1. IMAGING FOR ORTHOPAEDICS
- X-rays is done for screening (Cartilage not seen)
- CT Scan is done for bone Cortex and Calcification
- Calcification of Ligament–CT Scan
- MRI is done for Soft tissues/Cartilage/ Bone Marrow/Unilateral stress fractures (Investigation of choice)
-
MRI is done for occult fracture neck femur(May AIIMS 2012)
- Bone scan is done for bilateral stress fractures. (Investigation of choice) and metastasis.
-
Metastasis–PET CT scan > Bone Scan(AI 2011)
- Arthroscopy is done for joints Knee> Shoulder
- Tumors and Infection can mimic each other
-
Differentiated by tissue diagnosis(May AIIMS 2012)
- Culture is best for infection, T.B. Spine CT guided biopsy gold standard(May AIIMS 2012)
- Histopathology for tumors
2. INFECTIVE DISEASES OF BONE AND JOINT
- X-ray: After 24-48 hours loss of soft tissue planes and on day 7-10 periosteal reaction is seen. (Periosteal reaction is usually absent in tuberculosis)(AI 2008)
- Best radiological investigation for bone infection is MRI >Bone Scan(AI 2007)
- Bone and joint infections Gold standard is always culture and sensitivity
- Inflammatory Joint swellings order of investigations is
(AIIMS May 2009)
Acute Osteomyelitis
- Metaphysis is commonest and first affected(AIIMS May 2009)
- Lower femur metaphysis commonest site(AI 2008)
- Staphylococcus aureus most common organism overall(AIIMS Nov 2010)
- Sickle cell anemia –salmonella(PGI 97)
- I/V drug abusers-Pseudomonas
- Loss of movement of limb clinical indicator
Chronic Osteomyelitis
Causative organism; Staphylococcus Aureus
Sequestrum: Avascular piece of bone surrounded by granulation tissue-pathognomic of chronic osteomyelitis.
(PGI 2009)
Involucrum is dense sclerotic new bone surrounding the sequestrum At least 2/3rd surface of sequestrum should be surrounded by involucrum before carrying out sequestrectomy.
Treatment
Remove the sequestrum (Sequestrectomy)
Identify the organism and control the infection (most important step)
Fill the gap (Bone graft /Bone cement-Poly Methyl MethAcrylate)
Provide a good soft tissue coverage
Swelling With Multiple Discharging Sinus
Over mandible (or head - neck region) – Actinomycosis
(AI 2003)
On Foot – Madura foot/Maduromycosis
Paronychia – infection of nail bed Staph, organism is Staph Aureus
Felon – infection of pulp space, Staph Aureus, most commonly affects thumb > Index finger
(2012)
Infectious Tenosynovitis (Kanavel sign are seen)–Staph Aureus.
(AIIMS Nov 2007)
3. TUBERCULOSIS OF BONE AND JOINTS
- Tuberculosis is a disease affecting joints>bones
-
Hematogenous spread Paucibacillary lesions(AI 2012)
- Spine(50%)>hip(15%)>knee(10%) of all musculoskeletal cases
- Spina Ventosa is Tuberculosis of short bones of hand.
- Tuberculosis of shoulder is dry(no effusion) - caries sicca (dry)
- Potts spine – Tuberculosis of spine
- Paradiscal region commonest, rarest is synovitis of facet joints, Second Rarest is spinus process.(AIIMS Nov 2010)
- Most commonly affects Dorsal >lumbar>dorsolumbar junction
- Earliest Symptom pain(PGI June 2006)
- 1st Sign tenderness
- 1st Neurological Sign: Increased deep tendon reflexes or Clonus, Twitching of muscles may be even earlier.
- Motor weakness earliest, than sensory involvement than bowel bladder involvement
Investigations
- X-ray: Loss of Curvature of spine due to muscle spasm > Paradiscal Lesion
- MRI: Best Radiological Investigation
- CT Guided Biopsy: or tissue diagnosis- Best Investigation(AIIMS May 2012)
Please Note:
FABER: Flexion, Abduction and External Rotation
FADIR: Flexion, Adduction and Internal Rotation
Ankylosis: Pathological Fusion of Joint
Arthrodesis: Surgical Fusion of Joint.
(PGI 2008)
T B hip in HIV AVN Hip in HIV | Incidence More Common Less Common | |
|---|---|---|
Incidence | More Common | Less Common |
Deformity | FABER stage of synovitis may be prolonged on treatment than subsequently with onset of arthritis – FADIR | Limitation of abduction and internal rotation so initially position is adduction and external rotation (opposite to movements limited) and than subsequently with onset of arthritis FADIR |
Unilateral usually | Bilateral usually |
(AIPG 2008)
TRIPLE deformity of knee posterior subluxation/External rotation and flexion
4. ORTHOPAEDICS ONCOLOGY
Important points to remember
- Most common bone tumors – Secondaries
- Most common primary malignant bone tumor – Multiple Myeloma
- Second most common primary malignant bone tumor – Osteosarcoma
- Commonest malignant bone tumor of flat bone – Chondrosarcoma
- Commonest Tumor of Skull Vault Ivory Osteoma or Compact Osteoma or Eburnated Osteoma(Latest 2012)
- Commonest true benign tumor – Osteoid osteoma
- Most common benign tumor of spine – Hemangioma
- Benign bone tumor have well defined margin, uniform consistency on feel and narrow zone of activity.
- Malignant tumor have ill defined margins, variable consistency and wide zone of activity.(AIIMS May 2011)
Differential diagnosis of bone tumors
- Osteomyelitis has same clinical presentation as Ewings sarcoma and osteosarcoma
- Myositis ossificans mimics Osteosarcoma but Myositis has dense peripheral calcification and osteosarcoma has central calcification.
- Bone Infarct ~ Enchondroma(AIIMS May 2011)
- Bone islands ~ Osteoid osteoma(AIIMS May 2011)
- Fibrous dysplasia ~ Giant cell tumor(AIIMS May 2011)
Important ages and location
- 1st decade usually Ewings sarcoma (Can Be 5 To 20 Years), unicameral Bone Cyst
- 2nd decade usually osteosarcoma, Aneurysmal Bone Cyst.(AIPG 2007)
- After skeletal maturity Giant cell tumor (Epiphysis)
- Epiphyseal before skeletal maturity (chondroblastoma)(AIPG 2012)
- After 40 metastases or Multiple myeloma
Remember
1ST decade Diaphyseal –Ewings Sarcoma
2nd decade Metaphyseal -Osteosarcoma
Classical radiological features*
| Osteosarcoma but can be seen in any malignant lesion Ewing sarcoma but can be seen in any malignant lesion or chronic osteomyelitis Osteoclastoma,adamantinoma Chondrogenic tumors Osteogenic tumors |
Order of investigations usually X-rays than MRI and than Biopsy
Biopsy is the ultimate diagnostic technique.
Enneking's Classification System for bone tumors
(AIIMS 1Nov 2007)
Most of the benign tumors and cartilagenous tumors are treated by surgery
Osteosarcoma and cartilagenous tumors are radioresistant.
Unicameral bone cyst | Aneurysmal bone cyst | |
|---|---|---|
Age | 1st decade | 2nd decade |
Site | Proximal humerus, femur | Lower limb (however can occur anywhere) |
Location | Central (concentric) | Eccentric |
Expansile | Expansile | More expansile |
Symptoms | Asymptomatic | Pain is present |
Cavity | Single, Straw coloured fluid | Multiloculated, Haemorrhagic fluid |
Trement | Curettage | Extended Curettage |
Eccentric expansile cysts
Central cysts (may be expansile)
Osteochondroma – Bony Growth with Cartilage Cap
- M.C. cause of pain is Buristis over Osteochondroma
- Malignant transformation into chondrosarcoma (identified by MRI)
- Treatment: Extraperiosteal resection.
Osteoid Osteoma – M.C. Femur Diaphysis
- It is commonest benign true bone tumor, exceeded in incidence only by osteochondroma and nonossifying fibroma.
- The typical patient with an osteoid osteoma has pain that is worse at night and is relieved by aspirin or other nonsteroidal antiinflammatory medications. When the lesion is in a vertebra, scoliosis may occur.
- CT is the best study to identify the nidus and confirm the diagnosis.
- D/D of osteoid osteoma is bone island.
- Surgical management involves removal of the entire nidus burr-downtechnique.
- Rdiofrequency ablation is used for osteoid osteoma.
Enchondroma:
- Enchondroma-most common tumor of bones of hand.
- Multiple enchondromatosis is also known as Ollier disease.
- Maffuccis syndrome is Enchondroma, subcutaneous hemangioma a and phlebolith.
- Malignant transformation to chondrosarcoma may occur in <2% in solitary cases, 30% in Ollier's disease and 100% in Maffuccis syndrome.
- Treatment is extended Curettage
Chondroblastoma/Codman's Tumor
Classic “chicken wire” calcification
GIANT CELL TUMOR
Most common site is distal femur
Although these tumors typically are benign, pulmonary metastases occur in approximately 3% of patients
Malignant giant cell tumors represent less than 5% of total GCT.
Treatment of GCT at common sites*:
| Excision with Turn-o plasty* |
| Excision with Turn-o plasty* |
| Excision with fibular grafting |
| Excision* |
| Excision* |
- Adamantinoma: Most common long bone affected Tibia
- Ameloblastoma most commonly affects mandible
- Please note that most common tumor of mandible is squamous cell carcinoma.
Fibrous Dysplasia
- McCune-Albright syndrome refers to polyostotic fibrous dysplasia, cutaneous pigmentation(café au lait spots), and endocrine abnormalities.(Precoceous puberty).
- Mazabraud syndrome is polyostotic fibrous dysplasia with intra-muscular myxomas.
Tumor | Osteo Fibrous Dysplasia (Female) | Admantinoma (Male) | Fibrous Dysplasia (Female) |
Site | Tibial Diaphysis + Fibula | Tibia (MC Long Bone) | Femur, Cranio facial area |
Presentation | Swelling + Deformity | Swelling | Deformity |
Biopsy | Trabecular Bone with Fibrous Stroma with osteoblalsts | Epithelial Cells | Trabecular Bone with Fibrous Stroma |
X-ray appearance | Soap Bubble ± ground glass | Soap Bubble | Ground glass |
- Fibrous dysplasia of proximal femur has shepherd crook deformity
OSTEOSARCOMA
- Osteosarcoma may be more common in patients with the hereditary form of retinoblastoma and Li-Fraumeni syndrome.
- Pulsatile bone tumors in following order answer must be preferredOsteosarcoma>ABC>Angioendothelioma of bone >GCT(AIIMS May 2010, AIPG 2007)(Amongst metastasis RENAL and thyroid pulsatile metastasis.)
- Chemotherapy + Limb Salvage Surgery + Chemotherapy (Methotrexate is most important)
- Etoposide is not included in the ‘T-10’protocol for osteosarcoma
-
Osteosarcoma is radioresistant.(AIPG 2007)
Ewings sarcoma – Presentation like osteomyelitis
Classically, Ewing sarcoma appears radiographically as a destructive lesion in the diaphysis of a long bone (Femur) with an “onion skin” periosteal reaction.
Ewing sarcoma more often originates in the metaphysis of a long bone, but frequently extends for a considerable distance into the diaphysis. Origin is from marrow cells.
MIC 2 (CD 99) positive cells, glycogen positive cells are seen in Biopsy.
(AIIMS May 2012)
The t(11; 22) (q24; q12) is the most common translocation diagnostic of Ewing sarcoma and is present in greater than 90% of cases. Other diagnostic translocations, including t(21; 22) (q22; q12), trisomy 8, trisomy 12 t(7;22)(p22; q12), del 1 and t(17,22)
(AIPG 2012)
Poor prognositc Factors are: Males age > 12, Fever, anemia, Inceased TLC, platelets, LDH, Proximal lesion, chemoresistance, relapse and distant metastasis. (Last 3 are worst prognostic factors).
(AIIMS Nov 2010)
ABCD (Actinomycin D/Bleomycin /Cyclophosphamide/Doxorubicin) is chemotherapy
(Chemotherapeutic Regimen for Ewings sarcoma-involves age group when chidren learn ABCD)
Chondrosarcoma is most common tumor associated with Hyperglycemia.
(AIPG 2010)
Treatment of Chondrosarcoma is surgical excision.
Chordoma
Chordoma is rare malignant tumor originating from the remanants ofprimitive notochord. It commonly occurs in the sacrococcygeal or in the spheno-occipital regions. Sacrum is the most common site - Sacrum 50% clivus (35%), cervical thoracic/lumbar (15%).
> 40 multiple lesions in Bone diagnosis is metastasis > multiple myeloma.
Elderly with bone pains increased ESR and hypercalcemia is multiple myeloma till proved otherwise.
Metastatic Bone Disease
- Most common primary is Breast>Prostate overall
- Most common sites of primary for bone metastasis.
- In males – Prostate > Lung
- In Female – Breast > Lung
- In Children – Neuroblastoma
- Skeletal sites most frequently involved
- Spine (Lumbar)
- Lytic expansile metastasis seen in
- Renal Cancer
- Thyroid carcinomas
- Purely Osteoblastic secondaries
- Prostate/Carcinoid/Medulloblastoma(AIIMS May 2009)
- Metastasis distal to knee and elbow is rare and usually arises from a primary tumors of the
- Bronchus, Bladder and Colon (BBC)
“BBC Can Go Anywhere even distal to Elbow and Knee”
Metastasis from Bone to Bone
Soft tissue Sarcoma to Bone
Rhabdomyosarcoma is the most common soft tissue tumor in child.
Malignant fibrous histocytoma is the most common soft tissue tumor in adult.
Sarcomas metastasizing through lymphatic and causing lymph node involvement are:
The term ‘synovial cell sarcoma’ is a misnomer as synovial cell sarcomas do not arise from synovium.
(AIPG 2010)
5. FRACTURE AND FRACTURE HEALING
- 1st Centre of Primary ossification appears at end of 2nd month in intra-uterine life.(AIIMS Nov 2011)
- Rate of mineralization of newly formed osteoid estimated by tetracycline labelling.
- Fracture, Partial or complete loss of continuity of cortex.
- Tenderness is the commonest sign of fracture.
- Abnormal mobility and Loss of transmitted movements surest sign of fracture
- Direct trauma – Transverse > Comminuted fracture(AIIMS May 2003)
- Modelling – Growing skeleton
- Remodelling after Skeletal Maturity – Resorption + Bone deposition (apposition)Bone remodelling has both osteoclastic and osteoblastic activity at compression or tension site but the forces on bone decide where remodelling takes place compressile forces compression site and tensile forces tension site and in bone modelling there is osteoclastic activity at tension site and osteoblastic activity at compression site.(AIIMS May 2001)
- Bone apposition is seen in(AIIMS Nov 2001)Howship's lacunae or cutting cones in normal adults(After resorption)Subperiosteal cambium layer In fractured bones (Best example of bone apposition)and after cancellous bone grafting. Bone apposition in these 2 examples does not require resorption.
- Markers of Bone formationSerum bone specific alkaline phosphatase(AIPG 2007)Serum osteocalcin (very important marker)
- Marker of Bone Resorption(PGI June 2008), (AIIMS May 2008)Urine hydroxyprolineSerum tatarate resistant acid phosphatase (TRAP)
High oxygen tension, high pH (aiding alkaline phosphate activity) and stability (micromovement) predispose to osteoblasts hence enhances rate of union
Common Sites of Nonunion
Common sites of Malunion
6. ADVANCED TRAUMA LIFE SUPPORT
Any trauma patient should be managed in following sequent of events (ABCDEF) :
- Airway management with cervical spine stabilization (Cervical spine stabilization before Airway)
- Breathing (ventilation)
- Circulation
- Disability (neurological status) assesment
- Exposure and environmental control
- Fracture splintage
7. UPPER LIMB TRAUMATOLOGY
Shoulder
- Only one fourth of the large humeral head articulates with the glenoid at any given time.(2011)
- Four rotator cuff muscles are - supraspinatus, infraspinatus, subscapularis and teres minor.
