Contents

Basics and General Concepts of Trauma  1

Upper Limb Trauma  12

Lower Limb Trauma  27

Cumulative Trauma Disorders  37

Orthopaedic Oncology  43

Nerve Injuries  51

Metabolic Diseases of Bone  61

Orthopaedic Infections  72

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Spine : Injuries and Disorders  l.c 79
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Joint Disorders  86
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Paediatric Orthopaedics  91
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Sports Injuries  97
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 Basics and General Concepts of Trauma 1

BASICS AND GENERAL CONCEPTS OF TRAUMA ----- Active space -----

Anatomy of Bone  [Link]

COMPOSITION Bone (Osteon)

Organic component/ Water : Inorganic component :

osteoid ↑in children Calcium hydroxyapatite
(Bones Softer). (Principal mineral).

Cells (5-10%) Proteins (90 to 95%) :

• Collagen : Type 1 (Principal protein).
• Osteocalcin.

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• Osteonectin.
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gm
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Osteoblast : Osteoclast : Osteocyte :

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• Cell type : • Cell type : • Cell type :

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- Mononuclear cells. - Monocyte aggregates. Mature/resting osteoblast.

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• Function : - Multinucleated giant cells. • Features :

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- Lays down osteoid matrix • Function : - Most abundant.

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(Collagen) - Phagocytic. - Longest life span.

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Mineral deposition - Bone resorption & remodelling.

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• Rich in TRAP & carbonic anhydrase.

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Bone/osteon. Osteoblasts
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• Least in number.
• Rich in alkaline phosphatase.
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Osteoclast
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Note : Ruffled borders

• Meniscus of knee joint : Collagen type I.
Osteocyte
• Articular hyaline cartilage : Collagen type II
Calcified
matrix
Bone Markers : Bone
Formation markers Breakdown markers
• Pro collagen • Hydroxy proline
• Osteocalcin • Hydroxy lysine
• Osteonectin • N & C telopeptide
• Alkaline phosphatase (ALP) • Tartrate Resistant Acid Phosphatase (TRAP)
Note :
• Bone formation markers ↑ in bone resorption.
• TRAP ↑in osteoporosis (D/t ↑osteoclast activity).

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 2 Orthopaedics

----- Active space ----- Parts of Bone :

Medullary cavity :
• Children : Marrow. Epiphysis
• Adults : Fat. Metaphysis :
Endosteal lining Spongy/ cancellous
bone(Medulla)

Yellow bone marrow Diaphysis :

Compact bone Compact/cortical bone
Periosteum (Cortex)
Sharpey’s fibers
Nutrient arteries Metaphysis
Anchors periosteum Epiphysis
to bone

Growth Plate :

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Epiphysis
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Growth plate/epiphyseal plate/

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physeal plate
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(Only seen in children)

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Metaphysis
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X-ray AP view (Child)

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Note :
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Growth plate Longitudinal/interstitial growth.

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Growth plate structure :

Epiphysis
Layers
Epiphysis
Germinal layer
Metaphysis (Most important)
Proliferative layers Direction
of growth
Hypertrophic layer
(Weakest)
Layer of calcification
Layer of ossification

Metaphysis

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 Basics and General Concepts of Trauma 3

Physeal Injuries : ----- Active space -----

• Hypertrophic layer : M/C involved in traumatic injury.
• Germinal layer : Injury Growth affected.

Salter & Harris classification of physeal injuries :

Mnemonic : SALTER.
Type Image Features Prognosis

I • Fracture splits the growth plate without injuring

Good
(Split germinal layer (Through hypertrophic layer).
(Best)
fracture) • Normal growth on reducing the fracture.

• Fracture splits the growth plate.

• Fracture line goes towards the metaphysis.
II : M/C
• No injury to the germinal layer. Good
(Away)
• Normal growth on reducing the fracture.
• Metaphyseal fragment : Thurston holland.

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• Fracture line splits the growth plate and goes
III
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towards the epiphysis.
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Bad
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(Lower) • Germinal layer will be injured.

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• No growth on reducing the fracture.

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IV • Fracture line through all layers.

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(Through • Germinal layer injured. Bad

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everything) • Growth is impacted even on reducing the fracture.

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V • Impaction injury Crushes growth plate.

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(Rammed/ • Fracture is missed on X ray (No obvious # line). Worst

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crushed) • Late presentation with limb length discrepancy.

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Fractures [Link]

Diagnosis : Clinical Abnormal mobility/Radiological X-ray.

Causes of Fractures :
• Significant trauma Stress # (Normal bone ; abnormal loading) : Point tenderness +
• Insignificant trauma Pathological # (Abnormal/weak bone) :Pain before fracture d/t pre-existing lesion.

Localized causes : Generalized causes :

• Infection. • Osteoporosis (M/C) : Spine > hip > Colle’s.
• Ischemia. • Metastasis : Proximal femur & spine.
• Lesions. • Osteogenesis imperfecta.
• Cysts. • Osteopetrosis.
• Radiation. • Scurvy, Rickets/osteomalacia.
• Paget’s disease.
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 4 Orthopaedics

----- Active space ----- Note :

• Vertebral compression fractures : Wedge fractures.
(M/C bone involved in pathological #)
• Subtrochanteric proximal femur # : Banana #.
• Mirel’s criteria : To plan for prophylactic fixation
of pathological # (Score >8 : Prophylactic internal fixation).

Pathological # :
Stress Fractures : Head of humerus
• Pain after activity (Sudden ↑ in intensity/frequency).
• Lower limb bones > Upper limb bones.
• X-ray positive : 2 to 3 wks later.
• IOC : MRI (Soft tissue edema + ) Detects occult fractures (IOC).
• Multiple stress # : Bone scan.

Sites :

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1. Tibia. l.c
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2. Metatarsal : March fracture
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2nd > 3rd metatarsal; Neck > shaft.

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3. Multiple stress fractures Requires bone scan.

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March fracture
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Fracture Healing
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[Link]
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Primary healing Secondary healing

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Type of healing Direct/intramembranous healing Indirect/endochondral healing

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Callus formation Callus - Callus +

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Movement at # site Absolute stability Micromovements + (Relative stability)

• Pop/braces
• Compression plates • External fixation
Devices
• Lag screws • Bridge plating
• Intramedullary nailing

Rigid fixation (1° healing) Callus formation (2° healing)

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 Basics and General Concepts of Trauma 5

Stages of Secondary Healing : ----- Active space -----

1 Hematoma formation
Hematoma formation (2-3(2-3
days)days)

Granulation Tissue
Granulation tissue formation (2-3 weeks) :
2
Formation (Inflammation) (2-3 weeks)
Inflammation + fibroblasts

3 Callus formation(2-3
Callus Formation (2-3 months) :
months)
Fibroblasts Osteoblasts

4 Consolidation (2-3
Consolidation (2-3 years)
years)

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5 Bone remodelling
Bone remodelling (3 (3 years) :
years)
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Woven bone Lamellar bone

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Non-union [Link]
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Factors Affecting Fracture Healing :

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Patient : Age, nutrition, tobacco, alcohol. Type of # : Open, contaminated, interposed.

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Treatment : Improper immobilization (M/c) ; Tissue : Ischemia.

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inadequate reduction.
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Types :
Hypertrophic Atrophic
Fracture Smooth & sclerosed ends + visible fracture line

X-ray appearance

Callus formation Exuberant Absent

Bone biology Good Abnormal
Immobilisation Improper ±
Treatment Immobilization Autologous bone grafting

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----- Active space ----- Bone graft :

• M/C site : Iliac crest.
• MOA : Creeping substitution
(Canvas for bone to grow).

Bone graft extraction

Malunion [Link]

• Healing in anatomically abnormal position.

• TOC : Osteotomy (Cut, realign & fix bone).

Note :
Fractures that undergo malunion,
rarely/never undergo non-union
(& vice versa). Angulated malunion Osteotomy

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Bones with ↑risk of malunion vs non-union : l.c
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Malunion Non-union
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• Clavicle (M/C) • Lower 1/3rd of tibia (M/C)

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• Supra-condylar humerus • Scaphoid

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• Colle’s • Lateral condyle of humerus

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• Intertrochanteric (Extracapsular) • Neck of femur (Intracapsular)

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femur • Neck of Talus

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MANAGEMENT OF FRACTURES
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Intra-articular fracture Extra-articular fracture Patella/olecranon

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(Involves articular surface) (Fragment pulled by attached tendons)

Open reduction + Internal Conservative management Surgical Tension band wiring device (TOC) with
fixation with plates & screws management K-wires & stainless steel wires
POP/cast, slab, traction. (Definitive) (Distractive force Compressive force)

Upper limb : Lower limb :

Plating with screws Intramedullary rods/
nails with interlocking screws
Fractures of necessity : Require surgical management.
• Intra-articular #. • Monteggia/Galeazzi #.
• Lateral condylar humerus #. • Neck of femur #.

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 Basics and General Concepts of Trauma 7

Open Fractures [Link] ----- Active space -----

• Fracture + break in skin and underlying soft tissue.

- M/c pathogen : Staph. aureus. Affects healing
- Fracture hematoma escapes outside
• M/C involved : Tibia and phalanges.

Gustilo Anderson Classification : Wound size usually >10 cm

Type I Type II Type IIIa Type IIIb Type IIIc

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Wound <1 cm Wound 1-10 cm Open fracture Open fracture Open fracture +
long. + contaminated l.c
with periosteal vascular injury :
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environment : Sewage, stripping Distal pulses not
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farms or firearm injury. palpable.

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Management :
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A. Wound management :
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1. Broad spectrum antibiotics.

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2. Debridement. Sterile normal saline.

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3. Wound wash with Povidone iodine.

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H2O2.
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4. Wound closure delay if >6 hr old injury.

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New neurovascular injury.

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Edges cannot be approximated.

B. Fracture management :
External fixation Wound management & closure Definitive surgery.
1. Schantz pin with external rod :

Uniplanar EF with one rod Multiplanar EF Uniplanar EF

with 4 rods with 2 rods
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 8 Orthopaedics

----- Active space ----- 2. Illizarov ring fixator :

• Multiplanar.
• Rings and pins used.
• Distraction osteogenesis (AKA callotaxis) :
At 1 mm/day
(Can lengthen bone if required).
• Indications/uses :
- Open fracture.
- Non-union.
- Infected non-union.
- Fracture with bone loss.
- Limb lengthening.
- Deformity correction/malunion.
Distraction osteogenesis
3. Rail fixators/limb reconstruction system :

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Adjustable rods :
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Combination of compression
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& external fixation.

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Rods connected by
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Pins
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spanning over the joint

4. Spanning external fixator :
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• Spans across joint

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↑Stability.
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• Use : Periarticular fractures

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(Distal femur/proximal tibia #).

Complications of management : Ring sequestrum (M/C)

• Occurs at pin tract sites.
• Causes Heat necrosis d/t drilling.
Direct infection.

Stability of EF :
Improved by :
↑Number of pins, rods, planes (Biplanar > uniplanar).

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 Basics and General Concepts of Trauma 9

Amputation [Link] ----- Active space -----

Trauma Scores :
1. Mangled extremity severity score (MESS) : Score ≥7 = Amputation.
• V : Velocity of injury or soft tissue coverage.
• I : Ischemia time (Most important).
• S : Shock.
• A : Age of patient.
2. Limb salvage score.
3. Ganga score.

Types :
• Amputation : Cutting limb through the bone.
• Disarticulation : Cutting limb through a joint.
Terminology of Amputation :

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Hind :quarter/
LowerHemipelvectomy
limb Foot : l.c
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Hip
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disarticulation Intertarsal joint amputation

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Syme Chopart
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Midthigh/ Transmetatarsal
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above-knee
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(transfemoral)
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Amputation
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Lisfranc
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Knee Tarsometatarsal joint amputation

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disarticulation
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Below-knee
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(transtibial)
amputation
(M/C)
(M/C)
Syme’s
Transmetatarsal ampulation
Prosthesis :
amputation (ankle)
Toe
Ray SACH amputationJaipur foot
ampulation
Appearance Does not look normal Looks normal
Walking barefoot & Solid ankle cushion heel (SACH)
Not possible Possible
on uneven surfaces
Mobility Restricted Allowed
Dorsiflexion Absent Present
Inversion/eversion Absent Present
Squatting Not possible Possible
Cost High Low
Jaipur foot : Preferred for Indians
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 10 Orthopaedics

----- Active space ----- Advanced Trauma Life Support (ATLS) [Link]

Order of intervention :
1. Airway : Chin lift/jaw thrust with restriction of cervical spine motion.
2. Breathing.
3. Circulation (Stop the bleeding).
4. Disability or neurological status.
5. Exposure (Undress) and environment (Temperature control).

Note :
Fractures causing the most amount of blood loss : Pelvis > femur.

Pelvic Fracture Management :

Can cause 1.5-2 L of blood loss Hemorrhage & death.
1. Pelvis binder/hands/bedsheets : Tamponade the blood loss.
2. IV fluids : RL > NS.

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3. External fixation of pelvis (In compression).
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Avascular Necrosis (AVN)/Osteonecrosis

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[Link]
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Classification :
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Traumatic Non-traumatic
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(↑Intraosseous pressure ↓Blood flow)

# Neck of femur # Waist of scaphoid # Neck of talus • Idiopathic (M/C)
• Steroid use
AVN of head of AVN of proximal AVN of body of • Sickle cell disease
femur pole of scaphoid talus • Gaucher’s disease
• Alcohol abuse
• Perthes’ disease
• Caisson disease

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 Basics and General Concepts of Trauma 11

Bones with tendency for AVN : ----- Active space -----

• Head of femur. • Distal femoral condyle.
• Proximal pole of scaphoid. • Head of humerus.
• Body of talus. • Capitulum.
• Proximal pole of lunate.

X-ray :
• Dead bone appears white/sclerosed
on X-ray with jagged edges.
• Changes appear very late.
IOC : MRI (For early diagnosis).
TOC : Total hip replacement.

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AVN of head of femur Total hip replacement

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 12

----- Active space ----- UPPER LIMB TRAUMA

Clavicle Fracture [Link]

M/c fracture at birth & in newborn babies.

Patient presents supporting the injured side with the opposite arm, pushing the
elbow up.
Sites : Displacing forces in clavicle fracture :
Lateral (15%) Middle (80%) Medial (5%) Lateral fragment : Pulled down (Wt. of arm + pectoralis)
M/c Medial fragment : Pulled up (SCM + trapezius)

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M/c l.c
site
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Lateral 1/3 rd
gm

(Flat)
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Medial 2/3rd
s.

(Tubular)
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Fracture of clavicle
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Complications :
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• Malunion (M/c) : D/t displacement.

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• Neurovascular injury : Brachial plexus, subclavian vessels.

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• Non-union (Very rare).

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MANAGEMENT
Conservative Management :

Figure of 8 bandage Arm sling/arm pouch Combination of both.

Surgery :
Indications :
1. Open clavicle fracture. 3. Acromioclavicular joint involved.
2. Massive displacement. 4. Neurovascular injury.

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 Upper Limb Trauma 13

Shoulder Injuries [Link] ----- Active space -----

Shoulder joints : Anterior Posterior

• Ball & socket joint.
• Most mobile :
M/c dislocated joint
(50% of all joint dislocations)

Anterior (90-98%) > Posterior > Inferior.

Muscles of rotator cuff
ANTERIOR DISLOCATION
Head of humerus dislocated anteriorly.
Subtypes :
• Subcoracoid (M/c).
• Subclavicular.
• Pre glenoid.

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• Intrathoracic. ai
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Presentation :
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Attitude of limb :
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• Abduction & external rotated L oss of adduction

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& internal rotation.

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• Arm by the side of the body.

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• Loss of shoulder contour Flattened.

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Mechanism of injury H/o trauma.

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Fall on outstretched hand.

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Acute dislocation : Emergency Requires immediate reduction.

