ORTHOPEDICS Quick Review Pe os le MOE Be edd Anil Be] nS Stet el enas Sa A) ceenalad btealtnmoh stiamintal aclet i aaeeeiin toc then od Sl lt tial Nia aORTHOPEDICS Quick Review for NEET/DNB Apury Mehra M88, MS ORTHO, N.S ORTHO fp. SIC (eigum) cured 0y Anil Arora Thameem Saif Forewords SM Tull Sudhir Kumar SKS Marya @ JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi» Panama City + London * Dhaka * Kathmandux @]) saypee Brothers Medical Publishers (P} Ltd Headquarters slaypee Orathere Macca! Pubtehers (P} Led “¢8GH724, Ansa Poor, Daryagan New Dell 110002, India Phone: +01-11-49574257 Fax 81-11 40574314 Enmit jaypee® jaypecbrathers.com Overseas Offices JP Medical ud Jayeo= Highlights Medical Publishers Inc tee Sra cnn dee ti SSH OH (UI) Params City, Panama Phone: +48-2051700810 Prone, 507.001 0198 Fax 102-09-0008180 Fae 807-901-0899 Email infecjpredpubcor Email cservice phrecicalcom Jaypee Brothers Medical Publchers (P) Lid sJaypos Brothers Medical Publshers(P) Lid 17/18 Babar Road, locke, Shay Sherakhute, Kathmanda Mcharnmadpur, Dhaka-1207 Nepal Bangladesh Phere: +00877-9081 520878 obi: O80 81 2003485 Emit: jaypee.nepat gmail.com Ermail jaypeedhaks @graailcorn Website: wan jaypeetrothers com ‘Website: warm jaypencigtal com @ 2019, skype Brothers Medical Publishers All ights rezarved. No parl ofthis book may be reproduced inary lrrn cr by ary meares without the prior permission othe publisher. Inquiries tor bulk sales may be solicited at: jaypees@jaypectrothers.com “Thir tock has ben publidhed in good faith that the comlants prove! by the authar(s) certahed herein ate orginal, ard ie treed for cexlucaicnal purposes cnly. While everyellortis made to ensure accuracy al inkrmatin, the publisher and! the author(s) specially sclim ‘any damage, hab, or le incured, directly ce indy, rem fhe use or applestien ot ary of the contems of te werk. Wnt pecially ‘tated, all igures and ables are courtesy cf the authorsfs). Where appropriate, the readers sheull ccnsui witha specialist or contact the frarufacturer of te dig er deviem ‘Orthopedics Quick Review for NEET/ONB ret Eaton: 2013 WSN; g7a-08-s090-1084 Printed atThanks 10 the Almighty for Konoring, me with ht rowel vee spread ahi lie af ksowwli dey Maa Saraswati Goddess of Education Tidevficate any moor fo My pevtients wnito hace mare une in Corthapmventiciira come iy shurlenty oito hue nnd rae a keerFOREWORD Despite the availablity of more lucrative epportunities the current generation in business and technology, the brightest of ‘the young generation oF any country apts tor medicine av a carcer, Orthopacdics happens to be onwot the Most sought akter clinical discipline, tully aw:tre ofthe Long ya rs of arduous training involved for success inthe profession, Its just natural that ‘the bestamnongst the adenissin seekers Would be able keeheoll therasel vcs for the limited set available i Orthopsaectcs in the teaching, and training institute. Te: maineain objectivity ancl transparency, aclmviesions based upan abjective MCQ type oF questinns isthe best ofall assesementsystems, granting thano assessment system isreally. peréwcty. This book is intended to help the student to quickly review the subject for MEQ examinations. The table of contents of the book covers the wide: landscape of orthopacdic discipline Dr Apury Mehra over the last 9 yaars has been trying #© analyse the system of MCQ type examinations, callate and Syanisethe materia for underatandng a thegrachate evel This bok woul help the prospective candies to channali ‘heir thinking process for theadinissien tests, The questicr-answer style cf warious sections would alse help-the prospective culty (who compose the MCQs) to standardise the Frame word kor canstructing the question with Lease ambiguity andl For appropriate level of MBBS graduates [tis a laudable effort by Br Apury Melia, and itis a must- read far the acmisaion seekers S.M.Tu BRS, MS, PhD, FAMS Formerly: Director Instituteot Medical Sciences Banaras Hindu University Varanasi, inca Senior consultantspinal disonder and orthopedic VIMHANS Hospital, Nedtru Nagar, DelhiFOREWORD ‘Orthopacdies today has become one of the most sought ater branches in medicine ane similar i= the representation of number of questions in PGentrance examinations, Clear concepts andi crisp knowledge is often required tosolve MCS imespective of the type and Format of quesians. ‘Orthopedics quick review comes With a complete package for PG aspirantato hav tsced knowwledga, important pests to remember and re diagrams, images. flow charteand summary havebeen made keeping in mind theneed of students today. Thia book snot one for the shel but is for the last minutes specially chapters ike enmplete PN summary of Orthopaedics and for the stusents by the students. a concept Iactat thetime of exarnination.lkstrativ Dr Apury Mehra hascarefully included questions and topics keeping in mind that the wholespectrum of Orthopaedics iecoverad and retained by stuclents, The interactive DVD that camex along with itixalsa extremely Valuableta havea conceptual approach to MCOSarnd has lecture oFimportant topics which shall eof importance bo sluclents. Orthopaedics Quick: Review is a must read for Orthapsedies MCQS. Suowr Kumar Head of Department Department af Orthopaedicx eof Medical Sciences and GTB Hospital, Delhi University ColFOREWORD Dr Apury Mehra has pt tha new volume for thexepiring posgracatesinorthopoadic rg Wide there inamontan of knoe ledge and teks avallable dis lume comes few he hen os foung orthopaeds Surgeon whe Rie himself feed the ples and dices of eq .iing Enoatladge Many a texts are available to the examiners and seckers af information and each has a Favour of its an In thissase pur has a refreshing approach toWardsimparting information, The text comes With tsefal pictorial diagrams and X-Rays to illustrate concepts, Whilst putting, Forward amultiple choice question the author has givenan elaborateren soning for the best choice answer, He hasslassified the chapters With good deal of thought. 1 makes. simple read for those revising for examinations and subtly adds information to the candidates knowledge bank, tn fact the volume will be an asset in the collection af all those learning, and teaching the art of Orthopaedic surgery. SKS Marva Vice Chairman Max Healthesre, New Delhi Chairman Orthopedics, Max HealthcareABOUT THE EDITORS Ani Anona Dr (Prof) Anil Arora holds an experienceof more than 20 years in Orthopaedics. He has been Senior Orthopaedic Surgean and Professor ofrthspacdicsat University Collegeok Medical Selenees, Delhi He is an internationally known figure in Orthopaedics, He is a Joint Replacement Surges, currently He is Head Of The Department OF Orthopamlies at Max Superspeciality Hlexpital ancl Institute af Joint Replacement, Patpargan), Dali, He is known for his bllliant clinical skillsand knowledge, He has marty International and National Achievements and Awards Eo his erosit lhe: SIROT Award in USA. (Fist Indian torwin this award from a bedy of 85 countries), Weller Gold Meta AA Mehta Gold Medal of Indian Orthopaedic Assocation, Silver Jubilee Oration Award of Indian Odthopaedic Association He has also delivered White Paper of In jan Orthopacite Associaton | He has published about 0 research papers in various International, National and Regional fou | He ha about 20Chaptersin International and National Orthopaedic Text Backs Prof Anil Arora has carefully edited the book, THAMEEM SAIE Dr Thameem S0if, M.D.Mdicine, i a renowned teacher held in very high regard by medicas both in India and thet. He is an intellect ofhigh order with brilliant teaching skills His inputs have been found to be very valuable by his students aeross the country atid be has helped Hots of students achievethairdreamwot clearing the tough indian entranceexamsand theLISMLE.Mastafthe teppers fn the country today thank hin én their heare for playing an important role in thedr success, He is well known for solving MCQs by an organized approach to reach towards the answer. The BYD recording isan inferactivesission With the author abouthow te approach MCQs with last patterts proposed for National Eligibility Entrance Test. Fe fas carefully gone through the Bonk and his Suggestion has given birth toa chapter oneempletesummary oForthapondies For students toreise fn Last rirutes. tents of this book and has given valuable feesbacks in the making of thisPreface To OPOR NEET and DNB Edition Considering, the recent changes in the upcoming PGEF Frams and subsequent requirement of, stucentsthe committee has released Its FIRST NEET AND DNB Based modified ‘supplementary tition of OFQE Highlights Complete summary of Orthopaectics (with highlighted last S years AIIMS/AIPG Questions) 2 Quastions on expected NEFT patter {Tse 20 vears DNF Questions Special chapter For The Stuclents By The Students to clarify most common doubts Floweharts with Mnemonics All the questions tll 2012 ane covered All theseFentures In less than 100 pages so thatstuclents benefit to the maximum and are able taattempt all orthopaedics and associated topics for AIIM, DN and NEET Far LOOK OUT FOR THE COMPLETE EDITION OF ORTHOPAEDICS QUICK REVIEW (OPQR) IN DECEMBER 2012 [Releasing in Dec. 2012 Preface 1a Orthopaedics Quick Review (Orthopaedics today has Lecomea highly important subject in entrance Exams ‘The rapid Increase in conceptual questions andl increase In number af questions in major exams in year 2012 sets an example, Numberof questions of orthopaedics in IPG 2012 was 16 and from vast subject ike medicine the number af questions were about 24: continuing thesame trend in May AIIMS2012 Othopaedies agala had 13 MCQs andl Medicine 18 MCQ s, ‘The DNB paperin August inepiteoF mentioning less number oF questions had about 12 questions from arthopasdicsiout of total 160 questions).‘Thus it sa short strong subject that willhelp you score I you get the concepts ccerect Orthopedica quick review faa book made with an intention that students are able ta ead the Book within 5 days wth memorizing all the nmemonics with a target of $0 pages per day and that shauld complete itin Says t It also htes all the questions arranged front recent to backwards and alse the chapter sequence és according to the Limporteonce af topics im entrance exams, Abie beer sie. dof eacte chapter new questions on the Basis of Assertion! Reasoning, Images Truc & False questions have Yo practice for NET exams Last 80 pages are for revision ix last F weeks before you ge foray cxant that would help you remember all the important topics aaked in recent exams, They inclide sunrmary of entire orthopacdica{with highlighted! All [nda and ATMS quest ith @ckapter far the students by the students and also last 20years DNB questions as they wll be very fnrpartant latest Ail India will be NET based soith National Board of Exansiaation comducting te crane! I comes with an important OVD recording that gives you concepts ef important topics All the topics of all the exams til Deceraber 2012 are covered (Including NEET Exam) Itis a concept based book For matorizing forever ‘This book ie a demand based supply and is channelized according ta student nowds communicated to me during my teaching classes” ‘Apury MEHRAFOR MY PATRIOTS tut eng hbk pening Hn aca dna esos vo ee enero ants ceeeye weer saree aeons 2 A.message from the heart Dawa planfor the next day before you sleeps that by the Hime you getup forthe day yeu a (This small change has dene miracles in many lives) ealy have a target Minne requireotont to clear entrance exam 6 hours per day without mobile phone around you, for a period of six months non stop * “The selections inentrance are notbased upon intelligence and knowledgebut isbasee! on revision of recent topics and proper planning*. so keep revising? Don't count the days make the das count f If yon fee! miracles don't take prce seis ome fs for you “Avsier Encsteit Most of us take Einstein's name as synonymous with genius, but he dicin’t always shaw stich promise Finsteén did not speak until he w as four and didnot read until he wasse en, causing his teachers and parents to think he was mentally handicapped, low and antisocla, rently, he was expalled from school and was refused admance tothe “ori lect Seale snight have taka hin bi fanger, but ooat poop would agreethut hs eauyhton prety wl ‘the end, winning the Nobel Prige and changing the face aF Weclem physics My Grand Mother always used to tell me. Lines from Guru Granth Sahib. ‘ha tere toh Koi kho nahin sakta” Tu shram (Karam) kara chal bande. “Je usdi meher hove ta ten o v mil jauga jo tera ho nahin sakta”™ Chace your dreams and | pray to almighty lee grants ittSPECIAL THANKS TO ‘My saniorsat Max Superspeciality Hospital, Dr¢Pnof) Anil Arora and Dr Amit Sivastava forsupporting me in writings this book and managing things in my absence without thele support nothing would have taken place also extend my thanks fo thewhole unit for thessime, DrHarpreet Singh, MBBS, MS. Orthopaedics (MAMC) National Gold Medalist for verliying the contents ofthe boul, Dr Taruna Mehra MBBS, M.D Pudiatrics (MANIC) National Gold Medalist, Nephrology Fellowship (AIMS) For contributing to chaptar Peciatsice orthopaedics Dr Radhika (Bates) Taneja, MBBS, M.D. Raciodiagn Imaging and Radiology in Orthopaccies Dr Saurabh Taneja, MBAS, MLD. Anaesthesta (MAMC), National Gold Medalist, Consultant Sir Ganga Ram Hospital, Delhi for contibuting te chapter Advanged Trauina Life Supportand alse for histtever ending contributions to my lie. (MAMC) National Gold Mislalist for contributing to chapter Dr Rajesh Kaushal, hats, M.S. Anatomy (AIIM), for contributing conterts about Anatomy Dr Renu Chutani M.PT Physiotherapy and Dr Deepak Gaur M.P.T Physiotherapy for contributing physiotherapy Me Chaitanya Das for working Day in Day aut for this book with his Eantasticstamina, reat commanclan computer and Unity efforts to complete this project Mr Vijay Kumar and Mr Gauray Budaket for enordinating the work.ACKNOWLEDGMENTS ‘Thanks to my grand parents rit Vidyavati Mahra and Shri Javan Ram Mshra-for teaching me that there is ne-big.ger power than self belict ‘Thanks to my grand parents Smt Shanti Kapoor and Shri |. K-Kapoar for teaching me to always look upto god with faith ‘Thanks te my parents Smt Neeru Mehra and Shri Arun Kumar Mehra for alas sipporting the to chase my dreams. ‘Thanks to my parents im law Smt Satya Chutani and Me \gdish Chutani for taxching me value of honesty ‘Thanks to my wife Dr Taruna Mebra for her day to day support, encouragement and motivation that kept me going even beyond my olen limits, Alan For helping, me discover that even complex problemscan be resolved by simple approach, seth Family and Khanna Family and theie associated famibies Late Smt Krishna and Late Shri K.B, Seth and their family’ Set Satish and Late Sh, C.B. Seth and thetr family Smt Laja and Shei PB Seth and their family Smt Kunti and Shei G35, Khanna and their family Mis Vaishali ind Mr Ritesh Kapsor, Mehul and Arma Mrs Poonam Nagpal and Sanjay Nagpal Miss Renu Chutani and Master Ridham Nagapl Smt Usha Mehra and LateSh, Nirmal Mehra (Mrs Tulika Mishra and Nir Sushil Mehra, Ne Mrs Pallavi Mehra and Mr Sunil Mehra Smt Usha Mehra and and Alchil Me Sh.Chand Mehra t Mrs Bharatiand Me Sanjoey, Mrs Mili and Mr Partho chakraborthy. Mrs and Mr Manoj Mehra Mrs Kanchanand MrSubhash Khatri, Mr Siddharth and Mr Ayush Khatri Mrs Preeti and MrSurect Mrs Nayana and Mr Pradeep Kapoor, Tanyaand Rehan, Mis Meena and Mr Ramesh Suneja, Mex Karuna and Me Karan Mrs Kutsuin and Mr Mohan Suneja, MeVaibhav, Miss Chayan and Miss Chetna Sunes Mrs kammlesh and MeVinod Pahuija, Mir Gauray and Mr Saurabh Pahujs Mrs Shashi and Dushyant Tharsja, Miss Tants and Ir Prateck Thareja ‘Thanks teMaulana Azad Medical College, Delhi as an institution fardeveloping me intaa complete clinician ‘Thanks tthe great bateh af 1995 ‘Thanks to Depariment of Orthopesics University College of Medical Sciences, Delhi and All Teachers who Carved me into a complete Orthapaedician, Eschone of them may just be a re but in reality holds. great acaclemician, a great teachers great stirgeon underneath Prof Sudhir Kumar (Qur Head of Department Prof Anil Aros (My Ballliant Guicle) Dr Aditya Aggarwal Dr Anil Aggarwal Dr Anan Pal SingAcknowledgments Prof A.K. Jain (One of the most hare working orthopaedician I have some across) Dr ish, K Dhammni (His modesty is his identity truly genius) Dr Puneet Mishra Prof Shobha Arora (My Cerguicle and one of the most dynamic teachers) Prof MEPSingh Dr Manish Chacha (One of the mest brilliant person) Dr Amite Pankaj An to rose afame name | might face misced but their fportance sent Ses Special thanks to three prestigious pearls of orthopaedics for blessing the books. Prof. 5.M Tuli (Teacher of teachers) om mentioning his name only my head bows down with respect tor his approach tw cothoypaecies and to Lie Prof Sudhir Kumar Far letting rie prosper as a student oF science and verldying the content my lecture recorcing Dr SACS. Marya for belng-an important d oF many baoks himself ing Force and belnyg an ardent author ‘Thanks to my Seniors in aur Orthopasdics unit at Max Superspeciality Hospital, Delhi Praf Anil Arora who fs always there asa Teacher, a Mentor and like a Father to meand all 3 rales perfectly taken care Dr Amit Srivastava who has always traatie me likehis younger brother ‘Thanks to Dr Mulcesh Bhatia (A man with a great vision) and Mes Anu Bhatia, Directors of Br Bhatia Mecteal Institute for beinga constantsource of guidance to help me carve asa better teacher, ‘Thanks to thelr team far provicling- me fantastic support to perform as a teacher. (Mis fageuti Walia, Mrs Sakshi Jindal, Mrs Sonia Kobi, Mrs Chhaya, Ms, Peiney,Mr Ashish Mr Hera, Me Monu, Me Ravi, Mr Sunil, Me Madhav, Mr Sanjew, tr Mukesh, Me Anupam and all others who have always bbeen there Special thanks to Dr-Thameern Saif Forreasons and words even dictionary sould fall short off ‘Thanks to all my friends who actually were there attimes when almostno ane was there Dr Saurabh Taneja and De Radhika (Batra) Taneia [Dr Harpreet Singh and Dr Satnam kaur Dr Ashish Taneja and Dr Richa taneja [Dr Mrinal Pahwa and Dr Archana Fahwa [Dr Arun Arora and Dr Neha Arora [Dr Mayank Arora, Dr Pranay jan, Mr Paras Chhabra Dr Divesh Gi ati, Dr Rishi Narsimhan, De Bhagwat Prasad, Dr W. Anand Dr RLPSingh, Dr Manoj Goel, Dr Neeraj Goel, Dr Atul Jain, De Lalit kumar Dr Ashish Rustag., DrJaswanticumar, Dr Vipul Garg, Dr Aaj ain, Dr Prashant Medi, Dr Rajat Mahajen, Dr Vivek Keehhar, De br [Dr Manoj, Dr Vivek Chhimpa, Br Mentish Shingla, Dr