ORTHOPEDICS I. FUNDAMENTALS OF ORTHOPEDICS

PIONEERS IN ORTHOPEDICS  Hippocrates – first described splinting of fracture  Nicholas Andry - coined the term Orthopedia  Galen – traction in orthopedics  Sarmiento – functional cast brace.  Malgaigne – technique of internal fixation  HO Thomas – Thomas splint.  Lambotte – external fixator.  Gerhardt kuntscher – intramedullary nail.  Robert Denis – father of modern osteosynthesis.  llizarov – circular external fixator.  Sir John Charnley in 1960 first developed the procedure of total joint replacement.  First metallic hip replacement: Austin T Moore  John Hunter: described fracture healing  William Hey: described meniscal injuries & loose bodies  Antonius Mathysen: invented plaster of Paris  Macewen: first to perform osteotomy & bone grafting

Bone histology Trabecular bone (cancellous or spongy bone)  Lamellae do not form haversian systems  Epiphyses consist mainly trabecular bone

Compact bone  Basic unit - osteon  Osteon or Haversian system - composed of lamellae arranged around Haversian canals.  Central Haversian canal: neurovascular canal containing 1 or 2 capillaries.  Haversian canals communicate with each other via Volkman's canal (nutrient/vascular perforating channels)  Compact bone forms the diaphysis  Rich in glycoproteins & proteoglycans  highly basophilic  Biomechanically, the cement line is the weakest link in the microstructure of bone.

Parts of a bone  Epiphysis: ends & tips of bone, ossifies from secondary centres.  Epiphyseal growth plate (physis): part b/w epiphysis & metaphysis, zone of maximum growth.  Diaphysis: ossifies from primary centres, strongest part of the bone.  Diaphyseal nutrient arteries are directed away from the dominant growing epiphysis.  Metaphysis: o Zone of active growth o Highly vascularized zone o Hair pin arrangement of blood vessels. o More prone for injury. o Most common site of osteomyelitis in children.  Bones receive 5% to 10% of the cardiac output.  Long bones receive blood flow from three sources 1. The nutrient blood vessel that enters the diaphysis through the nutrient foramen 2. The metaphyseal complex, and 3. The periosteal capillaries.

COMPOSITION OF BONE  Made of both organic and inorganic components.  Bone matrix

Organic  The cells and the osteoid (organic part of the matrix).  The osteoid makes up 1/3 of the matrix & contributes to the bone's structure, flexibility and tensile strength

Collagen (-30%) of Non collagenous dry bone weight)  Type I collagen  Attachment / signaling proteins eg thrombospondin, (90% of osteoponin & fibronectin demineralized  Calcium binding proteins eg matrix gla protein & osteocalcin bone, & is (bone gla protein) produced by  Proteoglycans eg biglycan & decorin osteoblast)  Osteonectin, alpha-2 glycoprotein, sialoproteins (osteopontin) Type VI collagen   Alkaline phosphatase, TGF-beta, Bone morphogenetic protein (BMP), albumin.

OSTEOCALCIN  Produced by osteoblasts  Most abundant noncollagenous protein content(10% to 20%).  Associated with mineralization of the bone matrix.  Synthesis of osteocalcin is increased by 1, 25-dihydroxyvitamin D and inhibited by PTH & steroids

OSTEONECTIN  Produced by osteoblasts and platelets  Regulate the calcium concentration within the bone matrix and potentiate mineralization

Inorganic – Bone minerals (60-70% of dry weight)

 Poorly crystalline hydroxyapatite i.e. Ca10 (PO4)6 (OH)2 is major mineral  Calcium phosphate (small amount)

BONE MARKERS:

Markers of bone formation Markers of bone resorption  Serum bone specific alkaline  Urine & Serum cross linked N telopeptide & C phosphatase telopeptide  Serum osteocalcin  Urine deoxypyridinoline  Serum peptide of type-I collagen  Urine hydroxyproline  Urine hydroxylysine glycosides  Serum tartrate resistant acid phosphatase  Serum bone sialoprotein

Zones of Growth Plate  Zone of resting cartilage of growth plate  Zone of proliferation – rapid synthesis of collagen requiring vitamin C. It is affected in scurvy.  Zone of hypertrophy–thickest and weakest zone involved in fracture or epiphyseal slip (Slipped Capital Femoral Epiphysis)  Zone of maturing cartilage of growth plate (Vitamin D Dependant, affected in Rickets)  Zone of provisional calcification

OSTEOGENESIS  Always occur by replacing the pre existing connective tissue.  In the embryo, two types os osteogenesis occur: o Intra membranous ossification:  Occurs in the embryo when the mesoderm condenses into sheets of highly vascular connective tissue, which then forms a primary ossification center.  Bones that are fomed via intra membranous ossification are flat bone sof the skull. o Endochondral ossification:  Occurs in the embryo when the mesoderm initially forms a hyaline cartialge model, which then develops a primary ossification center at the diaphysis.  Later secondary ossificaiton centers form at the epiphysis at each end of the bone.  Bones that are fomed via endochondral ossification are humerus, femur, tibia and the other long bones.  Growth in the diameter of long bones occurs at the diaphysis by deposition of bone at the periphery (appositional growth) as osteoprogenitor cells within the periosteum differentiate into osteoblasts.  Bone growth is appositional.  New layers are added only to pre-existing surfaces and, unlike chondrocytes, osteocytes enclosed in lacunae do not divide or secrete new matrix.  The rigidity of mineralized bone matrix prevents internal expansion, which means that interstitial growth, which is characteristic of most tissues, is absent in bone.

During endochondral ossification, five distinct zones can be seen at the light-microscope level. Collagen:  Type I collagen is the most abundant form.  Type II is mainly seen in cartilage and vitreous humor.  Type Ill is seen in skin, lung andvascular tissues  Type IV is seen in thebasement membranes.  XVII-Skin hemi-desmosomes  XVIII-Many tissues (eg, liver, kidney)  XIX-Rhabdomyosarcoma cells. II. PRINCIPLES OF FRACTURE HEALING & ITS COMPLICATIONS

General Principles of Fractures and Dislocations  Based on fracture patterns (Orthopedic Trauma Association [OTA] classification)  Linear fracture: These could be transverse, oblique or spiral. o Angle < 30° with the horizontal - transverse. o Angle 30° > oblique.  Comminuted fractures: Fracture fragments are more than two in number  Segmental fractures: A fracture can break into segments and the segment could be two –level, three – level, and a longitudinal split or comminuted.  Bone loss: This could be a < 50 percent bone loss, more than 50 percent bone loss, or a complete bone loss.  Atypical Fractures  Greenstick fractures o Seen exclusively in children o Bone is elastic o Usually bends due to buckling or breaking of one cortex when a force is applied  Impacted fractures: Fracture fragments are impacted into each other and are not separated and displaced.  Stress or fatigue fractures o Usually an incomplete fracture o Commonly seen in athletes and in bones subjected to chronic and repetitive stress (e.g. third metatarsal fracture, fracture tibia, etc)  Pathological fractures o Occurs in a diseased bone o Usually spontaneous  Hairline or crack fracture: It is a very fine break in the bone that is difficult to diagnose clinically.  Torus fracture: compression fracture of the metaphyseal region with cortical buckling in a child

GUSTILO AND ANDERSON CLASSIFICATION OF OPEN FRACTURES  Includes the degree of open or closed soft-tissue injury.  Initially designed for open tibial fractures; however, now include all types of long bone fractures.

Grad Low-energy injury Wound less than 1 Simple transverse or short e cm in oblique fractures length, often from an inside-out injury Grad High energy injury Wound more than 1 Usually display some e cm comminution and have a II long minimal to moderate crushing component Grad High-velocity gunshots, close Extensive wounds Significant fracture e range more fragment comminution, and III shotgun blasts, motorcycle than 10 cm in length a great deal accidents, of soft-tissue damage or injuries with contamination from outdoor sites such as with tornado disasters or farming accidents.

 Grade IIIA: Extensive soft-tissue laceration with minimal periosteal stripping and have adequate bone coverage. These injuries include some gunshot injuries and segmental fractures and do not require major reconstructive surgery to provide skin coverage.  Grade IIIB: Extensive soft-tissue injury with periosteal stripping and require a flap for coverage.  Grade IIIC: involve vascular compromise requiring surgical repair or reconstruction to allow reperfusion of limb.

Fracture types based on nature of injury  Transverse fracture: d/t direct impact on bone.  Comminuted fracture: d/t crushing  Spiral fracture: d/t twisting  Oblique fracture: d/t compression

EPIPHYSEAL INJURIES  More common in children.  May lead to shortening because of premature epiphyseal fusion

Salter and Harris classification: Typ Definition Outcome Ie Through and parallel to physis Excellent II Through the physis with a metaphyseal Excellent III Throughfragment the physis and epiphysis Good, but may require ORIF because of potential intraarticular deformity IV Vertical fracture perpendicular to the physis Good, but unstable fracture requires (through epiphysis and metaphysis) ORIF V Physeal crush Poor (growth arrest) VI Perichondrial ring injury Good (possible angular deformities)

A Tillaux fracture of the ankle is a Salter-Harris III fracture.  Type II is the most common Salter-Harris fracture Type Example Treatment Prognosis I Radial neck epiphysis Closed reduction Good II Lowerseparation end radius epiphysis Closed reduction Good III Medial malleolus epiphysis Open reduction Growth disturbance can IV Lateral condyle of humerus Open reduction Growthoccur disturbance V Lower tibial epiphysis injury Conservative Growthcommon disturbance always

FRACTURE HEALING METHODS Endochondral fracture healing  Initial phase of cartilage formation  Followed by the formation of new bone on the calcified cartilage template Membranous fracture healing  Bone formation from direct mesenchymal tissue without an intervening cartilaginous stage  Combinations of endochondral healing and membranous healing are typical of normal fracture healing  Enchondral healing - observed between fracture gaps  Membranous healing - observed subperiosteally

Primary bone healing  Observed with rigid internal fixation  Characterized by the absence of visible callus formation  The fracture site is bridged by direct Haversian remodeling  There are no discernible histologic stages of inflammation or soft and hard callus formation.

Indirect Fracture Healing  Described by Ilizarov  Both external and internal callus are formed.  Seen in fractures treated by plaster immobilization and other forms of external and some limited internal fixation techniques.  Hunter's six stages of Indirect Fracture healing. o Stage of Impact: from the movement of impact until the complete dissipation of energy causing fractures. o Stage of Induction  Cells possessing osteogenic potential are activated  Other inducing factors are BMP (bone morphogenic protein), fall in oxygen tension, bioelectric effects. o Stages of Inflammation  Disruption of blood supply results in necrosis of the bone ends  There is hemorrhage, cellular proliferation and vascular ingrowths. o Stage of Soft Callus  Hematoma is organized with fibrous tissue, cartilage and woven bone  Fragments are united with fibrous or cartilaginous tissue or both. o Stage of Hard Callus  Bone fragments are firmly united with bone  If immobilization is complete, membranous bone healing takes place  In incomplete immobilization bone heals by endochondral ossification. o Stage of Remodeling  Fiber bone is converted to lamellar bone  Medullary canal is reconstituted  Callus diameter begins to decrease in size that takes a few months to several years  However, there will be no remodeling of rotational misalignment  Problems associated with indirect fracture healing o Less anatomic union. o Chances of malunion significant. o Delayed joint mobilization. o Possibility of fracture disease. Primary bone healing (Direct bone healing, Healing by primary intention)  Seen when bone fragments are anatomically reduced and rigidly fixed.  Cannot be obtained by closed methods of fracture treatment  Can be achieved by operative reduction and fixation with special techniques of plate and screws.  No external callus forms and there is no interposing fibrous tissue or cartilage tissue between the fracture sites.  The fracture site is bridged by direct haversian remodeling which is almost a direct osteon-toosteon hook-up.  This type of bone healing usually occurs in fractures treated by AO techniques.

STAGES OF FRACTURE HEALING (Frost, 1989) Stage of healing Approximate time Features Hematoma < 7 days Fracture end necrosis Granulation tissue Up to 2-3 weeks Development of vessels, fibroblasts, Callus 4-12 weeks Mineralizationosteoblasts etc... of granulation tissue. Callus- Characteristic & radiologically visible Remodeling 1-2 years LamellarClinically boneunited, formation no more mobile. Modeling Many years

 Pathognomic sign of fresh fracture: bony tenderness (crepitus)  M/c cause of pathological fracture: osteoporosis  Most important factor in fracture healing: immobilization.

FRACTURE DISEASE  Effect of immobilization on muscle tissue.  Immobilization and lack of activity result in atrophy.  Loss of muscle weight initially occurs rapidly and then tends to stabilize, and loss of strength occurs simultaneously.  Resistance to fatigue diminishes rapidly.  These changes are minimized if immobilization occurs with some stretching of the muscle.

CAUSES OF PATHOLOGICAL FRACTURES Generalized bone disease Primary malignant tumours 1. Osteogenesis imperfecta 7. Chondrosarcoma 2. Postmenopausal osteoporosis 8. Osteosarcoma 3. Metabolic bone disease 9. Ewing's tumour 4. Ntyelomatosis 5. Polyostotic fibrous dysplasia 6. Paget's disease Local benign conditions Matastatk tumours 1. Chronic infection Carcinoma in breast, lung, kidney, thyroid, 2. Solitary bone cyst colon 3. Fibrous cortical defect and prostate 4. Chondrornyxoid fibroma 5. Aneurysmal bone cyst 6. C hondroma 7. Monostotic fibrous dysplasia Crepitus A palpable (less commonly audible) vibratory or crackling sensation elicited with joint motion; fine joint crepitus is common and often insignificant in large joints; coarse joint crepitus indicates advanced cartilaginous and degenerative changes (as in osteoarthritis) Subluxation Alteration of joint alignment such that articulating surfaces incompletely approximate each Dislocationother Abnormal displacement of articulating surfaces such that the surfaces are not in contact Range of motion For diarthrodial joints, the arc of measurable movement through which the joint moves in a single Contractureplane Loss of full movement resulting from a fixed resistance caused either by tonic spasm of muscle Deformity(reversible) or by fibrosis of periarticular structures (permanent) Abnormal shape or size of a structure; may result from bony hypertrophy, malalignment of articulating structures, or damage to periarticular supportive structures Enthesitis Inflammation of the entheses (tendinous or ligamentous insertions on bone) Epicondylitis Infection or inflammation involving an epicondyle

Techniques in Fracture Treatment

Plaster of Paris: made by impregnating crinoline with plaster of Paris [CaSO4)2H201. When this material is dipped into water, the powdery plaster of Paris is transformed into a solid crystalline form of gypsum, and heat is given off.

Principle of llizarov's Method: Law of Tension Force  When a living tissue is slowly pulled apart at the rate of 1 mm/day, it creates a new tissue.  This is called distraction osteogenesis.

REDUCTION METHODS  Continuous traction: applied to the limb distal to the fracture, useful for shaft fractures that are oblique or spiral and easily displaced by muscle contraction. Types are o Traction by gravity: applies only to upper limb injuries. Eg: U-slab of plaster. o Skin traction: Holland strapping, o Skeletal traction: stiff wire or pin is inserted, usually behind the tibial tubercle for hip, thigh and knee injuries, or through the calcaneum for tibial fractures. o Fixed traction: Thomas' splint o Balanced traction o Combined traction:  Cast splintage  Functional bracing  Internal fixation  External fixation

Newer External Fixators  UMEX – Universal Mini External Fixator  An indigenous external fixator frame devised by Indian pioneers  It can be applied to any part of the human skeleton unlike conventional fixators universal frame  Comparatively less learning curve  It can be customized and modulated according to the needs  Better patient compliance

BONE GRAFTS  Cortical bone grafts: used primarily for structural support(fibula, tibia)  Slab graft  Cancellous bone graft: provides osteogenesis for healing  silver / strip graft  Autogenous grafts: taken from tibia, fibula or ilium.  Chip grafts are obtained from  Cancellous bone  M/c site for taking (harvesting) bone graft  Iliac crest  Common source for cortical bone grafting: fibula  Graft primarily provides scaffolding, upon which new bone is laid down. (Osteo conduction)  Muscle pedicle bone grafting  Non union fracture Neck Of Femur (Bakshi Operation or Meyer's operation)  M/c type of graft used in India-  autograft  Allograft bone is preserved by  by deep freezing (-70°C), by decalcifying it, and by formalin preservation  BMP-2 is used as bone healing stimulator

Open Reduction

Absolute indications Relative indications  Failure of closed reduction  Delayed union  Displaced intra articular fractures  Multiple fractures  Type-Ill & IV epiphyseal injuries  Pathological fractures  Major avulsion fractures  Ineffective closed reduction  Non-union  Associated vascular or neural injuries

Disadvantages Contraindications Infection  Closed fracture converted into an open  Small fragments fracture.  Weak and porotic bone  Fracture hematoma is disturbed.  Soft tissue damage  Scar tissue  Undisplaced or impacted fractures  Anesthetic problems.  Poor general and medical  Foreign body reaction due to metals condition

Indications for external fixation in open Indications for internal fixation in open fractures fractures  Grossly comminuted fractures  Intra-articular fractures  Grossly contaminated wounds  Multisystem injuries  Side swipe injuries  Multiple fractures  Periarticular fractures  Elderly patients  Pelvic fractures  Head injuries  Pilon fractures  Vascular injuries  Tibial plateau fractures  Tibial shaft fractures  Acetabular fractures

NON UNION  Delayed union: fracture that has not gone on to full bony union after 6 months.  Cessation of periosteal new bone formation before union has been achieved.  Non union: a fracture that fails to show progressive evidence of healing over a 4 to 6- month period  Most common reasons for non union: poor blood supply & inadequate immobilization.

Common sites of Non union Mal union Very common Common - Supracondylar humerus - Head & neck of femur. - Lower 1/3rd of tibia - Inter Trochanteric - Body of talus. - Lower 1/3rd of ulna fracture - Proximal pole & waist fractures of - Lateral condyle of - Colle's fracture. Pneumonic:scaphoid N-SLUFT humerus (Scaphoid, Lateral condyle of humerus, Ulna-lower 1/3rd , Femoral (Pneumonic: M-SIC) neck, Talus & Tibia- Lower 1/3rd )

COMPARTMENT SYNDROME  Increased pressure within a limited anatomic space  acutely compromising the microcirculation.  Occurs M/C in athletes during exercise.  Eg: Volkmann ischemic contracture.  Not always associated with nerve injury.  No sensory or motor deficit detected in the nerve domain distal to the involved compartment.

Etiologic Factors  Most common cause - Fractures  Most common fracture causing compartment syndrome: Tibial diaphyseal fracture  Most common cause in children: Fracture supracondylar humerus.

Pathophysiology:  Closure of small vessels due to increased compartment pressure increases the pressure on the walls of arterioles  Elevation of compartment pressure of > 30 mm Hg for > 8 hours is associated with irreversible tissue death.  Because the elevated pressure within the compartment is not high enough to occlude major arteries completely as they pass through the compartment, distal pulses usually remain strong in spite of increasing tissue ischemia in the affected soft-tissue compartment  It is best detected by compartment pressure monitoring.  Can occur at various sites in the body, but more commonly affect the anterior compartment of the forearm, the intrinsic muscles of the hand, and the lower leg.  In lower limb, the anterior and deep compartments of the leg are most frequently involved.

Clinical Findings  Pain out of proportion to the initial injury is the earliest sign.  Pain with passive muscle stretching is the most sensitive sign  Detection of impending Volkmann's ischemia (7Ps): o Pain on passive stretching (1st sign) o Pain out of proportion to physical examination findings o Pallor o Pulselessness o Positive passive stretch test  Late signs present only after permanent damage o Paresthesia o Paralysis

Treatment  Fasciotomy of the compartment.  Intracompartmental pressure readings within 30 mm Hg or less of the diastolic blood pressure are indications for fasciotomy.  Prophylactic fasciotomy should also be considered in patients in whom ischemia is present for more than 4 hours.  The volar compartment of the forearm is the upper extremity compartment most often requires release.  An epimysiotomy of the individual superficial and deep compartment muscle bellies should be performed as needed.  Care should be taken to ensure that the deep compartment musculature (the flexor pollicis  longus and flexor digitorum profundus muscles) is completely decompressed.

VOLKMANN'S ISCHEMIA  Early complication of supracondylar fracture.  Ischemic injury to the muscles and nerves of the flexor compartment of the fore arm.  D/t occlusion of brachial artery.  Tissue pressure readings within 30 mm Hg of the patient's diastolic blood pressure (perfusion pressure <30 mm Hg) are strongly suggestive of a compartmental syndrome  Muscles supplied by anterior interosseus artery are most susceptible, as it is an end artery.  Most commonly affected muscle: flexor pollicis longus & medial half of flexor digitorum profundus.  Median nerve is most commonly involved.  Treatment: fasciotomy

VOLKMANN'S ISCHEMIC CONTRACTURE  Late complication of supracondylar fracture Tsuge's classification of VIC Mild  Flexor digitorum profundus [FDP] involved  Flexor pollicis longus [FPL] involved Moderate  Involvement of FDP+FPL  Superficial finger flexor  Wrist flexors  Thumb flexors Severe  All flexors  Few extensors  Neurological deficit  Contracture of joint  Skin scarred  Bones deformed  lschemic muscles are replaced by fibrous tissue.  Marked atrophy of the forearm with flexion deformity of the wrist & fingers.  Skin- dry & scaly.  Volkmann's sign: possible to extend the fingers fully at the interphalangeal joints only when the wrist is flexed.  Rx: Volkmann's splint – a turn buckle splint, Maxpage operation.

PERIOSTEAL REACTION  A slowgrowing, benign process: will give the periosteum time to lay down dense, uniform, or solid new bone.  Fast-growing, malignant tumor: pattern of periosteal reaction will be interrupted, with a lamellated ("onion skin"), sunburst, or amorphous appearance.  Type of aggressive periosteal - Codman's triangle, in which the periosteum is lifted progressively farther from the bone as one moves toward the center of the lesion.  Benign lesions such as infection, eosinophilic granuloma, and osteoid osteoma may produce aggressive periosteal reaction.  When a benign pattern of periosteal reaction is seen, the probability of malignancy is very low.

COMPLEX REGIONAL PAIN SYNDROME (CRPS)  Described by Silas Weir Mitchell, a chronic progressive disease characterized by severe pain, swelling & skin changes. There is no cure.  CRPS is divided based on the presence of nerve lesion following the injury. Type-I Type-II(causalgia) Type-III  Reflex sympathetic dystrophy  Evidence of obvious  Irreversible (RSD), Sudeck's atrophy, reflex nerve damage changes in the neurovascular dystrophy  More intense pain. skin and bones (RND) or algoneurodystrophy,  Swelling spreads, hair  Marked muscle  Does not have demonstrable growth diminishes, atrophy nerve lesions nails become cracked,  Severely limited  Severe, burning pain at the brittle, grooved, and mobility of the site of the injury. spotty, affected area,  Muscle spasm, joint stiffness,  Osteoporosis and restricted mobility, rapid hair becomes severe and  flexor tendon and nail growth, and diffuse, joints thicken, contractions vasospasm (a constriction of and muscles  Displaced limb, the blood vessels)  atrophy marked bone softening and thinning

 Cause of this syndrome is currently unknown. Precipitating factors include injury and surgery.  Shoulder-hand syndrome is a variation of this phenomenon that often occurs with upper extremity disorders. Stiffness is characteristic, both at the shoulder and at the wrist and hand level.