- The tendon of the long head of biceps brachii muscle passes superiorly through the joint and restricts upward movement of humeral head on glenoid cavity.
- Rotator interval is interval between leading edge of supraspinatus and superior edge of subscapularis. Coracohumeral ligament passes with in rotator interval.(AIIMS 2006)
- Lift Off Test (Gerber's test) is done to assess the strength of subscapularis muscle.(AIIMS May 2012, AIPG 2010)
- Traumatic detachment of the ANTERIOR glenoid labrum has been called the Bankart lesion. Excessive laxity of the shoulder capsule also causes instability of the shoulder joint.
- Hill-Sachs lesion is a defect in the posterolateral aspect of the humeral head-Anterior dislocation of shoulder
- (RAMP)—Reverse Hill Sachs - Anteromedial humeral head -posterior dislocation of shoulder(AIPG 2012)
- Recurrent dislocation is most common in shoulder joint, accounting for nearly 50% of all dislocations. Most commonly subcoracoid type
- Recurrent Dislocation of Patella (2nd most common)
- Rarest involved joint in Recurrent Dislocation – Ankle(AIPG 2009)
- Recurrent Anterior Dislocation -Abduction and External rotation force(AIIMS Nov 2011)
- Most common early complication of anterior dislocation of shoulder is AXILLARY nerve injury
- Inferior dislocation also axillary nerve is involved.
- Anterior instability test: Anterior apprehension test, Fulcrum test, Crank test surprise test.
-
Jerk test is for posterior instability(AIIMS May 2010, AIIMS May 2009)
- Sulcus test for inferior instability (multi-directional instability)
- Clavicle is the most common fractured bone (over all) in adults.
- Clavicle is the most common bone fractured during birth.
- The weakest point of midclavicle is the junction of middle and outer third (i.e. medial 2/3rd and lateral 1/3rd).
- Sling immobilization/Figure of eight bandage rarely plating or K wire fixation.
- Malunion is the most common complication.
Valpeau bandage (dressing) is used in acromioclavicular dislocation, fracture clavicle and shoulder dislocation but it is most effective in acromioclavicular dislocation as it pushes lateral end of shoulder down wards and arm upwards, and thus helps maintaining reduction.
(AIIMS Nov 2008)
Fractures of Surgical Neck Humerus
Elderly osteoporotic females are usually involved.(in such cases it is usually impacted)
Peripheral nerve injuries are common, especially involving the axillary nerve.
Analgesics with arm sling usual treatment
Injury | Common Nerve Involvement |
|---|---|
Anterior or inferior shoulder dislocation | Axillary, (circumflex humeral) nerve |
Fracture surgical neck humerus | Axillary nerve |
Fracture shaft humerus | Radial nerve |
Fracture supracondylar humerus | AIN > Median > Radial > Ulnar (AMRU) |
Medial condyle humerus | Ulnar nerve |
Monteggia fracture dislocation | Posterior interosseous nerve |
Volkman's ischemic contracture | Anterior Interosseous Nerve |
Lunate dislocation | Median nerve |
Hip dislocation | Sciatic nerve |
Knee dislocation | C. Peroneal nerve |
Humerus shaft fracture; The most common cause of delayed union or nonunion is distraction at fracture site due to gravity and weight of plaster. A spiral fracture of the distal third of the humerus is called a Holstein-Lewis fracture. It is frequently associated with radial nerve palsy. Plating for treatment (usually)
Elbow Ossification
- C – Capitellum 2 years – Appear sequentially every 2 years
- R – Radius head 4 years – Appear sequentially every 2 years
- I – Internal (medial) epicondyle 6 years – Appear sequentially every 2 years
- T – Trochlea 8 years – Appear sequentially every 2 years
- O – Olecranon 10 years – Appear sequentially every 2 years
- E – External (Lateral) epicondyle 12 years – Appear sequentially every 2 years
Three point bony relationship is not disturbed in fracture supracondylar humerus as the fracture occurs above the level of these bony landmarks and Classicaly Disturbed -Dislocation of elbow (Classical example)
Age
- Lower humeral epiphyseal slip: 1-3
- Supra condylar humerus fracture: 5-8 years
- Lateral condyle humerus fracture: 5-15 years
Fractures of necessity (requiring surgery)
- Lateral condyle fracture humerus
- Displaced fracture olecranon and patella
- Fracture neck femur
- Galeazzi fracture dislocation
- Monteggia fracture in adults
- Articular fractures
Fracture lateral condyle Humerus – Treatment is Open reduction + K-wire fixation
- Complications of fracture lateral condyle humerus are
- Nonunion –cubitus valgus(Treatment Milch osteotomy)
- Malunion cubitus varus(Treatment Modified french osteotomy)
- Tardy ulnar nerve palsy(Treatment Anterior Transposition of ulnar nerve)
- Growth disturbances
Fracture Supracondylar Humerus
Supracondylar humeral fractures in children are most common elbow injuries, especially in children aged 5-8 years. Most common type of supracondylar fracture -Extension type (~98% of all supracondylar fracture).
Supracondylar humeral fractures are extra-articular with posterior displacement of the distal fragment.15
Associated nerve injuries most commonly involves anterior interosseous branch of median nerve
(AIPG 2011)
Treatment is closed reduction and cast if it fails or it fracture is displaced the fracture is fixed with K wires
Malunion – Cubitus varus (gun stock deformity) ~ Treatment modified French Osteotomy.
Baumans Angle-angle between the physis and long axis of humerus normal value 75 to 90 degrees it is increased in cubitus varus.
Fracture supracondylar humerus is:
Most common fracture associated with vascular injury.
Most common fracture to involve brachial artery. (10% cases)
Most common cause of volkman's ischemia and compartment syndrome in children.
Most common cause of volkman's ischemic contracture
Side swipe injury-open fracture dislocation of elbow seen due to accidents involving side swipe over elbow.
Compartment Syndrome-Tight cast think of compartment syndrome !
Compartment syndrome involves deep posterior compartment of leg>deep flexor compartment of forearm (commonest in children).
Clinical Feature
- The diagnosis of compartment syndrome is based on dramatically increasing pain (out of proportion to injury) after fracture/ any injury (1st symptom)
- Pain and resistance on passive extension of fingers (Distal most joint of extremity) (1st sign) “Stretch Pain”
- Pulse is not a reliable indicator
- Deep flexor muscles are involved particularly flexor digitorum profundus>Flexor Pollicis Longus.(AIIMS May 2012)
- Fasciotomy is recommended for impending tissue ischemia when the tissue pressure reaches 30 mm Hg or the difference between diastolic blood pressure and compartment pressure is less than 30 mm of Hg or neurovascular sign appear.
Volkmann's Ischaemic Contracture(VIC) – Most commonly involve deep flexor compartment of forearm (FDP > FPL)
The earliest nerve involved is Anterior interossei>median>ulnar.
Turn Buckle splint
Max Page Muscle Sliding Operation
Myositis Ossificans / Hetrotropic Ossification-History of Massage think of it !
Elbow > hip joint.
In elbow More commonly anteriorly than posterior
Trauma around elbow eg. fracture supracondylar humerus, dislocation or surgery.
Surgical trauma specially total hip replacement,.
Parameter | Myositis Ossificans | Tumor Calcinosis |
|---|---|---|
Etiology | Traumatic | Idiopathic/Familial |
Side/Site | Unilateral-Elbow | Bilateral-Knee |
Symptom | Painful | Painless |
Marker | ALP Levels Increased | PO4 Levels Increased |
Treatment Of Myositis Ossificans
30% of cases resolves spontaneously
In acute phase the treatment consist of limiting motion x 3 weeks.
Followed by only active exercises upto 1 year
Surgical excision > 1 year
Low dose irradiation, bisphosphonates and indomethacin may prevent hetrotopic ossification, but the radiation should be avoided inchildren.
Pulled Elbow/ Nurse Maid's Elbow – “Age 1 to 4 yrs and forearm is pronated”
It is subluxation of radial head or more accurately subluxation of the annular (orbicular) ligament which slips up over the head of radius and is reduced by forceful supination.
Fracture Olecranon treatment is Tension Band wiring or rarely excision which is contraindicated if Fracture is extending to coronoid process
Monteggia Fracture Dislocation
Fractures proximal third of the ulna with dislocation of proximal radioulnar joint. Posterior interosseous nerve injured because it takes a turn around radial head and injured with its dislocation.
Galeazzi Fractures of the Distal Third of the Radius with Dislocation of the Distal Radioulnar Joint
Fracture both bone forearm is treated in children with cast and in adults with plating
Position of immobilization is midprone in fracture both bone forearm (mid 1/3)
Night stick fracture is isolated fracture of ulna due to direct blow.
Colle's Fracture – (Extra-articular)
Colle's fracture is fracture of lower end of radius at its cortico cancellous junction
Most colles fractures can be successfully treated nonoperatively and cast is applied on opposite forces to displacement- That's why position of immobilization in colle's fracture is17
Complications of colles
Finger stiffness is most common complication.
Malunion is the 2nd most common complication and it leads to dinner fork deformity
Sudeck's Osteoneuro Dystrophy/Reflex Sympathetic Dystrophy /Causalgia/ Algodystrophy/ Complex Regional Pain Syndrome. Red Hot skiny skin, severe pain.
- CRPS type I is a regional pain syndrome that usually develops after tissue trauma eg colles(AIPG 2011)
- CRPS type II is a regional pain syndrome that develops after injury to a peripheral nerve, Median>Sciatic(Tibial trunk)
- Treatment is usually physiotherapy and results are poor.
- Reflex Sympathetic Dystrophy- Patchy Osteopenia
- Hyperparathyroidism- Generalised Osteopenia
- Tuberculosis- Disuse Osteopenia
Barton's Fracture – A fracture dislocation in which the carpus and a rim of distal radius are displaced together.
Chauffeur's Fracture – A radial styloid fracture.
Relative Incidence of Carpal Bone Fractures Scaphoid > Triquetral >Trapezium
Scaphoid: Middle third (Waist) fractures are most common. Distal pole avulsion type fracture is most common fracture type in children.
Sign – Tenderness in anatomical snuff box. Oblique view important for diagnosis.
MRI can diagnose occult fractures.
Treatment is glass holding cast if does not unite or markedly displaced fracture Headless screw is used.
Scapholunate dissociation ~ Terry Thomas sign.
Bennett Fracture-Intraarticular Fracture of base of 1st metacarpal with dislocation of carpometacarpal joint
Rolando fracture –comminuted intraarticular fracture of base of 1st metacarpal
Injuries with characteristic deformities:
Deformity | Injury |
|---|---|
Flattening of shoulder | Shoulder dislocation (anterior) |
Dinner-fork deformity | Colles’ fracture |
Garden-Spade Deformity | Smith Fracture |
Mallet finger | Avulsion of the insertion of the extensor tendon from distal phalanx |
Flexion, adduction and internal rotation of the hip | Posterior dislocation of the hip, arthritis |
Flexion, abduction, external rotation of the hip | Anterior dislocation of the hip, septic hip synovitis of hip joint/Fluid and Iliotibial Band Contrature (Polio) |
External rotation of the leg | Fracture neck of femur |
Trochanteric fracture (Lat border of foot touching bed) |
8. SPINAL INJURY
Vertebroplasty is percutaneous injection of bone cement (PMMA = polymethy methacrylate) into vertebral body. It can be used for osteolytic spinal metastasis, multiple myleoma, aggressive hemangiomas, vertebral compression fractures (Osteoporotic). Its use is contraindicated in infections, Tuberculosis.
(AIIMS May 2011)
Vertebroplasty prevents further collapse and kyphoplasty is correction of collapse of vertebra by using high pressures it is not preferred now.
- Central Cord Syndrome-Motor weakness with arm weakness out of proportion to leg weakness
Areflexic bladder bower and lower limbs
- With Symmetrical involvement – Conus medullaris Syndrome
- Asymmetrical involvement – Cauda equina syndrorne
Cervical spines has highest chances of dislocation without fracture as their zygapophyseal (facet) joints slope in almost antero posterior horizontal plane. Where as in thoracic and lumbar region facet joints are oriented vertically and inter locked.
Whiplash Injury
Hyperextension of lower cervical spine
Jefferson's Fracture
Jefferson fracture is burst fracture of ring of atlas (Cl) vertebrae
Burst fracture is a vertical compression fracture.
(AIPG 2007)
Hangman's Fracture
It occurs when a fracture line passes through the neural arch of the axis (C2) vertebrae traumatic spondylolisthesis of axis (C2) vertebrae on C3 –H2 (Hangmans involves 2ND Cervical Vertebra).
NOTE: C1 and C2 injuries usually do not cause neural deficit because of wide spinal canal here.
Flexion rotation injury is the most common spinal injury followed by compression extension injury (2nd most common).
(AIPG 2007)
Tear drop fracture is caused by combined axial compression and flexion injury.
Patient with head injury, unexplained hypotension warrants evaluation of Lower cervical spine> Thoracic spine
In axial load injuries (compression injuries), the most common site of trauma is at the thoracolumbar junction
Car seat belt injury causes chance fracture
LEVEL OF INJURY
Nerve Root | Muscle group used for motor grading in ASIA system | Other Motor | Sensory | Reflex |
|---|---|---|---|---|
C5 | Elbow flexion (Biceps, Brachialis) | Deltoid* (arm abduction) | Lateral shoulderLateral arm | Biceps |
C6 | Wrist extension (extensor carpiradialis longus andbrevis) | Thumb and index fingers | Brachio radialis | |
C7 | Elbow extensor (triceps) | Extensor digitorum* (finger extensor) Wrist flexion | Middle finger | Triceps |
C8 | Finger flexors (flexor digitorum profundus)/ | Ring and little fingers | ||
T1 | Hand intrisics (interossei) Finger abduction | Upper anterior forearm | ||
L2 | Hip flexors (iliopsoas) | Upper anterior thigh | ||
L3 | Knee extensor (quadriceps) | Thigh (hip) adduction | Lower anterior thigh Anterior knee | (knee) |
L4 | Ankle dorsiflex or (tibialis anterior) | Quadriceps* (knee extension) Hip adduction | Medial calf, medial border of foot | (knee) |
L5 | Great toe extensors (extensor hallucis longus) EHL | Peronei (foot eversion) Tibialis anterior (ankle dorsifiexion) Gluteus medius (hip abduction), Knee flexion Toe dorsiflexors | Dorsal surface foot Lateral calf Great toe all aspects | S1 |
Ankle plantar flexors (gastrocnemius and soleus)/FHL (Flexor Hallucis Longus) | Abductor hallucisGluteus — maximus (hip extension) | Plantar surface foot Lateral aspect foot including 5th toe all aspects | ankle reflex | |
*ASIA: American Spinal Injury Association. | ||||
MEASURMENT OF SUPRATROCHANTERIC SHORTENING
Shortening of limb length produced above the level of trochanter (due to femoral head, neck and hip joint lesions) is known as supratrochanteric shortening. And it is measured by follwing tests.
Qualitative Assessment
Patient lies supine and hip is extended
Schoemaker's Line SchUmaker- G
A line joining tip of trochanter and ASIS, when prolonged on both side, should meet in the central line at or above the umblicus. In case of proximal migration of greater trochanter the line on that side will meet its counter part below the umblicus and on the opposite side.
Morris's Bitrochanteric Test M – P – T
- The distance from the tip of the trochanter to the pubic symphysis should be equal.
