Essential Orthopedics-Maheshwari

Amputations, Prosthetics and Orthotics | 333 .2 e wrist drop (WHO), foot drop (AFO), poliomyelitis (Fig-40.2c). More and more orthoses are made (orthosis depending upon muscle power), available in ready to use designs; these can be rheumatoid arthritis, and spinal injury (Fig- adjusted to fit individual patients. Also, custom 40.2). Some surgical shoe modifications made made components of orthosis are available. These for different orthopaedic conditions are given in can be assembled and a caliper/orthosis made, Table–40.4. thus saving time. In newer designs, adjustment of height of the orthosis is possible in growing children. In recent years, quality of orthosis has improved with availability of better material and designing Contributed by: Dr. Sanjay Wadhwa, facilities. For polio, traditional calipers can now rofessor, be replaced by aesthetic plastic inserts which can go inside the shoes and can be worn under clothes Department of hysical Medicine All ndia nstitute of Medical Sciences, ew Delhi. What have we learnt? • Amputations are named according to their level. • ell constructed stump and ell tted prosthesis are key to good functions. • odern nomenclature of orthoses is based on the joints the orthosis is supposed to con- trol. • hoe modi cations help settle foot disorders. https://kat.cr/user/Blink99/

41C H A P T E R Arthroscopic urger TOPICS • rocedure • Limitations • Ad antages • Indications Sports medicine has become a fast growing sub- Fig-41.1 Knee arthroscopic surgery speciality of orthopaedics. Initially, it was to do with the knee injuries in competitive athletes, • Little immobilisation required: The only but now it has expanded to include the overall immobilisation of the knee is in the form of a care of an athlete at every level. The speciality small dressing for 48 hours. It allows the knee consists of care of the injured athlete, his pul- to be bent. It is possible for the patient to be up monary and cardiovascular build up, training and about in the house within 48 hours. Very techniques, nutrition etc. Hence, it has become little or no physiotherapy is required. a speciality with multi-disciplinary approach involving trainers, physical therapists, cardio- • Barely visible scars: Since the whole operation logists, pulmonologists, orthopaedic surgeons is performed through multiple small punctures, and general practitioners. the scars are barely visible. Arthroscopy is a technique of surgery on the • Possible under local anaesthesia: In selected joints in which tip of a thin (4 mm diameter) cases, it is possible to perform the operation telescope called arthroscope is introduced into a under local anaesthesia. The patient can joint, and the inside of the joint examined (Fig- literally walk into the operation theatre and 41.1). This is called diagnostic arthroscopy. Once walk out of it. the diagnosis is made, necessary correction can be done, there and then, by introducing micro- • Better assessment of the joint: Arthroscopy instruments through another small skin puncture. is the best modality for diagnosing a joint This is called arthroscopic surgery. Today, most pathology. Even MRI, which is a close next to operations on the joints, particularly on the knee arthroscopy gives only limited information. and shoulder, can be carried out arthroscopically. MRI, being a sensitive investigation, can This technique has revolutionised the treatment of sometime pick up lesions which may not be joint disorders. ADVANTAGES OF ARTHROSCOPIC SURGERY • Minimally invasive technique: The operation is performed through small punctures, without cutting open the joint. There is almost no blood loss. • Day-care surgery: The surgery is performed on day-care basis, which means that the patient is admitted on the morning of the operation and sent home the same evening.

Arthroscopic Surgery | 335 clinically significant (false positive), and also Table– 1.1: Indications for arthroscopic surgery may miss lesions which are better picked up by actually seeing them and probing them (false Knee Joint: negative). - Loose body removal - Partial or complete menisectomy • Dynamic assessment of the joint possible: - Chondroplasty (repair or removal of degenerated carti- Since it is possible to move the joint while arthroscopy is being performed, one can lage) actually see how the structures inside the joint - Excision of plicas, the thickened synovial folds in the appear when the joint is moved. A new group of abnormalities in the joint have come to light knee due to the possibility of dynamic assessement. - Correction of patellar maltracking For example, an abnormal tracking of the - Synovial biopsy patella (patella not moving concentrically in the - Synovectomy trochlear notch) may be seen very convincingly - Release of a stiff knee (Arthrolysis) arthroscopically. - Ligament reconstruction - Fusion of the knee (Arthrodesis) • New diagnostic possibilities: A number of new diagnostic possibilities have come to Shoulder Joint knowledge since the availability of arthroscope. - Loose body removal A whole new group of conditions in the knee - Debridement of loose labrum glenoidale called Plicas have been understood to be as- - Diagnosis of the cause of shoulder pain sociated with patient’s symptoms. Similarly, - Arthroscopic shoulder stabilisation in recurrent disloca- some lesions such as SLAP* lesions, which cause shoulder pain, can be diagnosed only tion of the shoulder arthroscopically. - Excision of AC joint - Subacromial decompression • Research possibility: Being a minimally - Release of a frozen shoulder invasive procedure, arthroscopy offers the - Rotator-cuff repair possibility of studying the changes in the intra-articular structures e.g., changes in an Ankle Joint implanted artificial ligament and its process - Loose body removal of acceptance by the body. - Correction of anterior impingement - Chondroplasty INDICATIONS FOR ARTHROSCOPIC SURGERY - Synovectomy - Synovial biopsy Arthroscopy may be done to confirm a diagnosis - Arthrodesis in case it has not been possible to do so otherwise. In most cases, a provisional diagnosis is made Elbow before proceeding with arthroscopic surgery. - Release of stiff elbow Once the diagnosis is confirmed arthroscopically, - Removal of loose body necessary corrective measures are taken. Some of - Synovectomy the common procedures which can be successfully performed arthroscopically are as shown in Wrist Table–41.1. - Diagnosis of wrist pain - Debridement of torn triangular cartilage EQUIPMENT - Synovial biopsy and synovectomy Arthroscopic surgery is an equipment dependent (b) To perform basic operations: Hand instru- surgery. Most of the equipment is imported and ments such as a probe, cutters, graspers, scis- expensive. The following equipment is necessary. sors, knives etc. (a) To visualise inside the joint: Arthroscope, (c) To perform complex operations: Instruments light source, fibre-optic cable, video camera such as motorized shaver, underwater cutting and TV monitor. cautery etc. Some special instruments are re- quired for particular operations such as ACL, * Superior Labrum Anterior-Posterior PCL reconstructions. An arthroscope is a 4 mm telescope having a 30o forward oblique angle (Fig-41.2). This obliquity helps in increasing the field of vision. Smaller size arthroscope is used for smaller joints. https://kat.cr/user/Blink99/

336 | Essential Orthopaedics maintaining it under pressure with the help of a fluid pump. Fig-41.2 An arthroscope LI I A I F A I PROCEDURE A I A ILI One needs to develop special psychomotor skills to be able to perform arthroscopic surgery. Following Arthroscopic surgery is not a panacea for each and are the commonly scoped joints. every joint disorder. It has no role where the disease is too early and can be managed with medicines and KNEE ARTHROSCOPY physiotherapy. Sometimes the damage is beyond Procedure on the knee is done with the patient arthroscopic repair. In the knee, arthroscopic under spinal or general anaesthesia. A tourniquet procedures have failed to produce significant is applied on the thigh. The knee is cleaned and relief in advanced stages of osteoarthritis. Also, a draped as would be done for any other major stiff knee with quadriceps scarring and adhesions knee operation. The arthroscope and instruments cannot be managed only arthroscopically, and open are introduced through small cuts called portals, surgery is required. as shown in Fig-41.3. The commonest portal is antero-lateral portal located just lateral to the In the shoulder, arthroscopy is not effective if the patellar tendon, at the level of the joint.This is the exact cause of pain has not been diagnosed before one through which the arthroscope is introduced. A surgery. Arthroscopy has limited role in treatment small video camera is attached to the arthroscope, of shoulder osteoarthritis, massive rotator- and the inside of the knee can be seen on the TV cuff tears and multidirectional instability. The monitor. The arthroscope can be moved to different fascinating aspect of arthroscopic surgery is that parts of the joint, and all the structures inside the what its limitation is today, may not remain so in joint are thoroughly examined. A second portal is future as advances in technology makes it possible. used for introducing probe or other instruments. The portal used commonly for this purpose is LA I made on the medial side of the patellar tendon (antero-medial portal). The crux of performing Arthroscopy has a steep learning curve. One has to arthroscopic surgery is the ability to bring the work within a confined space, and manoeuvering tip of the instruments in front of the telescope the scope as well as instruments is difficult. Rough (triangulation). movements can cause damage to the intra-articular structures and breakage of the rather delicate L A instruments. It is very useful in making a correct diagnosis in shoulder problems. The usual approach to Fig-41.3 Portals used in knee arthroscopic surgery arthroscopic shoulder examination is via a posterior portal. This is located 2 cm below and medial to the postero-lateral angle of the acromian. Other instruments such as a probe, are passed from anterior portals, all of which are lateral to the coracoid process. In order to ensure clear visibility, and since a tourniquet cannot be used, clarity is maintained by inflating the joint with saline and

EQUIPMENT Arthroscopic Surgery | 337 The equipment used for arthroscopy is expensive. The instruments being delicate, need continuous specific instruments are necessary. One has to keep care and replenishment. A number of procedure a big inventory of instruments and implants. There is no role of make-shift (Jugaad) in arthroscopic surgery. What have we learnt? • Arthroscopy is a fast developing eld of orthopaedics ith a steep learning curve. • ost operations on joints can be performed by keyhole surgery. It is particularly useful for knee and shoulder. Additional information: From the entrance exams point of view icrofracturing is done for osteochondral defects. https://kat.cr/user/Blink99/

42C H A P T E R Joint eplacement urger TOPICS • otal shoulder replacement • otal elbo replacement • emiarthroplast • otal joint replacement • artial knee replacement Joint replacement is a procedure whereby one or Fig-42.1 Types of hip replacement both the components forming a joint are replaced with artificial components (called prosthesis). The prostheses are made up of special metal alloy or special high density polyethylene. A lot of research has gone into choice of the material, designing of the prosthesis and technique of their implantation. But, even till today, no artificial joint is as good as God given joint. Following are some of the commonly performed joint replacement procedures. HEMIARTHROPLASTY (Partial joint replacement) This means replacing only one side of a joint. For instance the head of the femur is replaced with an artificial component while the acetabulum is left as it is. Hemiarthroplasty is indicated in situ- ations where only one half of the joint is affected, e.g., fracture neck of the femur in the elderly. A variety of prostheses are used – it could be a single piece (monopolar) or two piece (bipolar) prosthesis (Fig-42.1). In the latter, motion occurs between the two parts of the prosthesis itself. The prosthesis could be modular, where the prosthesis could be assembled on the table from a choice of combina- tion of stem and head sizes. The prosthesis could be cemented (bonded to the host bone by bone cement), or uncemented (a press-fit design where natural bonding occurs between the host bone and the prosthesis). The operative technique consists of exposing the hip, dislocating the hip, resecting the ends, preparing the medullary canal for receiving the prosthesis, implanting the prosthesis in the

canal, reducing the hip and closing the wound. Joint Replacement Surgery | 339 Post-operative rehabilitation is very important. A similar hemiarthroplasty operation is also done Fig-42.2 X-ray showing bilateral total hip replacement in the shoulder where the damaged head of the humerus is replaced with a prosthesis. replacement, full non-operative treatment should have been tried. Also should have been taken into TOTAL JOINT REPLACEMENT consideration, other less invasive joint preserving procedures such as osteotomy, joint debridement This means that both the components of the joint are and hemiarthroplasty. An arthrodesis may be a replaced – e.g., the head as well as the acetabulum more suitable option in some cases. are replaced in a total hip replacement operation. This Choice must be made between cemented and procedure is often required in patients suffering from uncemented joint replacement. In general, ce- arthritic afflictions of the joint. The procedure was mented arthroplasty is used in elderly people with first developed by Sir John Charnley in 1960. It has expected life of 10-15 years and uncemented in proved to be a successful operation giving 15-20 years younger people. of good function. Success of this operation depends upon the skill of the surgeon, his understanding of omplications It is a highly demanding operation. the basic biomechanics and the functional status of the joint before surgery. The following complications can occur: a) Deep venous thrombosis (DVT): This occurs These are expensive operations because good qual- ity artificial joints are imported. Just for an idea, due to inadvertent manipulation of the thigh the cost of the artificial joint itself is approximately during surgery, venous stasis in the limb due to immobility, and some inherent factors in s. 30,000–100,000 (variable). ood quality ndian the patient which put him at a higher risk joints have become available and give satisfactory for developing DVT. Treatment consists of results in the hands of those using them. Apart prevention of DVT by pharmacologic agents from the joint, training of the surgeon, standard such as heparin and its newer derivatives, of the operation theatre and post-operative care and by mechanical means such as continuous constitute essential ingredients to making this exercises of the leg, compression garments, operation successful. elevation of the leg etc. b) Nerve palsies: These are relatively infrequent. Total joint replacement operations started with Sciatic nerve is the most commonly affected, hip replacement, quickly went on to the knee, the particularly in procedures requiring complex shoulder, the elbow etc. Today, almost all joints hip reconstruction. of the body have been replaced with varying de- c) Vascular injury: This is uncommon, but can gree of success. Two most popular replacement occur mainly due to technical reasons. operations are the hip and the knee replacement. d) Fracture: These may occur during the pro- cess of implantation of the prothesis, mainly TOTAL HIP REPLACEMENT on the femoral side, or later due to stress concentration. The latter usually occurs just This is an operation where both, the acetabulum and the head of the femur are replaced with artifi- cial components. For the acetabulum, a cup made of high density polyethylene is used, and for the head a specially designed prosthesis made of metal alloy (cobalt-chromium alloy) is used. Both com- ponents are fixed in place with or without bone cement (Fig-42.2). Indications An overall indication of total hip replace- ment is incapacitating arthritis of the hip, severely affecting patient’s functions. t could result from a variety of reasons such as rheumatoid arthritis, osteoarthritis etc. Before considering a hip for https://kat.cr/user/Blink99/

340 | Essential Orthopaedics Fig-42.3 Total knee replacement is actually only a resurfacing operation distal to the tip of the femoral stem. Treat- ment depends upon the site and type of frac- the ends of tibia and femur to take the artificial ture, and it does prolong the rehabilitation. components. The important goal of the procedure is to achieve optimal alignment of the leg and soft e) Dislocation: The rate of dislocation of an ar- tissue balance between ligaments around the knee. tificial hip joint is between 1-8 per cent. It is This provides crucial stability to the artificial joint primarily due to malpositioning of the limb (Fig-42.5). The most recent advance in knee replace- during early post-operative period, malposi- ment surgery is use of computer navigation during tion of the replaced components, and later, surgery. This ensures accuracy. loosening of the components. It is fair to expect 10-15 years of excellent functions after a properly executed total knee replacement. f) Infection: This is the most serious of all com- The success of this operation depends upon proper plications. Prevention is the best way. selection of the patient, technically perfect execu- tion of the procedure and sincere rehabilitation g) Heterotrophic bone formation: New bone effort. formation around the components occurs in some cases such as ankylosing spondylitis, and omplications Following complications can occur: results in decreased range of joint movements. 1. Infection: Infection could be minor in the form TOTAL KNEE REPLACEMENT of wound breakdown, or a major infection necessitating another operation to clean up This is a relatively newer operation. In true sense, the term total knee replacement is a misnomer, Fig-42.4 Parts of an artificial knee joint since unlike the hip replacement where a part of the head and neck are actually removed and replaced with similar shaped artificial components, in the knee only the damaged articular surface is sliced off to prepare the bone ends to take the artificial components which ‘cap’ the ends of the bones. n a way, this could be more appropriately called a knee resurfacing operation (Fig-42.3). Indications Like in the hip, painful disabling arthritis is the main indication of doing a total knee arthro- plasty. It is contraindicated if there is a focus of sepsis, extensor mechanism is insufficient or if the joint is neuropathic. Relative contraindications are: a younger patient (less than 50 years), obesity and those in physically demanding profession where results may not be as good. he Implant and the rocedure The artificial knee joint consists of the following parts (Fig-42.4): a) A -shaped femoral component to ‘cap’ the prepared lower end of the femur. b) A tibial base plate to cover the cut flat surface of the upper end of the tibia. Either both cruci- ates or only anterior cruciate is excised. c) A plastic tray inserted between the above two metallic components. d) A patellar button made of polyethylene to replace the damaged surface of the patella. The procedure consists of a series of steps based on specially designed jigs. These jigs are used in a step by step manner. The whole idea is to prepare

