Essential Orthopedics-Maheshwari

Fig-33.4 Treatment of scoliosis by Milwaukee brace Scoliosis and Other Spinal Deformities | 283 buckle stretches the concave side of the curve, commonly in tuberculosis where usually two or thus correcting the deformity. more vertebrae are affected. • Localiser cast: This is a body cast applied with the spine in traction. A special localiser table is A required for this. The following are the common causes of diffuse Operative methods: Operative methods comprise kyphosis: of fusion of the spine. In congenital scoliosis, simple fusion is sufficient. In idiopathic scoliosis, a) Postural: This is the commonest type, seen in the spine is fused after achieving some correction tall individuals, especially in some tall women, by stretching the spine. Stretching could be done because of their tendency to stand with a pre-operatively by traction (Cotrel traction), forward stoop. It occurs in the upper dorsal localiser cast, or halo-pelvic distraction system. It spine, and can be corrected by postural training could be achieved per-operatively by Harrington's and physiotherapy. distraction system, Dwyer's compression assembly and Luque-Hartshill systems. b) Compensatory: If there is an exaggerated lum- bar lordosis due to some disease, the thoracic I spine develops compensatory kyphosis. This is a general term used for excessive backward c) Scheurmann's disease: It is a common type. convexity of the spine. It is of two types; round or There is a gentle round kyphosis in the lower angular. thoracic spine. It is due to osteochondritis affecting the ring-epiphyses of the vertebral Round kyphosis means a gentle backward bodies. On X-rays, the vertebral bodies curvature of the spinal column. It is caused by appear wedge-shaped, narrower in front. diseases affecting a number of vertebrae (e.g., senile There may be a dull constant pain during kyphosis). Such a kyphosis may be localised to a early stages of the disease, but later, only segment of the spine, or it may be diffuse. kyphosis remains. Conservative treatment is adequate for most patients with pain as the Angular kyphosis means a sharp backward complaint. If the deformity is severe, especially prominence of the spinal column. It may be if it is compromising the activities in any way, prominence of only one spinous process because surgical intervention may be required. of the collapse of only one vertebral body: as may occur in a compression fracture of a vertebra. This is d) Ankylosing spondylitis: The disease produces called as knuckle. There may be a kyphosis localised a stiff and kyphotic spine. It begins in young to a few vertebrae, and is called as gibbus. It is seen men as low backache, which gradually spreads to affect the whole spine. Chest expansion is reduced because of the limitation of movements at the costo-vertebral joints. In a few cases, hips and shoulders are also affected. L LI I Spondylolisthesis is forward displacement of a vertebra over the one below it (Fig-33.5a). It commonly occurs between L5-S1, and between L4-L5. Occasionally, the displacement is backwards (retrolisthesis). AL Normally, forward displacement of a vertebral body is prevented primarily by the engagement of its articular processes with that of the vertebra below it. The attachments of the intervertebral disc and ligaments between vertebrae also check this displacement, but to a small extent. Thus, any defect in this ‘chec ’ mechanism leads to https://kat.cr/user/Blink99/

284 | Essential Orthopaedics (retrolisthesis). Displacement is usually not severe, and neurological disturbance is Fig-33.5 Spondylolisthesis unusual. spondylolisthesis. Accordingly, spondylolisthesis d) Pathological: This type results from a genera- has been divided into the following types: lised or localised bone disease weakening the a) Isthmic: This is the commonest type overall. articulation between the vertebrae. The lesion is in the pars interarticularis*. Three e) Traumatic: This is a very rare type, where one subtypes are recognised: vertebra slips over other following an injury. • Lytic: Fatigue fracture of the pars inter IA I articularis Clinical features: The isthmic type of spondy- • ntact but elongated pars interarticularis lolisthesis presents in adolescents and young • Acute fracture of the pars interarticularis. adults. The degenerative type occurs in old age. The defect allows the separation of the two The presenting symptom is usually backache, halves of the vertebra. The anterior half (i.e., the with or without sciatica. Symptoms become worse body with the pedicles and superior articular on standing or walking. Sometimes, there may facet) along with the whole of the spinal column be neurological symptoms in the lower limbs. above it, slips forwards over the vertebra below. In a large number of cases, the abnormality is The posterior half of the affected vertebra (i.e., symptomless, and is detected on a routine X-ray laminae and inferior articular facets), remain taken during screening for a health checkup. with the lower vertebrae (Fig-33.5b). b) Dysplastic: In this, the least common type, there On examination, there is often a visible or palpable is a congenital abnormality in the development 'step' above the sacral crest due to the forward of the vertebrae, so that one vertebra slips over displacement of the spinal column. There may be the other. increased lumbar lordosis. There may be evidence c) Degenerative: This is seen fairly commonly of stretching of the sciatic nerve, as found by the in elderly people. The posterior facet joints straight leg raising test (SLRT). becomes unstable because of osteoarthritis, and subluxate. Vertebral displacement is X-ray examination: Anterior displacement of one occasionally backwards rather than forwards vertebra over other can be seen on a lateral view of the spine (Fig-33.6). The displacement can be graded into four categories depending upon the severity of slip. Grade I spondylolisthesis means vertebral displacement up to 25 per cent of the antero-posterior width of the lower vertebral body, whereas grade IV means the complete forward displacement of the affected vertebra. An oblique * Pars interarticularis - As the name suggests, it is the part of the Fig-33.6 X-ray of the lumbar spine, lateral view, showing vertebra bridging the superior and inferior articular facets. spondylolisthesis of L4 over L5 vertebra

Fig-33.7 Scottish dog sign (seen in Scoliosis and Other Spinal Deformities | 285 oblique views of the spine) A view of the spine may show defect in the pars interarticularis. In this view, in a normal vertebra, Principles of treatment: For a mild symptomless the pars interarticularis looks like a 'scottish dog' spondylolisthesis, no treatment is required. When (Fig-33.7). If the appearance is that of a scottish dog symptoms are mild, they are adequately relieved ‘wearing a collar’, the defect is in the isthmus (pars by conservative methods, such as a brace and spinal interarticularis), and the patient has a spondylolysis exercises. When symptoms are moderately severe (a defect without slipping of the vertebra). If the or more, especially if these hamper the activity of head of the ‘scottish dog’ is separated from the the patient, an operation may be required. neck, the patient has spondylolisthesis (a defect with slip of the vertebra.) Methods of treatment: These consist of conservative and operative methods. Conservative methods consist of rest and external support to the affected segment followed by flexion exercises. The patient is advised to change his job to a physically less demanding one. Operative methods consist of decompression of the compressed nerves if any, followed by fusion of the affected segments of the spine. This is commonly achieved by fusion between the transverse processes of adjacent vertebrae (inter- transverse fusion). Use of internal fixation devices like pedicular screws and rods has helped in early mobilisation of the patient. What have we learnt? • coliosis is side ays curvature of spine, different from kyphosis and lordosis, hich are antero-posterior curves. • on-structural scoliosis is transient, hereas structural is permanent. • Treatment depends upon severity of the scoliotic curve, its location and ho it is likely to affect cosmesis and functions. https://kat.cr/user/Blink99/

3C H A P T E R Arthritis and elated iseases TOPICS • Ank losing spond litis • ther rheumatological diseases • efinitions • heumatoid arthritis DEFINITIONS AETIOPATHOLOGY Arthritis is an inflammation of a joint. It is e l : The exact aetiology is not known. characterised by pain, swelling and limitation of Following factors have been thought to play a role joint movement. The cause may be purely a local in causation of the disease: pathology such as pyogenic arthritis, or a more generalised illness such as rheumatoid arthritis. Table–3 .2: New diagnostic criteria for rheumatoid arthritis (1987) Arthralgia is a term used for pain in a joint, without any associated signs of inflammation. • Morning stiffness • Swelling of three or more specified joints CLASSIFICATION • Swelling of joint(s) in the hands and wrist From the clinical viewpoint, arthritis can be • Symmetrical swellings divided into two types: (i) monoarthritis; and • heumatoid nodule (ii) polyarthritis. Some common causes of the two • heumatoid factor positive types are given in Table–34.1. • -ray changes – erosion or unequivocal peri-articular Table–3 .1: Types of arthritis osteopenia If four or more of these are present, it is rheumatoid Monoarthritis arthritis Pyogenic arthritis Tubercular arthritis Sensitivity of these criteria 3 per cent Haemophilic arthritis Specificity of these criteria 0 per cent Secondary osteoarthritis Gout - sometimes • A genetic predisposition is strongly suspected because of certain histocompatibility markers Polyarthritis associated with it (H A-drw4/H A-D 1). Rheumatoid arthritis Rheumatic fever • Agents such as mycoplasma, clostridium and Juvenile chronic polyarthritis some viruses (EB virus) have been implicated Primary osteoarthritis in its aetiology. Seronegative spondarthritis It is now believed that rheumatoid arthritis re- RHEUMATOID ARTHRITIS sults from exposure of a genetically predisposed individual to some infectious agent. This leads Rheumatoid arthritis is a chronic non-suppurative to autoimmunity and formation of immune com- inflammation of the synovial joints diagnosed as plexes with gM antibodies in the serum. These per the criteria laid down by American Rheumatism immune complexes are deposited in the synovial Association in 1 7 (Table–34.2). membrane and initiate a self-perpetuating chronic granulomatous inflammation of the synovial membrane.

Arthritis and Related Diseases | 287 a l : Initially the synovium becomes 3. rre er ible soft tissue and bony changes: oedematous, filled with fibrin exudates and cellular The pannus ultimately destroys the articular infiltrates. There is an increase in synovial fluid. cartilage and erodes the subchondral bone. As the inflammation persists, the synovium gets The joint becomes ankylosed usually in a hypertrophied and surrounds the periphery of the deformed position (fibrous ankylosis). It may articular cartilage to form a pannus. The articular be subluxated or dislocated. cartilage loses its smooth shiny appearance. The pannus extends over the cartilage from the a e a e : In rheumatoid arthritis there periphery and burrows into the subchondral bone. is sometimes evidence of diffuse vasculitis. The With further progress of the disease, the cartilage most serious lesions occur in the arterial tree; which becomes worn off and the bone surfaces become may be mild non-necrotising arteritis, or severe and raw. The joints gets deformed, initially because fulminant arteritis akin to polyarteritis nodosa. The of severe muscle spasm associated with pain, but latter is fatal. later due to fibrosis of the capsule and other soft tissue structures. DIAGNOSIS In some cases, adhesions develop between l al ea e : t occurs between the age of 20 apposing layers of pannus, leading to fibro to 50 years. Women are affected about 3 times more ankylosis, and later bon an lo i In an advanced commonly than men. Following presentations are disease, the joint capsule gets distended by the common: hypertrophied synovium and synovial fluid, and the ligaments supporting the joint are stretched, a) An ac te etrical ol art riti : Pain and resulting in subluxation of the joint. Osteoporosis develops in the bones adjacent to the diseased joint. stiffness in multiple joints (at least four), Peri-articular tissues, notably tendons and muscles become oedematous and infiltrated with cells, and particularly in the morning, mark the beginning may rupture spontaneously. of the disease. This may be followed by frank The co r e o t e i ea e varies from patient to patient. In some, it is no more than a mild arthritis symptoms of articular inflammation. The joints which totally recovers; in others it may be a severe, chronic debilitating disease, ultimately ending affected most commonly are the metacarpo- up in deformities. A typical case has a history of spontaneous remissions and exacerbations. Some phalangeal joints, particularly that of the index of the factors known to precipitate an attack are physical exertion, psychological stress, infections finger. Other joints affected commonly are as and occasionally, trauma. given in Table–34.3. tages of rheumatoid arthritis From clinical viewpoint Table–3 .3: Joints affected in Rheumatoid arthritis rheumatoid arthritis can be divided into three stages: Common • M joints of hand • joints of fingers 1. otentiall re er ible soft tissue proliferations: In e co on • Wrists, nees, elbows, an les this stage, the disease is limited to the synovi- nco on um. There occurs synovial hypertrophy and • Hip joint effusion. No destructive changes can be seen • Temporo-mandibular joint on -rays. • Atlanto-axial joint 2. ontrollable b t irre er ible soft tissue • Facet joints of cervical spine destruction and early cartilage erosions: -rays shows a reduction in the joint space, b) Other : The onset may be with fever, the cause of but outline of the articular surfaces is which cannot be established (PUO), especially maintained. in children. Sometimes, visceral manifestations of the disease such as pneumonitis, rheumatoid nodules etc. may antedate the joint complaints. ea a one finds swollen boggy joints as a result of intra-articular effusion, synovial hypertrophy and oedema of the peri- articular structures. The joints may be deformed (Table–34.4). https://kat.cr/user/Blink99/

288 | Essential Orthopaedics Table–3 . : Deformities in Rheumatoid arthritis Table–3 . : Extra-articular manifestations of Rheumatoid arthritis an • lnar drift of the hand Vasculitis • Digital arteritis lbo • Boutonniere deformity • aynaud s phenomenon Knee e atoi • Fever, s in lesions, chronic leg ulcers Ankle • Swan nec deformity no le • eripheral neuritis (mononeuritis Foot • Flexion deformity • arly - flexion deformity ero iti multiplex) • ecrotising arteritis involving coronary, Late - triple* subluxation t er mesentric or renal vessels • quinus deformity • Commonest site - olecranon • Hallux valgus, Hammer toe, etc. • Other sites - dorsal surface of * Flexion, posterior subluxation and external rotation. forearm, tendoachilles Joints of the hand show typical deformities as • ung and pleura - pleurisy, shown in Fig-34.1. There may be severe muscle parenchymatous nodules, spasm. Range of motion of the joints may be Caplan s syndrome, limited. In later stages, the joints may be subluxated Honey comb lung or dislocated. There may be fever, rash and signs suggestive of systemic vasculitis. The rash in • Heart - cardiomyopathy, pericarditis rheumatoid arthritis is typically non-pruritic and • ye - iridocyclitis maculo-papular on the face, trunk and extremities. • ervous system - peripheral neuritis, carpal tunnel syndrome • Anaemia • Felty s syndrome • Sjogren s syndrome • Amyloidosis • uxta-articular rarefaction • Soft tissue shadow at the level of the joint because of joint effusion or synovial hypertrophy • Deformities of the hand and fingers 2) l : It shows the following changes: • levated S • ow haemoglobin value • e atoi actor : This is an auto antibody directed against the Fc fragment of immunoglobulin G (IgG). RF can belong to –3 .1 e e ea a a a la a e a ea a : Although, rheumatoid arthritis is primarily a chronic polyarthritis, extra-articular manifestations are very common, and sometimes govern the prognosis of a case. These are given in Table–34.5. In estigations Following investigations are useful: –3 .2 a b a e 1) a l al e a a : This consists of a a la a e a -rays of both hands and of the affected joints. Following features may be present (Fig-34.2): • educed joint space • rosion of articular margins • Subchondral cysts