DIAGNOSIS: No specific test is available for CRPS. Tests available are:  Thermography & Radiography  Sweat testing & Electrodiagnostic testing Prevention: Vitamin C: A daily dose of 500 mg for fifty days is recommended Treatment:  Drugs: antidepressants, anti-inflammatory such as corticosteroids and COX-inhibitors such as piroxicam, bisphosphonates, vasodilators, GABA analogs such gabapentin and pregabalin, and alpha- or beta-antagonists, and the entire pharmacy of opioids.  Physical and occupational therapy  Mirror therapy  Graded motor imagery  Tactile discrimination training  Graded exposure to fearful activities  Local anesthetic blocks/injections  Spinal cord stimulators  Sympathectomy  Collateral meridian therapy  EEG Biofeedback III. TRAUMA, FRACTURES & DISLOCATIONS OF UPPER LIMB

Nerve involvement in upper limb injuries: Injury Nerve involved Anterior shoulder dislocation Axillary nerve (Circumflex Posterior dislocation of elbow Medianbranch) nerve Fracture surgical neck of humerus Axillary nerve Fracture shaft of humerus Radial nerve Fracture supracondylar humerus Radial/median nerve Fracture medial condyle humerus Ulnar nerve Monteggia fracture dislocation Posterior interosseous nerve Volkmann's Ischemic contracture Median nerve Lunate dislocation Median nerve Hook of hamate Deep branch of ulnar nerve Wrist injury Median nerve

Blood vessel involvement in Upper limb skeletal trauma Injuries Blood vessel involved Fracture clavicle Subclavian vessels Proximal humeral fractures Axillary vessels Supracondylar fracture of Brachial vessels Posteriorhumerus dislocation of elbow Brachial vessels Fracture both bones of the Anterior interosseous artery forearm SHOULDER DISLOCATION  Shoulder - M/C joint to undergo recurrent dislocation (2nd MC – patella)  Shoulder - M/C joint to undergo non recurrent (traumatic) dislocation  Anterior (antero-inferior) dislocation is the commonest type of shoulder dislocation (97%)  Sub coracoid is the M/C sub type of anterior dislocation.  M/C early complication of anterior dislocation of shoulder: Nerve injury (circumflex branch of Axillary nerve)  Mode of injury: o Recurrent anterior dislocation: Abduction & external rotation force o Posterior dislocation: indirect force producing marked internal rotation & adduction o Inferior dislocation: Severe hyper abduction force

Anterior Dislocation  Lesions o Bankart's lesion: avulsion of glenoidal labrum from neck of scapula o Hill Sach's lesion: compression fracture of postero lateral humeral head o Humeral avulsion of Glenohumeral ligaments (HAGL) o Concurrent rotator cuff or superior labrum anterior to posterior (SLAP) tear. o Bony Bankart (associated glenoid rim fracture) can lead to recurrent instability.  Clinical features: o Hand is kept at abduction, external rotation & extension. o Dugas test: patient is unable to touch the opposite shoulder o Callaway's test: increased vertical circumference of shoulder o Bryants test: anterior axillary fold is at a lower level o Hamilton ruler test: A straight ruler can touch if placed between acromion process and lateral epicondyle of humerus o Regiment badge sign: area of anesthesia around the deltoid d/t injury to axillayr nerve  Management o Kocher's method (preferred) o Stimson's gravity method o Hippocratic method o Hippocrates & Milch maneuver

Recurrent Shoulder Dislocation  Tests for recurrent dislocation: Shift and load test, Sulcus test, Apprehension test, Lachman test, Relocation test  Causes of recurrence: Inadequate immobilization, High velocity initial injury, Larger defect, Younger age

Treatment options:  TUBS – Trauma  Unidirectional  Bankart's lesion  Surgery  AMBRI - Atraumatic  Multidirectional, Bilateral  Rehabilitation, If surgery, Inferior capsular shift

Surgical procedures  Bankarts repair - detached anterior structures attached to glenoid rim by sutures  Putti platt - double breasting subscapularis muscle  Bristow procedure - transplantation of coracoid process to anterior rim of the glenoid cavity.

Posterior Dislocation  Causes: Direct blow from front, Epileptics & Electroconvulsive therapy  Signs o Vacant glenoid sign (6mm) o Light bulb sign o Trough line or reverse Hill-sach lesion o Void superior and inferior glenoid fossa o Loss of profile of neck of Humerus.

Inferior Dislocation  It is a rare injury caused by severe hyper abduction force.  Called luxatio erecta as the humeral head is subluxated (dislocated inferiorly & shaft points upwards (erected)  Arm locked in almost full abduction / elevation is the common symptom.  The patient comes with his arm fixed almost by the side of his head.  Axillary nerve is commonly injured

Position of arm in shoulder dislocation  Anterior Dislocation (preglenoid, Subcoracoid, Subclavicular type) o By the side of body in slight abduction o Locked in external rotation & internal rotation is restricted.  Posterior Dislocation o Difficult to diagnose because the patient may have normal contour of shoulder o Holds injured shoulder in internal rotation & examiner cannot externally rotate it.  Inferior Dislocation (Luxatio erecta / Subglenoid) o Locked in full abduction / elevation, fixed almost by the side of head

Anterior dislocation (95%) Posterior dislocation (5%) Mechanism  Direct force – blow from the  Direct force – blow from the of posterior aspect of the anterior aspect of the shoulder injury shoulder  Indirect force- due to Internal  Indirect force – due to rottion + Adduction + Flexion Abduction + External injury (common) rotation + Extension injury (common) Clinical  Severe pain  Severe pain features  Arm is held in abduction  Arm is in position of adduction and external rotation and internal rotation (Classical  Adduction is restricted 'sling' position)  Normal contour of shoulder  Abduction is restricted is lost  Normal contour of shoulder is  Anterior shoulder fullness lost  Posterior shoulder fullness Clinical test  Posterior aspect is flat  Anterior aspect is flat  Coracoid process is not  Coracoid process is more identified prominent  Axillary nerve injury may be present X-ray  Bankart's lesions (Lateral  Anterolateral defect defect anterior)  Vacant glenoid sign  Hill – Sachs lesion  Daylight sign ((complete gap) (posterolateral defect in the  The trough line. Similar to Hill – head of the humerus seen Sachs lesion and is found on the in 100% of cases). anteromedial aspect of the head  Erosions of rim of glenoid of the humerus Anterior dislocation Posterior dislocation Transthroraci C- shaped rolling line V – shaped rolling line c Techniqueslateral X-ray Closed reduction: Three Reduction under general of methods anesthesia distal traction on the reduction Hippocrates's method injured limb with lateral rotation on the Stimson's gravity method upper arm Kocher's method: Most effective and commonly followed method. Open reduction: indicated in failed closed reduction, soft tissue interposition, greater tuberosity fracture displaced > 1 cm after reduction and large glenoid rim fractures Complication  Recurrent dislocation,  Recurrent dislocation s Unreduced dislocation,  Unreduced dislocation Traumatic osteoarthritis  Traumatic osteoarthritis  Secondary osteoarthritis, Axillary nerve damage

History and Physical Examination of the Shoulder History Physical Examination Cuff Pain over the lateral shoulder Neer and Hawkin impingement signs tendonitis with Nightoverhead pain activity Normal ROM Mild weakness Mild weakness Pain relieved with lidocaine injection into the subacromial space Cuff tear Pain over the lateral shoulder Neer and Hawkin impingement signs with Nightoverhead pain activity Loss of active ROM Weakness Weakness Loss of ROM Pain relieved with lidocaine injection into Instability Joint "slips" out Apprehensionthe subacromial of spaceinstability with shoulder abduction and external rotation (anterior instability only) Pain and feelings of instability Apprehension of instability with with shoulder abduction and external shoulder abduction and external rotation relieved by rotation (anterior instability only) relocation test (if anterior instability Asymptomatic with the shoulder at rest AC joint History of fall onto the "point" of Tenderness at AC joint instability the (separation) shoulder Pain on top of the shoulder Deformity at AC joint: acromion displaced inferior to the distal clavicle Pain with cross-body movements Pain with cross-body movements Bump at the AC joint Pain relieved with lidocaine injection into the AC joint AC joint Pain on top of the shoulder Tenderness at AC joint arthritis Pain with cross-body movements Pain with cross-body movements Pain relieved with lidocaine injection into the AC joint Stiffness Decreased ROM Decreased active and passive ROM Pain with shoulder at rest but Pain relieved with lidocaine injection worse into the glenohumeral joint at the limits of ROM Arthritis Decreased ROM Decreased active and passive ROM Pain with shoulder at rest but Crepitus with motion worse Pain relieved with lidocaine injection with motion into the glenohumeral joint Crepitus with motion Biceps Pain over the anterior shoulder Speed and Yerguson tests tendonitis with Tenderness at the bicipital groove activity Pain relieved with a lidocaine injection into the bicipital groove

FRACTURE CLAVICLE  Clavicle - M/C bone fractured during birth  Clavicle - M/C fractured bone (overall) in adults.  Clavicle is the 2nd M/C fractured bone in children after distal radius & ulna.  The M/C site of fracture - junction of middle & outer third (medial 2/3rd and lateral 1/3rd )  Malunion is the M/C complication.  M/C: o Associated fracture: rib fracture o Vessel injured: subclavian vessels o Nerve injured: medial cord of brachial plexus  Mechanism of injury: Fall on shoulder or out stretched hand, during extraction of hand in breech delivery.  Perfect reduction is neither possible nor essential as fracture with even moderate displacements unite & give good functional result.  Investigation of choice: X ray in lordotic view  Treatment of choice: figure of eight strapping with tightening periodically and instruction to keep the shoulder from sagging forward.  Sabre method: rigid dressing over the fracture area.

SUPRASCAPULAR NERVE INJURY  Entrapment of the suprascapular nerve is associated with weight lifting, baseball pitching, volleyball and backpacking.  Compression of the nerve may occur from entrapment at the anterior suprascapular notch of the scapula or at the level of the spinoglenoid notch.  Compression is associated with poorly localized pain and weakness in the posterolateral aspect of the shoulder girdle.  This may be followed by atrophy of the supraspinatus or infraspinatus muscles.  Eventually there is weakness of forward flexion and external rotation of the shoulder.  The diagnosis is confirmed by electromyography and nerve conduction studies.

FRACTURE SURGICAL NECK OF HUMERUS  Axillary nerve and the posterior circumflex humeral artery pass to the deltoid region immediately posterior to the surgical neck.  Surgical neck is weaker  M/C site of proximal humerus fracture  The deltoid atrophies when the axillary nerve (C5 and C6) is severely damaged  Deltoid atrophy  Rounded contour of the shoulder disappears  flattened appearance of shoulder.

Indications for Primary Operative Treatment of Fracture Shaft Humerus  Intra – articular fracture extension  Pathological fracture  Segmental fracture  Failure to obtain or maintain adequate closed reduction (i.e.)  Shortening > 3cm  Angulation > 20°  Rotation > 30°

FRACTURE LATERAL CONDYLE HUMERUS  This is a transphyseal intraarticular injury usually involving immature skeleton of children & adolescent.  Cubitus varus / Lateral spur formation (pseudo-varus) is the most common complication  Delayed union / nonunion is most frequent problematic complication.  The most common sequel of nonunion with displacement - progressive cubitus valgus deformity.  Cubitus valgus is much less common after united lateral condylar fractures than cubitus varus.  Tardy ulnar nerve palsy is a late complication of progressive cubitus valgus deformity

FRACTURE SUPRACONDYLAR HUMERUS (MALGAIGNE'S FRACTURE)  Most common fracture around elbow in children and adolescent  Most common fracture associated with vascular injury, M/c fracture to involve brachial artery.  Most common cause of Volkmann's ischemia & compartment syndrome in children.  Most common cause of Volkmann's ischemic contracture.

Clinical presentation:  Commonly involves 3-10 years age group  Displacement: Commonly distal fragment has following displacements o Posterior (Dorsal or backward) tilt and shift o Proximal shift o Medial tilt o Medial / Lateral shift o Internal rotation  M/C mechanism of injury is fall on the outstretched hand with elbow in full extension.  'S'- shaped deformity of arm  Unusual posterior prominence of tip of Olecranon  Three point bony relations (of lateral & medial epicondyles and tip of Olecranon) maintained in relation to each other but not with respect to shaft of humerus.  Usually the injury is closed (without wound).

Complications: Early  Brachial artery injury  Anterior interosseous nerve – most commonly injured nerve (overall and in extension type) followed by median nerve and radial nerve  Ulnar nerve – most likely to be injured in flexion type  Volkmann's ischemia & compartment syndrome

Late complications:  Malunion leading to cubitus varus (gun stock deformity) is M/C complication.  Cubitus valgus deformity [Tardy ulnar nerve palsy]  Myositis ossificans  Volkmann's ischemic contracture

Note:  Cubitus varus (gun stock) deformity : fracture supra condylar humerus  Cubitus valgus deformity [Tardy ulnar nerve palsy], Salter Harris type IV & II injury, usually require operative treatment (OR & IF) to prevent nonunion/ delayed union: fracture lateral condyle of humerus  Dinner- fork deformity: Colle's fracture (lower end of radius)

M/C type of elbow injury in children & adolescents Fracture Supracondylar humerus M/C type of Supracondylar fracture Extension type M/C type of distal fragment displacement in Posterior (dorsal/ backward) fracture shift and tilt Supracondylar humerus or extension type fracture (because it occurs in extension type) Supracondylar humerus M/C displacement in flexion type fracture Anterior displacement & angulation Supracondylar tilt M/Chumerus complication of fracture Supracondylar Malunion M/Chumerus deformity produced by Malunion Cubitus varus (gun stock Cubitus varus deformity in fracture Supracondylar French/deformity) modified French osteotomy humerus (lateral close wedge osteotomy) is most commonly managed by The radial nerve is commonly injured in humeral shaft fractures, particularly at the junction of the middle and distal third (Holstein-Lewis fracture).

MONTEGGIA FRACTURE DISLOCATION  Fractures between the proximal third of the ulna and the base of olecranon combined with an anterior dislocation of the proximal radio ulnar joint.  Bado's classification of Monteggia Fracture

Type Direction of Direction of apex of ulnar shaft fracture radial angulation I (M/common) Anteriorhead dislocation Anterior II Posterior Posterior Ill Lateral Lateral IV Anterior  Fracture of both radius & ulna  Radius is fractured in proximal third below the bicepital groove

 Posterior interosseous nerve - most commonly injured nerve in forearm fractures, particularly in Monteggia fracture dislocation  Treatment: Rigid anatomical fixation by plating (DCP/LCDCP) is the method of choice.

GALEAllI FRACTURO  Fracture of the distal third of radius and dislocation of the distal radio – ulnar joint  Galeazzi fracture is called the "fracture of necessity".  Like monteggia fracture dislocation, it often goes unrecognized.  Treatment regimen of closed reduction & cast immobilization - unsatisfactory results.  Rigid anatomical fixation by plating (DCP/LC-DCP) is the treatment of choice in adults.

COLLE'S FRACTURE  Fracture of lower end of radius at its cortico cancellous junction  Common in old age, post menopausal woman  As a result of fall on outstretched hand (with wrist in extension)  M/C fracture in older people.  It results in dinner fork / silver fork/ spoon shaped deformity.  The bone fractures at the corticocancellous junction.  Distal fragment collapses into extension, dorsal displacement, radial tilt and shortening.  Other findings: o Dorsal displacement o Dorsal(volar) angulation o Proximal displacement o Radial displacement o Articular extension A. Colles' fracture. B. Smith fracture (reversed CoIles' fracture). C. Barton fracture (causes displacement of the anterior portion of the articular surface).

 Position of immobilization in Colle's fracture is palmar deviation (Flexion), Pronation, Ulnar deviation.

Complication of Colle's Fracture  Most common – wrist joint stiffness  Malunion 2nd M/C complication; leads to dinner fork deformity.  Sudeck's osteo dystrophy/ Reflex sympathetic dystrophy o Colle's fracture is the M/C cause of Sudeck's dystrophy in upper limb o Skin will be stretched & glossy o Seen only after the removal of cast o Treatment: Physiotherapy  Shoulder Hand Syndrome: characterized by a swollen, painful, stiff hand and a frozen shoulder'  Rupture of extensor pollicis longus tendon  Carpal tunnel syndrome: causing median nerve compression  Carpal instability  Triangular fibro cartilage complex (TFCC) injury and subluxation of inferior radioulnar joint.

Phases of Sudeck's osteo dystrophy/ Reflex Sympathetic Dystrophy Phase Characteri Acute Dystrophic Atrophic Painstic Localized, severe, More diffuse, throbbing Less severe; often involves and burning other Extremity Warm Cold, cyanotic, and Severeextremities muscle atrophy; edematous; muscle contractures Skin Dry and red Sweatywasting Glossy and atrophic X-ray Normal Reveals osteoporosis Reveals severe osteoporosis, and ankylosis of joints Duration 1-3 months 3-6 months Indefinite

ANATOMIC STRUCTURES IN COMPRESSIVE NEUROPATHIES Structure Description Clinical relevance Ligament of Spans from supracondylar process of Site of medial nerve Struthers distal humerus to medial epicondyle compression in pronator Arcade of Band with fascial fibers from medial Sitesyndrome of ulnar nerve Struthers intermuscular septum and medial head compression in cubital tunnel of triceps that attaches to medial syndrome Arcade of Frohse, Proximalintermuscular edge septumof supinator muscle Site of PIN compression in Recurrent leash PIN of syndrome Henry Osborne Leading edge of Flexor carpi ulnaris; Site of ulnar nerve ligament or fibers medial epicondyle and olecranon compression in cubital tunnel Osborne fascia and roof of cubital tunnel syndrome

INJURIES AROUND THE ELBOW

ELBOW DISLOCATION Three point bony relationship in elbow:  Tips of medial & lateral epicondyles and the olecranon process forms an isosceles triangle when the elbow is flexed & lies transversely in a straight line when the elbow is extended.  Relation is maintained in supracondylar fracture of humerus.  Relation is disturbed with increased intercondylar distance o Fracture medial condyle & epicondyle o Fracture lateral condyle & epicondyle o Fracture intercondylar humerus.  Relation is disturbed with maintained intercondylar distance o Fracture olecranon o Elbow dislocation.

 Mostly results from trauma with fall on an outstretched hand.  Valgus twist to the longitudinal force by the projecting trochlea  posterolateral dislocation (M/C).

Stimson classification: Proximal radioulnar joint intact Proximal radioulnar joint disrupted a. Posterior (90%)  posterolateral > a. Anteroposterior (radius is anterior, ulna posteromedial is posterior) b. Anterior b. Medial lateral (radius is lateral, ulna is c. Medial medial) d. Lateral

 The collateral ligaments usually are ruptured with injury to the brachialis muscle and coronoid.  Frequently involves people < 20 years of age  Mostly occur at the ulnohumeral joint. Treatment: closed reduction under GA (Pusher's technique or by Puller's technique). Terrible triad of the elbow)  Posterior dislocation of elbow  Radial head fracture  Fracture coronoid process of ulna

KILOH—NEVIN SYNDROME  An isolated lesion of the anterior interosseous nerve  AIN is the motor terminal branch of the median nerve  Innervates the o Flexor pollicis longus o Radial portion of flexor digitorum profundus (flexion of terminal phalanges of 2nd 3rd fingers) o Pronator quadratus  A lesion of this terminal branch mainly impairs flexion of the terminal phalanges of the thumb and index finger.  The patient can no longer form an "O" with these two fingers.

Radial Head Fracture Mason's Classification: Types Management Type I Undisplaced Aspiration of elbow within first 24 hours decreases pain fracture Early mobilization within 24 hours Type II Marginal fracture Excision head of radius MacLaughlin's criteria for with displacement immediate excision:  Angulation > 30°  Depression > 3 mm  Involvement of > 1/3rd of head Type III comminuted  Radial head excision is indicated within first 24 hours fractures  Excised head is replaced with prosthesis Type IV Radial head  Prompt reduction of the dislocation is a must fracture with  Assess status of the head. If it meets the criteria for posterior excision, do it within 24 hours. dislocation of elbow

CARPAL TUNNEL SYNDROME  Initial stage: o Dull pain in the arm at night (brachialgia paresthetica nocturna) o Wakes the patient from sleep and can be relieved by shaking and massaging the arms o The fingers are stiff and uncoordinated for a short time after the patient wakes up in the morning  Advanced stage: o Abnormal sensations (paresthesia) develop o Sense of touch is impaired, mainly in the thumb and index finger. o The Phalen wrist flexion sign or Phalen maneuver is positive in carpal tunnel syndrome.  Etiology: PRAGMATIC o P-Pregnancy o R-Rheumatoid arthritis o A-Arthritis degenerative o G-Growth hormone abnormalities (acromegaly) o M-Metabolic (gout, diabetes myxedema, etc) o A-Alcoholism o T-Tumors o I-Idiopathic o C- Connective tissue disorders (e.g. amyloidosis).

