Orthopaedics

WHERE THE ART OF MEDICINE

IS LOVED, THERE IS ALSO LOVE
FOR HUMANITY.
HIPPOCRATES

DR. ROHITH DANIEL

 Chapter I. Basic structure of bone
1. Parts of long bone

Parts of adult long bone Parts of a pediatric long bone

2. Types of bone

Cancellous bone Cortical bone Cancellous bone Cortical bone

Meshwork of trabeculae Densely packed tissue
Weaker Stronger
Higher vascularity Low vascularity
More surface area Lower surface area
More bone cells Less bone cells
Seen in metaphysis and epiphysis Seen in diaphysis

Cancellous bone Cortical bone

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3. Periosteum
• Outer covering of bone
• Covers all bone except sesamoid bones
• Covers entire bone except articular surfaces
• 2 layers
• Fibrous layer
• Cellular (Cambium) layer has Osteoprogenitor cells
• Functions
1. Appositional growth
2. Fracture healing
3. Blood supply

3. Composition of bone

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5. Cells of bone

Osteoprogenitor cells Osteoblast Osteocyte Osteoclast

Mesenchymal Lay down protein matrix Resting/ mature Formed by fusing
pluripotent stem cells of osteoid- osteoblasts together of
Collagen, osteonectin, monocyte progenitor
osteocalcin cells
Alkaline phosphatase 90% of all cells Least common
(ALP)
Longest life span Multinucleated
Ruffled borders
Howship’s lacunae
Tartrate resistant acid
phosphatase

6. Osteon (Haversian system)

Osteon is the basic structural unit of bone

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7. Blood markers for bone changes

Markers of bone formation

Alkaline Phosphatase
Osteocalcin
C terminal propeptide of protocollagen type 1
N terminal propeptide of protocollagen type 1

Markers of bone destruction

Tartrate resistant Acid Phosphatase (TRAP)
C terminal telopeptide fragment of type 1 collagen
N terminal telopeptide fragment of type 1 collagen

8. Bone remodeling

Definition
• Continuous dynamic process by which bone gets reshaped according to external forces
• Wolff’s law
• Bone remodels in response to mechanical stresses
• Heuter-Volkmann law
• Compression across physis will cause inhibition of growth, while traction will cause increased growth

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 Chapter II. Traumatology

Section II a. Basics

1. Definition of fractures
• Any partial or complete break in the continuity of cortex of bone is called fracture
2. Etiological classification

3. Pathological fractures
Occurs in a bone weakened by underlying pathology

Generalized causes Local causes

Rickets Infections
Osteoporosis Tumors
Osteomalacia Cysts
Scurvy Radiation
Osteopetrosis Ischemia
Pagets
Metastasis
Multiple myeloma

• MC cause worldwide: Osteoporosis

• MC cause in India : Nutritional
• MC local cause: Malignancy
• MC bone involved: Thoracic vertebra

4. Prophylactic fixation of bone

• Performed in the setting of lesions of bone with impending pathological fracture.
• To be done if Mirel’s score is more than 7

Mirel’s criteria
Score 1 2 3
Site Upper limb Lower limb Peritrochanteric
Pain Mild Moderate Severe
Lesion Blastic Mixed Lytic
Size < 1/3 1/3 to 2/3 > 2/3
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5. Stress fractures

• Also called fatigue fractures

• Occurs due to repetitive loading of a normal bone

Common stress fractures

Tibial shaft MC site for stress fracture
Neck of 2nd March fracture
Lower end fibula Runners fracture
Olecranon MC site in upper limb

6. Clinical features of fractures

• Symptoms
• Pain (MC/ most consistent)
• Swelling
• Deformity
• Signs
• Tenderness (MC/ most consistent)
• Crepitus, Deformity, Edema
• Abnormal mobility (pathognomonic)

7. Basics of treatment of fractures

• Reduction
• Closed
• Open
• Immobilization
• Cast
• Internal fixation
• External fixation
• Temporary devices

8. Inte rnal fixation

• Nailing preferred in
1. Fracture shaft of femur
2. Fracture shaft of tibia
• Plating preferred in
• All the other fractures

9. External fixation
External fixator

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Ilizarov Fixator

• Used in the treatment of open fractures

10. Rough flowchart of fracture treatment

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 11. Stages of fracture healing
Hematoma •Accumulation of 3 days
blood
• Necrosis of bone
ends
• Release of cytokines
Granulation tissue • Migration of 3 days to 3 weeks
mesenchymal cells
& fibroblasts
• Fibrous granulation
tissue
scaffold
Callus • Osteoblastic 3 weeks to 3 months Earliest sign on
differentiation Xray
• Laying of matrix
• Early calcification
Consolidation • Woven bone 2months to 2 years Clinically
formation united
Remodeling • Maturation to >2 years
lamellar bone

Section II b. Upper limb trauma

1. Fracture Clavicle
• MC fracture over all
• MC fracture in adults
• MC fracture during birth
• MC site: Medial 2/3rd and lateral 1/3rd junction
• MC zone: Middle 1/3rd
• Treatment : Figure of 8 brace
• MC Complication: malunion

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2. Floating shoulder
• Disruption of superior suspensory complex of shoulder
• Components of superior suspensory complex
1. Glenoid
2. Coracoid
3. Coracoclavicular ligament
4. Lateral part of Clavicle
5. Acromio clavicular joint
6. Acromion

• Floating shoulder - Disruption of any 2 or more of above

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3. Shoulder dislocation
• MC joint dislocation
• Types
• Anterior (MC)
• Posterior
• Inferior

Soft tissue stabilizers of shoulder

Static stabilizers Dynamic stabilizers
LIGAMENTOUS STRUCTURES MUSCLES
Glenoid labrum Supraspinatus
Superior gleno humeral ligament Infraspinatus
Middle gleno humeral ligament Subscapularis
Inferior gleno humeral ligament (strongest) Teres Minor
Capsule (weakest inferiorly) Long head of biceps

3a. Anterior dislocation shoulder

• MC type – Sub coracoid

• Attitude – Abduction & External rotation
• Tests
1. Dugas test
2. Hamilton ruler test
3. Callaway test
4. Bryant’s test
• Kocher’s method of reduction – ‘TEAM’

Clinical tests for shoulder dislocation

Duga’s test Inability touch the opposite
shoulder
Hamilton ruler test A straight ruler placed on the
lateral aspect of arm will be able
to touch the acromion and lateral
condyle humerus.
Callaway test Vertical circumference around
axilla is increased
Bryant’s test Anterior axillary fold at a lower
level

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Dugas test Callaway test Hamilton ruler test

Complications of anterior dislocation of shoulder

1. Axillary nerve injury

• MC early complication
• Deltoid palsy
• Loss of sensation of Upper lateral arm
• Regimental badge sign

2. Recurrent dislocation
• MC complication
• MC late complication

Recurrent dislocation of shoulder

Causes of Recurrent shoulder dislocation
Bankart lesion Tear in the anterior aspect of glenoid labrum
Bony Bankart lesion Tearing of the glenoid labrum anteriorly along
with fracture
of piece of bone from the anterior glenoid rim
Hill Sach’s lesion Defect in the posterolateral aspect of humeral
head

Surgeries for recurrent dislocation

Putti Platt operation Double breasting of subscapularis
Bankart repair Open/ arthroscopic
Bristow Latarjet procedure Transplantation of coracoid
to the anterior rim of glenoid

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3b.Posterior dislocation of shoulder
• Fall due to Electric shock / Epileptic seizure / ECT
• Attitude - Adduction and Internal rotation
• MC missed dislocation

Empty glenoid sign Electric bulb sign

3c. Inferior dislocation of shoulder

• Rarest form of shoulder dislocation
• Also called Luxatio Erecta
• Caused by hyperabduction injury
• Salute position

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4. Fracture neck of humerus
• FOOSH in elderly
• Neer’s classification
• Complications
• Shoulder stiffness (MC)
• Axillary N injury
• Avascular necrosis (MC in
4 part fracture)
• Implant used – PHILOS

Neer’s classification
One part Undisplaced fracture
Two part Displaced – 1 fracture line – 2 fragments
Three part Displaced- 2 fracture lines- 3 fragments
Four part Displaced- 3 fracture lines- 4 fragments

5. Fracture shaft of humerus

• FOOSH
• Treatment – usually conservative
• Coaptation splint (U- slab)
• Hanging cast
• Functional bracing (Sarmiento brace)
• Complications
• Malunion
• Nonunion
• Radial N injury – Fracture of distal 1/3rd humerus with
Radial N injury is called Holstein Lewis #

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Elbow fractures – basics
Three point bony relationship
• It is the relationship between the lateral epicondyle, medial epicondyle and the tip of olecranon

Isosceles Straight line with

triangle with the elbow
the elbow extended
flexed

Altered 3 point relationship Intact 3 point relationship

Fracture lateral condyle Supracondylar fractures
Fracture medial condyle Radial head dislocation
Fracture olecranon Radial head fractures
Dislocation elbow
Intercondylar fractures

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6. Supracondylar fracture of humerus
• MC elbow # in children
• Age – 4 -8 years
• Clinical findings
• Tenderness
• Edema
• Anterior pucker / Brachialis sign

Gartland classification
Type 1 Undisplaced fracture
Type 2 Partially displaced with
intact posterior periosteum
Type 3 Completely displaced

• Treatment
• Type 1 – Above elbow POP
• Type 2 – closed reduction and POP or K - wire fixation
• Type 3 – closed / open closed reduction and K - wire fixation
• Dunlop traction – skin traction used in olden days
• Complications
• MC fracture associated with vascular injury
• MC fracture to involve Brachial A
• MC cause of compartment syndrome in children
• MC cause of Volkmann ischemic contracture in children
• MC cause of Volkmann ischemic contracture overall

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 Dunlop traction

Complications of supracondylar fractures

• Early complications
• Vascular injury
• Nerve injury
• Compartment syndrome
• Late complications
• Malunion (MC complication)
• Cubitus varus deformity
• Volkmann ischemic contracture
• Elbow stiffness
• Myositis ossificans
• Osteonecrosis of trochlea

Complication 1. Brachial A injury

1. Spasm
• MC
• Results in ‘pink pulseless hand’
• Here the Radial and Ulnar pulses will be absent but capillary filling will be normal
• Pulse usually recovers after reduction of fracture
2. Thrombosis
• Suspected when distal pulses do not reappear even after reduction of #
• Needs exploration of Brachial A and thrombectomy
3. Tear
• Rare
• Life threatening
• Needs emergency repair

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Complication 2. Nerve injury
• Commonest nerves involved are
• Median (AIN) > Radial >Ulnar
• Tests for AIN
• OK sign/ Kiloh Nevin sign

Complication 3. Compartment syndrome

• Definition
• Elevation of pressure inside a closed fascial compartment causing decrease in perfusion to the limb leading to
irreversible muscle and neurovascular damage
• Causes
1. Fractures
2. Tight bandage/ cast
3. Burns
4. Surgeries
5. Dye injections

• Clinical features (6Ps)

1. Pain
2. Pallor
3. Pulselessness
4. Paresthesia
5. Paralysis
6. Pain on passive stretch – earliest and most important sign

Evaluation compartment pressure in an unconscious patient

• Compartment pressure measurement can be done with
1. Manometer
2. Whiteside's technique
• Compartment pressure > 30mm indicates compartment syndrome
• Treatment – Fasciotomy

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Whiteside's technique

Complication 4. Volkmann ischemic contracture

• Contracture of muscles leading to deformities usually as a result of compartment syndrome
• Causes
1. Compartment syndrome
2. Brachial A injury
3. Tight POP
• Muscles: FDP > FPL
• Nerve : AIN > Median > Ulnar
• Treatment : Turnbuckle splint

Complication 5. Malunion - Cubitus varus

• MC complication of SC #
• Gun stock deformity
• Defined as a decrease in carrying angle
• Carrying angle is the angle between the long axis of arm and forearm
• Treatment of cubitus varus
• Lateral closing wedge osteotomy
• French osteotomy

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Cubitus varus

Cubitus varus Reduced Carrying angle

Cubitus valgus Increased Carrying angle
Cubitus rectus Cubitus rectus Carrying angle = 0

Complication 6. Myositis ossificans

• Abnormal bone formation in soft tissues around a joint leading to stiffness
• New terminology - Heterotopic ossification
• Associated with - Massage
• MC muscle involved : Brachialis
• MC joints involved : Elbow > Hip
• Biopsy - Ackerman’s zone phenomenon

• X ray
• Radiolucent center with radiodense rim
• String sign
• Dotted veil appearance
• Treatment
• Immature - Indomethacin
• Mature - Excision + physiotherapy

Complication 7. Osteonecrosis of trochlea

• Fish tail deformity
• Progressive cubitus varus

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7. Fracture lateral condyle humerus
• Fracture is problematic as it is
1. Transphyseal so there is risk of growth arrest and deformities
2. Intraarticular so there is mixing of synovial fluid and fracture hematoma predisposing to nonunion
3. High chance of nonunion due to the pull of common extensors that are attached to the lateral condyle

• Complications
1. Non union
2. Cubitus valgus
3. Tardy ulnar N palsy

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Mechanism of complications

Nonunion lateral condyle #

↓
Growth arrest of lateral part of physis
↓
Medial side grows normally
↓
Medial part of distal humerus grows longer
compared to the lateral side
↓
Progressive Cubitus valgus
↓
Gradual stretching of the ulnar nerve
↓
Tardy ulnar N palsy

• Treatment
• It is a Fracture of necessity
• Has to be always treated with surgery - Open reduction +
screw/ K wire fixation

Fractures of necessity

Galeazzi fracture

Lateral condyle humerus fracture

Fracture neck of femur

8. Elbow dislocation
• Prominence of the olecranon
• Altered 3 point relationship
• MC type – Posterior
• Needs reduction ASAP
• Risk of Brachial A injury

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9. Terrible triad of Hotchkiss

10. Pulled elbow

• Also called ‘nurse maid’s elbow’
• Subluxation of radial head due to axial pull distal to the elbow
• Seen in children < 5 years
• Clinically - Pronated forearm
• X ray – normal
• Treatment – Supination of forearm

11. Fracture olecranon

• Avulsion fracture due to pull of Triceps

• Treatment- Tension Band Wiring
• Hume’s fracture- Fracture of olecranon + Anterior radial head dislocation

12. Radial head fractures

• Treatment
• Undisplaced #: cast
• Displaced / Comminuted #:
Excision of radial head

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13. Floating elbow
• Fractures of
• Humerus and
• Both bones of forearm
• Also called as side swipe injury /Baby car fracture
• Treatment - Fixation of all the fractured bones

14. Essex Lopresti fracture

• Combination of
1. Radial head fracture +
2. Interosseous membrane injury +
3. Distal radio ulnar Joint disruption
• Radial head excision is contra indicated as it can cause the proximal migration of radius resulting in
impingement of distal ulna on the carpal bones

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15. Monteggia fracture dislocation
• Fracture of proximal third of ulna with radial head dislocation
• Clinically
• Pain, swelling
• Restricted pronation, supination

• Treatment
• In Children
• Closed reduction and casting
• In Adults
• Open reduction and plating
• Complications
• Posterior Interosseous Nerve injury- Finger drop
• Malunion

