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LONG CASES
Chapter 1
Theories Discussed
• Thomas test
• Roll test
• Bryant's triangle
• Galleazi test / Allen's test
• Tredelenburg's sign • Telecopic test
• Gait • Craig's test
• Shoemaker's line • Chiene's test
• Kothari's angle • Patrick test / Fabere sign
• Nelaton's line • Psoas abscess
• Pelvic distraction test • Genslen's test
A. INSPECTION
Gait
Limp is an abnormal gait (see page 129).
Attitude / Deformity: Attitude is the position or posture of the body and limbs i.e. the typical
arrangement of the parts of the body, which is adopted by the patient for ease and comfort.
Deformity means distortion, disfigurement, flaw , malformation or mis-shape that affects the body
in general, or a part of it, producing an abnormal posture, which cannot be brought back to the
normal or anatomical position by the patient actively.
• With patient standing : Comment on - r---------------,-..,,....,..-:-:--=;;,-,=.-,
From front • Level of shoulder
• Anterior superior iliac
spine (ASIS) + iliac fossa + groin fold
• Patella
• Foot
From side • Lumbar lordosis
• Abnormal protrusion of ab-
domen / buttocks
• Supra + infratrochanteric depression Fig . 2 . 1. 1 : Noting temperature
From back • Scapula
• Centra_l furrow ~ve~ _spine (note scoliosis)
• Posterior superior 1l~ac spine (PSIS) (dimple of venus, above buttock)
* Gluteal folds + popllteal fossae + heels
N. B. : Always comment on scar, swelling, sinus, ulcer, pulsation, pigmentation and wasting.
• W~th pat~ent sitti~g : (sign!ficance in scoliosis only) . Always from the back (see page 254)·
• With patient supme : • Attitude _of the lower limbs and pelvis.
• Shortening of lower limb.
• With patient prone : For patients
· · who cannot stand , specially look for pres sure
sore I bed sore.
110
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BASIC CLINICAL EXAMINATION OF HIP 111
B. PALPATION
. On the lateral side of the hip Joint lies the neck femur and the trochanter on the med· 1
6
N. · · side the ace~abulurn and 1he pelvis , an? on the posterio~ side the fleshy gluteal muscl~:.
So the hip JOl~t 1s nearest .to. the skin surfa~e anteriorly, which corresponds to the
anterior hip point situated w1ttl1n the femoral triangle.
, Temperature : With the dorsum of the fin.gers ot you~ dominat hand note, compare and
rnenl on the temperature over the femoral triangle (see fig . 2.1.1) in the following order- f t
~f;e normal side, then the affected/pathological side and fin ally again the normal side. irs
A • Tenderness : Always look at the patient's face
when examining tenderness.
(A) Anterior hip point (Direct): It is situated 1.5 cm .
be low and lateral to the mid inguinal point i.e.,
mid point of the distance between the ASIS (anterior
superior iliac crest) , and the symphysis pubis, just
beside the femoral artery pulsation (see fig 2.1 .2-A).
Fig. 2.1.2A : Anterior hip point tederness (B) Bi-trochanteric compression test (Indirect) :
With the patient supine place both your hands
over both the trochanters so that the base of the
B hands (i .e., where the thenar and hypothenar emi-
nence meet) are in full contact with the center of
the trochanteric prominence. Now look at the face
of the patient and apply medialy directed force with
both your hands (see fig . 2.1.2-B). It is seen in con-
ditions like central dislocation; fracture of acetabu-
Fig. 2. 1.2s : Tenderness. Note : Exam- lum; femoral neck and trochanter; trochanteric bur-
iner is looking at the patient's face. sitis; TB hip; AVN ; Perthes disease etc.
PALPATION OF BONY LANDMARKS AROUND HIP
N.B. : The bony landmarks are the ASIS, tip of greater trochanter, symphysis pubis and the pubic
tubercle. To do this we first identify the pubic tubercle and the symphysis pubis. Then
following the inguinal ligament from the pubic tubercle we identify the ASIS, and finally
the greater trochanter.
(1) Have a female attendant for a female patient. Explain the procedure to the patient, (i.e., what
you will do and what the patient will be required to do) and ensure verbal consent.
- (2) Semiflex the hip and knee, and slightly abduct the
hip. Place one hand on the medial side of the knee
and request the patient to try and adduct the hip
against resistence, (which you apply with the hand
placed on the knee) . This makes the proximal at-
tachment of the adductor tendons visually very
prominent (see fig . 2.1.3-A).
(3) Now with your free hand's thumb/index finger , pal-
pate the prominent tendinous adductor attachment
up to the ischiopubic rami (i.~. , f~el th~ bone_). Then
move superiorly along the 1sch1opub1c ram1 to ~he
end of the bone (i.e. , the pubic crest, after which
the soft-tissues of abdomen begin.)
( ) Once you reach the medial e~d of th~ pubic ~rest,
4
move your palpating thumb/tndex finger shghtl~
medialy and lateraly to find the ~mall ?ony promi-
nence of the pubic tubercle. Confirm this by palpat-
ing the inguinal ligament which is a tough fibrous
structure attached to the pubic tubercle medially.
Fig. 2.1.3-B . Syrnphysis Pubis
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112 HANDBOOK FOR OR1HOPAEDICS EXAMINATION
- - -~ • - ' r , -~""'f
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BASIC CLINICAL EXAMINATION OF HIP 113
arative resistance I tig ht~ess to the ~ovement~ for both the lower limbs. If there is spasm the
~atient will complain of pain and you will feel resistance (see fig . 2.1.4-8) .
• Inguinal lymph nodes: Remember the anatomy .
• Sciatic point : It is palpated mid way between the ischial tuberosity and the posterior border
of the trochanter.
N.8. : • For cold abscess ----, Search in the femoral triangle, iliac fossa, gluteal region,
antero-medial part of the thigh , supra + infratrochanteric regions .
• For dislocation ----, Search for femoral head. Commonly in gluteal region for
posterior dislocation hip.
C. MOVEMENTS
THOMAS TEST FOR FIXED FLEXION DE,· ORMITY (FFD) OF HIP
N.B. : • FFD hip is the commonest hip deformity, firstly because in the flexed position, the joint
capsule becomes lax and thus attains the maximum intra articular volume. accommo-
dating the maximum amount of synovial fluid. The second reason is because the hip
flexor muscles are more powerful than the hip extensors.
• FFD is compensated / concealed with increased lumbar lordosis. (upto about 30°}
• If there is FFD there will be no extension, but further flexion is possible (free range) .
(1) Have a femal e attendant for a female patient. Explain the procedure to the patient, (i. e., what
you will do and what the patient will be required to do) and ensure verbal consent.
(2) Ensure the examining table is hard and flat. There should not be any cushion/mattress
padding. If this pre-requisite is not feasible then inform the examiner before hand.
(3) The patient should lie supine with both the lower limbs aligned in the longitudinal axis of the
body. Expose the patient from below xiphisternum to the knee, keeping the genitals covered.
(4) Stand on the "affected" side of the hip. Then bend low to bring your eye-line, between the bed
and the lumbar lordosis, to confirm there is a gap between the lumbar region and the bed.
You should see light on the other side (see fig. 2.1.5-A) .
(S) lnsuniate the hand/palm that is towards the head of the patient, between the bed anc.J the
lumbar lordosis, so that the dorsum of the hand touches the bed (see fig . 2.1.5-B).
(S) Then, grasping the opposite "normal/non-pathological" lower limb just below the knee , (with
your hand that is facing the foot of the patient) gradually flex the hip (the knee automatically
flexes with this manoevure if it is not ankylosed), until the lower back of the patient touches
the fingers and palm of your other hand (see fig . 2.1.5-C) .
(?) Then bring out the hand which is in-between the bed and the lumbar region of the patient.
and very gently fl ex the "normal/non-pathological" hip a few deg~ees more, just enough to
completely obliterate the lumbar lordosis. Be careful and stop Just when the lower back
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Fig. 2.1.5-C
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BASIC CLINICAL EXAMINATION OF HIP
11 5
(3) Standing on the affected/pathological side of the patient, gra.sp !h~ lower leg just.above the
·
ankl e with . d the patient's foot. Now ma1nta1ning knee extension, gradu-
your hand that 1s towar s I I f th ASIS St
all . d diall keeping your eyes on the eve o e . op
Y move the limb laterally an me Y, . 1 . · ''squrare" To confirm hold a mea-
When b0 th th ASIS t the same level 1.e. the pe vis is · '
. e are a . -C) d note that it is perpendicular to the long
su~ing tape joining both the ASIS (see fig 2. 1.7 , an
axis of the body.
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116 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
Abduction in flexion of hip . h as possible) and the knees, so that the feet lie
(1) Semiflex both the hips (or flex the hip as muc
side by side on the bed .
Fixed
Abduction
deformity
(R) hip
(1) The patient should lie supine with both the lower limbs aligned in the longitudinal axis of the
body. Expose the patient from below xiphisternum to the knee, keeping the genitals covered.
(2) Stand on the foot end of the patient and grasp both the lower legs just above the ankles,
and lift the limbs about 4"-6" from the bed. This "locks" the knee in extension/ hyperexten·
sion , and ensures that the tibia and femur will rotate in unison as one piece.
(3) Now simultaneously internally rotate (see fig . 2.1.9-A) both the legs , keeping your eyes on b?1h
the patell_ae. Next simultaneously externally rotate the legs (see fig . 2 .1.9-B) . The angle which
the anterior surface of the patella makes with the bed (the horizontal) denotes the degree 01
rotation . Note, compare and comment. '
Fig. 2.1.9-A
Fig. 2. 1 9 -B
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BASIC CLINICAL EXAMINATION OF HIP 117
(4) Next, try to touch both the soles of the feet together (see fig. 2.1.10-B) to asses external
rotation in flexion . Note, compare and comment.
Rotation in Prone Position :
(1) Request the patient to be prone, and then flex both the knees to 90°.
(2) Then request the patient to move both the feet maximally away from each other (see fig
2.1.11-A). Note, compare and comment on internal rotation.
(3) Finally request the patient to cross both the legs across each other (see fig. 2.1.11-B).
Note, compare and comment on external rotation .
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11 B HANDBOOK FOR ORTHOPAEDIC S EXAMINA flON
D.MEASUREMENT
• Linear :
A. Apparent-? (R) and (L)
B. True -? (R) and (L)
• Circumferential : Wasting
Measurement of Apparent length
N.B. • Treatment option - Heel raise on the affected side.
• Apparent shortening measurement gives an idea
about the amount of "compensation" the body has
done to "conceal" the hip deformity or scoliosis, in
order to keep both feet on ground, and both lower
limbs parallel.
(1) Have a female attendant for a female patient. Explain the procedure to the patient, (i.e., what
you will do and what the patient will be required to do) and ensure verbal consent. .
(2) Patient lies supine with both lower limbs parallel to each other and aligned in the long axis
of the body.
(3) Palpate and mark the suprasternal notch . This is done by palpating the subcutaneous
clavicle , from the acromio -clavicular joint , with your thumb and gradually sliding the
thumb medially (see fig. 2.1.12-A) to the promin ence of the sterno -c lavicul ar joint,
and then further medially toward s th e centre of manubrium-sterni , t ill the smoo th
concave bony depression of the suprasternal notch is palpated . (some recommend th e
Xiphi Sternum but it is mobile and difficult to palpate in obese patients) . . .
(4) Palpate and mark the tip of the medial maleoli of both th e ankles. This is done by sliding
the thumb along the subcutaneous antero-medial surface of th e distal tibia, till the sharp
end of the maleoli is palpated. To confirm , press the tip of medial maleolus with your
thumb, .an? then .dorsiflex a~d plantarflex the ankle to note that th e bony point under
thumb 1s _im.mob.1le. Now . slide the metal lic flat-end of a measuring tape from the h b.
Y:~~
upwards till 1t strikes the first bony point (see fig . 2.1.12-B) whi ch is held under your thum
to exactly locate the tip of the medial maleolus.
) F'
(5 inally place one end of the measuring tape at the suprasternal notch and requ est thep
patient .to firmly hold it. Holding the other end of th e measuring tape, place it over th et~e
of medial maleolus and note the length first of one limb (see fig . 2. 1.1 2-C) and then
other limb. Compare the lengths to get th e apparent shortening.
. . hO~
N.B. • Instead of requesting the patient to hold one end of the measuring tape you ma~ . I'll
both the ends of the tape with your both hands provided your arm-span is of sufficie
length .
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Fig. 2.1. 12-C
Fig. 2.1. 12-8
N.B. • Treatment option - Surgical correction to gain length on the affected side.
• St~ictly speaking, the true length of the lower limb should be measured from the topmost
point .o f the. head ~f femur, to the most inferior point of the calcaneum. This is clinically/
technically 1mposs1ble. Therefore the nearmost subcutaneous bony prominence that can
be easily palpated is utilized i.e. ASIS instead of the femoral head, and the tip of medial
maleolus instead of the calcaneum.
• The distance from the ASIS to the tip of medial maleolus always changes with abduction
or adduction of the hip. Therefore it is necessary to "square" the pelvis first and also
to measure both the limbs in identical position.
(1) Have a female attendant for a female patient. Explain the procedure to the patient, (i.e., what
you will do and what the patient will be required to do) and ensure verbal consent.
( ) The patient lies supine on the bed. Standing on the attected side first "square" the pelvis by
2 gently moving the affected lower limb, so as to place it in the position of the fixed abduction
(see Fig. 2. 1.13-A) /adduction deformity (see Fig. 2.1.13-B) as noted previously. This brings
Fig. 2. 1. 13-8
Fig. 2.1.13-A
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Fig. 2. 1. 13-IJ
Fig. 2.1 13-C
been placed . Place the metallic flat end of the measuring tape on lhe AS IS of the non.
affected lower limb and request the patient to hold it firmly in place . Holding the other end
ot the measuring tape, place it over the tip of medial mal eolus and note the true length ol
the non-affected side .
• Measurement of Limb Length Discrepancy (LLD) in Standing Position (see page 126)
GALLEAZI TEST OR ALLEN'S TEST
N.B. : Once you have noticed true shortening of a lower limb, the next job is to find out whether the
shortening is in the thigh (femoral segment), or in the leg (tibial segment) . This can be d~ne
by the Galleazi test, and also by true measurements (in cm) of the femoral segment _(,. e.
from ASIS to the medial joint line of the knee , when the pelvis is square) and the tibial
segment (i.e. from the medial joint line of the knee to the tip of the medial meleolus).
(1) Have a female attendant for a female patient. Explain the procedure to the patient, (i.e., what
you will do and what the patient will be required to do) and ensure verbal consent.
(2) Semiflex both the hips and knees of both
sides in such a way, that both the feet are
placed side by side, identically, in the
same plane. Confirm this by placing the
ulnar border of your hand which is towards
the feet of the patient, ensuring both heels
are in the same straight line (see fig .
2.1.14-A) .
(3) Now bend low to bring your eyeline hori-
zontally to the level of the knees. and note
the vertical-height-discrepancy of both the
Fig. 2.1.14-A
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11111-----
BASIC CLIN ICAL EXAMINATION OF HIP 121
Fig. 2.1.14-B ; Note : Right Femoral shortening Fig . 2.1.14-C ; Note : Right Tibial shortening
knees , which when present, signifies shortening. In femoral shortening, the knee is found to
be more proximal and in tibial shortening the knee is found to be a little distal to the opposite
knee (see fig. 2.1.14-B & 2.1.14-C)
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122 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
. lly measure and compare the lengths of all 3 sides of the triangle drawn on both th .
F ina e sides
(see fig. 2.1.15).
Interpretation : (i) Line c (base of the triangle) shortening actually quantifies the supratrocha t .
shortening. Causes may be coxa vara, malunited trochanteric fracture, posterior dislocn ~nc
. th . . f ation
of hip, destruction of the femoral head as sequ Iae o f sept 1c ar nt1s, racture neck of fem
(ii) Line B shortening indicates internal rotation or anterior tilting of the greater trochanter. Cau ur.
may be posterior dislocation hip, central dislocation hip, etc. Lengthe~ing of line B indica~::
external rotation of greater trochanter which may be due to trochantenc fracture, fixed flexion
deformity of hip etc.
(iii) Line A (hypotenuse of the triangle) shortening may be due to central dislocation hip, neglected
fracture neck femur with absorption of the neck, destruction of the femoral head as a sequelae
to septic arthritis etc.
N.B. : Reversed Bryant's triangle : when the upward migration of the tip of greater tro-
chanter is so much , so that it is palpated superior to the line B , t hen reversed Bryant's
triangle is drawn . Then , the total supratrochanteric shortening will be line C of the
normal side + line C of the affected side.
• CIRCUMFERENCIAL MEASUREMENT
N.B. : This test is very important because it notes. confirms and measures wasting of the thigh
muscles. This is the only hip examination where the affected side should always be first
and the opposide side is examined later for comparison.
(1) The patient lies supine on the bed with both lower limbs parallel and aligned in the longitudinal
axis. Visually note the level of the thigh where you note gross wasting , in comparison to the
other thigh. Mark the level on the affected side with a skin pencil.
(2) Palpate and mark the medial joint line of both the k nees. This is done by semi flexiing
the knee and then sliding your thumb , or the fl at m etallic end of a measuring tape from
below upwards, along the medi al as pect of proxim al ti bia, until the tape-end "lodges" into
a groove (see fig . 2 .1.16-A) . Confirm by gently fl exi ng and extending the knee, to note
that there is no movement of th e fl at metallic tape e nd.
(3) Now measure the length from the medi al joint line to the level marked in step 2 on th0
affected side. Then measure the same distance from the medial joint line of knee. on th0
non -affected side, and mark the level on the thigh w ith a skin pencil.
nd
(4) Finally, measure the circumference of th e thigh at the marked level, of both the thighs a
note the discrepancy (see fig. 2.1.16-B) i.e ., wasting at that level. Express yourself as follows
: On comparison, there is wasting of .. .. .. ..... cm on (R/L) side of thigh muscles, ........ cm
above the medial joint line of knee.
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BASIC CLINICAL EXAMINATION OF HIP
123
E. SPECIAL TESTS
OELENBURG 'S SIGN : This sign was original ly described to detect congenital dislo f
TRE ( ow called developmental dysplasia hip) in 1895. ca ion
of hip n . . .
NB. • For effective de.monstr~t1on .1n front o'. the exam1~er, repeatedly performing the test
· before the examiner arrives, 1s a good tip , because 1t weakens the abductor mechanism
of the hip.
• This tests the abductor mechanism of hip, and thus the stability of the hip (because
without effective functioning of the abductors, the hip is inherently unstable).
• Biomechanics of the principle of the sign : When a person stands on 2 legs, the body
weight is distributed equally on both the lower limbs. But when the person chooses to
stand/bear weight only on one leg, automatically the brain tries to align the whole body
weight of the trunk (i.e ., pelvis, abdomen , chest, head and neck) over the weight bearing
leg. This is achieved by strong muscle contraction of the abduc-
tors of that hip (mainly gluteus medius), which contracting from
below (i .e. the infe rior attachment at the lateral aspect of the 1
greater trochanter), pulls the ipsilateral iliac crest down towards
that side, causing tilting of pelvis (see fig. 2.1 .17-A). The spinal
column compensates by bending on the opposite direction to
maintain the erect posture. The fulcrum of this movement is the
centre of the hip joint, and the lever arm is mainly the neck of ]
the femur with contributions from the head and trochanteric
region. When any component of this osseo-muscular hip-abduc-
tion system fails , the test becomes positive. Fig. .1 . 1-A
2 1
• Pre-requisite : Patient should be able to stand unsupported . . .
on one leg for 30 sec. There should be no coronal plane deformity (fixed abduction /
adduction deformity) . The opposite hip, ipsilateral knee and ankle should be normal.
{1 ) Have a female attendant for a female patient. Explain the procedure to the patient, (i.e., what
you will do and what the patient will be required to do) and ensure verbal consen~ b h' d
(2) Request the patient to stand on the floor or hard bed (without mattress), and you stan e in
Fig. 2.1.17-C
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(4) Then reques t the patient to ,ta n J (J' ' • I j , 11t 1d1 1, h<; "r, <';IH~r;lo91r,8.lfaffr.,r,.tAcJ" ',JrJ,~ ,,r.
and inform th e examiner that th(, normr.il/ n ,ri ci ff c...t~d '>1rfo ', t 'Hrnpr.:I VI'~ h&, n<; r. ·
elevated , as evident from the visual e 11rJ6 nr,<.: rJf thrJ lo fLJI of th " dimpl~ vf 1~nu~ ', ~~,
crest gluteal folds , sca pula and houlde, r (s.&~ fig . 2.1.17 GJ . Thi'" r'3f,ffJ'~'3n ~ a p(.,-, ;;
Trendelenburg 's sign . •
Causes of Positive Trendelenburg 's sign
(1) Fulcrum failure : Developmental dysplasia of hip, d1 loca ion of hip, de rue,1ion of the f~r , ~
head as a sequlae to septic arthritis.
(2) Le ver arm failure : Fracture neck of femur, trochan bric fra" ure, co..<a 'Iara (le 1er arrn , , .
ened), Perthes disease .
(3) Abductor muscle(s) failure : Muscle weakness as in poliornyelities, mu cular d; strcp ·~,
motor neurone disease .
(4) Painful hip where any movement is undesirable : Rheumatoid arthritis, ankylosing spo jl1 ~
affecting the hip .
TELESCOPIC TEST : Th is is a test for asse ss ing the stab ility of hip .
(1) Have a female attendant for a female patient. Explain th e procedure to the pati ent, (i.e., wha
you will do and what the patient will be required to do) and ensure verbal consent.
(2) Stand on the affected/pathological side of the patient. When (R) hip is path ological, place
your (L) hand over the (A) iliac region of the patien t, so that your (L) thumb and thenar
eminence is pressing over the ASIS (which stabil izes the pelv is), and the fingertips are
touching the tip of the greater trochanter .
(3) Now flex the "affected/pathological" [i .e.(R)] hip and knee to 90° (or as close to 90") a~
possible) , and adduct the hip by holding the knee with your (A) hand (see fig. 2.UB·\ ·en
it is impossible to grasp the knee with your hand , then grip the lower thigh and knee betw
your (R) chest wall and the (A) shoulder into your armpit.
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BASIC CLINICAL EXAMINATION OF HIP 125
Now apply pressur~ along the longitudinal ~xis of the fem~r with your (R). hand (or armpit),
50 that you alternatively push- nd-pull (see fig. 2.1.18-B): S1multane_
ously with the tips of your
(L) hand's fin~ers, note the amount of movemenVexcurs1on of the tip of the trochanter of the
pathological side.
Then compare the amount of mo~em~nVexcursion of the opposite side , following the same
(S) rocedure, standing on the opposite side. If the movement on the "pathological/affected" side
ismore than the normal side, the test is said to be positive.
Difficulties faced
* In obese patients where palpation of the tip of the greater trochanter is difficult, and also
grasping the knee .
• In painful hip any movement is resisted by the patient. Pain is a relative contraindication .
MISCELLANEOUS TESTS
• Active SLR (Straight leg raising) test
• Ortolani test / Barlow test ~ When applicable i.e. , in infant with congenital dislocation of
hip, also called Developmental Dysplasia of Hip (DOH) [see page 274] .
Comment on :
A. Joint above/ Joint below (Knee)
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126 HANDBOOK FOR ORTHOP A[O ICS E-XAMINA l ION
pati ent) 10 fi rml y fi x th e pel vi s to the bed (by pr ss ing down , so that the lumbar lordo is i
bl iterated vi suall y) . Now wi th your other h, nd and forearm . upport both the knees of thepatien:
from below (sec fi g. 2 . 1. 19 -B ).
4 ) hen, gentl y . tart to extend both the hips unti l there i s resi stence, and there i a hint of reappearence
of the lumbar lordosi s.
(5) t and inform th xaminer that th e angle made between th e hori zontal as evident from y
· I b k ·I · our
forearm which i s facing the head of the pati ent (w h1 c 1 must e ept 1onzontal with the elbo
fi xin g the pel vi s) and the hangin g " path ological/affected" sides thi gh (supported by your oih:
hand) i s the FFD of the hip( ) .
Measurement of Limb Length Discrepancy (LLD) in Standing Position
N.B. • This method is believed to be more accurate for measuring LLD because it is done in the weight
bearin g po. ition. However, it can only be done in patients who can stand without much
discomfort, despite hip pathology.
• Pre-requisite : Wooden blocks to support the foot, each having height/width in increments
of 0 .5 cm (e.g. I cm, 1.5 cm, 2.0 cm, 2 .5 cm, 3.0 cm, 3 .5 cm ... etc.)
• lf the wooden block has to be placed under the " normal / non-affected" side, then it means
the affected ide i lengthened.
•
the ASiS and noting th at it i absolutely horizontal. l f re-
quired remove the block and insert another uitable block
until both ASIS are at the same level. The height/width of
the fi nal block placed is the LLD ( ee fi g. 2 . l.20)
Gauvain's Sign :
ll Fig . 2.1.20
When the extended hip is rotated there is spasmodic contraction of muscles around the hip joint
and abdominal muscles. This indicates active disease. May be found in TB Hip.
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- - - - - - ~ BASIC CLINICAL EXAMINATION OF HI 127
. , . Te t: \ 1 1th lhL' p, ticnt l ing s upine, dra a line. joinin ) borh 1h · A.S IS. Th . dr,i w
( 2) Ctuen . ·. I I N 11
ther line jorning the tip '- or both t 1c reale r Lr c 1a nt cr. ornw ll y. b th rh . lin . ., i; hot1 l h.
I
ano 110 ,· vcr, if one icle<, greater troc ha nt r has rni grn t d up wa rd s. lh •11th . Jin ·s will ht
Parallel. - · · in
· 1-1· · · b"I I I· · ·
'
convcrge nton that . ide . lh1s t st ,s . . . . .ec t1 e 111 1 at· n.1 11p. a frec 11 11 • (i-.c• fi g . 2 . I . 2 1- BJ .
1 elaton' Line : m1ally, any line Jommg the Sl and th lip of ischial tub rosity. wh .11 th , hip
~-- ~cxcd to 90", touch_e. /graze. the tip of th gre_ater lr~chan~er. _Wh ·n tl~cre is upw_arcl migralion of th , gr ·r,t •r
trochant r. then the llp of greater tro~hanter of_that 1de w ill _'1 e. up nor Lo th lrnc. R m ·mbcr, Nclation \
I.UlC ·I. 011 1Jv drawn on the affected .1de ( ee fig. .1.2 l-C) 1.e. no n d ror bilat r,1 1.
-~ -9. _,-- - - -
-Pc''
I
Fig. 2.1.21-8
~ Fig. 2.1.21 -C
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128 HANDBOOK fOR ORTHOPAEIJIC~ l Ar..t,N/, 1
,_,_0_N_ ~ ~ ~ - - ~ - -
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BASIC CLINICAL EXAMINATION OF HIP
129
, Barlow ,s (provocative) test and Ort olann's test : See page 275-276.
GAIT
Gai t i the pnrticular manner or tyle of walking incl uding rhythm, cadence and speed. It involve a
cyclic lo. and r g~ining of balanc~ ~y a hift of the li~e of grav ity in relati on to the centre of
aravity. perfect gait cycle ensure minimal energy expenditure during walking.
e
Gait Cycle : ln the Sta,ice p hase (60%) the foot is in contact with ground and undergoes 5 movements.
( I) In itialontact (Heel trike), (2) Loading Re ponse (Foot Flat), (3) Mid Stance, (4) Terminal Stance
(5) Toe Off (~re Swing) . ln _
Swing phase (40 '.7'0) the foot is not in contact with ground and has 3 parts'.
(A) Initial Swrng (Accelerat1on), (B ) Mtd Swrng, (C) Termina l Swing (Deceleration) (see fi g. 2.l.26).
(B) (C)
Fig. 2.1.26
• Antalgic gait : Reduced stance phase, because beari ng weight causes pain.
• Short-limbed gait : Affected shoulder moves conspicuously down and up and the affected
ide hemipelvis sags down when bearing weight. Not seen if shortening is< 2 cm. There may
be ip ilatera] equ inu /contralateral knee flexion during stance phase. If hortening i due to
infratrochante1ic cause then opposite side hemipelvis will rise in stance pha e.
• Trendelenburg gait : Seen when Trendelenburg's test is positive. The shoulder swings and
lurches downward on the affected side, and the opposite side hemipelvi sags down when
bearing weight.
• Cadence : It is defined as the number of steps per unit time. In normal gait, cad nee i about 100-
11 5 steps per minute. Cadence of a person is ubject to vari~u factor.
• Comfortable Walking Speed: It i. a characteri tic speed at which there I lea t n rgy con umption
per unit distance. It is about 80 metre per minute in a normal gait. .
• Step Length: It is defi ned as the di stance between corresponding successive point - of h el conta t
Of the Opposite feet. In a normal gait, the ri ght tep length i. equal st~~eft ~~ni.,_ lo~~r h:l C nta I of
• Stride Length : It is defined as the di stance between any two succe. s~ P '
th · . h st 'de length is double the step I ngth.
e same foot. In a normal gait, t e n ·ct 'd ct· ·tanc betwt: , 11 the line of step or
• Walking Base or Stride Width : It is defined as the SJ e-to-si e is '
the two feet.
N.B. •
Centre of gravity of the body lies I cm an 1erior to S2 vertebra.
. ht)
• . . . , b ti W/6 (W = body w tg .
Weight of a si ngle lower hmb ts a m . h hip J'oint is W/3 ( :s body , ig.ht)
. force acting on eac
In double legged stance joint reaction eight b aring hip is - ·' W .
• In single legged stance Jomt
. . reac tion force on t I1e w
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Chap ter 2
PERTHES DISEASE
Theories Discussed
• Pathology of Perthes disease
• Blood supply of the fem oral head
• Manageme nt of Perthes disease
• Clinical featu res of Perthes disease
• Classification of Perthes disease
• Head-at-Risk signs
• Sagging rope sign
• Sectoral sign
• Gearstick sign • Arthrodiatasis
• Also known as Legg-Calve-Perthes disease, Pseudo-coxalgia, O steochondritis deformans and
Coxa-juveniles. Legg, Calve and Perthes had described this disease independently in 1910.
• Age group : Commonly 4 to 9 years (may be 2 to 18 years) .
• Male : Female = 4 : 1 (In girls, age group is slightly lower) .
• Commonly height/weight/skeletal maturity of the patient is retarded when compared to a nor-
mal child and the patient often has small feet. Bilateral in 15% cases .
• Occasionally associated with hypospadias , undescended testis , hernia, pyloric steno-
sis, congenital heart/kidney lesions.
• Basically it is an avascular necrosis of
the femoral head (i .e ., capital femoral
Capsule
epiphyses) in a child .
.. -- 't
' , , .. (c) ...
, '
', ,,
Aetiology
Precise aetiology is controversial and debal·
'\ able and probably unknown. Hypofibrinolysisand
antithrombotic factor deficiency have been de·
scribed as contributory. (Controversial)
• Blood supply of the femoral head :
• Up to around 4 years , blood supply al
Extracapsular arterial the femoral head is from : (Fig. 2.2.1)
- anastomotic ring (a) Metaphyseal.
(b) Ligamentum teres (minimal).
Fig. 2.2.1 : Blood supply of femoral head. (c) Retinacular vessels ~
~ Mainly lateral epiphyseal vessels.
~ Branch of medial circumflex
femoral artery . . •
0111
• By 4 years , metaphyseal supply ,s ffica·
pletely blocked, mainly due to oss
tion of the physeal cartilage. . enturn
• By 7 years, supply from the hgarn
teres femoris develops fully. fernoral
• So between 4 years to 7 years, the
d nt on
head is complete ly depen e . acula'
Fig. 2.2.2 : Perthes disease. Note - Increased joint retinacular ve ssel s supply · Reli~psu/af
space, increased density of femoral head, flattening vessels are however at risk of c
of femoral head, broadened femoral neck. tamponade from -
130
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PERTHES DISEASE 131
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132 HANDBOOK FOR ORTHOPAE.DICS !: XAMINATION
TB hi~ excludedt)h. ·story of severe trauma requiring prolonged bed rest or hospitalization
• There ,s no pas I t· ·
. ·th h"gh fever requiring any treatment (post-trauma 1c or septic arthrilis
or severe pain w, ,
excluded) . .
On examination , the patient appears to be unde r ~1ze d and of _short stat_ure , has
Trendelenburg gait and wasting of muscles of right/left thigh/gluteal_ re~10n . Th~re 1s tender-
ness of anterior hip point and spasm of adductor muscles. There 1s _f,xe~ flex,_on deformity
of hip of about 10°115° , and abduction-in-flexion and internal r?tat1on-in-flex1on are_both
decreased , in comparison to the opposite hip. There is no swell1n~/tend~~ness of spine or
knee , and range of movements of knee is fu ll. Trendelenburg si gn 1s pos1t1ve . So my provi-
sional diagnosis is Perthes disease .
N.B . •
• Early in the disease , when the hip is irritable - All movements may be decreased, just
like TB hip, in which case diagnosis may be difficult. So beware.
• There may be apparent shortening due to muscle spasm but rarely true shortening. [Only
in cases of established severe coxa vara (rare) we find true shortening - then mention it].
• Often you will be interrupted while describing the summary, to clinically demonstrate what you
are saying . So, in this case be sure to first examine, confirm and record the main points i.e.,
1 . Trendelenburg gait : Must be able to describe/ demonstrate.
2. Wasting: Must be measured in comparison to the other side.
3. Anterior hip point : Location ; look at the face of patient while palpating for tenderness to
note painful grimace .
4. Roll-test : To note muscle spasm [Or gently abduct the affected sides thigh and palpate the
adductor to note taut adductor muscles.)
5. Thomas test : For fixed flexion deformity.
6. Demonstrate abduction and internal rotation : In both extension and flexion of hip.
7. Sectoral sign may be positive (see page 135)
8 · Mu st be ab~e to demonstrate apparent and true measurements of lower limb and draw
Bryant's triangle.
9. Mu~t know Trendelenburg's sign and give its explanation. Try quick/successive exarn~
nat,~n repeatedly ~or successful Trendelenburg's test. (It further weakens th~ glutef~r
m~d,~s muscle_which always ensures positive findings). If there is fixed adduction de
m1ty interpretation of the result will be erroneous
10. If not done gently/slowly d' . · hat you
· recor mg of hip movements might get changed from w I
recorded and what you de . . · cases 0
. . '. monstrate later m front of the examiner especially in d
here movements become more restricted with repeat~d hip movements an
imtabl_e hip, w_
associated
. pain - so allow rest to the 1·0·1nt before th e examiner
. comes.
How will you manage the case?
• First confirm the diagnosis with investigations.
1 . X-ray :
- Pelvis with both hips : AP (for comparison with other hip).
Lateral view of the affected hip.
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PEATHES DISEASE 133
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134 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
. t?
Wha t do you mean by contammen
The objective of containment treatment is to ~old the ~emoral head in t he acetabul
the period of "biologic plasticity" while necrotic bone 1s resorbed and living bone 18 _um duiiog
' · b · t· " th t h · d resto
through the process of ' creeping su st1tu 10n , so a w en repair an remodellin red
the head becomes almost spherical. Containment is useful only in the revasculariz \°"cu1s,
repair phase. Pre_requsit_ie - there sh_Ould be full range_of motion . Hinged abduction (:~oo aoa
t 36) is a contra1nd1cat1on to containment. Rad1olog1cally conta1 nment can be mea eredPag,
Wiberg 's CE angle (see page 275) in the AP view and break in the Shenton' s line an~u bi
arthrography by noting the medial dye pool. Containment should start before the l~te f also by
tation stage and should continue till late in the repair / reossification stage. ragrnen.
Containment can be done
(i) Conservatively by -
(a) Broomstick plaster.
(b) Scottish-Rite abduction splint _
Which holds the affected hip in abdu .
tion and internal rotation. c
Patients may have psyco-social problems,
with theese methods.
(ii) Surgically by osteotomy -
(a) Femoral ( Varus subtrochanteric
F" . . derotation osteotomy) - produces
ig . 2 ·2 .5 · Yaru derotat1on osteotomy. shortening and requ ires 2nd surgery for
(b) p I · (S • • implant removal.
Ce vic . a1ter mnommate osteotomy) - produces lengthening
(c) ombined Femoral + Pelvic - There ·11 b I' .
What will you suggest for this case ? w1 e no imb length discrepancy.
. Varus subtrochanteric derotation oste O t . .
is on the lower side which all f omy · Limb length recovers if patient's age
, ows or compensatory growth . (Fig . 2.2.5)
(phy is).
What are the cli11irnl H ead-at-Ri!.k sif(ll 1?
l . Female ex
(5) 2- When the patient is obese, overweight.
3. When the patient' age is on the higher ide. dad·
· · d fl x·1on an
4 · Wh en th ere 1s "progre s1ve" fixe e
oo (4)
duction deformities of the hjp.
0 I Ii!) .the prognovis ?
What I spooia ot·
· 1 is a self-limiting disease that hea
ou ly, ometimes with deformity . _ be,au'e
2 · PrognosL is betler when the age i ie,s. 1 , J,ttlJ
fig . 2.2.6 : Schematic
. . diagram of H ea d -a t -R1.
. k th ere i more ti me for remodelling of fll
si gn 1n X-ray . spltericity.
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PERTHES DISEASE 135
1 Girls ha ve , orsc prog.11os1~ than boys ( D( . .
·· · i n l forget . ·ig 1· .
.i niounl of head 111, oh cmcm ~ T h lcsse. · ' c nc1clcncc M : i,. ::: 4 . 1)
. . . • • , ' t 1, c better for p . ' . . .
5 Prognosi. is worse when 2 or more o f he l i ognos1s. (sec clas8if1 c·1t 1011 )
· · · ac -ar-r i l'k si ·· '
, how gro. s incongru1t of joint, functi onal and .·. ·. gns arc pre ·cnl. llowcvcr somcti . I
life. ' -rays do not alwar corre late " ' 1tl1 1· . p.i~~-lrce move ment of hi 1J 11""1'1y 11~ : ., 1· 1·me<, w l ~ n X ray~
.. c 1n1ca l r 1· • s.i 1s actory I1ff I ·
6. Wort ror Caterall lV , best for Caterall L. i nc in gs, and fu ctional abili ty . ' ' ,li er 111
may h,• flh rra,011,
\I llill
.
of ,lu,rteni110
,.,
in p erti1e, rfl\ea
. , ·>
Cox a ara, tlattening / de truction of the rem 11 . 11 •
ora 1ead, fixed Ile ·i d. . -
on cfonnity, lixcd adduction deformity.
~
te nor to middle. (9
~
(AP)
N_o head collapse but increased den -
s1ty of head .
3. Type Ill (Lat.) Type II
> 50% involvement with small poste-
rior viable part.
~ ~
(AP) > 50% involvement. Small lateral viable
part with head-within-head sign , and
metaphyseal changes resulting in the
broadening of neck. Type Ill
4. Type IV (Lat.) = 100% involvement. Epiphyses dense,
(AP)
sclerotic , flattened .
Collapsed , flattened head with lateral
protrusion out of acetabulum and short/
broad neck.
\\ Type IV
?r
Oo rou know of any other classification of Perthes disease?
~: t~erri~g l~teral pillar classification : Bassed on the height of the lateral pillar, defined as the lateral 15% to 30%
C _ e epiphys1s. Group A - no loss of lateral pillar height; Group B -less than 50% loss of lateral pillar height; Group
("' more than 50% loss of lateral pillar height. Group A has the best prognosis, group C the worst
~\Salter and Thompson classification : Bassed on the extent of subchondral fracture. Gro~p A -less than
Ira of th~ femoral head involved; Group B -more than half of the femoral head involved. However subchondral
/cture line is only visible in one-third of the patients. Group A has the best prognosis, group B the worst.
t")
Slulberg classification: Bassed on radiographic evaluation , after skeletal maturity to prognosticate the long-
ne;: outcome of the affected hip joint. Class I- Normal hip join!; Class II- Spherical head with enlargement, short
h k,_or steep acetabulum; Class Ill- Nonspherical head (ovoid, mushroom, or umbrella shaped); Class IV- Flat
ead, Class V - Flat head with incongruent hip joint. Class I and II do well, class Ill and IV develop early
osteoarth n·1·is, and class V have severe symptoms most requmng · · arth rop Ias ty.
N.B. : Salter and Thompson_ 2 groups, Herring - 3 groups,Caterall - 4 types, Stulberg - 5 classes.
What; s
S s ectoraJ sign ? . . .
ectoral sign is seen · ecros·is of femoral head (mainly affecting the anterolateral part) . The internal
rot t· m avascu 1ar n , . . . .
fle~1~_n of the hip will be full or slightly restricted when hip is extended, but will be grossly restricted when the hip 1s
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136 HANDB00 O n,
ti qu 1,, 01 PN the dlsoa e ?
,, ucr,ve u, ge,, ' d.o n to trc .,t . ~atformed femoral head - G arceau's chlelectom .
What 11re the re~ons valgus subtrochantenc o steotoml y, she lf acelab uloplasly (Stah eli) ; Coxa-magna ~·
H·nged
1 abduction - I stic acetabu um - t d/ C b r
r u ward sloping dys p a . . . . 1famoral physeal growth arres an or oxa- reva With
c~xa-ma; ;a ~lonp- pelvic osteotomy (Ch1an) , Cap1t_~h LLD - Morscher's triple osteolomy .
hinged a uc . dvancement; Coxa-breva w1
no LLD _ trochantenc a ? .
th rations le of valgus osteotomy · rf of the remoral head to roll into the acetabulum during
w ; a~/ s o~ the enlarged and deformed anterolatera).~? I~~ abduction" is associated with pain , and the patient
ai ut_
re alters hip joint mechanics. The resultant mg the deformed portion of the femoral head away frorn
ab duc 10n A I s osteotomy removes Th · .
0ft has restricted movement. va gu . . ruou s range of movement. e improvement in levor
en there 1s pain-free cong · h' d bd ·
the wieght-bearing area and ensures . immature patients, removing 1nge a uct1on allows
arm function and leg length results in a better gait pattern. 1n II .
the lateral acetabular ossification center to grow more norma y .
....
-- -
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Chapter 3
• Constitutes about 15% of all bone-TB , i.e. osteoarticular tuberculosis cases . 2nd most com-
mon bone - TB site after cari es spine .
• Usually it affects the adolescents/young adults/ch ildren , but in India it may affect any age
group.
• It is always secondary, i.e. spreads from the initial focus elsewhere (usually pulmonary TB)
via haematogenous route , to the bones and joints.
• In children below 1O years , if clinically ex-
amined only , there is chance of getting con-
fused with Perthes disease, because TB
hip may present itself differently for differ-
ent patients, i.e. often varied clinical pre-
sentation. (Sometimes, without investiga-
tion reports , even the exam iners can be
unsure about the correct diagnosis.)
Aetiology
Starting point (Fig . 2.3.1) or initial focus
after haematogenous spread, is from :
1 . Acetabular roof.
2. Epiphyses .
3. Metaphyseal region (Babcock's
triangle) .
4 . Greater trochanter.
Fig . 2.3.1 : Initial focus of TB hip. 5. Synovial membrane (Rarely) .
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V _ Complication s : Sublu al1on or dislocati on of femoral head occuring d
• Stage I I. . d . ue to
d r c psule/lig m nts, etc. Resu ting 1n wan ermg acetabulum. (Fig. 2· · )
36
01
I' s t tubercul r arthritis of right/left hip joint in stage 111 (or, II , IV) with rest
. . . nct1on
hip 1n m nts nd supratrochantenc shortening of ...... ... cm, presently 1n traction
tting TD for ........... days, in a ....... ... ... year old male/fe male patient. a
t ~ tn su nm ry or his case ? . .
E mpl : Rabi Barik . ..... .. year old b?Y , of lower soc1.o e.conom1c status , presented with limp
nd p in around righ left groin. The pain was often radiatin g to the knee , and sometimes t
pain wo e up the child during sleep (night cri~s) . There is histo~y . of .10w grade rise of bOd:
temperature in the evening, but no history of high fever or other Joint involvement or trauma
Som times there is history of family members or relatives/ neighbours/friends/classmates tak-
ing ATO . On e amination the patient has antalgic gait. There is wasting of the thigh muscles
and the affected lower limb has the attitude of flexion , adduction and internal rotation . Antenor
hip point is tender (sometimes bi-trochanteric compression test is also positive). The adductor
muscles are in spasm . There is fixed flexion deformity of .... .. degrees and all hip movements
are restricted (global restriction of movements). There is supratrochanteric true shortening of
.... ...... cm. T rendelenburg's sign positive . The patient is presently taking ATD , and is being
given surface / skeletal traction.
What are the points in favour of your diagnosis ?
1. From history : (say only the positives) .
(a) Low grade rise of temperature in the
afternoon or evening .
(b) Close contact with known TB patient.
(c) Night cries.
(d) T reatment history of ATD + traction
2 . From examination :
(a) Typical attitude of flexion-adduction-
internal rotation .
(b) Tender anterior hip point.
(c) Al/ movements are restricted (espe-
ciallyt) at the terminal part of move- Fig. 2 . 3 .2 : TB Hip. Note _ Extreme loss of joint
men . ·
(d) True supratrochanteric shortening of ... .... .. cm. space . Radiological stage Ill
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TUBERCULOUS ARTHRITIS OF HIP (TB HIP) 139
What .
are rrce bodies ? .
They are .in tra-articular mall piece
. f f'b ·
o 1 nn a nd arti cular cartilage.
ti/
Ca ~here be attitude of flexio11-abd11ctio11-ext emnl rotatw11,
11 11
1tenia/
• t · ?
· ; 11 tead of th e cla 'Sica/ fl e., io11-a,ldu -
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~ 'hat i\ flu• role of"" ( , , i11 " i'/1 hip ,,ati ·111 ·•
l . If the ,cc.,pon~c LO con~ 1 atl\t: 1,c,,1111c111 i~. 11111_ lavou1abl1 :dt ·, ,1 to 6 w ·ds or tra ction+ !\'I'
(not d c lini all by no 1mp1nvcrn · 111 of I a,11 , I ' 1HI · 111 c~s. 111u sL·I · spa sm an d rt:nli . f)
101
fcv r . .ind abc 1-nc, 11 by no appr ·c1ahk fa ll or hi gh l~SR va lUL'S), 111 ·n surg ·ry or joint ; ~1 ~or
· ' Dru.le.
mcnt a nd . nov ctomy is 111d 1cated .
2. urger is aho ind 1catc<l when the ri nal outco m c after l r ·a I 1nc11 t is 1111octeptoble -
(o) orr ti ve o teotomy is inc.Ii at ' c.l wh' n th hip i~ 011/,ylo.,·ed i11 /Jori position.
( b) rlhrode. is : II re mobility i s sac ri fic ·d l o gain
•
stabi lit y . • I L is i11di ca tcd in painru1 Jr;b
' fOII)
a11kylo.\is of hip in hard , rkin g, young and a ' Liv· udulls. ( h g. 2.3.3). A lso sec Page 271.
) Arthroplasty i . indi at d in sti ff hip, w hen th ·re is very l i ttl e or 11 0 movement.
(i) Ex i. i nal rthroplasty - (Girdl . tone's 01>cration) : Jl crc stability is sacrifi ced to gain
m bility . he femoral head is r moved and 6- 8 week s o f h ·avy skel l al lrncti on i. given to try
and create a pseudoarthrosis wi th fibrou ti ssue.
(ii) Repl acement Arthrop la ty - Total hip replacement (THR ) (Fi g. __ 3.4). Mu t be ure thal
the pati ent i . free from infec ti on befor e operati o n- better to wa it fo r few year after TD
comp letion . (Many urgeon's prefer to w ait for 2-3 yea r , w hile . ome urg on' report good
re ulL of T HR done after 6 months - 1 year after h aling o f th di a e.)
What is the position of hip in which arthrodesis is done '?
lexion 20" to 30° i.e., L0 for l yea r of age upt o 30 yea r ( increased lumbar lord an ·onipen. ate
upto 30° - necessary for ground clearence), neutral to 5° abdu cti on, neutral to 10° xt rnal nitaiion.
•)
If untreated or neglected, what may be the possible outcome which ca 11 be appr riat£'d i11 X-rOJ'' ·
J. ubluxation or Di location o f hip. (Fi g. 2.3.5)
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----"~"""""=...,..... TUBERCULOUS ARTHRITIS OF HIP (TS HIP) 141
What · · TB h . ?
15 Shanmugasundaram 's cfassificat,on of ,p ·
It is based on the X-ray appearence.
• In ch.Id ren - Normal type, Perthes type , o·is located hip type.
. cetabuli type Travelling acetabulum type .
1
• In ch'ildren and adults - Mortar and pestle t ype , Protrus10 a ·
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Chapter 4
FRACTURE N CK OF F MU
Theories Discussed
• Clinical features of fracture neck femur • Causes of non-union of fracture, n . .k fc,mur
• Classification of fracture neck fem ur • Treatment of· rracture n ck t mur
• Singh's Index • O steoporo sis
• An acute or recent fracture is not given as a long case. Usually old, untreated, n lect~d nGc.r
femur fractures are given. It is the commonest fracture due to senile osteoporo i •
• Only for fracture neck of femu r, non-union can be said , when the fracture has not unit&<J bf
3 months (also re member Flynn 's criterion for lateral condyle fracture hume rus - see pag~
65) For all other fractures , a minimum of 9 months must pass after the injury. In non-union
fracture neck of femur , commonly there is absorption of the femora l neck, usually seen 1n I.-
rays by 3 months . (Fi g. 2.4.1, 2.4.2).
• It is often termed as unsolved fracture beca use no treatm ent solu ti on , wh ich is 100%
successful , for all patient profiles could be found .
• Vertebral fractures and Calles fracture are commonly due to post-menopausal osteoporosis.
Other risk factors for fracture neck femur : Alcoholism , diabetes , osteomalacia, cystic-
tumors like GCT in the femoral neck, stroke (due to disuse) and post-radiation therapy.
• Common mechanism of injury is a trivial fall. Occasionally it is a blow to the greater trochanter
or sudden extreme external rotation of thf:
limb. However, in young people more se-
vere injury or trauma is often the cause,
because there is no weakening of bone due
to osteoporosis.
• Conventionally , fracture neck of femur
implies intracapsular fractures only. Other
extracapsular fractu res are conventionally
termed trochanteric fractures which commonly
unites and hence is not an u~solved problem.
What is your diagnosis ?
Fig . 2.4.1 : Non-union of fracture neck of femur. My provisional diagnosis is ~ this is a case
Note - Absorption of neck femur by 3 months. of non-union (if it is more than 3 months ~td.
otherwise say untreated or neglected or un·
properly treated) fracture neck of R/L femur.
of .. ... .. weeks duration in a ....... year old
female/male patient wh~ has been bedridden
and unable to bear ~eight for last ....... weeks.
(If the patient is presently under skeletal trac·
tion , then mention it. Also look for bedsores~
What is your case or what is the summar
of the case?
Example : Mrs. Marjina Bibi, 68 year olda~d
male ~atient, had a fall ...... ·: weeks a~o, and
experienced pain around right/left htp, after
Fig. 2.4 .2 : Non-union of fracture neck of femur. was unable to stand or walk immediately ,m·
Note - Absorption of neck femur. the fall. (Sometimes , if the tractu<e is
142
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FRACTURE NECK OF FEMUR 143
ed the patient may be able to sta'!dlwalk, ~nd later, when the fracture gets displaced or
pact ' k ·s
1
abso rbed, may become bedridden) . Since then she has been bedridden and unable
the nee weight. There is no history of fever, or other joint involvement and weakness/ paresthe-
t~ b~f~he limb. On examin~tion , th e patient appear~ maln?urished. The attitude is of fl exion,
sia t' on and external rotation of the limb, and there 1s wasting of the th igh and gluteal muscles.
abduc \s tend erness of the anterior hip point and bi-trochanteric compression test is positive.
Th~r~ straight leg raisi ng test (SLR) is negative . (In some cases of 'impacted' fracture s ,
ACtve SLR may be possible .) All active movements are impossible and any passive movement
1
~c :inful and restricted . T here is supra-trochanteric shortening of about 1 cm (may not be
15
r:Sent _ be careful and be ready .to demonstrate) . Tele~copic test is positive (sometimes may
P t be positive) . There 1s no swelling/tenderness/deformity of the spine or knee. So my provi-
~~nal diagnosis is non -union of R / L sided fracture neck of femur.
Note : Expect interruptions, questions and be ready to demonstrate the following -
1. Nutrition and wasting - (don't forget obesity is also malnourishment) .
2. Tenderness - (don't forget to look at patient's face, while demonstrating tenderness.)
• Anterior hip point. (Direct)
• Bi-trochanteric compression. (Indirect)
3 . All movements and all measurements including Bryant's triangle.
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, 44 HANDBOOK FOR ORTHOP EOICS l XAM INA I ION
0 • Sub-capital.
• Trans-cervical.
• Basal/Basicervical.
.4.4)
Clinically w/rat are the diff erences between intracapsular and extracap ular n eck f emar Jract11 re?
There is more shortening and ex ternal rotation in extra capsular fracture which also requires
high velocity trauma, occurs in a higher age group and ma y /, ave so.ft tissue contution/bruise.
Whal are the ••ariotts treatm ent optio11s, ill gen·
era/, for fra cture neck of f emur ? k
Operative treatment is a must for a11Y nee
II ac·
femur fracture. H owever no univer a Y f 0
cepted operati ve protocol for various type_
fractures in variou s age group and variou unie·
' . ·11 no"'·
from-initial injury st atu s, i s available 11
1. Recent Fractures (< 3 weeks) dies
•
(a) Und,.splaced fractures ( 1
SI¾) Reoar
° - . i, cre1vs
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FRACTURE NECK OF FEMUR 145
.. d ( hysiological age above 60 to 65 years) but fit a nd acti ve - T otal hi p re placeme nt is a good
(n) OI pprefcr hemiarthroplas ty w ith bipolar prosthesis .
. n. Some
110 . . . . .
op . .. Old (physwlog1cal age above 60 to 65 yea1s), but leading a sedentary life tyle, pe rforming only
11
. _('. ) f dai ly living (AOL) - he miarthropla ty w ith bipolar prosthesis. (Fig. 2.4.8)
cuv1t1e o . /N .
a Id Fractures/Delayed umon on-u mon
2
·~) Physiological age below 60 to 65 years, young and active, no osteoarthritic changes in
. ·oint (no acetabular changes) - A g e nuine a lte mpt s ho uld be made to preser ve th e bio-
1/le Iup 1 . . .