MUSCLE WASTING IN NERVE INJURIES: Muscle wasting Nerve involved Flat shoulder [deltoid muscle] Axillary nerve Thenar eminence Median nerve Hypothenar eminence Ulnar nerve Hollowing between metacarpals Ulnar nerve

FLEXOR TENDON ZONES [VERDAN ZONES] Location of Pulleys:  First annular pulley [Al]: over the metacarpophalangeal joint  Second annular pulley [A2]: middle portion of the proximal phalanges  Third annular pulley [A3]: over the proximal inter phalangeal joint  Fourth annular pulley [A4]: middle portion of the middle phalanges  Fifth annular pulley [A5]: over the distal inter phalangeal joint  A2 & A4: Essential in maintaining the mechanical advantage of the flexor tendons [critical pulleys]

Zone I Extends from insertion of the profundus on the distal phalanx to insertion of the flexor Zone II Extendsdigitorum from superficialis the proximal on theportion middle of thephalanx Al pulley to insertion of the superficialis tendon SIGNIFICANCE: Most problematic region of injury because it contains both the profundus and superficialis tendons in a relatively avascular region [No man's zone] Zone Ill From proximal edge of the Al pulley to the distal edge of the transverse carpal Zone IV Liesligament beneath the transverse carpal ligament Zone V Proximal to the transverse carpal ligament & includes the forearm EXTENSOR TENDON ZONES Zone I Extends from distal insertion of the extensor tendon to the attachment of the central slip at the proximal end of middle phalanx. Zone II Extends from the metacarpal neck to the proximal interphalangeal joint Zone From metacarpal neck to the distal border of the dorsal carpal ligament ZoneIll Area under the dorsal carpal ligament [extensor retinaculum] ZoneIV Proximal to the proximal margin of dorsal carpal ligament V

Extensor Contents Icompartments Extensor pollicis brevis, abductor pollicis longus II Extensor carpi radialis brevis & longus Ill Extensor pollicis longus IV Four tendons of extensor digitorum communis & extensor indicis V Extensorproprius digiti quinti VI Extensor carpi ulnaris

Testing of hand muscles Muscle Method of testing Flexor digitorum By stabilizing the middle phalanx & asking to flex the distal profundus interphalangeal Flexor digitorum Alljoint. the other fingers are kept in full extension & the finger being superficialis evaluated is Flexor pollicis Flexflexed the at interphalangeal the proximal interphalangeal joint of the thumb joint longus Extrinsic Extend the metacarpophalangeal joints of the fingers Interosseousextensors abduct the fingers & assess the strength of muscle force while muscle palpating the contraction of the hypothenar and the first dorsal interosseous muscles

Disorder/Deformity Nerve Injury Common Tendon Transfers following Nerve Palsies: Palsy Correction Radial  Flexor carpi radialis (FCR) transfer to extensor digitorum communis (EDC) tendons [Brand's transfer]  Pronator teres to extensor carpi radialis brevis(ECRB) tendon [Jones transfer]  Palmaris longus to the rerouted extensor pollicis longus (EPL) tendon.  Flexor digitorum superficialis of middle & ring fingers to extensor digitorum communis (EDC) tendons [Boyes transfer] Median  Bunnell procedure: Flexor digitorum superficialis of ring finger to opponens pollicis through a pulley of flexor carpi ulnaris.  Camitz procedure: Palmaris longus extended by a strip of palmar fascia to abductor pollicis brevis.  Burkhalter procedure: extensor indicis proprius is the tendon donor  Huber procedure: abductor digiti minimi is the tendon donor High  Brachioradialis muscle (radial nerve innervated) to the FPL tendon. median  Extensor carpi radialis longus (radial nerve innervated) tendon rerouted to the index FDP tendon in the mid forearm.  Transfer of the abductor digiti minimi muscle (ulnar nerve innervated) Ulnar  Flexor digitorum superficialis of middle or ring finger split, to radial lateral bands of other fingers  [Modified Stiles Bunnell procedure]  Paul Brand I: Extensor Carpi Radialis Brevis extended by Palmaris longus strips dorsally to the intermetacarpal spaces into radial lateral bands of middle, ring & little fingers.  Paul Brand I: Extensor Carpi Radialis longus extended by Palmaris longus strips volarly through the carpal tunnel into radial lateral bands of middle, ring & little fingers.  Riordan: ECRB tendon can be transferred to the thumb proximal phalanx to provide thumb pinch (adduction)  Zancolli "lasso" procedure: FDS divided, looped through a split in A2 pulley & sutured.  Boyes transfer: Brachioradialis is transferred to adductor pollicis.  Smith transfer: Extensor carpi radialis brevis tendon is transferred to adductor pollicis

DE QUERVAIN (THUMB EXTENSOR) TENOSYNOVITIS  Stenosing tenosynovitis of the 1st dorsal compartment of the wrist, which contains the o Abductor pollicis longus & o Extensor pollicis brevis  More common in females than in males.  Frequently seen in new mothers, in part secondary to repetitive lifting and setting down of the baby.  Associated with: Racquet sports, Fly fishing, Golf (often affecting the nondominant hand in golfers) and Rheumatoid arthritis  Patients present with pain, swelling, bogginess, crepitus and discomfort on the radial aspect of the wrist (1st dorsal compartment)  Tenderness is most acute at the very tip of radial styloid.  Positive Finkelstein test: Exacerbation of pain with the thumb clenched in the palm and ulnar deviation of the wrist.  Treatment: Immobilization of thumb and wrist, usually in a thumb spica splint; NSAIDs  Recalcitrant or recurrent symptoms often require surgical release of the 1st dorsal compartment.  The most serious complication of surgical intervention is transection of the dorsal sensory radial nerve, which lies in proximity to the 1st dorsal compartment.

TRIGGER THUMB/FINGER  Stenosing tenosynovitis of flexor tendon  Results from constriction of the fibrous digital sheath, preventing the free gliding of the contained flexor tendon (mainly Al pulley)  Locking or catching during active flexion-extension activity (passive manipulation may be needed to extend the digit in the later stages)  Palpable nodule in the line of the flexor digitorum superficialis (FDS), just distal to the MCP joint  The patient may present with a digit locked in a particular position, most often flexion

MALLET FINGER/ BASEBALL FINGER  Also called dropped finger, dolphin finger, "Virgin Finger", "Hannan Finger"  Avulsion of extensor tendon of the distal Interphalangeal joint from its insertion at the base of distal phalanx.  The classic mechanism of injury is a finger held rigidly in extension or nearly full extension when the finger is struck on the tip by a softball, volleyball, or basketball  The terminal phalanx is held flexed & patient cannot straighten it, but passive movement is normal.  Treatment: splint with the DIP joint in hyperextension for 8 weeks.

IMPORTANT FACTS  Extensor Carpi Radialis Brevis is the most commonly involved structure in lateral epicondylitis.  Inflammation of common flexor origin of forearm  Golfer's elbow (Epitrochleitis, Swimmer's elbow, Medial tennis elbow)  Inflammation of common extensor origin of forearm  lateral epicondylitis/Tennis elbow  Tennis elbow is nine times more common than Golfer's elbow.  Cozen's test is a physical examination performed to evaluate for lateral epicondylitis or, tennis elbow.  Student's/ Miner's elbow or Draughtsman elbow: Olecranon bursitis.  Boxer's elbow: (hyperextension overload syndrome or olecranon impingement syndrome) and is due to the repetitive valgus hyperextension by a boxer during jabbing.  Little leagues elbow: This is a medial epicondyle avulsion fracture. It is seen commonly in children and adolescents involved in throwing sports. IV. TRAUMA, FRACTURES & DISLOCATIONS OF LOWER LIMB

Muscle wasting in nerve injuries: Thigh wasting [Quadriceps] Femoral nerve Calf wasting [Gastro soleus Sciatic nerve muscle]

Nerve injuries in Lower limb skeletal trauma Meralgia paraesthetica Lateral cutaneous nerve of thigh. Mortan's Neuralgia Compression neuropathy of digital nerve of Foot drop Common Peronealfoot nerve Hip dislocation Sciatic nerve Knee dislocation Peroneal nerve

Blood vessel injuries in Lower limb skeletal trauma Dislocation of hip Femoral vessels Fracture femur Supracondylar fracture femur Popliteal vessels Dislocation of knee Proximal tibial fractures Posterior tibial vessels Fracture tibia and fibula Ankle injuries

 Femoral shaft fractures – blood loss could range from 500-2000 ml (Average: 1200 ml)  Pelvic fractures – blood loss could range from 1000-2500 ml.

INJURIES TO THE PELVIC RING

 Pelvic ring fractures account for 3% of all fractures.  The posterior sacroiliac ligamentous complex is the single most important structure for pelvic stability.  In pelvic fractures, intra pelvic haemorrhage is the most serious complication.

THE TILE CLASSIFICATION OF PELVIC RING DISRUPTIONS Type A: Fractures that involve the pelvic ring in only one place and are stable.  Type A1: Avulsion fractures of the pelvis, which usually occurs at muscle origins such as o Anterosuperior iliac spine for the sartorius, o Anteroinferior iliac spine for the direct head of the rectus femoris, o Ischia! apophysis for the hamstring muscles.  Type A2: Stable fractures with minimal displacement.  Type A3: Obturator fractures. Isolated fractures of the pubic or ischial rami are usually minimally displaced.

Type B: Fractures that involve the pelvic ring in two or more sites.  Type B1: Open-book fractures occur from anteroposterior compression.  Type B2 and B3: Lateral compression fractures.

Type C: Fractures those are both rotationally and vertically unstable  Result from a vertical shear mechanism, like a fall from a height.  Anteriorly: fracture of pubic rami or disruption of symphysis pubis.  Posteriorly: Sacroiliac joint dislocation or fracture in the sacrum or in the ilium with loss of the functional integrity of the posterior sacroiliac ligamentous complex. The hemipelvis is completely unstable.

TESTS FOR THE STABILITY OF HIP JOINT  Qualitative assessment tests:  Shoemaker's line  Chiene's parallelogram  Morris bitrochanteric tests  Nelton's line

Quantitative measurement: Bryant's triangle

Trendelenburg's sign:  Normally when the body weight is supported on one limb, the glutei (medius & minimus) of the supported side contract & raise the opposite & unsupported side of pelvis.  In paralysis of gluteus medius & minimus (i.e. injury to superior gluteal nerve) Trendelenburg's sign is positive but not in paralysis of gluteus maximus (i.e. inferior gluteal nerve injury) Trendelenburg's Test:  When both feet are supporting the body weight, the pelvis (anterior superior iliac spine) on the two sides lies in the same horizontal plane.  When only the right foot is supporting the body weight, the unsupported side of the pelvis is normally raised by the opposite gluteal medius and minimus  If the right gluteal medius and minimus are paralyzed, the unsupported left side of the pelvis drops. This is a positive Trendelenburg's test.

POSTERIOR DISLOCATION OF HIP  M/C type of hip dislocation in adults & children  Usually occurs in a road accident when someone seated in car is thrown forwards, striking the knee against the dashboard (dashboard injury)

Classification Schemes for Posterior Hip Dislocations Thompson & Epstein Type I Dislocations without or with minor fracture Type II Dislocation with a single large fracture of posterior acetabular rim. Type III Dislocation with comminution of posterior acetabular rim. Type IV Dislocation with fracture of acetabular floor. Type V Dislocation with fracture of femoral head

Stewart and Miford Type I Dislocation without fracture Type II Dislocation with posterior rim fracture (one or more fragments), but the hip is Type III Dislocationstable after withreduction. fracture of rim producing gross instability Type IV Dislocation with fracture head or neck of femour

Clinical features:  Shenton's line is broken.  Flexion, adduction and internal (medial) rotation deformity with shortening  Cause maximum shortening of limb  Most commonly associated with sciatic nerve injury  Vascular sign of Narath is positive i.e. due to posterior dislocation of hip joint, the vessels fall back unsupported so femoral arterial pulsation, which is felt against the head of the femur will be feeble or even may not be palpable.  Rx: closed reduction under general anesthesia.  Few methods of reduction: Stimson's gravity method, Allis maneuver, Bigelow maneuver and East Baltimore lift.  Open reduction is indicated when: o Closed reduction fails o Presence of intra articular loose fragment o Large acetabular fragment & from the weight bearing part of the acetabulum.  Bigelow's maneuver: femoral head is levered into acetabulum by abduction, external rotation and extension of hip  After reduction: patient is advised to avoid flexion, internal rotation, and adduction.  Traction is maintained until patient is pain free (2 wks). Position of Hip at the time of injury Pattern of injury Flexion, adduction, internal rotation Pure posterior dislocation Less flexion, less adduction (neutral or slight abduction), internal Posterior fracture Hyperrotation abduction + Extension Anteriordislocation dislocation

Anterior Dislocation Posterior Dislocation Central Incidence 10-15% Most common (70%) RareDislocation Mechanism(%)  Deceleration dash Dash board injury with hip in Direct blow over of board or motor  Flexion, adduction, trochanter d/t fall injury cycle injury with internal rotation = in thigh abducted & pure dislocation epilepsy or externally rotated  Less flexion, less convulsions  Fall from height adduction (neutral or  Blow to back in slight abduction) = squatted position posterior fracture dislocation Clinical  Extremity may  Flexion, adduction  No features appear and internal shortening  longer (medial) rotation of limb  Femoral nerve deformity  Limb is in may be damaged  Cause maximum neutral  External rotation, shortening of limb position Abduction &  Most commonly  The leg Flexion (in associated with does not obturator type) sciatic nerve injury rest in a  External rotation, characteris Abduction & tic position Extension (in pubic  There may type) be some narrowing of pelvic width Femoral Groin (anterior) Gluteal region Per rectal (PR) Head examination felt in Vascular Negative Positive (i.e. femoral Negative sign vessel not of Narath palpable) Nerve Femoral nerve (& Sciatic nerve - Hipinjured Decreasedvessels) Increased Decreased movement

FEMORAL NECK FRACTURES  Most common cause of a broken hip.  The femoral neck is the intracapsular portion of the proximal femur between the femoral head and the lesser and greater trochanters.  Most common in elderly patients.

Anatomical Fracture angle (Pauwel's Fracture displacement (Garden location classification) classification) Sub capital Pauwel's angle: angle formed Undisplaced: Trans by Stage-I: incomplete (Valgus impaction of cervical the line of fracture with the the Basi cervical horizontal plane. femoral head) Type-I: 30 degrees Stage-II: complete fracture without Type-II: 50 degrees displacement. Type-Ill: 70 degrees Displaced : Stage-Ill: complete fracture with partial displacement Stage-IV: complete fracture with full displacement.

 The higher the Garden number, the higher the incidence of avascular necrosis. Risk Factors  Osteoporosis - major risk factor for femoral neck fractures in the elderly  Factors that increase the risk of falling, such as an unsteady gait  Female gender (postmenopausal)  Physical inactivity  Caucasian race

Physical Exam  With unstable fractures, the leg often is rotated externally and shortened.  Active straight-leg raise will provoke pain.

Treatment Algorithm of Intra Capsular Femoral Neck Fractures UNDISPLACED: DISPLACED Ambulators: a. < 65 yrs, ambulator: CRIF (Treatment of Reduction & fixation: choice), or Open reduction-65% of cases. ORIF. Closed reduction- 75% of cases. b. 65-75 yrs, ambulator: CRIF House hold ambulators: c. > 75, ambulator: cemented bipolar Bipolar/ unipolar hemi arthroplasty. arthroplasty Complications like acetabular damage, OA, d. >75, minimal house hold ambulator: RA, Paget's cemented unipolar arthroplasty disease etc: e. >75yrs, extremely ill : percutaneous CRIF Total hip replacement f. Pre existing arthritis: Total Hip Replacement

 The two main treatment modalities are o Arthroplasty (hemi replacement & THR) and reduction o Internal fixation by canulated cancellous screws.  The prosthetic replacement allows immediate weight bearing & eliminates chances of nonunion and avascular necrosis and in limited life expectancy reduces the chances of reoperation.

Complications  Most common: Avascular necrosis  Second MC: Non union

Causes of non union  Cambium layer of periosteum which produce callus is missing. Therefore femoral neck must heal via direct endosteal healing only.  There is no contact with soft tissues which could promote callus formation.  Precarious blood supply: by tearing the ascending cervical branches or retinacular vessels the injury deprives head of its main blood supply.  Synovial fluid interferes with fracture healing as it prevents clotting of fracture hematoma and release angiogenic inhibiting factors.  Inadequate reduction and improper immobilization.  Tamponade effect of intracapsular hematoma causing floating of both fracture ends and making reduction difficult.

FRACTURE SHAFT OF FEMUR IN ADULTS Winquist and Hansen classification:  Type I: >75% bony contact  Type II: At least 50% cortical contact  Type III: <50% contact  Type IV: No bone contact

The AO/Orthopaedic Trauma Association classification:  Type 32A (simple), 32B (wedge), or 32C (complex)  Each type is subdivided as 1, 2, or 3 according to the inherent instability of the fracture configuration.

Treatment:  Splint the limb with a Thomas-type splint to help reduce blood loss from the fracture and relieve pain.  Most femoral shaft fractures are treated operatively with intramedullary nailing.

FRACTURE SHAFT OF FEMUR IN CHILDREN  Child abuse is the M/C cause of femoral fractures before walking age (< 2 years).  Pathologic fracture: Osteogenesis imperfecta, Aneurismal bone cyst. Non ossifying fibroma, Eosinophilic granuloma.  Osteogenesis imperfecta is diagnosed by presence of blue sclera, hearing loss, multiple fractures in different stages of healing and dentinogenesis imperfecta.

Management plan:  Pelvic harness (< 6 months age)  Gallow traction infants < 12 kg of weight.  Russell's traction skeletal traction on Thomas knee splint and skeletal traction without splint (Perkins traction) are more suitable for older children & adolescents.  Immediate or early spica casting is the treatment of choice in children 6 months to 6 years age for femoral fractures with < 2-3 cm of initial shortening and stable fracture pattern.

INTERTROCHANTERIC FRACTURE-FEMUR  Best managed by Closed Reduction/Open Reduction and internal fixation by dynamic hip screw (DHS), sliding hip screw, Medoff plate & intramedullary hip screw.  Conservative methods: Russell's traction & skeletal traction in a Thomas splint

Fracture Extracapsular Neck Femur Fracture lntracapsular Neck Femur Intertrochanteric fracture Subcapital fracture Transtrochanteric fracture Transcervical fracture Basal neck fracture Most common complication: Malunion Most common complication: Avascular necrosis, Managed by DHS, Ender's nails ManagedNon union by (2 ndCC m.c) screw or prosthetic replacement FEMORAL HEAD FRACTURES

AVASCULAR NECROSIS OF FEMORAL HEAD (Osteonecrosis; Aseptic necrosis; Chandler disease)  Most common cause: Idiopathic  Causes other than fractures (SCLERA) o S – Steroids o C – Caisson's disease o LE – Lupus Erythematosis o R – Radiation therapy o A – Alcoholism

LIGAMENTOUS INJURY OF KNEE JOINT Anterior cruciate ligament (ACL)  Attachments of ACL o In tibia immediately behind anterior horn of medial meniscus o Pass upwards, backwards and laterally o Posterior part of medial surface of lateral femoral condyle  Major stabilizer of knee.  Its mechanism is to stabilize internal rotation and extension of tibia on femur.  Its function is multiple in that it limits forward gliding of tibia on femur and limits hyperextension.  It makes a significant contribution to lateral stability and limits antero lateral rotation of tibia on femur.  It is intra-synovial.  ACL is most commonly injured with valgus, external (lateral) rotation, hyperextension, deceleration, and rotational knee movements

Posterior cruciate ligament (PCL)  Attachments of PCL o In tibia behind posterior horn of medial meniscus. o Passes upwards, forwards and medially. o Postural part of lateral surface of medial femoral condyle.  It is intra capsular, extra synovial and stouter ligamentous structure.  It limits backward glide of tibia of femur (posterior translation)  Checks hyperextension only after the ACL is ruptured  Classically injured by high velocity trauma with posterior dislocation of tibia on a flexed knee as in a 'dash board impact' in a motor car.

Most difficult action to perform in injury of  Anterior Cruciate ligament (ACL): Walking downhill  Posterior Cruciate Ligament (PCL): Climbing stairs

Anatomic Correlation of Clinical Ligament Instability Examination of the Knee Direction of Position Ligament Instability Force Varus or Full extension Posterior cruciate, posterior valgus capsule Varus Flexion at 30 degrees Lateral collateral ligament/complex Valgus Flexion at 30 degrees Medial collateral ligament Anterior Flexion at 30 degrees neutral position (AP) Anterior cruciate ligament Anterior Flexion at 90 degrees neutral internal or Anterior cruciate ligament external Posterior 90rotation degrees (sag test) Posterior cruciate ligament

Medial Meniscus Lateral Meniscus Semilunar (less circular) Semicircular (more circular) Larger in radius / diameter but Smaller in radius / diameter but wider in body & narrower in body & thinner in thicker in periphery Posteriorperiphery horn is larger than anterior Anterior & posterior horn are uniform in size Covershorn lesser (~ 65%) of tibial Covers more (~85%) of tibial articular surface articular surface Entire periphery is attached to joint Peripheral area where popliteus tendon crosses the capsule (medial capsular ligament) joint through popliteus hiatus is not attached Attached to medial collateral Not attached to lateral collateral ligament Doesligament not attach to either Attached to both cruciate ligaments, and cruciate ligaments posterior horn receives anchorage to medial femoral condyles by either the ligament of Humphry or Less mobile because of its Moreligament mobile of Wrisberg, because of its attachments Moreattachment prone to injury Less prone to injury

 An unhappy triad (or terrible triad, "horrible triangle", O'Donoghue's triad or a "blown knee") is an injury to the anterior cruciate ligament, medial collateral ligament, and the Medial meniscus.  Lateral meniscus tears are far more common than medial meniscus tears in sprains of the ACL TEST FOR LIGMENTOUS INSTABILITY OF THE KNEE Anterior Cruciate Ligament  Lachman's test: (most sensitive, done at 20' knee flexion)  Anterior drawer test (done at 90 knee flexion, least reliable test)  Pivot shift test  Flexion rotation drawer lest

Posterior Cruciate Ligament  Posterior tibial sag  Posterior drawer test  Reverse pivot shift test  Quadriceps active test

Meniscus  Mc Murray's test  Apley's grinding test  Payrs sign

Collateral ligament  Valgus / varus stress test

FRACTURE PATELLA Mechanism Management Direct: dash board injury, Undisplaced/ minimally displaced fracture with no (undisplaced crack/ extensor lag: comminuted Hemarthrosis aspiration, Cylinder tube cast. stellate fracture) Displaced transverse fracture with extension lag: Indirect: fall due to forceful Tension band wiring. contraction of quadriceps. Comminuted stellate fracture: Mild - partial patellectomy; Severe- total patellectomy.

Bulge sign – indicates an abnormal but small amount of fluid (effusion) in knee. This test can detect as little as 4-6 ml of fluid.

Q Angle (ASIS-patella-tibial tubercle) The Q angle is the angle formed between the tibial tubercle, the patella, and the femur.  Patients with malalignment (patellar subluxation) often have an increased Q angle.  Normal Q angle: 10 + 5 degrees.  Patients with generalized hypermobility have increased extension of the knee or genu recurvatum,  patella alta.  Increased valgus at the knee may be associated with increased femoral anteversion and external tibial torsion, sometimes referred to as miserable malalignment syndrome.  All three increase the Q angle & thus the chance of developing anterior knee pain.  Patella alta, or high-riding patella, is identified by measuring the length of the patellar tendon and dividing by the length of the patella. The upper limit of normal is 1.2.

BURSITIS  Weaver's bottom: ischial bursitis  Housemaid's knee/ Carpenter knee/Carpet-layer knee: Prepatellar bursitis (m/c patellar bursitis)  Clergyman's knee: Infrapatellar bursitis  Breast stroker's knee: bursa under pes anserinus  Bunion: bursitis of great toe  Tailor's ankle: bursitis of lateral malleolus

ANKLE INJURIES  Over 90% of ankle ligament injuries (twisted ankle or ankle sprain) involve the lateral ligament complex- usually the anterior tibiofibular ligament.

ANKLE LIGAMENTS Medial Collateral Ligament (Deltoid ligament)  It is strong ligament and major stabilizer of ankle joint  It has two components

Superficial Deep (Intra-articular) Resist eversion of hind foot Prevent external rotation of talus  Talo-tibial  Anterior & posterior talotibial  Naviculo — tibial  Calcaneo — tibial Lateral Collateral Ligament  It is a weak ligament so involved in over 90% of ankle ligament injuries.  It has three parts o Anterior talofibular ligament (ATFL): Most commonly injured o Middle calcaneo fibular (CFL) o Posterior talofibular (PTFL): Torn in most severe injuries.  When the ankle joint is in plantar flexion, the ATFL is positioned in line with the fibula and therefore placed under stress with an inversion injury and will be damaged.  When the ankle joint is in plantar flexion, the CFL is positioned in line with the long axis of the fibula and therefore subject to injury.

LAUGE- HANSEN CLASSIFICATION OF ANKLE INJURIES: Injury type On medial side Tibio-fibular On lateral side Others syndesmosis Adduction Fracture medial Normal Avulsion fracture malleolus with of an lateral malleolus oblique fracture or line lateral collateral Abduction Avulsion Normal Fracture of fracture of lateral medial malleolus at the malleolus or level medial collateral of ankle mortice Pronation Transverseligament injury Damaged Spiralwith fracture of external fracture the rotation injury of medial fibula above the malleolus level at the level of of ankle mortice or ankle no mortice fracture Supination Transverse Normal Spiral fracture of fracture of the external fracture the posterior rotation injury of medial lateral malleolus malleolus malleolus above the level of (trimalleolar at the level of ankle mortice fracture) ankle mortice Vertical Comminuted fracture of medial malleolus distal end of tibia & lateral compression malleolus

The Danis-Weber or AO Association of Osteosynthesis system concentrates on the pattern of the fibular fracture.  Type A fracture is distal to the level of the syndesmosis and frequently transverse.  Type B fracture is a spiral oblique fracture at the level of the Syndesmosis.  Type C fracture is proximal to the syndesmosis level.

