Essentials of Orthopedics RM Shenoy
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1Essentials of ORTHOPEDICS2
3Essentials of ORTHOPEDICS
Second Edition
RM Shenoy D Orth MS Orth Professor and Unit Head Department of Orthopedics Yenepoya Medical College (A constituent of Yenepoya University) Nithyananda Nagar, Derlakatte, Mangalore Karnataka, India Foreword M Shantharam Shetty
4
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Essentials of Orthopedics
First Edition: 2010
Second Edition: 2014
9789350903735
Printed at
5Dedicated to
My Wife Renu and Daughter Archana6
7Foreword
It was a pleasure of going through the pages of this highly informative well-presented book entitled Essentials of Orthopedics written by Dr RM Shenoy whom I had the pleasure of knowing him since his childhood and later as a student and now a revered colleague.
He has an inborn dominant gene of a writer and a leader. His mother an award winning writer of short stories and poems and father a grass root social worker of repute.
I am sure this book will be a beacon of light and guide for undergraduates to understand orthopedics and the postgraduates to have their basics well forwarded and to the practicing surgeons as a ready reckoner.
I am sure this book will find a place in the shelf of every Orthopedic Surgeon.
I wish Dr Ravi all the best in his endeavors and may the good God bless him in all his endeavors.
M Shantharam Shetty ms ortho frcs facs
Pro-Chancellor, Nitte University
Past President, Indian Orthopedic Association
AO Trustee 2003–2009
AO Trauma India Chairman 2009–2011
Mangalore, Karnataka, India8
9Good Wishes
Professor RM Shenoy is a teacher par excellence and committed to his profession. His dedication to academic activities is worth appreciating. He is an innovative Orthopedic Surgeon who is highly disciplined and meticulous in his work. He likes to improve the current status of medicine, always aiming at perfection. He expects the same from his pupils too. His original research of developing a single incision for exposure of forearm fracture speaks of his capabilities. This was published in the Journal of Bone and Joint Surgery, British 1995;77B(4):568-70. I find it to be an extremely good and a cosmetic exposure. The book Essentials of Orthopedics written by him is going to be a boon for both undergraduates and postgraduates as well as practicing Orthopedic Consultants. As a teacher, I am thrilled to see one of my pupils Prof RM Shenoy, reaching great heights and carving out a niche for himself among the Orthopedic Surgeons. I wish him good luck and expect many more innovative things from him in future.
PK Usman ms ortho
Former Professor
Department of Orthopedics
Kasturba Medical College
Mangalore, Karnataka, India
Former Emeritus Professor and HOD
AJ Institute of Medical Sciences
Mangalore, Karnataka, India10
11Preface to the Second Edition
The first edition of the book was written with an intent to impart basic orthopedic knowledge among medical fraternity in general and medical students in particular. The aim was to provide undergraduates with important concepts in orthopedics which would also serve as basic knowledge for postgraduates. I was indeed apprehensive about this venture, conception and execution of which took a considerable amount of time of every single day. However, it gives me great pleasure to see my efforts being well accepted and appreciated. I owe it to the medical fraternity, students and orthopedic colleagues for their support in taking this book forward to the second edition within few years of publication of the first.
With newer editions of any book, comes an unspoken requirement and responsibility. It is that of updating deficiencies that existed in the previous edition and also incorporating current information and practices. With that in mind, a few new chapters have been included on Poliomyelitis and Cerebral Palsy. Several short topics have also been included. An effort has also been made to simplify and re-write certain topics so as to precisely and effectively convey information. This includes the addition of flow charts wherever possible. I sincerely hope that this edition fulfills expectations of every reader and provides an enjoyable reading experience.
RM Shenoy12
13Preface to the First Edition
Medicine today is a highly specialized science. Innovations are too many and what was held good yesterday becomes obsolete today. Newer and newer concepts continue to evolve and to keep abreast with these one should have a sound basic knowledge of the subject. The subject orthopedics has very few books which impart this basic knowledge to a medical student. The book Essentials of Orthopedics is written keeping this fact in mind. It aims at imparting basic orthopedic knowledge to a student of medicine who has acquired basic knowledge of pre- and para-clinical subjects. The original concepts have been highlighted and the persons who put forth these concepts have been duly recognized. Every attempt has been made to narrate the concepts in a simplified manner keeping the originality. Wherever possible illustrations have been placed to help the reader to understand the subject. Radiographs have been used wherever required so that the learning process becomes easy because of the visual effect they impart. The essential topics have been covered methodically and adequately. On the whole this book is a complete book which imparts essential basic orthopedic knowledge to a medical student. Questions have been provided at the end of each chapter for revision as well as preparation for the examination. Suggestions are most welcome.
RM Shenoy14
15Acknowledgments to the Second Edition
Many people have come forth with suggestions and also helped me during the revision process of this title. I have tried my best to heed to every genuine criticism in the interest of the book. Foremost among my critics and if I may say, the toughest of them all, is my own dear daughter Dr Archana Shenoy, MBBS. She took it upon her to simplify the medical jargon that I sometimes would write and dedicated a lot of her time towards thorough revision of this title. Her involvement helped me fulfill many deficiencies observed in the previous edition.
