Ortho RR @academycerebellum

OrthoPedics
Quick Revision Notes

1
Section
Basic Science, Orthopedic Anatomy
and Imaging Orthopedic
Definition of Orthopedics Straight (Ortho) + Child (Pedics)
Father of Orthopedics (1) Nicolas Andry
Father of Orthopedics (2) H.O.Thomas
1 Thomas Test 2 Thomas SplintQ 3 Wrench 4 Collar 5 CTEV

shoes
15°
Fig. 1.1 Fig. 1.2
Father of Modern Orthopedics Robert Jones (Nephew of Thomas)
Father of Arthroscopy Watanabe Organic – Type 1

(tensile) (O.I.) 35%
Fig. 1.3
Fig. 1.4
Father of Arthoplasty Charnley Inorganic 65%
(Ca)10 (PO4)6 Fig. 1.5
(OH)2- Calcium
A B Hydroxyapatite.
Bone – type I collagenQ

Cartilage – Type II collagenQ
Ossify around
1. Metaphysis: Mc site for 18 yrs of age
infection & tumorsQ
2. Ewing’s sarcoma
diaphysisQ
Ossify around Fig. 1.7

16 yrs of age
Fig. 1.6
186
Cerebellum Quick Revision Notes
Epiphysis
Cartilage
Pressure Intra-articular and weight

Zone 1 Superficial Zone bearing eg. Head of humerus, lower end
Progenitor cells for articular cartilage of radius
High density chondrocytes….High water content
2
Zone Transition zone –Thickest zone Traction • Extra-articular
Chondrocytes are in Low density • K/a apophysis
• Due to pull/ of muscle attachment
Zone
• Ossify later than pressure epiphysis
3 Middle zone
Eg. Greater trochanter of femur and
Most active chondrocytes
tubercles of humerus
Highest density proteoglycans
Lowest density water content
Aberrant • It is an anatomical anomaly
Zone 4 Calcified cartilage • It is accessory ectopic epiphysis
Eg. Head of first metatarsal or base of fifth
metacarpal bone
Atavistic
Physis Phylogenetically independent but becomes fused.
• Epiphysis Eg. Coracoid process of scapulaQ
1 Resting zone(Reserve)-Storage disorders

2 Proliferative(Growth)-Dwarfs/Giants-Laron
syndrome(dwarfs+truncal obesity)/Scurvy
3. Maturation Zone-Trauma
4 Provisional Calcification-RicketsQ
• Metaphysis
Salter Harris Feature

types
Diaphysis I Fracture line is entirely with in Physis

Slip with causing epiphyseal slip
Metaphysis metaphysis II Fracture line extends from physis into the
fracture
Epiphysis Metaphysis (Thurston-Holland’s fragment
Q
Split of
Slip of epiphysis sign)
epiphysis Type I Type II Type III
III Fracture line extends from physis into the
Epiphysis causing epiphyseal split
Crushing of
Split of
physis (often IV Fracture line extends across the Epiphysis,
normal x-ray
epiphysis with as physis is (articular surface), Physis, and metaphysis
Metaphyseal cartilagenous)
fracture V Crush injury of physis with initially normal
Fig. 1.8 X-rays
Type IV Type V
187
Orthopedics
Harmones on The Bone

Parathyroid Hormone (PTH) Green colored are drugs used in Osteoporosis
Synovial joints:
Types of synovial joint Examples Types of synovial joint Examples
Q
• Acromioclavicular Q • Atlanto-occipital
Plane • Intercarpal Elipsoid • Wrist (radio-carpal)
• Intertarsal • Metacarpo-phalangeal (knuckle)
Q
• Elbow • Malleus-incus joint
Hinge • Sternoclavicular
• Interphalangeal Saddle
• First carpo-metacarpal
Q
• Atlanto-axial • Calcaneocuboid
Pivot (Trochoid) • Superior radio-ulnar Q
• Inferior radio-ulnar • Incus-stapes joint
• Shoulder
Ball and socket • Hip
• Temporo-mandibular
Condylar • Talo-calcaneo-navicular
• Knee joint
Some authors consider these joints condylar: Atlanto-occipital, wrist (radio-carpal), metacarpo-phalangeal (knuckle).
Some authors consider these joints as modified hinge: Temporo-mandibular, knee joint.
A B
Fig. 1.9
IR ER
Internal rotation External rotation B
A
of hip of hip
Limitation of abduction and internal rotation
Fig. 1.10 Fig. 1.11
188
Joint space
(Cartilage)
Cortex
Marrow
Muscle plane Soft tissue
Fat plane planes
Fig. 1.12
Fig. 1.13 Fig. 1.14
Fig. 1.15 Fig. 1.16
Genu Genu
varum =OA valgus = RA
Fig. 1.17 Fig. 1.18

1. Clavicle –highest landmark
2. Infraclavicular region – palpable part --> corocoid
3. 4:1 is ratio of head of humerus: glenoid (golf ball on a TEE)
C apitellum 2 yrs
R adial head 4 yrs
Internal epicondyle 6 yrs Fig. 1.19 Fig. 1.20
Trochlea 8 yrs
O lecranon 10 yrs
1st Metacarpal
External epicondyle 12 yrs is anterior
S
L
S L4 T P3
Scaphoid Lunate Triquetral Pisiform Fig. 1.21 Fig. 1.22
5 12
Sacroiliac
5
T T C H
Trapezium Trapezoid Capiatate Hamate
5 1 1
joint
↓
involved in
ankylosing
spondylitis
Fig. 1.23 Fig. 1.24
Capitate
- Largest carpal bone
- First to ossify
189
Orthopedics
Important views of X-rays

1. Brodens View : Subtalar joint Inversion, Eversion → To walk on
2.Von Rosen View : DDH uneven ground
3. Swimmers View : Cervicothoracic junction
4. Oblique view : Scaphoid
5. Judet View Q : Acetabulum (Pelvis)Tilt the pelvis →To see inside
6. Open Mouth view : Odontoid the acetabulum
7. Shentons Arch : Pelvis
Fig. 1.26
Lesion in bone or soft tissue Joint space

(Cartilage)
*
Cortex
Glass injury X-ray Marrow
Muscle plane Soft tissue
Fat plane planes
Bony lesion Soft tissue lesion Fig. 1.27
Cartilage
* Calcification
MRI CSF black T1
Cortex Marrow
MRI CSF white T2
*
(water is
Stress # white on T2)
MRI
CT scan
Infection/Tumor Fig. 1.28

MRI T1 image - anatomy
Biopsy Ewings & osteosarcoma T2 image - pathology
↓
Mimic osteomyelitis MRI:
Fig. 1.25
* Culture *Histopathology - Marrow (dark)
- Soft tissue
- Cartilage
3D images are seen on CT Infection Tumor
Sagittal plane
Coronal plane
al
Transverse plane
Fig. 1.29 Fig. 1.30

CT scan
Body planes Fig. 1.32a Fig. 1.32b

ACL PCL
Restrict Internal rotation Restrict external Fig. 1.31
+ Hyperextension rotation MRI
• Order in which investigations become positive in OM: MRI > Bone Scan > X-ray Q
• Bone Tumors : MRI CT Scan Osteoid Osteoma (Cortical)Q

Q
• DDH Shallowing of acetabulum. IOC MRI , Screening tool: USG (a) alpha angle decreases in DDH in USG
190
Joint
X-ray Bone biopsy
X-ray MRI •• After clinioradiological evaluation
Aspiration (USG guided)/Arthroscopy
* MRI (Cartilage/Soft tissues) Swelling of a joint
•• Vertical incision
•• Avoid NV structure
X-M A S
•• Round/Oval hole
Effusion or suspected Old ligamentous/ Limping child / Joint swelling •• Periphery
inflammatory process Meniscal injury
* Aspiration * Arthroscopy * Latest Questions •• Multiple sites
Musculoskeletal System Stress fracture Metastasis

1. 1st investigation X ray 1. Overall MRI 1. Single MRI
2. Next Investigation MRI 2. Unilateral MRI 2. Multiple PET scan
3. Best Investigation Biopsy 3. Bilateral Bone Scan 3. Multiple (Osteoblastic) Bone scan
Stress fracture/ SHIN splints March # - Metatarsal Neck 2nd >3rd
Periosteum : Osteosarcoma
Sunray
• Fibrous layer-Useless layer Periosteal Reaction appearance
• Cambium layer
Narrow zone Wide zone
Union-Neck of femur (Absent cambium
layer so high chance of Non union)
Periosteal reaction-Narrow (benign), Solid
Fig. 1.34
Wide(malignant)
Bone tumors-Osteochondroma/
Osteosarcoma
Osteosarcoma
Codman’s D
Fig. 1.33
Periosteum → origin of tumor Fig. 1.35
↓ Acute OM
Should be removed
(Extra periosteal resection).
GCT→ Only tumor
Ewings
to involve the joint. Non-aggressive reactions are thin, Solid, sarcoma
thick and irregular.
Aggressive reactions are Spiculated,
Onion peel
Fig. 1.37 apearance
Laminated, Hair on End, Sun burst,
disorganised, Interrupted and Codman's
Fig. 1.36
Classical Radiological features* triangle.
Ø Sun ray appearance*/Codman's triangle Osteosarcoma but can be seen in any malignant lesion
Ø Onion peel appearance* Ewing sarcoma but can be seen in any malignant lesion or chronic osteomyelitis
Ø Soap bubble appearance* GCT (Osteoclastoma) > Adamantinoma
Ø Patchy calcification* Chondrogenic tumors (Chondrosarcoma > Chondroblastoma)
Ø Homogenous calcification Osteogenic tumors (Osteosarcoma)
Calcification (CS>CB)> Osteogenic Tumor

191
Orthopedics
Types of Sequestrums
• Tubular or diaphyseal sequestrum is seen in acute pyogenic osteomyelitis.Q
• Ring sequestrum is seen in amputation stump and at Steinmann pins.Q
• Ivory sequestrum is seen in syphilis.
• Fine sandy sequestrum is seen in viral osteomyelitis.
• Coarse sandy sequestrum is seen in out of cavity TB (e.g., central body of vertebra)
• Flake or Feathery sequestrum is seen in the cavity tuberculosis (e.g., TB rib)
• Kissing sequestrum is seen in peridiscal TB vertebra.
• Button hole sequestrum is seen after radiation.
• Coke sequestrum is seen in cancellous bone.
• Bombay or black sequestrum is due to H2S and pollution.
• Black sequestrum is also seen in actinomycosis.
2a
Section Infection
FABER FADIR
Indications of Deformities of hip
emergency
surgery in ortho
1. Pelvic fracture
2.Vascular
3. Compartment Painless condition
syndrome - Mycetoma
4. Septic
- Charcots joint
Arthritis
Fig. 2a.1
Fig. 2a.2
Fig. 2a.2
Synovitis Posterior dislocation
Infection(Septic arthritis-Misnomer)
Arthritis
Ilio tibial band contracture(polio)
Anterior dislocation Hip : Posterior dislocation > Anterior dislocation Q

Fracture neck of femur: shortening + external rotation
Lower End Femur

Infection (Hematogenous) Knee
Staph. aureus
Osteomyelitis (Metaphysis) Septic arthritis
Reduced movements of Limb, toxic child Joint

and metaphysis tender (Clinical Diagnosis)
FABER at Hip
(Flexion, Abduction and External Rotation)
*
Osteomyelitis < 24 Hours Osteomyelitis > 24 Hours
6–12 years age Non-toxic 0–5 years age Toxic
Decreased movements (Fever, ESR, CRP)
X-ray – No Loss of Soft tissue planes X-ray – Loss of Soft tissue planes
of joint Absent movement of joint
MRI – Marrow changes in metaphysis MRI – Marrow changes in metaphysis * Transient Synovitis Septic arthritis (S. aureus)
Bone Scan – Increased activity Bone Scan – Increased activity

* X-MAS X-MAS
Rest
Surgery (Arthrotomy)+
Treatment is started with, IV antibiotics Treatment is Evacuation Antibiotics (6 weeks)
and Exploration of pus
and antibiotics for
6 weeks
Once condition begins to improve or
CRP values return to normal, Capital
(usually For 2 Weeks) then antibiotics femur
Note: Duration of antibiotics
are given orally for another 4 weeks.
is 6 week > 4 weeks
epiphysis
Fig. 2a.3
Organisms (S. Aureus)
Can cause Tom Smith Arthritis
multifocal Capital epiphysis of head of femur

IV drug abusers / Foot Human bite Animal bite Sickle cell anemia 1. __________________________
Pseudomonas Eikenella Pasteurella osteomyelitis Initially immobility; Later hypermobility

2. __________________________
Overall Diaphyseal Metaphyseal

Salmonella Salmonella Staph. aureus
193
Orthopedics
Brodies Abscess Chronic Osteomyelitis