. l/ori ooi nal head of fem ur , e ve n 1f there 1s AVN. Options are -
1001ca
" • Muscle-Pedicle-Bone-Graft (MPBG) and interna l fixation wi th screws.
• Vascularized fibular bone grafting and internal fixatio n w ith screws .
• Osteotomy : (l) McMurray's Osteotomy (o blique, intertrochanteric, a bduction, m edial dis-
placement) osteoto m y is useful for select patient profi le (Fig. 2.4.7). Produces shorte ning.
(2) Pauwel's Osteotomy (intertrochanteric repositioning valg us) sometimes done.
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OSTEOPOROSIS
• educt·ion in " Bone Tissue Mass" per unit volume of anatomical bon
It 1s abnorma 1 r . . . e.
t . al definition (1994) : Osteoporosis - Bone mineral density (BMD) <
WH 0 opera ion f 2 5) Osteopen· 'T ' 2·5 SD
below the mean for young adult ('T' score o < - . . ia - score of - 1 to - 2.5
Classification
Primary Secondary
A. Idiopathic A . Nutritional (scurvy, malabsorptio
• Juvenile (8-14 yrs) - Acute onset malnutrition etc.) n,
• Adult - Insidious onset B . Endocrinal (Hyperparathyroidism, Hy.
pogonad ism , Thyrotoxicosis etc.)
B. lnvolutional
C . Drug : Steroids, Anticonvulsant etc.
• Type I (Post menopausal) : Af-
D. Malignancy (Multiple myeloma, Leuke·
fects trabecular bone
mia, Metastatis etc.)
• Type II (Senile) : Affects both tra- E . Others (eg ., RA , TB , Chronic renal
becular and cortical bone. (> 70 yrs) failure , Immobilisation etc.)
Pathology
• Normally, bone remodelling is a process which is constantly going on due to a closely
coupled interaction of osteoblastic and osteoclastic activities. At around 4th decade 01
life, osteoclastic activity starts increasing with resultant bone loss of about 1?0
year. So there is constant decrease of the peak bone mass which was achieved in I e
Pt
3rd decade, which is further accelerated in females after menopause.
Clinical features
• Bone pain , fractures (vertebral fractures, hip fractures , Colles fracture) , deformities
(Dowager' s hump - dorsal kyphosis with increased cervical lordosis)
• Spinal cord compression/stenosis with associated neuropathy. . res·
• Symptoms of hypercalcaemia - anorexia, nausea, vomiting , abdominal pain, deP
sion, renal stones etc.
• Symptoms of underlying endocrinopathy when present.
Diagnosis
• x.-ray .: loss of trabecular pattern, cortical thinning, ground glass appearenf~e~::r~:
sis , .biconcave vertebral bodies, anterior compression wedge fractures 0
codfish vertebra, rarefaction of bone , Singh's index etc. . . e CT 5can
• Bone densitomerty : Dual energy X-ray absorptiometry (DEXA) , Qual1tativ
(most accurate), Single photon absorptiometry (SPA) etc.
Treatment
• Excercise, stop smoking, alcohol and offending drugs dietary modification.·paratide,
. . · Teri
• Drugs : Ralox1fen , lbandronate/R1sedronate, Calcitonin nasal spray'.d hormone·
Tibolone, Strontium ranelate, Hormone replacement therapy, parathyroi
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Chapter 5
• Unlike intracapsular fracture neck of femur, trochanteric fractures unite easily, so non-union is
rarely a problem. Therefore, commonly malunitedtrochanteric fractures are given as a long case.
• Trochanteric fractures are much more common than fracture neck of femur, and usually oc-
curs in osteoporotic bones in elde rly females after a fall , or direct blow to the greater tro-
chanter. In the young , road accidents or other such severe high-velocity trauma is the cause.
• The fracture is extracapsular, and the fracture line involves the greater trochanter,
lesser trochanter or both . When lesser trochanter is fractured and displaced, the frac-
ture becomes inherently unstable and difficult to manage.
• If the patient is walking with shortened limb for many years, he/she might complain of low
back pain due to pelvic tilt and lumbar scoliosis.
What is your diagnosis ?
My provisional diagnosis is that this is a case of ma/united trochanteric fracture with
coxa vara of the R/ L hip joint, with true shortening of ....... .. .. cm of the limb and restriction of
abduction / internal rotation movements , in a ... .... .... year old M/ F patient , who was
untreated / treated with ..... ..... .... (say skeletal / surface traction I boot plaster I derotation
shoe, etc. as the case may be) .
N.B. • All the features, like restriction
of movements may not be present
in your case. So examine, and if
you say, be ready to demonstrate.
What is your case ? What is the summary
of the case?
Example : Mrs . Bijonbala Das , 70 year old
female patient, had a fall .... ..... weeks ago
(or may have had an accidental injury) , and
immediately experienced pain around R/L
groin and was unable to stand or walk . She
has been bedridden since then and taken
s0 d Fig . 2 .5 . 1 : Trochanteric fracture .
me Pain-relieving medicines, and gra u- Note _ Fracture line involves the greater
~lly over the last 4 months , the ~ain has trochanter and lesser trochanter ~ Unstable
r ecr~ased considerably. (If the p_a tient h~s r plaster then say that instead, and always
ecei~ed any form of treatme~t, like traction
t
° On exa,mination , she has a short limbed
rn;ntion
9 the duration o~ tract1on/plaS er , r~~~2d and externally rotated . On palpation , the
9 It and the affected limb a~pears sh~ d ned and has irregular surface. [Since trac-
t reater trochanter appears thickened , roa eld be no tenderness) . There is fixed flexion
Ure is un·tI d ( Ith h malunited) there wou (
d f e a oug 1 . t'1 n of internal rotation and abduction may not be
pe Ormity of about 10° and also ref n\ it you can demonstrate clinically) . Th ere is supra-
tr~eshent - ~o shortening
e antenc be car~ful and
of 3 say
cm .o~ye~delenburg
r 's si gn is positive . So my provisional di -
147
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148 HANDBOOK FOR ORTHOPAl::DIC~
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Chapter 6
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- ~ - - ~ ~ - ~ --:-:~~:7:--~l)
~~I :;,;-;-
, XJ\M IN I\ 111 N
1 <,Q HANOI O I I l Ii l I II I\ )I , I
u,
limb , pp cHS shortenod. There is mi ld te nderness around
t °
nd 1nl 1n I rot lion 1 hip, •
1nd
•
11 111
A bony hard, smooth-s urfaced round mass is felt on d th e
, nt iio1 hip po111l , nd I It glut \ moves with gentle passive rotational movements / 0P
111 11 0 th
palp lion ol lh I fl c lut ·,I ' rh " · wn rnl triangle is I ss prominent / forceful on the left side e
· h r 1 t puls I ll 1n l 10 1 '0 ' . as
t1"HQ . mO , compared to the othe r side, wh en bilaterl distal
pulses are equal. ~V~scula~ sign of Narath).
Active moveme~t 1s .1mpo ss1ble and any Pas.
sive movemen t 1s painful. .The left hip is fixed
at 20° fl exion, 10° adduction and 10° internal
rotatio n. T here is true supra-trochanteric short-
e ning of 4 cm . (maybe reversed Bryant's tri-
angl e). Trendelenburg sign is positive (if the pa-
tient can s tand and b ear we ight on the left
lower limb) . So my provisional diagnosis is this
is a case of neglected , untreated, posterior dis-
location of left hip of 4 months duration.
N.B. • The pa tient may have weakness of
Fig. 2.6.2 : Anterior dislocation hip. ankle dorsiflexors (foot drop) or paresthesia
Note - Abduction deformity. / tingling numbness of the leg. This may be a
chief complain . It happens due to sciatic
nerve injury during initial trauma . A neuro-
logical examination should always be done in-
cluding power, reflex , sensation of both lower
limbs, and sciatic nerve palsy must be in-
cluded in your diagnosis (when found) .
What are the complications of hip dislo-
cation ?
A. Early complications -
1 . Sciatic nerve palsy : Usually neuropraxia.
2 . (Rarely) Injury to superior gluteal ar·
tery : He re the re is p rofu se bleeding,
Fig. 2.6.3 : Posterior dislocation hip. and pa tie nt may go into shock . It is an
Note - Adduction deformity . e me rg e ncy .
3. Irreducible dislocation : By closed manipulation. This happens when there is an associated
fracture of the acetabulum and the bone fragment impedes reduction .
B. Late complications -
1. Avascular necrosis of femoral head : Incidence increases with each hour of delay in reduction,
so hip dislocation is an emergency. Generally, clinical features of AVN appear after 1 to 2 years.
2 . Myositis ossifications : Uncommon .
3 . Osteoarthritis : Of the hip .
Ho~ will y~u m_a nage .the ca_s e : . nd
First, confirmation of d1agnos1s with X-ray ~ pelvis with both hips · AP vi ew (see fig. 2.6.3) a
left hip lateral. CT scan - to note any bone fragment or acetabul ar fr~cture. MR I to note AVN 1h0n
put the patient in heavy skeletal traction in abduction for 3 to 4 weeks w ith se rial portable X-rays
to note the descent of femoral head. Since the injury is more than· 3 months old, concentnc d
reduction only by traction is probably not going to happen, and an open reduction will be n~e~e ·
N. B . • Up to 1o to 1 2 weeks , only traction· ·in abduction can sometimes reduce the . 1oint.
ft r
8
which is not possible later, because fibrous tissue fills up the acetabular cavity. A _
closed reduction CT scan 1s useful to note the presence of any bony chips or fra~t
ments within the joint, which if present, operative removal should be done to preve
subsequent osteoarthritis and hip stiffness.
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p
Chapter 7
SCHEME OF EXAMINATION OF A SPINE CASE
Theories Discussed
• Ott test • Schober's test
• Neurological examination • Lhermitt' s test
• Lasegue's test • Bragard's test
• Muscle power grading - MAC scale • Classification of pressure sore
N.B. • Paraplegic patients are usually given as a case. Then there is no question of examining
gait or examination in standing or sitting posture. But it is always better to start by
mentioning gait.
• Start examination in prone position to inspect and palpate, then roll-over the patient to
supine position to inspect and do the neurological examination.
Inspection
1. With patient in prone position/from the back :
Comment on -
• Cachexia.
• Attitude.
• Hairline, length of neck.
• Level of shoulder.
• Level , symmetry of scapulae.
• Central furrow of the spine.
• Prominence of paraspinal muscles.
• Flanks --? Shape, symmetry, transverse furrows . . . .
· at lower border of the 12th nb and sacrosp1nalls.
• Renal angle --? Depress,on
• Posterior superior iliac crests . . . . .
• Dimple of venus (Posterior superior iliac spine).
• Abnormal swelling, fullness.
• Sinus .
• Abnormal tuft of hair, dimple.
• Cafe-au-lait spots.
• Fasciculation, atrophy of muscles, spasm)s. brasions/bruises.
• Bedsores (decu b"tI us ulcer
. , pressure
l sore a turning the patient supine
before . for .inspection.)
.
(It is better to palpate in prone posi ,on
2· From side : Lordosis, kyphosis.
3. From front, with patient supine :
• Attitude.
• Symmetry of the rib cage and sternum.
• Abnormal swelling, fullness.
• Anterior superior iliac spines.
• Iliac fossae.
• Bladder fullness , catheter-in-situ.
151
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• Anterior thigh (swelling /wasting) .
• Wasting, fasciculations, muscular spasms .
• Bedsores . (see page 160).
Palpation (mainly with patient prone)
• Local temperature.
• Tenderness : 3 types - . .
1. Direct - over spinous process. (Indicates post_e rior or advance~ anterior pathology)
2. Rotatory - twist side of spinous process. (Indicates early anterior pathology)
3. Thrust - gentle thumping.
• Gibbus - palpable step
• Paraspinal muscle tone (If atrophy - then soft, flabby. If in ~pasm - then fi ~m, cord like).
Kibler test : pinched skin ove r the paraspinal muscles will be less mobile when moved
longitudinally.
• Abnormal swelling -
- Cold abscess (see page 138).
- Meningocele (Note : cough impulse).
(Movements, measurements are of academic interest and will be discussed later, but you
must measure wasting.)
Movement
• Flexion
(1) Finger-floor distance (for dorsolumber spine) : Request the standing patient to try and
touch his/her feet with extended knees. Normally the finger-to-floor distance is 7 cm or less
(Fig. 2.7.1).
(2) Ott test (for dorsal spine) : Mark the C7 spinous process and another point 12 inches distal
to it. Request the patient to bend forward and note the increase in distance between the above
points. Normally it is 3 cm or more.
(3) Schober's test (for lumbar spine) : With the patient standing, place the 1O cm mark of a
measuring tape at the level of posterior-superior iliac spine and the o cm mark above. Then
request the patient to bend forward with extended knees and note the change in the distance.
Normally it is 5 cm or more.
• Extension
With _the patient standing and knees extended, stabilize the pelvis with your hand and req~est
the patients to tilt backwards. Note the angle which is formed with the vertical axis. Normally 1115
about 30°. (In facet joint arthropathy it may be painful and restricted) [Fig. 2.7.2].
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H M XA MINA I N A 153
• Lateral tlexion
w ·th the patient standing
~ the lateral malleolus of he ang le. S t ndin b
:~~cal axis . Normally it is about 30 ° (Fig . 2 .7 .3) .
• Rotation
Wi~h the patient _seated and arms folded across chest, request the patient to rotate his/her body on
the nght and left side. Standing behind the patient and looking from above note tha angle between the
plane of pelvis and a imaginary line joining the shoulders. Normally it is about 40° (Fig. 2.7.4) .
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154 HANDBOOK FOR ORTHOPAEDI CS EXAMINATI O
----~------- - - - - -
• Ankle jerk (S, , S 2 ) .
• Clonus (ankle / kn ee) : If there is < 6 contracti ons. 1t is pseudoclonus.
4. Sensory :
(a) Superficial -
• Pain (Tested with a pin) .
• Fine Touch (Tested with a wisp of cotton wool or tip of the index finger) .
• Temperature (Tested with test-tubes containing cold and warm water).
(b) Deep -
• Joint position sense (JPS) .
• Vibration sense (VS) (Tested with a vibrating tuning-fork of 128 Hz placed over lat
. e~
malleolus, medial malleolus, dorsum of first toe) .
(c) Cortical -
• 2 point discrimination (Tested with a pair of blunt dividers. For finger tips about 2mm
separation and for pulp of toes about 1cm of separation can be recognised).
• Stereognosis (Recognition of size, shape, weight and form tested with common objecls
like paper-weight, pensil , marbles, keys etc.)
Special tests
• Lhermitt's test : (Dangerous, should not be done routinely). In cervical cord compression,
passive flexion and extension of neck sometime produce electric shock like feelings of the
extremities .
• Femoral nerve stretch test : The patient lies prone. Stabilize the pelvis with one hand and
hold the leg with flexed knee with your other hand. Now extend the hip. If there is femoral nerve rool
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....
. g the leg till the pain disappears. Then forcefu lly dorsi fl ex the ankle keeping th k
iowe~in occurs now, 1t confi rms PIVD (Fig. 2.7.7). e nee extended.
If pain . . . . .
(3) Crossed stra1gdht d/eghra,s~tn{! t~sdt_: If_the ref is pa1n/paresthesia when the normal leg is raised
with the knee exten e , t en 1 1s 1n 1cat1ng o PIVD (usually large central disc prolax).
Grading of tendon reflexes
o _ Absen t.
1 - Normal.
2 - Brisk .
3 - Very brisk.
4 - Clonus. (~ 6 contraction after single stimulus. Exaggerated deep tendon reflex.)
N.B. • Posterior column sensations are - Joint position sense (JPS), vibration sense
(VS) and fi ne touch (tested with cotton) .
• Spinothalamic sensations are - Pain, temperature and crude touch (tested with
pressure on the ankle) .
• Cortical sensations - 2 point discrimination test and stereognosis.
• While changing posture of patient from supine to prone, or vice versa, attendants should
be called and gently log-rolling technique should be used, utilizing the bed cover, so
that the whole body rotates in one piece to ensure no further cord damage.
• Spinal movements - where does it occur mainly?
{a) Flexion _ Mainly lumbar (Schober's test) , also slight dorsal (Ott's test) .
(b) Extension - Lumbodorsal. . . .
{c) Lateral flexion _ Dorsal vertebra i.e. thoracic, and it is not possible without rotation.
(d) Rotation - Dorso-cervical.
(e) Nodding - Atlante-occipital.
{f) Head rotation - Atlante-axial.
Classification of Bedsore / Pressure sore
Europe ' 5 ystem ·
an Pressure Ulcer Advisory Panel grad mg · . .
• r> . t·on of the skin warmth , oedema, indurat1on or
\,;jrade 1 . f . t ct skin Disco 1oura , , . .
h · non-blanchable e ryth e ma o in a · . d' ·duals with darker skin ~ 1n whom 1t may appear
rd
a ness may also be used as indicators, particularly on ,n
blue 0
,v,
, ,.. r Purple. . . dermis or both. The ulcer is superficial and
\,;jrade 2 . I . g the ep1derm1s, '
Pr : Partial thickness skin loss 1nvo vin d' skin may be red or purple.
, '"'esents clinically as an abrasion or blister. Surroun ,ng osis of the subcutaneous tissue that may extend
wade 3 . d mage to or necr
d : full thinkness skin loss involving a '
0
, ,.. 'W n to, but not through underlying fascia. e to muscle bone, or supporting structures with or
\,;jrade 4 . rosis or damag ' I. f .
't./ : extensive destruction tissue nee ' h I and predisposes to fata in ect1ons.
th0
' Ut full thickness ski n loss. Extremely difficult to ea
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Chapter 8
CARIES S INE
Theories Discussed
• Aetiopathogenesis of caries spine • C linical features of caries spine
• Bladder involvement in caries spine • C old abscess
• Classification of TB paraplegia • Gibb us
• Management of caries spine • Bedsores
• India is almost endemic in tuberculosis . Most c ommon si te s are the lungs and lymph
nodes and then comes skeletal or osteoarticular TB .
• Almost 50% of skeletal tuberculosis occu rs in the spine. 2nd common osteoarticular site is
the hip, 3rd is knee . Sometimes caries spine is also called tuberculous spondylitis.
• Dorso-lumbar (Ds-L2) is the commonest site of spinal tuberculosis.
• It can occur in any age , but it is most common in young adults up to about 30 years of age.
• Skeletal TB is always secondary i.e. , it spreads via haematogenous route, from the primary
site (usually the lungs, sometimes intestine, lymph nodes, etc.) to the bones. In the spine,
infection sometimes passes via the Batson's venous plexus.
• Tuberculous infecti on commonly affects the ends of bones (unlike pyogenic infections where
metaphysis is commonly affected first). So in TB, involvement of the adjacent joint occurs
rapidly. (Septic arthritis resulting from pyogenic osteomyelitis is less common) .
• Whereas in other joints, TB heals by fibrous ankylosis, in spine bony ankylosis is the com·
mon outcome . This is due to destruction of the vertebral end-plates.
• Often, lack of constitutional features like weight loss, rise of body temperature in the evening,
anorexia, weakness, malaise together with unrelated history of trauma, makes early detection
of skeletal tuberculosis difficult, and you need to have a high degree of suspicion.
PATHOLOGY
1 . Initial focus in spine after haematogenous spread is at four sites (Fig. 2 .8 .1 ).
(a) Paradiscal (Commonest) : This !5
probably because the blood supply 15
common for the adjacent two verte·
bral paradiscal areas, together with th0
IV disc intervening disc, as it develops from
the same sclerotome.
(b) Central : Inside the body.
(c) Anterior : Anterior part of body.
(d) Posterior : e.g. Pedicle, transverse pro;
cess, lamina, spinous process. Th 95
are rare.
2 - Inter-vertebral disc which gets supp I'18s
I IIY
from adjacent vertebrae , is gradua e
Fig . 2 .8 .1 : Initia l foc us of carie s sp · destructed , thus in X- ray' s disc spac
3 . A s infection spreads there is hype ine .
. reduces and finally vanishes.
1 h' ' remia ~ ost eopo · and destruction of bony rarne1·f
ae, w 1ch then collapses under body . h . ros1s
the natural kyphosis of dorsal vertebra: e13 t. Smee the centre of gravity passes in front o_
' orsal vertebrae has an anterior wedge compres
15 6
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CARIES SPINE 157
. Example : Mr. Jalal Ansari, 26 year old male patient, 10 weeks back noticed weakness of the
nght leg, and then weakness of the left leg after about 7 days, together w ith anaesthesia of the
le_g which is more than 50% now. He found ditticulty in wearing shoes and then walking with any
slipper type of footwear and later climbing stairs. He had been suffering from back pain, which was
more severe at night, tor the last 4 months . He also gives history of chronic dry cough with rise
of body temperature in the afternoon for the last 6 months, where the fever was low-grade
int~r~ittent in nature and associated with night-sweats. On enquiring , he gave history of con-
Slncting girdle-type sensation near the groin level and that, initially he had pain radiating to
both lower limbs, which increased with coughing , sneezing and jolting. For last one month he
~ havin~ hesitancy of micturition and is often unable to hold faec~s ,. t?geth_er with seve~e
ack pain with radiation to both the lower limbs. The symptoms were ms1d1ous in onset and 1s
i~adu~lly pro~ressive over the last 6 months. T~ere is positive fam_ily history of t_uberculo~is.
ere 1s no history of headache/vomiting , convulsion, or diabetes mell1tus, hypertension or spinal
traum a or exposure to sexually transmitted disease. But there ·1s h.1s tory o f ma Ia,se · , anore .1a,
·
W~kness ~nd weight loss over the fast 6 months. (There ma~ be hi~tory of haemoptys_is) .
n examination the pati· ent looks malnourished and a norexic , but ,s alert, co-operative and
Obey s command 'He h x 2 cm oval-shaped pressure-sore over h.1s sacrum , w h.1c h .ts
superficial and
iher . ·
d ast a
oes no reac
3
chmth bone and there is wasting of both the lower limb muscles .
e . . .
e 1s tendern th tebra and there 1s a knuckle g1bbus over 0 9 -0, 0 . Active
move ess over e O9 ver . . . d'
ments of both . b . t possible on neurological exam in t1on . r g r ing ton ,
th
..
ere .
is clasp k .,,
1ower 11m s ts no
t· ·t p · d 1 ·
er ·is grade o Jerks are brisk an t , e r , an e and
kl
""ee
s ctonus Pl t m e spas fl
1c1 y
.
. tensor bilaterally, but there ,s pres nc o Join pos1·t·,on
ow ' · f · · t
...erise and Vibr t~n ar re eTxh,s efx my provisional diagnosis is ........ ( y yol~r di gn i
• 11 eritio a 10n sense. ere ore,
Wti ned before)
In Y do You say · . . xtension ? (Or) What i th dlff r nc b rw 11 1, pl ,
eJcte . parap1eg,a ,n e ·
A. " s10n and paraplegia in f/exion 7
. In extension t e - The lower limb has attitude of hip and kn
Plantar fl . YP . h kn·,te spastlclty in the extens or
ex,on, wit c Iasp
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nd oft n lh r 1 nd pl nt r rosponso , 8 y1
n Or
p r r111d I tract nd occurs
B h thigh c nd knee are flexed with lt)e ankle dors111ex0d, and rollex
~s/Jerr
r Tone 1s increased ,n he lie or group of muse 1es and plantar respons '
t nsor Sometime rt 1s associated 11h lie or spasms. It involves both the pyramid
1
trapyramrdal tracts, and occurs late ,n the course of the disease. a al)lj
I t utonom u I dd r nd h t I utom t,c b l dd r ?
When bufbocave,nosus ,efle and anal reflex are present, it indicates intact sa
. c~1
cord , and the prognosis rs bet er. It 1s called reflex or automatic bladder. When these re.
flexes are absent and there ,s tota l loss of penneal sensation, recovery is unlikely and it
called autonomous bladder. Here the bladder functions indepe ndently without any conne~~
lion wrth the sacral segment of the spinal cord .
What I c c " ' , c; ral e r ofd ?
Cold abscess is a non-pyogenrc abscess formed due to tuberculo us infection, and consists
of tubercular debns , caseous matenal , serum , WBC's and occasional TB bacilli. Since there
is no 'rubor', 'dolor', 'color' and other signs of inflammation of pyogenic infection (so-called
"hot abscess ") rt is called cold abscess .
Where ould you search for cold abscess in a patient of TB spine ?
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CARIES SPINE 159
. healing. first to reco ver is vibration sense and i·o,·nt ·t·
ounnQis the motor fun ctions. E xte nsor plantar response takes pos, ion . sense and last to
recover . · very 1ong time to recover.
. this the ordet of affection ?
15
WhY
. ·s
1 probably because the motor tracts are anteriorly placed w·ith · th d
This • • in e cor , and the verte-
bral paradiscal area is th e commonest area of affection, which lies just anterior to the cord.
Clinically what are the sequential ~igns and symptoms of untreated caries spine?
First there is . gait problems_ a~d in~oordi_ n ation, then spasticity, followed by paraplegia in
e tension and finally paraplegia in flexi on with loss of bowel / bladder sphincter control.
What are the types of gibbus ? How is gibbus formed ?
Common is external gibbus which is of 3 types.
1. Knuckle gibbus : One spin ous process is prominent on palpation because one verte-
bra co ll apses e.g., TB , trauma . (see page 256) .
2. Angular gib bus : 2 o r 3 vertebrae involved e.g., secondary metastatic deposits,
sometimes T B. (see page 256)
3. Round gibbus : 3 o r more vertebrae involved e.g., senile (osteoporotic) kyphosis,
Scheurman's disease . (see page 256)
4. Internal gibbus : Rare variety . Seen in late onset TB paraplegia.
What are the landmarks of spinous process palpation ? How do you establish the exact
level of the palpated spinous process clinically ?
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11 lOf'A UIC
• FBS/PPBS
• HIV - ELISA - May be positive
elude HIV in any adult onset (Ex.
myelitis or caries spine). OSfeo.
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CJinicallY wha t proce s . corre-
I
sponds to w'111t cord segment ?
(From below upwards)
Ll --) All sacral and coccygeal segment.
r12 --) Ls segment.
T11 --) L4 and L3 segment.
T1o--) L2 and L1 segment.
Tg --) T 12
Ts --) T11
T1--) T10
Ts to T , ~ Add 2 (e .g. , for T s ~ T 7 or
T3--) Ts)
Fig. 2.8.6 : c .aries ~pine with anterior-wedging of ver-
Cervical Add 1 (e.g ., for c3 ~ c4 or C s tebra , causing g1bbus and increased kyphosis.
~ Cs)
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162 HANDBOOK f- OR OR l HOP ION
• 'urnl<\~.il' JI cnmpl il'aL1011s del'elop, worsen , llr recur durin g th e co urse of conserv- .
agcmcnt.
· aL ,vc rn an,
• AdvanCL'd cases or 111.:uro l og i ca l in vo l ve ment e.g .. fl acc id par al y si ·, fl exo r spas ms,
bladdc, d ,sru 11c tio11 . > 50 ¼· senso ry l oss . bowel
Wlrat ·urgt>ry will you ,lo, if required ?
ntero-lateral decompression ±fusion . Fu ·ion is indi ca ted for symptomatic mechanical ·1nstabi lity
of spine, and al o to arre. t progression of kyphos is.
.B. • L esions from D and above ~ Upper motor neurone (U MN) bladder .
JO
• D • D 11 • L . L 1 ~ UM bladder. additionall y sy mpathetic and sensory loss .
I1 _ I -
• S1 , S1 • S and cauda equin a ~ Lower motor neurone (LMN) bladder.
- • -I
IV. Moderate angular kyphos > 3 vertebrae involved (K: 30°-60°) 6_24 months
V. Severe kyphos (Humpback)
•
> 3 vertebrae involved (K: > 60°)
Ill, IV, V have vertebral bodies destruction and collapse+ appreciable kyphos .
> 2 years
---
• K is the angle of kyphosis as measured by the technique of Dickson (1967) .
• In Stage Ill. IV, V - diagnosis is clear on conventional X-ray. CT scan and MRI would show advanced
changes , however, these are unnecessary except for difficult sites (Kumar, 1988).
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Chapter 2
ASIC CLINICAL EXAMINATION OF KNEE
Theories Discussed
• Genu recurvatum • Zohlen's sign/Clarke sign/Patellar grind test
• Friction test • Bulge test
• Patellar Hollow test • Patellar Tap test
• Cross Fluctuation test • Patella lift-off test
• Lachman test • Drawer tests (anterior, posterior)
• Pivot-shift test • Single foot hopping test
• Gravity sign/Sag sign test • Mc'murray's test
• Apley's grinding test • Thessaly test
• Glide test • Ober's test
• Apprehension test for patella dislocation • Wilson test
• Osteochondritis dessicans • Loose bodies
INSPECTION
• Have a female attendant for a female patient. Explain the procedure to the patient, (i.e., what
you will do and what the patient will be required to do) and ensurlerbal consent.
• The patient ~~uld be exami~e~n the f_ ollowing o~der- _f~rst in the ,' nding position, next ~n
@ squatting pos1t1on, then walkmg;=-tt,en with the patient s1t1ng on the ge of the bed, next in
~ supine position and finally in the prone positi~. When the patient is unable to stand, squat,
or walk, inform the examiner beforehand. l0
• Both the lower limbs should be exposed from the groin to the toes (for comparison), and the
patient should be examined on a hard and flat bed/couch without any cushion/padding/mattress.
• With the patient standing :
Standing in front of the patient, first observe the attitude and deformity. Note, compare and
comment on genu valgum/varum (see page 30), any swelling/wasting, the suprapatellar quad-
riceps bulge, patellar position/shape/size/symmetry, the supra and infra parapatellar fossae
(medial fullness may indicate intra-articular fluid), the patellar tendon, and the position of the tibial
tubercles. Then comment on any scar, sinus, skin condition, ulceration or venous prominence.
Then standing by the side of the patient,
note, compare and comment on any flexion
deformity / genu recurvatum (see fig 1.2.1-A)
any abnormal prominence of the fibular head
and the femoral condyles (as in triple deformity,
see page 26), and then on any swelling, scar,
flexion &enu sinus, skin condition, ulceration or venous
deformity
.-
J recurvatum
prominence. Genu recurvatum is hyperexten-
sion of knee which may be congenital (corrects
spontaneously with age), because of growth
plate inj~.uies (may be due to infection, tumour,
Fig 1.2.1-A trauma) malunited fractures around knee, or
10
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BASIC CLINICAL EXAMINATION OF KNEE 11
associated with generalized ligamentous laxity and p~~t polio residual paralysis (PPRP) . Liga-
ments may be stretched also due to chronic synov1t1s (e .g., rheumatoid arthritis) , hypotonia
associated with rickets , and Charcot's disease (see page 273) . In PPRP fixed equinus deformity
is usually associated . Recurvatum of knee in moderate degrees is actually helpful, because it
stabilizes the knee (which has weak quadriceps i.e., knee extensors) in hyper extension .
Finally, standing behind the patient, note, compare and comment on any swelling (see
;, page 177) , scar, sinus, skin condition , ulceration , or venous prominence . Look for any abnormal
prominence at the hamstring insertion (i .e., biceps femoris on the lateral side, semimembrano-
sus and semitendinosus on the medial side) .
• With the patient squatting : If you have previously noted genu valgum/varum, note and
comment on it again, in the squatting position (Flexion test, see page 31) . Note, compare and
comment on , whether the buttocks are touching the back of the heels when both heels are in
ground contact (if this is not possible, there might be hamstring and/or tendoachilles contrac-
ture). Finally request the patient to stand up and then enquire about any pain during squatting
or getting up (may be osteoarthritis , see page 271 ). Note and mention , that ability to squat
normally, with both lower limbs symmetrical, which indicates full range of knee flexion .
• With the patient walking (For gait, also see page 129) : First look for antalgic gait. Next, in the
swing phase note, compare and comment on the free-swing of the leg, or the absence of it (may
be due to patella-femoral pain). Finally in the stance phase, observe and comment on whether there
is full knee extension (or any hyperextension), and whether the knee "buckles" due to instability.
~ ith the patient supine : Most of the clinical tests of the knee are done in this position.
~ With both the lower limbs parallel and aligned along the long axis of the body, note compare
and comment on the attitude/deformity. Comment on genu valgum/varum , swelling/wasting,
suprapatellar quadriceps bulge, patellar position/shape/size/symmetricity, the supra and infra
parapatellar fossae , the patellar tendons and the position of the tibial tubercles.
• With the patient prone : Inform the examiner, that to avoid frequent position changes of the
patient, you intend to do the examinations in prone position, after completing the palpation,
movement, measurement and stability tests in the supine position .
PALPATION
N.B. • Palpation is done with the patient sitting on the edge of the bed and then in the supine
position. Always look at the~ of the patient, when noting tenderness. --
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12 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
2(igction test } With the patient supine and the knee extended , compress the patella with
~our fi ngers, into the intercondylar groove. Then with your other hand , glide the patella in the
intercondylar groove from medial to lateral and then from superior to inferior. Look at the
patient's face and note tenderness.
Fig 1.2.4-A
C
3. Facet tenderness test }. With the t·
Fig 1.2.4-B
. . ,. · pa 1ent supine d h
patella medially, simultaneously elevating it. Then an t e knee extended, push the
retropatellar facet (see fig 1.2.4-A) . Next push th~alpate and note tenderness of the medial
it, and palpate to note tenderness of the lateral r patella laterally simultaneously elevating
forget to look at the patient's face . _ _ _ etropatellar facet (see fig 1.2.4-8). Don't
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u'f'r/f'>fJ.I I) ~l?i! ,& lblintLU. ~nh~-
1
B. ~ oint lin~ te~de!_n~;-1 _: With th e patient sittin g a~d th e kn ee flexed to g~ palpate with your
thu m or . slide the metallic . b_lunt en? of a meas~ n~g tape) , ~rom be low upwards , along the
anteromed1 al surface of th e t1b1a, ~tarting fro m th e t1b1al tube ro s1ty unti l it "lodges" into a groove
(see fig 2.1. 16- A page 122). Th is shou ld be th e medial joint line, so mark it. Confirm by
passively flexing and extending the kn ee wh ile palpating the joint lin e. Repeat the procedure
along the antero-lateral surface to find the lateral joint line, and mark it. Then using th e pulps
of your thumbs , palpate circumferencially along the joint line, from anterior to posterior. Note and
comment on tende rn ess and/o r lump (may be men iscal cyst/torn me niscu s etc.) .
• Suprapatellar bulge : This may be due to synovi al thickening or intra-articular fluid .
Remember th at synovial thickening may also be palpated over the insertion of vastus medialis ,
which feels "boggy" or "doughy" (see page 27) .
• Intra-articular fluid : (Normally 0.5 ml - 1 ml) 2 methods are popular for detecting small
amount of fluid (Bulge test and Patellar hollow test) one method for detecting moderate
amount of fluid (Patellar-tap) and another method is done to detect large amount of fluid ( Cross-
f/uctuation) .
1 . Bulge test : It can be done with the
patient standing , with the knee extended.
Place your thumb and index finger on th e
medial and lateral parapatellar fossae, and
firmly compress the medial fossa (so as to
empty it) . Then sharply press the lateral
parapatellar fosa . The medial fossa will refill
with a "ri pple" (see fig 1.2.5-A). Fig 1.2.5-A
2 . Patellar Holl ow test : Normally, when the
knee is grad ually flexed , a hollow appears , and
then disappears just latera l to the patellar ten-
don . In the presence of intraarticular fluid , when
compared to the opposite knee , the refilling of
the hollow, occu rs at a lesser angle of flexion .
3. Patellar Tap : With the knee extended ,
compress the suprapatellar bulge with your
thumb and other fingers placed on both sides
(so as to empty it, and push the fluid down-
wards under the patella) . Now, with the tip of
the index and middle finger of your other hand ,
sharply tap the centre of the patella (see fig. Fig 1.2.5-B
1.2.5-B) so that it "sinks" to hit the intercondylar
groove of the femur and "bounces" up again .
This demonstrates a positive patellar tap test.
This test is ineffective when there is excessive
fluid causing "tight and tensed" swelling .
N.B. : Suprapatellar bursa communicates with
the knee joint and extends from the upper
pole of patella, approximately 1 width of the
patient's hand to distal thigh .
4 . Cross Fluctuation : Cannot be done in
very tense effusion. With the knee exten~ed, place
your thumb on one side and the other ringers on Fig 1.2.5-C
the other side of the suprapatellar bulge. Next,
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14 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
with your other hand , place the thumb and other fingers on the medial an? lateral infrapatellar fosae
respectively . Now alternatively squeeze the suprapatellar bulge and the infrapatellar fossae to feel
the transmitted "fluid impulse" across the joint (see fig 1.2.5-C).
• Other Swellings : Examine, note and
comment on any swelling (bony or soft tis-
sue) under the standard headings i.e. size,
shape, surface, margins, location, con-
sistency, fixity to surrounding structures,
skin over the swelling, tenderness, pulsa-
tility, and transillumination. Anterior soft
tissue swellings may be prepatellar bursa
(see page 176) infrapatel lar bursa (see page
177), or suprapatellar bursa . Posteriorly they
may be Morant Baker cyst (see page 177),
semimembranosus bursa (see page 178) or
popliteal aneurism (see page 178). Medially
they may be pes-anserine bursa (always
about 2-4 fingers below the joint line) , me-
dial meniscal cyst, or a torn part of the
medial meniscus. Lateral swellings may be
biceps femoris bursa (in between the fibular Fig 1·2 ·5 - 0
collateral ligament and the biceps) , or the bursa situated between the popliteus and the
femur, or the fibular collateral ligament.
• Patellar lift-off test : To note synovial thickening. With the knee in extension grasp the
edges of patella in pincer made of thumb and middle finger and try to lift up the patella. Normally
this is possible. In synovial thickening, the fingers slip-off the patella edges. (Fig . 1.2.50)
• Popliteal pulse : Palpate on both sides (for comparison) . The patient lies supine with
semiflexed knee at 30°. The fingertips of both hands are pressed in the middle of the popliteal
fossa (i.e., knee crease) while both thumbs rest on tibual tuberosity. It may be palpated in prone
position with knee partly flexed.
MOVEMENTS
N.B. • The main movement at the knee joint is flexion/extension. However some abduction/
adduction and some rotation (when the knee is flexed) is possible.
• If the patient can normally squat (as noted in inspection), then obviously full range of
flexion is posible, but it does not guarantee full extension.
• Crepitus during movement must be always noted, with your fingers over the patella,
which indicates patello-femoral incongruity/osteoarthritis.
• Testing the muscle power of the quadriceps and the hamstrings is also a must (for
MAC grading see page 155), before examining knee movements.
• Normal range of movement of flexion (from the zero or neutral position i.e. full
extension) is about 150°, which may be less in obese/muscular patients (because
the heels touch the buttocks at a lesser angle). Abduction/adduction and medial/
lateral rotation is about 5°-1 0°.
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BAS IC CLINICAL EXA MINAT ION O F KN EE 15
Full extension 1s the neutral or zero position wh en the thigh and leg are compl etely
aligned . straight, and moves in unison (further xte nsion is call ed hyperexte nsion i.e., genu
recurvatum deformity s e fig. 1.2.1-A} . Zero position can be noted wi th the patient supine on a
hard and flat bed/couch/table , without mattress/cushion/padding and requesting the patient to try and
touch the popliteal fossa to the bed (active) (see fig .1.2.6-C}. If there is a gap, apply downward
pressure over the patella with one hand, while lifting up the leg a few inches from the bed with your
other hand (by grasping the leg just above the ankle (passive - see fig . 1.2.6-D}. Remember that
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16 HANDBOOK FOR ORT HOPAE"D ICS EXAMINATIO N
• Medial/Lateral Rotation : Flex the hip and knee to 90° by grasping the leg just above
the ankle with one or you r hand , and stabilizing the knee with your other hand . Then
alternatively rotate the leg medially and laterally (see fig . 1.2.8) . Repeat the procedure for
the opposite knee . Note, compare and com ment.
MEASUREMENTS
• Wasting Noted in the thigh, (see page 122), and when present also in the leg.
• Q-Angle (see page 23)
STABILITY TESTS
N.B. • The main knee stabilizers are the anterior cruciate ligament (ACL), posterior curciate
ligament (PCL) , medial collateral ligament (MCL) and lateral collateral ligament (LCL).
Other structures that contribute to stability are the quadriceps (mainly vastus media-
lis) , the hamstrings, the joint capsule and the medial and lateral menisci.
• Patient usually gives history of "giving - way". When it happens during climbing stairs
- PCL may be torn, and when it happens during climbing downstairs - ACL may be torn.
• There are numerous stability tests described and practiced. Some commonly per-
formed and popular tests are described in this chapter.
• When Lachman test or Drawer test is positive, always note and comment on whether
the end point is "hard" or "soft".
Fig 1.2.9-A
Fig 1.2 9-B
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<• _,
BASIC C INlCA A
-~ j I ':-,
~ ;:,. . .-. . r .
patients stabilize the patie nt's thigh with one of your hand on th e anterior surface and your
own thigh on the posterior surface (see fig . 1.2.9-B) Then applying force try to move the
proxtmal tibia first anteriorly, and th en posteriorly (with respect to the distal femur) . Look
tor any subl uxation anteriorly and wh ether there is a tendency for medial rotation . When
medial rotation occurs it is a positive "Lachman sign" . Repeat the procedure with the
knee flexed to about 30°-60°. If the subluxation reduces spontaneously, then the MCL is
intact while the ACL is torn . If there is no reduction , then both AGL and MGL are torn .
Now repeat the procedure on the opposite knee . Note , compare and comment (don't forget
about the hard/soft end-point) .
2. Anterior Drawer Test : First do the sag
sign , (see fig .1.2.12-A & B) becau se if
present interpretation of the test will be
altered . With the patient supine , both
knees flexed to 90°, and both heels rest-
ing on the bed/table , seat yourself facing
sideways , on the patients feet. This sta-
bilizes the leg , while the weight of the
patient's trunk stabilizes the thigh . Now
firmly grasp the upper leg wih both your
hands, keeping the thumbs anteriorly and
the fingers posteriorly (see fig. 1.2.10). Fig 1.2.10 ; Note : Examiner sitting on the patient's feet.
Then alterntively apply force so as to
"push-and-pull" the leg, and look for any subluxation. Next, repeat the test on the opposite
knee. Note, compare and comment (don't forget about the "hard/soft" end-point). When there
is comparitively more anterior subluxation (positive anterior drawer sign) there may be
AGL injury/laxity, and when there is comparitively more posterior subluxation (positive
posterior drawer sign) , there may be PCL injury/laxity.
3. Pivot-Shift Test : First do the test for MCL (see page 18). With the patient supine and leg
extended, stand on the affected side of the patient. With your hand (which is towards the
head of the patient) , grasp the lateral femoral condyle placing your abducted/extended
thumb over the fibular head, (for stabilisation and palpation). With your opposite hand grasp
the ankle and medially rotate the leg (see fig. 1.2.11 -A). Then, apply valgus stress by
forcefully abducting the leg (which may cause anterior subluxation) and gradually start flexing
the knee. If there is ACL tear, you will feel a "click" at about 30° flexion , when the subluxed
tibia reduces (see fig. 1.2.11-B.). Remember reduction is due to the pull of the ilio-tibial band
(1TB). Interestingly, often the patient confirms that there was the same feeling of sudden
"giving-way" and later "stabilization".
4. Single foot hopping test : If the patient can perform single foot hopping, then op r tive
ACL reconstruction may not be indicated, except for atheletes or active sportspersons
O. E ·3
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18 HANDOOOK FOR OR HOPAEDICS EXAMINATION
2. Posterior Drawer Test : Already discussed- posterior drawer sign (see page 17).
• Tests for the MCL/LCL :
With the patient supi ne and knees extended , stand on the affected side of the patient.
Now, grasp and support the femoral condyles from below, with your hand (which is towards the
head of the patient) . Using your opposite hand grasp the patients leg just above the ankle. Then
lift the ankle about 6" from the bed/table and apply valgus stress (i .e., abduct the leg - see
fig . 1.2.7-A) to note MCL insufficiency. Similarly apply varus stress (i.e. , adduct the leg - see
fig . 1.2.7-B) to note LCL insufficiency. Repeat the procedure on the opposite limb , standing on
the other side of the patient. Note, compare and comment.
• Tests for meniscal injury :
N.B. • Medial meniscus is less "mobile" than the lateral meniscus. So medial meniscal injury
is more common than lateral meniscal injuries. e.g ., chronic ACL tear.
• All the signs which are positive for meniscal tears are also positive for meniscal cysts
and discoid meniscus.
• No clinical test has sufficient sensitivity or specificity for confirmatory diagnosis of
meniscal tears. Just as a positive test is not always pathognomic, a negative test
does not rule out a meniscal tear. About 25%-30% children with normal knees and
nearly about 1% of the general population is Mc'murray test positive!
• H/0 "clicking", "locking", increased pain with excercise/climbing stairs/squatting,
and occasional joint-effusion after minor trauma are important clues. Palpation of a torn
meniscus at the joint line, or tenderness at the joint line should make you suspicious.
Remember, the test may also be positive in osteoarthritis of knee. A combination of
history, palpation and special tests for menisci should reasonably place meniscal injury
in the list of differential diagnosis.
1 · . Mc'murray's Test : With the patient supine, stand on the affected/pathological side of th e
patient and grasp and support the patient's knee (for stabilization and palpation) , so as to place. t~e
~ulp of your. thumb on the. lateral joint line, and the pulp of your middle finger on the medial 1°1n;
line. ,:hen with your opposite ~and grasp the patient's foot and maximally flex the hip and th~ k~~-
(see fig . 1.2.13-A). Now, maximally abduct the leg and laterally rotate the ankle / leg and sirnu
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S-AStO CLINICA
neously, gradually extend the knee to goo flexion (see fig. 1.2.13-8). If the patient complains of pain
it suggests medial meniscal lesion. Repeat the procedure with medially rotated ankle / leg. If ther~
is complain of pain, it suggests lateral meniscal lesion. Interestingly the degree of flexion where the
pain/"snap" / "click" occu rs, indicates the site of lesion (when at about go 0 , the lesion is in the
middle third of the meniscus; when within 0°-60° of flexion, the lesion is in the anterior horn; when
0
at more than go fl exion , the lesion is in the posterior horn) . When the same procedure is done to
bring the knee from go 0 flexion to full extension (i.e. , 0° or neutral position) it is called Bragard test,
and if there is pain/"snap"/"click" then it suggests anterior third meniscal lesion.
2. Apley's Grinding Test : With the patient prone, hold the ankle and lift the leg (to flex the
knee to go 0 ) with one hand . With one of your knee stabilize the posterior thigh by pressing onto
it. Now rotate the ankle/leg medially and compress the knee applying force towards the bed (see
fig. 1.2.14-A). If there is complain of pain/"snap"/"click", it suggests lateral meniscal lesion. Next
rotate the ankle/leg laterally and repeat the procedure (see fig. 1.2.14-B) . When there is com-
plain of pain/"snap"/"cl ick", it suggests medial meniscal injury.
- - - -~ - - - - _~_:_- - I~ -~·
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~.;~~:-· 1·
SPECIAL TESTS
• Ober's test : This tests detects ilio-tibial band (ITB) contracturc. Reque t the patient to li e ideways on the
unaffected side with the hips and knees flexed (to obliterate lumbar lordo-i ). Then tanding behind th patient extend
the hip and knee of the affected limb maximally and try to addu t the hip ( e fig . 1.2 .17-A) . In ITB contracturc,
adduction will be restricted. Then abduct the hip to about 30° and then I t go . . o that the limb fall freely. In severn
1TB contracture the limb will not touch the table and remain suspended (sec fi g. 1.2 . 17-B).
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BASIC CLINICAL EXAMINATION OF KNEE
21
• Wilso~ Test : Thi te l is positive in Osteochoudritis De ·.\·icans, which is an aseptic necrosis of the subchondral
bone, classically of the articular urface of the medial f moral condy le, just beside the intercondylar t h h' h
· f f ti · . . . no c , w 1c may
fina lly cause separati
.· on o a part. o · 1e art icu1ar cartil age, producing
. "loose-bodies"· (Other causes. of Ioose-
, bod',es
include ynov.1al chondromal? i , .bro~en o le?phytes or ar!1 cular ca1iila.ge in osteoarthri tis, foreign bodies, torn
emdunar cartilage and om l1m · in d1 'ea es li ke haemoph1lta, tuberculosis and rheumato id arthritis). The condition
i common in ado le cent · who pre ent with knee pain + effu ion. With the patient supine, and th e knee fl exed to 900
tand on the aff~cted / patholo~ical 'ide of the pati~n.t, and ~·asp the ankle with one hand while stabilizing the kne~
with your oppo 1te hand. ow internally rotate the tibia (see fig 1.2. 11 -A) and gradually start extending the knee. The
patient will complai n of pain at so me point, where you hould stop extension, and externally rotate the tibi a. If the
pain i retie ed, then Wil on test i positive. Remember th at the investigation of choice is MRI.
• Grading of tenderness : (I ) Patient local izes pain (II ) Patient winces with pain (II I) Patient withdraws
the limb from the examiner (IV) Patient does not allow to be touched .
• Posterolateral (PLC) injuries : PLC consists mainly of the fibular or lateral collateral ligament (LCL) , the
popliteus tendon , and the popliteofibular ligament along with others structures like the mid-third lateral capsular
ligament (consists of meniscofemoral + mensicotibial parts) , and the biceps femoris . Patients have a varus
thrust gait. PLC injuries usually accompanies ACL and PCL injuries . Dial Test (posterolateral rotation test)
at 30° knee flexi on detects PLC lesion , and at 90° detects PLC+ PCL injuries. Other tests to detect PLC injuries
include External Rotation Recurvatum Test, Reverse Pivot Shift Test, Figure 4 Test.
• Anatomical axis of the femur: This is the line passing through the midpoints of femoral shaft (Fig 1.2.18A) .
Mechanical axis of femur : The line joining the center of the femoral head to the center of the intercondylar
•
notch (Fig 1.2 .1 BA).
Mechanical axis and anatomical axis of tibia : The line joining the center of the tibial plateau to the center of the
•
tibial plafond (Fig 1 .2.18B).
Anatomical tibio femoral angle : The anatomical axes of femur and tibia form a valgus angle of 6 ± 2degrees
•
(Fig 1 .2 .1BC) .
Hip knee ankle angle : The angle formed by the mechanical axes of femur and tibia. It determi nes the varus or
•
valgus deviation (Fig 1.2.180). . .
Mechanical lateral distal femoral angle (mLDFA): It is the lateral angle.between th~ mechanical axis o~ fe~ur
• . · · t 1· Normal value · 87 8 + 1 2° A change in mechanical lateral distal femoral angle s1gnif1es
and distal femora 1JOln ine. · · - · ·
varus/valgus due to femoral cause (Fig 1.2.18E). _ . . .
. d. · I ti"bial angle (mMPTA) : It is the medial angle between the mechanical axis of t1b1a
• Mechanical me 1a1proxima · · · · 1 · T
. . · . · t - Normal value · 87 2 +1.5°. A change in mechanical medial proximal t1b1al ang e s1gn1 ,es
and proximal t1b1a 1 Join 11ne. . · · -
varus/valgus due to tibial cause (Fig 1.2.18F) .
"-"-'-'-- Mechanical
Anatom ical
:1
: I
l
I
I
I
:
•
m I
I
I
I
; ' F
D E
C
A B
Fig 1.2.18
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Chapter 3
:ABITUAL DI LOCATION PATELLA (HDP)
Theories Discussed
• Types of patellar dislocation • Causes of habitual dislocation patella
• a-angle • Clinical features of HDP
• Imaging - measurements in HOP • Patellar tilt test
• Thigh-foot angle test • Femoral anteversion test
At fi rst sight, the most striking feature often is the prominence of the medial femoral condyle.
What is your diagnosis ?
This is a case of UR sided habitual dislocation of patella in a ..... year old M/F patient, with the
critical angle of dislocation .... ... degrees.
What are the types of patellar dislocation ?
• Habitual : Lateral dislocation of patella with each and every flexion of knee (i.e., always)
wh ich relocates with extension of knee. It may be secondary to quadriceps contracture .
• Recurrent : Dislocation is episodic and not with every flexion of knee (i.e., occasionally), and
number of episodes should be ~ 3.
• Persistant : Congenital permanently laterally dislocated patella that never relocates .
• Obligatory : Congenital habitual disloca-
tion of patella .
• Acute : Usually post-traumatic .
Causes
1 . Bony factors :
(a) Small patella , dysplastic patella
(b) High up patella (patella a/ta) .
(c) Trochlear dysplasia causing shallow
intercondylar or trochlear groove .
2. Soft tissue factors :
(a) Lateral side - Fig . 1.3 .1 : Lat eral dis loca tion of patella with
• Contracted lateral parapatellar reti - knee flexion .
naculum and capsule.
• Contracted tight vastus lateralis and ilia -tibial band e.g., aft er repeated injec-
tions , causing post-injection fibrosis . (see page 34) .
N.B. • Lateral contracture may be due to infection, trauma, lnjec ion, or congen t I.
• Low lying patella is known as patella baJa.
(b) Medial side -
• Generalized ligamentous laxity (e.g., Marfan's syndrome, Ehlers-Dantos syndrome, etc.).
• Vastus medialis hypoplasia or laxity (e.g., Post-polio residual paralysis, post-surgic 1
weakness).
3. Factors causing increased Q angle :
(a) When tibial tuberosity is more laterally placed. than normal.
22
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HABITUAL DISLOCATION PATELLA
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24 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
2. 'J ' sign/dynamic patellar tracking : In recurrent dislocation the sign may be positive, i.e. ,
slight lateral patellar subluxation as the knee approaches fu ll extension from 90° flexion with the
patient seated.
E. Measurement : (Compare with opposite knee)
1. Q an gle (in supine)
2. Wasting of quadriceps , measured just proximal to the patella.
F. Test other joints for generalized ligamentous laxity (see page 31)
How will you manage the case ?
Investigations : USG is useful in children when the patella is cartilagenous and not fully
ossified. X-rays are important in adu lts especially axial and lateral views . CT scan may be
done for noting trochlear dysplasia and patellar tilt and also for special measurements (TT :
TG ratio , see page 25) . MRI is useful in children (cartilagenous patella) and also can detect
medial patellofemoral ligament (MPFL) deficiencies in adults.
Operations : More than 100 operations has been described till date!!
1. Most operations have lateral release (of contractures in 1TB, retinaculum , capsule ,
vastus lateralis , etc .) followed by medial imbrication of vastus medialis.
2. In children where the growth plate has not fused , "3-in-1" procedure or Pesplasty is
useful.