Nerve injury : Axillary nerve injury (M/c).
Clinical Examination :
1. Hamilton’s ruler test : Ruler over lateral epicondyle of humerus touches acromion.
2. Duga’s test :
Difficulty in touching C/L shoulder
Dislocation
3. Callaway’s test :
↑girth of affected shoulder (Axilla).

4. Axillary nerve injury :

Compressed axillary N.
Loss of Motor function of deltoid, teres minor.
Sensory function : Regimental badge sign (Lateral aspect of upper arm).

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 14 Orthopaedics

----- Active space ----- X-Ray :

• AP view : Empty Subcoracoid dislocation
glenoid sign.
• Lateral view.

Treatment : AP view Lateral view

1. Modified Kocher’s Technique (TEAM) : M/c.
1. Traction 2. External rotation 3. Adduction 4. Medial/internal rotation

2. Stimson’s technique : 3. Hippocratic technique :

Patient prone • Countertraction : With foot.

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l.c • Traction : With arm.
Heavy object tied to dislocated limb
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Hang limb at the edge of table/bed

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Gradual traction overcomes muscle spasm

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Stimson technique
Reduction achieved.
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Complications :
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1. Bankart lesion (M/c) :

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Anterior dislocation of shoulder

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Glenoid labrum tears anteroinferiorly at 4-6 o'clock

Laxity of inferior glenohumeral ligament Bony Bankart

Avulsion fracture of anteroinferior glenoid,
↓ Stability along with a Bankart
Recurrent dislocations.
.

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 Upper Limb Trauma 15

2. Hill-Sachs lesion : ----- Active space -----

Recurrent dislocation

Head of humerus repeatedly

hits anterior glenoid rim

Indentation on posterolateral surface.

X-ray : Hill-Sachs lesion
Note :
• M/c complication of shoulder dislocation : Recurrent dislocation.
• M/c Early complication : Axillary nerve injury.
Late complication : Recurrent shoulder dislocation.
• M/c nerve injured in shoulder dislocation : Axillary nerve.
POSTERIOR DISLOCATION

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Presentation : ai
l.c
Mechanism of injury : In seizures.
gm

1. High velocity muscular movement (Specific) High voltage electric shock.

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2. Fall on outstretched hand. Electroconvulsive therapy (ECT).

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3. Trauma.
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Attitude of limb :
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• Adducted and internally rotated

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Loss of abduction & external rotation.

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• Shoulder contour : Not lost.

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• Pain + .
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X-Ray :
Light bulb/Electric bulb sign.

Normal X-ray X-ray in posterior dislocation

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 16 Orthopaedics

----- Active space ----- INFERIOR DISLOCATION

Presentation :
Mechanism of injury : Hyperabduction.
Attitude of limb : Arm by the side of the head (AKA luxatio erecta).

Note : Superior shoulder dislocation unlikely d/t acromion process.

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Shaft of Humerus Fracture l.c [Link]
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Features :
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Fracture b/w surgical neck of humerus & supracondylar area.

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Complication :
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Radial nerve injury (Closely associated with shaft).

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Management :
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• Conservative : U-slab/Hanging cast (Needs to be erect).

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• Surgical : ORIF with Plates + Screws.

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U slab Hanging cast ORIF with plates + screws

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 Upper Limb Trauma 17

Holstein-Lewis Fracture : ----- Active space -----

Site :
Junction of upper 2/3rd & lower 1/3rd..
(Radial nerve perforates lateral
intermuscular septum)

Causes entrapment of tethered radial nerve

Wrist drop + Thumb drop +

Finger drop + Sensory loss

Rx : Cock-up splint (Dynamic > Static).

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Radial nerve entrapment

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Fractures Around the Elbow [Link]

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Lateral condylar fracture vs. Supracondylar fracture :

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Lateral condylar fracture Supracondylar fracture

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Intra articular/
Type of fracture Extraarticular
# of necessity
Salter-Harris
Type IV Type I/II
classification type
3-point bony
Disturbed Maintained
relationship

Note :
3-point bony relationship also
disturbed in medial condyle #,
olecranon #, intercondylar # and
elbow dislocation.
On 90˚flexion On extension
Three point bony relationship in elbow
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 18 Orthopaedics

----- Active space ----- LATERAL CONDYLE FRACTURE

Commonly occurs in children. Salter-Harris type IV Humerus
Complications :
• Elbow stiffness.
• Non-union d/t :
Fracture fragment
- Pull by common extensor group of muscles.
- Compromised vascularity Radius
Ulna
• Damage to lateral growth plate :
Lateral condylar fracture
Growth of medial > lateral condyle.

Cubitus valgus Stretching of medial elbow structures

deformity
Tardy ulnar nerve palsy (Develops over weeks-months).
Carrying angles of elbow

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Cubitus varus Normal l.c
Cubitus valgus
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Forearm towards • Males : 5° Forearm away

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From
©

midline • Females : 7-10° midline from midline

SUPRACONDYLAR FRACTURE
m/c fracture around elbow in children.
H
Mechanism of injury : R
U
Fall on an outstretched hand Hyperextension
injury.

Types :
H
1. Based on displacement :
• Extension type (M/c) : Posterior displacement R
d/t pull of triceps U
• Flexion type : Anterior displacement (Rare).
Posteriorly displaced supracondylar #

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 Upper Limb Trauma 19

2. Gartland classification : ----- Active space -----

Type I Type II Type III

Undisplaced • Anterior cortex : Breached Displaced complete fracture
(Fracture line may not be visible) • Posterior cortex : Intact
(Incomplete fracture) Fish tail sign
Sail/fat pad sign

Fat pad/Sail sign :

Hematoma around fracture pushes away fat

Sail shaped lucency around supracondylar area.

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Management : l.c
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Undisplaced # :
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Conservative.
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Definitive Mx
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Displaced # :
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Surgery.
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Baumann’s angle Dunlop traction

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(To determine adequate (For temporary

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fracture reduction) stabilisation of fracture)

Complications :

Early (Neurovascular) Late

• Vessel injury : M/c Brachial artery.

Malunion (m/c) Myositis
- Compartment syndrome.
ossificans.
- Volkmann Ischemic contracture. Cubitus varus/
• Nerve injury : gunstock deformity
M/c : Ant. interosseous > Median > Radial. (↓ carrying angle).

Note : In children, M/c fracture causing Neurovascular injury.

Compartment syndrome.
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 20 Orthopaedics

----- Active space ----- Compartment Syndrome :

Clinical features :
1. Pain on passive stretch : Most important sign.
2. Puffiness (Swelling).
3. Pallor.
4. Paraesthesia.
5. Paralysis (Late sign).
6. Pulselessness (Very late sign).
Investigation :
Compartment pressure using manometer
(Useful in unconscious patients) : Manometry
• Normal : < 10 mmHg.
• Compartment syndrome : > 30 mmHg.
Treatment :

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Immediate removal of dressing/cast Fasciotomy (If no symptomatic improvement).
l.c
Fasciotomy :
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• Longitudinal incisions on superficial and deep

@
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compartments
77

reduce pressure and improve vascularity.

s.
ha

• Wound left open till pressure falls. Fasciotomy

ng
si
rit

Volkmann’s Ischemic Contracture :

am

Untreated compartment Sx can lead to fibrosis of

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forearm muscles (D/t ischemia)

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Volkmann’s ischemic contracture

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Treatment (Based on severity of contracture) :

• Mild : Turn buckle splint (Passive sketching).
• Moderate : Max page (muscle sliding) operation.
• Severe : Bone shortening.
Turn buckle splint/Volkman’s splint
Malunion :
M/c complication.
Gunstock/cubitus varus deformity :
• M/c deformity.
• D/t medial tilt + Internal rotation of distal fragment.
• Rx : Modified French osteotomy.

Cubitus varus deformity

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Myositis Ossificans : ----- Active space -----

• Rare complication.
• M/c muscle involved : Brachialis.
• M/c joint involved : Elbow > hip.
Pathogenesis :
Massage of fracture
Fracture hematoma dislodges
Myositis ossificans
Settles inside muscle
Bone forms inside muscle
Restriction of movement.

OLECRANON FRACTURE
om
l.c
ai
gm
@
36

Fracture
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fragment gets
s.
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pullled by triceps
ng
si
rit
am

Treatment :
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Tension band wiring with K-wires

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ar
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Elbow Dislocation & Pulled Elbow

©

[Link]

ELBOW DISLOCATION
• Ulno-humeral dislocation.
• M/c dislocation in children.
• M/c type : Posterior/posterolateral.
• M/c nerve injured : Ulnar nerve.

Elbow dislocation
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 22 Orthopaedics

----- Active space ----- PULLED ELBOW

Mechanism of injury :
In children <5 years :
Unossified smaller radial head in
larger annular ligament (Unstable).

Axial traction of extended & pronated elbow

Radial head pulled out of annular ligament.

Attitude of limb : Extended elbow & pronated forearm.

Treatment : Note :
• Self limiting. Terrible (Hotchkiss) triad of elbow :
• If painful : • Posterior elbow dislocation.
- Flex elbow & forcefully supinate forearm. • Coronoid fracture.

om
- Hyperpronation (Not recommended). • Radial head fracture.
l.c
ai
gm

Forearm Fractures
@

[Link]
36
77

Monteggia Fracture :
s.
ha

Fracture of upper 1/3rd ulna + Proximal RUJ disruption (Radial head dislocation).
ng
si

Disrupted PRUJ Fracture of ulna

rit
am
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©

Monteggia fracture
BADO classification :
Type I (M/c) Type II Type III Type IV

Radial head
dislocation : Anteriorly Posteriorly Laterally Anteriorly +
fracture of radius
Complications :
M/c injured nerve : Posterior interosseous nerve (Branch of radial nerve)
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Galeazzi/Reverse Monteggia Fracture/Piedmont Fracture : ----- Active space -----

Fracture of radius + DRUJ disruption/TFCC injury.
Piano key sign :
Ulna lifted distally

Goes down when pressed upon. Piano key sign

Fractures At Wrist  [Link]

Name Fracture Distal fragment displacement (Lateral View)

Colle’s Dorsally (Away from thumb)
Extraarticular
Smith Ventrally (Towards thumb)
Chauffeur Intraarticular Isolated radial styloid #

om
l.c
ai
gm
@
36
77

Colle’s fracture Smith’s fracture Chauffeur’s fracture

s.
ha

COLLE’S FRACTURE
ng
si

• Fracture of distal end of radius at cortico-cancellous junction.

rit
am

• Common in elderly post-menopausal females.

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Displacements (DILS) :
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1. Dorsal tilt/shift. 2. Impaction (Causes dinner fork deformity).

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3. Lateral tilt/shift. 4. Supination.

©

Treatment
1. Colle’s/Hand shaking cast (Conservative) :
Below elbow cast.
Position : Pronation, Ulnar deviation, Palmar flexion of wrist.
2. Surgery.

Sequence of reduction of Colle’s #

Countertraction Traction Palmar flexion to correct the dorsal tilt Ulnar deviation to correct the radial tilt

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 24 Orthopaedics

----- Active space ----- Complications :

• Malunion : Dinner fork deformity (M/c).
• Sudeck’s dystrophy/complex regional pain syndrome/reflex sympathetic
dystrophy fracture Tense swelling, shiny skin, tingling & numbness,
paraesthesia, anhidrosis.
• Rupture of extensor pollicis longus tendon.
• Carpal tunnel syndrome : Median nerve compression.
• Non-union (Rare).
SMITH FRACTURE/REVERSE COLLE’S FRACTURE
• Extra-articular fracture of distal end of radius with volar displacement.

Garden spade deformity.

Mechanism of injury : Fall on an outstretched hand with wrist in flexion.

om
l.c
ai
gm
@
36

Garden spade deformity

77
s.

CHAUFFEUR’S FRACTURE
ha
ng

AKA Hutchinson’s/Backfire fracture.

si
rit
am
|
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ro
ar

Isolated radial styloid fracture

M
©

Chauffeur’s fracture
Fractures of Hand [Link]

Carpal bones :
‘She Looks Too Pretty, Try To Catch Her’.
Scaphoid (S) : M/c fracture. Td Tz
Lunate (L) : M/c dislocated. P H C
Triquetrum (T). T
L S
Pisiform (P) Smallest.
Trapezium (Tz).
Trapezoid (Td).
Capitate (C) Largest.
Hamate (H). Carpal bones
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SCAPHOID FRACTURE ----- Active space -----

Mechanism of injury : M/c site of fracture
Fall on an outstretched hand.
Age group : Young adults.
Clinical Features :
Pain/swelling in anatomical snuff box.
Evaluation :
• X-ray :
- Oblique view (Best).
- AP Fracture may not be visible.
- Lateral
• MRI : For fractures not visible on X-ray.
Complications :

om
• Non-union (M/c).
• Avascular necrosis of proximal pole of scaphoid. l.c
ai
gm

Treatment :
@
36
77
s.
ha

Undisplaced fracture Displaced fracture

ng
si
rit

POP applied in glass holding position OR + IF with Herbert screw

am
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ro
ar
M
©

Note :
Scapho-lunate ligament injury :
Ligament injury Scapho-lunate dissociation : Terry Thomas sign.

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 26 Orthopaedics

----- Active space ----- FRACTURE OF BASE OF FIRST METACARPAL

• Intra-articular fracture of trapezio-metacarpal joint.
• Displacing forces : Abductor pollicis longus (APL) pull.
Bennet’s fracture Rolando’s fracture

APL

Partial Complete comminuted (T/Y shaped)

Displaced fracture Undisplaced fracture
BOXER’S FRACTURE

om
l.c
ai
gm
@
36
77
s.
ha
ng
si
rit
am
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Fracture of 5th metacarpal

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MALLET FINGER VS JERSEY FINGER

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©

Mallet finger Jersey finger

Hyperflexion injury (Eg : When ball hits the finger) Hyperextension injury
Mechanism
Injury to extensor digitorum communis tendon (Tear/avulsed) Injury to FDP tendon (Tear/avulsed)
of injury
Flexion of DIP Extension at DIP
Passively + Passively +
Extension at DIP
Actively - Flexion at DIP
Actively -
On Extensor tendon Middle phalanx
examination
Avulsion of flexor
Distal phalanx
digitorum profundus
Flexor tendon
Treatment Mallet/Stax splint -
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LOWER LIMB TRAUMA ----- Active space -----

Normal Hip Anatomy [Link]

Normal Hip X-ray :

Ilium
Sacroiliac joint Sacrum
Acetabulum Head of femur
Superior pubic ramus Greater trochanter
Ischium Obturator foramen
Lesser trochanter
Inferior pubic ramus
Pubic symphysis Shaft of femur

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X-ray of hip joint ai
l.c
gm

<120° 120°- 135° >135°

@

Note :
36

Coxa vara
77

Shenton’s line
s.
ha
ng

Neck shaft angle Limb shortening,

si
rit

Trendelenburg gait.
am

Landmarks at hip joint Coxa vara Normal Coxa valga

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Neck shaft angle

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Shenton’s line :
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• Continuous line from lower border of superior pubic ramus, laterally towards
©

head and neck of femur.

• Disturbed in any pathology of the hip.

Special Tests for Hip :

Trendelenburg test :
• To assess abductor mechanism of hip.
• Principle abductors of hip :
- Gluteus medius Supplied by superior
- Gluteus minimus gluteal nerve.
• Abductors help maintain gait :
I/L abductors help swing C/L limb.
• Helps moving the limb when other limb is in stance phase.

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----- Active space ----- Abductor failure :

Causes of abduction failure :
• Gluteus medius weakness.
• Gluteus minimus weakness.
• Superior gluteal nerve palsy.
• Coxa vara.

Test procedure :
• Ask patient to stand on each limb (30 secs).
• Observe ASIS.
• When patient stands on pathological side, sound Trendelenburg test
side sinks.
• Positive test : ASIS/PSIS of other side goes down.
Note :

om
B/L abductor failure Waddling gait. ai
l.c
gm

Thomas Test :
@

• AKA Hugh Owen Thomas well leg raise test.

