Orthopaedics has come a long way since the days of Nicholas Andry, a French physician, who is credited for coining the term, orthopaedics from two words, Ortho = straight and Paedics = child in 1741.
What was a primitive branch then restricted to correcting deformities in children, has developed into a full-fledged speciality with diverse scope ranging from simple treatment, as done by traditional bonesetters to highly advanced joint, spine and hand surgeries.
The development of orthopaedics as a speciality was pedestrian till 18th century. The discovery of anaesthesia and aseptic surgical techniques opened up new avenues of treatment like open reduction, debridement, etc. The discovery of X-rays by Roentgen and the introduction of the usage of Plaster of Paris by Albert Mathysen in 1852 revolutionised the diagnosis and management of orthopaedic disorders. Thus, orthopaedics started breaking through the deadlocks of a crude branch to that of a science.
But what really set the ball rolling was the sudden surge of orthopaedic cases firstly by the two World Wars and of late by the road traffic accidents which is on the rise, both in the developed and developing countries.
Polytrauma, multiple fractures and high-velocity injuries severely exposed the limitations of the conventional treatment in orthopaedics, as the fracture patterns were bizarre and complicated. Thus newer modalities of treatment like improved methods of internal fixation, the AO systems, the interlocking nail system, Ilizarov's method, etc. were introduced into orthopaedic management. Suddenly orthopaedics was being considered a highly specialised branch with vast scope.
Needless to say many pioneers both at the international and national level have contributed enormously for the development of this branch to the present what is today. We salute them for their contribution. A fitting tribute to them is to carry on the good work done by them and to raise the level of this branch to such dizzy heights so that the sufferings of mankind due to orthopaedic disorders is mitigated.
There is a strong notion among the students that orthopaedics is all about trauma. Nothing can be farther from the truth. Though trauma contributes to a major chunk of orthopaedic-related conditions yet it is not the sole contributor. Like any other system in the body, bones and joints are affected by a plethora of disease conditions ranging from congenital disorders, infections, tumours, etc. Degenerative disorders that seem to ravage the musculoskeletal system in old age completes the cup of misery. Needless to say one needs to be equipped both with knowledge and skill to gear up oneself to face the orthopaedic challenges being hurled at surgeons in double quick time of late.
Through this book, I endeavour to arm my students with the all important knowledge so essential to understand and unravel the mysteries surrounding orthopaedic-related conditions. Based on this knowledge, the necessary skills can be acquired through various stages of practical exposures. It always helps to know the common orthopaedic terminologies, tests, surgical procedures, etc. for better and easy understanding. Hence glossary is presented first. It is imperative to know about the fundamentals of bones and joints before undertaking the arduous journey of problems afflicting the musculoskeletal system. Thus basics of this system is talked about next. The ensuing chapters deal 4extensively first with the traumatic conditions and related problems, followed by non-traumatic conditions.
Finally, the tools required to acquire the all necessary skills are mentioned in the final chapters on instruments and implants. I fervently urge my students to be a stickler for basics and sophistication automatically follows. It pays to know, at the beginning itself, that the reverse is not true.
GLOSSARY
IMPORTANT CLASSIFICATIONS IN ORTHOPAEDICS
Spine
- Allen's—for cervical spine injuries.
- Anderson and D'olonzo's—for odontoid process fractures.
- McAffee's—for thoracolumbar fractures.
Upper Limbs
- Neer's—for proximal humeral fractures.
- Gartland's—for supracondylar fracture of the humerus (extension type).
- Bado's—for Monteggia fractures in adults.
- John Wein's—for Monteggia fractures in children.
- Stimson's—for posterior dislocation of the elbow joint.
- Shorbe's—for side swipe injuries of the elbow.
- Colton's—for olecranon fractures.
- Frykmann's—for Colles’ and Smith's fractures
- Mason's—for radial head fractures.
Pelvis Fractures
- Key and Conwell's.
- Tile's.
Lower Limbs
Hip Joint
- Garden's—for fracture neck of femur (intracapsular).
- Pauwell—for intracapsular fracture neck of femur.
- Perlington—for intracapsular fracture neck of femur.