I acknowledge my colleagues in Orthopedics for using this title as a teaching tool and forwarding several useful suggestions along the way. Here, I would like to specially thank Dr Sharath Rao, D Orth, MS Orth, Professor and Head, Department of Orthopedics, Kasturba Medical College, Manipal, who pointed out the absence of information on Poliomyelitis and Cerebral P alsy in the previous edition. I owe it to his keen observation, that those topics are now part of the current edition.
I recognize the help rendered to me by my residents at Yenepoya Medical College, notably, Dr Kashif Akhtar Ahmed, MBBS, (MS); Dr Tushar Jyothi, MBBS, (MS); Dr Musheer Hussain MBBS, (MS) and Dr Mohmad Irfan Nagnur, MBBS, (MS) especially during the period of final proofreading and correction.
I would also like to thank the innumerable students whom I have taught along the way, for popularizing this title and also providing some valuable suggestions.
I would also like to acknowledge the team of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, under the able leadership of its Group Chairman, Shri Jitendar P Vij for all the help and support provided during the course of revision of this title. I recognize the efforts put by Mr Venugopal, branch manager at the Bengaluru office for active support ensuring timely communication and publication of this edition.
Last but definitely not least; I would like to recognize the cooperation and sacrifices made by my dear wife Renu. I appreciate her for being with me throughout while enduring several sleepless nights and compromised family time that ensued during the course of preparation of this edition.16
17Acknowledgments to the First Edition
The author being honored by the revered Chancellor of Manipal University Dr Ramdas M Pai for completing 25 years of meritorious service.
At the outset, I would like to acknowledge my alma mater Kasturba Medical College which nurtured me for 39 long years first as an undergraduate student, then as a postgraduate and finally now as its faculty. I am thankful to the illustrious Chancellor of Manipal University, Dr Ramdas M Pai who guided me and gave me an opportunity to buildup my career as a young Orthopedic Surgeon. The guidance and encouragement which I had received then has put me on a sound footing today.
I am indebted to my teachers Professor M Shantharam Shetty, the Vice-Chancellor of Nitte University and President of Indian Orthopedic Association and Professor PK Usman, the two living legends who shaped my career as a teacher and an Orthopedic Surgeon.
I am grateful to my innumerable colleagues, interaction with whom considerably improved my knowledge and to the innumerable undergraduate and postgraduate students whom I have taught during the past 27 years and in the process learnt a lot.
I am extremely grateful to my present colleagues Dr Deepak Pinto, Dr Vivek Mahajan, Dr Saurabh Bansal and Dr Harshvardhan who helped me in many ways during the preparation of this book.
I acknowledge the inspiration given by my mother Smt Padma Shenoy, a State Award winning novelist, whose literary talents perhaps I have inherited, my wife Renu for kindling the spark within 18me to write a book for the benefit of the students thereby enabling me to transmit this scientific, pure and unsullied knowledge to the future generation and my daughter Archana for helping me in the proofreading and correction, as well as giving all possible help and support during completion of this task.
I also acknowledge my younger brother Dr Surendra Shenoy and sister-in-law Dr Shalini Shenoy for the help they have rendered in the preparation of this book.
And last but not least; I acknowledge the efforts of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, and its enterprising Chairman and Managing Director Shri Jitendar P Vij, the dedicated team of staff at Delhi office, and Mr Venugopal, branch manager at the Bengaluru office, who have worked with me promptly and efficiently in bringing out this book in a grand manner.
27General Orthopedics  
INTRODUCTION
The term “Orthopedics” is from the Greek words ‘Ortho’ meaning straight and ‘Pedia’ meaning Child. It was coined by Nicholas Andry (1658–1742) who in 1741 published L‘Orthopédie’ ou l'art de prévenir et de corriger dans les enfants, les difformités du Corps’ in Paris. This work of Nicholas Andry was translated into English as Orthopedia meaning the art of correcting and preventing the deformities in children. Thus wrote Nicholas Andry ‘I have found it of two Greek words, e.g. straight, free from deformity, and a child. Out of these two words I have compounded that of Orthopedia, to express in one term, the design I propose, which is to teach the different methods of preventing and correcting the deformities of children.’
But the current orthopedic practice does not limit itself to straightening a child. Today an orthopedic surgeon handles almost all the pathologies involving the musculoskeletal system, namely:
  1. Congenital anomalies, e.g. congenital talipes equinovarus (CTEV), developmental dysplasia hip (DDH), etc.
  2. Neoplasms, e.g. osteosarcoma, giant cell tumor, etc.
  3. Traumatic conditions, e.g. fractures, dislocations and fracture dislocations.
  4. Degenerative diseases, e.g. osteoarthritis, spondylosis, senile osteoporosis.
  5. Infections, e.g. osteomyelitis, pyogenic arthritis, bone and joint tuberculosis, etc.
  6. Metabolic and endocrinal abnormalities, e.g. rickets, hyperparathyroidism, etc.
Further subspecialties have developed such as ankle and foot surgery, surgery of the upper limb and hand, spinal surgery, arthroplasty, trauma surgery, arthroscopy, etc. Thus, currently Orthopedics has evolved into a highly specialized subject offering a variety of treatment options from simple plaster of Paris casts to skillful and complicated surgeries.
 