The Ottawa Ankle Rules were developed to assist in making the decision to take X ray of a suspected ankle fracture. X-ray examination is called for if there is:  Pain around the malleolus  Inability to take weight on the ankle immediately after the injury;  Inability to take four steps in the emergency department  Bone tenderness at the posterior edge or tip of the medial or lateral malleolus or the base of the fifth metatarsal bone.

STRESS FRACTURES  May occur in the pelvis, femoral neck, tibia, navicular and metatarsals.  The metatarsals are involved in 55% of cases, whereas the sesamoids and talus are involved in less than 1%  Occurs d/t significant increase in training and activity (Runner's fracture).  Risk factors: female athlete, poor nutrition, low bone density, and a history of menstrual disturbance.  MRI or technetium bone scans are the best diagnostic tests.  Treatment: rest and avoidance of high-impact activities until healing occurs.

CALCANEUM  Calcaneum is the most commonly fractured tarsal bone  In most cases the mode of injury is fall from height.  Usually associated with injury of spine (most common), pelvis or hip and base of skull  Most commonly associated injury of vertebral bodies, makes clinical & radiological examination of lumbo dorsal spine necessary in patients of calcaneum fracture  Fracture calcaneum is most often associated with other injuries: o Compression fracture of dorso – lumbar vertebrae o Fracture pelvis (pubic rami) and hip o Fracture base of skull (atlanto – axial injury) o Fracture talus o Vertical compression fracture of lower end tibia

TALUS  Articulates with the calcaneus and the remainder of the midfoot bones  Supports the body's weight and distributes the body's forces to the foot  Is critical to proper function of the foot  Is covered (~ 60%) with articular cartilage  Is vascularly supplied by vessels through a small area of the talar neck  Because of its the tenuous blood supply, the talus is predisposed to posttraumatic osteonecrosis. o High rate of osteonecrosis. o May fracture at talar neck, the talar body, and the processes of the talus. o Another common talus fracture is the talar dome osteochondral fracture  Classification of fracture patterns: o Talar neck fractures (m/c): Modified Hawkins system: . Type I: Nondisplaced vertical fracture of the talar neck . Type II: Displaced fracture of the talar neck with subluxation or dislocation of the subtalar joint; ankle joint is normal . Type III: Displaced fracture of the talar neck, associated with dislocation of the ankle and subtalar joints . Type IV: Extrusion of the talus o Talar body fractures: . Type I: Corona! or sagittal fractures . Type II: Horizontal fractures o Talar process fractures: . Posterior process fractures . Lateral process fractures  Etiology: high-energy trauma with forefoot hyperextension d/t o Motor vehicle collisions o High-energy falls o Snowboarding  Talar neck fratures are commonly associated with medial malleolar fractures.

HALLUX VALGUS  It is outward/ lateral deviation of great toe at the metatarsophalangeal joint  It is the commonest of the foot deformities (and probably of all musculoskeletal deformities)  Splaying of fore foot, with varus angulation os 1st metatarsal, predispose lateral angulation of great toe in people who wear shoes  Metatarsus primus varus may be congenital or result from loss of muscle tone in fore foot in elderly  Elements of deformity are: Lateral deviation and rotation of Hallux, together with prominence of medical side of head of 1st metatarsal (bunion)  Keller's operation: for hallux valgus correction

PES PLANUS Flatfoot, or pes planus, is a deformity of the foot in which the normal medial longitudinal arch of the foot has been lost. Signs and Symptoms  Flatfoot with low or no arch  Pain over medial arch  Deformity may progress with time.  May be exacerbated by walking, sports, high level of activity, or traumatic event  Abnormal shoe wear pattern  Increasing severity is associated with forefoot abduction and the ǎœtoo many toesǎ€? sign when the patient is viewed from behind.  Rigid flatfoot: o Loss of the normal longitudinal arch of the foot at all times o Restricted motion of the hindfoot  Flexible flatfoot: o Loss of arch only on standing on the affected foot, with reconstitution of the arch when the foot is dependent or when the patient toe-stands. o Normal motion of the hindfoot.

Radiography:  The calcaneal pitch is diminished and may approach 0° with more severe flatfoot deformity.  The talus-1st metatarsal angle increases with loss of arch. o This angle should normally be 0° with the talus and metatarsal collinear. o Angle measurements: o <15°, minor pes planus deformity; o 15-30°, moderate deformity o >30°, severe deformity Treatment of pes planus is nonsurgical in the form of shoe modification and inserts and stretching of a tight tendoachilles.

PES CAVUS (high instep, high arch, talipes cavus, cavoid foot, and supinated foot type)  Multiplanar foot deformity characterised by an abnormally high medial longitudinal arch.  Features: o Varus (inverted) hindfoot o Plantarflexed position of the first metatarsal o Adducted forefoot o Dorsal contracture of the toes.  Types Type Seen in Features Radiological findings Pes M/c type, seen Calcaneus in varus, Forefoot is typically cavovarus/idiop primarily in the first metatarsal plantarflexed in athic neuromuscular plantarflexed and a relation to disorders such as claw- the rearfoot Charcot-Marie- Tooth toe deformity disease and Friedreich's Ataxia Pes Seen primarily following The calcaneus is Large talo-calcaneal calcaneocavus paralysis of the triceps dorsiflexed and the angle foot surae forefoot is due to poliomyelitis plantarflexed. 'Pure' pes cavus Calcaneus is neither dorsiflexed nor in varus, and is highly arched due to a plantarflexed position of the forefoot on the rearfoot.

Signs and Symptoms  High arch  Calluses on forefoot or hindfoot  Difficulty with shoe wear  Patient: o May have heel varus or plantarflexion of the 1st metatarsal o May be asymptomatic o May complain of metatarsalgia (pain under metatarsal head region) o May develop recurrent ankle instability and/or sprains secondary to severe varus heel malalignment  Coleman block testing determines whether the hindfoot varus is flexible or rigid  Mild correctible deformities are managed with shoe modification or soft tissue procedures, including plantar fascia release, Achilles tendon lengthening, and extensor tendon recession. The claw toe deformities require flexor tenotomies with flexor-to- extensor transfer or extensor tendon recession. The bony procedures are done for rigid deformities. OPTIMAL POSITION OF JOINTS AFTER ARTHRODESIS Joint Angle Length Other Ankle 0° Dorsiflexion Slight TalusConsideration displaced 0-5° valgus of Hindfoot shortening posteriorly. 5-10° external rotation Males: neutral position Females: plantar flexion Knee 15° flexion Slight 5-8° flexion shortening Shoulder 20-30° flexion — Patient's hand should 20-40° abduction (lateral border of be 25-40°scapula) internal rotation able to touch the Hip 25° flexion Slight Dohead not destroy 0-5° abduction (measured between the shortening abductor shaft mechanism. 0-5°and aexternal line through rotation the ischia)

MOREL-LAVALLEE LESIONS  Post-traumatic, closed, internal degloving injuries.  Most frequently occur in the subcutaneous tissues adjacent to the greater trochanter.  MRI is the diagnostic imaging modality of choice  The lesions are typically oval, fusiform, or crescentic, consistent with fluid dissecting along traumatized fascial planes.  Frequently associated with underlying fractures, and are often identified within hours to days after the inciting trauma.  The presence of a capsule is an important imaging finding that can be used to help select surgery over conservative therapy.

Types of loose bodies Osteo cartilaginous Cartilaginous Fibrous Others Composed of bone & - Radiolucent - Radiolucent loose - Intra articular cartilage. loose bodies. bodies. tumors like Seen in: - Usually - Result from lipoma, a. Osteo chondritis traumatic. hyalinised synovium localized nodular dissecans(M/C) secondary to trauma, synovitis etc. b. Osteo chondral fracture inflammatory c. Osteophytes (osteo conditions etc... arthritis) d. Synovial osteo chondromatosis

SYNOVIAL CHONDROMATOSIS  Rare disorder in which the joint contains multiple loose bodies, in pearly clumps resembling sago ('snowstorm knee').  Cartilage metaplasia at their tips; these tips break free and may ossify.  X-rays reveal multiple loose bodies; on arthrography they show as negative defects.  Treatment: The loose bodies should be removed arthroscopically.

V. SPINE AND ITS PATHOLOGY

Important Landmarks Hard palate Arch of Atlas Mandible C2-3 Hyoid cartilage C3 Thyroid cartilage C4-5 First cricoid ring C6 Carotid (Chassaignac C6 (anterior tubercle of the transverse process of Vertebratubercle) prominens C7C6) Scapula spine T3 Scapula tip T7 Umbilicus L3-4 disk space Top of iliac crest L4-5 interspace PSIS S2 spinous process

STABLE SPINE  Stable spine is one which after the initial injury does not get displaced further  The spine is stable when atleast 2 columns of the spine are intact.  Denis' three column concept, the spine is considered to have three columns

Anterior column Middle column Posterior column  Anterior  Posterior longitudinal  Transverse process longitudinal ligament  Spinous process ligament  Posterior half of vertebral  Pedicle  Anterior half of body and intervertebral disc  Lamina vertebral body and  Faceted joints intervertebral disc  Interspinous ligament  Supraspinous ligament  Ligamentum flavum

Intervertebral Disk  Found between vertebral bodies from C2-3 to L5-S1 and rarely between the upper sacral vertebrae  Relatively avascular.  Only the outermost layers receive nutrients from peripheral vascularization.  The central portion (nucleus pulposus) receives nutrients through diffusion from the vertebral endplates.  Nucleus pulposus: made of predominantly type II collagen and is a remnant of the primitive notochord.  Annulus fibrosus: made of predominantly type I collagen.  The thickest layers are anterior; the thinnest are posterolaterally.  The thinner posterolateral sections of the annulus and PLL are the most common sites for disk herniations.

Bony Anatomy of the Spine  Mean spinal length = 71 cm Region & Alignmen Angles Features Number t (33 vertebrae Cervical : 7 Lordosis 20 to 40 degrees Foramina for vertebral artery (50% flexion- C1 (atlas): no vertebral body or spinous extension between process Occiput & C1; 50% C2 (axis): dens (odontoid process) Rotation between articulates with atlas C1&C2) Bifid spinous process and anterior tubercle except C7

Thoracic: 5 Kyphosis 1. 20-50 degrees Ribs (costal) facets present on T1-12 (Increases (mean 35) bodies and transverse processes with age) 2. T10 - 12 = Rounded foramen 5degrees 3. T12-L2 =3 degrees Lumbar: 5 Lordosis 1. 40-80 degrees Largest vertebrae bears 80% axial (decreases (mean 60 degrees) 2. load while facets bear 20% with age) 60%-70% between Mammilary processes project posteriorly L4 and S1 from the superior articular facets L3 endplate and pedicles are parallel to floor while standing

Sacrum: 5 Kyphosis Fusion of 5 spinal elements Four pairs of anterior (larger) and posterior sacral foramina with respective branches of sacral nerves Coccyx: 4 Kyphosis Fusion of lowest 4 spinal elements

LUMBAR DISC HERNIATION (Herniated nucleus pulposus, Slipped disc, Ruptured disc, Sciatica)  Major causes of acute and chronic lower back pain  May be associated with leg pain, weakness, and numbness  "sciatica".

Classification:  By location: o Posterolateral - most common; the posterior longitudinal ligament is the weakest structure. o Usually affects the ipsilateral nerve root of the lower lumbar vertebrae. o Far lateral herniations - affect the ipsilateral nerve roots of the upper lumbar vertebrae. o Central herniations - associated with back pain only, may lead to cauda equina syndrome.  By morphology: o Protruded: Eccentric bulge of the nucleus pulposus with intact annulus fibrosis o Extruded: The nucleus protrudes through the annulus but remains intact. o Sequestered: Nucleus not intact, and a free fragment within the spinal canal

Epidemiology  Most commonly seen in patients 30-50 years old; rare before age 20 years.  Men are affected more often than women.  The lumbar spine is the spinal level most commonly affected by disc herniation.  L4-L5 vertebral level is the most commonly affected level, followed by the L5-S1 level.

Pathophysiology  The intervertebral disc is made of an inner nucleus pulposus and an outer annulus fibrosis.  Formed primarily of type I and type II collagen  Vascular and neural elements are found exclusively within the peripheral fibers of the annulus fibrosus.  Nutrients flow to the intervertebral disc via diffusion from the hyaline cartilage endplates located above and below the disc.  Beginning in a person as young as 20 years old, the nucleus pulposus gradually looses water content.  With age, the intervertebral discs lose volume, shape, and viscoelastic ability.

Signs and Symptoms  Pain is the usual presenting symptom. o May affect the back only, leg only, or both o Pain often is aggravated by forward flexion of the lumbar spine and relieved by extension.  Numbness in the dermatome associated with the affected nerve root may occur.  Weakness in the muscle associated with the affected nerve root may occur. o L3-L4 herniation causes an L4 root compression characterized o Anterior tibialis weakness o Decreased patellar reflex  Medial knee and leg sensory changes. o L4-L5 herniation results in L5 symptoms, including o Altered sensation over the lateral aspect of the calf and the 1st dorsal web space  Extensor hallucis longus weakness  L5-S1 herniation compresses the S1 nerve root o Decreases ankle reflex o Decreased plantarflexion strength o Diminished sensation over the lateral aspect of the foot.  Saddle anesthesia and changes in bowel or bladder habits may indicate cauda equina syndrome.

Imaging  AP and lateral radiographs for patients with symptoms lasting >6 weeks.  CT myelography has been replaced by MRI (Investigation of choice)  Discography - localize the site of pain generation to the disc complex

Medical treatment  First Line treatment: Acetaminophen, NSAIDs, Narcotics in the early acute stage  Second Line treatment: Oral corticosteroids, Epidural corticosteroid and anesthetic injections

Surgery  Reserved for patients for whom aggressive nonoperative treatments have failed  Surgery is the first line of treatment for o Patients with severe progressive neurologic deficit o Development of cauda equina syndrome  Operative therapy is more effective in treating symptoms related to the lower extremities than those related to back pain.  Surgical options include: o Open discectomy, laminectomy, or laminotomy o Microscopic discectomy o Endoscopic discectomy

THORACIC DISC HERNIATION  Difficult condition to diagnose and treat because of its vague symptoms  Occurs most commonly occurs in the 5th decade  A slight male predominance is noted.  Patients may present with o Axial pain (localized from the middle to lower thoracic spine) o Radicular pain (T10 dermatomal is most common) o Myelopathy (bowel and bladder dysfunction)

DISC DEGENERATION/ PROLAPSE  Most common site: lumbar spine. (L4-L5 > L5-S1)  Second most common site: lower cervical spine. (C5-C6) Risk factors: smoking, sedentary work, motor vehicle driving, lifting heavy weight, stooping forward Types:  Central disc herniation: leads to compression of cauda equina.  Para central (para median) type: mostly unilateral radicular symptoms are seen.  Far lateral disc herniation: bulge is within or just lateral to neural foramina Clinical features:

 Lateral disc herniation of L4-5 compress L4 nerve root; of Ls-s1 compress L5 nerve root (less common type)

 Central or paracentral disc herniation at L3-4 compress L4; at L4-5 compress L5 and at L5s1 compress S1 nerve root (more common).

Lumbar Disk Radiculopathies L3-L4 (L4 Nerve) L4-L5 (L5 Nerve) L5—S1 (S1 Nerve) Pain Anterolateral Lateral thigh, Gluteal region, posterior thigh, distribution thigh, anterolateral calf, medial posterolateral calf, lateral anteromedial calf dorsum of foot, especially dorsum and undersurface of the to the ankle between the first and foot, particularly between fourth second toes and fifth toes Weakness Quadriceps Dorsiflexion of the foot Plantar flexion of foot Reflex femorisKnee None Ankle affected

Thoracolumbar Spinal Nerves Roo Motor Effects Sensory Effects Reflex T12t Hip flexor (iliopsoas) Groin None L1 Hip flexors Anterior proximal thigh None L2 Hip flexors and Anterior midthigh None adductors L3 Adductors and Distal thigh Patellar quadriceps Lateral, anterior (L1-3) (L2- Lateral, anterior, and medial femoral cutaneous L4) nerves of the thigh and obturator nerve L4 Quadriceps and Medial leg Patellar anterior Saphenous nerve (L2- tibialis L4) L5 EHL Lateral leg None Gluteus Medius Dorsum of foot EDL/EDB Lateral cutaneous Nerve of calf Medial plantar Nerve

S1 Peroneus longus and Lateral foot Achilles brevis Plantar foot Gluteus maximus Posterior calf Gastroc-soleus (51/2) Lateral plantar nerve

S1-4 Bowel/bladder Perianal region None Foot intrinsics S4-5 Sphincter Perianal None

Cervicothoracic Nerves Lev Nerve Motor Effects Sensory Effects Reflex el Root C1-2 C2 Clavicular head of Head and neck None sternocleidomastoid C2-3 C3 Trapezius, diaphragm Head and neck None C3-4 C4 Scapula, diaphragm Lateral neck/shoulder None C4-5 C5 Diaphragm, deltoid, biceps Lateral arm (axillary nerve) Biceps (elbow flexion) C5-6 C6 Wrist extensors, biceps, Radial forearm, thumb, and index Brachioradial triceps (supination) fingers (musculocutaneous nerve) is C6-7 C7 Triceps (elbow extension), Middle finger Triceps wrist flexors, finger extensors Pronation C7-8 C8 Finger flexors, interossei Ring and little fingers (ulnar None hand), medial forearm (Medial antebrachial T1-2 T1 Finger abductors Medial arm (ulnar forearm) None (interossei) (medial brachial cutaneous nerve)

SPONDYLOLISTHESIS  Abnormal AP translation of 2 vertebral bodies relative to each other.  Secondary to a defect in the pars interarticularis (spondylolysis) or the posterior ligamentous-bony restraints.  Spondylolysis is a defect in the pars interarticularis  Occurs most commonly at L5-S1.  The defect develops in 75% of the cases by 5 to 6 years of age.  In adults, progression of spondylolysis to spondylolisthesis is very unlikely.  Physical examination reveals limited extension and pain with extension.  Lateral X-ray: Scottie dog with a collar.  Spondylolisthesis is classified by type and by the severity of the slip.  Etiology: o Isthmic spondylolisthesis: stress fracture through a thin portion of the posterior elements (pars interarticularis). o Degenerative spondylolisthesis: degeneration and instability of the disc.

Classification: Class Associated Risk Factors Isthmic Family history, gymnastics, football lineman Congenital Spina bifida occulta Pathologic Metastatic cancer or infection Traumatic Often associated with spinal cord injury Degenerative Seen in 6th and 7th decades of life at L4-L5 latrogenic Removallevel of posterior restraints at prior surgery  Clinical features: o Pain localized to the low back and thigh area may be seen in association with sciatica from an L5 radiculopathy. o Back or leg pain o Gait abnormality o Abnormal posture (hyperlordotic) o History of trauma: Acute or mild repetitive, often sports-related

Meyerding Classification Spondylolisthesis Grade Percentage of Slip Grade 0 0 Grade I <25 Grade II 25-50 Grade III 51-75 Grade IV 76- 99 Grade V Complete displacement (spondyloptosis)

Classes of Spondylolisthesis Clas Type Age Description Level I s Congenital Child Congenital dysplasia of the S1 superior facet; L5-S1 hamstring spasm commonly seen Type A: horizontal orientation, spina bifida occulta Type B: asymmetric sagittal malorientation with intact neural arch, cauda equina syndrome, nerve compression Type C: failed vertebral body formation, lumbosacral angle deformities, congenital kyphosis II lsthmic 5 to Most common; fracture or elongation of L5 L5-51 50 pars; common in football linemen; gymnasts; III Degenerativ Elderl Degenerationballet dancers of sagitally oriented lumbar L4-5 (90%); e y facets (mostly at L4-5) L3-4 or L5- S1 (10%) IV Traumatic Young Acute fracture other than pars L5-51 V Pathologic Any Destruction of spinal elements Any VI Postsurgical Adult Resection of posterior elements/facets Any

 Conventional radiographs, including a spot lateral of L5, S1, allow assessment of the presence and degrees of spondylolisthesis. o Oblique views show the pars interarticularis (neck of the Scotty dog) and visualize the pars defect. o Flexion and extension views illustrate stability, particularly for degenerative and iatrogenic slips  When a clear pars defect is not visualized, a technetium bone scan can be used. o For this study, a SPECT scan should be ordered.  CT can aid in the diagnosis of occult pars interarticularis defects.  MRI often is not useful for identifying spondylitic defects.

THORACOLUMBAR SPINE FRACTURE AND DISLOCATION  Most spine fractures occur in the thoracolumbar region.  In the lower cervical spine, dislocations without fractures are common, but fractures and fracture-dislocations do occur.  T11-L1 is the most frequently injured area.  The Denis 3-column classification is the system most commonly used to describe thoracolumbar fractures. o Divides the thoracolumbar spine into 3 columns: . Anterior column: Anterior 2/3 of the vertebral body/disc . Middle column: Posterior 1/3 of the vertebral body/disc and posterior longitudinal ligament . Posterior column: Pedicles, facets, lamina, transverse, and spinous processes o Denis classification divides fractures into minor and major injuries: . Minor injuries: Fractures of spinous and transverse processes, pars interarticularis, and facets . Major injuries: Compression fractures, burst fractures, distraction-flexion injuries, fracture-dislocations, and distraction-extension injuries

Types of major spinal fracture:  Wedge fracture (compression fractures)-stable  Burst and compression-flexion ('teardrop') fractures– stable  Seat belt fracture (and 'chance fracture') – unstable  Fracture dislocation - unstable  In the lower thoracic spine, wedge compression fractures are most commonly encountered.  In the lumbar spine, both compression and burst fractures can occur.  Axial pain is localized to the fractured level.  Occasionally, patient's back becomes increasingly rounded and significant loss of height has occurred. This spinal deformity is known as the dowager's hump.  Initial treatment: analgesic therapy and bracing for comfort.

Vertebroplasty/ kyphoplasty  Bone cement is injected through a small hole in the skin (percutaneously) into a fractured vertebra.  Relieves back pain caused by vertebral compression fractures.  Not effective in treating osteoporosis-related compression fractures of the spine.  The cement (most commonly PMMA) quickly hardens and forms a support structure within the vertebra that provide stabilization and strength.  Kyphoplasty attempts to restore the height and angle of kyphosis of a fractured vertebra.

