigations
X-ray - A transverse fracture of the radius at the corticocancellous junction, and often the
ulnar styloid process is broken off
-Radial fragment is impacted into radial & backward tilt
CT Scan -If the configuration is not clear, very helpful in planning treatment

Management
For Undisplaced Fractures
Dorsal splint is applied for a day or two until the swelling has resolved, then the
cast is completed.
X-ray is taken at 10–14 days
i.if fracture has slipped surgery may be required;
ii. if not, the cast can usually be removed after 5 weeks to allow
mobilization.

For Displaced Fractures

- Reduced under anaesthesia (haematoma block, Bier’s block, axillary block or
general anaesthesia).
- The hand is grasped and longitudinal traction is applied (sometimes with
extension of the wrist to disimpact the fragments); the distal fragment is
then pushed into place by pressing on the dorsum while manipulating the wrist
into flexion, ulnar deviation and pronation.
For Impacted or Fragmented Low Energy Distal Radius Fracture
i. Volar locking plate
ii. K-wires

Complications

1. Stiffness(m/c)
2. Malunion- Dinner fork deformity
3. Rupture of EPL tendon
4. Sudeck’s dystrophy
5. Carpal tunnel syndrome- median nerve injury
6. Carpal instability
 Previous Year Questions

What is the sequence of the cast applied for Colle’s Fracture ? (INICET 2021 JULY)
A.Traction - Palmar flexion - Ulnar deviation- POP Cast
B.Palmar flexion - Traction - Ulnar deviation - POP Cast
C.Traction - Ulnar deviation - Palmar flexion - POP Cast
D. Palmar flexion - Ulnar deviation - Traction - POP Cast

Previous Year Questions

A female patient with a history of fall few months back presents with the deformity shown in the image. Probing into
history reveals it was managed with traditional treatment. This deformity is likely to be due to (AIIMS 2020)

A) Intra-articular fracture of wrist

B) Extra-articular fracture of wrist
C) Boxer's fracture
D) Barton's fracture

Smith fracture
Fracture of distal end of radius at cortico-cancellous junction
: Extra-articular fracture
Distal fragment displacement- Ventrally

:
MECHANISM: Fall on out stretched hand with wrist in flexion
DEFORMITY: Garden spade deformity
Treatment
Closed reduction + POP
Open reduction + internal fixation with plates

:
Barton fracture
Fracture of distal end of radius with intra-articular extension leading to subluxation of carpal bones
Types:
1. Volar

: 2. Dorsal
TREATMENT: Open reduction + internal fixation with plates
Chauffeur fracture
Fracture of radial styloid only
: A/k/a Driver’s fracture / Back-fire fracture
Intra articular #
:
TREATMENT: ORIF with plates
Scaphoid fracture
-
M/c carpal bone to get fractured
-
M/c site of #: Waist of scaphoid
MECHANISM : Fall on outstretched hand
Clinical features
-
Pain, tenderness at Anatomical snuff box
Investigations
-
XRAY - AP/ PA/ Lateral/ Oblique(best) views
-
MRI- IOC

Types of scaphoid fractures

-Fracture of waist of scaphoid (m/c)
-Fracture of distal 1/3rd(m/c in children)
-Fracture of proximal 1/3rd: Highest chance of non-union & avascular necrosis

Treatment
-Undisplaced #: Glass holding cast(Dorsi flexion & radial deviation of wrist)
-Displaced #: ORIF with Herbert screw(headless screw differential threading)

Complication
-Non-union
-Avascular necrosis
-Carpal tunnel syndrome
Previous Year Questions
An elderly male presented with a history of fall on outstretched hand following which he
developed swelling of the wrist. His X-ray is shown below. What is your diagnosis? (AIIMS 2017)
A) Fracture scaphoid
B) Fracture scaphoid with perilunate dislocation
C) Fracture hamate
D) Fracture capitate
 Spine & Regional conditions
Dennis three column concept of stability

Anterior column Middle column Posterior column

Posterior longitudinal
Anterior 2/3rd vertebral body Posterior 1/3rd vertebral body
ligament complex

Anterior 2/3rd vertebral disc Posterior 1/3rd vertebral disk Neural arch
Pedicel
Anterior longitudinal ligament Posterior longitudinal ligament Transverse process
Articular facets
Laminate
Spinous process

@
Single column injury: Managed conservatively
Be Two or Three column injury: Surgical management

Spinal trauma

M/c mode of injury - fall from height

M/c mechanism of injury - flexion > flexion with rotation
Most dangerous mechanism of injury is translation
All reflexes are lost in spinal injury
1st reflex to revert to normal: Bulbocavernous reflex
Motorcyclist Fracture

Hinge # of skull
Anterior
>
Skull divided into 2 halves
Posterior
JEFFERSON FRACTURE

M/c # of C1 vertebrae
: Caused by axial compression +/- extension
Spinal cord usually not damaged
: Neurological deficits usually not associated
Diagnosis
Xray(in open mouth)
>

IOC- CT scan

Treatment
Undisplaced stable injury- Cervical collar/ Halo cast
>

Unstable fracture- Atlanta-occipital fusion

>

Hangman’s fracture

Spondylolisthesis of C2 over C3

÷ 2nd m/c # of C2 after # odantoid

M/c cause: Road traffic accident
Classification for hangman’s fracture: Levine & Edwards’s
Mechanism
Extension with distraction

÷ Hyper extension
Axial compression
Flexion

Whiplash injury
Hyperextension injury of cervical spine
: Acceleration-Deacceleration injury
Cause sprain of anterior longitudinal ligament, but no fracture
: No neurological defect seen
Management
9
Neck collar
Clay shovelers injury
Avulsion fracture of spinous process of C7 > T1
: Commonly seen in clay shovelers
No neurological defects

:
Chance fracture
Named after GQ Chance
It usually occurs in the lower lumbar spine
: It is also known as jack-knife fracture
mechanism
Anterior part gets compression force and the posterior part suffers

:
distraction force

It is an unstable type of fracture and requires decompression

and fixation.
Management
Screws are put in the pedicle

prolapsed intervertebral disc (PIVD)

Seen in the young, middle age group

: Occurs due to loading the spine by heavy lifting, body builders leading to degeneration
of the disc
Bulging of disc posterior in the spinal canal
: M/c vertebral disc associated with prolapse : L4-L5 > L5-S1
clinical features
Sciatica pain Acute backache radiating to lower limb.
M/c cause of sciatic pain is PIVD
Patients will bend in order to reduce pain
Types of disc prolapse
1. Central
2. Paracentral (m/c)
3. Lateral (Far lateral)

Diagnosis
Test : SLRT (Straight leg raising test)/Lasegue sign
Patient lies down and hip is flexed -> Pain
Level identification: Dermatomes
Myotomes
Reflexes
IOC: MRI
Treatment
Acute : Rest (ideally in semi-fowler position) + NSAIDs and muscle relaxants for pain.

once pain reduces

Physiotherapy (back strengthening exercises)

no relief

Discectomy
Laminotomy
Hemilaminectomy
Laminectomy

Spondolysthesis
Slipping of one vertebra over another due to breach in pars interarticularis(Spondylolysis)
: M/c level: L5-S1
Causes
Dysplastic
: Degenerative(m/c): L5-S1
Isthmic- Pars innterarticularis: L5-S1
: Post. Traumatic
g
Pathological
 PRESENTATION: Pain +/- Radiculopathy

Investigations
g
X-ray: Oblique view of spine.
Normal : Scottish Terrier sign
: Spondylolysis : Scottish dog with collar sign
Spondylolisthesis: Beheaded Scottish Terrier dog sign

