Orthopedics Ready Reckoner

Prelims.
pdf
Chapter-01_Trauma in General and Injuries of the Lower Limb.pdf
Chapter-02_Injuries of the Upper Limb.pdf
Chapter-03_Spine.pdf
Chapter-04_Clinical Diagnosis of Peripheral Nerve and Brachial Plexus Injuries.pdf
Chapter-05_Examination of a Bone Tumor.pdf
Chapter-06_Important Clinical Tests and Radiological Signs in Different Bone and Joint Pathologie
Chapter-07_Multiple Trauma.pdf
Color Plate.pdf
Index.pdf
Orthopedics
Ready Reckoner
Orthopedics
Ready Reckoner
Second Edition
RM Shenoy D Orth MS Orth

Professor
Department of Orthopedics
Yenepoya Medical College
(A constituent of Yenepoya University)
Derlakatte, Mangalore, Karnataka, India
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ensure accuracy of information, the publisher and the author specifically disclaim any damage,
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Orthopedics Ready Reckoner

First Edition: 2010
Second Edition: 2013
ISBN: 978-93-5090-360-5
Printed at
Dedicated to
Our beloved Professor M Shantharam Shetty who is regarded as
teacher of teachers, a surgeon par excellence, and
above all, a kind hearted and affectionate
person whose prime concern has
always been well-being of others.
Contributors
Deepak Pinto MS Orth, FRCS (Glasg, UK) Vivek Mahajan MS Orth

Associate Professor Associate Consultant
Department of Orthopedics Department of Orthopedics
Kasturba Medical College Amandeep Hospital
(A constituent of Manipal University) Amritsar, Punjab, India
Mangalore, Karnataka, India
Preface to the Second Edition
It has given me immense pleasure to work on a second edition for this book. It is
meant to continue to serve as a handy clinical tool for the orthopedic fraternity.
It has been updated from the first edition to incorporate additional clinical
information to make it current and the state of art with the goal of making it even
more useful to readers. I am grateful for all the help and suggestions provided by
my previous co-authors, colleagues and readers who have served to enhance the
content of this book. My thanks are also due to M/s Jaypee Brothers Medical
Publishers (P) Ltd, New Delhi, India, for publishing this second edition of the
book.
RM Shenoy
Preface to the First Edition
Every resident doctor during the period of his or her training encounters situations
where guidance becomes necessary in the diagnosis and management of a case
in the casualty. This is specially true for cases of trauma which often are pretty
serious and if timely diagnosis and treatment is not instituted may result in
severe morbidity or even mortality. A small book which contains information
adequate enough to diagnose and practically manage a case in the casualty is
perhaps most desirable. With this idea in mind, this book Orthopedics Ready
Reckoner has been written. The text matter is compiled in such a way that in
no time the book provides the information required for an orthopedic resident
doctor, who is on duty in a trauma center/emergency room, for assessment and
timely intervention of an injured person. Chapter on examination of bone tumor
has also been included. Perhaps referring this book boosts his confidence while
managing the case and enables him to manage the case more efficiently without
delay. The X-ray pictures and illustrations are self-explanatory. We feel this
book fulfills such a need.
RM Shenoy
Deepak Pinto
Vivek Mahajan
Acknowledgments
We acknowledge with thanks the role of Manipal University where a sound

foundation for learning orthopedics was laid and the conducive environment it
provided to further our skills. We salute its illustrious Chancellor, DrRamdas
M Pai.
We are grateful to our parents for instilling in us a strong work ethic. We are
thankful to our wives for their constant love and support. We are also thankful
to our students and patients for providing us opportunities to learn so much over
the years. We acknowledge the services of Dr Saurabh Bansal, colleague and
Assistant Professor, in the preparation of this book.
Finally, our special acknowledgment to Shri Jitendar P Vij (Group Chairman),
Mr Ankit Vij (Managing Director), and Mr Tarun Duneja (Director-Publishing)
of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who
brought out this unique book in an excellent manner.
Contents
Section 1: Trauma in General and Injuries of the Lower Limb

1.1. Examination of Bone and Joint Injuries 2
1.2. Open Fractures 6
1.3. Fractures of the Pelvis 9
1.4. Hip Dislocations 13
1.5. Fractures of the Femoral Neck 16
1.6. Intertrochanteric Femoral Fractures 19
1.7. Subtrochanteric Femoral Fractures 22
1.8. Fractures of Patella 26
1.9. Tibial Plateau Fractures 28
1.10. Ankle Injuries 30
1.11. Tibial Pilon Fractures 37
1.12. Talar Neck Fractures 39
1.13. Calcaneal Fractures 41
1.14. Tarsometatarsal (Lisfranc) Fracture Dislocation 44
1.15. Jones Fracture 47
1.16. Nonunion 49
Section 2: Injuries of the Upper Limb

2.1. Fractures of the Clavicle 54
2.2. Shoulder Dislocations 56
2.3. Proximal Humeral Fractures 61
2.4. Supracondylar Fractures of the Humerus 63
2.5. Fractures of the Lateral Condyle 66
2.6. Elbow Dislocations 68
2.7. Monteggia Fracture-Dislocation 70
2.8. Essex-Lopresti Fracture-Dislocation 72
2.9. Galeazzi Fracture-Dislocation 74
2.10. Distal Radius Fractures 76
2.11. Scaphoid Fractures 82
2.12. Bennett and Rolando Fractures 87
2.13. Physeal Injuries 89
Section 3: Spine
3.1. Spine: General Considerations 94
3.2. Examination of Spinal Injuries 104
3.3. Spinal Injuries, Classification and Management 113
xiv Section 4: Clinical Diagnosis of Peripheral

Nerve and Brachial Plexus Injuries
4.1. Clinical Diagnosis of Peripheral Nerve and
Brachial Plexus Injuries 126
Section 5: Examination of a Bone Tumor

5.1. Examination of a Bone Tumor 142
Section 6: Important Clinical Tests and

Radiological Signs in Different Bone and Joint Pathologies
6.1. Important Clinical Tests and Radiological
Signs in Different Bone and Joint Pathologies 156
Section 7: Multiple Trauma

7.1. Multiple Trauma 186
Index 193
Prevention and Control of Leprosy
1
1
Section
Trauma in General and

Injuries of the Lower Limb
Section 01.indd 1 01-12-2012 10:33:10

2 1.1. Examination of BonE and Joint inJuriEs

One of the most common causes of mortality and morbidity is trauma.
Examination of an acutely injured person from an orthopedic preview helps in
triage of the patient.
History
It should be brief and relevant. It should help to identify the mechanism of
injury, the nature, severity of violence, extent of disabilities to the patient and
the symptoms pertaining to associated neurovascular injuries.
Age
Certain fractures are particularly seen in specific age, like epiphyseal separation
is seen only in children and adolescents. Colles fracture occurs in elderly
osteoporotic persons.
Mechanism of Injury
It can be interpreted by asking the mode of injury such as fall from height, RTA
and position of the limb or body at the time of injury, rotational force acting on
the body and the type of activity done by the patient at the time of injury.
By eliciting type of history we can divide the type of force as direct or
indirect and muscular.
Direct injuries are due to a hit by an object.
TappingThere is transverse fracture with minimal skin damage
CrushingMultiple fragments with extensive soft tissue injury.
Indirect injuries are due to a force acting on a limb which is fixed to a
point. This may be a bending force (leads to transverse or oblique fracture),
twisting force (spiral fracture), bending with axial compression force (double
oblique fracture with separation of butterfly fragment) or combination of all.
Muscular forceWhen a muscle is strongly contracted against resistance, it
may lead to an avulsion of a bone fragment at its attachment and a fracture,
e.g. patella, olecranon and lesser trochanter of femur.
A force of trivial nature causing a fracture in a bone which had a pre-existing
pathology is called a pathological fracture. The pre-existing pathology had
already weakened or softened the bone.
This softened bone breaks with a force of lesser magnitude.
Pain
Pain is felt during movements of the fractured site. It is least in impacted and
greenstick fracture. In a dislocation, pain is constant and unbearable. This is
because the soft tissues surrounding the joint are in a state of constant stretch.
Section 01.indd 2 01-12-2012 10:33:10

Examination of Bone
Prevention and and Joint
Control Injuries
of Leprosy
Loss of Function 3
Patient will be unable to move the fractured limb due to pain. In case of
dislocation patient is unable to move the involved joint. In either case there is
loss of function of the limb.
Deformity and Swelling

A fracture or dislocation often presents with swelling or deformity. Classical
deformity clinches the diagnosis, e.g. Dinner fork deformity, Garden spade
deformity, etc.
General Examination
Look for evidence of shock. Vitals should be noted. Consciousness and
orientation should be recorded at this stage.
Local Examination
Inspection
Prerequisites: Patient should be made to sit or lie down in a comfortable
position.
Part to be examined should be adequately exposed.
Injured side should always be compared to sound side.
Both limbs must be kept in identical position whenever possible.
Note: In a severly traumatized patient, clothes should be cut and removed and
the patient should be covered with a clean bid sheet.
Attitude: Position of the limb after injury gives a clue to a diagnosis, e.g. in
fracture neck femur, affected lower limb will be in external rotation.
In posterior dislocation of hip, thigh will be in flexion, adduction and internal
rotation.
In anterior dislocation of shoulder, the contour will be lost with prominence
of anterior axillary fold.
Swelling and deformity: The swelling is due to hematoma and edema and
deformity is due to displaced segment following a fracture or a dislocation.
Shortening: Always expected in a displaced fracture due to overlapping of
fractured segments, more obvious in fractures of the lower limb.
Overlying skin: To be examined for open wound, sinus and scar.
Compound/open fractureWound communicates with the fracture site.
Closed/simple fractureSkin is intact.
Edema, blebs and bullae are quite common due to interference with venous
return.
Section 01.indd 3 01-12-2012 10:33:10

4 Palpation
Confirmation of inspectory findings:
Temperature: A pulseless limb due to vascular injury will feel cold.
Loss of continuity and irregularity: Discontinuity and irregularity can be felt at
the site of the fracture. This is a definitive sign of fracture.
Abnormal mobility: A fracture is a discontinuity occurring in a bone following
injury. There will be abnormal mobility between two ends of fracture. This sign
should never be elicited in a fresh fracture. It is a sure sign of a fracture and to
be observed. When present the limb needs splinting immediately. It is usually
elicited to assess union of a fracture in follow-up of patients.
Crepitus: It is a sensation of grating which may be felt or heard when bone ends
are moved against each other. Commonly seen when there is comminution. Also
appreciated in hematoma, osteoarthritis, Charcots joint.
Swelling: Whether swelling is arising out of a bone or a joint or soft tissue is to
be ascertained.
Tenderness: Local bony tenderness is a sign of fracture. Site of tenderness in a
joint will give a clue to the diagnosis of injured structure. In joint injuries the
joint has to be stressed in various directions to make out the presence of subtle
ligament injuries, e.g. Medial collateral ligament injuryValgus stress test will
be positive.
Wound: Note the size and extent of the wound and degree of contamination.
Under aseptic precautions, the wound should be explored to note the position of
the broken fragments, loss of and extent of injury to the tissue and the presence
of a foreign body as well as contamination. Also observe the color of the muscles
to exclude any possibility of gas gangrene.
Measurement
May not be necessary in a fresh fracture. But certainly is necessary in a case of
nonunion.
Longitudinal: To know if there is any shortening.
Circumferential: To know if there is any wasting due to injury.
Movements
Assessment may not be necessary in a fresh fracture. But certainly is necessary
in a case of nonunion. Both active and passive movements should be tested
very very gently. In a fresh fracture they are extremely painful. The active
movements become limited or may not be possible at all but attempted passive
movements, in the vicinity, may show abnormal mobility. In a dislocation both
active and passive movements will be painfully and grossly restricted. In an old
fracture or unreduced dislocation, joint will become stiff due to intra-articualr or
extra-articular adhesions. A mechanical resistance to movements may be present
in myositis ossificans or intra-articular loose fragments.
Section 01.indd 4 01-12-2012 10:33:10

Examination of Bone and Joint Injuries
Neurovascular Examination 5
Adjacent neurovascular structures to an injured bone or joint should be examined
to rule out any injury to them.
Complications
Shock, venous thrombosis, pulmonary embolism, fat embolism, compartmental
syndrome are some of the early complications that can be associated with a
major fracture.
Infection, delayed union, malunion, nonunion, avascular necrosis, VIC,
myositis ossificans traumatica are the late complications.
Section 01.indd 5 01-12-2012 10:33:10

6 1.2. opEn fracturEs

I can assure you that even after most sophisticated operations succeed,
My delight is nothing in comparison with my feelings
I have after the successful management of an open fracture
Billroth (1866)
The above statement remains true even today. An open fracture with extensive
soft tissue defect still remains one of the most delicate and challenging problems
in trauma surgery.
An open fracture is defined as one in which a break in the skin and underlying
soft tissues, communicates with the fracture or its hematoma, or both and
exposes it to the external environment.
Classification
Gustilo and Anderson in 1976 described a prognostic classification scheme for
open fractures based on the size of the wound. However, Gustilo et al in 1984
reported a subclassification of type-III open fractures.
Based on Gustilo and Anderson Classification (Figure 1.2.1)
Type I: Open fracture as a result of low energy trauma. The features arewound
usually less than 1 cm, minimal soft tissue damage, and minimal contamination.
Type II: Open fracture due to a little severe trauma, high/low energy. Features
are laceration of more than 1 cm moderate soft tissue damage, minimal to
moderate contamination. The soft tissue stripping from the bone is none to
minimal and primary wound closure is possible.
Type III: Open fractures are due to a high velocity trauma. Features are extensive
soft tissue damage and crushing, and the injuries with extensive contamination.
Type IIIA: Despite skin loss, bone retains its soft tissue envelope irrespective of
the size of the wound.
Type IIIB: Extensive soft tissue injury with extensive periosteal stripping and
exposure of bone. Usually, flap coverage of the exposed bone is required.
Type IIIC: An open fracture with major vascular injury requiring repair. For
example, distal humerus fractures with a brachial artery injury.
Management of Open Fractures

Initial Management
All patients with open injuries must be assessed and resuscitated according to
the established principles of Advanced Trauma Life Support (ATLS). Special
Section 01.indd 6 01-12-2012 10:33:10

Open Fractures
Figure 1.2.1: Open fractures classificationbased on Gustilo and Anderson.

(For color version, see Plate 1)
emphasis must be placed on identification of associated life-threatening injuries.

After resuscitation secondary and tertiary surveys are mandatory to avoid
missed injuries which can be present in up to 20% of these patients.
Antibiotics: What, When and for How Long?

Although use of antibiotics is now considered therapeutic and mandatory, abuse
and misuse of antibiotics is perhaps most common in the management of open
injuries. Antibiotics with broad spectrum coverageusually a first generation
cephalosporin derivative is given for all type I and type II fractures. The
addition of aminoglycoside and penicillin is recommended for type III injuries.
Penicillin is very effective against clostridia group of organisms causing gas
gangrene and tetanus. One should never hesitate to test and use this wonder
drug especially when encountered with deep punctured wounds, wounds with
necrotic tissue and effused blood, wounds contaminated with silicic acid and
ionized calcium, wound with foreign bodies and those with secondary infection
Section 01.indd 7 01-12-2012 10:33:11

8 with aerobic organisms (All these are predisposing factors for Gas Gangrene).
Usually, antibiotics are given for five days followed by wound culture and further
treatment is based on those cultures. When gas gangrene is suspected in those
who are allergic to Penicillin other drugs such as Tetracyclines, Cephalosporins
and Piperacillin may be used.
Infection Control
The single factor which decides success or failure in open fractures is infection.
At every stage of treatment, all members of the team must pay special attention
to prevent contamination of the wound leading to infection.
Debridement: When and By Whom?

Debridement is fundamental to success. It is both an art and science and must
be performed by a person well-experienced in this field preferably by the senior
most member of the team.
Fracture Stabilization
Although the external fixator is the work-horse of a trauma surgeon, there
is enough material in literature to prove the safety and advantage of internal
fixation in stabilization of open fractures. It has an added advantage of being
very friendly to plastic surgical procedures without producing any hindrance
for flap rotation. Solid nails are preferred to hollow nails as intramedullary
implants.
It is a Teamwork
The team should comprise of a skilful anesthetist, an orthopedic surgeon and a
plastic surgeon for resuscitation, stabilization and reconstruction.
Section 01.indd 8 01-12-2012 10:33:11

Fractures of the Pelvis
1.3. fracturEs of thE pElvis 9
Disruption of the pelvic ring is a serious injury with significant mortality and
morbidity. Despite early, more aggressive resuscitation including the early
application of the external fixators, there is significant mortality in pelvic injuries.
Displacement of pelvic fracture is always associated with disruption of pelvic
ligaments leading to instability of pelvic ring. Stabilizing an unstable injury in
acute polytrauma is a conventional wisdom.
Mechanism of injury forms the key component in the classification, and
management of pelvic injuries.
Classification
The ideal pelvic injury classification system would facilitate identification of
injury. Predicts the morbidity and mortality in terms of associated injuries, and
forms the basis for treatment decisions.
Many authors have classified pelvic disruptions. Much of these classifications
are based on mechanism of injury and resultant instability of the pelvis. The
management hence is directed to stabilize the pelvis, which, in fact, is guided by
the mechanism of injury.
Pennal et al developed a mechanistic classification in which pelvic fractures are
described as anteroposterior compression injuries, lateral compression injuries,
or vertical shear injuries.
Tile modified the Pennal system to make it an alphanumeric system involving
three groups based on the concept of pelvic stability with radiographic signs of
stability and instability. He described pelvic ring disruption as stable (type A),
rotationally unstable (type B), or both rotationally and vertically unstable (type C).
Based on Tile's Classification (Figure 1.3.1)
Type A: Stable (Posterior Arch Intact)

A1: Fractures of the pelvis not involving the rim; avulsion injuries.
A2: Iliac wing or anterior arch fracture caused by direct blow.
A3: Transverse sacrococcygeal fracture.
Type B: Rotationally Unstable, Vertically Stable

(Incomplete Disruption of Posterior Arch)
B1: External rotation instability; open book injury.
B2: LC injury; internal rotation instability; ipsilateral only.
B3: LC injury; bilateral rotational instability (bucket handle).
LCLateral compression
Section 01.indd 9 01-12-2012 10:33:11

10
Figure 1.3.1: Pelvic ring fracturesbased on Tiles classification.
Type C: Rotationally and Vertically Unstable

(Complete Disruption of Posterior Arch)
C1: Unilateral injury.
C2: Bilateral injury, one side rotationally unstable, with the contralateral
side vertically unstable.
C3: Bilateral injury, both sides rotationally and vertically unstable with an
associated acetabular fracture.
Based on Tiles Fracture Types following Stabilization

Options can be Considered
OpenBook (Type B1)

If pubic symphysis opening < 2 cm: No stabilization required.
If symphysis opening >2 cm: Simple external fixator or symphyseal plate.
If laparotomy is required for exploration/stabilization of injuries and there
Section 01.indd 10 01-12-2012 10:33:11

Fractures of the Pelvis
is no fecal or urinary soiling, plate fixation is preferred; otherwise external 11

fixator preferred.
LC (Types B2, B3)

B2: No stabilization required as elastic recoil restores pelvic anatomy.
B3 (bucket-handle): Posterior complex (sacrum) commonly compressed.
Hence options are: (a) No stabilization is necessary; (b) Reduction using
external fixator or open reduction, if leg-length discrepancy is greater than
1.5 cm or gross pelvic deformity is present.
Rotationally and Vertically Unstable Injuries (Type C)

External fixation with or without skeletal traction/ORIF.
Based on Young and Burgess Classification (Figure 1.3.2)

Young and Burgess proposed a different modification of the original Pennal
classification, adding a new category of a combined mechanism for these injuries.
This system identifies four types of ring disruption based on the interpretation
of the radiographic image:
Lateral compression (LC).
Anteroposterior compression (APC).
Vertical shear (VS).
Combined mechanism of injury (CM).
Figure 1.3.2: Pelvic ring fracturesbased on

Young and Burgess classification.
Section 01.indd 11 01-12-2012 10:33:11

12 LC
It is the result of collapse of pelvis due to laterally applied force that shortens the
anterior sacroiliac (SI), sacrospinous (SS), and sacrotuberous (ST) ligaments.
One may see oblique fractures of the pubic rami, ipsilateral or contralateral to
the posterior injury. It is subdivided into three types based on degree of severity
as shown on the radiographic appearance:
Type I: Sacral impaction on the side of impact.
Type II: Crescent (iliac wing) fracture on the side of impact.
Type III: LC-I or LC-II injury on the side of impact; force is continued to
contralateral hemipelvis to produce an external rotation injury (windswept
pelvis) owing to sacroiliac, sacrospinous, and sacrotuberous ligamentous
disruption.
AP Compression (APC)
This is anteriorly applied force from direct impact or indirectly transferred force
via the lower extremities or ischial tuberosities resulting in external rotation
injuries, symphyseal diastasis, or longitudinal rami fractures. It is subdivided
into three types based on degree of severity:
Type I: Slight (<2.5 cm) widening of pubic symphysis. Anterior SI, ST and
SS ligaments are stretched but intact. Posterior SI ligaments intact.
Type II: More than 2.5 cm of symphyseal diastasis. Anterior SI, ST and SS
ligaments are disrupted; posterior SI ligaments intact.
Type III: Complete SI joint disruption with lateral displacement. Anterior
SI, ST and SS ligaments disrupted; posterior SI ligaments disrupted. Results
in extreme rotational instability with the highest rate of associated vascular
injuries and blood loss.
VS
Either symphyseal diastasis or vertical displacement anteriorly and posteriorly
occurs. Posterior displacement usually occurs through the SI joint, occasionally
through the fractured iliac wing or sacrum.
CM
Combination of injury patterns, LC/VS being the most common.
Section 01.indd 12 01-12-2012 10:33:11

Hip Dislocations
1.4. hip dislocations 13
The hip joint is an inherently stable joint, and hip dislocations are produced by
high energy trauma. Posterior dislocations occur much more frequently than the
anterior dislocation.
Posterior dislocation is also called as dashboard dislocation. It results
from a posteriorly directed force to the flexed knee with the hip also in a flexed
position. Lesser degrees of hip flexion and increasing amounts of hip abduction
at the time of impact results in an acetabular fracture. Anterior dislocation is
caused by a reverse mechanism to that of a posterior dislocation. The mechanism
is abduction and external rotation force to the affected limb.
Radiographic Evaluation
For the radiographic evaluation of a patient with hip dislocation anteroposterior
view of the pelvis should be taken before reduction and is repeated after
reduction. A 45-degree oblique Judet view of the pelvis is also necessary.
Classification
Hip dislocations are classified according to the position of the femoral head in
relation to the acetabulum.
The three basic types are as follows:
Posterior dislocation.
Anterior dislocation.
Central dislocation.
The associated acetabular or femoral fracture indicates the greater magnitude of
the force and severity of the injury.
Posterior Dislocation
Patients with an isolated posterior hip dislocation present with a classical flexion,
adduction, internal rotation, deformity of the lower limb and with shortening
of the limb extremity. No movement is possible at the hip and an attempted
movement is associated with very severe pain.
Based on Thompson and Epstein

Posterior dislocations are classified into five types (Figure 1.4.1):
Type I: Posterior dislocation with or without a minor fracture.
Type II: Posterior dislocation with a large single fracture of the posterior
acetabular rim.
Type III: Posterior dislocation with a comminuted fracture of the rim of the
acetabulum; with or without a major fragment.
Type IV: Posterior dislocation with fracture of the acetabular rim and floor.
Type V: Posterior dislocation with fracture of the femoral head.
Section 01.indd 13 01-12-2012 10:33:11

14
Figure 1.4.1: Posterior hip dislocationbased on

Thompson and Epstein classification.
Anterior Dislocation (Figure 1.4.2A)

The classical attitude of an anterior dislocation is flexion, abduction and external
rotation of the lower limb. Anterior dislocation also has been classified by
Epstein.
SuperiorPubic
With no fracture (simple).
With fracture of the head of the femur.
With fracture of the acetabulum.
InferiorObturator and Perineal
With no fracture (simple).
With fracture of the head of the femur.
With fracture of the acetabulum.
Central Dislocation (Figure 1.4.2B)

Central dislocation is referred to as medial position of the femoral head after a
fracture involving the medial wall of the acetabulum.
A B
Figures 1.4.2A and B: (A) Anterior dislocationpubic (Simple); (B) Central dislocation
(Fracture dislocation)
Section 01.indd 14 01-12-2012 10:33:12

Hip Dislocations
Management 15
Hip dislocation is an orthopedic emergency and should be reduced on an

emergency basis, as delaying the reduction significantly increases the risk of
osteonecrosis of the femoral head. Closed reduction of the hip initially should be
attempted in the emergency department under general anesthesia with adequate
muscle relaxation.
Guidelines for the treatment of hip dislocations without significant associated
femoral head or acetabular fractures:
Thompson and Epstein Type I
Reduction should be attempted taking into consideration direction of the
deforming force. For posterior dislocationflexion, adduction, and internal
rotation; for anterior dislocationabduction and external rotation in
extension. Traction in line with the affected femur along with good counter
traction at the pelvis and small amounts of rotation and adduction/abduction
completes the reduction.
Popular methods of reduction
Allis maneuver.
Stimson maneuver.
Bigelow maneuver.
Indications for Open Reduction of the Dislocated Hip

Dislocation irreducible by closed methods.
Nonconcentric reduction.
Fracture of the acetabulum or femoral head requiring open reduction and
internal fixation.
Ipsilateral femoral neck fracture.
Section 01.indd 15 01-12-2012 10:33:12

16 1.5. fracturEs of thE fEmoral nEck

We come to the world under the brim of pelvis and go out
of the world through the fracture neck of femur!!!
Classification
Fractures of the femoral neck have always presented several challenges to
orthopedic surgeons and remain in many ways even as the unsolved fracture as
far as treatment and results are concerned.
Various classifications have been described for these fractures. Structurally,
these are:
Impacted fractures.
Nondisplaced fractures.
Displaced fractures.
The most common classification of femoral neck fractures is that of Garden
(1961), as it is fairly simple and easily applied. It is based on degrees of
displacement. Garden believed that the various types of femoral neck fractures
represent different stages of displacement from the same mechanism.
In his classification, he described the trabecular angle or alignment
index serving as guide for accurate reduction before internal fixation is carried
out. On AP radiograph the angle between the primary compressive or medial
trabeculae (coming from the calcar and rising superiorly into the weight bearing
dome of the femoral head) and the medial cortex of the femoral shaft is around
160 degrees; these trabeculae also align with similarly oriented trabeculae in the
acetabulum.
On the lateral projection, the trabecular alignment from the head fragment to
the neck fragment normally is 180 degrees.
Based on Gardens Classification (Figure 1.5.1)

Garden stage I: The fracture is incomplete, with the head tilted in a posterolateral
direction. So this is a valgus impacted fracture with retroversion with increased
alignment index as well as angle of the trabeculae.
Garden stage II: Fracture is complete but undisplaced with no evidence of
impaction or change in trabecular angle but a break in compression trabeculae
is observed.
Garden stage III: Fracture is complete and partially displaced as judged by the
direction of the trabecular stream in the head fragment. The trabecular pattern of
the femoral head does not line up with that of the acetabulum as well as the neck.
Garden stage IV: The fragments are completely displaced, and the trabeculae
of the femoral head realign themselves and assume a linear orientation with the
trabeculae within the acetabulum. Complete dissociation of the head from the
neck is the hallmark of the stage IV.
Section 01.indd 16 01-12-2012 10:33:12

Fractures of the Femoral Neck
17
Figure 1.5.1: Fracture neck of femurbased on

Gardens classification.
However, broadly Garden stages I and II can be grouped together as

nondisplaced and stages III and IV can be grouped together as displaced.
Management
It is imperative to distinguish impacted fractures from nondisplaced fractures.
In impacted fractures the name itself suggests that there is impaction. The
fracture surfaces are crushed together or invaginated and trabeculae of the
neck are pushed into the soft trabecular bone of the head.
Impaction causes significant stability at the fracture site. Hence, conservative
or nonoperative approach is indicated. However, when these fractures are
operated and fixed not only the possibility of displacement is taken care of
but also they will certainly unite (rate of displacement with nonoperative
approach is around 15%). Hence can be treated surgically too.
All other stages from Garden stages II - IV are inherently unstable and
are unsuitable for nonoperative treatment. Surgery in the form of accurate
reduction and internal fixation is a must.
In elderly patients replacement arthroplasty is the preferred treatment.
Section 01.indd 17 01-12-2012 10:33:12

18
Figure 1.5.2: Fracture neck of femurbased on

anatomic classification.
Based on Anatomical Classification (Figure 1.5.2)

Based on this classification fracture neck of femur can be classified as:
Subcapital.
Transcervical.
Basal.
Section 01.indd 18 01-12-2012 10:33:12

Intertrochanteric Femoral Fractures
1.6. intErtrochantEric fEmoral fracturEs 19
Classification
These fractures occur through the intertrochanteric line in the region between
the greater and lesser trochanter, occasionally extending into the subtrochanteric
region.
Boyd and Griffin in 1949 classified Peritrochanteric femoral fractures into
four types as follows:
Based on Boyd and Griffin Classification (Figure 1.6.1)

Type I: Fractures that extend along the intertrochanteric line from the greater to
the lesser trochanter.
Type II: Comminuted fractures, the main fracture is along the intertrochanteric
line, with multiple fractures in the cortex. Look for the comminution in both AP
and lateral views to know the exact nature and behavior of the fracture.
Figure 1.6.1: Intertrochanteric fracturesbased on

Boyd and Griffin classification.
Section 01.indd 19 01-12-2012 10:33:12

20 Type III: Fractures that are basically subtrochanteric with at least one fracture
passing across the proximal end of the shaft, just distal to or at the level of lesser
trochanter along with intertrochanteric extension.
Type IV: Fractures of the trochanteric region and the proximal shaft, with
fracture in at least two planes, one of which usually is the sagittal plane and may
be difficult to see on routine anteroposterior radiographs.
Management
While operating an intertrochanteric fracture, the goal is to achieve a stable
fixation as well as a strong fracture fragment-implant assembly. It can be
influenced by following variables:
Bone quality.
Fracture geometry.
Type of reduction, i.e. anatomical or nonanatomical.
Type of implant.
Placement of implant.
Considering these factors various intertrochanteric fractures can be managed by
following methods:
Type I: Reduction usually is simple and is maintained with little difficulty.
These fractures which were being treated nonoperatively, later were treated
by Jewett nailing. These days Dynamic hip screw fixation is a preferred
method of fixation.
Type II: Reduction of these fractures is more difficult because the degree
of comminution varies. Dynamic hip screw fixation is usually the preferred
method for fixation of these fractures.
Type III: These fractures are more difficult to reduce as abductors tend to
displace the greater trochanter laterally and proximally, iliopsoas displaces
the lesser trochanter medially and proximally and adductors pull the distal
fragment medially and proximally. Intramedullary device seems to have
some advantage with respect to stability in these fractures. When feasible, it
is preferred to dynamic hip screw.
Type IV: Intramedullary nail fixation is preferred for these fractures.
Dynamic hip screw fixation can be used with modified techniques, e.g.
Dimon-Hughston technique.
Based on Evans Classification (Figure 1.6.2)

Evans devised a widely used classification system based on the division of
fractures into:
Stable.
Unstable groups.
He divided unstable fractures further:
Unstable fractures in which stability can be restored by anatomical or near
anatomical reduction.
Unstable fractures in which stability cannot be restored by anatomical or
near anatomical reduction.
Section 01.indd 20 01-12-2012 10:33:12

Intertrochanteric Femoral Fractures
21
Figure 1.6.2: Intertrochanteric fractures

based on Evans classification.
Evans type I: Fracture line extends upwards and outwards from the lesser
trochanter.
Evans type II: Reverse oblique fracture, with a major fracture line extending
downwards and outwards from the lesser trochanter. These fractures have a
tendency for medial displacement of the femoral shaft because of the adductor
muscle pull.
Section 01.indd 21 01-12-2012 10:33:12