Arthritis and Related Diseases | 289 any class of immunoglobulins i.e., IgG-RF, TREATMENT gM- F, gA- F, or g - F, but commonly done tests detect only the gM type of F. t Princi le ea e : Aims of treatment are as can be detected in the serum of the patient by follows: the following tests: a) n ction o re i ion an it aintenance: • Latex fixation test: This is an agglutination Disease activity is brought under control by test where the antibodies are coated to latex particles. ositivity in titres more than 1/20 drugs. b) re er ation o oint nction and re ention o is significant. Sensitivity is 0 per cent. • Rose-Waaler test: In this agglutination e or itie during the activity of the disease and test ee re bloo cell are used as a thereafter, by physiotherapy and splinting. carrier. Sensitivity is 0 per cent. c) e air o oint a a e which already exists, if it will relieve pain or facilitate functions. It sometimes requires surgical intervention e.g., • All patients with positive rheumatoid synovectomy. factor do not have rheumatoid arthritis. Conversely, all patients with rheumatoid e ea e : Above mentioned goals can arthritis do not have a positive rheumatoid be achieved by medical and orthopaedic treatment. factor. It is the constellation of signs and Medical treatment: Medical treatment essentially symptoms, titre in which the RF is positive, consists of anti-rheumatic drugs. These consist presence or absence of other positive tests, of: (i) non-steroidal anti-inflammatory drugs ( SA Ds): (ii) disease modifying anti-rheumatic etc, which determine whether the patient drugs (DMA Ds): and (iii) steroids. For details please refer to a Medicine textboo . has rheumatoid arthritis or not. Orthopaedic treatment: Orthopaedic treatment • al l e a a —See Table–22.2 on aims at prevention of deformity, preservation of page 177. joint functions and rehabilitation. It falls essentially into non-operative and operative methods of • al b : This can be obtained treatment. arthroscopically or by open methods. DIFFERENTIAL DIAGNOSIS Rheumatoid arthritis must be differentiated from Non-Operative Methods: These consist of the the following diseases: following: a) e l e e a : In SLE, • iot era : This consists of: (i) splintage of the joints in proper position during the the joint involvement is not symmetrical; nor acute phase: (ii) heat therapy – wax bath, hot water fomentation for symptomatic relief; (iii) are ankylosis and erosions common. Absence of joint mobilisation exercises to maintain joint functions; and (iv) muscle building exercises to anti-nuclear antibody factor (ANF) is in favour gain strength. of rheumatoid arthritis, although its presence • cc ational t era : Role of occupational therapy is to help the patient cope with his occupational does not confirm S . t is present in 25 per requirements in the most comfortable way, by modifying them. cent cases of rheumatoid arthritis, though in • e abilitation: Role of rehabilitation is to improve low titres. the functions of the patient with the help of devices like braces, walking aids etc. b) e a : This occurs in older patients. There is complete lack of the systemic features of rheumatoid arthritis such as fever, weight loss, fatigue etc. Distal inter-phalangeal joints are often involved. Duration of morning stiffness, joint swelling, ESR etc., are less compared to rheumatoid arthritis. Operative Methods: Surgical treatment of rheumatoid arthritis can be divided into: c) aa a : Characteristic s in (i) preventive surgery; (ii) palliative surgery; (iii) reconstructive surgery; and (iv) salvage and nail lesions may be present. Distal surgery. inter-phalangeal joints are usually involved. Rheumatoid factor is negative. https://kat.cr/user/Blink99/

290 | Essential Orthopaedics • Na al e ea e: It is well known • re enti e r er : This is done to prevent that rheumatoid arthritis is a disease with damage to the joint and nearby tendons by the inflamed, hypertrophied synovium. It consists variable natural history. It may be fulminant of synovectomy of the wrist, nee and M joints. i.e., damaging joints quic ly and producing • alliati e r er : This is done in situations where general condition of the patient does not deformities in spite of best care, or more usually permit corrective surgery, but some relief can be provided by limited surgical procedures such as a disease with persistent course punctuated with bone block operations, tendon lengthening etc. remissions and exacerbations. It is not possible • econ tr cti e r er : This has revolutionised the rehabilitation of patients with deformed to predict the precise nature of the disease in a and painful joints. It includes tendon transfers, interposition arthroplasties and total joint particular patient. replacement. With improvement in surgical techniques and better design of artificial joints, • e a a e a e : Women of child bearing age it is now possible to replace practically any joint of the body. The joints where total replacement is with predominant upper extremity involvement most popular are the hip, knee and metacarpo- phalangeal joints. have a progressively severe disease. Males, la ea e : Management depends upon the with sparing of upper extremity, where onset of stage of the disease, as discussed below: disease is under the age of 30 years, show less 1. otentiall re er ible soft tissue proliferation, where drug therapy constitutes the mainstay severe disease. of treatment. •T e e : It is generally believed that 2. ontrollable but irreversible soft tissue destruction and early cartilage erosion, where insidous onset disease progresses to have more a combination of drug therapy and orthopaedic treatment is required. severe disease. 3. A ance ta e o joint destruction with • ae a: Anaemia is associated with progressive subluxation or dislocation, where primarily surgical treatment is necessary. Drugs alone rheumatoid arthritis. Also, it is believed that are of no use at this stage. unresponsiveness of anaemia to oral iron Plan of treatment in these three stages is as given in Table–34. . therapy is a bad prognostic indicater. rognosis Following factors decide the outcome •a ea e e : High levels are of a patient diagnosed to have rheumatoid associated with more erosive arthritis. arthritis. • e a a : Apositive rheumatoid factor is associated with more progressive disease. High titres of rheumatoid factor, appearing early in the disease, carry a bad prognosis. • a l al e : Presence of erosions within 2 years of onset of the disease, is a bad prognostic indicator. • a l al a e : A case with synovial proliferation, with increased number of synovial cells with D antigen, carries bad prognosis. ANKYLOSING SPONDYLITIS ( arie strumpell disease) Ankylosing spondylitis is a chronic disease characterised by a progressive inflammatory Table–3 . : Staged therapy in rheumatoid arthritis ta e e ical r ical iot era Stage DMA Ds* Synovectomy oint mobilisation Stage SA Ds** Stage SA Ds Soft tissue repair Splints Arthroplasty DMA Ds Arthroplasty (joint replacement) Splints and SA Ds Arthrodesis walking aids * Disease modifying anti-rheumatic drugs ** on steroidal anti-inflammatory drugs

stiffening of the joints, with a predilection for the Arthritis and Related Diseases | 291 joints of the axial skeleton, especially the sacro- iliac joints. in the heel, pubic symphysis, manubrium sterni and costo-sternal joints. In later stages, AETIOPATHOLOGY kyphotic deformity of spine and deformity of the hips may be prominent features. The exact aetiology is not known. A strong b) n al re entation : Patient may occasionally association has been found between a genetic present with involvement of peripheral joints mar er—H A-B27 and this disease. Whereas, the such as the shoulders, hips and knees. Smaller incidence of H A-B27 is less than 1 per cent in joints are rarely involved. Sometimes, a patient general population, it is present in more than 5 with ankylosing spondylitis may present with per cent of patients with ankylosing spondylitis. chronic inflammatory bowel disease; the joint symptoms follow. a l : Sacro-iliac joints are usually the fir t to get involved; followed by the spine from the e a a it is found that the patient lumbar region upwards. The hip, the knee and walks with a straight stiff back. There may be a the manubrio-sternal joints are also involved diffuse kyphosis. Following clinical signs may be frequently. nitially synovitis occurs; followed present: later, by cartilage destruction and bony erosion. • ti ine: There may be a loss of lumbar lordosis. Resultant fibrosis ultimately leads to fibrous, followed by bony ankylosis. Ossification also Lumbar spine flexion may be limited. occurs in the anterior longitudinal ligament and • e t or etectin acro iliac in ol e ent: Following other ligaments of the spine. After bony fusion occurs, the pain may subside, leaving the spine tests may be positive in a case with sacro-iliac permanently stiff (burnt out disease). joint involvement: CLINICAL FEATURES • Tenderness, localised to the posterior superior iliac spine or deep in the gluteal e e la : This is a disease of young region. adults, more common in males (M : F 10 : 1). The following clinical presentations may be seen: • Sacro-iliac compression: Direct side to side a) la ic re entation: The patient is a young compression of the pelvis may cause pain at the sacro-iliac joints. adult 15-30 years old male, presenting with a gradual onset of pain and stiffness of the lower • aenslen s test: The hip and the nee joints back. Initially, the stiffness may be noticed of the opposite side are flexed to fix the only after a period of rest, and improves with pelvis, and the hip joint of the side under movement. Pain tends to be worst at night or test is hyperextended over the edge of the early morning, awakening the patient from table. This will exert a rotational strain over sleep. He gets better only after he walks about the sacro-iliac joint and give rise to pain or does some exercises. There may be pain (Fig-34.3a). • Straight leg raising test: The patient is as ed to lift the leg up with the knee extended. –3 .3 Te a la ae https://kat.cr/user/Blink99/

292 | Essential Orthopaedics cage. This can be detected clinically by diminished chest expansion, or by performing This will cause pain at the affected sacro- pulmonary function tests (PFT). There may iliac joint. also occur bilateral apical lobe fibrosis with cavitation, which remarkably simulates • Pump-handle test: With the patient lying tuberculosis on -ray. supine, the examiner flexes his hip and knee completely, and forces the affected knee across e) te ic: Generalised osteoporosis occurs the chest, so as to bring it close to the opposite commonly. Occasionally, a patient may develop shoulder (Fig-34.3b). This will cause pain on amyloidosis. the affected side. INVESTIGATIONS • e t or cer ical ine in ol e ent: In advanced stages, the cervical spine gets completely stiff. Radiological e a a (Fig-34.4): n a suspected The Fle che test may detect an early involvement case, -rays of the pelvis (A ), and dorso-lumbar of the cervical spine. spine (A and lateral) are required. Oblique views of sacro-iliac joints may be required in early stages • Fle che test: The patient stands with his heel to appreciate their involvement. Following changes and back against the wall and tries to touch may be seen on -ray of the pelvis: the wall with the back of his head without raising the chin. Inability to touch the head to • Haziness of the sacro-iliac joints the wall suggests cervical spine involvement. • rregular subchondral erosions in S joints • oracic ine in ol e ent: Maximum chest (a) (b) expansion, from full expiration to full inspiration is measured at the level of the –3 . a ae a l l. nipples. A chest expansion less than 5 cm aa indicates involvement of the costo-vertebral a e el e b la e al joints. e le e b a e l ba e a e al a a la a e a : In addition to articular symptoms, a patient with ankylosing al a el a e spondylitis may have the following extra-articular manifestations: • Sclerosis of the articulating surfaces of S joints • Widening of the sacro-iliac joint space a) c lar: About 25 per cent patients with • Bony an ylosis of the sacro-iliac joints ankylosing spondylitis develop at least one • Calcification of the sacro-iliac ligament and attack of acute iritis sometimes during the natural history of the disease. Many patients sacro-tuberous ligaments suffer from recurrent episodes, which may • vidence of enthesopathy – calcification at result in scarring and depigmentation of the iris. the attachment of the muscles, tendons and ligaments, particularly around the pelvis and b) ar io a c lar: Patients with ankylosing around the heel. spondylitis, especially those with a long standing illness, develop cardiovascular -ray of the lumbar spine may show the following: manifestations in the form of aortic incompetence, cardiomegaly, conduction • arin of vertebrae: The normal anterior defects, pericarditis etc. concavity of the vertebral body is lost because c) e rolo ical: Patients may develop spontaneous dislocation and subluxation of the atlanto-axial joint or fractures of the cervical spine with trivial trauma, and may present with signs and symptoms of spinal cord compression. d) l onar : Involvement of the costo-vertebral joints lead to painless restriction of the thoracic

Table–3 . Differential diagnosis of Ankylosing spondylitis Arthritis and Related Diseases | 293 Disease linical n e ti ation e Occurs at any age or sex Signs of TB spine on -rays TB spine Localised tenderness present Primary lesion in the chest Cold abscess present l oro i Constitutional symptoms present Posterior longitudinal ligament calcified, seen Family or past history of TB present on -rays nterosseous membrane calcification seen on Any age or sex Dental mottling present -rays Chest expansion normal Serum and urine fluoride studies – high levels aa on-specific, -rays normal bo acral train Localised tenderness present ESR normal SLRT positive No radiological changes i c rola e ESR normal Seen in elderly patients Osteophytes present teoart riti ESR normal ea e Any age affected enerally unilateral ytic lesions with sclerosis seen on -ray, o oint Cold abscess may be seen on CT, S high Cold abscess present teiti con en an Bilateral, non-specific ESR normal iliac sclerosis of ilium, Sclerosis of subchondral bone on the illiac Seen in parous women side of the SI joint only of calcification of the anterior longitudinal e e a : These are the following: • S : elevated ligament. • Hb: mild anaemia • H A-B27: positive (to be tested in doubtful cases) • oss of the lumbar lordosis. te ). • Bridging ‘osteophytes’ ( n e o DIFFERENTIAL DIAGNOSIS • a boo ine appearance. In early stages, ankylosing spondylitis may be confused with other disorders, as given in n the peripheral joints, -ray changes are similar to Table-34.7. those seen in rheumatoid arthritis, except that there is formation of large osteophytes and peri-articular calcification. Bony ankylosis occurs commonly. OTHER RHEUMATOLOGICAL DISEASES Disturbed purine metabolism leading to excessive accumulation of uric acid in the blood — an inherited disorder; or impaired excretion of uric acid by the idneys. The result is accumulation of o i bi rate crystals in some soft tissues. Tissues of predilection are cartilage, tendon, bursa atient, usually beyond 40 years of age, presents as (i) arthritis – M joint of the big toe being a a o rite ite onset is acute, pain is severe; (ii) bursitis – commonly of the olecranon bursa; or (iii) tophi formation deposit of uric acid salt in the soft tissue Confirmation of diagnosis – urate crystals in the aspirate from a joint or bursa, high serum uric acid levels Treatment – SA Ds, uricosuric drugs, uric acid inhibitors. e o i ro o ate crystal deposition Symptoms like those of gout eni c calcification may be seen on -rays of the nee Treatment - SA Ds. https://kat.cr/user/Blink99/

294 | Essential Orthopaedics aa a resentation is li e rheumatoid arthritis – a polyarthritis, i tal oint of hands involved (unlike rheumatoid arthritis, where these are spared) Classic s in lesions help in diagnosis Treatment is by steroids. la a An inherited defect in enzyme system involved in metabolism of phenylalanine and tyrosine. As a result homogentisic acid is excreted in patient s urine. As a long term result, it accumulates in the cartilage and other connecting tissues. oint symptoms occur after 40 years of age. Spine and shoulder joint are commonly affected. There may be evidence of pigment deposit in the sclera. Homogentisic acid is present in the urine, and results in the colour of the urine turning dark brown on standing (due to oxidation of homogentisic acid on exposure to air) -ray – i c ace calcification peri-articular calcification in large joints Treatment same as that for osteoarthritis. ae l a Occurs due to a number of bleeding disorders Occurs in males Joints affected commonly are knee, elbow and ankle May present as acute or chronic haemarthrosis. There are other manifestations of bleeding disorders -ray – non-specific signs including bone resorption, cyst formation, osteoporosis, i enin o intercon lar notc in t e nee Treatment – rest during acute stage along with factor supplementation or other deficient factor replacement. In the chronic stage, physiotherapy, bracing etc. are required. Deformities may be corrected by conservative or operative methods. e aa a These are changes seen in a neuropathic joint, where repeated strain (Charcot s joint) on a joint due to loss of sensations leads to severe degeneration Clinically, the joint manifests as painless effusion, deformity or instability The -ray changes are those of severe osteoarthritis but without much clinical findings like pain, muscle spasm etc. Treatment is difficult. Bracing is usually advised for some joints. Fusion of the joint may be required. TREATMENT preparations are preferred; (ii) iot era this o ecific t era is available. Aim is to control consists of proper posture guidance, heat therapy the pain and maintain maximum degree of joint and mobilisation exercises; (iii) ra iot era – in mobility. This can readily be achieved by life long some resistant cases; and (iv) o a t era pursuit of a structured exercise programme. In some cases surgical intervention is required. ea e e : Role of operative treatment is ea e e : These consist of: (i) in correction of kyphotic deformities of the spine by r — SA Ds are given for pain relief; ndo- spinal osteotomy, and joint replacement for cases methacin is effective in most cases; long acting with hip or knee joint ankylosis. What have we learnt? • There are t o types of arthritis in ammatory and degenerative. • heumatoid arthritis is a chronic polyarthritis of in ammatory nature, typically affect- ing peripheral joints. • Orthopaedic management of rheumatoid arthritis is aimed at prevention of deformity, correction of deformity and joint replacement. • Ankylosing spondylitis occurs in young men. Treatment is aimed at physiotherapy.