3. Medial patellofemoral ligament (MPFL) reconstruction : is a low risk-high reward
option indicated in MPFL deficiency ± trochlear dysplasia.
4. Elmslie-Trillat : Is a low-risk high reward distal realignment option when vastus medialis
obliqus functions well.
5 . Rotational high tibial osteotomy (for severe rotational deformity) and Fulkerson
distal realignment (when there is lateral facet arthritis of patella), are high risk-high
reward options .
X-rays : Ossification of patella begins in the 3rd year and is completed by 6th- 7th year.
1. AP view, both knees in standing (Ortho-scannogram is more useful) : To note genu valgum .
2 . Lateral view at 30° flexion :
(a) Blumensaats' line - Normally a line drawn from the roof of intercondylar notch touches the inferior
pole of patella. (Fig . 1.3.3) If patella is higher then it is patella alta.
(b) lnsall-Salvati Index - Length of patellar tendon : Length of patella = 1 : o. If it is ~ 1.2 (I.e ..
variation of 20%) then there is patella alta.
( c) Blackburne-Peel ratio - Ratio of the length of articular surface of patella to length from inferior pole
of patella to articular surface of tibia, normally is 0.54-1 .06.
( d) Crossing sign and Trochlear bump in the lateral view indicates dysplastic sulcus (trochlear groove).
· . 1.3.3 : Blumensaat's line (X-ray lateral view) . Fig. 1 .3.4 : Note : Laterally di lo t d p It I
Fig
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HABITUAL DISLOCATION PATELLA 25
1. Apprehension test : Not important in habitual but important in recurrent dislocation - (see page 20) .
2. Patellar tilt test : Done in 20° flexed knee . Examiners fingers are placed on the medial side of patella
and the thumb on the lateral sid e. Inability to raise
the lateral facet to the horizontal plane or sli ghtly
past , indicates tight lateral reti naculum .
3. Glide test (See page 20) .
4. Femoral anteversion test : See page 127
5. Thigh-foot angle test : With the patient prone
and the knee flexed 90° measure the angle made
by the axis of foot and thigh . Normally it is 8° to
10°. When > 30° it implies significant rotational
deform ity of t ibi a. (See Fig . 1.3.6) . Another
method of testing tib ial torsion is by using a
plumb-l ine with the patient seated.
6. Ober 's test : lliotibia l band (1TB) contracture Fig . 1.3.6
test (see page 20) .
Some commonly done distal realignment operative procedures for patellar stabilization
1. Pesplasty : Lateral release+ medial imbrication+ inferomedial dynamic-sling using Pes Anserinus ~ stabilizes
patella during knee flexion . Useful operation in children .
2. 3-in-1 procedure: Lateral release+ medial imbrication+ transfer of medial 113rd of patellar tendon to the
medial collateral ligament.
3. Hauser's operation : (Done where Q angle is very high) ~ Transposition of tibial tuberosity together with
the patellar tendon medially decreasing the Q angle . Done in adults . Unpopular.
4. Roux-Goldthwait operation : Transporting lateral half of patellar tendon medially.
5. Galeazzi operation : Semitendinosus infero-medial "check-rein ".
N.B. • Vastus lateralis pulls at 7°-9° angle . Vastus medialis (Longus) pulls at 14°- 18°angle . Vastus me-
dialis (Obliqus) pulls at 50°-55°angle . Vastus media/is obliqus is the most important muscle ,
counteracting dislocation . It is the dynamic stabilizer of patella during knee flexion .
• Recurrent dislocation is mainly caused by the incompetence of medial patellofemoral liga-
ment (MPFL), which provides about 60% of medial stabilization (c.f. glide test) .
• tnsa/1 operation : Suprapatellar vastus medialis supero-medial "check-rein " is a proximal re-
alignment operative procedure.
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Chapter 4
UBERCULOSIS OF KNEE
Theories Discussed
• Triple deformity • Etio-pathology of T . B. knee
• Natural history of T.B . knee • Clinical features of T. B. knee
• Management of T. B. knee • Double traction
• Poncet's disease • 'DOTS' treatment protocol
• Knee is the 3rd common site for osteoarticular T.B. (most common is the spine , 2nd com-
mon site is the hip) .
• T.B . of knee may occur in all ages , but it is more common in children.
• Usually well-established late cases are given for examination, but strong suspicion is re-
quired for early diagnosis in the synovitis stage , so that early treatment can be started
and eventually the knee function is better after completing treatment.
• Pathological stages are : Synovitis ~ early arthritis ~ late arthritis ~ complications
and deformities.
What is your diagnosis ?
This is a case of fibrous ankylosis due to tubercular arthritis of R/L knee, with deformities of flexior
/ posterior subluxation / lateral subluxation / lateral rotation / abduction of tibia, and joint effusion / col
abscess (may be in the leg) / sinus or sinuses and decreased range of movements (usually thl
terminal part is restricted first) / limb lengthening (very rarely) in a ....... year old M/F patient.
N.B. • Only mention the positive findings.
What are the points in favour of you r
diagnosis ?
1 . From history :
• Monoarticular affection .
• Insidious onset with repeated and pro·
tracted incidents of joint swelling with
pain/ stiffness , over a period of few
months.
Fig. 1.4.1 : T .B. of right knee showing semi-flexed • History of contact with T.B. patients
deformity of knee with posterior subluxation. among family / neighbours ; school
friends or associates / colleagues, etc. , or past history of pulmonary T.B., or T.B. of any
other part of the body. Mention lower socio-economic status when present.
• History of gradual increase in swelling and stiffness of joint with pain, and flexed attitude.
• History of night cries , where the patient wakes up from sleep in pain (see page 138).
• Constitutional symptoms, if any (e.g., evening rise of body temperature, chronic cough, weight loss).
• Treatment history of A.T.D. intake (may be reddish colouration of urine due to rifampicin) .
2 . From inspection :
• Initially : semi-flexed knee .
• Later : typical attitude of triple deformity , i.e. , flexion , posterior subluxation , lateral sublux-
ation (sometimes lateral rotation and abduction of tibia are also found) .
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TUBERCULOSIS OF KNEE 27
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28 HANDBOOK FOR ORTHOPAEDICS EXAM INATION
• Aspiration of effusion , aspirate sent for - Microscopy for AFB with ZN stain, AFB-Cul-
ture , P.C.R for mycobacterium tuberculosis.
Other investigations to detect pulmonary focus include - sputum for AFB for 2 consecutive
days and CXR - PA view.
Once the diagnosis is confirmed or strongly suspected, clinically and by investigations,
treatment plan is formulated .
Treatment : "Double" Traction (Fig . 1 .4.4) + A.T.D.
~ - - - + - - - -0
I
• A.T.D. : 4 drugs + Vit. B6 Some cen- I
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u U O I OF KN 29
Surgical Options :
(1 ) Debridem e flt - Sy11ovectomy : lt i aim d at c l nrin g th jo int r tu b rc ul a r d bri s a nd increa. in g the
va cul ari ty. Thi operation i indi at d in pnti 111. wi th v ry thi c k . y novi um , and tho e who are not
re pondin g after 6 - 8 week of A.T .D.
(2) Arthrodesi : lt i indicated in very painful a nd tiff joint. . whi ch has fix ed deformiti es, du e to fibrou s
a nkylo, i . Po ition : 15 ° fl ex ion , 5° va lg u , I0° ex tern a l ro tation .
(3) Total Knee R eplacement (TKR): Thi ofte n give. th e be t res ults. lt i wideJy be li eved th at an abso lute
e e nti a l prer qui ite for th e operation is that the patient should be totally free from infection before
the operation . So it is wi e r to wait fo r 1-2 year after co mpl etin g medi ca l trea tment.
N.B. • Some authors have reported very good resulls when TKR was done in p atients even with ac tive
tuberculo is while some surgeons wait for 6-9 months (even 2 years) before doing TKR .
• Other causes of triple deformity: Rheumatoid arthritis. post-traumatic, post-bum contracture.
• Poncet's disease (Tubercular rheumatism) is polyarthritis occuring in patients with tuberculosis, which
commonly affects the knee and ankle. It is aseptic (no mycobacterial involvement can be found in the
affected joints), and believed to the due to immune-reaction (reactive arthritis) . Diagnosis is done by
excluding other causes of polyaithriti s. It responds well to ATD.
~u: .
• H -t lsoni azid 600 mg; R -t Rifampic in 400 mg (if body weight < 60 kg) or 600 mg (if body we ig ht
> 60 kg); z -t Pyrazi namid e 1500 mg; E -t Ethambutol 1200 mg .
• 3 -t thri ce weekly do age i. e., a lte rn ate d ay .
• I 2 4 5 -t Number of month of treatment.
' ' ?,H i R z EJ + 4H JR mean 2 month s of 4 dru g c he moth era p y o n a lt e rn ate day .
~~fi~:ed.b;
3
4 month s of 2 dru g chem o th erapy on a lte rn ate da y .
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Chapter 5
E V GUM ( NOCK-KN )
Theories Discussed
• Causes of Genu Valgum / Varum • Genu -Valgum-Complex
• Flexion test • Rickets - Clinical features , X-Ray features
• Management of genu valgum • Blount's disease
It is an abnormal outward devi ation of th e long axis of the leg , with respect to the long
ax is of the thigh , in the coronal plane . Normally, the femur and tibia makes an angle of 7°
- 8° (apex medially) . When th is is exceeded , genu valgum is diagnosed .
CAUSES OF GENU VALGUM (Interchange 'medial ' and 'lateral' for causes of genu varum.)
Unilateral Bilateral
A. Traumatic - A. Idiopathic - Commonest .
(a) Fracture of lateral condyle of tibia B. Physiological - Disappears by about
and/or femur. 4 - 7 years .
(b) Trauma damaging the lateral part C. Congenital - e.g., Epiphyseal dysplasias.
of the growth plate (physis) . D. Metabolic - e.g. , Rickets .
B. Infective - E. Inflammatory - e.g. , Rheumatoid
(a) Damage to the lateral physis. arthritis. (Genu varum is common in os-
(b) Rarely , overgrowth of medial physis teoarthritis - see Fig . 1.5.2).
due to increased vascularity (may F. Paralytic - Disorders - Post-polio re-
be due to infection , trauma, tu- sidual paralysis , charcots disease (see
mour). page 263) .
C. Neoplastic - e.g. , exostosis , G. Miscellaneous - Osteogenesis
chondro-blastoma affecting physis . imperfecta (see page 262) Paget's dis-
D. Idiopathic ease , etc .
30
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----------------~~----~-
Wha t is your diagnosis ?
G NU VALGUM (KNOCK-KNEE) 31
N.B. • 1ay b a oc1 led with lax m dial co ll a te ra l liga me nt of kn ee , late ral disl oca ti on
of p t Ila , e t rna l ro t lion of proxim a l tib ia (meas ured by Thigh -Foot angle see
page 25 I I-foot (p es plan us) (see page 181) a ve rsion foot , va lgu s hee l, in-
er s d Q angle all of whic hx form the genu-va/gum -complex.
Ho a ou ,agno l1gamentous laxity ?
. The intermalleo lar distance al an kle in stand ing (we ight bea ring) position is increased ,
compared to the dis tance in su pine (with th e patella facing just slightly outwards).
2. Tests for general ized ligamentous laxi ty - bilateral hyperex tensi on of fifth/ index finger 2'. 90 °,
bilat era l thumb can be b ro ught to touch the vo lar d ista l forearm , bi lateral elb ow
hyperexten ti on 2'. 10°, bilateral genu recurvatu m 2'. 10°, and spinal hyperflexion allowing the
Fig. 1.5.2 : Genu va rum of left knee , a patient Fig. 1.5.3 : Genu valgum of left knee and genu va rum
of osteoarthritis. of ri ght knee - descri bed as Wind-blown deformity.
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ANDBOOK FOR ORTHOPAEDICS EXAMINATION
• On~e you get the case , mark ASIS , centre of patella , tibial tuberosity , medial mal-
leol1 at ankle , and Q angle of both the limbs .
How do you clinically assess I diagnose genu valgum and genu varum ?
1. Normally at birth th ere is physiologi cal genu varum of about 15°, at 1 1/ 2 - 2 years age it
becomes neutral. At 2 - 4 years age it is about 12° valgu s, and at 6 - 8 years it becomes
5° - 7° valgus which is normal in adults . In children < 1O years , when standing with the
patellae facing forward and both knees touching , the intermalleolar distance should be < 8
cm . For genu varum when standing with the patellae facing forward and both heels touch-
ing , the distance between two medial femoral condyles should be < 6 cm.
2 . Normally , the line joining ASIS to th e centre of patella , if extended below , just touches the
medial malleolus (see fig . 1.3 .2). In genu valgum , this line never touches medial malleolus ,
but falls more medially .
Why do you say due to rickets ?
• Age is in favour .
• Rachitic stigmata maybe found e.g., cran-
iotabes, frontal bossing , caput quadratum ,
delayed I deformed , poor dentition history,
pigeon chest. Harrison sulcus, pot belly ,
rickety rosary (most persistent/ common) ,
widened , broadened wrist, bowing legs etc.
• Might have treatment history suggestive
Fig . 1.5.4 : X-ray of bilateral wrists and knees
of rickets . showing features of ricket's
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G NU-VA LGUM (KNOCK-KNEE) 33
ti 11 r nu v lg um : 10 cm
f g . Wh en Q ng le is >
n 11 y rs, or in males > 12
ti n 'f r surgery . At age 10 y ars
m for ge nu va rum/intermalleol ar
lgum will n ed surg ry .
It i a progres ive tibia ara (not tri ctly genu varum) du e to abnorm al growth of the postero- medi al pa1t of prox imal
tibial growth plate. 80% are bi lateral. Internal rotati on of tibi a may be assoc iated. X- ray how typica l ' beak' haped
metaph i and media ll y flattened epiph ys i , and ometimes frag mentation. Correcti ve o teotomy with sli ght over
coITection i th e treatment.
lliotibial ba nd co fltracture is a k n o wn cause of ge11u valg um . What are th e 7 typical deformiti es, that are
aHociat d , it!, iliotibial ban d co ntracture ?
(1) Ini ti all y due to pelvic obliquity and fi ed abduction de form it y of hip, there may be appearent lenthenin g, bu t
fi nally there i true . horteni ng of the limb, (2) Ankle/foot : Tali pe eq uino varu s, (3) Leg : Ex tern al tibi al
tor ion (4) Knee: Fie ion co ntractu re, genu valgum (5) Hip : Flexion, abduction, external rotation (FLABER),
(6) Pelvi : Pelvic obliquity, (7) Spine: Iner ased lumber lordo i , lumber scolio i .
~ hat i\· COR '>
l t i the Center of Rotation of An gulation which how th e apex of th e defo rmi ty, ideally where th co rrec ti ve
o t otomy should be done for better re ult . l t i draw n over ortho- ·canogra m X-ray .
E ·5
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Chapter 6
Theories Discussed
• Clinical features of quadriceps contracture • Pathoanatomy of quadriceps contracture
• Ely's test • Management of quadriceps contracture
• On examination
(1) Increased lumbar lordosis
(2) Normal skin creases over the knee are absent.
(3) On passive knee flexion , dimpling of skin appears over the anterior thigh (not always
found) and knee flexion is not possible beyond 10°-15°. In the maximally flexed posi·
tion of the knee , the quadriceps feels taut and cord-like.
(4) Genu recurvatum , anterior subluxation of the tibia , or habitual dislocation of patella
may be associated .
(5) Wasting - decreased circumferrencial measurement of thigh .
(6) Decreased knee flexion .
(7) Ely test may be positive when rectus temoris muscle is affected (see page 36)
34
-,•1<_r:· ·· .• - ; . - · : - ~ - ~ --- ----- ~ - -
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Q UADR ICEPS CONTAACTURE
35
Which muscle is primarily affected ?
• Vastus intermedius is primarily affected. Vastus lateralis may also be affected in post
injection fibrosis .
Why dont you give your diagnosis as habitual dislocation of patella ?
• That is because patella dislocation was not present from birth , which developed later, sec-
ondary to progressive kn ee stiffness due to quadriceps con tract ure.
What are the treatment options of quadriceps contracture in general ?
• If detection is early, then passive quadriceps stretching exercises daily, i. e., several
times a day is beneficial. Can be tried up to 6 years of age.
• Surgery is not done before 6 years , but surgery is a 'MUST' when scar-contracture is
established. In established contractures , earlier the su rgery, better is the final outcome
and prognosis , because results deteriorate with delay .
How will you kn o w, whether vastu lateralis, va tu intermediu s or rec/u s f emori . i.1 contracted.? , .
• ff vas tu latera J1. 1.s 1nvo
. J ed . rh en u· ually ooenu valgum and habitual di location / ubluxat,on of patell a '
• It. rectu1- fcmon.s, 1.. 11. 1 ol ed • ther will be po itive Ely test.
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n 1H, [ I f MINATI N
halll,ll ' !- t\' ·111 r llh'ri, lt~htn ·~:- ,u1d /l11 i11i1,1til>11 l,r 1hc fem ra l ncr e. Bot h th e I "er limb. are tested for
mp:111.'l'll I h' t',lt1 ' 1\l II ' :< t'rl,111· 111111w lilt k . Exami ner stand: ovt:r th e p·1tient 1th one hand on the patient' s
1c' 1.
11." ' r b,I ' .ind tlh· ,,th 't h11ldi11i:. th, rl, ,1. l'he l ,:rn1incr p·ts i ivel. flexes th leg upon th e thigh trying to touch
th , lh' I I th, l lllll · ri.:-. l . , . I ). rt1 , test is I o:1tiv when th e pati nt j unabl e to touch the heel to the
l \lit ~· . w ,, I\ '1' tlh' hip , ith th1' h rni -1 l lvi: raise. off th tab le (fig. 1.6.2). or if there i extreme pain or
tini:.lin~ 111 b.1'k ,f I '~s .. \ JK sitiw lL'~t 111d1catcs ti ghtnc , fr tu s femo ri, , or femoral nerve irritation due 10
l\lml H:I ' t ,II I ':1 ,n u!.. . l l \ ' l l.'L'1' pai:. _ I ).
.B. • If the que tion i - ho, will ou manage this ·as ? Then (\a . fir t l will do an X-ray f th kne
joint to detect th bony change , and then dt: ide on the management. utlin ~ of th tr ·itment
option which are v ell-suited for th particular c·1se i aln.:ady di cu ' ed . Co,ms lli11Sl r th puti 111
and pati nt' guardian i v ry important, b cause prog11osi • is alwa) s guarded. and curly en ourag-
ing re ult may later deteriorat with tim . Exten. or lag i.' a compli ation .
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Chapter 9
BASIC C IN CAL EXAMINATION OF ELBOW
Theories Discussed
• Tinel's si gn • Flexion test for cubital tunnel syndrome
• Ochsne r's pointing index sign • Pen test
• Nail sign • Stability tests of elbow
INSPECTION
(1) Have a female attendant for a female patient. Explain the procedure to the patient, (i .e., what
you will do and what the patient will be required to do) and ensure verbal consent. The patient
should be fully exposed from the shoulders to the fingers on both the sides.
(2) The patient should stand (or sit on a stool , if there is difficulty in standing) . Both the upper limbs
should be ideally in the anatomical position i.e. , upper limbs by the side of the body in the
coronal plane , with elbows extended , forearms supinated , wrists in neutral position and thumb
and fingers extended . If the affected limb cannot be brought to the anatomical position , request
the patient to keep the affected limb as close to the anatcmical position as possible , and then
bring the opposite limb to identical position , so that both the upper limbs are symmetrical.
(3) From the front : Note, compare and comment on the attitude/deformity, under 2 headings -
obvious flexion deformity (when present), and the carrying angle (don 't mention carrying angle
when the elbow cannot be fully extended or the forearm fully supinated - see page 53) . Then
compare and comment on the biceps bulge, depression of the cubital fossa , upper forearm
shape and bulge , any noticeable wasting or fullness/lump/abnormal swelling (may be myositis
ossificans - see page 60) , scar, sinus , venous prominence.
• Then request the patient to abduct both the arms to 90°, and look for "gunstock deformity"
(see page 53; fig . 1.10.4).
(4) From the side : Note compare and comment on any fixed flexion deformity , the proximal
brachioradialis bulge, any lump/abnormal prominence (e.g. myositis ossificans , tip of the ole-
cranon in posterior dislocation elbow etc.) and wasting, scar, sinus , ve_nous prominence.
• Then request the patient to flex both the shoulders to 90°, keeping both limbs straight in
front with the palms facing upwards and note , compare and comment on any hyperextension
(see fig 1.9.1) or fixed flexion deformity.
Fig. : 1.9.1 : Note : hyperextension Fig. : 1.9.2 ; Note : 3 bony points relationship
45
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HANDBOOK FOR ORTHOPAEDICS EXAMINATION
46
From the back : Note, compare and comment on the tri ceps tendon , prominence of the
(5) olecranon , the para-olecranon hollowes/depress ions, prominence of the medial and late ral
epicondyle s, pre sence of any abnormal lump and wasting , sca r, sinu s, venous promi nence.
• Then request the patient to place both the hand s (1st web space) over the highest point of
iliac crests, with the elbows faci ng back (see fi g 1.9.2). Note , compare and comment on
the 3 bony point relationship (i. e., medial epicondyle , lateral epicondyle and the tip of the
olecranon) . Usually when the elbows are 90° fl exed, they "nearly" form an isosceles triangle,
with the intercondylar li ne forming the base.
PALPATION
N.B. • The most important aspect of elbow examination is probably the palpation of bony
landmarks. Remember, tenderness is sought and elicitated simultaneously.
• Don't forget to look at the patient's face when seeking tenderness .
• Temperature : With the posterior side of the fingers of your dominant hand , note and compare
the temperature over the cubital fossa and the anconeus triangle in the following order- first the
normal side, then the "affected/pathological" side, and finally again the normal side .
• Supracondylar ridges of right (R) elbow : [replace right (R) with left(L) when palpating the
left (L) elbow). With the patient standing (or sitting on a stool) stand on the right side and
slightly beh ind the patient and hold his/her (R) distal arm with your (R) hand , so that the elbow
is flexed to about 90°, and the arm is slightly abducted and extended until the tip of olecramon
becomes clearlt visible and _the forearm is maximally supinated . Now with yo ur left (L) thumb
on the lateral side ~nd t~e tip of y~ur (L) index or middle finger on the medial side and the (L)
palm on the posterior s1~e (see _fig 1.9.3) , start palpation from the fleshy/muscular midarm ,
gradually downwards unti l you find the sharp and pro_ minent bony ridges , both medially and
. you r thumb
laterally. Roll . (on the lateral
. ' I s1·d e )
side) and your index/middle finger (on the me d 1a
rom an
f . k ·t · enor to posterior
.
to confirm the bony ridges. Note, compare and co m en on th e1r
m t ·
th 1c ening , 1rregu 1anty and tenderness .
Fig . : 1.9.3
• Medial and lateral epicondyles of ri h F'.g . : 1.9.4
palpating the left (L) elbow]. First al !et (R) elbow : [re~lace nght (R) with left (L) when
condylar ridges (as described e t p ' locate a nd c?nfirm the medial and latera l supra-
middle finger tip downwards anda~ier).I Now gradually slide your palpating thumb and index/
outward ends, ~hich are the media:S~~ ly, till you r~ach the most pointed , sharp and prominent
co'.11ment on tenderness as in lateral de l~teral e~_,condyles ~see fig 1.9.4) . Note, compare and
ep1condylitis or golfer's elbow (see a :1condyllt1s or ten ni s elbow (see page 166) , medial
Normally epicondyles lie in the p 9 169 ) a nd also the symmetricity of the epicondyles.
coronal plane or sl' htl .
Olecranon and it's tip . Th . '9 Y posterior to the corona l plane .
• · · e u1na is a complet 9 I
proximal end. So start palpating the b
b .
Y su cutaneous bone, and the olecranon is its
su cutaneous bor der - o f the ulna from just bove the wrist
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BASIC CLINICAL EXAMINATION OF ELBOW
47
and gradually. proceed proximally till y~u reach the flare.d end , i.e., the olecranon . low proceed
upwards/proximally to reach t~e prom1~ent end of ulna 1.e., th e tip of olecronon. Note, compare
and comment on tenderness , 1rregulanty.
• 3 bony point relationship : The 3 points are the 2 epicondyles and the tip of the olecranon.
• Joint line : First palpate and confirm the lateral epicondyle. Then palpate further distally and
downwards till you find a transverse groove. (i.e., the space between the radial head and the
capitullum) . This represents the lateral joint line of the elbow. Confirmation is done by slightly
flexing /extending and pronating/supinating the elbow to note that there is no movement at the
joint line .
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48 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
MOVEMENTS
N.B. • Th elbow consists of 2 uniaxial joints. One is the humero-ulnar joint, which is a hinged,
or ginglymoid joint. The other consists of the humero-radial and proximal radio-ulnar
articulations, a pivoted, or trochoid , joint, allowing 2° of freedom in the elbow joint. So it
is a trochoginglymoid joint, or "sloppy" hinge.
• Essentially 2 sets o1 movements are tested at the elbow which are flexion/extension and
pronation/supination . During flexion/extension there is rotation of ulna around the hu-
merus. During pronation/supination there is rotation of radius around the ulna and occurs
at the superior, inferior and intermediate radio-ulnar joint which is represented by the
intarosseous membrane .
• The axis of pronation/supination movement roughly coincides with a straight line joining
the centre of the radial head to the base of the ulnar styloid/attachment of the triangular
fibrocartilage .
• Axis of rotation of elbow is through center of trochlea colinear with distal anterior cortex
of humerus, when viewed from the lateral aspect.
• Flexion/Extension : There are 2 ways of examining the flexion/extension movement.
(A) Patient seated beside a table : The vertical height of the table should be nearly upto
the level of the armpits of the seated patient. Request the patient to place both the upper
limbs parallely over the table , with the armpits wedged on to the edge of the table , so that
the elbows are extended, forearms supinated , wrists are in neutral position and the fingers
extended. Ensure that there is no gap between the arm and the table-top and the posterior
surface of the arm is firm ly in contact with the table-top along it's whole length (see fig.
1.9.7-A). Then request the patient to flex both the elbows maximally (by trying to touch the
ipsilateral shoulder with the fingers) . Stand on the side of the patient and note, compare
and comment on the range of flexion of both the elbows (see fig . 1.9.7-8). The normal range
is from 0° to 150°/160°.
B. Patient standing or sitting, but there is no table : Both the arms should be hanging freely
like a "plumbline", by the side of the body in the coronal plane . The elbows should be
extended, forearms supinated, wrists in the neutral position and the fingers extended . Then
request the patient to gradually flex both the elbows maximally (try to touch the ipsilateral
shoulder with the fingers) . Stand behind the patient fixing the arms to the body, and note
compare and comment on the range of flexion (see fig . 1.9.8) .
C. Hyperextension : To note hyperextension, request the patient to flex both the shoulders to
90° (in sitting or standing position) so that the elbows are fully extended , forearms supinated,
wrists in neutral position and the fingers extended. Due to gravity , any hyperextension at the
elbow will be revealed , when viewed from the side (see fig . 1.9.1).
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BAS IC CLIN ICAL EXAMINATION OF ELBOW
49
• Pronation and Supination : The patient can sit or stand . Both the arms should be hanging
freely like a "plumbline" by the side of the body in the coronal plane, and both the elbows
should be fl exed to goo (or as close to goo as possible) , keeping both forearms in the
midprone pos ition . Then request the patient to hold 2 long penci ls/pens in clenched fists,
keeping the wrists neutral (see fig . 1.g.g_A) . Standing behind the patient fix the arms to the
side of the body. Now request the patient to rotate the forearms maximally so that first the
fingers face downwards towards the floor (for pronation, see fig . 1.g,g_B) and then upwards
towards the roof (for supination see fig . 1.g,g_c) . Note the angles made by the pencils/pens
with the perpendicular, compare and comment. The normal range of movement, from
midprone position is about 80°/go 0 •
MEASUREMENT
N.B. • Ideally the true length of the arm should be measured from the topmost part of the hu-
meral head to the elbow joint line in the mid-axis of the arm . This is technically not
feasible or possible. So the nearest, easily palpable bony prominence is chosen for mea-
surement, i.e. , the angle of acromion (instead of the humeral head), and the lateral epi-
condyle (instead of the anterior joint line) .
• For the same reason the length of forearm is measured from the lateral epicondyle to the
tip of the radial styloid process .
• Both the upper limbs must be symmetrical in position while measurements are being taken.
• Length of arm : The angle of the ipsilateral acromion should be identified first and it is
palpated in the following way . With the pa-
tient sitting/standing , and with both the arms
hanging freely like a "plumbline", by the side
of the body in the coronal plane , stand be-
hind the patient. Then start palpating down-
wards from the fleshy/muscular region (mid-
point of the root of the neck and the shoul-
der , through the trapezius and the su-
praspinatus muscle) , till you feel the sharp
and nearly horizontal bony ridge , which is
the scapular spine (see fig . 1.9.10) . Now
start palpating lateral ly along the spi ne of
scapula till you reac.h the sha rp ang ular
bend at the outermost lateral part. This is Fig . : 1.9.1 o (a = scapular spine, b = angle of acromion)
the angle of acromion .
"
• For palpating and confirming the lateral epicondyle of the humerus, see page 46.
0 . E. - 7 -------------=--c::mc::::a-=::a::::===============.....,--
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50 HANDBOOK FOR ORTHOP/\EDI S EXAM INATION
• Keeping both the upper limb s in symmetric I po ition , m a ure th nee from hs
angle of acromion to the I t r I picondyl on both ide , cornpar and ornrnen .
• Length of forearm : Tl1e ipsil t ral r di I styloid tip should b identifi d firs and it i palpa ed
simultaneously along with the uln r styloid wi h your two ind x fingers in the followin vay.
• Styloid relation ship : With the fore rm pronated and the wri st se mifl xed stand in Iron of
the patient and using both your hands hold the patients sli ghtly palmar flexed hand so that
your thum bs are placed on the dorsum and your 3rd , 4th , 5th fingers support the palm . This
leaves both your index fingers free to si -
multaneously palpate the radial and ulnar
sty loids. Start palpating from the di stal
forearm (see fig. 1.9.11 ), along the medial
and late ral sid e in the coro nal plane,
where you wi ll fee l the subcutaneo us bo ny
borders. Proceed downwards and distall y
over the prominent outward flare of th e
distal radius and the ulnar head, till you
reach the sharp bo ny ends, wh ich are the
radi al and ulnar styloids. Note that the
19 1
radial styloid is mo re di stal than the ul nar Fig. : · ·1
styloid (more in pronation less in supination) . To confirm , deviate the wrist rad ially and ulnarly
(which makes th e styloids prominent). Then alte rn ately dorsiflex and palmarflex the patients
wrist usi ng your thumb and other fingers to note th at th ere is no movement of the styl oids .
• Fo r pal pating and confi rming the lateral epicondyle of the humerus, see page 46.
• Keeping both the upper limbs in a sym metrical position , measure the distance from the lateral
epicondyle to the radial styloid on both sides , compare and comment.
• Wasting : The girth of the arm and forearm is measured at a region , where visually th ere is
gross discrepancy. It should also be measured at the same distance from a fixed bony point
of th e elbow (e. g., the lateral epicondyle or the tip of the olecranon etc) for both sides. So first
measure the girth of the "affected/pathological" side where visually there is gross wasting,
then measure the distance from that level to the fixed bony point in the elbow (e.g., lateral
epicondyle), next measure the same distace form the fixed bony point of elbow in the "non-
affected/normal" side, and lastly measure the girth at that level. Note, compare and comment.
• 3 bony point relationship : Identify the lateral epicondyle , medial epicondyle and the tip of
olecranon , ¼{ith both the upper limbs in symmetrical position i.e. , either from the back with both
hands on the hips, elbows facing backwards (see fig. 1.9.2) , or from the front with both
shoulders flexed to 90° and elbows maximally flexed (see page 55) . Measure the inter-
epicondylar distance, ar:id the distances from the tip of the olecronon to the medial and lateral
epicondyles of both the sides. Compare and comment.
• Carrying Angle : see page 54.
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BASIC CLIN ICAL EXAMINAT ION OF ELBOW
51
2. Flexion test (for Cubltal Tunnel Syndrome) : Elbow is fully flexed and then you
maximally flex the wrist (see fig . 1.9.12-B) . Maintain the position for at least 5 minutes.
Maximal traction is applied on the ulnar nerve in this position , and any paresthesia along
the ulnar nerve distribution implicates compressive ulnar nerve neuropathy at the elbow.
3. Ochsner's pointing index sign : Request the patient to fold both hands with the fingers
interlocked . In median nerve palsy, there will be weakness of the flexor digitorum profundus
(FOP) and flexing the index finger will not be possible (see fig . 1.9.13-A) . Note - Index
finger has an additional extensor indices muscle attachment.
4. Pen test : Request the patient to place the palm on a table facing upwards. Hold a pen
over the thumb and ask the patient to try and touch the pen with the thumb so that the
thumb is abducted (points towards the ceiling) (see fig 1.9.13-B) . In median nerve palsy
abductor policis brevis weakness will not allow this . Movement takes place in 1st
metacarpo-trapezium joint which is a 'saddle joint '. Abductor policis longus which is
supplied by radial nerve cannot initiate abduction but can continue abduction .
5. Nail sign : Request the patient to oppose the tip of the thumb and the little finger. In
median nerve palsy , there will be weakness of the opponens pollicis muscle, and the
patient will adduct the thumb rather than oppose it. The patient will fail to touch the tips
of the thumb and the 5th finger.
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52 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
the elbow which causes stress at the medial and lateral collate ral ligaments of elbow
respectively . Repeat the procedure for the opposite elbow. Note, compare and comment
on the range of excursion and pain , to detect varus or valgus instability.
Fig. : 1.9.14-B
Fig. : 1.9.14-A
2. Test for posterolateral rotatory instability of elbow : It is the most common elbow
instability. With the patient supine, stand at the head end of the patient. Grasp the distal
forearm and maximally supinate the forearm with the elbow extended (see fig . 1.9.15-A)
Then apply a valgus stess and compression while gradually flexing the elbow (see fig
1.9.15-B). When postero-lateral instability is present, the patient will be afraid and bE
apprehensive when the elbow is flexed to about 25°-30°.
• Epicondylitis tests
(a) Tests for ,lateral epicondylitis of elbow (Tennis elbow) : Many tests practised e.g.
Thompson s test and Cozen's test (see page 167- 168), Chair test, Bowden test, Mill
test, Motion stress test, etc.
(b) Te5ts for med~al epicondylitis elbow (Golfer's elbow) : Many tests practised e.g.,
Reverse Cozens test, Forearm extension test, Golfer's elbow sign (see page 169).
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Chapter 1 O
CUBITUS VARUS
Theories Discussed
• Carrying angle • Causes of cubitus varus
• Management of cubitus varus • Supracondylar fracture of distal humerus
• Complication of supracondylar fracture • Management of supracondylar fracture
• Gartland classification • Soltanpur technique
• Baumann's angle • Myositis ossificans
What is your diagnosis ?
This is a case of R/L, dominanUnon-dominant sided cubitus varus deformity (or may be post-
traumatic stiff elbow with gunstock deformity), probably due to malun ion of supracondylar frac-
ture , with (or without) restricted flexion and restricted pronation with (or without) distal neurovas-
cular deficit, in a ...... year old M/F patient.
[Once you get the case, mark the carrying
angle of both the upper limbs and also the 3
bony points (see figs . 1.10.3 & 1.10.5 around
elbow)]
Why do you say cubitus varus ?
There is deviation of the forearm towards
midline, with respect to the arm , when com-
pared to the normal. side and also because
the normal "carrying angle " is reduced in
comparison to the opposite side (and may even
be of negative value) .
What is carrying angle ?
It is the angle between th e extended long
axis of the arm and the long axis of fore - Fig . 1 .10 .2 : Left-sided cubitus varus in fully ex-
arm , in fully extended elbow (neutral posi- tended elbow and ful l supinated forearm.
tion) and fully supinated forearm (i.e ., the anatomical pos it ion) . Normal carrying angle
values : Male : 7° - 10°; Female : 10° - 15° (average 11 °). With elbow flexed the angle between
the axis of arm and forearm becomes 6° varus (which helps in bringing the hand to mouth) .
N.B. • When carrying angle is 'Zero' --"7 it is sometimes called cubitus rectus.
• If full extension is not possible --"7 use post-traumatic stiff elbow with "Gunstock
Deformity" as diagnosis, instead of cubitus varus . State that the long axis of
forearm is inwardly (medially) deviated with respect to the long axis of arm . (Fig.
1.10.4). Never say cubitus varus .
• During flexion of elbow , internal rotation of ulna causes loss of carrying angle.
Thus, in fully flexed elbow, there is 6° varus angle . Clinically, axis of forearm is
53
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54 HANDBOOK FOR ORTHOPAEDICS EXAM INATION
drawn by joi ning the mid -points of a line joining the radi I and ur~, r 'tyr 1<1 1 , tJr.,
the line joining lateral and medial epicondyle s of the humeru (1n £, f0pi<.,;nrJ 111,
line) on the anterior surface of forearm . (Fig . 1. 10.3)
Axis of arm is drawn by joining the
midpoint of a line drawn from the tip of
anterior axillary fold to the most promi-
nent part of the deltoid bulge as seen
from the fro nt, to the midpoint of the 1.-+-- - - - a11 of arm
interepicon dylar line . (See Fig . 1.10.3) ~,.-+-- - - - interepic,ondyla, 1,ri..,
• Mark : (Fig. 1.10.3)
(a) Tip of anterior axillary fold . u1-+- 1s-:-,-- - - c,ur1/in angle
(b) Mo st prominent part of deltoid H+- -,-- - - - a:l'.is of forearm
bu lge.
(c) Medial epicondyle .
(d) Lateral epicondyle .
(e) Ulnar styloid . Fig. 1. 10 .3 : Carryin g Angle.
(f) Radial styloid.
• Cub itus varus deformity is NOT progressive , when it is due to trauma.
N.B. In lateral condyle fracture , only lateral supracondylar ridge is th ickened , and the 3 bony
points relationship is altered.
!
What are the other causes of cubitus varus ?
1. Infective : Medial growth plate damage.
2. Vascular : Osteonecrosis of trochlea.
3. Traumatic : Lateral condyle fracture of
humerus .
4. Neoplastic : Secondary to exostosis in
distal , lateral humerus .
5. Congenital : Epiphyseal dysplasia.
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C UBITUS VAAUS 55
How do you clinically confirm 'Medial tilt ", "Medial rotation ·· and "Posterior til t " ?
1. Length of arm (as measured from the ~ngl~ of acromion to the lateral epicondyle) is slightly
increased when compared to the opposite side , but the 3 bony points relationship is intact i.e.
medial epicondyle is at a higher level compared to the lateral epicondyle of same side and
the medial epicondyle of the normal side. This indicates medial tilt in coronal plane.
2. External rotation of sho uld er is decre ase d whil e intern al rotation is (ofte n) inc reased
when compared to the opposite si de . Th is ind ica tes medial rotation since there is no
rotation possible in the el bow joint. Also, the late ral epicondyle is palpated anteriorly w.r.t.
the lateral supracondylar ri dge .
3. Rotation and tilt can also be assessed by compari ng th e tri angle fo rmed by the 3 bony
points of both elbows , side by side, whe n both are flexed and po inting towards the back
(Fig . 1.10.SA) or in fro nt, (Fig . 1.10.58 ).
Fig. 1.10 .SA : Fig . 1.10.5B : Left sided restricted el bow fl ex ion
with 3 bony po int tri ang le media lly rotated .
4. Flexi on of elbow is restricted , and there is hyperextension (due to posterior tilt), but the
arc of movement is same. Mechanical obstruction by anterior bony sp ike due to posterior
sh ift will cause only restriction of flexion , with reduced arc of movement.
N.8. • If the initial question is - What are the points in favour of your diagnosis? Then
summarise as -
From history : Fall on outstretched hand , then the treatment history .
From inspection :
• Carrying angle is of negative value , (or say) ax is of the forearm is medially deviated
with respect to axis of the arm . (Do not mention carrying angle if elbow cannot be fully
extended.)
• '3' bony point relationship is maintained but the triangle is medially tilted in the coronal plane.
From palpation :
• Medial + Lateral supracondylar ridges are thickened and irregular.
• Three bony points relationship is intact, but the medial epicondyle is at a higher level
than the lateral epicondyle.
From movement :
• Internal rotation of shoulder i external rotation J, in comparison to the opposite side
but the total arc of motion is eqiJ. al.
• (If present) elbow flexion J, (see Fig . 1.10.58) extension i
From measurement : Length of arm i (maynot be present)
How will you manage· the case ?
lnvestigatjpn : X-ray
1. Both elbows, in one film , in ful l elbow exten si on and supinated forearm - AP view.
(To compare and as ses s th e ex act degree of correction that is required .)
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56 HANDBOOK FOR ORTHOPAEDICS EXAM INATION
2. Lateral view of the affected elbow (to assess the posterior tilt/shift).
Operations : Wait for at least 1 year after injury tor fu ll consolidation of fracture union.
1. Lateral , closing wedge supracondylar corrective osteotomy (French~modified French
osteotomy). (Fig . 1.10 .6 and 1.10 .7). Length of arm is shortened but 1s more stable and
unites qu ickly
2. Medial opening wedge supracondylar osteotomy (King's osteotomy). Here length o'.
arm is gained , but is less stable and there may be delayed union.
3. Others : Dome osteotomy, Step-cut osteotomy.
What can be the problems if operation is not done ?
Cubitus varus is a risk factor for lateral condyle fracture of humerus in future . Tardy ulnar
nerve palsy has been reported due to a fibrous band between 2 heads of flexor carpi ulnari s
or subluxation of the nerve . It is a visually disturbing cosmetic deformity . Also any nerve near
the fracture may get entrapped within the callus causing tardy nerve palsy - METEV'S SIGN.
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CUBITUS VARUS 57
N.B. • In elbow dislocation , most common mechanism is fall on outstretched hand with
slightly flexed elbow, because the ligamentous laxity is less after 9 years .
• About 75% of supracondylar fracture are postero-medially displaced . This is be-
cause the line of "pull" of the biceps brachialis is medial to the humeral shaft, and fall
on outstretched pronated hand forces the fractured fragment postero-medially.
• Commonly associated fractures are distal radius and proximal humerus .
E. · 8
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HANDBOOK FOR ORTHOPAEDICS EXAMINATION
58
t
Fig. 1.10.11 : Manipulation technique for reduction of extension type supracondylar fracture .
2. For displace.d fractures, Clo.sect ~eduction Percutaneous Pinning (CRPP) is the treat-
ment of choice, where manipulation under anaesthesia and · · · ·
confirmed in image-intensifier (C-Arm) Then , , . reduction 1s done , which 1s
2
duced to 'fix' the fracture Finall • . or 3 K wires are percutaneously intro-
1
for 3 weeks . . Y pu se is checked and plaster cast/slab is applied
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VA
s. When there is gross I/in
the fracture is open
Dunlop traction is
treatment. (Fig. 1.10.12
Disadvantages of Dunlop t
1. Cannot b applied v
2. Elevati on of fracture
m
ction :
( 11 1d11 11
II dtl <, 11 0 11 \
'rrI /1 [w
V I
of heart is not possibl
N.B. • Always che k post-r duction di ~J
,,,'
tal neurovascular statu . ,
,,
,'
• If open -reduction -int rn 1-fi lion
(ORIF) is done , it must be within
4 - 5 days, to reduce ch nc s of
myositis ossificans.
I . 10.12 : unlop tr lion .
D e cribed by Pro f. A . o ltanpur from T ehran . ir i a 2 ·<age tcchniqu for r ducti on of j7exion type supracondy lar
fractures , w her e lh e elbow i imm obili z d i n 90° fl cx i on. (No1e : ommonl y . .f7exio11 typ e fracture arc oft en
i mm obil ized in elbow ex ten i on. whi ch has th e added advan tage o f good X -ray vi ew , and thus early diagnosi of
cubitu varu s.) Fir t th e arm i pla tered ----t reducti on ----t I ng arm pla ter i compl eted.
Whal p recautio11 .1 are tak en to pre ,•ent ulnar nen•e injury. when iutroducing the m edial ·K ' wire in Cl?l'P '!
lnci si on i gi ven and direct vi ·uali zati on o f th e media l epi concly le i required. The m dial soft-ti s ue mas (con rain-
ing th e uln ar ner ve) i pu shed bac k posreriorl y wirh fin gers, and th e elbow i fully ext ended . The ' K ' wire i
introdu ced through a d r ill -s leeve.
What are th e d1ffere11ce.1 he/ ween ' Fren ch · and 'M od~fied French ' fl'cl111iqne ?
In Modifi ed French tec hniqu e the in ci · ion i po l ero - l at era l ( not po terior), osteoc lasi i clon e keepi ng a bony
hinge (not o teotomy) , and the whole tri ccp i mobili zed ( 1101 the lateral half of lricep ) with ulnar nerve di ssection .
What are th e ct1n 1·e1 of re1·tricted elbo w f/ l'.l"io11 aflL'r .111prncondy lar fracture ?
M yo iti s o sifi can . anr cri or bony pike. uni on in po teri or tilt . prol onged immobili za ti on, triceps contrac ture.
What i1 th e tim e of appearence of os ,ificatio11 ce11lrt'.1 around dbo w?
• Capit ellum : 1-2 y rs. l{adial head : 3-4 y r . I nt ' rn al (m di al) condy le : 5- 6 y r , T rochlea : 7- 8 yrs, O lecranon : 9-
10 yr . l sx ternal (l ateral ) oncly lc : 11 - 12 y r . ( Pnemoni CRJTO E).
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HANDBOOK r-on OIHtlOI /\I DI
£ XAMINAT ION
• Jfrtriu~ic cau.,·e.~ : ':ipsulo- li g:1111 ·1Hll11s. mu, ·1il11r a11d 01hcrs sort ti.~suc ·uuscs. /:,'g : Pos t burn c.:ontrn tun:. myositis
ossifi an ·. post opera11 vc scan in g. p:IIH: nts 11011 ·0111pli:inc • 10 r ·huhi l ita 1ion ·c lwdul ' .
• fllt rin.~ic cn 11~ ·.~ : 1i>st trau111:it1l' unr ·duc ·d/111nl11nit.:cl i n1ra-articu l ar fra c.: 1ur ·s, dislo ut io 11/s ublux.a1io11, i 111rnarti cular
loo ·c bodi ·s. µost inrcc t1 111.' i111ru-:11t1cu la1 aclh •s ions. loss o f articulnr carl i lag • cau si ng osc10,1r1hri t is. post inflnmma-
lOry .irthritis (<'g . Rhcu111,1toid arth1i1is), bony a11ky losis.
('/i11icol/ w /1111 , 11·(• / /, (' d(fj l'rt•111·1•., h t'lll' l'l' II i11tri11sil' and 1•.rtri11.1·ic N llf.l'(' .I' J
I n intrinsic c.1u~cs 1hcrc is a buuy .,·top 10 mov ·m •111 (vs . .,·oft .1·top ), g ross ly p~1i11 f ul 1110v ·1111.:111 (vs. I ss painful ).
gross was1ing of' muscl ·s (v~. I ·ss w:1s1i11g), .:arly os1coar1hr i1 is. and 11wy be a. socia1cd wit h co r onal p lane f ,for111il ) .
/low will y 11 11 lr t'M " c1H1• of .~t,ff l'lhowJ
l ntrin ·ic cau ·.:s : anhroplas1y (sec puge 62) . Ex 1ri11sic causes : sol'! 1issuc relc.isc by Bhat1acharya/ ol umn proccd ur .
Whal i,· 11,e t1 r1a t11mic11 / a nd f1•frophy.~i olo,:frof basi.v of th e n orm al 1·arryi11,: tm gfr J
• Anatomically 1hc media l c1is1ac I' 1ro hlca is 6 111 111 long 1· thun thc l:11cral cri sl u ' . Tclcophy, iolugi ally 1hc arryin,
ang le i u ·cful hccauM! th · for •a nn c:111 clca1 rhc hip hone whi le walking/ ·a rrying we ight. and 11 also help · in hand
to - mouth 111011011 .
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Chapter 11
0 TE IOR OISLOCATIO ELBOW
Theories Discussed
• Clinical features of posterior dislocation elbow • Terrible triad of elbow injury
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62 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
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Chapter 12
0 -UNION LATERAL CONDYLE HUMERUS
WITH CUBITUS VALGUS
Theories Discussed
• Management of lateral condyle fracture • Classification of lateral condyle fracture
• Tardy ulnar nerve palsy • Froment's sign
• Card test • Salter Harris classification
63
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64 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
3. Palpation :
b t der) situated in the lower part of the lateral supra
(a) A _bony mhassh (may e h~nh is not fixed to the skin and can be moved abnormally.
condylar ridge of t e umerus, w ic
(only very slightly) over the underlying bone .
(b) Distal part of the lateral supracondy-
lar ridge may be irregular.
4. Movement : Full extension of the elbow is
often not possible .
5. Measurement :
(a) 3 bony point relationship is changed.
(b) Carrying angle has increased.
(c) Arm length may or maynot increased.
6 . Valgus stress test may be positive.
7. Ulnar nerve : Palsy may be detected by
tests like Card test and Froment's sign
(see fig . 1.12.4-A, 1.12.4-8). Fig. 1.12.2 : Non-union lateral condyle humerus
with cubitus valgus .
N.B. • Motor weakness appears first, sensory deficit comes later. (see page 104).
• Painless abnormal movement is rarely found in this particular non-union. (see page 94)
How will you manage this particular case ?
First investigation : X-ray of elbow - AP view to confirm diagnosis (Fig. 1.12.2).
Operation :
1. Only anterior transposition of ulnar nerve is done (when there are features of tardy uln; r
nerve palsy), if good functional range-of-motion of elbow is present. It is the safest and tr ~
easiest option .
2. Open reduction is considered only when there is a large metaphyseal fragment an I
upward displacement is < 1 cm from joint surface (in X-ray) . Here fragment is never mob,
!ized to realign the articular surface, and only the metaphyseal part is fixed by screw (so
that further increase of deformity does not occur) and bone graft is also given .
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~ - ~ - - ~ - ~ - ~::
N~ N7,
·UNION LAT AAL ONOY HUM AUS WITH CUBITUS VALGUS es
I ,1,, ,1/ '''" ii/, '
I\ 1111 ; / I ,·nt "' '' J ,r 1 ' 1
1111 '
1111,111
ll /un " 1111 / " ,. ,, 111 11/ ta, I , ,111d1 /111 /1 "' 1111, '
.R. • Dlllll 0 11 lu~i,cl~ ,.,y l,llual l'I" ·011el;lc after fl,tlpatron bccau~c the frag me nt is ro tated a lmos t 180°. T he
out rnh\~l and drst,11 -nrn : t point '- a,brtraril taken to he th,· la tera l qnco nd y lc.
on -111111111 of l.u e , .ii ro nd le rare I ma) au . c cubit us a ru · cl ue to hyp r nti a and ove rg ro wth o f th e
lat ·r:il part of ph ys 1 (espc.:ially in Mi/cit T pe II ).
ometimcs the medial arm of the three bony point tria ng l · may be inc rease d clu e t s ublu xa ti o n o f th e
olccran n.
han cs or av:iscular necrosis :aft r surgery ma be minimi . ed with minimal pos te rio r di ssec ti o n a. bl ood
supp l is from 1he rosterior · id· .
• Cubitu: ~:ilgu. dut: to la teral cond le frac ture. is oft en a pron ress ive de formit y clu e to prox im a l mi g rati o n of
fragment 1ogc1hcr with media l c ll n1era l li ga m 111 la ·it y/con . l:l nl . trcrc hing .
• Part . of la1cral cond k : Part of mctap hy is, lati.:ra l part of phy. i. . lateral cpico nd yle. capite llum , lateral cris tac
of tro hi a.
• D ci . ion of : urg.cry is taken when Large metaph ysca l frag ment. di . pl ace ment < I 111 from jo.int. viab le lateral
ond . lar ph •. i. ts1cen in M RI ).
• Fi:h tail def rmi1 : Radiograp hic fi ndi ng in os tco ne ros i. of c:i pil llu m. nus c ubitu . va lg us.
• Opera ti ve : Remova l of th e ulnar n rv from i ts gr ovc in db w - n ·uro l sis ( i r 11 · ·l·ssar ) und :111tni or
tra n pos iti on to th e fl exo r . urfac o r elbow (s ubcu1 a11 ·o us/ i111rantu s ul ar/s ubn1u srn l11r) .
In all operation • medi al intermu scul ar eplum mu st b ' '· ·is d fro m !he coracob rn ·hi ulis mu s ·I •.
E -9
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66 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
. . ,. ·~0 11 or do both ~ides ~imullaneously. R.eq
· f I II • 1ornrtl ~I( IC I 01 .:on11" 111 ' liCM
Froment's sign : Fir t per 01111 t 1c ll'~l on 1 1 ' · the ncl i ·tl border of hand, and you try 10 ·
· r ·1i'r bt v ecn 1hc 1hun1 11 am 1 ' ' pu11
the patient to firml y gra~p a piece o P• 1l: . t . k '111d i n order LO ho ld 0 11 Lo t11e paper, there w·ii
the paper away . In ulnar nerve pa~ I • m1(111 1or 11o lic1s· w ill ic wc.i ·rl · . poll ici s w ill be used .in try ing
. to hold 0
1
be ne ion of th, intcrphal angca l joint (, cc li g 1. 12.4- /\ }. bccau~c cxoi · n
lo the paper. . . <>r do both sides simult aneously. Request the patient
. . 1 11c11111
ard tc t : irst perl orm l11e t '~t on tic
. '·ii side tor companso11
· .
· _
II it away (sec l1g 1.1 2.4-8 ). In ulnar nc
I
to firmly gra~p a card i 11-bt:1wccn the -Ith anc - t 1
sI r ., ·r ·111cl yo11 ll y lO pu
111,,c . . • ·11 l . we·1k ·1dduction of the 5th finger.
rve
~ ·11 b ak ·rnd there w 1 J C ' '
pals . the pahnar intc1To~sci mu · 1e w1 e I c· •
New additions : Type VI - Rin g like rnJury to periph eral port ion o f the ph y i . ( Ran g): Typ <' Vil - Li: lated
injury of the epiph ysea l plate ( Og den): 1) pe VIII - I so lated injury o f t h m et aph y i with po s. ibl c im pai r-
ment o f endoc hondra l o ssifi cati on ; Type IX - Inj ur y o f th e peri o tc um w h i c h may impai r int ram ' tn b r ano u~
oss ifi c atio n.