- If trochanter is externally rotated or displaced back distance will increase on that side and viceversa. In central fracture dislocation that side component is reduced.
Chiene's Parallelogram CAS -G
- The lines joining the two ASIS and two tips of trochanter should be parallel.
- In case one of the greater trochanter has moved proximally the lines will converge on that side.
Nelaton's Line: Patient lies on the normal/opposite side of the limb with preferably 90°flexion at hip. A line drawn from ischial tuberosity to ASIS should pass through the tip of greater trochanter. In case of supratrochenteric shortening the trochanter will be above this line.
Quantitative Measurement
Bryant's Triangle
- The patient lies supine and tips of trochanter and ASIS are marked on both sides.
- A perpendicular is dropped from each ASIS on to the bed. From tip of greater trochanter another perpendicular is dropped on to the first one, (base of the triangle). Now join the tips of greater trochanter to ASIS on respective side. Each side of this right angled triangle is compared with its counter part on the normal side.
- Any shortening of the base (i.e. more or less femoral axis continuation line), which may be because of shortening in the neck, head, joint or dislocation of joint can be measured.
TRENDELENBURG SIGN
Normally when the body weight is supported on one limb, the glutei (medius and minimus) of the supported side contract and raise the opposite and unsupported side of pelvis, if the abductor mechanism is defective the unsupported side of pelvis drops and this is known as positive trendelenburg's test.
Trendelenberg's test is done to assess the integrity of abductor mechanism. It is positive in the conditions in which any of the three — fulcrum(Femoral Head), lever arm (neck length) or power (muscles/nerve)is affected.
Causes of Positive Trendelenberg Test
Power-Paralysis of abductor muscles
- Superior gluteal nerve palsy (supply gluteus medius and minimus)
- Polio
- Iliotibial tract palsy
- Abductors of hip are - Gluteus medius and minimus (main)
- Tensor fascia lata and sartorius (accessory)
Decreased lever arm
- Fracture neck femur
Absence of stable Fulcrum about which the abductor muscles can act dislocation of hip. Destruction of femoral head as in Perthes disease, AVN, late stages of TB hip(stage 4 and 5) and septic arthritis.
Tuberculosis of Hip- Trendelenberg's test may be positive in TB hip only in late stages(stage 4 and 5) when the head of femur is destroyed.
Patients walk with positive trendelenbrug sign on. One hip- Lurching/Trendelenburg Gait and Both hip- Wadding Gait
Thomas test – to measure fixed flexion deformity of hip by neutralizing lumbar lordosis. Upto 30 degree flexion deformity of hip can be compensated by lumbar lordosis.
Shenton's line is an imeginary semicircular line joining the medial cortex of femoral neck to the lower border of superior pubic ramus. Its femoral part is of more significance. It is breeched in fracture neck femur, head femur, superior pubic rami and dislocation of hip.
Telescopic Test
In supine position, hip and knee are flexed as much as 90 degrees and thigh is pulled up and pushed down. Even in normal condition a slight amount of excursion of trochanter can be felt by other hand. If excursion is more, then this indicates instability of hip joint such as: old unreduced posterior dislocation, loss of neck and or head in old fractures neck femur and paralytic hip.
Pelvic Fracture
In pelvis fracture intrapelvic haemorrhage is by far, the most serious complication. Haemorrhage frequently results from fracture surfaces. Amount of blood loss is around 4 – 8 units.
- Stable
- Rotationally unstable but vertically stable; and
- Rotationally and vertically unstable. This classification is widely used in the current literature.
Cresent Fracture, is a type II lateral compression injury that extends from posterior iliac crest, passing through iliac wing (just behind gluteal pillar), and may then exit in greater sciatic notch or more commonly may enter the sacroiliac (SI) joint. Treatment is operative.
(AIIMS May 2009)
Straddle Fracture
Bilateral fracture of both pubic rami
Malgaigne Fracture
Fracture of pubis with a fracture of ilium near sacroiliac (SI) joint (Ipsilateral)
Kocher - Langenbeck (K - L) Approach Posterolateral approach to hip has good posterior exposure but limited superior and anterior exposure. Incidence of sciatic nerve injury is 2-6%.
Contraindicated in Morel – Lavallee lesion
(AIIMS May 2009 Nov 2009)
Fracture Around Hip
MRI is more sensitive(100% sensitivity) and specific for diagnosis of occult fracture neck femur.
Gardens classification for fracture neck femur
- Stage 1 : The fracture is incomplete, with head tilted in postero-lateral direction, i.e. into valgus, therefore is known as valgus (abduction) impacted fracture.
- Stage 2 : Complete fracture but undisplaced.
- Stage 3 : Complete fracture with partial displacement.
- Stage 4: Complete fracture with total displacement.
Pauwel's angle is the angle formed by the line of fracture with the horizontal plane
Deformity of hip
- Flexion, abduction, external rotation, apparent lengthening Synovitis
- Flexion, adduction. internal rotation, true shortening arthritis/posterior dislocation
- Flexion, abduction, external rotation, true lengthening-anterior dislocation
- External rotation, shortening-femoral neck fracture
- Marked external rotation, shortening-intertrochanteric fracture femur
Fracture Neck of Femur – Treatment
<65 years, < 3 week
- Closed reduction and internal fixation with multiple screw is the treatment of choice. In basicarvical fracture Dynamic Hip Screw can be done.
- If closed reduction is not possible open reduction and screw fixation is indicated
<65 years, > 3 week fracture osteotomy/Bone grafting + fixation.
>65 years
- No pre-existing arthritis – hemiarthroplasty
- Pre-existing arthritis—total hip replacement
Complication are Osteonecrosis > Nonunion > arthritis
(AIPG 2012)
Chances of AVN and nonunion in decreasing order is
- Subcapital > transcervical >basal >intertrochanteric
- Transphyseal >transcervical >cervicotrochanteric >intertrochanteric (in children)
Intertrochanteric fracture femur
- Extra age, extra pain,extra shortening extra external rotation(as compared to Neck femur)
- Treatment of choice Dynamic Hip Screw
- Most common complication is malunion
Most common dislocation of hip is posterior.
Associated fracture with dislocations do not have the classical deformities.
(AIPG 2012)
10. LOWER LIMB TRAUMATOLOGY
Subtrochanteric Femoral Fractures
- Russell and Taylor classification
- Treatment of choice is cephallomedullary nail
- Smith Paterson triflanged nail was used for internal fixation of fracture neck femur (not subtrochanteric femur).
Displacements In Fracture Shaft Femur
- Proximal third fracture: Proximal fragment flexes, abducts and externally rotates because of gluteus medius and iliopsoas
Diagnostic Criterion for Fat Embolism – Fracture shaft femur with breathlessness after 48 hours think of it:
Gurd's Major Criteria (4)
- Axillary or subconjunctival petechia
- PaO2 below 60 mmHg
- CNS depression
- Pulmonary oedema
Gurd's Minor Criteria (8)
- Tachycardia
- Pyrexia
- ANEMIA
- Thrombocytopenia
- Fat globules present in sputum
- Fat present in urine (GURD TEST)
- Increasing ESR
- Emboli present in retina
1 major +4 minor = fat embolism
- Treatment of fat embilism is oxygen and (IPPV)
Patella:
- Displaced Transverse Fracture
- Tension Band wiring by k-wires and stainless steel (SS) wire
- Comminuted Fracture
- At least proximal third of patella is intact -Partial Patellectomy
- Severe Comminution -Total Patellectomy
Management of Fracture Tibia
- Children –Above knee cast
- Adults – Trial of conservative management is given if it fails Interlock nailing.
Compartment syndrome of Leg – Test for toe dorsiflexion (AIIMS Nov 2008)
Use of Single Crutch – In the opposite side for Fracture both bone leg and Hip Pathology
Over 90% of ankle ligament injuries (twisted ankle or ankle sprain involve the lateral ligament complex usually the anterior talofibular ligament)
Malleolar Fracture
- The three malleoli are medial malleolus, lateral malleolus and posterior malleolus (the posterior part of the lower articulating surface of tibia).
- The mechanism of injury first word is position of foot and second word the direction of force
- The most common mechanism is supination-eversion (supination–external rotation).so supination is position of foot and external rotation direction of injury.
- Treatment is maintain the joint surface reduced.
Tibial Pilon Fracture
The terms tibial plafond fracture, pilon fracture, and distal tibial explosion fracture all have been used to describe intraarticular fractures of the distal tibia.
Fracture Talus-Complications – OA > AVN
- Secondary Osteoarthritis of ankle and/or subtalar joint occurs some years after injury in over 50% of patients. There are several causes: articular damage because of intial trauma, malunion, distortion of articular surface and AVN.
- Avascular necrosis of body, incidence varies with the severity of displacement: in type 1 <10%, in type II~40%, in typeIII >90% and in type IV 100%
Calcaneum is the most commonly fractured tarsal bone-Tuber angle of Bohler (Tuber-joint angle) –Reduced in fracture calcaneum and Crucial angle of Gissaine- increases in intraarticular fractures.
(AIIMS May 2007, AIPG 2007)
Calcaneum in over 20% of these patients suffer associated injury of spine (most common), pelvis or hip, base of skull and talus.
Angles in Orthopaedics
- Cobb's angle – Scoliosis
- Kite's angle – CTEV
- Meary's angle – Pes cavus
- Hilgenreiner's epiphyseal angle – Congenital coxa vara
- Baumann's angle – Supra condylar fracture
Chronic ankle instability can be satisfactorily treated by Waston- Jones operation. In which reconstruction of ankle ligaments is carried out.
Watson-Jones is also a lateral approach to the hip joint, which can be used for hip replacement (although rarely as more commonly used approaches are Moore's posterior and Hardinge's antero-lateral approach.)
(AIIMS Nov 2008)
11. FRACTURE MANAGEMENT
Plaster Casts And Their Uses:
Name of the cast | Use |
|---|---|
Minerva cast | Cervical spine disease |
Risser's cast | Scoliosis |
Turn-buckle cast | Scoliosis |
Shoulder spica* | Shoulder immobilization |
U-Slab/hanging cast | Fracture of the humerus |
Hip spica | Fracture of the femur |
Cylinder cast/tube cast | Fracture of the patella |
Patellar tendon bearing | |
cast(PTB cast) | Fracture of the tibia |
Colle's cast | Fracture lower end radius |
Glass holding cast | Fracture scaphoidQ |
Gallows traction – Fracture shaft femur < 2 years of age.
(AIIMS May 2012, Nov 2011, Nov 2010)
Rush pin is used for fracture shaft femur not for traction
Superficial heat therapy infrared therapy
(AIIMS May 2007)
Closed reduction: Fracture hematoma is not exposed hence it does not interfere with fracture healing hence better prognosis for Extra articular fractures
Open reduction: Fracture hematoma is exposed it is usually carried out for articular fractures as exact reduction is essential to prevent arthritis or open reduction is carried out if closed reduction fails or if additional procedure like bone grafting at farcture site is required.
Internal fixation the fixation device is under the coverage of soft tissues plating or nailing.
External fixation the fixation device is external to skin-external fixator or ilizarov fixator.
Management of fracture
- For long BonesIntramedullarv nailing eg K nail, interlocking nail, Rush nail, reconstruction nail –For lower limb diaphyseal fractures –Femur or TibiaPlating for upper limb fractures –humerus or radius or ulnaDynamic hip screw (DHS)-For Intertrochanteric fracture
- For short bones
Screws -articular fracture where headless screws(Herbert screw) are preferred eg scaphoid fracture
Cannulated cancellous screws- femur neck fracture
K-wire –fractures in children eg supracondylar fracture humerus (Closed reduced)or lateral condyle fracture(open reduced)
Tension band wiring –Patella or olecranon or medial malleolus
External fixator is used for open fracture
Ilizarov fixator is used for Shortening with discharging sinus, nonunion and also for CTEV.
(AIIMS Nov 2009)
Surgical Excision Never done in growth plate injury e.g. Lateral condyle fracture
Iliac crest is the ideal and most common site for harvesting bone graft.
(AI 2008)
Iliac crest is the site for 1st order bone grafting
Reimplantation of amputated limb 1st repaired is Bone. (Skin is preserved 1st)
Common Splints/Braces And Their Uses:
Name | Use |
|---|---|
| Emergency immobilization |
| Fracture femur Knee immobilization |
| Fracture femur, Knee and Tibia |
| Immobilization of fingers |
| CTEV |
| Radial nerve palsy |
| Ulnar nerve palsy/Median nerve palsy |
| Foot drop splint |
| Volkmann's ischemic contracture (VIC) |
| Neck immobilization |
| Brachial plexus injury |
| Cervical spine injury |
| Dorso-lumbar spinal injury |
| Dorso-lumbar immobilization |
| Scoliosis |
| Scoliosis |
| Backache |
| Lumbar Spine (T.B.) |
| Fracture shaft of femur in children below 2 years (or <12kg body weight) |
| Fracture shaft of femur in children below 2 years |
| Trochanteric fractures (described as skin traction) |
| Conventional skin traction |
| Fracture shaft femur in adults |
| Fracture shaft of femur in children |
| Correction of hip deformity |
| Correction of abduction deformity of hip |
| Supracondylar fracture of humerus |
| Supracondylar fracture of humerus |
| Cervical spine injuries |
| Cervical spine injuries |
| Scoliosis |
| Cervical spine |
| Scoliosis (usually Idiopathic or Dorsal) |
| Developmental Dysplasia of Hip |
| Legg Calve-Perthes Disease |
| Clavicle |
| Acromioclavicular dislocation > shoulder dislocation |
| Phalangeal and metacarpal fractures |
| Scaphoid fracture / Metacarpal fracture / Game keepers thumb |
| Humeral fracture |
| Distal forearm fracture |
| Elbow fractures |
| Phalangeal fracture |
12. AMPUTATIONS
Mangled Extremity Severity Score (MESS): Predictor for Lomb Survival after Crush Injury
“SIVA”- the destroyer will decide survival.
(AIIMS May 2011)
Type | Point |
|---|---|
Shock Group | 0-2 |
Ischemia Group | 1-4 |
Velocity of Trauma | 1-4 |
Age Group | 0-1 |
Total Score: | 11 |
MESS SCORE: Six or less consistent with a salvageable limb. Seven or greater amputation generally the evential result.
A way to remember total of amputation stumps in upper and lower limbs is 15
Upper limbs 8 inch above elbow stump+7 inch below elbow stump=15 (in inches)
Lower limbs 9 inch above knee stump+5.5below knee stump =14.5~15(in inches)
Myodesis is contraindicated, in severe ischemia because of the increased risk of wound breakdown.
(AIPG 2009)
Amputation neuroma the physiotherapy modality to be preferred is TENS > interferential therapy > Ultrasound. TENS and interferential therapy wroks on the principle of inhibiting pain gate pathway hence are better for control of neurogenic pain.
(AIIMS May 2012)
SACH (Solid Ankle Cushion Heel) foot does not allow ankle movements (required for squatting) and does not allow Subtalar movements (inversion and eversion movements required for walking on uneven grounds)Hence SACH foot is more suitable for western lifestyle and in Jaipur foot these movements are permitted hence it is more suitable for Indian scenario.
(ALPG 2012)
13. SPORTS INJURY
- Predominant collage in menisci/fibrocartilage – Type I collagen
- Predominant collagen in articular/hyaline cartilage – Type II collagen
- Physiological locking is internal rotation of Femur on Tibia.
- If knee is extended from flexed position tibial tuberosity moves towards lateral border of patella.
- The twisting force (rotation) in a weight bearing flexed knee is the commonest mode of meniscal (semilunar cartilage) injury. Medial meniscus > Lateral meniscus.(AIPG 2010)
- The commonest type of medial meniscal injury in a young adult is the bucket handle tear. This is vertical longitudinal tear that is complete.