35C H A P T E R egenerati e isorders TOPICS • Lumbar spond losis • steoarthritis • er ical spond losis OSTEOARTHRITIS (Osteoarthrosis) previous disease producing a damaged articular surface; (iv) internal derangement of the knee, Osteoarthritis (OA) is a degenerative joint disease. such as a loose body; (v) mal-alignment (bow Aetiology is multifactorial, and still not understood. legs etc.); and (vi) obesity and excessive weight. Commonly it is thought to be wear and tear of joints as one ages. Two types of OA are recognised – PATHOLOGY primary and secondary. Osteoarthritis is a degenerative condition primarily affecting the articular cartilage. The first change • Primary OA: This occurs in a joint e no o. It occurs observed is an increase in water content and depletion of the proteoglycans from the cartilage in old age, mainly in the weight bearing joints matrix. Repeated weight bearing on such a cartilage (knee and hip). In a generalised variety, the leads to its fibrillation The cartilage gets abraded trapezio-metacarpal joint of the thumb and the by the grinding mechanism at work at the points distal inter-phalangeal joints of the fingers are of contact between the apposing articular surfaces, also affected. Primary OA is commoner than until eventually the underlying bone is exposed. secondary OA. With further ‘rubbing’, the subchondral bone becomes hard and glossy (eb rnate Meanwhile, • Secondary OA: In this type, there is an underlying the bone at the margins of the joint hypertrophies to form a rim of projecting spurs known as o teo te primary disease of the joint which leads to A similar mechanism results in the formation of degeneration of the joint, often many years later. It may occur at any age after adolescence, bc on ral cysts and sclerosis. and occurs commonly at the hip (Table–35.1). Predisposing factors are: (i) congenital mal- The loose flakes of cartilage incite no ial development of a joint; (ii) irregularity of in a ation and thickening of the capsule, leading the joint surfaces from previous trauma; (iii) to deformity and stiffness of the joint. Often one compartment of a joint is affected more than the Table–3 .1: Causes of secondary OA of the hip other. For example, in the knee joint, the medial compartment is affected more than the lateral, A a c lar necro i leading to a varus deformity (genu varum). • diopathic • ost-traumatic e.g., fracture of femoral nec CLINICAL FEATURES • Alcoholism • ost-partum osteonecrosis The disease occurs in elderly people, mostly in • Chronic liver failure the major joints of the lower limb, frequently • atient on steroids bilaterally. There is a geographical variation in the • atient on dialysis joints involved, depending probably upon the daily • Sic le cell anaemia o a ara on enital i location o i l e tic art riti o t e i al nite ract re ract re o t e acetab l https://kat.cr/user/Blink99/

296 | Essential Orthopaedics INVESTIGATIONS activities of a population. The hip joint is commonly Radiolo al e a a : The diagnosis of affected in a population with western living habits, osteoarthritis is mainly radiological (Fig-35.1). The while the knee is involved more commonly in a following are some of the radiological features: population with Asian living habits i.e., the habit of squatting and sitting cross legged. • arrowing of joint space, often limited to a part of the joint e.g., may be limited to medial Pain is the earlie t symptom. It occurs intermittently compartment of tibio-femoral joint of the knee. in the beginning, but becomes constant over months or years. Initially, it is dull pain and comes • Subchondral sclerosis – dense bone under the on starting an activity after a period of rest; but later articular surface it becomes worse and cramp-like, and comes after activity. A coarse cre it may be complained of by • Subchondral cysts some patients. Swelling of the joint is usually a late • Osteophyte formation feature, and is due to the effusion caused by inflam- • oose bodies mation of the synovial tissues. ti ne is initially • Deformity of the joint due to pain and muscle spasm; but later, capsular contracture and incongruity of the joint surface e e a are made primarily to detect contribute to it. Other symptoms are: a feeling of an underlying cause. These consist of the following: 'instability' of the joint, and 'locking' resulting from loose bodies and frayed menisci. • Serological tests and S to rule out rheumatoid arthritis EXAMINATION • Serum uric acid to rule out gout Following findings may be present: • Arthroscopy, if a loose body or frayed meniscus • Tenderness on the joint line is suspected • Crepitus on moving the joint • rregular and enlarged-loo ing joint due to TREATMENT formation of peripheral osteophytes le ea e : Once the disease starts, it • Deformity – varus of the nee, flexion-adduction- progresses gradually, and there is no way to stop it. Hence efforts are directed, wherever possible, external rotation of the hip to the following: • ffusion – rare and transient a) To ela t e occ rrence of the disease, if the • Terminal limitation of joint movement • Subluxation detected on ligament testing disease has not begun yet. • Wasting of quadriceps femoris muscle b) To tall ro re of the disease and relieve 3 .1 a e ee a a e al e - symptoms, if the disease is in early stages. ee ea e ee c) To re abilitate the patient, with or without e ee a e e e al surgery, if his disabilities can be partially or a –a completely alleviated. e ea e : To achieve the above objectives, the following therapeutic measures may be undertaken: a) r : Analgesics are used mainly to suppress pain. A trial of different drugs is carried out to find a suitable drug for a particular patient. ong-acting formulations are preferred. b) on ro rotecti e a ent : Agents such as Glucosamine and Chondroitin sulphate have been introduced, claiming to be the agents which result in repair of the damaged cartilage. Their role as disease modifying agents has yet not been established, but these could be tried in some early cases.

Degenerative Disorders | 297 c) i co le entation: Sodium Hylarunon has • Joint replacement: For cases crippled been introduced. t is injected in the joint 3-5 with advanced damage to the joint, total times at weekly interval. It is supposed to im- joint replacement operation (Fig-35.2b) has prove cartilage functions, and is claimed to be provided remarkable rehabilitation. These chondroprotective. are now commonly performed for the hip and knee. An artificial joint serves for about d) orti e t era : This is a useful and harmless 10-15 years. method of treatment and often gives gratifying results. It consists of the following: • Joint debridement: This operation is not • ei t re ction in an obese patient. so popular now. In this, the affected joint • A oi ance o tre and strain to the affected is opened, degenerated cartilage joint in day-to-day activities. For example, smoothened, and osteophytes and the a patient with OA of the knee is advised hypertrophied synovium excised. The to avoid standing or running whenever results are unpredictable. possible. Sitting cross legged and squatting is harmful for OA of the knee. • Arthroscopic procedures: Arthroscopic • ocal eat provides relief of pain and stiffness. removal of loose bodies, degenerated menis- • erci e for building up the muscles cal tears and other such procedures have controlling the joint help in providing become popular because of their less inva- stability to the joint. sive nature. In arthroscopic chondroplasty, • The local application of co nter irritant the degenerated, fibrillated cartilage is and liniments sometimes provide dramatic excised using a power-driven shaver under relief. arthroscopic vision. Results are unpredict- able. e) r ical treat ent: In selected cases, surgery can provide significant relief. Following CERVICAL SPONDYLOSIS are some of the surgical procedures performed for OA: This is a degenerative condition of the cervical • Osteotomy: Osteotomy near a joint spine found almost universally in persons over 50 has been known to bring about relief in years of age. It occurs early in persons pursuing symptoms, especially in arthritic joints with 'white collar jobs' or those susceptible to neck deformities. A high tibial osteotomy for OA strain because of keeping the neck constantly in of the nee with genu varum (Fig-35.2a), one position while reading, writing etc. and inter-trochanteric osteotomy for OA of the hip have been shown to be useful for PATHOLOGY pain relief. The pathology begins in the intervertebral discs. Degeneration of disc results in reduction of disc space and peripheral osteophyte formation. The posterior intervertebral joints get secondarily involved and generate pain in the neck. The osteophytes impinging on the nerve roots give rise to radicular pain in the upper limb. xceptionally, the osteophytes may press on the spinal cord, giving rise to signs of cord compression. Cervical spondylosis occurs most commonly in the lowest three cervical intervertebral joints (the commonest is at C5-C6). CLINICAL FEATURES Complaints are often vague. Following are the common presentations: (a) High tibial osteotomy (b) Total knee replacement •a a e : This is the commonest . 3 .2 al ea e ea ee presenting symptom, initially intermittent but https://kat.cr/user/Blink99/

298 | Essential Orthopaedics later persistent. Occipital headache may occur • arrowing of the intervertebral foramen in cases if the upper-half of the cervical spine is affected. presenting with radicular symptoms, may be best seen on oblique views. • aa a : Patient may present with pain DIFFERENTIAL DIAGNOSIS radiating to the shoulder or downwards on the The diseases to be considered in differential outer aspect of the forearm and hand. There diagnosis of cervical spondylosis are: (i) other causes of neck pain such as infection, tumours may be arae t e ia in the region of a nerve and cervical disc prolapse; and (ii) other causes of upper limb pain like Pancoast tumour, cervical rib, root, commonly over the base of the thumb spinal cord tumours, carpal tunnel syndrome etc. (along the C6 nerve root). Muscle weakness is TREATMENT uncommon. le ea e : The symptoms of cervical • e : Patient may present with an spondylosis undergo spontaneous remissions and episode of giddiness because of vertebro-basilar exacerbations. Treatment is aimed at assisting the syndrome. natural resolution of the temporarily inflamed soft tissues. During the period of remission, the EXAMINATION prevention of any further attacks is of utmost importance, and is done by advising the patient There is loss of normal cervical lordosis and regarding the following: limitation in neck movements. There may be tenderness over the lower cervical spine or in the a) ro er nec o t re: Patient must avoid situations muscles of the para-vertebral region (myalgia). where he has to keep his neck in one position The upper limb may have signs suggestive of for a long time. Only a thin pillow should be nerve root compression – usually that of C6 root used at night. involvement. Motor weakness is uncommon. The lower limbs must be examined for signs of early b) ec cle e erci e : These help in improving cord compression (e.g. a positive Babinski reflex the neck posture. etc.). During an episode of acute exacerbation, the RADIOLOGICAL FINDINGS following treatment is required: X-rays of the cervical spine (AP and lateral) are • Analgesics sufficient in most cases. Following radiological • Hot fomentation features may be present (Fig-35.3): • est to the nec in a cervical collar • Traction to the nec if there is stiffness • arrowing of intervertebral disc spaces (most • Anti-emetics, if there is giddiness commonly between C5-C6). In an exceptional case, where the spinal cord • Osteophytes at the vertebral margins, anteriorly is compressed by osteophytes, surgical decom- and posteriorly. pression may be necessary. 3 .3 a e e al e a e al e LUMBAR SPONDYLOSIS e al l This is a degenerative disorder of the lumbar spine characterised clinically by an insidious onset of e el 5 6 e eb ae pain and stiffness and radiologically by osteophyte formation. CAUSE Bad posture and chronic back strain is the commonest cause. Other causes are, previous injury to the spine, previous disease of the spine, birth defects and old intervertebral disc prolapse.

Degenerative Disorders | 299 PATHOLOGY 3. a e l b a al e a e al e Primarily, degeneration begins in the intervertebral l ba l joints. This is followed by a reduction in the disc space and marginal osteophyte formation. De- ee e ae e e generative changes develop in the posterior facet joints. Osteophytes around the intervertebral fora- • arrowing of joint space of the facet joints men may encroach upon the nerve root canal, and • Subluxation of one vertebra over another thus interfere with the functioning of the emerging nerve. TREATMENT DIAGNOSIS le ea e : i e cervical spondylosis, lumbar spondylosis also undergoes spontaneous l al ea e : Symptoms begin as low remissions and exacerbations. Treatment is backache, initially worst during activity, but essentially similar to cervical spondylosis. In later present almost all the time. There may be the acute stage, bed rest, hot fomentation and a feeling of ‘a catch’ while getting up from a analgesics are advised. As the symptoms subside, sitting position, which improves as one walks a spinal exercises are advised. In some resistant few steps. Pain may radiate down the limb up cases, a lumbar corset may have to be used at all to the calf (sciatica) because of irritation of one times. Spinal fusion may occasionally be necessary. of the nerve root. There may be complaints of transient numbness and paraesthesia in the dermatome of a nerve root, commonly on the lateral side of leg or foot ( 5, S1 roots) respectively. EXAMINATION The spinal movements are limited terminally, but there is little muscle spasm. The straight leg raising test (S T) may be positive if the nerve root compression is present. RADIOLOGICAL FINDINGS Good AP and lateral views of the lumbo-sacral spine (Fig-35.4) should be done after preparing the bowel with a mild laxative and gas adsorbent like charcoal tablets. It is particularly difficult in obese patients, the ones usually suffering from this disease. Following signs may be present: • eduction of disc space • Osteophyte formation What have we learnt? • Osteoarthritis is a degenerative, progressive disorder. It commonly affects the knee and the back. • Treatment is preventive, if predisposing factors are kno n. • Once progressed, physiotherapy and surgery remain the only options. https://kat.cr/user/Blink99/

300 | Essential Orthopaedics Additional information: From the entrance exams point of view Osteoarthritis Rheumatoid arthritis haracteristic ndings Osteophytes and ne uxta-articular osteoporosis, bone formation osteophytes and ne bone formation usually absent oints Involved commonly Distal interphalyngeal joints rist joint, of hand ( eberden s nodes), metacarpophalyngeal joints, proximal interphalyngeal roximal interphalyngeal joints joints, knee, and hip of hand ( ouchard s nodes), oints not involved st carpometacarpal joint, hip, umbar spine, distal knee interphalyngeal joint etacarpophalyngeal joints and rist joint •  Type A synovial cells are phagocytes that engulf joint debris •  Type B synovial cells secrete synovial uid

36 A Affections of the oft issues TOPICS • anglion • arpal tunnel s ndrome • ursitis • Fro en shoulder • enos no itis • lantar fascitis • upu tren's contracture • Fibrositis • ennis elbo • ainful arc s ndrome • olfer's elbo • eralgia paraesthetica • de uer ain's tenos no itis • Fibrom algia • rigger finger and thumb BURSITIS It occurs commonly in trochanteric bursa or prepatellar bursa. Treatment is by surgical drainage Inflammation may occur in a normally situated and antibacterial drugs. bursa or in an adventitious bursa. It may arise from mechanical irritation or from bacterial infection. TENOSYNOVITIS Accordingly, there are two types of bursitis: Inflammation of the thin synovial lining of a tendon Irritative bursitis: This is the commoner of the sheath (Fig-3 .1) is termed tenosynovitis. t may two types. It is caused by excessive pressure or arise from mechanical irritation or from bacterial friction, occasionally due to a gouty deposit. infection. Inflammation of the bursa results in the effusion of Irritative tenosynovitis is commonly seen in a clear fluid within the bursal sac. With prolonged the tendons of the hand and results in pain and inflammation, the sac gets thickened and may swelling. Treatmentisbyrest,analgesicsandultrasonic cause pressure erosion on the adjacent bone. Some therapy. Some cases need local hydrocortisone commonly seen bursites are given in Table–3 .1. infiltration. Infective tenosynovitis is an infection of the Table-36.1: Common bursites synovial lining of the tendon by pyogenic or tubercular bacteria. Pyogenic infection is common Prepatellar bursitis Housemaid's knee Infrapatellar bursitis Clergyman's knee Fig-36.1 Synovial lining of tendon Olecranon bursitis Student's elbow Ischial bursitis Weaver's bottom On lateral malleolus Tailor's ankle On great toe Bunion Treatment: Most cases respond to analgesics, rest to the part and removal of the causative factor i.e., friction or pressure. In some resistant cases, the sac is infiltrated with hydrocortisone. Very rarely, excision of the bursa is required. Infective bursitis: Uncommonly, a bursa may get infected by a pyogenic or tubercular infection. https://kat.cr/user/Blink99/

