BASIC SCIENCE, ORTHOPEDIC ANATOMY

AND IMAGING ORTHOPEDICS

HISTORY OF ORTHOPEDICS
Introduction and History of Orthopedics
Nicolas Andry
•• Term Orthopedics is coined by Nicolas Andry
•• Ortho- Straight, Pedis-Child
•• Nicolas Andry wrote the 1st book of orthopedics & the emblem of orthopedics

H. O. Thomas (Hugh Owen Thomas)

•• Contributions include
○ Thomas splint
○ Wrench: For correction of Deformities
○ Thomas test: For flexion deformity of the hip
○ Collar: For cervical spine injuries
○ CTEV (Congenital Talipes Equino Varus) Shoes
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Orthopedics Notes

Important Information
•• Father of Orthopedics: Nicolas Andry > [Link]
•• Father of Modern orthopedics: Robert jones

Watanabe
•• Father of Arthroscopy
•• M/c joint in which arthroscopy done is: Knee > Shoulder
•• Largest joint in our body: Knee

John Charnley
•• Father of Arthroplasty
•• M/c Joint where Arthroplasty is done: Knee
•• Arthrodesis: Fusion of 2 or more bones in a joint

Image Based question approach

•• Keep optimum distance
•• Keep looking – don’t hurry (20 sec)
•• Seeing & believing that you have seen
•• Localize the body part
•• In an image go from normal to pathological area
•• Then look at choices
•• Sometimes you actually don’t need an image
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Basic Science, Orthopedic Anatomy and Imaging Orthopedics

Monteggia fracture [Fracture Ulna with Radial head dislocation]

BONE STRUCTURE
Basics
•• Metaphysis
•• Most vascular area of Bone
•• Most common Location for infection & Tumor
•• Diaphysis
○○ Middle part
○○ Ewing sarcoma occurs here.
•• Epiphysis
○○ Present towards the end of a Bone
○○ Covered by Articular cartilage
•• Upper end of bone: Epiphysis + Physis + Metaphysis

•• Middle of bone: Diaphysis

Bone Composition
•• 65% Inorganic [(ca)10 (PO4)6 (0H)2]: Calcium hydroxyapatite
•• 35% organic (Type 1 collagen)
•• Organic Component
○○ Matrix 95% + cells 5%
→ Matrix composed of Proteoglycans (compressile strength)
○○ Proteins
→ Composed of Collagen: Type 1
→ Provides Tensile strength
→ Non-collagen proteins are also present which includes
- Osteocalcin
- Osteopontin
- Osteonectin
•• Bone formation marker
○○ Osteocalcin
○○ Osteopontin
○○ Osteonectin
○○ Enzymes: Bone specific ALP
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Orthopedics Notes

•• Terms
○○ Osteoid: Immature Bone
○○ Osteon: Mature (Mineralized) Bone

Skeletal Maturity

•• Age at which the physis disappears and the Epiphysis Fuses to Metaphysis is K/a Age of skeletal maturity

•• Shoulder joint
•• Wrist joint Ossify at 18 years of age

•• Knee joint
•• Elbow joint
•• Hip joint Ossify at 16 years of age

•• Ankle joint

Zones of Articular cartilage

•• Zone 1
○○ Superficial zone
○○ Has high water content (as it is close to joint fluid)
○○ Contains
→ Progenitor cells for articular cartilage
→ High density chondrocytes
•• Zone 2
○○ Transition zone: Thickest zone
○○ Chondrocytes are in low density
•• Zone 3
○○ Middle zone
○○ Most active chondrocytes
○○ Highest density proteoglycans
○○ Low density water content
•• Zone 4
○○ Calcified cartilage
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Basic Science, Orthopedic Anatomy and Imaging Orthopedics

Epiphysis

Types of Epiphysis
1. Pressure Epiphysis
○○ Intra Articular & Weight Bearing
○○ E.g. Head of Humerus, Lower end of radius
2. Traction Epiphysis
○○ Extra articular
○○ K/a Apophysis
○○ Severe to pull & site of muscle attachment ossify later than pressure epiphysis.
○○ E.g. Greater & Lesser trochanter of femur, and Tubercles of Humerus.

Important information
Rotator cuff muscles
Mnemonic: Sit-s
•• Supraspinatus
•• Infraspinatus Attached to greater tuberosity and causes abduction and external rotation

•• Teres minor
•• Subscapularis: Attached to lesser tuberosity and causes internal rotation
Lift off test: to test for a lesion of the subscapularis muscle & scapular instability

3. Aberrant Epiphysis
•• Anatomical anomaly
•• Accessory ectopic epiphysis
•• E.g. Head of 1st metatarsal (or) Base of 5th Meta carpal.
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Orthopedics Notes

4. Atavistic Epiphysis
•• Phylogenetically independent but becomes fused.
•• E.g. Coracoid process of scapula.

Growth plate
•• Bridged between Epiphysis & Metaphysis
•• Consist of
○○ Resting zone (Reserve)
→ Storage disorders affects resting zone
→ E.g. Gaucher disease
○○ Proliferative zone (Growth)
→ Affecting the dwarfs and giants
→ E.g. Laron syndrome (dwarfs + truncal obesity).
○○ Maturation zone
→ Zone where fractures occurs
→ Hypertrophic
○○ Zone of provisional calcification
→ Mineralization disorder like Rickets affects zone of provisional calcification

Important Information
•• Beneath zone of provisional calcification is the Spongiosa
•• Scurvy affects the spongiosa because it affects the cross-linking of collagen

Salter-Harris Classification in children

•• Type 1: Slip of Epiphysis

•• Type 2
○○ Fracture line through the physis & extending to the metaphysis
○○ Most common type
○○ Aka Thurston – Holland sign
•• Type 3
○○ Fracture Line through the physis splitting Epiphysis into two
•• Type 4
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Basic Science, Orthopedic Anatomy and Imaging Orthopedics

○○ Split of epiphysis with metaphyseal fracture

•• Type 5
○○ Crush injury to the physis
○○ Often normal x-ray as physis is cartilaginous

PARATHYROID HORMONE ON BONE

Remodeling of bone
•• PTH acts on its receptor on Osteoblast which release the Rank-Ligand
•• Rank Ligand attach to the receptor on the Osteoclast and stimulate it causing remodeling

•• When there is excessive PTH levels

○○ E.g. Hyper parathyroidism due to PTH adenoma, there will be H/o Young female with renal stones,
abdominal groans (dyspepsia), psychic moans and Bones (Bone pains)
○○ Bones: High level of PTH →↑ stimulation of osteoblast→ ↑release of RANK ligand → ↑osteoclast
stimulation
→Osteoclast causes more Lysis → Bones become more hollow K/a Cystica → Cyst is filled with fi-
brous tissue K/a Fibrosa Cystica, since bone is getting involved its k/a Osteitis fibrosa cystica
○○ When there is blood in it then its K/a Brown tumor (due to blood degradation product giving it brown
colour)
•• Treatment of Osteoporosis
A. Drugs inhibiting the osteoclast
→Bisphosphonates
- DOC for Osteoporosis
- Rare side effect: It inhibits the remodeling cycle and prolonged usage for many years has a high chance of
causing fractures
→ Calcitonin
B. Drugs that inhibit the Rank ligand
→ Estrogen
→ Denosumab (S/c)
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Orthopedics Notes

A. Low dose PTH (20 μg s/c daily) stimulates osteoblast but cannot release RANK ligand, hence, it can be
used for treatment of Osteoporosis
B. Strontium
→ Acts on both pathways i.e. Stimulates formation & inhibits resorption as well.
→ Not preferred because of cardiac side effect

Calcium Homeostasis
○○ Decreased serum calcium stimulate calcium sensory receptors on parathyroid gland causing PTH
release
○○ PTH action
1. On the Bone: Stimulates specific receptors causing bone resorption thereby increasing the serum calcium.
2. Stimulate 1 - alpha – Hydroxylase causing formation of 1,25 (OH)2 D3 which will in turn results in Increased intestinal
absorption of calcium.
3. Acts on specific receptors on kidney causing Phosphaturia and decreases S. phosphate

Important Information
•• Any vitamin D deficiency will usually have a secondary hyper parathyroidism
○○ Serum PTH will be High
○○ Serum phosphate will be low
•• In Renal Rickets (phosphate retention disorder), the phosphate levels in blood will be high
Ball & Socket Joints

•• Includes
○○ Incudostapedial joint
○○ Shoulder joint
○○ Hip joint
○○ Talocalcaneal-navicular joint

Synovial Joints:
Types of synovial joint Examples
Plane • Acromioclavicular
• Intercarpal
• Intertarsal
Hinge • Elbow
• Interphalangeal
Pivot (Trochoid) • Atlanto-axial
• Superior radio-ulnar
• Inferior radio-ulnar
Condylar • Temporo-mandibular
• Knee joint
Ellipsoid • Atlanto-occipital
• Wrist (radio-carpal)
• Metacarpo-phalangeal (knuckles)
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Basic Science, Orthopedic Anatomy and Imaging Orthopedics

Saddle • Malleus-incus joint

• Sternoclavicular
• First carpo-metacarpal
• Calcaneocuboid
Ball and socket • Incus-stapes joint
• Shoulder
• Hip
• Talo-calcaneo-navicular
•• If Abduction & Internal rotation is normal there is no problem with hip & shoulder joints.

Atlanto occipital movement Atlanto – axial movement

Yes (flexion – Extension) Is no (rotation)

APPROACH TO NORMAL X-RAYS

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Orthopedics Notes

a. Cortex
•• Cortex: bone in the periphery
•• Fracture is a break in the cortex of the bone

b. Marrow: Central part of a bone

c. Soft tissue plane
•• Consists of Muscles & fascia
•• In osteomyelitis, earliest radiological feature is loss of soft tissue plane after 24 hours > periosteal
reaction (7-10 days)
d. Joint space

•• Consists of cartilage (not seen on x-rays)

•• Reduction of joint spaces refers to Arthritis
•• The medial compartment of the joint is destroyed leading to reduction in joint space & Distal part is
deviated medially in osteoarthritis: VARUS
•• In Rheumatoid Arthritis Distal part is deviated laterally: VALGUS (Knock knee)
•• X-rays is the first investigation for glass injury
•• Glass is coated with lead which is Radio-opaque

Important Information
•• Break in cortex: Fracture
•• Osteomyelitis: Loss of soft tissue planes after 24 hrs. of osteomyelitis and periosteal reaction happens
later
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Basic Science, Orthopedic Anatomy and Imaging Orthopedics

•• Tuberculosis loss of curvature of spine> reduced disc space

•• Joint spaces is cartilage (not seen on x-rays) and reduced joint space means arthritis

Shoulder
•• Clavicle is the highest bony landmark in AP X-ray of shoulder
•• Ratio between head of humerus & Glenoid 4:1 k/a “Golf ball on a tee”
•• In the Infra-clavicular area, the bony landmark palpable is “Coracoid”

Elbow

•• Capitulum is the first centre to ossify around elbow

•• Radial head: 2nd centre to ossify
•• Ossification around elbow
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Orthopedics Notes

Bone Age of ossification

• C - Capitulum • 2 years
• R - Radial head • 4 years
• I – Inner / medial epicondyle • 6 years
• T – Trochlea • 8 Years
• O – Olecranon • 10 Years
• E – External / lateral epicondyle • 12 Years
How to remember
•• CRITOE

Wrist

Radiocarpal joint
•• In AP view lower end of radius is wider, on it there is a boat shaped bone called as scaphoid and next to
it is the moon shaped lunate (Seen on lateral view)
•• The first metacarpal goes anterior
•• Ossification of carpal bone

Bone Age of ossification

She – Scaphoid 5 years
Looks – Lunate 4 years
Too – Triquetrum 3 years
Pretty – Pisiform 12 years
Try – Trapezium 5 years
To – Trapezoid 5 years
Catch – Capitate 1 years (1st to ossifiy)
Her – Hamate 1 years

How to remember
•• She Looks Too Pretty Try to Catch Her
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Basic Science, Orthopedic Anatomy and Imaging Orthopedics

Pelvis

•• Sacroiliitis: inflammation of sacro- iliac joint: seen in ankylosing spondylitis

•• Young man with lower back ache, reduced back movement, decreased chest expansion, HLA B27+ve
suggests Ankylosing spondylitis

IMAGING IN ORTHOPAEDICS
Different views in X-ray
1. Von-Rosen view

•• For developmental dysplasia of Hip

•• Shows Shallow acetabulum
2. Swimmer’s view

For cervico thoracic junction

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Orthopedics Notes

3. Judet View

•• To view different orientation of acetabulum

4. Open mouth view

•• Used for Odontoid fracture and to see upper cervical spine C1 and C2
5. Shenton’s Arch

•• Lost in fracture or dislocation (Fracture of pubic rami or dislocation of Hip)

Important views of X-rays

1. Broadens View: Subtalar joint – Inversion, Eversion → To walk on uneven ground
2. Von Rosen View: DDH
3. Swimmers View: Cervicothoracic junction
4. Oblique view: Scaphoid
5. Judet View: Acetabulum (Pelvis) – Tilt the pelvis → To see inside the acetabulum
6. Open Mouth view: Odontoid
7. Shentons Arch: Pelvis
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Basic Science, Orthopedic Anatomy and Imaging Orthopedics
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Orthopedics Notes
 INFECTION

OSTEOMYELITIS
Osteomyelitis basics
•• Mc organism: Staphylococcus Aureus.
•• Mc location: Metaphysis
•• Mc spread of infection: Hematogenous

Exceptions
•• Sickle cell anemia: Salmonella
○ Salmonella affects the Diaphysis (MC)
○ S. Aureus affects the Metaphysis
•• IV drug users: Pseudomonas
•• Foot infection: Pseudomonas.
•• Human bites: Eikenella
•• Animal bite: Pasteurella
•• Open injuries: Staph Aureus.
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Orthopedics Notes

Joint Infections
•• Faber at Hip
○○ 0-5-year-old, toxic child, Absent movement of joint: septic arthritis (S. aureus)
→ Diagnosis by X-MAS (X-ray, MRI, Aspirate by Ultrasound guidance)
→ Treatment: Surgery
○○ 6-12 years of age, Non-toxic, decreased movements of joint: Transient synovitis
→ Diagnosis by X-Mas (X-ray, MRI, Aspirate by Ultrasound guidance)
→ Treatment: Rest

Septic Arthritis Transient Synovitis

• FABER (+) (+)
• AGE < 5 Years 6-12 years
• Movement of Joint Absent Decreased

Septic arthritis
Diagnostic criterion (Morrey and associated criterion) 5 out of 6 must be present.
1. > 38.3° C temperature
2. Swelling of suspected joint
3. Pain in joint that increased with movement
4. Systemic symptoms
5. No other pathological process’
6. Satisfactory response to antibiotics therapy
○○ Knee is the most commonly affected joint: position is flexion
○○ Hip: position is flexion, abduction, and external rotation as this is the positon of maximum capacity of
joint to accommodate pus
○○ Treatment
○○ Arthrotomy (opening the joint capsule), surgical drainage (decompression), synovectomy and =
antibiotics (2 weeks IV and 4 weeks oral)
○○ No role of conservation management
○○ Septic arthritis results in bony ankyloses and it is the most common cause of bony ankyloses

Kocher’s criteria
1. Inability to bear weight
2. Temperature > 38.5° c
3. WBC > 12000/ microliter
4. ESR > 40MM/HR
1 point means 3% chance of Septic Arthritis
2 point means 40% chance of Septic Arthritis
3 point means 93% chance of Septic Arthritis
4 point means 99% chance of Septic Arthritis
Brodie’s Abscess
•• Sub-Acute Osteomyelitis > Chronic Osteomyelitis
•• Location: upper end of tibia
•• Lytic Lesion with sclerotic margin
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Infection

•• Seen in Immunocompetent host

CHRONIC OSTEOMYELITIS
Chronic Osteomyelitis
•• Acute: <2 weeks
•• Sub-acute: 2-3 weeks
•• Chronic: > 3 weeks (AKA dead bone)
•• Sequestrum: Dead bone (Sequestrum is cause of sinus)
○○ Looks white on Xray
○○ Surrounded by infected granulation tissue
•• Involucrum: Reactive live bone outside of sequestrum
•• Cloacae: sinuses through involucrum
•• Complications
○○ Amyloidosis
○○ Malignancy: Squamous cell carcinoma
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Orthopedics Notes

Garre’s Sclerosing Osteomyelitis

•• Chronic Osteomyelitis
•• Mandible> Tibia

Types of Sequestrums
•• Tubular or diaphyseal sequestrum is seen in acute pyogenic osteomyelitis.
•• Ring sequestrum is seen in amputation stump and at Steinmann pins.
•• Ivory sequestrum is seen in syphilis.
•• Fine sandy sequestrum is seen in viral osteomyelitis.
•• Coarse sandy sequestrum is seen in out of cavity TB (e.g., central body of vertebra)
•• Flake or Feathery sequestrum is seen in the cavity tuberculosis (e.g., TB rib)
•• Kissing sequestrum is seen in peridiscal TB vertebra.
•• Button hole sequestrum is seen after radiation.
•• Coke sequestrum is seen in cancellous bone.
•• Bombay or black sequestrum is due to H2S and pollution.
•• Black sequestrum is also seen in actinomycosis.

Treatment
1. Remove the Sequestrum
2. Control the infection
3. Fill the Gap using
○○ Bone graft: Taken from iliac crest
○○ Bone cement: Poly methyl meth acrylate (PMMA)

Paprika Sign
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Infection

•• While removing the dead done there is presence of bleeding from the live bone underneath the dead done
known as paprika sign
4. Provide soft tissue coverage

Negative pressure wound therapy (NPWT)

•• AKA vacuum assisted closure (VAC)

•• Vacuum dressing enhances healing of wound by removal of fluid collecting with it. • Suction pressure: -75
to -125 mm Hg
•• Continuous or intermittent
•• Gives Good Granulation tissue
•• Contraindications
○○ Malignancy
○○ Untreated OM
○○ Necrotic eschar
•• NPWT is also used for pressure sore.

