Textbook of Orthopedics (Includes Clinical Examination Methods in Orthopedics) John Ebnezar, Rakesh John
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Textbook of Orthopedics
A THOUGHT FROM THE STUDENT
God created the doctor and his patient. Together they created many hospitals and medical institutions. A happy world is what it would have been, had it not been the emergencies in between.
Let this book come in ‘handy’ when it matters the most.
’ K Sarawana
Textbook of Orthopedics Includes Clinical Examination Methods in Orthopedics
Fifth Edition
EDITOR JOHN EBNEZAR (A “PADMA SHRI AWARDEE”-2016) (“DR BC ROY NATIONAL AWARDEE” -2015) HONORARY DOCTORATE IN MEDICINE-ORTHOPEDICS (2016) PHD (YOGA) MD (ORTHO-HONS) MBBS D’ORTHO DNB (ORTHO) MNAMS SPORTS MEDICINE (AUSTRALIA) IOA-INOR FELLOW (UK) CONSULTING ORTHOPEDIC, SPORTS SPECIALIST, SPINE SURGEON AND HOLISTIC ORTHOPEDIC EXPERT Geriatric Orthopedic Surgeon Formerly, Vice-President, Indian Orthopedic Association Founder President, Geriatric Orthopedic Society of India (GOSI) Founder Director, Geriatric Orthopedic Association of India (GOAI) Founder President, Orthopedic Author's Association, and All India Medical Author's Association (AIMAA) President, Neuro-Spinal Surgeons Association of India (Karnataka) Chairman, Swaasthya Health Foundation® Chairman, Karnataka Orthopedic Academy® President, Bangalore WHOlistic Academy Chairman, Rakesh Cultural Academy President, Vaidya Kala Ranga, Bengaluru, Karnataka, India Medical Superintendant, CV Raman General Hospital, Bengaluru, Karnataka, India CEO, Parimala Health Care Services (AN ISO 9001:2008 Hospital), Bengaluru, Karnataka, India Chief Orthopedic and Spine Surgeon, Dr John's Orthopedic Center, Bengaluru, Karnataka, India Chairman, Ebnezar Medical Institute, Bengaluru, Karnataka, India Author of Over 200 Books in Orthopedics Editor-in-Chief, Journal of the Geriatric Orthopedic Association of India Editor, Journal of Yoga and Physiotherapy District Chairman for Health, Rotary District 3190 Guinness World Record Achiever in Book Writing – 2010, 2nd World Record in Book Writing (103 Books) – 2012 Guinness World Record Achiever in Social Service – 2015, Guinness World Record in Social Service – 2016 Winner of 177 International, National and State Awards/Felicitations A "Karnataka Rajyotsava Awardee – 2010" (Highest Karnataka Civilian Award) Co-author Rakesh John MBBS MS (Ortho) DNB (Ortho) MNAMS MRCS (England) Diploma SICOT Senior Resident Department of Orthopedics Postgraduate Institute of Medical Education and Research Chandigarh, India
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Textbook of Orthopedics
First Edition: 1996
Second Edition: 2000
Third Edition: 2006
Fourth Edition: 2010
Fifth Edition: 2017
9789386056689
_FM5Dedicated to
My mother (Late) Sampath Kumari who taught me that life is more than self and there is more joy in giving and sharing than taking, My wife Dr Parimala, my lovely children Rakesh and Priyanka who are an epitome of love, sacrifice, encouragement and inspiration, All my teachers who made me what I am today & All my students past and present
COMMENTS
I have gone through your book. It is very good for undergraduate students in orthopedics. Please accept my heartiest congratulations.
PS Ramani
Professor Emeritus
World Renowned Spine Surgeon
Formerly, Professor and Head
Department of Neurosurgery
LTMG Medical College
Sion, Mumbai, Maharashtra, India
Presentation is excellent, language is lucid, clarity of subject matter, very nice, illustrations and diagrams very good and sufficient. The author is definitely a good teacher.
Bhaskaranand Kumar
Formerly, Professor and Head
Department of Orthopedics
Kasturba Medical College
Manipal, Karnataka, India
Let me congratulate you on publishing such useful books for the benefit of postgraduate students and orthopedicians.
As it stands today, in my opinion these books are of more value than the Campbells Operative books which contain 900+ techniques and we do not even practise even 50 or 60 of them. Also, the textbooks contain topics which have no relevance to this part of the world. Congratulations once again for the excellent efforts. I will definitely recommend your books to the post- graduates when I meet with them.
NS Laud
(A “Padmabhushan Awardee”)
Formerly, Professor and Head
Department of Orthopedics
LTMG Medical College
Sion, Mumbai, Maharashtra, India
Formerly, President
Indian Orthopedic Association
FOREWORD
I sincerely admire the efforts of Dr John Ebnezar. It is an excellent book for the undergraduate and postgraduate students (their teachers too!). I like the style of his writing.
My heartiest congratulations on his solo herculean effort.
With best wishes.
