Kaushik Banerjee Orthopaedics

Section -II
LONG CASES
Chapter 1
BASIC CLINICAL EXAMINATION OF HIP
Theories Discussed
• Thomas test
• Roll test
• Bryant's triangle
• Galleazi test / Allen's test
• Tredelenburg's sign • Telecopic test
• Gait • Craig's test
• Shoemaker's line • Chiene's test
• Kothari's angle • Patrick test / Fabere sign
• Nelaton's line • Psoas abscess
• Pelvic distraction test • Genslen's test
A. INSPECTION
Gait
Limp is an abnormal gait (see page 129).
Attitude / Deformity: Attitude is the position or posture of the body and limbs i.e. the typical
arrangement of the parts of the body, which is adopted by the patient for ease and comfort.
Deformity means distortion, disfigurement, flaw , malformation or mis-shape that affects the body
in general, or a part of it, producing an abnormal posture, which cannot be brought back to the
normal or anatomical position by the patient actively.
• With patient standing : Comment on - r---------------,-..,,....,..-:-:--=;;,-,=.-,
From front • Level of shoulder
• Anterior superior iliac
spine (ASIS) + iliac fossa + groin fold
• Patella
• Foot
From side • Lumbar lordosis
• Abnormal protrusion of ab-
domen / buttocks
• Supra + infratrochanteric depression Fig . 2 . 1. 1 : Noting temperature
From back • Scapula
• Centra_l furrow ~ve~ _spine (note scoliosis)
• Posterior superior 1l~ac spine (PSIS) (dimple of venus, above buttock)
* Gluteal folds + popllteal fossae + heels
N. B. : Always comment on scar, swelling, sinus, ulcer, pulsation, pigmentation and wasting.
• W~th pat~ent sitti~g : (sign!ficance in scoliosis only) . Always from the back (see page 254)·
• With patient supme : • Attitude _of the lower limbs and pelvis.
• Shortening of lower limb.
• With patient prone : For patients
· · who cannot stand , specially look for pres sure
sore I bed sore.
110
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BASIC CLINICAL EXAMINATION OF HIP 111
B. PALPATION
. On the lateral side of the hip Joint lies the neck femur and the trochanter on the med· 1
6
N. · · side the ace~abulurn and 1he pelvis , an? on the posterio~ side the fleshy gluteal muscl~:.
So the hip JOl~t 1s nearest .to. the skin surfa~e anteriorly, which corresponds to the
anterior hip point situated w1ttl1n the femoral triangle.
, Temperature : With the dorsum of the fin.gers ot you~ dominat hand note, compare and
rnenl on the temperature over the femoral triangle (see fig . 2.1.1) in the following order- f t
~f;e normal side, then the affected/pathological side and fin ally again the normal side. irs
A • Tenderness : Always look at the patient's face
when examining tenderness.
(A) Anterior hip point (Direct): It is situated 1.5 cm .
be low and lateral to the mid inguinal point i.e.,
mid point of the distance between the ASIS (anterior
superior iliac crest) , and the symphysis pubis, just
beside the femoral artery pulsation (see fig 2.1 .2-A).
Fig. 2.1.2A : Anterior hip point tederness (B) Bi-trochanteric compression test (Indirect) :
With the patient supine place both your hands
over both the trochanters so that the base of the
B hands (i .e., where the thenar and hypothenar emi-
nence meet) are in full contact with the center of
the trochanteric prominence. Now look at the face
of the patient and apply medialy directed force with
both your hands (see fig . 2.1.2-B). It is seen in con-
ditions like central dislocation; fracture of acetabu-
Fig. 2. 1.2s : Tenderness. Note : Exam- lum; femoral neck and trochanter; trochanteric bur-
iner is looking at the patient's face. sitis; TB hip; AVN ; Perthes disease etc.
PALPATION OF BONY LANDMARKS AROUND HIP
N.B. : The bony landmarks are the ASIS, tip of greater trochanter, symphysis pubis and the pubic
tubercle. To do this we first identify the pubic tubercle and the symphysis pubis. Then
following the inguinal ligament from the pubic tubercle we identify the ASIS, and finally
the greater trochanter.
(1) Have a female attendant for a female patient. Explain the procedure to the patient, (i.e., what
you will do and what the patient will be required to do) and ensure verbal consent.
- (2) Semiflex the hip and knee, and slightly abduct the
hip. Place one hand on the medial side of the knee
and request the patient to try and adduct the hip
against resistence, (which you apply with the hand
placed on the knee) . This makes the proximal at-
tachment of the adductor tendons visually very
prominent (see fig . 2.1.3-A).
(3) Now with your free hand's thumb/index finger , pal-
pate the prominent tendinous adductor attachment
up to the ischiopubic rami (i.~. , f~el th~ bone_). Then
move superiorly along the 1sch1opub1c ram1 to ~he
end of the bone (i.e. , the pubic crest, after which
the soft-tissues of abdomen begin.)
( ) Once you reach the medial e~d of th~ pubic ~rest,
4
move your palpating thumb/tndex finger shghtl~
medialy and lateraly to find the ~mall ?ony promi-
nence of the pubic tubercle. Confirm this by palpat-
ing the inguinal ligament which is a tough fibrous
structure attached to the pubic tubercle medially.
Fig. 2.1.3-B . Syrnphysis Pubis
112 HANDBOOK FOR OR1HOPAEDICS EXAMINATION
(5) Once you have located the pubic tubercle, move

your palpating finger medially until you find a
groove. This is the symphysis pubis. You can als?
slide the flat metallic end of a measuring tape , until
it "lodges" into the groove (see fig . 2.1.3-B).
(6) To identify the ASIS , start palpating the inguinal
ligament from the pubic tubercle, and proceed (at-
erally through the soft tissues, until you feel the first
bony point. This is the lateral attachment of the
inguinal ligament i.e., the ASIS (see fig. 2.1.3-C).
(7) Now continue bony palpation from the ASIS, mov-
ing laterally and superiorly along the iliac crest, till
you reach the highest point of the iliac crest.
(8) Then from the highest point of the iliac crest, start
palpating downwards/inferiorly, along the soft tis-
sues (mainly gluteus medius) until you again feel a
bony point. This should be the greater trochanter.
(9) T o confirm , grasp the distal thigh with one hand
while the other hand is placed on the greater tro- Fig. 2 .1.3-D : Greater Trochanter
chanter, and then gently abduct/adduct or rotate
(see fig. 2.1 .3-0 ) the thigh . The greater trochanter should move in the same direction as
the thigh is being moved.
(1O) Finally palpate and find the most superior part of the greater trochanter ( which is a prominenl
bony point) that represents the tip of greater trochanter.
Alternative method : With the patient supine request the patient to try and sit up. Palpate
the taut rectus abdominis muscles, below the umbilicus to its attachment to the pubic crest.
Then the method is same as starting from (4).
• Greater trochanter : Size , shape , surface , level , tenderness , transmitted movements [Use
wo rds like thickened, broadened , irregular, etc., to describe shape and su rface]
• Anterior superior iliac spine (ASIS) : Level, tenderness . - -- - - - -- - - --::.a
• Iliac crest : Position , defect (if previous bone graft was
taken), tenderness
• Femoral pulse : Site, volume (Remember : Vascular
sign of Narath - see page 150)
• Gluteal region : Abnormal swelling (may be dislocated
femoral head - see page 149) / wasting .
• Iliac fossa : Fullness (may be psoas abscess). Pg. 127
• Posterior superior iliac spine : Level , tenderness
• lschial tuberosity: Patient is in the lateral position with
the side to be examined facing up-wards, the hip and knee
are flexed to 90° so that the gluteal muscles moves up un-
covering the tuberosity. It is palpated as a bony hard promi-
nence mid way between the posterior border of the trochanter
and the lower sacrum and coccyx, at the level of the gluteal
fold (see fig. 2.1.4-A) . It is confirmed by asking the patient to
flex the knee against resistance , to make the hamstrings taut
and palpating it's attachment on to the tuberosity .
• Adductor muscles (for spasm) Roll test : Standing
on the affected side of the patient, gently roll the thigh with
both your hands medially and laterally and note the com- Fig. 2., .4-B : Roll test
- - -~ • - ' r , -~""'f
arative resistance I tig ht~ess to the ~ovement~ for both the lower limbs. If there is spasm the
~atient will complain of pain and you will feel resistance (see fig . 2.1.4-8) .
• Inguinal lymph nodes: Remember the anatomy .
• Sciatic point : It is palpated mid way between the ischial tuberosity and the posterior border
of the trochanter.
N.8. : • For cold abscess ----, Search in the femoral triangle, iliac fossa, gluteal region,
antero-medial part of the thigh , supra + infratrochanteric regions .
• For dislocation ----, Search for femoral head. Commonly in gluteal region for
posterior dislocation hip.
C. MOVEMENTS
THOMAS TEST FOR FIXED FLEXION DE,· ORMITY (FFD) OF HIP
N.B. : • FFD hip is the commonest hip deformity, firstly because in the flexed position, the joint
capsule becomes lax and thus attains the maximum intra articular volume. accommo-
dating the maximum amount of synovial fluid. The second reason is because the hip
flexor muscles are more powerful than the hip extensors.
• FFD is compensated / concealed with increased lumbar lordosis. (upto about 30°}
• If there is FFD there will be no extension, but further flexion is possible (free range) .
(1) Have a femal e attendant for a female patient. Explain the procedure to the patient, (i. e., what
(2) Ensure the examining table is hard and flat. There should not be any cushion/mattress
padding. If this pre-requisite is not feasible then inform the examiner before hand.
(3) The patient should lie supine with both the lower limbs aligned in the longitudinal axis of the
body. Expose the patient from below xiphisternum to the knee, keeping the genitals covered.
(4) Stand on the "affected" side of the hip. Then bend low to bring your eye-line, between the bed
and the lumbar lordosis, to confirm there is a gap between the lumbar region and the bed.
You should see light on the other side (see fig. 2.1.5-A) .
(S) lnsuniate the hand/palm that is towards the head of the patient, between the bed anc.J the
lumbar lordosis, so that the dorsum of the hand touches the bed (see fig . 2.1.5-B).
(S) Then, grasping the opposite "normal/non-pathological" lower limb just below the knee , (with
your hand that is facing the foot of the patient) gradually flex the hip (the knee automatically
flexes with this manoevure if it is not ankylosed), until the lower back of the patient touches
the fingers and palm of your other hand (see fig . 2.1.5-C) .
(?) Then bring out the hand which is in-between the bed and the lumbar region of the patient.
and very gently fl ex the "normal/non-pathological" hip a few deg~ees more, just enough to
completely obliterate the lumbar lordosis. Be careful and stop Just when the lower back
Fig. 2. 1.5-A : Lumbar Lordosis Fig. 2.1.5-B
Fig. 2.1.5-C
touches the table. (Further flexion will cause

anterior tilting oi the pelvis) .
(8) Now request the patient to hold the "normal/
non-pathological" lower limb just below the
knee only to "maintain " the position of flexed
hip and knee. No further force should be ex-
erted (see fig. 2.1.5-0 ).
(9) Now try to insuniate your palm/hand between
the lumbar region and the bed, which shoul? F s-E
be impossible. At this stage, the "patholog1- 19· 2· 1·
cal/affected" sides hip would be automatically flexed to a certain degree.
(10) Ensuring the affected side is not abducted/adducted , gently apply downward pressure over
the anterior aspect of the thigh of the "pathological/affected" side, so that any extra hip flexion
(which may be due to muscle spasm/pain/postural habit/inconvenience) is obliterated (see fig.
2. 1.5-E). The angle formed between the longitudinal axix of the thigh, and the bed, is the FFD
of the hip.
Difficulties faced in performing the Thomas Test
(1) In very fat or obese patients, lumbar lordosis cannot be accurately assessed.
(2) In bilateral FFD hip, the opposite sides hip flexi on (to obl iterate the lumbar lordosis), gives
fallacious results (see page 125 for alternative method) .
(3) In patients with ipsilateral knee stiffness/ankylosis (where the knee cannot be flexed), the te5I
is difficult to perform.
N.B. : • The patient may not cooperate because of aggravation of pain in an already painful hip.
• When flexiing the '.'non-pathological/normal" hip, if the thigh touches the abdomen, a~Y
extra force to obliterate the lumbar lordosis will cause anterior tilting of the pe!Vl5,
producing inaccurate measurements.
After the Thomas Test note the free

range of flexion is noted by grasping the
ASIS and the hemipelvis with your left
hand and gradually flexing the affected
side hip with your right hand until the
pelvis moves (fig. 2.1 .6). Comment on
the smoothness of the arc of movement
whether associated with pain and the end
point (hard/soft) .
11 5
TEST FOR FIXED AB DUCTION I ADDUCTION DEFORMITY

N. B. : • You w!II notice t~at both t~e ASI~ ~re no t in the same level when there is fixed
1
abduct1on/adduct1on deformity (pelvis 1s not 'square"). If the pelvis is already "square"
(i.e., both the AS IS are a t the same level) then there is no fixed abduction/adduction
deformity.
• When there is no fixed abduction/adduction deformity, to test degree of abduction,
fix the pelvis with one hand (in children ; with thumb and tip of third finger - Fig. 2.1.7A;
in adult with the ulnar border of the forearm - Fig. 2.1.78) and abduct the limb, till
there is movement of the pelvis which is felt by your other hand - Fig. 2.1.7A. Similarly
adduct the limb to note the degree of adduction - Fig. 2.1.78.
• If their is fixed abduction deformity then there will be no adduction but there may be
some further abduction (free range) . Similarly there will be no abduction in fixed
adduction deformity, but there may be some further adduction (free range).
• Fixed abduction/adduction deformity is compensated / concealed by tilting of the
pelvis, which places both the ASIS at different levels.
Fig. 2.1.7-8 : Adduction in adults

Fig. 2.1.7-A : Abduction in child
(3) Standing on the affected/pathological side of the patient, gra.sp !h~ lower leg just.above the
·
ankl e with . d the patient's foot. Now ma1nta1ning knee extension, gradu-
your hand that 1s towar s I I f th ASIS St
all . d diall keeping your eyes on the eve o e . op
Y move the limb laterally an me Y, . 1 . · ''squrare" To confirm hold a mea-
When b0 th th ASIS t the same level 1.e. the pe vis is · '
. e are a . -C) d note that it is perpendicular to the long
su~ing tape joining both the ASIS (see fig 2. 1.7 , an
axis of the body.
(4) When the pelvis is 'squared' the limb will

either be abducted (then it is a fixed abduc-
tion deformity), or adducted (then it is a fixed
adduction deformity, see fig. 2.1.7-0 ).
(5) The angle made between the long axis of
the limb, with an imaginary straight line
drawn from the ipsilateral ASIS , parallel to
the long axis of the body (see fig. 2 .1.7-0 )
is the fixed abduction/adduction deformity.
116 HANDBOOK FOR ORTHOPAEDICS EXAMINATION
Abduction in flexion of hip . h as possible) and the knees, so that the feet lie
(1) Semiflex both the hips (or flex the hip as muc
side by side on the bed .
Fixed
Abduction
deformity
(R) hip
Fig. 2.1.8 Note : Restricted abduction in flexion of lhe Rhip.

(2) Now request the patient to try and touch the
lateral side of the knees onto the bed (which
Pelvis 'squared' deformity revealed causes abduction). Note, compare and com-
ment (see fig . 2.1.8) on active abduction in
Fig. 2.1.7-D flexed hip.
ROTATION EXTERNAL / INTERNAL

N.B. : • There is no compensatory / concealing mechanism for fixed rotation deformities.
• If the hip is fixed in internal rotation , there will be no external rotation though some
further internal solution may be possible (free range) . Similarly, it there is fixed external
rotation deformity, no internal rotation is possible but further external rotation (free
range) may be possible.
Rotation with hip extended
(2) Stand on the foot end of the patient and grasp both the lower legs just above the ankles,
and lift the limbs about 4"-6" from the bed. This "locks" the knee in extension/ hyperexten·
sion , and ensures that the tibia and femur will rotate in unison as one piece.
(3) Now simultaneously internally rotate (see fig . 2.1.9-A) both the legs , keeping your eyes on b?1h
the patell_ae. Next simultaneously externally rotate the legs (see fig . 2 .1.9-B) . The angle which
the anterior surface of the patella makes with the bed (the horizontal) denotes the degree 01
rotation . Note, compare and comment. '
Fig. 2.1.9-A
Fig. 2. 1 9 -B
Rotation with hip flexed

( ) Have a female attendant for a female patient. Explain th .
1 you will do and what the patient wil l be required to do)e prodcedure to the patient, (i. e., what
. · · . . an ensure verbal con t
(Z) Standing on the side which 1s being tested grasp the lower le nd . sen ·
to 90° (or as much as possible) . g a flex both the hips and knees
(3) Then pressing down on the knee move the ankles awa f . . .
asses internal rotation inflexion. Note, compare and co~~~~t.midllne (see fig 2.1.10-A) to
Fig. 2 .1.10-A Fig. 2.1 . 10-B
(4) Next, try to touch both the soles of the feet together (see fig. 2.1.10-B) to asses external
rotation in flexion . Note, compare and comment.
Rotation in Prone Position :
(1) Request the patient to be prone, and then flex both the knees to 90°.
(2) Then request the patient to move both the feet maximally away from each other (see fig
2.1.11-A). Note, compare and comment on internal rotation.
(3) Finally request the patient to cross both the legs across each other (see fig. 2.1.11-B).
Note, compare and comment on external rotation .
Active Passive Pain

Fixed Deformity
...____
L!U w L!!J OJ L!!J w ~ L!J

• FLEXION
•
...____ EXTENSION
• ABDUCTION
(1) In extension
(2) In flexion
~ADDUCTION
• EXTERNAL ROTN
( 1) Knee extended
(2) Knee flexed
(3) Prone
• INTERNAL ROTN
(i) Knee extended
(2) Knee flexed
(3) Prone ..
• Not f motion 1n fixed deform1t1es
e any further free range O t · found mainly in neurological
NB . nge of movemen 1s
· · • Differences in active and passive ra
or muscular problems.
11 B HANDBOOK FOR ORTHOPAEDIC S EXAMINA flON
Fig. 2.1.11 -A Fig. 2.1.11 -B
D.MEASUREMENT
• Linear :
A. Apparent-? (R) and (L)
B. True -? (R) and (L)
• Circumferential : Wasting
Measurement of Apparent length
N.B. • Treatment option - Heel raise on the affected side.
• Apparent shortening measurement gives an idea
about the amount of "compensation" the body has
done to "conceal" the hip deformity or scoliosis, in
order to keep both feet on ground, and both lower
limbs parallel.
you will do and what the patient will be required to do) and ensure verbal consent. .
(2) Patient lies supine with both lower limbs parallel to each other and aligned in the long axis
of the body.
(3) Palpate and mark the suprasternal notch . This is done by palpating the subcutaneous
clavicle , from the acromio -clavicular joint , with your thumb and gradually sliding the
thumb medially (see fig. 2.1.12-A) to the promin ence of the sterno -c lavicul ar joint,
and then further medially toward s th e centre of manubrium-sterni , t ill the smoo th
concave bony depression of the suprasternal notch is palpated . (some recommend th e
Xiphi Sternum but it is mobile and difficult to palpate in obese patients) . . .
(4) Palpate and mark the tip of the medial maleoli of both th e ankles. This is done by sliding
the thumb along the subcutaneous antero-medial surface of th e distal tibia, till the sharp
end of the maleoli is palpated. To confirm , press the tip of medial maleolus with your
thumb, .an? then .dorsiflex a~d plantarflex the ankle to note that th e bony point under
thumb 1s _im.mob.1le. Now . slide the metal lic flat-end of a measuring tape from the h b.
Y:~~
upwards till 1t strikes the first bony point (see fig . 2.1.12-B) whi ch is held under your thum
to exactly locate the tip of the medial maleolus.
) F'
(5 inally place one end of the measuring tape at the suprasternal notch and requ est thep
patient .to firmly hold it. Holding the other end of th e measuring tape, place it over th et~e
of medial maleolus and note the length first of one limb (see fig . 2. 1.1 2-C) and then
other limb. Compare the lengths to get th e apparent shortening.
. . hO~
N.B. • Instead of requesting the patient to hold one end of the measuring tape you ma~ . I'll
both the ends of the tape with your both hands provided your arm-span is of sufficie
length .
Fig. 2.1. 12-C
Fig. 2.1. 12-8
Measurement of True length in Supine Position
N.B. • Treatment option - Surgical correction to gain length on the affected side.
• St~ictly speaking, the true length of the lower limb should be measured from the topmost
point .o f the. head ~f femur, to the most inferior point of the calcaneum. This is clinically/
technically 1mposs1ble. Therefore the nearmost subcutaneous bony prominence that can
be easily palpated is utilized i.e. ASIS instead of the femoral head, and the tip of medial
maleolus instead of the calcaneum.
• The distance from the ASIS to the tip of medial maleolus always changes with abduction
or adduction of the hip. Therefore it is necessary to "square" the pelvis first and also
to measure both the limbs in identical position.
( ) The patient lies supine on the bed. Standing on the attected side first "square" the pelvis by
2 gently moving the affected lower limb, so as to place it in the position of the fixed abduction
(see Fig. 2. 1.13-A) /adduction deformity (see Fig. 2.1.13-B) as noted previously. This brings
both the ASIS to the same level.

( ) Palpate and mark both the ASIS and the tips of both the medial maleoli.
3
( ) Now place the metallic flat end of a measuring /ape on /he ASIS of the affected side
4 and request the patient to hold it fi rmly in place. Holding the other end of the measuring
tape, place it over the tip of medial maleo/us and not_e the true length of the affected
side (see Fig. _1. .c) tor fixed abduction deformity, and (see Fig. 2.1.13-D) tor
2 13
adducti
(S) Now on deformity.
move the non-affected lower limb so as to place it exactly in the same position of
abduction (see Fig . . . . E) / adduction (see Fig. 2. 1.13-F), as /he affected side had
2 1 13
Fig. 2. 1. 13-8
Fig. 2.1.13-A
Fig. 2. 1. 13-IJ
Fig. 2.1 13-C
been placed . Place the metallic flat end of the measuring tape on lhe AS IS of the non.
affected lower limb and request the patient to hold it firmly in place . Holding the other end
ot the measuring tape, place it over the tip of medial mal eolus and note the true length ol
the non-affected side .
Fig. 2.1.13-E Fig. 2.1.13-F
• Measurement of Limb Length Discrepancy (LLD) in Standing Position (see page 126)
GALLEAZI TEST OR ALLEN'S TEST
N.B. : Once you have noticed true shortening of a lower limb, the next job is to find out whether the
shortening is in the thigh (femoral segment), or in the leg (tibial segment) . This can be d~ne
by the Galleazi test, and also by true measurements (in cm) of the femoral segment _(,. e.
from ASIS to the medial joint line of the knee , when the pelvis is square) and the tibial
segment (i.e. from the medial joint line of the knee to the tip of the medial meleolus).
(2) Semiflex both the hips and knees of both
sides in such a way, that both the feet are
placed side by side, identically, in the
same plane. Confirm this by placing the
ulnar border of your hand which is towards
the feet of the patient, ensuring both heels
are in the same straight line (see fig .
2.1.14-A) .
(3) Now bend low to bring your eyeline hori-
zontally to the level of the knees. and note
the vertical-height-discrepancy of both the
Fig. 2.1.14-A
11111-----
BASIC CLIN ICAL EXAMINATION OF HIP 121
Fig. 2.1.14-B ; Note : Right Femoral shortening Fig . 2.1.14-C ; Note : Right Tibial shortening
knees , which when present, signifies shortening. In femoral shortening, the knee is found to
be more proximal and in tibial shortening the knee is found to be a little distal to the opposite
knee (see fig. 2.1.14-B & 2.1.14-C)
DRAWING BRYANT'S TRIANGLE

N.B. • When you have already confirmed true shortening, that is due to the femoral segment
(thigh) , the next job is to find out whether this shortening is in the supratrochanteric
segment (e.g. fracture neck femur, hip dislocation etc.) or in the infratrochanteric segment
(e.g. malunited fracture shaft femur, segmental bone los due to osteomyelities etc).
Bryant's triangle is an effective way to judge supratrochanteric shortening. There are
also other tests to assess supratrochanteric shortening e.g. Shoemaker's line, Nelaton's
line, Chiene's test etc. (see page 127).
• Bryant's triangle is ineffective in bilateral hip pathology and when the ASIS has been
removed tor bone graft.
• Digital Bryant's triangle is a quick method to assess supratrochanteric shortening. This
is done by placing your thumb on the ASIS, the middle finger (3rd) on the tip of greater
trochanter, and the index finger vertically below the ASIS in the horizontal plane of the
tip of the greater trochanter. Remember this is to be done simultaneously for both the
sides, for comparison.
(2) First "square" the pelvis by gently abducting (see fig . 2.1.13-A) , or adducting (see fig.
2.1.13-B) , the affected hip, so as to bring both the ASI S at the same level.
(3) Move the non-affected lower limb so as to place it exactly in the same position as the affected
lower limb (see fig. 2. 1.13-E and fig . 2. 1.13-F).
(4) Now palpate and mark both the ASIS and the tips of both the greater trochanter.
(S) Then draw triangles on both sides in the following way :
(a) Line A : Join the ASIS and the tip of
greater trochanter on each side.
(b) Line B : Draw a vertical line from the
ASIS to the bed, making it perpendicular
to the horizontal.
(c) Line C : Draw a line which is perpendicular
to line B which joins the tip of greater tro-
Fig . 2.1.15 chanter to line B of the same side.
. lly measure and compare the lengths of all 3 sides of the triangle drawn on both th .
F ina e sides
(see fig. 2.1.15).
Interpretation : (i) Line c (base of the triangle) shortening actually quantifies the supratrocha t .
shortening. Causes may be coxa vara, malunited trochanteric fracture, posterior dislocn ~nc
. th . . f ation
of hip, destruction of the femoral head as sequ Iae o f sept 1c ar nt1s, racture neck of fem
(ii) Line B shortening indicates internal rotation or anterior tilting of the greater trochanter. Cau ur.
may be posterior dislocation hip, central dislocation hip, etc. Lengthe~ing of line B indica~::
external rotation of greater trochanter which may be due to trochantenc fracture, fixed flexion
deformity of hip etc.
(iii) Line A (hypotenuse of the triangle) shortening may be due to central dislocation hip, neglected
fracture neck femur with absorption of the neck, destruction of the femoral head as a sequelae
to septic arthritis etc.
N.B. : Reversed Bryant's triangle : when the upward migration of the tip of greater tro-
chanter is so much , so that it is palpated superior to the line B , t hen reversed Bryant's
triangle is drawn . Then , the total supratrochanteric shortening will be line C of the
normal side + line C of the affected side.
• CIRCUMFERENCIAL MEASUREMENT
N.B. : This test is very important because it notes. confirms and measures wasting of the thigh
muscles. This is the only hip examination where the affected side should always be first
and the opposide side is examined later for comparison.
(1) The patient lies supine on the bed with both lower limbs parallel and aligned in the longitudinal
axis. Visually note the level of the thigh where you note gross wasting , in comparison to the
other thigh. Mark the level on the affected side with a skin pencil.
(2) Palpate and mark the medial joint line of both the k nees. This is done by semi flexiing
the knee and then sliding your thumb , or the fl at m etallic end of a measuring tape from
below upwards, along the medi al as pect of proxim al ti bia, until the tape-end "lodges" into
a groove (see fig . 2 .1.16-A) . Confirm by gently fl exi ng and extending the knee, to note
that there is no movement of th e fl at metallic tape e nd.
(3) Now measure the length from the medi al joint line to the level marked in step 2 on th0
affected side. Then measure the same distance from the medial joint line of knee. on th0
non -affected side, and mark the level on the thigh w ith a skin pencil.
nd
(4) Finally, measure the circumference of th e thigh at the marked level, of both the thighs a
note the discrepancy (see fig. 2.1.16-B) i.e ., wasting at that level. Express yourself as follows
: On comparison, there is wasting of .. .. .. ..... cm on (R/L) side of thigh muscles, ........ cm
above the medial joint line of knee.
Fig. 2. 1. 16-A Fig. 2 1 16-B
123
E. SPECIAL TESTS
OELENBURG 'S SIGN : This sign was original ly described to detect congenital dislo f
TRE ( ow called developmental dysplasia hip) in 1895. ca ion
of hip n . . .
NB. • For effective de.monstr~t1on .1n front o'. the exam1~er, repeatedly performing the test
· before the examiner arrives, 1s a good tip , because 1t weakens the abductor mechanism
of the hip.
• This tests the abductor mechanism of hip, and thus the stability of the hip (because
without effective functioning of the abductors, the hip is inherently unstable).
• Biomechanics of the principle of the sign : When a person stands on 2 legs, the body
weight is distributed equally on both the lower limbs. But when the person chooses to
stand/bear weight only on one leg, automatically the brain tries to align the whole body
weight of the trunk (i.e ., pelvis, abdomen , chest, head and neck) over the weight bearing
leg. This is achieved by strong muscle contraction of the abduc-
tors of that hip (mainly gluteus medius), which contracting from
below (i .e. the infe rior attachment at the lateral aspect of the 1
greater trochanter), pulls the ipsilateral iliac crest down towards
that side, causing tilting of pelvis (see fig. 2.1 .17-A). The spinal
column compensates by bending on the opposite direction to
maintain the erect posture. The fulcrum of this movement is the
centre of the hip joint, and the lever arm is mainly the neck of ]
the femur with contributions from the head and trochanteric
region. When any component of this osseo-muscular hip-abduc-
tion system fails , the test becomes positive. Fig. .1 . 1-A
2 1
• Pre-requisite : Patient should be able to stand unsupported . . .
on one leg for 30 sec. There should be no coronal plane deformity (fixed abduction /
adduction deformity) . The opposite hip, ipsilateral knee and ankle should be normal.
{1 ) Have a female attendant for a female patient. Explain the procedure to the patient, (i.e., what
you will do and what the patient will be required to do) and ensure verbal consen~ b h' d
(2) Request the patient to stand on the floor or hard bed (without mattress), and you stan e in
(3) the patient. t d first on

I/
the norma non-a ec
ff ted side on one leg. Note and
Now request the patient to s an - . 'd 's hemipelvis is raised, as evident from
th
inform the examiner that the affected pa ,? 1 1
~tca sis~ of that side's gluteal fold , scapula and
the elevated position of "dimple of venus ' 1iac ere
the shoulder (see fig. 2.1.17-B).
Fig. 2.1.17-C
(4) Then reques t the patient to ,ta n J (J' ' • I j , 11t 1d1 1, h<; "r, <';IH~r;lo91r,8.lfaffr.,r,.tAcJ" ',JrJ,~ ,,r.
and inform th e examiner that th(, normr.il/ n ,ri ci ff c...t~d '>1rfo ', t 'Hrnpr.:I VI'~ h&, n<; r. ·
elevated , as evident from the visual e 11rJ6 nr,<.: rJf thrJ lo fLJI of th " dimpl~ vf 1~nu~ ', ~~,
crest gluteal folds , sca pula and houlde, r (s.&~ fig . 2.1.17 GJ . Thi'" r'3f,ffJ'~'3n ~ a p(.,-, ;;
Trendelenburg 's sign . •
Causes of Positive Trendelenburg 's sign
(1) Fulcrum failure : Developmental dysplasia of hip, d1 loca ion of hip, de rue,1ion of the f~r , ~
head as a sequlae to septic arthritis.
(2) Le ver arm failure : Fracture neck of femur, trochan bric fra" ure, co..<a 'Iara (le 1er arrn , , .
ened), Perthes disease .
(3) Abductor muscle(s) failure : Muscle weakness as in poliornyelities, mu cular d; strcp ·~,
motor neurone disease .
(4) Painful hip where any movement is undesirable : Rheumatoid arthritis, ankylosing spo jl1 ~
affecting the hip .
Criticism of Tendlenburg 's sign

(1) Effective quadratus lumborum contraction , worki ng from below on the ipsilatera:I side and frc,
above in the contralateral side, may tilt the pelvis, giving a positive Trendelenburg's test.
(2) Deform ities of lowe r limbs like genu varum , or those due to malunited frac ures of tibia or
femur, which shifts the mechanical axis medially, may also indicate a talse-pos1 e
Trendeleubu rg's sign.
(3) Cond ition s causing painful sacro-il iac joints, may produce a false positive Trendelenburg's
sign (e.g. ankylosing spondylitis)
(4) In very obese patients it may be difficult to appreciate.
TELESCOPIC TEST : Th is is a test for asse ss ing the stab ility of hip .
(1) Have a female attendant for a female patient. Explain th e procedure to the pati ent, (i.e., wha
(2) Stand on the affected/pathological side of the patient. When (R) hip is path ological, place
your (L) hand over the (A) iliac region of the patien t, so that your (L) thumb and thenar
eminence is pressing over the ASIS (which stabil izes the pelv is), and the fingertips are
touching the tip of the greater trochanter .
(3) Now flex the "affected/pathological" [i .e.(R)] hip and knee to 90° (or as close to 90") a~
possible) , and adduct the hip by holding the knee with your (A) hand (see fig. 2.UB·\ ·en
it is impossible to grasp the knee with your hand , then grip the lower thigh and knee betw
your (R) chest wall and the (A) shoulder into your armpit.
Fig. 2.1.18-A Fig. 2.1. 18-B
Now apply pressur~ along the longitudinal ~xis of the fem~r with your (R). hand (or armpit),
50 that you alternatively push- nd-pull (see fig. 2.1.18-B): S1multane_
ously with the tips of your
(L) hand's fin~ers, note the amount of movemenVexcurs1on of the tip of the trochanter of the
pathological side.
Then compare the amount of mo~em~nVexcursion of the opposite side , following the same
(S) rocedure, standing on the opposite side. If the movement on the "pathological/affected" side
ismore than the normal side, the test is said to be positive.
Difficulties faced
* In obese patients where palpation of the tip of the greater trochanter is difficult, and also
grasping the knee .
• In painful hip any movement is resisted by the patient. Pain is a relative contraindication .
MISCELLANEOUS TESTS
• Active SLR (Straight leg raising) test
• Ortolani test / Barlow test ~ When applicable i.e. , in infant with congenital dislocation of
hip, also called Developmental Dysplasia of Hip (DOH) [see page 274] .
Comment on :
A. Joint above/ Joint below (Knee)
N.B. • Sacro-iliac joint is truly the joint above. Examine tenderness.

• For other tests of the SI joint see page 128.
B. Per-rectal examination.
C. Distal neurovascular status.
D. Other systems.
Finally the
1. Differential diagnosis
2. Provisional diagnosis ~ This is a case of ......... ... .... (then mention) . .
• Duration , site , cause (with the stage of presentation), o?vio.u~ and important comp~1-
cation (s) , treatment done ; receiving , changes in activities of daily living (AOL) / changes 1n
routine life, patient's age , sex .
Alternative to the Thomas test

N.B. : lt i a must for bilateral hip . f1xe
. d fl ex1on
. deformities and ipsilateral fixed knee deformities .
( 1) Have a female attendant for a female patient.

Explain the procedure to the patient, _(i.e.,
what you will do and what the patient will be
required to do) and en. ure verbal con ent.
2
( ) R que. t the patient to be prone and tide
down to the edO'e of the bed. so that the lower
li1nb. dangle d;wn fre , but the pelvis a nd th e
body remain .. upported on the bed.
(3) p acing
· .
the patient ·ct wa y · , place the el-.
I
f your uppet
bow and proximal forearm O d - the Fig. 2.1 .19-8
01
I.tmb (th at pornL
. towar. ds the hea
126 HANDBOOK FOR ORTHOP A[O ICS E-XAMINA l ION
pati ent) 10 fi rml y fi x th e pel vi s to the bed (by pr ss ing down , so that the lumbar lordo is i
bl iterated vi suall y) . Now wi th your other h, nd and forearm . upport both the knees of thepatien:
from below (sec fi g. 2 . 1. 19 -B ).
4 ) hen, gentl y . tart to extend both the hips unti l there i s resi stence, and there i a hint of reappearence
of the lumbar lordosi s.
(5) t and inform th xaminer that th e angle made between th e hori zontal as evident from y
· I b k ·I · our
forearm which i s facing the head of the pati ent (w h1 c 1 must e ept 1onzontal with the elbo
fi xin g the pel vi s) and the hangin g " path ological/affected" sides thi gh (supported by your oih:
hand) i s the FFD of the hip( ) .
Measurement of Limb Length Discrepancy (LLD) in Standing Position
N.B. • This method is believed to be more accurate for measuring LLD because it is done in the weight
bearin g po. ition. However, it can only be done in patients who can stand without much
discomfort, despite hip pathology.
• Pre-requisite : Wooden blocks to support the foot, each having height/width in increments
of 0 .5 cm (e.g. I cm, 1.5 cm, 2.0 cm, 2 .5 cm, 3.0 cm, 3 .5 cm ... etc.)
• lf the wooden block has to be placed under the " normal / non-affected" side, then it means
the affected ide i lengthened.
( l) Request the patient to tand in front of you. Palpate and note

the level of both the ASlS . lf there i any discrepancy in
the level of the ASl S, then only can you proceed with the
rest of the tep, .
(2) Now place a wooden block of appropriate hei ght/width
below the foot of the ide, where the ASIS is below the
opposite side. Confirm that both the ASfS are in the same
hori zontal plane by placing a mea uring tape j oining both
•
the ASiS and noting th at it i absolutely horizontal. l f re-
quired remove the block and insert another uitable block
until both ASIS are at the same level. The height/width of
the fi nal block placed is the LLD ( ee fi g. 2 . l.20)
Gauvain's Sign :
ll Fig . 2.1.20
When the extended hip is rotated there is spasmodic contraction of muscles around the hip joint
and abdominal muscles. This indicates active disease. May be found in TB Hip.
Other Tests for supratrochanteric shortening

1
For bi lateral supratroc?an~eric shortening Bryant' Triangle has no value. Here N elaton'. line
better th an Shoemaker s !me because umbilicu is a inconstant oft ti sue , tru cture.
(l) Shoemaker's L.ine : Line A of both the
sides Bryant' tri angle, when extended over the
abdomen, u ually cro es above the umbilicu
or at the umbilicus, in the central axi (the lin;
joining the uprastern al notch and the symphysi
pubis). ln case there is upward mi gration of the
greater trochanter, the lines will cro s below the
umbilicu. and away from the central axi , to-
ward, the non-affected ide. Also note that when
there i s bil ateral supratrochant ri c hortening,
both the line. wi ll cro below the umbilicu
(sec fi g. 2. 1.2 1-A). Fig. 2 .1.2 1-A
- - - - - - ~ BASIC CLINICAL EXAMINATION OF HI 127
. , . Te t: \ 1 1th lhL' p, ticnt l ing s upine, dra a line. joinin ) borh 1h · A.S IS. Th . dr,i w
( 2) Ctuen . ·. I I N 11
ther line jorning the tip '- or both t 1c reale r Lr c 1a nt cr. ornw ll y. b th rh . lin . ., i; hot1 l h.
I
ano 110 ,· vcr, if one icle<, greater troc ha nt r has rni grn t d up wa rd s. lh •11th . Jin ·s will ht
Parallel. - · · in
· 1-1· · · b"I I I· · ·
'
convcrge nton that . ide . lh1s t st ,s . . . . .ec t1 e 111 1 at· n.1 11p. a frec 11 11 • (i-.c• fi g . 2 . I . 2 1- BJ .
1 elaton' Line : m1ally, any line Jommg the Sl and th lip of ischial tub rosity. wh .11 th , hip
~-- ~cxcd to 90", touch_e. /graze. the tip of th gre_ater lr~chan~er. _Wh ·n tl~cre is upw_arcl migralion of th , gr ·r,t •r
trochant r. then the llp of greater tro~hanter of_that 1de w ill _'1 e. up nor Lo th lrnc. R m ·mbcr, Nclation \
I.UlC ·I. 011 1Jv drawn on the affected .1de ( ee fig. .1.2 l-C) 1.e. no n d ror bilat r,1 1.
-~ -9. _,-- - - -
-Pc''
I
Fig. 2.1.21-8
~ Fig. 2.1.21 -C
Craig's Test (Femoral anteversion test)

The patient lie prone with the knee fl exed to 90°. The examiner rotate the hip medially and laterally by
holding the leg with one hand while palpating the trochanter with the other hand (fig. 2. l .22 A), until the
outward mo t point in the lateral aspect of the trochanter is most prominent (the femora l neck is parallel to
the table.) The angle made with the ve11ical and the long axis of the tibia is the femoral an tever ion (see fig.
2.1.22-B). ormally it i about 10°-15°.
Fig. 2.1.22-A Fig. 2.1.22-B
Test for psoas abscess ..

A · . · f h. h fever where you note 1ltac fossa fullness ,
. Patient presenting with groin pam and h, story O ig . 'thritis of hip or psoas abscess (may
ra1sect J 1 . f h· ay be due to septic ar ,
b oca temperature and FFD o · 1P, m t t the rotation in flexion of the hip (see
1
ea compli cation of cari es spine - see page 158)- Gent y .es arthritis and if there i nearly normal
1
rPage . 117) . If rotation is re tricted/pain
· f u I, it is. due
. to sepbic USG •·
Otation the cause is psoas abscess. Confirmatton is done Y ·
128 HANDBOOK fOR ORTHOPAEIJIC~ l Ar..t,N/, 1
,_,_0_N_ ~ ~ ~ - - ~ - -
• Koth ari's Angle

This 1s useful in very painful hip. or where the s~
patient 1s uncooperative to allow "squaring" of the
pelvis With both the lower ltmbs para(lel ~~d aligned
'-- -....... ~-- ....
. .
with the long axis or the body, draw a line 101nmg both .. '
·.''
the ASIS (line A) and another joining the suprasternal
f- A
notch and the symphysis pubis, which denotes the
' .. ,- ..
..
·-,::-....-....
' "' . .'___ --"'=",._----
·--,
, .. ' j
..--,. .'
mid-line (line 8). Lastly drop perpendiculars joining ,. <... _-::,, ,
both the ASlS to the midlme line-C (see fig . 2.1.23) .
If the "affected/pathological" side's ASlS is at a lower
level, then 11 is fixed abduction deformity, and if it is
at a higher level, then it is fixed adduction deformity. Fig . 2.1.23
Tests for Sacroiliac joint
(1) Direct Tenderness : Elicited by pressing on the dimples just medial to the PSIS. Only test which does
not involve a pathological ipsilateral hip, which may give false positive result.
(2) Patrick test / Fabere sign : It is an important test to distinguish between sacroiliac (SI) joint disorders
and hip pathologies. With the patient supine request the patient to flex the knee of the "affected/pathologicar
side, and place the lower leg over the thigh of the "normal" side (see fig. 2.1.24-A). Standing on the "affected'
side of the patient place one hand on the opposite ASIS and iliac crest, and the opposite hand on the medial
aspect of the flexed knee (see fig. 2.1.24-8), and press downwards forcefully with both your hands. Repeat
the procedure for the opposite limb standing on the opposite side. Pain and I or restriction of downward motion
of the flexed knee suggests SI pathology.
Fig. 2.1.24-A Fig. 2.1.24-B

(3) Pelvic distraction test : Patient is supine. Place both your hands on
patients both ASIS with iliac crests and apply force so as to distract the ASIS ,
as trying to open a book. The patient will complain of pain in lower back
region when there is a sacro iliac pathology. (fig 2.1.25-A)
(4) Genslen's test : Patient lies supine with affected sides buttock over-
hanging by the side of the couch. Now maximally flex the hip and knee of
the normal side with one hand and with your other hand apply a extension force
on the affected sides thigh. The patient will complain of pain in sacrollllac
pathology. (fig.2.1 .25-B)
(5) Gillie's test : With patient
prone, fix/stabilize the normal
side pelvis and hyperextend
th e affected side's hip by lift-
ing up the leg by holding the
leg just above the ankle (fig.
2.7.5; page 154). This pro-
duces pain on the affected
side SI joint. It is similar to the
femoral nerve stretch test.
129
, Barlow ,s (provocative) test and Ort olann's test : See page 275-276.
GAIT
Gai t i the pnrticular manner or tyle of walking incl uding rhythm, cadence and speed. It involve a
cyclic lo. and r g~ining of balanc~ ~y a hift of the li~e of grav ity in relati on to the centre of
aravity. perfect gait cycle ensure minimal energy expenditure during walking.
e
Gait Cycle : ln the Sta,ice p hase (60%) the foot is in contact with ground and undergoes 5 movements.
( I) In itialontact (Heel trike), (2) Loading Re ponse (Foot Flat), (3) Mid Stance, (4) Terminal Stance
(5) Toe Off (~re Swing) . ln _
Swing phase (40 '.7'0) the foot is not in contact with ground and has 3 parts'.
(A) Initial Swrng (Accelerat1on), (B ) Mtd Swrng, (C) Termina l Swing (Deceleration) (see fi g. 2.l.26).
(B) (C)
Fig. 2.1.26
• Antalgic gait : Reduced stance phase, because beari ng weight causes pain.
• Short-limbed gait : Affected shoulder moves conspicuously down and up and the affected
ide hemipelvis sags down when bearing weight. Not seen if shortening is< 2 cm. There may
be ip ilatera] equ inu /contralateral knee flexion during stance phase. If hortening i due to
infratrochante1ic cause then opposite side hemipelvis will rise in stance pha e.
• Trendelenburg gait : Seen when Trendelenburg's test is positive. The shoulder swings and
lurches downward on the affected side, and the opposite side hemipelvi sags down when
bearing weight.
• Cadence : It is defined as the number of steps per unit time. In normal gait, cad nee i about 100-
11 5 steps per minute. Cadence of a person is ubject to vari~u factor.
• Comfortable Walking Speed: It i. a characteri tic speed at which there I lea t n rgy con umption
per unit distance. It is about 80 metre per minute in a normal gait. .
• Step Length: It is defi ned as the di stance between corresponding successive point - of h el conta t
Of the Opposite feet. In a normal gait, the ri ght tep length i. equal st~~eft ~~ni.,_ lo~~r h:l C nta I of
• Stride Length : It is defined as the di stance between any two succe. s~ P '
th · . h st 'de length is double the step I ngth.
e same foot. In a normal gait, t e n ·ct 'd ct· ·tanc betwt: , 11 the line of step or
• Walking Base or Stride Width : It is defined as the SJ e-to-si e is '
the two feet.
N.B. •
Centre of gravity of the body lies I cm an 1erior to S2 vertebra.
. ht)
• . . . , b ti W/6 (W = body w tg .
Weight of a si ngle lower hmb ts a m . h hip J'oint is W/3 ( :s body , ig.ht)
. force acting on eac
In double legged stance joint reaction eight b aring hip is - ·' W .
• In single legged stance Jomt
. . reac tion force on t I1e w
Chap ter 2
PERTHES DISEASE
Theories Discussed
• Pathology of Perthes disease
• Blood supply of the fem oral head
• Manageme nt of Perthes disease
• Clinical featu res of Perthes disease
• Classification of Perthes disease
• Head-at-Risk signs
• Sagging rope sign
• Sectoral sign
• Gearstick sign • Arthrodiatasis
• Also known as Legg-Calve-Perthes disease, Pseudo-coxalgia, O steochondritis deformans and
Coxa-juveniles. Legg, Calve and Perthes had described this disease independently in 1910.
• Age group : Commonly 4 to 9 years (may be 2 to 18 years) .
• Male : Female = 4 : 1 (In girls, age group is slightly lower) .
• Commonly height/weight/skeletal maturity of the patient is retarded when compared to a nor-
mal child and the patient often has small feet. Bilateral in 15% cases .
• Occasionally associated with hypospadias , undescended testis , hernia, pyloric steno-
sis, congenital heart/kidney lesions.
• Basically it is an avascular necrosis of
the femoral head (i .e ., capital femoral
Capsule
epiphyses) in a child .
.. -- 't
' , , .. (c) ...
, '
', ,,
Aetiology
Precise aetiology is controversial and debal·
'\ able and probably unknown. Hypofibrinolysisand
antithrombotic factor deficiency have been de·
scribed as contributory. (Controversial)
• Blood supply of the femoral head :
• Up to around 4 years , blood supply al
Extracapsular arterial the femoral head is from : (Fig. 2.2.1)
- anastomotic ring (a) Metaphyseal.
(b) Ligamentum teres (minimal).
Fig. 2.2.1 : Blood supply of femoral head. (c) Retinacular vessels ~
~ Mainly lateral epiphyseal vessels.
~ Branch of medial circumflex
femoral artery . . •
0111
• By 4 years , metaphyseal supply ,s ffica·
pletely blocked, mainly due to oss
tion of the physeal cartilage. . enturn
• By 7 years, supply from the hgarn
teres femoris develops fully. fernoral
• So between 4 years to 7 years, the
d nt on
head is complete ly depen e . acula'
Fig. 2.2.2 : Perthes disease. Note - Increased joint retinacular ve ssel s supply · Reli~psu/af
space, increased density of femoral head, flattening vessels are however at risk of c
of femoral head, broadened femoral neck. tamponade from -
130
PERTHES DISEASE 131
(a) Synovitis ~ .from viral/ ~ther mild subacute infections.

(b) Haemarthros1s ~ from intracapsular
trauma/fracture and haemophiliacs.
(c) septic arthritis of hip joint.
• Medical causes of ischaemia of the femo-
ral head , due to blockage of supplying ves-
sels :
(a) Gaucher's disease .
(b) Rickettsial infection .
(c) Caisson's disease.
(d) Cretinism .
• 2 or more repeated ischaemic incidents .
separated by a short span f t· . ' Fig . 2 .2.3 : Perthes diseases Caterall stage 111.
. 0 1me, 1.e., Note-Flattenedhead.
about 4 to 6 weeks , increase the risk of Perthes disease .
Pathology
May be divided into 3 stages.
1. l~chaemia and bo_ne death : Due to blocked blood supply, there is ischaemia. But,
since ar_t1cular ca~1la~e gets. nutrition from synovial fluid, it remains viable. Thus it ap-
pears thicker - which 1s seen 1n X-ray as larger joint space of hip (Fig. 2.2.2).
2. Revascularization, repair (reossification) : This leads to -
(a) Appositional new bone deposition on the avascular trabeculae .
(b) Calcification over necrosed marrow. This is visualized in X-rays as increased den-
sity of the femoral head or epiphyses.
N.B. • Fracture just below the cartilaginous epiphysis i.e. , subchondral fracture (fatigue/
stress fracture) , which in X-rays is pathognomic of avascular necrosis, is seen in
this stage because of accelerated dead bone resorption . Cystic changes of the
metaphyses is also seen due to sprouting metaphyseal vessels. Some dead trabe-
culae are resorbed and replaced by fibrous tissue which in X-rays show as fragmen-
tation .
3. Distortion and remodelling : The ultimate fate , and thu.s t~e shape/positi?n of the
femoral head, depends on the speed of repair/ revas~ulanzat,on. Slow repa1r-pr~ce~s
leads to loss of femoral head shape, which in turn, with further growth of the child, 1s
likely to result in distorted growth of the head and neck of femur. .
(a) Head : May be oval , mushroom shaped, laterally displaced , coxa magna (bigger)
coxa breva (smaller) or completely flattened .
(b) Neck : Short and broad .
(c) Neck-shaft angle : May be coxa va~~ - oral h seal growth arrest.
~~ . i:rochanteric overgrowth du~ to c~p,tial fem f1 d. pgi classification, treatment options
linical features , investigation includi.ng X-ray ~ in ~s in a long case .)
Wha ~nd Prognosi s are discussed in question-answer orm ,
15
Myt Your diagnosis ? th disease of R/L hip, with restricted
Provis·1 · · case of Per es
abduction on~1 diagnosis is that this 1s a . in a ........... year old boy/girl.
N.e and internal rotation , of ..... · duration . . resently receiving surface traction ±
anai • ~reatment - You may mention that the patient is p
w Qesics/anti-inflammatory drugs, etc.
~t~ .
Your case ? r old male child , presented with
(Desc ·b J I I Khan a yea 7 h. h/k
lirn n e the summary of the case) e.g. , a a . ' nd right/left groin/anterior t 1g nee
p Which . t d with pain arou
.... say wa s painless (may be assoc,a e hief complaint.)
When present. Rarely knee pain may be a c
132 HANDBOOK FOR ORTHOPAE.DICS !: XAMINATION
. t· ·t and relieved by rest. Pain insidious / acute in ons

g ravated with ac ,v, y d h" (d . et
• Pain w_as ag . . . / history of m inor trauma a roun 1p.. o not say , 1f absent) ·
• st
The re ,s pos~t1ve ~, ory_noh t abo ut ...... ... weeks back which recovered sponta ·
• There is similar history in t e pas ne.
/ · th treatment. . h
ou s1Y _w1 ~f
._ ........ other joint involvement, regular fever, ~hrornc coug . or tuberculosis o!
• There ,s no h1~tory . hb urs - (Rheumatic fever , Juvenile Rheumatoid Arthritis (JRA)
friends or family or neig O ,
TB hi~ excludedt)h. ·story of severe trauma requiring prolonged bed rest or hospitalization
• There ,s no pas I t· ·
. ·th h"gh fever requiring any treatment (post-trauma 1c or septic arthrilis
or severe pain w, ,
excluded) . .
On examination , the patient appears to be unde r ~1ze d and of _short stat_ure , has
Trendelenburg gait and wasting of muscles of right/left thigh/gluteal_ re~10n . Th~re 1s tender-
ness of anterior hip point and spasm of adductor muscles. There 1s _f,xe~ flex,_on deformity
of hip of about 10°115° , and abduction-in-flexion and internal r?tat1on-in-flex1on are_both
decreased , in comparison to the opposite hip. There is no swell1n~/tend~~ness of spine or
knee , and range of movements of knee is fu ll. Trendelenburg si gn 1s pos1t1ve . So my provi-
sional diagnosis is Perthes disease .
N.B . •
• Early in the disease , when the hip is irritable - All movements may be decreased, just
like TB hip, in which case diagnosis may be difficult. So beware.
• There may be apparent shortening due to muscle spasm but rarely true shortening. [Only
in cases of established severe coxa vara (rare) we find true shortening - then mention it].
• Often you will be interrupted while describing the summary, to clinically demonstrate what you
are saying . So, in this case be sure to first examine, confirm and record the main points i.e.,
1 . Trendelenburg gait : Must be able to describe/ demonstrate.
2. Wasting: Must be measured in comparison to the other side.
3. Anterior hip point : Location ; look at the face of patient while palpating for tenderness to
note painful grimace .
4. Roll-test : To note muscle spasm [Or gently abduct the affected sides thigh and palpate the
adductor to note taut adductor muscles.)
5. Thomas test : For fixed flexion deformity.
6. Demonstrate abduction and internal rotation : In both extension and flexion of hip.
7. Sectoral sign may be positive (see page 135)
8 · Mu st be ab~e to demonstrate apparent and true measurements of lower limb and draw
Bryant's triangle.
9. Mu~t know Trendelenburg's sign and give its explanation. Try quick/successive exarn~
nat,~n repeatedly ~or successful Trendelenburg's test. (It further weakens th~ glutef~r
m~d,~s muscle_which always ensures positive findings). If there is fixed adduction de
m1ty interpretation of the result will be erroneous
10. If not done gently/slowly d' . · hat you
· recor mg of hip movements might get changed from w I
recorded and what you de . . · cases 0
. . '. monstrate later m front of the examiner especially in d
here movements become more restricted with repeat~d hip movements an
imtabl_e hip, w_
associated
. pain - so allow rest to the 1·0·1nt before th e examiner
. comes.
How will you manage the case?
• First confirm the diagnosis with investigations.
1 . X-ray :
- Pelvis with both hips : AP (for comparison with other hip).
Lateral view of the affected hip.
PEATHES DISEASE 133
_ Arthrogram 1s user ul to see the shape

of femoral head and note subluxation .
_ USG : USG of ~i ~ may be done to note
2
effusion in the Joint.
3. MRI of hip is very useful for early de-
tection of subluxation of the femora l
he ad . It is a lso useful to show is-
chaemia , articular cartilage status , ef-
fusion , infarction, revascu lri zation .
4. Tc 99 bone scan : Shows decreased
upt a k e , especially at the anter o -
supero-lateral area of the head. (See
page 251) Useful for early detection of
ischaernia .
Fig . 2.2.4 : Perthes disease Caterall type IV.
5. Ha_emof!ram : ESR is n_ormal ?r mildly raised . If there is very high ESR it is probably due
:o infection where TLC 1s also !ncreased, with polymorphs increased in DC. ff only ESR is
1ncrea~ed, DC and TLC remains normal , and the case may be TB hip/ rheumatic fever/
Juvenile Rheumatoid Arthiritis .
What are the differential diagnosis ?
1. Transient non-specific synovitis (Irritable hip - common after viral or subclinical infec-
tions) : Bone scan will differentiate.
2. Early TB Hip : Here all movements are restricted , especial ly at the extreme last part of
the movement arc. Also ESR is increased . Mantoux test is often very high and rare ly
normal. TB- PCR / TB-culture may be positive in the fluid aspirated from the hip.
3. Low grade septic arthritis: Will have fever and other systemic features with high count in
TLC , and increased polymorphs and very high ESR.
4. Monoarticular juvenile rheumatoid arthritis.
5. (Rarely) Sickle-cell anaemia, Cretinism, Gaucher's disease.
What are the principles of management of Perthes Disease ?
. Universally acceptable guidelines for treatment is not available. More or less acceptable and a
logical protocol is based on the principle to ensure that, when the disease is completely healed the
femoral head is spherical, so as to prevent secondary degenerative arthritis of the hip in adult life.
• Treatment early in the course of the disease (onset to early fragmentation stage) : Chil-
dren $ 5 years of age - treatment is not needed ( "supervised neglect" I "masterly inactivity")
regardless of the severity of involvement of the femoral head, except when there is femoral
head subluxation where containment is needed. For children aged 5 to 8 years - containment
is requried when > 50% of the femoral epiphysis is necrotic (Caterall Ill , Salter-Thompson :
group B).For others regular 3 monthly follow-up with x-rays is. done to detect early subluxation
anct containment is started when subluxation is found . For children aged 8 to 12 years - con-
tainment is done as soon as the disease is diagnosed provided the disease is not in the late
stage of fragmentation (Caterall 11 / 111 , Herring : group B/C). Childr~n aged> 12 years - contain-
• rnent is useless, and they are treated as adults with osteonecros1s (A~N - see page 249) .
Treatment late in the course of the disease (from late fragmentation stage to complete
h~aling and reossification) : Here salvage procedures are needed depending on the defor-
mity of the femoral head or "hinged abduction ". Containment may be consided if the femoral
1
head can be contained without hinged abduction . For hinged abduction do valgus osteotomy .
'Treatment after healing of the disease (management of the sequelae) : Reconstructive
surgery (see page 136) .
. t?
Wha t do you mean by contammen
The objective of containment treatment is to ~old the ~emoral head in t he acetabul
the period of "biologic plasticity" while necrotic bone 1s resorbed and living bone 18 _um duiiog
' · b · t· " th t h · d resto
through the process of ' creeping su st1tu 10n , so a w en repair an remodellin red
the head becomes almost spherical. Containment is useful only in the revasculariz \°"cu1s,
repair phase. Pre_requsit_ie - there sh_Ould be full range_of motion . Hinged abduction (:~oo aoa
t 36) is a contra1nd1cat1on to containment. Rad1olog1cally conta1 nment can be mea eredPag,
Wiberg 's CE angle (see page 275) in the AP view and break in the Shenton' s line an~u bi
arthrography by noting the medial dye pool. Containment should start before the l~te f also by
tation stage and should continue till late in the repair / reossification stage. ragrnen.
Containment can be done
(i) Conservatively by -
(a) Broomstick plaster.
(b) Scottish-Rite abduction splint _
Which holds the affected hip in abdu .
tion and internal rotation. c
Patients may have psyco-social problems,
with theese methods.
(ii) Surgically by osteotomy -
(a) Femoral ( Varus subtrochanteric
F" . . derotation osteotomy) - produces
ig . 2 ·2 .5 · Yaru derotat1on osteotomy. shortening and requ ires 2nd surgery for
(b) p I · (S • • implant removal.
Ce vic . a1ter mnommate osteotomy) - produces lengthening
(c) ombined Femoral + Pelvic - There ·11 b I' .
What will you suggest for this case ? w1 e no imb length discrepancy.
. Varus subtrochanteric derotation oste O t . .
is on the lower side which all f omy · Limb length recovers if patient's age
, ows or compensatory growth . (Fig . 2.2.5)
What are th e Head-at-Ri\·k sign s in X- rays ? (Fig. 2.2.6)

L ateral
2l. G , subluxa
. . tion of the head (d ue torea111 . vecartil ag
· age s stgn in AP view (V- ha ed . . e overgrowth and adduction) .
. P porot1 c/l y t1 c are·i f d .
3. E
4 Speekle· d calc1fication seen lateral to ep1p
. h .
ys1s
c oun in the l ater al phy i s)
· ·
. xtens1ve metaphyseal changes like multi Ple c.Y t. , sho1tened
.
(I) • b1·oadened an d thickened
· femora I neek·
1h
____.,, 5 · Almo I horizontal alionment of the grow plaie
0
(phy is).
What are the cli11irnl H ead-at-Ri!.k sif(ll 1?
l . Female ex
(5) 2- When the patient is obese, overweight.
3. When the patient' age is on the higher ide. dad·
· · d fl x·1on an
4 · Wh en th ere 1s "progre s1ve" fixe e
oo (4)
duction deformities of the hjp.
0 I Ii!) .the prognovis ?
What I spooia ot·
· 1 is a self-limiting disease that hea
ou ly, ometimes with deformity . _ be,au'e
2 · PrognosL is betler when the age i ie,s. 1 , J,ttlJ
fig . 2.2.6 : Schematic
. . diagram of H ea d -a t -R1.
. k th ere i more ti me for remodelling of fll
si gn 1n X-ray . spltericity.
PERTHES DISEASE 135
1 Girls ha ve , orsc prog.11os1~ than boys ( D( . .
·· · i n l forget . ·ig 1· .
.i niounl of head 111, oh cmcm ~ T h lcsse. · ' c nc1clcncc M : i,. ::: 4 . 1)
. . . • • , ' t 1, c better for p . ' . . .
5 Prognosi. is worse when 2 or more o f he l i ognos1s. (sec clas8if1 c·1t 1011 )
· · · ac -ar-r i l'k si ·· '
, how gro. s incongru1t of joint, functi onal and .·. ·. gns arc pre ·cnl. llowcvcr somcti . I
life. ' -rays do not alwar corre late " ' 1tl1 1· . p.i~~-lrce move ment of hi 1J 11""1'1y 11~ : ., 1· 1·me<, w l ~ n X ray~
.. c 1n1ca l r 1· • s.i 1s actory I1ff I ·
6. Wort ror Caterall lV , best for Caterall L. i nc in gs, and fu ctional abili ty . ' ' ,li er 111
may h,• flh rra,011,
\I llill
.
of ,lu,rteni110
,.,
in p erti1e, rfl\ea
. , ·>
Cox a ara, tlattening / de truction of the rem 11 . 11 •
ora 1ead, fixed Ile ·i d. . -
on cfonnity, lixcd adduction deformity.
• Caterall classification (See n in X-rays) :

Lat. AP
1. Type I (Lat.) Anterior epiph ·
too< 50% .
ysea1involvement only that
' 0
(AP) Joint space increased but no head col-
lapse/deformity.
~
Type I
~l
2. Type II (Lat.)
~ ~0% involvement of epiphysis from an-
~
te nor to middle. (9
~
(AP)
N_o head collapse but increased den -
s1ty of head .
3. Type Ill (Lat.) Type II
> 50% involvement with small poste-
rior viable part.
~ ~
(AP) > 50% involvement. Small lateral viable
part with head-within-head sign , and
metaphyseal changes resulting in the
broadening of neck. Type Ill
4. Type IV (Lat.) = 100% involvement. Epiphyses dense,
(AP)
sclerotic , flattened .
Collapsed , flattened head with lateral
protrusion out of acetabulum and short/
broad neck.
\\ Type IV
?r
Oo rou know of any other classification of Perthes disease?
~: t~erri~g l~teral pillar classification : Bassed on the height of the lateral pillar, defined as the lateral 15% to 30%
C _ e epiphys1s. Group A - no loss of lateral pillar height; Group B -less than 50% loss of lateral pillar height; Group
("' more than 50% loss of lateral pillar height. Group A has the best prognosis, group C the worst
~\Salter and Thompson classification : Bassed on the extent of subchondral fracture. Gro~p A -less than
Ira of th~ femoral head involved; Group B -more than half of the femoral head involved. However subchondral
/cture line is only visible in one-third of the patients. Group A has the best prognosis, group B the worst.
t")
Slulberg classification: Bassed on radiographic evaluation , after skeletal maturity to prognosticate the long-
ne;: outcome of the affected hip joint. Class I- Normal hip join!; Class II- Spherical head with enlargement, short
h k,_or steep acetabulum; Class Ill- Nonspherical head (ovoid, mushroom, or umbrella shaped); Class IV- Flat
ead, Class V - Flat head with incongruent hip joint. Class I and II do well, class Ill and IV develop early
osteoarth n·1·is, and class V have severe symptoms most requmng · · arth rop Ias ty.
N.B. : Salter and Thompson_ 2 groups, Herring - 3 groups,Caterall - 4 types, Stulberg - 5 classes.
What; s
S s ectoraJ sign ? . . .
ectoral sign is seen · ecros·is of femoral head (mainly affecting the anterolateral part) . The internal
rot t· m avascu 1ar n , . . . .
fle~1~_n of the hip will be full or slightly restricted when hip is extended, but will be grossly restricted when the hip 1s
136 HANDB00 O n,
ti qu 1,, 01 PN the dlsoa e ?
,, ucr,ve u, ge,, ' d.o n to trc .,t . ~atformed femoral head - G arceau's chlelectom .
What 11re the re~ons valgus subtrochantenc o steotoml y, she lf acelab uloplasly (Stah eli) ; Coxa-magna ~·
H·nged
1 abduction - I stic acetabu um - t d/ C b r
r u ward sloping dys p a . . . . 1famoral physeal growth arres an or oxa- reva With
c~xa-ma; ;a ~lonp- pelvic osteotomy (Ch1an) , Cap1t_~h LLD - Morscher's triple osteolomy .
hinged a uc . dvancement; Coxa-breva w1
no LLD _ trochantenc a ? .
th rations le of valgus osteotomy · rf of the remoral head to roll into the acetabulum during
w ; a~/ s o~ the enlarged and deformed anterolatera).~? I~~ abduction" is associated with pain , and the patient
ai ut_
re alters hip joint mechanics. The resultant mg the deformed portion of the femoral head away frorn
ab duc 10n A I s osteotomy removes Th · .
0ft has restricted movement. va gu . . ruou s range of movement. e improvement in levor
en there 1s pain-free cong · h' d bd ·
the wieght-bearing area and ensures . immature patients, removing 1nge a uct1on allows
arm function and leg length results in a better gait pattern. 1n II .
the lateral acetabular ossification center to grow more norma y .
What ;s sagging~rope _sign? . . d Perth es disease, du e t o th e re mod elling process,

It is a radiological sign , sometim es seen in h_e a 1e . . (F l)
22
which represents the distal margin of metaphys1s that 1s rarefied ig ._ ._ . _ · - - - - -- - -- - - ,
....
-- -
Fig. 2 .2 .7 : Sagging-rope sign . Note - Lateral subluxation of head .

What is Gearstick sign ? . ·
When there is cap ital femoral physeal growth arrest as a s e qu e lae of P e rth es di sease then rela~iv.8
trochanteric overgrowth and coxavara occurs which w e ake n s th e a bdu c to rs . Wh e n th is occurs 1115
observed that , when the hip is in exten sion , hip abduction is limited by impi nge m ent b etween the greater
trochanter and the ilium , but wh en the hip is fl exed there is full abduc tion b ecause th e greater trochanter
moves posteriorly. Trochanteric advancement ope ration is indica te d he re .
What is the role of arthrodiatasis in Perthes disease ?
It is a new method of treatment of Perthes disease which means arti c ul ate d distraction . During the 518~8 01
revascularization , the bone of the femoral head is biologically weak . When this weak bone is subjected to weight·
bearing stresses across the edge of the acetabulum , the femoral head can become irreversibly deformed. Even
when the hip is not bearing weight , muscuIar contrac·
x·
tion can generate forces across the joi nt that may ~ze
ceed the body weight. Arthrodiatasis tries to neutr~epi·
muscular and weight-bearing forces on the femor~ rno·
physis, induce neovascularization , and pr~ven~t~n is
ral head deformation . The advantages of distra xin,BI
that it does not change th e anatomy of the pr? var/
15
femur, and it can be done even when the hlP d 11
19 .
stiff , where surgical containment 1s con train 1 rninor
. . . ' dCA
is done with external fixator (Fig. 2.2.8) , and ~f\SaKage.

complications like pin-track infection nd pin rerthritls,
Artrodiatasis is also used to tre t AVN , ost ~o nswbl
Fig . 2.2.8 : Note - The hinge _of the fixator is at the chondrolysis, neglocted hip dislocation. an u
level of the centre of rotation of the hip joint. capital femoral epiphysis. •
11
What is the .rational_e of heel•rai~e ~.t the non-~athologica/ ( norms I) sld which 1 , om tJm s u d 15
adjunct to ' superv,sed neglect I masterly mactlvlty" rreatment ?
It produces abduction of the pathological hip thus ensuring better containment
Chapter 3
TUBE C LO S ARTHRITIS OF HIP (TB HIP)

Theories Discussed
• Aetio -pathology of TB hip
• Clinical features of TB hip
• Radiology of TB hip
• Treatment of TB hip
• Complication s of TB hip
• Classification of TB hip
• Constitutes about 15% of all bone-TB , i.e. osteoarticular tuberculosis cases . 2nd most com-
mon bone - TB site after cari es spine .
• Usually it affects the adolescents/young adults/ch ildren , but in India it may affect any age
group.
• It is always secondary, i.e. spreads from the initial focus elsewhere (usually pulmonary TB)
via haematogenous route , to the bones and joints.
• In children below 1O years , if clinically ex-
amined only , there is chance of getting con-
fused with Perthes disease, because TB
hip may present itself differently for differ-
ent patients, i.e. often varied clinical pre-
sentation. (Sometimes, without investiga-
tion reports , even the exam iners can be
unsure about the correct diagnosis.)
Aetiology
Starting point (Fig . 2.3.1) or initial focus
after haematogenous spread, is from :
1 . Acetabular roof.
2. Epiphyses .
3. Metaphyseal region (Babcock's
triangle) .
4 . Greater trochanter.
Fig . 2.3.1 : Initial focus of TB hip. 5. Synovial membrane (Rarely) .
Pathology . . Of the femoral head and acetabulum takes place .

Gradual destruction of the art,cul~r. surfac~s ma erforate the capsule and become extra-
Cold abscess forms within the Joint, which YP
articular.
S t· only effusion. Hip is in a position of
• · · ·· No .joint destruc
tage I - Tubercular synov1t1s IAbEr) ion ,
because · · , ·intra-a rt'1cu lar
in this pos1t1on
Flexion + Abduction + External r~tat1o~e(~ is no shortening , but there may be apparent
Volume has the maximum capacity. T ..
lengthening. . the articular cartilage . Hip is in a pos1t1on of
• Stage II - Early arthritis : Destru.ct1on of r There is apparent sh~rtening, and so~e-
F'lexion + Adduction + Internal rotation (FIAd~?~ are res tricted , especially at the terminal
tirne s true shortening < 1 cm . All moveme .
Part due to muscle spasm . res of stage II are exaggerat~~ · There 15
• Stage Ill - Advanced arthritis : All f·eta· t~ of movements with fixed deform1t1es. (FIAdl r) .
true shortening > 1 cm , an d g· ross restnc ,o
137
V _ Complication s : Sublu al1on or dislocati on of femoral head occuring d
• Stage I I. . d . ue to
d r c psule/lig m nts, etc. Resu ting 1n wan ermg acetabulum. (Fig. 2· · )
36
01
I' s t tubercul r arthritis of right/left hip joint in stage 111 (or, II , IV) with rest
. . . nct1on
hip 1n m nts nd supratrochantenc shortening of ...... ... cm, presently 1n traction
tting TD for ........... days, in a ....... ... ... year old male/fe male patient. a
t ~ tn su nm ry or his case ? . .
E mpl : Rabi Barik . ..... .. year old b?Y , of lower soc1.o e.conom1c status , presented with limp
nd p in around righ left groin. The pain was often radiatin g to the knee , and sometimes t
pain wo e up the child during sleep (night cri~s) . There is histo~y . of .10w grade rise of bOd:
temperature in the evening, but no history of high fever or other Joint involvement or trauma
Som times there is history of family members or relatives/ neighbours/friends/classmates tak-
ing ATO . On e amination the patient has antalgic gait. There is wasting of the thigh muscles
and the affected lower limb has the attitude of flexion , adduction and internal rotation . Antenor
hip point is tender (sometimes bi-trochanteric compression test is also positive). The adductor
muscles are in spasm . There is fixed flexion deformity of .... .. degrees and all hip movements
are restricted (global restriction of movements). There is supratrochanteric true shortening of
.... ...... cm. T rendelenburg's sign positive . The patient is presently taking ATD , and is being
given surface / skeletal traction.
What are the points in favour of your diagnosis ?
1. From history : (say only the positives) .
(a) Low grade rise of temperature in the
afternoon or evening .
(b) Close contact with known TB patient.
(c) Night cries.
(d) T reatment history of ATD + traction
2 . From examination :
(a) Typical attitude of flexion-adduction-
internal rotation .
(b) Tender anterior hip point.
(c) Al/ movements are restricted (espe-
ciallyt) at the terminal part of move- Fig. 2 . 3 .2 : TB Hip. Note _ Extreme loss of joint
men . ·
(d) True supratrochanteric shortening of ... .... .. cm. space . Radiological stage Ill
How do you explain NIGHT CRIES ?

When awake , the periarticular muscles are in spasm Th . t ents which
might produce t t d f. . . 1s preven s movem ,
. con ac an nct1on of the damaged articular f D . sleep, spasm
disappears ~ contact of diseased/ . sur a~e~ . unng .
N . damaged articular surfaces ~ friction ~ pain .
ame the sites where cold-abscess from h.1 b
. P may e found.
Femoral triangle; posterior m d.1 1 . . . ctal
fossa; inguinal region· gluteal 're _e .a or sometimes lateral aspect of the thigh; 1schiore
Th b ' gion, may rarely track down to the popliteal fossa. .
e a scess usually spreads alon th ·oint 1s
breached i.e., it takes the path of g e ~essels and nerves once the capsule of the J )
. . Iea st resistence. May be a psoas abscess (see page 127
How wr/J you conf,rm your dia n · .
. . . g os,s (or what tnvestigations will you do) ?
1 . X-ray . - Pelvis with both hips . AP .
Affected h. . L ·. view (for comparison to other hip)
1P . ateral view .
Chest : PA view.
TUBERCULOUS ARTHRITIS OF HIP (TB HIP) 139
2. 8/ood : DC , TLC, Hb, FBS , PPBS . .

- ~~l~Atest lgA, lgG , lgM for mycobactenum t uberculos is (controversial)
=Exclude HIV in adults. . .. . . .
test (values above 14 are s1gn1f1cant but interpretation 1s controversial) .
3 Mantoux
. t aspirate for PCR for mycobacterium tuberculosis and TB-culture.
4.· Join
s. Synovial biopsy may be confirmatory.
What are the X-ray feat_ u res ? . . . .
• Stage 1 : Only soft tissue swelling a nd rare faction around the Joint i.e., periarticular os-
teoporosis (difficult to interpret, USG o f jo int may be useful in this stage) .
• Stage II : Sl ight diminution of joint s pace, localized osteoporosis and mild irregularity of the
articular margins.
• Stage Ill : Severely diminished joint space and grossly destructed articular margins, lead-
ing to incongruity of the joint su rfaces. (Fig . 2 .3.2)
• Stage IV : Already discu ssed i.e., untreated/ neglected cases/ complications (e.g. , hip
dislocati on , wanderin g acetabu lum , prot rusio acetabul i etc.) .

Perthes disease , sub-acute septic arthritis, transient synovitis AVN of femoral head, juvenile
rheumatoid arthritis (monoarticular variety) , traumatic cause like central dislocation of hip .
How will you treat the case ?
• Start ATD + Vit. B 6 • Usually 4 drugs ~ Rif + INH + PZN + Etham are given daily.
(DOTS programme is being used in several centres in India, see page 29).
Traction of the affected limb is given to -
1. Correct the deformity.
2 . Counter muscle spasm .
3. Ensure forced bedrest.
4. Maintain joint space and prevent further deform ity ~ thus relieving pain .
After about 3 to 4 weeks , when pain has subsided , hip mobilization exercises a re started
Within the ongoing traction. After 4 to 6 months , patient may be allowed to walk w ith weight
relieving callipers . Unprotected weight bearing may be allowed after 9 to 12 months.
What .
are rrce bodies ? .
They are .in tra-articular mall piece
. f f'b ·
o 1 nn a nd arti cular cartilage.
ti/
Ca ~here be attitude of flexio11-abd11ctio11-ext emnl rotatw11,
11 11
1tenia/
• t · ?
· ; 11 tead of th e cla 'Sica/ fl e., io11-a,ldu -
R.ar . ro aholl • . of the iliofemoral •y • li ga ment, or continuo us adoption

of Fl- e\y ll may happ~n due to de truct1on . nt for relief of pain, and al o wh n th patient was in
lr . Ab-Extern al rotation posture by the pat! ~
act1on/h 1· p-s p1ca
. .111 tha t pos1t10n
. . for a lo n 0o 11me.
~ 'hat i\ flu• role of"" ( , , i11 " i'/1 hip ,,ati ·111 ·•
l . If the ,cc.,pon~c LO con~ 1 atl\t: 1,c,,1111c111 i~. 11111_ lavou1abl1 :dt ·, ,1 to 6 w ·ds or tra ction+ !\'I'
(not d c lini all by no 1mp1nvcrn · 111 of I a,11 , I ' 1HI · 111 c~s. 111u sL·I · spa sm an d rt:nli . f)
101
fcv r . .ind abc 1-nc, 11 by no appr ·c1ahk fa ll or hi gh l~SR va lUL'S), 111 ·n surg ·ry or joint ; ~1 ~or
· ' Dru.le.
mcnt a nd . nov ctomy is 111d 1cated .
2. urger is aho ind 1catc<l when the ri nal outco m c after l r ·a I 1nc11 t is 1111octeptoble -
(o) orr ti ve o teotomy is inc.Ii at ' c.l wh' n th hip i~ 011/,ylo.,·ed i11 /Jori position.
( b) rlhrode. is : II re mobility i s sac ri fic ·d l o gain
•
stabi lit y . • I L is i11di ca tcd in painru1 Jr;b
' fOII)
a11kylo.\is of hip in hard , rkin g, young and a ' Liv· udulls. ( h g. 2.3.3). A lso sec Page 271.
) Arthroplasty i . indi at d in sti ff hip, w hen th ·re is very l i ttl e or 11 0 movement.
(i) Ex i. i nal rthroplasty - (Girdl . tone's 01>cration) : Jl crc stability is sacrifi ced to gain
m bility . he femoral head is r moved and 6- 8 week s o f h ·avy skel l al lrncti on i. given to try
and create a pseudoarthrosis wi th fibrou ti ssue.
Fig. 2.3.3 : Hip-arthrodesis Fig. 2.3.4 : Total hip replacement
(ii) Repl acement Arthrop la ty - Total hip replacement (THR ) (Fi g. __ 3.4). Mu t be ure thal
the pati ent i . free from infec ti on befor e operati o n- better to wa it fo r few year after TD
comp letion . (Many urgeon's prefer to w ait for 2-3 yea r , w hile . ome urg on' report good
re ulL of T HR done after 6 months - 1 year after h aling o f th di a e.)
What is the position of hip in which arthrodesis is done '?
lexion 20" to 30° i.e., L0 for l yea r of age upt o 30 yea r ( increased lumbar lord an ·onipen. ate
upto 30° - necessary for ground clearence), neutral to 5° abdu cti on, neutral to 10° xt rnal nitaiion.
•)
If untreated or neglected, what may be the possible outcome which ca 11 be appr riat£'d i11 X-rOJ'' ·
J. ubluxation or Di location o f hip. (Fi g. 2.3.5)
. 2 3.5.· Dislocated hip. Note : Destruction of

F19· . the head and superior acetabulum.
----"~"""""=...,..... TUBERCULOUS ARTHRITIS OF HIP (TS HIP) 141
d ·u g acctabulnm !lead m ov s up w ur~ s ,incl dor sall y l eav in g rh c l ow er p art of

2. wan er • cniply and Shcnlo n's li nes brok en. (Pi g. 2.3.6) du · 10 ;iccl abu l ar dc;slruction of rhe
ace1abu 1uni . ., . .
. b ari ng supc1olate 1<11 rM1 l.
we1ghl e,
·usio acetabuli - rernora l hea d breac hes t he ac c labular fl oor and pro lru cfos in to th e
'1
··
protl· D iagnosi s : Look for
. b rea k' .111 1· 110
·
-
pel vt.. , .
i chia l Kohl er s line .
· es Coxa Magna (Fig 2.3. 7) (due
4. omet 101 .
to hyperemi a and ovcrgrowt h o f the f em o-
ral t,ead), and Coxa Vara ( du e l o arrc l ed
ca pital epiph ysea l growth and undi sturbed
trochanteric growth) . If th ere is ava c ul ar
necrosi s of the head, i t mig ht appea r im i -
lar to Perthes disease in X- ra ys. O ccas ion-
ally there may be Coxa Breva ( small -s i zed
femoral hea d), mortar - and-pestle (ac - Fig. 2.3.7 : Sequele of TB hip. Note - Coxa magna.
etabul ar deepening d ue to des truction together w ith coxa breva) .
What is the usual outcom e of tubercular arthdtis ?
Fibrous ankylosis (B ony ankylo is is the outcome of untreated septi c arthritis. Il may rarely happen
in tuberculous arthri tis, when there is secondary septi c arthrili , usuall y after an inva i ve proce-
dure like aspirati on / inci sion + drainage.) However , in caries spine u ually bony ankyl osis happen .
ee page 270).
(for ankylo is,
What methods can be used for hip arthrodesis ?
l. Intra articular - e.g. Cobra pl ate arthrode i., Charnley's compres i on arthrode i .
2. Extra articular - e.g. B rittain's i schio-femora l arthrodesi , Albee's ilia-femoral arthrodes is.
In what conditions arthrodesis is contraindicated ?
I. When the contralateral hip, lumbar spine and ipsilateral knee i deranged.
2. When there is acti ve infection . It i s better to wai t for al least 6- 12 month after disease healing.
3. Always done after sk eletal maturity .
What can be the role of manipulation under anesthesia '·? l ·c·1 n from a bad positi on which
f 1
It may be done to try and bring the hip to a uncuona po
unsuitable for weight bearing, or try and increase the range of movement..
What · · TB h . ?
15 Shanmugasundaram 's cfassificat,on of ,p ·
It is based on the X-ray appearence.
• In ch.Id ren - Normal type, Perthes type , o·is located hip type.
. cetabuli type Travelling acetabulum type .
1
• In ch'ildren and adults - Mortar and pestle t ype , Protrus10 a ·
Wh• In adults - Atrophic type .

at Is PhemIster 's triad
. ? . . . space.
d gradual narrowing of 1oint
Pe · . 1 steoporos1s an
Gt npheral osseous lesion, juxta art1cu ar o t blltY and shortening. What can you do ?
'dlest one ,s exc1s10nal
. . arthropfas Yt produces ins a .
thening in its mechanical axis.
P 1· .· nd femoral Ieng
e vie support osteotomy for stabiltty a
Chapter 4
FRACTURE N CK OF F MU
Theories Discussed
• Clinical features of fracture neck femur • Causes of non-union of fracture, n . .k fc,mur
• Classification of fracture neck fem ur • Treatment of· rracture n ck t mur
• Singh's Index • O steoporo sis
• An acute or recent fracture is not given as a long case. Usually old, untreated, n lect~d nGc.r
femur fractures are given. It is the commonest fracture due to senile osteoporo i •
• Only for fracture neck of femu r, non-union can be said , when the fracture has not unit&<J bf
3 months (also re member Flynn 's criterion for lateral condyle fracture hume rus - see pag~
65) For all other fractures , a minimum of 9 months must pass after the injury. In non-union
fracture neck of femur , commonly there is absorption of the femora l neck, usually seen 1n I.-
rays by 3 months . (Fi g. 2.4.1, 2.4.2).
• It is often termed as unsolved fracture beca use no treatm ent solu ti on , wh ich is 100%
successful , for all patient profiles could be found .
• Vertebral fractures and Calles fracture are commonly due to post-menopausal osteoporosis.
Other risk factors for fracture neck femur : Alcoholism , diabetes , osteomalacia, cystic-
tumors like GCT in the femoral neck, stroke (due to disuse) and post-radiation therapy.
• Common mechanism of injury is a trivial fall. Occasionally it is a blow to the greater trochanter
or sudden extreme external rotation of thf:
limb. However, in young people more se-
vere injury or trauma is often the cause,
because there is no weakening of bone due
to osteoporosis.
• Conventionally , fracture neck of femur
implies intracapsular fractures only. Other
extracapsular fractu res are conventionally
termed trochanteric fractures which commonly
unites and hence is not an u~solved problem.
What is your diagnosis ?
Fig . 2.4.1 : Non-union of fracture neck of femur. My provisional diagnosis is ~ this is a case
Note - Absorption of neck femur by 3 months. of non-union (if it is more than 3 months ~td.
otherwise say untreated or neglected or un·
properly treated) fracture neck of R/L femur.
of .. ... .. weeks duration in a ....... year old
female/male patient wh~ has been bedridden
and unable to bear ~eight for last ....... weeks.
(If the patient is presently under skeletal trac·
tion , then mention it. Also look for bedsores~
What is your case or what is the summar
of the case?
Example : Mrs. Marjina Bibi, 68 year olda~d
male ~atient, had a fall ...... ·: weeks a~o, and
experienced pain around right/left htp, after
Fig. 2.4 .2 : Non-union of fracture neck of femur. was unable to stand or walk immediately ,m·
Note - Absorption of neck femur. the fall. (Sometimes , if the tractu<e is
142
FRACTURE NECK OF FEMUR 143
ed the patient may be able to sta'!dlwalk, ~nd later, when the fracture gets displaced or
pact ' k ·s
1
abso rbed, may become bedridden) . Since then she has been bedridden and unable
the nee weight. There is no history of fever, or other joint involvement and weakness/ paresthe-
t~ b~f~he limb. On examin~tion , th e patient appear~ maln?urished. The attitude is of fl exion,
sia t' on and external rotation of the limb, and there 1s wasting of the th igh and gluteal muscles.
abduc \s tend erness of the anterior hip point and bi-trochanteric compression test is positive.
Th~r~ straight leg raisi ng test (SLR) is negative . (In some cases of 'impacted' fracture s ,
ACtve SLR may be possible .) All active movements are impossible and any passive movement
1
~c :inful and restricted . T here is supra-trochanteric shortening of about 1 cm (may not be
15
r:Sent _ be careful and be ready .to demonstrate) . Tele~copic test is positive (sometimes may
P t be positive) . There 1s no swelling/tenderness/deformity of the spine or knee. So my provi-
~~nal diagnosis is non -union of R / L sided fracture neck of femur.
Note : Expect interruptions, questions and be ready to demonstrate the following -
1. Nutrition and wasting - (don't forget obesity is also malnourishment) .
2. Tenderness - (don't forget to look at patient's face, while demonstrating tenderness.)
• Anterior hip point. (Direct)
• Bi-trochanteric compression. (Indirect)
3 . All movements and all measurements including Bryant's triangle.
What are the probable reasons for non-

union of fracture neck of femur?
1. In displaced fractures, vascularity is
compromised . (Know everything about
the detailed blood supply to head and
neck of femur.) (See Fig. 2.2.1, page 130).
2. The intra-articular part has no soft tis-
sue attachment and only very thin/flimsy
periosteum, so healing is almost totally de-
pendent on the endosteum because no
callus is formed from the thin periosteum Fig. 2.4.3 : Recent fracture neck of femur (Garden 111).
(no camb ium layer) .
3. Synovial fluid prevents clotting of fracture haematoma , which is th e initial step of any
fracture healing. (See page 96) . . .
4. There is tamponade effect within the .caps ule due to blood , w hich further Jeopardizes
the blood supply from the existant retinacular blood v~ ss els.
5. Shearing force acting across the fracture line tends to displace the fracture .
How will you confirm your diagnosis ? What invesligst~ons ~Ill you do ? .
1. X-ray : • Pelvis with both hips : AP view (for comparison w ith the other hip).
• Affected hip Lateral view.

How can you classify neck femur fractures ?
1· Garden's classification (1961) - (Based on X-rays) .
• Stage I : Incomplete } Both are undisplaced fractures.
Stage fl
• Stage II : Complete
• Stage Ill : Partially displaced. (Fig . 2.4.3 )
• Stage IV : Completely displaced.
N.e. • This is the most popular and accepted classification
universally. However, this classification is based_o~ly on
AP view of X-rays and has high inter-observer vanatton. Stuge III Stage {\'
, 44 HANDBOOK FOR ORTHOP EOICS l XAM INA I ION
2 . Anatomical classification (Fig.