:
classification: meyerding classification

Grade Displacement Scottish dog sign

I O-25%
II 26-50%
III 51-75%
IV 76-100%

Eventually vertebrae slips and falls right in front: Spondyloptosis

AP view of spine in Spondylptosis: Inverted Napoleon

: Hat sign

Most common location : L5-S1 > L4-L5

Scoliosis

Greater than 10° lateral deviation of spine from its central axis
: More in females (poor prognostic factor for progression of scoliosis
Types/causes
g
Neuromuscular (extremely rare)
g
Child has cerebral palsy or muscular dystrophy
g
Congenital
g
Either vertebrae did not develop or did not segment properly
g
Wedge vertebrae
g
Hemi-Vertebrae(m/c)
g
Unilateral unsegmented bar vertebrae (Highest progression)
g
Block vertebrae (least progression)
g
Idiopathic (M/C)
g
No developmental anomaly and no neuromuscular problem
g
Infantile
g
Juvenile
g
Adolescent (m/c)

Treatment
g
Conservative: Milwaukee brace(children)
g

g
Riser’s cast(adults)
g
Surgery: Anterior or posterior spinal fusion

Previous Year Questions

In the given spine straightening surgery, the screws are fixed to which part of the vertebra ? (INICET 2020)
a. Spinous process
b. Lamina
c. Pedicle
d. Facet joint
e. Transverse process
Scoliosis screening in school children is done by? (AIIMS 2020)
A) Straight leg raising test
B) Forward bending test
C) Backward bending test
D) Single leg standing test

What is the type of scoliosis shown in the X-ray given below? (AIIMS 2019)

A) Congenital scoliosis
B) Postural scoliosis
C) Infantile scoliosis
D) Neuromuscular scoliosis
 Lower limb fractures
Shentons arc
g
By joining Medial cortex of femoral neck & lower border of superior pubic rami
,
Shenton ARC broken in ⑥
Fracture neck of femur
08
Dislocation of femoral head
•
Avascular necrosis

Trendelenberg test
Done to assess the integrity of abductors- Gluteus medius & Gluteus minmus
: Mechanical reasons 1. Neck of femur #, Coxa vara
2. Joint: Dislocation, Avascular necrosis, # Acetabulum

Hoover’s test

Examiner places his one hand under heel of healthy limb & asks the
patient to flex the affected hip against resistance

Downward pressure in healthy limb is Downward pressure is not felt in

felt by examiner in organic cause of functional cause of limb weakness
limb weakness & in healthy individuals

Previous Year Questions

A patient presented with lower limb weakness. The examiner places one hand under the
patient's heel and the patient is then asked to raise his other leg against downward resistance.
What is the test being performed? (AIIMS 2017)
A) Hoover's Test
B) Mc Bride Test
C) Waddell's Test
D) O'Donoghue's Test
THomas test
⑨
Used to detect FIXED FLEXION deformity of Hip
•
Affected hip is extended while contra lateral hip is held
flexed, flattening & immobilising lumbar spine
Negative
POSITIVE: Patient keeps the hip in flexion as this is

:
the position of ease & maximum joint capacity

Positive

Previous Year Questions

A 55-year-old female patient came with a flexion contracture of the hip. Which of the
following test is useful in diagnosis? (AIIMS 2018)
A) Allen's test
B) Trendelenburg test
C) Thomas test
D) Ober test

Pelvic injuries
Maximum blood loss: 1.5-2 litres
g
Classification used: TILE’S

INJURY PATTERN
I. Straddle # : # of B/L both pubic rami
II. Open book injury: Anterior-posterior compression injury
Rotationally unstable
Vertically stable
III. Malgaigne # : Disruption of pubic symphysis with # ilium near
Sacro-Iliac joint

IV. Bucket handle injury: Sacro iliac joint disruption & contra lateral superior and
inferior pubic rami #

V. Jumpers #: Forceful axial loading of spine & pelvis

Leads to dislocation of sacrum from lateral portion
Complications
A. Hemorrhage
B. Urogenital injuries
C. Nerves of limbo-sacral plexus
D. Diaphragm injury

Dislocation of hip joint

Anterior Posterior(m/c) Central

Impact occurs with limb Impact on knee when Femoral head is

Mechanism of injury flexed, abducted & knee & hip are flexed and forced medially
Externally rotated addicted (dash-board through floor of
injury) acetabulum

Hyperabduction, Flexion, adduction, Adduction,

Position of hip at
external rotation, internal rotation neutral rotation
time of injury
extension

Limb length Apparent lengthening Shortening Shortening

Palpation of At groin At gluteal region Per rectal

femoral head examination

Possible complications Femoral vessels Sciatic nerve Urethra

Previous Year Questions

A 14 yr old had an RTA post which he has immense hip pain due to sustaining posterior hip dislocation.What is the next
best step in management ? (INICET 2021 JULY)
A.CT Scan with 3D reconstruction
B.High weight traction
C.Open reduction and repair of posterior wall acetabulum
D.Immediate closed reduction and check for hip stability
A patient fell down from bicycle and started having pain around hip,shortening of Limb and attitude was
flexion,addiction, IR of Hip? (NEET-PG 2021)
A. Anterior dislocation
B. Transcervical fracture
C. Posterior dislocation
D. Intertrochanteric fracture
A 22-year-old male patient presents with a history of RTA. His leg is in abduction and external rotation. What could
be the cause? (AIIMS 2020)
A) Anterior dislocation of the hip
B) Posterior dislocation of the hip
C) Intertrochanteric fracture
D) Fracture neck of femur
Posterior dislocation of hip

Thompson & Epstein classification: Type I to V

Type V: when dislocation occurs with # of femoral head
Type V is subdivided by Pipkins classification

Pipkin’s classification

Type I Femoral head # caudal to fovea centralis

Type II Femoral head # cephalic to fovea centralis

Type III Femoral head # + femoral neck #

Type IV Type I/II/III with acetabulum #

Vascular sign of Nareth: Femoral artery pulsations are not felt

Treatment
g
Methods of reduction
A. East Baltimore method
B. Alli’s method
C. Bigelbow
D. Stimson method

Previous Year Questions

A 40-year-old patient presented to the emergency department following a road traffic accident. The radiograph of
his pelvis is shown below. What is the most likely diagnosis? (NEET PG2019)

A) Central dislocation of the hip

B) Fracture shaft of femur
C) Posterior dislocation of the hip
D) Anterior dislocation of the hip
Patellar fracture
g
The pull of Quadriceps femoral distracts the patellar fragments & prevents healing.

Undisplaced Lower pole Comminuted Comminuted

Transverse
undisplaced displaced

Treatment

Open reduction internal fixation + tension band wiring

Converts distractive forces into compressive forces

Cylindrical cast: conservative for undisplaced fracture, patient has no problem extending knees

Previous Year Questions

A 25-year-old male presented to the emergency department with pain and swelling of the right knee.
Radiograph shows the following finding. What is the best treatment for the given condition?(AIIMS 2017)
A) Tension band wiring with K-wires
B) Tension band wiring with cancellous screws
C) Cylinder cast
D) Patellectomy
Neck of femur fracture

Post menopausal/ Age related

Risk factors Diabetic
Alcoholic

Classifications

Subcapital (worst prognosis)

Intracapsular
A. Anatomical Transcervical (m/c)

Extracapsular Basicervical (best prognosis)

B. Powell’s classification

Type I < 30 degree

Type II 30-50 degree

Type III > 50 degree

Angle b/w # line & horizontal, higher the angle - More unstable
C. Garden’s classification
Based on alignment of trabaculae
I. Incomplete/valgus impacted fracture
II. Complete Undisplaced fracture
III. Complete Undisplaced fracture
IV. Complete fully displaced fracture

