08/19/2017

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By Live Dr - Wed Feb 11, 3:25 am

Orthopedics

Stages of fracture healing

STAGE DURATION
Stage of haematoma Less than 1 week
Stage of granulation tissue formation 2-3 weeks
Stage of callus 4-12 weeks
Stage of remodeling 1-2 years
Stage of modeling Many years

Fracture eponyms

Eponym Description
Barton’s fracture Distal radius, intra-articular
Colle’s Distal radius, extra articular with dorsal tilt
Smith’s Distal radius, extra articular with volar tilt
Galleazzi’s Distal ½ of radius with dislocation of distal radio-ulnar joint.
Monteggia Proximal ½ of ulna with dislocation of radial head
Chauffeur’s Radial styloid
Night stick Shaft ulna
Bennett’s Base of 1st metacarpal, intra articular
Rolando Base of  1st metacarpal, extra articular
Boxer’s fracture Neck 5th metacarpal
Mallet Avulsion tendon from distal phalanx
Hangman’s Second cervical vertebra
Malgaigne’s Pelvic disruption, injury on one side
Bumper Lateral condyle of tibia
Cotton Trimalleolar ankle fracture
Pott’s Bimalleolar ankle fracture
Aviators Neck of talus fracture
March Fracture shaft of 2nd metatarsal
Jone’s Fracture base of 5th metatarsal
Side sweep fracture/ Baby car fracture Elbow injury sustained when one puts one’s elbow projecting out of a car
Massonaise’s fracture Fracture of  neck of fibula
Pilon fracture Comminuted intra articular fracture of the neck of fibula
Clay shoveller’s fracture Avulsion fracture of the spinous process of vertebra
Straddle fracture Bilateral ischiopubic rami fracture

QUOTE CORNER

Don’t confuse fame with success. Madonna is one; Helen Keller is the other.-Erma Louise Bombeck.

ELEVENTH HOUR ORTHOPEDICS                                                                                                   218

*Colle’s fracture is the commonest fracture in adults above 40 years.

Dinner fork deformity is seen in malunited Colle’s fracture

*Sudeck’s osteodystrophy

Reflex sympathetic dystrophy

Colle’s fracture is its commonest cause in the upper limb

*Commonest complication of supracondylar fracture is cubitus varus deformity

Fracture of lateral condyle of humerus, results in cubitus valgus deformity, leading to tardy ulnar nerve palsy.

MISCELLANEOUS CONDITIONS

Tennis elbow Lateral epicondylitis

Pain and tenderness at the lateral epicondyle of the humerus due to inflammation at the origin of extensor muscles of forearm

Golfer’s elbow Medial epicondylitis

Pain and tenderness at the medial epicondyle of the humerus due to

Inflammation is at the origin of flexor tendons o0f forearm.

De Quervain’s tenovaginitis Pain and swelling over the radial styloid process

Inflammation of the common sheath of abductor pollicis longus and extensor pollicis longus tendons.

Tenderness is elicited by adducting the thumb.

Mearalgia paresthetica Paresthesia in the area of skin supplied by lateral cutaneous nerve of thigh as it gets trapped beneath the fascia
Gamekeeper’s thumb Tear of ulnar collateral ligament of thumb – metacarpophalangeal joint
Bowler’s thumb Neuritis of ulnar collateral branch of thumb digital nerve.
Jumper’s knee Tendonitis of quadriceps apparatus
Madelung deformity Developmental ulnar and volar tilt of distal end of radius with dorsal dislocation of ulna (manus valgus)
Dupuytren’s contracture Contracture of palmar aponeurosis

Flexion deformity of one or more fingers due to thickening and shortening of the palmar aponeurosis.

Frog hand Infection of midpalmar space, resulting in deep palmar abscess

Edema of dorsum of hand

Interphalangeal joint movements are not painful, while metacarpophalangeal joints movements are painful

*Non union is commonly seen in scaphoid, transcervical femoral, lower fourth of tibia

TRIVIAL TRUTH

Elephants have been known to remain standing after they die.