Nikbil Chaudhary and Be Ankur Bab Mr Navesn Parashar, Mrbanika, MrAmit Mr Rahul Mishra anc Ne Gopal (HYDERABAD) Mr Dhruw Kharbanda (LUCKNOW) Me Mowen and Me Simecr(BANGALORE) Me Amit Srivastava (Kolkatta) ‘Mes Ritu anel Me virtod (PUNE) Mie RAJESH (chandliyarh) aura Shacma jest singh, De Chandeep Singh, Dr Jatin Tala Dir Raman jeet, Dr Bi~ Acknowledgments. Me Hanseaj (Barca) Mrs jagruti walla and Nr Rajeey walla (thmedabad) Mr Amit Bhatiajaipur) Dr Rapehiwar(Nagp ur} Me Anilifubat) Me Rajcex(Chen [Dr Suresh) Kumar, De Shyam Bharti, Or Akshay. Dr Nimish, Dr Vimal, Dr Sudh Max hospital) Special thanks to Dr Yogishwar A.V. for carefully editing the back ‘And all those whaue name Lam not able toreenllece right naw but they are always inmy heart and Dr Manoj Dubey (Senior residents at ‘The team that works with me at Max Superspecality hospital, Delhi Especially Me Vijay Kumar, Mr Ashish Avasthi, Miss Payal Bhatia, Mr Gauray Buelakoti, Mr Kunal Walia, Mr Chaitanya Das, Mr Raj Kumar, Mr Ravi kurnar, Mr Sanjay, Mr Amresh Pandey & Miss Anita. “Thanks to all of then for working like a family, “Thanks to Shei JP-Vij, Gourp Chairman, Jaypee Brothers Meclical publishers For helping carve my work. ‘Thanks to Mr Bhupesh Arora, General Manager Publishing for helping me turn my dreana into reality “Thanks to Mes Preeti Parashar and Mr Manas Yadaw for helping-me coard inate the bok, “Thanks to Mr Subhash Chander for wandleriul patience to W ork ot my book to Fortmatand edit itwith great skills, d leafler with truly a touch oF class “Thanks to Mr Raju Sharma and Mr Harsh Fal Singh Rawat for designing my tinage “Thanks to Miro Seema for dratting the coverpage for the boul, Fram the Publisher $ Dock ‘We reques all the readers to provide us their valuable supgestions errors (if any) aie Jaypeemcaproduction gmail.com 0 85 tohelp us in fanher improvement of this book in the subsequent edition,FEW VALUABLE PEARLS BEFORE EXAMINATION Every time we would go to write an exam our seniors (at MAMC) will tell thece to us. 1. Sleep on tne and sleep well a night before, 2 Bee sap profrnbly spake your nest ffreyour best ad herp a postive stud mnembe or your wis (ond aneddo make a promisethat you will Reading Few jokes from a joke book has been found as a stres reliever by same, Onthe morningof the exam, never gaempty stomach never eattoo much, takea balanced meal, A fruit a sandwiteh and, {cup of coffee/tea is proferred by most 5. Always Gat ready an time and wear your mest comfortable clothes and shoes. Trying out naw elothesor anew shoewear is not advisable, Most prefersome music in moming hours to destress themselves Leave wtrly frot House for the centre and avoid driving at any cost ‘Make sure to carry your Photo Identity praoé, Admit card and Seationary. At the contre preferably involve yourself in some meditati Avoid in mingling with groups. 10, Please lo all the formualiies before the exan on time toavoid any last minute panie 11, Follow instructions the examiners ar invigilators at the c for stay With your Kanily or friend accompanying you. re clare not invalve in any comflice with them. During the exams... 1, Start the paperand read the question very carefully 2. ONE liners should be read 2 ties and message should be very clear what the examiner is askitg and than read all £ choices, 3. One by one try to rule ont options so that you have more probability ef getting theanswvers correct (Dr. Thaoreemt nul} 1 you select ane answer out nf 4 than your success probability is 25M% but if you rule out one answer than your success probability is 44% and if you areableto ruleour Zoptions than you have to mark from the remaining 2 choices thus your success probability Is 50%, 4. Dont make a mistake ot marking the firs answer withaut reacing all 4 choices, Maut af the examiners set 3 40 4% (questions on the prinelp le thatstudent marks thetirst answer on reflex .This makes atotal ef abcut 10 to 12.questions in Your exam thus canmakea huge difference egg Question is asked Mast common tumar of hand First choige isentchondroma Second is chandrcblaston Third is squamous cell earcinoma Fourth ts Chondmosarcoma Studenttakes itas a question oF bone turtors and mark the first answer as enehendroma only bo get i wrong without realiging that most common bene tumor of hand is eichondroma and mast camman turaor of hand is Squamous cell ‘arcinoina which is the answer here, 5. Please down try to find mistakes in questions For all practical reason try to answer questions taking them ax comectly framed yg Cheralyia pariesthetica invnlves which nerveéstudents think that theres printing mistake instead of Mera gia pparacsthetica and mark the answer as lateral cutaneous nerve of thigh but they are unaware that there Is a different Condition called as cheralgia paraesthetica which is compression neuropathy for superficial rachal nerveFew Valuable Pearls before Examination ‘Multiple lines.orelinical questions should be answered on remembering the Following points a. Age of the patient may help you decide the answer, >, Linilateral or bilateral may help you rule out fow chicos «Normal feature mentioned helps rule eut few choices eg inerensed in exteomnalacta, normal ALP niles out asteomalacta as ALP is always 1d. Pleasemakea note of important radiological fh Lings © Give vary high importanes to histopatholagical or biopsy features to arrive at diagnwsis and always give teae diagnosis more importance than radiological findings because radiological Rnding, can be nom specific if it fe mentioned abone tumor with codimans tangle and round calls which are Mic 2 pesitive than ans e willbe Ewing sarcoma on the basis oF biopsy Fnelings oF rouncl cells ane! mic positive cells iwheraas codmans triangle is More enmmonly seen in Osteosrooma burean be seen in any malignant bone tuner EL Always makea note whether most camman finding isasked or mast characteristic fading Is askex. fg Slmmilarly observe that wl tigation of choice is asked oF gold standard ins estigation i asked. IF you look: at questions investigation af choice rafersto-nuct investigation and yold standard refers th best west Fach question is highly waluable and dont take any question lightly haw much eanfident you are Tes very strange that studlents try to save time on the questions that they haveknowledge about and gh questions they are not aware of Actually you Must Focus strongly an Eopics you knew and answer their questions Carefully rather than giving mere Hime to topics you are unaware of, Most toppers spt the repeat topics eorrack as ‘compared to scoring high on new topics, How the things change for recent exams... (DNB/NEET/AIIMS/PGH)...It would be practically impossible to ‘separate your preparation. Hence a combined approach is suggested 1 2. Ie would bea good optionto write DNB exam as thesamebedy willbe condueting NEFT examalthengh they raightturn cout to be totally ditkirent at end, itis advisable to gerthmugh last 3 to 4 DNB papers, Ibis good feo last2 -APGI papers Last 7 years AIIMS papers would be important Memorize last 5 years all india questions Revise your notes you have made and also course nabes iE you had joined any: This iso time to Waste on Rnding answers to controversial quastions just decide an answer what you will mark iEthey Day oF weiting the exarn actually cid niet matter in August DNB ‘Your knowledge will be more important than any strategy Make use of avery single day Don t worgy as all across the country exarishave been prepenes! and everyone fs sailing In same boat yeu are not at a selective disadvantage Rather let others panic you plan ail act you ight actually been, Keep a positive attitude through out, All the best "Go crack iP, ‘Asurv MenaCONTENTS Premrrn) Imaging for Orthopedics Infection af tone and Joints ‘Tuberculosis of Bone 3nd Joints Orthapaedies Oncalogy Fraclure and Fracture Healing Advance Trauma Life Support Upper Limb Traumatology Spinal tnjury Pelvis and tip tnjury Lower limb-Traumatoloay Fraclure Management Amputations Sports Injury Neuromuscular Disease Peripheral Nerve tnjury Joint Disorders Metaboli Disorders of Bone Pediatric Orthoperlies Osteochondritis Avascular NecrosisCOMPLETE SUMMARY OF ORTHOPEDICS YaLdVWHOD IMAGING FOR ORTHOPAEDICS Xerays ix done g (Cartilagenotscan) 2, CT Scanis done for bone Cortex and Calcification : 3. Calcification of Ligament-CT Scan, 4. MRI is dors far Soft Hismuce/Cartilage/ Bone Marraw /Unilatiral straay fracturdn (Inventigation of choise) 5. MII is done for seul fracture nscle Rermur (say AIMS 2082) 6. Bonesean Is done for bilateral tress frackires, (Investigation of chew) ane metastacia, 7 Ma PET CT asan > Bane Scan carza Arthroscopy ix dons 2o> Shoulder 9, Tumors and Infection can mimic each othor 1, n wr infction Spine CT guid biopay gull standard 2. yy for Humes spent TE eetostiaed! fatshre bare Lsvion Bore o: Bul Teens] Krew A Bone Scan (an 2007) 3. Bone and joint infections Gold standard is always culture ancl sensitivity 4. Inflanimatory: Joint swellings onder of investigations is zeny Mat Aspiration ‘Swelling oF a joint XMAS ‘Acute Osteomyelitis, Metophysisis commonest and first affeetes! MS May 2009) (an 2008) 2010) Lower femur metaphysis commonest site Staphyloceccus auretis mos! Common arganism overall Sickle eell anennia ~salmonella (cist) © inv dnigabuner-Paeudorionss + Leese moveient on inal ind | I ABR arin iPocor. Abate Crome leon ae) PS eee (Pecienee Tet Ceti aee aes | [Kawa mec RT) aaron oa tae argue rier || pura Sia — Tae Ea Te Aitining | wales * Latest Questions Chronic Osteomyettis Causative organism: Seaphylococeus Aureus Involucrum iadense sclerotic new bon esurrouncling the sequestium Atleast 2/3nd surface of sequestrum should be surrounded by invelucrum before Carrying out seq uestractemy.Complete Summary of Orthopedics ‘Treatment Remove the sequestrum (Sequestrectomy) [entity the organism and contral the infection (most important step) Fill the gap (Gone graft Bone cement-Poly Methyl MethAcrylate} Provide gro soft iesuecoverage Swelling With Multiple Discharging Sinus Over mandible (or head = neck region) ~ Actinomyconis (a0) (Qn Foot Madura fect/Maduramyconia Paronychia—infection af nail bed Staph, organism {3 Staph Aureus Felon infection of pulp space, Staph Aureus, most commonly affects thumb > Index finger (oat Infectious Tenosynovitis (Kanavel sign are seen)-Slaph Aureus. . TUBERCULOSIS OF BONE AND JOINTS © Tuberculosis is 3 disease aflecting jaintsobones = Hematogenaus spread Paucibacillary lesions (an 20023 Spine 06) hi p(1S25)> kee LO%} fall muscu = Spl Tuberculosis of sh Ventona is Tubercilosis of short banes of hand. Ider fs dyno effusion) ~ caries sicca (dry) © Pottespine—Tuberculasis of spine ‘© Paradiscal ragion commonest, rarast ix synovitis of Facot joints, Second Ravest is spinus process, (ALUMS 2000) Moot commonly affscts Dorsal slumbar>dorsolmbar junction © Barliew Symptom pain June 2006), = IstSig tenderness © IstNeurologiea! 8 We Incresseel deep tendon refloxas or Clesnus, Twitehing of muscles may be aven aadier © Motor weakness earliest than sensory involvement than bawel bladder involvement Investigations. + Xerayt Low of Curvature of spine clue to muscle spisth > Paradiscal Lesion MRI: Best Radiological Investigation CT Guided Biopsy: or tissue (AIMS May 2023, Please Note: FABER: Flexion, Abduction and Eater: FADIR: Flexion, Adduction and Internal Rotation “Anylosis: Patholeg Arthradesis: Surgical Fusion of [ont Rotation cl Fusion of Joint soipedoyio.so Aewuins eyardulo5Orthopedics Quick Review sunyseng js8}27 , seein Saoysenbag Finer [ar] Fess ni ies TUB LONE @UOINNNELZS EC HOD | Jn | ‘soppedoyy ip jo Avewuing eyejduiogComplete Summary of Orthopedics ‘Good prognostic factors for Potts spine 2008) ‘Good |General condition Slow onset ‘Short duration Partial invelvement Active disease Early onset Youngerage “Good Slow Shart People Achieve Early at Young age” TBhipin Hv AYN Hip in HIV 1 Incidence More Corman Less Corwen — Deformity FABER stage of synovitis ray be prolonged Limit of abduction ard internal ration £0 fn treakent than subsequsrily with inally postions adduction and erierral rotation ret of artis ~ FADIA (opposite to overt Fite) and han subsequently wih cnset af artic FACIAL Unieral cmually (Bfsteral usu Tuberculosis houmatoiel arthritis Hiotibial bond contracture Petia Low clotting pawer Excess blaed ing hemophilia TRIPLE deformity of kne causes (are 2008) = Paseo eh] , soipedoyio.so Aewuins eyardulo5 Painfueght racvernent Hipand Knes Ta ‘Stor Sol ‘Sold is Bony 8 Spine — Bony ankylozicOrthopedics Quick Review . ORTHOPAEDICS ONCOLOGY Important points to remember = nose ommon bane tumors ~ Secondaries ‘© Most camumen primary malignant bore tumor ~ Multiple ntyetoma Second most common primary malignant bone tumor ~ Osteosarcorna * Commonest malignant bone tumor of flat bone ~ Chondrosarcoma © Commonest Tumor of Skull Vault Ivary Osteama or Campact Osteoma or Eburnated Ostearna (1atest 20023 Commonest true benigi turnor ~Osteoid osteoma = nose ommnon ber gh tumor of spine - Hemangioma ‘© Beniga bone tumor have well defined margin, uniform consistency on fee nd narow zone of activity Malignant tumorhave ill defined margins, variable consistency and wide zone of cls. (Ais My 1 aati) Differential diagnosis of bone-tumors Osteomyelitis has same clinical presentation as Ewings sarcoma ard osteosarcoma = Myositis ans mimics Osteosarconia but Myo is has dense peripheral cali fication and osteosarcoma fas central caleication Bone Infarct ~ Enchond rama (AitMS May 20003 Bone islands = Osteaid osteoma (aunts May 20093 © Fibrousdysplasia ~ Giant cell tumor (amas May 2000, Importantages and location + Ustdecade unually Fwingy sarcoma (Can Be § To 20 Years ), unicameral Bone Cyst Bhd decade usually osteosarcoma, Anteurysmal Bone Cyst (aura 20077 + After skeletal matusity Giant cell tumar (Fpiphy sis) + Epiphysea! before skeletal maturity (ehondreblastorna} taire 20023 Afler 40 metastanes or Multiple myeloma Remember IST decade Diaphyseal -Ewings Sarcoma Ind decade Mtaphyseal -Osteosareama Classical radiological teatures* ‘Sun ray appearance" |Cadtuaris tangle | Ostrosarcorma but can be e2en in ary maligrani lesion Complete Summary of Orthopedics + Grice peel appearance ing sarcoma but ean be ener in any malignant lesion er chrenicostecrnpeliia + Samp buble appearance’ + Patchy eaifcalan® CChondogenis tirmors + Homapenous caleleatin ‘Osteagenic turors (Orcler of investigations usually X-rays than MRI and than Biopsy’ Biopsy isthe ultimate diagnostic technique Enneking’s Classification System for bone tumors (au 5 INw 2007) Most ofthe benign turmom and criagenous tumors ae tested by surgery PER once enc crttenenn torre iretComplete Summary of Orthopedics Unicameral bone cyst ‘Ancuryzmal bane cyst ie “ie decade 2nd decade ‘Site Proximal humerus erin Lower imb (However can accur anpwters) Location ‘Cental (eoneantfe) scent Exparni Exeansile More exparile ‘Symptom ‘sympa Pain ic present Cavity ‘Sind, Straw coloured uid Miticculaied, Hemorrhagic Rui Tement Curmtage Extended Guretage Eccentric expansile cysts Central cysts (tay be expansile) ‘Non omifying fibroma Brodie’s absceas/rown tumor neuryml corey eee Bent cll tumor Feeedare a Ghondrcblaroms | Tomei NAG EXPANDS REECH — Cyst (Simple bone cyst) Osleochondroma - Bony Growth with Cartilage Cap MG. cause of pain is Buristis over Osteochonsirama + Malignant transformation inta chondrosarcoma (identified by MI} = Treat cil: Extraperiosteal renocton, Osteold Osteoma - M.C, Femur Diaphysis This commanest benign true kone tumer, excecded in incidence only by es achondrama and nonossifying fibroma © Thetypical patient withan ostesid osteoma has pain that i worse at night and is relieved by aspirin orathar nonsteroidal antiinflammatory medieations, When the lesian isin a vertebra, scollonis may’ occur, Cin the bet tidy bo identify the niduis and sonfirn the diagno, © D/Dofostenid osteoma fy bone island Surgical management involves removal of theentire nidus burrdowntechal que *Rdinfreg uency ablation in ned Far axtewid antec, Enchondroma: + Brehondromamost common tumnrof bones of hand. Multiple enchondromatonis is alse knew a= Ollier disease, + Maffuccis ayndromeis Enehorerama, subcutaneous hemangioma are phiebolith, Malignant transformation to chondresarconia may cxrur in'e2% insolitary eames, 20% in Olic’s disease anc 100% in Mafiesis syndrome + Trostmont is wstended Curetage g 3 By ° 5 k g i a ChondroblastomaiCodman's Tumor Classic “thicken Wire” calcification GIANT CELL TUMOR Most common site Is distal femur than Sth 04 total GET. ‘Alu this mors bypically oe igh, pulmonary métastan osc in appckimally vf pales Malignant lan cll umors represent iOrthopedics Quick Review Clases! Giant Cell varriant AcB.C ancl Non-OlssiFying fibroma. (al IMS May 2007) ‘Treatment af GCT at common sites" © Lower end of femur [Excision with Turns plasty + Upper era of i Eicon with Tur play + Lower end of radius Exision with Rbular grating © Lower and af un cision? + Upper end of fibula Excision? © Adamand bone affected Tibia Ameloblastoma mest commonly aftects mandible na: Most commana lo Please note that mest eomman tumor of mandible fs squamous cdl carcinoma. Fibrous Dysplasia McCune-Albright syndrome retars to pel postotie fibrous ysl a, eutancous pigmentation(eaks au latt spots), and endocrine abnormalities (Precoceous puberty) Mavabraud syndrome is polyostotie Hlrous dysplasia with intra-museular myxomas. Tumor (Osteo Frou Dysplasia (Female) | Admarsinoma (Male) | Fibou: Dysplasia Female) Site Tia Disphysie «Fits Tibi (MO Lang Gene) | Femur, Canis facil aren Presentation Saitng + Defornity ‘Swaling Defarrity Bicey Trabecular Bone wih Fibrous Epitielil Celle TTiabecubr Bane wih Flows Ska Sroms with oxtecbislete ray appearance ‘Soap Bubble # ground glace ‘Soap Buble ‘Ground ghee ‘© ibrous dysplasia of proscimal femur has shepherd crook deformity OSTEOSARCOMA + Osteosarcoma may be more common in patients with the hereeitary form of retinoblastor © Puleotile bane tumors inollowing order anew nd Li-Fraum en syndrome ‘must be preferred Osteosarcoma>ABC>Angigend athelioma of bone >GCT (ALIMS May 2010, aie 2007) (Amongst metastasis RENALand thyroid pulsatile metastasis) + Chemotherapy + Limb Salvage Surgery + Chemotherapy (Methotrexate fs most important) © Btopaside ts not included in the “T-10'protocol for emtecsarcomna © Osteasarcoma is radioreststant. (aire 207) Ewings sarcoma — Presentation like osteomyelitis Complete Summary of Orthopedics Classically, Ewing sarcoma appears radiographically a4 a destmictice leon fv the disphysis oF