Complications # NOF # IT
1. Avascular necrosis
Shortening < 1 inch Shortening > 1 inch
2. Non-union
3. Malunion Lateral margin of sole
ER of limb < 45 degree
is touching the couch
Tenderness in groin Over greater trochanter
Treatment

<65 yrs >65 yrs

<3 weeks >3 weeks Total hip replacement

Hemiarthroplasty
(If pre-existing arthritis +)
Subcapital/ Basicervical # MRI
Transcervical #
Viable head Non-viable
Cannulated Paediatric DHS
cancellous screw
fixation Fix + osteotomy Fix + vascularisation

Mcmurray Meyers
Pauwells Bakshi
Fibular vascular graft

Previous Year Questions

An elderly patient slipped in the bathroom and sustained injury over the left hip. The radiograph is
shown below. His attitude of the leg will be: (AIIMS 2017)
A) Shortened and abducted
B) Lengthened and internally rotated
C) Shortened and externally rotated
D) Flexed, adducted and internally rotated

Intertrochanteric fracture

Classification Boyd & Griffin

: Implants 1. DHS
2. Proximal femoral nail
Shaft of femur #
g
Implant of choice: Intrameduallary nail Age Rx
Plates/ External fixation Pallikal harness/ spica
0-6 months

6 months - 2 yrs Gallow’s traction

2-5 yrs Russel traction

10-15 yrs 90-90 femoral traction

If failed Surgical- flexible/rigid nail

Previous Year Questions

Fracture distal femur is stabilized as shown in image using:(AIIMS 2019)

A) Rail fixator
B) Illizarov fixator
C) K wire binding
D) Interlocking nail

Haglund deformity

A/k/a Pump bump/ Mulholland deformity

: Seen around Ankle
q
Bony enlargement formed at posterosuperior aspect of Calcaneum

CAUSE:chronic inflammation of retrocalcaneal bursa

Previous Year Questions

Haglund deformity is seen around which of the following joints? (AIIMS 2017)
A) Knee
B) Ankle
C) Wrist
D) Elbow
 Complications in orthopaedics
IMMEDIATE COMPLICATIONS EARLY COMPLICATIONS
Local Systemic Local Systemic

Injury to major vessel Infections Hypovolumic shock

Hypovolumic shock Volkman’s ischemia ARDS
Injury to muscle/ tendon
Compartment syndrome Crush syndrome
Injury to joint
Fat embolism syndrome
DVT & pulmonary embolism

LATE COMPLICATIONS

Delayed union/Malunion/Cross union

Avascular necrosis
Stiffness of joints
Sudeak’s dystrophy
Osteomyelitis
Myosotis ossification’s
Osteoarthritis of joints

Fat embolism syndrome

Usually seen on 2nd - 3rd day after fracture of long bones

i Occurs in population with fat in medullary cavity(adults)
1. Respiratory symptoms- Dyspnoea/Tachypnoea
Classical triad 2. Neurological symptoms- Confusion/Disorientation
3. Petechial rash in Avila, neck, periumbilical area

Causes
Related to injury Without injury
Soft tissue injuries Pancreatitis
Burns Diabetes mellitus
Liposuction Osteomyelitis
Bone marrow harvesting & transport Sickle cell Hb
Alcoholic liver disease
 GURDS CRITERIA
MAJOR CRITERIA MINOR CRITERIA
-Axillary or subconjuctival petechiae -Tachycardia
-Hypoxemia (PaO2 below 60 mmHg) -Fever
-Pulmonary Edelman -Retinal fat emboli
-CNS depression -Anemia
-Thrombocytopenia
-Fat globules in sputum, urine(guard test)
-Increasing ESR

INVESTIGATIONS
X-ray
B/L fluffy shadows develop as respiratory insufficiency worsens- SNOW STORM appearence

CT chest
- Focal areas of ground glass opacification with interlobular septal thickening
-Ill defined subpleural nodules

TREATMENT
Adequate O2 & ventilation
Medical Hemodynamic stability(blood hydration, prophylaxis for DVT)
Heparins: lipase activity
Corticosteroids

Early fixation of fracture

Surgical
Delay of intervention increases chance of fat embolism

Previous Year Questions

A patient came to the casualty after a RTA with fracture of femur. On 3rd day of admission, he developed
sudden breathlessness. Which of the following is the most common cause? (AIIMS 2017)

A) Hypovolemic shock
B) Pulmonary hypertension
C) Post trauma MI
D) Fat embolism
 Previous Year Questions

A patient was admitted to ICU 48 hours after the fracture of the femur. The saturation of oxygen in the rebreathing
unit was 100% but his Spo2 remained 60%. The patient is in a state of confusion. Chest radiograph showed lung
fields to be clear. What is the most likely diagnosis? (NEET PG 2020)
A) Pulmonary embolism
B) Fat embolism
C) ARDS
D) Occult pneumothorax

Compartment syndrome

When pressure in a closed osteomalacia’s compartment is increasing above 30mmHg

Causes
# tibia (m/c)
Soft tisssue injury
M/c muscle affected- Flexor digitorum profundus
# distal radius
Crush syndrome M/c cause of compartment syndrome in children- Supracondylar #
# forearm diaphysis
# shaft of femur
Clinical features
1. Pain on passive stretch
2. Puffiness/swelling
3. Pallor
4. Parenthesis
5. Paralysis(last to develop)
6. Pulselessness
Pathogenesis
Swelling of muscle inside the Compression of structures within
Ischemia Inflammation Further ischemia
fascia compartment compartment(vein > artery)

MANAGEMENT
-Limb elevation with POP removal
-Fasciotomy
Previous Year Questions
A man with a POP cast for forearm fracture is prescribed analgesics. The earliest way to check for
compartment syndrome is to look for: (AIIMS 2017)
A) disappearance of pulse by displacing the cast
B) discolouration of fingers
C) Decreased response to analgesics
D) dour and discharge
 Previous Year Questions

The earliest symptom of acute compartment syndrome is (AIIMS 2018)

A) Pain. B) Pallor. C) Paresthesia. D) Paralysis
Most delayed sign of compartment syndrome is ? (INICET 2021 JULY)
A.Pain on passive stretch
B.Pallor
C.Paralysis
D.Pulselessness

Volkmanns ischemia contracture

Ischemia

Fibrosis of forearm muscle

Flexion contracture of wrist & fingers

Sensory loss & motor paralysis in forearm & hand

Treatment
Mild contracture- Passive stretching using a turn buckle splint(Volkmann’s splint)
Moderate contracture- Muscle sliding operation
Severe contracture- Bone shortening

Crush syndrome
Injury to muscle leads to formation of toxic metabolite: Myoglobin

Enters blood

Myohemoglobin
Reperfusion injury

Promotes membrane damage &

capillary fluid re absorption
Free myoglobin- Renal failure failure
Myonecrosis: metabolic acidosis + Hyperkalemia & Hypocalcemia

Treatment
1. Prevention
2. Maintain high urine output with alkalisation of urine with sodium bicarbonate
3. Renal hemofilteration
4. Fasciotomy for compartment syndrome
Myositis ossificans

Bone tissue forms inside muscle or other soft tissue after an injury
: M/c joint- Elbow > Hip
Histologically resembles Osteosarcoma
: Xray : Initially negative, by 4-10th week: cotton wool appearence
Treatment
1. In acute phase: limit movements
2. Gradually active exercises are promoted ( passive exercises is C/I)
3. Avoid surgery till possible

Sudeck’s dystrophy
Complex regional pain syndrome(CRPS)
: Sympathetic over activity
Response: 1. Red hot shining skin(due to sympathetic over activity)
2. Patchy osteopenia/ hyperaemic osteopenia

TYPES
I. Post traumatic injury CRPS I - Sudeck’s
II. Post nerve injury CRPS - Causalgia