- Smillie Classification – Meniscus Injury
Meniscal Injury | Cruciate Injury/Collateral Ligament |
|---|---|
1. Effusion | Hemarthrosis |
2. Delayed Swelling | Immediate Swelling |
- Meniscal cysts- Lateral > Medial
The etiology of Achilies insertional tendonitis is overuse
Non-insertional achilles tendonitis is more common and is seen in Atheletes. It is seen 2–6 cms above the insertion of Tendoachilles.
(AIIMS Nov 2008)
Tendon rupture-supraspinatus, biceps, and achilles tendons
Most TA tears occurs in left leg in the substance of TA, 2-6 cm above the calcaneal insertion (watershed zone). Test for TA rupture is Simmonds test or thompson test.
Game Keeper's/ Skier's - Thumb: Injury to the thumb metacarpophalangeal joint ulnar collateral ligament. Due to forced radial deviatory of thumb. Steners lesion is associated. (Trapped adductor pollicis between torn ulnar collateral ligament) Treatment is cast for 4 weeks and if steners lesion is present then surgery.
(AIIMS Nov 2011)
Zone II (of flexor tendon injuries): Situated between the opening of the flexor sheath (the distal palmar crease) and insertion of flexor superficialis (flexor crease of proximal interphalangeal joint) is known as ‘no man's land’ or dangerous area of hand.
14. NEUROMUSCULAR DISEASE
Disc Degeneration and Prolapse
The commonest site of disc prolapse is lumbar spine. In more than 90% of cases lumbar disc herniation are localized at L4–5 (more common) and L5 – S1. The next commonest site of intervertebral disc prolapse is lower cervical spine (C5–6).
- Lower nerve root is affected usually like in L4-5 disc prolapse L5 nerve root is affected.
- L5 nerve root supplies Extensor Hallucis longus, thigh abductors, ankle dorsiflexion and sensory supply to lateral aspect of leg dorsum of foot and great toe. (It is most commonly involved in PIVD L4–5)(AIIMS May 2012, Nov 2011)
- S1 nerve root supplies Flexor hallucis longus, ankle plantar flexion,hip extension and sensation on sole of foot.
Investigations
- MRI is investigation of choice
Treatment
- Rest with Antiinflammatory Medications
- Indications for surgery:
- Bladder and bowel involvement
- Increasing Neurological deficit
- Failure of conservative treatment (6 weeks)
“Red Flag” and “Yellow Flag” signs for Back ache
Red Flag (Requires further workup) | Yellow Flag |
|---|---|
Red flags are possible indicators of serious spinal pathology: Thoracic pain Radicular impingement Fever and unexplained weight loss Bladder or bowel dysfunction History of carcinoma Ill health or presence of other medical illness Progressive neurological deficit Disturbed gait, saddle anaesthesia Age of onset <20 years or >55 years Prolonged steroid intake | Yellow flags are pyschosocial factors shown to be indicative of long term chronicity and disability: A negative attitude that back pain is harmful or potentially severely disabling Fear avoidance behaviour and reduced activity levels An expectation that passive, rather than active, treatment will be beneficial A tendency to depression, low morale, and social withdrawal Social or financial problems |
Chronic backache Prolonged bed rest is avoided
(AIPG 2009)
Spondylolysis is characterized by presence of bony defect at pars interarticularis, which can result in spondylolisthesis.
Spondylolisthesis is the slippage forward of one vertebrae upon another. L5 and S1 (most common)
Oblique or lateral view in spondylolysis dog with a collar in neck and spondylolisthesis beheaded Scottish Terrier sign
AP view is least useful except. In last stages on AP view inverted napolean hat sign is seen when complete slip occurs
(AIIMS Nov 2011)
- CT SCAN can diagnose early defects and slips
- MRI can diagnose cord compression
- CT. Scan and MRI are usually always done in spondylolisthesis
Frozen Shoulder or Adhesive Capsulitis
The cardinal feature is stubborn lack of active and passive movement in all directions. i.e. global restriction of movements in all planes. Often the first motion to be affected is internal rotation followed by abduction.
Painful Arc Syndrome
It is anterior shoulder pain in 60 - 120° of gleno humeral abduction. Most common cause is
Chronic supraspinatus tendinitis.
Tennis Elbow/ Lateral Epicondylitis
- It is chronic tendonitis of common extensor origin (esp. extensor carpi radialis brevis) on lateral epicondyle.
Cozen test is positive
Golfer's Elbow
Medial epicondylitis involving common flexor pronator origin.
De Quervain's Disease
The abductor pollicis longns and extensor pollicis brevis tendons may become inflammed benath the retinacular pulley at the radial styloid with in the first extensor compartment. Finkelstein's test is positive.
(AIIMS Nov 2011)
Dupuytren's Contracture
This is nodular hyper trophy and contracture of superficial palmar fascia (palmar aponeurosis).
(AIIMS Nov 2011)
- Higher incidence in epileptics receiving phenytoin therapy, diabetics, alcoholic cirrhosis, AIDS, pulmonary tuberculosis..
- Ectopic deposits may occur in dorsum of PIP joint (Garrod's/knuckle pads), sole of feet (Ledderhose's disease) and fibrosis of corpus cavernosum (Peyronie's disease)
- Flexion contracture most commonly occur at MP joint. >PIP joint> DIP joint.
- Ring finger is most commonly involved> little finger> thumb and index finger
- PIP contractures soon become irreversible
Treatment
- Wait and watch
- Primary indication of surgery is fixed contracture of >30 degrees at MP joint or >15 degrees contracture at PIP joint. surgery is subtotal fasciectomy. Closure may be done by Z plasty.
Stenosing Flexor Tenosynovitis Trigger Finger
Due to stenosing tenosynovitis the flexor tendon may become trapped at the enterance to its fibrous digital sheath. The usual cause is thickening of fibrous tendon sheath or constriction of mouth of fibrous digital sheath. (mainly Al pulley) at the level of metacarpophalangeal joint.
Mallet Finger/ Baseball Finger
It is avulsion of extensor tendon of the distal interphalangeal joint from its insertion at the base of distal phalanx.
An acute mallet finger should be splinted and the DIP joint is kept in hyperextension for 6–8 weeks.
Burisitis | Site |
|---|---|
Student's Elbow/miners elbow | Olecranon bursitis |
Housemaid's knee | Prepatellar bursitis |
Clergyman's knee | Infrapatellar bursitis |
Weaver's bottom | Ischeal bursitis |
Tailor's ankle | Lateral malleolus bursitis |
Bunion | Medial side of great toe-1st metatarsal head bursitis |
Bunionette | 5th toe of foot-5th metatarsal head bursitis |
Athletic Pubalgia – The primary pathology in Athletic Pubalgia is: Abdominal muscle strain.
(AI 2009)
Chondromalacia patellae Seen in adolescent females Patient has Anterior knee pain/Difficulty in climbing stairs/Movie Sign”/“Theater sign” increased pain on getting up after prolonged sitting..
15. PERIPHERAL NERVE INJURY
SEDDONS order of nerve injury
Neuropraxia 100% recovery and only wait and watch can apply splint till it recovers
(AIIMS May 2012)
Sunderland classification – type 1 to 5, Type 1 –neuropraxia, type 2 3,4-axonotmesis,type 5 neurotmesis.
Tinel sign positive and progressive in axonotmesis and sunderland type 2 and 3
EMG is the best test for nerve recovery
Autonomous zones-Median nerve tip of index finger/ulnar tip of little finger
(AIIMS May 2008)
Rate of nerve regeneration – 1mm/day
Incidence of iatrogenic nerve injury is <3 percent
Nerve | Trauma | Effect |
|---|---|---|
Axillary nerve | Dislocation of the shoulder (Anterior and Inferior) | Deltoid palsy |
Radial nerve | Fracture shaft of the humerus (lower 1/3rd) | Wrist drop |
Ulnar nerve | Fracture medial epicondyle humerus | Claw hand |
Sciatic nerve | Posterior dislocation of the hip | Foot drop |
Common peroneal nerve | Knee dislocation/Fracture of neck of the fibula | Foot drop |
Posterior Interosseous Nerve | Monteggia fracture | Finger drop |
Anterior interosseous nerve | Supra condylar fracture Humerus | Kiloh Nevin Sign |
Median nerve | Supracondylar fracture of humerus | Pointing index |
Brachial plexus most commonly –Erbs palsy(Policeman or waiters tip deformity)
Movements lost in ERBS palsy are
Preganglionic injury poor prognosis and in them Histamine test is positive
37Median nerve palsy – Claw hand -pointing index(Flexors)/Pen test(Abductor pollicis Brevis) and ape thumb deformity
Opposition is lost with median nerve palsy at wrist
Knuckle bender splint is used
Anterior interosseous nerve palsy –KILOH NEVIN sign
Ulnar nerve palsy – Claw hand-CARD TEST(Palmar interossei)/IGAWA TEST(Dorsal interossei/BOOK TEST/FROMENT SIGN (Adductor pollicis)/Wartenbergs sign
Ulnar paradox (lower injuries more severe) – due to FDP spared in lower nerve injury.
Knuckle bender splint is used.
Radial nerve – Wrist drop
Posterior interossei nerve palsy – Thumb drop or finger drop
Cock up splint is used
Entrapment Syndrome | Nerve involved |
|---|---|
Carpal tunnel syndrome | Median nerve (at wrist) (Most Common) |
Pronator syndrome | Median nerve (proximally compressed beneath - ligament of struthers, bicipital aponeurosis or origins of pronator teres or flexor digitorum superficialis). |
Cubital tunnel syndrome | Ulnar nerve (between two heads of flexor carpi ulnaris) |
Guyon's canal syndrome | Ulnar nerve (at wrist) |
Thoracic outlet syndrome | Lower trunk of brachial plexus, (C8 and T1) and subclavian vessels (between clavicle and first rib) |
Piriformis syndrome | Scaitic nerve |
Meralgia paraesthetica | Lateral cutaneous nerve of thigh |
Cheralgia paraesthetica | superficial radial nerve |
Tarsal tunnel syndrome | Posterior tibial nerve (behind and below medial malleolus) |
Morton's metatarsalgia | Interdigital nerve compression (usually of 3rd, 4th toe) |
Femoral nerve is usually not involved in Nerve Entrapment Syndrome
Carpal tunnel syndrome -compression of median nerve
Sensory symptoms can often be reproduced by percussing over the median nerve (Tinel's sign) or by holding the wrist fully flexed for a minute or two (Phalen's test) or tourniquet test or Dunkans direct compression over median nerve (most reliable clinical test for median nerve).
NCV investigation of choice
Tarsal tunnel syndrome – compression of posterior tibial nerve -Idiopathic > OA > RA
(AIPG 2009, 2007, AIIMS May 2009, AIPG 2007, AIIMS May 2010)
Meralgia paraesthetica-lateral cutaneous nerve of thigh
Fracture unite slower with muscular or neural disorders eg Polio
Contracture of iliotibial tract causes FABER(Flexion, abduction and External rotation) at hip and PERF (Posterior subluxation, External rotation and Flexion –TRIPLE Deformity) at knee.
Nerve Palsy | Presentation |
|---|---|
| Policeman tip deformity (Porter's tip deformity) |
| Winging of scapula |
| Pointing index Bendiction test, Pen test (tests abductor pollicis brevis) Oschner clasp test/Opposition of thumb lost /Ape thumb deformity |
| Book test (froment sign), Card test (PAD) – Palmar Interossei Igawa's test (DAB) – Dorsal interossei |
| Wrist drop, (Finger drop and Thumb drop Specifically in posterior interosseous nerve (PIN) injury) |
| Foot drop(complete) |
SIGNS AND TESTS
- Adson's test: for thoracic outlet syndrome
- Allen's test: for testing patency of radial and ulnar arteries
- Alli's test: for DDH
- Anvil test: for testing tenderness of the spine
- Ape thumb : for median nerve injury
- Apley's grinding test :for meniscus injury
- Apprehension test: for recurrent dislocation of the shoulder
- Barlow's test : for DDH
- Blue sclera : Osteogenesis imperfecta
- Bryant's test : for anterior dislocation of the shoulder
- Callways’ test : for anterior dislocation of the shoulder
- Chovstek's sign : for tetany
- Claw hand : for ulnar nerve injury
- Coin test: for dorso lumbar tuberculosis of spine
- Cozen's test: for tennis elbow
- Drawer test : for ACL and PCL injuries
- Anterior : for ACL injury
- Posterior : for PCL injury
- Finkelstein's test : for de Quervain's tenosynovitis
- Foot drop : for common peroneal nerve injury
- Froment's sign : for ulnar nerve injury
- Gaenslen's test: for SI joint involvement
- Galleazzi sign : for DDH
- Gower's sign : for musular dystrophy
- Hamilton ruler test: for anterior dislocation of the shoulder
- Lasegue's test: for disc prolapse
- Lachmann test: for ACL injury
- Ludloffs sign: for avulsion of lesser trochanter
- McMurray's test: for meniscus injury
- Nagffziger test: for disc prolapse
- Ober's test: for tight ilio- tibial band (e.g., in polio)
- 0’ Donoghue triad: traid of MCL, ACL and medial meniscus injuries occurring together
- Ortolani's test: for DDH
- Pivot shift test: for ACL injury
- Policeman tip : for Erb's palsy
- Runner's knee : Patellar tendonitis
- Sulcus sign: for inferior instability of the shoulder
- Thomas’ test: for hip flexion deformity
- Trendelenburg's test: for unstable hip
- Tinel's sign: for detecting improving nerve injury
- Volkmann's sign : for ischaemic contracture of forearm muscles
- Wrist drop : for radial nerve injury
16. JOINT DISORDERS
Synovial Fluid
Synovial Fluid: It is an ultradialysate of blood plasma transudated from synovial capillaries to which hyaluronic acid protein complex (mucin) has been added by synovial B cells.
Normal aging Vs osteoarthritic pathology of articular cartilage
(AIIMS May 2010, AIPG 2009)
Cartilage property | Aging | Osteoarthritis |
|---|---|---|
Total water content (Hydration) | Decreased | Increase (Decreased in advanced OA) |
Proteolytic Enzymes: | Normal | Increased |
Proreoglycan content | Decreased | Decreased |
New bone formation is a feature of noninflammatory arthritis, e.g. Osteoarthritis
Complications of THR
- Infection(AIPG 2010)
- Dislocation
- Mortality-MI> Cardiorespiratory Arrest>Pulmonary Embolism
Contraindications of Metal on Metal Bearing surfaces
- Patients with Renal Insufficiency (Chronic Renal Failure)
- Young females of child bearing age (Women who may potentially still have children)(AIPG 2010)
- Metal hypersensitivity
- They can also cause chromosomal changes
- Their role in carcinogenesis is under evaluation
Contraindications oF High Tibial Osteotomy (HTO) – (Usually done for osteoarthritis < 65 years of Age)
- Narrowing of lateral compartment cartilage space.
- Lateral tibial subluxation of >1cm
- Medial compartment bone loss of> 2or 3mm
- Flexion contracture of > 15 degrees
- Knee flexion of <90 degrees
- More than 20 degrees correction needed
- Rheumatoid arthritis(AIIMS May 2011)
Osteoarthritis
Osteoarthritis characterstically involves distal interphalangeal joint (Heberden's node), proximal interphalangeal joint (Bouchard's node) 1 carpometacarpal joint (base of thumb) of hand with sparing of metacarpophalangeal joint and wrist joint.
Due to decreased loading of painful extremity quadriceps weakness is common in patients of osteoarthritis of knee. Most impotantly Vastus medialis is affected.