a lang bone (Femur) with an nian skin perinsteal reaction, Ewing sarcoma more often originates in the metaphysis ofa lang bone, but Frequently extends for a considerable distance int the diaphysis, Origin is trom marrow cells. MIC 2 (CD 9%} positive cells, glycogen positive cells are seen in Biopsy (amnts May 2002) ‘The t(11; 22) ig24: q12) isthe most common translocation diagnostic uf Ewing sarcoma and is presentin greater than YOR& of ceases. Other tales 2012) Poor pragnosite Factors are: Males age > 12, Fever, anemia, inceased TLC, platelets, LDH, Proximal lesion, Been. relapse and distant metastanis, (Last 3 are worst prognostic factors). (alana Pe 2000} jagnestic translocations, including 21; 22% (q22 q12}, trisomy 8, tsomy 12 47:22 )pp22: qQd}, del 1 and W722)Complete Summary of Orthopedics = Trestinent of Ewing's Sarcoma ~ Chemotherapy fallowed by surgery followed by chemotherapy. ABCD (Actinomycin DyBleamyein |Cyclophosphamide!Doxorubicin}- fs chemotherapy group when chidren lesen ACD) (Chemotherapeutic Regiman for wings sarcoms-involves ag CChonslrasarcofna is most common Lumar azsaciated with Hyperalycemise (areg 20109 ‘Treatment of Chondrosarcama is surgical excision Chordema (Churdan ie rte malignant tumor originating fom the remancrs he sphtenc-accital rogios, Sacrum i the most erm ate ~ Seer fpritive malochant, 1! concmonly occu ti the sacrococcygend or fit Sir cliewes (35%), cerca! thoraciebunebar (1546) > 40 multipletosions in Hone diagnosis is metastasis > multiple myslor: Elderly with bone pains ineraased FSR and hypercalcemia is multiple mys Jama til proved otherwise Metastatic Bone Dizeace 1 Meu cmmon uensey pinay fr bone eta — bie eerie ha emule Bret ang — nChildren—Newroblastoma Skeletal sites most frequently involved = Spine (umnbar) * Lylicexpansile metastasts seen in — Renal Cancer = Thyroid carcinomas Purely Ostecblastic secondaries = Prostate/Carcinaid/Nted ulleblastarna (ames May 2009) ‘© Metastasis distal to knee and elbow is rate and usually arises fram a primary tumors of the = Bronchus, Bladder and Colon (BBC) “BBC Can Go Anywhere even Metastasis fram Bone ta Bone Soft tissue Sarcoma to Bone distal ta Eibow and Knee’ as Bone ta Bone ‘Synovial Cal Sarcoma ae Osteosarcoma Anglonareoms oe Nearestastoma Rhabdomyenarcoma ; HEwings Sarcoma Lipo sarcoma Wy | ‘Angiosarcama BONE SARLA Rhalsdornyosartama is the Most commen soft-tissue harmo i child, Malignant filsrous histocytoma fs the most eamnmon soft Hsu turner in acl Sarcomas metastasizing through lymphatic and causing lymph nade involvement are: soipedoyio.so Aewuins eyardulo5 Gerreell sarcoma Lymphosarcema Epithelial sarcoma ‘Angiosarcoma Rhabdomycnrcoma Malignant fibrous histiocytoma ‘Syria cell sarcoma cuentas Tet Sei srcomas anomie ll trcomas fo tao accom, arc 20Complete Summary of Orthopedics . FRACTURE AND FRACTURE HEALING Is Cente of Primary ossification appears akend of 2nd month in intra-uterine life. (ANIMS Nice 2000) Rate of mineralization of newly formed cxteoid estimated by tetracyeline labelling. Fracture, Partial or complete lnss of continuity of cortex. Tendorness isthe commonest sig of fracture Abnormal mobility and Loss of transmitted movements surest sign of Fractie Direct trauma ~"Transverse » Camminuted fracture iA Modelling = Growing skeleton Remedeting afer Skeletal Maturity — Resorption + Bane deposition (apposl IMS May 2003) omy Bone rarodelling bas both osteoclastic and osteoblastic activity at compression or Censton site ut tre forces om bane decide iohore remodelling takes place compressile forces compression site ard tensile farces tension site an ix bone modelling there is osteoclastic activity at tension site and osteoblastic activity at compression site, (AIINS May 2007) Bone apposition is seen in CAINS Nw 200) Howship'stacunae or cutting comes in normal adults fter resorption) Subpericstsal cambsiurn layer In fractured bones (8 nple of bone apposition)and after cancellous bone grating, Boneapposition in these 2 examplesdass not require nesceptian. Markers of Bone formation Serum bone specific alkaline phosphatase (aire 207) Seruim dstedcalcin (very important rarer! Marker of Bone Resorption (PGT June 2008), (AMES May 2008) Urine hydroxyproline Serunn tatarate res ot avid phosphatase (TRAP High osugen tension, high pH (aiding alkeline phosphate activity) and stability (nicrom osteoblasts hence enhances rate of union vat) predispose to Common Sites oF Nenunion Femurneck Lateral condyle of humerus na lower 1/2ed Body of Talus, Lower 1/4rd of Tibia Seaphoid ELI-LS g 3 By ° 5 k g i a Common sites.ef Malunion Malurion [ntrtrochentrie octane femur ‘Supracundylar humerus Colles eactare MSCOrthopedics Quick Review Fash ‘Cinisllysbrarmal mab alse To sna t novernents proximal Fafa Desh n cores ety aaa (Gaen Peaches ‘Glesod Fracture stages 2 aetum Hooinal Pyare lage = =) EE Se] tas 1 ie] ee * wan” || Exeter palm Slage 2 Granalaton| ae Sage Cana ae retical siete ie fied dscese— ei eras achive P| ettarsol shaft trost corre Sige 4 Cormeen ‘inscal ia Stage 5. Romadsl ns] [ (one) | sarise Bove rel 6. ADVANCED TRAUMA LIFE SUPPORT “Any trauma patient should be managed in following sequent of events(ABCDEF) : AL Airceay managentent with cervical spine stabilization (Cervical spine stabilization bx fore Airway) B. Brathing feentiation) Complete Summary of Orthopedics ©. Cresco D. Disability (neurological status) assesment E, Exposure and environmental control F. Fracture splintag 7. UPPER LIMB TRAUMATOLOGY ‘Supraspinatas Infraspinatus Shoulder “Tenet minar 1. Only one fourth of the large humeral head articulates with the glensid atany given time. Subseapularis come | Four rotator cuffmuscles are -suprospinatus,infaspinatus, subscapularis and teres minor. | SEESComplete Summary of Orthopedics 3. The inferior pact of shoulder joint capsule isthe weakest area. 4. The tendon of the long head of biceps brachil muscle passessuperiorly thro of humeral head on glencid cavity tand restricts upward movement 5. Relator interval isinterval bel een leading edge of supraspinallusand superior edge of subscapularis, Coracohurneral ligament passes with in rotator interval, (AMS 2005) 5. LiL OFF Tsk (Gerber's tes) is done to assess the strength of subscapularis muscle, (AMUMS May 2032, AIP 2070) Traumaticedetachment oéthe ANTERIOR gleneid labrum has been call the Bonar! levi, Entei elavity of the shoulder capsule alsacauses instability of the shoulder joint 8. Hill-Sachs lesion isa defect in the posterolateral aspect of the humeral head-Anterior dislocation of shoulder 9. (RAMP)—Reverse Hill Sachs ~ Anteromedial hutneral head -posterior dislatation of shoulsler (area 2012 10, Recurrent dislocation is mast common in shoulder joint, subsoracoid type ccouinting for nearly S1P% of all dislocations, Most commanly AL Recurrent Dislocation of Patella (2nd most commen) 12, Rarest invalved joint in Recurrent Dislocation - Ankle (aire 2009) 13, Recurrent Anterior Dislocation -Abduction and External rotation farce (ANNA No 20019 Bryants Kecher’smathed (Mest commen) Dugg test (Most comman} fimpussn’s gravity method Eallaway’s tet Hippocratic method Hamilton ruler test EDCH — Test for shoulder dislocation KSH — Manenure for reduction of anterior dislaeation Mest cummon eatly complication of anterior dislocation of shoulder is ANILLARY nerve injury Inferior dislacatian also axillary nerve is invol ved. = Anterior instability test: Anterinr appreherminn test, Fulcrum test, Crank tent surprise tet + Jerk test fs for ponterior Instability (AIIMS May 2010, AIMS May 2009) + Sulcus tet for inferior instability (mul «tonal instability) = Claviele is the mast ecanmon fractured bone {overall in adults = Claviele is the mast ecanmon bone fractured during weakest point of midelavicle isthe junetion of middle and outer third (lc. medial 2/rd and lateral 1/ rd), g Immobilization/ Figure of eight bandag « rately plating or K wire fixation, = Malunion fs them {tcommen complication ‘Volpeaubandage (dressing) is used in acromioclaviculardistocation, fractureclavicleand shoulder disloca effective mnbut itis mont acromicelavicular dislacation ast pushes Lateral end of shoulder dawn wards and arm upwards, and thus helps maintaining reduction, (AUNSS Noo 2008) Fractures. of Surgical Neck Humerus Elderly osteoporotic Fomsles are usually involved {in such eases i is usually impactee) Peripheral nerve injuries are common, expecially involving the axillary ners Analgesics with arm sling usual treatment soipedoyio.so Aewuins eyardulo5Orthopedics Quick Review Injury [Anierior ar inderior shoulder disbcatin Fracture eargical neck humerus Frace shalt humerus Fracite supracardylar hurrenis Macial condyle humerus Manieggia facture delocatian Vollinan’s ieshernis contracture Lunate dislocation Hip dislocation Knee dislocation Commen Nerve Involvement Axillary, (ccurnlex hurmeral) nerve Axillary meme Ratio nerve AIN Mian > Radial» Linar (AML) Ulnar nerve Posterior inferomreou nerve Aniorior Interassecus Nerve Median nerve Sciatis nerve G Peroneal nerve 8 3 a a 5 3 7 E 8 a e 5 ‘Humerus shaft fracture; The mast commancauseof dayed union or nanunian isdistraction atfracture site due to gravity and weight of planter, A spiral fracture of the distal third of the humerus is called a Helbteir-Lewin fracture, It is Frequently asscciatad with radial nerve palsy, Plating For treatment (usually) Elbow Ossitication ~ Capitellum 2 years — Appear sequentially every 2 yaars = Radius head 4 y ars — Appearsequentially avery 2 years = Infernal (medial) epicondyle 6 years — Appear sequentially every 2 years ~Trochlea B years Appear sequentially every 2 years = Olecranon 10 years Appearsaquentially every 2 years = sternal (Lateral) episontyle 12 modmEA ars — Appearsequentially every 2y Tiarce point bony relationship is not disturbed in fracture siyoracondylar haumerts as the fracture eccurs above dhe Level of these boy landmarks and Classicaly Disturbed -Distocation of elbow (Classical example) Age 1. Lower humeral epiphyseal slip: 1-3 2. Supra condylar humerus fracture 5-8 years Lateral candyle humerus fracture: 5-15 years .cturas of necessity (requiring surgery) Later Fracture neck feorur 4 5. Montesa fracture in adults 6 com yle fractere hueareras 2. Disptaced fracture olecranon and patella sarzi fracture dislocation Articular fractres .cture lateral condyle Humerus - Treaimant Is Open reduction + K-wira fixation. Complications of fracture lateral condyle humerus are © Nenuninn -cubitus valgus(Trestmont Milzh estestormy) = Malunion eubitus varus(Treatment Modified french ostootomy?) Tardy ulnar nerve palay(Treatment Antes Growth disturbances Tearsposition af ulnar nerve) Fracture Supracondylar Humerus Supracondylar humeral fracturesin children are most coramon elbow injuries, expecially in children aged 5:8 years, Mest common ty pe oF st pracondylar fracture -Fxtension type (-88% ofall supracenylar Fract Supracondy lar humer Fractures are extra-articular with pestorine displacemant of the distal fragmentComplete Summary of Orthopedics ‘Medial (internal rotation/ Medial tilt/ Medial ar lateral shift, Impaction (proximal sift) Dorsal displacement? Dorsal tilt “Associated nerve injuries most commonly involves anterior interosseaus branch of median nerve “Anterior interawscous nerve ‘Median ner Radial nerve [Ulnar nerve tin flexion type) zz AMRU (Onder of Nerve Involved) (aire xan “Trestment is closed reduction and cast it it fails art fracture is displaced the fracture is fixed with K wires ‘Malunion = Cubitus varus (gun stock deformity! = Treatment mod fied French Qsteotomy. Baumans Angleangle between the physisand long axisof humerus normal value 75 tal degrees itiaincreased in cubitus Fracture supeacondylar hurnerus (3: ints! with vascular injury Most commen fracture to involve brachial artery. (10Abeases) Most commen eause of welkman's ischemia and comparkmant syndrome in children, Most commen ea useof wolkman's ix Most commen fracture 9 emic contracture Sideswipe injury-open fracture dislocation of elbaw seen due to accident volving side swipe over elbow. Compartment Syndrome-Tight cast think of compartment syndrome | Compartment syndrome invelves deep ponterlor compartment of legedeep Rlexar compartment of Farearmy (commonest in hileren) Clinical Feature The diagnosis of Compartinent syndrome is Basest on dratalicaly incréasing pain (ou of proportion te injury) afber frseture) any injury (Ist symptom) Pain andl resistance On passive extension of fingers (Distal most joint of extremity) (Lstsigind “Stretch Pain’ Pulse fs nota reliable indicator Deep Flevor muscles are invalved particularly flexordligitorum profundus>Flewr Pallic's Lon gus.(A.MS May 2012) ‘© Fasciotomy is nacommended for impending tise ischemia when the tissue pressurereaches Kime Hgor the difference between diastolic blood pressure and compartment pressure is lem than 30 mm of Hg ar neurovascular sign appear soipedoyio.so Aewuins eyardulo5 Volkmann's Ischaemic Centractura(VIC) — Mest commonly Involve deop ‘tlexor compartment ef forcarm (FDP > FPL) ‘The earliest nerve involved is Anter\ar interosset>median> ulnar. Tum Bucklesplint Max Page Musele Sliding Operation Myositis Ossificans / Hotrotropic Ossification-History of Massago think of it! Elbo > hip nt:Complete Summary of Orthopedics Orthopedics Quick Review In elbow More commonly anteriorly than posterior Trauma rund elbow fracture supricondylar humerus, dislseation or surgery. Surgical trauma specially total hip replacement, Parameter Myesitiz Ositicane: “Tumor Caleinosi= Etolegy “TWaumatic Ieiopatictaritia! SideiSite Uniaterl Elkow Eilteral- Knee Symptom Paintul Pines Maver ALP Level Increased FO, Leva rcresced ‘Treatment Of Myositis Ossificans BUM of cases texolves apotancatisly In acute phasetthe treatment consist of limiting motion x3 weeks, Followed by only active exercises upto year Surgical excision > L yoar Lave dase irtadiation, biaphesphonales and indomethacin may preventhelsalopicossification, but the radiation should be avaided inchildren. Pulled Elbow! Nurse Mald’s Elbow - “Age 1 to 4 yrs and forearm Is pronated”™ Tey subluxation of radial head or more accurately subluxation of the annular (orbiculae ligament which slips up ower the bead of radium and is recluced by forceful supination. Fracture Olecranon treatment is Tension Band wiring orrarely excision which Is contraindicated It Fracture is extending te coronold process ‘Monteggia Fraclure Dislocation Fractures proximal third ofthe ulna withdislocation of proximal radioulnar joint, Posterior interosseous nerveinjured became it tnkes a tumm around radial head and injured with its dislocation, Galeazzi Fractures of the Distal Third af the Radius with Dislocation of the Distal Radioulnar Joint Fracture bath bone foraarm is trented in children with cast and in adults with plating, Position of immnbiligaton is inidpprane in fractute both sone Foraatm (avid 1/3) [Night slick fracture is isolated fracture of ulna due todirest blow. i CColle's frachur eis fracture of lawer endl oF radii at is sottion cancel aus junction Colle's Fracture - (Extra-articul ‘Supination Lateral displacement /Latoral tilt angulation Impaction (Proximal shift) [Pero deacon ang | SLIP ~ (Dislacement in Cole's) ‘Mont colles fractures can be successfully treated nonaperstively and cast is applied on appasite forces to displacerment= ‘That's why position of immobilization in colle’ Fracture inComplete Summary of Orthopedics Bronation Palmar angulation ‘Ulnar deviation Bro-Bag-lnds—Called as Hand shaking east Complications of colles Finger stiffness is most common complication. Malunion is the 2nd most common complication and it leads ta dinner fork deformity Susleck's Osteoneura Dystrophy/Reflex Sympathetic Dystmphy /Causalgial Algedystraphy/ Complex Regional Pain Syndrome, Res! Hlot skiny skin, severe pain. CRPS type Lisa regional pain syndrome thatusually develops afher fisue trauma eg colles (area 2001) © CRS type © Trootinent is usually physiotherapy and results are poor sre 3 pain syndrome that devel ps after injury to a periphoral nerve/Miedian>Seciatic Tibial trunk) = ke 1 Sympathetic Dystrophy ehiy Ostecpenia *Hyperparalltyroidism- Generaliseel Osteopenia Tuberculosis: Disuse Osteopenia Barton's Fracture fracturedislos on in Which the sarpus and arith of distal radium are displaces! logether ChauFfewr’s Fracture— sh radial styloid fracture Relative Incidence of Carpal Bone Fractures Seaphoid > Triquetral >Trapexium ‘Semple: Mick children, third (Waist) fractures are most common. Distal pole avulsion type fracture is most commen fracture type in Sign ~Tenslermis in anatomical snuff box, Oblique view important for diagnosis. MII can diaggnone oceult Fractures ‘Trestmant is glass holding eastiFdocs nok uniteo markedly displaces Fracture Hallas seraw is used, Stapholunate dissotiation ~ Terry Thatnas sign. ennett Fracture intraarticular Fracture of base of 1 metacarpal with dislecation of earpemetacarpal joint Rolando fracture—tamminuled intraarticular fracture af laze of L" metacarpal Injuries with characteristic deformities: Detormity tnry lating of shoulder ‘Shoulder dislocation (ants Dinner tonity Cole tactae Garden Spade Deleriy Sith Fracture Mallet finger [Auusin ofthe intern of the celermar tendon fom distal phalanx Flexion, adluction and intemal tation of the hip Posterior distecation of the hip, artic Flexion, abduction, extemal rola ol the hip Aneriarditocation olthe hip, septic hip ‘novi of hip joint Fluid and itbial Band Contrsture(Potich Enternal aan ofthe eg Fracture neck of fermur ‘Trochantevc factre (Lat border af font touching be) g 3 By ° 5 k g i a8 3 g z 6 3 : E 8 3 e 8 Orthopedics Quick Review tee Hea, | | ams inci uses eaceea| eocene are Pinar Hewes ret andre theme linstecceg rior is ~ Coe Frachunsa off eras 116°).199 aMnG Ry) ~—T_ tng earner puny [UDRP Set irvekeésigeg] — |Eeorumecec tone 4. dee! aci cer fcteaorece But Pen jaro Eee l * Latest Questions 8. SPINAL INJURY \Vertebroplasty is pereutarsous injection of bone cement (PMMA = polymethy methacrylate) inta vertebral bedy. It ean be used for ostiolyHe spinal motastasis, multiple mylooms, aggressive hemangiomas, vartubral compression Fractures (Qstoopomntic) Its use is contraindicated in infections, Tuberculosk TALIMS May 2071 3 \Vertebroplasty provants Furth colla peo and kyphorplasty is correction of cllapa uf wortobra by using high prisourss isnot protered now. Central Cord Syndrome-Mulor weakness With arm teakness out of propertion be lag Weaknem ‘Areflexic bladder bower and lower limbs + With Symmetrical involvement Conus madullaris