Treatment
NSAIDs
: Peripheral nerve block
Trigger point injection
: Sympathetic block

Avascular Necrosis (AVN)

Rare but sever complication of certain fractures when blood supply to a segment of bone is affected
COMMON SITES
Head of femur( # neck of femur & posterior dislocation of hip)
Body of talus(# through neck of talus)
Proximal pole of scaphoid(# through waist of scaphoid)
Clinical features
-Groin pain/Hip pain
-Painful limp: Antalgic gait
-Reduced range of movements: Internal rotation> Abduction
-SECTORAL SIGN: Limitation of IR of hip when hip is flexed
 NON-TRAUMATIC CAUSES
•

Idiopathic (chandler’s disease)

•

Steroids
Sickle cell disease
:
Caisoon’s disease
Gaucherie disease
: Radiotherapy
a
Alcoholism
Investigations
XRAY:

Crescent sign Hawkin's sign

Subchondral collapse Seen in the fracture of
of head of femur neck of talus

IOC: MRI

Treatment : FICAT & ARLET CLASSIFICATION

Stage I: Normal XRAY, but MRI + Conservative Rx: Bisphonates

Stage II A: Sclerosis, cysts seen but no collapse Conservative Rx: Bisphosphonates
Stage II B: Crescent sign + Rx: Core decompression
Stage III: Sphericity is lost Rx: Osteotomy
Stage IV: Advanced Arthritis Rx: Total Hip Replacement

Previous Year Questions

An overweight male (90 Kg) presented with complaints of not being able to squat and rest pain of left hip for 6
months duration. He had a past history of steroid andcreatine use. His X-ray revealed destruction of the articular
surface of femoral head with the presence of subchondral cysts and positive crescent sign. His MRI is suggestive of
marrow edema. What is your diagnosis? (AIIMS2017)
A) Tuberculosis of Hip
B) Fracture neck of Femur
C) Osteochondroma of Femur
D) Osteonecrosis of femoral head
 Nerve injuries
Incomplete injury
One of the 3 nerve sheath: Intact.
: Distal segment of axon undergoes wallerian degeneration
Proximal limb regenerates.
: Bundle of naked axonal sprouts formed : Neuroma in continuity

Complete resection
If all layers lost, proximal limb forms neuroma without sheath- End neuroma
f

Classification of nerve iniury

SEDDON SUNDERLAND

Temporary physiological, reversible I

conduction block

Slow conduction
Neuropraxia
Eg : Tourniquet Palsy,
Saturday night palsy,
crutch Palsy
Recovery: Spontaneous, 100% (3-6Weeks)
Splints : Prevent contracture
Only Axons injured II
Axonotmesis Nerve continuity intact III
IV
Eg : Fracture, dislocations

AXON + all sheaths injured

End neuroma
Neurotmesis V
No recovery
RX- Repair + Graft
Eg: Lacerations.
Evaluation & management of nerve injuries
Best investigation : Nerve conduction studies
Treatment
I
Conservative (in neuropraxia/axonotmesis)
Closed fracture : Splint
: Exploration Open fracture
: Obvious nerve injury
I
Nerve injury while manipulation

Types of nerve repair

Primary < 6 hrs
: Delayed primary 7-18 days Best method: End to end repair.
I
Secondary > 18 days

M/c nerve graft : Sural nerve > Saphenous nerve

: Tendon transfer, if the nerve injury > 1yr

To augment length of tendon transferred, Tendons used : Palmaris longus

Plantaris tendon
Prognosis of nerve injuries
Good prognosis
-Neuropraxia
-Early repair
-Radial nerve (most resilient, almost purely motor)
-Vascularity intact
-End to end repair
-Growing age - children
Worst prognosis with ulnar and sciatic nerve

Axillary nerve injury

Route value : C5 - C6.

Deltoid muscle -Abduction of shoulder(15-90°)
Motor
Supply Teres minor -External rotation
Sensory Regimental badge area
Mechanism
-Shoulder dislocation
-Surgery of proximal humerus/ fracture of surgical neck of humerus
-IM injection into deltoid muscle

Deformity
Adduction + internal rotation
: Sensory loss over regimental area

Management
Abduction splint

:
Musculocutaneous nerve injury
Coraco brachialis
Motor supply Biceps brachii - supination of forearm + flexion at elbow
Brachialis - flexion at elbow

Sensory supply Lateral aspect of forearm

Deformity
- Extension at elbow + pronation of forearm.

Median nerve

A/k/a Labourer's nerve

Route value : C5-T1

Superficial branch - Sensory of thenar area

Deep branch- Muscle of hand and sensory supply of Fingers (1st 3-1/2 fingers on Volar
aspect & tip of 1st 3-1/2 fingers in dorsal aspect)

Motor supply: Supply anterior compartment of forearm except flexor carpi ulnaris
and medial half of flexor digitorum profundus

Autonomous zone of median nerve - tip of index Anger.

Autonomous zone of ulnar zone - tip of little finger.
Autonomous zone radial zone - dorsum first webspace.
 Directly supply - Flexor digitorum superficialis

Through anterior interosseous nerve E

Flexor pollicis longus
Flexor digiorum
: Profundus (lateral half)

•
Supply thenar muscles except adductor pollicis.

•
Thenar muscle Abductor pollicis brevis.
: Flexor pollicis brevis,
Opponence polluicis brevis.
: Lumbricals (1,2).

Injuries
A. At wrist - Loss of thenar muscle tone WASTING
: Loss of thumb abduction, flexion and opposition Ape hand deformity
Opponens splint is given for ape hand deformity.
Pen test -Palm facing upward and touch a pen held above it with thumb

:
B. At cubital fossa
Flexor pollicis longus. Injury
Flexor digitorum profundus.
: Flexor digitorum superficialis. Index finger doesn't flex on making fist

Pointing index/ Benediction sign Clasp hand/

Oschner clasp sign

C. Injury to anterior interosseous nerve (in supracondylar humerus fracture)

Flexor pollicis longus Lost weak OK sign
: Flexor digitorum profundus

Ulnar nerve injury

A/k/ a musician's nerve
Route value : C7- T1
Sensory supply : Medial 1½ of hand
 Motor supply: Flexor carpi ulnaris
Medial half of flexor digitorum profundus
In hand: Hypothenar muscle, adductor pollicis
Interossei(palmar & dorsal), lumbricals(3,4)

Injury to ulnar nerve : Partial claw hand deformity

Complete claw hand deformity (in ulnar + median nerve palsy)

: Knuckle bender splint is used for claw hand.
Interossei function
1. Palmar interossei: adduction
Card test positive if action is lost.
:
2. Dorsal interossei: abduction
Fan the finger (egawa test)
BOOK TEST
Hold the book between thumb Flexion of thumb (due to lack of adduction)

:
and index finger Froment sign
CARD TEST

For palmar interossei (adductors)

Examiner inserts a card between two extended fingers and the patient is asked
to hold it as tightly as possible while the examiner tries to pull the card out

The power of adductors can thus be judged

ulnar paradox

Higher ulnar nerve palsy Less clawing/ less deformity.

Ulnar nerve injury at wrist Flexor digitorum profundus spared Significant clawing
: Ulnar nerve at elbow Flexor digitorum profundus paralyzed Less clawing
modified Jones tendon transfer
&
If the patient comes late with radial nerve palsy.
Wrist drop (paralyzed ECRL/ECRE) - pronator teres used

Finger drop (paralyzed extensor digitorum communis) flexor carpi ulnaris used

Thumb drop (paralyzed extensor pollicis longus): Flexor carpi radialis used.