GS Kulkarni
MS MS (Ortho) FICS
Professor
Department of Orthopedics and Director
Orthopedics Hospital and Post Graduate Institute of Orthopedics
Swasthiyog Pratishthan
Miraj, Maharashtra, India
(Recognised for MS (Ortho), D (Ortho), Courses by
Shivaji University and Medical Council of India,
Delhi and Recognised for Dip NB (Ortho), MNAMS
by National Board of Examinations, Delhi
Editor, Clinical Orthopedics India
Secretary, ASAMI, India (Ilizarov Association)
Chief Research Director, Sandhata Medical Research Society
Miraj, Maharashtra, India
FOREWORD
I am very glad that Dr John Ebnezar has written an excellent book on orthopedics.
The book is extremely informative and is most up-to-date. It is very stylishly written and is neatly designed. It has so many unique features which is hitherto unprecedented in the history of textbook writing.
What makes this book stand out from the rest is that, it never provides the reader with a single dull moment and makes the reading very interesting and thought provoking. It keeps the reader engrossed and the students will find it very gripping and absorbing.
I am sure students will enjoy reading this book and will find it very useful in their preparation for the examination.
I wish him all the success.
N Ramesh
Formerly, Professor and Head
Department of Orthopedics
Bowring and Lady Curzon Hospital
Bangalore Medical College
Bengaluru, Karnataka, India
FOREWORD
Dr John Ebnezar has been my assistant and has worked with me for over two years. Knowing him it is hardly surprising that he has written a textbook of orthopedics for such is his keeness and interest in teaching the students. He enjoys teaching and is tremendously popular among the students.
The book is very comprehensive, simple and is neatly written. Never before any book on orthopedics has come out with so many innovations and this kindles and sustains the interest in the readers. A good book is one which apart from evincing interest in the readers about the subject, makes them desirous to know more and more about it. This book does that and I am sure students will enjoy reading it and the roller coaster experience it provides. The practical approach and suggestions will help the students in their preparations for the examination.
This is the first ever textbook written by an Orthopedic Surgeon from Karnataka and I am happy that it comes from my assistant. It is indeed befitting that I write a foreword for his book.
I wish him all the best.
YA Somasundara
Formerly, Senior Professor and Head
Department of Orthopedics
Bangalore Medical College
Bengaluru, Karnataka, India
PREFACE TO THE FIFTH EDITION
It is almost 2 decades when my Textbook of Orthopedics hit the market. Ever since I have been deluged with an unprecedented love, support and encouragement from teachers and students from all over the country. More than my effort, it is this universal liking that has made this book what it is today. It has broken all the conventional barriers and is galloping triumphantly into the fifth edition. With each passing year, this book has grown from strength to strength. It is both heartening and humbling to hear encomiums from senior professors to undergraduates. Postgraduate students in orthopedics find this book invaluable. In short, this book has catered to the needs of all and sundry in orthopedics. In this edition, I have made sincere attempts to live up to the expectations bestowed upon me by scores of people. I am placing the fifth edition of this book in your hands with the following changes:
 
Highlights
My book has been widely appreciated for columns like quick facts, vital facts, flowcharts, points to ponder, mnemonics, etc. and many students have told me that they just read these just before the examinations. These columns give them the gist of the entire chapters in a jiffy and it is a great boon to them. Copying is the best complement and I now see so many new books coming out in the market in orthopedics are copying this method of mine thereby stamping their approval of my beliefs and thoughts.
Section on Clinical Examination Methods in Orthopedics continues to be offered as a free supplement with this edition.
Nobody is infallible. I am grateful to all those who wrote to me pinpointing certain mistakes in the previous edition. I have corrected these and incorporated the meaningful suggestions. I will be glad to have your feedback on this fifth edition too and help me in my endeavor to maintain high standards. Hope my efforts will be well appreciated by the teachers and students community at large. I will be highly obliged if you can send me your comments, criticisms and suggestions. I will be too happy to make the changes if there are any lacunae.
John Ebnezar
(A “Padma Shri Awardee”)
(“Dr BC Roy National Awardee“)
Rakesh John
PREFACE TO THE FIRST EDITION
While I was a final year MBBS student, I fell in love with orthopedics lock stock and barrel. The subject fascinated me so much that I was drawn towards it like a magnet. I always wanted to do something to the subject I loved most. This book is a small effort on my part in this regard.
Students often questioned me during my undergraduate teaching sessions as to which book they should read for orthopedics. Whenever I suggested the standard books written for them, they said they found them too inadequate and that the bigger books were too much for them. So they were in a situation of either too little or too much. I then asked them as to what sort of book they need? They said that, they wanted a book which is comprehensive and at the same time examination oriented. I learnt that my notes were actively being circulated among the students and after each examination, students came back to me and told that they had done extraordinarily well after reading my notes. This surprised me as I had always taught them more than required. I was a firm believer of the fact that by pruning the subject one cannot do justice to it. Examination should be a part of the learning process and not vice versa. I then decided to write a book for them which was adequate, neither less nor more. Little did I realize then that I was embarking on a journey which was arduous and tumultous. I slogged for three long years to bring out this book. Hope students find my effort informative and useful.
Despite being meticulous, I am sure there will be plenty of mistakes in the book. I request the students to point them out unhesitatingly so that I can improve upon. This book will be a useful handbook for postgraduate students also.