AXIS AND DEVIATIONS
Any deviation from the anatomical axis () towards or away or rotation along the axis results in deformities. The following terminologies are used to describe these deviations in the limbs.
  1. Varus means deviation towards the midline and Valgus means deviation away from the midline.
  2. Torsion means rotation in its axis. If rotation occurs in an inward direction, it is known as Intorsion.
    If the rotation occurs in an outward direction it is known as Extorsion.
Thus in the limbs the deformities are described as follows:
 
Anteversion (Only in the Hip Region)
Angle of inclination of the long axis of the femoral neck with reference to the transcondylar plane of the distal femur is known as version.28
Figure 1: The anatomical position of the human body and different planes and axes.
Figure 2: Normal anteversion of 1515° in an adult.
If this inclination is anterior it is known as Anteversion () and if the inclination is posterior it is known as Retroversion.
Anteversion is around 30° at birth. Progressively decreases during growth and remains at 5–15° in adults. It is always more in women than in men.
 
CURVATURE AND DEVIATIONS
 
Deviations in the Spine
The spine has normal curvatures. It is curved in a forward direction (Lordosis) in the cervical and lumbar region and in a backward direction (Kyphosis) in the thoracic and sacral region. These are the normal lordotic and kyphotic curves present in the spine. When these normal curvatures get diminished or exaggerated or bending occurs in a lateral direction, deformity develops in the spine.
Kyphosis—excessive backward (posterior) curvature of the spine.
Lordosis—excessive forward (anterior) curvature of the spine.
Scoliosis—sideward (lateral) bending of the spine.
In some of the disorders, the normal curvature may get obliterated and spine may adopt a straight posture.
 
Deviations in the Foot
Normal foot has an axial relation as well as a curvature. It is placed at right angles to the ankle and has an arch on the plantar aspect. Thus, the deformities may appear as a single deviation from normal or as a combination of deviations. Accordingly they are expressed using following terminologies.
Pes planus—the normal arch of the foot is lost.
Pes plano-valgus—along with planus, the foot has deviated in an outward direction (laterally).
Pes cavus—the arch is exaggerated.
Pes cavovarus—along with exaggerated arch and the foot has deviated in an inward direction (medially).
Equinus—the foot is fixed in plantar flexion.
Calcaneus—the foot is fixed in dorsiflexion.
Equinovarus, equinocavovarus and calcaneovalgus deformities (as a result of combination of deviations) are also seen. The nomenclature itself is self-explanatory.
 