• Per'.chondral ring of Lacroix : Connects metaphyseal periosteum w ith Perichondral ring of L Cro1
carltlagenous epiphysis, thus stabilizing the epiphysis to the physis. Metaphyse I rt ry
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Chapter 13
EG · ECTED (OR IMPRO ERL Y TREATED)
M TEGG A FRACTURE
Theories Discussed
• McLaughl in's line • Management of Monteggia Fracture
• Monteggia equivalent inJuries • Bado's classification or types
• G. B. Monteggia described an injury pattern in the proximal forearm in 1814 where the upper
third of ulna was fractu red and the radial head was dislocated.
• Bado in 1969 fou nd variety of lesions, where disruption of the radio-humero-ulnar joint is
present. tog eth er with diaphyseal ulnar fracture . He called it Monteggia lesion.
• Clinically, the lesion is often missed, especially the radial head dislocation, due to swelling
of the elbow. spontaneous relocation of radial head, or lack of strong suspicion of the clinician
N.B. : • Fracture of distal radius with subluxation/dislocation of distal radio-ulnar joint is known
as Galeazzi fracture, which is 3 times more common than Monteggia fracture (see page 228).
• In X-ray of elbow , look for an imaginary straight line drawn from the centre of radial
shaft and head, which always passes through the centre of capitulum - irrespective of
any position of elbow, or any view of X-ray. This is McLaughlin's line which can detect,
even subtle subluxation of the radial head.
• Mechanism of injury :
(a) Fall on outstretched and pronated
forearm (commonest).
(b) Hyperextension.
(c) Rarely - direct blow on to the back
of upper forearm .
• In c ongenital radia l head dislocation ,
(which is D/ D) radial head shape is dis-
torted, co mmonly bilateral , posterior
dislocation .
What is your diagnosis ?
This is a case of neglected (if no treatment Fig. 1.13.1 : Neglected Monteggia - Anterio r type.
received) I improperly treated (if treatment re- Note - Ulna is malunited and radial head is dislocated.
ceived), malunited Monteggia fracture of R/ L,
dominant/non-dominant side of .. .. .. months duration, with restriction of elbow and forearm move-
ments, and "bowing" deformity of the ulna, ± pain (when present) in a ..... year old M/F patient,
with (or without) radial nerve pal sy. (Include cubitus valgus if present) .
What are the points in favour of your diagnosis ?
1. History of injury : To right (or left) elbow and forearm ~here ~he mechanis~ of injury was
fall on outstretched and maximally pronated forearm , 1mmed1ately after whi ch there was
severe pain and swelling and inability to move the elbow thro~gh. its full range of moti~n.
2. History of plaster : Immobilization of ...... .. duration (or any other 1nd1genous treat~entXrece1ved
in cases of improperly treated cases) with no subsequent regular follow-up and serial -rays.
67
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68 HANDBOOK FOR ORTHOP ArDICS EXAMINATION
3. on inspection : Typical deformity _whic~ is seen cohmrnonly i. ~f., an csri()r ari9 "&
and undue bony pro minence ante ri orly JUS I be low I e cub, a 1 o sa.
N.B. • There may be some other angulation (c~bitus varus/valgu ) or promin'3 :,e a'1/h ,J & ,.
the type of Monteggia fracture , so de sen be what you see frorn th~ f o ai d ,s , e:.
4 . On palpation : , , .
(a) Tenderness may be prese nt, if th~ fr~ctur~ ha~ n~t tu.lly uni ed. 1:regula / _,.,
ulnar shaft with di stinct c hange in d1rect1on , ind1ca ing angulation (an e, 10 /
lateral) of the ulnar shaft. .
(b) Bony-hard , smooth , rounded , prominence palpated on the ant~rror/la .Brn!IP
aspect of elbow which moves very slightly on atte mpted pronat1on/sup1 a 10
ment ~ probably radial head.
(c) Distal radio ulnar joint (DRUJ) instability - Piano key sign positive may be found (see . 7r ,.
5. Movements : Movements of elbow and forearm are restricted (say exact range of eme ,.
6. Measurements : Forearm may be shortened in compari son to the other forear : e
measured in identical position (anatomical position may not be feasible).
7 . Valgus stress test may be positive. (can cause cubitus valgus) .
8. Test for radial , ulnar and median nerve. (see page 105, 106).
How will you manage this case ?
First confirmation of diagnosis by X-ray of forearm includ ing e lbo w a nd tris , A P a d
lateral view . Then treatment : (1) In adults - excision of rad ia l head with co rre c i e
osteotomy of ulna followed by internal fixation of ulna with plating and a lso bone g a ing
(Boyd's procedure) . (2) In children - if functional range of movement (RO M is good ai
till 14 years . If ROM is bad or age is ~ 13 years , obliq ue osteotomy of ulna (for Ieng he ning .
open reduction of radial head with annular ligament reconstruction , with and finally i n erna
fixation of ulna is don e (sometimes with transcapitelar radial head p in fixation). RI may be
done to note cartilage status and shape of radial head and capitellum - before operation .
How will you treat an acute Monteggia fracture ?
Gentle manipul ation unde r anaesthesia to stably relocate the radial head which is
possible when ulnar length is restored by traction and sup ination , a nd if needed d irect
press~re over ~he radial head . Check X-ray o.r check in image intensifier C-arm m~chine).
If radial head 1s not reduced by closed manipulation 4 then open red ucti on an d in ernal
fixation of ulna , almost always relocates the radial head .
~~
Bado ' Cla s ification or Typ e
I. Type I (60%) Anterior angul ation of ulna ith anterior di loca-
tio n of th e radial head.
I Ll 2. Type JI (20%) Po terior angulation o ulna with po. tenor or po ·
~
Lerolateral dislocation of radial head.
3. Type ffl (I 5%) ~ Lateral angulauon o ulna v. ith lateral or ancerol 1-
eral di. loca tion of the radial head .
4. Type IV (5%) 4 Ant erior angulation ith fracture of b th radiu
111 IV and ulna at ame level. \\ith nten o r di I • th n
of radia l head.
N.B. ~o~plications: Progressive valgus. Tardy ulnar nerve pal M .· .
postenor mterosseous nerve palsy. y. yo 1u o 1fica1ion. Pain/ 11ffn . T
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Section - I
SHORT CASES
Chapter 1
Theories Discussed
• Types of CTEV • Probable causes of idiopathic CTEV
• Causes of acqu ired CTEV • Patho Anatomy of CTEV
• Joints involved in the CTEV deformities • Treatment options of CTEV
• Role of X-Rays/ USG/MRI in CTEV • Pirani Score
• Ponseti technique , • Kite's technique
• Bansahel/Dimeglio Modified French technique • Arthrogryposis multiplex congenita
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2 HANDtaOOl< FOR ORTHOPAEDICS EXAMINATION
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'' \'.'~'
,..Jo. -.!,;;.,\ ,!.........,·. . .... . . . I -· ,
,,j,,. ~, _, ·,I \ ! ,,, , • ( • • •
.. "'. - . ;••,.&. . . . , , , .,,,,.( , ' , , . ., :..·· - ' ~.
I .,
Ca11 1l,t1rt• b,• a11y 11.H ucwted 1•u,c11ltir ""'m"' Y •
Yes. Many patients have hypoplasuc or abscnl an1erio r tibial artery.
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4
HANDBOOK FOR ORTHOPAEDICS EXAMINATION
How can you asses.,· the ,\'l!l'erlly <J( ,, duh.ftJol nm/ dorn111N1t the lr<'nlmt•llf prc>gn:~·s ?
This can be done by Pirani Score, which is ··i mple. ha, high inter-observer and int ra-ob erver reliabi lity,
and is an useful clinica l tool for assessment or unoperated clubfeet less than 2 years of age. Exttmination is
divided into "Look", "FeeJ" and "Move" - separately for the hind fool and midfoot components.
0 Nom1al dorsiflexion
'MOVE' 0.5 0 No medial crease
Foot reaches plantagradc
Rigidity of 'MOVE' 0.5 Mild medaal crease
with knee extended
-
equinus l Fixed equinus Medial I Deep crease
crca.o,e altering contour of foot
I Foot should bt mm~,t ru tht P4mdon of ,na..u,nlllfl cat
rectton ""htn cuse.sn"g tlat mtd,al ,·rta:11I
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CONGENITAL TAU PES EQUINOVARUS (CTEV) 5
Treatmeut
There are numerous lechni ques practised. The " l11temalio11al Clubfoot S tudy Group" has approved 3 melh-
ocls as standardized con crval1\le regimen~ for treating dubl'ool - Po11seti technique, 1Ja11sahcl/Dimeglio Modi-
fied French tech11iq11e aud Kite 's technique.
t{ Pouseti Technique J
The goal is to get a pain free. plantigrade. pliable. flmctiona l, co metica lly acceptab le foot which requ ires
no speciali zed footwear after completio n of treatme nt. Surgica lly treated clubfeet, at adulthood, are more
cosmeti call y acceptable, but are often weak. s tiff. painful and s hows early arthriti c changes. Cons-erv-alive
I!,auageroent by Ponseti regi me is rapid ly becoming the most popul ar technique, both in the developed and
deve lopin g world, givi ng exce lle nt and cons istent long-term res ults. even 30 - 40 years after completion of
trearment. Recurre nce rntes vary from I 0%- JO%, most of which can be successfol ly treated by repeating rhe
procedure.
Pa t110anatomical basis
Histological studies of tinkle and foot ligaments from virgin clubfee1. fetuses and s tillborn babies show abundalll.
young. highly cellular collagen which is "wavy" (Crimps). These crimps allow stretchability. Cnmps reappear in the
strelcbed ligaments after 4 - 5 days. wbicb allows further stretchjng. There are 2 phases of trearmenl - "serial-plaster-
casting" and "mruntenance" up to 4 years of age. This is essential because the genes respons ible for clubfooJ are active
from 12th to 20th week of fetal life, but some ac.ti vi ties persist up to 3-5 years of age. 111e fulcrwn is deemed 10 be the
head of talus.
=
~ ntages of Po11seli technique :
(a) Lesser number of manipulation and ca~ting is required. wluch saves money and time.
(b) Lesser incidence of recurrence and very few require surgery later.
(c) Even when not fu lly correcLed, the foot functions very well for a very long time.
(d) A simple technique. which can be performed by trained physiotherapists. Thus can be useful in remote/nm1f
areas where doctors are scarce.
II Bansahel/ Dimeglio Modified French Techni uc
Daily manipulation by skilled physiotherapist for30 minu1es~ temporary immobilization with adh~ ive ,tr:.1m1ing '4
Continuous Passive Motion (CPM) machine used for mobilization during slt:cp. After 2 - 3 months. manipulation is
done thrice weekly. Strapping is continued till 1he child is ambul.itory. after which Dc1111i:~-Brown 11igltt-spli11t (see
page 196) is worn. Disadvantages are :
l . Nearly 50% require surgery later. Cosil y in 1hc lvng ru11.
2, Require::, daily visll . which may not be feasi ble.
The mothe r should manipulate 6 1ime after each feed/nappy t:han~e. Th1.: force apphi.'d J1'd ~on~l 11011
iiChievcd urc co ntrolled by smct instruction LO stop manipulat ,011 when there 1s hland1111i 111 ,\..111 lo,
o.1bou1 5 - 8 .!>i!!Conds, ur I he baby stan s cry,og
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6 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
Wh<II i.~ tit<· l!Xlc'11f of ,,t,"·rn, t111d in . . OJ., IIH ' /1111•,•1 /1111b ,., ii opplie,I? .
ll'hnf paHtWtl . • .
Fi g. l. l .4a : Cotton wrapped limbs just before ter must be s lit immediately and loosened, lo pre-
plasterin g. Note the extent. vent compartment syndrome.
What nrt• rht· operati1•,, Of)tio11., 11ml at ll'ltid, age ~roup are th ey advisal,/e ?
1. Soft tissue operation :
• 6 - 18 months ~ (Turco opcn.1tion ~ PMR
i.e.. Postero Med ial Release).
• J 8 months - 4 years ~ (CSTR i.e.. Compl ete
Subt-alar Release).
2. Bouy operation :
• 4 - 7 years ~ Di lwyn Evans operation. or
Dwyer's Calcaneal Osteotomy.
• After 12 years ~ Triple arthrodesis.
JESS (Joshi 's External Stabi/izatio11 System) or
Jlizarov technique (see page 24 l) of external fi xator
application ~10d gradual correction of the deformity can
be done in the age group 3 - 8 years. for complete and
sometimes partial correction of the deformity. (set!
fig!. 1.4b)
N.B. : When foot is corrected by any means (i.e .. mother's manipulation or serial plasttring or opera11on).
maintenance of corrected position i~ by -
L Dennis Brown Splil&t : Worn for 24 hours when the child is not walki11g. It 1s U!ied only at njg.bt
wh.en the child is walki ng (see page 196).
2. CTEV Boot/Callipers with i11side iron and outside T- strap ; When the c hi ld 1s walking
(see page 196).
Fur how long t\ thl! ma111tP11a11ce requin·,I ?
Till there is active aud strong el'ersi<Jn + dor,\ iflexio11 t>f foot , and at ·o when the child
lo the age of 6 years).
I\ walking (ne.1rly 0 11
1
Whal happe11.1· Jj tltt1re ; \ "" llt'lt1•1 dt1r1tj/11x 1rm / t•1·i'nio11 tills - 6 v,•ar, (H /wul-g11i11,: ({gc r•
Tendon transfer ope~ation : operatively muscle is transferred lo add pOwl!r cvcnors/do, ">ilk,or, fr.Ill'"
10
ferred muscle 1s usually mvertor and plantar tlexor e.g•• llbiahs p()slcrior.
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CONGENITAL TAU PES EOUINOVARUS (CTEV)
7
U'/"'t 1, C111d11nah int·i-.wu'!
.
Popular incision f'or CSTR/Dilwyn Evans procedur'.
. .
r· I.,
c . , om ,,,~e of I Sl tt1etalarsc1 I 4 b l , .
~ rises to anl,.le Jo1111 posienorly ~ lowe,s to cuboid laterall y. e (m medial tnt1lleolu"
What i, urthro~r~ po,i-; mull iplc, COllJ!t'11i rn '!
It 1!- u non- progressive co ngenital disorder du ., 10 · . ·
. . . .... 11111 uuLenne myodysLropl , .
volv 1ng all 4 limbs . Sk in ts thin and sh•n 1' t1 g w 1·111 f s· 1: h . ,y, most commonly in-
' u 1 orm -s aped JOllll ' 1· I h
movemen. l. [3iop y of' sp111al co rd reve·tls sp·1 ·. b . . :i, w 11c, ave sma ll arcs of
• · , 1se num er ol an tenor horn c II ti
disorgamzed manner. e · m t are arranged in :J
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HANDBOOK FOR 0ATHOP1'l 01r.s cXAMIN/\ l ION
8
hind the lateral malleolus, further stabilizes the
ankle joint while the foot is abducted beneath it,
and avoids any lendency for the poste rior
calcaneofibular ligament to pull the fibula posteri-
orly during manipulation.
• Manipulate the foot: Next, by abducting the foot in
supination along with stabilising the foot by the thumb
over the head of the talus, further abduct the foot as
far as possible without causing discomfort to the in-
fant. Hold the correction with gentle pressure for about
60 seconds, then release. The lateral motion of the
Fig. 1.1.8 ; Foot manipulation navicular and the anterior part of the ca/caneum in-
creases, as the clubfoot deformity gets corrected.
1st 2nd 3rd 4th Full correction should be possible after the fourth or
u
fifth cast. For very stiff feet, more casts may be re-
UAP
quired. The foot is never pronated.
• Second, third and fourth casts: (Fig. 1 .1.9) Dur-
ing this phase of treatment. the adduction and varus
are fully corrected. The distance between the me-
dial malleolus and the tuberosity of the navicular
when palpated with the fingers , tells the degree of
correction of the navicular. When the clubfoot is
Lat
corrected, the distance measures approximately
1.5 to 2 cm and the navicular covers the anterior
surface of the head of the talus.
• Foot appearance after the fourth cast : Full
correction of the cavus, adduction and varus are
usually noted . Equinus improves but when this
correction is not adequate, it necessitates a
tendoachilles tenotomy. In very flexible feet,
Frg. 1.1 .9 : Shapes of serial plaste( casts equinus may be corrected by additional casting
Courtesy : Global Help (www.globaf-help.org) wi th0 ut tenotomy . When in doubt, perform the
tenotomy.
• Steps in cast application : Before each cast fs applied the foot ·s ·
lay~r. of cast padding for effective mouldlng of the foot. Main i i manipulated . A~ply only a thin
position by holding the toes when the cast is bein- a lied ;? th
n e foot at the maximum correcled
1 st
then extend the cast to the upper thigh . The foot sioufci b · r apply the cast below the knee and
!'he "holder's" fingers to provide sufficient space for th ~ held by the toes and plaster wrapped over
plaster. (Fig. 1.1.10) e oes. Do not try to fotce cotrection after
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CONGENITAL TAUPES EOUINOVAAUS {CT£V) 9
• Characteristics of adequate abduction : Conflrm that the foot 1s suf1ic1enlly abducted 10 safely bring
the foot into 15 to 20 degrees of dors1flexion before performing tenotomy. The best sign of sufficient
abduction is the ability to palpate the anterior process of the calcaneum as 11 abducts from beneath the
talus . Abduction of approximale ly 60 ° - 70° in relation 10 the frontal plane of the tibia is possible. Neutral
or slight valgus of os calcis is present (determined by palpating the posteri or os calcis} when abduction
is adequate.
• Tendoachilles tenotomy : Tendoachilles cord tenotomy is performed under local anaesthesia . Per1orm
; the tenotomy approximately 1 cm above the calcaneus . A ''pop" is fell as the lendon ts released. An
additional 10° to 15° of dorsiflexion is usually gained after the teno1omy.
• Post-tenotomy cast : Apply the fifth cast with the foot abducted 60° to 70° with respect to the frontal plane
of the tibia. The foot is never pronated. This cast is kept inlacl for 3 weeks after complete correction. Af1er 3
weeks, the cast is removed. At the completion of casting, the foot appears to be overcorrected into abduc-
tion with respect to the normal foot. which prevents recurrence and does not create a pronated root.
• Bracing protocol : The brace Is applied immediately after the last cast is removed i.e., 3 weeks alter
tenotomy. The brace consists of open toe , high. top and straight-last shoes attached to a bar. For unilat-
eral cases, the brace is set at 75° of external rotation on the clubfool side and 45° of external rotation
on the normal side. [Fig. 1.1.11]
In bilateral cases , it is set at 70° of external rota-
tion on both sides. The bar should be of sufficient
length so that the heels. of the shoes are at shoulder
width + 1". A common error is to prescribe too short a
bar, which may be uncomfortable for the child. A nar-
row brace is a common reason for lack of compliance
and non-compliance is an important cause of relapse.
The bar should be bent 5° to 10° with the convexity
away from the child to hold the feet in dorsifl exion. The
brace should be worn full time (day and night) for the
first 3 months after the tenotomy cast is removed . Al-
ter that, the child should wear the brace for 12 hours at
night and 2 to 4 hours in the middle of the day for a total
of 14 to 16 hours during each 24 hour period. This
protocol continues until the child is 4 years of age.
Occasionally. the child will develop excessive heel val-
gus and external tibial torsion while using lhe brace In
such instances, the external rotation of the shoes on
the bar should be reduced from approximately 70u 10
40°. After putting on the brace , the child returns ac-
cotding to the following schedule (to note relapse/re-
currence).
• 2 weeks (to note compliance issues) Fig. 1 . 1. 11 Brace (ankle 1001 orthos1s}.
Courtesy Global Help {www.gtobat lletp org)
• 3 months (to start the nights-and-naps pro-
tocol)
• Every 4 months until the age of 3 years (for monitoring)
• Every 6 months until the age of 4 years
• Every 1 to 2 years until skeletal maturity
N.B. • The most common cause of relapse ,s non-compl/ance to rhe post-tenotomy bracing p1ogramme
and lower educational fevel of parents
• For recurrence m children > 21/: years or age tibialis ante,,or tendon transfer may be needeo,
which is considered an integral part of the Ponsetl regimen
0 E -2 ----------!!!!!iiiiii:,;!:5'=:~5=:~=:::::::======::::;~::::=:::::=:::J
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Chapter 7
Theories Discussed
• Apley 's 'scratch test • Drop arm test
• Apprehension test for shoulder dislocation • Yergason test
INSPECTION
• Have a fema le attendent for a female patient. Explai n the procedure to the patie nt and
ensure verbal consent.
• Patient should be examined with him/her sitting on a stool , or (if he/she is of very short
height then) in standing positi on sequentially from the front, side , back and above.
• The patient should be exposed from the neck to the finger tips on both the sides , including
the axilla . Both upper limbs should be in the anatomical position or as close as possible to
the anatomical position .
• From the front: Note bilaterally , compare , and comment on
• Skin : Blebs , scars, sinus , discolouration , venous prominence .
• Attitude : May be diagnostic e.g. , shoulder dislocation (Fig. 1.7.1), Erbs palsy, (Fig. 1.7.2) etc.
Fig . 1.7.1 : Attitu de after Shoulder Dislocation . Note Fig. 1 .7.2 Attitude after Erbs palsy
the flattened contour of left shoulder. Pol ice man's t ip!
37
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H Nt I 0 lXAMINAl l N
• ram ti d llo1ci bul _ , ny II ucning/swelling , the sides of the arm , and the
nl , ntr· tur , you may find a groove in the deltoi d .
ov rs the 2nd to 7th rib, with the scapular spine at the
omm nt on th e scapular symmetry (winging of scapula,
pg . I) , supraspinatus and infraspinatus fos~ae, posterior axillary
olio is (I v I of shou lder may become asymmetrical due to scoliosis) .
rom : C 1nm nt on th symm try of the a ngle of acro mion , sup raclavicular and
u I pinntu I
PALPATION
• T mp r tur : omp r th e temperature of both the sho ulders with the back of your fingers .
• r ndernes : Comment on tenderness , as you have noted in bony and soft-tiss ue palpation.
• Bony palpation : St nd behind the patient and start pa lpating bilateraly, systematically in
th following ord r -
upra tern I n t h, sternoclavicular Joint, clavicle, co ra coid process (in adults it lies 2 to
2.5 cm below and just lateral to the point of the deepest concavity of the clavicle . It faces
anterol t rally, is covered by the pectora li s major, and it's tip and medial border is palpable),
acro,nio lavicul r joint. (Request the patie nt to flex [fig . 1.7.3] and extend the shoulder to con-
firm the movement al the joint) , acromion , greater tuberosity (inferior to the lateral edge of the
acromion , separated by a "step-off" or indentation). bicipital groove (anteromedial to the greater
tuberosity palpated best when the arm is externally rotated [Fig . 1.7 .4]. It conta ins the tendon
of the long head of biceps) , scapular spine (palpate posteriorly and medially from the angle of
acrom ion. Medially it loses prominence beca use it is covered by levator scapulae) and the
vertebral border of scapula .
Fig . 1. 7 . 3
Fig . 1 . 7 . 4
• Soft-tissue palpation : Done in passively extended sho u Id er.
• Rotator Cuff: In extended
. . . shoulder th e supraspinatus
· ·
, infraspinatus and teres minor can
be palpated as a unit, Just inferior to the anterior border of th · b b I is
is not palpable . e acrom1on , ut su scapu ar
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BASIC CLINICAL EXAMINATION OF SHOULDER 39
• Axilla : Stand in front of the patient, abduct the arm with on e hand and palpate the axilla
with the index and middle fi~ger of yo.ur other hand . Note the axillary artery pulsation , lymph
node enlargement, any swelling, and finally palpate the walls (anterior wall - pectoralis major,
posterior wall - latissimus dorsi, medial wall - se rratu s anterior , lateral wall - proxima l hu-
meral shaft with the bicipital groove) .
• Muscles : Sternoclei domastoid , pectoralis major, biceps , deltoid , trapezius , rhomboids , latis-
simus dorsi , serratus anterior.
MOVEMENTS
N.B. • Examine flexion , extension , abduction , adduction, external rotation and internal rota-
tion , actively and passively .
• Always examine the normal side first for comparison .
Apley 's "Scratch " test : Quickly evaluates the patients active range of motions.
• Abduction and external rotation : Request the patient to reach behind his head and
touch the supero-medial angle of the opposite sides scapula . (see Fig . 1.7.5)
• Adduction and internal rotation : Request the patient to touch the opposite sides acro-
mion . Next, request the patient to reach behind his back, to try and touch the inferior
ang le of the opposite sides scapula . (see Fig . 1.7.6)
Fig . 1 .7 .6
Fig . 1 .7 . 5
;~~~y
1 1
N.B. • 30 of abduction, 20 occurs in the glenohumeral joint and 10 int.he. scapulothorac1~
• t· (· e 1 ·n 2 . 1 ratio) upto 120°, but in the last 60° maionty of movemen
art1cu 1a 10n ,. ., .
occurs in the scapulothoracic articulation . . . o r which the scapula
0 9
• If the scapula is fixed, ~ure ~lenohumera.l a~~~~~ :/~h:b~~~ e~u~a:~~ches the acromion
begins to rotate). A.t this point~ th~II surtci possible when the humerus is externally
and further abduction to 180 w1 on y e '
... . th acromion from the neck of humerus .
rotated, d1s1mpact1.ng e . of the sea ula i.e., 200-300 anterior to
• Abduction/adduction occurs in the p~:i~~ally the m~vements are tested in the
the coronal plane . However , conve
coronal plane .
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40 HANDBOOK FOR ORTHOPAEDICS EXAM INATION
• Passive Movements
• Abduction : Stand behind the patient and stabilize the scapula by firmly fixing the infe rior
angle of scapula with one hand [Fig . 1.7.7(a)] or pressing down firm ly on top of the_shoulder with
one hand [Fig . 1.7.7(b)], and move the patients arm with your other hand , grasping the fl exed
elbow.
• Adduction : Stand in front of the patient and move the arm across the front of the body.
(see Fig. 1.7.8)
• Flexion (180°) Extension (45°)
Stand behind the patient, stabilize the scapula with one hand and grasp the patients distal
arm just above the elbow. Then swing the arm posteriorly in the sagittal plane to note exten-
sion, (see Fig . 1.7.9) and then anteriorly to note flexion . (see Fig. 1.7.10)
Fig . 1.7.8 Fi g . 1 .7 . 9 F i g . 1 . 7 . 10
• Rotation
1. Rotation in abduction : Request the patient to abduct both shou lders to 90° with the
elbow flexed to 90° and the fingers pointing forward . This is the neutral position. Then request
the patient to move the forearms so that the fingers point towards the ceiling (external rotation
- see Fig. 1.7.11), and towards the floor (i nternal rotation - see Fig. 1.7.12). Internal rotation
can also be noted with the patient's hand on his back (Fig. 1.7 .6).
2 . Rotation in anatomical position : Stand in front of the patient and fix the patients 90"
flexed elbow to the waist with one hand, wh ile grasping the wrist with your other hand. Using
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BAS IC CLIN ICAL EXAM INATIO N OF S
. . HOULDER 41
the forearm as the indicator of the rang e of mot·
. . ion , externally rot t ( .
internally rotate (see Fig. 1.7 .14) Compare with ·th th . a e see Fig. 1.7.13) and th
. . e o er side and c en
externa I ro tation 1s 45 0 - 90° and internal rotation is 550_ 700 omment. Normal range 01
N.B. : Internal rotation can be tested with the pati·e t d ·
· . n s orsum of hand t h"
described at which level the hand is (e.g. sacral/I b /I ouc ing the vertebra and
um ar ower or upper thoracic) see fig . 1.7.6.
F i g . 1 . 7 . 11
F ig. 1 . 7 . 12
F i g . 1.7 . 13 F ig . 1 . 7 . 14
MEASUREMENT
• Linear : Length of the arm (see page 49)
• Circumferrential : Measure the girth of the arm of the pathological side first, at the level ,
where visually there is maximal wasting . Then measure the distance from that level to the angle
of acromion on the pathological side . Finally measure the girth on the normal side , equidistant
from the angle of acromion .
OTHER JOINTS
Cervical spine tendern ess and movem ents should be noted beca use it can be a source of
refer red pain . Test dermatome sen sation (C4 - T 4) also look fo r generalized joint laxity. (see
page 31) which can cause shoulder instabil ity .
D. E. - 6
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42
SP · IAL T T
• Drop
reque st th
abducted o
primarily in th
Fig . 1 .7 . 15 ig . 1 . 7 . 1
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Chapter 8
RAC URE
Theories Discussed
• Clinical features of deltoid contracture • Sanmugasundaram test
• Sprengel 's deformity • Klippel-Fie l-Trenauny syndrome
This is a relatively rare condition which may occur due to post-injection fibrosis of the
deltoid m~scle , an? the most im portant differential diagnosis is of Sprengel's deform ity
(both having prominence of scapula with its medial border rotated upwards , and often
scoliosis and prominence of humeral head anteriorly) . Other causes of deltoid contracture
inclu de idiopathic and familial.
Fig. 1.8.1.A : Deltoid contracture of left should er Fig . 1.8.1.B : Note : Prom inent scapula with medial
showing abnormal prominence of humeral head and border rotated upwards and elbow not touching the
a groove in mid-deltoid area . side of the body.
What is your diagnosis ?
Th is is a case of deltoid contracture of UR side due to post-injection fibrosis in a .... year
old M/ F patient.
What are the points in favour of your diagnosis?
1. History of repeated / multiple injections in deltoid in the past.
2. On inspection :
(a) From front• Elbow not touching the side of body . Arm is (often) internally rotated
and in extension .
• Shoulder is drooping with depressed acromion and there is ab normal promi
nence of the humeral head .
• Wasting / atrophy of muscles around shoulder (especially deltoid) is present.
(b) From side • Sometimes arm is in extension (posterior part of deltoid involved) .
• Depression/groove in the mid -deltoid area (middle part of deltoid involved)
(Fig . 1.8.1.A) .
(c) From back • Prominent scapula with the medial border rotated upw rds (like Sprengel's
deform ity) (Fig . 1.8.1.B) .
• Scol iosis with convexity in the opposite side is seen .
43
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4 XAMINAllON
3 . On palpation :
(a) Cord -like tough tru cture (f It more prominently on adduction of the arm) ,n the del oid.
(b) Acrom1on (oft n) 1s I ngthcn d (d ue to pull of cont racted mu cle fibre ) a compared to
the other side .
(c) Hurn ral he d I v ry pro min ent.
4 . Movements :
(a) Adduction is gross ly reduced . On attempt of adduction , (often) the other deformities be-
come more prominent.
(b) (Som etimes) External rotation of the shoulder is decreased.
(c) All other movements are full range and painl ess.
5. Special test :
Sanmugasundaram test - Ask the patient to touch 2 elbows and the ulnar borders of both
forearms in 90° flexed elbow . In deltoid contracture, this is not possi ble. (Test is false positive
in obese or very muscular individuals).
How will you treat the case ?
Surgical release of the contracted fibres should be done (most commonly intermediate deltoid
fibres; remember to protect the axillary nerve .) followed by physicaltherapy .
Wl,y don r/11• /111111 " ral '1Ntd nppt•a r .rn pro111i11 e11t '!
Due 10 on11n ucd grow th of the hum ra l head in pr sence of fixed length of the contracted deltoid mu\cle fibre~. there i\ partial
anterior :ublu;\a\t on of th" head . Init ia ll y, thi s 1s compe nsat.ed by rotatio11 of the scapula medially wh ich hide!> the dcforrruty (w
to present / show / cxa m1nc 1he case, with both sca pul ae in sy mme tri cal posi ti o n). Later, the ant.erior prominence of lhe
humera l head becomes obvious.
SPRENG EL'S DEFORMITY:
ormall y th scapul a de. cend~ cornpl ett:ly by 3 months after bi rth . Sprengel' deformiry occurs d ue to imperfect capu/ar de cenl.
X-ray : mal l and hig h- up sca pul a. He mi vertc bra, with occa. io nal cervica l rib. In Sp re ngel', deformity, 1rapez1us i
o ft e n abse nt an d leva to r sc apulae + rh o mb o id is re pla ced by omovert ebra/ bar.
Cli11ically : Low hairline, ·hon neck (o fte n webbed), elev at ed s ho uld er, small scapu la, high-up scapula, with cervico-
dor al . coliosis I kyphos is (Fig. 1.8.2). Us uall y full ra nge o f moveme m is pre. e nt . but ometime boulder abduction or
neck move me nt · may he restri cted .
Treatme11t : Mild va ri e ty-> no treatme nt. S urgery, if don e, mu st be wi thin 3 - 6 year Brac hi a! plex us injury is a erious
compli catio n after 6 yea rs.
....--,~-~-,.
'·. :~~~,
' :: ~; :.1111..
,•'4:. •
·.~-. '
. ,, -.l f· '
·-·
·-
..;.~·, . '
I .~,
-.
~-
...
.B. • You may be a k d to demon:trate mu cle po r testing of deltoid and also of serratus anterior, trapezius, rhomboids
KLIPPEL-l<'IEL-TRENAUNY SYNDROME : About 35% of patient al o have associated Sprenger deformity Com-
monly bilat ·ral. Commo n sign of the dt o rde r are a . ho rt neck, low hairline and re tricted mobility ol the upper pine +
\ColioM~. ·ptna bifid a. c k ft pala te. anomalies of the kid ney . Un egmentation of the cervical ertebra I th cau · ·o
fu,cd cr1chra 1~ a lwa ~ seen in X-rays . Treatment i, ymp1oma1ic . Surgery to relieve cervical in tab1h1y . ~o mcuon 1 °
the ~ptnal 1:md 01 to crn rect scolio~i~ may be considered 1f nece ary .
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Chapter 14
Theories Discussed
• Maisonneuve's test • Watson test I Scaphoid shift test
• Bu nnell- Littler test • lntriusic plus deformity
• Grip test • Grind test
INSPECTION
N.B. • The patient should be exposed from the arm , to the wirst and hand.
• Both the upper limbs should be examined side-by-side in exactly similar positions, from
the dorsal , volar , radial and ulnar surfaces (by supinating/pronating the forearms).
• The patient is examined from the front, in standing position , or sitting on a stool, or
in the supine position .
• Attitude/Deformity : Note and comment on "dinner fork" deformity (e.g. Colles' fracture -
see page 79) , abnormal prominence of the ulnar head (e.g. malunited Colles' fracture , Madelung
deformity - see page 84, dislocation of the distal radioulnar joint) , wrist drop (e.g . radial nerve
palsy, see page 105) , claw hand (e.g ., ulnar nerve palsy - see page 104), radial deviation of
hand (e.g. congen ital radial club hand - page 279, Madelung deformity - page 84) , ulnar
deviation of hand (e .g. rheumatoid arthritis) , abnormal lateral prominence of the base of the 1st
metacarpal (e.g. Benett's fracture - see page 232) .
• Swelling/Wasting : Describe any swelling under standard headings (see page 14), which
may be due to joint inflammation (e.g. rheumatoid arthritis) , tenosynovitis (e.g. De Quervain's
disease - see page 171 ), gangl ion (see page 173), small mid-wrist volar swelling (e.g. lunate
dislocation) , swelling over the distal interphalangeal joint (Heberden 's nodule - see page 271 ),
or over the proximal interphalangeal joint (Bouchard 's nodule - see page 271 ).
Note and comment on wasting of the thenar eminence (e.g . median nerve palsy - see page
105, carpal tunnel syndrone - see page 81) the hypothenar eminence (e .g. ulnar nerve palsy
- see page 105), intermetacarpal wasting (e .g. wasting of the lumbricals and the interossei as
in ulnar nerve palsy) , and forearm muscles .
• Scar, sinus, skin condition, ulcer, and venous prominence - Note and comment.
PALPATION
• Temperature : With the dorsum of the fingers of your dominant hand, note and comment
on the comparitive temperature , by palpating first the normal wrist, then the abnormal wrist, then
again the normal wrist, serially from tfhe dor-
sum, volar, radial and ulnar side of the wrists.
• Tenderness : Don't forget to look at the
patient's face while eliciting tenderness . Note
and comment on tenderness of the anatomi-
cal-snuffbox (Fig 1.14.1) (for scaphoid fracture
- see page 229) , the distal ¼ th of the radius
(for Colles' fracture ; Smith's fracture - see
page 82; Barton's fracture - see page 83), Fig. : 1.14.1
69
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70 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
the radial styloid (for chauffeur's fractu re - see page 82), ju st di stal to the radial styloict
over the tendon of abductor poll icis longu s (for DO - see page 171 ) .. th e ulnar stylo id (for
fracture , which is often associated with Colle s' fracture) , any swe lling (e.g. GCT - see
page 88), the wrist joint line (see below) , just di sta l to the joint line , dorsally, in the axis of
the 3rd finger (for lunate dislocation and perilunate dislocation) , the di stal radio-ulnar joint
(found in recent Galeazzi fracture - see page 228 , and often associated with Colles'
fracture) , and the base of the first metacarpal (for Benn ett's fracture - see page 232).
• Styloid relationship : See page 50 and Fig . 1.9.11
• Distal radio-ulnar joint (DRUJ) instabity/subluxation - Piano key sign : With the
forearm pronated hold the distal radius with the trumb and fingers of one hand (to stabilize),
and hold the ulnar head using your other hand (see fig 1.14.2-A). Then try to subluxate the
DRUJ by applying volarly directed force on the ulnar head, with one hand and look for abnormal
mobility (see fig . 1.14.2-B) . For comparison test the opposite wrist in the same way. Note,
compare and comme nt, (also see page 82).
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BASIC CLINICAL EXAMINATION OF THE WRIST 71
• swelling : Palpate and comment on any swelli ng under the standard headings (see page
14 which may be ganglion (see page 173), compound palmar ganglion (see page 173), GCT
),
(see page 88) , tenosynovitis as i~ DO _(see page 171), or synovial thickening as in rh eumatoid
arthritis, thyroid disease, hyper-uncaem,a (gout) etc.
MOVEMENTS
N.B. • Th ere are 2 basic movements at the wrist. (a) palmarflexion / dorsiflexion.
(b) ulnar deviation / radial deviation.
• The neutral or "zero " position of the wrist is where the axis of the 3rd matacarpal is
exactly aligned with the axis and the plane of the forearm.
• Normal range of movement of wrist are : palmar flexion - 80° to 90°, dorsiflexion - 60°
to 70°, radial/ulnar deviation - 20°-30°, supination / pronation - see page 49.
• Dorsiflexion / palmarflexion : Request the patient to approxi mate both the palms in front
of the chest so that both the thenar and hypothenear eminences touch their counterparts (as in
"namaste I namashkar" - see fig 1.14.4-A) . Then request the patient to maintain the palm
contact and simultaneous ly, gradually elevate both the elbows as far as possible . This demon-
strates dorsifl exion (see fig 1.14.4-B) . Note, compare and comment.
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72 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
• Radial/Ulnar deviation : With the patient's elbow flexed to 90°, forearm pronated , grasp the
patient's distal forearm with one hand, and the patients pa.Im (acr~ss t.he metacarp~ls) with Your
opposite hand. Now, ensuring that there is no palmarfle~1on/dors1tlex1on of the wnst, gradually
deviate the hand, first medially (for radial deviation - see fig 1 .14.6-~) and. th en laterally (for ulnar
deviation - see fig 1.14.6-B). Repeat the procedure on the opposite wnS!. Note, compare and
comment.
MEASUREMENTS
• Linear : Length of the forearm - see page 50.
• Circumferencial : This indicates wasting / swelling. Measure the girth of the wrist (at the joint
line) and forearm (at a fixed distance from the lateral epicondyle of humerus - see page 50) at the
level, where there is visually noticeable wasting of the forearm musculature. Note, compare and
comment.
SPECIAL TESTS
t • ~a~son test (Scaph~id. shift test~ tests wrist stability) : Hold the patient'. pronat d hand with
he wnS t rn full ulnar deviation and light exten ion. With your other hand apply dorsally directed
force over
.
the
.
volar
.
aspect
. .
· St ct·ista I to the radius
of w11·· t JU · (scapho1d).
· Now radially deviate and nex
th
e wnS t ~hde mamt~mmg pres ure on the scaphoid. If the caphoid ublu xate. b yond the dorsal rim
of the radws the test 1 po itive· The pa t'1ent may complam · . . 229)
of pam 111 fracture caphoid (see pag ·
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BASIC CLINICAL EXAMINATION OF THE WRIST 73
• Mu de testing : cry i111porta11t 10 test tile inL' •rity of the muscles, •1,p ·cial ly fl exor digitorum
P) 11 , r digit rum sup rlicialis Fl S), n ·xor poll icis J ngus (FPL), .ind ex tensor p lici s
profun du. (FD •
longu. (EPL).
ig. fi g. : L 14.8-13
J. FDP : eat the patient in fron t of a tab le and reque t the pati ent Lo pl ace th e hand fl at on the
table with the palm facing upward .. Now place yo ur 2nd , 3rd an d 4th fin gers of yo ur domin ant
hand , on the index fin ger of th e pati ent, ju. t proximal to th e di stal interph al augea l (DIP) j oint ( ee
fig . 1.14.8- ), so th at th e proxima l interph alangeal (PIP) joint and metacarpophalan gea l ( M C P)
joi nt remai n extended. ow req ue t the pati ent to try and flex the DIP (see fig 1. 14.8- B ) . The ame
procedure i. repeated for all the 8 fin ger (excluding the thumb ) of both hand for compari son. In
FDP weakne / injury, th i would not be possible, because the tendon . lip for each finger inserts onto
the ba e of the di tal phalanx. Painfu l fl ex ion would suggest teno y noviti or H eberden'. node.
E. • 10
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7 '1
p1 on·cl11rr 011 llll' oppw,tll' tl11 1111 h. 111 trnn 0 1 i11 p11 l'd l ·l' l./1\l ' I,, lltr l h- x iu11 I rx lrn o., i 1111 (r •!-.IJL:''I.
" IV ·lyJ
W tll hr i1np:111 L'd . l'. 11111111 ll h) Vl' lll ' tll ~11 / 1 'l'S I~ l(' IH>sy 11o v 11i.,.
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BASIC CLINI CA L EXAMINATION OF THE WRIST 75
• Grip T e ·t : Tl1ert:, ur
,, · le. ts ror the ~rip
_, .
I. Pinch grip : Thi t ts lh Jumbirical a nd the in terossei and needs intact sensation of the pulp f
th thurnb and inde: fing r. Reque. t the patient to pick up a pin, u ing the index and thumb o f one
hand (, ee rig l.1 4. l - ). and then , itb the opposite hand for compari on.
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Chapter 15
Theories Discussed
• Compartme nt synd ro me • Clinical features of VIC
• Volkman 's si gn • Causes of VIC
• Patholog y of VIC • Diagnosis of VIC
• Management of VIC • Potential sites of VIC
• Indic ati ons of fasciotomy • Check Rein deformity
• VIC is the result of vascular insult to deep tissues of the limb producing ischaemia,
primaily of the muscles and secondarily of nerves , as a sequele of compartment syndrome.
• Compartment syndrome is defined as an elevation of interstitial pressure in a closed
osseofascia/ compartment that resu lts in microvascular compromise .
What is your diagnosis ?
This is a case of Volkman 's ischaemic con-
tracture of R/ L forearm which is the dominant
sign (with flexor ± extensor compartment in-
volvement; may also involve the hand) after
... treatment received for supracondylar frac-
ture (sometimes fracture both bone forearm) ,
with (or without) involvement of median/ulnar
nerves and contractures of metacarpopha-
langeal / interphalangeal (MCP/IP) joints, of .. .
Fig. 1.15.1 : Typ ical deformity in VIC of forear m
months duration , in a .... year old M/ F patient.
and hand . What are the points in favour of diagnosis?
1. From history : Patient had an injury
around elbow/forearm for which he/she
was treated with long-arm plaster immo-
bil ization in a flexed elbow, after which the
patient had intense pain (not relieved by
the usual dose of analges ics) . The
pain increased on passive extension
of the fingers. Gradually, the patient de-
veloped numbness of fingers , and subse-
quently the characteristic deformity.
2. On inspection :
(a) Forearm is thin , wasted and (some-
times extensively) scarred .
(b) Typical deform ity of pronated fore -
Fig. 1.15.2 : Vol kman 's si gn .
arm , flexed wris t, extended MCP
Note : Increased flexion of fin gers when wrist is extended.
joints sometimes and flexed IP joints
(i. e., claw ing) (Fig. 1.15.1).
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VOLKMAN'$ ISCHAEMIC CONTRAC UR (VIC)
77
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78 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
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Chapter 16
Theories Discussed
• Deformities in Calles fracture
• Clinical features of Calles fracture
• Comp lication of Calles fracture
• Carpal tunnel syndrome
• Complex Regional Pain Sy nd rome
• Man agement of Calles fracture
• Smith fracture
• Barton 's fracture
• Chauffeur's fracture
• Criterion for acceptability of reduction
Calles fracture was first described by Abraham Calles in 1814, much before X-ray was invented!
It is a transverse fracture of the distal radius, about 2 cm from the distal articular surface
comr:nonly at the _corticocan~e llous j unction , which may sometimes involve fractures of ulna;
st
Yl_oid a~d sometimes have intra-articular involvement of the radiocarpal joint and has the six
typical displacements . '
Typical displacements :
1 . Dorsal shift )
2. Dorsal tilt
3. Lateral shift Noted clearly
4 . Latera l tilt in X-rays
5 . Impaction
6 . Supination (not appreciated in X-rays) .
• It is the most common fracture of the
elderly people (> 60 years) , very common
in women with post-menopausal osteo -
porosis , and almost always occurs with fall
on outstretched hand . To the naked AP view Lat. view
eye , it appears classically as dinner- Fig . 1.16.1 : Collesfracture.
fork deformity when the wrist is viewed from the side (however, it is not always found) .
N.B. • Normally the radial styloid is about 1 cm distal to the ulnar styloid, but in Calles frac-
ture, both the styloids lie almost at the same level. This is an important clinical test.
• Usually there is comminution on the dorsal and lateral aspects of the fracture line,
while the palmar and medial aspects have clear and sharp margins.
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80 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
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MALUNITEO COLLES FRACTURE 81
• Causes of CTS :
C oll s fracture.
A myloid disease.
R aynauds phenomenon.
P regnancy.
A berrant forearm muscles / anatomy.
L ipoma / other tumours in wrist.
Tunnel is smaller in women {Typically the
patient is an elderly, female typist or computer
operator).
Syn ovitis non-specific idiopathic of wrist
(? viral).
Fig . 1.16.3 : Malun ited Colles fracture.
D iabetes .
R heumatoid arthritis.
0 besity .
M yxoedema.
(0) E dema from infection / inflammation.
• Clinical signs/symptoms of CTS :
(a) Burning pain (may be night-cries) over lateral 3 1/ 2 portion of the hand including fingers
(median nerve distribution).
(b) Tinel's sign from wrist area, on median nerve, usually produces tingling.
(c) Phalen's test : Acute wrist flexion for 60 seconds produces tingling at median nerve
distribution.
(d) Durkan 's test direct carpal compression (with thumb) ~ produces tingling pain .
(e) Blood pressure cuff test ~ Shows signs of nerve compression.
(f) Late cases have thenar musculature atrophy.
• Investigations for CTS :
(a) Nerve conduction velocity (NCV) test is diagnostic.
(b) MRI of carpal tunnel gives good visuality of compression.
• Treatment of CTS : Physcialtherapy, Surgical decompression of the carpal tunnel.
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82 HANDBOOK FOR ORTHOPAEDICS EXA I
Treatment options :
1. If functional disability is minimal , physicaltherapy is sufficient.
2 . To improve range of motion and for cosmesis - Darrach 's operation ~ excision of dista:
ulna
W at s the echnique of manipulation for a case of fresh Co/les frac ture ?
First elbow is flexed to relax brachioradialis . T raction and counter-traction across the wrist
is given with the forearm in pronation, which disimpacts the fracture fragments and also
neutralizes the lateral tilt and lateral displacement. Then the distal fragment is pushed volarly
and the wrist is simultaneously brought into palmar and ulnar deviation to complete the reduction.
Final position is pronation, pa/mar 1/exion
and ulnar deviation.
What is Reverse Co/Jes fracture ?
It is also known as Smith fractw where
there is volar tilt of the d i stal rad iu$ with a
garden spade deformity, o r volar
displacement of the hand and distal radius.
Mechanism of injury is a fall onto a flexed
wrist with the forearm supinated. It is a very
unstable fracture often requiring open
Fig. 1.16.5 : Smith fracture . reduction and internal fixation (Fig . 1.16.S).
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MALUNITED COLLES FRACTURE 83
Fig. l. 16.6 : Volar B111ton . Fi g. 1. 16.7: Dorsa l Bart on. F ig. 1.1 6 .8:
• Treatment : Mosl fracture. require open red uctio n and intern al fi xatio n (ORlF) (Fig. J . 16.8). R arely, som e dorsal
Barton' . fracture can be managed conservati vely w ith c losed reduction and pl aster cast immobilizatio n.
Chauffeur's Fracture
• It i an avul ion fracture of the radia l styloid (Fig.
I. 16.9) w ith ligament remaining allached to the
tyloid , which cause. minimal or no displaceme nt.
O ften associa te d with pe rilu na te di s loca ti o n/
scapholunate di s ociation, e tc. due to assoc iated
intercarpal ligamentous injuries.
• M echanism of injury : Compre sion of the sty lo id
against the caphoid, when the wri Li in dorsiflex ion
and ulnar deviation.
• Treatment : Alth ough be low elbow plaste r cas t Fig. I. l 6.9 : Chauffe ur' s fr acture
ex tendin g up to th e metaca rpal head wi th the w ri st uln a r dev iated m ay be suffic ie nt for treatme nt, it often
req uires OR JF .
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Chapter 17
AD LU G DEFORMITY
Theories Discussed
• Aetiology • Patho logy
• Cl inical Featu re s • Management
• Con genital , Madelung deformity presents most commonl y after 10 years of age, and the
deformity increases until the bone growt h stops . It is frequently bilateral , and it is more
common in females than males .
• First descri bed by Malgaigne, later by Madelung .
Aetiology
1. Idiopathic } U II b'I
I t 1
2. Congen ital (Autosomal dominant) sua Y a era
3. Post-trau mat ic } .
. h . Usually unilate ral
4 . D1ap ysea ac 1as1s
1
Pathology
1. Defective inner 113rd radial epiphysis causes more growth of the outer 213rd of radius
distally, causing volar + ulnar angulation of the distal radius , resulting in undue prominenr-e
of the distal ulna and volar subluxation of the hand and carpus (Fig. 1.17.1 ).
2. Forearm is often shortened (in comparison to other side) due to misdirected growth .
AP vie w
Fig . 1.17 .1 : Madelun def . Lat. view
9 orm,ty. Note - Vol ar subluxation of the carpus and hand,
a nd defect in distal and medial radius .
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MADELUNG DEFORMITY 85
It is a case of Madelung deformity of R/L / bilateral wrist , with the typical deformitie (
· / s see
patho logy) , proba bl y congenita 1 post-infective / post-traumatic / or due to diaphyseal acl ·
. .
. as1s,
in a .... .. year old M/F patient.
N.B. • X-ray findings : Radial inclination : 22° -23 °, Radial height : 11 mm - 12 mm, Volar Ti lt : 11 - 1-". Lllnar
variance : 0°.
• Madelung deformity may be associated with : Dyschondroplasia, achondroplasia. Turm:r·~ : . mlromc..
Mucopolysacchoroidosis, Multiple epiphyseal dysplasia.
• Radiolunate Vicker's ligament causing tethering at medial part of piphysi · mu be I aus, of gro lh
disturbance, leading to Madelung deformity .
• Surgery will be ·needed for functional disability and chroni c persisling puin.
(i) For skeletally immature -Milch recession osteotomy; E, cisiou of Yickcr'1- ligum nt + piph · iol :-.b
· ) u· I •1 llll ost otom ' of
(11..) For skeletally mature - Darrach 's oeteotomy (di. lal ulnar rei.ett1on ; nip :mar.,,
di stal radial metaphysis ± Darroch 's oeteotomy + exc1· 100
· o cv·1 k·er · s r1gam n1
• Parents must be counselled that the range of movements nev r impro . er :-.ignillc,mtl • nnd d •lm11111i '
may recur ~ after any procedure.
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Chapter 18
OSTEOSARCOMA
Theories Discussed
• Management of osteosarcoma
• Clinical features of osteosarcoma
• Usually , osteosarcoma cases have lesi ons in di stal femur , proximal tibia , or proximal
humerus, although infrequently it can occur in the scapula, ilium , ulna, radius , etc.
• It is the most common primary mal ignant bone tumour of non-haemopoetic origin.
Overall, it is the 2nd most common primary malignant bone tumour. (1st is mul-
tiple myeloma which has haemopoetic origin).
What is your diagnosis ?
This is a case of osteosarcoma of R/L, proximal/distal , tibia/femur humerus , with (or without)
(a) Patholog ical fracture (rare). (see page 246).
(b) Distal neurovascular deficit (mention specific nerve inyolvement if diagnosed).
(c) Probable lung metastasis (search for chest symptoms/signs).
(d) Adjacent joint effusion ± decrease in the range of movement in a ..... . year old male /
female patient.
N.B.:
• Pre-operative chemotherapy - targeted at mi cro-
metastasis that has a lre ady occurred - e.R., in
lungs . Patient is followed up at 6 -8 weekly inter-
vals with recording of body weight, Hb %, Alk.
PO., local X-ray and CXR (CT if possible), a nd
inspection of the a mputati o n tump .
• Histological picture - tumour cell s s urrounded. by
osteotid matrix is characteristic. Cells are mainly
spindle-shaped with hyperchromatic nuclei.
• Nnat11ral history, if left untreated - Fig. 1.18.4 : Clinical photo of proxim_al tibial osteosarcoma.
Lung meta ta is ~ IO to 12 months. Nole _ Shiny kin with venous prominence.
Deterioration. death ~ by 2 years.
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Chap 19
eories Discussed
• Clinical features of GCT • Management of GCT
• Giant-cells • Aneurismal bone cyst
GCT is a tumour of uncertain origin , with variable growth potential. It is benign, bu local!
aggressive, and has a tendency for local recurrence . (Abou t 1% case is believed to be primaril:
maHgnant) . Usually GCT cases have lesions in distal femur, proxima l tibia an d dis tal radius
although it may affect almost any bone. What is your diagnosis ? '
This is a case of giant cell tumour of R / L
proximal / distal, tibia / femur / rad ius, wit '
(or without)
1. Pathological frac ture. (See page 246)
2 . Dis tal neurovascu lar deficit.
3 . Adjacen t jo int effu si on .