ELEVENTH HOUR ORTHOPEDICS                                                                                                        219

*Compartment syndrome

Stretch test is the earliest sign of impending compartment syndrome

Compartment pressure of > 40 mm of water is indicative of compartment syndrome

Degree of sprain Characteristic
First Tear of only few fibres
Second From third to almost all the fibres of ligament are disrupted

movements are normal

Third Complete tear of ligament

Common sites of avascular necrosis

Fracture neck femur Necrosis femoral head
Fracture scaphoid waist Necrosis of proximal pole of scaphoid
Fracture neck talus Necrosis of body of talus

*Nerve degeneration

Proximal part undergoes primary or retrograde degeneration.

Part of the neuron distal to the point of injury undergoes secondary or Wallerian degeneration.

The rate of recovery of axon is 1mm /day.

Motor march- The muscle nearest to the site of injury recovers first followed by others from proximal to distal.

NERVE PALSIES

Wrist drop Radial nerve palsy
Foot drop Common peroneal nerve palsy
Winging of scapula Paralysis of serratus anterior in long thoracic nerve palsy
Claw hand / Main-en-griffe Paralysis of lumbricals in ulnar nerve palsy
Ape thumb Paralysis of opponens pollicis in median nerve palsy
Pointing index Paralysis of flexor digitorum superficialis in median nerve palsy
Saturday night palsy / crutch palsy Radial nerve
Honeymoon palsy Median nerve palsy
Neurapraxia Physiological disruption of nerve conduction in the absence of  structural changes, Complete spontaneous recovery occurs

QUOTE CORNER

If A equals success, then the formula is A equals X plus Y plus Z. X is work. Y is play. Z is keep your mouth shut. Albert Einstein

ELEVENTH HOUR ORTHOPEDICS                                                                                                       220

Axonotmesis Axons are damaged but the internal structure is preserved

Spontaneous recovery possible

Neurotmesis Structure of the nerve is damaged by actual cutting

Nerve repair is required, no spontaneous recovery

Muscle wasting in nerve injuries

Flat shoulder Axillary nerve
Flat thenar eminence Median nerve
Flat hypothenar eminence Ulnar nerve
Hollowing between metacarpals Ulnar nerve
Thigh wasting Femoral nerve
Calf wasting Sciatic nerve

Splints used in nerve injuries

Axillary nerve Shoulder abduction splint
Radial nerve palsy Cock-up splint
Ulnar nerve palsy Knuckle bender splint
Sciatic nerve palsy Foot drop splint
Charcot’s joint Joints affected
Diabetic arthropathy Foot joint
tabes dorsalis Knee and hip
diabetes mellitus Foot
Syringomyelia Upper limb
Oschner’s clasping test Interlock the digits of both the hands and flex the metacarpophalangeal and interphalangeal joints

In median nerve palsy, lateral part of flexor digitorum profundus, will get paralysed leading to pointing index.

Hook sign Suppurative tenosynovitis

Metacarpophalangeal joint movement is not painful, while interphalangeal movements are painful.

Book test / Froment’s sign In ulnar nerve paralysis, adductor pollicis will be paralyzed and the patient will not be able to grasp the book between the thumb and index finger
Simon’s test diagnostic of ruptured tendo Achilles
Kanavel’s sign seen in ulnar bursa infection

Point of maximum tenderness is over the part lying between transverse palmar creases.

TRIVIAL TRUTH

Cigarette smoking is more addictive than all illicit drugs except crack and heroin combined.

ELEVENTH HOUR ORTHOPEDICS                                                                                                         221

*Scurvy

Barlow’s disease

Reason- Vitamin C deficiency.

Decreased activity of enzymes, prolyl and lysyl hydroxylase required for hydroxylation of lysine and proline, affecting collagen synthesis.

When scurvy and rickets, both are present (Barton’s disease), then signs of scurvy dominate because of diminished osteoblastic activity.

Radiological signs of Scurvy (usually studied in knee joints)

Signs Description
Wimberger’s sign / Signet ring/ Halo sign Sclerotic rim around epiphysis
White line of Frankel Zones of provisional calcification
Trummerfield’s zone Radiolucent cortex proximal to white line.
Pelkan spur/ Corner sign Marginal metaphyseal infarction with healing.
Pencil thin cortex Cortical thinning.
Ground glass shaft Rarification of cortical bone.
Scorbutic rosary Sharp elevation at costochondral junction.
Raised periosteum Subperiosteal haematoma.
clinical features OF RICKETS
Craniotabes (earliest manifestation of rickets)

Bossing of frontal and parietal bones

Delayed closure of fontanelle.