Osteomyelitis in new born

•• Organisms: S. aureus
•• Location: metaphysis
•• Mechanism of spread: Haematogenous
•• Multifocal (spread wide)
•• Paucity of clinical signs (New born has less immunity)
•• Poor prognosis

Multifocal osteomyelitis
1. SAPHO syndrome
•• Synovitis
•• Acne
•• Pustulosis
•• Hyperostosis (thickened bone)
•• Osteitis (inflamed bone)
•• Auto immune disease (HLA B27 positive)
•• Treatment: NSAIDS / steroid / DMARDS
(Please note for Multifocal osteomyelitis choose SAPHO > Salmonella infection in SCA)
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Orthopedics Notes

JOINTS & SOFT TISSUE INFECTION

Infections of hand
•• Mc Infection of Hand: Paronychia
•• Mc organism: S. Aureus

1. Felon or Whitlow
•• Involves pulp space
•• Usually involves the Thumb > index finger
•• Treatment: Vertical incision: preferred
•• Fish mouth (Horizontal) incision: Not preferred
•• Complication: Osteomyelitis> Tenosynovitis
2. Paronychia
•• MC infection of Hand
•• Involves nail bed
•• MC organism [Link]
•• Rx: Antibiotics + surgical drainage (sometimes requires removal of part of nail)
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Infection

3. Infectious Tenosynovitis

•• Infection of flexor tendon sheath of finger causing flexion, Percussion tenderness, pain on stretch and
uniform swelling.
4. Kanavel’s Sign
•• Pain on extension (stretch)
•• Fusiform swelling
•• Flexion of finger
•• Tenderness along tendon sheath: Most specific

Spaces of hand

•• Thenar Space: Index finger tendon &1st Lumbrical

•• Mid palmar space: Middle finger, Ring & Little fingers 2nd, 3rd, & 4th Lumbricals
•• Forearm Space of Parona
○○ The place where Radial & Ulnar bursa joins
○○ Infection of Little finger can go to thumb but not to index finger
•• Function of lumbricals: Metacarpophalangeal joint flexion and Interphalangeal joint extension
•• Nerve supply: 1st two Lumbricals supplied by Median nerve, 3rd & 4th Lumbricals are supplied by Ulnar
nerve
•• Injury to Median / Ulnar nerve will cause Claw Hand
○○ Hyper extension of Metacarpophalangeal joint
○○ Flexion of Inter phalangeal joint
•• Rx of Claw Hand: Knuckle bender splint
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Orthopedics Notes

Mycetoma

•• AKA Madura Foot

•• Has multiple discharging sinuses
•• “Dot in Circle Sign” in MRI
•• Mycetoma is a Chronic progressive granulomatous exogenous infection of subcutaneous tissue
•• Actinomycetoma (Rapid) and eumycetoma (slow)
•• Caused by thorns / soil (barefoot): Exogenous
•• Involves all structures except nerves and tendons
•• Triad: Tumor like swelling (painless), sinuses and Granules

•• Sunray appearance & Codman’s triangle is seen

•• Involves all structures except nerves & tendons
•• Lytic cavities in bone

Important Information
•• Painless conditions
1. Mycetoma
2. Charcot’s Joint (neuropathic)
 TUBERCULOSIS

TUBERCULOSIS OF BONE & JOINTS

Basic
•• Mc primary site: lung > Lymph nodes
•• Hematogenous spread & lesions are paucibacillary (difficult to isolate)
•• Order of involvement of various parts: Spine > hip > Knee
○ TB Spine: “Pott’s spine”
○ Shoulder: “Caries Sicca” (dry, does not produce effusion)
○ Digits: “Spina Ventosa” (periosteal reaction is seen)

TB spondylitis

•• TB of spine is also called as TB spondylitis or Potts spine

•• Tb spine involves 2 consecutive vertebrae (lower half of upper vertebra & upper half of lower vertebrae)
along with disc in between
○ As the arises from same mesodermal somite, they have common segmental artery supplying it.
•• TB is called as paradiscal lesion (involves 2 contiguous vertebrae along with disc)
•• M/C paradiscal lesion
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Orthopedics Notes

•• This infection is anterior to neural tissue

•• Rarest lesion: facet joint > spinous process

Pott’s spine
•• 2 vertebral disease
•• Involves the vertebra and disc
•• Bone and cartilage
•• Paradiscal
•• Anterior disease
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TUBERCULOSIS

•• Posterior element and single vertebral disease is malignancy

•• Winking owl sing: destruction of one of the pedicles seen in malignancy

•• Blind bat sign: destruction of both the pedicles seen in malignancy

•• Location: DL>D>L>DL junction
•• DL junction: D11 – D12, L1
•• Earliest symptoms: pain
•• Earliest sign: tenderness
•• Earliest neurological sign: increased deep tendon reflex (clonus)

Treatment
•• ATT+ rest + surgery when indicated (middle path regimen)
•• Indication of surgery in any disease of spine
1. Bowel bladder involvement
2. Worsening
3. No improvement
Surgery approach for TB spine
•• Anterior: not used, because of too many structures
•• Posterior: Not used, can damage posterior structurer of vertebrae leading to instability
•• Left side approach: aorta; preferred as artery can be repaired
•• Right side approach: IVC, not used (difficult to repair once torn cannot be repaired)
•• Two surgical approaches in TB spine
1. Antero lateral decompression + bone grafting
2. Anterior decompression + bone grafting: Better Results
Important Information
•• Never touch posterior elements in Pott’s spine

Good prognostic factors

1. Young age
2. Early disease
3. Active disease
4. Slow worsening
5. Normal spinal cord
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Orthopedics Notes

Features Better Prognosis Poor Prognosis

•• Duration of cord involvement •• Shorter •• Longer (>12 months)
•• Speed onset •• Slow •• Rapid
•• Age •• Slow •• Rapid
•• Age •• Younger •• Older
•• Vertebral disease •• Active •• Healed
•• Cord in MRI •• Normal •• Myelomalacia / syrinx (cord damaged)

Few terminologies
•• Arthrodesis
○○ Surgical fusion
○○ Bony
○○ Painless
○○ Cobra plate is used for hip arthrodesis
•• Ankyloses: pathological fusion of a joint

Fibrous ankylose Bony ankylosis

•• Painful (because some movement is present in •• Painless
fibrous)
•• TB hip & knee, Rheumatoid Arthritis •• Septic arthritis > TB spine > ankylosing
spondylitis
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TUBERCULOSIS

Joint replacement
Types of prosthesis
Hemi-arthroplasty
1. Austin Moore: stem has two fenestration / holes
2. Thompson: prosthesis without fenestration

Thompson prosthesis Austin Moore

Total hip replacement

•• Replace both side of the joints
•• Both acetabulum & femur
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Orthopedics Notes

Cemented Uncemented
Using cement Using porous coating
Cheap Expensive
Elderly patients Patient with normal bone quality (young patients)
Shorter half life Longer half – life image
Complications of THR
•• Infection (Rare)
•• Dislocation (Rare)
•• Mortality causes: MI > CRA (cardio-respiratory arrest) >PE (Pulmonary embolism)
•• Metal associated complications
○○ Hypersensitivity
○○ Teratogenicity (contraindicated in young female)
○○ Renal insufficiently
○○ Chromosomal abnormalities (prostate & lung CA)
○○ Carcinogenesis

TB Hip
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TUBERCULOSIS

Acetabulum > Babcock’s triangle.

•• Area of femur with decreased monocytes macrophage system

•• Commonest area where TB bacilli sits in Femur
•• Commonest area affected in TB hip: acetabulum
•• Mc site in Femur: Babcock’s triangle

Stages of TB hip
1. Synovitis: FABER (lengthening)
2. Early arthritis: FADIR + < 1 cm shortening
3. Late arthritis: FADIR + > 1 cm shortening (gross movements restricted)
5. Wandering acetabulum (misnomer – femoral head wanders)
6. Fibrous ankyloses (TB arthritis)

Pestle and Mortar Appearance seen in TB Hip

Peri articular osteopenia
Due to hyperemia caused by inflammation of TB hip
1st radiological feature of TB arthritis: peri articular osteopenia
1st radiological feature of TB spine: loss of curvature of spine
TB knee
•• Gradual pain: as TB is chronic infection
•• Limp
•• Knee flexion: more capacity
•• Synovitis: flexion of knee joint
•• Radiological evidence: synovial proliferation / synovitis
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Orthopedics Notes

•• Complication: Triple deformity

1. P – posterior subluxation of tibia
2. ER – external rotation
3. F – flexion of knee
How to remember
PERF

•• Triple deformity of knee is also seen in

○○ Tuberculosis
○○ Rheumatoid arthritis
○○ Iliotibial band contracture
○○ Polio
○○ Low clothing power (hemophilia)
○○ Excess bleeding
 ORTHOPEDICS ONCOLOGY

GENERAL PRINCIPLES OF BONE TUMOR

General principle

Dx of bone tumor: Part affected > Age of patient

•• Part affected
○ Metaphysis: Osteo sarcoma
○ Diaphysis: Osteoid osteoma, Adamantinoma, Ewing’s sarcoma
○ Epiphysis: Chondroblastoma > Giant cell tumor
→ Epiphysis with calcification: Chondroblastoma
•• Upper end of humerus: Simple bone cyst (unicameral bone cyst) > Chondroblastoma (calcified)
•• Aneurysmal bone cyst: Tibia
•• Lower end femur: Osteosarcoma and Giant cell tumor
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Orthopedics Notes

•• Epithelial Tumors
○○ Tibia: Adamantinoma
○○ Mandible: Ameloblastoma mandible most common tumor is SCC

Enneking staging of Bone tumors

•• Part affected > age
•• Age
○○ 1st decade: Ewing Sarcoma
○○ 2nd decade: Osteo Sarcoma
○○ After skeletal maturity (20-40 years): GCT
○○ ES 2nd > 1st decade
○○ After 40 years: Metastasis > Multiple myeloma
•• Most common tumor of bone: Metastasis
○○ Metastasis usually come from: breast > Prostrate > Lungs
○○ If metastasis occur in children, then it will be from: Neuroblastoma
•• Most common primary tumor of bone: Multiple myeloma

Polyostotic lesion / multiple lesions

•• Exostosis aka Osteo chondroma (developmental malformation)
•• Fibrous dysplasia (developmental malformation)
•• Enchondromas
•• GCT
•• Ewing sarcoma

Radioresistant Bone tumors

•• Osteo sarcoma
•• Chondrosarcoma
•• Malignant fibrous Histiocytoma

Geographical lesions:
IA: Well defined with sclerotic margins: Simple Bone Cyst (SBC), Fibrous dysplasia
IB: Well defined without sclerotic rim: Aneurysmal Bone Cyst (ABC), Giant Cell Tumor (GCT)
IC: Ill defined margins: Chondrosarcoma
II: Moth Eaten: Multiple Lytic lesions: Myeloma metastasis
III: Permeative: Poorly demarcated, numerous lytic lesions: Ewings sarcoma, Myeloma, metastasis
 3
ORTHOPEDICS ONCOLOGY

Most common sites:

• Unicameral bone cyst Upper end humerus
• Upper end humerus (Metaphyseal) UBC > CB (Epiphyseal)
• Aneurysmal bone cyst Lower limb metaphysis (Tibia and femur)
• Osteoid osteoma Femur > Tibia
• Osteoma (Ivory or Compact or Eburnated) Skull and facial bones
• Enchondroma Short bones of hand
• Epithelial bone tumors
a. Adamantinoma (Long bones) Tibia
b. Ameloblastoma Mandible (SCC)
• Multiple myeloma Lumbar vertebrae
• Metastasis Thoracic vertebrae

Metastatic bone disease

•• Most common primary is Breast > Prostate > Lung
•• Most common sites of primary for bone metastasis
○○ In males – Prostate > Lung
○○ In female – Breast > Lung
○○ In Children – Neuroblastoma
•• Skeletal sites most frequently involved
○○ Spine (Dorsal)
•• Purely Osteoblastic secondaries (PCM)
○○ Prostate/Carcinoid/Medulloblastoma

Metastasis from Bone to Bone – ‘BONE’

4
Orthopedics Notes

Excision of bone tumors

•• Intracapsular excision: remove tumor from centre

•• Marginal excision: remove tumour from the pseudocapsule
•• Wide local excision (3cm margin): Commonest Surgical procedure done in orthopedic oncology
•• Radical excision: entire bone or segment is removed

General principles
•• Benign and cartilaginous tumors: Operated
•• Most common surgery wide local excision (3cm margin)
•• Cystic lesions: curettage (UBC)
•• With chemical to kill residual cells: extended curettage
○○ M/c chemical: Phenol
○○ Best chemical: Liquid N2
○○ Conditions in which Extended curettage is done
→ Aneurysmal Bone Cyst
→ Chondroblastoma
→ Giant Cell Tumor
→ Enchondroma
•• Malignant Tumors: neoadjuvant Chemotherapy followed by Surgery with 3 cm margin followed by Adjuvant
chemotherapy
•• Ewing’s is most radiosensitive bone tumor
•• Both Ewing’s and Osteosarcoma peak in the 2nd decade
•• Ewing’s sarcoma and osteosarcoma presents like Osteomyelitis
•• Ewing’s sarcoma and osteosarcoma involve the Femur
 5
ORTHOPEDICS ONCOLOGY

○○ Ewing’s sarcoma: Diaphysis

○○ Osteosarcoma: Metaphysis
•• Both Ewing’s sarcoma and osteosarcoma are Treated by neoadjuvant Chemotherapy followed by Surgery
with 3 cm margin followed by Adjuvant Chemotherapy

BENIGN BONE TUMORS

•• Unicameral Bone Cyst / Simple Bone Cyst

•• Upper end of Humerus

•• Single cavity, central
•• In Metaphysis
•• 1st decade of life
•• Filled with straw coloured fluid
•• Trapdoor sign
•• Fallen leaf sign (Fallen fragment sign)

•• Treatment
○○ Curettage + Bone grafting (iliac crest)
○○ Aspiration + steroids
○○ Aspiration + sclerosants
6
Orthopedics Notes

Bone Curette

Bone Gauge
Bone Nabbler

Aneurysmal Bone Cyst (ABC)

•• Multiloculated Eccentric & Expansible

•• 2nd decade of life
•• In metaphysis
•• Commonly in Tibia
•• MRI “Fluid Fluid Level” seen (Multiple septate)

•• Treatment
○○ Extended curettage: best chemical used (liquid nitrogen)
○○ Embolization: Highly vascular tumor (Blocks Arterial supply)

UBC Aneurysmal bone cyst

Age 1st decade 2nd decade
Site Proximal humerus Lower limb (however can occur anywhere)
Location Central (concentric) Eccentric
Expansile Expansile More expansile
Symptoms Asymptomatic Pain is present
Cavity Single, straw – coloured fluid Multiloculated, hemorrhagic fluid
Treatment Curettage Extended curettage
 7
ORTHOPEDICS ONCOLOGY

Codman’s tumour
•• Chondroblastoma
•• Epiphyseal tumor with calcification
•• Usually seen before skeletal maturity
•• Seen in upper end of Humerus
•• Rx- Extended curettage

Important Information
•• Codman’s tumor: Chondroblastoma
•• Codman’s triangle: aggressive bone lesions or periosteal reactions

Non-Ossifying Fibroma
•• AKA Fibrous cortical defect
•• Most common Benign lesion
•• In 1st decade
•• Involves the Metaphysis
•• Self-resolving
•• Not premalignant

Osteochondroma (Exostosis)

•• Before Skeletal maturity

•• Diaphyseal aclasia (development malformation)
•• Large to feel small on X-rays
•• Usually grows away from the joint
8
Orthopedics Notes

•• Very commonly seen around the knee and around the shoulder
•• Malignant transformation
○○ Solitary osteochondroma in <1% can turn malignant into Chondrosarcoma
•• Multiple osteosarcomas in <6% can turn into malignant Chondrosarcoma
Malignant degeneration to Chondrosarcoma can be suspected when
○○ Cartilage thickness > 2cm (measured by MRI)
○○ Rapid increase in size
○○ Growth after Skeletal Maturity
○○ Loss of Differentiation (Cortico -Medullary differentiation)
•• Treatment: Extraperiosteal resection (Removal along with periosteum)

Periosteum Elevator
Osteoid Osteoma

○○ Night pain relieved by taking salicylates

○○ Diaphyseal lesion
○○ Cortical tumour “Thickened Cortex”
○○ Nidus: Lytic centre with Sclerotic margin
○○ Nidus has both Osteoblastic and Osteolytic cells
•• Rx: Radio frequency ablation > surgical excision
Ivory Osteoma/Compact Osteoma or Eburnated Osteoma
•• Seen in skull vault
•• Incidental finding
•• Requires no treatment
 9
ORTHOPEDICS ONCOLOGY

Enchondroma

•• Most common tumor of bones of hand / feet

•• On biopsy Hyaline cartilage can be seen
•• Rx extended curettage
•• 5% cases premalignant

Syndrome associated with Enchondroma

1. Ollier’s Syndrome
•• Only enchondromas
•• Multiple
•• Malignant in 30% cases
2. Mafucci Syndrome

•• 100% pre-malignant
•• Multiple enchondroma + Hemangioma + Phlebolith (calcified superficial veins)

Chondroma

•• Popcorn calcification
•• O-ring sign
10
Orthopedics Notes

Important Information
•• Popcorn calcification is also seen in Breast Fibroadenoma, Lung Hamartomas, Bone - Chondroma
•• Ring Sign: Scaphoid-Lunate dissociation
•• Rim sign: Chronic Osteomyelitis

Giant Cell Tumour (GCT)

• To differentiate between Aneurysmal bone cyst and GCT

ABC GCT
Metaphyseal before skeletal maturity Seen at epiphysis after skeletal maturity

Only tumour that can involve the joints

•• Only bone tumour that can involve the cartilage
•• GCT has 2 types of cells
○○ Giant cells
○○ Mononuclear cells: Malignant cells
 11
ORTHOPEDICS ONCOLOGY

•• GCT: Soap bubble appearance

•• Egg shell crackling

Important Information
•• Tumor of distal end radius is always GCT until proven otherwise
•• Mc site of giant cell tumor is lower end femur
•• Lower end femur is Mc site for
○○ Giant cell tumor
○○ Osteosarcoma
○○ Osteomyelitis

Giant cell variants

1. FCD (or) non–Ossifying fibroma (commonest) fibrous cortical deficit
2. FD (fibrous Dysplasia)
3. ABC closest
4. UBC
5. Chondroblastoma
6. Chondromyxoid fibroma
7. Osteoblastoma / osteosarcoma
8. Brown tumor (Hyper parathyroidism)
GCT GCT variants
•• Identical nucleus (multiple mono nuclear cells combine to from a •• Non- identical nucleus
giant cell)

•• Tissue biopsy to differentiate b/w GCT & GC variants

•• Treatment
○○ M/c treatment: Extended curettage
○○ Excision: More common in upper end of fibula / Lower end of ulna
○○ Excision + Reconstruction with Fibula: Lower end radius

Important Information
•• Two locally Aggressive Tumor
○○ GCT
○○ Adamantinoma
•• 3% of GCT can have metastasis
12
Orthopedics Notes

Fibrous Dysplasia

Mc type is Monostotic
•• Shepherd crook deformity bone is replaced by fibrous tissue
•• Ground glass appearance & bone looks hazy
•• At upper end of femur can have a Lytic lesion with sclerotic margin K/a “Rind Sign”
•• Developmental malformation

McCune Albright syndrome

•• Has 3 P
○○ Polyostotic fibrous dysplasia (multiple bones involved)
○○ Precocious puberty
○○ Pigmentation (café Au lait- coffee colored spots)

Mazarbraud’s syndrome
•• Mazarbraud’s syndrome is polyostotic fibrous dysplasia with intramuscular myxomas

Important Information
•• Multiple GCT: Goltz syndrome
•• Olliers syndrome: Enchondromas
•• Mafuci syndrome: Enchondromas+ hemangiomas + phleboliths

Langerhans cell Histiocytosis

•• Letterer Siwe Disease: <3 years fatal
•• Hand Schuller Christian D isease: Lytic skull lesion, Exophthalmos & Diabetes insipidus
•• Eosinophilic Granuloma
○○ Solitary bone (or) lung lesion (Pulmonary Histiocytosis)
○○ Skull: most common bevelled lytic lesion
○○ On Biopsy: cells with “Birbeck Granules” (Tennis Racket appearance)
○○ Spontaneous resolution
 13
ORTHOPEDICS ONCOLOGY

Hemangioma

•• X-rays shows
○○ Corduroy appearance
○○ Vertical striations in vertebra: “Jail bar appearance”
•• CT Scan
○○ Shows unequal dot signs K/a “Polka Dot Sign”, characteristic & very rare

•• Rx: Spontaneous Resolution (rarely requires Radio therapy)

Vanishing Bone Disease

•• Aka Gorham’s disease
•• Cause: Angiomatosis of bone

MALIGNANT BONE TUMORS

Pulsatile bone tumor
•• “When we open the tumor, the margins of tumor have pulsatility”
○○ Osteosarcoma (Most Important)
○○ Aneurysmal Bone Cyst
○○ Giant cell tumor

Osteosarcoma
•• Cancer of the Young
14
Orthopedics Notes

•• Occurs in 2nd decade

•• Radiation induced sarcoma (after 10-15 year of Radiotherapy)
•• Radio-resistant bone tumor
•• Matrix (Osteoid) forming bone tumor
•• OS & soft tissue sarcomas are associated with germline retinoblastomas
•• <1% Paget’s aka Osteitis deformans will have Osteosarcoma
•• Feature: Pain / Night pain

Important Information
•• Night pain relieved on taking salicylates: osteoid osteoma
•• Types
1. Classical: Intramedullary / intra-osseous
2. Periosteal: Arise from cambium layer
3. Parosteal: Posterior aspect of lower femur – Good prognosis
4. Pagetoid: AKA Osteitis deformans - Worst prognosis

•• Treatment: T-10 protocol

○○ Methotrexate is a very important drug (Etoposide not used)
○○ Chemotherapy → Excision → Calculate the % of necrosis
→ > 95% necrosis: chemosensitive tumor, Same chemotherapy is given post-op
→ < 95% necrosis: chemo - resistant, New Chemotherapy combination
○○ T-10 Protocol: 70% 5 years survival
•• Prognosis
○○ Depends on
→ Extent of disease(Staging)
→ Pulmonary metastasis (M/c site of metastasis)
→ Systemic metastasis> Pulmonary metastasis: Liver metastasis have poorer prognosis as compared
to pulmonary metastasis
→ Grade of lesion: higher the grade poorer the prognosis
•• OS is malignancy causing pneumothorax
 15
ORTHOPEDICS ONCOLOGY

Ewing’s sarcoma
•• Origin: marrow cells (marrow biopsy useful to see the extent of the disease)
•• Localizes in the diaphysis
•• Age: second decade> First decade
•• Pain: universal complaint
•• Present like osteomyelitis

•• Genetic defects
○○ Ewing sarcoma is round cell tumor with glycogen positive cells
○○ Associated with Trisomy 8, Trisomy 12
○○ Translocation t (11;22) is the most common translocation
○○ Other diagnostic translocations are: t (21;22) and t(7;22)
○○ Specific marker: MIC2 (CD99)
•• Poor prognostic factors
○○ Age >12, Male, Proximal, fever, Anemia
○○ Increased TLC/ Platelets/ ESR/ LDH
○○ Poorest Factors include
→ Metastasis
→ Chemoresistant
→Relapse
•• All Ewing’s sarcomas are always high grade
•• Treatment
→ Pre-op CT
→ Wide excision

Chondrosarcoma
•• Involves the Pelvis
•• Has dense calcification
•• Associated with Hyperglycemia
16
Orthopedics Notes

•• Best prognosis amongst the malignant tumors

•• Chondrosarcoma (Best prognosis)> Osteosarcoma >>> Ewing’s sarcoma (worst prognosis)

Chordoma
•• Rare malignant Tumor
•• Origin: from the remnants of primitive notochord
•• Commonly occurs in the sacrococcygeal or in the spheno-occipital regions.
•• Most common site: sacrum (50%)> clivus (35%)>Junction of cervico thorax / lumbar (15%)
•• On Biopsy: Physaliferous cells are seen
•• Treatment
○○ Surgery is the mainstay
○○ ± Radiotherapy (if required)

Synovial sarcoma
•• Misnomer (Do not arise from synovium)
•• Characteristic translocation → (X:18) giving rise to SYT-SSX fusion gene
•• Near the joint bursae
•• It is a biphasic tumor with epithelial and mesenchymal components
•• Treatment – Excision

Multiple Myeloma
•• Lytic tumor
•• Plasma cells (destroys whole body / bone)
•• Features: Bone pain + High ESR + Hypercalcemia
•• Criteria
1. M proteins in serum / urine
2. Bone marrow plasma cells / Plasmacytoma
3. End organ damage like Lesion, anemia, hypercalcemia, ↑ creatinine, hyper viscosity, amyloidosis,
bacterial infection (> 2 episodes per year)
•• Punched out lytic lesions
•• Plasma cell leukemia > 20% plasma cells in peripheral Smear

Lytic lesions in skull

•• Causes
 17
ORTHOPEDICS ONCOLOGY

○○ M - Metastasis
○○ E - Eosinophilic granuloma
○○ L - Langerhans’s cell histiocytosis & Lymphoma
○○ T - Tuberculosis
○○ H - Hyperparathyroidism (Rarest cause)
○○ O-steomyelitis
○○ R - Radiotherapy
○○ M - Multiple myeloma
○○ E – Epidermoid
How to remember
•• MELTHORME
•• Punched out lytic lesion: Multiple myeloma

•• Bevelled lytic: Eosinophilic granuloma

•• Permeative (big) lesion: Langerhans’s cell Histiocytosis

•• Salt & pepper skull: Hyperparathyroidism (rarest)

Other skull changes

•• Cotton wool skull: Paget’ Disease
18
Orthopedics Notes

•• Osteoporosis circumscripta: Paget’s Disease

•• Hair on end appearance: Hemolytic anemia (BV) & Thalassemia

 19
ORTHOPEDICS ONCOLOGY
Bevelled lesion - [Link]

Multiple Myeloma

Pagets Hemolytic anemia

Plasmacytoma
20
Orthopedics Notes

•• Solitary Bone Lesion

•• May occur in spine, pelvis, skull, ribs (or) Femur
•• No Plasmacytosis in Marrow, no other clinical manifestations of Myeloma.
•• Absence of Hypercalcemia, renal failure, anemia (or) additional bone Lesions
•• Microscopy: Tumor is composed of neoplastic plasma cells.