BADO Angulation Radial head

classification of ulna dislocation
Type1 Anterior (MC) Anterior
(extension type)
Type2 Posterior Posterior
Type3 Lateral Lateral
Type4 Fracture both bones Anterior
at proximal 1/3rd

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16. Night stick fracture
• Isolated fracture of shaft of ulna
• Self defence fracture
• Treatment
• Casting
• ORIF in displaced #

17. Fracture both bones forearm

• Treatment
• Closed reduction and cast
• Open reduction and plating

Position of immobilization
Proximal third Supination
Middle third Mid prone
Distal third Pronation

18. Galeazzi fracture

• Fracture of distal 1/3rd radius with DRUJ dislocation
• Reverse Monteggia/ Piedmont fracture
• Treatment
• Fracture of necessity
• Open reduction and plate fixation
• Complication – Malunion

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19. Colles fracture
• Fracture at the cortico cancellous junction of distal radius with dorsal displacement
• MC fracture in elderly
• Seen in post menopausal women

• Clinical features
• Pain, swelling
• Dinner fork deformity
• Classical displacements
• Dorsal tilt , Dorsal displacement
• Impaction (most important)
• Lateral tilt, Lateral displacement
• Supination

Treatment
• Closed reduction
• Hand shake cast / Colles cast
• Position
• Pronation
• Palmar flexion
• Ulnar deviation

• Complications
1. Joint stiffness
2. Malunion - Dinner fork deformity
3. Carpal tunnel syndrome
4. Sudek’s osteodystrophy
5. EPL tendon rupture

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20. Smith’s fracture
• Fracture of distal radius with volar displacement
• Reverse Colles fracture
• Treatment
• Closed reduction and Above elbow cast
• Open reduction and plating if closed reduction fails
• Complication
• Malunion - Garden spade deformity

21. Chauffeur’s fracture

• Intra articular fracture of radial styloid
• Backfire fracture/ Hutchinson fracture
• Treatment – cast / screw fixation

22. Barton’s fracture

• Intra articular fracture of the the rim of distal radius where the fracture fragment displaces along with the
carpus and hand.
• Types - Volar Barton # and Dorsal Barton #
• Treatment
• Open reduction and plate fixation

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23. Scaphoid fracture
• MC carpal bone to fracture
• Classical sign - Tenderness of anatomical snuff box
• Sites of fracture
• Distal pole – MC in children
• Waist – MC in adults
• Proximal pole – MC for complications
• Rx of Undisplaced # - Below elbow cast in glass holding
position for 12-16 weeks
• Rx of Displaced # - Herbert screw fixation

Scaphoid cast

Complications of scaphoid fracture

1. Non union
• MC complication
• Prox pole > Waist > Distal pole #
2. Avascular necrosis
• Prox pole > Waist > Distal pole #
• Reason for proximal pole having maximum incidence of complications is the weird blood supply of scaphoid
Blood supply of scaphoid is from a branch of Radial A which
• Enters distally and progresses proximally
• Blood supply decreases as you go farther from the distal pole

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24. Scapholunate dissociation
• Fall with wrist pain without fracture
• Scapholunate ligament injury
• MC wrist ligament injury
• Terry Thomas sign

25. Boxers fracture

• Fracture neck of 5th metacarpal
• Treated with casting in James position

26. Bennet fracture dislocation

• Definition
• Intra articular fracture of the base of 1st metacarpal with
displacement of whole shaft radially due to pull of APL
• Treatment
• Wagner technique of closed reduction and percutaneous K
wire fixation

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27. Rollando fracture
• Definition
• Intra articular comminuted (T/ Y) fracture of base of 1st metacarpal
• Treatment
• Open reduction and Plate fixation

28. Mallet finger

• Also called Baseball finger
• Forceful passive flexion of DIP causing extensor tendon avulsion from distal phalanx
• Features
• Flexed attitude of DIP
• Inability to actively extend
• Treatment - Mallet splint

29. Jersey finger

• Forceful passive extension of flexed DIP joint causing flexor tendon avulsion from distal phalanx
• Features
• Extended attitude of DIP
• Inability to actively flex

Section II c - Lower limb trauma

30. Pelvic fractures
• Mechanism- high velocity trauma
• Risk of hypovolemic shock and death
• Classifications
• Based on the mechanism
• Young and Burgess classification
• Based on stability
• Tile’s classification
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Young and Burgess classification
Anteroposterior Open book Disruption of pubic
compression fracture symphysis and the pelvis
opens like a book

Lateral Crescent Posterior iliac wing fracture

compression fracture with extension into the
sacroiliac joint

Wind swept Combination of unilateral AP

pelvis compression (open book)
injury with a contralateral
lateral compression injury

Vertical shear Malgaigne Disruption of the ipsilateral

fracture superior and inferior pubic
rami and sacroiliac joint

Combined

Tiles classification
Type A Stable fractures
Type B Rotationally unstable but vertically stable
Bucket handle fracture (bilateral rotational instability)
Type C Rotationally and vertically unstable

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Duverney’s Jumper’s fracture Straddle fracture
fracture

Management of pelvic fractures

Immediate Early
Tie a pelvic bandage Blood transfusion
Apply pelvic binder Pelvic external fixator
IV crystalloids Angioembolization of bleeding vessels

Pelvic external fixator pelvic binder

31. Hip dislocations

• Hip is inherently a very stable joint
• Dislocation occurs only is high energy trauma

Hip dislocations Posterior disloacation Anterior dislocation Central dislocation

Incidence Dashboard injury Rare Rarest
Cause Commoner Fall from height RTA
Deformity FAD IR FABER Variable
Limb length Shortening Lengthening Mild shortening
Femoral head position Gluteal region Scarpa’s triangle Per recal
Nerve injury Sciatic N Femoral N -
Vascular injury Rare Femoral A -

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Posterior dislocation

X-ray findings
Shenton’s line Broken
Femoral head Dislocated
Limb length Shortened
Attitude of femur Adduction Internal rotation

Anterior dislocation

X-ray findings
Shenton’s line Broken
Femoral head Dislocated
Limb length Lengthened
Attitude of femur Adduction Internal rotation

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Central dislocation

X-ray findings
Shenton’s line Broken
Femoral head Dislocated
Limb length Shortened
Attitude of femur Adduction Internal rotation

Treatment of hip dislocation

• Closed reduction ASAP
• Delayed reduction leads to AVN
Complications
• AVN of femoral head
• Osteoarthritis

32. Fracture neck of femur

• Common in elderly
• Age
• >60years : Fall
• Young : high velocity trauma
• Symptoms
• Pain
• Inability to weight bear
• Signs
• Tenderness Scarpa’s triangle
• Mild external rotation
• Blood supply of femoral head

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 Garden classification
Type I Incomplete valgus impacted fracture
Type II Undisplaced fracture
Type III Partially displaced fracture
Type IV Completely displaced fracture

Pauwel’s classification
Type I < 30°
Type II 30°- 50°
Type III > 50°

Treatment protocol

Complications
• Nonunion due to
1. Precarious blood supply
2. Absence of cambium layer in periosteum
3. Synovial fluid inactivates the hematoma
• AVN of femoral head

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33. Fracture shaft of femur
• Mechanism - High velocity trauma
• High risk of complications
1. Hypovolemic shock
2. Fat embolism
3. DVT
4. Nonunion
5. Malunion
• Management of #SOF
• Primary aim of treatment is to resuscitate the patient as the #
• Can be associated with polytrauma
• And blood loss in shaft of femur fractures can reach upto 1L – 1.5 L
• Follow ATLS protocol
• Once patient is stable # fixation is done

Fracture management
• Temporary stabilization - Thomas splint
• Definitive Rx - Intramedullary nailing
• External fixation only in open fracture
• Old methods
• Russel’s traction
• Kuntscher Nail (K nail)

Thomas splint
Russel’s traction Kuntscher Nail (K nail)

Shaft of femur fracture in children

• MC site : Proximal 1/3rd

Age Treatment
< 2 years ( < 12 kg) Gallows traction
2 – 5 years Hip Spica
5 – 10 years Enders nail / TENS
> 10 years Interlocking nail

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TENS Hip Spica Gallows traction

Fat embolism syndrome

• Definition
• Systemic disorder characterized by organ damage due to fat particles in micro circulation
• Features
• Classical triad
• Time delay : 24 – 72 hours
• GURD’S criteria

Symptom triad of fat embolism

Respiratory symptoms Dyspnoea
Tachypnoea
Cerebral symptoms Confusion
Delirium
Altered behavior
Petechial rash Axilla, chest, periumbilical area
Conjunctiva of lower lid

m triad of fat embolism

• Causes
1. Trauma (90%) - # SOF, # Tibia
2. Surgeries
• Joint reconstruction surgeries
• Liposuction
3. Diseases
• Diabetes
• Acute pancreatitis
• Sickle cell disease
4. Burns
• Prevention
• Early stabilization of fracture
• Maintaining hydration
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• Treatment
• Oxygen support
• Mechanical ventilation
• Human albumin infusion

34. Fracture patella

• Avulsion fracture due to pull of quadriceps
• Types
• Undisplaced
• Cylinder/ tube cast
• Transverse
• Tension band wiring
• Comminuted
• Patellectomy

DD of patella fracture
• Bipartite patella
• Patella ossifies as 2 separate segments which later fuses by synchondrosis

Saupe’s classification
Type I Inferior pole 5%
Type II Lateral border 20 %
Type III Superolateral border 75 %

Differentiation Fracture patella Bipartite patella

Clinical Pain after Asymptomatic
presentation trauma
Pattern Jagged edges Smooth rounded
edges
Orientation Usually Curved-
transverse/ Superolateral
comminuted Vertical- Lateral

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Type I Type II Type III

35. Fracture shaft of tibia

• RTA – MC mechanism
• Tibia is the MC bone involved in
1. Open fractures
2. Stress fractures
3. Nonunions
• Middle 1/3rd distal 1/3rd junction
• Watershed zone

PTB cast
• Treatment
• Undisplaced
• Above knee Plaster cast followed by
• Patellar tendon bearing(PTB) cast
• Displaced
• Closed fractures : Interlocking intramedullary nail
• Open fractures: External fixator

36. Ligament injuries and ligament avulsion fractures

• Anterior talo fibilar ligament (ATFL)
• MC ligament sprain in the body
• Footballer’s ankle
• Anterior ankle joint instability
• Due to chronic ligament tears
• Watson Jones procedure
• Anterior inferior tibio fibular ligament
• Tillaux- Chaput fracture – AITFL avulsion # from the tibia
• Wagstaffe – Le fort fracture – AITFL avision # from the fibula

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37. Fractures around the ankle
Eponymous fractures
Maisonneuve fracture Medial malleolus fracture with proximal 1/3rd fibula
fracture
Pott’s fracture Bimalleolar fracture
Cotton fracture Trimalleolar fracture
Bosworth fracture Fracture lateral malleolus with irreducible ankle
dislocation
Curbstone fracture Avulsion fracture posterior lip of distal tibia
Runner’s fracture Stress fracture distal fibula
Pilon fracture Intra articular # of distal articular surface of tibia

Pott’s fracture

38. Fractures of calcaneus

• MC fractured tarsal bone
• Mechanism - Fall from height
• Eponyms - Lover’s/ Don Juan/ Casanova #
X ray-
• Bohler’s angle- Reduced in fractures
• Gissane’s crucial angle- Increased in fractures
Treatment -
• Minimally displaced # - Cast
• Displaced - ORIF - Plating
Bohler’s angle
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Gissane’s crucial angle

39. Talus fracture

• High chance of Avascular necrosis due to precarious blood supply
• Aviator’s astragalus - Talar neck fracture
• Snow boarder’s fracture - Fracture lateral process of talus
• Hawkin’s classification
• Complications
1. Osteoarthritis (MC)
2. Non union
3. Avascular necrosis
• Hawkins' sign
• Area of radioleucency in the subchondral bone of talus
• It is a sign of revascularization and viability of talus

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40. Fractures of the 5th metatarsal
1. Pseudo Jones fracture (zone 1)
• # line in tarso-MT joint
• Avulsion fracture
• Peroneus brevis
• Cast application

2. Jones fracture (zone 2)

• # line in inter-metatarsal joint
• Watershed zone
• Chance of nonunion high
• Screw fixation
3. Dancer’s fracture (zone 3)
• Stress fracture

Section II d. Open fractures

• Fractures associated with wounds
• Fracture hematoma communicates with the outside environment.

• Problems of open fractures

1. High chance of infection of the wound, bone and implants
2. High chance of nonunion due to
• Loss of hematoma
• Soft tissue stripping which compromises periosteal blood supply
3. Difficulty of wound care in plasters

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1. Gustilo Anderson classification

Grade I Wound < 1cm Absence of grade III features

Grade II Wound 1- 10 cm
Grade III Wound > 10cm III A Wound > 10cm
• High energy trauma Adequate
• Extensive soft tissue damage periosteal
• Segmental/ comminuted coverage
fractures III B Extensive
• Gross contamination periosteal
• Vascular injury stripping requiring
skin grafting / flap
cover
III C Vascular injury
requiring repair

2.Treatment of open fractures

Grade I Internal fixation

Grade II, Uncontaminated, < 6 hour Internal fixation
Grade IIIA Contaminated, > 6 hour External fixation
Grade III B External fixation + plastic procedure
Grade III C External fixation + Vascular repair

3. External fixation
• Device which stabilizes the bone from outside the body

4. MESS score
• Mangled extremity severity score
• MESS score is used for deciding on weather to perform amputation in traumatic limb damage.
• <7 - salvage
• >7 – amputation

43
Section II e. complications of fractures
1. Common Arterial injuries associated with fractures

Subclavian A Clavicle fracture

Axillary A Fracture neck of humerus
Brachial A Supracondylar fracture humerus
Femoral A Anterior dislocation hip
Fracture shaft of femur
Popliteal A Posterior dislocation knee
Proximal tibia fractures
Dorsalis pedis A Lisfranc fracture dislocations

44
2. Common nerve injuries associated with fractures

Brachial plexus Fracture clavicle

Axillary N Shoulder dislocation
Fracture neck of humerus
Radial N Holstein Lewis fracture
Ulnar N Medial condyle humerus fracture
Flexion type SC fracture humerus
Nonunion lateral condyle humerus
Median N Supra condylar fracture humerus
Anterior interosseous N Supra condylar fracture humerus
Posterior interosseous N Fracture neck of radius
Monteggia fracture dislocation
Radial head dislocations
Deep branch of ulnar N Hook of hamate fracture
Sciatic N Posterior dislocation hip
Common peroneal N Neck of fibula fracture

3. Nonunion
• Failure of healing of a fracture
• Definition
• Absence of union even after 9 months
• No progress radiologically for last 3 months
• Delayed union
• Absence of union even after 6 months
• MC bone: distal 1/3rd of tibia

Common fracture nonunions

Tibia lower 1/3rd
Lateral condyle humerus
Talus
Scaphoid
Neck of femur

Hypertrophic nonunion Atrophic nonunion

Exuberant callus formation Absence of callus formation
Cause Causes
• Inadequate immobilization Poor quality of bone at fracture ends
Gap at fracture site
• Treatment – fixation of # Fixation + bone grafting

Elephant Horse Oligotrophic

Foot Hoof
45
Wedge Comminuted Gap Atrophic
Non-union nonunion nonunion nonunion

46
 Chapter III. Tumor and tumor like lesions of bone

Section III a. Important bone tumors and its identification

Tissue of origin Benign Malignant

Bone Osteoid osteoma Osteosarcoma
Osteoblastoma
Cartilage Enchondroma Chondrosarcoma
Osteochondroma
Chondroblastoma
Fibrous tissue Non ossifying fibroma Fibrosarcoma
Haemopoetic Multiple myeloma
Lymphoma
Vascular Hemangioma
Unknown Giant cell tumor Ewing's sarcoma
Adamantinoma

Tumor like conditions

Simple bone cyst
Aneurysmal bone cyst
Fibrous dysplasia
Eosinophilic granuloma

For identifying tumors on X ray or form a clinical vignette 4 tables need to be learnt.