• Immunocompetent host If dead bone + than chronic OM
• Subacute osteomyelitis>Chronic
Osteomyelitis • Sequestrum Q
• Upper end tibia
Dead bone (Cause of sinus)
• Sclerotic margin
• Not seen in HIV (+ve) patients
Fig. 2a.4
• Involucrum
Reactive bone
Humerus
Femur
Sequestrum Fig. 2a.6 • Cloacae
Skin
Normal bone Sinuses through Involucrum
Involucrum
Involucrum • Complications-Amyloidosis, Malignancy
Cloacae Involucrum
Periosteal
reaction
Sequestrum
Cloacae
Garres OM :
Fig. 2a.5
1. Chronic OM 2. Mandible>Tibia
NPWT: /Vaccum Assisted Closure Q Treatment

• Remove sequestrum (PAPRIKA Sign)Q
Enhances healing • Control the infection(Most important)
pressure -75 to-125 • Fill the gap(Bone graft/Bone Cement)
mm Hg • Soft tissue coverage
• NPWT
Fig. 2a.7
Continuous or intermittent gives good granulation

tissue C/I malignancy/Untreated OM/Necrotic
Complications
ESCHAR
- Amyloidosis
- Malignancy – Scc
Osteomyelitis
Acute Osteomyelitis Subacute Osteomyelitis Chronic Osteomyelitis
Solid Periosteal Reaction

Femur Humerus
Sequestrum Fig. 2a.11
Skin
Normal bone Involucrum
Involucrum
Involucrum
Fig. 2a.9 Cloacae
Periosteal
reaction
Fig. 2a.8 Sequestrum
Cloacae
Fig. 2a.10
194
1.Multifocal Osteomyelitis SAPHO Syndrome

Osteomyelitis in newborn: Synovitis Auto immune disorder
1. S. aureus > Group B Strep > Gram Negative. Acne
2. Multifocal (>50% cases) Pustulosis
3. Paucity of Clinical Signs Hyperostosis
4. Hematogenous spread, metaphyseal Osteitis
5. Poor prognosis Treatment: NSAIDS/STEROIDS/DMARD
2. Sickle Cell Anemia : Can cause multifocal osteomyelitis
Infections of hand
1. Felon 2. Paronychia
• Pulp Space.Q
• • Thumb >index finger • • Mc infection of hand
• Infects the nail bed. To treat it sometimes
• • Vertical incision • part of the nail has to be removed.
• Osteomyelitis>tenosynovitis
Felon
Paronychia
Fig. 2a.12 Fig. 2a.13
Q
3. Infectious tenosynovitis (Kanavels sign)
Infection of the flexor tendon sheath of finger.
1. Pain on stretch
2. Uniform swelling
3. Flexion of finger
4. Tenderness most specific
along the sheath Index finger tendon
Fusiform
swelling Midpalmar
Pain on Slight flexion
extension space (2nd, 3rd
or 4th lumbrical) Thenar space
(1st lumbrical)
Ulnar bursa Radial bursa
Fig. 2a.14 Fig. 2a.15

Tenderness along tendon sheath
• Mycetoma is a chronic progressive granulomatous exogenous

infection of subcutaneous tissue Q
• Actinomycetoma(rapid) and eumycetoma(slow)
• Thorns/soil –exogenous Multiple discharging sinuses
• Involves all structures except nerves and tendons

• Triad-Tumor like swelling(Painless) ,sinuses and granules
Fig. 2a.16
Mycetoma
2b
Section Tuberculosis
1. Hematogenous spread • Lung is the most common Primary site>L.nodes
• Hematogenous spread and lesions are Paucibacillary • Caries Sicca-Shoulder

2. Paucibasillary
• TB Spine –Potts spine • Spina Ventosa-Digits
3. Spine > Hip > Knee
Potts Spine
• 2 vertebral Disease
• Vertebra and disc
• Bone and cartilage
• Paradiscal
• Anterior disease Fig. 2b.1

• Posterior elements and single vertebral disease is -Malignancy Rarest
- Facet joints
- Spinous process
Chronic pain, constitutional

symptoms, night pain T.B.
Back pain Potts spine Good Prognostic Factors

1.Young age
1st Symptom: pain * 2. Early diease
1st sign: Tenderness
1st Neurological Sign:
Increased DTR/Clonus 3. active disease
4. slow worsening
* X-ray, MRI: 5. normal spinal cord
Paradiscal Lesion
Biopsy (CT-guided)
Gold Standard
Treatment: Rest + ATT.

Middle path regimen If Indicated Surgery
Q
Indications of Surgery (any stage)
- Bowel/Bladder Involvement
- Increasing neurological deficit
- No improvement on
conservative management
Surgery: Transverse
Rib
Sequelae-bony Anterolateral/Anterior process
ankylosis Decompression +
Bone grafting
Pedicle
Anterior Part of
vertebral body
decompression Left side approach
as aorta safer to handle
is better
Anterolateral approach
structures removed
*Never touch posterior elements in TB spine
196
Cobra plate is used for hip arthrodesis
Arthrodesis Ankylosis Arthroplasty

Surgical fusion Pathological Fusion
Bony Fig. 2b.3 Girdlestone excision arthroplasty

Austin (For Chronic hip infections - TB)
Moore
Painless Thompson
Fig. 2b.2
Bony Fibrous
Painless Painful
Septic arthritis >Tb Spine TB Hip and Knee

Ankylosing spondylitis Rheumatoid arthritis
Fig. 2b.4 Hemiarthoplasty
TB Arthritis
Peripheral Spine RA (Fibrous) AS (Bony)

(Fibrous ankylosis) (Bony ankylosis)
Fig. 2b.5THR
Complications of THR :
1. Infection 4. Metal Associated c. Teratogenicity
a. Hypersensitivity d. Chromosomal
2. Dislocation abnormalities Fig. 2b.6
b.Renal insufficiency e. Carcinogenesis ? Cemented THR Uncemented THR
3. Mortality –Myocardial infrarection>Cardiorespiratory 1. Elderly 1.Young
2. Cheaper 2. Normal Bone
arrest>(Pulmonary embolism-Thrombolysis) 3. Weak bone quality
4. Cement 3. Longer ½ life
between bone & metal 4. Costly
Embdic phenomenon – normal internal of 48 hours

T.B.
Chronic pain, constitutional

symptoms, night pain
Femure head migrates
in destroyed joint
Hip
C/F – Gradual pain
Fig. 2b.7 Knee
limp, flexion and synovitis
* Stage I
Synovitis
* Early
Stage II
arthritis
Stage III
Late arthritis
* Subluxation
Stage IV * Stage V TRIPLE
Excision arthroplasty Fibrous deformity
(FABER) + (FADIR + < 1 cm (FADIR + > (Wandering Ankylosis
Lengthening Shortening) 1 cm Shortening) Acetabulum)
Rest + ATT
ATT + Arthroplasty
or Arthrodesis
1. Acetabulum – Commonest site of TB Hip
2. Babcock’s D – Commonest site in head of femur Arthroplasty
Arthrodesis
197
Orthopedics
Hyperanemia – more blood supply – causes periarticular osteopenia.

TRIPLE
* Latest Questions
deformity
Tuberculosis
• Posterior subluxation Rheumatoid arthritis
of tibia Iliotibial band contracture
• External rotation of leg
• Flexion of knee Polio
Low clotting power
Excess bleeding (hemophilia)
PERF
Q
TRIPLE deformity of Knee
3
Section
Biopsy cofirmatory
Onco Secrets
Benign Malignant
Geographic lesions:
IA: Well defined with sclerotic margins:
Simple Bone Cyst (SBC), Fibrous
dysplasia
Diagnosis
IB: Well defined without sclerotic rim:
Aneurysmal Bone Cyst (ABC) Giant
CB> GCT CB Cell Tumor (GCT)
Age < Part
Epiphysis + IC: Ill defined margins: Chondrosarcoma
1. 1st Decade Ewing Sarcoma Epiphysis Calcification
II Moth Eaten: Multiple Lytic lesions:
Myeloma metastasis
2. 2nd Decade Osteosarcoma III Permeative: Poorly demarcated,

Ewing’s – maximum number numerous lytic lesions: Ewings sarcoma,
O.osteoma Myeloma, metastasis
of cases seen in 2nd decade >1 decade
3. After Skeletal maturity GCT

(20-40 yrs) Adamantinoma
4. > 40 years Metstasis>Multiple Myeloma

E.Sarcoma
Metaphysis OS
Fig. 3.1
Most common sites:

• Unicameral bone cyst Upper end Humerus
• Upper end humerus (Metaphyseal) UBC > CB (Epiphyseal)
• Aneurysmal bone cyst Lower limb metaphysis
(Tibia and femur)
• Osteoid osteoma Femur>Tibia
• Osteoma (Ivory or Skull and facial bones
Compact or Eburnated)
• Enchondroma Short bones of hand
• Epithelial bone tumors Osteochondroma
Polyostotic bone lesions
a. Adamantinoma (Long bone) Tibia Enchondroma
b. Ameloblastoma Mandible (SCC) GCT
Fibrous Dyslapsia
• Multiple myeloma Lumbar vertebrae
ES
• Metastasis Thoracic vertebrae
Radioresistant Bone Tumors Osteosarcoma
Chondrosarcoma
Metastatic Bone Disease
• Most common primary is Breast > Prostate > Lung
• Most common sites of primary for bone metastasis.
– In males – Prostate > Lung
– In Female – Breast > Lung Metastasis from Bone to Bone – ‘BONE’
– In Children – Neuroblastoma
• Skeletal sites most frequently involved
– Spine (Dorsal) Q
• Purely Osteoblastic secondaries (PCM)
– Prostate/Carcinoid/Medulloblastoma
199
Orthopedics
General Principles for treatment of bone tumors

• Benign and cartilagenous tumors-Operated
Radical resection
• Most common surgery –Wide local excision(3cm margin)
Wide resection
• Cystic lesions –curettage -UBC
• With chemical to kill residual cells-extended curettage-
Marginal resection
Phenol/Liquid N2-ABC/CB/GCT/EC Q
Intralesional resection
(Debulking) • Malignant-Neoadjuvant CT-Sx-AC
• Ewings is most radiosensitive bone tumor Q
Tumor
Reactive zone
Fig. 3.2 Surgical excision
Unicameral bone cyst: Single central cavity Aneurysmal Bone Cyst: Multi Loculated Eccentric
1. 1st decade, metaphyseal Fig. 3.3 1. 2nd decade, metaphyseal
2. Cortex break and fall in the cavity 2. Fluid – fluid level on MRI – ABC
– fallen leaf sign 3. Tibia most common site
3. Trap doors sign – cortex break, 4. Rx: Extended curretage
and it moves up and down due to fluid
Rx: 1. Curettage + Bone grafting
2. Aspiration + steroids
3. Aspiration + slerosants
Fig. 3.4
Brodie’s abscess/Brown tumor Fig. 3.5

Eosinophilic granuloma Non ossifying fibroma
Enchondroma Aneurysmal bone cyst
Chondroblastoma Giant cell tumor
Hemophilia Eccentric
BEECH – Cyst NAG – Expands

(Cyst in centre) Expansile eccentric cysts
(Simple bone cyst)
Chondroblastoma Fibrous Cortical Defect / Non Ossifying Fibroma
:Codman’s tumor • Most common benign lesion

Ephiphysis + Calcification; Treatment: • 1st decade
Extended curettage • Metaphyseal
Fig. 3.6 • Self resolving
• It is not premalignant
200
Osteochondroma Exostosis
Malignancy Single - < 1% Multiple -6%
- Bone with cartilage cap
Malignant Degeneration Chondrosarcoma Q
Diaphyseal aclasia- • Cartilage thickness >2 cm
Development malformation • Rapid increase in size
Large to feel small on xrays • Growth after skeletal maturity
• Loss of differentiation
Pain • Grows away from bone Treatment :
• Grows till skeletal maturity Extraperiosteal resection
Fig. 3.7
Bursitis Removal along with
periosteum
Osteoid Osteoma : Nidus : Diaphyseal Ivory Osteoma

Night pain relieved on salicylates • Compact Osteoma Or Eburnated Osteoma
• Skull Vault
Diaphyseal
• Requires No Treatment
Nidus(seed) in cortex -lytic lesion
surrounded by sclerosis
Osteoblastic and Osteolytic
cells are seen
1. Premalignant -5% cases

2. Most common tumor of bones
Enchondroma of hand and feet.
3. On biopsy hyaline cartilage seen
4. Rx.: Extended curettage
Olliers • OlliErs syndrome-Only

Fig. 3.8
(30% malignant) enchondromas Q
Mafucci
(100% malignant) • Mafucci syndrome
(Many things)-multiple
enchondroma + Fig. 3.9
hemangiomas+phleboliths Fig. 3.10 Fig. 3.11
GCT upper end tibia ABC upper end tibia
Giant Cell Tumor
Lower end Radius Upper end Tibia Upper end Femur Lower end Femur
Fig. 3.12 Fig. 3.13 Fig. 3.14 Fig. 3.15