ANKYLOSIS
Ankylosis is defined as abnormal immobility and consolidation of a joint secondary to destruction ( and ).29
Figure 3: An unsound bony ankylosis of the elbow as a sequel of pyogenic arthritis.
Though the ankylosis is bony and free of pain it is considered unsound because the fusion has not occurred in a functional position of the elbow which is 70° of flexion.
Figure 4: Arthrodesis of knee joint.
 
Causes
  1. Trauma
  2. Infection
  3. Prolonged immobilization
  4. Disuse
 
Types
  1. Fibrous ankylosis: In this type of ankylosis, fibrous tissue bridges the destroyed portion of the joint. Movement is possible but is painfully restricted.
  2. Bony ankylosis: Here bone bridges the destroyed articular surfaces. The joint is completely fused and no movement is possible. The ankylosis is painless.
  3. Sound ankylosis: Bony ankylosis in functional position is known as sound ankylosis.
  4. Unsound ankylosis: Either fibrous ankylosis or bony ankylosis in deformed position is known as unsound ankylosis ().
  5. True or intra-articular ankylosis: The stiffness occurs because of changes which have taken place inside the joint resulting in damage to the articular cartilage.
  6. False or extra-articular ankylosis: The stiffness of the joint is due to the fibrosis and contracture of the soft tissues that surround the joint and not because of damage to the articular cartilage.
 
ARTHRODESIS
Surgical fusion of a joint is known as arthrodesis ().
 
Indication
A destroyed, degenerated, deformed and painful joint without function, where relief of pain and achieving stability is a prime concern, is the indication for fusion.
 
Types of Arthrodesis
  1. Intra-articular
  2. Extra-articular
  3. Combined intra- and extra-articular
 
Position of Arthrodesis
The joint is fused in a position of maximum function. This position is known as functional position of a joint. It varies from joint to joint, e.g.
 
Examples of Arthrodesis
  1. Blair's fusion of the ankle for old fracture neck of the talus with avascular necrosis (AVN).
  2. Wrist arthrodesis for AVN and nonunion of the scaphoid fracture with painful degenerative arthritis.
 
ARTHROPLASTY
Arthroplasty is a procedure by which a destroyed, degenerated, deformed, painful joint is rendered painless along with restoration of its lost movement.
 
Types
  1. Excision arthroplasty: The diseased portion is removed and a false joint is allowed to form, e.g. Girdle stone procedure for tuberculosis (TB) hip.
  2. Interposition arthroplasty: A muscle or fascia is interposed between the two articular surfaces in order to promote painless movements e.g. fascia lata interposition in elbow arthroplasty.
  3. Hemiarthroplasty: One-half of the joint is replaced. Other half is left alone e.g. Austin Moore's prosthetic replacement of head and neck of the femur in fracture neck of the femur. The acetabulum is untouched.
  4. Total joint arthroplasty: Replacement of both the articular surfaces with an artificial prosthesis, e.g. a total hip replacement, a total knee replacement.
 
ORTHOPEDIC SPLINTS
Splint is a device used to externally support and to give rest to the limb or an appendage. They are made of various materials. These days, polymers of plastic are being used in a big way to prepare various splints.
 
 
Static Splints
These splints only support and give rest to the part, e.g. cock-up splint, posterior gutter splint, etc.
 
Dynamic Splints
These splints not only give support and rest to the part but also assist and allow movement of the recovering as well as uninjured structures e.g. knuckle bender splint, dynamic wrist drop splint, etc.
 
Specific Types of Splints
 
Thomas’ Splint ()
It is a splint described by Sir Hugh Owen Thomas. It was initially used to immobilize the knee joint in tuberculosis of the knee. Hence was known as Thomas’ bed knee splint.
 
Design of the Thomas’ Splint
Figures 5A and B: Thomas’ splint. Note the convergence of the side bars, placement of the ring which is at 120° to the inner bar and for universal use, the bars are welded to the ring in the middle bisecting it into two equal halves.
Note: Originally the side bars were welded to the ring at the junction of anterior 2/3 and posterior 1/3 to accommodate the girth of the thigh. So, there were separate splints for right and left lower limb.
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Measurement of the ring: The oblique circumference at the groin is measured below the gluteal fold, crossing the ischial tuberosity to the anterosuperior iliac spine. Then 4 inches are added to this circumference.
Measurement of the length: 4–6 inches more than the length of the limb.
Application: A proper sized splint has to be used for giving desirable support. Adequate padding of the splint and taking care to avoid pressure points is a must.
Uses of Thomas’ Splint
  1. In the first-aid treatment of the fracture of the lower limbs.
  2. In children for the definitive treatment of fracture femur.
  3. In the temporary immobilization of lower limb for shorter periods, e.g. postoperative immobilization.
 