Brachial Plexus Injuries

Normally starts from : C5, C6, C7, C8, T1

Can start from C4 - Prefixed/Preset brachial plexus
Can end at T2 - Postfixed/ Post set brachial plexus
No branches in the divisions.

winging of scapula Pseudo-winging

•

Paralysis of Serratus anterior ooo

Paralysis of Trapezius and rhomboid.

Oo
Supplied by long thoracic nerve (C5, C6, C7)

Previous Year Questions

Patient unable to abduct the upper limb following a fall. The root value of the involved nerve is likely?
(INICET 2020)
a. C5
b. C6
c. C4
d. C7
Erb's Paralysis
←
Most common type of brachial plexus injury (upper trunk injury)
←
Usually happens at birth

Erb's Point: Point of confluence of C5 andC6 nerve root where Suprascapular

(the nerve to subclavius) leaves.

Nerves affected
Supraspinatus
←
Suprascapular nerve supplies:
Infraspinatus
Biceps brachii
←
Musculocutaneous nerve supplies:
Brachialis

Deltoid
Axillary nerve supplies :
Teres minor
←

Deformity

Waiter's tip/ Policeman's tip/ Porter's tip.

a
Shoulder goes into adduction, Internal rotation, and Pronation (Supination affected)
Klumpke's Paralysis
←
Due to hyperabduction injury
←
Less common
←
Complete clawing of hand (combined median & ulnar component of C8 & T1)

Management
←
For both Erb's Paralysis & Klumpke's
←

Paralysis : usually neuropraxia

Aeroplane splint

if doesn't recover

Plexus reconstruction

If not possible

Nerve repair, grafts, transfers

Sciatic nerve injury
Common peroneal nerve [CPN]
Sciatic nerve (proximal to popliteal fossa) divides into

: Tibial nerve (deep) : Goes posteriorly

Common peroneal nerve [CPN]- Wraps around the head of fibula and divides into
Supplies lateral compartment of leg (Evertors)
a. Superficial branch
Sensory supply to dorsum of foot

Supplies anterior compartment of leg (Ankle dorsiflexors)

b. Deep branch
Sensory supply to Ist webspace
na
INJURY TO COMMON PERONEAL NERVE
na
Injury due to fracture on neck of fibula, injury to lateral part of knee
Foot Drop-> High stepping gait/Foot drop gait.
: TREATMENT : Foot drop splint/AFO (Ankle foot orthosis).
&
Sciatic nerve injury:
Causes: Iatrogenic (m/c) due to hip surgery
: Other cause : Hip dislocation and gunshot injuries

Carpal Tunnel Syndrome

M/c entrapment neuropathy

: Median nerve entrapment at wrist in carpal tunnel under flexor retinaculum/transverse
carpal ligament

Etiology
M/c cause is idiopathic
: Hypothyroidism
Rheumatoid arthritis
: Pregnancy
Acromegaly
: Gout
Colle's fracture
: Amyloidosis
Clinical features
a. Females > males
b. 30 - 60 years
c. Burning pain, tingling, numbness, and paraesthesia in median nerve distribution (Sensory)
Pain usually at night and the patient hangs the hand over the edge of bed for relief

Diagnosis
Clinically: Phalen's and Reverse Phalen's test
Handheld in particular fashion for 30-60 secs.

:
Durkan's test (best clinical test)
Direct median nerve compression test
IOC: Nerve conduction studies (decreased velocity of impulse due to nerve compression)

Treatment

Conservatives (Rest, steroids, and splints)

: Surgical release

Syndrome/ Pathology Nerve Site of compression/Injury

Carpal tunnel syndrome Median At wrist

Behind the medial

Cubital tunnel Ulnar
condyle humerus

Guyon's canal Ulnar Under the Pisio-hamate

ligament
Pronator syndrome Median nerve Heads of PT

Supracondylar
Kiloh-Nevin Syndrome AIN
humerus #

Meralgia parasthetica Lateral Cutaneous Under Inguinal ligament

Nerve of thigh (tight Belt)
Pyriformis & Obturator
Piriformis syndrome Sciatic Nerve
Internus muscle

Posterior Tibial Nerve Behind medial malleous

Tarsal tunnel syndrome
Below the flexor Retinaculum
of foot
 Previous Year Questions

The most specific test for carpal tunnel syndrome is? (AIIMS 2020)
A) Durkan's test
B) Phalen test
C) Tinel test
D) Two point discrimination

Popliteal Artery Syndrome

-
Congenital anomaly Medial head of gastrocnemius
-
M/c injured artery : Popliteal artery wraps around the popliteal artery
M/c cause : Dislocation of Knee, Distal femur fracture
Gastrocnemius hypertrophy
-

-
M/c injured artery in upper limb : Brachial artery
M/c cause is supracondylar humerus fracture
Popliteal artery compression
-

Ischemia
 Sports injuries
Sports injuries are low velocity injuries
Strain: Tendon is injured
M/c tendon injured : Supraspinatus > Tendo Achilles
Sprain : Ligament injured
M/c ligament injured : Anterior talotibular ligament.

Anatomy of knee joint

Medial tibial collateral ligament - Extends from medial epicondyle of femur to medial
condyle of tibia
- Adherent to the medial meniscus
- Medial meniscal injury is more common than
lateral meniscal injury
- Extracapsular, Extrasynovial

Lateral/ Fibular collateral ligament - Attaches to lateral epicondyle of femur and head of tibula
- Popliteal tendon is between LCL and lateral meniscus
- Extracapsular, Extrasynovial

Medial meniscus -Attached to tibia via coronary ligaments

Lateral meniscus -Intracapsular, Intrasynovial

Anterior cruciate Ligament - Attached to anterior tibial spine

- Crosses from medial to lateral and Anterior to posterior
- Intracapsular, Extrasynovial

Posterior cruciate ligament - Attached to 1 cm below and behind articular

surface of tibia
- Crosses from Lateral to medial and
Posterior to anterior
- Intracapsular, Extrasynovial
Functions of knee ligaments

COLLATERALS MENISCI CRUCIATE LIGAMENTS

Varus/valgus/coronal plane Made of collagen Sagittal/ Anteroposterior

stabilisers plane stabilisers

MCL prevents ACL prevents:

lateral deviation of Rotational stabilisers
Anterior translation of tibia
leg
Hyperextension of knee
LCL prevents Shock absorbers PCL prevents
medial Posterior translation of tibia.
deviation of leg Hyperflexion of knee.

Mechanism of injury of knee ligaments

COLLATERALS MENISICI CRUCIATE LIGAMENTS

MCL : Valgus force Twisting injury ACL: Anterior translation

Medial meniscus more commonly injured of tibia.
LCL : Varus force Hyperextension
Pathological locking of knee: of knee.
Prevents full extension of knee PCL: Posterior
M/c tear : Bucket handle tear translation of
knee.
Hyperflexion of
knee

Clinical diagnosis in sports injuries

1. Collateral ligaments
M/c ligament injured around the knee: MCL
Valgus/ Varus stress test
Performed at 30° of flexion- Positive if Knee opens up
MCL tear : Application of valgus force
LCL tear : Application of varus force
2. Menisci
Patient presents with twisting injury, swelling may be delayed

Tests for menisci

Mcmurray test Apleys Grinding Joint line tendeness test (best)

Apply rotationalforce while Patient in prone position Finger when pressed on joint
flexing & extending Knee line elicits pain
Examiner twists tibia
Pain or a click
Pain or a click

Other tests for menisci: Thessaly test and ege's test.

3. Cruciate ligaments :
Patient complains of Twisting injury, "pop" at the time of injury
: Swelling immediately after injury
ACL tear : Difficulty going down the stairs.
PCL tear: Difficulty going up the stairs.