Syndrome © Asymmetrical involvement — Cauda aquina syndrome (Cervical spines has highest chancos of dislocation Without fracture as Hole 2ygapophyseal face) joints dopo in almost ankere posterior horvontal plane, Whore as in thoracie and lumbor rogion faect joints areesrientad vortially andl intar lacked Whiplash Injury Hyperextension of lnwer cervical spine Jefferson's Fracture Jloffersan fractures burst Fracture of ring of atlas (Cl) vertebrae Burst fracture isa vertical comprimion fracture (aura 20077Complete Summary of Orthopedics Hangman’ Fracture Teeccurs when a fracture line passa through the neural arch of the axis (C.) vertwbrae traumatic apencylolisthesis of axis {C.) vertebrae on C,-H, (Hangrmans inval ves 2° Cervical Vertebra}. NOTE: C, and C, injuries usually do not cause neural defieit because of wide spinal eanal here Flexion rotati Injury is the most common spinal injury followed by compression extension Injury (nd most common}. (aire 2007) “Tear drop fracture is catised by combined asial compression ane flexian injury Pationt with head injury, unexplained hypotension Warrants evaluation of Lower cervical spine> Thoracic spine fh anal land injuries compress fajuries), He sont consnton sie of Erawnte sat te Hhoracobrnber uoutiot Consent bet jury enuses chance Fincture Pair eompreone waned eee welavoneuet welesiasi, beware a. = Nc] aay mines Nc] srene] [Aci song ten al I Spor anaes Sangiee) Tekin et aeemar so PEE iso Lise f Peas = Ea [Serna | Se ; | ee) [eee , > Pinger tina * Latest Questions soipedoyio.so Aewuins eyardulo5 Sai fonOrthopedics Quick Review LEVEL OF INJURY cyte Wise net Cy: (Mille Fingen) eB (Rng 8 Lite Frage) Co Taerad part ot (bg, dorcurm of foot Great t= Sok bate teat 1 fing be Fig. 1.4: Dematames (Sensory 5 upply} Seay er her eer — Rees enna Ce__| Ew esos (Ses Baca) [BHGE om ablciny [lalla we | Bere te Ws edercon tensor oe ads npr adie 3 | Eerie fico) [Era ic Tales = 2 Soe eo 3 fe erie em im Taga i ae 5 fie mae =a $ ae 8 Te [ii ter fama) Tes ane Syren eee fi saris ices E peas tect ) SS SS 3 Vipauicon et | et seme ortega Fore fol aap | ones — hallucis longue) EHL | Tibialis anisricr fark Lateral call g fesiover Sutsernedun|[Geal eat pec (hipabuction), Kee flexion [Toe dovstiesors si ‘Ankle plantar Hlexor= [Abuser ralucioGiutews — | Planar etsface fact ‘anide een (gaetrocnemiue and coleve)FHL | maxims ip extension) Lateral pect ft (Flexor Halas Longe) inclding 5* toe all epecte ASIA: Anuerican Spinal Injury AssociationComplete Summary of Orthopedics MEASURMENT OF SUPRATROCHANTERIC SHORTENING Shorten supratruchanterie shortening, And ibis measured by follwing Qualitative Assessment Patient lies supine and hip Is extended Schoemaker’s Line SchUmalcer G “Anterior Superior line Spine “umblicus Greater Trochanter SchUmaker- G A line joining tip of trochanter and ASIS, when prolonged ontsothsde, should most in the contr Line at ar sbavetheumblicus, Incase of proximal migrationof greater trochanter the line on that side will moet its counter part bbelow the umblicus and on the opposite side, ‘Morris's Bitrachanteric Test M=I'=T Moris ubic Symphysis (Greater Trochanter MET ‘©The distance From the tipof the trochanterto thepubic symphysis should be egal IF trochanter is entemally rolatisl or dixplaced back distance will inerease on that sida and vicevers. In central fracture distoeation that side campanent ix reduced Quantitative Meas urement Bryant's Tangle s oflimb length produced abovethe level of trachanter {due to femoral head, neck and hip joint lesions) isknown ay Chiene's Parallelogram CAS -G Anterior Superior Hliac Spine Grester Trechanter cAS-G ©The Linmsjoining the two AsiSand two Hips of trochanter should be parallel * Inca one ofthe} eater trochanter has moved proximally the lines will converge on that side Nelaton’s Lines Patient lies on the normal/epponite ideo the Limb with preferably 90°flexionat hip. A knedrawn trom ischial tuberosity ta ASIS should pass through the tip of greater trochanter, In case of suprattochenterie shortening the trochanter will be above this line Nelaton Line [Anterior Superior lliac Spine Ischeal Tubemaity Greater Trochan ter The patient liey supine and tipaof trochanter and ASIS are marked an both sides A perpendicular in dropped from each ASIS on to the bed, From tip of greater trchantsr ancther perpendicular ix dropped on tothe first one, (hase ofthe triangle), Now join the tips of greater trachanter to AIS on rospactive sid, Each sideof this right angled triangle iscompared with its counter part cn the normal side, neck, head, joitt or dislscation of jeintesn be measured. Any shortening of the base (ie, more or lem Femoral axis cuntinuaian line), which may be becatine of shorten g 3 By ° 5 k g i aOrthopedics Quick Review TRENDELENBURG SIGN Normally when the body wel ght fs supportod on one lim, the glutei (medius and minimas) of the supported side contract and rise the epposite and unsupported side of pelvis, ifthe abductor mechanismn is clefective the unsupported side of pelvis drops and this it known as ponitive trenchelenburg’s test ‘Trencidenberg’s tes is done fo assess the integrity of abductor mechanism. It is pasitive in the-sondlitions in which any ofthe three — fulerur(Femeral Head), lever arm (ruck Length) or power (muselcs/nervelis afFacted Causes of Positive Trendelenberg Test meumeusass woods Prove Paralyssaf auctor muscles | | rn Supsior glib ratve palay upply gltous meds dnd \ nim ses Tete lictibial tract palsy: sneer cans Alductars.f hip are luteus medias and minimus (rin) Tensor fascia lata and sartorins faccessory) Decreased lever arm } Fracture neck femur “Absence af table Fulerum about which theabduetor muscles can e fact dislacation of hip. Destruction of femoral head as in Parths disease, AVN, late stages of TH hip( ta arthritis. ‘Tuberculosis of Hip- Trendelenberg’s test may be positive in TE hip only in Late stagenfstayye 4 and 8) when the hesd oF femur is deste Pationts walk with positive trendelenbrug sign an. One hip Lurching//Trereelenburg Cait and Both hips Wadding Cait ‘Thomas test - to nteasuire fixed flexinn deformity of hipby neutralicing lumbar lordcnis. Upto 30 degree Flexion determity of hip can be compensated by lumbar lordosi Shenton’s line is an imaginary setnicircular ine joining the medial corte of Femoral neck to the lower boner oF superior pubic ramus. ts feroral part is oF more significance. Its bresched in Fracture neck femur, head Femut, superior pube rami and islacation of hip. ) Fig 1.2: Trenderienbera Test ge 4 and 5) and septic Ler Complete Summary of Orthopedics Fig. 1.3: Thomas Tet to Astens Hip Flesicn Fig. 1: Krmy Peis Telescopic Test In supine position, hip and nce are flexed as muich a 90 degress and thigh i pulled up and pushed dawn, Even in-normal condition slight amount of excursicn of trochanter can be felt by other han. if excursion ly more, then this indicates insta bility fof hip joint such as: old unreduced posterior dislocation ,lons af neck and or head in old Fractures neck fernur and paralytic hip, Polvic Fracturo PARE 12 pelvis fracture intrapelvie haemorrhage Is by far, the most serious complication. Haemorrhoge frequently results fram fracture surfaces. 3 week fracture asieatomy,/ Bone grafting + fixation 65 Years + No pre-esisting arthritis — hetniarthraplasty © Pre-existing arthritis—total hip: replacement soipedoyio.so Aewuins eyardulo5 (Complication areQstecnacronia > Nionunon > arthritis (aire 20123 Chances of AVN and nonunion in decreasing order is ‘© Subcopital > transcervical »basal >intertrachanteric #Transphy'seal otranscervical >servicotrachanteric >intertrachanteri¢ (in children) Intertrochanteric fracture femur Extra age, extra pain extra shortening extra external rotation(as compared to Neck Fermust ‘Trealtment of choice Dynamic Hip Serew ‘© Most common complication is malunionComplete Summary of Orthopedics “Lalas! Questions Orthopedics Quick ReviewComplete Summary of Orthopedics eet: Usually poste Hise dtes (postetor, jar 1 [Leama] Rotana (lam i Ted pares) FAD) Charuavor| [Sapna ean) [PRES ERRR “ettactra || | choteome | hase | [SMa] | Srecson paper Extensor + er ten Clinica orasentston Sra ERE et Intiachre sosatone is eral bs soipedoyio.so Aewuins eyardulo5 Fuatetor Giaonstany af i] (Eiecad eau af uaa sion F801) * Latest QuestionsOrthopedics Quick Review Complete Summary of Orthopedics 10. LOWER LIMB TRAUMATOLOGY ‘Subtrochanteric Femoral Fractures Russell and Taylor classification © Trostment of choice is eqahallomedullary nail Displacements In Fracture Shaft Femur Smith Paterson triflanged nail was used For internal fixation of Fracture neck fermur (not subkrochanteric Femur) + Proxine! tr! fractune: Proximal fragment flees, abducts and externally rotatesbeca.use of gluteus medius.and ilicpseas Diagnostic Criterion tor Fat Embolism — Fracture shaft femur with breathlessness after 48 hours think of it Gure's Major Criteria (4) * Asillary er subconjunctival petechia © Pao below 6a mmrg © CNS depression © Pulmonary cedema Gurd's Miner Criterla (8) = Tachycardia © Pyrexia | ANEMIA *Thrombocytepenia ‘© Fat globules present in sputum Fat present in urine (GUD TEST) increasing ESR © Embolt prosont in retina 1 major #4 minor = fat embolism Treatment of fat embilism is oxygen and (1PPY) Patella: Displaced Transverse Fr = Tension Band wiring by k-winss and stainless sted (SS) wire = Comminuted Fracture = At least proniemal third of patella i intact -Partial Patellectomy’ = Severe Comminution “Total Patellectomy ‘Management of Fracture Tibia © Childnen-Abave knew cast 4 Adults— Trialof consoruative management is givin iF it fails Interlsek nailing ‘Compariment syndrome of Leg - Test tor tee dorsiflexion Use af Sin Cratch—Jn the opposite side For Fracture both bone lng and Hip: Pathology (AUN Nexo 2008) Over H0% of ankle ligament injuries (twisted ankle or ankle sprain involve the lateral ligament complex usually the anterior talofibular ligament)Complete Summary of Orthopedics Malleolar Fracture + the three malisoli are medial malleolus Jateral malleolus and po malleolus (the posterior part of the lower articulating surface of tibia) and second word the direction of force +The mechanism af injury fest word is position off +The mest common mechanisti is uipinationeversion (supination-extemal rofition).s0 supinitionis position of fectand external rotation dnection of injury. + reattnent is maintain the joint surface reduces. Tibial Plion Fracture “The terms tibial plod fmeture. pen fea Fractures of the distal Hbia, re, and dist! tial expfason fracture all have been used ta describe intraarticular Fracture Talus-Complleations - OA > AVN. + Seeondary Ontecort oFankleand/orsubtalarjointoccurs some years after injury in over 40% of patients. There are several causes articular damage because of intial irauina, malunion, distortion of adficullar surface and AVN 407%, in typell + Avascular necrosis of bodly, incidence varies with the severity of displaeesnent: in type 110%, in type SO0R%, ane in type LV 10cR& ‘Caleancuit is the most commonly Fractured tarsal bonTuber angléof Behler (Tub joint angle)—Reduced in fracture caleaneu and Crucial angio Gissaine- increases in intraarticular Fractures (AUIMS May 2007, APG 2007) Calcareurn in over 20% of these patients suffer amscciated injury of spine (mest common), pelvis or hip,base of skull and talus, Anglas In Orthopaedics + Cobb's angle -Sealionis cTEY + Kitesangle + Moary’s ang + Hllgenreiner's epiphyseal angle ~ Congenital coxa vara + Baumann’s angle ~ Supra condylar Fracture (Chronic ankle instability can besatisfactorily treated by Waston-Jones operation. In which reconstruction of ankleligaments is carried out. Walson-Jonesis also 4 lateral approach to the hip joint, which can be used for hip replacement (although rarely as more commonly used apysmaches are Moore's posteriorand Hardin ge's antero-lateral appproach.) TALIMS Rap 2008) g 3 By ° 5 k g i aOrthopedics Quick Review a] fewer ET] Phsnamanied ania 9 ale 2 eee art Facus en dorset Jeep ace wont ara env] averse Calle) ermatee seat x arate vacant] Ficus vith sabi rasan eae Ud vn SI stance # Complete Summary of Orthopedics € Fico #1era-artouler Poeun toe ard =, eaianmnaine mera Tarkan Fane Fives ma a ict rick af the fa tunes #-coae of in waletere Lovee -Csiaraum Weare (Glarsiovelors# Seiraus seas Is cari vert Mowat poe une ver digucetr of 2 pronina aioaine onl “sizer at re rah st ierat VAC Somtegpa se va [Daetieaid # -2cterar seieaton “wih Boats ava "acliae ne # dpalaiewl sible ee 6 ~ [Burge ¥ Lateral soil conde ‘Chepers ¥-slelceaten ~~] rregh inlertarsal is * Latest QuestionsComplete Summary of Orthopedics 11, FRACTURE MANAGEMENT Plaster Casts And Thelr Uses: Hame ofthe cast Use Cervical epine disease inser east Tunn-buchle cast ‘Shouller spica! UsStibthanging cxet Hip spies Offer exettine east Patelisr tendon bearing cast{PTH coat) Cole's cast Glass holding coat Seofarie Scolosie Shoulder immaiiation Frocture of he humerus, Fracture of he fem Froeture ofthe pa Fracture ofthe fkia Fracture lomer end radius Frociure seaphoide Gallows traction ~ Fracture shaft femur <2 years of age. ‘Rush pin is used for fracture shalt feriur nok for traction Superficial heat therapy infrared therapy (ANMS May 20079 Closed reduction: Fracture hematoma is nest exposed henee it dows not interfere with fracture healing hence better prognosis far Fstra articular fracture (autnts May 2012, Neve 2011 200) Open reduction: Fracture hematoma is exposed itis usually eaetied oub for articular fractures as exact reduetion is Sci resent atts ov open reduction is atid ou # eos rection hails additonal prosedue lke bone grating at facture site s require Internal fixation the foxation device is under the coverage of soft tissues plating or wailing. External fixation the fivation device ’s external fo skineextemal fixator or ilizarox fixator. ‘Management of fracture i. For long Bones Intramedullary nailing-ex K nail, interlocking nail, Rush nail, reconstruction nail ~For lower lin diaphyseal fractures -Fomur or Tibia Plating for upper lnm Fractures humerus or radiusor ulna Dynamic hip screw (DHS)-For Intertrochanterie Fracture fi, For short bones Serews articular fracture whore headlows acraws(Herbert screw} are preferred eg seaphoid Fracture Cannulated cancellous screws femur neck fracture K-wire fractures in children eg supracondylar fracture humerus (Closed reduced) or Lateral condyle fracture(opent reduce) Tension band wiring Patella or olecranon or medial malleolus External fixator Is used for open fracture Ilizarov fixator is used for Shartening with discharging ainus jnon union andl also For CTEV. Surgical Excision Never done in growth plate injury eg. Lateral condyle fracture Hiacerest isthe ideal and most common site for harvesting bone graft. Tiacerest is the site for 1" order bone geaiting FALIMS Now 2009) (ara) Reimplantation of amputated limb 1st repaired Is Bone. (Skin is preserved ist) g 3 By ° 5 k g i aOrthopedics Quick Review Complete Summary of Orthopedics (Common Splints/Braces And Thelr Uses: Nome Use + Grammer aire splint + Thomas spline 5 aher rau splint = Aluminium spine + Dennis Bron lin! + Codeup epint 5 Keuede bener splint + Tesraisina splint + Vlkmann's spintor Tuan Buskle splint + Four- post edlar + Reroplane splint Emergency immotiliation Fracture ferur Knee inrnatiization Fracture erm Knee and ibis Immatiieaion of finger cre Fadia! nerve pay Upar nerve pley/Medion nerve paley Foo drop splint Volkrmanns fachernis contracture (VIC) Neck inmablizatien Brachial plesue hiury + SOM brace (Sterna acetal maneoular immobilization trase}Cervical spine inary + ASHE (Antari inal hyper extension) brace + Tayhr'sbrace 5 Mwaukee brace © Boston brace + Lumbar corset + Gobitrite br + Gallows’ s action + Byants traction + Fussell faction + Bucks waction © Petkine easton + on degrees-90 degrees traotion + Agnes-Huni traction + Welleg traction + Dunop traction © Smith txetin + Headhaler traction + Ghutslield traction + Hlorpesie tration + Minnerva eas, Halo device + izes east, Milwaukee tence, Gotan brace + Pals harnass, Vor Rasen splint Held or Craig splint + Broom sick (Pete) cast © Figuie of aight baring © Vales sling and ence = Gutter slit + Thumb spiea sein! + Sugar tong Distal sugar teng'Revetee suger tong + Double ugar tone + Buy sapging Dorsorlrnbar spiral inary orsorkrnbar immobiizaticn Scaliaie Seoliie Baskache Lumbar Spine (1. Fracture shaftof femur in chien blew 2 years for <12kg bad weight) Fracture shaltof feu in chien blow 2 years Troshanteric Hactures (desaribed as skin traction) Canvertienal kin traction Froctine chat femur in ade Fracture shaft fem in chiltren (Correction ot hip delonnity Carrection of abuction deforrty of hip [Supracardylar facture of humerus ‘Supracandylar xctire of humerus ervial spine inns ervial spine hives Scoliais Carvical spine ‘Scotia (ususlly laiepathi ar Daren!) Developmental Dysplasia ol Hip Legg Gahe-Perthes Disease Chavicl [Acteerielovieulatcibeaton > shoulder dislsetion Phalangeal and rictacarpalractsres ‘Scaphoid fracture / Metacarpl fracture Gare: keepers thumb Hamer racine Diet forentm fracture Elbow tactutes Phalangeal fractureOrthopedics Quick Review 12. AMPUTATIONS: Mongled Extremity Severity Score (MESS): Predictor for Lomb Surv after Crush Injury “SIVA™- the destroyer will decide surviv [ans May 2011) Tyee Point ‘Shock Group be lachernia Group oe Velocity of Trauma 1 Age Group 0 Total Scare! W MESSSCORE:Si or ln consistent with 1salvageabe limb. Seven or greater aemputa tan generally the event res ‘A way to remember taal of amputation stumps in uper and lower limb {218 Ups rnba 9 nth abe elbow shutp+7 inch beldn lb aturyp=15 Gn inches) | Lowertimbs0 inch above nee stumps sbelow knee stump =148-13(in Inches) Myodesis fs contraindicated, in severe Ischemia because of the increased risk of wound breakdown. (AIPG 2008) Ainputation neuroma the physiotherapy modality te be preferred is TENS > inkerferential therapy> Ulta sound, TENS: and interferential therapy wroks on the principle of inhibiting pain gate pathway hence are better for control oF neureygenic pain, (AIMS May 2002) SACH (Solid Ankle Cushion Heel foot does not allow ankle movements (required Hor squatting) and does not allow Subtalirmow ements inversion and aversion movements required ker walking on Uneven grounds)HenceSACH foot is more suitable for western lifestyle and in Jaipur foot these movements 3 permitted hance i is maresuitable for Indian scenario. YALPG 2012) 13. SPORTS INJURY + Predominant collage in menisd/fibrocartlage—Type [eallagen + Predominant