ROOT INVOLVEMENT Roots Sensory system Motor system

C2 Sensation decreased over back of the C2 - C4 root involvement survival of

C3 ↓scalp sensation over anterior aspect of the patient is rare

C4 ↓neck sensation over lateral aspect of neck and inferiorly over clavicles down to the rib C5 ↓ sensation over the lateral deltoid ↓voluntary activity of deltoid and

C6 ↓ sensation over the radial aspect of the ↓bicepsECRL, ECRB activity forearm, thumb, index and middle finger

C7 ↓ sensation over the ulnar border of ring ↓ triceps, finger extensors, pronator and teres and FCR activity small fingers C8 ↓ sensation over ulnar border of hand and ↓FDS or profundus activity forearm

T1 ↓ sensation over the medial aspect of the upper arm

T2 ↓ over the anterior chest wall above the Intrinsic function of the hand is intact FCR – flexornipple carpi radialis, ECRL-extensor carpi radialis longus, ECRB-extensor carpi radialis brevis, FDS-flexor digitorum superficialis VI. DEGENERATIVE AND METABOLIC BONE DISORDERS

RICKETS Radiographic findings:  Thickening & widening of growth plate (physis) & narrowing of joint space  Indistinct and hazy metaphysis that is abnormally wide with cupping or flaring  Delayed appearance & bowing of diaphysis, with thinning of cortices.  Cupping & splaying of metaphysis  Looser's zone in 20%

OSTEOMALACIA  Vitamin D deficiency is the most common cause of osteomalacia  Painful proximal muscle weakness (especially pelvic girdle); bone pain and tenderness.  Decreased bone density from defective mineralization.  Decrease in the rate of bone turnover and an increase in the amount of uncalcified osteoid.  Laboratory abnormalities o Increased alkaline phosphatase o Decreased 25-hydroxyvitamin D o Hypocalcemia o Hypocalciuria o Hypophosphatemia, o Secondary hyperparathyroidism

Radiological features  The classical feature: Pseudo fracture or Looser's zone  Triradiate pelvis in females  Protrusion-acetabuli: acetabulum protruding into the pelvis.  More commonly there is diffuse fading of skeleton leading to biconcave (cod fish) vertebra due to disc pressure and indentation of acetabulum producing trefoil or champagne glass pelvis.

OSTEOPOROSIS  Characterized by o Reduced bone mineral density(BMD) o Microarchitectural deterioration of bone tissue  Loss of bone osteoid that reduces bone integrity, resulting in an increased risk of fractures  Common in women after menopause due to estrogen deficiency  Most common sites of osteoporotic fractures: vertebrae (mc), hip, forearm (Colles fracture)  Fractures of the vertebrae with compression cause kyphosis - production of a typical "widow's hump"  M/C form is involutional osteoporosis

Risk factors for osteoporotic fracture Non modifiable Estrogen deficiency Potentially modifiable  Personal h/o fracture as an  Early menopause (< 45  Current cigarette adult years) or bilateral smoking  h/o fracture in first degree ovariectomy  Low body weight (< 58 relative  Low calcium intake kg)  Female sex  Alcoholism  Recurrent falls  Advanced age  Impaired eyesight  Inadequate physical  White race despite adequate activity  Dementia correction  Poor health Investigations  Serum calcium, phosphate, PTH, alkaline phosphatase - NORMAL  Dual-energy x-ray absorptiometry (DXA) is a highly accurate technique for measuring bone density  Bone densitometry cannot distinguish osteoporosis from osteomalacia  T-score – for postmenopausal women o Osteoporosis: T-score of –2.5 or below o Osteopenia: T-score between –1.0 and –2.5 o Normal: T score – 1.0  The "Z score" is used to express bone density in premenopausal women, younger men, and children,

SINGH INDEX  Classification system for bone density of the femoral neck based on the visibility of the trabecular types that can be seen in the femoral neck.  Five trabecular types can be present in the proximal part of the femur: o Principal compression o Secondary compression o Primary tensile o Secondary tensile o lntertrochanteric  As osteoporosis progresses these trabeculae get thinner and eventually disappear.  Singh index: o Grade 1: only thin principal compression trabeculae visible o Grade 2: principle compression trabeculae present, other trabeculae nearly resorbed o Grade 3: principle tensile trabeculae thinned and breakage in continuity present o Grade 4: principal tensile trabeculae thinned without loss of continuity o Grade 5: principle tensile and compression trabeculae readily visible with prominence of ward triangle o Grade 6: all trabeculae visible and of normal thickness  Grade 3 and below indicate definite osteoporosis.

Drugs used in the treatment of osteoporosis  Bisphosphonates o First line of treatment o Most potent bisphosphonate – Zolendronate (once yearly IV; also used in Philadelphia chromosome +ve CML) o Increase BMD and reduce bone resorption o Alendronate and residronate reduce risk of vertebral and non vertebral fracture o Characteristic feature of bisphosphonate toxicity – osteonecrosis of jaw  Hormone replacement therapy - risk of breast cancer, strike, thromboembolic phenomenon  Estrogen  Calcium, Vitamin D, PTH  Calcitonin - intranasally  Raloxifene (selective estrogen receptor modulator, SERM) o Reduces risk of vertebral fractures(but not non vertebral fracture) o Increases BMD o Side effects: muscle cramps, hot flushes, venous thromboembolism o Reduces risk of breast cancer o No cardiovascular or cerebrovascular side effects o Reduces serum LDL, cholesterol, lipoprotein(a), fibrinogen  Teriparatide – a PTH analogue  Strontium; Tibolone  Donesumab: blocks RANK receptor of osteoclasts – twice yearly SC administration  In women with uterus progestins are prescribed in combination with estrogens to reduce the risk of uterine cancer. Progestins may increase the risk of breast cancer

Osteoporosis Osteomalacia Definition Bone mass decreased Bone mass variable Mineralization normal Mineralization decreased Age of Generally elderly, Any age Onset postmenopausal Etiology Endocrine abnormality Vitamin D deficiency Age Renal tubular acidosis Idiopathic Abnormality of vitamin D metabolic pathway Hypophosphatemic syndromes

Symptoms Pain referable to fracture site Generalized bone pain

Lab Serum Ca, PO4, alkaline Serum Ca, PO4 low/normal Findings phosphatase Alkaline phosphatase elevated normal Causes of Osteopenia [Decreased Bone Mass]  Rheumatoid arthritis, Ankylosing spondylitis  Osteomyelitis  Osteonecrosis of femoral head  Rickets  Multiple myeloma  Metabolic bone diseases

FRAGILITY FRACTURE  Fracture resulting d/t any fall from standing height or less.  M/c areas fractured: hip, spine and the wrist.  Fractures are: o Colles fracture o Fracture head of femur o Vertebral fractures OSTEOARTHRITIS Synonyms: Degenerative joint disease, Wear-and-tear arthritis

Clinical features  Degenerative disorder with minimal articular inflammation.  No systemic symptoms  Variable or intermittent over time (good days and bad days)  Pain (earliest symptom) occurs during or just after joint use and then gradually resolves.  Morning stiffness is usually brief (<30 min)  Causes varus deformity of the knee in late stages.  If the synovial fluid white count is >1000 per µA, inflammatory arthritis or gout or pseudogout are likely  The knee is the most commonly affected joint, followed by the hand and hip.  Osteoarthritis is the most commonly seen form of appendicular arthritis.

Pathology  The pathologic sine qua non is hyaline articular cartilage loss  In knees, meniscal degeneration is part of the disease

Joints commonly involved Joints spared  Proximal inter phalangeal joint (PIP) Bouchard's  Wrist, Elbow, Ankle nodes  Metacarpophalangeal joints(MCP)  Distal inter phalangeal joint (DIP) Heberden's  Carpometacarpal joints (except nodes base of thumb)  First Carpometacarpal joint (squaring of thumb base)  First metatarsophalangeal joint  Hip, knee - antalgic gait  Cervical and Lumbosacral spine

X-ray  Joint space narrowing  Subchondral sclerosis  Osteophytes  Bone cysts

RHEUMATOID ARTHRITIS  Most common inflammatory arthritis in women  Symmetric peripheral polyarthritis  Female gender, cigarette smoking are risk factors  Strongly associated with HLA-DR4

Pathogenesis  Accumulation of neutrophils in the synovial fluid and along the synovial surface(not in the synovial stroma)  Aggregation of organizing fibrin covering the portions of synovium and floating in the joint space as rice bodies  Pannus formation - a mass of synovium and synovial stroma consisting of inflammatory cells, granulation tissue and fibroblasts which causes erosion and destruction of articular cartilage (principle target) eventually resulting in ankylosis

Clinical features  Early morning joint stiffness lasting more than 1 hour and easing with physical activity  Earliest involved joints are typically the small joints of the hands and feet  Wrists, metacarpophalangeal (MCP), proximal interphalangeal (PIP) joints are most frequently involved  Subcutaneous rheumatoid nodules, most commonly situated over bony prominences but also observed in the bursae and tendon sheaths

Joints involved  Symmetrical involvement of MCP, PIP and MTP  Large joint involvement is common but occurs later  Spine is spared except the cervical spine which is commonly involved

Deformities  Flexor tendon tenosynovitis is a frequent hallmark of RA and leads to decreased range of motion, reduced grip strength, and trigger fingers  Swan neck deformity– hyperextension of PIP with flexion of DIP  Button hole or boutonniere deformity – flexion of the PIP joint with hyperextension of the DIP  Z-line deformity of the thumb - subluxation of the first MCP with hyperextension of the first interphalangeal (IP) joint  Ulnar deviation of fingers – subluxation of MCP, with subluxation of the proximal phalanx to the volar side of the hand  Cock-up toe – dorsal subluxation of MTP  Piano-key movement of the ulnar styloid – inflammation about the ulnar styloid and tenosynovitis of the extensor carpi ulnaris  Pes planovalgus (flat feet)  Hammer toe & Wind – sweep deformities of toes  Late triple knee deformity

Laboratory features: Synovial fluid WBC counts: 5000 - 50,000 WBC/µ3 (<2000 WBC/µ3 in Osteoarthritis) Radiological features  Juxtaarticular osteopenia  Bone erosions (often first evident at the ulnar styloid and at the juxtaarticular margin)  Narrowing of joint space due to loss of articular cartilage

Rheumatoid factor  Autoantibody, usually IgM  Not specific for RA (absence cannot exclude RA); Positive in 70-90% patients  Positive RF is associated with worse prognosis  Level parallels the activity of the disease  Anti-CCP antibody more specific than Rheumatoid factor in the diagnosis of RA  Anti-CCP positivity – worse prognosis Criteria for diagnosis of RA (four or more of the following)  Morning stiffness > 1hr  Arthritis of 3 or more joints  Arthritis of hand joints  Rheumatoid nodules  Rheumatoid factor  Radiological changes  Duration of 6 weeks or more

Extra articular manifestations - more common under the following conditions  History of smoking  Early onset of significant physical disability  Test positive for serum RF Ocular Cardiac Pulmonary  Scleritis, episcleritis  Pericarditis(MC),  Nodules (MC)  Scleromalacia myocarditis,  Fibrosing alveolitis  Keratoconjunctiviti endocarditis  Bronchilitis s sicca  Pericardial effusion  Exudative Pleural effusion Felty's syndrome  Conduction defects with low glucose and pH  Nodular RA Vasculitis Caplan's syndrome  Splenomegaly  Pyoderma  Coal worker's pneumoconiosis  Neutropenia gangrenosum  RA Amyloidosis  Mononeuritis multiplex

Treatment  DMARDs- methotrexate (first choice) hydroxychloroquine, sulfasalazine, leflunomide  NSAIDs, Corticosteroids  Anti-TNF-α: Etarnacept, Infliximab, Certolizumab  Anakinra (anti-IL-1), abatacept, monoclonal antibody(rituximab, tocilizumab)

ANKYLOSING SPONDYLITIS  Marie – Strumpell or Bechtrew's disease  Primarily affects the axial skeleton, peripheral joints  Disease usually begins in the second or third decade  Male to female prevalence is 2-3:1  HLA-B27 is present in 80-90% of patients

Clinical features  The age at onset is usually in the late teens or early 20s  The initial symptom is usually dull pain, in the lower lumbar or gluteal region, accompanied by morning stiffness that improves with activity and returns following inactivity  Sacroiliitis is often the earliest manifestations of AS  Restriction of movement of lumbar spine in all directions  Progressive limitation of back motion and of chest expansion  Transient acute arthritis of the peripheral joints occurs in about 50% of cases, most commonly the hips, shoulders, and knees  Enthesopathy, a hallmark of the spondyloarthropathies, can manifest as swelling of the Achilles tendon at its insertion, plantar fasciitis (producing heel pain), or "sausage" swelling of a finger or toe (less common in Ankylosing spondylitis than in psoriatic arthritis).  Anterior uveitis in 20-25%.  Spondylitic heart disease – AV conduction defects and aortic regurgitation - in 3- 5% of patients with long-standing disease

Radiological features  The earliest radiographic changes are usually in the sacroiliac joints – bilaterally symmetrical sacroileitis  Pseudo widening of the joint space  Inflammation where the annulus fibrosus attaches to the vertebral bodies initially causes sclerosis (shiny corner sign) and then characteristic squaring of the vertebral bodies  Bamboo spine – late radiographic appearance of spine

PSORIATIC ARTHRITIS 5 major presentations of Psoriatic Arthropathy (PsA) a) Arthritis of DIP joints b) Asymmetric oligoarthritis  Most characteristic when a finger or toe is involved leading to sausage digit or dactylitis c) Symmetrical polyarthritis  Resembles RA but nodules and extraarticular features are absent d) Axial involvement (spine and sacroiliac joints) e) Arthritis mutilans – widespread shortening of digits (telescoping)

Clinical features  Pustular psoriasis is associated with severe disease  Dactylitis, enthesitis and tenosynovitis are common  Shortening of digits because of underlying osteolysis is particularly characteristic of PsA  Rapid ankylosis of proximal interphalangeal (PIP) joints early in the course of disease is common  Nail involvement is seen in almost all patients  Uveitis and aortic insufficiency are seen after long standing disease

Radiological features  Characteristics of peripheral PsA include DIP involvement along with o Classic pencil-in-cup deformity o Marginal erosions with adjacent bony proliferation (whiskering) o Small-joint ankylosis o Osteolysis of phalangeal and metacarpal bone, with telescoping of digits  Characteristics of axial PsA include asymmetric sacroiliitis (when compared to ankylosing spondylitis) o Less zygapophyseal joint arthritis o Fluffy hyperperiostosis on anterior vertebral bodies o Severe cervical spine involvement, tendency to atlantoaxial subluxation o Relative sparing of the thoracolumbar spine o Paravertebral ossification o Asymmetric sacroileitis o Atypical syndesmophytes. Treatment: etanercept, infliximab, adalimumab and golimumab

Seronegative spondylo arthropathies  Ankylosing spondylitis  Psoriatic arthritis  Arthritis associated with IBD  Reiter's syndrome

GOUT  More common in men  Precipitation of monosodium urate monohydrate (MSU) crystals into the joints  The first episode of acute gouty arthritis frequently begins at night with dramatic joint pain, swelling, warmth, redness, and tenderness  Usually mono articular, m/c site is the metatarsophalangeal joint of big toe(Podagra)  Serum uric acid levels > 7.0mg/dL more prone for gout  Any factor that cause an abrupt increase or decrease in urate level can provoke an acute attack  Abrupt fall precipitates acute attack more commonly  Serum uric acid levels may be normal or low at the time of acute attack  Examination of synovial fluid with polarized light and identification of characteristic strongly negative bifringent bright yellow needle shaped urate crystals.  Infra and extra capsular joint involvement without osteopenia  Tophi is the hallmark of gout appear as punched out cysts or deep erosions with over hanging bony edges (Martel or G's sign)  Tophi: seen in cartilage, skin, bursa, pinnae, elbow, Achilles tenon & distal IP joints.  Allopurinol is used in the treatment of chronic gout(contraindicated in acute gout)  Drugs increasing urate excretion: Probenecid, Sulfinpyrazole and benzbromarone  Drugs increasing urate metabolism: Recombinant urate oxidase-Rasburicase & Pegloticase.  For acute attack: colchicine and NSAIDs (except aspirin)

Factors precipitating acute attack  Dietary excess  Uncontrolled administration of  Hypouricemic therapy diuretics or aspirin  Trauma, Surgery  Excessive ethanol  MI, stroke  Steroid withdrawal

Gout Pseudogout (CPPD arthropathy)  Most common site: MTP joint of big toe  Knee  Monosodium monourate crystals –  Calcium pyrophosphate dehydrate needle rhomboid, positively birefringent  shaped, negatively birefringent NEUROPATHIC JOINT OR CHARCOT'S JOINT  Progressive destructive arthritis from loss of pain sensation and proprioception (position sense)

Causes  Diabetes mellitus (tarsal , tarsometatarsal) – most common cause; downward collapse of the tarsal bones leads to convexity of the sole (rocker foot)  Tabes dorsalis (knee, hips, ankles)  Meningomyelocele  Syringomyelia (shoulder, elbow)  Amyloidosis  Leprosy (hands, feet)  Peroneal muscle atrophy

X-ray  Changes of osteoarthritis with joint space narrowing, subchondral bone sclerosis, osteophytes, and joint effusions followed by marked destructive and hypertrophic changes  The joint margins in a neuropathic joint tend to be distinct, while in osteomyelitis, they are blurred

Arthritis and number of joints involved Monoarticular Pauciarticular (2-4) Polyarticular ( > 5)  Gout  Osteoarthritis  Reiter's disease  Rheumatoid  Trauma  Tubercular  Psoriatic arthritis arthritis  Gonococcal  Lyme disease  Inflammatory bowel  SLE  Neuropathic  Leg-perthes  disease  Septic disease  Hemophilia Pattern of Joint Involvement Osteoarthritis Rheumatoid Psoriatic Involved PIP, DIP and 1' CMC PIP,Arthritis MCP, wrist DIP,Arthritis PIP and any (carpometacarpal) joint joints Spared MCP (metacarpo phalangeal) and DIP joint Sparing of any wrist joint Disease Joint involved Diabetes Midtarsal (M/C ) Tabes dorsalis Knee (M/C) ,hip ankle and lumbar spine Leprosy Interphalangeal (hands), Metatarsophalangeal (feet) and lower Syringomyelia Shoulderlimbs (glenohumeral), elbow, wrist and cervical Myelomeningocele Anklespine & intertarsal joints Congenital insensitivity to Ankle & intertarsal joints Chronicpain Alcoholism Metatarsophalangeal & Interphalangeal joints WBC count Group I (Noninflammatory) Group II (Inflammatory) Group III (Purulent) (< 2000 white cells/mcL) (2000-75,000 white (> 100,000 white cells/mcL) cells/mcL) Osteoarthritis Rheumatoid arthritis Pyogenic bacterial Trauma Acute crystal-induced infections Osteochondritis dissecans synovitis Osteochondromatosis (gout and pseudogout) Neuropathic arthropathy Reactive arthritis Hypertrophic Ankylosing spondylitis osteoarthropathy Rheumatic fever2 Pigmented villonodular Tuberculosis synovitis

Joint inflammation Present Rheumatoid arthritis, SLE, Gout Absent Osteoarthritis

PAGET'S DISEASE OF BONE (OSTEITIS DEFORMANS)  High bone turnover and disorganized osteoid formation  Bone pain – usually the first symptom  Kyphosis, bowed tibias, large head  Frequent "chalkstick" fractures with slight trauma  Extensive skull involvement - cranial nerve palsies from impingement of the neural foramina.  Involvement of the petrous temporal bone frequently causes hearing loss (mixed sensorineural and conductive)  Histology: Mosaic like appearance of osteoid secondary to rapid disordered bone resorption and production  Osteosarcoma may develop in long-standing lesions but is rare (<1%).  Serum calcium and phosphate: normal  Alkaline phosphatase, Urinary hydroxyproline, Serum C-telopeptide (CTx): elevated.  Radiologic findings : o Osteoporosis circumscripta- during the lytic phase of disease in the skull, o Blade of grass & flame-shaped margin-acutely marginated demineralization of long bones o Picture frame vertebrae - mixed lytic and sclerotic phase in the spine o Cotton wool skull -mixed lytic and sclerotic phase in the skull.  Treatment: bisphosphonates, nasal calcitonin

HYPERPARATHYROIDISM  Most commonly in the seventh decade and in women  Most common cause: single parathyroid adenoma  Causes a loss of cortical bone and a gain of trabecular bone  Low bone density is typically most prominent at the wrist.  Severe, chronic hyperparathyroidism can cause, pathologic fractures, brown tumors and cystic bone lesions throughout the skeleton, a condition known as osteitis fibrosa cystica  X-ray findings o Subperiosteal resorption of bone (especially in the radial aspects of the fingers) o Loss of the lamina dura of the teeth. o Mottling of the skull (salt-and-pepper appearance) o Articular cartilage calcification (chondrocalcinosis) o Osteosclerosis of the vertebral bodies -rugger jersey spine (in renal osteodystrophy)

Loose bodies in the knee (Joint Mice) Non-traumatic Traumatic  TB arthritis  Intra – articular fracture  Rheumatoid arthritis, Osteoarthritis  Meniscal injuries  Osteochondritis dissecans  Organized hemarthrosis  Synovial chondromatosis  Detached articular cartilages  Hemarthrosis, Hemophilia  Foreign bodies.

Clinical Features:  A sense of giving way.  A feeling of something is moving within the joint.  Pain and effusion within the knee.  Locking episodes. Gold Standard treatment: Arthroscopic removal.

RADIOLOGICAL FEATURES OF ACROMEGALY  Skull: vault thickened, enlarged pituitary fossa, ballooned/asymmetrical floor of pituitary fossa.  Mandible: prognathism with increased angle  Spine: kyphosis, enlarged vertebral bodies, posterior scalloping of vertebral bodies  Chest: Increased AP diameter, enlarged length and caliber of ribs  Hands: enlarged bases, tufting of phalanges  Feet: thickening of heel pad  Long bones: thickened d/t periosteal new bone formation  Joints: widening of joint spaces

RADIOLOGICAL FEATURES OF CUSHING'S SYNDROME  Skull: Normal pituitary fossa  Skeleton: osteoporosis, vertebral collapse, kyphosis  Wedged vertebral bodies  Multiple, painless vertebral fractures  Necrosis of femoral head  Secondary osteoarthritis

RADIOLOGICAL FEATURES OF HYPOPITUITARISM  Skull: Unfused sutures  Skeleton: Small but normal proportions  Slender bones  Small pituitary fossa  Unfused epiphyses RADIOLOGICAL FEATURES OF HYPERTHYROIDISM  Skull: exophthalmos  Osteopenia  Cortical striation- acropachy  Early appearance and accelerated growth of ossification centres  Cardiac enlargement and thymus enlargement

RADIOLOGICAL FEATURES OF HYPOTHYROIDISM  Delayed closure of fontanelles  Large sella  Poorly developed paranasal sinus  Brachycephalic dentition  Delayed fusion of epiphyses  Fien or coarde stippling  Fragmentation  Increase in width of intervertebral space  Bullet shaped vertebral bodies

Case vignettes  Child with bone deformities (rickets)  An elderly person with a fracture of the femoral neck or a vertebral body following comparatively minor trauma (postmenopausal Or post-climacteric osteoporosis)  An elderly Patient with bone pain and multiple compression fractures of the spine (osteomalacia).  A middle-aged person With hypercalcaemia and pseudogout (hyperparathyroidism)  X-rays may show stress fractures, vertebral compression, Cortical thinning, loss of trabecular structure or Merely an ill-defined loss of radiographic density – Osteopaenia (osteomalacia or Osteoporosis) VII.BONE INFECTIONS

OSTEOMYELITIS  M/C agent: Staphylococcus aureus  M/C mode of infection: hematogenous.  M/C site is thoraco lumbar spine.  In children metaphysis (d/t hair pin arrangement of blood vessels) of long bone is commonly involved.  The hip joint is the most commonly affected in young patients.  The pathological sequence is inflammation, suppuration, necrosis, reactive new bone formation & ultimately resolution & healing.  DA necrosis, pieces of dead bone separate as sequestra.  It is lighter than live bone & normal bone pattern is lost.  Involucrum is the dense sclerotic new bone surrounding the sequestrum. (obvious from the 2nd week)  Bony changes do not appear on x-ray for 7-14days  X ray: earliest finding- periosteal new bone deposition (periosteal reaction) at metaphysis, takes about 7-10 days.  Bone scan: shows increased uptake in the metaphysis, positive before the changes appear on an X ray.

