Fmge Mission 200+ Feb-2024 Orthopedics

FMGE Mission 200+ Feb-2024
ORTHOPEDICS
By
Dr. Apurv Mehra
Mission 200+ FMGE 2.0: Orthopedics
“Your Course Completion, Our Responsibility"
Thanks to the Almighty for

honoring me with the torch and
art to spread the light of knowledge
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Orthopedics means Straight Child.
Coined by Nicolas Andry, Father of Orthopedics
Thomas – British Father,

R. Jones – Modern Father, Charnleys – Arthroplasty

Splint Wrench Test Collar
X-rays are usually 1st investigation that can
show all layers except Cartilage.

Bone
• 65%-Inorganic-(Ca)10(Po4)6(OH)2-
Calciumhydroxyapatite
• 35% - Organic

Skeletal maturity=Epiphysis fuses to
Metaphysis
Zones of articular cartilage
Zone 1 : Superficial Zone

Progenitor cells for articular cartilage
High density chondrocytes….High water content
Zone 2 : Transition zone –Thickest zone
Chondrocytes are in Low density
Zone 3: Middle zone
Most active chondrocytes
Highest density proteoglycans
Lowest density water content
Zone 4:Calcified cartilage

Epiphysis
Growth Plate
• E
• Resting zone(Reserve)-Storage disorders
• Proliferative(Growth)-Dwarfs/Giants-
Laron syndrome-(dwarfs+truncal obesity)
• Maturation Zone-Trauma
• Provisional Calcification-Rickets
• M





X RAYS


• Break in cortex is fracture

• Osteomyelitis-Loss of soft tissue planes after
24 hours of osteomyelitis>periosteal reaction
• Tuberculosis loss of curvature of
spine>reduced disc space
• Joint space is cartilage (not seen on xrays)and
reduced joint space means arthritis





Sacroilitis AS

Shentons arch

CT SCAN
MRI
MARROW
CARTILAGE
SOFT TISSUES

Cruciates
Pcl restricts External rotation
Acl restricts Hyperextension & IR

Marrow edema
stress fracture/occult fracture
BONE SCAN-BLASTIC ACTIVITY
Stress fracture
Overall- MRI
Unilateral –MRI
Bilateral-Bone scan
Edema well before radiographic changes are apparent. MRI is

as sensitive as bone scintigraphy while providing greater
anatomic detail and specificity. The multiplanar capability of

PET CT-Fluorodeoxyglucose
METS
Single-MRI
Multiple –PET SCAN
Multiple (OsteoBlastic)-Bone Scan

INFECTION?
Pain ,Fever and Swelling

• Tumors And Infection Can Mimic Each Other
(Ewings Sarcoma(dia) >Osteo Sarcoma)
• Metaphyseal
• Differentiated By Tissue Diagnosis
• Culture For Infection
• Histopathology For Tumors
• Culture All Biopsies ,Biopsy All Cultures

Infection/ Tumor
Biopsy
Culture Histopathology
Infection Tumor

Next investigation-MRI
Best investigation(Gold standard)-Tissue diagnosis-Biopsy

DDH-Developmental Dysplasia of hip
• IOC-MRI
• Screening of hip instability-USG

X-ray
MRI
Aspiration/Arthroscopy
Swelling of a joint
X-MAS
Aspiration is done USG guided
Stress fracture
• March Fracture-Metatarsal neck 2nd > 3rd

• Olecranon
• Pars interarticularis-L5
• Cast /Rest

Narrow zone vs wide zone

Sun Ray appearance

Codman’s Triangle

Onion Peel Appearance

CLASSICAL RADIOLOGICAL FEATURES

1. Sun ray appearance/Codmans Triangle Osteosarcoma but can be seen in any
malignant lesion
2. Onion peel appearance Ewing sarcoma but can be seen in any
malignant lesion or chronic
osteomyelitis
3. Soap bubble appearance Osteoclastoma(GCT)>Adamantinoma
4. Patchy calcification Chondrosarcoma>Chondroblastoma
5. Homogenous calcification Osteogenic tumors(Osteosarcoma)

Cartilagenous tumors-Mottled calcification
Osteosarcoma

Biopsy is Gold Standard: Tumor & Infection.
Multiple Mets: PET Scan > Bone Scan;
bone scan is for Osteoblastic mets like Prostate.
OM; X-ray → MRI. But MRI shows changes
earlier.
Infection
ORTHO – STAPH-Metaphyseal
• Sickle cell Anemia-Salmonella -Diaphyseal

• IV drug abusers-Pseudomonas
• Foot puncture wounds-Pseudomonas
• Open injuries-Staph
• Human bites-Eikenella
• Animal bite-Pasturella

FABER=Maximum capacity
FADIR
Deformities at hip
• FABER: Synovitis
Infection(Septic arthritis-Misnomer)
Ilio tibial band contracture(polio)
Anterior dislocation
• FADIR: Posterior dislocation/Arthritis
• Posterior dislocation > Anterior dislocation

OM: Hematogenous, Metaphysis and Staph
aureus, S.C.A: Salmonella.