Fig . 1 .19.1 : Cl inical photograph of distal radial N.B. • Joint effusion is more common in
swelling . GCT than in osteosarcoma.
• Mention only the positive findings.
4 . Decreased range of movement in a
... ...... . year old male / female patient.
What are the points in fa vour of your diag-
nosis ?
1 . Age : 20- 40 year s . Commonly seen
after the closure of growth plate.
2. Sex : Female s have slightly higher
pre-do inance (M : F = 1 : 1.5). .
3. Site : Most common distal femur ...., pr~xi·
Fig. 1.1 9.2 : Proximal tib ial swell ing around knee
mal tibia (Fig . 1 .19 .2) -, distal radius
(F ig . 1.19 .1) .
4 . History:
(a) Slow growing tumour, long duration of swelling (> 4 to 6 months). ·n in a
(b) Common.l y swelling at ~irst, later appe~ra'!ce of pain (s_udden onset of P;;;gnant
progressively slow growing tumour may indicate patholog,cal fracture or m
tra'!sformation) . the 1esion
(c) Patient may give previous history of trauma , which is usually unrelated to
and only serves to draw the attention of the patients.
5. Examination : surfaced,
h
(a) Bony hard (or firm). eccentrically located swelling , slightly warm , smool malignant
skin over swelling is free . Soft tissue and ski n may be involved when
transformation has occurred . . . t d ainlY due to
0
(b) Adjacent joint effusion may be pre se nt. Joint movement 1s restnc ' m
mechanical obstruction .
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G IANT CELL TUMOUR (0STEOCLASTOMA)
89
(c) Skin may be shiny with veno u s
prom inence (especia lly wit h ma lig -
nant transformation) .
(d) "Cracked egg shell" may be rare ly
felt on palpation but it should never
be tried , because it causes cort ical
break, and may lead to rap id growth .
(e) Distal neurovascular deficit, if present,
may be due to compression , or some-
ti mes due to mal ignant change .
Why is it called osteoclastoma or
osteoclastoma alba ?
Previously, it was thought that the cells of
orig in were osteoclasts . Hence the name.
Alba = White ~ denotes hyp ovascularity .
How will you investigate this case ?
1 . X-ray of local part -
AP view , Lateral vi ew .
2 . Biopsy is a mu st and diagnostic -
(i) FNAC : In expert hands .
(ii) Open - More useful , sensitive, specific.
3 . CT Scan is used to note cortical integ-
ri ty , recurrence ,
4 . MRI intraosseous and soft tissue spread
How wo uld you treat the case ?
A. If on histology the tumour is benign
and the cortex intact then ~ thorough Fig. 1 .19 .3 : GCT of d istal radius .
curettage ~ 5 % phenol + 70 % alcohol Not e - Ecce nt ric , ex pa ns ile , epiphys io -metaphy-
sea l , osteol ytic les io n w ith sharp demarcation of
appl icat ion ~ bone cementing . If small ma rg in a nd soa p-bubble appearance .
le si on , thorough curettage may be fol -
lowed up with bone grafting.
N.B. • Curettage + bone graft, had high
rate of recurrence (upto 50%). Ad-
equate meticulous curettage
(using power burr) and cortical
window as large as lesion re-
duces recurrence (15%) .
• Bone cement has the added advan-
tage of exothermic reaction . When
the cement " sets ", it gives off
heat , which kills remnants of tu -
mour cells .
B. If on histology , malignancy is s~g-
Fig . 1 _1 g.4; GCT of proximal tibia .
gested or the cortex is broken th8 ~ wide Note - Eccentric , expansile . epiphys10-metaphy eal ,
local excision of the whole tumour, includ- osteolytic les ion extending up to subcondral bone
ing its co veri ng, is done followed by re- and soap-bubble appea ran ce .
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90 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
Fig. 1 .19 .5 : GCT of distal tibia . Fig . 1.19.6: GCT of proximal fibu la.
Note - Expansile , eccentri c , osteo lytic lesion .
1. For distal radius , ipsilateral pro ximal fi bula is used for reconstructi on.
2. Fo r tumours around knee , fo r young active patients arthrodes is may be done , when
joint is involved . If joint is not involved curettage and bone grafting is done and regular
foll ow up is requi red to detect recurrence .
3. Custom-made prosthesis may also be used.
N.B. • Malignant GCT has pulmonary metastasis in 3% cases (mortality 1.5%) wh ich is de-
tected by CT Scan and surgery is the prefered treatment option for th is lesion .
Are giant elh excf1Hi~·cly for111d only i11 t/11, t11111111ir :'
No. Giant ' ll ar fo und in many bone tumour. or
tumour- lik nditi n - all ha e o. t olyti c le ion .
F ibrou dy 1 la ia
on- ~. i f in o fi.br ma
0 l iti ' ri br u
U nica m ra t bon cy t
hondrom y oid fibrom a, chondrobla wma
H YP rparathyroidi m.
Fig . 1. 19.7 : GCT Di tal Radiu with co rti ca l break but
with di stin ct demarca tion of tumour and normal bone N.B. • M nemonic : FAN-OUCH
ti sue - probably beni gn.
, r rar1"1il' 1 t1/
· t i., IIth e..diflere11ce between 111111ouro1n giant cell\ anrl <>ti, r g1a111
What . II ., , J J
c,• , . r ,a/ ure t ,e o1,1e
ce ,. :
g ta11
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GIANT CELL TUMOUR (OSTEOCLASTOMA) 91
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Chapter 20
EXOSTOSIS
Theories Discussed
• Aetio-pathogenesis of exostosis • Clinical features/complications of exostosis
• Management of exostosis • Trevor disease
It is the most common benign bone tumour (some consider this to be a hamartoma).
What is your diagnosis?
This is a case of :
1. Multiple exostosis (may be single).
2. R/ L lower± upper limb (pelvis , scapula
may also be involved) .
3 . ± Deform iti es ( e.g ., genu valgurn /
varum , ankle valgus / varus , dorso-lat-
eral bow in g of radius , ulnar deviation
of wrist , etc .) .
4. ± Shorten ing of limbs .
Fig . 1.20 .1 : Pedunculated exostosis of supracondylar 5.± Neurovascu lar deficit (paresthesia,
reg ion of femu r. Note - It is pointing upwards to-
wards diaphys is from metaphyseal region . motor weakness) .
6. In a ..... ye ar old male/ female patient.
What are the other names of exostos ,s?
1. O steochondroma (us ually sessile variety) .
2 . Diap hyseal ac las is (m isnomer) , heredi·
tary multiple exos tos is , metaphyseal aclasis.
3 . Cartilage ca pped ex ostos is (usua lly pe·
duncul led variety .
What i th th ory of gene s (how does it
for, 1) ?
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XOSTOSIS 93
May be malignancy. fr clur of the b e of growth. bursiti s o·f the ov rlying burs and direct
impingement on nerves.
What are I e ,n ,c n of oper tion 1.c. EXCIS/ONAL BIOPSY ?
1. suspicion of malignancy due to : Sudden rapid increase in size/growth of tumour; Growth
continuing/restarting after skeletal maturity i.e., when longitudinal growth has stopped; Sudden ap-
pearance of pain in previ ously pain less swelling (must be differe ntiated from bursitis) ; Skin
changes - venous prominence , warm tender swelling ; X-ray - stippled calcification ; MRI -
cartilage cap > 1 .5 cm .
2 . Jeopardizing normal function or activities of daily living (AOL) :
• Mechanical obstruction to the range of motion ( e.g. , posterior femoral growth impedes knee
flexion - see fig. 1.20.2).
• Compressive manifestations causing neurovascular deficit (e.g., foot drop in proximal fibular
exostosis compressing the peroneal nerve) .
• Radial head dislocation , if present must be relocated . Patellar subluxation due to genu
valgum necessitates operation .
3. Cosmetic : To correct deformities like bowing by appropriate corrective osteotomies.
4. If single exostosis : May be excised.
Why is the actual size (estimated clinically) always more than the radiological size?
Because the cartilage cap is not seen in X-ray and clinical assessment of size includes the
cartilage cap and also the overlying bursa .
What is the chance of ma lignancy? What malignancy?
About 1% chance of Chondrosarcoma, rarely osteosarcoma. histiocytoma. In hereditary mul-
tiple exostosis chance of malignancy is about 5-15%.
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Chapter 21
10
Theories Discussed
• Definition of non -union • Causes of non-union
• Types of non-union • Clinical features of non-union
• Management of non-union • Holstein -Le wis fracture
• Stages of fracture union • Wolff's law
Non-union of a fracture is a state in wh ich all healing processes have ceased as judged by
clinical and radiological evidence , beyond the stipulated optimum time for healing , for that par-
ticular bone , site of fracture , type of fracture and age .
Definition of FDA panel (1986)
A fracture is said to be non-un ited , when
at least 9 months have passed since injury
and the last 3 months have elapsed without
progress in heal ing, cl inically and radiologically.
N.B. • Exception - for fracture of neck
femur ~ termed non-union after 3
months from inju ry (not 9 months-
see page 142) , and Flynn 's crite-
rion for lateral condyle humerus (see
page 65) .
Causes of non-union
• Distraction (especially by grav ity or
Fig. 1.21.1 : Hypervascular non-union of distal tibia .
excessive traction ).
Note - Broadened fracture ends. • Infection , inadequate fixation , ill-advised
operation , insufficient immobilization .
• Segmental fractures , soft-tissue interposition.
• Comminuted fractures.
• Open fractures.
N.B. • Mnemonic: DISCO d'
1
Special causes for tibia non-union (in ad •
tion to above)
• Delay in weight-bearing, distal third fracture.
• Intact fibula . (Controversial)
• Soft-tissue severe damage.
N.B. • Mnemonic : DIS
Fig. 1.21 .2 : Ava scu lar non -union humeral shaft . General factors
Note - Sclerosed , atrophied fracture ends. . radiation.
M • • Old age , malnutrition , steroids
•
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NON-UNION 95
W/"I
It is a case of non-_union_of upper/ middle / lower third , shaft of ........... (name of bone), probably
due to ........... (1nfect1on, d1stract1on , etc.) ± distal neuro-vascular defi cit, in a ... ..... . year old patient.
N.B. • If suffi.ci~nt time sine~ injury ha~ not p~ssed , and/ or there is tenderness at the fracture
site, 1t 1s better t? give ~ou r ~1agnos1s as delayed union (not non-union).
• If open wound/ discharging sinus, or other signs of infection are present diagnosis of
infected non-union shou ld be given. '
• Infection, open fractures , improper fixation / inadequate immobilization are among the
most common causes of non-union.
ha ti he o nts in fa vour of your diagnosis ?
1. History of trauma, .. ..... months back , after which .... treatment received for .... period .
2. Abnormal attitude/position of limb + visible deformity (describe) .
3. No tenderness or muscle spasm .
4. Painless abnorma l movement, in 2 planes , at the fracture site (very important) .
s. Palpable gap or discontinuity in the bone (on palpation) .
6. Lack of transmitted movement from one end to other, with passive manipulation .
7. Signs of open fracture / infection / operation --, scar, sinus , soft-tissue loss , etc.
8. Wasting of muscles (disuse atrophy).
9. Distal neurological status and vascular status.
1o. End of fractured bones are irregular on palpation .
11. Length of limb is decreased (may be increased if there is distraction).
N.B. • The movements at the adjacent joints are often stiff. While examining the movements "of
the distal joint, firmly fix the distal fragment of the fracture to avoid "trick movements .
How will you manage the case ?
First investigation ~ X-rays to confirm diagnosis and determi~e whether the non-union is hy-
pertrophic or atrophic variety, and also assess the state of healing.
Treatment principles .
1 A I . Open reduction ~ freshening of fracture ends ~ removal of fibrous + ~~ar
. vascu ar . . f r t s iliac
tissues ~ opening the medullary canal. Then stable interna 1 1xa 10n + au ogenou
2. cHrest cance,llousobol
ypervascu ar : n ynestag~!f~ii:~tion , after freshening the fracture ends, can give good results.
amic com ress ion pl ate (DCP) (see page 2 12), interlocking nail .
• Fixation
(see page devices commo nly used are dylnt·
. ,
l p ed in cases of bone loss / short eni ng, concomitant
239) a n d II izarov s externa
. .ixa 1or u 1)]. '
24
other deformities, infected non -union , etc ( ee page . h b · in PTB plas ter
• Functional cast Bracing (seepage 223 ),. For tibia ' fibulotom y follow ed by we 1g t - earn10o
cast ac hi eves uni o n.
Prerequisites of PTB (Patellar tendon bearing)
Plaster treatment - ~
• Skin below th e knee should be intact.
• Angulation not more than 10° , les. er the better.
• Contact at fracture ends greater than 70%.
• Evidence of ca llu see n in X-ray .
• Fibu la should not be unit ed or intact. - ated
. . . • I d , e nt all y mo 1iv
• Pati ent 1s phy sicall y capab e an n de spite pai n. . . .
t
to tart walkin g with th e PTB pl aS er, . ff ture of th e j un ction of middle-t hird a nd
· d with fracture)
• Often radi a l nerv e pal sy is a soc1~t~Lewis °
non-u111onwhereracth e nerve i· t,·apped with in th e fractur . ""
!owcr-third shaft hum~ru (1_1°~:ei~CV to be done after 3 week ·
it co mes out o f th e . p1ral gioo ·
(3) Callus formation (Soft callus) : The new cell are ost~ogeni c and chond roge~ic, and there are also
osteocl a ts. Thi s den se ce llu lar ma with its patches of 1mmatu~e bone and cartil age form s th e callus
whi ch is both periostea l and endo tea l. Then minera li za ti on be~ms, and gradu all y the callus becomes
harder and tro nge r, whi ch prevents movements at the fra cture site. Transfor mmg growth factor (TGF-
~), bone morphogenic protein s (BMP) and fibrob las t growt h fac tor (FGF) enh ances thi s proces.
(4) C Onsolidation (Hard callus) : Osteo blastic and osteoclas ti c ac ti vities continue in tandem to gradually
transform the woven bone into lamellar bone which ensures solidity and strength of the callus. Usually
this takes months to rigidly bridge the fractured bone ends.
(5) Remodelling (Modelling) : By continuous and simultaneous bone resorpti on and form ation, gradually
the medu ll ary cavitie are fo rm ed and rejoined at the fr actured ends, together with removal of outward
exten ion of ca llu s. Greater capac ity of remodellin g is when more growth potenti al is left (children).
when ite is nearer to joint, angulation/tilt is in the pl ane of primary movement of the joint .
N .B. • Callus is formed in response to movement, (rigidly internally fix ed fra ctures show poor callus), which
serves to stabilize the fractured fragment s. It grows stronger where the load/ stress is more, according
to Wolff's law, which states that the mass and architecture of bone always adjusts to the prevailing
forces which are acting on the bone. It means stronger / thicker bone develops in those areas of the
bone where there is maximum load / stress, but di suse, non-weight bearin g, weightlessne s will pro·
duce poor quality bones .
• Marke~ of bone format!on - serum alkaline phospatase, osteocalcin . Marker of bone resorption - serum
and unne N - telopepttde, C - telopeptide, Urine hydroxy proline, Deoxy pyridinoline.
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Chapte r 22
0 IC 0 EOMY LITI
Theories Discussed
• Clin ical features of osteomyelilis • Sequestrum
• Aetiopathogenesis of osteomyelitis • Management of osteomyelitis
• Complications of osteomye litis • To m Smith Arthriti s
• Brodie's Abscess • Garre's osteomyelitis
Long persisting infection of bone, along with absence of any systemic symptoms, pre-
senting commonly with discharging sinus/sinuses is chronic osteomyelitis.
Aetiology
1. Sequele of acute osteomyelitis .
2. Sequele of open fractures .
3. Sequele of operative procedures usually
with internal fixation .
4. Chronicity inherent of the infective organ -
ism e.g., fungal infection s, tuberculosis .
What is your diagnosis ?
It is a case of chronic pyogenic osteomyeli-
tis , affectin g proximal / distal part of femur /
tibia / fibu la, etc ., of R/L side , of ....... weeks
duration , as a sequele of acute osteomyelitis
/ open fractures/ post-operative infection , etc. ;
with (or without) decreased range of move-
ment of adjoin ing joints , with (or ~ithout) ~n -
gular deformity of thigh/ leg , etc ., with (or ~1th -
out) shortening / lengthening of leg/ thigh /
arm, etc ., with (or without) pathological fra~-
tu re , without (or with) distal neurovascular defi-
cit in ... .. . year old M / F patient. . . Fig . 1 .2 2.1 : Chronic, osteomyelitl of ti~i with
7
N.B. • Mention only the positive findings . se vere destru ction/ loss ot d1 phy is.
. f your diagnosis ?
What are the points ,n favour 0
A. History :
1. Past history of trivial traun:ia I open
fracture/ operative intervention , raised b~dy
temperature or fever , with pain and swelling
of the local part. h. h
· · W IC
2. Emergence of discharging sinus,
·is sometimes quiescent and some t'im es flares
up, i.e., waxing-waning pattern of sym~toms.
. . e of bone chip s or si nus howlnq proullng i , nu
. 3. History of d1scharg " _ 'k " mate- Fig . 1.22.2 : ~Isch rgln.g I prox1rn I t.ibi I m t ,pt1ys1,
spicules (fish-bone like) or chalk II e lation tissue in th rog1on o
na1 (pathognomonic).
97
· 13
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98 HANDBOOK FOR ORTHOPAEDICS EXAMINATIO N
B. Inspection :
1 . Deform ity (if present) . describe.
2. Sinus - (a) Site
(b) Num ber .
(c) Opening _ Usually has sprouting granu lation tissue (indicates pre sence of se.
questrum or fo reign body) .
(d) Floor. margins
(e) Sk in condition around sinus opening - puckered, shiny , loss of hair , hypo
1
hyperpigmented , excoriation , etc.
(f) Discharge - purulent, serosanguine ous seropurulent, etc .
3. Scars of other healed sinus / previous operation(s) .
4. Swell ing / wasting of adjoining soft tissues .
N.B . • Tubercular chronic sinus has wide opening with thin , bluish and undermined
margins.
• Mention only positive findings .
D. Movement of joints above I below- Range of movement is usually decreased and often the
joints are stiff.
E. Measurements - Shortening {30% of cases) or lengthening (5 % of cases) of affected part
may occur. (65% cases have no limb length discrepancy) .
F. Regional lymph nodes - Enlarged , mildly tender, discrete in pyogenic but matted, elas·
tic to firm in consistency in TB .
G. Signs of pathological fracture (if present) - Tenderness , abnormal movement at frac·
ture site , absence of transmitted movements, etc .
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CHRONIC OSTEOMYELITIS 99
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100 HANDBOOK FOR ORTHOPA DIC EXAMINAT IO N
3 _ Thin wa lled , primitive, nasce nt vess els in betwe~ n trabecul ae of degenerating cartilage
cell s -"7 all ows easy outward passage of bacte ri a.
Once extravas cular , the organisms easi ly proliferate in a ver~table culture -broth con-
4 · ta ining blood and degenerati ng cells . Trivial trauma may contribute to the haematoma.
5. Lack of active phagocytosis in metaphysis (Hobo - 1924) .
• For detectin g infection after implant urgery most sen iti ve le I are IL- 6>CRP> R. Pro alcitonin au d
TNF o. are th e most specific in ve ti gati on. .
• The grow th plat e (phys i ) acts as a barri er to prea d of infe Li on from metaphysis to piphY J>·
0 s Ieomye t'll1· S Iea ct ·mg to septic
· art I1r1t1 ·s thu een < 2 year. (du e to tran s-phy. ea ! vasculature) and adu lh. d<00
· ·s 1 .
h · ) S · th · · I
p y 1s . ept1c ar ritt s ca n a so occur 111 · joint. where th e ph ysis is intraarti ular e.g., Hip .. hou Ider · r,i ,a1
head, di stal fibul a.
. .
• Mo t co mmon orga111 m I staphylococc us a11reu . Mo l co mmo n other ': group 8 streptoco
ccus '.! ..l
,I'. . • Ill ..-1111 I11
weeks ; H. JnJlu enza 111 age gro up 6 month s to 4 year ; pseudomonas in drug addict ·Jungol o,kO
pati en ts on parent era l th erapy; staph.epidermidis aft er i rnplant surgery .
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.i·t,r t are tlte ( 0111plrct1 1011, of, hro111c <1 1,· 0111 )' , 1,1" ? N.U. • Mncmoni : A PAGE
1
1. , ngular d1.:for1111til of long boni.::-, a ru ~/va lg u:-- c.lue lo p,1rt1 a l arfc.:c ti o n o l g row1·h pl ate.:.
2. P athologi al fractu1l':-- (\l'l' pugc _..J(i)
3. , myloic.l d,sca,es .
. . 111 g (30%), lcn ,t11enin g (5· %) '·111 cl tinch ·,in g ·c11 ·1m b 1cnglh (65%)
4. , rowth intc, ferlllCl' : Shortrn
5. I~p1thcl1 onrn (111al1g1rnn ·yo! sinus tract, ~k in) . ·
(b)
(d)
(c)
Fi g. 1. 22.6 Con servative treatment follow -up in a child - (a) Chronic o teo myeliti s of di stal tibia ;
(b) Small sequestrum ; (c) Gradually resorption ; (cf) Almo. t totally resorped.
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XA IN ION
102 HAND OOK f on f iH
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CHRONIC OSTEOMYELITIS 103
Salmonella infection; as a sequelae of open fractures; after diaphyseal implant surgery; long
standi ng sup eriorly located metaphyseal osteomyelitis .
What is the classification of chronic osteomyelitis?
Cierny-Mader staging syste m for chronic osteomyelitis is based on physiological and ana-
tomical criteria , to determi ne the stage of infection . It is helpful in determining if treatment
should be simple or complex , curative or palliative , and limb sparing or ablative .
ANATOMICAL TYPE (Fig. 1.22.9)
Ill : Localized - Well-dema rcated lesion. Full-thickness cortical sequestration and cavita-
tion . Complete debridement would not cause instability .
IV : Diffuse - Features of I, II , Ill + mechanical instability, either at presentation or after
appropriate treatment, and requires complex reconstruction.
- ~- S ---,-.f'C-:.=
~--~- c-,#.--,._
PHYSIOLOGICAL CLASS
A ·. Normal - lmmunocompe t e nt . Normal response to infection
. and surgery
..
B : Compromised - Local or sys temic immunocomprom1sed. Def1c1ent would healing
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Chapter 23
PH RA N AVE INJURIES - CLAW HAND,
W 1ST DROP AND FOOT DROP
Theories Discussed
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PERIPH£- RAL N
• Ulnar paradox When injury is proxlm I to th lbow, I. •, hlgh ..up le Ion, th Ion fl ex r
slips to the 4th and S~h fing ers, (flexor digi_torum pr~fundu ) whl h r I paraly . So
clawing is not so prominent, because th0r 1s no fl x1on of th 4th n 5 h fin g r , lthou h
there is ulnar nerve injury. This is the paradox. ·
11
• Pathology of clawing : The "intrinsic muscles of hand (lnterossel and /umbr/ca/s) prima-
rily flex the MCP joint and extend the IP joints. Paralysis of the intrinsic muscles causes just
the opposite, due to the unopposed pu ll of the antagonist muscl s that produces extension of
MCP and flexion of IP joints, which is clawing. This is also because the fingers cannot be
extended by the long extensor muscles, which requires stabilization of the MCP joint
Autonomous zone : Ulnar nerve - Tip of the 5th finger; Median nerve - Tip of the index finger.
Clinical features of ulnar nerve lesions
• Low lesions (Forearm) : (1) Wasting of the hypothenar eminence ; (2) Clawing of the 4th
and 5th fingers ; (3) Froment's sign positive (see page 66). Because of add uctor pollicis
paral ysis, the_yatient substitutes the functi on of adductor pol li cis wi th flex or pollicis ; (4)
Card test pos1t1ve (see page 66) Because of palmar intero ssei paralysis - no fin ger adduction is
possible; (5) Autonomous zone - Hypoesthesi a of the tip of 5th fin ge r.
• High lesions (Arm) (Ulnar paradox) : (1)
Flexor carpi ulnaris is paralysed, so wrist de-
viates laterally (radially) whe n actively flexed
(palpate the muscle when doing this test.) ; (2)
No appreciable clawing; (3) Rest, as in low
lesions of ulnar nerve.
Clinical features of median nerve injury
• Low lesions ( Wrist) : ( 1) Thenar promi-
nence wasting ; (2) Pen test positive (see
page 51); (3) Nail sign (see page 51 ); (4)
Hypoesthesia of lateral 3 1/ 2 fingers , especially
at the autonomous zone. Fig . 1.23.4 : Dupuytren's contracture of little finger.
• High lesions (Elbow) : {1) Ochsner's pointing index sign positive (see page 51 ); (2)
Flexion of the IP joint of thumb is not possible due to paralysis of the flexor pollicis longus (see
page 73, Fig . 1.14.10-A); (3) Rest, as in low lesions.
N.B. • If you get a case of clawed hand, you might confuse it with Dupuytren's contracture or VIC.
DUPUYTREN 'S CONTRACTURE
• It is proliferative fibroplasia of the pa/mar aponeurosis (also affects plantar fascia in 5% cases).
• M : F = 1O : 1; Autosomal dominant hereditary trait. Associated with : Prolonged phenytoin
herapy , alcoholic cirrhosis of liver, diabetes , pulmonary TB, and AIDS.
• Most commonly affects the ring finger, 2nd common is the little finger. (Fig . 1.23.4)
• Clinically : Flexion of both MCP and IP joints. Thickened dorsal knuckle pads ~ Garrot's
Pads. (Note : In clawed hand there is extension of the MCP and flexion of the IP joint) .
• Treatment : Radiotherapy is helpful in very early cases . Operation - Fasciectomy with
0st -operative splinttage / For severe cases - Resection + Arthrodesis.
• Prognosis : Guarded . High recurrence rate .
WRIST DROP
• Commonest peripheral nerve to be injured is the radial nerve.
• Wrist drop means inability to extend the wrist (and MCP joints, and thumb) "actively" .
• Chances of recovery is highest for radial nerve injury because it is predominantly a motor
nerve, it does not control fi ne movements of the hand , and it has a large diameter.
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106 HANDBOOK FOR ORTHOPA.:E:_
D_:_:
IC:_:S:__
E~XA
~M~ IN_A_T~IO
_N_ ~ - - - - ~ ~ - - ~ -- ~ -
Autonomous zone : Deep peroneal nerve - 1st dorsal web space; Tibial nerve - Sole of the toot.
• Clinically :
1. Low lesions -
. . t (bY tne
(a) Deep peroneal nerve mJury : No dorsiflexion, no 1nvers1on. But can evert too
peroneus longus and brevis) .
(b) Superficial peroneal nerve injury : No eversion but can dorsitlex / invert toot.
2 . High lesions - Tibial nerve is injured and the hamstrings are also paralyzed .
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- ~ ~INJ URIES - CLAW HANO, WRIST DROP, FOOT DAOP 07
1
• Treatment ·
1. Conservative - Foot drop splint an d physicaltherapy . NCV is done to assess the level
and seventy of inJury .
2. Operative - If nerve is seve red .
• After nerve injury (axonolrnc. i. or ne uronolmesi ·) lbere i a degenerative process which proceeds to atleast the nearest
node of Ranvi r. Primary or retrograd degenerat ion proceeds proximall y from the si te of injury while secondary or
Wallerian d generation (Au gu ' lu s Wal ler- 185 l ) proceed distally from the point of injury. For the first 3 days defini te
morph ologi al ha ng are se n in lb e axon and respon e to faradic stimulation ca n be obtajned . By 3 days there is
fra gm 11tation and . hrinkage du e lo fluid los . By day 7 macrophages start clearing up the debris and there is increased
chwa11n cell milo is, whic h fill up th e vacant ·paces. This process is completed by 15-30 days (average 3 weeks). The
time required for degeneration varies between sensory and motor segments and is also related to the size and myeliniza-
tion of th e nerve fibre.
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Chapter 24
Theories Discussed
• Brien 's needle test
on/ Imm nd' T SI
• Ma and Griffith technique
Kn fl xion t I
• M y b n untr ted/incompl etely treated case after an acute injury in the past.
• Commonly it is n overu s injury, affecting people in 30-45 years age group. Athletes are
mor su c p tib l .
• Prior ndinosis ( ege n rative change) or paratendinitis (paratendon inflammation) can
11 r co ll gen stru cture, whi ch has le ss structural strength .
Wh t i your di gnosi ?
Thi s is a cas of R/L sided , untreated/incompletely treated rupture of Achilles tendon, of ......
months duration , with ankl e plantar fl exion power of ....... (MAC grading), due to (say what you
have lea rn ed from hi story) , in a ...... year old M/F person .
Wh t may be the predisposing factors?
Intrinsic : Ag eing , high BMI , Limb length discrepancy (LLD) , increased femoral anteversion,
subtalar hyperpronation, excessive forefoot varus/valgus , muscle imbalance of leg , collagen vas·
cular di sease, autoimmune di sease.
Extrinsic : Local steroid injection , prolonged corticosteroid or fluoroquinolone therapy, sudden
increase in running duration/intensity or altered running surface, repetitive trauma.
Wh t may be the precipitating factor?
Eccentric mechanical overloading du e to sudden viol ent dorsiflexion of a plantar flexed ankle.
What are th points In favour of your di gno Is ?
1 . H/0 untreated cut injury or sudden sharp pain t the back of heel while running/jumping or any
other positive relevant hi story at the time of rupture .
2. Single leg heel raise test : Patient cannot stand on toes, one legged , on the affected side,
3. Skin/Contour : Scar, depression/swelling , brui se
4 . Palpabl e gap in TA continuity . (M ay not be found If th . injury is 2·3 d ys old because of
organised haematoma) .
5. Ankl e dorslfl ex lon increased but plantar
fl e xion dec rea se d (although long flexor
mu scles of the toes may produce om
plantar fl ex ion)
6. Thompson/Simmond' Test Po ltlv : On
squeezing the calf muscles, the foot nor-
mally goes into plantar fl exion. When th
foot remains neutral or dorsiflex d th t t
I po itive . (see Fig. 1.24.1)
7 . M ti ' Knee flexlon te t po ltlv : With
th p ti nt pron and I g d ngling from I . I '4 1
101'
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T NDOA
" .., ·a \ttr:: ~:2. . . -, . . >,
l ~ ~
the edge of the table, request the patient to flex both k 900
into plantar flexion . In this patient the foot remains neu~r~~/~ to . · Normally . the foot goes
8. Brien 's needle test : A needle is inserted 10 cm proxim I t ;;s~flexe~ (s.ee Fig. 1.24.2)
the visible portion of needle moves proxima lly with da ~fl . insertion 1~ midline. Normally
flexion. (The test should not be done if the patient do ors, tex!on and distally with plantar
es no give consent)
Ho w will you conf,rm the diagnosis ?
1. USG : Cheap and confirmatory investigation.
2. MRI : Most sensitive and specific. Not done routinely .
3. X-Ray Heel Lateral view :
(a) Obliteration of Kager's fat pad - Posterior border f , ·
by flexor hallucis longus (FHL) posteriorly b t d
Fig . 1.24.3) .
°
Kh~lger s triangle bounded anteriorly
Y en oac I es (TA) becomes indistinct (see
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Section-II/
SPOT CASE
Theories Discussed
, Torticollis (wryneck)
, Tennis elbow • Frozen shoulder
, cozen 's test • Thompson's test
, Golfer's elbow • Radial tunnel syndrome
, Baseball Pitcher's elbow • Cubital tunnel syndrom e
• Student's elbow
, Javelin throwers elbow
• Pulled elbow
• Radio-ulnar synostosis
• De Ouervain's disease
• Finkelistein's test
• Intersection syndrome
• Ganglion
• Compound palmar ganglion
• Trigger finger
• Bowler's thumb
• Gamekeeper's thumb/Skier's thumb
• Mallet finger (baseball finger)
• Bursae around the knee
• Prepatellar bursitis (Housemaids knee)
• lnfrapatellar bursitis (Clergyman's knS,e}
• Morant Paker cyst/Popliteal cyst
• Semimembranosus bursitis • Popliteal aneurysm
• Achilles tend initis
• Retrocalcaneal bursitis/Haglund deformity
• Plantar fascitis (Policeman's heel) • Tarsal tunnel syndrome
• Pes planus (Flat foot) • Hallux valgus
TORTICOLLIS (WRYNECK)
• 2 varieties - Congenital and Secondary,
A. Congenital Muscular Torticollis [CMT]
Pathology :
The sternomastoid (SM) muscle on one side
is fibrotTc,'7 and so does not elongate with
growth ~ shortened muscle ~ deformity,
Etiology
Unestablished. Probably birth injury (or in-
utero injury) ~ compression of st~rnom_astoid
muscle (SM) ~ muscular ischaem1a ~ infarc-
tion ~ fibrosis ~ contracture (c.f. VIC).
Clinically . ,
• Associated with breech delivery . It is
commonly right sided. . ,
• Other congenital anomalies like d~velop-
ental dysplasia hip (DOH), congenital tal-
~ uinovarus (CiEV[and me~atarsus
ipes eq often found concomitantly,
Fig, 3. 1 : Right sided torticollis. adductus are
163
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164 HANDBOOK FOR ORTHOPAEDICS EXAM INATION
B. SECONDARY TORTICOLLIS
1. Prolapsed lntervertebral Disc PIVD) : Most common cause of torticollis in adults.
Common in the C6 , affecting the C6 and 7 nerve roots (so always test clinically Cc, anawf.
Patient presents wrl h brachalgia . Investigation ~ MRI. Treatment ~ Cervical trac·
0
tion , physical therapy , operation . (See page 261 for more information) .
2 . Spasmodic torticollis : A type of dystonia . Muscle spasm may be trigger~d by
rective manipulation or psychological disturbances . Some cases are associated w·n
c~t~
basal ganglion lesions (MRI confirms) . Treatment ~ Difficult. Injection botY!!D!ill1 1~~
1
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PO CA8 8 1
' I
toilet ablutions, etc. \I I '
• Stiffness -) Internal rotation is com-
I \
''
mon/ affected first. Then gradually ab- / ' I
I '' /
I
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Fig . 3.4(A) : Normal joint space . Fig . 3.4(8) : Contracted inferomedial joint space.
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SPOT CASES 167
• It occurs with activities that need repetitive pronation/supination, or wrist extension in pr-
onated forearm.
pathoanatomy - Cause
• cumulative microtrauma from repetitive stress due to eccentric and concentric muscular
contractions, with overload on the wrist extensor origin .
• Extensor carpi radialis brevis (ECRB) is the most common culprit. The o~igin of EC~B
impinges on t he lateral part of the capitulum during elbow extension / flex1on . Also , with
elbow extended , forearm pronated and wrist flexed the ECRB tendon is further stretched
over the edge of the radial head . It can also inv~lve the extensor carpi rad ialis longus
(ECRL) and extensor digitorum communis (EOC) . [Fig. 3.5]
Aetiology
2 schools of thought :
1. Modern ~iew - Tendinosis : It is a non-inflammatory lesion , because histolog i-
cally no increase in neutrophils and lymphocytes are found . Rather , first f ibro-
blastic, _th~n vascu_lar hyp~rplasia ~ abnormal collagen production occurs. (Hence termed
as ang1of1brob/ast1c tendmosis)
2. Old v~ew - Tendinitis : It is a chronic inflammatory tissue response to fatigue stresses ,
by which the body attempts to hasten the rate of tissue healing, to compensate for the
increased rate of collagen micro-damage.
Clinically
• Insidious onset. Sometimes patient gives history of mild trauma.
• Pain is worse when wringing clothes, using screwdriver, using hammer, ope rating accelera-
tor of 2-wheelers , lifting/carrying items with pronated forearm and flexed elbow , rotating
doorknob, turning a key or even shaking hands!
• Tenderness distal to the lateral epicondyle of the elbow, over the origin of ECRB is found ,
which may later extend to the muscle belly in posterior proximal forearm.
• Sometimes weakness of grip and / or paresthesia over posterior forearm and hand is found .
• Provocative tests :
(a) Thompson's test : Patient's shoulder is flexed to 60°, elbow extended , forearm pr-
onated and wrist extended. Then the examiner applies pressure on the 2nd / 3rd metac-
arpal , trying to flex and ulnar deviate the wrist, which produces sharp pain (see fig 3.6) .
EDC
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168 HANDBOOK FOR OATHOPA DIC XAMINA noN
(b) Cozen's test : Against reslstenco, k pEl tl nt I < xi< rH I Wfl 1, l{,,op n J tti, ,,lbrJw 11,JJUJ J
and the torearm pron tad (see fig 3.7) .
(c) For other tests - se page 52.
Differential Diagnosis
1. Radial Tunnel Syndrome : It is th e posterior int ro ou n rvo WI ~) ntr· rirn nt b~-
tween the superficial and deep fibres of the supinal:Of mu cl . Cllnl ally, r 1n 1 with rCJ l tod
supination in 20°-30° flexed elbow. Pain Is located 3- 4 cm distal to tho lat ral cp/condylc.
2. Osteochondral, intra-articular lateral elbow /es/on : (0 I ochondrltl de ican of
capitellum) Patients may Clo snapping _ locking. Maximum tenderne Is found po terlor to
the lateral epicondyle, over the posterior radio-capitellar joint.
Investigations
• X-rays are useless and totally unnecessary. Rarely it may show calcificatfon.
• USG : May be useful. Shows focal hypoechoic area on normal background.
• MRI : It can quantify diseased tendon thickening , identify intra-articular pathology like os-
teochondral lesion.
N.B. : Tennis Elbow is a clinical diagnosis. MRI is rarely done, which is useful only for recal·
citrant disease and planning of surgery.
Treatment
Always start ice application in the acute phase.
1. Conservative : Nearly always successful (95% cases) .
(a) Activity modification : Avoid pain-producing activities.
(b) Physical therapy : Ultrasound therapy (UST), friction-massage , lnterferential therapy
(I FT) , high voltage galvanic stimulation, remedial exercises. Effective in the long term.
(c) lntralesional Injection : Triamcelone 1 cc ± 1% lidnocaine, 1-3 doses injected with a gap
of 3 weeks. Side effects - Pain worsening in the next 72 hours, and (rarely) whitish skin
patch or skin atrophy. Very effective for short term relief.
(d) Bracing : Dynamic wrist extensor orthotic which limits wrist extension . Also non·
elastic proximal forearm strapping which effectively shifts the functional ori gn of
ECRB distally.
(e) Acupuncture : Provides effective short term relief when done by expert hands.
2 . Surgery : Considered only after 6-12 months of failed conservativ e management.
i.e., in patients with refractory symptoms (only about 5% need surgery and success
rate is only about 60%.)
Options :
(i) Open debridement.
(ii) Percutaneous release .
(iii) Arthroscopic debridement.
Newer experimental treatments :
1. Injections : Autologus blood, platelet-rich blood, botulinum toxin.
2. Transdermal glyceryl trinitrate patches to deliver Nitrous Oxide (NO) which is needed tor
tendon healing.
3. Low-level laser therapy.
4. Extra-corporeal shock wave (ECSW).
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SPOT CASES 169
Pain
1 . Tenderness over the medial epicondyle
initially. Later , may extend to the proxi-
mal , vol ar and the ulnar-side of forearm.
2. Worsened by repeated wrist flexion and
strong gripping activi ti es , like pu l l-
through strokes of swim ming, hard hit
forearm shots in racquet sports , or force-
fully throwing a ball. FC R
Provocative tests
1. Golfer's elbow sign : With elbow semi-
flexed and forearm supinated, isometric
resisted wrist and elbow extension pro-
duces pain. (Fig. 3.9)
2. Sometimes resisted pronation also pro-
duces sharp pain .
3. Other tests - see page 52 . Fig. 3.8 : Anatomy of medial epicondyle .
Differential Diagnosis
1. Cubital Tunnel Syndrome : Often concomitantly present. It is actually ulnar nerve
entrapment between the humeral head and the ulnar head of flexor carpi ulnaris (FCU) ,
producing symptoms of compressive ulnar nerve neuropathy (see page 104, 105) . NCV
confirms diagnosis .
2. Baseball Pitcher's Elbow : Hypertrophy of the distal humerus with incongruent elbow joint ±
loose bodies ± osteoarthritis, due to repeated forceful throwing activities.
3. Little Leagure's Elbow : Partial avulsion of the medial epicondyle.
Treatment
It is a more challenging and difficult condition to treat than tennis elbow .
[All other features in introduction , pathoanat-
omy , clinical features , investigations and
treatment are SAME as in tennis elbow .]
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170 HANDBOOK FOR ORTHOPA ED ICS EXAM IN ATION
PULLED ELBOW
Usual history is that of a 3- 4 year child being sudd en ly jerked by the hand/forearm
and the child cries out in pain and holds the forearm in pronat ion . No X-ray change5
are found . Mistakenly thought of as subluxation of the radial head . It is actually the
subluxation of the orbicular ligament , which moves up over the radial head, on °
the radio-capitella r joint .
Treatment : Spontaneous reduction usually occurs. The aim is to rest the limb in a collar·
and-cuff sling. Occasionally manipulation maybe required which is forceful supination
and then elbow flexion , which reduces the lesion with a "snap" .
--
CONGENITAL RADIO-ULNAR SYNOSTOSIS
Commonly
(1) The synostosis is at the proximal radio-ulnar joint.
(2) It is bilateral rather than unilateral.
(3) It has familial trait, more from the paternal side .
Types • Wilkie classification
(I) The medullary canals of the proximal radius and ulna
~re fused to~ether for several centimetres , and there
1s malformation of the proximal radius. The radial shaft
has an. excessive and abnormal anterior bow, and its
len~th 1~ much more than the ulna. (Fig . 3 .11)
(II) Radius 1s nearly no_rmal and fused to the proximal ulna
only for a few cen_t1metre~, but the radial head is dislo-
cated. Often associated _with polydactyli , syndactyli or ab-
sence of the thumb. This type is often unilateral.
Clinically
It is a very disabling condition when b'i later I Th f
· f
1s 1xeh
searc
d ·
t ·
pronat1o_
a· e orearm
n an? no supination is possible. Always
or congenital finger anomalies and · I d .
your diagnosis. inc u e them in
Fig . 3 .11 :
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SPOT CASES 171
X-rays
AP and Lat. views are diagnostic.
Treatment
very difficult to restore supination even with operative release of the synostosis . This is
because of the abnormal soft-tissues , like absent or abnormal supinator muscle, narrowed
interosseous membran_~ and muscle contractures. The goal of treatment is to achieve an
improved functional pos1t1.on by derotation osteotomy, especially when the condition is bilat-
eral. Fortunately most children adapt and manage well. If flexion/extension is adequate then,
tor dominant hand 20° pronation is functional. For non-dominant hand - for Indians supination
is preferable (for toilet ablution), for western population pronation is preferable (for typing,
computer mouse use etc).
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HANDBOOK FOR ORTHOPAEDICS EXAMINATION .
172
d n sheath ove r l e r
h ± thickened tendon sheath.
adial styloid
=-- ---ir.---:--.........
3 . 0/E : Tendernessf of thlfi~gen rirely crepi -
Varying degrees o swe ,
tus may be found.
4 Provocative tests : d
· b . flexed + adducte ,
(a) ::~npt!de r:S~;ed '!bdu.ction + ~xten~i~n
f thumb is typically painful. (Fig. 3. )
(b) ~inkelstein'~ test : .Thumh~~obuft~ ~::~
base of 5th finger (i.e ., t 1
+ adducted + opposed) -? clench oth.er
fingers over thumb into a clenched f~st
-? then forcefully ulnar deviate the wrist
-? sharp pain is felt . (Fig. 3 . 14)
5 . Many other tests e.g. , Muckard Test.
Investigations
• X-ray """"""7 USELESS. Fig . 3 .13 : Provocative test for DQ.
• USG/MRI - Not required. May show ten-
don sheath thickening .
• Exclude - Hyperuricaemia, infection , dia-
betes mellitus, rheumatoid arthritis , thyroid-
disease. (Blood for uric acid, RA factor ,
FBS , PPBS, TSH , ESR, DC, TLC , e~.)
Differential Diagnosis
1 . Intersection syndrome : Also known as
crossover syndrome, and peritendinitis-
crepitants. It is commonly seen in weight-
lifters and rowers. Clinically , there is pain ,
swelling, crepitus over the tendons of EPL
and abductor pollicis longus, about 5 cm
proximal to the extensor retinaculum , due
to tenosynovitis at the crossing of the ab -
ductor pollicis longus (APL) + extensor
pollicis brevis (EPB), over the extensor
carpi radialis longus (ECRL) + extensor
carpi radialis brevis (ECRB). Fig . 3 .14 : Finkelstein's te 5t
· es ~r8
• Physical therapy : Pulsed UST, IFT, TENS , friction massage and stretching e ercis
all very useful. con·
• lnj~c~ion : ~elieves s.y mptoms in about 60% cases (Triam elone ± 1% lidnocaine).
traind1cated in gout, diabetes and infection. coni·
0
• ·
perat,ve re I ease o f tendon sheath : Remember · t·ons
anatomical vana 1
are
o h '
monly found ( > 50% have "aberrant" duplicated tendons of APL and about 5
absent EPB) .
Prognosis
In most patients , recurrence occurs after 1-2 years.
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SPOT CASES 173
ANGLION
llnl<,nll
• I ttlnl I vml hly c hing lum whi . . . .
• Cl , i . lly lh lump is • ( p . ch fluctuates rn size (more Joint movement = size t)
1,rm sometime ·t
n n I 1 ncl 1 (m oy b l nd r) s I may _be so tense th at it is almost bony hard) ,
rnny n l mov with th th
nd~nsm~o ' ~ell-defined , cystic and fluctuant which may or
I
111111 · ll 11 l t ,,., y b po sitive . · ccasional ly it may be multiloculated . Rarely transillu -
Tr om nt
I ion with a rim of normal t' .
rnon wh n ny abnormal tissu . f,ssue . is th e t reatment of choice. Recurrence is com-
e 1s 1e t behind.
lg . 3.15 : Gang lion over dorsal wrist. Fig . 3.16 : Compound palmar ganglion .
l'rootrn nt
• Xolud / treat TB and RA (start ATD / DMARD). In TB, aspirate fluid -? lnj. streptom~cin -?
Pli: 'I r Immobilization (splinting) . Repeat weekly for 4- 6 weeks. If unsuccestul (and 111 RA)
> ornr,let excision of the fle)(or tendon sheath is done after 6 weeks.
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[ D c L XAMINA 1 ION
174 HANDBOOK FOR ORTHOPA I
Aetiology
• Unknown . May be du e to overuse (repetitive microtra um a), col lagen disease or acute
local trauma .
Pathoanatomy
Trauma / infl ammation heali ng by fibrosis ~ "bu nching-up" of the flexor synoviurn at
the annular one (A 1) pulley and also at the level of metacarpophalangeal (MCP) joint ~
causing nodular fibrosis ~ i.e. , th ickening of the palmar tendon sheath of the flexor tendon.
slip ~ making the tendon -slip get trapped at the shea th entrance. Forceful extension re-
lieves the entrapment with a sharp "click" (wh ich the patient may feel to be at the level of
interphalangeal (IP) joint) ~ thus called "triggering".
Clinically
Treatment
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SPOT CASES 175
N.B. : Gamekeeper 's Thumb I Skier's Thumb : Injury to the ulnar collateral ligament
at the 1st MCP j o int level after snow-skiing accident, or fall on outstretched hand
with radial a nd p a lmarly abducted thumb. There is pain, swelling, echymosis at
thumb base with greatest tenderness on the ulnar side of the thumb base. A
prominent lump is palpable which is the torn ulnar collateral ligament being dis-
placed by th e adductor aponeurosis. Abnormal thumb rotation may also be found.
Plain X-rays and stress X-rays are useful for diagnosis. Surgery is the treatment.
Aetiology
1. Occurs when the finge r tip is for cibly extended e.g., while catching a cricket ball /
base ba ll if th e b all st rikes the finger
tips rath ~r than th e palm ; or when tuck-
ing bedsheets/blan kets under a heavy
mattress .
2. Often du e to direct trauma to th e fin -
ger tip . H e re , predi s po si ng fac to.r s
may be c hroni c attrition, or se nil e
chang es.
Clinically
1. Distal interphalangeal (DIP) joint .is flexed
and passive exte nsion is possible, but
there is no active extension.
2· Du e to un b a la n ce d ex te n sor mec ha-
nis m , s o me tim es th e p ro xi m al inte r-
Ph al an g ea l ( PIP ) j o i nt is hyp e rex -
ten ded , ca u sin g swan-neck defor-
mity. (Fig . 3 .18 and 3 .19) Fig. 3 . 18 : Mallet ring finger with swan-neck
X-rays deformity. Note _ PI P joint is hyperextende.d and
DIP joint is flexed, i.e. swan-neck deformity.
Lateral view of the finger is diagnostic.
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HANDBOOK FOR ORTHOPAEDICS EXAMI NATION
176
Treatment O
• .
1 . Fragment< 30% . Malle~ finger SPiint for
DIP, leaving PIP free . It _is worn_continu.
ously for 6- 8 week~ . Night splinting f
anothe r 2- 6 weeks 1s beneficial. or
2 . Fragment > 3 0% and open injuries .
Operative fixation. ·
3 . Chronic I neglected mallet finge, .
Treated only when the re is severe Pain.
gross cosmetic deformity or when it i'
. 3 19 . Lat. view X-ray showing avulsion fracture significantly impairing hand function con~
F19· · · k
of the base of distal phalanx and swan-nee sider DIP arthrodesis.
deformity of PIP joint.
MALLET THUMB
• Rupture of the extensor pollicis longus due to fraying of the tendon at wrist e.g., after
Calles fracture or rheumatoid arthritis.
• Direct repair of tendon gives poor result. Tendon transfer is a better option.
PREPATELLAR BURSITIS
(HOUSEMAIDS KNEE)
• ~arely seen in housemaids , but common
in carpet-layers and miners.
• Commonly due to constant friction be-
t~een the patella and the skin (fig 3.2 .1)
;1th repeated knee flexion /extension '
a~~~hf:u~ommon cause is after a~
J Y e.g ., fall , or a direct blo
over the patella. w
• The knee joint is uninvolved T . .. .. - Medial
fluctuant well - circu· ms 'b· · here IS a Fig. 3.20 : P.repatellar burs1t1s. Note d
er, ed sw 11 ·I · olve
between the patella d . e ng parapatellar groove ~ joint not inv he
Ir . an the skin It . (then t
swe mg is warm and tender) · may get infected , especially in children
• Treatment is aimed at the ·
cause of bursT1 ges.
is and not the secondary pathological chan
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....
SPOT CASES 177
1 . Non -infected : Avoid knee ling . Aspiration + co mpression "Jones " bandage + steroid
injection . If recurrent ~ operati on. .
2. Infected : Aspiration + antibi oti c (i njection locally and orally) + cylinder s lab
immobil ization.
• Surgery is ind icated in chronically infected inflamed bursae with thickened walls .
Excision is done .
• After treatment - Quadriceps exercise and physical therapy.
INFRAPATELLA R BURSITIS (CLERGYMAN'S KNEE)
POPLITEAL CYST
• When associated w ith osteoarthritis , it is called Baker Cyst or Morant Baker Cyst
(First described in 1877).
• In children , the cyst sometimes communicates with the joint, but the joint is normal.
In adults, 98% joints are pathological [e.g., rheumatoid arthritis, osteoarthritis , medial
meniscal posterior horn damage, etc.)
Pathoanatomy
1. Commonly due to synovial herniation or
rupture between the capsule and oblique
popliteal ligament.
2. May be a distended bursa - commonly
the bursa between the medial head of
gastrocnemius or the semimembrano-
sus bursa (the~ called semimembrano-
sus bursitis) . These 2 bursae communi-
cate with the knee joint.
Clinically
1
· ~Ystic , fluctuant, non - tender , poste -
rio
. r mid!ine swelling be low the joint Back view
. . Side view
line , Whi c h becomes prominent with Fig. 3.22 . Morant Baker Cyst.
2 knee ex ten sio n (Fig . 3 .22 ), but reduces / disappe.ars with knee flexion .
· ~arely the cyst may leak I rupture , and fluid can tr.1ckle down to the calf through an
intram usc ular route taking the path of least r_es1sJence ...Then the calf becomes
~~Olien and tender , and sometimes Homan 's sign 1s pos1t1ve . Must rule out deep-
ein- thrombosis in these cases.
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0111 , ,, ti I L I no Is b t th b
I • t m/111< mb, ino u . Bursitis : Inflamed, enlarged bursa e ween e sem1mem ranosus
M) 11 tl<hHI ,md IIH in di I head of gastrocnem1us muscle , or the bursa between the StA
mhrn ''"d lh 1 llll d1,,1 t1b1. I condyle . . . . . .
• /1111t'. 1/I)' ,., , 1nl ss, fluctuant lump , medial to the mid/me, which is prominent in
l lt nd I 1-.n (rig. 3.23) , but reduces
with kn lie 10n.
• I 11 11/llt'III O nign neglect 1s often ef-
t t1v< (dis ,pp t1r s with time) . Surgical
l 1s1on m y produce 1ecurrence.
~. Pop/It nl An urysm : It 1s the most com -
mon l11nb • n u1ysm. Often bilateral. Clini-
t,,,lly p in b hind knee + stitrness ~
1,\1 1 puls. ltl • walling (N B. : If throm-
b • l ci , th r I no pulsation)
Tr trn nt of Popllt al Cyst
1.spit .,lion I tnJ l1ydrocortisone + com-
prl ~s1on b, nd ge.
· Surg1 .:ll c1s1on . Recurrence is common .
• . l r 1ll1ng the intra-articular pathology (e.g.,
synov ctomy 111 RA , meniscectomy in
m nisc. I d mage, etc.) + excision of the
cy · t is benelicial. Arthroscopy is very
us lul lo, valuation of joint pathology and
tr tm nt sim ultaneously. Fig. 3.23 : .Semimembranosus Bursitis.
N.B. : Jumper's knee (patellar tendinitis - see page 12); Weaver's bottom (ischiogluteal
bursitis)
ACHILLES TENDINITIS
• Very difricult / challenging to treat, and patience is required.
• Associated with obesi ty , hypertension, OCP use, diabetes, rheumatoid arthntis. s st emic
lupus eryth ematosus, Relter's disease. ankylosing spondylitis. reactive arthrihs.
Types
lnsertional and Non-lnsertional.