2
0 • Sub-capital.
• Trans-cervical.
• Basal/Basicervical.
.4.4)
3. Pauwel's classification : Created 1

dieting non-union or fixation failure after ~r Pre.
·
t1ve · , an d b ase d on th e angle Pera.
f.1xat 10n
01 th
Sub-capital Trans-cervical Basal fracture line upwards to meet an imaginary h ~
Fig . 2.4.4 : Anatomical classification of fracture zontal line· d rawn th roug h t he transtuberculon.
neck femur . (iliac crest) plane on AP view . ar
<30° 30- 50° >70° • Type I : Pauwel' s angle <30°
• Type II : Pauwel' s angle 30°-70°
• Type Ill : Pauwel's angle >70° (Fig. 2.4.S)
The higher the angle , poorer the prognosis.
What are the complications of this fracture ?
1. Non-union .
2. Avascular necrosis of the femoral head,
Type II
and early secondary osteoarthritis.
Type I Type Ill
3 . Thrombo-embolism/DVT (rare).
Fig. 2.4.5 : Pauwel's classification.
Since physiological age of the patient is more than 65 years and the patient has a sedentary
lifestyele with functi onal requirements of only activities of daily living (AOL) , and it is also an
old displaced fracture , I would plan a hemiarthroplasty operation with Bipolar prosthesis. (Oon'I
forget - prosthesis will last about 8-15 years , after which the patient may need total hip re·
placement) (See Fig. 2.3.4).
Clinically w/rat are the diff erences between intracapsular and extracap ular n eck f emar Jract11 re?
There is more shortening and ex ternal rotation in extra capsular fracture which also requires
high velocity trauma, occurs in a higher age group and ma y /, ave so.ft tissue contution/bruise.
Whal are the ••ariotts treatm ent optio11s, ill gen·
era/, for fra cture neck of f emur ? k
Operative treatment is a must for a11Y nee
II ac·
femur fracture. H owever no univer a Y f 0
cepted operati ve protocol for various type_
fractures in variou s age group and variou unie·
' . ·11 no"'·
from-initial injury st atu s, i s available 11
1. Recent Fractures (< 3 weeks) dies
•
(a) Und,.splaced fractures ( 1
SI¾) Reoar
° - . i, cre1vs
of any age, fixation with 3 cannulated hip ·

(osteosynthesi ) (Fi g. 2.4.6). b dividtd
(b) Displaced fractures (85%) - May . e _
d f nc11on
into 3 group according to age an u
60 1
o 6J-
(i) Y o un g ( phy siol ogica_l age ~elo~ osteopof(l·
O
years) and acti ve patient with no n k w (o. 1eo·
Fig . 2 .4 .6 : Fracture neck femur - Fixation with 3 i : fixation with 3 cannulated hip ere . ·k faciors
cannulated hip screws (osteosynthesis). synthesis). When there i o. teoporo is or _n ihefJPY
of osteoporos1 are presen e.g. n eumato1 art mt1s, renal failure, alcoholi m. on 1er01·ct/·adianon
· t ( I ·d I · · 1
etc.), especially when age is > 40-45 years : total hip replacement.
FRACTURE NECK OF FEMUR 145
.. d ( hysiological age above 60 to 65 years) but fit a nd acti ve - T otal hi p re placeme nt is a good
(n) OI pprefcr hemiarthroplas ty w ith bipolar prosthesis .
. n. Some
110 . . . . .
op . .. Old (physwlog1cal age above 60 to 65 yea1s), but leading a sedentary life tyle, pe rforming only
11
. _('. ) f dai ly living (AOL) - he miarthropla ty w ith bipolar prosthesis. (Fig. 2.4.8)
cuv1t1e o . /N .
a Id Fractures/Delayed umon on-u mon
2
·~) Physiological age below 60 to 65 years, young and active, no osteoarthritic changes in
. ·oint (no acetabular changes) - A g e nuine a lte mpt s ho uld be made to preser ve th e bio-
1/le Iup 1 . . .
. l/ori ooi nal head of fem ur , e ve n 1f there 1s AVN. Options are -
1001ca
" • Muscle-Pedicle-Bone-Graft (MPBG) and interna l fixation wi th screws.
• Vascularized fibular bone grafting and internal fixatio n w ith screws .
• Osteotomy : (l) McMurray's Osteotomy (o blique, intertrochanteric, a bduction, m edial dis-
placement) osteoto m y is useful for select patient profi le (Fig. 2.4.7). Produces shorte ning.
(2) Pauwel's Osteotomy (intertrochanteric repositioning valg us) sometimes done.
Fig. 2.4.7 : McMurray osteotomy - fi xed with Fig. 2 .4 .8 : Bipolar posthesis

Tubman's plate .
(b) Physiological age above 60 to 65 years

• Fit and active Jifesty le - Tota l hi p rep lace men t (Fi g. - ·- .4)
• Unfit and sedentary lifestyle - Bipolar prosthesis. (rig. _.4_ )
What muscles may be used for Muscle-Pcdiclc-Bonc-Graft (MPBG) ?

Ou~dratus femoris (Judet , Meyers), tensor fascia lata (Bakshi). gluteus medius (Hibbs). sartorius (LI). gluteus
rnaxirnus (Onosun). MPBG a lso increases the vascu larity of the femoral head, thus being usefull in AVN.
What is Singh 's index?
Rad·1 · o ·
. olog1ca1 appreciation of osteoporosis can be done only after 30 1/o loss of bone mineral density.
Singh's index is usefull to asses osteoporosis by noting the trabeculae in proximal femur, seen in AP view X-rays.
• Grade 6 : All trabeculae presen t (as in a normal person with no o st eoporosis) .
: ~rade 5 : Loss of trochanteric and secondary tensile trabeculae , attenuated secondary compressive trabeculae.
rade 4 : Loss of secondary compressive trabeculae, attenuated primary tensile trabeculae .
• Grad 3 · · )
e : Break in the primary tensile trabeculae (sign of osteopenia ·
• Grade 2 .
• · Severe loss of primary tensile trabeculae.
fio Grade 1 : Only primary compressive trabeculae may be seen (severe osteoporosis).
Wever this index correlates poorly with bone mineral density (BMD) measured by DEXA scan
. 19
OSTEOPOROSIS
• educt·ion in " Bone Tissue Mass" per unit volume of anatomical bon
It 1s abnorma 1 r . . . e.
t . al definition (1994) : Osteoporosis - Bone mineral density (BMD) <
WH 0 opera ion f 2 5) Osteopen· 'T ' 2·5 SD
below the mean for young adult ('T' score o < - . . ia - score of - 1 to - 2.5
Classification
Primary Secondary
A. Idiopathic A . Nutritional (scurvy, malabsorptio
• Juvenile (8-14 yrs) - Acute onset malnutrition etc.) n,
• Adult - Insidious onset B . Endocrinal (Hyperparathyroidism, Hy.
pogonad ism , Thyrotoxicosis etc.)
B. lnvolutional
C . Drug : Steroids, Anticonvulsant etc.
• Type I (Post menopausal) : Af-
D. Malignancy (Multiple myeloma, Leuke·
fects trabecular bone
mia, Metastatis etc.)
• Type II (Senile) : Affects both tra- E . Others (eg ., RA , TB , Chronic renal
becular and cortical bone. (> 70 yrs) failure , Immobilisation etc.)
Risk factors for osteoporosis
Non-modifyable Potentially modifyable

• Personal H/0 fracture • Smoking
• H/0 fracture in 1st degree relatives • Alcoholism
• Female sex • Estrogen deficiency
• Advanced age • Sedentary lifestyle
Pathology
• Normally, bone remodelling is a process which is constantly going on due to a closely
coupled interaction of osteoblastic and osteoclastic activities. At around 4th decade 01
life, osteoclastic activity starts increasing with resultant bone loss of about 1?0
year. So there is constant decrease of the peak bone mass which was achieved in I e
Pt
3rd decade, which is further accelerated in females after menopause.
Clinical features
• Bone pain , fractures (vertebral fractures, hip fractures , Colles fracture) , deformities
(Dowager' s hump - dorsal kyphosis with increased cervical lordosis)
• Spinal cord compression/stenosis with associated neuropathy. . res·
• Symptoms of hypercalcaemia - anorexia, nausea, vomiting , abdominal pain, deP
sion, renal stones etc.
• Symptoms of underlying endocrinopathy when present.
Diagnosis
• x.-ray .: loss of trabecular pattern, cortical thinning, ground glass appearenf~e~::r~:
sis , .biconcave vertebral bodies, anterior compression wedge fractures 0
codfish vertebra, rarefaction of bone , Singh's index etc. . . e CT 5can
• Bone densitomerty : Dual energy X-ray absorptiometry (DEXA) , Qual1tativ
(most accurate), Single photon absorptiometry (SPA) etc.
Treatment
• Excercise, stop smoking, alcohol and offending drugs dietary modification.·paratide,
. . · Teri
• Drugs : Ralox1fen , lbandronate/R1sedronate, Calcitonin nasal spray'.d hormone·
Tibolone, Strontium ranelate, Hormone replacement therapy, parathyroi
Chapter 5
MALU ITED TR OCHANTERIC FRACTURE

Theories Discussed
• coxa vara
• Treatment of trochanteric fracture
• Unlike intracapsular fracture neck of femur, trochanteric fractures unite easily, so non-union is
rarely a problem. Therefore, commonly malunitedtrochanteric fractures are given as a long case.
• Trochanteric fractures are much more common than fracture neck of femur, and usually oc-
curs in osteoporotic bones in elde rly females after a fall , or direct blow to the greater tro-
chanter. In the young , road accidents or other such severe high-velocity trauma is the cause.
• The fracture is extracapsular, and the fracture line involves the greater trochanter,
lesser trochanter or both . When lesser trochanter is fractured and displaced, the frac-
ture becomes inherently unstable and difficult to manage.
• If the patient is walking with shortened limb for many years, he/she might complain of low
back pain due to pelvic tilt and lumbar scoliosis.
My provisional diagnosis is that this is a case of ma/united trochanteric fracture with
coxa vara of the R/ L hip joint, with true shortening of ....... .. .. cm of the limb and restriction of
abduction / internal rotation movements , in a ... .... .... year old M/ F patient , who was
untreated / treated with ..... ..... .... (say skeletal / surface traction I boot plaster I derotation
shoe, etc. as the case may be) .
N.B. • All the features, like restriction
of movements may not be present
in your case. So examine, and if
you say, be ready to demonstrate.
What is your case ? What is the summary
of the case?
Example : Mrs . Bijonbala Das , 70 year old
female patient, had a fall .... ..... weeks ago
(or may have had an accidental injury) , and
immediately experienced pain around R/L
groin and was unable to stand or walk . She
has been bedridden since then and taken
s0 d Fig . 2 .5 . 1 : Trochanteric fracture .
me Pain-relieving medicines, and gra u- Note _ Fracture line involves the greater
~lly over the last 4 months , the ~ain has trochanter and lesser trochanter ~ Unstable
r ecr~ased considerably. (If the p_a tient h~s r plaster then say that instead, and always
ecei~ed any form of treatme~t, like traction
t
° On exa,mination , she has a short limbed
rn;ntion
9 the duration o~ tract1on/plaS er , r~~~2d and externally rotated . On palpation , the
9 It and the affected limb a~pears sh~ d ned and has irregular surface. [Since trac-
t reater trochanter appears thickened , roa eld be no tenderness) . There is fixed flexion
Ure is un·tI d ( Ith h malunited) there wou (
d f e a oug 1 . t'1 n of internal rotation and abduction may not be
pe Ormity of about 10° and also ref n\ it you can demonstrate clinically) . Th ere is supra-
tr~eshent - ~o shortening
e antenc be car~ful and
of 3 say
cm .o~ye~delenburg
r 's si gn is positive . So my provisional di -
147
148 HANDBOOK FOR ORTHOPAl::DIC~
agnos1s 1s mal united R/ L trochante .

nc fra
tu re with coxa var a . c.
Normal Name some causes of coxa vara.
neck-shaft angle 1 . Congenital coxa vara.
2. Acquired :
(a) Sequele of Perthes disease.
(b) Sequele of septic arthritis.
(c) Malunited trochanteric fracture.
(d) Sequele of ric kets.
(e) Fibrous dysplasia (See page 268).
(f) Slipped capital femoral epiphyses.
(g) Achon droplasia.
Coxa vara Coxa valga (h) Paget's disease.
Fig. 2.5.2 : Neck-shaft angle. (i) Cretinism .
What do you mean by coxa vara ?

When the femoral neck-shaft angle is de-
creased from the normal value of 125°-127°.
Usually when < 120°, it is called coxa vara.
How would you manage this case?

First I would confirm the diagnosis with a X·
ray of pelvis of both hips - AP view (and in
long-standing cases , where there is complain
of back pain, X-ray of L.S. spine - AP view,
to search for lumbar scoliosis).
Then considering her age of 70 years, and
the complain of groin and back pain, I would
Fig. 2 .5.3 : Malunited Trochanteric fracture.
Note - Coxa Vara. first give only 2.5 cm shoe raise for the af·
fected limb with physicaltherapy as a trial for
4 to 6 weeks. If even after that the patient 15
dissatisfied , then a corrective subtrochanteric
valgus osteotomy may be considered.
How would you have treated a fresh frac·

ture of the trochanter ?
Operative fixation with dynamic hiP,. s:;:.
(OHS); ideally closed reduction under innthen
intensifier' (C-Arm) on a fracture table,) see
5
internal fixation w ith a OHS (Fig . 2- .4
page 213.
tion if1
What is the role of skeletal trac
trochanteric fracture ? IIY ireat
5
It is sometimes used to succes fu 5 that
· ensure ·t
trochanteric fractures. Traction H wever, 1
0
there is minimal or no coxa vara. _ month5
23
requires prolonged bedrest, up to es deeP·
Fig. 2.5.4 : Unstable trochanteric fracture internally and may cause problems like bedsor 1.~n etC·
fixed with D.H.S. . . . depress ,
vein-thrombosis, pneumonia,
Chapter 6
N ECTED UN AT D POST RIOR

I ATION OF HIP
Theories Discussed
• Type of dislocation of hip • Clinical features of dislocation hip
• complication of dislocation of hip • Management of dislocation of hip
1. Since th e hip joint is inh erently very stab le , viol ent injuries like road traffic accidents are
needed to dislocate a hip.
2. Urgent and immediate treatment is required for acute hip dislocation because the complica-
tion rate increases with the time elapsed since injury. It is an emergency.
3. Most common type of hip dislocation (almost 75% to 80%) is the posterior hip dislocation .
Other varieties include anterior dislocation (see fig. 2.6.2) and central dislocation.
4. Majority of dislocations are associated with fracture of the rim of acetabulum. These cases
are then called fracture dislocations.
5. Sometimes the injury is missed, especially
when there are other associated injuries,
like fracture shaft of femur, or the patient
is unconscious . So , X-ray of pelvis with
both hips should be done in all cases of
fracture shaft femur and vice versa.
6. Common mechanism of injury for posterior
dislocation is , when after a collision the
person(s) in the front seat of a car is thrown
against the dashboard (dashboard in-
jury) where the knee strikes with the
hip and knee in flexed position , and there-
fore the femoral head dislocates posteriorly.
This is a case of L / R sided posterior dislo-
C~tion of the hip, untreated for ..... ..... months
With the patient unable to bear weight on the
~ffected side for the same duration, hav-
ing true shortening of 4 cm in a .. ...... .. year Fig. 2.6.1 : Acute posterior ~islocati.on of left hip .
Old male/female patient. Note _ Attitude of flexion, adduction and internal rotation .
What is · h ary of the case ?
r:- your case ? What ts t e summ . h d ar accident while driving about
cxampJ . M . . 9 Id male patient, a a c •
4 e · r. Shahid Jabil , 2 year O . d h·s left groin and was unable to move
h. months back and immediately felt severe pain _a_ro~n r~e fractures chest or abdominal inju-
ri:s left l~wer limb . (Mention if there were ot~e; ~nJit~sh~ was uncon~cious, he would not give
0
h·1st or history of unconsciousness, etc. Don g limb) Subsequently he was attended by
t?
a ory of immediate pain / ~nability_ move ~he
1
r::U~ly
the . pain subsided, but he still couldn't
rn quack-doctor who gave him medicines, an thg of bedrest he came to the hospital and was
adove the left lower limb. After about .3 m~n 1. sen) There is no history of fever, weakness or
Pa rnitted i'!
and was under skeletal _tra~tiont~~ ~ lo~er limb has an attitude of flexion , adduction
resthesia of the limb. On examination,
149
- ~ - - ~ ~ - ~ --:-:~~:7:--~l)
~~I :;,;-;-
, XJ\M IN I\ 111 N
1 <,Q HANOI O I I l Ii l I II I\ )I , I
u,
limb , pp cHS shortenod. There is mi ld te nderness around
t °
nd 1nl 1n I rot lion 1 hip, •
1nd
•
11 111
A bony hard, smooth-s urfaced round mass is felt on d th e
, nt iio1 hip po111l , nd I It glut \ moves with gentle passive rotational movements / 0P
111 11 0 th
palp lion ol lh I fl c lut ·,I ' rh " · wn rnl triangle is I ss prominent / forceful on the left side e
· h r 1 t puls I ll 1n l 10 1 '0 ' . as
t1"HQ . mO , compared to the othe r side, wh en bilaterl distal
pulses are equal. ~V~scula~ sign of Narath).
Active moveme~t 1s .1mpo ss1ble and any Pas.
sive movemen t 1s painful. .The left hip is fixed
at 20° fl exion, 10° adduction and 10° internal
rotatio n. T here is true supra-trochanteric short-
e ning of 4 cm . (maybe reversed Bryant's tri-
angl e). Trendelenburg sign is positive (if the pa-
tient can s tand and b ear we ight on the left
lower limb) . So my provisional diagnosis is this
is a case of neglected , untreated, posterior dis-
location of left hip of 4 months duration.
N.B. • The pa tient may have weakness of
Fig. 2.6.2 : Anterior dislocation hip. ankle dorsiflexors (foot drop) or paresthesia
Note - Abduction deformity. / tingling numbness of the leg. This may be a
chief complain . It happens due to sciatic
nerve injury during initial trauma . A neuro-
logical examination should always be done in-
cluding power, reflex , sensation of both lower
limbs, and sciatic nerve palsy must be in-
cluded in your diagnosis (when found) .
What are the complications of hip dislo-
cation ?
A. Early complications -
1 . Sciatic nerve palsy : Usually neuropraxia.
2 . (Rarely) Injury to superior gluteal ar·
tery : He re the re is p rofu se bleeding,
Fig. 2.6.3 : Posterior dislocation hip. and pa tie nt may go into shock . It is an
Note - Adduction deformity . e me rg e ncy .
3. Irreducible dislocation : By closed manipulation. This happens when there is an associated
fracture of the acetabulum and the bone fragment impedes reduction .
B. Late complications -
1. Avascular necrosis of femoral head : Incidence increases with each hour of delay in reduction,
so hip dislocation is an emergency. Generally, clinical features of AVN appear after 1 to 2 years.
2 . Myositis ossifications : Uncommon .
3 . Osteoarthritis : Of the hip .
Ho~ will y~u m_a nage .the ca_s e : . nd
First, confirmation of d1agnos1s with X-ray ~ pelvis with both hips · AP vi ew (see fig. 2.6.3) a
left hip lateral. CT scan - to note any bone fragment or acetabul ar fr~cture. MR I to note AVN 1h0n
put the patient in heavy skeletal traction in abduction for 3 to 4 weeks w ith se rial portable X-rays
to note the descent of femoral head. Since the injury is more than· 3 months old, concentnc d
reduction only by traction is probably not going to happen, and an open reduction will be n~e~e ·
N. B . • Up to 1o to 1 2 weeks , only traction· ·in abduction can sometimes reduce the . 1oint.
ft r
8
which is not possible later, because fibrous tissue fills up the acetabular cavity. A _
closed reduction CT scan 1s useful to note the presence of any bony chips or fra~t
ments within the joint, which if present, operative removal should be done to preve
subsequent osteoarthritis and hip stiffness.
p
Chapter 7
SCHEME OF EXAMINATION OF A SPINE CASE
Theories Discussed
• Ott test • Schober's test
• Neurological examination • Lhermitt' s test
• Lasegue's test • Bragard's test
• Muscle power grading - MAC scale • Classification of pressure sore
N.B. • Paraplegic patients are usually given as a case. Then there is no question of examining
gait or examination in standing or sitting posture. But it is always better to start by
mentioning gait.
• Start examination in prone position to inspect and palpate, then roll-over the patient to
supine position to inspect and do the neurological examination.
Inspection
1. With patient in prone position/from the back :
Comment on -
• Cachexia.
• Attitude.
• Hairline, length of neck.
• Level of shoulder.
• Level , symmetry of scapulae.
• Central furrow of the spine.
• Prominence of paraspinal muscles.
• Flanks --? Shape, symmetry, transverse furrows . . . .
· at lower border of the 12th nb and sacrosp1nalls.
• Renal angle --? Depress,on
• Posterior superior iliac crests . . . . .
• Dimple of venus (Posterior superior iliac spine).
• Abnormal swelling, fullness.
• Sinus .
• Abnormal tuft of hair, dimple.
• Cafe-au-lait spots.
• Fasciculation, atrophy of muscles, spasm)s. brasions/bruises.
• Bedsores (decu b"tI us ulcer
. , pressure
l sore a turning the patient supine
before . for .inspection.)
.
(It is better to palpate in prone posi ,on
2· From side : Lordosis, kyphosis.
3. From front, with patient supine :
• Attitude.
• Symmetry of the rib cage and sternum.
• Abnormal swelling, fullness.
• Anterior superior iliac spines.
• Iliac fossae.
• Bladder fullness , catheter-in-situ.
151
• Anterior thigh (swelling /wasting) .
• Wasting, fasciculations, muscular spasms .
• Bedsores . (see page 160).
Palpation (mainly with patient prone)
• Local temperature.
• Tenderness : 3 types - . .
1. Direct - over spinous process. (Indicates post_e rior or advance~ anterior pathology)
2. Rotatory - twist side of spinous process. (Indicates early anterior pathology)
3. Thrust - gentle thumping.
• Gibbus - palpable step
• Paraspinal muscle tone (If atrophy - then soft, flabby. If in ~pasm - then fi ~m, cord like).
Kibler test : pinched skin ove r the paraspinal muscles will be less mobile when moved
longitudinally.
• Abnormal swelling -
- Cold abscess (see page 138).
- Meningocele (Note : cough impulse).
(Movements, measurements are of academic interest and will be discussed later, but you
must measure wasting.)
Movement
• Flexion
(1) Finger-floor distance (for dorsolumber spine) : Request the standing patient to try and
touch his/her feet with extended knees. Normally the finger-to-floor distance is 7 cm or less
(Fig. 2.7.1).
(2) Ott test (for dorsal spine) : Mark the C7 spinous process and another point 12 inches distal
to it. Request the patient to bend forward and note the increase in distance between the above
points. Normally it is 3 cm or more.
(3) Schober's test (for lumbar spine) : With the patient standing, place the 1O cm mark of a
measuring tape at the level of posterior-superior iliac spine and the o cm mark above. Then
request the patient to bend forward with extended knees and note the change in the distance.
Normally it is 5 cm or more.
• Extension
With _the patient standing and knees extended, stabilize the pelvis with your hand and req~est
the patients to tilt backwards. Note the angle which is formed with the vertical axis. Normally 1115
about 30°. (In facet joint arthropathy it may be painful and restricted) [Fig. 2.7.2].
Fig. 2.7 .1 : Finger-ftoor distance

Fig. 2.7.2 : Extension
H M XA MINA I N A 153
• Lateral tlexion
w ·th the patient standing
~ the lateral malleolus of he ang le. S t ndin b
:~~cal axis . Normally it is about 30 ° (Fig . 2 .7 .3) .
Fig. 2.7.3 : Lateral flexion Fig. 2.7.4 : Rotation
• Rotation
Wi~h the patient _seated and arms folded across chest, request the patient to rotate his/her body on
the nght and left side. Standing behind the patient and looking from above note tha angle between the
plane of pelvis and a imaginary line joining the shoulders. Normally it is about 40° (Fig. 2.7.4) .
Neurological examination (done mainly with the patient in supine position)

1. Higher functions : Consciousness , alertness , orientation , speech .
2. Motor :
(a) Bulk- Wasting/hypertrophy
(b) Tone- Hypertonia occurs in upper motor neurone lesions (clasp-knife spasticity) basal ganglia
disease, Parkinson 's disease (cogwheel rigidity) . Hypotonia occurs in lower motor
neurone lesions, cerebellar disease, tabes dorsalis and sensory neuropathies .
(c) Power- Active straight leg rising (SLR) , extensor hallucis longus (EHL) , ti bia li s
anterior, quadriceps, iliopsoas, hamstrings, gastrocnemius.
(d) Co-ordination (heel shin-ankle test, finger-nose test).
(e) Involuntary movements.
3 . Reflex :
(a) Superficial -
• Abdominal reflex (T to T ) : Look at the umbilicus. Difficult to appreciate in obese
7 12 .
patients, umbilical hernia, patients with post-operative scars. .
• Cremasteric reflex (L , Lz). (Absent in UMN lesions and L~N les1?ns _o f L1 , L2 )
1
• Plantar response reflex (L , S ). In UMN lesions th~re 1s d?rs1flex1on of 1st toe ,
5 1
fanning of the other toes , dorsiflexion of ankle , and flex1on of hip and knee .
• Anal reflex (S 3 , S 4 ).
• Bulbocavernosus reflex (S 3 , S4). . . .
.a. · Anal and Bulbocavernosus reflex is absent in cauda equina syndrome. It 1s also important
to detect whether a patient has come out of spinal shock.
(b) Deep -
• Knee jerk (L2 , L3 , L4) .
154 HANDBOOK FOR ORTHOPAEDI CS EXAMINATI O
----~------- - - - - -
• Ankle jerk (S, , S 2 ) .
• Clonus (ankle / kn ee) : If there is < 6 contracti ons. 1t is pseudoclonus.
4. Sensory :
(a) Superficial -
• Pain (Tested with a pin) .
• Fine Touch (Tested with a wisp of cotton wool or tip of the index finger) .
• Temperature (Tested with test-tubes containing cold and warm water).
(b) Deep -
• Joint position sense (JPS) .
• Vibration sense (VS) (Tested with a vibrating tuning-fork of 128 Hz placed over lat
. e~
malleolus, medial malleolus, dorsum of first toe) .
(c) Cortical -
• 2 point discrimination (Tested with a pair of blunt dividers. For finger tips about 2mm
separation and for pulp of toes about 1cm of separation can be recognised).
• Stereognosis (Recognition of size, shape, weight and form tested with common objecls
like paper-weight, pensil , marbles, keys etc.)
Special tests
• Lhermitt's test : (Dangerous, should not be done routinely). In cervical cord compression,
passive flexion and extension of neck sometime produce electric shock like feelings of the
extremities .
• Femoral nerve stretch test : The patient lies prone. Stabilize the pelvis with one hand and
hold the leg with flexed knee with your other hand. Now extend the hip. If there is femoral nerve rool
Fig. 2.7.5 : Femoral nerve stretch test

Fig. 2 .7 .6 : Lasegue's test
compression (specially L2, L3 PIVD) there will
be anterior thigh radiating pain (Fig . 2.7.5) .
• Sciatic nerve stretch test :
(1) Lasegue's test : With the patient supine
and knee extended lift up the leg while looking
at the patient's face . Stop further movement
when the patient complains of pain and note the
angle between the leg and the horizontal.
Normally it is about 80°. In PIVD the angle is
less (Fig. 2.7.6).
(2) Bragard's test : In Lasegue test, from the
point where the patient complains of pain, start Fig. 2.7.7 : Bragard's test
....
SCHEME OF EXAMINATION OF A SPINE CASE 155
. g the leg till the pain disappears. Then forcefu lly dorsi fl ex the ankle keeping th k
iowe~in occurs now, 1t confi rms PIVD (Fig. 2.7.7). e nee extended.
If pain . . . . .
(3) Crossed stra1gdht d/eghra,s~tn{! t~sdt_: If_the ref is pa1n/paresthesia when the normal leg is raised
with the knee exten e , t en 1 1s 1n 1cat1ng o PIVD (usually large central disc prolax).
Grading of tendon reflexes
o _ Absen t.
1 - Normal.
2 - Brisk .
3 - Very brisk.
4 - Clonus. (~ 6 contraction after single stimulus. Exaggerated deep tendon reflex.)
Medical research council scale (MRC) (Grading power)

• Grade O - Complete paralysis.
• Grade 1- Flicker of contraction (say rarely, because it is very hard to re-demonstrate).
• Grade 2- Gravity eliminated movement possible (e.g., side to side leg movement).
• Grade 3- Possible against gravity, but not against examiner's resistance (e.g., SLR test).
• Grade 4- Possible against examiner's resistance, but less in comparison to the normal side.
• Grade 5- Normal, full power.
N.B. • Posterior column sensations are - Joint position sense (JPS), vibration sense
(VS) and fi ne touch (tested with cotton) .
• Spinothalamic sensations are - Pain, temperature and crude touch (tested with
pressure on the ankle) .
• Cortical sensations - 2 point discrimination test and stereognosis.
• While changing posture of patient from supine to prone, or vice versa, attendants should
be called and gently log-rolling technique should be used, utilizing the bed cover, so
that the whole body rotates in one piece to ensure no further cord damage.
• Spinal movements - where does it occur mainly?
{a) Flexion _ Mainly lumbar (Schober's test) , also slight dorsal (Ott's test) .
(b) Extension - Lumbodorsal. . . .
{c) Lateral flexion _ Dorsal vertebra i.e. thoracic, and it is not possible without rotation.
(d) Rotation - Dorso-cervical.
(e) Nodding - Atlante-occipital.
{f) Head rotation - Atlante-axial.
Classification of Bedsore / Pressure sore
Europe ' 5 ystem ·
an Pressure Ulcer Advisory Panel grad mg · . .
• r> . t·on of the skin warmth , oedema, indurat1on or
\,;jrade 1 . f . t ct skin Disco 1oura , , . .
h · non-blanchable e ryth e ma o in a · . d' ·duals with darker skin ~ 1n whom 1t may appear
rd
a ness may also be used as indicators, particularly on ,n
blue 0
,v,
, ,.. r Purple. . . dermis or both. The ulcer is superficial and
\,;jrade 2 . I . g the ep1derm1s, '
Pr : Partial thickness skin loss 1nvo vin d' skin may be red or purple.
, '"'esents clinically as an abrasion or blister. Surroun ,ng osis of the subcutaneous tissue that may extend
wade 3 . d mage to or necr
d : full thinkness skin loss involving a '
0
, ,.. 'W n to, but not through underlying fascia. e to muscle bone, or supporting structures with or
\,;jrade 4 . rosis or damag ' I. f .
't./ : extensive destruction tissue nee ' h I and predisposes to fata in ect1ons.
th0
' Ut full thickness ski n loss. Extremely difficult to ea
Chapter 8
CARIES S INE
Theories Discussed
• Aetiopathogenesis of caries spine • C linical features of caries spine
• Bladder involvement in caries spine • C old abscess
• Classification of TB paraplegia • Gibb us
• Management of caries spine • Bedsores
• India is almost endemic in tuberculosis . Most c ommon si te s are the lungs and lymph
nodes and then comes skeletal or osteoarticular TB .
• Almost 50% of skeletal tuberculosis occu rs in the spine. 2nd common osteoarticular site is
the hip, 3rd is knee . Sometimes caries spine is also called tuberculous spondylitis.
• Dorso-lumbar (Ds-L2) is the commonest site of spinal tuberculosis.
• It can occur in any age , but it is most common in young adults up to about 30 years of age.
• Skeletal TB is always secondary i.e. , it spreads via haematogenous route, from the primary
site (usually the lungs, sometimes intestine, lymph nodes, etc.) to the bones. In the spine,
infection sometimes passes via the Batson's venous plexus.
• Tuberculous infecti on commonly affects the ends of bones (unlike pyogenic infections where
metaphysis is commonly affected first). So in TB, involvement of the adjacent joint occurs
rapidly. (Septic arthritis resulting from pyogenic osteomyelitis is less common) .
• Whereas in other joints, TB heals by fibrous ankylosis, in spine bony ankylosis is the com·
mon outcome . This is due to destruction of the vertebral end-plates.
• Often, lack of constitutional features like weight loss, rise of body temperature in the evening,
anorexia, weakness, malaise together with unrelated history of trauma, makes early detection
of skeletal tuberculosis difficult, and you need to have a high degree of suspicion.
PATHOLOGY
1 . Initial focus in spine after haematogenous spread is at four sites (Fig. 2 .8 .1 ).
(a) Paradiscal (Commonest) : This !5
probably because the blood supply 15
common for the adjacent two verte·
bral paradiscal areas, together with th0
IV disc intervening disc, as it develops from
the same sclerotome.
(b) Central : Inside the body.
(c) Anterior : Anterior part of body.
(d) Posterior : e.g. Pedicle, transverse pro;
cess, lamina, spinous process. Th 95
are rare.
2 - Inter-vertebral disc which gets supp I'18s
I IIY
from adjacent vertebrae , is gradua e
Fig . 2 .8 .1 : Initia l foc us of carie s sp · destructed , thus in X- ray' s disc spac
3 . A s infection spreads there is hype ine .
. reduces and finally vanishes.
1 h' ' remia ~ ost eopo · and destruction of bony rarne1·f
ae, w 1ch then collapses under body . h . ros1s
the natural kyphosis of dorsal vertebra: e13 t. Smee the centre of gravity passes in front o_
' orsal vertebrae has an anterior wedge compres
15 6
CARIES SPINE 157
sion fracture, which g_ives rise to the g!b-

bUS (Fig. 2.8.2) . Wedging , and hence g1b-
bus, is less marked in lumbar or cervical
spine, whic~ has a natural lordosis instead
of a kyphOSIS.
_As destruction and caseation spreads, there
4
may be co ld abscess an d pressure on
the spinal cord from caseous material , de-
bris, abscess ~ causing neurological symp-
toms. Cold abscess m ay also present as a
psoas abscess (see page 127 and page 138)
This is a case of paraplegia in extension
grade IV, due_ to c~mpressive myelopath;
caused by canes spine, where the lesion is
most probably at the level of 0 1 2 segment of
the cord, with bowel , bladder incontinence and
anaesthesia > 50% of the normal , (say only if
present) and pressure-sore over sacrum in a
26 year old male patient, who has been bed-
ridden for the last 3 months.
What is the summary of the case ? What is Fig. 2.8.2: Lat. view X-ray of Dorsolumbar spine showing
your case ? caries spine with kyphosis. Note - Loss of disc space.
. Example : Mr. Jalal Ansari, 26 year old male patient, 10 weeks back noticed weakness of the
nght leg, and then weakness of the left leg after about 7 days, together w ith anaesthesia of the
le_g which is more than 50% now. He found ditticulty in wearing shoes and then walking with any
slipper type of footwear and later climbing stairs. He had been suffering from back pain, which was
more severe at night, tor the last 4 months . He also gives history of chronic dry cough with rise
of body temperature in the afternoon for the last 6 months, where the fever was low-grade
int~r~ittent in nature and associated with night-sweats. On enquiring , he gave history of con-
Slncting girdle-type sensation near the groin level and that, initially he had pain radiating to
both lower limbs, which increased with coughing , sneezing and jolting. For last one month he
~ havin~ hesitancy of micturition and is often unable to hold faec~s ,. t?geth_er with seve~e
ack pain with radiation to both the lower limbs. The symptoms were ms1d1ous in onset and 1s
i~adu~lly pro~ressive over the last 6 months. T~ere is positive fam_ily history of t_uberculo~is.
ere 1s no history of headache/vomiting , convulsion, or diabetes mell1tus, hypertension or spinal
traum a or exposure to sexually transmitted disease. But there ·1s h.1s tory o f ma Ia,se · , anore .1a,
·
W~kness ~nd weight loss over the fast 6 months. (There ma~ be hi~tory of haemoptys_is) .
n examination the pati· ent looks malnourished and a norexic , but ,s alert, co-operative and
Obey s command 'He h x 2 cm oval-shaped pressure-sore over h.1s sacrum , w h.1c h .ts
superficial and
iher . ·
d ast a
oes no reac
3
chmth bone and there is wasting of both the lower limb muscles .
e . . .
e 1s tendern th tebra and there 1s a knuckle g1bbus over 0 9 -0, 0 . Active
move ess over e O9 ver . . . d'
ments of both . b . t possible on neurological exam in t1on . r g r ing ton ,
th
..
ere .
is clasp k .,,
1ower 11m s ts no
t· ·t p · d 1 ·
er ·is grade o Jerks are brisk an t , e r , an e and
kl
""ee
s ctonus Pl t m e spas fl
1c1 y
.
. tensor bilaterally, but there ,s pres nc o Join pos1·t·,on
ow ' · f · · t
...erise and Vibr t~n ar re eTxh,s efx my provisional diagnosis is ........ ( y yol~r di gn i
• 11 eritio a 10n sense. ere ore,
Wti ned before)
In Y do You say · . . xtension ? (Or) What i th dlff r nc b rw 11 1, pl ,
eJcte . parap1eg,a ,n e ·
A. " s10n and paraplegia in f/exion 7
. In extension t e - The lower limb has attitude of hip and kn
Plantar fl . YP . h kn·,te spastlclty in the extens or
ex,on, wit c Iasp
nd oft n lh r 1 nd pl nt r rosponso , 8 y1
n Or
p r r111d I tract nd occurs
B h thigh c nd knee are flexed with lt)e ankle dors111ex0d, and rollex
~s/Jerr
r Tone 1s increased ,n he lie or group of muse 1es and plantar respons '
t nsor Sometime rt 1s associated 11h lie or spasms. It involves both the pyramid
1
trapyramrdal tracts, and occurs late ,n the course of the disease. a al)lj
I t utonom u I dd r nd h t I utom t,c b l dd r ?
When bufbocave,nosus ,efle and anal reflex are present, it indicates intact sa
. c~1
cord , and the prognosis rs bet er. It 1s called reflex or automatic bladder. When these re.
flexes are absent and there ,s tota l loss of penneal sensation, recovery is unlikely and it
called autonomous bladder. Here the bladder functions indepe ndently without any conne~~
lion wrth the sacral segment of the spinal cord .
What I c c " ' , c; ral e r ofd ?
Cold abscess is a non-pyogenrc abscess formed due to tuberculo us infection, and consists
of tubercular debns , caseous matenal , serum , WBC's and occasional TB bacilli. Since there
is no 'rubor', 'dolor', 'color' and other signs of inflammation of pyogenic infection (so-called
"hot abscess ") rt is called cold abscess .
Where ould you search for cold abscess in a patient of TB spine ?
I would search in the paravertebral areas,

lumbar "Petit's triangle", iliac fossae , femoral
triangle, buttocks , thighs and the popliteal
fossa . Besides it may cause psoas abscess,
if the lesion is at, or below T 12 level. If the
lesion is in upper thoracic or cervical verte-
brae, then neck, axilla , retropharyngeal
space, anterior and lateral chest walls should
also be searched .
What is called early onset paraplegia and

Fig . 2.8.3 : Cold abscess in left lumbar paraver-
wha t are the causes of it ? What is
tebral area. Seddon 's classification ?
GRIFFITH AND SEDDON '$ CLASSIFICATION OF TB PARAPLEGIA:

-
Early onset paraplegia Late onset paraplegia
-
1. Appears within the first 2 years of 1. Paraplegia occurs after 2 years of on·
onset of disease. set of disease.
2 . Usually due to compression from in- 2. Usually due to sequestrum, internal
flammatory oedema , TB granulation gibbus, spinal canal stenosis, vertebral
tissue, caseous material, cold ab - deformity.
scess.
3. Prognosis is better. 3. Prognosis is guarded/worse.
th
Neurologically what is affected first and what is affected last ? During healing, what 15 e
order of recovery ?
.
M otor f unctions . . . . I s ciurnsY
are affected f,rst, and the first symptoms are twrtchrng of muse e , is
gait, bris k jerks with extensor plantar response , ankle and knee clonus . Then sensory
affected. Joint position sense and vibration sense is last to be affected.
CARIES SPINE 159
. healing. first to reco ver is vibration sense and i·o,·nt ·t·
ounnQis the motor fun ctions. E xte nsor plantar response takes pos, ion . sense and last to
recover . · very 1ong time to recover.
. this the ordet of affection ?
15
WhY
. ·s
1 probably because the motor tracts are anteriorly placed w·ith · th d
This • • in e cor , and the verte-
bral paradiscal area is th e commonest area of affection, which lies just anterior to the cord.
Clinically what are the sequential ~igns and symptoms of untreated caries spine?
First there is . gait problems_ a~d in~oordi_ n ation, then spasticity, followed by paraplegia in
e tension and finally paraplegia in flexi on with loss of bowel / bladder sphincter control.
What are the types of gibbus ? How is gibbus formed ?
Common is external gibbus which is of 3 types.
1. Knuckle gibbus : One spin ous process is prominent on palpation because one verte-
bra co ll apses e.g., TB , trauma . (see page 256) .
2. Angular gib bus : 2 o r 3 vertebrae involved e.g., secondary metastatic deposits,
sometimes T B. (see page 256)
3. Round gibbus : 3 o r more vertebrae involved e.g., senile (osteoporotic) kyphosis,
Scheurman's disease . (see page 256)
4. Internal gibbus : Rare variety . Seen in late onset TB paraplegia.
What are the landmarks of spinous process palpation ? How do you establish the exact
level of the palpated spinous process clinically ?
C1 - Most prom inent spinous process at the

base of the neck.
03 - Level of the medial end spinous process of
scapula with upper limb in anatomical position.
D1 - Level of the inferi or angle of scapula.
Li - Level of the highest point of iliac crest.
S2 - Level of the posterior superior iliac spine
(dimple of venus) [Fig . 2.8.4) .
Differential diagnosis
1· Pyogenic osteomyelitis of spine (commo~I~
after surgery or catheterisation of urogenit~ F. : Spinal landmarks for palpation .

· h se vere pain
tract). Here onset is sudden, wit 9· 2 ·8·4
1
anct high swinging temperature. of the spine. May present clinic~lly

2 onest neosplasrn . ff ted (unlike caries
. ~econdaries in spine is the com:sc spaces are not/mini~ally abl=~der breast, lymph
like TB spine , but in X- rays the . from prostrate , ~nnary KT) ,
Spine) . Also a primary carcino_genh1c t~;~~rfound . (Mnemonic - PUB~I . s are intact
nocte intestine kidney thyroid s ou ss and in X-rays , disc space
3 . , , ' . s inal tenderne
· Spma1 tumour · Here, there is no p II unaffected
(some.times ped.icles are affected) . t onset. Disc spaces are usua y .
4 t . of trauma, acu e
· raumatic paraplegia : History .
S. Brucellosis fungal infections (rarely) ·11 you confirm your diagnosis ?
kow . ' ? How w,
w,11 You investigate the case · O)
1 ut 30 to 5 ·
. Blood : • ESR - Increased (Abo
11 lOf'A UIC
• DC - (May be) relative lympho

cytosi8
• Hb - (May be) decreased. ·
• FBS/PPBS
• HIV - ELISA - May be positive
elude HIV in any adult onset (Ex.
myelitis or caries spine). OSfeo.
• TB-PCR, E~ISA for lgG, lgM, lgA for

mycobactenal tuberculosis _ Co
. I s11y
an d controversra . Not routinely don
e.
2 . X-ray : X-ray of spine, centering the sus-
pected affected area (known by tender-
ness, girdle-sensation, motor-level, etc.).
Look for : (a) In Lateral view - Inter verte-
bral disc space decrease, or even fusion of
adjascent vertebrae (Fig. 2.8.5) and kyphotic
deformity measurement.
(b) In AP view - Para-vertebral soft-tissue
Fig. 2.8.5 : Lat. view X-ray of dorsolumbar spine shadow, indicative of abscess.
showing caries spine.
3 . MRI : (Costly) Is the investigation of choice, as it shows cord compression, canal steno-
sis, cold abscess, condition of disc and bone, etc.
4. CT guided FNAC, open biopsy: May be needed to confirm the disease, and material may
be sent for culture and histopathological examination (HPE) and TB-culture.

Bedrest and four drug ATD (Rifampicin , INH , Ethambutol , Pyrazinamide) regime (may
consider DOTS , see page 29) with vitamin B6 (sometimes Ca 2± supplementation), together
with nutritious diet will be started and periodical clinical examination of the neurological
status , local spinal tenderness , appetite, weight will have to be done along with laboratory
investigations like ESR . Periodic X-rays are done to note signs of healing (like sharpening
and becoming prominent of the vertebral end-plates at paradiscal region , and mineraliza-
tion/calcification of the trabeculae). If there is no perceptible change after 4 weeks of ATD,
then a myelography/MRI and operative intervention is planned, to decrease the disease·
load , increase vascularity and hasten healing. (Cold abscess if present, should be drained
after 3 weeks of chemotherapy, by aspiration and instillation of streptomycin) . Besides this,
care of the bladder and pressure sore has to be taken.
What are the areas where bedsores can occur?
Sacrum, ischial tuberosities, scapula , occiput, greater-trochanter, heel, lateral and medial
malleoli of ankle, olecranon, and over tibial and femoral condyles (lateral and medial).
How would you take care of the bladder function ?
Persistent in-dwelling catheter should be discouraged as it leads to infection. If patient
has incontinence, condom catheter is used. In urinary retention intermittent catheterization 10
·
relieve the bladder every 4 . to 6 hours should be done, using ' ·
full aseptic technique (The
patient may be taught aseptic self-catheterization).
CJinicallY wha t proce s . corre-
I
sponds to w'111t cord segment ?
(From below upwards)
Ll --) All sacral and coccygeal segment.
r12 --) Ls segment.
T11 --) L4 and L3 segment.
T1o--) L2 and L1 segment.
Tg --) T 12
Ts --) T11
T1--) T10
Ts to T , ~ Add 2 (e .g. , for T s ~ T 7 or
T3--) Ts)
Fig. 2.8.6 : c .aries ~pine with anterior-wedging of ver-
Cervical Add 1 (e.g ., for c3 ~ c4 or C s tebra , causing g1bbus and increased kyphosis.
~ Cs)
Which vert eh rae ,s m

· JJo lvement may cause psoas abscess? How will you clinically diagnose it ?
From a ny vertebrae T, to L . For c lin ica l di agnos is see page 127.
2 5
How will Jou tak e care of pressure sores ?

is Pressu re sores rarely heal if pressure over the sore is not removed. First en ure that the bed sheet
ne not crumpled and has n o w rinkl es. The patient s hould always avoid pressure on bony promi -
andnces for Io ng periods,
. s o c han ge of p os ture every 2 to 3 ho ur 1s. mandatory. (The patient party
&hou~tte nd ant co uld be taught the 'log-rolling' technique to change pos ture frequent ly). The skin
va~ di b.e massaged with oil 2 to 3 times daily to keep it . upple and moi s t and main tain cutaneous
, cu ant y. W a ter- bed, or ai r-cushion mattress, 1f
thick . e should be used , or at least a 4" to 6"
. possibl
ever spo nge mattress. A s for th e existent sore, s lou g h . ho uld be removed, the wound cleansed
va~cyl d~y (at leas t twice) with normal saline and dressed with topi cal medicines which encourage
Wq,u an . ty and grnn,1a1; ;,s,e. Plasnc ,rgery JS · the last resort. (For c1ass,· r·1cat,on
· see page 155)
00 1
Kt I\ the .
. importance ' OJ, t carceY
of kypho.\i~· ;11 the prognosH ' ' ?
spine .
may YPhosis may go o n increasing even after the di sease has healed (as late as after 5- lO years), which
oftc/rod uce late o n set paraplegia decreased vital capacity and severe back pain . This happe ns more
(c.g When 2 or more vertebrae are ' affected a nd when
· · proJo nge d active
there is · growt b potential left
reg~i S 10 years age at treatment compl e ti o n). and the les ion is in the thoracic vertebrae. He nce
incrc:.~ { 0 llow-up of these hi g h-ri sk patient is m~ndato~Y at 3-? months inte rval for early detection of
W1iu, g kyphosis. (Can be a rrested w ith o pe rauve spin al fusion).
• . 1·,cations for ~url(ery 1n
th e 11u
llri, . ~pt·,1e •.,
. cartes
No improvement
· ·
after 4- 6 weeks of conservative management.
162 HANDBOOK f- OR OR l HOP ION
• 'urnl<\~.il' JI cnmpl il'aL1011s del'elop, worsen , llr recur durin g th e co urse of conserv- .
agcmcnt.
· aL ,vc rn an,
• AdvanCL'd cases or 111.:uro l og i ca l in vo l ve ment e.g .. fl acc id par al y si ·, fl exo r spas ms,
bladdc, d ,sru 11c tio11 . > 50 ¼· senso ry l oss . bowel
Wlrat ·urgt>ry will you ,lo, if required ?
ntero-lateral decompression ±fusion . Fu ·ion is indi ca ted for symptomatic mechanical ·1nstabi lity
of spine, and al o to arre. t progression of kyphos is.
.B. • L esions from D and above ~ Upper motor neurone (U MN) bladder .
JO
• D • D 11 • L . L 1 ~ UM bladder. additionall y sy mpathetic and sensory loss .
I1 _ I -
• S1 , S1 • S and cauda equin a ~ Lower motor neurone (LMN) bladder.
- • -I
Clas ification of TB Paraplegia, based on motor weakness (Goel, Tuli, Kumar)

I egli gible - Pati ent unaware. Doctor detects extensor pl antar/or ank le cl onus.
U Mild - Patient aware. walk wit h upport.

lU Moderate - Patient bedridden. Paralysi in extension . Sensory defi cit < 50%.
lV evere - lll + paraly i in flex ion/ flaccid paralysis / fl exor spa m s. Sensory deficit > 50%.
BO\ el / bladder control disturbance.
Clinico-radiological classification of typical tubercular-spondylitis (Kumar 1988)
Stage Clinico-radiological features Usual duration
I. Pre-destructive Straightening of curvatures , spasm of

perivertebral muscles, scinti-scan would < 3 months
show hyperemia, MRI shows marrow oedema
11. Early-destructive Diminished disc space + Paradiscal erosion
('Knuckle' < 10°), MRI shows marrow oedema 2-4 months
and break of osseous margins, CT scan shows
marginal erosions or cavitations
111. Mild angular kyphos 2-3 vertebrae involved (K: 10°-30°) 3-9 months
IV. Moderate angular kyphos > 3 vertebrae involved (K: 30°-60°) 6_24 months
V. Severe kyphos (Humpback)
•
> 3 vertebrae involved (K: > 60°)
Ill, IV, V have vertebral bodies destruction and collapse+ appreciable kyphos .
> 2 years
---
• K is the angle of kyphosis as measured by the technique of Dickson (1967) .
• In Stage Ill. IV, V - diagnosis is clear on conventional X-ray. CT scan and MRI would show advanced
changes , however, these are unnecessary except for difficult sites (Kumar, 1988).
Chapter 2
ASIC CLINICAL EXAMINATION OF KNEE
Theories Discussed
• Genu recurvatum • Zohlen's sign/Clarke sign/Patellar grind test
• Friction test • Bulge test
• Patellar Hollow test • Patellar Tap test
• Cross Fluctuation test • Patella lift-off test
• Lachman test • Drawer tests (anterior, posterior)
• Pivot-shift test • Single foot hopping test
• Gravity sign/Sag sign test • Mc'murray's test
• Apley's grinding test • Thessaly test
• Glide test • Ober's test
• Apprehension test for patella dislocation • Wilson test
• Osteochondritis dessicans • Loose bodies
INSPECTION
• Have a female attendant for a female patient. Explain the procedure to the patient, (i.e., what
you will do and what the patient will be required to do) and ensurlerbal consent.
• The patient ~~uld be exami~e~n the f_ ollowing o~der- _f~rst in the ,' nding position, next ~n
@ squatting pos1t1on, then walkmg;=-tt,en with the patient s1t1ng on the ge of the bed, next in
~ supine position and finally in the prone positi~. When the patient is unable to stand, squat,
or walk, inform the examiner beforehand. l0
• Both the lower limbs should be exposed from the groin to the toes (for comparison), and the
patient should be examined on a hard and flat bed/couch without any cushion/padding/mattress.
• With the patient standing :
Standing in front of the patient, first observe the attitude and deformity. Note, compare and
comment on genu valgum/varum (see page 30), any swelling/wasting, the suprapatellar quad-
riceps bulge, patellar position/shape/size/symmetry, the supra and infra parapatellar fossae
(medial fullness may indicate intra-articular fluid), the patellar tendon, and the position of the tibial
tubercles. Then comment on any scar, sinus, skin condition, ulceration or venous prominence.
Then standing by the side of the patient,
note, compare and comment on any flexion
deformity / genu recurvatum (see fig 1.2.1-A)
any abnormal prominence of the fibular head
and the femoral condyles (as in triple deformity,
see page 26), and then on any swelling, scar,
flexion &enu sinus, skin condition, ulceration or venous
deformity
.-
J recurvatum
prominence. Genu recurvatum is hyperexten-
sion of knee which may be congenital (corrects
spontaneously with age), because of growth
plate inj~.uies (may be due to infection, tumour,
Fig 1.2.1-A trauma) malunited fractures around knee, or
10
BASIC CLINICAL EXAMINATION OF KNEE 11
associated with generalized ligamentous laxity and p~~t polio residual paralysis (PPRP) . Liga-
ments may be stretched also due to chronic synov1t1s (e .g., rheumatoid arthritis) , hypotonia
associated with rickets , and Charcot's disease (see page 273) . In PPRP fixed equinus deformity
is usually associated . Recurvatum of knee in moderate degrees is actually helpful, because it
stabilizes the knee (which has weak quadriceps i.e., knee extensors) in hyper extension .
Finally, standing behind the patient, note, compare and comment on any swelling (see
;, page 177) , scar, sinus, skin condition , ulceration , or venous prominence . Look for any abnormal
prominence at the hamstring insertion (i .e., biceps femoris on the lateral side, semimembrano-
sus and semitendinosus on the medial side) .
• With the patient squatting : If you have previously noted genu valgum/varum, note and
comment on it again, in the squatting position (Flexion test, see page 31) . Note, compare and
comment on , whether the buttocks are touching the back of the heels when both heels are in
ground contact (if this is not possible, there might be hamstring and/or tendoachilles contrac-
ture). Finally request the patient to stand up and then enquire about any pain during squatting
or getting up (may be osteoarthritis , see page 271 ). Note and mention , that ability to squat
normally, with both lower limbs symmetrical, which indicates full range of knee flexion .
• With the patient walking (For gait, also see page 129) : First look for antalgic gait. Next, in the
swing phase note, compare and comment on the free-swing of the leg, or the absence of it (may
be due to patella-femoral pain). Finally in the stance phase, observe and comment on whether there
is full knee extension (or any hyperextension), and whether the knee "buckles" due to instability.
~ ith the patient supine : Most of the clinical tests of the knee are done in this position.
~ With both the lower limbs parallel and aligned along the long axis of the body, note compare
and comment on the attitude/deformity. Comment on genu valgum/varum , swelling/wasting,
suprapatellar quadriceps bulge, patellar position/shape/size/symmetricity, the supra and infra
parapatellar fossae , the patellar tendons and the position of the tibial tubercles.
• With the patient prone : Inform the examiner, that to avoid frequent position changes of the
patient, you intend to do the examinations in prone position, after completing the palpation,
movement, measurement and stability tests in the supine position .
PALPATION
N.B. • Palpation is done with the patient sitting on the edge of the bed and then in the supine
position. Always look at the~ of the patient, when noting tenderness. --
• Temperature : With the back of the

fingersof your dominant hand, note , compare
and comment on the local temperature over
the medial (see fig 1.2.1-B) and lateral
parapatellar fossae , first on the normal side ,
then the affected/pathological side, and again
on the normal side . Then slide the back of
your fingers downwards from the thigh , over
the knee and onto the legs (of both the lower
limbs) to note, compare and comment on the
"temperature gradient". Normally the tem-
perature decreases from superior to inferior.
N.B. : Temperature increases in infection,
malignancy. -------~-- Fig 1.2.1-B
• Tenderness- (A)(Bony tendernesi )

With the knee flexed to 90°, (with the patient sitting
or supine) palpate the femoral condyles and the tibial
condyles (see fig . 1.2.2), circumferencially from ante-
rior to posterior. There may be tenderness at the at-
tachments of the medial collateral ligament (MCL) ,
lateral collateral ligament (LCL), and ilio-tibial band
(1TB) . Next palpate the fibular head (for biceps femoris
insertional tendinopathy, or injury to the superior tibio-
fibular ligament). Then palpate the patella (tenderness
Fig 1.2.2
at the superior pole may be due to quadriceps insertional
tendinopathy, and tenderness at the inferior pole may be due to
Jumper's knee). Don't forget to look at the patient's face.
Finally note retropatellar tenderness, (found in
retropatellar cartilage damage) by the following 3 tests.
1. ~ ohlen 's sign/Clarke sign/Patellar grind tesV : With
the patient supine and the knee extended, apply simultaneous
medial and lateral pressure over the proximal patella so as to
press it into the intercondylar groove . Then ask the patient to
contract (or "tense") the quadriceps. This will cause pain. Re-
peat the same procedure for both the knees , at 30°, 60° and
90° flexion. When the patient complains of pain during the
procedure, the test is positive at that angle(s) of flexi on . Don't
Fig 1.2.3 forget to look at the patient's face (see fig 1.2.3).
2(igction test } With the patient supine and the knee extended , compress the patella with
~our fi ngers, into the intercondylar groove. Then with your other hand , glide the patella in the
intercondylar groove from medial to lateral and then from superior to inferior. Look at the
patient's face and note tenderness.
Fig 1.2.4-A
C
3. Facet tenderness test }. With the t·
Fig 1.2.4-B
. . ,. · pa 1ent supine d h
patella medially, simultaneously elevating it. Then an t e knee extended, push the
retropatellar facet (see fig 1.2.4-A) . Next push th~alpate and note tenderness of the medial
it, and palpate to note tenderness of the lateral r patella laterally simultaneously elevating
forget to look at the patient's face . _ _ _ etropatellar facet (see fig 1.2.4-8). Don't
u'f'r/f'>fJ.I I) ~l?i! ,& lblintLU. ~nh~-
1
BASIC CLINICAL EXAMINATION OF KNEE

------ 13
B. ~ oint lin~ te~de!_n~;-1 _: With th e patient sittin g a~d th e kn ee flexed to g~ palpate with your
thu m or . slide the metallic . b_lunt en? of a meas~ n~g tape) , ~rom be low upwards , along the
anteromed1 al surface of th e t1b1a, ~tarting fro m th e t1b1al tube ro s1ty unti l it "lodges" into a groove
(see fig 2.1. 16- A page 122). Th is shou ld be th e medial joint line, so mark it. Confirm by
passively flexing and extending the kn ee wh ile palpating the joint lin e. Repeat the procedure
along the antero-lateral surface to find the lateral joint line, and mark it. Then using th e pulps
of your thumbs , palpate circumferencially along the joint line, from anterior to posterior. Note and
comment on tende rn ess and/o r lump (may be men iscal cyst/torn me niscu s etc.) .
• Suprapatellar bulge : This may be due to synovi al thickening or intra-articular fluid .
Remember th at synovial thickening may also be palpated over the insertion of vastus medialis ,
which feels "boggy" or "doughy" (see page 27) .
• Intra-articular fluid : (Normally 0.5 ml - 1 ml) 2 methods are popular for detecting small
amount of fluid (Bulge test and Patellar hollow test) one method for detecting moderate
amount of fluid (Patellar-tap) and another method is done to detect large amount of fluid ( Cross-
f/uctuation) .
1 . Bulge test : It can be done with the
patient standing , with the knee extended.
Place your thumb and index finger on th e
medial and lateral parapatellar fossae, and
firmly compress the medial fossa (so as to
empty it) . Then sharply press the lateral
parapatellar fosa . The medial fossa will refill
with a "ri pple" (see fig 1.2.5-A). Fig 1.2.5-A
2 . Patellar Holl ow test : Normally, when the
knee is grad ually flexed , a hollow appears , and
then disappears just latera l to the patellar ten-
don . In the presence of intraarticular fluid , when
compared to the opposite knee , the refilling of
the hollow, occu rs at a lesser angle of flexion .
3. Patellar Tap : With the knee extended ,
compress the suprapatellar bulge with your
thumb and other fingers placed on both sides
(so as to empty it, and push the fluid down-
wards under the patella) . Now, with the tip of
the index and middle finger of your other hand ,
sharply tap the centre of the patella (see fig. Fig 1.2.5-B
1.2.5-B) so that it "sinks" to hit the intercondylar
groove of the femur and "bounces" up again .
This demonstrates a positive patellar tap test.
This test is ineffective when there is excessive
fluid causing "tight and tensed" swelling .
N.B. : Suprapatellar bursa communicates with
the knee joint and extends from the upper
pole of patella, approximately 1 width of the
patient's hand to distal thigh .
4 . Cross Fluctuation : Cannot be done in
very tense effusion. With the knee exten~ed, place
your thumb on one side and the other ringers on Fig 1.2.5-C
the other side of the suprapatellar bulge. Next,
with your other hand , place the thumb and other fingers on the medial an? lateral infrapatellar fosae
respectively . Now alternatively squeeze the suprapatellar bulge and the infrapatellar fossae to feel
the transmitted "fluid impulse" across the joint (see fig 1.2.5-C).
• Other Swellings : Examine, note and
comment on any swelling (bony or soft tis-
sue) under the standard headings i.e. size,
shape, surface, margins, location, con-
sistency, fixity to surrounding structures,
skin over the swelling, tenderness, pulsa-
tility, and transillumination. Anterior soft
tissue swellings may be prepatellar bursa
(see page 176) infrapatel lar bursa (see page
177), or suprapatellar bursa . Posteriorly they
may be Morant Baker cyst (see page 177),
semimembranosus bursa (see page 178) or
popliteal aneurism (see page 178). Medially
they may be pes-anserine bursa (always
about 2-4 fingers below the joint line) , me-
dial meniscal cyst, or a torn part of the
medial meniscus. Lateral swellings may be
biceps femoris bursa (in between the fibular Fig 1·2 ·5 - 0
collateral ligament and the biceps) , or the bursa situated between the popliteus and the
femur, or the fibular collateral ligament.
• Patellar lift-off test : To note synovial thickening. With the knee in extension grasp the
edges of patella in pincer made of thumb and middle finger and try to lift up the patella. Normally
this is possible. In synovial thickening, the fingers slip-off the patella edges. (Fig . 1.2.50)
• Popliteal pulse : Palpate on both sides (for comparison) . The patient lies supine with
semiflexed knee at 30°. The fingertips of both hands are pressed in the middle of the popliteal
fossa (i.e., knee crease) while both thumbs rest on tibual tuberosity. It may be palpated in prone
position with knee partly flexed.
MOVEMENTS
N.B. • The main movement at the knee joint is flexion/extension. However some abduction/
adduction and some rotation (when the knee is flexed) is possible.
• If the patient can normally squat (as noted in inspection), then obviously full range of
flexion is posible, but it does not guarantee full extension.
• Crepitus during movement must be always noted, with your fingers over the patella,
which indicates patello-femoral incongruity/osteoarthritis.
• Testing the muscle power of the quadriceps and the hamstrings is also a must (for
MAC grading see page 155), before examining knee movements.
• Normal range of movement of flexion (from the zero or neutral position i.e. full
extension) is about 150°, which may be less in obese/muscular patients (because
the heels touch the buttocks at a lesser angle). Abduction/adduction and medial/
lateral rotation is about 5°-1 0°.
. • Flexion/E~tension : During inspection if you have already noted normal squatting,

,~form the examiner that full flexion is possible. When the patient can flex the ipsilateral
hip to at leas~ 9_0°, then knee-flexion can also be noted in the supine position , by trying
to touc_h the 1ps1lateral butt~ck with the heel (see fig . 1.2.6-A) actively and passively. If
the patient cannot flex the hip to 90°, knee-flexion can be examined in the prone position
(see fig . 1.2.6-8) in the same way.
BAS IC CLINICAL EXA MINAT ION O F KN EE 15
Full extension 1s the neutral or zero position wh en the thigh and leg are compl etely
aligned . straight, and moves in unison (further xte nsion is call ed hyperexte nsion i.e., genu
recurvatum deformity s e fig. 1.2.1-A} . Zero position can be noted wi th the patient supine on a
Fig 1.2.6-A Fig 1.2.6- B
hard and flat bed/couch/table , without mattress/cushion/padding and requesting the patient to try and
touch the popliteal fossa to the bed (active) (see fig .1.2.6-C}. If there is a gap, apply downward
pressure over the patella with one hand, while lifting up the leg a few inches from the bed with your
other hand (by grasping the leg just above the ankle (passive - see fig . 1.2.6-D}. Remember that
Fig 1.2.6-C : Note - Fu ll active extension is not possible Fig 1.2.6-D
when it is possible passively, but impossibe

actively, it is quadriceps lag i.e., quadriceps
muscle power deficiency. If full extension is im-
possible even "passively" then it is fixed-flex-
ion-deformity (FFD). Full extension can also be
examined in the sitting position , with the legs
Fig 1.2.6-E ; Note : Quadriceps lag
hanging freely (see fig . 1.2.6-E} .
• Abduction/Adduction : With the patient
supine and the knee extended, grasp the leg
just above the ankle with one hand and lift up
the leg about 6" from the bed. With your other
hand support the popliteal fossa so that your
thumb and fingers are placed ~:m both the sides
of the femoral condyles. Now abduct (see fig .
1.2.7-A) / adduct (see fig . 1.2.7-B) the leg by
applying valgus/varus stress respectively. Re-
peat the procedure on the other knee . Note,
compare and comment. Fig 1.2.7-A
16 HANDBOOK FOR ORT HOPAE"D ICS EXAMINATIO N
• Medial/Lateral Rotation : Flex the hip and knee to 90° by grasping the leg just above
the ankle with one or you r hand , and stabilizing the knee with your other hand . Then
alternatively rotate the leg medially and laterally (see fig . 1.2.8) . Repeat the procedure for
the opposite knee . Note, compare and com ment.
Fig 1.2.7-B Fig 1.2.8
MEASUREMENTS
• Wasting Noted in the thigh, (see page 122), and when present also in the leg.
• Q-Angle (see page 23)
STABILITY TESTS
N.B. • The main knee stabilizers are the anterior cruciate ligament (ACL), posterior curciate
ligament (PCL) , medial collateral ligament (MCL) and lateral collateral ligament (LCL).
Other structures that contribute to stability are the quadriceps (mainly vastus media-
lis) , the hamstrings, the joint capsule and the medial and lateral menisci.
• Patient usually gives history of "giving - way". When it happens during climbing stairs
- PCL may be torn, and when it happens during climbing downstairs - ACL may be torn.
• There are numerous stability tests described and practiced. Some commonly per-
formed and popular tests are described in this chapter.
• When Lachman test or Drawer test is positive, always note and comment on whether
the end point is "hard" or "soft".
• Tests for the ACL

1. Lachman Test : Th is test has a very high sensitivity , but it is difficult to perform in
patients who are fat or very muscular. Standing by the side of the patient , grasp the lower
thigh with one hand and with your opposite hand grasp the upper leg with the thumb on
the joint line, and flex the knee to about 15°- 20° (see fig . 1.2 .9-A). For muscular or fat
Fig 1.2.9-A
Fig 1.2 9-B
<• _,
BASIC C INlCA A
-~ j I ':-,
~ ;:,. . .-. . r .
patients stabilize the patie nt's thigh with one of your hand on th e anterior surface and your
own thigh on the posterior surface (see fig . 1.2.9-B) Then applying force try to move the
proxtmal tibia first anteriorly, and th en posteriorly (with respect to the distal femur) . Look
tor any subl uxation anteriorly and wh ether there is a tendency for medial rotation . When
medial rotation occurs it is a positive "Lachman sign" . Repeat the procedure with the
knee flexed to about 30°-60°. If the subluxation reduces spontaneously, then the MCL is
intact while the ACL is torn . If there is no reduction , then both AGL and MGL are torn .
Now repeat the procedure on the opposite knee . Note , compare and comment (don't forget
about the hard/soft end-point) .
2. Anterior Drawer Test : First do the sag
sign , (see fig .1.2.12-A & B) becau se if
present interpretation of the test will be
altered . With the patient supine , both
knees flexed to 90°, and both heels rest-
ing on the bed/table , seat yourself facing
sideways , on the patients feet. This sta-
bilizes the leg , while the weight of the
patient's trunk stabilizes the thigh . Now
firmly grasp the upper leg wih both your
hands, keeping the thumbs anteriorly and
the fingers posteriorly (see fig. 1.2.10). Fig 1.2.10 ; Note : Examiner sitting on the patient's feet.
Then alterntively apply force so as to
"push-and-pull" the leg, and look for any subluxation. Next, repeat the test on the opposite
knee. Note, compare and comment (don't forget about the "hard/soft" end-point). When there
is comparitively more anterior subluxation (positive anterior drawer sign) there may be
AGL injury/laxity, and when there is comparitively more posterior subluxation (positive
posterior drawer sign) , there may be PCL injury/laxity.
3. Pivot-Shift Test : First do the test for MCL (see page 18). With the patient supine and leg
extended, stand on the affected side of the patient. With your hand (which is towards the
head of the patient) , grasp the lateral femoral condyle placing your abducted/extended
thumb over the fibular head, (for stabilisation and palpation). With your opposite hand grasp
the ankle and medially rotate the leg (see fig. 1.2.11 -A). Then, apply valgus stress by
forcefully abducting the leg (which may cause anterior subluxation) and gradually start flexing
the knee. If there is ACL tear, you will feel a "click" at about 30° flexion , when the subluxed
tibia reduces (see fig. 1.2.11-B.). Remember reduction is due to the pull of the ilio-tibial band
(1TB). Interestingly, often the patient confirms that there was the same feeling of sudden
"giving-way" and later "stabilization".
Fig 1 .2 .11-A Fig 1.2.11 -B
4. Single foot hopping test : If the patient can perform single foot hopping, then op r tive
ACL reconstruction may not be indicated, except for atheletes or active sportspersons
O. E ·3
18 HANDOOOK FOR OR HOPAEDICS EXAMINATION
• Tests for the PCL : . .

1 Gravit Si n/Sa Si n : With the patient supine, st and beside th e pati ent a nd support both
· Y g ~ 9 .h
the ankles posteriorly wit your an
h d and forearm (which is towards the feet of the patient)
d t 90° ( t· ·
. th t bO th the hips and the kn ees are flexe o see 19 1.2.12_
Then lift up the leg so a If th ·
·
A) . Bend low an d bnng down your eye line to . the level of. the knees.) If ere 1s PCL tear/
laxity, the affected knee will droop/sag posteriorly . (s~e. fig . 1·2 · 12 - 8 · . ~ou apply poste-
riorly directed force over the tibial tubero sitie~ .. maintaining th e same position , and there is
appreciable posterior sublu xation, it is a pos1t1ve Godfrey test.
Fig 1.2.12-A Fig 1.2.12-B
2. Posterior Drawer Test : Already discussed- posterior drawer sign (see page 17).
• Tests for the MCL/LCL :
With the patient supi ne and knees extended , stand on the affected side of the patient.
Now, grasp and support the femoral condyles from below, with your hand (which is towards the
head of the patient) . Using your opposite hand grasp the patients leg just above the ankle. Then
lift the ankle about 6" from the bed/table and apply valgus stress (i .e., abduct the leg - see
fig . 1.2.7-A) to note MCL insufficiency. Similarly apply varus stress (i.e. , adduct the leg - see
fig . 1.2.7-B) to note LCL insufficiency. Repeat the procedure on the opposite limb , standing on
the other side of the patient. Note, compare and comment.
• Tests for meniscal injury :
N.B. • Medial meniscus is less "mobile" than the lateral meniscus. So medial meniscal injury
is more common than lateral meniscal injuries. e.g ., chronic ACL tear.
• All the signs which are positive for meniscal tears are also positive for meniscal cysts
and discoid meniscus.
• No clinical test has sufficient sensitivity or specificity for confirmatory diagnosis of
meniscal tears. Just as a positive test is not always pathognomic, a negative test
does not rule out a meniscal tear. About 25%-30% children with normal knees and
nearly about 1% of the general population is Mc'murray test positive!
• H/0 "clicking", "locking", increased pain with excercise/climbing stairs/squatting,
and occasional joint-effusion after minor trauma are important clues. Palpation of a torn
meniscus at the joint line, or tenderness at the joint line should make you suspicious.
Remember, the test may also be positive in osteoarthritis of knee. A combination of
history, palpation and special tests for menisci should reasonably place meniscal injury
in the list of differential diagnosis.
1 · . Mc'murray's Test : With the patient supine, stand on the affected/pathological side of th e
patient and grasp and support the patient's knee (for stabilization and palpation) , so as to place. t~e
~ulp of your. thumb on the. lateral joint line, and the pulp of your middle finger on the medial 1°1n;
line. ,:hen with your opposite ~and grasp the patient's foot and maximally flex the hip and th~ k~~-
(see fig . 1.2.13-A). Now, maximally abduct the leg and laterally rotate the ankle / leg and sirnu
S-AStO CLINICA
neously, gradually extend the knee to goo flexion (see fig. 1.2.13-8). If the patient complains of pain
it suggests medial meniscal lesion. Repeat the procedure with medially rotated ankle / leg. If ther~
is complain of pain, it suggests lateral meniscal lesion. Interestingly the degree of flexion where the
Fig 1.2.13-A Fig 1.2.13-8
pain/"snap" / "click" occu rs, indicates the site of lesion (when at about go 0 , the lesion is in the
middle third of the meniscus; when within 0°-60° of flexion, the lesion is in the anterior horn; when
0
at more than go fl exion , the lesion is in the posterior horn) . When the same procedure is done to
bring the knee from go 0 flexion to full extension (i.e. , 0° or neutral position) it is called Bragard test,
and if there is pain/"snap"/"click" then it suggests anterior third meniscal lesion.
2. Apley's Grinding Test : With the patient prone, hold the ankle and lift the leg (to flex the
knee to go 0 ) with one hand . With one of your knee stabilize the posterior thigh by pressing onto
it. Now rotate the ankle/leg medially and compress the knee applying force towards the bed (see
fig. 1.2.14-A). If there is complain of pain/"snap"/"click", it suggests lateral meniscal lesion. Next
rotate the ankle/leg laterally and repeat the procedure (see fig. 1.2.14-B) . When there is com-
plain of pain/"snap"/"cl ick", it suggests medial meniscal injury.
Fig 1.2.14-A Fig 1.2.14-B
3. Thessaly Test : With the patient standing,

request the patient to stand on the affected leg
only keeping the knee flexed to 20°, while you
hold the patient's hands for maintaining balance
Fig 1.2.14-C
(see fig. 1.2.14-C). Then request the patient to
twist the body to one side and then to the other
side, 3 times (producing rotational force in the
knee). If there is meniscal lesion, there will be
pain at the medial or lateral joint line and a
feeling of "locking".
- - - -~ - - - - _~_:_- - I~ -~·
~.;~~:-· 1·
20 HANDBOOK FOR ORTHOPAEDICS EXAMINATION ......·~,.

- _,_,
SPECIAL TESTS
• Glide test for (R) knee : lRe pl ac ( R) with (L)

for e xa minin g th e (L) kn ee ]. It is an use ful tes t to
note the ti ghtn e s a nd th e deg ree of te ns ion of th e
lateral and medial parapat e llar retin acu lum . Norma l
patellar excursion is half the breadth of patell a or 1
quadrant. With th e patien t supine. tand on the (R)
id e of the patient. Using your (L) thumb and index
finger gra. p the proximal patella , a nd gra p the di stal
patella with the (R) thumb and index fi nger (see fig .
Fig 1.2.15
1.2. 15) . ow forcefu lly glide I push the patella. fir t
laterlly and then medially . Repea t the procedure for th e (L) knee standing on the (L) side of the patient.
Co mpari tiv ely, when exces ivc mobility is noticed, the sa me procedure is repeated with the quadriceps tensed,
by requ sti ng the patient to lift the lower limb about 8"- 12" off the bed . Excessive lateral mobility sugge t lax
medial patellofemoral ligament (MPFL) and incompetence of the medial retinaculum (v ice-versa for excessive medi al
mobility), and thus increa ed risk for habitual di slocation of patella. Any crepitation which may be felt during patellar
movement indicates retropatellar chondropath y / osteoarthiritis.
• Apprehension test for patellar dislocation in (L)

knee : [Replace (L) with (R) for examining the (R)
knee]. This test is positive fo r recurrent di slocation of
patella and rarely for hab itual dislocation of patella (see
page 22). With the patient supin e, stand on the (R) side
of the patient. Using your (L ) hand, place your fingers
on th e lateral femoral condyle and the thumb on the
medial margin of the pateUa (see fig. 1.2.16). With your
(R) hand grasp the lower leg and gradually tart flexing
the knee, simultaneously applyi ng laterally directed pres-
sure with your (L) thumb , trying to forcefully dislocate
the patella laterally. Look towards the face of the patient.
For a po itive test the patient will be anxious and ap-
prehensive, may complain of pain, and / or resi t any
further knee flexion. Fig 1.2.16
• Ober's test : This tests detects ilio-tibial band (ITB) contracturc. Reque t the patient to li e ideways on the
unaffected side with the hips and knees flexed (to obliterate lumbar lordo-i ). Then tanding behind th patient extend
the hip and knee of the affected limb maximally and try to addu t the hip ( e fig . 1.2 .17-A) . In ITB contracturc,
adduction will be restricted. Then abduct the hip to about 30° and then I t go . . o that the limb fall freely. In severn
1TB contracture the limb will not touch the table and remain suspended (sec fi g. 1.2 . 17-B).
Fig 1.2.17-A Fig 1.2.17-B
BASIC CLINICAL EXAMINATION OF KNEE
21
• Wilso~ Test : Thi te l is positive in Osteochoudritis De ·.\·icans, which is an aseptic necrosis of the subchondral
bone, classically of the articular urface of the medial f moral condy le, just beside the intercondylar t h h' h
· f f ti · . . . no c , w 1c may
fina lly cause separati
.· on o a part. o · 1e art icu1ar cartil age, producing
. "loose-bodies"· (Other causes. of Ioose-
, bod',es
include ynov.1al chondromal? i , .bro~en o le?phytes or ar!1 cular ca1iila.ge in osteoarthri tis, foreign bodies, torn
emdunar cartilage and om l1m · in d1 'ea es li ke haemoph1lta, tuberculosis and rheumato id arthritis). The condition
i common in ado le cent · who pre ent with knee pain + effu ion. With the patient supine, and th e knee fl exed to 900
tand on the aff~cted / patholo~ical 'ide of the pati~n.t, and ~·asp the ankle with one hand while stabilizing the kne~
with your oppo 1te hand. ow internally rotate the tibia (see fig 1.2. 11 -A) and gradually start extending the knee. The
patient will complai n of pain at so me point, where you hould stop extension, and externally rotate the tibi a. If the
pain i retie ed, then Wil on test i positive. Remember th at the investigation of choice is MRI.
• Grading of tenderness : (I ) Patient local izes pain (II ) Patient winces with pain (II I) Patient withdraws
the limb from the examiner (IV) Patient does not allow to be touched .
• Posterolateral (PLC) injuries : PLC consists mainly of the fibular or lateral collateral ligament (LCL) , the
popliteus tendon , and the popliteofibular ligament along with others structures like the mid-third lateral capsular
ligament (consists of meniscofemoral + mensicotibial parts) , and the biceps femoris . Patients have a varus
thrust gait. PLC injuries usually accompanies ACL and PCL injuries . Dial Test (posterolateral rotation test)
at 30° knee flexi on detects PLC lesion , and at 90° detects PLC+ PCL injuries. Other tests to detect PLC injuries
include External Rotation Recurvatum Test, Reverse Pivot Shift Test, Figure 4 Test.
SOME IMPORTANT BIOMECHANICAL PARAMETERS OF LOWER LIMB
• Anatomical axis of the femur: This is the line passing through the midpoints of femoral shaft (Fig 1.2.18A) .
Mechanical axis of femur : The line joining the center of the femoral head to the center of the intercondylar
•
notch (Fig 1.2 .1 BA).
Mechanical axis and anatomical axis of tibia : The line joining the center of the tibial plateau to the center of the
•
tibial plafond (Fig 1 .2.18B).
Anatomical tibio femoral angle : The anatomical axes of femur and tibia form a valgus angle of 6 ± 2degrees
•
(Fig 1 .2 .1BC) .
Hip knee ankle angle : The angle formed by the mechanical axes of femur and tibia. It determi nes the varus or
•
valgus deviation (Fig 1.2.180). . .
Mechanical lateral distal femoral angle (mLDFA): It is the lateral angle.between th~ mechanical axis o~ fe~ur
• . · · t 1· Normal value · 87 8 + 1 2° A change in mechanical lateral distal femoral angle s1gnif1es
and distal femora 1JOln ine. · · - · ·
varus/valgus due to femoral cause (Fig 1.2.18E). _ . . .
. d. · I ti"bial angle (mMPTA) : It is the medial angle between the mechanical axis of t1b1a
• Mechanical me 1a1proxima · · · · 1 · T
. . · . · t - Normal value · 87 2 +1.5°. A change in mechanical medial proximal t1b1al ang e s1gn1 ,es
and proximal t1b1a 1 Join 11ne. . · · -
varus/valgus due to tibial cause (Fig 1.2.18F) .
"-"-'-'-- Mechanical
Anatom ical
:1
: I
l
I
I
I
:
•
m I
I
I
I
; ' F
D E
C
A B
Fig 1.2.18
Chapter 3
:ABITUAL DI LOCATION PATELLA (HDP)
Theories Discussed
• Types of patellar dislocation • Causes of habitual dislocation patella
• a-angle • Clinical features of HDP
• Imaging - measurements in HOP • Patellar tilt test
• Thigh-foot angle test • Femoral anteversion test
At fi rst sight, the most striking feature often is the prominence of the medial femoral condyle.
This is a case of UR sided habitual dislocation of patella in a ..... year old M/F patient, with the
critical angle of dislocation .... ... degrees.
What are the types of patellar dislocation ?
• Habitual : Lateral dislocation of patella with each and every flexion of knee (i.e., always)
wh ich relocates with extension of knee. It may be secondary to quadriceps contracture .
• Recurrent : Dislocation is episodic and not with every flexion of knee (i.e., occasionally), and
number of episodes should be ~ 3.
• Persistant : Congenital permanently laterally dislocated patella that never relocates .
• Obligatory : Congenital habitual disloca-
tion of patella .
• Acute : Usually post-traumatic .
Causes
1 . Bony factors :
(a) Small patella , dysplastic patella
(b) High up patella (patella a/ta) .
(c) Trochlear dysplasia causing shallow
intercondylar or trochlear groove .
2. Soft tissue factors :
(a) Lateral side - Fig . 1.3 .1 : Lat eral dis loca tion of patella with
• Contracted lateral parapatellar reti - knee flexion .
naculum and capsule.
• Contracted tight vastus lateralis and ilia -tibial band e.g., aft er repeated injec-
tions , causing post-injection fibrosis . (see page 34) .
N.B. • Lateral contracture may be due to infection, trauma, lnjec ion, or congen t I.
• Low lying patella is known as patella baJa.
(b) Medial side -
• Generalized ligamentous laxity (e.g., Marfan's syndrome, Ehlers-Dantos syndrome, etc.).
• Vastus medialis hypoplasia or laxity (e.g., Post-polio residual paralysis, post-surgic 1
weakness).
3. Factors causing increased Q angle :
(a) When tibial tuberosity is more laterally placed. than normal.
22
HABITUAL DISLOCATION PATELLA
(b) Genu valgum .

(c) Increased femoral ante version ('lntoe ga it' and 'sq · r
(d) External tibial torsio n. um mg patella ' are associ ated).
(e) Tight, contracted , lateral parapatell ar ratinacul am
What is Q angle ?
First descri bed by Brattstrom it is the ang le formed between th r ··· . .
ili ac spin e (ASIS ) to the ce ntre of patella and another line ·o· . e ~~e Joining anterior supe ri or
tib ial tuberosity , with .the knee. fl exed at abo. ut 300 (to stab) in1tnhge pate
I ize
e cle
lan~in
re the
of patella
centre to
of the
the
troc. h lea ) and ,, patient supine . .Q an gle in males is 3° _ 10° an d in
) ,. the · f emale s ·1t 1·s 15° + 5°
(Figt.h 1. 3.2 d. .a st nd
a s for quadriceps, and Q angle indicates the direction of pull of p; ell ~
b y e qua nceps .
ASIS
Once the case has been given, the clinical features
to be noted are -
A. History : There may be history of trau ma.
1. Pain : .Diff u.se ,. aching ante ri or knee pa in t hat
agg ravates with cl imbing stairs .
. 2 . Insecurity : Tends to fa ll often , especially when run-
ning.
3. "Giving-way" sensation .
4 . Abnormal promi nence / swelling of medial femo -
ral condy le.
5. Repeated intramuscular injection in lateral thigh
in the past.
B. • Inspection with the patient standing :
1. Genu valgum (may be present) .
2. Knee effusion (may be present) .
3. Quadriceps wasting - especially vastus medialis.
4. Externally rotated tibia (compare the tibial tuberos-
Q
ity and the shin with the opposite limb. To confirm
do Thigh-Foot angle test - see page 25, Fig . 1.3.6) . Fig. 1.3.2 : Q an gle .
5. Scar mark -7 antero-laterally on th igh (may be

post-infective/traumatic/surgical ).
• Inspection with the patient sitting
1 . Patella Alta / smal l patella (compare with opposite knee) .
2. Active patellar tracking : With the knee extendended and quadriceps relaxed , req uest
the patient to tense/tighten the quadriceps . Normally the patella should move more
superiorly than laterally .
C. Palpation (with the patient supine) : Look for, and note patello-femoral crepitus.
1 . Medial tenderness is found only in recurrent dislocation (not in habitu al dislocati on).
2. Retropatellar tenderness I lateral retinacular tenderness .
3. Cord-like tight supero-lateral band is more prominent on flexion of the knee when the
patella is firmly held in its normal position .
4. Flabby / lax medial capsule and retinaculum .
5. Hypoplasia of lateral condyle (compare with opposite knee) .
6. Palpation of scar (fixity to the deeper structures when present)
D. Movement : 1. Critical Angle i.e., the degree of knee flexion at wh ich the patell a slips
out from the intercondylar groove or trochlea . The lower the critical angle , more severe is the
cond ition and poorer the prognosis .
2. 'J ' sign/dynamic patellar tracking : In recurrent dislocation the sign may be positive, i.e. ,
slight lateral patellar subluxation as the knee approaches fu ll extension from 90° flexion with the
patient seated.
E. Measurement : (Compare with opposite knee)
1. Q an gle (in supine)
2. Wasting of quadriceps , measured just proximal to the patella.
F. Test other joints for generalized ligamentous laxity (see page 31)
How will you manage the case ?
Investigations : USG is useful in children when the patella is cartilagenous and not fully
ossified. X-rays are important in adu lts especially axial and lateral views . CT scan may be
done for noting trochlear dysplasia and patellar tilt and also for special measurements (TT :
TG ratio , see page 25) . MRI is useful in children (cartilagenous patella) and also can detect
medial patellofemoral ligament (MPFL) deficiencies in adults.
Operations : More than 100 operations has been described till date!!
1. Most operations have lateral release (of contractures in 1TB, retinaculum , capsule ,
vastus lateralis , etc .) followed by medial imbrication of vastus medialis.
2. In children where the growth plate has not fused , "3-in-1" procedure or Pesplasty is
useful.
3. Medial patellofemoral ligament (MPFL) reconstruction : is a low risk-high reward
option indicated in MPFL deficiency ± trochlear dysplasia.
4. Elmslie-Trillat : Is a low-risk high reward distal realignment option when vastus medialis
obliqus functions well.
5 . Rotational high tibial osteotomy (for severe rotational deformity) and Fulkerson
distal realignment (when there is lateral facet arthritis of patella), are high risk-high
reward options .
X-rays : Ossification of patella begins in the 3rd year and is completed by 6th- 7th year.
1. AP view, both knees in standing (Ortho-scannogram is more useful) : To note genu valgum .
2 . Lateral view at 30° flexion :
(a) Blumensaats' line - Normally a line drawn from the roof of intercondylar notch touches the inferior
pole of patella. (Fig . 1.3.3) If patella is higher then it is patella alta.
(b) lnsall-Salvati Index - Length of patellar tendon : Length of patella = 1 : o. If it is ~ 1.2 (I.e ..
variation of 20%) then there is patella alta.
( c) Blackburne-Peel ratio - Ratio of the length of articular surface of patella to length from inferior pole
of patella to articular surface of tibia, normally is 0.54-1 .06.
( d) Crossing sign and Trochlear bump in the lateral view indicates dysplastic sulcus (trochlear groove).
· . 1.3.3 : Blumensaat's line (X-ray lateral view) . Fig. 1 .3.4 : Note : Laterally di lo t d p It I
Fig
HABITUAL DISLOCATION PATELLA 25
( e) Axial views (popular as skyline view) at 20°-

45 0 tlexed knee and quadriceps re laxed is
the most important routine view . Both knees
are Xrayed for comparison , in identical po-
sition . Patellofemoral relationship, pate ll ar
shape , patellar tilt , su bluxation/dislocation ,
femoral trochlear dysplasia are noted . Wh en
in doubt (mi nimal tilt) , TT- TG (Tibial tuber-
osity - Trochlear groove) distance should be
measured . When >20 mm , distal realig nment
procedure is a must.
N.B. TI- TG distance is better evaluated in CT scan .
Fig . 1.3.5 : Axial view
Special tests :
1. Apprehension test : Not important in habitual but important in recurrent dislocation - (see page 20) .
2. Patellar tilt test : Done in 20° flexed knee . Examiners fingers are placed on the medial side of patella
and the thumb on the lateral sid e. Inability to raise
the lateral facet to the horizontal plane or sli ghtly
past , indicates tight lateral reti naculum .
3. Glide test (See page 20) .
4. Femoral anteversion test : See page 127
5. Thigh-foot angle test : With the patient prone
and the knee flexed 90° measure the angle made
by the axis of foot and thigh . Normally it is 8° to
10°. When > 30° it implies significant rotational
deform ity of t ibi a. (See Fig . 1.3.6) . Another
method of testing tib ial torsion is by using a
plumb-l ine with the patient seated.
6. Ober 's test : lliotibia l band (1TB) contracture Fig . 1.3.6
test (see page 20) .
Some commonly done distal realignment operative procedures for patellar stabilization
1. Pesplasty : Lateral release+ medial imbrication+ inferomedial dynamic-sling using Pes Anserinus ~ stabilizes
patella during knee flexion . Useful operation in children .
2. 3-in-1 procedure: Lateral release+ medial imbrication+ transfer of medial 113rd of patellar tendon to the
medial collateral ligament.
3. Hauser's operation : (Done where Q angle is very high) ~ Transposition of tibial tuberosity together with
the patellar tendon medially decreasing the Q angle . Done in adults . Unpopular.
4. Roux-Goldthwait operation : Transporting lateral half of patellar tendon medially.
5. Galeazzi operation : Semitendinosus infero-medial "check-rein ".
N.B. • Vastus lateralis pulls at 7°-9° angle . Vastus medialis (Longus) pulls at 14°- 18°angle . Vastus me-
dialis (Obliqus) pulls at 50°-55°angle . Vastus media/is obliqus is the most important muscle ,
counteracting dislocation . It is the dynamic stabilizer of patella during knee flexion .
• Recurrent dislocation is mainly caused by the incompetence of medial patellofemoral liga-
ment (MPFL), which provides about 60% of medial stabilization (c.f. glide test) .
• tnsa/1 operation : Suprapatellar vastus medialis supero-medial "check-rein " is a proximal re-
alignment operative procedure.
Chapter 4
UBERCULOSIS OF KNEE
Theories Discussed
• Triple deformity • Etio-pathology of T . B. knee
• Natural history of T.B . knee • Clinical features of T. B. knee
• Management of T. B. knee • Double traction
• Poncet's disease • 'DOTS' treatment protocol
• Knee is the 3rd common site for osteoarticular T.B. (most common is the spine , 2nd com-
mon site is the hip) .
• T.B . of knee may occur in all ages , but it is more common in children.
• Usually well-established late cases are given for examination, but strong suspicion is re-
quired for early diagnosis in the synovitis stage , so that early treatment can be started
and eventually the knee function is better after completing treatment.
• Pathological stages are : Synovitis ~ early arthritis ~ late arthritis ~ complications
and deformities.
This is a case of fibrous ankylosis due to tubercular arthritis of R/L knee, with deformities of flexior
/ posterior subluxation / lateral subluxation / lateral rotation / abduction of tibia, and joint effusion / col
abscess (may be in the leg) / sinus or sinuses and decreased range of movements (usually thl
terminal part is restricted first) / limb lengthening (very rarely) in a ....... year old M/F patient.
N.B. • Only mention the positive findings.
What are the points in favour of you r
diagnosis ?
1 . From history :
• Monoarticular affection .
• Insidious onset with repeated and pro·
tracted incidents of joint swelling with
pain/ stiffness , over a period of few
months.
Fig. 1.4.1 : T .B. of right knee showing semi-flexed • History of contact with T.B. patients
deformity of knee with posterior subluxation. among family / neighbours ; school
friends or associates / colleagues, etc. , or past history of pulmonary T.B., or T.B. of any
other part of the body. Mention lower socio-economic status when present.
• History of gradual increase in swelling and stiffness of joint with pain, and flexed attitude.
• History of night cries , where the patient wakes up from sleep in pain (see page 138).
• Constitutional symptoms, if any (e.g., evening rise of body temperature, chronic cough, weight loss).
• Treatment history of A.T.D. intake (may be reddish colouration of urine due to rifampicin) .
2 . From inspection :
• Initially : semi-flexed knee .
• Later : typical attitude of triple deformity , i.e. , flexion , posterior subluxation , lateral sublux-
ation (sometimes lateral rotation and abduction of tibia are also found) .
TUBERCULOSIS OF KNEE 27
w !ling m b kn ffusio n ± synovial thicke ning) .