collagen in aviculae/hyaline cartilage ~ Type Il collagen * Physiolngial lacking s intemal rotation of Fernur on Tibia + lekncets extended from Hlexed peniion tibial tuberosity moves towards lateral border of patella + Thetwisting tose (rotation) in a welght Benen flesed kre is the commonest mode of meniseal (semilunar earllage) injury. Medial meniscus > Lateral meniscos (aire 2010) = Thecommonest type of medial meniscal injury in a young, adult is the bucket handle tear. This s vertical longitudinal, tear that is complete Smillie Classification — Meniscus Injury Wenizesl Injury ‘CraciateInjuryiCallateral Ligament 1. Efusion Vernartreie 2 Delayed Sweling Immediate Sweting + Meniscalleyste Lateral > Medial Complete Summary of Orthopedics ‘The etiology’ chilies insertional tendonitisis wveruse Non-insertional achilles tendonitis is more eoramon and is seen in Atheletes, Ie is sean 2-6 ems abowe the insertion of Tercleachilles 0 2008) Tendon rupture-supraspinatus, biceps, and achilles tendons Most TA tears occurs in left lag in the substance of TA, 2 rupture fs Simmonds test ar thompson test. Game Keeper's! Skier’ -‘Thumb: Injury tw the thumb metacarpophalangea! joint ulnar collateral ligament. Due ty foreeed radial devialory of thumb. Staiers lesion is associated. (Trapped! adductor pollicis Between torn ulnar collateral ‘Treatment fseast fort wwecks and if steners lesion is present then su | 22 | Zone I (af flexor tendon injuriesk Situated Letween the npening ef the flexor steath (the distal palmar ereame) and inscttion of flexor superficial lexor ersaseof proximal interphalangeal joint) is known as“itowian’s lanl’ or dangerous area of hand fem above the ealeancal in jon (watershed gana), Tast Roe TA,Complete Summary of Orthopedics L I 1 Fae ge eae Poteree rece] [lana Peco] mas res| FETS Sa Panes) ey TEL 7a} . = [ * ~- eam [rica] Sata | Se 1 lara it ae egicgiiee:| Our sae ao a nyhngergtpa vb = Tash Fed Roa soipedoyio.so Aewuins eyardulo5 ia RL aie * Latest Questions ‘Amerolseral Gamer: ACI. LCL + Lateral half of Joint Capsule Posterolatral Gamer: LCL. + Poplitous (Most important) AdL: Anterior Cruciate Ligament PCL: Posterior Cruciate Ligament LE: Lateral Collateral Ligament MOL: Mosial Collateral LigamentOrthopedics Quick Review 1 8 3 g z 6 3 : E 8 3 e 8 4 14, NEUROMUSCULAR DISEASE Disc Degeneration and Prolapse ‘The commonest site of disc prolapse is lumbar spine, ln mone than 90% af canes Lumbar disc herniation are Localized at Ly (More common) and (5, The next cammonest site of intervertsboral dise prolapse ts lower cervical spine (C. Lower nerve root is affected usually like in L, ,dise prolapse L, nerve root is affect + L,nerve root supplies Fxtemor Hallucis Lon gus, thigh abductors, ankle dorsiflexion and sensory supply to Lateral 24pect of leg dorsum of foot and great toe. (ix most commonly involved in PIVD L,_,) (AIMSiMay 2012, Nw 20011 #5; nerve ront supplice Flesor hallucis longus, ankle plantar flesionhip extension and semsatinn on ale af Fant Investigations MRL is investigation of choice Treatment 1. Rest with Antiinflammatery Medications 2. Indisalions for ourgery: Bladder and bowel invelverent + Increasing Neurological deficit © Failure of conservative treatment (6 weeks) “Red Flag” and “Yellow Flag” signe tor Back ache Fad Flag (Requires further workup) Yellow Fing Redllags are possible Fdcators of serious Yellow tg are pyachesocialctors shown tobe indicative of tinal phaloay: Jong town chronicity and dieabliy, ‘Thome pain Aregatie atfide tat back pain harm er potentially Radicular impingement severely dicatirg Fever and unexplained weigh! las Fear avoidance Eehaviaur and reduced actrtIevels Bladder or bowel dystnatien An expectation that pative, rather than active rearaent istry of eatehnern= ‘wil be etic heather preeanoe of her medical inse= Aterdency to depressicn, law oral, and social wither=wal Progressive neuralogical deficit Social or financial pratlems Disturbed gai, saddle anaesthesia [Age of onset 220 year of 988 yaar Prolonged sterei intake Chronic backache Prolonged bed rest is avoided (aire 2009) Spondylalysis is characterized by presence of bony defect at parsinterarticularis, which can result in spondylolisthess Spondylalisthenis is the slippage Forward cf ane tebrae Upon another, LS.and SI (most commen) Oblique or lateral view in spendylolysis dogs with a collar in neck and spendylolisthesis beheaded Seoltish Terrier sign AP view is Least useFul except In last stages on AP view inverted napolean hat sign is seen when complete slip occurs (AUNIS No 2001) CT SCAN san diagnose early defects and lips MRI can diagnine cord compression CT. Sean and MRI are usually alyrays don: n spondylotisthosis Frozen Shoulder or Adhesive Capsu! ‘The cardinal feature in stubbori lack of astive and passive movement in all dircctians ic, global restriction of mevemen | planes, Often the First motion ta be atfected (stntemal tation followed by abdtetionComplete Summary of Orthopedics Painful Arc: Syndrome Is anterior shoulder pin fn 60 -120° of glen humeral abduction. Most comm cause is (Chronic supraspinatus tendinitis Tennis Elbow! Lateral Eplcondylltis Tis chronic tendonitis of common extensor crigin (cop. axtunses carpi radials brevis) on La Coren testis po epicondyle, Golfer's Elbow Medial epicondylitis involving; enmman Fase pronator origin, De Quervain's Disease “The abductor pollicis langn and extensor pollicis brevis eedore may bezome in flammed benath the retinacular pulley at the radial styloid sith inthe first extenser compartment, Finkelstoin’s teat is positive TANS Dupuytren's Contracture ‘This fs reculat hyper traphy and contracture of superficial palmar Fascia (palmar aponcunsss) (AUMS Nw 207) ‘© Higher incidencein spileptics receiving phenytoin therapy, diabetics alooholiccirrhowis, AIDS, pulmonarytuberculosis.. + Ectopic deposits may accur in dorsum of PP joint (Garrod’/kruckle pads), sole of feet (Led derhone’s disease} and fibrosis of ccepus cavemosum (Peyronie's dincane) . on contracture most commonly occur at MP joint. =PLP joint DIP Ring finger fs mont commonly involvod> litle Rnger> thumb and index finger PIP cantracturen saon become irreversible Treatment © Waitand watch Primary indication of surgery is Fixed contracture of >40 d surgery Is subtotal fasciectomy.Closure may beclane by Z plasty’ yess at MP jint oF >15 degrees contractute at PIP jint. ‘Stonosing Flexor Tenosynovitis Trigger Fingor Due to stencsing tenosynowitis the flexar tendon may became trapped at theenterance tn its ibrous digital sheath, The tual cai is thickening of fibrous tension sheath or consfriction of mauth of fists digital sheath, (mainly Al pulley) atthe lave cof metacarpophalangeal joint Mallet Finger! Baseball Finger soipedoyio.so Aewuins eyardulo5 [tis avulsion of extensir tendon af the distal interphalangeal joint from its insewtion at the base af distal phalans. ‘An acute mallet finger should besplinted and the DIP joint is kept in hyperextension for 6-8 weeks, Borieitic Site “Slrent:Elbowerninersellcw ‘Olecrancn bursitis Howerna's Ines Prepatellar bursitis Clergyrman's knee Infrpatetiar burst Weaver’ betta lecheal bursts Tailors ankle Lateral malleskss bursiis Bunion sie of reat toe- metatarsal head bursitis Bunicnetts sth tos of foot sth metatarsal hese uri “Athletic Pubalgia ~The primary pathology in Athletic Pubalgia ist Abdominal muscle strain. (ar 2009) Sign’ /*Theater sign’ increased pain on getting up afler prolonged sitting, Chondromalacla patellae Secn in adolescent Females Patient has Anterlor knew pain/Difficulty in climbing stairs! Movie Ps |Orthopedics Quick Review 15. PERIPHERAL NERVE INJURY SEDDONS order of nerve jury Neuroprasia Anonolmesis Naurotmesis NAN Nouropraxia 100% recoteny ard only wat wd scale cave ayy spt B88 mecomers (as ‘Sinerland clraaication ~ type Ita 5, Type 1 -meimpraia, type? 3-anonatinesis type 5 nenaotmecis, “Tine OA » RA. (AlPG 2009, 2007, AIMS May 2009, AIPG 2007, AIMS May 2170) Meralgia parsestheticn-Lateral cutaneous nerve af thigh Fracture unite slower with museular or neural di (Contracture of ilintibial tracteausos FABER(Fledion, abduction and External rotation ) at hip and PERF (Postoricr subsliaxation, External rotation and Flexion =TRIPLE Deformity) at knee. Nerve Paley Presentation 1. Eib’s palsy Poceman tip delonity (Porkr's tp defwriy) 2. Nene of bel (Long thoracic nerve) pay Winging of scapula 3, Median Nenee Paley (Labours reve} Pointing irviex Bandiction tect Pan tart (lexte abstr pals: brevis) Dechner claep tes Oppraiion of thumb lot Jape tnt etry 4. Ulnar nerve patsy (Musician nerve} Book test (homent sign), Cord test (FAD) — Palmar Intros Jgana's teat (BAB) ~ Dorsal intero=osi 5. Risa! nerve palny \Wrisestop, (Finger erp and Thumm Specifeally in posteriatinteroemeci= rere (PIN inj) 15. Common peonet! nerve poley Feat drapfecmplee) {Lateral popliteal nerve ply sciatic nerve ply g 3 By ° 5 k g i aComplete Summary of Orthopedics Orthopedics Quick Review SIGNS AND TESTS © Adson's tests for thntacie cutletsynerome Allen's tet: For testing pateney of radial and ulnar arterics All's tev: for DOH 1g tendernens af the spine Ape thumb : for median nerve injury finding test sor meniscus + baron’ tn for DH Bryant's et fo aneror diction ofthe shoulder © Chow hand: fr wor nerve injury + Comte dons fur tseeonsf pine + Cone for terns elo + Onwer t#or AC ond RCL nurs 2 eee ACL ny = Tetra for PELs + Finkelatsin’s tests far de Quervain’s tenosynovitis © Font drop :for common perineal nerve injury = Froment’s sign : for ulnar nerve injury © Gaenalan’s test: For 5 jaint involvement © Galleagsi sign : fer DDH. © Gavrer’s sign : for muslar dystrophy Hamilton ruler tet: for anterior dislacation of the shoulder Langue’ test: For disc prolapse © Lachmann test: far ACL injury = Ludlafis signe for avulsion of lewer trochanter © MfeNurray’'s tos: for meniscus injury + Nagfelger tet: For dise prolapme Ober's tet Far tight ilie- bial Band (e.g. in polis) #0 Donaghue triac traidlof MCL, ACL and medial meniscus injuries occurring to © Oftolani’s text: for DDH Pivot shift bint for ACL injury © Policeman tip: for Frb's salsy Runner's knee : Patellar tendonitis © Sulcus sign: for inferior instability ofthe shoulder © Thormas’ tet: for hip flenion deformity © Trondelenburg’s test: for unstable hip 4 Tinel's sign: for detecting improving nerve injury Volkmann's sign : for chaemie contracture of forearm muncles Wrist drop : for radial nerve injuryComplete Summary of Orthopedics camera soipedoyio.so Aewuins eyardulo5 * Latest Questions1 Orthopedics Quick Review 16. JOINT DISORDERS: ‘Synovial Fluid Synovial Flufds Its an ultradialysato of blond plasma transudated from synovial capillaries to whieh hyaluronic acid prstein complex (mucin) has been added by eynovial B cell Normal aging Vs ostioarthrilic pathology of atticular cartilage (ALIMS May 2010, AiG 2009) Gartlage property Agiog Osteoarthritis ‘Total wer content (Hydration) Decreseed Increase (Decreased in advanced OA) Protashyie Enzymes: Norm Ierensed Prorenglyean cantent Decresend Decreased New bon formation is feature of noninflaramatory arthritis, «g, Ostecarthritis Complications of THR: Complete Summary of Orthopedics Infection (aire 22003 Dislocation Mottality-Ml> Cardionaspiratory Arrest>Pulmonary Emblist) Contraindications of Metal on Metal Rearing surfaces Patiants with Renal Insufficiency (Chronic Renal Young females child bearit Metal hypersinsitivity They can also cause chromosomal changes ure} (Woman whe may psstontially stl chiltron) (arrc 2010) The role in carcinngermsis is under evaluation Contraindications oF High Tibial Osteotomy (HTO) — (Usually dane for osteoarthritis. < 65 years of Age) rraing of sublnsation of > Lem teral compartmant cartilage space, © Lateral tl : partment bone lens of> or Sr {© Flexion contracture of> 15 degrous + Knee floxion of <9 degrees + More than 20 degrees correction needed (AIIMS May 2010) Rheumatoid artheitin Osteoarthritis. (Ostenarthritischaracterstically involves distal interphalangeal joint (Heberdensncele}, pres imal interphalangeal foint(Bouchard!s| pede) | carpometacarpal int (base of thumb) oFhand with sparing OF metacarpephalangeal joint and wrist joint DIP Heberden’s rede DH Due to decrsased Loading of painful ectremity quadsiceps weaknows is common in patients of osteoarthritis of ne. Most impotantly Vastus medialis is affected, YALIS Now 2071, AIPG 2507. AIMS May 2007, AIPG 3011) CClassitication system and stage wise management for OA know Initia treatment is alWways conservative Clinical picture is maresignificant than radiclogy or xr changes If activities of daily living are affected surgery is advicest Surgery fir young is HG (iF not contra ineicatud) it centrainaicated TKR is performed Surgiry for elcerly (>66 years) is TKR HTO-High Tibial Ostecterny TKR-Total Knee ReplacementComplete Summary of Orthopedics ‘AblbackGrade Definition “Tresiment in young ‘Treatment in Elderly Grate 1 “Teint space narronira ‘Gonservatve fails HTO) Carservatne H fala THR Grade 2 Joint space obtteration Gorservatve if fails HTO Carmervative i ails TAR Grave 2 nor tone ation (0-5 me Cancenvatve it fate surgery it Carsarvative i fale TKR bone loss <3 ram HTO atherwise TKR Grate 4 Moderate bone atti (510 mm) TKR 11 Grane 5 ‘Sevete bone tion (+14 mn) 118 118 *samm Bane Loss HTO is Conlasindkated STH Tota Knee Pepltcement Rhoumatoid Arthritis ‘lseeieston Gia Yor Rheumatoid Artis 2010 Se eit invale ment {lag int oho ew, fp nee, ane) ° 1 2-10 es 1 {eral ots (UCP, PI, Thum I AT, wrt 2 1510 mal ite a 20 jit (font sa an a serology Negative RE and negate ACPA a Lom pose on pose ani. CP ite ines ULM) 2 High postive FF or high pete aii GOP nics (nes ULN) a ‘eule-phace reactants Normal GRP are somal ESF ° 9 [Astra CRP or abnormal ESR 1 5 Durston of eymptome “mei a q 26 weeks: 1 Ss 9 “Total Score 10 2 2 Score 6 Indicses —LA 3 The 1987 Revised Criteria For Diagnosis Of RA 3 1. Guidelines for slascifisation 4 of 7 criterion are requircd to classify a paticnt as having RA Patients with 2 or more @ criteria are nest excluded, a 2 Criteria fa~d must be present For at least 6 weeks and b-e must be abserved by physician) a Arts of rman pintansy, needy physician silanes, haves tinue veingarointinon, hot just bony ower grnwth, The 14 possible joint areas involved are right o¢ loft proximal interphalangeal (PIP), ‘metacarpophalangeal (MCP), waist, l bow, knee, ankle and metaiarsephalangeal joints (MTP). (A llMS Nov 2008) 6. Sarthetis of hand joints e.g. wit, MIP of PIP joints 4. Symmetrical arthritis ie, simultandous invalvement of same joinkarea un bath siden of body. © Rhoumiafal! miles: Subeutaneous acdules aver bany prominences, extensor surfaces of justa articular region, (Pathogenic) F. Serum dheumatoid factor § Rafllogicaf changes: Bony erosion oF unequivocal bony decaleificatiar articular (join space + Womenare: fculae ostiuporcnis and narrowing of periar Life, with 80% of all patients developing the clisa we between ageof 35 and SU. The incidence of RA is mare than mos grestor in #64 yearsold women enmpared te 18-29 years old women fected three times moreofien than men, The anset is mest frequent during 4th and Sth decade of glOrthopedics Quick Review ‘Significance of Rheumatoid Factor (RF) If prownt in high titre, t designates potiants at risk for soverosystamic disaase, Poor Prognostic Factors of RA EF ‘Acute Phane ‘Advanced Age ‘One Year duration Nodulos Erosions/ ESR/Econamically weak RA.ONE ‘Swan - neck deformity’ £9, hyporostonsicn of PIP joints with compensatory flexion of the distal interphalangeal joints Boutonniare deformity Le. flexion contracture of PIP jeintsand extension of DIP pints 1 —— Patter of Joint Involvement Complete Summary of Orthopedics (Octeoarthritc Rheumatoid Arthritic, Pooriatie Arthritic Ire PIP, DIP and 1" CMC PIP,MGP, wrist DP, PP ard anit (compernetacat pa) jsinte ‘spared MCP (netacarpo ple DIP jont ‘Sparing ot ary jint langeall and wisi Ankylosing Spondylitis (AS)/ Marie~ Strumpell or Bechtrew’s Disease Diagnostic Criteria — Modified New York Criterion ‘© esontial eritcria is definite racing raphic sacrolitis Supporting crileria: one oF thew th = Inflammatory back pain ~ Limitsel chest exparsian (<5 cm at 48hICS) not a rok ~ Limited lumbar spine mation in both 3 Jble criterion in elderly bocause of pulmonary disorders al and frantal plane (Schober test / Madifiod Schober tost) Inflammatory Back pain 4/5 present Pain for > 3 months celbaw shoulders ankle> wrist hip + Ankle most commonly invnlved in children © Arthtoscopy is relatively contraindicated Intramuscular Bleeding In lower limbs most commen sites nf bleeding is (opsaas> quadriceps © Truppertimisthe mest common siteof blesding ix deltaic Most hemophilie pseudotumor are caused by subperiosteal hamortha ge and the most enmmon Incaticn is in thigh (or), Next in frequency areakeomen, pelvis, ant tibia Neuropathic Joint Disease! Charcet's Joint Ibis progressive destructive arthritis arising from loss af pain sensation and proprioesption {position serme). Diabetes mellitus (ost common) cause, jaints involved ane Midtarsal (most commen)> txtsametstarsal motatarsoph: al and ankle joint Disease ‘Jin Involvement “Disteies ————=—=~S*S*~*«WMiarsal (most common) av somtntarsal, metajarsophalangealardankle joint» knosandspine ‘Tabee dorelie Knee(moct common), hip, ankle ant lumbar epi Leproey Hand an foot joint: Syringernyetin SShoulier(glnakumeral), slow wrist and eetien! spine Myslemeningconte Arie and fact Congeritslinccraivily te pin Ankle and foot Chon Alsohalsm Foot Amyloiceaie PPererea! Mircle atrophy (Chtoot Marie tooth diese) Theappoarance suggest that mavements would be ag and yet than woul be anticipated but iscften painless, The parade is involvement. spncetic the amount of pain experienced is le od on daggroe of joint ‘© Usui treatment is bracing or arthrodesis total ankle Replacement is enntraindicated, Congenital Syphilis CClutton’s joint is painions, symmetrical, stor usual in several woke, effusion mostly invalving knee in #16 yearsof age Spontaneaus remission fx Nom emmsive arthritis : SLE Non daforming arthritis: Beheots Disease ‘reainvolved + Septic Knee + Syphitic arias Knee + Gonncaccal aiitist Knee g 3 By ° 5 k g i aOrthopedics Quick Review Diseaee ‘rea invalved = cour UP jet og te + Pecudogout* Knee + Rheumatoid anes Metzsarpophalangea int = Arisylasing spondylti® + Diabetic charcot int! + Senile ceteoporosic" © Paget diners” Sacre iliac im Fool jin tarsal) Vertetea + Ostecchontrte dessisans! Knee + Actinompeni™ Mandible = Hoemeptie nti Knee > ise prolazae* ‘Acute