22 1.7. suBtrochantEric fEmoral fracturEs

Subtrochanteric fracture is a fracture between the lesser trochanter and a
point approximately 7.5 cm distal to the lesser trochanter. Subtrochanteric
region is a site of very high biomechanical stresses. High compressive forces
are experienced by medial and posteromedial cortices whereas lateral cortex
experiences a high tensile stress.
There are various deforming forces in this region; proximal fragment is
pulled into abduction by gluteus medius, into external rotation by short external
rotators, and into flexion by the psoas. The distal fragment is pulled proximally
and into varus by the adductors.
Young individuals with normal bone sustain these fractures usually due
to high energy trauma whereas older individuals with osteoporotic bones can
sustain these fractures even with a minor fall.
Classifications
Boyd and Griffin (1949) included subtrochanteric fractures as a variant of
peritrochanteric fractures in their classification as types 3 and 4. There are
various classification systems for subtrochanteric fracture indicating the
uncertainty regarding the treatment and prognosis of this complex fracture.
Based on Fieldings Classification

Based on Fieldings classification these fractures are classified based on the level
of fracture:
Type 1: At the level of lesser trochanter.
Type 2: 2.5 to 5 cm below the lesser trochanter.
Type 3: 5 to 7.5 cm below the lesser trochanter.
Transverse fracture may fit into this classification, but oblique and
comminuted fractures may involve a larger area and more than one level.
Seinsheimer developed a classification system based on the number of
fragments and the location and configuration of the fracture lines.
Based on Seinsheimer Classification (Figure 1.7.1)

Type I: Nondisplaced fracture or one with less than 2 mm of displacement.
Type II: Two-part fracture.
Type IIa: Transverse fracture.
Type IIb: Spiral fracture configuration with the lesser trochanter attached to the
proximal fragment.
Type IIc: Spiral fracture configuration with the lesser trochanter attached to the
distal fragment.
Type III: Three-part fracture.
Type IIIa: Three part spiral fracture configuration with the lesser trochanter a
part of the third fragment.
Section 01.indd 22 01-12-2012 10:33:12

Subtrochanteric Femoral Fractures
23
Figure 1.7.1: Subtrochanteric fracturesbased on Seinsheimer classification.
Section 01.indd 23 01-12-2012 10:33:13

24 Type IIIb: Three-part spiral fracture configuration with the third part a butterfly
fragment.
Type IV: Comminuted fracture with four or more fragments.
Type V: Subtrochanteric-intertrochanteric configuration. It includes any subtro-
chanteric fracture with extension through the greater trochanter.
The problem with the Fielding and Seinsheimer classification is that they do
not separate fractures according to the different treatment methods. So with the
development of modern reconstruction nails, also called as second generation
intramedullary nails, these classification systems become less useful for deciding
the implant required for fixation of these fractures.
As far as the decision of the implant required for the fixation of subtrochanteric
fractures is concerned, the two major variables should be considered:
Whether the fracture is extending into the greater trochanter posteriorly and
involving the piriformis fossa because piriformis fossa is the most commonly
used nail entry portal.
Whether there is continuity of the lesser trochanter.
Based on these two variables which influence the treatment, Russell and
Taylor devised a classification system for the subtrochanteric fractures.
Based on Russell and Taylor Classification (Figure 1.7.2)

There are broadly two types:
Type I: Fractures that do not extend into the piriformis fossa.
Type II: Fractures that involve the piriformis fossa.
Each type is further subclassified based on the lesser trochanter continuity.
Type IA: Fractures not extending into the piriformis fossa and the lesser
trochanter is intact. Comminution and fracture lines extend from below the
lesser trochanter to the femoral isthmus; any degree of comminution may be
present in this area.
Type IB: Fractures not extending into the piriformis fossa and the lesser
trochanter is fractured. Comminution and fracture lines involving the area of the
lesser trochanter and the medial femoral cortex.
Type IIA: Fractures that involve the piriformis fossa as the fracture extends from
the lesser trochanter to the isthmus. But there is no significant comminution of
the lesser trochanter.
Type IIB: Type IIA + significant comminution and loss of continuity of the
lesser trochanter and medial femoral cortex.
Russell and Taylor recommended the following treatment options based on
their classification:
IA: As the piriformis fossa is intact with intact lesser trochanter so standard IM
interlocking nailing can be done.
IB: Piriformis fossa is intact but there is comminution of lesser trochanter and
medial femoral cortex so reconstruction IM nailing should be done.
Section 01.indd 24 01-12-2012 10:33:13

Subtrochanteric Femoral Fractures
25
Figure 1.7.2: Subtrochanteric fracturesbased on

Russell-Taylor classification.
IIA: There is involvement of the piriformis fossa however, the lesser trochanter
is intact; therefore, a dynamic hip screw fixation or reconstruction IM nailing
should be done.
IIB: There is involvement of the piriformis fossa with comminution of the lesser
trochanter and medial femoral cortex, therefore a dynamic hip screw with bone
grafting or a reconstruction IM nailing should be done.
In brief, in type I fractures closed IM nailing should be attempted so as to
minimize the vascular compromise of the fracture fragments. In type II fractures,
the extension into the piriformis fossa complicates closed nailing techniques.
In fractures with intact lesser trochanter, medial stability is present. So plate
fixation can be done.
Newer nails have been developed with a trochanteric entry portal, so one
should be very careful while doing nailing in type II fractures as there are even
more chances of comminution of the trochanter. Therefore, a careful attention
to the surgical technique is required so as to avoid further comminution of the
fracture or displacement of the fracture during nailing.
Section 01.indd 25 01-12-2012 10:33:13

26 1.8. fracturEs of patElla

Patella is predisposed to direct trauma because of its subcutaneous location.
However, patellar fractures can also occur by indirect trauma like violent
contraction of quadriceps with the knee in flexion. Usually, most patellar
fractures are caused by combination of both direct and indirect trauma. The
most significant effects of patellar fractures are loss of continuity of the extensor
mechanism of the knee and the potential incongruity of the patellofemoral
articulation hence, they should be properly addressed and managed well.
Classification (Figure 1.8.1)

They can be classified broadly as:
1. Undisplaced.
2. Displaced.
Figure 1.8.1: Classification of patella fractures.
Section 01.indd 26 01-12-2012 10:33:13

Fractures of Patella
Displaced fractures are further subclassified based on the fracture 27

configuration as:
A. Transverse.
B. Lower or upper pole.
C. Comminuted.
D. Vertical.
E. Osteochondral.
Patellar fractures are usually associated with hemarthrosis and retinacular
tears. Surgical treatment is advocated as the patient is not able to extend the
knee indicating the disruption of extensor mechanism and torn retinaculum.
Suspected patellar fractures should be evaluated with anteroposterior, lateral,
and axial (Merchant) views. Transverse fractures are usually appreciated better
on a lateral view. Vertical and osteochondral fractures on axial view.
As a first aid measure all the acute patellar fractures should be splinted with
extremity in extension so as to avoid the further displacement and locally ice
packs should be applied. Closed patellar fractures with minimal displacement
(23 mm), minimal articular incongruity (23 mm), and an intact extensor
retinaculum can be managed conservatively with cylindrical/AK cast for 6
weeks.
Indications for Surgery

Usually all patellar fractures with disrupted extensor retinaculum should be
operated as early as possible and the knee is mobilized. Delay increases the
morbidity. These include:
Open patellar fractures.
Patellar fractures with retinacular tears.
Displacement more than 2 to 3 mm.
Articular incongruity more than 2 to 3 mm.
Open fracture of patella is a surgical emergency. The goal of surgery in
patellar fractures is to restore articular congruity along with repair of extensor
retinaculum (quadriceps plasty) and early mobilization. Various methods
of fixation described are, wiring techniques like circlage wiring or tension
band wiring, screw fixation, etc. Partial patellectomy may have to be done in
comminuted fractures of the distal or proximal pole of the patella; the small
fragments are removed with preservation of the large fragment. However,
when there is extensive comminution and significant loss of fragments and
reconstruction of the articular surface is impossible, complete patellectomy may
have to be performed, especially if the patient is elderly. It is rarely done in
young individuals.
Section 01.indd 27 01-12-2012 10:33:13

28 1.9. tiBial platEau fracturEs

Tibial plateau fractures also known as Bumper or Fender injury are intra-articular
fractures caused by usually high energy trauma like motor vehicle accidents and
are common in younger age group; whereas in elderly patients with osteoporotic
bones these fractures occur even with a less violent trauma.
A varus or valgus force along with axial loading is the usual mechanism
for these fractures. These fractures are commonly associated with ligamentous
injuries. Minimally displaced fractures, fractures with local compression and
split compression are to be carefully assessed for the presence of ligament
injuries.
Schatzker, McBroom, and Bruce classified these fractures into six types.
Schatzker classification (Figure 1.9.1).
Type IPure split of the lateral plateau: A typical wedge shaped uncomminuted
fragment is split off and displaced laterally and downwards. This fracture is
common in younger age group. If displaced, it can be fixed with transverse
cannulated cancellous screws.
Type IILateral plateau split combined with depression: A lateral split is
seen, and in addition to the split there is a depression in the articular surface. It
is common in older age with osteoporotic bones. If the depression is more than
5 to 8 mm, or instability is present, it should be treated with open reduction with
elevation of the depression and bone grafting. The fracture should be fixed with
cancellous screws along with buttress plating for the lateral cortex.
Figure 1.9.1: Tibial plateau fracturesbased on Schatzker classification.
Section 01.indd 28 01-12-2012 10:33:13

Tibial Plateau Fractures
Type IIIPure central depression: The articular surface is depressed with 29

intact lateral cortex. It is usually seen in osteoporotic bones. If the depression is
more than 5 to 8 mm or if the instability is present, it should be treated with open
reduction with elevation of the depression and bone grafting along with buttress
plating for the lateral cortex.
Type IVMedial plateau fracture: There may be a pure split or split with
comminution/depression. In this fracture, tibial spine may also be involved.
These fractures have a tendency to angulate into varus. Therefore, they should
be treated with open reduction and fixation with cancellous screws and buttress
plating for the medial cortex.
Type V Bicondylar fractures: In these fractures there is a split of both the
plateaus. But there is a continuity of metaphysis and diaphysis. This helps to
differentiate these fractures from type VI. Bicondylar fixation should be done
with cancellous screws and buttress plating.
Type VI: Plateau fracture with separation of the metaphysis from the diaphysis.
There is uni- or bicondylar fracture along with fracture of the proximal tibia. It
is a highly unstable fracture because of dissociation of diaphysis and metaphysis
and should be treated with buttress plating and cancellous screws. Usually types
IIII are low energy injuries and types IVVI are high energy injuries.
To summarize these fractures should be managed according to the AO
principles for the management of intra-articular fractures:
Atraumatic anatomical reduction of the articular surfaces.
Stable fixation of the intra-articular fragments.
Reconstruction of the metaphysis with bone grafting and buttressing by
buttress plate.
Functional postoperative treatment without immobilization.
Intra-articular reconstruction must be undertaken as early as possible and
with least trauma to the tissues. It has been recognized that preserving the
viability and integrity of the soft tissue envelope of the metaphysis is the key to
success. MIPPO technique should also be kept in mind while treating these
injuries.
Section 01.indd 29 01-12-2012 10:33:14

30 1.10. anklE inJuriEs

Ankle fractures cause disruption of not only the bony component but also the
ligament and soft tissue anatomy of ankle joint. The severity of trauma may
range from ankle sprains to fracture dislocations. The outcome depends on the
identification of the mechanism of injury and subsequent restoration of anatomy
of the ankle.
Sir Percival Pott was the first to describe an ankle fracture in 1768, i.e. a
fibular fracture with deltoid ligament disruption. The bimalleolar fracture was
described by Dupuytren in 1819, which was actually the supination-eversion
(external rotation) type of the ankle fracture. Maisonneuve in 1840 described a
spiral fracture in the proximal part of fibula, caused by external rotation. Tillaux,
in 1872 described the avulsion fracture from the tibial insertion of the anterior
tibiofibular ligament. In the year 1915, FJ Cotton described a trimalleolar
fracture. All of these have become eponymous names for certain types of ankle
fractures (Figure 1.10.1).
Radiographic Assessment
For radiographic assessment of ankle injuries AP, lateral, and mortise views
are taken and following parameters are evaluated:
Figure 1.10.1: Eponymous names for ankle fractures.
Section 01.indd 30 01-12-2012 10:33:14

Ankle Injuries
On AP View 31
Tibiofibular overlap that is overlap between anterior tibial tubercle and fibula
if < 10 mm implies syndesmotic injury.
Interosseous clear space (Chaput clear space) > 5 mm signifies syndesmotic
injury.
A difference in width of the medial and lateral aspects of the superior joint
space if > 2 mm indicates medial or lateral ligament disruption.
On Lateral View
The dome of the talus should be centered under the tibia and congruous with
the tibial plafond.
Look for the posterior tibial tuberosity fractures, as well as direction of the
fibular injury.
Tibiotalar line both on AP and lateral radiographs must pass through the
center of the tibia and the center of the talus.
On Mortise View (Foot in 1520 of Internal Rotation)

Medial joint space is less than 4 mm, with talar tilt less than 2 mm.
Talocrural angle, i.e. angle between the intermalleolar line and a line parallel
to the distal tibial articular surface. It should be between 83 +/- 4 degrees.
Talar tilt (0, with a tolerance of 5 difference between two ankle joints).
After reduction the results are evaluated on a control X-ray and acceptable
results are up to 2 mm of residual displacement, especially for the fibular length
and up to 0.5 mm of talar displacement.
Classification
There are many classifications for ankle fractures involving the mechanism
of injury as well as correlation with fracture patterns. The most common
classifications are those of Danis-Weber and Lauge-Hansen. Danis-Weber is
much easier for the clinical use but is too simple to cover the complex mechanism
of ankle injuries.
Based on Danis-Weber Classification (Figure 1.10.2)

The Danis-Weber classification is based on the level of the fibular fracture, the
level of the tibiofibular syndesmotic disruption and potential ankle instability.
Three types of ankle fractures are described:
Type A: There is a transverse fibular fracture below the joint line, with the intact
syndesmosis and these fracture types correspond to the supination-adduction
fracture type of Lauge-Hansen.
Type B: It involves a fracture at the level of the ankle joint line, with a partial
syndesmotic injury as the anterior syndesmotic ligament is injured whereas
Section 01.indd 31 01-12-2012 10:33:14

32
Figure 1.10.2: Ankle fracturesbased on Danis-Weber classification.
the posterior syndesmotic ligament remains intact. It corresponds with the

supination-eversion (external rotation) injury of the Lauge-Hansen classification.
Type C: There is a fibular fracture proximal to the tibiofibular joint with associated
disruption of the syndesmosis. Here two subtypes of fractures are recognized:
A diaphyseal one called as Dupuytren fracture and a proximal one called as
Maisonneuve. This type of fracture corresponds with the pronation-eversion
(external rotation) type of injury of Lauge-Hansen. These have the greatest
susceptibility to instability.
The major drawback of the Danis-Weber classification is that it ignored
the medial side of the ankle joint and emphasized on the fibula and tibiofibular
syndesmosis.
Ankle Mortise Ring Concept of Stability (Figure 1.10.3)

To know the stability of the ankle injuries, the ankle can be considered as a
ring in which bones as well as ligaments play an equally important role in the
maintenance of the stability of the joint. If the ring is broken at one place the
ring remains stable. The single break with distortion of the ring should be fixed.
However, when it is broken in two places the ring is unstable because a portion
of it can be or is dislocated. Ligament disruption is seen as widening of the ankle
mortise and along with fracture can lead to instability of the ankle joint because
the ring is broken at two places. Therefore, it needs open reduction and stable
internal fixation.
Based on Lauge-Hansen Classification

The most accepted classification of ankle injuries was given by Lauge-Hansen
in 1948 based on the cadaveric studies. It demonstrated that the fracture pattern
depends upon the:
Position of the foot at the time of the injury.
Direction of the deforming force at the moment of the injury.
Section 01.indd 32 01-12-2012 10:33:14

Ankle Injuries
33
Figure 1.10.3: Ring concept of stability. (For color version, see Plate 2)
There are six main groups based on Lauge-Hansen classification:

1. Supination-external rotation (eversion).
2. Supination-adduction.
3. Pronation-external rotation (eversion).
4. Pronation-abduction.
5. Vertical compression.
6. Unclassifiable.
Supination-External Rotation (Figure 1.10.4)

This is the most common mechanism of injury accounting for 40 to 75% of the
ankle injuries.
Stage I: Produces the disruption of the anterior tibiofibular ligament with or
without an associated avulsion fracture at its tibial or fibular attachment.
Stage II: Results in the typical oblique or spiral fracture of the distal fibula.
Stage III: Produces either a disruption of the posterior tibiofibular ligament or a
fracture of the posterior malleolus.
Stage IV: Produces either a transverse avulsion-type fracture of the medial
malleolus or a rupture of the deltoid ligament.
Complete bony failure pattern produces a trimalleolar fracture otherwise
known as Cottons fracture.
Supination-Adduction (Figure 1.10.5)

It is the only type of ankle injury associated with the medial displacement of the
talus.
Section 01.indd 33 01-12-2012 10:33:14

34
Figure 1.10.4: Ankle fracturesbased on Lauge-Hansen classificationsupination-

external rotation. (For color version, see Plate 2)
Figure 1.10.5: Based on Lauge-Hansen classificationsupination-adduction.

Stage I: It produces either a transverse avulsion type fracture of the fibula distal
to the level of the joint or a tear of the lateral collateral ligaments.
Stage II: Results in a vertical fracture of the medial malleolus.
The supination-adduction type of injury is characterized by a transverse fracture
of the distal fibula and a relatively vertical fracture of the medial malleolus.
Pronation-External Rotation (Figure 1.10.6)

Stage I: Produces either a transverse fracture of the medial malleolus or a
rupture of the deltoid ligament.
Section 01.indd 34 01-12-2012 10:33:14

Ankle Injuries
35
Figure 1.10.6: Based on Lauge-Hansen classificationpronation-external rotation.

Stage II: Results in the disruption of the anterior tibiofibular ligament with or
without avulsion fracture at its insertion site (Anterior Tillaux fracture).
Stage III: Results in an oblique or spiral fracture of the distal fibula at or above
the level of the syndesmosis up to the neck (Maisonneuve fracture).
Stage IV: Produces either a rupture of the posterior tibiofibular ligament or an
avulsion fracture of the posterolateral tibia (Posterior Tillaux fracture).
Stage V: Oblique or comminuted fracture of the lower 1/3rd of the fibula.
(Dupuytrens fracture).
So the pronation-external rotation mechanism is characterized by a deltoid
ligament tear or a fracture of the medial malleolus and a spiral oblique fracture
of the fibula relatively high above the level of the ankle joint or a fracture of
the lower 1/3rd of the fibula. The inferior tibiofibular syndesmotic disruption is
always seen, either incomplete or complete (partial or total).
Pronation-Abduction
Stage I: Results in either a transverse avulsion fracture of the medial malleolus
or a rupture of the deltoid ligament.
Stage II: Produces a high transverse bending or a short oblique/comminuted
fracture of the distal fibula at or above the level of the syndesmosis.
Vertical compressionSubclassified by Reudi-Allgower classification (next
chapter).
Section 01.indd 35 01-12-2012 10:33:15

36 Management
There are few important rules in the treatment of the ankle fractures:
Anatomical restoration of ankle mortise as soon as possible is a must.
Maintaining the fibular length is the key to success, hence to be fixed first.
Fractures and fracture-dislocations should be reduced as soon as possible, as
gross displacement can lead to impairment of the peripheral circulation, and
skin sloughing.
Early mobilization gives excellent results.
Section 01.indd 36 01-12-2012 10:33:15

Tibial Pilon Fractures
1.11. tiBial pilon fracturEs 37
Intra-articular fractures of the distal tibia are known as tibial pilon fractures,
also called as tibial plafond and distal tibia explosion fractures. Most of these
fractures are caused by high energy trauma.
Mechanism of Injury
Axial/vertical compression due to fall from height.
Shear.
Combined compression and shear.
Usually AP, lateral, and mortise radiograph of ankle are sufficient for evaluation.
Classification
Classification of these fractures is important in determining their prognosis and
chosing the optimal treatment. Reudi-Allgower classification is the commonly
used classification for these fractures (Figure 1.11.1).
Figure 1.11.1: Tibial Pilon fracturesbased on

Reudi and Allgower classification
Section 01.indd 37 01-12-2012 10:33:15

38 Based on Reudi and Allgower Classification

It is based on the severity of comminution and the displacement of the articular
surface. Prognosis correlates with the increasing grade. It divides the tibial
plafond fractures into three categories:
Type I: Nondisplaced cleavage fractures that involve the joint surface.
Type II: Fractures have cleavage-type fracture lines with displacement of the
articular surface, but minimal comminution.
Type III: Displaced fractures with significant articular comminution and
metaphyseal impaction.
Management
NonoperativeFor type I by immobilization in a long leg cast for 6 weeks.
OperativeFor displaced fractures.
Goals of operative fixation:
Maintenance of fibular length and stability.
Restoration of tibial articular surface.
Bone grafting of metaphyseal defects.
Buttressing of the distal tibia.
Section 01.indd 38 01-12-2012 10:33:15

Talar Neck Fractures
1.12. talar nEck fracturEs 39
Anderson coined the term aviators astragalus in 1919 for talar neck fractures
based on his observation of occurrence of these fractures in Royal Flying
Corps. There are various problems associated with talar neck fractures. They
are difficulty in assessment, surgical approaches, timing of surgery, method of
fixation, frequency of postoperative complications.
Classification
Hawkins in 1970 classified talar neck fractures into three typestype I, II
and III. This is the most widely used classification, as it is simple, provides
guidelines for treatment, and enables to predict the outcome. Canale and
Kelly added another type to Hawkins classification and labeled it as type IV
(Figure 1.12.1).
Figure 1.12.1: Talar neck fracturesbased on

Hawkins classification and type IV of Canale and Kelly.
Section 01.indd 39 01-12-2012 10:33:15

40 Based on Hawkins Classification

Type I: Nondisplaced talar neck fractures. (However, it should be thoroughly
evaluated before labeling it as a type I). It can be managed conservatively with
below knee cast for 8 to 12 weeks.
Type II: Displaced talar neck fractures with subluxation or dislocation of the
subtalar joint. These fractures should be managed with prompt open reduction
and internal fixation. Achieving closed reduction may not be possible.
Type III: Talar neck fractures with dislocation of the subtalar and ankle joints.
Type IV (Canale and Kelly): An additional type was described by Canale and
Kelly in which not only the body of the talus is extruded from the ankle mortise,
but also the head of the talus is subluxated or dislocated from the navicular
articulation.
Type III and type IV fractures should be managed on emergency basis for two
reasons:
1. Pressure from the dislocated talar body on the skin and neurovascular
structures leads to sloughing of skin, neurovascular insult, or both.
2. The blood supply to the talus, if occluded, and not severed can be restored
only through emergency reduction of the displaced body.
Incidence of osteonecrosis increases significantly from Type I to Type IV.
Hawkins Sign
A thin line of subchondral atrophy along the dome of the talus. It indicates the
presence of vascularity and excludes osteonecrosis. It is usually seen at 6 to 8
weeks after trauma, on a good anteroposterior radiograph of ankle.
Section 01.indd 40 01-12-2012 10:33:15

Calcaneal Fractures
1.13. calcanEal fracturEs 41
The calcaneum is the most frequently fractured tarsal bone. While extra-articular
calcaneal fractures managed simply with casts give good results, surgical
management of intra-articular calcaneal fractures still remains controversial.
Classification
Calcaneal fractures can be extra-articular or intra-articular depending upon:
Position of foot relative to ankle at the time of trauma.
Direction and magnitude of deforming force.
Bone quality of the patient.
Extra-articular Calcaneal Fractures

The extra-articular calcaneal fractures can involve the body, anterior process,
or tuberosity.
Intra-articular Calcaneal Fractures

These fractures are usually caused by an axial loading such as fall from a height.
The initial radiographic evaluation should include:
AP and oblique view of the foot to assess the anterior process and
calcaneocuboid involvement.
Lateral view of the ankle and calcaneum to assess the height loss (loss of
Bohler angle) and rotation of the posterior facet (Figure 1.13.1).
An axial view to assess the varus position of the tuberosity and width of the
heel.
Borden view which is taken to evaluate congruency of the posterior facet.
On the lateral radiograph Bohler tuber joint angle and Gissane (crucial) angle
give useful information with respect to subtalar joint and should be assessed both
preoperatively and postoperatively.
Bohler tuber joint angle: It is the angle between a line drawn from the highest
point of the anterior process of the calcaneum to the highest point of the posterior
facet and a line drawn tangential from the posterior facet to the superior edge
of the tuberosity. Normally the angle is between 20 to 40; a decrease in
this angle indicates that the weight-bearing posterior facet of the calcaneum has
collapsed.
Gissane (crucial) angle: It is an angle formed by two strong cortical struts
extending laterally, one along the lateral margin of the posterior facet and
the other extending anterior to the beak of the calcaneum. This angle can be
visualized directly beneath the lateral process of the talus. Normally the angle is
between 100 to 130. Increase in the angle indicates collapse of the posterior
facet (Figure 1.13.1).
Section 01.indd 41 01-12-2012 10:33:15

42
Figure 1.13.1: Bohler and Gissane angle.
Based on Essex-Lopresti Classification (Figure 1.13.2)

Intra-articular calcaneal fractures are of two types:
Joint depression type: If the fracture line producing the posterior facet
fragment exits behind the posterior facet and anterior to the attachment of
the Achilles tendon.
Tongue type: If the fracture line producing the posterior facet fragment exits
straight backwards distal to the Achilles tendon insertion.
There are more descriptive and more complex classification systems for the
calcaneal fractures like Crosby and Fitzgibbons and Sanders classification. They
are all CT based.
Figure 1.13.2: Intra-articular calcaneal fracturesbased on Essex-Lopresti classification.

Also showing loss and restoration of Bohler angle following injury and after surgery.
Section 01.indd 42 01-12-2012 10:33:15

Calcaneal Fractures
The advantage of the Sanders classification is its precision regarding the 43

location and number of fracture lines through the posterior facet, however
both the systems lack the description of the other important aspects of the
calcaneal fractures, like heel height and width, varus-valgus alignment and
calcaneocuboid involvement.
Management
Extra-articular Calcaneal Fractures
These fractures can be treated effectively with cast immobilization and non-
weight bearing for 6 weeks.
Only exception is the displaced tuberosity avulsion fracture which should
be managed by open reduction and internal fixation, as it serves as the
attachment of the Achilles tendon. A good fixation restores the power of
Achilles tendon.
Intra-articular Calcaneal Fractures

The challenges with the management of intra-articular calcaneal fractures are:
Adequate pain relief both immediately as well as in the long-term.
Adequate restoration of subtalar joint function.
Reduction of the risk of subtalar osteoarthritis.
Goals of Treating an Intra-articular Calcaneal Fracture

Restoration of congruency of the posterior facet of the subtalar joint (Gissane
angle).
Restoration of the height of the calcaneum (Bohlers angle).
Restoration of calcaneal width.
To decompress the subfibular space for the peroneal tendons.
To realign the tuberosity into the valgus position.
To reduce the calcaneocuboid joint.
Section 01.indd 43 01-12-2012 10:33:15

44 1.14. tarsomEtatarsal (lisfranc) fracturE dislocation

Tarsometatarsal (TMT) injuries are rare, however if overlooked, can lead
to long-term pain and disability. Therefore precise anatomical reduction and
stabilization should be achieved as soon as possible. Jacques Lisfranc de St.
Martin (17901847) was a French gynecologist and surgeon in the Napoleonic
army. He described the amputation through the tarsometatarsal joint called as
Lisfranc amputation, but he did not describe the fracture dislocation himself.
Radiological Evaluation
To evaluate the suspected Lisfranc injury radiograph should be taken with
weight bearing if possible.
Following X-ray parameters are used for identifying Lisfranc injury
(Figs 1.14.1 to 1.14.3):
On AP view the first metatarsal lines up medially and laterally with the
medial cuneiform.
The first metatarsal-cuneiform articulation should have no incongruency.
Medial border of the 2nd metatarsal aligns itself with the medial border of
middle cuneiform.
Lateral border of 3rd metatarsal aligns itself with the lateral border of lateral
cuneiform.
On oblique view the medial border of 4th metatarsal aligns itself with the
medial border of cuboid.
Disturbance in these normal relations is seen in Lisfranc's injury.
Figure 1.14.1: AP-view (foot): Lateral Figure 1.14.2: Oblique view (foot): Medial and
border of the 1st metatarsal aligned lateral borders of the 3rd (lateral) cuneiform
with lateral border of 1st (medial) cunei- should align with medial and lateral borders of
form. Medial border of 2nd metatarsal is 3rd metatarsal. Medial border of 4th metatar-
aligned with medial border of 2nd (inter- sal is aligned with medial border of cuboid. Lat-
mediate or middle) cuneiform. eral margin of the 5th metatarsal may project
lateral to cuboid by as much as 3 mm.
Section 01.indd 44 01-12-2012 10:33:16

Tarsometatarsal (Lisfranc) Fracture Dislocation
45
Figure 1.14.3: Lateral view (foot): A line drawn along long axis of talus should intersect
long axis of the 1st metatarsal.
Further following specific features should be looked into:

A fleck sign should be sought in the medial cuneiformsecond metatarsal
space representing an avulsion of the Lisfranc ligament.
The compression fracture of the cuboid should be sought.
The naviculocuneiform articulation should be evaluated for subluxation on
both AP and lateral views.
Dorsal or plantar displacement should be evaluated on lateral view.
Clinical Evaluation and Classification

For clinical evaluation Trevino and Kodros described a rotation test in which
stressing the second tarsometatarsal joint by elevating and depressing the second
metatarsal head relative to the first metatarsal head elicits pain at the Lisfranc joint.
Look for any ecchymosis at the plantar aspect of foot indicating the significant injury.
Quenu and Kuss were the first to classify these fractures into a simple
system based on the direction of the metatarsal displacement as three groups,
homolateral, isolated and divergent.
Hardcastle (1979) modified this classification into current accepted classification
and Myerson (1986) relabeled the same (Figure 1.14.4):
Type ATotal incongruity: There is incongruity of the entire TMT joint. Also
called as homolateral injury. Displacement may be sagittal, coronal or both.
Type BPartial incongruity: There is a partial incongruity. The displaced
segment is in one plane. These injuries are further subdivided as:
Medial B1: Displacement affects the first metatarsal either in isolation or
combined with displacement of 2nd, 3rd or 4th metatarsal.
Lateral B2: Displacement affects the 2nd5th metatarsal, not the first.
Section 01.indd 45 01-12-2012 10:33:16

46
Figure 1.14.4: Tarsometatarsal (Lisfranc) fracture dislocationbased on Myerson

classification.
Type CDivergent: There can be partial or total displacement. The first metatar-
sal displaces medially and lateral metatarsals, 2nd5th, single or in combination,
displace laterally. These injuries are usually high energy injuries, associated with
significant swelling, and prone to complications, especially compartment syndrome.
Subtle Lisfranc injuries: Faciszewski et al (1990) described these injuries
where displacement is revealed only by weight bearing X-rays.
Management
There is no role of closed treatment (as once the soft tissue swelling subsides
there are high chances of redisplacement).
Reduction achieved by closed or open methods and secured with K-wire or
screws is the accepted method of treatment.
Type A injury can be treated by passing a K-wire across the first TMT joint
and a second laterally into the 5th TMT joint.
For type B injuries a single lateral K-wire for the lateral segment for lateral injuries
and two K-wires into the first TMT joint for medial injuries should be used.
However for type C injuries, two medial and one lateral K-wire can be used.
Inadequate anatomical reduction and stabilization yields poor results.
Complications include osteoarthritis of the TMT joint, deformities like pes
planus, cavus or planovalgus, chronic pain, prominent exostosis and painful gait.
Section 01.indd 46 01-12-2012 10:33:16

Jones Fracture
1.15. JonEs fracturE 47
There is still a lot of confusion in the classification of Jones fracture even after
more than a century of its original description by Sir Robert Jones in 1902,
when he himself sustained this fracture while dancing. We prefer the three zone Pls.
concept by Lawrence et al when classifying these fractures.
check
Based on Lawrence et al Classification (Figure 1.15.1) figure
Zone I is the most proximal tuberosity avulsion fracture, also called as pseudo-
Jones or Dancers fracture. They are most common (93%).
Zone II is the metaphyseal-diaphyseal region, also the level of the fourth and
fifth metatarsal articulation. This is the true Jones fracture location.
Zone III is the proximal diaphyseal stress fracture. The fracture is distal to the
4th5th metatarsal articulation.
Mechanism of Injury
Zone I and Zone II fractures are due to acute injury whereas the Zone III
fractures are usually pathological stress fractures.
Zone I avulsion fracture of the base of the fifth metatarsal is caused by the
inversion and overpull of the peroneus brevis muscle. The peroneus brevis
is inserted into the tubercle at the base of the fifth metatarsal bone and severe
inversion stresses applied to the foot may give rise to a crack fracture or to
complete avulsion of the fragment of bone to which the tendon is inserted.
Usually AP and lateral and oblique view of the foot are sufficient for
radiological evaluation.
Epiphyseal line at the base of the tubercle in children, and the sesamoid
bones should not be confused with the avulsion fracture.
Figure 1.15.1: Lawrence et al classification:

