Exam Preparatory Manual for Undergraduates: Orthopedics Sandip Ghosh
INDEX
A
Achondroplasia 9
Allis tissue forceps 139
Amputation 44
stump 44
Ankylosis 100
fibrous 101
treatment 101
types 100
Arthritis 21
enteropathic 21
gouty 23
psoriatic 21
rheumatoid 18, 23, 52
septic 17
Arthroscopy 48, 106
complication 106
Austin Moore prosthesis 144
B
Backache 91
Baker's cyst 105
treatment 105
Baumann's angle 127
Below-knee amputations 45
Bholer's stirrup 145
Blood pool phase 104
Bone
chisel 137
cutting forcep 138
cyst
aneurysmal 35, 36, 158
simple 35
forearm 87
gouge 140
graft 102
types 102
leg 152
lever 139
malignant tumor of 33, 38
nibbler 138
osteotomy of 141
phase 104
pliars 137
scan 104
tap 138
tumors 33, 52, 99
Brodie's abscess 96
signs 96
symptoms 96
treatment 96
C
Calcaneum, treatment of 72
Carpal tunnel syndrome 99
signs 99
symptoms 99
Catarrhal classification 121
Cauda equina compression 91
Chondrosarcoma 40
Clubfoot 2
Cobb's angle 93
Codmann's triangle 104
treatment 104
Colles fracture 75, 89
complication of 90
treatment 89
Compartment syndrome 65, 80
Crohn's disease 21
Crystal deposition disorders 22
Cubitus valgus 87, 106, 128
Cubitus varus 86, 87, 127
D
de Quervain's disease 100
etiology 100
treatment 100
Diabetic peripheral neuropathy 128
Diaphyseal aclasis, pathology of 8
Distal femoral locking plate 149
Distal humerus, shaft of 157
Drill bit 142
Drill guide 142
Dunn's osteotomy 87
Dwarfism 9
Dysplasia hip, developmental 5
E
Elbow, dislocation of 83
Endocrine disorders 28
Ewing's sarcoma 39, 40
treatment of 40
Exostosis 34
F
Familial hypophosphatemic rickets 31
Fat embolism 67
Femur
distal 146
fracture
head of 61
neck of 5658, 143, 144, 157
shaft of 134, 154
head of 60
nonunion fracture neck of 113
procedure, fracture shaft of 133
Foot drop 128
Fracture 51, 56, 63, 75, 79, 87, 152
acetabular 61
calcaneum 72
classification of 51
clavicle 75
comminuted 157
compound 53
displaced 90
distal humerus 75, 146
greenstick 55
intercondylar 85
intertrochanteric 58, 59
lateral condyle 75, 128
lateral malleoli 71
medial condyle 75, 81
metacarpals 90
metatarsal bones 74
olecranon 85
treatment 133
open 53, 69
patella, treatment of 63, 133
pathological 52
pelvis 62
classification of 62
treatment of 62
X-ray of 153
phalanges 90
proximal humerus 78, 146
X-ray of 159
radial head 84
scaphoid 90
subtrochanteric 59
supracondylar humerus 75, 80
complication of 81
talus 72
treatment of 72
tarsal bones 73
treatment of 52, 82
undisplaced 90
Frozen shoulder 101
etiology 101
treatment 101
G
Galeazzi fracture dislocation 75, 88
Ganglion 110
treatment 110
Garden's classification 57
Genu valgum 24, 25, 132
Genu varum 24, 25, 131
Giant cell tumor 37
Golfer's elbow 109
treatment 109
Gout 22
Gouty tophi 22
Granuloma, eosinophilic 36
Gustilo-Anderson classification 69
H
Harrison's sulcus 131
Hemarthrosis 47, 48
Hemiarthroplasty 60
Hereditary multiple exostosis 8