(a) (b) Joint Replacement Surgery | 341 Fig-42.5 X-ray of the knee, AP view showing (a) Partial knee replacement (b) Total knee replacement 5. Extensor mechanism complications: Handling of extensor mechanism is required during the the joint. Sometimes the infection may not be course of the operation. These may occur due controlled, and removal of the prosthesis and to avulsion of the patellar tendon, inadvertent fusion of the joint may become necessary. cutting of the tendon etc. 2. Deep Venous Thrombosis (DVT): It occurs as 6. Knee stiffness: The patient may not be able to a result of immobility. Treatment is on lines as regain range of motion due to heterotropic bone discussed in hip section. formation or intra-articular adhesions. 3. Nerve palsy: Common peroneal nerve palsy PARTIAL KNEE REPLACEMENT sometimes occurs in cases requiring dissection ( nicond lar eplacement) on the lateral side of the knee. Spontaneous recovery occurs in most cases. This is a newer operation, done for a knee where only a part is damaged (partial damage). Here the 4. Fractures: Fractures may occur while perform- knee is opened using a small incision, a cap is put ing the operation, particularly in osteoporotic on top of the damaged part without removing any bones of a bedridden rheumatiod patient. Frac- ligaments, muscles, etc. In selected cases, this works tures may occur late through the bones near the as well as the more invasive total knee replacement. prosthesis due to stress concentration in that It is indicated in strictly partially damaged knee. area. TOTAL SHOULDER REPLACEMENT This operation has limited indications because osteoarthritis of the shoulder is an uncommon condition. Most patients with stiff, painful shoulder due to other causes manage to live with it. Like in the hip, here also, the cup (glenoid) and the ball (head humerus) are replaced. TOTAL ELBOW REPLACEMENT This is indicated in stiff and painful elbows due to rheumatoid arthritis and as a fall out of elbow injuries. The techniques have now got established to ensure good functions for 10-15 years. What have we learnt? • oint replacement surgery is ell established ith practically all joints of the body hav- ing been replaced. • ip, knee and shoulder replacement are common. • oint replacement can be partial or total depending upon hether one or both articulating surfaces are replaced. Additional information: From the entrance exams point of view • etal on metal joints are contraindicated in omen of child bearing age. • ost common cause of death after total hip replacement is pulmonary thromboembolism. • ite to harvest rst order, primary and cancellous bone graft is pelvis and iliac crest. It is also the best site to harvest the same. https://kat.cr/user/Blink99/

Annexures Annexure - I Clinical Methods GENERAL treatment has the patient taken for it, and ultimately, what functional level of activity does the patient possess. For The art of clinical methods can be mastered only in the ward. extracting relevant information, background knowledge of It essentially consists of the following: different diseases, their presentation, their complications etc. are necessary. The following discussion is only to form Developing a rapport with the patient: The patient should concepts in clinical orthopaedics. There is no ‘always’ in be made comfortable in a chair or on a couch. Initial general medicine. At places the reader may find over-emphasis; these talking will make the patient feel at home, and give the are only meant to highlight some concepts. examiner an idea of the mental status of the patient. Patients usually feel at ease with one of their relatives with them. Broadly, the history tells us about the disease aetiology (i.e., Patients have a concept that doctors are extremely busy whether it is infection, tumour etc.), and the examination about people, and forget half the things when they face a doctor. It the site of involvement (i.e., whether it is the bone or joint or is the duty of a doctor to present himself as a well-composed, the tendon etc., the tissue affected). well-dressed, full of concern, not-in-a-hurry person. GENERAL INFORMATION Establishing communication with the patient so that you can understand what he says and means. Patients have their First note the name, age, sex, address and occupation of the own concepts about diseases and their causes. Do not get patient. Some of this information may be helpful in thinking carried away by what they say. Ascertain what they mean by about the possible diagnosis, as discussed below: intelligent cross questioning. Table–1: Diseases which occur at a particular age History taking: This consists of two parts. The first part is the presenting complaint i.e., what complaint has brought • olio 1-2 yrs. the patient to the hospital. The second part is the history of • ic ets ( utritional) 1-2 yrs. present illness i.e., the sequence of events starting from the • erthes’ disease 5-10 yrs. onset of the problem till the time of presentation. It is best to • Slipped capital epiphysis 12- 1 yrs. let the patient say whatever he has to, or whatever he feels • Acute Osteomyelitis/arthritis about his illness. You can always extract relevant information • Bone malignancies 15 yrs. by moderating history. •D 10-20 yrs. • heumatoid arthritis 20-40 yrs. Examination: This consists of examining the patient to look 20-40 yrs for salient features which may be in support of or against the diagnosis. It is best to arrive at some differential diagnoses Age: There are fractures which occur more commonly in on the basis of the history, before beginning the examination. children, others occur more often in adults or in the elderly. Therefore, the aims of clinical history and examination are Hence by knowing the age, one can think of possible injuries as follows: which could occur at that age. Patients with congenital a) To arrive at a diagnosis i.e., to find out the cause of the malformations such as CDH present early in life. Infections and bone tumours are common in children. Degenerative problem. diseases occur at an older age. Some diseases occur in a b) To find out whether the basic disease has produced particular age group and age consideration becomes very important in the diagnosis of these diseases (Table–1). any complication. For example, a patient with chronic osteomyelitis may have developed shortening of the bone Sex: Some diseases are more common in males; some others due to effect of the disease on the growth plate. c) To determine what way has the disease or its complication, in females. Table–2 lists some of these diseases. n general, all if any, affected the functions of the patient. For example, in type of injuries are nearly as frequent in males as in females. the case of a patient with affection of the lower limb there may be decreased ability to wal – there may be limp, or Table–2: Sex predisposition in Orthopaedic diseases support may be needed for walking. • CDH Females The last part of the wor -up — the functional disability, is • Slipped epiphysis Males the most important in orthopaedics. It represents the way the • heumatoid arthritis Females disease has affected the functions of the patient; and it is this • An ylosing spondylitis Females that concerns us and the patient the most. Upon it depends • Osteomalacia Females the treatment planning. Occupation: What the patient does has a lot of relevance in HISTORY TAKING orthopaedics in two ways: (a) a number of complaints can be History taking is not merely a record of what the patient says, traced back to the kind of occupation. For example a patient, but it is an art of understanding and collecting information who is required to bend forward and lift heavy weight in the regarding what happened to the patient, what could have course of his job, may develop back strain; (b) in cases where caused it, what way the patient has been affected by it, what cure is not possible, physical requirements of the patient become the basis for deciding the treatment. For example, a

344 | Essential Orthopaedics little limp due to instability, at the cost of gaining movements e) Was the patient given any treatment? Did he get any at the hip, may be acceptable for a housewife. The same may be X-ray done at that time? These suggest that the injury was severely disabling for a heavy manual worker, who may prefer serious enough. a stiff but stable hip. Similarly the living style of a patient (e.g., the habit of sitting on the floor), may become an important In case one is sure that the disease is not related to trauma consideration in planning the treatment. inquire into the type of onset of the symptoms – whether acute, subacute or chronic. PRESENTING COMPLAINTS Progress of the disease: This consists of finding out how the History taking begins with asking the patient what exactly bothers him (i.e., what is his complaint?), and for how long. It symptoms progressed over a period of time. The questions takes a little while to be able to understand what and for how one must ask are: Whether it is a progressively worsening long has the problem been. One should let the patient say what disease? Is it a disease with remissions and exacerbations? Is he has to say, rather than obstructing his flow of thoughts and it a disease which came rather suddenly and subsided over trying to fit them into the ‘sequence of questions’ you have a period of time? etc. etc. Any treatment carried out during learnt in the ‘boo ’. Often, the patient’s story is required to be this period and its effect should also be noted. At the end, guided by some clarification and direct questions. The following one should make an assessment of the current status of the are some of the common complaints of an orthopaedic patient. patient, his functional activity, severity of pain, etc. (Table–3). • ain • Difficulty in using the limb (usually upper limb) Table–3: Sample history • nability to wal (patient is brought in a wheel chair, trolley, After a history taking session, a student should be able to in the lap) arrange the sequence of events in this way: • imp The patient was all right till ......... when he noticed ........ There • Deformity of a limb was no* history of trauma related to the onset. The symptom • Swelling appeared slowly**. Gradually the patient noticed additional • Stiffness symptoms such as (....... ). He consulted ........ and was • Wea ness prescribed ........ There was some*** relief with that treatment. • Discharging sinus In the meanwhile, the symptoms worsened.**** The patient • Altered sensation could not do ....... things. ow the patient can not do ........ There are usually more than one presenting complaints. If so, * or yes. ** or suddenly *** or no relief. ****or improved/ note the sequence in which they appeared. did not change. HISTORY OF PRESENTING ILLNESS COMMON COMPLAINTS OF AN ORTHOPAEDIC PATIENT One must give the patient time to settle down. A general The following is an account of some of the common complaints greeting, or a nonspecific talk will make the patient at ease. of an orthopaedic patient and the way they are analysed. One should let the patient narrate the ‘story’ of his illness. The following points need to be brought out from patient’s account: Pain: This is the commonest complaint. The pain may be at the Onset of Symptoms: Broadly, orthopaedic diseases can be site of the disease or it may be a pain referred from some other part. The following details about the pain need to be elicited. divided into two groups – trauma related and nontrauma a) What is the exact site of the pain? Try to be as specific as related. Hence, the first question to be asked is whether or not there was a trauma preceding the onset of symptoms. A possible. It helps to ask the patient to point to the site of pain. number of patients may falsely implicate an unrelated episode b) Does the pain radiate to some other area? It is common in of trauma as the cause of their disease. A detailed inquiry into the nature of the injury, the period between the injury and limbs to have pain originating in one part and radiating onset of the symptoms etc. can help in deciding whether injury to another part (Table–4). did play a role in causing the disease or not. The following leading questions help in this assessment. Table– : Radiation of pain Radiation to a) When did the injury occur in relation to the onset of Site from shoulder, arm symptoms i.e., immediately preceding, or a few days or arm weeks before*. ec forearm and hand b) How did the injury occur? i.e., to assess whether severity Shoulder girdle pain of the trauma was sufficient to cause whatever the patient Elbow loin complains of, and also to know the exact mode of the injury. Thoracic spine gluteal region c) Did the patient have symptoms (such as pain, swelling back of thigh and knee etc.) immediately following the trauma or did they occur umbar Spine front of thigh and knee 'after a few days or weeks'? umbo-sacral spine knee d) Was the patient able to carry out his activities despite the SI joint shin of tibia injury or in the case of a child, did the child continue to Hip play after the ‘injury’ Obviously, if this was so, the episode Thigh of trauma is unlikely to be related to the symptoms. Knee * It is a fact that sometimes there may be a long period between c) Is the pain present at all times? A pain due to neoplasia is the injury and onset of symptoms (of course unrelated). present at all times; it may fluctuate, but is persistent. A pain due to trauma is maximum within 4 to hours of injury and then starts subsiding. A pain of inflammatory origin builds up rather suddenly and then subsides. emissions and exacerbations are seen in pain due to chronic inflammatory diseases such as rheumatoid arthritis. A sudden appearance of pain in a rather painless https://kat.cr/user/Blink99/

disease is an indication of change in the nature of the Annexure I | 345 disease. For example, it could be malignant change in a benign swelling, or a pathological fracture through a bone the swelling progresses indicates its aetiology. A neoplastic affected with some disease. swelling eeps on growing, whatever the rate may be. On d) What aggravates or relieves the pain? A pain of mechanical the other hand, an inflammatory swelling has remission origin becomes worse with activity, and improves with after an initial rapid onset. The key question is whether the rest. On the other hand, a pain of chronic inflammation swelling ever reduced in size – if it did, suggests that it is not like osteoarthritis and rheumatoid arthritis comes up after a neoplastic swelling*. Swellings at more than one site are a period of rest, and improves with activity. seen in diseases like neurofibromatosis, multiple exostosis, e) What term can best describe the pain? This sometimes helps in multifocal tuberculosis or polyarthritis etc. localising the cause of the pain. A dull ache usually arises from a deeper structure; a shooting pain may indicate a Stiffness: Stiffness is a symptom of joint involvement. In early neurogenic pain or that due to acute inflammation. f) Are there any other symptoms associated with the pain? In stages of the disease, stiffness occurs due to protective spasm of most painful conditions of inflammatory, neoplastic or the muscles around the joint. This is nature’s way of avoiding traumatic origin, pain is associated with the swelling, movement at a painful joint. In late stages the joint becomes though in some cases it may not be clinically detectable. A stiff due to intra-articular and extra-articular adhesions. In referred pain or a pain of neurogenic origin may not have advanced stages, severe limitation of joint movement occurs. any local symptoms. This is called ankylosis of the joint. The cause of ankylosis could be intra-articular or extra-articular (Table– ). n inflammatory Difficulty in using the limb: This is usually a result of the pain. diseases like rheumatoid arthritis and ankylosing spondylitis, stiffness increases after rest (e.g., after an overnight sleep) but Sometimes, stiffness of joints deformity or muscle weakness improves with activity. may be responsible for the difficulty in using the limb. Table– : Causes of ankylosis Inability to walk: The cause of this is the same as above. It is a a la important to know at what rate has the disease progressed to • TB cause whatever limitation of walking i.e. whether it has been • Septic arthritis sudden, over days, over weeks etc. • iral arthritis Limp: This is a common early symptom in a patient with lower a a la • Myositis limb disease. imp is of two types – painful or painless. Causes • Arthrogyposis Multiplex Congenita of limp are as given in Table–5. • Burn contracture • Scleroderma and other such diseases Table– : Causes of Limp Weakness: Weakness of a limb is due to loss of muscle power. a ll • Any traumatic condition of the limb This could be secondary to disuse atrophy of the muscle or • Any inflammatoiy condition of the limb e.g., TB hip due to some neurological condition. The cause of neurological • Osteoarthritis hip weakness may be affection of the brain, (e.g., a stroke), spinal cord (e.g., poliomyelitis), nerve (e.g. neuropathy), a le l neuro-muscular junction (e.g., myasthenia) or muscle (e.g., • olio affecting lower limb myopathy). If there is no associated sensory loss, the cause • Coxa vara deformity of the hip may be either myopathy, neuropathy of a motor nerve, polio, • CDH or other motor neurone diseases. The onset of weakness may • Deformity of a joint or bone be sudden as in injury; or insidious as in myopathy, leprosy • Fused hip, nee or an le etc. Weakness is progressive in neuropathy and myopathy, but it improves with time (in the first few months) in polio. Deformity: It is required to know the onset of the deformity. Discharging sinus: A sinus discharging pus over a period of A deformity following an episode of injury could be due to subluxation or dislocation of a joint, or malunion or nonunion time, not healing with usual treatment, may indicate deeper of a fracture. It may be as a result of a complication related to infection. This could be an underlying bone infection. History the trauma (e.g., C following a fracture). n an acute painful of discharge of a piece of bone (sequestrum) from the sinus condition the deformity comes up due to the muscle spasm is a sure evidence of bone involvement. Other causes of a initiated by the pain. ater, contractures of the muscles and persistent discharging sinus are as listed in Table–7. capsule develop. Gradual progress of the deformity occurs in chronic infections, growth related disorders, or in gradually Table– : Causes of persistent discharging sinus worsening diseases. It is important to know whether the deformity is progressive or static; and what does the deformity • eneralised disease li e diabetes not allow the patient to do. • esistant bacteria • Fungal infection Swelling: Swelling. with or without pain, is a common • Osteomyelitis • Foreign body complaint. When without or with a little pain it is due to a • pithelialisation of the sinus benign growth or a low grade malignant growth. Swelling • Scar tissue around the sinus following a fracture may be due to callus formation or • Malignant change in the sinus displacement at the fracture site. Swelling associated with pain is due to inflammatory or neoplastic disorders. The way * Sometimes, a neoplastic swelling may reduce in size due to tumour degeneration.