201
Orthopedics
GCT Common in females Q

Fibrous dysplasia : Shepheral crook deformity
McCune-Albright syndrome refers to polyostotic fibrous
20-40 years Malignant component dysplasia, cutaneous pigmentation(café au lait spots), and
Lower end femur Mononuclear giant endocrine abnormalities (Precoceous puberty).
3% Mets to Lungs cells Q - Common in female
Treatment of Osteclastoma (GCT)

1. Extended Curettage by PMMA or phenol or liquid nitrogen
and bone grafting it is procedure of choice for most lesions.
2. Excision
Shepherd Crook deformity
Lower end of ulna
Upper end of fibula
3. Excision and replacement by vascularized bone graft
Lower end of radius where upper end of fibula is grafted
Q
Giant cell variants (Tumor with giant cells)
•Brown tumor of hyper parathyroidism
•Aneurysmal bone cyst (closest) and unicameral bone cyst
•Non ossifying fibroma (commonest) and Fibrous dysplasia Rind sign
•Osteoblastoma and Osteosarcoma Fig. 3.16 Fig. 3.17 Fig. 3.18
•Chondromyxoid fibroma and Chondroblastoma
Note: (GCT – Mononuclear & Giant cells
Both cells have identical nucleus)
LCH Hemangioma
• Letterer Siwe Disease-<3 years Corduroy
Fatal pattern on X-ray
• Hand Schuller Christian Disease-
Lytic skull lesions,exophthalmos and - Jail bar appearance
Diabetes Insipidus
• Eosinophilic Granuloma-Solitary Fig. 3.19 Polka dot
bone or lung Lesion(Pumonary on CT Scan
Histiocytosis X)-skull most
common bevelled lytic lesions CHORDOMA
Biopsy-Cells with Birbeck
• Origin notochordal remnants
Granules-Tennis racket appearance
• Second common malignancy of spine after
Spontaneous Resolution
multiple myeloma
• Most commonly in sacrum
• Physaliferous cells are seen
• Treatment is surgical excision +/- radiation
Synovial Cell Sarcoma

• The term ‘synovial cell sarcoma’ is a misnomer as synovial cell sarcomas do not arise from synovium.
• Characteristic translocation (X; 18) giving rise to SYT – SSX fusion genes.
• Near the joint -bursae.
• Synovial sarcoma is biphasic tumor with epithelial and mesenchymal components
• Treatment is excision
202
Pulsatile bone tumors.

1. Osteosarcoma>ABC>Angioendothelioma of bone > GCT | 2. Amongst metastasis Renal and thyroid have pulsatile metastasis
Osteosarcoma
Osteosarcoma is the cancer of young • Osteitis deformans (paget’s)
• Radiation induced sarcoma
• Radioresistant bone tumor
• Matrix(OSTEOID) forming bone tumor
• Osteosarcoma and soft tissue sarcomas are
associated with germline retinoblastomas Fig. 3.20
Common site: lower end femur
Pain/ Night pain : Osteosarcoma
Treatment Prognosis
T 10 protocol • Extent of disease • Systemic mets>pulmonary mets
• Etoposide-NOT used • Pulmonary mets (Mc site • Grade of lesion
• Methotrexate is very of mets) • OS is malignancy causing
important agent pneumothorax
• Origin –Marrow cells-Marrow biopsy useful to see

Ewing sarcoma the extent of the disease. Treatment
• Age-Second decade > first Decade • Pain - universal complaint Preoperative chemotherapy
• Bone-Femur Diaphysis • Presents like Osteomyelitis Wide excision (or amputation)
Chemotherapy for 1 years
Genetic Defects: Round cell tumor Subsequently radiotherapy
with glycogen positive cells. may be given.
• Ewing sarcoma is round cell tumor with Prognosis Q
glycogen positive cells Poor prognostic factors for
• The t(11;22) is the most common Q ewings sarcoma
translocation, Other diagnostic • Age>12/Male/Proximal/Fever/Anemia Fig. 3.21
translocations are - t(21;22), and t(7;22) • Increased TLC/Platelets/ESR/LDH
• Trisomy 8 ,trisomy 12 • Metastasis
• Chemoresistant
• MIC2(CD99) is a specific marker Q • Relapse
Chondrosarcoma
• Chondrosarcoma - Pelvis
• Hyperglycemia
• Best prognosis amongst the malignant
tumors.
Fig. 3.22
Multiple Myeloma Plasma Cell Leukemia
• Bone Pains + high Esr + hypercalcemia Plasma cell leukemia->
• Criterion 20% plasma cells in
1) M Proteins(serum/urine) peripheral smear
2) Bone Marrow plasma cells/Plasmacytoma
3) End Organ Damage (Lesions/anemia/hypercalcemia/increased
Cr/
Hyperviscosity/Amyloidosis/bacterial Infections)
• Punched Out Lytic Lesions
203
Orthopedics
Q Bevelled lesion - E. granulosoma

Skull Lytic Lesions
A A
M Mets
Eosinophilic granulosoma
E
Langerhans cell
L histocytosis/Lymphoma
B
T Tuberculosis (TB)
H Hyperparathyroidism
Permeative lesions
O Osteomyelitis
LCH
R Radiotherapy
M Multiple Myeloma (MM) C
E Epidermoid
Fig. 3.23
Punched out
Lytic lesions
MM
Salt pepper skull Hyperparathyroidism
Note: Some other skull X-rays which are important.

D E
D1 D2
Fig. 3.24 Fig. 3.25

Cotton wool skull Osteoporosis circumscipta Hair on end appearance
4
Section Nerve Injury
Palmaris longus – hand to fingertip (graft) of Radiation n → Most common n affected
Seddon’s Classification tendon Best prognosis
Plantaris – forearm to fingertip (if need longer) No tests
Neuropraxia:Tinels Sign Negative Fracture end of humerus →Most
common cause of radial nerve injury
• Physiological block in nerve conduction /100%
Recovery/One Moment Sunderland Classification of
nerve injury and its relation
Axonotmesis:Tinels sign positive and progressive to seddon’s classification
• Damage to axon Sheath/motor march
Classifications
Sunderland Seddon’s
I Neuropraxia
Neurotmesis:Tinels sign is positive and non-progressive II, III, IV Axonotmesis
V Neurotmesis
• Complete nerve transection
Fig. 4.1
Flex metacarpophalangeal
Extend interphalangeals
"Regimental Badge" area
Injury:
1. Shoulder dislocation
2. Fracture-upper end of
* Axillary Nerve Sensory Zone humerus Fig. 4.2 Fig. 4.3
(Regimental Badge Sign) 3. Injection into deltoid Lumbrical Lumbrical
QQ
Ulnar Nerve Claw hand-Ulnar/median Median Nerve QQ
Claw
Test for ulnar nerve hand
1 Card test-palmar interossei
Pointing index-Median Nerve

Flexors (FDS+Lateral 1/2 FDP)
Oschner clasp test

Benediction test
Pen test-Median nerve
abductor pollicis brebis
2 Igawa test - Dorsal Interossei
3 *Book test-adductor pollicis

Adductor
pollicis
(Ulnar nerve)
Negative
(Normal) Thumb in
same plane
*Froment sign Ulnar nerve palsy

as palm
Flexor pollicis
*Ape (Simian) thumb deformity

and substitutes
for adductor pollicis
longus (Anterior
interossei nerve)
Median Nerve
5 Wartenberg sign-abducted
little finger-Ulnar nerve palsy Flexion at MCP
(Knuckle bend)
Flexion
by FDP
Extension at
IP Joints
Supplied by
anterior
interossei
Flexor nerve
*Knuckle bender splint- Ulnar nerve/Median nerve pollices longus
* Latest Questions
Kiloh Nevin sign-AIN
205
Orthopedics
Redial Nerve
Radial nerve Crutch palsy
Saturday night palsy
Honeymoon palsy
Wrist Drop
ECRL/B
BR
Dorsum of 1st Web space
Radial nerve autonomous zone
Injury to Nerve
Open (Neurotmesis) Closed

Finger Drop Sunderland 5
Repair * Splint
- Radial Nerve – Cockup splint
- Ulnar/Median N. – K-nuckble
Bender Splint
(Most advise initially expectant
management)
* Cock-up splint-Radial nerve Direct repair Repair with graft

e.g. Sural nerve
Modified Jones Transfer
Progression EMG (2-3 wks) *Neuropraxia Sunderland 1
100% Recovery
• Pronator Teres to Extensor carpi
radialis longus/Extensor carpi Defibrillation
radialis brevis Satisfactory Unsatisfactory
• Flexor carpi ulnaris to Extensor
digitorum communis
• Flexor carpi radialis to Extensor
pollicis longus (Extensor pollicis
brevis and Abductor pollicis
longus)
Flexion of elbow
Abduction of shoulder
External rotation at shoulder
Supination of forearm
Erbs palsyQ Klumpke’s palsyQ

C5,C6 Nerve root C8 T1 nerve root
Policeman or Waiter More common

Claw hand
tip deformity Waiter tip deformity +
Horner’s syndrome
Better prognosis
Fig. 4.4
206
NERVE ENTRAPMENT SYNDROMES / COMPRESSION NEUROPATHY
Q
– Phalen’s / Reverse Phalen’s Test
1. Adsons test
2. Wrights test
3. Roos test Q
Q
Thoracic outlet syndrome Allens test
Associated with
Thoracic outlet
syndrome
Fig. 4.5
Q
Cervical rib
Adson’s Test Roos Test Wright Test Fig. 4.9
Plan A
Rest + NSAIDs
↓
Local steroids → Surgery
Fig. 4.6 Fig. 4.7 Fig. 4.8
5 General +
Extra articular fracture – close reduced
Intra articular fracture – open reduced
Section Upper Limb Traumatology

Fracture Break in the cortex Consistent sign - Tenderness
Surest sign
• Abnormal mobility
• Failure to transmit movements proximally
• Crepitus
Most Common Most common tendon – Supra spiratans > Biceps > Tendoachilles
Facture at Birth Clavicle
Facture in Children Forearm (R>U)
Dislocation Shoulder (Anterior)
Dislocation in Children Elbow (post)
Rarest Dislocation Ankle
Sprain - Lateral Sprain – Anterior Talofibular ligament/
- Medial On medial side : - Deltoid ligament
Tendon injury
Markers of bone resorption Markers of bone formation
• Hydroxyproline/Pyridinoline/deoxypyridinoline/ • Osteocalcin/ALP/Serum procollagen
Telopeptides (N and C terminal) Type 1(N and C terminal)
Stages of Bone Union

• Hematoma – blood –from marrow + with cells
• Granulation tissue
• Callus -3 weeks-Micromovements allows callus formation
• Consolidation
Fig. 5.1
• Remodelling
Non union – Bone not united at 9 months

Primary SeCoNdary Hypertrophic NU Atrophic NU
Excess callus Avascular bone ends.
Callus Absent Present
formation Rx Freshen the margin
Biological Rx Stabilization +
healing No Yes
Bone grafting +
Examples Plating Nailing/Casts Stabiliazation
Cubitus Valgus
Cubitus Varus
Fig. 5.3
Fig. 5.2
Q Q
208
Swimmers – Most common joint damaged – shoulder
Gustilo and Anderson Classification is used for open fracture Treatment of open fracture – Debridement + external fixation
Shoulder Dislocation
AnteriorQ Inferior Posterior

Down and Out Dugas Test Luxatio
Erecta Up and In
Callaway test
Electric Empty
Hamilton Ruler test bulb glenoid
sign sign
Fig. 5.4a Fig. 5.4b

Anterior Dislocation Bryant’s test
Posterior Dislocation
In anterior dislocation Reduction Kochers In posterior dislocation
Arm – abducted Head at level of
Head – below the joint joint, adduction
Epilepsy / Electric Shock
Recurrent Shoulder Dislocation
Anterior Posterior
Anteriomedial
defect
in humeral head
seen in posterior
dislocation
Fig. 5.6
Fig. 5.5
Test anterior instability

Test for Shoulder Instability Matsen's classification for recurrent
instability of shoulder Surgery for Instability
•• Anterior: Anterior Drawer / Apprehension test /
Fulcrum / Crank TUBS AMBRII • Bankarts repair
T: Traumatic A: Atraumatic • Putti plat-Double
•• Posterior: Jerk test U: Unidirectional M: Multidirectional breasting of
•• Inferior: Sulcus test B: Bankart's B: Bilateral Subscapularis
S: Surgery R: Rehabilitationa • Bristow Latarjet-
I: Inferior capsular
Better prognosis shift procedure Coracoid transfer
I: Internal closure to anterior glenoid
Good prognosis Poor prognosis