INSERTIONAL
• Common in older people. .. . .. sumP
• Always associated with retrocalcaneal burs1t1s and/or Hsglund deformity l Pump . t1an1·
1
deformity - see n in X-ray) . Haglund deformity is an exos1os1s caus d b chronic ~ j )
1
ma tion of the adventitious bursa th t separates the t ndo , chilles from s~in F ;s
5 0
i·
Th e bursa is present in 50% which may be inflamod with tnction and from tight
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SPOT CASES 179
Aetiology
Overuse and repeated m1crotrauma (e.g., in runners and jumpers).
ClinicaUy . . . .
1 dious onset, gradually progressive pain at the tendo ach1lles (TA) insertion , especially at
~
th;:;des, wh ich j with walking uphill , or on hard surfaces. Pain / stiffn~ss after night's sleep
or morning stiffness after a period of rest. On palpation ~ soft-tissue 1s thickened.
investigation
X-ray ~ Posterior heel spur or Haglund de-
formity on lateral view (Fig 3.24) . USG and
MRI can demonstrate the TA condition .
Treatment
1. Conservative (Effective in 95%) :
(a) Heel raise, ice application , foot ankle
orthosis (FAO) , night-splints and NSAID are
useful.
(b} Physical therapy - UST, eccentric
strengthening of the gastrosoleus + stretch-
ing of tendoachilles .
(c) Glyceryl trinitrate topical patches.
Fig. 3.24 : Haglund deform ity.
N.B. - lnj. Hydrocortisone is RISKY because it may cause TA rupture, so try to avoid it.
2. Surgery (may be needed for 5%) : Done after failed conservative treatment for 6-12 months.
Partial (< 50%) debridement + TA lengthening, is the surgery of choice.
NON-INSERTIONAL
• Common in older athletes , males with tight TA / hamstings, those wearing improper shoes or
training improperly.
• Always associated with a hypovascular zone, 2-6 cm proximal to TA insertion .
Pathological types
1. Peritendinitis (sheath)
2. Tendinosis (tendon)
3. Paratendinitis (sheath + tendon)
Clinically
Sarne as insertional.
'treatrnent
1· Con
2 . Surgservative : Same as insertional. ·
MRI ery : If > 50% tendon is involved 1n
may' bcoun sel th e patient. Tendon transfer
e necessary. Fig . 3.25 : Bulbou s nodule at TA insertion.
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180 HANDBOOK FOR ORTHOPAEDICS EXA MINATION
X-rays
• Have limited role . May show calcaneal spur (Fig. 3.26) which is irrelevant because many
patients with calceneal spur have no heel pain , whereas many patients having heel pain have
no calcaneal spur.
Differential Diagnosis
1. Tarsal Tunnel Syndrome is concomi-
tantly present with plan tar fasc itis in
2 % pa tients. It is due to entrapment of
the 1st lateral branch of posterior tibial
nerve . Cl inically burn ing pa in/paresthesia
of the heel ± pos iti ve Tinel 's sign , but
never medial heel tenderness. Treatment
medial heel wedge , intralesional steroid
injection , surgery.
2. Tendinitis of flexor hallucis longus or
flexor digitorum brevis.
3. Stress fractures.
Treatment
1. Conservative : > 90% patients can be . 1
r
successfully treated conservatively . Fig. 3.26 : Calcanea spu ·
f b icated or
(a) Soft-heeled shoes tor constant use. Silicone or rubber heel -cups and pre a r
customized soft-heel-inserts are useful.
(b) Ankle dorsiflexion night splints.
(c) Stretching exercises tor tendo achilles , plantar fascia and the lumbiricals. 1 .0 fllaY
5
(d) Jntralesional _i~je~tion of Triamcelone 1cc ± 1% lidnocaine. Repea_ ted inj~~~ ; ~0eK
at_1on ~ so not more than 2 injections are given , at 1nterva
prod~ce calc1f1c_
and 1t must be tnJected deep into the plantar fasc ia to avoid fat-pad atrophY·
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SPOT CASES 181
(e) Activity modification for run ners - must reduce running distance.
(f) Physical therapy - lnte rfere ntial therapy (IFT) , ultrasoun d th e rapy (UST) , frict ion
massage , muscle stimulation - especially the lumbiricals.
2 . Extracorporeal Shock Wa ve (ECS W) : Recently starte d with promising results. Rec-
ommended if conservative treatment fails. Shock waves are believed to initiate fas -
cia! tissue healing which affects pain receptor physiology. A single high energy dose of
electrohyd ra ulic ECSW , with the patient anaesthetised, is the gold standa rd.
3. Surgery : Rarely requ ired. Principle : Partial release of the plantar fascia (one-th ird to
maximum half) from th e medial calcaneal tube rosity (greater cut may cause pes pla-
nu s) , ± neurolysis of the nerve -to-abdu ctor digi ti minimi . May be done by open method
or arth roscopically.
Clinically
• Perturbed and anxious parents usually
present asymptomatic children . In ado-
lescents and adults, there may be com -
Fig . 3.27 : Rockerbottom toot. plaints of pain , occasionally with mild
Note : Plantarflexed talus and flat foot. swelling of proximal dorso-lateral foot ,
wh· h d ·ght bearing or activity (e.g. , walking , running , climbing
1c appears after prolonge we1
stairs, etc.). This is foot-strain. 'd d front) and then in non -
• E · . . t d·ng
1 (from back, s1 e an
xam1ne the patient first in s an . t'1 t flex ible from rigid variety) . Note the
Weight bearing sitting position (to diffe~en ~oen with medially tilted talar head , calca -
Valgus heel (Fig . 3 .28) mild subtala~ sub uxa ~ calcaneocubo id joints, forefoot supina-
~ea1 eversion , abduction of talonavicular ::amine the knees/ hips.
tion , tight/shortened tendo achilles. Also
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182 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
Fig. 3.28 : Back view. Note - Valgus heel. Fig. 3.29 : Side view . Note - Prominent navicular.
Treatment
• Physiological variety needs no treatment.
Hypermobile and compensatory varieties
do well with medial-arch raised shoe with
fi rm hee l counter, extended medial
counter and Thomas heel. Phys ical
therapy to strengthen muscles, reduces
pain which is due to foot strain.
• For anomalous anatomy, surgery may be
needed if conservative treatment fails to Fig . 3 .30 : AP view . X-ray foot showing acces·
relieve symptoms.
sory navicular.
HALLUX VALGUS
• Commonest foot deformity. Commonly bilateral and in the elderly (> 50 years) females.
th
• It is the lateral deviation of the 1st toe, often associated with deformity and symptoms 01 e
othe r toes.
• May be familial, especially when seen in adolescents.
Aetiology r·
shoe wea
• Barefooted and open-toe sandal wearing people seldom have ha/lux va/gus. ver, onlY
ing (especially shoes with narrow toe-box) induces valgus of the great toe . Howe
when it is "excessive", it is termed as hallux valgus. . 11()(1
. pred1spo51 t
• Varus angulat1on of the 1st metatarsal with "splaying" ot forefoot is a common MTP 101n
to lateral angulation of great toe. Sometimes there may be subluxat1on of the 1st
In advanced cases , corns, calluses and metatarsalgia are found. uscle t~
• Associated with rheumatoid arthritis, and also with elderly people with reduced rn
of the forefoot.
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111 11111 I ,I 11111 1111,11 • ,, 111111 ,, ,1111 1l'1,1,r1
1r11
/0111 1, d 1t1 II I/ii )I I I 111/111 l1 f 1111 lit1I tit,
pu•,I, 11111 11 11111111, , , 11,1 ,•,111 I/ l1n11 1 hi
fdY , 11111111 /1 111111 trl lt 11lt11 : IHl,11 ,1 ,,, 1111,
I · I M 11 ' /111111 tll , 111 1lrll,1 1l11 11,w •rt l', l/11
d1 loll illly II llf 11YI !If JII II rl I
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lf, Vlnllcrn 111 tit, I •ii 11 1111 ti 11 •1 ,l (I lfJ 'l ': I )
• Lrowdl11q ol 11 1 ,1 1 tr,, , ll1J1 l1J ,,. ,, r,rl rJ;
VI t ltO Jl or '"" 11 11111/, ttl ,y ( )( , ( , lj(
Clinically
• Most are asymptomatic with no comp lains excep t cosmes is. W orried p aront often brinQ
smiling adolescents as patients.
• Pain : May be due to bursitis (inflamed bunion) , or hammer toe or socondary osteoa rthritis
of the 1st MTP joint.
X-rays
Standing, weight bearing views are needed. In AP view, hallux ang le > 15"-20'•, and
intermetatarsal a ngle > 10° is diagnostic.
Treatment
. More than 130 operations have b ee n d esc ribe d in lite rature, which demonstrates that it
1
s a complex problem and no si ngle operation can b e unive rsa lly successfu l fo r al l patient s.
Surgery is only indicated in symptomatic patients, and also to prevent progressive worsen-
Ing of deformities. Names of some common op eration s are as follow s - Mcbrlde's
bunionectomy, Chevron 's osteotomy , Mltchell's o steotomy, WIison 's osteotomy ,
Keller's osteotomy, Arthrodesis, etc.
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- - - --- -- -- ---r..:-,--- ·-•wr..,. ,w_______
ww ---
Section-V
X-RAYS
Theories Discussed
• Types o1 tracture • Greenstick fracture
• Clavicle fracture • Shoulder d1slocat1on - acute, recurrent
• Arthroscopy • Humeral Shaft fracture
• Olecranon fracture • Tension Band Wiring
• Radial head fracture • Radial neck fracture
• Essex-Lopresti fracture • Galeazzi fracture (Piedmont fracture)
• Scaphoid fracture • Bennett's fracture
• Rolando fracture • Femoral shaft fracture
• Patella fracture • Tibial shaft fracture
• Gustilo Andersons classification • Interlocking Nail
• External fixation • llizarov ring fixators
• 01stract1on osteogenes1s • Ankle fracture
• Maisonneuve fracture • Calcaneal fracture
• Jones fracture • Pathological fracture
• Rolando fracture • Femoral shaft fractu re
• Malunion • Avascular necrosis of femoral head
• Osgood-Schlatte r's disease • Johansson-Larsen disease
• Pell igrini-Steida disease • Sever's disease
• Spina bifida • Scoliosis
• Kyphosis • Scheurman's disease
• Ankylosing Spondylitis • Spondylolisthesis , Spondylolysis
• Spondylosis • Prolapsed lntervertebral Oise (slipped disc)
• Cauda equina syndrome • Osteogenesis lmperfecta
• Below knee amputation • Ewing's Sarcoma
• Simple bone cyst (unicameral bone cyst) • Fibrous Dysplasia
• Osteoid Osteoma • Compact Osteoma (ivory exostosis)
• Osteoblastoma • Ankylosis )
h
• Osteoarthritis knee • Charcot joint (neuropathic arthropal Y
• Developmental dysplasia of hip (DOH) • Ortolani's test Barlow's test
• Congenital pseudoarthrosis tibia • Congenital radial club hand
8 edicS•
• Plain ~-r~s remain the .si~gle most important investigation for diagnosis in orth 0 P
even 1n t~1s era of soph1st1cat~d and modern imaging techniques. . r:,.iwars
• Systematic, st~p-~y-step , meticulous obse rvation is the crux of X-ray reading.
hold (or place in vi ew-box) the X-ray film in anatomical position . hatJil·
• Firstly , stu_dying the soft-tissu~s, then the bones and fin ally the joints is an ~sefu'torei9n
(a) So!!-t,~ e-~ : Note swelling , wasting , density changes (e .g ., calcification),
bodi es, gas-bubbles (e.g., gas gangrene) .
(b) Bones : Trace the outlines from one end to the other _
2 14
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X-RAYS 215
I I
·.:I ·. i
.
(3) F rac ture I me attern . T ra nsverse oblique, spiral, comminuted , segmental , bone-
p . ·
loss (Fig. 5.2).
(4) Intra-articular extension : Look for joint involvement.
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2·
CLAVICLE FRACTURE
/tBS
• On~ of the most common bo~es to fracture in children is the clavicle . It also ~
quickly an uneventful#~, without any functional -eo d ..;e
· I b · 'S' h d · h h · 1 par Y· ones
• -Clav1c e, emg -s ape , wit t e medial end convex f d d lateral end c it
. . b orwar an akes
forward -4 the 1unct1on etween the 2 parts occurs in the middle third -4 which m
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susceptible to fracture . Also , the middle ·rd .
tachment distal to subclavius mu ~hi does ~ot have any muscle or ligament at-
t go1, of . sc 1e, which makes 1t extra vulnerable for traclure .
• Ab ou o c 1av1c 1e fractures have
other associated fractures ~ commonly
rib fractu re.
Mechanism of Injury
1. Fall onto the shoulder ~ about 87% .
2. Direct trauma to clavicle ~ about ?%.
3. Fall onto outstretched hand ~ about S%.
Clinicall y
• Patient usually presents with the affected
arm across chest (adducted) and the el-
bow supported by the contralateral hand
Fig . 5.4 : AP v iew X-ray of left shoulder, left
• Skin overly ing the fracture may b ·
clavicle and upper chest wall showing displaced
"tented " a~d a subc uta neous lum~ fracture of middle third of clavicle .
may be obvious. Very rarely , it may be
an open fracture~
• On palpation ~ tenderness , and crepi-
~ the fracture site , is found .
• Distal neurovascular examination is
essential. The chest should be auscul-
tated for symmetric breath sounds .
• The distal part is pulled down by the
delto id and pectoraITs muscles, whereas
the proximal portion is g_u lled up by
the sternomasto id , causing the typi -
cal displacement (Fig . 5.4) .
X-rays Fig. 5.5 : Post-operative X-ray of right clavicle
AP views are almost always enough to di- middle third fracture fixed with plate and
agnose clavicle fractures . screws - AP view .
Allman Classification
• Group I - Fracture Middle Third (80%).
• Group II - Fracture ~ Third (15%).
• Group Ill - Fracture Medial Third (5%).
Treatment
1 . Conservative : MOST FRACTU_BES CAN BE SllCCESSEllLLY TREATED NON-
0.f§_RATIVEL y by a simple collar-and-cj:!ff sling for 3- 4 weeks and then early shoul-
der mobilization exercises (especially tor old patients who might develop shoulder stiff-
ness). Figure-of-8 bandage do not have any special advantage.
2· Operative indications :
(a) Neurovascular involvement - Immediate intervention.
(b) Non-union - Most co mmon indication for operation.
(c) Fracture distal 1/3 rd with torn coracoclavicular ligament in an adult.
(d) Open fractures and fractures with "tented" skin , which have the potential of becom-
ing open fracture s, if the skin is torn .
(e) Floating shoulder injuries.
{f) Grossly displaced middle third fractures in young active adults. (see Fig . 5.4 and 5 .5)
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218 HANDBOOK FOR ORTI-.OPA OICS EXAMINATION
Complications
. . . . b non-o erative management. Function remains excellent.
1. Ma/umon . I~ almos~ inev1tablem~on es~ecially in the elderly - physical therapy is useful.
2. Shoulder st,ffn~s~ · Not unco . · nc which requires immediate treatment.
3. Neurovascular tnJury : ~are. It is an en:ierge d ~ t rnal fixati on (ORIF - see fig. 5.5)
4 . Non-union : Rare. Requires open reduction an in e .
SHOULDER DISLOCATION
ANTERIOR DISLOCATION
Mechanism of Injury
1. Indirect trauma : Most common mechanism . When the shoulder is in abduction :n~
external rotation -) sudden severe extension causes anterior dislocation. Examp 1ud·
while standing in a speeding bus facing the driver, and holding the overhead rod, a 5 nd
den deceleration due to brakes being applied -) the body moves forward while th e hat r·
. produces sudden extension in an already abducted and .ex
holds on to the rod -) this e
h the
nally rotated shoulder. The same may happen with a fall on outstretched hand wit
shoulder abducted and externally rotated .
2 . Direct trauma : Anteriorly directed impact to the posterior part of shoulder. . r)
. . .
3. Convulsions or electr,c shock : Commonly causes posterior dislocation (rare ly anteno .
Clinically d and
• Patient typically supports the injured upper limb at the elbow with the opposite hane 'pain·
the shoulder is in a position of slight abduction and external rotation. There is se::; with a
The rounded , lateral shoulder bulge is lost, which looks flat and square toget
very prominent acromion. he ar(l'l·
• .
A bony spherical mass .1s palpated anteriorly, which moves with gentle rota t·10n of t et~rll.
• Due to p~in and .muscle spas~. the p~tient does not allow any movement 5 to be
ined , but 1t examined - adduction and internal rotation is lost. . noted·
• Axillary nerve sensation over the lateral part of deltoid (military-badge area) 15
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• special tests :
(a) Hamilton's ruler test - Normally a
-
ruler placed on the lateral aspect of
th shoulder cannot touch the acro-
mion and the lateral condyle of the
humerus at the same time , due to th
deltoid bu lge. After an terior disloca-
tion of shoulde r, it is possible.
(b) Dugas test - Patient cannot touch
the opposite shoulder which requires
adduction and internal rotation . Subcoracoid Subgl enold
(c) Cal/aways test - Circumference of
the affected shoulder is increased in
comparison to the opposite shoulder.
Classification
Acco rding to the position of the humeral
head (Fig. 5.7) .
1. Subcoracoid .
2. Subglenoid .
3. Subclavicular. Subclav/cu/ar Jntralhoraclc
4. lntrathoracic . Fig. 5.7 : Types of anterior shoulder dislocation.
X-rays
1 . AP view : Shows overlapping of humeral head and the glenoid . Usually the head lies
medial and inferior to the glenoid .
True lateral-scapular view : X-ray beams are aimed along the spine of scapula. This
2. _
1s needed to differentiate between anterior and posterior dislocations (20°- 30° anterior
to coronal plane) .
3. Special views :
(a) Hill-Sach view - It is an AP view with maximum internal rotation of the shoulder
that is possible . Useful to detect H/11-Sach lesion ~ which is a defect/flattening/
excavation of the postero-lateral part of the humeral head , caused by impact with
the anterior margin of the glenoid.
(b) Stryker-Notch view - More effective in detecting Hill-Sach lesions.
(c) West-Point view - Taken with the patient in prone position . Useful to detect gle-
noid rim lesions , e.g . Bankart's lesion.
N.B.:
• MRI is indicated to detect Bankart's /es/on (it is a defect In the anterior part of the
glenoidal labrum and anterior capsule, which is torn/avulsed as the head dislocates) and
• rotator cuff injuries (common in the elde~ly). . ,,. . ..
CT scan is indicated to detect loose bodies, und1splaced 1mpress1on fractures and
Bony Bankart's lesion (anterior glenoid rim defects).
Treatment
hReduction under analgesic/sedative/anaesthetic cover ~ maintain reduction In arm -to-
~e~st ban?~ge for 3 weeks ~ then active, approp_riate, ra~ge-of-movement exercises un-
Pos:ehab1lltation programme . For the elderly patients , this must be started as soon as
Fi Ible (about 15 days) .
8 ducti
M on Techniques
any have been described . Some commonly pract1~ed m~thods a~e -
1, Hippocratic method : When no assistant 1s available, this method is very useful.
Surgeon places one foot across the axillary folds on to the chest wall , while exerting
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r
'2 - HANDBOOK FOR OR HOPAEDICS EXA 11NAT10
steady, axial and manual traction to the slightly abducted arm . Looks very crude , but
is very effective. . o
2. Kocher's method : To the slightly abducted arm , elbowt· is b(:t t_o ~ho • kth en traction
is given , followed by gen tle and gradual externa( rot_
a ion is is . e ey manoeu.
vre) to about 80°, then adduction and lastly. med!al (internal) rotation . [~n~monlc :
Tr.E.Ad.-Me]. In osteoporotic bones, there 1s a risk of fracture, so caution 1s advis-
able in the elderly patients . .
3. Stimson 's (gravity) method : Sedated patient lies prone, with the affe~ted arm hang.
ing free and a Sib we ight hanging from the wrist. ~~kes abo~~ 2?,- 30 minutes.
4. Saha 's method : Taking the shoulder gently to the Zero position (where the sum total
of all the muscle forces acting from various directions becomes zero) - reduction is
achieved very easily.
Comp Iications
1. Recurrent dislocation shoulder (RDS) is the most common complication.
2. Axillary nerve injury : Neuropraxia. Usually recovers spontaneously and completely.
3. Fracture-Dislocation : If there is fracture of greater tuberosity of humerus, it usually falls
into place after successful reduction. Other fractures might require operative intervention.
4. Shoulder stiffness : Very common in patients aged > 40 years. Physicaltherapy and
exercises are required, keeping in mind that full abduction can return only after full
external rotation has been achieved.
5. Unreduced dislocation : Rare. Prognosis is guarded.
• When an anterior dislocation tears only the capsule, complete healing is the expected
outcome. But if the glenoidal labrum is detached (Bankart's lesion) , repair is unlikely.
This happens most commonly in young patients (80% to 90% at about 20 years).
• Bankart's lesion , Hill-Sach lesion and defect of the anterior rim of glenoid are bracketed
together as essential lesions for recurrent dislocation shoulder.
• Incidence is unrelated to the type or length of post-reduction immobilization after the
first episode. Patient's activity is however an independent factor for developing RDS.
• Most recurrences occur within the first 2 years of the first episode. Common in males.
Subgroups (Masten)
1. TUBS : ~raumatic, ~nilater~I,_Ban_kart's lesion (present), Surgery (is required) .
2 . ~MBR/1 . Atrau~at1c , M~lt1direct1onal , Bilateral , (responds to) Rehabilitation, lnfe·
rior-Capsular-Sh1ft-operat1on 1s useful (if operat·
· i on ·1s require
. d) , .in t erva 1 ( ro tator) clo·
sure may b e d one.
Clinically
1 . Exclude general ligamentous laxity (as in Marfan' d CP . · ts thumb,
s syn rome) ~ test M Join ,
pes planus, elbow hyperextension, etc. (see page 31 )
2. Test the - ·
(a) Power of deltoid muscle, and also the external a d . t f houtder.
(b) Axillary nerve _ Sensory and motor. n m erna I rotators o s
3. Apprehension test : With patient supine with the sh . ·de of the bed,
bring the arm at 300 450 900 1200 f . oulder hanging by the s1 t('f to
· , , o abduction~ pati t f 1 · e and rnaY
resist abduction. (see page 42) If . en ee s msecur fof1 bY
. apprehension test is neg f d th 8 augments ' s
trying to forcefully push the humeral head ante . a ive O rtorrn Joi>'
1
Relocation Test - when a posteriorly directe~1ofr Y. If _the he~d moves out pe al head ,ne
orce 1s applied to the humer
head reduces, an d w hen the force is released pat· f .
tent eels pam.
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4. Load shift test : With th e patient up rig ht, axial compress ion is applied to the humeru s
(load) foll owed by altern ate anterior and posterior shift of the hum eral head by holding the
humeral head.
5 . Anterior/posterior drawer sign : To detect anterior/posterior stability.
x-rays
• Lo ok tor Hi ll -Sach and Banka rt' s lesion and al so ante rior gl enoid rim d e fects in the
West-Poin t view , Stryker-Notch view, Hill-Sach view , AP and lateral view s .
• AR THROGRAM may be usefu l to detect rota tor cuff injuri es .
N.B. : MRI and CT scan may be indicated for reasons mentio ned before (See page 219).
Treatment
Surgery is indicated for patie nts having ~ 3 episodes , especially for the TUBS s ubgro up .
Numerous operations have been described and recommended . Some commonly done pro-
cedures are -
1. Bankart operation : Glenoidal labrum and the torn capsule is reattached . Useful when
bony defect is less than 30%. May be done arthroscopically .
2. Latterjet operation : When there is bony Bankart defect of more than 30% .
3. Magnuson-Stack operation : Detaching the subscapularis and capsule , and reattach-
ing them more laterally. Abduction and external rotation are comprom ised .
4. Boytchev's operation : Re-routing of coracobrachialis and the short head of biceps from
over the subscapularis to under the subscapularis ~ thus making subscapularis taut.
5. Putti-Platt operation : Dividing , then double-breasting the subscapularis muscle .
External rotation is reduced post-operatively.
ARTHROSCOPY
• Commonly performed minimally invasive procedure, where instruments are introduced
into joints through very small incisions, enabling "key-hole" surgery.
• Knee is the most common joint where arthroscopy is done, followed by the shoulder,
but ankle , hip, wrist and elbow joints are all amenable to arthroscopy .
• Useful for diagnostic, and also for treatment of various cond itions e.g ., men iscec-
tomy, meniscal repair, anterior cruciate ligament reconstruction , foreign body/ loose
P body removal, synovectomy, Bankart lesion repair , rotator-cuff injury repair etc .
rocedure : Tourniquet is used for most cases . The arthroscope consists of rod-lens
sy st em (Which magnifies the image) , a solid-state camera (which improves resolution
:i~d Colo~r) and a fibre-optic light source . The ca~er~ transmits the picture t? a tel~vi-
n monitor. The joint is continuously irrigated (with ringer lactate/ normal saline) which
:~i~ures cl~ar vision, and joint-distension with the fluid is ~elpful f~r haemost~s is . One
tio Portal 1s used for the arthroscope , while another (sometimes 2) 1s used for mtroduc-
Clo~;~ other operating instruments like the probe . After the procedure , skin incisions are
DI by 1 or 2 stitches and the patient may go home the same day (Day Care surgery) .
sad" , .
dime ~ntages : Steep learning curve : Since arthroscope provides mono-ocular and 2
ellpe ~siona1 vision depth perception is difficult. Skill only comes by extensive practice and
4 rience . '
d\'anta e '.which takes long time . . . .. .
9 s · 1. Low morbidity : Reduces post-operative pain, en~ur~s ~~1ck rehab1htat1on .
2 . Cosmesls : No ugly scars , due to very small ~krn _rnc1s1ons .
3. Cost-effective : Less hospital stay, less comphcat1ons and. t~us. less cost.
4 - More accuracy : Structures can be seen (even when the Joint 1s moving)
and "palpated" by probe (most commonly used arthroscopic instrument)
and biopsied .
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Complications : 1. Haemarthrosis .
2. Infection.
3. Thromboembolic disease .
4. Damage to intra-articular structures.
Contraindication
1. Risk of septic arthritis due to local skin condition, or a remote infecti ve focu s.
2. Ankylosis is a relative contraindication .
N.B. • "Empty fossa" sign , "Cyclops" sign are found in AGL injuri~s: " ~rive-through"
sign in PLC injury of knee and "Sourcil" sign in rotator-cuff inJunes.
-
HUMERAL SHAFT FRACTURE
• The cross -sectio n of the humeral shaft gradually changes from circular proximally
to antero-posteriorly flatte ned distally .
• Humerus is well covered by muscles,
which ensures good vascularity , and
thus helps in union. Also , muscles hide
any deformity which may result from
malunion .
• Radial nerve lies in very close proximity
of the shaft, making it liable to injury.
Mechanism of Injury
• Direct : Common . Usual ly transverse ,
short oblique or comminuted fractures.
• Indirect : Fall on outstretched arm re-
sults in spiral or long oblique fractures .
Clinically
Patient presents with pain, swelling, defor- Fig. 5 .8 : AP view of X-ray of humerus and shoulder
mity. There is tenderness, crepitus and ab- showing transverse fracture shaft of humerus in the
normal movements at the fracture site. Radial middle third. with lateral angulation and shift.
nerve must be examined for neurodeficit.
X-rays
AP and lateral views including shoulder and
elbow joint is needed.
Treatment
More than 90% fractures unite without
surgery. If there is malunion , then 20°-300
angulation and up to 3 cm shortening is ac-
ceptable . Muscle bulk hides the deformity .
A. Conservative :
1. Ha':ging-~rm Cast : Suitable for long
ob_l1.que/sp1ral fractures with shortening.
Ut1l.1zes gravitational force whereby the
weight of the cast provides traction.
Relative contraindication is a trans- Fig . 5 . 9 · X -ray of middle third humeral sha ft
fracture being treated w ith U-sla b.
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p ,
X-RAYS 223
verse or sh ort obliq ue fractures , which may end up in non-union due to distraction .
patient must be upright or semi-upright for this principle to work (must sleep propped-
up) (see fig. 5 .10).
2 . U-slab or Coaptation Splint : Indicated for transverse and short oblique frac-
tu res with minimal shortening . Additionally collar-a nd-cuff sling is used some -
tim es with a rm to chest bandage . Gravitational force is also used here , but with-
out the additional weight of the plaster cast , which reduces the chance of d istrac-
tion . Slab is applied from the root of neck ~ across lateral arm ~ around elbow
~ up across medial arm ~ to the axilla (see fig . 5 .10) .
3 . Functional Cast Bracing (FCB) : Util izes the effect of soft-tissue (muscles) com·
pression by " Hoop-Stress " to maintain fracture alignment, at the same time al-
lowi ng elbow motion . An anterior and posterior "shell" is held together with velcro
strap s, which are tightened daily. Often , hanging-arm cast or coaptation splint is
changed to cast bracing after about 3 weeks . (see page 95 for FCB in Tibia) .
4. Shoulder Spica Cast : It plays a
very limited role because indicated
patients for this method do very well
with surgery . The arm is kept ab -
ducted , thus eliminating gravity in-
duced distraction .
B. Operative :
• Indications -
1. Segmental fractures .
2. Pathological fractures (see page 246).
3. Holstein-Lewis fracture (see page 95).
4. Where associated injuries compel bed-
rest i.e., upright position is not feasible.
5. Where acceptable alignment is not
achieved with conservative measures.
(a) Coaptation splint •
(b) Hanging-arm cas t
Fig. 5 .10
6. Fractures associated with vascular
injuries.
N . . alsy and the plan of management is operative then
.8. • When there rs radial _ne~ve P 51
·ttin must be done.
radial nerve exploration in the same g
• Methods -
. . (ORIF) using plate and screws.
1- Open reduction internal fixation · 1 d reduct,·on tech-
by open reduction or c ose
2 - Interlocking nails (ILN) - may be d one
nique (see page 239) .
Cornplications . .
1 R ·n middle third fractures. The lesion 1s
· Bdia/ nerve injury (Nearly 18%) : Com~ont'~n returns by 3-4 months . NCV has to
1
~europraxia or axonotmesis, and usu~lly un~ tracture - page 95) .
e done at about 3 weeks (see Holstein Lewis erse fractures soft-tissue inter-
2. Non . . t are ~ transv , .. .
. -union (Nearly 15%) : Risk tac ors . and inadequate immob1lrzat1on .
Posrtio . d. t I third fractures ,
3 n, distraction, proximal or rs a be injured .
Vascular injury : Rare but serious . Brachial artery may
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224 IION
OLECRANON FRACTU E
• The olecranon ts vu lnerable to rracture because of its subcutaneous location . It is
relatively uncommon in the younger population and rare in children .
Mechanism of Injury
o;rect trauma (may be due to a simple fall on the point of elbow) is a common cause of
olecranon fracture , especially in the elderly patients.
• In the younger population (although uncommon) , indirect trauma is the cause where
a fall on a partially tlexed elbow with strong and sudden contracti on of th e triceps
muscle results in an avulsion fracture of the oclecranon .
• Very high velocity trauma (e.g., road traffic accidents , gunshot injuries) prod uces com-
plex fracture patterns, which are often a combination of both the above mechanisms.
Clinically
• Patients typically present the affected upper extre mity supported by the contralat-
eral hand, with the elbow in slight f lexion . The elbow is swollen , and the re may be
abrasions .
Treatment Objectives
1 . Restoring :
Type 1 Type 2 Type 3
(a) Articular surface .
Fig . 5.12 : Classification of olecranon fractures . (b) Elbow extensor mechanism.
2. Preventing :
(a) Elbow stiffness, i.e. ensuring full range of movement.
(b) Complications.
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X- RAY S 225
Treatment
, Non-operative ·
1. Indicated for -
(a) Non -dis placed fractures t hat
does not separate wit h elbow
flexion to 90°.
(b) Disp !ac_ed fractures in poorly
functioning old patients.
2. Long arm plaster cast at about 45° to
60° flexion is kept for 2 to 3 weeks
then active and assisted exercise~
are started. Follow-up X-ray is done
at 7 to 15 days to exclude late frac-
Fig . 5 . 13 : Post-operative X-ray after T B W for
ture displacement.
olecranon fracture - AP and Lat. view .
• Operative :
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When wire is used for internal fixation of tr.i t11t ·,. n t it wir e is applied on the tension
surface of the bone , the procedure is called 1 W
Working Principle of TB W .
• When a fra cture d bo ne is centrally
loaded, the re is uniform compres -
sJOn at fracture site, but if it is ec-
ce ntrica lly loaded , the n there is dis-
tract ion on t he tensile su rface . [Fig .
5.14- (a)] .
• If the tensi le surface is kept fixed , the
eccentric force cannot open up the
(b) ( c) fracture , and the distracting tens ile
force is changed to compressive force.
( I)
[Fig . 5.14-(b)].
Fractures that can be fixed by TBW.
Fractures of patella, olecranon , medial
and lateral malleolar fractures of ankle ,
fracture greater tuberosity humerus. Also
fracture lateral end of clavicle , metacarpal
(diaphyseal) fractures , greater trochanter
of femur can be fixed by TBW.
Pre-requisites
(a) (b) (c) 1. Bony cortex on the compressive side
( 11 ) must be sufficiently strong to withstand
Fig. 5.15 : In knee (I) or olecranon (II). Fractures ~ the compressive loads generated, oth-
(a) , flexion of knee or elbow joint, causes opening erwise it may cause comminution and
up of fractures~ (b) . TBW causes dynamic com- thus fixation failure . The fracture
pression at the fracture site ~ (c) . should be nearly perpendicular to the
plane of motion of the nearby joint.
2. The wire used must be strong enough to
withstand the distracting tensile forces,
otherwise it may cause wire breakage
and implant failure.
3. Adjoining joint movement must be en-
couraged very early after operation for ef-
fective compression at the fracture site.
4. Prestressing (tightening) the wire is a
must [which tends to open up the fr~c -
tu re at the compress ion side (fig .
5.16)], so that the bone remains loaded
in static compress ion .
5 · 'K' wires are commonly used as an ad·
juvant implant, which prevents fractur~
translation, shearing , rotation. and pro
Fig . 5.16 : Prestressing of the tension band. vides anchorage points for the wire.
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X-RAYS 227
Advantages
1. Minimal implant material is used to achieve excellent fracture fixation .
2. Provides dynamic compression at fracture site .
3. Minimal post-operative immobilization is requ ired and at a low cost.
complications
1. Subcutaneously placed wires may cause wire prominence , skin irritation , pain and even
skin breakdown .
2. Wire may break early or may get cut-out from bone.
3. Needs second operation for implant removal.
Clinlcally
1 · Mild pain/swelling ~ often a missed diagnosis. . . .
2 · . d noted which i with passive pronat1on/supinat1on.
· Direct tenderness over radial hea ' t Essex Lopresti fracture see
3 Al d. t I forearm (to rue
1 ou - •
· ways palpate wrist and is a f edial collateral liga me nt of elbow with
Page 228), and note the competence O m
Valgus stress test.
ray8
.
AP view· . (n eutral rotation forearm , X-ray beam directed
Lateral view· Greenspan view
45° . .
cephalad). elude DRUJ (Distal Radio-Ulnar Joint) injury .
ray of the wrist is always done to ex
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Clas i ,cation (Fig . 5. 18)
I. Non displaced.
11 . Marginal with displacement.
Ill. Comminuted.
IV . Associated elbow dislocation .
Treatment according to classification
II Il l IV
• I ~ Non-operative : Collar-and_-cuff sling Fi . 5 _1 8 : Classification of radial head fracture.
+ early movements + analgesics. 9
• II ~ Intra-articular lidnocai ne injection ~ note range of motion . If nearly full ROM ~
treat as in I. If ROM ..1, then ORI F with a screw ± T-plate . . .
• Ill ~ Excision of radial head. Metal prosthesis is sometimes used afte r excision.
• IV ~ Elbow dislocation red uction is done. Then fracture is treated , as above .
Complications
1 . Joint stiffness of elbow and limitation of pronation/supination .
2. DRUJ injury with wrist pain .
3. Post-traumatic osteoarthritis due to articular incongruity.
RADIAL NECK FRACTURE
• Common in children, not in adults . Most are Salter-Harris IV injuries. (see page 66)
• Mechan ism of injury ~ Same as tor radial head fractures .
• Up to 30 °-40° angulation of head is
acceptable ~ only treatment required is
collar-and-cuff sling and early movement
from 2- 3 weeks.
• > 45° angulation ~ Manipulation under
anaesthesia to bring angle to 30°- 45° ~
then collar-and -cuff sling .
• If manipulation fails to achieve accept-
able angulation ~ Open reduction.
• Complications of ORIF ~ Stiffness, pre-
mature physeal closure , non-union and
Fig . 5 .19 : Angulation of head after fracture avascular necrosis of radial head, radio·
neck radius . ulnar synostosis , myositis ossificans.
ESSEX-LOPRESTI FRACTURE
• Longitudinal disruption of forearm interosseous membrane + radial head fracture + distal
radio-ulnar joint (DRUJ) injury.
• W_rist pain is _the most important and significant sign. Very oft en a missed diagno·
s,s. Lateral view X-ray of the wrist is a must.
• Never excise the radial head , if there is DRUJ injury.
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• Fo r all di stal 1/ 3rd radial fractures , suspect involvement of the distal radio-ulnar
jo int (DRUJ) until proved otherwise .
• It is a "Fracture of Necessity" because it always requires "Open reduction and internal
fix ati o n" (O RIF) . Non-operative treatment results in loss of re duction , with the chief
defo rming fo rces coming from pronator quadratus , brach ioradialis , extensor pollicis lon -
gus , abdu ctor pollicis longus and the weight of the hand .
Note: • Reverse Galeazzi fracture~ fracture of distal ulna with disruption of the DRUJ .
• Night stick fracture ~ isolated ulnar-shaft fracture, usually due to a direct blow .
Mechanism of Injury
1. Fall on outstretched hand with pronated forearm .
2. Direct trauma on dorso-lateral aspect of the wrist.
Clinically
Pain , swel ling of mid-forearm . The pain i
with stress ing of th e DRUJ . Prominence of
distal ulna is striking .
X-rays
Radius is angu lated dorsally + Signs of
DRUJ injury which are -
1. Fracture ulnar stylo id .
2. Widened DRUJ on AP view. (Fig 5.20)
3 . Subluxated ulnar head on lateral view.
4. > 5 mm shortening . (see Fig 5.21 )
Fig. 5 .20 : AP view X-ray of wrist and lower
Treatment forearm show ing G aleazzi fracture .
No te : widened DRUJ
Open reduction and internal fixation (ORIF)
With plate and screws ~ at least 3 screws on
either side of fracture ~ X-ray (or C-arm)
evaluation to note DRUJ reduct ion . If reduced
~ PQp cast for 6 weeks . If subluxated , it
mu st be reduced and 'k' wire fixati on is don e,
Which ·18
kept for 6- 8 weeks .
Cornp1 icati ons
,. Ma/union ~ Results in loss of prona -
tion/supination . Rarely , may cause re-
current dislocation of DRUJ .
2 Fig . 5.21 : Lat. view X-ray of wrist and lowe r
· IV 0 n-un; after forearm showing Galeazzi fracture .
ORIF R on . ~ Very unc?mmon
· equ1res bone grafting. Not e : subluxated ulnar head
SCAPHOID FRACTURE
• It is th
• M e most common fracture of the carpal bones .
0st
commonly occ urs in young adults (NOT in children or the elderly) .
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230 HANDBOOK FOR 1
• Mechan ism of Injury : Fall on outstretched hands, with hyp rexte nd ed elbow and radial
deviation of wrist.
N.B. • Scaphoid moves with nearly all carpal motions especially volar flexion .
• 80% of the scaph oid is covered with articular car1ilage (hen~e d~ not have soft
tissue attach ments, which is vital for vascularity) because it articulates with 4
bon es - radius, lunate, trapezium and trapezoid .
• Vascular supply (Fig. 5.22) : Majority (70%) is from the do rsal branch of radial
artery which enters the proximal pole of scaph oid vi a the dorsal inte rcarpa l liga-
ment through the dorsal ridge . The distal pole has minor vascu l ar s upply (20%-
30% ) entering through the tubercle from volar branch of rad ial artery. Thus
proximal fractures have a very high possibility of avascular necrosis and non-union.
Tuberosity and distal fractures usually unite , and about 80% of w aist fractures also
unite .
Diagnosis
Delayed d iagnosi s is common , wh ich
delays treatment and wo rs ens prognosis.
• Clinically :
1. Anatomical snufi- box fullness , and
tenderness .
2. Watson test - Pain with dorsal dis-
placement, as the pronated wrist is
moved from ulnar to radial deviation
Fig. 5 .22: (see page 72) simultaneously flexing
the wrist and applying dorsally di·
rected pressure over the scaphoid.
• Radiological :
1 . Postero-anterior view X -ray , with
the hand clenched in a fist (to ex·
tend the scaphoid) and the wrist in
ulnar deviation . Lateral view, to·
gether with radial oblique and ulnar
oblique views are also essential , be·
cause diagnosis is often missed .
Fig. 5 .2 3 : Locations of scaphoid fracture .
25% to 30% fractures may not be
obvious in initial X-rays.
2 . MRI may be very useful fo~ early diagnosis (by 3,d day) . Gadolinium enhanced MRI
detects vascular compromise .
99
3 . C T Scan , Tc bone scan (see page 251) • are also useful for earIy d'1agnos1s.
·
Treatment
I. For young adults with history of fall on outstretched hands foll d b · t ain/discorn·
'ff / 11· d h . , owe y wns p
f o rt/ st1 ness swe ing an aving tenderness of anatomical sn f f-b BUT no evidence
of fracture in X -rays ~ Thumb Spica scaphoid cast immobi~zati: · for 2- 3 weeks ~
repeat X-ray , to look for fracture (often resorption of fracture end makes t he occult
fracture visible after 2- 3 weeks) .
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X·AAYS 23 1
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FIRS METACARPAL BA E FRACTU ES
• There are 2 well known types : Ben nett's rracture (partial intra-articu lar involvement) and
Rolando fracture (complete intra -articular
2nd meta carpal
involvement) .
1. Bennett's fracture
• First descri bed in 1882 by Irish surgeon
Bennett.
• It is an intra-articular fracture through the
base of the first metacarpal. (see Fig.
5.25)
APL attach men t
Bio-mechanics
Fig . 5.25 : Bene tt's frac ture
• The metacarpal shaft is pu ll ed proxi mally
and laterally by unopposed pull of the abductor pollicis longus (APL) , while the distal metac-
arpal is supinated and adducted by the adductor pollicis.
• Reducti on by tracti on and manipulation is easy , but maintaining the reduction is difficult.
It is not ad visable to attempt reduction after 6 weeks from injury, because of poor results.
Treatment
1. Closed reducti on and percutaneous 'K' wire fixation is best , when poss.ible. Otherwise
open reducti on and internal fixation (ORIF) by 'K' wire may be requ ired .
2 . Plaster cast immob ilization is rarely successful in maintaining the reduction , bu t up to
3 mm of incongru ity can be acceptable .
Complication
Malun ion is common when treatment is non-surgical , which often leads to painful osteoar-
thritis of the 1st carpo metacarpal joint. It is best treated with arthrodesis.
2. Rolando fracture
• First described in 1910.
• It is a 'Y' or T - shaped comminuted
fracture of the base of the 1st metacar-
pal. Usually it never causes displace-
ment of the metacarpal shaft.
• Treatment is always surgery . Most can
be succesfully treated with closed re·
duction and percutaneous internal h a·
tion with 'K' wires. If closed reducuo~
fails , open reduction internal fi atrot
Fig. 5.26 : Rolando fracture (ORIF) will be required .
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X f AYS 23
Mechani n of Injury
• In young adults - high v loc ity traum Ilk r d trutrl uccld nl (n I A) or I ,II from h 10111.
• In elderly pa tients, suspect pathologlcal tr ctur unt I prov d oth r'Wl
clinicall y
• Patient cannot walk/st nd ; th er is gro thigh w lllnc nd cJ lorml ry, wl ll1 ,llort· n cl nnd
externally rotated leg . Often pali nl pr ents with shock, th I for r gul II rnonllorlnc ol
pulse, blood pressure and sensorium I mu 1.
• Examination of the ipsilateral hip and knee is Import nl N rly r.:0% ,n, y 111v or
hip injuries.
• Do not forget to exami n e the abdom n, ch st, p lvi s, spin n I oth r l lmlJ' for an y
polyt rauma patient.
X-rays
1. AP and lateral vi ew of the femur includ-
ing the hip and knee.
2 . AP view of pelvis with both hips is
mandatory.
Treatment
• Emergency : Treatment for shoc k is
essential . Thomas splint is useful
while resuscitation or during p a ti e nt
transport (see page 19 1 ) .
• Definitive :
1. lntramedullary interlocking nails (ILN
- see page 239) is the treatmenl of
choice for mos t adults, the elderly
and also for pathological fractures .
(see pag e 246, 247) .
AP-mid h,dl, florl-obllqu Loi low1 r 11-J rel, Ion • l)llquo
2. Early reduction a nd internal fixation
Fig . 5 .2/ : roc l lJ1 tw it t mur
is important for patients with associ~
ated inju ries.
3. Besides ILN other methods of inte rnal fixation ,nc_ l ud
(especia lly f~r distal 1/3rd fractures) and 'K' n ii llxat,on (
4. For open fractures external fixation (see page 240) is u ful but 11 h llrnlt cJ ro l a
• t. ILN is also use ruI for O p n fractu r ' ·
a defini tive treatmen
188, 18<)
5 . Skeletal traction is only used temporarily for patien t t· blliLatlon. (
Complications
1
· Shock : Most patients need blood tranSfuSion .
2 F t h 1ae a r
· at embolism : Dy spnoea, tachycardia , pe ec Important f ;lluri n p< r1t1 J
observations at short time- intervals are necessary .
3 . Va · omerg ncy d m ndtn<J mJ nt c,p mtlv 1n1r 1-
scu/ar injury : Uncommon , but ti ts an
vention .
4. ltJfect;on : Rare in closed fractures Common ,n open fraclur
5. Afatunfon · C ommon Iy occu rs w,th conservative !realm nt.
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-
FOR ORTHOP EDIGS E !NATION
Fig . 5 .28 : AP vi ew X- ray of pelvis with both hips Fig . 5.29 : AP and Lat. view X-ray of fracture shaft
and right femu r a nd kn ee s how in g spiral fracture femur treated with TENS.
of middle thi rd of right femoral shaft.
1. Age < 6 months : Pavlik harness or posterior splint. Up to 30° angulation , 15 mm shorten-
ing is acceptable .
2. Age 6 months to 6 years : Immediate hip spica if angulation is within 15° in AP view, 20°
in l'a teral view and there is $; 2 cm shortening (which are acceptable) . Otherwise, surface
traction is given for 3 weeks until acceptable alignment is reached , then hip spica is done.
3. Age 6 years to 12 years : Flexible intramedullary nails (e.g., Titanium Elastic Nail i.e.,
TEN) are introduced retrogradely, avoiding the physis (Fig . 5.29) .
4 . Ag·e 12 years to 16 years : ILN or flexible nails (TEN) .
PATELLA FRACTURE
1 . Constitutes about 1 % of all skeletal injuries.
2 · M : F =. 2 : 1 · Patella is the largest sesarnoid bone of the body. Its subcutaneous position
makes it susceptible to direct trauma. Unilateral patellar fractures are the most common.
3 · There are 7 articular facets of the patella - the lateral facet being the 1arge st
(50% of surface area) .
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X-RAYS 235
_ Medial and lateral extensor retinacu lu m are strong longitudinal expansions of the quadri -
4 ceps muscles. When these are uninjured, active knee extension is preserved desp ite
the patella fra cture.
5. usefu lness of the patel la - to increase the mechanical advantage and leverage of the
quadriceps, to protect the femoral condyles from direct trauma and to help in nourishment
of th e fe moral articular surface .
Mechanism of Injury
1. Indirect : Forcible contraction of the quadriceps, with the knee in semiflexed position ,
usually results in a transverse fracture .
2. Direct : Displacement is minimal because the medial and lateral extensor retinaculum ex-
pansions are preserved . Skin contusions and abrasions may be found .
3 . Most patellar fractures are a combination of direct and indirect forces.
Clinically
• Swell ing of the knee , and sem iflexed attitude of knee. Abrasions may be present.
• Tenderness is noted and a palpable 'gap' is often felt over the fracture site.
• Active knee extension must be noted to determine retinaculum expansion injuries. This
may be facilitated by aspiration of the haemarthrosis and intra-articular inj ection of
lidnocaine.
N.B. : Open fractures must be ruled out. This is done by aspirating the knee joint with a 18G
needle ~ injecting 50 ml sterile normal saline through the same 18G needle ~ if saline
flows out through the wound , then the fracture is open .
• Open fracture is a surgical emergency . Immediate debridement and copious irri gation
must be done , followed by soft-tissue coverage with in 5 days . T hi s reduces the
chance of infection .
• All efforts should be made to avoid total patellectomy , because then about 15%
to 30% of quadriceps power is lost. Patellectomy is d?ne onl y for se~~rely comminuted
"stellate" fractures with unsalvageable fragments , and in very old , deb1l1tated , and poorly
functioning patients .
X-rays
• Lateral view : To note d isplacement of the fractures .
• AP view : To distinguish between bipartite patella (pre_s_ent in ~% of popul~tion _where the
margins are smooth , located at the supero-lateral pos1t1on , 50 1/o cases being bilateral}.
• Axial view (Skyline view) : To identify osteochondral or "marginal" fractu res (ve rtical
fractures). [Fig . 5 .31]
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2 f A It I AMII I I I( IJ
Trcatm nt
1 lmtia/Jy : Ice ,1ppli<'<1l1011, cylinc..J r pl,1 IN ',lalJ {lrurn ,JIJr1vrJ :JrtYl 1J tr1 th{) 'WJirlJ,
2 Non-operative . Incite l d lor clo:,o cJ Ir, c, luro', with rn1r11rnurn 1Jl',pl:cJr,1; rrr1,n1 ("' % ,,,,t,J
and intact ex len ~or retinaculum. Cyltnd r plablor cw,t for 6 Fj 1/t<J<;Y'> ,,, rJur1<; ! l ift ,,,,.,.
metric quadricep s exercises and oncou rag rnont of oarly wrJi9rJ1 bt.s~rir, , I t1<;r '"'"'.,I
removal gradual knee flexion a nd iso toni c quadricop•, .,/ <Jrr,1', <;, r.,(<j 'A;, rtr)rJ ,
3 . Operative :
(a) Ind/cat d for fr,:; r..turc:;., 1111tt1 ~ 2 r; ,,,
dtspl' com en I, /. e., frc,r, urn ., ~ r,(,,i.
ated wi1h retinac:.,ular ~/ p<:tn i n <,~r,:,
an d open frar, ture .
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X-RAYS 237
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- - - -========------ial- 1-~==-·- ---
__
.__ 238 HANDBOOK FOR ORTHOPAEDIC~ XAMINATION
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INTERLOCKING NAIL (ILN)
is the most common implant used for fixation of diaphyseal fractures of long
• 0ries, which has made the non-locked nails (e.g., 'K' nail) almost obsolete despite
i lower cost, simple technique and less instrumentation .
iJ
Locking is done by inserting screws from one cortex~ through holes in the nail ~
• up to th e opposite cortex . When this is done proximal and distal to the fracture , it
ensures ROTATIONAL STABILITY (mai n advantage over non-locked nails) , and
also mai ntains length (prevents collapse) . At least 2 holes are present at the proxi-
mal and distal ends of the interlocking nail for screw insertion.
Suitabl e bones for ILN ~ tibia , femur and humerus are common . Midshaft ra-
• dius/ulna fractures are also amenable to ILN .
Indications
1. Closed fract ures of the shaft, which
are not very close to the joints (for fe-
mur, it is ideal when the fracture is be-
tween the lesser trochanter and the
condyles) .
2. Pathological fractures (see page 246)
3. Non-unions and pseudoarthrosis .
4. Malunions and deformities (see page
248)
5. Open fractures up to Gustilfo Ill A (Ill
B is controversial) .
Newer use
1. Arthrodesis of knee joint wi th a long
femur-tibia nail.
Limb-lengthening over ILN , using an
additional external fixator.
Closed vs. Open nailing
Closed nailing means where the fracture
nd
site is not opened during operation , a
th d cu F. 5 37 : Midshaft fracture femur treated
e nail is inserted antegrade an per . - ,g. · with ILN
t~neously. It is the method-of- ch01_c e · .
since it retains periosteal vascularity I duction is not possible , open reduction
and reduces infection . However, if accepta~de red but non-union and infection rates are
folio .. be cons1 ere ,
Wed by antegrade nailing may
much higher for open nailing .
Reamed vs. Unreamed nailing
4dvanta f .
ges o Reammg : . lant) can be used .
;· larger diameter nail (thus st_ron~~;s'~:e bone graft, which has osteoinductive property .
. Bone-dust produced by reaming d a smooth procedure.
3 N ·1 · ick easy an
· a, insertion becomes qu · d th ough endosteal blood supply is damaged.
4· Periosteal blood supply is increase '
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Disadvantages of Reaming :
1. Destroys endosteal vasculature and causes necrosis of the inne r cortex.
2. He at is generated and t he raised intramedullary pressure increases the
chances of fat embolism .
3. In open fractures , reaming may disseminate contaminati on/infection . However some
authors claim reaming decreases infection , when irrigation and aspiration is simul-
taneously done. (Reaming-Irrigati on -Aspiration)
4. Undisplaced occult butterfly fracture fragment may get displaced.
Advantages of ILN
1. Early mobility/ambulation of the patient reduces post-operative complications.
2. Provides rotational stability in a load-sharing implant. (Remem ber-plates are load
bearing implants).
Disadvantages of ILN
1. Needs specialized fracture-table and C-arm image intensifier, which increases the cost.
2 . Needs expertise which comes with a steep learning-curve.
3. Locking is difficult in proximal 114 th and distal 114 th fractures .
Dynamization
When locking screws are present only at one end of the nail , it is called dynamization.
Commonly the shorter fragment is kept locked . It permits compression at the fracture
site , which is beneficial in delayed unions . Since static locking (screws at both ends)
uniformly achieves good union , routine dynamization is not practised / advocated .
EXTERNAL FIXATION
• It is a process of rigid stabilization of fractures by percutaneously placed pins or
tensioned wires , which are then connected to an external frame (the implant as -
sembly is placed at some distance from the body) .
Types - Pin fixators and Ring fixators .
1 . Pin Fixators : Very useful for trauma management. The application is quic ·
5 varieties of frame constructions are possible (Fig . 5.38) .