Langerhans cell Histiocytosis (Eosinophilic granuloma)

•• May present as solitary Lytic Lesion or Multi systemic involvement

•• In the skull, present as Lytic Lesion of Bone
•• Histiocytic cells, admixed eosinophils, plasma cells, Giant cell
•• Langerhans cells- oval nuclei with Longitudinal grooves resembling coffee bean.
•• IHC: CD1a+, S100+
•• EM: Birbeck Granules, Tennis racket shaped organelles in cytoplasm

Metastatic tumors of bone

•• Most common primary is Breast (Also into orbit) > Prostrate Overall
•• Most common site of primary for bone metastasis
○○ In males: prostrate> Lung
○○ In Female: Breast> Lung
○○ In Children: Neuroblastoma
•• Skeletal sites most frequently involved spine (Dorsal)
•• Lytic expansile metastasis seen in
1. Renal cancer
2. Thyroid carcinoma
•• Purely osteoblastic secondaries: prostate/ Carcinoid / medulloblastoma
•• Metastasis distal to knee and elbow is rare and usually arise from a primary tumor of the bronchus,
bladder and colon (BBC). “BBC can go anywhere even distal to Elbow and Knee.
 NERVE INJURY

Seddon’s classification
•• Seddon’s Neuropraxia
○ Physiological block in the Nerve conduction
○ There is 100% recovery & Occurs spontaneously
○ Tinel sign negative
•• Seddon’s axonotmesis
○ Damage to Axon sheath/Motor march
○ Tinel sign positive
○ Progressive
•• Neurotmesis
○ Complete nerve transection
○ Tinel sign positive

Sunderland’s classification
•• Sunderland’s Type 1 is Seddon’s Neuropraxia
•• Sunderland’s type 2, 3, and 4 is Seddon’s Axonotmesis
•• Sunderland’s type 5 is Seddon’s neurotmesis

Important Information
•• Based on prognosis Sunderland type 4 behaves as type 5

Tinel’s sign

•• Based on Law of projection

•• Indicates regeneration of nerve
•• Law of projection says that we can stimulate only anatomically damaged nerve, but not physiologically
damaged nerve like neuropraxia
2
Orthopedics Notes

•• Hence Tinel’s sign is negative in Neuropraxia.

•• Law of projection says when we stimulate anatomically damaged (demyelinated) nerve along its course by
closing the eyes of the patient he will perceive sensation at distal most part of limb even if that part is
not there. (Eg Phantom Limb)
•• Speed of nerve regeneration is 1mm/day or 1 inch / month
•• Tinel’s sign in
○○ Neuropraxia: Negative
○○ Axonotmesis: Positive and progressive
○○ Neurotmesis: Positive but static

Axillary Nerve

•• Supplies Teres minor & deltoid

•• Sensation: upper arm
•• Regimental Badge area: Loss of sensation at this site Known as Regimental badge Sign
•• Damaged due to
1. Shoulder dislocation: Anterior or Inferior
2. Fracture of upper end of Humerus
3. Injection into deltoid muscle
Management of axillary nerve injury
•• Excellent response to nonoperative treatment
•• Favourable results can be expected for the rest if surgical repair is undertaken within 6 months of injury
•• Surgical options include neurolysis, nerve grafting, and neurotization.
•• Majority of patients who required a surgery underwent a nerve grafting procedure.
•• The result of nerve grafting have been encouraging, due to the relatively short distance from the lesion
to the motor end plate and the mono fascicular nature of the proximal portion of the axillary nerve

Musculocutaneous nerve injury

•• Large branch of the lateral cord
•• C5-7
•• Brachialis, coraco-brachialis, and biceps
•• End as lateral cutaneous nerve of forearm
•• Uncommon injuries: iatrogenic, stab injuries to axilla
•• Only cause weakening of flexion at shoulder, elbow, and supination at elbow
 3
NERVE INJURY

•• Loss of lateral forearm sensation

Lumbricals

•• Medial 2 lumbricals supplied by ulnar nerve

•• Lateral 2 lumbricals supplied by median nerve
•• Action of lumbricals
•• Extension of interphalangeal joint
•• Flexion of metacarpophalangeal joint,
•• Paralyzed lumbricals: Claw Hand (Hyperextension of MCP Flexion of IP joint)

Ulnar Nerve injuries

•• Palmar interosseous Nerve: Adduction
•• Dorsal interosseous Nerve: Abduction
•• Test for ulnar nerve injuries o Card Test: Holding a card between fingers (adduction) & trying to pull the
card out
4
Orthopedics Notes

○○ Igawa test: middle finger has only dorsal interossei can move middle finger either side (“abduction”)
○○ Book test: ask patient to hold book between his thumb & finger

○○ Froment’s sign: flexor pollicis longus is substituting for adductor pollicis

Important Information
○○ Flexor pollicis longus is supplied by AIN, branch of median nerve
○○ Wartenberg test: little finger stays abducted due to paralysis of ulnar nerve

•• Ulnar paradox: The amount of clawing is dependent upon the site of ulnar nerve injury
○○ If injury around the elbow: high ulnar nerve palsy, less clawing
○○ If injury is at the wrist: low ulnar nerve palsy, more clawing

Median nerve injuries

•• Test for median nerve injury
○○ Pointing index
 5
NERVE INJURY

○○ Benediction test: or pope’s attitude

•• Pen test: abductor pollicis brevis

•• Ape thumb deformity

•• Kiloh nevin sign: check for AIN, branch of median nerve

Important Information
•• Muscles supplied by AIN
6
Orthopedics Notes

1. Flexor Digitorum profundus (Lateral half)

2. Flexor pollicis longus
3. Pronator quadratus
•• AIN is commonly damaged in Supracondylar fracture of Humerus

Claw Hand

•• Medial 2 lumbricals: ulnar nerve

•• Lateral 2 lumbricals: median nerve
•• Action of lumbricals: extension of interphalangeal joint and flexion of metacarpophalangeal joint
•• Knuckle bender splint: used for ulnar nerve > median nerve

Radial Nerve injuries

•• Most common nerve damaged in human body
•• Most common cause: Fracture of shaft of Humerus

•• Shaft of Humerus divided into 3 parts

○○ Upper 1/3rd
○○ Middle 1/3rd
○○ Lower 1/3rd: Radial nerve injured (50%)
•• Holstein Lewis sign: Radial nerve injury in lower 1/3rd fracture of shaft of Humerus
•• Paralysis of ECRL & ECRB will cause Wrist drop
 7
NERVE INJURY

•• Posterior interosseous nerve injury: Loss of finger extension called as finger drop
•• Sensory distribution of radial nerve is Dorsum of 1st web space.
•• Saturday night / crutch palsy
○○ Occurs due to compression of radial nerve in the radial groove while putting hand on chair or the
crutch

Radial Nerve Injury

High Low PIN SRN
• BR paralyzed • Wrist drop • Finger drop • Sensory loss
+ + • Pure motor nerve so no sensory ±
loss
• Wrist drop • Finger drop • ECRB
+ +
• Finger drop • Sensory loss
+
• Sensory loss

Posterior Interosseous nerve injury

•• Pierces Arcade of Frohse (area in supinator)
•• Causes finger drop
•• No sensory loss
•• Injury occurs at Head of radius
8
Orthopedics Notes

•• Cock-up splint is used for radial nerve palsy

•• Modified jones transfer for radial nerve palsy
○○ Pronator teres to wrist extensor: For wrist drop
○○ Flexor carpi ulnaris to finger extensor: For finger drop
○○ Flexor carpi radialis to thumb

Injury to nerve
Open Closed
•• Neurotmesis •• Splint
•• Sunderland 5 ○○ Radial nerve: Cockup splint
•• Repair: Direct repair or Repair with graft e.g., ○○ Ulnar/median nerve: Knuckle Bender Splint
Sural nerve •• If it doesn’t recover: EMG (2-3 weeks) –
defibrillation

Good Prognostic Factors for a nerve injury

•• G - Growing Age: Good repair
•• O- Only motor
•• O- Only sensory
•• D - Distal
•• N - Neuropraxia: 100% recovery
•• E - Early repair
•• R - Radial nerve: best prognosis
•• V - Vascularity maintained
•• E - End to end
 9
NERVE INJURY

How to remember
•• Good Nerve

Erb’s palsy and Klumpke’s Palsy

Erb’s palsy Klumpke’s palsy (claw hand)
•• Upper trunk of brachial plexus •• Lower trunk of brachial plexus
•• C5 / C6 •• C 8 / T 1
•• More common
•• Waiter tip deformity •• Claw Hand + Horner’s syndrome
•• Better prognosis •• Poor prognosis

Movement lost in Erb’s palsy

•• F - Flexion of elbow
•• Ab - Abduction of shoulder
•• ER - External rotation
•• S - Supination of forearm
FABErS Lost in erbs - Movements are Lost
How to remember
•• FAbErS Lost in erbs
•• Most common tendon to be used for graft
1. Palmaris longus: bridges gap between hand and fingertip
2. Plantaris: Bridges gap between forearm & fingertip

Compression Neuropathy
•• AKA Nerve entrapment syndrome
•• It is compression of a nerve in a closed space
•• Most common compromised nerve: Median Nerve
•• Most common entrapment syndrome: Carpal Tunnel syndrome
•• Femoral nerve very rarely involved in Nerve entrapment syndrome

Carpal tunnel syndrome

More common in females
•• Cause
○○ Idiopathic (most common)
○○ Pregnancy
○○ Hypothyroidism
10
Orthopedics Notes

○○ Hyperparathyroidism
○○ RA
○○ Colle’s (fracture of distal radius)
•• Tests: Phalen’s / Reverse Phalen’s / Tinel’s / Durkan’s direct compression (Most Specific)

Entrapment Syndrome Nerve Involved

•• Carpal tunnel syndrome •• Median Nerve (at wrist most Common): Phalen’s / Reverse Phalen’s Test
•• Pronator syndrome •• Median nerve (proximally compressed beneath ligament of Struthers,
bicipital aponeurosis, or origin of pronator teres or FDS)
•• Cubital tunnel Syndrome •• Ulnar nerve (between two heads of flexor carpi ulnaris)
•• Guyon’s Canal syndrome •• Ulnar nerve (at wrist)
•• Thoracic outlet •• Lower trunk of brachial plexus (C8 and T1) and subclavian vessels
syndrome (between clavicle and first rib)
•• Piriformis syndrome •• Sciatic nerve
•• Meralgia paraesthetica •• Lateral cutaneous nerve of thigh
•• Tarsal tunnel syndrome •• Posterior tibial nerve (behind and below medial malleolus)
•• Morton’s metatarsalgia •• Interdigital nerve compression (Usually of 3rd, 4th toe)
•• Cheralgia Paraesthetica •• Superficial radial nerve

Thoracic outlet syndrome

•• Tests
○○ Adson’s test
○○ Wright’s test
○○ Roos test
•• Presents with C8 & T1 Symptoms (T1 is more common)

Adson's test Wright's test Roos test

Management of compression neuropathy

•• Plan A: Rest + NSAIDS → if not treated give Local steroids → if not treated then do Surgery
•• Allen’s Test: indicates the patency of the radial and ulna artery in profusely supplying the hand
 11
NERVE INJURY

Popliteal entrapment syndrome

•• Compression of popliteal artery at medial head of gastrocnemius
•• Exercise induced claudication
•• Decreased pulses on ankle flexion

Sciatic Nerve injury

•• Two components tibial nerve centrally arranged fibers and common peroneal nerve peripherally arranged
fibers
•• The injury to sciatic nerve sometimes can present as an injury to common peroneal nerve because these
fibers are peripheral and more prone to pressure.
•• Sciatic nerve divides into
1. Common peroneal nerve: further divides into
a. Superficial peroneal nerve
b. Deep peroneal nerve
2. Tibial nerve: gives Sural nerve supplying lateral part of foot
 GENERAL + UPPER LIMB TRAUMATOLOGY

TRAUMA GENERAL
•• Fracture: Break in continuity of cortex (macro or microscopic)
•• According to ATLS: ABC (Airway, Breathing, Circulation) but Cervical spine has to be stabilized 1st.
•• In Cardiac Patients According to ATLS: CAB (Circulation, Airway, Breathing)

Sure signs of Fracture

•• Includes
1. Abnormal mobility (best option)
2. Failure to transmit movements proximally
[Link]
•• Most Consistent sign: Tenderness

Commonest
•• Bone to Fracture in Human body: Clavicle (middle 3rd)
•• Bone to Fracture at birth: Clavicle
•• Bone to Fracture in children: Forearm (radius>ulna)
•• Dislocation: Shoulder (Anteriorly)
•• Dislocation in children: Elbow (Posterior)
•• Rarest to dislocate: Ankle
•• M/c ligament injury / Sprain: Anterior Talofibular Ligament
•• Medial ligament damaged around ankle: Deltoid ligament
•• Most common tendon injured: Supraspinatus > Biceps Brachii >Tendo Achilles

Markers
•• Bone resorption markers
○ Hydroxyproline
○ Pyridinoline
○ Deoxypyridinoline
○ Telopeptides (N & C terminal)
•• Bone formation markers
○ Osteocalcin
○ ALP
○ Serum Pro-collagen type 1(N & C terminal)
2
Orthopedics Notes

Important Information
•• Paget’s disease: All markers are increased (↑ Bone formation and ↑ Resorption)
•• Multiple Myeloma: No increase in bone formation marker (ALP) as it is a lytic disease
•• ↑ALP in multiple myeloma seen only in fracture

Stages of Fracture Healing

Callus formation
1. Stage of fracture Hematoma
•• If Hematoma is inside the skin: closed fracture
•• If skin broken & blood comes out: Open Fracture
2. Granulation tissue
3. Callus formation (takes place after 3 weeks)

4. Consolidation (where solid bone starts forming)

5. Remodeling

Types of fractures based on pattern

•• Transverse fracture
○○ Fracture forms an angle of less than 30 degrees with horizontal
○○ Cause: Tension / direct trauma
 3
GENERAL + UPPER LIMB TRAUMATOLOGY

•• Oblique fracture
○○ Fracture forms an angle of more than 30 degrees with horizontal
○○ Cause: Compression injury
•• Spiral fracture
○○ Cause: twisting injury
○○ Has maximum chances of union
•• Comminuted fracture
○○ Direct trauma/ Bending
○○ Bone is broken into multiple fragments

Types of fracture based on environment

•• Open / Closed

Gustilo Anderson classification

•• Grades of classification
○○ Grade 1: Clean wound of < 1 cm length
○○ Grade 2: Wound > 1cm in length without extensive soft tissue damage, skin flap or avulsion
○○ Grade 3: Wound associated with extensive soft tissue damage, comminution, contaminated, segmental
fractures, Gunshot injuries or farm house injuries
○○ Grade 3a: Adequate periosteal coverage is there
○○ Grade 3b: Significant periosteal stripping and it requires secondary bone coverage procedure like skin
grafting or flap
○○ Grade 3c: Open fracture with Vascular injury that requires vascular repair
○○ Treatment
○○ Overall treatment: Debridement + External fixator

Pathological Fractures
•• A fracture in an abnormal bone is referred to as pathological fracture.
•• Vertebral bodies (thoracic and lumbar) are the most often affected bones followed by neck femur and
lower end radius (collie’s fracture).
•• Most common cause is osteoporosis followed by metastasis.
•• In India most common cause is nutritional
•• Commonest local cause of pathological fracture is secondary to malignant lesion
•• Most common site is Thoracic vertebrae
•• Commonest generalized cause is osteoporosis (Site is vertebral column)
•• Pathological fracture in generalized disease usually heal in time
•• Pathological fracture in benign lesion usually heal but take longer time
•• Pathological fracture in infected / Malignant lesion may not unite at all
4
Orthopedics Notes

Mirel’s criteria
Number Assigned
Variable 1 2 3
•• Site •• Upper limb •• Lower limb •• Peritrochanteric
•• Pain •• Mild •• Moderate •• Severe
•• Lesion •• Blastic •• Mixed •• Lytic
•• Size •• <1/3 diameter of bone •• 1/3 – 2/3 •• >2/3 diameter of bone

•• So, patients with maximum risk of pathological fractures are having lytic peritrochanteric lesion involving
> 2/3 diameter with severe pain
•• Patients with ≤ 7 score are observed, but those with score > 8 should have prophylactic internal fixation

ATLS: Advanced Trauma Life Support

•• The Assessment of severely injured patients consists of four overlapping phases
1. Rapid primary evaluation
2. Restoration of vital functions
3. Detailed secondary evaluation
4. Definitive care
○○ Prehospital phase: ± Airway maintenance ±Control of external bleeding and shock ± Immobilization of
the patient ± immediate transport to closest appropriate facility
○○ Hospital phase: ± Triage ± primary survey (ABCDEF)
→A – Airway and cervical spine stabilization
→B – Breathing and ventilation
→C – Circulation and control of bleed
→D – Disability and deformity
→E – Environment and Exposure
→F – Fracture splintage.
DCO: Damage control Orthopedics
•• Early fracture stabilization while minimizing the second hit cause by prolonged surgical procedures
•• Shorter procedures are favored
•• Closed reduction with minimally invasive temporary fixation
1. Mostly done with borderline patients: ISS > 20 with thoracic injury or > 40 without thoracic injury
2. Polytrauma patients with abdominal / pelvic trauma and hemodynamic shock (BP <90 mm hg)
3. Lung contusion
4. Mean pulmonary artery pressure > 24 mm Hg
5. If MPAP increases by 6 mm while reaming

Supracondylar fracture of humerus

 5
GENERAL + UPPER LIMB TRAUMATOLOGY

•• Extra-articular fracture (Occurs away from the joint)

•• Rx: Closed Reduction and fixation

Lateral condyle intra-articular fracture

•• Joint is affected
•• Articular surface needs to be restored
•• Rx: Open reduction

Fracture healing
Primary healing Secondary healing
Callus •• Absent •• Present
Biological healing •• No •• Yes
Examples •• Plating •• Nailing / casts

Non-Union Types
•• Condition where the fracture does not unite for 9 months of which the last 3 months, there is no
progress in healing.
•• Types
1. Hypertrophic (Vascular)
2. Atrophic (avascular)
Hypertrophic Atrophic
• Vascular • Avascular
• High amount of callus • No callus
• Rx: stabilize, callus will change into consolidation • Rx: Freshen the fracture + stabilize + bone graft
6
Orthopedics Notes

•• Fractures known for non-union

○○ F - Femur Neck fracture: (Cambium layer absent)
○○ L – Lateral condyle of Humerus
○○ U – Ulna lower 1/3rd
○○ T – Body of Talus, Lower 1/3rd of Tibia
○○ S – Scaphoid

How to remember
•• FLUTS
•• Most Common Complication in Scaphoid: Non-union > Avascular necrosis

Fractures known for malunion

•• M - Malunion
•• I - Intertrochanteric Fracture Femur
•• S - Supracondylar Humerus
•• C - Colle’s Fracture / Clavicle fracture

How to remember
•• MISC

UPPER LIMB
Rotator cuff injuries
•• Rotator cuff muscles: Sit-s
○○ Supraspinatus
○○ Infraspinatus
○○ Teres minor
○○ Subscapularis: inserts on lesser tuberosity, Internal rotator
•• Lift off test: To check damage to subscapularis
 7
GENERAL + UPPER LIMB TRAUMATOLOGY

•• Treatment for Rotator cuff tear

○○ Repair
○○ If Irreparable, then do tendon transfer

Shoulder Dislocation

•• Usually occurs with abduction and external rotation force

•• In Anterior Dislocation: Down/Out (Arm is abducted)
•• In Posterior Dislocation: Up/In (Arm is Adducted)
•• Tests
○○ Dugas Test: Inability to touch the opposite shoulder in dislocated shoulder
○○ Callaway Test: Circumference of axilla lengthens in dislocated shoulder.
○○ Hamilton Ruler Test: When ruler placed on lateral epicondyle ruler touch lateral epicondyle and
acromion simultaneously in dislocated shoulder.
○○ (Normally it can’t)
○○ Bryant’s test: lower level of axillary fold which can be observed from a distance in dislocated shoulder.
•• Management
○○ Kocher’s maneuver: most common
○○ Stimpson’s maneuver: gravity assisted reduction.