• Presence rib th lnus with its di scharg ing material , in the standard way) .
• Quadric
N.B. • M itiv finding s .

• D the pop litea l fossa in standing and in prone position, with the
i n, nd in extension .
3. From palpation :
• Loe I t mper ture : m y be warm .
• Tend mess present , e pecially along th e joint lines , and regions of synovial reflections.
• Swelling when present-describe under standard headings (see page 14) .
N.B. • Have good know ledge of the anatomy of synovial reflections in knee because
you might invite a question .
• Swelling description :
(a) Synovium is boggy , spongy and doughy . It is palpated best over the insertion of
vastus media/is to patella be cause the muscle (not tendon or aponeurotic) gets
wasted early , whereas on the lateral side , the tough thick iliotibial band and
underlying aponeu rotic muscle attachments and quadriceps retinaculum insertion
hinder good appre ciati on of synov ial consistency . Start palpating from medial
sides towards patella . (Wasting of vastus medialis occurs first probably because
phylogenetically this muscle appears last)
(b) Pattelar lift-off test : (see page 14) . To note synovial thickening.
(c) P resence of effusion / fluid , as demonstrated by clinical tests like cross fluctuation
test / patellar tap test / bulge test / patellar hollow test (see page 13).
• Reg ional or inguinal lymphadenopathy , with characteristic features of tuberculous lym-
phadenopathy i .e ., matted , elastic , firm in consistency .
• Hamstrings especially the biceps femoris , is in spasm / is contracted / is very taut.
• Palpation of sinus (if present).
4 . From movements:
• Range of movement is decreased (usually it starts from limitation of the terminal arc, and
later may present as a completely stiff kn ee . Mention the range of movement.)
5 . From measurements:
• Wasting of quadriceps (measured in the area of max . muscle bulk) . in comparison to
• Lengthening of leg (rarely) due to peri -epiphyseal hyperaemia . } the other limb
How does the infection start and spread? What
is the pathology ? What is the natural history?
There is haematogenous dissemination from
a primary focus --? the knee infection starts
usually from the synovium , and sometimes
from the subchondral bone (fe mur / tibia /
patella) and uncommonly from a juxta articular
osseous focus. Initially there is synovi al co n-
gestion with effusion --? later tuberculous granu-
lation tissue (pannus) spreads fro m the synovial
reflections at the joint margins which eventu -
ally grows inwards and destroys the articular
cartilage / meniscus / cruciate ligaments / and Fig . 1.4 .2 : X-ray of T.B. of knee (Lal. view).
Note - Posterior subluxation of tibia and severely
subchondral bone ~ that ultimately heals by
reduced joint spaces.
fibrous ankylosis (see page 270) .
28 HANDBOOK FOR ORTHOPAEDICS EXAM INATION
Destruction of t he cruciate ligaments , together with the pull of hamstrings especially

biceps femoris (lateral hamstring is more powerfu l tha n medial hamstrings) , and supine
attitude aiding gravity for posterior sag are the causes for th e typic al triple deformity.
1. Rheumatic arthritis in child.
2 . Rheumatoid arthritis in adults.
3. Sub-acute pyogenic synoviti s / arthritis.
4. Traumatic synovitis (due to meniscal tear/ loose bodies / ACL tear, etc.) .
Can there be bony ankylosis in tuberculous arthritis ? (Fig. 1.4.3)

Yes , when there is super-added secondary septic arthritis, which may be from an invasive
procedure like aspiration / biopsy / surgery, or development of a discharging sinus or rarely via
haematogenous spread from a septic focus,
elsewhere in the body. However, bony ankylo-
sis is the rule in vertebral tubercular arthritis
(see page 271 ).
Firstinvestigations to confirm the diagnosis.
• ESR, CRP, Hb, DC, TLC, FBS , PPBS.
• Mantoux test. (Controversial)
• X-ray of knee : A.P. and Lat. view.
• ELISA (for lgA, lgG , lgM). Costly and
controversial.
• Exclude HIV.
Fig. 1.4.3 : Bony ankylosis . • Biopsy : FNAC, Needle true-cut bi-
Note - Co ntin ua tion of tra beculae from one bone opsy, Open biopsy of synovium, Core biopsy
to the other across the pre-existant joint. from osseous or periarticular lesion - if seen
in X-ray or C .T. scan.
• Aspiration of effusion , aspirate sent for - Microscopy for AFB with ZN stain, AFB-Cul-
ture , P.C.R for mycobacterium tuberculosis.
Other investigations to detect pulmonary focus include - sputum for AFB for 2 consecutive
days and CXR - PA view.
Once the diagnosis is confirmed or strongly suspected, clinically and by investigations,
treatment plan is formulated .
Treatment : "Double" Traction (Fig . 1 .4.4) + A.T.D.
~ - - - + - - - -0
I
• A.T.D. : 4 drugs + Vit. B6 Some cen- I
tres use DOTS programme (page 29). l t

• Traction is useful
(1) To correct / prevent deformi-
ties ,
(2) To distract articular margins,
prevent friction , and minimize
pain .
(3) To relieve muscle spasm ,
(4) To ensure forced bed-rest and
Fig . 1.4.4 : Double traction .
non -weight bearing.
u U O I OF KN 29
N.B . • Deformity correction is best done by doubl tr ti n ( ~1 . 1 .11 .4) .

• Partial weight bearing is allowed t I st ft r month with rutch s but gentle knee
bending exercises are allowed earlier when th ut f tur s ·ubsid
• If clinically there is no improvement with A.T.D. for 6 w ks thon debridement ;
synovectomy operation may be done .
• Unprotected weight bearing is usually started afte r bout 1 year.
• If there is a painful and stiff knee, despite th treatment, arthrodesls may be done to
relieve the pain. In children , it is done only after growth compl etion. (see page 271 ).
Surgical Options :
(1 ) Debridem e flt - Sy11ovectomy : lt i aim d at c l nrin g th jo int r tu b rc ul a r d bri s a nd increa. in g the
va cul ari ty. Thi operation i indi at d in pnti 111. wi th v ry thi c k . y novi um , and tho e who are not
re pondin g after 6 - 8 week of A.T .D.
(2) Arthrodesi : lt i indicated in very painful a nd tiff joint. . whi ch has fix ed deformiti es, du e to fibrou s
a nkylo, i . Po ition : 15 ° fl ex ion , 5° va lg u , I0° ex tern a l ro tation .
(3) Total Knee R eplacement (TKR): Thi ofte n give. th e be t res ults. lt i wideJy be li eved th at an abso lute
e e nti a l prer qui ite for th e operation is that the patient should be totally free from infection before
the operation . So it is wi e r to wait fo r 1-2 year after co mpl etin g medi ca l trea tment.
N.B. • Some authors have reported very good resulls when TKR was done in p atients even with ac tive
tuberculo is while some surgeons wait for 6-9 months (even 2 years) before doing TKR .
• Other causes of triple deformity: Rheumatoid arthritis. post-traumatic, post-bum contracture.
• Poncet's disease (Tubercular rheumatism) is polyarthritis occuring in patients with tuberculosis, which
commonly affects the knee and ankle. It is aseptic (no mycobacterial involvement can be found in the
affected joints), and believed to the due to immune-reaction (reactive arthritis) . Diagnosis is done by
excluding other causes of polyaithriti s. It responds well to ATD.
'DOTS' FOR T.B.

' DOTS ' programme is be ing used in several centres in Indi a. Under the Rev ised Nation al Tuberc u-
losis Control Programme (RNTCP), impl e me nted throu g ho ut lndi a, " Directly Ob erved Treatme nt ,
Short-course" (DOTS) chemotherapy ha s been advocated. O s teoarticular tuberculosis fall under
the Extra-pulmonary T.B. infection and treatment schedul e ha s 3 ca tegories .
• Cat. J : Seriou s ly ill, NEW extra-pulmonary cases. Treatment is 2H3R JZ JE3 + 4H JRJ. Addi-
tional 1 month if s putum is +ve after first 2 month s .
• Cat. II : Extra-pulmonary cases who have Relapse or Failure . Treatment is 2H JRJZ3EJS 33 +
I HJ R3Z 3fa + 5HJR3fa
• Cat. JI/: N ew ext ra - pulmonary case NOT eriou ly ill. Treatment i 2H 3RJZ3 + 4 H R1.
~u: .
• H -t lsoni azid 600 mg; R -t Rifampic in 400 mg (if body weight < 60 kg) or 600 mg (if body we ig ht
> 60 kg); z -t Pyrazi namid e 1500 mg; E -t Ethambutol 1200 mg .
• 3 -t thri ce weekly do age i. e., a lte rn ate d ay .
• I 2 4 5 -t Number of month of treatment.
' ' ?,H i R z EJ + 4H JR mean 2 month s of 4 dru g c he moth era p y o n a lt e rn ate day .
~~fi~:ed.b;
3
4 month s of 2 dru g chem o th erapy on a lte rn ate da y .
Chapter 5
E V GUM ( NOCK-KN )
Theories Discussed
• Causes of Genu Valgum / Varum • Genu -Valgum-Complex
• Flexion test • Rickets - Clinical features , X-Ray features
• Management of genu valgum • Blount's disease
It is an abnormal outward devi ation of th e long axis of the leg , with respect to the long
ax is of the thigh , in the coronal plane . Normally, the femur and tibia makes an angle of 7°
- 8° (apex medially) . When th is is exceeded , genu valgum is diagnosed .
CAUSES OF GENU VALGUM (Interchange 'medial ' and 'lateral' for causes of genu varum.)
Unilateral Bilateral
A. Traumatic - A. Idiopathic - Commonest .
(a) Fracture of lateral condyle of tibia B. Physiological - Disappears by about
and/or femur. 4 - 7 years .
(b) Trauma damaging the lateral part C. Congenital - e.g., Epiphyseal dysplasias.
of the growth plate (physis) . D. Metabolic - e.g. , Rickets .
B. Infective - E. Inflammatory - e.g. , Rheumatoid
(a) Damage to the lateral physis. arthritis. (Genu varum is common in os-
(b) Rarely , overgrowth of medial physis teoarthritis - see Fig . 1.5.2).
due to increased vascularity (may F. Paralytic - Disorders - Post-polio re-
be due to infection , trauma, tu- sidual paralysis , charcots disease (see
mour). page 263) .
C. Neoplastic - e.g. , exostosis , G. Miscellaneous - Osteogenesis
chondro-blastoma affecting physis . imperfecta (see page 262) Paget's dis-
D. Idiopathic ease , etc .
Fig . 1.5 .1 : Genu valgum . Deformity disappears on Defo rm ity pe rs is ts on sit1ing4

sitt ing ~ Femur is at faul t. T ibia is at fa ult
30
----------------~~----~-
Wha t is your diagnosis ?
G NU VALGUM (KNOCK-KNEE) 31
Th is is a case of untla ler I / bil I r I, g nu v I um wit th d formity being mainly in the

fe mur / ibia (or both} . ,tt,
int rm ll eo l r d ist nc of ..... cm in stand ing , pro bably du e to
ri ckets / post-in fect iv / 1 iop lh1 c , et . in .... ... yea r old M/ pati ent.
N.B. • 1ay b a oc1 led with lax m dial co ll a te ra l liga me nt of kn ee , late ral disl oca ti on
of p t Ila , e t rna l ro t lion of proxim a l tib ia (meas ured by Thigh -Foot angle see
page 25 I I-foot (p es plan us) (see page 181) a ve rsion foot , va lgu s hee l, in-
er s d Q angle all of whic hx form the genu-va/gum -complex.
Ho a ou ,agno l1gamentous laxity ?
. The intermalleo lar distance al an kle in stand ing (we ight bea ring) position is increased ,
compared to the dis tance in su pine (with th e patella facing just slightly outwards).
2. Tests for general ized ligamentous laxi ty - bilateral hyperex tensi on of fifth/ index finger 2'. 90 °,
bilat era l thumb can be b ro ught to touch the vo lar d ista l forearm , bi lateral elb ow
hyperexten ti on 2'. 10°, bilateral genu recurvatu m 2'. 10°, and spinal hyperflexion allowing the
Fig. 1.5.2 : Genu va rum of left knee , a patient Fig. 1.5.3 : Genu valgum of left knee and genu va rum
of osteoarthritis. of ri ght knee - descri bed as Wind-blown deformity.
base of palms to touch th e ground . (5 out of 9 - if found is diagnostic) About 5% of normal

population may have this laxity.
Ho w do you confirm whether the deformity is in the femur I tibia or both - clin ically ?
F/exion test : On flexion of knee , if the deformity disappears ~ femur is at fau lt (Fig . 1.5.1).
If deform ity persists ~ tibia is at fault. If partial deformity persists ~ both tibia and femur
are contributory . This is because , at full flexion of knee , the tibia has very little contact with
the poste rior articu lar surface of distal femur , and if the deformity still persists in this pos i-
tion , then tibia surely is responsible . Thi s may be tested either by aski ng the patient to
squat (Fig. 1.5.1), or by full flexion of the knee (see fig 1.2.6-A and fig . 1.2.6 -B : page 14) .
N.B. • For radiological diagnosis to know whether femur or tibia is at fault - see page 21.
• Dwarfs with abnormally short trunk have genu valgum and those with abnormally
short limbs have genu varum .
• Usually for genu valgum , femur deformity is common , and for genu varum , tibia
deformity is common .
ANDBOOK FOR ORTHOPAEDICS EXAMINATION
• On~e you get the case , mark ASIS , centre of patella , tibial tuberosity , medial mal-
leol1 at ankle , and Q angle of both the limbs .
How do you clinically assess I diagnose genu valgum and genu varum ?
1. Normally at birth th ere is physiologi cal genu varum of about 15°, at 1 1/ 2 - 2 years age it
becomes neutral. At 2 - 4 years age it is about 12° valgu s, and at 6 - 8 years it becomes
5° - 7° valgus which is normal in adults . In children < 1O years , when standing with the
patellae facing forward and both knees touching , the intermalleolar distance should be < 8
cm . For genu varum when standing with the patellae facing forward and both heels touch-
ing , the distance between two medial femoral condyles should be < 6 cm.
2 . Normally , the line joining ASIS to th e centre of patella , if extended below , just touches the
medial malleolus (see fig . 1.3 .2). In genu valgum , this line never touches medial malleolus ,
but falls more medially .
Why do you say due to rickets ?
• Age is in favour .
• Rachitic stigmata maybe found e.g., cran-
iotabes, frontal bossing , caput quadratum ,
delayed I deformed , poor dentition history,
pigeon chest. Harrison sulcus, pot belly ,
rickety rosary (most persistent/ common) ,
widened , broadened wrist, bowing legs etc.
• Might have treatment history suggestive
Fig . 1.5.4 : X-ray of bilateral wrists and knees
of rickets . showing features of ricket's

1. Investigations :
(a) X-ray of both hips + femur + knees + tibia + ankle + foot - in standing, with patella1:
facing forward - AP view (orthoscannogram). The line joining anterior hip point (precisely
the centre of the femoral head) to the centre of patella, when extended below, passes
through the 2nd web space and the centre of ankle. In genu valgum, this line touches the
1st web space or falls more medially. Also X-ray of both wrists - AP view to exclude
rickets .
(b) Blood investigations for rickets ~ Ca 2+J,, PQ4+J,, Alk. P04i; Ca2+ x p 2 - < 2.4 m.mol/L.
2. Treatment: (Rough guideline) Treatment should be individualized depending on the degree
of deformity , the condition of physis, the sex / age of patient and the aetiology .
• o - 4 yrs . ~ No active treatment. Just regular observation .
• 4 - 8 yrs .~ Conservative. Medial heel raise, occasionally bracing (e.g., Mermaid
splint or knock-knee brace). Orthotics/braces can be very useful sometimes but may
promote ligamentous laxity. Controversial role .
• g - 12 yrs . ~ Operative stapling of medial growth plate (Hemi-epiphyseal stapling). It
is done only when the lateral epiphysis is intact, viable and growing . (Interchange 'me·
dial' and 'lateral ' for hemi-epiphyseal stapling treatment for genu varum) .
• > 12 yrs . (in females may be considered even at 11 years) ~ Corrective osteotomY.
If the length of limb is shorter, then lateral open wedge is done to gain length. If medial
closing wedge is done , limb length is reduced . Usually High Tibial Osteotomy is done
for genu varum and supra condylar femoral osteotomy is done for genu valgum .
• llizarov's external fixator may be very useful for deformity correction .
0 E
G NU-VA LGUM (KNOCK-KNEE) 33
ti 11 r nu v lg um : 10 cm
f g . Wh en Q ng le is >
n 11 y rs, or in males > 12
ti n 'f r surgery . At age 10 y ars
m for ge nu va rum/intermalleol ar
lgum will n ed surg ry .
, , i ,II, i 1 J r ,wl· <./ J a11glr ·.

ln 'r':l: :rng.l ·h:rn" l l pat ' li ar di ' l ' a ti n. Is . trac ki ng of pa te ll a is di sturbed and may
'au:, howirc mala angle i.· alwa 1: in r asecl in g nu vn lgum .
r • Pt .' t- ,nm, Li . l).'t-inkL'ti , ' 'au:(" give Io. itive l1istory and n ·oplastic, inflammatory cases have positive
fin ling, '.
• S ,·tr op rat· i11 a rive ri k f . Fir. t it. D (6 la kh un it sin 0 le dose) ·upplement atio n is started for
m di':\\ m~uu~ rn m till th I i -\i nical and radiolo 0 ica1 ign of healing (3 - 6 months). Before surgery,
\' it. mu. t le , 1 pp for at l a r 3 , k. to pr nt pos t-operati ve hypercalcaemi a and extra-osseous
'al 'ifi-:1ti n.
f th e chil d p Li t . pare nt , mu st be co un sell ed a bout th e probability of
re'urring f rmity. which ma_ need _nd operati o n, after a few years.
• If:.? m gr wth p t nti aJ i left ( a age 12 yr .). urgical overcorrecti on is done to co mpensate for future
gr wth .
• Genu Yarum ne ·er correct with age, but worsens. Thus decision fo r opera tion s may be taken earlier.
• Preoperati\ e cli ni al and radio logica l exa minatio n should indi ca te wheth er di stal femora l or proximal
tibial o teotomy i needed. and al o the degree of correction needed. It is ideal ly do ne by locating CORA
ee below). and id ntifying the ape · of th e deformity.
X-ray features of ricket Fig . 1. - .4 and Fig. 1.5 .5)

• Epiph e -? Widening and de layed appea ra nce.
• etaph e -? Cupping and playing.
• Diaph e ~ Decreased bone den ity i.e.. rarefacti o n.
• Bon deformitie like genu arum/ algu m.
• Double contouring of the haft. due to ubperiostea l
o teoid ti ue deposi tion .
• Greenstick fr actures ( ee page. 2 16)
Fig . 1 .5.5 : X-ray fea tures of ri ckets
~ hat i B lo uut '. disea e ?
It i a progres ive tibia ara (not tri ctly genu varum) du e to abnorm al growth of the postero- medi al pa1t of prox imal
tibial growth plate. 80% are bi lateral. Internal rotati on of tibi a may be assoc iated. X- ray how typica l ' beak' haped
metaph i and media ll y flattened epiph ys i , and ometimes frag mentation. Correcti ve o teotomy with sli ght over
coITection i th e treatment.
lliotibial ba nd co fltracture is a k n o wn cause of ge11u valg um . What are th e 7 typical deformiti es, that are
aHociat d , it!, iliotibial ban d co ntracture ?
(1) Ini ti all y due to pelvic obliquity and fi ed abduction de form it y of hip, there may be appearent lenthenin g, bu t
fi nally there i true . horteni ng of the limb, (2) Ankle/foot : Tali pe eq uino varu s, (3) Leg : Ex tern al tibi al
tor ion (4) Knee: Fie ion co ntractu re, genu valgum (5) Hip : Flexion, abduction, external rotation (FLABER),
(6) Pelvi : Pelvic obliquity, (7) Spine: Iner ased lumber lordo i , lumber scolio i .
~ hat i\· COR '>
l t i the Center of Rotation of An gulation which how th e apex of th e defo rmi ty, ideally where th co rrec ti ve
o t otomy should be done for better re ult . l t i draw n over ortho- ·canogra m X-ray .
E ·5
Chapter 6
RIC P CON ACT
Theories Discussed
• Clinical features of quadriceps contracture • Pathoanatomy of quadriceps contracture
• Ely's test • Management of quadriceps contracture
• Muscle contractures are either idiopathic/congenital, infective, (osteomyelitis of femur

may cause tethering of quadriceps) post surgical (for fracture shaft of femur) or acquired
due to ischaemic myositis, post-traumatic myositis or commonly , injection myositis.
• Post-injection fibrosis is seen in the deltoid (see page 43), quadriceps , triceps and the
gluteal muscles .
• Quad riceps contracture is evident very early in life , and almost always in the infancy or
childhood.
This is a case of progressively worsening quadriceps contracture of the UR side due to post-
injection fibrosis , in a ..... year old M/F patient. [If there is no H/0 injections , then give th..;
diagnosis as congenital quadriceps contracture. If genu recurvatum, habitual dislocation p,
tella ± patella alta or anterior tibial dislocation is associated , then include them in yot ·
diagnosis].
What are the points in fa vour of your diagnosis?
• From history
(1) Repeated/multiple injections were given (usually antibiotics) in the thigh during infancy
childhood .
(2) Several years later, there was gradual and progressive but painless decrease of
knee flexion , resulting in the patient not being able to squat, or sit cross-legged.
N.B. : After skeletal maturity the condition is non-progressive.
• On examination
(1) Increased lumbar lordosis
(2) Normal skin creases over the knee are absent.
(3) On passive knee flexion , dimpling of skin appears over the anterior thigh (not always
found) and knee flexion is not possible beyond 10°-15°. In the maximally flexed posi·
tion of the knee , the quadriceps feels taut and cord-like.
(4) Genu recurvatum , anterior subluxation of the tibia , or habitual dislocation of patella
may be associated .
(5) Wasting - decreased circumferrencial measurement of thigh .
(6) Decreased knee flexion .
(7) Ely test may be positive when rectus temoris muscle is affected (see page 36)
34
-,•1<_r:· ·· .• - ; . - · : - ~ - ~ --- ----- ~ - -
Q UADR ICEPS CONTAACTURE
35
Which muscle is primarily affected ?
• Vastus intermedius is primarily affected. Vastus lateralis may also be affected in post
injection fibrosis .
Why dont you give your diagnosis as habitual dislocation of patella ?
• That is because patella dislocation was not present from birth , which developed later, sec-
ondary to progressive kn ee stiffness due to quadriceps con tract ure.
What are the treatment options of quadriceps contracture in general ?
• If detection is early, then passive quadriceps stretching exercises daily, i. e., several
times a day is beneficial. Can be tried up to 6 years of age.
• Surgery is not done before 6 years , but surgery is a 'MUST' when scar-contracture is
established. In established contractures , earlier the su rgery, better is the final outcome
and prognosis , because results deteriorate with delay .
What do y ou kno w about th e patho-anatomy .

.,
• Corn pre sion of mu scle- bund le. and ca p,·11 an·e · d u 10 the 11olu111 e and inJ·ury du to rh e toxicity of rh e
inj ected dru g ca uses - . .. . .
(i) Fibrosi of the vastu s interm ediu and tethering of the r ct.u s femon. to the femu, a1ou11d the uprapatel 1ar
pouch (sometimes more proxima ll y) .
(1
·1
·) Adi1 1·on between th e patell a and the femorn l co ndy lcs may occu r. .
(iii) Sometime , f ibrosis of th e va. Ills lat rali . and its ex pansion occur, re. ultrng
· · tJ1e1•r adhe 1011 to the
111
/. o ·aJ condy les Thi s may cau. e habitual di. loca ti on of p.atell a.
em lly,
(i v) Fina 1 a ru al hort
· t:nin
· g of th e re ru. femori . occur. . In rerm.. o f prognos1· , rh i i · the worst case
. cenario.
How will you kn o w, whether vastu lateralis, va tu intermediu s or rec/u s f emori . i.1 contracted.? , .
• ff vas tu latera J1. 1.s 1nvo
. J ed . rh en u· ually ooenu valgum and habitual di location / ubluxat,on of patell a '
a.. ociate~. . . . n oe nu re urvatum ± knee hyperexrension may be found.

• Jf vast us ,ntcrmed1u ,s ,n ol ed. th '=' .
• It. rectu1- fcmon.s, 1.. 11. 1 ol ed • ther will be po itive Ely test.
n 1H, [ I f MINATI N
halll,ll ' !- t\' ·111 r llh'ri, lt~htn ·~:- ,u1d /l11 i11i1,1til>11 l,r 1hc fem ra l ncr e. Bot h th e I "er limb. are tested for
mp:111.'l'll I h' t',lt1 ' 1\l II ' :< t'rl,111· 111111w lilt k . Exami ner stand: ovt:r th e p·1tient 1th one hand on the patient' s
1c' 1.
11." ' r b,I ' .ind tlh· ,,th 't h11ldi11i:. th, rl, ,1. l'he l ,:rn1incr p·ts i ivel. flexes th leg upon th e thigh trying to touch
th , lh' I I th, l lllll · ri.:-. l . , . I ). rt1 , test is I o:1tiv when th e pati nt j unabl e to touch the heel to the
l \lit ~· . w ,, I\ '1' tlh' hip , ith th1' h rni -1 l lvi: raise. off th tab le (fig. 1.6.2). or if there i extreme pain or
tini:.lin~ 111 b.1'k ,f I '~s .. \ JK sitiw lL'~t 111d1catcs ti ghtnc , fr tu s femo ri, , or femoral nerve irritation due 10
l\lml H:I ' t ,II I ':1 ,n u!.. . l l \ ' l l.'L'1' pai:. _ I ).
Fig . 1.6.1 Fig . 1.6 .2
n hat i: th , r I of .Y-ray., in a en.·t• of q11adricep!-; co11tracture ?

l1ang , ·Hen \'er ,'e n in art C'l . . bu t '- ra have a d fi nit role in un tr at d. n =I t d ae
n are -
Pat Ila : H 1 p pl a.' ia fragmenrati n f th inferior pol . pat Ila al ta . pr ~ • iv ht ral di pla em nt.
(ii Kne joint : 1 gl t d old r pati nt. ma hav fl att ned f m rat nd ,i~ .. g nu re ur atum. ·mkri 1r
ublu ·ation/di . locati n of th e ribi and gro d g n nti n of the knc j int
.B. • If the que tion i - ho, will ou manage this ·as ? Then (\a . fir t l will do an X-ray f th kne
joint to detect th bony change , and then dt: ide on the management. utlin ~ of th tr ·itment
option which are v ell-suited for th particular c·1se i aln.:ady di cu ' ed . Co,ms lli11Sl r th puti 111
and pati nt' guardian i v ry important, b cause prog11osi • is alwa) s guarded. and curly en ourag-
ing re ult may later deteriorat with tim . Exten. or lag i.' a compli ation .
• Surgical optio11s are -

D Se11gupta 's proximal quadriceps release : Indicated in 1.:arl comrncturc, wh1.:n th r an n . ie-nifi-
cant bony chang sin the kne joint. Proximal rdca e ha th advantage ()fl :s r p . t-opuati\~ Im
quadricep -lag, and decrea ed incidem:e of po. t-op rativc knee haemarthr . i '.
D Tlrompso11 's quadricep!,p[as~y : Succ1.:cds ry wdl when -
(i) Rectt1, femoris mu cle i not involved, or minimally in ol ed .
(ii) Rectu fcmori . can be uccc ·sfully di .• ect d out of the fibrou · . c '\r ti • u
(iii) Rectu femori achie e it ma ·imal str ngth and pokn, , du 10 diligent I o.'t-o~rnll · r-
ci. e and phy. icaltJ1erap .
D If gen11 rec11rvat1m1 -) Supracond Jar femoral o. t otom 1•
D If habitual di locatio11 patella ( c pag -4. __ )

0 If se,•ere degenerative changes+ symptoms Con ·id r anhrod ·i-.
Chapter 9
BASIC C IN CAL EXAMINATION OF ELBOW
Theories Discussed
• Tinel's si gn • Flexion test for cubital tunnel syndrome
• Ochsne r's pointing index sign • Pen test
• Nail sign • Stability tests of elbow
INSPECTION
(1) Have a female attendant for a female patient. Explain the procedure to the patient, (i .e., what
you will do and what the patient will be required to do) and ensure verbal consent. The patient
should be fully exposed from the shoulders to the fingers on both the sides.
(2) The patient should stand (or sit on a stool , if there is difficulty in standing) . Both the upper limbs
should be ideally in the anatomical position i.e. , upper limbs by the side of the body in the
coronal plane , with elbows extended , forearms supinated , wrists in neutral position and thumb
and fingers extended . If the affected limb cannot be brought to the anatomical position , request
the patient to keep the affected limb as close to the anatcmical position as possible , and then
bring the opposite limb to identical position , so that both the upper limbs are symmetrical.
(3) From the front : Note, compare and comment on the attitude/deformity, under 2 headings -
obvious flexion deformity (when present), and the carrying angle (don 't mention carrying angle
when the elbow cannot be fully extended or the forearm fully supinated - see page 53) . Then
compare and comment on the biceps bulge, depression of the cubital fossa , upper forearm
shape and bulge , any noticeable wasting or fullness/lump/abnormal swelling (may be myositis
ossificans - see page 60) , scar, sinus , venous prominence.
• Then request the patient to abduct both the arms to 90°, and look for "gunstock deformity"
(see page 53; fig . 1.10.4).
(4) From the side : Note compare and comment on any fixed flexion deformity , the proximal
brachioradialis bulge, any lump/abnormal prominence (e.g. myositis ossificans , tip of the ole-
cranon in posterior dislocation elbow etc.) and wasting, scar, sinus , ve_nous prominence.
• Then request the patient to flex both the shoulders to 90°, keeping both limbs straight in
front with the palms facing upwards and note , compare and comment on any hyperextension
(see fig 1.9.1) or fixed flexion deformity.
Fig. : 1.9.1 : Note : hyperextension Fig. : 1.9.2 ; Note : 3 bony points relationship
45
HANDBOOK FOR ORTHOPAEDICS EXAMINATION
46
From the back : Note, compare and comment on the tri ceps tendon , prominence of the
(5) olecranon , the para-olecranon hollowes/depress ions, prominence of the medial and late ral
epicondyle s, pre sence of any abnormal lump and wasting , sca r, sinu s, venous promi nence.
• Then request the patient to place both the hand s (1st web space) over the highest point of
iliac crests, with the elbows faci ng back (see fi g 1.9.2). Note , compare and comment on
the 3 bony point relationship (i. e., medial epicondyle , lateral epicondyle and the tip of the
olecranon) . Usually when the elbows are 90° fl exed, they "nearly" form an isosceles triangle,
with the intercondylar li ne forming the base.
PALPATION
N.B. • The most important aspect of elbow examination is probably the palpation of bony
landmarks. Remember, tenderness is sought and elicitated simultaneously.
• Don't forget to look at the patient's face when seeking tenderness .
• Temperature : With the posterior side of the fingers of your dominant hand , note and compare
the temperature over the cubital fossa and the anconeus triangle in the following order- first the
normal side, then the "affected/pathological" side, and finally again the normal side .
• Supracondylar ridges of right (R) elbow : [replace right (R) with left(L) when palpating the
left (L) elbow). With the patient standing (or sitting on a stool) stand on the right side and
slightly beh ind the patient and hold his/her (R) distal arm with your (R) hand , so that the elbow
is flexed to about 90°, and the arm is slightly abducted and extended until the tip of olecramon
becomes clearlt visible and _the forearm is maximally supinated . Now with yo ur left (L) thumb
on the lateral side ~nd t~e tip of y~ur (L) index or middle finger on the medial side and the (L)
palm on the posterior s1~e (see _fig 1.9.3) , start palpation from the fleshy/muscular midarm ,
gradually downwards unti l you find the sharp and pro_ minent bony ridges , both medially and
. you r thumb
laterally. Roll . (on the lateral
. ' I s1·d e )
side) and your index/middle finger (on the me d 1a
rom an
f . k ·t · enor to posterior
.
to confirm the bony ridges. Note, compare and co m en on th e1r
m t ·
th 1c ening , 1rregu 1anty and tenderness .
Fig . : 1.9.3
• Medial and lateral epicondyles of ri h F'.g . : 1.9.4
palpating the left (L) elbow]. First al !et (R) elbow : [re~lace nght (R) with left (L) when
condylar ridges (as described e t p ' locate a nd c?nfirm the medial and latera l supra-
middle finger tip downwards anda~ier).I Now gradually slide your palpating thumb and index/
outward ends, ~hich are the media:S~~ ly, till you r~ach the most pointed , sharp and prominent
co'.11ment on tenderness as in lateral de l~teral e~_,condyles ~see fig 1.9.4) . Note, compare and
ep1condylitis or golfer's elbow (see a :1condyllt1s or ten ni s elbow (see page 166) , medial
Normally epicondyles lie in the p 9 169 ) a nd also the symmetricity of the epicondyles.
coronal plane or sl' htl .
Olecranon and it's tip . Th . '9 Y posterior to the corona l plane .
• · · e u1na is a complet 9 I
proximal end. So start palpating the b
b .
Y su cutaneous bone, and the olecranon is its
su cutaneous bor der - o f the ulna from just bove the wrist
BASIC CLINICAL EXAMINATION OF ELBOW
47
and gradually. proceed proximally till y~u reach the flare.d end , i.e., the olecranon . low proceed
upwards/proximally to reach t~e prom1~ent end of ulna 1.e., th e tip of olecronon. Note, compare
and comment on tenderness , 1rregulanty.
• 3 bony point relationship : The 3 points are the 2 epicondyles and the tip of the olecranon.
• Joint line : First palpate and confirm the lateral epicondyle. Then palpate further distally and
downwards till you find a transverse groove. (i.e., the space between the radial head and the
capitullum) . This represents the lateral joint line of the elbow. Confirmation is done by slightly
flexing /extending and pronating/supinating the elbow to note that there is no movement at the
joint line .
• Right (R) radial head : [replace right (R)

with left (L) when palpating the left (L) el-
bow] . Start with palpating the lateral epi-
condyle then the lateral joint line (as de-
scribed above) . Move below and distally to
note a dimple and palpate its distal portion
to find the smooth , rounded surface of
bone , just below the joint line, which should
be the radial head . To confi rm , keep the
pulp of your left (L) thumb on the radial
head, and holding the patient's distal fore-
arm with your right (R) hand, gradually and
alternatively pronate and supinate the fore- Fig. : 1.9.5
arm . Your left (L) thumb pulp , would notice the simultaneous and similar movement of the
radial head . (fig. 1.9.5)
• Lump : Any abnormal swelling should be palpated wh ich can be a non-united fracture (e .g.
fracture lateral epicondyle) or myositis ossificans (usually felt anteriorly just above the
cubital fossa , within the brachialis muscle). Describe the lump under standard headings
(see page 14).
• Palpation of the right (R) ulnar nerve at the level of the elbow : The ulnar nerve descends
into a groove (cubital tunne~ behind the medial epicondyle, and it is palpated in the following way.
With the patient standing (or sitting on a stool) stand on the right side and slightly behind the
patient and hold his/her (R) distal arm with
your (R) hand, so that the elbow is flexed to
about 90°. Then , with the pulp of the 2nd,
3rd, 4th fingers of your (R) hand, palpate
just above and posterior to the medial epi-
condyle in a rolling motion from side to side
(see fig . 1.9.6) . Continue palpating down-
wards in the same manner until you feel a
cord like, slippery structure. This should be
the ulnar nerve . Continue palpating along
it's course to behind the medial epicondyle.
Note, compare with the opposite side and
comment on tenderness/beading , Tinel 's
sign (see page 104) and pliability. Fig. : 1.9.6
• Palpation of intra-articular fluid : It is difficult to appreciate small amounts of fluid in the

elbow joint. If there is a moderately large collection of fluid , then it will be felt as a small cystic
swelling in the anconeus triangle . When there is a large collection then cross-fluctuation may
be elicitated between the anconeus triangle and the medial para-olecranon bulge.
MOVEMENTS
N.B. • Th elbow consists of 2 uniaxial joints. One is the humero-ulnar joint, which is a hinged,
or ginglymoid joint. The other consists of the humero-radial and proximal radio-ulnar
articulations, a pivoted, or trochoid , joint, allowing 2° of freedom in the elbow joint. So it
is a trochoginglymoid joint, or "sloppy" hinge.
• Essentially 2 sets o1 movements are tested at the elbow which are flexion/extension and
pronation/supination . During flexion/extension there is rotation of ulna around the hu-
merus. During pronation/supination there is rotation of radius around the ulna and occurs
at the superior, inferior and intermediate radio-ulnar joint which is represented by the
intarosseous membrane .
• The axis of pronation/supination movement roughly coincides with a straight line joining
the centre of the radial head to the base of the ulnar styloid/attachment of the triangular
fibrocartilage .
• Axis of rotation of elbow is through center of trochlea colinear with distal anterior cortex
of humerus, when viewed from the lateral aspect.
• Flexion/Extension : There are 2 ways of examining the flexion/extension movement.
(A) Patient seated beside a table : The vertical height of the table should be nearly upto
the level of the armpits of the seated patient. Request the patient to place both the upper
limbs parallely over the table , with the armpits wedged on to the edge of the table , so that
the elbows are extended, forearms supinated , wrists are in neutral position and the fingers
extended. Ensure that there is no gap between the arm and the table-top and the posterior
surface of the arm is firm ly in contact with the table-top along it's whole length (see fig.
1.9.7-A). Then request the patient to flex both the elbows maximally (by trying to touch the
ipsilateral shoulder with the fingers) . Stand on the side of the patient and note, compare
and comment on the range of flexion of both the elbows (see fig . 1.9.7-8). The normal range
is from 0° to 150°/160°.
Fig. : 1.9.7-A Fig . : 1.9.7-B Fig. : 1.9.8
B. Patient standing or sitting, but there is no table : Both the arms should be hanging freely
like a "plumbline", by the side of the body in the coronal plane . The elbows should be
extended, forearms supinated, wrists in the neutral position and the fingers extended . Then
request the patient to gradually flex both the elbows maximally (try to touch the ipsilateral
shoulder with the fingers) . Stand behind the patient fixing the arms to the body, and note
compare and comment on the range of flexion (see fig . 1.9.8) .
C. Hyperextension : To note hyperextension, request the patient to flex both the shoulders to
90° (in sitting or standing position) so that the elbows are fully extended , forearms supinated,
wrists in neutral position and the fingers extended. Due to gravity , any hyperextension at the
elbow will be revealed , when viewed from the side (see fig . 1.9.1).
BAS IC CLIN ICAL EXAMINATION OF ELBOW
49
• Pronation and Supination : The patient can sit or stand . Both the arms should be hanging
freely like a "plumbline" by the side of the body in the coronal plane, and both the elbows
should be fl exed to goo (or as close to goo as possible) , keeping both forearms in the
midprone pos ition . Then request the patient to hold 2 long penci ls/pens in clenched fists,
keeping the wrists neutral (see fig . 1.g.g_A) . Standing behind the patient fix the arms to the
side of the body. Now request the patient to rotate the forearms maximally so that first the
fingers face downwards towards the floor (for pronation, see fig . 1.g,g_B) and then upwards
towards the roof (for supination see fig . 1.g,g_c) . Note the angles made by the pencils/pens
with the perpendicular, compare and comment. The normal range of movement, from
midprone position is about 80°/go 0 •
(A) (B) (C)

Fig . : 1.9.9 : 3 Pronation and Supination
MEASUREMENT
N.B. • Ideally the true length of the arm should be measured from the topmost part of the hu-
meral head to the elbow joint line in the mid-axis of the arm . This is technically not
feasible or possible. So the nearest, easily palpable bony prominence is chosen for mea-
surement, i.e. , the angle of acromion (instead of the humeral head), and the lateral epi-
condyle (instead of the anterior joint line) .
• For the same reason the length of forearm is measured from the lateral epicondyle to the
tip of the radial styloid process .
• Both the upper limbs must be symmetrical in position while measurements are being taken.
• Length of arm : The angle of the ipsilateral acromion should be identified first and it is
palpated in the following way . With the pa-
tient sitting/standing , and with both the arms
hanging freely like a "plumbline", by the side
of the body in the coronal plane , stand be-
hind the patient. Then start palpating down-
wards from the fleshy/muscular region (mid-
point of the root of the neck and the shoul-
der , through the trapezius and the su-
praspinatus muscle) , till you feel the sharp
and nearly horizontal bony ridge , which is
the scapular spine (see fig . 1.9.10) . Now
start palpating lateral ly along the spi ne of
scapula till you reac.h the sha rp ang ular
bend at the outermost lateral part. This is Fig . : 1.9.1 o (a = scapular spine, b = angle of acromion)
the angle of acromion .
"
• For palpating and confirming the lateral epicondyle of the humerus, see page 46.
0 . E. - 7 -------------=--c::mc::::a-=::a::::===============.....,--
50 HANDBOOK FOR ORTHOP/\EDI S EXAM INATION
• Keeping both the upper limb s in symmetric I po ition , m a ure th nee from hs
angle of acromion to the I t r I picondyl on both ide , cornpar and ornrnen .
• Length of forearm : Tl1e ipsil t ral r di I styloid tip should b identifi d firs and it i palpa ed
simultaneously along with the uln r styloid wi h your two ind x fingers in the followin vay.
• Styloid relation ship : With the fore rm pronated and the wri st se mifl xed stand in Iron of
the patient and using both your hands hold the patients sli ghtly palmar flexed hand so that
your thum bs are placed on the dorsum and your 3rd , 4th , 5th fingers support the palm . This
leaves both your index fingers free to si -
multaneously palpate the radial and ulnar
sty loids. Start palpating from the di stal
forearm (see fig. 1.9.11 ), along the medial
and late ral sid e in the coro nal plane,
where you wi ll fee l the subcutaneo us bo ny
borders. Proceed downwards and distall y
over the prominent outward flare of th e
distal radius and the ulnar head, till you
reach the sharp bo ny ends, wh ich are the
radi al and ulnar styloids. Note that the
19 1
radial styloid is mo re di stal than the ul nar Fig. : · ·1
styloid (more in pronation less in supination) . To confirm , deviate the wrist rad ially and ulnarly
(which makes th e styloids prominent). Then alte rn ately dorsiflex and palmarflex the patients
wrist usi ng your thumb and other fingers to note th at th ere is no movement of the styl oids .
• Fo r pal pating and confi rming the lateral epicondyle of the humerus, see page 46.
• Keeping both the upper limbs in a sym metrical position , measure the distance from the lateral
epicondyle to the radial styloid on both sides , compare and comment.
• Wasting : The girth of the arm and forearm is measured at a region , where visually th ere is
gross discrepancy. It should also be measured at the same distance from a fixed bony point
of th e elbow (e. g., the lateral epicondyle or the tip of the olecranon etc) for both sides. So first
measure the girth of the "affected/pathological" side where visually there is gross wasting,
then measure the distance from that level to the fixed bony point in the elbow (e.g., lateral
epicondyle), next measure the same distace form the fixed bony point of elbow in the "non-
affected/normal" side, and lastly measure the girth at that level. Note, compare and comment.
• 3 bony point relationship : Identify the lateral epicondyle , medial epicondyle and the tip of
olecranon , ¼{ith both the upper limbs in symmetrical position i.e. , either from the back with both
hands on the hips, elbows facing backwards (see fig. 1.9.2) , or from the front with both
shoulders flexed to 90° and elbows maximally flexed (see page 55) . Measure the inter-
epicondylar distance, ar:id the distances from the tip of the olecronon to the medial and lateral
epicondyles of both the sides. Compare and comment.
• Carrying Angle : see page 54.
MISCELLANEOUS AND ,SPECIAL TESTS FOR ELBOW

• Neurovascular examination : /
Examine the median nerve, radial nerve and the ulnar nerve (see page 101 ). Next note the
radial pulse and the nail-bed return .
1. Tinel's sign (for Cubital Tunnel Syndrome) : Inflammation , injury, comp ression and
traction can cause ulnar nerve neuropathy . Using a reflex hammer or the tip of the your
index finger with the patient's elbow flexed to 90°, gently tap on the slippe ry and cord-like
structure (ulnar nerve) behind the medial epicondyle of elbow and enquire about radiating
pain , level of radiation I tingling into the forearm (see fig . 1.9.12-A; also see page 104).
BASIC CLIN ICAL EXAMINAT ION OF ELBOW
51
Fig. : 1.9.12-A Fig. : 1.9.12-B
2. Flexion test (for Cubltal Tunnel Syndrome) : Elbow is fully flexed and then you
maximally flex the wrist (see fig . 1.9.12-B) . Maintain the position for at least 5 minutes.
Maximal traction is applied on the ulnar nerve in this position , and any paresthesia along
the ulnar nerve distribution implicates compressive ulnar nerve neuropathy at the elbow.
3. Ochsner's pointing index sign : Request the patient to fold both hands with the fingers
interlocked . In median nerve palsy, there will be weakness of the flexor digitorum profundus
(FOP) and flexing the index finger will not be possible (see fig . 1.9.13-A) . Note - Index
finger has an additional extensor indices muscle attachment.
4. Pen test : Request the patient to place the palm on a table facing upwards. Hold a pen
over the thumb and ask the patient to try and touch the pen with the thumb so that the
thumb is abducted (points towards the ceiling) (see fig 1.9.13-B) . In median nerve palsy
abductor policis brevis weakness will not allow this . Movement takes place in 1st
metacarpo-trapezium joint which is a 'saddle joint '. Abductor policis longus which is
supplied by radial nerve cannot initiate abduction but can continue abduction .
Fig . : 1.9.13-A Fig .: 1.9.13-B
5. Nail sign : Request the patient to oppose the tip of the thumb and the little finger. In
median nerve palsy , there will be weakness of the opponens pollicis muscle, and the
patient will adduct the thumb rather than oppose it. The patient will fail to touch the tips
of the thumb and the 5th finger.
• Stability tests of elbow

1 . Ligamentous instability of the (R) elbow for varus / valgus stress : With the pati.ent
seated or standing, s'tand on the (R) side of the patient and firmly grasp the lower arm J~st
above the elbow with your (L) hand, and hold the distal forearm with your (R) hand, keeping
the elbo~semiflexed to about 30° and the forearm supinated . Then forcefully abduct (see
fig . 1.9.14-A - for valgus stress test) and adduct (see fig . 1.9.14-B - for varus stress test)
the elbow which causes stress at the medial and lateral collate ral ligaments of elbow
respectively . Repeat the procedure for the opposite elbow. Note, compare and comment
on the range of excursion and pain , to detect varus or valgus instability.
Fig. : 1.9.14-B
Fig. : 1.9.14-A
2. Test for posterolateral rotatory instability of elbow : It is the most common elbow
instability. With the patient supine, stand at the head end of the patient. Grasp the distal
forearm and maximally supinate the forearm with the elbow extended (see fig . 1.9.15-A)
Then apply a valgus stess and compression while gradually flexing the elbow (see fig
1.9.15-B). When postero-lateral instability is present, the patient will be afraid and bE
apprehensive when the elbow is flexed to about 25°-30°.
Fig. : 1.9.15-A Fig. : 1 .9.15-B

.1-
• Epicondylitis tests
(a) Tests for ,lateral epicondylitis of elbow (Tennis elbow) : Many tests practised e.g.
Thompson s test and Cozen's test (see page 167- 168), Chair test, Bowden test, Mill
test, Motion stress test, etc.
(b) Te5ts for med~al epicondylitis elbow (Golfer's elbow) : Many tests practised e.g.,
Reverse Cozens test, Forearm extension test, Golfer's elbow sign (see page 169).
N.B. • Mobile wad of. 3 (Henry)

. . · J us t a bove 1ateral ep1condyle
· ·
- extensor carpi radialis brev1s,
extensor carpi rad1alls longus and brachioradialis.
• Brdachf ioradhialis is th e only muscle which extends from distal end of one bone to the distal
en o anot er bone · It's primary tunerion ·1s elbow flexion in midprone position ' of the forearm,
Chapter 1 O
CUBITUS VARUS
Theories Discussed
• Carrying angle • Causes of cubitus varus
• Management of cubitus varus • Supracondylar fracture of distal humerus
• Complication of supracondylar fracture • Management of supracondylar fracture
• Gartland classification • Soltanpur technique
• Baumann's angle • Myositis ossificans
This is a case of R/L, dominanUnon-dominant sided cubitus varus deformity (or may be post-
traumatic stiff elbow with gunstock deformity), probably due to malun ion of supracondylar frac-
ture , with (or without) restricted flexion and restricted pronation with (or without) distal neurovas-
cular deficit, in a ...... year old M/F patient.
[Once you get the case, mark the carrying
angle of both the upper limbs and also the 3
bony points (see figs . 1.10.3 & 1.10.5 around
elbow)]
Why do you say cubitus varus ?
There is deviation of the forearm towards
midline, with respect to the arm , when com-
pared to the normal. side and also because
the normal "carrying angle " is reduced in
comparison to the opposite side (and may even
be of negative value) .
What is carrying angle ?
It is the angle between th e extended long
axis of the arm and the long axis of fore - Fig . 1 .10 .2 : Left-sided cubitus varus in fully ex-
arm , in fully extended elbow (neutral posi- tended elbow and ful l supinated forearm.
tion) and fully supinated forearm (i.e ., the anatomical pos it ion) . Normal carrying angle
values : Male : 7° - 10°; Female : 10° - 15° (average 11 °). With elbow flexed the angle between
the axis of arm and forearm becomes 6° varus (which helps in bringing the hand to mouth) .
N.B. • When carrying angle is 'Zero' --"7 it is sometimes called cubitus rectus.
• If full extension is not possible --"7 use post-traumatic stiff elbow with "Gunstock
Deformity" as diagnosis, instead of cubitus varus . State that the long axis of
forearm is inwardly (medially) deviated with respect to the long axis of arm . (Fig.
1.10.4). Never say cubitus varus .
• During flexion of elbow , internal rotation of ulna causes loss of carrying angle.
Thus, in fully flexed elbow, there is 6° varus angle . Clinically, axis of forearm is
53
drawn by joi ning the mid -points of a line joining the radi I and ur~, r 'tyr 1<1 1 , tJr.,
the line joining lateral and medial epicondyle s of the humeru (1n £, f0pi<.,;nrJ 111,
line) on the anterior surface of forearm . (Fig . 1. 10.3)
Axis of arm is drawn by joining the
midpoint of a line drawn from the tip of
anterior axillary fold to the most promi-
nent part of the deltoid bulge as seen
from the fro nt, to the midpoint of the 1.-+-- - - - a11 of arm
interepicon dylar line . (See Fig . 1.10.3) ~,.-+-- - - - interepic,ondyla, 1,ri..,
• Mark : (Fig. 1.10.3)
(a) Tip of anterior axillary fold . u1-+- 1s-:-,-- - - c,ur1/in angle
(b) Mo st prominent part of deltoid H+- -,-- - - - a:l'.is of forearm
bu lge.
(c) Medial epicondyle .
(d) Lateral epicondyle .
(e) Ulnar styloid . Fig. 1. 10 .3 : Carryin g Angle.
(f) Radial styloid.
• Cub itus varus deformity is NOT progressive , when it is due to trauma.
Wh y do you say "probably due to ma/union of supracondy/ar fra cture " ?

1. Hist ory of fall on outst retc hed hands followed by pa in and swelling at elbow, fo r wh1'j
the pati ent receive d plaster cas t immob iliza ti on (mention ext ent of plaster and the p i-
tion of elbow and fo re a rm within plaster) for about 3 wee ks (or may have rece iv
ind igenous treatmen t by quacks/bone setters) . After removal of plaster, the patient gradua y
no tic ed th e de formity.
2. On inspection : Reduced carrying angle (or say gunstock deformity) (Fig. 1.10.4).
3. On palpation :
(a) The lateral supracondylar ridge and the med ial supraco ndyl ar ri dg e a re thicken e 1
and sli ghtly irregular (Note --) th is ind icates heal ing/ hea led fractu re) .
(b) The re lat ionsh ip of 3 bony points (i. e ., tip of olecranon , med ia l ep ic o nd yl e an c
latera l ep ico ndy le) is unal tered but the whole triang le is medially rotated (i n com -
parison with the oppos ite elbow) (see fig. 1.10.5B).
4. Lengthened arm but normal forearm length . (may be unchanged due to overriding .
5. Most co mmon cause of cubi tus varus .
N.B. In lateral condyle fracture , only lateral supracondylar ridge is th ickened , and the 3 bony
points relationship is altered.
!
What are the other causes of cubitus varus ?
1. Infective : Medial growth plate damage.
2. Vascular : Osteonecrosis of trochlea.
3. Traumatic : Lateral condyle fracture of
humerus .
4. Neoplastic : Secondary to exostosis in
distal , lateral humerus .
5. Congenital : Epiphyseal dysplasia.
Fig. 1.10.4 : Gunstock deformity.

What specific "ma/united-position " is responsible for cubitus varus? ~
Medial tilt/shift, medial (internal) rotation and posterior tilt/sh ift. - of the distal humerus
C UBITUS VAAUS 55
How do you clinically confirm 'Medial tilt ", "Medial rotation ·· and "Posterior til t " ?
1. Length of arm (as measured from the ~ngl~ of acromion to the lateral epicondyle) is slightly
increased when compared to the opposite side , but the 3 bony points relationship is intact i.e.
medial epicondyle is at a higher level compared to the lateral epicondyle of same side and
the medial epicondyle of the normal side. This indicates medial tilt in coronal plane.
2. External rotation of sho uld er is decre ase d whil e intern al rotation is (ofte n) inc reased
when compared to the opposite si de . Th is ind ica tes medial rotation since there is no
rotation possible in the el bow joint. Also, the late ral epicondyle is palpated anteriorly w.r.t.
the lateral supracondylar ri dge .
3. Rotation and tilt can also be assessed by compari ng th e tri angle fo rmed by the 3 bony
points of both elbows , side by side, whe n both are flexed and po inting towards the back
(Fig . 1.10.SA) or in fro nt, (Fig . 1.10.58 ).
Fig. 1.10 .SA : Fig . 1.10.5B : Left sided restricted el bow fl ex ion
with 3 bony po int tri ang le media lly rotated .
4. Flexi on of elbow is restricted , and there is hyperextension (due to posterior tilt), but the
arc of movement is same. Mechanical obstruction by anterior bony sp ike due to posterior
sh ift will cause only restriction of flexion , with reduced arc of movement.
N.8. • If the initial question is - What are the points in favour of your diagnosis? Then
summarise as -
From history : Fall on outstretched hand , then the treatment history .
From inspection :
• Carrying angle is of negative value , (or say) ax is of the forearm is medially deviated
with respect to axis of the arm . (Do not mention carrying angle if elbow cannot be fully
extended.)
• '3' bony point relationship is maintained but the triangle is medially tilted in the coronal plane.
From palpation :
• Medial + Lateral supracondylar ridges are thickened and irregular.
• Three bony points relationship is intact, but the medial epicondyle is at a higher level
than the lateral epicondyle.
From movement :
• Internal rotation of shoulder i external rotation J, in comparison to the opposite side
but the total arc of motion is eqiJ. al.
• (If present) elbow flexion J, (see Fig . 1.10.58) extension i
From measurement : Length of arm i (maynot be present)
How will you manage· the case ?
lnvestigatjpn : X-ray
1. Both elbows, in one film , in ful l elbow exten si on and supinated forearm - AP view.
(To compare and as ses s th e ex act degree of correction that is required .)
2. Lateral view of the affected elbow (to assess the posterior tilt/shift).
Operations : Wait for at least 1 year after injury tor fu ll consolidation of fracture union.
1. Lateral , closing wedge supracondylar corrective osteotomy (French~modified French
osteotomy). (Fig . 1.10 .6 and 1.10 .7). Length of arm is shortened but 1s more stable and
unites qu ickly
Fig . 1.10.7 : Pre- & post-o pe ra t ive AP vi ew of

Fig . 1.10.6 : French osteotomy . French osteo tomy.
2. Medial opening wedge supracondylar osteotomy (King's osteotomy). Here length o'.
arm is gained , but is less stable and there may be delayed union.
3. Others : Dome osteotomy, Step-cut osteotomy.
What can be the problems if operation is not done ?
Cubitus varus is a risk factor for lateral condyle fracture of humerus in future . Tardy ulnar
nerve palsy has been reported due to a fibrous band between 2 heads of flexor carpi ulnari s
or subluxation of the nerve . It is a visually disturbing cosmetic deformity . Also any nerve near
the fracture may get entrapped within the callus causing tardy nerve palsy - METEV'S SIGN.
SUPRACONDYLAR FRACTURE ELBOW

• It is a MUSI KNOW for all orthopaedic exam inees . In children , about 70% of fractu res
around elbow are supracondylar fractures.'
• It may come in theory paper, and may be asked in any practical table .
• Most comrri'on in 5-8 y,ears of age. After 9 years, elbow dislocation is more common .
• More common in boys than girls. More common in the non-dominant side (majority- left) .
Why is this fracture more common in 5-8 years of age ?
1. At this stage remodelling of bones occur constantly and rapidly , and there is decreased
antero-posterior diameter in the supracondylar reg:,on of humerus. Thus the cross-section
is flattened (not round or oval), which reduces its sfructural strength.
2. Ligamentous laxity in this age, increases the risk of "hyperextension" elbow injuries.
3. Presence of radial fossa, coronoid fossa and olecranon tossa , furt~er weakens the bone.
4. Anteri_or capsule is thicker and stronger than the posterior capsule. In extension, the taut
~nterior capsule acts like a fulcrum , due to which, th e olec ranon gets fir mly engaged
in t~e olecran~n fossa , and with hyperextension , the olecranon pro c es s ?nay strike
against the th,n supracondylar region , thus fracturing it. __
CUBITUS VARUS 57
What is the mechanism of injury ?

Fall on outstretched hands with hyperextended elbow.
What are the types or classifica tion of s upracondylar frac ture hum erus ?
1. Extension type - 98% (distal fragment is posteriorly displaced) .
Gartland classification (Fig . 1.10.8) -
Type I : Non -displaced .
Type II : Displaced with intact posterior cortex or periosteal hinge .
Type Ill : Completely displaced .
Type I Type If Type Ill

Fig . 1.10.8 : Supracondylar fracture - Extension type .
2. Flexion type 2% (Fig. 1.10.9) (distal frag-

ment is anteriorly d isplaced) .
Type I : Non-displaced .
Type 11 : Dis placed but intact anterior
cortex .
Type Ill : Completely displaced . Fig . 1.10.9 : Supracondylar fracture- Flexion type .
N.B. • In elbow dislocation , most common mechanism is fall on outstretched hand with
slightly flexed elbow, because the ligamentous laxity is less after 9 years .
• About 75% of supracondylar fracture are postero-medially displaced . This is be-
cause the line of "pull" of the biceps brachialis is medial to the humeral shaft, and fall
on outstretched pronated hand forces the fractured fragment postero-medially.
• Commonly associated fractures are distal radius and proximal humerus .
What are the complications of supracondylar fracture ?

A. EARLY COMPLICATIONS -
1. Neurological injury (7%) : Most are neuropraxias (see page 104) requiring regular
observation up to 3 to 6 months . If there is no recovery by 3 to 6 months, then opera-
tive exploration ± neurolysis may be considered .
• Radial nerve injury is common with postero -medial disp lacement.
• Median nerve or i ts anterior i ntero sse ou s branch injury is common in postero-
lateral displacemnet and also overall commonest in all supracondylar fractu res .
• Ulnar nerve injury is most common with flexion type of supracondylar fractures .
2. Vascular injury : Clinically nail -bed return , radial pulse and Pul se-Oxymeler measure-
ment of nailbed return is essential. Commonly , vascu lar statu s is restored after frac-
E. · 8
58
ture reduction . If circulation does not

return after reduction, with the elbow
immobilized at less than 45 0 flexion ,
within 5-10 minutes , vascular surgeon
should be consulted .
N.B. • Only absence of Radial pulse is not

significant, which may return even
after 1 week.
3. Acute compartment syndrome : Se-

rious but rare. This can be exacerbated
by elbow hyperflexion , when there is Fig . 1.10.1 o : Neurovascular Entrapment.
excessive swelling around the elbow.
B. LATE COMPLICATIONS -
1. Deformities : Cubitus varus is the commonest. Medial rotation of the fractured frag-
ment leads to medial tilt which causes cubitus varus. Very rarely, cubitus valgus may
be seen .
2. Myositis ossificans traumatica : Rare complication. Occurs usually after repeated ~~
nipulation of the elbow and/or regular massage. (see page 60) . Incidence of myos1t1s
ossificans also increases if open-reduction-internal-fixation (ORIF) is done >5 days after
injury .
How would you treat an extension type fracture ?
1. Undisp/aced and minimally displaced fractures - After reduction (see Figure 1.10.11)
are immobilized in plaster slabs for 3 weeks , with the elbow in maximal f/exion that does
not jeopardize the radial pulse, with the forearm in pronation when displacement was
postero-medial (decreases chances of cubitus varus), or in supination when displacement
was postero-lateral (increases stability). Extent of plaster is from the deltoid muscle inser-
tion to the proximal palmar crease and just short of the knuckles , excluding the base of the
thumb .
Reduction by pressure over olecranon , Gradual elbow flex-
Traction and while maintaining traction .
counter-traction . ion , forearm prona-
tion while checking
radial pulse .
t
Fig. 1.10.11 : Manipulation technique for reduction of extension type supracondylar fracture .
2. For displace.d fractures, Clo.sect ~eduction Percutaneous Pinning (CRPP) is the treat-
ment of choice, where manipulation under anaesthesia and · · · ·
confirmed in image-intensifier (C-Arm) Then , , . reduction 1s done , which 1s
2
duced to 'fix' the fracture Finall • . or 3 K wires are percutaneously intro-
1
for 3 weeks . . Y pu se is checked and plaster cast/slab is applied
3. If satisfactory closed reduction cannot b d .

open reduction and internal fixar b e one,, ?r r.adia! P~ls~ remains jeopardized, then
. . , , . ion Y 2 or 3 K wires 1s indicated .
4. Two d1verg1ng K wires are first introdu d f .
fracture fixation is checked If u t bl ce rom th e lateral eprcondyle and stability of the
· ns a e then a 3rd 'K' · · ·
t dt
(avoiding the ulnar nerve) from th ' d. wire 1s introduced very carefully
epicondyle. (Fig. 1.10.13 and Fig . 1~.~ epic 0nd Y1e, or sometimes from the lateral
VA
s. When there is gross I/in
the fracture is open
Dunlop traction is
treatment. (Fig. 1.10.12
Disadvantages of Dunlop t
1. Cannot b applied v
2. Elevati on of fracture
m
ction :
( 11 1d11 11
II dtl <, 11 0 11 \
'rrI /1 [w
V I
of heart is not possibl
N.B. • Always che k post-r duction di ~J
,,,'
tal neurovascular statu . ,
,,
,'
• If open -reduction -int rn 1-fi lion
(ORIF) is done , it must be within
4 - 5 days, to reduce ch nc s of
myositis ossificans.
I . 10.12 : unlop tr lion .
Fig . 1.10. 13 : 2 'K' wire Fig . 1. 10.14 : 3'K'wire
What i ~ Cioltanpur tec/111iq11 e '?
D e cribed by Pro f. A . o ltanpur from T ehran . ir i a 2 ·<age tcchniqu for r ducti on of j7exion type supracondy lar
fractures , w her e lh e elbow i imm obili z d i n 90° fl cx i on. (No1e : ommonl y . .f7exio11 typ e fracture arc oft en
i mm obil ized in elbow ex ten i on. whi ch has th e added advan tage o f good X -ray vi ew , and thus early diagnosi of
cubitu varu s.) Fir t th e arm i pla tered ----t reducti on ----t I ng arm pla ter i compl eted.
Whal p recautio11 .1 are tak en to pre ,•ent ulnar nen•e injury. when iutroducing the m edial ·K ' wire in Cl?l'P '!
lnci si on i gi ven and direct vi ·uali zati on o f th e media l epi concly le i required. The m dial soft-ti s ue mas (con rain-
ing th e uln ar ner ve) i pu shed bac k posreriorl y wirh fin gers, and th e elbow i fully ext ended . The ' K ' wire i
introdu ced through a d r ill -s leeve.
What are th e d1ffere11ce.1 he/ ween ' Fren ch · and 'M od~fied French ' fl'cl111iqne ?
In Modifi ed French tec hniqu e the in ci · ion i po l ero - l at era l ( not po terior), osteoc lasi i clon e keepi ng a bony
hinge (not o teotomy) , and the whole tri ccp i mobili zed ( 1101 the lateral half of lricep ) with ulnar nerve di ssection .
What are th e ct1n 1·e1 of re1·tricted elbo w f/ l'.l"io11 aflL'r .111prncondy lar fracture ?
M yo iti s o sifi can . anr cri or bony pike. uni on in po teri or tilt . prol onged immobili za ti on, triceps contrac ture.
What i1 th e tim e of appearence of os ,ificatio11 ce11lrt'.1 around dbo w?
• Capit ellum : 1-2 y rs. l{adial head : 3-4 y r . I nt ' rn al (m di al) condy le : 5- 6 y r , T rochlea : 7- 8 yrs, O lecranon : 9-
10 yr . l sx ternal (l ateral ) oncly lc : 11 - 12 y r . ( Pnemoni CRJTO E).
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MYOS I T IS O SIFI CANS lRCU M SC RIPTA

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Chapter 11
0 TE IOR OISLOCATIO ELBOW
Theories Discussed
• Clinical features of posterior dislocation elbow • Terrible triad of elbow injury
What is your diagnosis?

This is a case of untreated/improperly treated , posterior dislocation of A/L, dominant/non-
dominant elbow of ....... . months duration , ± neurodeficit , ± myositis ossificans traumatica
± associated malunited fracture around elbow (mention the specific fracture) , in a ... .... .
year old patient. (Say only the positive findings) .
N.B. • A recent or fresh dislocation will never be given
as a case, because its treatment is an emer-
gency. Once you get the case, mark the 3
bony points of both elbows, radial and ulnar
styloids, and the angle of acromion.
• The fractures commonly associated with el-
bow dislocation are -
• Radial head
• Coronoid process of ulna
Fig. 1. 11 .1 : X-ray-showing disloca-
• Medial epicondyle tion of elbow with fracture medial
• Very rarely olecranon, trochlea. epicondyle.
What are the points in favour of your diagnosis?

1. History :
(a) Patient had a fall on outstretched hand with slightly flexed elbow, after which there
was pain, swelling and inability to move the elbow .
(b) There may be history of indigenous treatment , massage and bone-setting attempts.
Repeated attempts of massage is a risk factor for myositis ossificans traumatica.
2. Inspection :
(a) The point of olecranon and the tri-
ceps tendon insertion is very promi-
nent on the affected side in com-
parison to the other side.
(b) Attitude ~ semiflexed elbow.
(c) Elbow antero posteriorly broadened.
(d) Wasting of periarticular muscles (if the
case is of long duration).
3. Palpation :
(a) 3 bony point relationship is altered .
(b) A bony hard mass (may be tender),
smooth surfaced, anterior and just
above the cubital fossa , not fixed to
skin, is palpable (myositis ossificans
Fig . 1 .11 .2 : Posterior dislocation elbow .
traumatica) . (Fig. 1.11 .3)
61
4 . Movement : Range of movement - both fl ex ion/exte n sion and pronation/supination 15

grossly reduced in comparison to the oth er limb .
5. Measurement :
(a) Length of forearm is reduced with norm al arm length (in comp arison to the other
limb) .
(b) Distance between the 3 bony points is changed . If late ra l epicondyle to olecranon
distance is decreased = posterolateral dislocation . If medial epicondyle to olecranon
distance is decreased = posteromedial dislocation .
(c) Circumferrential measurement at the level of cubital crease is increased.
6. Tests for neurodeficit for the ulnar, median and radial nerve must be done (see page 105).
How will you manage this case?

• First confirm diagnosis by X-ray of elbow ~ AP and Lat. view , and note other lesions if
present, like myositis and other fractures. (see Fig . 1.11 .1 & 1.11.2)
• Then prognosis of operative intervention is explained to patient/patient party, which is
guarded and not very favourable (post-operative elbow stiffness remains) .
• Operative procedure : open reduction of humero-ulnar joint, with lengthening of con-
tracted/tight triceps (V ~ Y plasty) and maintaining reduction with internal fixation (usually
with a 3 mm K-wire/steinman pin driven through olecranon into the medullary cavity of
humerus + another pin through the capitellum into the radius). Alternatively hinged exter-
nal fixator may be used to allow controlled early movement.
• May require arthroplasty in adults ~ lnterpositional arthroplasty (fascia!).
~ Replacement arthroplasty (total elbow replacement.
~ Resection arthroplasty.
What is ' 'terrible triad " of elbo w injury'!

Di slocati on elbow + radial head fraclure + coronoicl proces fracl ure
What is th e pathoa11ato111y of elb ow dislocation injury ?

Capsuloligamentous injury during di loca ti on progre ses from latera l 10 m cl '· 1 · 1 .
Medial collateral ligament i the mos t importa nt elbow stab·1·· . Tl '" w rt 1 .1 po. ter l at r.i l rotatory me hani ~111.
of ct· J II · ' 1 rzer · 1e las t stru c ture 10 b ·111 · d ·
me 13 co atera 1 ligament, and first to be inJ·urecl is the lat . 1 " . c JLJr i s the ant eri or h,1nd
in th e · f · · era co 1atera 1 li g·,ment wl · J1 • I
in error portion o f the l ateral epi condyle I· 1 . ' ,, c rs avu cd from tuhcrck
wire i rep,e ent s th e cent.re of r ot11tio11 or c lb
What kind of joint is elbow joint ? w.
The elbow i s composed f . d
gin I m ' d . . o_ two in epenclent uni axia l joint s One i , I h ..
g Y 01 , Joint. The other I the humeroradial 8 d . . · . s c hum ' rou lnar J0 111 t. whi ch i s a hi11 1,1 ·cl. 01
allowing 2 degr f f . 11 pr ox im al rad rou ln ar ·rrt'e I· · . . . t.
.. ,, . ees O reedom 111 th e elbo w ·oint Tl . . . ' 1 u ,llron~, a p1vot ccl , or tro cho1d, Join
sloppy hin ge type of joint. J . 11 ar11 cul at1 0 11 ha. bee n term ed a tro ch og in gl ymo1d Joint. or
What a~e tire mo,,em ents in th e elbo w Joints ?

Motion in the elbo w in · vo 1ves rotation of h
of the r adiu s around LI . . . t e ulna around the hum , d · . . .
elbo . h i e u 1na during supin ati on and . crus unng fi e ' n and e I ·n ,on a11 I , 0111r10n
w 1s at t e center of the hi · pronatr o n The in 'l'i I f · . '
rotation of th e elbow r true . ca when viewed from th e l a;era l , ~ ' n c ~t r o fl ex ,o n and e ten sion 1'01 the'.
humeru s through th ,es ant erior to th e humeral midi inc . d a. pc~ t and I 2 to 3 mm in diamc ti.:t.Th. II , is ol
e center of trochlea ( in l ateral view) . ,l n on a line clr:I\ 11 al on g th , an1error cOl'tc, o l ,ti,·
Chapter 12
0 -UNION LATERAL CONDYLE HUMERUS
WITH CUBITUS VALGUS
Theories Discussed
• Management of lateral condyle fracture • Classification of lateral condyle fracture
• Tardy ulnar nerve palsy • Froment's sign
• Card test • Salter Harris classification

This is a case of non-union lateral condyle R/L dominant/non-dominant humerus and cubitus
valgus deformity with (or without) tardy ulnar nerve palsy in a .. .. year old M/F child.
Wha t orth opaedic injuries can be associa ted with lateral condyle fracture of humerus ?
1. Dislocation of elbow .
2. Fracture radial head.
3. Fracture olecranon (may be greenstick).
4. Fracture medial epicondyle (humerus).
N.B. • Even malunion of lateral condyle can

cause cubitus valgus.
• Once you get the case , mark the car-
rying angle of both the upper limbs.
• Average age for occurrence of lat-
eral condylar physeal injuries is
around 6 years.
What are the points in favour of your

diagnosis ?
Fig . 1.12.1 : Left-sided cubitus valgus deform ity.
1. History:
(a) Trauma to the elbow, after which there was immediate pain and swelling around the
elbow.
(b) The patient received no/inadequate treatment for the injury (mention specifics) .
(c) History of gradual outward angulation of the forearm from elbow , together with a small
but prominent swelling on the lateral part of the elbow.
(d) History of gradual weakness of grip/hand functions with (or without) tingling , numb -
ness of little finger and the medial border of forehand (when there is tardy ulnar
nerve palsy) (see page 65) .
(e) May also give history of pain/weakness of the elbow .
2 . Inspection :
(a) Carrying angle is increased in comparison to the other side . (Fig . 1.12. 1)
(b) Abnormal prominence on the lateral side of elbow .
(c) Wasting of hypothenar muscle (when there is tardy ulnar nerve palsy) .
63
3. Palpation :
b t der) situated in the lower part of the lateral supra
(a) A _bony mhassh (may e h~nh is not fixed to the skin and can be moved abnormally.
condylar ridge of t e umerus, w ic
(only very slightly) over the underlying bone .
(b) Distal part of the lateral supracondy-
lar ridge may be irregular.
4. Movement : Full extension of the elbow is
often not possible .
5. Measurement :
(a) 3 bony point relationship is changed.
(b) Carrying angle has increased.
(c) Arm length may or maynot increased.
6 . Valgus stress test may be positive.
7. Ulnar nerve : Palsy may be detected by
tests like Card test and Froment's sign
(see fig . 1.12.4-A, 1.12.4-8). Fig. 1.12.2 : Non-union lateral condyle humerus
with cubitus valgus .
N.B. • Motor weakness appears first, sensory deficit comes later. (see page 104).
• Painless abnormal movement is rarely found in this particular non-union. (see page 94)
How will you manage this particular case ?
First investigation : X-ray of elbow - AP view to confirm diagnosis (Fig. 1.12.2).
Operation :
1. Only anterior transposition of ulnar nerve is done (when there are features of tardy uln; r
nerve palsy), if good functional range-of-motion of elbow is present. It is the safest and tr ~
easiest option .
2. Open reduction is considered only when there is a large metaphyseal fragment an I
upward displacement is < 1 cm from joint surface (in X-ray) . Here fragment is never mob,
!ized to realign the articular surface, and only the metaphyseal part is fixed by screw (so
that further increase of deformity does not occur) and bone graft is also given .
What may be th e complicatiu11.1 if up erath•e fixation i i' n ut don e'!

• Progre sive cubitus va lgus, elbow insla bi lily, l:ll'dy 11lnar nerve palsy .
llow will you treat a fresh fra cture of lateral w 11r~yl f h um l'ru.1· '!
• Mos1 fra ctures require in_ternal fi xa lion by 'K' wires after open rcd11 tion and m in imal d issecl /0 // of o f'! ti\s ucs (io
pre_ven1 avascular necrosis). Fracture 1hat arc undi spl accd or displaced < 2 mm in X-ray ma y be lre.itcd con\Cr·
va t, vely by long arm cas1 and weekl y X-ray exa mination follow-up, to note late di sp lace ment.
Can any oth er frnl'l ure aro1111d tir e elbow be re 1·p tm sihle for c,1/,;1,11 ,·a lg rH d 'form,ty '!
Rare ly upraco nd ylar fracture, es pec iall y the po ·tero la1ern l displacement variety. S~me1imcs n.:g lected Monregg,a
N.B. • !11
X-r~y. th e fra gment looks much ma iler in ~ize than felt clini ally This I becau c much ol the fragment
is cartilaginous and i ' thu not , ecn in X-ray. · ·
• Initially. minimally di spl:i d f
· • cc racture may become complete!) di splaced larer. So follow -up we kly.
• Fractures pre enting after 3 •k . , b .
. .. wee ~ arc etter treated wtth regular ob<,er ation and follo" -ur Early anrenor
Iran. po lfJOn of ulnar nerve is 111 d . I h
fare attem >t . , 1 . • JCatec " en y mptom. of ulnar nerve pal y de velop . Thi~ 1 bc,.,u
• If h , .
I ,1 open reduction have h1· oh · d
. e
r
rnci nee o ava,cular n cro i of rhc lateral conJ ylc
r e patient demands and 111 i ts . . _
,upracondyl· · on co. metic correction de pile good lunct,onal ahility. then a n1rrcdJ' ·
ar o tcotomy may be done (Mi/ell osteotomy) .
~ - ~ - - ~ - ~ - ~::
N~ N7,
·UNION LAT AAL ONOY HUM AUS WITH CUBITUS VALGUS es
I ,1,, ,1/ '''" ii/, '
I\ 1111 ; / I ,·nt "' '' J ,r 1 ' 1
1111 '
1111,111
If th l' fT,lllUfl h,1' 1h11 111111 ·d I 1_ I\·,·!..,. ll ,, 1· 1,1\\ I
ricd .,~ 111111 111111111
ll /un " 1111 / " ,. ,, 111 11/ ta, I , ,111d1 /111 /1 "' 1111, '
.Iii/cl, rfn, , (11ra1ion -

• r,r, / (tt1K, mm,111\ S.rlt,·1 ll .111" t_ p.: I V. d
I 111 rc l,111\1.'h . 1.1hl •. fr.1.:1u1c lino: do.:s n ll in ·
1 11h, th.: tn .: hk.1. ,111,tlkr fragment.
• 7'1'/1 f/(COllllll\11) , Jlttr 11 ,111"1 l\p~ 11 , l' l-

bO\\ ,cl.11111·1 u11~1.1l I·. frar1111,· l111l' tend
11111 the trn hl..:a. largl.'r fragml'nt (Fo , . .rl1,·r
II :mi~ dassi t'i ·:11 i1 11 sec page 66) hu me rus w ilh
.R. • Dlllll 0 11 lu~i,cl~ ,.,y l,llual l'I" ·011el;lc after fl,tlpatron bccau~c the frag me nt is ro tated a lmos t 180°. T he
out rnh\~l and drst,11 -nrn : t point '- a,brtraril taken to he th,· la tera l qnco nd y lc.
on -111111111 of l.u e , .ii ro nd le rare I ma) au . c cubit us a ru · cl ue to hyp r nti a and ove rg ro wth o f th e
lat ·r:il part of ph ys 1 (espc.:ially in Mi/cit T pe II ).
ometimcs the medial arm of the three bony point tria ng l · may be inc rease d clu e t s ublu xa ti o n o f th e
olccran n.
han cs or av:iscular necrosis :aft r surgery ma be minimi . ed with minimal pos te rio r di ssec ti o n a. bl ood
supp l is from 1he rosterior · id· .
• Cubitu: ~:ilgu. dut: to la teral cond le frac ture. is oft en a pron ress ive de formit y clu e to prox im a l mi g rati o n of
fragment 1ogc1hcr with media l c ll n1era l li ga m 111 la ·it y/con . l:l nl . trcrc hing .
• Part . of la1cral cond k : Part of mctap hy is, lati.:ra l part of phy. i. . lateral cpico nd yle. capite llum , lateral cris tac
of tro hi a.
• D ci . ion of : urg.cry is taken when Large metaph ysca l frag ment. di . pl ace ment < I 111 from jo.int. viab le lateral
ond . lar ph •. i. ts1cen in M RI ).
• Fi:h tail def rmi1 : Radiograp hic fi ndi ng in os tco ne ros i. of c:i pil llu m. nus c ubitu . va lg us.
TARDY ULNAR NERVE PALSY

T ardy mean occurring late ;,e.. I t on et ulnar n rv pa lsy. an cur long aft r grow th ompl Li on due to
friction neuriti .
Causes of Tardy Ulnar Nerve Pal y
1. onunion of lateral condy le humeru . ca u ing progre cubitu va lgus.
2. D i placed medial epi ond y le humeru
3. Elbow di location.
4. Con tu ion of the ul nar nerve.
5. Shallow ulnar groove (pos tero-media l part of epi oncl y le of huni> ru i:) , i . •.. cubit.al tunn I.
6. Hypopla ia of humeral tro hlea.
7. Rarely due to cubitu · va ru . deformity.
Clinical features
Weaknes of grip, ting I ing / n um bne s of li1tl e fin ger, pos i Li v, Carri te.,·t (s · fi g I. I _,4-B). pos it iv • From ,,,, '.,·
ig11 (see fig . l.1 2.4-A). Flexion te t ( ee page 5 1) i po iti v .
In vestigation
Nerve conduction ve locity te t (NCY) i. co nfirmalory.
Treatment
• Con erva tive: Elbow ex tension splint s, esp " iall y to b wo rn 11 111 ighl. 0
• Opera ti ve : Remova l of th e ulnar n rv from i ts gr ovc in db w - n ·uro l sis ( i r 11 · ·l·ssar ) und :111tni or
tra n pos iti on to th e fl exo r . urfac o r elbow (s ubcu1 a11 ·o us/ i111rantu s ul ar/s ubn1u srn l11r) .
In all operation • medi al intermu scul ar eplum mu st b ' '· ·is d fro m !he coracob rn ·hi ulis mu s ·I •.
E -9
. . ,. ·~0 11 or do both ~ides ~imullaneously. R.eq
· f I II • 1ornrtl ~I( IC I 01 .:on11" 111 ' liCM
Froment's sign : Fir t per 01111 t 1c ll'~l on 1 1 ' · the ncl i ·tl border of hand, and you try 10 ·
· r ·1i'r bt v ecn 1hc 1hun1 11 am 1 ' ' pu11
the patient to firml y gra~p a piece o P• 1l: . t . k '111d i n order LO ho ld 0 11 Lo t11e paper, there w·ii
the paper away . In ulnar nerve pa~ I • m1(111 1or 11o lic1s· w ill ic wc.i ·rl · . poll ici s w ill be used .in try ing
. to hold 0
1
be ne ion of th, intcrphal angca l joint (, cc li g 1. 12.4- /\ }. bccau~c cxoi · n
lo the paper. . . <>r do both sides simult aneously. Request the patient
. . 1 11c11111
ard tc t : irst perl orm l11e t '~t on tic
. '·ii side tor companso11
· .
· _
II it away (sec l1g 1.1 2.4-8 ). In ulnar nc
I
to firmly gra~p a card i 11-bt:1wccn the -Ith anc - t 1
sI r ., ·r ·111cl yo11 ll y lO pu
111,,c . . • ·11 l . we·1k ·1dduction of the 5th finger.
rve
~ ·11 b ak ·rnd there w 1 J C ' '
pals . the pahnar intc1To~sci mu · 1e w1 e I c· •
Fi g. 1. 12.4-B Card test

Fig. 1.1 2 .4- ro ment' s . i gn
SALTER HARRIS CLASSIFICATI ON O F PHYSE AL INJUR IES

IN CHILDREN (M = Meta physes E = Epiphyses)
Remember Complications of physeal injuries are growth disturbances.
Type I Type II Type Ill Type IV Type V
Type I : Complete separation of epiphysis. Occurs through zone of hypertrophy .

