Textbook of Orthopaedics John Ebnezar
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1Textbook of Orthopedics
2
A Thought from the Student
God created the doctor and his patient. Together they created many hospitals and Medical Institutions. A happy world is what it would have been, had it not been the emergencies in between.
Let this book come in ‘handy’ when it matters the most.
Dr K Sarawana
3Textbook of Orthopedics
Fourth Edition
John Ebnezar MBBS D'Ortho, DNB (Ortho), MNAMS (Ortho), DAc, DMT, PhD (Yoga) Sports Medicine (Australia), INOR Fellow (United Kingdom) Consulting Orthopedic and Spine Surgeon and Holistic Orthopedic Expert, Sports Specialist Formerly Assistant Professor of Orthopedics Devaraj Urs Medical College Kolar, Karnataka Senior Specialist in Orthopedics Department of Orthopedics Victoria Hospital Bangalore Medical College Currently Chief Consulting Orthopedic Surgeon and Medical Director Parimala Health Care Services, An ISO 9001:2000 hospital Bengaluru Chairman Ebnezar Orthopedic Center, Bengaluru Chairman Dr Ebnezar's Medical Institute President Geriatric Orthopedic Society President All India Medical Author's Association Chairman The Physically Handicapped and Paraplegic Charitable Trust of Karnataka President The Karnataka Orthopedic Academy Director Bangalore Holistic Orthopedic Centre, Bengaluru President Vaidya Kala Ranga, Bengaluru Chairman Rakesh Cultural Academy
4Published by
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Textbook of Orthopedics
© 2010, John Ebnezar
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 1996
Second Edition: 2000
Third Edition: 2006
Fourth Edition: 2010
9788184487442
Typeset at JPBMP typesetting unit
Printed at
5
To
My mother (Late) Sampath Kumari
who taught me that life is more than self and there
Is more joy in giving and sharing than taking?
My wife Dr Parimala, my lovely children Rakesh and Priyanka
Who are an epitome of love, sacrifice, encouragement and inspiration?
All my teachers
Who made me what I am today
&
all my students past and present6
7Foreword
With hardly a handful of orthopedic surgeons taking to writing books, I have watched Dr John Ebnezar silently grow over the decade to become a leading author in the field of Orthopedics. He has so far authored a mind boggling 17 orthopedic books single handedly, and still counting — truly a global record. John has a natural flair for writing and his books are liked by all, from medical students, teachers, to the general public. This book is a well accepted orthopedic textbook in the country and has a global presence too with an Italian edition and the book being stocked in prestigious NHS Trust libraries across UK, a high honor. The book is very informative, thought provoking and entertaining. In this is blended scientific knowledge and life philosophy in a very subtle way, which makes the book unique.
I had always told John to write a book for postgraduate students in orthopedics for I felt that a small comprehensive book dealing with postgraduate orthopedics is the need of the hour. I am happy he has acted on my advice. His textbook though originally meant for undergraduate students, inadvertently went on to become a book popular with postgraduate students. They felt it extremely useful to them but rather short, and undergraduate students felt the book to have a bit more than needed for them. He has now corrected this imbalance by upgrading this book into a full-fledged small textbook for postgraduate students in orthopedics. Accordingly you will find new chapters and sections on trauma, geriatric orthopedics, arthroplasty, arthroscopy, surgical techniques and even on Evidence Based Orthopedics, the latest significant development in the world of orthopedics. I was supposed to write a chapter on Pediatric Orthopedics for this edition but could not do so due to paucity of time. However I promise to add this chapter for the next edition.
Like all the previous editions, Dr John Ebnezar has maintained all those ingredients that have made the book so popular with everyone for over a decade and half now. Simple writing, lucid language, clarity of thought, good and innovative diagrams, clinical photographs, good X-rays are all there in plenty. To spice up, are the mnemonics, anecdotes and his philosophical touch to the subject. He has successfully tried and is successful in unconventional ideas in textbook writing like autobiographical anatomy which is a bold experiment.
I congratulate Dr John Ebnezar on his stupendous efforts and the very fact that the book is seeing its 4th edition is undoubtedly a matter of great pride and honor for him. I am sure that the readers will extend the same support and encouragement to this edition like all his previous editions. John is a good trendsetter as 8far as orthopedic writing is concerned and is worthy of emulation. He has truly put India on the global map and deserves praise and accolades for all his efforts.