(A) Zone I; (B) Zone II; (C) Zone III fracture.
Section 01.indd 47 01-12-2012 10:33:16

48 Management
Zone I: Avulsion Fractures
Avulsion fracture can be managed nonoperatively with a walking cast.
Zone II: Jones Fracture

Jones fracture is slow to unite due to vascular watershed. If they are
undisplaced, they can be managed nonoperatively with cast immobilization
for 6 weeks.
Indications for operative intervention for Jones fracture:
High performance athletes.
Recreational athletes.
Nonathletes with delayed union.
Zone III: Stress Fractures

Operative intervention is required.
Section 01.indd 48 01-12-2012 10:33:16

Nonunion
1.16. nonunion 49
There is no clear criterion for defining a fracture as nonunion, however in 1986

a US FDA Panel defined nonunion as when a minimum 9 months have elapsed
since injury and the fracture shows no visible progressive signs of healing
for 3 months. It implies that there is no union and the process of healing has
stopped. However, this criterion cannot be universally applied, to all fractures.
Nine months are too long a period to wait for the union. So it is fair to conclude
that three consecutive reviews during the stipulated period for union shows
no progressive signs of healing and changes of nonunion develop at the site
of fracture both clinically as well as radiologically, one can perhaps call it as
nonunion.
Following features can be seen on radiograph of an established nonunion:
There is no callus formation in atrophic nonunion, however, if there is callus
formation, there would not be a bridging callus across the fracture site.
Fracture ends appear smooth and regular.
There will be obliteration of the medullary canal.
Fracture ends are sclerotic.
Classification
Weber BG and Cech O from Switzerland in 1976 assessed the vascularity of
fracture ends by Strontium 85 uptake and classified nonunions as:
Hypervascular (Hypertrophic) nonunion
Avascular(Atrophic) nonunion
However, they are further subclassified as follows:
Hypervascular Nonunions (True Delayed Unions) (Figure 1.16.1)
Elephant Foot Type

Presents with exuberant expansile callus and the picture resembles the foot of an
elephant. It is the result of movement occurring at the fracture site before union
has occurred, e.g. premature weight bearing.
Horse Hoof Type

Presents with little callus and picture resembles a horse hoof. Perhaps, this is the
result of instability at the fracture site following inadequate reduction or fixation.
Oligotrophic Type
These are hypervascular but are not hypertrophic and do not show callus. They
are considered to be the result of major displacement/distraction persisting after
treatment.
Section 01.indd 49 01-12-2012 10:33:16

50
Figure 1.16.1: Hypervascular nonunionbased on

Weber BG and Cech O classification.
Avascular Nonunions (True Nonunions) (Figure 1.16.2)

a. Torsion wedge type: Seen when there is an intermediate fragment with poor
blood supply. It unites on one side but does not unite on the other.
b. Comminuted type: Is the result of many intermediate fragments with poor
blood supply.
c. Defect type: Seen when there is bone loss.
d. Atrophic type: Seen when intermediate fragments are small and are missing.
The defect is replaced by scar tissue.
Causes of Nonunion
Inherently the nature of injury eg high velocity and low velocity and the nature
of the fracture open / closed determines the chances of a fracture non union.
I addition certain factors listed below contribute to non union.
Vascular insufficiency - Loss of soft tissue coverage
- Periosteal stripping (iatrogenic)
- Damage to nutrient vessel
- Segmental fracture
Mechanical instability - Inadequate reduction
- Inadequate fixation
- Excessive traction/distraction
- Bone loss
Pathological destruction - Infection
- Metabolic diseases
- Radiation
Miscellaneous comorbid factors - Old age
- Nutritional deficiency
- Diabetes
- Drugs, e.g. steroids, etc.
Section 01.indd 50 01-12-2012 10:33:16

Nonunion
51
Figure 1.16.2: Avascular nonunionbased on

Weber BG and Cech O classification.
Management
Basic Factors Influencing Healing of Nonunion and Treatment
Mechanical instability leading to hypervascular nonunionstable fixation/
immobilization.
Biologically inert (atrophic) but mechanically stablebiological stimulation
by bone grafting or physiological stimulation by functional loadingcast
brace or Ilizarov/Orthofix.
Biologically inert (atrophic) and mechanically unstablestabilization and
biological stimulation by fixation and grafting or physiological loading with
stabilization like Ilizarov/Orthofix.
Gap nonunion, shortening, avascular nonunionBone transportation and
lengthening using Ilizarov technique or Orthofix or Allograft and internal
fixation.
Section 01.indd 51 01-12-2012 10:33:17

Section 2
53
Injuries of the Upper Limb
Section 02.indd 53 01-12-2012 10:35:00

54 2.1. Fractures of the Clavicle

Clavicle fractures are one of the most common fractures to occur. Usually
standard anteroposterior radiographs are sufficient for the evaluation of clavicle
fracture. However, 30 degrees cephalad tilt view can be taken to provide an
image without the thoracic overlap.
Classification
Based on Allman Classification (Figure 2.1.1)
Allman classified clavicle fracture into the three groups:
Group I: Includes the middle third fracture which is the most common type in
both children and adults (80%).
Group II: Includes the distal third fractures (15%). It is subclassified according
to the location of the coracoclavicular ligament with respect to the fracture.
Type I: Minimal displacementInterligamentous fracture between the conoid
and trapezoid ligament or between the coracoclavicular and acromioclavicular
(AC) ligaments; ligaments still intact.
Type II: Displaced secondary to a fracture medial to the coracoclavicular
ligaments; there is a high incidence of nonunion. Two types:
IIA: Conoid and trapezoid attached to the distal segment.
IIB: Conoid torn trapezoid attached to the distal segment.
Figure 2.1.1: Clavicle fracturebased on Allman classification.
Section 02.indd 54 01-12-2012 10:35:00

Fractures of the Clavicle
Type III: Articular fractures involving the articular surface of the AC joint 55
with no ligamentous injury.
Group III: Includes fractures of the proximal third (5%). It contains five subgroups:
Minimal displacement.
Displaced.
Intra-articular.
Epiphyseal separation.
Comminuted.
Rarely fracture of the clavicle requires open reduction and internal fixation.
Following are the indications:
Neurovascular involvement.
Fractures of the lateral end near the AC joint in an adult.
A persistent wide separation of the fragments with soft tissue interposition.
Floating shoulder.
Nonunion.
Section 02.indd 55 01-12-2012 10:35:00

56 2.2. Shoulder Dislocations

The shoulder is the most common major joint to dislocate. The shoulder
dislocations are classified as:
Anterior dislocation.
Inferior dislocation.
Anterior Dislocation
Most common type, accounting for almost 90% shoulder dislocations.
Mechanism of Injury
Indirect trauma to the upper extremity with the shoulder in abduction,
extension and external rotation is the most common mechanism.
Direct trauma, by an anteriorly directed impact to the shoulder from the
posterior.
Clinical Evaluation
The patient holds the injured shoulder in slight abduction and external
rotation.
There is squaring of the shoulder due to prominent acromion.
Dislocated humeral head can be palpated anteriorly.
Positive Dugas test, Hamilton ruler test and Callaway sign.
Look for integrity of the axillary nerve.
Tests
a. Dugas test: Patient is asked to touch the opposite shoulder.
If the patient is unable to touch the opposite shoulder the test is positive.
If the patient is able to touch the opposite shoulder the test is negative.
A negative test in a case of anterior dislocation of the shoulder suggests
the presence of a fracture of the surgical neck of the humerus.
b. Hamilton ruler test: When the head of the humerus is in the glenoid cavity,
the bulging contour of the deltoid muscle prevents one from placing a ruler
touching both acromion and lateral condyle of the humerus. In dislocation
this contour is lost and it is possible to place a ruler straight across the
shoulder touching both, the acromion and the lateral condyle of the humerus.
The test is said to be positive.
c. Bryants sign: Positive sign is shown by lowering and prominence of the
anterior axillary fold.
d. Callaways test/sign: Increase in girth of the shoulder.
Section 02.indd 56 01-12-2012 10:35:00

Shoulder Dislocations
Radiological Evaluation (Figure 2.2.1) 57

On X-rays look for following osseous lesions:
Bony Bankart lesion: Avulsion of anteroinferior labrum off the glenoid rim.
May be associated with a glenoid rim fracture.
Hill-Sachs lesion: A posterolateral head defect due to impression fracture on
the glenoid rim.
Look for greater tuberosity, acromion or coracoid fractures.
AP and axillary view are usually sufficient.
Velpeau axillary view if standard axillary view cannot be done.
Special views.
West point axillary view: To look at the anteroinferior glenoid rim (Bony
Bankart lesion).
Hill-Sachs view: To visualize a posterolateral defect (Hill-Sachs lesion).
Stryker notch view: To visualize the posterolateral humeral head defects.
Management
Nonoperative
Closed reduction under sedation and muscle relaxation under anesthesia by
Kochers manipulation which is done in four stages followed by immobilization
for 46 weeks in a sling:
Stage I: Traction is applied in the direction in which the humerus is lying by
holding the elbow with one hand and wrist with the other. Counter traction
is given with a folded towel in the axilla by the assistant.
Stage II: While maintaining the traction, the humerus is gently rotated
laterally by moving the forearm out to the extreme of rotation.
Figure 2.2.1: Anterior shoulder dislocation.
Section 02.indd 57 01-12-2012 10:35:01

58 Stage III: While the limb is held in lateral rotation, the elbow is brought
forward to the front of chest, into the position of adduction.
Stage IV: The arm is put into full medial rotation (after reduction).
Many times reduction can be achieved in stage I and stage II itself as the
shoulder attains the position which it had occupied just after the dislocation,
because of the counter traction force.
Indications for Surgery

Soft tissue interposition.
Displaced greater tuberosity fracture.
Glenoid rim fracture > 5 mm in size.
Earlier the surgery, better is the result. Open reduction after 3 weeks is
associated with high risk of neurovascular complications.
Posterior Dislocation
It is rare as compared to anterior dislocation accounting for 10% of shoulder
dislocations.
Mechanism of Injury
Indirect trauma: With shoulder in adduction, flexion and internal rotation.
Direct trauma: Direct impact applied to the anterior aspect of the shoulder.
Clinical Evaluation
The patient holds the injured shoulder in adduction and internal rotation.
Dislocated humeral head may be palpated posterior to the shoulder, with
flattening of the anterior shoulder, and prominent coracoid process.
Radiological Evaluation (Figure 2.2.2)

AP and axillary views or a Velpeau view should be done.
On AP view look for:
Absence of normal elliptical overlap of the humeral head on the glenoid.
Empty glenoid sign.
Trough sign: It is an impaction fracture of the anterior humeral head caused
by the posterior rim of glenoid, i.e. reverse Hill-Sachs lesion.
Management
Nonoperative
Closed reduction under anesthesia with traction applied in the direction of the
deforming force with gently lifting the humeral head into the glenoid fossa.
Section 02.indd 58 01-12-2012 10:35:01

Shoulder Dislocations
59
Figure 2.2.2: Posterior shoulder dislocation.
Shoulder should be immobilized in external rotation with the arm strapped to

the chest for 36 weeks.
Indications for Operative Intervention

Major displacement of an associated lesser tuberosity fracture.
A large posterior glenoid fragment.
Irreducible dislocation.
Impaction fracture on the posterior glenoid preventing reduction.
Reverse Hill-Sachs lesion.
Major fracture of the humeral head that requires fixation or replacement.
Inferior Glenohumeral Dislocation

It is a very rare injury, also called as Luxatio erecta.
Mechanism of Injury
Hyperabduction force causing impingement of the neck of the humerus on
the acromion.
Clinical Evaluation
The patient presents in a salute fashion with the raised arm and inability to
bring it down.
Humeral head can be palpated in the axilla or lateral chest wall.
Section 02.indd 59 01-12-2012 10:35:01

60
Figure 2.2.3: Inferior shoulder dislocation.

AP and axillary view should be done.
AP radiograph shows the inferior dislocation of the humeral head and
superior direction of the humeral shaft along the glenoid margin.
Look for any associated fractures.
Management
NonoperativeReduction should be attempted with the traction in the line
with humeral position. Reduction is very easy.
Immobilize the shoulder in a sling for 46 weeks.
Very rarely needs an open reduction because sometimes the dislocated
humeral head buttonholes through the inferior capsule thereby preventing
the closed reduction.
Section 02.indd 60 01-12-2012 10:35:01

Proximal Humeral Fractures
2.3. Proximal Humeral Fractures 61
Use adequate radiograms to understand the traumatic lesion, be careful

denying older patients effective treatment, use a safe and simple surgical
approach, know the options for internal fixation, recognize the value of
prosthetic replacement, avoid technical pitfalls, and thoughtfully supervise the
postoperative care.
RH Cofield (1988)
This statement of Cofield covers all aspects of the treatment of proximal humeral
fractures from the first evaluation to the final outcome and reflects how difficult
are these fracture to manage. Proximal humerus fractures are common in old
age due to osteoporosis. There are various deforming forces in the proximal
humerus fractures:
The greater tuberosity is displaced superiorly and posteriorly by the
supraspinatus and external rotators.
The lesser tuberosity is displaced medially by the subscapularis.
The humeral shaft is displaced medially by the pectoralis major.
The deltoid insertion causes abduction of the proximal fragment.
Classification
Usually AP and axillary view are sufficient to assess the proximal humerus
fractures radiologically. Neer classified the proximal humerus fracture based on
the four part anatomy of the proximal humerusthe humeral head, the lesser
and greater tuberosities, and the proximal humeral shaft.
Based on Neer Classification (Figure 2.3.1)

Undisplaced fractures.
Two-part displaced fractures.
Three-part displaced fractures.
Four-part displaced fractures.
A part is defined as displaced if there is more than 1 cm of displacement or
there is more than 45 of angulation.
Since the nature of displacement in proximal humeral fractures varies, the
treatment also varies from fracture to fracture.
Steps in Decision Making

The first step in treatment decision is to determine if displacement and
angulation are acceptable for a particular patient.
The second step is to determine whether the humeral head and shaft move as
a unit.
If both these conditions are present, the fracture is stable and in an acceptable
position and can be managed nonoperatively.
Section 02.indd 61 01-12-2012 10:35:01

62
Figure 2.3.1: Proximal humerus fracture

based on Neer classification.
Section 02.indd 62 01-12-2012 10:35:01

Supracondylar Fractures of the Humerus
2.4. Supracondylar Fractures of the Humerus 63
Pity the young surgeon whose first case is a fracture around the elbow.
Mercer Rang
The above statement shows that historically these fractures got much evil
reputation. However, the evolution of efficient management technique over the
last few decades has eliminated most of the complications associated with these
fractures. These fractures are common in the age group of 510 years because
of following reasons:
At this age the bone structure is weaker due to metaphyseal remodeling.
Ligamentous laxity is common.
Presence of hyperextension.
There are few signs on X-ray which can help to diagnose and to evaluate these
injuries (Figure 2.4.1):
On AP View
Baumanns Angle
It is the angle of which lateral condylar physeal line forms with the long axis of
the humerus. An average of 72 (range 64 to 81) could be considered normal.
Humeral-ulnar Angle
It is angle subtended by the intersection of the diaphyseal bisectors of the
humerus and ulna. This best reflects the true carrying angle.
Figure 2.4.1: Elbow radiology.
Section 02.indd 63 01-12-2012 10:35:01

64 Metaphyseal-diaphyseal Angle
It is the angle between the bisector of humeral shaft and the line delineating the
widest portion of the distal humeral metaphysis.
On Lateral View
Fat Pad Sign
There are fat pads which occupy the fossae at the distal end of the humerus.
Anterior (coronoid) fat pad.
Posterior (olecranon) fat pad.
Posterior fat pad is a more reliable indicator of elbow injury than anterior.
Tear Drop
It is formed by the posterior margin of the coronoid fossa anteriorly, the anterior
margin of the olecranon fossa posteriorly.
Anterior Humeral Line

When extended distally, this line should intersect the middle third of the capitular
ossification center.
Supracondylar humeral fractures can be hyperextension or hyperflexion
injuries. Extension injuries are more common (95%) and are sustained due to
fall on an outstretched hand with elbow in extension. Flexion injuries are usually
sustained by an impact on the olecranon with the elbow in flexion.
Classification
Extension fractures.
Flexion fractures.
Extension type fractures were classified by Gartland into three main groups. In
extension type fractures, the fracture line extends obliquely from anteroinferior
to posterosuperior (Figure 2.4.2).
Type I: The fracture is undisplaced or minimally displaced.
Type II: There is an obvious fracture line with displacement of the distal
fragment, but there is still an intact cortical hinge posteriorly.
Type III: Fragments are completely displaced and periosteum may be
stripped.
Flexion type fractures: The fracture line extends obliquely from posteroinferior
to anterosuperior (Figure 2.4.2).
Management
It is important to discuss with the parents before the onset of treatment and emphasize
the fact that this is an injury of great magnitude with considerable soft tissue damage
and stiffness of the elbow will occur during the early phase of healing.
Section 02.indd 64 01-12-2012 10:35:01

Supracondylar Fractures of the Humerus
65
Figure 2.4.2: Supracondylar humerus fracture extension type

based on Gartland classification and flexion type.
Type I: Undisplaced Fractures

Usually immobilization in a posterior splint with elbow in 90 flexion and
forearm in neutral position for 3 weeks is sufficient.
Type II: Displaced with Intact Posterior Hinge

Fracture should be reduced under anesthesia and if found to be stable in flexion,
posterior plaster splint is given in more than 90 flexion. Pin fixation of type II
fractures gives a distinct advantage of early mobilization
Type III: Totally Displaced Fractures

The fracture should be reduced under anesthesia and percutaneous pinning is
done.
Attention!!
1. Avoid all the possibilities of developing vascular compromise, iatrogenic
nerve palsies and varus malposition during management of supracondylar
fracture.
2. Always carry out periodic and repeat assessment when vascular injury is
present and being managed.
Section 02.indd 65 01-12-2012 10:35:02

66 2.5. Fractures of the Lateral Condyle

After supracondylar fractures, these are the second most common elbow
fractures in children and occur around 6 years of age.
Mechanism of Injury
Avulsion of the lateral condyle by the common extensors origin.
Evaluation
By AP and lateral radiographs of the elbow.
On radiographlook for:
Amount of displacement, in specific, rotation of the fragment.
The fragment is always much bigger than the radiographs shows as most of
it is cartilaginous.
Classifications
Based on Milch Classification
Based on Milch classification, these fractures are classified into two types
(Figure 2.5.1):
Type I: The fracture extends medially from the lateral aspect of the lower
humerus into the capitulo-trochlear groove. This is a true Salter-Harris type
4. It is inherently stable and elbow remains stable.
Type II: The fracture starts at the lateral cortex and then extends into the
area of the trochlea. This is a Salter-Harris type 2. The tendency to angulate
and translate makes elbow inherently unstable.
Figure 2.5.1: Physeal fractures of the lateral condyle

based on Milch classification.
Section 02.indd 66 01-12-2012 10:35:02

Fractures of the Lateral Condyle
Other Classification 67
Based on amount of displacement classified as:
Undisplaced.
Moderately displaced.
Completely displaced and rotated.
Management
If the displacement is minimal, conservative management is acceptable with
immobilization in an above elbow plaster for 3 weeks with radiographic
follow-up at weekly interval looking for displacement.
Displaced fractures require open reduction and internal fixation with K
wires. Early removal of wires at 3 weeks is suggested.
Speed called these fractures as fracture of necessity.
Section 02.indd 67 01-12-2012 10:35:02

68 2.6. Elbow Dislocations

The elbow is a modified hinge joint with a high degree of intrinsic stability.
20% of the elbow dislocations are associated with fractures. Simple dislocations
are those without fractures whereas complex dislocations are associated with
fractures.
Classification (Figure 2.6.1)

Posterolateral dislocation.
Posteromedial dislocation.
Anterior dislocationusually associated with olecranon fractures.
Mechanism of Injury
Posterior dislocations are usually due to fall on an outstretched hand.
Direct force over the posterior aspect of the forearm causes anterior
dislocation.
Figure 2.6.1: Types of elbow dislocation.
Section 02.indd 68 01-12-2012 10:35:02

Elbow Dislocations
Radiographic Evaluation 69
AP and lateral view of the elbow.

Look for the associated fractures.
Management
Reduction should be done with early mobilization.
Closed reduction should be attempted under anesthesia.
Operative intervention is done when the closed reduction fails or the
concentric reduction could not be achieved or associated fractures prevent
reduction.
Terrible Triad of Elbow

This term was coined by Hotchkiss. It is a combination of:
Coronoid fracture.
Elbow dislocation.
Radial head fracture.
Combination of this triad makes the elbow very unstable.
Usually this triad should be managed with operative intervention. Results are
generally poor with restriction of movements.
Section 02.indd 69 01-12-2012 10:35:02

70 2.7. Monteggia Fracture-Dislocation

This is a combination of fracture of the ulna with dislocation of the proximal
radioulnar joint with or without fracture of the radius. The radiocapitellar
articulation also gets disturbed in Monteggia fracture which makes it more
unstable when compared to Galeazzi fracture.
Usually AP and lateral view of the elbow and forearm is sufficient for the
evaluation and preferably wrist should be included in the radiograph. On X-ray
look for:
Radiocapitellar Line
Normally, a line drawn through the radial head and shaft should line up with
the capitulum.
Classification
Based on Bados Classification
Based on Bados classification these injuries are of four types (Figure 2.7.1):
Type I: Fracture of the middle or proximal third of the ulna with anterior
placement of the radial head and characteristic angulation of the ulna with
apex pointing anteriorly.
Type II: Fracture of the middle or proximal third of the ulna with posterior
placement of the radial head and often a fracture of the radial head and
characteristic angulation of the ulna with apex pointing posteriorly.
Type III: Fracture of the ulna just distal to the coronoid process with lateral
placement of the radial head.
Type IV: Fracture of the proximal or middle third of the ulna with anterior
placement of the radial head and fracture of the radius below the bicipital
tuberosity.
Monteggia Fracture Equivalents

Three Monteggia fracture equivalents have been described:
Type I: Isolated radial head fracture with superior radioulnar joint dislocation.
Type II: Ulna and proximal radius (neck) fracture.
Type III: Both bones proximal third fractures with the radial fracture more
proximal than the ulnar fracture.
Humes Fracture: It is a variant and high Monteggia fracture characterized
by fracture of the olecranon and superior radioulnar dislocation with anterior
dislplacement of the head of the radius. Commonly occurs in children.
Section 02.indd 70 01-12-2012 10:35:02

Monteggia Fracture-Dislocation
71
Figure 2.7.1: Monteggia fracturebased on Bados classification.
Management
In children it can be treated conservatively by closed reduction and cast
application.
In adultsopen reduction and internal fixation.
Radioulnar joint instability after reduction needs reconstruction of the
annular ligament.
Associated radial head fractures may need fixation.
Section 02.indd 71 01-12-2012 10:35:02

72 2.8. Essex-Lopresti Fracture-Dislocation

It is fracture of the radial head or neck with dislocation of the distal radioulnar
joint.
Mechanism
Fall on the outstretched hand can result in a fracture of the radial head or
neck, disruption of the distal radioulnar joint, and tearing of the interosseous
membrane for a considerable distance proximally, when the deforming force
is transmitted axially through the forearm.
Diagnosis (Figure 2.8.1)

Often missed. When in doubt, a full length X-ray of the forearm should be
advised.
Careful evaluation of the proximal and distal radioulnar joint clinically and
radiologically gives the diagnosis.
Management
Treatment includes restoration of both proximal as well as distal radioulnar
joint components of the injury.
Radial head excision in this injury will result in proximal migration of the
radius; resulting in wrist pain from ulnar carpal impingement and elbow
pain from radiocapitellar impingement.
Disruption of the distal radioulnar joint must be recognized early before
the radial migration; as the late reconstruction often is unsatisfactory if the
migration has already occurred.
Open reduction and internal fixation of the proximal radial fracture and
pinning of the distal radioulnar joint is the ideal treatment. Pin is removed
after six weeks.
Figure 2.8.1: Essex-Lopresti fracture.
Section 02.indd 72 01-12-2012 10:35:02

Essex-Lopresti Fracture-Dislocation
Replacement of the radial head is done if the radial head fracture is irreparable 73
along with transfixation of the distal radioulnar joint with a pin to allow
healing of the interosseous membrane.
Injury to the interosseous membrane, distal radioulnar joint or triangular
fibrocartilage complex may cause the chronic wrist pain.
Section 02.indd 73 01-12-2012 10:35:02

74 2.9. Galeazzi Fracture-Dislocation

Also called as Piedmont fracture. It is the fracture of the distal third of the
radius (or sometimes distal ) with dislocation of the distal radioulnar joint
(DRUJ).
Campbell coined the term the fracture of necessity for this combination.
There are several deforming forces which cause the loss of reduction and
make this fracture unfit for nonoperative treatment:
Pronator quadratus tends to pronate the distal fragment with proximal and
volar displacement.
Brachioradialis tends to cause proximal displacement and shortening.
Weight of the hand results in dorsal angulation of the fracture and subluxation
of the distal radioulnar joint.

AP and lateral X-ray of the forearm with wrist and elbow should be taken. Look
for the following signs of DRUJ injury:
Fracture of the ulnar styloid.
Widened DRUJ on AP X-ray.
Subluxation of ulna on lateral X-ray.
Radial shortening > 5 mm.
Figure 2.9.1: Galeazzi fracture.
Section 02.indd 74 01-12-2012 10:35:03

Galeazzi Fracture-Dislocation
Management 75
In childrencan be treated by closed reduction and cast application.

In adultsopen reduction and internal fixation is the treatment of choice.
Dislocation of the distal radioulnar joint at the time of injury should be
suspected with a displaced fracture of the distal third of the shaft of the
radius.
Rigid anatomical fixation of the radial shaft fracture generally reduces the
distal radioulnar joint dislocation.
If distal radioulnar joint is still unstable, it should be temporarily transfixed
with a single Kirschner wire with the forearm in supination for 6 weeks.
Galeazzi fracture dislocation when unrecognized leads to poor results.
Section 02.indd 75 01-12-2012 10:35:03

76 2.10. Distal Radius Fractures

Fractures of the distal radius are among the most common fractures of the
upper extremity. These fractures are common in the elderly population due to
osteopenia.
Usually PA and lateral views of the wrist are sufficient for the evaluation of these
injuries. There are few normal radiographic relationships for the evaluation of
distal radius fractures:
Radial inclination: Average 23 (13 to 30) (Figure 2.10.1A).
Palmar (Volar) tilt: Averages 11 to 12 (0 to 28) (Figure 2.10.1B).
Radial length: Averages 11 mm (8 to 18 mm) (Figure 2.10.1C).
C
Figures 2.10.1A to C: (A) Radial inclination; (B) Palmar tilt; (C) Radial length.
Section 02.indd 76 01-12-2012 10:35:03

Distal Radius Fractures
Classification 77
Beginning with the classic description by Sir Abraham Colles in 1814, numerous
authors have attempted to classify these injuries.
Commonly used classifications are:
Frykman classification.
Fernandez classification.
Melones classification.
Actually these are classifications for fractures of the distal radius, and
classical Colles fracture is a part of these classifications.
Based on Frykman Classification (1967)

Frykman classified distal radius fractures based on the involvement of radiocarpal
and radioulnar joints, with or without ulnar styloid fractures into following types
(Figure 2.10.2):
Type I: Extra-articular distal radius fracture without ulnar styloid fracture.
Type II: Extra-articular distal radius fracture with ulnar styloid fracture.
Type III: Intra-articular distal radius fracture involving radiocarpal joint
without ulnar styloid fracture.
Type IV: Intra-articular distal radius fracture involving radiocarpal joint
with ulnar styloid fracture.
Type V: Intra-articular distal radius fracture involving distal radioulnar joint
without ulnar styloid fracture.
Type VI: Intra-articular distal radius fracture involving distal radioulnar
joint with ulnar styloid fracture.
Type VII: Intra-articular distal radius fracture involving radiocarpal and
distal radioulnar joint without ulnar styloid fracture.
Type VIII: Intra-articular distal radius fracture involving radiocarpal and
distal radioulnar joint with ulnar styloid fracture.
Ulnar styloid fracture

Fracture Absent Present
Extra-articular I II
Intra-articular involving III IV
radiocarpal joint
Intra-articular involving distal V VI
radioulnar joint (DRUJ)
Intra-articular involving VII VIII
radiocarpal and DRUJ
Guidelines for Acceptable Reduction of the Distal Radial

Fractures (Nana et al and Graham)
Radial shortening < 5 mm at distal radioulnar joint.
Radial inclination on posteroanterior radiographs > 15.
Section 02.indd 77 01-12-2012 10:35:03

78
Figure 2.10.2: Distal radius fracturebased on Frykman classification.
Section 02.indd 78 01-12-2012 10:35:03

Sagittal tilt on lateral projection between 15 dorsal tilt and 20 volar tilt. 79
Intra-articular step-off or gap < 2 mm of radiocarpal joint.
Articular incongruity < 2 mm of sigmoid notch of distal radius.
Based on Fernandez Classification

Fernandez classified the distal radius fractures based on the mechanism of
injury. It is a preferred classification because the associated ligamentous injuries,
subluxation, fracture of the neighboring carpal bones, as well as concomitant
soft tissue damage are directly related to the quality and degree of violence
sustained. He classified the distal radius fractures into five types (Figure 2.10.3):
Type I: Extra-articular metaphyseal bending fractures like Colles (dorsal
angulation) or Smith (volar angulation) fractures. One part of the cortex fails
in tension, and the part opposite to it is comminuted and impacted.
Type II: Fractures are intra-articular and are caused by the shearing. These
include volar Barton, dorsal Barton, and radial styloid fractures.
Type III: These fractures result from compression injuries that cause intra-
articular fractures and impaction of the metaphyseal bone. These include
complex articular fractures and radial pilon fractures.
Type IV: These are avulsion fractures of ligamentous attachments that occur
with radiocarpal fracture-dislocation.
Type V: These fractures are caused by high-velocity injuries involving
multiple forces and extensive injury.
Figure 2.10.3: Distal radius fracturebased on Fernandez classification.
Section 02.indd 79 01-12-2012 10:35:03

80 Management
Type I: Mostly nonoperative, rarely surgical.
Type II: Always need open reduction and internal fixation with buttress
plating, especially Barton's fracture.
Type III: Presence of significant intra-articular damage, radial shortening and
angulation dictates the surgical treatment (the shortening of the distal radius
by 10 mm reduces the forearm pronation by almost 50% and supination by
30%).
Type IV: Operative intervention is required.
Type V: Always unstable, and are frequently open fractures, may require
percutaneous pinning and external fixation.
Based on Melones Classification (1984)

Melone identified four major fragments of the distal radius:
Radial shaft.
Radial styloid area.
Dorsal medial facet.
Volar medial facet.
The classification is based on a consistent mechanism, i.e. lunate impaction
injury. Melone classified the intra-articular distal radius fractures into five types
(Figure 2.10.4):
Figure 2.10.4: Distal radius fracturebased on Melone classification.
Section 02.indd 80 01-12-2012 10:35:03

Type I: Stable, nondisplaced with minimal comminution. 81

Type II: Unstable die puch fractures, dorsal or volar.
IIA: Reducible.
IIB: Irreducible.
Type III: Spike fracture with contused volar structures.
Type IV: Split fracture; medial complex fractured with dorsal and palmar
fragments displaced separately.
Type V: Explosion fracture; severe comminution with major soft tissue
injury.
Section 02.indd 81 01-12-2012 10:35:04