Now about the highlights of this book:
To make the book more educative and also to present an enjoyable reading, I have tried certain innovative methods which hitherto has not been attempted in textbook writing. I am confident that it will be received well.
John Ebnezar
ACKNOWLEDGMENTS
Bringing out the fifth edition of the Textbook of Orthopedics turned out to be a marathon effort. My belief that it would be a smooth sailing considering the experience of the previous four editions went topsy-turvy. I ended working harder for this venture. A mammoth effort like this cannot be stage managed by a single person hence I would like to recall with gratitude the role played by these good samararitans in making my dream a reality.
First and foremost, I would like to offer my reverence to my beloved mother Late Smt Sampath Kumari, who unfortunately could not live to see the book getting completed. A disciplinarian and idealistic mother to the core. I owe my very existence and success to her. I thank my wife Dr Parimala, my son Rakesh, who is now a Senior Resident in the Department of Orthopedics at Postgraduate Institute of Medical Education and Research, Chandigarh, India, who also has co-authored this book, and my beautiful and lovely daughter Dr Priyanka, for the unstinted and unflappable love, warmth, encouragement and support.
I thank all my teachers who shaped my personality and career right from primary school to my postgraduation in orthopedics. I thank all the colleagues of Victoria Hospital, Bangalore Medical College, for their cooperation. I thank my artist friend Mr Linus, for creating such beautiful diagrams as desired by me. His creativity in imagining and translating my thoughts into pictures and producing the right impressions are worthy of praise. But for his skill, the book would not have been what it is today. I thankfully acknowledge with fond memories the role played by students Dr KR Raghavi, Dr Raghvendra, Dr Santosh and Dr Roopa in this endeavor of mine. I also thank my Junior Reasearch Assistant Dr Yogita in lending me a helping hand. I also thank all the staff of my hospital, for helping me.
A lot of credit should go to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Mr Tarun Duneja (Director–Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for kindly agreeing to publish this book and accomplishing the task in a splendid manner.
I thank all the teachers and students for patronizing and supporting my book. Finally, I thank God Almighty, for all the blessings and the gift of life.
INTRODUCTION
Orthopedics has come a long way since the days of Nicholas Andry, a French Physician, who is credited for coining the term, orthopedics from two words, Ortho = straight and Pedics = child in 1741.
What was a primitive branch then restricted to correcting deformities in children, has developed into a full-fledged specialty with diverse scope ranging from simple treatment, as done by traditional bonesetters to highly advanced joint, spine and hand surgeries.
The development of orthopedics as a specialty was pedestrian till 18th century. The discovery of anesthesia and aseptic surgical techniques opened-up new avenues of treatment like open reduction, debridement, etc. The discovery of X-rays by Roentgen and the introduction of the usage of plaster of Paris by Albert Mathysen in 1852 revolutionized the diagnosis and management of orthopedic disorders. Thus, orthopedics started breaking through the deadlocks of a crude branch to that of a science.
But what really set the ball rolling was the sudden surge of orthopedic cases firstly by the two World Wars and of late by the road traffic accidents which is on the rise, both in the developed and developing countries.
Polytrauma, multiple fractures and high-velocity injuries severely exposed the limitations of the conventional treatment in orthopedics, as the fracture patterns were bizarre and complicated. Thus, newer modalities of treatment like improved methods of internal fixation, the AO systems, the interlocking nail system, Ilizarov's method, etc. were introduced into orthopedic management. Suddenly, orthopedics was being considered a highly specialized branch with vast scope.
Needless to say many pioneers both at the international and national level have contributed enormously for the development of this branch to the present what is today. We salute them for their contribution. A fitting tribute to them is to carry on the good work done by them and to raise the level of this branch to such dizzy heights so that the sufferings of mankind due to orthopedic disorders are mitigated.
There is a strong notion among the students that orthopedics is all about trauma. Nothing can be farther from the truth. Though trauma contributes to a major chunk of orthopedic-related conditions yet it is not the sole contributor. Like any other system in the body, bones and joints are affected by a plethora of disease conditions ranging from congenital disorders, infections, tumors, etc. Degenerative disorders that seem to ravage the musculoskeletal system in old age complete the cup of misery. Needless to say one needs to be equipped both with knowledge and skill to gear up oneself to face the orthopedic challenges being hurled at surgeons in double quick time of late.
Through this book, I endeavor to arm my students with the all important knowledge so essential to understand and unravel the mysteries surrounding orthopedic-related conditions. Based on this knowledge, the necessary skills can be acquired through various stages of practical exposures. It always helps to know the common orthopedic terminologies, tests, surgical procedures, etc. for better and easy understanding. This is presented in the glossary. It is imperative to know about the fundamentals of bones and joints before undertaking the arduous journey of problems afflicting the musculoskeletal system. Thus basics of this systems are talked about in relevant sections. The chapters deal extensively first with the traumatic conditions and related problems, followed by non-traumatic conditions.
The tools required to acquire the all necessary skills are mentioned in the Appendix on instruments and implants. I fervently urge my students to be a stickler for basics and sophistication automatically follows. It pays to know, at the beginning itself, that the reverse is not always true.