302 | Essential Orthopaedics LI I AL F A in the flexor tendons of the hand. Tubercular In early stages, thickening of the palmar aponeurosis tenosynovitis of the sheaths of the flexor tendons is felt at the bases of ring and little fingers. Later, of the forearm at the level of the wrist occurs a flexion deformity of the fingers develops. commonly (compound palmar ganglion). Dupuytren's contracture can be differentiated from a similar deformity due to contracture of the flexor ' A tendons; in the former only the MP and PIP joints ( ontracture of the palmar aponeurosis) are flexed, unlike the latter where the DIP joints are also flexed. This is a condition characterised by a flexion deformity of one or more fingers due to a thickening and A shortening of the palmar aponeurosis. The cause is unknown, but a hereditary predisposition has been An elderly patient with mild contracture does not established. There is an increased incidence of the need any treatment. If the deformity is significant disorder among cirrhotic patients and in epileptics and hampers the activity of the patient, excision on sodium hydantoin. of the palmar aponeurosis (subtotal excision) may A AA be required. Normally, the palmar aponeurosis is a thin but tough membrane, lying immediately beneath the I L skin of the palm. Proximally, it is in continuation (Lateral epicond litis) with the palmaris longus tendon. Distally, it divides into slips, one for each finger. The slip blends with the This is a condition characterised by pain and fibrous flexor sheaths covering the flexor tendon of the tenderness at the lateral epicondyle of the humerus finger, and extends up to the middle phalanx (Fig- due to non-specific inflammation at the origin of 3 .2a). n Dupuytren s contracture, the aponeurosis or a the extensor muscles of the forearm. Although, it part of it becomes thickened and slowly contracts, is sometimes seen in tennis players, other activities drawing the fingers into flexion at the metacarpo- such as squeezing clothes, carrying a suitcase etc. phalangeal and proximal inter-phalangeal joints are frequently responsible. (Fig-3 .2b). The ring finger is the one affected most commonly. The contracture is generally limited LI I AL F A to the medial three fingers. Sometimes, it may be associated with a thickening of plantar fascia or One finds tenderness, precisely localised to the that of the penile fascia ( eyronie s disease). lateral epicondyle of the humerus. Painisaggravated by putting the extensor tendons to a stretch; for Fig-36.2 Dupuytren's contracture example, by palmar-flexing the wrist and fingers with the forearm pronated. Elbow movements are normal. X-ray does not reveal any abnormality. A The patient is initially treated with analgesics–anti- inflammatory drugs for a week or so. If there is no response, a local injection of hydrocortisone at the point of maximum tenderness generally brings relief. LF ' L ( edial epicond litis) This is a condition similar to tennis elbow where the inflammation is at the origin of the flexor tendons at the medial epicondyle of the humerus. Treatment is on the lines of a tennis elbow.

de AI ' II Affections of the Soft Tissues | 303 This is a condition characterised by pain and 3. T e e – a l swelling over the radial styloid process. It results from inflammation of the common sheath of cases, splitting of the tight tendon sheath may be abductor pollicis longus and extensor pollicis required. brevis tendons (Fig-3 .3). On examination, the tenderness is localised to the radial styloid process. A LI Pain is aggravated by adducting the thumb across the palm and forcing ulnar deviation and on asking It is the commonest cystic swelling on the dorsum the patient to perform radial deviation against of the wrist. It results from mucoid degeneration of resistance (Fin elstein s test). There may be a the tendon sheath or the joint capsule. Ordinarily, palpable thickening of the sheath. there are no symptoms other than the swelling itself. Sometimes, a mild discomfort or pain is A experienced. The cyst may sometimes be so tense In early stage, rest to the wrist in a crepe bandage as to resemble a solid tumour of the tendon sheath. or a slab, analgesics and ultrasonic radiation may Often the cyst is multi-loculated. Aspiration of the bring relief. In some cases, a local infiltration of cyst is performed and an injection of hylase given. hydrocortisone is required. A chronic case may If the cyst recurs, excision may be required. need slitting and excision of a part of the tendon sheath. A AL L Fig-36.3 de Quervain's tenosynovitis This is a syndrome characterised by the compression (affected tendon sheaths) of the median nerve as it passes beneath the flexor retinaculum (Fig-3 .5). I FI Fig-36.5 The carpal tunnel This is a condition resulting from the constriction of the fibrous digital sheath, so that free gliding of CAUSES the contained flexor tendon does not occur. Any space occupying lesion of the carpal tunnel may be responsible. Some of the common causes LI I AL F A are given in Table–3 .2. Initially, the only symptom is pain at the base of the affected finger, especially on trying to passively extend the finger. As the sheath further thickens, the contained tendon gets swollen proximal to it (Fig-3 .4). The swollen segment of the tendon does not enter the sheath when an attempt is made to straighten the finger from the flexed position. This is called ‘loc ing of finger’. This loc ing can be overcome either by a strong effort in which case the finger extends with a snap-like trigger of a pistol or by extending the finger passively with other hand. A In early stages, local ultrasonic therapy provides relief. In a long standing problem, a local injection of hydrocortisone relieves the pain. In some https://kat.cr/user/Blink99/

304 | Essential Orthopaedics Table–3 .2: Causes of carpal tunnel syndrome LA A FA I I • diopathic The commonest cause This is a common cause of pain in the heel. It • nflammatory causes heumatoid arthritis occurs as a result of inflammation of the plantar aponeurosis at its attachment on the tuberosity of • ost-traumatic causes Wrist osteoarthritis the calcaneum (Fig-3 . ). The pain is worst early Bone thic ening after a in the morning, and often improves with activity. • ndocrine causes Colles' fracture On examination, there is marked tenderness over Myxoedema, the medial aspect of the calcaneal tuberosity, at the Acromegaly site of attachment of the plantar fascia. LI I AL F A Fig-36.6 Causes of heel pain The patient is generally a middle aged woman 1. ea e al a e 2. la a a complaining of tingling, numbness or discomfort in the thumb and radial one and a half fingers 3. Fat pad inflammation 4. Retro-calcaneal bursitis i.e., in the median nerve distribution. Tingling is more prominent during sleep. There is a feeling 5. Achillis tendinitis 6. Diseases of subtalar joint of clumsiness in carrying out fine movements. On examination, features of low median nerve X-rays sometimes show a sharp bone spur projecting compression are found (see page ). erve forwards from the tuberosity of the calcaneum. Its conduction studies show delayed or absent significance is doubtful since it is also found in conduction of impulses in the median nerve across some cases without heel pain. Analgesics, the use the wrist. Treatment is by dividing the flexor of a heel pad and local induction of steroids brings retinaculum, and thus decompressing the nerve. relief in most cases. F L FI I I ( eriarthritis shoulder) This is a non-specific condition where there is pain This is a disease of unknown aetiology where the in certain muscles, with tenderness when they gleno-humeral joint becomes painful and stiff are gripped. One can palpate small, firm nodules, because of the loss of resilience of the joint capsule, mostly over the trapezius and spinal muscles. possibly with adhesions between its folds. Often, These nodules are supposed to be trigger points. there is a history of preceding trauma. The disease There are no other objective signs. The patient is commoner in diabetics. responds to ultrasonic therapy or local steroid infiltration. LI I AL F A AI F L A It produces pain and stiffness of the shoulder. In early stages, the pain is worst at night, and the This is a clinical syndrome in which there is pain in stiffness limited to abduction and internal rotation the shoulder and upper arm during the mid-range of the shoulder. Later, the pain is present at all of gleno-humeral abduction (Fig-3 .7). Following times and all the movements of the shoulder are are the common causes: severely limited. • Minor tears of the supraspinatus tendon A • Supraspinatus tendinitis This is a self-limiting disease lasting for - months, after which in most cases, the inflammation subsides, leaving a stiff but painless shoulder. Treatment is by analgesics, hot fomen- tation and physiotherapy. An intra-articular injection of hydrocortisone may speed up the recovery. Stiffness can be prevented by continuous shoulder mobilising exercises.

3 . a la e Affections of the Soft Tissues | 305 • Calcification of supraspinatus tendon or excision of the anterior, often prominent part of • Subacromial bursitis the acromion. • Fracture of the greater tuberosity AL IA A A I A In all these conditions, the space between the upper-end of the humerus and the acromion gets This is a feeling of tingling, burning, and numb- compromised, so that during mid-abduction the ness in the skin supplied by the lateral cutaneous tendon of the rotator-cuff gets nipped between nerve of the thigh as it gets entrapped in the fascia the greater tuberosity and acromion. X-ray of the just medial to the anterior superior iliac spine. shoulder may show calcific deposit, or a fracture Treatment is non-specific with analgesics, local of the greater tuberosity or acromion. Treatment hydrocortisone etc. Sometimes, surgical decom- consists of ultrasonics to the tender point and pression of the nerve may be required. anti-inflammatory drugs. Some cases need an injection hydrocortisone in the subacromial space FI AL IA This is a widespread disease characterized by multiple tender points, affecting both sides of the body – both above and below the waist, lasting more than 3 months. t is nown to be associated with irritable bowel, headache, dysmenorrhea and chronic fatigue syndrome. It is an entity, distinct from fibrositis which is a localised disorder. Aetiology is not known, but it is proposed to be a part of fatigue syn- drome. Diseases like hypothyroidism, SLE, hyperparathyroidism and osteomalacia need to be ruled out by careful investigation. Treat- ment is by patient counselling, avoidance of aggravating factors, physical therapy and an- tidepressants. What have we learnt? • ursae are de ated baloons around areas hich are subjected to friction. They get in ammed and produce pain. • Dupuytren's contracture is contracture of palmer fascia. • Tennis elbo and golfer's elbo are epicondylitis. • de uervain's disease is tenosynovitis of tendons around the rist. • ro en shoulder is idiopathic capsular in ammation of shoulder, usually responds to physiotherapy. • ainful arc syndrome occurs because of impingement of rotator-cuff. https://kat.cr/user/Blink99/

306 | Essential Orthopaedics Additional information: From the entrance exams point of view Types of super cial heat therapy Hot bath, chemical pack, paraf n ax bath, infrared lamp, moist air cabinet. Types of deep heat therapy Short ave diathermy, micro ave therapy, ultrasound therapy. O rien s test done for a tight iliotibial band. Dupuytren s contracture Surgery re uired if proximal interphalyngal joint contracture and metacarpophalyngeal joint contraction . evel of tendon sheath constriction in trigger nger is metacarpophalyngeal joint (A pulley). ursa pes anserinus is bet een the tendons of the sartorius, gracilis, semitendinosus and the tibial collateral ligament. Thoracic outlet syndrome is best diagnosed via clinical examination. Athletic pubalgia is due to strain of the rectus abdominus muscle.

37 A etabolic one iseases TOPICS • perparath roidism • Fluorosis • onstitution of bone • isturbances of organic constituents • one and calcium • steoporosis • ickets and steomalacia CONSTITUTION OF BONE Flow chart-37.1: Constitution of bone Osseous tissue is made up of organic and inorganic BONE AND CALCIUM material along with water. Relative proportions of these constituents are as shown in Flow chart-37.1. Bone serves as a storehouse for 99 per cent of the body's calcium. Changes in the calcium ion activity Inorganic constituents of bone: It constitutes 65 per in the extracellular fluid affects multiple biological cent of the dry weight of bones. The bulk of this processes. Hence, special regulatory mechanisms is calcium and phosphate, which in an adult is are required to provide an overall control of this primarily crystalline (hydroxyapatite crystals). Besides calcium, other minor mineral constituents are Magnesium, Sodium, Potassium etc. Although, the bone contains a large amount of calcium, only about 65 per cent of it is in an exchangeable form. Organic constituents of bone: On a dry weight basis, the organic matrix constitutes 35 per cent of the total weight of human bones. Of this, 95 per cent is collagen; other constituents being polysaccharides (mucoproteins or glycoproteins) and lipids (includ- ing phospholipids). Table–3 .1: Effects of PTH, vitamin D and calcitonin on kidney, GIT and bone Agent Effect on Kidney GIT Bone serum levels Direct action PTH Ca, P Direct action — mobilisation of Ca Vitamin D renal phosphate from bone Calcitonin Ca, excretion (phosphaturia) Direct action resorption of Ca absorption of Direct action Ca, P — Ca and P from gut mobilisation of Ca excretion of Ca — from bone urinary from bone mobilisation of Ca https://kat.cr/user/Blink99/

308 | Essential Orthopaedics b) Osteosclerotic diseases: These are diseases characterised by an increase in bone mass (e.g., activity. If for any reason, the serum level of calcium fluorosis). falls below its normal value, the body can react in three specific ways: (i) it may increase intestinal c) Osteomalacic diseases: These are diseases absorption; (ii) it may decrease urinary excretion; characterised by an increase in the ratio of the or (iii) it may increase the release of calcium from organic fraction to the mineralised fraction bone. The factors responsible for monitoring these i.e., the available organic matter is under- activities are parathyroid hormone (PTH), vitamin mineralised (e.g., osteomalacia). D and calcitonin as given in Table–37.1. In cases with acute lowering of the serum calcium d) Mixed diseases: These are diseases that are a level, such as that induced by the administration combination of osteopenia and osteomalacia of calcium complexing substances, the intestinal (e.g., hyperparathyroidism). tract and kidney cannot act swiftly enough to restore the level to normal. In this instance, the I first supply of calcium comes from the lacunar and canalicular surfaces of the bone. This effect is Osteoporosis is by far the commonest metabolic believed to be an equilibrium exchange. It accounts bone disease. It is characterised by a diffuse for only a small amount of mineral and lasts for reduction in the bone density due to a decrease only a few minutes. After this source is depleted, in the bone mass. It occurs when the rate of bone and if the serum level of calcium is still low, resorption exceeds the rate of bone formation. parathyroid hormone secretion is stimulated as a direct consequence of the lowered serum level CAUSES of calcium. This hormone provides a second source of calcium from the bone, from the zone Several aetiological factors may be operative in a surrounding the osteocytes. This is called osteocytic given patient. Commonest factor in males is senility osteolysis. This happens first in cancellous bone and in females is menopause. Table–37.2 gives and finally in cortical bone. Increase in the number some of the causes of generalised osteoporosis. and activity of osteoclasts results in resorption of large amount of bone. This type of resorption is Table–3 .2: Causes of generalised osteoporosis called osteoclastic resorption. There are four types of metabolic bone diseases • Senility (Fig-37.1). • Post-immobilisation e.g. a bed-ridden patient a) Osteopenic diseases: These diseases are • Post-menopausal • rotein eficienc characterised by a generalised decrease in bone mass (i.e., loss of bone matrix), though nadequate inta e – old age, illness whatever bone is there, is normally mineralised Malnutrition (e.g., osteoporosis). Mal-absorption Excess protein loss (3rd degree burns, CRF etc.) Fig-37.1 Metabolic bone diseases • Endocrinal Cushing's disease Cushing's syndrome Hyperthyroid state • Drug induced Long term steroid therapy Phenobarbitone therapy LI I AL F A Osteoporosis is an asymptomatic disorder unless complications (predominantly fractures) occur. Loss of bone mass leads to loss of strength so that a trivial trauma is sufficient to cause a fracture. Dorso-lumbar spine is the most frequent site. Pain from these fractures is usually the reason for a person to consult a physician. Other fractures whose aetiology has been linked to underlying osteoporosis are Colles' fracture and fracture of the neck of femur.