Joint
FABER at Hip
(Flexion, Abduction and External Rotation)
6-12 years age Non-toxic 0-5 years age Toxic (Fever,

decreased movements of joint ↑ESR, ↑CRP) Absent
movement of joint
Transient Synovitis
Septic arthritis (S. aureus)
X-MAS
X-MAS
Rest
Surgery (Arthrotomy) +
Antibiotics (6 weeks)

Tom Smith Arthritis-Hypermobile Hip

Brodies abscess
• Subacute osteomyelitis>Chronic
Osteomyelitis
• Upper end tibia
• Sclerotic margin

Chronic OM: Sequestrum (dead bone-diagnostic) and
on removal, you will see live bone (PAPRIKA Sign)

Paprika Sign
Multifocal OM – SAPHO Sx > SCA
NPWT:

Paronychia: M.C. infection of hand → Nail bed, Felon
or Whitlow infection of pulp space.

Infectious Tenosynovitis-Kanavels signs
Thenar space- index finger tendon-1st lumbrical

Midpalmar space –middle ring and little fingers-2nd /3rd and 4th
lumbrical

Mycetoma - Dot in Circle Sign (MRI)
Painless
• Mycetoma
• Charcot’s Joint

Tuberculosis
Tuberculosis of musculoskeletal system
• Lung is the most common Primary site>L.nodes

• Hematogenous spread and lesions are
Paucibacillary
• Spine –Potts spine
• Hip
• Knee
• Caries Sicca-Shoulder
• Spina Ventosa-Digits

T.B : S > H > K. Spine Paradiscal involvement
i.e. 2 vertebra; Motor > Sensory > Urinary
Paradiscal Lesion
(Rarest Facet Joints >Spinous Process)

Potts Spine
• 2 vertebral Disease
• Vertebra and disc
• Bone and cartilage
• Paradiscal
• Anterior disease
• Posterior elements and single vertebral disease is

-Malignancy

Potts Spine Clinically
• Sympton-Pain
• Sign- Tenderness
• Neurological sign –Increased deep tendon
reflex.

• Treatment ATT +Rest + Surgery when

indicated.
• Indications of surgery in any disease of

spine –
Bowel bladder involvement
Worsening
No improvement
Spine: ATT + Surgery when indicated – Middle
Path Regimen
Surgery
• Anterolateral decompression +bone

grafting
• Anterior decompression + bone grafting
• Never touch posterior elements in Potts

spine

Winking Sign

Cobra plate is used for hip arthrodesis
• Arthrodesis –surgical fusion-Bony-Painless
• Ankylosis –pathological fusion of a joint
• Fibrous ankylosis –painful-TB Hip and Knee/RA

• Bony ankylosis–painless -Septic arthritis >Tb
Spine/AS


Austin Moore Thompson Prosthesis
Spine: Loss of Curvature
Hip: Periarticular O’penia
Complications of THR
• Infection
• Dislocation
• Mortality –MI>CRA>(PE-Thrombolysis)
• Metal associated complications-
• Hypersensitivity
• Renal insufficiency
• Teratogenicity
• Chromosomal abnormalities
• ?Carcinogenesis


Stages of TB hip- Babcocks Triangle

1.Synovitis-FABER(Lengthening)
2.Early arthritis-<1cm shortening+FADIR
3.Late arthritis->1cm shortening+FADIR
4.Wandering Acetabulum
5.Fibrous ankylosis
Tuberculosis Hip -Acetabulum is the commonest site.

Hip – FABER – FADIR – WANDERING
Acetabulum
TB Spine: Bony Ankylosis
TB Hip/Knee: Fibrous Ankylosis

TRIPLE Deformity
• Posterior subluxation of tibia

• External rotation of leg
• Flexion of knee
PERF

Orthopedic Oncology
Benign: Well-defined margins, uniform consistency
Malignant: Ill-defined margin, variable consistency


• Epi=CB>GCT(ECG)
• Epi + Ca=CB
• Upper end humerus=UBC>CB
• Meta = OS
•Dia=OO/Ada/ES
Epithelial tumors:
• Tibia =Adamantinoma
• Mandible=Ameloblastoma
• (Mandible most common tumor is SCC)

Bone tumors-Enneking staging
• Part affected>Age
• 1st decade-ES
• 2nd decade-OS
• ES 2ND >1ST Decade
• After Skeletal Maturity-GCT
• After 40 years-Mets>MM

Jhaadu = Curettage
Jhaadu + Pocha = Extended Curettage
Excision
General principles
• Benign and cartilagenous tumors-Operated