SEQUESTRUM:  Ring sequestrum: Amputation stumps & around pin tracks  Tubular sequestrum: Hematogenous osteomyelitis, segmental fractures  Rice grain/sandy/feathery sequestrum: Tuberculosis  Black sequestrum: Actinomycosis

Organism Common Occurrence Staphylococcus aureus M/C organism in osteomyelitis, acute hematogenous Osteomyelitis (90%), and infected metal Group B streptococci Infants < 1 year old Haemophilus influenzae Children 1-16 years old Pseudomonas aeruginosa Nosocomial, puncture wound through shoe Pasteurella multocida Animal bite Eikenella corrodens Human bite Salmonella Sickle cell disease Anaerobes Diabetic ulcers, fight bites Candida albicans, Aspergillus, Atypical Immunocompromised mycobacteria Escherichia coli Neonatal Neisseria gonorrhea Septic arthritis in young sexually active adult

BRODIE'S ABSCESS  Localized form of subacute osteomyelitis  Commonly involves the medulla  Commonly affects the long bones of the leg (proximal femur > tibia) and can cross the physis.  Caused by low virulent organisms, in 50% cases, S.aureus is the cause.  X-ray: lytic lesion with a sclerotic bone & a cortically confined radiolucency mostly seen in the metaphyseal region of the long bones.  Signs: intermittent attacks of pain & swelling  Diagnosis: biopsy  Treatment: excision/ curettage

GARRE'S OSTEOMYELITIS  Non suppurative, diffuse, sclerosing inflammation  Marked sclerosis & cortical thickening in diaphysis  M/C site: tibia> mandible

SALMONELLA OSTEOMYELITIS  Subacute type of osteomyelitis  Occurs during the convalescent phase after an attack of typhoid.  Common site: ulna> rib> vertebra> tibia  Involves multiple bones, may be bilaterally  X ray: diaphyseal sclerosis.  Occurs more commonly in children with sickle cell anemia Note: M/C cause of osteomyelitis in sickle cell anemia: Staph.aureus

TOM SMITH ARTHRITIS  Septic arthritis of hip in infants (chondrolysis)  Child presents with limp, unstable gait, shortening of limb and increased hip movements in all directions.  Telescopy test is positive.  M/C cause of bony ankylosis.

TUBERCULOSIS OF SPINE / POTT'S SPINE / CARIES SPINE/TUBERCULAR SPONDYLITIS  M/C site of skeletal tuberculosis in adults: Spine followed by hip > knee>elbow  M/C site of skeletal TB in children: hip  M/C infective pathology of spine is tuberculosis.  Acute pyogenic infection of spine is uncommon & mostly caused by Staph. aureus  Initial focus: cancellous bone of vertebral body

 Dorsolumbar region (112>L1) is the M/C involved segment in adult (Children- Upper thoracic segment)  The paradiscal type is M/C type  Wedging or Concertina collapse: in central type  The route of spread is mostly hematogenous (through artery and Bateson's plexus).  M/C cause for kyphosis & cold abscess.  Back pain is the commonest symptom.  Earliest deformity: loss of lumbar lordosis; M/C earliest sign: paravertebral muscle stiffness  Unusual sign: aneurysmal sign  Earliest radiological sign: reduction of intervertebral disc space.  Gibbus is seen.  M/C complication-cold abscess.  Paravertebral abscess occurs in almost all cases.  Investigation of choice- MRI  Clonus is the most prominent early sign of Pott's paraplegia.  Paraplegia in flexion is grade - IV Pott's paraplegia  Cystic TB of bone is treated by ATT + curettage.  M/c performed surgery- Antero lateral decompression.  TB of spine  bony ankylosis, other bones & joints fibrous ankylosis

TUBERCULOSIS OF KNEE  Tuberculosis of the knee is the classical cause of triple deformity [also seen in Rheumatoid arthritis] o Flexion o Posterior subluxation of tibia o External (lateral) rotation of tibia  It can be treated by ATT and arthrodesis (done by POP-immobilization / Charnleys method)  Tuberculosis arthritis is M/C cause of fibrous ankyloses.  The Thomas half-ring splints was devised by H.O. Thomas, initially for immobilization for tuberculosis of the knee. o It is now commonly used for the immobilization of hip and thigh injuries.

TUBERCULOSIS OF HIP  Characteristic: multiple cavitation.  Loss of joint space  Travelling (wandering) acetabulum (Pestle & Mortar appearance)  Protrusio acetabul  Dislocated hip.

Stages of TB Hip: STAGE-I (SYNOVITIS) STAGE-II (ARTHRITIS) STAGE-III(EROSION) - Apparent lengthening. Apparent shortening True shortening, cartilage is - Position of hip: Position: destroyed. Flexion, Abduction, Flexion, adduction, internal Position: External Rotation rotation (FAdIR) Flexion, adduction, internal (FAbER) rotation (FAdIR)

Attitude of limb Flexion, Abduction, External Rotation (FAbER) Flexion, adduction, internal rotation  Stage I of TB hip (FAdIR Stage) II of TB hip  Anterior dislocation of hip  Stage III of TB hip  Fracture shaft of femur  Posterior dislocation of hip  Polio hip  Traumatic dislocation of hip.  Hip joint effusion

PHEMISTER TRIAD  Juxta articular osteoporosis  Peripheral osseous lesions  Gradual narrowing of interosseous space.  Seen in TB arthritis, fungal disease & Rheumatoid arthritis PONCET'S DISEASE  Reactive arthritis during active tuberculosis.  Most commonly seen as polyarticular arthritis of the hands and feet.  Cultures of synovial fluid remain negative.

TUBERCULOSIS OF OTHER BONES  Spina ventosa: tuberculosis of short bone [phalanges] - TB dactylitis  Characterized by lytic lesion on X ray with new bone formation.  Caries Sicca: TB shoulder joint without production of pus.  Common site of TB in

Long bones Tibia TB arthritis Hip Synovial TB Knee Tendon TB Flexor tendon at wrist [compound palmar Bursa Trochantericganglion] bursa. VIII. PEDIATRICS ORTHOPEDICS

 In children, epiphysial separations and fractures are more common than ligamentous injuries.  Mk fracture in children: Greenstick fractures of lower end of radius  Clavicular fractures are very common injuries in infants and children.

INFANTILE CORTICAL HYPEROSTOSIS (CAFFEY'S DISEASE)  A self limiting disorder characterized by soft tissue swelling, rapid sub periosteal new bone formation, cortical thickening of under lying bones, fever and irritability.  Classically, the onset of disease occurs before 5th month of life with resolution by 3 years of age.  Most common site involved in sporadic cases: Mandible  Most common site involved in familial cases: Tibia

Green stick fracture  Unique in children because immature bone is more flexible and has a thicker periosteum than mature adult bone.  The cortex in tension fractures completely while the cortex in compression remains intact but frequently undergoes plastic deformation.  Hence it is an incomplete fracture.  It is necessary to complete the fracture on the intact compression side for reduction & POP application.

PULLED ELBOW (nursemaid's elbow)  Downward dislocation of the head of the radius from the annular ligament.  Common injury in children under the age of 6 years.  Presents with a typical history of the child being jerked by the arm and subsequently complaining of pain and inability to use the arm.  The limb is held more or less immobile with the elbow fully extended and the forearm pronated; any attempt to supinate the forearm is resisted.  Diagnosis: Clinical. X-rays are usually obtained in order to exclude a fracture.  Treatment: reduction. The elbow is quickly supinated and then slightly flexed; the radial head is relocated with a snap.

DEVELOPMENTAL DYSPLASIA OF HIP (DDH)/ CONGENITAL DISLOCATION OF HIP (CDH)  Risk factors o Faulty intrauterine position (breech) o Familial o First born, Female child  Often associated with torticollis, metatarsus adductus & oligohydramnios. (d/t intrauterine crowding)  Abduction is limited (especially in flexion)  Asymmetrical thigh folds  Short limb as shown by higher buttock folds  Galeazzi or Allis sign: lowering of knee on affected side in a lying child with hip & knees flexed.  Trendelenberg's Test, Telescopy & Vascular sign of Narath is positive  Diagnostic tests for infants o Barlow's Test o Ortolani's Test  Every hip with signs of instability – however slight –should be examined by ultrasonography

Radiological features:  In Von Rosen's view following parameters should be noted: o Perkin's line o Hilgenreiner's Line o Shenton's line (Broken in DDH) o Acetabular index: Normally < 30° o CE angle of Wiberg: Normal value is 15-30°  Normally the head of femur lies in the lower and inner quadrant formed by two lines (Perkin's & Hilgenreiner's)  In DDH the head lies in outer & upper quadrant.  Femur neck more anteverted  Delayed appearance & retarded development of ossification of head of femur.  Failure of development of acetabulum  increase in the slope of the acetabular roof.  In mild cases, the only abnormality may be increased steepness of acetabular alignment, so that the acetabular angle is greater than 35 degrees.

Treatment Plan: Neonate & Young Child (1-6 month):  Pelvic harness for 6 weeks after hip reduces, is treatment of choice  lifeld-Craig splint, Von- Rosen splint and Frejka pillow.

Pre walking child:  6-18 months: Traction/ close reduction, If unsuccessful; open reduction  18- 24 months: Close/ open reduction (anterolateral approach) ± Salter pelvic osteotomy. Walking child (2 years -6 years): Open reduction (antero lateral approach) & femoral shortening with or without Salter osteotomy.

HIP FRACTURE IN THE CHILD  Most common cause: Trauma Delbet-Colonna classification: Type-I Type-II Type-III Type-IV Transphyseal Transcervical Cervico- Inter- Femoralseparation head separates Most common type 2ndtrochanteric most common trochanteric from Most fractures are Osteonecrosis in neck through the growth displaced 25% plate Osteonecrosis in Least common type ~50% (displaced Occurs in young children fractures at higher risk than nondisplaced)

Clinical features:  Swelling in the inguinal crease, gluteal region, proximal thigh  Limb held in external rotation, flexion, and adduction to relieve capsular distention  Resistance to any movement: Active hip motion is impossible if the fracture is displaced, and passive motion (especially flexion, abduction, and internal rotation) is restricted and painful  Pain and sometimes crepitus with hip motion  Pseudoparalysis of the affected limb in infants.  Type-I fractures: 100% chance of avascular necrosis.

Management:  If the hip is dislocated, make one attempt at closed reduction, then try open reduction.  If open reduction is attempted, the surgical approach should be in the direction of the dislocation: Posterior for posterior dislocation, anterior for anterior dislocation.

LEGG – CALVE – PERTHE'S DISEASE / OSTEOCHONDRITIS DEFORMANS JUVENILIS / COXA PLANA  Osteonecrosis of the proximal femoral epiphysis  Commonest osteochondroses  Eighty percent affected are males between the age group 4-8 years.  Two episodes of infarction. o First episode cause is not known. o Second episode is due to subchondral fracture.  Subchondral fracture heralds onset of true Perthes'  Painless limp is the characteristic symptom.  Decreased abduction, internal rotation is present.  Catterall's grading helps plan the treatment.  Salter and Thompson's grading has prognostic value.  Best evaluated by MRI.

SCHEUERMANN'S DISEASE  Self-limiting skeletal disorder of childhood.  Also known as Scheuermann's kyphosis, Calve disease, and idiopathic juvenile kyphosis of the spine.  The vertebrae grow unevenly with respect to the sagittal plane  The anterior angle is often greater than the posterior.  This uneven growth results in the signature "wedging" shape of the vertebrae, causing kyphosis.

COXA VARA Decrease in angle between the femoral head or neck, or both, and the femoral shaft (Mikulicz angle <120°)

Fairbank classification:  Idiopathic: congenital or developmental  Rachitic: usually associated with active rickets.  Adolescent: secondary to slipped capital femoral epiphysis.  Traumatic: usually following fracture of the femoral neck (rare in children).  Inflammatory: secondary to tuberculosis or other infection.  Secondary to other underlying bone diseases such as : o Osteogenesis imperfecta o Cretinism o Dyschondroplasia o Paget's disease o Osteoporosis o Tumour-like conditions (e.g. fibrous dysplasia).

Classification based on site:  Capital coxa vara: severe osteoarthritis, Legg-Perthes' disease, chondro- osteodystrophy, cretinism, septic arthritis of hip, etc.  Epiphyseal coxa vara: slipped capital femoral epiphysis.  Cervical coxa vara: o Children: rickets, bony dystrophy etc... o Adult: osteomyelitis, osteoporosis, Paget's disease, fibrous dysplasia etc...

Associations:  Congenital dislocation of hip - developmental hip dysplasia  Faulty development of the femur  Craniocleidodysostosis  Camptodactyly arthropathy coxa vara pericarditis (CACP) syndrome

Course:  Do not seek medical attention until the child is 3 to 7 years of age.  There may be a separate triangle of bone in the inferior portion of metaphysis - Fairbank's triangle.  Shepherds Crook deformity is a severe form of coxa vara where the proximal femur is severely deformed with a reduction in the neck shaft angle beyond 90 degrees.  Coxa vara associated with cleidocranial dysostosis is usually present at birth, and patients have clavicular abnormalities, wormian bones, and abnormal dentition.  Rx: Subtrochanteric corrective osteotomy.

GENU VARUM/ BOW LEGS  Knee is abnormally divergent & ankles approximated.  B/L bow legs can be estimated by measuring the distance between the medial malleoli when heels are touching; it should be < 6cm.  Primary deformity: lateral angulation of the knee.  A normal children show: o Maximum varus at 6 months to 1 year of age o Neutral alignment by 1-1/2 to 2 years of age o Maximum genu valgum (8°) at 4 years of age o Gradual decrease in genu valgum to 6° by 11 years of age.  The presence of genu varum after 2 years of age can be considered abnormal.  The causes of genu varum are: Physiological genu varum: M/C o OA knee, Rickets, Paget's disease, Blount's disease o Tibia vara: growth retardation at the medial aspect of proximal tibial epiphysis resulting in o progressive bow leg.  Treatment: o Brace therapy in children less than 3 years. o If age> 3 years: Osteotomy  Critical age for osteotomy in genu varum: 4 years  Genu recurvatum: hyperextension at the knee joint [commonest cause: polio (quadriceps contracture)]  Idiopathic tibia vara - M/C pathologic disorder producing a progressive genu varum deformity.

BLOUNT'S DISEASE (TIBIA VARA)  Special type of genu varum where the postero medial part of the proximal tibial epiphysis fails to grow during the first 3 years of life.  The knee is stable in full extension, but the medial femoral condyle may sublux posteromedially (into the depressed medial tibial plateau) at 10-20 degrees of flexion.  This is called Siffert-katz sign.

GENU VALGUM  Outward deviation of the longitudinal axes of both tibia & femur.  Most dramatic at 3-6 years of age [physiologic genu valgum]  The commonest cause of genu valgum (knock knee) is idiopathic > rickets.  Normal knee alignment is approximately 10 to 15° of varus at birth, which progresses to neutral alignment at about 18 months of age.  The anatomic angle may be as high as 15 degrees of valgus & it gradually remodels spontaneously to the adult average value of 5-7 degrees of valgus.  Long axis of tibia and fibula moves lateral to the long axis of femur  Miserable malalignment syndrome o Increased valgus at the knee o Increased femoral anteversion o External tibial torsion. o All three increase the quadriceps Q angle and thus the chance of developing anterior knee pain.

Treatment plan:  < 4 yrs – No treatment  4-10 yrs – Heel raise, knock-knee brace.  10-14 yrs – Epiphyseal stapling.  14-16 yrs – Wait until skeletal maturity, as it is too late for stapling and too early for osteotomy, as it may recur.  >16 yrs – Osteotomy.

Criteria for Surgical Treatment:  Deformities above 15 degrees  Patients over 7 years of age  If the patient is skeletally immature  medial tibial epiphyseal hemiepiphysiodesis.  In the skeletally mature, Supracondylar closed wedge distal femoral osteotomy is necessary at the center of rotation of angulation (CORA).

CONGENITAL CLUBFOOT (CTEV)  Commonest foot deformity.  More common in males.  Types: o Idiopathic type – No apparent cause, commonest variety. o Osseous type –associated with absence of tibia and fibula. o Muscular type – Arthrogryposis multiplex congenital or multiple congenital contractures. o Neuropathic type – Due to spina bifida, etc.  Components: o Equinus deformity (Plantar flexion) - ankle joint o Varus deformity (Inversion and internal rotation) – subtalar (talocalcaneal) joint o Forefoot adduction - mid tarsal joint, mainly at talonavicular joint o Forefoot cavus - mid tarsal joints  Underdeveloped calf muscles and contracted tendon (Achilles tendon- posteriorly)  May be associated with arthrogryposis, sacral agenesis, amniotic bands, Larson syndrome, diastrophic dwarfism, Mobius syndrome, Freeman-Sheldon syndrome, Myelodysplasia.  Bones are smaller & the neck of talus is angulated, calcaneum is small & concave medially  X- ray: reduced talo calcaneal angle (Kite's angle) (normal: 30 degrees), parallelism of talus and calcaneus.  Most common relapse in CTEV – adduction

Treatment  Clubfoot always requires treatment, which should begin at birth.  The initial approach is passive manipulation and strapping or corrective plaster casts. o Sequence of correction: adduction  inversion  equinus o If not done in this order, it leads to rocker bottom foot. (Rx: Grice procedure)

Conservative Management of CTEV _ Kites method – followed earlier Ponsetti method now At birth Manipulation by mother Manipulationpreferred and cast Change of cast Every 2 weeks Weekly Correction order C-A-V-E C-AV-E Fulcrum while Calcaneocuboid joint Head of talus manipulating Duration of 6 to 9 months 6 to 8 weeks treatment

 Surgical methods: o Postero medial soft tissue release (PMSTR) o Limited soft tissue release. . For equinus alone - posterior release . For adduction alone - medial release . For cavus alone - plantar release o Tendon transfer (minimum age - 5 years): tibialis anterior is transferred to the outer side of foot. o Dwyer's osteotomy(minimum age - 3 years) o Dilwyn- Ewan's procedure, Wedge osteotomy o Triple arthrodesis (done after 12 years of age): fusion of the following joints . Subtalar . Calcaneo cuboid . Talo navicular (most difficult) o Ilizarov's technique [modified simpler technique: JESS fixation]  Maintenance of fixation: CTEV splints, Denis Brown splints, CTEV shoes  One common approach uses the so-called Cincinnati incision.  CTEV shoes: o Mainly used when the child starts walking (upto 5 years of age). o Has a straight inner border  prevents forefoot sdduction. o Has an outer shoe raise  prevents foot inversion. o No heel  prevents equinus CALCANEAL VALGUS (Pes Calcaneal Valgus, Talipes Calcaneal Valgus, Congenital Talipes Calcaneal Valgus)  Second M/C foot deformities seen at birth  Entire foot is held in the dorsiflexed everted position  Most severe form - the foot lies adjacent to the anterior border of the tibia

Age Painful limp Painless limp 1-3 years Septic arthritis/osteomyelitis Developmental dysplasia of the hip Transient synovitis Neuromuscular, e.g. cerebral palsy Trauma - accidental/non-accidental Unequal leg length Juvenile idiopathic arthritis 3-10 Transient synovitis Perthes disease (chronic) years Septic arthritis/osteomyelitis Developmental dysplasia of the hip Trauma Neuromuscular disorders, e.g. Juvenile idiopathic arthritis (JIA) muscularDuchenne's dystrophy Perthes disease (acute) Juvenile idiopathic arthritis Malignant disease, e.g. leukaemia 11-16 Slipped upper femoral epiphysis Slipped upper femoral epiphysis years Avascular(acute) necrosis of the femoral Juvenile(chronic) idiopathic arthritis Juvenilehead idiopathic arthritis Dysplastic hip Trauma Septic arthritis/osteomyelitis Bone tumours

SKULL FRACTURES  Linear fractures are the most common, and usually require no intervention for the fracture itself.  Depressed fractures are usually commnuted, with broken portions of bone displaced inward—and may require surgical intervention to repair underlying tissue damage.  Diastatic fractures widen the sutures of the skull and usually affect children under three.  Basilar fractures are in the bones at the base of the skull. IX. BONE TUMORS

CLASSIFICATION OF PRIMARY BONE TUMOURS Type Form Benign Malignant Osteoblast (19%) Bone, shows Osteoid osteoma Osteosarcoma active Osteoblastoma ossification Chondroblast (22%) Cartilage Osteochondroma Chondrosarcoma Chondroma Chondroblastoma Chondromyxoid fibroma Fibroblast Collagen & Non ossifying fibroma Desmoplastic fibroma fibrous tissue Fibrous dysplasia Fibrosarcoma Metaphyseal fibrous defect Histiocytic FibrousSolitary histiocytomabone cyst Malignant fibrous histiocytoma Osteoclast Lytic bone Osteoclastoma Malignant osteoclastoma lesions Aneurysmal bone cyst Adamantinoma Noto chordal remnants Chordoma Hematopoietic Multiple myeloma (40%) Reticulum cell sarcoma Malignant Hodgkin's disease Ewing's sarcoma Lympho sarcoma Vascular Hemangioma Hemangio-endothelioma Hemangio pericytoma Neurogenic Neurilemmoma Lipogenic Lipoma Lipo sarcoma

 Primary malignant bone tumor o Most common: Multiple myeloma o 2nd most common: Osteosarcoma  Osteochondroma - most common benign tumour.  Osteoclastoma: 1/3 is benign, 1/3 is malignant, and 1/3 is frankly malignant.  Ewing's tumour o M/c malignant tumor of flat bones o M/c malignant tumour with multi centric origin  Bateson's vertebral venous plexus allows cells to enter the vertebral column Classification Use Enneking system For staging benign & malignant musculoskeletal tumors American joint committee on For staging cancer (AJCC) system -Soft tissue sarcomas & Bone sarcomas Edmonton Classification For cancer pain Mirel's Criteria For risk of impending fracture in bone metastases

ENNEKING SYSTEM CLASSIFICATION FOR BONE TUMORS  Stage: I - Latent lesion o IA low grade intracompartmental o IB low grade extracompartmental  Stage: II - Active lesion o IIA high grade intracompartmental o IIB high grade extracompartmental  Stage: Ill – Aggressive lesion: Any grade any compartment, but metastasis