Ostocempelii® + Broies Abecees" Betwaen Li ard Ls Upper end of Tibia Difference between tumor calcinosis and Myositis ossitican Parameter Myeaitiz Ozeificane Tamer Caleines Etcoay Trauratie bo paltic Faria Sileite Uriltera- Elbow Bilateral Knee Symptom Pini Painkess Marker ALP increased Increased PO, ALP is marker of heterotropic Ossifcation. In questions they ask unilateral calcification thenansiver is my asitisand the Pekjchenex Femur » Shall Tibia Lower ere of femur (Metsphyss) ask bilatera| ealel fication then answer is PSEUDGOUT Feature ‘Gout (Protein Aclohol intake) ‘Synovial id Analysis | Uric acid crystal Needle or od shaped syste, Negalively binge! crystals Aasecintad with ACTH, glusseerticsid withirawal, hypauicamic Complete Summary of Orthopedics sherapy, Hyperuicaeria. “Alcohol and Protein intake” Clinicalpesentaton Inceree pin Irae ‘Smaller joints (uot ceenrncly ‘metalasophalan geal jaind of big fac] Peeudgout (Hpothyreidicm aecociated) Galdum pyrophosphate crystal, Bhorbol shaped crystal, Positive bihingord crystals Four HS ie. hyperpatathyraisier, hemochtamtaie, hypophoephatasa, hypomagnecerninare sccociated Most common azzaciation is Hypothyroidism (Chondrecalcinesie 2. appearance of cakiiz ‘material in articular cartlage and rnenis Mecterate pin Larper ints most cornmanty, kreComplete Summary of Orthopedics rencdular deposits of monosodium urate monshyd rate crystals, with an amcciated foreign body reactinn. Its depasited in minute eum Muscles in connective Hsaue eg, * " re ‘Tendon have tophi + Bunae eg olecranon bursa /pariarticular tissue * —‘Tendons Burse © Synaviuim and joints *Pinnae (cartilage) of ear Articular © Ligaments #Articular ends of bone Icaetilage © Subeutanenus Haste + Kidney Kidney Tophi may uleerate through skin or destroy cattilage and periatticular bane re Acthritis with Softtisaue nodules Rheumatuid aithritio 3. Pigmented villonodular synovitis 4. Multicenteriereticulohistacytosis 5. Amylaidosis 6. Sarcaidenis LIL=BACKS- Trophy Mest common cause of anernaly of craniower bral junctions ix Atlanto-oesipital fusion, Ankylosing spondylitis rareley Involves cranioveriebral junction and rheumatoid atthritis is a common staninvertebral junction anomaly. (AUMS Craniovertobr (CV) Junetion Anomalies: (Base of Skull + C, +.) ‘Malformation of Qcctput Bons © Bos lar invagination © Condylar hypoplasia Malformation of Atlas {C,) Malformation of Axis (C) 8 edantoideum (dysgenisis of odontoid in which upper portion of adentsid ix seperated from base by a gap nesembling uununited fracture} Other causes ates © Spondyloepiphyseal dysplas Mucopolysaccharidenis storage disease Klippel -feil syndrome Osteagenesis Imperfects Ankylosing spondylitis (rarest cause) Achondioplasia Down's syndrome Neurofibramatosis Rheumatoid arthritis ‘Achondroplasia Rheumatoid arthritis Atlantoraxial abnormalities Jurofibramabosis Down's syndrome )ssipital abnormalities ‘ucopolysaccharidsis Craninvertebral (CW) Junction Anomalies Ankylosing Spondylitis (Rarest Cause) Ostacgencis imperfecta “Klippel fel syndrome ARANDOM Cause of CV] abnormalities is AS OKI g 3 By ° 5 k g i aOrthopedics Quick Review * Latest Questions Complete Summary of OrthopedicsComplete Summary of Orthopedics 17. METABOLIC DISORDERS OF BONE. ‘There are four types of metabolic bone diseases. 1. Osteopenic diseases These diseases are characterized by a generalized decrease in bone mass (he, loss of bone matrix), though whatever bone is ther ly mineralized (eg, osteoporon). b. Osteascleratic cise acterized by an increase in bone mass (ag, fluorosis) © Osteomtalacte diseases: Those are diseases characterized by an increase im the tatio of the organic fraction to the mineralized fraction ie, the available organs matter iv undemineralived 4. Med déseases: The sambinationef osteopenia and esteomalacia (e.g sa: Thare are disenses can edison tata hhyperpatathyred diem). + Rickets Lack of adequate! bones, * Osteo malacia: Lack of adequate mineralisation of trabecular bore + Osteoporosis: Proportionaie lass of bone volume and mineral + Seuroy: Defect in osteoid formation ralization of grow Rickets PR i on Abdomen protuberant Bowing of bone nintaben Costochondral Junction prominent Rosary, Diaphragm pull - Hamrisom groove (Lateral indentation of chest due to pull of diaphragm on ribs)/ Double Mallaclis Enamel defect of teeth Forward sternum ~ Pigaan chest Growth plate - widening Hypocaloemia causing Hyper PEH Irritability Joint deformities - Genu Valgum/Genu Varum Kyphasis Loovers Zones Milestone dal Rickets Eageta/ primary hyperparathyroid iam Qsteormalacia bone Oncological Renal Rickels OD BOOR fone Increases ALP alcium Phosphate ALP PTH Otopront NORMAL NORMAL NORMAL NORMAL Flcketeiocteomalacia Nar iow Low High High Primary Hyperparathycidiams High Low High High Pagel disease Normal Normal High Normal g 3 By ° 5 k g i aComplete Summary of Orthopedics Orthopedics Quick Review Hyporparathyroidicm Primary (adenoma Secondary(usually due to esteorialacia) (Clinical Features More ase ca High Low oF normal PTH Very high High NOTE: Von Reckling! Reckli replaced by fbrnus fieue and there fs eystica that is ey3th 1ausen's diganse of hone is alu called as cxteitis fibroma eystien (it should rest be confused with Von hauser's disease (Neurofibromatosis type 1}: In Ostutis fibrusa cytica there is fibroma that is bony trabeculae are cavity in bone filled with blood and blood degradation products ives i Brown solu, Radlological Features of Hyper parathyroldicm Subpericnteal reorption of terminal tufts af phalanges, lateral end of clavicle and symphysis pubs, Loss of lamina clura (i.e thin cortical bane of tooth socket surrounding eth isseen as thin white line, i resorbed) Irmgular, diffuse rarefaction of bones Le. genoralized astiopenia, thinning of cortices, ard indistinct Eomy trabeculae. brown tumor Salt pepper appearance of shall SCHE may be seen avascular necrosis Rarely AVN Treatment is usually conservative and includes adequate hydration and decreased calcium intake, The indications of parathyroidectemy are marked hypercalcemia, recurentrenal calcul, piagressivenephmealcinosis and severe osteoporeas, Milkman'increment fractures alo known a2 loorer's zones of oslecid zones are pruclofractures seen in osteomalacia moat commonly femur neck. Rugger Jersy Spine Ruger jery spine is produced ky allernating region of lense bone and areas of central vertebral radiolucensies, Causes of Rugger lersey Spi i. Renal extendystmphy due ta hyperparathyroidinn Scomteoscleronis ii. Osteopatrosis SCURVY (VIT C: DEFICIENCY) Scurvy: De jency of Vitamin C, causing defect imosteaid formation, Pathology Vit ie necessary For hydroxplation of lysine and proline to hydroxylysine and hydroayprofing, two aminoacids crucial for proper cross linking of triple helix of collagen. So deficiency causes Failureof calla ger synthesis or primitivecoilagen formation, throughout the body, including in blood vessels, predisposing to hasmorrhage. = nbones sone of proliferation is affected primatily oH and occurs fram gums, alimentary tract, subcutaneous Hisue, and boncexpecially at the most actively growing metaphysis and bereath periosteum = Masmorrhage ard fractures are common, but attempts of repair is diuordered, The provisional zone of calcification ia weak leading ta epiphyseal separations, © Dysfunetio | osteoblast (Flat resembling Fibroblast) eauses failure nf osteaid formation resulting in goneraliced stecporcais| Chondroblast and mingralization is unaffected leading to persistence of calcified carlilage approching metaphysis sen radiologically as opaque white line af junction of physis and metaphysis [Frankel's line) Ostecelasts are normal, thin and fragile trabeculae and cortices of bone are seen, © Dentin formation in testh is abnormal die to defective collagenComplete Summary of Orthopedics Clinical Feature © tdevalops after 6= 12 months of dietary deprivation thus nat sain in neonates Farliest features are restlenness, frtfulnen, inital Joss of appetite and Failure to thrive Gums may be spongy and bleeding, Subporicstval haemorrhasgeis 2 distinet sign cccuring most commonly in distal femur and tibia and prowimal humerus, causing exerticiating tenderness pain near the large jaints, The child lies still to minimize pain at minimally move the flected limbs (Pseusloparalysis)~ (Frogs Like Pasture is sttsined by child} =k norrhage in soft Hssue, joint, kidney, gut and poctachiae may be = Anemia ind impaired wound healing is-seen Beading of ribs at costochondral ction (Sconbutic Rosary), Systemic action (fever) ix absent initially, NOTE! In Rickets « Rosary is Round and nonetender, and in Scurvy itis Sharp and tence. Radlological Feature + Ostecpenia (ground glass appearance) (Iat sign) with thinning f cortex (Penel thin cortex) Metaphysis may be defurmed or fractured. Frankel’ line (zone of provisional calcification incre je and stands Out compared to the severly nab in width and opacity) due to failure of resorption of caleified jpenic metaphysis, Scurvy line arscorbutic zone(Trummerfeld zon) is radiolticent taney erselsand adjacent tthe dense provisi anal zone. + Margins of the epiphysis appears relatively scleratic, termed ringing of epiphyses or wimberger's sign (Ring sign) = Important ‘© Lateral metaphyseal spur (Pelkan spur}at ends of metaphysis is produced by autward projection of zane of pravisional calcification and periosteal reaction, Comneror angle sign fs peripheral metaphyseal left Subpericateal haemorthagee ‘Brankele/Eracture (metaphysis) Ring sign Osteopenia Sones Cleft ~Coer SiG Scurvy line (Trurmmer feld sone) Belkan spur swntarearn FROGS like Pesture (FROGS LIKE posture inscurvy) g 3 By ° 5 k g i a Fig. 1:5: Scurvy OSTEOPOROSIS © Tacore lee than -2.5 in exkeoparenis © Ostecproronis with a Fracture fs so xtecporas Upto age of 70, colle’s fracture is mc fracture in osteoporotic patiant; and after 70 years.age vertebral fracture is me. fracture, Strontium dectoases bane resorption and increases bone Formation. (ar 2008)Complete Summary of Orthopedics Orthopedics Quick Review Factors that HINDER Bone Gause - Osteoporosi 1 Sons SGD Inherited dsordors [Nuttitional disorder (most sommom cats in India) rigs pcarnal Dice heuralogjal Disorder i HINDER Heparin AAleohol, Alumni Lithium [Cytotonie [Anticonvulsants Thyvenine i HALCAT Hemotologicals Leukernia, Lymphoma Hypogonadal states «.g, Turner syndrame, Klin Inherited es, Ostasgemasis Impe tous syndrome, ta, Matfan syndrome. 3. Nutritional e.g, Malnutrition, Malabsorption 4. Drugs ag. Anticonvulsants, Aleshel, Heparin, Lithium, Aluminium, Cytotosis drugs, Eucwssive Thyroxine 5. Endccrinal disardetso,¢, Hyperparathytoidixi Thyrotexiccsis IDDM, Cushing Syndrome 6 Rhoumatoleygial Disorders # Rhoumatoid Arthritis, # Ankylasing Spansiylitis Treatment Dirty tincd in emteoporosis Inhibit neorption: Blephosph es, Denosumab, calcitonin, estrogen, SHRM, gallium nitrate 2. Stimulate formation: Teriparatide(PTH analogue}, calcium, calcitriol, fluorides. 3. Both actions: Strontium Randate Fluorusis causes intorosesous membrane ossification and incroased dereity in skull val = Dental change — Secondary Hyperparathy Infantile cortical hyperastosis -Caffey’s Disease Hypervilaminosis Dand A san cate bone abnormalities, Paget's DiseacelOstolts Deformans Iis characterized by excessive disorganized bane turnover, that encompasesexcessive ostenclastic acti by disorganized excessive new kone formation. eis tha osteoclast that appear lara i Fig. 1.8:2ray Paluie: Pager Dieeste initially Fllenved rons ostinblast ant and irregular w etened Fig. 1.72Xtny Femur Pagets DiseateComplete Summary of Orthopedics © Thenew bone formed is abnormal, very vascular and langer (deforms and fractures) thin preexisting bore which leads to sottical widening and contibutes to the deformity, 4 Thediagnontic histological featureof pogets discame ix irregular areasof Lamellar bone fitting together like. jigsaw with randomly distributed cement fines, Iheither occurs in one bone (monestotic Paget's disease) or multiple bores (polyostotic Paget's disease), Etiology Genetic infection by paramynovinus (mensles and respiratory syfieytial virus) has been linked. + Pollupleysistagy: Increased bone resurption accompanied by aed erated bone Formation is charactoristie feature + Initial astealytic phave Involves prorninent bone resorption and marked hypervaseula ization (Radiol ogically seen as advancing Iytle walge or blade of grass lesion) 2nd phase of active bone fomn, lamellar bone with structurally weak woven bore that bend, bow and fracture ex jon and reworption replaces normal nea sclerotic (burnt aut} phase, bane resorption daclines pre cor mosaic bone gressively and lead to hard, danse, lawvascular pagetic Clinical Features Deis are bolowe 20, and mostare over agge SO years Most poople are asymptomatic + Thesites most commonly involved are~ pelvis, tibia followed by skull, spine, cla Affects men more commonly ‘© Pain {s mast common presenting symjstom leand femur Limb Look bent and! Feels thick, and skin is unduly warm due to high vascularity hence the are astutis deforma, Skull show frontal honsinig andi platysasia Comysitcations: 1, Pagetodd bone lacks the strength of normal bone, ‘wa result-it deforms and Fractures more-asily. 2. Cranial nerve = 2nd, Sth, 7th, Beh paley iss 3. Neue compression and spinal stenosis is soon, 4. Deafness due to nee compression > otoselerasis 5. High output cardiac failure, Hyporcalcemia (iF immobilized) §Osteesarcoma (215%) eases (poorest prognesls) 7. Steal syndrome je, blood és diverted from intemal organs to kel spinal claudication, K.Ostecarthritis of Hip and Knae is sonnon, ton system, may lead ta cerebral Ischemia ana Diagnosis A. Serum calcium and phosphate levels are usually normal B. Incressad marker oflune formation (e.g. alkaline phosphatase and §. Ostecealcin) (ALP Levels areused for monitoring, pagets) Increased markers of bone neerption Serum and urinary deoxypyridincline, N lopeptine and C-telopaptide Urinary hydioxy pro Urinary deoxypyrdineline (24 Haus assesament} is mest valuaisle Radiological Features Long bone 2cray show deformity, enlargement or ecpanslan of bene with settical thickening coarsening of trabecular ‘markings and lytic and sclerotic changes Skull ray reveal “cotton wool” oF astenporasis cincumscripta thickening of diplote area, Increasing Hat Sizet Vertebral cortical thicken causing ivory vertebrae = Palvie radiograph show selarotictleopacti 1g at superior and inferior end plates creates a picture frame vertebrae and diffuse sclercoin 3 ine (Brinn sign), Fusion oF disruption of saercilise joints, ete g 3 By ° 5 k g i aComplete Summary of Orthopedics Orthopedics Quick Review Treatment Indications are A. Tocontrol symptoms of sctive disease ax bone pain, fracture, neurlogical complicationsorpain from radiculopathy or arthmpathy 5. To decrease Local blood flow and minimizeoperative blood low in pationts undergoing surgery Te decrease hyperealeiuris D.To decrease complications -Whan site of invelvement invalwes weight basi joints bones, skull, vertebral hades and major E, —Biphasphonates are drug of chaice and calsitonin io F. Surgery is done foe patholo sed to relieve pain. | Fracture, esieoarthe nerve entrapment and spine decompression, ACHONDROPLASIA. A primary defect of enchondral bone formation Autosomal dominant (but 4? Csccewsive growth hormone an the mature skeleton. trident hand and starfish hand. are spontandous mutations); The efit of They have normal intelli CLEIDOCRANIAL DYSOSTOSIS Ibis an autozomal dominant (AD) disorder caused by CBFAL gine on chromomome 6 p 21 responsible for osteoblast specific transcription factor and regulation of ostenblastic differentiation. In this disorder bones formed by intramembranots nssiffcation are abnormal (primarily clavicles, cranium and pelvis) —Aleent clavicle “Morquias syndrome has Mast severe skeletal abnormalities amongst Mucopolysaccahridases Osteogenesis ImpertectaiLobstein Vrolik’s/ BrittleBone Disease = Ostecgnests Imperfecta/Labstein Vrolik’s/Britile Bone Disease * hiv a genetic disorder of connective tissue determines! by quantitative and/ ar qualitative defect in type | sollagen formation. So there is alteration inthe structural intexrity, ora reduction inthe tal smount oF type collagen, onset the majpr components of fibrillar connective tfsue in skin, ligaments, bones, selera,and teeth, Ibis inherited from 1 parent in autesomal dominant (AD) fashion, may cccur as spontancous mutation, of, rarely as autosomal recessive (AR) trait Thedefining clinical features aré Osidopenia causing repeated propensity to fracture, generally after minor trauma and often with out much pain or swelling Any fracture pattem may be seen, and no particular fracture pattern is specifically diagnostic. Fractures hedl a a normal rate. Fracture callus is typically whispy but on rare aces sarcoma on radiographs According to theseverity of disease Fractures nay cecur in uterus, at birth, or after birth priarto or after walking age Recurrent fractures arediscov ered during infancy and throtighout childhond because ofeombinationof disuse cxteopenia, pprogressive lang bane datormity and jaint stiffness From immabilzation Lower limb fractures aremore common than upper limb. Femur is commonest bone fractured followed by tibia. Rrequancy af Fractures decline sharply after adolescence or puberty, altho (elimacterie) women Naw bane is pia may be very large and hyperplastic, resem shit may rise gain in postmenopausal For longtime due to dafective osteoid formation, thus lasing ts malunion and severe deformities, acetabular protrusion fotto pais), hel et head, kyphoscolicsis, Howing, etc Hyper laxity of gaments, with resultant hy permobility of joint is corumon, head and hip joint dislocation and DDE can occur. Rarely recurrent dislocation of patella, raComplete Summary of Orthopedics Radiological Feature = Popeotn ealeifiation and whotlsf radiodansities, © Skull has a mushroom appearance with a very thin calvariuim Dysplasia = Wormian bares, are detached portions of primary omificaticn centers of adjacent | | Osteoxerests Imperficta snificant, it should be more Triscsmics ranged in general masate membrane bones, Thowe are seen in skull x-ray. Ta be si than Lin number, messture.at least & mm x Lim, and tse pattern. ‘© Wormian bones are present im-astiagenesis imperfecta, other bone dysplasias such as cleidocranial dysplasia, congenital hypothyroidism, and same trisciies, Hypothy iim boTH (Ocular Invelvement + “Blue or grey sclerae”, is because of uveal plament showing through