Type 11 : Commonest. Separation of epiphysis with fracture of a t ria ngular piece of bone from metaphy-
sis (Thurston-Hofland sign).
Type Ill : Fracture of epiphysis i.e., Intra-a rtic ul a r exte nsion of the fracture .
Type IV : Intra-articular fracture of epiphysis with the fracture line extending to metaphysis.
Type V : Crushing of epiphysis .
New additions : Type VI - Rin g like rnJury to periph eral port ion o f the ph y i . ( Ran g): Typ <' Vil - Li: lated
injury of the epiph ysea l plate ( Og den): 1) pe VIII - I so lated injury o f t h m et aph y i with po s. ibl c im pai r-
ment o f endoc hondra l o ssifi cati on ; Type IX - Inj ur y o f th e peri o tc um w h i c h may impai r int ram ' tn b r ano u~
oss ifi c atio n.
4 Zones of physis (From epiphysis towards metaphysis)
1. Germinal zone (zone of resting chodrocytes) : Haphazard horizontal orien -

tation of cell groups.
2. Proliferative zone : Cellular proliferation occurs wi lh cells arranged into Epiphysis
long1tud1nal columns.
3- Hypertr':'phic zone _: Extracellular matrix production , cellular hypertrophy ,
Germinal Zone (
apoptos1s, vascular invasion occurs.
Proliferative zone [
4
· En dof_chd 0ndral ossification zone : Provisional calcification zone / zone of
ca 1c11e cartilage . Hypertroph1c zone [
• G roove of Ranvier : T riangular structure at periphery ol physis contain·

_ Endochondral os-
sificalton zon e
mg f1bhroblas ts, chondroblasts. osteoblasts. Contributes to peripheral
growl . Groove of Ranv1er
• Per'.chondral ring of Lacroix : Connects metaphyseal periosteum w ith Perichondral ring of L Cro1
carltlagenous epiphysis, thus stabilizing the epiphysis to the physis. Metaphyse I rt ry
Chapter 13
EG · ECTED (OR IMPRO ERL Y TREATED)
M TEGG A FRACTURE
Theories Discussed
• McLaughl in's line • Management of Monteggia Fracture
• Monteggia equivalent inJuries • Bado's classification or types
• G. B. Monteggia described an injury pattern in the proximal forearm in 1814 where the upper
third of ulna was fractu red and the radial head was dislocated.
• Bado in 1969 fou nd variety of lesions, where disruption of the radio-humero-ulnar joint is
present. tog eth er with diaphyseal ulnar fracture . He called it Monteggia lesion.
• Clinically, the lesion is often missed, especially the radial head dislocation, due to swelling
of the elbow. spontaneous relocation of radial head, or lack of strong suspicion of the clinician
N.B. : • Fracture of distal radius with subluxation/dislocation of distal radio-ulnar joint is known
as Galeazzi fracture, which is 3 times more common than Monteggia fracture (see page 228).
• In X-ray of elbow , look for an imaginary straight line drawn from the centre of radial
shaft and head, which always passes through the centre of capitulum - irrespective of
any position of elbow, or any view of X-ray. This is McLaughlin's line which can detect,
even subtle subluxation of the radial head.
• Mechanism of injury :
(a) Fall on outstretched and pronated
forearm (commonest).
(b) Hyperextension.
(c) Rarely - direct blow on to the back
of upper forearm .
• In c ongenital radia l head dislocation ,
(which is D/ D) radial head shape is dis-
torted, co mmonly bilateral , posterior
dislocation .
This is a case of neglected (if no treatment Fig. 1.13.1 : Neglected Monteggia - Anterio r type.
received) I improperly treated (if treatment re- Note - Ulna is malunited and radial head is dislocated.
ceived), malunited Monteggia fracture of R/ L,
dominant/non-dominant side of .. .. .. months duration, with restriction of elbow and forearm move-
ments, and "bowing" deformity of the ulna, ± pain (when present) in a ..... year old M/F patient,
with (or without) radial nerve pal sy. (Include cubitus valgus if present) .
What are the points in favour of your diagnosis ?
1. History of injury : To right (or left) elbow and forearm ~here ~he mechanis~ of injury was
fall on outstretched and maximally pronated forearm , 1mmed1ately after whi ch there was
severe pain and swelling and inability to move the elbow thro~gh. its full range of moti~n.
2. History of plaster : Immobilization of ...... .. duration (or any other 1nd1genous treat~entXrece1ved
in cases of improperly treated cases) with no subsequent regular follow-up and serial -rays.
67
68 HANDBOOK FOR ORTHOP ArDICS EXAMINATION
3. on inspection : Typical deformity _whic~ is seen cohmrnonly i. ~f., an csri()r ari9 "&
and undue bony pro minence ante ri orly JUS I be low I e cub, a 1 o sa.
N.B. • There may be some other angulation (c~bitus varus/valgu ) or promin'3 :,e a'1/h ,J & ,.
the type of Monteggia fracture , so de sen be what you see frorn th~ f o ai d ,s , e:.
4 . On palpation : , , .
(a) Tenderness may be prese nt, if th~ fr~ctur~ ha~ n~t tu.lly uni ed. 1:regula / _,.,
ulnar shaft with di stinct c hange in d1rect1on , ind1ca ing angulation (an e, 10 /
lateral) of the ulnar shaft. .
(b) Bony-hard , smooth , rounded , prominence palpated on the ant~rror/la .Brn!IP
aspect of elbow which moves very slightly on atte mpted pronat1on/sup1 a 10
ment ~ probably radial head.
(c) Distal radio ulnar joint (DRUJ) instability - Piano key sign positive may be found (see . 7r ,.
5. Movements : Movements of elbow and forearm are restricted (say exact range of eme ,.
6. Measurements : Forearm may be shortened in compari son to the other forear : e
measured in identical position (anatomical position may not be feasible).
7 . Valgus stress test may be positive. (can cause cubitus valgus) .
8. Test for radial , ulnar and median nerve. (see page 105, 106).
How will you manage this case ?
First confirmation of diagnosis by X-ray of forearm includ ing e lbo w a nd tris , A P a d
lateral view . Then treatment : (1) In adults - excision of rad ia l head with co rre c i e
osteotomy of ulna followed by internal fixation of ulna with plating and a lso bone g a ing
(Boyd's procedure) . (2) In children - if functional range of movement (RO M is good ai
till 14 years . If ROM is bad or age is ~ 13 years , obliq ue osteotomy of ulna (for Ieng he ning .
open reduction of radial head with annular ligament reconstruction , with and finally i n erna
fixation of ulna is don e (sometimes with transcapitelar radial head p in fixation). RI may be
done to note cartilage status and shape of radial head and capitellum - before operation .
How will you treat an acute Monteggia fracture ?
Gentle manipul ation unde r anaesthesia to stably relocate the radial head which is
possible when ulnar length is restored by traction and sup ination , a nd if needed d irect
press~re over ~he radial head . Check X-ray o.r check in image intensifier C-arm m~chine).
If radial head 1s not reduced by closed manipulation 4 then open red ucti on an d in ernal
fixation of ulna , almost always relocates the radial head .
Whal are Monteggia equivalent inj uri<•.1· '!

I. Only radial head dislocation. (Fig. 1. 13.2)
2. Fracture uln a with fracture rad ial neck. Fig. I . I 3.2
3. Fracture uln a with frac ture radial sha ft proxi-
mally.
~~
Bado ' Cla s ification or Typ e
I. Type I (60%) Anterior angul ation of ulna ith anterior di loca-
tio n of th e radial head.
I Ll 2. Type JI (20%) Po terior angulation o ulna with po. tenor or po ·
~
Lerolateral dislocation of radial head.
3. Type ffl (I 5%) ~ Lateral angulauon o ulna v. ith lateral or ancerol 1-
eral di. loca tion of the radial head .
4. Type IV (5%) 4 Ant erior angulation ith fracture of b th radiu
111 IV and ulna at ame level. \\ith nten o r di I • th n
of radia l head.
N.B. ~o~plications: Progressive valgus. Tardy ulnar nerve pal M .· .
postenor mterosseous nerve palsy. y. yo 1u o 1fica1ion. Pain/ 11ffn . T
Section - I
SHORT CASES
Chapter 1
CONGENITAL TALIPES EQUINOVARUS (CTE~
Theories Discussed
• Types of CTEV • Probable causes of idiopathic CTEV
• Causes of acqu ired CTEV • Patho Anatomy of CTEV
• Joints involved in the CTEV deformities • Treatment options of CTEV
• Role of X-Rays/ USG/MRI in CTEV • Pirani Score
• Ponseti technique , • Kite's technique
• Bansahel/Dimeglio Modified French technique • Arthrogryposis multiplex congenita
• It is a very common foot deformity, frequently given in examination.

• M : F = 2 : 1, 50% cases are bilateral , 25% cases are associated with breech delivery.
This is a case of R/L sided; unilateral/bilat-
eral ; untreated/neglected/ incompletely treated/
relapsed ; idiopathic; mild-mobile/severe-rigid
variety of congenital talipes equinovarus defor-
mity, in a .... . month old boy/girl.
[Always search for other congenital abnor-
malities, and include them in your diagnosis
when found e.g .. development dysplasia hip
(page 274), spina bifida (page 253), congeni-
Fig. 1.1 .1 : Talipes equinovarus.
tal radio-ulnar synostosis (page 170), unde-
scended testis , cleft lip, cleft palate, syn-
dactyly, polydactyly, constriction rings , etc.]
What does talipes mean?
Tali i.e., talus (ankle in Latin) , Pes i.e ..~
Literally ~ Talar foot , figuratively ~
walking on talus ; practically meaning any
deformity of foot and ankle .
[Clubfoot ~ bat (club) shaped toot]
Why do you say idiopathic congenital
varfety?
Because no othe r cause could be found.
Fig. 1.1.2 : Bilateral CTEV with marked calf
and the deformity was present from birth.
muscle atrophy and deep crease just above heel.
2 HANDtaOOl< FOR ORTHOPAEDICS EXAMINATION
What may be the ...auses cf "Congenital" talip es equtnovarus'>

1. Idiopa thic. (Common~
._;r.s p ina bifida (see page 253) ,
3. A rthrogrypos is multiplex congenita. (see pag e 7)
l)t:Cerebral palsy.
Can talipes equmovarus be non-congenital (i. e. acquired) ?
Yes . Causes -
J)1 Post-polio residual paralysis (but do not mention before 6 months of age).
~ (Post-burn contractures .
\..{2-(Volkman 's lschaemic Contracture (V IC) of leg . (see page 76)
(4) Cerebral palsy.
(5) Leprosy.
(6) Rarely post- tra umat ic , from tars al injuries .
How can you clinically differentiate congen ital from acquired ta/ip es?
In CTEV - The varus component of the deformity is usually more prominent, but in acquired
variety usually the equinus component is more prominent.
What do you mean by untreated I neglected I relapsed I incompletely treated ?

1. Untreated : Has not received any treatment till date.
2. Neglected : No treatment received till the age of 9 months to 1 year, ie., when the child has
started walking .
3. Incompletely treated : Discontinuation of treatment schedule (Which includes maintenance
of the fully corrected foot in appropriate splints after full deformity correction) .
4. Relapsed : The deformity comes back after all the components of the deformity were totally
corrected. Usually equinus recurs first.
5. Recurrent : When deformities reappear while treatment is still going on.
-
What are the foot deformities ? In which joints
do they occur?
N.B. : Mnemonic : CA VE
1. Cavus : Exaggeration of the longitudi-
nal arch of foot, contributed by many
joints.
2. Adduction of forefoot : At midtarsal ~oint
i.e., Talonavicular + Calcaneocubotd.
3. V-arus of hindfoot : At subtalar joint i. e.,
Fig. 1.1.3 : Rigid CTEV toot with renitorm Talocalcaneal joint.
shape , small heel , forefoot adduction . deep 4. Equinus : At ankle joint i.e., Tibio~talar
crease in the medial border ol toot and concave joint with small contribution from fibula
medial border. In the ankle mortise.
What are the differences between mild/mobile type and severe/rigid type ? Whal are
the characteristic features of each type?
Clin ical characterrst1cs/ diffe renc.es are -
'' \'.'~'
,..Jo. -.!,;;.,\ ,!.........,·. . .... . . . I -· ,
,,j,,. ~, _, ·,I \ ! ,,, , • ( • • •
.. "'. - . ;••,.&. . . . , , , .,,,,.( , ' , , . ., :..·· - ' ~.
Severe/Rigid Type MIid/Mobile Type

, . On passive manipulatiGn, the foot cannot 1 . Foot can be passively manipulated appre-
be corrected appreciably to an anatomically ciably to a corrected position.
neutral position.
2 . Atrophied, wiry calf muscles (gastro-soleus) . 2. Calf muscles are not so atrophied.
3. Small sized heel. 3. Heel size comparable to the opposite side.
4. Deep crease just above the heel. 4 . No crease.
5. Small sized, reniform shaped foot. 5. Size/shape comparable to the opposite side.
6. Deep crease in the medial border of the 6. No deep crease in the sole.
foot.
7 . Concave medial border, convex lateral bor- 7. Both borders of foot are very slightly de-
der of foot. viated.
8. Distance between nav1cular and the tip 8. Appreciable definite gap between the nav-
of medial malleolus is much reduced icular and medial malleolus.
(sometimes almost touching) .
9. Head of talus is subluxated outside the ankle 9. Talar head not palpable.
mortise and can be palpated anteriorly.
1O. Callosity on the antero-lateral part of the 1 o. Callosity rarely present (if present, more on
foot, if the child is walking. the lateral border of foot).

Treatment of CTEV is aceording to the a€Je of presentation of patient , and the type of
deformity (i.e., mild/ mobile or severe/rigid variety) . Firstly. proper counselling must be
done to parents about-
1. That the condition is completely curable.
~Needs tong follow-up at least upto 4 years of age and sometimes more.
$.Possibility of recurrence .
4 . May need one , or more than one operation .
There are various treatment regimens practised , all of which employs serial plaster-
casting , of which the Ponseti technique is currently the most popular.
I .,
Ca11 1l,t1rt• b,• a11y 11.H ucwted 1•u,c11ltir ""'m"' Y •
Yes. Many patients have hypoplasuc or abscnl an1erio r tibial artery.
f ,\ tl,cr e u,iy Will' / <1 di ug 11<1H' (TE \I 11n1t•11t1ff1/h '!

Yes. USG at about l ~-20 weeks, with abou1~accuracy
• Th 1foot looks sunilar to a clubfoot during 9th week of gest.uuon, but gradually gets corrected
N• B• eaorma
over ti,ne, with growth.
if A11UUOC.entesis increases &he chance of clubfoot.
4
Role of X-rays i11 CT£1' . .

, I I c lin icu l ·1nd X-ffly ,; have lz.nuted role. X-rays are
• Drnenosn, and trea1111enL dce,sJOtll- are con1p ete Y ' ·
hard t~i ,ntcr)'>rel. rt produce and measure because - .
(i) o, fficulty in pllSlllOning a stiff and deformed foo t 1n a stanuard fashi o n u~der ~he X-ray beam.
(ii) Up to I yea!' onl y Lhe talus. calcuneum and the metatarsals are ossifie<.I , and cuboid o:mfies at 6 months.
Cuneiform o~sili~~ after I year and navicular after 3 years.

(id } Os.sific nuclei do not represent the true shape of predominantly carti laginous tarsals.
liv) Poor cQrrela1ion between radiological ,Hid cl in1cal outcomes.
MRI ca11 1,qwever demot111tr(lfe the gratl11al deformity correction wilh serial p/aster-c~·ts.
• If X-rays arc taken, weigllt-beari,rg f ilms should be taken whenever possi ble. T his helps to assess progress
with treatment.
• '.! views -4 AP view in plantarflexion aod latera1 view i n dorsiflexion are required.
• Talocalcaneal angle in normal foot should be about 30° - 35° in both views. } j, i11 CTEV
• Talometatarsnl angle ~ to note forefoot adduction (normal 5° - 15°).
iHwr are the probable cnrne.~ (l1ypotll esi~ ) oj idiopathic CTEV '!
I. Hereditary : Autosomal domjnant with incomplete (40%) pene1rance.
2. lntrauterw e causes :
(a) I1mauterine pressure abnormalities.
(b) AmnioLiC fhud tension abnormalities.
3 . Talus abnormalities : ln the neck region of talus lies the primary deformity . Sofl tissue deformi 1ies are
caused secondarily.
4. Fibrosis of_soft tissues : Muscles + ligaments in the postero-mediaJ part of the ankle undergoes comracture.
This is the primary abnormality whereas bony changes are secondary.
5. A_!!estedfetal development : Before bt1th, foot is in equinovarus which gets con-ected by birth.
6. Neuromuscular causes like myelomeni ngocele. arthrogryposis multiplex congenita.
N.B. • Mnemonic - HIT-FA N
How can you asses.,· the ,\'l!l'erlly <J( ,, duh.ftJol nm/ dorn111N1t the lr<'nlmt•llf prc>gn:~·s ?
This can be done by Pirani Score, which is ··i mple. ha, high inter-observer and int ra-ob erver reliabi lity,
and is an useful clinica l tool for assessment or unoperated clubfeet less than 2 years of age. Exttmination is
divided into "Look", "FeeJ" and "Move" - separately for the hind fool and midfoot components.
Pirani Score (hind foot) t•irani Score (midfoot)

'LOOK' 0 No heel crease 'LOOK' 0 No deviation from Stl"aighl line
Posterior 0.5 ~ d heel crease Lateral 0.5 Medial deviation distally
crease 1 Deep heel crease borcler I Severe deviation pm,i.fo1ally
() Hard heel (calcaneum in 0 Reduced talonavicular Joint
'FEEL' nonnal position)
Empty 'PEEL' 0.5 Subluxed but redut;1ble talo-
0.5 Mild softness
heel sign I Head of nuvicular joint
Very sofl heel (calcaneum
not palpable) talus I lrrcducibll! talon:w1cular joint
~
0 Nom1al dorsiflexion
'MOVE' 0.5 0 No medial crease
Foot reaches plantagradc
Rigidity of 'MOVE' 0.5 Mild medaal crease
with knee extended
-
equinus l Fixed equinus Medial I Deep crease
crca.o,e altering contour of foot
I Foot should bt mm~,t ru tht P4mdon of ,na..u,nlllfl cat
rectton ""htn cuse.sn"g tlat mtd,al ,·rta:11I
CONGENITAL TAU PES EQUINOVARUS (CTEV) 5
Treatmeut
There are numerous lechni ques practised. The " l11temalio11al Clubfoot S tudy Group" has approved 3 melh-
ocls as standardized con crval1\le regimen~ for treating dubl'ool - Po11seti technique, 1Ja11sahcl/Dimeglio Modi-
fied French tech11iq11e aud Kite 's technique.
t{ Pouseti Technique J
The goal is to get a pain free. plantigrade. pliable. flmctiona l, co metica lly acceptab le foot which requ ires
no speciali zed footwear after completio n of treatme nt. Surgica lly treated clubfeet, at adulthood, are more
cosmeti call y acceptable, but are often weak. s tiff. painful and s hows early arthriti c changes. Cons-erv-alive
I!,auageroent by Ponseti regi me is rapid ly becoming the most popul ar technique, both in the developed and
deve lopin g world, givi ng exce lle nt and cons istent long-term res ults. even 30 - 40 years after completion of
trearment. Recurre nce rntes vary from I 0%- JO%, most of which can be successfol ly treated by repeating rhe
procedure.
Pa t110anatomical basis
Histological studies of tinkle and foot ligaments from virgin clubfee1. fetuses and s tillborn babies show abundalll.
young. highly cellular collagen which is "wavy" (Crimps). These crimps allow stretchability. Cnmps reappear in the
strelcbed ligaments after 4 - 5 days. wbicb allows further stretchjng. There are 2 phases of trearmenl - "serial-plaster-
casting" and "mruntenance" up to 4 years of age. This is essential because the genes respons ible for clubfooJ are active
from 12th to 20th week of fetal life, but some ac.ti vi ties persist up to 3-5 years of age. 111e fulcrwn is deemed 10 be the
head of talus.
=
~ ntages of Po11seli technique :
(a) Lesser number of manipulation and ca~ting is required. wluch saves money and time.
(b) Lesser incidence of recurrence and very few require surgery later.
(c) Even when not fu lly correcLed, the foot functions very well for a very long time.
(d) A simple technique. which can be performed by trained physiotherapists. Thus can be useful in remote/nm1f
areas where doctors are scarce.
II Bansahel/ Dimeglio Modified French Techni uc
Daily manipulation by skilled physiotherapist for30 minu1es~ temporary immobilization with adh~ ive ,tr:.1m1ing '4
Continuous Passive Motion (CPM) machine used for mobilization during slt:cp. After 2 - 3 months. manipulation is
done thrice weekly. Strapping is continued till 1he child is ambul.itory. after which Dc1111i:~-Brown 11igltt-spli11t (see
page 196) is worn. Disadvantages are :
l . Nearly 50% require surgery later. Cosil y in 1hc lvng ru11.
2, Require::, daily visll . which may not be feasi ble.
Ill. [ K1TE's Technique (

Should be started soon after bii:th. Ca/ca11eoc11boitljoi11t is deemed 10 bt· 1h~f1i/cm111 . A 3 po1111 pressure,., i,pplwd
with one hand grasping and distrw.:ung the forefoot and pus hing navic ular 1:.itcrally. the othl!r hand holds Hw hed
and gives counterpre sure over the calcaneocuboid jo,int. simultaneously evc1ting the heel and uhduct111g the loot.
B elow-knee pla11tt r casting is finall y done. which js changed weekly. Ptr:H forefoot adduction. the n hind f(,t1t
varus. lastl y equinus is corrected. Reversing the order may <;ausc r ockerbottom l'oot (M 11emo11i1·: /\d. \I.E.Rb =
AdductiQ11, Varu.~, Equillus, Rockerbottom ). After correct1on of forefoot adduction und hind foot ,,urns. dors1nex1t)n
is started to con-eel cquinus. Dennis- Brown spl1nL is worn ~1f1er correction. Dio;advanlagc'> ;1rc: thJt 11 rc4uirl!~ nu1n1:r-
ou.. sessions (average about 20) and 1:; a costly and lengthy procedure.
If }'t1r \1/ll/t' rt•m.011 1erial pla:rlt'r w~tmg cllllfHlt ht ,uur, ,I w,in u/111 hut/, ,. /wt •• 1/11·011 11tf11,. ,
The mothe r should manipulate 6 1ime after each feed/nappy t:han~e. Th1.: force apphi.'d J1'd ~on~l 11011
iiChievcd urc co ntrolled by smct instruction LO stop manipulat ,011 when there 1s hland1111i 111 ,\..111 lo,
o.1bou1 5 - 8 .!>i!!Conds, ur I he baby stan s cry,og
Wh<II i.~ tit<· l!Xlc'11f of ,,t,"·rn, t111d in . . OJ., IIH ' /1111•,•1 /1111b ,., ii opplie,I? .
ll'hnf paHtWtl . • .
After mun,pulnti on, plaster 1s appli ed from groin

10 toes with knee fl e1.ed to 90° . and a11k le- foof kept
in the maximall y corrected posi tion . Knee flexion re-
laxes the gas tro-soleus muscle, hence rendoachilles
i s relaxed, which prevent equinus. Knee flexion also
prevents the plaster from 's lippin g-off' ·
N.B. • 11 is mandatory to check capi ll ary circu-

lation of toes , (especiall y the little toe) by nail
bed testing after any plaster. manipulation or op-
eration. lf di stal vascularity is in dou bt. the plas-
Fi g. l. l .4a : Cotton wrapped limbs just before ter must be s lit immediately and loosened, lo pre-
plasterin g. Note the extent. vent compartment syndrome.
What nrt• rht· operati1•,, Of)tio11., 11ml at ll'ltid, age ~roup are th ey advisal,/e ?
1. Soft tissue operation :
• 6 - 18 months ~ (Turco opcn.1tion ~ PMR
i.e.. Postero Med ial Release).
• J 8 months - 4 years ~ (CSTR i.e.. Compl ete
Subt-alar Release).
2. Bouy operation :
• 4 - 7 years ~ Di lwyn Evans operation. or
Dwyer's Calcaneal Osteotomy.
• After 12 years ~ Triple arthrodesis.
JESS (Joshi 's External Stabi/izatio11 System) or
Jlizarov technique (see page 24 l) of external fi xator
application ~10d gradual correction of the deformity can
be done in the age group 3 - 8 years. for complete and
sometimes partial correction of the deformity. (set!
fig!. 1.4b)
Fig. I. I .4b : Josh i' s Ex ternal Stabii'i t uti on System

Why i f triple arthrodesi.~ delay ed Iii/ 1 I - 11 yc,11·., of ((~e ?
Because the growth of foo t bont:s are complete/near co mplete tll that age.
N.B. : When foot is corrected by any means (i.e .. mother's manipulation or serial plasttring or opera11on).
maintenance of corrected position i~ by -
L Dennis Brown Splil&t : Worn for 24 hours when the child is not walki11g. It 1s U!ied only at njg.bt
wh.en the child is walki ng (see page 196).
2. CTEV Boot/Callipers with i11side iron and outside T- strap ; When the c hi ld 1s walking
(see page 196).
Fur how long t\ thl! ma111tP11a11ce requin·,I ?
Till there is active aud strong el'ersi<Jn + dor,\ iflexio11 t>f foot , and at ·o when the child
lo the age of 6 years).
I\ walking (ne.1rly 0 11
1
Whal happe11.1· Jj tltt1re ; \ "" llt'lt1•1 dt1r1tj/11x 1rm / t•1·i'nio11 tills - 6 v,•ar, (H /wul-g11i11,: ({gc r•
Tendon transfer ope~ation : operatively muscle is transferred lo add pOwl!r cvcnors/do, ">ilk,or, fr.Ill'"
10
ferred muscle 1s usually mvertor and plantar tlexor e.g•• llbiahs p()slcrior.
CONGENITAL TAU PES EOUINOVARUS (CTEV)
7
U'/"'t 1, C111d11nah int·i-.wu'!
.
Popular incision f'or CSTR/Dilwyn Evans procedur'.
. .
r· I.,
c . , om ,,,~e of I Sl tt1etalarsc1 I 4 b l , .
~ rises to anl,.le Jo1111 posienorly ~ lowe,s to cuboid laterall y. e (m medial tnt1lleolu"
What i, urthro~r~ po,i-; mull iplc, COllJ!t'11i rn '!
It 1!- u non- progressive co ngenital disorder du ., 10 · . ·
. . . .... 11111 uuLenne myodysLropl , .
volv 1ng all 4 limbs . Sk in ts thin and sh•n 1' t1 g w 1·111 f s· 1: h . ,y, most commonly in-
' u 1 orm -s aped JOllll ' 1· I h
movemen. l. [3iop y of' sp111al co rd reve·tls sp·1 ·. b . . :i, w 11c, ave sma ll arcs of
• · , 1se num er ol an tenor horn c II ti
disorgamzed manner. e · m t are arranged in :J
Details of the Ponseti Technique
• First four or five casts (more if necessary) : Start

soon after birth. Make the infant and family com-
fortable. Allow the infant to feed during the manipu-
lation and casting process. Casts are removed,
Pirani score noted, manipulation and r e-casting is
repeated weekly.
• Reduce the cavus : Firstly, cavus is corrected by

positioning the forefoot in proper alignment with the Fig. 1 1.5 . Cavus reduction.
hind toot. The cavus is always supJ:>le in newborns Note · The foot looks more deformed in supination
and requires only supinating the forefoot to achieve
a normal longitudinal arch of the foot. Alignment of
the forefoot with the hind foot to produce a normal
arch is necessary for effective abduction of the foot
to correct the adduction and varus.
• Exactly locate the head of the talus : First, pal-
pate the mafleoli with thumb and index finger of
one hand while the toes and me\atarsals are held
with the other hand. Next, slide your thumb and Fig. 1.1 .6 : Locating the head of talus
index finger ot first hand forward to palpate the
head of the talus In front of the ankle mortise.
You can feel the prominent lateral part of the talar
head covered by skin in front of the lateral malleo-
lus. The anterior part of the calcaneus will be felt
beneath the talar head .
• Stabi/lze the talus : Stabilizing the talus with the
thumb provides a pivot point aro.und which the foot
Is abduc ted. The Index finger of the ·same hand
that is stabilizing the talar head when placed be-
HANDBOOK FOR 0ATHOP1'l 01r.s cXAMIN/\ l ION
8
hind the lateral malleolus, further stabilizes the
ankle joint while the foot is abducted beneath it,
and avoids any lendency for the poste rior
calcaneofibular ligament to pull the fibula posteri-
orly during manipulation.
• Manipulate the foot: Next, by abducting the foot in
supination along with stabilising the foot by the thumb
over the head of the talus, further abduct the foot as
far as possible without causing discomfort to the in-
fant. Hold the correction with gentle pressure for about
60 seconds, then release. The lateral motion of the
Fig. 1.1.8 ; Foot manipulation navicular and the anterior part of the ca/caneum in-
creases, as the clubfoot deformity gets corrected.
1st 2nd 3rd 4th Full correction should be possible after the fourth or
u
fifth cast. For very stiff feet, more casts may be re-
UAP
quired. The foot is never pronated.
• Second, third and fourth casts: (Fig. 1 .1.9) Dur-
ing this phase of treatment. the adduction and varus
are fully corrected. The distance between the me-
dial malleolus and the tuberosity of the navicular
when palpated with the fingers , tells the degree of
correction of the navicular. When the clubfoot is
Lat
corrected, the distance measures approximately
1.5 to 2 cm and the navicular covers the anterior
surface of the head of the talus.
• Foot appearance after the fourth cast : Full
correction of the cavus, adduction and varus are
usually noted . Equinus improves but when this
correction is not adequate, it necessitates a
tendoachilles tenotomy. In very flexible feet,
Frg. 1.1 .9 : Shapes of serial plaste( casts equinus may be corrected by additional casting
Courtesy : Global Help (www.globaf-help.org) wi th0 ut tenotomy . When in doubt, perform the
tenotomy.
• Steps in cast application : Before each cast fs applied the foot ·s ·
lay~r. of cast padding for effective mouldlng of the foot. Main i i manipulated . A~ply only a thin
position by holding the toes when the cast is bein- a lied ;? th
n e foot at the maximum correcled
1 st
then extend the cast to the upper thigh . The foot sioufci b · r apply the cast below the knee and
!'he "holder's" fingers to provide sufficient space for th ~ held by the toes and plaster wrapped over
plaster. (Fig. 1.1.10) e oes. Do not try to fotce cotrection after
Fig. 1.1 10 · Steps r

N . . o plaster cast application
ote : 1. The foot being hel<!l in .. -
2. The above knee .POSit,on OY holding the toes .
extension of l
P aster being done last
CONGENITAL TAUPES EOUINOVAAUS {CT£V) 9
• Characteristics of adequate abduction : Conflrm that the foot 1s suf1ic1enlly abducted 10 safely bring
the foot into 15 to 20 degrees of dors1flexion before performing tenotomy. The best sign of sufficient
abduction is the ability to palpate the anterior process of the calcaneum as 11 abducts from beneath the
talus . Abduction of approximale ly 60 ° - 70° in relation 10 the frontal plane of the tibia is possible. Neutral
or slight valgus of os calcis is present (determined by palpating the posteri or os calcis} when abduction
is adequate.
• Tendoachilles tenotomy : Tendoachilles cord tenotomy is performed under local anaesthesia . Per1orm
; the tenotomy approximately 1 cm above the calcaneus . A ''pop" is fell as the lendon ts released. An
additional 10° to 15° of dorsiflexion is usually gained after the teno1omy.
• Post-tenotomy cast : Apply the fifth cast with the foot abducted 60° to 70° with respect to the frontal plane
of the tibia. The foot is never pronated. This cast is kept inlacl for 3 weeks after complete correction. Af1er 3
weeks, the cast is removed. At the completion of casting, the foot appears to be overcorrected into abduc-
tion with respect to the normal foot. which prevents recurrence and does not create a pronated root.
• Bracing protocol : The brace Is applied immediately after the last cast is removed i.e., 3 weeks alter
tenotomy. The brace consists of open toe , high. top and straight-last shoes attached to a bar. For unilat-
eral cases, the brace is set at 75° of external rotation on the clubfool side and 45° of external rotation
on the normal side. [Fig. 1.1.11]
In bilateral cases , it is set at 70° of external rota-
tion on both sides. The bar should be of sufficient
length so that the heels. of the shoes are at shoulder
width + 1". A common error is to prescribe too short a
bar, which may be uncomfortable for the child. A nar-
row brace is a common reason for lack of compliance
and non-compliance is an important cause of relapse.
The bar should be bent 5° to 10° with the convexity
away from the child to hold the feet in dorsifl exion. The
brace should be worn full time (day and night) for the
first 3 months after the tenotomy cast is removed . Al-
ter that, the child should wear the brace for 12 hours at
night and 2 to 4 hours in the middle of the day for a total
of 14 to 16 hours during each 24 hour period. This
protocol continues until the child is 4 years of age.
Occasionally. the child will develop excessive heel val-
gus and external tibial torsion while using lhe brace In
such instances, the external rotation of the shoes on
the bar should be reduced from approximately 70u 10
40°. After putting on the brace , the child returns ac-
cotding to the following schedule (to note relapse/re-
currence).
• 2 weeks (to note compliance issues) Fig. 1 . 1. 11 Brace (ankle 1001 orthos1s}.
Courtesy Global Help {www.gtobat lletp org)
• 3 months (to start the nights-and-naps pro-
tocol)
• Every 4 months until the age of 3 years (for monitoring)
• Every 6 months until the age of 4 years
• Every 1 to 2 years until skeletal maturity
N.B. • The most common cause of relapse ,s non-compl/ance to rhe post-tenotomy bracing p1ogramme
and lower educational fevel of parents
• For recurrence m children > 21/: years or age tibialis ante,,or tendon transfer may be needeo,
which is considered an integral part of the Ponsetl regimen
0 E -2 ----------!!!!!iiiiii:,;!:5'=:~5=:~=:::::::======::::;~::::=:::::=:::J
Chapter 7
L XAMINATION OF SHOU DER
Theories Discussed
• Apley 's 'scratch test • Drop arm test
• Apprehension test for shoulder dislocation • Yergason test
INSPECTION
• Have a fema le attendent for a female patient. Explai n the procedure to the patie nt and
ensure verbal consent.
• Patient should be examined with him/her sitting on a stool , or (if he/she is of very short
height then) in standing positi on sequentially from the front, side , back and above.
• The patient should be exposed from the neck to the finger tips on both the sides , including
the axilla . Both upper limbs should be in the anatomical position or as close as possible to
the anatomical position .
• From the front: Note bilaterally , compare , and comment on
• Skin : Blebs , scars, sinus , discolouration , venous prominence .
• Attitude : May be diagnostic e.g. , shoulder dislocation (Fig. 1.7.1), Erbs palsy, (Fig. 1.7.2) etc.
Fig . 1.7.1 : Attitu de after Shoulder Dislocation . Note Fig. 1 .7.2 Attitude after Erbs palsy
the flattened contour of left shoulder. Pol ice man's t ip!
• Contour : Note the shape and symmetry of

(i) Clavicle - from the sternoclavicular joint to the acromioclavi_cular joint. .
(ii) Deltoid bulge _ when there is wasting / atrophy o~ the del!Old , the greater tuberos1ty
becomes prominent. In shoulder dislocation there 1.5 flatt~nmg of the rounded contour
with an indentation (step-off) just below the acrom1on (Fig. 1.71 ).
(iii) Any obvious swelling.
• Deltopectoral groove , anterior axillary fold .
• Supraclavicular and infraclavicular fossae , pectoralis muscle bulge .
37
H Nt I 0 lXAMINAl l N
• ram ti d llo1ci bul _ , ny II ucning/swelling , the sides of the arm , and the
nl , ntr· tur , you may find a groove in the deltoi d .
ov rs the 2nd to 7th rib, with the scapular spine at the
omm nt on th e scapular symmetry (winging of scapula,
pg . I) , supraspinatus and infraspinatus fos~ae, posterior axillary
olio is (I v I of shou lder may become asymmetrical due to scoliosis) .
rom : C 1nm nt on th symm try of the a ngle of acro mion , sup raclavicular and
u I pinntu I
PALPATION
• T mp r tur : omp r th e temperature of both the sho ulders with the back of your fingers .
• r ndernes : Comment on tenderness , as you have noted in bony and soft-tiss ue palpation.
• Bony palpation : St nd behind the patient and start pa lpating bilateraly, systematically in
th following ord r -
upra tern I n t h, sternoclavicular Joint, clavicle, co ra coid process (in adults it lies 2 to
2.5 cm below and just lateral to the point of the deepest concavity of the clavicle . It faces
anterol t rally, is covered by the pectora li s major, and it's tip and medial border is palpable),
acro,nio lavicul r joint. (Request the patie nt to flex [fig . 1.7.3] and extend the shoulder to con-
firm the movement al the joint) , acromion , greater tuberosity (inferior to the lateral edge of the
acromion , separated by a "step-off" or indentation). bicipital groove (anteromedial to the greater
tuberosity palpated best when the arm is externally rotated [Fig . 1.7 .4]. It conta ins the tendon
of the long head of biceps) , scapular spine (palpate posteriorly and medially from the angle of
acrom ion. Medially it loses prominence beca use it is covered by levator scapulae) and the
vertebral border of scapula .
Fig . 1. 7 . 3
Fig . 1 . 7 . 4
• Soft-tissue palpation : Done in passively extended sho u Id er.
• Rotator Cuff: In extended
. . . shoulder th e supraspinatus
· ·
, infraspinatus and teres minor can
be palpated as a unit, Just inferior to the anterior border of th · b b I is
is not palpable . e acrom1on , ut su scapu ar
• Subacromial and subdeltoid

. . . bursa : From the anter,·o r e d ge o f the acrom,on
. the bursae
may exte nd upt.o the b1c1p1tal gro?ve. _From the lateral edge of acromion the bur~ae extends
und er the deltoid muscle separating 1t from the rotator cuff.
BASIC CLINICAL EXAMINATION OF SHOULDER 39
• Axilla : Stand in front of the patient, abduct the arm with on e hand and palpate the axilla
with the index and middle fi~ger of yo.ur other hand . Note the axillary artery pulsation , lymph
node enlargement, any swelling, and finally palpate the walls (anterior wall - pectoralis major,
posterior wall - latissimus dorsi, medial wall - se rratu s anterior , lateral wall - proxima l hu-
meral shaft with the bicipital groove) .
• Muscles : Sternoclei domastoid , pectoralis major, biceps , deltoid , trapezius , rhomboids , latis-
simus dorsi , serratus anterior.
MOVEMENTS
N.B. • Examine flexion , extension , abduction , adduction, external rotation and internal rota-
tion , actively and passively .
• Always examine the normal side first for comparison .
Apley 's "Scratch " test : Quickly evaluates the patients active range of motions.
• Abduction and external rotation : Request the patient to reach behind his head and
touch the supero-medial angle of the opposite sides scapula . (see Fig . 1.7.5)
• Adduction and internal rotation : Request the patient to touch the opposite sides acro-
mion . Next, request the patient to reach behind his back, to try and touch the inferior
ang le of the opposite sides scapula . (see Fig . 1.7.6)
Fig . 1 .7 .6
Fig . 1 .7 . 5
• Abduction (180°), Adduction (45°)

·r 15 20 0 of abduction occurs purely in the glenohumer~I joint. After that , f~r
0 _
;~~~y
1 1
N.B. • 30 of abduction, 20 occurs in the glenohumeral joint and 10 int.he. scapulothorac1~
• t· (· e 1 ·n 2 . 1 ratio) upto 120°, but in the last 60° maionty of movemen
art1cu 1a 10n ,. ., .
occurs in the scapulothoracic articulation . . . o r which the scapula
0 9
• If the scapula is fixed, ~ure ~lenohumera.l a~~~~~ :/~h:b~~~ e~u~a:~~ches the acromion
begins to rotate). A.t this point~ th~II surtci possible when the humerus is externally
and further abduction to 180 w1 on y e '
... . th acromion from the neck of humerus .
rotated, d1s1mpact1.ng e . of the sea ula i.e., 200-300 anterior to
• Abduction/adduction occurs in the p~:i~~ally the m~vements are tested in the
the coronal plane . However , conve
coronal plane .
• Passive Movements
• Abduction : Stand behind the patient and stabilize the scapula by firmly fixing the infe rior
angle of scapula with one hand [Fig . 1.7.7(a)] or pressing down firm ly on top of the_shoulder with
one hand [Fig . 1.7.7(b)], and move the patients arm with your other hand , grasping the fl exed
elbow.
Fig. 1 . 7 .7(a) F i g . 1.7 .?(b )
• Adduction : Stand in front of the patient and move the arm across the front of the body.
(see Fig. 1.7.8)
• Flexion (180°) Extension (45°)
Stand behind the patient, stabilize the scapula with one hand and grasp the patients distal
arm just above the elbow. Then swing the arm posteriorly in the sagittal plane to note exten-
sion, (see Fig . 1.7.9) and then anteriorly to note flexion . (see Fig. 1.7.10)
Fig . 1.7.8 Fi g . 1 .7 . 9 F i g . 1 . 7 . 10
• Rotation
1. Rotation in abduction : Request the patient to abduct both shou lders to 90° with the
elbow flexed to 90° and the fingers pointing forward . This is the neutral position. Then request
the patient to move the forearms so that the fingers point towards the ceiling (external rotation
- see Fig. 1.7.11), and towards the floor (i nternal rotation - see Fig. 1.7.12). Internal rotation
can also be noted with the patient's hand on his back (Fig. 1.7 .6).
2 . Rotation in anatomical position : Stand in front of the patient and fix the patients 90"
flexed elbow to the waist with one hand, wh ile grasping the wrist with your other hand. Using
BAS IC CLIN ICAL EXAM INATIO N OF S
. . HOULDER 41
the forearm as the indicator of the rang e of mot·
. . ion , externally rot t ( .
internally rotate (see Fig. 1.7 .14) Compare with ·th th . a e see Fig. 1.7.13) and th
. . e o er side and c en
externa I ro tation 1s 45 0 - 90° and internal rotation is 550_ 700 omment. Normal range 01
N.B. : Internal rotation can be tested with the pati·e t d ·
· . n s orsum of hand t h"
described at which level the hand is (e.g. sacral/I b /I ouc ing the vertebra and
um ar ower or upper thoracic) see fig . 1.7.6.
F i g . 1 . 7 . 11
F ig. 1 . 7 . 12
F i g . 1.7 . 13 F ig . 1 . 7 . 14
MEASUREMENT
• Linear : Length of the arm (see page 49)
• Circumferrential : Measure the girth of the arm of the pathological side first, at the level ,
where visually there is maximal wasting . Then measure the distance from that level to the angle
of acromion on the pathological side . Finally measure the girth on the normal side , equidistant
from the angle of acromion .
OTHER JOINTS
Cervical spine tendern ess and movem ents should be noted beca use it can be a source of
refer red pain . Test dermatome sen sation (C4 - T 4) also look fo r generalized joint laxity. (see
page 31) which can cause shoulder instabil ity .
D. E. - 6
42
SP · IAL T T
• Drop
reque st th
abducted o
primarily in th
Fig . 1 .7 . 15 ig . 1 . 7 . 1
• Apprehension test for anterior dislo-

cation shoulder : With the patient supine with
the shoulder just outside the edge of bed pas-
sively abduct and externally rotate the sho~l-
der with flexed elbow with one hand , and with
your other hand apply anteriorly directed force
on the humeral head . If the shoulder i s
"dislocatab/e ", the patient will have a signifi-
cant look of apprehension or alarm on his face ,
and will resist further motion . (Fig. 1.7 .16) Also
see page 220 .
• Yergason Test : Standing by the side of
the patient request the patient to flex the el-
bow to 90°. Place your finger tip s of one of
your hand in the bicipital groove and grasp the
patients forearm with your other hand . The pa-
tient is then requested to supinate the forearm
against resistence, which places isolated tension on the long h blcipi•
tal groove is a sign of a lesion in the long head of biceps l ndon .
SUGGESTIONS l•'OR FURTlllm LEARNIN(;

Jobe test/Empty can sign - for supn1spinatus L·ar / rotator- ·urr 1111pi 111, ·ni ·111 : (;Hbn s ulH·onirolcl l1111l 11 111••
. .
men t tes l - 1mp1ng menL betw en ro1 a1or- u l'f' ancJ coraco1d . : Johe apprclwn1.lon- rdo ·ut 011 fr ·1 111 (I 1 t •11 ~' I ii ~h
. d d . . d
between pnmary an s con ary 1mp1ngemenl u · lo t1111 enor · 1111,tuhiltl y: Sp,•i•cl t 'NI lo , h1tT p 1,·11(I111111, ··111d
" SLAP" le ion · Lift-off lest (lag sign) - fc)I cJ ·1·ction of rup111r · >I' suh1,rnpul t1 i 1.., : Udly 1>•·,,,., 11 kt 1111 11 h cupv
laris weakness: Drop sign - for infraspinalus: Nc •r impinl!,t>mcnl lc), 1 - I<1 io tat111 t·,dl 1111 pin rn1w11t / Im• 111 1
adhesive cap uliti /osteoarthritis / ca lei fi e lendiniti s / Uankart k s1on / ".' 1./\ 1'" Ii· 1011 , / 111111111111 ·I 1 1 1d111 ,11lh1111 ·
Hawkins-kennedy lest- for bun,itis / rotator-cuff impin gl' n1c111 / Bun ,11 1 l(-., 1, 111 s / .. ·1. p" Ii· 1011 / ,11101 11111~ 1·1"
icular arthriti s; External rotation lag sign - for :.,u pra..,p111 atus and 1nf1 a 11 1111 111 : ti; ·frrnnl rntal 011 .,...,., h ·\I 1"'
infr, spinatus and the tere. minor: Internal rotation lag sign - lor , ub. ctqHl ltn 1 . ornm ', 11• 1 llll iqH,I p111 1111
Chapter 8
RAC URE
Theories Discussed
• Clinical features of deltoid contracture • Sanmugasundaram test
• Sprengel 's deformity • Klippel-Fie l-Trenauny syndrome
This is a relatively rare condition which may occur due to post-injection fibrosis of the
deltoid m~scle , an? the most im portant differential diagnosis is of Sprengel's deform ity
(both having prominence of scapula with its medial border rotated upwards , and often
scoliosis and prominence of humeral head anteriorly) . Other causes of deltoid contracture
inclu de idiopathic and familial.
Fig. 1.8.1.A : Deltoid contracture of left should er Fig . 1.8.1.B : Note : Prom inent scapula with medial
showing abnormal prominence of humeral head and border rotated upwards and elbow not touching the
a groove in mid-deltoid area . side of the body.
Th is is a case of deltoid contracture of UR side due to post-injection fibrosis in a .... year
old M/ F patient.
1. History of repeated / multiple injections in deltoid in the past.
2. On inspection :
(a) From front• Elbow not touching the side of body . Arm is (often) internally rotated
and in extension .
• Shoulder is drooping with depressed acromion and there is ab normal promi
nence of the humeral head .
• Wasting / atrophy of muscles around shoulder (especially deltoid) is present.
(b) From side • Sometimes arm is in extension (posterior part of deltoid involved) .
• Depression/groove in the mid -deltoid area (middle part of deltoid involved)
(Fig . 1.8.1.A) .
(c) From back • Prominent scapula with the medial border rotated upw rds (like Sprengel's
deform ity) (Fig . 1.8.1.B) .
• Scol iosis with convexity in the opposite side is seen .
43
4 XAMINAllON
3 . On palpation :
(a) Cord -like tough tru cture (f It more prominently on adduction of the arm) ,n the del oid.
(b) Acrom1on (oft n) 1s I ngthcn d (d ue to pull of cont racted mu cle fibre ) a compared to
the other side .
(c) Hurn ral he d I v ry pro min ent.
4 . Movements :
(a) Adduction is gross ly reduced . On attempt of adduction , (often) the other deformities be-
come more prominent.
(b) (Som etimes) External rotation of the shoulder is decreased.
(c) All other movements are full range and painl ess.
5. Special test :
Sanmugasundaram test - Ask the patient to touch 2 elbows and the ulnar borders of both
forearms in 90° flexed elbow . In deltoid contracture, this is not possi ble. (Test is false positive
in obese or very muscular individuals).
Surgical release of the contracted fibres should be done (most commonly intermediate deltoid
fibres; remember to protect the axillary nerve .) followed by physicaltherapy .
Wl,y don r/11• /111111 " ral '1Ntd nppt•a r .rn pro111i11 e11t '!
Due 10 on11n ucd grow th of the hum ra l head in pr sence of fixed length of the contracted deltoid mu\cle fibre~. there i\ partial
anterior :ublu;\a\t on of th" head . Init ia ll y, thi s 1s compe nsat.ed by rotatio11 of the scapula medially wh ich hide!> the dcforrruty (w
to present / show / cxa m1nc 1he case, with both sca pul ae in sy mme tri cal posi ti o n). Later, the ant.erior prominence of lhe
humera l head becomes obvious.
SPRENG EL'S DEFORMITY:
ormall y th scapul a de. cend~ cornpl ett:ly by 3 months after bi rth . Sprengel' deformiry occurs d ue to imperfect capu/ar de cenl.
X-ray : mal l and hig h- up sca pul a. He mi vertc bra, with occa. io nal cervica l rib. In Sp re ngel', deformity, 1rapez1us i
o ft e n abse nt an d leva to r sc apulae + rh o mb o id is re pla ced by omovert ebra/ bar.
Cli11ically : Low hairline, ·hon neck (o fte n webbed), elev at ed s ho uld er, small scapu la, high-up scapula, with cervico-
dor al . coliosis I kyphos is (Fig. 1.8.2). Us uall y full ra nge o f moveme m is pre. e nt . but ometime boulder abduction or
neck move me nt · may he restri cted .
Treatme11t : Mild va ri e ty-> no treatme nt. S urgery, if don e, mu st be wi thin 3 - 6 year Brac hi a! plex us injury is a erious
compli catio n after 6 yea rs.
....--,~-~-,.
'·. :~~~,
' :: ~; :.1111..
,•'4:. •
·.~-. '
. ,, -.l f· '
·-·
·-
..;.~·, . '
I .~,
-.
~-
...
Fig . 1. 8.2 : S p re nge l 's d eform i ty .
.B. • You may be a k d to demon:trate mu cle po r testing of deltoid and also of serratus anterior, trapezius, rhomboids
KLIPPEL-l<'IEL-TRENAUNY SYNDROME : About 35% of patient al o have associated Sprenger deformity Com-
monly bilat ·ral. Commo n sign of the dt o rde r are a . ho rt neck, low hairline and re tricted mobility ol the upper pine +
\ColioM~. ·ptna bifid a. c k ft pala te. anomalies of the kid ney . Un egmentation of the cervical ertebra I th cau · ·o
fu,cd cr1chra 1~ a lwa ~ seen in X-rays . Treatment i, ymp1oma1ic . Surgery to relieve cervical in tab1h1y . ~o mcuon 1 °
the ~ptnal 1:md 01 to crn rect scolio~i~ may be considered 1f nece ary .
Chapter 14
A C C I ICA XAMINATION OF THE W IS
Theories Discussed
• Maisonneuve's test • Watson test I Scaphoid shift test
• Bu nnell- Littler test • lntriusic plus deformity
• Grip test • Grind test
INSPECTION
N.B. • The patient should be exposed from the arm , to the wirst and hand.
• Both the upper limbs should be examined side-by-side in exactly similar positions, from
the dorsal , volar , radial and ulnar surfaces (by supinating/pronating the forearms).
• The patient is examined from the front, in standing position , or sitting on a stool, or
in the supine position .
• Attitude/Deformity : Note and comment on "dinner fork" deformity (e.g. Colles' fracture -
see page 79) , abnormal prominence of the ulnar head (e.g. malunited Colles' fracture , Madelung
deformity - see page 84, dislocation of the distal radioulnar joint) , wrist drop (e.g . radial nerve
palsy, see page 105) , claw hand (e.g ., ulnar nerve palsy - see page 104), radial deviation of
hand (e.g. congen ital radial club hand - page 279, Madelung deformity - page 84) , ulnar
deviation of hand (e .g. rheumatoid arthritis) , abnormal lateral prominence of the base of the 1st
metacarpal (e.g. Benett's fracture - see page 232) .
• Swelling/Wasting : Describe any swelling under standard headings (see page 14), which
may be due to joint inflammation (e.g. rheumatoid arthritis) , tenosynovitis (e.g. De Quervain's
disease - see page 171 ), gangl ion (see page 173), small mid-wrist volar swelling (e.g. lunate
dislocation) , swelling over the distal interphalangeal joint (Heberden 's nodule - see page 271 ),
or over the proximal interphalangeal joint (Bouchard 's nodule - see page 271 ).
Note and comment on wasting of the thenar eminence (e.g . median nerve palsy - see page
105, carpal tunnel syndrone - see page 81) the hypothenar eminence (e .g. ulnar nerve palsy
- see page 105), intermetacarpal wasting (e .g. wasting of the lumbricals and the interossei as
in ulnar nerve palsy) , and forearm muscles .
• Scar, sinus, skin condition, ulcer, and venous prominence - Note and comment.
PALPATION
• Temperature : With the dorsum of the fingers of your dominant hand, note and comment
on the comparitive temperature , by palpating first the normal wrist, then the abnormal wrist, then
again the normal wrist, serially from tfhe dor-
sum, volar, radial and ulnar side of the wrists.
• Tenderness : Don't forget to look at the
patient's face while eliciting tenderness . Note
and comment on tenderness of the anatomi-
cal-snuffbox (Fig 1.14.1) (for scaphoid fracture
- see page 229) , the distal ¼ th of the radius
(for Colles' fracture ; Smith's fracture - see
page 82; Barton's fracture - see page 83), Fig. : 1.14.1
69
the radial styloid (for chauffeur's fractu re - see page 82), ju st di stal to the radial styloict
over the tendon of abductor poll icis longu s (for DO - see page 171 ) .. th e ulnar stylo id (for
fracture , which is often associated with Colle s' fracture) , any swe lling (e.g. GCT - see
page 88), the wrist joint line (see below) , just di sta l to the joint line , dorsally, in the axis of
the 3rd finger (for lunate dislocation and perilunate dislocation) , the di stal radio-ulnar joint
(found in recent Galeazzi fracture - see page 228 , and often associated with Colles'
fracture) , and the base of the first metacarpal (for Benn ett's fracture - see page 232).
• Styloid relationship : See page 50 and Fig . 1.9.11
• Distal radio-ulnar joint (DRUJ) instabity/subluxation - Piano key sign : With the
forearm pronated hold the distal radius with the trumb and fingers of one hand (to stabilize),
and hold the ulnar head using your other hand (see fig 1.14.2-A). Then try to subluxate the
DRUJ by applying volarly directed force on the ulnar head, with one hand and look for abnormal
mobility (see fig . 1.14.2-B) . For comparison test the opposite wrist in the same way. Note,
compare and comme nt, (also see page 82).
Fig. : 1.14.2-A Fig . : 1.14.2-B

• Joint line : With the patient's elbow flexed and forearm pronated , us ing your dom inant
hand hold the patients palm with your thumb placed on the dorsum and your 3rd 4th 5th
fi~gers suppering the thenar and hypothenar eminence , while your index finger su~port~ the
distal fore~rm just proximal to . the wrist (see fig 1.14.3-A) . Now, with the tips of your 2nd,
3rd, 4th f1nge'.s of the opposite hand, start palpating from the base of the metacarpals,
gradually mo.v1ng pr?ximally, while your dominant hand alternately dorsiflexes / palmar
flexes the wrrst (se~ fig 1.. 14.3-B) . At abou.t t~e inter styloid line, you will feel a gap wh ich
opens and closes with wrrst movement. This 1s the dorsal joint line of the wrist.
Fig. 1.14.3-A Fig. 1.14.3-B
BASIC CLINICAL EXAMINATION OF THE WRIST 71
• swelling : Palpate and comment on any swelli ng under the standard headings (see page
14 which may be ganglion (see page 173), compound palmar ganglion (see page 173), GCT
),
(see page 88) , tenosynovitis as i~ DO _(see page 171), or synovial thickening as in rh eumatoid
arthritis, thyroid disease, hyper-uncaem,a (gout) etc.
MOVEMENTS
N.B. • Th ere are 2 basic movements at the wrist. (a) palmarflexion / dorsiflexion.
(b) ulnar deviation / radial deviation.
• The neutral or "zero " position of the wrist is where the axis of the 3rd matacarpal is
exactly aligned with the axis and the plane of the forearm.
• Normal range of movement of wrist are : palmar flexion - 80° to 90°, dorsiflexion - 60°
to 70°, radial/ulnar deviation - 20°-30°, supination / pronation - see page 49.
• Dorsiflexion / palmarflexion : Request the patient to approxi mate both the palms in front
of the chest so that both the thenar and hypothenear eminences touch their counterparts (as in
"namaste I namashkar" - see fig 1.14.4-A) . Then request the patient to maintain the palm
contact and simultaneous ly, gradually elevate both the elbows as far as possible . This demon-
strates dorsifl exion (see fig 1.14.4-B) . Note, compare and comment.
Fig. : 1.14.4-A Fig . : 1.14.4-B, Note: restricted (L) wrist dorsiflex-

ion.
Next, request the patient to approximate the dorsum of the wrists , hands and fingers (see fig
1.14.5-A) , and gradually lower both the elbows , maintaining the contact. This demonstrates
palmarflexion (see fig 1.14.5-B). Note , compare and comment.
Fig. : 1.1 4. 5-B , Note: restricted (R) wrist palmarflexion.

Fig. 1.14.5-A
• Radial/Ulnar deviation : With the patient's elbow flexed to 90°, forearm pronated , grasp the
patient's distal forearm with one hand, and the patients pa.Im (acr~ss t.he metacarp~ls) with Your
opposite hand. Now, ensuring that there is no palmarfle~1on/dors1tlex1on of the wnst, gradually
deviate the hand, first medially (for radial deviation - see fig 1 .14.6-~) and. th en laterally (for ulnar
deviation - see fig 1.14.6-B). Repeat the procedure on the opposite wnS!. Note, compare and
comment.
Fig. 1.14.6-A Fig. 1.14.6-B
MEASUREMENTS
• Linear : Length of the forearm - see page 50.
• Circumferencial : This indicates wasting / swelling. Measure the girth of the wrist (at the joint
line) and forearm (at a fixed distance from the lateral epicondyle of humerus - see page 50) at the
level, where there is visually noticeable wasting of the forearm musculature. Note, compare and
comment.
SPECIAL TESTS
• Maisonneuve's test : Req ue t the pa-

tient to fl ex both the elbow to 90° and keep
the forearms pronated . Then request the pa-
tient to maximally dorsiflex the wri st. The te t
i po itive when there i compari ti ve ly more
noticeab le hyperextension at the affected wri. t
joint. Thi is often found in malunited Colle '
Fig. : 1.14.7, Note: hyperextension of the (R) wrist. fracture (see fig. 1.14.7) .
t • ~a~son test (Scaph~id. shift test~ tests wrist stability) : Hold the patient'. pronat d hand with
he wnS t rn full ulnar deviation and light exten ion. With your other hand apply dorsally directed
force over
.
the
.
volar
.
aspect
. .
· St ct·ista I to the radius
of w11·· t JU · (scapho1d).
· Now radially deviate and nex
th
e wnS t ~hde mamt~mmg pres ure on the scaphoid. If the caphoid ublu xate. b yond the dorsal rim
of the radws the test 1 po itive· The pa t'1ent may complam · . . 229)
of pam 111 fracture caphoid (see pag ·
BASIC CLINICAL EXAMINATION OF THE WRIST 73
• Mu de testing : cry i111porta11t 10 test tile inL' •rity of the muscles, •1,p ·cial ly fl exor digitorum
P) 11 , r digit rum sup rlicialis Fl S), n ·xor poll icis J ngus (FPL), .ind ex tensor p lici s
profun du. (FD •
longu. (EPL).
ig. fi g. : L 14.8-13
J. FDP : eat the patient in fron t of a tab le and reque t the pati ent Lo pl ace th e hand fl at on the
table with the palm facing upward .. Now place yo ur 2nd , 3rd an d 4th fin gers of yo ur domin ant
hand , on the index fin ger of th e pati ent, ju. t proximal to th e di stal interph al augea l (DIP) j oint ( ee
fig . 1.14.8- ), so th at th e proxima l interph alangeal (PIP) joint and metacarpophalan gea l ( M C P)
joi nt remai n extended. ow req ue t the pati ent to try and flex the DIP (see fig 1. 14.8- B ) . The ame
procedure i. repeated for all the 8 fin ger (excluding the thumb ) of both hand for compari son. In
FDP weakne / injury, th i would not be possible, because the tendon . lip for each finger inserts onto
the ba e of the di tal phalanx. Painfu l fl ex ion would suggest teno y noviti or H eberden'. node.
Fig. : 1.1 4.9-A Fig. : 1.14.9-B

2. FDS : Seat the pati ent in front of a tabl e and req ue t the pati enL Lo place the hand flat on the
table w ith th e palm fac ing up ward . . Now pl ace yo ur 2nd and 3rd finger. over the patient ' 2nd and
3rd finger, and your 4 th fingers on the pati ent'. 5th finger o th at the PIP, DIP and MCP remajn
extended (see fi g 1.14.9-A) and FOP is neutrali zed. Now reque t the pati ent to fl ex th 4 th fin ger '
PJP ( ee fi g J. 14.9- B) . Repea t the proced ure for the pati ent' 3rd fi nger (immobili zing the 2nd , 4th
and 5th fin ger ), and for compari . on repeat th e procedur or the patien t's oppo ite hand . Jn inj ured
torn FDS , thi s wi ll not be possibl e, and painful fl ex ion wou ld . ugge t t no, ynoviti . . Thi . i. becau e
FDS tendon slip. insert o nto the base of th e middle ph alanx . Thu normal PIP fl x ion indicate
normal FDS function .
3. FPL+ EPL: Gra. p th pati nt's thumb ju t below the int rphalangeal IP) joint ·o a. lo immobiliz
the 1 t MCP joint. Then request th pati ent Lo fl x ( e fi g 1.1 4.10- A) and xL nd (.ee fi g J.14.JO-
B) Lhe interphalangeal (IP) joint o f the Lhum b (which t . l Lh FPL and PL r p cti v Jy). Rep at Lhe
E. • 10
7 '1
p1 on·cl11rr 011 llll' oppw,tll' tl11 1111 h. 111 trnn 0 1 i11 p11 l'd l ·l' l./1\l ' I,, lltr l h- x iu11 I rx lrn o., i 1111 (r •!-.IJL:''I.
" IV ·lyJ
W tll hr i1np:111 L'd . l'. 11111111 ll h) Vl' lll ' tll ~11 / 1 'l'S I~ l(' IH>sy 11o v 11i.,.
Fig. : 1. 14. 1013

• Runncll-Litll •r l st : Thi s t •st is i111por1ant for Yo lk111 an's isc.:lraemic.; c.;o ntracrure (Yf ) o f the hand.
·qu ·st th · p:.llil..'111 to k •e p th 1..' lbow l'l cxed 10 90'\ f'or arms pronal cd and w ri st cx tern ed, and then
acti •I I •11t:h th · hand into a !'i sl (w hi ch tests ac ti ve full rl ex ion or the M 'P, Pl P ancJ the DJP). Jf
1'11.: · ion is re s1ri t ·d appl y prcssur · ov ·r 1he clorsum of f'in gcrs Lo Les t /'or any f'urlh cr fl ex i on (passi vely).
Th •n r quest lhc pa1ient 10 acti v ly c t •nd lh fin gers and w h n full ex tcn. ion i s no t possible, apply
pr s. usr' 0 11 lh ' >l ar surface of rin gers and n tc full pass i ve ex tension . Now, grasp the proximal
phalan · r the rin g ·rs t imrnobi li z M P j ints in neutral positi on, and request the p ati ent Lo
1h
a 1iv ·ly fi e (sec fi g I . 14. 1 1- /\) and ex lend the Pl P and DIP (sec fi g I . 14. J J-B ). Jf the pati ent cann l
Fig. 1.1 4.1I -A Fig.: 1. 14. 11 -B
acti ve ly or passi vely, n ex or extend the PJP and

DIP joint (with the MCP extended) , it is becau.e
of th e "con . Lant leng th " phenomenon /
horten·
in g of the int n-o et, w h ich may be due 10
i, chaemic contracture. ( Remember , even in
i chaemi c contracture, when the wri t i. Oexed,
PIP and DIP n ex ion is often po sible).
N.B. • lntriusic plus deformity : (. ee fig I. I 4.1Z)

MCP is lightly Oexed, PIP and DIP are
·~1
extended, the thumb adducted, wi
Fig. 1. 14. 12 prominent tran ver e arch of hand.
BASIC CLINI CA L EXAMINATION OF THE WRIST 75
• Grip T e ·t : Tl1ert:, ur
,, · le. ts ror the ~rip
_, .
I. Pinch grip : Thi t ts lh Jumbirical a nd the in terossei and needs intact sensation of the pulp f
th thurnb and inde: fing r. Reque. t the patient to pick up a pin, u ing the index and thumb o f one
hand (, ee rig l.1 4. l - ). and then , itb the opposite hand for compari on.
Fi g. : l.14. 13-A Fig.: 1.14. 13-B

2. Key grip : Thi. le. ls the e n ory compone nt of the lateral aspect of the index finger, wh ich may
be impaired in radial nerve le ions. Reque t the patient to hold a key normally i.e., between the
thumb and th tip of the index. ( ee fig l.14.13-B)
3. Power grip : Whe n there i ulnar/median nerve lesio ns, max ima l and forcefu l fin ger flexion is
difficult, and then lhe test is po itive. Reque t the pati ent to firm ly hold a pen, while you try to
pull-away the pen (see fig. l.14.1 3-C). If you are successful , the test is positi ve.
Fig.: 1.1 4.1 3-C Fig.: 1.1 4. 13-D

4. Chuck grip : Request the patient to firmly grip a ping- pong/golf ball , and you try to extricat the
ball from the patient's hand (see fi g l.1 4 . l 3-D). You will ucceed only when there i weakne _ of
thumb adduction / finger tlexion (i.e., tests the ulnar and medi an nerve) .
5. Grip Strength ; Reme mber that the re wi ll be difference of strength between adu lts and children,
men and wome n etc . Inflate a blood pressure
c uff to 200mm Hg and request the patient to
squeeze the infl ated c uff.
• Grind Test : Thi s tests the base of the 1st
MCP. H o lding the patient's thumb with o ne
hand , and the 1st metacarpal with your o ppo _ite
hand , appl y axia l co mpressive force , whil e rotat-
ing the thumb ( ee fi g. 1. 14 . 14). T he patie nt
would complain of pain in osteoarthriti . o f the
1st MCP, Be nnett' fracture (see page 232), or
Fig. 1.1 4.14
Rolando fracture ( ee page 232) .
Chapter 15
V K A I CHAEMIC CONTRACTURE (VIC)
Theories Discussed
• Compartme nt synd ro me • Clinical features of VIC
• Volkman 's si gn • Causes of VIC
• Patholog y of VIC • Diagnosis of VIC
• Management of VIC • Potential sites of VIC
• Indic ati ons of fasciotomy • Check Rein deformity
• VIC is the result of vascular insult to deep tissues of the limb producing ischaemia,
primaily of the muscles and secondarily of nerves , as a sequele of compartment syndrome.
• Compartment syndrome is defined as an elevation of interstitial pressure in a closed
osseofascia/ compartment that resu lts in microvascular compromise .
This is a case of Volkman 's ischaemic con-
tracture of R/ L forearm which is the dominant
sign (with flexor ± extensor compartment in-
volvement; may also involve the hand) after
... treatment received for supracondylar frac-
ture (sometimes fracture both bone forearm) ,
with (or without) involvement of median/ulnar
nerves and contractures of metacarpopha-
langeal / interphalangeal (MCP/IP) joints, of .. .
Fig. 1.15.1 : Typ ical deformity in VIC of forear m
months duration , in a .... year old M/ F patient.
and hand . What are the points in favour of diagnosis?
1. From history : Patient had an injury
around elbow/forearm for which he/she
was treated with long-arm plaster immo-
bil ization in a flexed elbow, after which the
patient had intense pain (not relieved by
the usual dose of analges ics) . The
pain increased on passive extension
of the fingers. Gradually, the patient de-
veloped numbness of fingers , and subse-
quently the characteristic deformity.
2. On inspection :
(a) Forearm is thin , wasted and (some-
times extensively) scarred .
(b) Typical deform ity of pronated fore -
Fig. 1.15.2 : Vol kman 's si gn .
arm , flexed wris t, extended MCP
Note : Increased flexion of fin gers when wrist is extended.
joints sometimes and flexed IP joints
(i. e., claw ing) (Fig. 1.15.1).
76
VOLKMAN'$ ISCHAEMIC CONTRAC UR (VIC)
77
3. on palpation : Cord-like , fibrotic musculature on the volar su rface of forearm

. · dh h d · .
somet1.me
the scarre d sk in 1s a erent to t e un erl ymg muscles .
4. Volkman 's ~;g~ :fWI hedn wthrist ish exMtecnd ed , the ~ ~ P and IP joints b come more flexed, but
when the wrist 1s exe , en t e P and IP Joints can be extended more in com ·
to the pos1·t·10n of ex t en d e d wn.st (F'1g. 1.15 .2) . panson
N.B. • ~olk~an's sign is d~e to con~tanf.length-phenomenon because the muscles become

f1brot1c and lose their contractile properties, thus effectively having only a fixed length.
5. Pronation/supination movements a re gross ly re stri cte d. Sometimes elbow and wrist
movements are also restricted .
6. Signs of median/ ulnar nerve palsy (if and wh en prese nt) [see page 104, 105].
7. Signs of MCP/IP joint contractures (if present) : The finger joints are stiff and have little
or no movement in any position of the wric;t.
8. Signs of fracture : e.g., Thickened , irregular, medial and lateral supracondyl ar ridges wi th
intact 3-point-relationship at elbow for supracondyla r fracture, or angulation of ulna and
radius fo r both bone fractures .
9. Power of long flexors of fingers is reduced : Flexor digitorum profundus (FOP), flexor
digitorum sublimis (FDS) and flexo r pollicis longus (FPL) (see page 73).
10. When hand muscles are involved : There is flexion at MCP joint with extension at IP
joints, and adducted thumb (Bunnell's intrinsic plus defo rm ity - see page 74) .
What are the possible causes of VIC ?
1. Crush injuries, fractures.
2. External compressi on (tight bandaging , plastering) .
3. Internal bleeding (e.g. haemophilia) .
4. Intra-arterial injections , especially in drug addicts.
5. Post-burn contractu res .
What muscles are most commonly affected in the forearm ?
Flexor digitoru m profundus (FOP) and flexor pollicis longus (FPL). Type I muscles are more
vulnerable than Type II muscles.
Which artery is chiefly responsible in the forearm ?
Anterior interosseous artery. There is an elliptical infarct (Seddon's ellipsoid) in its long
axis within FOP . (muscle sequestrum)
N.B. • Pathology - j lntracompartmental pressure ~ vascular compromise ~ ischaemia of
muscles ~ infarction of muscles - typically elliptical in shape ~ since muscles cannot
regenerate, they are replaced by fibrous tissue ~ contracture. Median nerve in the fore-
arm lies in the centre of the ellipsoid infarct, and thus is vulnerable to ischaemia.
Diagnosis of impending VIC or Volkman 's ischaemia (i.e., before there is establ ished
contracture )
1 . Pain : Most constant feature is the stretch pain. Pain increases with extension of fin-
gers, thus stretching the flexor muscles. Gentle passive extension of fi ngers , even to
neutral position, causes severe pain . Pain is out of proportion to the inju ry .
2. Pallor : Earliest feature is capillary nailbed return l (appreciated clinically and by pulse-
oxymeter readings).
3. Paresthesia and numbness : Appears much later.
4. Pulseless : Not a constant feature. Often radial pulse is present in ischaemia, and ab-
sence of rad ial pulse does not automatically indicate impending VIC .
s. Swelling/tenderness of fingers and forehand. On palpation , tightness of the forehand
muscles is felt.
N.B. • Impending VIC is a MEDICAL EMERGENCY and must be addressed URGENTLY
Managem ent of impending VIC :

1. All bandages/plasters/splints are removed urg ently .
2 . Limb is elevated to the level of heart; elbow straig hte ned to only 3 0° flex ion , and the lirnb
is careful ly observed repeatedly at short inte rvals.
3 . If no improvement occurs , fasciotomy operation must be d one to decompress the
osseofascial compartment.
N.B. • In the same sitti ng internal fixation of the fracture is al so done .
• If facilities are avai lab le, measurement of intracompartmental pressure is done dur-
ing observati on before deciding on fasciotomy .
How will you manage a case of established VIC ?

Investigations -
1. X-ray : To note the fracture status.
2. Ne rve conduction velocity (NCV) : To assess nerve functions and level of neural injury.
3. Electromyography (EMG) : To assess muscle contractil ity .
Treatments -
1. For mild variety (No nerve involvement and only f/exor digitorum profundus/flexor pollicis
longus involved) : Sp li ntin g and physicaltherapy. If no substantial improvement of
hand functi on occu r, then Max-page muscle slide operation is performed.
2. For moderate (All muscles of volar surface involved, with neurodeficits) : Max-page op-
eration + neuro lysis + tendon transfer if required .
3. For severe (All muscles of volar + extensor compartment involved + neurodeficit +
scarred sk in + j oint contracture) : Scar excision ± muscle slide ± proximal rtJW
carpectomy ± wrist arthrodesis .
What are th e potential sites f or V I C, in general ?

I. Volar compartment of forearm.
2. Hand , foot.
3. Anterior and deep po terior compartments of leg.
4. Buttocks, shoulders, arms are rare sites .
What are th e indication for Jasciotomy :
1. For No rmotensive patients:
(a) Positive clinical findings, together with _
(b) Compartment pressure> 30 mmHg.
2. For Hyporensive
. patients : Compartment pressure> 20 mm Hg.
NB· · • Wa1t fo r at leas t 3 to 4 h b f .
regeneration f dmo nt s e ore pl annin g th e operatio n, becau e there may be some
o nerves an some hand fu ncf b .
• > 70~ VIC . ion may e rega ined wi th inten ive phy icaltherapy.
0
occur af ter both-bone fra t . h·t
• p . f . . c UJ es w I e onl y 15% VIC after upracondylar fracture.
rognos1s a ter operati on is guarded d . ti . . o
too much im . an patien patient party mu t be coun. elled about not expecun~
. provement, post-operatJ vely.
• Reperfu 10n injury : TNF a IL . . . .
occ urs the e infl · , ' ' _etc. remain localized m ischaemic muscles. When reperfusion
sy nd rome (S IRS).
ammatory mediators d
· can sprea and cau e Sy temic inflammatory respons
e
Do you know about any other co d 't' .

II I LOI/' ht I, pre e11t,· ,·,,1 ,.
"Check-rein deformit y" of th · »' con ·tanl -length-phenom non " '!.
e great toe. whic h O d . d 10
ca JI u f om1ed after fracture di tal th · ·ct .b. cc ur ue to tethering of the flexor haluci · longu · ten on
. . 11 ti ia or omet' f ·1t~ ~.J
w hen I he ankle 1. in neutra l or in do . . ime a ter ankle . urgery. The 1rreat toe cannot bed r ·
r 111 e ion · but can be d or 1. fl exed \i hen the ankleb i in equinu .
Chapter 16
MA U ITED COLLES FRACTURE
Theories Discussed
• Deformities in Calles fracture
• Clinical features of Calles fracture
• Comp lication of Calles fracture
• Carpal tunnel syndrome
• Complex Regional Pain Sy nd rome
• Man agement of Calles fracture
• Smith fracture
• Barton 's fracture
• Chauffeur's fracture
• Criterion for acceptability of reduction
Calles fracture was first described by Abraham Calles in 1814, much before X-ray was invented!
It is a transverse fracture of the distal radius, about 2 cm from the distal articular surface
comr:nonly at the _corticocan~e llous j unction , which may sometimes involve fractures of ulna;
st
Yl_oid a~d sometimes have intra-articular involvement of the radiocarpal joint and has the six
typical displacements . '
Typical displacements :
1 . Dorsal shift )
2. Dorsal tilt
3. Lateral shift Noted clearly
4 . Latera l tilt in X-rays
5 . Impaction
6 . Supination (not appreciated in X-rays) .
• It is the most common fracture of the
elderly people (> 60 years) , very common
in women with post-menopausal osteo -
porosis , and almost always occurs with fall
on outstretched hand . To the naked AP view Lat. view
eye , it appears classically as dinner- Fig . 1.16.1 : Collesfracture.
fork deformity when the wrist is viewed from the side (however, it is not always found) .
N.B. • Normally the radial styloid is about 1 cm distal to the ulnar styloid, but in Calles frac-
ture, both the styloids lie almost at the same level. This is an important clinical test.
• Usually there is comminution on the dorsal and lateral aspects of the fracture line,
while the palmar and medial aspects have clear and sharp margins.

It is a case of malunited Calles fracture of R/L side, which is the dominant side of .... months
duration, with deformities of dorsal tilt and displacement, and also lateral tilt and displacement, with
stiffness of wrisVfingers/elbow/shoulder, in a ... year old M/F patient. ± Reflex sympathetic dystrophy
N.8. • Mention positive points only.

• RSD is now called Complex Regional Pain Syndrome (CAPS). (see page
81 ).
79

1. Age / Sex are in favour. (Remember Post~
menopausal women and aged males) .
2 . History :
• F~ II on ?utstretche~ hand , fol l~wed by
immediate pain and swe ll ing of the wrist.
• History of plaster immobilization for 4 _ 6
weeks with the typical extent of Col/es
plaster i.e., from just below the elbow
to proximal pa/mar crease (volarly) and
short of knucles (dorsally) and
excluding the thumb, with the wrist in
slight pa/mar flex ion and ulnar deviation,
and the forearm pronated.
3. Inspection : The wrist appears to be
broadened and rad ially dev iated with
prominent ulnar head and there is dorsal
and lateral tilt. (Fig 1.16.2)
4. Palpation :
• No tenderness of bones (bones in th e
Fig. 1.16.2 : Maluni ted Calles fracture . process of heal ing are tender and so
Note - Broadene d wrist, prom inent uln ar head and they cannot be designated as malunited
dorsal and lateral tilt. because union process is not complet0 . )
• Distal radius is irregular / thickened / broadened .
• The tip of ulnar styloid and radial styloid are almost at the same level.
5. Movement :
• Wrist movements are restricted , especially palmar flexion / dorsiflexion / abduction / adduction .
• Pronation / supination of forearm is also restricted .
• Movements of elbow / shoulder/ fingers and MCP and IP joints may also be restricted .
6 . Measurement : Length of forearm as measured from tip of lateral epicondyle of humerus ~c
radial styloid is shortened , in comparison to the opposite forearm . Circumferrential girth 1s
increased at the level of radial styloid .
7. Maisonneuve 's test : May be positive (see page 72) .
8. Piano key sign : May be positive (see page 70).
What are the complications of Co/fes fracture ?
I. Early complications :
1 . Distal vascular compromise due to tight plaster - so nailbed return should be observed.
2. Distal neural compromise due to stretching or compression of the median nerve and
sometimes the ulnar nerve - so clinical nerve function tests are done. (see page 1OS)
N.B. • In above cases, splitting of plaster ventrally is done first, which often relieves symptoms.
However, post-reduction X-rays may warrant remanipulation and plaster.
3. Loss of reduction - As seen in check X-rays , after manipulation .
II. Late complications :
1 t
· S iffness of almost any joint in the upper limb can occur. So mobiliza tion ercise of 1118
should~r / .elbow I fingers should be started early.
2
· Malumon is very common . Probable causes of loss of reduction r omminuted do<
surface, osteo-porosi s, and rupture of distal radiouln r Jig m nts.
3
· Carpal tunnel syndrome (CTS): Uncommon , and occurs I t (months/y rs I t r) . Pt1 :,I
therapy Is useful but surgical decompression is th e definitiv - tr tm nt.
MALUNITEO COLLES FRACTURE 81
• Causes of CTS :
C oll s fracture.
A myloid disease.
R aynauds phenomenon.
P regnancy.
A berrant forearm muscles / anatomy.
L ipoma / other tumours in wrist.
Tunnel is smaller in women {Typically the
patient is an elderly, female typist or computer
operator).
Syn ovitis non-specific idiopathic of wrist
(? viral).
Fig . 1.16.3 : Malun ited Colles fracture.
D iabetes .
R heumatoid arthritis.
0 besity .
M yxoedema.
(0) E dema from infection / inflammation.
• Clinical signs/symptoms of CTS :
(a) Burning pain (may be night-cries) over lateral 3 1/ 2 portion of the hand including fingers
(median nerve distribution).
(b) Tinel's sign from wrist area, on median nerve, usually produces tingling.
(c) Phalen's test : Acute wrist flexion for 60 seconds produces tingling at median nerve
distribution.
(d) Durkan 's test direct carpal compression (with thumb) ~ produces tingling pain .
(e) Blood pressure cuff test ~ Shows signs of nerve compression.
(f) Late cases have thenar musculature atrophy.
• Investigations for CTS :
(a) Nerve conduction velocity (NCV) test is diagnostic.
(b) MRI of carpal tunnel gives good visuality of compression.
• Treatment of CTS : Physcialtherapy, Surgical decompression of the carpal tunnel.
4. Sudeck's osteodystrophy (Causalgia I Reflex sympathetic dystrophy I Complex

regional pain syndrome) : Patient complains of hyperalgesia, allodynia , redness ,
changing sweating pattern , stiffness , weakness and sometimes in late cases - trophic
changes of hair, nail , skin (thin shiny skin with hair loss, ridged brittle nails) . X-rays
show periarticular osteopenia.
• Clinical features of complex regional pain syndrome (CRPS)

Dy Discolouration
S Stiffness Due to abnormal and prolonged
T Trophic changes of skin/nails sympathetic nervous response affecting
R Redness the sensory, vasomotor, sudomotor
0 Osteopenia components of the nerve
P Painful swelling
Hy Hyperhydrosis
Treatment ~ Physicaltherapy, and NSAID + Tricyclic antidepressants.
5. Rupture of the extensor pollicis longus tendon : Rare. May occur after trivial injury
and undisplaced fracture ~ probably due to vascular injury to te ndon , or the constant
82 HANDBOOK FOR ORTHOPAEDICS EXA I
fnction/ attnlion with 1ster's lub rel wh r lh ndon ch · nq 5 direction h / ab,,, 1 4,

Occurs af er rnon hs. nd surg1 al r p tr 1s l h I r trn ;n t
6 . Distal radioulnar joint (DRLJJ) in ability ( u lo n'" ngu l,, r fibroJ r, rtil ' & t aq r.il,c.r
complains of ulnar sided pain Ion afl r h fractu r ha~ hf r. I c , anrJ wr. akne, ,,, 1 ~~
w ith oc asion 1 "clichng 1111th r 1.,., I') •
m O V 0 m O n t S . 0 n t re r · le '.j In '.j ·-:
prorn1n0n ulnar head i, unu ·t
. . , ia11
mobile (Piano key sign - ee pa 9e ?f:
N.B . • Ulnar styloid non
.
-un ion can al (i
produce ulnar pain.
How w11/ you m n gc rh,s ca e of mal n

I fractur ?
First confirmatio n of diagnosis by X-ray 1
wrist in AP and late ral views .

Fig 1 16 4 Malun1ted Colles fracture.
Treatment options :
1. If functional disability is minimal , physicaltherapy is sufficient.
2 . To improve range of motion and for cosmesis - Darrach 's operation ~ excision of dista:
ulna
W at s the echnique of manipulation for a case of fresh Co/les frac ture ?
First elbow is flexed to relax brachioradialis . T raction and counter-traction across the wrist
is given with the forearm in pronation, which disimpacts the fracture fragments and also
neutralizes the lateral tilt and lateral displacement. Then the distal fragment is pushed volarly
and the wrist is simultaneously brought into palmar and ulnar deviation to complete the reduction.
Final position is pronation, pa/mar 1/exion
and ulnar deviation.
What is Reverse Co/Jes fracture ?
It is also known as Smith fractw where
there is volar tilt of the d i stal rad iu$ with a
garden spade deformity, o r volar
displacement of the hand and distal radius.
Mechanism of injury is a fall onto a flexed
wrist with the forearm supinated. It is a very
unstable fracture often requiring open
Fig. 1.16.5 : Smith fracture . reduction and internal fixation (Fig . 1.16.S).
N.B. • For malunited Colles fracture ost . J hi's

External Stabilizatio S ' · eotomy ± bone graft ing followed by external fixation (e.g. 0 .
d , n Ystem - JESS) with us Ofr · me111ne
one to gain proper r· ct· . ·e 1gamento-tax is principle and di traction. 1s so
a ia11 ength and alignment.
Do you kno w about an oth .
y erdts falradialfra ct11 re?
Y es. Barton '~ r . ·
r r . . . Jracture dislocation wh· h d al o
ac ial lylo1d fracture. (Chaurre ' . r ,c may be dorsal Barion fracture or volar Barton fracture an
JJ ' ur s Jracture I Ba kf"
c ire fracture/ Hutchinson 's fracture) .
MALUNITED COLLES FRACTURE 83
Burton': F radurc Hi ·lo alio11/S 11hl11 a t io n

• Thc doNil o r, olar nm ol the d 1,1al rndiu, i!-. di ~pl .ic ·d don,:ill y < r volarl y ,dong with the ca rpal bones and the hand .
Volar Bnrton \.fract11re i., more 0111111 011, than Dor.w t Harton 's f m ct11re.
• Mechanism of injury : Fa ll onto dor~inc , ·ti wri~ t whe n the rr a rm is pronale cl . hearing forces cause the
fracture.
Fig. l. 16.6 : Volar B111ton . Fi g. 1. 16.7: Dorsa l Bart on. F ig. 1.1 6 .8:
• Treatment : Mosl fracture. require open red uctio n and intern al fi xatio n (ORlF) (Fig. J . 16.8). R arely, som e dorsal
Barton' . fracture can be managed conservati vely w ith c losed reduction and pl aster cast immobilizatio n.
Chauffeur's Fracture
• It i an avul ion fracture of the radia l styloid (Fig.
I. 16.9) w ith ligament remaining allached to the
tyloid , which cause. minimal or no displaceme nt.
O ften associa te d with pe rilu na te di s loca ti o n/
scapholunate di s ociation, e tc. due to assoc iated
intercarpal ligamentous injuries.
• M echanism of injury : Compre sion of the sty lo id
against the caphoid, when the wri Li in dorsiflex ion
and ulnar deviation.
• Treatment : Alth ough be low elbow plaste r cas t Fig. I. l 6.9 : Chauffe ur' s fr acture
ex tendin g up to th e metaca rpal head wi th the w ri st uln a r dev iated m ay be suffic ie nt for treatme nt, it often
req uires OR JF .
X-ray criteria for acceptable healing of Calles fracture

• Radial length : shortening < 5 mm
• Radial inclination > 15°
• Ti lt : Dorsal 15°, Volar 20°
• Articular Step-off < 2 mm at radiocarpal joint.
• Articular incongruity < 2 mm al the sigmoid notch.
X-ray measurement of alignment
• Radial inclination : 22°
• Radial height : 11 to 12 mm
• Radial tilt : 11 ° - 12° Volar
• Ulnar variance : + 2mm
Chapter 17
AD LU G DEFORMITY
Theories Discussed
• Aetiology • Patho logy
• Cl inical Featu re s • Management
• Con genital , Madelung deformity presents most commonl y after 10 years of age, and the
deformity increases until the bone growt h stops . It is frequently bilateral , and it is more
common in females than males .
• First descri bed by Malgaigne, later by Madelung .
Aetiology
1. Idiopathic } U II b'I
I t 1
2. Congen ital (Autosomal dominant) sua Y a era
3. Post-trau mat ic } .
. h . Usually unilate ral
4 . D1ap ysea ac 1as1s
1
Pathology
1. Defective inner 113rd radial epiphysis causes more growth of the outer 213rd of radius
distally, causing volar + ulnar angulation of the distal radius , resulting in undue prominenr-e
of the distal ulna and volar subluxation of the hand and carpus (Fig. 1.17.1 ).
2. Forearm is often shortened (in comparison to other side) due to misdirected growth .
AP vie w
Fig . 1.17 .1 : Madelun def . Lat. view
9 orm,ty. Note - Vol ar subluxation of the carpus and hand,
a nd defect in distal and medial radius .
84
MADELUNG DEFORMITY 85
What is your diagnosis I case ?
It is a case of Madelung deformity of R/L / bilateral wrist , with the typical deformitie (
· / s see
patho logy) , proba bl y congenita 1 post-infective / post-traumatic / or due to diaphyseal acl ·
. .
. as1s,
in a .... .. year old M/F patient.
What are the points in fa vour of your diagnosis ?