Stimpson’s maneuver
8
Orthopedics Notes

○○ Hippocrates Maneuver: not used

Shoulder Instability
•• Anterior: ABER (Abduction + External rotation) + Extension
•• Posterior: ADIR (Adduction + Internal rotation)
•• Inferior: Multi directional (Hyperlaxity, Ehler Danlos, Marfan syndrome, Osteogenesis imperfecta Aka
Laxed joint/ Luxatio Erecta)

a. Anterior Instability
•• Tests
○○ Anterior drawer
○○ Apprehension test
○○ Fulcrum / Crank test

•• Mechanism: Abduction + External rotation

b. Posterior Instability
•• Test: jerk test
○○ Mechanism: Adduction + internal rotation
 9
GENERAL + UPPER LIMB TRAUMATOLOGY

c. Inferior instability
•• Sulcus test for multidirectional instability

Complications of shoulder dislocation

•• MC complication of shoulder dislocation: Recurrent shoulder dislocation

a. Bankart’s lesion
•• Anterior tear in Glenoid labrum in anterior dislocation

b. Hill Sachs posterolateral defect

•• Defect of Humeral head in Anterior dislocation
10
Orthopedics Notes

c. Reverse Hill Sach’s: Anteromedial defect in Posterior dislocation

Matsen’s classification for recurrent instability of shoulder

TUBS AMBRII
•• T - Traumatic •• A - Atraumatic
•• U - Unidirectional •• M - Multi directional
•• B - Bankart’s •• B - Bilateral
•• S – Surgery •• R - Rehabilitation (Hyperlaxity)
•• I - Inferior capsular shift procedure
•• I - Internal closure
•• Good prognosis •• Poor prognosis

Surgery for shoulder instability

•• Bankart’s repair
•• Putti plat: double breasting of subscapularis (tightening)
•• Bristow Latarjet: Coracoid transfer to anterior glenoid

Posterior Dislocation
•• Causes: Epilepsy, Electric shock
•• Empty Glenoid sign or Electric bulb sign: Glenoid cavity is relatively empty because head is out
•• Most missed dislocation in human body.

Inferior Dislocation
•• Hyper abduction
•• Luxatio erecta (Hyperlaxity Syndrome)
 11
GENERAL + UPPER LIMB TRAUMATOLOGY

Nerve Injuries
Injury Common Nerve Involvement
•• Anterior or inferior Shoulder •• Axillary, (circumflex humeral) Nerve
dislocation
•• Fracture surgical neck humerus •• Axillary nerve
•• Fracture shaft Humerus •• Radial Nerve
•• Fracture Supracondylar Humerus •• AIN > median > radial > ulnar (AMRU)
•• Medial condyle humerus •• Ulnar Nerve
•• Cubitus Valgus •• Tardy Ulnar Nerve Palsy
•• Monteggia fracture dislocation •• Posterior interosseous nerve
•• Volkmann’s ischemic contracture •• Anterior interosseous nerve
•• Lunate Dislocation •• Median Nerve
•• Hip Dislocation •• Sciatic nerve
•• Knee Dislocation •• Common Peroneal Nerve (foot drop)

Foot drop (CPN Palsy)

FOOSH: “Fall on outstretched Hand”

a) Colle’s fracture: Most commonly seen in elderly, osteoporotic

b) Scaphoid: young
c) Supracondylar # of Humerus: In children
d) Fracture clavicle
e) Surgical neck of humerus fracture
f) Lateral condyle fracture humerus
g) Head and neck fracture of radius
h) Galeazzi fracture dislocation
i) Radial styloid fracture

Fractures of necessity (requiring surgery)

•• Galeazzi fracture dislocation
12
Orthopedics Notes

•• Lateral condyle fracture humerus

•• Displaced fracture olecranon and patella
•• Fracture neck femur
•• Monteggia fracture in adults
•• Articular fractures

Fracture of humerus
•• Indication of surgery
1. Vascular injury (Absolute indication)
2. Multiple fracture (As part of damage control)
3. Pathological fracture (fix / tissue)
4. Radial Nerve involvement after reduction

Important Information
•• Surgical Emergencies in Ortho
1. Pelvic Fracture
2. Compartment Syndrome
3. Vascular Injury
4. Septic Arthitis

Clavicle
•• MC bone to fracture
•• Most Common - Occurs in Middle 1/3rd
•• At junction of Medial 2/3rd and Lateral 1/3rd (2nd common)
•• Treatment: Observation / Sling / Figure of 8 Bandage
•• Operative indications are increasing
•• Indication for Surgery
a) Comminuted fracture
b) Open fracture
c) Floating shoulder

Three-point bony relationship in elbow (Makes inverted triangle in 90 degrees flexion

of elbow)
•• Medial epicondyle
•• Lateral epicondyle
•• Tip of Olecranon

Coronal plane deformities

•• Cubitus Varus
○○ Carrying angle decreases
○○ Seen in supracondylar fracture humerus
 13
GENERAL + UPPER LIMB TRAUMATOLOGY

•• Cubitus Valgus: Lateral (distal part goes laterally)

○○ Carrying angle increases
○○ Seen in lateral condylar humerus fractures

Supracondylar Humerus fracture

•• Undisplaced fracture of humerus: Posterior fat is elevated “Fat pad sign”

•• Fracture is displaced: Distal fragments goes posteriorly Extension
•• Treatment: close reduction and look for reappearance of pulse
•• Other Treatment
○○ Smith’s traction
○○ Dunlop traction
•• If reduction is not proper, it can lead to cubitus Varus (Gun stock deformity)
14
Orthopedics Notes

Lateral Closing wedge osteotomy

•• To treat any varus, a wedge of Bone from Lateral side is taken out (more from lateral and less from
medial) as lateral border is bigger and medial border is shorter k/a Lateral closing wedge osteotomy

Bauman’s angle
•• Angle between elbow and cubitus Varus & it’s corrections are measured according to it
 15
GENERAL + UPPER LIMB TRAUMATOLOGY

Fracture Lateral Condyle Humerus

•• Intra-Articular Fracture
•• Treatment: Open Reduction + K wire
•• Complication
1. Non Union (Cubitus Valgus)
2. Malunion (Cubitus Varus) Very rare
3. This can also lead to ‘’Tardy Ulnar nerve palsy

Important Information
•• Malunion in SCH #:
○○ Very common
○○ Leads to cubitus Varus

Gartland classification – Supracondylar fracture of humerus

•• Extension type of injury (95%)
•• Types
○○ Type 1: Un displaced
○○ Type 2: Displaced with posterior hinge intact
○○ Type 3a: Displaced fracture with lateral hinge broken (PM)
○○ Type 3b: Displaced fracture with medial hinge broken (PL)
○○ Type 4: Completely displaced flexion type (5%)

Monteggia Fracture

•• Medial bone (Ulna)

•• Mouth (upper ½) # with Radial head dislocation

Bado classification of Montegia fracture

•• Type 1: Anterior dislocation of radial head with proximal third ulnar fracture
○○ Classical monteggia fracture dislocations
16
Orthopedics Notes

○○ This type was originally described by monteggia in 1814

○○ Most common type

•• Type 2: Posterior dislocation of radial head with proximal third ulnar fractures

•• Type 3: lateral dislocation of radial head with proximal third ulnar fracture

•• Type 4: anterior radial head dislocation as well as proximal third ulnar and radial shaft fractures
 17
GENERAL + UPPER LIMB TRAUMATOLOGY

Surgery: Bell tawse procedure

Galeazzi fracture
(more common than Monteggia )

A. Fracture of Radius (Lower ½)

B. Dislocation of Distal Radio-Ulnar Joint
C. Interosseous Membrane Damaged
D. Triangular Fibro-Cartilage Complex (TFCC) Damaged (Found in Distal Radio-Ulnar Joint)

Colle’s and Smith fracture

•• Colle’s fracture
○○ Extra articular
○○ Most common Fracture of elderly females
○○ Fracture of distal radius in the Forearm with dorsal (posterior displacement) of the wrist & hand
○○ “Dinner fork” / “Bayonet deformity”
○○ Mech of injury fall on outstretched hand
○○ Distal part is supinated, Lateral displacement,Imapacted Bony fragments
○○ Treatment
→Traction then Pronation + Palmar Angulation + Ulnar deviation
→Cast Below Elbow (Exception) Handshaking Cast
•• Smith’s fracture (Reverse Colle’s)
○○ Fracture of distal radius in which the distal fracture fragment is displaced volarly (ventrally)
○○ Mech of injury: fall on outstretched hand
○○ Garden spade deformity
○○ Treatment: Supination + Lateral force + Posterior force
18
Orthopedics Notes

Pulled elbow (Traction injury)

•• History of traction
•• Radial head pulled out of annular ligament ‘’Nursemaid elbow’’
•• Radial head: Responsible for 85% of pronation & supination
•• Position: Forearm is pronated (supination is lost)
•• Age: 1 – 4yrs (mean = 3yrs)
•• X- rays: insignificant
•• Treatment
○○ Forceful supination + Flex it to position the head back
○○ Self- resolving condition
○○ As supination can be gravity assisted.

Fractures of lower end of radius

•• Lateral view: 1st Metacarpal is anterior.
•• Fracture breaks the joint: intra-articular
•• Away from joint: extra-articular
•• Dislocation: Complete loss of contact of 2 joint structures
•• Subluxation: Partial loss of contact of 2 joint structures
 19
GENERAL + UPPER LIMB TRAUMATOLOGY

Barton fracture

Intra-articular fracture: Fracture of articular surface of radius with Volar (anterior) subluxation of wrist.
•• Volar Barton > Dorsal Barton
•• Treatment
○○ Fixation by plating Volar Barton: Anterior

Normal Anatomy of wrist

•• Lateral view
○○ Radius
○○ Anterior scaphoid
○○ In the center capitate
○○ Moon shaped bone lunate
•• The blood supply will come from distal to proximal in scaphoid

Scaphoid fracture
•• Most common carpal bone to fracture
•• Blood Supply is distal to proximal
•• Fracture usually occurs in the waist (mid-point) and Blocks blood Supply distal to proximal in Scaphoid
fracture causes Avascular necrosis of proximal pole
•• In children, distal pole fracture is common
20
Orthopedics Notes

•• Overall, Most common site of fracture → waist of the scaphoid

•• Scaphoid fracture shows tenderness in anatomical snuff box.
•• Management
○○ Glass holding cast
○○ Herbert screw for fixation

AVN Scaphoid Herbert screw Glass holding cast

•• AVN of scaphoid: AKA Osteonecrosis occurs in proximal pole

Scapho-Lunate dissociation
•• Gap between scaphoid & lunate k/a Terry Thomas sign / David letterman sign
•• Ring sign: Scaphoid looks like a ring

Ring sign
Bennetts Fracture Dislocation
•• Fracture at base of 1st Metacarpal
•• Rolando fracture: Only # at base of 1st MC, No dislocation
•• Bennett’s Fracture dislocation (common in boxers) # at base of 1st MC due to pull off a muscle ‘’Abductor
pollicis longus tendon’’ displaced

1. Bennett’s fracture 2. Rolando fracture

•• Fracture dislocation at base of 1st •• Intra – articular fracture (as it involves base of 1st Mc)
MC due to pull of a muscle causing
•• Fracture at base of 1st MC
dislocation
•• No dislocation
 21
GENERAL + UPPER LIMB TRAUMATOLOGY

Reverse Bennetts fracture

•• Fracture involving base of 5th metacarpal

Boxers fracture

•• Fracture involving the neck of 5th metatarsal

•• Commonest

Wrist dislocation

•• Lunate dislocation: lunate comes out and rest of the bone stay
○○ “Pie sign” in AP view
○○ Spilled tea cup / Pot sign in lateral view

•• Perilunate dislocation: Lunate stays and rest of the bone goes out
○○ More common
22
Orthopedics Notes

Articular Extra-articular
•• Definition •• # at articular surface •• # at shaft, ligament / tendon / Muscle
/ Nerve
•• Restricted movements •• Active & passive •• Active

Complications of trauma
•• Compartment syndrome: Cast
•• Myositis ossificans: H/o Massage
•• Sympathetic overactivity: Sudeck’s
•• Fat embolism: Worst prognosis / Fracture of femur/ Forty-eight hours

Compartment Syndrome
•• History of tight cast
•• MC area: Deep posterior compartment of leg > Deep flexor forearm
•• Earliest symptom - pain out of proportion to injury
•• Earliest sign - pain on passive stretch at distal most joint of extremity Management: Remove the cast
(pain – not controlled by analgesics)
•• Pulse Normal: because micro-circulation is only affected. Hence, it is not a reliable indicator.
•• Normal Pressure at leg: <11 mmHg
•• Calf pressure during walking: 200 – 300 mm Hg
•• Treatment: Fasciotomy (release up to deep fascia)
•• Indication
○○ Pressure > 30 mm Hg
○○ Neurovascular compromise
○○ Paresthesia (+): do fasciotomy

Volkmann’s ischemic contracture

•• Sequelae of compartment syndrome
•• More common in upper limb
•• Deep flexor compartment of forearm
•• Flexor digitorum profundus > flexor pollicis longus
•• Order of N. involvement: Anterior interosseous> Median > Ulnar
•• Management
○○ Turn buckle splint
○○ Max page muscle sliding operation
 23
GENERAL + UPPER LIMB TRAUMATOLOGY

Myositis ossificans
•• H/o of massage often present
•• Unilateral
•• Elbow
•• Brachialis > Biceps
•• Management
○○ Immobilization = 1st 3 weeks
○○ Only Active exercises (no passive exercise) = 3 weeks to 1 yr.
○○ Surgery > 1 yr.

Sudeck’s dystrophy
•• Complex regional pain syndrome
•• Sympathetic over-activity
•• Lankfort’s Triad
Stimulus (injury)

Response Activity (sympathetic overactivity)

•• Response: Due to sympathetic overactivity

1. Red hot shining skin
2. Patchy osteopenia / hyperemic osteopenia
•• Types
○○ Type 1: Post – traumatic (after Colle’s #) ~ sudeck’s
○○ Type 2: nerve injury (usually medial nerve) ~causalgia
Treatment: Exercises to continue Results are poor

Complications of Colle’s
1. Finger stiffness – most common
2. Mal union → dinner fork deformity
3. Rupture of extensor pollicis longus
4. Carpal tunnel syndrome
5. Sudeck’s dystrophy
 SPINE + PELVIS + LOWER LIMB
TRAUMATOLOGY

SPINE, PELVIS AND LOWER LIMB

•• Normal curvature of spine

○ Cervical Lordosis (inwards)
○ Thoracic - Kyphosis (outwards)
○ Lumbar - Lordosis

Exaggerated lumbar Lordosis

•• Excessive inward curvature
•• Causes
○ S - Spondylo-listhesis
○ O - besity/Osteoporosis
○ A - Achondroplasia
○ P - Postural
How to remember
•• SOAP

Scoliosis
•• Lateral curvature of spine with rotational element of vertebra
•• Causes
○ Idiopathic
○ Congenital
○ Postural
2
Orthopedics Notes

•• Adam’s test: when the patient bends forward, the spine will become straight if it’s a postural (or)
nonstructural scoliosis
•• Failure of segmentation
○○ Block vertebra
○○ Unsegmented vertebra
•• Mixed – unsegmented bar with
hemivertebrae
○○ Hemi vertebra can be
→ Fully segmented
→ Semi segmented
→ Incarcerated
→ Non segmented

Cobb’s angle

•• Two lines are drawn one at the top of the curve and other at the bottom of the curve
•• The angle between the perpendiculars of these lines is the angle between the two lines
•• The angle between the two lines is same as the angle between the perpendiculars to each line
•• It is important to quantify & treat it
•• Rx
○○ Cobb’s angle < 30 degree: Observation
○○ 30-45 degree: Brace (Milwaukee / boston)
○○ >45 degrees: Corrective surgery
 3
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

• Risser’s sign

○○ If a patient has almost fused skeletal maturity, the scoliosis won’t change much for the growth
○○ Dividing iliac crest from anterior superior iliac spine to PSIS as its fuses
○○ Fusion
→ 0-25% - Risser sign 1
→ 26-50% - Risser sign 2
→ 51-75% - Risser sign 3
→ 70-100% - Risser sign 4
→ Complete Fusion - Risser sign 5
○○ In Risser sign 4 or 5 surgery is done if the curves > 50 degree
○○ In Risser sign 1 & 3 observation is done as there is a chance of correction as the child grows older.

Block vertebrae

Spinal Fractures
1. Jefferson fracture: Burst fracture of C1
2. Hangman’s fracture: Traumatic spondylolisthesis of C2(axis) over C3
3. Burst fracture: Vertical compression injuries
4. Whiplash injury: Sprained neck. Easier were called as railroad spine/ Erichsen’s disease Hyperextension
followed by flexion.
5. Flexion – Compression:
a. Wedge compression
b. Tear drop (may have bone fragment from antero-inferior part of vertebra).
6. Flexion – distraction: Facet dislocation
7. Clay- Shoveler’s fracture: Avulsion fractures of spinous process of C7 > D1 Vertebra
8. Motor Cyclists fracture (Hinged fracture): Transverse fracture across base of skull leading to separation
into anterior – posterior.
9. Undertakers fracture: Tearing of C6-7 disc space causing subluxation, caused by Undertaker’s handling
the dead body.
Spinal Cord Injury Without Obvious Radiological Abnormality (SCIWORA): Pediatric injury (<8yrs). Xrays
are normal but there is neural deficit. This is due to lax ligaments permitting traction injury to cord. Cervical
spine is most commonly affected.
4
Orthopedics Notes

Jefferson’s fracture

•• Fracture of Atlas’s (C1)

•• Occurs due to vertical compression force, causing the disruption of the ring of C1 known as the burst
fracture
•• Neural deficit is rare (because wide spinal canal)
 5
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

Hangman’s fracture

•• Traumatic sp ondylolisthesis of C2 (axis) over C3 with fracture through pars – inter articularis of C2
•• Slip of C2 over C3 verterba called as spondylodisthesis.

Clayshoveller’s fracture
•• Fracture of spinous process of C7 > D1.
SCIWORA (spinal cord injury without radiographic abnormality)
•• Occurs in pediatric age group <8 years.
•• X rays: Normal
•• But there is neural deficit due to lax ligaments (flexibility in children) permitting traction injury to cord.
•• MC affected cervical spine
Whiplash injury /railroad spine /Erichsen’s disease
•• Sprained neck due to hyperextension followed by flexion
•• Happens when sudden breaks are applied in a fast moving vehicle.

Crutchfield tongs
6
Orthopedics Notes

•• Applied on the parietal bone of the skull

•• Use for cervical spine traction.

NEUROGENIC SHOCK
•• Autonomic dysregulation seen in the patients with spinal cord injuries
•• The trauma leads to a state of shock caused unopposed parasympathetic action with a complete loss of
sympathetic response.
•• It is a diagnosis of exclusion
•• Triad of hypotension. bradycardia. and temperature dysregulation is seen.
•• Systolic blood pressure of < 100 mmHg heart rate of less than 80 per minute.
•• Other causes of neurogenic or spinal shock apart from trauma are spinal anesthesia (most common),
Guillain-Barre syndrome, autonomic nervous system toxins, transverse myelitis.