(a) Unilateral uniplanar.
w
(b) Bilateral uniplanar.
cJ
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(c) Unilateral biplanar (Delta frame) .
(d) Bilateral biplanar.
(e) Modular frame - Various combina-
tions of the above.
Choice of frame must take into ac-
count the following considerations -
(i) Safe 'anatomical co rr ido rs'
tor pi n insertion , avo iding
nerves and vessels .
(ii) Adequate access to wounds for
secondary procedures like skin Double rods - anterior Delta frame
grafting. and posterior
(iii) Suffici ent stability against de- Fig . 5.39 : Cro ss section of bone with
forming forces . pins and clam ps.
2. Ring Fixators : T he work of Russi an scientist , GA. llizarov , with ring f ixators and
especially the concept of distraction osteogenesis has immensely en ri ched o rth o -
paedic surgery . Co mplete o r pa rt ial ri ngs are secured to bone w ith half-p ins o r
tension ed wires , while the ri ngs are interconn ected with rods or articulated implants .
The diameter and tension of the wi re are important for frame stability. The size , num-
ber and location of the rings are also important. (Fig . 5.40) .
Corticotomy Osteogenesis
New bone
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(d) However, t 1::. d .ime consu'"l1111g nnd an elaborate p roc ess that does not allow much
soft-tissue a1.;cess and 1s not suitable for initial trauma management.
1 0 . Deformity correction ,
~1
and for patient transport.
9. Limb-lengthening commonly
~one :,'-'ith
ring t,xators
Advantages
1 . Rigid stabilization of open fractures
without fracture exposure ~ de-
creases chances of infection and pre-
serves vascularity .
Fig . 5.42 : Anterior external fixator frame used 2 . Allows monitoring of open wounds to
for pelvic fracture . assess the viability of soft-tissues
and also permits skin -grafting , d ressing, etc ., without disturbing the fracture .
3 . Early motion of the adjoining joints preven t s joint stiffness, muscle atrophy and
osteoporosis.
4 . Compression/distraction (as required) can be done at the fracture site.
5 . Limb-lengthening , gradual deformity correction and treating infected non-unions are all
significant advantages.
Disadvantages
• Assembled external frame may be cumbersome and a psychological burden which
may lead to non-compliance and rejection, psychiatric problems.
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• Most pati ents need 2 nd op:
era
:~t:i o:n:-:(f;o:r-
: --;=;::= : ~ - = == =-== ===~~::::'.'~:::::=i.
pe rm ane nt sta bili z ation) ~ defini -
tiv e interna l fixat ion .
com pl icat ions
1. Pin- tract infection : Very common .
Mi nim ized wit h meticulous technique
and regular care of the exposed pins/
wires/frame (cleaning with antiseptics) .
2. Neurovascular injury : It occurs dur-
ing pin inse rtion and is avoidable with
soun d knowledge of the safe anatom i-
cal corrid o rs of the limb .
3. Impalem e nt of soft-tissues : Ten -
dons may ruptu re and muscles may
fibrose , caus ing j o int st iffness .
4 . Re-fractures : May happen either
through t he p in-tract in the bone (after
pin removal) or through the original
fracture si t e (due to minimal peri-
osteal callus) .
5. Compartment syndrome : The intro-
duction of pin increases compartmental Fig . 5.43 : AP and Lat. view X-ray showing pin external
pressure (see page 76) fixator used for treating fracture in both bone leg .
ANKLE FRACTURE
•Most ankle fractures happen due to low-energy trauma due to "twisting" injury (rotational
mechanism). Rarely high-energy trauma causes severe fracture patterns which may in-
volve the tibial plafond (pilon fracture).
• Bimalleolar fractures = Pott's fracture , Trimalleolar fractures = Cotton's fracture.
Mechanism of injury : The foot remains in contact with the ground while the patient falls down, which
causes the talus to tilt and rotate within the small and fixed space of the ankle mortise. This causes
breakage of the lateral maleolus, or/and medial maleolus and sometimes the posterior maleolus.
~l~ssification : (I) Danis Weber - Based on the level of fibular fracture in relation to the inferior
t,b,o-fibular syndesmosis. (Fig. 5.44)
• Weber A : Transverse fracture of fibula, below the syndesmosis.
• Weber B : Oblique fracture of
fibula, may be in the sagittal
plane , at the level of the syn-
desmosis .
• Weber C : Severe fracture
patterns , above the level of
the syndesmosis .
(II) L
auge-Hansen - Based on the
rotational mechanism of injury
(a) Supination - Adduction ,
(b) Supination - External Rotation ,
Weber B WeberC
(c) Pronation - Abduction Weber A
(d) Pronation - External rotation . Fig . 5.44 : Ankle fracture
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h fir I p 1 rt ()I th n, rn d scnb s the pos1t1on of the foo t at the time of injury, while the
cond p rt d , nl c • th dir ell n of force pplied to the fool.
Clinic lly On 111 pl cllon note the amount of swelling. T here ~ ay be . blisters and echymo_ ses
which prov1d clu to th location of the injury (which may be in the ligaments). On palpation,
most 11nport nt i t nderness, which again locates the injury. Look for tender.ness ov~r. the deltoid
ligament, th entire fibula, base of the 5 1h metatarsal , calcaneum and th~ ~rndtarsal Joints. Arteria
dorsalis pedis and posterior tibial pulse should be noted alongwith superf1c1al peroneal nerve sen-
sation over the dorsum of foot.
Special Tests -
(1) Squeeze test : Compress the tibia and fibula in the m id-calf region. If there is anterior
ankle pain , the test 1s positive which means there is syndesmotic injury/diastasis of the
inferior tibio-fibular joint.
(2) External Rotation test : Knee is flexed to 90°, the ankle is kept in neutral position, and
then the ankle is forcefully externally rotated. If there is ankle pain, it indicates diastasis/
syndesmotic injury.
(3) Thompson test : Compression of the calf muscle, normally cause plantar flexion. When
this is not seen , it indicates tendoachilles injury.
X-rays - AP view, lateral view and mortise view (30° oblique view) is essential.
X-ray of the leg and knee should be done to detect Maisonneuve fracture, which is a spiral
fracture of the proximal third fibula with a tear of the interosseous membrane, syndesmotic injury and
fracture of the medial malleolus or rupture of the deep deltoid ligament. It is often missed.
Treatment - Main goal of treatment is anatomical reduction of the fibula, restoring it's exact
length. Assessing the stability of the fracture is also crucial for planning treatment. Ankle fracture is
stable when there is no widening of the medial and lateral joint space in the mortise view, and the
tibiotalar joint space is congruous. When unstable, or fibular length is decreased, operation is a must.
• Timing of surgery : If there is swelling/blisters, there should be a delay of 10-14 days for
soft tissue, recovery. Below knee plaster slab and foot elevation is done.
• Fibular fractures : Usually fixed with plates and screws. Other methods like 'k' wire fixa-
tion (page 21 0), tension-band-wiring (page 226) , intramedullary nail (e.g . Rush nail - page
21 O; Titanium elastic nail} , intramedullary screw fixation can also be done. (Fig. 5.45}
• Medial maleolar fractures : Usually fixed with 2 maleolar screws with washers, after removing
the piece of periosteum that gets entrapped anteromedially in the fracture . (Fig. 5.45}
• Posterior maleolar fractures : When fragment size is >30% of the articular surface it should
be fixed by a 'lag' screw directed from anterior to posterior. Fragment <30% need not be
fixed, if fibular length is maintained.
Complications -
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CALCANEAL FRACTUR ·
• Mos fre qu ently fractured tarsal bon e. 2% o'f II fr t'ur
• Also called Lover's fracture or Don Juan fracture . s,
Mechanism of Inj ury
1. Fall from height : The most common
mechanism. Axial loading causes the ta-
lus to be driven into the calcaneum from
above, which breaks the superior cortex .
2. Car accidents : Due to the brake/ac-
c ele rator ped a l forcefully impacting
onto the driver' s hee l.
3. Twisting forces : Causes extra-articular
fractures . Lat. view X-ray of hind-fool Axial view X~ray of ca/-
Clinically and ankle showing tongue caneum showing mini-
fracture of ca lcaneum mally displaced fracture
1. Pa in, swelling , tenderness, echy-
moses , blistering (due to massive Fig . 5.46 : Calcaneum fracture .
swe lling) and w idening of the heel .
2. Look fo r compartment syndrome (see page 76) of foot (seen in 10% cases of calcaneum
fracture ) ~ may cause clawing of the 5th toe .
3. Always search for fractures of lumbar spine (associated in 10% cases) , pel vi s, hip,
femu r, knee and ankle .
Essex-Lopresti Classification
1. Extra-articular (25% to 30%) : This does not involve the posterior facet of taloca lca-
neal j oin t. It incl udes fractures of the anterior process , medial process , tuberosity,
sustentaculum tali and body fractures but does not involve the subtala r joint.
2. Intra-articular (70% to 75%)
Undisplaced fractures , "tongue frac-
tures", "joint depression fractures"
and comminuted fractures .
X-rays
1, Lateral view and axial view is a must. In
lateral view note Bohler tuber joint
angle (20 ° t~ 40 °) which decreases and
Gissane crucial angle (95 ° to 105 °)
Which increases with the collapse of the
posterior facet of talocalcaneal articular
Fig . 5.47 : Line diagram of lateral view of
surface (Fig . 5.47). calcaneum showing Bohler angle
2 · Always X-ray the spine and the ipsi- {B) and Gissane angle (G) .
lareral lower limb. undisplaced/minimally displaced calcanea l
3 · CT Scan is the best imaging option for
fractures , and tor operative planning .
lteatment Options
1· Non-operative : Indicated for undisplaced/minimally displac~d fr~ctures.
• Ice application , elastic crepe bandage, . foot elevation in below -k~ee (BK) POP
slab ~ all reduce swelling . ROM exercises are started early. Weight bearing is
allowed after 10 - 12 weeks .
2. Operative : Indicated tor displaced extra-articular fractures and all intra-articular fractures.
ORIF with plates and screws through lateral approach ± bone graft is done.
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46 HANDBOOK FOR ORTHOPAEDICS EXAM INATION
PATHOLOGICAL FRACTURE
• Fracture in a bone which has been weak d
strength, due to destructive processes (eene by . th e loss of integri ty and structural
Paget's disease) is called a pathological t~!~tir:.c•noma) o r invasive disorders (e.g.,
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Mechanism of Injury
TRIVIAL or MINI MAL TRAUMA is th e most comm
occur spon aneously ( e. g. ' fracture nee k of femu r in .
on cause and. sometimes th e fract ure may
t
causes of Pathological Fracture pal,ents with severe osteoporosis).
i m perfecta .
3. Paget's disease.
Clinically
History
: Fracture resulting from normal activities or minimal tr_auma.
Parn or discomfort at the fracture site Jong before the m1ury.
• Past history of fractures . There may be multiple incidences .
• Weight loss, lump, cough, haematuria, etc. ~
may suggest malignancy.
Examination
ab~~te _wasting , scars , sinus . Look tor lymphadenopathy , th_yroi_d nodule , breast Jump ,
m1na1 mass hepatomegaly. Always do PA and PV examination .
lnve t· ,
s •gation 4
2
• Complete blood count ESA, Ca +, po/-, AlkP0 , Hb.
: ~rinalyses, hour u;ine hydro,ypro\ine (for Paget's disease).
24
erum electrophoresis (for multiple myeloma) .
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- - ----·--·-----
AND800K FOR ORTW P, EDI
MALUNION
• A fracture that heals in a non-anatomical position is called malunion . It is a preventable
condition ~ with appropriate, knowledgeable and skilful treatment.
Problems
Fig . 5.50 : AP view of X-ray distal femur and Fractures of clavicle shaft humerus , bolh
knee showing malunion . bone forearm , trocha~teric fracture, Colles
fracture.
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Treatment
. 4 principles of acceptability of fracture
unt0n must be re membered while tr r
each. individual case. In order of d ecreas-
ea ing
ing im portance , these are -
1. A lig nme nt.
2. Rotation .
3. Length restoration.
4. Actual fragment pos ition . Fig. 5 .51 : Malunited fracture of both bone
forearm . Note the angu/ation.
Acceptability is especially important h
·t · · . w en
1 1s near a 1omt
. or the deformity is m. th e
~ Iane o f motion of the joint (where remodel-
ling can occur) , if growth potential persists.
• Axi~I alignment deformity, in < 9 year old
patients , commonly corrects itself with
growth . Rotational deformities do not
correct with growth.
• Su rgery is considered only when a
malunion impairs function , and not when
it is demanded , although cosmesis is im-
portant. If ope ration is done, it must be
at least 6 to 12 months after the injury - Fig . 5.52 Corrective osteotomy and
Open reduction and interna l fixation (OAIF) done
except for intra-articul ar fractures and
with Dynamic c ompress ion plate (DCP).
Monteggia fractures .
• Corrective surgery at the malunion site is not always necessary e.g ., malunited trochan-
teric fracture with varus deformity (coxa vara) --7 corrective subtrochanteric valgus os-
teotomy is considered as a compensatory procedure. Also, "shaving-off" the protruding
bony spike may be done in malunited clavicle fracture and supracondylar fracture .
• Commonly, malunited site is osteotomized --7 internal fixation in anatomical position is
done ~ bone graft is given for early union. (Fig. 5 .51 and 5 .52)
• lfizarov's ring external fixator is a very efficient method for correcti ng malunion which
simultaneously corrects alignment, rotation and restores length (see page 241 ) .
Special Cases
,. Arthrodesis : (see page 271 ) considered for malunited intra-articular fractures e.g ., ankle
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250 HANDBOOK FOR ORTHOP
--~~__::____:_-----~~-----~-~-...........
Aetiology
1 · Idiopathic or Primary ---) 50%.
2 . Secondary ~ Steroid , Traum a, Alcohol , G aucher' s diseases, Caisson ' s disease ,
Renal osteodystrophy , Infection , Sickle -cell anaemia , Irrad iat ion , Systemic lupus
erythematous .
.
~ Capillary tamponade /
. Vicious cycle of intraosseous ischaemia.
occurs , causing subchondral fractures
(stress fractures) and later loss of
shape and deformity.
Fig. 5 .54 ·
Clinically
• History of alcohol , steroid , trauma . Pain is initially felt only with a particular movement,
usually abduction . . . . .
• Limp is common. Wasting 1s s~en m cases ":'h1ch present late.
• Tenderness, stiffness, later f x d defo
with passive flexion he e
• sectoral sign (see page 3
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X-RAYS 251
OSGOOD-SCHLATTER' A
' A
ri~t0 Physiti.s/Epiphysitis of the tibial tubercle. Som tlm c w \J '.
associated with avascularity .
~-• ---
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....w::::.:::::::s:::w: - .........
Aetiology
It is probably a traction injury of the apophysis of the tibial tuberosity, into which th e patellar
tendon is inserted. Patella alta is often associated. (see page 23)
Clinically
• Always occurs in adolescents where there is rapidly growing physis. .
• Pain atter running , jumping, cycling , climbing stairs, etc. is the com mon co'.11pla'.n .
• Tender lump over tibial tuberosity is tound. Active resisted knee extension is painful.
X-ray
May show fragmentation. (Fig . 5.57)
Differential Diagnosis
Johansson-Larsen disease : Patellar ten-
don partially avulsed from the lower pole of pa-
tella, due to traction tendinitis. X-ray ~ often
shows calcification around lower pole patella.
Treatment
• Rest, Ice, NSAIDs , Activity modifica-
tion - most effective .
SEVER'S DISEASE
Aetiology
It is the apophysitis/epiphysitis of the posterior calcaneal tuberosity at the tendoachilles in-
sertion. It is a traction injury.
Clinically
Patient is around 1 o years of age. Pain +
tenderness over posterior calcaneum is found.
X-ray
Density of the epiphysis is increased. Frag-
mentation may be found . (Fig. 5.58)
Differential Diagnosis
"_Cal~aneal knob " in girls (15-20 years) ,
which 1s often bilateral. Posterolateral promi-
nence of calcaneum is found .
Treatment
Fig . 5.58 : Sever's disease.
. ''.R INA" is effective (Rest, ice , NSAID, ac-
Note : fragmentation on the left side. tivity. modification). Open-back shoes are es-
sential .
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X-RAYS 253
N.B. : seli n's dis~~se : Traction epiphysitis of 5th metatarsal base; Freiberg's disease :
crushing osteo?hondnt,s _of 2nd/3rd metatarsal head; Kohler's disease : Crushing osteochon-
dritis of the _nav1cular; Kembock'~ ~isease : lschaemic necrosis of lunate due to chronic stress;
panner's disease : Osteochondnt,s of the capitullum; de Clave's disease : Vertebra plana in
eosinophilic granulo_ rl:'a; Kumell's disease : Vertebral body epiphysitis in adults; Calve dis-
ease : Osteochondnt,s of vertebral body in a child ; Mandi's disease : Greater trochanter epi·
physitis; Thieman_n's disease : Multiple phalangeal epiphysitis; Diaz's disease : Talus epi-
physitis; Hass' s disease : Humeral head epiphysitis; Ellman 's disease : Radial head epiphysi-
tis; Burn's disease : epiphysitis of distal ulna; Mauclaire's disease : epiphysitis of metacarpal
heads; Buchman's disease : epiphysitis of Iliac crest; Koenig's disease : femoral condyle
epiphysitis of a child ; Pierson's disease : epiphysitis of symphysis pubis: Milch's disease :
lschial apophysitis; Chandlers disease : Osteochondritis of femoral head in adults; Llffert-
Arkin disease : Osteochondritis of distal tibia.
SPINA BIFIDA
• It is an embryonic defect, where there is failure of fusion of the 2 halves of ~osteri_or
vertebral arch , together with maldevelopment of the neural_tube ~nd the overlying . ski~.
This combination is also called Dysraphism . When one infant 1s affected , the risk ,s
10 times more in the 2nd child .
• It is common in the lumbar and the lumbosacral region .
• There may be neurological deficits, urinary symptoms (90% ca_ ses) , te nd ency of spon-
th
taneous fractures and also the overlying skin may be anaeS et,c.
Subgroups
According to the pathology and severity -
1. Spina Bifida Occulta Mildest and the
most common type. Has the best prog-
nosis .
• Tuft of hair, dimple , defect in th e
overlying skin , sinus, lipomaS, cyS t s
~ may be found over the lower b~ck,
pointing to the underneath lesion .
Most common site is S1.
· the
• May cause muscle imbalance in
lower limbs which may ultimately cause
deformitie; (e.g . DOH , genu recur- Fig. 5 _59 : AP view x -_ray o_f _lumbo sacral spine
vatum , CTEV). May also cause cauda- showing spina b1flda of S1.
equina syndrome. (see page 261 ).
herniate through the foramen magnum.
2. Hydrocephalus Brainstem cerebellum m~Y Raised intracranial pressure may cause
. .d (CSF) obstruction.
causing cerebro spinal flu, h Prognosis is guarded .
rnental retardation and cerebral atrop y. r prognosis. Bladder sphincter dystunc-
3 s . type. Has poo
· Pma Bifida Cystica Most severe . .
tio . 4 varieties - k'
n 1s very common . There are . ith CSF, herniates. Covered by normal s tn.
(a) Meningocele : Meningeal sac filled w taining nerve roots and portion of the spinal
(b) Mye/omeningocele : Meningeal sac con
cord herniates. No skin cover. st of the neural groove. Very common. May be
(c) Af rowth-arre
yelocele : Occurs due to 9 k. cover.
associated with CSF leak. No s ,n
- --- - -
~ ~-- - -
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(d) Syringomyelia : Dilated central canal of spinal cord within herniated meningeal sac.
Diagnosis
Prenatal : Alpha Feto Protein (AFP) level rises in amniotic fluid and serum. At birth ~ skin
defect or herniation is obvious . MRI is indicated for spina bifida occulta.
Treatment
• Folic acid supplementation prenatally decreases the incidence .
• Operative closure of defects is hazardous , especially for levels above L1 .
• Teamwork of neurosurgeon , orthopaedic surgeon , urologist, paediatrician, physiotherapists
and occupational therapists is needed. Parent counselling is a must.
• For those with better prognosis ~ skin closure is done within 48 hours.
• For hydrocephalus ~ Early operation is required to prevent brain damage . Usual ly
ventriculo-caval shunt with a valve is done.
• For deformities ~ Manipulation and plaster is NOT DONE (because of the risk of skin
ulceration and spontaneous fractures) in the 1st year. Later, proximal deformities can be
corrected before the distal ones.
SCOLIOSIS
• It is an apparent lateral curvature of the spine . Apparent because it is actually a triplanar
deformity with antero-posterior, lateral and rotational components . (Fig . 5 .60)
Types
I. Postural : Compensatory or secondary to non-spinal causes e.g. , limb length discrepancy
(LLD) or pelvic tilt.
11. Structural : Deformity in a particular spinal segment. Secondary curves develop to coun-
terbalance the initial or primary curve.
The curves increase till bony growth con-
tinues. There are 4 varieties -
(a) Idiopathic (80%) : Age of onset sub-
classifies it into Adolescent (90% are
girls > 10 years) , Juvenile (4 to 9
years). Infantile (< 3 years, rare) .
(b) Osteopathic : Vertebral anomalies
like hemivertebra , tused / unseg ·
mented verteb ra are found . (e.g.,
Sprengel ' s deformity - see page 44)
(c) Neuropathic : Unbalanced paraver·
tebral muscle power causes bending
e.g., in postpolio residual paralysis,
muscular dystrophies, cerebral palsy.
(d) Miscellaneous : e.g ., Neurofibro·
matosis .
Clinically
Fig . ~_- 60 : PA view X-~ay of dorso-lurnbo-sacral spine
and iliac crests showing dorso-lurnbar-scoliosis with
• Clo ~ Backache , abnormal anterior cos·
convexity towards right and unossified iliac crests . tal prominence , skew-back deformity.
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X A.AYS :,,5~
• Other examination
. : Hip prominent on concave side
· ·
scapula prominent on conv01 side .
Rib hump is commonly found , posteriorly and som~times anteriorly.
• When the patient sits and the curve dis-
appears or .decreases ~ Postural. If curve
appears or increases ~ Structural.
• Always measure lower limb lengths to
rule out LLD.
X-rays
Full length PA view and lateral view of
spine, and AP view of iliac crest is a must.
• Amount of curvature is noted by the angle
subtended by a line joining upper border of
uppermost vertebra in the curve, and the
lower border of the lowermost vertebra ~
called Cobb's angle.
• Iliac crests are observed for skeletal ma-
turity, because once they ossify, no fur-
ther increase of the deformity occurs.
Special Investigations
• Pulmonary fun ction tests to note vi-
Fig. 5.61 : PA view X-ray of dorso-tumbar-spine
tal capacity , which if decreased , is a
showing scoliosis with convexity towards left.
risk-factor for surgery.
Treatment
• Non-operative : Milwaukee-Brace, Boston-Brace, spinal exercises.
• Operative : After correction of deformity by distracting the concave side , maintenance
can be done by posterior instrumentation e.g. Harrington system (rods and hooks) ,
Luque system (rod and sublaminar wiring) , Cotrel-Dubousset system (pedicle screw , hooks
and rods) , or anterior instrumentation e.g., Dwyer, Zielke, Kaneda. Bone grafts are al-
ways given for spinal fusion .
KYPHOSIS
• Dorsal curvature, or posterior convexity of the spi ne is ca lled kyphosis . It is normal in
the thoracic spine, but when excessive
~ abnormal/ pathological .
Common causes of Structural Kyphosis
according to age
;hild ~ Congenital.
~olescent ~ Postural , or Scheurman 's
disease
~~ults ~Ankylos ing spondylitis. .
erly ~ Osteoporosis, Paget's disease.
N.a • ·• For any age always exclu d e t u-
bercu1 . '
in lnd?515 (Fig. 5.65) as a cause, especially
fr ia. Other causes ~ Post-traumatic
s.~~~:)~s or fracture dislocations. [Fi g.
Fig. 5 .62 : Dorsal kyphosis.
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Types
1. Postural : Most common . Reducab le by postural training and exercises.
2. Compensatory : Counterbalances fixed-flexion-deformity of hip, o r increased lumbar
lordosis .
3 . Structural : Osteoporotic kyphosis, Scheurman's disease, ankylosing spondylitis, caries
spine.
• Osteoporotic Kyphosis - Very common in the elderly. 2 varieties.
1 . Post-Menopausal Women : Usually 1 or 2 anterior-wedge-compression-fracture of
dorsal vertebra occurs . Main complain is lumbo sacral pain , due to compensatory
increase of lumbar lordosis and concomitant osteoarthritis . [Fig . 5 .64(A)]
2. Senile : Both men and women are af-
fected . Usual occurance of multiple ver-
tebral anterior-wedge-compression -frac-
tu res . Complains of back pain. Has
smooth rounded curvature . Must ex-
clude metastasis and multiple myeloma.
Fig. 5.64 (A) : Lat. view X-ray of dorso- Fig. 5.64 (B) : Lat. view X-ray of dorso- Fig. 5.65 : Lat. view X-ray of dorso-
lumbar spine showing osteoporotic an- lumbar spine showing post-traumatic lumbar spine showing caries spine
terior-wedge-compression-fracture of anterior-wedge-compression-frac- of 0 12 and L 1 vertebra with angular
012 and L 1 vertebra with round gib- ture of L 1 vertebra with knuckle gib- gibbus and yphosis.
bus and kyphosis. bus and kyphosis.
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Ankyfos ing Spondylitis
~
Stiffness + kyphosis in a young adult is the hall .
inspiration is seen (normal 7 cm) . Other ·oint m~rk. Chest expans,_on < 4 cm with full
eneralized chronic inflammatory d. J s (e.g., _~ips, shoulders) are involved because it's
ag isease . Sacro1/iac joints a · / d ., .
only affects males very rarely the f . re mvo ve ear,1est. Com-
1
;arly : "Squaring" 'of vertebra; Lat:rm·a .~:~ HLAB21 I~ se.~um is_~osi!ive in 30% cases. XR -"7
discs). (See page 271 - Fig. 5.81) . mboo-spme (oss1f1cat1on across intervertebral
Treatment
General principles -
• Cu:ves .~ 40° -"7 Postural training, back strengthening exercises .
Child with growth potential for 1-2 years -? spinal extension braces may be useful.
• Curves > 60° in adolescents (having growth potential) , or patients with neurological
symptoms -"7 need surgery.
SPONDYLOLISTHESIS
• Most commonly an acquired condition. M : F = 2 : 1.
• Forwar~ slippage of a vertebra over the next (lower) vertebra is called spondylolisthesis. It is
a chronic overload inju ry .
• It is common in L , because maximum overload and shearing forces are active there.
5
Types
1 · lsthmic (Lytic) : Commonly an acquired condition wh ich appears in children (not new-
borns) . There is a defect in pars intercularis (which allows the forward slippag e) as
a result of fatigue fracture and/ or repeated breaking and healing of the pars fracture ,
leading to elongation or attenuation of the pars . It is a non-progressive disease and
slippage > 50% is rare , but progressive inte rvertebral (IV) disc degeneration always
occurs . Risk factors include activities like gymnastics , pole-vault, weight-lift ing , vol-
leyball , football and dancing .
2 · Degenerative : Degenerative changes in facet joints and intervertebral (I V ) discs allow
forward slippage of vertebra (commonly L4 - L5), but the pars is intact. Assoc iated with
spinal canal stenosis osteoarthritic changes and sacralization of L4 . It is 5 times more
common in women > 40
years. Slippage > 50% is ra re.
3· ~ongenital (Dysp/astic) : Not an uncommon enti!Y· The superi~r facets ar~ defective from
b~rth which allows slow but progressive forward slippage. Sometimes associated with spina
b1fida occulta. When multisegmentary -? may cause scoliosis .
4· ;r~umatic : Uncommon. Acute fracture of facets, pedicle or lamina may destabilize the
S. :ine and_ allow forward slippage. . . .
imathotog,ca/: Rare. Attenuation of ped1cle due to weakened bones, e.g. , in osteogenesis
P Perfecta , TB , neoplasms, etc.
6 · u:~t-Surgical : Very rare . Removal of > 50% of bones from facet joints make the jo ints
G sable , allowing forward slippage.
~ADING
I/ : Meyerd·
2 _ ing Grading : is according to percentage o f d',spIacement. Grade I : 0-25%, Grade
5 50 01/o, Grade 111 : 11_ %, Grade IV : 75-100%, Grade V (Spondy/optosis) ~ 100%.
50 75
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258
HANDBOOK FOR ORTHOPAEDICS EXAMINATION
Clinically
• May present by 7-8 years, but slippage may not be seen till later.
• Low ?ack pain (LBP), and radiating pain to the lower limbs which may worsen on walking
and improves with sitting/lying supine (typical symptoms of sp inal canal stenosis with
neurogenic claudication). Intensity of pain j during adolescent growth spurt, and also
during exercising/athletic activities .
• 0 /E -, Unduly protuberant abdomen , flattened buttocks , transverse loin creases and tight
hamstrings are seen . Occasionally a palpable "step" may be felt over the affected spinous
process .
Investigations
• X-ray : Standing views are essential because 15% cases may reduce spontaneously
in t he supine position. Lateral , right and left ob lique views clearly demonstrate the
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Fig. 5.67 : Spondylolisthesis Spondylolysis Spondylosis Retrolisthesis
NOTE:
1. Retro/isthesis : Backward slippage of one vertebra on to the vertebra immediately below.
2. Spondylolysis : It is a bony defect of the pars intercularis (but no slippage). May later
become spondylolisthesis. (Scottie-dog collar sign, but not beheaded scottie-dog sign) .
[Fig. 5.66(8)]
3. Spondyloptosis : Grade V Meyerding spondylotisthesis.
4. Spondylosis : Degenerative changes of the spine. (See below)
SPONDYLOSIS
• It is actually a non-specific terminology that includes multiple . spinal _abn_or~ali~ies, all _of
which are precipitated by chronic intervertebral disc degeneration, which 1s inevitable with
ageing. By 50 years , > 95% of lumbar discs have at least some degenerative changes, and
osteoarthritic changes of spine has already begun.
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- -------- ...
260 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
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X-RAYS 261
Posterior longitudinal
ligament
N.B. . . L, -L, PIVD causes L, nerve root compression --> sensory loss of anteromedial leg
•• and knee; quadriceps and hip adductor power ! ; depressed patellar jerk.
L,-L, PIVD causes Ls nerve root compression --> sensory loss of the outer side of
leg and dorsum of tool, extensor hallucis tongus (EHL) power ! ; and Ls s, PIVD
:uses 5 nerve root compression --, ptantarflexion power ! , eversion power ! , sen-
• . ry loss 1of the lateral bor<ter of toot and depressed ankle jerk.
• ~sc prolapse can also occur in the cervical spine, usually in the C( C, or due to c.-c,.
0 dden flexion and rotation of the neck. In C, root Involvement biceps reflex ,I, wrllll
:•tensor power !, sensation of thumb and index ,J.. In C, .... tllC8P ..,...~ ·.
exor power ! . sensation of middle finger .J.. ClintcaflY - pain/s
-+
LBPcerv· . .
. •cal collar/traction + med1cat1ons.
ep· is commonly recurrent (70-90%1 and wffh me
:odes of greater intensity and duration.
90 cases get well without treatment in 6- 2 weekS (
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26
2 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
Diagnostic Imaging
(i) Ne urofibroma of the cauda-equina may cause sciatica. (ii) Tumours of vertebra ~ X-
rays show bone destruction. (iii) Infection / Ankylosing Spondylitis ~ raised ESR , X-rays
s how erosive changes.
Treatment
• Conservative : 97% get well satisfactorily with proper conservative care .
(i) Absolute bed rest for 2- 3 days followed by relative bed rest for 2-3 weeks is success-
ful in almost 90% cases.
(ii) Analgesi c/anti-inflammatory medicines are very useful adjuvants .
(iii) Physical therapy - UST, IFT, pelvic traction and exercises are useful. Rehabilitation is a
must.
(iv) Injection - Local anaesthetics and corticosteroids are useful, given by expert hands
with the needle placed accurately under the control of C-arm image intensifier. Epidu-
ral blocks can also be given .
(v) Chymopapain induced chemonucleolysis of the protruded/extruded NP is an option.
• Operative : Only 1-3% patients require surgery. After surgery : Sciatic rel ief - 80%, back
pain relief - 50%, failed low back surgery syndrome - 15%, persistent and significant
complains after surgery - 40%.
N.B. : Absolute indications for surgery are cauda-equina syndrome and deterioration of
neurological status. Relative indications are - patients not responding to conservative
management, thus causing significant loss of function/activity/work. Discectomy is
done and access to the disc is via laminotomy, laminectomy, microdiscetomy, etc.
• Rehabilitation : It is a must after recovery from pain. Patient is taught isometric exercises
and how to sit, or lie down or bend . This reduces the chances of future recurrence .
OSTEOGENESIS IMPERFECTA
It is a hereditary condition that occurs due to defective synthesis of Type I collagen, which
affects the bones, teeth , ligaments, sclera and skin. Multiple, or repeated instances of fractures
is characteristic, and bowing deformities occur due to malunion and osteopenia.
Clinically :
Common f~atures in all 4 !ypes are - susceptibility to fractures with minimal trauma, osteopen1a,
generalized hgamentous laxity, blue sclera and dentigerous imperfecta.
• Type I : (Mild) ~uto~~mal Dominant; Most common : Infants have repeated and multiple
tr~cturns even with tnv1_a1trauma that heals easily. They develop deep blue scfera and gener·
allzed hgafmentous la x1ty ,_ andd hsometimes teeth abnormalities. A er p be,ty ,actures
are less requen 1. 1mpa1re earing due to otosclerosis is co
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• Ty e // : (L ethal) : Many are stillborn .
s k ull h as " wormian-bones" and is
poo rly deve loped . However, sclera is nor-
mal. Only few survive more than a month .
• Type Ill: (Severe) Autosoma/ Recessive :
Multiple fractures and severe bony de-
fo rmities including kyphoscoliosis are no-
ticed . Marked joint laxity , but the bluish
sclera gradually whitens with time . Very
few survive till adulthood.
• Type IV: (Moderate) Autosomal Domi-
nant : S imilar to Type I, but sclera are
light - b lue which becomes normal in
adults . H earing is normal.
Investigations
Prenatal d iagnosis is possible by amniocen-
Fig. 5 .72 : AP view X-ray of whole body showin g
tesis and qua ntifying inorganic pyrophos-
malunited fra ctu res of both femurs and tibias and
phate levels in blood ~ which is increased . left humerus with bowing deformities of legs~
Parent counselling to consider legal abortion , Osteogenesis lmpertecta .
which should be done .
Differential Diagnosis : Remember ~ Battered Baby Syndrome.
Treatment
• Splinting when fractures happen ; minimizes deformity.
• Surgery is aimed at correction of bowing deformities : multiple osteotomies ~ realignment of
fragments ~ IM nail fixation of long bones (Sofield-Millar). May need multiple surgeries.
4
5
:~rns :
2 · Trauma : Common indication in the younger population (men > females).
3 ·_ Thermal and electric. Aggressive and early debridement is necessa ry initially.
ostbite : Initial treatment is rapid rewarming in waterbath at 4ooc-44oc temperature.
· Infect •ons
· : Primary c losure of any contam ·ina t e d woun d produces high · r i sk o f
:~s gangrene . Extensive and aggressive debrldement , followed by "Gui llotine" (open)
6 r Putat,on is done .
7
n~:::i~rs
C s,s
:(e._infection
and
g., Osteosarcoma) Limb-salvage att~mpts, ofte~ have great~r ri~ks like wound
~ which may warrant multiple surgeries. Amputation is wiser.
ongenitat anomalies ·. Underdeveloped, rudimentary and non-functioning lower limb vesti.ges.
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- -~ ~ ==.--==:;i-a:iiiiiij- -- - ~-
264 HANDBOOK f OR
Varieties
I
t1ve definitive procedure.
1. Closed amputation : Most commonly done as an e ec ' du re It ·is a
emergency proce .
2. Open (Gu illotine) amputation : Commonly done as an th stump -t requires 2nd
provisional procedure where the skin is not closed o_ver e . al level second-
.
operation (after 1 O to 14 days) --7 options .. rea mputat1on at a prox1m '
ary closure or plastic surgery .
Level
• Exact level of amputation is a ?al~nce
between the "hope-for-more fun cti on (for
distal levels) and "lowered risk of com-
plications" (for proximal levels) .
• Transcutaneous oxygen measure-
ments are of great help to gauge vascu-
larity (th is is impo rt a nt e sp ec ia lly in
ischaemic limbs).
• In non-ischaemi c limb , the musc ul oten-
dinous junction of the gastrocnem ius is
an useful landmark.
• A stump that is 15 cm f rom medial joint
line of the knee is ideal. < 3 cm stump
is worse than through-the-knee-disa r-
ticulation .
Fig . 5 .73 : Lat. v iew X-ray of knee showing • Working principle -t 2 .5 cm of bone
con ical below kn ee amputation stump . length for each 30 cm of height, is to be
retained . (i.e. , 1 inch for 1 foot) .
• However, advances in modern prosthetics have decreased the importance of level, be-
cause excellent function can be given with any length of stump .
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---
- 3. (a) For ~on -isch_ae,:nic limb - equal anterior and posterior flaps .
(b) For 1schaem1c limb - options are :
• Long posterior and very short anterior flap .
• Equal medial and lateral flaps.
c. Muscles : Muscle suture is done using either one of the two techniques -
1 . Tendon myodesis : Muscle groups sutured to bone under physiological tension .
Contraindicated in ischaemic limbs.
2. Myoplast~ : Mus~les sutured to opposite muscle group or facia. Commonly done in
young active patients with non-ischaemic limbs.
D. Nerves : Nerves should be dissected out, pulled gently distally and sharply cut so that it
retracts proximally (due to elasticity) to the level of (or above) the bone-cut.
E. Bones : O steotomy is done at th e proposed level , with anterior tibia bevelled and
fibula c ut 3 c m pro xi mal for a conical stump. (Some surgeons cut both bones at
same leve l for a Square-stump) . Excessive periosteal stripping is avoided , be -
caus e it may c ause ring-sequestrum .
~fter Care
1. Plaster of Paris cast is moulded and applied for rigid dressing. Cast should be changed
weekly , until the stump shrinks permanently and the wound heals. This prevents oedema,
enhances wound healing and early maturation of stump, decreases post-operative pain,
prevents knee flexion contracture, and allows early mobilization/ambulation.
2. Early prosthetic fitting results in better and quicker rehabilitation .
3. Ideally, multidisciplinary team approach is needed, which includes orthopaedic surgeon ,
physical medicine specialist, psychologist, occupational therapist and social worker.
Complications
A. EARLY :
1 . Wound necrosis : Unnecessary long stump, suturing under excessive tension or
stump haematoma are detrimental , and so are smoking and protein energy malnutri-
tion . (Serum albumin < 3.5 g/dl is a risk factor).
2. Infection : Gas gangrene is the most dreaded complication (common with is-
chaemia and haematoma) .
B. LA TE . f .h . f . )
1. Skin : Contact dermatitis and eczema are common (do not con use wit in ect1on .
Ulceration is mainly due to ischaemia . .
2 · Muscles : Excessive . 1 adding -cushion of the stump induces feeling of
muse e- p
insecurity .
3. Nerves · d
( · neuroma, which may be ten er.
a) Cut nerve always forms a f ons are ~ educating the patient about
(b) Ph 1· b · Difficult to treat. OP 1
antom tm pam - . f the stump; Clonazepam.
th e poss1·b·1·t
11 y; repe
ated percussion o
. d to ill-fitting prosthesis , especially over the
• (c) Residual limb pain - Mainly ue
I
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-
C M
Pathology
• Begins ,n the bone marrow , probably
from endothelial cells. Spreads via the
Haversian system to the bone surface -,
subperiosteal new bone fo rmation -,
destruction --? when repeated layer after
layer --? causes " Onion-peel " appear-
ance in X-rays. (Fig . 5.74)
• Directly spreads to the adjoining soft-
tissues thus involving it.
• Metastasis is mainly v ia blood to the
lungs and bones ; rarely to the regional
lymph nodes .
Clinically
• Often there is history of trauma which is
unrelated and irrelevant .
• First there is pain (throbbing , intermit-
ig. 5.74 : AP and lat. view X-rays of femoral shaft tent) , th en appears swelling . Also there
showing diaphyseal postero-medial 'moth-eaten' cor-
t1c I destruction with 'onion-scale' periosteal reaction
may be low grade fever and malaise.
nd sofHissue swelling Ewing's sarcoma. • Local temperature is raised , and
there is tenderness .
Investigations
• Blood : ESRi, may be leucocytosis.
• X-rays :
1 . Diaphyseal "moth-eaten " lesion which may be _
• Lytic with permeative margins.
• Blastic . with codmans triangle , su nray app earance
• C ys t I C. ·
2. 'Onion-peel' appearance .
3. May entire ly invo lve only the soft-tissues . ( F.
. · tg. 5 75)
• B l opsy : O pen b 1opsy ts a must. Sample shoul . ·
sues. Often pus like material is found duri d ,~elude bone and adJ.oining soft-tls-
ng operation .
N.B. It is essential to recognize the histol · .
··h very f ew mt·tot1
wr. ·c figures
· ogical picture O f ma lignant round cell tumour
and very rut
1 8
osteomyelitis . Slroma, as different from osteosarcoma or
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lfferentiaf Diagnosis
1. Chronic osteomyelitis (clinically similar
~ pain , fever, tenderness, swelling , lo-
cal temperature I ). ln 111 bone scan is
useful to differentiate .
2. Metastatic neuroblastoma , osteoblasto-
ma, non -hodgkins lymphoma.
3. Prim ary sub-acute osteomy elitis. (see
page 102)
reatment
Chemotherapy, radiotherapy , surgery ~ all
ave a role. Combination is ideal.
1. Chemotherapy : Vincristine , Actino-
mycin D , Cyclophosphamide , Doxo-
rubicin , lfosfamide and Etoposide are
useful drugs.
2. Radiotherapy : It is a highly radi -
osensitive tumour, but has high re-
currence rate . Fig. 5 .75 : AP and lat. view X-rays of knee , leg and
3. Surgery : ankle showing destruction of proximal fibula with pe-
(a) Local amputation. riosteal reaction and soft-tissue swelling -
(b) Resection of bones, such as - ribs, probabl y Ewing's sarcoma.
fibula , clavicle .
SIMPLE BONE CYST
• Metaphyseal, benign lesion . Also called unicameral bone cyst. M : F=2 : 1.
• Age group ~
1. 4 to 8 years ~ Active stage : Nearer
to the epiphysis; recurrence rare .
2. 8 to 13 years ~ Latent stage :
Nearer to the diaphysis; recurrence
common .
• Most common site ~ proximal humerus.
Then comes proximal femur and proxi-
mal tibia.
• A_lways central (not eccentric) ~ Occu-
~ies most of the width of the bone, but
is less than the width of the physis .
. (Fig. : 5. 76)
hnica11y
• As
• Yrnptomatic - Common.
Symptomatic -
; · Pathological fractures (see page 246)
· Growth disturbances (common when
close to the epiphyses) . Fig. 5.76 : AP view X-ray of right shoulder, humerus and
3
· Deformities (e.g ., Coxa vara in proxi- elbow showing proximal humeral central osteolytic lesion
rnai femoral lesions). extending up to the diaphysis _, simple bone cyst.
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Pathology
• Not expansile (c.f. , GCT, ABC) . It grows longitudinally along the axis of the bone.
• Contains pale-yellow ish clear fluid , rich in PGE 2 . Fluid press ure is high in active le-
sio ns, b ut low in o ld and la te nt lesions .
• Cyst walls are lined w ith membrane which have occasional g iant -cells. This membrane 1s
chiefly responsible for post-opera tive recurre nces.
Treatment
• Non- operative treatment is a dequ a te tor mo st les ion s, e ven those with patho l. og1cal
fractures . It is 'self-limiting' and so , it is be tte r to avoid surge ry and hence avoid post-
operative complications like growth di s turbances.
Options :
1. Aspiration of cyst flu id and methylpredniso/one injection intralesionally. May be
repeated after every 2 months for healing . Steroids reduce PGE1 activity.
2. For pathological fractures ~ manipulation and plaster casting achieves good union.
3. Surgery ~ thorough curettage of cyst walls (to remove memlbrane) foll owed by
bone grafting . Indicated for latent stage lesions with fractures , or patients w ith risk of
impending fractures .
FIBROUS DYSPLASIA
• Developmental disorder where normal trabecular bone 1s gradually replaced by fibrous tissue
• May be Monostotic (affecting single bone) , Polyostotlc (a ff e cting multiple bones).
Monomelic (involving one limb} .
Cllnlcal'ly
M y b ymptom he - i f monoslollc 1n
non -w 1ght b ring on s e g , ribs)
2 dolescent
X.-r
1.
2. ac , e
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p
X-RA Y S 269
N,S. : II tt1e ma rgins ~re . ill-defined, and there is cortical break with adj ace nt so ft-
tissue mass ~ may indicate malignant change to Fibrosarcoma.
Treatment
• Monostotic, non-weight bearing bone ~ No treatment, only regular observation .
• Other options :
1. Curettage and bone grafti ng. Cortical bone graft is used as much as possible (e .g .,
fib ula) for su ppl ementin g stren gth to the thin cortex . Cortico -cancellous iliac c rest
bone graft chips may be used to fill-up the rest of the cavity . If it is still insufficient,
bone-cement/ bone graft substitutes may be used .
2. Deformities may need osteotomies and internal fixation .
3. For pathological fractures ~ Curettage + Bone grafting + Internal fixation .
OSTEOID OSTEOMA
• This very small benign tumour causes very severe pain . Rarely it is painless.
• Commonly found in the femur and tibia, but all bones , except th e skull bones can be
affected. Common in males, in the first 3 decades of their lives.
Clinically
• Continuous severe pain which is localized , but sometimes referred over a larger area.
• Peculiarly , the pain is worse at night and responds very well to sa/icylates (aspirin).
• Prolonged symptoms may gradually lead to muscle wasting , weakness or limp.
• Spinal lesions may cause paravertebral muscle spasm and subsequent scoliosis.
• When metaphyseal (i.e., near a joint), swelling and stiffness of the joint may happen .
Pathology
Nucleus consists of reddish or dark-brown lesion , consisting of disorganized osteoid and
bone cells, which are surrounded by dense bone .
X-rays
D(aphyseal or metaphyseal lesions, surroun~e~ by ~ery _dense sclerosis_(double ~e.nsit~
sign is diagnostic) and th ickened cortex, within which lies a small rad1oluscent n,dus
often invisible.
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?7() HA DBOOK f OR OH f1( Al IJI( S f X AM ll lAf lO f J
- - - - - - ~ ~ ~ - - - - - - - - - - - -._i
N.B. : • Comp ct O teoma (Ivory Exo tosl ) Pai nlo.,. s, benign , ivory-ha rd tumo ur,
usu lly in tho kull , r roly 1n th e nlero-m0d1al surface of the t1b1a. It may pro-
cJuc nourolog,cri l symptom s, when l't appea rs in Iha inner-tabl e of the skull.
• Os e ob lastoma (Giant Osteoid Oste om a) - Very simila r to osteoid osteoma ,
but much larger and more common in th e spine and fla t bones (e .g., sca pula,
pelvis, etc.) .
ANKYLOSIS
• Im mobil ity or s1iff ening of a Joint, oft on ,n an abnormal po sition , due to su rg ery, injury
o r disease is call ed ankylosis which 1n Greek means 'ben t condition '.
• Whe n res ulting from chronic inflammatory arth ritis, the a ffected joint te nds to assume
th e least pa1nlul pos1t1on , and gradually becomes permanen tly fixed .
Types :
1 . Extracapsu/ar : Due lo skin, fascia, muscles, tendo n sheath , ten don contractures -
which are outside th e j o int e.g ., myositis ossi fican s (see pag e 60). po st-burn
con tractures, Arthrogrypo sis multi plex cong enita (see pag e 7) .
2. Capsular : Due to adherent capsule e.g., adhesive capsulitis shoulder (frozen shoulder) ,
(see page 164) or prolonged immobilization causing capsular fi bros is and contracture.
3. lntracapsular : 2 varieties .
(a) Fibrous ankylosis (False ankylosis) : Du e to prolife rati on of fi b ro us tissue . Usu-
ally starts from the synovium , which has lost its endothelial linin g. It is th e com -
mon outcome of tubercu lar a rth ritis (exce pt cari es sp ine) . Some movement is
always possible, but pain is always ass ociate d with any kind of movement.
N.B. There may be -
Long fibrous union : Relatively greater range of movement, less pain.
Short fibrous union : Relatively lesser range of movement, more pain .
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b) 8 , a nkylosis. (True ankyloSIS . ) : It is due t 0
( 1ag e a nd s ynov,a l m e mbrane a nd . . to ta l destruction of articular carti -
th ·r .
septt c a r ri 1s , ca ri es s p ine a nk p ro.l1 fe rat1 on of os t eo b l asts . Found in untreated
1 nd
ti s , etc . When s urgi c ally inducedy ~s~n g spo ylitis (Fig 5 .81 ), rheumato id arthri -
1
No moveme nt is po ss ible X -ra ' h ,s ca ll ed arthrodesi s (art ificial a nkylosis)
· ys s ow conti n t' f ·
bo ne to t h e othe r , across the j o· t (F ' ua ion o bony trabeculae from one
79 5 8
an k ylosis, and it is en t ire ly du e \no th~gd~ · • · 0) . Pain is lesser than in fibrous
rreatment options sease process and not ankylosis .
OSTEOARTHRITIS KNEE
• Os_teoarthritis (OA) is the most common of all joint diseases caus ing disability. OA may be
pr,mary (polyarticular, usually presenting > 35 years of age) or secondary (monoarticular,
due t?joint incongruity) . Prognosis is better for the primary type, because the natural pro-
gression of the disease is slower. Of the large joints, the knee is most commonly affected .
~ommonly it is bilateral. Prevalence rises steeply with age, and after menopause it is higher
in females than males. It is often associated with Heberden's nodules. (Heberden's nod-
ules are nodules in distal interphalangeal joints of fingers; Bouchard nodules are nodules
of proximal interphalangeal joint, associated commonly with pri mary osteoarth ritis) .
• OA is a dynamic disease of synovial joints, whi ch ca n have multiple aetiologies e.g .,
trauma (intra-articular fractures , ligament/ meniscal injuries, etc.) infection overload-
~ng (e.g ., obesity , inappropriate repetitive activity like unsuitabl e sports, prolong ed walk-
;"9, stair-climbing, etc.) . Normal daily activities produce loads on the knee, which are 2
0 7
•
OA istimes the body
a result of both weight.
mechanical and biological processes that destabilize the normal
cycle of synthesis and degradation of articular cartilage and subchondral bone, which leads
~~ softening , fibrillation , ulceration and loss of the articular cartilage, togetherwith sclerosis.
urnat1on , subchondral cyst formation and osteophyte form ation of the subchondral bone.
Patho
. 9 e nesls - sequential stages
(1) "Water-logging" of cartilage which 1.ncreases the
. .. llty
~ha~ce of pro teoglyc n extr ct,bi
(ii) from the matrix. Microscopically the cartilage remains intact.
~icroscopic defects appear in the cartilage due to loss of proteogtycans from within th
atnx, which results in a less elastic and less stiff cartilage.
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(iii) Loading on tho damaq d arti,l ro g 1 .ds 10 criondrocyl damage. which releal ses en-
I0 f urth r proteoglycan oss.
zymes that furth er dam g s lh me tri x nd thus I < cJ s
· . . ·b ti n (due o elasticity) is losl and
(iv) T he import nt fun t1on of c rt1lage 1. . , to d dlstn u O .
joint loading 1s now concontr I d on th e unpro1ecied subchondral b~ne , which .leads lo
· ,, t·on and reactive sclerosis at the
focal lrabocular d g nor 110n , subc hondral cys t orma 1
zone of m xim I lo ding .
(v) Carti lage at th Joint edg s slarts repairing (hyperplasia) and endocho nd ral ossification
occurs causing osteophyl s .
(vi) Frayed cartilage and broken osleophytes may ultimately lead to loose-bodies which
causes mechanical irritation , resulting 1n an inf lammato ry process .
Patho,logy
X-Rays
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~ ive
cons
(i) Arc·lge sic~ / q~adriceps ~xercise / ac-
ti ,111 mod 1f1~at1on (avo1d1ng squatting ,
cl imbing stairs , prolonged walking , us-
ing com modes rather than Indian style
to ilets) / ambulatory aids (walking
stic ks. e lbow crutches , elastic knee
support) .
(ii) Ph ysica l the rapy - IFT , UST, SWD ,
leg traction, etc .
(iii) In tra-artic ular injections - steroids ,
Hyaluro nic acid. AP
Fig . 5.84 : TKR
Operative Options
(i) Arthroscopic lavage + joint debridement + removal of loose bodies.
(ii) Proximal tibial (realignment) osteotomy - commonly varus knee is corrected to a
normal valgus knee. (High Tibial Osteotomy - HTO)
(iii) Joint replacement I total knee replacement (TK R) - best and inev itable option for
aged patients with disabling symptoms. Pain relief is dramatic. (Fig. 5 .84
(iv) Arthrodesis - rarely done , which provides a stable , painfree but motionless joint.
• Charcot (1 868), described a destructive arthropathy due to tabes dorsalis , which no en-
compasses all conditions affecting the nervous system and leads to the joint being insen-
sible to pain and joint-position-sense . Commonest cause now is diabetes me1tit,u s.
Pathology
• In contrast to OA h. h ·s a dynamic process of concom1ttant · .
degeneration n.d rep Ir
Cha W IC 1 ·ct d t t· d" . •
of threat's disease is chiefly a continuous and rap1 . es rue tve con itton. due to bse,nce
e normal "reflex-safeguards" (because of destruction of the afferent propriocepti e fibr )
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·> 14 HAN DBOOK FOR OR
of joints agains: injury or abnor.m.al stress. Un:ecognized repetitive trauma is the main culprit,
because even ,n neuropath1c Joints , destructi ve processes can be prevented/minimized b
proper treatment and sufficient protection after sprai ns, eftusions or fractures. y
Articular cartilage is destroyed, bo ny/cartilaginou s fragments appear in the joints (loose
bodies); there is thickening of synovial membrane and joint effu sion tog etherwith capsular
and ligamentous laxity causi ng joint instability/subluxation .
lin ically
• The appearance of marked joint swe lling , severe joint laxity/instabil ity and progressive
deformity, in a patient who paradoxically does not complain of pai n, even with movement
is almost diagnostic. Search for the cause of neuropathy.