I wish him and the book all the best and feel privileged to write this foreword for the fourth edition.
Prof Dr Ashok N Johari
Pediatric Orthopedic and Spine Surgeon
Lilavati, Bombay and Nanavati Hospitals,
BJ Wadia Hospital for Children
Sir JJ Hospital and Grant Medical College, Mumbai
President Elect, Indian Orthopedic Association
President, Pediatric Orthopedic Society of India
President, Indian Academy of Cerebral Palsy
Editor-in-chief, Journal of Pediatric Orthopedics (B)
Chairman, The Child Foundation
9Forewords
FOREWORD TO THE FIRST EDITION
I sincerely admire the efforts of Dr John Ebnezar. It is an excellent book for the undergraduates and postgraduate students (their teachers too!). I like the style of his writing.
My heartiest congratulations on his solo Herculean efforts.
With best wishes
GS Kulkarni
MS, MS (Ortho), FICS
Professor of Orthopedics and Director
Orthopedics Hospital and Postgraduate Institute of Orthopedics
Swasthiyog Pratishthan, Miraj
(Recognized for MS (Ortho), D (Ortho), Courses by
Shivaji University and Medical Council of India,
Delhi and Recognized for Dip NB (Ortho), MNAMS
By National Board of Examinations, Delhi
Editor, Clinical Orthopedics India
Secretary ASAMI-India (Ilizarov Association)
Chief Research Director, Sandhata Medical Research Society, Miraj
FOREWORD TO THE SECOND EDITION
I am very glad that Dr John Ebnezar has written an excellent book on Orthopedics.
The book is extremely informative and is most up-to-date. It is very stylishly written and is neatly designed. It has so many unique features which is hitherto unprecedented in the history of textbook writing.
What makes this book stand out from the rest is that, it never provides the reader with a single dull moment and makes the reading very interesting and thought provoking. It keeps the reader engrossed and the students will find it very gripping and absorbing.
I am sure students will enjoy reading this book and will find it very useful in their preparation for the examination.
I wish him all the success.
Dr N Ramesh
Former Head of the Department and Prof of Orthopedics
Bowring and Lady Curzon Hospital
Bangalore Medical College
Bengaluru
Karnataka, India10
FOREWORD TO THE THIRD EDITION
Dr John Ebnezar has been my assistant and has worked with me for over two years. Knowing him it is hardly surprising that he has written a textbook on Orthopedics for such is his keenness and interest in teaching the students. He enjoys teaching and is tremendously popular among the students.
The book is very comprehensive, simple and is neatly written. Never before any book on Orthopedics has come out with so many innovations and this kindles and sustains the interest in the readers. A good book is one which apart from evincing interest in the readers about the subject, makes them desirous to know more and more about it. This book does that and I am sure students will enjoy reading it and the roller coaster experience it provides. The practical approach and suggestions will help the students in their preparations for the examination.
This is the first ever textbook written by an Orthopedic Surgeon from Karnataka and I am happy that it comes from my assistant. It is indeed befitting that I write a foreword for his book.
I wish him all the best.
Dr YA Somasundara
Former Senior Professor and Head of the Department of Orthopedics
Bangalore Medical College
Bengaluru
Karnataka, India
11Preface to the Fourth Edition
When the textbook of orthopedics was released for the first time in 1996, I never in my wildest dream ever fathomed that the book will reach this far. Year after year, edition after edition, it has grown from strength to strength and today I am extremely pleased to place the fourth edition in your hands. The entire credit of making this book a runaway success belongs to the undergraduate and postgraduate students, and teachers. The book has gone global and occupies a proud possession in prestigious NHS Trust libraries across UK and has an Italian Edition too. Indian medical authors penetrating the impregnable western market and carving a niche for themselves is a rare spectacle. The hitherto unthinkable in the not so distant past is a reality now.