346 | Essential Orthopaedics b) It gives an idea of the extent of disability caused by the abnormal gait so that the treatment could be aimed at PAST ILLNESS correction of the gait. Some illnesses in the past may give rise to symptoms years Gait can be evaluated by observing a person walk in slow after apparent ‘healing’ of the disease. motion. ormal gait has a definite pattern. t is made up of Some of these are as follows: a number of gait cycles (Fig-1). One gait cycle constitutes the • An old injury: Osteoarthritis, presenting with pain and period from heel strike of a leg to its next heel strike. Gait cycle can be divided into two phases: stiffness, is common many years after a joint is damaged a) Stance phase due to injury or infection. b) Swing phase • n an old infection, recurrence may occur years after apparent healing of the infection. Stance phase: This is the part of the gait cycle when the foot • An old tubercular lesion anywhere in the body, may is on the ground. It starts with heel strike and ends with toe present as TB in the bone or joint. off. t constitutes 0 percent of the gait cycle and consists of essentially three events. PERSONAL HISTORY • Heel stri e – when heel stri es the ground • Mid stance – when the whole foot is flat on the ground, and The occupation of the patient, his living style, the kind of • ush off – when the body is propelled by ta ing a push from physical activity he is required to do, etc., have a bearing on his treatment. the foot; first the heel goes off the ground, and finally the toes. Swing phase: This is the part of the gait cycle when the foot is FAMILY HISTORY off the ground. It starts with toe off and finishes when the foot is ready to stri e the ground again. t constitutes 40 percent of This may be relevant in a genetically transmitted disorder the gait cycle, and consists of essentially the following events: and in tuberculosis. • Acceleration: Once the foot is off the ground, the leg moves EXAMINATION forward with the help of hip flexors. • Mid swing: This is the mid part of the swinging leg. Before beginning the examination of a patient, the doctor must • Deceleration: The swinging leg is slowed down to get the ensure the following: a) Patient is comfortably lying on a couch, or sitting on a chair. foot ready for heel strike. b) The part to be examined is exposed, and also the opposite Normal gait: In normal walking, each leg goes through a limb, in the case of examination of a limb. This provides an opportunity of comparing the involved limb with the stance phase and a swing phase alternately. The rhythmic opposite, normal one. repetition of such cycles provides grace to the gait. ormal c) Things required to examine a patient are available. These gait is mechanically efficient, and therefore, only minimal are as follows: energy is consumed while walking. In case the rhythm of the • An inch tape gait is disturbed due to any reason, one lands up using extra • atellar hammer energy for walking, and thus gets easily tired. • Cotton wool, pins, a tuning for • S in mar ing pen Abnormal gait: There are number of reasons for abnormality • oniometer to measure angles of gait. Usually there are a combination of factors. Some of GENERAL EXAMINATION: A general review of the different the typical abnormal gaits which are of value in making a diagnosis are as shown in Table– . systems of the body, as is done in any other case, is performed. EXAMINATION OF THE HIP REGIONAL EXAMINATION: This differs from region to region, and The hip joint is special in the following ways: will be discussed subsequently. a) It is a joint thickly covered with soft tissues, thus making GAIT ANALYSIS: Evaluation of gait constitutes an important part it difficult to elicit signs. of orthopaedic examination for the following reasons: a) It gives a clue to the cause of gait abnormality and hence the diagnosis. 1 a le https://kat.cr/user/Blink99/

Annexure I | 347 Table– : Abnormal gaits Pattern Cause Gait Time taken on the affected leg is reduced. Painful condition of the leg Antalgic or painful gait Body weight is shifted quickly to the normal leg. TB hip, heumatoid hip, Stiff hip gait Ankylosing Spondylitis Stiff knee gait ifts the pelvis, and swings it forward TB knee, Painful stiff knee Short limb gait with leg in one piece Congenital short femur, Trendelenburg gait or The leg is circumducted and brought Shortening secondary to fracture Gluteus medius gait forward in order to get clearance. Dislocated hip, CDH Gluteus maximus lurch Becomes apparent only if the limb is shorter than Congential coxa vara Quadriceps lurch 2 inches. The body on the affected side moves Fracture neck of femur Hand-knee gait up and down every time the weight is borne Gluteus medius paralysis on the affected leg. Gluteus maximus paralysis High stepping gait or in polio Foot drop gait The body swings to the affected side every time Quadriceps paralysis weight is borne on that side Scissor gait Polio The body swings backwards every time weight is borne Common peroneal nerve palsy, Sciatic nerve palsy The person walks by hyperextending, and thereby locking the knee Cerebral alsy The person walks with hand on the knee to prevent the knee from buckling in a quadriceps deficient knee with flexion deformity. Due to drop of the foot, the leg is lifted more in order to get clearance. First to touch the ground is the forefoot, and not the heel. egs are crossed in front of each other while walking due to spasm of the adductors of the hip b) There are a number of diseases exclusive to the hip, for Inability to walk: This may be due to a painful condition or example, erthes’ disease, slipped femoral epiphysis. due to mechanical failure in the region of the hip (e.g., fracture neck of the femur, polio etc.) c) The compensatory mechanisms mask the deformities at the hip e.g., the flexion deformity is masked by forward Swelling: A swelling arising from the hip comes to notice tilting of the pelvis. very late, except when it is from the greater trochanter or pubic bone. d) It is near the private parts, hence proper exposure and cooperation of the patient becomes difficult. e : Deformity of the hip may be the presenting symptom. The patient walks with a bend at the hip. The cause HISTORY TAKING of the deformity could be the hip joint per se or the structures Presenting Complaints: As the hip is a deep joint, the patient around the hip (e.g., psoas spasm due to inflammatory lesion in the vicinity of the psoas). often cannot localize the site of his problem. ather, he complains of what he finds difficult to do. Common complaints HISTORY OF PRESENTING COMPLAINTS of a patient with hip disease are as follows: Pain: When pain is the major presenting complaint, the a e in the front of the thigh or sometimes in the knee*. Pain in the groin can be a referred pain from upper following details need to be elicited. lumbar spine. • Where is the pain n the groin, in front of the thigh, outer Inability to squat: This is due to stiffness of the hip. The side of the hip, back of the hip**. stiffness may be due to painful spasm of the muscles around • Does the pain radiate ain from the hip radiates to the the hip or because of the adhesions within or around the hip. knee, but not beyond. If the pain radiates beyond, its origin Limb: This may be painless as in CDH or coxa vara, or painful could be from the spine. as in early arthritis. • Duration of the pain: Short duration pains are due to trauma, acute infections, acute arthritis etc. ong duration * A pain from the hip is often referred to the knee. ** Pain in the gluteal region is not from the hip, it is usually from S spine or S joints.

348 | Essential Orthopaedics pains are due to chronic infections, chronic arthritis, Any compensatory mechanism – increased lumbar lordosis to secondary osteoarthritis, tumours etc. compensate for the flexion deformity, and pelvic tilt (as noted • Onset and progress of the pain: The main idea is to find by position of the ASISs on the two sides) to compensate for out whether there was any trauma at the time of onset of the abduction or adduction deformities. the pain, and whether there is remission and exacerbation of the pain. e can be observed when the patient, trying • What exaggerates or relieves the pain : This may give a to keep the leg on the ground produces plantar-flexion at the clue to the nature of the disease. ipsilateral ankle or by keeps the opposite normal knee flexed. EXAMINATION a le e a e e e: This is an index of Exposure: Proper exposure is essential for examination of the disuse atrophy of the muscles, and indicates long duration of the illness. ote especially the gluteal muscles and the hip. The part of the body below the mid-thorax should be quadriceps. exposed, except for the area of the private parts, which should be covered with a small cloth. In Indian culture, especially Any swelling: ote especially in the gluteal region, in the in a female patient, such an exposure may not be socially region of greater trochanter and in the groin. The greater acceptable. t is a must to have a female attendant/nurse trochanter may appear more prominent due to its proximal while examining the hip of a female patient. While examining migration in some hip diseases. a patient with hip disease, the examination couch should be away from the wall. This makes it possible to go to both sides ae a a a eale e of the body to examine the respective hip. It also allows space for abduction of both the hips. operation: Scar of a healed sinus is puckered as against that of a superficial skin infection. T e ele b e : This is a test to establish the stability Gait: Observe the gait of the patient. The following are some of the hip. A hip is stable if the abduction mechanism of the of the common gait patterns in hip diseases. A combination hip is effective in preventing the pelvis from dipping on the of these may be present. opposite side, when weight is borne on the limb. The test and Antalgic gait: In a painful hip disease, the patient can hardly its explanation are as follows: bear weight on the affected side. So, he quickly takes the weight off the affected limb to the normal limb. Hence, he keeps the affected limb on the ground for a shorter time than the normal side. Trendelenburg gait: In a hip disease, where the hip joint is not stable, (i.e., the abductor mechanism of the hip is not effective) in order to avoid falling, the torso of the patient tilts to the affected side. In case of a bilateral unstable hip, the swing may be bilateral – the so called waddling gait (e.g., in bilateral CDH). Short limb gait: If the affected limb has become short due 2 T e ele b e. to some disease, when the patient walks, the whole affected side of the body dips down in order to make it possible for the aTe ae a e al l b e e e patient to bring the foot to the ground. t is the ‘up and down’ movement of the half of the body, which is characteristic of a short limb gait as against the ‘sideways lurching’ seen in a Trendelenburg gait. Circumduction gait: When the hip is ‘fixed’ in abduction, .bTe ae a ea e e l b e e there occurs apparent lengthening of the limb. In order to walk in such a situation, the patient has to ta e the affected ‘long . e ab e a limb’, in a round about fashion, and thus ta e the step forward. • Test: The ASISs of both sides should be exposed. The le e : With mild flexion deformity of the patient is asked to stand on the normal leg. As he does so, the opposite ASIS will be lifted up i.e., the pelvis will be hip, the patient manages to wal ‘straight’ by compensatory tilted towards the side bearing weight (Fig-2). ow, the patient is asked to stand on the affected side. If the hip on lumbar lordosis. f the deformity is more than 30o, the patient this side is not stable, the opposite ASIS will dip down. In order to avoid falling, the patient will tilt his torso to the can no longer compensate, and is required to stoop forward at affected side and thus balance himself. the hip to be able to walk. This also happens in patients with • Explanation: When a person stands on both legs, the centre of gravity falls in between the two feet (the base). As soon ankylosing spondylitis, where compensatory lumbar lordosis as one leg is lifted off the ground, the centre of gravity of the body falls outside the base (single foot this time). The is not possible due to stiffness of the spine. pelvis on the opposite side tends to dip. This is prevented by the balancing done by the body by tilting the pelvis EXAMINATION WITH THE PATIENT STANDING toward the side on which the person is standing. The tilting is possible due to ‘effective contraction’ of the abductor The patient should be examined first in standing position. The examiner observes him from front, from the side and from the back. The following points are noted: be – flexion, abduction, adduction or rotation deformity at the hip. https://kat.cr/user/Blink99/

muscles of the hip (mainly gluteus medius). This abductor Annexure I | 349 mechanism can be compared to a lever (Fig-2. box). The fulcrum of the lever is the centre of the hip, the load is trochanter is proximal than on the opposite side. This can be the weight of the body trying to tilt the pelvis down. This roughly judged by keeping the thumb at the ASISs and feeling load is counter-acted by the abductor muscle force which the greater trochanters with middle finger so as to appreciate acts through the lever-arm (the neck of the femur). Any the distance between the two on two sides (Fig-3). The other failure in the effectivity of the abductor mechanism causes method of finding this out is by drawing a Bryant’s triangle dipping of the ASIS on the opposite (normal) side. This as discussed subsequently: could occur if: (a) there is no fulcrum – e.g., dislocation of the hip, destruction of the head; (b) ineffective lever-arm Swelling: Whether the swelling is in relation to the pelvis or (the nec of the femur) – e.g., fracture of the nec of the the femur can be found by observing whether it moves with femur; (c) ineffective contraction of abductor muscles – the femur. A dislocated head may be palpable in the gluteal e.g., weakness of the muscles due to polio or abductor region (in posterior dislocation of the hip) or in the groin (in muscles acting ineffectively through a short lever-arm (as anterior dislocation of the hip). A swelling in relation to the in coxa vara). trochanters similarly moves on moving the thigh. EXAMINATION WITH THE PATIENT LYING ON THE COUCH Inspection: Ask the patient to lie as straight as he can and observe the following: e ea e e e if it can be distinctly seen. ormally, with the patient lying straight, both the ASlSs should be square (i.e., at the same level). If the ASIS on the affected side is more proximal, an adduction deformity may be present. The reverse of this may occur in abduction deformity. Lumbar lordosis: An exaggerated lumbar lordosis may be 3 al a e ea e a e. a result of tilt of the pelvis to compensate for the flexion deformity. . ea e a e . a a a ae T e a e a be ee e le e . There may be a a ea ab e ae rotational deformity of the hip as noticed by in or out turning of the patella. Deformity and Range of Movements: Hip deformities are often Palpation: Following points are noted on palpation. not apparent because of compensatory mechanisms. It is customary to look for the deformity and test for range of Temperature especially of the groin and over the swelling, motion simultaneously. In a normal person the position of if any. complete extension is taken as zero position. In cases with deformities, the arc of movement from the deformed position Tenderness especially in the groin, over the greater trochanter. of the hip to whatever further movement is possible, is noted. Tenderness in the gluteal region is usually due to sciatic pain The following are the methods of finding out the extent of arising from the spine. different deformities of the hip. Abnormal swelling: Any abnormal swelling is examined with le e : This is the commonest deformity of the regard to its site of origin, size, shape, surface, consistency, tender or not, margins, fixity to the bone and other structures. hip, probably because the flexors of the hip are stronger than the extensors. When there is spasm of the muscles, the Te e ea e a e : Greater trochanter is the stronger flexors pull the hip in flexion. The test to evaluate most lateral, bony structure around the hip. It is often difficult the degree of the flexion deformity is called Thomas’ test, as to feel it in an obese person. The way is to palpate the shaft discussed below: of the femur, and move the hand up. The most prominent • Thomas’ Test: Aim of the test is to remove the compensatory bony structure at the proximal end of the thigh is the greater lumbar lordosis so that the flexion deformity becomes trochanter. t can be confirmed by moving the thigh – it should obvious and can be measured. The patient is asked to lie move with the thigh. Another bony prominence which can supine on a hard surface, with legs straight. He may be often be mistaken as ASIS is the ischeal tuberosity, but can be able to do so despite the flexion deformity by producing differentiated as the latter does not move with the movement excessive lumbar lordosis. The same can be appreciated of the thigh. A dislocated head or a myositic mass around by the examiner passing his hand behind the patient’s the hip, if present, can be confused as the trochanter. The lumbar spine. ow, the sound hip of the patient is flexed trochanter is thickened in diseases involving the trochanter gradually. After the hip flexion is complete, the pelvis as in – malunited inter-trochanteric fracture, fibrous dysplasia begins to tilt (Fig-4). This obliterates the lumbar lordosis, and trochanteric bursitis. as can be felt by the hand under the lumbar spine. As this happens, the affected hip will automatically come to be al a e ea e a e : In diseases of in the deformed position (flexion position). The angle the hip where the head of the femur is dislocated or damaged, between the affected thigh and the bed is the degree of or if there is a fracture of the neck of the femur, the greater flexion deformity. One must be careful not to overflex