- Delbet's—for fracture neck of femur in children.
- Seinsheimer's—for subtrochanteric fracture of femur.
- Thompson Epstein—for fracture dislocation of the hip.
- Fielding's—for subtrochanteric fracture of the femur.
- Judet—for central dislocation of the hip.
- Neer—for supracondylar fracture of the femur.
Knee and Proximal Tibia
- Smillie's—for meniscal injury.
- Hohl and Moore's—for fracture of the proximal tibia.
- Elli's—for fracture of shaft of tibia and fibula.
Ankle
- Lauge Hansen—for ankle injuries.
- Dennis Weber—for ankle injuries.
Foot
- Essex-Lopresti—for calcaneal fractures.
Peripheral Nerve Injuries
- Sunderland.
- Seddon.
Epiphyseal Injuries
- Salter and Harris.
Miscellaneous
- Gustilo and Anderson's—for open or compound fractures.
IMPORTANT RADIOLOGICAL APPEARANCES
Hip Joint
- Trethovan’ sign—seen in slipped capital femoral epiphysis.
- Risser's sign—seen in iliac bone epiphysis.
- Shenton's line—for hip dislocations and displaced hip fractures.
- Hilgenreiner's line—for CDH.
- Perkin's line—for CDH.
- Sagging rope sign—for Perthes’ disease.
- Tear drop sign—for Perthes’ disease.
- Garden's criteria—for fracture neck of femur.
Knee Joint
- Insaal and Blumensaat's lines—for patella alta.
Ankle Joint
- Hawkin's sign—avascular necrosis talus.
- Böhler's angle—for calcaneum.
- Crucial angle of Gissane—for calcaneum.
Shoulder
- Goldie's sign—for periarthritis or frozen shoulder.
- Maloney's line—for shoulder joint, similar to the Shenton's line.
Elbow Joint
- Crescent sign—absence of the normal radiolucent gap of the elbow on the lateral view.
- Tear drop sign—seen in the lateral view of the elbow.
- Anterior humeral line—a line drawn along the anterior border of the distal humeral shaft.
- Fish tail sign—the sharp anterior border of the proximal fragment in supracondylar fracture of the humerus.
- Coronoid line—a line directed proximally along the anterior border of the coronoid process of the ulna.
- Bauman's angle—angle between the horizontal line of the elbow and the line drawn through the lateral epiphysis and the long axis of the forearm.
- MacLaughlin's line—a straight line drawn along the centre of the shaft of the radius cuts the capitulum in the centre irrespective of the position of the elbow.
Hand
- Kaplan's lesion—presence of a sesamoid bone within the metacarpophalangeal joint of the finger (commonly index).
- Scapholunate angle—for carpal injuries.
Spine
- Aneurysmal sign—Pott's spine (anterior type).
- Scottish terrier sign—for spondylolysis due to fracture in pars.
Infection
- Sequestrum—seen in chronic osteomyelitis.
- Cloacae and involucrum—chronic osteomyelitis.
- Spina ventosa—tubercular dactylitis.
- Protrusio acetabuli, Mortal Pestle appearance—TB hip.
- Concertina collapse—TB spine.
Metabolic Disorders
- Champagne glass appearance—rickets.
- Moth-eaten appearance—renal rickets.
- Looser's or Milkman's line—osteomalacia.
- Pin head stippling—primary hyperthyroidism.
- Ground glass and biconcave vertebrae—osteoporosis.
- White line of Frankel—scurvy.
- Scurvy line—scurvy.
- Wimberger's line—scurvy.
- Pelkan spur—scurvy.
Developmental Disorders
- Shepherd's crook deformity—fibrous dysplasia.
- Ribbon ribs—von Recklinghausen's disease.
- Marble bone—osteopetrosis.
- Quadrilateral ilium—achondroplasia.
Congenital Disorders
- von Rosen's line—CDH.
- Kite's index—CTEV.
- Hourglass tibia—congenital pseudarthrosis of tibia.
Bone Tumours
- Soap-bubble appearance—seen in giant cell tumour.
- Onion peel—seen in Ewing's sarcoma.
- Sunrise sign—seen in osteogenic sarcoma.