Table 1.Tumors in different age groups

0-10 years Simple bone cyst

Eosinophilic granuloma
5-20 years Ewing's sarcoma Peak incidence in 2nd decade
10- 20 years Osteosarcoma
Most benign tumors
20- 40 years Giant cell tumor
Adamantinoma
40-60 years Chondrosarcoma
Secondary osteosarcoma
Above 60 years Metastasis, multiple myeloma

Table 2. Tumors in different parts of bone

Epiphysis Metaphysis Diaphysis

Giant cell tumor Osteochondroma Adamantinoma
Chondroblastoma Osteosarcoma Osteoid osteoma
Chondrosarcoma Lymphoma
Enchondroma Fibrous dysplasia
Aneurysmal bone cyst Ewing’s sarcoma
Non ossifying fibroma
Simple bone cyst

Infection (osteomyelitis)

47
Table 3. Types of Periosteal reactions

• Benign tumors Ewing’s Osteosarcoma

• Infections

Flowchart for tumor identification

48
Table 4. Special features of tumors on x ray

Enchondroma Simple bone cyst Aneurysmal bone cyst Non ossifying fibroma
Usually hands Uniloculated cyst Multiloculated cyst Multiloculated
Radiolucent with Fallen fragment sign More central Very eccentric
popcorn Trap door sign Expansile Non expansile
calcification No sclerotic margins Sclerotic margin

Section III b. Benign tumors

1. Osteoid osteoma
• Most common true benign bone tumor of bone
• Age: 5 to 20 years
• Site : Diaphysis
• MC bone : Femur
• Presents as pain relieved by NSAIDS especially aspirin
• X ray - Cortical lytic area (nidus) surrounded by extensive sclerosis

Section III b. Benign tumors

• Investigation of choice: CT scan
• Double density sign in bone scan
• Spontaneous resolution in 5-7 yrs
• Treatment
• NSAIDS and observation
• Radiofrequency ablation

49
2. Osteoblastoma
• Similar to osteoid osteoma as it also forms a nidus with
surrounding sclerosis and also has similar biopsy features.

Osteoid osteoma Osteoblastoma

Nidus < 2cm Nidus > 2cm
Femur> Tibia Vertebra >> Proximal humerus
Spontaneous resolution Progressive
Pain resolved by NSAID Unresponsive to NSIADs
Surgery rarely required Excision always required

3. Osteochondroma
• Also called Exostosis
• Not considered a true bone tumor but a developmental aberration
• MC benign bone tumor
• Metaphysis
• 10-20 years

• X ray findings
• Has a pedicle with expanded end
• Grows away from joint line
• Cortex and medullary canal is continuous with parent bone

50
• Causes of Pain
1. Bursitis (MC)
2. Fracture
3. Nerve compression
4. Malignant change
• Malignant transformation
• <1% risk
• Chondrosarcoma
• Features of malignant change
1. Pain
2. Growth of tumor after skeletal maturity
3. Loss of cortical and medullary continuity
4. Disorganized calcification in the cap
5. Increased size of cartilage cap (>2cm)
• Treatment - Excision in symptomatic
• After skeletal maturity
• Extra periosteal excision

4. Hereditary multiple exostosis

• Also called Diaphyseal Eclasis
• Autosomal dominant
• EXT gene mutation
• Features
• Multiple osteochondromas
• Short stature
• 5-10% risk of malignant change
• Treatment - Excise only the symptomatic osteochondromas

5. Enchondroma
• Benign cartilage tumor of medullary cavity
• Metaphyseal
• Age: 10-25 years
• MC site: Hand > feet> femur
• MC bone tumor of hand and feet
• Treatment
• Asymptomatic - observation
• Symptomatic- Curettage and bone grafting

51
• X-ray : Radiolucent lesion +
• spotty calcification/
• pop corn calcification/
• rings and arc calcification

Associated syndromes of enchondroma

OLLIER’S Disease MAFFUCCI’s syndrome

Multiple enchondromas Multiple enchondromas
Soft tissue angiomas
Phleboliths
30% risk of malignant 100% risk of malignant
transformation transformation

52
6. Chondroblastoma
• Codman’s tumor
• Epiphyseal tumor
• Age : 10-25 years
• MC site : Around the knee>proximal humerus
• Pulmonary metastasis : 1%
• Treatment : curettage and bone Grafting

• X-ray : Epiphyseal lytic lesion that could be

• Clear
• Stippled
Calcification

• Biopsy- Chicken Wire/ Cobble Stone arrangement of chondroblasts

7. Giant Cell Tumor/ Osteoclastoma

• Age- 20 to 40
• Epiphyseal
• More common in females
• Distal femur> prox tibia> distal radius> sacrum
• MC bone tumor of distal radius
• 3% mets to lungs
• Clinical examination: Egg shell cracking

53
• X ray findings
• Eccentric
• Expansile
• Epiphyseal
• Eats the bone (osteolytic)
• Soap bubble appearance
• Biopsy

• Giant cells which look similar to osteoclasts

• Mononuclear stromal cells
• Actual tumor cells
• Produce RAND ligands that stimulate osteoclasts
• Treatment
• Extended curettage
• GCT in difficult to access areas (pelvis/ spine)
• Denosumab ( blocks RANK ligand)

8. Non ossifying fibroma

• Fibrous cortical defect
• Most common benign lesion of bone
• Metaphysis
• Age: <20 years
• Most common site: around knee
• Spontaneous resolution
• Jaffe Campanacci syndrome
• Multiple NOF

• X ray findings
• Very Eccentric
• Thin Sclerotic margin
• Non expansile

9. Hemangioma
• Benign tumor
• MC site : Vertebral body
• Asymptomatic
• No treatment is needed
• Xray - Corduroy / jail bar
• CT - Polka dot sign

54
10. Simple bone cyst
• Unicameral bone cyst
• Age: 0-10 years
• Metaphyseal
• MC site: Proximal humerus> Proximal femur
• Can spontaneously resolve

Simple bone cyst continued…

• Xray
• Well demarcated cystic lesion
• Trap door sign
• Fallen fragment sign
• Treatment
• Observation
• Aspiration and injection of steroids
• Curettage,bone grafting and fixation

Trap door sign Fallen fragment sign

11. Aneurysmal bone cyst

• Metaphyseal
• Age <20 years
• Around the knee
• Xray
• Multiloculated cyst
• Expansile
• Lytic
• CT- multiple fluid levels
• Presents as painful swelling
• Treatment: Extended curettage with bone grafting

55
12. Fibrous dysplasia
• Benign developmental disorder characterized by expanding
intramedullary fibro-osseous tissue
• Age: 20-30
• GS alpha protein mutation
• 2 types
• Monostotic- Proximal femurshepherd crook deformity
• Polyostotic – Maxilla – leonine facies Shepherd crook deformity Alphabet soup/ Chinese
letter pattern

• X ray findings
• Ground glass appearance
• Rind sign
• Biopsy
• Alphabet soup/ Chinese letter pattern
• Treatment
• Observation
• Biphosphonate
• Surgery only for fractures or deformity correction
• 1% risk of osteosarcom
56
 McCune Albright syndrome

Polyostotic Fibrous dysplasia

Pigmentation - Cafe au lait spots

Precocious puberty

Mazabraud syndrome
Polyostotic Fibrous dysplasia
Intra muscular myxomas

13. Eosinophilic granuloma

• Single bone is involved
• MC site- Skull> Ribs> Spine
• Xray
• Skull: Punched out lesions
• Spine: Vertebra plana
• Long bones: Great mimicker
• Electron microscopy – Birbeck granules
• Spontaneous resolution

Section IIIc. Malignant Tumors

14. Osteosarcoma
• MC primary malignant tumor of bone
• MC primary malignancy of bone: multiple myeloma
• MC malignancy of bone: metastasis
• 10-20 years
57
• Metaphyseal tumor
• MC site: Distal Femur> Prox Tibia
• Associations
• Rothmund Thompson syndrome
• Li Fraumeni syndrome
• MC site of Mets- Lung > Bone

• X-ray findings
• Metaphyseal
• Codman's triangle
• Sun burst appearance
• Gold standard for diagnosis : biopsy
• Treatment
• Surgery + chemo
• T 10 regimen
• Most radio resistant tumor

15. Chondrosarcoma
• Primary or secondary
• Secondary chondrosarcoma arises from pre existing lesions
• Age: 40 -70 years
• Metaphyseal
• MC site: Pelvis > Proximal Femur
• Treatment - Excision alone

• X ray
• Radiolucent mass
• Large areas of calcification
• Popcorn calcification
58
16. Ewings sarcoma
• MC tumor of bone in 1st decade
• Ewing's sarcoma is most common in 2nd decade
• Age: 5-20 years
• Arises from the diaphysis
• MC site: Femur
• Translocation 11:22
• Fusion protein (EWS- FLI1) is a oncogene

• X-ray
• Diaphyseal lytic lesion
• Onion peel periosteal
Reaction

• Biopsy:
• Sheets of round blue cells though out
• Pseudo rosettes
• Treatment
• Treatment of choice is Neoadjuvant chemo and surgery
• Ewing’s is the most radiosensitive tumor, however radiotherapy is not used as radiation in very young
children can lead to secondary osteosarcoma few years late which will be fatal.

Markers for Ewing’s sarcoma

MIC2 (CD99) +
PAS +
Diastase +

Only radiosensitive bone tumors

Hemangioendothelioma
Ewing's sarcoma
Lymphoma of bone
Plasmacytoma
59
17. Adamantinoma
• Rare low grade malignant tumor
• Age: 20-40 years
• Diaphysis
• MC site: Tibia
• MC metastasis- lung
• Treatment - Surgical resection

• X-ray
• Multiple lytic lesions
• Surrounding sclerosis
• Soap bubble appearance

18. Metastatic disease of bone

• Most common malignancy of bone: Metastasis
• MC primaries for bone mets: Breast > Prostate> Lung
• MC primaries for mets in children: Neuroblastoma
• MC bone involved : Spine> proximal femur
• MC part of spine involved: Thoracic > Lumbar
• MC site of pathological fracture : Femur

19. Important X ray findings

Winking owl sign Rain drop skull

60
20. Most common sites of tumors

Most tumors of bone Around the knee joint

Ameloblastoma Mandible
Simple bone cyst Proximal humerus
Enchondroma Short bones of hand
Osteoblastoma Vertebra
Hemangioma
Chondrosarcoma Around hip joint
(pelvis>proximal femur)
Osteoid osteoma Femoral diaphysis
Ewing's sarcoma
Admantinoma Tibial diaphysis

21. Genetics in bone tumors

EXT gene mutation HME
GS alpha mutation Fibrous dysplasia
Translocation 11:22 Ewing’s sarcoma
Translocation X:18 Synovial sarcoma

61
 Chapter IV. Infections of bone and joint
Section IV a. Pyogenic infections

1. Osteomyelitis
• Infection of bone and bone marrow
• MC bone involved: Femur
• MC bone involved in adults : Vertebra
• MC part of bone involved : Metaphysis
• MC organism – Staphylococcus

Types of osteomyelitis
Acute osteomyelitis < 2 weeks
Subacute osteomyelitis 2weeks – 2 months
Chronic osteomyelitis > 2 months

Etiological agent in special situations

Sickle cell anemia Salmonella
IV drug users
Foot puncture wound Pseudomonas
Animal bite Pasteurella
Human bite Eikenella
Prolonged parenteral therapy
Chronic granulomatous disease
Fungal
Fishermen M. Marinum

Pathology of osteomyelitis

62
 Subperiosteal Pus collection under the
abscess periosteum
Sequestrum Piece of dead bone inside
abscess cavity which harbors
bacteria
Involucrum New bone formed
Cloaca Opening in the involucrum
through which pus escapes
Sinus Opening in the skin through
which pus drains out

Types of sequestrum
Tubular / diaphyseal Severe acute OM children
Ring/ annular Around external fixator
pins
Black Fungal osteomyelitis
Coke TB osteomyelitis
Coarse Sandy
Feathery/ flake Syphilis
Coralliform Perthe’s disease
Fine sandy Viral psteomyelitis
Buttonhole Post radiation

2. Acute osteomyelitis
• Occurs in
• Children (MC)
• Elderly
• Immunosuppressed
• IV drug users
• Clinical features
• Fever
• Pain of a limb
• Unable to move affected limb
• Pseudoparalysis
• Blood : Elevated total count, ESR, CRP, Procalcitonin

Radiology in acute osteomyelitis

Xray First change 24-48 Soft tissue shadow
hours around bone
First bony change 7-10 days Periosteal reaction
MRI First change < 24 hours Marrow edema
Bone Technetium 99 Gallium67 Indium111
scan labelled WBC

Treatment of acute osteomyelitis

• Presentation before 24 hours
• Sample for blood culture and sensitivity
• Start parenteral broad spectrum antibiotics
• Start appropriate antibiotics once culture report arrives
• IV antibiotics for 2 weeks and
• Oral antibiotics for 4 weeks
• Presentation after 24 hours
• Drainage of abscess + antibiotics

63
3. Chronic osteomyelitis
• Sequelae of acute osteomyelitis
• Symptoms
• Sinus
• Discharge of bone piece – pathognomonic symptom
• Signs
• Multiple scars
• Thickened rough skin
• Skin adhered to underlying bone
• Sinus – clinical hallmark
• Sequestrum - pathological hallmark

• Xray
• Abscess cavity - radiolucent
• Sequestrum - radiodense
• Involucrum
• Cloaca
64
• Treatment
• Surgery + Antibiotics
• Sequestrectomy and sauzerization
• Paprika sign – formation of spots of bleeding after curettage indicating removal of all dead and infected tissue.
• Complications
1. Acute exacerbations
2. Pathological fractures
3. Malignant change of long standing sinus - Squamous cell carcinoma
4. Amyloidosis

4. Brodie's abscess
• Form of sub acute osteomyelitis
• Infection by a low virulence organism in a high immunity host
• MC site : Proximal tibia
• X ray
• Well circumscribed radiolucent area
• Metaphysis
• Sclerotic margin
• MRI: Penumbra sign/ Rim sign
65
5. Garre’s sclerosising osteomyelitis
• Type of chronic osteomyelitis
• MC site: mandible> tibia
• Presents as swelling
• Xray
• Small lytic area
• Diaphysis
• Surrounded by sclerosis
• Fenestration + antibiotics
• DD- osteoid osteoma

6. Septic arthritis
• Infection of the joint cavity
• Commonest pathogens
• Staph aureus
• Sexually active: N. gonorrhea
• IV drug users: Pseudomonas
• MC joint involved- Knee
• MC joint involved in children –Hip