350 | Essential Orthopaedics T ae e e a ee e is extended gently, till the lordosis starts showing up. The e a ea e e e angle between the body and the thigh indicates the flexion lumbar lordosis is to be removed deformity at the hip. Range of Flexion: Once the flexion deformity is measured the patient is asked to hold the normal knee flexed, the examiner keeping his one hand under the lumbar spine. The affected hip is now gently flexed further, beyond the position of the deformity. The arc of motion (from deformed position to the position of possible flexion) constitutes the range of motion of the hip. ormally, it is possible to flex the hip so much that the front of thigh touches the abdomen. In cases, where the hip flexion is limited, the pelvis will start tilting as the hip is forced beyond the limit of flexion. This becomes apparent as the hand under the lumbar spine can feel the movement at the spine. Hence we write that the range of hip flexion is from 20o – 120o (150o). The figure in the brac et shows the OM on the normal side. It is important to keep one hand over the ASIS so as to detect tilting of the pelvis while performing this test. t is possible to ‘flex’ a completely fused hip by 30o – 40o, the movement actually occurring at the spine. b e : A patient with abduction deformity compensates, and may appear ‘straight’ by tilting the pelvis (Fig- ). n abduction deformity, the pelvis on the affected the normal hip, as this results in excess tilting of the pelvis anteriorly, thereby falsely exaggerating the flexion deformity. roblems of Thomas’ test: These are as follows: • t is difficult to perform in a female patient as proper exposure is not always possible. • t is difficult to perform in fat patients as in them lordosis cannot be appreciated. • n a painful hip, the patient may be hurt during the test and thus may become uncooperative. • t is difficult to perform this test if both the hips are affected or if the ipsilateral knee is stiff and deformed. In the case of bilateral hip deformity, better method is to put the patient prone at the edge of the couch in such a way that the body is on the couch with the legs hanging out (Fig-5). The lumbar spine is seen straight (no lordosis) and flexion deformity at the hip becomes obvious. With the palm of the hand stabilising the lumbar spine, the hip ea a a ab ee e ae e le e eb e side tilts down (hence the ASIS is lower). The opposite of this ae e e occurs in adduction deformity (i.e., ASIS on the affected side goes up). By removing the compensatory affect of the pelvic el e l ba l a a all tilt one can make the deformity obvious, and measure it. This obliterated is done in the following way: • Test for detecting adduction and abduction deformities: et the patient lie as straight as he can with both the legs parallel to each other. In doing so, in case an abduction or adduction deformity is present, the patient will tilt the pelvis depending upon the deformity and conceal it. The examiner first palpates the ASISs on the two sides. This is done by moving his thumb from the groin laterally, and the first bony prominence detected is the ASIS. These are marked. Possibilities are that: (a) both the ASISs are at the same level (pelvis is square) which means that there is no abduction or adduction deformity; (b) ASIS on the affected side is higher (more proximal) than that on the normal side, which means that there is adduction deformity, https://kat.cr/user/Blink99/

ae ee a –ab e e Annexure I | 351 e e . b e a ea ae a e l e or external rotation deformities become more noticeable when one observes from the foot end of the patient's bed. Comparing that the pelvis is square the two sides is important for this. otational deformities cannot be compensated or concealed. compensated by the pelvic tilt; (c) ASIS on the affected side is lower than that on the normal side, which means Range of Rotations: ange of motion of rotation can be measured that there is abduction deformity compensated by the with the hip in extension or in flexion. With the hip extended, pelvic tilt. Once it is nown that the pelvis is not square, the leg is held by the thigh and the knee. The leg is gently we know which deformity is present. The next step is to turned inward and outward. This gives an idea whether there square the pelvis to be able to measure the deformity. This is any gross limitation of rotations. Precise measurements can is done as follows: be made by testing rotations with the hips in flexion. This is done on one leg at a time. The leg is held at the knee with one Depending upon which deformity is present, the only hand and at the an le with the other hand (Fig- a). The hip thing one has to do is to produce that very deformity. and nee are flexed to 0o. The rotation movement is produced As this is being done, the ASIS on the affected side will at the hip by moving the leg as a lever. The arc made by the move up or down as the case may be, and the pelvis will leg shows the amount of internal or external rotation. This be squared (Fig-7). This is chec ed by feeling the two can be compared with the same on the opposite side. ange ASISs and joining them with a measuring tape. The angle of rotations can be tested on the two sides simultaneously between the long axis of the body and that of the leg is the (Fig- b). This gives an instant idea of limitation of rotation degree of abduction–adduction deformity. on the affected side. (a) (b) a e ea ae a e le a a eb b e le e e Range of Adduction and Abduction: Once the adduction- ae ee e : ange of hip abduction deformity is measured, the next step is to see how much further adduction-abduction movement is possible. One movements is tested in other positions as discussed: must remember that if a hip has an adduction deformity, no abduction movement will be possible and vice versa. The only Abduction-in-flexion: This is a good, quick method of movement which may be present is movement in the direction of the deformity. This is again measured as arc of movement comparing abduction movement on the two sides. The hips from deformity position to whatever further movement is possible. For example, it could be 20o of abduction deformity are flexed to 45o with the knees and ankles together. with further abduction from 20o to 50o. t is noted as ‘abduction deformity 20o, with OM 20o – 50o ( 0o)’. The figure in the Both the nees are now ‘opened apart’ so as to allow the outer bracket is the range of abduction on the normal side. The side of the knees to touch the couch. A limitation of abduction precaution required while measuring the range of abduction becomes obvious as the knee on the affected side remains at and adduction movement is that the pelvis should not be a higher level (Fig-9). allowed to move while this is being done. This is checked by keeping one hand over the opposite ASIS while moving the Limb Length Measurement: Shortening of the limb is common hip, and detecting any movement of the ASIS, (and hence that of the pelvis). in hip diseases. Some of the shortening is compensated by the • roblem of the test: Sometimes, squaring is not possible patient by: (a) tilting the pelvis down on that side; (b) plantar due to fixed pelvic tilt, as may occur in a patient with lumbar scoliosis. It may also not be possible to square a pelvis with old injury where the normal anatomy is disturbed. ae : Gross rotational deformities may be noticed by loo ing at the patella or the foot. ormally, the patella faces 5o to 10o outward. If it faces inwards compared to the opposite side, internal rotation deformity is present and ea ab le b e e simultaneously vice-versa for the external rotation deformity. Minimal internal

352 | Essential Orthopaedics flexing the foot; and (c) flexing the knee on the normal side. While examining for shortening, it is important to note: (a) whether shortening is present; (b) if yes, whether it is true or apparent shortening; (c) if it is true shortening, whether it is from the hip (supra-trochanteric) or from some other part of the limb. It is customary to measure the apparent length (the length of the limb with compensatory mechanisms allowed) and true length (the actual length of the limb after removing the compensatory mechanism). Accordingly, after comparing the lengths on the two sides, apparent and true shortenings are calculated. It is the apparent shortening which concerns the patient i.e., the shortening which remains even after compensation by the body. True shortening is of significance to the clinician for diagnosis, as it is the shortening produced by the disease due to actual destruction or shortening of the bone. There may be a situation where all bones and joints are all right, 1 e le ea e e a but the limb is 'short'. This will be due to deformity at the hip, and will be called apparent shortening. There will be no true the leg is short, the thigh is short or the shortening is above shortening in this situation. On the other hand, there may be the trochanter. The last one is called supra-trochanteric true shortening of the bones, but the body, by compensating shortening and is important in the diagnosis of hip this shortening, may make the leg appear equal. Hence, there diseases. will be no shortening effectively (no apparent shortening), although true shortening is present, and can be detected by • Measurement of supra-trochanteric shortening: A quick unmasking the compensatory mechanism. assessment of supra-trochanteric shortening can be made by feeling the greater trochanters in relation to respective • Measurement oj apparent length: This is simpler to ASISs. The patient lies supine. The examiner places his measure. The patient lies supine on the couch, as straight hands on both the hips as shown in the Fig-3. page 34 . as he can. Both the legs should be parallel and in alignment The thumbs are placed on ASISs, the tips of the middle with the body. Measurement is ta en from any fixed fingers over the tips of the trochanters and tip of the point in the midline of the trunk (e.g., Xiphisternum, index finger over an imaginary point at the intersection suprasternal notch etc.) upto the prominent tip of the of two perpendiculars – one dropped from AS S over the medial malleolus. o attempt is made to correct any bed and the other from tip of the greater trochanter on deformity while measuring the apparent length. to the first one. This gives a rough idea about proximal migration of the greater trochanter mostly* due to supra- • ea e e e le : The patient lies supine. The trochanteric shortening. Supra-trochanteric shortening can be accurately measured by drawing Bryant’s triangle first step is to check whether the pelvis is square. If yes, (Fig-11). the length is measured from ASIS to the tip of the medial malleolus. If the pelvis is not square, the same is done first (as discussed on page 351). As the pelvis is square, the hip deformity will show up. The limb length, from ASIS to tip of the medial malleolus is measured in the deformed position of the limb. When the normal limb is being measured for comparison, it is necessary that it be placed in the position as that of the affected limb. Hence, before measuring the normal limb, the pelvis must be squared, and the limb should be in a position, identical to that of the affected limb. • Leg length measurement in standing position: In a 11 a a le hip without deformity, a quick and accurate method of . measuring true shortening is as follows: The patient is . . ea e ae asked to stand against a wall, facing the examiner. The pelvis may be tilted due to shortening of the limb. The examiner puts wooden blocks under the foot on the shorter side, one after another, till the ASISs on the two sides are level (Fig-10). The thic ness of the bloc s is measured. This indicates the amount of true shortening. Similarly, if the affected limb is longer, insert wooden blocks under the foot on the normal side, till the pelvis is square. The height of the wooden blocks indicates true lengthening of the affected limb. CT scanogram is the radiological method of accurately measuring the limb length. • Supra-trochanteric shortening: Any disparity in length e ee la (true length) of the limb has to be further examined to find out as to which segment of the limb is short i.e., whether * Sometimes, the trochanter is pointed as in coxa vara. https://kat.cr/user/Blink99/

Annexure I | 353 Bryant’s Triangle: The patient lies supine with the pelvis 12 Tele e a square and the limbs in identical position. The tips of the e e e a e a e ea e a e eel e e greater trochanters and ASISs on both the sides are marked. le e ll a A perpendicular is dropped from each ASIS on to the bed. ee e ae From the tip of the greater trochanter, another perpendicular is applied by the other hand dropped on to the first one. The tips of the greater trochanters are joined to the ASISs on the respective sides. This forms a fracture-dislocation or pathological condition affecting the triangle ABC. Each side of the triangle is compared with its acetabulum. An examination of the abdomen, to look for counterpart on the normal side. The side BC of the triangle any intra-abdominal cause for the deformity of the hip (e.g., measures supra-trochanteric shortening. This may be due to: a psoas abscess) may be done. Examination of the inguinal (a) dislocation of the hip; (b) central fracture-dislocation of lymph nodes should be done. the hip; (c) destruction of the head or acetabulum or both; (d) fracture of the neck of the femur; (e) coxa vara deformity of DIFFERENTIAL DIAGNOSIS the hip; and (f) malunited inter-trochanteric fracture. The most important sign, the key to the diagnosis of a hip Some other tests have been described to roughly assess the disease is movements of the hip. If movements are markedly position of the greater trochanter, but as these are difficult to restricted in all directions (ankylosis), the disease could perform and are not accurate, these are no longer used. Some be a severely damaging arthritis such as septic arthritis, of these are as follows: tuberculosis, rheumatoid arthritis etc. If the hip movements are well preserved but there is pain and terminal limitation of • Nelaton’s line: With the hip in 0° of flexion, a line joining movements, a secondary OA of the hip is more li ely. Some ASIS and ischeal tuberosity passes through the tip of the movements may be more limited than others if the head is greater trochanter on that side. Therefore, in cases with deformed, as may occur in avascular necrosis, old erthes’ supra-trochanteric shortening, the trochanter will be disease etc. imitation of movement in only one direction proximal to this line. usually indicates an extra-articular cause. For example, a child with psoas spasm due to infective focus in the vicinity • Shoemaker’s line: With the patient lying supine, the line of the psoas may have flexion deformity of the hip (hence no joining ASIS and tip of the greater trochanter is extended extension possible), but other movements, especially rotations, on the side of the abdomen on both sides. will be normal. Similarly, in coxa vara deformity of the hip, abduction is limited but with increased abduction (actually it ormally, these lines meet in the midline, above the is merely a change in the arc of motion). Hip movements may umbilicus. In case one of the greater trochanter has be increased in all directions in a case of non-union of fracture migrated proximally, the lines will meet on the opposite of the femoral neck or in a case of old Tom-Smith arthritis. side of the abdomen, and below the umbilicus. • Chiene’s lines: With patient lying supine, lines are drawn The other important sign of hip disease is stability of the hip joining the two ASISs and the two greater trochanters. as seen by performing telescopy or by Trendelenburg’s test. If positive, it narrows the possibilities of diagnosis to a few. ormally, these ma e two parallel lines. n case one of the trochanter has moved proximally, the lines will converge on that side. • Morris’ bistrochanteric test: This is used for detecting inward migration of the greater trochanter, as may occur in a central fracture-dislocation of the hip. It is no longer used. Telescopy: It is to test stability of a hip. The patient lies supine on the couch, with the affected side towards the examiner. Keep one hand (the right hand for examination of the left hip) to stabilise the pelvis using the thenar eminence over the ASIS and the fingers of this hand on the greater trochanter (Fig-12). The nee and the hip are flexed to 0o. With the other hand holding the knee, a gentle push and pull force is applied along the long axis of the thigh. An up and down movement of the greater trochanter can be felt by the fingers in case the hip is unstable. A positive telescopy means that either the head is out of the acetabulum, or there is a fracture of the neck of the femur. In bulky individuals, it is difficult to perform this test and also to feel the greater trochanter. The whole limb may have to be gripped between the chest wall and the arm to be able to apply push and pull force. It is easy to perform this test in young children with CDH, in which it is a very useful test. OTHER EXAMINATION Examination of the ipsilateral knee, the contralateral hip, the spine and neurovascular status of the limb must always be done in a case with hip disease. A per rectal examination may be required if it is a suspected case of TB hip, central