36
77

• Used to assess flexion contracture/flexion

s.
ha

deformity of the hip.

ng
si

Thomas test
rit
am
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Hip Dislocation
ro

[Link]
ar
M
©

Posterior dislocation (M/C) Anterior dislocation

Mechanism of
Dashboard injury Deceleration injury, fall from height.
injury

Attitude of limb
F, AD, IR : F, AB, ER :
1. Flexion at hip 1. Flexion at hip
2. Adduction at thigh 2. Abduction at thigh
3. Internal rotation 3. Externally rotated limb

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----- Active space -----

Posterior dislocation (M/C) Anterior dislocation

Length of limb Shortened Lengthened
Posterior Head lies outside
dislocation acetabulum
Shenton's line is Shenton's line is
broken broken
X-ray features
Adduction and Abduction and
Internal rotation External rotation
of limb & limb
Lesser trochanter is not visible
Palpation Head palpable in gluteal region Head palpable in femoral triangle

Management :

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Closed reduction
Not reducing d/t muscle spasm l.c
ai
gm
@

Closed reduction under anaesthesia No reduction Open reduction + Apply skeletal traction
36
77
s.
ha

Complications :
ng
si

1. Avascular necrosis : M/c (If not reduced within 6-12 hrs post injury).
rit
am

2. Sciatic nerve injury : In posterior dislocation.

|

Presents with foot drop/high stepping gait d/t common peroneal nerve injury.
w
ro
ar
M

Proximal Femur Fractures [Link]

©

: Head of femur
: Intracapsular neck
: Extracapsular neck
Acetabulum
Med. circumflex artery

Capsule Profunda femoris

Intracapsular NOF fracture Medial circumflex femoral
(Disrupts blood supply) artery
Extracapsular NOF/ Lateral circumflex
intertrochanteric fracture femoral artery
Blood supply to head of femur

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 30 Orthopaedics

----- Active space ----- Types :

Neck of femur/Intracapsular fracture Intertrochanteric/extracapsular fracture
Age (Elderly) 50-60 yrs 70-80 yrs
Sex Female >>> males Female > males
Trauma Trivial fall Moderate to severe fall
Pain Mild pain Moderate to severe pain
Location of pain Scarpa's triangle Trochanteric region
Shortening < 1 inch > 1 inch
Deformity/ External rotation >45° (Lateral part of
External rotation <45° (Capsule limits it)
attitude foot touches the bed)
AVN (45°) > Non-union (30%) (Due to Malunion/Coxa vara/↓ in neck-shaft
Complication
disruption of blood supply) angle (No distruption of blood supply)

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Intracapsular fracture
Shenton's line l.c
ai
Extracapsular
gm

X-ray fracture
Joint capsule
@

Joint capsule
36
77
s.
ha
ng
si
rit

Neck of Femur Fracture :

am

Classification : Anatomical, Pauwel’s & Garden’s classifications

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Treatment :
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< 65 yrs ≥ 65 yrs

Age of fracture
Replacement
< 3 weeks > 3 weeks

Closed reduction IF + MRI Hemiarthroplasty (In > Total

cannulated cancellous previously normal hip) : (In previously
screws Implant : Austin moore, abnormal hip) :
Non-viable HOF Viable Thompson, Bipolar (Best). Eg : Osteoarthritis.

Fix + vascularisation procedures : Fix + osteotomy :

• Meyers • McMurray
• Bakshi • Pauwels (Better)
• Fibular vascular graft
If both fail + young patient

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 Lower Limb Trauma 31

Hemiarthroplasty : Replacement of only head and neck of femur. ----- Active space -----
Total arthroplasty : Replacement of head & neck of femur + Acetabular cup.

CRIF with calculated Total replacement Hemi replacement

cancellous screws
Prosthesis

Bipolar (M/c) Austin moore Thompson

om
l.c
ai
Intertrochanteric Fracture :
gm
@
36
77
s.
ha
ng
si
rit

Untreated IT
am

fracture
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Coxa vara
©

Management :
1. Surgical : Maintain neck shaft angle (125°-130°) with devices & prevent coxa vara.

a. Proximal femoral nail with locking b. Dynamic hip screw : Sliding compression mechanism.
and stabilization screws :
Best modality.
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 32 Orthopaedics

----- Active space ----- 2. Conservative management :

In inoperable cases (Age, comorbidities)

Derotation boot :
• Allows healing in malunited position
• Prevents external rotation

Shaft of Femur Fracture [Link]

Fat Embolism Syndrome (FES) :

Pathogenesis : Leaking of intramedullary fat into circulation.
Clinical features : Not seen in children.
• Cutaneous : Petechial rash

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• Cardiorespiratory : Dyspnoea/tachypnoea 24-48 hrs after
l.c
polytrauma
• CNS : Depression, coma, anxiety
ai
gm
@

Shaft of femur fracture

36

Dx : GURDS criteria.
77
s.
ha

Major criteria (4) Minor criteria (8)

ng
si

• Axillary/Subconjunctival • Tachycardia • Fat globules in urine

rit
am

petechia. • Fever (Lipuria) : Gurd test

|

• PaO2 below 60 mmHg • Anemia • ↑ ESR

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• CNS Depression • Thrombocytopenia • Retinal emboli

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• Pulmonary edema • Fat globules in sputum

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I major + 4 minor = Fat embolism

Management of FES :
• Prevention : Immobilisation + Early fixation of fracture.
• Treatment : Supportive O2+ IPPV.

Treatment of Femur Shaft Fracture :

Age Rx
<6 m Pavlik harness
6 m-5 yrs Hip spica cast (If <2 yrs/<12 kg : Gallows traction)
5-10 yrs Flexible nails (Ender’s nail, TENS)/Plates if unstable
>10 yrs Intramedullary interlocking nails

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 Lower Limb Trauma 33

----- Active space -----

. Intramedullary Titanium elastic nailing system Gallow’s traction :

interlocking nails : Adults (TENS) : Older children • M/c used in children <2 yrs.
• F/b cast.

om
l.c
ai
gm
@

Pavlik’s harness : Young children Hip spica cast : Young children

36
77
s.
ha

Leg Injuries
ng

[Link]
si
rit

Patella Fracture :
am

H/o direct trauma to knee.

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Rx : Tension band wiring with K wires.

ar
M
©

Tension band wiring Patella fracture

Bipartite Patella :
• Congenital anomaly : Accessory ossification centre.
• small separated fragment d/t incompletely
fused patella at superolateral pole.
• Incidental finding on X-ray.
• Rarely painful.

Management : Conservative.
Bipartite patella

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 34 Orthopaedics

----- Active space ----- Tibial Shaft Fracture :

Management :
1. Patellar tendon bearing cast (Conservative).
2. Definitive treatment : CRIF with intramedullary rod/nail with interlocking screws.

Tibia and fibular shaft # Intramedullary rod/Nail with screws Patellar tendon bearing cast

Runner’s Fracture :

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Stress fracture of the fibula seen ai
l.c
in marathon runners.
gm
@
36
77
s.
ha
ng

ANKLE JOINT
si
rit

Anatomy :
am
|

Medial Posterior malleolus

w
ro

malleolus Talus
ar

Lateral
M

malleolus Talus Calcaneus

©

AP view Lateral view

Ankle Fractures : Posterior Medial Lateral
Types : Lateral malleolus Medial malleolus malleolus malleolus malleolus

Lateral
malleolus

Isolated lateral malleolus # Bimalleolar/Pott's # Trimalleolar/Cotton's #

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 Lower Limb Trauma 35

Management : ----- Active space -----

Closed reduction Slab application
( Neurovascular assessment before & after) Care for neurovascular deficit/compartment sx

Definitive Sx (Once swelling ↓).

FOOT FRACTURES

Calcaneal Facture :
Mechanism of injury :
Fall from height landing on feet.

Gissane’s angle
Angles to assess reduction :
• ↓ Bohler's angle.

om
• ↑ Gissane's angle.
l.c
ai
gm
@
36

Aviator’s Fracture : Bohler’s angle

77

• Fracture talar neck.

s.
ha

• ↑Risk of avascular necrosis of body of talus.

ng
si

• Hawkins classification of talar neck fracture.

rit
am

• Blood supply of talus : Dorsalis pedis Sinus tarsi A.

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Fracture
ro

Chopart's Fracture : neck of talus

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M

Fracture of intertarsal joint.

©

Aviator's fracture
Lisfranc's Fracture :
Fracture of tarso-metatarsal joint.

Talus Navicular Cuboid

Chopart's Note :
Amputation at :
Calcaneum • Intertarsal joint : Chopart's amputation.
Lisfranc's
• Tarsometatarsal joint : Lisfranc's amputation.

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 36 Orthopaedics

----- Active space ----- Robert Jones fracture :

Fracture of base of 5th metatarsal.
Articulation of 4th and 5th metatarsals

Zone 3 (Stress fracture)

Zone 2 (True Jones fracture) In watershed area (↓vascularity) Non-union.
Zone 1 (Pseudo jones fracture) D/t avulsion of peroneus brevis tendon.

Rx :
• Non-weight bearing short leg cast for 6-8 weeks.
• Intramedullary screw fixation if displacement + (Ideal Rx).

om
Nerve Injuries [Link]
l.c
ai
gm

Injury Common nerve involvement

@

Anterior or inferior shoulder dislocation Axillary, (Circumflex humeral) nerve

36
77

Fracture surgical neck humerus Axillary nerve

s.
ha

Fracture shaft humerus Radial nerve

ng
si

Fracture supracondylar humerus AIN > Median > Radial > Ulnar (AMRU)
rit
am

Medial condyle humerus Ulnar nerve

|

Cubitus Valgus Tardy ulnar nerve palsy

w
ro

Monteggia fracture dislocation Posterior interosseous nerve

ar
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Lunate dislocation Median nerve

©

Hip dislocation Sciatic nerve

Neck of fibula fracture Common peroneal nerve

Summary of Femur Fractures :

≥ 65 y Hemiarthroplasty/Total hip replacement

Intracapsular NoF fracture
<65 y MRI : Osteotomy Fails
Intertrochanteric fracture : DHS/PFN (All age groups)

Femur shaft fracture : Nailing (All age groups)

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 Cumulative Trauma Disorders 37

CUMULATIVE TRAUMA DISORDERS ----- Active space -----

Shoulder Joint  [Link]

Anatomy :
• Ball & socket joint.
• Supported by rotator cuff muscles & glenoid labrum.
Posterior Anterior
Supraspinatus :
Supraspinatus Coracoid Process
In supraspinous fossa.

Infraspinatus : Acromion
In infraspinous fossa

om
Teres minor ai
l.c
gm

Subscapularis :
@

• In subscapular fossa.
36

• Forgotten tendon Subscapularis

77
s.

of rotator cuff.
ha

Rotator cuff muscles

ng
si
rit
am

Impingement/Painful Arc Syndrome :

|

Impingement of supraspinatus tendon > subacromial bursa in narrow subacromial

w
ro

space upon abduction.

ar
M
©

Evaluation :
1. Painful arc test :
Clavicle
Acromion.
Max. pain b/w 60°-120° Impingement of tendon
(Mid-abduction pain) (sub-acromial space).

Impingement of the rotator cuff

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 38 Orthopaedics

----- Active space ----- 2. Provocative tests :

Hawkin’s impingement test Neer’s impingement test

Rotator Cuff Tear :

M/C tendon tear : Supraspinatus > tendo achilles.
Causes : Degeneration (Elderly) > trauma (Young).
Evaluation :
Muscle Nerve supply Action Test
Supraspinatus Suprascapular nerve Abduction Beer can test, empty can test, Jobe’s test

om
Upper & lower l.c
Internal
ai
Subscapularis Lift off test, belly press test, bear hug test
subscapular nerve rotation
gm
@
36
77
s.
ha
ng
si
rit
am
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Liftoff test
ro
ar

Empty can test

M
©

Jobe’s test Belly press test

Treatment :
• Avoid painful & overhead activities.
• Physiotherapy.
• NSAIDs.
• Steroid injections.
• Arthroscopic tendon repair.
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 Cumulative Trauma Disorders 39

Rupture of Long Head of Biceps Tendon : ----- Active space -----

Proximal rupture of long head of biceps tendon

Distal migration of muscle belly.

Popeye sign

Elbow Joint [Link]

Tennis elbow (M/C) Golfer’s elbow

Lateral epicondylitis Medial epicondylitis
(Inflammation of common extensor origin) (Inflammation of common flexor origin)

om
l.c
ai
gm

Pathology
@
36
77
s.
ha
ng
si
rit

Earliest affected muscle Extensor carpi radialis brevis > longus Flexor carpi radialis
am

Cozen’s test : Reverse Cozen’s test :

|
w

Extend wrist against resistance Flex wrist against resistance

ro

Evaluation
ar
M

Pain at lateral condyle Pain at medial condyle

©

Treatment :
• Activity modification. • NSAIDs.
• Counterforce brace : • Physiotherapy.
Prevents movement from reaching • Steroids.
the origin of muscle. • Debridement.

Counterforce brace Cozen’s test

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 40 Orthopaedics

----- Active space ----- Hand & Wrist Joints [Link]

De Quervain’s Disease :
Stenosing tenosynovitis
Abductor pollicis longus 1st dorsal compartment of wrist
and inflammation of
Extensor pollicis brevis
Causes : Clinical profile :
• Overuse. • F > M.
• Rheumatoid arthritis. • Pain over radial styloid.

Evaluation :
EPB
APL EPB APL

om
l.c
Finkelstein’s test Eichhoff’s test
ai
gm
@

Dupuytren’s Contracture :
36

Repetitive trauma Abnormal cord like fibrosis of palmar fascia Contracture

77
s.

Idiopathic (M/C). of finger.

ha
ng

Diabetes mellitus.
si

Etiology
rit

Alcoholism (Liver failure).

am

Trauma.
|
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Clinical profile :
ro
ar

• M > F.
M

Finger : Ring finger. Dupuytren’s contracture

©

• M/C involved
Joint : Metacarpophalangeal joint.
Ectopic types (In other parts of the body)

Peyronie’s disease Ledderhose disease

(Penis) (Soles of feet)

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 Cumulative Trauma Disorders 41

Trigger Finger : ----- Active space -----

Pathophysiology :
A2
Trauma Stenosis of A-1 pulley (At MCP joint) A3

Obstruction of flexor tendon passing through it

A4
A5
Difficulty in opening the finger

Finger suddenly opens on forceful extension. Pulleys of hand

Etiology : Clinical profile :

• Trauma (M/C) • F > M.
Finger : Ring finger.
• Rheumatoid arthritis • M/C involved
Tendon : Flexor digitorum profundus (FDP).
• Diabetes mellitus.
Gamekeeper’s Thumb/Skier’s Thumb : Bowler’s Thumb :

om
Hyperabduction of thumb Neuroma of ulnar digital nerve of thumb
l.c (D/t perineural fibrosis).
ai
gm

Tear/avulsion of ulnar collateral

@
36

ligament (UCL) of thumb at 1st MCP joint.

77
s.
ha
ng

Ulnar digital
si

nerve
rit
am
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ro
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M
©

Bursitis [Link]

Inflammation of bursae d/t overuse Swelling, redness, pain.

Types :

1. Housemaid’s knee 2. Clergyman’s knee 3. Student’s elbow 4. Haglund’s/Pump bump

deformity

Calcification of
bursa forms a bony
bump behind the
ankle.

Prepatellar bursitis Infrapatellar bursitis Olecranon bursitis Retrocalcaneal bursitis

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 42 Orthopaedics

----- Active space ----- Thoracic Outlet Syndrome [Link]

Entrapment of neurovascular structures as they pass through the thoracic outlet.

Thoracic Outlet :
Anterior scalene muscle.
Posterior scalene muscle.
Boundaries
Clavicle.
First rib.
Brachial plexus (M/C).
Contents
Subclavian vessels (Artery > vein).
Causes of Compression : Clinical Features :
• Abnormal positioning of neck/ Nerve compressed : Paraesthesia, tingling,
upper limb. numbness.
• Lung tumor (Upper lobe).

om
Artery compressed : Claudication Pain.
Diagnosis : l.c
ai
gm

Clinical evaluation : +ve test if pain/neurological symptoms/↓pulse +

@

(Clinical evaluation > MRI).