Bohler-Braun Splint ()
This splint bears the name of two people Bohler and Braun. It has two components. A lower component on which the lower limb rests, i.e. Braun splint and an upper component to which a set of 3 pulleys are attached at strategic places for different applications i.e. Bohler's modification.
Uses of Bohler-Braun splint
  1. In the definitive treatment of lower limb fractures by skeletal traction.
  2. As a temporary support and for elevation of the limb.
Figure 6: Bohler-Braun splint
Showing the lower portion (frame) on which the limb rests and to which is attached at right angles a U stirrup with a system of Pulley's.
 
TRACTIONS
The meaning of the word traction is to pull.
 
Types of Traction
  1. Skin or surface traction: The skin is used as a medium for application.
  2. Skeletal or bone traction: The bone is used as a medium for application.
 
Methods of Traction
  1. Fixed traction: In this, no weights are suspended. The traction unit is fastened to the splint at its end.
  2. Sliding or the balanced traction: In this, weights are suspended to the traction unit. These weights act as a force. One end of the cot (either foot end or head end) is raised so that the body weight acts as a counter force. Between these two forces, namely the weight suspended on one side and the body weight on the other, the fracture maintains the desirable position of reduction that is achieved.
 
Skin Traction ()
It is one of the well accepted methods of giving traction. In the past adhesive tapes were used. Because of skin irritation these are now given up. Traction units made of foam and latex rubber are readily available for use.
Application: The traction units are tied to the limbs with the help of bandages and weights are suspended (sliding traction) or a fixed traction is given on a splint. Maximum weight which can be used for skin traction is 5–7 kilograms.
Uses of skin traction
  1. Temporary immobilization and immobilization for a shorter period.
  2. Treatment of pediatric fractures, e.g. Gallows traction.
  3. Treatment of prolapsed intervertebral disk.
Figure 7: Skin traction applied to the lower limb. In this, only below knee traction is shown. When needed an above knee traction can also be applied.
32
 
Skeletal Traction
Devices used: ()
Sites of skeletal traction
  1. Calcaneum.
  2. Lower end of the tibia.
  3. Upper end of the tibia ().
  4. Lower end of the femur.
  5. Greater trochanter.
  6. Through the metacarpals.
  7. Through the olecrenon.
  8. Skull traction.
Uses of skeletal traction
  1. Immobilization for a longer period.
  2. Preoperative distraction.
  3. Definitive treatment of fracture.
Figure 8: BS—Bohler's stirrup, A—‘K’ wire, B—Steinmann pin, C—Denham's pin.
Note: Pre operative distraction is necessary to keep the fracture ends apart and prevent overriding of fragments when there is delay in definitive treatment. This makes the later reduction simple in closed reduction and fixation of fractures.
 
Skull Traction
Skull traction is given for cervical spine injury, i.e. in cases of fractures, dislocations and fracture dislocations of the cervical spine.
Devices used: Crutchfield tongs, Barton's tongs, Gardner Well's tongs, etc. ( and ).
Complications of skeletal traction
  1. Infection and osteomyelitis.
  2. Loosening and cut through.
  3. Nerve palsies (in some areas because of faulty insertion or positioning the limb after traction).
  4. Splintering of bone (unskilled insertion).
Figure 9: Skeletal traction through the upper end of the tibia using the Steinmann pin and the Bohler's stirrup.
Figure 10: Crutchfield tongs used for skull traction.
33
Figure 11: Application of skull traction.
 
OSTEOTOMY
Surgically cutting the bone under direct vision using an osteotome (an instrument which is used to cut the bone) is known as osteotomy. These days the power saw is used for the same. The procedure is indicated for correction of deformities in:
  1. Malunion of fractures, e.g. malunited distal radius fracture.
  2. Osteoarthritis, e.g. a high tibial osteotomy.
  3. Genu valgum of rickets.
  4. Osteotomies for Developmental Dysplasia of Hip (DDH).
 
OSTEOCLASIS
Manually breaking the bones (intentional) without opening the site is known as osteoclasis. This procedure is done under anesthesia for correction of deformities in:
  1. Greenstick fractures.
  2. Early phase of fracture union when the callus is soft.
 