Fig. 5.5
209
Orthopedics
“FOOSH” (Fracture due to fall on outstretched hand)
Anterior of inferior Axillary, (circumflex humeral) Fracture clavicle

shoulder dislocation nerve Holstein lewis fracture
Surgical neck of humerus fracture
lower 1/3rd humerus
Fracture surgical neck Axillary nerve fracture can damage
Supracondylar fracture humerus
radial nerve
humerus Lateral condyle fracture humerus
Fracture shaft humerus Radial nerve Head and neck fracture of radius
Fracture supracondylar AIN > Median > Radial >Ulnar Galeazzi fracture dislocation
humerus (AMRU) Colle's fracture (Most common)
Medial condyle humerus Ulnar nerve
Fig. 5.7 Radial styloid fracture
Cubitus valgus Trady Unar Narve Palsy Fracture scaphoid
Monteggia fracture dislocation Posterior interosseous nerve
Volkman’s ischemic contracture Anterior interosseous nerve
Lunate dislocation Median nerve
Hip dislocation Sciatic nerve Foot drop Fractures of necessity (requiring surgery)
Knee dislocation C. Peroneal nerve Fig. 5.8 • Galeazzi fracture dislocation
• Lateral condyle fracture humerus
• Displaced fracture olecranon and patella
Humerus (Indications of surgery of # in humerus) • Fracture neck femur
• Vascular injury • Monteggia fracture in adults
• Articular fractures
• Multiple fracture
• Pathological fracture Clavicle
• Radial nerve involvement after reduction • Most common bone to fracture
• Middle 1/3rd (Mc)
• At junction of Medial 2/3rd and Lateral 1/3rd
Three point relationship at Elbow In 90° flexion of elbow. • Observation/sling/figure of 8 bandage Q

Lateral Epi, Medial Epi + Olecranon make a triangle • Operative indications are increasing
Fracture Supracondylar Humerus

• Undisplaced fracture fat pad sign
• Displaced fracture- Posteromedial displacement
• Treatment: Reduction + K wire Q
• Complication : Cubitus varus Q
(Gun stock deformity)
Fig. 5.9
Brachial artery injury can cause Valgus – lateral
pulselessness. (closed reduction and look for Cubitus varus – medial
Carrying angle – due to trochlea lower in female
reappearance of pulse ↓
More in female
Smith & Dunlop tractions used for it
Fracture Lateral condyle Humerus
Most common complication – Gun stock Intra-articular

deformity, open reduction + K wire fixation
(Cubitus varus) Cubitus valgus deformity Q
Treatment: Lateral closing, Wedge osteotomy
210
Fig. 5.10 Monteggia fracture Anterior Fig. 5.12 Galeazzi Fracture
Commonest Triangular
I II fibrocartilage
Posterior complex
damage
Lateral
Interosseous
membrane
damage
Fractures of necessity Q
(requiring surgery)
Fracture ulna + dislocation III Both bones fracture monteggia
classification — Bado
IV • Galeazzi fracture dislocation
radial head Q • Lateral condyle fracture
Fig. 5.11 Bado Classification humerus
Rx. Surgery: Bell Tawse • Displaced fracture olecranon
procedure and patella
• Fracture neck femur
• Monteggia fracture in adults
• Articular fractures
Extra-articular - Distal end radius fracture
PC AS
Explain to the rule of splintage

Fig. 5.15 Normal
Dinner fork deformity

Fig. 5.17 - Smith
Fig. 5.16
Fig. 5.13 Fig. 5.14 Garden spade deformity
Complications of Colles Fracture:

1.Finger stiffness (Mc) 4. Carpal tunnel syndrome
2. Dinner fork deformity 5. Sudeck’s dystrophy
3. Rupture of EPL (Extensor pollicis longus)
211
Orthopedics
Pulled Elbow
• Nursemaids elbow
• Radial head out of Annular ligament

• Age 1 to 4 years
• Pronation
• Forceful supination is treatment to position the head
Barton fracture - Intra-articular back Q
Intra-articular fracture lower radius with wrist subluxation.
Terry thomas sign/David Letterman sign
Scaphoid Fracture Scapholunate Dislocation
• Anatomical Snuffbox tenderness

• Most common carpal bone to fracture
• Fractures at the waist
• Distal pole fracture in children
• Blood supply distal to proximal
• Glass holding cast Q
Fig. 5.18
Bennett's Rolando
Bennetts fracture Rolando fracture
dislocation Pull by
adductor pollicis
Most important
Intra-articular
pull is by Intra-articular
fracture
abductor Comminuted
Base of 1st pollicis longus
metacarpal pull fracture of Base
by abductor of 1st metacarpal
pollicis longus
Fig. 5.19
Fig. 5.20
Wrist Dislocation C
Phalanx
Capitate
1. Perilunate (Mc): Lunate in L
R
place other carpal bones Lunate
dislocate Radius
2. Lunate dislocation :Lunate
dislocates
Fig. 5.21
Fig. 5.22
PIE sign Spilled
Normal Lunate Perilunate Teapot/cup sign
Articular Non-articular
Restricted Active and Active

movements passive
212
Compartment Syndrome - Capillary Network Volkmann’s Ischaemic Contracture (VIC)

Most common area-Deep posterior compartment of leg>deep
Area Area • Deep Flexor compartment Forearm
Flexor forearm
Symptom Pain out of proportion to injury Q Muscle • FDP>FPL
Sign Pain on passive stretch at distal most joint of extremity Nerve • AIN>MEDIAN>ULNAR
Pulse is not a reliable indicator-as microcirculation is affected
Normal Pressure
Pressure <11 mm Hg Calf Pressure during walking-200-300 mm Hg Splint • TURN BUCKLE SPLINT
Treatment Fasciotomy(Release upto deep fascia) Surgery • Maxpage Muscle Sliding Operation
Indications Pressure >30 mmHg Neurovascular Compromise Q

Pulse is not reliable indicator – as microcirculation is
Sudecks Dystrophy
affected
• Crps-Complex Regional Pain Syndrome
Myositis Ossificans
• Type 1 Traumatic(colles)
• History of Massage often present Q Stimulus
• Unilateral • Type 2 Nerve Injury(median)
• Elbow most common area involved
• Sympathetic Overactivity
• Brachialis>Biceps
• Immobilization 1st 3 weeks • Red hot shiny skin- Response
• Only Active Exercises No Passive Exercises-3 weeks to 1 year • Patchy Osteopenia- Response
• >1 year-Surgery
• Lankfort’s Triad(stimulus, activity, response)
• Exercises To Continue
• Results Poor
6 Spine + Pelvis +
Section
Lower Limb Traumatology
Scoliosis Congenital Upper border
of scoliosis
Cervical curve
Perpendiculars
Idiopathic 58°
Cobb's angle
Thoracic curve used to
management
Perpendiculars
A B C
Lumbar curve
Lower border of scoliosis

Pelvic curve Cobb's angle
Fig. 6.1
Wedge
Semisegmented Fully segmented vertebrae Block Unsegmented Unsegmented bar
hemivertebrae vertebrae bar with hemivertebrae
Fig. 6.2
Spinal Fractures
1. Jefferson fracture: Burst fracture of C1
2. Hangman's fracture: Traumatic spondylolisthesis of
C2(axis) over C3
3. Burst fracture:Vertical compression injuries
4. Whiplash injury: Sprained neck.
Easier were called as railroad spine/ Erichsen's disease
Hyperextension followed by flexion.
5. Flexion – Compression:
a. Wedge compression
b. Tear drop (may have bone fragment from antero-
inferior part of vertebra).
Anterior
column 6. Flexion – distraction: Facet dislocation
Posterior 7. Clay- Shoveler's fracture: Avulsion fractures of spinous
Posterior column
column
process of C7 > D1 Vertebra
Fig. 6.3 8. Motor Cyclists fracture (Hinged fracture): Transverse
Columns of acetabulum fracture across base of skull leading to separation into
anterior – posterior.
9. Undertakers fracture: Tearing of C6-7 disc space causing
Spur Sign → Both column fracture subluxation, caused by Undertaker's handling the dead
of acetabulum body.
Spinal Cord Injury Without Obvious Radiological
Abnormality (SCIWORA): Pediatric injury (<8yrs). X-
rays are normal but there is neural deficit. This is due to
lax ligaments permitting traction injury to cord. Cervical
spine is most commonly affected.
Fig. 6.4
Spur sign
TRENDELENBERG TEST-DROP
Q Normal hip abductors Weak hip abductors Q
Trendelenburg's test Thomas test
Normal hip
Hip abductors-gluteus medius and Drop of pelvis
Thomas test
gluteus minimus on normal side
on bearing weight
for hip flexion
Superior gluteal nerve on diseased hip
deformity
Positive means drop of pelvis on

opposite(normal)side
15°
Bilateral –waddling gait
Fig. 6.6: Spur Sign Fig. 6.5
Fig. 6.6
Normal is Negative (No drop)
214
Fracture Neck of Femur Fracture Intertrochanteric Femur
60/f 80/M
Intracapsular More common
60/F Extra pain
↓Pain Extra shortening
↓Shortening Extra external rotation
↓External (Lateral border of foot
rotation touches
Fig 6.7 : Garden Classification the bed) An
dis
• Proximal femoral nail >

Dynamic hip screw
30° Horizontal
70° Fracture Neck of Femur – Treatment

A Fracture 1. <65 years, £ 3 week
line
• Closed reduction and internal fixation with multiple screw
C is the treatment of choice. In basicarvical fracture Dynamic
50°
Hip Screw can be done.

– If closed reduction is not possible open reduction and
B
screw fixation is indicated.
According to the angle the 2. <65 years, > 3 week fracture,
Fig 6.8 : Pauwels Classification fracture makes with the osteotomy/Bone grafting + fixation.
horizontal line 3. ³ 65 years
Anatomical (level of fracture)
• No pre-existing arthritis – hemiarthroplasty
Risk of AVN Subcapital > Transcervical > Intertrochanteric
4 Pre-existing arthritis (any age) — total hip replacement
Complication are Osteonecrosis(AVN) > Nonunion > arthritis
Delbert Classification for Pediatric fracture

neck femur
Type
1. Transepiphyseal
2. Transcervical
3. Cervicotrochanteric
Fig. 6.10 DHS
4. Intertrochanteric
Incidence 2 > 3 > 4 > 1.
Fig. 6.11
Fig. 6.9 PFN Ring (Most trabblesome part)
Diagnostic Criterion for Fat Embolism – Gurd's Minor Criteria (8)

Gurd's Major Criteria (4) Ÿ Tachycardia
Ÿ Axillary or subconjunctival petechia Ÿ Pyrexia Thomas Splint
Ÿ PaO2 below 60 mmHg Ÿ ANEMIA Fig. 6.12
Ÿ CNS depression Ÿ Thrombocytopenia
Ÿ Pulmonary oedema Ÿ Fat globules present in sputum
Ÿ Fat present in urine (GURD TEST)
1 major + 4 minor = fat embolism

Ÿ Increasing ESR Age wise treatment of SoF (Shaft of Femur) Q
Ÿ Emboli present in retina
spica TENS (Titanium I/L Nail ≥10 yr

<5 yr Elastic Nail System) (Interlock)
5-10yr
215
Orthopedics
Hip dislocation Q
Pure dislocation Fracture dislocation

without fracture (Atypical Positions)
Anterior Posterior (90%)
Anterior
*+Head
Lengthening
anterior
* Shortening
Typical positions + Head posterior (Gluteal)
Central Posterior Fracture dislocation
dislocation
Usually posterior
Flexion, abduction and Flexion, adduction and
Head in pelvis - Head gluteal (posterior)
external rotation (FABER) internal rotation (FADIR)
(per rectal) - Shortening
- Clinical presentation
of FADIR or FABER lost
in fracture dislocations
Flexed &
adducted
*
thigh
shortening
Pipkins type IV:
Dislocation with fracture
femur head & acetabulum
Internal
rotation
of lower
limb NOTE : “Any mass that moves with rotation of thigh is femoral head.”
Floating
Knee
Anterior dislocation Closed reduction of dislocation
Posterior dislocation of hip Floating Knee Fig. 6.13

Principle bones
Vascular sign narath positive above & below
(Pulsation not felt) is positive
lose contact
Normally—Negative
Ottawa Ankle Rules
The Ottawa Ankle Rules were developed to assist in making the decision to order an xray in a patient with ankle injury. X-ray examination is called
for if there is:
1. Pain around the malleolus
2. Inability to take weight on the ankle immedialtely after the injury
3. Inability to take four steps in Emergency Department
4. Bone tenderness at the posterior edge or tip of the medial or lateral malleolus or the base of the fifth metatarsal bone.
If x-ray examination is considered necessary, antero-posterior, lateral and 'mortise (30 degree oblique) views of the ankle should be obtained.
Angles in orthopedics
Normal is 20-40 degree, decreases

1. Q angle →→ measure around knee joint
in fracture calcaneusm
→ increased in patellar subluxation/ dislocation
Fig. 6.14
2. Cobb’s angle → Scoliosis Q
Normal 3. Kites angle → CTEV Q
95-105
degree
(increase in
fracture
calcaneum)
216
Plaster casts and their uses:

Fig. 6.17
Name Use
Minerva cast Cervical spine disease Fig. 6.16

Risser’s cast Scoliosis
Turn-buckle cast Scoliosis
Shoulder spica* Shoulder immobilization Fig. 6.15 Cylinder cast
PTB cast
U-slab Hanging cast
U-Slab/hanging cast Fracture of the humerus
Hip spica Fracture of the femur
Common Splints/Braces and their Users:
Cylinder cast/tube cast Fracture of the patella
Patellar tendon bearing Fracture of the tibia
Cast (PTB cast)
Colle’s cast (Hand shaking) Fracture lower end radius
• Cock-up splint
Glass holding cast Fracture scaphoidQ
• Knuckle bender splint
Extra articular
fracture of
distal end radius
• Dunlop trac on
• Smith’s trac on
Hand shaking
cast
Hand
Fig. 6.19
shaking
to reduce
Fig. 6.18 Glass holding cast

Hand shaking
• Thomas splint
• Bohler-Braun splint
• Dennis Brown splint
Fig. 6.20 Fig. 6.21 Clavicle figure 8 • Gallow’s trac on

Dunlops
• Russell’s trac on
a
b
w
• Agnes- Hunt trac on
w • Palvic harness, Von Rosen splint Ilfeld or Craig

Fig. 6.22 Fig. 6.23 BB splint w splint or Bachelor cast
Mallet-finger-splint
• Milwaukee brace
Fig. 6.25
Russells traction Milwaukee brace • Minnerva cast. Halo device
Fig. 6.24
• Risser’s cast. Milwaukee brace, Boston brace
Runner’s fracture – involves lower part of fibula
Lauge Hansen classification → for ankle fracture 217
Orthopedics
I = fracture which involves the joint

surface or have concomitant joint injuries
* Jefferson # -atlas (C1)

* Hangman's # -axis (C2)
Hangman's fracture
Jefferson's fracture
* Night stick # shaft ulna

*Colles # -extra-articular Chauffers Colles fracture
radius with dorsal
displacement and smith
(Reverse colles)
(I) Chauffers #
-radial styloid
Bucket handle open book pelvic fracture
(I) Bartons # -intra-articular

radius with subluxation
of wrist
*(I) Crescent # -iliac
blade with SI
Straddle # -bilateral
pubic rami
Malgaigne
Straddle
(I) Malgaigne # -ipsilateral pubic and SI
(I) Maisonneuve # -spiral fracture

neck of fibula with medial malleolus
* (I) Pilon # -intra-articular Pilon fracture

Classification
fracture tibial end
1. Allman's: Fracture clavicle
2. Campbells/ Rockwood: AC Joint
* (I) Aviators # -neck of the talus 3.

4.
Neers: Proximal Humerus
Gartland: Supracondylar Humerus
5. Milch: Lateral Condyle Humerus
6. Masons: Head Radius
Jones # -base of 5th metatarsal 7. Bados: Monteggia
Aviators fracture 8. Frykmanns/ Fernandez: Colles
9. Dennis: 3 Columns of spine
10. Young & Burges/Tiles: Pelvis
11. Judet & Lectournel: Acetabulum
12. Thompson & Epstein: Posterior dislocation
13. Pipkins: Head of femur
Jones
14. Gardens/Pauwels/Anatomical: Neck femur
fracture 15. Boyd & Griffith/ Evans: Intertrochanteric fracture
Pseudo-Jones 16. Winquist & Hansen's: Shaft femur
fracture
17. Schatzkers: Proximal tibia
(I) Lover’s # -calcaneum fracture 18. Ruedi and Allgower : Distal tibia
19. Hawkins : Neck talus
20. Essex Lopresti (X-ray)/ Sanders(CT Scan):
Calcaneum
Left foot
21. Gustilo Anderson: Open fracture
Jones - pseudo jones 22. Tscherne: Soft tissue injury in closed fracture
218
I = fracture which involves the joint

surface or have concomitant joint injuries
Supracondylar fracture Clay-shoveller’s # -spinous process

lower cervical vertebrae
Proximal humerus fractures
Monteggia
Malgaigne # -supracondylar
(I) Monteggia # -upper ulnar *

with dislocation of
proximal radioulnar joint
(I) Galeazzi # -lower radius with

Galeazzi fracture dislocation of distal radioulnar
(I) Rolando # -intra *

articular first
metacarpal base
(I) Bennets # -1st *

metacarpal base
Boxers fracture with dislocation
Mallet Finger # -avulsion *

of extensor tendon from
distal phalanx
Boxers # -5th metacarpal neck
Bumper fracture (I) Dashboard # -posterior dislocation

with acetabulum fracture
(I) Bumper # -lateral tibial condyle
Cotton fracture (I) Cottons # -trimalleolar *
(I) Potts # -bimalleolar *

Potts fracture (I) Choparts # -dislocation
through intertarsal joints
March # -2nd and 3rd metatarsal neck *
Choparts fracture
Lisfrancs fracture
(I) Lisfranc # -tarsometatarsal joints *

*Latest Questions
March fracture
1. Open injuries- external fixator
2. Tension band wiring: Fracture patella or olecranon
3. Upper limb bones plating
4. lower limb nails 219
Orthopedics
Treatment of Fractures
• Extraarticular Fractures CR
• Intrarticular Fractures OR
• Small Bone Fractures Screws/K Wires
• Children Non Operative Except Periarticular
Fractures
• Children K(Kirschner) Wires
TYPES OF PLATE
1. Dynamic compression plates: These are used to fix the
diaphyseal region and can be used as neutralization
A B C
Buttress mode or compression mode.
2. LCDCP: Limited contact–DCP It decreases the contact Fig. 6.27 Nail
with bone surface hence preserving bone vascularity.
3. Locking Compression plate -The Screw locks in screw Distraction Histiogenesis
holes of the plates hence the name – locking plates.
Indications of locking plates : Tibia
(shin bone)
External
Ÿ Osteopenic bone fixator
Fracture
Ÿ Metaphyseal areas
Ÿ Periprosthetic fractures
Ÿ Failed fixation (nonunion)
External
fixation
Fig. 6.28: Ilizarov Fixator
Fig. 6.29Tension Band Wiring Fig. 6.30 Fig. 6.31

Osteotome Bone Curette
Screw threads
Cortical screw Cancellous screw Locking head screw
Fig. 6.32 Screws & Plates Fixation Fig. 6.33 DCP Fig. 6.34 LCDCP Fig. 6.35 LCP
220
Fig. 6.36 Bone Cutter Fig. 6.37 Bone Nibbler Double Action Fig. 6.38 Bone Holding Forceps
Fig. 6.39 Bone Plate Holding Forceps Fig. 6.40 Fergusson Bone Holding Forceps Fig. 6.41 Lane Bone Holding Forceps
7
Section
Arthritis
RA involves upper cervical spine

OA
RA
Fig. 7.1
Fig. 7.2
Osteoarthritis Rheumatoid Arthritis Psoriatic Arthritis (Caspar Criterion)
Involved PIP, DIP and 1st CMC PIP, MCP, Wrist DIP, PIP and any joint
(Carpometacarpal) Joints
Spared MCP (Metacarpo phalangeal), DIP joint usually
Wrist and Ankle
Clinical cases and senarios
Ankylosing spondylitis* Sacro iliac joint
Rheumatoid arthritis Metacarpophalangeal joint
Pseudogout* Knee
Gout* MTP joint of Great Toe
Septic Knee
Syphilitic arthritis* Knee
Gonococcal arthritis* Knee
Diabetic charcot joint* Foot joint (midtarsals)
Senile Osteoporosis* Vertebra
Pagets disease* Pelvic bones > Femur > Skull > Tibia
Osteochondritis dessicans* Knee > Elbow
Actinomycosis* Mandible
Haemophilic arthritis* Knee (Children-Ankle)
Acute Osteomyeltiis* Lower end of femur (Metaphysis)
Brodies Abscess* Upper end of Tibia

222
Fig. 7.3 OA: Fig. 7.4 Fig. 7.5

Genu Varus
Involves
Wedge to 2/3rds
Medial across tibial
plateau width MCL
compartment laxity
Quadriceps Lateral
Wasted closing
and medial
opening
wedge Re-tensioned
MCL
A B
Osteoarthritis – Management: 2.Young 3. Elderly
1. Initial • Surgery for young –HTO(High • 60 or More-TKR (Total Knee
• Initial treatment conservative Tibial Osteotomy) (upto 20 Replacement)(Movement
• If activities of daily living are degrees deformity) normal,proprioception good and
affected-surgery mild insignificant Sensory loss)
The 1987 Revised Criteria For Diagnosis of RA

OA Knee RA Knee
Varus arthritis Valgus synovitis 1. Guidelines for classification 4 of 7 criterion are
sclerosis Oeteopenia required to classify a patient as having RA Patients
with 2 or more criteria are not excluded.
Classification Criteria for Rheumatoid Arthritis -2010 Score
2. Criteria (a - d must be present for at least 6
weeks and b- e must be observed by physician)
Joint involvement 1 large joint (shoulder, elbow, hip, knee, ankle) 0
2–10 large joints 1 a. Morning stiffness, in and around joint lasting 1
1–3 small joints (MCP, PIP, Thumb IP, MTP, wrists) 2 hour before maximal improvement.
4–10 small joints 3 b. Arthritis of 3 or more joint areas, observed by a
>10 joints (at least 1 small joint) 5 physician simultaneously, have soft tissue swelling
Serology Negative RF and negative ACPA 0 or joint effusion, not just bony over growth.The
Low-positive RF or low-positive anti-CCP antibodies (3 times ULN) 2 14 possible joint areas involved are right or left
High-positive RF or high-positive anti-CCP antibodies (>3 times ULN) 3 proximal interphalangeal (PIP),
Acute-phase reactants Normal CRP and normal ESR 0
metacarpophalangeal (MCP), wrist, elbow, knee,
Abnormal CRP or abnormal ESR 1 ankle and metatarsophalangeal joints (MTP).
Duration of symptoms <6 weeks 0 c. Arthritis of hand joints eg. wrist, MP or PIP joints.
>6 weeks 1 d. Symmetrical arthritis i.e. simultaneous involvement
Total Score 10 Score ≥ 6 indicates – R.A of same joint area on both sides of body.
e. Rheumatoid nodules: subcutaneous nodules over
bony prominences, extensor surfaces or juxta
Extensor articular region. (PATHOGNOMIC)
defect
(at PIP)
f. Serum rheumatoid factor .
g. Radiological changes: bony erosion or unequivocal
Flexor
bony decalcification, periarticular osteoporosis and
Fig. 7.7 defect of PIP narrowing of articular (joint) space.
Ulnar deviation
of fingers
Fig. 7.6
223
Orthopedics
Akylosing Spondylitis : HLA B 27 positive
Fig. 7.8 Pencil in Cup Fig. 7.9 Acro-osteolysis Fig. 7.10 Arthritis Mutilans
Psoriasis Scleroderma RA
Diagnostic Criteria – Modified NewYork Criterion

Essential criteria is definite radiographic sacroilitis- (SI Joint (more on iliac side of joint)-
Ÿ
• Enthositis Q Never diagnose ANKYLOSING SPONDYLITIS WITHOUT SACROILITIS
• Peripheral jts involved in 30% cases Ÿ Supporting criteria: one of these three
1. Inflammatory back pain
• Anterior uveitis is most common 2. Limited chest expansion (<5 cm at 4thICS) not a reliable criterion in elderly because of
extra articular manifestation (30%) pulmonary disorders
• Cardiac defects are seen 3. Limited lumbar spine motion in both saggital and frontal plane
Q
(Schober test /Modified Schober test)
Psoriatic arthritis SI joint Tests
Enteropathic arthritis • Gaenslen test

Ankylosing spondylitis (>90%) • Patrick test
Reitter’s syndrome/reactive arthritis • Figure of 4
SAPHO syndrome • FABER test
-Spine
-lesion on
-soles & palm
Fig. 7.11
PEARS (HLA B27 Postive) Sacroilitis – AS Image
A B
Fig. 7.14
Fig. 7.13 Dagger Sign
Fig. 7.12 Bamboo Spine Trolley Track Sign
- Bony ankylosis Calcification of Calcification of

- Fusion of vertebra interspinous ligament interspinous ligament
and facet joints.
Most common cause
224 Multiple loose bodies
Elderly
Fig. 7.15
Synovial chondromatosis
Feature Gout Pseudogout
Fluid analysis Uric acid Crysals, Needle Calcium Pyro PO4 Crystals, Rhomboid
Joint Involved 1st MTP Great toe Knee
Association Protein + Alcohol Hypothyroidism
Charcots Joint
Totally deranged
anatomy and
destroyed joint
Fig. 7.16 Hemophiliac Arthropathy PENIA

• Periarticular osteopenia
1. Neuropathic Joints (painless) • Squaring of patella
• Epiphyseal Enlargement
- Loss of proprioceptive fibres • Widened notch
• Decreased joint space
- Joint is totally destroyed • Subarticular cyst
• Arnold Hilgartner
- Treatment – Arthrodesis – surgical fusion of joint classification
Fig. 7.17
Cause of widening of notch

- Hemophilia
- RA
- JRA (Juvenile Rheumatid
arthritis)
Fig. 7.19
Fig. 7.18
225
Orthopedics
Synovial Fluid Analysis