• Most common surgery –Wide local excision(3cm margin)
• Cystic lesions –curettage -UBC
• With chemical to kill residual cells-extended curettage-Phenol/
Liquid N2-ABC/CB/GCT/EC
• Malignant-Neoadjuvant CT-Sx-AC
• Ewings is most radiosensitive bone tumor

Single central cavity: UBC (Fallen Leaf Sx)

Multiloculated Eccentric: ABC
Night pain relieved on Salicylates: O. Osteoma
Large to feel, small on X-rays: Bone covered by Cartilage:
O’chondroma
Epi + Ca: Chondroblastoma (Codmans Tumor)
MC tumor of Bones of Hand & Feet: Enchondroma

UBC-single/central/upper Humerus

Fallen Leaf Sign

ABC-Multiloculated eccentric

Nidus-lysis with surrounding sclerosis

Osteochondroma(Exostosis)
Diaphyseal aclasia-Development malformation
Large to feel small on xrays
CODMANS TUMOR

ENCHONDROMA-Hyaline Cartilage

• Mafucci syndrome(Many things)-multiple
enchondroma+hemangiomas+phleboliths
• OlliErs syndrome-Only enchondromas

Mafucci Syndrome

Lytic Lesion that goes closest to the joint:
G.C.T
Tumor of DER is GCT Till proved otherwise

Upper End Tibia
GCT
ABC
Giant Cell Tumor
Lower End Radius Upper End Tibia Upper End Femur

Lower end femur

Shepherd Crook Deformity

FIBROUS DYSPLASIA-Shepherd crook

deformity


Rind Sign
MC Acune Albright Syndrome
• Polyostotic fibrous dysplasia

• Precoceous puberty
• Pigmentation(Café au lait-Coffee coloured)

Langerhans Cell Histiocytosis

• Letterer Siwe Disease-<3 years Fatal
• Hand Schuller Christian Disease-Lytic skull
lesions,exophthalmos and Diabetes Insipidus
• Eosinophilic Granuloma-Solitary bone or lung
• Lesion(Pumonary Histiocytosis X)-skull most common
bevelled lytic lesions
• Biopsy-Cells with Birbeck Granules-Tennis racket appearance
• Spontaneous Resolution

Vertical Striations-Hemangioma
JAIL BAR APPEARANCE

Polka Dot Sign

Chordoma
Osteosarcoma is the Cancer of Young

• Radiation induced sarcoma
• Radioresistant bone tumor
• Matrix(OSTEOID) forming bone tumor
• Osteosarcoma and soft tissue sarcomas are
associated with germline retinoblastomas

Pain/Night Pain
T 10 protocol
• Etoposide-NOT used
• Methotrexate is very important agent

Prognosis
• Extent of disease
• Pulmonary mets(Mc site of mets)
• Systemic mets>pulmonary mets
• Grade of lesion
• OS is malignancy causing pneumothorax

Ewings Sarcoma
• Origin –Marrow cells-Marrow biopsy useful to see

the extent of the disease.
• Age-Second decade > first Decade
• Bone-Femur Diaphysis
• Pain - universal complaint
• Presents like Osteomyelitis

Onion peel appearance + soft tissue
component
Genetic Defects
• Ewing sarcoma is round cell tumor with glycogen
positive cells
• The t(11;22) is the most common
translocation ,Other diagnostic translocations are -
t(21;22), and t(7;22)
• Trisomy 8 ,trisomy 12
• MIC2(CD99) is a specific marker

Poor prognostic factors for ewings sarcoma
• Age>12/Male/Proximal/Fever/Anemia
• Increased TLC/Platelets/ESR/LDH
• Metastasis
• Chemoresistant
• Relapse

Treatment
Preoperative chemotherapy
Wide excision (or amputation)
Chemotherapy for 1 years
Subsequently radiotherapy may be given.

1st decade + Onion peel + DIA : ES. Also ES
2nd > 1st decade
2nd decade + Meta + Codman’s triangle; Sun-
ray: OS
Multiple Myeloma
• Bone Pains + high Esr + hypercalcemia
• Criterion
1) M Proteins(serum/urine)
2)Bone Marrow plasma cells/Plasmacytoma
3)End Organ Damage
(Lesions/anemia/hypercalcemia/increased Cr/Hyperviscosity/Amyloidosis/bacterial
Infections)
• Punched Out Lytic Lesions
• Plasma cell leukemia->20% plasma cells in peripheral smear

Mets: B > P > L; Dorsal Spine
Skull: Punched Out Lesion: M.M.
Punched Out Lesions


Cotton wool skull

Osteoporosis Circumscripta

Hair on End Appearance

Nerve Injury
• Neuropraxia → 100% recovery

• Axonotmesis → Tinel Sign positive
• Neurotmesis → Tinel Sign positive and static

• EMG is best test for Nerve recovery

• Median Nerve: Index Finger
• Ulnar Nerve: Little Finger
• Radial Nerve: Web space
• Radial Nerve – MC Nerve involved