LOCATION OF BONE TUMORS Epiphysis Metaphysis Diaphysis Multiple  Chondroblasto  Chondrosarcoma  Fibrous dysplasia  Leukemia ma  Enchondroma  Osteofibrous (metastasis)  Brodie abscess  Osteochondroma dysplasia  Multiple  Subchondral cyst  Osteoblastoma  Adamantinoma hereditary exostoses  Giant cell tumor  Solitary bone cyst  Langerhans cell  Langerhans cell  Fibrous dysplasia  Osteosarcoma histiocytosis histiocytosis  Eosinophilic  Osteoclastoma (in  Ewing sarcoma  Polyostotic  Granuloma children)  Leukemia, fibrous  Clear cell  Chondromyxoid lymphoma dysplasia  chondrosarcoma fibroma  Osteoid osteoma  Enchondromato Metastasis &  Unicameral bone  sis myeloma after 40 cyst years Pelvis Anterior Elements of Posterior Elements Rib Spine of Spine  Ewing sarcoma  Langerhans cell  Aneurysmal  Fibrous  Osteosarcoma histiocytosis bone cyst dysplasia  Osteochondroma  Leukemia  Osteoblastoma  Langerhans cell  Metastasis  Metastasis  Osteoid osteoma  histiocytosis  Fibrous dysplasia  Giant cell tumor  Ewing sarcoma  Metastasis

Age Benign Malignant Other 0-5yr (Child) -Eosinophilic granuloma -Leukemia -Osteomyelitis -Unicameral bone cyst -Metastatic -Stress fracture (rare) neuroblastoma 6-18 yrs -Unicameral bone cyst -Ewing's Sarcoma -Osteomyelitis (young -Aneurysmal bone cyst -Osteo Sarcoma -Fibrous dysplasia adolescent) -Nonossifying fibroma -Eosinophilic granuloma -Enchondroma -Chondroblastoma -Chondromyxoid fibroma -Osteoblastoma 19-40 yr -Osteoclastoma -Ewing's Sarcoma (Adult) -Eosinophilic granuloma >40 yrs -Metastasis -Paget's disease (middle -Multiple myeloma -Hyperparathyroidism aged old) -Lymphoma -Osteomyelitis -Paget's osteo sarcoma -Chondrosarcoma -Fibrosarcoma -Malignant fibrous histiocytoma Radiolucent bone lesion with well defined borders Eccentric, Expansile Centric Non-expansile (or minimally expansile) with - Aneurysmal bone cyst - Simple bone cystMarginal Sclerosis - Giant cell tumor - Eosinophilic granuloma - Non ossifying fibroma - Enchondroma - Fibrous cortical defect - Chondroblastoma - Chondromyxoid fibroma - Brodie's abscess

 Expansile & Purely lytic–Aneurysmal bone cyst.  Non expansile and partly or extensively ossified – Osteoblastoma  Lytic bone lesions are seen in : o Osteoblastoma o Chondroblastoma o Chondromyxoid fibroma o Osteofibrous dysplasia o Osteosarcoma o Osteoclastoma/ Giant cell tumor o Aneurysmal bone cyst o Adamantinoma

Fibrous Cortical Defect/Nonossifying Fibroma (Benign metaphyseal cortical defect; Metaphyseal fibrous defect; Benign fibrous histiocytoma; Fibrous xanthoma)  Developmental abnormality in children and adolescents with open physes.  Occurs eccentrically in the metaphyses of long bones, most commonly in the distal femur, proximal tibia, or distal tibia  Occur in 35% of healthy children with open physes.  Etiology: focal area of increased periosteal resorption during growth.  Associated Conditions: o Neurofibromatosis o Jaffe-Campanacci syndrome . Rare, congenital disorder . Cafe-au-lait pigmentation . Nonskeletal abnormalities . Mental retardation  Mostly asymptomatic. painful if a pathologic fracture occurs  X ray: a lytic (radiolucent) lesion is seen eccentrically in the metaphyses of long bones. o Based in the cortex o Overlying cortex if thinned o Surrounded by a scalloped, reactive rim of sclerotic (radiopaque) bone o Often appears multiloculated, producing a "bubbling" appearance

FIBROUS DYSPLASIA (Osteitis fibrosa cystica)  Benign bone process in which there is a failure to produce mature lamellar bone.  Focal defects in bone quality  Is characterized by multiple, gradual bone deformities; a risk of endocrinopathy and a tendency toward pain in the lesions  Cafe-au-lait spots are common signs in multifocal disease.  Precocious puberty may occur as early as the 1st year of life.  Associated with McCune-Albright syndrome (the triad of polyostotic fibrous dysplasia, cafe-aulait spots, and precocious puberty) is an age-related risk factor.

A. B.

 X ray: o Long lesion in a long bone o Ground glass appearance o shepherd's crook appearance of the proximal femur:

SIMPLE/ SOLITARY/ UNICAMERAL BONE CYST  Usually in males (M: F=2:1).  Always arise in juxta – physeal metaphysis  MC sites: proximal humerus (50%) and femur (25%)  Mostly asymptomatic, pain and swelling are usually very mild.  X ray: centrally located, radiolucent lesion of the metaphysis, slightly and symmetrically expansile (ballooned appearance).  Fallen leaf (fragment) sign is pathognomic manifestation  Curettage and bone grafting is done for enlarging lesions (even after steroid injection), large cyst at high risk of fracture and if pathological fracture develops or cyst in the proximal femur.

ANEURYSMAL BONE CYST  The M/C sites are femur and tibia  Usually involves metaphyseal region (but on occasions may extend to epiphysis or diaphysis)_  Posterior vertebral element is more commonly involved than body (giant cell tumor is more common in body).

X.ray  Eccentric, metaphyseal lesion  Asymmetrically expansile (finger in balloon or pencil in cup appearance)  Purely radiolucent lesion  May show focal cortical destruction or present as smooth bordered expansion, a trabeculated or bubbly intramedullary appearance and surrounding host bone sclerosis.  CT scan shows characteristic fluid level  Treatment includes curettage & bone grafting ± cementation/ Cryotherapy.  Osteoblastoma (which is also more common in posterior element) non expansile & partly or extensively calcified

CHONDROBLASTOMA  Codman tumor or Epiphyseal chondromatous giant cell tumor.  Generally found in the epiphyses of long bones.  The humerus is most commonly affected, followed by the tibia and femur.  Benign tumour of immature cartilage cells.  Radiography: Lytic lesion in the epiphysis with a thin sclerotic rim.

Pathological Findings  Presence of chondroblasts on microscopic section.  Cells are described as looking plump or like fried eggs.  Chicken wire calcification.

Treatment  Surgical excision is recommended to prevent progressive growth of the lesion with destruction of the epiphysis.  Bone grafting is needed.

CHONDROSARCOMA  Consists of malignant chondrocytes (cartilage cells) occuring inside a cartilage matrix.  It most commonly affects the proximal femur, pelvic girdle, knee, and spine.  Most chondrosarcomas arise de novo (primary chondrosarcomas)  Secondary chondrosarcomas may arise in pre-existing lesions, such as osteochondromas or enchondromas in patients with Oilier disease and Maffucci syndrome.  Plain AP and lateral radiographs o An intramedullary lesion with stippled and ring-like calcification. o Cortical bone changes usually are substantial: erosions, thickening, and bone destruction.  Surgery is the mainstay of treatment.

OSTEOID OSTEOMAS  Commonest benign tumor of true bone  Lesions smaller than 2 cm.  Affects males more frequently in patients between 10 and 20 years of age  Usually located in the posterior elements & frequently involves the lumbar spine > the dorsal spine.  Pain is caused by excess prostaglandin E2 produced by the proliferating osteoblasts [relieved by aspirin] OSTEOBLASTOMA  Consisting of vascular osteoid & new bone  Occurs in the jaw & spine.  Occurs in the diaphysis or metaphysis [never in epiphysis]  Treatment: curettage.

GIANT CELL TUMOR (OSTEOCLASTOMA)  It is an aggressive but benign tumor of bone.  Most common between ages 20 and 40 years (uncommon before age 20 or after 50)  Most common site: knee  The most common symptom: pain and swelling about the joint  Gaint cell tumors are epiphyseal in origin and they arise after epiphyseal closure.

Treatment  Small lesions: Curettage, chemical cautery by PMMA and/or bone grafting  Lower end of ulna, upper end of fibula: Excision or Complete resection  Lower end of radius where upper end of ipsilateral fibula is grafted: Excision & replacement by vascularized bone graft.  Lower end of femur & upper end of tibia: Excision & arthrodesis prosthetic replacement.  Malignant recurrent GCT of extremity: Amputation.  Spine: Radiotherapy (RT is a cause of malignant transformation of GCT)

OSTEOGENIC SARCOMA/OSTEOSARCOMA  M/C primary malignant tumor of bone.  Arises in the medullary cavity of metaphysis of long bone  Most common site: lower end femur followed by upper end tibia.  Mostly in 2nd decade.  M/C primary bone tumor causing lung metastases (micro metastasis present in almost 90% cases).  Lymphatic metastases may occur.  The classic radiographic appearance is that of a destructive lesion of bone that is itself forming bone.  Rapid cortical destruction and periosteal reaction at the proximal or distal margin may produce the classic "Codman triangle".  Alternatively, radial reactive trabeculation may produce a sunburst appearance.  Typical features (occasionally seen in other rapidly growing tumours) o Sunray appearance (d/t new bone formation) o Codman's triangle (d/t periosteal elevation)  It is diagnosed by bone biopsy.  Highly radio resistant  Treated by chemotherapy followed by limb salvage surgery/ amputation  Drug approved for pulmonary metastasis in Osteosarcoma: Erlotinib hydrochloride (HER1/EGFR tyrosine kinase inhibitor)  Secondary osteosarcoma is seen in o Paget's disease o Bone infarction o Bone dysplsia eg. fibrous dysplsia o Survivors of retinoblastoma o Post radiation

EWING SARCOMA (Round cell sarcoma)  Most commonly involves the diaphysis or metaphysis of long bones.  The second most common malignant bone tumor of childhood, after osteosarcoma  Affects males more often than females  Bone pain is the most common symptom  The patient often presents with systemic symptoms of fever, malaise, and weight loss.  Plain radiographs o A large lytic lesion usually in the diaphysis or metaphysis of long bones (frequently the fibula) o Variable amount of reactive new bone formation o Periosteal reaction, with a characteristic "onion skin" appearance.  Pathological Findings o Numerous small, round cells - blue on hematoxylin and eosin staining. o Histologically similar to: Metastatic neuroblastoma, Lymphoma, Rhabdomyosarcoma

Treatment  Multiagent chemotherapy and external beam irradiation  If surgery is indicated, a wide surgical margin is necessary.

ENCHONDROMA  A common benign lesion of mature hyaline cartilage in the medullary canal of the metaphysis or metadiaphysis  Commonly involves the short tubular bones (usually proximal phalanx)  Most common bone tumor of the hand  Most common destructive bone lesion in hand

Associated Conditions  Enchondroma protuberans: Eccentric enchondroma may cause bulging of the cortex.  Enchondromatosis (Oilier disease) o Multiple enchondromas: o Widespread involvement of the skeletal system by chondromas o Typically unilateral o Affected limbs are short & sarcomatous transformation can occur  Maffucci syndrome o Multiple enchondromas with soft-tissue hemangiomas o Affected bones cannot tubulate, so ends have a clubbed appearance.

Enchondroma Low-grade chondrosarcoma  Painless condition  Painful condition  Lack of growth  Slow-growing lesion  Bone scan variability  Bone scan variability  Uniform matrix calcification  Presence of lucent regions  Lack of endosteal erosion  Endosteal erosion  Uniform small bland cells  Mild cellular atypia  Low cellularity  Moderate to high cellularity  Ki-67-positive status

Hereditary Multiple Exostoses/ diaphyseal aclasia: highly penetrant, autosomal dominant trait characterized by slightly stunted growth of long bones and multiple osteochondromas.

SUMMARY OF FEATURES OF BONE TUMORS: Physaliferous cells Chordoma Homer wright pseudo rosettes, Onion skin lesions Ewings sarcoma Bone tumour resembling osteomyelitis Ballooned appearance, Fallen leaf sign Unicameral bone cyst Finger in balloon, Pencil in cup appearance Aneurysmal bone cyst Herring bone arrangement of fibroblasts Fibrosarcoma Benign bone condition with cellular atypia Chondromyxoid fibroma Honeycomb appearance Adamantinoma Pinwheel pattern Non-ossifying fibroma Storiform/ whorled/ radiating bundles Fibrous cortical defect Shepherd crooks deformity of femur, Ring of orange Fibrous dysplasia Smoky matrix, Leontiosis ossea Coast of maine appearance Polyostotic fibrous dysplasia/ McCune Driven snow appearance PindborgsAlbright syndrome tumour String sign Parosteal osteosarcoma Target calcification Osseous lipoma Polka dot sign, Corduroy/ accordion vertebra Vertebral hemangioma Nocturnal pain relieved by salicylates Osteoid osteoma Double density sign Nocturnal pain not relieved by salicylates Osteoblastoma Trumpet shaped metaphysic Diaphysealaclasis Coat hanger appearance O ring sign, Punctate/ stippled calcification Enchondroma Flicks/ wisp of calcifications in a luscent area Celery stick appearance Associated with Olliers disease & Maffucci Eccentricsyndrome geographic lytic lesion Chondroblastoma Dense punctate mottled calcification Chickenwire mineralization, Codmans tumour Codmans triangle, Sunray appearance Osteosarcoma Bone tumour with calcified secondaries Most common malignant bone tumour to appear Chondrosarcoma benign radiologically, Endosteal scalloping Dense popcorn/comma calcification Eccentric epiphyseal lytic lesion with soap bubble Giant Cell Tumor Winkingappearance owl sign (loss of pedicles in the vertebra) Bone metastasis

CHARACTERISTIC HISTOLOGY OF BONE TUMORS:  Neoplastic new bone/Osteoid formation in sarcomatous stroma: Osteosarcoma.  Lucent nidus of osteoblastic tissue surrounded by reactive sclerosis: Osteoid osteoma.  Multinucleate giant cells: Osteoclastoma  Chicken wire calcification- Chondroblastoma  Small, blue round cells with PAS positive diastase, bone destruction: Ewing's sarcoma.

Bone tumor Most common site Unicameral bone cyst Proximal humerus > femur Aneurysmal bone cyst Femur & tibia Enchondroma Small bones of hands (& feet) Osteochondroma (Exostosis, MC Distal femur > upper tibia > proximal humerus benign bone tumor) Osteoid osteoma Femur > tibia (diaphysis) Osteosarcoma Distal femur> upper tibia (metaphysis) Ewing's sarcoma Femur > tibia (diaphysis) Fibrous dysplasia Upper end femur (22%) > tibia (21%)> lower femur Chondroblastoma Humerus(12%) Chondrosarcoma Proximal femur Chordoma Sacrum (M/C) > spheno occipital region (clivus)> anterior vertebral body i.e. involves only axial skeleton Adamantinoma Mandible Multiple myeloma Vertebrae

Malignancy Most common Genetic Mutation Ewing's Sarcoma Balanced chromosomal translocation t(11; 22) >>t(21;22), Synovial sarcoma Balancedt(7;22) chromosomal translocation t(x;18)

Fibrous dysplasia Activating mutation of GS alpha surface protein Osteosarcoma Missense mutation in Rb, p53 tumor suppressor gene; and RECQL 4 gene (in patients with Rothmund Thomson Syndrome)

Synovial Sarcomas  Fourth most common soft-tissue sarcoma  Seen in young adults between 15 and 35 years of age and affects males slightly more than females. The name of this tumor suggests a synovial cell origin, but only 10% of synovial sarcomas are found in a major joint.  They frequently arise from juxtaarticular structures, especially around the knee, and they can also arise from tendon sheaths, bursa! sacs, fascia! planes, and deep muscles.  Synovial sarcomas can be seen about the shoulder, arm, elbow and wrist and are the most common soft-tissue sarcoma in the foot.  Tumor shows a typical biphasic pattern composed of epithelium-like cells that form nests, clefts, or tubular structures surrounded by malignant fibroblastic spindle cells.  If the lesion shows no biphasic component, it is difficult to confirm the diagnosis of synovial sarcoma.  Molecular characterization of this tumor reveals a particular translocation, t(X;18), representing the fusion of SYT (at 18q11) with either SSX1 or SSX2 (both at Xp11).

SECONDARY BONE TUMORS  Most common bone malignancy — Metastases  Most common primary carcinoma metastasizing to bone is : breast> prostate> lung (CSDT)  The tumors most commonly metastasizing to bone o Ca Lung in male o Ca Breast in female  Sites of bone involved in metastases: vertebrae>proximal femur>pelvis>ribs>proximal humerus >skull  Secondaries in the bone are uncommon distal to the elbow and knee  M/C symptom is bone pain in the spine  M/C primary source of solitary skeletal metastasis at the time of diagnosis is — Renal cell carcinoma  Mostly blastic: Prostate, carcinoid  Usually lytic but frequently blastic : Breast  Invariably lytic: Kidney, thyroid

BAUER'S POSITIVE CRITERIA FOR SURVIVAL IN METASTATIC BONE CANCER  A solitary metastasis  No pathological fracture  No visceral metastases  Renal or breast primary  No lung cancer X. MISCELLANEOUS BONE DISORDERS

Entrapment Neuropathies Nerve Entrapment Site Location of Pain Cranial nerves VII, Styloid process or Ipsilateral tonsil, base of tongue, IX, stylohyoid temporomandibular joint, and ear (Eagle's and X ligament syndrome)

Brachial plexus Scalenus anticus muscle Ulnar side of arm and forearm (scalenus or a anticus cervical rib syndrome) Suprascapular Suprascapular notch Posterior and lateral shoulder Mediannerve nerve Pronator teres muscle Proximal forearm and palmar surface of the first three digits (pronator syndrome) Median nerve Carpal tunnel Palmar surface of the first three digits (carpal tunnel syndrome) Ulnar nerve Cubital fossa (elbow) Fourth and fifth digits of the hand (cubital tunnel syndrome) Ulnar nerve Guyon's canal (wrist) Fourth and fifth digits of the hand Lateral femoral Anterior iliac spine Anterolateral thigh (meralgia paresthetica) cutaneous nerve under the inguinal ligament Obturator nerve Obturator canal Upper medial thigh Saphenous nerve Subsartorial tunnel Medial calf (adductor canal) Sciatic nerve Sciatic notch Buttock and leg (piriformis syndrome) Common peroneal Fibular neck Lateral distal leg and foot nerve Deep peroneal Anterior tarsal tunnel Big toe or foot Superficialnerve Deep fascia above the Anterior ankle and dorsum of foot peroneal ankle nerve Posterior tibial Posterior tarsal tunnel Undersurface of foot (tarsal tunnel Interdigitalnerve nerve Deep transverse tarsal Betweensyndrome) toes and foot (Morton's neuroma) ligament

OSTEOCHONDRITIS DISSECANS (OCD)  Area of avascular bone commonly affecting the knee of a skeletally immature child.  Usually non inflammatory  40% of patients have a history of prior knee trauma to a mild or moderate degree.  The medial condyle (lower lateral part) is involved 85%  Fifty percent of loose bodies in the knee are associated with OCD.  Wilson's sign positive: pain is felt in straightening the flexed knee in medial rotation.  Best X ray view: intercondylar view (Tunnel view/Notch view)  The majority of juvenile lesions (presenting before closure of growth plates) heal spontaneously.  In the skeletally mature, there is a higher incidence of bone fragmentation (subchondral fracture).

Treatment:  Juvenile lesions can be treated nonsurgically with rest  Surgical treatment for adult OCD (OCD after growth plate closure) is typically recommended.

OSTEOCHONDRITIS Disease Site Kohler's Navicular bone Kienbock's Lunate Perthe's Femoral head Scheurmann's Ring epiphysis of vertebra Calve's Central bony nucleus of vertebral body Frieberg's 2nd metatarsal head Islene's 5th meta tarsal base Osgood Shlatter's Tibial tuberosity Sever's Calcaneal apophysis Johansson – Lower pole of patella Presiser'sLaren's Scaphoid Panner's Capitulum

MYOSITIS OSSIFICANS  Heterotrophic calcification and ossification in muscle tissue.  Types: o Myositis ossificans progressive: between the ages of 5 and 10 years (younger than age 20) o Myositis ossificans paralytica: Occurs in proximal paralyzed muscles. o Myositis ossificans circumscripta: Caused by focal trauma; Common as a sports injury o Myositis ossificans traumatica, the most common type  Dislocation & avulsion injuries are more prone than fractures.  Elbow & hip are commonly involved.  Vulnerable muscles: Brachialis (most commonly involved), quadriceps, adductors.  Dotted veil or cotton wool appearance in X-ray.

OSTEOGENESIS IMPERFECTA  The central feature of 01 is a severe decrease in bone mass that makes bones brittle  Associated features: deafness, blue sclera, laxity of joints, dental abnormalities (dentiginous imperfecta)  Disease of the mesodermal tissues with deposition of normal collagen in bone, skin, sclera and dentine.  Heredity, Mendelian recessive – in prenatal cases; Mendelian dominant – in postnatal cases.  Mutations of the COL1A1 and COL1A2 genes, which encode for type I procollagen.  Continuously beaded or broken ribs and crumpled long bones (accordina femora)  Kyphoscoliosis can impair respiration, cause cor pulmonale, and predispose to pulmonary infections  Appearance of "popcorn-like" deposits of mineral in x-rays of the ends of long bones is an ominous sign  Bones break easily but heal well with abundant callus  Fracture is usually subperiosteal and heals by periosteal bone formation.

Sillence classification: Type Severity Features Sclera Inheritan IA, IB Mild Most common, mild to moderate bone Bluee AD ce fragility, little or no deformity II Lethal, rarely Extremely fragile bones, severe Blue AR survive infancy deformity, perinatal III Severe Progressively deforming, moderate to Normal AR severe deformity, progressive, neonatal IVA, IVB Moderately Mildfractures to moderate bone fragility, long Normal AD severe bone/spine deformity, A with dental involvement ACHONDROPLASIA  Achondroplasia is the most common skeletal dysplasia.  AD, acquired by most patients (70%) as a new mutation  Characteristics: o Patient height < 4.5 feet at maturity o The greatest shortening occurs in the proximal humerus and femur. o Hypoplasia of the midface and frontal bossing o Spinal stenosis is the most serious possible complication  A characteristic separation between the 3rd and 4th fingers leads to the "trident hand" of achondroplasia.