Tests for ACL

Anterior drawer test Lachman test

•
Patient in supine position & knee flexed to •
Most sensitive test performed in
90°, foot is stabilised acute or chronic ACL tear
•
Tibia is held and translated anteriorly •

Knee flexed to 20 °, Tibia is pushed

anteriorly
•
Torn ACL translates by 5-6mm.
•
False negative is sometimes seen when
•
Torn ACL translates anteriorly
hamstring muscles are in spasm

Other tests used for ACL : Pivot shift test (most specific) and Lelli test.

Lachman test is preferred in the painful knee

 Tests for PCL
Posterior drawer test Godfrey sag Test

Patient lies in supine position & knee Patient lies in supine, knees & hips are
flexed to 90 degree, tibia is pushed flexed to 90 degree.
posteriorly Examiners hand supports patients heel.

Torn PCL translates by 5-6mm Torn PCL sags

Investigations
O' Donoghue triad (unhappy triad)
IOC for all ligament injuries: MRI Anterior cruciate ligament (ACL)
Medial collateral ligament (MCL)
Gold standard: Collateral ligament injury- MRI
Medial meniscus
Meniscal injury- Arthroscopy
Cruciate ligament- Arthroscopy

Treatment
Conservatively managed with braces in 90% cases
Collateral ligament injury: Surgery done in <10% cases.

Tear in red zone : Meniscorrhaphy (meniscal repair)

Tear in white zone : Meniscectomy.
Meniscal injury:

-Arthroscopic reconstruction or open reconstruction

performed
Cruciate injury:
-Arthroscopic reconstruction preferred (minimally
invasive and better outcome)

Grafts : Hamstrings (Semitendinosus and Gracilis) or

Patellar tendon.

Predicted Question

All of the following structures can lead to hemarthrosis when injured except:
A) Medial meniscus
B) Osteochondral fracture
C) Cruciate ligaments
D) Collateral ligament
 Previous Year Questions
In case of a meniscal tear repair, which of the following zones heals best? (AIIMS 2020)
A) Red zone
B) White zone
C) Gray zone
D) Red+White zone
Which of the following is not true about the posterior cruciate ligament: (AIIMS 2017)
A) Extra synovial
B) Prevent the posterior displacement of tibia
C) Primary action is to prevent the internal rotation of knee joint
D) Attached to anterolateral aspect of medial condyle
 Joint disorders
Basics
A-cells: Phagocytic
Cells in synovium
B-cells: Secrete hyaluronic acid(lubrication)

Non- Newtonian thixotropic fluid

(Viscosity of fluid decrease on applying force)

Viscosity decreased Viscosity unchanged

Inflammatory conditions Trauma
Gout Osteoarthritis
Septic arthritis
TB arthritis
Rheumatoid arthritis

Synovial fluid analysis

Normal: Clear, < 200 PMN/㎕

Infection: Pyogenic: >50000 cell/㎕

TB: 10000 to 20000 cell/㎕

Osteoarthritis
6
M/c joint disease
Chronic non- inflammatory joint disorder
: M/c muscle affected in OA: Quadriceps/ Hamstring > Gastrocnemius
Classification

Primary OA Secondary OA
-M/c Causes: Trauma
-Idiopathic Overweight
AVN
Calcium deposition disorders
Metabolic disorders(Alkaptonuria)
Types

Localised Generalised
(>2 joints affected)
•
Knee(m/c)
•
Hand
as
DIP(m/c)
ooo
Hip
•

Spine

Clinical features
Pain: during active & passive movements
Decrease movements: wasting of muscles
M/c muscle involved- Quadriceps(vastus medialis)

DEFORMITIES IN OSTEOARTHRITIS
HAND: Inflammation around the joints
Nodular swelling at- PIP: Bouchard’s node
DIP: Heberden’s node
KNEE: Genu varus(tibia medialised)
Medial side of knee bears more weight (destroyed)

XRAY
1. Decrease joint space- earliest finding
2. Bone density increased- Sclerosis
3. Subchondral necrosis cysts
4. Osteophytes- Regeneration of bone around necrotic cysts
(Break off & form loose bodies)
 X-rays of the knee, AP and Lateral views, showing
osteoarthritis of the knee (reduction in joint space
on the medial side, osteophyte formation –arrow)

Treatment
Conservative management
-Physiotherapist, Heat, Strengthening(vastus medialis strengthening)
-Walking with support
-Braces
-NSAIDs: Acetaminophen
-COX inhibitors
-Cartilage protectors: Glucosamine, Chondroitin sulphate
-Lubrication: visco supplements(Inj. Hyaluronidase)

Surgical methods
1. Arthroscopic joint washout
2. High tibial osteotomy(HTO)
3. Unicondylar/ Total knee replacement (UKR/TKR)
4. Total hip replacement(THR)

UKR: For OA involving medial condyle only

Previous Year Questions

The most common form of arthritis is? (AIIMS 2018)

A) Rheumatoid arthritis
B) Psoriatic arthritis
C) Seronegative arthritis
D) Osteoarthritis
 Previous Year Questions

A patient presented with pain in the hand. The joints involved were proximal interphalangeal joint, distal
interphalangeal joint and first carpometacarpal joint. The wrist and metacarpophalangeal joints were
spared. What is the likely diagnosis? (NEET PG 2020)
A) Osteoarthritis
B) Rheumatoid arthritis
C) Psoriatic arthritis
D) Pseudogout

High Tibial Osteotomy(HTO)

-To correct genu varum
-Metaphysis of proximal tibia cut & separated - gap filled with bone block &
protected with plate
Contraindications
-When >20 degree correction required
-Narrowing of lateral compartment
-Bicompartmental disease/ RA
-Flexion contracture > 15 degree
-Lateral tibial subluxation > 1cm
-Medial compartment bone loss > 2-3mm
-Knee flexion <90 degree
-Varus deformity > 15 degree
-Valgus deformity > 12 degree

Total knee replacement(TKR)

Femoral component
•

3 components Tibial component

Linear

Complications of TKR
Femoral prosthesis
Patellar clunk syndrome
Mechanical irritation
Fibrous nodule(scar tissue) formation
at superior pole of patella

Mechanical catching on extension of knee

 Previous Year Questions
Which of the following is true regarding the scar tissue in patellar clunk syndrome? (AIIMS 2018)
A) Superior pole of patella, impinging during flexion
B) Superior pole of patella, impinging during extension
C) Inferior pole of patella, impinging during flexion
D) Inferior pole of patella, impinging during extension

Total hip replacement

-Cemented
Types
-Uncemented: proffered in young patients
Prosthesis coated with hydroxy apatite(increases formation of new bone)

Materials used
1. Metal on Polyethylene acetabular cup
2. Ceramic on ceramic
3. Metal on metal
C/I of metal on metal prosthesis
Hypersensitivity
•

Renal impairment
•

Females(metal ions- teratogenic & carcinogenic to foetus)

•

Components
POWER LIQUID
-PMMA -Monomer: MAA
-Initiator: Benzoyl peroxide -Accelerator: Dimethyl para toluidine
-Radio opacifier: Zirconium dioxide/Barium sulphate -Stabilizer: Hydroquinone
-Antibiotics, Aminoglycosides

Complications
Cementing process
h

Infections
Mixing time: 5 to 6 min
Dislocation
h

Setting time: 3 to 4 min

Aseptic loosening
"

Pulmonary thromboembolism Bone cement: helps in attaching implant to the bone

i Sciatic nerve injury
Rheumatoid arthritis (RA)

Chronic autoimmune disorder, disease of synovium

: M/c inflammatory arthritis
Erosive type: Destroys joint
: Females > Males
Decrease life expectancy
: M/c cause of death: Coronary artery disease
Most sensitive marker: Rheumatoid factor(RF)
: Most specific: Anti-CCP