thineollagen layer. © Satum's ring is white aclera immediately surrounding the cornea Arcus juvenilis or ambryotaan, i opacity in periphery of carne © Hyperopia and retinal detachmant ‘Auditory Involvement Deafness, usually ansetting in adolescence oF adulthood may beeither of the conductive type dus to otosclerosis or of nerve type, caused by precure on the auditory nerve ax itemerges from the skull Dentinagenes imperteca/Grumbiing of Te Theenamd isementiaily norm. Dentine affected” 1 it of ectodermal origin, nce mesenchymal Both deciduous and permanent testh are involved. They break easily and are prone ta eatries, Yellowish brown or bluish sgray discolouration of teeth is common, © Thelewer incisors, which errupt first are mare soveraly affected. ‘Skin and Muscle Involvement os is thin and translucent. Subcutaneaus haemorrhages may occur. # Muselos arehypatonie mostly die to multiple fractures and deformities, Hemias may oectir Metabolic Features * _Exessnive sweating, heat intolerance are due ty hypermetabelic sate = Susceptible to mali nant hyperthermia duriag general anesthesia, Diagnosis of Osteogenesis imperfecta # Amplecular defect intype | procollagen can be detected in 2/3 of patients by incubating skin fibroslasts with radioactive amine acids and then analysing the pro a chains by polyacrylamide gd alectrephrats Mutations are defined by sequencing of genomic DNA. Exact mulation is identified by using 100 polymerase chain reactions (KCR) ts analyse 10,000 bases in each of toe col Afters mutation in type Ip esl identified, tar For prenatal diagnosis, Chorionic villi biopsy a © Pronatal USG shows mvultiple fractunes, Jimple PCR test ean be usod bs setae family members at riske 2 weeks demortrates synthesis of abnormal pro schains gem g 3 By ° 5 k g i a Silence classification: Type Ifo 1¥ AD Type Land IV / AR Type Il & lil 1. Autosomal dominant Bone Fragibilty, Blue selera and fracture ane seen after birth (Mast commen) Tl, Autoncenal recesive is Lethal in perinatal perieds and lacks blue sclera TL. AR (Dentinogensis imperfecta), Crumpled femur, fracture at birth 1. Autosomal dominant = Normal sclera, Normal hearing, Treatment «ghettos tei) Dd or alan thea sn + diate pace coLimecconian8 3 a a 5 3 7 E 8 a e 5 Orthopedics Quick Review OSTEOPETROSIS Marble bone disease or Albers schonberg disease Etiopathelogy Ikisa diaphyseal dysplasia characterized by failure of bone resorption due to functional deficiency of onteoclast. The bone contains increased number af ustaoclants but thine don't reserb bone ax evidenced by absence of ruffled bueders and claat zonesand ara unable ts respond ta PTH, Duo ta functional doficiancy oF estucclasts,calelfied chandroid [eatiage) and primitive woven bone prsistsdown into metaphysis andiaphysis laseing to catvosc| cromix andl increasod brittenews fone (marble bone isaac) © Inheritance depends on form of disease: Malignantostecpe! and late osis (congonital form) is autowarnal raconaivo (AR, 11q rnsct Ontcopetronis tarda (adolescence J adult form) ix AD (1P 21) intermediate Form i AR, ‘coinercta. serve fin ome am Fig. 1.8: Xray of ectenpetrotic bene Clinical Presentation # Autesomal dominant benign or tard ostespetrosisis aften di with mild anemia, patholagical fractures premature cm Autsomal recessive malignant (congenital) asteop Obliteratinn of marrow cavity by buny ove Paneytoponia develops rltin Severe infections exp. Mandible Extramedullary hematopacsi= causing hopaksplenomegaly. Cranial now palates (Bony Ovengrovith of Cranial Foramemn) nd 7th and Ath - blindnes and dastnass rowed in adult asymptomatic pationts, It may pprosont oarthritis, and rarely osteomyelitis of mandible ris clinically presents at birth or in early infancy because of rovrth resulting in inability of bone marrow to participate in harmabopoissis. in abnormal blacding, aasy bruising, progrossive anemia, and failure ts thrive Fragile brittle bores Patholngical fractures Radiologica! hallmark is incraasad radiopacity of bones, There is ns distinetion butvraon cortical and eancellous bone, bbecaune intramedullary eamal fs filled with bone Endobones (os in os oF bone with in bone appearance) and eugger jersey spine Treatment ia bone marreny tranyplant ‘Muscle mon! Contmonty affected by congenital absence is Pecioralis major METABOLIC BONE DISEASES (Conmse Trabecular Pattern-HOP-G Hacmoglcb incpathies /Hacmanginma Ostenporonis/Ostecmalacia Paget's dimaase |caauchor’s disease HOPGComplete Summary of Orthopedics Short Metacarpal (s) or Metatarsal (6}-T1P ‘Tumer's syndrome Idiopathic (Eseucdo/ Bot traumatic /ost infarction TE “Bone within a Bone! Appearance Nn Nha GOPAL Normal Neonate Growth arest/necovery lines Osienpetrosis lAcromegaly Lead poisoning ‘NaNhaGOrAat Paget's discaze/ Prostaglandin & therapy Erlenmeyer Flask Deformity GOL POT Gaucher'sdisanse Ostecpetrosis Lead poisoning {ahalsssaemia GOL-POT Byle's disease (metaphyseal dysplasia) Ostecdysplasty (Melnick ~ Needles syndrome) g 3 By ° 5 k g i aOrthopedics Quick Review sajpedoyyi9 jo Asewuing 8}9)dwog iComplete Summary of Orthopedics 18. PEDIATRIC ORTHOPAEDICS Coxa Vara It is mduced angle between neck and shaft of femurdia toscme growth anomah upper femoral epiphysis (infantile typo) orsecondary to variaus other pathologies facquired), ‘The normal femoral neck shalt angle is 140° at birth, decreas called coxa wars. 1g to 135 degrees in adull life, An angle of <120 degrees is (Classification (Causes) of Coxa Vara Congenital Cosa Vara Congenital famoral ceficieney with eoxa vara © Developmental coxa » Aquired Cota Vara © SCEE (alipped capital amoral o = Sagu physis) 12 oF avascular necrosis af amoral epiphysis + Logg Cave Perthe’s dincane + Fomoral neck fracturo, Intertrochantere fracture © Rickats Clinical lens limp ina child who fa just started walking ‘© ShorteningeLimitation of abduction and intem rotation Radiolegical # Resdusdd neck shafE angle (varus) + Vertical epiphysis plate ‘© Separate triangle af bore in inf * Hilgenrsiners epiphyseal ang cou smedial pat of metaphysis called as Fair Bank's triangle isle betwoen horizontal line joining conter (triradiste cartilage) of each hip jentoinar’s lina) and line parallel to physiss the narra an; fs about 3D dggroes, ‘Treatmont (based on HE Angle) —Hllgenreiners epiphyseal angle. >” but <0?" Observat >” of iFshortening ix progressive, Subtrochanterie valgus osteotomy Legg Calve Perthe’s Disease/Ostecchendritis Deformans Juvenilis/Coxa Plana It can be defined ay ostenneeron genetic) Factors tof the prenimal Fermoral of physio in a gro s child caused by poorly understood (ron Etiology © Theprosipitating ca years aba 9 isinchemia of femoral head, Bebweend and almost entirely on the lateral epiphysoal fd to pressure Fromm an oFFasion, 1 io unknowbut the cardinal spin the path ger Femoral heasl depinds for its blood auipply and venous drain vemols when situation in retinactla makes them suscoptible to stretching Pathogenesi Clinical Presentation Bilateral in 10% eases ‘© Most froquont symptom i imp that is exacerbated by activity and alleviated with ros, g 3 By ° 5 k g i aOrthopedics Quick Review © and most frequent complaint is sain ‘© Tho classical child is small often thin, extremely active, constantly running and jumping, and Ture 3 Sams age cutremes of al maventente are diinnished and 1B: Perms imac Sh oobi eae aeanyainer eraser tater (ogg Robeson ae eee sea eral i tee hen ee erect ey Se a pom oeeds Cee eee es . tha Pip meireaine: Course of Disease eerrarimert, Mos content actor afeting courses poten’ age at 4 venga outst cote cuiies Gunes teas ents eee een icc ont ue ar Hood at Risk si nin perthes are: (These indicate pee developra tof fernur head from femur epiphysis) head Speckled calcification lateral to thecspstal epiphysis + Lateral subluxation nf the femnar = Gage signen radiolucent °V" shaped defect in the lateral epiphysis andl adjacent fictaphysis. ing Rope Sign — metaphyseal scleratic band Fig. 1.10: Treatment of Perthes: MII is the investigation of choice At first x ray may seem normal, though subtle changes such as widening of jaint space and light asymmetry of nssifieation cenires are usually present{isalupe scan hay show void in antetolatetal partof fetioral head). The classical feature of increased nsity (sclerosis) of the owsification nucleus occur Later and may-be.accompanied by Fragmentation or crescentic subarticular fracture (best seen in lateral view). The head tendato flaiten and enlarge (coxa plana} 8 3 g z 6 3 : E 8 3 e 8 ‘The mainaim of treatment is containment of femoral head in acetabulum, Nan surgical containment is achieved by orthotic braces All braces aeuct the affected hip, mest allow for hip flexion, and some control ratation of the limb. Broomstick ar petrie cast issues Surgical containment is through (1) Femoral vans derotation osteotomy, (2) Chiari osteotomy and chislectomy (surgically removing protuding fragments of Femoral head usually antero lateral ‘Slipped Capital Femoral Epiphysis Buri there i> upward and anteriar mavemnent of femoral neck on the capital epiphysis, So the epiphysis is located primarily Bi posteriorly ancl meally relative to the femoral neck. period of rapid growth, due taaweakening of upper Femoral physis and shearing stron fram excemive body weight,Complete Summary of Orthopedics Actiolo: oy opty © Thecause is unknown in vast majntty of patients + Many of the patients are either fat and sexually immature or excessively thin we and fall. " ‘© pedocrinopathiewsuch as Hypothyroidism (most commen) Growth hormone cxcem ctuned by growth horifione deficiency conditions Sa treated by grouth hormone administration, Chronic renal failure (Hyperpardthyroisism) a © Primary hyperparathyretdie Pan hypopituitarism associated with intracranial tumors © Craniopharyngtoma © MEN2 Turner's syndrome * Klinfelters =yndmmne Rubinstein Taybi syndrome 4 Prior pelvic iadiation Mana times it presents in growth spurt Feuer abr Fig. 111; Slipaed Gap errs ehh ve Pathogenesis and Pathology Slip occurs through hypertiaphic zane ef growth plate cl hhypogcnadal male (1ciposo genital syndrome) sally in obese Norindlly, pitutary gmwth hormoneactivity simulates ri pid growth andinereitees physéal hypertrophy during puberty (adolecent growth spurt, This is balanced by increasing; ganadal hormone activity, which promotes physea maturation snd epiphyseal fusion, So growth hormone excess oF hypogonadian is pravacative of SCFE Phyneal disruption causes premature fusion of epiphysix usually with in2 years of the onset of sythptoms, Clinical Picture #Amadelescent child boys 13-1Sand girls 11-13) typically overweight or very thinanal tall presents-with pain sametirncs and Antal gi limp, with the affected side held ina position of ineradsed external rotation, (turningout of leg). Restriction tf internal rotation, abduction and flexice © Acclassical sign is tendency of thigh te ratate in to progressively mare extemal rotation, as the affected hip is ftexed calledas Axia deviation. (Similar to Perthes) Slipping usually occurs 4 series of minot events rather than. sudden, acute qpised.e Patient with unstable acute or acute on chronic SCFE characteristically present with sudden onset of severe, fraetute like pain usually as a rewalt of a relatively minor fall or bwisting Injury = Chondrolysis complicating SCPE ppreants with more continucus pin, hip held in an external rotated position at rest, with flexion contracture and global restriction af hip mation. The patient usually complain of pain thinagh out the are DF motion rather than juskat ity erratic 20% cases will have evidence of contralateral slip, oti nf patients will have bilateral involvement when assnciated with endocrinapathies, © Chondrelysis (Destruction of Cartilage) and avascular necrosixare possible complications Thatheran esti enna singe o ating long dur le sie ‘A line drawn langential to superior nest otter ae femoral neck (Klein's ine) on AP wiew c's 2 pan t 2a Ine pane ' ‘ pips | poertor to Ith Somme Mane nes SaaS Septet stl poe Bite epiphysisor nat at all trethowana stan. Fig. 1.12: adiclogjeal diagnos of lipped capital femoral epiphysis g 3 By ° 5 k g i aOrthopedics Quick Review Steel's metaphyseal sign ina crescent shaped area oF ineransad density overlying metaphysis adjescent to physix (on AP of Fernoral neck and posteriorly displaced capital view) Ibis dueto overlapping epiphysis A frag log’ lateral view is best For aut dotting mill slip. ‘speneaue “Te B9 acan show increased uptake in rd he capital femoral physisin SCFE, decreased (Berar tuptake with in cpiphysis is highly specific SANT for AVN. When chondrmlysis is prownt, there is increased uptakenf isntapeonboth ices oF th MIL ip incl in entigation for ag =~ ‘Treatment SCPE is usually a progresivediseise that requires prompt surgical treatment. Bscouse the changesin the chronic Farm nccurs so slowly itis impossible tp manipulate the femceal head into a better pesition. So treatment curiats of fixing the slip in its survent position and preventing progress, This is done by inserling one ur Mors setews or Pin across the growth ple (pinning im Sita). Acute slips, if unstable may be gently eshiced before Ration abit creases the chances FAWN. Fig. 1.43: Treatment of lipped capital femoral epiphysis Developmental Dysplasia of Hip (DDH).-shallow acetabulum DDH is failure of maintenance of Femoral head ducts malfortastions of gosta bulum of femur RON of eases of DDH accu in fis, DDH fs more commonin firthorn children as primigravida uterus and abdominal muscles are unstretched and subject the felusto prolanged periodsof abnoarfial pesitianing. This crowding phenomenon is the cauntof ils association with tarticellis and metatarsus adsluctus, Oligohydramnics causes limites Fenic Flatenes fetal mobility and thus increases risk of DDH. Bresch nctanar realy presentation is another strong association factor. But the win pregnaney does not increase the risk. Familial sesnciation is sce Displeces (Caucasions ane Native Americans have higher incidence suparcheaal fn compared to Blacksand Asiare, ical Diagnosis Abduction i imited (espacaly in flexion) Asymmetric thigh Folds = Barlow’sTest Jat part — In position oF 90 dagtee flexion af hips anc knees, the hip is adducted and pushed And this will lead to dislocation of hip (but not if already dislocate!) Pathology ucelalalum BAAHARLO! "DAD" Le. Barlow's tect - Dislocation By Adduction (DAd). ‘This in Borlows wedislocate hip joint, nd part ~Now the hip is abducted and pulled, This will Complete Summary of Orthopedics Y repanna Nera poaten oteru! boP yf ew "dlunk indicating reduction of hap. J Some consider anly Lat part a Barlow's Root Fig. 1.14: Dispiares speotsteral AL Ortolani’s Test ~thetfirst twoalphabets © and B (Ortolani for Reduction } and far Reductinn we devabeluetion of hip. Distecation Reduction Abduetion RAb C.Trendelenbery tent telescopy and vancular sign of Narath is postiveComplete Summary of Orthopedics Duenevsed met um Kr eeeuelloa In OH flndeules D241 ghar Fig. 1.45: Teal for DDH, Fig (1.16: A, Decreased abduction in DDH B, Galexzzi cr Allis Tet Radiological Features In Vor Rosen's view following parameters should be noted : = Perkin’s line :Vertical line drawn at the outer border of scatalsulum | . wsiner’s ine; Horizontal line drawn at the level of tri onal DpH radiate cartilage, Head J (Superolateral 8 and shentone Shenton’s line: Smooth curve formed by inferior burderof neck, tee trobere cof Femur with superior margin of cbturator foramen, “Acetabular Index: angle between Hil triradiate cpiphysinto lateral edgeof acetabulum, Normal value in 20 = 10 degree {Centre adge) angle of Wiberg normal values pts 20-30 degeae is angle betweun Perkins line and a fine jaining contre of epiphysis ta edge of acetabulum, ners fine and line from Fig. 147: DOH Xray Normally the head lies in the lower and inner quadrant formed by two lines (Peskin's and Hilgerseiner’y). fn DDH the had lies in outer and spper quadrant Shenton’s line fs broken Delayed appearance and retarded developmant of assfication of head of femur Sloping shalleny acetabulum Superior and lateral displacement of femoral head. + Acetabular index increases and CE angle reduces in DDH. Troatment Plan of DDH | Doateearet 1 is hee fnpero ners Neonate and Young Child(1- month) Closed reduction, Pavlik harness Higeraners Te 6-18 months -open reduction is caiied out 18.36 month ee caret se (Open redctinn +famaral rotation ostectomy = palvicostectomy Normal ap Walking child(3-years-6 years) (Irae ada Open reduction (anterolateral approchland femoral shorlsning — Saiinstine with Acetabular reconstruction procedure: (sulker's, Chiari pelvic displacement and Pemberkan steotomy) 6-10 years treatmentshould beavoices (fearof AVN) in bilateral DDH, inunilateral same a5 above LL years: in cases of painful hips due to Osteoarthritis THR may be dane (but should be delayed tll skeletal maturity) Fig. 1.18: DDH- Related anatomy 8 soipedoyo.so Aieuiuins eyeiculComplete Summary of Orthopedics Orthopedics Quick Review Pediatric Hip Probleme I Tapia ip ‘Mle shape of Tarai Synovial ato svene Femur Hea (to 12 year f [oon] T Deceased Abduction + Decreased Ir roitn Eatemme a a FABER | a = acelabulim “AVN a Femoral Slipede. Feral Tanta reason Eviphais (Peres) Epiohysis T (Oh Hip lesion knee gas t te Axil AXIS DEVIATION a Tsiniin Hip Winks Hip Reduced eskiced ‘Traumatic dislocation of distal femoral epiphysis anterior and lataral Congenital dislocation of Knee-Hyper extension (Genu recurvatum) Is the most common presentation Genu Valgum - the commenest cause of genu valgum (Knock Knae) Is kdopathie > Rickets. NOTE: Usually OA Causes Varum/' RA Valgum, Genu Varum (Bow-Logs) *Kneeare abnormallydivergent and ankles approximated, Bilateral bow legs can be estimated by mersuring thedistance hhotween Hh madi! malleol when heels are touching; itshould be « Gem ts Label ss Gen Varun. Normally 8 er. + Anormal children show maximum varus at 6 months to L year of y neutral alignment by 1-1/2 to 2 years of age, jenu valgum (8°) at yearsof age, and a gradual decrease in: im to 6 degrees by 11 years of The presence of gant varum aller 2 years of age can be considered abnormal, ay spontaneous resolution of the varus fa neuttal fbio femoral aligment by 2 years of age and ta adult valgus alignment after years of age is well documented The causes gen varum ne simile ge valgum encept hatte detive growth fen the medal ide ‘Two Important causes are discussed below: * Dhysialegical ena varum, which remains the most common etiology, even in a deformity that is slave ko resolve and