History
• There may be positive family history of Madelung deformity / diaphyseal aclasis .
• There may be history of trauma / infection , which could have damaged the medial part of
the distal radial ep iphysis .
Inspection
• Wrist is broadened , ulnar head is prominent dorsally, with the radius angulated ulnarwards
and volarly.
Palpation
• The ulnar head can be pushed back volarly. [However, this may not be possible in long
standing cases . Then , X-rays in lateral view and AP view is helpful (Fig. 1.17.1)] .
Movements :
• Wrist dorsiflexion is severely restricted.
• Pronation / supination is restricted.
• On measurement, length of forearm is short. (Would be difficult to prove in bi late ral
cases .)
First confirmation of diagnosis by X-rays .
Children have excellent function and little or no pain . For them , regular follow up and observa-
tion i.e., conservative treatment is ideal.
N.B. • X-ray findings : Radial inclination : 22° -23 °, Radial height : 11 mm - 12 mm, Volar Ti lt : 11 - 1-". Lllnar
variance : 0°.
• Madelung deformity may be associated with : Dyschondroplasia, achondroplasia. Turm:r·~ : . mlromc..
Mucopolysacchoroidosis, Multiple epiphyseal dysplasia.
• Radiolunate Vicker's ligament causing tethering at medial part of piphysi · mu be I aus, of gro lh
disturbance, leading to Madelung deformity .
• Surgery will be ·needed for functional disability and chroni c persisling puin.
(i) For skeletally immature -Milch recession osteotomy; E, cisiou of Yickcr'1- ligum nt + piph · iol :-.b
· ) u· I •1 llll ost otom ' of
(11..) For skeletally mature - Darrach 's oeteotomy (di. lal ulnar rei.ett1on ; nip :mar.,,
di stal radial metaphysis ± Darroch 's oeteotomy + exc1· 100
· o cv·1 k·er · s r1gam n1
• Parents must be counselled that the range of movements nev r impro . er :-.ignillc,mtl • nnd d •lm11111i '
may recur ~ after any procedure.
Chapter 18
OSTEOSARCOMA
Theories Discussed
• Management of osteosarcoma
• Clinical features of osteosarcoma
• Usually , osteosarcoma cases have lesi ons in di stal femur , proximal tibia , or proximal
humerus, although infrequently it can occur in the scapula, ilium , ulna, radius , etc.
• It is the most common primary mal ignant bone tumour of non-haemopoetic origin.
Overall, it is the 2nd most common primary malignant bone tumour. (1st is mul-
tiple myeloma which has haemopoetic origin).
This is a case of osteosarcoma of R/L, proximal/distal , tibia/femur humerus , with (or without)
(a) Patholog ical fracture (rare). (see page 246).
(b) Distal neurovascular deficit (mention specific nerve inyolvement if diagnosed).
(c) Probable lung metastasis (search for chest symptoms/signs).
(d) Adjacent joint effusion ± decrease in the range of movement in a ..... . year old male /
female patient.
N.B. • Mention only the positive findings.

What are the points in favour of your diag-
nosis?
1. Age : Usually below 25 years (second
decade commonest) .
2. Sex: Males have slightly higher incidence.
3. Site : Metaphyseal area of bone (femur/
tibia / humerus, etc.).
4. History :
. (a) First there was pain (often more at
ntght) later followed by swelling. ·
(b) Fast ro · Fig . 1 -18.1 : Osteosarcoma of distal femur.
. g wing tumour (suggests ma- Note - Sun-ray appearance and Codman's triangle.
llgnant nature) ~ patie t h h .
n as s ort duration of complaints , about 2 - 6 months.
N.B. • Very sudden rapid ex b ·
may be due t~ biops ac;r at1on of growth occurs after cortical break which
Y or ,racture.
(c) Progressive weakness, weight loss .
(d) (Rarely) History of cough and h ' cach~x,a ~ these appear at a very late stage.
(e) Patient may give history of t aemoptysis suggesting lung metastasis.
1
serves to draw the patient's ~:::;i~~ which is usually unrelated to the lesion, and on Y
5. Examination : ·
(a) Severe pallor - patient is usually .
(b) Skin over tumour - shiny and st ~~re anaemic than cachectic.
h
(c) Warm , tender, margins _ ill-de;~~d e~ wi~h prominent veins (indicates rapid g~owl )der
standard headings used for any s ir
ar~egated consistency (describe swelling un
we ing ' see page 14).
86
OSTEOSARCOMA 87
(d) Small effusion may be present in

the adjacent joint. Movements of
adjacent join t, if restricted, is usu-
ally due to mechanical obstru lion and
effusion .
(e) Regional lymph node - Only 25% to
30% cases have lymphadenopathy .
Being a sarcoma, it mainly metasta-
sizes via blood to the lungs, liver, etc.
(f) Distal neurovascular deficit , if
present , strongly suggests mal ig -
nancy (look for distal pulse / nailbed
return , and finger / toe movements /
sensation) .
What ,nves 1gat1ons would you prescribe? Fig . 1.18.2 : Osteosa rcoma of postero -lateral distal
femur with sun-ray appearance .
• Blood : Hb%; Alk P04 level is noted pre-
operatively and if i post-operatively, then
indicates recurrence or metastasis .
• X-ray : Local part. (look for sun-ray ap-
pearance, Codman 's triangle.
- Chest X-ray (to look for metastasis).
• Biopsy for histopathology : For confirma-
tion of diagnosis.
• Rarely, CT scan / MRI of tumour is done ,
before planning limb-sparing -surgery , to
note cortical break and soft tissue in-
volvement.
N.B. • CT scan is more sensitive to find
lung metastasis .
• Bone scan (see page 251) is occasion- Fig . 1.18.3 : Osteosarcoma of distal femur with
sun-ray appearance, Codman's triangle .
ally done to search for "skip lesions".
• Doppler / angiography is needed sometimes , to note relation of main vascular channels
with the tumour.
How wou e case ?
Neo-adjuvant chemotherapy + surgery ,. . , - -operative chemotherapy ~ tolioWea
high-up amputation ~ followed by chemotherapy.
N.B.:
• Pre-operative chemotherapy - targeted at mi cro-
metastasis that has a lre ady occurred - e.R., in
lungs . Patient is followed up at 6 -8 weekly inter-
vals with recording of body weight, Hb %, Alk.
PO., local X-ray and CXR (CT if possible), a nd
inspection of the a mputati o n tump .
• Histological picture - tumour cell s s urrounded. by
osteotid matrix is characteristic. Cells are mainly
spindle-shaped with hyperchromatic nuclei.
• Nnat11ral history, if left untreated - Fig. 1.18.4 : Clinical photo of proxim_al tibial osteosarcoma.
Lung meta ta is ~ IO to 12 months. Nole _ Shiny kin with venous prominence.
Deterioration. death ~ by 2 years.
Chap 19
eories Discussed
• Clinical features of GCT • Management of GCT
• Giant-cells • Aneurismal bone cyst
GCT is a tumour of uncertain origin , with variable growth potential. It is benign, bu local!
aggressive, and has a tendency for local recurrence . (Abou t 1% case is believed to be primaril:
maHgnant) . Usually GCT cases have lesions in distal femur, proxima l tibia an d dis tal radius
although it may affect almost any bone. What is your diagnosis ? '
This is a case of giant cell tumour of R / L
proximal / distal, tibia / femur / rad ius, wit '
(or without)
1. Pathological frac ture. (See page 246)
2 . Dis tal neurovascu lar deficit.
3 . Adjacen t jo int effu si on .
Fig . 1 .19.1 : Cl inical photograph of distal radial N.B. • Joint effusion is more common in
swelling . GCT than in osteosarcoma.
• Mention only the positive findings.
4 . Decreased range of movement in a
... ...... . year old male / female patient.
What are the points in fa vour of your diag-
nosis ?
1 . Age : 20- 40 year s . Commonly seen
after the closure of growth plate.
2. Sex : Female s have slightly higher
pre-do inance (M : F = 1 : 1.5). .
3. Site : Most common distal femur ...., pr~xi·
Fig. 1.1 9.2 : Proximal tib ial swell ing around knee
mal tibia (Fig . 1 .19 .2) -, distal radius
(F ig . 1.19 .1) .
4 . History:
(a) Slow growing tumour, long duration of swelling (> 4 to 6 months). ·n in a
(b) Common.l y swelling at ~irst, later appe~ra'!ce of pain (s_udden onset of P;;;gnant
progressively slow growing tumour may indicate patholog,cal fracture or m
tra'!sformation) . the 1esion
(c) Patient may give previous history of trauma , which is usually unrelated to
and only serves to draw the attention of the patients.
5. Examination : surfaced,
h
(a) Bony hard (or firm). eccentrically located swelling , slightly warm , smool malignant
skin over swelling is free . Soft tissue and ski n may be involved when
transformation has occurred . . . t d ainlY due to
0
(b) Adjacent joint effusion may be pre se nt. Joint movement 1s restnc ' m
mechanical obstruction .
88
G IANT CELL TUMOUR (0STEOCLASTOMA)
89
(c) Skin may be shiny with veno u s
prom inence (especia lly wit h ma lig -
nant transformation) .
(d) "Cracked egg shell" may be rare ly
felt on palpation but it should never
be tried , because it causes cort ical
break, and may lead to rap id growth .
(e) Distal neurovascular deficit, if present,
may be due to compression , or some-
ti mes due to mal ignant change .
Why is it called osteoclastoma or
osteoclastoma alba ?
Previously, it was thought that the cells of
orig in were osteoclasts . Hence the name.
Alba = White ~ denotes hyp ovascularity .
How will you investigate this case ?
1 . X-ray of local part -
AP view , Lateral vi ew .
2 . Biopsy is a mu st and diagnostic -
(i) FNAC : In expert hands .
(ii) Open - More useful , sensitive, specific.
3 . CT Scan is used to note cortical integ-
ri ty , recurrence ,
4 . MRI intraosseous and soft tissue spread
How wo uld you treat the case ?
A. If on histology the tumour is benign
and the cortex intact then ~ thorough Fig. 1 .19 .3 : GCT of d istal radius .
curettage ~ 5 % phenol + 70 % alcohol Not e - Ecce nt ric , ex pa ns ile , epiphys io -metaphy-
sea l , osteol ytic les io n w ith sharp demarcation of
appl icat ion ~ bone cementing . If small ma rg in a nd soa p-bubble appearance .
le si on , thorough curettage may be fol -
lowed up with bone grafting.
N.B. • Curettage + bone graft, had high
rate of recurrence (upto 50%). Ad-
equate meticulous curettage
(using power burr) and cortical
window as large as lesion re-
duces recurrence (15%) .
• Bone cement has the added advan-
tage of exothermic reaction . When
the cement " sets ", it gives off
heat , which kills remnants of tu -
mour cells .
B. If on histology , malignancy is s~g-
Fig . 1 _1 g.4; GCT of proximal tibia .
gested or the cortex is broken th8 ~ wide Note - Eccentric , expansile . epiphys10-metaphy eal ,
local excision of the whole tumour, includ- osteolytic les ion extending up to subcondral bone
ing its co veri ng, is done followed by re- and soap-bubble appea ran ce .
con struction e .g.,
Fig. 1 .19 .5 : GCT of distal tibia . Fig . 1.19.6: GCT of proximal fibu la.
Note - Expansile , eccentri c , osteo lytic lesion .
1. For distal radius , ipsilateral pro ximal fi bula is used for reconstructi on.
2. Fo r tumours around knee , fo r young active patients arthrodes is may be done , when
joint is involved . If joint is not involved curettage and bone grafting is done and regular
foll ow up is requi red to detect recurrence .
3. Custom-made prosthesis may also be used.
N.B. • Malignant GCT has pulmonary metastasis in 3% cases (mortality 1.5%) wh ich is de-
tected by CT Scan and surgery is the prefered treatment option for th is lesion .
Are giant elh excf1Hi~·cly for111d only i11 t/11, t11111111ir :'
No. Giant ' ll ar fo und in many bone tumour. or
tumour- lik nditi n - all ha e o. t olyti c le ion .
F ibrou dy 1 la ia
on- ~. i f in o fi.br ma
0 l iti ' ri br u
U nica m ra t bon cy t
hondrom y oid fibrom a, chondrobla wma
H YP rparathyroidi m.
Fig . 1. 19.7 : GCT Di tal Radiu with co rti ca l break but
with di stin ct demarca tion of tumour and normal bone N.B. • M nemonic : FAN-OUCH
ti sue - probably beni gn.
, r rar1"1il' 1 t1/
· t i., IIth e..diflere11ce between 111111ouro1n giant cell\ anrl <>ti, r g1a111
What . II ., , J J
c,• , . r ,a/ ure t ,e o1,1e
ce ,. :
g ta11
Tum ourous gian

.
t cells
.
~ urnerou cent ra ll y pl aced nuc 1e .1,. Langerhan ,.s giant
. ell -,--" 15_25 , peripherallY
arranged nuclei ; Fore1g11 -bodv giant cells -t Abou t 10 c . 11
· · ntra Y p 1a ·ed and anety of ·ize. of nuclei.
!low w1/I )'OIi de/al f)o .,·J-opt•rato•e r •curr nee o.f (, I ·>
1. Clinically : Pain .
2. Radiologically :
(a) D !ructi on of bone graft and reap p ra nee of af11 ng h d
teo l ti areas wh r curellage alld bone gr
bee n done.
GIANT CELL TUMOUR (OSTEOCLASTOMA) 91
(b) Failure of de elo pme~ t o r ·c_lero ti c _ri ng or

margin. at the edge~ ot th I • 10 11 wh ich no r-
mally appea rs by 6 month s.
(c) Co nt amina tion and rc~~-rr e '.1 ce in so ft ti . -
ues are detected b calcd 1cat10 n.
3. Bioc hemicall : In creas cl ·e rum Ta rtrate-Re-
. i tant id Pho sphatase (TR P) in blood.
\I !,al ; the importance of giant alls in histological
,radi//~ ?
' '
Grading d pend on the nu mber of pind le cell .
Grade f ~ Benign : Few pi nd le ce ll , n umero us
gia nt cell ; Grade fl ~ Aggressive : Fewer gia nt cell , Fig. L. J9.8 : Malignant vari ety of GCT with coni cal break,
~ 1or pindle cell s; Grade lll ~ Maligna nt : Rare gia nt soft ti ss ue in vo lveme nt a nd hazy de marcation of norm al
bo ne and tum our with so ft ti ss ue swe llin g.
cell , nu m rou pi ndle ce ll s.
N.B. • Pre-operati vely erurn T artrate-Resi tant Acid Pho sphatase levels are high in patient with GCT ,
whi ch fa lls ig nificantly after operative treatment, and may ri se again with recurrence.
• Advantages of bone cement over bone graft: Early detection of recurrence, early weight bearing (aug-
mentation with divergent screw placement, if used, increases strength) , exothermic reaction.
• Extended curettage : Curettage followed by - liquid nitrogeo/phenol/electrocautery or bone cement.
• Sandwich graft: Bone graft~ gel foam ~ bone cement (from .joint to metaphysis)
• Unicoodylar recon truction may be done using patella as graft.
• Radiation increa e chance of malignancy, biphosphonates reduces recurrence rate.
• Incisional biopsy principle: Same surgeon (conversant with amputation flaps) who will do the definitive
urgery should do the biop y; longitudinal skin incision, so that it can be incorporated with the incision for
definitive surgery ; approach through intramuscular plane; round/oval shaped sample taken; bone cement
plug to fill defect; meticulous haemostatis ; drain outlet colinear with skin incision ; avoid wide retention
sutu res for kin clo ure.
ANEURISMAL BONE CYST (ABC)

• Very imil ar to GCT in clinical prese ntati on, X-rays and even hi tolo gy and treatme nt.
• on-neop lastic but vasocystic, benign meta ph ysea l le ion .
• Common in 5-40 yea rs of age, but ca n be found in any age or any bone.
Fig . 1. 19.9 : ABC of proximal tibi a .

• 30% of ABC may be a ociated with other bone tumours like GCT, fibro u. dy. plasia , t .
• Clini ca lly may be asy mptomati c, or th ere ma y be pain , w llin g, pathological fractur ·.
• X-ray~ Eccentric , ex pan ile, osteolytic, metaphy ea l lesion (like G T) . GCT abuts th sub ·hondral bone but
ABC does not extend up to the articul ar margi n.
• Treatment ~ Curettage+ bone graft (25 % rec urrence), or c urett ag + bon e c m nt. lf anatomi<.:ally
fe a ible ( .g., pro xi mal fibula) wi de resection may be done .
Chapter 20
EXOSTOSIS
Theories Discussed
• Aetio-pathogenesis of exostosis • Clinical features/complications of exostosis
• Management of exostosis • Trevor disease
It is the most common benign bone tumour (some consider this to be a hamartoma).
This is a case of :
1. Multiple exostosis (may be single).
2. R/ L lower± upper limb (pelvis , scapula
may also be involved) .
3 . ± Deform iti es ( e.g ., genu valgurn /
varum , ankle valgus / varus , dorso-lat-
eral bow in g of radius , ulnar deviation
of wrist , etc .) .
4. ± Shorten ing of limbs .
Fig . 1.20 .1 : Pedunculated exostosis of supracondylar 5.± Neurovascu lar deficit (paresthesia,
reg ion of femu r. Note - It is pointing upwards to-
wards diaphys is from metaphyseal region . motor weakness) .
6. In a ..... ye ar old male/ female patient.
What are the other names of exostos ,s?
1. O steochondroma (us ually sessile variety) .
2 . Diap hyseal ac las is (m isnomer) , heredi·
tary multiple exos tos is , metaphyseal aclasis.
3 . Cartilage ca pped ex ostos is (usua lly pe·
duncul led variety .
What i th th ory of gene s (how does it
for, 1) ?
Essentially it is an aberration of growth . Some

ce ll s , at the margi ns of growth plate , begin. 1~
grow centrifugally, rather than the normal wh 1.c
is longitudinally. As longitudinal growth contin·
ues of the rest of he bone the exostosis gra~u·
al ly moves away left behind) ' towards th9 d1a-
· t to·
phys1s Thus the exostosis alwa ys po,n 5 r
Fig . 1.20 .2 : o terior l·emoral and posterior tibia l
wards th s d laphysi~
.
. (Fig . 1201)
·. · . · Whentheno-
, rowth) , the
exostosis re stric nee fie ,on . mal growth stops (1.e. long1tud1nal g . . detor·
exostos·1s grn th also stops . The bowm~ dinal
miti es/s~orten1ng are explained by partial
inv olvement of the g owth plate . Here 1ong1tu
growth 1s sacrificed tor lateral growth .
Describe the bony swelling (s).
Bony h d · . . bout
· ar . , non- ender, sess1le/peduncula ed. smooth surfaced and the size of swelling but
···: cm in drameter with well defined marg os , not a ached to ~kin or supertrc,al s ructur s
an mg from bone (mention particulars e.g., antero-med1al part of distal 1/ th of (L) femutJ,
92
XOSTOSIS 93
Wha d n ppe r nc of pnin in • pi vious/y p in/ xo to i ?
May be malignancy. fr clur of the b e of growth. bursiti s o·f the ov rlying burs and direct
impingement on nerves.
What are I e ,n ,c n of oper tion 1.c. EXCIS/ONAL BIOPSY ?
1. suspicion of malignancy due to : Sudden rapid increase in size/growth of tumour; Growth
continuing/restarting after skeletal maturity i.e., when longitudinal growth has stopped; Sudden ap-
pearance of pain in previ ously pain less swelling (must be differe ntiated from bursitis) ; Skin
changes - venous prominence , warm tender swelling ; X-ray - stippled calcification ; MRI -
cartilage cap > 1 .5 cm .
2 . Jeopardizing normal function or activities of daily living (AOL) :
• Mechanical obstruction to the range of motion ( e.g. , posterior femoral growth impedes knee
flexion - see fig. 1.20.2).
• Compressive manifestations causing neurovascular deficit (e.g., foot drop in proximal fibular
exostosis compressing the peroneal nerve) .
• Radial head dislocation , if present must be relocated . Patellar subluxation due to genu
valgum necessitates operation .
3. Cosmetic : To correct deformities like bowing by appropriate corrective osteotomies.
4. If single exostosis : May be excised.
Why is the actual size (estimated clinically) always more than the radiological size?
Because the cartilage cap is not seen in X-ray and clinical assessment of size includes the
cartilage cap and also the overlying bursa .
What is the chance of ma lignancy? What malignancy?
About 1% chance of Chondrosarcoma, rarely osteosarcoma. histiocytoma. In hereditary mul-
tiple exostosis chance of malignancy is about 5-15%.
N.B. • Risk factors for malig11ant change

(i) Multiple exostosis (rather than single).
(ii) Sessile (rather than pedunculated).
(iii) Proximal e.g., pelvic, scapular, (fig.
1.20.3) proximal humeral rather than di s-
tal like knee/elbow/wri t.
• During excisional biopsy, always include the
overlying bursa and the periosteum . Do not
re~·ect subperiosteally which may lead to re-
currence.
• Cartilage over the growth is hyaline cartilage.
• In planned surgery, ideally one should wait
till the osteochondroma is sufficiently away
from the growth plate (i.e., becomes diaphy-
Fig. 1.20.3 : Scapula exostosls
eal) to safeguard the growth plate.
• Hereditary multiple exo tosis i. autosomal dominant , ith variable p n trance. hromo, om 8, 11. 19
is responsible. Sarcomatou. chang is mainly due to chromosomes 8 a nd 11 ·
( .
··> H /Ill t i\· Tn•1•<>r di,·,•a\ 1' .,
a11 there be eptph\'Sl•nl O.\lcnch"11r1ro111a . .
T . · . , . . D l ·a epiptw ealis hemimclica) : It 1s ·p1ph s~ul ost •o hondroma
revor disease (Fairbanks di ease. Y P. as• . < IO. e·•r~ 01. ·w·•' t pi al l 111 ol in thl 111 • li nl sidt> of th ·
affe t' · · 1· b 1ly seen in ma 1 ... ~ •cc~·
. c tn? a ingle lowe1 1m . .com~m - . 10 :llizl!d O ergro, th of curtilagc . 11 ·01111110111 afk ·ts di ~tal
epiphys1 leading to asy mmetn cal l11nb d formit du to
femur, di tal tibia and talu .
Chapter 21
10
Theories Discussed
• Definition of non -union • Causes of non-union
• Types of non-union • Clinical features of non-union
• Management of non-union • Holstein -Le wis fracture
• Stages of fracture union • Wolff's law
Non-union of a fracture is a state in wh ich all healing processes have ceased as judged by
clinical and radiological evidence , beyond the stipulated optimum time for healing , for that par-
ticular bone , site of fracture , type of fracture and age .
Definition of FDA panel (1986)
A fracture is said to be non-un ited , when
at least 9 months have passed since injury
and the last 3 months have elapsed without
progress in heal ing, cl inically and radiologically.
N.B. • Exception - for fracture of neck
femur ~ termed non-union after 3
months from inju ry (not 9 months-
see page 142) , and Flynn 's crite-
rion for lateral condyle humerus (see
page 65) .
Causes of non-union
• Distraction (especially by grav ity or
Fig. 1.21.1 : Hypervascular non-union of distal tibia .
excessive traction ).
Note - Broadened fracture ends. • Infection , inadequate fixation , ill-advised
operation , insufficient immobilization .
• Segmental fractures , soft-tissue interposition.
• Comminuted fractures.
• Open fractures.
N.B. • Mnemonic: DISCO d'
1
Special causes for tibia non-union (in ad •
tion to above)
• Delay in weight-bearing, distal third fracture.
• Intact fibula . (Controversial)
• Soft-tissue severe damage.
N.B. • Mnemonic : DIS
Fig. 1.21 .2 : Ava scu lar non -union humeral shaft . General factors
Note - Sclerosed , atrophied fracture ends. . radiation.
M • • Old age , malnutrition , steroids
•
Types of non-union (Class1f1cat1on) according to strontium s5 uptake . . e<J.

1
A. Hypervascular type : due to mechanical failure . (Fig . 1 .21 . 1). Vascularity not cornprorn.; d.
0
B . Avascular type : due to biological failure . (Fig . 1 . 21 . 2 ) . Vascularity cornprorn'
94
NON-UNION 95
W/"I
It is a case of non-_union_of upper/ middle / lower third , shaft of ........... (name of bone), probably
due to ........... (1nfect1on, d1stract1on , etc.) ± distal neuro-vascular defi cit, in a ... ..... . year old patient.
N.B. • If suffi.ci~nt time sine~ injury ha~ not p~ssed , and/ or there is tenderness at the fracture
site, 1t 1s better t? give ~ou r ~1agnos1s as delayed union (not non-union).
• If open wound/ discharging sinus, or other signs of infection are present diagnosis of
infected non-union shou ld be given. '
• Infection, open fractures , improper fixation / inadequate immobilization are among the
most common causes of non-union.
ha ti he o nts in fa vour of your diagnosis ?
1. History of trauma, .. ..... months back , after which .... treatment received for .... period .
2. Abnormal attitude/position of limb + visible deformity (describe) .
3. No tenderness or muscle spasm .
4. Painless abnorma l movement, in 2 planes , at the fracture site (very important) .
s. Palpable gap or discontinuity in the bone (on palpation) .
6. Lack of transmitted movement from one end to other, with passive manipulation .
7. Signs of open fracture / infection / operation --, scar, sinus , soft-tissue loss , etc.
8. Wasting of muscles (disuse atrophy).
9. Distal neurological status and vascular status.
1o. End of fractured bones are irregular on palpation .
11. Length of limb is decreased (may be increased if there is distraction).
N.B. • The movements at the adjacent joints are often stiff. While examining the movements "of
the distal joint, firmly fix the distal fragment of the fracture to avoid "trick movements .
First investigation ~ X-rays to confirm diagnosis and determi~e whether the non-union is hy-
pertrophic or atrophic variety, and also assess the state of healing.
Treatment principles .
1 A I . Open reduction ~ freshening of fracture ends ~ removal of fibrous + ~~ar
. vascu ar . . f r t s iliac
tissues ~ opening the medullary canal. Then stable interna 1 1xa 10n + au ogenou
2. cHrest cance,llousobol
ypervascu ar : n ynestag~!f~ii:~tion , after freshening the fracture ends, can give good results.
amic com ress ion pl ate (DCP) (see page 2 12), interlocking nail .
• Fixation
(see page devices commo nly used are dylnt·
. ,
l p ed in cases of bone loss / short eni ng, concomitant
239) a n d II izarov s externa
. .ixa 1or u 1)]. '
24
other deformities, infected non -union , etc ( ee page . h b · in PTB plas ter
• Functional cast Bracing (seepage 223 ),. For tibia ' fibulotom y follow ed by we 1g t - earn10o
cast ac hi eves uni o n.
Prerequisites of PTB (Patellar tendon bearing)
Plaster treatment - ~
• Skin below th e knee should be intact.
• Angulation not more than 10° , les. er the better.
• Contact at fracture ends greater than 70%.
• Evidence of ca llu see n in X-ray .
• Fibu la should not be unit ed or intact. - ated
. . . • I d , e nt all y mo 1iv
• Pati ent 1s phy sicall y capab e an n de spite pai n. . . .
t
to tart walkin g with th e PTB pl aS er, . ff ture of th e j un ction of middle-t hird a nd
· d with fracture)
• Often radi a l nerv e pal sy is a soc1~t~Lewis °
non-u111onwhereracth e nerve i· t,·apped with in th e fractur . ""
!owcr-third shaft hum~ru (1_1°~:ei~CV to be done after 3 week ·
it co mes out o f th e . p1ral gioo ·
---~--------------' Scanned by CamScanner

'ormally how doe a fracture heal ? Unite ? (fig. 1.2 1.3)

• Without rigid internal fi xatio n. a long tubul ar bone heals in 5 stages . N.B. • Mnemonic: HICal CoRe
( I) Hae,~a~oma for mation and tissue destruction : _The trauma_that causes a fr actu re, concomi tant!
al o 1nJures the urroun din g blood ve els which res ults 111 the dea th of bone at the fra I Y
' c ured
urface fo r 1-2 mm.
(2) Innammation
J'
and cellular
'
J'Jroli"eration
J'
·. T here is subperi osteal and endostea l cellular
'.
·prolife~ .%
due to the acute inflammatory reactio n. The clotted hae n:1ato~a aro und the frac ture site 1s invaded b
the cell . thus bridgin g the gap and developing new capill an es. Y
(3) Callus formation (Soft callus) : The new cell are ost~ogeni c and chond roge~ic, and there are also
osteocl a ts. Thi s den se ce llu lar ma with its patches of 1mmatu~e bone and cartil age form s th e callus
whi ch is both periostea l and endo tea l. Then minera li za ti on be~ms, and gradu all y the callus becomes
harder and tro nge r, whi ch prevents movements at the fra cture site. Transfor mmg growth factor (TGF-
~), bone morphogenic protein s (BMP) and fibrob las t growt h fac tor (FGF) enh ances thi s proces.
(4) C Onsolidation (Hard callus) : Osteo blastic and osteoclas ti c ac ti vities continue in tandem to gradually
transform the woven bone into lamellar bone which ensures solidity and strength of the callus. Usually
this takes months to rigidly bridge the fractured bone ends.
(5) Remodelling (Modelling) : By continuous and simultaneous bone resorpti on and form ation, gradually
the medu ll ary cavitie are fo rm ed and rejoined at the fr actured ends, together with removal of outward
exten ion of ca llu s. Greater capac ity of remodellin g is when more growth potenti al is left (children).
when ite is nearer to joint, angulation/tilt is in the pl ane of primary movement of the joint .
N .B. • Callus is formed in response to movement, (rigidly internally fix ed fra ctures show poor callus), which
serves to stabilize the fractured fragment s. It grows stronger where the load/ stress is more, according
to Wolff's law, which states that the mass and architecture of bone always adjusts to the prevailing
forces which are acting on the bone. It means stronger / thicker bone develops in those areas of the
bone where there is maximum load / stress, but di suse, non-weight bearin g, weightlessne s will pro·
duce poor quality bones .
• Marke~ of bone format!on - serum alkaline phospatase, osteocalcin . Marker of bone resorption - serum
and unne N - telopepttde, C - telopeptide, Urine hydroxy proline, Deoxy pyridinoline.
H ae matoma Infl amm atio n Caltu R emodelling

Co n olidati on
Fi g. 1.2 1.3 : Fra lure healin g (Mn emoni c _ HI al CoRe)
What is "gap healing" and "co ntact healing" ?
• ·alJUI
• dGap h ea I mg ·
: fn so ]'di .
I y immobi le frac tured end (e g aft
. • ·, r open red uct1on
. intern
. a1 r·1xa 1·,on) -t no l:• 11,h
eve_1op_s ~ I~ tead there is new bo ne fo rmation directl y betwe n the frag m nts. When ga p i. ;:,200 µ111; I'
gap 1s filled fir t by woven bone which later remodel 10 1 b If h . ?00 µni rhe g,P
fill ed directly by lamell ar bone. · ame 11ar one. t e gap 1 <- ·
1.1b conl,,I
· t ,·na l fi atio n "-'.d
• Contact. healing f : In impacted cancellou s bone fracture . or w here t here rs - 10
0 111 ,
_ Dynarn ic Co mpre ·,on Pla t·,n g (. ec pag ZO"- )J dJr ' I bn ,: •
press1on at the. rac tu re end. , [e.g., DCP-
the frac tu re. 1te occur , wi th ou t any int ermediate tep _
Chapte r 22
0 IC 0 EOMY LITI
Theories Discussed
• Clin ical features of osteomyelilis • Sequestrum
• Aetiopathogenesis of osteomyelitis • Management of osteomyelitis
• Complications of osteomye litis • To m Smith Arthriti s
• Brodie's Abscess • Garre's osteomyelitis
Long persisting infection of bone, along with absence of any systemic symptoms, pre-
senting commonly with discharging sinus/sinuses is chronic osteomyelitis.
Aetiology
1. Sequele of acute osteomyelitis .
2. Sequele of open fractures .
3. Sequele of operative procedures usually
with internal fixation .
4. Chronicity inherent of the infective organ -
ism e.g., fungal infection s, tuberculosis .
It is a case of chronic pyogenic osteomyeli-
tis , affectin g proximal / distal part of femur /
tibia / fibu la, etc ., of R/L side , of ....... weeks
duration , as a sequele of acute osteomyelitis
/ open fractures/ post-operative infection , etc. ;
with (or without) decreased range of move-
ment of adjoin ing joints , with (or ~ithout) ~n -
gular deformity of thigh/ leg , etc ., with (or ~1th -
out) shortening / lengthening of leg/ thigh /
arm, etc ., with (or without) pathological fra~-
tu re , without (or with) distal neurovascular defi-
cit in ... .. . year old M / F patient. . . Fig . 1 .2 2.1 : Chronic, osteomyelitl of ti~i with
7
N.B. • Mention only the positive findings . se vere destru ction/ loss ot d1 phy is.
. f your diagnosis ?
What are the points ,n favour 0
A. History :
1. Past history of trivial traun:ia I open
fracture/ operative intervention , raised b~dy
temperature or fever , with pain and swelling
of the local part. h. h
· · W IC
2. Emergence of discharging sinus,
·is sometimes quiescent and some t'im es flares
up, i.e., waxing-waning pattern of sym~toms.
. . e of bone chip s or si nus howlnq proullng i , nu
. 3. History of d1scharg " _ 'k " mate- Fig . 1.22.2 : ~Isch rgln.g I prox1rn I t.ibi I m t ,pt1ys1,
spicules (fish-bone like) or chalk II e lation tissue in th rog1on o
na1 (pathognomonic).
97
· 13
98 HANDBOOK FOR ORTHOPAEDICS EXAMINATIO N
B. Inspection :
1 . Deform ity (if present) . describe.
2. Sinus - (a) Site
(b) Num ber .
(c) Opening _ Usually has sprouting granu lation tissue (indicates pre sence of se.
questrum or fo reign body) .
(d) Floor. margins
(e) Sk in condition around sinus opening - puckered, shiny , loss of hair , hypo
1
hyperpigmented , excoriation , etc.
(f) Discharge - purulent, serosanguine ous seropurulent, etc .
3. Scars of other healed sinus / previous operation(s) .
4. Swell ing / wasting of adjoining soft tissues .
N.B . • Tubercular chronic sinus has wide opening with thin , bluish and undermined
margins.
• Mention only positive findings .
C. Palpation - 1. Temperature - may be elevated in acute exacerbation (flare up).

2. Tenderness -
• of sinus ,
• of underlying bone .
3. Irregular surface + thickening of under·
lying bone.
4. Sinus -
• Wall of sinus - thickened , fibrotic.
• Fixed to underlying bone, tender.
• Purulent / serous discharge on
Fig. 1.22 .3 : Discharging sinus with sprouting
granulation tissue .
pressure .
D. Movement of joints above I below- Range of movement is usually decreased and often the
joints are stiff.
E. Measurements - Shortening {30% of cases) or lengthening (5 % of cases) of affected part
may occur. (65% cases have no limb length discrepancy) .
F. Regional lymph nodes - Enlarged , mildly tender, discrete in pyogenic but matted, elas·
tic to firm in consistency in TB .
G. Signs of pathological fracture (if present) - Tenderness , abnormal movement at frac·
ture site , absence of transmitted movements, etc .
N.B. • Never try to elicit crepitus at the fracture site.

What is a sequestrum ?
. . . . . . aration or
It 1s a dead piece of bone, present within living bone, either in the process of seP rf ce and
completely separated fro.m living bone by granulation tissue , having a smooth outer ~~n aaiso be
a rough inner surface. Literally sequestrum means stand separated. (Sequestrurn
formed aseptically due to avascular necrosis) .
Wha t are the types of sequestrum ?
(a) According to colour
1. Feathery I sandy -) TB .
CHRONIC OSTEOMYELITIS 99
2. Coralliform > pyogenic.

3. Ivory syphilitic.
4. Black - > actinornycosis .
5. Green > pseudomonas .
(b) According to shape
1. Ring sequ es trum ~ p in-tract infec-
tion, am putation stump .
2. Pencil like -> infants .
3. Cylindrical infants.
4 . Conical amputation stump.
Why is one surface smooth, and the other
rough I irregular ?
• Side in contact with pus is smooth.
• Side in c ontact w ith granulation tis s ue
is irregul ar.
How is the sequestrum formed ?
lschaemia to a part of bone , caused by -
1. Toxic thrombosis of feeding vessels.
2 . Periosteum is lifted up by subperiosteal
abscess - the pus coming from within Fig . 1.22 .4 : Ch ronic osteomy elitis of proximal
medullary canal through Volkman's fibul a wi th sequest rum .
channels to the subperiosteal space. So periosteal nutrition supply is lost.
3. Stretching / external compression of vessels, from granulation tissue / new bone formation.
What is the importance of sequestrum in chronic osteomyelitis ?
It behaves like a foreign body and acts as substrate (just like implants) for adherence of infective
organisms (via biofilm), and since it is avascular, antibodies / antibiotics do not reach these adher-
ent organisms in sufficient concentration. This leads to chronicity of the infection .
What are the cause s of persistence of a sinus ?
1. Presence of foreign body / sequestrum . r----::
,- :::::::::::::::=============-=--=.- --~
2. Non-dependant drainage.
3. Epithelization of tract.
4. Fibrosis of tract walls , which prevents
collapse .
5. Chronicity of organism (tuberculosis, ac-
tinomycosis) .
6. Malignancy of tract.
What is the difference between a fistula
and a sinus?
Sinus is a blind track from the external sur- Fig. 1.22.5 : Hair-pin llke course of metaphyseal
face to the deeper tissues. Fistula is a commu - vascu lature In proximal tibia .
nicating track between two epithelial surfaces.
In which part of a long bone does acute osteomyet,tls start and why ?
It always begins in the metaphysis. Possible reasons are -
1. Hair-pin like bend of ve ssels in that region. (Fig . 1.22.5)
2. Vascular stasis, due to the "U" bend .
100 HANDBOOK FOR ORTHOPA DIC EXAMINAT IO N
3 _ Thin wa lled , primitive, nasce nt vess els in betwe~ n trabecul ae of degenerating cartilage
cell s -"7 all ows easy outward passage of bacte ri a.
Once extravas cular , the organisms easi ly proliferate in a ver~table culture -broth con-
4 · ta ining blood and degenerati ng cells . Trivial trauma may contribute to the haematoma.
5. Lack of active phagocytosis in metaphysis (Hobo - 1924) .
N.B . • Salmonella osteornyelitis is commonly diaphyseal and seen in sickle-cell anaemia.

What is the pathological sequence of osteomyelitis ?
1. Inflammation : Earliest change is acute inflammation -"7 intraosseous pressure i ~
thrombosis of vessels -"7 pain .
2. Suppuration : Pus forms in the medullary canal -"7 moves along Volkman's channel
-"7 comes outside medulla -"7 subperiosteal abscess -"7 periosteal stripping. In children,
bones where physis is intracapsular (hip , shoulder, etc.) ----7 septic arthritis may occur.
3 . Necrosis -"7 Periosteal stripping + lntraosseous pressure i results in ischaemia ~
necrosis -"7 sequestrum formation .
4. New bone formation -"7 lnvolucrum (envelope) is formed. If infection persists, pus discharges
through perforations in involucrum called cloaca -"7 ultimately forms sinus, leading to the skin.
First investigations :
1. X-ray of (say the part) AP and lateral view.
2. Blood for FBS / PPBS, ESR , CRP, Hb, DC , TLC. Exclude HIV , especially in adults.
3. Pus for culture and sensitivity to antibiotics (C/S).
4. Sinogram .
Occasionally CT scan , MRI, bone-scan (see page 251 ), anti-staphylococcus antibodies, etc. ,
may be indicated before deciding on the treatment.
Differential diagnosis : Ewings Sarcoma (see page 266).
Treatment : Varies according to the individual case.
1 . Saucerization and Sequestrectomy : Commonly done operative procedure. Done
when involucrum is well formed and strong (avoids post-operative fractures) ,
and sequestrum is completely separated . It converts a tight narrow cavity into a
wide-mouthed , shallow cavity , also opens up vascular channels , and dead bone is
simultaneously removed .
2. Sometimes for bones like metatarsals, fibula , ribs, clavicle ~ resection may be done.
3. In children , often sequestrectomy is not done and conservative management is sue·
cessful in resorption of sequestrum (Fig . 1.22.6).
• For detectin g infection after implant urgery most sen iti ve le I are IL- 6>CRP> R. Pro alcitonin au d
TNF o. are th e most specific in ve ti gati on. .
• The grow th plat e (phys i ) acts as a barri er to prea d of infe Li on from metaphysis to piphY J>·
0 s Ieomye t'll1· S Iea ct ·mg to septic
· art I1r1t1 ·s thu een < 2 year. (du e to tran s-phy. ea ! vasculature) and adu lh. d<00
· ·s 1 .
h · ) S · th · · I
p y 1s . ept1c ar ritt s ca n a so occur 111 · joint. where th e ph ysis is intraarti ular e.g., Hip .. hou Ider · r,i ,a1
head, di stal fibul a.
. .
• Mo t co mmon orga111 m I staphylococc us a11reu . Mo l co mmo n other ': group 8 streptoco
ccus '.! ..l
,I'. . • Ill ..-1111 I11
weeks ; H. JnJlu enza 111 age gro up 6 month s to 4 year ; pseudomonas in drug addict ·Jungol o,kO
pati en ts on parent era l th erapy; staph.epidermidis aft er i rnplant surgery .
.i·t,r t are tlte ( 0111plrct1 1011, of, hro111c <1 1,· 0111 )' , 1,1" ? N.U. • Mncmoni : A PAGE
1
1. , ngular d1.:for1111til of long boni.::-, a ru ~/va lg u:-- c.lue lo p,1rt1 a l arfc.:c ti o n o l g row1·h pl ate.:.
2. P athologi al fractu1l':-- (\l'l' pugc _..J(i)
3. , myloic.l d,sca,es .
. . 111 g (30%), lcn ,t11enin g (5· %) '·111 cl tinch ·,in g ·c11 ·1m b 1cnglh (65%)
4. , rowth intc, ferlllCl' : Shortrn
5. I~p1thcl1 onrn (111al1g1rnn ·yo! sinus tract, ~k in) . ·
(b)
(d)
(c)
Fi g. 1. 22.6 Con servative treatment follow -up in a child - (a) Chronic o teo myeliti s of di stal tibia ;
(b) Small sequestrum ; (c) Gradually resorption ; (cf) Almo. t totally resorped.
Tom Smith Arthritis

• ft is acute hip septic arthriti s of infants first described by Torn Smith in 1874.
• lni_ti al focus of infection i u. ually the umbilicus or skin. It may be a sequlae of o teomyelitis of metaphysi~/
epiphy is , where the abscess gets ruptured into the joint becau e the phy.\·is is intracapsular. Hip di locate.
later. There i. strong poss ibility of upper femoral epiphy. is destruction as it is cartilag inous. If not fatal , then
th e infan t recover rapidly without complication , but often with loss of femoral head .
• Risk factors - prematurity , umbilical vein catheterisation , femoral vein puncture.
• Clinically: (i) Septicaemic infant with minimal ign and ymptom ·
(ii) Hip is nexed, abducted and externall y rotated with ometimes an "occasional" ab ce in
the thi gh or buttock .
• X-rays : Capsular di ten ion Uoint pace j) ~ superolatera l sublu xat io~ of femora l head~ di sl_ocation
~ (occasionally ) subpeno. teal new bone formauon around
-7
osteoporo is of proximal femoral metaphy e
proximal femur. Later X-ray may how loss of femoral head.
• Treatment: (i) Joint a piration to confirm diagno i ~
aspirate sent for C/S .
(ii) rgent decompression arthrotomy + I. V. antibiotics.
XA IN ION
102 HAND OOK f on f iH
St I BA( 'UTE OSTEOMY • LITI S

I 11 I l' l t I ll 11 I " l il. II ,I ( I l' I I / l' d I
iu sidioa s onset. Mo sl co mmon organi sm is coagula e +
• TI ii\ t jll' (I I IH)lll
\l",1,ljlll\lh<lllli\;lll llll . ' ' .. .· f ' ·.
. n 1 .. i~ t L' ll l'l' ol 111 pat1 · 11 t 1s good a a1nst lh c 111 cclln g orgarn sm.
• lt li.ql il l l l \ l l < , l l l l I 1H\ l l \ , ,
(II) 1 il l' 111 1111, 0 1 a 1 a111s111 1s I ·ss virul ent.
• . lll'll ,t l l' ,
1 111 11 11
, .11il' tl L'' ol I sion s /J rodie's A bscess, Garre 's sclerosing osteomyelitis, Large bone
1
(lhH·,·., ,· .i nd l .o alh•,I dittr,lly.,·eal lesion ·.
I. Brodie's Abscess (Fi g. 1.22.7)

• Firs t d sc ribed by Brodie in 1836.
• O curs without any previous illness in young
·,dulls.
• C ntral les ion of suppurative necrosis in
metaphysis containing scanty pus, which is
u ually sterile .
• X-rays may show some sclerosis around the
lesion and some periosteal reaction.
• Differential diagnosis- Osteoid Osteoma. (see
page 269)
• Treatment - Curettage and bone graft + antibi-
otics.
II. Garre's Sclerosing Osteomyelitis (Fig.

l .22.8)
• It is a sclerosing and non-suppurative osteomy·
elitis, commonly found in adolescents.
• There is symmetrical thickening of cortico can·
cellous bone with partial obliteration of the mar·
row space, in the metaphysis or diaphysis.
• History is commonly of an adolescent or you~g
adult presenting with prolonged low-grade p~n
and mild swelling and tenderness. commonly in
the femur or tibia.
• Differential diagnosis - osteoid o teoma (see page
269) and Ewing sarcoma. ( ee page 266).
III. Large Bone Abscess
Fi g. 1.22 .8 : Garre', Ostcomyeliti . . • Commonly found in the distal tibia. It is a rne!llh·
N0 t c - ·symmetn·cal thi ckenin g of cortico cancel - PI1yseal lesion which may cros. th growt .
lou s bon e with partial oblit eration of the marrow . plate. However, there is no perio, teal reacuon,
. IV, Localized Diaphyseal Lesion .
• Somcllmcs X-rays show "onion-peel'' a . osis of
Ewings sarcoma. ppcarnncc " nd hence it is an important differential diagn ·
Why does sequestrum appear dense and I . .

sc erotic ,n X-rays?
9
Because there is no bone resorption and bee . 18 tion tissL1
and thereafter by hyperaemic normal b, one. ause it is surrounded by pus/granu
CHRONIC OSTEOMYELITIS 103
What are the causes of diaphysea/ chronic osteomyelitis?
Salmonella infection; as a sequelae of open fractures; after diaphyseal implant surgery; long
standi ng sup eriorly located metaphyseal osteomyelitis .
What is the classification of chronic osteomyelitis?
Cierny-Mader staging syste m for chronic osteomyelitis is based on physiological and ana-
tomical criteria , to determi ne the stage of infection . It is helpful in determining if treatment
should be simple or complex , curative or palliative , and limb sparing or ablative .
ANATOMICAL TYPE (Fig. 1.22.9)
1: Medullary - Endosteal disease .

11 : Superficial - Limited to the surface of the bone . Infection is secondary to coverage
detect.
Ill : Localized - Well-dema rcated lesion. Full-thickness cortical sequestration and cavita-
tion . Complete debridement would not cause instability .
IV : Diffuse - Features of I, II , Ill + mechanical instability, either at presentation or after
appropriate treatment, and requires complex reconstruction.
- ~- S ---,-.f'C-:.=
~--~- c-,#.--,._
Medullary Superficial Localized Diffuse
Fig . 1.22 .9 (C = Cortex ; M = Medulla; S = Soft tissue)
PHYSIOLOGICAL CLASS
A ·. Normal - lmmunocompe t e nt . Normal response to infection
. and surgery
..
B : Compromised - Local or sys temic immunocomprom1sed. Def1c1ent would healing
capacity . . . t nt are potentially more damaging than the presenting

C : Prohibitive - Morb1d1ty of trea me
condition . t elitis in children
J . hematogenous os eomy
ones classification of chronic . (B _ localized cortical seques-
8 . Sequestrum 1nvo 1ucrum 1 . . .
Type A : Brodie abscess; Type · . rum · 8 _ sequestrum with sclerotic invo 1~c~u~,
trum; 82 - sequestrum with structural involuc )· r' 3e C . Sclerotic. Physeal damage is md1-
B4 . t t ral involucrum , YP · .
- sequestrum without s ru_ cu (Distal) to the classification .
cated with addition of P(Prox1mal) or D
. munity I local vasculity .
What are the factors which affect ,m . d·abetes mellitus, chronic hypoxia,
.. nal and hepatic failure , . I .
Systemic factors : Malnutrition , re . immune def1c1ency. ..
immune disease malignancy, extremes of age, tasis major vessel compromise , artent1s,
' d venous s , h
Local factors : Chronic lymphe ei:na , diation fibrosis , neuropat Y·
small vessel disease, extensive scarring, ra
Chapter 23
PH RA N AVE INJURIES - CLAW HAND,
W 1ST DROP AND FOOT DROP
Theories Discussed
• Seddon's class ifi cation • Claw Hand

• oupuytren' s contracture • Wrist drop and Saturday night palsy
• Foot drop • Factors influencing nerve regeneration
• Wal lerian degeneration • Strength duration curve
Peripheral nerve injury classification

• SEDDON'S classification :
1 . Neuropraxia - Contusion or compression. Reversible ~ recovery com~lete. .
2. Axonotmesis - Axon breakdown, intact Schwann cells and endoneurrum. Recovery 1s
good within 2 years .
3. Neuronotmesis - Axon + Schwann cells + endoneurium disrupted. Recovery poor.
• Order of damage progression and recovery
1. First to go : Motor function. Then Epineurium
sensory ~ (sequentialy in order) prop-
riocepti on ~ touch ~ temperature . Perineurium
2 . Last to go : Pain -
In recovery , order is reversed , i.e. , first to re- Endoneurium
cover is pain, last to recover is motor functions.
• Tinels sign Fig . 1 .23 .1 : Schematic diagram showing cross·
Percussion along the course of an injured section of a nerve .
nerve ~ tingling and hyperesthesia is felt by the patient at the distribution of the nerve, BUT it
should be for several seconds (not transient) . It indicates sprouting neuroma at the end of th e
injured nerve (nerve regeneration) . Rate of progression is 1 mm per day i.e., about 3 cm in a month_
CLAW HAND
• Clawing : Extension of metacarpo-phalangeal (MCP) and flexion of inter-phalangeal (IP) joints.
• Two types :
1. Ulnar clawing - 4th and 5th fingers are more conspicuously clawed . This is due to injury
to the ulnar nerve only (Fig. 1.23.2) . . d
2
· (TRl!E) Claw han.d - All fingers are clawed. This is due to injury to both ulnar nerve an
median nerve (Fig . 1.23.3) .
Fig . 1.23 .2 : Uln ar claw hand . Note - Wasting of

intri nsic muscles .
Fig. 1.23.3 . Tru claw hand
104
PERIPH£- RAL N
• Ulnar paradox When injury is proxlm I to th lbow, I. •, hlgh ..up le Ion, th Ion fl ex r
slips to the 4th and S~h fing ers, (flexor digi_torum pr~fundu ) whl h r I paraly . So
clawing is not so prominent, because th0r 1s no fl x1on of th 4th n 5 h fin g r , lthou h
there is ulnar nerve injury. This is the paradox. ·
11
• Pathology of clawing : The "intrinsic muscles of hand (lnterossel and /umbr/ca/s) prima-
rily flex the MCP joint and extend the IP joints. Paralysis of the intrinsic muscles causes just
the opposite, due to the unopposed pu ll of the antagonist muscl s that produces extension of
MCP and flexion of IP joints, which is clawing. This is also because the fingers cannot be
extended by the long extensor muscles, which requires stabilization of the MCP joint
Autonomous zone : Ulnar nerve - Tip of the 5th finger; Median nerve - Tip of the index finger.
Clinical features of ulnar nerve lesions
• Low lesions (Forearm) : (1) Wasting of the hypothenar eminence ; (2) Clawing of the 4th
and 5th fingers ; (3) Froment's sign positive (see page 66). Because of add uctor pollicis
paral ysis, the_yatient substitutes the functi on of adductor pol li cis wi th flex or pollicis ; (4)
Card test pos1t1ve (see page 66) Because of palmar intero ssei paralysis - no fin ger adduction is
possible; (5) Autonomous zone - Hypoesthesi a of the tip of 5th fin ge r.
• High lesions (Arm) (Ulnar paradox) : (1)
Flexor carpi ulnaris is paralysed, so wrist de-
viates laterally (radially) whe n actively flexed
(palpate the muscle when doing this test.) ; (2)
No appreciable clawing; (3) Rest, as in low
lesions of ulnar nerve.
Clinical features of median nerve injury
• Low lesions ( Wrist) : ( 1) Thenar promi-
nence wasting ; (2) Pen test positive (see
page 51); (3) Nail sign (see page 51 ); (4)
Hypoesthesia of lateral 3 1/ 2 fingers , especially
at the autonomous zone. Fig . 1.23.4 : Dupuytren's contracture of little finger.
• High lesions (Elbow) : {1) Ochsner's pointing index sign positive (see page 51 ); (2)
Flexion of the IP joint of thumb is not possible due to paralysis of the flexor pollicis longus (see
page 73, Fig . 1.14.10-A); (3) Rest, as in low lesions.
N.B. • If you get a case of clawed hand, you might confuse it with Dupuytren's contracture or VIC.
DUPUYTREN 'S CONTRACTURE
• It is proliferative fibroplasia of the pa/mar aponeurosis (also affects plantar fascia in 5% cases).
• M : F = 1O : 1; Autosomal dominant hereditary trait. Associated with : Prolonged phenytoin
herapy , alcoholic cirrhosis of liver, diabetes , pulmonary TB, and AIDS.
• Most commonly affects the ring finger, 2nd common is the little finger. (Fig . 1.23.4)
• Clinically : Flexion of both MCP and IP joints. Thickened dorsal knuckle pads ~ Garrot's
Pads. (Note : In clawed hand there is extension of the MCP and flexion of the IP joint) .
• Treatment : Radiotherapy is helpful in very early cases . Operation - Fasciectomy with
0st -operative splinttage / For severe cases - Resection + Arthrodesis.
• Prognosis : Guarded . High recurrence rate .
WRIST DROP
• Commonest peripheral nerve to be injured is the radial nerve.
• Wrist drop means inability to extend the wrist (and MCP joints, and thumb) "actively" .
• Chances of recovery is highest for radial nerve injury because it is predominantly a motor
nerve, it does not control fi ne movements of the hand , and it has a large diameter.
106 HANDBOOK FOR ORTHOPA.:E:_
D_:_:
IC:_:S:__
E~XA
~M~ IN_A_T~IO
_N_ ~ - - - - ~ ~ - - ~ -- ~ -
• Pathology : Radial nerve inne1vates the tri -

ceps , extensors of wrist, fingers a~d th ~m_b
and also the supinator and brach1orad1al1s
muscle . Injury to the radial nerve at any le_
vel
always paralyses the extens?r.s of wrist,
thumb and fingers at the MCP 101nt.
• Autonomous zone : 1st dorsal web space
of hand .
• Clinical features : 1. Low lesions (El-
bow) - Finger, wrist and thu mb extension
is lost.
N.B. • Patient can extend IP joints due to the action of the intrinsic muscles.
2. High lesions (Arm) - (a) Autonomous zone sens_ation lost (first dors~I web sp~ce of hand)·
(b) Brachioradialis and supinator muscle power 1s lost; (c) Rest, as 1n low lesions. '
3. Very high lesions (Axil/a) : (Saturday night palsy/Crutch palsy)
Triceps is paralyzed , so active elbow extension is lost. Rest, as above in high lesions.
N.B. • Must know muscle testing in clinical examination and must be able to demonstrate, for
all the muscles mentioned - triceps, supinator, brachioradialis, extensors digitorum,
extensor pollicis longus - and be sure to palpate the tendons while testing.
• Treatment :
1. Initially "Long Cock-up Splint'' (see page 197) or 'Dynamic Cock-up Splint'' and physicaltherapy.
Nerve conduction velocity (NCV) test is done to note the level and type of injury.
2. If no response by 9 months then operation (Tendon transfer/Arthrodesis , etc.).
FOOT DROP
• Causes of foot drop :
1. Medical cause - LEPROSY.
2. At knee: (Injuring the peroneal nerve) -
(a) Iatrogenic :
(i) While giving proximal tibial skeletal
traction .
(ii) Tight plastering causes compression
of the peroneal nerve at fibular neck.
(b) Fractures : Fibular neck, lateral tibial (a) Foot drop (b) Foot drop splint
condyle. Fig . 1.23 .6
(c) Dislocations : Superior tibio-fibular join t, knee dislocation.
(d) Tumours : Exostosis or other bony tumours , lateral meniscal tumours/cysts.
3 · Above knee : (Injuring the sciatic nerve) - (a) Posterior dislocation hip ; (b) Frac!~~~
acetabul_um; . (~) :racture shaft femur; (d) Intramuscular injections ; (e) Gun-shot or 0
penetrating miunes .
4 · 0th er causes : Post-polio residual paralysis (PPRP), extensor tendon injuries.
Autonomous zone : Deep peroneal nerve - 1st dorsal web space; Tibial nerve - Sole of the toot.
• Clinically :
1. Low lesions -
. . t (bY tne
(a) Deep peroneal nerve mJury : No dorsiflexion, no 1nvers1on. But can evert too
peroneus longus and brevis) .
(b) Superficial peroneal nerve injury : No eversion but can dorsitlex / invert toot.
2 . High lesions - Tibial nerve is injured and the hamstrings are also paralyzed .
- ~ ~INJ URIES - CLAW HANO, WRIST DROP, FOOT DAOP 07
1
• Treatment ·
1. Conservative - Foot drop splint an d physicaltherapy . NCV is done to assess the level
and seventy of inJury .
2. Operative - If nerve is seve red .
• After nerve injury (axonolrnc. i. or ne uronolmesi ·) lbere i a degenerative process which proceeds to atleast the nearest
node of Ranvi r. Primary or retrograd degenerat ion proceeds proximall y from the si te of injury while secondary or
Wallerian d generation (Au gu ' lu s Wal ler- 185 l ) proceed distally from the point of injury. For the first 3 days defini te
morph ologi al ha ng are se n in lb e axon and respon e to faradic stimulation ca n be obtajned . By 3 days there is
fra gm 11tation and . hrinkage du e lo fluid los . By day 7 macrophages start clearing up the debris and there is increased
chwa11n cell milo is, whic h fill up th e vacant ·paces. This process is completed by 15-30 days (average 3 weeks). The
time required for degeneration varies between sensory and motor segments and is also related to the size and myeliniza-
tion of th e nerve fibre.
For ensory deficit.

• Autonomous zone : Small area exclusively suppli ed by the injured nerve (i.e., no overlap of any other nerve
di tribution) .
• Intermediate zone : Rough Iy corresponding to the anatomical di stribution of the nerve, larger in surface area than
the autonomou zo ne.
• Maximal zone : Adjacent nerves are damaged. Larger area than the intermediate zone. When _a ner:e i~ int_a ct
and adjacenl ne rves are blocked or sectioned, the area of sensibility exceeds the gross anatorrucal distnbut10n
of th e nerve.
Critical delay
=
For repair of all nerves is 9 months for motor, 15 "'::,
C = Chronaxie
UT = Utilisation time
mo nth s for sensory functions to return. ::,
E A= Rheobase
C
Tests for sympathetic fibres
• For Anhydrosis : Ninhydrin printing teSt, S tarch-
Iodine test. . ) sk· UT
• For Trophic changes : Nails (brittle, nd ged ' m ---- -- -- --,.----- ---. C':--"r----
: R
(thin). ..
• Vasodilatation : In complete injuries, extremJtles are Duration
warmer an d pinker. Fig.1.23.7

23 7
Strength Duration curve (Fig. I . · ) . . . occur below a minimum strength
. tion = Constant. No st1mu 1at10n w1 11 . .
For any threshold stimulu s, Strength X Dura . . trength which can stimulate a tissue is called rheobase. The
~ hatever may be the duration and .vice versa: Th:
lime required by the rheobase to stimulate a ussu
;~:l~~:t~lisation time. If a stimulus of double therheobase is applied,
.
· · s called chrona.xie.
the time required to stimulate the ttss u~ i N.B. • MNEMONIC : ALEGED-TYPE
Factors influencing nerve regeneration
A ge : Successful in children, less in elderly. . '
L eve! Better prognosis for distal injuries th_an phroximv!~ularity is good' there is no tension at the repair site'
E nds Of nerve after repair. Goo d prognos1s . . we en
there is a s uitable bed with no scar ~issu .
er the prognosis.
G ap : Greater the gap, poor . . . f eration theatre. uickl )
O
E xperience/Skill of surgeon/Fac1ht1es o p . (because muscle fibres atrophy q y.
. s more than sensory . .
D elay : Affects motor function ry has better prognosis. I severe axonotmesis, the pro •·
T urely senso . nd in some ess
ype : Purely motor or P curs after neuroprax1a a f: om proximal to distal.
• Motor March : When recovery oc d' tal muscles. It progresses r
ma] muscles recover earlier t:han the is
Chapter 24
L D ACH L ( A) RUP URE
Theories Discussed
• Brien 's needle test
on/ Imm nd' T SI
• Ma and Griffith technique
Kn fl xion t I
• M y b n untr ted/incompl etely treated case after an acute injury in the past.
• Commonly it is n overu s injury, affecting people in 30-45 years age group. Athletes are
mor su c p tib l .
• Prior ndinosis ( ege n rative change) or paratendinitis (paratendon inflammation) can
11 r co ll gen stru cture, whi ch has le ss structural strength .
Wh t i your di gnosi ?
Thi s is a cas of R/L sided , untreated/incompletely treated rupture of Achilles tendon, of ......
months duration , with ankl e plantar fl exion power of ....... (MAC grading), due to (say what you
have lea rn ed from hi story) , in a ...... year old M/F person .
Wh t may be the predisposing factors?
Intrinsic : Ag eing , high BMI , Limb length discrepancy (LLD) , increased femoral anteversion,
subtalar hyperpronation, excessive forefoot varus/valgus , muscle imbalance of leg , collagen vas·
cular di sease, autoimmune di sease.
Extrinsic : Local steroid injection , prolonged corticosteroid or fluoroquinolone therapy, sudden
increase in running duration/intensity or altered running surface, repetitive trauma.
Wh t may be the precipitating factor?
Eccentric mechanical overloading du e to sudden viol ent dorsiflexion of a plantar flexed ankle.
What are th points In favour of your di gno Is ?
1 . H/0 untreated cut injury or sudden sharp pain t the back of heel while running/jumping or any
other positive relevant hi story at the time of rupture .
2. Single leg heel raise test : Patient cannot stand on toes, one legged , on the affected side,
3. Skin/Contour : Scar, depression/swelling , brui se
4 . Palpabl e gap in TA continuity . (M ay not be found If th . injury is 2·3 d ys old because of
organised haematoma) .
5. Ankl e dorslfl ex lon increased but plantar
fl e xion dec rea se d (although long flexor
mu scles of the toes may produce om
plantar fl ex ion)
6. Thompson/Simmond' Test Po ltlv : On
squeezing the calf muscles, the foot nor-
mally goes into plantar fl exion. When th
foot remains neutral or dorsiflex d th t t
I po itive . (see Fig. 1.24.1)
7 . M ti ' Knee flexlon te t po ltlv : With
th p ti nt pron and I g d ngling from I . I '4 1
101'
T NDOA
" .., ·a \ttr:: ~:2. . . -, . . >,
l ~ ~
the edge of the table, request the patient to flex both k 900
into plantar flexion . In this patient the foot remains neu~r~~/~ to . · Normally . the foot goes
8. Brien 's needle test : A needle is inserted 10 cm proxim I t ;;s~flexe~ (s.ee Fig. 1.24.2)
the visible portion of needle moves proxima lly with da ~fl . insertion 1~ midline. Normally
flexion. (The test should not be done if the patient do ors, tex!on and distally with plantar
es no give consent)
Ho w will you conf,rm the diagnosis ?
1. USG : Cheap and confirmatory investigation.
2. MRI : Most sensitive and specific. Not done routinely .
3. X-Ray Heel Lateral view :
(a) Obliteration of Kager's fat pad - Posterior border f , ·
by flexor hallucis longus (FHL) posteriorly b t d
Fig . 1.24.3) .
°
Kh~lger s triangle bounded anteriorly
Y en oac I es (TA) becomes indistinct (see
Fig. 1.24.2 Fig. 1.24.3

(b) Toyger's angle - Angle between the skin over distal TA and posterior surface of calca-
neum when > 150°, raises a strong suspicion of TA rupture.
(c) Avulsion fracture from calcaneal tuberosity.
What are the treatment options for acute TA ruptures?
1. Conservative management with serial long leg plaster cast initially with knee in flexion and
ankle in equinus, and gradually bringing the knee to full extension and ankle to neutral flexion.
Indicated in patients > 65 years , with diabetes mellitus/peripheral vascular disease/
immunocompromised/tobacco users/localized skin disease.
2. Surgical : End to end repair with non-absorbable suture by Bunnel, Kessler or Krackow
technique. Advantages are lower re-rupture rates and early return to ADL. Disadvantages are
chances of problems in skin healing and damage t.o s~~al nerve. ~ecommended f?r young
active persons who needs early return to normal daily hvmg/occupat1on. Post-operation reha-
bilitation is similar to conservative management.
How will you treat this case ? .
Surgically, because this is a untreated/improperly treated old TA ruptur~. Options are :
(1) Gastrocnemius fascia turn down flap : Lindholm or Bosworth technique
(2) Plantaris graft · Lynn technique ·
(3) Tendon transfe~ : Flexon halucis longus - (Wapener's technique? or peroneus brev1s
(4) V - Y plasty of gastroenemius : Abraham and Pankovich technique.
What may be the complications of surgery_?_ . Infection/fistula formation; Re-rupture; Scar
Wound necrosis, delayed healing; Sural nerve inJury,
adhesion.
Recent Advances : · xeno aft
Use of fibrin glue, platelet rich plasma (PRP), extracellular matnX if} ·
Ma and Griffith technique : . . al ope» · ue ·ch
Applicable to acute rupture . Percuia.neou.s/nuoun )'~&DDle.nt. eles wo d
lem . Di advantages are : inadequate repatr, teodon m
Section-II/
SPOT CASE
Theories Discussed
, Torticollis (wryneck)
, Tennis elbow • Frozen shoulder
, cozen 's test • Thompson's test
, Golfer's elbow • Radial tunnel syndrome
, Baseball Pitcher's elbow • Cubital tunnel syndrom e
• Student's elbow
, Javelin throwers elbow
• Pulled elbow
• Radio-ulnar synostosis
• De Ouervain's disease
• Finkelistein's test
• Intersection syndrome
• Ganglion
• Compound palmar ganglion
• Trigger finger
• Bowler's thumb
• Gamekeeper's thumb/Skier's thumb
• Mallet finger (baseball finger)
• Bursae around the knee
• Prepatellar bursitis (Housemaids knee)
• lnfrapatellar bursitis (Clergyman's knS,e}
• Morant Paker cyst/Popliteal cyst
• Semimembranosus bursitis • Popliteal aneurysm
• Achilles tend initis
• Retrocalcaneal bursitis/Haglund deformity
• Plantar fascitis (Policeman's heel) • Tarsal tunnel syndrome
• Pes planus (Flat foot) • Hallux valgus
TORTICOLLIS (WRYNECK)
• 2 varieties - Congenital and Secondary,
A. Congenital Muscular Torticollis [CMT]
Pathology :
The sternomastoid (SM) muscle on one side
is fibrotTc,'7 and so does not elongate with
growth ~ shortened muscle ~ deformity,
Etiology
Unestablished. Probably birth injury (or in-
utero injury) ~ compression of st~rnom_astoid
muscle (SM) ~ muscular ischaem1a ~ infarc-
tion ~ fibrosis ~ contracture (c.f. VIC).
Clinically . ,
• Associated with breech delivery . It is
commonly right sided. . ,
• Other congenital anomalies like d~velop-
ental dysplasia hip (DOH), congenital tal-
~ uinovarus (CiEV[and me~atarsus
ipes eq often found concomitantly,
Fig, 3. 1 : Right sided torticollis. adductus are
163
. h. weeks of birth at the clavicular attachment (so

t' ed in SM wit 1n 2 . b rne .
• A lump may b~ t) ~ which becomes prominent Y 6- 8 weeks ~ rn
tirriesalsoaflhe mastoid attachmen mains then the deformity becomes permanent ay
disappear by one ye ar · If the
. lump th re Head' is tilted on the a ff ecte d s1·d e and rotated
·
• The defo rmity worsens with gr~w Id.er elevated and asymmetrical f~~rne~~
the opposite side ; ips(later_al s _ou f SM Squinting of eyes may occur . (see fig . ~ )
occurs with progressive f1bros1s o . .
. p dOtumour. Actually a hematoma caused due to birth
N B . Sternomasto1d tumour - seu -
. ·tr~uma, which usually resolves oy 3 months.
Differential Diagnosis . t bra fused vertebra , etc) (ii) Neck

(i) Bony anomalies of the cervical spine _(her:n1ver e '
lymphadenitis (iii) Causes of secondary tort1co;ll.:.:1s~. ------=.::.=-=-=-=-------,
Treatment
• Up to 1 year : Daily regular manipulation/
stretching is succesful in 90% cases . For
maintenance of correction , cervical collar
may be worn until the neck muscles are
strong enough .
• Persisting deformity after 1year needs
surge ry to prevent facial asymmetry .
Opt ions are (See fig . 3 .2) . Preopera-
Bipolar
release
(~
tive councelling is a must.
(a) Unipolar release Clavicular head_, if
necessary a so sternal ead, protecting
the anterior jugular vein) .
(b) Bipolar release _( Clavicular ~nd
mastoid heads, protecting the spinal
Fig . 3.2 : Operative options .
acessory nerve).
• Post operatively - Halter traction for 3 weeks , then hard cervical collar . .
• Surgery should be done before 6 years (ideally 1_-4_years) , so that sufficient gro:"Jh potent:~
is left, which will prevent facial asymmetry , squinting of eyes , etc. Binocular v1s1on may
distrubed if surg ical correction is done at higher age .
B. SECONDARY TORTICOLLIS
1. Prolapsed lntervertebral Disc PIVD) : Most common cause of torticollis in adults.
Common in the C6 , affecting the C6 and 7 nerve roots (so always test clinically Cc, anawf.
Patient presents wrl h brachalgia . Investigation ~ MRI. Treatment ~ Cervical trac·
0
tion , physical therapy , operation . (See page 261 for more information) .
2 . Spasmodic torticollis : A type of dystonia . Muscle spasm may be trigger~d by
rective manipulation or psychological disturbances . Some cases are associated w·n
c~t~
basal ganglion lesions (MRI confirms) . Treatment ~ Difficult. Injection botY!!D!ill1 1~~
1
intralesionally is a promising option . . rte·

3. Others : P~st burn contr~ctures , ~nky.losing spondylitis , infections (TB, pyogen1c), ve
bra! anomalies, tumours (intracranial , intraspinal) .
FROZEN SHOULDER (ADHESIVE CAPSULITIS .,

. ------ ------ sulllis
• Duplay (1906) first described it as "Periarthritis". Nevasier later called it "Adhesive CaP
Also known as pericapsulitis , adhesive bursitis , etc.
• "Tightening" and "shrinking" of the shoulder capsule is sometimes found (about 2°/0 )·
Aetiology
Idiopathic initiation . Hypothesis are - . iS·
(1.) M'
1crotrauma ~ local tissue breakdown ~ auto-immune response ~ periC 8 ps1.1hl
PO CA8 8 1
Always secondary lo condition s lik rot, tor-cufl I ,I n , blclpil al 1on<ilniti,, , bur' 1, 1

around shoulder, etc.
pathoanatomy
• Unknown "triggenng:· factor starts the sequenc ol ~vent >. chro.ni lnflamrna1ory r <:1 Ction
ithin the subsynov1al layer of the capsul > he ling with flbro 1 , cap ul · r flbro( fs - ,
wontracture -) adhesions synovial fluid volume deer asos .
• ~istologically : Active fibroblast1c proliferation _(like dupuyetren's contractu r ) in the rotator
interval , anterior capsule and coracohumeral ligament.
Lundber Classification
1. Primar _: o "triggering" event found . Except pain and stitfness, no other abnormality found.
2. secondar : "Triggering " event found . Occurs after trauma , immobilization, cere-
brovascular accident (CVA), myocard ial infarcti on ( ~. _thoracic surgery, e .
Clinically
• Associated with diabetes, cervical disc disease, thyroid disease, hyperlipidemia etc.
• Common in~ e ~within the age group of 40- 70 year.
• Usually the patient presents late -) after 6-12 weeks of the onset of symptoms.
• Typically symptoms are patterned into 3 overlapping phases (i) Pain, but less stiffness
(ii) Incre asing stiffness , which becomes more than pain after 4- 12 months (iii) Pain
disappears by 18 months , but some residual stiffne ss , especially restricted external
rotation may remai n. (see fig . 3.3)
• Pain is initially felt only on extremes of
movement but later may become a con-
~tant dull ache. Patient often wakes up dur-
ing sleep when lying on the affected side.
Sometimes pain is referred to the C5 and C6 Pain Stiffness ROM
dermatomes. Pain i with act1v1t1es hke
i
combing hair, fastening brassiere, reaching ' ' /
the back hip-pocket, removing vests/kurtas, ' ' I

'
' )'. /
I
' I
toilet ablutions, etc. \I I '
• Stiffness -) Internal rotation is com-
I \
''
mon/ affected first. Then gradually ab- / ' I
I '' /
I
uction, flexion an external rotation di-

minishes. 6 12 18
• 0/E - Wasting of the shoulder muscles Time-)
and te..o.gerness over the anterior part of Fig . 3.3 : Timetable for symptoms of adhesive
greater tuberosity ± tenderness of the bi- capsulitis shoulder.
ceps tendon within the bicipital groove.
Investigations
• ,!rays : Unremarkable . Sometimes regional osteoporosis and cystic changes of the
, greater tuberosity is seen. X-rays are not routi~ely done._ . . . . _
Arthrograph : Contracted joint, especially the mferomed1al Joint space, with irregular mar
gins see ig. 3.4] is often seen. Not routinely done.
Note : Often arthrography significantly decreases symptoms due to joint capsule distension.
• MRt : Not routinely indicated. Shows slight i in vascularity, but may be useful only to
exclude all other shoulder pathologies.
01
fferential
Diagnosis .
' Po d II decreases with time i.e., opposite
~-traumatic stiffness : Here, the stiffness gra ua Y ~ ~- - - - -
rozen shoulder symptoms.
' 0;8 .. . ( for Calles fracture, etc.)
Use stiffne s : After pl~ter immob1hzat1on e.g.,
Fig . 3.4(A) : Normal joint space . Fig . 3.4(8) : Contracted inferomedial joint space.
•@tator cuff injury : Supraspinatus commonly affected . MRI confirms.

• Reflex Sympathetic Dystrophy (RSD) : Also known as complex regional pain syn-
drome. May be after CVA, Ml , thoracic surgery. May lead to shoulder-hand-syndrome.
(see page 81)
• Tubercular arthritis of shoulder : Typically it is a dry lesion with no cold abscess.
Treatment
It is a self-limiting disease , which resolves by 18 months (about 10% may have slighl
residual stiffness).
1. Conservative : Nearly always successful.
(a) Physical therapy - lnterferential therapy (IFT), Ultrasound therapy (UST), Transcutane·
o'us electrical nerve stimulation (TENS) [especially in muscle wasting] may be useful.
(b) Exercises - Avoid abduction at first . Pendulum exercise or free-swinging_ exe~·
cises , reciprocal pulfey exercises and capsular-stretching exercises are useful in
the beginning.
N.B. : Fu// abduction is not possible before full external rotation. (see page 39)
(c) Injections - Triamcelone ± 1 % lidnocaine intralesionally , may be beneficial.
(d) Manipulation-under-anaesthesia (MUA) - External rotation ~ abduction ~ flexion.
N.B. =. MU~ mu st be done very carefully because of the risk of fracture or dislocation,
especially m the osteoporotic bone.
(e) Joint distension by intra-articular sterile saline.
2
· ~Rarely indicated. Options are _
(a) u~n release.
(b) Arthroscopic capsular release.
TENNIS ELBOW (LATERAL EPICONDYLITIS ELBOW) nis

• Although backhand str k . . . . . . ional ten
players, whereas Sach~ eTm tennis may incite pain, it is rarely seen in prof~55 it 0ccur5
more in persons not pl n . e nd ul.kar was a patient of tennis elbow ! Intere st ing1y,
. aymg active sports
• It 1s the most common cause 0 f h . ·
. c ronic elbow pain
• Common in the 4th and 5th d . · ·n
• It is a self-limitin di ecade'. and in the dominant arm. . . rnodificat10
and conservativegmansaease. There is relief from pain within 1 year, with act1v1ty
gement.
SPOT CASES 167
• It occurs with activities that need repetitive pronation/supination, or wrist extension in pr-
onated forearm.
pathoanatomy - Cause
• cumulative microtrauma from repetitive stress due to eccentric and concentric muscular
contractions, with overload on the wrist extensor origin .
• Extensor carpi radialis brevis (ECRB) is the most common culprit. The o~igin of EC~B
impinges on t he lateral part of the capitulum during elbow extension / flex1on . Also , with
elbow extended , forearm pronated and wrist flexed the ECRB tendon is further stretched
over the edge of the radial head . It can also inv~lve the extensor carpi rad ialis longus
(ECRL) and extensor digitorum communis (EOC) . [Fig. 3.5]
Aetiology
2 schools of thought :
1. Modern ~iew - Tendinosis : It is a non-inflammatory lesion , because histolog i-
cally no increase in neutrophils and lymphocytes are found . Rather , first f ibro-
blastic, _th~n vascu_lar hyp~rplasia ~ abnormal collagen production occurs. (Hence termed
as ang1of1brob/ast1c tendmosis)
2. Old v~ew - Tendinitis : It is a chronic inflammatory tissue response to fatigue stresses ,
by which the body attempts to hasten the rate of tissue healing, to compensate for the
increased rate of collagen micro-damage.
Clinically
• Insidious onset. Sometimes patient gives history of mild trauma.
• Pain is worse when wringing clothes, using screwdriver, using hammer, ope rating accelera-
tor of 2-wheelers , lifting/carrying items with pronated forearm and flexed elbow , rotating
doorknob, turning a key or even shaking hands!
• Tenderness distal to the lateral epicondyle of the elbow, over the origin of ECRB is found ,
which may later extend to the muscle belly in posterior proximal forearm.
• Sometimes weakness of grip and / or paresthesia over posterior forearm and hand is found .
• Provocative tests :
(a) Thompson's test : Patient's shoulder is flexed to 60°, elbow extended , forearm pr-
onated and wrist extended. Then the examiner applies pressure on the 2nd / 3rd metac-
arpal , trying to flex and ulnar deviate the wrist, which produces sharp pain (see fig 3.6) .
EDC
Fig. 3.7 : Cozen's test.

F19. 3.5 . Exten I . . . 3 6 . Thompson's test.
· sor muse e ong1n. F 1g. . .
168 HANDBOOK FOR OATHOPA DIC XAMINA noN
(b) Cozen's test : Against reslstenco, k pEl tl nt I < xi< rH I Wfl 1, l{,,op n J tti, ,,lbrJw 11,JJUJ J
and the torearm pron tad (see fig 3.7) .
(c) For other tests - se page 52.
Differential Diagnosis
1. Radial Tunnel Syndrome : It is th e posterior int ro ou n rvo WI ~) ntr· rirn nt b~-
tween the superficial and deep fibres of the supinal:Of mu cl . Cllnl ally, r 1n 1 with rCJ l tod
supination in 20°-30° flexed elbow. Pain Is located 3- 4 cm distal to tho lat ral cp/condylc.
2. Osteochondral, intra-articular lateral elbow /es/on : (0 I ochondrltl de ican of
capitellum) Patients may Clo snapping _ locking. Maximum tenderne Is found po terlor to
the lateral epicondyle, over the posterior radio-capitellar joint.
Investigations
• X-rays are useless and totally unnecessary. Rarely it may show calcificatfon.
• USG : May be useful. Shows focal hypoechoic area on normal background.
• MRI : It can quantify diseased tendon thickening , identify intra-articular pathology like os-
teochondral lesion.
N.B. : Tennis Elbow is a clinical diagnosis. MRI is rarely done, which is useful only for recal·
citrant disease and planning of surgery.
Treatment
Always start ice application in the acute phase.
1. Conservative : Nearly always successful (95% cases) .
(a) Activity modification : Avoid pain-producing activities.
(b) Physical therapy : Ultrasound therapy (UST), friction-massage , lnterferential therapy
(I FT) , high voltage galvanic stimulation, remedial exercises. Effective in the long term.
(c) lntralesional Injection : Triamcelone 1 cc ± 1% lidnocaine, 1-3 doses injected with a gap
of 3 weeks. Side effects - Pain worsening in the next 72 hours, and (rarely) whitish skin
patch or skin atrophy. Very effective for short term relief.
(d) Bracing : Dynamic wrist extensor orthotic which limits wrist extension . Also non·
elastic proximal forearm strapping which effectively shifts the functional ori gn of
ECRB distally.
(e) Acupuncture : Provides effective short term relief when done by expert hands.
2 . Surgery : Considered only after 6-12 months of failed conservativ e management.
i.e., in patients with refractory symptoms (only about 5% need surgery and success
rate is only about 60%.)
Options :
(i) Open debridement.
(ii) Percutaneous release .
(iii) Arthroscopic debridement.
Newer experimental treatments :
1. Injections : Autologus blood, platelet-rich blood, botulinum toxin.
2. Transdermal glyceryl trinitrate patches to deliver Nitrous Oxide (NO) which is needed tor
tendon healing.
3. Low-level laser therapy.
4. Extra-corporeal shock wave (ECSW).
SPOT CASES 169
GOLFER'S ELBOW (MEDIAL EPICON DVLITIS ELBOW)

(Similar to Tennis Elbow. Only the differences with Tennis ~ /bow are mentioned.)
• Not infrequently found, but incidence is much lower than tennis elbow . .
• commonly involves the pronator teres (PT) and flexor carpi radialis (FCR) . (Fig. 3.8)
Pain
1 . Tenderness over the medial epicondyle
initially. Later , may extend to the proxi-
mal , vol ar and the ulnar-side of forearm.
2. Worsened by repeated wrist flexion and
strong gripping activi ti es , like pu l l-
through strokes of swim ming, hard hit
forearm shots in racquet sports , or force-
fully throwing a ball. FC R
Provocative tests
1. Golfer's elbow sign : With elbow semi-
flexed and forearm supinated, isometric
resisted wrist and elbow extension pro-
duces pain. (Fig. 3.9)
2. Sometimes resisted pronation also pro-
duces sharp pain .
3. Other tests - see page 52 . Fig. 3.8 : Anatomy of medial epicondyle .
1. Cubital Tunnel Syndrome : Often concomitantly present. It is actually ulnar nerve
entrapment between the humeral head and the ulnar head of flexor carpi ulnaris (FCU) ,
producing symptoms of compressive ulnar nerve neuropathy (see page 104, 105) . NCV
confirms diagnosis .
2. Baseball Pitcher's Elbow : Hypertrophy of the distal humerus with incongruent elbow joint ±
loose bodies ± osteoarthritis, due to repeated forceful throwing activities.
3. Little Leagure's Elbow : Partial avulsion of the medial epicondyle.
Treatment
It is a more challenging and difficult condition to treat than tennis elbow .
[All other features in introduction , pathoanat-
omy , clinical features , investigations and
treatment are SAME as in tennis elbow .]
STUDENT'S ELBOW (OLECRA-

NON BURSITIS)
• Not commonly found . It is an infrequent
lesion .
• It is the inflammation of the bursa be-
tween the olecranon and the t riceps ten -
~on . Occurs due to repetitive / pro -
10nged leaning on the elbow , e.g., pro-
inged studying in a desk or table , or a Fig. 3.9 : Golfer' s elbow sign .
low onto the posterior elbow .
170 HANDBOOK FOR ORTHOPA ED ICS EXAM IN ATION
• Common in the 2nd to 5th decade of life. P in .i

surfaces , but all other movements (a~t1ve , pass 1v
• Occas ion ally , the loc al temperat~re is
raised and the re is soft-tiss ue thicken -
ing ove r the olec ran on .
• Always rule out gout and rheumatoid
arthritis, because they are commonly
assoc iated .
Javelin Throwers Elbow (triceps tendini -
tis / posterior tendinitis elbow) : Rare lesion .
Tenderness is over the triceps insertion . Re -
sisted elbow extension when the elbovv is
partially flexed , and forea rm supinated is a
confirmatory provocative test . Pathoanato -
my is the same as for tennis elbow .
Treatment
Same as for tennis elbow . Fig . 3.1O : Student's elbow.
PULLED ELBOW
Usual history is that of a 3- 4 year child being sudd en ly jerked by the hand/forearm
and the child cries out in pain and holds the forearm in pronat ion . No X-ray change5
are found . Mistakenly thought of as subluxation of the radial head . It is actually the
subluxation of the orbicular ligament , which moves up over the radial head, on °
the radio-capitella r joint .
Treatment : Spontaneous reduction usually occurs. The aim is to rest the limb in a collar·
and-cuff sling. Occasionally manipulation maybe required which is forceful supination
and then elbow flexion , which reduces the lesion with a "snap" .
--
CONGENITAL RADIO-ULNAR SYNOSTOSIS
Commonly
(1) The synostosis is at the proximal radio-ulnar joint.
(2) It is bilateral rather than unilateral.
(3) It has familial trait, more from the paternal side .
Types • Wilkie classification
(I) The medullary canals of the proximal radius and ulna
~re fused to~ether for several centimetres , and there
1s malformation of the proximal radius. The radial shaft
has an. excessive and abnormal anterior bow, and its
len~th 1~ much more than the ulna. (Fig . 3 .11)
(II) Radius 1s nearly no_rmal and fused to the proximal ulna
only for a few cen_t1metre~, but the radial head is dislo-
cated. Often associated _with polydactyli , syndactyli or ab-
sence of the thumb. This type is often unilateral.
Clinically
It is a very disabling condition when b'i later I Th f
· f
1s 1xeh
searc
d ·
t ·
pronat1o_
a· e orearm
n an? no supination is possible. Always
or congenital finger anomalies and · I d .
your diagnosis. inc u e them in
Fig . 3 .11 :
SPOT CASES 171
X-rays
AP and Lat. views are diagnostic.
Treatment
very difficult to restore supination even with operative release of the synostosis . This is
because of the abnormal soft-tissues , like absent or abnormal supinator muscle, narrowed
interosseous membran_~ and muscle contractures. The goal of treatment is to achieve an
improved functional pos1t1.on by derotation osteotomy, especially when the condition is bilat-
eral. Fortunately most children adapt and manage well. If flexion/extension is adequate then,
tor dominant hand 20° pronation is functional. For non-dominant hand - for Indians supination
is preferable (for toilet ablution), for western population pronation is preferable (for typing,
computer mouse use etc).
Cleary and Omer classification Tachdijan classification

(I) Fibrous syn ostosis (I) Absent radial head, osseous
(II) Reduced radial head , os- synostosis
seous synostosis (II) Dislocated radial head osseous
(111) Posteriorly dislocated radial synostosis
head osseous synostosis
(IV) Anteriorly d islocated radial (111) Fibrous synostosis
head osseous synostosis
D. Q. (DE QUERVAIN'S DISEASE)

• Also called DQ tenosynovitis and stenosing tenovaginitis of abductor pollicis longus (APL)
and extensor po/licis brevis (EPB).
Aetio-pathoanatomy
• Stenosis occurs at the point where the tendon direction changes , because a fibrous sheath
acts as the pulley, causing maximal friction at that site. (Fig . 3.12)
• Overuse syndrome : Repetitive
thumb movements, especially those
APL need ing strong pinch grip and/ or pro-
EPB longed and sustained ulnar deviation
of wrist ~ excessive friction of ten -
dons w i th in tendon sheaths ~
microtrauma ~ inflammatory response
of synovium ~ painful thickening of
ext ensor pollicis bre vis, abductor
pollicis longus tendon sheaths (b ut
the tendons remain normal).
• Sub-clinical collagen disease : Rheu -
matoid arthritis, thyroid disease, etc., are
often associated.
Fig . 3.12 : Anatomy of tendons in wri st.
Clinically
1
· Common : In 30 to 50 years; women > men. .
2. w1 . . . . nin shrubs or even lifting a filled glass of
story : Pain i with wringing clot_heS, pr~f-b gx or the radial styloid (pain may radiate
Water. Patients point to the anatomical snub) ~inch grip is very painful (see page 75) .
up along the forearm , or down to the thum ·
HANDBOOK FOR ORTHOPAEDICS EXAMINATION .
172
d n sheath ove r l e r
h ± thickened tendon sheath.
adial styloid
=-- ---ir.---:--.........
3 . 0/E : Tendernessf of thlfi~gen rirely crepi -
Varying degrees o swe ,
tus may be found.
4 Provocative tests : d
· b . flexed + adducte ,
(a) ::~npt!de r:S~;ed '!bdu.ction + ~xten~i~n
f thumb is typically painful. (Fig. 3. )
(b) ~inkelstein'~ test : .Thumh~~obuft~ ~::~
base of 5th finger (i.e ., t 1
+ adducted + opposed) -? clench oth.er
fingers over thumb into a clenched f~st
-? then forcefully ulnar deviate the wrist
-? sharp pain is felt . (Fig. 3 . 14)
5 . Many other tests e.g. , Muckard Test.
Investigations
• X-ray """"""7 USELESS. Fig . 3 .13 : Provocative test for DQ.
• USG/MRI - Not required. May show ten-
don sheath thickening .
• Exclude - Hyperuricaemia, infection , dia-
betes mellitus, rheumatoid arthritis , thyroid-
disease. (Blood for uric acid, RA factor ,
FBS , PPBS, TSH , ESR, DC, TLC , e~.)
1 . Intersection syndrome : Also known as
crossover syndrome, and peritendinitis-
crepitants. It is commonly seen in weight-
lifters and rowers. Clinically , there is pain ,
swelling, crepitus over the tendons of EPL
and abductor pollicis longus, about 5 cm
proximal to the extensor retinaculum , due
to tenosynovitis at the crossing of the ab -
ductor pollicis longus (APL) + extensor
pollicis brevis (EPB), over the extensor
carpi radialis longus (ECRL) + extensor
carpi radialis brevis (ECRB). Fig . 3 .14 : Finkelstein's te 5t
2. Osteoarthritis of the first trapeziometacarpal joint . Pain is sty/oid,

and never over the tendon sheath. always distal to the
3 . Non-union scaphoid -? anatomical snuff-box tenderness is always present.