• Lumbricals action
• Paralysis: Claw hand, Knuckle Bender Splints

Lumbricals

CARD TEST-PAD-ULNAR NERVE INJURY

Book test-Adductor pollicis – ulnar nerve

FROMENT SIGN –FPL SUBSTITUTES IN

ULNAR NERVE INJURY

WARTENBERG SIGN-ABDUCTED 5TH RAY-

ULNAR NERVE INJURY

Pointing Index

Benediction test

Pen test-Abductor Pollicis Brevis

Ape Thumb Deformity

Kiloh nevin sign -AIN

CLAW HAND

KNUCKLE BENDER SPLINT

Ulnar Nerve>Median nerve

WRIST DROP-FRACTURE HUMERUS
Type to enter a caption.

Sensory Zone Radial Nerve

Radial Nerve
High Low PIN SRN
BR Paralysed WD FD SL
+ + ±
WD FD ECR B
+ +
FD SL
+
SL
Cock Up Splint

• Erbs Palsy: C5-C6

• Shoulder abd./Elbow flexion lost
• Klumpke’s Claw Hand (C8/T1)

WAITERS TIP DEFORMITY -ERBS

COMPRESSION NEUROPATHY
CTS Median Nerve
• Idiopathic
• Pregnancy
• Hypothyroidism
• RA
• Hyperparathyroidism
• Colles
• Females

PHALENS TEST

• T.O.O
• Adsons/Wrights/Roos
• Allen’s test: Patency of R/U artery

Adson’s Test

Roos Test

Wright Test

Allens Test

GENERAL + UPPER LIMB
TRAUMATOLOGY
Sure Signs Fracture
• Abnormal mobility
• Failure to transmit movements proximally
• Crepitus
• Consistent sign - Tenderness

Commonest
• Fracture
• Fracture at birth
• Fracture in children
• Dislocation
• Dislocation in children
• Rarest dislocation
• Sprain-Anterior Talofibular ligament

Stages
• Hematoma
• Granulation tissue
• Callus -3 weeks
• Consolidation
• Remodelling


Supracondylar Extra-articular
CLOSED REDUCTION
Lateral Condyle Intra-articular
Primary Healing Secondary healing
Callus Absent Present
Biological healing No Yes
Examples Plating Nailing/Casts

Gustilo Anderson Classification
Swimmers-Shoulder is prone to injury
Lift off Test-internal Rotation Subscapularis –
Forgotten tendon
Shoulder M.C. joint to dislocate; anteriorly;

Head:Glenoid ratio 4:1
Head → Down & out to joint (Hip/Shoulder

anterior dislocation)

Shoulder Dislocation
DCH
Dugas test
Callaway Test
Hamilton Ruler Test
KSH
Kochers –Most common
Stimpsons maneuvre-Gravity assisted
Hippocrates Maneuvre-Not used

Stimpsons Maneuvre
Hippocrates
Instability
• Anterior- ABER
• Posterior- ADIR
• Inferior-Multidirectional

Bankar ts lesion – Anterior tear in glenoid

labrum-Anterior dislocation

HILL SACHS POSTEROLATERAL DEFECT OF
HUMERAL HEAD IN ANTERIOR DISLOCATION
Posterior dislocation: Empty Glenoid sign.

Up & In
Electric/Light Bulb Sign

• Shoulder –Axillary nerve

• Humerus –Radial Nerve
• Supracondylar humerus-AMRU
• Elbow dislocation-Ulnar nerve
• Cubitus valgus –Tardy ulnar nerve palsy
• Wrist dislocation –Median nerve
• Hip dislocation –Sciatic nerve
• Knee dislocation – Common Peroneal Nerve


Monteggia fracture-PIN

Foot Drop

FOOSH

FOOSH
• Fracture clavicle
• Surgical neck of humerus fracture
• Supracondylar fracture humerus
• Lateral condyle fracture humerus
• Head and neck fracture of radius
• Galeazzi fracture dislocation
• Colle's fracture (Most common)
• Radial styloid fracture
• Fracture scaphoid

S.C.H: Cubitus Varus (Postero-medial disp.)
L.C.H: Cub. Valgus
S.C.H: AMRU
L.C.H: Cub Valgus: Tardy Ulnar Nerve Palsy

Carrying Angle

3 point relationship
• Medial epicondyle
• Lateral epicondyle
• Tip of olecranon

Supracondylar Fracture

Smith Traction Dunlop Traction

Fracture Supracondylar Humerus

Gun Stock Deformity = Cubitus Varus

Fracture Lateral Condyle Humerus

• Monteggia: Fracture Ulna with dislocation R.H.