• Normal synovial fluid is clear, WBC count ≤ 200/ uL
• Non-inflammatory synovial fluid is clear, viscous, amber colored with a WBC 200/ul-2000/uL and a predominance of mononuclear
cell.
• Inflammatory fluid is turbid, yellow, with an increased WBC count 2,000 to 50,000/uL and a polymorphonuclear leukocytic
predominance.
• Inflammatory fluid has reduced viscosity, diminished hyaluronic acid.
• Infections (pyogenic) is purulent, WBC count > 50,000/uL, PMN > 90% .
• Infections (Tuberculosis/granulomatous) is yellow, turbid, WBC count 10,000–20,000/uL, PMN 60% and presence of lymphocytes,
plasma cells and histiocytes.
CHARACTERISTIC DEFORMITIES OF HAND AND FOOT IN RA

'Z-deformity', i.e. radial deviation of the wrist with ulnar deviation of the digits, often with palmar subluxation of proximal phalanges.
Q
'Swan-neck deformity', i.e. hyperextension of PIP joints with compensatory flexion of the DIP joints.
Boutonniere deformity, i.e. flexion contracture of PIP joints and hyperextension of DIP joints. It is due to rupture of extensor tendon.
Hyperextension of 1st interphalangeal joint and flexion of MP joint with a consequent loss of thumb mobility and pinch—Swan Neck
deformity of thumb.
Eversion at hindfoot (subtalar joint), plantar subluxation of metatarsal heads, widening of forefoot, hallux valgus, and lateral deviation and
dorsal subluxation of toes; hammer toe (flexion of PIP).
Wind swept deformities of toes, i.e. valgus deformities of toes in one foot and varus in other (as wind sweeps all the structure in one
direction).
8
Section
Metabolic Disorders of Bone-
THE BENDS!
Rickets:
1. N to ↓ Ca+2
2. ↓ PO43+ (Except CRF) → have↑PO43+
NOTE: 3. ↑ALP,↑PTH
Q
• Rickets: Lack of adequate mineralization of growing bones.
• Osteo malacia: Lack of adequate mineralization of trabecular bone.
• Osteoporosis: Proportionate loss of bone volume and mineral.
• Scurvy: Defect in osteoid formation Q
Fig. 8.3
Widening Whitening
Cupping, splaying
and flaring of
radius and ulna
Fig. 8.1 Fig. 8.2
X-ray Knee RicketsQ
Rickets Fig. 8.4 X-ray knee Scurvy Q
A–Abdomen protuberant
B–Bowing of bones (on weight bearing)
C–Costochondral Junction prominent - (Rosary), Craniotabes (open fontanelles) • Wimberger ring sign-Sclerotic margin of
D–Diaphragm pull - Harrisons groove (lateral indentation of chest due to epiphysis-Scurvy
pull of diaphragm on ribs)/Double malleolus • Wimberger corner sign-metaphyseal
E–Enamel defect of teeth and delayed dentition defect in Congenital Syphilis
F–Forward sternum - Pigeon chest (Pectus carinatum) • White line of frankel; Scurvy; Heating
G–Growth plate - widening Rickets; Lead poisioning methotrexate
H–Hypocalcemia causing Hyper PtH therapy
I–Irritability
J–Joint deformities - Genu valgum/genu varum/coxa vara
(reduced neck shaft angle of femur)
K–Kyphosis
L–Loosers zones Osteotomy correction only
Frankels/Fracture (metaphysis)
M–Milestone delayed once radiological healing takes place
Ring sign (Wimberger Ring Sign)
Muscle weakness In healing rickets – white line of Frankel
Osteopenia
R–Rickets
Cleft ~Corner SiGn
Osteomalacia Scurvy line (Trummer feld zone)
Pelkan spur
Females FROGS like Posture

Triradiate Pelvis (FROGS LIKE posture in scurvy)
Fig. 8.5 Protrusio acetabuli-Otto Pelvis Coxa vara
(Bilateral) Hypophosphatemic Rickets
Osteoid/osteon>1 • X Linked Dominant
• PHEX gene mutation
Tetracycline labelling • Normal Ca,PTH,Vit D
Biopsy gold standard • High ALP • Increase incidence of skeletal deformities
227
Orthopedics
Pseudo Fracture
Pseudo Fracture /Milkman Fracture/ Loosers Zones
Arterial indentations on softened bone
Osteomalacia/HyperPTH/Neurofibromatosis
Neck Femur/Pubic Rami
Rest /Treat Primary Cause
Hyperparathyroidism
• Subperiosteal resorption • Salt pepper skull
• Osteitis fibrosa cystica • Loss of lamina dura
• Rotting fence post appearance • Very rarely AVN
• Brown tumor
Achondroplasia
• Enchondral ossification defect

• Normal intelligence
• Limb dwarfism
• Trident or starfish hand
• Champagne glass pelvis
Fig. 8.6 Fig. 8.7 Achondroplasia

Bullet shaped vertebra
Cleidocranial Disorder
• Autosomal Dominant Normal collarbone CCD
• Intramembranous ossification defect Collarbone

Partly missing
collarbone
• Absent clavicle-Shoulders can meet in midline

• Squashed face
• Delayed dentition Fig. 8.8 Fig. 8.8 Fig. 8.8
• Scoliosis and coxa vara
Osteopetrosis
• Carbonic anhydrase II Proton pump Genetically defective-Bone resorption Q

• Marble Bone
• Functional Deficiency Osteoclasts
• Pancytopenia/Anemia/Infection
• Hepatosplenomegaly Fig. 8.9
• Blindness/Deafness–2/7/8 Marble Bone
Fig. 8.10
• Bone healing delayed but few studies claim normal healing Rugger Jersey spine
• Marrow Transplant
228
Q
Pagets Disease
• Osteoclast Larger Irregular
• Excessive Disorganised Bone Turnover
• Age > 50 years,Males
• Pelvis Commonest
• Pain Most Common Symptom
• Ca And P Normal
• Alp Raised
• The diagnostic histological feature of pagets disease is cement lines.
• Ivory Vertebra/Cotton Wool Skull
• Osteosarcoma(1%)
• Bisphosphonates Most Potent
• Calcitonin Good For Pain Control Fig. 8.11 Fig. 8.12 Fig. 8.13
Ivory Vertebra Picture frame vertebra Cotton wool skull
Osteoporosis : Singh Index
• Bone mineral density –DEXA SCAN Q • Hemiplegic-Humerus maximum loss of bone mineral
• T SCORE density
• O to -1-Normal Drugs
• -1 to -2.5-Osteopenia • Estrogen
• <-2.5 –Osteoporosis • Bisphosphonates–Increases hip fracture
• Severe osteoporosis Osteoporosis with fractures • Calcitonin
(vertebra>Hip>Colles) • Low dose PTH –stimulates osteoblasts Fig. 8.14
• Normal Ca,PO4,Alp Codfish Vertebrae
Q
Osteogenesis imperfecta
• Defect in type I collagen formation. • Deafness
• Autosomal dominant (AD) • Dentinogenesis imperfecta
• Osteopenia causing repeated propensity to • Sillence classification
fracture. Fractures heal at a normal rate. • Gene therapy
• Lower Limb,Femur • Path#-Bailey Dubow rods(adjust nail length with
• Hyper laxity,DDH growth)
• Blue Sclera Fig. 8.15
1. 2. 3. Osteopathia
Melorheostosis Osteopoikilosis
Fig. 8.16 striata
Ivory Vertebra Fig. 8.17
Candle dripping Spotted bone Striated bone
disease disease disease
229
Orthopedics
CRF > Osteopetrosis
Pagets
Fig. 8.18 Fig. 8.19
Ankylosing
Fig. 8.20
Spondylitis
Achondroplasia
Fig. 8.21
Fig. 8.23
Osteoporosis >Osteomalacia
Fig. 8.22
9
Section
Amputations, Sports injury and
Neuromuscular Disorders –THE PAIN!
Mangled Extremity Severity Score (MESS)
MESS Score:Total Score is 11, Six or less consistent with a salvageable limb. Seven
or greater amputation is generally the eventual result.
Jaipur foot
(Natural Looking)
Amputation neuroma
Rx:
1. Surgery
2. Transcutaneous electrical
nerve stimulation (TENS)
inhibits pain gate pathway Fig. 9.1 Fig. 9.2
(Dr. P.K. Sethi)
Q
Amputation Reimplantation
• Bone BE FAN VS
• Choparts Inter-tarsal • Extensor tendon
• Flexor tendon
• Lisfranc's Tarso-metatarsal • Arteries
• Nerves
• Syme's 0.6 cm above the talar dome • Veins
• Skin coverage.
Arthroscope:
1. 4 mm diameter Portals of Knee Arthrscopy
2. 30 degree
Anterolateral portal Anteromedial portal Superolateral portal Posteromedial portal Gillquist portal
(Trans Patellar
portal )
• Most common approach • Additional viewing of • Patello femoral • Repair of posterior horn
• 1 cm above joint line and lateral compartment articulation and excision meniscal tears
1cm lateral to patellar tendon • Instrumentation of medial plicae • Removal of posterior
• Universally see all structures loose bodies
except
i. PCL
ii. Anterior part lateral
meniscus
iii. Posterior horn medial
meniscus
Anterolateral Corner:ACL + LCL + Lateral half of Joint Capsule 231
Posterolateral Corner: LCL + Popliteus (Most important) PCL – restrict external rotation Orthopedics
ACL – restrict internal rotation and hyper extension
Traumatic Knee ACL PCL
* Postero-lateral Antero-lateral Posterior Force Varus Force Valgus Force * Home

Bounce
Test
Flexion
Corner Injury Corner Injury
* Dial Test Pivot Shift Test PCL LCL MCL

Extension
Difficulty going Varus Stress Test *Valgus Stress Test

downhill in 30° flexion in 30° flexion
Feel compared
* Knee extension from flexed position

Normal feel-Hard/Firm
Torn structure-Rubbery/Spongy Feel
Torsion, Flexed Knee + (Empty feel not seen)
Torsion + Flexed Knee Valgus Force
* (Medial
Meniscal Tear
> Lateral)
ACL Tear
McMurrays Test Positive/

* Lachman Test Positive
Apleys Grinding Test
Thessaly Test/ Ege’s Test MATE
*
90 degrees knee
Rehabilitate + Arthroscopic
C f pu
lin ll flexion required
o
ic
ACL Reconstruction to perform the test
ia
n'
s
lin
* Peripheral 1/3rd Tear * Inner 2/3rd Tear

e H
am
Repair Arthroscopic
st
rin
Excision
g'
s
lin
e
of
pu
ll
Patella Femur
Anterior drawer test-ACL
Posterior
cruciate
ligament Knee joint
Anterior
cruciate
ligament
Rotatory
movement
Arthroscope
Another Meniscus
arthroscopic
instrument Meniscal ligament Tibia
Mcmurray test-Menisci
(Medial > Lateral)
* Latest Questions
PLeAD:
ACL
Lachman Anterior drawer test
test Lelli test
Pivot shift test Anteromedial part Posterolateral part
Flexion stability Extension stability
231
232
Disc prolapse Q
Flexor tendon injuries • Clinical presentation-lower

back ache radiating to lower CSF
Distal to sublimis white so
Zones of flexor tendon limb T2 image
• Mri investigation of choice
Pulley 5 Forearm
Zone I • LUMBAR –DEHYDRATED
A5
4 Carpal tunnel • L4-L5>L5-S1
A4
A3 3 Lumbrical • LOWER NERVE ROOT