OSTEOSYNTHESIS
The method of stabilizing fractures using implants is known as osteosynthesis. Implants act as an internal splint e.g. plates, screws and nails. Different designs of plates, e.g. LC DCP (limited-contact dynamic compression plate), LCP (locking compression plate), ‘T’ plates, ‘L’ plates, etc. nails, e.g. titanium elastic nails, ender nails, interlocking nails, proximal femoral nails, etc. screws, e.g. cortical screw, cancellous screw, malleolar screw, Herbert screw, etc. are available for osteosynthesis and are used as per indication.
 
TYPES OF ARTICULATIONS (JOINTS) IN THE HUMAN BODY
The three basic types of articulations (joints) seen in the human body are:
 
Fibrous Articulation (Joints)
 
Suturous
In this type the sutural membrane exists between the bones, e.g. in the skull. Subsequently the two bones fuse, the membrane disappears and a synostosis develops ().
 
Syndesmotic (Syndesis—Bound Together)
The bony components are held (bound) either by interosseous ligaments at the end or by interosseous membrane along its surface, e.g. inferior tibiofibular syndesmosis and radioulnar syndesmosis ().
Figure 12: Suturous articulation.
Figures 13A and B: Syndesmotic articulation.
34
 
Cartilaginous Articulation (Joints)
 
Synchondrosis (Syn—Together, Chondros—Cartilage: Meaning Joined Together with Cartilage)
Seen in a growing bone and in pediatric age group. The intervening hyaline cartilage of this articulation disappears with growth, e.g. junction of epiphysis with diaphysis ().
 
Amphiarthrosis (Amphi—On Both Sides, Arthro—Articular: Meaning Articulation on Both Sides)
In this type of articulation the ends of the bone are covered with articular cartilage and a fibrocartilagenous disk exists between them. This intervening disk binds them as well as the periosteum of the bone. Such articulation is seen in the median plane, e.g. pubic symphysis, between the two vertebral bodies in the spinal column ().
 
Synovial Articulation (Joints)
This type of articulation is seen mainly in the limbs. The articulation is known as diarthrosis and the joint is known as diarthrodial or synovial joint. In a synovial articulation, the ends of the bones are covered with articular cartilage and the whole structure is enclosed within a fibrous capsule which is continuous with the periosteum on either side. The inner surface of the capsule as well as the areas of bone and the intraarticular structures which are not covered by articular cartilage are lined by a synovial membrane. This synovial membrane secretes synovial fluid which lubricates the joint. A good range of movement exists in these joints. Hence, these joints are supported by ligaments which give additional stability.
The different types of synovial articulation are as follows:
  1. Gliding or arthrodial, e.g. intertarsal and intercarpal articulation. A gliding movement (translation) takes place in these joints. The articular surfaces are neither concave nor convex. They are flat and conducive for gliding ().
  2. Hinge or Ginglymous (Greek—means hinge), e.g. humeroulnar articulation of the elbow joint. A unidirectional movement takes place in this articulation along a transverse axis, i.e. flexion and extension ().
    Figure 14: Synchondrosis.
    Figures 15A and B: Amphiarthrosis.
    Figures 16A and B: Gliding joints.
    35
  3. Condyloid, e.g. wrist joint, temporomandibular joint. This is a shallow articulation between a condyle and an elliptical concave surface. A wide range of movement takes place in these joints except rotation in its axis ().
  4. Pivot or Trochoid (Greek—Trochos means wheel), e.g. superior radioulnar joint, atlantoaxial joint. A rotational movement takes place around a pivot in these articulations ().
  5. Saddle or Sellaris (Latin—Sella means Saddle), e.g. carpometacarpal joint of the thumb. In this articulation a wide range of movement takes place between the two articular surfaces, which are individually concavo-convex and correspond with each other ().
    Figure 17: Hinge joint.
    Figure 18: Condyloid joint.
    Figure 19: Pivot joint.
  6. Ball and socket or enarthrosis (Greek—En means In), e.g. shoulder and hip joint. A wide range of movement, unidirectional as well multidierctional; single or in combination occurs in this joint including rotation in its axis ().
  7. Combined type, e.g. knee joint and ankle joint. These joints have properties of Hinge (maximum) as well as pivot and gliding (minimum), respectively (). In the knee, after complete extension the tibia rotates externally like a pivot joint and joint gets locked. In the ankle joint, minor degrees of gliding takes place in extremes of dorsiflexion and plantar flexion. This happens because of inherent design of the articular surface.
Figure 20: Saddle joint.
Figure 21: Ball and socket joint.
Figure 22: Combined type.
36
 