- Codman's triangle—seen in osteogenic sarcoma.
- Nidus—osteoid osteoma.
- Fluffy, cotton wool, bread crumb or popcorn—chondrosarcoma.
- Pedicle sign—multiple myeloma.
IMPORTANT FRACTURES WITH EPONYMS
Spine
- Hangman's fracture—fracture pedicle lamina of C2 vertebra.
- Whiplash injury—ligament injury of the neck.
- Chance fracture—horizontal avulsion fracture of lumbar spine.
Upper Limbs
- Essex-Lopresti fracture—fracture head of the radius with dislocation of the inferior radioulnar joint.
- Night stick fracture—fracture of the shaft of the ulna.
- Galeazzi fracture—fracture distal radius with subluxation or dislocation of the inferior radioulnar joint.
- Fracture of necessity—other name for Galeazzi.
- Reverse Monteggia fracture—other name for Galeazzi.
- Colles’ fracture—fracture distal end of radius.
- Smith's fracture—fracture distal end of radius with palmar displacement.
- Chauffeur's fracture—fracture of the radial styloid process.
- Bennett's fracture—intra-articular fracture of the base of the first metacarpal bone.
- Rolando's fracture—extra-articular fracture of the base of the first metacarpal bone.
- Jersey finger—avulsion of flexor digitorum profundus from its insertion on distal phalanx.
- Baseball thumb—avulsion of ulnar collateral ligament.
- Mallet finger or baseball finger—avulsion of the extensor tendon from base of the distal phalanx.
- Barton's fracture—rim fracture of the distal end of the radius.
Pelvis
- Malgaigne's fracture—disruption of the pelvic ring with injury to the pubic symphysis and sacroiliac joint on the same side.
Lower Limbs
- Dash board fracture—fracture patella.
- Bumper's fracture—comminuted lateral condyle fracture tibia.
- Pott's fracture—bimalleolar fracture.
- Cotton's fracture—trimalleolar fracture.
- Aviator's fracture—fracture neck of the talus.
- Jone's fracture—fracture base of the fifth metatarsal bone.
- March fracture—stress fracture of the second metatarsal bone.
IMPORTANT CLINICAL TESTS IN ORTHOPAEDICS
Neck
- Adson's test—for thoracic outlet syndrome.
Shoulder Joint
Tests for anterior dislocation of shoulder:
- Bryant's test.
- Callaway's test.
- Dugas test.
- Hamilton ruler test.
- Regiment badge test—for axillary nerve injury.
Elbow Joint
- Cozen's test—for tennis elbow.
- Gunstock deformity—malunited supracondylar fracture humerus.
- S-shaped deformity—seen in supracondylar fracture humerus.
Forearm
- Volkmann's test—for Volkmann's ischaemia of the forearm.
Wrist Joint
- Wrist drop—for radial nerve injury.
- Thumb and finger drops—for radial nerve injury.
- Finkelstein's test—for de Quervain's disease.
Hand
- Police tip deformity—for Erb's palsy.
- Claw hand—for ulnar nerve injury.
- Benediction test—for median nerve injury.
- Ape thumb deformity—for median nerve injury.
- Pointing index—for median nerve injury.
- Kanaval sign—for ulnar nerve bursitis.
- Froment's sign—for ulnar nerve injury.
- Tinel's sign—for peripheral nerve injury recovery.
Spine
- Straight leg raising test (SLRT)—passive straight leg raising test in disc prolapse.
- Fazerstazan test—SLRT with dorsiflexion of the foot.
- Laségue test—hip flexed, knee flexed and the leg is slowly straightened.
- Buckling sign—after doing SLRT knee is suddenly flexed.
- Sicard's test—after doing SLRT great toe is dorsiflexed.
- Well leg raise test—SLRT of the normal leg.
- Bilateral SLRT—SLRT of both the legs.
- Femoral nerve stretch test—reverse SLRT for high disc prolapse.
- Coin test—for TB spine.
Sacroiliac Joint
- Pump handle test.
- Gaenslon's test.
Hip Joint
- Barlow's test—test for CDH in the newborn.
- Ortolani's test—test for CDH in infant between 3 and 9 months.