What makes this book so successful when most of the books released stay in the racks and sink without a trace or rarely go beyond the first edition? I feel more than the support, patronage and encouragement from all concerned, it is the love of the students and teachers that has brought the book this far. Yes I re-iterate it is the overwhelming love that is the secret of the longevity of this book. My book has received tremendous love from all quarters. Medical books are known to survive because of their scientific content presented well. But in my case I feel it is the unconditional love that has made it stand the test of time. Be it undergraduate students, teachers, postgraduate students, orthopedic surgeons, physiotherapy students, it is a hit with all. During conferences, workshops, CME's, teaching courses, seminars, personal and private meetings when I meet medical students and teachers, they all tell how much they love my book. One lady medical student from Gulbarga has written to me saying that she has totally fallen in love lock, stock and barrel with my book. Another postgraduate student said that my book has shaped his life more than his career. This I consider a very high praise and an ultimate complement. Shaping lives is a far bigger achievement than shaping careers. This is the job of self development books and not medical books. If my book has achieved this unique dual distinction then I feel my life is fulfilled as I have touched the lives of my readers. One medical student recently, who bumped into me in a private wedding party, said that he has read each and every word in my book and even the prelims and hence knows the names of my wife and children too! A very senior orthopedic surgeon and teacher also told me that he was very impressed with the last few sentences in my acknowledgments and this motivated him. An ophthalmologist spoke about the preface in glowing terms. A book is normally judged by its contents and not by its preface or preliminary pages. But my book has broken this traditional benchmark and has been equally appreciated for its preliminary pages! I feel happy, proud and privileged to hear such glowing tributes from everyone about my book. It is not that my book has no flaws. In fact it has in plenty. But just as parents overlook the follies of their children and love them unconditionally, my readers have overlooked and forgiven all my lapses.
Fourth edition has corrected one major anomaly of the previous editions. It was slightly bigger for undergraduate and smaller for postgraduate students. Undergraduate students told me that the book is very good and they want to read it but regretted its size while the postgraduate students felt the book to be very good but inadequate for them. I had the option of downsizing the book to undergraduate expectations or raise the book to postgraduate expectations. I noticed that this book, written originally for undergraduates, was embraced more by postgraduate students. Though not totally unexpected it indeed was a pleasant surprise. After a lot of deliberations and interaction with students, teachers and publishers, I decided to 12choose the latter course of action and have now upgraded the book into a full-fledged small textbook for postgraduate students in orthopedics. I as an orthopedic PG student had read big textbooks with several volumes and found the necessity of having a small book that could be handy to read during the course, exams, bed side discussions, etc. This book precisely achieves that long pending need of orthopedics postgraduates.
To attain this objective I have strived for the following things in this new edition:
Apart from all these new developments, I have retained the old flavor that has made this book such a huge success. With this book I have tried to set right one anomaly mentioned previously by giving the postgraduate students a small comprehensive and compact book. I eagerly await their response. Undergraduate students need not be disappointed that this book has now totally gone beyond their reach. I am coming out shortly with a compact, neat very interesting smaller version which will fulfill all their aspirations and expectations. Wait for it.
The book has grown because of your love, patronage and support. I hope you will extend the same for the fourth edition too. Please do not hesitate to criticize or correct me. I request you to write to me with all the corrections and suggestions so that I can rectify my flaws. Looking forward to your reaction.
Regards and thanks,
John Ebnezar
13Preface to the First Edition
While I was a final year MBBS student, I fell in love with Orthopedics lock stock and barrel. The subject fascinated me so much that I was drawn towards it like a magnet. I always wanted to do something to the subject I loved most. This book is a small effort on my part in this regard.
Students often questioned me during my undergraduate teaching sessions as to which book they should read for Orthopedics. Whenever I suggested the standard books written for them, they said they found them too inadequate and that the bigger books were too much for them. So they were in a situation of either too little or too much. I then asked them as to what sort of book they need? They said that, they wanted a book which is comprehensive and at the same time examination oriented. I learnt that my notes were actively being circulated among the students and after each examination; students came back to me and told that they had done extraordinarily well after reading my notes. This surprised me as I had always taught them more than required. I was a firm believer of the fact that by pruning the subject one cannot do justice to it. Examination should be a part of the learning process and not vice versa. I then decided to write a book for them which was adequate, neither less nor more. Little did I realize then that I was embarking on a journey which was arduous and tumultuous? I slogged for three long years to bring out this book. Hope students find my effort informative and useful.
Despite being meticulous, I am sure there will be plenty of mistakes in the book. I request the students to point them out unhesitatingly so that I can improve upon. This book will be a useful handbook for postgraduate students also.