Metabolic Bone Diseases | 309 • Densitometry: This is a method to quantify osteoporosis. In this method absorption of photons (emitted from gamma emitting isotopes) by the bone calcium is measured. Two types of bone densitometry are available – ultrasound based and -ray based. D A scan is an -ray based bone densitometry, and is the gold standard in the quantification of bone mass. • Neutron activation analysis: In this method, calcium in the bone is activated by neutron bombing, and its activity measured. • Bone biopsy. 3 .2 a e al e a e al e A showing marked osteoporosis Since the aetiology of osteoporosis is multifactorial and the diagnosis usually delayed, treatment On examination, the findings are subtle and can becomes difficult. There are no set treatment be missed. A slight loss of height and increased methods as yet. The principle objectives of kyphosis due to compression of the anterior part treatment are alleviation of pain and prevention of of the vertebral bodies is seen in most cases. fractures. Treatment can be divided into medical and orthopaedic. A I L I AL F A Medical treatment: This consists of the following: Radiological evidence of decreased bone mass is • High protein diet: Many elderly patients suffer more reliable, but about 30 per cent of the bone mass must be lost before it becomes apparent from malnutrition. Increasing their protein on -rays (Fig-37.2). Following features may be intake may increase the formation of organic noticed on -rays: matrix of the bone. • Loss of vertical height of a vertebra due to • Calcium supplementation: Its role is doubtful, collapse. but may be helpful in cases with deficiency of calcium in their diet. • Cod fish appearance: The disc bulges into the adjacent vertebral bodies so that the disc • Androgens: These hormones have an anabolic becomes biconvex. effect on the protein matrix of bone, and in some instances ameliorate symptoms. • Ground glass appearance of the bones, conspicuous in bones like the pelvis. • Estrogens: Estrogens have been shown to halt the progressive loss of bone mass in post- • Singh's index: Singh et al. graded osteoporosis menopausal osteoporosis. into 6 grades based on the trabecular pattern of the femoral neck trabeculae. Details are outside • Vitamin D: This is given, in addition to the above, the scope of this book. to increase calcium absorption from the gut. • Metacarpal index and vertebral index are other • Fluoride: The use of fluoride is still under study. methods of quantification of osteoporosis. It is supposed to make the crystallinity of the bone greater; thereby making bone resorption I I A I slower. These include the following, some of them more • Alandronate: These are used in once a day dose, recent: empty stomach. Oesophagitis is a troubling complication. • Biochemistry: Serum calcium, phosphates and alkaline phosphatase are within normal limits. • Calcitonin: Parentral administration of calcitonin Total plasma proteins and plasma albumin may helps in building up the bone mass and also acts be low. as an analgesic. https://kat.cr/user/Blink99/

310 | Essential Orthopaedics Teriparatide: Anabolic agent increasing osteo- Table–3 .3: Types of rickets blastic new bone formation. Type 1 Denosumab, Strontium: Antiresorptive agents. a) e to a eficienc o ita in Orthopaedic treatment: Thisconsistsofthefollowing: • Diminished inta e e.g., malnutrition • Diminished absorption e.g., • Exercises: Weight bearing is a major stimulus to bone formation. Increased guarded activity – mal-absorption syndrome would therefore be of benefit to the patient. – gastric abnormalities – biliary diseases • Bracing: Prophylactic bracing of the spine by • ac of exposure to sunlight using an ASH brace or Taylor brace may be b) Due to disturbance in vitamin D metabolism useful in prevention of pathological fractures in • Hepatic factor e.g., a severely osteoporotic spine. – lac of 25 hydroxylation of vitamin D – increased degradation of vitamin D in I A ALA IA patients on prolonged anti-convulsant therapy • enal factor e.g., Rickets and osteomalacia are the diseases where the – lac of 1 hydroxylation (autosomal recessive) organic matrix of the bone fails to calcify properly, • nresponsiveness of target cells to 1-25 dihydroxy leaving large osteoid seams. Manifestations of the vitamin D two diseases are different only with respect to the • enal osteodystrophy stage in life at which they occur. Rickets occurs in the growing bones of children; osteomalacia in the Type II bones of adults. Both conditions are primarily due a) Defective absorption of phosphates through renal to a deficiency of vitamin D or a disturbance in its metabolism secondary to renal disease. tubules • Hypophosphataemic ric ets (x-lin ed dominant) Vitamin D and its metabolism: The endogenous • Fanconi syndrome form of vitamin D i.e., cholecalciferol, is found in • enal tubular acidosis the skin as a product of cholesterol metabolism • Oncogenic ric ets in a process requiring ultraviolet radiation. The b) Diminished intake or absorption of phosphates exogenous form of the vitamin is usually D3. The two most important nutritionally useful forms in softening of the bones and development of of vitamin D are D2 (ergocalciferol) and D3 deformities. (cholecalciferol). CAUSES Steps in activation: The basic forms, vitamin D2 and D3 are inactive until hydroxylated. The first step of There are two types of rickets i.e., Type I and Type hydroxylation (25 hydroxylation) occurs in the liver (Table–37.3). n Type , there is either a deficiency and the second step (1 hydroxylation) occurs in the of vitamin D or a defect in its metabolism. In Type II, idney. 1,25 dihydroxylated form is the active form the rickets occurs due to a deficiency of phosphates and stimulates the intestinal absorption of calcium in the extra-cellular fluid because of defective and also acts on the bone. tubular resorption or diminished phosphate intake. Nutritional deficiency continues to be the commonest Control: The most sensitive of the physiological cause of rickets in developing countries because of actions of 1-25 dihydroxy vitamin D is to poor socio-economic conditions. increase intestinal absorption of calcium. The action of vitamin D metabolites in bone tissue is LI I AL F A controversial. To calcify the bone matrix properly, small amounts of the metabolites are necessary Nutritional rickets occurs in children about 1 year old. along with sufficient calcium. It may occur in older children with mal-absorption syndrome. Following are the clinical features: I • Craniotabes: This is the manifestation of rickets Rickets is a disease of the growing skeleton. It is seen in young infants. Pressure over the soft characterised by failure of normal mineralisation, membranous bones of the skull gives the feeling seen prominently at the growth plates, resulting of a ping pong ball being compressed and released. • Bossing of the skull: Bossing of the frontal and parietal bones becomes evident after the age of 6 months.

Metabolic Bone Diseases | 311 • Broadening of the ends of long bones, most create a depression in the soft metaphyseal end, prominently around wrists and knees. It is seen giving rise to a cup shaped appearance (Fig- around 6-9 months of age. 37.4). • Delayed teeth eruption is noticed in infants. Fig-37.4 Radiological features of rickets • Harrison's sulcus: A horizontal depression, along • Splaying of the metaphysis: The end of the the lower part of the chest, corresponding to the metaphysis is splayed because of the pressure insertion of diaphragm. by the cartilage cells accumulating at the growth • Pigeon chest: The sternum is prominent. plate. • Rachitic rosary: The costo-chondral junctions on the anterior chest wall become prominent, giving • Rarefaction of the diaphysial cortex occurs late. rise to appearance of a rosary. • Bone deformities: Knock knees, bow legs and • Muscular hypotonia: The child's abdomen becomes protruberant (pot belly) because of coxa vara are common deformities in older marked muscular hypotonia. Visceroptosis and children. lumbar lordosis occurs. • Deformities: Deformities of the long bones I I A I resulting in knock knees or bow legs is a Serum calcium is usually normal or low, serum common presentation of rickets, once the child phosphate is low, but serum alkaline phosphatase starts walking. is high. A I L I AL F A A Early radiological changes are observed in the It consists of medical and orthopaedic treatment. lower ends of the radius and ulna. -rays of both Medical treatment: Administration of vitamin D wrists and nees – antero-posterior views are 6,00,000 units as a single oral dose induces rapid used for screening a patient suspected of rickets. healing. If the line of healing (a line of sclerosis on Following radiological signs may be seen (Fig- the metaphyseal side of the growth plate) is not 37.3): seen on -rays within 3-4 wee s of therapy, same dose may be repeated. In cases where the child • Delayed appearance of epiphyses. responds to vitamin D therapy, a maintenance • Widening of the epiphyseal plates: Normal width dose of 400 . . of vitamin D is given per day. If there is no response even after the second of the epiphyseal plate is 2-4 mm. n ric ets it is dose, a diagnosis of refractory rickets is made. increased because of excessive accumulation of Such patients are evaluated in detail by multi uncalcified osteoid at the growth plate. speciality team of nephrologist, endocrinologist • Cupping of the metaphysis: Normally, the and physician. metaphysis meets the epiphyseal plate as a Orthopaedic treatment: It is required for the smooth line of sclerosis (zone of provisional correction of deformities by conservative or calcification). In rachitic bones, this line is absent operative methods. and the metaphyseal end appears irregular. The a) Conservative methods: Mild deformities correct cartilage cells accumulating at the growth plate spontaneously, as rickets heals. Some surgeons 3 .3 a e e use specially designed splints (mermaid showing changes in rickets https://kat.cr/user/Blink99/

312 | Essential Orthopaedics 3. a el le e splints) or orthopaedic shoes for correction of on the pubic rami knee deformities. b) Operative methods: Moderate or severe rapid resorption and slow mineralisation and deformities often require surgery. This can be may be surrounded by a collar of callus. performed any time after 6 months of starting the medical treatment. Corrective osteotomies, • Triradiate pelvis in females. depending upon the nature of deformities, are performed. • Protrusio-acetabuli i.e., the acetabulum protruding into the pelvis. OSTEOMALACIA • Bone biopsy: A bone biopsy from the iliac Osteomalacia, which means softening of bones, is crest usually confirms the diagnosis. The the adult counterpart of rickets. It is primarily due characteristic histological finding is excessive to deficiency of vitamin D. This results in failure to uncalcified osteoid. replace the turnover of calcium and phosphorus in the organic matrix of bone. Hence, the bone content • Serum: The serum calcium level is low, the is demineralised and the bony substance is replaced phosphates are low and alkaline phosphatase by soft osteoid tissue. high. A IL A It is common in women who live in ‘purdah,’ and When osteomalacia is due to defective intake, lack exposure to sunlight. Other causes are: dietary vitamin D supplementation therapy, as for rickets, deficiency of vitamin D, under-nutrition during brings dramatic results. Vitamin D in daily pregnancy, mal-absorption syndrome, after partial maintenance doses of 400 . . is sufficient. f there gastrectomy, etc. is mal-absorption, higher dose or intramuscular dose may be needed. In patients with renal LI I AL F A disease, alfa-calcidol (an activated form of vitamin In its early stages, symptoms and signs are non- D) may be used. Calcium supplementation should specific and the diagnosis is often missed. also be given. In addition, the underlying cause Following presentations may be seen: is treated. • Bone pains: Skeletal discomfort ranging from AA II backache to diffuse bone pains may occur. Bone tenderness is common. Clinical bone disease occurs in less than half of the patients with hyperparathyroidism. For reasons • Muscular weakness: The patient feels very unknown, hyperparathyroidism tends to present weak. He may have difficulty in climbing up either with bone disease or with renal stones, but and down the stairs. A waddling gait is not not both. unusual. Tetany may manifest as carpopedal spasm and facial twitching. Before we discuss this topic further, here is a brief account of the action of parathyroid hormone on • Spontaneous fractures occur usually in spine, bone. and may result in kyphosis. a a e a b e: The parathyroid I I AI hormone acts directly on the bone to release Following investigations may be carried out: calcium into the extra-cellular fluid by stimulating • Radiological examination: lain -rays appear to be of ‘poor quality’ i.e., not sharp and well- defined. Following findings may be present (Fig-37.5): • Diffuse rarefaction of bones. • Looser's zone (pseudo-fractures): These are radiolucent zones occurring at sites of stress. Common sites are the pubic rami, axillary border of scapula, ribs and the medial cortex of the neck of the femur. These are caused by

osteoclastic resorption. It activates the adenyl Metabolic Bone Diseases | 313 cyclase so that the formation of cyclic AMP is increased, which in turn increases the synthesis -ray of the region with symptoms. Following of specific lysosomal enzymes. These enzymes signs may be present (Fig-37.6): break down the organic matrix of bone and release calcium. • Irregular, diffuse rarefaction of the bones. • Salt pepper appearance: The skull bones show a LI I AL F A well-marked stippling, but the opaque areas are The disease can affect either sex, but is more small pin head size. common in women. The majority of cases occur • Loss of lamina dura: A tooth socket is made up of from the third to fifth decades of life. Following are thin cortical bone seen as a white line surround- the more common presenting complaints: ing the teeth. This is called the lamina dura. It • Bone pains: This is the most common initial gets absorbed in hyperparathyroidism. • Sub-periosteal resorption of the phalanges is feature. There is tenderness on palpating a diagnostic feature of hyperparathyroidism the bones, especially in the lower limbs and (generalised variety). Resorption may also occur back. Pain is usually associated with general at lateral end of the clavicle. weakness, pallor and hypotonia. • Spine shows central collapse of the vertebral • Pathological fracture: Fractures occur with trivial body and biconvex discs. injuries and unite in a deformed position. Common sites of fractures are dorso-lumbar • Pelvis and other bones show coarse striations spine, neck of the femur and pubic rami. with clear cyst-like spaces. • Brown's tumour: This is an expansile bone lesion, a collection of osteoclasts. It commonly affects • Brown's tumour is an expansile lytic lesion, which the maxilla or mandible, though any bone may appears like a bone tumour, generally affecting be affected. the maxilla/mandible. • Anorexia, nausea, vomiting and abdominal cramps are common presenting complaints. • Extra-osseous radiological features such as renal • Occasionally, renal colics with haematuria, calculi etc. may be present. because of renal calculus, may occur. I I A I A I L I AL I I A I • Serum calcium is high, phosphates low and X-ray examination consists of the lateral view of the skull, dorso-lumbar spine (AP/lateral views), alkaline phosphatase high. both hands (AP view), pelvis (AP view) and • Urinary excretion of calcium is low and that of phosphates high, as found on 24 hour urine analysis. • Investigations for finding the underlying cause of hyperparathyroidism i.e., CT scan of the neck for parathyroids, and for the evaluation of other organs for ectopic secretion of parathormone. (a) (b) (c) Subperiosteal resorption in phalanges Sub-periosteal resorption Salt pepper appearance of lateral end of the clavicle 3. a ae e aa https://kat.cr/user/Blink99/

314 | Essential Orthopaedics (a) (b) Sclerosis Inter-osseous A Calcified ligaments (arrow) membrane calcification It consists of: (i) removal of the basic cause; (ii) orthopaedic treatment; and (iii) urologic treatment. Fig-37.7 Radiological features of fluorosis a) Treatment of the basic cause is by surgical • Spine: Increased density, calcification of the excision of the hormone secreting tissue. posterior longitudinal ligament. b) Orthopaedic treatment is directed towards • Pelvis: Increased density, calcification of the adequate protection of the softened bones ischio-pubic and sacro-iliac ligaments. from all deforming stress and strain. Once the disease has been arrested and recalcification of • Forearm and leg: Interosseous membrane bones occurs, the established deformities may calcification. be corrected surgically. I I A I c) Urology treatment: This is directed towards • Elevated serum fluoride levels. the removal of calculi and maintenance of renal • Elevated fluoride levels in urine and drinking functions. water. FL I • A biopsy shows high fluoride levels in bones. Fluorosis is a disease where excessive deposition IFF IAL IA I of calcium occurs in bone and soft tissues. It Fluorosis is an osteosclerotic disease, and must be results from excessive ingestion of fluorides in differentiated from other causes of osteosclerosis drinking water. The fluoride content of normal given in Table–37.4. water is less than 1 PPM. In India and parts of south east Asia, large areas have been reported A with high water fluoride content. Fluorosis is an Prevention is the most important aspect of endemic disease and a public health problem in treatment of this difficult disease. Defluorination some states of India i.e., Punjab, Andhra Pradesh, Tamil Nadu etc. Table–3 . : Cause of generalised osteosclerosis LI I AL F A • Fluorosis The symptoms and signs may pertain to skeletal • aget s disease of bone system or teeth. • enal osteodystrophy • Secondaries from prostate, other organs a) Skeletal fluorosis: The patient complains • Marble bone disease (osteopetrosis) of pain in the back and joints. There may be associated stiffness of the spine and • ngelmann s disease paraesthesias in the limbs. In advanced stages, the patient presents with spastic paraparesis and anaemia. Paraparesis occurs because of cord compression resulting from calcification of the posterior longitudinal ligament and subsequent pressure on the cord. b) Dental fluorosis: This is the earliest sign of fluorosis. The earliest to occur is mottling of the enamel, best seen in the incisors of the upper jaw. Later the teeth get eroded and fall off. A I L I AL I I A I -rays of the spine, pelvis and forearms are required in a suspected case. Following features may be seen (Fig-37.7):

of the water is carried out as a public health Metabolic Bone Diseases | 315 programme. Patients improve symptomatically once the defluorinated water is used for some time. tendencies typically producing perifollicular haemorrhages over the lower part of the thighs. I A F A I I Petechial haemorrhages and spontaneous bruises may occur anywhere in the body, but usually LA I first in the lower extremities. In infantile scurvy, Ingestion of certain agents called lathyrogens important features are lassitude, anaemia, painful causes profound alterations in the collagen of limbs due to sub-periosteal haematoma, and connective tissues and bones. The bones of such scorbutic rosary (bead like thickening of the ribs individuals are soft, their arteries become weak due to calcified sub-periosteal haematomas). and develop aneurysms. Treatment is removal of Treatment is by supplementation with vitamin C. causative factor. L A AI I This disease is caused by deficiency of vitamin C The principle polysaccharide of bone is a (ascorbic acid). The result is decreased production mucopolysaccharide — chondroitin-4-sulfate and poor quality collagen. In adults, it presents with (chondroitin sulfate A). In certain diseases called swollen gums, gingivitis and abnormal bleeding as mucopolysaccharidosis, there is increased excretion of polysaccharides in the urine. Loss of these polysaccharides from bone and cartilage results in specific skeletal deformities. What have we learnt? • of eight of the bone is inorganic. • Osteoporosis is de ciency in matrix, hereas osteomalacia is de ciency of mineralisa- tion of bone. • ickets and osteomalacia are diseases of de ciency in bone mineralisation. • yperparathyroidism results in mobilisation of calcium from bone. • luorosis is excessive deposition of calcium in bone and soft tissues. Additional information: From the entrance exams point of view • ugger jersey spine is seen in renal osteodystrophy and is due to hyperparathyroidism. • ilkman fractures are pseudofractures in adults. https://kat.cr/user/Blink99/