(AIIMS Nov 2011, AIPG 2007, AIIMS May 2007, AIPG 2011)
Classification system and stage wise management for OA knee
- Initial treatment is always conservative
- Clinical picture is more significant than radiology or xray changes
- If activities of daily living are affected surgery is adviced
- Surgery fir young is HTO (if not contraindicated) if contraindicated TKR is performed
- Surgery for elderly (>65 years) is TKR
- HTO-High Tibial Osteotomy
- TKR-Total Knee Replacement
Ahlback Grade | Definition | Treatment in young | Treatment in Elderly |
|---|---|---|---|
Grade 1 | Joint space narrowing | Conservative if fails HTO | Conservative if fails TKR |
Grade 2 | Joint space obliferation | Conservative if fails HTO | Conservative if fails TKR |
Grade 3 | Minor bone attrition (0-5 mm) | Conservative if fails surgery if bone loss <3 mm HTO otherwise TKR | Conservative if fails TKR |
Grade 4 | Moderate bone attrition (5-10 mm) | TKR | TKR |
Grade 5 | Severe bone attrition (>10 mm) | TKR | TKR |
* >3 mm Bone Loss HTO is Contraindicated | |||
* TKR – Total Knee Replacement. | |||
Rheumatoid Arthritis
Classification Criteria for Rheumatoid Arthritis -2010 | Score | |
|---|---|---|
Joint involvement | 1 large joint (shoulder, elbow, hip, knee, ankle) | 0 |
2–10 large joints | 1 | |
1–3 small joints (MCP, PIP, Thumb IP, MTP, wrists) | 2 | |
4–10 small joints | 3 | |
>10 joints (at least 1 small joint) | 5 | |
Serology | Negative RF and negative ACPA | 0 |
Low-positive RF or low-positive anti-CCP | ||
antibodies (3 times ULN) | 2 | |
High-positive RF or high-positive anti-CCP | ||
antibodies (>3 times ULN) | 3 | |
Acute-phase reactants | Normal CRP and normal ESR | 0 |
Abnormal CRP or abnormal ESR | 1 | |
Duration of symptoms | <6 weeks | 0 |
>6 weeks | 1 | |
Total Score 10
Score > 6 indicates – R.A
The 1987 Revised Criteria For Diagnosis Of RA
- Guidelines for classification 4 of 7 criterion are required to classify a patient as having RA Patients with 2 or more criteria are not excluded.
- Criteria (a - d must be present for at least 6 weeks and b- e must be observed by physician)
- Morning stiffness, in and around joint lasting 1 hour before maximal improvement.
- Arthritis of 3 or more joint areas, observed by a physician simultaneously, have soft tissue swelling or joint effusion, not just bony over growth. The 14 possible joint areas involved are right or left proximal interphalangeal (PIP), metacarpophalangeal (MCP), wrist, elbow, knee, ankle and metatarsophalangeal joints (MTP).(AIIMS Nov 2008)
- Arthritis of hand joints e.g. wrist, MP or PIP joints.
- Symmetrical arthritis i.e. simultaneous involvement of same joint area on both sides of body.
- Rheumatoid nodules: Subcutaneous nodules over bony prominences, extensor surfaces or juxta articular region. (Pathognomic)
- Serum rheumatoid factor.
- Radiological changes: Bony erosion or unequivocal bony decalcification, periarticular osteoporosis and narrowing of articular (joint) space.
- Women are affected three times more often than men. The onset is most frequent during 4th and 5th decade of life, with 80% of all patients developing the disease between age of 35 and 50. The incidence of RA is more than 6 times greater in 60-64 years old women compared to 18-29 years old women.
Significance of Rheumatoid Factor (RF)
If present in high titre, to designates patients at risk for severe systemic disease.
Poor Prognostic Factors of RA
‘Swan - neck deformity’ i.e. hyperextension of PIP joints with compensatory flexion of the distal interphalangeal joints
Boutonniere deformity i.e. flexion contracture of PIP joints and extension of DIP joints.
Pattern of Joint Involvement
Osteoarthritis | Rheumatoid Arthritis | Psoriatic Arthritis | |
|---|---|---|---|
Involved | PIP, DIP and 1’ CMC (corpometacarpal) joints | PIP, MCP, wrist | DIP, PIP and any joint |
Spared | MCP (metacarpo pha langeal) and wrist | DIP joint | Sparing of any joint |
Ankylosing Spondylitis (AS)/ Marie- Strumpell or Bechtrew's Disease
Diagnostic Criteria – Modified New York Criterion
- Essential criteria is definite radiographic sacroilitis
- Supporting criteria: one of these three
- Inflammatory back pain
- Limited chest expansion (<5 cm at 4thICS) not a reliable criterion in elderly because of pulmonary disorders
- Limited lumbar spine motion in both saggital and frontal plane (Schober test /Modified Schober test)
- Inflammatory Back pain 4/5 present
- Pain for > 3 months
- <40 years age
- Insidious Onset
- Improves with Exercise No improvement with rest
- Pain at night
Never diagnose Ankylosing spondylitis without sacroilitis
(AIIMS May 2010)
Ankylosing hyperostosis | Ankylosing spondylitis | |
|---|---|---|
Age | Elderly | Young |
Sacroilitis | Absent | Always present |
Chest expansion | Mild restriction | Marked but not reliable in elderly |
Tendernes | Dorsolumbar | Sacroiliac |
ESR | Normal to mild rise | High |
Syndesmophytes | Present | Present |
Hemophilic Arthropathy
Clotting factors
- <1% – Spontaneous Haemorrhage
- 1-5% – Haemorrhage on Mild Trauma
- >5% – Haemorrhage on Significant Trauma
Joint Bleeding
- Weight bearing joints are most commonly involved, with the frequency of involvement in decreasing order, knee> elbow> shoulder> ankle> wrist> hip
- Ankle most commonly involved in children
- Arthroscopy is relatively contraindicated.
Intramuscular Bleeding
- In lower limbs most common sites of bleeding is iliopsoas> quadriceps
- In upper limb the most common site of bleeding is deltoid
- Most hemophilic pseudotumors are caused by subperiosteal hemorrhage and the most common location is in thigh (50%). Next in frequency are abdomen, pelvis, and tibia.
Neuropathic Joint Disease/ Charcot's Joint
It is progressive destructive arthritis arising from loss of pain sensation and proprioception (position sense). Diabetes mellitus (most common) cause. Joints involved are Midtarsal (most common)> tarsometatarsal metatarsophalangeal and ankle joint.
Disease | Joint Involvement |
|---|---|
Diabetes | Midtarsal (most common)> tarsometatarsal, metatarsophalangeal and ankle joint> knee and spine |
Tabes dorsalis | Knee(most common), hip, ankle and lumbar spine |
Leprosy | Hand and foot joints |
Syringomyelia | Shoulder (glenohumeral), elbow, wrist and cervical spine |
Myelomeningocele | Ankle and foot |
Congenital insensitivity to pain | Ankle and foot |
Chronic Alcoholism | Foot |
Amyloidosis | Peroneal Muscle atrophy (Charcot Marie tooth disease) |
- The appearance suggest that movements would be agonizing and yet it is often painless.
- The paradox is diagnostic the amount of pain experienced is less than would be anticipated based on degree of joint involvement.
- Usual treatment is bracing or arthrodesis. total ankle Replacement is contraindicated.
Congenital Syphilis
Clutton's joint is painless, symmetrical, sterile effusion mostly involving knee in 8-16 years of age. Spontaneous remission is usual in several weeks.
- Non erosive arthritis : SLE
- Non deforming arthritis : Behcets
Disease | Area involved |
|---|---|
| Knee |
| Knee |
| Knee |
| MP joint of big toe |
| Knee |
| Metacarpophalangeal joint |
| Sacro iliac joint |
| Foot joint (tarsals) |
| Vertebra |
| Pelvic bones > Femur > Skull > Tibia |
| Knee |
| Mandible |
| Knee |
| Between L4 and L5 |
| Lower end of femur (Metaphysis) |
| Upper end of Tibia |
* Difference between tumor calcinosis and Myositis ossifican | |
Parameter | Myositis Ossificans | Tumor Calcinosis |
|---|---|---|
Etiology | Traumatic | Idiopathic/Familial |
Side/Site | Unilateral-Elbow | Bilateral-Knee |
Symptom | Painful | Painless |
Marker | ALP increased | Increased PO4 |
ALP is marker of heterotropic Ossification.
In questions if they ask unilateral calcification then answer is myositis and if they ask bilateral calcification then answer is usually tumor calcinosis.
PSEUDGOUT
Feature | Gout (Protein Aclohol intake) | Pseudgout (Hpothyroidism associated) |
Synovial fluid Analysis | Uric acid crystal Needle or rod shaped crystal, Negatively birifringent crystals | Calcium pyrophosphate crystal, Rhomboid shaped crystal, Positive birifringent crystals |
Associated with | ACTH, glucocorticoid withdrawal, hypouricemic therapy, Hyperuricaemia. “Alcohol and Protein intake” | Four ‘H'S i.e. hyperparathyroidism, hemochromatosis, hypophosphatasia, hypomagnesemia are associated. Most common association is Hypothyroidism Chondrocalcinosis i.e. appearance of calcific material in articular cartilage and menisci is seen. |
Clinicalpresentation | Intense pain | Moderate pain |
Involved Joint | Smaller joints (most commoly metatarsophalangeal joint of big toe) | Larger joints most commonly, knee |
Pathology
Tophi (=porous stone) are nodular deposits of monosodium urate monohydrate crystals, with an associated foreign body reaction. It is deposited in minute clumps in connective tissue eg.
- Bursae eg olecranon bursa/periarticular tissue
- Tendons
- Synovium and joints
- Pinnae (cartilage) of ear
- Ligaments
- Articular ends of bone
- Subcutaneous tissue
- Kidney
- Tophi may ulcerate through skin or destroy cartilage and periarticular bone
Arthritis with Soft-tissue nodules
- Gout
- Rheumatoid arthritis
- Pigmented villonodular synovitis
- Multicenteric reticulohistocytosis
- Amyloidosis
- Sarcoidosis
- Most common cause of anomaly of craniovertebral junctions is Atlanto-occipital fusion.
- Ankylosing spondylitis rareley involves craniovertebral junction and rheumatoid arthritis is a common cause of craniovertebral junction anomaly.(AIIMS Nov 2011)
Craniovertebral (CV) Junction Anomalies: (Base of Skull + C1 + C2)
Malformation of Occiput Bone:
- Basilar invagination
- Condylar hypoplasia
Malformation of Atlas (C1)
Malformation of Axis (C2)
OS odontoideum (dysgenesis of odontoid in which upper portion of odontoid is seperated from base by a gap resembling ununited fracture)
Other causes are:
- Spondyloepiphyseal dysplasia
- Achondroplasia
- Mucopolysaccharidosis storage disease
- Down's syndrome
- Klippel - feil syndrome
- Neurofibromatosis
- Osteogenesis imperfecta
- Rheumatoid arthritis
- Ankylosing spondylitis (rarest cause)
17. METABOLIC DISORDERS OF BONE
There are four types of metabolic bone diseases.
- Osteopenic diseases: These diseases are characterized by a generalized decrease in bone mass (i.e., loss of bone matrix), though whatever bone is there, is normally mineralized (e.g., osteoporosis).
- Osteosclerotic diseases: There are diseases characterized by an increase in bone mass (e.g., fluorosis).
- Osteomalacic diseases: These are diseases characterized by an increase in the ratio of the organic fraction to the mineralized fraction i.e., the available organic matter is undemineralized.
- Mixed diseases: These are diseases that are a combination of osteopenia and osteomalacia (e.g., hyperparathyroidism).
NOTE:
- Rickets: Lack of adequate mineralization of growing bones.
- Osteo malacia: Lack of adequate mineralization of trabecular bone.
- Osteoporosis: Proportionate loss of bone volume and mineral.
- Scurvy: Defect in osteoid formation
Rickets
A – Abdomen protuberant
B – Bowing of bones
C – Costochondral Junction prominent - Rosary, Craniotabes
D – Diaphragm pull - Harrisons groove (Lateral indentation of chest due to pull of diaphragm on ribs)/Double Malleolus
E – Enamel defect of teeth
F – Forward sternum - Pigeon chest
G – Growth plate - widening
H – Hypocalcemia causing Hyper PtH
I – Irritability
J – Joint deformities - Genu Valgum/Genu Varum
K – Kyphosis
L – Loosers Zones
M – Milestone delayed
R – Rickets
Calcium | Phosphate | ALP | PTH | |
|---|---|---|---|---|
Osteoporosis | NORMAL | NORMAL | NORMAL | NORMAL |
Rickets/osteomalacia | N or low | Low | High | High |
Primary Hyperparathyroidism | High | Low | High | High |
Paget's disease | Normal | Normal | High | Normal |
Hyperparathyroidism
Primary (adenoma) | Secondary(usually due to osteomalacia) | |
|---|---|---|
Cllinical Features | More | Less |
Ca | High | ow or normal |
PTH | Very high | High |
NOTE: Von Recklinghausen's disease of bone is also called as osteitis fibrosa cystica (it should not be confused with Von Recklinghausen's disease (Neurofibromatosis type 1): In Osteitis fibrosa cytica there is fibrosa that is bony trabeculae are replaced by fibrous tissue and there is cystica that is cystic cavity in bone filled with blood and blood degradation products gives it Brown colour.
Radiological Features of Hyper parathyroidism
- Subperiosteal resorption of terminal tufts of phalanges, lateral end of clavicle and symphysis pubis.
- Loss of lamina dura (i.e. thin cortical bone of tooth socket surrounding teeth is seen as thin white line, is resorbed)
- Irregular, diffuse rarefaction of bones i.e. generalized osteopenia, thinning of cortices, and indistinct bony trabeculae.
- Brown tumor
- Salt pepper appearance of skull
- SCFE may be seen avascular necrosis
- Rarely AVN
Treatment is usually conservative and includes adequate hydration and decreased calcium intake. The indications of parathyroidectomy are marked hypercalcemia, recurrent renal calculi, progressive nephrocalcinosis and severe osteoporosis.
Milkman's/Increment fractures also known as looser's zones or osteoid zones are psudofractures seen in osteomalacia most commonly femur neck.
Rugger Jersy Spine
- Rugger jersy spine is produced by alternating regions of dense bone and areas of central vertebral radiolucencies.
- Causes of Rugger Jersey Spine are:
- Renal osteodystrophy due to hyperparathyroidism & osteosclerosis
- Osteopetrosis
SCURVY (VIT C: DEFICIENCY)
Scurvy: Defeciency of Vitamin C, causing defect in osteoid formation.
Pathology
- Vit C is necessary for hydroxylation of lysine and proline to hydroxylysine and hydroxyproline, two aminoacids crucial for proper cross linking of triple helix of collagen. So deficiency causes failure of collagen synthesis or primitive collagen formation, throughout the body, including in blood vessels, predisposing to haemorrhage.
- In bones zone of proliferation is affected primarily.
- Haemmorhage, is capillary in origin and occurs from gums, alimentary tract, subcutaneous tissue, and bone especially at the most actively growing metaphysis and beneath periosteum.
- Haemorrhage and fractures are common, but attempts of repair is disordered. The provisional zone of calcification is weak leading to epiphyseal separations.
- Dysfunctional osteoblast (flat resembling fibroblast) causes failure of osteoid formation resulting in generalized osteoporosis
- Chondroblast and mineralization is unaffected leading to persistence of calcified cartilage approching metaphysis seen radiologically as opaque white line at junction of physis and metaphysis (Frankel's line)
- Osteoclasts are normal, thin and fragile trabeculae and cortices of bone are seen.