No man's land
A2
COMPRESSED-L5
2 FDS
Zone II
A1
Treatment:
• Rest +NSAIDS
Q
Lumbrical No Man's Land • Local Steroids
Zone III origin
1 FDP • Surgical Fig. 9.4
Carpal
Decompression
Zone IV tunnel
a. Laminotomy
Proximal to b. Laminectomy
Zone V carpal tunnel
c. Hemilaminectomy
Fig. 9.3
Yellow flag signs – no further work up and management required Red flag signs of back ache – indicative of further work up
and management
Ÿ Pyschosocial factors shown to be indicative of long term Ÿ Thoracic pain
chronicity and disability: Ÿ Fever and unexplained weight loss
Ÿ A negative attitude that back pain is harmful or potentially Ÿ Bladder or bowel dysfunction
severely disabling Ÿ History of carcinoma
Ÿ Fear avoidance behaviour and reduced activity levels Ÿ Ill health or presence of other medical illness
Ÿ An expectation that passive, rather than active, treatment will Ÿ Progressive neurological deficit
be beneficial Ÿ Disturbed gait, saddle anaesthesia
Ÿ A tendency to depression, low morale, and social withdrawal Ÿ Age of onset <20 years or >55 years
Ÿ Prolonged steroid intake
Ÿ Radicular impingement
Nerve Muscle group used for motor grading in
Root ASIA system
C5 Elbow flexion (Biceps, Brachialis) + Shoulder Abduction
C4 C4
C6 Wrist extension (extensor carpiradialis longus C6: Thumb and
C7: index finger *
and brevis) (Middle finger) C5 T2
C7 Elbow extensor (triceps) C3
T2
C7 C4
C8: (Ring and C6 C5
T2 C5
C8 Finger flexors (flexor digitorum profundus) little finger) C8 T1
3
4
5
4
T1 Hand intrisics (interossei) Finger abduction L5: Lateral part of
5
7
6
leg, + dorsum of 8 T1
L2 Hip flexors (iliopsoas) foot + great toe
9
10 T1
11
C6
L3 Knee extensor (quadriceps) S1 L2
L1 12 C6
L3
S1: Sole L5 L4 S3
L4 Ankle dorsiflex or (tibialis anterior) and 5th toe C8
C6
L5 Great toe extensors (extensor hallucis longus) EHL L4: Medical part C7
C7
of leg and foot
S1 Ankle plantar flexors (gastrocnemius and soleus)/
Disc Prolapse (System 1)
FHL (Flexor Hallucis Longus) Preffered (System 2)
Fig. 9.5
233
Orthopedics
Superior
articular process Haglund Deformity Prominent calcaneal tuberosity
(cor of scotic dog)
Pedicle (eye)
Pars inter-articularis
(Neck of dog)
Dog Break-spondyloysis
-dog with Collar in neck
Transverse
process (Head)
Fig. 9.7 Rx: Plan A
Isthmus (Neck)
Lamina and spinous

process (Body)
Inferior articular Dupuytren’s Contacture
process (forolog)
Opposite inferior Diabetes mellitus
articular process
(hind leg)
Fig. 9.6
Palmar Aponeurosis-Flexion deformity
Slip of one vertebra over other-spondylolisthesis
-Beheaded Dog or Beheaded Scottish Terrier Sign • MCP>PIP>DIP Fig. 9.8
• Ring Finger>Little Finger
Q • Wait and watch
Game Keepers Thumb
• If more than 30 degrees deformity at MCP
Forced radial deviation or more than 15 degrees at PIP-Subtotal
Fasciectomy
Torn ulnar collateral ligament at
• Collagenase has also been used
MCP of thumb.
Rx Cast application
• Mallet Finger Avulsion of extensor
tendon from distal phalanx
Rx: Splint
• Jersey Finger Avulsion of FDP from distal phalanx Fig. 9.9
Rx surgery
1. Tennis Elbow Lateral Epicondylitis (ECRB>ECRL)
• Bowlers Thumb Compression of ulnar digital nerve of
2. Golfers Elbow Medial Epicondylitis thumb Rx: Plan A
3.
Hallux Valgus Lateral deviation of great toe
ROTATOR CUFF SYNDROME INCLUDES

Rx: Plan A
i. Subacute tendonitis (Painful arc syndrome-painful
abduction between 60º–120º)
ii. Chronic tendonitis (Impingement syndrome; Neer's test is used
for it )
iii. Rotator cuff tears.
Dequervains tenosynovitis
Treatment:
DeQuervains TS • Physiotherapy + NSAIDS
• Local injection of steroids Fig. 9.11
Abductor Pollicis Longus
• Surgery if required for impingement syndrome or rotator
Extensor Pollicis brevis
cuff tears (especially in young individuals)
Fig. 9.10
Frankeistein test Frozen shoulder
Rx: Plan A Common in DM
limitation of IR(Internal rotation) + abduction Rx Plan A
234
Avascular necrosis and Osteochondritis

Osteochondritis
Q
1. Keinbock -lunate
2. Kohler - navicular
3. Panners - Capitulum
4. Perthes - femur head
5. Scheurmann - ring epiphysis of vertebrae
6. Calves - central bony nucleas of vertebrae
7. Frieberg- 2nd metatarsal head
8. Islene- 5th metatarsal base
9. Osgood shattler's -tibial tuberocity
10. Sever's - calcaneum
11. Johanson-Larsens - lower pole of patella
12. Osteochondritis Dissecans-
Fig. 9.12
Snow cap sign: AVN of Humeral head
Lateral epiphyseal Most
arterial group important group
Subsynovial
intracapsular Distal pole
arterial ring
Ascending
cervical
arteries Blood supply is
distal to proximal
Medial femoral Extracapsular

circumflex artery arterial ring Proximal pole undergoes avascular
necrosis more proximal the fracture
more avascular necrosis
Most important group
Fig. 9.13 Fig. 9.14
Blood supply to femur head (posterior aspect)
Anterolateral
aspect of
Head is involved
Fig. 9.15 Fig. 9.16 (MRI-IOC)
Area of necrosis
Fibular graft
Fig. 9.17 Fig. 9.18

Muscle Pedicle Graft Fig. 9.19
Core Decompression
THR
10
Section
Pediatric orthopedics-
The big guys area !
Altered shape of femoral head – limitation of abduction and M:F
Disease B/L
internal rotation
Normal axis – clavicle
DDH 1:6 20%
Axis deviation – Axilla (In case of destroyed femoral head)
IOC – MRI
Perthes 3:1 20%
TOC – Maintain hip reduced
SCFE 3:1 40%
Fig. 10.2: DDH

Fig. 10.1
IR ER
ER Fig. 10.3
DDH
• Small epiphysis Rx:
• Superolateral displacement of femur epiphysis • Pavlik Harness
• Vascular sign of Narath Positive
• Von Rosen Splint
• Shenton’s arch is broken
Tests: Ortolani & Barlow’s • Bachelors cast
Allis or Galleazzi test
Klisic test
RISK FACTORS DDH
• Oligohydramnios
• Metatarsus adductus
DAD Abduction to
• Congenital Muscular Torticollis adduction reduce (RAB)
to dislocate
• Talipes Calcaneovalgus > Ctev
• Family history
• Breech Barlow maneuver Ortolani maneuver
Rx:
• Females Fig. 10.4
• Pavlik Harness
• First born child
• Von Rosen Splint
• Left
• Bachelors cast
• Twin pregnancy is not a risk factor
Perthe’s disease - MRI IOC
Avascular necrosis of femoral epiphysis.Age 4-8 yrs, 20% B/L

B/L more common in males, Classically painless may be self
resolving.Radiological signs: Gage’s , Sagging Rope sign,
Crescent sign Rx.: Maintain abduction
Fig. 10.5
236
Slipped Capital Femoral Epiphysis

• Age 11-20
Trethowan sign
• CAUSE- Endocrinopathies and Growth spurt.Q (In SCFE due to
slip line passes
• A classical sign is Axis deviation Kleiins line–along
neck of femur cuts superior to it.)
• DIAGNOSIS-MRI VERY SENSITIVE a part of epiphysis
• Flexion restricted
Kleins line
Normal
Rx Fixation Fig. 10.6
DMD Normal Skull

Mastoid
CMT process
1. X-linked Recessive (Xp 21)
2. Dystrophin gene mutation is seen • It is associated with Sternum Sterno-
cleidomastoid
muscle
3. Boys (more common) breech delivery,
Clavicle
4. Average age of presentation is 4 years Fig. 10.7 shoulder
5. Patient is Unable to walk by 12 years of dystocia, birth Sternum
age injury and SCM Torticollis
6. Average life span is 26 years ischemia/tumor.

7. Proximal muscle weakness is seen • Associated with
8. Pseudohypertrophy of calf Fig. 10.7 and Metatarsus
adductus,DDH,CTEV
tongue is seen Q • The head is tilted Fig. 10.9
9. Gait—patient is usually a toe walker toward the involved SCM
10. Scoliosis is seen and the
11. Gower’s sign (patient climbs chin is rotated towards the contralateral shoulder,
on himself)Fig. 10.8 producing the ‘Cock robin’ appearance. Q
12. Cardiomyopathy and congestive • SCM on involved side may feel tight and hard and a
heart failure is seen mass or knot can be detected in the body of SCM in
first 3 months of life.
13. There is increase in Creatine Kinase
• It can disappear spontaneously
and EMG shows Muscle damage.
• There may be asymmetrical development of face
Definitive diagnosis is by Muscle biopsy (plagiocephaly).
and genetic studies • Treatment: Unipolar (one head of SCM) or bipolar
(two heads of SCM) release, Optimum age: 1–4
years.
Fig. 10.8
KFS
• Classical triad of Short ‘web’ neck (prominence of trapezius muscle),Low hair line, and
Restricted neck movements.
• It is associated with congenital osseous fusions (synostosis) due to failure of segmentation
of the cervical spine, involving two or more vertebrae.
• Scoliosis (~60%)
• Sprengel’s deformity Q (~50%) it is congenital elevated or undescended scapula
(Omovertebral bone bridges the cervical spine to the scapula and limits the neck and shoulder Fig. 10.10
motion)
237
Orthopedics
Blounts Disease Genu Varum
• The abnormality is
characterized by Blounts Disease Physiological Genu Varum
• varus (Tibia>genu)
• Genu recurvatum and
• Internal torsion of
the tibia
Fig. 10.11
Vertical
talus
Rocker Bottom foot

Causes: 1. Incorrect correction of CTEV
Fig. 10.12 Fig. 10.13 2.Vertical talus Fig. 10.14
Pes Planus
• Flat foot refers to obliterated medial longitudinal arch.
• Heel is often in valgus called as planovalgus
• Pes Planus is of 2 types (Jacks test)
• Flexible : Disappears on non-weight bearing. Management is conservative
• Rigid : Due to Congenital Vertical talus or RA or Infection or tarsal coalition(AD-Talocalcaneal and calcaneonavicular) or
tibialis posterior dysfunction. They often require surgical intervention
CTEV
Kites method –followed earlier Ponsetti method now preferred
At birth Manipulation by mother initial weeks Manipulation and cast
Change of cast Every 2 weeks Weekly
Correction order C-A-V-E C-AV-E
Fulcrum while manipulating Calcaneocuboid joint Head of talus
Duration of treatment 6–9 months 6–8 weeks
Aim: Equalize
both borders
Small
medical Large lateral
border border
Fig. 10.15
238
Pirani scoring (6 parameters) Evans

(Calcaneocuboid Wedge)
Talar head Lat border curvature
Heel Medial crease
Equinus Posterior crease
Fig. 10.17
To Score CTEV severity
Age wise treatment of CTEV 3 to 5 Years 5 to 8 Years

Calcaneocuboid wedge Soft tissue release
+ +
<1 cast
Soft tissue release Evans
Above knee cast:
As rule of splintage
+
immobilize one joint Dwyers
above one joint below
and to correct ankle
equinus knee has to
be immobilized thus
above knee cast
Fig. 10.16
Posteromedial soft
tissue release
Post. Post. Med CSTR

Complete
Fig. 10.18 subtalar release Lateral based
wedge of calcaneum Fig. 10.19
Dwyers Osteotomy
CTEV
1. <1 year cast (starting from birth), Ponsetti method (tenotomy of tendoachilles is carried out).
2. 1–3 years Soft tissue release-Posteromedial soft tissue release (Turcos)
3. But in children older than 3 years of age lateral column shortening procedures are often performed in conjunction with posteromedial
soft tissue release.
4. 3–8 years
a. Soft tissue release together with shortening of lateral side of foot by Evan - Dillwyn Procedure (i.e. resection and fusion of calcaneo
cuboid joint)
b. Dwyer’s osteotomy of calcaneum is done to correct calcaneal varus in > 5 years.
5. 8–10 years Wedge Tarsectomy is done as deformity is more and requires multiple bones to be removed.
6. ³ 10 years
Triple arthrodesis is necessary for recurrent or persistent clubfoot deformity in older children (chronic cases). It is best done at > 10
years of age when foot growth is complete and the bones are ossified to achieve good fusion. It involves fusion of three joints: TN:Talo-
Navicular;TC:Talo-Calcaneal; CC: Calcaneo-Cuboid
7. Thomas designed CTEV Shoes (straight Inner Border, Outer Shoe Raise & No Heel) Fig. 10.20
8. Dennis Brown splint is used and it encourages
abduction and dorsiflexion of foot
9. Parallelism of talus and calcaneum in A.P as well as lateral views is seen in CTEV
239
Orthopedics
BBS Pediatric fracture

1. A classic finding is a 1. Torus # - Buckling of cortex at
chip fracture in which a metaphysio diaphysis junction Q
corner of the metaphysis
2. Plastic deformation: Bend in
of a long bone is torn off
the bone
with damage to epiphysis
and periosteum.
3. Green stick fracture one
cortex breaks.
2. Metaphyseal bucket handle fractures are seen. Fig. 10.21
3. Fractures are spiral femur > humerus >tibia. Fig. 10.22
4. Sub epiphyseal micro fractures are seen (not seen on X-rays—seen on Greenstick
MRI).
5. Nobbing fractures are seen in the ribs due to shaking of the child.
fracture
6. Skull has egg shell fractures, occipital impression fractures and fractures
crossing the suture line.
7. Good quality skeletal survey. Baby gram is not preferred
The defects in tibia or fibula
Fig. 10.23
Radial club hand
(radial hemimelia)
Absent radius and all
radial components of
upper limb (radial artery
Postero-medial + thumb)
Congenital Fibular bowing
Tibial
pseudo hemimelia hemimelia
arthrosis
of tibia
Fig. 10.24
240
Madelung Deformity :Deformity in lower end radius Polio