Now about the highlights of this book:
To make the book more educative and also to present an enjoyable reading, I have tried certain innovative methods which hitherto have not been attempted in textbook writing. I am confident that it will be received well.
John Ebnezar
15Acknowledgments
Fourth edition of the Textbook of Orthopedics is a special book as it is now updated into a full-fledged short textbook for postgraduate students. This was in the offing for a very long time now as my book was most popular among them. Believe me it was one hell of an effort as it was a gigantic task. I had to seek the opinions of my friends, teachers and post-graduate students in creating a book that would cater to all their requirements. I feel this is the first short postgraduate text book of orthopedics. I would like to recall the role played by so many friends and well wishers who made this dream of mine into a reality.
My beloved mother late Smt Sampath Kumari deserves a very special thanks for instilling right values in me that guided me to undertake ventures like books, teaching and social service. She was a disciplinarian and idealistic mother to the core. I owe my very existence and success to her. I thank my wife Dr Parimala, my son Rakesh who is now doing his houseman ship at Mysore Medical College and my beautiful and lovely daughter Priyanka for their unstinted and unflappable love, warmth, encouragement and support.
I thank all my teachers who shaped my personality and career right from primary school to my postgraduation in orthopedics, especially the staff of JN Medical College, Belgaum. I thank all the colleagues of Victoria Hospital, Bangalore Medical College for their cooperation. I thank my artist friend Mr. Linus for creating such beautiful diagrams as desired by me whose creativity in imagining and translating my thoughts into pictures and producing the right impressions are worthy of praise. But for his skill, the book would not have been what it is today. Dr KR Raghavi and Dr Raghvendra were two of my best students and have motivated and helped me in bringing out the first edition of this book. I also thank my Junior Research Assistant Dr Yogita who actively supported me in bringing out this edition. I also thank all the staff of my hospital for helping me.
I thank Shri Jitendar P Vij (Chairman and Managing Director), M/s Jaypee Brothers Medical Publishers (P) Ltd, and his entire team for the hard work, cooperation, support and commitment in bringing out this book for postgraduate orthopedic students. My special thanks to Mr. Tarun Duneja, Director (Publishing), Mr. K.K. Raman (Production Manager), Mr. Venugopal (Branch Manager) and all the Bengaluru Branch staff and Mr. Bharat Bhushan (DTP Operator), Mrs Sonia Mehta (Graphic Designer) for their hard work and dedication. I reserve my special thanks to Mr. Akhilesh Kumar Dubey and Mr. Aravind Kumar for interacting with me continuously and putting in a lot of effort into creating a very good book.
I express my sincere gratitude to all the teachers and students for patronizing and supporting my book. I am grateful to all my critics who helped me see and overcome all the mistakes in my book. For all the blessings and the gift of life, I remain indebted to God the Almighty.
21Introduction
Orthopedics has come a long way since the days of Nicholas Andry, a French physician, who is credited for coining the term, orthopedics from two words, Ortho = straight and Pedics = child in 1741.
What was a primitive branch then restricted to correcting deformities in children, has developed into a full-fledged specialty with diverse scope ranging from simple treatment, as done by traditional bonesetters to highly advanced joint, spine and hand surgeries.
The development of orthopedics as a specialty was pedestrian till 18th century. The discovery of anesthesia 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 revolutionized the diagnosis and management of orthopedic disorders. Thus, orthopedics 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 orthopedic 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 orthopedics, 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 orthopedic management. Suddenly, orthopedics was being considered a highly specialized 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 orthopedic disorders are mitigated.
There is a strong notion among the students that orthopedics is all about trauma. Nothing can be farther from the truth. Though trauma contributes to a major chunk of orthopedic-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, tumors, etc. Degenerative disorders that seem to ravage the musculoskeletal system in old age complete the cup of misery. Needless to say one needs to be equipped both with knowledge and skill to gear up oneself to face the orthopedic challenges being hurled at surgeons in double quick time of late.
Through this book, I endeavor to arm my students with the all important knowledge so essential to understand and unravel the mysteries surrounding orthopedic-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 orthopedic terminologies, tests, surgical procedures, etc. for better and easy understanding. 22This is presented in the glossary. 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 systems are talked about in relevant sections. The chapters deal extensively first with the traumatic conditions and related problems, followed by non-traumatic conditions.
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.