354 | Essential Orthopaedics The third important sign is the amount of true supra- which may present with pain in the knee (e.g., a referred pain trochanteric shortening. Only a little true shortening occurs from a disease of the hip, presenting as pain in the knee). in most hip diseases. Greater amount of shortening occurs in a dislocated hip, a non-union of fracture of the femoral neck, HISTORY-TAKING Tom-Smith arthritis etc. Classic deformities at the hip may Presenting Complaints: Following are the usual presenting also help in diagnosis. complaints: aa a ae ea e • ain in the nee • Swelling Inspection • Deformity Patient Standing • Stiffness • Mechanical symptoms such as a give-way, something • ait getting stuck, a catch etc. • Obvious deformity • Compensating mechanism - lordosis, pelvic tilt • Shortening History of Present Illness: A detailed account of the presenting • Wasting of muscles complaints, looking at since when is it present; how it started; how the other symptoms have added on; how activity • Swelling all around makes a difference, if any; how any treatment has made a difference; natural progress of the symptoms (whether • Sinus, scar intermittent, gradually progressive, gradually subsiding, etc.) will constitute the contents of the history of presenting • Trendelenburg’s test complaints. Most deformities related to arthritis are painful. Patient lying Painless deformities may occur in paralytic diseases (e.g., polio, CP) or if the joint is completely destroyed and fused. • AS Ss on two sides Deformity in arthritis is the flexion deformity; varus (bowing of legs) and valgus (knock knees) deformities may be present. • umbar lordosis ecurvatum (hyperextension) deformity may occur in polio al a or due to a fracture in the region of the knee. • Temperature • Tenderness • Swelling - details of swelling • reater trochanter – Thic ening – roximal migration Measurement • Degree of deformities: Flexion, Add.–Abd., otation EXAMINATION • ange of movement: Flexion, Add.–Abd., otation The patient should be examined in the lying down position: first in supine position and then in prone position. Always • Apparent shortening/lengthening compare the affected knee with the opposite, normal knee. • True shortening/lengthening, and in which component Exposure: The whole limb on the affected as well as unaffected of the leg is it? side should be exposed. It is difficult to examine the knee when the thigh is half covered by tightly rolled up trousers • Bryant’s triangle or pyjama. Telescopy Gait: Observe the gait of the patient. A deformity of the nee Ipsilateral knee will be obvious. ecurvatum deformity can be best appreciated when the patient walks. A patient with weakness of the Contralateral hip quadriceps muscles may wal with ‘hand- nee gait’ i.e., he supports his knee on the front with his hand when he takes Spine weight on the leg, and thus ‘prevents the nee from buc ling . e a la e el b Inspection: The following points are noted on inspection: aa e ab e ee e EXAMINATION OF THE KNEE e aa e: Flexion deformity is the commonest. The knee joint is special in the following ways: Initially, it occurs due to spasm of the hamstring muscles a) It is the major weight bearing joint of the body, hence its in any painful condition of the nee. ater, the capsule and diseases are very disabling. b) It is a superficial joint, hence more prone to injuries. other structures around the knee develop contracture, and c) It is a joint whose stability is dependent primarily on the the deformity becomes permanent. A slight flexion deformity ligaments, and hence ligament injuries are common. d) The joint has intra-articular structures like the menisci, a (basically an inability to extend the knee completely) is often common source of knee symptoms. termed as ‘loc ing’. True loc ing means inability to extend e) The joint has a large synovial space, hence it is commonly the nee for terminal 15o to 20o, but, flexion from there is involved in the diseases affecting the synovium. possible. This kind of block to extension, if due to meniscus A number of orthopaedic diseases such as osteomyelitis and sarcoma occur around the knee. tear, is more springy’. oc ing due to hamstring spasm, The knee is therefore, affected in a wide variety of orthopaedic osteoarthritis or loose body (pseudo-locking) is not springy. conditions. Broadly, these can be divided into trauma-related and non-traumatic. While examining a patient with knee oc ing due to loose body occurs in different positions of the complaints, one must think of the conditions affecting the knee joint per se (e.g., arthritis); those affecting the bones constituting knee, and gets locked and unlocked early. Flexion movement the joint (tumours around the knee); and diseases elsewhere, from the position of locking may not be free and complete in osteoarthritis. https://kat.cr/user/Blink99/

In advanced stages of arthritis, the capsule and ligaments Annexure I | 355 of the knee become lax. This leads to flexion, posterior subluxation and lateral rotation of the tibia, the so-called triple femoral condyles: or (b) if it is too little to be able to displacement. The leg may be abnormally abducted (valgus) lift patella enough. It will also be negative if there is a or adducted (varus). flexion deformity of the knee. Hence, it is not a very reliable test. Swelling: An early swelling of the knee can be appreciated The fluid within the joint could be effusion, blood or pus. on inspection. Comparison of the two knees will show that What exactly it is, can be guessed from history of onset of hollows, normally present on each side of the patella have the symptoms and associated symptoms. Haemarthrosis been filled up. The swelling may be diffuse – which indicates builds up quickly, effusion slowly. In case there is pus an intra-articular pathology; or localized to one part of the inside the joint, signs of inflammation may be prominent. joint. In the latter case, depending upon the location, it could b) Synovial thickening: Hypertrophied synovium and be: (a) an inflammed bursa; (b) a tumour arising from within thickened capsule is a feature of chronic arthritis. The or in the vicinity of the knee; or (c) a malunited fracture of thickening may be appreciated in the suprapatellar pouch one of the bones constituting the knee. Different bursae in where it feels li e a boggy swelling. Minimal synovial relation to the knee, which may present as swelling are: (a) thic ening can be appreciated by rolling one’s fingers over semi-membranosus bursa causes painless oval swelling at the medial femoral condyle where one can feel a ‘chord the postero-medial aspect of the knee; (b) infra-patellar bursa li e’ structure, suggestive of the thic ened synovium and (Clergyman’s nee) lying deep to the ligamentum patellae; (c) capsule. pre-patellar bursa (Housemaid’s nee) lying in front of the c) Bony thickening: Bony thickening can be appreciated by patella; (d) Morrant-Ba er s cyst – a posterior herniation of palpation of the swelling. The swelling may be all around the synovial membrane in the popliteal fossa. A swelling can due to osteophytes, or localised to one of the condyles — be seen distending the suprapatellar pouch, giving rise to a as may occur in a bone tumour. In order to appreciate an horseshoe shaped swelling, and is suggestive of effusion into early bony swelling, one should feel the bones forming the knee. Thickening of the capsule and bones can only be the knee on both sides, and appreciate any difference in appreciated on palpation, specially on comparing it with the thickness, smoothness etc. opposite, normal side. An extra-articular swelling of diffuse nature (e.g., cellulitis), extends all over the knee, over the Tenderness: The joint may be diffusely tender, as in cases of patella, patellar tendon, and also far beyond the anatomical infective arthritis. Tenderness may be localised to a particular limits of the knee joint. area. Joint line tenderness, on medial or lateral side occurs in meniscus tears or osteoarthritis. With the knowledge of surface Muscle wasting: Wasting of the thigh muscles is indicative of anatomy, different parts of the bones, patellar tendon, medial significant knee pathology. It can be appreciated on inspection and lateral collateral ligaments are pressed systematically when both thighs are exposed, side by side. Wasting of the leg with tip of the thumb, and tenderness correlated with the muscles should also be noted. underlying structure. Skin over the knee: It may be stretched and shiny in an Muscle wasting: Wasting of the muscles can be measured by inflammatory disease. There may be an active sinus or a scar measuring the girth of the thigh and that of the leg at fixed of a healed sinus, indicating an infective pathology. A scar of points from the pole of patella. Obtain the measurement on an old injury may suggest a direct hit on the knee. both sides and compare. Palpation: Palpation is carried out to find the following: Deformity: Full extension of the knee is taken as zero degree, Temperature of the overlying skin. and from there how much it is bent constitutes the flexion deformity. Attempt at gently correcting the deformity may Swelling: If there is swelling, its nature i.e., fluid, synovial give a ‘springy’ feel (indicative of loc ing). or it may result thickening or bony swelling, should be made out as discussed in muscle spasm in a painful knee. The block may be bony as below: occurs in an osteoarthritic knee. Any varus or valgus deformity can be measured with the help of a goniometer. Posterior a) Fluid within the joint: Fluid within the joint can be detected subluxation of the tibia becomes obvious when one looks at by one of the following tests: the knee from side. • Cross fluctuation test: When there is adequate fluid in the joint, it fills up the supra-patellar pouch. With Range of Movement: Active range of movement shows one hand over the pouch and the other on the sides of the patellar tendon, one can feel cross-fluctuation the capability of the patient to use his muscles within the between the fluid in the supra-patellar pouch and that constraints of pain. It may be diminished if the muscles on the side of the patella. are weak. Passive range of movements show how much • Patellar tap: With the knee fully extended, the supra- the destruction of joint articulating surfaces, and resultant patellar pouch is emptied by pressing it with one hand. adhesions have occurred. imitation of joint movement, The fluid comes to lie between the patella and femoral both flexion and extension suggests intra-articular pathology. condyles, and thus ‘lifts’ the patella. ow one can, with Sometimes, there may be extra-articular block to flexion (due to a gentle tap on the patella, feel it hitting the femoral bony mass behind the knee) or due to tight quadriceps muscle condyle and springing back. This sign may be negative holding the knee on the front (as occurs in quadriceps fibrosis). even in the presence of fluid if: (a) either there is very large, tense effusion not allowing the patella to hit the ormally, the range of flexion is enough to bring the heel in contact with the buttock, but comparison with the opposite normal knee is the best. A few degrees of hyperextension is possible in a normal knee.

356 | Essential Orthopaedics 13 e e lae a e e Tests for integrity of the ligaments: There are four main ligaments above the knee and the other grasps the upper end of the tibia (Fig-13c). The extent of anterior glide indicates in the nee. The medial collateral ligament (MC ), lateral integrity of anterior cruciate ligament. This test is difficult to perform in bulky, muscular individuals, collateral ligament ( C ), anterior cruciate ligament (AC ) as in them it is difficult to hold the thigh and tibia. and posterior cruciate ligament ( C ). ntegrity of these can be tested by the following tests. • e al a la e al lla e al l a e 13a : With the •e a e l a e : This ligament is injured patient lying supine, the leg is lifted and held in the axilla. uncommonly. One can suspect such an injury by carefully The nee is ept in 20o to 30o of flexion*. Gentle adduction observing backward sagging of the upper end of the tibia. (to test C ) and abduction (to test MC ) force is applied, It can be further confirmed by the following test: as if one is trying to ‘force open’ the joint on one or the • Posterior drawer test: It is like anterior drawer test except, one has to make a note of how much is it other side. The fingers over the joint line can appreciate possible to push the tibia backwards. ‘opening-up’ of the joint. ven if the joint does not open up but an attempt to do so produces pain at the ligament, it indicates a partial tear of the ligament being tested. Tests for meniscus injury: These are as follows: • Anterior cruciate ligament: This is the most frequently • ae 13 : With the patient lying on injured ligament of the knee. It can be tested by the a couch, the surgeon stands at the side of the injured following methods: limb. He grasps the foot firmly with one hand and the • Anterior drawer test (Fig-13b): The patient lies supine. knee with the other. The knee joint is completely flexed. The nee is flexed to 0o with the foot flat on the couch. The foot is rotated externally and the leg abducted. The The examiner sits lightly on the foot to stabilise it. joint is now slowly extended keeping the leg externally The upper end of the tibia is held between two hands rotated and abducted. As the torn cartilage gets caught in such a way that fingers are behind the knee, the during this manoeuvre, the patient will experience pain thenar eminences over the tibial condyles and the or a click may be heard and felt. The angle at which these tips of the thumbs, one on each femoral condyle. symptoms occurs indicates the position of the tear. The The fingers behind the knee check for relaxation of more posterior the tear, the more flexed position of the knee the hamstrings when this test is being performed. is, when the sign becomes positive. A similar test with the A gentle pull is applied on the upper end of tibia foot internally rotated and leg adducted is carried out for and forward movement of the tibia in relation to the laternal meniscus tears. femoral condyles appreciated. ormally, there is a • le e : The patient lies prone on the couch. glide of upto half a centimeter. Anything more than this is suggestive of AC laxity. The surgeon places one hand on the back of the thigh, • Lachmann test: This test is considered better than and with the other hand flexes the nee is flexed to 0o. anterior drawer test. In this test, the knee is kept in The surgeon now applies compression along the long 15 to 20o of flexion. One hand supports the thigh just axis of the tibia while rotating it on the femur (grinding movement). Pain during this movement indicates a * With the nee in flexion (20-30°). the main restrain to meniscal tear. Pain on lateral rotation indicates a medial medio-lateral instability are the collateral ligaments. meniscal tear while that on medial rotation indicates a lateral meniscal tear. https://kat.cr/user/Blink99/

Annexure I | 357 Examination with the patient lying prone: In prone position, EXAMINATION OF THE ELBOW one looks for any tenderness over the muscle attachments The elbow joint is special in the following ways: (sprain), any swelling over site for semimembranosus bursa, a) It is superficial joint any swelling in the popliteal fossa (due to Morrant-Ba er s b) A number of important neurovascular structures lie in cyst or lymph nodes etc.). close proximity of the elbow, and are prone to damage in Examination of the neurovascular structures of the limb distal disorders of the elbow. c) Bones around the elbow are commonly injured during to the knee is carried out in all cases. The ipsilateral hip may childhood. be examined in case no significant abnormal findings are d) The elbow is very prone to stiffness. evident on examination of the knee, as the knee pain could be a pain referred from the hip. The opposite knee should also be HISTORY TAKING examined, as often knee diseases are bilateral. Presenting complaints: Following are the usual presenting DIFFERENTIAL DIAGNOSIS complaints: a e ee ell : A non-traumatic knee swelling a : This occurs commonly in the arthritis affecting the could be due to arthritis of the knee. If it involves only one elbow. The elbow is one of the joint affected in a polyarticular joint (monoarthritis), the usual causes are tuberculosis, septic disease, but uncommonly it could be involved alone e.g., in arthritis, villo-nodular synovitis, chronic traumatic synovitis tuberculosis of the elbow. More commonly, the pain around and haemophiliac arthritis (see relevant sections of the book the elbow is due to extra-articular diseases such as lateral for details). In children, it could be a presentation of juvenile epicondylitis (tennis elbow); medial epicondylitis (golfer’s chronic polyarthritis – monoarticular type. Bilateral nee elbow); olecranon bursitis (student’s elbow, etc.). symptoms may be due to osteoarthritis (in elderly people), rheumatoid arthritis (in younger, usually females), gout, Swelling: Pain and swelling usually occur together. With osteo-chondritis, etc. limitation of movements of the joint, an arthritic condition is more likely. A swelling without much pain may point to a e e : The cause of the flexion deformity a neoplasm in the elbow region. History of remissions is an could be arthritis affecting the joint, in which case there will important indicator of inflammatory pathology. be painful limitation of movements. If the deformity is due to ‘burnt out’ arthritis or due to polio, it is painless. A severe e : This is a common and disabling symptom. It limitation of movement usually indicates an infective arthritis hampers the utility of the hand by restricting its reach. It is either tubercular or pyogenic. algus and varus deformities of usually as a result of painful arthritis and associated muscle the knee occur commonly. The causes of these are as discussed spasm. In late conditions. intra-articular and extra-articular on page 324. adhesions contribute to stiffness. Elbow joint is highly prone to develop post-traumatic stiffness due to myositis. a e ee: It is a very complex symptom. The causes can be divided broadly into traumatic (meniscus tear, ligament e : Flexion deformity occurs in any arthritic tears, fracture, etc.) or inflammatory (arthritis group). ac of condition, or as a result of post-traumatic stiffness. arus significant generalised signs and presence of specific signs go or valgus deformities occur, usually following fractures in favour of traumatic causes. Often, it is difficult to diagnose around the elbow. Cubitus varus occurs commonly due the cause, and such a case is broadly termed as nternal to a malunited supracondylar fracture of the humerus. Derrangement of the Knee or DK. Cubitus valgus occurs in fracture of the lateral condyle of the humerus. Hyperextension deformity occasionally occurs in a aa a ae ee ea e supracondylar fracture malunited in extension. Inspection Past history: In a case with an old elbow injury, details of injury • Deformity and attitude and treatment received are important. One must as for history of massage, in particular. This is often the cause of stiffness • Swelling due to myositis ossificans. • Muscle wasting • S in over the nee al a • Temperature EXAMINATION • Tenderness Exposure: The whole upper limbs on both the sides should • Swelling—whether fluid, synovium or bone be exposed. • Muscle wasting e ae ee Inspection: Following points are to be noted: Te e l a e Te e al e aa e: Flexion deformity is obvious on Examination with patient lying prone putting the affected limb next to the normal limb. arus and • Swelling valgus deformities become apparent only in full extension of • Tenderness the elbow, because it is only in full extension that the deformed Ipsilateral hip part of the lower end of the humerus articulates with the Contralateral knee forearm bones. Hyperextension deformity is usually mild and e a la e el b can be appreciated by looking from the side.