36
77
s.
ha

Head turned towards Head turned to

ng

affected side, neck opposite side

si
rit

extended
Abduct + externally Same as
am

rotate shoulder Adson’s test

|
w
ro
ar

Extend elbow
M
©

a. Adson’s test b. Reverse Adson’s/Halstead’s test

Hyperabduction of shoulders
Abduct shoulder + flex elbow.
Open & close hands for 3 mins.
Extension of
Reproduces symptoms of neck
vascular claudication
c. Roo’s test d. Wright’s hyperabduction test
Treatment :
Conservative : Surgical :
• Rest. Excision of first rib/cervical rib/tumor (Lung).
• Splint.
• Physiotherapy.
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 Orthopaedic Oncology 43

ORTHOPAEDIC ONCOLOGY ----- Active space -----

Approach to Bone Tumors  [Link]

Periosteal Reaction : Periosteum

• Reaction of periosteum to an insult/stimulus.
Insult/stimulus (Pathology)
• Periosteal insult New bone formation
Periosteal reaction
Prevents the spread of underlying pathology.
Tries to contain the
Types : spread of the pathology
• Slow growing/indolent lesion : Thick/solid periosteal reaction.
• Rapidly growing/aggressive lesion : Thin/lamellated periosteal reaction.
X-ray features of periosteal reaction :

om
Features Tumors (M/C)
Onion peel l.c
Ewing’s sarcoma
ai
gm

Sunburst/sunray appearance
@

Osteosarcoma
36

Codman’s triangle
77

Solid/thick Osteomyelitis
s.
ha

Sites of Bone Tumors : Onion peel appearance

ng
si

Sites Tumors (M/C) (Lamellated/Layered)

rit
am

Around the knee (Distal femur/proximal tibia) M/C site overall

|

Proximal humerus Simple bone cyst

w
ro

Small bones of hands & feet Enchondroma

ar

• Hemangioma
M
©

Spine • Osteoblastoma
• Metastasis
Classification Based on Location in Bone :
Location Tumors
Epiphysis • Chondroblastoma : Growth plate visible (Child) Sunburst appearance
(In contact with epiphyseal plate) • Giant cell tumor : No growth plate (Adult) D/t calcification of
Sharpey’s fibers
• Ewing’s sarcoma
• Osteoid osteoma
Diaphysis
• Adamantinoma (Soap bubble)
• Fibrous dysplasia
• Osteosarcoma
• Osteochondroma
Metaphysis • Aneurysmal bone cyst
• Unicameral bone cyst
• Non-ossifying fibroma Codman’s triangle
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----- Active space ----- Classification Based on Age Group :

Age group Tumor
5 to 25 y Ewing’s sarcoma (2nd decade > 1st decade)
10 to 20 y Primary osteosarcoma (M/C malignant BT in children)
20 to 40 y Giant cell tumor (After skeletal maturity)
Secondary osteosarcoma :
40 to 60 y • D/t Paget’s disease, radiation, teriparatide use
Chondrosarcoma
>60 y Metastasis, multiple myeloma, adamantinoma, chordoma

Pulsatile Bone Tumors :

Vascular Pulsatile Bruit present on auscultation.
• Osteosarcoma Most pulsatile. • Giant cell tumor.
• Aneurysmal bone cyst. • Metastasis from kidney and thyroid.

Metastasis/Secondaries :

om
M/C malignant bone tumor. l.c
ai
M/C source : Ca breast > Ca prostate > Ca lung (Neuroblastoma in children).
gm
@

M/C location : Lumbar > thoracic vertebrae.

36
77

Characteristics of secondaries : Secondaries from 1° Bone Tumor :

s.
ha

• M/C location : Lungs.

ng

Purely blastic Purely lytic

si

• Kidney • Bone to bone metastasis :

rit

• Prostate
am

• Medulloblastoma • Thyroid - Ewing’s sarcoma

|

• Carcinoids • Breast (Lytic ± Blastic) - osteosarcoma.

w
ro

Miscellaneous :
ar
M

• M/C primary malignant bone tumor : Multiple myeloma > osteosarcoma.

©

• M/C primary non-hematological malignant bone tumor :

Osteosarcoma > chondrosarcoma.
• M/C benign bone tumor : Osteochondroma/exostosis.
• M/C true benign bone tumor : Osteoid osteoma.

Fibrous Dysplasia [Link]

Pathology : X-ray :
• Developmental anomaly. • Ground glass appearance.
• Bone tissue replaced by • Rind sign : Dense rim
fibrous tissue. around fibrotic tissue.
• M/C in femur. • Shepherd’s crook deformity.

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 Orthopaedic Oncology 45

Biopsy : Best Ix. ----- Active space -----

Chinese letter pattern appearance

Ground glass/Hazy/ Rind sign Shepherd’s crook deformity
Luscent appearance
McCune-Albright Syndrome
Treatment : Bisphosphonates.
• Polyostotic fibrous dysplasia (Multicentric).
• Pigmentation : Café au lait spots.
• Precocious puberty.

Bone Cysts [Link]

om
Simple Bone Cyst (SBC) vs Aneurysmal Bone Cyst (ABC) : ai
l.c
gm

Simple bone cyst (SBC) Aneurysmal bone cyst (ABC)

@

Unilocular Multi-loculated
36
77

Symmetrical expansion Assymetric expansile/ballooning

s.

Radiological features of
ha

Centric Eccentric
ng

aneurysmal bone cyst :

Metaphyseal
si
rit

10-20 years old

am

Proximal humerus Around the knee

|
w
ro

Contains clear/straw coloured fluid Contains blood Growth plate +

ar

Rx : (Child)
M
©

• Aspiration ± injection of
Extended curettage using liquid Multiloculated
steroids/sclerosants
nitrogen, phenol or bone cement lesion in
• Excision & curettage with
autologous bone graft metaphysis

Radiological features of simple bone cyst :

Growth
plate + Chip of the
(Child) cortex breaks &
freely falls down
Metaphyseal
lesion
Chip of bone
hinges at
the cortex

Simple bone cyst Fallen leaf sign Trap door sign

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 46 Orthopaedics

----- Active space ----- Osteochondroma/Exostosis [Link]

M/C benign bone tumor (M/C site : Distal femur).

Developmental malformation of growth plate.
Can be sessile or pedunculated.
Clinical Features :
1. Usually asymptomatic; grows with skeleton.
2. Pain : D/t bursitis (M/C)
nerve compression, fracture.
3. Bony pedicle + cartilaginous cap growing
away from growth plate.
4. Malignant transformation : Chondrosarcoma.
5. Signs :
- >2 cm cap (On MRI).
- Heavy calcification of cap (On X-ray).

om
- Persistence of growth after skeletal maturity.
ai
l.c
Treatment :
gm
@

Extra periosteal excision (At skeletal maturity/signs of malignant transformation).

36
77
s.
ha

Enchondroma [Link]
ng
si

General Features :
rit
am

• M/C bone tumor in small bones of hands & feet.

|

• Location : Metaphyseal.
w
ro

Lucent lesion
• Rx : Extended curettage + bone graft.
ar

in metacarpal
M

(Cartilaginous)
©

Associated Syndromes :
Enchondroma
1. Maffucci’s syndrome : 2. Ollier’s Syndrome :
• Multiple enchondromas. • Multiple enchondromas.
• Cavernous hemangiomas, • 30% cases are premalignant.
• lymphangiomas.
• 100% cases are premalignant.

Multiple hemangiomas of hand Ollier’s syndrome

Note : M/C tumor of the hand : Squamous cell carcinoma.
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Chondroblastoma [Link] ----- Active space -----

Clinical features :
• AKA Codman’s tumor.
• Epiphyseal lesion.
• M/C in children.
• 10-25 yrs
(Before skeletal maturity).
Chondroblastoma Biopsy findings :
X-ray : Punctate/stippled calcification. Chicken wire calcification
Treatment : Excision curettage with autologous bone graft.
Osteoid Osteoma [Link]

• M/c true benign tumor. • M/c site : Femur.

• Children and adolescents. • Eccentric/cortical lesion.
• Location : Diaphysis.

om
Clinical features : ai
l.c X-ray findings :
• Central nidus Produces prostaglandins Pain.
gm

Central lucent
• Night pain that responds to salicylates (Eg : Aspirin).
@

nidus (<2 cm).

36

• Swelling (In thigh or leg).

77
s.

•
ha
ng

Treatment : Dense surrounding

si

• NSAIDs (Pain relief).

rit

sclerosis.
am

• Radiofrequency ablation.
|

• Excision curettage.
w
ro

• MR guided focused ultrasound destruction.

ar
M

Giant Cell Tumor/Osteoclastoma

©

[Link]

General Features : Sites :

• Locally aggressive. • Distal end of femur (M/C).
• Location : Epiphysio-metaphyseal. • Proximal end of tibia.
• Females > males. • Distal end of radius (Classical).
• 20-40 years (After skeletal maturity). • M/C tumor occuring in distal end of radius.

Clinical feature : Egg shell crackling.

Biopsy :
• Multinucleated osteoclast-like giant cells,
surrounded by mononuclear cells (Tumor cells).
• Tumor cells : Stromal mononuclear cells.
Soap bubble appearance
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 48 Orthopaedics

----- Active space ----- Treatment : Extended/extensive curettage + adjuvant treatment.

• Techniques :
- Phenol. - High speed burr.
- Liquid nitrogen. - H2O2.
- Argon beam.
Prognosis :
• Local recurrence : 20% cases. 2° osteosarcoma.
• Risk of malignant transformation : <5% into Fibrosarcoma.
• Metastasis to lungs : 3%. Malignant fibrous histiocytoma.
Summary of GCT
• Epiphyseal location.
• Occurs after epiphyseal fusion.
• Eccentric.
•
om
Expansile.
• Eggshell crackling. l.c
ai
gm

• Extended curettage.
@
36

Giant Cell Tumor Variants :

77
s.

Tumors rich in giant cells :

ha
ng

• Non-ossifying fibroma (M/C). • Fibrous dysplasia.

si
rit

• Aneurysmal bone cyst • Simple bone cyst.

am

(Closest resemblance). • Brown’s tumor.

|
w

• Chondromyxoid fibroma. • Osteosarcoma (Telangiectatic).

ro
ar

• Chondroblastoma.
M
©

Hemangioma [Link]

General Features :
• Occurs in elderly population. • Site : Spine > skull > pelvis.
• Benign, asymptomatic vascular bone tumor.

Radiological Features :
X-ray :
• Vertical striations :
Jail bar/jail house appearance.
• Corduroy appearance.

CT scan :
Polka dot sign (Axial view). Jail bar/jail house appearance Polka dot sign

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 Orthopaedic Oncology 49

Osteosarcoma [Link] ----- Active space -----

General Features :
• M/C bone tumor seen in children.
• Bimodal presentation 2nd decade : 1° osteosarcoma.
Older population : 2° osteosarcoma
(D/t Paget’s disease, radiation exposure).
- 1° osteosarcoma > 2° osteosarcoma.
• Location : Metaphyseal (M/C Distal femur).
• Most radio-resistant tumor.
• M/C radiation induced bone tumor.

X-ray :
• Sun ray/sunburst appearance. • Codman’s triangle : Elevated periosteum.

om
Gross Specimen : ai
l.c
gm
@
36
77

Elevated periosteum
s.
ha

Striations (Codman’s triangle)

ng

(Sunray/Sunburst app.)
si
rit
am

Growth plate
|
w
ro
ar
M
©

Treatment :
Neoadjuvant chemotherapy (Prior to surgery)

Surgery/limb ablation

Adjuvant chemotherapy (Post surgery).

Chemotherapeutic agents : T10 protocol.

• Actinomycin. • High dose methotrexate.
• Cyclophosphamide. • Doxorubicin.
• Bleomycin. • Vincristine.

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----- Active space ----- Ewing’s Sarcoma [Link]

General features :
• M/C tumor in 1st decade of life. • Location : D iaphysis of femur
• Occurrence : M  /C in 2nd decade (Mid thigh swelling).
(5-20 yrs). • High grade sarcoma
• Males > females.
Poor prognostic factors :
• Metastasis. • Leukocytosis.
• Male. • Chemoresistance.
• Fever, anemia. • Relapse.
• ↑ESR. • Size of the lesion.
• Age >12 yrs.

Clinical features :

om
• Presents like infection. • Signs of inflammation (Clinical + lab).
l.c
• Mid thigh/leg swelling. • Incidental h/o trauma.
ai
gm
@
36

Biopsy : Best Ix.

77

• Small, round blue cells with pseudo-rosettes.

s.
ha

• PAS +ve & Diastase digestible.

ng
si

• MIC-2 (CD99) on immunohistochemistry : Specific marker.

rit
am

• Karyotyping : Translocation t(11;22) M/C.

|

Other translocations :
w
ro

- t(21;22), t(7;22).
ar
M

- Trisomy 8.
©

Ewing’s sarcoma
- Trisomy 21.
X-ray : Treatment :
Onion peel/lamellated appearance. • Rx : Chemotherapy + limb salvage/
resection ± adjuvant radiation.
• Radiosensitive (But radiotherapy is not
preferred: D/t ↑ chance of recurrence &
2° malignancies).

Onion peel/lamellated appearance

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 Nerve Injuries 51

NERVE INJURIES ----- Active space -----

Structure of nerve :
Fascicle
Epineurium
Perineurium
Endoneurium
Axon

Classification of Nerve Injuries [Link]

Two classifications : Seddon’s and Sunderland’s.

om
l.c
Seddon’s classification :
ai
gm

Neuropraxia Axonotmesis Neurotmesis

@
36

Nerve compression Axons injured with

77

Complete transection of
atleast one nerve
s.

Mechanism nerve
ha

Temporary, reversible sheath intact

ng

(Continuity lost)
physiological conduction block (Continuity maintained)
si
rit

Neuroma No neuroma Neuroma in continuity End neuroma

am

<100% recovery No recovery Repair +

|

Recovery 100% recovery spontaneously

w

(1 mm/day) graft
ro
ar

Tinel’s -ve Progressive +ve Tinel’s Non-progressive +ve Tinel’s

M

Motor march - + -
©

• Tourniquet palsy • Lacerations

• Fracture
Examples • Saturday night palsy • Cut wound
• Dislocations
• Crutch palsy • Incised wound
Tinel’s sign :
Percussion from distal Nerve stimulation Sensations distal Tingling.
to proximal direction to neuroma
Motor march :
Gradual recovery of muscle function from proximal Distal following axonotmesis.
High vs. low nerve injury :
Higher/more proximal injuries have greater disability/deformities.

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 52 Orthopaedics

----- Active space ----- Axillary & Musculocutaneous Nerve Injuries [Link]

Axillary Nerve Injury :

Root value : C5, C6.
Features :
Motor supply Sensory supply
• Deltoid (Abduction of shoulder)
Lateral aspect of
Innervation • Teres minor (External rotation
proximal shoulder
of shoulder)
Deformity Adducted & internally rotated Regimental badge sign
Mechanism of injury :
• Shoulder dislocation (M/C).
• Proximal humerus fracture.
• Iatrogenic.

Musculocutaneous Nerve Injury :

om
Motor supply l.c Sensory supply
ai
gm

Anterior compartment of arm :

@

• Biceps brachii : Forearm supination >

36

Innervation Elbow flexion Lateral aspect of forearm

77
s.

• Coracobrachialis
ha

• Brachialis : Elbow flexion

ng
si

Deformity Extended elbow with pronated forearm Paresthesia, tingling, numbness

rit
am

Mechanism of injury : Shoulder dislocation.

|
w

Median/Labourer’s Nerve Injury

ro

[Link]
ar
M

Innervation :
©

Mixed nerve

Motor supply Sensory supply

• Forearm : Anterior compartment • Lateral 3 1/2 Palmar.

muscles except flexor carpi • Only tips Dorsal.
ulnaris & medial half of flexor Autonomous zone
digitorum profundus. of median nerve
• Hand : All thenar muscles except
adductor pollicis & lumbricals 1,2.