GENERAL ABBREVIATIONS
#
Fracture
ABC
Aneurysmal Bone Cyst
ACL
Anterior Cruciate Ligament
AFO
Ankle Foot Orthosis
AK
Above Knee
AMP
Austin Moore Prosthesis
ANA
Antinuclear Antibody
AS
Ankylosing Spondylitis
AVN
Avascular Necrosis
BK
Below Knee
BMP
Bone Morphogenic Protein
CMC
Carpometacarpal Joint
CRP
C-Reactive Protein
CT
Computerized Tomography
CTEV
Congenital Talipes Equinovarus
CTS
Carpal Tunnel Syndrome
DCP
Dynamic Compression Plate
DDH
Developmental Dysplasia Hip
DHS
Dynamic Hip Screw
DIP
Distal Interphalangeal Joint
DRUJ
Distal Radioulnar Joint
DTR
Deep Tendon Reflexes
EMG
Electromyography
ESR
Erythrocyte Sedimentation Rate
FWB
Full Weight-Bearing
GCT
Giant Cell Tumor.
HME
Hereditary Multiple Exostosis
HNP
Herniated Nucleus Pulposus
IL
Interlocking
IM
Intramuscular
IM
Intramedullary
IP
Interphalangeal
IT
Iliotibial
IVDP
Intervertebral Disk Prolapse
LC DCP
Limited Contact Dynamic Compression Plate
LCP
Locking Compression Plate
LISS
Less Invasive Stabilization System (Acronym)
LP
Lumbar Puncture
MCL
Medial Collateral Ligament
MCP
Metacarpophalangeal (Joint)
MED
Multiple Epiphyseal Dysplasia
MIPPO
Minimally Invasive Percutaneous Plate Osteosynthesis (Acronym)
MRI
Magnetic Resonance Imaging
MTP
Metatarsophalangeal (Joint)
NSAID
Nonsteroidal Anti-inflammatory Drug
OA
Osteoarthritis
OI
Osteogenesis Imperfecta
ORIF
Open Reduction Internal Fixation
OS
Osteosarcoma
PCL
Posterior Cruciate Ligament
PET
Positron Emission Tomography
PIP
Proximal Interphalangeal (Joint)
PSA
Prostate Specific Antigen
RA
Rheumatoid Arthritis
RF
Rheumatoid Factor
ROM
Range of Motion
SCFE
Slipped Capital Femoral Epiphysis
SLE
Systemic Lupus Erythematosus
SPECT
Single Photon Emission Computed Tomography
TENS
Transcutaneous Electrical Nerve Stimulation
TFCC
Triangular Fibrocartilage Complex
THR
Total Hip Replacement
TKR
Total Knee Replacement
TMJ
Temporomandibular Joint
UBC
Unicameral Bone Cyst
VIC
Volkmann's Ischemic Contracture
 
COMMON SYNDROMES IN ORTHOPEDICS
 
Albright's Syndrome
Characterized by, polyostotic fibrous dysplasia, caféau-lait spots and precocious sexual puberty.
 
Maffucci's Syndrome
Characterized by multiple Enchondromata, soft tissue hemangiomas in the skin and the viscera with dyschondroplasia.
 
von Recklinghausen's Disease
Characterized by multiple cutaneous neurofibromata, café-au-lait spots and musculoskeletal abnormalities, e.g. scoliosis. It is autosomal dominant.37
 
Nail Patella Syndrome
Characterized by hypoplastic nails, unusually small patellae, subluxated head of the radius, pelvic horns and congenital nephropathy. It is autosomal dominant.
 
Morquio-Brailsford Disease
Characterized by dwarfism, moderate kyphosis, short neck, protuberant sternum, increased joint laxity and genu valgum. It is autosomal recessive.
 
Frolich Syndrome
Associated with slipped capital femoral epiphysis. Characterized by delayed skeletal maturity with poor secondary sexual characters and adiposity (obesity).
 
Fanconi's Syndrome
Characterized by renal rickets with glycosuria, phosphaturia and aminoaciduria. It is autosomal dominant.