82 2.11. Scaphoid Fractures

Ever since Cousin and Destot (1889) recognized fracture scaphoid, it has
remained as one of the important injuries around wrist next only to the fracture
of the lower end of the radius for following reasons:
The scaphoid serves as a mechanistic key that controls wrist stability.
The scaphoid acts as a principal bony support between proximal and distal
rows of carpus for carrying compressive loads from the hand across the wrist
to the distal forearm.
Mechanism of Injury
Compression injury: Results from a longitudinal load or impaction of the
wrist. It usually results in a non-displaced fracture.
Hyperextension injury: Fall on an outstretched hand with acutely dorsiflexed
wrist wherein a compressive force is exerted by the head of the capitate on
the concave side of the bone. Position of radial or ulnar deviation would
probably decide whether break would occur at the waist, proximal or distal
end which results in a displaced or angulated unstable fracture.
Diagnosis
Tenderness over the anatomical snuff box.
Tenderness over the scaphoid tubercle (Freeland, 1989).
Painful limitation of wrist and thumb movements.
Positive compression test (Chen, 1989).
Scaphoid lift test: Pain with dorsal-volar shifting of the scaphoid.
Watson test: Painful dorsal scaphoid displacement as the wrist is moved
from ulnar to radial deviation with pressure/compression force applied over
the tuberosity.
X-rays, diagnose 97% of fracture scaphoid (Dickson and Leslie). Of the
remaining 3%, 2% can be diagnosed by repeating the X-ray at the end of
2 weeks. 1% which are not diagnosed by X-ray are incomplete fractures.
Russe (1960) suggested following four views to diagnose scaphoid fractures:
PA view of the wrist with fingers flexed (wrist is dorsiflexed).
Lateral view of the wrist.
Radioulnar oblique view in 45 degrees pronation.
Radioulnar oblique view in 45 degrees supination.
Section 02.indd 82 01-12-2012 10:35:04

Scaphoid Fractures
Classification 83
Russe Classification (Based on the Fracture Pattern) (Figure 2.11.1)

Horizontal oblique.
Transverse.
Vertical oblique.
Horizontal oblique and transverse fractures are stable when undisplaced
whereas vertical oblique fractures are always unstable.
Scaphoid fractures can also be classified based on displacement as:
Stable: Nondisplaced fractures with no step-off in any plane.
Unstable: Displacement with 1 mm or more step off, scapholunate angulation
> 60 or radiolunate angulation > 15.
Based on Herberts Classification (Figure 2.11.2)

This is an alphanumeric classification which may have a prognostic significance.
Type A: These are stable acute fractures.
A1: Fracture of the scaphoid tubercle.
A2: Incomplete fracture of the scaphoid waist.
Type B: These are unstable acute fractures.
B1: Distal oblique fracture of the scaphoid.
B2: Complete fracture of the scaphoid waist.
Figure 2.11.1: Scaphoid fracturebased on Russe classification.
Section 02.indd 83 01-12-2012 10:35:04

84
Figure 2.11.2: Scaphoid fracturebased on Herbert classification.
Section 02.indd 84 01-12-2012 10:35:04

Scaphoid Fractures
B3: Trans-scaphoid pole fracture of the scaphoid. 85

B4: Trans-scaphoid perilunate fracture dislocation.
B5: Comminuted fracture of the scaphoid.
Type C: Delayed union of the scaphoid fracture.
Type D: Established nonunion of the scaphoid fracture.
D1: Fibrous nonunion without any deformity. It is stable.
D2: Pseudoarthrosis with early deformity. It is unstable.
D3: Nonunion with sclerotic changes in the fracture fragments with
advanced deformity.
D4: Avascular necrosis of the fracture fragments with fragmentation of
the proximal pole.
Management
Aim of Treatment
Aim of the treatment of scaphoid fractures is to achieve union as early as possible
and restore the function early to minimize the disability. It may be achieved by
nonoperative or by operative methods of management.
Indications for Nonoperative Treatment

Nondisplaced distal third fractures.
Tuberosity fractures.
Nonoperative treatment consists of immobilization in scaphoid cast for six
weeks.
Indications for Operative Treatment

Fracture displacement > 1 mm.
Radiolunate angle > 15 degrees.
Scapholunate angle > 60 degrees.
Associated carpal dislocation.
Vertical oblique fracture.
Humpback deformity.
Nonunion.
Operative Treatment
Most involve the insertion of screws like Herberts screw or Acutrak screw.
Controversy exists about open versus percutaneous techniques.
Open techniques are needed for fractures with unacceptable displacement
and for nonunion.
Closed techniques are appropriate for acute fractures with minimal displacement.
Section 02.indd 85 01-12-2012 10:35:04

86 Management of Suspected Scaphoid Fractures

In patients with suspected scaphoid fractures and normal X-rays, scaphoid
cast is given for 12 weeks.
X-ray should be repeated if the patient is still symptomatic at the end of two
weeks.
If patient is symptomatic but X-rays are normal, consider MRI.
Note: Suspected fracture scaphoid is usually an incomplete fracture and
rarely gives probelms. Investigations are done mainly to establish the diagnosis
and for legal purposes. Whereas missed or neglected displaced fracture scaphoid
can give rise to serious complications.
Section 02.indd 86 01-12-2012 10:35:04

Bennett and Rolando Fractures
2.12. Bennett and Rolando Fractures 87
Too often these fractures are treated as minor injuries,

and major disability results
PR Lipscomb
This statement was made by PR Lipscomb, in 1963 for the fractures of the hand
and it holds very true for the Bennett and Rolando fracture.
Bennett Fracture
In 1882, Edward Bennett, an Irish surgeon, described an intra-articular fracture
through the base of the first metacarpal in which shaft is displaced laterally by the
unopposed pull of the abductor pollicis longus. However, the medial projection
of the base of the thumb metacarpal on which the volar oblique ligament attaches
remains in place. The keypoint about this injury is that the fracture allows the
part of the base of the metacarpal to displace in a radial direction. So the outcome
is a fracture dislocation or a fracture subluxation.
Radiographic Evaluation (Figure 2.12.1)

AP and lateral view of the hand are usually sufficient.
To get the better picture of the saddle-shaped trapezio-metacarpal joint and
the displacement of the fracture fragment special Geddas radiographic
projections can be taken (tilted views of the carpometacarpal joint).
Management
Nonoperativemanipulation and cast application.
Take a check X-ray, and if the articular incongruity is < 13 mm, continue
plaster for 6 weeks.
Figure 2.12.1: Bennetts and Rolando fracture.
Section 02.indd 87 01-12-2012 10:35:04

88 Operative
If articular incongruity is > 3 mm percutaneous pinning should be done,
e.g. Wagner technique.
Open reduction and fixation is done if:
Closed pinning fails.
Fragment is reasonably large.
Regaining full movements is very much essential for the patient.
Rolando Fracture
It is a comminuted Y-shaped fracture of the base of first metacarpal described
by Rolando in 1910. It usually does not result in diaphyseal displacement as in a
Bennett fracture. It can be managed effectively by percutaneous pinning (Figure
2.12.1).
Section 02.indd 88 01-12-2012 10:35:04

Physeal Injuries
2.13. Physeal Injuries 89
Injuries that involve the physis and epiphysis may cause the cessation of growth
and resultant angular deformities.
Blount established few general rules concerning the prognosis of fractures of
the shafts of long bones and the amount of spontaneous correction of any angular
deformity to be expected. These rules are based on:
Age of the child.
Location of the fracture.
Degree of angulation.
Blounts Laws
Greater angulation is accepted when the child is young and the deformity is
near the end of the bone.
Reduction must be almost perfect when the child is near maturity or if the
fracture is near the middle of the bone.
Spontaneous correction of an angular deformity is greatest when the
angulation is in the plane of motion of a nearby hinged joint.
Rotational deformities are permanent.
The extremities tolerate valgus angulation of the long bones more readily
than varus angulation.
Classifications
Based on Salter and Harris Classification (Figure 2.13.1)
There are various classifications, but the most commonly used classification
is that of Salter and Harris. It is based on the radiographic appearance of the
fracture. This classification depicts the amount of involvement of the physis,
the epiphysis, and the joint. The higher the classification, the more likely is
physeal arrest or joint incongruity to occur. There are five types based on this
classification:
Type I: It is a transphyseal fracture involving the hypertrophic and calcified
zones. It occurs due to shearing force. Prognosis is usually excellent because
of the preservation of the reserve and proliferative zone, although complete
or partial growth arrest may occur in displaced fractures.
Type II: Transphyseal fracture that exits through the metaphysis. The
metaphyseal fragment is identified by the Thurston-Holland sign. The
periosteal hinge is intact on the side with the metaphyseal fragment.
Prognosis is excellent, although complete or partial growth arrest may occur
in displaced fractures.
Type III: Transphyseal fracture that exits the epiphysis causing intra-
articular disruption as well as disrupting the reserve and proliferative zones.
Section 02.indd 89 01-12-2012 10:35:05

90
Figure 2.13.1: Physeal injuries in childrenbased on Salter-Harris classification.
Anatomic reduction and fixation without violating the physis is essential.

Prognosis is guarded, because partial growth arrest and angular deformity
are common complications.
Type IV: Fracture that traverses the epiphysis and the physis, exiting the
metaphysis and disrupting all four zones of the physis. Anatomic reduction
and fixation without violating the physis is essential. Prognosis is guarded,
because partial growth arrest and angular deformity are common complica
tions.
Type V: Crush injury to the cartilage cells of the physis. Usually it is
diagnosed in retrospective. Prognosis is poor, because growth arrest and
partial physeal closure are common.
Ogden devised a more detailed classification that fits almost every fracture
pattern in and around physis. His first five classes are basically the same as those
of Salter-Harris.
Ogden Types VI to IX
Type VI: Injury to the perichondral ring at the periphery of the physis.
Usually it is seen in open injury. Prognosis is guarded, because peripheral
physeal bridges are common.
Type VII: Fractures involving the only epiphysis. It includes osteochondral
fractures and epiphyseal avulsions. Prognosis depends on the location of the
fracture and the amount of displacement.
Section 02.indd 90 01-12-2012 10:35:05

Physeal Injuries
Type VIII: Metaphyseal fracture. Hypervascularity may cause angular 91

overgrowth.
Type IX: Diaphyseal fracture.
Management
Some of the physeal injuries are amenable for closed manipulation and
immobilization.
Indications for Operative Intervention

Open physeal injuries.
Displaced intra-articular physeal injuries (Salter-Harris types III and IV).
Associated vascular injury.
Associated compartment syndrome.
Unstable fractures.
Section 02.indd 91 01-12-2012 10:35:05

Section 3
93
Spine
Section 03.indd 93 01-12-2012 10:36:51

94 3.1. Spine: General ConSiderationS
Epidemiology
There are approximately 11,000 new spinal cord injuries each year with
male/female ratio 4:1.
In older patients (>75 years of age), 60% of vertebral fractures are caused
by a fall.
For patients with a spinal cord injury, the overall mortality during the initial
hospitalization is 17%.
Approximately 2 to 6% of trauma patients sustain a cervical spine fracture.
Anatomy
The spinal cord occupies approximately 35% of the canal at the level of the
atlas (C1) and 50% of the canal in the lower cervical spine and thoracolumbar
segments.
The conus medullaris represents the caudal termination of the spinal cord.
The cauda equina (literally translated means horses tail) represents the
motor and sensory roots of the lumbosacral myelomeres.
A reflex arc is a simple sensorimotor pathway that can function without using
either ascending or descending white matter, long-tract axons. A spinal
cord level that is anatomically and physiologically intact may demonstrate
a functional reflex arc at that level despite dysfunction of the spinal cord
cephalad to that level.
Mechanism of Injury
A long-standing and fundamental problem of spinal injury classification systems
based on presumed mechanism of injury is that the same mechanism of injury
can result in morphologically different patterns of injury; similar morphologic
patterns of injury can also be the result of different injury mechanisms, and the
patterns of head deflection do not predict the spinal injury patterns. Several
characteristics of the injury force that determine the extent of neural tissue damage
have been identified. These include the rate of force application, the degree of
neural tissue compression, and the duration of neural tissue compression.
Primary
Primary injury refers to physical tissue disruption caused by mechanical forces:
Contusion: This sudden, brief compression by a displaced structure affects
central tissues primarily and accounts for the majority of primary injuries and
is thus responsible for the majority of neurologic deficits. Contusion injuries
are potentially reversible, although irreversible neuronal death occurs along
with vascular injury with intramedullary hemorrhage.
Section 03.indd 94 01-12-2012 10:36:51

Spine: General Considerations
Compression: Injury results from decreased size of the spinal canal; it may 95
occur with translation or angulation of the spinal column, as with burst
injuries, or with epidural hematomas. Injury occurs by:
a. Mechanical deformation interrupting axonal flow.
b. Interruption of spinal vascularity resulting in ischemia of neurologic
structures.
Stretch: Injury results in longitudinal traction, as in the case of a flexion-
distraction injury. Injury occurs as a result of capillary and axonal collapse
secondary to tensile distortion.
Laceration: This is caused by penetrating foreign bodies, missile fragments,
or displaced bone.
Secondary
Changes in local blood flow.
Tissue edema.
Metabolite concentrations and concentrations of chemical mediators.
This pathophysiologic response, referred to as secondary injury, can propagate
tissue destruction and functional loss.
Clinical Evaluation
Assess the patient: Airway, breathing, circulation, disability, and exposure
(ABCDE). Avoid the head-tilt-chin-lift maneuver, hypoxia, and hypotension.
Initiate resuscitation: Address life-threatening injuries.
Evaluate the patients level of consciousness.
Evaluate injuries to head, chest, abdomen, pelvis, and spine.
The spine must be protected. Log roll the patient to assess the spinal column,
examine the skin for bruising and abrasions, and palpate spinous processes
for tenderness and diastasis. Evaluate for noncontiguous spinal injuries;
many authors have emphasized the need to evaluate the spinal column for
injuries to more than one level.
Injuries of the vertebral column tend to cluster at the junctional areas: the
craniocervical junction (occiput to C2), the cervicothoracic junction (C7-
T1), and the thoracolumbar junction (T11-L2). These areas represent
regions of stress concentration, where a rigid segment of the spine meets
a more flexible segment. Also contributing to stress concentration in
these regions are changes at these levels in the movement constraints of
vertebrae.
Among these injuries, the most serious and most frequently missed is
craniocervical dissociation.
Three common patterns of noncontiguous spinal injuries are as follows:
Pattern A: Primary injury at C5-7, with secondary injuries at T12 or in the
lumbar spine.
Pattern B: Primary injury at T2-4 with secondary injuries in the cervical spine.
Pattern C: Primary injury at T12-L2 with a secondary injury at L4-5.
Section 03.indd 95 01-12-2012 10:36:52

96 Assess injuries to the extremities.

Complete the neurologic examination to evaluate reflexes, sensation (touch,
pain), and motor function.
Perform a rectal examination to test for perianal sensation, resting tone, and
the bulbocavernosus reflex.
Spinal Shock
Spinal shock is defined as spinal cord dysfunction based on physiologic rather
than structural disruption. Resolution of spinal shock may be recognized
when reflex arcs caudal to the level of injury begin to function again, usually
within 24 hours of injury.
Spinal shock should be distinguished from neurogenic shock, which refers to
hypotension associated with loss of peripheral vascular resistance in spinal
cord injury.
Neurogenic Shock
Neurogenic shock refers to flaccid paralysis, areflexia, and lack of sensation
to physiologic spinal cord shutdown in response to injury.
It is most common in cervical and upper thoracic injuries.
It almost always resolves within 24 to 48 hours.
The bulbocavernosus reflex (S3-4) is the first to return.
It occurs secondary to sympathetic outflow disruption (T1-L2) with resultant
unopposed vagal (parasympathetic) tone.
Initial tachycardia and hypertension immediately after injury are followed by
hypotension accompanied by bradycardia and venous pooling.
Hypotension from neurogenic shock may be differentiated from cardiogenic,
septic, and hypovolemic shock by the presence of associated bradycardia,
as opposed to tachycardia.
Treatment is based on administration of isotonic fluids, with careful
assessment of fluid status (beware of overhydration).
Recognizing neurogenic shock as distinct from hemorrhagic shock is critical
for safe initial resuscitation of a trauma patient. Treatment of neurogenic
shock is pharmacologic intervention to augment peripheral vascular tone. It
may be essential for effective resuscitation. Fluid overload from excessive
fluid volume administration, typical in treatment of hemorrhagic shock, can
result in pulmonary edema in the setting of neurogenic shock.
Bulbocavernosus Reflex
The bulbocavernosus reflex refers to contraction of the anal sphincter in
response to stimulation of the trigone of the bladder with either a squeeze on
the glans penis, a tap on the mons pubis, or a pull on a urethral catheter.
The absence of this reflex indicates spinal shock.
The return of the bulbocavernosus reflex, generally within 24 hours of the
initial injury, hallmarks the end of spinal shock.
Section 03.indd 96 01-12-2012 10:36:52

The presence of a complete lesion after spinal shock has resolved portends a 97
virtually nonexistent chance of neurologic recovery.
The bulbocavernosus reflex is not prognostic for lesions involving the
conus medullaris or the cauda equina (Figure 3.1.1).
Definitions of terms describing spinal cord injury
Impairment Loss of motor and sensory function

Disability Loss in daily life functioning
Tetraplegia Loss of motor and/or sensory function in the cervical
segments
Paraplegia Loss of motor and/or sensory function in the thoracic,
lumbar, or sacral segments
Dermatome Area of skin innervated by sensory axons within each
segmental nerve
Myotome Collection of muscle fibers by the motor axons within each
segmental nerve
Neurologic level The most caudal segment with normal sensory and motor
function on both sides
Sensory level The most caudal segment with normal sensory function on
both sides
Motor level The most caudal segment with normal motor function on
both sides
Skeletal level Radiographic level of greatest vertebral damage
Sensory score Numeric summary value of sensory impairment
Motor score Numeric summary value of motor impairment
Incomplete injury Partial preservation of sensory and/or motor function below
the neurologic level AND sensory and/or motor preservation
of the lowest sacral segment
Complete injury Absence of sensory and motor function in the lowest sacral
segment
Zone of partial Dermatomes and myotomes caudal to the neurologic level
preservation that remain partially innervated. Only used in complete
injuries
Neurogenic and hypovolemic shock
Neurogenic shock Hypovolemic shock

As a result of loss of sympathetic outflow As the result of hemorrhage
Hypotension Hypotension
Bradycardia Tachycardia
Warm extremities Cold extremities
Normal urine output Low urine output
Section 03.indd 97 01-12-2012 10:36:52

98
Figure 3.1.1: Diagrammatic representation of bulbocavernosus reflex. Compression of glans

penis will cause contraction of anal sphincter. Return of this cord mediated reflex indicates
the termination of spinal shock and grave prognosis.
The lateral cervical spine radiograph is routine in the standard evaluation of
trauma patients. Patients complaining of neck pain should undergo complete
radiographic evaluation of the cervical spine, including anteroposterior and
odontoid views.
Lateral radiographic examination of the entire spine is recommended in
patients with spine fractures when complete clinical assessment is impaired
by neurologic injury or other associated injuries.
Computed tomography scans or tomograms may be necessary for cervical
spine clearance in patients with questionable or inadequate plain radiographs
or to assess occipitocervical and cervicothoracic junction.
Magnetic resonance imaging (MRI) may aid in assessing spinal cord or root
injury, as well as degree of canal compromise.
Classification
The functional consequences of spinal cord injury are usually described by terms
that refer to the severity and pattern of neurologic dysfunction:
Complete spinal cord injury.
Incomplete injury.
Transient spinal cord dysfunction.
Section 03.indd 98 01-12-2012 10:36:52

Spinal cord and conus medullaris reflexes 99

Reflex Location of Stimulus Normal Abnormal
lesion response response
Babinski Upper motor Stroking the Toes plantar Toes extend
neuron plantar aspect of flexion and splay
foot proximal
lateral to distal
medial
Oppenheim Upper motor Rubbing the Toes plantar Toes extend
neuron tibial crest flexion and splay
proximal to
distal
Cremasteric T12-L1 Stroking the Upward No motion of
medial thigh motion the scrotum
proximal to of the
distal scrotum
Anal wink S2-S4 Stroking skin Anal No anal sphincter
around anus sphincter contraction
contracts
Bulbocavernosus S3-S4 Squeezing the Anal No anal sphincter
penis in males, sphincter contraction
applying contracts
pressure to
clitoris in females,
or tugging the
bladder catheter
in either
Grading of Neurologic Injury

Spinal Cord Injury: Complete
No sensation or voluntary motor function is noted caudal to the level of
injury in the presence of an intact bulbocavernosus reflex (indicating intact
S3-4 and resolution of spinal shock).
Reflex returns below the level of the cord injury.
It is named by last spinal level of partial neurologic function.
Poor prognosis.
Spinal Cord Injury: Incomplete

Some neurologic function persists caudal to the level of injury after the
return of the bulbocavernosus reflex.
As a rule, the greater the function distal to the lesion and the faster the
recovery, the better the prognosis.
Section 03.indd 99 01-12-2012 10:36:52

100 Sacral sparing is represented by perianal sensation, voluntary rectal motor

function, and great toe flexor activity; it indicates at least partial continuity
of white matter long tracts (corticospinal and spinothalamic).
Descriptions of incomplete cord injury patterns
Syndrome Lesion Clinical presentation

Bell cruciate Long tract injury at the level Variable cranial nerve
paralysis of decussation in brainstem involvement, greater upper
extermity weakness than
lower, greater proximal
weakness than distal
Anterior cord Anterior gray matter, descending Variable motor and pain and
corticospinal motor tract, and temperature sensory loss with
spinothalamic tract injury with preservation of proprioception
preservation of dorsal columns and deep pressure sensation
Central cord Incomplete cervical white matter Sacral sparing and greater
injury weakness in the upper limbs
than the lower limbs
Brown-Squard Injury to one lateral half of cord Ipsilateral motor and
and preservation of contralateral proprioception loss and
half contralateral pain and
temperature sensory loss
Conus medullaris Injury to the sacral cord (conus) Areflexic bladder, bowel,
and lumbar nerve roots within and lower limbs. May have
the spinal canal preserved bulbocavernosus
and micturition reflexes
Cauda equina Injury to the lumbosacral nerve Areflexic bladder, bowel, and
roots within the spinal canal lower limbs
Root injury Avulsion or compression injury Dermatomal sensory loss,
to single or multiple nerve roots myotomal motor loss, and
(brachial plexus avulsion) absent deep tendon reflexes
Nerve Root Lesions

Isolated root lesions may occur at any level and may accompany spinal cord
injury.
This may be partial or complete and results in radicular pain, sensory
dysfunction, weakness, hyporeflexia, or areflexia.
Cauda Equina Syndrome

This is caused by multilevel lumbosacral root compression within the lumbar
spinal canal.
Clinical manifestations include saddle anesthesia, bilateral radicular pain,
numbness, weakness, hyporeflexia or areflexia, and loss of voluntary bowel
or bladder function.
Section 03.indd 100 01-12-2012 10:36:52

Grading Systems for Spinal Cord Injury 101
Frankel Classification
Grade A: Absent motor and sensory function.
Grade B: Absent motor function, sensation present.
Grade C: Motor function present, but not useful (2 or 3/5), sensation present.
Grade D: Motor function present and useful (4/5), sensation present.
Grade E: Normal motor (5/5) and sensory function.
Treatment
Immobilization
1. A rigid cervical collar is indicated until the patient is cleared radiographically
and clinically A patient with a depressed level of consciousness (e.g. from
ethanol intoxication) cannot be cleared clinically.
2. A special backboard with a head cutout must be used for children to
accommodate their proportionally larger head size and prominent occiput.
3. The patient should be removed from the backboard (by logrolling) as soon
as possible to minimize pressure sore formation.
Medical Management of Acute Spinal Cord Injury

Intravenous methylprednisolone:
May improve recovery of neurologic injury.
Is currently considered the standard of care for spinal cord injury if
it is administered within 8 hours of injury; it improves motor recovery
among patients with complete and partial cord injuries.
Has a loading dose of 30 mg/kg:
- 5.4 mg/kg/hour over the next 24 hours if started within 3 hours of
spinal cord injury.
- 5.4 mg/kg/hour over the next 48 hours if started within 8 hours of
spinal cord injury.
Has no benefit, similar to other to steroids, if started more than 8 hours
after injury.
Is not indicated for pure root lesions.
Experimental pharmacologic agents include:
Naloxone (opiate receptor antagonist).
Thyrotropin-releasing hormone.
GMI gangliosides: A membrane glycolipid that, when administered
within 72 hours of injury, resulted in a significant increase in motor
scores. Administer 100 mg/day for up to 32 days after injury. It is not
recommended for simultaneous use with methylprednisolone.
Section 03.indd 101 01-12-2012 10:36:52

102 Complications
Gastrointestinal: Ileus, regurgitation and aspiration, and hemorrhagic gastritis
are common early complications, occurring as early as the second day after
injury. Passage of a nasogastric tube and administration of histamine (H2)
receptor antagonists should be used as prophylaxis against these potential
complications.
Urologic: An indwelling urinary catheter should remain in the patient during
the acute, initial management only to monitor urine output. Following this,
sterile intermittent catheterization should be undertaken to minimize potential
infectious sequelae.
Pulmonary: Acute quadriplegic patients are able to inspire only using their
diaphragm, because their abdominal and intercostal muscles are paralyzed.
Vital capacity ranges from 20 to 25% of normal, and the patient is unable
forcibly to expire, cough, or clear pulmonary secretions. Management of
fluid balance is essential in the patient in neurogenic shock, because volume
overload rapidly results in pulmonary edema with resolution of shock.
Positive pressure or mechanical ventilation may be necessary for adequate
pulmonary function. Without aggressive pulmonary toilet, pooling of
secretions, atelectasis, and pneumonia are common and are associated with
high morbidity and mortality.
Skin: Problems associated with pressure ulceration are common in spinal
cord-injured patients owing to anesthesia of the skin. Turning the patient
every 2 hours, careful inspection and padding of bony prominences, and
aggressive treatment of developing decubitus ulcers are essential to prevent
long-term sequelae of pressure ulceration.
Clearing the Spine

A cleared spine in a patient implies that diligent spine evaluation is complete
and the patient does not have a spinal injury requiring treatment.
The necessary elements for a complete spine evaluation are:
1. History to assess for high-risk events and high-risk factors.
2. Physical examination to check for physical signs of spinal injury or
neurologic deficit.
3. Imaging studies based on an initial evaluation.
Patients with a diagnosed cervical spine fracture have at least one of
the following four characteristics: Midline neck tenderness, evidence
of intoxication, abnormal level of alertness, or several painful injuries
elsewhere. Therefore, criteria for clinical clearance are:
1. No posterior midline tenderness.
2. Full pain-free active range of motion.
3. No focal neurologic deficit.
4. Normal level of alertness.
5. No evidence of intoxication.
6. No distracting injury.
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Radiographs are not necessary for patients who are alert, are not intoxicated, 103
have an isolated blunt trauma, and have no neck tenderness on physical
examination.
The process of clearing the thoracolumbar spine is similar to that for clearing
the cervical spine. Only anteroposterior and lateral view radiographs are
necessary. Patients with clear mental status, no back pain, and no other
major injuries do not need radiographs of the entire spine to exclude a spinal
fracture.
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104 3.2. examination of Spinal injurieS

It is important to understand that a spinal injury has two components. The column
injury which is an injury to the bony structure and spinal cord injury which is
an injury to the neurological system. Both can coexist or can exist separately.
History
Mode of Injury
The type of spinal injury depends on the severity of the violence.
Sudden jolt as may occur in car or bus accident or at the time of lifting
weight from bent position may cause injury to the spinal ligaments.
Fractures and fracture-dislocation usually result from severe violence, e.g.
fall from a height or fall of a heavy weight on the back. Diving in shallow water
may cause dislocation of the cervical vertebrae.
Pure dislocation is not seen in thoracic or lumbar region.
Car accident following a sudden break when the seat-belt is fastened may
cause injury to the lumbar vertebrae. This is commonly known as seat-belt
injury. In civil life most injuries are due to indirect violence and the most
common site of lesion is about C6.
The second most frequent site is in the region of L1.
The thoracic region is seldom involved.
Neurological Deficit
If there is paralysis, enquire into the time and mode of its onset.
Immediate paralysis is due to compression or crushing of the spinal cord in
fracture-dislocation.
Paraplegia which has occurred late and is gradually extending upwards may be
due to traumatic intraspinal hemorrhage. Hemorrhage may occur within the
cord itself (hematomyelia) or in the extramedullary region (hematorrachis).
The patient must be asked whether there is any sense of constriction around
the trunk (girdle pain). If present, note its level.
The Frankel grade, according to the Congress of Neurological Surgeons,
serves as a classification guide for spinal injuries. When a spinal cord injury
occurs, patients are often told they have an injury at a given spinal cord level
and are given a qualifier indicating the severity of injury, such as complete or
incomplete.
A - Complete neurological injury. No motor or sensory function detected
below level of lesion.
B - Preserved sensation only. No motor function detected below level of
lesion, some sensory function below level of lesion preserved.
C - Preserved motor, nonfunctional. Some voluntary motor function
preserved below level of lesion but too weak to serve any useful
purpose, sensation may or may not be preserved.
Section 03.indd 104 01-12-2012 10:36:53

Examination of Spinal Injuries
D - Preserved motor, functional. Functionally, useful voluntary motor 105

function below level of injury is preserved.
E - Normal motor function. Normal motor and sensory function below
level of lesion, abnormal reflexes may persist.
Grading of Muscle Power by Medical Research Council, London

0. Complete paralysis.
1. Flicker of contraction.
2. Contraction with gravity eliminated alone.
3. Contraction against gravity alone.
4. Contraction against gravity and some resistance.
5. Contraction against powerful resistance.
Examination for Spinal Cord Injuries

This should be carried out before examination of the spinal column since in
presence of cord lesion, patient should be disturbed as little as possible.
Upper Limbs
Attitude: According to the level of fracture-dislocation of the cervical region,
the upper extremities assume a characteristic attitude.
A. If they lie immobile against the trunk and completely paralyzed the level of
injury is at the 5th cervical segment because of paralysis of all the muscles
of the upper limb below the shoulder level. Any severe lesion above this
level will cause paralysis of the phrenic nerve and will lead to respiratory
paralysis and death.
B. When the lesion is at the 6th cervical segment the patient lies helplessly on
the back with the arm abducted and externally rotated and the forearm flexed
and supinated. The attitude is caused by irritation of the 5th cervical segment
which supplies supraspinatus and deltoid to cause abduction of the shoulder.
Infraspinatus and teres minor to cause lateral rotation of the shoulder; biceps
causes flexion and supination of forearm.
C. In lesion of the 7th cervical segment the arm is partially abducted and
internally rotated with the forearm flexed and pronated possibly due to
irritation of the 6th cervical segment which supplies teres major, anterior
fibers of deltoid and subscapularis to cause internal rotation of shoulder;
biceps and mainly brachioradialis to cause midprone flexion of elbow.
D. In case of lesion of the 8th cervical and 1st dorsal segments there will be
paralysis of the intrinsic muscles of the hand and will lead to a deformity
known as main-en-griffe.
E. Any lesion below the 1st dorsal segment will not cause any impairment of
the movement of the upper extremities up to the finger tips.
Sensation: Sensation of various parts of the upper limb is tested by pin prick, a
wisp of cotton, a test tube with cold or hot water or with reverse of a tuning fork.
Section 03.indd 105 01-12-2012 10:36:53

106 Loss of sensation will be according to the level of cord lesion. There is a zone of
hyperesthesia between the normal and anesthetic skin (Figures 3.2.1A and B).
Muscle power: This is tested of various muscles against resistance. According
to the level of cord lesion, various muscles of the upper limb will lose power.
Reflexes of Upper Extremity

Biceps reflexC5
Brachioradialis reflexC6
Triceps reflexC7
Lower Limbs
Attitude: The whole of the lower limb will be paralyzed when the level of the
spinal cord injury is at or above 10th thoracic vertebra.
When the injury is below the 1st lumbar vertebra only the cauda equina will
be injured and the lower limb below the knee will be affected and will lie flaccid
paralyzed.
Muscle power: If the patient walks, it may be assumed that there is no injury to
the cord. In the supine position the patient is asked to move his ankles and toes
against resistance. The patient is also asked to raise the legs one after the other.
By this one can assess the muscle power of the lower limb muscles. Similarly,
the patient is asked to move the upper limb against resistance.
Sensation: Loss of sensation will be according to the level of cord lesion or
injury to the cauda equina. Run the point of a pin from anesthetic to the normal
area and note if there is a zone of hyperesthesia intervening (Figures 3.2.2A
and B).
A B
Figures 3.2.1A and B: Pictorial depiction of various dermatomes. Actually there is
considerable overlap between the adjacent dermatomes.
Section 03.indd 106 01-12-2012 10:36:53