SPINAL SHOCK
•• Acute loss of motor, sensory and reflex functions below the level of injury.
•• Absence of anal wink and bulbocavernosus reflexes and by flaccid paralysis.
•• It is a temporary phenomenon and recovers usually in 24 to 48 hours even in severe injuries but can
persist for weeks or rarely months.
•• There is no specific treatment for spinal shock.
 7
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

Management of spinal cord injury

8
Orthopedics Notes

Trendelenburg test

•• To check stability of hip

•• Stability of hip depends on
•• Proper femur head & Acetabulum
•• Normal hip abductors (G. medius & Minimus)
•• Superior gluteal nerve
•• Positive means drop of pelvis on opposite (normal) side
•• Trendelenburg test is normally negative (hip muscles & hip nerves are normal).
•• When Patient stands on one leg, despite gravitational pull the pelvis doesn’t drop down due to pull of the
muscle, the hip is kept straight.
•• In the same scenario, if the side of the hip is not normal (or) there is a damage in hip muscles (or) nerve
the pelvis will drop and cannot be elevated on the opposite side. Known as positive Trendelenburg sign.
•• Drop is on opposite side to the damage.
•• Bilateral positive: Waddling gait.

Thomas Test

•• Done for hip flexion deformities

•• When the hip of the opposite side is flexed lumbar lordosis is obliterated by rotation of pelvis on
obliteration of lumbar lordosis, flexion deformity of hip becomes prominent.
•• Lumbar lordosis is compensated up to 30degree hip flexion
•• If flexed > 30 degree the flexion deformity of the abnormal side of hip will be prominent which was
hidden by lumbar lordosis.

Important Information
•• Thomas test: hip
 9
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

•• Thompson test: Tendo-achilles Tear

Thompson test
•• Tendo-achilles tear
○○ 2-6 cm above the insertion

Pelvis

•• When there is an injury to the pelvis, it will disseminate through the acetabulum (fusion of Ilium, Ischium
& Pubis) it will dissipate in the entire pelvis
•• IOC for anterior /posterior column fracture – CT scan, x-ray – Judet view
•• Spur sign: Bilateral columnar fracture.
•• “Judet & Letournal classification”.

Upper end of femur

•• Mainly weight bearing
•• The weight of the upper limb & trunk is transmitted to the lower limb & to the ground through the hip
joint
•• Wolfe’s law: bone formation is along the lines of stress

•• The trabeculae of acetabulum are in same line with the head of femur and neck of femur
•• It is continued till the posteromedial aspect at upper end of femur [calcar femorale]
•• When there’s a fracture of neck of femur the trabeculae b/w acetabulum, head of femur and neck
relationship is altered.

Gardens classification
10
Orthopedics Notes

•• Stages
○○ Stage 1: When there is a fracture that is incomplete,but the trabeculae goes into valgus
○○ Stage 2: complete fracture, all trabeculae aligned
○○ Stage 3: Partial displacement, All trabeculae malaligned
○○ Stage 4: Trabeculae of acetabulum and head aligned but neck not aligned
•• Stage 1 and 2 behaves similar in treatment and prognosis
•• Stage 3 and 4 behaves similar in treatment and prognosis

Pauwels classification

•• Pauwels 1: Angle the fracture line makes with horizontal is < 30 degrees
•• Pauwels 2: angle 30 – 50 degrees
•• Pauwels 3: Angle ≥50 degrees
 11
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

Neck of femur vs inter trochanteric fracture

Neck of femur Inter trochanteric area
•• Intracapsular area •• Extracapsular area
•• 60-year, female •• 80-year, male
•• Less pain •• More pain
•• Less shortening •• More shortening
•• Less external rotation (<45 degrees) •• More external rotation (>45degrees)
•• Known for Avascular necrosis •• Known for malunion

Treatment: Intertrochanteric fracture

•• Cephalo-medullary nail aka proximal femoral nail Dynamic Hip screw
12
Orthopedics Notes

Delbet classification for pediatric Fracture Neck femur

•• Type
1. Trans epiphyseal
2. Transcervical
3. Cervico trochanteric
4. Intertrochanteric
•• Incidence: 2>3>4>1

Fracture neck femur

•• Treatment
•• < 65 Years, < 3 weeks: screw fixation
○○ <65 years of age, > 3 weeks of fracture: Bone graft or osteotomy
○○ ≥65 years: hemiarthroplasty
○○ If Fracture neck femur + Arthritis: Total hip replacement

Patellar fractures
 13
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

•• Occurs due to violent muscular pull (indirect), direct trauma

•• Tube cast may be used

•• Displaced transverse fracture: tension band wiring by K-wire and stainless steel (ss) wire
•• Comminuted fracture: at least proximal third of patella is intact (partial patellectomy)
•• Severe comminution: total patellectomy

Bipartite Patellar
•• A bipartite patella is a condition where the patella is made up of two separate bones instead of one. It
occurs when the patella fails to fuse properly during development, leading to a bipartite appearance. This
condition is typically asymptomatic and may go unnoticed for many years. However, in some cases, it can
cause pain, swelling, or discomfort, especially during physical activity.
•• The Xray of opposite knee must be taken as the condition is bilateral in 50% of cases and this condition
is more common in males than females.
•• Management of bipartite patella usually involves conservative measures to alleviate symptoms. These
measures may include rest, ice, and physical therapy to strengthen the Quadriceps muscles surrounding
the knee and reduce stress on the patella. In more severe cases, a brace may be recommended to provide
additional support and reduce stress on the patella. Pain medications and anti-inflammatory drugs may
also be prescribed to relieve pain and reduce inflammation.
•• If conservative measures fail to provide relief, surgery may be considered. Surgery for bipartite patella
typically involves removing the smaller bone fragment and smoothing the joint surface to reduce friction
and alleviate pain. In rare cases, surgery may involve fusing the two patellar fragments together to
create a single patella.
•• Overall, the management of bipartite patella is focused on relieving symptoms and improving function.
With appropriate treatment, most people with this condition can return to their normal activities without
significant limitations.
14
Orthopedics Notes

Tibial fracture
•• Proximal tibia fractures: Schatzker classification, three column classification- split/ depression/
comminution, lateral/ medial/ anterior/ posterior
•• Tibia shaft fractures- transverse / oblique spiral
•• Distal tibial pilon fracture
•• Ankle fracture-medial and posterior malleolar fractures
•• Tibia is very commonly associated with open injuries

Plaster casts and their uses:

Name Use
Minerva cast Cervical spine disease
Risser’s cast Scoliosis
Turn-buckle cast Scoliosis
Shoulder spica Shoulder immobilization
U-Slab/hanging cast Fracture of the humerus
Hip spica Fracture of the femur
Cylinder cast/tube cast Fracture of the patella
Patellar tendon bearing Cast (PTB Fracture of the tibia
cast)
Fracture lower end
Colle’s cast (Hand shaking) radius
Glass holding cas Fracture scaphoid
Common Splints/Braces and their Uses:
Name Use
Crammer-wire splint Emergency immobilization
Aluminum splint Immobilization of fingers
UPPER LIMB
Cock-up splint Radial nerve palsy
Knuckle bender splint Ulnar nerve palsy/Median nerve palsy
Volkmann’s splint or Turn Buckle splint Volkmann’s ischemic contracture (VIC)
Aeroplane splint Brachial plexus injury
Dunlop traction Supracondylar fracture of humerus
Smith’s traction Supracondylar fracture of humerus
 15
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

Figure of eight bandage Clavicle

Velpeau sling and swathe Acromioclavicular dislocation > shoulder dislocation
Gutter splint Phalangeal and metacarpal fractures
Thumb spica splint Scaphoid fracture/Metacarpal fracture/Game keepers
thumb
Sugar tong Humeral fracture
Distal sugar tong/Reverse sugar tong Distal forearm fracture
Double sugar tong Elbow fracture
Buddy strapping Phalangeal fracture
LOWER LIMB
Thomas splint Fracture femur, knee immobilization
Bohler-Braun splint Fracture femur, knee and tibia
Dennis Brown splint CTEV
Toe-raising splint Foot drop splint
Gallow’s traction Fracture shaft of femur in children below 2 years (or 12 kg
body weight)
Bryant’s traction Fracture shaft of femur in children below 2 years
Russell’s traction Trochanteric fractures
Buck’s traction Conventional skin traction
Perkins traction Fracture shaft femur in adults
90 degrees-90 degrees traction Fracture shaft of femur in children
Agnes-Hunt traction Correction of hip deformity
Well-leg traction Correction of abduction deformity of hip
Pelvic harness, Von Rosen splint, Ilfeld or Developmental Dysplasia of Hip
Craig splint or Bachelor cast
Broom stick (Petrie) cast Legg-Calve-Perthes Disease
SPINE
Four-post collar Neck immobilization
SOMI brace (Sterno occipital mandibular Cervical spine injury
immobilization brace)
ASHE (Anterior spinal hyper extension) Dorso-lumbar spinal injury
brace
Taylor’s brace Dorso-lumbar immobilization
Milwaukee brace Scoliosis
Boston brace Scoliosis
Lumbar corset Backache
Goldthwaite brace Lumbar spine (T.B.)
Head-halter traction Cervical spine injuries
Crutchfield traction Cervical spine injuries
Halo-pelvic traction Scoliosis
Minnerva cast, Halo device Cervical spine
Risser’s cast, Milwaukee brace, Boston Scoliosis (usually idiopathic or Dorsal)
brace
16
Orthopedics Notes
 17
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY
18
Orthopedics Notes
 19
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

Age wise treatment of fracture shaft of femur

•• If child is < 5 years: SPICA
○○ 5-10 years: TENS -Titanium Elastic Nail System
•• ≥10 years: interlock nail

Fat Embolism
•• 1 major + 4 minor criteria = Fat embolism
•• Gurd’s Major criteria
○○ Axillary or subconjunctival petechia
○○ PaO below 60 mm Hg 2
○○ CNS depression
○○ Pulmonary oedema
•• Gurd’s Minor criteria
○○ Tachycardia
○○ Pyrexia
○○ Anemia
○○ Thrombocytopenia
○○ Fat Globules present in sputum
○○ Fat present in urine
○○ Increasing ESR or plasma viscosity (PV)
○○ Emboli present in retina
•• Treatment
○○ Oxygen<40%
○○ IPPV
○○ Dextran (decreases RBC AGG)
○○ Aprotinin (decrease platelet AGG)
○○ Lipolytic: Heparin
○○ Hypertonic glucose (Decrease FFA production)
○○ Steroids to Avoid pneumonitis
20
Orthopedics Notes

Floating Knee

•• Fracture involving a major bone above and a major bone below a joint is k/a floating knee
•• Treatment: fixation

Hip dislocation
•• Dislocation have typical presentation: FABER / FADIR
•• Fracture dislocation have atypical presentation
•• Anterior Lengthening
•• Posterior and central shortening

Dashboard injury
•• Posterior hip dislocation
•• Flexion, adduction, internal rotation and shortening
•• Femoral artery pulsation felt around head of femur k/a Vascular sign of Narath
•• In posterior dislocation vascular sign of Narath is positive(Femoral Artery pulsations not felt)
 21
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

Central dislocation of hip

•• Head of femur felt on per rectal examination
•• Limb shortening

Head with acetabular fracture

•• Shortening
•• Classical deformities of posterior dislocation not present
•• Head posterior
•• Pipkins type 4: shortening and gluteal mass with atypical features
22
Orthopedics Notes

Angles in orthopedics
•• Bohlers angle

○○ Angle along the joint line and calcaneal tuberosity

○○ 20-40 degree
○○ Decrease in fracture calcaneum
•• Angle of gissaine
○○ Angle on the articular surface
○○ Normal: 95 – 105 degrees
○○ Increases in fracture calcaneum

Q angle

○○ If increased then there is higher chance of patella subluxation or dislocation

•• Insall Salvati ratio = ligamentum patellae / patellar length
○○ < 0.8 = patella baja
○○ >1.2 = patella alta
 23
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

•• Kites angle: CTEV

•• Cobbs angle: Scoliosis

Cast, Splint and Traction

•• Hanging cast – Fracture Humerus

•• U slab - Fracture Humerus

•• Cylinder cast: fracture of patella

•• Patella tendon bearing cast: Tibia fracture

24
Orthopedics Notes

•• Glass holding cast:

Fracture scaphoid

•• Hand shaking cast

Colles Fracture

•• Dunlop traction supracondylar fracture humerus

•• Clavicle figure of 8 bandage
•• Mallet finger splint mallet finger
 25
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

FRACTURE MANAGEMENT
TYPES OF FRACTURE
Jefferson fracture

•• Fracture of Atlas’s (C1)

•• Occurs due to vertical compression force, causing the disruption of the ring of C1 known as the burst
fracture
•• Neural deficit is rare (because wide spinal canal)

Hangman fracture

•• Traumatic spondylolisthesis of C2 (axis) over C3 with fracture through pars – inter articularis of C2
•• C2 over C3 slip of verterba called as spondylodisthesis.

Night stick fracture

•• Isolated fracture of the shaft of ulna

•• No dislocation of proximal (or) distal joint
•• Eg: A thief defending the stick of the guard with the Forearm in front
26
Orthopedics Notes

Chauffer’s fracture

•• Intraarticular fracture Involving radial styloid

Colle’s Fracture

•• Extra articular Fracture

•• 1st metacarpal is Anterior with a Posterior Displacement

Bucket handle fracture

•• Fracture of Posterior element on one side and the Anterior on the other side
•• Type B pelvic injury
 27
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

Open Book fracture

•• When the posterior elements provides a hinge and the anterior elements open on it, it’s an Open book
Fracture
•• Type B pelvic injury

Malgaigne Fracture

Fracture of Anterior and Posterior elements of Pelvis on the same side

Straddle Fracture

•• Bilateral superior and Inferior Pubic Rami Fracture

28
Orthopedics Notes

Pilon Fracture

•• Intra articular
•• Communited fractured involving the lower end of the Tibia

Aviators Fracture

•• Vertical fracture d/t Force on the body of talus

Jones fracture
•• Fracture of base of 5th metatarsal

Pseudo Jones fracture

•• Fracture of Tip of base of 5th metatarsal

Proximal Humerus Fracture

 29
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

1. Shaft
2. Head
3. Greater tuberosity
4. Lesser tuberosity

•• Extension type Posterior Displacement of supracondylar fracture humerus

Monteggia’s Fracture

•• Fracture of Ulna with a Dislocated Radial Head

•• Type I MC

Galeazzi Fracture

•• Fracture to the Radius with damage to the Distal Radio-Ulnar joint

Boxer’s Fracture
30
Orthopedics Notes

•• AKA street fighters’ fracture

•• Fracture neck of 5th metacarpal

Bumper Fracture

•• Fracture involving the upper end of lateral tibial plateau

Cotton Fracture

•• AKA Tri-Malleolar Fracture

•• Fracture involves 3 malleoli
•• Lateral Malleolus involving Fibula
•• Medial Malleolus involving Tibia
•• Posterior Malleolus involving Tibia

Pott’s Fracture

•• Bimalleolar Fracture
•• Medial and Lateral Malleoli are Fractured
 31
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

Chopart’s Fracture

•• Inter-tarsal injury

Lis-Francs Fracture

•• Tarso-metatarsal Injury

March Fracture

•• Involves the neck of 2nd metatarsal > 3rd Metatarsal

32
Orthopedics Notes

Extra edge For INICET

ANKLE INJURIES
Lauge- Hansen Classification of Ankle Fractures

Foot Position Supination Pronation

Force Adduction + inversion Abduction + Ext. Rotation

Position – Force (First word is position & second is force) Fracture

•• Supination – Adduction •• Vertical fracture of Medial Malleolus
•• Horizontal Fracture of Lateral Malleolus
•• Supination – External(MC) Rotation •• Horizontal fracture of Medial Malleolus
•• Pronation - Abduction
•• Pronation – External Rotation
•• Supination – External Rotation •• Oblique fracture of Lateral
•• Pronation – External Rotation •• Malleolus (Fibula)
•• Pronation –Abduction •• Horizontal fracture of Medial Malleolus
•• Comminuted Fracture of Lateral
Malleolus

Summary
Foot Force M. Malleolus L. Malleolus
Adduction Vertical Horizontal
Supination External Rotation* (MC) Horizontal Oblique

Ext. rotation Horizontal Oblique

Abduction Horizontal Horizontal

Pronation (comminuted)
 33
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

•• Fracture of lower end of fibula

CLASSIFICATION OF FRACTURE
1. Allman’s: Fracture clavicle 12. Thompson & Epstein: Posterior dislocation
2. Campbells/ Rockwood: Ac joint 13. Pipkins: Head of femur
3. Neers: Proximal humerus 14. Gardens/PauweIs/Anatomical: Neck femur
4. Gartland: Supracondylar humerus 15. Boyd Griffith/ Evans:Intertrochanterlc fracture
5. Milch: Lateral condyle humerus 16. Winquist Hansen’s: Shaft femur
6. Masons: Head radius 17. Schatzkers: Proximal tibia
7. Bados: Monteggia 18. Ruedl and Allgower: Distal tibia
8. Frykmanns/ Fernandez: Colles 19. Hawkins: Neck talus
9. Dennis: 3 Columns of spine 20. Essex Lopresti (X-ray)/ Sanders (CT scan):Calcaneum
10. Young & Burges/ Tiles: Pelvis 21. Gustilo Anderson: Open fracture
11. Judet & Letournel: Acetabulum 22. Tscherne: Soft tissue Injury in closed fracture

Neers classification

•• For proximal humerus

Dennis 3 column theory

•• Divides vertebra into 3 parts
○○ Anterior part in the anterior column
○○ Posterior in the middle column
○○ Pedicle in the posterior column
•• If 2 out of 3 columns are involved: unstable injury
34
Orthopedics Notes

TREATMENT OF FRACTURE
Operative management of injuries
•• Extra articular fractures CR: Hematoma preserved
•• Intra articular fracture OR: Prevent the Arthritis
•• Small bone fracture screws / K wires
•• Children non-operative except Peri-articular fractures Children K (Kirschner wires)

Kirschner Wires

Tractions
•• Are conservative Methods
•• Skin traction: Pad the area apply the splint apply weight 3-4 kg
•• Skeletal traction: Steenmanpin, k-wires or any metallic pin will go into the bone and apply traction where
up to 10% of bodyweight or 20kg of Weight is used

T B W: Tension Band Wiring

•• It is a correct position of implant which can be a wire/plate by which there is conversion of distractive
forces into compressile forces on the tension surface.
•• Done for patellar, Olecranon and medical malleolus fractures.