66
• Symptoms
• Fever, Swelling, warmth around the joint
• Signs
• Effusion of the joint, Warmth
• Severe pain through out the range of motion
• Joint will be held in position of ease

• Blood tests
• Elevated TC, ESR,CRP, Procalcitonin
• Blood culture
• Xray
• Widening of joint space
• Joint destruction in late stages
• MRI – Synovial thickening

• Joint aspiration
• Arthrocentesis
• If frank Pus
• Send for culture and sensitivity
• Plan immediate surgery

• Complications
1. Rapid Joint destruction
• Secondary Osteoarthritis
• Bony Ankylosis
2. Osteomyelitis
3. Septicemia
• Treatment
• Surgical emergency
• Arthrotomy + Joint debridement +Lavage
• Start antibiotics

Bony ankyloses Fibrous ankylosis

Fusion by bone Fusion by fibrous tissue
No movement Minimal movement
Painless Painful
Xray- crossing of trabeculae absent
Causes
Septic arthritis Tuberculosis
TB spine
Ankylosing spondylosis
Rheumatoid arthritis

67
7. Tom smith arthritis
• Septic arthritis of hip in infants (<1year)
• Fast progressing & very destructive
• Can cause chondrolysis of entire femoral head
• Pain, unable to move limb, fever
• Surgical emergency - Arthrotomy
• Complication
• Destruction of proximal femoral epiphysis
resulting in an unstable hip
• Features of unstable hip
• Shortening
• Limping
• Telescoping of hip

8. Transient synovitis of hip

• Idiopathic self limiting inflammation of synovium of hip
• MC cause of limp in a child
• Age: 4-10 years
• Painful limp
• Fever is rare
• Hip
• Lengthened
• FABER
• Only terminal ROM painful
• X ray- medial joint space widening
• Differentiated from Tom Smith arthritis by Kocher criteria
• Rest and analgesics

KOCHER CRITERIA
NON WEIGHT BEARING
TEMP >38.5O C (101.3O F)
ESR >40 MM/HR
WBC >12,000 CELLS/MM3

9. Flexor tendon tenosynovitis

• Kanavel cardinal signs
1. Fusiform swelling of finger
2. Flexed attitude of finger
3. Tenderness over the flexor tendon
4. Pain on attempted passive extension
• Treatment
• Antibiotics
68
• I & D if necessary
10. Felon
• Infection of pulp of distal phalanx
• Complications
• Osteomyelitis of distal phalanx
• Tenosynovitis flexor tendon
• Incision and drainage + antibiotics

11. Paronychia
• Infection of nail fold (epinychium)
• ‘Run around’
• MC: Thumb
• Treatement
• Antibiotics
• I&D if needed

Section IV b. Skeletal Tuberculosis

• Organism: Mycobacterium tuberculosis
• Always secondary
• MC primary site : Lungs > Viscera
• MC site affected: Spine > Hip > Knee
• MC infection of spine in India : TB > Staph aureus

69
1. TB spine (Tuberculous spondylitis)
• Also called Potts spine
• MC form of skeletal TB (50%)
• MC - Dorsolumbar > Dorsal > Lumbar
• Local features
• Earliest symptom: pain
• Night pain
• Earliest sign: Para spinal muscle spasm
• Military attitude
• Constitutional symptoms
• Low grade fever
• Evening rise of temperature
• Loss of weight and appetite
• Blood investigations – Very high ESR
• MRI – for Potts paraplegia
• CT guided biopsy
• Biopsy - Gold standard

• X-ray findings
• Earliest sign: straightening of spine
• Reduction in disc space
• Destruction of adjacent vertebral end Plates
70
 Types of TB spine
Paradiscal (MC) Adjacent margins of 2
consecutive vertebrae
Reduction in intervertebral
disc space
Central Central part of vertebra
Anterior Spread from abscess to
anterior part of vertebrae
Posterior (Appendicial) Only the posterior elements

Complications
1. Deformity
2. Neurological deficit
• Paraplegia
• Bowel and bladder
3. Bony ankylosis
4. Abscess
• Psoas abscess
• Paravertebral abscess
Kyphotic deformity
• Gibbus
• Externally visible kyphotic deformity in TB
• MC cause of kyphosis in males

Types of TB kyphosis
Knuckle kyphosis 1 vertebra
Angular kyphosis 2-3 vertebra
Round kyphosis > 3 vertebra

Tuberculous paraplegia
• Potts paraplegia
• Damage to the spinal cord due to various causes
• MC associated with –Thoracic TB

Clinical staging of Potts paraplegia

Stage 1 Negligible Patient has only pain and no weakness
Ankle clonus/ extensor plantar/ exaggerated DTR
Stage 2 Mild Has weakness but can walk with support
Stage 3 Moderate Unable to walk but intact bowel and bladder
Stage 4 Severe Unable to walk and lost bowel and bladder

Early onset Late onset

(within 2 years) (after 2 years)
Caseation tissue Internal gibbus
Abscess Sequestrum
Granulation tissue Displaced disc
Edema around cord Debris
Ischemia of cord Severe deformity
GOOD PROGNOSIS POOR PROGNOSIS

Treatment of Pott’s paraplegia

In western countries
• Early surgery (Hong Kong operation)
In India
• Middle path regime - Dr. S.M Tuli
• ATT to start with
71
• Surgery only if
necessary
Middle path regime
Step 1- Bed rest + Spine brace + ATT
Step 2 - Monitoring
Step 3 - Surgery if indicated

Indications of surgery
1. Bowel and bladder involvement
2. Worsening of paraplegia while on ATT
3. Appearance of a new neurological deficit while on ATT
4. No improvement in paraplegia even after 3-4 weeks of ATT

Left Anterolateral decompression

• Parts Removed in T B Decompression
• Rib
• Transverse process
• Pedicle
• Part of vertebral body
• Affected disc
• Bone grafting + fixation

2. Tuberculosis of hip joint

• 2nd MC site of skeletal TB
• MC sites of origin – Roof of acetabulum

72
Sites of origin of TB hip

Stages of TB hip
Stage 1 Synovitis FABER Widening of medial
Apparent lengthening joint
space
Stage 2 Early arthritis FADIR Periarticular
Apparent shortening osteopenia
(<1cm)
Stage 3 Advanced arthritis FADIR
True shortening
(>1cm)
Stage 4 Advanced arthritis FADIR Wandering
with subluxation/ Gross true shortening acetabulum
dislocation Mortar and pestle
appearance
Stage 5 Fibrous ankylosis Very limited painful
movement

X ray findings in TB hip

• Phemister triad
• Joint space narrowing
• Peri-articular Osteopenia (1st x ray change)
• Peripheral Erosions
• Mortar and pestle appearance
• Wandering acetabulum

73
Treatment of TB hip
• Stage 1,2 - Rest + ATT + traction
• Stages 3,4, 5 - Surgery for the destroyed hip + ATT

Surgical options in TB hip

Girdle stone Excision of femoral head • Restores mobility
arthroplasty • Loss of stability
Arthrodesis of hip Surgical fusion of hip joint • Restores stability
• Loss of mobility
Total hip replacement Replacing the hip joint • Restores both mobility and
with prosthesis stability
• Risk of reinfection
• Performed after 10-15 years

3. Tuberculosis knee
• Deformity in advanced TB knee
• Triple deformity
• Posterior subluxation
• External rotation of tibia
• Flexion of knee
4. Miscellaneous TB infections
1. Carries Sicca – Dry type TB shoulder
2. Spina Ventosa – TB dactylitis
3. Poncet’s Disease – Reactive polyarthritis secondary to active TB

74
Chapter V. Metabolic bone diseases
Calcium Homeostasis
• Normal levels : 9-11 mg/dl

Hormones Produced from Stimulus Action

Parathormone Parathyroid glands Hypocalcemia ↑ Calcium
(PTH)
Vitamin D Sunlight Hyperparathyroidis ↑ Calcium
Diet m
Calcitonin C - cells of thyroid Hypercalcemia ↓ Calcium

Conditions causing Secondary

Hyperparathyroidism
• Any condition which reduces serum Calcium levels
1. Vitamin D deficiency
• Rickets
• Osteomalacia
2. Calcium deficiency
3. Chronic Renal failure
PTH action on bone

75
Metabolic diseases of bone

1. Rickets
• Defective mineralization of bone in a skeletally immature child
• Etiology
• Vitamin D deficiency
• Nutritional deficiency
• Malabsorption
• Sunlight deficit
• Renal diseases
• Liver diseases

76
Clinical features

77
 Most common B/L genu varum B/L genu valgum Wind swept
cause (Bow legs) (Knock knees) deformity
Children Rickets Idiopathic > Rickets Rickets
Adults Osteoarthritis > Rheumatoid arthritis Rheumatoid
Rheumatoid arthritis > osteoarthritis arthritis

Blood changes in rickets

• Serum Vit D - ↓
• Calcium - ↓ / N
• PTH - ↑
• Serum PO4 - ↓
• Alkaline Phosphatase (ALP) - ↑

X ray findings in rickets

• Physis - Widening (Earliest change)
• Metaphysis
• Splaying
• Cupping
• Fraying

Treatment of Vitamin D deficiency

STOSS regimen (single dose) 3L – 6L IU deep IM / oral

Weekly Vitamin D 50K – 60 K IU for 8 -12 weeks
High dose daily Vitamin D 2000-5000 IU daily X 4-6 weeks

Evaluation of recovery
• X ray in the best method to assess healing
• White line of Frankel
• Blood tests
• First change - ↑PO4
• End point – normal ALP

78
Treatment of deformities
• Young growing child
• Braces – Mermaid splint
• Older child
• Osteotomy and correction
• Timing of surgery
• After Vit D supplementation
• After x ray shows healing
• After ALP is normalized

2. Osteomalacia
• Defective mineralization of bone in an adult due to Vitamin D
deficiency
• Seen in Young Females
• Symptoms
• Generalized body pain
• Polyarthralgia
• Fatigue
• Blood changes – same as rickets
• Treatment – Vit D supplementation

X ray findings in osteomalacia

• Looser zones
• Milkman fractures
• Pseudo fractures
• Transverse to long axis of bone
• MC site : Neck of femur
• Triradiate pelvis, Trifoil pelvis
• Protrusio acetabuli, Otto pelvis

79
3. Scurvy
• Multisystem disorder resulting from deficiency of Vitamin C
• Vitamin C is essential for hydroxylation of proline and lysine
• Hydroxylysine and hydroxyproline are the raw materials for collagen synthesis
• So, in effect scurvy results in deficiency of collagen

X ray changes in scurvy

• Diaphysis
1. Osteopenia - earliest sign
2. Ground glass appearance
3. Pencil thin cortex
4. Subperiosteal hemorrhage
• Metaphysis
1. Frankel’s white line
2. Trummerfeld zone/ Scorbutic zone / Scurvy line
3. Pelkan spur
• Epiphysis - Wimberger sign

80
Treatment of scurvy
• Vitamin C 1- 2 g OD X 3 days
• Followed by 500 mg OD X 1 week.
• Followed by 100mg OD X 3 months
Barton’s disease
• Vitamin C and Vitamin D deficiency in the same patient

4. Primary Hyperparathyroidism
• Here there is uncontrolled excessive production of Parathyroid hormone from a diseased parathyroid gland.
• Etiology
1. Parathyroid adenoma (MC)
2. Parathyroid hyperplasia
• Pathology
• Excessive PTH production
• Loss of negative feed back

Clinical features of primary hyperparathyroidism

81
Bone changes of hyperparathyroidism

• Blood changes in hyperparathyroidism

• Calcium - ↑↑
• PTH - ↑↑
• Serum PO4 - ↓↓
• Alkaline Phosphatase (ALP) - ↑
• Treatment - Excision of the parathyroid adenoma

5. Renal Osteodystrophy
• Disorder of bone seen in Chronic Renal Failure
• X ray findings - Rugger jersey spine

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• Blood changes
• Calcium - ↓↓
• PTH - ↑↑
• Serum PO4 - ↑↑
• Alkaline Phosphatase (ALP) - ↑
• Serum 1, 25 OH Vit D - ↓
• Treatment
• High dose Vitamin D- 5L IU daily or
• 1,25 OH Vitamin D

6. Osteoporosis
• Condition characterized by decreased bone mass resulting in disruption of bone microarchitecture

Primary osteoporosis Secondary osteoporosis

Senile (MC) Steroids
Postmenopausal Cushing’s disease
Hyperthyroidism
Liver diseases
Chronic renal failure

• Clinical features
• Pain due to micro fractures
• Increased risk of fractures
• Fragility fractures
• Kyphosis of spine
• Dowager’s hump

• X ray findings in spine

• Biconcave vertebra
• Fish mouth appearance
• Lincoln log vertebra

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 Common osteoporotic fractures
Colles #
Vertebral #
Hip #

• DEXA scan
• Dual Energy X-ray Absorptiometry
• Investigation of choice
• Most accurate
• Least radiation
• T score vs Z score
• Interpretation of DEXA score is always comparative
• T – score : Comparison with a normal, race, gender matched individual of 30 years
• Z – score : Comparison with a normal race, gender matched individual of the same age

WHO Classification (T score)

0 to -1 Normal
-1 to -2.5 Osteopenia
< -2.5 Osteoporosis
< -2.5 + fracture Severe osteoporosis

Z score < -2 Osteoporosis

Treatment of osteoporosis

Decreases bone resorption Increases bone formation Both

Bisphosphonates (DOC) Teriparatide Strontium Ranelate
Denosumab Abaloparatide
SERM – Raloxifene Romosuzumab
HRT – Estrogen

Supplements used in osteoporosis

Calcium 800 – 1200 mg/ day
Vitamin D 400 – 800 IU / day
Calcitonin (nasal spray) 200 – 400 IU / day

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Bisphosphonates
• DOC of osteoporosis
• Mechanism
• Pyrophosphate analogues
• Induces osteoclast apoptosis
• Contraindicated in presence of fractures
Teriparatide , Abaloparatide
• PTH analogues
• Mechanism
• Low doses of PTH activates osteoblasts without stimulating osteoclasts
• DOC for severe osteoporosis with Fractures

Denosumab
• Monoclonal AB blocking RANK Ligand

Romosuzumab
• Blocks protein Sclerostin
• Sclerostin stimulates production of RANKL in osteoblasts

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7. Paget’s disease (osteitis deformans)
• Chronic disease of bone remodeling characterized by abnormal osteoclastic activity resulting in replacement
of normal bone with excessive, weak and hyper-vascular bone.
• 5th decade
• Males > females
• Etiology
• Idiopathic
• Paramyxovirus infection
• Phases- Lytic, Mixed & Blastic

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Complications
1. Fractures – Banana Fractures
2. Cranial N palsy – 2,5,7 & 8
3. Deafness - Conductive and sensorineural
4. Spinal canal stenosis
5. High output cardiac failure
• MC cause of death
6. Steal syndrome
7. Osteosarcoma
• 1% risk
• Poorest prognosis

X ray findings in Paget’s disease

• Lytic phase
• Flame shaped /Blade of grass appearance
• Osteoporosis circimscripta
• Mixed phase
• Picture frame vertebra
• Ivory vertebra
• Cotton wool skull
• Blastic phase
• Tam O shanter skull
Tests
• Elevated ALP
• Biopsy - gold standard
• Mosaic pattern

