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By Live Dr - Wed Feb 11, 3:25 am
Stages of fracture healing
|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|
|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|
|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|
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
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.
|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
Elephants have been known to remain standing after they die.
ELEVENTH HOUR ORTHOPEDICS 219
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|
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.
|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|
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|
|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.
Cigarette smoking is more addictive than all illicit drugs except crack and heroin combined.
ELEVENTH HOUR ORTHOPEDICS 221
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)
|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|
Always remember that striving and struggle precede success, even in the dictionary- Sarah Ban Breathnach
ELEVENTH HOUR ORTHOPEDICS 222
|Premalignant bone lesions|
|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|
|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
|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|
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.|
|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.
Dense but brittle bones
I’d rather be a failure at something I enjoy than a success at something I hate.- George Burns
ELEVENTH HOUR ORTHOPEDICS 224
|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-
Hand-Schuller Christian disease
Literere Siwe disease
Tubercular arthritis of hip joint
Stage of synovitis or stage of apparent lengthening.
|Flexion, abduction, external rotation|
Stage of arthritis or stage of apparent shortening.
|Flexion, adduction, internal rotation|
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.|
Swelling of 3 or more specified joints
Swelling of joints in the hand and wrist
Rheumatoid factor [positive
Erosion or unequivocal periarticular osteopenia on X ray
|Joints commonly affected in r.a.|
Proximal interphalangeal joint
A shark can detect one part of blood in 100 million parts of water
ELEVENTH HOUR ORTHOPEDICS 225
|Felty’s syndrome||Rheumatoid arthritis
High titres of rheumatoid arthritis
|Caplan’s syndrome||Rheumatoid arthritis
|Still’s disease||Rheumatoid arthritis
Rheumatoid factor absent
*Indication of steroids in R.A.
Most common cause of Mononeuritis multiplex- poly ateritis nodosa
Rh factor is Ig M type.
*Tuberculosis of knee/ Rheumatoid arthritis of knee
Flexion, posterior Subluxation and external rotation
Spina ventosa-tubercular dactylitis (phalanges)
Commonest joint to dislocate
Stripping of the glenoidal labrum and periosteum from the anterior surface of glenoid and scapular neck
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-
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
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.
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