Term “Orthopedics” was invented by Nicholas Andrey which stands for orthos (“correct”, “straight”) and paideion (“child”).
Q. Define fracture. Discuss in detail the classification of the fracture.
Fracture definition:
Fracture is a break in the continuity of a bone.
Classification:
- Based on etiology: Traumatic, pathological.
- Based on displacements:
- Displaced—shift, angulation, rotation
- Undisplaced.
- Based on relation with the external environment:
- Compound/open
- Simple/closed.
- Based on the pattern:
- Transverse: Caused by a bending force
- Oblique: Caused by bending force with an additional component along long axis
- Spiral: Caused by twisting force
- Comminuted: Caused by compression force along long axis of the bone
- Segmental: Here there are two fractures but at different levels
- Wedge fracture.
- Complete or incomplete.
Q. List the physical signs of fracture.
Physical signs of fracture are as follows:
- Painful abnormal movement in a limb due to movement at the site of the fracture
- Crepitation in between the bone ends (Definitive sign of fracture)
- Deformity seen or felt
- Bruising around the fracture
- Tenderness over fracture site
- Pain on stressing the limb by bending or longitudinal compression
- Impaired function
- Swelling at fracture site:
- If first and second points are present it is almost certain that a fracture is present
- First and second points are absent in the case of impacted fracture, e.g. Colles' fracture.
Q. List indications for leaving a fracture untreated.
Indications for leaving a fracture untreated are:
- In children for whom remodeling will correct the position
- Elderly patients for whom function is more important than cosmetic aspect.
Q. Define compound or open fractures. Mention its types and complications.
Definition:
These fractures have break in overlying skin or soft tissue leading to fracture communicating with the external environment.
Types:
Internal compounding | External compounding |
---|---|
Fracture compounding from within the sharp fracture fragments pierce the skin from within resulting in an open fracture | Compounding from without the object lacerates the skin and soft tissue from outside as it breaks the bone |
Complications:
- Infection (Osteomyelitis)
- Delay union
- Nonunion.
Q. Define pathological fracture. Discuss the etiology, clinical features and management of the same.
Definition:
A fracture is said to be pathological when fracture occurs in a weakened bone by a pre-existing bone disease.
- They occur frequently, spontaneously with minimal trauma
- Most common cause is osteoporosis
- Common bones affected are: Thoracolumbar spine, femoral neck, Colles' fracture.
Etiology:
Localized diseases | Generalized diseases | |||
---|---|---|---|---|
Inflammatory | Neoplastic | Miscellaneous | Hereditary | Acquired |
• Pyogenic osteomyelitis • TB osteomyelitis | • Benign: Giant cell tumor, Enchondroma • Malignant: Osteosarcoma, Ewing's sarcoma • Secondary: From lung, prostate, breast | • Simple bone cyst • Aneurysmal bone cyst • Secondary to polio • Eosinophilic granuloma | • Osteogenesis imperfecta • Osteoporosis • Dyschondroplasia | •Osteopetrosis • Rickets • Osteomalacia • Scurvy |
Clinical features:
- Fracture may occur after minimal trauma or may be spontaneous
- Past history of discomfort in the place of fracture
- May be a known case of malignancy
- Pain, swelling in the region of fracture.
Investigations:
- X-ray
- Bone scan
- Serum marker: Alkaline phosphatase.
Treatment:
- Treat the cause
- Enhance the process of union by bone grafting
- Mobilize the patient after surgical stabilization of fracture.
Prognosis: Depends on the cause
- Union occurs in: Paget's diseases, osteoporosis, osteogenesis imperfecta.
- Delayed union in:
- Bone cyst
- Benign bone tumors.
- Treatment fails in:
- Osteomyelytic lesion
- Malignant tumors.
Fig. 1.3: X-rays of antero posterior and lateral views showing pathological fracture of femur secondary to osteomyelitis
Q. Define sprain/injury to ligaments. Discuss the classification and management of the same.
Definition:
Injury to ligament is termed as sprain.
Classification:
Based on amount of fibers torn.
First degree | Second degree | Third degree | |
---|---|---|---|
Fibers Torn | Few fibers are torn <30% | Most fibers torn 30-60% | Complete tear >60% |
Pain | Minimal | Present | Minimal |
Swelling | Minimal | Present | Present |
Function loss | May or may not be present | Present | Present |
Hemarthrosis | Absent | Present | Present |
Diagnostic test: Stress test
When the ligament is stressed: In first and second degree sprain there will be severe pain, in third degree the joint will open up.
Investigation:
- X-ray (Stress view of X-ray taken for valgus/varus deformity of knee, elbow and ankle)
- MRI
- Arthroscopy (also therapeutic).
Treatment:
- First degree: Rest, NSAIDs
- Second degree: Immobilization for 4 to 6 weeks followed by gradual mobilization
- Third degree: Surgical repair, weight bearing only after 3 months.
Mnemonic: Acute sprains are treated with RICE: Rest, ice, compression and elevation.
Q. Define Fracture disease. Discuss its features and treatment.
Definition: It is a clinical condition characterized by:
- Chronic edema
- Soft tissue atropy
- Osteoporosis
- Intermuscular fibrosis
- Muscle atropy
- Subcutaneous fat atropy
- Nonphysiological adhesions between bone and fascia and hence stiffness.