• Galeazzi: Fracture Radius with DRUJ disruption

Monteggia-Bell Tawse Procedure

Galeazzi Fracture Dislocation

Colles and Smith Fracture

Colles fracture

• Smith fracture: Extra-articular fracture with

anterior displacement
• Garden spade deformity

SMITH FRACTURE GARDEN SPADE

DEFORMITY

PULLED ELBOW

PULLED ELBOW
• Nursemaids elbow
• Radial head out of Annular ligament
• Age 1 to 4 years
• Pronation
• Forceful supination is treatment to
position the head back

Articular fracture
a. Radial Styloid – Chauffer’s fractures

b. Barton with Wrist S/L
BARTON FRACTURE

Normal Anatomy of Wrist

Blood Supply Distal to Proximal

Anatomical Snuff Box

Scaphoid Fracture

Glass Holding Cast

AVN Scaphoid

Anatomical Snuff-Box
When the thumb is fully extended, the depression of the anatomical snuff-box is seen on
the lateral aspect of the wrist immediately distal to the radial styloid process. The snuff-
box is bounded on its anterolateral (radial) side by the tendons of abductor pollicis
longus (laterally) and extensor pollicis brevis (Immediately medial), and on its
posteromedial/ulnar side by the tendon of extensor pollicis longus. Running a finger
along extensor pollicis brevis enables palpation of the superficial radial nerve, which
can be rolled from side to side on the tendon. The cephalic vein passes through the roof
of the snuff-box, where it is visible and palpable, and the pulsation of the radial artery
can be palpated deeply on its floor.
Three bones are palpable distal to the radial styloid process along the floor of the
anatomical snuff-box: the convex, ovoid proximal articular surface of the scaphoid (best
palpated during alternating wrist abduction/adduction), the radial aspect of the
trapezium and the expanded base of the first metacarpal. The first carpometacarpal
joint forms a palpable depression distal to the trapezium. When wrist stability is
clinically assessed throughout its range of movements, the scaphoid may be
compressed bidigitally, between index finger and thumb, along its oblique ling axis
between the tubercle and articular surface. Similarly, the trapezium may be compressed
between its tubercle and radial aspect.
Base of 1st MC:
a. Rolando (I/A)
b. Bennett’s (I/A with dislocation)

Bennetts Fracture Dislocation

Rolando

Boxers Fracture

Wrist Dislocation

Pie sign –Lunate dislocation

Spilled tea cup/Pot sign -Lunate dislocation

• C-C
• M-M
• S-S
• F-F

Compartment syndrome-Cast
• Most common area-Deep posterior compartment of
leg>deep Flexor forearm
• Symptom-Pain out of proportion to injury
• Sign-Pain on passive stretch at distal most joint of

extremity
• Pulse is not a reliable indicator-as microcirculation is

affected

• Pressure <11 mm Hg
• Calf Pressure during walking-200-300 mm Hg
• Fasciotomy(Release upto deep fascia)

• Indications-Pressure >30 mmHg
• Neurovascular Compromise

Volkmanns Ischemic Contracture
• Deep Flexor compartment Forearm

• FDP>FPL
• AIN>MEDIAN>ULNAR
• TURN BUCKLE SPLINT
• Maxpage Muscle Sliding Operation

TURN BUCKLE SPLINT

MYOSITIS OSSIFICANS
• History of Massage often present

• Unilateral
• Elbow
• Brachialis>Biceps
• Immobilization 1st 3 weeks
• Only Active Exercises No Passive Exercises-3 weeks to 1 year
• >1 year-Surgery

Myositis Ossificans

Sudecks Dystrophy
• Crps-Complex Regional Pain Syndrome
• Sympathetic Overactivity
• Lankfort’s Triad (stimulus, activity, response)
• Red hot shiny skin
• Type 1 Traumatic (colles)
• Type 2 Nerve Injury(median)
• Patchy Osteopenia
• Exercises To Continue
• Results Poor

Inflammed Look

Patchy Osteopenia
• C. Syndrome: Relentless Pain/Stretch Pain (Microcirculation):

Cast
• M. Ossificans: Massage (↓ Movements)
• Sudeck’s Dystrophy: Symp. Overactivity. Red Hot Shiny Skin
• Fat Embolism: Femur fracture, 48 hours
• Breathlessness/↓ Saturation

• C. Syndrome: Fracture Tibia
a. Deep post compression leg
b. Deep flexor forearm
• M. Ossificans: Elbow: Brachialis > Biceps Brachi
• Sudeck’s Dystrophy: Colle’s fractures
• Fat Embolism: Femur fracture

Articular Pain will restrict both active & passive

movements
Non-articular pain restricts active movements

Elbow dislocation: Posterior, Ulnar Nerve M.C.
involved. MC to dislocate in child

SPINE + PELVIS + LOWER LIMB
TRAUMATOLOGY

Cervical + Lumbar – Lordosis
Thoracic – Kyphosis
Scoliosis
• Idiopathic
• Congenital
• Postural


Cobbs Angle
• Cauda Equina Syndrome: Asymmetric

• Conus Medullaris Syndrome: Symmetric
• Spinal Shock: Complete Loss; BCR 1st to reappear