External fixators
•• Used for open injuries
•• Debridement is done and applied outside the skin.
•• Schanz screws of different size is used
•• Universal Clamp and Rods
 35
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

TYPES OF PLATES
1. Dynamic compression plate: (DCP)
•• Used to fix the diaphyseal region and can be used as neutralization Buttress mode (or) compression mode
and compress mode and compress the fracture site.
•• A drill is used to make hole into the bone and threads are made. Screws are used to fix the plate

2. Limited contact -DCP (LCDCP)

•• It decreases the contact with bone surface
•• Hence preserving bone vascularity

3. Locking Compression plate

•• The screw locks in screw holes of the plates hence the name locking plates
•• Indications
○○ Osteopenic bone
○○ Metaphyseal areas
○○ Periprosthetic fractures
○○ Failed fixation (non-Union)
36
Orthopedics Notes

1. Cancellous Bone Screw 2. Cortical Bone Screw

•• More distance between threads •• Threads throughout the screw

INSTRUMENTS USED IN ORTHOPEDICS

Osteotome Curette
• Used for cutting by the both cutting edges / • Used for scooping out the dead necrotic material
sides

0
Bone cutter Bone Nibbler
Used to freshen the margins and prepare the Used to nibble out pieces of bone to freshen the margins.
grafts to be placed at any place.
 37
SPINE + PELVIS + LOWER LIMB TRAUMATOLOGY

Bone holding forceps Bone plate holding forceps

• Always have dentations • One side is toothed and the other side is smooth
• Toothed side is for bone holding and smooth side
for plate

Interlock nailing
•• Used for Lower limb fractures (Intramedullary implant)
•• Secondary healing
•• Callus will be formed
•• Bone is Locked with Screw to prevent mal-rotation

External Fixators

•• For open Injuries

Ilizarov External fixator

•• Used in cases of non-union.
•• In case of shortening used to increase the length of the Limb
•• Works on the principle of “Distraction Histogenesis”
•• Cut at different bony ends
•• Wait for callus to form and gradually distract it
38
Orthopedics Notes

Some common errors in the book

Incorrect Correct
Rolando: Extra-articular Intra-articular
Lisfrancs TMT
M/c bone to fracture at birth: humerus •• Clavicle
Thurston Holland: Type 4 Type 2
Supracondylar: radial nerve AIN
CTEV cast / B/K A/K
Fracture healing Consolidation / remodelling
EGAWA test IGAWA Test
 ARTHRITIS

Osteoarthritis Rheumatoid Arthritis Psoriatic Arthritis (Caspar

Criterion)
Involved • PIP, DIP and 1st CMC • PIP, MCP, Wrist • DIP, PIP and any joint
(carpometacarpal) joints
Spared • MCP • DIP joint usually
(Metacarpophalangeal),
Wrist and Ankle

Clinical cases and scenarios

Ankylosing spondylitis Sacro iliac joint

Rheumatoid arthritis Metacarpophalangeal joint
Pseudogout Knee
Gout MTP joint of Great Toe
Septic Knee
Syphilitic arthritis Knee
Gonococcal arthritis Knee
Diabetic charcot joint Foot joint (midtarsals)
Senile osteoporosis Vertebra
Pagets disease Pelvis bones > Femur > Skull > Tibia
Osteochondritis dessicans Knee > Elbow
Actinomycosis Mandible
Haemophilic arthritis Knee (Children- Ankle)
Acute osteomyelitis Lower end of femur (Metaphysis)
Brodies abscess Upper end of Tibia
2
Orthopedics Notes

Ankylosing spondylosis
Young male
Lower back ache: sacroiliac join involvement
Reduced chest inspection
Hand are spared
Less common
Controlled by swimming & cycling
Bone tumors
More common in males
GCT and fibrous dysplasia: more common in females
Osteoarthritis
•• MCP Spared
•• Based of thumb (1st matecarpal joint): characteristic feature DIP > knee
•• DIP involvement: Boundchards Nodes

Cardinal sign of osteoarthritis

•• Narrowing of joint space
•• Subchondral sclerosis (age related)
•• Marginal osteophytes
•• Subchondral cysts

OA involving knee
•• Genu varum [‘o’ between legs]
•• Medial compartment is involved
•• Muscle involved → quadriceps, specifically vastus medialis
•• Specific fiber → vastus medialis obliqus
 3
ARTHRITIS

Osteoarthritis knee treatment

•• Initially – conservative
○○ Physiotherapy + lifestyle modification + glucosamine
•• If daily activities are affected: surgery
○○ Young Pts: surgery
→ High tibial osteotomy (up to 20degrees deformity)
○○ Less than 60 years: correct deformity
○○ 60 or more than 60 years: total knee replacement
•• High tibial osteotomy: removal of wedge of a bone where the lateral border is bigger than the medical
border which is called as lateral based wedge osteotomy
HTO- High Tibial Osteotomy

•• Total knee replacement: replaces the joints surface and it gives good movement, proprioception good and
mild insignificant sensory loss.

Patellar clunk syndrome

•• After Total knee replacement: Patella makes noise when the knee moves from flexion to extension
•• Fibrotic nodule at the upper end of patella
4
Orthopedics Notes

•• Treatment: arthroscopic debridement

Osteoarthritis – Management:
1. Initial 2. Young 3. Elderly
•• Initial treatment – •• Surgery for young – HTO •• 60 or more – TKR (Total Knee
conservative (High Tibial Osteotomy) (up Replacement) (movement
to 20 degrees deformity) normal, proprioception good
•• If activities of daily living
and mild insignificant sensory
are affected – surgery
loss)

Rheumatoid arthritis
•• Young female
•• Bilateral hand pain
•• Morning stiffness (age is not criteria)
•• Most common area involved in spine is upper cervical spine (AKA craniovertebral junction)
•• Craniovertebral junctional involvement: RA>AS> Gout
•• C1-C2 anomaly: spine flexion / extension view

Classification Criteria for Rheumatoid Arthritis -2010 Score

Joint involvement 1 large joint (shoulder, elbow, hip, knee, ankle) 0
2–10 large joints 1

1–3 small joints (MCP, PIP, Thumb IP, MTP, wrists) 2

4–10 small joints 3

>10 joints (at least 1 small joint) 5

Serology Negative RF and negative ACPA 0

2
Low-positive RF or low-positive anti-CCP antibodies (3
times ULN)

High-positive RF or high-positive anti-CCP antibodies (>3 3

times ULN)

Acute-phase reactants Normal CRP and normal ESR 0

Abnormal CRP or abnormal ESR 1
Duration of symptoms < 6 weeks 0
> 6 weeks 1
Total score 10 Score - R.A.
>6 indicates
 5
ARTHRITIS

The 1987 Revised Criteria for Diagnosis of RA

1. Guidelines for classification 4 of 7 criterion are required to classify a patient as having RA Patients with
2 or more criteria are not excluded.
2. Criteria (a - d must be present for at least 6 weeks and b- e must be observed by physician)
a. Morning stiffness, in and around joint lasting 1 hour before maximal improvement.
b. Arthritis of 3 or more joint areas, observed by a physician simultaneously, have soft tissue swelling or
joint effusion, not just bony over growth. The 14 possible joint areas involved are right or left proximal
inter phalangeal (PI PM), metacarpophalangeal (MCP), wrist, elbow, knee, ankle and metatarsophalangeal
joints (MTP).
c. Arthritis of hand joints eg. wrist, MP or PIP joints.
d. Symmetrical arthritis i.e. simultaneous involvement of same joint area on both sides of body.
e. Rheumatoid nodules: subcutaneous nodules over bony prominences, extensor surfaces or juxta articular
region. (PATHOGNOMIC)
f. Serum rheumatoid factor.
g. Radiological changes: bony erosion or unequivocal bony decalcification, periarticular osteoporosis and
narrowing of articular (joint) space.

Pathogenesis of RA
•• T cell contribution to bone degradation
○○ T cells can activate variety of cell types involved in bone degradation and resorption
○○ T cells directly attack the cartilage cells, and they also indirectly stimulate the dendritic cells which
release the bone and degradation enzymes
○○ It will also stimulate the macrophage and fibroblast like synoviocyte which directly damages the bone
and the cartilage
•• Systemic response
○○ Systemic auto reactivity / genetics activates the innate immunity which activate the dendritic cells,
FLS, and Macrophage
○○ Dendritic cells activates the nT cells (naïve T cells) to aT cells (activated T cells)
○○ This cause an immune response and cause damage to synovium

Deformities of RA
•• Swan neck deformity

○○ Flexion at DIP and hypertension at PIP

○○ Flexion in sufficiency of PIP
•• Boutonniere deformity / button hole deformity

○○ Extensor deficiency at PIP joint

6
Orthopedics Notes

○○ Hyperextension of DIP & flexion of PIP

•• Deformity of thumb
•• Ulnar deviation of fingers

Poor prognostic factors of RA

CHARACTERISTIC DEFORMITIES OF HAND AND FOOT IN RA

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

OA Knee RA Knee
Varus arthritis Valgus synovitis
Sclerosis Osteopenia

Psoriasis
Cup & pencil appearance
Sausage digits
Opera glass hand, paravertebral ossification
 7
ARTHRITIS

Miscellaneous information
•• Pencil in cup seen in psoriatic arthritis

•• Arthritis mutilans: seen in RA and psoriasis

Ankylosing spondylitis
•• HLA B27 positive in more than 90 % cases of AS
•• Diagnostic criteria - Modified New York Criterion
○○ Essential criteria: definite radiographic sacroiliitis plus one of the following supporting criteria
1. Inflammatory back pain
2. Limited chest expansion
3. Limited lumbar spine motion in both sagittal and frontal plane (schober test / modified schober
test)

Characteristic features
1. Enthesitis: inflammation of insertion of tendons and ligament
2. Axial skeleton disease: 30 % only appendicular (peripheral joints) Plus one of the following disease of
roots joints
3. 30% causes anterior uveitis MC extra-articular manifestation:
4. Cardiac defects

Radiographic findings
○○ Bamboo spine (bony ankyloses)
○○ Squaring of vertebrae
○○ Inter-spinous ligament calcification: dagger sign
○○ Facet calcification of joints + inter spinous ligament trolley Track Sign
○○ Sclerosed vertebral edges: romanus sing
8
Orthopedics Notes

•• Test for AS
○○ SI joint
→ Gaenslen test
→ Patrick / FABER test
→ Figure of 4
→ Pump handle test
→ Side to side compression test
○○ Cervical spine: fleche test
Characteristic Ankylosing Spondylitis Ankylosing Hyperostosis (DISH)
Joint Sacroiliac Dorsolumbar
Age Young Elderly
Chest movement Marked restriction Mild restriction
 9
ARTHRITIS

•• Urine turn black on standing + Disc calcification alkaptonuria

•• Eye involvement
○○ Kesra: kerato – conjunctivitis sicca (KVS) > episcleritis > scleritis – RA
○○ Anterior uveitis: AS

CASPAR criterion for psoriatic arthritis

•• To be classified as having PSA, a patient must have inflammatory joint disease (joint, spine, enthesitis)
with > 3 of the following 5
1. Evidence of psoriasis (One of these)
a. Current psoriasis
b. Personal history
c. Family history
2. Psoriatic nail dystrophy
3. Negative RF
4. Dactylitis (One osa, b)
a. Current
b. History
5. Radiological evidence of juxta-articular new bone formation
10
Orthopedics Notes

Acroosteolysis: Scleroderma

Gout
•• Inflamed great toe
•• Middle aged businessman (usual history)
•• Great Toe: Martels sign (overhanging bone) seen in Alkaptonuria
•• Punched out Erosions (Rat bite erosions) with history of great toe pain

Characteristic Gout Pseudogout

•• Joint •• 1ST MTP Great Toe •• Knee
•• Crystal •• Uric Acid negatively birefringent •• Calcium Pyrophosphate positively
Deposited – Needle-shaped birefringent – Rhomboid-shaped
•• Association •• Protein + Alcohol intake •• Hypothyroidism
•• X-ray •• Bone and soft tissue erosion •• Chondrocalcinosis (calcification of the
cartilage)

Charcot joints

•• Totally destroyed joints

•• Neuropathic joints
 11
ARTHRITIS

•• Loss of proprioceptive fibers

•• Anatomy deranged
•• Painless
•• Other painless ds: mycetoma
•• Indication for Arthrodesis
•• MC cause: Diabetes

Disease Joint Involvement

•• Diabetes •• Midtarsal (Most common) > tarsometatarsal, metatarsophalangeal and ankle joint
> knee and spine
•• Tabes dorsalis •• Knee (most common), hip, ankle and lumbar spine
•• Leprosy •• Hand and foot joints
•• Syringomyelia •• Shoulder (Glenohumeral), elbow, wrist and cervical spine

Hemophilia
•• Inflammatory condition
•• MC affects knee joints
•• In Children: Ankle
•• X-ray findings: PENIA
○○ Periarticular osteopenia
○○ Squaring of patella
○○ Epiphyseal enlargement
○○ Widened notch
○○ Decreased joint space (arthritis)
○○ Subarticular cyst
○○ Arnold Hilgartner classification

Hemosiderotic Synovitis
•• Occurs in chronic intraarticular bleeding. Example, hemophilia
•• Microscopy
○○ Fine villous projections may be present
○○ Hemosiderin pigment is present
○○ No proliferation of mononuclear cells
○○ No multinucleated Giant cells
12
Orthopedics Notes

Synovial Chondromatosis
•• MCC of multiple loose bodies in a joint
•• MC Joint: Knee
•• Loose body above, but not at joint because synovium of knee travel beneath patella in suprapatellar area,
synovium is continuous with knee cavity.

•• MCC of loose bodies: Osteoarthritis (Knee)

•• Osteoarthritis →→ VARUS
•• RA-Valgus
•• Valgus in one and Varus in other knee: Windswept deformity/Tackle deformity
•• Causes: Rickets > RA

•• Synovial fluid finding

○○ Viscosity: due to hyaluronic acid
○○ Normal synovial fluid is clear, WBC count less than or equal to 200/uL
○○ Inflammatory fluid WBC count 2,000 to 50,000/uL and a polymorphonuclear leukocytic predominance.
○○ Inflammatory fluid has reduced viscosity & diminished hyaluronic acid.
 13
ARTHRITIS

○○ Infections (pyogenic) is purulent, WBC count >50,000/uL

○○ Infections (tuberculosis/granulomatous) WBC count 10,000-20,000/L, PMN 60% and presence of
lymphocytes, plasma cells and histiocytes
Pigmented villonodular synovitis
•• Benign lesion of synovium
•• Usually occurs in knee joint
•• Microscopy
○○ Proliferating Hyperplastic synovium with papillary projection
○○ Consists of mononuclear cells, Multinucleated Giant cells, foamy cells and Hemosiderin
containing Macrophages
 METABOLIC DISORDERS

NOTE:
•• Rickets: Lack of adequate mineralization of growing bones.
1. N to ↓ Ca+2
2. ↓ PO43+ (Except CRF → have ↑ PO43+)
3. ↑ ALP,↑ PTH
•• Osteomalacia: Lack of adequate mineralization of trabecular bone.
•• Osteoporosis: Proportionate loss of bone volume and mineral.
•• Scurvy: Defect in osteoid formation

•• ALP in children = 3-5 (Adult)

•• Phosphate in child = Adult + 1 mg / dl
•• Image of Wrist = rickets
•• Image of Knee = scurvy, Rickets
•• To differentiate
2
Orthopedics Notes

○○ Cupping, splaying, and Flaring: Rickets

○○ White line of Frankel + Wimberger ring sign: Scurvy

Rickets
•• Mineralization defect
•• Generalized muscle weakness
•• Widening knees / wrist
•• Rachitic Rosary(B): Prominent Non- tender and round costochondral junction
•• Harrison’s groove: Sub costal sulcus d/t pull of diaphragm Genu valgum / varum (C)
•• Coxa vara: Reduced neck shaft angle of femur.
•• Enamel defect (tooth)
•• Cupping, splaying, flaring (D)
•• Osteotomy correction done only once healing takes place
•• White line of frankel (E): Healing rickets (F)

Hypophosphatemic Rickets
•• X-Linked dominant
•• PHEX gene mutation
•• Normal Ca, PTH, Vit D
•• ↑ ALP
 3
METABOLIC DISORDERS

•• Increased Incidence of skeletal deformities.

Osteomalacia
•• Osteon = bone; malacia = Softening
•• Adult counterpart of Rickets
•• Tetracycline labelling is used to calculate turnover
•• Osteoid/ Osteon > 1
•• Triradiate pelvis
•• Gold standard Investigation: Biopsy

•• Otto pelvis due to protrusio acetabuli

Scurvy

•• Occur in knees of children

•• Sharp and tender rosary
•• Disease due to lack of vit c (Ascorbic acid)
•• Findings
○○ Wimberger ring sing: Sclerotic margin of epiphysis
○○ Wimberger corner sign: Metaphyseal defect in congenital syphilis
4
Orthopedics Notes

Scurvy

○○ White line of Frankel: classical of scurvy

X-Ray Epiphysis Scurvy Rickets
White line of frankel Sclerotic margins • Sclerosed Always White • Normal If +nt→ healing rickets Wide(A)

Important Information
•• Wimberger ring sing → Scurvy → Sclerotic margin of epiphysis
•• Wimberger corner sign → Congenital syphilis → Metaphyseal defect
•• White line of frankel → Scurvy, Healing Rickets, Lead poisoning, Methotrexate therapy.

Umbauzanon
•• Found in bone softening disorders such as
i. Osteomalacia > Rickets
ii. Hyper PTH
iii. Neurofibromatosis
•• Lesions found in N.O.F and Pubic Rami
•• Indentation of cortex due to arterial pulsation Known as Pseudo-fracture. / Milkman fracture. / Losers
Zone
 5
METABOLIC DISORDERS

•• Treatment: Treat the primary cause, Rest

Congenital Rubella
•• Celery Stalk appearance
•• Also seen in chronic degeneration of ACL

Hyperparathyroidism
•• Sub periosteal Resorption
•• Osteitis Fibrosa Cystica
•• Rotting fence post appearance
•• Brown tumor
•• Salt pepper skull
•• Loss of lamina dura
•• AVN rarely.
6
Orthopedics Notes

Achondroplasia
•• Enchondral ossification defect
•• Normal intelligence
•• Limb dwarfism
•• Trident hand or starfish hand
•• Champagne glass pelvis [Width>depth]
•• Bullet nose vertebra
•• Limb dwarfism
•• Causes: Due to FGFR mutation leading to enchondral ossification defect

Tirdent Hand Starfish hand Bullet nose vertebrae

Short fourth metacarpal

•• Turners syndrome
 7
METABOLIC DISORDERS

•• Pseudohypoparathyroidism

Cleidocranial disorder
•• AD
•• Intramembranous ossification defect
•• Absent clavicle: Shoulders meet in midline
•• Squashed / flat face
•• Delayed dentition
•• Scoliosis and coxa vara
•• Deformities in spine or reduced neck shaft angle

Osteoclast Defects
•• Osteopetrosis > Paget’s (Multifactorial)

Osteopetrosis / Albers Schonberg disease / Marble bone disease

•• CA II proton pumps defect genetically –Bone resorption

•• Known as Marble bone ds.
•• Functional deficiency of Osteoclasts
•• Pancytopenia/ Anemia/ Infections
○○ Pancytopenia due to absent bone marrow
○○ Anemia: secondary hematopoiesis
○○ Infection: Osteomyelitis of mandible
8
Orthopedics Notes

•• Hepatosplenomegaly
•• Blindness: 2nd CN Compression
•• Deafness: 8th CN Compression
•• M/c compressed CN: 7th CN (Facial)
•• Delayed bone healing but few studies claim normal healing.
•• T/t: Bone marrow Transplant (I/v)

•• Bone within a bone appearance (Also in Sickle cell Anemia)

•• Rugger jersey spine (Renal Osteodystrophy)

•• Erlen Mayer flask deformity seen in Gaucher’s >Osteopetrosis.

Erlenmeyer Flask

Paget’s Disease
•• Osteitis Deformans
•• ↑ Bone formation
•• ↑ Bone Resorption
•• Osteoclast defect → larger, irregular
•• Excessive Disorganized bone turnover
 9
METABOLIC DISORDERS

•• Age > 50 yr., Males (6th decade onwards)

•• Pelvis commonly affected
•• M/c symptom pain
•• Normal Ca+2 and P
•• ↑ALP
•• Diagnostic histological Feature → Cement lines → Mosaic pattern (or) Marble pattern (A)
•• Ivory vertebra; picture frame vertebra / Cotton wool skull (↑ head/ hat size)
•• Osteosarcoma (1%)
•• Blade of Grass/ flame appearance: Brim Sign
•• Doc: Bisphosphonates
•• Calcitonin Good for pain control

•• Picture frame vertebra

•• Blade of grass or flame appearance

10
Orthopedics Notes

•• Increasing hat size

•• Brim sign

Important Information
•• Rim Sign Chronic Osteomyelitis.
•• Brim Sign Paget’s disease
•• Ring Sign Scapho-Lunate dislocation
•• Wimberger Ring Sign Scurry
•• O’ Ring Sign chondroma

Osteoporosis
•• Normal Ca, P and ALP
•• ↓Bone mineral density measured by DEXA scan. (Dual emission X-ray absorptiometry)
•• T Score
○○ 0 to -1 = Normal
 11
METABOLIC DISORDERS

○○ -1 to – 2.5 = Osteopenia
○○ <- 2.5 = Osteoporosis
•• Severe Osteoporosis: Osteoporosis with fracture Vertebra > fracture Hip > Colles fracture
•• In Hemiplegic patient: Humerus has max loss of bone mineral density
•• Treatment
○○ Estrogen: (-) Rank L
○○ Bisphosphonates: (-) osteoclast but increase hip fracture after prolonged use. (Drug of choice for
osteoporosis)
○○ Calcitonin: (-) Osteoclast
○○ Low dose PTH (20μg/dL) (Teriparatide): (+) Osteoblasts.
•• Drugs
○○ ↑ Formation: Fluoride, PTH
○○ ↓ Resorption: -Bisphosphonates, calcitonin, Denosumab, and estrogen
○○ Strontium acts on both the pathways
○○ X-Ray findings
 Codfish vertebrae (Osteoporosis > Osteomalacia)

Osteogenesis imperfect

•• Defect in Type 1 collagen formation

•• AD
•• Osteopenia causing repeated propensity of fracture
•• Fracture heals at a normal rate
•• MC involved: Femur (LL)
•• Mc cause of multiple fractures at birth
12
Orthopedics Notes

•• Hyperlaxity, DDH
•• Blue Sclera
•• Deafness
•• Dentinogenesis imperfecta
•• Sillence classification
•• Pathological fracture: Bailey Dubow rods (adjust nail length with growth)
•• Treatment: Gene therapy

Types of Spines
•• Rugger Jersey Spine seen in
○○ Chronic Renal Failure
○○ Osteopetrosis

•• Picture frame/ Ivory vertebra: Paget’s

•• Bullet shaped vertebra: Achondroplasia

 13
METABOLIC DISORDERS

•• Cod fish vertebra: Osteoporosis

•• Bamboo Spine: Ankylosing Spondylitis

Causes of IVORY Vertebra

•• L – Lymphoma
•• I - Infections (TB)
•• M - Medulloblastoma/ Metastases
•• P - Paget’s (M/c)
•• H - Hemangioma
•• OR steosarcoma/ Osteoblastoma
How to remember
•• LIMPHO

Hyperostosis disorders
[Link] dripping disease/ Melorheostosis
14
Orthopedics Notes

•• Sclerosis over the bone

•• Looks like dripping of the wax

2. Osteopoikilosis
•• Spotted bone disease
•• Periarticular, symmetrical, and uniform size bony spots

3. Osteopathia striata
•• Striations over entire skeleton

Renal osteodystrophy
•• Renal Osteodystrophy: Bony changes are combination of Rickets + Hyperparathyroidism + Osteoporosis
+ Osteosclerosis.
•• Renal osteodystrophy is more common in CRF. It is driven by presence of secondary hyperparathyroidism.
•• Pathophysiology begins with damaged glomerulus’s inability to excrete phosphorus.
•• Hyperphosphatemia shuts down the production of vit D thus causing decreased calcium absorption from
small intestine.
•• Hypocalcaemia triggers release of PTH which enables the demineralization of bone to increase serum
calcium level.
•• Osteosclerosis when present, is most common at the base of the skull and in vertebra causing horizontal
stripped Rugger Jersey appearance.
•• Rugger Jersey vertebrae’ appears like sandwiches. With osteo- sclerosis adjacent to the end plates but
relative radiolucency in the middle of vertebrae. It is seen in renal osteodystrophy and osteopetrosis.
•• In patients of renal osteodystrophy. Rugger Jersey appearance is due to hyperparathyroidism and
osteosclerosis.
•• Renal abnormalities precede the bony changes by several years. Children are stunted and myopathy is
common.
•• Epiphysiolysis (displacement of epiphysis) may be seen. Next point low calcium and high phosphate is seen
treatment is high dose of vit D (5,00,000 IU daily), in resistant cases small doses of 1.25 DHCC may be
effective.