- Galeazzi's test—knee flexion test for CDH.
- Thomas test—for fixed flexion deformity of the hip.
- Trendelenburg's test—test for abductor mechanism of the hip.
- Ober's test—test for iliotibial band contracture as in polio.
Pelvis
- Destot's sign—pelvic fracture.
- Roux's sign—pelvic fracture.
- Earle's sign—pelvic fracture.
Knee Joint
- Lachman's test—anterior drawer test at 30 degree knee flexion in acute injuries.
- Drawer's test—for anterior cruciate ligament (ACL) tear.
- McMurray's test—test for meniscal injuries.
- Ludloff's test—for avulsion of the lesser trochanter.
- Apley's compression test—for meniscal injuries.
- Apley's distraction test—for knee collateral ligament injuries.
- O'donoghue's triad—injury to the medial meniscus, medial collateral and anterior cruciate ligaments.
- Pivot shift test—for ACL tear.
IMPORTANT ORTHOPAEDIC SURGERIES BY NAMES
Upper Limbs
Shoulder Joint
- Putti-Platt's—Overlapping and tightening of subscapularis tendon for recurrent dislocation of shoulder.
- Bankart's—detached anterior structures attached to glenoid rim by sutures.
- Bristow's—transplantation of coracoid process to anterior rim of the glenoid cavity in recurrent dislocation of shoulder.
- Staple capsulorrhaphy of Destot's and Roux—same as Bankart's but staples used instead of sutures.
- Magnusan and Stack—lateral advancement of subscapularis tendon.
- Eden Hybinette—anterior bone graft over glenoid and scapular neck.
- MacLaughlin—for posterior dislocation of the shoulder.
Elbow Joint
- French osteotomy—lateral closed wedge osteotomy for cubitus varus.
- King's osteotomy—medial open wedge osteotomy for cubitus varus.
- Max page—releasing of structures from medial epicondyle of humerus for VIC.
Wrist Joint
- Fernandez—dorsal wedge osteotomy for Colles.
- Campbell—lateral wedge osteotomy for Colles.
Lower Limbs
Hip Joint
- Yount—sectioning of iliotibial band.
- Meyer—muscle pedicle (quadratus femoris) graft for posterior wall comminution in fracture neck of femur.
- Girdlestone—surgical excision of the hip joint.
Knee Joint
- Wilson—for flexion deformity of the knee.
- Hauser—for recurrent dislocation of the patella.
- Campbell—for recurrent dislocation of patella.
Foot
- Triple arthrodesis—fusion of the subtalar, talonavicular and calcaneocuboid joints.
- Lambrinudi—for severe equinus deformity of the foot.
- Dwyer—lateral closed osteotomy for varus foot deformity.
- Evan—resection of calcaneocuboid joint for CTEV.
- Garceau—transfer of tibialis anterior to middle cuneiform for CTEV.
- Turco—one-stage release of posteromedial structures in mild CTEV.
- MacKay—one-stage release of posteromedial and posterolateral structures in severe CTEV.
- Grice-Green—subtalar fusion.
- Jones’—surgical correction of foot deformity.
- Keller's—surgical correction of halux valgus deformity.
- Steindler's—release of plantar fascia short plantar muscles and long plantar ligament in cavus foot deformity.
TERMINOLOGIES ASSOCIATED WITH FRACTURES
- Fracture—a break in the continuity of the bone.
- Simple fracture—fracture that does not have an open wound in the skin.
- Compound or open—fracture in which there is an open wound at the skin or soft parts that leads into the fracture.
- Comminuted—fracture with multiple fragments.
- Avulsion fracture—small fracture near a joint that usually has a ligament or tendon attached to it.
- Impacted fracture—fracture whose ends are driven into each other.
- Displaced fracture—fracture whose ends are separated.
- Undisplaced fracture—fracture whose ends are not separated.
- Greenstick fracture—incomplete fracture due to break in one cortex of the bone in children.
- Pathologic fracture—fracture that occurs due to bone weakness due to a local or generalised bone disorder.
- Intra-articular fracture—fracture that involves the joint surface of a bone.