Jefferson’s Fracture

Hangman’s fracture

C. S. Fracture

• Jefferson’s: Atlas
• Hangman’s : C2
• Whiplash: Hyper extension – flexion

Motor Cyclist/Hinged fracture: Skull into
anterior – posterior
SCIWORA: Peds < 8yrs
Crutchfield Tongs –Cervical Spine Traction

Bryant’s triangle: Supratrochanteric
Shortening
TRENDELENBERG TEST-DROP
Normal hip
Hip abductors-gluteus medius and
gluteus minimus
Superior gluteal nerve
Positive means drop of pelvis on

opposite(normal)side
Bilateral –waddling gait

Thomas test

Thompson test-Tendoachilles tear


• Intertrochanteric Fracture Malunion (Lat.

Border of foot touches the bed)
• NOF: AVN > NU
• Scaphoid (NU > AVN)

Fracture Neck of Femur

Fracture Intertrochanteric Femur

Gardens Classification

Pauwels Classification

Risk of AVN

Proximal Femoral Nail

Dynamic Hip Screw –Intertrochanteric #

Neck Femur

GALLOWS TRACTION- SHAFT FEMUR

FRACTURE <2 YEARS AGE

Thomas splint

SPICA

• Hip dislocation P (FADIR) > A (FABER)

• Sciatic Nerve Palsy
• Long Term OA


Anterior dislocation- Flexion abduction and

external rotation

Anterior dislocation – Head anteriorly and

lengthening

Dashboard Injury
>

Posterior Dislocation Flexion Adduction

Internal Rotation and shortening

POSTERIOR DISLOCATION-HEAD GLUTEAL

VASCULAR SIGN OF NARATH

• Tibial Pilon: I/A fracture lower end tibia

• Talus fracture: OA (Subtalar > Ankle) > AVN
• Calcaneum fracture: Bohler’s < ↓
Gissaine < ↑

• Cobb’s < Scoliosis

• Kite’s < CTEV
• Baumann’s < SCH

Bohlers Angle/Angle of Gissaine

Q angle

Insall Salvati Ratio = Ligamentum Patellae/Patellar length
< 0.8 = Patella Baja
>1.2 = Patella Alta

• Hanging Cast – Humerus

• Cylinder Cast – Patella
• PTB – Tibia
• Hand Shaking – Colle’s
• Glass Holding Cast – Scaphoid

Hanging Cast

U-
Slab

Cylinder Cast

Hand Shaking

Dunlop Traction

Clavicle Figure 8
MALLET-FINGER-SPLINT

BB Splint

Russell Traction


Milwaukee Brace

Jeffersons Fracture

Hangman Fracture

Night Stick Fracture

Chauffers

Colles Fracture

Bucket Handle Fracture


Malgaigne

Straddle

Pilon Fracture

Aviators Fracture

Jones-Pseudo Jones

Proximal Humerus Fracture

Supracondylar fracture

Monteggia

Galeazzi fracture

Boxers fracture

Bumper fracture

Cotton fracture

Potts fracture

Choparts fracture

Lisfrancs fracture

March fracture

Runner Fracture

Neers classification

Dennis 3 columns

Tractions

TBW

EXTERNAL FIXATOR


Locking Plate

Screws
Cortical Cancellous
Locking
Head






Interlock Nailing

EXTERNAL FIXATOR

Rail Fixator

Ilizarov External Fixator

ARTHRITIS
• Osteoarthritis
• DIP
• Knee (Med. Comp)
• Hand – 1st CMC Joint
• OA Knee: G. Varum
• Quads Wasted
• ADL affected Sx
• <60: HTO
• ≥60: TKR

• RA: DIP Spared

• MCP Commonest
• Knee: Genu Valgum
• Swan Neck Deformity
• Boutonniere Deformity
• Ulnar deviation of fingers

• Sacroilitis + Young male + ↓ Chest Exp.

• Bamboo Spine
• Dagger sign
• Trolley track sign

• Neuropathic Joint/Charcot’s – proprioception fibers –

DM – midfoot joint

• Gout: 1st MTP

• Uric acid – Neg. Birefringent
• Needle-shaped



Genu varum –Medial Compartment

Quadriceps

KNEES

HTO=High Tibial Osteotomy





Z Deformity-thumb

Ulnar Deviation

Pencilin Cup

Acro-osteolysis

Arthritis Mutilans

Sacroilitis AS

AS
• Bamboo spine
• Squaring of vertebra

Dagger Sign

Trolley Track Sign

Romanus Sign

Disc Calcification

DISH

GOUT

CHONDROCALCINOSIS

Great Toe-Martels sign(overhanging bone)