358 | Essential Orthopaedics Swelling: Early swelling of the elbow joint may be noticed on SOME SPECIAL TESTS looking at the elbow from behind with the patient sitting on a stool with his hands on the thigh (elbow in about 30o flexion). Wringing test: When the patient is asked to wring a towel, Fullness on the two sides of the triceps tendon indicate fluid pain is felt at the lateral epicondyle in tennis elbow. in the joint. A swelling just proximal to the joint, or on one side of the joint may be due to a malunited fracture, callus e e : With the forearm pronated, ask the patient to formation, myositis ossificans or a tumour. make a tight fist. The examiner now holds the fist and palmar- flexes the wrist. Pain will be felt at the lateral epicondyle in a Muscle wasting: This can be appreciated on exposing the case of tennis elbow. other arm. Wasting of the arm muscles and that of the shoulder muscles should be noticed. Ipsilateral hand and shoulder should be examined in a case of Skin over the elbow: Any healed sinus, scars of operation elbow disease as there may be secondary involvement of may be present. these joints. Palpation: Following points should be noticed: Distal neurovascular structures: i e elsewhere in the limb, all Temperature: This is increased in arthritic conditions or the peripheral pulses and nerves should be examined. inflammatory conditions. aa a ae elb ea e Tenderness: Diffuse tenderness indicates arthritis. ocalised tenderness may occur in tennis elbow (over lateral epicondyle), Inspection in golfer’s elbow (over medial epicondyle), and in students’ elbow (over the tip of the olecranon). • Deformity and attitude Muscle wasting: The severity of muscle wasting can be • Swelling measured at a fixed distance from a bony point, and compared with the opposite normal side. • Muscle wasting Stability: Medio-lateral stability of the elbow is ascertained • S in over the elbow by alternatively stressing the elbow. al a Three bony point relationship: This is an important sign. It is helpful in diagnosing different traumatic conditions • Temperature around the elbow. With the elbow in 0o flexion, the three bony points around the elbow i.e., the medial epicondyle, lateral • Tenderness epicondyle and tip of the olecranon form a near-isosceles triangle (page- 1). The base of the triangle is formed by the Muscle wasting line joining the two epicondyles and the apex by the tip of the olecranon. In a supracondylar fracture the relationship of three • Stability of the elbow bony points is maintained (normal). In posterior dislocation of the elbow, the triangle is reversed. In intercondylar fractures • Three bony point relationship of the elbow, and in malunited fracture of lateral condyle of the humerus, the base of the triangle is broadened. e Sometimes, identification of the three bony points becomes ae ee difficult due to a number of other bony prominences – either from a malunited fracture, or due to myositic masses of Special tests - Wringing test, Cozen’s test bone. It is therefore, best to identity the three bony points as follows: Palpate the medial and lateral supracondylar ridges Ipsilateral shoulder and hand of the humerus, about 4 to 5 cm proximal to the elbow. The most prominent points, as one follows the ridges, are the e a la e el b epicondyles. For identifying the tip of the olecranon, one follows the subcutaneous border of the ulna proximally. EXAMINATION OF THE SHOULDER Deformity: Flexion deformity of the elbow is measured The shoulder joint is special in the following ways: a) t is a joint complex made up of mainly two joints — the considering full extension as zero. arus, valgus deformities can be measured as an angle between the long axis of the gleno-humeral joint (shoulder joint proper), and the arm and that of the forearm, with the forearm supinated. scapulo-thoracic joint. Hyperextension deformity is measured with full extension b) It is a very unstable joint because the ball (the head of the as the zero reference point. humerus) is bigger than the cup (the glenoid). The capsule is lax, and thus allows a large range of movement. Range of movement: of flexion is measured from zero position c) The shoulder is prone to stiffness, primarily because the lax capsule has a tendency to develop contracture whenever or from the position of the deformity — up to as much flexion immobilised. possible. t is noted as flexion 20o to 0o (150o), with the range in the bracket being the movement on the normal side. Any HISTORY TAKlNG pain, muscle spasm, crepitus during movement is noted. The Presenting complaints: The following are some of the common nature of limitation of flexion; soft in arthritis, and ‘bony bloc ’ in malunion and myositis may be appreciated. presenting complaints: • ain • Stiffness • nstability • Swelling HISTORY OF PRESENTING COMPLAINTS a : A shoulder pain may be of traumatic origin, when it is sudden onset with a history of clear cut trauma. It could be a fracture in the region of the shoulder, a subluxation or dislocation of the shoulder, or tear of one of the soft tissues around the shoulder (e.g., rotator-cuff tear, deltoid contusion, etc). Pain without a history of antecedent trauma could be from the shoulder joint per se – as may https://kat.cr/user/Blink99/

Annexure I | 359 occur in periarthritis of the shoulder; or from structures and infraspinatus when there is a rupture of the rotator-cuff. around the shoulder – as may be due to rotator-cuff tendinitis, In long standing cases, the deltoid and the arm muscles may biceps tendinitis, acromio-clavicular (AC) joint arthritis, etc. also be wasted. An important cause of pain in the shoulder is referred pain. It could be from cervical spine disease, visceral pathologies Skin over the swelling may be inspected for stretching and such as angina, cholecystitis, etc. engorged veins, or any healed or active sinuses, particularly in the axilla, in an infective pathology. ocation of the pain may point toward its aetiology. ain at the top of the shoulder is usually from the AC joint. The patient Attitude: In most affections of the shoulder, the arm is held can, more or less point to the site of pain with a finger. Pain at by the side of the chest. Any deviation from normal can be the lateral side of the arm, in the region of the deltoid is usually noticed by comparing the two sides. An attitude of internal from rotator-cuff disease or a disease from deep shoulder joint. rotation may be present in a case with posterior dislocation of The patient points to the pain with whole of his palm over the the shoulder. Sometimes the shoulder girdle appears elevated deltoid. Pain in the front of the shoulder and forearm is usually due to a high scapula (Sprengle’s shoulder). due to biceps tendinitis or subacromial bursitis. Palpation: Following points are noted on palpation: e : It is a very disabling symptom, and makes it difficult for the patient to take his hand in different directions, Te e a e e if any, of the skin overlying the shoulder particularly while changing clothes. The shoulder joint is should be noted. very prone to get stiff. Stiffness could be due to pain and the associated muscle spasm – as occurs in acute painful Tenderness: Different bones forming the shoulder are conditions. It could be primarily stiffness with not much examined for tenderness. Start from the sterno-clavicular joint, pain, as in chronic conditions such as periarthritis. Shoulder shaft of clavicle, lateral end of the clavicle, AC joint, acromion, commonly gets stiff following trauma or immobilisation due spine of the scapula and borders of the scapula. The base of the to any reason. Stiffness in all directions, specially limitation of neck, rotator-cuff area just distal to the margin of the acromion rotations points to intra-articular pathology (e.g., periarthritis); process, biceps tendon, and the deltoid are also examined for limitation in only one direction (e.g., limitation of mainly tenderness. A diffuse tenderness is present in an arthritis of abduction) points to a localised, extra-articular cause (e.g., the shoulder. ocalised tenderness may indicate a disease of rotator-cuff tendinitis). In cases of visceral diseases presenting the underlying structure. as pain in the shoulder, the range of movement of the shoulder is normal. Swelling: If there is a diffuse, fluctuant swelling, the cause could be fluid in the joint. It is best felt in the axilla. A cystic Instability: The patient presents with symptom that the swelling beneath the acromion, without any fullness in the shoulder ‘comes out’. ess frequently the complaint is more axilla occurs in subacromial bursitis. The swelling may vague – such as a sudden onset pain or the arm dropping be localised to lateral end of the clavicle (due to AC joint ‘dead’ (dead arm syndrome). Symptoms occur while throwing arthritis), subacromial area (subacromial bursitis), below something or doing some overhead activity. A careful history the coracoid (in a dislocated shoulder), or any other place into the first episode is important. The history about what (due to a tumour). happened and how it was treated helps. An X-ray taken, if any, at the time of the first episode may leave no doubt whether the Range of movement: The movements present at the shoulder ‘ instability’ is due to recurrent dislocation or not. joint are flexion, extension, abduction, adduction, internal EXAMINATION and external rotations, and circumduction. Abduction and adduction movements occur in the plane of the scapula. Thus, Exposure: The patient is examined sitting on a stool, so that it in abduction, the arm is carried not only laterally but also forward. Flexion and extension occur in a plane perpendicular is possible to go around the shoulder. The trunk is exposed to that in which adduction – abduction occur. t is important (except the brassiere in a female patient). that the movements at the shoulder joint (the gleno-humeral joint) are tested in isolation. This is done by stabilising the Inspection: The shoulder is inspected from front, from side, scapula. Movement of the scapula may be wrongly considered as that at the shoulder, by a novice. A‘good’ range of movement and from behind. Following findings are noted: may be possible even in the presence of a stiff shoulder as a result of movement of the scapula. Following are the methods e l e : ormally, the shoulder is round —the of testing passive and active shoulder movements: roundness contributed by the head of the humerus and the bulky deltoid. The shoulder may appear flat if the head is not ae e e : The patient sits on the stool. The in place (i.e., dislocated) or destroyed; or if the deltoid has got wasted due to diseases such as polio, tubercular arthritis, etc. examiner stands behind him, stabilises his scapula with one The shoulder may appear swollen due to effusion into the joint or due to subdeltoid bursitis. If it is due to effusion, the swelling hand (Fig-14a), and holds his flexed elbow with the other. extends all around; and also, fullness can be seen (and later felt) in the axilla. Swelling may also be due to old injury or a tumour The arm is gradually abducted till the scapula starts moving in the region of the shoulder; in which case, the swelling will be localised to one side. The AC joint may be unusually prominent (this can be made out by the hand stabilising the scapula). in cases with AC joint subluxation or arthritis. ormally, up to 100o of abduction is possible at the gleno- Muscle wasting: This occurs in any chronic problem of the shoulder. It is more marked in the region of supraspinatus humeral joint. Abduction beyond 100o occurs at the shoulder girdle. Adduction can be carried out only up to neutral position because the arm very soon comes in contact with the chest wall. The arm is brought in flexion and extension. ormal range of flexion is 75o and that of extension is 45o. For testing rotations, with one hand the scapula is stabilised, with the other, the elbow is held flexed. The forearm acts as a

360 | Essential Orthopaedics (a) (b) (c) b e ea a a a a a e le 1 Te ae e e a e le be lab l e all e. a e a la a e a e e al rotation on two side pointer, showing how much range of internal and external SPECIAL SIGNS rotation is present (Fig-14b). ormally, about 0o of internal and external rotation are present. External rotation of the two a l a : This is a test to detect subacromial impingement sides can be compared by doing the above manoeuvre on both of the rotator-cuff as a cause of shoulder pain. The patient is sides simultaneously (Fig-14c). asked to gradually abduct his shoulder with the arm rotated internally. t will be noticed that the pain starts at around 40o to Active movements: The importance of examining active range of 50o of abduction, and disappears at about 120o abduction. This movements lies in the fact that these may be limited in patients is because the rotator-cuff gets impinged between the head of with normal passive movements. This occurs in paralytic the humerus and the acromion between this arc of abduction. diseases of the shoulder, and incomplete tear of the supraspinatus tendon. Active abduction may be limited due to pain caused Drop-arm sign: This is a sign suggestive of complete tear of by impingement in the subacromial space, commonly due to the rotator-cuff. The examiner abducts the arm of the patient, supraspinatus tendinitis. In diseases of the AC joint, the extreme while stabilising the scapula with the other hand. Once 0o of shoulder abduction may be limited due to pain. of abduction is achieved, the patient is asked to hold the arm in the air as the examiner leaves the elbow. In case there is a Measurement: This involves measuring the length of the arm, complete tear of the rotator-cuff, the patient will not be able to hold the arm, and it will drop by the side of the trunk. a circumference of the arm (for muscle wasting). ength of the arm is measured from the angle of acromion process to Apprehension sign: This is a test to detect an unstable tip of the lateral condyle of the humerus. The angle of the shoulder. The shoulder is abducted and externally rotated. acromion is felt as follows: one feels the spine of the scapula As the examiner loads the shoulder along the long axis of and palpates laterally. The angular prominence felt is the angle the arm, the patient becomes apprehensive, and tries to resist of the acromion. Muscle bul is measured on both the arms at any further movement by using his hand or by making the a fixed distance from the point of acromion. shoulder stiff by muscle spasm. aa a ae l e ea e EXAMINATION OF A PATIENT WITH OLD FRACTURE Inspection Examination of a patient with an old fracture is carried out • Contour of the shoulder with an aim to find out the following: a) Whether the fracture has united or not: If it has united, • Muscle wasting whether the union has occurred in proper position or not. • Swelling When a fracture has united but not in acceptable position, it is called as malunion. If the fracture has not united, it • S in over the swelling/shoulder is judged whether it is on way to union (delayed union), or there are signs suggestive of non-union, as will be • Attitude of the arm discussed subsequently. b) What secondary effects has the fracture produced on the limb al a as a whole (e.g., joint stiffness. muscle wasting or myositis). c) Whether there is any damage to the neurovascular structures • Temperature of the affected limb, with the injury or due to treatment. • Tenderness HISTORY TAKING • Swelling and its details sually, the patient gives a history of clear trauma. Often, there is an underlying disease in the bone to have lead to the fracture e Measurements • Arm shortening • Muscle wasting ae e e –a ea a e Special signs • ainful arc • Drop-arm sign • Apprehension test https://kat.cr/user/Blink99/

Annexure I | 361 and subsequent problem in union. So it is wise to ask a direct Examination of nerves and vessels going across the fracture site question whether the patient was alright before the episode of injury. Details of the type of fracture (whether open or not); is carried out by examining the part of the limb distal to the details of treatment especially whether the immobilisation fracture. was sufficient; and finally, what the patient is not able to do because of the fracture; should be brought out in the history. Any complication of the fracture, such a dystrophy etc. are noted. EXAMINATION DIFFERENTIAL DIAGNOSIS Exposure: The patient should be seated comfortably, with the A fracture presenting late could be one of the following: a) e : o mobility, no pain on stressing, no deformity limb supported. The whole of the limb should be exposed, as also the opposite, normal limb. or shortening. b) Malunited: o mobility, no pain on stressing but with Inspection: Important features to be noted are as follows: deformity and/or shortening. ea e : A comparison with the c) e : Abnormal mobility with or without pain at the opposite limb is important. fracture site. If there is mobility without pain, it is called Swelling may be due to malposition of the fracture fragments pseudarthrosis. In some cases, there may be no appreciable or due to callus formation. abnormal mobility, but only pain on stressing the fracture site. Some cases of non-union appear clinically united a suggestive of a compound fracture in the past. except that the patient cannot bear weight on the limb. It Wasting of the muscles and deformity of the joints may be is difficult to differentiate these from a delayed union, and present. diagnosis is made only on X-rays. aa a ae la e Palpation: Following features are noted on palpation: Inspection • Deformity Te e e a e e e a e: This is an important • Shortening sign of an un-united fracture. • Swelling • Wasting al a b e e : This is to examine whether the • Scar alignment and apposition of the bone is alright. Any bony al a irregularity in the form of a gap, a sharp elevation or a bend • Temperature indicates an improper position of the bone. This is a definite • Tenderness sign of old fracture. • alpation of bone ends b al b l a e a e e: This is a • Abnormal mobility pathognomonic sign of non-union of a fracture. Mobility should be tested in both antero-posterior and medio-lateral • Absence of transmitted movements planes. It is often difficult to appreciate minimal mobility in an obese person or if the fracture is close to a joint. Presence Measurement of a crepitus while looking for abnormal mobility and also any pain on stressing the fracture site are important signs of • Shortening an un-united fracture. • Muscle wasting ae e e a ae Ipsilateral joints Neurovascular bundle b e e a e e e : This test is another way EXAMINATION OF A PATIENT WITH BONY of judging whether the fracture has united or not. It is useful LESION in fractures of the shaft of femur, tibia and humerus. One end of the bone is rotated with one hand, while with the other, the HISTORY TAKING movement is felt at the other end. If there is no transmitted movement, the fracture is mobile. Following are relevant in the history: Limb length measurement: It is important to keep the following Age: Bone tumours occur at specific ages as shown in Table–2 .7, page 244. Osteomyelitis is common in children, in mind while measuring the limb length. but may present any time in life. a) Did the patient have any pre-existing limb length Sex: Some tumours are more common in females, and others in discrepancy? males. Males develop osteomyelitis more commonly than females. b) The normal limb must be placed in the same position as Presentingcomplaints:It may be only pain in early stages of malignant the affected limb. tumours, but pain and swelling may be present together. Benign imb length is measured from any two prominent bony tumours generally have little pain until a pathological fracture points of the affected bone. Shortening indicates the amount occurs through the tumour (e.g., through a bone cyst). of overlapping at the fracture site. Following are the common presenting complaints of patients Examination of the joints proximal and distal to the affected bone presenting with bony lesion: • ain to detect any deformity, swelling, limitation of movements • Swelling should be done. There may be an associated injury to the • ain and swelling nearby joint.