3C H A P T E R iscellaneous Affections of the one TOPICS • eneralised bone disorders • A ascular necrosis • steochondritis • ome other de elopmental abnormalities of orthopaedic interest RGGENERALISED BONE DISORDERS VACHONDROPLASIA dThis is a condition caused by the failure of normal ossification of bones, mainly the long bones, iteresulting in dwarfism (Fig-38.1). Since growth of the trunk is only marginally affected, the arfi i i ro ortionate the limbs being out of proportion nwith the trunk. Shortening is especially marked in Uthe ro i al segments of the limbs. spinal canal stenosis. Common causes of dwarfism are given in Table–3 .1. Table–3 .1: Common causes of dwarfism • Achondroplasia • Dyschondroplasia • Diaphysial aclasis • Multiple epiphyseal dysplasia • Cretinism • Malnutrition • Morquio s, Hurler s, Hunter s diseases - OSTEOGENESIS IMPERFECTA 9 (Fragilitas ossium, Vrolik's disease) This is a condition characterised by tendency for ir9 re ent ract re because of ea an brittle bones. It results from defective collagen synthesis, and thus affects other collagen containing soft tissues such h as the skin, sclera, teeth, ligaments etc., as well. The ta disease is commonly inherited as an autosomal dominant disorder, but a severe variant is known to occur where the inheritance is autosomal recessive. Typically, the patient has a tendency for frequent fractures, usually with minimal trauma. Associated features are blue sclera, joint laxity and otosclerosis 3 .1 la a in adulthood. Patients with the severe type do not survive beyond a few years, but those with the The disease is of autosomal dominant inheritance, milder disease live their full life interrupted by but many cases arise from a fresh gene mutation. frequent fractures. The fractures unite normally Intelligence is normal. Typically, the patient has but deformities secondary to malunion or joint a large skull with a bulging vault and forehead, contractures may occur. The tendency to fracture a flat nose, short limbs, short and stubby fingers often reduces with age. Some of the common and increased lumbar lordosis. These patients lead causes of tendency for easy fracture are given in a near normal life, except for a few who develop Table–3 .2.

Miscellaneous Affections of the Bone | 317 Table–3 .2: Causes of tendency for easy fractures PAGET'S DISEASE ( steitis deformans) • Osteogenesis imperfecta This is a condition characterised by a progressive • Osteoporosis tendency for one or more bones to bend, get • Osteopetrosis thickened and spongy. Tibia is the bone affected • Osteomalacia most commonly. The cause is not known, but it is understood to be a defect in the osteoclast • olio limb functions, so that irregular bone resorption and increased bone turnover occurs. The bone is soft DIAPHYSIAL ACLASIS and vascular in the initial stages, but becomes ( ultiple e ostosis) dense and hard later. The disease begins after 40 This is a condition characterised by multiple, years of age. Presenting complaints are dull pain, cartilage-capped bon o t ro t from the and bowing and thickening of the affected bone. metaphysis of long bones, and some from flat X-rays show multiple confluent lytic areas with bones. It is inherited as an autosomal dominant interspread new bone formation. Bone scan shows disorder. The basic defect is that of remodelling. The an increased uptake. Serum alkaline phosphatase columns of cartilage at the epiphyseal plate grow is elevated. Usual complications are pathological rapidly and sideways due to poor remodelling fracture and malignant change. Treatment is by forces. -rays typically show a ‘trumpet-shaped’ calcitonin or diphosphonate. metaphysis and bony projections from it (Fig-3 .2). The problem is of dwarfism, pressure effects of NEUROFIBROMATOSIS the exostosis, deformities, and a tendency of the A generalised variety of neurofibromatosis exostosis to undergo malignant change. Since, it (von ec linghausen s disease) may have s eletal is impractical to excise all the exostosis, the one disturbances like scoliosis, solitary bone lesions, causing symptoms is excised. pseudarthrosis of the tibia, compressive myelo- pathy, local gigantism, limb length inequality etc. 3 .2 a b ee e In addition, other soft tissue manifestations of the disease may be present. For details, please refer to l le e e a Surgery textbook. OSTEOPETROSIS HISTIOCYTOSIS X ( arble bone disease, Albers chonberg disease) This comprises of a group of diseases characterised by proliferation of histiocytes in the bones. Three This is a disorder characterised by en e b t brittle clinical entities are recognised: bone (marble bones). In a less severe, autosomal dominant variety the patient has a tendency a) l a l a: This is a solitary bone to fracture. In a severe, congenital, autosomal lesion, commonly seen in the femur, tibia, spine recessive variety, the child may have severe and ribs. The patient usually presents with a anaemia, jaw osteomyelitis and cranial nerve dull pain or a pathological fracture. Treatment palsies. Most of the patients of the latter type do is curettage and bone grafting. not survive for long. b) a lle a ea e: It is a variation of (a), where the lesions are found at multiple sites. c) e e e ea e: This is the most severe form. There is involvement of multiple bones. It begins in childhood and progresses rapidly to death. OSTEOCHONDRITIS These are a group of miscellaneous affections of the growing epiphyses in children and adolescents. Typically, a bony nucleus of the epiphysis affected by osteochondritis becomes temporarily softened; https://kat.cr/user/Blink99/

318 | Essential Orthopaedics and while in the softened stage it is liable to deformation by pressure. erthes disease, the osteochondritis of the epiphysis of the head of the femur is the co one t Osteochondritis is sometimes classified into: (i) cr in t e or osteochondrosis; (ii) o teoc on riti i ecan and (iii) traction o teoc on riti or traction apophysitis. Table–3 .3 gives names of some of the common osteochondrites. Table–3 .3: Common osteochondrites 3 .3 a ae e e ea e e ae ite a ecte .e l be l e be able a e - • erthes disease Femoral head a e ea l a e Capitulum unate bone Tibial tubercle Calcaneal tuberosity avicular bone Metatarsal head ing epiphysis of vertebrae Central bony nucleus of vertebral body 5th metatarsal • anner s disease • Kienboc s disease • Osgood Shlatter s disease • Sever s disease G• Kohler s disease • Freiberg s disease R• Scheurmann s disease • Calve s disease V• selin s disease itedPERTHES' DISEASE depending upon the extent of involvement of the head. He also describes the adverse prognostic ( o a plana, seudoco algia) signs ea at ri i n nThis is an osteochondritis of the epiphysis of reatment Preventing the head from mis-shapening the femoral head. In this disease, the femoral while the bone is in softening phase, is the primary aim of the treatment. The head is required to be ept Uhead becomes partly or wholly avascular and inside the acetabulum while the revascularisation -deformed. The cause is not definitely known, but takes place (head containment). This may be achieved by conservative methods (plaster, splint it is supposed to be due to recurrent episodes of etc) or by operation (containment osteotomy). 9ischaemia of the head in the susceptible age group, AVASCULAR NECROSIS probably precipitated by episodes of synovitis. Avascular necrosis (A ) of the bone due to loss of a vascularity of a part of the bone occurs commonly ir9Pathologically, the disease progresses in three after a fracture or dislocation (e.g., A of head of the femur in a fracture of the femoral neck). ill-defined stages: (i) stage of synovitis; (ii) stage Sometimes, a part of the bone undergoes avascular of trabecular necrosis; and (iii) stage of healing. necrosis spontaneously. The head of the femur is a common site of A . t occurs in adults between hThe disease occurs commonly in boys in the a e the ages of 20-40 years. Some of the causes of taro of 5-10 years. The child presents with pain avascular necrosis of the femoral head are given in Table–3 .4. Table–3 . : Causes of avascular necrosis of femoral in the hip, often ra iatin to t e nee There may be head limping or hip stiffness. On examination, findings • diopathic – commonest may be minimal – sometimes the only findings • Alcoholism being a limitation of abduction and internal • Steroid therapy rotation and shortening. Radiological examination • Sic le cell disease • atient on renal dialysis reveals collapse and sclerosis of the epiphysis of • atient on anti-cancer drugs the femoral head. Hip joint space is increa e In • ost-partum necrosis fact, the contrast between the paucity of symptoms • oucher s disease • Caisson s disease and signs in the presence of gross X-ray changes iagnosis The disease is often bilateral (75%). is striking (Fig-38.3). Bone scan may show a decreased uptake by the head of the femur. Four Patient complains of pain in the groin or in front of groups have been described by Catterall (1 72), the thigh. Pain is present at all times, but increases

on exertion. X-rays may be normal in early stage; Miscellaneous Affections of the Bone | 319 if suspicion is strong, a bone scan may be done. In later stage, an osteolytic lesion can be seen in diffuse osteosclerosis of the head, but the shape supero-lateral part of the head. There may be of the head may be maintained. In advanced stage, the head collapses (Fig-38.4). Eventually, changes 3. a a a la e of secondary osteoarthritis become apparent. M ea e e ee scan is the best modality for early diagnosis of avascular necrosis. reatment In early stages, diagnosis is often missed as there are no X-ray findings. Core decompression and fibular grafting is done if the head of the femur has not got deformed. In later stages, once the head gets deformed, muscle-pedicle bone grafting using tensor facia lata has been shown to produce good results (Baksi). In some cases with involvement of a part of the head, an inter- trochantric osteotomy has been described. In cases with changes of advanced osteoarthritis, total hip replacement becomes necessary. SOME OTHER DEVELOPMENTAL ABNORMALITIES OF ORTHOPAEDIC INTEREST 1. Ollier s disease • ot familial (multiple enchondromas) • Masses of cartilage in the metaphysis remain unossified Dyschondroplasia • Defective ossification 2. Melorrheostosis • Candle bone disease 3. Osteopathia striata 4. Osteopoi ilosis • Striped bones disease 5. Morquio s disease • Spotted bones disease 6. Hunter s disease • Familial (autosomal recessive) disease 7. Hurler s disease • ives rise to dwarfism affecting both, limbs and trun ( argoylism) • Mental development nor al • orneal o acit sometimes present • -ray – typical tonguing of lumbar vertebrae 8. ngelmann s disease • Keratan sulphate in urine 9. Caffey s disease • Familial x-linked disease (infantile cortical • Defect is the excretion of large amount of Keratan sulphate in urine hyperostosis) • Dwarf with dorso lumbar yphosis, noc nees, flat feet • Mental deficiency a occur • o corneal opacity • Familial (autosomal recessive) disease • ives rise to dwarfism of both, limbs and trun • Defect is an error in development of fibroblasts • There is excretion of dermatan sulphate and heparitan sulphate in urine • Typical facial appearance • Mental development abnor al • Corneal opacity re ent • -ray typical ‘bea ’ in 2nd lumbar vertebra • Familial (autosomal recessive) disease • Symmetrical, fusiform enlargement and sclerosis of shafts of the long bones in children. Femur affected commonly. • Epiphysis is spared • on-familial disease • Starts early in life (before the 5th month) • There is a formation of sub-periosteal bone on the shafts of long bones, and on the mandible • el li itin co r e re ol e b ear o a e • Tibia more common than ulna in familial form Contd... https://kat.cr/user/Blink99/

320 | Essential Orthopaedics Contd... 10. Albright s syndrome • Polyostotic fibrous dysplasia and precocious puberty 11. Arthrogryposis multiplex • Defective development of muscles congenita (AMC) • Stiff, deformed joints • Multiple joint dislocations with shapeless extremities • May present as clubfoot 12. Myositis ossificans • Ectopic ossification, often beginning in trunk progressiva • Short big toe 13. Multiple epiphyseal • east rare type dysplasia • Affects all the epiphyses, resulting in stunted growth, deformities (varum, valgum etc.) • Epiphysis looks ill defined, irregular on X-rays 14. Spondylo-epiphyseal dysplasia • Spine is also involved in addition to limb epiphyses 15. Metaphyseal dysplasia • Autosomal recessive ( yle s disease) • A modelling defect results in rlenmeyer flas deformity of the 16. Blount s disease G17. Cleido-cranial dysostosis VR18. ail patella syndrome ited19. Marfan s syndrome (Arachnodactly) n20. Apert syndrome distal femur and proximal tibia • The growth of the medial-half of the proximal tibial epiphysis is retarded, resulting in severe tibia vara deformity in childhood, common in West Indies • Faulty development of membranous bones • Clavicles are absent • Skull sutures remain open • Coxa vara • Wide foramen magnum • Familial disorder • Hypoplastic nails and absence of patella • Spider fingers • Associated atrial regurgitation • Occular lens dislocation • Tower shaped head • Syndactyly 9 - UWhat have we learnt? ir9• Achondroplasia produces disproportionate d ar sm. • Osteogenesis imperfecta is the cause of fre uent fractures. • Diaphyseal aclasis is an autosomal dominant disorder. h• Avascular necrosis commonly affects head of the femur. It is common in patients ith tasickle cell disease. Additional information: From the entrance exams point of view • Investigation of choice to diagnose early erthe s disease is I. • Vertebra plana seen in eosinophilic granuloma, E ing s sarcoma, T , Calve s disease, leukemia and metastasis. • Trident hand is seen in achondroplasia. • Osteogensis imperfecta is due to abnormal type I procollagen in the body. • uscles most commonly absent congenitally are pectoralis major and minor. • Ostochondritis dessicans most commonly affects lateral part of medial femoral condyle.