- Dentin formation in teeth is abnormal due to defective collagen
Clinical Feature
- It develops after 6 – 12 months of dietary deprivation thus not seen in neonates.
- Earliest features are restlessness, fretfulness, irritability, loss of appetite and failure to thrive
- Gums may be spongy and bleeding.
- Subperiosteal haemorrhage is a distinct sign occuring most commonly in distal femur and tibia and proximal humerus, causing excruciating tenderness pain near the large joints. The child lies still to minimize pain or minimally move the affected limb (Pseudoparalysis) - (Frogs Like Posture is attained by child)
- Haemorrhage in soft tissue, joint, kidney, gut and petechiae may be seen.
- Anemia and impaired wound healing is seen
- Beading of ribs at costochondral junction (Scorbutic Rosary).
- Systemic reaction (fever) is absent initially.
NOTE: In Rickets - Rosary is Round and non-tender, and in Scurvy it is Sharp and tender.
Radiological Feature
- Osteopenia (ground glass appearance) (1st sign) with thinning of cortex (Pencil thin cortex)
- Metaphysis may be deformed or fractured.
- Frankel's line (zone of provisional calcification increases in width and opacity) due to failure of resorption of calcified cartilage and stands Out compared to the severly osteopenic metaphysis.
- Scurvy line or scorbutic zone (Trummer feld zone) is radiolucent transverse band adjacent to the dense provisional zone.
- Margins of the epiphysis appears relatively sclerotic, termed ringing of epiphyses or wimberger's sign (Ring sign) - Important.
- Lateral metaphyseal spur (Pelkan spur) at ends of metaphysis is produced by outward projection of zone of provisional calcification and periosteal reaction.
- Corner or angle sign is peripheral metaphyseal cleft
- Subperiosteal haemorrhagee
OSTEOPOROSIS
- T score less than -2.5 is osteoporosis
- Osteoporosis with a fracture is severe osteoporosis
Upto age of 70, colle's fracture is m.c. fracture in osteoporotic patient; and after 70 years age vertebral fracture is mc. fracture.
Strontium decreases bone resorption and increases bone formation.
(AI 2008)
Factors that HINDER Bone Cause - Osteoporosis
Hemotological: Leukemia, Lymphoma
- Hypogonadal states e.g. Turner syndrome, Klinfelteus syndrome.
- Inherited e.g. Osteogenesis Imperfecta, Marfan syndrome.
- Nutritional e.g. Malnutrition, Malabsorption
- Drugs e.g. Anticonvulsants, Alcohol, Heparin, Lithium, Aluminium, Cytotoxic drugs, Excessive Thyroxine.
- Endocrinal disorders e.g. Hyperparathyroidism, Thyrotoxicosis IDDM, Cushing Syndrome
- Rheumatological Disorders:
- Rheumatoid Arthritis,
- Ankylosing Spondylitis
Treatment
- Drug used in osteoporosisInhibit resorption: Bisphosphonates, Denosumab, calcitonin, estrogen, SERMS, gallium nitrate.
- Stimulate formation: Teriparatide(PTH analogue), calcium, calcitriol, fluorides.
- Both actions: Strontium Ranelate.
Fluorosis causes interosseaous membrane ossification and increased density in skull vault.
- Dental changes
- Secondary Hyperparathyroidism
Infantile cortical hyperostosis -Caffey's Disease
Hypervitaminosis D and A can cause bone abnormalities.
Paget's Disease/Osteitis Deformans
It is characterized by excessive disorganized bone turnover, that encompasses excessive osteoclastic activity initially followed by disorganized excessive new bone formation. It is the osteoclast that appear larger and irregular whereas osteoblast are relatively normal.
- The diagnostic histological feature of pagets disease is irregular areas of lamellar bone fitting together like a jigsaw with randomly distributed cement lines.
- It either occurs in one bone (monostotic Paget's disease) or multiple bones (polyostotic Paget's disease).
Etiology
- Genetic infection by paramyxovirus (measles and respiratory syncytial virus) has been linked.
- Pathophysiology: Increased bone resorption accompanied by accelerated bone formation is characteristic feature.
- Initial osteolytic phase involves prominent bone resorption and marked hypervascularization (Radiologically seen as advancing lytic wedge or blade of grass lesion) 2nd phase of active bone formation and resorption replaces normal lamellar bone with structurally weak woven bone that bend, bow and fracture easily.
- In 3rd sclerotic (burnt out) phase, bone resorption declines progressively and leads to hard, dense, less vascular pagetic or mosaic bone.
Clinical Features
- It is rare below 20, and most are over age 50 years
- Most people are asymptomatic
- The sites most commonly involved are - pelvis, tibia, followed by skull, spine, clavicle and femur
- Affects men more commonly
- Pain is most common presenting symptom
- Limb look bent and feels thick, and skin is unduly warm due to high vascularity hence the name osteitis deformans. Skull show frontal bossing and platybasia
Complications:
- Pagetoid bone lacks the strength of normal bone. As a result it deforms and fractures more easily.
- Cranial nerve ~ 2nd, 5th, 7th, 8th palsy is seen.
- Nerve compression and spinal stenosis is seen.
- Deafness due to nerve compression > otosclerosis
- High output cardiac failure, Hypercalcemia (if immobilized)
- Osteosarcoma (<1%) cases (poorest prognosis)
- Steal syndrome i.e. blood is diverted from internal organs to skeleton system, may lead to cerebral ischemia and spinal claudication.
- Osteoarthritis of Hip and Knee is common.
Diagnosis
- Serum calcium and phosphate levels are usually normal.
- Increased marker of bone formation (e.g. S. alkaline phosphatase and S. Osteocalcin) (ALP levels are used for monitoring pagets)
- Increased markers of bone resorptionSerum and urinary deoxypyridinoline, N telopeptine and C-telopeptideUrinary hydroxy proline
- Urinary deoxypyridinoline (24 hours assessment) is most valuable.
Radiological Features
- Long bone X-ray show deformity, enlargement or expansion of bone with cortical thickening coarsening of trabecular markings and lytic and sclerotic changes.
- Skull X-ray reveal “cotton wool” or osteoporosis circumscripta, thickening of diploic area. Increasing Hat Size!
- Vertebral cortical thickening at superior and inferior end plates creates a picture frame vertebrae and diffuse sclerosis causing ivory vertebrae
- Pelvic radiograph show sclerotic ileopectinal line (Brim sign), fusion or disruption of sacroiliac joints, etc.
Treatment
Indications are
- To control symptoms of active disease as bone pain, fracture, neurological complications or pain from radiculopathy or arthropathy.
- To decrease local blood flow and minimize operative blood loss in patients undergoing surgery.
- To decrease hypercalciuria
- To decrease complications -When site of involvement involves weight bearing bones, skull, vertebral bodies and major joints.
- Biphosphonates are drug of choice and calcitonin is used to relieve pain.
- Surgery is done for pathological fracture, osteoarthritis, nerve entrapment and spine decompression.
ACHONDROPLASIA
- A primary defect of enchondral bone formation. Autosomal dominant (but 80% are spontaneous mutations). The effect of excessive growth hormone on the mature skeleton.
- They have normal intelligence, trident hand and starfish hand.
CLEIDOCRANIAL DYSOSTOSIS
- It is an autosomal dominant (AD) disorder caused by CBFA1 gene on chromosome 6 p 21 responsible for osteoblast specific transcription factor and regulation of osteoblastic differentiation. In this disorder bones formed by intramembranous ossification are abnormal (primarily clavicles, cranium and pelvis). —Absent clavicle
Morquios syndrome has Most severe skeletal abnormalities amongst Mucopolysaccahridoses
Osteogenesis Imperfecta/Lobstein Vrolik's/ BrittleBone Disease
- Osteogenesis Imperfecta/Lobstein Vrolik's/Brittle Bone Disease.
- It is a genetic disorder of connective tissue determined by quantitative and/or qualitative defect in type I collagen formation. So there is alteration in the structural integrity, or a reduction in the total amount of type I collagen, one of the major components of fibrillar connective tissue in skin, ligaments, bones, sclera, and teeth.
- It is inherited from a parent in autosomal dominant (AD) fashion, may occur as spontaneous mutation, or, rarely as autosomal recessive (AR) trait.
- The defining clinical features are Osteopenia causing repeated propensity to fracture, generally after minor trauma and often with out much pain or swelling.
- Any fracture pattern may be seen, and no particular fracture pattern is specifically diagnostic. Fractures heal at a normal rate.
- Fracture callus is typically whispy but on rare occasions it may be very large and hyperplastic, resembling osteogenic sarcoma on radiographs.
- According to the severity of disease fractures nay occur in uterus, at birth, or after birth prior to or after walking age.
- Recurrent fractures are discovered during infancy and throughout childhood because of combination of disuse osteopenia, progressive long bone deformity and joint stiffness from immobilzation
- Lower limb fractures are more common than upper limb. Femur is commonest bone fractured followed by tibia.
- Frequency of fractures decline sharply after adolescence or puberty, although it may rise again in postmenopausal (climacteric) women
- New bone is pliable for long time due to defective osteoid formation, thus leading to malunion and severe deformities. eg acetabular protrusion (otto pelvis), helmet head, kyphoscoliosis, bowing, etc.
- Hyper laxity of ligaments, with resultant hypermobility of joint is common.
- Rarely recurrent dislocation of patella, radial head and hip joint dislocation and DDH can occur.
Radiological Feature
- Popcorn calcification and whorls of radiodensities.
- Skull has a mushroom appearance with a very thin calvarium
- Wormian bones, are detached portions of primary ossification centers of adjacent membrane bones. These are seen in skull x-ray. To be significant, it should be more than 10 in number, measure at least 6 mm x 4mm, and be arranged in general mosaic pattern.
- Wormian bones are present in osteogenesis imperfecta, other bone dysplasias such as cleidocranial dysplasia, congenital hypothyroidism, and some trisomies.
Ocular Involvement
- “Blue or grey sclerae”, is because of uveal pigment showing through thin collagen layer.
- Saturn's ring is white sclera immediately surrounding the cornea
- Arcus juvenilis or embryotoxon, is opacity in periphery of cornea.
- Hyperopia and retinal detachment may occur
Auditory Involvement
Deafness, usually onsetting in adolescence or adulthood may be either of the conductive type due to otosclerosis or of nerve type, caused by pressure on the auditory nerve as it emerges from the skull.
Dentinogenes Imperfecta/Crumbling of Teeth: “Dentine affected”
- The enamel is essentially normal, as it is of ectodermal origin, not mesenchymal
- Both deciduous and permanent teeth are involved. They break easily and are prone to carries. Yellowish brown or bluish gray discolouration of teeth is common.
- The lower incisors, which errupt first are more severely affected.
Skin and Muscle Involvement
- Skin is thin and translucent. Subcutaneous haemorrhages may occur.
- Muscles are hypotonic mostly due to multiple fractures and deformities. Hernias may occur
Metabolic Features
- Excessive sweating, heat intolerance are due to hypermetabolic state
- Susceptible to malignant hyperthermia during general anesthesia.
Diagnosis of Osteogenesis Imperfecta
- A molecular defect intype I procollagen can be detected in 2/3 of patients by incubating skin fibroblasts with radioactive amino acids and then analyzing the pro a chains by polyacrylamide gel electrophoresis.
- Mutations are defined by sequencing of genomic DNA. Exact mutation is identified by using 100 polymerase chain reactions (PCR) to analyse 10,000 bases in each of two collagen genes.
- After a mutation in type I pro collagen gene is identified, a simple PCR test can be used to screen family members at risk or for prenatal diagnosis. Chorionic villi biopsy at 8-12 weeks demonstrates synthesis of abnormal pro áchains
- Prenatal USG shows multiple fractures.
- Sillence classification: Type I to IV
AD Type I and IV / AR Type II & III
- Autosomal dominant Bone fragibility, Blue sclera and fracture are seen after birth (Most common)
- Autosomal recesive is Lethal in perinatal periods and lacks blue sclera
- AR (Dentinogensis imperfecta), Crumpled femur, fracture at birth
- Autosomal dominant - Normal sclera/ Normal hearing
Treatment
- Bisphosphonates (Decreases Osteoclastic bone resorption): One of the few indications of Bisphosphanates is growing age.
- Ideal treatment replace COLIAI or COLIA2 gene.
OSTEOPETROSIS
Marble bone disease or Albers schonberg disease
Etiopathology
- It is a diaphyseal dysplasia characterized by failure of bone resorption due to functional deficiency of osteoclast. The bone contains increased number of osteoclasts but these don't resorb bone as evidenced by absence of ruffled borders and clear zones and are unable to respond to PTH. Due to functional deficiency of osteoclasts, calcified chondroid (cartilage) and primitive woven bone persists down into metaphysis and diaphysis leading to osteosclerosis and increased brittleness of bones (marble bone disease)
- Inheritance depends on form of disease: Malignant osteopetrosis (congenital form) is autosomal recessive (AR, 11q 13) and late onset Osteopetrosis tarda (adolescence /adult form) is AD (1P 21)
- Intermediate form is AR
Clinical Presentation
- Autosomal dominant, benign or tarda osteopetrosis is often diagnosed in adult asymptomatic patients. It may present with mild anemia, pathological fractures premature osteoarthritis, and rarely osteomyelitis of mandible.
- Autosomal recessive malignant (congenital) osteopetrosis clinically presents at birth or in early infancy because of Obliteration of marrow cavity by bony overgrowth resulting in inability of bone marrow to participate in hematopoiesis. Pancytopenia develops resulting in abnormal bleeding, easy bruising, progressive anemia, and failure to thrive
- Severe infections esp. Mandible
- Extramedullary hematopoesis causing hepatosplenomegaly.
- Cranial nerve palsies (Bony Overgrowth of Cranial Foramen) 2nd, 7th and 8th - blindness and deafness
- Fragile brittle bones
- Pathological fractures
- Radiological hallmark is increased radiopacity of bones. There is no distinction between cortical and cancellous bone, because intramedullary canal is filled with bone
- Endobones (os in os or bone with in bone appearance) and rugger jersey spine
- Treatment is bone marrow transplant
Muscle most Commonly affected by congenital absence is Pectoralis major
METABOLIC BONE DISEASES
Coarse Trabecular Pattern-HOP-G
‘Bone within a Bone’ Appearance NnNha GOPAL
Erlenmeyer Flask Deformity GOL POT
18. PEDIATRIC ORTHOPAEDICS
Coxa Vara
It is reduced angle between neck and shaft of femur due to some growth anomaly at upper femoral epiphysis (infantile type) or secondary to various other pathologies (acquired).
The normal femoral neck shaft angle is 160° at birth, decreasing to 135 degrees in adult life. An angle of <120 degrees is called coxa vara.
Classification (Causes) of Coxa Vara
Congenital Coxa Vara
- Congenital femoral deficiency with coxa vara
- Developmental coxa vara
Aquired Coxa Vara
- SCFE (slipped capital femoral epiphysis)
- Sequelae of avascular necrosis of femoral epiphysis
- Legg-Calve Perthe's disease
- Femoral neck fracture, Intertrochanteric fracture.
- Rickets
Clinical
- Painless limp in a child who has just started walking
- Shortening-Limitation of abduction and internal rotation
Radiological
- Reduced neck shaft angle (varus)
- Vertical epiphysis plate
- Separate triangle of bone in infero-medial part of metaphysis called as Fair Bank's triangle
- Hilgenreiners epiphyseal angle; angle between horizontal line joining center (triradiate cartilage) of each hip (Hilgenreiner's line) and line parallel to physis; the normal angle is about 30 degrees.
Treatment (based on HE Angle) – Hilgenreiners epiphyseal angle.