362 | Essential Orthopaedics • nability to use the limb, due to wea ness, pain or can create confusion in differentiating it from an inflammatory pathological fracture. swelling. HISTORY OF PRESENTING COMPLAINTS EXAMINATION Position: A patient with suspected lower limb tumour should Onset of symptoms and their progress is important in considering differential diagnosis. Most tumours are insidious be made comfortable on a couch and the affected leg should in onset, but often the patient gives a history of antecedent be well-supported. A patient with upper limb swelling can trauma at the onset. On detailed questioning, it can be be examined, sitting on a stool. A patient with swelling of the ascertained whether the trauma was related; usually it is not. hand should be asked to rest his hands on the table. An insidious onset disease which comes rather suddenly, is usually inflammatory while an insidious onset progressive Exposure: Exposure of the whole of the involved limb is disease suggests a neoplasm or a chronic infection. Course of the disease is progressive in case of a neoplasm, howsoever essential. It should permit examination of the most proximal slow it may be. On the other hand, an inflammatory swelling part of the limb (e.g., axillary lymph nodes in case of upper has remissions and exacerbations. The various symptoms of limb). It is wise to have the following questions in mind before a patient presenting with a bony lesion should be evaluated proceeding for examination. in this light. a) From which structure of the limb is the swelling arising: a : This is the commonest symptom. Onset of pain is Is it from the bone, joint, muscle, fascia, nerve or vessel? insidious, but sometimes, a history of trauma (mostly b) Whether the swelling is benign or malignant? insignificant or unrelated) is present. Pain is constant at all c) Whether the swelling has produced any secondary effects times in a neoplastic swelling. such as restriction of joint movement, pathological fracture Swelling: Benign tumours present with swelling and little etc. or no pain. In some benign tumours like osteoid osteoma, d) Whether there is any evidence of regional (to lymph nodes) pain is the main presenting symptom. Onset of the swelling or distal metastasis (to lungs etc.)? is insidious. The swelling grows at a slow rate (over months e) Whether the neurovascular status of the limb is okay? or years) or remains static. Benign swellings such as an osteochondroma is related to growth of the patient, and stop Whatever sequence of examination is adopted, at the end, the growing once the child attains maturity. A change in the rate examiner should be able to get answers to the above questions. of growth of a pre-existing swelling is ominous – there may be a malignant change in the swelling. Similarly, appearance of Inspection: Begin with something most striking. It could be pain in a painless swelling may indicate a malignant change, or a complication such as a pathological fracture. swelling, a deformed joint, muscle wasting etc. A swelling from the bone expands usually in all directions. Swelling: Following features are noted on inspection: Some swellings from the bone grow eccentrically (e.g., • Site: Be precise about the site of the swelling, especially GCT). Swelling arising from structures other than the bone are localised to one side of the limb. Swelling near a whether it involves the ends* of the bone or away from the joint may produce limitation of joint movements; either by ends. Is the appearance nodular? Is the swelling all around producing a mechanical block to motion, or due to the pain the limb or more on one side than the other? A swelling associated with motion. Swelling may produce pressure on in all directions is usually malignant. A swelling on one the adjacent neurovascular bundle of the limb, and produce side may be an eccentrically growing bone swelling such symptoms thereof. The latter does not occurs in benign as GCT, osteochondroma etc.; or it could be a swelling swellings. If a swelling appears benign on the basis of the arising from structures outside the bone. history, inquire about similar swellings elsewhere (e.g., • Shape and size: An approximate size; whether the swelling diaphyseal achlasis). is diffuse or well-defined; whether it is spherical, fusiform or irregular should be noted. aa ell : This is a common complaint, mostly in • Surface: Whether the surface appears smooth or lobulated should be noted. malignant tumours. The appearance of pain first or swelling • Skin over the swelling: Whether the skin over the swelling has any signs suggestive of infection – these are first, is of academic significance only. It has to be differentiated discharging sinuses, redness and oedema of the skin. The skin becomes tense, glossy, and often red over a from pain and swelling of inflammatory origin. One ey rapidly growing large tumour such as an osteosarcoma. The subcutaneous veins get engorged. There may be scar question is whether the pain and swelling ever subsided of the previous biopsy or an operation. Any pressure effects on the limb, such as oedema of the completely or significantly. This occurs in inflammatory distal limb, nerve palsy etc. should be noted. disorders, and not in neoplastic disorders. e e : Joints develop deformities as an after effect of osteomyelitis – either due to direct involvement Inability to use the limb: Inability to walk is usually a of the joint (see page 75), or secondary to its effect on the complaint in tumours of the lower limb. A pathological growth plate. In tumour, deformity may occur due to its effect fracture, often without any trauma at all, may occur in a on the growth plate or due to painful contracture of the joint tumour which is primarily an osteolytic lesion (e.g., GCT). as a result of painful spasms of the muscles around the joint. The other reason for not being able to use the limb may be Flexion deformity at the knee is common in tumours around paralysis of the limb muscles due to a tumour pressing on some nerve or a tumour arising from a nerve. * A swelling at the end of the bone right next to the joint line means that it is originating from the epiphysis (as occurs Associated complaints such as fever may be present in some in GCT) sarcomas. t is a common symptom in wing’s sarcoma, and https://kat.cr/user/Blink99/

the nee. arus or valgus deformities occur at different joints Annexure I | 363 due to irregularity at the growth plate, as may occur in an osteochondroma or osteomyelitis. pong’ type of crepitus what is called egg shell crac ling. This is due to ping pong ball-like springiness of the thin a e le around the swelling may rim of bone surrounding the tumour. A soft swelling is be noted. usually due to fluid in a bursa, a cold abscess, or just a lump of fat. ee l e e of the distal • Fixity to the surrounding structures: First thing to decide is whether the swelling is fixed to the underlying bone. Grip neurovascular structures e.g., loss of hair, shriveled up skin, the swelling carefully between your fingers and appreciate mobility in more than one directions. Beware of the feeling ulcer, trophic changes in the nails etc. should be noted. of ‘movement’ of the muscles over the swelling as that of the swelling. A swelling fixed to the bone is usually taken Palpation: Before examining the patient, ensure that he is as arising from the bone or periosteum. arely, a swelling from outside the bone may be deep, and may appear to comfortable, and has gained the confidence that you are not be ‘fixed’ to the bone. going to suddenly press or move the already painful part. If the swelling is from a bone, assess whether it has Start examining from the least painful area to the most painful invaded the surrounding muscles, skin, nerve or vessels area. Keep talking to the patient to divert his attention, and as discussed below. Fixity to the surrounding structures is thus allay his fears. One can never be too gentle in handling an important sign to differentiate between a benign and a a patient! It is suggested to follow a defined order while malignant swelling. palpating; otherwise, important findings may be missed. But, a) Fixity to the muscles: A swelling infiltrating into at the end, answers to questions mentioned above is sought – you may like to look for some specific signs; otherwise missed. a muscle will restrict flexibility of that muscle, and hence, there will be checkrein type of limitation of the Local temperature: ocal rise of temperature is best felt with joint motion. Also, the power of the involved muscle the back of the fingers. A comparison with the other side or the will be reduced. nearby normal skin may be useful. A local rise of temperature b) Fixity to the skin: S in is ‘fixed’ early in a malignant is a characteristic finding of an inflammatory swelling, but the growth from a subcutaneous bone such as the tibia. If skin over a sarcoma may have a rise in temperature due to this doesn’t happen, the growth is most li ely benign. increased vascularity of the tumour. In other areas, where the bone is deep, it may take long before skin fixity occurs. The skin may sometime get Tenderness: It is best to ask the patient to point to the most stretched over a huge underlying tumour, and appear tender area, and avoid palpating that area till the end (if at all fixed to it. necessary). Do not just keep palpating here and there with no c) Fixity to the nerve or vessel will cause signs of nerve aim. oo at the face of the patient. He will wince with pain palsy or vascular insufficiency distal to the tumour. A if the area being palpated is tender. There is no need to ask malignant tumour in the vicinity of a nerve will nearly the patient about ‘pain’. Tenderness is more mar ed in an always infiltrate the nerve if it has reached a reasonable inflammatory swelling than in a neoplastic swelling. size. le a e : To be able to say that the ulcer or If it is clear that the swelling is not fixed to the bone (i.e., it is not arising from the bone), make out from which structure is it sinus is related to the underlying bone, one must be able to arising. First step is to decide whether it is deep to the muscles within the muscles or superficial to it. For this, the patient is demonstrate its fixity to the bone. asked to contract the concerned muscle against resistance. A tumour which is deep to the muscle becomes less prominent; eal e ell : isual impression of the swelling a tumour superficial to the muscle becomes more prominent; and the one in the muscle remains same. Also, the tumour is now corroborated. If it is a diffuse bony swelling, it could superficial to the muscle remains as mobile as it was before the muscle contracted; whereas the one within the muscle becomes be due to osteomyelitis. A more localised swelling occurs in ‘immobile’ due to fixity provided by the contracted muscle belly. a neoplasm. Following points are considered in connection A swelling originating from a nerve is suspected if there is a major branch of a nerve in that area. Also, tapping such a with any bony swelling: swelling may produce paraesthesias in the region of sensory distribution of the nerve. A swelling in relation to the vessel • Size of the swelling: Measure in two directions (e.g., length may elicit pulsation, either transmitted or expansile depending upon the exact nature of the swelling. and breadth), or simply, so many by so many cms. Other signs: Presence of a thrill on palpation or a bruit on • Location: For swelling arising near a joint, one has to make auscultation may indicate a highly vascular tumour or an out whether it is from the joint itself, very near the joint arterio-venous malformation. (from epiphyseal region) or a little away from the joint Any deformity of the limb: Abnormal mobility due to (from metaphyseal region). For this, it is required to be pathological fracture or any limb length discrepancy should be looked for. able to define the joint line clearly. • Extent: oo at the extent of the swelling – whether it is growing all around, or on one side; whether it is a pedunculated or sessile swelling. • Surface: ote whether the swelling is smooth, or nodular. Malignant swellings are smooth, ill-defined as against the benign swellings which may be smooth or nodular, but well-defined. • Margins: Palpate the margins of the swelling. Are these well defined, or is it that the swelling merges with the surrounding tissues rather imperceptibly? • Consistency: The swelling may be bony hard, as in a case of benign bony swelling such as osteochondroma. The swelling may be firm as in most sarcomas. The consistency may be variable from soft to hard in a malignant growth. n swelling due to CT, it may be possible to elicit ‘ping

364 | Essential Orthopaedics Enchondroma Movement of the neighbouring joints: egional lymphadenopathy • Age group: 15 to 30 years • Bones: Small bones of the hand (phalanges, metacarpals and distal neurovascular status should always be examined. etc., usually multiple A general examination of the patient, to look for secondaries • Site: Diaphysis • Others features: ong duration, benign swellings. Swelling in a suspected case of malignancy, should be done. Also, a general review of all systems is made to assess the overall is the main complaint. health status of the person. aa a ae b le DIFFERENTIAL DIAGNOSIS Inspection Diagnosis of bone tumours depends upon: (i) age of the • Swelling patient; (ii) the bone affected; and (iii) the site (epiphysis, metaphysis or diaphysis). Characteristic clinical features of - Site some of the common bone tumours are discussed below (for - Shape and Size details consult relevant text). - Surface - Skin over the swelling Osteosarcoma - Pressure effects • Deformity of the adjacent joint • Age group: 15 to 25 years, and after 45 years • Muscle wasting • Bones: Around the nee, upper humerus • Signs suggestive of distal neurovascular involvement • Site: Metaphysis • Others features: sually short duration (3– months); pain al a • Temperature and swelling present; signs of a malignant swelling such • Tenderness as diffuse margins, fixity to muscle and skin, dilated veins • lcer, sinuses etc. present. • Details of the swelling Ewing's Sarcoma - Size-measure it - Site • Age group: 10 to 15 years, occasionally up to 30 years - Extent • Bones: Tibia, femur, also flat bones – ileum, scapula, ribs - Surface • Site: Diaphysis - Margins • Others features: sually short duration (1–2 months); may - Consistency - Fixity to the surrounding structures present with fever, pain and swelling and thus confused with infection. Signs of a malignant swelling present. Other Signs Chondrosarcoma • Thrill, bruit over the swelling • Age group: 20 to 50 years e el b • Bones: pper femur, flat bones • Site: Diaphysis or metaphysis e a la a el b • Others features: ariable duration (few months to few EXAMINATION OF THE SPINE years), usually slow growing. History of an underlying osteochondroma, usually well defined with a little pain. A patient with spine disorder presents either with pain usually in the cervical or lumbo-sacral region; or with a deformity. The Osteoclastoma (Giant cell tumour) deformity may be a kyphosis (stooping forward) or scoliosis (sideways bending). Sometimes, there may be no or minimal • Age group: 20 to 40 years (after fusion of epiphysis) symptoms in the back, but are primarily in the limbs: upper • Bones: Around the nee, lower end of radius limb pain in cervical disorders (brachalgia), and lower limb • Site : piphysis pain in lower limb disorders (sciatica). • Others features: ariable duration of pain (3– months), At times, the presenting symptom of a patient with spine often presents with sudden-onset pain due to pathological disorder is neurological deficit — quadriplegia, paraplegia fracture. Usually well-capsulated, smooth, eccentric or paraesthesias and weakness pertaining to one or more growth, not infiltrating the nearby tissues. nerve roots. Osteochondroma: The commonest benign tumour (tumour-like HISTORY TAKING swelling) of the bone. Presenting complaints: Following are the common presenting • Age group: 10 to 20 years (during growth period) • Bones: Around the nee or upper humerus (if a solitary complaints: osteochondroma). Around the knee, shoulder, and wrist a in the neck or back. (in multiple osteochondromas) • Site: Metaphysis or diaphysis Radiating pain in the upper limb, girdle pain along the trunk, • Other features: ong duration (months to year), slow or sciatic pain along the back or front of the leg. growing, grows as long as the child grows. A well defined, painless benign swelling may produce mechanical block to a ae e a a ea e in a part of the limb due to movement of the adjacent joint. Deformity or distal neural deficit, may present with complications. involvement of one or more nerve roots. https://kat.cr/user/Blink99/