Treatment
• Bisphosphonates : DOC
• Calcitonin - Pain management

8. Osteogenesis imperfecta
• Brittle bone disease / Lobstein Vrolik disease
• Spectrum of disorders characterized by congenital defect in quantity / quality of collagen type I, resulting in
extremely weak bones that present as recurrent, multiple fractures.
• COL 1A gene mutation - AD or AR

Sillence classification

Genetics Defect Sclera Severity

Type 1 AD Quantitative Blue Mildest
Type 2 AR Qualitative Blue Lethal in
perinatal period
Type 3 AR Qualitative Normal Most severe
survivable form
Type 4 AD Qualitative Normal Moderately
severe

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Clinical features
• Skeletal system
• Fractures with slight trauma
• Multiple B/L symmetrical fractures
• MC bone # : femur > tibia
• Normal fracture healing
• #s Malunites causing deformities
• Wormian bones
• Ring shaped epiphysis

• Ocular signs
• Blue sclera
• Saturn ring
• Arcus Juvenilis
• Auditory - Deafness
• Teeth
• Dentigenous imperfecta
• Normal enamel
• Discolored, Brittle teeth
• Lower incisors are most affected

• Medical Treatment
• Bisphosphonates
• Pamidronate IV cyclical therapy till 5years
• Then yearly Zolindronic acid
• Deformity correction
• Realignment osteotomy
• Shish kebab osteotomy
• Scofield Millar operation

88
9. Osteopetrosis
• Marble bone disease or Albers Schonberg disease
• Congenital condition characterized by defective osteoclastic resorption of immature bone that presents with
increased frequency of long bone fractures, cranial nerve palsies, and low back pain
• AD / AR

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X ray findings
• Diffuse sclerosis of bones
• Lack of cortico – cancellous differentiation
• Narrow/ Absent medullary canal
• Erlenmeyer flask appearance of distal femur
• Endobones (‘Os in Os’ appearance)
• Sandwich vertebrae

Summary of lab Calcium PTH PO4 ALP

findings
Rickets / ↓/N ↑ ↓ ↑
Osteomalacia
Primary ↑↑ ↑↑ ↓↓ ↑
hyperparathyroidism
Renal ↓ ↑ ↑↑ ↑
osteodystrophy
Paget’s disease N N N ↑
Osteoporosis N N N N

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 Chapter VI. Pediatric orthopaedics

Section VI a. Congenital anomalies

1. Klippel Feil Syndrome
• Triad of
• Short neck
• Low hair line
• Restricted neck movement
• Cause – failure of segmentation of cervical vertebra resulting formation of a block vertebra

2. Sprengel Shoulder
• Congenital Undescended scapula
• Omovertebral bone – abnormal connection between scapula and cervical spine which prevents normal
descend of scapula
• Clinical features
• High scapula
• Small, triangular scapula
• Restriction of abduction

• Treatments
• Woodward operation
• Green’s operation
• Age : 3 – 8 years

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3. Congenital Muscular Torticollis
• Wry neck due to congenital contracture of sternocleidomastoid muscle
• Idiopathic - Limited compartment syndrome of SCM
• Clinical features
• Cock Robbin appearance
• Head tilted to same side
• Face and chin tilted to opposite side
• Thick contracted SCM
• Palpable nodule (SCM tumor)

• Treatment
• Spontaneous resolution
• < 1 year
• Stretching
• > 1 year
• Unipolar release – mild
• Bipolar release – severe

4. Poland Syndrome
• Congenital, unilateral absence of Pectoralis major
• MC congenital absence of muscle
• Risk factor – Maternal Diabetes

5. Cleidocranial Dysostosis
• Congenital absence/ hypoplasia of clavicles
• Autosomal dominant
• Defect in intramembranous ossification
• Ability to approximate the shoulders
Anteriorly

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6. Madelung deformity
• Deformity of wrist due to disruption of the ulnar volar physis of the distal radius
• Seen in adolescent girls
• Deformity
• Distal radius
• Shortened
• Will have an ulno-volar curvature
• Distal ulna
• Lengthened

• Etiology
• Idiopathic
• Vicker’s ligament
• Treatment
• Asymptomatic
• Physiotherapy
• Symptomatic
• Corrective osteotomy of radius +
• Shortening osteotomy of ulna

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7. Congenital knee dislocation

• Congenital severe genu recurvatum

8. Congenital dislocation of patella

• ‘Smiley face’ paella

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9. CTEV (Congenital Talipes Equinus Varus)
• MC congenital anomaly in India : CTEV
Classical deformities
C Cavus Exaggerated medial long. arch
A Adductus Exaggerated forefoot adduction
V Varus Exaggerated subtalar inversion
E Equinus Exaggerated ankle plantar flexion
• Internal tibial torsion
• Reduced girth of leg

Etiology
• Primary
• Idiopathic (MC)
• Secondary
• Neurological disorders
• Spina bifida
• Meningomyelocele
• Myelodysplasia
• Poliomyelitis
• Syndromes
• Arthrogryposis Multiplex Congenita
• Larsen’s syndrome
Pathoanatomy

95
Dorsiflexion test
• Screening test for a new born
• In a neonate it must be possible to dorsiflex the foot and touch the anterior aspect of leg
• If its not possible then it indicated CTEV

Mild Mod Severe

Mid foot score
Medial crease 0 0.5 1
Curved lateral border 0 0.5 1
Talar head reducibility 0 0.5 1
Hind foot score
Posterior crease 0 0.5 1
Empty heel 0 0.5 1
Rigid equinus 0 0.5 1

Treatment of Club Foot

0 -1 year Joints and soft tissues supple Ponseti technique
1-3 years Soft tissue contractures Posteromedial soft tissue
release
(PMSTR)
Turco’s procedure
3-5 years Soft tissue contractures + PMSTR +
Forefoot adduction is fixed Dilwyn Evan’s procedure
5-8 years Soft tissue contractures + PMSTR +
Forefoot adduction is fixed + Dilwyn Evan’s procedure +
Varus is fixed Dwyer’s osteotomy
8- 10 years All deformities are fixed Wedge tarsectomy
> 10 years Grossly deformed foot and ankle Triple arthrodesis

Ponseti’s method
• Developed by Dr. Ignacio Ponseti
• Success rate : >90 %
• Principle
• Serial manipulation and casting
• Above knee casts
• Cast changed every week

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• First cast
• Should be applied ASAP
• Practically around 2 weeks of age
• First step is correction of Cavus
• Subsequent casts
• Correction of Varus and Adduction
• Manipulation done with Talar head as fulcrum
• Last step
• Correction of Equinus

Maintenance of correction
1. Dennis brown splint
• Foot maintained in abduction and dorsiflexion
• Full time wearing till 1year of age
• Night time wearing till 5 years of age
2. CTEV shoes
• Day time wearing from the time starts to walk till 7 years

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PMSTR
• Open the poseromedial aspect of foot and ankle and
• Release of all contracted structure in the medial and posterior aspects of foot and ankle
• Turco’s procedure

Dilwyn Evan procedure

• Lateral column shortening +
calcaneocuboid fusion

Dwyer’s osteotomy
• Lateral closing wedge osteotomy of Calcaneus

Triple arthrodesis
• Surgical fusion of
• Sub talar joint
• Calcaneocuboid joint
• Talonavicular joint
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10. Congenital vertical talus
• Rocker bottom foot

Radial club hand

11. Radial club hand

• Radial Hemimelia
• Congenital partial / total absence of radius usually along with thumb
• Associations
• TAR syndrome
• Fanconi syndrome
• VACTRL syndrome
• Holt Oram syndrome
• Trisomy 13
Section VI b. Pediatric hip disorders
Coxa vara
Its defined as a Neck shaft angle < 120

Congenital Acquired
Congenital Coxa Vara Slipped Capital Femoral Epiphysis
Perthe’s disease
Rickets
Post traumatic

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Clinical features of coxa vara
• Adduction, External rotation deformity
• Limitation of Abduction and Internal rotation
• Shortening
• Trendelenburg sign +ve
• Axis deviation
• Knee axilla sign
• Obligatory external rotation

Trendelenburg test
• Single leg stand on normal side
• Opposite pelvis moves up
• Single leg stand on affected site
• Normal pelvis sag down

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1. Congenital Coxa Vara
• Ossification defect in inferior femoral neck
• Clinical features
• Age: 1-6 years
• Painless limp
• Signs – of coxa vara

• X ray
• Vertical physis
• Fairbank’s triangle
• Treatment
• Mild – observation
• Severe – valgus osteotomy

2. Slipped Capital Femoral Epiphysis

• Transphyseal separation and slipping of the epiphysis relative to proximal femur
• Direction of slip - Posteriorly and inferiorly
• Age: Around time of puberty (12 -16 years)
• Etiology : Idiopathic

Risk factors
Obesity (MC risk factor)
Hypothyroidism
Hypogonadism
Growth Hormone over-suplimentation
Renal osteodystrophy
Prior radiation

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• Symptoms - Painful Limp
• Clinical features
• All features of coxa vara
• Increased extension and decreases flexion
• X –ray : Trethowan’s sign
• Klein’s line not passing through the capital femoral epiphysis
• Klein’s line is the line drawn along the upper border of the neck of femur
• Treatment - In situ percutaneous screw fixation

3. Developmental Dysplasia of hip

• Spectrum of disorders characterized by acetabulum of inadequate depth resulting in unstable/ subluxed /
dislocated hip in a child
• MC congenital anomaly world wide

Risk factors of DDH

• First born
• Female
• Fetal malposition
• Breech
• Frank breech (MC)
• Family history
• Oligohydramnios
• Amniotic Fluid deficiency
Clinical features of DDH
• Symptoms
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• Limitation of abduction
• Asymmetrical thigh folds
• Shortening
• Limping

Signs of DDH

Less than 3 months 3 months to 1 year More than 1year

Limitation of abduction Limitation of abduction Shortening
Asymmetric thigh folds Shortening Toe walking
Barlow test Klisic test Trendelenburg sign
Ortolani test Allis ( Galeazzi) sign Trendelenburg gait
Vascular sign of Narath +

Ortolani test
• Test for Dislocated Hip
• Procedure – examiner reduces the hip and the entry of femoral head into acetabulum produces a click
• Click of entry

Barlow test
• Test for Dislocatability / Instability
• Provocative test
• 2 steps
• Step 1
• Flex, Adduct and axial force to dislocate the hip (click of exit)
• Step 2
• Abduct to relocate the hip
• Similar to Ortolani
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Allis sign
• Galeazzi sign
• Knee at a lower level due to posteriorly dislocated femoral head
• Positive only in unilateral cases
Klisic test
• Used in Bilateral DDH
• Line is drawn ASIS and tip of GT
• Normal – line passes at or above umbilicus
• DDH – line passes below umbilicus

Investigations
• X ray – dislocated hip
• USG – best screening test up to 4m of age
• MRI – for planning surgery
• Arthrogram

Treatment of DDH
0-6 months Pavlik harness, Von Rosen splint
6 – 18 months Closed reduction + Hip spica cast
• Bachelor cast
• Human position
After 18 months Surgery

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4. Perthe’s disease
• Idiopathic reversible avascular necrosis of femoral capital epiphysis in a child
• Characterized by femoral head destruction followed by reformation
• 4-8 years
• Male: female – 5:1
• Etiology – unknown

Clinical features
• Symptoms
• Painless limp
• Progresses to painful limp
• Signs – of coxa vara
X ray findings
• Fragmentation of femoral capital epiphysis
• Collapse of epiphysis
• Crescent sign – because of Subchondral Collapse

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Treatment
• Rationale
• Preserve shape of head till revascularization
• Non weight bearing
• Methods
• Petrie cast / Broomstick cast

Section VI c. Pediatric knee disorders

• Normal : 7° valgus
• Genu Valgum
• Genu Varum
• Genu Recurvatum
• Wind Swept Knees

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1. Genu Valgum
• Knock knees (B/L genu valgum)
• Intermalleolar distance > 8cm

Causes of genu valgum

Bilateral Unilateral
Idiopathic (MC) Physeal injuries
Physiological • Trauma
Renal rickets • Infection
• Ischemia
Skeletal dysplasia Malunited fractures
Rheumatoid arthritis Tumors
( MC in adults) • Fibrous dysplasia

2. Genu Varum
• Bow legs : B/L genu varum
• Intercondylar distance > 6cm

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 Causes of genu varum
Bilateral Unilateral
Nutritional rickets (MC) Blount’s disease

Physeal injuries
• Trauma
Physiological • Infection
Mucopolysaccharidosis • Ischemia
Blount’s disease
Osteoarthritis Malunited
(MC in adults) fractures

3. Genu Recurvatum
• Pathological hyper extension of knee > 5°
• Causes
• Ligamentous hyperlaxity
• Congenital knee dislocation
• Poliomyelitis
• Muscular dystrophy
• Arthrogryposis
• Blount’s disease

4. Blount’s disease
• Infantile Tibia Vara
• Idiopathic osteochondrolysis of medial proximal tibial physis and epiphysis resulting in progressive genu
varum
• Triad
• Tibia Vara
• Genu Recurvatum
• Internal Tibial Torsion
• Clinical features
• Bow legs
• Siffert Katz sign +
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• X-ray
• Metaphyseal beaking
• Metaphyseo diaphyseal angle of Drennan > 11°
• Treatment
• Mild - Brace
• Severe - Proximal tibia valgus Osteotomy

Section VI d. Pediatric trauma

Important MCQs
• MC fracture in children : Distal radius
• 2nd MC fractures in children: Hand
• MC fracture at birth : Clavicle
• MC dislocation in children : Elbow
• MC elbow fracture in children: SC #
Humerus

Types of pediatric fractures

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1. Plastic deformation
• Permanent deformity of bone without fracture
• MC bone involved - Ulna
• Treatment - Correct deformity and cast

2. Green stick fracture

• Unicortical fracture
• Bending force
• Treatment
• Osteoclasis + fracture reduction +cast

3. Torus fracture
• Buckle fracture
• Caused due to Axial loading
• Occurs at the metaphyseo – diaphyseal junction
• Treatment - Traction + Casting

4. Layers of the physis

• Germinal layer – most important
• Proliferative layer
• Hypertrophic layer - weakest
• Layer of enchondral ossification

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5. Salter Harris Classification of physeal injuries

5a. Type I physeal injury

• X- ray will be normal
• Usually a clinical diagnosis
• MRI – marrow edema
• Treatment
• Only Cast application
• Prognosis : Best
5b. Type II physeal injury
• X ray
• Sail sign
• Thurston Holland fragment
• Treatment
• Closed reduction
• Casting
• Prognosis : good

111
5c. Type III, IV physeal injuries
• Problems
• Intra articular
• Proliferative and germinal zones injured
• Treatment
• Undisplaced – cast
• Displaced – closed / open reduction + internal fixation
• Prognosis – Variable

5d. Type V physeal injury

• Retrospective diagnosis
• Worst prognosis as there is risk of developing
• Shortening or
• Angular deformities
• Treatment
• Osteotomy and correction of
deformities
• Limb lengthening surgery
112
6. Miscellaneous pediatric fractures
• Tillaux fracture – SH type 3
• Triplane fracture – SH type 4
• Toddler fracture - Spiral oblique fracture of distal 2/3rd of tibia
• Metaphyseal corner fracture -
Pathognomonic of Battered baby syndrome