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 Nerve Injuries 53

Anterior Interosseous Nerve : ----- Active space -----

• Branch of median nerve.
Flexor pollicis longus (Flexion of thumb IP joint).
• Purely motor nerve : Supplies
Lateral half of FDP (Flexion of DIP).
AIN injury :
• D/t supracondylar humerus fracture.
• No sensory deficit.
• Kiloh Nevin/Weak Ok sign + .

Normal OK sign Weak OK sign

Median Nerve Injury at Wrist :
• Loss of sensation of lateral 3 1/2 fingers.
• Wasting of thenar eminence.
Abduction
• Loss of thumb Flexion Ape hand/thumb

om
Opposition deformity. ai
l.c
gm
@

Pen test :
36

• To assess abduction of thumb (Abductor pollicis brevis).

77
s.

Procedure :
ha
ng

- With palm facing upwards, patient asked to touch

si
rit

pen with thumb.

am

- Positive if patient fails to do so.

|
w
ro

Median Nerve Injury at Elbow :

ar
M

FPL.
©

Manifestations of wrist lesion + loss of functions of FDS.

FDP.
Pointing index/Benediction sign/Pope sign/Ochsner clasp sign :
FDS : Flexion of PIP & MCP joints.
Evaluates function of
FDP : Flexion of DIP, PIP, MCP joints.

Index finger doesn’t flex on making a

fist in median nerve injury at elbow.
Note : Actions of thumb.
• Abduction : Perpendicular to plane of palm.
• Extension : Parallel to plane of palm.

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 54 Orthopaedics

----- Active space ----- Ulnar/Musician’s Nerve Injury [Link]

Innervation :
Sensory supply :
• Medial 1.5 fingers (Volar & dorsal).
• Autonomous zone : Tip of little finger.
Motor supply :
Posterior Anterior
Arm : No supply.
Sensory supply of ulnar nerve
Forearm :
• Medial half of FDP. • Flexor carpi ulnaris.
Hand :
• Hypothenar muscles. • Interossei group of muscles.
• Adductor pollicis (Thenar muscle). • Lumbricals 3 & 4.

Ulnar Nerve Injury at Wrist :

om
Site : Guyon’s canal behind pisohamate ligament.
Manifestations : l.c
ai
gm

• Partial clawing of hand : D/t lumbricals 3 & 4.

@

• Hypothenar wasting.
36
77

• Loss of sensations in medial 1 1/2 hand.

s.
ha

• Loss of palmar & dorsal interossei.

ng

Partial claw hand

si
rit

Note :
am

Complete clawing : Median + ulnar nerve palsy.

|
w
ro
ar
M
©

Complete claw hand Knuckle bender splint :

Rx for claw hand (Partial/complete)
Evaluation :
1. Card test :
To evaluate : Palmar interossei (Adduction of fingers).

2. Egawa test : Card test

To evaluate : Dorsal interossei (Abduction of 2 , 3 , 4 , 5 fingers).
nd rd th th

3. Fanning of fingers : To evaluate dorsal interossei.

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 Nerve Injuries 55

4. Book test : ----- Active space -----

• To evaluate : Adductor pollicis.
• Procedure : Patient asked to hold an object between
thumb & index finger

Lack of adduction compensated by flexor

Adductor pollicis normal
pollicis longus (Median nerve supply)

Flexion of thumb (Froment sign).

Ulnar Nerve Injury at Elbow :
Site : Cubital tunnel, behind medial condyle. Froment’s positive
Manifestation : ↓Clawing/deformity.
Ulnar Paradox :
• High ulnar nerve palsy (Elbow) ↓Clawing/deformity (FDP paralyzed).
• Low ulnar nerve palsy (Wrist) ↑Clawing/deformity (FDP spared).
om
l.c
ai
Radial Nerve Injury
gm

[Link]
@

Radial nerve
36

Course and Supply :

77

Very high radial nerve palsy

s.
ha

First elbow extensor :

ng

Branch to long head of triceps

si
rit

Branch to Lateral head of triceps

am

High radial nerve palsy Branch to medial head of triceps

|

(At spiral groove : M/c) Branch to anconeus

w
ro
ar
M

Low radial nerve palsy

©

Branch to extensor carpi radialis

longus (ECRL) (First wrist extensor) Posterior interosseous nerve
PIN palsy (PIN) (Deep motor branch)
(At radial head)
Superficial branch (Sensory branch
to medial 3 1/2 finger excluding tips)
Branches of PIN
Autonomous zone : Dorsum
of first web space

Sensory supply
(R : Radial nerve)
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 56 Orthopaedics

----- Active space ----- Levels of Radial Nerve Injury :

Level of injury Location of injury Manifestations
Finger drop, thumb drop, sensory loss,
Very high radial nerve palsy Axilla
wrist drop, inability to extend elbow
Finger drop, thumb drop, sensory loss,
High radial nerve palsy (M/C) Spiral groove
wrist drop
Low radial nerve palsy Lateral condyle Finger drop, thumb drop, sensory loss
PIN palsy Radial head Finger drop, thumb drop

Holstein Lewis Fracture :

• M/C cause of radial nerve injury.
• Lower 1/3rd humerus # :
Causes radial nerve entrapment

Wrist drop, finger drop, thumb drop, sensory loss.

Holstein Lewis fracture

om
Treatment :
l.c
ai
gm
@
36
77
s.
ha

Cock up splint (Rx for wrist drop)

Wrist drop
ng
si
rit

Static Dynamic Prevents

am

(Extends wrist) (Extends wrist + allows flexion of fingers) contractures.

|
w
ro

Summary of Nerve Function Tests

ar

[Link]
M
©

Nerve Test/sign Muscle

Book test Adductor pollicis
Froment sign Flexor pollicis substitutes for adductor pollicis
Ulnar
Card test Palmar interossei
Egawa test Dorsal interossei
Ape thumb Thenar muscle wasting
Pen test Abductor pollicis brevis
Median Kiloh Nevin sign/pincer Flexor digitorum profundus +
grasp flexor pollicis longus (AIN)
Pointing index/Benediction Flexor digitorum superficialis +
sign/Ochsner clasp lateral half of flexor digitorum profundus
Finger & thumb drop Extensors (PIN)
Radial
Wrist drop Extensors of wrist ECRL

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 Nerve Injuries 57

Brachial Plexus Injury [Link] ----- Active space -----

A
Erb’s point A :
• C5
• C6 B
Confluence
• Suprascapular
nerve

om
Types of brachial plexus injuries : l.c
ai
gm

• Supraclavicular injury (Upper roots & trunks) Erb’s palsy (Best prognosis).
@

• Infraclavicular injury (Lower roots & trunks) Klumpke’s palsy B .

36
77

• Combined/mixed palsy (Worst prognosis).

s.
ha
ng

Mechanism of injury :
si

Traction (Stretching)
rit
am
|
w

• During birth • Hyperabduction injury : Fall from

ro
ar

• RTA/ fall height while holding onto an object

M
©

• Traction on arm (Presenting part)

during birth

Supraclavicular injury (M/C). Infraclavicular injury.

Erb’s Palsy :
Nerves injured Muscles affected Deformity
Supraspinatus Adduction
Suprascapular
Infraspinatus Internal rotation
Deltoid Adduction
Axillary Policeman’s/Waiter’s/
Teres minor Internal rotation Porter’s tip deformity
Biceps brachii Elbow extension, pronation
Musculocutaneous
Brachialis Elbow extension

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 58 Orthopaedics

----- Active space -----

Airplane splint : Rx for Erb’s palsy Erb’s palsy

Klumpke’s Palsy :
C8, T1 injury

Combined ulnar + median nerve palsy Loss of sympathetic supply to eye (T1)

Complete clawing of hand Parasympathetic overactivity on eye

om
Horner’s syndrome
l.c
(Ptosis, miosis, anhidrosis, loss of ciliospinal reflex)
ai
gm
@
36

Ptosis
77

Miosis
s.
ha
ng

Rx : Plexus reconstruction.
si
rit
am

Common Peroneal Nerve Injury [Link]

|
w
ro

Innervation :
At neck of fibula
ar
M
©

Superficial branch Deep branch

Motor supply Sensory supply Sensory supply Motor supply

Lateral compartment of leg Dorsum of 1st web space Anterior compartment of leg
(Evertors of foot) foot of foot Dorsiflexors of ankle/foot

Causes of injury : Neck of fibula #/lateral condyle of tibia/Bumper fracture

Manifestations :
Dorsiflexion Equinovarus deformity
• Loss of ankle
Eversion (Plantar flexion & inversion).
• Gait : High stepping/foot-drop gait/steppage gait
(To overcome dragging of foot d/t foot drop).

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 Nerve Injuries 59

----- Active space -----

Foot drop/Toe-raising
splint/Ankle-foot orthosis :
Rx of foot drop Common peroneal nerve
Equinovarus deformity
in relation to fibula

Entrapment Neuropathies [Link]

Nerve trapped under a structure Delayed conduction of stimulus.

Syndrome/pathology Nerve Site of compression/injury

om
Carpal tunnel
Median At wrist
syndrome (M/C) ai
l.c
Cubital tunnel Ulnar Behind the medial condyle humerus
gm
@

Guyon’s canal Ulnar Under the pisohamate ligament

36

Pronator syndrome Median nerve Heads of pronator teres

77
s.

Kiloh Nevin syndrome AIN Supracondylar humerus fracture

ha
ng

Cheralgia Radial styloid, insertion of brachioradialis

Superficial radial nerve
si

paraesthetica (Wrist watch, cuffs, bangles)

rit
am

Meralgia Lateral cutaneous nerve

Under inguinal ligament (Tight belt)
|

paraesthetica of thigh
w
ro

Pyriformis syndrome Sciatic nerve Pyriformis & obturator internus muscle

ar
M

Tarsal tunnel Behind medial malleolus below the flexor

Posterior tibial nerve
©

syndrome retinaculum of foot (RA)

Morton metatarsalgia Interdigital nerve of foot Between 3rd & 4th toe

Carpal Tunnel Syndrome :

• Median nerve entrapment in carpal tunnel (At wrist) under flexor retinaculum/
transverse carpal ligament.
• M/C entrapment neuropathy (M/c entrapped nerve : Median nerve).

Etiology :
Conditions causing ↑pressure inside carpal tunnel.
Idiopathic : M/C cause.
• Hypothyroidism (Myxedema).
• Rheumatoid arthritis (Inflammation).

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 60 Orthopaedics

----- Active space ----- • Pregnancy (Fluid retention).

• Acromegaly (Excessive growth of bone & soft tissue).
• Activity causing wrist compression (Eg : Typing).
• Colle’s fracture (Hematoma Compression).
• Gout.
• Amyloidosis.
• Diabetes mellitus.
Clinical features :
• Middle aged female.
• C/o pain : Carpal tunnel syndrome
- Type of pain : Burning, tingling & numbness.
Maximum at night.
- Distribution : Along lateral 3 1/2 fingers
Relieved on shaking her hand
• Thenar muscle wasting & weakness. (Flick sign).
Evaluation :

om
1. Phalen’s test ai
l.c 2. Reverse Phalen’s test
gm
@
36
77
s.
ha
ng
si
rit
am

Position held for Dull aching pain, numbness, Position held for
|
w

approx. 1 minute paresthesia, tingling along approx. 1 minute

ro
ar

median nerve distribution

M
©

3. Durkan’s test :
• Best clinical test.
• Direct median nerve compression between thenar & hypothenar eminence
for 30 seconds Reproduces symptoms.
4. Tourniquet test.
Nerve conduction studies : IOC.
Treatment :
Conservative : Rest, steroids, splints.
No improvement
Surgery : Release of flexor retinaculum.

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 Metabolic Diseases of Bone 61

METABOLIC DISEASES OF BONE ----- Active space -----

Physiology Of Bone [Link]

Bone Markers :
Formation markers Breakdown markers
Osteoblast activity ↑ Osteoclast activity ↑

1. Procollagen I 1. Hydroxyproline
2. Osteocalcin 2. Hydroxylysine
3. Osteonectin 3. N & C telopeptide
4. Alkaline phosphatase (ALP) 4. Tartrate resistant acid phosphatase (TRAP)

om
l.c
ai
Note :
gm

Bone resorption ↑Formation markers (↑Bone turnover).

@
36
77

Calcium Homeostasis :
s.
ha
ng

↓Ca2+ ↑PTH
si
rit
am

↑Ca2+ reabsorption PTH receptors on

|
w

↑PO43- excretion osteoblasts

ro
ar
M
©

25-hydroxy 1,25-dihydroxy Release of RANK ligand

Vitamin D vitamin D - Denosumab
(Stored) (Active form) Resorption by osteoclasts

↑Absorption of Normal Ca2+ levels

Ca2+ and PO43- -ve feedback
↑ALP
in the gut Parathyroid gland
(D/t new bone synthesis)
(↓PTH)

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 62 Orthopaedics

----- Active space ----- Metabolic Bone Disorders [Link]

Classification :
Parathyroid 1˚ Hyperparathyroidism
hormone
Minerals
Abnormal Ca2+, PO43- and PTH.
Rickets
Vitamin D
(Deficiency) Osteomalacia

Procollagen Osteogenesis imperfecta (Genetically abnormal collagen).

Bone Matrix
(Collagen) Vitamin C (deficiency) Scurvy.
Collagen

Osteoblasts

om
Cells Increased function
ai
l.c Paget’s disease.
Osteoclasts
gm

Decreased function Osteopetrosis.

@
36
77

Low bone mass Osteoporosis Normal lab parameters.

s.
ha

Rickets
ng

[Link]
si
rit

Causes :
am

• Vitamin D deficiency : M/c cause.

|
w

- Nutritional (M/c cause).

ro
ar

- Malabsorption.
M
©

- Lack of sunlight exposure.

- Liver and kidney disease.
- Drugs.
• Ca2+ deficiency.
• PO43- deficiency.

Labs :
• Ca2+ : ↓/Normal (Early disease).
• ↑PTH.
• ↓PO43-.
• ↑ALP.

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 Metabolic Diseases of Bone 63

Clinical Features : ----- Active space -----

1. Skull : Earliest changes.

Delayed
- Craniotabes/softening of skull/ping pong closure of Wide sutures
fontanelles
skull : Earliest change.
- Frontal bossing. Frontal
bossing Craniotabes
- Delayed closure of fontanelle.

2. Chest : Dental Rachitic

hypoplasia rosary
- Rachitic rosary : Costochondral junction
swelling (Blunt and non-tender).
- Pigeon chest/pectus carinatum : Pectus Harrison’s
carinatum sulcus
Prominent sternum.
- Harrison sulcus : Due to bending of Swelling in wrist Bowing of
softened ribs by diaphragm contraction. and ankle joints legs

om
3. Long bone deformities :
- Only seen once child starts l.c
ai
gm

weight bearing.
@

- Not seen in infants.

36
77
s.

4. Hip joint : Coxa vara (Proximal femur).

ha
ng
si
rit
am

Valgus on
|
w

one side
ro
ar

Varus on
M

one side
©

Bending of
long bone
shaft
B/L genu varum B/L genu valgus Windswept deformity
(M/c presentation) • Children/Overall B/L genu varum
Rickets (M/c).
• Adults RA (M/c).

Note :
Scorbutic rosary (In scurvy) : Sharp & tender.

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 64 Orthopaedics

----- Active space ----- Radiological Features :

Normal Rickets
Fraying-ragged edges
Diaphysis
Cupping of metaphysis

Metaphysis Splaying of metaphysis

Growth plate Widening of epiphyseal plates

Epiphysis

White line of Frankel

(Mineralization of
growth plate)

om
l.c
ai
gm
@
36
77
s.
ha
ng
si
rit
am

Healing rickets
|
w

Osteomalacia
ro

[Link]
ar
M

Features :
©

• Female > males.