107
A B
Figures 3.2.2A and B: Dermatomes and autonomous sensory
zones of lower limb.
In cauda equina lesion, the sacral roots may be involved producing anesthesia
in the back of the legs and a saddle area of the perineum with urinary retention.
Reflexes: Initially all the reflexes may be lost during the stage of spinal shock.
Gradually, the reflexes reappear according to the level of the lesion. The time
lapse between disappearance and reappearance of the reflexes depends on the
severity of the cord lesion. In severe cases it may take as long as 3 weeks for
the return of reflexes.
If the reflexes fail to return by this time complete transverse section of the
cord may be suspected.
Signs of Grave Prognosis

If the cord transection is complete the prognosis is poor. During the stage of
spinal shock there is flaccid paralysis with absence of perianal sensation and
complete lumbar and sacral areflexia which may last for 24 hours to 7 days.
Return of bulbocavernosus reflex and anal wink which are normal cord mediated
reflexes signifies the termination of the stage of spinal shock and indicates grave
prognosis.
Bulbocavernosus Reflex (Figure 3.1.1)

It is a polysynaptic reflex mediated through S1, S2, S3 segments of the spinal
cord. The reflex is elicited by applying compression over the glans penis by
squeezing or tugging on indwelling catheter at the same time monitoring reflex
contraction of anal sphincter.
Section 03.indd 107 01-12-2012 10:36:53

108 Anal Wink

Otherwise known as anal reflex, perineal reflex, anocutaneous reflex is mediated
through S1, S2, S3, segments of the spinal cord. The pudendal nerve carries
these signals to the spinal centers.
The reflex is elicited by using a sharp pin and inducing a noxious tactile
stimulus on the skin around the anal sphincter. This results in reflex contraction of
the sphincter indicating the intactness of the reflex arc (Figures 3.2.3A and B).
Interpretation
i. Absence of the reflexstage off spinal shock.
ii. Return of the reflexspinal shock has passed off and prognosis is grave.
iii. If spinal shock does not exist/not suspected but the reflexes are absent,
these tests indicate that there can be conus medullaris or cauda equina
lesion.
The bladder center is situated at the lumbar enlargement representing the S2, S3,
S4 sacral segments. This center is concerned in supplying the detrusor muscle of
Figure 3.2.3A: Diagrammatic representation of testing perianal anesthesia. Persistence of

anesthesia is an indicator of complete cord injury. Discrimination between sharpness and
dullness when present indicates incomplete injury.
Figure 3.2.3B: Diagrammatic representation of anal reflex. Return of this reflex after termi-
nation of spinal shock in a person who remains as a quadriplegic indicates grave prognosis.
Section 03.indd 108 01-12-2012 10:36:53

the bladder and injury to this level of cord will lead to paralysis of the detrusor 109
muscle resulting in overflow incontinence. The bladder is an autonomous bladder
(Figure 3.2.3C).
The patient, however, retains the nerve supply of the abdominal muscles
which may be contracted voluntarily at a time interval to evacuate the bladder.
This process may be assisted by suprapubic compression with the help of the
patients both hands (Figure 3.2.3D).
In case of lesion of the spinal cord above the lumbar enlargement after an
initial phase of retention due to spinal shock, the bladder reflexes reappear and
become uninhibited by the superior control resulting in an automatic bladder,
i.e. the bladder evacuates by itself as soon as the intravesical pressure rises to a
certain extent.
Note the nature of the respiration. It is abdominal type in lesion above T2
due to paralysis of the intercostal muscles. Diaphragm which supplied by the
phrenic nerve (C 2,3,4) is intact and is responsible for this type of breathing.
Look for the distended bladder, incontinence of urine and priapism (persistent
erection of the penis). In long-standing cases one may expect presence of trophic
ulcerbed sores over the pressure points.
Figure 3.2.3C: Diagram showing the normal mechanism of voiding of urine and the level of
lesions responsible for the development of automatic and autonomous bladder.
Figure 3.2.3D: Credes maneuver. Firm suprapubic pressure is applied to express the urine
from the bladder.
Section 03.indd 109 01-12-2012 10:36:54

110 Reflexes of Lower Extremity

KneeL2, L3, L4
AnkleL5, S1
Superficial reflexes
AbdominalT8 to T12
CremastericL1, L2
AnalS1, S2 and S3
Examination of the Spinal Column

When the patient is brought in with paralysis, utmost care has to be exerted
during the examination of the spinal column.
If the patient is rotated, the unstable fracture may increase damage to the
spinal cord. Even without paralysis these cases should be handled with extreme
care.
The patient may be lifted by an assistant just sufficiently to permit the
surgeons hand to be introduced under the site of the lesion.
The patient may be examined in a better way if he is very carefully turned
by at least two, preferably by three persons onto one side.
Inspection: At first the skin of the back is inspected for presence of any abrasion
or braising to indicate the probable level of injury. One should also look for a
swelling, which may indicate a hematoma or a prominent spinous process due
to fracture-dislocation.
Palpation: First of all the spinal column is palpated by running a finger along
the spinous processes and transverse processes. Holdsworth test is performed
by running a finger along the spinous processes. Abnormal gap in the line of
the spinous processes indicates tear in the interspinous ligament which indicates
unstable fracture.
Abnormal prominence of a spinous process indicates fracture-dislocation of
the spine, the most prominent spinous process is the one below the displaced
vertebra.
In compression fracture the most prominent spine is the one above the
crushed vertebra. Swelling in this region usually indicates a hematoma which
will elicit fluctuation.
Pressure is exerted along the line of the spinous processes of the vertebrae
with the thumb of the clinician.
In case of sprain of the spinal column, there will be localized tenderness at
the site of the ligamentous injury. If the muscle fibers are torn similar tender spot
can be elicited.
In fracture of the vertebra, however minor, will produce tenderness when
pressure is exerted on the corresponding spinous process.
Sometimes abnormal mobility maybe elicited which should not be routinely
looked for as it may increase injury to the spinal cord.
Section 03.indd 110 01-12-2012 10:36:54

Percussion: It is done gently with fingertip over the spinous processes. This 111
elicits tenderness if there is fracture of the spinal column.
Movements of the spinal column are not tested at this stage until and unless
the clinician is sure that the patient is not having any fracture of the spinal
column which may cause injury to the spinal cord due to such movement.
Rectal examination will help in detecting fracture of the coccyx.
General Examination
In case of spinal injury the patient must be examined generally to exclude any
other associated injury:
Abdominal injury: More fatal and requires immediate surgical intervention.
Head injury: A careful watch must be made all throughout the scalp along
with palpation to exclude such injury.
Thoracic injury: Transverse pressure towards the midline from both sides of
the thoracic cage will elicit tenderness if there is any fracture of the rib or
sternum.
To exclude sternal fracture the clinician should press along the sternum from
above downwards for its whole extent. Sternal fracture is often missed.
Injury to the pelvis injury: Excluded by a transverse pressure on both the
iliac crests with both hands towards the midline. Fracture of the ilium will
show tenderness.
Lastly, one should exclude any injury to the limb which may be associated
with such type of injury.
Special Investigations
X-ray examination: Two views anteroposterior and lateral must always be
taken to compare the depths of the vertebrae.
Slight diminution of the depth of one vertebra as seen in the lateral view is
the only finding in wedge or compression fracture.
It may be emphasized here that there will be no narrowing of the intervertebral
space.
In case of fracture-dislocation the line of the posterior surfaces of the bodies
of the vertebrae is noted.
If any vertebra has encroached on the spinal canal, that vertebra is supposed
to be fracture-dislocated.
A fracture of the transverse process of the vertebra is best seen in the antero-
posterior view.
Diagnosis of Specific Types of Spinal Injuries

Fracture of the spine is often associated with damage to the spinal cord:
Stable: Associated with cord damage and movement of the spine is safe.
Unstable fractures are either associated with cord damage or if not, movement
of the spine can damage the spinal cord.
Section 03.indd 111 01-12-2012 10:36:54

112 Stability does not depend on the fracture itself only, but on the integrity of
the ligaments, particularly the posterior ligament complex, being formed by
the supraspinous, interspinous ligaments, the capsules of the facet joints and
possibly the ligamentum flavum.
Burst fracture: Here the compression force acts on the straight position of the
spine. The body of the vertebra fractures vertically. This is an unstable injury.
Backward hinge (Extension injury): In the cervical region it may fracture atlas
or axis, anterior ligaments may tear. This is also stable injury. In the lumbar
region it may result in fractured lamina. Young toddler, who falls on his buttock,
may sustain such an injury and may be the starting point of spondylolisthesis.
Forward hinge (Flexion injury): It is common in lumbar vertebrae. The
posterior ligaments will remain intact but the body of the vertebra crumbles.
This is stable. These injuries are rare in the neck as the chin touches the sternum
before any fracture occurs.
Shearing force: It causes instability. Rotation causes ligamentous damage.
Usually rotation is associated with flexion. A slice of bone may be sheared off
the top of one vertebra and the posterior facet is fractured.
Fractures of the spinous processes, transverse processes and laminae are
grouped under the nomenclature of incomplete fractures. These are mostly
due to direct violence. Spinous processes are most liable to fracture in the
dorsal region, and Shovellers fracture of the 7th cervical spine is really a stress
fracture. Transverse processes are most prone to be fractured in the lumbar
region as they are longer and rather unprotected.
Dislocation of the spine: A dislocation without fracture occurs mostly in the
cervical region. The oblique and vertical directions of the articular processes in
the thoracic and lumbar regions, respectively, will not allow dislocation without
a fracture. Barring dislocation following hanging, which occurs between the
atlas and axis, dislocation of the cervical spine usually occurs between the 4th
and 5th or 5th and 6th, caused by acute flexion resulting from fall on the head.
In unilateral cases, the head is deviated to the opposite side with severe pain
referred along the corresponding nerve root which is nipped in the intervertebral
foramen. In the lumbar spine a comparable mechanism occurs in the so called
seat-belt fracture, where following a car accident the body is thrown forward
against the seat-belt. The posterior ligaments are torn but there may be no
fracture. The spine, however, is angulated and the upper facet may leap-frog
over the lower.
The section to follow gives information about different types of injuries
seen in the spine.
Section 03.indd 112 01-12-2012 10:36:54

Spinal Injuries, Classification and Management
3.3. Spinal injurieS, ClaSSifiCation and manaGement 113
Upper Cervical Spine C1, 2 (Figures 3.3.1A and B)

To visualize upper cervical spine open mouth view should be taken; distance
between odontoid process and lateral masses should be equal on both sides.
Cervical Spine (Figures 3.3.2 and 3.3.3)

Patient complaining of neck pain should undergo complete radiographic
evaluation of the cervical spine, including anteroposterior (AP), lateral, oblique
view and odontoid views.
One must visualize the atlanto-occipital junction, all seven cervical vertebrae,
and the cervicothoracic junction (as inferior as the superior aspect of T1).
This may necessitate downward traction on both upper extremities or a
swimmers view (upper extremity proximal to the X-ray beam abducted 180
degrees, axial traction on the contralateral upper extremity, and the beam
directed 60 degrees caudad).
Lateral cervical spine radiograph detects 85% of cervical spine injuries.
On the lateral cervical spine radiograph, following things should be noted:
Acute kyphosis or loss of lordosis.
Continuity of radiographic lines; anterior vertebral line, posterior vertebral
line, facet joint line, or spinous process line.
Widening or narrowing of disk spaces.
Increased distance between spinous process or facet joints.
Abnormal retropharyngeal swelling, which depends of the level in question;
1. At C1: >10 mm.
2. At C3, C4: > 4 mm.
3. At C5, C6, C7: > 15 mm.
Cervical Spine Injuries

Injuries to Upper Cervical Spine (Occiput to C2)
1. Dislocations of atlanto-occipital joint (Figures 3.3.4A to C)
Almost always fatal
A B
Figures 3.3.1A and B: Normal C1-2 spine X-ray.
Section 03.indd 113 01-12-2012 10:36:54

114
A B
Figures 3.3.2A and B: Normal lower cervical spine X-rays anteroposterior (AP) and lateral.
A B
Figures 3.3.3A and B: Normal lower cervical spine X-rays oblique and swimmers.
A B C
Figures 3.3.4A to C: Atlanto-occipital injuries.
Section 03.indd 114 01-12-2012 10:36:54

2. Atlas fracture (Figures 3.3.5A to C) 115

A. Posterior arch fracture-treatment is halo vest/cervical orthosis 812
weeks.
B. Lateral mass fracture-treatment is as follows:
Undisplaced to minimal displaced:
Halo vest/cervical orthosis 812 weeks.
Displaced laterally > 7 mm beyond the articular surfaces of the axis:
Reduction followed by halo traction for 36 weeks followed and
subsequently maintained in halo vest.
C. Burst fracture (Jefferson)treatment is same as lateral mass fracture.
3. Rupture of transverse ligament
Pure ligamentous injury
Lateral views should be carefully checked for retropharyngeal hematoma,
which suggests an acute injury, and for small flecks of bone avulsed off the
lateral masses of C1.
Anterior widening of the atlanto-dens interval of more than 5 mm on the
flexion view suggests that the transverse ligament is incompetent. Flexion
and extension views should be made under the supervision of the physician,
and the patient must be closely monitored for alterations in neurological or
respiratory function.
Two types:
Type I: Disruptions of the substance of the ligament. Initial treatment consists
of immobilization through skull traction and then posterior stabilization of
the C1-2 with a Gallie type of fusion.
Type II: Fractures and avulsions involving the tubercle insertion of the
transverse ligament on the lateral masses of C1. Treatment is by rigid
cervical orthosis.
4. Rotary subluxation of C1 on C2
Presents with torticollis and restricted neck motion open-mouth view
reveals wink sign caused by overriding of the C1-2 joint on one side and
a normal configuration on the other side. Acute rotary subluxation of C1-2
can be reduced by closed means followed by halo vest immobilization for
812 weeks. Late detection needs wiring of C1-2 and posterior cervical
arthrodesis.
B C
Figures 3.3.5A to C: Atlas fractures.
Section 03.indd 115 01-12-2012 10:36:55

116 5. Occipital condyle fractures

Based on Anderson and Montesano classification these are classified into type
Iimpaction, type IIbasilar skull fracture. Both types are stable injuries
and treated in cervical orthosis for 12 weeks, type IIIavulsion fracture
unstable injuries and are treated with trial of halo vest and if unsuccessful
then posterior cervical arthrodesis.
6. Axis fracture
a. Dens fracture (Figures 3.3.6A to C)
Based on Anderson and DAlonzo dens fractures are classified into:
Type I: Oblique fractures of the odontoid; uncommon, treated with
cervical orthosis.
Type II: Fracture of the neck at the junction with the body; unstable,
translation of >5 mm needs posterior cervical arthrodesis.
Type III: Fracture involving the body; good rates of union due to a large
cancellous base.
Undisplaced fractures halo vest immobilization. Displaced fracture
requires reduction halo traction followed by a halo vest for 812 weeks.
b. Traumatic spondylolisthesis of the axis (Hangman fractures) (Figures
3.3.7A to D)
Based on Levine and Edwards classification there are three types:
Type I: Minimally displaced, stable, treated by 12 weeks of immobiliz-
ation in a rigid cervical orthosis.
Type II: Result in anterior transla tion and significant angulation.
Treatment consists of application of skull traction through tongs or a
halo ring with slight extension of the neck over a rolled up towel for 3 to
6 weeks followed by a halo vest 612 weeks.
Type III: Combined bipedicular fracture with posterior facet injuries.
They have both severe angulation and translation of the neural arch
C
Figures 3.3.6A to C: Dens fractures.
Section 03.indd 116 01-12-2012 10:36:55

117
A B
C D
Figures 3.3.7A to D: Traumatic spondylolisthesis of axis.
fracture and unilateral or bilateral facet dislocation at C2-3 bilateral

oblique wiring and posterior cervical fusion C2-3 level, with halo vest
immobilization for 3 months.
Note: Most of these fractures are lethal. Mortality rate is high.
Injuries to Lower Cervical Spine (C3-7)

They are classified according to the:
a. Mechanism of injury (Allen et al).
b. Anatomical structures injured.
1. Posterior ligamentous injury.
2. Unilateral facet dislocation.
3. Fractures of vertebral body (Figure 3.3.8).
1. Compressive flexion (shear mechanism resulting in teardrop fractures)
(Figure 3.3.9)
Stage I: Blunting of anterior body, posterior elements remain intact.
Stage II: Beaking of the anterior portion of the body; along with loss
of anterior vertebral height.
Stage III: Occurrence of inferior subchondral plate fracture.
Stage IV: Posterior subluxation (inferoposterior) <3 mm into the spinal
canal.
Stage V: Teardrop fracture; posteroinferior margin >3 mm into
the spinal canal, failure of the posterior ligaments including posterior
longitudinal ligament.
Section 03.indd 117 01-12-2012 10:36:55

118
Figure 3.3.8: Unifacetal cervical dislocation.
Figure 3.3.9: Sequence of events in a compressive flexion.
2. Vertical compression (Burst fractures) (Figure 3.3.10)

Stage I: Superior or inferior endplate fractures with no displacement.
Stage II: Fracture through both endplates with minimal displacement.
Stage III: Burst fracture with displace ment of fragments both peri-
pherally and into the spinal canal.
3. Distractive flexion (dislocations) (Figures 3.3.11 and 3.3.12)
Stage I: Ligament failure posteriorly with divergence of the spinous
processes, and facet subluxation.
Stage II: Unilateral facet disloc ation with translation always < 50%.
Stage III: Bilateral facet dislocation with translation of 50% or > 50%
and perched facets.
Stage IV: Bilateral facet dislocation with 100% translation (total
dislocation).
4. Compression extension (Figure 3.3.13)
Stage I: Unilateral vertebral arch (laminar) fracture.
Stage II: Bilateral laminar fracture without other tissue failure.
Section 03.indd 118 01-12-2012 10:36:55

119
Figure 3.3.10: Sequence of events in a vertical compression.
Figure 3.3.11: Sequence of events in a distractive flexion.
A B
Figures 3.3.12A and B: Cervical spine fracture dislocation.
Section 03.indd 119 01-12-2012 10:36:56

120
Figure 3.3.13: Compressive extension.
Stages III and IV: These are between stages II and V and explained
theoretically.
Stage V: Bilateral vertebral arch fracture with full vertebral body
displacement anterio rly with complete ligamentous failure both at the
posterosuperior and anteroinferior margins.
5. Distractive extension (Figure 3.3.14)
Stage I: Failure of anterior ligament complex or transverse fracture of
the vertebral body resulting in widening of the disk space without any
posterior displacement.
Stage II: Stage I plus failure of posterior ligament complex along with
superior displacement of the body into the canal.
6. Lateral flexion
Stage I: Unilateral compression fracture of the vertebral body plus a
vertebral arch fracture on the ipsilateral side without displacement.
Stage II: Ipsilateral displacement of the arch on the anteroposterior (AP)
view or failure of the ligaments on the contralateral side with articular
process separation.
Treatment depends upon the osseoligamentous structures injured and the
resultant instability.
Figure 3.3.14: Sequence of events in a distraction extension.
Section 03.indd 120 01-12-2012 10:36:56

Treatment 121
Immobilization with cervical orthosis (for stable fractures) or Gardner-Wells
tongs traction (for unstable injuries).
Vasopressor support is indicated for suspected neurogenic shock.
Patient with neurologic injuries should be considered for intravenous
methylprednisolone per NASCIS II and III protocol (30 mg/kg loading dose
and then 5.4 mg/kg for 24 hours if started within 3 hours, for 48 hours if
started within 8 hours. Steroids have no benefit if they are started more than
8 hours after injury.
Surgical stabilization of lower cervical spine (C3-C7):
1. Posterior decompression and fusion.
2. Bilateral lateral mass plating.
3. Anterior decompression and fusion.
Thoracic and Lumbosacral Injuries
Thoracolumbar Fractures
Three-column theory proposed by Denis to understand thoracolumbar injuries
divides the spine into an anterior column made up of anterior longitudinal
ligament, the anterior half of the vertebral body, and the anterior portion of
the annulus fibrosus, the middle column consisting of the posterior longitudinal
ligament, the posterior half of the vertebral body, posterior aspect of the annulus
fibrosus and the the posterior column includes the neural arch, the ligamentum
flavum, the facet capsules, and the interspinous ligaments.
McAfee et al classified according to the mechanism of injury into:
1. Wedge compression fractures: Isolated failure of the anterior column due
to forward flexion. Rarely associated with neurological deficit except when
multiple adjacent vertebral levels are affected.
2. Stable burst fractures: Middle columns fail due to a compressive load, with
no loss of integrity of the posterior elements.
3. Unstable burst fractures (Figures 3.3.15A and B)
Anterior and middle columns fail in compression, and posterior column is
disrupted. There is a tendency for post-traumatic kyphosis and progressive
neural symptoms because of instability.
4. Chance fractures: Horizontal avulsion injuries of the vertebral bodies caused
by flexion about an axis anterior to the anterior longitudinal ligament.
5. Flexion distraction injuries: Flexion axis is posterior to the anterior
longitudinal ligament. The anterior column fails in compression while the
middle and posterior columns fail in tension. This injury is unstable because
the ligamentum flavum, interspinous ligaments, and supraspinous ligaments
usually are disrupted
6. Translational injuries: The neural canal is disrupted. Usually all three
columns have failed in shear. At the affected level, the spinal canal has been
displaced in the transverse plane (Figures 3.3.16A and B).
Section 03.indd 121 01-12-2012 10:36:56

122
A B
Figures 3.3.15A and B: Burst fracture thoracolumbar (TL) spine.
A B
Figures 3.3.16A and B: Thoracolumbar spine fracture dislocation.
Treatment
1. Wedge compression fractures
Stable fractures are treated with an extension orthosis (Jewett brace or
thoracolumbar spinal orthosis).
Unstable fractures are treated with hyperextension casting or open
reduction and internal fixation.
2. Stable burst fractures
Hyperextension casting.
3. Unstable burst fractures
Anterior, posterior and combined approaches are used for fixation.
4. Chance fractures
Hyperextension casting one level bony injuries.
For injuries with compression of the middle and posterior columns with
ligamentous disruption posterior spinal fusion with compression should
be performed.
Section 03.indd 122 01-12-2012 10:36:56

5. Flexion distraction injuries 123

Generally, these are highly unstable injuries that require surgical
stabilization.
Posterior surgery is usually most useful for achieving reduction and
stability in these injuries (Figures 3.3.17A and B).
Sacral Fractures (Figure 3.3.18)

1. Region of the ala.
2. Region of the sacral foramina.
3. Region of the central sacral canal.
Lumbosacral Dislocation
Type I: Unilateral facet dislocation with or without facet fracture.
Type II: Bilateral facet dislocation with or without facet fracture.
A B
Figures 3.3.17A and B: Thoracolumbar fracture fixation.
Figure 3.3.18: Sacral fracture along with pelvis fracture.
Section 03.indd 123 01-12-2012 10:36:56

124 Type III: Unilateral facet dislocation and contralateral facet fracture.
Type IV: Dislocation of the body of L5 with bilateral fractures of the pars
interarticularis.
Type V: Dislocation of the body of L5 with fracture of the body or pedicle with
or without injury to the lamina or facet.
Spinal Injuries Peculiar to Children

Atlantoaxial Rotatory Subluxation
Type I: Simple rotatory displacement without anterior shift of C1.
Type II: Rotatory displacement with anterior shift of 5 mm or less C1 on C2.
Type III: Rotatory displacement with anterior shift of C1 on C2 > 5 mm.
Type IV: Rotatory displacement with a posterior shift.
Section 03.indd 124 01-12-2012 10:36:56

Clinical Diagnosis of Peripheral Nerve and Brachial Plexus Injuries
Section 4
125
Clinical Diagnosis
of Peripheral
Nerve and Brachial
Plexus Injuries
Section 04.indd 125 01-12-2012 10:38:49

126 4.1. Clinical Diagnosis of Peripheral Nerve and

Brachial Plexus Injuries
Classification of Nerve Injury

Based on Seddon's classification (1943):
A. Neuropraxia
In this, the injury is either contusion or compression of the nerve. There is
a physiological block in conduction of the nerve impulse but the anatomical
continuity is preserved. It is the result of transient ischemia. No Wallerian
degeneration observed. Recovery is complete, e.g. Saturday night palsy,
crutch palsy, etc.
B. Axonotmesis
In this, the axons break but the endoneurial tube is preserved. Occurs as a
result of traction and stretching of the nerve. Though Wallerian degeneration
occurs, good functional recovery is possible because of the intact nerve
sheath, e.g. birth injury (except avulsion injury), tardy ulnar nerve palsy,
etc.
C. Neurotmesis
Complete division of the nerve. Both nerve fibers and sheath are disrupted.
May be partial or complete. Recovery is impossible without repair. Failure
to recover and poor recovery is not uncommon. At times need secondary
reconstructive procedures to gain useful function.
Based on Sunderland classification (1951): (In brief)
I Degree Neuropraxia of
Conduction of the nerve is interfered. Seddon's

II Degree
Continuity of the axon is interfered.
III Degree These represent varying
Continuity of the endoneurial tube and its grades of axonotmesis of

contents is interfered Seddons
IV Degree
Continuity of the funiculus and its
contents is inerfered
V Degree
Continuity of the entire nerve trunk is interfered Neurotmesis of
(Disruption of the entire nerve) Seddons

VI Degree of Mackinnon-Dellon (1988)
A combination of varying grades of Sunderlands which co-exist in the same
nerve. It means a part of the nerve may have neuropraxia. Other part may have
axonotmesis.
Section 04.indd 126 01-12-2012 10:38:49

Diagnosis 127
Diagnosis is done on the basis of clinical evaluation of autonomic disturbance,

sensory changes, motor changes and by performing relevant special tests.
Sensory and motor loss develops immediately after injury. Autonomic
disturbance though present after injury, takes sometime to establish. Certain
changes develop progressively over a period of time and are seen after a few
weeks, e.g. muscle wasting.
A scar/penetrating wound along the course of the nerve especially at right
angles indicates the possibility of neurotmesis.
Autonomic and Sensory Changes

a. Smoothness and dryness of the skin.
b. Atrophy of the pulp and conical tapering of the digits.
c. Brittle nails.
d. Loss of callosities and creases.
e. Absence of sweating.
f. Trophic ulcers.
g. Loss of sensation over the sensory area supplied by the peripheral nerve
especially in the autonomous zone.
Sensory Zones of a Peripheral Nerve

Three zones are recognized. They are the maximal zone, the intermediate zone,
and the autonomous zone.
Maximal zone: Maximal area supplied by a peripheral nerve.
Intermediate zone: It is the area of overlap of the maximal zone of the different
peripheral nerves.
Autonomous zone: Area exclusively supplied by a particular peripheral nerve
(Figures 4.1.1A to E).
Sensory loss over the autonomous zone is a sure sign of a particular
peripheral nerve injury. Of immense help in a quick diagnosis especially in a
case of polytrauma.
Motor Changes
a. Paralysis of the muscles supplied by the peripheral nerve resulting in loss of
function.
b. Pathognomonic deformities as a result of muscle imbalance.
Median nerve: Injury at a higher level, results in both ape thumb (Figure
4.1.2) and pointing index deformity (Figure 4.1.3).
Injury at a lower level, results in only an ape thumb deformity
Ulnar nerve: Ulnar claw hand (Figure 4.1.4).
Section 04.indd 127 01-12-2012 10:38:49

128
A B
C D
E
Figures 4.1.1A to E: Autonomous zones of different peripheral nerves: (A) Radial nerve;
(B) Median nerve; (C) Ulnar nerve; (D) Common peroneal nerve; (E) Sciatic nerve.
Figure 4.1.2: Normal hand (left) where the thumb is placed at right angles to the other fingers
and the hand with thumb deformity (right) where the thumb is remaining by the side of the
other fingers. (For color version, see Plate 4)
Section 04.indd 128 01-12-2012 10:38:49

129
Figure 4.1.3: A positive Ochsners clasp test and the pointing index sign.
Figure 4.1.4: A classical ulnar claw hand with hyperextension at the metacarpophalangeal
joints and flexion at the interphalangeal joints of ring and little finger only. Hypothenar muscle
atrophy is pronounced. Note the scar at the elbow along the course of the nerve (marked by an
arrow) which indicates possibility of neurotmesis of the nerve. (For color version, see Plate 5)
Combined ulnar and median nerve: Simian hand (hand of an Ape)

Radial nerve: Wrist drop (Figure 4.1.5A)
Posterior interosseous nerve: Finger drop and thumb drop (Figure 4.1.5B).
Sciatic nerve: Flail foot.
Posterior tibial nerve: Claw toes.
Lateral popliteal nerve: Foot drop.
Section 04.indd 129 01-12-2012 10:38:49

130
A B
Figures 4.1.5A and B: The classical attitude of: (A) Wrist drop; and
(B) Finger drop. (For color version, see Plate 6)
These pathognomonic deformities when present are diagnostic of a peripheral

nerve injury.
Special Tests
a. Ochsners clasp test.
b. Pen test.
c. Card test.
d. Book test and Froment's sign.
e. Igawas sign.
f. Tinels sign.
Median Nerve
Ochsners Clasp Test

This is a test employed to diagnose high median nerve injury. It is performed
by asking the patient to clasp the hands. When there is high median nerve injury
the index finger remains straight and points forwards (pointing index) indicating
paralysis of its flexor digitorum superficialis and flexor digitorum profundus.
The test is positive when there is pointing index.
Though median nerve supplies the lateral two profundi the middle finger
does not point. This is because the middle finger profundus takes origin from a
common aponeurosis for medial two profundi which are supplied by the ulnar
nerve. Hence, when the medial two profundi contract to some extent the middle
finger profundus also contracts (Figure 4.1.3).
Pen Test
This is a test employed to test the abductor pollicis brevis muscle. The test is
done by asking the patient to place the hand flat on the table with the palm facing
upwards and keeping a pen at some distance over the thumb. Next he is asked
Section 04.indd 130 01-12-2012 10:38:50

to touch the pen with his thumb. If the patient is able to touch the pen with his 131
thumb abducted, the test is negative. If the patient is not able to touch the pen,
the test is positive.
The test is positive both in high and low median nerve injury (Figure 4.1.6).
Ulnar Nerve
Card Test
This is a test employed to test the interossei muscle. The function of the
palmar interossei is adduction and the dorsal interossei is abduction. The test is
performed by asking the patient to hold a card inserted between the two fingers.
During the process, first the finger abducts and then while gripping the card it
adducts. The test is said to be positive when the patient is not able to grip the
card between the fingers and card is easily pulled out by the examiner who uses
a similar grip to pull out the card (Figure 4.1.7).
Figure 4.1.6: A negative pen test. The person is able to touch the pen using his abductor
pollicis brevis. (For color version, see Plate 6)
Figure 4.1.7: Card test being performed. Note that both the examiner and the subject to be
examined should use the same grip, i.e. interdigital clasp. (For color version, see Plate 6)
Section 04.indd 131 01-12-2012 10:38:50

132 Book Test and Froments Sign

It is a test employed to test the adductor pollicis muscle. The patient is asked to
hold a book in the 1st web space. The examiner holds the same book in a similar
manner and tries to pull out the book. When adductor pollicis is paralyzed
the patient uses flexor pollicis longus to hold the book and prevent it from
slipping out of the hand. This results in flexion of the thumb at the proximal
interphalangeal (PIP) joint and a positive test (Figure 4.1.8).
Igawas Sign
This is a quick test to assess the interossei. The patient is made to place the hand
on the table and asked to raise the middle finger and move it side to side. If the
interossei are paralyzed he is not able to do so (Figure 4.1.9).
Figure 4.1.8: Book test being performed and the Froments sign. Note the flexion of the IP
joint of the thumb which is brought about by the flexor pollicis longus. (For color version, see
Plate 7)
Figure 4.1.9: Igawas test being performed. Note how the other fingers are stabilized and the
middle finger is made to move sideways both medially and laterally, testing both palmar and
dorsal interossei. (For color version, see Plate 7)
Section 04.indd 132 01-12-2012 10:38:50