113
 Chapter VII. Nerve injuries

Section VII a . Basics

114
2. Pathophysiology of nerve injury

4. Tinel’s sign
• Percussion along the course of a nerve from distal to proximal induces tingling sensation at the site of a
neuroma
• Seen in both Neuroma in continuity and End neuroma
• Non – progressive Tinel’s sign is seen in end neuroma
• Progressive Tinel’s is seen in Neuroma of continuity
5. Motor march
• Progressive recovery of muscles from proximal to distal
• Seen in neuroma in continuity

6. High vs Low nerve injury

• Higher the level of injury worse the disability and deformity
• Lower the level of injury lesser the disability and deformity
• Exception : Ulnar Paradox

7. Classification of nerve injuries

SEDDON SUNDERLAND
classification classification
Neuropraxia I
Axonotmesis II
III
IV
Neurotmesis V

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7a. Neuropraxia
• Temporary conduction block
• No anatomical damage
• Incomplete loss of function
• Tinel’s sign negative
• Prognosis – BEST
• Full recovery in around 6 weeks
Treatment of neuropraxia
• Wait for spontaneous recovery
• Prevent contractures
• Splints
• Passive exercises

7b. Axonotmesis

• Axon is cut but at least one sheath is intact

• Wallerian degeneration takes place
• Neuroma in continuity
• Progressive Tinel’s sign
• Rate of regen – 1 mm /day
• Motor march is seen
• Prognosis – Variable

Treatment protocol

116
7c. Neurotmesis
• Axon along with all three sheaths cut
• End neuroma
• Non – progressive Tinel’s sign
• Motor march is absent
• Worst prognosis
• Treatment – Nerve repair

Types of Nerve repair

Primary repair < 6 hours • Clean incised cut
• Early presentation
Delayed primary repair 7- 18 days • Late presentation
• Unclean
• Crushed edges
Secondary repair > 18 days

8. Investigations
• Neve Conduction Study (NCS)
• Investigation of choice
• Electromyography (EMG)
• Earliest indicator of nerve injury

9. Prognostic factors of nerve injury

G Growing age
O Growing age
O Only sensory
D Distal lesion

N Neuropraxia
E Early repair
R Radial N
V Vascularity maintained
E End to end repair

Nerve with best prognosis

Radial Nerve

117
 Nerves with worst prognosis
Sciatic Nerve
Ulnar Nerve

10. Sunderland classification

Axon Endo Peri Epi

Section VII b. Injuries of specific nerves

1. Axillary nerve injuries

• Origin –Posterior cord
• Root value – C5, C6
• Land mark– Neck of humerus
• Motor supply
• Deltoid
• Teres minor
• Sensory supply
• Lateral cutaneous nerve of arm

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• Causes of injury
1. Shoulder dislocation (MC)
2. Fracture neck of humerus
3. Iatrogenic
4. I/M injections
• Motor deficit

• Deltoid paralysis
• Loss of shoulder abduction
• Between 15° - 90°
• Teres minor paralysis
• Asymptomatic
• Sensory loss
• Over the upper lateral arm
• Regimental Badge sign
• Deformity - Adduction of shoulder
• Treatment - Abduction splint

119
2. Musculocutaneous nerve injury
• Origin – Lateral cord
• Root value – C5, C6, C7
• Motor supply
• Biceps
• Brachialis
• Coracobrachialis
• Sensory supply
• Lateral cutaneous N of forearm

• Causes of injury
1. Shoulder dislocation
2. Iatrogenic
3. As part of brachial plexus injury
• Motor deficit
• Brachialis paralysis

• Weakness of flexion of elbow

• Biceps paralysis
• Weakness of supination of forearm
• Weakness of flexion of elbow
• Sensory loss
• Lateral aspect of forearm

120
3. Median Nerve injuries
• Origin – Lateral And Medial Cords
• Root value – C5, C6, C7, C8, T1
• Motor supply

Forearm – Superficial Forearm – Superficial Hand

Pronator Teres Flexor Digitorum Profundus – Abductor Pollicis
Lateral 1/2 Brevis
Flexor Carpi Radialis Flexor Pollicis Longus Flexor Pollicis Brevis
Palmaris Longus Pronator Quadratus Opponens Pollicis
Flexor Digitorum Superficialis Lumbricals 1, 2

• Sensory supply
• Lateral 2/3rd of palm
• Lateral 3 . fingers palmar aspect
• Tips of 3 . fingers dorsal aspect
• Carpal tunnel syndrome
• Palmar cutaneous branch is spared
• Paresthesia of only the fingers
• Autonomous zone
• Area of skin exclusively supplied by a single nerve
• Median N – Tip of Index finger

Scenario 1 - Median nerve injury at the wrist

• Muscles involved
• Abductor Pollicis Brevis – Loss of thumb abduction
• Flexor Pollicis Brevis – Loss of thumb flexion
• Opponens Pollicis – Loss of thumb opposition
• Ape thumb deformity
• Thumb lies in the same plane as palm
• Pen test - Test for Abductor Pollcis Brevis
• Treatment - Opponens splint

121
Scenario 2 - Median Nerve injury at elbow
• Features of Median N injury at wrist +
• FDS paralysis
• Loss of flexion of PIP joint of all fingers
• FDP medial . will cause some flexion of PIP of ring and index
finger
• FDP – Lateral . paralysis
• Loss of flexion of DIP joint of Index finger and middle finger
• FPL paralysis
• Loss of flexion of IP joint of thumb

Signs of high median N palsy

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Tests for Anterior Interosseous Nerve

OK sign / Kiloh Nevin sign

4. Ulnar nerve injuries

• Origin – medial cord
• Root value – C8, T1
• Motor supply

Forearm Thenar Muscle Hypothenar Muscles Others

Flexor Carpi Ulnaris Adductor Palmaris Brevis All Palmar Interossei
Pollicis
Flexor Digitorum Abductor Digiti All Dorsal Interossei
Profundus Minimi
- Medial .
Flexor Digiti Minimi Lumbricals 3, 4
Opponens Digiti
Minimi

• Sensory supply
• Medial 1 . fingers and corresponding area of hand dorsally and palmarly
• Autonomous zone
• Tip of little finger

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Scenario 1 - Ulnar nerve injury at the wrist

Features of Ulnar N palsy

Muscle involved Loss of function Tests/ signs
3rd , 4th Lumbricals Flexion At MCP Joint • Claw Hand
Extension At IP Joints
Adductor Pollicis Adduction Of Thumb • Book Test
• Froment’s Sign
All Palmar Interossei Finger Adduction • Card Test
• Wartenberg sign
All Dorsal Interossei Finger Abduction • Egawa Test

Claw hand deformity

• Paralysis of 3rd, 4th Lumbricals
• Over action of EDC and FDP
• Other names
• Intrinsic minus deformity
• Mein en Griffe

• Partial claw hand

• Isolated Ulnar N Injury
• Complete claw hand
• Ulnar N + Median N Injury
• Klumpke’s paralysis
• Treatment – Knuckle bender splint

124
Book test and Froment’s sign

• Book test - Inability to hold on to a book between thumb and palm against resistance
• Froment’s sign - Tricking the Book test by flexing the IP joint which is done by FPL supplied
by Median N

Card test
• Test for Palmar Interossei
• Inability to hold onto a card placed in between fingers against resistance

Wartenberg sign
• Paralysis of Palmar Interossei to little finger
125
• Inability to bring the little finger close to the middle finger

Egawa test
• Test for Dorsal Interossei to middle finger
• Inability to move the middle finger sideways

Scenario 2 - Ulnar nerve injury at the elbow

• All features of ulnar N injury at wrist will be present but the following are the differences
1. The clawing will be less as the FDP medial half which is responsible for the hyperflexion of IP joints is also
paralyzed - Ulnar N paradox
2. Weakness of ulnar deviation of wrist due to FCU paralysis

5. Radial nerve injuries

• MC nerve injury
• Best prognosis
• Origin – posterior cord
• Motor supply – refer table
• Sensory supply
• Posterior aspect of arm and forearm
• Dorsal aspect of lateral 3 . fingers
• Autonomous zone
• Dorsum of 1st web space

Axilla Arm Forearm

Triceps Triceps Extensor Carpi Radialis Brevis
Long (Med and Lat head)
Head Anconeus Supinator
Brachioradialis Extensor Digitorum
Extensor Carpi Extensor Digiti Minimi
Radialis Longus
Extensor Carpi Ulnaris
Extensor Pollicis Longus
Extensor Pollicis Brevis
Abductor Pollicis Longus
Extensor Indices

126
Radial N injury
Features
• Wrist drop
• Finger and thumb drop
• Sensory loss
Causes
1. Crutch palsy
2. Saturday night palsy
3. Holstein Lewis fracture
4. Iatrogenic

• Crutch palsy
• Occurs while using a long crutch
• Pressure of the upper end of the crutch on the Radial N causes damage.
• Saturday night palsy
• Occurs while sleeping on a barstool in inebriated state with arm hanging on top the back rest.

127
PIN palsy
Features
• Finger & thumb drop
• No sensory loss
Causes
1. Fracture radial neck
2. Radial head dislocation
3. Monteggia fractures

Treatment of Radial N injuries

• Cock up splint
• Static
• Dynamic

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6. Erb’s palsy
• Upper brachial plexus injury
• C5, C6, (C7) roots involved
• Injury to Erb’s point
• Deformity
• Shoulder adduction
• Shoulder IR
• Elbow extension
• Forearm pronation
• Wrist palmar flexion
• Finger flexion
• Deformity
• Waiter’s tip deformity/
• Policeman tip deformity/
• Porter’s tip deformity
• Treatment
• Aero plane splint

7. Klumpke’s palsy
• Lower brachial plexus injury
• C8, T1 involved
• Main nerves involved
• Ulnar N
• Median N
• Sympathetic from T1
• Hyperabduction injury
• Clinical features
• Complete claw hand
• Horner’s syndrome
• Components of Horner's syndrome
• Ptosis
• Loss of Ciliospinal reflex
• Enophthalmos
• Miosis
• Anhydrosis

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8. Long Thoracic Nerve injury
• Also called - Nerve of Bell
• Supplies Serratus anterior
• Functions of Serratus anterior
• Protraction of shoulder
• Overhead abduction of shoulder
• Stabilization of medial border of scapula
• Paralysis causes ‘Winging of scapula’
• Abnormal prominence of medial border of scapula while attempting to push against a wall

9. Common Peroneal Nerve injury

• Branch of Sciatic N
• Root value : L4, L5, S1, S2
• Branches
• Superficial Peroneal N
• N of the lateral compartment of leg
• Supplies the evertors of foot
• Deep Peroneal N
• N of the anterior compartment of leg
• Supplies dorsiflexors of foot
• Causes of CPN palsy
• Trauma around fibular neck
• Fibular neck fracture
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• Knee dislocation
• Tumors
• Hansen’s disease

• Clinical features of CPN palsy

• Foot Drop – due to palsy of dorsiflexors and evertors of foot
• High stepping Gait
• Sensory loss
• Dorsum of foot
• 1st web space
• Treatment
• Foot drop splint

Section VII c. Compression Neuropathies

• Nerve dysfunction that occurs due to chronic compression of nerves by surrounding anatomical structures.

Carpal Tunnel Syndrome Median N

Pronator Teres Syndrome Median N
Struther’s Syndrome Median N
Cubital Tunnel Syndrome Ulnar N
Guyon’s Canal Syndrome Deep branch of Ulnar N
Cheiralgia Paresthetica Superficial Radial N
Thoracic Outlet Syndrome Lower trunk of Brachial plexus
Subclavian vessels

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 Piriformis Syndrome Sciatic N
Meralgia Paresthetica Lateral femoral
cutaneous N
Tarsal Tunnel Posterior Tibial N
Syndrome
Morton’s Interdigital N of
Metatarsalgia 3rd web space

Carpal Tunnel Syndrome

• Compression of Median N in the carpal tunnel of wrist
• MC compression neuropathy
• Carpal tunnel
• Floor – Deep Carpal arch
• Roof – Flexor Retinaculum
(Transverse Carpal Ligament)

MC associations
• Hypothyroidism
• Diabetes
• Rheumatoid arthritis
• Pregnancy
• Acromegaly
• Gout
• Alcoholism
• Amyloidosis
• Sarcoidosis
• Malunited Colles fracture

Clinical features
• Female : male – 8:1
• Age : 30 – 60 years
• Symptoms
• Paresthesia/ pins and needles /burning sensation
• Over lateral 3 . fingers
• Worst at night - Sleep disrupted
• Shake sign
• Weakness of grip in late stages

Clinical tests for CTS

1. Phalen’s test
2. Reverse Phalen’s test
3. Durkan’s test
4. Tourniquet test
5. Closed fist sign
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Phalen’s test
• Wrists are kept in forced palmar flexion
• Hold for 60 seconds
• Reproduction of symptoms – positive test

Reverse Phalen’s test

• Wrists are kept in forced dorsiflexion
• Hold for 60 seconds
• Reproduction of symptoms – positive test

Durkan test
• Carpal tunnel compression test
• Median N compression test
• Direct compression over the carpal tunnel for 30 seconds
• Reproduction of symptoms – positive test
• Best clinical test

Treatment of
• Night time use of wrist splints
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• Steroid injections
• CTS release surgery

Thoracic Outlet Syndrome

• Compression of NV structures between Clavicle, 1st rib and Scalene muscle
• Structures compressed
• Brachial plexus (95%)
• Subclavian A and V
• Causes
• Scalenus anterior syndrome
• Manual laborers
• Body builders
• Cervical rib
• Malunited clavicle fractures

Clinical features
• Nerve compression (MC)
• C8, T1
• Weakness of muscles of hand
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• Paresthesia of medial aspect of forearm, hand
• Venous congestion
• Edema of upper limb
• Arterial occlusion
• Cold upper limb, Cyanosis & Pa

Tests for TOS

• Adson’s test
• Shoulder slightly abducted and extended
• Head tilted to same side
• Look for Reduction in radial Pulse volume
• Reverse Adson’s test (Halstead test)
• Similar to Adson’s test
• But head tilted to opposite side
• Wright’s Hyper abduction test
• Shoulder is hyper abducted and examined for loss of radial pulse volume
• Roos test
• Patient abducts and externally rotates the shoulder and holds the position
• He clenches and opens his fists for 60 sec.
• Pain indicates positive test

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 Chapter VIII. Disorders of Spine
Basics anatomy
Spinal column
• 33 vertebrae
• Intervertebral Discs
• Spinal cord
• Ends at L1
• 31 pairs of spinal nerves

Structure of a Vertebra

136
Pars Interarticularis

Small strip of bone that links facet joints of a vertebra

with the facet joints of the vertebra below it.