>40° but <60° Observation
>60° or if shortening is progressive. Subtrochanteric valgus osteotomy
Legg Calve Perthe's Disease/Osteochondritis Deformans Juvenilis/Coxa Plana
It can be defined as osteonecrosis of the proximal femoral epiphysis in a growing child caused by poorly understood (non genetic) factors.
Etiology
- The precipitating cause is unknown but the cardinal step in the pathogenesis is ischemia of femoral head. Between 4 and 8 years of age femoral head depends for its blood supply and venous drainage almost entirely on the lateral epiphyseal vessels whose situation in retinacula makes them susceptible to stretching and to pressure from an effusion.
Pathogenesis
Clinical Presentation
- 4 to 8 years of age
- Male > Female
- Bilateral in 10% cases
- Most frequent symptom is limp that is exacerbated by activity and alleviated with rest.
- The classical child is small often thin, extremely active, constantly running and jumping, and limping after strenuous physical activities.
- Abductor limp, a combination of antalgic and Trendelenburg gait and positive Trendelenburg test on the involved side.
- During the very early phase, joint is irritable so extremes of all movements are diminished and painful.
- Later on most movements are full, but abduction (especially in flexion) is nearly always limited and usually internal rotation also. When the hip is flexed it may go into obligatory external rotation (catterall's sign) and knee points towards axilla. (Normally goes towards mid-clavicular region)
Course of Disease
Most consistent factor affecting course is patient's age at onset of disease. Younger age better prognosis. Out come is also affected by duration from onset to complete resolution; the shorter the duration the better the final results.
Head at Risk sign in perthes are: (These indicate poor development of femur head from femur epiphysis)
- Lateral subluxation of the femoral head
- Speckled calcification lateral to the capital epiphysis
- Gage sign-a radiolucent ‘V'shaped defect in the lateral epiphysis and adjacent metaphysis.
- Sagging Rope Sign – metaphyseal sclerotic band
Investigation
MRI is the investigation of choice.
At first x ray may seem normal, though subtle changes such as widening of joint space and slight asymmetry of ossification centres are usually present (isotope scan may show void in anterolateral part of femoral head). The classical feature of increased density (sclerosis) of the ossification nucleus occurs later and may be accompanied by fragmentation or crescentic subarticular fracture (best seen in lateral view). The head tends to flatten and enlarge (coxa plana)
Management
The main aim of treatment is containment of femoral head in acetabulum. Non surgical containment is achieved by orthotic braces All braces abduct the affected hip, most allow for hip flexion, and some control rotation of the limb. Broomstick or petrie cast issued
Surgical containment is through (1) Femoral varus derotation osteotomy, (2) Chiari osteotomy and chielectomy (surgically removing protuding fragments of femoral head usually antero lateral).
Slipped Capital Femoral Epiphysis
During a period of rapid growth, due to weakening of upper femoral physis and shearing stress from excessive body weight, there is upward and anterior movement of femoral neck on the capital epiphysis. So the epiphysis is located primarily posteriorly and medially relative to the femoral neck.
Aetiology
- The cause is unknown in vast majority of patients.
- Many of the patients are either fat and sexually immature or excessively thin and tall.
- Endocrinopathies such as Hypothyroidism (most common)Growth hormone excess caused by growth hormone deficiency conditions treated by growth hormone administration.
- Chronic renal failure (Hyperparathyroidism)
- Primary hyperparathyroidism
- Pan hypopituitarism associated with intracranial tumors
- Craniopharyngioma
- MEN 2 B
- Turner's syndrome
- Klinfelters syndrome
- Rubinstein Taybi syndrome
- Prior pelvic irradiation
- Many a times it presents in growth spurt.
Pathogenesis and Pathology
Slip occurs through hypertrophic zone of growth plate classically in obese hypogonadal male (adiposo genital syndrome)
Normally, pitutary growth hormone activity stimulates rapid growth and increases physeal hypertrophy during puberty (adolescent growth spurt). This is balanced by increasing gonadal hormone activity, which promotes physeal maturation and epiphyseal fusion. So growth hormone excess or hypogonadism is provocative of SCFE.
Physeal disruption causes premature fusion of epiphysis-usually with in 2 years of the onset of symptoms.
Clinical Picture
- An adolescent child (boys 13-15 and girls 11- 13) typically overweight or very thin and tall presents with pain some times and Antalgic limp, with the affected side held in a position of increased external rotation, (turning out of leg). Restriction of internal rotation, abduction and flexion.
- A classical sign is tendency of thigh to rotate in to progressively more external rotation, as the affected hip is flexed called as Axis deviation. (Similar to Perthes)
- Slipping usually occurs as a series of minor events rather than a sudden, acute episode. Patient with unstable acute or acute on chronic SCFE characteristically present with sudden onset of severe, fracture like pain usually as a result of a relatively minor fall or twisting injury.
- Chondrolysis complicating SCFE presents with more continuous pain, hip held in an external rotated position at rest, with flexion contracture and global restriction of hip motion. The patient usually complain of pain through out the arc of motion rather than just at its extremities.
- 20% cases will have evidence of contralateral slip. 60% of patients will have bilateral involvement when associated with endocrinopathies.
- Chondrolysis (Destruction of Cartilage) and avascular necrosis are possible complications
Investigation
A line drawn tangential to superior femoral neck (klein's line) on AP view will intersect a portion the lateral capital epiphysis normally. With typical posterior displacement of capital epiphysis this line will intersect a smaller portion of the epiphysis or not at all trethowans sign.
60Steel's metaphyseal sign is a crescent shaped area of increased density overlying metaphysis adjescent to physis (on AP view). It is due to overlapping of femoral neck and posteriorly displaced capital epiphysis.
A frog leg's lateral view is best for detecting mild slip.
Tc 99 scan show increased uptake in capital femoral physis in SCFE, decreased uptake with in epiphysis is highly specific for AVN. When chondrolysis is present, there is increased uptake of isotope on both sides of the joint.
MRI is useful investigation for diagnosis
Treatment
SCFE is usually a progressive disease that requires prompt surgical treatment. Because the changes in the chronic form occurs so slowly it is impossible to manipulate the femoral head into a better position. So treatment consists of fixing the slip in its current position and preventing progression. This is done by inserting one or more screws or pins across the growth plate (pinning in Situ). Acute slips, if unstable may be gently reduced before fixation but it increases the chances of AVN.
Developmental Dysplasia of Hip (DDH) -shallow acetabulum
DDH is failure of maintenance of femoral head due to malformations of acetabulum or femur 80% of cases of DDH occur in girls. DDH is more common in first born children as primigravida uterus and abdominal muscles are unstretched and subject the fetus to prolonged periods of abnormal positioning. This crowding phenomenon is the cause of its association with torticollis and metatarsus adductus. Oligohydramnios causes limited fetal mobility and thus increases risk of DDH. Breech presentation is another strong association factor. But the twin pregnancy does not increase the risk.
Familial association is seen.
Caucasions and Native Americans have higher incidence as compared to Blacks and Asians.
Clinical Diagnosis
- Abduction is limited (especially in flexion)
- Asymmetric thigh folds
- Barlow's Test
1st part — In position of 90 degree flexion of hips and knees, the hip is adducted and pushed.
And this will lead to dislocation of hip (but not if already dislocated)
BAAHARLO! “DAD” i.e. Barlow's test - Dislocation By Adduction (DAd).
This in Barlows we dislocate hip joint.
IInd part – Now the hip is abducted and pulled. This will cause ‘clunk’ indicating reduction of hip.
Some consider only 1st part as Barlow's test
- Ortolani's Test – the first two alphabets O and R (Ortolani for Reduction) and for Reduction we do abduction of hip.It is similar to 2nd part of Barlow's test
- Short limb as shown by - Higher buttock folds, Galeazzi or Allis sign is lowering of knee on affected side in a lying child with hip and knees flexed.
- Trendelenberg's test, telescopy and vascular sign of Narath is positive.
Radiological Features
- In Von Rosen's view following parameters should be noted
- Perkin's line ;Vertical line drawn at the outer border of acetabulum
- Hilgenreiner's line; Horizontal line drawn at the level of tri-radiate cartilage.
Shenton's line: Smooth curve formed by inferior border of neck of femur with superior margin of obturator foramen.
Acetabular Index: angle between Hilgenreiners line and line from triradiate epiphysis to lateral edge of acetabulum. Normal value is 20 – 40 degrees.(Centre edge) angle of Wiberg normal values upto 20-30 degree is angle between Perkins line and a line joining centre of epiphysis to edge of acetabulum.
- Normally the head lies in the lower and inner quadrant formed by two lines (Perkin's and Hilgenreiner's). In DDH the head lies in outer and upper quadrant
- Shenton's line is broken
- Delayed appearance and retarded development of ossification of head of femur
- Sloping shallow acetabulum
- Superior and lateral displacement of femoral head.
- Acetabular index increases and CE angle reduces in DDH.
Treatment Plan of DDH
Neonate and Young Child(1-6 month) –Closed reduction, Pavlik harness
6-18 months -open reduction is carried out
18-36 month
Open reduction +femoral rotation osteotomy ± pelvic osteotomy
Walking child(3 years-6 years)
Open reduction (antero lateral approch) and femoral shortening with Acetabular reconstruction procedure: (Salter's, Chiari's pelvic displacement and Pemberton osteotomy).
6-10 years: treatment should be avoided (fear of AVN), in bilateral DDH, in unilateral same as above.
>11 years: in cases of painful hips due to Osteoarthritis, THR may be done (but should be delayed till skeletal maturity)
Traumatic dislocation of distal femoral epiphysis anterior and lateral
Congenital dislocation of Knee-Hyper extension (Genu recurvatum) is the most common presentation
Genu Valgum - the commonest cause of genu valgum (Knock Knee) is Idopathic > Rickets.
NOTE: Usually OA Causes Varum/ RA Valgum
Genu Varum (Bow-Legs)
- Knee are abnormally divergent and ankles approximated. Bilateral bow legs can be estimated by measuring the distance between the medial malleoli when heels are touching; it should be < 6cm to label as Genu Varum. Normally 8 cm.
- A normal children show maximum varus at 6 months to 1 year of age, neutral alignment by 1-1/2 to 2 years of age, maximum genu valgum (8°) at 4 years of age, and a gradual decrease in genu valgum to 6 degrees by 11 years of age.
- The presence of genu varum after 2 years of age can be considered abnormal, as spontaneous resolution of the varus to neutral tibio femoral alignment by 2 years of age and to adult valgus alignment after 3 years of age is well documented.
- The causes of genu varum are similar to genu valgum except that the defective growth is on the medial side.
Two important causes are discussed below:
- Physiological genu varum, which remains the most common etiology, even in a deformity that is slow to resolve and appears to be pathological. It is a deformity with tibio femoral angle of at least 10 degrees of varus, a radiologically normal appearing growth plate, medial bowing of the proximal tibia and often of the distal femur. The legs of most newborns are bowed, with 10-15 degrees of varus angulation. When the infant begins to stand and walk the bowing may appear more prominent and often appears to involve both the tibia and distal femur. Radiograph may be indicated if the varus deformity persists beyond 2 years of age or progresses. Non resolving, assymmetrical deformity is the main indication for radiographs.
- Tibia vara is defined as growth retardation at the medial aspect of proximal tibial epiphysis and physis usually resulting in progressive bow leg. Two forms of deformity areBlount distinguished, according to age at onset, two types of tibia vara: infantile, which begins before 8 years of age, and adolescent, which begins after 8 years of age but before skeletal maturity. Nowadays following classification is followed:
- Infantile tibia vara (Blount's disease) in which patient is <3 years old at the onset of condition (more common). It is characterized by abrupt angulation just below the proximal physis, an irregular physeal line, a wedge shaped epiphysis, and a beak like medial metaphysis. Apparent lateral subluxation of proximal tibia is often present. The triad of Blounts is Tibia vara, Genu Recurvatum (hyperextension), and internal tibial torsion(internal rotation of tibia).Metaphysio diaphyseal angle is measured and angle more than 11 degrees require close observation
- 63Late onset tibia vara includes Juvenile form occuring between 4 and 10 years of age and adolescent form occuring after 10 years of age.Non physiological causes of genu varum, include skeletal dysplasia (eg. metaphyseal chondrodysplasia, spondyloepiphyseal dysplasia, multiple epiphyseal dysplasia, achondroplasia), metabolic diseases (eg. renal osteodystrophy, vit D resistant rickets), post traumatic deformity, post infectious sequelae, and proximal focal fibrocartilagenous dysplasia. In patients with familial hypophospatemic rickets, the bone disease is active during early infancy, when physiological varus is present
- If the child is between 3 to 4 years of age HKAFOs i.e. hip knee ankle foot orthosis, medial upright elastic Blount's brace especially if there is only unilateral involvement. Full time orthotic treatment (i.e. 23 hours a day) is traditional, so that the knee is fully protected during the day.
- Surgical overcorrection of mechanical axis to at least 5 degrees valgus, with lateral translation of distal osteotomy fragment achieved by 4 years of age is believed to be optimal. The risk of delaying corrective osteotomy (even few months) past the critical age of 4 years can result in failure to achieve permanent reversal of the inhibition of proximal medial physis.
- High tibial osteotomy just distal to the patellar tendon insertion with fibular osteotomy in proximal third diaphysis is recommended.
Rocker Bottom Foot
Rocker bottom foot, is a foot with a convex plantar surface with a apex of convexity at the talar head is due to wrong correction of CTEV or oblique talus.
Treatment is Grice Procedure.
Club Foot/ Congenital Talipes Equino Varus (CTEV)
Club is a stick to play golf CTEV foot resembles it so called as club foot.
Talipes is a generic term for foot deformity that centers around the talus (Talipes = talus and pes = foot). In its most characteristic form there are usually said to be four elements of deformity Equinus of ankle, inversion of foot, adduction of fore foot and medial rotation of tibia. In India the most common congenital anomaly is CTEV where as in western countries DDH is the commonest.
Etiology and Associated Anomalies
- Idiopathic (most common)
- Secondary club foot:
- Neurological disorders and neural tube defects eg myelonieningoceleand spinal dysraphism Paralytic disorder (muscular imbalance) as polio, spina bifida, myelodysplasia, and Freidreich's ataxia
- Arthrogryposis multiplex congenita, Larsen syndrome, Sacral agenesis, tibial deficiency, constriction rings and amniotic bands
- Hip deformities are associated e.g. DDH
Pathological Anatomy
- The club foot characteristically involves foot ankle and leg. Deformities of foot may be in the hind foot (ankle and subtalar joints), mid foot (mid tarsal i.e. talonavicular and calcaneocuboid joints) and forefoot.
- Talo calcaneo navicular joint complex is area involved in pathomechanics of all hind foot and mid foot deformities.
- Clubfoot is always associated with a permanent decrease in calf circumference related to fibrosis of calf musculature.
- In a new born child it is possible to dorsiflex and evert the foot till the dorsum of foot and it touches anterior surface of tibia. This is not possible in CTEV. This is known as ‘dorsiflexion test’ and can be used as a screening test.
Ankle (Tibio talar) Joint
Plantar flexion or Equinus
Subtalar (Talocalcaneal) Joint
- Inversion
Mid tarsal (talonavicular and calcaneocboid) Joint
- Adduction (medial subluxation) and inversion (supination) of mid and fore foot
Pirani/Dimeglio scoring is for CTEV
- Kites angle – AP view talocalcaneal angle.
- Normal value is 20 to 40 degrees (decreased in CTEV)
MOST COMMON RELAPSE in CTEV— adduction
Conservative Management of CTEV
Kites method –followed earlier | Ponsetti method now preferred | |
|---|---|---|
At birth | Manipulation by mother initial weeks | Manipulation and cast |
Change of cast | Every 2 weeks | Weekly |
Correction order | C-A-V-E | C-AV-E |
Fulcrum while manipulating | Calcaneocuboid joint | Head of talus |
Duration of treatment | 6 to 9 months | 6 to 8 weeks |
65NOTE: First cast in CTEV is applied in supination to correct Cavus. Subsequently in Kites one defomity is corrected at a time, adduction first than Varus and than Equinus.