appedts to be pathological, t i a deformity with Hbic femoral angle of at least 10 agrees of varus, a radiologically normal appearing growth plate, medial bowing of the proximal tibia and often of the distal Fernur. The lege of most newboms are bowed, with 10-18 degreesof varus angulation, When theinfant begire tostand ane walk the banving may appearmore prominent and oflenappear tainvolve both the tibia and distal fermut, Radicg varus deformity persistsbeyand 2 yearsof agent progremes, Non nisalving amymimetricaldetarmity is the main incication for radingraph: © Tibbia vara is defined as gronsth retardation at the medial aspactof proximal in progressive bowe leg. Two forms of deformity ane blount distinguished, according toagieat creat, two types of tibia vara: infantile, which beginstbefore 8 years of age, and adolescent which beginsafterB yearsof age but beforeakel cal maturity. Nawadaya following clasoification is Fallowex!s epiphysisand physis usually resulting 1, Infantile tibia vara (Blount’s disease) in which patient is <3 yeats old at the onset af condition (more carmen) Te is characterized by abrupt angulation just below the prusimal physis an ieregular physcal line, a wedge shaped epiphysis, and a beak like medial metaphysis, Apparsnt lateral sublusation of prosimal tibia ivoflen prenents The triad oF Blounts fx Tibia vara , Gen Recurvatiim (hyperextension), anal internal t tibia) Metaphysiadiaphyseat angle is measured and angle mote than LL degrees require close observation torsionintemal rotation oFComplete Summary of Orthopedics 2 Late onset tibia vara includes Juvenile form occuring alter 10 years ag tween band LO years of ageand adolescent form assuring, Non physiological causds of genu varum, include skeletal dysplasia (eg, metaphyseal chonerodysplasia, spendyloepiphyseal dysplasia, multiple epiphyseal dysplasia, achondroplasia), metabolic diseases (eg. renal ostendystrophy, vit D resistant rickets), post traumatic deforriity, post infectious sequelae, andl proximal focal Ribrosattilagenous dysplasia, In patients with familial hypophospatemic rickets, the bore dincane is active during csrly infarey, when physiological varus is present agsire an anaes canes came ara Ean, ee toes edu inenaicaleai pescime nestle Fig. 1.19: Blunts Disease Fig. 1.20: Osteotomy to carect Van in Blount: ifthe child is between 30 4years nf age HILAFOs Le, hip knee ankle foot orthosis, medial upright elastic tlaunt'sbrace pecially there is only unilateral involvement Full time orthotic treatment (Le. 25 hours day) fs tra the knee is fully protected during the day. + Surgical overcorrectian af mechanical axis boat least Sdegrees valgus, with Lateral translation distal asteotorny fragment achieved by 4 years of ageis believed to be optimal, The Fiskof delaying ecerective asteatomy (even few mon th) past the critical age of 4 yonrs can result in Frihite ta achieve permanent reversal of the inhibitian of proximal medial physi onal, sc that + High bial cofeotorny js distal tothe patellar tendon insttion with fibular cotéokomy in pronimal third dlaphysis ix recumeneree Rocker Bottom Foot aT Rocker bottom foot, sa foot with aconvex planla surface witha apex of conver fnlar head is du bo wrong correction af CTE or oblique tli, ‘Treatment is Grice Procedure. > Club Foot’ Congenital Talipes Equino Varus (CTEV) Fig. 1.20 Cub fa sick to play gsIFCTE fat nsembles it ocala s club Foot 7 Talipes is gonutic tm furbot dif that cons atin 2 the talus [Talipes — talus and pes ~ foot). In its most characteristic form there are usually said to be four elements lof deformity Equinuy of ankle, inversion of foot, adduction af fore foot and mesial rotation of Hibia, In India the most common, DDI the commonest winnie: 5 attired Fig. 1.22 1 g 3 By ° 5 k g i aOrthopedics Quick Review Etiology and Associated Anomalies ve necin mesma a — ‘s deficit borer Lange tale ip deformities are acouciated e.g, DDH, Fig i2asciey = Pathological Anatomy Complete Summary of Orthopedics The club foot charaeteristically involves foot ankle and leg. Deformities of fact may be in the hind foot (ankle and subtalar joints), mid Fook (mid tarsal i. talonavicular and caleaneocub aid joints} andl forefoot ‘Talo calcanea navicular joint comples is area involved in pothemechanics ofall hind fact and mid Fact doforrition, Clubfootis always assaciatsd with a permanent decrease in calf circumference related to fibro of calf munculabare Ina new bor child it is possible ta dorsiflex and evert the Faot till the dorsum of foot and it tauches anterior surface of “This isnot pomible in CTEV. This i known an dorsiflesin tot‘ and ean be aned am a screening bet Ankle (Tibiotalar} Joint Plantar flexion or Equinus Subtalar (Talocalcaneal) Joint Inversion ‘Mid tarsal (tafonavicular and calcaneacbotdh Joint #Adauction (media! subluxation} and inversion (supination) of mid and Fore foot PiranUDimneplio storing 18 for CTE Cavus increased plantar arch ‘Adduction (Adduction of farefnat and mid foat:) YYarus or Inversion (Inversion offi mieLand bind foot) Equinus (Equinus (plantar lexian) of ankle) CAVE (Onler of Correction of CTEV) Kites angle = AP view talacalcaneal angl = Normal Value is 20 ta 40degrees( decreased in CTEV) MOST COMMON RELAPSE In CTEV— adduction Conservative Management of CTEV Kites methad —Aellowed eater Poncetti mathed now preferred -attinth Manipulation by meter rial wks, Manipulation and cast Change af cast Every 2 weak Weskiy Correction crder CAVE Cane Fulcrum while manigulaing Galearmceubuid joint Head of faluz Duration et fester to 9 momhs 608 necksComplete Summary of Orthopedics NOTE: First cast in CTEV is applied in supination to correct Cavum, Subsequently in Kites one defamity is corrected at atime, adduction flat than Varusand than Equuinun, In ponsetti method adduction and Varus are cotracted simultansously and Equinus is corrected a lt “Thus in Kites method one d ofarmity is corructed ata Hime but in ponsetti adduction and varus are corrected simultaneously, ejimus i corrected at en in tt Above knee (28t: As rule of splintaye immobilize one jeint above one joint below and te correctankle equinus knee has ts be immobilized this above krwseast If this onder of carrection is not followed and the exjuinus is corrected before adduction and inversion by forcefully darsiflesing the foot, it may actually move a mid tarsal jaints (rot at ankle joint) producing tmcker bottom doforraity: Even if thecortection fsachieved maintenance af foot in Dennis Broun splint ix required Whole firme upto 1 year ane after 1 year diay time CTE shoes and nig Dennis brown splint istised Upto 7 yearsef age, (as recurrence after? yes ts oF Known} ‘The objective is to achieve fideally) overcorrection Sometimes it may be necemary to perform percutaneaus Tendo Achilles lengthening (Tenotomy) in arsier ta overcome equinus (Ponsetti method) time net Operative Treatment ‘The results of early operation, in particular neonatal surgery. have not boon shan ta be Better than thowe of late surgery Delaying surgery until the child is near walking age has the advanta of operating of larger foot (making surgery easier) Asal of eons inrarirsarepe? shove are jirt se aw ‘ardio ecroctarkic Ryne ime nae Ee irrasiiaed Posteromédial oft tisue release (Cincinnati Cravitord, Fig. 1.25: Alive knee CTEV cast ‘Turco, Carrol incisions) is bast dene at young age (1-8 years), but in children older than 7 year of age lateral coluran shortening pracedures are often perfnrmed in canjuncion with, Posteromedial ont tinue relen Posterior release or complete subtalar release can also be performed 3-8 years Saft timsie release together with shortenin foot by Lichtblau’s Progedure (i.c, Shorts oral side of ing of calcaneal neck proximal twealeansscubid joint), Preferred in eb-years of age fs caleanescuboid fusion is more dificult to achieve in this Fig. 1.27; Lateral Colurn Shortening oslo el Fig. 1.26: Sol issue releases age. Evan- Dillwyn Procedure (.c.riscet anand fusionof ealeanes ceuboid joint) In 38 years of age fesp> years) is ideal procedure Duyer's osteotomy of caleancum is done ta correct caleaneal varus in >S years Evans used 2 g (tana a ‘wedge of caesar a Fig. 1.26: Deere Oxteotery fo correct heel vas (9B yr) soipedoyio.so Aewuins eyardulo5Complete Summary of Orthopedics Orthopedics Quick Review Sto 10 years Wedge Tarsoctomy is doieas dfrmity is more and req uires multiple bones to be removed, Tinie azvedees a "eld akn Fig. 1.29: Wedge Tarsectorny (8-10 yrs} Fig. 1.90: ripe Arthrodesis [+19 y=) > 10 years ‘Triple arthrodesis fs noceysary for recurentar persistent clubfont deformity in older children (ehra > 10 years oF age when foot growth is complete and the bone are cxilied to achieve sora fusion, case). It iy best done at Itinvalves fusion of three joints: TN» Tala-Navicular; TC ~ Tale-Caleaneal; CC—Calcaneo - Cuboid © PRoudoarthrosis (most commonly of talonavicular pint iscommonest complication, which ean be reduced by performing, surgery after skeletal maturity and doing internal fixation, [ESS and Hizaroy extemal Fisators alse can be uses to correct defcrmity after skeletal maturity, CTEV shoes has cuter shoe raise, straight medial border and no he. Pollickzation iy transposition of Finger ta replace (reconstruct) absent thumb done in Radial Club hand (absent radius} [Airc 2008) Absent or defeciency in Radius and associated with inadequately developed Thumb also called as Radial Club Hand Absent Radlus or thumb Is acseclated with + Thisomy 13.18 + Fancanlasyrdmme + Tar syndrometthrombeytopenia absant rads) + Vater syndrome (vertebral anomalies anorectal malformation! TrachewrnesuphagealRtula/ssophagsalaticia/rodialshibhand Bk TAG rtd and gested as ure ronal agenssin) + Holroram nyrdrome cardiac defects with sbment rcs) Betodermal dysplasia Very rarely leukemias * Order of investigations in a patient with absent racins is Echncardiography> platelets count >karyotypingsbore marrow Treatment 1. Centealtaation of ulna 2. Pollicieation i transpasition af finger to replace (reconstruct) absent thumbs This reconstruction ofthumb is wsually done by migrating inex finger to the position of thumb in a patient with congenital absence of maked hypoplasia of thumbs Tendon transfers Fig. 1.31: PllicizationComplete Summary of Orthopedics FRACTURES IN CHILDREN “The intmature skeleton hay several unique properties that affect the management of injusice in children, These propertien Include thicker periostem, soft bones, an ineteased resiliency to stress, af iereased potential to remadel, shorter healing times, and the prwnce of 2 pliysis, This can lead tn same-chatacteristic fracture patterns in pediattic population. Distal radius ait ulna is the most common site of frachure in children lecounting For nesely a quarter of frackure and in frequency is Hand injury Ard in frequency are elbow injuries amengst them suppracendylar fracture humerus are ment commen and ath common iselaviele fracture adults and durin © Plense remember that Clavicleis the mast common fractured bane i bie * Dislocations and commninuted fractures are rirein children Remember mast common joint todislocate in adults is shoulder but in children is Elbow. Remodeling Potential In Children Remodelling of bone is best (maximum) for metaphyseal a deformity Battered baby syndrome + elsa term used to define a clinical condition in young children usually under 3 years oFage who have recelved non Accidental violsice or injury, on efté or more occasions at the hands af aft acult responsible for child's welfare This syndrame must beeunsicered in any child lation deformity and least (wort) for diaphyseal rotation |. In wham degree and type of injury is at variance with the history given. When Injuries of different agesand in different stages of healing are Found. lil, When there {3 purposeful delay in seeking medical attention despite serious injury. Iv. Who exthibits evidence of fracture of amy bone, subeixral hematoma, failure to thrive, soft tisse swelling or skin bruising fecchaarasis) EPIPHYSEAL INJURY. Fractures characteristics 4. Inflicted fractures the shaft are more likely to be spina! rather than transverse, 2. Aclansic finding isa chip fracturein whicha comer ofthe mataphysisof along bane istorn aff with damage toepiphysts oT wn, {| | ra | ven 4} spe 6 | I Bes Sines Set Tel "ae sis “mart in ob" f yet fat \ | ae ype ines erdpocr sono esi veh Per ve ‘or detente, alley Jas Cassitoaton For Eclpryscal inure Fig. 1.32:Salter Hanis Clossication Fot Epiphysest Injiry g 3 By ° 5 k g i a8 3 g z 6 3 : E 8 3 e 8 Orthopedics Quick Review Epiphyseal enlargement Most commen eauses oF o iphyseal ena (Causes of Fpiphyseal enlargement are jement are chron inflammatien (e.g. JRA) due ts ehronie ineressa in blood flow. a Solitary Post filanarcator (IRA, Septic ardbet Hemopl ¥ Trewr disor (Diesphesia epiphyseal emetic) i, Pethcs dscns (it repair stare) {Homophilc arta) fe. Turner aera Generalized i, “Hyperthyro iii, Spondyleapiph McCune Abel weal dysplasia ive ht syndrome Epipyseal dysgenesis/Fragmented/punctate epiphysis- Hypathyreidism Kilppel Fell Syndrome Kippel Feil Syndrome is congenital fusion of one or tore cervical Verkebrae presenting: With classical triad of low hair line, short ‘wel! nacke(prontinenee of trapeaius nusele), and limited ck ristign seen in 50% eases Abnarinal head position, true trticollis, and restricted range of mation, without an obviaus SCM isternoclel do mastoid) contracture, is an indication for X-rays of cervical spine for eviclence of cervical fusion. Itisassaciatod with cong hwo oF mote vertebed ita! cxeous fusions {syncstusis) and failure of segmentation of the cervical spine, involving ‘Such fusions can involve the craniccervigal junction foceipul to2), the subssial cervical spine or both; and revults froma failure oFthe normal division oF the cervical somitescluring the and tm Ath wask oF erabryengensi, Vertebra Plana ‘Vertebra plana is collapse and inereases censity of ane vertebral beady, with normal or increased dist space, Caines are Fosinophilfe granuioms (histiocytosis), Fwings’s sarcoma, metastasis, leukemis, | Met=tasis tuberculosis (very rare) and Calvew disease (ostecehandritis of vertebral body) B/E (Congenital scoliosis block vertebra carty the bast prognosis and least progression. [Leukemia (Order of progression isunsegmented bar ~ with hemivartebra > umegmented bar > hemivertesra > IB /Trums Wed gevartebra block vertebra, Riser localisersastis uses in the management of Idicpathie sooliemis, MELT Neurofibromatosis (NF) ry, hamartamatous disorder, that affects central and ps theral nervous Systm, skaletal, skin and di tissue, Ibis ane of thecommonest single gene disorder affecting theskeletal system NF - 1/Von Recklinghausen’s Disease ‘© Most common single genedisonder affecting, human nervous systern © Also called au periphetial neurofibromatosis, dus fs defect in chtomascme 17, AD inheritance, and SIMs patien is result frow new mutation, 100% penetrance Les individual with abno 17 will show same elinical Feature. | chromosome * Clinical presentation includes ~ cafe au lait spots (most common fenture) axillary, and inguinal freckling (2nd mc), cutaneous neurofibromas, ple form neurofibrumas{-%.are promalignanl), Liseh nodules is, weruccous hyper} (thickened cvergiownval ety snftskin),elaphantiass (pachyder! abnormalities (scoliosis, congenital pseudoarthresis of tibia, hemihypertrophy) and engri sabillty) Complications include epilepsy, hydrocephalus, cognitive deficits, intracranial tumor, optic gli pPresovious puberty, hypothalmie dy shunetion, renal artery stenosis and hypertersicn short stature, Diagnostic criterla for NF-1 are met if twro or more criteria are found > cafe sus Lait pots, atleast Sina in greatest ciaanoter in adults and Shane in children, oF any type or one plesiform neurofibroria Axillary o inguinal Freckli 5 (ences sign)Complete Summary of Orthopedics Linch nodule firis hamartomas) Optic glioma ‘© fuscule skeltal on such 2 sphenoid dysplasia, orthinning of cortex of long bone, with or with aut prcudcarthrosis 9A first degree relative (parunt, sibling, ot effspring) with NE-1 by sbuve erHeria Also known as central netre fik roma tems bila ral acoustic neurofibramatosis and is due to defect in tong arm of chromosome 22, + Less common type, AD inheritance, and 50% cases are due to new mutator Musculoskeletal deformities encountered in NE ~ 1 are sgancrally absent in NE Bthnerve vestibular schwannomas occur in nearly every individual with NF2 (not seen in NFL), Meninginma occur in 80" canes [Diagnostic crea for NIE-2 are met Ufa person has either a he followin ge Bilateral Bth nerve masses seen on MRL A first degree relative with NF2 and either a unilateral Bth nerve mas oF be of the Follow Neurofitroma + Meningicra Glioma * Schwannoma Juvenile posterior subeapaular lenticular opacity NOTE: Usually Skeletal disorders are Autosomal Dominant ane! Inborn errors of rietabolisra are Autosomal Recessive. Congenital Pseudoarthrosis Pceudoarthrosis Iisa false joint that may develop after fracture thathas not united properly due to inadequate immobilization, Ifa nonunion allows for too much mation alang the fracture gap, the central potion of the eallus undergoes cystic degeneration and the luminal surface can actually bocome lined by synovial like cells, creating a false joint filled vith clear Fluid known ax proudearthrosis Most Common Cause of Pseudoarthrosis Ieliopathic Neurofibromatosis (NF- L}— (Actually an association, not a eat) (Causes of Psoudearthrosis are 1. Neurofibromatosis (S%s patients of prcudoarthmsis have NF) Nonunion of fracture fineluding patholo Congenital (mostly in lower to middle third of tibia with cupping of proximal bone end and pointing of distal bane end) 1 fractsres) A. Ostooyenesi imperfecta 5. Fibroum dysplasia, 6. Cleidoeranial dysplasia 7. Ankylosing spond ylitsiin fused bambeo spine) 5. Pent surgical eg-Triplearthmdesis, spinal fusion aya complication. + Tibia is most commonly invalved bone. Five forma of cong pretidoarthosisnf tibia are— dysplastic, cystic, slerati, fibular and chubfont ‘or congenital banl type. The montcommon dysplastic type is tapered at defsctive sites an hour glans (Comttistion, itis ssanciated with naurofibrama tsi Prato ‘atesjent Cea unkroun © Poor fracture healing andl rscurrent fracture is eammon even if union is achieved Cast immobilization is gener Initial treatment is mailing and bone grafting or Hlizaraw Fleator. © Vascularised Fi bulae graft is done if multiple failed surgeries. ly unsueseeefl 4.33: Peeudoarthreeie g 3 By ° 5 k g i a