Section VIII a. Trauma to spine

MCQs

• MC cause – Fall From Height

• MC cause in India – Fall From Height
• MC cause in developed countries – RTA
• MC area of spine to be fractured – Lower Thoracic
• MC vertebra fracture –D12
• MC mechanism of injury – Flexion >Flexion rotation
Cervical spine injuries
• MC fracture associated with spinal cord injury
• MC vertebral dislocation
• C1, C2 fractures are special because of unique shape

1. Jefferson’s fracture
• Burst fracture of ring of Atlas (C1) vertebra
• Mechanism – Vertical compression
• Neurological deficit is rare
• Treatment - Philadelphia collar

2. Hangman’s fracture
• Traumatic spondylolisthesis of C2 over C3
• Often fatal
• Mechanism - Judicial hangings / RTA
• Highly unstable fracture
• High chance of cord injury
• Treatment - Surgical fixation

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3. Odontoid fracture
• Fracture of the dens of Axis (C2) vertebra
• Cause – RTA
• Mechanism – Hyperextension of neck

Anderson – D’ Alonzo classification

• Watershed area
• High chance of nonunion
• Screw fixation

4. C3 to C7 fractures
• Compressive flexion – Tear Drop Fracture
• Vertical compression – Burst Fracture

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5. Clay Shoveler’s
• Avulsion fracture of spinous process of one / more of lower cervical/ upper thoracic vertebra
• MC involved – C7

6. Whiplash injury
• Ligamentous injury of the cervical spine due to sudden hyperextension followed by hyperflexion
• Rear end car collision
• Clinical features
• Neck pain
• Restriction of neck movements
• No neurological deficit

• X ray – normal
• MRI – ALL tear
• Treatments - Cervical collar and Analgesics

7. SCIWORA
• Spina Cord Injury With Out Radiographic Abnormality
• Seen in children
• Presents with para/ quadriplegia but X-ray will be normal
• Mechanism : In children bones are flexible so it absorbs the
energy without fracture, however the spinal cord is not stretchable, hence cord edema develops
• MRI – investigation of choice

139
8. Thoracolumbar spine fractures
CLASSIFICATION based on mechanism of injury
1. Wedge compression fracture – associated with osteoporosis
2. Stable burst fracture
3. Unstable burst fracture
4. Flexion distraction injury
5. Translation fractures - Worst prognosis
6. Chance fracture

9. Chance fracture
• Seat (lap) belt injury
• Cause – RTA
• Front end collision
• Sudden deceleration
• Folding over of spine
• Jackknife fracture
• Types
• Soft tissue Chance injury
• Bony Chance fracture
• Features
• Unstable fracture
• Risk of cord damage
• Treatment
• Surgical fixation

140
10. Stabilization of spine fractures

Philadelphia collar Four post collar

Taylor’s brace ASH brace

11. Surgical spine fixation

• Pedicle screw fixation
• Moss Miami fixation

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Section VIII b. Miscellaneous spine conditions
1. Inter Vertebral Disc Prolapse (IVDP)
• Tear in the annulus fibrosis resulting in prolapse of nucleus pulposus causing compression of adjacent nerve
roots

Symptoms
• Back pain
• Bladder symptoms
• Radiculopathy
• Radiating pain
• Sensory loss
• Motor weakness
Clinical tests for IVDP
• Straight leg raise (SLR) test
• Lasegue’s sign
• Raising the affected leg with knee in extension causes
pain
• Crossed SLR
• SLR on contralateral side causes pain on the affected side
• Pathognomonic of IVDP

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• Investigation
• X ray – reduced disc space
• MRI - IOC
• Treatment
• Bed rest , analgesics , physiotherapy
• Epidural steroid injection
• Discectomy

2. Spondylolysis
• Defect in the Pars Interarticularis
• Unilateral
• Bilateral
• Risk of spondylolisthesis

• MC site – L5
• Adolescent athletes
• Back pain
• Complication – Spondylolisthesis
• Treatment
• Rest
• Spinal brace

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3. Spondylolisthesis
• Anterior subluxation of a vertebra over its inferior vertebra due to defect in Pars Interarticularis
• Complications
• Instability of the spine
• Nerve compression
• MC site : L5 – S1

• Symptoms
• Back pain radiating to one LL
• Buttock pain
• Cauda equina syndrome
• Signs
• Heart shaped buttocks
• Low midline sill
• Palpable step off

X ray findings
Lateral view
• Subluxed vertebrae AP view
• Inverted Napoleon hat sign Oblique view
• Beheaded Scotty dog Appearance

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Meyerding Classification

Management of spondylolisthesis
• Rest
• Spinal brace
• Physiotherapy
• Surgery

4. Lumbar Canal Stenosis

• Chronic Condition characterised by narrowing of Lumbar Spinal Canal causing compression of spinal cord or
its emerging nerve roots.
• MC location : L4- L5
• Age: > 65 years
• Males > females
Causes
1. Degenerative/spondylotic changes (MC)
2. IVDP
3. Post-surgical
4. Vertebral fractures
5. Inflammatory - Ankylosing Spondylitis
6. Secondary to systemic diseases
• Paget Disease
• Acromegaly
• Fluorosis

Clinical features
• Neurogenic claudication
• Buttock pain
• Bowel & bladder symptoms

145
Neurogenic claudication
• Back pain radiating to lower limbs which is worsened on activity especially walking
• Characteristic feature of the pain is that it will
• Worsen with spine extension
• Walking downhill
• Descending stairs
• Get relieved by spine flexion
• Walking uphill
• Climbing stairs
• Forward bending
• Shopping cart sign

Claudication Vascular Neurogenic

Provocative factor Walking Walking
Pain character Cramping Numbing / Aching
Direction of Distal – Prox Prox – Distal
radiation
Walking uphill Painful Painless
Bicycle test Positive Negative
Pulse Abnormal Present
Skin Loss of hair, Shiny Normal
Weakness Rare Occasional
Back movements Normal Restricted
Atrophy Common Rare

5. Scoliosis
• Lateral bending of spine usually associated with a rotational deformity

146
Adam’s forward bending test
• Helps differentiate structural scoliosis from non structural scoliosis
• On forward bending
• Non structural scoliosis
• Deformity disappears
• Structural scoliosis
• Deformity persists and
• Prominent rib develops hump on one side

Adolescent Idiopathic Scoliosis

• MC type of scoliosis
• Progressive scoliosis seen in adolescents
• Unknown etiology
• Female : male – 10:1
• 10 – 18 years

School screening of scoliosis

• Routinely done for adolescent girls in western countries
• Extension of Adam forward bending test
• Use of Scoliometer / Inclinometer
• Value > 7 – patient is referred to a spine Surgeon

Cobb’s angle
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• Used for measuring the scoliosis
• On a AP X-ray of spine
• Angle between a line passing along the upper end plate of
upper end vertebra and a line passing along he lower end
plate of lower end vertebra
• End vertebrae are the ones that are maximally tilted to
midline
• Apical vertebra is the vertebra that is maximally deviated
away from midline
• Uses
• Plan treatment
• Access the progression

Braces in scoliosis

Milwaukee brace
• CTLSO brace
• Apex above T7
• Worn through out the day
• Good results
• Poor compliance

148
Boston brace
• TLSO brace
• Apex T8 and below
• Can be worn under the dress
• More compliance

Charleston bending brace

• For night time wearing

Surgical procedure
• Correction of scoliosis
• Fixation with pedicle screws and Harrington rods

149
 Chapter IX. Joint Disorders

1. Osteoarthritis
• Degenerative disease of joint that causes progressive loss of articular cartilage
• MC joint disorder
• Based on etiology
• Primary
• Secondary
Primary Osteoarthritis
• Idiopathic osteoarthritis
• Associated with aging process
• Types
• Localized - Knees > Hips
• Generalized – Hands

Secondary osteoarthritis
• Underlying cause that damages the cartilage
• Causes
1. Intra articular fractures
2. Meniscus / Cartilage injury
3. Septic arthritis
4. Avascular Necrosis
5. Perthe’s disease
6. SCFE

Pathology of OA

150
Clinical features of knee osteoarthritis
• Pain
• Pain after activity
• Night pain
• Stiffness
• Deformity - Genu Varum (MC)
• Locking - Associated with loose bodies
• Signs
• Tenderness around the joint line
• Pain on both active and passive movement
• Crepitus

X ray findings
• Joint space narrowing - Earliest
• Deformity
• Subchondral cysts
• Sclerosis of bone ends
• Osteophytes
• Loose bodies

151
Treatment
1. Conservative methods
• Weight reduction
• Activity modification
• Physiotherapy
• Knee braces
2. Medications
• NSAIDs
• Glucosamine sulphate
• Diacerin
• Chondroitin sulphate
3. Minimally invasive methods
• Intra articular injections
• Hyaluronic acid
• PRP
• Steroids
• Arthroscopic joint wash out
4. Surgical
• Total Knee Arthroplasty
• Done in end stage OA knee

2. Rheumatoid Arthritis
• Chronic autoimmune multisystem disease where the primary involvement is of the musculoskeletal system
• MC Inflammatory Arthritis
• Primarily synovial disease
• Symmetrical joint involvement

Joints involved
• MCP (MC) > wrist > PIP
• DIP spared
• Knees > Hip
• Ankle and Feet
• Spine
• Very rarely Cervical spine can be
affected
• Chance of C1 – C2 subluxation

Pathophysiology of RA

152
Clinical features
• Females >> Males
• Polyarthralgia
• Early morning stiffness
• Small joints of hand involvement Knees, hips involvement
• Skin nodules

Hand changes in RA
• Ulnar drift at MCP joints
• Swan Neck deformity
• Boutonniere deformity
• Hitchhiker’s thumb
• Z deformity of thumb

Boutonniere’s deformity

Swan neck deformity

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Foot changes in RA
• Hallux Valgus
• Hammer toe
• Wind swept deformity of toes

Knee changes in RA
• Genu Valgum (MC)
• Genu Varum
• Wind swept knees

X ray findings
• Periarticular osteopenia (earliest)
• Uniform joint space narrowing
• Erosions of articular surface
• Sub chondral cysts
• No osteophytes
• Deformities

154
Treatment - Medical
• DMARDs
• Methotrexate
• Pain management
• Paracetamol
• NASIDs
• Opioids
• Steroids
• Bridging therapy
Treatment - Interventional
• Intraarticular steroid injections
• Deformity correction
• Braces
• Surgical
• Joint replacement surgeries
• TKR
• THR

Seronegative Spondyloarthropathies

Rheumatoid Seronegative
Arthritis Spondylo
arthropathy
Rheumatoid Factor Positive Negative
HLA B27 Negative Positive
Hand involvement Common Rare
Spine and adjacent Rare Common
joint involvement
Gender F>M M>F

Seronegative Spondyloarthropathies

Ankylosing Spondylitis

Psoriatic Arthritis

Reactive Arthritis

Enteropathic Arthropathy

3. Ankylosing spondylitis
• Marie – Strumpell disease / Bechtrew’s Disease
• Chronic Seronegative Autoimmune Spondyloarthropathy characterized mainly by bridging spinal osteophyte
formation resulting in fused immobile spine.
• Clinical features
• Males > Females
• 15 – 25 years
• HLA B 27 positive
• Axial > Peripheral
• Sacroiliac joint > Spine > Hip

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Pathology

Clinical features
• Back pain / Gluteal pain
• Morning stiffness / Back stiffness
• Kyphosis - Question mark posture
• Reduced chest expansion
• Enthesitis

Test for spine stiffness - Modified Schober test

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Extra articular manifestations
1. Atlantoaxial subluxation
2. Anterior uveitis
3. Apical fibrosis
4. Aortic regurgitation
5. AV conduction block
6. Ig A nephropathy
7. Amyloidosis
8. Achilles enthesitis

X ray findings in Ankylosing Spondylitis

• Earliest change - Narrowing of SIJ

• Diagnosis
• Essential criteria + at least 1 supporting criteria
• Essential criteria
• Sacroilitis
• Supporting criteria
• Limited chest expansion
• Limited lumbar spine mobility
• Back pain > 3 months
• Treatment
• Physiotherapy
• Exercises – swimming
• NSAIDs
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• TNF blockers
• Infliximab
• Etanercept
• Adalimumab

4. Psoriatic Arthropathy
• Seronegative spondyloarthropathy associated with Psoriasis
• Seen in 10 % cases of psoriasis
• HLA B 27 positive – 60%

Clinical features
• Asymmetric Oligoarticular Arthritis
• MC joint involved – DIP
• Male = Female
• Diagnostic criteria – CAPSAR

Hand changes in Psoriatic Arthropathy

• Clinical changes
• Sausage digits
• Opera glass hands
• Arthritis Mutilans
• Xray findings
• Pencil in cup deformity
• Gull wing appearance

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5. Reactive Arthritis
• Also known as Reiter's Syndrome
• Seronegative spondyloarthropathy triggered by a prior infection.
• Triad of
• Urethritis
• Conjunctivitis / Uveitis
• Arthritis
• Associated lesions
• Circinate balanitis
• Keratoderma Blennorrhagicum

6. Hemophilic Arthropathy
• Joint damage occurring in Hemophilia
• Clotting factor VIII or IX deficiency
• Problem – Bleeding with trivial trauma
• Knee > Elbow > shoulder > ankle
• Presents with recurrent hemarthrosis
• Treatment
• Rest +NSAIDs +Ice
• Aspiration is avoided

X ray findings
• Squaring of patella
• Widening of intercondylar notch
• Squaring of condyles

159
7. Gout
• Disorder of purine metabolism characterized by hyperuricemia leading to deposition of Monosodium
Urate crystals in joints and periarticular tissues.
• Normal UA levels : 3.5 to 7 mg/dl

Clinical features of acute gout

• Middle age
• Male > Female
• History of increased consumption of Red meat / Alcohol
• Pain in the joints
• 1st MTP joint (MC)
• Ankle
• Knee
• Elbow
Clinical features of chronic gout
• Tophi
• Chalky white deposits of MSU in soft tissues

160
X ray findings
• Punched out lesions
• Rat bitten appearance
• Overhanging sclerotic margins
• Martel G sign

Joint aspiration
• Investigation of choice
• Microscopy will reveal Monosodium
Urate (MSU) crystals which are
• Needle shaped
• Negatively Birefringent

Treatment of gout
• Acute gout
• NSAIDs
• Colchicine
• Steroids
• Chronic gout
• Xanthene oxidase inhibitors
• Allopurinol
• Febuxostat
• Topiroxostat
• Rasburicase
• Uricosuric drugs
• Probenecid
• Benzbromarone

161
8. Pseudogout
• Deposition of CPPD crystals in joint resulting in inflammation
and chondrocalcinosis
• Calcium Pyrophosphate Dihydrate
• Elderly patients
• Females > Males
• Associated with Hypothyroidism
• Affect large joints : Knee (MC)
Joint aspiration
• Investigation of choice
• Microscopy revelas CPPD crystals
• Rhomboid
• Positively birefringent

DIFF GOUT PSEUDO GOUT

AGE 40-60 YEARS >60 YEARS
GENDER M>F F>M
MC JOINT INVOLVED 1ST MTP JOINT KNEE JOINT
SYMPTOMS SEVERE PAIN MODERATE PAIN
CRYSTAL MSU CPPD
X RAY EROSIONS CALCIFICATIONS

9. Neuropathic joint
• Joint destruction occurring due to loss of sensations and proprioception.
• Caused by the loss of auto protective function resulting in recurrent micro traumas.
• Charcot’s joint

162
 CAUSES OF NEUROPATHIC JOINT
DIABETIC NEUROPATHY MC CAUSE
MID TARSAL >TARSOMETATARSAL
SYRINGOMYELIA SHOULDER
SYPHILIS KNEE
LEPROSY IP JOINTS OF HAND
TRAUMATIC NERVE INJURY