Erosions with h/o great toe pain

CHARCOTS

Widened Intercondylar Notch
Hemophilia
TB
JRA

Synovial Chondromatosis


METABOLIC DISORDERS OF BONE
• Rickets: Widening
• Scurvy: whitening – White Line of frankel
• Wimberger Ring Sign

• Hyper PTH: Bone resorption

• Brown Tumor
• Salt & Pepper Skull

Osteoporosis
• Dexa Scan – T-Score < -25

• Codfish Vertebra
• Osteoporosis > Osteomalacia
• > 65 years female screening
• Pagets O’clast defect

• Pelvis Pain
• Ivory Vertebra
• Cotton Wool Skull

• Osteopetrosis
• Rugger Jersey Spine
• Marble Bone Disease

Osteogenesis Imperfecta Col 1 defect


Wrist - Rickets

Healing Rickets

Rickets


Scurvy

S R

Lamina Dura

Lamina dura pathology
Normal lamina dura Loss of lamina dura

Salt Pepper Skull

Rotting fence post appearance

BROWN TUMOR


Bullet Nose Vertebra

Trident Hand

Star Fish Hand

Shoulders meet in midline

OSTEOPETROSIS-ABSENT BONE MARROW

Osteopetrosis

Osteopetrosis
• Bone within a bone (Also Sickle cell Anemia)

• Rugger jersey spine(Classically Renal osteodystrophy)

•Rugger Jersey Spine: CRF > Osteopetrosis

Erlenmeyer Flask Deformity

Picture Frame Vertebra

Ivory Vertebra

Cotton Wool Skull

Increasing Hat size

Osteoporosis Circumscripta

Brim Sign

Blade of Grass/Flame appearance

Codfish vertebrae
(Osteoporosis/Osteomalcia)

Osteogenesis Imperfecta

Osteopetrosis



AMPUTATIONS, SPORTS INJURY &
NEUROMUSCULAR DISORDERS
MESS: Survival of limb
• S – Shock
• I – Ischemia
• V – Velocity
• A – Age
• Total 11
• ≥ 7 amputation
BE – FAN VS
• Jaipur Foot: Natural Looking

• SACH Foot: Artificial Looking
• Cannot squat/Can’t walk Barfoot

• MM > LM (Bucket Handle tear in young)

• Mechanism Twist on Flexed Knee

• ACL: Valgus, flexion & rotation

• AM
• PL (Ext.)
• Prevents Hyperextension injury
• Lachman
• Anterior Drawer Test
• Pivot Shift test
• Lelli

• PCL: Prevents ER
• Posterior Force

Dial test: Posterolateral Corner
Tendon: SS > Biceps > TA (Biceps Injury Causes
Popeye)
MC ligament – ATFL
• Mallet Finger: Avulsion of Extensor tendon from distal

phalanx
• Splint
• Jersey Finger: FDP avulsion
• Sx

• Frozen shoulder: Adhesive Capsulitis – all

movements are lost.
• Rx: plan A

• Painful arc Sx: 60 – 120 degree pain

• Rx: Plan A

• Tennis Elbow: Lateral Epicondylitis

• Golfer’s Elbow: Medial Epicondylitis
• Student’s Elbow: Olecranon Bursitis
• House maid’s Knee: Prepatellar Bursitis
• Clergyman’s Knee: Infrapatellar Bursitis

• Hallux valgus → Lateral deviation of great toe.

SACH FOOT

JAIPUR FOOT-Dr P K Sethi



Dial test-PCL /PL CORNER

Pivot shift test-anterolateral corner-ACL/LCL/

Lateral half joint capsule

• PCL restricts External rotation

• ACL restricts Hyperextension & IR

Anterior Drawer Test

Lachman test(20 Degrees Flexion)-ACL

O’Donoughe Triad-MAM

McMurray Test

Meniscus peripheral 1/3rd is Vascular

MCL-LMC

Flexor Tendon Injuries

• Disc prolapse causes Sciatica

• MRI – IOC
• L4-L5 – Commonest
• Lower Nerve Root Compressed

• Plan A: Rest + NSAIDS

• Local Steroids
• Surgery

• L4: TA, Medial part

• L5: EHL, Dorsum
• S1: FHL, Sole

• Spondylolisthesis: Slip L5-S1

• Beheaded Scottish Terrier Sign
• Spondylolysis: Break in Pars Inter-articularis
• Dog with Collar in Neck

PIVD-Posterolateral
Clinical presentation-lower back ache radiating to lower limb

MRI investigation of choice

Pars interarticularis

Lysis-L5
Listhesis-L5-S1

Gamekeepers Thumb: UCL MCP 1st
Gamekeepers thumb-Steners lesion

ECRB>ECRL
COZEN

Dequervains tenosynovitis Abductor Pollicis Longus

& Extensor Pollicis Brevis-Finkelstein Test

Haglund deformity

DUPUYTRENS CONTRACTURE

Mallet finger


Jersey Finger

Jersey Finger
• FDP
• Operative


Keinbock

Kohler

Scheurmanns Disease

Avascular Necrosis

Blood supply distal to proximal

Avascular Necrosis

Snow cap sign AVN humeral head

Anterolateral aspect of femoral head

Sectoral sign is seen

Crescent sign on xrays

PEDIATRIC ORTHOPEDICS
• Painless Limp: Perthes 4-8 years
• AVN
• SCFE: 11-20
• Abduction + Internal Rotation Limited
• CTEV: Clubfoot
• Pirani Score