Rachitic rosary- prominent costochondral junction.

Harrison’s groove-horizontal depression along the lower border of chest corresponding to attachment of diaphragm.

Pigeon breast-forward projection of sternum

Pot belly- hypotonia of abdominal muscles.

*Ewing’s sarcoma is the most radiosensitive tumor, but not most radiocurable tumour.

Codman’s triangle Triangular area of subperiosteal new bone at the tumor host junction seen in osteosarcoma.
Sunray appearance New bone laid along the blood vessels within the tumor growing centrifugally seen in osteosarcoma.
Onion peel appearance New bone formation in layers, seen in Ewing’s sarcoma

QUOTE CORNER

Always remember that striving and struggle precede success, even in the dictionary- Sarah Ban Breathnach

ELEVENTH HOUR ORTHOPEDICS                                                                                                         222

Premalignant bone lesions
Paget’s disease

Dipahysial aclasia

Enchondromatosis

Post radiation

Most common bone tumour Secondaries (metastasis) from other regions
Most common benign bone tumour Osteochondroma
Most common true benign bone tumour Osteoid osteoma
Most common primary bone malignancy Multiple myeloma , followed by osteosarcoma

BONE GRAFTS

Autogenous graft Graft is taken from the patient himself, from sites like iliac crest, upper end of tibia, fibula.
Allogenous graft Can be obtained form cadavers (Cadaveric graft)

Allogenous grafts from the mother are used when a child’s bone reserves are not enough to fill a big gap

Also the bone preserved by deep freezing, by decalcifying or formalin preservation can be used for allogenous bone grafting.

Xenografting Bone grafts from some other species are used.
Artificial bones Hydroxyapatite derived from corals.

MANAGEMENT OF CLUBFOOT BY AGE

Age Procedure
0-1 months Manipulation by mother
1-6 months Manipulation with plaster cast
6m-3yrs Posterolateral soft tissue release
4-8 years Evan’s surgery (posteromedial soft tissue release with calcaneocuboid fusion)
8-11 years Wedge tarsectomy
>12 years Triple arthrodesis
Already operated Ilizarov technique
Order of manipulation in CTEV
C-Cavus

A-Adduction

V-Varus

E-Equinus

TRIVIAL TRUTH

The length of your foot is the same as that of your forearm between your wrist and the inside of your elbow. Give it a try…you’ll be amazed!

ELEVENTH HOUR ORTHOPEDICS                                                                                                      223

*If not corrected in this order then it can lead to Rocker bottom feet

Incidence of club foot-1/1000

Spina bifida occulta Mildest and the commonest

Failure of the fusion of vertebral arches results in bifid spinous process

Spina bifida aperta Failure of fusion of not only vertebral arches but also soft tissues, skin and meninges
Meningocele Protrusion of meninges  through a defect in the neural arch

Contains only csf

Meningomyelocele Protrusion of meninges with some neural element
Syringomyelocele Spinal cord with dilated central canal (Syringomyelia) lies within the meningial sac
Myelocele Central canal opens to the exterior.
Epiphyseal enlargement jra
Epiphyseal widening Rickets
Epiphyseal dysgenesis Hypothyroidism

Acute osteomyelitis

Treatment within 48 hrs of onset of symptoms Conservative (antibiotics)
Beyond 48 hours Surgical exploration
Sequestrum Dead bone, surrounded by infected granulation tissue
Involucrum Dense sclerotic bone overlying sequestrum

*Tom Smith arthritis is septic arthritis in infancy-Head of the femur is completely destroyed

Osteogenesis imperfecta Tendency for frequent fracture, due to brittleness of bones

Autosomal dominant inheritance

Associated with blue sclera, joint laxity and otosclerosis

Diaphysial aclasia Multiple exostoses

Multiple cartilage capped bony outgrowths from the metaphysis of long bones.

Inherited as autosomal dominant

X ray shows trumpet shaped metaphysic & bony projections.