• Young age.
Symptoms :
• Polyarthralgia.
• Bone pains.
• Proximal myopathy. Looser zones :
Stress # that have
Investigations : healed with mineral
X-ray : deficit material.
1. Pseudofractures :
- AKA milkman’s line/looser zone.
- M/c site : Neck of femur, clavicle,

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 Metabolic Diseases of Bone 65

ribs, pubic rami. ----- Active space -----

2. Protrusio acetabuli : Head of femur protrudes into the acetabulum.

Tumor induced osteomalacia

Causes :
1. Fibrosarcoma.
2. Osteoblastoma.
3. Osteosarcoma.
4. Non-ossifying fibroma.

Treatment :
Vitamin D :
1. Stoss regimen : 3 lakh - 6 lakh IU deep IM/oral (stat or over 1-5 days).
2. Daily : 2k - 5k IU for 4-6 weeks.

om
3. Weekly : 50k - 60k IU for 8-12 weeks. ai
l.c
Scurvy
gm

[Link]
@
36

Defect in collagen maturation of osteoid (Mineralization : Normal).

77

Features of scurvy
s.
ha
ng
si

Bone (Radiological features) Blood vessel (Symptoms)

rit

• Diaphysis :
am

- Ground glass appearance

|

Costochondral Bleeding Easy Bone :

w

- Pencil thin cortex

ro

junction : gums. bruising. Subperiosteal

• Metaphysis :
ar

Scorbutic rosary. hemorrhage

M

- White line of Frankel

©

- Scorbutic zone
- Pelkan’s spur D/d : B/L knee pain.
• Epiphysis : • Healing rickets.
Wimberger ring sign. • Congenital syphillis.
• Plumbism.
• Leukemia.

White line of Frankel Bleeding gums

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 66 Orthopaedics

----- Active space ----- X-ray Findings :

Pencil thin cortex
Ground glass appearance
Pelkan’s spur
White line of Frankel
Scorbutic zone
(Trummerfeld zone)
Wimberger ring sign.

Treatment :
Vitamin C supplementation.
Primary Hyperparathyroidism [Link]

MCC : Adenoma.
Pathophysiology : ↑PTH ↑Ca2+ (Despite negative feedback).
Lab findings : ↑Ca2+ ; ↑ PTH ; ↓PO43- ; ↑ALP.
om
l.c
ai
Clinical Features :
gm

Due to excess bone breakdown :

@
36

↑PTH ↑bone resorption

77
s.
ha
ng

Teeth : Salt and pepper skull Phalanges Bone :

si
rit

Resorption of Brown tumor

am

lamina dura.
|

Breakdown of bone
w
ro
ar

Cavities formed
M
©

Filled with blood

Subperiosteal resorption Hb breaks down
Due to ↑S. Ca :2+ on radial side to hemosiderin.
• Bones.
• Stones.
• Groans.
• Psychiatric overtones.
• Fatigue.

Brown tumor

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 Metabolic Diseases of Bone 67

Renal Osteodystrophy [Link] ----- Active space -----

Lab values : X-ray spine :

• ↓Ca2+.
• ↑Phosphate.
• ↑PTH.
• ↑ALP.

Rugger Jersey spine

(Also seen in osteopetrosis)
Osteoporosis [Link]

Quantitative defect : Porous bone disease (Normal lab values).

Pathogenesis :
Ageing

om
Causes an imbalance b/w osteoblast & osteoclast (Bone formation < Resorption)
ai
l.c
gm

↓Strength of bone
@
36
77

Weak bones and microfractures.

s.
ha

Etiology :
Osteoporosis
ng
si
rit
am

Primary Secondary :
|

• Drugs :
w
ro

Type 1 : Type 11 : - Steroids.

ar
M

Post menopausal Senile (Age) - Heparin.

©

(M/c risk factor). (M/c cause). • Hormones : Cushing’s.

• Immobilization.
• Weightlessness/space.
Note : Estrogen is protective against osteoporosis. • Rheumatoid arthritis.
Clinical Features : Kyphosis : Forward bending of spine
• Back pain : Earliest symptom.
Pain before fracture (Constant
weight bearing).
• Fragility fracture :
- M/c complication.
- Sites : Spine, neck of femur/hip, Colle’s fracture
• Deformity : Kyphosis (Forward bending of spine).
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 68 Orthopaedics

----- Active space ----- Investigations :

Vertebral fracture Neck of femur fracture Colles’ fracture Codfish vertebra

Screening : (After 30% bone loss)
IOC : Bone mineral density scan.
• Performed using DEXA (Dual energy X-ray absorptiometry) scan.
• Assess spine, hip, calcaneus.
• T-score :

om
Bone mineral density compared to young male/female (30y) : Highest density.
l.c
ai
T-score (Standard deviations) Diagnosis
gm

Screening in osteoporosis
@

0 to -1 Normal • Women ≥ 65yrs.

36

-1 to -2.5 Osteopenia • Men ≥ 70yrs.

77

• Fracture with trivial trauma > 50yrs.

s.

Osteoporosis
ha

≤ -2.5
ng

< -2.5 with fracture Severe osteoporosis

si
rit

Treatment :
am
|

↓Bone resorption ↑Bone formation Does both

w
ro

Bisphosphonates (DOC) Teriparatide (rPTH) : Small doses

ar

↑Risk of osteosarcoma.
M

Denosumab Strontium
©

SERM : Raloxifene Abaloparatide (PTHrp) ranelate

Hormone replacement therapy for post-menopausal women Romosozumab
Note : M/c vertebral # in osteoporosis : Lower thoracic and upper lumbar.
Bisphosphonates :
• Adverse effects :
Prolonged use of bisphosphonates (5 - 7 yrs)

↓Osteoclastic activity
(Lower than osteoblastic activity)

Atypical fractures around hip. Atypical fracture

• Drug holiday : Temporarily stop using bisphosphonates (1-2yrs)

& switch to other drugs (Teriparatide).
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 Metabolic Diseases of Bone 69

Paget’s Disease/Osteitis Deformans [Link] ----- Active space -----

• Male > female. • Pelvis > tibia.

• Incidence : 5th decade.
Etiology : Lab Findings :
• Idiopathic (M/c). • ↑ALP : 10x to 100x.
• SQSTM1 gene mutation. • s. Ca2+ : Normal.
• Paramyxovirus. • s. PO43- : Normal.
Pathophysiology :
Osteolytic activity
Osteoblastic activity
Lytic phase Mixed phase Blastic phase

Clinical Features :
1. Pain (M/c).

om
2. Bone is warm to touch & thickened/irregular. ai
l.c
3. Weak bone (Banana fracture).
gm

4. Cranial foramen stenosis : CN 2, 5, 7, 8 (Hearing disturbances).

@

Banana fracture
36

5. Otosclerosis.
77
s.

6. Thickening of skull : Frequent changes in hat size.

ha
ng

Radiological Features :
si
rit

1. Lytic phase :
am

• Blade of grass/Flame shaped appearance.

|
w
ro

• Osteoporosis circumscripta : Circumscribed lesion in the skull.

ar
M
©

Blade of grass deformity

2. Mixed phase :

Picture frame vertebrae Ivory vertebrae Cotton wool skull

(Sclerosis at edges)

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 70 Orthopaedics

----- Active space ----- 3. Blastic phase :

Thickening of skull

Tam o’ Shanter skull

Treatment :
Zoledronate :
• Long acting bisphosphonate.
• Suppress osteoclastic activity.
Complications :
• High output cardiac failure (Causes death).
om
• Transformation to osteosarcoma (D/t ↑bone turnover).
l.c
ai
gm

Osteogenesis Imperfecta [Link]

@
36

• Genetically abnormal collagen.

77

• COLA 1 gene defect.

s.
ha
ng

Types :
si
rit

AD : Weak bone Recurrent pathological fractures.

am

Clinical Features :
|
w

1. Deformities : D/t multiple fractures in the same bone.

ro
ar

2. Blue sclera.
M
©

3. Easy bruising.
4. Multiple fractures in different stages of healing. Note :
5. Delayed dentition. Multiple fractures can be
Labs : Normal. seen in antenatal scan.

Choroid is
visible d/t
thin sclera

Blue sclera

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 Metabolic Diseases of Bone 71

----- Active space -----

Deformities d/t multiple fractures Fractures in different stages of healing

OSTEOPETROSIS
AKA Marble bone disease.
Pathophysiology :
↓Osteoclast function ↓Resorption ↑Bone formation  edullary cavity obliterated by new
M
bone.
C/f :
om
• Excessive thickened bone. l.c
ai
• Aplastic anemia : Anemia, thrombocytopenia, leucopenia.
gm
@

• Multiple infections.
36
77

X-ray : Rugger jersey spine.

s.
ha
ng

Summary [Link]
si
rit
am

Calcium PTH PO43- ALP

|
w

2° hyperparathyroidism/
ro

↓/ Normal ↑ ↓ ↑
rickets/osteomalacia
ar
M

Renal osteodystrophy ↓↓ ↑ ↑↑↑ ↑

©

1° hyperparathyroidism ↑↑↑ ↑↑↑ ↓ ↑

Osteoporosis Normal
Paget’s disease Normal ↑↑↑

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 72

----- Active space ----- ORTHOPAEDIC INFECTIONS

Osteomyelitis [Link]

In young children or elderly population : D/t relatively low immunity.

Routes/Source of Infection :
• Hematogenous (M/C) : From pre-existing infection.
• Direct. • Open fracture.
• Post surgical. • From septic arthritis.
Etiology :
Staphylococcus aureus :
• M/C organism. • M/C cause of osteomyelitis in :
• M/C cause of : - Developed countries.
om
- Osteomyelitis overall. l.c - Developing countries.
ai
gm

- Acute osteomyelitis. - Immunocompromised (HIV/AIDS).

@

- Chronic osteomyelitis. - Open fracture.

36
77

- Post surgical.
s.
ha

Exceptions :
ng
si

Osteomyelitis in Organism
rit
am

Sickle cell disease patients Salmonella

|

IV drug abusers Pseudomonas

w
ro

Following animal bite Pasteurella

ar
M

Following human bite Eikenella

©

Prolonged parenteral therapy Fungal organisms

Site :
Metaphysis of long bone : M/C femur (Distal > proximal) > tibia.

Reasons of metaphyseal involvement :

• Most vascular region of bone.
• Hairpin loop arrangement of blood
vessels Sluggish blood flow.
• ↓ monocytes & macrophages.

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 Orthopaedic Infections 73

Pathophysiology : ----- Active space -----

Acute osteomyelitis :
• Organism reach metaphysis : <24 hours.
Systemic manifestations : Fever, pain.
• Abscess formed : After 24 hours.
Chronic osteomyelitis :
• Sequestrum :
- Dead bone formed.
- Hallmark of chronic osteomyelitis.
• Periosteal reaction : ~10 days Involucrum (New bone forming around the
pathology).
• Pus escapes through cloaca (Break in involucrum) and sinus (Break in skin).
Hallmarks :
Note : Duration
Acute Chronic
• Acute : <2 weeks.

om
Clinical hallmark Fever & pain Sinus • Subacute : 2-4 weeks.
Pathological hallmark Abscess Sequestrum l.c • Chronic : >4 weeks.
ai
gm

ACUTE OSTEOMYELITIS
@
36

Investigations :
77

Radiology :
s.
ha
ng
si

MRI : Bone scan : X-ray :

rit

Picks up earliest • Technetium 99 • Changes detected after 24

am

changes within 24 • Gallium 67 ↑Accumulation hours of disease onset.

|
w

hrs of disease onset : • Indium 111 labelled in infection • Earliest X-ray change (within
ro

Marrow edema. WBC (Best) 48 hours) : Soft tissue

ar
M

lucency/shadow around bone.

©

• Earliest bony changes on

Biopsy : X-ray (7-10 days/2 weeks) :
• Gold standard. Periosteal reaction..
• Tissue sample collected from site of infection.

Treatment and Complications :

Treatment : Antibiotics (2 wks parenteral f/b 4 wks oral) ± Drainage of abscess.
Complications :
1. Chronic osteomyelitis : M/C. 4. Septic arthritis : Bone Infection Joint.
2. Septicemia. • Prevented by growth plate.
3. Growth disturbance. • Common in :
- <2 yr : Before growth plate formation.
- Adults : After growth plate fusion.

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 74 Orthopaedics

----- Active space ----- CHRONIC OSTEOMYELITIS

Features :
Discharging sinus
• Sequelae/complication of
acute osteomyelitis. Involucrum
• >4 weeks following infection. Sequestrum
• Clinical hallmark : Sinus.

Chronic osteomyelitis

Investigations :
X ray/CT :
• Loss of corticomedullary
differentiation.
• Sequestrum.

om
• Involucrum.
l.c
• Cloaca.
ai
gm
@

Treatment : Loss of corticomedullary differentiation

36

Always surgical + antibiotic cover.

77
s.
ha

Steps :
ng

Sinus tract excision

si
rit
am

Sequestrectomy
|
w
ro
ar

Curettage till fresh blood seen

M
©

(Paprika sign +ve) Sequestrectomy

Saucerisation :
Debridement to make the mouth wide.

Dead space closed with bone graft/cement.

Paprika sign
Saucerisation

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 Orthopaedic Infections 75

Types of Sequestrum : ----- Active space -----

Sequestrum Associated conditions

Coraliform Perthe's
Amputation stump/
Annular/ring
pin tract sites
Tubular/diaphyseal (M/C) Acute pyogenic osteomyelitis
Feathery/flake/coarse sandy Tuberculosis (TB) Infection around pin tract :
Fine sandy Viral osteomyelitis Ring sequestrum
Button hole Post radiation (D/t heat necrosis)
Ivory Syphilis

Complications :
1. Pathological fracture (M/C) : D/t weakened bone.
2. Acute exacerbation.
3. Squamous cell carcinoma (SCC) : D/t Neoplastic changes of sinus tract.

om
4. Amyloidosis.
l.c
ai
SUBACUTE OSTEOMYELITIS
gm
@

No sinus or sequestrum (AKA Brodie’s abscess).

36
77

Pathogenesis :
s.
ha

• Patient has good immunity.

ng

Infection contained.
si

• Organism has low virulence.

rit
am
|

Brodie's abscess
w
ro

Course Subacute
ar
M

M/C site Tibia (Proximal end)

©

Pus +
MRI • Acute dull aching pain
Clinical feature
• Low grade fever
Elevated ESR & CRP +
X-Ray Penumbra sign : Central lucency surrounded by
MRI dense sclerotic rim.
Rx Antibiotics ± debridement
X-Ray

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 76 Orthopaedics

----- Active space ----- Septic Arthritis [Link]

• Surgical emergency :
If pus not removed from joint immediately Destruction of joint.
• Children (<5 yrs) > Elderly people.
• M/C route : Hematogenous.

Site : Organism :
• M/C site : Knee • M/C : Staphylococcus aureus.
(Ends of bone exposed). • IV drug abusers : Pseudomonas.
• Infants : Hip (Tom Smith’s arthritis). • Sexually active : Gonococcus.

Clinical Features :
Young child presents with :
• High grade fever. Hip : FABER
• Flexion
• Local inflammatory features : • Abduction

om
- Swelling. • External
l.c
rotation
ai
- Redness.
gm

- Pain (Joint effusion stretches

@
36

pain sensitive capsule) Knee : 5 -30o

77

flexion
s.

No movement at joint.
ha

• Joint in position of ease ↑joint volume

ng

↓Pain.
si
rit
am
|
w
ro

Treatment :
ar

Position of ease
M

Arthrotomy (TOC) : Irrigation & debridement of septic

©

joint contents under antibiotic cover.

Complication :
Bony ankylosis : End sequelae of neglected septic arthritis.
Organisms release proteolytic enzymes :
Collagenases, metalloproteinases, elastases.