3C H A P T E R Miscellaneous Regional Diseases TOPICS • eformities of the knee • opliteal c st • orticollis • Loose bodies in joints • er ical rib • Flat foot • bser ation hip • eformities of the toes • o a ara • lipped capital femoral epiph sis TORTICOLLIS (Wry neck) tumour. The lump disappears spontaneously within a few months, leaving a fibrosed muscle. Torticol- This is a deformity of the neck where the head and lis occurs more commonly in children with breech neck are turned and twisted to one side. It may be presentation. permanent, temporary, or spasmodic. Spasmodic torticollis is the commonest. Table–3 .1 gives some Diagnosis: The child usually presents at 3-4 years of of the common causes of torticollis. Most often, torticollis is secondary to pain and reflex muscle age, often as late as puberty. The head is tilted to spasm and recovers once the inflammatory one side so that the chin faces to the opposite side process subsides. Congenital torticollis, a common (Fig-3 .1). The sterno-mastoid is prominent on the cause of permanent torticollis, is of orthopaedic side the head tilts, and becomes more prominent interest. on trying to passively correct the head tilt. n cases presenting in the first few wee s of life, a lump Table–3 .1: Causes of torticollis may be felt in the sterno-mastoid muscle. Facial asymmetry develops in cases who present later • Congenital Sterno-mastoid tumour in life. adiological examination is normal, and is • nfection Tonsillitis carried out to rule out an underlying bone defect Atlanto-axial infections such as scoliosis. • eflex spasm Labyrinthitis • eurogenic Acute disc prolapse (cervical) Treatment: n a child presenting with a sterno- Spasmodic condition • Ocular Paralytic condition mastoid tumour, progress to torticollis can be • Others Compensation for squint prevented by passive stretching and splinting. The same may also be sufficient for mild deformities in heumatoid arthritis 3 .1 T ll Spasmodic torticollis CONGENITAL TORTICOLLIS (Infantile torticollis, Sterno-mastoid tumour) The sterno-mastoid muscle on one side of the nec is fibrosed and fails to elongate as the child grows, and thus results in a progressive deformity. The cause of fibrosis is not known, but it is possibly a result of ischaemic necrosis of the sterno-mastoid muscle at birth. vidence in favour of this theory is the presence of a lump in the sterno-mastoid mus- cle in the first few weeks of life, probably a swollen ischaemic muscle. This is termed sterno-mastoid https://kat.cr/user/Blink99/

322 | Essential Orthopaedics younger children. For severe deformities, especially in older children, release of the contracted sterno- mastoid muscle is required. t is usually released from its lower attachment, but sometimes both attachments need to be released. Following surgery, the neck is maintained in the corrected position in a Callot's cast. CERVICAL RIB This is an additional rib which arises from the 7th cervical vertebra. t is usually attached to the first rib close to the insertion of the scalenus anterior muscle, and is present in less than 0.5 per cent of the population. It may be a complete rib, but more 3 .2 a ee e a e al b often it is present posteriorly for a short distance Gonly; the anterior part being just a fibrous band. The cervical rib is usually unilateral and is more Rcommon on the right side. RADIOLOGICAL EXAMINATION -ray examination may show a well-formed rib articulating posteriorly with transverse process of C7 vertebra. t is attached anteriorly to middle of the 1st rib. More often there is no fully developed cervical rib but merely an enlargement of the transverse process of the seventh cervical vertebra (Fig-3 .2). LI I AL F A Vn 0 per cent of cases, there are no symptoms; an dextra rib is detected on an -ray made for some iteother purpose. In others, it produces symptoms after the age of 30 years, probably because with declining youth the shoulders sag, increasing nthe angulation of the neurovascular structures of the upper limb as they come out of the neck. It Uis more often symptomatic in females. A patient may present with the following symptoms: IFF IAL IA I -a) e l al A patient with cervical rib is to be differentiated 9the brachial plexus (T1 dermatome), along the from those presenting with pain radiating down ir9medial border of the forearm and hand, is the the upper limb due to other causes. Some of these : Tingling and numb- causes are as follows: ness along the distribution of the lowest part of a) a al el e: The symptoms are in the median nerve distribution. octurnal pain hness in the use of the hand. is characteristic. commonest complaint. There may be weakness b) e al e le : n cases with cervical tab) a la disc prolapse and spondylosis, pain radiates to and wasting of the hand muscles and clumsi- the outer side of the arm and forearm. Associ- : These are uncommon. ated limitation of nec movement and charac- teristic -ray appearance may help in diagnosis. Compression of the subclavian artery may c) al le : Syringomyelia or other result in an aneurysm distal to constriction. spinal cord lesions may cause wasting of the This is a potential source of tiny emboli to the hand, but other neurological features help in hand and may cause gangrene of the finger tips. reaching a diagnosis. There may be a history of pain in the upper d) l a e limb on using the arm or elevating the hand may mimic this lesion but can (claudication). be differentiated on clinical examination or by electrodiagnostic studies. c) al : Occasionally, the patient TREATMENT presents with a tender supraclavicular lump Conservative treatment is usually rewarding. t consists of ‘shrugging the shoulder’ exercises to (the anterior end of the cervical rib) which, on palpation, is bony hard and fixed.

Miscellaneous Regional Diseases | 323 build up the muscles, and avoidance of carrying heavy objects li e shopping bag, buc et full of water, suitcase etc. Occasionally, surgical excision of the fir t rib may be required to relieve compression on the neurovascular bundle of the upper limb. OBSERVATION HIP ( ransient s no itis) This is a non-specific synovitis of the hip seen in 3 .3 a e el e children 4- years of age. t results in a painful ee a aa e ee stiffness of the hip which subsides after 2-3 wee s of rest and analgesics. -ray examination and the e a a le S are normal. t is termed ‘observation hip’ angle (Fig-3 .4). Treatment is by a subtrochanteric because it must be ‘observed’ and differentiated corrective osteotomy. from the following conditions: a) a l e e a : Some cases of early tuberculosis or septic arthritis may have features similar to observation hip. A high S , systemic symptoms, and persistent signs may necessitate a biopsy; especially in countries where tuberculosis is common. b) : A mono-articular rheuma- toid arthritis may resemble an ‘observation hip’. c) e e ea e: n its early stages, before -ray findings appear, erthes’ disease may resemble a transient synovitis, but further follow up shows characteristic -ray changes of the former. Treatment: t consists of bed rest and analgesics. 3 . a a a – a ba a le ecovery occurs within a few wee s. COXA VARA LI A I AL F AL I I Coxa vara is a term used to describe a reduced In this condition, the upper femoral epiphysis angle between the nec and shaft of the femur. t may get displaced at the growth plate, usually may be congenital or acquired. postero-medially, resulting in coxa vara. The slip occurs gradually in majority of cases, but in some I FA IL A A A it occurs suddenly. This is coxa vara resulting from some un nown growth anomaly at the upper femoral epiphysis. A It is noticed as a painless limp in a child who has just started wal ing. n severe cases, shortening of Aetiology is not nown but it is thought to be a the leg may be obvious. On examination, abduction result of trauma in the presence of some not yet and internal rotation of the hip are limited and the understood underlying abnormality. t occurs leg is short. -rays will show a reduction in nec - more commonly in unduly fat and sexually shaft angle (Fig-3 .3). underdeveloped; or tall, thin sexually normal children. The epiphyseal plate may be too vertical. There may be a separate triangle of bone in the inferior LI I AL F A portion of the metaphysis, called Fairban s tri- Following are the salient clinical features: • e: t occurs at puberty (between 12-14 years). https://kat.cr/user/Blink99/

324 | Essential Orthopaedics • e : It is commoner in boys. • e: t occurs on both sides in 30 per cent of cases. • There is a definite history of trauma in some cases. • It is commoner in patients with endocrine abnormalities. resenting s mptoms ain in the groin, often radiating to the thigh and the nee is the common 3 . Te a presenting complaint. Often in the initial stages, the symptoms are considered due to a ‘sprain’, and TREATMENT are disregarded. They soon disappear only to recur. Limp occurs early and is more constant. amination The leg is found to be externally rotated Gand 1-2 cm short. imitation of hip movements is characteristic – there is limited abduction and Rinternal rotation, with a corresponding increase in adduction and external rotation. When the hip Vis flexed, the nee goes towards the ipsilateral daxilla (Fig-3 .5). Muscle bul may be reduced. Trendelenburg s sign may be positive. t is based on the following considerations: a) T ea e a a e l : This is by closed reduction and pinning, as for a fracture of the neck of the femur. b) T ea e a a al l : This depends upon the severity of the slip present. f it is hir99 - Unite3 . l al e a a tae . T e ee less than 1/3 the diameter of the femoral nec , the epiphysis is fixed internally in situ. If the slip is more than 1/3, a corrective osteotomy is performed at the inter-trochanteric region. c) T ea e e a e e e in unilateral cases: Since the incidence of bilateral involvement is 30 per cent, prophylactic pinning of the unaffected side in a case with unilateral slip is justified. l e a al e al F I I F KNEE a a lla KNOCK KNEES (Genu Valgum) This is a condition where the knees are abnormally approximated and the an les abnormally divergent (Fig-3 .7a). Causes: The commonest type is idiopathic, almost invariably bilateral. The deformity basically results A I L I AL F A from the unequal growth of two sides of the growth -ray changes are best seen on a lateral view of the plate of the lower femoral epiphysis or upper tibial hip. The following signs may be present: epiphysis (Table–3 .2). • e : The growth plate is displaced Clinical features: hysiological genu valgum appears towards the metaphyseal side. A line drawn along the superior surface of the nec remains at the age of 2-3 years and nearly always corrects superior to the head unlike in a normal hip where by the age of . t may be associated with flat feet. it passes bisecting the head –Trethowan s sign The degree of deformity is estimated by measuring the inter-malleolar distance, with the child lying (Fig-3 . ). supine, with the nees in contact. n genu valgum • la e al e : The head is angulated on the secondary to a disease such as rickets, there will be neck. This can be detected early. findings suggestive of the primary disease.

Table–3 .2: Causes of genu valgum Miscellaneous Regional Diseases | 325 Idiopathic Causes: Idiopathic is the commonest type. In others, Post-traumatic • Fractures of the lateral femoral or tibial condyles causes similar to those for genu valgum can be • Damage to the lateral side of the lower femoral or upper identified, except that the defective growth is on the medial side of the epiphyseal plate. Blount s tibial epiphyses or epiphyseal plates disease is a special type of genu varum where the o t in a ator postero-medial part of the proximal tibial epiphysis • Damage to the lateral side of the lower femoral or upper fails to grow during the first 3 years of life. tibial epiphyses or epiphyseal plates by infection Clinical features: An ugly deformity is the main Neoplastic causes • A tumour causing a growth disparity at the epiphyseal complaint. Severity of deformity can be estimated by measuring the distance between the two nees plate e.g., chondroblastoma with the an les held together. f the distance is more Bone softening than cm, further investigations for an underlying • ic ets and osteomalacia cause are required. • Bone dysplasias • heumatoid arthritis Treatment: diopathic type usually corrects spon- Stretching of joints • Charcot s disease taneously. Shoes with an outer raise (3/1 inch) • aralytic disease are usually prescribed. f bowing persists be- Cartilage thinning yond childhood, surgical correction may be re- • OA of the lateral compartment of the nee quired. Treatment: Spontaneous recovery occurs in most A (Fig c) idiopathic cases. A medial shoe raise (3/1 inch) is This means hyperextension at the nee joint. t may sometimes prescribed. t has no proven scientific be congenital or acquired. olio is the commonest rationale but does help in satisfying anxious cause of acquired genu recurvatum. Others causes parents. f the inter-malleolar distance is 10 cm or are: (i) diseases nown to produce lax ligaments more by the age 4, the child may need an operation. (Marfan s syndrome, Charcot s arthropathy); (ii) A supracondylar closed wedge osteotomy is epiphyseal growth defects; and (iii) malunited performed. fractures. BOW LEGS ( enu arum) Treatment: It is difficult. Generally, support with This is a condition where the knees are abnormally braces is required. n some cases, upper tibial divergent (bow li e) and the an les abnormally corrective osteotomy may be required. approximated (Fig-3 .7b). 3. e e e ee https://kat.cr/user/Blink99/

326 | Essential Orthopaedics LI AL This follows a synovial rupture or its herniation in the popliteal region. t may be osteoarthritic (Morrant- Ba er s cyst) or secondary to rheumatoid arthritis. The lump is in the midline and fluctuant, but is not tender. t may shrin following nee aspiration if it is connected to the knee, or may leak or rupture so that the fluid tracks down the calf. Arthroscopic excision is the treatment of choice for symptomatic cases not responding to conservative treatment. LOOSE BODIES IN JOINTS 3 . e e –a a This is a common problem, seen most frequently of the foot which predispose to formation of a flat in the nee joint. A fractured osteophyte, becoming foot. Some common causes of flat foot are given loose in an osteoarthritic, is the commonest in Table–3 .3. Gcause. Other causes are nee osteochondritis, I AL FLA F ( ertical talus) osteochondral fractures, synovial chondromatosis The feet of all newborns appear flat because the postural tone of the intrinsic muscles has not yet Retc. n synovial chondromatosis, the number of developed; but in some, the foot is not only flat but also its undersurface is convex (roc er-bottom bodies is more than 50- 0. The complaint of a patient foot). Such a foot may be in severe valgus. This is due to a congenital anomaly where the talus Vwith a loose body in the joint is sudden loc ing of lies in a vertical position rather than the normal dthe joint. Often he can feel the loose body within horizontal (Fig-3 . ). Diagnosis can usually be itethe joint. Most loose bodies are radiopaque and can confirmed by ta ing an -ray of the foot (lateral view), on which one can see the head of the talus be seen on plain -rays. n some, an arthroscopic facing vertically downwards. The navicular, along examination may be required. Treatment is removal with rest of the foot, rests on the dorsal surface of the talus. Treatment is difficult. In mild cases, the nof the body arthroscopically or by opening the joint. footwear is modified to provide an arch support UFLA FOOT at mid foot. n severe cases, corrective surgery is -This is a foot with less developed longitudinal arches. required. ele ant anatom A normal foot has longitudinal and Table–3 .3: Causes of flat foot 9transverse arches. The longitudinal arch consists e a al a e Congenital of medial and lateral components resting on a • nfantile or physiological ir9common pillar posteriorly – the tuberosity of the calcaneum (Fig-3 . ). The talus is the eystone of the arches. t receives the body weight and trans- hmits it to the arches below. Through the arches, tathe weight is transmitted to the ground via the tuberosity of the calcaneum and the heads of first and fifth metatarsals. • Congenital vertical talus Acquired The integrity of the arches is maintained by the • Occupational plantar ligaments, the plantar aponeurosis, the • Obesity extrinsic and intrinsic muscles and the structure • Postural of the bones of the foot. igaments are the most • Secondary to anatomical defect elsewhere External rotation of the limb important of these structures; especially the spring enu valgum ligament, long plantar ligament, short plantar ligament, interosseous ligaments and plantar quinus deformity of the an le aponeurosis. Of the muscles, tibialis posterior and peroneus longus are more important. Varus deformity of the foot Causes: Idiopathic flat foot is the commonest. There e aral tic Flaccid flat foot Spasmodic Due to peroneal spasm Arthritic Traumatic heumatoid arthritis Fracture calcaneum are factors related to the anatomical development

3 . e al e al al Miscellaneous Regional Diseases | 327 I FA IL FLA F person, post-traumatic flat foot following a fracture This is the most common type. The child is brought of the calcaneum, flat foot secondary to genu valgum usually soon after he starts wal ing with the etc. The other type is spasmodic flat foot where there complaints that he walks on flat feet. There is is a spasm of the peronei muscles due to some sometimes a tendency for frequent falls. Arches painful condition of the foot such as rheumatoid develop as the child grows, and no special treatment arthritis, tuberculosis, inter-tarsal bar etc. is required. n some children, the feet may remain flat but there are no symptoms. Either of the parents F I I F usually have flat feet. Such individuals lead a normal life except that they are prone to developing foot ALL AL strain and are unfit for joining professions requiring t is the lateral deviation of the great toe at high levels of physical fitness (e.g., army). Foot the metatarso-phalangeal joint. Causes are exercises are taught and arch support is given in the many, but it is commonly due to rheumatoid shoes. In late adulthood, pain in the foot and stiffness arthritis, wearing pointed shoes with high heels, after physical exertion are common complaints. idiopathic etc. Usually there are no symptoms. If symptoms are present, surgical correction may be A I FLA F necessary. Common operations performed are: (i) These are static flat feet, where there has been a osteotomy of nec of the first metatarsal (Mitchell s structural change in the foot e.g., flail foot in a fat osteotomy); (ii) excision of the metatarsal head (Mayo s operation); and (iii) excision of the base of the proximal phalanx (Keller s operation). ALL I I This means a stiff big toe due to OA of the metatarso-phalangeal joint of the great toe. t is usually a result of old trauma, arthritis etc. HAMMER TOE t is a fixed flexion deformity of an inter-phalangeal joint of the toe, usually with callosity over the prominent proximal joint. What have we learnt? • ibrosis of sterno-mastoid muscle is the cause of torticollis. • ervical rib arises from th cervical vertebra. • In infantile coxa vara, neck-shaft angle is reduced. • lipped capital femoral epiphysis is a disease of adolescence, commonly associated ith endocrine disorders. • enu valgus, enu varum, at foot are developmental disorders hich often get cor- rected ith gro th. Additional information: From the entrance exams point of view • teel s metaphyseal blanch sign and cham s loss of dense triangular appaearance of infero- medial articular neck is seen in . • hocomelia is a defect in the development of long bones. • adelung s deformity is seen in the rist. • ongenital pseudoarthrosis of the tibia and bula and musculoskeletal deformities are seen in neuro bromatosis type II. They are treated by internal xation and bone grafting. https://kat.cr/user/Blink99/