Treatment
· es ~r8
• Physical therapy : Pulsed UST, IFT, TENS , friction massage and stretching e ercis
all very useful. con·
• lnj~c~ion : ~elieves s.y mptoms in about 60% cases (Triam elone ± 1% lidnocaine).
traind1cated in gout, diabetes and infection. coni·
0
• ·
perat,ve re I ease o f tendon sheath : Remember · t·ons
anatomical vana 1
are
o h '
monly found ( > 50% have "aberrant" duplicated tendons of APL and about 5
absent EPB) .
Prognosis
In most patients , recurrence occurs after 1-2 years.
SPOT CASES 173
ANGLION
llnl<,nll
• I ttlnl I vml hly c hing lum whi . . . .
• Cl , i . lly lh lump is • ( p . ch fluctuates rn size (more Joint movement = size t)
1,rm sometime ·t
n n I 1 ncl 1 (m oy b l nd r) s I may _be so tense th at it is almost bony hard) ,
rnny n l mov with th th
nd~nsm~o ' ~ell-defined , cystic and fluctuant which may or
I
111111 · ll 11 l t ,,., y b po sitive . · ccasional ly it may be multiloculated . Rarely transillu -
Tr om nt
I ion with a rim of normal t' .
rnon wh n ny abnormal tissu . f,ssue . is th e t reatment of choice. Recurrence is com-
e 1s 1e t behind.
lg . 3.15 : Gang lion over dorsal wrist. Fig . 3.16 : Compound palmar ganglion .
COMPOUND PALMAR GANGLION

• It i a actua lly a distention of the common flexor tendon sheath at the wrist, due to chronic
ln fl · mmalion , and the sw elling is usually found both proximal and distal to the flexor reti-
naculum .
• V ry common ly associated with rheumatoid arthritis (RA) and tuberculosis (TB) .
• Synovium i thickened and the fluid often contains fibrin particles in the shape of 'melon seeds'.
• v nlu,:rlly th tendons may rupture due to attrition and fraying .
C1intca11y
• P1c1inl · non-tender sw elling typically hour-glass-shaped, bulging proximal and distal to the
' Cross-fluctuation test may b e pos1"t'1ve.
II X r r linacu lum (r-ig. 3.16).
l'rootrn nt
• Xolud / treat TB and RA (start ATD / DMARD). In TB, aspirate fluid -? lnj. streptom~cin -?
Pli: 'I r Immobilization (splinting) . Repeat weekly for 4- 6 weeks. If unsuccestul (and 111 RA)
> ornr,let excision of the fle)(or tendon sheath is done after 6 weeks.
[ D c L XAMINA 1 ION
174 HANDBOOK FOR ORTHOPA I
TRIGGER FINGER / TRIGGER TH UMB

.. tenovaginitis digital s tenosing tenovag initi s, snapping finger
• Also ca lled d 1g1 1a1 ' t t·t d' , , etc
• . er finger / thumb is a complet 1y separa e en I Y, 1scu ssed in page 17 ·
[Congenita 1 1ngg . ., 5]
· d ·th d,·abetes mellitus rheumatoid arthritis and gout.
• Associate w1 ,
• Most commonly, the 4th and 3rd fingers are aftected.
Aetiology
• Unknown . May be du e to overuse (repetitive microtra um a), col lagen disease or acute
local trauma .
Pathoanatomy
Trauma / infl ammation heali ng by fibrosis ~ "bu nching-up" of the flexor synoviurn at
the annular one (A 1) pulley and also at the level of metacarpophalangeal (MCP) joint ~
causing nodular fibrosis ~ i.e. , th ickening of the palmar tendon sheath of the flexor tendon.
slip ~ making the tendon -slip get trapped at the shea th entrance. Forceful extension re-
lieves the entrapment with a sharp "click" (wh ich the patient may feel to be at the level of
interphalangeal (IP) joint) ~ thus called "triggering".
Clinically
• Common in the 4th and 5th decade and in

the 3rd, 4th fingers and the thumb (then
called trigger thumb) .
• Symptoms have insidious onset and are
gradually progress ive . Initially the pa-
tient hears/feels a "clic k/snap" on flex-
ion/extension of the affected finger ~
then gradual difficulty in extending fin- palmar
gers from flexed position ~ after that , aponeurosis
patent can only extend finger pass ively
with a painful sharp click/snap~ finally ,
cannot even flex fingers .
• Tender nodule over metacarpal head
region is found , sometimes with a
fusiform distal swelling and some Fig . 3.17 : Anatomy of flexor tendons at MCP
crepitus.
joint level.
Differential Diagnosis of Trigger Thumb
• Bowler's Thumb · T ende I d ol

thu b b · r ump ue to perineural fibrosis of the ulnar digital nerve
tim:s th eca~se ~f overuse . Tingling/paresthesia of the pulp of the thumb is felt. sorne·
ere 1s skin atrophy.
Treatment
1 . Conserv~tive : Effective for the majority.

(a) Phys,ca/ threapy - UST . . nighl
splints . ' LASER , stretching exercises , flexor muscle stimulation,
(b) Injection _ (lntr 1 .
a es1onal) Triamcelone 1o¼ 1·d .
• o I nocame.
2. Operative : Release of the fl
exor tendon sheath.
SPOT CASES 175
CONGENITAL TRIGGER FINGER / TH UMB

• No history of "snapping/trigge ring" of fingers; rather the finger re mains constantly flexed.
• Diagnosis is often missed or it is mi sdiagnosed as dislocation.
• Most common in the thumb, therefore called congenital tri gger thumb .
• Al though called congenital or infantile , and sometimes associated with trisomy 13, it is
probably an acquired condition ~ often not noticed before 1- 2 years of age .
• Due to narrowing and thicke ning of the dig ital flexor sheath with occa sional formation
of gang lion cyst , there is impediment of th e normal gliding movements of the flexor
tendon sl ip. Hence extensi on is difficult.
• Treatment : 30% heals spontaneously, especially when detected before 1 year ~ for
them stretc hing exercises, splinting and regular observation may be sufficient.
• Always operate between 2- 3 years of age . Delay is unwarranted.
N.B. : Gamekeeper 's Thumb I Skier's Thumb : Injury to the ulnar collateral ligament
at the 1st MCP j o int level after snow-skiing accident, or fall on outstretched hand
with radial a nd p a lmarly abducted thumb. There is pain, swelling, echymosis at
thumb base with greatest tenderness on the ulnar side of the thumb base. A
prominent lump is palpable which is the torn ulnar collateral ligament being dis-
placed by th e adductor aponeurosis. Abnormal thumb rotation may also be found.
Plain X-rays and stress X-rays are useful for diagnosis. Surgery is the treatment.
MALLET FINGER (BASEBALL FINGER)

• It is actually an avulsion fracture (Fig . 3.19) of the distal phalanx of a finger at the insertion
of the extenso r tendon slip . It may be an open injury.
Aetiology
1. Occurs when the finge r tip is for cibly extended e.g., while catching a cricket ball /
base ba ll if th e b all st rikes the finger
tips rath ~r than th e palm ; or when tuck-
ing bedsheets/blan kets under a heavy
mattress .
2. Often du e to direct trauma to th e fin -
ger tip . H e re , predi s po si ng fac to.r s
may be c hroni c attrition, or se nil e
chang es.
Clinically
1. Distal interphalangeal (DIP) joint .is flexed
and passive exte nsion is possible, but
there is no active extension.
2· Du e to un b a la n ce d ex te n sor mec ha-
nis m , s o me tim es th e p ro xi m al inte r-
Ph al an g ea l ( PIP ) j o i nt is hyp e rex -
ten ded , ca u sin g swan-neck defor-
mity. (Fig . 3 .18 and 3 .19) Fig. 3 . 18 : Mallet ring finger with swan-neck
X-rays deformity. Note _ PI P joint is hyperextende.d and
DIP joint is flexed, i.e. swan-neck deformity.
Lateral view of the finger is diagnostic.
HANDBOOK FOR ORTHOPAEDICS EXAMI NATION
176
Treatment O
• .
1 . Fragment< 30% . Malle~ finger SPiint for
DIP, leaving PIP free . It _is worn_continu.
ously for 6- 8 week~ . Night splinting f
anothe r 2- 6 weeks 1s beneficial. or
2 . Fragment > 3 0% and open injuries .
Operative fixation. ·
3 . Chronic I neglected mallet finge, .
Treated only when the re is severe Pain.
gross cosmetic deformity or when it i'
. 3 19 . Lat. view X-ray showing avulsion fracture significantly impairing hand function con~
F19· · · k
of the base of distal phalanx and swan-nee sider DIP arthrodesis.
deformity of PIP joint.
MALLET THUMB
• Rupture of the extensor pollicis longus due to fraying of the tendon at wrist e.g., after
Calles fracture or rheumatoid arthritis.
• Direct repair of tendon gives poor result. Tendon transfer is a better option.
BURSAE AROUND KNEE

• Bursa is a fluid filled sac, near a joint, which is present between the skin and tendon, or
between the tendon and bone , which may or maynot communicate with the nearby joint.
• Bursae reduce friction between adjascent moving structures.
• Bursae are susceptible to inflammation (causing bursitis). Causes are - low grade inflamma-
tion as in gout, rheumatoid arthritis, TB, syplilis , or due to acute and chronic, repetetive
trauma (overuse), or infections which may be acute, sub-acute or chronic.
• Bursae around knee can be divided into 4 groups -
(i) Anterior : Prepatellar bursa, superficial infrapatellar bursa, deep infrapatellar bursa, and
suprapatellar bursa, occasionally between tibial tuberosity and skin.
(ii) Medial : Pes anserine bursa, tibial collateral ligament bursa, semimembranosus bursa,
medial head of gastrocnemius bursa.
(ii!) Lateral : !liotibialb~nd bursa, fibular collateral lig8:ment bursa, lateral head of gastrocne-
m1us bursa, f1bulopopl1teal bursa (between LCL and popliteus) , subpopliteal bursa (between
popliteus and lateral femoral condyle) .
(iv) Posterior : Popliteal cyst, Morant
Baker cyst.
PREPATELLAR BURSITIS
(HOUSEMAIDS KNEE)
• ~arely seen in housemaids , but common
in carpet-layers and miners.
• Commonly due to constant friction be-
t~een the patella and the skin (fig 3.2 .1)
;1th repeated knee flexion /extension '
a~~~hf:u~ommon cause is after a~
J Y e.g ., fall , or a direct blo
over the patella. w
• The knee joint is uninvolved T . .. .. - Medial
fluctuant well - circu· ms 'b· · here IS a Fig. 3.20 : P.repatellar burs1t1s. Note d
er, ed sw 11 ·I · olve
between the patella d . e ng parapatellar groove ~ joint not inv he
Ir . an the skin It . (then t
swe mg is warm and tender) · may get infected , especially in children
• Treatment is aimed at the ·
cause of bursT1 ges.
is and not the secondary pathological chan
....
SPOT CASES 177
1 . Non -infected : Avoid knee ling . Aspiration + co mpression "Jones " bandage + steroid
injection . If recurrent ~ operati on. .
2. Infected : Aspiration + antibi oti c (i njection locally and orally) + cylinder s lab
immobil ization.
• Surgery is ind icated in chronically infected inflamed bursae with thickened walls .
Excision is done .
• After treatment - Quadriceps exercise and physical therapy.
INFRAPATELLA R BURSITIS (CLERGYMAN'S KNEE)
separated from the knee synovium by a

fat pad (see fig . 3.2.1)
• Sometimes associated w ith gout and
I!'f/ ~ ;:,.
• lnfrapatellar bursa is located between the tibial tuberosity and the patellar tendon, and is
';;n, ~ d
/ { : ~,
!
f
syphillis. May get infected . iJ!J ! 1~,',
• When distended, the fluctuant swelling Prepate llar ~# ·
obliterates the depression on each side of
the patellar tendon.
Bursa
;
1
11 ',,f'fm
• When infected , there is loss of full '
knee extension and full flexion , to-
gether with tenderness . Proximal tibial lnfrapatellar
osteomyelitis and septic arthritis Bursa
should be excluded.
• Treatment - As in prepatellar bursitis.
Fig . 3.21 : Bursae around knee.
• Deep infrapatellas bursa : Bursitis may mimic Osgood-Schlatter's disease, especially
is the adolescents . MRI can be diagnostic.
POPLITEAL CYST
• When associated w ith osteoarthritis , it is called Baker Cyst or Morant Baker Cyst
(First described in 1877).
• In children , the cyst sometimes communicates with the joint, but the joint is normal.
In adults, 98% joints are pathological [e.g., rheumatoid arthritis, osteoarthritis , medial
meniscal posterior horn damage, etc.)
Pathoanatomy
1. Commonly due to synovial herniation or
rupture between the capsule and oblique
popliteal ligament.
2. May be a distended bursa - commonly
the bursa between the medial head of
gastrocnemius or the semimembrano-
sus bursa (the~ called semimembrano-
sus bursitis) . These 2 bursae communi-
cate with the knee joint.
Clinically
1
· ~Ystic , fluctuant, non - tender , poste -
rio
. r mid!ine swelling be low the joint Back view
. . Side view
line , Whi c h becomes prominent with Fig. 3.22 . Morant Baker Cyst.
2 knee ex ten sio n (Fig . 3 .22 ), but reduces / disappe.ars with knee flexion .
· ~arely the cyst may leak I rupture , and fluid can tr.1ckle down to the calf through an
intram usc ular route taking the path of least r_es1sJence ...Then the calf becomes
~~Olien and tender , and sometimes Homan 's sign 1s pos1t1ve . Must rule out deep-
ein- thrombosis in these cases.
0111 , ,, ti I L I no Is b t th b
I • t m/111< mb, ino u . Bursitis : Inflamed, enlarged bursa e ween e sem1mem ranosus
M) 11 tl<hHI ,md IIH in di I head of gastrocnem1us muscle , or the bursa between the StA
mhrn ''"d lh 1 llll d1,,1 t1b1. I condyle . . . . . .
• /1111t'. 1/I)' ,., , 1nl ss, fluctuant lump , medial to the mid/me, which is prominent in
l lt nd I 1-.n (rig. 3.23) , but reduces
with kn lie 10n.
• I 11 11/llt'III O nign neglect 1s often ef-
t t1v< (dis ,pp t1r s with time) . Surgical
l 1s1on m y produce 1ecurrence.
~. Pop/It nl An urysm : It 1s the most com -
mon l11nb • n u1ysm. Often bilateral. Clini-
t,,,lly p in b hind knee + stitrness ~
1,\1 1 puls. ltl • walling (N B. : If throm-
b • l ci , th r I no pulsation)
Tr trn nt of Popllt al Cyst
1.spit .,lion I tnJ l1ydrocortisone + com-
prl ~s1on b, nd ge.
· Surg1 .:ll c1s1on . Recurrence is common .
• . l r 1ll1ng the intra-articular pathology (e.g.,
synov ctomy 111 RA , meniscectomy in
m nisc. I d mage, etc.) + excision of the
cy · t is benelicial. Arthroscopy is very
us lul lo, valuation of joint pathology and
tr tm nt sim ultaneously. Fig. 3.23 : .Semimembranosus Bursitis.
• Pe Anserlne bursa : It is placed in-between the pes anserine (sartorius, gracilis,

s m1tendinosus attachment on the proximal medial tibia) , and the medial coll ateral
119 m nl and small part of the medial tibial condyle. It is often consfused with popliteal
cyst, but it never extends to the thigh or communicate with the joint, and it is always
situated medially (not ce ntrally) .
• Suprapatellar bursa : It is placed between the quadriceps expansion and the femur. It is
formed due to failure of regression of the transverse septum , in the embryonic stage. in
between the suprapatellar plica and the knee joint.
• lllotiblal bursa : II is placed in-between the ilio-tibial band near it's insertion on to the
Gardy's tubercle, and the adjascent tibial surface . Bursitis is due to repetetive trauma
or overuse.
N.B. : Jumper's knee (patellar tendinitis - see page 12); Weaver's bottom (ischiogluteal
bursitis)
ACHILLES TENDINITIS
• Very difricult / challenging to treat, and patience is required.
• Associated with obesi ty , hypertension, OCP use, diabetes, rheumatoid arthntis. s st emic
lupus eryth ematosus, Relter's disease. ankylosing spondylitis. reactive arthrihs.
Types
lnsertional and Non-lnsertional.
INSERTIONAL
• Common in older people. .. . .. sumP
• Always associated with retrocalcaneal burs1t1s and/or Hsglund deformity l Pump . t1an1·
1
deformity - see n in X-ray) . Haglund deformity is an exos1os1s caus d b chronic ~ j )
1
ma tion of the adventitious bursa th t separates the t ndo , chilles from s~in F ;s
5 0
i·
Th e bursa is present in 50% which may be inflamod with tnction and from tight
SPOT CASES 179
Aetiology
Overuse and repeated m1crotrauma (e.g., in runners and jumpers).
ClinicaUy . . . .
1 dious onset, gradually progressive pain at the tendo ach1lles (TA) insertion , especially at
~
th;:;des, wh ich j with walking uphill , or on hard surfaces. Pain / stiffn~ss after night's sleep
or morning stiffness after a period of rest. On palpation ~ soft-tissue 1s thickened.
investigation
X-ray ~ Posterior heel spur or Haglund de-
formity on lateral view (Fig 3.24) . USG and
MRI can demonstrate the TA condition .
Treatment
1. Conservative (Effective in 95%) :
(a) Heel raise, ice application , foot ankle
orthosis (FAO) , night-splints and NSAID are
useful.
(b} Physical therapy - UST, eccentric
strengthening of the gastrosoleus + stretch-
ing of tendoachilles .
(c) Glyceryl trinitrate topical patches.
Fig. 3.24 : Haglund deform ity.
N.B. - lnj. Hydrocortisone is RISKY because it may cause TA rupture, so try to avoid it.
2. Surgery (may be needed for 5%) : Done after failed conservative treatment for 6-12 months.
Partial (< 50%) debridement + TA lengthening, is the surgery of choice.
NON-INSERTIONAL
• Common in older athletes , males with tight TA / hamstings, those wearing improper shoes or
training improperly.
• Always associated with a hypovascular zone, 2-6 cm proximal to TA insertion .
Pathological types
1. Peritendinitis (sheath)
2. Tendinosis (tendon)
3. Paratendinitis (sheath + tendon)
Clinically
(FNon-tender bulbous nodule at TA insertion

thig. 3.25) . Pain is more at the start and ~t
e end of exerc ise . Morning stiffness 1s
Presen t.
Investigation
Sarne as insertional.
'treatrnent
1· Con
2 . Surgservative : Same as insertional. ·
MRI ery : If > 50% tendon is involved 1n
may' bcoun sel th e patient. Tendon transfer
e necessary. Fig . 3.25 : Bulbou s nodule at TA insertion.
180 HANDBOOK FOR ORTHOPAEDICS EXA MINATION
PLANTAR FASCITIS (POLICEMAN'S HE EL)

• Common , but a very challenging prob lem to treat. .
· b middle-aged women and young male runners / Jumpers.
• Common in o ese . d I' · R ·t , d'
• Must exclude rheumatoid arth ritis, ankylos1ng spon y it1s, e1 er s isease , osteoarthritis
diabetes mellitus and gout. '
Aeti ology .
The exact cause is sti ll unknown . There ar.e numerous hypoth~s1s : ~-9·, fat-pad degen.
eration; wind lass mechanism of plan~ar fascia as toes are do'.s 1fl exe_ d , entrapme.nt of the
st branch of lateral plantar nerve ; m1crotrauma to _plantar fasc ia leading to chronic inflam.
1
mation of perifascia l tissues; increased cal caneal intraosseous pressure ; seronegative ar-
thritis ca usin g inflammation , etc.
Pathoanatomy
Oedematous calcaneal attachment of plantar aponeurosis, with thickening of the central cord
of plantar fascia.
Clin icall y
• Pain in the pl antar part of hee l with maximal te ndern ess over the medial process of
the calcaneal tuberosity. Pain is worse on arisi ng from sleep in the morning, and also atter
prolonged sitting. After walking for a few minutes, the pa in gradually diminishes.
• Always search for limb length discrepancy (LLD) because heel pain is common in the shorter
limb. Also look fo r tight tendo achilles , pes planus (flat feet ) and pes cavus (high arched feet).
• Ankle dorsiflexion and great toe extension may be decreased.
X-rays
• Have limited role . May show calcaneal spur (Fig. 3.26) which is irrelevant because many
patients with calceneal spur have no heel pain , whereas many patients having heel pain have
no calcaneal spur.
1. Tarsal Tunnel Syndrome is concomi-
tantly present with plan tar fasc itis in
2 % pa tients. It is due to entrapment of
the 1st lateral branch of posterior tibial
nerve . Cl inically burn ing pa in/paresthesia
of the heel ± pos iti ve Tinel 's sign , but
never medial heel tenderness. Treatment
medial heel wedge , intralesional steroid
injection , surgery.
2. Tendinitis of flexor hallucis longus or
flexor digitorum brevis.
3. Stress fractures.
Treatment
1. Conservative : > 90% patients can be . 1
r
successfully treated conservatively . Fig. 3.26 : Calcanea spu ·
f b icated or
(a) Soft-heeled shoes tor constant use. Silicone or rubber heel -cups and pre a r
customized soft-heel-inserts are useful.
(b) Ankle dorsiflexion night splints.
(c) Stretching exercises tor tendo achilles , plantar fascia and the lumbiricals. 1 .0 fllaY
5
(d) Jntralesional _i~je~tion of Triamcelone 1cc ± 1% lidnocaine. Repea_ ted inj~~~ ; ~0eK
at_1on ~ so not more than 2 injections are given , at 1nterva
prod~ce calc1f1c_
and 1t must be tnJected deep into the plantar fasc ia to avoid fat-pad atrophY·
SPOT CASES 181
(e) Activity modification for run ners - must reduce running distance.
(f) Physical therapy - lnte rfere ntial therapy (IFT) , ultrasoun d th e rapy (UST) , frict ion
massage , muscle stimulation - especially the lumbiricals.
2 . Extracorporeal Shock Wa ve (ECS W) : Recently starte d with promising results. Rec-
ommended if conservative treatment fails. Shock waves are believed to initiate fas -
cia! tissue healing which affects pain receptor physiology. A single high energy dose of
electrohyd ra ulic ECSW , with the patient anaesthetised, is the gold standa rd.
3. Surgery : Rarely requ ired. Principle : Partial release of the plantar fascia (one-th ird to
maximum half) from th e medial calcaneal tube rosity (greater cut may cause pes pla-
nu s) , ± neurolysis of the nerve -to-abdu ctor digi ti minimi . May be done by open method
or arth roscopically.
PES PLANUS (FLAT FOOT)

The loss of th e normal medial longitudinal arch of foot, wh ich results in the medial border of foot
touching (or nearly touchi ng) the ground is called pes planus.
Aetiopathological varieties
1. Compensatory : In (a) G enu valgum (b) Externally rotated feet (Charl ie Chaplin gait)
(iii) Fixed fore foot varus or ankle equinus.
2. Hypermobile joints : In disorders like Marfan's Syndrome , Ehlers-Danlos syndrome , etc.
3. Anomalous anatomy :
(a) Congenital vertical talus (Rockerbottom foot) [Fig . 3.27]
(b) Accessory navicular (Fig. 3.30)
(c) Tarsal coalition -? Calcaneonavicular coalition , Talocalcaneal coalition , etc.
4. Physiological : very common in 1-3 years of age. Usually disappears by 9 years.
Note: MNEMONIC : CHAP

Classification
1. Flexible : Arch appears when non-weight
bearing, or with the passive dorsiflexion
of the great toe .
2. Rigid: In patients with congenital vertical
talus or tarsal coalition , the arch never
appears.
Clinically
• Perturbed and anxious parents usually
present asymptomatic children . In ado-
lescents and adults, there may be com -
Fig . 3.27 : Rockerbottom toot. plaints of pain , occasionally with mild
Note : Plantarflexed talus and flat foot. swelling of proximal dorso-lateral foot ,
wh· h d ·ght bearing or activity (e.g. , walking , running , climbing
1c appears after prolonge we1
stairs, etc.). This is foot-strain. 'd d front) and then in non -
• E · . . t d·ng
1 (from back, s1 e an
xam1ne the patient first in s an . t'1 t flex ible from rigid variety) . Note the
Weight bearing sitting position (to diffe~en ~oen with medially tilted talar head , calca -
Valgus heel (Fig . 3 .28) mild subtala~ sub uxa ~ calcaneocubo id joints, forefoot supina-
~ea1 eversion , abduction of talonavicular ::amine the knees/ hips.
tion , tight/shortened tendo achilles. Also
X-ray . . essential . Non -standing Lateral and oblique views rna

Standing AP an~ Lat. views are d t sal coa lition . Look for accessory navicular in A~
show calcaneonav1cular bony bar a~ a; t in Lat view . (Fig . 3.27)
view (see fig . 3.30) , and plantar flex1on o a Ius .
Fig. 3.28 : Back view. Note - Valgus heel. Fig. 3.29 : Side view . Note - Prominent navicular.
Treatment
• Physiological variety needs no treatment.
Hypermobile and compensatory varieties
do well with medial-arch raised shoe with
fi rm hee l counter, extended medial
counter and Thomas heel. Phys ical
therapy to strengthen muscles, reduces
pain which is due to foot strain.
• For anomalous anatomy, surgery may be
needed if conservative treatment fails to Fig . 3 .30 : AP view . X-ray foot showing acces·
relieve symptoms.
sory navicular.
HALLUX VALGUS
• Commonest foot deformity. Commonly bilateral and in the elderly (> 50 years) females.
th
• It is the lateral deviation of the 1st toe, often associated with deformity and symptoms 01 e
othe r toes.
• May be familial, especially when seen in adolescents.
Aetiology r·
shoe wea
• Barefooted and open-toe sandal wearing people seldom have ha/lux va/gus. ver, onlY
ing (especially shoes with narrow toe-box) induces valgus of the great toe . Howe
when it is "excessive", it is termed as hallux valgus. . 11()(1
. pred1spo51 t
• Varus angulat1on of the 1st metatarsal with "splaying" ot forefoot is a common MTP 101n
to lateral angulation of great toe. Sometimes there may be subluxat1on of the 1st
In advanced cases , corns, calluses and metatarsalgia are found. uscle t~
• Associated with rheumatoid arthritis, and also with elderly people with reduced rn
of the forefoot.
• I 1fflll did 111 I pl lflf l I 11,, II I I ti 1,t,11111111 /
111 11111 I ,I 11111 1111,11 • ,, 111111 ,, ,1111 1l'1,1,r1
1r11
/0111 1, d 1t1 II I/ii )I I I 111/111 l1 f 1111 lit1I tit,
pu•,I, 11111 11 11111111, , , 11,1 ,•,111 I/ l1n11 1 hi
fdY , 11111111 /1 111111 trl lt 11lt11 : IHl,11 ,1 ,,, 1111,
I · I M 11 ' /111111 tll , 111 1lrll,1 1l11 11,w •rt l', l/11
d1 loll illly II llf 11YI !If JII II rl I
,tho m 101r1y
I 011 11111 1 wld ll 1 I, 1111,n 11 1,d Wllh rri/1/J t,,l
lf, Vlnllcrn 111 tit, I •ii 11 1111 ti 11 •1 ,l (I lfJ 'l ': I )
• Lrowdl11q ol 11 1 ,1 1 tr,, , ll1J1 l1J ,,. ,, r,rl rJ;
VI t ltO Jl or '"" 11 11111/, ttl ,y ( )( , ( , lj(
• 1°1 1 111 1 I 11 ,11 1 1 1/ 111 >1 d jJ1tm il111 fll ,t

:,t 11 , dw lo 1r11 111 11 IH,r1,, lhlr,l<t r11r1q
Fig. 3.31 ; Hallux valgus . Notth t1u111on , nd hu r•, (l)llttl on) for, r11111,,,, t1bt1t rm1il
incroas d loraloot width.
joi nt nn JUI 1110 11.
• With increasing deformity, rn di I capsulo Is si r t 11 d nncl IOtl(J loncfon " ' 11 ,,, ll;1lltJ/ M''
shifted laterally, causing in-l ernal rotation (p ron ... tlon) of hullu.x, · o tfln t 11,,i rw ll point'., rm,<J,
ally and the abduc to r hallucis now lies below th rn ll1t·1r: ul ti, nd n.11.h<J r th11r1 rn, rJlr1I to 11,
Adductor hallucis, being now unopposed by th b hJ tor h~llu 1,, lnc n u tt11> v,,I JU, ,,>,
deformity. Fi nally fl exor hallucis bre vis, fle.xor h llucls longus, xl n or rwlluci', lo ngu ,
all contribute towa rd s increas ing th e va lgus, due to '1bow-strlng" ff 01.
• Derangeme nts may ultimately lead lo osteoarthritis (OA) of tho 1 t MTP Joint,
Clinically
• Most are asymptomatic with no comp lains excep t cosmes is. W orried p aront often brinQ
smiling adolescents as patients.
• Pain : May be due to bursitis (inflamed bunion) , or hammer toe or socondary osteoa rthritis
of the 1st MTP joint.
X-rays
Standing, weight bearing views are needed. In AP view, hallux ang le > 15"-20'•, and
intermetatarsal a ngle > 10° is diagnostic.
Treatment
. More than 130 operations have b ee n d esc ribe d in lite rature, which demonstrates that it
1
s a complex problem and no si ngle operation can b e unive rsa lly successfu l fo r al l patient s.
Surgery is only indicated in symptomatic patients, and also to prevent progressive worsen-
Ing of deformities. Names of some common op eration s are as follow s - Mcbrlde's
bunionectomy, Chevron 's osteotomy , Mltchell's o steotomy, WIison 's osteotomy ,
Keller's osteotomy, Arthrodesis, etc.
- - - --- -- -- ---r..:-,--- ·-•wr..,. ,w_______
ww ---
Section-V
X-RAYS
Theories Discussed
• Types o1 tracture • Greenstick fracture
• Clavicle fracture • Shoulder d1slocat1on - acute, recurrent
• Arthroscopy • Humeral Shaft fracture
• Olecranon fracture • Tension Band Wiring
• Radial head fracture • Radial neck fracture
• Essex-Lopresti fracture • Galeazzi fracture (Piedmont fracture)
• Scaphoid fracture • Bennett's fracture
• Rolando fracture • Femoral shaft fracture
• Patella fracture • Tibial shaft fracture
• Gustilo Andersons classification • Interlocking Nail
• External fixation • llizarov ring fixators
• 01stract1on osteogenes1s • Ankle fracture
• Maisonneuve fracture • Calcaneal fracture
• Jones fracture • Pathological fracture
• Rolando fracture • Femoral shaft fractu re
• Malunion • Avascular necrosis of femoral head
• Osgood-Schlatte r's disease • Johansson-Larsen disease
• Pell igrini-Steida disease • Sever's disease
• Spina bifida • Scoliosis
• Kyphosis • Scheurman's disease
• Ankylosing Spondylitis • Spondylolisthesis , Spondylolysis
• Spondylosis • Prolapsed lntervertebral Oise (slipped disc)
• Cauda equina syndrome • Osteogenesis lmperfecta
• Below knee amputation • Ewing's Sarcoma
• Simple bone cyst (unicameral bone cyst) • Fibrous Dysplasia
• Osteoid Osteoma • Compact Osteoma (ivory exostosis)
• Osteoblastoma • Ankylosis )
h
• Osteoarthritis knee • Charcot joint (neuropathic arthropal Y
• Developmental dysplasia of hip (DOH) • Ortolani's test Barlow's test
• Congenital pseudoarthrosis tibia • Congenital radial club hand
8 edicS•
• Plain ~-r~s remain the .si~gle most important investigation for diagnosis in orth 0 P
even 1n t~1s era of soph1st1cat~d and modern imaging techniques. . r:,.iwars
• Systematic, st~p-~y-step , meticulous obse rvation is the crux of X-ray reading.
hold (or place in vi ew-box) the X-ray film in anatomical position . hatJil·
• Firstly , stu_dying the soft-tissu~s, then the bones and fin ally the joints is an ~sefu'torei9n
(a) So!!-t,~ e-~ : Note swelling , wasting , density changes (e .g ., calcification),
bodi es, gas-bubbles (e.g., gas gangrene) .
(b) Bones : Trace the outlines from one end to the other _
2 14
X-RAYS 215
(i) Periosteum : Note new bone formation (e .g. , in osteomyelitis , osteosarcoma ,

healing ractures, callus , myositis ossificans) .
(ii) Cortex : Note break (e.g., fractures) , damage (e.g., giant-cell tumour) , deformities
(e.g., widening in Paget's disease or bowing in rickets, osteogenesis imperfecta ,
malunion, exostosis) .
(iii) Endosteum : Note whether sharp/prominent, or hazy/excavated (e.g., osteomyelitis).
(iv) Medutlary cavity : Look for density changes (e .g., rarefied in cysts, or increased
density in seques'frum) .
• If there is a fracture - note :
(1) Level : e.g ., middle/ upper/lower third fractures of long bones, or waist fractures of
scaphoid .
(2) Displacement : Note shift (translation) , tilt (angu lation) , twist (rotation), length (dis-
traction/ impaction) (Fig . 5.1 ).
I I
·.:I ·. i
Medial angulation Impaction Twist

Shift Distraction
/ Lateral tilt
Fig. 5 _1 : Schematic diagram of fracture displacement in fracture both-bone leg.
.
(3) F rac ture I me attern . T ra nsverse oblique, spiral, comminuted , segmental , bone-
p . ·
loss (Fig. 5.2).
(4) Intra-articular extension : Look for joint involvement.
Com minuted Segmental Bono·los

Oblique Spiral
. . of fracture line patterns in fracture humerus.
Fig .5 .2 : Schematic diagram
2·
. k f ures..... Found exclusively in chllgren who have thick periosteum and

(5) Green-st,c rac h th "f t " b
. - sticit of b-ones which tends to "buckle" bones , rat er an rac ure ones, caus.
high ela Y ' ing tilt or angulation, but never shift. It is
often an "incomplete" fracture. There is
no breach in the continuity ot the perios.
teum . The bone ts bent, "pfastically" miS:-
shapen , and usually no crack can be
identified in the X-rays (see fig. 5.3). It is
commonly seen in the forearms , and
sometimes in the legs , although it can
occur at many other sites. Tenderness
is the most important clinical findings, at
the fracture site, while deformity may be
evident on inspection . Conservative,
non-operative treatment by manipulation-
under-anaesthesia and plaster-cast irn-
Fig. 5 .3 : Green-stick fracture mob il ization heals most of the frac-
tures satisfactorily, because even if there is a malunion , remodel ling occurs appropri-
ately in children .
(6) Pathological fractures : See page 246 , 247 .
(c) Joints : Study the joint space, congruity and look for osteophytes, loose bodies.
• Two is better than one : Usefulness in X-rays
(1) Two views : e.g., Commonly AP and lateral; may be AP and oblique for foot or hand.
One view is often misleading because it gives only one dimensional picture.
(2) Two joints : X-ray films must include the joint above and below the bone being X·
rayed (especi ally important for forearm fractures , shaft femur fractures , ankle
fractures , etc .) .
(3) Two limbs : Contralateral limb X-ray of the same part and view is very useful in undisplaced
or minimally displaced fractures or early AVN, Perthes disease , Garden type I neck femur
fracture (e.g., for hip pathology , do X-ray of pelvis with both hips - AP) . .
(4) Two occasions : Repeating X-rays after 2- 3 weeks is often useful for fractures which
are not detected shortly after injury (e.g., scaphoid fracture) .
(5) Two injuries : Look for logically associated fractures which may be at a totally tar·
removed location e.g., if there is fracture calcaneum due to fall from height, there maY
be associated spinal fracture , hip fracture or pelvic fractures.
• Always ~erbal~y co.mmunicate X-r~ys, as if you are talking over telephone and the. listener
can entirely v1~ua.1tze the X-ray with closed eyes, without actually seeing the rad1ogr.aph.
• Start by mentioning the skel~tal maturity i_by noting the physis) , view (e.g., AP view)d
then t~e part _of th~ body b_e1ng ~een (e.g. , pelvis with both hips, hip with femur an
knee). tn the ftlm With the Side (rtght ?r left), before describing the main lesiO~ (e,gif
showing transverse fracture of the middle third of the shaft with lateral angulat1on~-
written you can also menti?n the name of the patient, date of X-ray , a~ i
• Some of the commonly given X-rays are included in this section with discus~ 10~
10
relevant features . However, remember - numerous oth X- n also be give
· t·
examma ton . er rays ca
CLAVICLE FRACTURE
/tBS
• On~ of the most common bo~es to fracture in children is the clavicle . It also ~
quickly an uneventful#~, without any functional -eo d ..;e
· I b · 'S' h d · h h · 1 par Y· ones
• -Clav1c e, emg -s ape , wit t e medial end convex f d d lateral end c it
. . b orwar an akes
forward -4 the 1unct1on etween the 2 parts occurs in the middle third -4 which m
susceptible to fracture . Also , the middle ·rd .
tachment distal to subclavius mu ~hi does ~ot have any muscle or ligament at-
t go1, of . sc 1e, which makes 1t extra vulnerable for traclure .
• Ab ou o c 1av1c 1e fractures have
other associated fractures ~ commonly
rib fractu re.
Mechanism of Injury
1. Fall onto the shoulder ~ about 87% .
2. Direct trauma to clavicle ~ about ?%.
3. Fall onto outstretched hand ~ about S%.
Clinicall y
• Patient usually presents with the affected
arm across chest (adducted) and the el-
bow supported by the contralateral hand
Fig . 5.4 : AP v iew X-ray of left shoulder, left
• Skin overly ing the fracture may b ·
clavicle and upper chest wall showing displaced
"tented " a~d a subc uta neous lum~ fracture of middle third of clavicle .
may be obvious. Very rarely , it may be
an open fracture~
• On palpation ~ tenderness , and crepi-
~ the fracture site , is found .
• Distal neurovascular examination is
essential. The chest should be auscul-
tated for symmetric breath sounds .
• The distal part is pulled down by the
delto id and pectoraITs muscles, whereas
the proximal portion is g_u lled up by
the sternomasto id , causing the typi -
cal displacement (Fig . 5.4) .
X-rays Fig. 5.5 : Post-operative X-ray of right clavicle
AP views are almost always enough to di- middle third fracture fixed with plate and
agnose clavicle fractures . screws - AP view .
Allman Classification
• Group I - Fracture Middle Third (80%).
• Group II - Fracture ~ Third (15%).
• Group Ill - Fracture Medial Third (5%).
Treatment
1 . Conservative : MOST FRACTU_BES CAN BE SllCCESSEllLLY TREATED NON-
0.f§_RATIVEL y by a simple collar-and-cj:!ff sling for 3- 4 weeks and then early shoul-
der mobilization exercises (especially tor old patients who might develop shoulder stiff-
ness). Figure-of-8 bandage do not have any special advantage.
2· Operative indications :
(a) Neurovascular involvement - Immediate intervention.
(b) Non-union - Most co mmon indication for operation.
(c) Fracture distal 1/3 rd with torn coracoclavicular ligament in an adult.
(d) Open fractures and fractures with "tented" skin , which have the potential of becom-
ing open fracture s, if the skin is torn .
(e) Floating shoulder injuries.
{f) Grossly displaced middle third fractures in young active adults. (see Fig . 5.4 and 5 .5)
218 HANDBOOK FOR ORTI-.OPA OICS EXAMINATION
Complications
. . . . b non-o erative management. Function remains excellent.
1. Ma/umon . I~ almos~ inev1tablem~on es~ecially in the elderly - physical therapy is useful.
2. Shoulder st,ffn~s~ · Not unco . · nc which requires immediate treatment.
3. Neurovascular tnJury : ~are. It is an en:ierge d ~ t rnal fixati on (ORIF - see fig. 5.5)
4 . Non-union : Rare. Requires open reduction an in e .
SHOULDER DISLOCATION
• Types : . to the num ber of ep1so

1 . According . des .. Acute and Recurrent dislocation .shoulder
. (RDS).
2. According to the d1rectJOn of dis-
loca tion : Anterior, e£sterior and
Multidirectional. -
• More than 90% are anterior dislocations.
• Shoulder is the most common joint to
d islocate {E_bout 45 % of all disloca-
tions) . This is attributed to the -
(a) Shallowness of the glenoid fossa in
relation to the humeral head.
(b) Enormous range of movemen t
that is permissible in the shoulder
joint.
(c) Ligamentous laxity or glenoid d~s-
plasia (when present) also contrib-
utes.
Fig. 5.6 : AP view X-ray of right shoulder and
upper chest wall showing subcoracoid • Occurs almost always in adults (very
variety of shou lder dislocation . very rarely in children) .
ANTERIOR DISLOCATION
Mechanism of Injury
1. Indirect trauma : Most common mechanism . When the shoulder is in abduction :n~
external rotation -) sudden severe extension causes anterior dislocation. Examp 1ud·
while standing in a speeding bus facing the driver, and holding the overhead rod, a 5 nd
den deceleration due to brakes being applied -) the body moves forward while th e hat r·
. produces sudden extension in an already abducted and .ex
holds on to the rod -) this e
h the
nally rotated shoulder. The same may happen with a fall on outstretched hand wit
shoulder abducted and externally rotated .
2 . Direct trauma : Anteriorly directed impact to the posterior part of shoulder. . r)
. . .
3. Convulsions or electr,c shock : Commonly causes posterior dislocation (rare ly anteno .
Clinically d and
• Patient typically supports the injured upper limb at the elbow with the opposite hane 'pain·
the shoulder is in a position of slight abduction and external rotation. There is se::; with a
The rounded , lateral shoulder bulge is lost, which looks flat and square toget
very prominent acromion. he ar(l'l·
• .
A bony spherical mass .1s palpated anteriorly, which moves with gentle rota t·10n of t et~rll.
• Due to p~in and .muscle spas~. the p~tient does not allow any movement 5 to be
ined , but 1t examined - adduction and internal rotation is lost. . noted·
• Axillary nerve sensation over the lateral part of deltoid (military-badge area) 15
• special tests :
(a) Hamilton's ruler test - Normally a
-
ruler placed on the lateral aspect of
th shoulder cannot touch the acro-
mion and the lateral condyle of the
humerus at the same time , due to th
deltoid bu lge. After an terior disloca-
tion of shoulde r, it is possible.
(b) Dugas test - Patient cannot touch
the opposite shoulder which requires
adduction and internal rotation . Subcoracoid Subgl enold
(c) Cal/aways test - Circumference of
the affected shoulder is increased in
comparison to the opposite shoulder.
Classification
Acco rding to the position of the humeral
head (Fig. 5.7) .
1. Subcoracoid .
2. Subglenoid .
3. Subclavicular. Subclav/cu/ar Jntralhoraclc
4. lntrathoracic . Fig. 5.7 : Types of anterior shoulder dislocation.
X-rays
1 . AP view : Shows overlapping of humeral head and the glenoid . Usually the head lies
medial and inferior to the glenoid .
True lateral-scapular view : X-ray beams are aimed along the spine of scapula. This
2. _
1s needed to differentiate between anterior and posterior dislocations (20°- 30° anterior
to coronal plane) .
3. Special views :
(a) Hill-Sach view - It is an AP view with maximum internal rotation of the shoulder
that is possible . Useful to detect H/11-Sach lesion ~ which is a defect/flattening/
excavation of the postero-lateral part of the humeral head , caused by impact with
the anterior margin of the glenoid.
(b) Stryker-Notch view - More effective in detecting Hill-Sach lesions.
(c) West-Point view - Taken with the patient in prone position . Useful to detect gle-
noid rim lesions , e.g . Bankart's lesion.
N.B.:
• MRI is indicated to detect Bankart's /es/on (it is a defect In the anterior part of the
glenoidal labrum and anterior capsule, which is torn/avulsed as the head dislocates) and
• rotator cuff injuries (common in the elde~ly). . ,,. . ..
CT scan is indicated to detect loose bodies, und1splaced 1mpress1on fractures and
Bony Bankart's lesion (anterior glenoid rim defects).
Treatment
hReduction under analgesic/sedative/anaesthetic cover ~ maintain reduction In arm -to-
~e~st ban?~ge for 3 weeks ~ then active, approp_riate, ra~ge-of-movement exercises un-
Pos:ehab1lltation programme . For the elderly patients , this must be started as soon as
Fi Ible (about 15 days) .
8 ducti
M on Techniques
any have been described . Some commonly pract1~ed m~thods a~e -
1, Hippocratic method : When no assistant 1s available, this method is very useful.
Surgeon places one foot across the axillary folds on to the chest wall , while exerting
r
'2 - HANDBOOK FOR OR HOPAEDICS EXA 11NAT10
steady, axial and manual traction to the slightly abducted arm . Looks very crude , but
is very effective. . o
2. Kocher's method : To the slightly abducted arm , elbowt· is b(:t t_o ~ho • kth en traction
is given , followed by gen tle and gradual externa( rot_
a ion is is . e ey manoeu.
vre) to about 80°, then adduction and lastly. med!al (internal) rotation . [~n~monlc :
Tr.E.Ad.-Me]. In osteoporotic bones, there 1s a risk of fracture, so caution 1s advis-
able in the elderly patients . .
3. Stimson 's (gravity) method : Sedated patient lies prone, with the affe~ted arm hang.
ing free and a Sib we ight hanging from the wrist. ~~kes abo~~ 2?,- 30 minutes.
4. Saha 's method : Taking the shoulder gently to the Zero position (where the sum total
of all the muscle forces acting from various directions becomes zero) - reduction is
achieved very easily.
Comp Iications
1. Recurrent dislocation shoulder (RDS) is the most common complication.
2. Axillary nerve injury : Neuropraxia. Usually recovers spontaneously and completely.
3. Fracture-Dislocation : If there is fracture of greater tuberosity of humerus, it usually falls
into place after successful reduction. Other fractures might require operative intervention.
4. Shoulder stiffness : Very common in patients aged > 40 years. Physicaltherapy and
exercises are required, keeping in mind that full abduction can return only after full
external rotation has been achieved.
5. Unreduced dislocation : Rare. Prognosis is guarded.
RECURRENT DISLOCATION SHOULDER (RDS)
• When an anterior dislocation tears only the capsule, complete healing is the expected
outcome. But if the glenoidal labrum is detached (Bankart's lesion) , repair is unlikely.
This happens most commonly in young patients (80% to 90% at about 20 years).
• Bankart's lesion , Hill-Sach lesion and defect of the anterior rim of glenoid are bracketed
together as essential lesions for recurrent dislocation shoulder.
• Incidence is unrelated to the type or length of post-reduction immobilization after the
first episode. Patient's activity is however an independent factor for developing RDS.
• Most recurrences occur within the first 2 years of the first episode. Common in males.
Subgroups (Masten)
1. TUBS : ~raumatic, ~nilater~I,_Ban_kart's lesion (present), Surgery (is required) .
2 . ~MBR/1 . Atrau~at1c , M~lt1direct1onal , Bilateral , (responds to) Rehabilitation, lnfe·
rior-Capsular-Sh1ft-operat1on 1s useful (if operat·
· i on ·1s require
. d) , .in t erva 1 ( ro tator) clo·
sure may b e d one.
Clinically
1 . Exclude general ligamentous laxity (as in Marfan' d CP . · ts thumb,
s syn rome) ~ test M Join ,
pes planus, elbow hyperextension, etc. (see page 31 )
2. Test the - ·
(a) Power of deltoid muscle, and also the external a d . t f houtder.
(b) Axillary nerve _ Sensory and motor. n m erna I rotators o s
3. Apprehension test : With patient supine with the sh . ·de of the bed,
bring the arm at 300 450 900 1200 f . oulder hanging by the s1 t('f to
· , , o abduction~ pati t f 1 · e and rnaY
resist abduction. (see page 42) If . en ee s msecur fof1 bY
. apprehension test is neg f d th 8 augments ' s
trying to forcefully push the humeral head ante . a ive O rtorrn Joi>'
1
Relocation Test - when a posteriorly directe~1ofr Y. If _the he~d moves out pe al head ,ne
orce 1s applied to the humer
head reduces, an d w hen the force is released pat· f .
tent eels pam.
4. Load shift test : With th e patient up rig ht, axial compress ion is applied to the humeru s
(load) foll owed by altern ate anterior and posterior shift of the hum eral head by holding the
humeral head.
5 . Anterior/posterior drawer sign : To detect anterior/posterior stability.
x-rays
• Lo ok tor Hi ll -Sach and Banka rt' s lesion and al so ante rior gl enoid rim d e fects in the
West-Poin t view , Stryker-Notch view, Hill-Sach view , AP and lateral view s .
• AR THROGRAM may be usefu l to detect rota tor cuff injuri es .
N.B. : MRI and CT scan may be indicated for reasons mentio ned before (See page 219).
Treatment
Surgery is indicated for patie nts having ~ 3 episodes , especially for the TUBS s ubgro up .
Numerous operations have been described and recommended . Some commonly done pro-
cedures are -
1. Bankart operation : Glenoidal labrum and the torn capsule is reattached . Useful when
bony defect is less than 30%. May be done arthroscopically .
2. Latterjet operation : When there is bony Bankart defect of more than 30% .
3. Magnuson-Stack operation : Detaching the subscapularis and capsule , and reattach-
ing them more laterally. Abduction and external rotation are comprom ised .
4. Boytchev's operation : Re-routing of coracobrachialis and the short head of biceps from
over the subscapularis to under the subscapularis ~ thus making subscapularis taut.
5. Putti-Platt operation : Dividing , then double-breasting the subscapularis muscle .
External rotation is reduced post-operatively.
ARTHROSCOPY
• Commonly performed minimally invasive procedure, where instruments are introduced
into joints through very small incisions, enabling "key-hole" surgery.
• Knee is the most common joint where arthroscopy is done, followed by the shoulder,
but ankle , hip, wrist and elbow joints are all amenable to arthroscopy .
• Useful for diagnostic, and also for treatment of various cond itions e.g ., men iscec-
tomy, meniscal repair, anterior cruciate ligament reconstruction , foreign body/ loose
P body removal, synovectomy, Bankart lesion repair , rotator-cuff injury repair etc .
rocedure : Tourniquet is used for most cases . The arthroscope consists of rod-lens
sy st em (Which magnifies the image) , a solid-state camera (which improves resolution
:i~d Colo~r) and a fibre-optic light source . The ca~er~ transmits the picture t? a tel~vi-
n monitor. The joint is continuously irrigated (with ringer lactate/ normal saline) which
:~i~ures cl~ar vision, and joint-distension with the fluid is ~elpful f~r haemost~s is . One
tio Portal 1s used for the arthroscope , while another (sometimes 2) 1s used for mtroduc-
Clo~;~ other operating instruments like the probe . After the procedure , skin incisions are
DI by 1 or 2 stitches and the patient may go home the same day (Day Care surgery) .
sad" , .
dime ~ntages : Steep learning curve : Since arthroscope provides mono-ocular and 2
ellpe ~siona1 vision depth perception is difficult. Skill only comes by extensive practice and
4 rience . '
d\'anta e '.which takes long time . . . .. .
9 s · 1. Low morbidity : Reduces post-operative pain, en~ur~s ~~1ck rehab1htat1on .
2 . Cosmesls : No ugly scars , due to very small ~krn _rnc1s1ons .
3. Cost-effective : Less hospital stay, less comphcat1ons and. t~us. less cost.
4 - More accuracy : Structures can be seen (even when the Joint 1s moving)
and "palpated" by probe (most commonly used arthroscopic instrument)
and biopsied .
Complications : 1. Haemarthrosis .
2. Infection.
3. Thromboembolic disease .
4. Damage to intra-articular structures.
Contraindication
1. Risk of septic arthritis due to local skin condition, or a remote infecti ve focu s.
2. Ankylosis is a relative contraindication .
N.B. • "Empty fossa" sign , "Cyclops" sign are found in AGL injuri~s: " ~rive-through"
sign in PLC injury of knee and "Sourcil" sign in rotator-cuff inJunes.
-
HUMERAL SHAFT FRACTURE
• The cross -sectio n of the humeral shaft gradually changes from circular proximally
to antero-posteriorly flatte ned distally .
• Humerus is well covered by muscles,
which ensures good vascularity , and
thus helps in union. Also , muscles hide
any deformity which may result from
malunion .
• Radial nerve lies in very close proximity
of the shaft, making it liable to injury.
Mechanism of Injury
• Direct : Common . Usual ly transverse ,
short oblique or comminuted fractures.
• Indirect : Fall on outstretched arm re-
sults in spiral or long oblique fractures .
Clinically
Patient presents with pain, swelling, defor- Fig. 5 .8 : AP view of X-ray of humerus and shoulder
mity. There is tenderness, crepitus and ab- showing transverse fracture shaft of humerus in the
normal movements at the fracture site. Radial middle third. with lateral angulation and shift.
nerve must be examined for neurodeficit.
X-rays
AP and lateral views including shoulder and
elbow joint is needed.
Treatment
More than 90% fractures unite without
surgery. If there is malunion , then 20°-300
angulation and up to 3 cm shortening is ac-
ceptable . Muscle bulk hides the deformity .
A. Conservative :
1. Ha':ging-~rm Cast : Suitable for long
ob_l1.que/sp1ral fractures with shortening.
Ut1l.1zes gravitational force whereby the
weight of the cast provides traction.
Relative contraindication is a trans- Fig . 5 . 9 · X -ray of middle third humeral sha ft
fracture being treated w ith U-sla b.
p ,
X-RAYS 223
verse or sh ort obliq ue fractures , which may end up in non-union due to distraction .
patient must be upright or semi-upright for this principle to work (must sleep propped-
up) (see fig. 5 .10).
2 . U-slab or Coaptation Splint : Indicated for transverse and short oblique frac-
tu res with minimal shortening . Additionally collar-a nd-cuff sling is used some -
tim es with a rm to chest bandage . Gravitational force is also used here , but with-
out the additional weight of the plaster cast , which reduces the chance of d istrac-
tion . Slab is applied from the root of neck ~ across lateral arm ~ around elbow
~ up across medial arm ~ to the axilla (see fig . 5 .10) .
3 . Functional Cast Bracing (FCB) : Util izes the effect of soft-tissue (muscles) com·
pression by " Hoop-Stress " to maintain fracture alignment, at the same time al-
lowi ng elbow motion . An anterior and posterior "shell" is held together with velcro
strap s, which are tightened daily. Often , hanging-arm cast or coaptation splint is
changed to cast bracing after about 3 weeks . (see page 95 for FCB in Tibia) .
4. Shoulder Spica Cast : It plays a
very limited role because indicated
patients for this method do very well
with surgery . The arm is kept ab -
ducted , thus eliminating gravity in-
duced distraction .
B. Operative :
• Indications -
1. Segmental fractures .
2. Pathological fractures (see page 246).
3. Holstein-Lewis fracture (see page 95).
4. Where associated injuries compel bed-
rest i.e., upright position is not feasible.
5. Where acceptable alignment is not
achieved with conservative measures.
(a) Coaptation splint •
(b) Hanging-arm cas t
Fig. 5 .10
6. Fractures associated with vascular
injuries.
N . . alsy and the plan of management is operative then
.8. • When there rs radial _ne~ve P 51
·ttin must be done.
radial nerve exploration in the same g
• Methods -
. . (ORIF) using plate and screws.
1- Open reduction internal fixation · 1 d reduct,·on tech-
by open reduction or c ose
2 - Interlocking nails (ILN) - may be d one
nique (see page 239) .
Cornplications . .
1 R ·n middle third fractures. The lesion 1s
· Bdia/ nerve injury (Nearly 18%) : Com~ont'~n returns by 3-4 months . NCV has to
1
~europraxia or axonotmesis, and usu~lly un~ tracture - page 95) .
e done at about 3 weeks (see Holstein Lewis erse fractures soft-tissue inter-
2. Non . . t are ~ transv , .. .
. -union (Nearly 15%) : Risk tac ors . and inadequate immob1lrzat1on .
Posrtio . d. t I third fractures ,
3 n, distraction, proximal or rs a be injured .
Vascular injury : Rare but serious . Brachial artery may
224 IION
OLECRANON FRACTU E
• The olecranon ts vu lnerable to rracture because of its subcutaneous location . It is
relatively uncommon in the younger population and rare in children .
Mechanism of Injury
o;rect trauma (may be due to a simple fall on the point of elbow) is a common cause of
olecranon fracture , especially in the elderly patients.
• In the younger population (although uncommon) , indirect trauma is the cause where
a fall on a partially tlexed elbow with strong and sudden contracti on of th e triceps
muscle results in an avulsion fracture of the oclecranon .
• Very high velocity trauma (e.g., road traffic accidents , gunshot injuries) prod uces com-
plex fracture patterns, which are often a combination of both the above mechanisms.
Clinically
• Patients typically present the affected upper extre mity supported by the contralat-
eral hand, with the elbow in slight f lexion . The elbow is swollen , and the re may be
abrasions .
• There is tenderness at the fracture site,

and a 'gap' is often palpated over the
subcutaneous olec ranon. Crepitus may
be present.
• Inability to extend the elbow actively
against gravity demonstrates discontinu-
ity of the triceps extensor mechanism.
X-ray
• True lateral X-ray is essenti al to show
comminution , the degree of articular sur-
face involvement and radial head dis·
placement (if any) .
Fig. 5.11 : X-ray of elbow - AP and Lat. view • AP view is needed mainly to exclude as-
showing fracture olecranon .
sociated fractures or dislocations.
Classification (Fig. 5.12)

• Type 1 ~ Proximal third fractures.
• Type 2 ~ Middle third fractures.
• Type 3 ~ Distal third fractures.
Treatment Objectives
1 . Restoring :
Type 1 Type 2 Type 3
(a) Articular surface .
Fig . 5.12 : Classification of olecranon fractures . (b) Elbow extensor mechanism.
2. Preventing :
(a) Elbow stiffness, i.e. ensuring full range of movement.
(b) Complications.
X- RAY S 225
Treatment
, Non-operative ·
1. Indicated for -
(a) Non -dis placed fractures t hat
does not separate wit h elbow
flexion to 90°.
(b) Disp !ac_ed fractures in poorly
functioning old patients.
2. Long arm plaster cast at about 45° to
60° flexion is kept for 2 to 3 weeks
then active and assisted exercise~
are started. Follow-up X-ray is done
at 7 to 15 days to exclude late frac-
Fig . 5 . 13 : Post-operative X-ray after T B W for
ture displacement.
olecranon fracture - AP and Lat. view .
• Operative :
1. Tension Band Wiring (TBW) : Commonly done procedure (see below).

2. lntramedullary screw fixation using 6.5 mm cancellous lag screw.
3. Comb ination of both TBW and screw fixation .
4 . Plate and screw fixation - Indicated where there is comminution and bone loss.
5. Excision of proxi mal fragment and suturing the triceps to the distal fragmen t -
(a) Done only when enough olecranon portion is left to form stable base for trochlea.
(b) Up to 80% of olecranon can be excised without appreciably affecting the stabil-
ity of th e elbow joint.
(c) Advantages ~ No chance of non-union or arthritis . Disadvantage - j the elbow
becomes less efficient.
Indications for excision of proximal fragment : Not indicated for fractures extending up to
the coronoid. . I
.
( 1) Severely comminuted fractures ,
Eccentric
loading
'f i
where other fixation techniques
are impossible .
(ii) Non-articular fractures .
(iii) Failed cases of open reduction inter-
nal fixation (ORIF).
Tensile
(iv) Non-unions.
surface
(v) Type Ill (Gustilo-Anderson) open kept
fractures (see page 237). fixed.
CornPllcations
1
· Non-union compressive~
2· Red · m surface
Tensile
uced range-of-motion. Most co -
rnonly elbow extension is reduced .
3
· Subcutaneous location of the hardware
used ·
etc in operation (e.g., 'k' wires, screws, (b )
(a)
4 P .) rnay cause pain .
· tho~t-traumatic humeroulnar osteoar - Fig. 5 .14 : Principle of TB W.
r1ti s .
When wire is used for internal fixation of tr.i t11t ·,. n t it wir e is applied on the tension
surface of the bone , the procedure is called 1 W
Working Principle of TB W .
• When a fra cture d bo ne is centrally
loaded, the re is uniform compres -
sJOn at fracture site, but if it is ec-
ce ntrica lly loaded , the n there is dis-
tract ion on t he tensile su rface . [Fig .
5.14- (a)] .
• If the tensi le surface is kept fixed , the
eccentric force cannot open up the
(b) ( c) fracture , and the distracting tens ile
force is changed to compressive force.
( I)
[Fig . 5.14-(b)].
Fractures that can be fixed by TBW.
Fractures of patella, olecranon , medial
and lateral malleolar fractures of ankle ,
fracture greater tuberosity humerus. Also
fracture lateral end of clavicle , metacarpal
(diaphyseal) fractures , greater trochanter
of femur can be fixed by TBW.
Pre-requisites
(a) (b) (c) 1. Bony cortex on the compressive side
( 11 ) must be sufficiently strong to withstand
Fig. 5.15 : In knee (I) or olecranon (II). Fractures ~ the compressive loads generated, oth-
(a) , flexion of knee or elbow joint, causes opening erwise it may cause comminution and
up of fractures~ (b) . TBW causes dynamic com- thus fixation failure . The fracture
pression at the fracture site ~ (c) . should be nearly perpendicular to the
plane of motion of the nearby joint.
2. The wire used must be strong enough to
withstand the distracting tensile forces,
otherwise it may cause wire breakage
and implant failure.
3. Adjoining joint movement must be en-
couraged very early after operation for ef-
fective compression at the fracture site.
4. Prestressing (tightening) the wire is a
must [which tends to open up the fr~c -
tu re at the compress ion side (fig .
5.16)], so that the bone remains loaded
in static compress ion .
5 · 'K' wires are commonly used as an ad·
juvant implant, which prevents fractur~
translation, shearing , rotation. and pro
Fig . 5.16 : Prestressing of the tension band. vides anchorage points for the wire.
X-RAYS 227
Advantages
1. Minimal implant material is used to achieve excellent fracture fixation .
2. Provides dynamic compression at fracture site .
3. Minimal post-operative immobilization is requ ired and at a low cost.
complications
1. Subcutaneously placed wires may cause wire prominence , skin irritation , pain and even
skin breakdown .
2. Wire may break early or may get cut-out from bone.
3. Needs second operation for implant removal.
RADIAL HEAD FRACTURE

• Radial head provides stability in valgus-stress of elbow. It becomes most important
when there is simultaneous inju ry to the interosseous membrane and the ligaments ,
and the muscle tendon units around the elbow.
• Proximal migration of the radius can oc-
cur after e xcisi on of rad ial head. So
avoid excision of radial head before
skeletal maturity, which may cause
cubitus valgus , radio-ulnar synosto-
sis , radial deviation of hand, etc.
• Radial head fractures are found almost
always in adults, and never in chil-
dren (may be because it is cartilagi-
nous in children) .
Mechanism of Injury
1. Fall on outstretched hand.
2. Associated with Monteggia fractures
(posterior type) and ligamentous inju-
ries, but very rarely associated with Fig . 5.17 : AP vi ew X-ray of elbow showing
capitulum fractures. minim ally di sp laced radial head fracture .
Clinlcally
1 · Mild pain/swelling ~ often a missed diagnosis. . . .
2 · . d noted which i with passive pronat1on/supinat1on.
· Direct tenderness over radial hea ' t Essex Lopresti fracture see
3 Al d. t I forearm (to rue
1 ou - •
· ways palpate wrist and is a f edial collateral liga me nt of elbow with
Page 228), and note the competence O m
Valgus stress test.
ray8
.
AP view· . (n eutral rotation forearm , X-ray beam directed
Lateral view· Greenspan view
45° . .
cephalad). elude DRUJ (Distal Radio-Ulnar Joint) injury .
ray of the wrist is always done to ex
Clas i ,cation (Fig . 5. 18)
I. Non displaced.
11 . Marginal with displacement.
Ill. Comminuted.
IV . Associated elbow dislocation .
Treatment according to classification
II Il l IV
• I ~ Non-operative : Collar-and_-cuff sling Fi . 5 _1 8 : Classification of radial head fracture.
+ early movements + analgesics. 9
• II ~ Intra-articular lidnocai ne injection ~ note range of motion . If nearly full ROM ~
treat as in I. If ROM ..1, then ORI F with a screw ± T-plate . . .
• Ill ~ Excision of radial head. Metal prosthesis is sometimes used afte r excision.
• IV ~ Elbow dislocation red uction is done. Then fracture is treated , as above .
Complications
1 . Joint stiffness of elbow and limitation of pronation/supination .
2. DRUJ injury with wrist pain .
3. Post-traumatic osteoarthritis due to articular incongruity.
RADIAL NECK FRACTURE
• Common in children, not in adults . Most are Salter-Harris IV injuries. (see page 66)
• Mechan ism of injury ~ Same as tor radial head fractures .
• Up to 30 °-40° angulation of head is
acceptable ~ only treatment required is
collar-and-cuff sling and early movement
from 2- 3 weeks.
• > 45° angulation ~ Manipulation under
anaesthesia to bring angle to 30°- 45° ~
then collar-and -cuff sling .
• If manipulation fails to achieve accept-
able angulation ~ Open reduction.
• Complications of ORIF ~ Stiffness, pre-
mature physeal closure , non-union and
Fig . 5 .19 : Angulation of head after fracture avascular necrosis of radial head, radio·
neck radius . ulnar synostosis , myositis ossificans.
ESSEX-LOPRESTI FRACTURE
• Longitudinal disruption of forearm interosseous membrane + radial head fracture + distal
radio-ulnar joint (DRUJ) injury.
• W_rist pain is _the most important and significant sign. Very oft en a missed diagno·
s,s. Lateral view X-ray of the wrist is a must.
• Never excise the radial head , if there is DRUJ injury.
GALEAZZI FRACTURE (PIEDMONT FRACTURE)

• G~leazzi fr~cture is the f~acture of radial diaphysis at the junction of middle and distal 3rd,
with associated subluxat1on or dislocation of the DRUJ It . . ommon than
Monteggia fracture. · 15 3 times more c
• Fo r all di stal 1/ 3rd radial fractures , suspect involvement of the distal radio-ulnar
jo int (DRUJ) until proved otherwise .
• It is a "Fracture of Necessity" because it always requires "Open reduction and internal
fix ati o n" (O RIF) . Non-operative treatment results in loss of re duction , with the chief
defo rming fo rces coming from pronator quadratus , brach ioradialis , extensor pollicis lon -
gus , abdu ctor pollicis longus and the weight of the hand .
Note: • Reverse Galeazzi fracture~ fracture of distal ulna with disruption of the DRUJ .
• Night stick fracture ~ isolated ulnar-shaft fracture, usually due to a direct blow .
Mechanism of Injury
1. Fall on outstretched hand with pronated forearm .
2. Direct trauma on dorso-lateral aspect of the wrist.
Clinically
Pain , swel ling of mid-forearm . The pain i
with stress ing of th e DRUJ . Prominence of
distal ulna is striking .
X-rays
Radius is angu lated dorsally + Signs of
DRUJ injury which are -
1. Fracture ulnar stylo id .
2. Widened DRUJ on AP view. (Fig 5.20)
3 . Subluxated ulnar head on lateral view.
4. > 5 mm shortening . (see Fig 5.21 )
Fig. 5 .20 : AP view X-ray of wrist and lower
Treatment forearm show ing G aleazzi fracture .
No te : widened DRUJ
Open reduction and internal fixation (ORIF)
With plate and screws ~ at least 3 screws on
either side of fracture ~ X-ray (or C-arm)
evaluation to note DRUJ reduct ion . If reduced
~ PQp cast for 6 weeks . If subluxated , it
mu st be reduced and 'k' wire fixati on is don e,
Which ·18
kept for 6- 8 weeks .
Cornp1 icati ons
,. Ma/union ~ Results in loss of prona -
tion/supination . Rarely , may cause re-
current dislocation of DRUJ .
2 Fig . 5.21 : Lat. view X-ray of wrist and lowe r
· IV 0 n-un; after forearm showing Galeazzi fracture .
ORIF R on . ~ Very unc?mmon
· equ1res bone grafting. Not e : subluxated ulnar head
SCAPHOID FRACTURE
• It is th
• M e most common fracture of the carpal bones .
0st
commonly occ urs in young adults (NOT in children or the elderly) .
230 HANDBOOK FOR 1
• Mechan ism of Injury : Fall on outstretched hands, with hyp rexte nd ed elbow and radial
deviation of wrist.
N.B. • Scaphoid moves with nearly all carpal motions especially volar flexion .
• 80% of the scaph oid is covered with articular car1ilage (hen~e d~ not have soft
tissue attach ments, which is vital for vascularity) because it articulates with 4
bon es - radius, lunate, trapezium and trapezoid .
• Vascular supply (Fig. 5.22) : Majority (70%) is from the do rsal branch of radial
artery which enters the proximal pole of scaph oid vi a the dorsal inte rcarpa l liga-
ment through the dorsal ridge . The distal pole has minor vascu l ar s upply (20%-
30% ) entering through the tubercle from volar branch of rad ial artery. Thus
proximal fractures have a very high possibility of avascular necrosis and non-union.
Tuberosity and distal fractures usually unite , and about 80% of w aist fractures also
unite .
Location of Fracture (Fig. 5.23)

• Most common is the waist (60% to 80%) . Least common : Proximal pole.
Diagnosis
Delayed d iagnosi s is common , wh ich
delays treatment and wo rs ens prognosis.
• Clinically :
1. Anatomical snufi- box fullness , and
tenderness .
2. Watson test - Pain with dorsal dis-
placement, as the pronated wrist is
moved from ulnar to radial deviation
Fig. 5 .22: (see page 72) simultaneously flexing
the wrist and applying dorsally di·
rected pressure over the scaphoid.
• Radiological :
1 . Postero-anterior view X -ray , with
the hand clenched in a fist (to ex·
tend the scaphoid) and the wrist in
ulnar deviation . Lateral view, to·
gether with radial oblique and ulnar
oblique views are also essential , be·
cause diagnosis is often missed .
Fig. 5 .2 3 : Locations of scaphoid fracture .
25% to 30% fractures may not be
obvious in initial X-rays.
2 . MRI may be very useful fo~ early diagnosis (by 3,d day) . Gadolinium enhanced MRI
detects vascular compromise .
99
3 . C T Scan , Tc bone scan (see page 251) • are also useful for earIy d'1agnos1s.
·
Treatment
I. For young adults with history of fall on outstretched hands foll d b · t ain/discorn·
'ff / 11· d h . , owe y wns p
f o rt/ st1 ness swe ing an aving tenderness of anatomical sn f f-b BUT no evidence
of fracture in X -rays ~ Thumb Spica scaphoid cast immobi~zati: · for 2- 3 weeks ~
repeat X-ray , to look for fracture (often resorption of fracture end makes t he occult
fracture visible after 2- 3 weeks) .
X·AAYS 23 1
Fig . 5 .24 : AP view X-rays of wrist sh owing scaphoid fracture a t wa ist.
• If no fracture seen ~ no active treatment.

•If fracture is seen -
(a) Undisplaced, or displaced < 1 mm; continue cast immobilization for 12 weeks.
(b) If d isplaced > 1 mm , scapholunate angle > 60 °, radiolunate angle > 15 °,
then operation is indicated (open reduction internal fixation and bone grafting).
II. When fracture is seen in the initial X-ray, same protocol as above is followed.
Complications and their treatment
1. Osteonecrosis (A vascular necrosis, Preiser's disease) : Common in proximal 3rd
fractures . Nearly 40% incidence. Treatment options are operation ~ rad ial
styloidectomy + excision of the proximal avascular fragment.
2· Non-union : Established non-unions have Humpback deformity and Dorsal intercalated
segmental instability (DISI). Treatment options are -
1. For young : Herbert screw fixation and bone grafting/vascular bone grafting.
2. For old patients with minimal symptoms : Radial styloidectomy or no treatment.
3· Osteoarthritis of wrist : Treatment -
1. If localized : Radial styloidectomy. .
2. If majority of radiocarpal joint is involved : Arthrodes1s.
Extent
T of Scaphoid "Thumb spica" Plaster Cast
here are 2 views.
1· Munster cast : From just below the elbow p_rox_;mally. to the _ba.se of thumb nail and
proximal palmar crease distally, with the wrist 1n radial dev1at1on and neutral flex -
ion, and the thumb in functional position.
2. Long arm : Above elbow proximally to the same extent distally.
N.e•• If the long arm cast is used, then it is kept for first six weeks, after which it is
changed to the Munster cast. .
• Long arm cast, often gives better end results - more union rates and less os-
teonecrosis.
FIRS METACARPAL BA E FRACTU ES
• There are 2 well known types : Ben nett's rracture (partial intra-articu lar involvement) and
Rolando fracture (complete intra -articular
2nd meta carpal
involvement) .
1. Bennett's fracture
• First descri bed in 1882 by Irish surgeon
Bennett.
• It is an intra-articular fracture through the
base of the first metacarpal. (see Fig.
5.25)
APL attach men t
Bio-mechanics
Fig . 5.25 : Bene tt's frac ture
• The metacarpal shaft is pu ll ed proxi mally
and laterally by unopposed pull of the abductor pollicis longus (APL) , while the distal metac-
arpal is supinated and adducted by the adductor pollicis.
• Reducti on by tracti on and manipulation is easy , but maintaining the reduction is difficult.
It is not ad visable to attempt reduction after 6 weeks from injury, because of poor results.
Treatment
1. Closed reducti on and percutaneous 'K' wire fixation is best , when poss.ible. Otherwise
open reducti on and internal fixation (ORIF) by 'K' wire may be requ ired .
2 . Plaster cast immob ilization is rarely successful in maintaining the reduction , bu t up to
3 mm of incongru ity can be acceptable .
Complication
Malun ion is common when treatment is non-surgical , which often leads to painful osteoar-
thritis of the 1st carpo metacarpal joint. It is best treated with arthrodesis.
2. Rolando fracture
• First described in 1910.
• It is a 'Y' or T - shaped comminuted
fracture of the base of the 1st metacar-
pal. Usually it never causes displace-
ment of the metacarpal shaft.
• Treatment is always surgery . Most can
be succesfully treated with closed re·
duction and percutaneous internal h a·
tion with 'K' wires. If closed reducuo~
fails , open reduction internal fi atrot
Fig. 5.26 : Rolando fracture (ORIF) will be required .
FEMORAL SHAFT FRACTURE

. · f . becau
• It 1s one of the most common ractures . It needs urgent and serious attention
there may be blood loss from 1L to 2L, which may lead to shock. 111 1
• Femur being the heav(e~t, largest and the main load-bearing bone , femur fractures
cause prolonged morb1d1ty and severe disability.
O
• Thick thigh musculature envelopes the bone, which is protective but when fracture c •
it results in wide displacements (due to deforming muscle forces) .
X f AYS 23
Mechani n of Injury
• In young adults - high v loc ity traum Ilk r d trutrl uccld nl (n I A) or I ,II from h 10111.
• In elderly pa tients, suspect pathologlcal tr ctur unt I prov d oth r'Wl
clinicall y
• Patient cannot walk/st nd ; th er is gro thigh w lllnc nd cJ lorml ry, wl ll1 ,llort· n cl nnd
externally rotated leg . Often pali nl pr ents with shock, th I for r gul II rnonllorlnc ol
pulse, blood pressure and sensorium I mu 1.
• Examination of the ipsilateral hip and knee is Import nl N rly r.:0% ,n, y 111v or
hip injuries.
• Do not forget to exami n e the abdom n, ch st, p lvi s, spin n I oth r l lmlJ' for an y
polyt rauma patient.
X-rays
1. AP and lateral vi ew of the femur includ-
ing the hip and knee.
2 . AP view of pelvis with both hips is
mandatory.
Treatment
• Emergency : Treatment for shoc k is
essential . Thomas splint is useful
while resuscitation or during p a ti e nt
transport (see page 19 1 ) .
• Definitive :
1. lntramedullary interlocking nails (ILN
- see page 239) is the treatmenl of
choice for mos t adults, the elderly
and also for pathological fractures .
(see pag e 246, 247) .
AP-mid h,dl, florl-obllqu Loi low1 r 11-J rel, Ion • l)llquo
2. Early reduction a nd internal fixation
Fig . 5 .2/ : roc l lJ1 tw it t mur
is important for patients with associ~
ated inju ries.
3. Besides ILN other methods of inte rnal fixation ,nc_ l ud
(especia lly f~r distal 1/3rd fractures) and 'K' n ii llxat,on (
4. For open fractures external fixation (see page 240) is u ful but 11 h llrnlt cJ ro l a
• t. ILN is also use ruI for O p n fractu r ' ·
a defini tive treatmen
188, 18<)
5 . Skeletal traction is only used temporarily for patien t t· blliLatlon. (
Complications
1
· Shock : Most patients need blood tranSfuSion .
2 F t h 1ae a r
· at embolism : Dy spnoea, tachycardia , pe ec Important f ;lluri n p< r1t1 J
observations at short time- intervals are necessary .
3 . Va · omerg ncy d m ndtn<J mJ nt c,p mtlv 1n1r 1-
scu/ar injury : Uncommon , but ti ts an
vention .
4. ltJfect;on : Rare in closed fractures Common ,n open fraclur
5. Afatunfon · C ommon Iy occu rs w,th conservative !realm nt.
-
FOR ORTHOP EDIGS E !NATION
FEMORAL SHAFT FRACTUR E IN CHI LDREN

Counselling of parents 1s most important, because slight malunion and shortening is ac-
cepted, and often there 1s compensatory growth, which ultimately equalizes the limb length.
• In a child < 2 years, consider Battered Baby Syndrome or child abuse, especially if there
are arious fractures in different stages of healing .
• Pathological fractures may be found in child with osteogenesis imperfecta, bone cysts, etc.
Trea ment
Options and modalities are changing . Conventionally "Gallows traction " was used for
children < 2 years , and surface traction followed by hip spica cast for child > 2 years.
Contemporary treatment options are -
Fig . 5 .28 : AP vi ew X- ray of pelvis with both hips Fig . 5.29 : AP and Lat. view X-ray of fracture shaft
and right femu r a nd kn ee s how in g spiral fracture femur treated with TENS.
of middle thi rd of right femoral shaft.
1. Age < 6 months : Pavlik harness or posterior splint. Up to 30° angulation , 15 mm shorten-
ing is acceptable .
2. Age 6 months to 6 years : Immediate hip spica if angulation is within 15° in AP view, 20°
in l'a teral view and there is $; 2 cm shortening (which are acceptable) . Otherwise, surface
traction is given for 3 weeks until acceptable alignment is reached , then hip spica is done.
3. Age 6 years to 12 years : Flexible intramedullary nails (e.g., Titanium Elastic Nail i.e.,
TEN) are introduced retrogradely, avoiding the physis (Fig . 5.29) .
4 . Ag·e 12 years to 16 years : ILN or flexible nails (TEN) .
PATELLA FRACTURE
1 . Constitutes about 1 % of all skeletal injuries.
2 · M : F =. 2 : 1 · Patella is the largest sesarnoid bone of the body. Its subcutaneous position
makes it susceptible to direct trauma. Unilateral patellar fractures are the most common.
3 · There are 7 articular facets of the patella - the lateral facet being the 1arge st
(50% of surface area) .
X-RAYS 235
_ Medial and lateral extensor retinacu lu m are strong longitudinal expansions of the quadri -
4 ceps muscles. When these are uninjured, active knee extension is preserved desp ite
the patella fra cture.
5. usefu lness of the patel la - to increase the mechanical advantage and leverage of the
quadriceps, to protect the femoral condyles from direct trauma and to help in nourishment
of th e fe moral articular surface .
Mechanism of Injury
1. Indirect : Forcible contraction of the quadriceps, with the knee in semiflexed position ,
usually results in a transverse fracture .
2. Direct : Displacement is minimal because the medial and lateral extensor retinaculum ex-
pansions are preserved . Skin contusions and abrasions may be found .
3 . Most patellar fractures are a combination of direct and indirect forces.
Clinically
• Swell ing of the knee , and sem iflexed attitude of knee. Abrasions may be present.
• Tenderness is noted and a palpable 'gap' is often felt over the fracture site.
• Active knee extension must be noted to determine retinaculum expansion injuries. This
may be facilitated by aspiration of the haemarthrosis and intra-articular inj ection of
lidnocaine.
N.B. : Open fractures must be ruled out. This is done by aspirating the knee joint with a 18G
needle ~ injecting 50 ml sterile normal saline through the same 18G needle ~ if saline
flows out through the wound , then the fracture is open .
• Open fracture is a surgical emergency . Immediate debridement and copious irri gation
must be done , followed by soft-tissue coverage with in 5 days . T hi s reduces the
chance of infection .
• All efforts should be made to avoid total patellectomy , because then about 15%
to 30% of quadriceps power is lost. Patellectomy is d?ne onl y for se~~rely comminuted
"stellate" fractures with unsalvageable fragments , and in very old , deb1l1tated , and poorly
functioning patients .
X-rays
• Lateral view : To note d isplacement of the fractures .
• AP view : To distinguish between bipartite patella (pre_s_ent in ~% of popul~tion _where the
margins are smooth , located at the supero-lateral pos1t1on , 50 1/o cases being bilateral}.
• Axial view (Skyline view) : To identify osteochondral or "marginal" fractu res (ve rtical
fractures). [Fig . 5 .31]
Fig. 5.31 : Skyline view of knee showing marginal,

F"ig · 5 ·3 O : Lateral view X-ray o f knee showing
. vertical patella fracture.
transverse middle third patella fracture .
2 f A It I AMII I I I( IJ
Trcatm nt
1 lmtia/Jy : Ice ,1ppli<'<1l1011, cylinc..J r pl,1 IN ',lalJ {lrurn ,JIJr1vrJ :JrtYl 1J tr1 th{) 'WJirlJ,
2 Non-operative . Incite l d lor clo:,o cJ Ir, c, luro', with rn1r11rnurn 1Jl',pl:cJr,1; rrr1,n1 ("' % ,,,,t,J
and intact ex len ~or retinaculum. Cyltnd r plablor cw,t for 6 Fj 1/t<J<;Y'> ,,, rJur1<; ! l ift ,,,,.,.
metric quadricep s exercises and oncou rag rnont of oarly wrJi9rJ1 bt.s~rir, , I t1<;r '"'"'.,I
removal gradual knee flexion a nd iso toni c quadricop•, .,/ <Jrr,1', <;, r.,(<j 'A;, rtr)rJ ,
3 . Operative :
(a) Ind/cat d for fr,:; r..turc:;., 1111tt1 ~ 2 r; ,,,
dtspl' com en I, /. e., frc,r, urn ., ~ r,(,,i.
ated wi1h retinac:.,ular ~/ p<:tn i n <,~r,:,
an d open frar, ture .
(b) Operative op tions :

(i) T e n sion b an d t1 irin g r ~ ~
pag e 226) .
(ii) C i rcu m fer ential (c er cla9~J
wir ing .
(iii) Pa rtia l pa tel le ctomy (uppe o
lower pole e/4cision) .
Fig. 5.32 : Lat. view X-ray of knee showing TBW
done tor fracture patella. (iv) Screw fixation .
TIBIAL SHAFT FRACTURE

• T ibia is the most common long bone that gets fractured . Fibula fractures are ery co -
monly associated with it.
• T ibial shaft is triangular in cross-section and the antero-medial surface is subcutaneo s.
So open fractures are more common in the tibia .
• Since the tibia is not entirely surrounded by muscles (d istal 113rd hav e only e -
dons and ligaments) it has precarious blood supply, which increases the risk o· o -
union , delayed union , and infection .
Mechanism of Injury
1 . Direct : High velocity trauma [e.g., road
traffic accidents (RTA) or gunshot
wounds] is a common cause . Displaced
comminuted fractures with severe soft -
tissue injury is the usual result.
2 . Indirect :
{a) Fall from low height and landing with
a twisted foot may cause spiral and
minimally displaced fractures with
little soft-tissue injury.
(b) Stress fractures - Found in military re-
cruits and ballet dancers.
Clinically
1. Neurovascular (dista l) status : Very im-
portant. Examine dorsalis pedis and pos-
terior tibial artery pulse, together with com-
. . .b. I s aft a
mon peroneal and tibial nerve functions . Fig . 5.33 : AP view X-ray or nght 11 1a
ankle showing spiral fracture of the midd e-
X-RAYS 237
2. Co µartme~t- s~ndrome : Must be searched for (see page ?G) .

3. Soff.tissue m1unes : Open wounds/fracture blisters should be assess d and docurnonf rJ,
and sketched in the history sheet.
4. Knee ligaments : Integrity must be examined. Injury of the ligaments is common .
5. Other bones : lpsilateral hip, femur, knee and ankle examina tion is a must.
Gustilo and Andersons classification of open fractures

I. Skin wound < 1 cm, pierced from inside to outside . Minimal muscle con tusion. Simple
transverse or short oblique fractures .
II. Laceration > 1 cm . Severe soft-tissue damage. Simple fracture patterns with minimal
com minution .
Ill. Extensive soft-tissue damage often with a crushing component.
A : Adequate bone coverage present. Segmental fractures, gunshot injuries.
B : Bone exposed with periosteal stripping and requiring soft-tissue flap closure. Mas-
sive contamination.
C : Associated vascular injury.
. . d fibula showing both bone fracture .

. ri ht knee, trbra an
Fig. 5.34 : Lateral and AP vrew of 9
X-rays . . eluding knee and ankle is a must.