Pathology

Inflammation of synovium

Micro vascular proliferation

Pannus formation

Immune complex deposition in vessels

Synovial destruction

Cartilage destruction

Joint subluxation

Poor prognostic factors

High RF, ESR, CRP
: Subcutaneous nodules
Erosions on XRAY
: History of disease > 1 yr

Radiological features
1. Juxtaarticular osteopenia/ Osteoporosis
2. Decreased joint space
3. Marginal erosions(panus)
Deformities in RA

1. Swan neck deformity

Flexion at DIP
: Extension at PIP
2. Boutonnière deformity
Flexion at PIP
: Extension at DIP
3. Z-deformity
s
Radial deviation of wrist & ulnar deviation of fingers
4. Hammer toe
5. Hallux valgus
6. B/L Genu valgum
7. Wind swept deformity
Z-deformity
M/c cause of wind swept deformity: Rickets > RA

Hammer toe

Hallux valgus

(Mallet finger- Isolated deformity)

(RA- Affects multiple fingers)
MANGEMENT
•

Physiotherapy
•

DMARD: methotrexate(DOC)- stopped 1-3 months prior to pregnancy

•
Immunosuppressants: Leflunomide
•

Infiliximab/ Adalimumab: TNF alpha inhibitors

•

Anakinra: IL-1 receptor antagonist

•

Rituximab: Anti CD-20 antibody

SURGICAL MANAGEMENT
Synovectomy
: Partial/subtotal replacement
Deformity corrections

Previous Year Questions

Rheumatoid arthritis management in a patient with deformity is: (NEET PG 2019)

A) Steroids
B) Methotrexate with steroids
C) Methotrexate with anti-TNF
D) Steroids only after NSAIDs fail

Spondyloarthropathies
•

RF negative
•
Young population affected
Males > Females
: HLA-B27 positive in 90%
•

Extra articular manifestations: Uveitis

1. Ankylosis spondylitis(m/c)
2. Enteropathic arthritis
3. Psoriatic arthritis
4. Reactive arthritis: Reaction to infections(chlamydia, shigella)
5. Reiter’s syndrome: Conjunctivitis
Urethritis
Polyarthritis
Ankylosing spondylitis
K
Seronegative arthropathy
k
Axial skeleton involved
k
M/c involved- Sacroiliac joint
k
Enthesitis - inflammation of the entheses, the sites where tendons
or ligaments insert into the bone

PATHOGENESIS
Enthesitis

Erosion & destruction

Calcification & bone formation

Clinical features
•

Age group: 15-25 yrs CLINICAL TESTS

00

Males > Females Schober’s test

&

Low back ache/ Gluteal pain(indicative of sacroilitis) Gaenslen’s test

K

Uveitis Pump handle test

"

Early morning stiffness

DIAGNOSTIC CRITERIA
k
Essential criteria- Sacroilitis
k
Supportive criteria- Decreased lumbar spine movement( Schober’s test)
Decreased chest expansion
Inflammatory back pain

INVESTIGATIONS
Anemia
k

Increased ESR, CRP

k

RADIOLOGICAL FEATURES
Trolley track sign
Spine- Loss of curvature
•

•
Dagger sign
Vertical/ bridging syndesmophytes •

Shiny corner sign/ Romans lesion

Squaring of vertebrae

Bamboo spine appearence

MANAGEMENT
•

Exercise
•

NSAIDs to decrease pain

•

Anti TNF alpha

•

Surgeries to correct deformities

Trolley track sign

Previous Year Questions

20 yr old patient presenting with chronic Low backache and early morning stiffness since
last two years. Since last 6 months there are bilateral heel pains also.Most likely diagnosis
for this patient is ?(NEET-PG 2021)
A. TB Spine
C. Mechanical pain
B. Ankylosis spondyLitis
D. Disc prolapse
A 26 yr old male with backache, morning stiffness and reddening of eyes with an X-Ray presented in
OPD.Most likely diagnosis for this patient is ?(NEET-PG 2021)
A. Rheumatoid Arthritis
B. Ankylosis spondylitis
C. Psoriatic arthritis
D. Osteoporosis
Most specific for ankylosing spondylitis: (AIIMS 2019)
A) HLA B27
B) Bilateral Sacroiliitis
C) ESR
D) Lumbar laxity

Psoriatic arthritis
Males = females
: Middle age affected
Joints involved
Aymmetrical : oligoarticular involvement (m/c)
: M/c joint involved : DIP
Clinical Features Diagnostic criteria:
•
Dactylitis - Sausage digits Caspar criteria History of psoriasis
@

•
Shortening of digits RF-Ve
⑥

•
Arthritis mutilans X-ray findings
@

•
Telescoping of fingers Dactylitis
00

Nail changes
•

Xray

Pencil cup deformity due to absorption of phalanges

Treatment
I
Methotrexate

Hemophilic arthropathy

Recurrent spontaneous bleeding into joints

Synovitis

Articular cartilage destruction

•
M/c involved: knee > elbow
•

Subperiosteal bleeding

Arthroscopy / Aspiration : Relative contraindication

(risk of infection)

Bleeding into muscles: iliopsoas > Quadriceps

Triple deformity : Posterior subluxation

External rotation
Flexion of Knee
Radiological finding
-Juxtaarticular osteopenia
-Decrease in joint space
-Widening of inter condylar notch
-Squaring of patella
Treatment
Ice packs, analgesics, rest
^

Aspiration- only in severe cases

^

Treat hemophilia
^

Gout
^
Occurs due to deposition of Uris acid crystals in synovium
^
Purine metabolism defect
^
Increased S.uric acid levels
^
M/c joint: 1st metatarsophalangeal joint
Clinical features
^

Pain On aspiration(IOC)- Needle/Rod shaped crystals

^
Swelling MSU crystals
Negatively birefringent
Radiological findings
Joint destruction
^

Punched out lesions

^

Overhanging/ Martel/ G sign

:
Treatment

Acute phase Chronic phase

NSAIDs- Indomethacin(m/c) Xanthine oxidase inhibitors: Allopurinol, Febuxostat

Colchicine Uricosuric drugs: Probenecid

Pseudogout
Females > Male
Elderly
: M/c site: knee joint
Calcium pyrophosphate dihydrate(CPPD) deposition -Polygonal shape

:
Treatment
Aspiration & compression bandage
-Positively birefringent
 Amputations & Prosthesis
Amputations
Principle: Tourniquets- Reduce bleeding
Contraindication: Ischemia, PVD

Amputation - All structures are cut

Structures cut in
Disarticulation - When cut through a joint(bone is not cut)

Types of amputation

Closed When the skin is closed in the primary surgery

•

Open/Guillotine When the skin is kept open & closed in the second stage
-Infected/ contaminated stump
-Amputations for ischemia indications

Indications
ABSOLUTE RELATIVE

1. Irreparable blood supply- diseased or injured limb 1. Infections

2. Fulminant infection- Gas gangrene 2. Burns
3. Micro vascular ischaemia 3. Frost bite
4. Diabetic gangrene 4. Trauma
5. Tumour
6. Nerve injury
Peripheral vascular disease is the most common cause of
7. Contracture
amputations.

Mangled Extremity Severity Score (MESS) score can help decide between amputation and limb salvage in crushing
injuries.

Components of MESS: Shock

Ischemia Total score is 11.
Velocity Six or less is consistent with a salvageable limb
Age

Amputation in children

Disarticulation is preferred over amputation

: Multiple revisions of stump required
Methods of Amputation

1. All structures should be respected at proper level- proper stump created

2. Muscles should be approximately 5cm above the bones, so that bones are easily covered
3. Nerves should be stretched & then cut so that they retract into soft tissue
4. Muscles attached by
I. Myodesis: Muscle attachment to bones
C/I: Ischaemia, PVD
II. Myoplasty: Attachment of opposite muscle groups
Done in PVD amputations
5. Level of amputation
I. Forequarter amputation: Entire upper extremity in the interval b/w scapula
and chest wall is removed.