Pectus Excavatum
•• Inward Sternum Associated with
•• Prematurity
•• Congenital heart disease
 15
METABOLIC DISORDERS

•• Poland syndrome
•• Marfan’s syndrome
•• Noonan syndrome
•• Homocystinuria
•• Decreased pulmonary functions
•• Mitral valve prolapse

Table – Calcium, Phosphorus, PTH relations in diseases

Lab findings in rickets Calcium (usually P h o s p h o - PTH ALP 25 1,25
N↓) rus
( U s u a l l y ( U s u a l l y (OH)D (OH)2 D
(Usually ↓) ↑) ↑)
Vit D deficiency N↓ ↓ ↑ ↑ ↓ ↓N↑
VDOR Type I N↓ ↓ ↑ ↑ N ↓
VDOR Type II N↓ N↓ ↑ ↑ N ↑↑
CRF N↓ ↑ ↑ ↑ N ↓
Dietary P deficiency N ↓ N ↑ N ↓
XLH-Hypophosphatemia Rick- N ↓ N ↑ N ↑
ets
ADHR-Hypophosphatemia N ↓ N ↑ N ↓
Rickets
Fanconi syndrome (Proximal N ↓ N ↑ N ↓
RTA)
Dietary Ca deficiency N↓ ↓ ↑ ↑ N ↑

•• Paget’s disease usually has normal calcium and phosphorous. Prolonged immobilization for fractures can
cause hypercalcemia
16
Orthopedics Notes
 AMPUTATIONS, SPORTS INJURY &
NEUROMUSCULAR DISORDERS

AMPUTATIONS & SPORTS INJURY

Mangled Extremity severity score (MESS)
•• Tells about survival of a limb after crush injury Includes 4 parameters
○ S - Shock
○ I - Ischemia
○ V - Velocity of Trauma
○ A - Age of the patient
•• Total score = 11
•• ≥ 7 limb cannot survive, requires amputation

Amputation
•• Overall, Most Common Cause in the World: Peripheral vascular disease
•• Most Common Cause in India: Road Traffic accidents (RTA)

Important types of amputation

1. Chopart’s Amputation 1. Lisfranc’s Amputation
• Inter-tarsal amputation • Tarso-metatarsal area.

3. Symes amputation
• Through the ankle 0.6 cm above the talar
dome

Amputation neuroma
•• Occurs due to amputation of a limb
•• Treatment: Excision (surgery) & control the pain
•• Pain can be controlled by
1. TENS (Transcutaneous electrical nerve stimulation): Inhibits pain gate pathway
2. IFT (Interferential therapy): Uses same principle
3. Ultra-sonic therapy
2
Orthopedics Notes

•• Pain management: TENS > IFT > US

Principles of amputation
•• Understand the cause of the condition demanding amputation
•• Decide the level of the amputation
•• Decide the desired length of the stump
•• Arteries to be ligated, veins to be coagulated (both should not be ligated together – avoid AV-fistula)
•• Nerves should be pulled out and a cut to be done at a very high level to prevent neuroma coming on to
the stump
•• Bone ends should be rounded
•• Muscles usually are divided at least 5 cm distal to the intended bone resection
•• Ideal stump is required for optimal outcome.
•• Ideal amputation stump
1. Non tender
2. Well healed
3. Non adherent
4. Skin at end of stump mobile sensate skin
5. Properly constructed to allow satisfactory fitting of prosthesis

Level of amputation
•• Cardinal rule: Preserve all possible length consistent with good coverage of stump
•• Type of amputation traditional length of stump
○○ Above knee: 23 cm (9 inches)
○○ Below knee: 14 cm (5.5 inches)
○○ Above elbow: 20 cm (8 inches)
○○ Below elbow: 18 cm (7 inches)

Methods of closure Myodesis / myoplasty

•• Muscles are stabilized by myodesis (suturing muscle or tendon to bone) or by myoplasty (suturing muscle
to the periosteum or the fascia of opposing musculature).
•• If possible, myodesis should be performed to provide a stronger insertion, help maximize strength, and
minimize atrophy
•• Myodesed muscles continue to counter-balance their antagonists, preventing contractures and maximizing
 3
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

residual limb function.

•• Myodesis may be contraindicated, however, in severe ischemia because of the increased risk of wound
breakdown.

Amputation in children
•• Krajbich summarized the general principles of childhood amputation surgery as follows:
1. Preserve length
2. Preserve important growth plates
3. Perform disarticulation rather than trans-osseous amputation whenever possible,
4. Preserve the knee joint whenever possible
5. Stabilize and normalize the proximal portion of the limb
6. Be prepared to deal with issues in addition to limb deficiency in children with other clinically important
conditions.

Reimplantation of limbs
•• B - Bone “Bone is repaired first’’
•• E - Extensor tendon
•• F - Flexor tendon
•• A - Arteries
•• N - Nerves
•• V - Veins
•• S - Skin coverage ‘’ Skin is preserved first but repaired last’’
How to remember
•• BE FAN VS

Prosthesis
•• To replace amputated foot
1. SACH (Solid Ankle Cushion Heel) Foot: Western lifestyle foot

2. Jaipur Foot: Indian foot/ natural looking foot; created by Dr. P.K. Sethi
4
Orthopedics Notes

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

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

Jaipur foot
(Natural Looking)

Amputation neuroma
Rx:
1. Surgery
Prosthesis SACH foot
2. Transcutaneous electrical Jaipur foot
• Appearance nerve stimulation (TENS)
• Does not look
[Link]
9.1 • Looks normal Fig. 9.2
inhibits pain gate pathway
• Requires shoe • Can walk barefoot
(Dr. P.K. Sethi)
• Keel • Long Keel restricting movements • Small keel allowing all movements
• Ankle movements • Present
• Not present • Squatting possible (sits on ground)
• Squatting not possible
Amputation Reimplantation
• Inversion / Eversion • Not present • Bone
• Present
BE FAN VS
• Choparts Inter-tarsal
(subtalar joint movements) • Hence difficult to walk on
• Extensor tendon
• So can walk on uneven grounds
• Flexor tendon
Tarso-metatarsal
• Lisfranc's
Uneven grounds • Arteries
• Nerves
• Cost • Syme's High
0.6 cm•above the talar dome • Veins • Low
• Skin coverage.

Arthroscopy with different portals

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

Anterolateral portal Anteromedial portal Superolateral portal Posteromedial portal Gillquist portal
(Trans Patellar
portal )
• Most common approach • Additional viewing of • Patello femoral • Repair of posterior horn
• 1 cm above joint line and lateral compartment articulation and excision meniscal tears
1cm lateral to patellar tendon • Instrumentation of medial plicae • Removal of posterior
• Universally see all structures loose bodies
except
i. PCL
ii. Anterior part lateral
meniscus
iii. Posterior horn medial
meniscus

•• Knee arthroscopy
 Anterolateral Corner:ACL + LCL + Lateral half of Joint Capsule
Posterolateral Corner: LCL + Popliteus (Most important) PCL – restrict external rotation
ACL – restrict internal rotation and hyper extension 5
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

Traumatic Knee ACL PCL

* Postero-lateral Antero-lateral Posterior Force Varus Force Valgus Force * Home

Bounce
Test
Flexion

Corner Injury Corner Injury

* Dial Test Pivot Shift Test PCL LCL MCL

Extension

Difficulty going Varus Stress Test *Valgus Stress Test

downhill in 30° flexion in 30° flexion
Feel compared

* Knee extension from flexed position

Normal feel-Hard/Firm
Torn structure-Rubbery/Spongy Feel
Torsion, Flexed Knee + (Empty feel not seen)
Torsion + Flexed Knee Valgus Force

* (Medial
Meniscal Tear
> Lateral)
ACL Tear

McMurrays Test Positive/

* Lachman Test Positive
Apleys Grinding Test
Thessaly Test/ Ege’s Test MATE
*
90 degrees knee
Rehabilitate + Arthroscopic

C f pu
flexion required

lin ll
o

ic
ACL Reconstruction to perform the test

ia
n's
lin
* Peripheral 1/3rd Tear * Inner 2/3rd Tear

e
H
am
Repair Arthroscopic

st
rin
Excision

g's
lin
e
of
pu
ll
Patella Femur
Anterior drawer test-ACL
Posterior
cruciate
ligament Knee joint
Anterior
cruciate
ligament
Rotatory
movement

Arthroscope

Another Meniscus
arthroscopic
instrument Meniscal ligament Tibia

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

Flexion stability Extension stability

430
Knee joint
6
Orthopedics Notes

•• Lateral Collateral Ligament → Varus force

•• Medial Collateral Ligament →Valgus force
•• Medical & lateral menisci → Torsion & rotation
•• Torsion - happens only when the knee is flexed
•• In extension, knee is locked
•• Anterior Cruciate Ligament: Torsion + Valgus (Found inside the joint + goes Medially)
•• Posterior cruciate ligament: Posterior force

1. PCL Restricts External rotation: Dial test

 7
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

1. Godfreys Test

•• Hip is placed on 90 degrees of flexion along with the 90-degree knee flexion. Here the foot is resting on
the examiners hand
•• The tibia is seen sagging posteriorly in a PCL deficient knee.
1. Hip flexed to 45 degree and knee flexed to 90 degrees, hamstrings are relaxed. Thumbs of both the
hands placed over tibial tuberosity and the fingers of both hands posteriorly around the proximal tibia
push the tibia behind. The amount of translation is visualized and felt.
•• Affected - > the anterior step is lost, and the tibia is found sagging behind the femur in flexion as
comparable to the opposite side
8
Orthopedics Notes

Test for ACL (Anterior Cruciate Ligament)

INSALL SALVATTI RATIO

•• A – is the length of the patella tendon

•• B – is the length of the patella
•• The index is calculated as A/B
•• If it is more than 1.2 it indicates a high patella Alta and if less than 0.8 then patella Baja (Low patella)

O’ Donoghue triad

•• 3 structures are damaged – dangerous

1. M - Medial collateral ligament
2. A - Anterior cruciate ligament
 9
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

3. M - Medial meniscus
•• Test to differentiate cervical spine strain (muscle) & sprain (ligament)

McMurray test (Rotational test)

•• Can hear tear
•• Receives blood supply from Periphery.
•• So Peripheral 1/3rd is vascular. Hence it can be repaired
•• Inner 2/3rd → excised if damaged
•• Tests for menisci
○○ M- MC Murray
○○ A - Apley grinding test
○○ T - Thessaly
○○ E - Ege’s test
How to remember
•• MATE

•• Bucket handle tear of medial meniscus: Double PCL sign

10
Orthopedics Notes

Bounce home test

•• When knee is Flexed and then suddenly extended, there is a feel.

•• Feel on Knee extension
○○ Hard: If bone rubs on bone
○○ Normal Firm If cartilage rubs
○○ Rubbery: Torn ACL or menisci is present-abnormal
○○ Empty feel is never felt
○○ There will always be a feel

Structure of knee anterior to posterior

•• M - Anterior Horn of Medial Meniscus (Most Anterior)

•• C - Anterior Cruciate ligament
•• L - Anterior horn of Lateral Meniscus
•• L - Posterior horn of Lateral meniscus
•• M - Posterior horn of Medial meniscus
•• C - Posterior Cruciate ligament (Most posterior)
 11
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

How to remember
•• MCL-LMC

NEUROMUSCULAR DISORDERS
Flexor tendon injuries

•• Flexor tendons are derived into 5 zones based on their level.

○○ Zone I - FDP
○○ Zone II - FDS called as “No man’s land” (as surgeries done in Zone II causes poor result)
○○ Zone III - Lumbricals
○○ Zone IV - carpel tunnel
○○ Zone V – Forearm

PIVD: (PROLAPSED INTERVERTEBRAL DISC)

•• Prolapse is More common in posterolateral than central.

•• Clinical presentation: Lower back ache radiating to Lower Limb aka sciatica
•• IOC: MRI (T2) weighted.
•• M/C site L4 -L5 > L5-S1 (as lumbar is usually dehydrated)
•• Lower nerve root compressed: L5 (M/C)
•• In cervical spine C5 C6 > C6 C7

MYOTOMES
•• C5 - Shoulder abduction + elbow flexion
•• C6 - Wrist extension
12
Orthopedics Notes

•• C7 - Elbow extension
•• C8 - Finger flexion
•• T1 - Intrinsic muscle of hand
•• L2 - Hip flexion
•• L3 - Knee extension
•• L4 - Ankle dorsiflexion
•• L5 - Extensor hallucis longus
•• S1 - Flexor hallucis longus

Dermatomes of lower limb

•• L4 - Medial border of leg + foot
•• L5 - Lateral border of leg, dorsum of foot & great toe all around
•• S1 - Sole of little toe all round

Yellow flag sign

•• Indicates Psychosocial factors as a reason for pain

Red flag sign

•• Indicates serious spinal pathology
•• Signs Includes
○○ Bladder or bowel dysfunction
○○ History of carcinoma
○○ Progressive neurological defects
○○ Steroids > 4 weeks

Treatment of disc prolapse

•• Pla n A
○○ Rest + NSAIDS + Physiotherapy (TENS)
○○ Local steroids
○○ Surgical decompression
→ Laminotomy
→ Laminectomy
→ Hemilaminectomy
 13
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

Lumber canal stenosis syndrome

•• Narrowing of lumbar canal < 10 mm: Neurogenic claudication
•• Narrowing can be due to thickening of tissues like ligamentum flavum & fibrosis all around.
•• Treatment: Laminectomy / Laminoplasty

Hoovers sign

•• Maneuver aimed to separate organic from non-organic paresis of leg.

•• Relies on the principle of synergistic contraction.
•• Normal: Hip flexion on right side; heel pressure felt on left side.
•• Paralyzed right leg: Paralyzed right side, can’t flex but effort present

Malingering
•• Not able to lift right leg, No pressure at left heel.
•• Waddell test can also be done to detect malingering.
14
Orthopedics Notes

•• Lumbar vertebrae in oblique view radiograph gives Scottish dog appearance

Spondylolysis
•• Fracture of vertebra of level L5 in pars interarticularis (neck) gives dog with collar in neck / broken neck
/ elongated neck appearance.

Spondylolithesis

•• M/C at the level of L5 -S1.

•• Separation of fractured pars interarticularis gives beheaded Scottish terrier sign appearance
 15
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

Important Information
•• Spondylolisthesis on AP view in “Inverted Napoleon hat” appearance.

•• Inverted Napoleon hat sign

•• Seen in end stage of Spondylolithesis

Trigger Finger
•• Stenosing tenosynovitis of the flexor leading to trapping at the entrance to its fibrous digital sheath
(mainly A1 pulley) at the level of metacarpophalangeal joint
•• Local trauma/unaccustomed activity/rheumatoid arthritis (RAV / diabetes mellitus/gout.

•• Commonest is ring and middle fingers

•• Patient frequently notes catching/locking/triggering of affected finger after forceful flexion.
•• In some instances, the opposite hand must be used to passively bring the finger into extension.
•• Patient notices that finger clicks as he or she bends it; when the hand is unclenched the affected finger
remains bend at the proximal interphalangeal joint, but with further effort it suddenly straightens with
a snap.
•• Triggering is more pronounced in morning than later in day. A tender nodule can be felt in front of
metacarpophalangeal joint.

Treatment
•• Injection of methyl prednisolone into the tendon sheath.
•• Surgical release of Al pulley. A2 pulley must be spared to preserve effective digital flexion.
•• In patients of RA, the entire annular pulley system should be preserved to prevent further ulnar drift
of fingers.
•• These patients are treated by teno-synovectomy and excision of one slip of flexor digitorum superficialis.
16
Orthopedics Notes

•• In children it is worth waiting until the child is a year Old, as spontaneous recovery often occurs.

Game Keeper’s Thumb

•• AKA Skiers’ thumb
•• M/C Injury of Metacarpophalangeal joint
•• Ulnar collateral ligament tear due to forced radial deviation.
•• Injury most commonly involves the phalangeal insertion of Ulnar Collateral ligament.
•• Tx:
○○ Cast application
○○ Surgery is done when fibers of adductors policies interfere with healing of ligaments known as Steners
lesion

Tennis Elbow

•• AKA lateral epicondylitis

•• Inflammation of common extensor origin: ECRB > ECRL
•• Cozen Test: Wrist dorsiflexion resisted by causing pain

Important Information
•• Tennis Elbow: Lateral Epicondylitis (ECRB > ECRL)
•• Golfers Elbow: Medial Epicondylitis
•• Students Elbow/Miner’s elbow: Olecranon Bursitis
•• Housemaids’ Knee: Prepatellar Bursitis (commonest)
•• Clergyman’s Knee: Infrapatellar Bursitis
•• Weaver’s bottom: Ischial bursitis
 17
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

•• Tailor’s ankle: Lateral malleolus bursitis

•• Bunion: Medial side of great toe – 1st metatarsal head bursitis
•• Bunionette: 5th toe of foot – 5th metatarsal head bursitis

Dequervain’s Tenosynovitis

•• Inflammation of abductor pollicis longus / extensor pollicis brevis. (both muscles enter 1st extensor
compartment of wrist)
•• Finkelstein test is done for diagnosis
•• Treatment for all the above conditions
○○ Plan A: Rest + NSAID’s → Steroids → Surgery

Haglund’s Deformity

•• Prominent calcaneal tuberosity + an overlying bursitis

•• Treatment
○○ Plan A: Rest + NSAID’s → Steroids → Surgery

Dupuytren’s contracture

•• Contracture of Palmar aponeurosis: Flexion Deformity

18
Orthopedics Notes

•• Joint involved: MCP > PIP > DIP

•• Ring Finger > Little Finger
•• Treatment
○○ Wait & watch
○○ If > 30 0 deformity at MCP or > 15 0 at PIP – then subtotal fasciectomy is done.
○○ Collagenase has also been used which was taken from Clostridial.

Important Information
•• These patients usually always has history of DM / alcoholism

In Dupuytren’s Contracture
LEDDERHOSE disease

•• Associated with Dupyutrens contracture

•• Has plantar fibromatosis
•• Also associated with frozen shoulder
•• So one can look for the hand and the feet in a case of frozen shoulder.

Mallet finger

•• Avulsion of extensor tendon from distal phalanx

•• AKA baseball finger
•• Treatment: Mallet splint → 6-8 weeks

Jersey finger
•• Avulsion of FDP from distal phalanx
•• Treatment: Operative since it is in Zone I
 19
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

Bowler’s thumb
•• Perineural fibrosis during bowling of ulnar digital nerve of thumb.
•• Treatment: Plan A

Hallux Valgus
•• Lateral deviation of great toe.
•• Bilateral involvement is also noted
•• Treatment
○○ Keller’s Surgery
○○ Arthrodesis
○○ Arthroplasty
20
Orthopedics Notes

Rotator cuff syndrome

•• Includes
○○ Subacute tendonitis (Painful arc syndrome – Pain on abducton between 60° -120°)
○○ Chronic tendonitis (Impingement syndrome – Neers test is used)
○○ Rotator cuff tears

•• Treatment
○○ Physiotherapy + NSAIDS.
○○ Local injection of steroids.
○○ Surgery if required for impingement syndrome or
○○ Rotator cuff tears (especially in young individuals).