Every fracture is a complex tissue injury to bone and soft tissue.
Fracture leads to local inflammation, pain and hence to circulatory disturbance.
This local inflammation, pain, circulatory disturbance leads to dysfunction of the joint and muscle and hence to fracture disease.
Treatment: As by AO principle:
- Physiotherapy
- Anatomical reduction of fracture fragments
- Internal fixation.
Q. Discuss Salter Harris fracture classification of epiphyseal injury.
Q. Discuss classification of epiphyseal injury.
Basis of the classification: Salter Harris classification utilizes visualizing long bone distal portion with diaphysis superiorly placed and epiphysis inferiorly placed.
Salter Harris classification, its treatment and prognosis is given in the table.
Type | Feature | Treatment | Prognosis |
---|---|---|---|
1 | S lipped epiphysis | Closed reduction | Good |
2 | Above the epiphyseal plate | Closed reduction | Good |
3 | Lower than the epiphyseal plate | Open reduction | Growth disturbance can happen |
4 | Through both above and below epiphyseal plate | Open reduction | Growth disturbance common |
5 | Raised epiphysis, as in a compression injury | Conservative | Growth disturbance always |
Mnemonic: Remember the features of this classification as SALTR.
Q. Define Ankylosis. Mention its causes. Describe its types and management.
Q. Differentiate between bony and fibrous ankylosis.
Definition: Ankylosis is the fusion of a joint, often in an abnormal position, usually resulting from destruction of articular cartilage and subchondral bone.
Etiology:
- Intra-articular causes
- Extra-articular causes.
Intra-articular causes | Extra-articular causes | |
---|---|---|
Bony | Soft tissue | Skin: Contracture, postburn Subcutaneous tissue: Dupuytren's contracture Muscle: Fibrosis, myositis, neoplasm Tendons: Fibrosis, neoplasm, burns Blood vessels: Aneurysm, e.g. popliteal artery in popliteal fossa Bone: Inflammatory condition, tumors |
Intra-articular fracture Pyogenic, OM TB OM Collagen arthrodesis Degenerative changes Neoplasm | Capsular contracture Synovitis Intra-articular ligamentary affections |
Types:
- Bony ankylosis
- Fibrous ankylosis.
Bony Ankylosis | Fibrous Ankylosis |
---|---|
Is called true ankylosis as there is bony fusion | Also called false ankylosis as the bones are connected by fibrous tissue |
Non-yielding even on stress | Yielding even on stress |
No pain on stress | Pain is present on stress |
Marked atrophy of surrounding soft tissue, especially muscles | No marked atrophy of surrounding soft tissue |
X-ray findings | X-ray findings |
1. Bony trabaculations across joints: present 2. Joint line absent | 1. Trabaculations across joints: absent 2. Joint line present |
Treatment | Treatment |
1. Detailed assessment regarding loss of function 2. If treatment is required rehabilitate to original job or change the job 3. Surgical options:
| 1. Detailed assessment 2. Planned physiotherapy 3. Analgesics 4. Reassurance 5. Treatment of primary cause 6. Surgical options:
|
Q. Comparison of fracture in children and adults.
Points | Fracture in Children | Fracture in Adults |
---|---|---|
Susceptibility to fracture | More common in children | Less common |
Special varieties of fracture seen | Green-stick fracture Physeal fracture | No special variety seen |
Diagnosis | Fracture in children is diagnostically problematic | Comparatively easy |
Healing | More rapid healing | Relatively slow |
Remodeling potential | Greater remodeling potential | Relatively less |
Nonunion | Nonunion is uncommon in children | More common |
Treatment | Closed reduction is the treatment of choice Internal fixation is often minimal | Open reduction and internal fixation is often required |
Note that:
- Commonest fracture in children: Fracture of distal shaft of humerus
- Most common bone fractured in the body: Clavicle
- Most common bone fractured during birth: Humerus
- Most common joint to dislocate: Shoulder
- Most common site of IVDP: L4-L5
GLOSSARY OF ORTHOPEDIC TERMS
Term | Definition | Example |
---|---|---|
Dislocation | The articular surface are not opposed and that the restraining ligaments and probably the capsule have been partially or completely torn | Anterior dislocation of shoulder Posterior dislocation of hip |
Subluxation | Partial displacement of one side of the joint or the other, but; less severe distortion than dislocation | Subluxation of radial head |
Reduction | Action required to obtain anatomical alignment | Reduction of shoulder dislocation |
Varus | Towards midline | Genu varum—bow leg, coxa vara |
Valgus | Away from midline | Genu valgum, coxa valga |
Cox | Hip | |
Genu | Knee | |
Talipes | Ankle | |
Pes Calcaneus | Foot Heel points down | Calcaneovalgus foot |
Equinus | Heel is high pointing up | Club foot |
Cavus | High arched foot | |
Rocker Bottom | Foot concave heel in equinus | Congenital vertical talus |
Anteversion | Femoral neck angled forwards in relation to the shaft | |
Retroversion | Femoral neck angled backwards in relation to the shaft | |
Recurvatum | Hyperextension of bone or joint | Congenital dislocation of knee, tibia recurvatum |
Q. List the fractures seen in fall from height.
The fractures seen in fall from height:
- Fractured tarsal bone
- Spinal fractures
- Pelvic fracture or hip injuries
- Base of skull.