Osteoporosis Marble-bone disease

Albers-Schonberg disease

Dense but brittle bones

QUOTE CORNER

I’d rather be a failure at something I enjoy than a success at something I hate.- George Burns

ELEVENTH HOUR ORTHOPEDICS                                                                                                        224

TABLE CONTINUED…

Paget’s disease Osteitis deformans

Progressive tendency for one or more bones to bend, get thickened and spongy, followed by increased density and hardening

Pathological fractures and malignant change can occur

Histiocytosis X Proliferation of histiocytes in the bones, includes-

Eosinophilic granuloma

Hand-Schuller Christian disease

Literere Siwe disease

Achondroplasia Trident hand

Globular skull

Dwarfism

Prognathism

Tubercular arthritis of hip joint

STAGE ATTITUDE
Stage 1

Stage of synovitis or stage of apparent lengthening.

Flexion, abduction, external rotation
Stage 2

Stage of arthritis or stage of apparent shortening.

Flexion, adduction, internal rotation
Stage 3

Stage of erosion or stage of true shortening.

Flexion, adduction, internal rotation
Diagnostic criteria of rheumatoid arthritis
If  4 or more criteria are present, it is r.a.
Morning stiffness

Swelling of 3 or more specified joints

Swelling of joints in the hand and wrist

Symmetric swellings

Rheumatoid nodule

Rheumatoid factor [positive

Erosion or unequivocal periarticular osteopenia on X ray

Joints commonly affected in r.a.
Metacarpophalangeal  joint

Proximal interphalangeal  joint

Wrist

Knees

Elbows

Ankles

TRIVIAL TRUTH

A shark can detect one part of blood in 100 million parts of water

ELEVENTH HOUR ORTHOPEDICS                                                                                                         225

Felty’s syndrome Rheumatoid arthritis

Splenomegaly

Neutropenia

High titres of rheumatoid arthritis

Caplan’s syndrome Rheumatoid arthritis

Pneumoconiosis

Still’s disease Rheumatoid arthritis

Splenomegaly

Leucocytosis

Rash

Rheumatoid factor absent

*Indication of steroids in R.A.

Mononeuritis multiplex

Most common cause of Mononeuritis multiplex- poly ateritis nodosa

Rh factor is Ig M type.

*Tuberculosis of knee/ Rheumatoid arthritis of knee

Triple Subluxation

Flexion, posterior Subluxation and external rotation

Spina ventosa-tubercular dactylitis (phalanges)

*Shoulder dislocation

Commonest joint to dislocate

Bankart’s lesion-

Stripping of the glenoidal labrum and periosteum from the anterior surface of glenoid and scapular neck

Hill-Sach’s lesion-

Depression on the humeral head in its posterolateral quadrant due to impingement by anterior edge of the glenoid on the head.

*Three points relationship in elbow is formed by-

Medial epicondyle

Lateral epicondyle

Tip of olecranon

Tip of radius is considered as fourth point

When elbow is flexed to 90 degrees, theses three points form a near isosceles triangle, where as on extension, they lie in a straight line.

They are important in diagnosing injuries around elbow joint

QUOTE CORNER

Success doesn’t come to you…you go to it. Marva Collins

ELEVENTH HOUR ORTHOPEDICS                                                                                                         226

*Carrying angle of elbow-

Normal in males-11 degrees

In females 14 degrees

*Ilizarov principle is-

Distraction histogenesis- distraction osteogenesis

*Biphosphonate is the treatment of choice for Paget’s disease.

*Drummer boy’s palsy

Dorsally displaced distal fragment with Lister tubercle causes attrition rupture of Extensor pollicis longus tendon.

*Plaster of Paris / Gypsum salt

CaSO4 ½ H2O → Ca SO4 2H2O

This is an exothermic and irreversible reaction.

*Shortening of lower limb upto 2 cm is compensated by shoe raise

More than 2 cm should be undertaken for limb length equalization procedure

*Slipped disc is most common at L4- l5- level

Disc is thinnest at the thoracic region and thickest at the lumbar region.

TRIVIAL TRUTH

In 300 BC, women were not allowed to attend medical school, so Agnodice got around this by impersonating a male student. She continued this practice afterwards until one of her patients did not want a “man” to examine her. So Agnodice disrobed and revealed her real gender. She was put on trial for practicing medicine while female! The townspeople mobbed the trial and pleaded for her life. She was pardoned.

ELEVENTH HOUR ORTHOPEDICS                                                                                                         227

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