Frozen shoulder
•• AKA adhesive capsulitis.
•• It is a feature of DM patients & they usually have night pain.
•• It is characterized by adherence of capsule to each other causing limitation of internal rotation and
abduction.
•• Gradually all movements lost.
•• Treatment: Plan A

Prayer sign

•• It is a clinical test in which the patient is not able to approximate both the palmar surfaces of the hand
and fingers
•• This is seen in early onset diabetes mellitus
•• This indicates higher chances of early complication affecting minor and major vessels.

Osteochondritis Dissecans
•• Osteochondritis dissecans (OCD) is a condition that develops in joints, most often in children and
adolescents.
 21
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

•• It occurs when a small segment of bone begins to separate from its surrounding region due to a lack of
blood supply.
•• As a result, the small piece of bone and the cartilage covering it begin to crack and loosen.
•• Treatment
○○ Microfracture technique is done
○○ Multiple hole are made in the underlying bone which will regenerate the Cartilage

Important Information
•• Other Varieties of Osteochondritis
○○ Keinbock - Lunate
○○ Kohler - Navicular
○○ Freiberg - 2nd Metatarsal Head
○○ Islene – 5th metatarsal Base
○○ Sever’s - Calcaneum
○○ Panners - Capitulum
○○ Perthes - Femur head epiphysis
○○ Osgood shattler’s - Tibial tuberosity
○○ Sinding Larson’s - Lower pole of patella
○○ Scheurmann - ring epiphysis of vertebrae
○○ Calves - central bony nucleus of vertebrae
○○ Johanson-Larsens - lower pole of patella
○○ Osteochondritis Dissecans

Variants of Osteochondritis
1. Keinbock

•• Lunate
•• Ds of young
•• Pain: Base of 3rd MC
•• Very painful on wrist dorsiflexion
•• Treatment: Arthrodesis / arthroplasty
22
Orthopedics Notes

2. Kohler disease

•• Osteochondritis of navicular

3. Scheurman’s disease

•• Osteochondritis of Spine

Avascular Necrosis
•• Death of bone due to poor blood Supply

Most common site Cause

1 Head of femur Neck of femur & Posterior dislocation of hip
2 Proximal pole of scaphoid Fracture through waist of scaphoid
3 Body of talus Fracture of Neck of talus
4 Proximal pole of lunate Dislocation
5 Capitulum
6 Distal femoral condyles
7 Humeral head
 23
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

•• Image shows snowcap sign: AVN of Humeral head

•• Scaphoid
○○ Scaphoid has retrograded blood supply which is from distal to proximal pole.
○○ During fracture, there is poor blood supply to the proximal pole as the fracture is usually at the waist
of the scaphoid leading to AVN of proximal pole.

•• Blood supply: Profunda femoris which is from middle circumflex femoral Artery, a branch of lateral
epiphyseal artery. The arteries are easily compressed causing AVN.
•• MC cause of AVN: idiopathic “Chandelier’s disease”

•• Femur AVN
○○ Affects anterolateral aspect of femoral head o IOC – MRI
24
Orthopedics Notes

• Sectoral Sign: reduction in • Crescent sign on X-ray –on fem- • Double line sign on MRI
IR and Abduction oral joint surface

FICAT AND ARLET STAGING: AVN femoral head

Stage 0
•• Preclinical and pre-radiographic: “Silent hip”

Stage I
•• Earliest clinical manifestation: Pain with limited movement of hip joint
•• Radiographs are normal patchy osteoporosis in comparison with the opposite side

Stage II
•• Clinical signs persist, or worsen
•• Radiographs show changes in the trabecular pattern of the femoral head
•• Sclerosis and lucency or even a mixed image

Stage III
•• X-ray shows significant arthritis: Pathognomonic imaging features
○○ Crescent line: Due toa subchondral fracture
○○ Out of round appearance: Segmental flattening of the femoral head
○○ Joint space is preserved or even increased

Stage IV
•• Terminal phase
•• Hip movement is progressively diminished until only a small range of flexion remains
•• X-ray shows significant arthritis

Diagram 24.1
 25
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS

Treatment of AVN
1. Core decompression (↓ pressure) + Fibular graft (↑vascularity)

2. Muscle pedicle graft

i. “Meyer’s graft”: In AVN of femur; Quadratus femoris muscle is used
ii. Joshi’s graft: Tensor fascia Lata muscle used.

3. Total hip replacement: Currently used

Ganglion
•• MC swelling of hand & wrist
•• Cystic structure
•• No synovial living
•• Found in dorsal wrist – scapholunate
•• Treatment: Plan A
26
Orthopedics Notes

Baker’s cyst
•• Semi-membranous
•• At medial head of gastrocnemius-compress popliteal artery
•• Pressure diverticulum may arise
•• Prominent on extension
•• Causes associated with it: OA / RA / Pigmented villo nodular synovitis / medial meniscus injury
•• Treatment: Excision if symptomatic

Compound Palmar Ganglion

Compound palmar ganglion is chronic inflammation of common sheath of flexor tendon both above and below
flexor retinaculum causing hourglass swelling.
•• RA and tuberculosis are the commonest cause.

Snapping Knee Syndrome

•• KNEE: Snapping of tendons at the posteromedial corner of the knee when knee goes into extension from
flexion. Tendons of pes anserinus (Semitendinosus and Gracilis) are involved.

Snapping hip syndrome

•• Dancer’s hip or coxa saltans is a clinical condition characterized by a palpable or audible snapping sensation
that is heard during of the hip joint.
•• This is most commonly an overuse phenomenon, but may be brought on by trauma, including intramuscular
injection into the gluteus maximus and surgical procedures.
 27
AMPUTATIONS, SPORTS INJURY & NEUROMUSCULAR DISORDERS
 PEDIATRIC ORTHOPEDICS

Introduction
•• Altered shape of femoral head-Limitation of abduction & internal rotation

IR ER

•• Internal rotation: leg goes out, hip goes in

•• External Rotation: Leg goes in, hip goes out
•• Normal axis: clavicle
•• In internal rotation & abduction when you flex the knee, the Knee goes towards the clavicle: Normal Axis
•• If hip is destroyed, knee goes towards axilla (Axis deviation)
•• Investigation of Choice: MRI
•• Treatment of Choice - Maintain the hip reduced (do Abduction of hip)

Disease M: F Bilateral
1. Development dysplasia of Hip / CDH 1:6 20%
2. Perthes Disease (4-8y) 3:1 20%
3. Slipped capital femoral epiphysis (11-20y) 3:1 40%

Development Dysplasia of Hip

•• Epiphysis of femur small Acetabulum flat / shallow
2
Orthopedics Notes

X-ray Findings

•• Shallow / flat acetabulum

•• Head goes up K/a Supero-lateral dislocation
•• Central edge angle: center of epiphysis forms an angle with Perkins line
•• IOC: MRI
•• In DDH, femoral artery pulsations are not felt Vascular sign of Narath positive

Different Tests
1. Ortolani maneuver

○○ Reduction of hip by abduction

2. Barlow maneuver
○○ Dislocation of hip by adduction
 3
PEDIATRIC ORTHOPEDICS

3. Allis or Galeazzi test

○○ For superolateral dislocation

○○ Knee of normal side is higher than the knee of affected side
4. Klisic’s Test
○○ For measurement of DDH for bilateral Allis test disease

X-ray findings
1. Perkins line

○○ Vertical line at the edge of acetabulum

○○ In normal hip, the epiphysis is inner to Perkin’s line & lower to Hilgenreiner’s line
○○ In DDH, the epiphysis is upper to Hilgenereiners line & outer to Perkins’s line
○○ Acetabular Index: The slope of acetabulum with the horizontal line
○○ In DDH, acetabulum index keeps on increasing as the disease worsens / progresses
2. Shenton’s arch
○○ An arch over the proximal femur & pubic rami
○○ In DDH, senton’s arch is broken
4
Orthopedics Notes

3. Hilgenreiner’s line

○○ Horizontal line to triradiate cartilage

4. Acetabular index
○○ Vertical/ shallow acetabulum
○○ Increases in DDH

USG in DDH
•• Screening tool
•• Alpha angle decreases
•• Beta angle increases in DDH

On X-Rays
•• In DDH
○○ Acetabular index: Increases
○○ Central edge angle: Decreases

Risk factors for DDH

•• Oligo hydramnios
•• Metatarsus adducts (medial deviation of metatarsals)
•• Congenital muscular torticollis (Cock- robin appearance)
•• Talipes calcaneovalgus (Heel prominent) > CTEV (clubfoot)
•• Family history
•• Breech presentation
•• Females
•• First born child
•• Left side is more commonly affected
•• Twin pregnancy is not a risk factor
 5
PEDIATRIC ORTHOPEDICS

•• A strong association exists between congenital dysplasia of the hip and other musculoskeletal
•• abnormalities such as Congenital torticollis, Metatarsus adductus and Talipes calcaneo-valgus.
•• The most common intra uterine position places the left hip of the fetus against the maternal sacrum.
This could partially explain the increased incidence of DDH in the left hip.
•• Ligamentous laxity as a contributing factor in congenital dysplasia of Hip. Increased incidence of DDH →
Swaddle infants with hip in extension;
•• Flexion & abduction prevents DDH
•• Hence DDH is uncommon in India.

Management
•• Maintain abduction by using
1. Pavlik harness
2. Von Rosen splint
3. Bachelors cast
6
Orthopedics Notes

•• Up to 6 months: Closed reduction (maintain abduction)

•• 6 months to 18 months: Open reduction
•• 18 months to 3 years: femoral correction
•• >3 years: femoral and pelvic correction

Perthes Disease

•• Avascular necrosis of femoral epiphysis

•• 4-8 years of age
•• Self – resolving
•• More common in male
•• Initial x-ray in normal in Perthes IOC: MRI
•• Aim: Maintain abduction
•• Head will migrate superolateral
•• Signs
○○ Gage’s sign: Refraction in the lateral part of the epiphysis and subjacent metaphysis
 7
PEDIATRIC ORTHOPEDICS

○○ Sagging rope sign

○○ Crescent sign

•• Treatment: maintain the head abducted

•• Management: Broom stick cast

Slipped Capital Femoral Epiphysis (SCFE)

•• Age: 11-20 Years

•• Misnomer: “Metaphysis slips”, not the epiphysis

•• Cause: Endocrinopathies (Hypothyroidism) and Growth spurt
•• IOC: MRI
•• Along with IR + abduction, flexion is restricted
•• AP X- ray of pelvis
•• Klein’s line: Line over the neck, it must have a part of epiphysis above it
8
Orthopedics Notes

•• Trethowan’s sign: When epiphysis goes down, then there is nothing above the line
•• Management: Fixation

Duchene Muscular Dystrophy

•• X-linked recessive (Xp 21)
•• Defect in Dystrophin gene (Largest gene in human)
•• Swollen calf Pseudohypertrophy of calf (Fibrous fatty deposit)
•• Average age of presentation is 4 years (occurs in < 5 years of age)
•• Proximal muscle weakness is seen
•• Pseudohypertrophy of calf & tongue is seen
•• Gower’s sign: Patient uses his own body to climb up as there is proximal muscle weakness.

•• Definitive diagnosis is by muscle biopsy and genetic studies

•• M/c nerve involved is sural nerve

Congenital muscular torticollis

 9
PEDIATRIC ORTHOPEDICS

•• Sternocleidomastoid muscle is affected

•• AKA wry neck (or) twisted neck
•• Associated with breech delivery, shoulder dystocia, birth injury and SCM ischemia / tumor (like
compartment syndrome)
•• Associated with metatarsus adductus, DDH, CTEV (cock-robin appearance)
•• Knot can be detected in the body of SCM in first 3 months of life
•• It can disappear spontaneously (90% by 1 year)
•• There may be asymmetrical development of face (Plagiocephaly)
•• Treatment: surgery
○○ Optimum age to operate: 1-4 years
○○ < 1 year: disappears
○○ 4 years: Plagiocephaly

Klippel-Feil syndrome
•• Posterior hair line very low
•• Short neck
•• Decreased movements
•• It is associated with congenital osseous fusion of the cervical spine, involving one or more vertebra.

•• Short web neck (prominence of Trapezius)

•• Most common associated disease: Scoliosis (60%)

•• Associated disease: Sprengel’s deformity (50%) (Short high scapula)

Poland syndrome
•• Congenital variations COMMONEST in pectoralis
•• Clinical features: Flattened chest wall. With hypoplastic ribs, an elevated nipple and may present with
unilateral hyper radiolucency of the lung on a roentgenogram.
10
Orthopedics Notes

•• Can have a dextrocardia if left side involved

•• Abnormalities in limbs also have been reported like radial bone abnormality and webbed finger.
•• Diagnosis is Often established on ultrasound and is mainly based on the absence of a muscle belly or
tendon.

Important Information
•• Lower end of femur and tibia goes medially: Genu varum
•• Only the tibia goes medially: Tibia varum

Blount’s Disease in GWS

•• Characterized by
○○ Varus (Tibia> genu)
○○ Genu recurvatum (Hyperextension of knee)
○○ Internal torsion of tibia
•• Sudden deviation of tibia due to posteromedial defect occurring metaphysis – diaphysis junction.

Blount’s Physiological bowing

Side 60% bilateral 100% bilateral
Progress Progresses Resolves
Treatment Tx required Observation
•• Tx of Blount’s Disease: High tibial osteotomy

Rocker bottom foot

•• Convexity of sole Cause
1. Due to incorrect correction of CTEV
 11
PEDIATRIC ORTHOPEDICS

2. Vertical talus
•• Normally talus is horizontal

PES PLANUS (FLATFOOT)

•• In normal foot, the arch is formed with heel as the center. The arch is due to medial longitudinal arch.
•• Flat foot refers to obliterated / lost medial longitudinal arch
•• Types (Jacks test)
1. Flexible
○○ Arch disappears on non-weight bearing (arch disappears when placed on ground & comes back
○○ when foot is lifted off)
○○ Mgt → conservative
2. Rigid
○○ Flat on both ground & when lifted
○○ Due to congenital vertical talus (or) RA (or) infection or tarsal coalition (AD – talocalcaneal and
calcaneo navicular) or tibialis posterior dysfunction
○○ They often require surgical intervention,

Club foot / Congenital Talipes Equino Varus(CTEV)

•• Combination of 4 deformities
1. C - Cavus (↑arch)
2. A - Adduction (medial deviation of fore foot &mid-point)
3. V - Varus (inversion at sub-talar joint)
4. E - Equinus (Plantar flexion at ankle)

How to remember
•• CAVE
•• Order of correction
○○ Cavus → Adduction → varus → Equinus
12
Orthopedics Notes

○○ If not corrected correctly, leads to rocker – bottom foot

Pirani scoring for CTEV

Parameters
1. Equinus
2. Lateral part of head of talus
3. Heel
4. Curvature of lateral border
5. Medial crease
6. Posterior crease

Pirani scoring
•• T -Talar head
•• H - Heel
•• E – Equinus
•• L - Lateral curvature
•• M - Medial crease
•• P - Posterior crease
 13
PEDIATRIC ORTHOPEDICS

How to remember
•• THE LMP

Kites method – followed earlier Ponsetti method – now pre-

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

1. <1 year cast (starting from birth), Ponsetti method (tenotomy of tendoachilles is carried out).
2. 1-3 years Soft tissue release – Posteromedial soft tissue release (Turcos)
3. But in children older than 3 years of age, lateral column shortening procedures are often performed in
conjunction with posteromedial soft tissue release.
4. 3-8 years
a. Soft tissue release together with shortening of lateral side of foot by Evan-Dilwyn Procedure (i.e., resection and
fusion of calcaneo cuboid joint)
b. Dwyer’s osteotomy of calcaneum is done to correct calcaneal varus in >5 years.
5. 8–10 years Wedge Tarsectomy is done as deformity is more and requires multiple bones to be removed.
6. >10 years
Triple arthrodesis is necessary for recurrent or persistent clubfoot deformity in older children (chronic cases).
It is best done at > 10 years of age when foot growth is complete and the bones are ossified to achieve good
fusion. It involves fusion of three joints:
TN: Talo-Navicular; TC: Talo-Calcaneal; CC: Calcaneo-Cuboid
7. Thomas designed CTEV Shoes (straight Inner Border, Outer Shoe Raise & No Heel)
8. Dennis Brown splint is used and it encourages abduction and dorsiflexion of foot
9. Parallelism of talus and calcaneum in A.P as well as lateral views is seen in CTEV

Management
1. Kite’s method
•• At birth: Manipulation by mother for 1st 2 weeks
•• At 2 weeks old: cast application
•• Order of correction: C-A-V-E (calcaneo-cuboid area) One at a time
•• The deformity is corrected in 6-9 months
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Orthopedics Notes

2. Ignacio V ponsetti’s method

•• At birth: apply cast (includes manipulation also)
•• Change cast every 7 days
•• As collagen fibers recontract on day 8 as change cast before that.
•• Order of correction → C-AV-E
•• Adduction & Varus can be corrected together Push Head of talus laterally (kite’s error → calcaneo-
cuboid)
•• The deformity is corrected in 6-8 weeks

At Birth
•• Manipulation and cast
•• Upto 1 year of age same treatment
•• Above knee cast
•• Weekly changed

Treatment
1. Birth up to 1 yr.
•• Manipulation (Head of talus) + cast
•• Tendo Achilles tenotomy (at end to correct Equinus)
2. 1-3 years = soft tissue released STR (PMSTR – Turcos)

3. 3 years = STR + Bony wedge

4. 3-5 years of age

•• Evan’s procedure + STR

•• Evan’s: Calcaneo-cuboid wedge
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PEDIATRIC ORTHOPEDICS

5. 5-8 years of age

•• Evan’s Procedure + STR + Dwyer’s calcaneal osteotomy (to correct heel Varus in > 5 years of age)
6. 8-10 years of age

•• Wedge tarsectomy
•• Wedge is taken out from multiple tarsal bones.
7. Beyond 10 years of age → Triple arthrodesis (fusion of three joints)
a) Talonavicular - most difficult to fuse
b) Talocalcaneal
c) Calcaneocuboid

CTEV Shoes
•• By Thomas
•• Straight medial border → for Cavus & adduction
•• Outer raise → for Varus
•• No heel → for Equinus
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Orthopedics Notes

•• Given up to 7 years of age

Important Information
•• <1-year-old → only splint
•• >1-year-old → splint at night and CTEV shoes at day

Dennis Brown splint

•• Applied 23 & half 24 hours a day & Bilateral side

Resistant clubfoot
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PEDIATRIC ORTHOPEDICS

•• AMC → Arthrogryposis multiplex congenita NF → Neurofibromatosis

Battered baby syndrome

•• AKA Infantile whiplash syndrome
•• Child is manipulated by guardian / parents
•• Injury in metaphysis
1. At corner: chip fracture
2. Metaphyseal bucket handle fracture
3. In femur: Fractures are spiral
4. Sub-epiphyseal micro-fractures are seen on MRI
5. Nobbing fractures are seen in the ribs
6. X-ray of specific parts required → skeletal survey; Babygram are not done

Types of pediatric Injuries

1. Torus fracture

•• Buckling of cortex at metaphyseo-diaphyseal junction

•• Torus- bend seen at the bottom of a pillar
2. Plastic deformation

•• Bend without a break

3. Green stick fracture
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Orthopedics Notes

•• Single cortical breech

Congenital pseudo arthrosis tibia

•• Arthrosis is between 2 bones and has hyaline cartilage and synovial fluid
•• Pseudo arthrosis because it is in middle of a bone
•• Occurs due to non-union, failed surgery or congenital deformities
•• Cause: Idiopathic
•• Associated with neurofibromatosis
•• Leads to anterolateral defect of tibia

Crawford classification of Congenital pseudo arthrosis tibia

•• Type I: Anterolateral bowing of tibia

•• Type II
○○ Antero lateral bowing
○○ Increased cortical thickness
○○ Narrow medullary canal
○○ Tubular defect
•• Type III: Cystic lesion
•• Type IV: Presence of cyst, fracture or frank pseudo arthrosis
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PEDIATRIC ORTHOPEDICS

•• Treatment: Bone graft + stabilization by Ilizarov

Radial hemimelia

•• Radial club hand

•• Deficiency of radial bone and thumb (40% of hand)
•• Hand deviated to radial side
•• Associated conditions
1. Holt Oram syndrome
2. VACTERL

Fibular Hemimelia

•• Fibula absent

Tibial Hemimelia

•• Absent Tibia

Posteromedial Bowing
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Orthopedics Notes

•• Self-resolving

Madelung deformity

•• Defect in the palmar and ulnar aspect of lower radius Prominent ulnar head
•• 50% are bilateral
•• More common in female
•• Associated with turner syndrome
•• Has excellent functions

Polio
•• Involves lower limb > upper limb
•• Most common muscle to be affected → Quadriceps femoris (Partial)
•• “Hand-knee gait”
•• Most common completely paralyzed muscle →Tibialis anterior In upper limb → Deltoid
•• Hand muscles (very rare): Opponens pollicis
•• Acute Fatality is due to involvement of respiratory muscles