Tinels Sign 133

This sign was described by Jules Tinel a French physician (18791952). The test
is performed by percussion of the nerve along its course from distal to proximal
there by causing stimulation. At the site where the nerve is irritable patient
experiences pins and needles/ tingling down the course of the nerve. It is a useful
sign after nerve repair when done at intervals and the findings are recorded.
Three types of responses are observed:
a. Strong response at the site of injury not progressing distallyindicates poor
prognosis (recovery).
b. Fading response at the site of injury progressing distallyindicates good
prognosis (recovery).
c. Persistent response at the site of injury as well as progressing distally
unpredictable prognosis (recovery).
Note: The Tinels sign does not predict the quality or quantity of regeneration.
So also it does not predict the return of function. It only suggests the type of
nerve regeneration, i.e. whether the regeneration is proceeding in an orderly
manner or not. Functional recovery is dependent on several other factors such
as status of the muscle, status of the joint, presence of associated tendon injury,
age of the patient, type of the nerve, etc.
Diagnostic Tests
Electromyography (EMG)
The action potential generated in the muscle is recorded graphically both at
rest and during activity (voluntary motor action potentials) by the insertion of a
needle electrode. It is done at early and late intervals, as well as before and after
repair and interpreted.
Denervation potentials: Every muscle is inherently vibrant with an electrical
potential. This electrical potential remains masked as long as the muscle has an
intact nerve supply. This is because the impulse generated by a peripheral nerve
is much greater than the resting inherent electrical potential of the muscle. When
there is denervation, no impulse is transmitted through the peripheral nerve.
Thus, it is possible to record this inherent electrical potential of the muscle. This
is recorded initially as sharp positive waves and later as fibrillatory waves and
known as denervation potentials (Figures 4.1.10A toC).
A B C
Figures 4.1.10A to C: Action potential during EMG study: (A) Electromyogram showing nor-
mal insertional activity; (B) Electromyogram showing positive sharp wave of denervation
potential; (C) Electromyogram showing spontaneous fibrillation potentials of denervation.
Section 04.indd 133 01-12-2012 10:38:50

134 Thus following conclusions are drawn:

a. Presence of fibrillation potentials indicates denervation.
b. Absence of denervation potentials as late as 3 weeks indicates intactness of
nerve.
c. Absence of voluntary motor unit potentials indicates paralysis of the nerve.
d. Presence of voluntary motor unit potentials indicates intact functional nerve.
e. Polyphasic motor unit potential developing after denervation indicates
reinnervation.
Strength Duration Curve

The curve uses the motor conduction property to assess the status of the injured
nerve. As the name indicates, this is a curve plotted on a graph for different
strengths and different durations of electrical stimulation within a physiological
limit (Galvanic/ Faradic current). The surface electrodes are used for stimulation.
The physiological limit of stimulation is expressed in terms of rheobase and
chronaxie.
Rheobase
It is the minimal strength of the current of infinite duration required to stimulate
a muscle (e.g. 300 milliseconds/long duration).
Chronaxie
It is the duration required to stimulate a muscle with the current strength of twice
the rheobase. Chronaxie in a human skeletal muscle varies from 0.08 to 0.32
milliseconds.
A muscle with intact nerve responds to any strength and any duration of
current within this physiological limit. The contraction is directly proportional to
the strength and duration of the stimulus. Whereas a paralyzed muscle does not
respond to a stimulus of low strength of short duration (Faradic). But responds
only to a stimulus of high strength and long duration (galvanic). So the response
is absent for a Faradic stimulation but is present for a galvanic stimulation.
Hence the curve plotted, smoothly ascends to the right of the normal curve. As
regeneration takes place or in a partially injured nerve, the curve starts shifting
to the left and a kink develops in the curve. And finally when the regeneration is
complete the curve descends, becomes flatter and near normal (Figure 4.1.11).
Starch Iodine Test (Tests Autonomic Function)

In starch iodine test the area in question is first painted with iodine and kept dry.
Then starch powder is sprinkled and sweating is induced (covering with cloth
or making the patient drink a cup of hot coffee). If sweating is present the color
changes to purple indicating intactness of autonomous innervation. If absent, no
color change is observed indicating loss of autonomic function.
Section 04.indd 134 01-12-2012 10:38:50

135
Figure 4.1.11: Changes in the strength duration (SD) curve during denervation as well as at
regeneration. Strength duration curve: (A) A normal nerve curve (reinervation); (B)A curve
seen in denervation (shift to the right); (C) Partial denervation (regeneration) showing a kink
in the curve.
Motor and sensory grading in nerve injuries

Motor Grading:
Grade 0 No movement.
Grade 1 A flicker of movement.
Grade 2 Movement possible when gravity is eliminated.
Grade 3 Movement possible against gravity.
Grade 4 Movement possible against gravity and resistance.
Grade 5 Normal power (complete recovery).
Figure 4.1.12 which shows the methods of testing tibialis posterior for Grade 5
power.
Sensory Grading:
S 0 No sensation.
S 1 Presence of pain sensation.
S 2 Presence of pain and some touch.
S 3 Presence of pain and touch with no overreaction.
S 3+ Presence of pain touch with two point discrimination.
S 4 Complete recovery (normal).
Diagnosis of Brachial Plexus Injuries

Brachial plexus can get injured either by direct penetrating wounds, e.g. assault,
bullet and missile injuries or by traction force, e.g. vehicular accidents, birth
injuries, etc. in which the angle between the shoulder and the neck widens
(increases) (Figure 4.1.13).
A thorough knowledge of anatomy is essential for an accurate diagnosis
with reference to the level of lesion. The lesion can be at the level of the roots,
trunk, divisions or cord. The functional loss is directly related to the paralysis of
the corresponding nerves which take origin from these. Examination of various
muscles helps in the conclusion.
Further, it is necessary to distinguish between pre- and postganglionic type
of injury. The prognosis in preganglionic type is poor as repair is difficult.
Section 04.indd 135 01-12-2012 10:38:50

136
Figure 4.1.12: The method of assessing the power of tibialis posterior tendon both against
gravity and resistance. Note the subject is made to cross the limb over the other and asked
to invert the foot against resistance whichis applied by the examiner at the forefoot. The tibi-
alis posterior stands out prominently just behind and little above the medial malleolus. (For
color version, see Plate 8)
Figure 4.1.13: Diagrammatic representation of brachial plexus with roots trunks, divisions
and cords. The plexus shown here is prefixed with contribution from C4.
Prognosis in postganglionic type is better as repair is possible. Absence of

Horners syndrome and absence of cutaneous axon reflex indicates that the
lesion is postganglionic.
Section 04.indd 136 01-12-2012 10:38:50

Signs of Preganglionic Lesions 137

a. Intractable burning pain in a sensationless, paralyzed extremity.
b. Presence of spinal fractures.
c. Horners syndrome: It is characterized by ptosis, anophthalmos, miosis and
anhidrosis.
d. Cutaneous axon reflex: This reflex is elicited by inducing irritation by placing
a drop of histamine over the skin along the distribution of the nerve to be
examined and scratching the site (may also be done by injecting histamine
intradermally). Normal reaction is vasodilation followed by wheel and a
flare (triple response). This reflex is absent in postganglionic lesions where
the response is only a wheel. No flare response is seen.
e. Posterior cervical electromyography may show denervation potentials in
posterior cervical paraspinal muscles indicating the lesion is preganglionic.
f. Presence of long tract signs in the lower limbs indicating the involvement of
the spinal cord and the proximal nature of the injury.
g. CT myelography/magnetic resonance imaging (MRI) may show pseudo
meningoceles indicating root avulsion and the lesion is preganglionic.
Unreliable during the early phase as dural tears can also give a false picture
of pseudomeningocele.
Upper Plexus Injury Erbs Paralysis (Figure 4.1.14)

It is characterized by involvement of C5, C6 nerve roots. (C7 involvement may
or may not be present).
Functional loss results in a typical attitude of the upper limb. The limb remains
by the side of the trunk with shoulder in adduction internal rotation, elbow in
extension, forearm in pronation and wrist in flexion and ulnar deviation. This is
because of the paralysis of abductors namely the deltoid and supraspinatus and
external rotators namely infraspinatus and teres minor at the shoulder; paralysis
Figure 4.1.14: Characteristic attitude of the Porters tip hand of Erbs palsy.
Section 04.indd 137 01-12-2012 10:38:50

138 of flexors namely the biceps, brachialis and the brachoiradialis at the elbow;
paralysis of the supinator at the forearm.
As the limb hangs by the side of the body and resembles the attitude of a
porter waiting for the tip, it is known as the porters tip hand.
Sensory loss over the deltoid, lateral aspect of the forearm and hand is seen.
Paralysis of the serratus anterior supplied by long thoracic nerve, rhomboids
and levator sapulae muscle supplied by dorsal scapular nerve indicates that the
lesion is proximal to the origin of these nerves (these nerves take origin from the
roots, before the plexus is formed) and may be preganglionic.
Erbs Points
It is a point where five nerves meet. They are:
i. C5 root.
ii. C6 root.
iii. Upper trunk.
iv. Suprascapular nerve.
v. Nerve to subclavius.
Note: If you consider the anterior and posterior divisions of the trunk, then it is
considered as a point where six nerves meet.
Lower Plexus Injury, Klumpkes Paralysis

It is characterized by involvement C8 T1 nerve roots. C7 involvement may or
may not be present.
Functional loss is sensory and motor deficits involving C8 T1. Hence, there
is paralysis of intrinsic muscles of the hand along with wrist and finger flexors.
The sensory deficit is on the medial aspect of the hand, forearm and arm.
Whole Plexus Injury

It is characterized by complete flaccid paralysis of the entire upper limb.
Considered as one of the most serious injuries as chance of recovery is very
poor.
Injuries of the trunks: Injuries of the upper trunk manifests with similar deficits
as their rami. But the long thoracic and dorsal scapular nerve escape paralysis.
Injuries of the lower trunk manifests with similar deficits as their rami. But
there is no sympathetic involvement and Horners syndrome is not seen.
Injuries of the divisions: Injuries of the divisions of the plexus is extremely rare
and it is difficult to distinguish from trunk and cord injuries.
Injuries of the cords: Injuries of the cords manifest with paralysis of the nerves
which take origin from the respective cords. Paralysis of the muscles supplied
by these nerves and sensory loss in the corresponding autonomous zones are the
diagnostic features.
Section 04.indd 138 01-12-2012 10:38:51

Nerves from the lateral cord: 139

i. Lateral pectoral.
ii. Musculocutaneous.
iii. Lateral root of the median nerve.
Nerves from the medial cord:
i. Medial pectoral.
ii. Medial cutaneous nerve of the forearm.
iii. Medial cutaneous nerve of the arm.
iv. Medial root of the median nerve.
v. Ulnar nerve.
Nerves from the posterior cord:
i. Upper subscapular.
ii. Lower subscapular.
iii. Thoracodorsal.
iv. Radial.
v. Axillary.
Section 04.indd 139 01-12-2012 10:38:51

Examination of a Bone Tumor
Section 5
141
Examination of a
Bone Tumor
Section 05.indd 141 01-12-2012 10:40:01

142 5.1. Examination of a Bone Tumor

Examination begins with a good history taking. Following are the questions
to be asked in the history apart from noting down the name, address, sex,
socioeconomic status, etc.
1. What is the age?
Age has an important relationship to the tumor. Certain tumors are common
in certain age groups, e.g. Ewings tumor between 515 years (Figure 5.1.1),
osteosarcoma between 1020 years (Figures 5.1.2A and B), giant cell tumor
between 2040 years, etc. (Figure 5.1.3). Secondaries in the bone are seen
in elderly people. Osteochondroma is seen in adolescent age group.
2. How did the swelling start? What are the associated symptoms? What is the
progress?
Onset: It is insidious in benign tumors. Whereas in malignant tumors
unexplained pain precedes the onset of swelling.
Constitutional symptoms: They are absent in benign tumors. Whereas in
malignant bone tumors the constitutional symptoms are always present.
Rate of progress: Rapid growth suggests malignancy and vice versa. Rapid
growth occurring in a tumor of long-standing duration indicates malignant
transformation (Figure 5.1.4).
Figure 5.1.1: Onion skin appearance of an Ewings tumor.
Section 05.indd 142 01-12-2012 10:40:02

143
A B
Figures 5.1.2A and B: Three classical features of osteosarcoma
1(A) Sunray appearance; 2(B) Cumulus cloud appearance;
3The bottom arrow in A shows the Codmans triangle.
Figure 5.1.3: Epiphyseal eccentric, expansile, lytic lesion involving lower radius without
sclerotic rim suggestive of giant cell tumor.
3. Any other complaint?

For example, loss of appetite, loss of weight, anemia and cachexia indicates
fairly advanced stage of the malignant tumor (Figure 5.1.5). Pulmonary
metastasis may cause respiratory symptoms. Metastasis in the spinal column
may cause backache and neurological symptoms. In short when the tumor
metastasizes and involves other systems, corresponding systemic features
develop.
Section 05.indd 143 01-12-2012 10:40:02

144
Figure 5.1.4: Classical wind blown calcification

of chondrosarcoma.
Figure 5.1.5: Multiple punched out lesion

in the skull suggestive of multiple myeloma.
Local Examination
Inspection
Attitude of the Limb
The patient develops some amount of immobility in the limb if the tumor is
malignant whereas if it is benign this immobility is insignificant. A pathological
fracture makes the limb totally immobile (Figure 5.1.6).
Section 05.indd 144 01-12-2012 10:40:02

145
Figure 5.1.6: A pathological fracture in a unicameral

bone cyst (UBC)
Changes over the skin:

a. Stretched shiny skin indicates a large sized tumor.
b. Dilated tortous vein indicates venous obstruction and possibility of malignancy.
c. Visible pulsation indicates increased vascularity or a tumor of vascular origin.
d. Redness over the skin indicates inflammation.
Palpation
Palpation starts by palpating structures in a methodical manner from superficial
to deep.
Skin
If the skin is not pinchable, it indicates that the tumor has infiltrated the skin
and shortly a break may develop and proceed towards fungation. This feature
is not generalized but may be present at certain places where the growth had
been rapid. Presence of signs of inflammation suggests malignancy or secondary
infection, e.g. adventitious bursitis in an osteochondroma.
Muscles
If the muscles are freely mobile, it indicates that the tumor is not adherent to the
muscle and probably the tumor is benign. If the muscles are not freely movable,
it suggests the adherence of the tumor and probably the tumor is malignant and
has infiltrated the muscle.
Surface of the Tumor
If the surface is smooth and regular, it is suggestive of benign tumor.
If the surface is variable and irregular, it is suggestive of malignant tumor.
Section 05.indd 145 01-12-2012 10:40:02

146 Consistency of Bone Tumor

If hard, suggests the predominance of bony element (Figure 5.1.7).
If firm, suggests predominance of cartilaginous element.
If soft, suggest predominance of vascular and fibrous tissue element.
Variegated consistency is a feature of malignant tumor. Whereas a uniform
consistency is a feature of benign tumor.
A change in consistency towards softening indicates degeneration (tumor
necrosis). Fungation indicates fairly advanced stage of the tumor.
Plane of the Bone Tumor
It is always deep and the tumor is arising from the bone, fixed to the bone and
moves with the bone . This can be made out by noting down the size of the
tumor when the overlying muscle is made to contract. The tumor becomes less
prominent.
The plane of other tumors are differentiated as follows:
If it is arising from the muscle, the tumor becomes more prominent and the
tumor becomes less mobile on muscle contraction.
If it is arising from the facial planes, there is no relation to muscle contraction
and mobility of the tumor. The skin over the tumor is pinchable.
If it is from the skin, the skin is not pinchable.
Figure 5.1.7: A lytic lesion with exaggerated zone of sclerosis without break suggests
benign tumor. In this case, the tumor was an osteoid osteoma.
Section 05.indd 146 01-12-2012 10:40:02

Tenderness 147
This should be elicited last. If elicited at the beginning, patient will become
uncooperative.
Tenderness is a sign of malignancy. Tenderness may also be seen when there
is secondary infection or a pathological fracture. Tenderness developing in a
benign tumor indicates a malignant transformation.
Movements of the Joints

Limitation of joint movements and association of pain during joint movements
is a feature of malignant bone tumors. Joint movements never become restricted
or painful in a benign tumor except when the tumor is in the vicinity of a joint
and causes mechanical obstruction, e.g. oseochondroma.
Regional Lymph Nodes

Enlarged firm or hard nodes which are tender and in later stages get fixed to the
underlying structures suggest lymphatic spread.
Examination of Other Systems

It is important to examine thorax and abdomen, i.e. respiratory and gastrointestinal
systems and look for abnormal mass, organomegaly, etc.
In spinal tumors, neurological examination is a must.
Investigations
After the clinical examination, proper X-rays (Box 5.1.1) and if indicated other
investigations like ultrasound abdomen, CT, MRI and bone scan may become
necessary for detailed evaluation. Bone biopsy is the confirmatory investigation
and it also helps in planning the treatment.
Reading of an X-ray in a Case of Bone Tumor

Following order may be adopted while reading an X-ray of a bone tumor. A
methodical reading will help in clinching the diagnosis.
1. Age of the patient (Table 5.1.1):
This is made out by looking for the epiphysis and the growth plate. If
present, it is a growing skeleton. If absent, the skeleton is a mature skeleton.
Presence of osteoporosis indicates that it is an aged skeleton.
Middle aged person's skeleton shows features between porotic and adult
skeleton.
Certain tumors are common in certain age groups, e.g. Ewing's tumor 515
years, osteosarcoma 1525 years, giant cell tumor 2030 years, multiple
myeloma in elderly persons, etc.
Hence, an attempt should be made to ascertain the age of the patient
radiologically.
Section 05.indd 147 01-12-2012 10:40:02

148 Table 5.1.1: The relationship of age to tumor.
Age Benign tumor Malignant tumor

1020 Fibrous dysplasia, Osteosarcoma, Ewing's tumor
Osteochondroma, aneurysmal
bone cyst, unicameral bone cyst,
benign chondroblastoma, osteoid
osteoma
2040 Giant cell tumor Chondrosarcoma
> 40 Rare Myeloma, fibrosarcoma,
Secondary sarcomas,
secondaries
2. Bone involved:
Certain tumors are common in long bones and in appendicular skeleton,
while others are common in flat bones and axial skeleton, e.g. osteosarcoma
is commonly seen in long bones,
Multiple myeloma is commonly seen in flat bone and the vertebra.
Box 5.1.1: A summary of different radiological features seen in bone lesions and
their probable diagnosis.
Radiological features Probable diagnosis

Kissing bones (lytic lesions in adjacent GCT, Angiosarcoma, Pigmented
epiphysis) villonodular synovitis, Infections
Codmans triangle Osteosarcoma, Osteomyelitis, ABC
Complete sclerotic rim, no break Benign lesion (95% accuracy)
Cumulus cloud appearance Osteosarcoma, Stress fracture
Epiphyseal, solitary, eccentric lytic lesion with Chondroblastoma, Enchondroma, GCT
sclerotic margin
Epiphyseal, solitary, lytic lesion without GCT
sclerotic margin
Expansile lesion, poorly demarcated with Chondrosarcoma
windblown calcifications
Expansile lesion nontrabeculated lesion Benign tumor (majority of cases),
Grade I sarcoma, Solitary Myeloma,
Metastasis (a small percent of cases)
Expansile, trabeculated lesion Grade I sarcoma, GCT, Myeloma
Fallen fragment sign Simple bone cyst
Finger-in-the-balloon appearance ABC
Ground glass appearance Fibrous dysplasia, Osteoblastoma,
Grade I osteosarcoma
Onion-skinning Ewings sarcoma, Subacute
Osteomyelitis, Eosinophilic granuloma
Punched out lesions Multiple myeloma
Ring-like to popcorn density Enchondroma and secondary
Chondrosarcoma
Section 05.indd 148 01-12-2012 10:40:02

3. Site of involvement (Figure 5.1.8): 149

Tumors have a definite relation with respect to origin. They arise either from
the epiphysis/metaphysis/diaphysis. So site of origin helps in the diagnosis.
Site in the bone-
EpiphysisGiant cell tumor.
Long bone MetaphysisOsteosarcoma.
DiaphysisEwing's tumor.
Vertebra BodyPrimary tumor.

AppendagesSecondary deposits
4. Type/nature of invlovement (Box 5.1.1):
OsteogenicOsteoid osteoma, osteosarcoma
OsteolyticOsteoblastoma, multiple myeloma, simple bone cyst
Lodwick has identified and classified the patterns of destructive (lytic) lesions
as follows into III Grades (Figures 5.1.9A to C).
Grade I: Geographic: Sharply defined border
A: Thick sclerotic rim
B: Thin sclerotic rim
C: No sclerotic rim
Grade II: Moth-eaten: Ragged border
are to be considered as

malignant unless proved otherwise.
Grade III: Permeative: Wide zone of

transition
5. Extent of involvement:
Skipped lesions and spread of the tumor beyond the confines of the bone are
to be observed. This has a definite bearing on treatment.
Figure 5.1.8: Femur showing the site of origin of different bone tumors.
Section 05.indd 149 01-12-2012 10:40:03

150
A B C
Figures 5.1.9A to C: Diagrammatic representation and radiographs of the types of destruc-

tive lesions (lysis) based on description by Lodwick: (A) Grade IGeographic (sharply defined
border); (B) Grade IIMotheaten (ragged border); (C) Grade IIIPermeative (wide zone of
transition).
6. Type of periosteal reaction (Figure 5.1.10):

Type of periosteal reaction when present helps to differentiate benign,
malignant and specific tumor types. Following are the types of periosteal
reaction that may be present.
Solid
Thin
Thick
Interrupted
Codman's triangle
Lamellated (onion skin)
Perpendicular or spiculated or sunray (regular)
Sunburst (irregular)
Disorganized or complex
A combination of both solid and interrupted
7. Specific characteristics (Box 5.1.1):
Also inherited disorders of the skeleton and subacute infections are to be
kept in mind while reading an X-ray as they may mimic bone tumors, e.g
Melorheostosis, Paget's disease, subacute osteomyelitis, Brodie's abscess, etc.
Section 05.indd 150 01-12-2012 10:40:03

151
Figure 5.1.10: Different types of periosteal reactions seen in bone tumors.
Role of Angiography
Angiography has a role to play when there is need to assess the vascularity of
the tumor and to localize the vessel when a radical surgical procedure is being
planed. Sometimes the vessel may get involved in the tumor tissue and separation
becomes difficult during surgery. Hence, a need arises to sacrifice some of
the branches. In such cases preoperative angiography is useful in determining
the presence of good and adequate vascular anastomosis which can salvage the
limb, e.g. brachial artery involvement at the elbow, popliteal artery involvement
around the knee.
Angiography also helps in identifying skipped lesions when used with other
imaging techniques, e.g. CT angio.
Tumor blush: Osteosarcoma is a tumor which promotes neovascularization.
Hence, there is enhancement of the contrast medium. This is referred to as
'Tumor blush'. After giving chemotherapy if this neovascularization is not seen
(disappearance of vascularity), it infers that the chemotherapy has been effective.
Role of Other Advanced Investigations

These advanced investigations are expensive but give accurate information when
needed. Should never be asked for when there is no need.
Bone scan: Bone scan using Technetium 99 m diphosphonate (99 m Tc- HDP)
is of immense help as it clearly shows the hot spots in the skeleton. Even the
smallest of the tumors can be diagnosed as well as the skipped metastasis.
Section 05.indd 151 01-12-2012 10:40:03

152 Computed tomography (CT) scan: CT scan is not a substitute for radiographs
or bone scan but it is an adjuvant to these investigations, when there is a need
for clear delineation of tissues. It is useful to assess the intra- and extraosseous
extension and also helps in early detection of tumors before radiological changes
are seen.
Magnetic resonance imaging (MRI): MRI delineates the soft tissues better than
CT and useful in visualizing the soft tissue extension and invasion of the tumor
into the neighboring structures, e.g. muscles, vessels and nerves. This helps in
staging of the tumor and planning of the surgery.
Positron emission tomography (PET) scan: It reveals how the body part is
functioning unlike CT and MRI which simply give an image. It is not only useful
in early diagnosis but also useful in evaluating response to treatment.
A radioactive tracer FDG (Fluorodeoxyglucose) is inserted into the human
body. This molecule of glucose tagged with the radioactive tracer is utilized by
the tissues for energy and as it breaks down it emits positrons. The gamma rays
emitted indirectly by the positrons, is detected by the machine and a 3D color
image is reconstructed. The image reveals the functional process going on in
the human body by detecting the metaboilc changes occurring at the cellular
level. The diseased cell utilizes glucose in a different manner than a normal cell.
Hence, the image obtained is a functional image which helps in early diagnosis
of a disease as well as evaluating response to treatment. All the modern PET
machines allow a CT image along with PET scan, simultaneously. So the
investigation is known as PET CT.
The disadvantage of PET is that it is almost five times more expensive than
MRI and almost eight times more expensive than a Technitium 99 m bone scan.
Note: A by product of FDG, i.e. F18 is being effectively used for a bone
scan. This reduces the cost of bone scan.
After the clinical examination, investigations and confirming the diagnosis
a conclusion should be drawn with respect to the exact status of the tumor.
This dictates the treatment. Benign tumors do not pose much problem. A total
excision results in cure. But a malignant tumor poses a challenge, as it may recur
or cause metastases. Enneking system of staging (1980) helps in taking decisions
while treating malignant tumors.
Enneking Staging:
ILow-grade tumor
AIntracompartmental
BExtracompartmental
IIHigh grade tumor
AIntracompartmental
BExtracompartmental
IIIEither grade with distant metastasis
Accordingly a curative or palliative treatment is planned. A biopsy of the lesion
is a must before surgery.
Section 05.indd 152 01-12-2012 10:40:03

Bone Biopsy 153

Bone biopsy is done to confirm the clinical diagnosis or when clinical diagnosis
is uncertain because of bizzare presentation (Questionable clinical diagnosis). It
gives an accurate diagnosis as well as other information such as extent of the
tumor the margins, aggressiveness of the tumor, etc. When cells studied show
more atypical features the tumor is considered more malignant. Open biopsy
procedures of the past have been replaced by more refined procedures, e.g.
needle and core biopsy. These less invasive procedures avoid spillage of the
cells and contamination of surrounding tissue with malignant cells unlike open
biopsy procedures of the past. Thus, they help in salvaging the limb in malignant
bone tumors.
Indications for biopsy:
1. Benign aggressive lesions.
2. Malignant lesions.
3. Lesions with uncertain clinical diagnosis.
Contraindication:
1. Benign lesions (e.g. osteochondroma, an excision biopsy indicated).
Note: Most of the lesions these days are diagnosed by a good clinical history,
physical examination, radiologic and imaging studies and laboratory data.
Biopsy is only confirmatory.
Things one should know before attempting a biopsy:
Basic Information
Most of the malignant bone tumors are of mesenchymal origin and are
sarcomas. They grow in a centripetal fashion. Most immature part is found at
the growing edge of the tumor. A reactive zone is formed between the tumor
and the compressed surrounding normal tissue. This zone is composed mainly
of neovasculature and inflammatory cells.
Satellite lesions: When microextension of the tumor is found in the reactive
zone, the lesions are known as 'Satellite lesions'.
Skipped lesions: When lesions are found in the same anatomic compartment
but outside the reactive zone they are known as 'skipped lesions'. They are
commonly found in high grade sarcomas and rarely in low grade sarcomas.
Note: Sarcomas push the surrounding tissues and form a reactive zone whereas
Carcinomas do not. Carcinomas infiltrate the surrounding tissues.
Procedure of Specific Information

1. Sampling error: This occurs when the biopsy is taken from a region other
than the primary disease, e.g. reactive zone. To avoid this, the anatomic
location of the biopsy site should always be planned well in advance.
2. Incision: When open biopsy is planned the incision should always be in an
area of resection of a future definitive surgical procedure. If a drain is kept,
the drian track also should be similarly placed.
Section 05.indd 153 01-12-2012 10:40:03

154 3. Staging: Biopsy is always planned after the imaging studies are complete and
the staging of the tumor is done. If not, the biopsy may superimpose the true
and artificial radiologic changes at the site and may contradict the findings of
imaging.
4. Heterogenity: Malignant sarcomas generaly exhibit heterogeneity.Different
types of tissue are seen in different areas. When heterogeneity is suspected
multiple samples have to be taken from different areas.
5. Route of entry: The entry to the tumor should be from a safe anatomic site
avoiding the vital structures such as nerves and vessels.
6. Hemostasis: A good hemostasis is must after biopsy to prevent systemic
dissemination of the malignant cells.
7. Definitive procedure: Definitive surgical procedure should be planned as
early as possible after the biopsy. A 'frozen section' report is reliable enough
when it correlates with the clinical and radiological findings and provisional
diagnosis.
Techniques of Biopsy
1. Fine needle aspiration cytology (FNAC): A 22-gauge needle is used. Procedure
yields very little tissue. Suitable only when the lesion is homogeneous and
soft. Rarely used for bone tumors.
2. Core biopsy: A 14-gauge needle with a trocar and stilette is used. Core of tis-
sue is taken from multiple sites and studied. Image guidance is always preferred
because it helps in placing the needle accurately at the areas to be biopsied.
3. Open biopsy: Procedure yields good amount of tissue for histopathologic
study. These days it is employed only when the core biopsy report is
inconclusive or ancillary studies are necessary for detailed planning. Open
biopsy provides adequate material for performing other supportive studies such
as immunohistochemistry, cytogenetics, molecular genetics, flow cytometry,
and electron microscopy, etc. These studies are useful in final diagnosis,
subclassification of bone tumors, and definitive treatment.
It is a good practice always to send the biopsied specimen for culture and
vice versa.
Section 05.indd 154 01-12-2012 10:40:03

Important Clinical Tests and Radiological Signs
Section 6
155
Important Clinical Tests and

Radiological Signs in
Different Bone and
Joint Pathologies
Section 06.indd 155 01-12-2012 10:41:11

156 6.1. Important ClInICal tests and radIologICal sIgns In

dIfferent Bone and JoInt pathologIes
Congenital Anomalies
DDH
Clinical Features
Up to 23 Months (the neonate)
The hip is always dislocatable and reducible. The classical test of Barlows and
Ortolanis is always positive.
Barlows Test (Figure 6.1.1A)
With the baby in supine position (on the couch or mothers lap), the examiner
holds babys both the knees and gives a gentle adduction push to one of the knees.
If the hip is dislocatable, the feel of femoral head jumping out of the acetabulum
is made out by the fingers placed in the region of the greater trochanter.
The release of pressure slips the head back into the acetabulum.
Ortolanis Test (Figure 6.1.1B)
This is the reverse of Barlows test. In this test the examiner tries to reduce
the dislocated hip. The test is performed with the baby in supine position as
in Barlows test. The babies thigh is grasped between the thumb and the index
finger. With the other fingers the greater trochanter is gently lifted up, abducting
the hip at the same time. The clunk of reduction is felt. When the hip is adducted,
the head gently slips out (Barlows test).
A B
Figures 6.1.1A and B: Tests of: (A) Barlow and
(B) Ortolani being performed to dislocate and relocate/reduce the hip.
Section 06.indd 156 01-12-2012 10:41:11

These tests have to be repeated a couple of times to make certain that there 157
is DDH. Also should be performed on the other hip to assess the status of the
other hip.
After 36 Months (the infant)
During this period the irreducibility becomes gradually established. As the hip
remains in dislocated position other physical findings appear.
a. Asymmetry of the thigh and gluteal folds (Figures 6.1.2A and B).
b. Shortening of the thigh.
c. Superior location of the greater trochanter.
d. Positive telescopy.
e. Discrepancy in the levels of the knee (Allis, Perkin's or Galeazzi sign)
(Figure 6.1.3A).
f. Limitation of abduction (Figure 6.1.3B).
g. Klisic test (Figures 6.1.4A and B).
A B
Figures 6.1.2A and B: Asymmetry of skin creases on the involved side in a unilateral DDH.
A B
Figures 6.1.3A and B: (A) Asymmetry in the level of the knees which is known as Allis,
Perkins or Galeazzi sign. On the involved side in a unilateral DDH, the knee will be at a lower
level; (B) Limitation of abduction of the involved right hip.
Section 06.indd 157 01-12-2012 10:41:11

158
A B
Figures 6.1.4A and B: Klisic test. Note the imaginary line cutting through the umbilicus in a
normal hip and cutting midway between the umbilicus and the pubis in a DDH.
With the child supine the index finger is kept over the anterior superior iliac
spine and the middle finger over the greater trochanter. Next an imaginary line
is drawn between the two. This line when extended upwards cuts through the
umbilicus in a normal hip.
In DDH because the trochanter is elevated, this line passes halfway between
the umbilicus and pubis.
After the Child Begins to Walk
a. The shortening becomes pronounced in unilateral cases.
b. Trendelenburg gait develops in unilateral cases and waddling gait in bilateral
cases.
c. Exaggerated lumbar lordosis secondary to flexion contracture at the hip
becomes noticeable (Figure 6.1.5).
Note: Delay in milestones may or may not be observed. However, if there is
a delay in walking, the possibility of DDH should be kept in mind.
Investigations
a. Ultrasound is a useful investigation in the newborn in whom X-ray imaging
is of no use because of cartilaginous nature of the bones. It should be used
judiciously and findings should always be correlated with clinical findings to
prevent overdiagnosis. (For more information refer a and b angle of Graf).
b. MRI is a better investigation than ultrasound. But, it is expensive and is
accompanied by the disadvantage of sedating the newborn.
c. X-ray gives useful information in an infant, only after 3 months.
With the help of Hilgenreiners and Perkins line and the Shentons line the
location of the femoral head can be assessed. Also the center edge angle
Section 06.indd 158 01-12-2012 10:41:11