Clinical features
• Deformity
• Swelling
• Loss of function
• No pain
• Bag of bones feel
• Neuro exam – Sensory deficit

X ray - 6 Ds
1. Distended
2. Disorganized
3. Dislocated
4. Debris – Intraarticular Loose Bodies
5. Density increased (sclerosis)
6. Destruction

Treatment
• Very difficult to treat
• Braces can be given in order to support the joint
• CROW - Charcot Restraint Orthotic Walker
• Arthrodesis – High failure rate
• Arthroplasty – Contraindicated

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 Chapter X. Sports injuries

1. Stabilizers of the knee joint

• Antero posterior (Sagittal plane) stabilizers
• Anterior Cruciate Ligament (ACL)
• Posterior Cruciate Ligament (PCL)
• Mediolateral (Coronal plane) stabilizers
• Medial Collateral Ligament (MCL)
• Lateral Collateral Ligament (LCL)
• Rotary stabilizers
• Posterior Lateral Corner Complex (PLC)
• Antero Lateral Ligament (ALL)

2. Anterior cruciate ligament

• Function
• Preventing anterior translation of knee
• Mechanism of injuy
• Hyperextension
• Non contact Pivoting
• Causes of injury
• Sports injury – Football
• RTA

164
• Associated injuries
1. Segond fracture
• Capsular avulsion fracture of the anterolateral corner of tibial plateau
2. Lateral Meniscus tear
3. Medial Meniscus tear
• Features of Acute ACL tear
• Pain

• Feeling of instability
• Tests for ACL tear
• Anterior Drawer Test
• Lachman test
• Bounce home test
• Pivot shift test

Anterior Drawer Test

• Flex knee to 90 degrees
• Stabilize foot by sitting on it
• Make sure hamstrings are relaxed
• Keep thumbs on either sides of patellar tendon
• Apply anterior force on tibia
• Feel for translation of tibia
• Anterior translation indicates ACL tear

Lachman test
• Flex the knee to 20 – 30 degrees
• Apply anterior force on tibia
• Anterior translation is +ve
• Better than ADT as it
• Can be done in acute setting
• Takes hamstring out of the equation
• More sensitive

Investigations
• X – ray
• Segond fracture – seen in acute ACL tear
• MRI - Imaging of choice
• Diagnostic arthroscopy - Gold standard Investigation
165
Treatment of ACL tear
• Arthroscopic ACL reconstruction
• Grafts commonly used
• Semitendinosus
• Gracilis
• Patellar tendon central 1/3rd

3. Posterior Cruciate Ligament

• Function
• To prevent posterior translation of knee
• Causes
• RTA – Dash Board injury
• Sports – Hyperflexion injury
• Tests for PCL tear
• Posterior Drawer test
• Godfrey’s Sag sign
• Quadriceps active test
• Investigations
• MRI
• Diagnostic arthroscopy
• Treatment
• Arthroscopic PCL reconstruction

166
4. Medial Collateral Ligament
• Attachments
• Proximal – Medial Femoral Epicondyle
• Distal – Medial Tibial Condyle and Tibial shaft
• At the joint line - Medial Meniscus
• Function - Stabilization against valgus forces

• Mechanism of injury
• Valgus stressing of knee beyond physiological limit
• Causes
• Fall
• RTA
• Sports injury

Tests for MCL tear

• Valgus Stress Test
• Done with knee at 0 and 30 degrees flexion
• Patient lies supine
• Thigh is stabilized
• Valgus force applied on the leg
• Observe for opening up of joint on the medial side
• Opening up only at 30 degrees
• Only MCL tear
• Opening up at 0 and 30 degrees
• MCL + ACL tear

167
Management
• Investigation
• MRI - IOC
• Treatment
• Conservative - Cast for 3 weeks
• Surgery - MCL repair

5. Lateral Collateral Ligament

• Attachments
• Proximal – Lateral Femoral Epicondyle
• Distal – Fibular head
• Function
• Stabilization against varus forces

• Mechanism of injury
• Varus stressing of knee beyond physiological limit
• Causes
• Fall
• RTA
• Sports injury

168
Tests for LCL tear
• Varus Stress Test
• Done with knee at 30 degrees flexion
• Patient lies supine
• Thigh is stabilized
• Varus force applied on the leg
• Observe for opening up of joint on the medial side

• Management
• Investigation
• MRI - IOC
• Treatment
• Conservative
• Cast for 3 weeks
• Surgery
• LCL repair

6. Postero Lateral Corner (PLC) complex

• Also known as Arcuate complex
• Provides Posterolateral rotational stability of knee
• Tests for PLC injury are
1. Dial Test
2. External Rotation Recurvatum Test
3. Postero Lateral Drawer Test
4. Reverse Pivot Shift

169
 ACL Prevents anterior translation • Anterior drawer test
• Lachman Test
• Bounce home test
• Pivot shift test
PCL Prevents posterior translation • Posterior drawer test
• Godfrey’s sag sign
• Quadriceps active test
MCL Protects against valgus stresses • Valgus stress test
LCL Protects against varus stresses • Varus stress test
PLC Posterolateral rotational stability • Dial Test
• External Rotation
Recurvatum Test
• Posterolateral Drawer Test
• Reverse Pivot Shift
ALL Anterolateral rotational stability • Pivot shift test

7. Meniscus injury
• There are 2 menisci
• Medial meniscus
• Larger
• C - shaped
• Immobile
• Most commonly injured
• Lateral meniscus
• Smaller
• O – shaped

170
• Blood supply of meniscus
• Peripheral 1/3rd (red –red zone) – from perimeniscal capillary plexus
• Middle 1/3rd (red – white zone) – from few branches of perimeniscal capillary plexus
• Inner 1/3rd (white – white zone)– completely avascular and depends on the synovial fluid for nutrition

Meniscus tears
• MC meniscus to be injured- Medial Meniscus
• Causes
• Twisting injury of the knee
• Fall / Sports injury /RTA
• Degeneration in meniscus
• Osteoarthritis of knee
• Symptoms
• Pain
• Swelling of knee – Delayed
• Clicks
• Locking - seen in Bucket handle tears
• Tests of meniscus tear
• Mc Murray test
• Apley tests
• Thessaly test
• Ege’s test

Mc Murray test – Medial Meniscus

• Hold the knee with one hand and palpate the medial joint line
• Hold the foot with other hand
• Externally rotate the tibia
• Flex and extend the knee
• Positive – Pain/ Click

171
Mc Murray test – Lateral Meniscus
• Hold the knee with one hand and palpate the lateral joint line
• Hold the foot with other hand
• Internally rotate the tibia
• Flex and extend the knee
• Positive – Pain/ Click

Apley tests

Ege test

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Thessaly test

Treatment of meniscus tears

• Arthroscopic Meniscus repair
• Red - red zone tears
• Arthroscopic Partial Meniscectomy
• White – white zone tears

Unhappy triad of O’Donoghue

• Tear of
• ACL +
• MCL +
• Medial meniscus

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 Chapter XI. Avascular Necrosis and
Osteochondritis

• Avasuclar necrosis is the death of bone due to

disruption of blood supply

Pathophysiology

List of common Osteochondrosis

Keinbock Lunate
Kohler Navicular
Perthe’s Femoral head in children
Chandler’s (MC) Femoral head in adults
Scheurmann’s Ring epiphysis of vertebra
Calve’s Central bony nucleus of vertebra

Frieberg 2nd MT head

Iselin 5th MT base
Osgood Schlatter Tibial tuberosity
Sinding Larsen Johansson Lower pole patella
Sever’s Calcaneum
Panner’s Capitulum of elbow
Prieser’s Scaphoid
Schmeir Pisiform
Haas Head of humerus

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1. AVN of femoral head (Chandler’s disease)
• Avascular necrosis of femoral head leading to collapse and
deformation of femoral head, later resulting in osteoarthritis
• Idiopathic
Risk factors of Chandler’s disease
1. Steroid use
2. Alcohol abuse
3. Anti Retrovirals
4. Gaucher’s disease
5. Caisson’s disease
6. Blood anomalies
• Sickle cell disease
• Thrombophilia
• Protein C deficiency
• Protein S deficiency

Clinical features
• Males > Females
• Pain
• Limping
• Restriction of Abduction and Internal rotation
Investigations
• MRI
• Investigation of choice
• Double density sign
• X-ray
• Sclerosis
• Fragmentation
• Collapse
• Crescent sign

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Treatment
• Early stage
• Core Decompression alone
• Core Decompression with vascularized fibular graft
• Late stage with Osteoarthritis
• Total Hip Replacement

2. Keinbock Disease
• AVN of Lunate resulting in its collapse leading to radiocarpal instability and arthritis
• Lunatomalacia
• Males >> Females
• 20 – 40 years
• Idiopathic
• Risk factors
• Negative ulnar variance
• Repetitive trauma
• I pattern blood supply

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• Symptoms
• Pain and Reduced grip strength
• Signs

• Tenderness in lunate fossa

• Knuckle of middle finger at lower level
• X ray
• Sclerosis
• Fragmentation
• Collapse
• Arthritic changes

• Treatment
• Radius shortening osteotomy
• Ulnar lengthening surgery
• Distal radius decompression
• Vascularized bone grafts

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 Chapter XI. Miscellaneous orthopedic conditions

1. Painful arc syndrome

• Condition in which patient suffers shoulder pain between 60 – 120 degrees of abduction and other ranges are
pain free
• This occurs because subacromial space is the minimum at this range
• Causes
• Subacromial Bursitis
• Supraspinatus Tendinitis
• Supraspinatus Tears
• Calcific Tendinitis

2. Adhesive capsulitis
• Also called Frozen shoulder / Periarthritis shoulder
• Idiopathic condition characterized by global reduction in passive and active range of motion of shoulder due
to fibrosis and adhesions in the capsule
• Cause – unknown
• Risk factors
• Diabetes Mellitus
• Hypothyroidism
• Cervical disc disease
Stages of Adhesive capsulitis
• Stage of Pain
• Pain is the predominant feature
• Mild stiffness
• Stage of Stiffness
• Pain reduces
• Stiffness is predominant feature
• Stage of Thawing
• Gradual return of movements

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• Clinical signs
• Shoulder movement restriction
• All movements are restricted
• External rotation is the first movement to be affected
• Both active and passive ROM is restricted
• Investigations
• X ray – Osteopenia
• MRI – Loss of axillary recess
Treatment
• First line
• Control of Diabetes / Hypothyroidism
• Analgesics
• Physiotherapy
• Second line
• Steroid injection
• Hydrodilatation
• Third line
• Arthroscopic capsular release

3. Long Head of Biceps Tendinitis

• Long head of biceps passes through the shoulder joint and attaches on the top of glenoid
• Any pathology of shoulder will cause LHB tendinitis
• Chronic inflammation will cause thinning of the LHBT resulting unexpected spontaneous rupture.
• Rupture of LHBT will result in Popeye sign

4. Tennis elbow
• MC cause for elbow pain in adults
• Also called Lateral epicondylitis
• Tendinosis and inflammation of the origin of the common extensor tendons.
• Caused by overuse of wrist extension
• MC muscle involved – ECRB
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• Causes
• Tennis players – due to Backhand shot overuse
• Manual labourers, Carpenters, plumbers, electricians
• Symptoms
• Pain on activities
• Over the lateral aspect of elbow

Tests for Tennis Elbow

• Cozen sign
• Wrist extension against resistance causes pain
• Maudsley sign
• Middle finger extension against resistance causes pain
• Mills test
• Passive palmar flexion of wrist with extended elbow causes pain

Treatment
1st line
• Activity modification
• Analgesics
• Counterforce brace 2nd line
• Steroid injection
• PRP injection Last resort
• Open release of common extensors

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5. Golfer’s elbow
• Medial epicondylitis / Swimmer’s elbow
• Tendinosis and inflammation of the origin of the common flexor tendons.
• Overuse of wrist flexion
• MC muscle involved – FCR
• Tests – Reverse Mill’s Test
• Treatment – same as Tennis elbow

6. De Quervain’s Tenosynovitis
• Tenosynovitis of the 1st dorsal compartment.
• Tendons involved – APL and EPB
• Causes - Overuse of thumb
• Symptoms
• Pain over the wrist and base of thumb
• Finkelstein test

• Examiner grasps the patient’s thumb and quickly jerks the hand into ulnar deviation causing pain
• Eichhoff test
• Patient is asked to clench the fist with thumb inside the palm.
• Then the wrist is ulnar deviated causing pain

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• Treatment
• Thumb spica splint
• Steroid injection
• Surgical release of 1st dorsal
Compartment

7. Dupuytren’s contracture
• Condition characterized by nodular hypertrophy of superficial palmar fascia resulting in formation of fibrotic
cords in the palm which contracts over time to produce fixed flexion deformity of fingers
• Ring > Little > Middle > Index finger
• Cause – Idiopathic
• Risk Factors
• Family History - AD
• Alcoholism
• Smoking

182
• Treatment
• Steroid injections
• Needle aponeurectomy
• Clostridium Histolyticum collagenase injection
• Open release
• Subtotal fasciectomy
• Total fasciectomy
• With / without skin transplantation

8. Trigger finger
• Localized thickening of the flexor tendon of finger which prevents its smooth gliding at the level of the A1
pulley resulting in progressive pain, clicking, catching and locking of the digit.
• MC finger – Ring finger
• MC tendon – FDP
• Treatment – A1 pulley release

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9. Bowler’s thumb
• Perineural fibrosis involving the ulnar digital nerve of the thumb
10. Ganglion cyst
• Ganglion Cysts are mucin-filled synovial cysts seen around the wrist
• MC swelling in hand and wrist
• MC site of origin - Scapholunate ligament
• Treatment
• Aspiration and steroid injection
• Surgical excision

CYST

11. Compound Palmar ganglion

• Pus collection in the distal forearm and palm
• Connected through the carpal tunnel under the flexor retinaculum
• Hour glass abscess
• Usually seen in TB
• Can cause Carpal Tunnel Syndrome

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12. Morrant Baker cyst
• Also called Popliteal cyst
• Pulsion (pressure) diverticulum of knee joint
• Causes
• Osteoarthritis
• Rheumatoid arthritis
• Treatment
• Treat underlying cause
• Excision

12. Bursitis
• Inflammation of bursae in the body
• Cause – Trauma / Chronic Microtrauma
• MC bursitis – Sub acromial bursitis

Housemaid’s knee Pre patellar bursitis

Clergyman’s knee Infra patellar bursitis
Student’s elbow Olecranon bursitis
Haglund deformity Retrocalcaneal bursitis
Weaver’s bottom Ischial bursitis
Tailor’s bunion Lateral aspect of 5th metatarsal

13. Bunion (Hallux valgus)

• Bump on the 1st MTP joint
• Associated with Hallux Valgus deformity
• Lateral deviation of great toes
• Treatment
• Bunion splint
• Bunionectomy + Chevron osteotomy/ Scarf osteotomy

185
14. Haglund deformity
• Calcification posterior aspect of calcaneum
• Symptoms – pain and lump behind the heel
• Treatment
• Physiotherapy
• Surgical excision rarely

186
 THE FUTURE BELONGS TO
THOSE WHO BELIEVE IN THE
BEAUTY OF THEIR DREAMS.
ELEANOR ROOSEVELT

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