DDH


Pavlik Harness


Perthes Disease

Gage’s Sign

Sagging Rope Sign




Gower’s Sign –Climbing on himself

Congenital Muscular Torticollis

Klippel Feil Syndrome

Rocker Bottom

Incorrect correction of CTEV or Vertical talus

Club

CTEV –most important is Talonavicular

complex abnormalities

If only the world was fair…

they buried us they didn’t know we were seeds…
Ignacio V Ponsetti

At Birth
• Manipulation and Cast
• Upto 1 year of age same treatment
• Above knee cast
• Weekly changed

Soft tissue release-1 to 3 years
PMSTR-Turcos
>3 years
STR +Lateral column shortening

Evans procedure 3 to 8 years of age
calcaneocuboid wedge
Dwyers calcaneal osteotomy to correct heel
varus >5 years of age
Wedge tarsectomy-to correct more deformities
more bones removed 8 to 10 years of age
Triple arthrodesis-Most difficult to fuse talonavicular
other joints fused talocalcaneal and calcaneocuboid
done >10 years of age
CTEV Shoes

Dennis Brown Splint

Torus =Buckling


Plastic deformation

Green Stick Fracture

Congenital pseudoarthrosis tibia

Radial hemimelia –Radial Club Hand

Fibular Hemimelia
Tibial Hemimelia
Posteromedial Bowing

Madelung Deformity

Polio
Lower limb>UL
The most common muscle to be affected is Quadriceps
Femoris(Partial)-Hand knee gait
The most common completely paralyzed muscle in polio is tibialis
anterior.
Upper limb -Deltoid
Hand muscles(Very rare)-Opponens Pollicis
Acute fatality is due to involvement of the respiratory muscles

Attitude +Passion > Talent

What is this
Better Performance and achievements
Pre game evaluation everytime-26 years
3 Pearls of Success
…..COMMITMENT
………….HARDWORK
AND FINALLY…..SURRENDER TO GOD…..

“BHAGWAD GEETA”

Surrender to God ???
Dare to chase ….Your Dreams
Respect yourself!
MY SUCCESS
Your Selection
My students are always my Pride

Draw A Plan For The Next Day
Before U Sleep …
Beautiful Lines from
GURU GRANTH SAHIB:
‘’Teri kismat da likha tere toh koi kho nahin sakta’’

Tu shram kara chal bande……….
‘’Je usdi meher hove ta tenu o v mil jauga jo tera ho nahin sakda’’
HUM HONGE KAMYAAB
Honge kaamyaab, honge kaamyaab

hum honge kaamyaab ek din
ho ho mann main hai vishwas
poora hai vishwas
hum honge kaamyaab ek din.
hogi shanti charo aur

hogi shanti charo aur
hogi shanti charo aur ek din
poora hai vishwas
hogi shanti charo aur ek din

hum chalenge saath saath

dale haathon main haath
hum chalenge saath saath ek din
ho ho ho mann main hai vishwas
poora hai vishwas
hum chalenge saath saath ek din.
Nahi darr kisi ka aaj

nahi bhay kisi ka aaj
Nahi darr kisi ka aaj ke din
poora hai vishwas
nahi darr kisi ka aaj ke din.

Thank you

Fmge Mission 200+ Feb-2024 Orthopedics

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FMGE Mission 200+ Feb-2024

Thanks to the Almighty for

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Thomas – British Father,

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Zones of articular cartilage

Zone 1 : Superficial Zone

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• Break in cortex is fracture

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Edema well before radiographic changes are apparent. MRI is

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Pain ,Fever and Swelling

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Best investigation(Gold standard)-Tissue diagnosis-Biopsy

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DDH-Developmental Dysplasia of hip

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• March Fracture-Metatarsal neck 2nd > 3rd

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Narrow zone vs wide zone

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Sun Ray appearance

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Onion Peel Appearance

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CLASSICAL RADIOLOGICAL FEATURES

3. Soap bubble appearance Osteoclastoma(GCT)>Adamantinoma

4. Patchy calcification Chondrosarcoma>Chondroblastoma

5. Homogenous calcification Osteogenic tumors(Osteosarcoma)

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• Sickle cell Anemia-Salmonella -Diaphyseal

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• FADIR: Posterior dislocation/Arthritis

• Posterior dislocation > Anterior dislocation

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6-12 years age Non-toxic 0-5 years age Toxic (Fever,

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