II. Krukenberg amputation: For blind patients, converts forearm stump into pincer

III. Mid foot amputation:

Lisfranc - TMT joint
Chopart - Mid tarsal joint
Pirogoff - Calcaneum is rotated forward to be fused with tibia, after
vertical resection through middle part of calcaneum
Hind foot amputation - Syme: Distal tibia & fibula - proximal to periphery of ankle
Sarmiento: Distal tibia & fibula - 1.3cm proximal to ankle
Boyd: Talectomy, foreword shift of calcaneum -
calcaneotibial arthrodesis
6. Ideal length of stump
I. Above knee : 9-10 cm distal to end of prosthetic socket
II. Below knee : 12.5-17.5cm from medial knee joint line
III. Above elbow - Atleast 3.8 cm proximal to elbow
IV. Below elbow - Minimum 3.8-5cm is preferable rather than amputation through elbow

Complications of amputation
I. Hematoma V. Persistent pain
II. Infection VI. Phantom limb
III. Necrosis VII. Amputation neuroma
IV. Contractures VIII. Sequestrum formation
Re implantation of Limb

When -Wound is clean

-Low MESS(mangled extremity severity)score

Order : 1. Bone
2. Extensor tendons
3. Flexor tendons
4. Artery
5. Nerve
6. Vein
7. Skin

Prosthesis
SACH foot Jaipur foot
(Solid Ankle Cushion Heel)

Appearence Does not look normal Looks like normal foot

Keel Long keel, blocks movement Small keel, allows all movements

Shoes Requires shoes to walk Walk barefoot

Ankle movements Absent Present

Cost Costly Cheaper

 Austin-Moore prosthesis Thompson prosthesis

Used for replacement of femoral Prosthesis for the head of the femur,
head in a case of fracture of the neck similar to AM prosthesis
of the femur in elderly persons -Indicated in cases where the neck of
-Used only without cement the femur is absorbed
-Can be used with or without cement

Total knee prosthesis

Predicted Question
A 35 year old patient comes to the emergency room late following road traffic accident and on
examination capillary refilling time is delayed in the right lower limb. Which of the following is
not an indication for amputation in this patient?
A) Fulminant Gas Gangrene
B) Ankle-Brachial Index < 0.45
C) Severe Peripheral Vascular disease
D) Transcutaneous Oxygen Tension 40mmHg

Transcutaneous Oxygen Tension below 20 mmHg is an indication for amputation

 Previous Year Questions
You are the intern on duty and you receive patients who have been in a road traffic accident. For which of the
following patients will you urgently call the orthopedic resident on call? (NEET PG 2018)
A) Patient with recurrent shoulder dislocation
B) Patient with a fractured arm with capillary refill time of less than 3 seconds in his fingers
C) Patient with a fractures arm with a 10 cm long incision over the arm
D) Patient with a fractured arm with capillary refill time of 5 seconds in his fingers

Capillary refill time indicates limb perfusion and if it is more than 3 seconds, it indicates inadequate limb perfusion
 Advanced surgeries in orthopaedics

Arthroscopy

Inserting a scope into joint

Arthroscope: 1. 4mm diameter
2. 30 degree(all structures can be visualised)

KNEE ARTHROSCOPY

-M/c approach
Anterolateral portal - 1 cm above joint line & 1cm lateral to patellar tendon
- Universally see all structures except I. PCL
II. Anterior part lateral meniscus
III. Posterior horn medial meniscus
Anteromedial portal - Additional viewing of lateral compartment
- Instrumentation

Superolateral portal - Patello femoral articulation & excision of medial plane

- Repair of posterior horn meniscus tears

Posteromedial portal
- Removal of posterior loose bodies
Gillquist portal - Passed through ligamentum patellae
(Transpatellar)

SHOULDER JOINT ARTHROSCOPY

-Posterior port : most commonly used
 Instruments & Implants
Instruments
PERIOSTEUM ELEVATOR

-To elevate the periosteum

-Elevation of the periosteum is necessary in all operations on the bone because all the
important structures such as vessels, nerves, tendons, etc. are outside the periosteum

The periosteum is not elevated in some operations such as excision of osteochondroma, where the
periosteum is excised with the osteochondroma to avoid recurrence.

Bone lever

To lever out a bone from the depth of a wound

after the periosteum has been elevated

BONE NIBBLER

µg_BtB•B B a eaoBa
q
Common bone nibblers are:
(i) straight nibbler – for general use
(ii) curved nibbler – for spinal surgery
(iii) double action nibbler – straight or curved

••
It is used for nibbling the bone
•
The double-action nibblers are mechanically superior
 Previous Year Questions

Identify the instrument given below. (AIIMS 2019)

A) Bone nibbler
B) Bone curette
C) Plate holding forceps
D) Bone holding forceps

BONE CUTTER

It is used for cutting a bone into small pieces.

Eg: cutting bone grafts
Bo

OSTEOTOME
r
It is used for osteotomy (cutting a bone)
-Its both edges are bevelled
GE

BONE CHISEL
r
It is like an osteotome except that only one of its
surfaces is bevelled.
OBEAH -It is used for removing a protruding bone or levelling a
bone surface
E.g: for levelling excessive callus, removing
an osteochondroma, etc.

MALLET

It is used for hammering osteotome, chisel

BONE CURETTE
For curetting a cavity in the bone or for
removing fibrous tissue from fracture ends
of an old fracture
BONE GOUGE

Concave bladed chisel used for cutting on

bq-BBB@ABBGt
round bone surfaces.

BONE AWL
Pointed thin instrument for making a

:
hole in the bone.
-There is an eye at its tip to thread a
wire through the bone
BONE HOLDING FORCEPS

Lane’s forceps – for holding the femur, tibia, etc.

Lion-toothed forceps

: Self-retaining – AO type forceps

Previous Year Questions

Identify the name of the instrument given below (AIIMS 2017)
A) Bent Hohmann Retractors
B) Bone holding forceps
C) Bone Distractors
D) Bone curretes

The following instrument is used for (AIIMS 2019)

A) Nibbling the ends of the bones
B) Holding the bone and plate
C) Controlled Traction of fracture segments
D) Cutting the K- wire
 Traction instruments
Kirschner wire
Used for:
(i) Internal fIxation of small bones
(ii) Giving traction
(iii) Fixing fractures in children
(iv) Ilizarov’s fixation system.

Steinmann pin
Used for skeletal traction

Common sites:
-Upper end of tibia
-Supracondylar region of the femur
-Calcaneum.
Bohler's stirrup

Used for holding a Steinmann pin and applying traction

K-wire stirrup with tensioner

When skeletal traction is to be applied with the help of K-wire,

the strength of the wire is increased by subjecting it to an axial
tension by a tensioner
 Plates & Screws
DYNAMIC COMPRESSION PLATE(DCP)

A dynamic compression plate is a metallic plate used

in orthopedics for internal fixation of bone, typically
after fractures

LCDCP
•
Low /Limited contact DCP
•
No extra periosteal damage
•

Preserve bone vascularity

LOCKING PLATE

-Fracture fixation devices with threaded screw holes

-Osteoporotic patients

DYNAMIC HIP SCREW

It has two components

1. lag screw
2. barrel

Lag screw slides freely inside the barrel, so that if there is collapse
at the fracture site, the screw does not cut out of the cortex; it
telescopes into the barrel.
Cancellous bone screw Cortical bone screw

More distance b/w threads Threads throughout the screw