- Fatigue or stress fracture—fracture due to repeated minor stresses.
- Torus or buckle fracture—fracture caused by compression of the cortex most commonly in the distal region.
- Epiphyseal fracture—fracture of the growth plate usually in the long bones.
- Occult or hidden fracture—as clinical condition that suggests a fracture. Radiographs 2 to 3 weeks later may show the fracture line or a new bone formation.
- Nonunion—complete failure of fracture union.
- Malunion—union of a fractured bone in a position other than anatomical.
- Cross-union—side-to-side union of fracture.
IMPORTANT ORTHOPAEDIC TERMINOLOGIES
Joint
- Ankylosis—restriction of joint motion.
- Arthrodesis—surgical fusion of a joint.
- Arthroplasty—surgery to restore motion and function to a joint.
- Arthrotomy—opening of a joint.
- Effusion—escape of fluid into a joint cavity.
- Dislocation—complete disruption in the continuity of a joint.
- Subluxation—partial disruption in the continuity of the joint.
- Fracture dislocation—dislocation that occurs in conjunction with a fracture of the bone if incomplete it is called fracture subluxation.
- Osteoarthritis—degeneration of a joint.
- Osteophytes—new bone growth due to degeneration of the joint.
- Arthrocentesis—joint aspiration.
- Arthroscopy—inspection of a joint through an arthroscope.
- Strain—muscle tear.
- Genu—pertains to knee.
- Cubitus—pertains to the elbow.
Movements
- Flexion—forward bending of the joint.
- Extension—backward bending of a joint.
- Abduction—movement away from the midline.
- Adduction—movement towards the midline.
- Pronation—to rotate the forearm in such a way that the palm looks downwards when the arm is in the anatomical position.
- Supination—to rotate the forearm in such a way that the palm looks forwards when the arm is in the anatomical position.
- Eversion—turning outward of the foot.
- Inversion—turning inward of the foot.
Spine
- Spondylitis—inflammatory condition of the spine.
- Spondylosis—degenerative condition of the spine.
- Spondylolysis—defect in the pars interarticularis of the vertebra.
- Spondylolisthesis—slipping of one vertebra over the other.
- Kyphosis—curvature of the spine with posterior convexity.
- Lordosis—curvature of the spine with anterior convexity.
- Scoliosis—abnormal lateral curvature of the spine.
- Radicular pain—shooting pain due to a spinal nerve involvement.
- Sciatica—shooting pain along the course of the sciatic nerve.
- Laminotomy—opening made in the lamina.
- Hemilaminectomy—partial removal of the lamina.
- Laminectomy—complete removal of the lamina.
- Fenestration—opening made in ligamentum flavum between two laminae.
Foot and Ankle
- Equinus—plantar flexion of the foot.
- Calcaneus—dorsiflexion of the foot.
- Planus—flat foot.
- Cavus—hollow foot.
- Talipes—talus (ankle) + pes (foot).
- Pes—foot.
- Hallux—great toe.
Tendons and Nerves
- Tenotomy—cutting a tendon.
- Tenodesis—attaching a tendon to another tendon or bone.
- Tenolysis—freeing a tendon from adhesions.
- Tendon transfer—transferring a tendon from one site to the other.
- Neurolysis—freeing a nerve from adhesions.
- Neurorrhaphy—repairing a sectioned nerve.
- Neurectomy—sectioning a nerve.
IMPORTANT OSTEOTOMIES IN ORTHOPAEDICS
Upper Limbs
- French—for cubitus varus deformity.
- King's—for cubitus varus deformity.
Hip Joint
- McMurray—for nonunion fracture neck femur.
- Shanz—for nonunion fracture neck femur.
- Pauwel—for nonunion fracture neck femur.
- Salter—for CDH.
- Pemberton—for CDH.
- Steel—for CDH.
- Chiari—for CDH.
- Derotation osteotomy—for CDH.
- Innominate osteotomy—for Perthes.
Knee
- High tibial osteotomy (HTO) for genu varum deformity in osteoarthritis.
Spine
- Spinal osteotomy—for ankylosing spondylitis.
Foot
- Dwyer's—for varus deformity of the heel.