Hill sac's sign 76
Hip
postseptic sequelae of 162
tuberculosis of 115
septic arthritis of 16, 17
Housemaid's knee 105
treatment 105
Humerus
condylar fracture of 85
fracture
neck of 77
shaft of 78, 142
Hydrocephalus 12
Hypercalcemia 32
Hypochondroplasia 9
Hypophosphatemia 32
I
Injury, meniscus of 48
Intertrochanteric fracture, treatment of 58
J
Joint
elbow 79
hip 56
K
Kite's view 2
K-nail 133, 147, 151
Knee
dislocation 66
injury 47, 128
signs 47
symptoms 47
instability 48
ligament injuries 49
Kyphoscoliosis 91
L
Legg-Calve-Perthes disease 120
Limb muscles 91
M
Madelung's deformity 97
Mallet finger 103
treatment 103
Map test 99
Marble bone disease 10
Menopause 99
Metabolic disorders 28
Metastasis 52
Midfoot varus 2
Monteggia fracture dislocation 75, 88
Multiple epiphyseal dysplasia 10
Myeloma, multiple 41
Myositis ossificans 108
classification 108
treatment 108
Myxoedema 99
N
Necrosis, avascular 26, 27
O
Osteoarthritis 24
pathology of 24
Osteochondroma 34
Osteogenesis imperfecta 6, 7, 160, 161
Osteolysis 15, 126
Osteomyelitis 13
acute 13, 14
chronic 15, 16, 119, 137, 162
Osteonecrosis 26
Osteopetrosis 10, 11
Osteoporosis 28, 29, 52
Osteosarcoma 38
treatment of 39
Osteotome 141
P
Patella 63
Pauwel's classification 57
Pelvis, fracture of 62
Periosteum elevator 136
Perthes disease 120
pathophysiology of 121
treatment of 121
Phalanx 74
Plate fixation 134, 135
Postseptic sequelae 117
Prosthesis, bipolar 144
R
Radial club hand 97
treatment 98
Radial nerve palsy 107
Recurrent dislocation, treatment of 77
Reiter's disease 23
Reiter's syndrome 21
Rheumatic disorders 18, 21
Rheumatoid arthritis
pathology of 18
sign 19
treatment 19
Rickets 30, 131
adult hypophosphatemic 31
hypophosphatemic 31
renal 32
Ring fixator 55
S
Schanz pin 149, 150
Sciatica pain 91
Septic arthritis, pathology of 16
Shoulder, dislocation of 76, 77
Skeletal dysplasia 7
types of 7
Smith fracture 75
Spina bifida 11, 12
cystica 12
occulta 12
pathology of 12
Spinal disorders 91
Spondylitis, ankylosing 20, 21
Spondylolisthesis 94
pathology 94
treatment 95
types 94
Spondylosis, cervical 93
Sports injury 47, 48
Steinmann pin 145
Stress fracture 52
Subtrochanteric fracture, treatment of 60
Syme's amputation 45
T
Talipes 1
equinovarus, congenital 1
Talocalcaneal angle 3
Tardy ulnar nerve palsy 106
Tendo achillis 103
Tennis elbow 108
treatment 109
Tension band wiring 64, 71, 133
Thomas test 116
Tibia
fracture of 69
lower end of 158
Tibial pseudarthrosis, congenital 11
Total hip replacement 19
Total knee replacement 19, 25
Trendelenburg's test 113
Trigger finger 103
Trimalleolar fracture, treatment of 71
Tubular fixator 55
U
Ulcerative colitis 21
Ulnar claw hand 98, 106
Upper limb amputation, types of 43
V
Vitamin D-deficient rickets 31
Volkmann's ischemic contracture 109
treatment 110
W
Wrist drop 107, 129
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Chapter Notes