In ponsetti method adduction and Varus are corrected simultaneously and Equinus is corrected at last.
Thus in Kites method one deformity is corrected at a time but in ponsetti adduction and varus are corrected simultaneously, equinus is corrected at end in both.
Above knee cast: As rule of splintage immobilize one joint above one joint below and to correct ankle equinus knee has to be immobilized thus above knee cast.
If this order of correction is not followed and the equinus is corrected before adduction and inversion by forcefully dorsiflexing the foot, it may actually move at mid tarsal joints (not at ankle joint) producing rocker bottom deformity.
Even if the correction is achieved maintenance of foot in Dennis Brown splint is required whole time upto 1 year and after 1 year day time CTEV shoes and night time Dennis brown splint is used upto 7 years of age. (as recurrence after 7 years of age is not known)
The objective is to achieve (ideally) overcorrection. Sometimes it may be necessary to perform percutaneous TendoAchilles lengthening (Tenotomy) in order to overcome equinus (Ponsetti method)
Operative Treatment
The results of early operation, in particular neonatal surgery, have not been shown to be better than those of late surgery. Delaying surgery until the child is near walking age has the advantage of operating of larger foot (making surgery easier).
Posteromedial soft tissue release (Cincinnati, Crawford, Turco, Carrol incisions) is best done at young age (1 -3 years).
But in children older than 3 years of age lateral column shortening procedures are often performed in conjunction with posteromedial soft tissue release.
Posterior release or complete subtalar release can also be performed.
3-8 years
Soft tissue release together with shortening of lateral side of foot by
Lichtblau's Procedure (i.e. Shortening of calcaneal neck proximal to calcaneocuboid joint). Preferred in <6 years of age as calcancocuboid fusion is more difficult to achieve in this age.
Evan - Dillwyn Procedure (i.e. resection and fusion of calcaneo cuboid joint)
In 3-8 years of age (esp> 6years) is ideal procedure.
Dwyer's osteotomy of calcaneum is done to correct calcaneal varus in >5 years.
Wedge Tarsectomy is done as deformity is more and requires multiple bones to be removed.
> 10 years
Triple arthrodesis is necessary for recurrent or persistent clubfoot deformity in older children (chronic cases). It is best done at > 10 years of age when foot growth is complete and the bones are ossified to achieve good fusion.
It involves fusion of three joints: TN - Talo-Navicular; TC – Talo-Calcaneal; CC – Calcaneo - Cuboid
- Pseudoarthrosis (most commonly of talonavicular joint) is commonest complication, which can be reduced by performing surgery after skeletal maturity and doing internal fixation.
- JESS and Ilizarov external fixators also can be used to correct deformity after skeletal maturity.
- CTEV shoes has outer shoe raise, straight medial border and no heel.
-
Pollicization is transposition of finger to replace (reconstruct) absent thumb done in Radial Club hand (absent radius)(AIPG 2008)
Absent or defeciency in Radius and associated with inadequately developed Thumb also called as Radial Club Hand
Absent Radius or thumb is associated with
- Trisomy 13,18
- Fanconis syndrome
- Tar syndrome(thrombocytopenia absent radius)
- Vater syndrome (vertebral anomalies,anorectal malformation/Tracheo-oesophageal fistula/esophageal atresia/radial club hand /renal agenesis)
- Holt oram syndrome (cardiac defects with absent radius)
- Ectodermal dysplasia
- Very rarely leukemias
- Order of investigations in a patient with absent radius is Echocardiography> platelets count >karyotyping>bone marrow.
Treatment
- Centralization of ulna
- Pollicization is transposition of finger to replace (reconstruct) absent thumbThis reconstruction of thumb is usually done by migrating index finger to the position of thumb in a patient with congenital absence or maked hypoplasia of thumb.
- Tendon transfers.
FRACTURES IN CHILDREN
The immature skeleton has several unique properties that affect the management of injuries in children. These properties include thicker periosteum, soft bones, an increased resiliency to stress, an increased potential to remodel, shorter healing times, and the presence of a physis. This can lead to some characteristic fracture patterns in pediatric population.
- Distal radius and ulna is the most common site of fracture in children accounting for nearly a quarter of fracture.
- 2nd in frequency is Hand injury
- 3rd in frequency are elbow injuries amongst them suppracondylar fracture humerus are most common and
- 4th common is clavicle fracture
- Please remember that Clavicle is the most common fractured bone in adults and during birth.* Dislocations and comminuted fractures are rare in children.Remember most common joint to dislocate in adults is shoulder but in children is Elbow.
Remodeling Potential In Children
Remodelling of bone is best (maximum) for metaphyseal angulation deformity and least (worst) for diaphyseal rotation deformity.
Battered baby syndrome
- It is a term used to define a clinical condition in young children usually under 3 years of age who have received non accidental violence or injury, on one or more occasions at the hands of an adult responsible for child's welfare.
- This syndrome must be considered in any child
- In whom degree and type of injury is at variance with the history given.
- When injuries of different ages and in different stages of healing are found.
- When there is purposeful delay in seeking medical attention despite serious injury.
- Who exihibits evidence of fracture of any bone, subdural hematoma, failure to thrive, soft tissue swelling or skin bruising (ecchymosis)
EPIPHYSEAL INJURY
Fractures characteristics
- Inflicted fractures of the shaft are more likely to be spiral rather than transverse.
- A classic finding is a chip fracture in which a corner of the metaphysis of a long bone is torn off with damage to epiphysis and periosteum.
Epiphyseal enlargement
Most common causes of epiphyseal enlargement are chronic inflammation (e.g. JRA) due to chronic increase in blood flow. Causes of Epiphyseal enlargement are.
a. Solitary
- Post inflammatory (JRA, Septic arthritis)
- Perthes disease (in repair stage)
- Hemophilia (Hemophilic arthropathy)
- Turner syndrome
- Trevor disease (Dysplasia epiphysealis hemimelica)
b. Generalized
- Hyperthyroidism
- Acromegaly or cerebral gigantism
- Spondyloepiphyseal dysplasia
- Rickets
- McCune-Albright syndrome
Epipyseal dysgenesis/Fragmented/punctate epiphysis- Hypothyroidism
klippel Feil Syndrome
Kippel Feil Syndrome is congenital fusion of one or more cervical vertebrae presenting with classical triad of low hair line, short ‘web’ neck (prominence of trapezius muscle), and limited neck motion seen in 50% cases.
Abnormal head position, true torticollis, and restricted range of motion, without an obvious SCM (sternocleido mastoid) contracture, is an indication for X-rays of cervical spine for evidence of cervical fusion.
It is associated with congenital osseous fusions (synostosis) and failure of segmentation of the cervical spine, involving two or more vertebrae. Such fusions can involve the craniocervical junction (occiput to C2), the subaxial cervical spine or both; and results from a failure of the normal division of the cervical somites during the 3rd to 8th week of embryogenesis.
Vertebra Plana
Vertebra plana is collapse and increased density of one vertebral body, with normal or increased disc space. Causes are Eosinophilic granuloma (histiocytosis), Ewings's sarcoma, metastasis, leukemia, tuberculosis (very rare) and Calves’ disease (osteochondritis of vertebral body).
Congenital scoliosis block vertebra carry the best prognosis and least progression.
Order of progression is unsegmented bar – with hemivartebra > unsegmented bar > hemivertebra > wedge vartebra > block vertebra. Risser localiser cast is used in the management of Idiopathic scoliosis.
Neurofibromatosis (NF)
It is heriditary, hamartomatous disorder, that affects central and peripheral nervous system, skeletal, skin and deeper soft tissue. It is one of the commonest single gene disorder affecting the skeletal system.
NF - 1/Von Recklinghausen's Disease
- Most common single gene disorder affecting human nervous system.
- Also called as peripherial neurofibromatosis, is due to defect in chromosome 17.
- AD inheritance, and 50% patients result from new mutation. 100% penetrance, i.e. individual with abnormal chromosome 17 will show same clinical feature.
- Clinical presentation includes - cafe au lait spots (most common feature) axillary, and inguinal freckling (2nd m.c), cutaneous neurofibromas, plexiform neurofibromas (~5% are premalignant), Lisch nodule on iris, veruccous hyperplasia (thickened overgrown valvety soft skin), elephantiasis (pachydermatocele), optic glioma, skeletal abnormalities (scoliosis, congenital pseudoarthrosis of tibia, hemihypertrophy) and cognitive deficits (learning disability).
- Complications include epilepsy, hydrocephalus, cognitive deficits, intracranial tumor, optic glioma, short stature, precocious puberty, hypothalmic dysfunction, renal artery stenosis and hypertension.
Diagnostic criteria for NF-1 are met if two or more criteria are found
- > 6 cafe au- lait spots, at least l5mm in greatest diameter in adults and 5mm in children.
- Neurofibromas of any type or one plexiform neurofibroma
- Axillary or inguinal freckling (crowe's sign)
- Optic glioma
- Musculo skeletal lesion such as sphenoid dysplasia, or thinning of cortex of long bone, with or with out pseudoarthrosis
- A first degree relative (parent, sibling, or offspring) with NF-1 by above criteria.
NF-2
- Also known as central neuro fibromatosis or bilateral acoustic neurofibromatosis and is due to defect in long arm of chromosome 22.
- Less common type, AD inheritance, and 50% cases are due to new mutation.
- Musculoskeletal deformities encountered in NF – 1 are generally absent in NF – 2.
- 8th nerve vestibular schwannomas occur in nearly every individual with NF2 (not seen in NFl).
- Meningioma occur in 50% cases.
Diagnostic criteria for NF-2 are met if a person has either of the following:
- Bilateral 8th nerve masses seen on MRI
- A first degree relative with NF2 and either a unilateral 8th nerve mass or two of the following
- Neurofibroma
- Meningioma
- Glioma
- Schwannoma
- Juvenile posterior subcapsular lenticular opacity
NOTE: Usually Skeletal disorders are Autosomal Dominant and Inborn errors of metabolism are Autosomal Recessive.
Congenital Pseudoarthrosis
Pseudoarthrosis
It is a false joint that may develop after a fracture that has not united properly due to inadequate immobilization. If a nonunion allows for too much motion along the fracture gap, the central portion of the callus undergoes cystic degeneration and the luminal surface can actually become lined by synovial like cells, creating a false joint filled with clear fluid- known as pseudoarthrosis.
Most Common Cause of Pseudoarthrosis
Idiopathic> Neurofibromatosis (NF- 1) – (Actually an association, not a cause)
Causes of Pseudoarthrosis are
- Neurofibromatosis (50% patients of pseudoarthrosis have NF)
- Nonunion of fracture (including pathological fractures)
- Congenital (mostly in lower to middle third of tibia with cupping of proximal bone end and pointing of distal bone end)
- Osteogenesis imperfecta
- Fibrous dysplasia
- Cleidocranial dysplasia
- Ankylosing spondylitis (in fused bamboo spine)
- Post surgical eg. Triple arthrodesis, spinal fusion as a complication.
- Tibia is most commonly involved bone. Five forms of congenital pseudoarthosis of tibia are — dysplastic, cystic, sclerotic, fibular and clubfoot or congenital band type.
- The most common dysplastic type is tapered at defective site; an hour glass Constriction, it is associated with neurofibromatosis.
- Poor fracture healing and recurrent fracture is common even if union is achieved.
- Cast immobilization is generally unsuccessful.
- Initial treatment is nailing and bone grafting or Ilizarov fixator.
- Vascularised Fibular graft is done if multiple failed surgeries.
19. OSTEOCHONDRITIS DISSECANS
- It is a poorly understood disorder, which leads to softening and seperation of a portion of joint surface; resulting in development of small segment of necrotic bone in joint.
- Knee (lower- lateral part of medial femoral condyle) is the most commonly affected joint. Elbow (capitulum) is 2nd common.
- The cause is trauma either a single impact with the edge of patella or repeated microtrauma.
- Patient is usually adolescent male, presents with intermittent ache and swelling, localized tenderness and Wilson's sign (i.e. pain is felt in extension of flexed knee in medial rotation, but not in lateral rotation)
- The best X ray view is intercondylar (tunnel view-30 degrees knee flexion)MRI can make early diagnosis of cartilagenous lesions.
Treatment Options
O’ Driscoll ‘4R’ for treatment
- Relief by physiotherapy and pain control modalities few lesions can resolve over time
- ResectExcision if small fragment
- Replace the joint surface
- Restore the cartilage lesionFixation with headless screws (Herbert Screw) and protected weight bearing till union.If lesion <2 cm2 – Autologous Chondrocyte Transplantation that is cartilage cells are grown in artificial media and than transplanted into cartilage defect.Micro fracture technique or abrasion arthroplasty – Making drill holes at the base of lesion causing regeneration of fibrocartilage and filling the defect of hyaline cartilage (in normal joint). Thus it is substituting for hyaline cartilage by fibrocartilage.
Types of osteochondritis
20. Avascular Necrosis
Head of femur (most common)
Incidence of AVN in fracture neck Femur -Subcapital>transcervical>basicervical
(AIPG 2012)
Most important lateral epiphyseal branch of medial circumflex femoral artery
Scaphoid (proximal pole AVN)-because blood supply distal to proximal
Talus (Body)
Lunate
AVN of Femur head
Idiopathic (Chandliers disease) – most common veriety
Causes of AVN of femoral head
- Trauma: Neck femur fracture, Posterior dislocation of hip.(>12 hour duration)
- Substance: Alcohol, steroid use.
- Infection: Septic arthritis, osteomyelitis
- Storage disorders: Gaucher's disease
- Caisson disease: Dysbaric osteonecrosis(Nitrogen accumulates)
- Hemoglobinopathy and Coagulation disorder: Sickel cell disease, Familial thrombophiiia. Hypofibrinolysis, Hypolipoproteinemia
- Congenital disorders: Perthe's disease, Slipped capital femoral epiphysis.
- Hematological malignancies: Leukemia, lymphoma. Polycythemia.
- Hyperlipedemia: Nephrotic syndrome
- Other: SLE, ionising radiation, Pregnancy, pancreatitis, Amyloid, Renal failure and dialysis, Hyperparathyroidism.
NOTE: Think AVN as an answer if mentioned any disease for which steroids are given eg Nephrotic syndrome or pemphigus vulgaris.
Ficat and arlet staging/university of Pennsylvania staging.
Limitation of abduction and internal rotation(HIV positive on therapy with decreased abduction and internal rotation consider AVN as an answer)
(AIPG 2008)
Sectoral sign clinically
Crescent sign on xrays
MRI (Investigation Of Choice) – Double line sign
Treatment
- Early stages protected weight bearing.
- Pre collapse stage –core decompression to decrease intraosseous pressure in femoral head(Intra Osseous Pressure Normal 10-20 mm Hg it is 3-4 times in AVN) drill holes are made in femoral head this procedure also opens the channels for vascular ingrowths and it is also supplemented with bone grafting(Vascular or non vascular) or electrical stimulation or Bone Morphogenic Proteins.
- Muscle Pedicle graft –Quadratus femoris/Tensor fascia lata graft can be fixed in femoral head to augment vascularity.
- Rotational osteotomy –To get the intact part of femoral head in acetabulum weight bearing area (anterolateral aspect of femur head)this is an extensive procedure requiring vascular repair along with it.
- Arthritis/Collapse of femoral head – Total hip replacement one of the very commonly done procedure as most patients present at stage of arthritis.