AF> .b. and fibula , 1n
l anct lateral view of the whole ti ,a
reatrnent . . rotational deformity cannot be corn-
s·
Pe ince knee and ankle a re primarily
· hinge 1omts,
during redu ction .
nsatect Which should be remembered d e Allows early motion, care of the soft-
, d e proce ur ·. . -
· Operative : Most c ommonly . ~n of immobilization. Options are .
tissues and prevents complication h ·ce tor most (see page 239). (see Fig.5.35)
( tment of c o1
a) Interlocking Nail {ILN) - Trea
- - - -========------ial- 1-~==-·- ---
__
.__ 238 HANDBOOK FOR ORTHOPAEDIC~ XAMINATION
(b) Plate and screw fixation - Usefu l for

the proximal and distal fractures .
(c) Externa l fixator - Used for open
fract ures - Gusti lo IIIB , select
cases of IIIA, or fractures with peri-
articular extension (see page 240).
2. Non-operative :
• May be useful for closed, stable and
minimally displaced fractures .
• Criteria for acceptable reductions -

(i) < 5° varus/valgus angulation.
(ii) < 10° anteroposterior angulation.
(iii) < 10° rotational deformity.
(iv) < 1 cm shortening.
(v) > 50% cortical contact.
• Working Principle - After reduc-

tion , the ASIS , centre of patella and
the base of 2nd toe , should be in the
same straight line. Compare with the
normal limb.
• Initially long leg cast , followed by
PTB functional cast bracing (see
Fig. 5.35 : AP and lateral view X-ray of segmental
page 93) with EARLY and progres-
tibial shaft fracture treated with ILN.
sive weight bearing is required.
Complications
1. Ma/union : Common with non-operative tre atment. (see Fig. 5.36)
2. Non-union : Associated with ope n

fractures (Gustilo Ill) , infection , high
velocity injuries, intact fibula , inadequate
fixation (see page 94) .
3. Infection : Common in open injuries.
4 . Knee/ankle stiffness : Common with
non-operative treatment.
5. Compartment syndrome : Anterior
compartment is commonly involved, and
highest compartment pressures are
found during reduction . (see page 76)
6 . ~eflex sympathetic dystrop.hy : Se~~
1n conservatively treated patients, wi d
prolonged immobilization and delaye
weight bearing. (see page 81)
7 · Neurovascular injury : Not so cornrnon~
Suspect in severely displaced and ope
fractures .
Fig. 5 .36 : Midshaft tibial fracture treated with ILN 8 . Fat embolism : Rare but a very serious
showing fracture malunion . complication .
INTERLOCKING NAIL (ILN)
is the most common implant used for fixation of diaphyseal fractures of long
• 0ries, which has made the non-locked nails (e.g., 'K' nail) almost obsolete despite
i lower cost, simple technique and less instrumentation .
iJ
Locking is done by inserting screws from one cortex~ through holes in the nail ~
• up to th e opposite cortex . When this is done proximal and distal to the fracture , it
ensures ROTATIONAL STABILITY (mai n advantage over non-locked nails) , and
also mai ntains length (prevents collapse) . At least 2 holes are present at the proxi-
mal and distal ends of the interlocking nail for screw insertion.
Suitabl e bones for ILN ~ tibia , femur and humerus are common . Midshaft ra-
• dius/ulna fractures are also amenable to ILN .
Indications
1. Closed fract ures of the shaft, which
are not very close to the joints (for fe-
mur, it is ideal when the fracture is be-
tween the lesser trochanter and the
condyles) .
2. Pathological fractures (see page 246)
3. Non-unions and pseudoarthrosis .
4. Malunions and deformities (see page
248)
5. Open fractures up to Gustilfo Ill A (Ill
B is controversial) .
Newer use
1. Arthrodesis of knee joint wi th a long
femur-tibia nail.
Limb-lengthening over ILN , using an
additional external fixator.
Closed vs. Open nailing
Closed nailing means where the fracture
nd
site is not opened during operation , a
th d cu F. 5 37 : Midshaft fracture femur treated
e nail is inserted antegrade an per . - ,g. · with ILN
t~neously. It is the method-of- ch01_c e · .
since it retains periosteal vascularity I duction is not possible , open reduction
and reduces infection . However, if accepta~de red but non-union and infection rates are
folio .. be cons1 ere ,
Wed by antegrade nailing may
much higher for open nailing .
Reamed vs. Unreamed nailing
4dvanta f .
ges o Reammg : . lant) can be used .
;· larger diameter nail (thus st_ron~~;s'~:e bone graft, which has osteoinductive property .
. Bone-dust produced by reaming d a smooth procedure.
3 N ·1 · ick easy an
· a, insertion becomes qu · d th ough endosteal blood supply is damaged.
4· Periosteal blood supply is increase '
Disadvantages of Reaming :
1. Destroys endosteal vasculature and causes necrosis of the inne r cortex.
2. He at is generated and t he raised intramedullary pressure increases the
chances of fat embolism .
3. In open fractures , reaming may disseminate contaminati on/infection . However some
authors claim reaming decreases infection , when irrigation and aspiration is simul-
taneously done. (Reaming-Irrigati on -Aspiration)
4. Undisplaced occult butterfly fracture fragment may get displaced.
Advantages of ILN
1. Early mobility/ambulation of the patient reduces post-operative complications.
2. Provides rotational stability in a load-sharing implant. (Remem ber-plates are load
bearing implants).
Disadvantages of ILN
1. Needs specialized fracture-table and C-arm image intensifier, which increases the cost.
2 . Needs expertise which comes with a steep learning-curve.
3. Locking is difficult in proximal 114 th and distal 114 th fractures .
Dynamization
When locking screws are present only at one end of the nail , it is called dynamization.
Commonly the shorter fragment is kept locked . It permits compression at the fracture
site , which is beneficial in delayed unions . Since static locking (screws at both ends)
uniformly achieves good union , routine dynamization is not practised / advocated .
EXTERNAL FIXATION
• It is a process of rigid stabilization of fractures by percutaneously placed pins or
tensioned wires , which are then connected to an external frame (the implant as -
sembly is placed at some distance from the body) .
Types - Pin fixators and Ring fixators .
1 . Pin Fixators : Very useful for trauma management. The application is quic ·
5 varieties of frame constructions are possible (Fig . 5.38) .
(a) Unilateral uniplanar.
w
(b) Bilateral uniplanar.
cJ
(a) (b) (c)

Fig. 5.38 : Frame arrangemen
(c) Unilateral biplanar (Delta frame) .
(d) Bilateral biplanar.
(e) Modular frame - Various combina-
tions of the above.
Choice of frame must take into ac-
count the following considerations -
(i) Safe 'anatomical co rr ido rs'
tor pi n insertion , avo iding
nerves and vessels .
(ii) Adequate access to wounds for
secondary procedures like skin Double rods - anterior Delta frame
grafting. and posterior
(iii) Suffici ent stability against de- Fig . 5.39 : Cro ss section of bone with
forming forces . pins and clam ps.
N.B. : For increased stability -

1. Distance of extern al frame from the body must be less.
2. Greater diameter of the pins and rods gives greater stability.
3. Pre -stressing of the pins, before "securing" the external rods with clamps , is e s -
sential.
4. Poste riorly placed interconnecting rods (w .r.t the pins)/ doub/e rods (1 an te rior ,
1 posteri or)/ de/ta frame ~ all increase stability. (Fig. 5 .39)
5. Pin separation distance across the fracture must be reduced.
2. Ring Fixators : T he work of Russi an scientist , GA. llizarov , with ring f ixators and
especially the concept of distraction osteogenesis has immensely en ri ched o rth o -
paedic surgery . Co mplete o r pa rt ial ri ngs are secured to bone w ith half-p ins o r
tension ed wires , while the ri ngs are interconn ected with rods or articulated implants .
The diameter and tension of the wi re are important for frame stability. The size , num-
ber and location of the rings are also important. (Fig . 5.40) .
Corticotomy Osteogenesis
New bone
Bone loss Distraction

at 1 mm/day Gap closed
( Fig. 5.40 : Distraction Osteogenesis.

a) Very useful for sim ultaneous and gradual co rrection of multiplanar de formities
nd
(b) ; ?omple~ reconstructions . .
: ns1oned wires can grip small bony fragments and also o steoporot1 c bones (where
(c) Pt~s cannot get sufficient purchase) .
D'.straction osteogenesis ~ bone elongation at 1 mm/day is a muc h utilize d p ri nci ple
with ring fixators (0.25 mm every 6 hours is better) (Fig. 5 .40 ) .
(d) However, t 1::. d .ime consu'"l1111g nnd an elaborate p roc ess that does not allow much
soft-tissue a1.;cess and 1s not suitable for initial trauma management.
Indications of External Fixators

There are no absolute ind1cat1on, and each pati ent must be individualized.
1 . Open fractures ~ especially Grade
Ill Gustilo-Anderson (see page 237).
2 . Fractures with bone loss (where in-
te rnal fixation is not feasible) may re-
quire initial length maintenance , and
later distraction osteogenesis for
bone transport.
3 . Infected non-unio ns/fr a ct u res ~
useful because it achieves fixation ,
with implants being far away from the
fracture which prevents infection from
disturbing union.
4 . Li gamentotaxis ~ especially for
comminuted intra-articular frac-
Fig. 5.41 : llizarov ring fixator on right leg. tures of th e distal radius , or tib ial
plateau fractures . Here the tixator applies traction on the ligaments and joint capsule,
and thus pulls the fragments into alignment.
5. Some pelvic fractures ~ especial ly those which are rotationally unstable but ver-
tically stable (Fig . 5.42).
6. Fractures associated with burns.
7. Arthrodesis (see page 188, 271 )
8. Temporary stabilization of fractures
1 0 . Deformity correction ,
~1
and for patient transport.
9. Limb-lengthening commonly
~one :,'-'ith
ring t,xators
Advantages
1 . Rigid stabilization of open fractures
without fracture exposure ~ de-
creases chances of infection and pre-
serves vascularity .
Fig . 5.42 : Anterior external fixator frame used 2 . Allows monitoring of open wounds to
for pelvic fracture . assess the viability of soft-tissues
and also permits skin -grafting , d ressing, etc ., without disturbing the fracture .
3 . Early motion of the adjoining joints preven t s joint stiffness, muscle atrophy and
osteoporosis.
4 . Compression/distraction (as required) can be done at the fracture site.
5 . Limb-lengthening , gradual deformity correction and treating infected non-unions are all
significant advantages.
Disadvantages
• Assembled external frame may be cumbersome and a psychological burden which
may lead to non-compliance and rejection, psychiatric problems.
• Most pati ents need 2 nd op:
era
:~t:i o:n:-:(f;o:r-
: --;=;::= : ~ - = == =-== ===~~::::'.'~:::::=i.
pe rm ane nt sta bili z ation) ~ defini -
tiv e interna l fixat ion .
com pl icat ions
1. Pin- tract infection : Very common .
Mi nim ized wit h meticulous technique
and regular care of the exposed pins/
wires/frame (cleaning with antiseptics) .
2. Neurovascular injury : It occurs dur-
ing pin inse rtion and is avoidable with
soun d knowledge of the safe anatom i-
cal corrid o rs of the limb .
3. Impalem e nt of soft-tissues : Ten -
dons may ruptu re and muscles may
fibrose , caus ing j o int st iffness .
4 . Re-fractures : May happen either
through t he p in-tract in the bone (after
pin removal) or through the original
fracture si t e (due to minimal peri-
osteal callus) .
5. Compartment syndrome : The intro-
duction of pin increases compartmental Fig . 5.43 : AP and Lat. view X-ray showing pin external
pressure (see page 76) fixator used for treating fracture in both bone leg .
ANKLE FRACTURE
•Most ankle fractures happen due to low-energy trauma due to "twisting" injury (rotational
mechanism). Rarely high-energy trauma causes severe fracture patterns which may in-
volve the tibial plafond (pilon fracture).
• Bimalleolar fractures = Pott's fracture , Trimalleolar fractures = Cotton's fracture.
Mechanism of injury : The foot remains in contact with the ground while the patient falls down, which
causes the talus to tilt and rotate within the small and fixed space of the ankle mortise. This causes
breakage of the lateral maleolus, or/and medial maleolus and sometimes the posterior maleolus.
~l~ssification : (I) Danis Weber - Based on the level of fibular fracture in relation to the inferior
t,b,o-fibular syndesmosis. (Fig. 5.44)
• Weber A : Transverse fracture of fibula, below the syndesmosis.
• Weber B : Oblique fracture of
fibula, may be in the sagittal
plane , at the level of the syn-
desmosis .
• Weber C : Severe fracture
patterns , above the level of
the syndesmosis .
(II) L
auge-Hansen - Based on the
rotational mechanism of injury
(a) Supination - Adduction ,
(b) Supination - External Rotation ,
Weber B WeberC
(c) Pronation - Abduction Weber A
(d) Pronation - External rotation . Fig . 5.44 : Ankle fracture
h fir I p 1 rt ()I th n, rn d scnb s the pos1t1on of the foo t at the time of injury, while the
cond p rt d , nl c • th dir ell n of force pplied to the fool.
Clinic lly On 111 pl cllon note the amount of swelling. T here ~ ay be . blisters and echymo_ ses
which prov1d clu to th location of the injury (which may be in the ligaments). On palpation,
most 11nport nt i t nderness, which again locates the injury. Look for tender.ness ov~r. the deltoid
ligament, th entire fibula, base of the 5 1h metatarsal , calcaneum and th~ ~rndtarsal Joints. Arteria
dorsalis pedis and posterior tibial pulse should be noted alongwith superf1c1al peroneal nerve sen-
sation over the dorsum of foot.
Special Tests -
(1) Squeeze test : Compress the tibia and fibula in the m id-calf region. If there is anterior
ankle pain , the test 1s positive which means there is syndesmotic injury/diastasis of the
inferior tibio-fibular joint.
(2) External Rotation test : Knee is flexed to 90°, the ankle is kept in neutral position, and
then the ankle is forcefully externally rotated. If there is ankle pain, it indicates diastasis/
syndesmotic injury.
(3) Thompson test : Compression of the calf muscle, normally cause plantar flexion. When
this is not seen , it indicates tendoachilles injury.
X-rays - AP view, lateral view and mortise view (30° oblique view) is essential.
X-ray of the leg and knee should be done to detect Maisonneuve fracture, which is a spiral
fracture of the proximal third fibula with a tear of the interosseous membrane, syndesmotic injury and
fracture of the medial malleolus or rupture of the deep deltoid ligament. It is often missed.
Treatment - Main goal of treatment is anatomical reduction of the fibula, restoring it's exact
length. Assessing the stability of the fracture is also crucial for planning treatment. Ankle fracture is
stable when there is no widening of the medial and lateral joint space in the mortise view, and the
tibiotalar joint space is congruous. When unstable, or fibular length is decreased, operation is a must.
• Timing of surgery : If there is swelling/blisters, there should be a delay of 10-14 days for
soft tissue, recovery. Below knee plaster slab and foot elevation is done.
• Fibular fractures : Usually fixed with plates and screws. Other methods like 'k' wire fixa-
tion (page 21 0), tension-band-wiring (page 226) , intramedullary nail (e.g . Rush nail - page
21 O; Titanium elastic nail} , intramedullary screw fixation can also be done. (Fig. 5.45}
• Medial maleolar fractures : Usually fixed with 2 maleolar screws with washers, after removing
the piece of periosteum that gets entrapped anteromedially in the fracture . (Fig. 5.45}
• Posterior maleolar fractures : When fragment size is >30% of the articular surface it should
be fixed by a 'lag' screw directed from anterior to posterior. Fragment <30% need not be
fixed, if fibular length is maintained.
Complications -
Early : (i) Distal neurovascular compromise

(ii) Wound breakdown , infection
(iii) Compartment Syndrome
Late : (i) Non-union - almost 10% of medial
maleolar fractures
(ii) Loss of reduction , malunion
(iii) Joint stiffness
(iv) Complex Regional Pain Syn·
drome (see page 8 1)
Fig. 5.45 (v) Osteoarthritis.
CALCANEAL FRACTUR ·
• Mos fre qu ently fractured tarsal bon e. 2% o'f II fr t'ur
• Also called Lover's fracture or Don Juan fracture . s,
Mechanism of Inj ury
1. Fall from height : The most common
mechanism. Axial loading causes the ta-
lus to be driven into the calcaneum from
above, which breaks the superior cortex .
2. Car accidents : Due to the brake/ac-
c ele rator ped a l forcefully impacting
onto the driver' s hee l.
3. Twisting forces : Causes extra-articular
fractures . Lat. view X-ray of hind-fool Axial view X~ray of ca/-
Clinically and ankle showing tongue caneum showing mini-
fracture of ca lcaneum mally displaced fracture
1. Pa in, swelling , tenderness, echy-
moses , blistering (due to massive Fig . 5.46 : Calcaneum fracture .
swe lling) and w idening of the heel .
2. Look fo r compartment syndrome (see page 76) of foot (seen in 10% cases of calcaneum
fracture ) ~ may cause clawing of the 5th toe .
3. Always search for fractures of lumbar spine (associated in 10% cases) , pel vi s, hip,
femu r, knee and ankle .
Essex-Lopresti Classification
1. Extra-articular (25% to 30%) : This does not involve the posterior facet of taloca lca-
neal j oin t. It incl udes fractures of the anterior process , medial process , tuberosity,
sustentaculum tali and body fractures but does not involve the subtala r joint.
2. Intra-articular (70% to 75%)
Undisplaced fractures , "tongue frac-
tures", "joint depression fractures"
and comminuted fractures .
X-rays
1, Lateral view and axial view is a must. In
lateral view note Bohler tuber joint
angle (20 ° t~ 40 °) which decreases and
Gissane crucial angle (95 ° to 105 °)
Which increases with the collapse of the
posterior facet of talocalcaneal articular
Fig . 5.47 : Line diagram of lateral view of
surface (Fig . 5.47). calcaneum showing Bohler angle
2 · Always X-ray the spine and the ipsi- {B) and Gissane angle (G) .
lareral lower limb. undisplaced/minimally displaced calcanea l
3 · CT Scan is the best imaging option for
fractures , and tor operative planning .
lteatment Options
1· Non-operative : Indicated for undisplaced/minimally displac~d fr~ctures.
• Ice application , elastic crepe bandage, . foot elevation in below -k~ee (BK) POP
slab ~ all reduce swelling . ROM exercises are started early. Weight bearing is
allowed after 10 - 12 weeks .
2. Operative : Indicated tor displaced extra-articular fractures and all intra-articular fractures.
ORIF with plates and screws through lateral approach ± bone graft is done.
5TH METATARSAL BASE FRACTURE (JONES FRACTURE)

• There are 3 zones through which the fracture can occur, and each has its differe nt mecha-
nism of injury, treatment schedule and prognosis . There are many classificati on s/types de-
scribed in orthopaedic literature, of which a very acceptable description is given below.
Zone I fractures
It is an avulsion fracture, due to the pull of the lateral band of the p lantar apo neurosis,
wh en there is sudden inversion of the hindfoot with the body weight fal ling on t o the 5th
metatarsal. This injury pattern often concomitantly causes injury to the latera l ligame nt of
t he ankle, especial ly its anterior talofibular part. So always do the inversion s tress tes t an d
resis ted eversion test (to detect ligament injury), and directly palpate the 5th m etatarsal
base to elicit tenderness (to detect fracture) . Treatment ~ weight bearing pla ste r ca sts (BK
cast with wa lking heel) for 6-8 weeks .
Zone II fractures
This is the true Jones frac ture which oc-
curs at the junction of the metaphysis and dia-
physis of the proximal 5th metatarsal. Mecha-
nism of injury is adduction of the forefoot re-
sulting in a very high tensile stress along the
lateral border of the 5th metatarsal. Treatme nt
~ same as zone I, but the plaster cast is kept
for 8- 1 O weeks .
Zone Ill fractures

It is a stress fracture of the proximal dia-
physis seen commonly in high performance
at_hletes .. Mechan ism of inj ury is repetitive cy-
clic loading of the bone . Classically the pain
starts much before any X-ray findings. Treat-
ment ~ non-weight bearing plaster cast for 6-
8 weeks (till pain subsides) , then same as for
Fig . 5.48 : Jones fracture
zone I, for another 4- 6 weeks .
Surgical indications
1 Significantly displaced fractures in zone II or Ill es · ·
. . . . , pec1a 11 Y 1n athletes .
2 Non-union , which is not infrequent in zone Ill fractu res .
N.B. :
Danc~r's Fracture : Spiral or oblique fracture of the distal "
standing on the ball of great toe with fully plant fl 5th metatarsal, due to rolling-over'' when
ar exed feet Rarely ·t I
of the 2 nd metatarsal. Plaster cast immobiliz r f · '. may a so occur in the base
a ion or -a weeks is sufficient tor treatment.
5
PATHOLOGICAL FRACTURE
• Fracture in a bone which has been weak d
strength, due to destructive processes (eene by . th e loss of integri ty and structural
Paget's disease) is called a pathological t~!~tir:.c•noma) o r invasive disorders (e.g.,
Mechanism of Injury
TRIVIAL or MINI MAL TRAUMA is th e most comm
occur spon aneously ( e. g. ' fracture nee k of femu r in .
on cause and. sometimes th e fract ure may
t
causes of Pathological Fracture pal,ents with severe osteoporosis).
A. Benign bony lesions (common .

years) m < 20
N.B. : Mnemonic : FCI

1. Fibrous dysplasia , Fibrous co rtical
defect.
2. Cyst -
(a) Aneuris mal bone cyst.
(b) Unicame ral bone cyst.
3. Infections -
(a) Chronic pyogen ic osteomyelitis
(b) Tubercular osteomyelitis. .
8 · Malignant bony lesions
N.B. :
Mnemonic : COME
1.Chondrosarcoma.
2.Osteosarcoma .
3.~ultiple myeloma, metastatic depos-
its (from primary malignancy in
"PUBLIKT" i.e., prostrate, uterus, blad-
der, lungs, intestine, kidney, thyroid).
4. Ewing ' s sarcoma , Eosinophilic Fig. 5.49 : AP view X-ray of right humerus, shoulder
granuloma. and elbow showing proximal humeral, central, osteoly1ic
lesion extending up to diaphysis, with cortical break
C. Bone diseases (common> 40 years)
simple bone cyst with pathological fracture.
N.B. : Mnemonic : MOP
- Myelomatosis , metabolic bone disease (e.g., rickets , osteomalacia, hyperp ara-
1
thyroidism).
2. Osteoporosis (the most common cause of pathological fracture), Osteogenesis
i m perfecta .
3. Paget's disease.
Clinically
History
: Fracture resulting from normal activities or minimal tr_auma.
Parn or discomfort at the fracture site Jong before the m1ury.
• Past history of fractures . There may be multiple incidences .
• Weight loss, lump, cough, haematuria, etc. ~
may suggest malignancy.
Examination
ab~~te _wasting , scars , sinus . Look tor lymphadenopathy , th_yroi_d nodule , breast Jump ,
m1na1 mass hepatomegaly. Always do PA and PV examination .
lnve t· ,
s •gation 4
2
• Complete blood count ESA, Ca +, po/-, AlkP0 , Hb.
: ~rinalyses, hour u;ine hydro,ypro\ine (for Paget's disease).
24
erum electrophoresis (for multiple myeloma) .
- - ----·--·-----
AND800K FOR ORTW P, EDI
CXR , whole abdomen USG .

99
• Whole body Tc bone scan. (See page 25 1)
• Special tests ~ PSA, PTH , CEA, thyroid function test.
Treatment
• Systemic treatment to tackle the main pathology is essential ~ as in osteoporosis, osteoma-

lacia, hyperparathyroidism, malignancy , etc.
• Fractures through primary benign lesions heal very well. Surgery is not needed.
• Fractures through metastasis and malignant lesions never heal. Surgery is essential,
except in patients with a very short life expectancy .
• Operation is a must for -
(a) Femoral neck fractures (Hemiarthroplasty/THR).
(b) Paget' s disease with fracture (Internal fixation) .
(c) Vertebral fractures causing neurocompro mise.
• Post-operative loss of fixation (e.g., loosening of screws) is a common complication due
to poor bone quality. Bone-cement augmentation is useful to prevent this.
N.B. : Prophylactic fixation is considered for -
• Peritrochanteric lesions.
• Lytic lesions > 2.5 cm in diameter or occupying > 2/3 diameter of the bone.
• Cortical bone destruction > 50%.
• Severe pain hampering the activities of daily living (AOL) .
MALUNION
• A fracture that heals in a non-anatomical position is called malunion . It is a preventable
condition ~ with appropriate, knowledgeable and skilful treatment.
Problems
1 . Cosmetic ugliness due to the deformity.

2. If involving joint surfaces ~ causes pain
and early osteoarthritis.
3 . Angular or rotational deformities can dis-
turb positioning of the upper limb or can
cause gait problems in the lower limbs.
4 . Limb length discrepancy ~ when short-
ening becomes significant in the lower
limb (> 3 cm) .
5 . Mechanical obstruction to joint moti on
~ if near a joint e.g. , malunited supra·
condylar fracture humerus with anterior
bony spike ~ restricts elbow flexion.
Cause
Improper fracture reduction or inadequate,
ineffective immobilization .
Common Sites
Fig . 5.50 : AP view of X-ray distal femur and Fractures of clavicle shaft humerus , bolh
knee showing malunion . bone forearm , trocha~teric fracture, Colles
fracture.
Treatment
. 4 principles of acceptability of fracture
unt0n must be re membered while tr r
each. individual case. In order of d ecreas-
ea ing
ing im portance , these are -
1. A lig nme nt.
2. Rotation .
3. Length restoration.
4. Actual fragment pos ition . Fig. 5 .51 : Malunited fracture of both bone
forearm . Note the angu/ation.
Acceptability is especially important h
·t · · . w en
1 1s near a 1omt
. or the deformity is m. th e
~ Iane o f motion of the joint (where remodel-
ling can occur) , if growth potential persists.
• Axi~I alignment deformity, in < 9 year old
patients , commonly corrects itself with
growth . Rotational deformities do not
correct with growth.
• Su rgery is considered only when a
malunion impairs function , and not when
it is demanded , although cosmesis is im-
portant. If ope ration is done, it must be
at least 6 to 12 months after the injury - Fig . 5.52 Corrective osteotomy and
Open reduction and interna l fixation (OAIF) done
except for intra-articul ar fractures and
with Dynamic c ompress ion plate (DCP).
Monteggia fractures .
• Corrective surgery at the malunion site is not always necessary e.g ., malunited trochan-
teric fracture with varus deformity (coxa vara) --7 corrective subtrochanteric valgus os-
teotomy is considered as a compensatory procedure. Also, "shaving-off" the protruding
bony spike may be done in malunited clavicle fracture and supracondylar fracture .
• Commonly, malunited site is osteotomized --7 internal fixation in anatomical position is
done ~ bone graft is given for early union. (Fig. 5 .51 and 5 .52)
• lfizarov's ring external fixator is a very efficient method for correcti ng malunion which
simultaneously corrects alignment, rotation and restores length (see page 241 ) .
Special Cases
,. Arthrodesis : (see page 271 ) considered for malunited intra-articular fractures e.g ., ankle
fracture/ Pilon fracture.

· Patellectomy : Indicated for malunited patella fractures with severe symptoms .
2
· Excision of deformed portion of bone --7 e.g ., tor malunited olecranon fractures
3
(see page 224) .
FEMORAL HEAD AVASCULAR NECROSIS (AVN)
• ~VN can occur in the scaphOid, lunate, talus , capilul um, femoral condyles, humeral head,
ut most commonly it is the head of femur that is affected.
• cAl I t.hese bones (small c ubOidal , or having
· conve.x surfaces) are covered by avascular
s art1lage , with no muscle/tendon attachment, which ensures that there 1s hmited blood
upply to the subchondral bone .
250 HANDBOOK FOR ORTHOP
--~~__::____:_-----~~-----~-~-...........
Aetiology
1 · Idiopathic or Primary ---) 50%.
2 . Secondary ~ Steroid , Traum a, Alcohol , G aucher' s diseases, Caisson ' s disease ,
Renal osteodystrophy , Infection , Sickle -cell anaemia , Irrad iat ion , Systemic lupus
erythematous .
N.B. : Mnemonic : STAG CRISIS

3 . 50% is bilateral, of which 50%-80% is steroid induced .
Pathology
• The medullary cavity is virtually a closed
compartment (Fig. 5 .53) . Bone ischaemia
can occur in 4 ways-
Vein
1 . Arterial insufficiency : Post-trau-
matic cases.
Fat cells +
N.B. : If there is bleeding inside a
joint, and if the joint capsule is not
torn ~ intra-articular pressure i ~
Fig. 5 .53 : Medullary cavity - a closed osseous
compartment. venous tamponade may occur.
2. Venous occlusion : Veins may be thrombosed after infection , or venous tamponade

may occur after synovitis or intra-articular bleeding may cause tamponade.
3. Capillary occlusion : Nitrogen bubbles (Caisson's disease) , 'sickling' (Sickle-cell
anaemia) , fat embolism (alcohol, steroid) .
4 . /ntraosseous but extra vascular capillary tamponade : Compression due to fat
cell swelling (alcohol , steroid) , or direct compression by large macrophages stuffed
w ith glucocerebrosides (Gaucher' s disease).
• AVN as compartment syndrome : lschaemia triggers a chain of events in a vicious
cycle similar to compartment syndrome (Fig. 5 .54).
/ Arterial occlusion ~ • Bone cells die after 48 hours of anoxia,
and osteoblastic activity lays down new
Marrow bone over the dead bone (sclerosis
Vascular seen in X-rays). If new bone formation
stasis oedema
cannot keep pace, then fragmentation
.
~ Capillary tamponade /
. Vicious cycle of intraosseous ischaemia.
occurs , causing subchondral fractures
(stress fractures) and later loss of
shape and deformity.
Fig. 5 .54 ·
Clinically
• History of alcohol , steroid , trauma . Pain is initially felt only with a particular movement,
usually abduction . . . . .
• Limp is common. Wasting 1s s~en m cases ":'h1ch present late.
• Tenderness, stiffness, later f x d defo
with passive flexion he e
• sectoral sign (see page 3
X-RAYS 251
Ficat and Arlet Classification

• Stage 1 : (Asymptomatic)
. X-ray __,.
----, Normal· Bon
• Stage 2: (Pain) X-ray ~ Sclerosis M ' e scans ~ cold spot. MRI ~ useful
be subc~ondr~I fr_acture, but the ~ha a~ ·
of head 1s maintained (Fig. 5 _55 ). 8 P
scan ~ i uptake. ' on e
• Stage 3 : (Pai n + Stiffness) X-ray ~
Loss of the shape of head, collapse.
• St~ge 4 : (Severe symptoms) X-ray ~
Join t space J, , acetabular change s
secondary osteoarthritis (Fig. 5_56). '
Treatment
Non_-operative/conservative treatment has
very l1m1ted role. Surgical options :
1. Core decompression : Effective in Fig. 5.~5 : AP view X-ray of pelvis with both hips
st~ge 1 and early stage 2. Good pain showing AVN of right femoral head - stage 2.
relief, even in stage 3.
2. Mul~iple drilling and muscle
ped,cle bone graft (see page 145)
3 · Vascularized fibular bone graft or
Vascularized iliac bone graft.
4. Osteotomies : Planned to transfer
weight bearing from the necrotic
area to the normal part of the head.
5. Total hip replacement : High failure
rate . Unsuitable for the young.
N.B. : • SPECT (single photon emission
computed tomography) is most
accurate for earliest detection.
• MRI and bone scan detect A VN
~ery early and core biopsy con-
fr~ms the diagnosis. X-ray diagno-
sis may be earliest at 2 months
and becomes obvious by 9 Fig. 5.56 : AP view X-ray of rigl'lt hip showing
months whereas MRI diagnosis AVN f emor I head sl o 4.
may be earliest at 2 weeks and
becomes obvious by 2 months.
• Bone Scan : Photo~ emission by radion euclides are uptaken by ti u

-~~e recorded by gamma camera in 2 stages - (i) Blood pool ph s imm di t ly
99
(11) Bone phase _ after 3 hours. Tc methyl ene dlphosphon t ('I,. lit h lll s
commonly used. Gaa1 is also used. Bone .sc n c n d, t ct_ ~tr Ir , cttir
small bone abscess, osteoid osteoma, penprosthetlc 1111 ct, n ', rlh 111 ell ,, ,
early bone metastas is _ whic h is difficu lt to se In X-r y . Inell um 1 \t II d
!eucocytes can differentiate ewings sarcoma lrom ost omy Ii\\ . n " I \h
investigation of choice to detect AVN with non-Ill~nium imp\ ml In l\u .
OSGOOD-SCHLATTER' A
' A
ri~t0 Physiti.s/Epiphysitis of the tibial tubercle. Som tlm c w \J '.
associated with avascularity .
~-• ---
....w::::.:::::::s:::w: - .........
Aetiology
It is probably a traction injury of the apophysis of the tibial tuberosity, into which th e patellar
tendon is inserted. Patella alta is often associated. (see page 23)
Clinically
• Always occurs in adolescents where there is rapidly growing physis. .
• Pain atter running , jumping, cycling , climbing stairs, etc. is the com mon co'.11pla'.n .
• Tender lump over tibial tuberosity is tound. Active resisted knee extension is painful.
X-ray
May show fragmentation. (Fig . 5.57)
Johansson-Larsen disease : Patellar ten-
don partially avulsed from the lower pole of pa-
tella, due to traction tendinitis. X-ray ~ often
shows calcification around lower pole patella.
Treatment
• Rest, Ice, NSAIDs , Activity modifica-
tion - most effective .
N.B. : Mnemonic : RINA

Fig . 5 .57 : Osgood-schlatter's di sease .
• Bosworth operation ~ Bone peg inser-
Note - fragmentation of tibial tuberosity .
tion. Relieves symptoms.
N.B. : Pelligrini-Steida disease : Ossification in a haematoma. Usually occurs after injury to
the medial collateral ligament of the knee, although there is no history of trauma.
SEVER'S DISEASE
Aetiology
It is the apophysitis/epiphysitis of the posterior calcaneal tuberosity at the tendoachilles in-
sertion. It is a traction injury.
Clinically
Patient is around 1 o years of age. Pain +
tenderness over posterior calcaneum is found.
X-ray
Density of the epiphysis is increased. Frag-
mentation may be found . (Fig. 5.58)
"_Cal~aneal knob " in girls (15-20 years) ,
which 1s often bilateral. Posterolateral promi-
nence of calcaneum is found .
Treatment
Fig . 5.58 : Sever's disease.
. ''.R INA" is effective (Rest, ice , NSAID, ac-
Note : fragmentation on the left side. tivity. modification). Open-back shoes are es-
sential .
X-RAYS 253
N.B. : seli n's dis~~se : Traction epiphysitis of 5th metatarsal base; Freiberg's disease :
crushing osteo?hondnt,s _of 2nd/3rd metatarsal head; Kohler's disease : Crushing osteochon-
dritis of the _nav1cular; Kembock'~ ~isease : lschaemic necrosis of lunate due to chronic stress;
panner's disease : Osteochondnt,s of the capitullum; de Clave's disease : Vertebra plana in
eosinophilic granulo_ rl:'a; Kumell's disease : Vertebral body epiphysitis in adults; Calve dis-
ease : Osteochondnt,s of vertebral body in a child ; Mandi's disease : Greater trochanter epi·
physitis; Thieman_n's disease : Multiple phalangeal epiphysitis; Diaz's disease : Talus epi-
physitis; Hass' s disease : Humeral head epiphysitis; Ellman 's disease : Radial head epiphysi-
tis; Burn's disease : epiphysitis of distal ulna; Mauclaire's disease : epiphysitis of metacarpal
heads; Buchman's disease : epiphysitis of Iliac crest; Koenig's disease : femoral condyle
epiphysitis of a child ; Pierson's disease : epiphysitis of symphysis pubis: Milch's disease :
lschial apophysitis; Chandlers disease : Osteochondritis of femoral head in adults; Llffert-
Arkin disease : Osteochondritis of distal tibia.
SPINA BIFIDA
• It is an embryonic defect, where there is failure of fusion of the 2 halves of ~osteri_or
vertebral arch , together with maldevelopment of the neural_tube ~nd the overlying . ski~.
This combination is also called Dysraphism . When one infant 1s affected , the risk ,s
10 times more in the 2nd child .
• It is common in the lumbar and the lumbosacral region .
• There may be neurological deficits, urinary symptoms (90% ca_ ses) , te nd ency of spon-
th
taneous fractures and also the overlying skin may be anaeS et,c.
Subgroups
According to the pathology and severity -
1. Spina Bifida Occulta Mildest and the
most common type. Has the best prog-
nosis .
• Tuft of hair, dimple , defect in th e
overlying skin , sinus, lipomaS, cyS t s
~ may be found over the lower b~ck,
pointing to the underneath lesion .
Most common site is S1.
· the
• May cause muscle imbalance in
lower limbs which may ultimately cause
deformitie; (e.g . DOH , genu recur- Fig. 5 _59 : AP view x -_ray o_f _lumbo sacral spine
vatum , CTEV). May also cause cauda- showing spina b1flda of S1.
equina syndrome. (see page 261 ).
herniate through the foramen magnum.
2. Hydrocephalus Brainstem cerebellum m~Y Raised intracranial pressure may cause
. .d (CSF) obstruction.
causing cerebro spinal flu, h Prognosis is guarded .
rnental retardation and cerebral atrop y. r prognosis. Bladder sphincter dystunc-
3 s . type. Has poo
· Pma Bifida Cystica Most severe . .
tio . 4 varieties - k'
n 1s very common . There are . ith CSF, herniates. Covered by normal s tn.
(a) Meningocele : Meningeal sac filled w taining nerve roots and portion of the spinal
(b) Mye/omeningocele : Meningeal sac con
cord herniates. No skin cover. st of the neural groove. Very common. May be
(c) Af rowth-arre
yelocele : Occurs due to 9 k. cover.
associated with CSF leak. No s ,n
- --- - -
~ ~-- - -
(d) Syringomyelia : Dilated central canal of spinal cord within herniated meningeal sac.
Diagnosis
Prenatal : Alpha Feto Protein (AFP) level rises in amniotic fluid and serum. At birth ~ skin
defect or herniation is obvious . MRI is indicated for spina bifida occulta.
Treatment
• Folic acid supplementation prenatally decreases the incidence .
• Operative closure of defects is hazardous , especially for levels above L1 .
• Teamwork of neurosurgeon , orthopaedic surgeon , urologist, paediatrician, physiotherapists
and occupational therapists is needed. Parent counselling is a must.
• For those with better prognosis ~ skin closure is done within 48 hours.
• For hydrocephalus ~ Early operation is required to prevent brain damage . Usual ly
ventriculo-caval shunt with a valve is done.
• For deformities ~ Manipulation and plaster is NOT DONE (because of the risk of skin
ulceration and spontaneous fractures) in the 1st year. Later, proximal deformities can be
corrected before the distal ones.
SCOLIOSIS
• It is an apparent lateral curvature of the spine . Apparent because it is actually a triplanar
deformity with antero-posterior, lateral and rotational components . (Fig . 5 .60)
Types
I. Postural : Compensatory or secondary to non-spinal causes e.g. , limb length discrepancy
(LLD) or pelvic tilt.
11. Structural : Deformity in a particular spinal segment. Secondary curves develop to coun-
terbalance the initial or primary curve.
The curves increase till bony growth con-
tinues. There are 4 varieties -
(a) Idiopathic (80%) : Age of onset sub-
classifies it into Adolescent (90% are
girls > 10 years) , Juvenile (4 to 9
years). Infantile (< 3 years, rare) .
(b) Osteopathic : Vertebral anomalies
like hemivertebra , tused / unseg ·
mented verteb ra are found . (e.g.,
Sprengel ' s deformity - see page 44)
(c) Neuropathic : Unbalanced paraver·
tebral muscle power causes bending
e.g., in postpolio residual paralysis,
muscular dystrophies, cerebral palsy.
(d) Miscellaneous : e.g ., Neurofibro·
matosis .
Clinically
Fig . ~_- 60 : PA view X-~ay of dorso-lurnbo-sacral spine
and iliac crests showing dorso-lurnbar-scoliosis with
• Clo ~ Backache , abnormal anterior cos·
convexity towards right and unossified iliac crests . tal prominence , skew-back deformity.
X A.AYS :,,5~
• Other examination
. : Hip prominent on concave side
· ·
scapula prominent on conv01 side .
Rib hump is commonly found , posteriorly and som~times anteriorly.
• When the patient sits and the curve dis-
appears or .decreases ~ Postural. If curve
appears or increases ~ Structural.
• Always measure lower limb lengths to
rule out LLD.
X-rays
Full length PA view and lateral view of
spine, and AP view of iliac crest is a must.
• Amount of curvature is noted by the angle
subtended by a line joining upper border of
uppermost vertebra in the curve, and the
lower border of the lowermost vertebra ~
called Cobb's angle.
• Iliac crests are observed for skeletal ma-
turity, because once they ossify, no fur-
ther increase of the deformity occurs.
Special Investigations
• Pulmonary fun ction tests to note vi-
Fig. 5.61 : PA view X-ray of dorso-tumbar-spine
tal capacity , which if decreased , is a
showing scoliosis with convexity towards left.
risk-factor for surgery.
Treatment
• Non-operative : Milwaukee-Brace, Boston-Brace, spinal exercises.
• Operative : After correction of deformity by distracting the concave side , maintenance
can be done by posterior instrumentation e.g. Harrington system (rods and hooks) ,
Luque system (rod and sublaminar wiring) , Cotrel-Dubousset system (pedicle screw , hooks
and rods) , or anterior instrumentation e.g., Dwyer, Zielke, Kaneda. Bone grafts are al-
ways given for spinal fusion .
KYPHOSIS
• Dorsal curvature, or posterior convexity of the spi ne is ca lled kyphosis . It is normal in
the thoracic spine, but when excessive
~ abnormal/ pathological .
Common causes of Structural Kyphosis
according to age
;hild ~ Congenital.
~olescent ~ Postural , or Scheurman 's
disease
~~ults ~Ankylos ing spondylitis. .
erly ~ Osteoporosis, Paget's disease.
N.a • ·• For any age always exclu d e t u-
bercu1 . '
in lnd?515 (Fig. 5.65) as a cause, especially
fr ia. Other causes ~ Post-traumatic
s.~~~:)~s or fracture dislocations. [Fi g.
Fig. 5 .62 : Dorsal kyphosis.
Types
1. Postural : Most common . Reducab le by postural training and exercises.
2. Compensatory : Counterbalances fixed-flexion-deformity of hip, o r increased lumbar
lordosis .
3 . Structural : Osteoporotic kyphosis, Scheurman's disease, ankylosing spondylitis, caries
spine.
• Osteoporotic Kyphosis - Very common in the elderly. 2 varieties.
1 . Post-Menopausal Women : Usually 1 or 2 anterior-wedge-compression-fracture of
dorsal vertebra occurs . Main complain is lumbo sacral pain , due to compensatory
increase of lumbar lordosis and concomitant osteoarthritis . [Fig . 5 .64(A)]
2. Senile : Both men and women are af-
fected . Usual occurance of multiple ver-
tebral anterior-wedge-compression -frac-
tu res . Complains of back pain. Has
smooth rounded curvature . Must ex-
clude metastasis and multiple myeloma.
• Scheurman's Disease (Fig. 5.63)

Adolescent kyphosis. Common in the lower
thoracic spine due to vertebral end-plate epi-
physis osteochondritis. There is anterior
wedging, and intervertebral discs may herni-
ate into the vertebral bodies (schmorl 's nod-
ules) (see page 261 ). Most commonly seen in
girls having smooth rounded kyphos is and
those complaining of backache . Tight ham-
strings are often associated .
Fig. 5.63 : Lat. view X-ray of dorso-lumbar spine show-
• Caries Spine
ing rounded kyphosis with vertebral end-p late
osteochondritis ~ Scheurman's disease. See Section II, Page 156
Fig. 5.64 (A) : Lat. view X-ray of dorso- Fig. 5.64 (B) : Lat. view X-ray of dorso- Fig. 5.65 : Lat. view X-ray of dorso-
lumbar spine showing osteoporotic an- lumbar spine showing post-traumatic lumbar spine showing caries spine
terior-wedge-compression-fracture of anterior-wedge-compression-frac- of 0 12 and L 1 vertebra with angular
012 and L 1 vertebra with round gib- ture of L 1 vertebra with knuckle gib- gibbus and yphosis.
bus and kyphosis. bus and kyphosis.
Ankyfos ing Spondylitis
~
Stiffness + kyphosis in a young adult is the hall .
inspiration is seen (normal 7 cm) . Other ·oint m~rk. Chest expans,_on < 4 cm with full
eneralized chronic inflammatory d. J s (e.g., _~ips, shoulders) are involved because it's
ag isease . Sacro1/iac joints a · / d ., .
only affects males very rarely the f . re mvo ve ear,1est. Com-
1
;arly : "Squaring" 'of vertebra; Lat:rm·a .~:~ HLAB21 I~ se.~um is_~osi!ive in 30% cases. XR -"7
discs). (See page 271 - Fig. 5.81) . mboo-spme (oss1f1cat1on across intervertebral
Treatment
General principles -
• Cu:ves .~ 40° -"7 Postural training, back strengthening exercises .
Child with growth potential for 1-2 years -? spinal extension braces may be useful.
• Curves > 60° in adolescents (having growth potential) , or patients with neurological
symptoms -"7 need surgery.
SPONDYLOLISTHESIS
• Most commonly an acquired condition. M : F = 2 : 1.
• Forwar~ slippage of a vertebra over the next (lower) vertebra is called spondylolisthesis. It is
a chronic overload inju ry .
• It is common in L , because maximum overload and shearing forces are active there.
5
Types
1 · lsthmic (Lytic) : Commonly an acquired condition wh ich appears in children (not new-
borns) . There is a defect in pars intercularis (which allows the forward slippag e) as
a result of fatigue fracture and/ or repeated breaking and healing of the pars fracture ,
leading to elongation or attenuation of the pars . It is a non-progressive disease and
slippage > 50% is rare , but progressive inte rvertebral (IV) disc degeneration always
occurs . Risk factors include activities like gymnastics , pole-vault, weight-lift ing , vol-
leyball , football and dancing .
2 · Degenerative : Degenerative changes in facet joints and intervertebral (I V ) discs allow
forward slippage of vertebra (commonly L4 - L5), but the pars is intact. Assoc iated with
spinal canal stenosis osteoarthritic changes and sacralization of L4 . It is 5 times more
common in women > 40
years. Slippage > 50% is ra re.
3· ~ongenital (Dysp/astic) : Not an uncommon enti!Y· The superi~r facets ar~ defective from
b~rth which allows slow but progressive forward slippage. Sometimes associated with spina
b1fida occulta. When multisegmentary -? may cause scoliosis .
4· ;r~umatic : Uncommon. Acute fracture of facets, pedicle or lamina may destabilize the
S. :ine and_ allow forward slippage. . . .
imathotog,ca/: Rare. Attenuation of ped1cle due to weakened bones, e.g. , in osteogenesis
P Perfecta , TB , neoplasms, etc.
6 · u:~t-Surgical : Very rare . Removal of > 50% of bones from facet joints make the jo ints
G sable , allowing forward slippage.
~ADING
I/ : Meyerd·
2 _ ing Grading : is according to percentage o f d',spIacement. Grade I : 0-25%, Grade
5 50 01/o, Grade 111 : 11_ %, Grade IV : 75-100%, Grade V (Spondy/optosis) ~ 100%.
50 75
258
Clinically
• May present by 7-8 years, but slippage may not be seen till later.
• Low ?ack pain (LBP), and radiating pain to the lower limbs which may worsen on walking
and improves with sitting/lying supine (typical symptoms of sp inal canal stenosis with
neurogenic claudication). Intensity of pain j during adolescent growth spurt, and also
during exercising/athletic activities .
• 0 /E -, Unduly protuberant abdomen , flattened buttocks , transverse loin creases and tight
hamstrings are seen . Occasionally a palpable "step" may be felt over the affected spinous
process .
Investigations
• X-ray : Standing views are essential because 15% cases may reduce spontaneously
in t he supine position. Lateral , right and left ob lique views clearly demonstrate the
Normal - Intact neck Pathological- Beheaded

Fig. 5.66(8) : Scottie-dog collar
Fig. 5.66(A) : Scottie-dog collar sign (oblique view)
sign (oblique view).
slippage (Scottie-dog collar sign in oblique views . Fig . 5 .66). On AP vi ew , lucency

at pars or reactive sclerosis (Napoleon 's Hat Sign), or spina bifida may be noted.
Flexion/extension views are useful for pre-operative decision making .
• CT : Very useful in doubtful cases.
• MRI : To note neurological involvement (compression) .
• CT myelography : Done only if MRI is inconclusive.
Treatment
• Conservative : Effective for most -
(a) Physical therapy (Traction , UST, TENS , spinal flexion exercises).
(b) Lumbo-sacral (LS) belts , modified Boston-overlap-brace.
(c) Injections -
(i) Facet joint -, steroid + local anaesthetic injections. (Triamcelone + lidnocaine
(ii) Epidural anaesthetic injections-, effectively reduces pain .
• Surgery : Indications -
(a) Significant neurological involvement causing paresthe sia/paralysis /bladd ,-
bowel dysfunction .
(b) Continuous and progressive slippage (seen in serial X-rays) with Grade Ill lesions.
(c) Severely disabling symptoms affecting activities of daily living (AOL).
Fig. 5.67 : Spondylolisthesis Spondylolysis Spondylosis Retrolisthesis
NOTE:
1. Retro/isthesis : Backward slippage of one vertebra on to the vertebra immediately below.
2. Spondylolysis : It is a bony defect of the pars intercularis (but no slippage). May later
become spondylolisthesis. (Scottie-dog collar sign, but not beheaded scottie-dog sign) .
[Fig. 5.66(8)]
3. Spondyloptosis : Grade V Meyerding spondylotisthesis.
4. Spondylosis : Degenerative changes of the spine. (See below)
SPONDYLOSIS
• It is actually a non-specific terminology that includes multiple . spinal _abn_or~ali~ies, all _of
which are precipitated by chronic intervertebral disc degeneration, which 1s inevitable with
ageing. By 50 years , > 95% of lumbar discs have at least some degenerative changes, and
osteoarthritic changes of spine has already begun.
• It is found in the cervical region (Cervi - Reduced disc space

cal spondylos is) , commonly in Cs- s
c
and C -C . In the lumbo-sacral region Osteophyte
6 7
(Lumbo sacral spondylosis) , it is com-
mon in Lc l s, and L 5- S ,.
• When IV Discs degenerate , they l~se
height , become flat , lose their function
and becomes fibrotic from elaS t ic .
nd
These lead to displaced facet joints a
nd
ultimately facet joint arthropathy , a
sometimes osteophytes (bony spurs)
~PPear at the margins of vertebral bod·
ies . Sometimes Schmor/'s nodules Fig. 5_6a : Lat. view X-ray of Lumbar Spondylosis
are also formed . (Fig . 5.70B)
- -------- ...
PROLAPSED INTERVERTEBRAL DISC(PIVD) (SLIPPED DISC, DISC PROLAPSE)

• Prolapsed lntervertebral Disc (PIVD) is one of the most common causes of low back pain .
Anatomy of lntervertebral (IV) Disc (Fig . 5.69)
• I~ discs are composed of three components -
(i) Nucleus Pulposus (NP) - Central and gelatinous. It is made of proteoglycan matrix,
which is rich in water, but the water content continuously decreases with age (water
content is about 90% in adolescents; 70% at 70 years of age) .
(ii) Annulus Fibrosus (AF) - Surrounds the NP in the horizontal plane. It is made of
concentric laminae of collagen consisting of radial and concentric fibres and in each
successive lamina, the fibre orientation changes. The outer fibres are attached to the
margins of the vertebral bodies, whereas the inner fibres surround the NP and are joined
to the vertebral end plate. All fibres of AF have a vertical component wh ich resists
distraction of vertebral bodies with forward/backward bending. Obliquity of the fibres
ensure strength in both the horizontal and vertical directions. (Figure 5.69)
(iii) Vertebral End plates (VE)- It 'sandwiches' the NP from above and below. It is made of
cartilage which layers the superior and inferior surfaces of each and every vertebral body
within the area of ring apophysis. It is firmly bound to the AF due to their collagen fibre
insertion into it, but it is weakly attached to the vertebral bodies .
Pathology of PIVD
• IV discs dessicate with age, and the NP gradual ly loses its turgid , gelati nous property
to become fibrotic . Concomittantly fissures develop parallel to VE in the AF which are
commonly directed posteriorly. This causes herniation of NP through the fissures ,
when they are excessively loaded/pressurized/compressed (Fig . 5.70 A) . NP first pro-
trudes then extrude, and finally may sequestrate. They may also perforate the VE
superiorly/inferiorly causing Schmorl's nodules. (Fig. 5.70 B)
• Herniation causes reactive bone formation around protruding materials at the vertebral
margins (osteophytes) , and also around Schmorl's nodules. This presents the classical X-
ray picture of spondylosis = disc space l., osteophytes ± schmorl's nodules ± lordosis
j, and may be scoliosis (due to inflammation causing paravertebral muscle spasm).
• Facet joint displacement always occurs, because IV disc space is reduced , which leads to
facet joint osteoarthritis. In severe cases
osteophytes at the facet joints may nar
row the IV foramen and cause compres·
VE sive neuropathy.
• Pain is not only due to mechanical com-
pression and structural dysfunction .
NP Intact inflammation and subsequent
neuro-chemical release are also contribu·
tory. Hence the size of the lesion or the
degree of neural compression often 0 ?
not correlate with the severity of pain.
High concentration of phospholipase A2
is found in herniated discs which acts as
rate limiting enzyme for the release of
arachidonic acid from cell membran~:
Leukotrienes. prostaglandlns, plate/e
Concentric
fibres of AF
activating factors bradykin/ns,
cytoklnes, lnterleukl:.S, nltrlt: oJtld• -
Fig. 5.69 : Anatomy of IV Disc are also contributow.
'"----
X-RAYS 261
Posterior longitudinal
ligament
P~otrusion Extrusion Schmorl's nodule

Postero
. . ·-Lateral
. hernia - Poster,·o r h ernratron
. .
Frg. 5 ·?O(B) : Sagital section of disk herniation
tron .1mp1ng1ng nerve ro ot indent in g th ecal sack
Frg. 5.70(A) : Cross-section of d,.sk h ern,atron
. .
Clinically (Acute PIVD)

• onset low the
back ain (LBP . g ad ult (20-:40 years) who gives history of acute
Typically patient
This may be foliowed by
is an youn
(a;r't .
started while bending/ stooping and lifting weight.
Pain is worse on coughing/ sneae~g j ·a11~· to (the . buttock or t~e lower limb (sciatica) .
paresthes· / I ng JO rng as rn a bumpy ride). Later there may be
ia_musc e weakness. Rarely
cauda-eq_uma compression may oc·
~ur, c~using urinary retention (some·
times incontinence) and sensory loss
over the sacrum and perineum
(saddle-shaped anesthesia) .
• The p~tient has a slight bent attitude to
~ne ~1de (listing) (Fig . 5 . 71 ). Often
here 1s midline tenderness and paraver-
~ebral muscle spasm . Straight leg ris -
ing _test ( Lasegues ' test) produces
rad1cular symptoms at < 70° and is pain-
ful , and there may be crossed sciatic
is
tens_,·on when the non-symptomatic leg
raised. Muscle power sensation and
ref exes are decreased .' Ely's test may
be Ipositive (page 36) Fig. 5 .7 1 : Listing
N.B. . . L, -L, PIVD causes L, nerve root compression --> sensory loss of anteromedial leg
•• and knee; quadriceps and hip adductor power ! ; depressed patellar jerk.
L,-L, PIVD causes Ls nerve root compression --> sensory loss of the outer side of
leg and dorsum of tool, extensor hallucis tongus (EHL) power ! ; and Ls s, PIVD
:uses 5 nerve root compression --, ptantarflexion power ! , eversion power ! , sen-
• . ry loss 1of the lateral bor<ter of toot and depressed ankle jerk.
• ~sc prolapse can also occur in the cervical spine, usually in the C( C, or due to c.-c,.
0 dden flexion and rotation of the neck. In C, root Involvement biceps reflex ,I, wrllll
:•tensor power !, sensation of thumb and index ,J.. In C, .... tllC8P ..,...~ ·.
exor power ! . sensation of middle finger .J.. ClintcaflY - pain/s
-+
LBPcerv· . .
. •cal collar/traction + med1cat1ons.
ep· is commonly recurrent (70-90%1 and wffh me
:odes of greater intensity and duration.
90 cases get well without treatment in 6- 2 weekS (
26
Diagnostic Imaging
• MRI is the investigation of choice for PIVD .

• X-rays in acute PIVD, X-rays are usually normal but may show spondylotic chang es
wh e n there are several similar past history.
(i) Ne urofibroma of the cauda-equina may cause sciatica. (ii) Tumours of vertebra ~ X-
rays show bone destruction. (iii) Infection / Ankylosing Spondylitis ~ raised ESR , X-rays
s how erosive changes.
Treatment
• Conservative : 97% get well satisfactorily with proper conservative care .
(i) Absolute bed rest for 2- 3 days followed by relative bed rest for 2-3 weeks is success-
ful in almost 90% cases.
(ii) Analgesi c/anti-inflammatory medicines are very useful adjuvants .
(iii) Physical therapy - UST, IFT, pelvic traction and exercises are useful. Rehabilitation is a
must.
(iv) Injection - Local anaesthetics and corticosteroids are useful, given by expert hands
with the needle placed accurately under the control of C-arm image intensifier. Epidu-
ral blocks can also be given .
(v) Chymopapain induced chemonucleolysis of the protruded/extruded NP is an option.
• Operative : Only 1-3% patients require surgery. After surgery : Sciatic rel ief - 80%, back
pain relief - 50%, failed low back surgery syndrome - 15%, persistent and significant
complains after surgery - 40%.
N.B. : Absolute indications for surgery are cauda-equina syndrome and deterioration of
neurological status. Relative indications are - patients not responding to conservative
management, thus causing significant loss of function/activity/work. Discectomy is
done and access to the disc is via laminotomy, laminectomy, microdiscetomy, etc.
• Rehabilitation : It is a must after recovery from pain. Patient is taught isometric exercises
and how to sit, or lie down or bend . This reduces the chances of future recurrence .
OSTEOGENESIS IMPERFECTA
It is a hereditary condition that occurs due to defective synthesis of Type I collagen, which
affects the bones, teeth , ligaments, sclera and skin. Multiple, or repeated instances of fractures
is characteristic, and bowing deformities occur due to malunion and osteopenia.
Clinically :
Common f~atures in all 4 !ypes are - susceptibility to fractures with minimal trauma, osteopen1a,
generalized hgamentous laxity, blue sclera and dentigerous imperfecta.
• Type I : (Mild) ~uto~~mal Dominant; Most common : Infants have repeated and multiple
tr~cturns even with tnv1_a1trauma that heals easily. They develop deep blue scfera and gener·
allzed hgafmentous la x1ty ,_ andd hsometimes teeth abnormalities. A er p be,ty ,actures
are less requen 1. 1mpa1re earing due to otosclerosis is co
• Ty e // : (L ethal) : Many are stillborn .
s k ull h as " wormian-bones" and is
poo rly deve loped . However, sclera is nor-
mal. Only few survive more than a month .
• Type Ill: (Severe) Autosoma/ Recessive :
Multiple fractures and severe bony de-
fo rmities including kyphoscoliosis are no-
ticed . Marked joint laxity , but the bluish
sclera gradually whitens with time . Very
few survive till adulthood.
• Type IV: (Moderate) Autosomal Domi-
nant : S imilar to Type I, but sclera are
light - b lue which becomes normal in
adults . H earing is normal.
Investigations
Prenatal d iagnosis is possible by amniocen-
Fig. 5 .72 : AP view X-ray of whole body showin g
tesis and qua ntifying inorganic pyrophos-
malunited fra ctu res of both femurs and tibias and
phate levels in blood ~ which is increased . left humerus with bowing deformities of legs~
Parent counselling to consider legal abortion , Osteogenesis lmpertecta .
which should be done .
Differential Diagnosis : Remember ~ Battered Baby Syndrome.
Treatment
• Splinting when fractures happen ; minimizes deformity.
• Surgery is aimed at correction of bowing deformities : multiple osteotomies ~ realignment of
fragments ~ IM nail fixation of long bones (Sofield-Millar). May need multiple surgeries.
BELOW KNEE AMPUTATION

• Historically , amputation was probably the first surgery to be performed.
• Below knee amputation is the most common amputation which is done.
• Disarticulation means removal of a limb (or a part of the limb) from a joint (does not need
osteotomy) , but amputation is removal of a part of the limb in between 2 joints (needs
osteotomy) .
lndicat·ions
li:~ngular absolute indication is ~ irreversible ischaemia in a .dise~sed or severely traumatized
' but amputation can be life saving in malignancy or severe 1nfect1ons (e.g., gas gangrene).
1· Peripheral vascular disease : Most common indication , especially in the elderly .
4
5
:~rns :
2 · Trauma : Common indication in the younger population (men > females).
3 ·_ Thermal and electric. Aggressive and early debridement is necessa ry initially.
ostbite : Initial treatment is rapid rewarming in waterbath at 4ooc-44oc temperature.
· Infect •ons
· : Primary c losure of any contam ·ina t e d woun d produces high · r i sk o f
:~s gangrene . Extensive and aggressive debrldement , followed by "Gui llotine" (open)
6 r Putat,on is done .
7
n~:::i~rs
C s,s
:(e._infection
and
g., Osteosarcoma) Limb-salvage att~mpts, ofte~ have great~r ri~ks like wound
~ which may warrant multiple surgeries. Amputation is wiser.
ongenitat anomalies ·. Underdeveloped, rudimentary and non-functioning lower limb vesti.ges.
- -~ ~ ==.--==:;i-a:iiiiiij- -- - ~-
264 HANDBOOK f OR
N.B.: • MNEMONIC: TB -fT & C.

• s causing
Rel tive ind1cat,ons : Chronic and refractory in fec l io_n.. f t d de form ities and
needing repea ted surgeries e.g., chrome os teomyelitis · in ec e non-unions, etc.
Varieties
I
t1ve definitive procedure.
1. Closed amputation : Most commonly done as an e ec ' du re It ·is a
emergency proce .
2. Open (Gu illotine) amputation : Commonly done as an th stump -t requires 2nd
provisional procedure where the skin is not closed o_ver e . al level second-
.
operation (after 1 O to 14 days) --7 options .. rea mputat1on at a prox1m '
ary closure or plastic surgery .
Level
• Exact level of amputation is a ?al~nce
between the "hope-for-more fun cti on (for
distal levels) and "lowered risk of com-
plications" (for proximal levels) .
• Transcutaneous oxygen measure-
ments are of great help to gauge vascu-
larity (th is is impo rt a nt e sp ec ia lly in
ischaemic limbs).
• In non-ischaemi c limb , the musc ul oten-
dinous junction of the gastrocnem ius is
an useful landmark.
• A stump that is 15 cm f rom medial joint
line of the knee is ideal. < 3 cm stump
is worse than through-the-knee-disa r-
ticulation .
Fig . 5 .73 : Lat. v iew X-ray of knee showing • Working principle -t 2 .5 cm of bone
con ical below kn ee amputation stump . length for each 30 cm of height, is to be
retained . (i.e. , 1 inch for 1 foot) .
• However, advances in modern prosthetics have decreased the importance of level, be-
cause excellent function can be given with any length of stump .
Technical Considerations for Surgery

A. Haemostasis :
1 . Tourniquet is a must for all , except for ischaemic limbs.
2. Large vessels (e.g., posterior tibial artery) must be doubly ligated. Before closure, tour-
niquet must be removed and meticulous small vessel haemostasis should be done.
3. Suction drainage (or at least a penrose drain) is a must to prevent haematoma. Drain is
removed after 48 hours. It prevents haematoma, infection and wound dehiscence.
B . Skin :
1. Skin flaps are cut so that their combined length is about 1 1; 2 times the width of the
limb, at the proposed amputation site (which is obviously more proximal).
2. Thick fascia-cutaneous flaps are desirable, and dissection is unwarranted.
-
---
- 3. (a) For ~on -isch_ae,:nic limb - equal anterior and posterior flaps .
(b) For 1schaem1c limb - options are :
• Long posterior and very short anterior flap .
• Equal medial and lateral flaps.
c. Muscles : Muscle suture is done using either one of the two techniques -
1 . Tendon myodesis : Muscle groups sutured to bone under physiological tension .
Contraindicated in ischaemic limbs.
2. Myoplast~ : Mus~les sutured to opposite muscle group or facia. Commonly done in
young active patients with non-ischaemic limbs.
D. Nerves : Nerves should be dissected out, pulled gently distally and sharply cut so that it
retracts proximally (due to elasticity) to the level of (or above) the bone-cut.
E. Bones : O steotomy is done at th e proposed level , with anterior tibia bevelled and
fibula c ut 3 c m pro xi mal for a conical stump. (Some surgeons cut both bones at
same leve l for a Square-stump) . Excessive periosteal stripping is avoided , be -
caus e it may c ause ring-sequestrum .
~fter Care
1. Plaster of Paris cast is moulded and applied for rigid dressing. Cast should be changed
weekly , until the stump shrinks permanently and the wound heals. This prevents oedema,
enhances wound healing and early maturation of stump, decreases post-operative pain,
prevents knee flexion contracture, and allows early mobilization/ambulation.
2. Early prosthetic fitting results in better and quicker rehabilitation .
3. Ideally, multidisciplinary team approach is needed, which includes orthopaedic surgeon ,
physical medicine specialist, psychologist, occupational therapist and social worker.
Complications
A. EARLY :
1 . Wound necrosis : Unnecessary long stump, suturing under excessive tension or
stump haematoma are detrimental , and so are smoking and protein energy malnutri-
tion . (Serum albumin < 3.5 g/dl is a risk factor).
2. Infection : Gas gangrene is the most dreaded complication (common with is-
chaemia and haematoma) .
B. LA TE . f .h . f . )
1. Skin : Contact dermatitis and eczema are common (do not con use wit in ect1on .
Ulceration is mainly due to ischaemia . .
2 · Muscles : Excessive . 1 adding -cushion of the stump induces feeling of
muse e- p
insecurity .
3. Nerves · d
( · neuroma, which may be ten er.
a) Cut nerve always forms a f ons are ~ educating the patient about
(b) Ph 1· b · Difficult to treat. OP 1
antom tm pam - . f the stump; Clonazepam.
th e poss1·b·1·t
11 y; repe
ated percussion o
. d to ill-fitting prosthesis , especially over the
• (c) Residual limb pain - Mainly ue
4 . bony prominences . . duces contractures . Rigid plaster cast dressing

· Jo,nt contractures : Ambulation re
5 is useful to prevent contractures ._ non-weight bearing , it becomes osteoporotic and
· ~one : Spur is common. If stump is
is liable to fracture .
L
I
-
C M
N.l . rm, or ni ta ta rs from neuroblastoma .

frorn small cell carcinoma of lungs.
• Common in the lower limbs and the pel-
vis . but can occur in any bone .
• Common in the diaphysis, but any part
(even the whole bone) may be involved.
Pathology
• Begins ,n the bone marrow , probably
from endothelial cells. Spreads via the
Haversian system to the bone surface -,
subperiosteal new bone fo rmation -,
destruction --? when repeated layer after
layer --? causes " Onion-peel " appear-
ance in X-rays. (Fig . 5.74)
• Directly spreads to the adjoining soft-
tissues thus involving it.
• Metastasis is mainly v ia blood to the
lungs and bones ; rarely to the regional
lymph nodes .
Clinically
• Often there is history of trauma which is
unrelated and irrelevant .
• First there is pain (throbbing , intermit-
ig. 5.74 : AP and lat. view X-rays of femoral shaft tent) , th en appears swelling . Also there
showing diaphyseal postero-medial 'moth-eaten' cor-
t1c I destruction with 'onion-scale' periosteal reaction
may be low grade fever and malaise.
nd sofHissue swelling Ewing's sarcoma. • Local temperature is raised , and
there is tenderness .
Investigations
• Blood : ESRi, may be leucocytosis.
• X-rays :
1 . Diaphyseal "moth-eaten " lesion which may be _
• Lytic with permeative margins.
• Blastic . with codmans triangle , su nray app earance
• C ys t I C. ·
2. 'Onion-peel' appearance .
3. May entire ly invo lve only the soft-tissues . ( F.
. · tg. 5 75)
• B l opsy : O pen b 1opsy ts a must. Sample shoul . ·
sues. Often pus like material is found duri d ,~elude bone and adJ.oining soft-tls-
ng operation .
N.B. It is essential to recognize the histol · .
··h very f ew mt·tot1
wr. ·c figures
· ogical picture O f ma lignant round cell tumour
and very rut
1 8
osteomyelitis . Slroma, as different from osteosarcoma or
lfferentiaf Diagnosis
1. Chronic osteomyelitis (clinically similar
~ pain , fever, tenderness, swelling , lo-
cal temperature I ). ln 111 bone scan is
useful to differentiate .
2. Metastatic neuroblastoma , osteoblasto-
ma, non -hodgkins lymphoma.
3. Prim ary sub-acute osteomy elitis. (see
page 102)
reatment
Chemotherapy, radiotherapy , surgery ~ all
ave a role. Combination is ideal.
1. Chemotherapy : Vincristine , Actino-
mycin D , Cyclophosphamide , Doxo-
rubicin , lfosfamide and Etoposide are
useful drugs.
2. Radiotherapy : It is a highly radi -
osensitive tumour, but has high re-
currence rate . Fig. 5 .75 : AP and lat. view X-rays of knee , leg and
3. Surgery : ankle showing destruction of proximal fibula with pe-
(a) Local amputation. riosteal reaction and soft-tissue swelling -
(b) Resection of bones, such as - ribs, probabl y Ewing's sarcoma.
fibula , clavicle .
SIMPLE BONE CYST
• Metaphyseal, benign lesion . Also called unicameral bone cyst. M : F=2 : 1.
• Age group ~
1. 4 to 8 years ~ Active stage : Nearer
to the epiphysis; recurrence rare .
2. 8 to 13 years ~ Latent stage :
Nearer to the diaphysis; recurrence
common .
• Most common site ~ proximal humerus.
Then comes proximal femur and proxi-
mal tibia.
• A_lways central (not eccentric) ~ Occu-
~ies most of the width of the bone, but
is less than the width of the physis .
. (Fig. : 5. 76)
hnica11y
• As
• Yrnptomatic - Common.
Symptomatic -
; · Pathological fractures (see page 246)
· Growth disturbances (common when
close to the epiphyses) . Fig. 5.76 : AP view X-ray of right shoulder, humerus and
3
· Deformities (e.g ., Coxa vara in proxi- elbow showing proximal humeral central osteolytic lesion
rnai femoral lesions). extending up to the diaphysis _, simple bone cyst.
Pathology
• Not expansile (c.f. , GCT, ABC) . It grows longitudinally along the axis of the bone.
• Contains pale-yellow ish clear fluid , rich in PGE 2 . Fluid press ure is high in active le-
sio ns, b ut low in o ld and la te nt lesions .
• Cyst walls are lined w ith membrane which have occasional g iant -cells. This membrane 1s
chiefly responsible for post-opera tive recurre nces.
Treatment
• Non- operative treatment is a dequ a te tor mo st les ion s, e ven those with patho l. og1cal
fractures . It is 'self-limiting' and so , it is be tte r to avoid surge ry and hence avoid post-
operative complications like growth di s turbances.
Options :
1. Aspiration of cyst flu id and methylpredniso/one injection intralesionally. May be
repeated after every 2 months for healing . Steroids reduce PGE1 activity.
2. For pathological fractures ~ manipulation and plaster casting achieves good union.
3. Surgery ~ thorough curettage of cyst walls (to remove memlbrane) foll owed by
bone grafting . Indicated for latent stage lesions with fractures , or patients w ith risk of
impending fractures .
FIBROUS DYSPLASIA
• Developmental disorder where normal trabecular bone 1s gradually replaced by fibrous tissue
• May be Monostotic (affecting single bone) , Polyostotlc (a ff e cting multiple bones).
Monomelic (involving one limb} .
Cllnlcal'ly
M y b ymptom he - i f monoslollc 1n
non -w 1ght b ring on s e g , ribs)
2 dolescent
X.-r
1.
2. ac , e
p
X-RA Y S 269
N,S. : II tt1e ma rgins ~re . ill-defined, and there is cortical break with adj ace nt so ft-
tissue mass ~ may indicate malignant change to Fibrosarcoma.
Treatment
• Monostotic, non-weight bearing bone ~ No treatment, only regular observation .
• Other options :
1. Curettage and bone grafti ng. Cortical bone graft is used as much as possible (e .g .,
fib ula) for su ppl ementin g stren gth to the thin cortex . Cortico -cancellous iliac c rest
bone graft chips may be used to fill-up the rest of the cavity . If it is still insufficient,
bone-cement/ bone graft substitutes may be used .
2. Deformities may need osteotomies and internal fixation .
3. For pathological fractures ~ Curettage + Bone grafting + Internal fixation .
OSTEOID OSTEOMA
• This very small benign tumour causes very severe pain . Rarely it is painless.
• Commonly found in the femur and tibia, but all bones , except th e skull bones can be
affected. Common in males, in the first 3 decades of their lives.
Clinically
• Continuous severe pain which is localized , but sometimes referred over a larger area.
• Peculiarly , the pain is worse at night and responds very well to sa/icylates (aspirin).
• Prolonged symptoms may gradually lead to muscle wasting , weakness or limp.
• Spinal lesions may cause paravertebral muscle spasm and subsequent scoliosis.
• When metaphyseal (i.e., near a joint), swelling and stiffness of the joint may happen .
Pathology
Nucleus consists of reddish or dark-brown lesion , consisting of disorganized osteoid and
bone cells, which are surrounded by dense bone .
X-rays
D(aphyseal or metaphyseal lesions, surroun~e~ by ~ery _dense sclerosis_(double ~e.nsit~
sign is diagnostic) and th ickened cortex, within which lies a small rad1oluscent n,dus
often invisible.
Bone scans and CT scans may be

required tor exact positional diagno-
sis because intense sclerosis may
hide the nidus.
Differential
Diagnosis
1' Brod·tes abscess and Ewing's sarcoma.
reatment
Cornp1
Sion ewthe _en -block resection of th~dle -
(che ' 1_c h must include the n1 us
is eked 1n X-ray of the excised bone) ,
8
int ffecr1ve . Bone graft ± prophy Iac t·1c
Cis~rnai fixation may be required if ex-
ion we a k ens the bone and ma k es 1
liabl ·t
8 Fig. 5.7N : Ostcoid O, tcom.1
for fracture .
?7() HA DBOOK f OR OH f1( Al IJI( S f X AM ll lAf lO f J
- - - - - - ~ ~ ~ - - - - - - - - - - - -._i
N.B. : • Comp ct O teoma (Ivory Exo tosl ) Pai nlo.,. s, benign , ivory-ha rd tumo ur,
usu lly in tho kull , r roly 1n th e nlero-m0d1al surface of the t1b1a. It may pro-
cJuc nourolog,cri l symptom s, when l't appea rs in Iha inner-tabl e of the skull.
• Os e ob lastoma (Giant Osteoid Oste om a) - Very simila r to osteoid osteoma ,
but much larger and more common in th e spine and fla t bones (e .g., sca pula,
pelvis, etc.) .
ANKYLOSIS
• Im mobil ity or s1iff ening of a Joint, oft on ,n an abnormal po sition , due to su rg ery, injury
o r disease is call ed ankylosis which 1n Greek means 'ben t condition '.
• Whe n res ulting from chronic inflammatory arth ritis, the a ffected joint te nds to assume
th e least pa1nlul pos1t1on , and gradually becomes permanen tly fixed .
Types :
1 . Extracapsu/ar : Due lo skin, fascia, muscles, tendo n sheath , ten don contractures -
which are outside th e j o int e.g ., myositis ossi fican s (see pag e 60). po st-burn
con tractures, Arthrogrypo sis multi plex cong enita (see pag e 7) .
2. Capsular : Due to adherent capsule e.g., adhesive capsulitis shoulder (frozen shoulder) ,
(see page 164) or prolonged immobilization causing capsular fi bros is and contracture.
3. lntracapsular : 2 varieties .
(a) Fibrous ankylosis (False ankylosis) : Du e to prolife rati on of fi b ro us tissue . Usu-
ally starts from the synovium , which has lost its endothelial linin g. It is th e com -
mon outcome of tubercu lar a rth ritis (exce pt cari es sp ine) . Some movement is
always possible, but pain is always ass ociate d with any kind of movement.
N.B. There may be -
Long fibrous union : Relatively greater range of movement, less pain.
Short fibrous union : Relatively lesser range of movement, more pain .
Fig. 5.79 : AP view X-ra y of pe lvis wilh both hips

showing bony ankylosis o f right hip a nd the Fig. 5 .80 : Bony ankylosis of elbow.
SI joint s -. Ankylo sing spondyli11 s. Note - Continuation of trabeculae from humerus to
ulna and radius across pre-existant joint.
b) 8 , a nkylosis. (True ankyloSIS . ) : It is due t 0
( 1ag e a nd s ynov,a l m e mbrane a nd . . to ta l destruction of articular carti -
th ·r .
septt c a r ri 1s , ca ri es s p ine a nk p ro.l1 fe rat1 on of os t eo b l asts . Found in untreated
1 nd
ti s , etc . When s urgi c ally inducedy ~s~n g spo ylitis (Fig 5 .81 ), rheumato id arthri -
1
No moveme nt is po ss ible X -ra ' h ,s ca ll ed arthrodesi s (art ificial a nkylosis)
· ys s ow conti n t' f ·
bo ne to t h e othe r , across the j o· t (F ' ua ion o bony trabeculae from one
79 5 8
an k ylosis, and it is en t ire ly du e \no th~gd~ · • · 0) . Pain is lesser than in fibrous
rreatment options sease process and not ankylosis .
1. Pharmacological : For d isease control

e.g ., DMARD for rh eu m a toid arthrit i
ATD for tuberculosis , etc. S,
2. Physical therapy : Important in cap -
sul ar a nd extracapsular v arieties , and
al ~o afte r any s u rgica l p roced u re for
qui ck re habilitation .
3. Surgery :
(a) Arthroplasty :
(i) Excisiona l arth roplasty.
(ii) lnterpositional arthroplasty.
(iii) Rep lacement arthroplasty. AP view Lat view
(b) Arthro/ysis. Fig. 5.81 : Ankylosing spondylitis of spine.
Note : 'Bamboo spine' and sclerosed SI joints (AP)
(c) Soft-tissue release - e.g ., in burn
and Lumbar kyphosis (Lat)
con tracture .
OSTEOARTHRITIS KNEE
• Os_teoarthritis (OA) is the most common of all joint diseases caus ing disability. OA may be
pr,mary (polyarticular, usually presenting > 35 years of age) or secondary (monoarticular,
due t?joint incongruity) . Prognosis is better for the primary type, because the natural pro-
gression of the disease is slower. Of the large joints, the knee is most commonly affected .
~ommonly it is bilateral. Prevalence rises steeply with age, and after menopause it is higher
in females than males. It is often associated with Heberden's nodules. (Heberden's nod-
ules are nodules in distal interphalangeal joints of fingers; Bouchard nodules are nodules
of proximal interphalangeal joint, associated commonly with pri mary osteoarth ritis) .
• OA is a dynamic disease of synovial joints, whi ch ca n have multiple aetiologies e.g .,
trauma (intra-articular fractures , ligament/ meniscal injuries, etc.) infection overload-
~ng (e.g ., obesity , inappropriate repetitive activity like unsuitabl e sports, prolong ed walk-
;"9, stair-climbing, etc.) . Normal daily activities produce loads on the knee, which are 2
0 7
•
OA istimes the body
a result of both weight.
mechanical and biological processes that destabilize the normal
cycle of synthesis and degradation of articular cartilage and subchondral bone, which leads
~~ softening , fibrillation , ulceration and loss of the articular cartilage, togetherwith sclerosis.
urnat1on , subchondral cyst formation and osteophyte form ation of the subchondral bone.
Patho
. 9 e nesls - sequential stages
(1) "Water-logging" of cartilage which 1.ncreases the
. .. llty
~ha~ce of pro teoglyc n extr ct,bi
(ii) from the matrix. Microscopically the cartilage remains intact.
~icroscopic defects appear in the cartilage due to loss of proteogtycans from within th
atnx, which results in a less elastic and less stiff cartilage.
(iii) Loading on tho damaq d arti,l ro g 1 .ds 10 criondrocyl damage. which releal ses en-
I0 f urth r proteoglycan oss.
zymes that furth er dam g s lh me tri x nd thus I < cJ s
· . . ·b ti n (due o elasticity) is losl and
(iv) T he import nt fun t1on of c rt1lage 1. . , to d dlstn u O .
joint loading 1s now concontr I d on th e unpro1ecied subchondral b~ne , which .leads lo
· ,, t·on and reactive sclerosis at the
focal lrabocular d g nor 110n , subc hondral cys t orma 1
zone of m xim I lo ding .
(v) Carti lage at th Joint edg s slarts repairing (hyperplasia) and endocho nd ral ossification
occurs causing osteophyl s .
(vi) Frayed cartilage and broken osleophytes may ultimately lead to loose-bodies which
causes mechanical irritation , resulting 1n an inf lammato ry process .
Patho,logy
(i) Continuous and progressive articular

cartilage disintegration.
Osteophyto (ii) Subchondral cystic changes of bone .

Sharpening
of tibial spine (iii) Sclerosis of the adjacent surrounding
bone .
'Diminished
medial tlbio-
(iv) Bony excrecences (osteophyte) for-
femoral joint- mation .
Subchondral
space
cyst (v) Fibrosis of the joint capsule (causing
sti ffn ess) .
Fig . 5.82 : AP view X - ray of OA knee
Initially (macroscopically) there is fraying and fibrillation of the cartilage , which finally
"gives-way" at the points of maximal load ing, to expose the bone wh ich finally lead s to that
area of bone to become "burnished" or eburnated (ivory-like-smoothness) .
Clinically
• Typically patients are obese with genu varum , and > 45 years of age , with the chief com-
plaint of medial knee p~in , which gets .worse on squatting, sitting cross-legged , climbing
stairs or prolonged walking . After a penod of rest the joint feels stiff.
• Q/E- Genu varum, medial joint tenderness ± quadriceps wasting + 1·oint effus · yn-
. t· d fl ex,on
ovial thickening ± 1xe
· d f · -
e orm,ty ± Morant Baker cyst (see page 177)
ron -+ s
X-Rays
• ~~ view (in standing, weight-bearing po-

si~i~n) -) tibio-femoral joint-space is di-
minished, commonly in the medial com-
Patellar ~a_rtment (initially) . Sharpening of the
osteophyte tibial spine s , (Fig . 5 .82) osteophytes and
su~cho nd ral cysts with surrounding scle-
rosis are commonly seen .
• Lat. view -) patello-femoral QA is clear-
ly demonstrated. Often there is supra-
patella~ calcification and patellar osteo·
p~ytos,s (Fig. 5.83) . (Suspect pyro·
Fig . 5.83 : Lat . view X - ray of OA knee P osphafe arthropathy if only the pa-
tello'f emoral compartment is affected) .
~ ive
cons
(i) Arc·lge sic~ / q~adriceps ~xercise / ac-
ti ,111 mod 1f1~at1on (avo1d1ng squatting ,
cl imbing stairs , prolonged walking , us-
ing com modes rather than Indian style
to ilets) / ambulatory aids (walking
stic ks. e lbow crutches , elastic knee
support) .
(ii) Ph ysica l the rapy - IFT , UST, SWD ,
leg traction, etc .
(iii) In tra-artic ular injections - steroids ,
Hyaluro nic acid. AP
Fig . 5.84 : TKR
Operative Options
(i) Arthroscopic lavage + joint debridement + removal of loose bodies.
(ii) Proximal tibial (realignment) osteotomy - commonly varus knee is corrected to a
normal valgus knee. (High Tibial Osteotomy - HTO)
(iii) Joint replacement I total knee replacement (TK R) - best and inev itable option for
aged patients with disabling symptoms. Pain relief is dramatic. (Fig. 5 .84
(iv) Arthrodesis - rarely done , which provides a stable , painfree but motionless joint.
NEUROPATHIC ARTHROPATHY (CHARCOT JOINT)
• Charcot (1 868), described a destructive arthropathy due to tabes dorsalis , which no en-
compasses all conditions affecting the nervous system and leads to the joint being insen-
sible to pain and joint-position-sense . Commonest cause now is diabetes me1tit,u s.
Other causes: (Mnemonic - SyMPATHY)

Sy : Syringomyel ia and spina-bifida.
M Myelomeningocele: Multiple sclerosis .
p Peripheral neuropathy (alcohol. a itami-
nosis); Post renal transplant arthropathy.
A Amylo id neuropathy ; aerodystrophic neu-
ropathy; Articular steroid injection .
T Tabes Dorsal is (NeurosyphiHis) : Traum
injury to spinal cord/peripheral ne' e .
H Hansens Disease (Leprosy): Hereditary
sensory neuropathy (congenital indiffer-
?·
Fi 5 85
Note · : Charcot ankle joint and foot. ence to pain) .
a .!"gross erosion , near total destruction of
r icular surface and subluxated joint. Y Yaws .
Pathology
• In contrast to OA h. h ·s a dynamic process of concom1ttant · .
degeneration n.d rep Ir
Cha W IC 1 ·ct d t t· d" . •
of threat's disease is chiefly a continuous and rap1 . es rue tve con itton. due to bse,nce
e normal "reflex-safeguards" (because of destruction of the afferent propriocepti e fibr )
·> 14 HAN DBOOK FOR OR
of joints agains: injury or abnor.m.al stress. Un:ecognized repetitive trauma is the main culprit,
because even ,n neuropath1c Joints , destructi ve processes can be prevented/minimized b
proper treatment and sufficient protection after sprai ns, eftusions or fractures. y
Articular cartilage is destroyed, bo ny/cartilaginou s fragments appear in the joints (loose
bodies); there is thickening of synovial membrane and joint effu sion tog etherwith capsular
and ligamentous laxity causi ng joint instability/subluxation .
lin ically
• The appearance of marked joint swe lling , severe joint laxity/instabil ity and progressive
deformity, in a patient who paradoxically does not complain of pai n, even with movement
is almost diagnostic. Search for the cause of neuropathy.
X-ray
• Initial X-rays are very similar to OA, but osteophytes are rare. Hallmark is intra-articular
calcification and gross erosion of articular surfaces , in a displaced and distorted joint. In
advanced cases t:here is total destruction of the join t (see fig . 5.85).
• Rapidly Destructive OA : Commonly associated with crystalline calcium hydroxyapatite
(HA) deposition. Com mon in shoulder with rotator cuff lesions (Milwaukee shoulder), but
also found in the hip and knee . X-rays show periarticular calcification and destruction of
sub-articular bone with gross joint disruption.
Treatment
• S ince stopping or slowing down the destructive process is impossible, even the mildest of
injuries in a neuropathic joint should be meticulously observed and treated , which often
prevents future destructive arthropathy. The hyperemic inflammatory process after injury
must be allowed to subside totally before allowing weight-bearing or surgery.
• Fo r establ ished disease-splintage of unstable joints, and using protective calipers and
spl ints .
• For weight bearing unstable joints (ankle, knee, hip) - arthrodesis should be considered.
DEVELOPMENTAL DYSPLASIA OF HIP (DOH)

N.B. • Previously called congenital dislocation of hip.
• Associated strongly with congenital torticollis (8 in 100 - see page 163), metatarsus
adductus and talipes calcaneovalgus.
• Common in whites, uncommon in blacks and chinese.
Incidence
• Case detection is about 5-20/1000 live
birth I which comes down to 1/1000 at
3 weeks. Orthopaedicians success at
detection is more than paediatricians.
• Family history is positive 1 in 7 and
incidence is higher in the first born,
and in breech deliveries.
• M : F = 1 : 4, (L) sided > bilateral :>
Fig. 5.86 : AP view X-ray of pelvis with both hips
showing dislocated left hip. (R) sided.
Aetiology and Path ogenesis : There are many theories none of which are conclusive. Example
are genetic factors, hormonal factors (increased maternal oestrogen, progesterone, relaxin levels
,pwho
mentous
carry laxity)
babies ' intra
withuttheis
. h.
enne malpos1l ion (e .g. breech), and postnatal factors (e.g.
1
Assymmetrical gluteal d ~s abducted , have less incidence of DOH)
an groin skin fold ·
• Age - 6m : O rtolani test d s is an unreliable sign .
. . an Barlow test · ·.
spfas1a , Ortolarn/Barlow test may be . is positive. However if there is acetabular
negative at birth d DOH
, Age 6m - 18m : Gradual d • an may develop later.
ecrease of abducr d
ps (see fig . 5.87) . When the patient t . ron ue to adductor co ntracture devel -
.,atltlling gait. Later there will by positiv s ~rts walkrng , there will be Trendlenburg's sign and
r-___ _ ___ _ ______ e__aleazzi test (see page 115 and fig. 2.1. 14-A. B, C).
Fig. 5.88 ; Note ; P = Perkin's line, H = Hilgenreiner's

Fig . 5.87 line, CE = Wiberg 's centre-edge angle
Note : Decreased abduction of dislocated left hip.
• Age 18m -36m : Wide perineum , increased lumbar lordosis and shortened limb with LLD .
n~sligation : USG is the investigation of choice from 0-6m. X-Ray interpretations of the older
1ld requires the help of Perkin's line. Hilgenreiner's line, Shenton's line, Wiberg 's centre-
ge (CE) angle, and acetabular index (see fig . 5.88)
reatment : Different at different age groups.
• Age 0-6m : Pavlik harness has about 95% success , but has the complication of AVN
rare). It is essential to check the reduceabifity/stability of the hip before applying the harness.
mmediate check X-ray is a must with the harness in-situ (for readjustments of straps when
equired). Harness has to be worn constantly until Ortolani/Barlow test is negative.
• Age 6m - /Bm : Pre-operative surface-traction __, percutaneous adductor tenotomy __,
perative closed reduction --, check arthrogram. If arthrogram finding is - medial dye-pool < 5-
mm, it is acceptable reduction and hip-spica plaster is done. If there is 'hourglass constric-
on', then open reduction will be needed (see below) .
• Age 18m _ 36m : Open reduction and redirectional osteotomy of either the proximal femur,
' the pelvis, or both. Options tor pelvic osteotomY .include Salter's i_nnomi_nate osteotomy,
;;""!'rton's acetabuloplasty, Staheli's. shelf operatron , Steel trrple rnnomrnate osteotomy
tat osteotomy) , and Chiari medial displacement osteotomy.
' . Age > 36m : Difficult to treat. Will need open reduction , but never give pre-operative
action , because incidence of AVN will be more.
~ Ortolani's test : Hold both the thighs of the baby with your_<humbs medi ally and your_ fi ngers
Se trochanter. Then flexing both ,he hi ps to 90° gradually and 1multane~u ly abduct the hrp (see
· ). In DOH abd ·t · . b < 900 ( ee fig 5.90) bu t when medi all y direc ted pressure is applied
. 89
Cr th ' thUC 10n WI 11be ereduction
. e trochanter ' .
with a " click
. " , and then 90 0 abdu ctio
•
n will
•
be pos ,bl
.
.
1 as . . . , ere may
pO Siti ve Ortolani Test.
Fig. 5 .89 Fig . 5 90
• B, rlow's tei,t (Pro ocati c) :

hi, deL cts unstab le, di Locatable hi p in the
newborns. Pl ace bolh y ur th um bs in Lhe
oroin and gras p th thi ghs (sec fi g. 5.9 1), fl ex
0 ~
bolh Lhe hips Lo 90°, and app ly longitudinal

compress i ve force w hi le adducLi ng and ab-
ductin g Lh e hip, Lrying Lo di . locate the hi p.
The tes t i posi tive when you are ab le Lo dis-
Fig . 5.91 locate the hi p.
SLIPPED CAPITAL FEMORAL EPIPHYSES (SCFE)

• Also known as femoral capital epiphysiolysis . It is an uncommon disease .
• Slipped cap ital femoral epiphysis is a misnomer because the epiphysis remains within
the acetabulum (held by the ligamentum teres femoris) and actually the metaphysis
moves upward and outward whi le the epiphysis remains in the acetabulum.
• Common in boys during pubertal growth spurt (12 to 14 years) .
• Twice more common on the left side .
Aetiology
• 30% cases are " acute" slips due to tra uma . Sometimes there are " acute-on-chronic"
slips but majority are gradual and slowly " progressive" slips.
• Hormonal inbalance during puberty may be the primary cause . Normally the pituitary
hormones cause growth-plate (physis) hypertrophy leading to rapid growth , wh il e the
gonadal hormones ensure phys is maturation and finally epiphyseal fution . When there
is hormonal imbalance (as found in the hypogonadal 'Frohlich type' children , or _in
juvenile hypothyroidism) the slip occurs through the hypertrophic zone of the physis.
• Other factors responsible are overweight/obese children , femoral neck retrove rsion ,
increased vertical obliquity of the physis .
Pathology
The capital femoral epiphysis remains within the acetabulum while t he neck of the femur_is
displaced anteriorly causing external rotation of the femoral shaft. When there is gross dis~
placement , the anterior retinacular ve ssels are torn and the only vascularity to the femoral hea _
18
from the posterior retinacular vesse ls . Damage to these vessels during manipulation or op
era~ion may cause avascular necros is (AVN) . Physeal displacement also leads to premat~re
fusion ?f th e epiphysis (within 2 years of the s lip) which may cause permanent external rotation
deformity of the lower limb and apparent coxa-vara.
- ----·- ~~--"'
X-RAYS 277
ClinicallY
patient is usually a boy in the pubertal
thin, who com~lains of ~ain in the groin som:tT~i;oup, eith_e r _overwei~ht o, excessively t II and
h
uexion , abduction and internal-rotation are d wil radiation lo thigh or knee. Thorn 1s limp;
deformity with shortening . There may be h e~reased and later t~ere is ri ed e ternat-ro t t1on
sic diagnostic sign is increasing external rie;.
e te~sion or the hip . Kn ee-axilla sign : A clas -
a ion with increasing hip flextion.
X-ray
1. A P view : Often the diagnosis may be missed,
· .
especially early in th e disease.
• Metaphyseal
meta blanch sign. of St
h ses due . _eel .. A crescent1c area or .increased density in the
P Y to supenmpos1t1on of displaced femoral head (double density) .
Fig. 5.93
Fig. 5.92 : Trethowan's Sign
Trethowan's sign : A line (Klein's line) drawn along the superior border of the femo-
• ral neck cuts the femoral head. In SCFE the line passes above the femoral head .
(see Fig . 5.92)
• Capener's sign : The posterior acetabular margin normally cuts the medial corner
of the metaphysis. In slip, the whole metaphysis remains lateral to the acetabular
margin .
• Herndon 's hump : Bare area over the anterior and superior area of femoral neck
that gets remodeled and becomes a hump. (see Fig. 5.93)
• Shenton's line : Broken.