X-ray
• Initial X-rays are very similar to OA, but osteophytes are rare. Hallmark is intra-articular
calcification and gross erosion of articular surfaces , in a displaced and distorted joint. In
advanced cases t:here is total destruction of the join t (see fig . 5.85).
Differential Diagnosis
• Rapidly Destructive OA : Commonly associated with crystalline calcium hydroxyapatite
(HA) deposition. Com mon in shoulder with rotator cuff lesions (Milwaukee shoulder), but
also found in the hip and knee . X-rays show periarticular calcification and destruction of
sub-articular bone with gross joint disruption.
Treatment
• S ince stopping or slowing down the destructive process is impossible, even the mildest of
injuries in a neuropathic joint should be meticulously observed and treated , which often
prevents future destructive arthropathy. The hyperemic inflammatory process after injury
must be allowed to subside totally before allowing weight-bearing or surgery.
• Fo r establ ished disease-splintage of unstable joints, and using protective calipers and
spl ints .
• For weight bearing unstable joints (ankle, knee, hip) - arthrodesis should be considered.
Incidence
• Case detection is about 5-20/1000 live
birth I which comes down to 1/1000 at
3 weeks. Orthopaedicians success at
detection is more than paediatricians.
• Family history is positive 1 in 7 and
incidence is higher in the first born,
and in breech deliveries.
• M : F = 1 : 4, (L) sided > bilateral :>
Fig. 5.86 : AP view X-ray of pelvis with both hips
showing dislocated left hip. (R) sided.
Aetiology and Path ogenesis : There are many theories none of which are conclusive. Example
are genetic factors, hormonal factors (increased maternal oestrogen, progesterone, relaxin levels
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,pwho
mentous
carry laxity)
babies ' intra
withuttheis
. h.
enne malpos1l ion (e .g. breech), and postnatal factors (e.g.
1
Assymmetrical gluteal d ~s abducted , have less incidence of DOH)
an groin skin fold ·
• Age - 6m : O rtolani test d s is an unreliable sign .
. . an Barlow test · ·.
spfas1a , Ortolarn/Barlow test may be . is positive. However if there is acetabular
negative at birth d DOH
, Age 6m - 18m : Gradual d • an may develop later.
ecrease of abducr d
ps (see fig . 5.87) . When the patient t . ron ue to adductor co ntracture devel -
.,atltlling gait. Later there will by positiv s ~rts walkrng , there will be Trendlenburg's sign and
r-___ _ ___ _ ______ e__aleazzi test (see page 115 and fig. 2.1. 14-A. B, C).
~ Ortolani's test : Hold both the thighs of the baby with your_<humbs medi ally and your_ fi ngers
Se trochanter. Then flexing both ,he hi ps to 90° gradually and 1multane~u ly abduct the hrp (see
· ). In DOH abd ·t · . b < 900 ( ee fig 5.90) bu t when medi all y direc ted pressure is applied
. 89
Cr th ' thUC 10n WI 11be ereduction
. e trochanter ' .
with a " click
. " , and then 90 0 abdu ctio
•
n will
•
be pos ,bl
.
.
1 as . . . , ere may
pO Siti ve Ortolani Test.
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Fig. 5 .89 Fig . 5 90
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- ----·- ~~--"'
X-RAYS 277
ClinicallY
patient is usually a boy in the pubertal
thin, who com~lains of ~ain in the groin som:tT~i;oup, eith_e r _overwei~ht o, excessively t II and
h
uexion , abduction and internal-rotation are d wil radiation lo thigh or knee. Thorn 1s limp;
deformity with shortening . There may be h e~reased and later t~ere is ri ed e ternat-ro t t1on
sic diagnostic sign is increasing external rie;.
e te~sion or the hip . Kn ee-axilla sign : A clas -
a ion with increasing hip flextion.
X-ray
1. A P view : Often the diagnosis may be missed,
· .
especially early in th e disease.
• Metaphyseal
meta blanch sign. of St
h ses due . _eel .. A crescent1c area or .increased density in the
P Y to supenmpos1t1on of displaced femoral head (double density) .
Fig. 5.93
Fig. 5.92 : Trethowan's Sign
Trethowan's sign : A line (Klein's line) drawn along the superior border of the femo-
• ral neck cuts the femoral head. In SCFE the line passes above the femoral head .
(see Fig . 5.92)
• Capener's sign : The posterior acetabular margin normally cuts the medial corner
of the metaphysis. In slip, the whole metaphysis remains lateral to the acetabular
margin .
• Herndon 's hump : Bare area over the anterior and superior area of femoral neck
that gets remodeled and becomes a hump. (see Fig. 5.93)
Frog-lateral view
AP view
< 30°
1. Mild/minor t 33%
31 °-50 °
2. Moderate 33%-50%
> 50°
3. Severe > 50%
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Tr
• ti /rntn 1 h 2 er u d ,r tm
•
n
r ll mpt lo e reduc ion because it nea rly lw ys c u os AV . p n
!1 t t1on by 1 2 screws is done. although th1 s m y lso c us AV 11
ur le I d: o c to echrf que in expert ha nds oft n produce good
ompli c ion
1 'S1 1pp1ng ' ol th op osit hip · About 20°0 to 40°0 . So look out tor it.
2. AVN : N rly lways an iatrogenic compl1ca t1on. due to manipulation/ope ration . Oi
3 Articul r chondrolys1s · May lead to early osteoarth ri tis and loss of mobi Hty.
4. Co -v It is 'apparent' co a-var a because ess entia lly it is retrove rsi on of the
T
CONGENITAL PSEUDOARTHROSIS OF TIBIA
• Cong rntal pseudoarthrosis of the tibia is a misnomer, because it is not a true pseudoar-
th ros1s . Th non-union (pseudoarthrosis) develops after birth through a detect present in
th ibia since birth . It is basically a fracture with which the child is born and which has
falied to unite till now.
• Most common site - junction of upper 213rd and lower 1/3rd of tibia .
• It is notorious for failure to achieve union and refractory to most forms of limb salvage
treatment.
Aetiology : Not clearly understood.
• Hy pothesis -
(i) Nutriti onal defici encies
(ii) Constriction bands
(iii) Intra-uterine pressure effects
• Sometimes associated with -
(i) Neurofibromatosis
(i i) Fibrous dysplasia
Clinically
• H/0 repeated fracture at the same site .
May be bilateral.
• Anterolateral angu lation of the tibia at Fig . 5.94 : Note anterior bowing, sclerotic end5
the junction between upper 213rd and and partial obliteration of medulla.
tower 113rd.
There is shortening , valgus deformity at the anl< '
•
abnorma l moboli 1y . lack of transmitted mov ernent
· Iess
( pain 5,
• Signs of non union
palpable gap)
Tendo-achilles may be contracted
•
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• , :-ife-au-lait s pots may be s o . Roughofed
neurofibromatosis. (ii) Coast eefnM-ame
_(i) :Coast California : ~m~oth edges, seen in
Radiological classification (Boyd's) ges, seen rn frbrous dysplasia.
Treatment
Counselling about guarded prognosis, requirement of multiple operations, even ampu-
• tatron rs a must. Consider the anticipated shortening of tibia, and other deformities of
the tibia principle
Surgical . : Excision of the pseudoarthrosis site with removal of all hamartoma-
• tous tissues + intramedullary fixation (Peter-William's rod - Anderson 's technique) +
bone grafting. Jf anticipated shortening is 3- 5 cm, options are - vascularised fibular graft
Seekh-Kabab
Indications operation).
tor amputation : When anticipated tibial shortening > 5 cm; _failure of multiple
• operations is the past; severe functronal rmparrment, when the srte rs < 2.5 cm from
Compr
ications
~ffiness of ankle and toot; refracture; ankle valgus ; shortening
. .
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cation, fibular / tibial hem1melta , clubfoot (p ge 1) . kyphos1
163) , rib deformities and cleft palate may be present . (p g 255), tort1coll1s (pr:1rJe
Patho-anatomy
1.
Bone and joint . Small scapula , short clavicle and deficiencies of th ap,tEJllum , J
tro~hlea are common . Ulna is short, thick and curved . Total absence of rad u or d,"~'
1
radial deficiency is found . Scaphoid and trapezium are often absent or hypopla"~'~ 1
Thumb including the first metacarpal is absent in 80% cases . ·
2. Muscle and tendon : Long head of biceps is absent , short head is hypopla tic
brach ialis is deficient, and brachioradialis is absent in 50% cases . Abnormalities are
found in any muscle that attaches to the radius e .g . extensor carpi radialis longus and
b revis , pronator teres , tlexor carpi radialis , palmaris longus , flexor pollic1s longus, pr-
onator quadratus . and supinator .
3 . Nerve and artery : Radial nerve ends at the elbow . An enlarged median nerve substi-
tutes for the absence of the radial nerve . Radial artery is often absent.
Clinically
• Shortend forearm , ulnar bowing and manus valgus (hand may be pe rpendicular to the
forearm) , shortening or absence of the thumb is seen .
• Elbow motion is reduced, more in flexi on than in extens ion . T rue pronation/supinat1on
is ab s ent. There may b e stiffness of fi ngers and wrist.
• Fo re arm is shortend by 50%-70% in comparison to the opposite _f~rea rm . Arm length
may be reduced . G ri p strength is decreased. Neurovascular def1c1t may be present.
X-ray
• Useful to assess associated abnor-
mali t ies o f elbow/wr ist/hand and to
measu re hand-forearm angle and
ulnar bowing. Ossification is delayed ,
so final determination of deficiencies
of carpus/ rad ius should be done after
the age of 8 years .
Treatment
• Non-operative : Initially passive
stretching of tight radial-sided struc- Fg 5 95 : Note thickened curved ulna. distal ~dial
tures by the mother at each diaper d~ticie~cy , absence of 1st metacarpal and rud1rnen·
change and bed time . ~p.l int is used tary thumb , hypoplastic carpal bones.
when forearm is of sufficient leng th . . . t car al malaignment.
Serial plaster casting can be done but it will n~t c~rrec p r us on the distal end
• Operative : Done at 6-12 months of a~e. Centrahzatl?n of the c~ pdone together ith
of the ulna in conjunction with soft tissue release is co~"!'on \oo ~ severe cases
closing-wedge osteotomy to correct ulnar bowing ~hen it is ~ r ss~e1 distraction (f r
centralizing the wrist is very difficult during operation . So so I be useful to corre t
stretching) using an external fixator is done. T~n~on transfers ca~hs after centralis tion.
muscular imbalance (e.g. flexor carpi ulnaris) and it 1~ d~ne 6 - 12 mo~f ·ng the rudim nt ry
Pollicization using the index finger is done when indicated , sacn ic,
thumb .
complications
• Disruption of the ulnar growth plate and subsequent ·increase in
· LL 0 ·
• Ankylosis/arthrodesis of the wrist joint. ·
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Chapter 2
INSTRUMENTS & IMPLANTS
Theories Discussed
• Bone Graft • Sterilization
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INSTRUMl:NTS & IMP ANf
bone . '.hus any inst~ument applied over the peri osleum will lend to slip , and proce
dures like bo~e cutlrng a nd drilling would be very difficult.
2. When the penosteum, along with lhe adjacent soft-tissues is held apart by bone levers
away from the bone ~ using any ,nstru- '
ment is safer because nerves , blood
vessels, muscles, tendons are retracted
away from the operative zone .
3. Stripp ing pe r iost e um , a n d ele v at -
ing it along with the adjacent soft-tis-
sues helps in easier reduction of dis-
placed fractures, to restore normal ana-
tom ical bony continuity.
In what orrhopaee11c opera ion periosteum
elevator 1s NOT us£ d?
1. When operating on patella (e.g., patellec-
tomy, tension-band-wiring , etc.) .
2. Excision biopsy of exostosis.
In whst operation have you seen this to be
used ?
(Always say about the operation which you
have seen and can confidently answer the indi-
cations. patient-position, operative steps, etc.) Fig. 4.2.3 : Different types of bone levers .
Example : lntramedullary Kuntscher nailing for fracture shaft femur, Saucerization and seques-
trectomy for chromic osteomyelitis, Tension-band-wiring for fracture olecranon , Amputations.
Sterilization procedure : See page 213 .
B.OSTEOTOME
• Osteo = Bone; Tomy = Cutting. Thus osteotome is an instrument for cutting bone.
• There are 2 varieties - straight, and cuNed. ____ _ 3
What are ,ts parts ? (Fig. 4.2.4)
1. Blunt, flat end - For the mallet (hammer)
to strike.
2. Handle - For the surgeon to hold with the
non-dominant hand.
3. Quadrangular flattened shaft, gradually
tapering to sharp end with both sides bev-
elled - to cut bone (available in various
breadths).
NA. : In chisel, the sharp end has one-side
i.:veQtJd ~,.Page 202) Fig. 4 .2 .4 : Osteotomes - Straight variety.
When and why la it used? What Instrument is essential for usmg alongwlth osteotome ?
Used for cutting bone. Mallet is essential for striking the blunt end of the osteotome for
cutting bone.
Whar Instrument I• ••••ntlal before u sing the osteotome ?
Bone levers are essential to hold the periosteum away from the bone, to prevent slipping of
the Sharp end of the osteotome. Drill holes in the bone prevent splintering.
tvh• Olher ln, trumenl• may I» used to cut bone ?
talion saw, Gigli-wlre, bone-nibbler, bone cutting forceps, rongeurs, etc.
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RTHOPAEDICS EXAMINATION _ _- ~ - ~ - - - -- - ~ - . . __ _ ~
C. CHISEL
• Chisel is similar to osteotome with the only difference being, it is sharp with one-side bevelled.
How is the bevelled-end useful ?
When the flat surface is placed on the bone and the mallet is struck on the flattened
opposite end , a thick chunk of bone is removed '. If the bevelled surface is in bone contact
while cutting , a thin slice of bone is removed .
Where ha ve you seen a chisel being used?
1. Bone graft removal from iliac crest.
2 . Saucerization.
3 . To remove excess callus when operating
on old ~ntreated fractures or hypertrophic
non-union cases.
4. Removing bone chips around screws and
plates , before removing them .
5 . Rarely, it can be used as an periosteum
elevator.
N.B. Box chisel is useful in Fig . 4 .2.5 : Chisel.
hemiarthroplasty operation .
D. BONE GOUGE
What are its parts ? (Fig. 4.2.6)
1. Flat, blunt end : For the mallet to strike (mallet i .
s held with the dominant hand).
2 · Handle : For the surgeon to hold, with th e
non-dominant hand .
3 · Trough-like curved blade concave on one
surface with a sharp end.
Whaf is the utility of the concave, trough-likt
blade ?
It automatically accommodates the bone
chunks that has been cut and ensures easY
Fig. 4 .2.6 : Bone gouge. removal. ·
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•1. Sites from where bone graft i
Iliac crest :
- Anterior (commonly) and po t
2. Fibula :
- Except distal 7 to 8 cm (f r . nkl rn rt1,,
. ~a~:l~a~~:l~n~a~~t~~ fore ps r u · r1 It r lrlll h JI 11 rr 1r11 1di
3
4. Sometimes e;cised fem~arkel nh lrodm ol , 1' 1"1011, If., xi,' ,J l/lil (1111'1' J/ 11111 Ill d ' IH l111 i ) ,
. . or r • , c 1h t , tl , d 11 1111111 Jt di
• lnd,cat,ons of bone grafting :
To ~asten and ~~omote union in pdi n1 < with norH H1l or1 , :111!1 d I 1y1 I fltilr II qi II., 111/t ·
To fill bony cav1t1es or de·l ect e.g., fl r 1 , U rll' II r1 , t lrl b!Jfl/ r vc;I 1 ( <1 I qlr
Arthrodesis of joints : ensures bony 1u \ n
To bridge bone loss defects nd thu o t~bll•·h ontlnulty IJ1/111
Arthroeriasis : Bone block spacer to llmi1 rnt>v m nt u r'
Types of bone graft :
Cortical (e .g ., Fibula) : Used wh r ·tructurnl upp t't I 11 , !11 d , , J , 1111111lj I , JH
bony cavities , and simultan ous ly n urino th r I · n II : poi ul 111,1 , 11VII v wnll ,
Cancel/ous (e .g., taken from In b tw n th lnn r •,n J 1, 1 , ,1llrAd nl I• , I 111 ,rn
crest) : Used to promote ost og n ·I· .g., tr LI tnf nl I n rt 11t1lr,t JJ
Cortico-cancef/ous (tak en from ·l ull lhl kn llif1 ,r ·I ,, 111 11, totni di ,d q111 ln P 1d
1
proximal tibia) : Used wh ere both o 'l nr ·\ incl ·trn t11 n1I 11, 11 111 1 I 11 q1i11t ti
Although strictly speaking not b n r· II , bu'I 11 ow n I 1y 11 , r, t1111r 11111 , I, 11 , t , w
is injected at the fracture lte to prc:,moto/h r I n l, nlln J,
Bone graft substitutes : Tric· lcl um ph ·phut , olh r di , 11 I 111111 pl11 pl\111 1 11\ttill !i ,
Mechanism of action : t ol lfl I
Osteoinduction : Recruits ho ·t lt rn II
Osteoconduction : Acts as ·c' rr Id I r v I r 11
Osteogenesis : Bone morphog In (
E. SEQUESTRUM 0
I cl It h ,Id th I 11111 l II I
It is NOT a sequestr ctomy 1 re P · It u
remove it, and not cut th u trum .
hat are Its p rts 7
1. Serrated and fenestrated blad rn ·
tions are useful tor firm grip of th ' -
questrum while fen stration llow tor
accommodating th e sequ strum .
2. Handles with finger nd thumh grip With
I th
no catch : This prev nts cru hln
equestrum.
21
on proc dur :
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F. - ON CUTTIN 0 P (Fi . 4 .2 .8)
• Available with straight or curvod bl, cJ •,. M,1y ~HJVO ,In JI' r <Jouhlo ful ,rurr,.
• Used for -
1. Cutting fibu la, phalanges, melac rp I Im lair r~al' , rih , nd < plnou
2. Fashioning the bone graft piec Into lh xnct cJ 'Ir cJ hap
Sterllizatlon procedure : See pag 2 13
ulcrum
Curvod
end
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I. VOLKMAN'S BONE CURETTE
• Has a Ion~ handle with serrations for proper grip and has sharp edged, curved, spoon like
trough at ,ts end .
• used for -
1. Scrap ing the walls of cavities of be-
nig n bo~e tum ours like bone cysts ,
ben ign giant-cell tumours , aneurysmal
bone cysts, etc. Double ended
2. Scrapi ng osteomyelitic cavities (after bone curette
saucerization) or Brodie's abscess.
3. To remove immature callus and fi -
brous ti ssue from neglected fracture
ends of bone , so as to freshen them
before attempting reduction of the
fracture.
4. Freshening sinus or fistula tracts . Fig . 4.2 .11 : Bone curette .
Sterilization procedure : See page 213
J. BRADAWL
• Has a handle at one end and a sharp arrow-head with a small eye or hole at the other end.
May be curved. Eye
• Used for -
1. Opening medullary cavities of bones, <~
when operating on old untreated frac- . . ,5
tu res , which removes the fibrous plug Fig . 4 ·2 -12 · Bradawl (Cobbler awl)
from fracture ends and aids healing. This is done before reduction of the fracture.
2. Suturing tendons to bones (e.g. , patella and patellar tendon ; triceps ~endon t~ ole-
cranon) where a wire is passed through the hole and the bradawl 1s used like a
cobbler's needle.
K. AWL
• Has a handle and a sharp trocar pointed
tip but no eye.
• Used to make a hole in bone e.g., for
making the starting point for introduc-
tion of intramedullary nails. Fig . 4 .2. 13 : Kuntcher's diamond-pointed awl.
Sterilization procedure : See page 2 1 3
L. LOWMAN'S CLAMP OR LOWMAN'S FORCEPS
• May be 3 pronged or 4 pronged.
• Used for -
1 , Holding the fracture at ~ re?uc~d
position while internal f1xat1on is
being done by plates or nails. The
Plate is held clamped to the bone.
2. Rarely, may be used as a bone hold- Fig. 4.2.14 : 3 pronged owman's
Ing forceps. force .
213
I atlon procedure : see page
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PROSTHESIS FOR HIP HEMIARTHROPLASTV
• Prosthesis may b · .
• C e unipo 1ar or bipolar. Unipolar variety is rarely used nowadays
T~:monly' used unip_olar prosthesis ~re of 2 varieties - Austin Moore's pros;hesis
mpson s pr~sthes1s. They are available in various sizes, according to the d' and
th e head , the sizes being imprinted on the stem. iameter of
8. : Normal femoral neck anteversion is about 15°, which should be maintained when
seating the prosthesis.
4. Shoulder: This has a relatively sharp edge, which snugly fits into the medullary part of the
greater trochanter and prevents rotation of the prosthesis within the medullary canal.
5. Stem with 2 fenestrations : This is inserted into the medullary canal of femur. It is the
quadrangular in cross-section which prevents rotation. The tip is smooth, blunt and tap~r-
ing, which prevents accidental fracture of the lateral femoral cortex when improperly in-
serted. The fenestrations make the prosthesis lighter and self-locking, because it allows
bone growth through the fenestrations, which locks the prosthesis and fixes it rigidly.
Where/when Is A. M. prosthesis used ?
For hemiarthroplasty of hip operation. Indicated primarily in more than 3 weeks old fracture
neck of femur of elderly persons (physiological age > 65 years) and when the patient has
poor general health, and the only functional demands are of activities of daily living (AOL).
About 1.25 cm of calcar must be present --+ if not, Thompson's prosthesis is done.
What I the disadvantage of hemlarthroplasty operations of hip ?
The biological femoral head is replaced with a metallic head, therefore after about 1O to
5 yea~s acetabul_ar damage occur due to wear, producing secondary osteoarthritis and even
protrus10 acetabuh. There is limitation of motion, and pain. Then prosthesis is removed and
total hip replacement (THR) is done.
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INSTRUMENTS & IMPLANTS 207
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OPAEDlCS EXAMINATION
T~e. small head size of the inner bearing produces less torque to movement, res • •
1
fnct1on and wear. Internal component wear is minimum with inner head size ofui~~g 1n less
28
2. The c~ntre of the outer cup sphere is distal to the centre of the inner head _rnrn.
valgus setting (positive eccentricity) . Thus there is lesser load on acetabulum pro~es~lting in
friction and wear. ucing less
What is the disadvantage of bipolar over unipolar hip prosthesis?
Sometimes it is difficult to reduce during operation .
Steri lizati on : Available in pre-sterilized pack.
.8. : Femur has a natural antero-lateral bowing. When we insert a straight nail in a curved
canal, the nail has to adjust by bending slightly, otherwise it would fracture the cortex
at he bone curve. If there was no slot, then the tube would be weak at the bend on
the tensile surface, and might break when body weight i applied. (Fig. 4 2.19)
• It has 2 eyes or fenestrations at both
ends - This is used for extraction of the
nail. The hook of the nail extractor is in-
serted in the eye (Fig. 4.2.18).
Where is this nail used ?
For fixation of diaphyseal fractures of the Tensile
'
Slot
femoral shaft - ideally the fractures that are surface
transverse or short-oblique at the level of isth-
mus (narrowest part of medullary canal).
(It is unsuitable for distal femoral fractures
because the wide medullary canal would not (a) (bl
provide a tight fit.) der 1oad
Whar Is the principle of fix•t,·on with K nails? Fig . 4.2.19: (a) A curved lube when us~ ton 1rie
111
may break on the 1ens1le surface; (b) 0
Principle of 3 point fixation. This is because tensile surface prevents breakage.
a straight nail ~s being passed into a curved . . . rad
canal. The 3 points are the 2 ends, and the isthmus of femur. or where the na,I is'" con
e opposite cortex at the curve.
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INSTRUMENTS & IMPLANTS 209
N.B. : For this, the modern concept of interlocking I. M. nail is now extensively used
(see page 239).
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21 0
HANDBOOK FOR ORTHOPAEDICS EXAMINATION
It has sharp trocar pointed ends and a cylindri cal shaft. S ome have diamond-pointed
others may be th readed for bette r bon e purchase (Fig. 4 .2.20) . end and
R. RUSH NAIL
Available in various diameters and lengths. Used for intramedullary nailing. Rarely used.
What are its parts ? Describe the impla nt.
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INSTRUMENTS & IMPLANTS 211
To strike -
1. Osteotome .
2. Chisel.
Fig . 4.2.22 : Mal let.
3. Bone Gouge .
4 . Kuntscher nail (via a "punch"). p thesis (via a "punch").
5 - /Thompson ros . .
. Austin Moore Prosthesis . h pierced the 2nd cortex, as in skeletal traction .
5
6. Steinman pin's blunt end when ,t a
· k' end
7. Rush nail - bent 'hockey stic ·
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212 HANDBOOK f OH om If >PM ()IC! ' I XI\MINI\, ,, I
Function o f Bono Plat : I folcfa lrnc tu r 1HI!. 111 d If 111 •, rr1 rdn 1,li n•, 11 111nrr1ont , nnu transmit
fo rces from on n ci of tll hon to th 0 111 1, p1 u ft c tl11 I ruHI t,ypri·: 1 111 0 Ill fr CIL1 ro (lottd.
bearing Implant).
Dynamic Compress ion Pl ote (DCP) : Sci' w holo, ru' !,lop tJ In : uch ,1 w y thot scr
tightening th rough lh holes c·1uses th pint to 111ovr> .1 1 90 lo tl w cJlroc tlon or tho doscendl~w
11
screw, thus affecting comprossion nt lho frnc tur t,lt Ui;, cJ In Ir acturo hnft of radius, ulnag
humerus and sometimes temur nd tibic1 . '
Low Contact Dynamic Compression Plato (LC DCP) : lJc sign cJ lo rr sorv0 poriosteal vas-
cularity, which is impaired wi·th OCP. Uso Sr mo , · OCI .
Reconstruction Plate : Can be mouldod/ bonl In , II pl tr10Q. Usolul In dist I humeral fractures
clavicle fractures , otc. '
Locking Plate : Has 2 conjoinod holes ono of which Cr n bo usocJ for locking screw Insertion.
It has the advantage of good structural strongth ovon when tho scrows have unlcortical bone
purchase making it very useful for osteoporotic bones. Usoful in proximal humerus , distal and
proximal tibr a, dis tal femur.
Clinical ap~lication : As. neutralisation plate, buttress plate, compression plate condylar plate
and for tensron band platrng. •
Difference between cortical and cancellous C o rkscrew T rocar Tip
screws Tip
• Thread diameter : cancellous > cortical.
• Pitch (distance between threads) : can- Pa rtla(
cellous > cortical. Threaded
• Nature : ca.ncellous -> modified wood-type
screw; cortical -> machine-type screw.
• Tap : not needed for cancellous screw.
Cortical Cance llous
N.B. : S~rews are always inserted into pre- Malleolar
dnlled and tapped holes.
Fig . 4 ·2 · 24 : Different varieties of Scrows
Common use : . Cortical -> when platin radial
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IN STRUMENTS & IMPLANTS 213
STERILIZATION
• Sterilization is the process of destroying all life including spores .
• Disinfection is the killing of infectious agents outside the body by direct exposure to
chemical or physical agents.
Procedures for sterilization
A. For instruments which do not have sharp cutting ends (e.g., Austin Moore prosthesis ,
Kuntscher nails, Lowman's forceps, bone holding forceps , mallet, Esmarch bandage , etc.) .
Autoclave : 121 °c temperature at 15 to 20 pounds per square inch pressure for 20 to 30
minutes after the desired temperature and pressure is achieved.
N.B.: • If sharp instruments are autoclaved, their sharp ends must be well padded and
covered with cotton, otherwise sharpness will be lost.
• For Esmarch bandage - powder is applied profusely, between each roll of bandage
and then covered by cloth/bandage.
B.For sharp instruments (e .g . , osteotome , chisel, gouge , bone nibbling forcep , bone
cutting forcep , periosteum elevators, K wires, Steinman pin, etc.) autoclaving is the best
option. Sometimes Sterilization is done by keeping the instruments immersed in Cidex
~2% glutaraldehyde) for a minimum of 10 hours. After removal from Cidex , the instrument
implant is washed in sterile normal saline , before use.
0ther sterilizing procedures
1· Some implants (like prosthesis) and materials (like Bone-cement, catgut and other suture
materials) are pre-sterilisized by manufacturer, and comes in sealed packages.
2· Gamma ray irradiation can be used for sterilization.
3· Bolling water for about 1 hour is also sometimes used for sterilization.
4· ~ormalln tablets, kept within a closed air-tigh~ ch~mber is used for sterilization, espe-
cially for instruments of arthroscopy and electric drills, etc.
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section-IV
INSTRUMENTS & IM PL TS
SPLINTS,
Chapter 1
SPLINTS
Theories Discussed
• Tourniquet
• Plaster of paris bandage • Fixed traction and Sliding traction
• Skeletal traction • Fisk splint
• Tobruk splint . • Dennis-Brown splint
• Perkin's traction and Buck's traction
184
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SPLINTS, INSTRUMENTS & IMPLAN TS l -
sured length . Numb er of layers is about 6-8 for upp er limbs and 10-12 for low er
limbs (more for adul ts , less for chi ldren) . Then the whole length of the multiple
layers is secure ly held at both ends, suita bly folded , dipped in wate r an d retained
till no air bubbles are coming out . Finally it is taken out of water and held vertically,
simultaneously squee zing the entire length gently from top to bottom wh ich drai ns
out the excess water , and also incorporates all layers into one slab . Then it is
appl ie d on the des ired surface of the limb , covering about 50%-70% of the circum -
ference and bandaged onto the cotton covered limb . The desired position of limb is
maintained , until the slab 'sets' and gets hard .
What factors can alter the setting time of plaster ?
1. Temperature of water used (Hot water ~ faster setting ~ less critical setting time).
2. Manufacturers , pre -decided setting time varies for each brand . (Additives are added to
hemihydrated calcium sulphate powder to alter the setting time) .
3. Impurities ~ Plaster of paris, when present in the water, which is used for dipping (due to
previous similar use of the same container) hastens setting time .
4. Humidity of atmosphere and room temperature .
N. B. : The interlocking of the crystals formed are very essential for rigidity and strength.
Motion during critical setting time interferes with this interlocking, and reduces the
strength of the cast. Critical setting time begins when plaster is in the rich, thick and
creamy stage. Plaster drying occurs due to the evaporation of water, which is in
excess and not required for crystallization. Evaporation is influenced by air-tempera-
ture and humidity.
Wha t are the uses of plaster of paris bandage ?
A. Non-orthopaedic uses :
1. Immobilization after skin grafting near a joint.
2. Immobilization after repairing blood vessels, nerves, tendons (e.g., tendo achilles).
3. To make moulds , which are used for making braces.
B. Orthopaedic uses : . .
1. As first aid_ Provisional , temporary immobilization after any fracture / d1slocat1on or
tAraudma,: ·t· t tment _ Of certain fractures like fracture shaft humerus, green-stick
2. s e mr rve rea · · 11 y d.1sp 1ace d
lar fracture humerus Calles fracture, minima
fractures , type I supraco ndy ,
fractures of both bone legs, etc. h
. · PTB plaster for fracture of both bone legs . Also for umerus.
3. Functional cast . bracmgu II - lmost after all orthopaedic· operations · ( ·
exceptions - THR ,
4. Post-operatrve - sua y a
meniscectomy, etc .) as a slab. .
5 o , · · Serial plaster casting e.g., CTEV.
. e,ormrty correction - W lk' ·,ron in below-knee plaster. (see page 197)
6 A · · h 1· ·ng orthoses - a 1ng
· s partial werg t re revr . d f containment in Perthes disease.
7· Brooms trc · k PIas ter - . Sometimes huse . ue or
e g Calcaneum fracture and distal radial fracture.
8. As external fixator - Pin plaster tee niq · ·•
9. Hip-spica ·
10 N d M·nnerva jacket Risser . , t (f r ·s)
s cas or sco 101 .
· owadays rarely use - 1 '
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186 HANDBOOK FOA ORTHOPAEDICS EXAMINATION
What advice would you give to the patient after any plaster ?
1. Constant finger / toe movements (to prevent oedema and maintain circt tion).
2. Do not bring the plaster in contact with water. Keep it dry.
3 Report immediately if fingers / toes are swollen/ bluish- bl ac k/ n um b/ in extrern .
· ·
which is not relieved by the ordinary · d ose .
analgesic e Pain
4 _ Range of movement (ROM) exercises of all other joints in that limb, which are not Within
the plaster at least 2/3 times daily.
8. ESMARCH BANDAGE
What is this ?
This is Esmarch bandage , rolled up, of 4/6 inch width.
What is this made of ?
Made of latex.
What is this used for ?
1. Exsanguination.
2. Tourniquet (sometimes) .
Can this be an ideal tourniquet ?
No, because the pressure exerted cannot be measured/controlled. Ideally, pneumatic tourni·
quet should be used.
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What is the ideal s ite for applying a tourmqu t 7
Tourniquets are us~~lly applied 1n the most proximal parl or the l1rnb, ,.e .. wh re ,EH ,
single bone a~d suf!ic,ent muscle bulk which d1sporses the cull-pressur1> rvanly, • nd 1hu i
prevents localized high pressure . Esmarch bandage is always applied over c1 ,nglc r,one
What is the ideal and safe rour n tQL ' ,m ,Pr net lo , ,r "
There is no ideal tourniquet time (, e. the time between appl1cal1on and removal of 1011rn1-
quet) since it varies with the age of the patient and the vasculanly or the local arr ::i J .,1 rilly 11
is 1 to 1½ hours for upper extremity and 11/2 to 2 hours for the lower ex lremity. Every cflorl
should be made to shorten the tourniquet time.
What tourniquet pressure should be u ed when u ing pneumatic 'ou n quet ?
This varies with the age of patient, systolic blood pressure and size of the extremity, includ-
ing the muscle bulk. In normotensive patients -
For upper extremity - Systolic BP + 50 to 75 mm Hg.
For lower extremity - Systolic BP + 100 to 150 mm Hg or twice the systolic BP
What are the causes of tourniquet paralysis ?
1. Excessive tourniquet pressure.
2. Insu fficien t tourniquet pressure causes passive congestion , lead in g to
haemorrhag ic infiltra tion of the nerves.
3. Application without reviewing local anatomy e.g., peroneal nerve over fibular head, may be
involved if tourniquet is applied there, as it is a superficial structure.
What are the clinical features of tourniquet paralysis syndrom?
Motor paralysis with hypotonia, sensory dissociation (touch, pressure, vibration, joint position
sense are lost but pain/hyperalgesia is present).
What are the features of post-tourniquet syndrome ?
It happens due to prolonged ischaemia (not pressure) . There is pallor, oedema/puHiness of
fingers, numbness (sensory), weakness (motor) and joint stiffness.
What can be the complications of using tourniquet ?
1. Compartment syndrome.
2. Pulmonary embolism.
3. Rhabdomyolysis.
What will you do If you find a post-operative patient coming to the ward with the tourni-
quet still in-situ over the proximal part of a limb ?
If more than 5 to 6 hours have passed, tourniquet should not be removed as the patient's
lite may be threatened by toxic metabolites and Crush syndrome might occur. Amputation is
done after counselling and when consent is given. It less than 4 hours have passed , immediate
removal of tourniquet should be done to try and save the limb. Here, patient party should be
counselled about guarded prognosis.
ft.I. : This is gross medical negligence, and is unlikely to occur with pneumatic tourniquets.
How is an Esmarch bandage applied for expressive exsanguination and as a tourniquet ?
Th_e assistant elevates the limb (this also produces reflex vasoconstriction) . Then at the
P~oiumal part of the limb cotton is wrapped in sufficient width , so that no part of the tourniquet
WIii be in contact with th~ skin. Then, one esmarch bandage is wrapped over the limb starting
from the tips of fingers or toes, and then stretching the . bandage so as to apply tensio~ wi~h
~ turn, overlapping the previous turn by about half t,11 the edge of th~ cotton pa_dd1ng ,s
··~-·-bed. The assistant then holds this end. Another Esmarch bandage ,s now applied as a
et over the cotton wrapping, where the first 3 to 4 turns are applied with tension by
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AMINATION
th
stretching the bandage, and the rest is just wrapped without tension over ·e previous turn .
nd
Finally, the tapes at the end are tied and the starling time of tourn iquet is noted a recordod.
The bandage initially used for exsanguinatlon , is then removed .
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nd th 0th
tella a e er axial. line touching the anterior border of fibular head. Used for pelvic
nd
fractures a trochantenc fractures, only for initial 3 weeks. [Fig. 4.1.4(b) and 4.1 .6(b)]
3. D1sts1 tibfladl .: tsl ct~b. abo~e the ankle joint, midway between the anterior and posterior
borders o 1s a 1 1a. [Fig . 4.1.4(d)]
4. Calcdatneadl'trtacl tt~ob~ : 2 cm behind and 2 cm below the tip of lateral malleolus of ankle. It is
use or 1s a 1 1a1 1ractures . [Fig. 4.1.4(e)]
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A sma~I skin incision is made at the correct
entry point.
The steri lized Steinman pin' s sharp end is
introduced through the site of entry from the
lateral side (i.e ., 2" infe rior and posterior to
the tibial tubercle) [Fig . 4 .1.6(b)] . Then it is
pushed by hand till it reaches the bone sur-
face . Then a T-handle or hand-drill is used to
pierce the bone and is cont i nued till it
pierces the medial cortex (felt by sudden loss
Fig. 4 .1.5 : Direction of Steinman pin in 15° external of resistance) . T hen a mallet is used to tap
rotation of lower limb. the blunt end of the pin till it comes out of the
skin. The direction of pin should be such that
it is perpendic ular to the long axis of tibia, when the t ibia is slightly (about 15°) externally
rotated (Fig. 4. 1.5). Finally, puckered skin surfaces at ski n-pi n interface is smoothened . Ben-
zoin-soaked gauze piece is wrapp ed around the 2 ski n-pin interfaces and cotton is wrapped
and bandage is applied which should incorporate the knee to mini mize reactionary knee effu-
sion . After recovery from anaesthesia, ankle and toe exten sion is checked to rule out peroneal
nerve injury.
Why is the starting point lateral and not medial ? Why hand drill or T-hand/e is used
when the pin is in the bone ?
Th is is because the peronea l nerve is on the lateral side . A si mp le hand-held pin ad-
vancement is slow and more control led, which reduces the chan ce of nerve injury. Using
the drill can be risky and cause soft-tissue damage when advancing of the steinman pin
into the soft-tissues .
Why is the mallet not used, (instead of the drill) to pierce the bone ?
It may cause splintering and fracture of the bone , which might lead to early pin loosening .
.e. :
• All lower limb tractions are given from the lateral side.
• You can describe any lower limb skeletal traction using this format, since the point of
_ •..,,...~. entry is known.
, monly local anaesthesia is used.
-.-..,....,·'."Jl- m
-~ ----·
{a ) (b)
F g. 4.1.6: (a) Local anaesth~tic i~j~ction for proximal tibial traction; (b) Entry point
proximal hb1al traction; (c) Distal femoral skeletal traction
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SPLINT . IN8TAUM N 8 & IMP AN
sth
Local anae esia procedure : First skin testing with t % lldnoc.il n Is do no. Wt1o n
no allergic reaction is found , lidnoca1ne m1ect1on 1s infiltr ted usi ng th o n cell o Jw;t l1ko
the Steinman
th pin at the entry point. , e . going up to the bon , thon gradu ally withdraw ·
mgth e need le While continuing lo infiltrate tho soft tissues til l th o neodlo com es ou t
of e skin . T he same procedure 1s repeated at the e pect~d si lo of ox,t of tho pin on
the medial aspect. A minimum S minutes wait 1s a must tor the drug 10 take full anaes-
thetic effect, before introducing the Steinman pin
It is advisab
4. introdu c ed . le to give a short course of ant1b1otic I analgesic covor aft er the pin is
It depends upon the site of fracture , age of the patient, weig ht of the patient, mussle bu lk
etc. the exacts w e ight is final ly fixed by trial after regular observatio n clin ically and rad io-
logically. Usually fo r shaft femur fracture 10% of body weight is given. When more wei gh t is
used the bed end s ho uld be raised mo re for effective counter traction. (see fig.4 .1 .12).
8. Lateral I outer side bar : It is angled out about 5 cm (2 ') below ti'
troch anter1c
· prommen
· ce . Its length is more than
. the medial/inner
h
exactly dissect the ring and are exactly opposite lo each ot er
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ter bar, and it is straight. The ring i
. shorter than the ou s
C M dial I inner bar : Length is
. se~ at an angle of 1200 to the inner ba.r ~he groove of the W-s~ape is useful when giving
D. W-shaped joining of the 2 side b~::e.nts slipping of the tr~ctron cord. .
fixed-traction, where the groov~ p h / variable ring srzes, and proper size of ring
. bl ·n variable lengt s
The Thomas splint is ava1la e I h patient.
and length is chosen individually for eac . / patient ?
·nt for a part1cu ar
'b Thomas sP'l ' .
Ho do you chooselprescn e a then add 6- 9 inches (20 cm) (Frg. 4.1.9).
f om crotch to hee I' h . h'
1 Length of inner bar : Measure r . . mference between t e 1sc 1al tuber-
2. Circumference of ring : Measure the obliqueT~.rc~s the inner diameter of the ring . If the
15
· osity and gluteal fold to crotch and groin area. t to measure the circumference causes
ary move men s h· h
affected limb is swollen and necess . the contralateral, unaffected t rg and then
pain to the patient, you can then meas~re
add 5 cm (2 '1, to accommodate the swelling .
. · f'xed traction, and not so important in
N.B. : Size of ring is very crucial ~hen grvrng r orts the limb.
sliding traction, where the splrnt merely supp
·
How would you prepare a Thomas splint for usmg · a patient ?·
t·t m
First confirm the size of inner bar and the diameter o f th e ring · Then , bandage is .1sed to
form U-shaped layers [to accommodate the I
A small c~shio.n is ma?e (~" x 3'.' of cotton roll wrapped over by bandag e,
it is put
postero-medrally in the m1d-th1gh region to maintain the normal antero-lateral bow . the femur.
Finally, after the traction is given, a 6" crepe
bandage is wrapped around the thigh and
splint to prevent side-to-side movement and
rotation of thigh, and also to fix the cushion in
between the thigh and the splint.
What is counter traction ?
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the traction force , is called counter-t . . .
sliding traction system or by gettin raction . It can be given by using gravity / body weight in
aoot of the lower limb , when using Tgh 0a Purchase to a proximal part of body by the splint (e.g.,
r mas splint) · f. ·
What IS · fixed traction ?. Wh at IS . S/idin in a 1xed traction system.
.
When counter traction acts via ~ traction ?
patient's b~dy (m~st be proximal ti~h appliance , which gets a purchase on a part of the
fixed tractio_n (Figure 4 .1 . 11 ). For lo:e~tt~chrn~nts of th~ muscles in spasm) , it is called
Counter traction , and thus elevat·i 1mb fixed traction body weight is not used in
' on
toot end of the bed 1s not necessa T . _e of th ()q I JI
.
suitable in a Th omas spl in t ry.
. his IS
. t·ing ring
closely f 1t . gets Purcha, since the
crotch, groin · and the outward fl se on th e
.
iliac crest . Fixed .
traction can maiaret .of th e
not obtain a reduction , and is rno~t a,~ and
tor transverse fractures . su itable
Advantage :
Less chance of fracture d' t . Fig. 4. 1.11 : Fixed traction
. 1s ract1on
When body weight (whole or part f . ·
O nd
counter traction, it is called sliding t / ) u er the influence of gravity is used to provide
tends. to slide
h. h in the opposite direract· ion . Here foot end of the bed is elevated, so the body
c 10n of
traction, w 1c . acts by hanging Weights over
a pulley (see fig. 4 .1.12). This method can be
u~ed to gradually obtain a reduction, but
this may also lead to distraction . Thus trac-
tion weight must be lessened , when reduction
is obtained and you need to just maintain
reduction. So daily assessment of limb
length and biweekly portable X-ray assess-
ment is required . Bed end elevation is about
1" for 1 pound traction weight. It can obtain
and maintain reduction . Fig . 4. 1.12 : Sliding traction (note foot end
elevation).
How do you monitor/regularly check a patient in traction ?
1. Regular check-up for pressure sores over heel, sacrum , ischial tuberosities, scapula, etc.
2. Regular portable X-rays to note position of fracture and prevent distraction/a ngu lation .
Initially biweekly for first 2 weeks. Then weekly for ano the r 2 weeks. Suitable adjust-
ments for weight and directio n are made .
3. Examination for early detection of pin-trac_t infect_ion (pain at ~he site_. disch~rge , loosening
or undue mobility of p in) for skeletal tract10~ patients .. For skin traction patients, note skin
condition or distal "slippling" of the adhesive strapping.
4· Chec k d 1sta
' 1 n e urovasc u la r status (sensation , movements
. of to es, nail bed return )
and pain· on p assive
. a n kl e do rsiflexion (may be sign of early compartment
. syndrome).
5R . . i needed to prevent equinus deformity. Knee mobilization,
· egular active ankle exe rcises s St f quadriceps exercises should be taught to the
When possible should be encouraged . a ic/ d .
Patient and en~ou raged to do them regularly ai 1y.
,8, . . 1.s. u, 1.:, ful for patier'II tran pon in lower limb fracture· as
Tl10 nl'I~ ·plint
Be ide · b ing used for traction. ' d relic, pain.
It· immobilizes
. · moderat 1 , an
the fracture ire
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,.a, i\ a fobruA ,plim '.'
hi I It l'd traction of lowl'r ltmh lit a Thomn1- ,pltnl over whi ,1t plaswr casin g is done rrom groi n-L0
~ 1th ankl 1111wutrul pn,it,on. This ,s \lsl'ful as firsl aid a11d for lransport of pall cnts . It wa s used widcl - ~e.
th World War I. Yduring
E. BOHLER-BRAUN SPLINT
It is actually Bohter's modification of Braun's splint.
• Original Braun's splint only had one pulley for distal tibial or calcaneal skeletal tracuon
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. .J'
..
. _-_:
___
SPLINTS, INSTRUMENT$
• Braun's modification . Add ·t·
· 1 IOn of 2
pulleys are useful for proximal .. more
distal fem o ral traction . tibial and
(a Pull~y~ - C alcaneal / distal t'b'
1 ial trac-
tion (original) .
(b Pulley) - Di stal femoral/proxi ..
traction . ma1 t1b1a1
(c Pulley) - C a n be used to ch .
. ange line/
f
angle o traction , when required.
It is some ti m es used t o
. d . p revent
equinus eform1ty of ankle.
Fig. 4.1.13 : Bohler-Braun splint.
What are the advantages of Thoma .
s sp/,nt over Bohler 's splint and vice versa ?
1. Thomas splint can be used to give fi .
2. Thomas splint is Ii hter xed traction (not Bohler's) . .
using bed-pan/urin1's for ~n~ les~ cumber~om~ .. thus the patien t is more comfortable in
. e ecat1on and m1ctunt1on , when in traction.
3. Thomas splint can be used as Tobruk splint wh ich is useful for fi rst aid. (See page 194 )
Advantages of Boh/er's splint
1. Cha~ging the angle of traction (as and whe n required) can be done without chang ing any
traction arrangement , but by ch anging th e pull eys.
2. Can be used to giv e simultaneou s traction through cal caneum/ lower tibial and proximal
tibial/distal femoral.
What is Perkin 's traction ?
This is basically skeletal traction , without using any splint, i.e., the limb is supported only
on pillows maintaining the anterior bow of femur and keeping the tendo achilles free from any
contact. The foot end of the bed is raised and early joint movements are encouraged .
What is Buck's traction ?
This is basically skin/surface traction, without using any spl int. This is exclusively used for
temporary management of fractures of femoral neck or for undisplaced acetabular fractures or
after reduction of hip dislocation or to treat ~bout 5° to 10° fixed f)exio.n deformity of hip or knee .
Here also, pillows are used to support the limb and the bed end 1s raised .
What is a Charnley's traction unit ?
It consists of a proximal tib ial Stei nman pin incorporated within a below-knee plaster
cast together with a derotation bar in the sole
(Fig. 4.1.14). The advantages are :
(a) Ankle eqinus is preven ted (very. co~ -
mon in prolonged traction) ; (b) Ten do achilles is
Protected from pressure sores by the well-pad-
ded plaster; (c) Prevents rotation of t.h~ d 1st a l
fragment; (d) lpsilateral femo ral and tibial frac-
ture can be treated simultaneously. Fig. 4.1.14 : Charnley's traction unit.
F. CTE V _ SHOES/CALLIPER
• Po ular . . ,. don't put your finger inside the shoe , you might as well put your
fin P . saying is If you s put your fin ger inside the shoe, then see the sole/heel ,
. ger in your mouth". So a Iw ay . uestion
1.e., from front and back before answerin g any q ·
• Cl · . . . d f t-ankle-orthosis (FAO), rather than a shoe.
ass1cally , 1t 1s better calle oo
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CTEV Shoe (Open Toe)
What IS thi ?
This ,s an foot-ankle-orthos1s (FAO) , com-
monly called CTEV shoe (or calliper).
What are the pe , If atu,e ? (Fig. 4 . 1. 15)
1. Stra,,ght medial border.
2. No heel.
Straight medial border
3 . Slight (about 1/8 '1 lateral sole raise .
4 . Inner iron bar.
5 . Outer T-strap.
6 . Open toe .
N.B. : When inner iron bar and T-strap is
absent, it is a CTEV shoe. When
1/8' lateral sole raise
inner bar and T-strap is present, it
is a calliper.
How is it useful ?
It helps to maintain a fully corrected CTEV
deformity, while the foot is growing and the
child has started to walk. The straight me-
dial border prevents forefoot adduction; ab- No heel
sence of heel prevents equ in us ; lateral
raise plus the outer T-strap (when tightened Fig. 4.1.15 : CTEV shoe and calliper - Open toe type.
and adjusted) prevents heel varus .
When will you prescribe this orthosis ?
When the child has started walking (approx. 10 months to 16 months of age) and a fully
corrected CTEV deformity has been achieved, either by operative or conservative method.
DENNIS-BROWN SPLINT
• Often called Dennis-Brown night splint, because it is used when the child .
and not walking. (i.e., even when the child is crawling on all 4 limbs) . The d
encourages muscle development.
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G. COCK-UP SPLINT
Three varieties.
1. Short cock-up splint : Hold
the fingers (Fig . 4 .1 .17) Th·s only th e wrist in extension. Distal margin ends below
. ,s allows fin fl .
2. Lo_ng cock~up splint : Holds both ger ex,on , and thus prevents stiffness.
th
wnst and fingers in extens·,o . e
· · n . 0 1stal
margin 1s up to the tips of th r
(Fig. 4.1.18). e mgers
3. Dynamic cock-up splint is s .
omet,mes
used. wh ere the. patient can act·ive1y flex
the f mgers, which ensures th t th .
·tt a e fin-
ger stI ness does not occur. Fig. 4. 1.17 : Short cock-up splint.
----------------
Weight bearing, and bears th ew ·
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. ....... . ..
,
~
\
•.;
' A XAMINATION
How is it applied ?
First a below knee plaster cast is ap
with the ankle in neutral position . Then
metal side bars and cross pieces are m
ally moulded (so that they fit snugly, m
taining total contact with the plaster
such a way that the superior border of
cross pieces are 2.5 cm below the fib
neck and the centre of rubber heel cori
sponds approximately with the centre
the sole . Finally few layers of plaster-i
pregnated-bandage is appl ie? ov_e r t~e. wal
ing iron , securely incorporating ,t within t
plaster cast . The patien t can start weig
bearing once the plaster is totally dry.
How is it useful ?
It allows protective weight bearing , actin
as a weight - relieving orthosis , and at th
same time immobilizing the ankle, tarsal an
metatarsal bones. The weight is shared and
transmitted through the whole plaste r cast,
Fig. 4.1.20 : Below knee plaster cast with Walking Iron.
onto the rubber heel.
For what conditions can walking iron be used ?
1. Fractures of metatarsals , and tarsals (e . g. , cuneiform , cubo id , navicula r)
2. Undisplaced or minimally displaced fractures of the calcaneum , talus or an 1'' hen
protected weight bearing is started after the initial non-weigh t bearing pe
3. Sometimes for infections of the ankle and foot , alongwith suitable antibiotics
I. WALKING HEEL
What is it?
It is a walking heel made of rubber.
What are its parts and what is the impor-
tance ot each part? (Fig. 4.1.21)
1. Thin peripheral extension on both
al.des : For convenience of wrapping
PO.P bandage over it, which allows the
heJ1 to be incorporated within the below-
k (e.e-plaster cast.
0 CD
;R/bbed thick broad base : Prevents
-~~-.....
1 ,_ing and maintains balance during
..::-,.._,.,.·ng or standing. 1 1
al transverse slot In the heel :
~p bandage wrapping which pro-
secure fixation .
ed rounded medial hump : For
Ing total contact with the longi -
medial arch of the foot. .9 .4. 1. 2 1 . W !king 11
F1 I.
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SPLINTS, INSTRUMENTS & IMP
Where /1 ve you n it to be used ?
OTHE SPLINTS : Mallet finger 's splint (see page . 176 and Fig. 4.1.22),
Foot drop spll nt (see. page 106) , Von Rosen splint, Pavlik Harness [ Fig. 4. 1 .24I (used in
developmental dysplas,a of hip [see page 2751) , Knuckle Bender splint (used in ulnar nerve
injuries; simultane ously flexes the Mcp joints ol all digits without blocking IP joints or wnsl
motion), Aeroplane Splint (shoulder-abduction splint used in brachia! plexus injury, and some-
limes in the conservative management of proximal humeral and rarely for humeral shatt frac-
tures), Volkman's Turn buckle splint [Fig. 4.1.23] (used in elbow conlractures) , Mermaid
ru
. d e lphia collar [Fig . 4 .1.25] (usedt· duringd transportation/
splint (used treatment
conservative for genu vaof pam) ie Ph1la
• nts r .) h cerv ·ical spine inju ry/pre-opera 1ve an pas t-operative
wit
.
periods of cervical spine surgery etc .
NT FRACTURES
NAMES OF SOME IMPORT A , Fracture : fracture of both pedicles
b . Hangman s ,
. racture of c, verte ra; ture : Spinous process C7, T, ; Boxers
Jefferson's Fracture - F 2 . Clay Shovelers Frac _ N ck of talus; Bumper Fracture :
or pars interarticulans 4 of C , rpal· Aviator's Fracture ·( e mon)/ ro141tt/5u-, metartarsal neck.
Fracture : Neck of 1h;s111 metacature ,: Stress fracture of 2nd com 3
Lateral tibial plateau .· March Frac
l
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