40C H A P T E R Amputations, rosthetics and rthotics TOPICS • Amputations • pecial features of amputations in children • rostheses in orthopaedic practice • rthoses in orthopaedic practice AMPUTATIONS Table– .1: Indications for amputation Amputation is a procedure where a part of the limb • njury is removed through one or more bones. It should • eripheral vascular disease, including diabetes be distinguished from disarticulation where a part • nfections e.g., gas gangrene is removed through a joint. For simplifying this • Tumours discussion, the term ‘amputation’ is applied to • erve injuries both these procedures. Amputation of lower limb • Congenital anomalies is more commonly performed than that of upper limb; however, partial amputation of fingers or amputation is most often secondary to injury or its hand is common in developing countries, mainly sequelae. In children, limbs may be deficient since as a sequelae of farm and machine injuries. birth. Amongst the acquired causes, injury and malignancy top the list. INDICATIONS TYPES Overall, injury is the commonest cause of amputation in developing countries. The injury Guillotine or Open Amputation may be sustained in traffic accidents, in agriculture fields during harvesting season, in riots etc. This is where the skin is not closed over the Upper limb amputations occur commonly by kutti amputation stump, usually when the wound is chopper or thresher machines. Train accidents, at a not healthy. The operation is followed, after some level railway crossing, unaware of a coming train, period, by one of the following procedures for is a common cause of lower limb amputation. Some constructing a satisfactory stump: common indications for amputation are given in Table–40.1. • Secondary closure: Closure of skin flaps after a few days. Indications for amputation vary in different age groups. In the elderly (50-75 years), peripheral • Plastic repair: Soft tissues are repaired without vascular disease with or without diabetes is cutting the bone and skin flaps are closed. the main cause. In younger adults (25-30 years), • Revision of the stump: Terminal granulation tissue and scar tissue, as well as a moderate amount of bone is removed and the stump reconstructed.

Amputations, Prosthetics and Orthotics | 329 • Re-amputation: This is amputation at a higher Classification of amputation on the basis of its level level, as if an amputation is being performed for is given in Table–40.2. the first time. Table– .2: Nomenclature of amputation by levels losed Amputation Name Part of the limb removed This is where the skin is closed primarily (e.g., most elective amputations). Upper limb Scapula lateral 2/3 of clavicle • Forequarter whole of the upper limb SURGICAL PRINCIPLES – FOR CLOSED TYPE amputation emoval through the gleno-humeral Amputation surgery is a very important step • Shoulder joint in the rehabilitation of an amputee, and must Through the arm be approached as a plastic and reconstructive disarticulation procedure. Following are some of the basic • Above elbow Through the elbow principles to be followed meticulously: amputation Through the forearm bones a) Tourniquet: Use of a tourniquet is highly • lbow desirable except in case of an ischaemic limb. Through the radio-carpal joint disarticulation b) Ex-sanguination: Usually a limb should be • Below elbow emoval of a finger with respective squeezed (ex-sanguinated) by wrapping it with metacarpal from carpo-metacarpal joint a stretchable bandage ( smarch bandage) before amputation Ma ing forceps with two forearm bones a tourniquet is inflated. It is contraindicated in • Wrist cases of infection and malignancy for fear of spread of the same proximally. disarticulation • ay amputation c) Level of amputation: With modern techniques of fitting artificial limbs, strict levels adhered • Kru enburg s to in the past are no longer tenable. rinciples amputation guiding the level of amputations are as follows: • The disease: Extent and nature of the disease Lower limb or trauma, for which amputation is being done, is an important consideration. One • Hindquarter Whole of the lower limb with one side tends to be conservative with dry-gangrene (vascular) and trauma, but liberal with amputation of the ilium removed acute life threatening infections and malig- nancies. • Hip Through the hip • Anatomical principles: A joint must be saved as far as possible. These days, it is possible to fit disarticulation artificial limbs to stumps shorter than ‘ideal’ length, as long as the stump is well healed, • Above nee Through the femur non-tender and properly constructed. • Suitability for the efficient functioning of amputation the artificial limb: Sometimes, length is compromised for efficient functioning of • Knee Through the nee an artificial limb to be fitted on a stump. For example, a long stump of an above- disarticulation knee amputee may hamper with optimal prosthetic fitting. • Below nee Through the tibia-fibula amputation • Syme s amputation Through the an le joint • Chopart s Through talo-navicular joint amputation • isfranc s Through inter-tarsal joints amputation Skin flaps: The skin over the stump should be mobile and normally sensitive, but atypical skin flaps are preferable to amputation at a more proximal level. Muscles: Muscles should be cut distal to the level of bone. Following methods of muscle sutures have been found advantageous: • Myoplasty i.e., the opposite group of muscles are sutured to each other. • Myodesis i.e., the muscles are sutured to the end of the stump. These are contraindicated in peripheral vascular diseases. Nerves are gently pulled distally into the wound, and divided with a sharp knife so that the cut end retracts well proximal to the level of bone section. https://kat.cr/user/Blink99/

330 | Essential Orthopaedics COMPLICATIONS arge nerves such as the sciatic nerve contain 1. Haematoma: Inadequate haemostasis, loosening relatively large vessels and should be ligated before of the ligature and inadequate wound drainage are they are divided. the common causes. Haematoma results in delayed wound healing and infection. It should be aspirated Major blood vessels should be isolated and and a pressure bandage given. doubly ligated using non-absorbable sutures. The tourniquet should be released before skin closure 2. Infection: The cause generally is an underlying and meticulous haemostasis should be secured. peripheral vascular disease, diabetes or a haematoma. Wound breakdown and occasionally Bone level is decided as discussed earlier. spread of infection proximally may necessitate Excessive periosteal stripping proximally may lead amputation at a higher level. A wound should not to the formation of ring sequestrum from the end be closed whenever the surgeon is in doubt about of the bone. Bony prominences which are not well the vascularity of the muscles or the skin at the padded by soft tissues should be resected. Sharp cut end. Any discharge from the wound should edges of the cut bone should be made smooth. be treated promptly. Drain: A corrugated rubber drain should be used 3. Skin flap necrosis: A minor or major skin flap for 4 -72 hours post-operatively. necrosis indicates insufficient circulation of the skin flap. It can be avoided by taking care at the time After treatment: Treatment, from the time of designing skin flaps that as much subcutaneous amputation is completed till the definitive tissues remain with the skin flap as possible. Small prosthesis fitted, is important if a strong and areas of flap necrosis may heel with dressings but maximally functioning stump is desired. Following for larger areas, redesigning of the flaps may be care is needed: required. • re in : There are two types of dressings used 4. Deformities of the joints: These results from after amputation surgery: (i) conventional or improper positioning of the amputation stump, soft dressing; and (ii) rigid dressing. The latter leading to contractures. A mild or moderate has been found to be advantageous for wound contracture is treated by appropriate positioning healing and early prosthetic fitting. and gentle passive-stretching exercises. Severe deformity may need surgical correction. Soft Dressing: This is conventional dressing using gauge, cotton and bandage. 5. Neuroma: A neuroma always forms at the end of a cut nerve. In case a neuroma is bound down to Rigid Dressing: In this type of dressing, after a the scar because of adhesions, it becomes painful. conventional dressing, a well moulded o cast is applied on to the stump at the conclusion of ainful neuroma can usually be prevented by surgery. This helps in enhancing wound healing dividing the nerves sharply at a proximal level and maturation of the stump. In addition, the and allowing it to retract well proximal to the end patient can be fitted with a temporary artificial of the stump, to lie in normal soft tissues. If it does limb with a prosthetic foot (pilon) for almost form, it is to be excised at a more proximal level. immediate mobilisation. 6. Phantom sensation: All individuals with • Positioning and elevation of the stump: This is acquired amputations experience some form of required to prevent contracture and promote phantom sensation, a sensation as if the amputated healing. part is still present. This sensation is most prominent in the period immediately following • Exercises: Stump exercises are necessary for amputation, and gradually diminishes with time. maintaining range of motion of the joint proximal to the stump and for building up hantom pain is the awareness of pain in the strength of the muscles controlling the stump. amputated limb. Treatment is difficult. • Wrapping the stump helps in its healing, shrinkage and maturation. This can be done with a crepe bandage. • ro t etic fittin an ait trainin : This is started usually 3 months after the amputation.

SPECIAL FEATURES OF AMPUTATIONS IN CHILDREN Amputations, Prosthetics and Orthotics | 331 These are called body powered prostheses; in others Amputations in children have the following special an external source of power, usually rechargeable features: batteries is used. In general, more distal the amputation, more • Children may have amputation since birth. functional the individual is with the use of • A disarticulation is preferred to an amputation a prosthesis. oor candidates for functional prosthetic fitting are the following: through the shaft of a long bone at a more a) A lower limb amputee with ischaemic limb, proximal level. This is because disarticulation preserves the epiphysis distally, and therefore with an open or poorly healed wound. growth of the stump continues at the normal b) An above- nee amputee with 45 degrees rate. • As the child grows, terminal overgrowth of the flexion contracture at the hip. bone occurs and needs frequent revisions. c) A below-elbow amputee with a flail elbow and • A child needs frequent changes in the size of the artificial limb. shoulder. • Children tolerate artificial limbs much better and d) Bilateral above- nee amputee with short get used to wearing it more quickly. stumps. PROSTHESES IN ORTHOPAEDIC PRACTICE arts of a prosthesis The prosthesis consists of a socket, Prosthetics is a unit of rehabilitation medicine dealing with the replacement of whole or a part designed to be in close contact with the stump; of a missing extremity with an artificial device. a suspension to hold the socket to the stump; a The device so manufactured is called a prosthesis. prosthetic extension with substitue joints; and a terminal device (Fig-40.1). The soc ets are shaped ses of prostheses A prosthesis may be used to .1 e e replace a body part externally (e.g., an artificial limb) or internally (e.g., an artificial hip joint). according to the shape of the stump. These could be During the past two decades considerable progress end bearing sockets – where end of the stump bears has occurred in prosthetics and rehabilitation of the weight, or total contact socket – where the weight an amputee. Improved materials, new designs, is distributed evenly throughout the surface of the and better evaluation and fitting techniques have socket. The socket is the fundamental component resulted in prostheses that are lighter and stronger, to which the remaining components are attached. and provide improved function, cosmesis and Most soc ets are double-walled. A plaster cast comfort. By and large, prosthetic replacement of the moulding of the stump is used to fabricate the lower limb offers excellent restoration of function, socket for optimal fit, function and comfort. and the cosmetic appearance is satisfactory. However, providing prosthesis for the upper * Solid Ankle Cushioned Heel. limb is more dificult. It is almost impossible for a mechanical device to reproduce the versatility, dexterity and appearance of the natural hand. One of the most important aspect of a rehabilitation programme for a patient with amputation is to orient the patient realistically as to what the prosthesis can and cannot do. A prosthesis can be: (i) cosmetic – to provide normal appearance or (ii) functional – to provide function of the missing part. The prosthesis does not have sensation, proprioception or muscle power. The power is provided to a prosthesis by forces arising from movement of the residual or other side limb. https://kat.cr/user/Blink99/

332 | Essential Orthopaedics Traditionally, the terminal device of a lower limb • AFO An le Foot Orthosis prosthesis is a prosthetic foot, called SACH* • KAFO (previously called below- nee caliper) foot. It is a simple device that has a wooden core • HKAFO Knee-An le-Foot Orthosis surrounded by a solid rubber foot. This permits (previously called above- nee caliper) a combination of stiffness with pliability. The • KO Hip-Knee-An le-Foot Orthosis cushioned heel absorbs the impact of heel strike. • CO (previously called above- nee caliper n ndia, at aipur, SACH foot has been modified • WHO with pelvic band) in a number of ways to make it suitable for • CT SO Knee Orthosis (previously called nee barefoot walking. Essentially, these modifications • FO brace) are: (i) appearance of the foot is that of a normal Cervical Orthosis foot; and (ii) it allows movement at forefoot and (previously called cervical collar) midfoot, making walking on uneven surfaces Wrist Hand Orthosis easier. Similarly, for an above- nee amputee, a (previously called coc up splint) prosthesis has been developed at A MS, ew Cervico-Thoraco- umbo-Sacral Orthosis Delhi, which permits squatting and sitting cross- (previously called body brace) legged. Upper limb prostheses are named by the Foot Orthosis level of amputation. Some of the commonly used (previously called surgical shoes) prostheses are given in Table–40.3. Orthoses can be divided into static and Table– .3: Commonly used prostheses dynamic types. Static orthoses are used: (i) to support an arthritic joint or a fractured bone; (ii) • Above- nee amputation uadrilateral soc et prosthesis • Below- nee amputation TB ( atellar Tendon Bearing) to prevent joint contractures in a paralytic limb; prosthesis • Syme s amputation Canadian Syme s prosthesis and (iii) for serial splinting of a joint to correct • artial foot amputation Shoe fillers contracture. na ic ort o e are used to apply forces to a joint which is damaged by arthritis or when the muscles that normally control the joint are weak. Recently, electrically operated prostheses have USES OF ORTHOSES been developed. These have opened up a new Orthoses are used for the following functions: world of freedom and function for persons with amputation, but these are very expensive. There • To immobilise a joint or body part e.g., a painful joint have been a number of advances in designing of • To prevent a deformity e.g., in a polio limb prosthesis. With the help of computers, the socket • To correct a deformity e.g., in ol mann s contracture can be so designed keeping in mind particular areas • To assist movement e.g., in a polio limb over which pressure could be relieved. • To relieve weight bearing e.g., in an un-united fracture • To provide support e.g., to a fractured spine ORTHOSES IN ORTHOPAEDIC PRACTICE Some common clinical conditions requiring orthoses are cervical spondylosis or whiplash injury Orthotics is the unit of rehabilitation which deals (common cervical collar or cervical orthosis), with improving function of the body by the application of a device which aids the body part. Table– . : Surgical shoes Flat foot The device so manufactured is called an orthosis. • Shoe with Thomas heel Flat foot NOMENCLATURE OF ORTHOSES (C and heel*) Clubfoot Until recently, the terms braces, calipers, splints, and corsets, used to name and describe orthoses • Shoe with arch support lantar fascitis were not uniform. ow a logical, easy to use • CT shoes Corns system of standard terminology has been • Shoe with heel pad Metatarsalgia developed. This system uses the first letter of the • Shoe with metatarsal pad name of each joint which the orthosis crosses in • Shoe with metatarsal bar enu valgum correct sequence, with the letter O (for orthosis) • Shoe with medial raise enu varun attached at the end. Some of the commonly used • Shoe with lateral raise Short leg orthoses are given below: • Shoe with universal raise * Croo ed longated heel