Destroy articular cartilage

Raw ends of bone exposed Bony ankylosis

Heal with fusion

Bony ankylosis.
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 Orthopaedic Infections 77

Note : Other types of ankylosis. ----- Active space -----

Bony Fibrous
Fusion between raw ends of bone Bone Fibrous tissue
Pyogenic septic arthritis
Causes TB arthritis
TB spine (Spondylitis)
Movement - +
Pain - +
Stability of joint Stable Unstable

Tom Smith’s Arthritis :

Septic arthritis of hip in infancy (<1 year).
Pathogenesis : Chondrolysis.
Clinical features :
• Hyper mobility of hip joint Telescopy test +ve.
• Limb shortening. Tom Smith’s arthritis

om
Tuberculosis ai
l.c [Link]
gm

M/C site :
@

• In the body : Lungs.

36

• Musculoskeletal system : Spine TB spondylitis > hip TB arthritis > knee arthritis.
77
s.

• In spine : Dorsolumbar > dorsal > lumbar (In children : Cervical spine).
ha
ng

Route : Hematogenous.
si
rit

Variants :
am

Caries sicca : TB shoulder (Dry/non-exudative TB).

|
w
ro

Spina ventosa : TB fingers (Filling up of air appearance).

ar
M

TB SPINE (TB SPONDYLITIS)

©

Patterns of Involvement :

Paradiscal (M/C) Central Anterior/wet/exudative Posterior (Rarest)

(In children)

Note : TB spine vs spine metastasis on MRI.

• Disc involved (Bad disc) TB spine (Good prognosis).
• Disc spared (Good disc) Metastasis (Bad prognosis).
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 78 Orthopaedics

----- Active space ----- Clinical Features :

Constitutional features : Local findings :

• Low grade fever. • Back pain (Earliest symptom).
• Malaise. • Paraspinal spasm/tenderness (Earliest sign) : Military attitude,
• Night pains. cautious gait.
• Evening rise of • Cold abscess.
temperature. • Deformity (D/t vertebral collapse)
Spinous process felt prominently on palpation :
- Knuckle : Prominence of 1 spinous process.
- Gibbus : Prominence of 2-3 spinous process.
- Angular kyphosis : Prominence of >3 spinous process.

Angular kyphosis
Investigations :

om
X-ray :
l.c
• Disc space narrowing (D/t destruction/dessication of disc) : Earliest.
ai
gm

• Para vertebral abscess.

@

• Vertebral destruction.
36
77

MRI (IOC) :
s.
ha

• Disc involved.
ng

• Paradiscal disease involving bone and cartilage.

si
rit
am

MRI CT guided biopsy : Gold standard.

|

Complications :
w
ro

Pott’s paraplegia :
ar
M

TB spine (Pott’s spine) Compresses on spinal cord Neurological signs.

©

Clinical features :
• Early neurological manifestations (UMN findings).
• Late : Bowel & bladder involvement.
Treatment :
Middle path regimen :
ATT for 18-24 months + rest + Taylor's brace
MRI : Cord compression

Improvement • No improvement/neurological manifestation

• Worsening/bowel & bladder involvement

Continue treatment Surgical decompression

Note : Limping child Septic arthritis (Fever + ), Perthe’s disease (No fever).
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 Spine : Injuries and Disorders 79

SPINE : INJURIES AND DISORDERS ----- Active space -----

Anatomy of Vertebrae  [Link]

Typical vertebral anatomy :

Posterior Anterior Posterior
Spinous Transverse
process process Facet of superior
articular process
Facet of Intervertebral disc
superior
Vertebral arch : Inferior articular
articular
Lamina process
process
Anterior Pedicle
Spinous process

om
Body
Superior view
l.c Left posterolateral view
ai
gm

• Part of vertebrae between superior & inferior articular facet : Pars

@
36

interarticularis.
77
s.
ha

Common spinal injuries :

ng

M/c site of :
si
rit

• Vertebral fracture :
am

Lower thoracic/T12.
|
w

• Vertebral dislocation :
ro
ar

Cervical spine (D/t horizontally arranged articular facets).

M
©

• Spinal cord injury :

Cervical spine (Thickest part of spinal cord).

Spinal Fractures [Link]

JEFFERSON’S FRACTURE
Fracture of C1 (Atlas).
Cause : Axial loading/compression

Fragments burst away.

(No neurological damage)

Jefferson’s fracture

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 80 Orthopaedics

----- Active space ----- HANGMAN’S FRACTURE

Defined as :
1. Fracture dislocation of C2 over C3.
2. Pars interarticularis fracture :
Spondylolysis.
3. Slipping of C2 over C3 :
Spondylolisthesis.
Hangman’s fracture
CLAY SHOVELLER’S FRACTURE
Shoveling

Strong contraction of upper limb muscles

Avulsion of C7 spinous process (C7 > T1)

CHANCE FRACTURE

om
AKA Jackknife fracture/Seatbelt fracture. l.c
Clay shoveller's fracture
ai
gm

Mechanism of injury :
@

Car impact with seatbelt on

36
77
s.

Flexion at lower thoracic, upper lumbar

ha
ng

spine with distraction forces.

si
rit
am

Fracture of spine (Posterior to anterior)

|
w
ro
ar

Chance fracture
M

COMPRESSION VS. BURST FRACTURES

©

Compression Fracture Burst Fracture

Causative Factor Osteoporosis Significant trauma
Mechanism Flexion Compression Axial loading
Wedging of vertebra (Anterior column Convex anterior & posterior
shortened, posterior column maintained) walls

Characteristic
Features

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 Spine : Injuries and Disorders 81

Prolapsed Intervertebral Disc (PIVD) [Link] ----- Active space -----

M/c : L4-L5 > L5-S1

Leads to compression of spinal nerves (Spinal cord terminates at L1 level in adults).
Types of PIVD :
1. Far-lateral :
Impinges exiting
nerve roots.

2. Paracentral (M/c) :
Impinges traversing
nerve roots

L4-L5 disc prolapse L4-L5 disc prolapse

Presentation : Progression of Disc Prolapse :

• H/o lifting heavy objects.

om
• Sciatica (PIVD m/c) : ai
l.c
Pain radiating from back to
gm

limbs.
@
36
77

Management :
s.
ha

SLRT (Straight leg raising test) :

ng
si
rit
am

Causes stretching of compressed

|

nerve
w
ro

Produces pain
ar
M

Neurological examination :
©

To localize the lesion depending on nerve roots involved.

Root Myotome Dermatome supplied Reflex
C5 Elbow flexion - Biceps
C6 Wrist extension Thumb Supinator (Brachioradialis)
C7 Elbow extension & wrist flexion Lateral 2 fingers Triceps
C8 Finger flexion Medial 2 fingers -
T1 Finger abduction - -
L2 Hip flexion/Iliopsoas - -
L3 Knee extension/Quadriceps - Knee
L4 Ankle dorsiflexors/Tibialis anterior Medial aspect of foot (Quadriceps)
L5 Hip abductors/Extensor hallucis longus Dorsum of foot -
S1 Ankle plantar flexors/Gastrosoleus Lateral aspect of foot Ankle (Gastrosoleus)
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 82 Orthopaedics

----- Active space ----- IOC : MRI. Treatment :

• Acute case : Rest in Semi-Fowler position.
• Physiotherapy.
• Surgery : Disc decompression (If no
improvement/worsening of symptoms)
- Laminectomy.
- Laminotomy.
- Discectomy.

L5-S1 disc prolapse

Cauda Equina Syndrome :
• Massive disc prolapse : Central prolapse
Multiple nerve root compression. (Massive)
• Clinical features :

om
- Bowel & bladder involvement + . Compressed
l.c nerve roots
- Saddle anaesthesia.
ai
gm

• Management : Emergency decompression. Cauda equina syndrome

@
36
77

Lumbar Canal Stenosis/Neurogenic Claudication

s.

[Link]
ha
ng
si

Pathology :
rit

↓Joint stability +
am

Degeneration of spine Osteophyte proliferation around joint.

|
w

Stenosis
ro
ar

Clinical features :
M

• Back pain radiating to lower limbs in an elderly patient.

©

• Neurogenic claudication : Pain on walking Rest (Pain ↓) Able to walk.

• Pain :
- Worse on extension (Walking, standing upright)
- Better on flexion (Sitting/leaning forward)

Neurogenic claudication

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 Spine : Injuries and Disorders 83

Neurogenic vs. Vascular claudication : ----- Active space -----

Neurogenic Vascular
Walking (Upright) Causes symptoms
Sitting Relieves symptoms
Pain Starts in the back Starts in the calf
Standing stationary Causes symptoms Relieves symptoms
Relieves symptoms
Climbing upstairs Worsens symptoms
(Flexion)
Postural changes Yes No
Pulses Normal Abnormal

Spondylolysis, Spondylolisthesis and Spondyloptosis [Link]

Spondylolysis : Spondylolisthesis :
• Pars intra-articularis • Slipping of one vertebra over

om
fracture. the other.
• X-ray : ‘Scottish terrier l.c
• M/c location : L5-S1.
ai
gm

with a collar’ sign. • Step sign (X-ray ; Palpable)

@
36
77
s.
ha
ng
si
rit
am
|
w
ro
ar

Scottish terrier with collar sign Beheaded scottish terrier sign Step sign
M
©

Spondylosis Spondylolisthesis Spondyloptosis :

Listhesis beyond the length Inverted Napoleon hat sign
of the vertebral body. (Spondyloptosis)

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 84 Orthopaedics

----- Active space ----- Scoliosis [Link]

Lateral deviation of spine : >10° from central axis.

Classification :
Structural or Non-structural (Differentiated by Adam’s forward bending test)
a. Structural/Fixed b. Non-structural/Postural

Scoliosis persists on bending forward Scoliosis disappears on bending forward

om
Evaluation :
l.c
ai
Measurement of Cobb’s angle.
gm
@
36
77
s.
ha
ng
si
rit
am
|
w
ro
ar
M
©

Types of Structural Scoliosis :

1. Idiopathic (M/c)
• No visible anomaly on X-ray.
• F > M.
• Subtypes : Infantile, juvenile, and adolescent (M/c).

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 Spine : Injuries and Disorders 85

2. Congenital ----- Active space -----

• Anomalies + on X-ray.
• Subtypes :

Failure of formation Failure of segmentation Mixed

Semi Fully Wedge Block Unsegmented Unsegmented

segmented segmented vertebrae vertebrae bar bar with
hemivertebrae
Hemivertebrae (M/c)

om
Treatment : l.c
ai
gm

Braces : Prevents progression of deformity.

@
36
77
s.
ha
ng
si
rit
am
|
w
ro

Milwaukee brace Boston brace Charleston brace

ar

Note : Taylor’s brace is used in thoracic spine injury & TB.

M
©

Surgery :
• Severe abnormality/Inadequate
correction.
• Rods and screws used.
- Screws inserted into pedicle
- Harrington rods connect
the screws.

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 86

----- Active space ----- JOINT DISORDERS

Osteoarthritis  [Link]

M/C joint disease : D/t cartilage degeneration.

Clinical Features :
• Inflammatory changes : Absent/Unnoticed.
• Usually involves knee & hip joint.
• Pain Decreased range of motion Muscle wasting (M/c : Vastus medialis).
• Crepitations.
• Deformity/swelling.
X-ray Features :

om
1. ↓ Joint space (Earliest finding) :
l.c
D/t cartilage destruction.
ai
↓Joint space
gm

2. Subchondral sclerosis.
@

Subchondral
36

3. Subchondral cysts.
77

sclerosis
4. Osteophytes : Regenerating bone.
s.
ha

Can break off to form loose bodies in the joint

ng
si

(M/c cause in elderly).

rit

Deformities :
am

OA knee Normal knee

1. B/L genu varum.
|
w
ro

2. Heberden’s node & Bouchard’s node : High - Heberden’s (DIP) ; Low - Bouchard’s (PIP).
ar
M

Heberden's
©

node
Bouchard's
node

Joints Involved in OA vs Rheumatoid Arthritis :

Osteoarthritis Rheumatoid arthritis
• Distal Interphalangeal (DIP) • MCP
Joints
• Proximal Interphalangeal (PIP) • Wrist
Involved
• 1st carpometacarpal (CMC) • PIP
Joints • Wrist • DIP
Spared • Metacarpophalangeal • Axial joints (Spine)
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 Joint Disorders 87

Rheumatoid Arthritis (RA) [Link] ----- Active space -----

Synovial disease : M/C inflammatory arthritis.

General Features :
• Female > Male.
• Erosive arthritis : Destroys joint (vs SLE : Non-erosive).
• Chronic autoimmune multisystem disease.
• Morning stiffness + .
• Symmetrical peripheral joint involvement.
• Joints involved Upper limb : MCP > Wrist > PIP.
Lower limb : Knee & Hip.
Diagnosis :
• ↑CRP, ESR.
• Rheumatoid factor + : Most sensitive.
• Anti-CCP (Cyclic Citrullinated Peptide) : Most specific.

om
Subchondral
X-ray : l.c osteopenia
ai
1. Narrowed joint space.
gm
@

2. Osteoporosis : Juxtaarticular Generalized.

36

3. Marginal erosions.
77
s.

4. No sclerosis/osteophytes.
ha
ng
si
rit
am

Deformities in RA : Rheumatoid arthritis

|
w

1. Boutonniere’s deformity. 6. Hammer toes

ro
ar

2. Swan-neck deformity. 7. B/L genu valgum.

M
©

3. Z-deformity. Note : Mallet finger

4. Windswept deformity. • Only injured finger affected.
5. Hallux valgus. • H/o trauma.
Flexion of PIP & compensatory extension of DIP
Soft tissue inflammation
Extension of PIP & compensatory flexion of DIP
Joint deformity.

Swan-neck deformity Boutonniere’s deformity

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 88 Orthopaedics

----- Active space -----

Fingers deviated
to ulnar side

Metacarpals
deviated to
radial side
Hallux valgus
Z-deformity

om
Hammer toes l.c Windswept deformity
ai
gm

Spondyloarthropathies (Sero-negative)
@

[Link]
36
77

Inflammatory arthritis : Spine & joints.

s.
ha

Rheumatoid factor : -ve.

ng

Conditions involved : General features :

si
rit

1. Ankylosing spondylitis (M/c). • Young males > Females.

am

2. Enteropathic arthritis : Inflammatory • HLA B27 + .

|
w
ro

bowel disease. • Extra-articular symptoms : Uveitis.

ar

3. Psoriatic arthritis.
M
©

4. Reactive arthritis : Shigella,

Chlamydia.
Note : Rheumatoid arthritis is a/w scleritis.
ANKYLOSING SPONDYLITIS
AKA Marie-Strumpell disease/Bechterew’s disease.
Normal S-I joint
General features :
• Axial > Peripheral joints :
Sacro-iliac (SI) joint (M/c); Spine; Hip.
• Pathology : Enthesopathy.
Clinical Features :
1. Morning stiffness : Improves with activity.
2. ↓ Lumbar spine movement. Ankylosis & Sclerosis
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 Joint Disorders 89

3. Sacroilitis : ----- Active space -----

- Juxta articular erosion.
- Blurring of margins.
- Sclerosis Fusion of joint.
Bamboo spine :
• Fusion and squaring of spine.
• Calcification b/w vertebrae Restriction of movement.
• Inflammation Syndesmophyte formation Fusion Bamboo spine
(Disc visible ; Vertebra fused)
Vertical/bridging syndesmophytes.
Dagger sign : Trolley track sign :

Calcification of paraspinal
ligaments & interspinous
Calcification of ligaments

om
only interspinous
ligament l.c
ai
gm
@
36
77

Clinical tests :
s.
ha

1. ↓ Chest movements. 1. Measure

ng

2. For sacroilitis : distance

si
rit

- Gaenslen’s test. b/w 2

am

points
- FABER test/Figure of 4 test.
|
w

- Pump handle test. Erect spine Flexed spine

ro
ar

3. For testing lumbar spine motility : 2. Measure same distance on flexion :

M

Spine does not open upon flexion (D/t

©

Schober/Modified Schober test. fusion).