159
Figure 6.1.5: Exaggerated lumbar lordosis indicating the presence of flexion deformity in a
neglected bilateral DDH. The child will have a waddling gait.
of Wilberg and the acetabular index can be measured (Figures 6.1.6 and
6.1.7).
Hilgenreiners and the Perkins line divides the hip into four quadrants.
A normal hip lies usually in the lower inner quadrant. A subluxated or
dislocated hip moves towards the upper outer quadrant.
d. Arthrography gives useful information regarding the concentric nature of
reduction.
CTEV
Deformities in Clubfoot
The deformities present are:
a. Equinus.
b. Adduction.
c. Inversion.
These deformities are present both in the forefoot and in the hindfoot.
The combination of adduction and inversion results in varus deformity. The
deformities are the result of tight tendons and ligaments. All the ligaments of the
ankle (except on the lateral side) and tendons of the posteromedial compartment
of the ankle are contracted (Figures 6.1.8A and B).
Ligaments Involved
All the ligaments around the talus with the exception of lateral side are contracted.
Medially
i. The deltoid ligament.
ii. The talonavicular ligament.
iii. The plantar calcaneonavicular ligament (Spring ligament).
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160
Figure 6.1.6: Picutre showing the following:

HLHilgenreiners line. It is a horizontal line drawn passing through the center of the triradi-
ate cartilage.
PLPerkins line. It is a line drawn perpendicularly down from the bony edge of the acetabu-
lum.
SShentons line. It is a line along the neck of the femur to the inner margin of the pubic
bone. It forms a smooth C shaped curve.
BSBroken Shentons line. This is seen in subluxation/dislocation.
HDimension H. This is the height measured from the top of the ossified femur to the Hil-
genreiners line.
DDimension D. This is measured from the inner border of the tear drop to the center of the
tip of the ossified femur.
Dimensions H and D quantify proximal and lateral displacement of the hip respectively. They
are useful even at an age where the epiphysis of the head of the femur is not ossified.
A B
Figures 6.1.7A and B: (A) Center-edge angle of Wilberg: It is an angle formed between the
Perkin's line and the line drawn from the lateral lip of the acetabulum passing through the
center of the femoral head. In older children (1013 years) the angle should always be more
than 10; (B) Acetabular index: This is an angle formed between a line drawn along the mar-
gin of the roof of the acetabulum and Hilgenreiners line average angle in newborn is about
27.5. It decreases with age. Medial gap: This is the distance between the inner margin of
the tear drop and the inner margin of the neck of the femur. The gap increases in dislocation.
Always compared with the the opposite hip. Not useful in bilateral cases.
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161
A B
Figures 6.1.8A and B: Bilateral clubfoot seen from (A) the front and (B) the back showing
all the classical deformities. Note that the deformities are present both in the forefoot and the
hindfoot. Also note the size of the heel which is small. (For color version, see Plate 9)
Posteriorly
i. Posterior talofibular ligament.
ii. Posterior calcaneofibular ligament.
Inferiorly
i. The interosseous talocalcaneal ligament.
In addition to this the posterior capsule of the ankle and the subtalar joint and
the plantar fascia are also contracted.
Tendons and Muscles Involved
i. Tibialis posterior.
ii. Flexor digitorum longus.
iii. Flexor hallucis longus.
iv. Tendoachilles.
v. Abductor hallucis brevis (in the foot).
Radiological assessment of clubfoot (Figures 6.1.9A and B)
Angles in radiological views Normal CTEV

AP view
Talocalcaneal angle-a 1540 < 15
Talo-first metatarsal angle-b 015 < 0
Lateral view
Talocalcaneal angle 2545 < 25
Tibiocalcaneal angle 4060 > 70
(Maximum dorsiflexion angle)
Diagnosis
It is a straightforward diagnosis. In severe cases, the foot is placed upside
down. The size of the heel and the foot is small. Always rule out other
associated congenital anomalies and teratological causes, e.g. spina bifida,
meningomyelocele, arthrogryposis multiplex congenita, etc.
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162
A B
Figures 6.1.9A and B: The angle (a) the talocalcaneal angle in AP view, and
(b) the talo 1st metatarsal angle in AP view in normal foot (A) and in clubfoot (B).
Congenital Vertical Talus and Congenital Oblique Talus
Pathological Anatomy
Bone
The talus is fixed in a vertical position with associated hypoplasia of the talar
head and the neck. The talonavicular joint is dislocated and the navicular bone
is displaced dorsally articulating with the dorsal aspect of the neck of the talus.
There is varying degree of subluxation of the calcaneocuboid joint. Thus, there
is elongation of the medial column and shortening of the lateral column of the
foot.
Ligaments
The tibionavicular and the dorsal talonavicular ligaments are contracted. This
prevents the reduction of the talonavicular joint. Also the posterior capsule of
the ankle is contracted.
Muscles and Tendons
The tibialis anterior, extensor hallucis longus, extensor digitorum longus,
peroneus brevis and tendoachilles are contracted. The tibialis posterior and the
peroneal tendons are displaced anteriorly and may act as dorsiflexors instead of
plantar flexors.
Diagnosis
The condition is easily diagnosed at birth. The convex plantar surface of the foot,
severe dorsiflexion and abduction of the foot, the valgus and equinus position of
the heel are the striking features.
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Radiological Features (Figures 6.1.10A to C) 163

AP view (Figure 6.1.10A)
Increased talocalcaneal angle
Forefoot is in abduction.
Lateral view
Calcaneus is in equinus.
Talus is vertically placed (Normal is horizontal).
Navicular is displaced dorsally.
Lateral plantar flexion view
To assess the talar metatarsal and calcaneal metatarsal axis. Both are
increased because of equinus position of the bones (Normal values are 3
and 10, respectively).
Lateral dorsiflexion view
To assess the heel equinus.
Note: The lines drawn for assessment of the position of the talus and the calcaneum
in relation to the rest of the foot are all drawn along the long axis of the bones. In
the AP view, they are divergent and in the lateral views, they are almost vertical and
nearly at right angles to the horizontal (except the line of the calcaneum). Hence,
they derive the names tibiocalcaneal, tibiotalar, talocalcaneal, talohorizontal,
talometatarsal, calcaneometatarsal, etc. (Figures 6.1.11A and B).
A B
C
Figures 6.1.10A to C: (A) Congenital oblique talus. Note that it has all the features of a
vertical talus except that; (B) The talonavicular joint subluxates in neutral position of the foot;
and (C) Gets reduced in equinus. The arrow shows the same. (For color version, see Plate 9)
Section 06.indd 163 01-12-2012 10:41:12

164
A B
Figures 6.1.11A and B: (A) An infant with congenital vertical talus. The soft tissue shadow shows
the convexity of the plantar surface of the foot. The talus is near vertical and the calcaneum is
in plantar flexion. The navicular bone has not appeared but note the position of the metatarsals.
They are dorsally displaced indicating the dorsal displacement of the navicular; and (B) An adult
with neglected congenital vertical talus with secondary degenerative arthritis. It is a rocker bottom
foot. Note that the tibiotalar and the talohorizontal angle are near 180 and 90, respectively.
Differential Diagnosis
Congenital Oblique Talus
This resembles congenital vertical talus but with certain differences as shown in
Figures 6.1.10A to C.
Clinical Tests and Signs in Hip Pathologies

Classical attitudes of lower limb seen in different hip pathologies:
A. Flexion abduction external rotation
1. Fracture neck of the femur.
2. Intertrochanteric fracture.
3. Anterior dislocation of the hip.
4. Transient synovitis.
5. I stage tuberculosis.
6. Acute pyogenic arthritis of the hip.
B. Flexion adduction internal rotation
1. Posterior dislocation of the hip.
2. II and III stage tuberculosis.
C. Adduction and external rotation
1. Slipped capital femoral epiphysis.
D. Limitation of abduction and internal rotation
1. Perthes disease.
Clinical Tests
A. Telescopy
This test is positive in an old case of pathologic dislocation of hip, e.g. septic
arthritis of infancy and to some extent in old fracture neck of the femur with
resorption of the neck.
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The test is performed by placing the patient supine on the examination table. 165
The examiner stands on the involved side. Next the involved hip and the
knee is flexed with one hand and the lower femur is held firmly at the knee.
The examiner then places the other hand with the thumb over the pelvis
anteriorly and the middle finger palpating the greater trochanter posteriorly.
With the hand holding the knee the thigh is adducted to about 510 and a
gentle push is given to the femur towards the examination table. At the same
time the middle finger appreciates the movement of the greater trochanter
in a backward direction. Next without changing the position of the limb
the examiner exerts a pull on the flexed and adducted thigh in a forward
direction. The greater trochanter again moves in a forward direction to
its original position. This backward and forward movement of the femur
resembles the movement of the tube of a telescope and is appreciated by
the palpating middle finger. Hence, the name Telescopy is given for the test
(Figure 6.1.12).
B. Axis deviation
This is seen in slipped capital femoral epiphysis (SCFE).
A normal hip flexion causes the knee to point towards the shoulder. In a
SCFE because of the slip (which has occurred in a posterior and inferior
direction) the knee falls away from the shoulder on flexion of the hip. This
sign is referred to as axis deviation.
Measurement of Limb Length Discrepancies

i. True measurement
Mechanism of compensation
Any fixity developing in the hip joint due to a pathology is always
compensated by the mobility of the spine which results in tilting of the
pelvis. This mechanism is essential in order to bring the limbs parallel
to each other during walking. An adduction deformity causes apparent
shortening and abduction deformity causes apparent lengthening of the
limb. Flexion deformity exaggerates the normal lumbar lordosis and the
pelvis tilts forwards.
So when there is an adduction deformity, the spinal column tilts with
a concavity to the same side and a compensatory scoliosis develops.
Figure 6.1.12: Method of performing the telescopy test.
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166 This causes the pelvis to tilt and the anterior superior iliac spine (ASIS) on
the same side moves up (Is at a higher level when compared to the opposite
side) (Figure 6.1.13).
When there is an abduction deformity the spine tilts with a convexity to
the same side and again a compensatory scoliosis develops. This causes
the pelvis to tilt and the anterior superior iliac spine on the same side
moves down (Is at a lower level when compared to the opposite side)
(Figure 6.1.14).
So to measure the true limb length this pelvic tilt has to be nullified. This
is known as squaring of the pelvis.
Squaring of the pelvis
To square the pelvis the limb is abducted further in abduction deformity
and adducted further in adduction deformity till the ASIS is brought to
the same level (during squaring the movement is taking place in the spine
because of the fixity at the hip).
Measurement
It is done by keeping the uninvolved limb in same degree of adduction or
abduction as that of the affected limb after squaring the pelvis (This does
not disturb the position of the pelvis because the hip is normal and the
movement is taking place at the normal hip). The limb length is measured
with a measuring tape from the ASIS to the knee joint and then the medial
malleolus after marking these bony points.
ii. Apparent measurement
Apparent measurement of the limb is measured as the limb appears to be
(as it is without squaring, in the same deformed position). It is measured
from the umbilicus to the knee joint and then to the medial malleolus.
Figure 6.1.13: Compensation of the spine for an adduction deformity at the hip with develop-
ment of scoliosis concavity of which is to the same side as that of the lesion in order to make
the limb parallel to the other normal limb.
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167
Figure 6.1.14: Compensation of the spine for an abduction deformity at the hip with develop-
ment of scoliosis convexity of which is to the same side as that of the lesion in order to make
the limb parallel to the other normal limb.
Inference:
i. If apparent and true measurement is the same, it means no compensation
has taken place.
ii. If apparent and true measurement is different, it means compensation has
taken place.
When there is true shortening in the lower limb, it may be in the
supratrochanteric portion (above the trochanter), infratrochanteric portion
(below the trochanter up to the condyles) or in the tibia (leg component).
Measurement of Supratrochanteric Shortening
This is measured by drawing Bryants triangle. The triangle is drawn in supine
position by drawing three lines as follows. The first line is drawn joining the
anterior superior iliac spine and the greater trochanter. The second line is
drawn from the anterior superior iliac spine vertically downwards towards the
examination table. The third line is a perpendicular line joining these two lines
(Figure 6.1.15).
A similar triangle is drawn on the opposite side (Figure 6.1.16).
The supratrochanteric shortening is measured by measuring the length of the
third line and comparing the same with the opposite normal side.
Other inferences of a Bryant triangle are:
a. It identifies the proximal migration of the trochanter.
b. It also identifies the anterior or posterior migration (position) of the trochanter
when the second line is measured and compared with the opposite normal
side. Increased length indicates posterior migration (position). Decreased
length indicates anterior migration (position) (Figure 6.1.16A).
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168 Note: Bryants triangle is not of use in a bilateral hip pathology for measurement
of supratrochanteric shortening. In a bilateral hip pathology, it only gives a
rough indication of migration of the trochanter.
Other lines for assessment of migration of the trochanter and their inference:
Nelatons Line
This line is drawn with the patient lying in lateral position. A flexible measuring
tape is placed between the ischial tuberosity and the anterior superior iliac spine
(ASIS). In a normal person the tip of the greater tochanter just touches the line.
When there is proximal migration of the trochanter, this line cuts a considerable
portion of the greater trochanter.
Note: Nelatons line is the only line which indicates proximal migration of the
trochanter in a bilateral hip pathology.
Shoemakers Line (Figures 6.1.15 and 6.1.16C)
A line which is drawn from the greater trochanter to the anterior superior iliac
spine and continued upwards is supposed to touch the umbilicus and meet its
counterpart in the midline.
If the greater trochanter is displaced upwards, this line passes below the
umbilicus and cuts its counterpart on the opposite side of the midline (Figure
6.1.16C).
Morris Bitrochanteric Test
In this test, a caliper is used to measure the distance between the greater
trochanter and the pubic symphysis, always compared with the opposite normal
side. In a central dislocation of the hip, the distance decreases and it identifies
the medial displacement of the trochanter.
Chienes Test
The line joining the two ASIS and the two greater trochanter are normally
parallel.
In proximal migration of the trochanter, the lines converge on the affected
side (Figure 6.1.16B).
Figure 6.1.15: Different lines drawn in normal hips.
Section 06.indd 168 01-12-2012 10:41:13

169
Figure 6.1.16: Changes when the right hip is affected, AShortening in the Bryants triangle;
BConverging lines in the Chienes test; CMeeting of the two Shoemakers line below the
umbilicus to one side (opposite side) of the midline.
Note: All the lines except Nelatons lines are not of much use in bilateral hip
pathology.
Measurement of Infratrochanteric Shortening:
This is done by measuring from the tip of the greater trochanter to the inferior
pole of the patella. Inferior pole of the patella roughly corresponds to the knee
joint line. Both the bony points the trochanter as well as the joint line (Ref:
Inferior pole of the patella) are marked before measurement.
Measurement of Shortening of the Tibia:
This is measured from the joint line to the medial malleolus.
Note:
a. Always the values are compared with the values of the opposite normal side.
b. Opposite limb is kept in identical position while measuring the true limb
length discrepancy.
Measurement of Fixed Deformities

i. Flexion deformity
Thomas test: This test is performed by making the patient lie on a firm
examination table (and not a sagging mattress). One hand of the examiner is
insinuated at the back between the cot and the lumbar spine. Then with the
other hand the normal limb is flexed till the back just touches the insinuated
hand. This is an indication of nullifying the compensation of exaggerated
lumbar lordosis. Further flexion of the normal limb would obliterate the
normal lumbar lordosis as well. So at this point note the angle which the
involved limb makes with a horizontal. This gives the degree of flexion
deformity. Try to extend the involved limb passively to make sure that
there is flexion deformity (Figures 6.1.17 and 6.1.18).
ii. Measurement of adduction/abduction deformities and free range of adduction/
abduction.
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170
Figure 6.1.17: The presence of exaggerated lumbar lordosis secondary to fixed flexion
deformity.
Figure 6.1.18: Method of performing Thomas test to assess the amount of fixed flexion de-
formity. Please note the insinuated hand between the examination table and the back. The
flexion of the normal limb should stop the moment the back touches the insinuated hand.
Continued flexion would otherwise obliterate the normal lumbar lordosis also. Angle F is the
angle of flexion deformity.
First the pelvis is squared. To assess the abduction deformity the involved
limb is adducted palpating the ASIS at the same time. The attempted
adduction should immediately stop at that point when the anterior superior
iliac spine begins to move down. The movement that has taken place from
the position of squaring till the ASIS has begun to move is the free range
of abduction, and the remaining is the fixed abduction deformity. Opposite
is the maneuver for assessing the adduction deformity.
From the squared position the involved limb is abducted. The attempted
abduction should immediately stop at that point when the ASIS begins
to move up. The movement that has taken place from the position of
squaring till the ASIS has begun to move is the free adduction, and the
remaining is the fixed adduction deformity.
When there is no free movement of adduction/abduction, the ASIS starts
moving immediately with attempted abduction/adduction. In such cases, the
position of limb on squaring gives the degree of fixed adduction/abduction
deformity.
Trendelenburg Gait (Figure 6.1.19)

This is a type of gait that occurs when the abductor mechanism which is
responsible for abduction at the hip is affected. The mechanism has three
components:
a. The fulcrum which is the head of the femur.
b. The lever which is the neck of the femur.
c. The power which is the gluteus medius.
Section 06.indd 170 01-12-2012 10:41:13

171
Figure 6.1.19: Changes occurring in the hip in Trendelenburg gait. In this illustration the
right hip is the involved hip.
Any abnormality of these, occurring alone or in combination disturbs the

function of abductor mechanism and results in this type of gait. The fulcrum is
disturbed in dislocation of the hip. The lever is disturbed in fracture neck of the
femur. The power is disturbed in paralysis of gluteus medius.
Pathomechanics of Trendelenburg Gait

The abductor mechanism has two-fold function. Acting from above, it abducts
the limb. On weight bearing, the limb is fixed and it acts from below and this
causes lifting of the pelvis. So when the pelvis is lifted up the anterior superior
iliac spine on the opposite side moves up. When the abductor mechanism is
affected this lifting of pelvis does not take place. Instead the pelvis sags on the
opposite side when weight is borne on the affected limb.
This causes the anterior superior iliac spine on the opposite side and the
shoulder on the same side to dip down for maintaining the balance. A characteristic
lurch develops on the affected side resulting in Trendelenburg gait.
When there is bilateral affection of the abductor mechanism a bilateral
Trendelenburg gait or a Waddling gait results.
Section 06.indd 171 01-12-2012 10:41:13

172 Note: For a Trendelenburg gait to be positive there has to be range of free
adduction in the involved hip.
Knee Joint Pathologies

Tests for Ligament Injuries
Valgus stress test, varus stress test, Lachman test, anterior drawer test, posterior
drawer test is provided.
Tests for Collateral Ligaments
Valgus Stress Test: (Medial Collateral Ligament)

The test is performed with the patient in supine position lying comfortably on
the examination table. The examiner stands by the side of the patient and the
lower end of the lateral femur is supported by the palm of the hand, at the same
time the limb is held at the ankle by the other hand and lifted up and abducted
a little with the knee in extension. Next a gentle valgus stress is given using the
tibia as a lever. The stress is gradually increased till the patient experiences mild
pain and the degree of opening of the medial joint is observed (Figure 6.1.20).
Figure 6.1.20: Performance of valgus stress test.
Section 06.indd 172 01-12-2012 10:41:13

Varus Stress Test: (Lateral Collateral Ligament) 173

This test is performed almost in a similar manner to the valgus stress test. The
examiner stands by the side of the patient on the medial side of the limb and after
supporting the medial part of the lower end of the femur with one hand a varus
stress is given by the other hand using tibia as a lever, till the stress becomes
little painful. The opening of the joint is recorded (Figure 6.1.21).
Note:
a. Greater degrees of opening up joint with knee in extension indicates severe
disruption and perhaps involvement of anterior cruciate ligament.
b. Also perform this test in 515 (degrees) of flexion of the knee as sometimes
the instability may not be appreciated in extension because of locking.
Tests for Cruciate Ligaments
Anterior Drawer Test: (Anterior Cruciate Ligament)

This test is performed with the patient in supine position lying comfortably on
the examination table.
Next the hip is flexed to 45 and the knee is flexed to 90 and the examiner
sits on the ankle of the patient. This stabilizes and prepares the limb for the test.
Then the upper part of the leg in the tibial condylar region is gripped firmly and
Figure 6.1.21: Performance of a varus stress test.
Section 06.indd 173 01-12-2012 10:41:13

174 the limb is pulled forwards. At the same time the anterior translation is observed
(Figure 6.1.22).
Posterior Drawer Test: (Posterior Cruciate Ligament)

This test is performed in a similar fashion as that of anterior drawer test except
that the upper part of the leg is pushed backwards instead of being pulled
forwards. The posterior translation is observed (Figure 6.1.23).
Note: Performing these tests in internal and external rotation gives information
about the rotary instability.
Figure 6.1.22: Anterior drawer test being performed.
Figure 6.1.23: Performance of posterior drawer test.
Section 06.indd 174 01-12-2012 10:41:13

Lachman Test: (Anterior Cruciate Ligament) 175

This test is performed with the knee in 30 of flexion. The position of the
patient is supine on the examination table. With the knee flexed to 30 the test is
performed by grasping the upper part of the leg and drawing the tibial condyles
anteriorly. Anterior translation is observed (Figure 6.1.24).
Advantages over anterior drawer test:
a. The test can be performed when there is hemarthrosis which does not allow
90 flexion of the knee.
b. Sometimes in 90 flexion the meniscus may block the anterior translation
acting like a door stopper and the anterior drawer test may prove negative.
As Lachman test is performed in 30 flexion of the knee joint this possibility
does not exist.
Points to Remember
It is ideal to perform the test on opposite normal knee first not only to gain
confidence of the patient but also to get an idea about the pre-injured status
taking normal knee as reference.
Negative results of the stress tests do not rule out ligament injury, especially
when there are other clinical signs and the patient is apprehensive. Examination
under anesthesia is a must in such situations.
Tests for Meniscus
Mechanism of Injury
During normal flexion and extension of the knee joint the menisci follow the
femoral and the tibial condyle and allow a smooth gliding. But when there is an
abnormal stress of rotation instead of following the condyles they start moving
on the condyles. Thus, they are drawn into the center of the joint where they
get trapped, pinched and torn. Flexion, abduction, external rotation stress at the
knee causes internal rotation of femur on the tibia and draws the medial meniscus
Figure 6.1.24: Performance of Lachman test.
Section 06.indd 175 01-12-2012 10:41:13

176 into the center and injuries it. The reverse, i.e. flexion, adduction, internal
rotation stress causes external rotation of femur on the tibia and draws the lateral
meniscus into the center of the joint and injuries it. The site of tear is related
to the degree of flexion. In more flexion, more posterior part of the meniscus
(posterior horn) is involved. In more extension (lesser degrees of flexion) more
anterior part is involved. Thus, the tear begins posteriorly and extends from
posterior to anterior direction as the knee extends from a flexed position.
Types of Tear (Figure 6.1.25)

A. Longitudinal tear: May proceed to become a Bucket handle tear.
B. Radial tear: May proceed to become a Parrot beak tear.
C. Horizontal tear: May proceed to become a Flap tear.
D. Combined tear: A combination of different tears, generally seen in a
degenerative meniscus (in elderly).
Diagnosis
Signs and Symptoms
a. Constant pain in the knee aggravated by movement.
b. Tenderness in the joint line (medial/lateral).
c. Swelling when effusion is present.
d. Sensation of giving way.
Figure 6.1.25: Different types of meniscal tears.
Section 06.indd 176 01-12-2012 10:41:14

(Other causes for sensation of giving way are loose bodies, chondromalacia 177
patella, weakness of quadriceps, instability due to ligament injury).
e. Pathological locking. This is seen only in Bucket handle tear. Pseudo-
locking is seen in acute injuries of the knee with hemarthrosis.
Note: Sensation of giving way and pathological locking occurs when the torn
portion of the meniscus comes in contact with the articular surface of the femur
during movement.
Clinical Diagnostic Tests

1. McMurrays test
a. For medial meniscus: With the patient lying supine on the examination
table the knee is completely flexed. To check the medial meniscus the
examiner palpates the posteromedial joint with one hand and holds the
foot with the other. The leg is then externally rotated and the knee is
gradually extended. A click is appreciated when the torn portion of the
medial meniscus comes in contact with the femur.
b. For lateral meniscus: With the patient lying supine on the examination
table the knee is completely flexed. To check the lateral meniscus the
examiner palpates the posterolateral joint with one hand and holds the
foot with the other. The leg is then internally rotated and the knee is
gradually extended. A click is appreciated when the torn portion of the
lateral meniscus comes in contact with the femur.
The medial meniscus is more commonly injured than the lateral meniscus.
The click appreciated is not only felt but can be audible at times. The
tear of the posterior portion of the meniscus produces a click in 0-90of
movement as the knee is extended from a completely flexed position. The
tear involving the middle and anterior portion of the meniscus produces
a click beyond 90 of movement.
2. Apleys grinding test: With the patient prone the knee is flexed to 90 and
the thigh is fixed against the examination table. The leg is then held, pulled
upwards and a rotational strain is given. When ligaments are torn this part of
the test is painful.
Next the leg is pushed downwards and rotated while the joint is slowly flexed
and extended. When the meniscus is injured, pain is observed in the joint.
3. Squat test: This test is performed by asking the patient to take full squats with
the leg and the feet together, alternately in internal and external rotation.
Pain in the joint in internally rotated position (external rotation of femur
on the tibia) suggests injury to the lateral meniscus and pain in externally
rotated position (internal rotation of femur on the tibia) suggests injury to the
medial meniscus.
Note: Presence of pain and click are diagnostic of meniscal injury. But absence
does not rule out tears of the meniscus.
Section 06.indd 177 01-12-2012 10:41:14

178 Shoulder Joint Pathologies

Tests for Anterior Dislocation Shoulder
Tests
a. Dugas test: Patient is asked to touch the opposite shoulder.
If the patient is unable to touch the opposite shoulder, the test is positive.
If the patient is able to touch the opposite shoulder, the test is negative.
A negative test in a case of anterior dislocation of the shoulder suggests
the presence of a fracture of the surgical neck of the humerus.
b. Hamilton ruler test: When the head of the humerus is in the glenoid cavity,
the bulging contour of the deltoid muscle prevents one from placing a ruler
touching both acromion and lateral condyle of the humerus. In dislocation
this contour is lost and it is possible to place a ruler straight across the
shoulder touching both, the acromion and the lateral condyle of the humerus.
The test is said to be positive.
c. Bryants sign: Positive sign is shown by lowering and prominence of the
anterior axillary fold.
d. Callaways test/sign: Increase in girth of the shoulder.
Radiological Signs of a Posterior Dislocation Shoulder

Investigation: X-raysA standard AP view is taken. This gives oblique profile
of the glenoid. Following signs are seen:
a. Loss of elliptical overlap: Normally there is an overlap of at least 1/3rd of
the head over the posterior glenoid (obliquely profiled glenoid). This overlap
becomes less or absent.
b. Empty (vacant) glenoid sign: The glenoid cavity is void of articulating head
of the humerus (Figure 6.1.26).
Figure 6.1.26: Loss of elliptical overlap as well as empty glenoid sign suggestive of
posterior dislocation of the shoulder.
Section 06.indd 178 01-12-2012 10:41:14

History and presentaion Probable diagnosis 179

Pain during night Impingement
Pain while throwing (Athlets) Glenohumeral joint instability/
impingement
Pain and Clunk during overhead motion Glenoidal labrum disorder
Sudden onset of pain and inability to move Calcific tendinitis
Pain associated with swelling and fever Bursitis/septic arthritis
Total loss of movement following trauma/seizures Dislocation/fracture
Generalized laxity Shoulder instability
The chart showing the history and presentation of different shoulder pathologies.
Tests for Rotator Cuff Disorders

1. Supraspinatus
Drop Arm Test
Position: Patient seated on and examination stool or standing.
Test: The examiner gently abducts the patient's shoulder to the maximal
degree possible.
After instructing and cautioning the patient about the possible drop, the
Examiner releases the patient's arm and asks him or her to slowly lower the
arm back to the side.
Interpretation: A drop arm sign is said to be positive when the patient is able
to lower the arm partly, usually to about 90 to 100 of shoulder abduction
then loses control of the arm, which suddenly drops to the waist.
Testing the Strength of Supraspinatus
Position: The patient is seated on an examination stool or standing.
This muscle can be tested in 90 abduction external rotation and 20 forward
flexion (Full can position)/90 abduction neutral rotation and 20 forward
flexion/90 abduction internal rotation and 20 forward flexion of the
shoulder (Empty can position). The rotation at which the shoulder is placed
during testing does not make any difference in the testing.
Test: With the elbow bent at right angle, the arm is placed in 90 abduction,
20 forwards from the mid-coronal plane, and is held in a few degrees
of external rotation/neutral/internal rotation. The examiner then applies
resistance to this position while the patient tries to hold this position against
resistance.
Interpretation: The test is positive when inability to hold the arm or weakness
is observed.
When the patient is able to hold the arm and no weaknes is observed the test
is negative.
2. Infraspinatus and teres minor:
External Rotation Stress Test
Position: Patient seated on an examination stool or standing with arms by
his or her side neutral flexion and abduction, elbow flexed and forearm in
mid prone/supination.
Section 06.indd 179 01-12-2012 10:41:14

180 Test: The shoulders are then externally rotated 45 to 60 degrees. The
examiner then applies force against the dorsum of the hands, attempting to
internally rotate the shoulders back to neutral and patient is asked to resist
this.
Interpretation: Pain and weakness suggest inflammation or tearing of the
infraspinatus or the teres minor or both.
Testing the Strength of Infraspinatus
Patient is asked to place the arms tightly at the sides with the elbows flexed
to 90. The patient is then asked to externally rotate the arms while the
examiner provides resistance.
3. Infraspinatus
Drop Sign
Position: The patient is seated on an examination stool with his or her back
to the examiner.
Test: The affected arm is held at 90 degrees of abduction in the scapular
plane and at almost full external rotation with the elbow flexed at 90 degrees.
The patient is then asked to maintain this position actively as the examiner
releases the wrist while supporting the elbow.
Note: External rotation in abduction is mainly by infraspinatus. In this
position action of teres minor is eliminated.
Interpretation: The sign is positive if a lag or drop occurs.
The sign is negative if the patient is able to hold the limb in the position of
abduction external rotation.
External Rotation Lag Sign
Position: The patient is seated on an examination stool with his or her back
to the examiner.
Test: The elbow is passively flexed to 90 degrees, and the shoulder is held
at 20 degrees of abduction and near maximal external rotation (maximal
external rotation minus 5 degrees to avoid elastic recoil in the shoulder) by
the examiner. The patient is asked to maintain the position of external rotation
actively as the examiner releases the wrist, while maintaining support of the
arm at the elbow.
Interpretation: The sign is positive when a lag, or angular drop, occurs.
The sign is negative if the patient is able to hold the limb in the position of
abduction, external rotation.
4. Teres minor
Horn Blowers Sign or Patte Test
Position: Both the examiner and the patient are standing with the examiner
by the side of the patient.
Test: The patients arm is elevated to 90 in the scapular plane. The examiner
then flexes the elbow to 90 degrees, and externally rotates the shoulder and
without leaving the support at the elbow instructs the patient to maintain the
position.
Interpretation: The test is said to be positive when weakness or pain is
observed and the shoulder moves into internal rotation making the forearm
and the hand drop to the front of the face (the position resembles as if
blowing a horn).
Section 06.indd 180 01-12-2012 10:41:14