• Lower limb>UL
More common in females
• The most common muscle to be affected is Quadriceps
• ♀50% B/L Femoris(Partial)-Hand knee gait
• Associated with • The most common completely paralyzed muscle in polio
Turner’s syndrome is tibialis anterior.
• Functions are excellent • Upper limb -Deltoid
• Hand muscles(Very rare)-Opponens Pollicis
• Acute fatality is due to involvement of the respiratory
muscles
Fig. 10.25
11
Section
One Liners
Top 10 Must-know topics 7. Investigation Of Malignant bone tumors-

1. Eponymous fractures WITH Mx a. Always done by transverse incision = False
2. Casts, splints, orthotics b. Sample should be taken from 2 different planes. = True
3. Sports injuries, clinical tests c. Sample should be taken before any radiological
4. Peds orthopedics esp hip investigation. = False
5. Bone tumors d. Sample should be taken from periphery and not from
6. Arthritis necrotic centre. = True
7. Nerve injuries
8. Amputations Metabolic bone diseases
9. Scoliosis 1. Osteogenesis imperfecta will cause frequent fractures of long
10. Osteoporosis bones in a child. (NEET 2022)
2. A post-menopausal woman with previous history of colles
PYQs for quick revision as one-liners fracture is complaining of backache. Most likely a case of
Bone tumors osteoporosis .
1. The following x ray is showing multiple swellings in hand and -Calcium requirement is 1200 mg per day in post menoposal
wrist which is seen in multiple enchondromatosis. (NEET female.
2022) -Oral vit D3 can be given along with oral calcium
-When bisphosphonates/ zoledronic acid / Teriparatide are
given together ,that hampers the action of each other hence
given sequentially.
-Bisphosphonates can be easily given upto 3 yrs (3-5ys) -Oral
bisphosphonates can be given for longer time than IV. (NEET
2021)
3. Given image is showing X ray with normal bone density but at
bone ends we can see WHITE LINE OF FRENKEL and
2. A 20 years old male complains of gradual swelling around wrist WIMBERGER RING which is diagnostic radiological features
for 3 months. Given x-ray is showing soap bubble appearance of SCURVY. (NEET 2021)
at lower end of radius suggestive of GCT.(NEET 2021)(FMGE)
4. An old lady complains of chronic back pain since a few months.

Image shown below have codfish vertebra which is seen in
3. A 30-year man presents with swelling over knee joint. Biopsy osteoporosis.(NEET 2020)
reveals mononuclear and giant cells. Most likely diagnosis is
GCT. (NEET 2020)
4. Most probable diagnosis for a lesion at tibial diaphysis with
interrupted periosteal reaction visible on surface of bone will
be Ewing's sarcoma. (INI CET MAY 2022)
5. A 10-year-old child was operated for a tumor in the lower end
of femur. The gross specimen of the resected tumor is shown
below. The diagnosis is Osteosarcoma. (INI CET Nov 2020) 5. Bisphosphonates are used as a first line management for
postmenopausal female with osteoporosis. (NEET 2020)
6. A 60-year-old postmenopausal woman comes with a history of

Colles' fracture 6 months ago. Her DEXA scan reveals T score
of -2.5. The next best step is to prescribe her Alendronate.
(INICET NOV 2021)
6. Treatment: 7. In osteoporosis, serum calcium and alkaline phosphatase levels

a. GCT- Curettage. are usually normal. (INICET JUNE 2021)
b. Osteosarcoma - Wide excision. 8. Bone scan is not used for diagnosing osteoporosis. (INICET
c. Simple bone cyst – Steroid injection. NOV 2020)
d. Osteoid osteoma – Radiofrequency ablation. 9. Osteomalacia with high urinary phosphate levels is seen in
242
oncogenic osteomalacia.(AIIMS JUNE 2020) 3. Given below is the image of Spanning fixator used in
10. 70 yr old male have pain over hip and move with limping of leg periarticular fracture of knee. (NEET 2022)
and reduced joint space. X-ray was shown this is due to left
hip reduced joint space/haziness, irregular opacities over right
femoral hip, consistent with AVN hip (INI CET MAY 2022)
4. Patient check came in emergency dept with Galeazzi fracture.

Arthritis Management in emergency would include – Check vascularity ,
1. A 20-year-old patient presenting with chronic low back pain close , reduce , POP slab (NEET 2022)
and early morning stiffness since last 2 years associated with 5. A patient fell down riding a bicycle, he started having pain
bilateral heel pain. The most likely diagnosis is Ankylosing around hip, shortening of limb, attitude of limb was Flexion,
spondylitis.(NEET 2021) Adduction and internal rotation (FADIR). These features are
2. A 26-year-old male with back ache, morning stiffness and seen in posterior dislocation of hip. (NEET 2021)
reddening of eyes. X-ray given below show bamboo spine , 6. Nerve injuries are more common in posterior dislocation of
dagger sign and bilaterally fused sacroiliac joints. Most likely hip while vascular injuries are more common in anterior hip
diagnosis is Ankylosing Spondylitis. (NEET 2021) dislocation. (INICET MAY 2022)
7. Attitude of limb in post. Dislocation hip is Adduction and
Internal rotation. (INI CET MAY 2022)
8. A patient came to be emergency department with a
radiograph showing posterior dislocation of hip. No associated
fractures are seen. The next step in management is closed
reduction. (INICET JUNE 2021)
9. A man suffered RTA with injury to hip. On examination lower
limb abducted and externally rotated. The diagnosis is Anterior
4. Involvement of PIP, DIP and 1st CMC with sparing of wrist dislocation(AIIMS JUNE 2020)
and MCP is seen in osteoarthritis. (NEET 2020) 10. Finkelstein test has been shown in the following image which
5. A female presents with pain and swelling over multiple helps to diagnose De quervain tenosynovitis . It involves the
peripheral small joints and deformity shown below. The most APL and EPB tendons. (NEET 2020)
likely diagnosis is RA. (NEET 2020)
7. A woman presented with morning stiffness that gradually

resolves over one hour. It is associated with raised ESR and
CRP. HLA DR4 is related to the prognosis. (INICET NOV
2020)
11. Popeye sign - (NEET 2020)
Fractures
1. MC complication of untreated radial head dislocation is
cubitus valgus. (NEET 2022)
2. Given the radiograph of a 13-year-old child presented with fall 12. Amputation may be needed in severe cases of Frost bite.
on elbow. It is suggestive of Fracture of humerus.(NEET 2022) (INICET MAY 2022) (FMGE)
13. A patient suffered from tibial fracture following a road traffic
accident. He complained of pain on passive flexion. His
posterior tibial and dorsalis pedis pulses were palpable, but he
had loss of sensation in the 1st web space. The next step is to
measure anterior compartment pressure. (INICET NOV
2021)
14. The sequence of performing a Thomas test(INICET NOV
2021) = Checking for lumbar lordosis, Overcorrection on the
normal side, Passive extension of affected hip, Measure the
flexion angle. (INICET NOV 2021)
243
Orthopedics
244
34. Mid pole fracture of patella is managed by tension banding by acetabulam using round ligament -> Placing the head back into
K-wire. (FMGE 2022) acetabulum.
3. CTEV (AIIMS NOV 2019)
a) 50% cases are in males and are bilateral.
b) Forefoot is adducted and supinated.
c) With Ponseti technique, correction is upto 90%
d) Cavus should be corrected first.
5. TYPES OF SPLINTS (FMGE 2022)

1. Dennis-brown splint (used for CTEV)
Infections
1. Most common pattern of involvement of pott's spine is
Paradiscal. (INI CET MAY 2022)
2. Ring sequestrum is associated with External pin fixator. (AIIMS
JUNE 2020)
3. Indications for surgery (including biopsy) in a patient with
Potts spine are = Drug resistant Tb, Doubtful diagnosis,
Evolving cauda equina syndrome. Cold abscess without 2. Patella tendon bearing brace
neurological involvement is not an indication (AIIMS JUNE
2020)
Nerve injuries
1. Median nerve is involved in the following test. Test name is
PEN test which is used to test ABDUCTOR POLLICIS BREVIS
supplied by median nerve. (NEET 2021)
2. A patient presenting with multiple humeral shaft fracture 3. Taylor brace splint
following which he had difficulty in flexion elbow and
supination of forearm. He also complaints of loss of sensation
over lateral—side of forearm. Most likely nerve involved is
musculocutaneous (NEET 2021)
3. Hyperextension at MCP joint and flexion at IP joint occurs

due to involvement of Lumbricals muscle. (NEET 2020)
4. The marked structure supply the lumbrical of the index 4. Pavlik harness (used for DDH)
finger= Median nerve. .(INI CET MAY 2022)
5. Most sensitive test for carpal tunnel syndrome is Durkan

test.(AIIMS JUNE 2020)
6. Splint – Cockup splint used for radial nerve pasly(AIIMS NOV

2019)
Spine
1. The following x-ray of spine shows lateral curvature (
scoliosis) and angle marked is for its measurement – Cobb's
angle . (NEET 2020)
Peds ortho
1. A small child was playing with her maid where she rotated
him by holding from arms. Immediately after, the child started
crying. On examination, his arm was pronated. History of
traction on elbow and pronated forearm is classical of pulled
elbow . (NEET 2020) 2. Bending forward test is used for the evaluation of
2. Steps of surgery of DDH in a child < 2 years. (AIIMS NOV scoliosis.(AIIMS JUNE 2020)
2019)
Capsulotomy -> Femoral osteotomy -> Identification of true
245
Orthopedics
3. A patient presents with scoliosis. X-ray shown below. The

likely cause is Congenital. (AIIMS NOV 2019)
4. In spine straightening surgeries, screws used for fixation are

inserted through pedicle of the vertebra. (INI CET Nov 2020)
5. A 45-year-old male presents with long standing history of

back pain for 20 years and chest tightness. Lateral radiograph
of the cervical spine is shown. The likely diagnosis is DISH.
(AIIMS JUNE 2020)

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OrthoPedics

Quick Revision Notes

Father of Orthopedics (1) Nicolas Andry

Father of Orthopedics (2) H.O.Thomas

1 Thomas Test 2 Thomas SplintQ 3 Wrench 4 Collar 5 CTEV

Fig. 1.1 Fig. 1.2

Father of Modern Orthopedics Robert Jones (Nephew of Thomas)

Father of Arthroscopy Watanabe Organic – Type 1

Bone – type I collagenQ

Ossify around Fig. 1.7

1 Resting zone(Reserve)-Storage disorders

Salter Harris Feature

Diaphysis I Fracture line is entirely with in Physis

Harmones on The Bone

Fig. 1.17 Fig. 1.18

R adial head 4 yrs

Internal epicondyle 6 yrs Fig. 1.19 Fig. 1.20

Important views of X-rays

Lesion in bone or soft tissue Joint space

Infection/Tumor Fig. 1.28

Fig. 1.29 Fig. 1.30

Body planes Fig. 1.32a Fig. 1.32b

• Bone Tumors : MRI CT Scan Osteoid Osteoma (Cortical)Q

* Aspiration * Arthroscopy * Latest Questions •• Multiple sites

Musculoskeletal System Stress fracture Metastasis

Stress fracture/ SHIN splints March # - Metatarsal Neck 2nd >3rd

Calcification (CS>CB)> Osteogenic Tumor

Anterior dislocation Hip : Posterior dislocation > Anterior dislocation Q

Lower End Femur

Osteomyelitis (Metaphysis) Septic arthritis

Reduced movements of Limb, toxic child Joint

Bone Scan – Increased activity Bone Scan – Increased activity

Can cause Tom Smith Arthritis

multifocal Capital epiphysis of head of femur

Pseudomonas Eikenella Pasteurella osteomyelitis Initially immobility; Later hypermobility

Overall Diaphyseal Metaphyseal

Brodies Abscess Chronic Osteomyelitis

NPWT: /Vaccum Assisted Closure Q Treatment

Continuous or intermittent gives good granulation

Acute Osteomyelitis Subacute Osteomyelitis Chronic Osteomyelitis

Solid Periosteal Reaction

1.Multifocal Osteomyelitis SAPHO Syndrome

Fig. 2a.12 Fig. 2a.13

Ulnar bursa Radial bursa

Fig. 2a.14 Fig. 2a.15

• Mycetoma is a chronic progressive granulomatous exogenous

• Involves all structures except nerves and tendons

• Hematogenous spread and lesions are Paucibacillary • Caries Sicca-Shoulder

• Vertebra and disc

• Bone and cartilage

• Anterior disease Fig. 2b.1

Chronic pain, constitutional

Back pain Potts spine Good Prognostic Factors

Treatment: Rest + ATT.

Cobra plate is used for hip arthrodesis

Arthrodesis Ankylosis Arthroplasty

Bony Fig. 2b.3 Girdlestone excision arthroplasty

Septic arthritis >Tb Spine TB Hip and Knee

Peripheral Spine RA (Fibrous) AS (Bony)