The distance b/w 2 points does not ↑.
Note :
Non-erosive arthritis : SLE (Joint inflammation + No loss of articular cartilage + No
destruction of subchondral bone).

Crystal Deposition Arthropathies [Link]

GOUT
• Purine metabolism abnormality.
• ↑s. uric acid (UA) production ( N values : 3.5 to 6.5 mg/dL).
Pathogenesis :
Sudden change Deposition in cold Local inflammatory Collateral damage
in s. UA levels peripheral joints reaction & pain.
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 90 Orthopaedics

----- Active space ----- Clinical Features :

• Preponderance : • Acute gouty pain : AKA tophi.
- Middle aged. • M/C joint : 1st MTP.
- Male > Female.
- Consumption of : A lcohol, red meat, chemotherapy.
Investigations :
X-Ray : Joint aspiration : IOC for acute gouty attack.
1. Overhanging/ Characteristics of crystals Monosodium urate (MSU).
Martel’s G sign. Needle shaped.
2. Joint destruction. Negatively birefringent on
3. Punched out lesion. polarising light microscopy.

om
l.c
ai
gm
@

Synovial fluid aspirate

36
77

Management :
s.
ha

Acute gouty attack : Pain management

ng
si

• NSAIDs : Indomethacin (DOC).

rit
am

• Avoid aspirin.
|
w

Chronic gout : ↓s. UA levels.

ro
ar

• Xanthine oxidase inhibitors : Allopurinol, Febuxostat.

M

• Uricosuric drugs : Probenecid.

©

• Lifestyle modification.
PSEUDO-GOUT
General features : Investigations :
• M/C in elderly patients.
• Female > Male.
• A/w hypothyroidism.
• M/c affects knee joint
(Large joints).
Synovial fluid aspirate :
• Calcium pyrophosphate
dihydrate crystals.
• Polygonal. X-ray : Chondrocalcinosis
• Positive birefringence.
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 Paediatric Orthopaedics 91

PAEDIATRIC ORTHOPAEDICS ----- Active space -----

Characteristics of paediatric bones :

1. More water content :
• Flexible and resilient to stress. • Bends > breaks.
2. Thicker periosteum.
Effects of Applying Force to the Bone :
Outer surface : Convex
Distractive/tension force
Force within
physiological
Applying force limits
Force beyond physiological limits

om
Outer cortex breaks :
Greenstick/unicortical fracture l.c
ai
gm
@
36
77
s.
ha

Common Pediatric Fractures :

ng

1. M/C # in children : Greenstick.

si
rit

Forearm : Radius > ulna.

am

2. M/C # at birth : Clavicle.

|
w

3. M/C # in child following fall on outstretched hand : Supracondylar humerus #.

ro
ar
M

Note : M/C # in humans overall Clavicle #.

©

Osteochondrosis [Link]

• Osteochondrosis is a self-limiting abnormality of bone growth.

• Involves ossification centres
Osteochondrosis Bone
in the epiphysis.
Perthes disease (M/C) Femoral epiphysis
• Begins in childhood as a
Kohler’s disease Navicular bone
necrotic condition.
Keinbock’s disease Lunate
• D/t primary vascular event or
Panner’s disease Capitulum (Elbow pain)
repetitive trauma.
Osgood - Schlatter’s disease Tibial tuberosity
• M/C cause : Idiopathic.
Sever’s disease Calcaneal epiphysis

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 92 Orthopaedics

----- Active space ----- PERTHES DISEASE

AKA Coxa plana/Legg-Calve-Perthes disease.
• Idiopathic, spontaneous osteonecrosis.
• Site : Femoral epiphysis.
• Clinical features Pain at the hip.
Limping gait after activity.
• Management : Perthes disease
Rest (Vascularity recovers Symptoms improve).

Miscellaneous Paediatric Orthopedic Pathologies [Link]

SPRENGEL’S DEFORMITY
• Congenital undescended hypoplastic scapula.
• Limits shoulder mobility.
• Associations :

om
Klippel Feil syndrome (M/C).
l.c
ai
KLIPPEL FEIL SYNDROME
gm

• Segmentation defect of cervical spine : Sprengel’s deformity

@
36

1. Short webbed neck.

77
s.

2. Low set hairline.

ha
ng

3. Restriction of neck movement.

si
rit

Associations :
am

• Scoliosis (M/C).
|
w
ro

• Sprengel shoulder.
ar
M

• Genito-urinary anomalies.
©

• Ocular/auditory/cardiac defects.
Klippel Feil syndrome
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)
AKA sub-capital neck of femur #.
• Split # at growth plate of capital femoral epiphysis.
• Type 1 Salter Harris.
• Femur Head : Within acetabulum (Misnomer). Mild
Neck : Slips.

Causes :
• Idiopathic.
• A/w endocrinopathies :
Hypothyroidism (M/C), hypogonadism, ↑growth hormone. Moderate
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 Paediatric Orthopaedics 93

Clinical features : ----- Active space -----

• Usual age : Around puberty Males : 13 to 17 yrs.
Females : 11 to 14 yrs.
• Associated hypogonadism, high pitched voice &
gynecomastia in boys. Severe
• Coxa vara : Risk factors
- Gradual/sudden pain at hip. • Male > female.
- Restricted abduction & internal rotation. • ↑Weight for age children.
- Axis deviation : Knee points to I/L shoulder on hip flexion
(Normally towards C/L shoulder).
- Trendelenburg gait.
• Externally rotated toe.
Normal SCFE
Investigation :
• IOC : MRI.
• X-ray : Trethowan’s sign.
om
Line drawn on the lateral aspect of neck of femur l.c Epiphysis
ai
gm

does not intersect with head of femur. Klein’s line

@

(Drawn at the
36

lateral aspect of
77

neck of femur)
s.
ha
ng
si
rit

Developmental Dysplasia of the Hip (DDH)

am

[Link]
|

Idiopathic spontaneous subluxation of femoral head.

w
ro
ar

Epidemiology :
M

• Usually seen in 1st born female • Caucasians > Asians.

©

child with fetal malpresentation • 1 : 1000 live births.

(M/c breech : Frank breech with • Females > males.
extended knees).
• Strong family history.
Etiology : Idiopathic (M/C).
Pathology : Developmental anomaly Lack of concavity Femoral head
of acetabulum (Flat/shallow/concave) slips out.
Clinical Features :
1. Short limb : Asymmetrical thigh & gluteal folds.
2. Vascular sign of Narath : Femoral pulsations -
(Displaced femoral head Palpation not possible).

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 94 Orthopaedics

----- Active space ----- Clinical Diagnosis :

1. <3 month old child :
• Barlow’s test.
• Ortolani’s test.
2. >3 month old child : Ortolani’s test
• Allis/Galeazzi sign :
One knee higher than other on knee flexion.
• Trendelenburg gait/waddling gait.

Investigations :
Allis/Galeazzi’s sign
Screening IOC : USG.
Confirmation test : X-ray
(MRI Additional investigation). Normal DDH
• Hilgenreiner’s line (H) : P
Line passing through centers of H

om
both triradiate cartilage.
l.c
• Perkins line (P) :
ai
gm

- Line perpendicular to the Hilgenreiner’s line.

@
36

- Passes through lateral edge of acetabulum.

77

- Head of femur Normal : Inner, lower quadrant.

s.
ha

DDH : Upper, outer quadrant.

ng
si
rit

Treatment :
am
|
w

Age Treatment
ro
ar

0-6 months Pavlik harness, Von rosen splint

M

Von Rosen splint

Reduction : Open/closed
©

6-18 months
Smith Peterson approach
18-36 months Femoral osteotomy
>3 years VDRO + pelvic osteotomy (Salter, Pemberton)
>10 years Total hip replacement after skeletal maturity

Pavlik harness
BILATERAL KNEE DEFORMITY
B/L genu varum (Bow legs) B/L genu valgus Wind swept deformity
M/C cause in
Rickets > Idiopathic Idiopathic > Rickets Rickets
children
M/C cause in Osteoarthritis > Rheumatoid arthritis >
Rheumatoid arthritis
adults Rheumatoid arthritis Osteoarthritis

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 Paediatric Orthopaedics 95

Congenital Talipes Equinus Varus (CTEV) [Link] ----- Active space -----

M/C anomaly of foot.

Epidemiology :
• 50% cases : B/L. • A/w with breech &
• Male > female. oligohydramnios
• First born child. (Not twin pregnancy).
Causes :
• Idiopathic (M/C).
CTEV
• Spina bifida.
• Arthrogryposis multiplex congenita.

Pathology :
• Cavus : Exaggeration of medial longitudinal arch.
• Adduction : At talonavicular/mid tarsal joint

om
• Varus : At talocalcaneal/subtalar joint.
l.c
• Equinus : At ankle joint.
ai
gm

• Internal rotation of tibia.

@
36
77

Investigations :
s.
ha

X-ray : Kite’s angle (Talocalcaneal angle).

ng

CTEV deformity
• Normal : 20 to 40°
si
rit

• Clubfoot : ↓
am

Screening :
|
w

Dorsiflexion test : Dorsiflexion Tip of toe touches

ro
ar

shin.
M
©

Treatment :
• Started within 2 weeks.
• Manipulation of foot (To correct deformity)
f/b POP cast : Done serially for 8-9 wks. Kite’s angle
Ponseti method :
• Fulcrum of correction : Talar head.
• Order of manipulation : CAVE.
Cavus Adduction & Varus Equinus.

• Method : Dennis Brown splint

Apply POP cast (Above knee) ≥1 wk Remove Manipulate.

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 96 Orthopaedics

----- Active space ----- Maintenance :

• Before child starts walking (<1 yr) : Dennis Brown
Straight inner border :
splint. To correct adduction
• Once child starts walking (>1 yr) :
- Day : CTEV shoe.
Outer raise : To correct
- Night : Dennis Brown splint. inversion & varus
Triple arthrodesis :
• Presentation at >10 yrs. Absence of heel : To
• Joint fusion surgery. CTEV shoes correct equinus
• Most important : Talonavicular joint.
Joshi’s external stabilization system (JESS) :
For CTEV resistant to treatment.

om
JESS
Achondroplasia l.c [Link]
ai
gm

M/C cause of disproportionate dwarfism.

@
36

Cause :
77
s.

FGFR3 gene mutation on Chr. 4 (Autosomal dominant > sporadic).

ha
ng

Pathology :
si
rit

• Endochondral ossification defect.

am

• Intramembranous ossification : Normal.

|
w

Clinical features :
ro
ar

• Proximal limb shortening (Rhizomelic

M
©

shortening).
• Trunk is usually normal. Frontal bossing Brachydactyly
• Patients have normal IQ and sexual development.
• Brachydactyly : Short, stubby fingers.
• Frontal bossing of skull.
Note :
• Starfish hand :
Limping child D/d :
All fingers are of the same length.
• Septic arthritis :
• Trident hand :
High grade fever,swelling at hip.
Exaggerated gap b/w middle and
• Transient synovitis :
ring finger.
Low grade fever; slightly ↑ESR, CRP.
• Bullet nose vertebrae.
Bullet nose vertebrae • Perthes disease :
• Champagne glass pelvis.
No fever; no ↑ESR or CRP.
• Saddle nose.
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 Sports Injuries 97

SPORTS INJURIES ----- Active space -----

Anatomy Of Knee Joint [Link]

Soft tissue structures

Extracapsular Intracapsular

Intrasynovial Extrasynovial

Collaterals : Menisci : Cruciate :

• Medial collateral ligament (MCL) • Medial meniscus (MM) • Anterior cruciate ligament (ACL)
• Lateral collateral ligament (LCL) • Lateral meniscus (LM) • Posterior cruciate ligament (PCL)
om
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Anterior
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Femur
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Medial Lateral PCL

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MM ACL
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MM
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ACL LM LM
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MCL LCL
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LCL
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Tibial
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MCL
PCL
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Head of tuberosity
©

Axial section : Superior view Fibula

Femur Anterior view

LFC MFC MCL

Note :
ACL Articular cartilage
• MCL : Adherent to MM.
Meniscus
• LCL : Not adherent to LM.
LCL PCL

Fibula
Tibia

Posterior view
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 98 Orthopaedics

----- Active space ----- Injury To Collateral Ligaments  [Link]

Function of Collaterals :
Coronal plane stability.

Clinical Features :
Forceful varus Forceful valgus

LCL tear MCL tear

Adduction/ Abduction/
Varus stress test Valgus stress test
(At 30o flexion) (At 30o flexion)

Lateral sided Medial sided

knee pain knee pain

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MCL (M/c injured around knee) > LCL.
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Management :
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• Conservative brace (90%). Edema d/t

36

• Surgery (10%). MCL tear

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MRI (Coronal view) : IOC

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Injury To Menisci 
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[Link]
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Functions Of Menisci :
©

• Shock absorbers.
• Rotational stabilizers.
Forces :
• Torsion/forceful twisting of knee.
Menisci (Torn)
• Bucket handle tear (M/c type of injury).
• MM > LM injury.
Bucket handle
Clinical Features : tear
Delayed onset :
Radial tear
• Knee pain.
• Swelling : Mild to moderate effusion.
• Pathological locking of knee (Incomplete extension) :
- D/t trapping of fragment of menisci between tibial and femoral condyles.
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Evaluation : ----- Active space -----

1. McMurray’s test :
2. Apley’s grinding test :
Prone position
Grind knee

At 90o flexion
Hyperflexion of knee Rotation + force Extension of knee
(Provokes pain)
3. Joint line tenderness : Best test.
Investigations :
1. MRI (Sagittal view) : IOC.
Anterior horn
2. Arthroscopy : Gold standard.
Heterogenous
appearance

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Posterior horn
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Normal Posterior horn meniscal tear
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Treatment :
@
36

1. Meniscorrhaphy : Red zone tear (Good blood supply).

77
s.

2. Meniscectomy : White zone tear.

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Red zone
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Nutrition to meniscus : Red-white

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• Peripheral : Genicular vessel.

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zone
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• Central : Synovial fluid. White zone

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Zones based on blood supply

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Injury To Cruciate Ligaments  [Link]

©

Function :
Sagittal plane stabilizers.

ACL PCL
Prevent translation of tibia Anteriorly Posteriorly
Knee movement prevented Hyperextension Hyperflexion
Forceful anterior Forceful posterior
Injured by
translocation translocation

Clinical Features :
• Twisting injury to knee with hemarthrosis.
• Instability on walking.
• Difficulty going downstairs (ACL tear)/Upstairs (PCL tear).
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 100 Orthopaedics

----- Active space ----- Evaluation :

ACL injury :
1. Anterior drawer test : Painful in acute knee.
90o flexion of knee (45o hip flexion)

Anterior translation of tibia. Anterior drawer test

2. Lachmann’s test : Most sensitive/best test.
20o-30o flexion of knee

Anterior translation of tibia

1. Pivot shift test : Most specific.

PCL injury : Lachmann’s test

1. Posterior drawer test : 2. Godfrey sag test :
90o flexion at
hip & knee

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90o flexion of knee
l.c
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Posterior
gm

Posterior translation/ translation

@

sag of tibia
36

d/t gravity.
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s.
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Investigations :
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MRI (Sagittal view) : IOC.

rit
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Arthroscopy : Gold standard.

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Treatment :
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Reconstruction with grafts (Gracilis/semitendinosus).

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Miscellaneous 
©

[Link]

Summary of structures in the knee :

Function Structure Test
Collateral Coronal plane Medial collateral ligament Valgus stress test
ligaments stabilizer Lateral collateral ligament Varus stress test
Rotational stabilizer Medial meniscus • McMurray test
Meniscus
& shock absorbing Lateral meniscus • Apley’s grinding test
• Lachmann’s (Best)/sensitive
Anterior cruciate ligament • Anterior drawer test
Cruciate Sagittal plane • Pivot shift (Specific)
ligaments stabilizer
• Posterior drawer test (Best)
Posterior cruciate ligament
• Godfrey’s sag test
Unhappy/Painful/O’ Donoghue triad of knee : ACL tear + MCL tear + MM injury.
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©
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©
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