5. Subscapularis 181
i. Belly Press Test (Napoleon Test)
Position of the patient: The patient is seated on an examination stool
or standing.
Test: Patient is asked to press the abdomen with the flat of the hand
placed at the belly button (unumbilicus) keeping the arm in maximal
internal rotation.
Interpretation: If the strength of the subscapularis is impaired, maximal
internal rotation cannot be maintained, patient feels weakness, and the
elbow drops back behind the trunk. The test is positive.
If the patient is able to maintain the position the test is negative.
ii. Lift-off Test (Gerber)
Position of the patient: The patient seated on an examination stool or
standing. The arm is internally rotated, and the dorsum of the hand is
placed against the lower back.
Test: The patient is then asked to lift off the arm further backwards.
Interpretation: If the patient is unable to lift the dorsum of the hand off
the back, the test is positive.
A patient with a normal subscapularis is able to lift off the arm further
backwards from this position.The test is said to be negative.
iii. Internal Rotation Lag Sign
The position of the patient: The patient is seated on an examination
stool or couch with his or her back to the examiner. The affected arm is
held by the examiner at the elbow, in internal rotation and placed behind
the trunk, with the elbow in 90 of flexion and the shoulder in 20 of
abduction and 20 extension with dorsum of the hand resting over the
lumbar spinal region.
Test: Next the dorsum of the hand is held at the wrist and passively lifted
away from the lumbar region by the examiner until almost full internal
rotation is reached. The patient is then asked to maintain this position
actively as the examiner releases the wrist while maintaining support at
the elbow.
Interpretation: The sign is positive when a lag occurs and the limb drops
back to the lumbar region.
The sign is negative when the person is able to hold the limb away from
the lumbar region without dropping.
Note: Rupture of subscapularis will allow more external rotation on
examination.
6. Anterior and Posterior Drawer Test
These tests are for detecting instability of the shoulder:
Position: The patient is seated on an examination stool or a couch.
Test: The examiner stands behind the patient. To evaluate the right shoulder,
the examiner grasps the patients shoulder with the left hand to stabilize the
clavicle and superior margin of the scapula while using the right hand to
move the humeral head anteriorly and posteriorly.
Interpretation: Significant anterior or posterior mobility of the humeral head
suggests instability.
Section 06.indd 181 01-12-2012 10:41:14

182 7. Gerber-Ganz Anterior Drawer Test

Position: The patient is supine with the affected shoulder positioned such
that it projects slightly past the edge of the examining table.
Test: The affected shoulder is held in 80120 of abduction, 020 of
flexion, and 030 of external rotation as loosely and without pain as
possible. The examiner immobilizes the scapula with the left hand (with
the index and middle fingers on the scapular spine and the thumb on the
coracoid). With the right hand, the examiner tightly grasps the patients
proximal upper arm and pulls it anteriorly.
Interpretation: When an aterior translation is observed the test is positive.
8. Sulcus Sign
This is a sign for inferior glenohumeral instability:
Position: The patient is seated on an examination stool or standing.
Test: With one hand, the examiner stabilizes the patient's contralateral
shoulder while exerting a distal pull on the patient's relaxed affected arm
with the other hand. This is best done by grasping the patient's arm at the
elbow with the elbow slightly flexed.
Interpretation: The sign is positive when sulcus forms between the acromion
and the head of the humerus.
9. Apprehension Tests
These tests are performed to identify anterior and posterior instability of the
glenohumeral joint.
i. Anterior Apprehension Test
Position: The patient is lying supine on the examination table or siting
on an examination stool.
Test: The upper limb with elbow flexed to 90 is held at the elbow with
one hand and then moved passively into 90 of abduction and maximal
external rotation taking care to prevent the subluxation or dislocation
(that might occur during the test) by supporting the humerus with the
other hand.
Interpretation: The test is said to be positive when the patient complains
of pain and develops apprehension and tries to prevent the external
rotation movement.
ii. Posterior Apprehension Test
Position: Patient is lying supine on the examination table.
Test: The upper limb is moved passively into flexion adduction and
internal rotation and a gentle backward trust is given at the elbow.
Interpretation: The test is said to be positive when the patient complains
of pain and develops apprehension and tries to prevent the internal
rotation movement or the thrust.
Elbow Joint Pathologies

Carrying Angle
Definition of carrying angle, cubitus varus and cubitus valgus: The angle made
by the long axis of the arm with the long axis of the forearm in extended position
Section 06.indd 182 01-12-2012 10:41:14

of the elbow is known as Carrying Angle. Normal angle is 510 in males 183
and 1015 in females.
When this Carrying Angle reverses it is said that the elbow is in cubitus
varus and when this Carrying Angle increases it is said that the elbow is in
cubitus valgus (Figure 6.1.27).
Note: If there is a flexion deformity at the elbow carrying angle cannot be
measured. This angle always is measured with the elbow in extension.
Baumanns Angle
In children, it is difficult to assess the accuracy of reduction of varus in a
supracondylar fracture. The Baumanns angle helps to determine the accuracy.
It is an angle formed by a line along the long axis of the humerus and the line
along the coronal axis of the capitellar physis. Normal angle is around 80. If the
angle increases it indicates the varus position of the fragment (Figure 6.1.28).
The Three Bony Points

The lines joining the three bony points namely the medial epicondyle, the lateral
epicondyle and the tip of the olecranon form a triangle in 90 flexed position
of the elbow. This relation is disturbed in posterior dislocation of the elbow
but maintained in supracondylar fracture. Further the distance between the
Figure 6.1.27: Cubitus varus deformity at the elbow and the axis and angle of deformities
at the elbow. (For color version, see Plate 11)
Section 06.indd 183 01-12-2012 10:41:14

184
Figure 6.1.28: The Baumanns angle normal and abnormal.
Figure 6.1.29: Relationship of the three bony points, namely the medial epicondyle, the
lateral epicondyle and the olecranon which form a triangle in 90 flexion of the normal elbow.
epicondyles and the olecranon will be disturbed in medial and lateral condylar
fracture as well as in intercondylar fractures when compared to the opposite
normal side. The intercondylar distance also is altered in intercondylar fractures
(Figure 6.1.29).
Section 06.indd 184 01-12-2012 10:41:14

Multiple Trauma
Section 7
185
Multiple Trauma
Section 07.indd 185 01-12-2012 10:42:18

186 7.1. Multiple Trauma
Basic Concepts of Diagnosis and Management of Polytrauma

Polytrauma is defined as:
Injury severity score > 18.
Hemodynamic instability.
Coagulopathy.
Closed head injury.
Pulmonary injury.
Abdominal injury.
Field Triage
Assessment and establishment of airway and ventilation.
Assessment of circulation and perfusion.
Hemorrhage control.
Patient extrication.
Shock management.
Fracture stabilization.
Patient transport.
Trauma Deaths
Three phases have been identified:
i. Immediate, e.g. severe brain injury, disruption of heart or major blood
vessels.
ii. Early, e.g. intracranial bleeding hemopneumothorax, splenic or liver rupture,
etc.
iii. Late, e.g. sepsis, multiorgan failure.
Golden Hour
Chance of survival diminishes rapidly after 1 hour. This critical period is
known as golden hour in a severely injured patient.
It is very much important to know these facts before a person attempts
to treat a severely injured patient. Adequate facilities and the services of the
specialists in the field of orthopedics, general surgery, cardiothoracic surgery,
neurosurgery, spinal surgery, plastic surgery and anesthesiology should be
available 24 hours, in a center where these cases are managed.
Resuscitation of a Severely Injured

Some of the devices and equipment used for emergency resuscitation (Figures
7.1.1 to 7.1.4)
Section 07.indd 186 01-12-2012 10:42:18

Multiple Trauma
187
Figure 7.1.1: Foley's catheter used to record urine output. (For color version, see Plate 12)
Figure 7.1.2: Suction tubes used for aspiration. (For color version, see Plate 13)
Figure 7.1.3: Ambu bag used for ventilation. (For color version, see Plate 13)
Section 07.indd 187 01-12-2012 10:42:19

188
Figure 7.1.4: Cervical collar. (For color version, see Plate 13)
Follows A, B, C, D, E:
AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXPOSURE
Maintenance of Airway and Breathing

Inspection of upper airway.
Suction of secretions.
Nasal, endotracheal, nasotracheal airway or tracheostomy.
Indications for Intubation

Need for control of airway.
Need for prevention of aspiration in unconscious patients.
Need for hyperventilation.
Obstruction to airway from facial trauma and edema.
Breathing
Most common cause of ineffective ventilation after establishment of airway
includes malposition of endotracheal tube, pneumothorax and hemothorax.
Maintenance of Circulation
Hemodynamic stability defined as normal vital signs, maintained with only
maintenance of fluid volumes.
Minimum of two large bore IV lines is essential.
Alternatively saphenous vein cut down in adults or intraosseous (tibia) in
children.
Serial monitoring of BP and urine output with possible central venous
monitoring.
Serial hematocrit.
Section 07.indd 188 01-12-2012 10:42:19

Multiple Trauma
Differential Diagnosis of Hypotension in Trauma 189

Hypotension is always seen secondary to shock. The following are the features
of different types of shock:
Cardiogenic shockDiagnosis: Hypotension distended neck veins, muffled
heart sounds.
- Pericardial tamponade.
Neurogenic shockDiagnosis: Hypotension without tachycardia or vaso-
constriction because of sympathetic disruption with thoracic level spinal cord
injury.
Septic shockDiagnosis: Hypotension accompanied by fever, tachycardia,
cold skin and multiorgan failure.
Hemorrhagic shockDiagnosis: Consider this in patients with large open
wounds, pelvic or femoral fractures, abdominal or thoracic trauma. All these
conditions lead to massive blood loss.
Classification of Hemorrhage and Management

Aim: To maintain BP, pulse as well as volume and oxygen carrying capacity of
blood.
Class I: Less than 15% blood loss, pulse rate normal, BP normal.
Treatment: Infusion of crystalloids to maintain and avoid fall of pressure.
Class II: 1530% blood loss, tachycardia with normal BP.
Treatment: Infusion of crystalloids.
Class III: 3040% blood loss, tachycardia, tachypnea and hypotension.
Treatment: rapid crystalloid replacement, then blood.
Class IV: >40% blood loss marked tachycardia and hypotension.
Treatment: Immediate blood replacement.
Disability in a case of polytrauma (Evaluation of a case of polytrauma).
Glasgow Coma Scale (GCS)
Glasgow coma scale Score

A. Eye opening (E)
1.Spontaneous 4
2.To speech 3
3.To pain 2
4.None 1
B. Best motor response (M)
1.Obeys commands 6
2.Localize to stimulus 5
3.Withdraws to stimulus 4
4.Flexor posturing 3 Contd...

5.Extensor posturing 2
6.None 1
C. Verbal response (V)
1.Oriented 5
2.Confused conversation 4
Section 07.indd 189 01-12-2012 10:42:19
3.Inappropriate words 3
A. Eye opening (E)
1.Spontaneous 4
2.To speech 3
3.To pain 2
4.None 1
B. Best motor response (M)
1.Obeys commands 6
2.Localize to stimulus
Orthopedics Ready Reckoner 5
190 3.Withdraws to stimulus

Contd... 4
4.Flexor posturing 3
5.Extensor posturing 2
6.None 1
C. Verbal response (V)
1.Oriented 5
2.Confused conversation 4
3.Inappropriate words 3
4.Incomprehensible phonation 2
5.None 1
Revised Trauma Score (RTS)

Sum of respiratory rate, systolic BP and GCS
Revised trauma score: Trauma scoring system
Revised trauma score (RTS) Rate Score

A. Respiratory rate (breaths/min) 1029 4
> 29 3
69 2
15 1
0 0
B. Systolic blood pressure (mm Hg) > 89 4
7689 3
5075 2
14 1
0 0
C. Glasgow coma scale (GCS) conversion 1315 4
912 3
68 2
45 1
3 0
Injury Severity Score (ISS)

It is based on abbreviated injury scale for the individual injuries from 1 (mild)
to 6 (total).
Each injury is allocated to one of six body regions (head, face, chest, abdomen,
extremities and/or pelvis).
Section 07.indd 190 01-12-2012 10:42:19

Multiple Trauma
Total ISS score is calculated from the sum of squares of the three worst regional 191
values (ISS = A2 + B2 + C2) ISS ranges from 175.
Evaluation of multiple trauma patientInjury severity score (ISS)
Abbreviated injury scale defined body areas (external structures)

1. Soft tissue
2. Head and neck
3. Chest
4. Abdomen
5. Extremity and/or pelvis
6. Face
Severity code
1. Minor
2. Moderate
3. Severe (non-life-threatening)
4. Severe (life-threatening)
5. Critical (survival uncertain)
6. Fatal (dead on arrival)
Exposure
It is important to undress the trauma patient completely and examine entire
body. These are all high velocity and high impact injuries with possibility of
involving more than one system.
Lateral cervical spine.
AP chest.
AP pelvis.
Lateral thoracolumbar spine possibly CT of head, cervical spine, thorax,
abdomen or pelvis.
Decision to Operate
Early operative intervention is absolutely indicated in major fractures. Indications
include:
a. Specific injuries, e.g.
Fractures of the pelvis, femur and multiple fractures.
Fractures of neck of femur and talus.
Hand injuries.
Intra-articular fractures.
Pediatric fractures and physeal injuries.
Section 07.indd 191 01-12-2012 10:42:19

192 b. Fractures with complications

These complications are either vascular, visceral or neurological, e.g.
Impending or active compartment syndrome.
Open fractures and crush injuries.
Unstable spine injuries.
Vascular injuries.
Section 07.indd 192 01-12-2012 10:42:19

PLATE 1
Figure 1.2.1: Open fractures classificationbased on

Gustilo and Anderson.
Plate.indd 1 01-12-2012 10:30:00

PLATE 2
Figure 1.10.3: Ring concept of stability.
Figure 1.10.4: Ankle fracturesbased on Lauge-Hansen classificationsupination

external rotation.
Plate.indd 2 01-12-2012 10:30:00

PLATE 3
Figure 1.10.5: Based on Lauge-Hansen classificationsupination-adduction.
Figure 1.10.6: Based on Lauge-Hansen classificationpronation-external rotation.
Plate.indd 3 01-12-2012 10:30:01

PLATE 4
C
Figures 2.10.1A and C: (A) Radial inclination; (B) Palmar tilt; (C) Radial length.
Figure 4.1.2: Normal hand (left) where the thumb is placed at right angles to the other fingers
and the hand with thumb deformity (right) where the thumb is remaining by the side of the
other fingers.
Plate.indd 4 01-12-2012 10:30:01

PLATE 5
Figure 4.1.3: A positive Oschners clasp test and the pointing index sign .
Figure 4.1.4: A classical Ulnar claw hand with hyperextension at the metacarpophalangeal
joints and flexion at the interphalangeal joints of ring and little finger only. Hypothenar muscle
atrophy is pronounced. Note the scar at the elbow along the course of the nerve (marked by
an arrow) which indicates possibility of neurotmesis of the nerve.
Plate.indd 5 01-12-2012 10:30:01

PLATE 6
A B
Figures 4.1.5A and B: The classical attitude of (A) Wrist drop; and (B) Finger drop.
Figure 4.1.6: A negative pen test. The person is able to touch the pen using his abductor
pollicis brevis.
Figure 4.1.7: Card test being performed. Note that both the examiner and the subject to be
examined should use the same grip, i.e. inter digital clasp.
Plate.indd 6 01-12-2012 10:30:02

PLATE 7
Figure 4.1.8: Book test being performed and the Froments sign. Note the flexion of
the IP joint of the thumb which is brought about by the Flexor pollicis longus.
Figure 4.1.9: Igawas test being performed. Note how the other fingers are stabilized and
the middle finger is made to move sideways both medially and laterally, testing both palmar
and dorsal interossei.
Plate.indd 7 01-12-2012 10:30:02

PLATE 8
Figure 4.1.12: The method of assessing the power of tibialis posterior tendon both against
gravity and resistance. Note the subject is made to cross the limb over the other and asked to
invert the foot against resistance which is applied by the examiner at the forefoot. The tibialis
posterior stands out prominently just behind and little above the medial malleolus.
Figure 4.1.14: The characteristic attitude of the Porters tip hand of Erbs palsy.
Plate.indd 8 01-12-2012 10:30:02

PLATE 9
A B
Figures 6.1.8A and B: Bilateral clubfoot seen from (A) the front and (B) the back showing
all the classical deformities. Note that the deformities are present both in the forefoot and the
hindfoot. Also note the size of the heel which is small.
C
Figures 6.1.10A to C: (A) Congenital oblique talus. Note that it has all the features of a
vertical talus except that (B) The talonavicular joint subluxates in neutral position of the foot
and (C) Gets reduced in equinus. The red arrow shows the same.
Plate.indd 9 01-12-2012 10:30:03

PLATE 10
B
Figures 6.1.11A and B: (A) An infant with congenital vertical talus The soft tissue shadow
shows the convexity of the plantar surface of the foot. The talus is near vertical and the cal-
caneum is in plantar flexion. The navicular bone has not appeared but note the position of the
metatarsals. They are dorsally displaced indicating the dorsal displacement of the navicular; and
(B) An adult with neglected congenital vertical talus with secondary degenerative arthritis. An
adult with rocker bottom foot. Note that the tibiotalar and the talohorizontal angle are near 180
and 90, respectively.
Plate.indd 10 01-12-2012 10:30:03

PLATE 11
Figure 6.1.27: Cubitus Varus deformity at the elbow and the axis and angle of different
deformities at the elbow.
Red lineShows the long axis of the arm and this line is continued downwards. The line is
straight and the angle is zero (0).
The angle formed between the Red and the Yellow line is the normal carrying angle which is
515. Yellow line indicates the axis of the normal forearm.
The angle formed between the Yellow and Blue line shows increased carrying angle which
is seen in cubitus valgus.The Blue line indicates the axis of the forearm in cubitus valgus
The angle formed between the Red and the Green line shows reversal of carrying angle seen
in cubitus varus. The Green line is drawn along the long axis of the forearm.
Note: Yellow and Blue lines are the lines which would be drawn along the axis of the forearm
in a normal elbow and in an elbow with cubitus valgus deformity respectively. The red line
which is continued downwards is a hypothetical line along the long axis of the arm indicating
0 carrying angle. The green line is a line which is drawn along the axis of the forearm in a
cubitus varus deformity.
Plate.indd 11 01-12-2012 10:30:03

PLATE 12
Figure 6.1.29: Relationship of the three bony points, namely the medial epicondyle, the
lateral epicondyle and the olecranon which form a triangle in 90 flexion of the normal elbow.
Figure 7.1.1: Foleys catheter used to record urine output.
Plate.indd 12 01-12-2012 10:30:03

PLATE 13
Figure 7.1.2: Suction tubes used for aspiration.
Figure 7.1.3: Ambu bag used for ventilation.
Figure 7.1.4: Cervical collar.
Plate.indd 13 01-12-2012 10:30:03

Index
Page numbers followed by f refer to figure
A Bony Bankart lesion 57

Book test and Froments sign 130, 132
Abdominal injury 111, 186 Boyd and Griffin classification 19, 19f
Abductor Brachial plexus injuries 126
hallucis brevis 161 Brachioradialis reflex 106
pollicis brevis 131f Bradycardia 97
Absence of reflex 108 Breathing 95, 188
Acetabular fracture 10 Brodies abscess 150
Advanced trauma life support 6 Bryants
Alignment index 16 sign 56, 178
Allis triangle 167, 169f
maneuver 15 Bulbocavernosus reflex 96, 98f, 107
sign 157 Burst fracture 112, 118
Allman classification 54, 54f thoracolumbar spine 122f
Anterior Buttressing of distal tibia 38
and posterior drawer test 181
apprehension test 182 C
cord 100
cruciate ligament 173, 175 Calcaneal fractures 41
decompression and fusion 121 Card test 130, 131
dislocation 13, 14, 56, 68 Cardiogenic shock 189
of hip 164 Carrying angle 182, 183
drawer test 173 Cauda equina 94, 100
fat pad 64 syndrome 100
humeral line 64 Cause contraction of anal sphincter 98f
sacroiliac ligaments 12 Central
shoulder dislocation 56, 57f cord 100
superior iliac spine 166, 168 dislocation 13, 14, 14f
Anteroposterior compression 11 Chance fractures 121, 122
Apleys grinding test 177 Chienes test 168, 169f
Apprehension tests 182 Chronaxie 134
Asymmetry of thigh and gluteal folds 157 Circulation 95
Atlantoaxial rotatory subluxation 124 Clavicle fracture 54f
Atlanto-occipital injuries 114f Claw toes 129
Atlas fractures 115f Closed head injury 186
Attitude of limb 144 Codmans triangle 143f, 148, 150
Aviators astragalus 39 Comminuted fractures 19
Avulsion fractures 48 Complete
Axis fracture 116 disruption of posterior arch 10
Axonotmesis 126 spinal cord injury 98
Compression
B extension 118
injury 82
Backward hinge 112 of glans penis 98f
Bados classification 70, 71f Compressive
Barlows test 156 extension 120f
Baumanns angle 63, 183, 184f flexion 117
Belly press test 181 Computed tomography scan 152
Benign aggressive lesions 153 Congenital
Bennett fracture 87, 87f anomalies 156
Biceps reflex 106 oblique talus 162, 163f, 164
Bicondylar fractures 29 Consistency of bone tumor 146
Bigelow maneuver 15 Conus medullaris 94, 100
Bilateral reflexes 99
injury 10 Core biopsy 154
lateral mass plating 121 Coronoid fracture 69
Blounts laws 89 Credes maneuver 109f
Blunting of anterior body 117 Crosby and Fitzgibbons and Sanders
Bohler classification 42
and Gissane angle 42f Cumulus cloud appearance 143f, 148
tuber joint angle 41 Cutaneous axon reflex 137
194 D Flexor
digitorum longus 161
Danis-Weber classification 31, 32 hallucis longus 161
Dashboard dislocation 13 pollicis longus 132f
Definition of Foleys catheter 187f
carrying angle 182 Four-part displaced fractures 61
terms describing spinal cord injury 97 Froments sign 132f
Deformity 3
Frykman classification 77, 78f
Deltoid ligament 159
Dens fracture 116, 116f
G
Diabetes 50
Dislocation of Galeazzi
atlanto-occipital joint 113 fracture 74, 74f
spine 112 dislocation 74, 75
Displaced fractures 16 sign 157
Distal Gardens classification 16, 17f
radioulnar joint 74
Gartland classification and flexion type 65f
radius fracture 76, 78f-80f
Gerber-Ganz anterior drawer test 182
Distractive
Giant cell tumor 143f
extension 120
Gissane angle 41
flexion 118
Dorsal medial facet 80 Glasgow coma scale 189, 190
Dugas test 56, 178 Golden hour 186
Dynamic hip screw fixation 20 Grading
of muscle power 105
of neurologic injury 99
E
systems for spinal cord injury 101
Elbow Guidelines for treatment of hip
dislocation 68, 69 dislocations 15
radiology 63f Gustilo and Anderson classification 6
Electromyography 133
Elephant foot type 49 H
Empty glenoid sign 178, 178f
Epiphyseal separation 55 Hamilton ruler test 56, 178
Erbs Hand injuries 191
paralysis 137, 137f Hangman fractures 116
points 138 Hawkins
Essex-Lopresti classification 39f, 40
classification 42, 42f sign 40
fracture 72, 72f Head injury 111
Evans classification 20, 21f Hemodynamic instability 186
Ewings tumor 142 Hemorrhagic shock 189
Extension Herbert classification 83, 84f
fractures 64 Hill-Sachs lesion 57
injury 112 Hip dislocations 13
type fractures 64 Horizontal tear 176
External rotation Horn blowers sign 180
lag sign 180
Horners syndrome 136
stress test 179
Humes fracture 70
Extra-articular calcaneal fractures 41, 43
Humeral ulnar angle 63
Humpback deformity 85
F Hypotension 97
Fat pad sign 64 Hypothenar muscle atrophy 129f
Fernandez classification 77, 79, 79f
Fieldings classification 22 I
Fine needle aspiration cytology 154
Ilizarov technique 51
Flail foot 129
Impacted fractures 16
Flexion
abduction Inadequate
external rotation 164 fixation 50
internal rotation 164 reduction 50
deformity 169 Indirect trauma 58
distraction injuries 121, 123 Inferior
fracture 64 dislocation 56
injury 112 glenohumeral dislocation 59
type fractures 64 shoulder dislocation 60f
Index
Infraspinatus and teres minor 179 Neuropraxia 126 195
Injury severity score 186, 190, 191 Neurotmesis 126
Inspection of upper airway 188 Nondisplaced fractures 16
Interdigital clasp 131f Nonunion 49
Internal rotation lag sign 181 Normal urine output 97
Interphalangeal joints 129f Nutritional deficiency 50
Intertrochanteric
femoral fractures 19 O
fracture 19f, 21f, 164
Intramedullary Occipital condyle fractures 116
device 20 Occurrence of inferior subchondral plate
nail fixation 20 fracture 117
Ochsners clasp test 129f, 130
J Olecranon fractures 68
Onion skin 150
Joint depression type 42 appearance of Ewings tumor 142f
Jones fracture 47, 48 Ortolanis test 156
Osteoid osteoma 146f
K
P
Kirschner wire 75
Kissing bones 148 Pagets disease 150
Klisic test 157, 158f Palmar tilt 76
Klumpkes paralysis 138 Patellar fractures with retinacular tears 27
Knee joint pathologies 172 Pathological fracture 2
Kochers manipulation 57 in unicameral bone cyst 145f
Pathomechanics of Trendelenburg
L gait 171
Patte test 180
Lachman test 175 Pediatric fractures 191
Lauge-Hansen classification 32-34, 34f Pelvic ring fractures 10f, 11f
Lift-off test 181 Pelvis
Limitation of abduction 157 fracture 123f
Lisfrancs injuries 44, 46 injury 111
Longitudinal tear 176 Pen test 130
Low-grade tumor 152 Periosteal stripping 50
Lumbosacral dislocation 123 Perkins sign 157
Perthes disease 164
M Piedmont fracture 74
Placement of implant 20
Magnetic resonance imaging 152 Plane of bone tumor 146
Management of Plantar calcaneonavicular ligament 159
intra-articular fractures 29 Plexus injuries 125
open fractures 6 Pointing index sign 129f
suspected scaphoid fractures 86 Positron emission tomography scan 152
McMurrays test 177 Posterolateral dislocation 68
Measurement of supratrochanteric Posteromedial dislocation 68
shortening 167 Pronation
Mechanism of injury 2, 37, 47, 56, 58, abduction 33, 35
66, 94, 175 external rotation 33, 34
Median nerve 127, 130 Proximal
Melones classification 80, 80f humeral fractures 61
Metacarpophalangeal joints 129f interphalangeal joint 132
Milch classification 66, 66f Pulmonary injury 186
Monteggia fracture 70, 71f Pure central depression 29
Morris bitrochanteric test 168
Movements of joints 147 R
Muscle 145
power 106 Radiocapitellar line 70
Myerson classification 46f Radiolunate angle 85
Reflexes 107
N of lower extremity 110
of upper extremity 106
Napoleon test 181 Regional lymph nodes 147
Neer classification 61, 62f Restoration of
Nelatons line 168, 169 Bohler angle 42f
Nerve root lesions 100 tibial articular surface 38
196 Return of reflex 108 fracture dislocation 44, 46f
Reudi and Allgower injuries 44
classification 37, 37f, 38 Teardrop 64
Revised trauma score 190 fracture 117
Ring concept of stability 33f Techniques of biopsy 154
Rolando fracture 87, 87f, 88 Teres minor 180
Role of angiography 151 Terrible triad of elbow 69
Root injury 100 Thomas test 169
Russe classification 83, 83f Thompson and Epstein classification 14f
Russell-Taylor classification 24, 25f Thoracolumbar
fracture 121
S fixation 123f
spine fracture dislocation 122f
Sacral fractures 123 Tibial
Sacrospinous ligaments 12 pilon fractures 37, 37f
Sacrotuberous ligaments 12 plateau fractures 28, 28f
Salter-Harris classification 89, 90f Tibialis posterior 161
Scaphoid fracture 82, 83f, 84f Tiles classification 9, 10f
Scapholunate angle 85 Tinels sign 130, 133
Schatzker classification 28f Total incongruity 45
Sciatic nerve 129 Totally displaced fractures 65
Seddons classification 126 Trabecular angle 16
Segmental fracture 50 Translational injuries 121
Seinsheimer classification 22, 23f Trauma
Sensory zones of peripheral nerve 127 in general and injuries of lower limb 1
Septic shock 189 scoring system 190
Shearing force 112 Traumatic spondylolisthesis of
Shentons line 160 axis 116, 117f
Shock management 186 Trendelenburg gait 170, 171f
Shoemakers line 168, 169f Triceps reflex 106
Shortening of thigh 157 Two-part displaced fractures 61
Shoulder
dislocations 56 U
joint pathologies 178
Signs of Grave prognosis 107 Ulnar nerve 127, 131, 139
Slipped capital femoral epiphysis 164, 165 Undisplaced fractures 61, 65
Spine 93, 93 Unifacetal cervical dislocation 118f
Spring ligament 159 Upper
Squaring of pelvis 166 cervical spine 113
Squat test 177 limbs 105
Stable burst fractures 121, 122 plexus injury 137
Starch iodine test 134
Stimson maneuver 15 V
Strength duration curve 134
Stress fractures 48 Valgus stress test 172
Subacute osteomyelitis 148 Varus stress test 173
Subtrochanteric Vertical
femoral fractures 22 compression 33, 35, 118
fractures 23f, 25f oblique fracture 85
Sulcus sign 182 shear 11
Sunray appearance 143f Volar medial facet 80
Superior location of greater trochanter 157
Supination W
adduction 33, 34f
external rotation 33, 34 Warm extremities 97
Supracondylar fractures of humerus 63 Wedge compression fractures 121
Suprascapular nerve 138 Whole plexus injury 138
Surface of tumor 145 Wrist drop 129
Swelling 3, 4
Systolic blood pressure 190 X
X-ray examination 111
T
Talar neck fractures 39, 39f Y
Talonavicular ligament 159
Tarsometatarsal Young and Burgess classification 11, 11f

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Prelims.

RM Shenoy D Orth MS Orth

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

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Orthopedics Ready Reckoner

Deepak Pinto MS Orth, FRCS (Glasg, UK) Vivek Mahajan MS Orth

We acknowledge with thanks the role of Manipal University where a sound

Section 1: Trauma in General and Injuries of the Lower Limb

Section 2: Injuries of the Upper Limb

xiv Section 4: Clinical Diagnosis of Peripheral

Section 5: Examination of a Bone Tumor

Section 6: Important Clinical Tests and

Section 7: Multiple Trauma

Trauma in General and

Section 01.indd 1 01-12-2012 10:33:10

2 1.1. Examination of BonE and Joint inJuriEs

Section 01.indd 2 01-12-2012 10:33:10

Deformity and Swelling

Section 01.indd 3 01-12-2012 10:33:10

Section 01.indd 4 01-12-2012 10:33:10

Section 01.indd 5 01-12-2012 10:33:10

6 1.2. opEn fracturEs

Based on Gustilo and Anderson Classification (Figure 1.2.1)

Management of Open Fractures

Section 01.indd 6 01-12-2012 10:33:10

Figure 1.2.1: Open fractures classificationbased on Gustilo and Anderson.

emphasis must be placed on identification of associated life-threatening injuries.

Antibiotics: What, When and for How Long?

Section 01.indd 7 01-12-2012 10:33:11

Debridement: When and By Whom?

Section 01.indd 8 01-12-2012 10:33:11

1.3. fracturEs of thE pElvis 9

Based on Tile's Classification (Figure 1.3.1)

Type A: Stable (Posterior Arch Intact)

Type B: Rotationally Unstable, Vertically Stable

Section 01.indd 9 01-12-2012 10:33:11

Figure 1.3.1: Pelvic ring fracturesbased on Tiles classification.

Type C: Rotationally and Vertically Unstable

Based on Tiles Fracture Types following Stabilization

OpenBook (Type B1)

Section 01.indd 10 01-12-2012 10:33:11

is no fecal or urinary soiling, plate fixation is preferred; otherwise external 11

LC (Types B2, B3)

Rotationally and Vertically Unstable Injuries (Type C)

Based on Young and Burgess Classification (Figure 1.3.2)

Figure 1.3.2: Pelvic ring fracturesbased on

Section 01.indd 11 01-12-2012 10:33:11

Section 01.indd 12 01-12-2012 10:33:11

1.4. hip dislocations 13

Based on Thompson and Epstein

Section 01.indd 13 01-12-2012 10:33:11

Figure 1.4.1: Posterior hip dislocationbased on

Anterior Dislocation (Figure 1.4.2A)

Central Dislocation (Figure 1.4.2B)

Section 01.indd 14 01-12-2012 10:33:12

Hip dislocation is an orthopedic emergency and should be reduced on an

Indications for Open Reduction of the Dislocated Hip

Section 01.indd 15 01-12-2012 10:33:12

16 1.5. fracturEs of thE fEmoral nEck

Based on Gardens Classification (Figure 1.5.1)

Section 01.indd 16 01-12-2012 10:33:12

Figure 1.5.1: Fracture neck of femurbased on