 Achondroplasia results from a defect in the fibroblast growth factor receptor-3 protein (FGFR3)

OSTEOPETROSIS (MARBLE BONE DISEASE, ALBERS SCHONBERG DISEASE)  Diaphyseal dysplasia characterized by failure of bone resorption due to functional deficiency of osteoclast.  The bone contains increased number of osteoclasts but these don't resorb bone and are unable to respond to PTH.  Inheritance depends on from of disease: o Malignant osteopetrosis (congenital form) is AR (11q13) o Osteopetrosis tarda (adolescence / adult form) is AD (1p21) o Intermediate form is AR o Osteopetrosis associated with renal tubular acidosis (due to lack of carbonic anhydrase-II) is AR Other features:  Brittle bones, Bone within bone appearance  Rugger jersey spine  Hepato splenomegaly  Deafness, Blindness  Pancytopenia, recurrent infection & bleeding disorder.  X-ray: increased radio opacity of bones

Pseudoarthrosis  Fractures  Osteogenesis imperfecta  Neurofibromatosis  Fibrous dysplasia  Congenital

Features of Postpoliomyelitis Residual Paralysis  Asymmetric muscle involvement  Commonly involve the lower limbs  M/c muscle involved: Quadriceps [only partial paralysis]  Muscle undergoing complete paralysis: tibialis anterior.  M/c muscle affected in upper limb: opponens pollicis.  Pure motor involvement without sensory loss.  The common deformity occurring in the hip is a flexion deformity, with the hip abducted & externally rotated.  In the knee, deformity is flexion, posterior subluxation and external rotation  In the foot, equinovarus deformity is the commonest

Dupuytren's Contracture  Proliferative fibroplasias of the subcutaneous palmar tissue, forming nodules of cords along its ulnar border.  Results in finger contractures, and knuckle pads on the dorsum PIP joints.  May be associated with Dupuytren's lesions in medial plantar fascia and plastic induration of penis  Seen in people employed in rock drilling due to the vibrations of the machine.  times more common in males.  Usually begins with ring finger at the distal palmar crease and later involves little finger.  Flexion of MCP and PIP joints occur.  Radiotherapy: only during early fibroblastic phase.  Surgery: o Subcutaneous fasciotomy: preferred in elderly & arthritis, 72% recurrence rate. o Partial selective fasciectomy: indicated only when the ulnar two fingers are involved, commonly done procedure, 50% Recurrence o Fasciectomy with skin grafting

Rugger jersey spine Seen in  Osteopetrosis or Albers – Schonberg disease o X-Ray: Endobones, known os-in-os or bone with in a bone appearance  Renal Osteodystrophy o Osteosclerosis when present, is most common at the base of the skull and in vertebra leading to horizontal stripped rugger jersey appearance.

Painful Arc Syndrome  It is anterior shoulder pain in 60-120° of gleno – humeral abduction.  Most common cause: Chronic supraspinatus tendinitis  Other causes: Calcification of supraspinatous tendon, Partial (not complete) tears of supraspinatus tendon, Fracture of greater tuberosity, Subacromial bursitis

Note: Subluxation of the Radial Head- (Nursemaid Elbow) Four cardinal signs of Kanavel in acute suppurative tenosynovitis:  Pain on passive digital extension  Flexed position of the digit  Symmetric swelling of the digit, which may include the palm  Tenderness with palpation along the flexor tendon sheath.

Sprengel's Shoulder  Failure of descent of the scapula, which is developmentally a cervical appendage i.e. congenital high scapula  Common associations: Klippel-Feil syndrome, congenital scoliosis, genitourinary anomalies, and cardiac defects

Torticollis  Cock-robin deformity; Sandifer syndrome (torticollis resulting from gastroesophageal reflux disease and hiatal hernia.  Torticollis (wry neck) - rotational deformity of the upper cervical spine.  The head is tilted to the involved side and the chin rotated to the opposite side.  This is most often seen in the newborn period.  M/c cause is rotatory subluxation of the atlantoaxial joint.  Congenital muscular torticollis usually is evident in the first 6-8 weeks of life.  Hallmark sign: Tilting of the head to 1 side with limitation of ROM  Usually the patient rotates the head away from the neutral (straight) position, but not toward it.  Patients may present with a neck mass (contracted sternocleidomastoid muscle).  Neck pain is a common complaint, but it usually occurs in adults.  It is often associated with deformity of the head (plagiocephaly).

Absent Radius or Thumb is associated with  Trisomy 13,18  Fanconi syndrome  TAR syndrome (thrombocytopenia + absent radius)  VATER syndrome (Vertebral anomalies, Anorectal malformation / Tracheo-oesophageal fistula / Esophageal atresia / Radial club hand / Renal agenesis)  Holt-Oram syndrome (cardiac defects with absent radius)  Ectodermal dysplasia  Order of investigations in a patient with absent radius is Echocardiography > platelet count > karyotyping >bone marrow.

Os Odontoideum  Pseudarthrosis between the odontoid process and the body of the axis.  It can cause significant atlantoaxial instability and myelopathy  Can result in sudden death

Classic triad in Klippel - Feil syndrome  Short webneck  Low posterior hair line  Limited cervical neck motion.

FRACTURES WITH EPONYMS  Aviators - fracture of neck of talus.  Baby car: fracture of distal end of humerus with proximal radius/ulna  Barton's (Marginal fracture) – intra-articular fracture of distal articular surface of radius (fracture dislocation of radiocarpal joint)  Bennett's dislocation – Oblique intra-articular fracture of base of first metacarpal with subluxation of trapezio – metacarpal joint dislocation.  Boxer's - Ventrally displaced fracture through neck of fifth metacarpal.  Bumper - Comminuted depressed fracture of lateral tibial condyle.  Buttonhole - fracture with loss of bone as in gunshot wound.  Chauffer's - radial styloid fracture  Chance -horizontal fracture through vertebra (body, pedicles, laminae) due to sudden deceleration with lap-only seatbelt; usually LI or L2  Clay shoveller's - a fracture of spinous process of Tl vertebra  Colles' - fracture occurring in adults at the corticocalcaneal junction of the distal radioulnar joint.  Cough - fracture Rib (fifth or seventh) caused by coughing.  Cotton's - trimalleolar ankle fracture.  Galeazzi -fracture of distal third of radius with dislocation of distal radioulnar joint. (synonyms:-reverse Monteggia fracture, piedmont fracture and fracture of necessity)  Monteggia - fracture of proximal third of ulna with anterior dislocation of proximal radioulnar joint.  Night stick: isolated fracture shaft of ulna.  Gosselin's - V Shaped fracture of distal end of tibia.  Green Stick - also called Hickory stick or Willow fracture. Bending of a bone with incomplete fracture  Jefferson's - burst fracture of the Atlas (CI).  Jone's - avulsion fracture of base of fifth metatarsal.  Hangman's - Traumatic spondylolisthesis of C2.  March - Stress fracture of shaft of second of second or third metatarsal.  Pond - depressed skull fracture in infants.  Pott's - Bimalleolar ankle fracture.  Rolando's - complete extra articular fracture across the base of the first metacarpal.  Smith's - Reverse of Colle's fracture (fracture distal end of radius with ventral tilt & angulation)  Tripod - involving the inferior orbital rim, lateral orbital wall and fracture\dislocation of zygomatic arch  Essex-Lopresti fracture: radial head fracture with disruption of distal radio-ulnar joint and interosseaous membrane Laugier fracture: trochlear fractures  Leforte-Wagstaff fracture: Anterior fibular tubercle avulsion fracture by the anterior tibiofibular ligament, usually associated with Lauge- Hansen SER type fracture patterns  Malgaigne's fracture: Sacroiliac disruption with pubic rami fractures.  Maisonneuve fracture: fracture of the proximal third of the fibula with an external rotation type injury.  Pilon's: fracturedistal end of tibia.  Pseudo jones: Fractures of the styloid process.  Seymour fracture: distal phalangeal growth plate fracture.  Segond fracture: seen on AP x-ray (lateral capsular sign) is a capsular avulsion from the lateral tibial metaphysic that is highly associated with ACL disruption  Tillaux fracture - Fractures of the lateral margin of the distal tibia  Tillaux-Chaput fracture: Avulsion of anterior tibial margin by the anterior tibiofibular ligament; tibial counterpart of LeForte –Wagstaff fracture  Lisfranc: Tarsometatarsal Fracture/Dislocations

CLASSIC FEATURES  Wormian bones: Osteogenesis imperfecta (Fragilitas ossium)  Pulsatile bone tumor – Osteosarcoma > GCT  Tumor with Hyperglycemia – Chondrosarcoma > Multiple Myeloma.  Sun ray appearance: Osteosarcoma  Soap bubble appearance: Osteoclastoma  Onion-peel appearance: Ewing's sarcoma  Patchy calcification: Chondrosarcoma  Risser's sign: Epiphysis of iliac bones  Aneurysmal sign: TB spine (anterior type)  Tonguing of vertebra: Morquio- Brails disease  Trethowan's sign: Slipped capital femoral epiphysis  Sagging rope sign: Perthes disease  Tinel's sign: sensation of hyperesthesia felt over the muscle supplied by an injured nerve.  Febella: Sesamoid bone in the lateral head of gastrocnemius  Spondylosis: degenerative spine disease  Spondylolysis: break in posterior elements (at pars interarticularis)  Spondylolisthesis: slip of one vertebra over other

Fractures of necessity (requiring surgery)  Lateral condyle fracture humerus  Displaced fracture olecranon and patella  Fracture neck femur  Galeazzi fracture dislocation  Monteggia fracture in adults  Articular fractures

Classical deformities Possible diagnosis Wry neck Cervical spine injuries. Drooping of shoulder Clavicle fracture. Flat shoulder Anterior dislocation of shoulder. S-shaped deformity of humerus Supracondylar fracture humerus. Dinner fork deformity Colles' fracture Boutonniere deformity Rupture of central extensor slip of Sheperd crook deformity Fibrousfinger dysplasia Mallet finger Rupture of distal end of index Jersey finger Ruptureextensor of distal end of FDP of index Flexion, adduction and internal rotation Posteriorfinger. dislocation of hip Flexion, abduction and external rotation of Anterior dislocation of hip Incompletelower limb external rotation of lower limbs Fracture neck femur (intra – capsular) Complete external rotation of lower limbs Trochanteric fractures, shaft femur, leg bones S-shaped ankle Anklefractures dislocations.

GAITS  Antalgic gait: occurs in painful condition of lower limb  Trendelenburg gait: occurs in an unstable hip due to CDH, gluteus medius weakness etc...  Stiff hip gait: occurs in ankylosis of the hip  Duck waddling gait: occurs in B/L CDH  Scissoring gait: occurs in cerebral palsy  High stepping gait: occurs in foot drop  Circumduction gait: occurs in hemiplegia  Charlie- Chaplin gait: occurs in tibial torsion  Sailor's gait: occurs in B/L CDH

SIGNS AND TESTS: Condition Test / sign Thoracic outlet syndrome Adson's test Patency of radial & ulnar arteries Allen's test CDH Alli's test Testing the tenderness of the spine Anvil test Median nerve injury Ape thumb Meniscus injury Apley's grinding test Recurrent shoulder dislocation Apprehension test CDH Barlow's test Anterior shoulder dislocation Bryant's test & Callaway's Dorso lumbar TB of spine Cointest test Tennis elbow Cozen's test Anterior : ACL injury , posterior: PCL injury Drawer test Cervical spine involvement in ankylosing Fle'che test Despondylitis Quervain's tenovaginitis Finkelstein's test Common peroneal nerve injury Foot drop Ulnar nerve injury Froment's sign/test Sacro iliac joint involvement in ankylosing Ganslen's test Anteriorspondylitis shoulder dislocation Hamilton ruler test Infection of ulnar bursa Kanavel's sign Disc prolapse Lasegue test ACL injury Lachmann test Avulsion of lesser trochanter Ludloff's sign Menisci injury McMurray's test Disc prolapse Nagffziger test Tight ilio tibial band.(polio) Ober's test CDH Ortolani's test ACL injury Pivot shift test Erb's palsy Police man tip Inferior dislocation of the shoulder Sulcus sign Hip flexion deformity Thomas test Unstable hip due to any reason Trendelenberg's test Nerve degeneration Tinel's sign Ischemic contracture of fore arm muscles. Volkmann's sign Patellar tendinitis Runner's test Translucency of the talar dome secondary to Hawkin's sign subchondral atrophy, 6-8 weeks after talar neck fracture Typical deformities in dislocations  Shoulder – abduction deformity.  Elbow–flexion deformity.  Hip: Anterior – flexion abduction and external rotation deformity.  Posterior - flexion abduction and internal rotation deformity.  Knee – flexion deformity.  Ankle – varus deformity.

Angles in Orthopedics  Carrying angle: elbow  Pauwel's angle: fracture neck of the femur  Bohler's angle: fracture of calcaneum  Bowman's angle: Supracondylar fracture of humerus  Kite's angle: angle in CTEV  Neck shaft angle: of the femoral neck.  Perlington angle: angle of fracture line respect to vertical line in fracture neck of femur  Cobb's angle: severity of scoliosis

TRACTIONS AND THEIR APPLICATION  Gallow's traction/ Bryant's traction: fracture shaft of femur in children < 2 years  Russell's traction: Trochanteric fractures  Buck's /Pelvic traction: Conventional skin traction for low backache  Perkin's traction: fracture shaft of femur in adults  90°-90° traction: fracture shaft of femur in children  Agnes Hunt traction: correction of flexion hip deformity  Well leg traction: correction of adduction/abduction deformity of hip  Dunlop/ Smith traction: Supracondylar fracture of humerus  Calcaneal traction: open fractures of ankle or leg  Metacarpal traction: open forearm injuries  Head-halter/Crutchfield traction: cervical spine injuries  Crutchfield or Garden wells tongs: skull traction in cervical spine injuries  Halo pelvic traction: scoliosis

Splints and their application  Cramer –wire splint: emergency immobilization  Thomas/Bohler Braun splint: fracture femur  Aluminum splint: Immobilization of fingers  Dennis Brown splint: CTEV  Crammer wire splint: emergency immobilization of fracture  Cock up splint: radial nerve palsy  Knuckle bender splint: ulnar nerve palsy  Toe-raising splint: foot drop  Four post collar: neck immobilization  Mermaid splint: for treatment of rickets  Aeroplane splint: brachial plexus injury  SOMI brace: cervical spine injury  ASHE(Anterior Spinal Hyper Extension) brace: Dorso lumbar spinal injury  Taylor's brace: dorso lumbar immobilization  Lumbar corset: back ache  Volkmann's splint: Volkmann ischemic contracture  Von Rosen splint: for congenital dislocation of hip

Braces for the treatment of Scoliosis  The Milwaukee brace/cervical thoraco lumbosacral orthosis: can be used for nearly all curvatures.  Boston brace: cosmetically more acceptable  The underarm brace/ lumbosacral orthosis (LSO): can be used to treat lumbar scoliosis  Charleston night bending brace: worn only during the night, in the treatment of idiopathic scoliosis.

IMPLANTS AND THEIR USES  Kuntscher nail: for fracture shaft of the femur.  Kirschner wire (K-wire): for small bone fixation  S.P. Nail: for fracture neck of the femur  S.P. Nail with Mc laughlin's plate: for intertrochanteric fracture  Dynamic hip screw (DHS): for intertrochanteric fracture  Moore's pins: for fracture neck of the femur  Talwalkar nails: for fracture of radius & ulna  Condylar blade plate: for condylar fractures of the femur  Buttress plate: for condylar fractures of the tibia.  Rush nail: for diaphyseal fractures of the long bones  Seidel nail: for fracture shaft of the humerus  G.K. Nail: for femoral/tibia shaft fracture  Interlocking nail: for femoral/tibia shaft fracture  Gamma nail: for inter or subtrochanteric fractures  Steinmann pin: for skeletal traction  Harrington rod: for fixation of the spine  Hartshill rectangle: for fixation of the spine  Luque rod: for fixation of the spine  Steffi plate: for fixation of the spine  Ender's nail: for fixing of intertrochanteric fracture  Austin-moore prosthesis (Fenestrated hip prosthesis)/Thompson prosthesis: for fracture neck of the femur  Charnley prosthesis: for total hip replacement  Insall Burstein prosthesis: for total knee replacement  Neer's prosthesis: for shoulder replacement  Soutter's prosthesis: for elbow replacement  Baksi's prosthesis: for elbow replacement  Swanson prosthesis: for finger joint replacement

Casts and their application  Frog leg/ Lorenz cast/ Batchelor cast: for congenital dislocation of hip.  Callot's cast: for congenital torticollis  Minerva cast/jacket: cervical spine disease/injuries  Risser's cast/ turn buckle cast: Scoliosis  Shoulder spica: shoulder immobilization  U-slab/ Hanging cast: fracture of the humerus  Colle's cast: Colle's fracture  Hip spica: fracture of the femur  Cylinder cast: fracture of patella  Patellar Tendon Bearing (PTB): fracture of tibia

Named Surgeries in Orthopedics  Bankart's procedure/ Putti-plat procedure/ Bristow's procedure recurrent dislocation of the shoulder  Steindler's release: cavus deformity of the foot  Wilson's release: flexion deformity of the knee  Dwyer's osteotomy: varus of heel in CTEV  Dilwyn Evan's operation: correction of CTEV  Grice-green operation: subtalar arthrodesis  Soutter's release: flexion deformity of hip in polio  Yount's release flexion deformity of knee in polio  Hauser's operation: for recurrent dislocation of patella  Jone's operation: for foot deformity in polio  Keller's operation: for hallux valgus correction  Lambrinudi operation: for correcting equinus procedure deformity of the foot  Turco's procedure: for CTEV  Tension-band wiring: for fracture patella & olecranon  Girdlestone arthroplasty: for TB hip  Meyer's operation: for fracture neck of femur  Hongkong operation: radical debridement and arthrodesis for Pott's paraplegia

Radiological views for certain fractures/dislocations  Judet view: acetabular fracture  Oblique view of the wrist: fracture scaphoid  Mortice view: ankle injuries  Merchant view/ Skyline view/ Axial view: fracture patella  Sunset view: for patella femoral dysplasia  Von Rosen view: for CDH  Shenton's line: hip X ray

OSTEOTOMY: making a cut in the bone  Mc Murray's osteotomy for fracture neck femur  Wilson's osteotomy for congenital coxa vara  Pauwel's osteotomy for fracture neck femur  High tibial osteotomy for OA knee with varus  Dwyer's osteotomy – for CTEV  Derotation osteotomy for C.D.H.  Salter's/Chiari Digas osteotomy for CDH  Pemperton osteotomy for CDH  Spinal/Smith Peterson osteotomy : ankylosing spondylosis  French osteotomy for cubitus varus deformity  Dimon-houston osteotomy for intertrochanteric fracture  Sandwich osteotomy for slipped epiphysis

Upper limb amputations  Ray amputation: removal of fingers with metacarpals from CMC joint.  Krukenberg's amputation: making forceps with two forearm bones.

Foot Amputations Midfoot Amputations Hindfoot Amputations  Lisfranc. A: tarsometatarsal joint  Syme. A: Distal tibia & fibula 0.6cm (Lisfranc Joint) proximal to the periphery of ankle joint  Chopart. A: mid tarsal amputation  Sarmiento. A: Distal tibia & fibula 1.3cm  Pirogoff. A: Calcaneum is rotated  proximal to the ankle joint and excision of forward & fused to tibia after vertical medial & lateral malleoli section through its middle  Boyd. A: Talectomy

Type of amputation Traditional length of Above knee 12cm stump Below knee 14cm Above elbow 20cm Below elbow 18cm

CLASSIFICATIONS  Neer's: for upper end of humerus fractures  Gustilo's: for open fractures  Salter and Harris: for epiphyseal injuries  Lauge Hansens: for ankle injuries  Pauwel's: for fracture neck of the femur  Frykman's : fracture distal radius  Hawkins: talus fracture  Winquist /Weber: fibular fracture  Russell and Taylor: subtrochanteric femur fractures.  Letournel: acetabular fractures  Garden: acute fractures of femoral neck  Seddon's : for nerve injuries  Bado's : Monteggia fracture dislocation  Marchetti and Bartolozzi: spondylolisthesis  Scheurmann's: Kyphosis  Thompson & Epstein: posterior hip dislocation  Stewart & Miford: posterior hip dislocation  Pipkin's: femoral head

SYNDROMES  Apert's syndrome: tower shaped head with syndactyly  Ollier's disease: multiple enchondromas  Melorrheostosis: candle bone disease  Osteopathia striata: striped bone disease  Osteopoikilosis: spotted bone disease  Caffey's disease: infantile cortical hyperostosis  Pyle's disease: Metaphyseal dysplasia(modeling defect resulting in 'Erlenmeyer flask' deformity of the distal femur & proximal tibia )  Blount disease: severe tibia vara in childhood, common in west Indies  Nail patella syndrome: hypoplastic nails with absence of patella

Musculoskeletal Genetic Disorder Genetic Mutation Achondroplasia FGF receptor 3 Osteogenesis imperfect Type I collagen Pseudoachondroplasia Cartilage oligomeric matrix protein (COMP) Marfan syndrome Fibrillin Spondyloepiphyseal dysplasia Type II collagen Multiple epiphyseal dysplasia COMP or type IX collagen (COL9A2) Thanatophoric dysplasia FGF receptor 3 Diatrophic dysplasia Sulfate transporter Duchenne muscular dystrophy Dystrophin X-linked hypophosphatemic rickets PEX (cellular endopeptidase) Osteopetrosis Carbonic anhydrase type II Fibrous dysplasia Gia (receptor-coupled signaling protein) Schmid metaphyseal dysplasia Type X collagen Jansen metaphyseal chondrodysplasia PTH/PTHrP receptor Multiple hereditary exostoses EXT1, EXT2 genes Hypochondroplasia FGF receptor 3

OTHER IMPORTANT POINTS  Collar Button Abscess: infection of the web space  Hallux rigidus: stiff big toe due to osteo arthritis of the great toe at the meta torso phalangeal joint  Hammer toe: fixed flexion deformity of the proximal inter phalangeal joint of the toe.  Jaipur foot: terminal device of a lower limb prosthetic foot. o Inexpensive, water-resistant, and quick to fit and manufacture. o Made of polyurethane. o Fitted free of cost by Bhagwan Mahavir Viklang Sahyata Samiti. o Superior to its SACH (Solid Ankle Cushion Heel), mainly in the range of movements it offers.  James position: position of hand immobilization in hand crush injury (MP joints in 90degree flexion &IP joints in extension )  Lumbago: fibrositis in lumbar fascia leading to chronic backache  Madelung deformity: defective growth of the distal radial epiphysis resulting in deformity of the distal end of the radius & dorsal dislocation of ulna  Manus valgus/ Radial club hand: lateral deviation of hand due to congenital absence of radius  Rocker bottom foot/ congenital vertical talus: vertically placed talus due to developmental deformity  Melon seed bodies: seen in pure synovial TB during synovectomy  Morant Baker's cyst: median posterior popliteal cyst due to OA, RA or TB.  Brodie's bursa: under medial head of gastrocnemius.  Motor march: seen in nerve injuries. The muscle nearest to the site of injury recovers first, followed by others as the nerve reinnervates muscles from proximal to distal order  Rate of nerve recovery: 1mm/day  Night cries/ starting pain: characteristic of TB hip in children  Robert Jones bandage: bandaging an injured knee in 3 layers of cotton with crepe bandage  O' Donoghue triad: simultaneous injury to medial collateral ligament, medial meniscus & anterior collateral ligament.  Soutter's release/ Wilson's release/ Steindler's release: for residual paralysis in polio.  Skier's thumb/Game keeper's thumb: sprain or rupture of ulnar collateral ligament of 1st MCP Joint.  Wolff's law of bone remodeling: bone hypertrophy occurs in the plane of stress  Strands of fibrous tissue connecting the bone to the periosteum: Sharpe's fibres.  Ulnar artery is the M/C site of upper extremity arterial thrombosis (ulnar hammer / hypothenar hammer syndrome).  Pronator syndrome: pain that is usually more severe in the volar forearm than in the wrist or hand.  Double-Crush Syndrome: occasional simultaneous presentation of cervical radiculopathy with peripheral entrapment neuropathy.  Pes planus (flat foot) is a condition in which the medial longitudinal arch is depressed or collapsed  Pes cavus (claw foot) is a condition in which the medial longitudinal arch is unduly high  Cyclist's Palsy: compression of ulnar nerve in bicyclists who ride with their hands in an extended position against the hand grips put pressure on the hooks of their hamates (handlebar neuropathy)

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