2 · Lat view : Most reliable view tor diagnosis of the slip. (see Fig . 5.93) .
Clas 81·t
ication
A-p v~ Based on magnitude of the displacement, expressed in % of the width of the femoral neck on
ew and Epiphysio-femoral
· shaft angle seen on frog-latera I v,ew.
·
Frog-lateral view
AP view
< 30°
1. Mild/minor t 33%
31 °-50 °
2. Moderate 33%-50%
> 50°
3. Severe > 50%
Tr
• ti /rntn 1 h 2 er u d ,r tm
•
n
r ll mpt lo e reduc ion because it nea rly lw ys c u os AV . p n
!1 t t1on by 1 2 screws is done. although th1 s m y lso c us AV 11
ur le I d: o c to echrf que in expert ha nds oft n produce good
ompli c ion
1 'S1 1pp1ng ' ol th op osit hip · About 20°0 to 40°0 . So look out tor it.
2. AVN : N rly lways an iatrogenic compl1ca t1on. due to manipulation/ope ration . Oi
3 Articul r chondrolys1s · May lead to early osteoarth ri tis and loss of mobi Hty.
4. Co -v It is 'apparent' co a-var a because ess entia lly it is retrove rsi on of the
T
CONGENITAL PSEUDOARTHROSIS OF TIBIA
• Cong rntal pseudoarthrosis of the tibia is a misnomer, because it is not a true pseudoar-
th ros1s . Th non-union (pseudoarthrosis) develops after birth through a detect present in
th ibia since birth . It is basically a fracture with which the child is born and which has
falied to unite till now.
• Most common site - junction of upper 213rd and lower 1/3rd of tibia .
• It is notorious for failure to achieve union and refractory to most forms of limb salvage
treatment.
Aetiology : Not clearly understood.
• Hy pothesis -
(i) Nutriti onal defici encies
(ii) Constriction bands
(iii) Intra-uterine pressure effects
• Sometimes associated with -
(i) Neurofibromatosis
(i i) Fibrous dysplasia
Clinically
• H/0 repeated fracture at the same site .
May be bilateral.
• Anterolateral angu lation of the tibia at Fig . 5.94 : Note anterior bowing, sclerotic end5
the junction between upper 213rd and and partial obliteration of medulla.
tower 113rd.
There is shortening , valgus deformity at the anl< '
•
abnorma l moboli 1y . lack of transmitted mov ernent
· Iess
( pain 5,
• Signs of non union
palpable gap)
Tendo-achilles may be contracted
•
• , :-ife-au-lait s pots may be s o . Roughofed
neurofibromatosis. (ii) Coast eefnM-ame
_(i) :Coast California : ~m~oth edges, seen in
Radiological classification (Boyd's) ges, seen rn frbrous dysplasia.
• Type I : Defect p resent since birth.

• Type . : Most
sc eroIIre · h pa
wrt common type
rtial/total · Hourr g1ass defect sinee b"rth
obliter r . Ends ot tibia are tapered
ated t
I with neurofi bromatosis Poa ion of medul_lary canal. Most common type associ~
. · orest prognosis .
• Type Ill : Cystic lession at the SI·t e.
•
T v
Type IV : Sclerotic site , but ends are not tapered,
medullary canal is not obliterated
• ype : Associated with fibular dysplasia.

• ~{i~aVI : P seudoarthrosis occuring through an intraosseous schwannoma/neurofi-
Differential diagnosis
Battered baby syndrome : . Mu ltiple fracture at dilterent sites at ditterent stages of
1. healing . History of fam ily dispute may be present and it is unlikely after 3 years age.
2. Osteogenesis imperfecta : See page 262.
Treatment
Counselling about guarded prognosis, requirement of multiple operations, even ampu-
• tatron rs a must. Consider the anticipated shortening of tibia, and other deformities of
the tibia principle
Surgical . : Excision of the pseudoarthrosis site with removal of all hamartoma-
• tous tissues + intramedullary fixation (Peter-William's rod - Anderson 's technique) +
bone grafting. Jf anticipated shortening is 3- 5 cm, options are - vascularised fibular graft
or distraction histogenesis (llizarov) .

For multiple deformities and non-union options are - multiple osteotomies and Taylor
• spatial frame or multiple osteotomies and intramedullary rod (Sofield-Millar operation/
Seekh-Kabab
Indications operation).
tor amputation : When anticipated tibial shortening > 5 cm; _failure of multiple
• operations is the past; severe functronal rmparrment, when the srte rs < 2.5 cm from
' the ankle.

Langenskiold's operation : oone to correct vaJgus deformity at the ankle.
' Newer modalities : rh BMP 2, 7 and cathode electrical stimulator.
Compr
ications
~ffiness of ankle and toot; refracture; ankle valgus ; shortening
. .
CONGENITAL RADIAL CLUB HAND

11 is longitudinal, failure of formation-of-parts , along _the radial (lateral) border_of upper
• extremity P d . malformations of bones, Joints, muscles, tendons, ligaments
, ro ucing many d" 1 d l . •
,nerves and blood vessels. AJso known as ,a ,a . ysp as1a. . .
, ncrdences is t : oo.ooo. bilateral in so% cases. Rrght srde rs common rn unilateral cases.
• 1
;1iology is unknown. Exposure to thalidomide, phenobarbitone. amitryptlline, alcohol and
ad1at1on are r" k f t sometimes associated with Holt-Oram syndrome, VATER syn-
dro
(s me, VACTERAL15 acsyndrome.
ors. Fanconr· anemra · and TAR syn d rome. Co-ex1sting
· DDH
ee page 274), proximal radiouJnar synostosrs (page 170), congenital radial head dislo-
cation, fibular / tibial hem1melta , clubfoot (p ge 1) . kyphos1
163) , rib deformities and cleft palate may be present . (p g 255), tort1coll1s (pr:1rJe
Patho-anatomy
1.
Bone and joint . Small scapula , short clavicle and deficiencies of th ap,tEJllum , J
tro~hlea are common . Ulna is short, thick and curved . Total absence of rad u or d,"~'
1
radial deficiency is found . Scaphoid and trapezium are often absent or hypopla"~'~ 1
Thumb including the first metacarpal is absent in 80% cases . ·
2. Muscle and tendon : Long head of biceps is absent , short head is hypopla tic
brach ialis is deficient, and brachioradialis is absent in 50% cases . Abnormalities are
found in any muscle that attaches to the radius e .g . extensor carpi radialis longus and
b revis , pronator teres , tlexor carpi radialis , palmaris longus , flexor pollic1s longus, pr-
onator quadratus . and supinator .
3 . Nerve and artery : Radial nerve ends at the elbow . An enlarged median nerve substi-
tutes for the absence of the radial nerve . Radial artery is often absent.
Clinically
• Shortend forearm , ulnar bowing and manus valgus (hand may be pe rpendicular to the
forearm) , shortening or absence of the thumb is seen .
• Elbow motion is reduced, more in flexi on than in extens ion . T rue pronation/supinat1on
is ab s ent. There may b e stiffness of fi ngers and wrist.
• Fo re arm is shortend by 50%-70% in comparison to the opposite _f~rea rm . Arm length
may be reduced . G ri p strength is decreased. Neurovascular def1c1t may be present.
X-ray
• Useful to assess associated abnor-
mali t ies o f elbow/wr ist/hand and to
measu re hand-forearm angle and
ulnar bowing. Ossification is delayed ,
so final determination of deficiencies
of carpus/ rad ius should be done after
the age of 8 years .
Treatment
• Non-operative : Initially passive
stretching of tight radial-sided struc- Fg 5 95 : Note thickened curved ulna. distal ~dial
tures by the mother at each diaper d~ticie~cy , absence of 1st metacarpal and rud1rnen·
change and bed time . ~p.l int is used tary thumb , hypoplastic carpal bones.
when forearm is of sufficient leng th . . . t car al malaignment.
Serial plaster casting can be done but it will n~t c~rrec p r us on the distal end
• Operative : Done at 6-12 months of a~e. Centrahzatl?n of the c~ pdone together ith
of the ulna in conjunction with soft tissue release is co~"!'on \oo ~ severe cases
closing-wedge osteotomy to correct ulnar bowing ~hen it is ~ r ss~e1 distraction (f r
centralizing the wrist is very difficult during operation . So so I be useful to corre t
stretching) using an external fixator is done. T~n~on transfers ca~hs after centralis tion.
muscular imbalance (e.g. flexor carpi ulnaris) and it 1~ d~ne 6 - 12 mo~f ·ng the rudim nt ry
Pollicization using the index finger is done when indicated , sacn ic,
thumb .
complications
• Disruption of the ulnar growth plate and subsequent ·increase in
· LL 0 ·
• Ankylosis/arthrodesis of the wrist joint. ·
Chapter 2
INSTRUMENTS & IMPLANTS
Theories Discussed
• Bone Graft • Sterilization
A. FARABEUF'S PERIOSTEUM ELEVATOR

• It is the most commonly used orthopaedic instrument and is needed in 2 ost all ortho-
paedic operations.
- , - - - - 3 ---.i-
• Remember ~ In fracture fixation, peri-
osteal stripping ca n ad versely affect
the blood supply (an d thus bone-heal·
ing) . So stripping shou ld be minimized.
What are its parts ? (Fig . 4.2.1)
1 . Handle : (Flat , long) For gripping.
2 . Thumb rest : (Serrated and concave) It
gives better grip of thumb when placed
on it , and prevents slipping . It also
directs and controls the force applied.
Biomechan ically it shortens the effec-
tive lever-arm, by acting as a fulcrum be·
tween the handle and the tip.
N.B. : The thumb-rest acts as a fulcrum and
the handle as lever arm. So the length of the
handle : thumb rest to sharp end, is always about
3 : 1 to give better mechanical advantage.
3. Sharp , bevelled, curved tip : This end is
Fig. 4.2.1 : Farabeuf's periosteum elevator. applied to the bone , to strip-off the perios·
teum and the curvature adjusts to the
rounded contour of the bone. Safety rule :
Always keep blade in contact with bone -
avoiding vessels and nerves.
What instrument 1s used before and after
using the periosteum elevator ?
Scalpel blade is used to cut the periosteurn
before the periosteum elevator is insinuated in
between the bone and periosteum. Bone leve~~
are used after stripping the periosteUf'.', to 11~t-
the periosteum along with its sof1-t1s 5 ue
tachments away from the bone. (Fig. 4-2·2)
te tht
Why do we need to srr,p and ,:/eV 8
per,osteum in orthopaedic surgery ?
Fig . 4 .2 .2 : Operative step showing use of bone Because -
lever (Bl) in retracting soft-tissues away from the ,· perY
1 . Periosteum is a tough and 5 IP 1116
bone after elevation of periosteum . structure intimately encasing
200
INSTRUMl:NTS & IMP ANf
bone . '.hus any inst~ument applied over the peri osleum will lend to slip , and proce
dures like bo~e cutlrng a nd drilling would be very difficult.
2. When the penosteum, along with lhe adjacent soft-tissues is held apart by bone levers
away from the bone ~ using any ,nstru- '
ment is safer because nerves , blood
vessels, muscles, tendons are retracted
away from the operative zone .
3. Stripp ing pe r iost e um , a n d ele v at -
ing it along with the adjacent soft-tis-
sues helps in easier reduction of dis-
placed fractures, to restore normal ana-
tom ical bony continuity.
In what orrhopaee11c opera ion periosteum
elevator 1s NOT us£ d?
1. When operating on patella (e.g., patellec-
tomy, tension-band-wiring , etc.) .
2. Excision biopsy of exostosis.
In whst operation have you seen this to be
used ?
(Always say about the operation which you
have seen and can confidently answer the indi-
cations. patient-position, operative steps, etc.) Fig. 4.2.3 : Different types of bone levers .
Example : lntramedullary Kuntscher nailing for fracture shaft femur, Saucerization and seques-
trectomy for chromic osteomyelitis, Tension-band-wiring for fracture olecranon , Amputations.
Sterilization procedure : See page 213 .
B.OSTEOTOME
• Osteo = Bone; Tomy = Cutting. Thus osteotome is an instrument for cutting bone.
• There are 2 varieties - straight, and cuNed. ____ _ 3
What are ,ts parts ? (Fig. 4.2.4)
1. Blunt, flat end - For the mallet (hammer)
to strike.
2. Handle - For the surgeon to hold with the
non-dominant hand.
3. Quadrangular flattened shaft, gradually
tapering to sharp end with both sides bev-
elled - to cut bone (available in various
breadths).
NA. : In chisel, the sharp end has one-side
i.:veQtJd ~,.Page 202) Fig. 4 .2 .4 : Osteotomes - Straight variety.
When and why la it used? What Instrument is essential for usmg alongwlth osteotome ?
Used for cutting bone. Mallet is essential for striking the blunt end of the osteotome for
cutting bone.
Whar Instrument I• ••••ntlal before u sing the osteotome ?
Bone levers are essential to hold the periosteum away from the bone, to prevent slipping of
the Sharp end of the osteotome. Drill holes in the bone prevent splintering.
tvh• Olher ln, trumenl• may I» used to cut bone ?
talion saw, Gigli-wlre, bone-nibbler, bone cutting forceps, rongeurs, etc.
RTHOPAEDICS EXAMINATION _ _- ~ - ~ - - - -- - ~ - . . __ _ ~
fl t I Ost otomy ? What is Osteoclasis ?

Osteotomy is the surgical sectioning of bone . It is ta~ing out a part or all of a bone, or cutting
int or through a bone. Osteoclasis is surgical destruction of partial . bony C?rtex . The ?one may
be broken and then reshaped with the aid of manipulation , metal pin, casting or bracing.
Whe, ha ve your seen osteotome being used ?
For t kin g bone graft, excision of exostosis , osteotomies (French osteotomy/ McMuray's os-
teotomy, tor saucerization operation , fish-scaling of bone surfaces before bone-grafting.
In p r ocedures like osteotomy and saucerization, what is d one before using the
osteotome ?
Dri ll holes are fi rst made marking the line of proposed osteotomy, and then the osteotome is
used - first to join the dri ll holes, and finally to cut the bone. This pre-drilling weakens the
corte , prevents "chipping-off" of bone and irregularity of the osteotomised bone surface,
thus ensuring a straight, smooth clean-cut bone surface at the desired angle and direction .
Sterilization procedure : See page 213
C. CHISEL
• Chisel is similar to osteotome with the only difference being, it is sharp with one-side bevelled.
How is the bevelled-end useful ?
When the flat surface is placed on the bone and the mallet is struck on the flattened
opposite end , a thick chunk of bone is removed '. If the bevelled surface is in bone contact
while cutting , a thin slice of bone is removed .
Where ha ve you seen a chisel being used?
1. Bone graft removal from iliac crest.
2 . Saucerization.
3 . To remove excess callus when operating
on old ~ntreated fractures or hypertrophic
non-union cases.
4. Removing bone chips around screws and
plates , before removing them .
5 . Rarely, it can be used as an periosteum
elevator.
N.B. Box chisel is useful in Fig . 4 .2.5 : Chisel.
hemiarthroplasty operation .
D. BONE GOUGE
What are its parts ? (Fig. 4.2.6)
1. Flat, blunt end : For the mallet to strike (mallet i .
s held with the dominant hand).
2 · Handle : For the surgeon to hold, with th e
non-dominant hand .
3 · Trough-like curved blade concave on one
surface with a sharp end.
Whaf is the utility of the concave, trough-likt
blade ?
It automatically accommodates the bone
chunks that has been cut and ensures easY
Fig. 4 .2.6 : Bone gouge. removal. ·
•1. Sites from where bone graft i
Iliac crest :
- Anterior (commonly) and po t
2. Fibula :
- Except distal 7 to 8 cm (f r . nkl rn rt1,,
. ~a~:l~a~~:l~n~a~~t~~ fore ps r u · r1 It r lrlll h JI 11 rr 1r11 1di
3
4. Sometimes e;cised fem~arkel nh lrodm ol , 1' 1"1011, If., xi,' ,J l/lil (1111'1' J/ 11111 Ill d ' IH l111 i ) ,
. . or r • , c 1h t , tl , d 11 1111111 Jt di
• lnd,cat,ons of bone grafting :
To ~asten and ~~omote union in pdi n1 < with norH H1l or1 , :111!1 d I 1y1 I fltilr II qi II., 111/t ·
To fill bony cav1t1es or de·l ect e.g., fl r 1 , U rll' II r1 , t lrl b!Jfl/ r vc;I 1 ( <1 I qlr
Arthrodesis of joints : ensures bony 1u \ n
To bridge bone loss defects nd thu o t~bll•·h ontlnulty IJ1/111
Arthroeriasis : Bone block spacer to llmi1 rnt>v m nt u r'
Types of bone graft :
Cortical (e .g ., Fibula) : Used wh r ·tructurnl upp t't I 11 , !11 d , , J , 1111111lj I , JH
bony cavities , and simultan ous ly n urino th r I · n II : poi ul 111,1 , 11VII v wnll ,
Cancel/ous (e .g., taken from In b tw n th lnn r •,n J 1, 1 , ,1llrAd nl I• , I 111 ,rn
crest) : Used to promote ost og n ·I· .g., tr LI tnf nl I n rt 11t1lr,t JJ
Cortico-cancef/ous (tak en from ·l ull lhl kn llif1 ,r ·I ,, 111 11, totni di ,d q111 ln P 1d
1
proximal tibia) : Used wh ere both o 'l nr ·\ incl ·trn t11 n1I 11, 11 111 1 I 11 q1i11t ti
Although strictly speaking not b n r· II , bu'I 11 ow n I 1y 11 , r, t1111r 11111 , I, 11 , t , w
is injected at the fracture lte to prc:,moto/h r I n l, nlln J,
Bone graft substitutes : Tric· lcl um ph ·phut , olh r di , 11 I 111111 pl11 pl\111 1 11\ttill !i ,
Mechanism of action : t ol lfl I
Osteoinduction : Recruits ho ·t lt rn II
Osteoconduction : Acts as ·c' rr Id I r v I r 11
Osteogenesis : Bone morphog In (
E. SEQUESTRUM 0
I cl It h ,Id th I 11111 l II I
It is NOT a sequestr ctomy 1 re P · It u
remove it, and not cut th u trum .
hat are Its p rts 7
1. Serrated and fenestrated blad rn ·
tions are useful tor firm grip of th ' -
questrum while fen stration llow tor
accommodating th e sequ strum .
2. Handles with finger nd thumh grip With
I th
no catch : This prev nts cru hln
equestrum.
21
on proc dur :
F. - ON CUTTIN 0 P (Fi . 4 .2 .8)
• Available with straight or curvod bl, cJ •,. M,1y ~HJVO ,In JI' r <Jouhlo ful ,rurr,.
• Used for -
1. Cutting fibu la, phalanges, melac rp I Im lair r~al' , rih , nd < plnou
2. Fashioning the bone graft piec Into lh xnct cJ 'Ir cJ hap
Sterllizatlon procedure : See pag 2 13
ulcrum
Curvod
end
Fig. 4.2.8 : Bone cutting forceps. Fig. 4.2.9 : Bone nlbblers.

N.B. : Double fulcrum is useful to augment and multiply the force applied (double action).
G. BONE NIBBLER OR BONE NIBBLING FORCEPS (Fig. 4.2.9)

• Available with straight or curved ends. May have si ngle or double fulcrum .
• Used for -
1. Smoothening the cut bone-end of amputation stump , or after remova,I of exostosis.
2 . Sometimes used to cut calcar of fe.moral neck to desired le,ngth , before inserting
prosthesis in hemiarthropl asty operation of hip .
3. Removing adherent soft-ti ssues f'rom bone graft pieces, bef'or placi ng hem.
4 . Freshening fracture ends to remove callus/fibrous ti ss u before fracture fixation .
Sterilization procedure : See pa ge 213
H. BONE HOLDING FORCEPS

• Used for -
1 . Holding the bone, so as to manipulate them and co rrectly reduce fracture fragments.
2 . Steady the bone while reaming, cutting , nibbling or drilling a bone.
Fig . 4.2.10 Vanous types of bone holding fore p .
I. VOLKMAN'S BONE CURETTE
• Has a Ion~ handle with serrations for proper grip and has sharp edged, curved, spoon like
trough at ,ts end .
• used for -
1. Scrap ing the walls of cavities of be-
nig n bo~e tum ours like bone cysts ,
ben ign giant-cell tumours , aneurysmal
bone cysts, etc. Double ended
2. Scrapi ng osteomyelitic cavities (after bone curette
saucerization) or Brodie's abscess.
3. To remove immature callus and fi -
brous ti ssue from neglected fracture
ends of bone , so as to freshen them
before attempting reduction of the
fracture.
4. Freshening sinus or fistula tracts . Fig . 4.2 .11 : Bone curette .
J. BRADAWL
• Has a handle at one end and a sharp arrow-head with a small eye or hole at the other end.
May be curved. Eye
• Used for -
1. Opening medullary cavities of bones, <~
when operating on old untreated frac- . . ,5
tu res , which removes the fibrous plug Fig . 4 ·2 -12 · Bradawl (Cobbler awl)
from fracture ends and aids healing. This is done before reduction of the fracture.
2. Suturing tendons to bones (e.g. , patella and patellar tendon ; triceps ~endon t~ ole-
cranon) where a wire is passed through the hole and the bradawl 1s used like a
cobbler's needle.
K. AWL
• Has a handle and a sharp trocar pointed
tip but no eye.
• Used to make a hole in bone e.g., for
making the starting point for introduc-
tion of intramedullary nails. Fig . 4 .2. 13 : Kuntcher's diamond-pointed awl.
Sterilization procedure : See page 2 1 3
L. LOWMAN'S CLAMP OR LOWMAN'S FORCEPS
• May be 3 pronged or 4 pronged.
• Used for -
1 , Holding the fracture at ~ re?uc~d
position while internal f1xat1on is
being done by plates or nails. The
Plate is held clamped to the bone.
2. Rarely, may be used as a bone hold- Fig. 4.2.14 : 3 pronged owman's
Ing forceps. force .
213
I atlon procedure : see page
PROSTHESIS FOR HIP HEMIARTHROPLASTV
• Prosthesis may b · .
• C e unipo 1ar or bipolar. Unipolar variety is rarely used nowadays
T~:monly' used unip_olar prosthesis ~re of 2 varieties - Austin Moore's pros;hesis
mpson s pr~sthes1s. They are available in various sizes, according to the d' and
th e head , the sizes being imprinted on the stem. iameter of
M. AUSTIN MOORE'S PROSTHESIS

This is a self-locking variety of prosthesis.
What are its parts ? (Fig. 4.2.15)
lateral
1. Head : Spherical. Fits into acetabulum. collar
2. Neck : Constriction below head. hole
3 . Collar : This sits on the calcar femorale
of femoral neck after proper insertion and
body weight is predominantly transmitted
from the acetabulum , through the head Fenestrations
and neck to the collar, and finally to the
strong calcar femorale, when the patient
is standing. The collar also has a small
hole placed laterally , which is used -
(a) For extraction of prosthesis, when
required .
(b) For assessing and controlling ante-
version of the prosthesis , which is
usually done by inserting a Steinman
pin or straight artery forceps through Fig. 4.2 .15 : Austin Moore's prosthesis.
the hole, when the prosthesis is being inserted, into the proximal femoral medullary
cavity.
8. : Normal femoral neck anteversion is about 15°, which should be maintained when
seating the prosthesis.
4. Shoulder: This has a relatively sharp edge, which snugly fits into the medullary part of the
greater trochanter and prevents rotation of the prosthesis within the medullary canal.
5. Stem with 2 fenestrations : This is inserted into the medullary canal of femur. It is the
quadrangular in cross-section which prevents rotation. The tip is smooth, blunt and tap~r-
ing, which prevents accidental fracture of the lateral femoral cortex when improperly in-
serted. The fenestrations make the prosthesis lighter and self-locking, because it allows
bone growth through the fenestrations, which locks the prosthesis and fixes it rigidly.
Where/when Is A. M. prosthesis used ?
For hemiarthroplasty of hip operation. Indicated primarily in more than 3 weeks old fracture
neck of femur of elderly persons (physiological age > 65 years) and when the patient has
poor general health, and the only functional demands are of activities of daily living (AOL).
About 1.25 cm of calcar must be present --+ if not, Thompson's prosthesis is done.
What I the disadvantage of hemlarthroplasty operations of hip ?
The biological femoral head is replaced with a metallic head, therefore after about 1O to
5 yea~s acetabul_ar damage occur due to wear, producing secondary osteoarthritis and even
protrus10 acetabuh. There is limitation of motion, and pain. Then prosthesis is removed and
total hip replacement (THR) is done.
INSTRUMENTS & IMPLANTS 207
What are the complications of this ope ra t ion? ·

Pain (gro in , thig h , k nee ) ; dislocati on · seps · ;· f .
·t· t t· ) f , rs rn ectron · heterotrophic ossification (myositis
ossr ,cans raum a ,ca ; racture of proximal femur. '
Sterili zation procedure : See page 21 3
N . THOMPSON 'S PROSTHESIS

This is very similar to the Austin Moore
prosthesis , with the following differences.
1. Indications : Used where the length of
calcar femorale is less than 1 cm . Other
criteria are the same as for Austin Moore
prosthesis .
2. Parts : Has no fenestrations in the stem
and no hole in the collar and has no shoul-
der. So it is not a self-locking variety.
Fig . 4.2.16 : Thompson's prosthesis . 3 . For firm fixation : It is always used

with bone-cement. Thus it is very dif-
ficult to extract or remove , if and when required e.g ., when rev is ion to THR will be
needed, after about 10-15 years .
Advantage over Austin Moore
Since bone-cement fixation is done, very early mobilization and weight bearing can be given
within the patient's tolerability of pain ~ as early as 1st post-operative day.
O. BIPOLAR HIP PROSTHESIS

• It may be fixed or modular (head and stem ar~ sepa~ate and .availab_le in different sizes). This
prevents limb length discrepancy, reduces risk of d1slocat1on and 1f THR 1s required for acetabular
damage , only the head component needs to be changed .
What are its parts?

1. Head : It has 2 bearings - outer larger si ze beari~~
nd
[cup which articulates with the acetabul~m], a .n
. [h d · hich articulates with
ner smaller size bearing ea w . HMWPE)
ultra high molecular weight polye th ylene (U
coated inner lining of the outer cup .] Inne r bearing
d · modular variety
2. Neck : Length can be change in
according to head size .
•
1
cemented (but may
3. Stem : In fixed variety common Y t but in modu- Stem
be uncemented) used wi 1h boni-ce:~~emented.
lar variety it may be cemente or .
. over unipolar hip
What is the advantage of b1po1ar
Prosthesis? .
r at the inner bearing .
1. Most of the mov~men~ occ~ the outer bearing with
There is negligible articulation °
tabular damage. Also Fig. 4.2.16a : Bipolar hip prosthesis .
&cetabulum, which produces less aier
8
which reduce load.
UHMWPE acts as a shock absor
OPAEDlCS EXAMINATION
T~e. small head size of the inner bearing produces less torque to movement, res • •
1
fnct1on and wear. Internal component wear is minimum with inner head size ofui~~g 1n less
28
2. The c~ntre of the outer cup sphere is distal to the centre of the inner head _rnrn.
valgus setting (positive eccentricity) . Thus there is lesser load on acetabulum pro~es~lting in
friction and wear. ucing less
What is the disadvantage of bipolar over unipolar hip prosthesis?
Sometimes it is difficult to reduce during operation .
Steri lizati on : Available in pre-sterilized pack.
P. KUNTSCHER'S INTRAME DULLARY NAIL

German surgeon Kuntscher made this nail for fixing fractures of shaft femur.
What are its parts ?
• It has 2 blunt ends which reduces the Fig. 4.2.17 : Kuntscher's intramedullary nail.
chance of cortical break while insertion.
• It is hollow which allows bone marrow continuity and preserves bone nutrition . It also
allows guide-wire passage , when guide wire is used (Fig. 4.2.18) .
• In cross-section , it is clover leaf in t;:.::::::;~..4------ Clover leaf
shape - This prevents rotation within Slot - - cross-section
the medullary cavity (Fig. 4.2 .18).
• It is not a complete tube, and there is a Eye or
slot or gap in the circumference of the Fenestration
whole length of the nail, which allows it
to bend slightly on the tensile surface Fig . 4.2 .18 : Blunt hollow end with clover leaf
(antero-lateral) of femur. (Fig . 4.2.19) cross-section and eye.
.8. : Femur has a natural antero-lateral bowing. When we insert a straight nail in a curved
canal, the nail has to adjust by bending slightly, otherwise it would fracture the cortex
at he bone curve. If there was no slot, then the tube would be weak at the bend on
the tensile surface, and might break when body weight i applied. (Fig. 4 2.19)
• It has 2 eyes or fenestrations at both
ends - This is used for extraction of the
nail. The hook of the nail extractor is in-
serted in the eye (Fig. 4.2.18).
Where is this nail used ?
For fixation of diaphyseal fractures of the Tensile
'
Slot
femoral shaft - ideally the fractures that are surface
transverse or short-oblique at the level of isth-
mus (narrowest part of medullary canal).
(It is unsuitable for distal femoral fractures
because the wide medullary canal would not (a) (bl
provide a tight fit.) der 1oad
Whar Is the principle of fix•t,·on with K nails? Fig . 4.2.19: (a) A curved lube when us~ ton 1rie
111
may break on the 1ens1le surface; (b) 0
Principle of 3 point fixation. This is because tensile surface prevents breakage.
a straight nail ~s being passed into a curved . . . rad
canal. The 3 points are the 2 ends, and the isthmus of femur. or where the na,I is'" con
e opposite cortex at the curve.
How would } o d e, mine the length of the nail pre-oper atively ?

Clinically : Length = Tip of greater trochanter to the lateral knee joint line minus 2 cm . Mea-
surement is taken on the non-affected thigh.
Radiologically : Digita l X-rays , with exact magnification values can be used to calculate
length .
What are the complications of this operation ?
1. Splintering of cortex when hammering - happens chiefly with non-anatomical reductions.
2. Proximal migr.ation of nail causes pain in buttock's region. Often a bursa forms over it in
the gluteal region. Rarely, there may be distal migration also.
3. Post-operative knee effusion and if there is distal migration, then the knee stiffens.
4. Fat embolism may occur, due to reaming.
5. Stuck Nail - due to inadequate reaming, and thus nail impaction.
N.B. : Do not forget to keep sterilized and ready 'K' Nail extractor when operating. The
nail may get jammed during insertion ~ Stuck Nail !
-~~-~~-----~
6. Nail breakage.
7. Infection .
What is the disadvantage of K nail ?
Though it has clover leaf cross-secti.on , it does not provide sufficient rotational stability.
N.B. : For this, the modern concept of interlocking I. M. nail is now extensively used
(see page 239).
What are the methods of insertion ?

1. Retrograde Nailing : (Open method where the fracture site is opened .) Here the nail is
first introduced from the fracture surface into the proximal fragment and then through
the pyritorm tossa of the superior surface of femoral neck and finally brought outside
via a skin incision on the buttocks . Then the fracture is reduced and the nail is ham-
mered back into the distal fragment.
2. Antegrade Nailing : (Usually closed metho~ i.e., fracture sit~ is not opened , but can be
done by open method also, if closed reduction of fracture falls) ~~re the ~ntry point is
the pyriform fossa of the superior surface of femoral n~ck. An 1nit1al hole 1s made with
an awl , then a guide wire is introduced to th e fracture s.1te, throug~ !h~ medullary canal
and finally into the distal fragment, and then ~fter reaming , the nail 1s inserted fro~ the
proximal fragment to the fracture site . .Fracture 1s now reduced (closed or open) , and finally
the nail is hammered gently into the distal fragment.
What are the pre- equisites for an effective I.M. Nailing operation?
1 · Correct diameter to snugly fit into the isthmus.
2. S_lot facing anterolaterally (tensile surface) and eye facing posteromedially (compres-
sive surface) - (See Fig . 4 .2 .19) .
3 . Correct length _ so that the nail is about 2 cm above knee joi.nt distally just above the
Patella and protruding 2 cm outside greater trochanter proximally (for easy remova l
When needed) .
Slerlllzatlon procedure : See page 2 13
Q. KIRSCHNER'S WIRE (K WIRE)
~:i is one of the most popular and profusely used implant in orthopaedic surgery . Available in
oua diameters - 1 mm to 3.0 mm.
21 0
What are its parts ?
It has sharp trocar pointed ends and a cylindri cal shaft. S ome have diamond-pointed
others may be th readed for bette r bon e purchase (Fig. 4 .2.20) . end and
Where/ when is it used ? Magnified view of end

1. For definitive fixation of fractures like -
(a) Supracondylar fracture humerus in a child.
(b) Lateral condyle fracture humerus in a child.
(c) Fixing physeal injuries in a child .
(ct) Fracture metacarpals/ metatars a ls.
(e) Fracture radial neck.
(f) Percutaneous fixation of Calles fracture.
(g) Fracture of surgical neck humerus .
2. For temporary and provisional fixa -

tion (before selecting the proper-sized
and contoured implant for definitive fixa- (a) Trocar point (b) Diamond point
tion) of fractures around knee, elbow
Fig. 4 .2 .20 : Kirschne r's wire (K wire).
and ankle like -
(a) Distal humeral fractures with intra-articular extensions.
(b) Tibial plateau and proximal tibial fractures which are comple.x/comminuted.
(c) Distal femoral fractures with intra-articular extensions.
(d) Calcaneal fracture provisional fixation .
3 . As an adjuvant implant in tension-band-wiring operations of -
Fracture patella, fracture olecranon, supracondylar fracture humerus, ankle malleoli frac·
tures (medial and lateral) .
4 . In application of JESS external fixation e.g., in congenital talipes equinovarus.
5. In fixation of navicular to talus after Turco's posteromedial release operation in congenital
talipes equinovarus .
What precautions should be taken while inserting 'K' wires ?
1. Always use electric high speed power drill. Hand drills tend to bend the wire.
2. Always use a drill guide/sleeve to protect the surrounding soft-tissues and accurately
direct the 'K' wires.
What is done, after the 'K' wire is inserted into a bone, at the end of the operation? WhY ?
The protruding end is bent at an angle of ~ 90° and the remainder length is cut-off. W~ile
bending , hold/support the wire with a Kocher forcep or small tip plier, and grasp the protr_
uding
extra length with another plier. This prevents undue movement at the fracture site. Bendi~g 1~
done to ensure easy removal of the wire when its purpose is served and also to prevent migra
tion of the wire inside the bone . ' .d
When one end protrudes outside skin (as in JESS), a piece of thin rubber catheter is apphe
over the exposed end, to prevent injuries to the opposite limb.
R. RUSH NAIL
Available in various diameters and lengths. Used for intramedullary nailing. Rarely used.
What are its parts ? Describe the impla nt.
. It hl~sdo.nelen d b evelled , and the opposite

·
end is bent like a hockey stick. In cross-secron
I
it
1s cy in rica .
What ; ~ · ••se to an orthopaedic surgeon?

1. Definitive fixation of fractures like
(a) Fracture both-bone forearm.
(b) Fracture fi bula in distal 113rd.
2. Rarely used for distal humeral fracture fixa-
tion .
Where does the bent end lie when fixing frac-
ture of both-bone forearm and fibula ? Fig . 4.2.21 : Rush nail.
Radius : (distally , at wrist); Ulna : (proximally, at elbow); Fibula : (distally, at ankle).
What is the chief disadvantage of Rush nail ?
It does not prevent rotational movements at the fracture site, since there is no locking
mechanism (as in interlocking nails) and also because it is cylindrical in cross-section .
N.B. : Nails with square cross-section is als0 available.

What is the utility of the hockey stick like bend ?
1. Prevents migration of the nail intraosseously.
2. Provides good grip for easy extraction , when required .
What is the utility of the bevelled end ?
1. Easily moves along the medullary cavity, when hammered , due to the pointed (not sharp)
bevelled end.
2. If the nail gets stuck in the cortex, then the bevelled end is rotated about 90° for smooth
passage in the intramedullary canal. .
What are the principles of fracture fixation by an intramedullary nail ?
1. 3 point fixation : a straight nail is introduced in a curved canal.'
. • . 1 t (unlike plates which are load-bearing) .
2. It is a load-shari~g •~P and compression at the fracture site, wh ich hastens healing.
3. Allows for dynam1zat1on an
Sterilization procedure See page 2 13
S. MALLET
What are its parts ? (Fig. 4 .2.22) . .

. . head _ used 10 strike an instrument or implant.
1. Heavy blunt and flat ended cyli nd rical . .
2. Hand!~ - flattened in cross-section for gripping .
How is it held ? Which hand is used ? . h n dominant hand holds and steadies the
1· . t hand while t e no - )
. t 1s always held with the domman 'k ( osteotome, chisel, bone-gouge ·
instrument or implant which is to be struc e.g., 1
Where I when is mallet used '? 2
To strike -
1. Osteotome .
2. Chisel.
Fig . 4.2.22 : Mal let.
3. Bone Gouge .
4 . Kuntscher nail (via a "punch"). p thesis (via a "punch").
5 - /Thompson ros . .
. Austin Moore Prosthesis . h pierced the 2nd cortex, as in skeletal traction .
5
6. Steinman pin's blunt end when ,t a
· k' end
7. Rush nail - bent 'hockey stic ·
--~~
212 HANDBOOK f OH om If >PM ()IC! ' I XI\MINI\, ,, I
T. BONE PLATES AND S C A

--~-~----~-~~--
<i
...................,_,,,.......,_~
Function o f Bono Plat : I folcfa lrnc tu r 1HI!. 111 d If 111 •, rr1 rdn 1,li n•, 11 111nrr1ont , nnu transmit
fo rces from on n ci of tll hon to th 0 111 1, p1 u ft c tl11 I ruHI t,ypri·: 1 111 0 Ill fr CIL1 ro (lottd.
bearing Implant).
Dynamic Compress ion Pl ote (DCP) : Sci' w holo, ru' !,lop tJ In : uch ,1 w y thot scr
tightening th rough lh holes c·1uses th pint to 111ovr> .1 1 90 lo tl w cJlroc tlon or tho doscendl~w
11
screw, thus affecting comprossion nt lho frnc tur t,lt Ui;, cJ In Ir acturo hnft of radius, ulnag
humerus and sometimes temur nd tibic1 . '
Low Contact Dynamic Compression Plato (LC DCP) : lJc sign cJ lo rr sorv0 poriosteal vas-
cularity, which is impaired wi·th OCP. Uso Sr mo , · OCI .
Reconstruction Plate : Can be mouldod/ bonl In , II pl tr10Q. Usolul In dist I humeral fractures
clavicle fractures , otc. '
Locking Plate : Has 2 conjoinod holes ono of which Cr n bo usocJ for locking screw Insertion.
It has the advantage of good structural strongth ovon when tho scrows have unlcortical bone
purchase making it very useful for osteoporotic bones. Usoful in proximal humerus , distal and
proximal tibr a, dis tal femur.
- ~ ...- For rocking screw

>
Dynamic Compression Plate (OCP)
Screw
Inserted
through
non
Reconstruction Plate rocking
hole
Low contact DCP Locking Plate
Fig . 4.2.23 : Different vari e ties of Plates
Clinical ap~lication : As. neutralisation plate, buttress plate, compression plate condylar plate
and for tensron band platrng. •
Difference between cortical and cancellous C o rkscrew T rocar Tip
screws Tip
• Thread diameter : cancellous > cortical.
• Pitch (distance between threads) : can- Pa rtla(
cellous > cortical. Threaded
• Nature : ca.ncellous -> modified wood-type
screw; cortical -> machine-type screw.
• Tap : not needed for cancellous screw.
Cortical Cance llous
N.B. : S~rews are always inserted into pre- Malleolar
dnlled and tapped holes.
Fig . 4 ·2 · 24 : Different varieties of Scrows
Common use : . Cortical -> when platin radial
-> medr~I ~alleolus of ankle. Herbe;t screw t~r,

Cance/~ous -> rn proximal/ distal tibia d1stal fe ' ulnar, h~meral, tibial , femoral shaft tractures.
proximal humerus, calcaneum. Ms/leoJar
pl~t~ly wrthrn bone) -> scaphoid fracture and so'~ rs. head l~ss" i.e., can be embedded com·
Clinical application : As posit/ I etrmes radial head fractures
(for inter-fra on ng screw (fixing I t ·
gmentary compression) [A I8 P a es to the bone) and as a lag screw
f ragment but en · · 9 screw m t t . 1
cancello~s sere g~~e t~htly (get good purchase) in th usd. urn freely (loosely) in the proxrm~
proximal fra m w e t reads must be entire! in
thinner drill-~it fs"t sh~uld .be over-drilled with r e . ,stal fragment. For partially threado
lar;:~ d~rstal fragment. For cortical screw tho
use · It rs most effective when the rame t er drill-bit and tor distal fragmenl
screw is at 90° to the plane of fracture.!
IN STRUMENTS & IMPLANTS 213
u. SCREW/SLI DING HIP SCREW

What are its pa,
It consists of a specialized lag scre w (Richard screw) and a barrel-plate with an angle (nor-
mally 135° but available in 130°, 140° etc) with the plate having holes for screw insertion . It may
be a long barrel plate or short barrel plate.
Where is it used ? Richard screw
For fixation of trochante ric fractu res of hip.
What is the advantage 01 usmg this?
After fracture fixation , the smooth part of
5-hole barrel-plate
the Richard screw slides inside th e barrel
(controlled collapse) produci ng compression
at the fracture site, thus ensuring union .
How should the lag screw be inserted ?
It is inserted over a guide wire which should
be in the centre of the femoral neck in both
AP and Lateral views, and the sum of the tip-
apex-distance should be < 25 mm. Fig. 4.2.25 : Dynamic hip screw
When do we use long barrel plate?
For lag screw length > 80 mm.
What is the usual mode of failure of the OHS?
Bone cut-out. This happens when tip-apex distance is > 25 mm.
STERILIZATION
• Sterilization is the process of destroying all life including spores .
• Disinfection is the killing of infectious agents outside the body by direct exposure to
chemical or physical agents.
Procedures for sterilization
A. For instruments which do not have sharp cutting ends (e.g., Austin Moore prosthesis ,
Kuntscher nails, Lowman's forceps, bone holding forceps , mallet, Esmarch bandage , etc.) .
Autoclave : 121 °c temperature at 15 to 20 pounds per square inch pressure for 20 to 30
minutes after the desired temperature and pressure is achieved.
N.B.: • If sharp instruments are autoclaved, their sharp ends must be well padded and
covered with cotton, otherwise sharpness will be lost.
• For Esmarch bandage - powder is applied profusely, between each roll of bandage
and then covered by cloth/bandage.
B.For sharp instruments (e .g . , osteotome , chisel, gouge , bone nibbling forcep , bone
cutting forcep , periosteum elevators, K wires, Steinman pin, etc.) autoclaving is the best
option. Sometimes Sterilization is done by keeping the instruments immersed in Cidex
~2% glutaraldehyde) for a minimum of 10 hours. After removal from Cidex , the instrument
implant is washed in sterile normal saline , before use.
0ther sterilizing procedures
1· Some implants (like prosthesis) and materials (like Bone-cement, catgut and other suture
materials) are pre-sterilisized by manufacturer, and comes in sealed packages.
2· Gamma ray irradiation can be used for sterilization.
3· Bolling water for about 1 hour is also sometimes used for sterilization.
4· ~ormalln tablets, kept within a closed air-tigh~ ch~mber is used for sterilization, espe-
cially for instruments of arthroscopy and electric drills, etc.
section-IV
INSTRUMENTS & IM PL TS
SPLINTS,
Chapter 1
SPLINTS
Theories Discussed
• Tourniquet
• Plaster of paris bandage • Fixed traction and Sliding traction
• Skeletal traction • Fisk splint
• Tobruk splint . • Dennis-Brown splint
• Perkin's traction and Buck's traction
A. PLASTER OF PARIS BANDAGE

What is this ? machine-made , plaster of ~aris impregnat~d
This is a sample of commercially available, bandage, of 3/4/6 inch width , marketed in
the brand name of .. .... .. ... (read the name
on the cover and also the width which is
mentioned in cm).
What is the chemical formula of plaster of
paris ?
CaS04 . ½H20 (hemihydrated salt of cal·
Fig. 4.1.1 : Plaster of paris bandage. cium sulphate).
t is the chemical reaction for which it has its utility ? . d be·
~~~s an exothermic reaction, where plaster of paris cor,:ies (n c~~tact with water an
comes mouldable at first and then hard. The following principle 1s ut1l1zed.
CaS04. 1/ 2H20 + 1/ 2 H20 ~ CaS04. H20
(Soft) (Hard) . sum).
(i.e., Anhydrous hemihydrated calcium sulphate --1 Hydrated calcium sulphate (Gyp
Hotter the water, more heat is generated.)
How have you seen it being used ? ster ol
1. As a Cast: First the proposed area is wrapped and padded in cotton . T~en P1~ Then
paris bandage is dipped in water and retained till no air bubbles are coming 0; · uicklY
it is brought out of water and gently squeezed holding the ends, and then use ~erlW
before it becomes hard. It is wrapped concentrically, each successive layer ~ rend,
ping 1/3 to 1/2 of the previous layer, starting from one end and going to_ t~e 0 ~:;nkfeS
disregarding the fracture site or the underneath pathology, avo1dm9 Then
and creases and without excessive tightening or loosening of the wraps~ 00 th·
5
the plaster is moulded where required, simultaneously the end-margins are
ened (to prevent skin irritation) and the whole surface is polished . ea·
2. As a Slab : After cotton padding, the limb is held in the desired position an~ ~ab-
surement is taken from the proximal end to the distal end of the propose rnea·
Plaster of paris bandage is folded one layer over the previous layer, tor th e
184
---
SPLINTS, INSTRUMENTS & IMPLAN TS l -
sured length . Numb er of layers is about 6-8 for upp er limbs and 10-12 for low er
limbs (more for adul ts , less for chi ldren) . Then the whole length of the multiple
layers is secure ly held at both ends, suita bly folded , dipped in wate r an d retained
till no air bubbles are coming out . Finally it is taken out of water and held vertically,
simultaneously squee zing the entire length gently from top to bottom wh ich drai ns
out the excess water , and also incorporates all layers into one slab . Then it is
appl ie d on the des ired surface of the limb , covering about 50%-70% of the circum -
ference and bandaged onto the cotton covered limb . The desired position of limb is
maintained , until the slab 'sets' and gets hard .
What factors can alter the setting time of plaster ?
1. Temperature of water used (Hot water ~ faster setting ~ less critical setting time).
2. Manufacturers , pre -decided setting time varies for each brand . (Additives are added to
hemihydrated calcium sulphate powder to alter the setting time) .
3. Impurities ~ Plaster of paris, when present in the water, which is used for dipping (due to
previous similar use of the same container) hastens setting time .
4. Humidity of atmosphere and room temperature .
N. B. : The interlocking of the crystals formed are very essential for rigidity and strength.
Motion during critical setting time interferes with this interlocking, and reduces the
strength of the cast. Critical setting time begins when plaster is in the rich, thick and
creamy stage. Plaster drying occurs due to the evaporation of water, which is in
excess and not required for crystallization. Evaporation is influenced by air-tempera-
ture and humidity.
Wha t are the uses of plaster of paris bandage ?
A. Non-orthopaedic uses :
1. Immobilization after skin grafting near a joint.
2. Immobilization after repairing blood vessels, nerves, tendons (e.g., tendo achilles).
3. To make moulds , which are used for making braces.
B. Orthopaedic uses : . .
1. As first aid_ Provisional , temporary immobilization after any fracture / d1slocat1on or
tAraudma,: ·t· t tment _ Of certain fractures like fracture shaft humerus, green-stick
2. s e mr rve rea · · 11 y d.1sp 1ace d
lar fracture humerus Calles fracture, minima
fractures , type I supraco ndy ,
fractures of both bone legs, etc. h
. · PTB plaster for fracture of both bone legs . Also for umerus.
3. Functional cast . bracmgu II - lmost after all orthopaedic· operations · ( ·
exceptions - THR ,
4. Post-operatrve - sua y a
meniscectomy, etc .) as a slab. .
5 o , · · Serial plaster casting e.g., CTEV.
. e,ormrty correction - W lk' ·,ron in below-knee plaster. (see page 197)
6 A · · h 1· ·ng orthoses - a 1ng
· s partial werg t re revr . d f containment in Perthes disease.
7· Brooms trc · k PIas ter - . Sometimes huse . ue or
e g Calcaneum fracture and distal radial fracture.
8. As external fixator - Pin plaster tee niq · ·•
9. Hip-spica ·
10 N d M·nnerva jacket Risser . , t (f r ·s)
s cas or sco 101 .
· owadays rarely use - 1 '
What may be the complications after any pla5 fer ?

1 o· . d e to tight plastering - which may lead to compartment
· istal neurovascular compromise u
syndrome and VIC.
2, Pressure sores on skin. · ·
. is needed for bony prominences hke the fibular head,
c.Qfton pa mgdd
es, etc.
186 HANDBOOK FOA ORTHOPAEDICS EXAMINATION
What advice would you give to the patient after any plaster ?
1. Constant finger / toe movements (to prevent oedema and maintain circt tion).
2. Do not bring the plaster in contact with water. Keep it dry.
3 Report immediately if fingers / toes are swollen/ bluish- bl ac k/ n um b/ in extrern .
· ·
which is not relieved by the ordinary · d ose .
analgesic e Pain
4 _ Range of movement (ROM) exercises of all other joints in that limb, which are not Within
the plaster at least 2/3 times daily.
What is wedge correction of plaster ? When

is it useful ?
If there is an angu lation deformity at the

fracture site (seen in X-ray), then wedge cor-
rection technique is usefu l. Here the plaster is
split at the level of fracture ( opposite the apex
of angulation) , wedge is opened, angulation is
corrected , and the opened wedge gap is
replastered. About 10°-15° angulation may be
Fig . 4 .1.2 : Wedge correction of angulation . corrected in this way (Fig. 4.1 .2).
8. ESMARCH BANDAGE
What is this ?
This is Esmarch bandage , rolled up, of 4/6 inch width.
What is this made of ?
Made of latex.
What is this used for ?
1. Exsanguination.
2. Tourniquet (sometimes) .
Can this be an ideal tourniquet ?
No, because the pressure exerted cannot be measured/controlled. Ideally, pneumatic tourni·
quet should be used.
What are the cases where exsanguination is contraindicated ?

1. Infection (e.g., osteomyelitis, septic arthritis) } This is because - it maY ~e~~.11
2. Malignancy or suspicion of malignancy. in spread of infective foci 0
3. Deep vein thrombosis - May lead to pulmonary embolism . lignant cells or thrombus.
When is tourniquet not used ?
1. Buerger's disease or peripheral arterial insufficiency.
2. Sickle-cell anaemia - May lead to sickle-cell crisis.
3. Crush injuries - Vascularity already compromised .
4. Sometimes for TBW of patella / olecranon operations, due to technical simplicity.
Why or how is tourniquet useful ? oper,r
It provides a bloodless operative field which aids operative precision and shOrten 5
tive time. It also helps in clearly identifying tissues, and prevents blood loss.
What is the ideal s ite for applying a tourmqu t 7
Tourniquets are us~~lly applied 1n the most proximal parl or the l1rnb, ,.e .. wh re ,EH ,
single bone a~d suf!ic,ent muscle bulk which d1sporses the cull-pressur1> rvanly, • nd 1hu i
prevents localized high pressure . Esmarch bandage is always applied over c1 ,nglc r,one
What is the ideal and safe rour n tQL ' ,m ,Pr net lo , ,r "
There is no ideal tourniquet time (, e. the time between appl1cal1on and removal of 1011rn1-
quet) since it varies with the age of the patient and the vasculanly or the local arr ::i J .,1 rilly 11
is 1 to 1½ hours for upper extremity and 11/2 to 2 hours for the lower ex lremity. Every cflorl
should be made to shorten the tourniquet time.
What tourniquet pressure should be u ed when u ing pneumatic 'ou n quet ?
This varies with the age of patient, systolic blood pressure and size of the extremity, includ-
ing the muscle bulk. In normotensive patients -
For upper extremity - Systolic BP + 50 to 75 mm Hg.
For lower extremity - Systolic BP + 100 to 150 mm Hg or twice the systolic BP
What are the causes of tourniquet paralysis ?
1. Excessive tourniquet pressure.
2. Insu fficien t tourniquet pressure causes passive congestion , lead in g to
haemorrhag ic infiltra tion of the nerves.
3. Application without reviewing local anatomy e.g., peroneal nerve over fibular head, may be
involved if tourniquet is applied there, as it is a superficial structure.
What are the clinical features of tourniquet paralysis syndrom?
Motor paralysis with hypotonia, sensory dissociation (touch, pressure, vibration, joint position
sense are lost but pain/hyperalgesia is present).
What are the features of post-tourniquet syndrome ?
It happens due to prolonged ischaemia (not pressure) . There is pallor, oedema/puHiness of
fingers, numbness (sensory), weakness (motor) and joint stiffness.
What can be the complications of using tourniquet ?
1. Compartment syndrome.
2. Pulmonary embolism.
3. Rhabdomyolysis.
What will you do If you find a post-operative patient coming to the ward with the tourni-
quet still in-situ over the proximal part of a limb ?
If more than 5 to 6 hours have passed, tourniquet should not be removed as the patient's
lite may be threatened by toxic metabolites and Crush syndrome might occur. Amputation is
done after counselling and when consent is given. It less than 4 hours have passed , immediate
removal of tourniquet should be done to try and save the limb. Here, patient party should be
counselled about guarded prognosis.
ft.I. : This is gross medical negligence, and is unlikely to occur with pneumatic tourniquets.
How is an Esmarch bandage applied for expressive exsanguination and as a tourniquet ?
Th_e assistant elevates the limb (this also produces reflex vasoconstriction) . Then at the
P~oiumal part of the limb cotton is wrapped in sufficient width , so that no part of the tourniquet
WIii be in contact with th~ skin. Then, one esmarch bandage is wrapped over the limb starting
from the tips of fingers or toes, and then stretching the . bandage so as to apply tensio~ wi~h
~ turn, overlapping the previous turn by about half t,11 the edge of th~ cotton pa_dd1ng ,s
··~-·-bed. The assistant then holds this end. Another Esmarch bandage ,s now applied as a
et over the cotton wrapping, where the first 3 to 4 turns are applied with tension by
AMINATION
th
stretching the bandage, and the rest is just wrapped without tension over ·e previous turn .
nd
Finally, the tapes at the end are tied and the starling time of tourn iquet is noted a recordod.
The bandage initially used for exsanguinatlon , is then removed .
What precautions should be taken ?

1. Always record the tourniquet time.
2. Ensure no chemicals like povidone-iodine gets unde r the cotton because it may cause
chemical burns to the skin.
3. Ensure the tourniquet is removed before the closure of wound 10 identi fy bleeding points
and secure haemostasis. This prevents post-operative haematoma/soakage/infectlon.
C. STEINMAN PIN AND BOHLER'S STIRRUP
Describe the parts of Steinman pin.

It has one sharp trocar-pointed end , rounded smooth shaft a nd a blunt opposi te end with
quadrangular cross-section . The diameter vari es from 4 to 6 mm , and it Is available In various
lengths.
What are the uses of Steinman pin ?

• Used for giving skeletal traction to limbs.
Sometimes used for internal fixation , e.g., after surgical open reduction of hip dislocation
elbow dislocation.
ettmes used for fracture reduction aid and internal fixation, e.g., calcaneal fracturos
ssex-Lopresti manoeuvre, finally doing a pln plas ter type extern al fixation .
etlmes used for external fixation, e.g., biplanar, uniaxlal frame for fractur tibia.
for intra-articular arthrodesis of hip, e.g., for managing a painful hip following T. B.
r-thorough debridement of the joint, and obtaining bl ee ding v scular urlaces of
I head and acetabulum, the hip joint is fixed with a Steinman pin nd profuse bona
given to ensure bony fusion.)
Wh t I th u l' of Boll/, · t1r,up?
It is excluslvo ly us d for k I I I tr ctlon
where the round d loop nd Is u d lor tyln
the nylon tr ctlon cord , nd ti, 2 llmb ol 111
Nylon-cord tied here
'U' shaped p rt Is u d o t1x h , 1rrup with
the Stelnm n pin . Thi s n 1bl to ,lit , th lint
/ direction of tr ction , ccordln 10 th( n d ol
the P tl ent , w ithout rot.ilin o 01 movlnq 1hc
Stelnm n pin within the bonr (I I I. ).
Bohler'&
stirrup Wh t r th It 1/0 11
c n b glv " ?
1 . Proxlm11I tibia/
2 cm inf rior to lh
Stelman pin
Used for troch nt .11
and f moral h t tr '
[Fig 4 1 4(c) anct '1
Steinman-pin in-situ, 2. DI tel f•mor I C"
byecrewa.
one grazin t
nd th 0th
tella a e er axial. line touching the anterior border of fibular head. Used for pelvic
nd
fractures a trochantenc fractures, only for initial 3 weeks. [Fig. 4.1.4(b) and 4.1 .6(b)]
3. D1sts1 tibfladl .: tsl ct~b. abo~e the ankle joint, midway between the anterior and posterior
borders o 1s a 1 1a. [Fig . 4.1.4(d)]
4. Calcdatneadl'trtacl tt~ob~ : 2 cm behind and 2 cm below the tip of lateral malleolus of ankle. It is
use or 1s a 1 1a1 1ractures . [Fig. 4.1.4(e)]
(a) Olecranon (b) Distal femoral (c) Proximal tibial
(d) Distal tibial (e) Calcaneal
Fig . 4 .1 .4 : Various skeletal traction sites.
What are the complications of skeletal traction ?

1. Pin tract infection is very common.
2. Physeal injury : When used in children -4 the pin passes through or grazes the epiphyses.
3. (Rarely) Distraction at fracture site , when a very large traction force is applied, especially
in children .
4. Damage to adjacent nerves if the pin is incorrectly positioned or introduced e.g., pero-
neal nerve damage in proximal tibial skeletal traction may lead to "foot-drop".
S. ligamentous damage, if huge traction force is given (e.g., in knees, when proximal tibial
traction is given).
•r le distal femoral traction not kept beyond 3 weeks ?

This is because prolonged distal femoral traction leads to fibrosis of the quadriceps and
nee stiffness. If it is required to carry on traction , then after 3 weeks it is changed to
troximat tibial traction .
Ctlh how proximal tibia/ traction is given.
After shaving and antiseptic dressing of the local part, the patient is taken to OT. Under local
$Jtneral anaesthesia and after painting the local part sequentially with savlon , spirit and
dlne, and also draping, assistant holds the limb in slight external rotation (like a normal
(sea Fig. 4.1.5)), at the same time giving counter-force from the medial side.
A sma~I skin incision is made at the correct
entry point.
The steri lized Steinman pin' s sharp end is
introduced through the site of entry from the
lateral side (i.e ., 2" infe rior and posterior to
the tibial tubercle) [Fig . 4 .1.6(b)] . Then it is
pushed by hand till it reaches the bone sur-
face . Then a T-handle or hand-drill is used to
pierce the bone and is cont i nued till it
pierces the medial cortex (felt by sudden loss
Fig. 4 .1.5 : Direction of Steinman pin in 15° external of resistance) . T hen a mallet is used to tap
rotation of lower limb. the blunt end of the pin till it comes out of the
skin. The direction of pin should be such that
it is perpendic ular to the long axis of tibia, when the t ibia is slightly (about 15°) externally
rotated (Fig. 4. 1.5). Finally, puckered skin surfaces at ski n-pi n interface is smoothened . Ben-
zoin-soaked gauze piece is wrapp ed around the 2 ski n-pin interfaces and cotton is wrapped
and bandage is applied which should incorporate the knee to mini mize reactionary knee effu-
sion . After recovery from anaesthesia, ankle and toe exten sion is checked to rule out peroneal
nerve injury.
Why is the starting point lateral and not medial ? Why hand drill or T-hand/e is used
when the pin is in the bone ?
Th is is because the peronea l nerve is on the lateral side . A si mp le hand-held pin ad-
vancement is slow and more control led, which reduces the chan ce of nerve injury. Using
the drill can be risky and cause soft-tissue damage when advancing of the steinman pin
into the soft-tissues .
Why is the mallet not used, (instead of the drill) to pierce the bone ?
It may cause splintering and fracture of the bone , which might lead to early pin loosening .
.e. :
• All lower limb tractions are given from the lateral side.
• You can describe any lower limb skeletal traction using this format, since the point of
_ •..,,...~. entry is known.
, monly local anaesthesia is used.
-.-..,....,·'."Jl- m
AP View Lat. View AP View
-~ ----·
{a ) (b)
F g. 4.1.6: (a) Local anaesth~tic i~j~ction for proximal tibial traction; (b) Entry point
proximal hb1al traction; (c) Distal femoral skeletal traction
SPLINT . IN8TAUM N 8 & IMP AN
sth
Local anae esia procedure : First skin testing with t % lldnoc.il n Is do no. Wt1o n
no allergic reaction is found , lidnoca1ne m1ect1on 1s infiltr ted usi ng th o n cell o Jw;t l1ko
the Steinman
th pin at the entry point. , e . going up to the bon , thon gradu ally withdraw ·
mgth e need le While continuing lo infiltrate tho soft tissues til l th o neodlo com es ou t
of e skin . T he same procedure 1s repeated at the e pect~d si lo of ox,t of tho pin on
the medial aspect. A minimum S minutes wait 1s a must tor the drug 10 take full anaes-
thetic effect, before introducing the Steinman pin
It is advisab
4. introdu c ed . le to give a short course of ant1b1otic I analgesic covor aft er the pin is
What is the differ ence of Denham p,n and

Steinman pin ?
Denham pin h as threaded central por-
tion . It is used when the bone is os-
teoporot1c , so that the th readed part gets
better grip and pur chase in the os-
teoporot1c bon e , thus redu cing the chance
of pin loosening or cut-ou t. Fig. 4 .1.7 : Denham pin in-situ Tibia, seen in cross-
section . Nole - Threaded central portion.
What should be the weight used fo r traction?
It depends upon the site of fracture , age of the patient, weig ht of the patient, mussle bu lk
etc. the exacts w e ight is final ly fixed by trial after regular observatio n clin ically and rad io-
logically. Usually fo r shaft femur fracture 10% of body weight is given. When more wei gh t is
used the bed end s ho uld be raised mo re for effective counter traction. (see fig.4 .1 .12).
D. THO MAS BED- K NEE SPLINT

It was designed by Hugh Owen Thomas (1876) as a device for treatment of tuberculosis of
for patients on bed. Thus it was called bed-knee splint. So originally it was used for
te/chronic inflammation of knees (like TB) only, although now it is mostly used in hip
s. It is called universal because it can be used for both the left and the right sides.
iption of parts (Fig . 4 .1.8 )
A. Well-padded oval/circular ring, cov~red by soft lea~h~r/foam. This part is in dir~ct con-
tact with the proximal thigh and groin area, and so 1t 1s under pressure and tension , and
the soft padding prevents pressure sores .
Fig . 4.1.8 : Thomas bed-knee spli, t
8. Lateral I outer side bar : It is angled out about 5 cm (2 ') below ti'
troch anter1c
· prommen
· ce . Its length is more than
. the medial/inner
h
exactly dissect the ring and are exactly opposite lo each ot er
ter bar, and it is straight. The ring i
. shorter than the ou s
C M dial I inner bar : Length is
. se~ at an angle of 1200 to the inner ba.r ~he groove of the W-s~ape is useful when giving
D. W-shaped joining of the 2 side b~::e.nts slipping of the tr~ctron cord. .
fixed-traction, where the groov~ p h / variable ring srzes, and proper size of ring
. bl ·n variable lengt s
The Thomas splint is ava1la e I h patient.
and length is chosen individually for eac . / patient ?
·nt for a part1cu ar
'b Thomas sP'l ' .
Ho do you chooselprescn e a then add 6- 9 inches (20 cm) (Frg. 4.1.9).
f om crotch to hee I' h . h'
1 Length of inner bar : Measure r . . mference between t e 1sc 1al tuber-
2. Circumference of ring : Measure the obliqueT~.rc~s the inner diameter of the ring . If the
15
· osity and gluteal fold to crotch and groin area. t to measure the circumference causes
ary move men s h· h
affected limb is swollen and necess . the contralateral, unaffected t rg and then
pain to the patient, you can then meas~re
add 5 cm (2 '1, to accommodate the swelling .
. · f'xed traction, and not so important in
N.B. : Size of ring is very crucial ~hen grvrng r orts the limb.
sliding traction, where the splrnt merely supp
·
How would you prepare a Thomas splint for usmg · a patient ?·
t·t m
First confirm the size of inner bar and the diameter o f th e ring · Then , bandage is .1sed to
form U-shaped layers [to accommodate the I
rounded thigh (Fig. 4 .1.1 O)], which is wound -pt

I
around the outer and inner bars. This U I
I
shape is continued till 1O" (25 cm) from the I
'W' end of the bar. (This leaves the tendo la1:;.::::"'__

-_ ·=_ _ __ -=--_ &'---/
achilles and heel free from any pressure-
inches
sores). Then a thick layer of cotton roll or
gamjee-dressing-tissue is spread over the Fig. 4.1.9 : Measurement of length o er Bar.
bandage trough, and finally another thin sin-
gular layer of bandage is wrapped over the cotton/gamjee, maintaining the U s h . Lastly,
leucoplast or, any other adhesive bandage is used, to fix the padding onto th ,ner and
outer bar, starting from the ring and ending about 2 inch (5 cm) in excess of
padding,
distally. The last few inches of the adhesive bandage is wrapped on to the side 1
the padding does not slip. .;, so that
A small c~shio.n is ma?e (~" x 3'.' of cotton roll wrapped over by bandag e,
it is put
postero-medrally in the m1d-th1gh region to maintain the normal antero-lateral bow . the femur.
Finally, after the traction is given, a 6" crepe
bandage is wrapped around the thigh and
splint to prevent side-to-side movement and
rotation of thigh, and also to fix the cushion in
between the thigh and the splint.
What is counter traction ?
f Coun~er t;~ction is absolutely necessary

othr an~ rac ron system to work, because
o: erw,se the who~e pro~imal part of the . .__,___. .
Will be pulled rn the line of traction. Fig. 4 · 1, 1O : Bandage wrapping of Thomas Splin1'
c.e iacting in the linea 1 . maintening U-shape.
be part of the b 0 d r Y opposrte direction of th . d which
Y proximal t h e traction force app 11e ,
o t e fracture being pulled as -a - whole towards
the traction force , is called counter-t . . .
sliding traction system or by gettin raction . It can be given by using gravity / body weight in
aoot of the lower limb , when using Tgh 0a Purchase to a proximal part of body by the splint (e.g.,
r mas splint) · f. ·
What IS · fixed traction ?. Wh at IS . S/idin in a 1xed traction system.
.
When counter traction acts via ~ traction ?
patient's b~dy (m~st be proximal ti~h appliance , which gets a purchase on a part of the
fixed tractio_n (Figure 4 .1 . 11 ). For lo:e~tt~chrn~nts of th~ muscles in spasm) , it is called
Counter traction , and thus elevat·i 1mb fixed traction body weight is not used in
' on
toot end of the bed 1s not necessa T . _e of th ()q I JI
.
suitable in a Th omas spl in t ry.
. his IS
. t·ing ring
closely f 1t . gets Purcha, since the
crotch, groin · and the outward fl se on th e
.
iliac crest . Fixed .
traction can maiaret .of th e
not obtain a reduction , and is rno~t a,~ and
tor transverse fractures . su itable
Advantage :
Less chance of fracture d' t . Fig. 4. 1.11 : Fixed traction
. 1s ract1on
When body weight (whole or part f . ·
O nd
counter traction, it is called sliding t / ) u er the influence of gravity is used to provide
tends. to slide
h. h in the opposite direract· ion . Here foot end of the bed is elevated, so the body
c 10n of
traction, w 1c . acts by hanging Weights over
a pulley (see fig. 4 .1.12). This method can be
u~ed to gradually obtain a reduction, but
this may also lead to distraction . Thus trac-
tion weight must be lessened , when reduction
is obtained and you need to just maintain
reduction. So daily assessment of limb
length and biweekly portable X-ray assess-
ment is required . Bed end elevation is about
1" for 1 pound traction weight. It can obtain
and maintain reduction . Fig . 4. 1.12 : Sliding traction (note foot end
elevation).
How do you monitor/regularly check a patient in traction ?
1. Regular check-up for pressure sores over heel, sacrum , ischial tuberosities, scapula, etc.
2. Regular portable X-rays to note position of fracture and prevent distraction/a ngu lation .
Initially biweekly for first 2 weeks. Then weekly for ano the r 2 weeks. Suitable adjust-
ments for weight and directio n are made .
3. Examination for early detection of pin-trac_t infect_ion (pain at ~he site_. disch~rge , loosening
or undue mobility of p in) for skeletal tract10~ patients .. For skin traction patients, note skin
condition or distal "slippling" of the adhesive strapping.
4· Chec k d 1sta
' 1 n e urovasc u la r status (sensation , movements
. of to es, nail bed return )
and pain· on p assive
. a n kl e do rsiflexion (may be sign of early compartment
. syndrome).
5R . . i needed to prevent equinus deformity. Knee mobilization,
· egular active ankle exe rcises s St f quadriceps exercises should be taught to the
When possible should be encouraged . a ic/ d .
Patient and en~ou raged to do them regularly ai 1y.
,8, . . 1.s. u, 1.:, ful for patier'II tran pon in lower limb fracture· as
Tl10 nl'I~ ·plint
Be ide · b ing used for traction. ' d relic, pain.
It· immobilizes
. · moderat 1 , an
the fracture ire
,.a, i\ a fobruA ,plim '.'
hi I It l'd traction of lowl'r ltmh lit a Thomn1- ,pltnl over whi ,1t plaswr casin g is done rrom groi n-L0
~ 1th ankl 1111wutrul pn,it,on. This ,s \lsl'ful as firsl aid a11d for lransport of pall cnts . It wa s used widcl - ~e.
th World War I. Yduring
What i. a f't,A ,pli11t ?

_his_a modified Thoma:,. ~plint 10 hich a k11eef1exio11 picc~ i_s attached lo 1~1c t~o sicl~ bars in level wi ih
a ,: ot kncl' movl'mcnt (al the k dot the adduclor-tubcrclc of di stal femur wh i ch approximately coincid. the
. . · I • ·· ' ti · 1·
the a 1,) . The ax,~,, not a ~,mpk point. but 1s a complex po ycenlt ic Pd ,way O movement. omrnonl
cs With
Pier on\' k11ee flexio11 pit•ct , u:,.ed no, aclays. Y, a
Wlaat i · Pi,•r ,m '.Ii k11el' flex ia11 pi1•cc ? /low is it rm:jid ?

It i. u~ed in con1unc1ion with ·1 Thomn~ s11lin1 to all ow knee fl cx ion. It is useful becau e knee nex ion allow
• . · ' • . . . s ear] y
~n t mobil11atHHl. l'< ntrol. rotation, prcvcnl!> trc1ch1ng of the po. tenor knee capsu1e and the posterior cruciat
hgaml'nt. e
SURFACE/ SKIN TRACTION

• Usually used in children . For fractures it is always applied distal to the fracture site.
• The traction force is applied over a large skin area to spread the load and make the .
traction more efficient and the patient comfortable.
• It may be adhesive skin traction or non-adhesive skin traction. This can be assembled
individually or commercially available apparatus may be used. The maximum traction
weight that can be applied is 15 lb for adhesive and 1O lb for non-adhesive.
• Adhesive strapping which is non-stretchable longitudinally is used after shaving the limb.
All bony prominences (malleoli of ankle condyles of knee , ulnar head, rad ial styloid,
umeral epicondyles etc) must be protected with sufficient cotton padd ing before apply-
ng skin traction.
en there is abrasions in the skin.

n there is lacerations of the skin , in the area to which the traction is to be applied.
jrculation impairment may cause varicose ulcers or impending gangrene.
of dermatitis.
ortening of the limb due to over-riding of the fractu re , when the traction
quired will be greater than can be applied through the skin .
• of skin traction
e allergic reactions to the adhesive .
excoriation of the skin from slipping of the adhesive strapping .
..pressure sores around the malleoli and over the tendo achilles.
neal nerve palsy, or any other nerve palsy .
pj,Qg Is too tight there may be distal sott tissue swell ing.
E. BOHLER-BRAUN SPLINT
It is actually Bohter's modification of Braun's splint.
• Original Braun's splint only had one pulley for distal tibial or calcaneal skeletal tracuon
. .J'
..
. _-_:
___
SPLINTS, INSTRUMENT$
• Braun's modification . Add ·t·
· 1 IOn of 2
pulleys are useful for proximal .. more
distal fem o ral traction . tibial and
(a Pull~y~ - C alcaneal / distal t'b'
1 ial trac-
tion (original) .
(b Pulley) - Di stal femoral/proxi ..
traction . ma1 t1b1a1
(c Pulley) - C a n be used to ch .
. ange line/
f
angle o traction , when required.
It is some ti m es used t o
. d . p revent
equinus eform1ty of ankle.
Fig. 4.1.13 : Bohler-Braun splint.
What are the advantages of Thoma .
s sp/,nt over Bohler 's splint and vice versa ?
1. Thomas splint can be used to give fi .
2. Thomas splint is Ii hter xed traction (not Bohler's) . .
using bed-pan/urin1's for ~n~ les~ cumber~om~ .. thus the patien t is more comfortable in
. e ecat1on and m1ctunt1on , when in traction.
3. Thomas splint can be used as Tobruk splint wh ich is useful for fi rst aid. (See page 194 )
Advantages of Boh/er's splint
1. Cha~ging the angle of traction (as and whe n required) can be done without chang ing any
traction arrangement , but by ch anging th e pull eys.
2. Can be used to giv e simultaneou s traction through cal caneum/ lower tibial and proximal
tibial/distal femoral.
What is Perkin 's traction ?
This is basically skeletal traction , without using any splint, i.e., the limb is supported only
on pillows maintaining the anterior bow of femur and keeping the tendo achilles free from any
contact. The foot end of the bed is raised and early joint movements are encouraged .
What is Buck's traction ?
This is basically skin/surface traction, without using any spl int. This is exclusively used for
temporary management of fractures of femoral neck or for undisplaced acetabular fractures or
after reduction of hip dislocation or to treat ~bout 5° to 10° fixed f)exio.n deformity of hip or knee .
Here also, pillows are used to support the limb and the bed end 1s raised .
What is a Charnley's traction unit ?
It consists of a proximal tib ial Stei nman pin incorporated within a below-knee plaster
cast together with a derotation bar in the sole
(Fig. 4.1.14). The advantages are :
(a) Ankle eqinus is preven ted (very. co~ -
mon in prolonged traction) ; (b) Ten do achilles is
Protected from pressure sores by the well-pad-
ded plaster; (c) Prevents rotation of t.h~ d 1st a l
fragment; (d) lpsilateral femo ral and tibial frac-
ture can be treated simultaneously. Fig. 4.1.14 : Charnley's traction unit.
F. CTE V _ SHOES/CALLIPER
• Po ular . . ,. don't put your finger inside the shoe , you might as well put your
fin P . saying is If you s put your fin ger inside the shoe, then see the sole/heel ,
. ger in your mouth". So a Iw ay . uestion
1.e., from front and back before answerin g any q ·
• Cl · . . . d f t-ankle-orthosis (FAO), rather than a shoe.
ass1cally , 1t 1s better calle oo
CTEV Shoe (Open Toe)
What IS thi ?
This ,s an foot-ankle-orthos1s (FAO) , com-
monly called CTEV shoe (or calliper).
What are the pe , If atu,e ? (Fig. 4 . 1. 15)
1. Stra,,ght medial border.
2. No heel.
Straight medial border
3 . Slight (about 1/8 '1 lateral sole raise .
4 . Inner iron bar.
5 . Outer T-strap.
6 . Open toe .
N.B. : When inner iron bar and T-strap is
absent, it is a CTEV shoe. When
1/8' lateral sole raise
inner bar and T-strap is present, it
is a calliper.
How is it useful ?
It helps to maintain a fully corrected CTEV
deformity, while the foot is growing and the
child has started to walk. The straight me-
dial border prevents forefoot adduction; ab- No heel
sence of heel prevents equ in us ; lateral
raise plus the outer T-strap (when tightened Fig. 4.1.15 : CTEV shoe and calliper - Open toe type.
and adjusted) prevents heel varus .
When will you prescribe this orthosis ?
When the child has started walking (approx. 10 months to 16 months of age) and a fully
corrected CTEV deformity has been achieved, either by operative or conservative method.
DENNIS-BROWN SPLINT
• Often called Dennis-Brown night splint, because it is used when the child .
and not walking. (i.e., even when the child is crawling on all 4 limbs) . The d
encourages muscle development.
Describe the parts of D-B splint.

asically it has a pair of CTEV shoes,
is fixed to a transverse metal bar with
ed at about 20° external rotation .
•16(b)]
(a) View from
'bed when all the deformities

fully corrected by operative or
e means, and the child has not
ing. When the child starts
sed only while the child is (b) View from below
Fig . 4 .1 .16 : Den ni s -Brown splint.
G. COCK-UP SPLINT
Three varieties.
1. Short cock-up splint : Hold
the fingers (Fig . 4 .1 .17) Th·s only th e wrist in extension. Distal margin ends below
. ,s allows fin fl .
2. Lo_ng cock~up splint : Holds both ger ex,on , and thus prevents stiffness.
th
wnst and fingers in extens·,o . e
· · n . 0 1stal
margin 1s up to the tips of th r
(Fig. 4.1.18). e mgers
3. Dynamic cock-up splint is s .
omet,mes
used. wh ere the. patient can act·ive1y flex
the f mgers, which ensures th t th .
·tt a e fin-
ger stI ness does not occur. Fig. 4. 1.17 : Short cock-up splint.
Indications for use

1. For wrist drop/radial nerve palsy .
2. After
. extensor - tendon surgery of forarum
wnst or hand, to relax the sutured tiss ues. '
3. In VIC (mild variety) or after corrective
surgery for VIC or wrist drop.
Fig . 4. 1.18 : Long cock -up sp li nt.
H. BOHLER'S WALKIN G IRON

What is it ?
It is Bohler's walking iron of .. .... ... inch length .
How will you measure the desired length for a particular patient ?
Length = From 1 .5 cm below fibular neck to the sole + 5 cm.
What are its part s a nd wha t is the importance of each part ? (Fig . 4.1 .19)
1. Metal cross-pieces (bars) ~ can be

moulded for better grip below the
neck of the fibula , and give more sur-
face area for firmly incorpor ating it
within the plaster cast.
2- Metal upright side bars ~ for _Plaster
cast incorporation and load-sharing .
3. Rounded flares of side bars ~ accom-
. I nd
modates the prominence of me d ,a a
lateral malleoli of ankle .
4. Terminal part of the s,·d e ba rs ~
keeps the rubber heel at a diSt ance from
the plastered sole of the foot, th us p.ro-
k. g dunng
tecting the plaster from brea in '
weight bearing .
b d surface
5. Rubber heel ~ provides roa during . : Bohler's walking iron .
. . . g balance Fig. 4 · 1 · 19
area for mamtam,n eight
----------------
Weight bearing, and bears th ew ·
. ....... . ..
,
~
\
•.;
' A XAMINATION
How is it applied ?
First a below knee plaster cast is ap
with the ankle in neutral position . Then
metal side bars and cross pieces are m
ally moulded (so that they fit snugly, m
taining total contact with the plaster
such a way that the superior border of
cross pieces are 2.5 cm below the fib
neck and the centre of rubber heel cori
sponds approximately with the centre
the sole . Finally few layers of plaster-i
pregnated-bandage is appl ie? ov_e r t~e. wal
ing iron , securely incorporating ,t within t
plaster cast . The patien t can start weig
bearing once the plaster is totally dry.
How is it useful ?
It allows protective weight bearing , actin
as a weight - relieving orthosis , and at th
same time immobilizing the ankle, tarsal an
metatarsal bones. The weight is shared and
transmitted through the whole plaste r cast,
Fig. 4.1.20 : Below knee plaster cast with Walking Iron.
onto the rubber heel.
For what conditions can walking iron be used ?
1. Fractures of metatarsals , and tarsals (e . g. , cuneiform , cubo id , navicula r)
2. Undisplaced or minimally displaced fractures of the calcaneum , talus or an 1'' hen
protected weight bearing is started after the initial non-weigh t bearing pe
3. Sometimes for infections of the ankle and foot , alongwith suitable antibiotics
I. WALKING HEEL
What is it?
It is a walking heel made of rubber.
What are its parts and what is the impor-
tance ot each part? (Fig. 4.1.21)
1. Thin peripheral extension on both
al.des : For convenience of wrapping
PO.P bandage over it, which allows the
heJ1 to be incorporated within the below-
k (e.e-plaster cast.
0 CD
;R/bbed thick broad base : Prevents
-~~-.....
1 ,_ing and maintains balance during
..::-,.._,.,.·ng or standing. 1 1
al transverse slot In the heel :
~p bandage wrapping which pro-
secure fixation .
ed rounded medial hump : For
Ing total contact with the longi -
medial arch of the foot. .9 .4. 1. 2 1 . W !king 11
F1 I.
on the lateral side : Makes the heel lighter.
SPLINTS, INSTRUMENTS & IMP
Where /1 ve you n it to be used ?
In p tellar t ndon bearing plaster (PTB) . (See page 95)

How i it u ful ?
Prevents breakage of Plaster when weight bearing .
OTHE SPLINTS : Mallet finger 's splint (see page . 176 and Fig. 4.1.22),
Foot drop spll nt (see. page 106) , Von Rosen splint, Pavlik Harness [ Fig. 4. 1 .24I (used in
developmental dysplas,a of hip [see page 2751) , Knuckle Bender splint (used in ulnar nerve
injuries; simultane ously flexes the Mcp joints ol all digits without blocking IP joints or wnsl
motion), Aeroplane Splint (shoulder-abduction splint used in brachia! plexus injury, and some-
limes in the conservative management of proximal humeral and rarely for humeral shatt frac-
tures), Volkman's Turn buckle splint [Fig. 4.1.23] (used in elbow conlractures) , Mermaid
Fig . 4 . 1 .22 : Mallet Finger's splint

Fig . 4.1 .23 : Volkman 's Turn Buckl e splint
F.19 .4. 1 . 24 : Pavlik Harness

Fig. 4 .1.25 : Philadelphia collar
ru
. d e lphia collar [Fig . 4 .1.25] (usedt· duringd transportation/
splint (used treatment
conservative for genu vaof pam) ie Ph1la
• nts r .) h cerv ·ical spine inju ry/pre-opera 1ve an pas t-operative
wit
.
periods of cervical spine surgery etc .
NT FRACTURES
NAMES OF SOME IMPORT A , Fracture : fracture of both pedicles
b . Hangman s ,
. racture of c, verte ra; ture : Spinous process C7, T, ; Boxers
Jefferson's Fracture - F 2 . Clay Shovelers Frac _ N ck of talus; Bumper Fracture :
or pars interarticulans 4 of C , rpal· Aviator's Fracture ·( e mon)/ ro141tt/5u-, metartarsal neck.
Fracture : Neck of 1h;s111 metacature ,: Stress fracture of 2nd com 3
Lateral tibial plateau .· March Frac
l

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Section -II

BASIC CLINICAL EXAMINATION OF HIP

(5) Once you have located the pubic tubercle, move

Fig. 2. 1.5-A : Lumbar Lordosis Fig. 2.1.5-B

touches the table. (Further flexion will cause

After the Thomas Test note the free

TEST FOR FIXED AB DUCTION I ADDUCTION DEFORMITY

Fig. 2.1.7-8 : Adduction in adults

(4) When the pelvis is 'squared' the limb will

Fig. 2.1.8 Note : Restricted abduction in flexion of lhe Rhip.

ROTATION EXTERNAL / INTERNAL

Rotation with hip flexed

Fig. 2 .1.10-A Fig. 2.1 . 10-B

Active Passive Pain

L!U w L!!J OJ L!!J w ~ L!J

Fig. 2.1.11 -A Fig. 2.1.11 -B

Measurement of True length in Supine Position

both the ASIS to the same level.

Fig. 2.1.13-E Fig. 2.1.13-F

DRAWING BRYANT'S TRIANGLE

Fig. 2. 1. 16-A Fig. 2 1 16-B

(3) the patient. t d first on

Criticism of Tendlenburg 's sign

Fig. 2.1.18-A Fig. 2.1. 18-B

N.B. • Sacro-iliac joint is truly the joint above. Examine tenderness.

Alternative to the Thomas test

( 1) Have a female attendant for a female patient.

( l) Request the patient to tand in front of you. Palpate and note

Other Tests for supratrochanteric shortening

Craig's Test (Femoral anteversion test)

Fig. 2.1.22-A Fig. 2.1.22-B

Test for psoas abscess ..

• Koth ari's Angle

Fig. 2.1.24-A Fig. 2.1.24-B

(a) Synovitis ~ .from viral/ ~ther mild subacute infections.

. t· ·t and relieved by rest. Pain insidious / acute in ons

_ Arthrogram 1s user ul to see the shape

What are th e Head-at-Ri\·k sign s in X- rays ? (Fig. 2.2.6)

• Caterall classification (See n in X-rays) :

What ;s sagging~rope _sign? . . d Perth es disease, du e t o th e re mod elling process,

Fig. 2 .2 .7 : Sagging-rope sign . Note - Lateral subluxation of head .

is done with external fixator (Fig. 2.2.8) , and ~f\SaKage.

TUBE C LO S ARTHRITIS OF HIP (TB HIP)

Pathology . . Of the femoral head and acetabulum takes place .

How do you explain NIGHT CRIES ?

2. 8/ood : DC , TLC, Hb, FBS , PPBS . .

What are the differential diagnosis ?

R.ar . ro aholl • . of the iliofemoral •y • li ga ment, or continuo us adoption

Fig. 2.3.3 : Hip-arthrodesis Fig. 2.3.4 : Total hip replacement

. 2 3.5.· Dislocated hip. Note : Destruction of

d ·u g acctabulnm !lead m ov s up w ur~ s ,incl dor sall y l eav in g rh c l ow er p art of

Wh• In adults - Atrophic type .

What are the probable reasons for non-

• Affected hip Lateral view.

2 . Anatomical classification (Fig.

3. Pauwel's classification : Created 1

of any age, fixation with 3 cannulated hip ·

Fig. 2.4.7 : McMurray osteotomy - fi xed with Fig. 2 .4 .8 : Bipolar posthesis

(b) Physiological age above 60 to 65 years

What muscles may be used for Muscle-Pcdiclc-Bonc-Graft (MPBG) ?

Risk factors for osteoporosis

Non-modifyable Potentially modifyable

MALU ITED TR OCHANTERIC FRACTURE

agnos1s 1s mal united R/ L trochante .