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Genetic DisordersCHAPTER 1

 
CONGENITAL TALIPES EQUINOVARUS (CTEV)
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Why are you saying that the deformity is congenital?
  1. Deformity since birth
  2. Bilateral presentation
  3. Male (usually).
What is the meaning of talipes?
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2
What are the components of CTEV?
  1. Hindfoot-equinus
  2. Midfoot varus
  3. Forefoot adduction and supination
  4. Internal tibial torsion
How do you know equinus is present?
Hindfoot equinus confirmed by:
  1. Small highly placed heel, facing towards sky
  2. Equinus crease at heel
  3. Tight TA (tendo achilles tendon).
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Clubfoot
How do you confirm midfoot varus?
  1. Varus crease at medial border of foot.
  2. Small, less prominent medial malleoli and large more prominent lateral malleoli.
  3. Small, concave medial border and large convex lateral border.
How do you confirm forefoot adduction?
By medial deviation of all the toes.
What investigation do you suggest in CTEV child?
  1. X-ray of affected foot (AP in planter flexion and lateral in stressed dorsiflexion, also called Kite's view).3
 
ANGLE MEASUREMENT
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  1. Talocalcaneal angle:
    • AP view: 35–40—normal
    • Lateral view: 30–35—normal
      In CTEV—0° or both axis are parallel to each other.
  2. Talo 1st metatarsal:
    • Normal—AP (AP view)—15–20°
    • CTEV—5°–10°
Lateral view—talotibial—normal 70–75° (in CTEV—decrease).
Tibiocalcaneal—normal—75–85° (CTEV—decrease).
  1. Photography (foot print in stamp pad)
  2. Clinical photography
How will you treat a case of CTEV?
Conservative:
  1. Manipulation + strapping (by bandage)—started immediately after birth.
  2. Denis Brown splint.
  3. Corrective POP cast above knee at 60° knee flexion.
             ↓
    Continue till 3 months of age—80% gets corrected by this method.
Surgery: After 3 months, if not corrected by conservative method:
  1. Tenotomy.
  2. Soft-tissue release—PMSTR (posteromedial soft tissue release).
In PMSTR following structures are usually cut and released:
  1. Capsular release
    • Ankle joint (posterior + medial)
    • Talotibial joint4
    • Talocalcaneal (whole of it)
    • Talonavicular (sup. + inf. + med.).
  2. Ligament release:
    Spring (talocalcaneonavicular)
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    Incision at plantar fascia.
  3. Tendon release:
    • Tendoachilles (z-plasty)
    • Tibialis posterior
    • Flexor hallucis longus
    • Flexor digitorum longus.
Master knot of Henry—tight tendinous fascia structure at the insertion of tibialis.
Posterior at the base of navicular.
If the deformity is not getting corrected by PMSTR—extensile release can be done.
Extensile release: PMSTR and release of following structures:
  1. Lateral capsule of ankle joint + calcaneocuboid joint capsule.
  2. Fibular collateral ligament.
If deformity more than 2 years (continue till 4 years):
  1. Calcaneal wedge osteotomy
  2. Dillwyn Evan's procedure
  3. Tarsectomy
  4. Metatarsectomy.
After 4 years: Extra-articular arthrodesis (Grice green arthrodesis)—continue till 10 years.
If deformity: > 10 years—Triple arthrodesis
Management of CTEV at any age:
  • JESS fixator
  • Ilizarov's external fixator (ring fixator).
 
CONGENITAL VERTICAL TALUS
How do you diagnose a case of congenital vertical talus?
Talus is vertical in this deformity which is presented by flat foot deformity, since birth.5
Investigation:
Talocalcaneal angle measurement in X-rays.
Management by:
  1. Corrective foot brace
  2. Corrective surgery—osteotomy.
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DEVELOPMENTAL DYSPLASIA HIP (DDH)
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DDH at left hip.
Old name of DDH is congenital dislocation of hip (CDH).6
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Neglected DDH in an young guy
What is the clinical features of DDH?
Clinical features: In child, dislocated femoral head on the post aspect of hip joint.
  • Immobility of affected limb
  • May be shortening present
  • Muscle wasting of gluteal and quadriceps muscle
  • Deformity of the affected limb (flexion, adduction)
             ↓
      Confirmed by—Barlow's test and Ortolani's test.
How will you investigate a case of DDH?
Birth history
Clinical features:
Investigation proper:
  1. X-ray pelvis with both hip (AP view) and affected hip + thigh (lateral view).
  2. MRI of both hip.
  3. To differentiate any other clinical condition—CRP, routine blood test is required.
How will you do treatment?
Conservative—abduction pillow/brace (Milwalky/Pavlik harness brace)— up to the age of 6 months of child.
If no correction—operative management by corrective derotation osteotomy.
 
OSTEOGENESIS IMPERFECTA
What is the incidence?
It is one of the commonest heritable bone disorders (1 in 20000).
It is a connective tissue disorder (defect in collagen type I).7
What are the commonest feature?
  • Osteopenia
  • Proneness to fracture
  • Laxity of ligaments
  • Blue sclera
  • Crumbling teeth.
What is the clinical features?
Type I (Mild)
  • Majority develop fractures a year or two later
  • Deep blue sclera
  • General joint laxity.
Type II:
  • Severe lethal—still born infant
  • Respiratory difficulties.
Type III:
  • Diagnosed at birth or more than 6 years
  • Kyphoscoliosis
  • Triangular face, blue grey sclera
  • Wormian bones in skull.
Type IV:
  • Short stature
  • Scoliosis
  • Pale blue sclera
  • Hearing affected.
How will you manage a case osteogenesis imperfecta?
  • Splinting of fracture
  • Open reduction and internal fixation with nail or plate
  • Mobilization to prevent osteoporosis
  • Multiple osteotomies of deformity correction.
 
SKELETAL DYSPLASIA
What are the different types of skeletal dysplasia?
  1. Diaphyseal aclasis
  2. Achondroplasia
  3. Hypochondroplasia
  4. Multiple epiphyseal dysplasia8
  5. Osteopetrosis
  6. Proximal focal femoral deficiency.
 
DIAPHYSEAL ACLASIS (HEREDITARY MULTIPLE EXOSTOSIS)
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What are the clinical features of diaphyseal aclasis?
  • Multiple bony lump over long bone, scapula, pelvis
  • Discovering childhood
  • Genu varum/valgum or ulnar deviation
  • Lump may cause neurogenic symptoms by pressing on nerve.
What is the pathology of diaphyseal aclasis?
It is a congenital disorder with autosomal dominant. Basically there are accumulation of multiple solitary exostosis or osteochondroma.
What is the X-ray finding of diaphyseal aclasis?
Broadening of metaphysis with pedunculated or sessile exostosis.
How do you treat the diaphyseal aclasis?
  1. Excision of osteochondromatic mass, when they will put pressure on vessel or nerve.
  2. Corrective osteotomy for genuvarum or valgum.9
 
ACHONDROPLASIA (DWARFISM)
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What are the clinical features of achondroplasia?
It is autosomal dominant disorder:
  1. Large skull, prominent forehead.
  2. Shortening of all limbs (mostly proximal segment).
  3. Too long trunk.
  4. Prominent buttock with flexed hip, knee.
  5. Bow legs or flexion deformity at elbow.
What is the X-ray finding of achondroplasia?
Short tubular bone with wide metaphysic and small pelvis.
How do you treat the achondroplasia?
  1. Corrective osteotomy for genuvarum or valgum.
  2. Limb lengthening by ilizarov fixator.
  3. Excision of mass, when they will put pressure on vessel or nerve.
 
HYPOCHONDROPLASIA
Write short notes on hypochondroplasia?
  • It is a autosomal dominant disorder and mild form of achondroplasia
  • Shortness of stature and increased lumbar lordosis is the commonest features
  • Other features of achondroplasia may be present
  • Treated by limb lengthening by ilizarov fixator.10
 
MULTIPLE EPIPHYSEAL DYSPLASIA
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Write short note on multiple epiphyseal dysplasia?
Pathology: Autosomal dominant disorder due to abnormal development and ossification of epiphyses.
Clinical features: Newborn or child with multiple deformity:
  • Growth retardation
  • Joint pain
  • Secondary osteoarthritis
  • May be severe crippled.
Investigation: X-ray—irregular/abnormal epiphyseal line.
  • Delayed appearance of epiphyses.
Treatment:
  1. Corrective osteotomy for genuvarum or valgum
  2. Reconstructive surgery for secondary OA
 
OSTEOPETROSIS (MARBLE BONE DISEASE)
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11
Write short notes on osteopetrosis?
Pathology: Autosomal dominant disorder, benign lesion.
Clinical features: Patient is asymptomatic usually, diagnosis done after fracture occur.
Pathological fracture or nerve compression may occur.
X-ray: Increased density of all bones with wide cortex and narrow medullary canal, with sclerosis.
Treatment: Symptomatic.
 
PROXIMAL FOCAL FEMORAL DEFICIENCY
Write short notes on osteopetrosis?
In this case, proximal femur is absent or cartilaginous or shortened.
Clinical features: Shortened limb, Coxa vara.
X-ray: Large gap between acetabulum and upper third femur.
Treated by limb lengthening by ilizarov fixator.
 
CONGENITAL TIBIAL PSEUDARTHROSIS
Write short notes on congenital tibial pseudarthrosis?
  • Anterior bowing of tibia in infant/child usually
  • May or not affecting fibula
  • X-ray: Gap in shaft of tibia, and looking like fracture nonunion
  • Biopsy: Histopathology shows neurofibroma or fibrous dysplasia
  • Treatment by bone grafting/ilizarov
  • Prognosis may not be good, and may lead amputation.
 
SPINA BIFIDA
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It is congenital disorder in which the two halves of the posterior vertebral arch have failed to fuse.12
Describe the pathology of spina bifida?
There are four types:
  1. Spina bifida cystica:
    • Meningocele
    • Myelomeningocele.
      Baby presents with paralysis, associated with hip dislocation, talipes, claw toes.
  2. Spina bifida occulta:
    • A midline dimple in overlying skin
    • Tuft of hair
    • Splitting of spinal cord
    • Pigmented nevus (diastematomyelia).
  3. Hydrocephalus:
    • Distal tethering of cord
    • Cause herniation of cerebellum
    • Obstruction in CSF circulation
    • Ventricles and skull enlarges.
  4. Neurological dysfunction
What investigation will you do for spina bifida?
  • X-ray whole spine (AP/lateral view)
  • Muscle charting
  • MRI brain/spine
  • NCV study.
What treatment will you offer to spina bifida?
  • Skin closure at day 1
  • Ventriculocaval shunt at 1st week
  • Stretch and strap at 1st month
  • Orthopedic surgery—according to need
  • Urogenital surgery, if needed.