Annexure I | 365 More extensive weakness of limbs e.g., paraplegia or 1 le e le all e e l be e e quadriplegia. between two adjacent spinous processes HISTORY OF PRESENTING ILLNESS spine disease is examined first standing, then lying supine a : Pain is a common symptom. It is mostly non-specific but and then lying prone. following are some characteristic pains indicating a specific diagnosis. Inspection: Following points are noted on inspection: • Sharp, shooting pain down the limb, which is exaggerated a : Observe the gait as the patient wal s into the room. A side by coughing or on minimal movements. This indicates a lurching gait may suggest a scoliosis. A patient with painful disc prolapse. condition of the spine walks rather cautiously, with short • Dull boring pain which increases on exertion and gets steps and a stiff spine. A patient with acute disc prolapse has relieved on rest is due to osteoarthritis. a forward stoop and sideways tilt of the torso on the pelvis. • ain in a young male, associated with stiffness, more early in the morning, which wears off as the person e : ormally, the nec has lordosis (forward curve), gets involved in daily chores, could be seronegative the dorsal spine is kyphotic and lumbar spine lordotic. The spondarthritis (SSA). nape of the neck is in a straight line above the natal cleft. The • Bac ache associated with pain and numbness, radiating position of the shoulder, scapular blades, lumbar hollows down the leg, especially on exertion and gets relieved on and iliac wings is symmetrical. Any deviation could be due rest is indicative of spinal canal stenosis. Such a symptom to a disease. is called neurological claudication. • Bac pain in the dorso-lumbar region in the young may A diffuse kyphosis occurs in ankylosing spondylitis, be due to traumatic or infective pathology. Schuermann’s disease, osteoporosis etc. A localised yphosis may be very sharp due to collapse of one vertebra (a knuckle Neurological symptoms: Complaints such as weakness, type) or localised to collapse of 2 to 3 vertebrae (gibbus numbness and paraesthesias are often associated with spinal disorders. Symptoms localised to one limb usually indicate disc pathology. Bilateral lower limb weakness and loss of sensation occurs usually in dorsal and dorso-lumbar spine diseases. A cauda equina syndrome presentation occurs in lumbar spine diseases. eurological symptoms in TB spine and in tumours are gradual in onset; in disc prolapse these are rather sudden. EXAMINATION Exposure: A proper exposure of the whole spine is crucial. A female patient should be asked to change and wear a gown open from the bac . A female attendant/nurse should be present when examining a female patient. Position: A patient with cervical spine disease is examined sitting on a stool, so that the examiner can observe from front, side or back. A patient with lumbar spine or dorso-lumbar 1 l al e ee e e e a a le a e T b ae e e

366 | Essential Orthopaedics aa a ae e ea e type). oss of lumbar and cervical lordosis occurs in painful Inspection conditions of that part of the spine. Scoliosis may be obvious, • ait or may be detected on carefully comparing the symmetry • osture of the spine as discussed above. A transverse deep furrow, • Deformity more like a step, may be seen in the lumbo-sacral region • Swelling in spondylolisthesis. Swelling in the paravertebral region • aravertebral muscle spasm or a little away could be due to a cold abscess. Prominence of one spinous process (knuckle) occurs in traumatic spine. al a Prominence of more than two spinous processes (gibbus) occurs commonly in ott’s spine. • Tenderness Palpation: Following points are noted: • Swelling Tenderness: Ask the patient to point to the site of pain. A • rominence of the spinous processes general localisation of the site of disease can be made by gently hitting the spine from top to bottom with a fist. More ae ee specific localisation is made by pressing the spinous processes with the thumb. e l al e e le Movements: Following movements of the spine are noted: • Motor • Flexion: The patient is asked to bend forward and touch • Sensory his feet. While he does so, the examiner feels the movement between the spinous processes, away from one another • eflexes (Fig-15). Also, one should loo for spasm of the erector spinae muscles on both sides of the spine, when flexion SI joint examination is being tested. aa ab e e • e le : The patient is asked to bend sideways, and any limitation noted. • Lasegue Test: This is a modification of S T where first the hip is lifted to 0o with the knee bent. The knee • Rotations: The patient is asked to sit on a stool and side is then gradually extended by the examiner. If nerve rotations are examined. stretch is present, it will not be possible to do so, and the patient will experience pain in the back of the thigh Neurological testing: A complete neurological examination of or leg. the limb, especially if there are symptoms such as radiating • Motor power: These are examined in different muscle pain, paraesthesia or weakness, is necessary. This consists of groups of the limb, especially that of H , an le the following. dorsiflexors in a case of disc prolapse. • Stretch test (Fig-1 ): These are S T and femoral stretch test • Sensory Loss: These are examined dermatome-wise, for root compression in a disc prolapse as discussed below: especially in 4, 5, S1 dermatomes. • Straight Leg Raising Test (SLRT): This test indicates • e le e : The deep and superficial reflexes, and Babinski nerve root compression. With the patient lying on a reflex are examined. couch, his affected leg is lifted gradually with the knee straight. As this is done, the patient complains of pain Examination of the lower limb: ength of both the legs should be or ‘stretching’ at the bac of the thigh or in the calf (not back of the knee). The angle at which this occurs measured. Sometimes, a disparity is the cause of scoliosis. Both is noted. A positive S T at 40o or less is suggestive the hips should be examined, as there could be simultaneous of root compression. The leg is now lowered a little till involvement of the hips and spine; or the hip disease may be the stretching’ becomes less. At this angle if the an le responsible for the spine deformity. is passively dorsiflexed, the pain at the back of thigh or in the calf will again be felt. This is called reinforcement General examination: Following examination should be done positive (Bragard’s sign). Sometimes, a S T performed on the unaffected side, may give rise to pain on the in a case with spine disease: affected side. This is termed a contralateral positive S T • oo for cold abscesses away from the site of tuberculosis and is a very specific sign of root compression, possibly by a disc prolapse. of the spine (see page 1 7). • Chest should be examined to loo for a tubercular focus there or to rule out an old chest disease as a cause of scoliosis. • xamination of the breast, idney, prostate, thyroid and abdomen is necessary if secondaries are being suspected in the spine. https://kat.cr/user/Blink99/

Annexure - II Orthopaedic Terminology FRACTURES e a: fracture of proximal 1/2 of the ulna with dislocation of head of the radius Fracture: A break in the continuity of bone : isolated fracture shaft of the ulna • Avulsion: bone piece pulled off by attached muscle or : bimalleolar ankle fracture la : fracture of base of 1st metacarpal, extra-articular ligament : distal radius fracture, extra-articular with volar • : vertebral body fracture where fragments burst out tilt of the distal fragment in different directions DISLOC0ATIONS • Chip: just a sliver of bone chipped off Dislocation: Complete separation of joint surfaces Subluxation: Incomplete separation of joint surfaces • Closed (Simple): the skin over the fracture intact e al: present at birth • Comminuted: fracture in multiple pieces e : develop later in life • Complicated: fracture associated with a complication such ab al: occurs every time the joint is moved a l al: occurs due to some disease of the joint, as a vascular injury e.g. sepsis. e e : occurs again and again • Compression: vertebral body fracture where the body is T a a : due to Injury compressed DISLOCATIONS WITH EPONYMS • Displaced: fragments separated a : dislocation through talo-navicular joints e e : elbow dislocation where ulna and radius • ee : fracture in children where one cortex breaks dislocate in opposite directions a : dislocation through inter tarsal joint and the other cortex bends a e: wrist injury where lunate bone comes out to lie in front of other carpal bones • Impacted: fracture where one fragment gets jammed with a e e a: inferior dislocation of shoulder the other fragment el : gradual shift of the acetabulum into the pelvis (e.g. in osteomalacia) • Open (Compound): the fracture communicates with e l a e: wrist injury where the lunate remains in outside through a rent in the skin and overlying soft its place and the other carpal bones dislocate around it dorsally tissues. l l e : movement of one vertebra over • a l al: the broken bone had an underlying another (usually 4 over 5) a : A break in the continuity of a ligament weakness a : A break in muscle fibres • Segmental: fracture at two levels in the same bone SIGNS AND TESTS • Stress (Fatigue): fracture caused due to repeated stress at e : for thoracic outlet syndrome lle e : for testing patency of radial and ulnar arteries one point ll e : for CDH • Traumatic: cause of the fracture is injury l e : for testing tenderness of the spine e b: for median nerve injury • la e : not displaced, only a crack le e : for meniscus injury FRACTURES WITH EPONYMS e e e : for recurrent dislocation of the shoulder Aviators: fracture of the neck of the talus a : distal radius, intra-articular fracture a l e : for CDH e e : fracture of base of the 1st metacarpal, intra- l e le a: Osteogenesis imperfecta articular a e : for anterior dislocation of the shoulder e : fracture of nec of 5th metacarpal alla a e : for anterior dislocation of the shoulder e : comminuted fracture of lateral condyle of the e : for tetany tibia la a : for ulnar nerve injury a e : radial styloid fracture lle : distal radius, extra-articular fracture with dorsal tilt of the distal fragment : trimalleolar ankle fracture allea : fracture of distal 1/2 of the radius with dislocation of distal radio-ulnar joint a a : fracture pedicle-lamina of C2 vertebra e : fracture of the base of the 5th metatarsal al a e : pelvic ring disruption with both pubic rami and sacro-iliac injury on the same side alle : avulsion of attachment of ext tendon from base of the distal phalanx a : stress fracture of shaft of 2nd metatarsal

368 | Essential Orthopaedics e : for dorso lumbar tuberculosis of spine • D Fracture-dislocation e e : for tennis elbow • Fracture a e e : for AC and C injuries • HLA Human leukocyte antigen a e : for AC injury • Internal derrangement of the knee e : for C injury • Knee jerk el e e : for de uervain’s tenovaginitis • a. ateral : for common peroneal nerve injury • LM ateral meniscus e : for ulnar nerve injury • LS umbo-sacral ae le e : for SI joint involvement • MM Medial meniscus allea : for CDH • Metacarpo-phalangeal e : for muscular dystrophy • MWD Micro wave diathermy al le e : for anterior dislocation of the shoulder • erve conduction velocity a a el : for infection in ulnar bursa • on-weight bearing a e e e : for disc prolapse • OA Osteoarthritis a a e : for AC injury • ORIF Open reduction internal fixation l : for avulsion of lesser trochanter • Posterior cruciate ligament a e : for meniscus injury • Proximal inter-phalangeal a e e : for disc prolapse • Prolapsed intervertebral disc be e : for tight ilio-tibial band (e.g., in polio) • Plaster of Paris e a : triad of MC , AC medial meniscus • Peripheral systemic sclerosis injuries occurring together • T Patellar tendon bearing la e : for CDH • Partial weight bearing e : for AC injury • RA heumatoid arthritis l e a : for rb’s palsy • RoM ange of motion e ee: patellar tendinitis • SI Sacro-iliac l : for inferior dislocation of the shoulder • Superior labrum anterior posterior tear T a e : for hip flexion deformity • SLE Systemic lupus erythematosus T e ele b e : for unstable hip due to any reason • SLRT Straight leg raising test (e.g., CDH) • SOS If necessary T el : for detecting improving nerve injury • SSA Sero-negative spond-arthritis la : for ischaemic contracture of forearm • SWD Short-wave diathermy muscles • THR Total hip replacement : for radial nerve injury •T Tendon jerk •T Total knee replacement SOME ABBREVIATIONS USED IN • Ultrasonic waves ORTHOPAEDICS • WNL Within normal limit • Abd Abduction SOME ORTHOPAEDIC TERMS • ACL Anterior cruciate ligament • Add Adduction • Arthrocentesis: aspiration of a joint • ADL Activities of daily living • Arthrodesis: fusing a joint • AE Above elbow • Arthrography: imaging a joint with dye inside it • Ankle jerk • Arthrolysis: releasing a stiff joint • Above knee • Arthroplasty: creating a new joint • Antero-posterior • Arthroscopy: looking into a joint with a telescope • ASIS Anterior superior iliac spine • Arthrotomy: opening up a joint • Bilateral • Closed reduction: setting a fracture in position by • Both bones • Below elbow manipulation • Biceps jerk • Epiphysiodesis: knocking out an epiphyseal plate to stop • Below knee • Biopsy its growth • CDH Congenital dislocation of the hip • Fenestration: removing ligamentum flavum (from in- • Cerebral palsy •T Congenital talipes equino-varus between the laminae) • Distal inter-phalangeal • Hemi-laminectomy: removing half of the lamina •T Deep vein thrombosis • Laminectomy: removing whole of the lamina • Electromyography • Laminotomy: making a hole in the lamina • Flexor digitorum profundus • Neurectomy: cutting a nerve (as in CP) • FDS Flexor digitorum superficialis • Neurolysis: releasing a tight nerve • FFD Fixed flexion deformity • Neurorraphy: repairing a nerve • Open reduction: setting a fracture by operation • Osteoclasis: rebreaking a uniting fracture (to obtain better reduction) • Osteogenesis: new bone formation • Osteosynthesis: reconstructing a fractured bone https://kat.cr/user/Blink99/

Annexure II | 369 • Osteotomy: making a cut in the bone • elle e a : for hallux valgus correction • Derotation osteotomy for CDH • Lambrinudi operation: for correcting equinus deformity • Dimon-Houston osteotomy for inter-trochanteric of the foot fracture • e e e a : for fracture neck of the femur • Dwyer’s osteotomy for CT • la e e: for recurrent dislocation of the the • French osteotomy for cubitus varus deformity shoulder • High tibial osteotomy for OA nee with varus • e elea e: for flexion deformity of the hip in polio • McMurray’s osteotomy for fracture nec femur • e le elea e: for cavus deformity of the foot • auwel’s osteotomy for fracture nec femur • Tension-band wiring: for fracture patella, olecranon • emperton osteotomy for CDH •T e e: for CT • Salter’s osteotomy for CDH •l elea e: for flexion deformity of the knee • Sandwitch osteotomy for slipped epiphysis • elease: for flexion deformity of the knee in polio • Spinal osteotomy for an ylosing spondylosis • Wilson ‘s osteotomy for congenital coxa vara ANATOMICAL POSITIONS AND DIRECTIONS • Te a e : changing the direction or action of a tendon PLANES • Tenodesis: attaching a tendon to another tendon or bone nal: side-to-side, dividing into anterior and posterior portions • Tenolysis: releasing a tendon from adhesions al: transverse, dividing into superior and inferior • Tenotomy: cutting a tendon portions IMPLANTS AND THEIR USES a al: antero-posterior, dividing into left and right portions • Austin-Moore prosthesis: for fracture neck of the femur •a e : for elbow replacement JOINT MOTION • e la e: for condylar fractures of the tibia b ction: movement of a part away from the body : movement of a part towards the body • Charnley prosthesis: for total hip replacement : being in close contact • Condylar blade plate: for condylar fractures of the femur e : turning the foot outward e : straightening a joint • DHS: for inter-trochanteric fracture e al a : outward rotation e.g., patella facing outward • e a l: for fixing inter-trochanteric fracture le : bending a joint e al a : inward rotation e.g., patella facing • a l: for femoral or tibial shaft fracture inward e : turning the foot inward • a a a l: for inter or sub-trochanteric fractures a : twisting inward e.g., palm facing down • Harrington rod: for fixation of the spine a n: twisting outward e.g., palm facing up • Hartshill rectangle: for fixation of the spine • all e e : for total knee replacement • Interlocking nail: for femoral or tibial shaft fractures • e e: for small bone fixation • e a l: for fracture shaft of the femur • Luque rod: for fixation of the spine • e : for fracture neck of the femur RADIOLOGICAL SIGNS • ee e : for shoulder replacement • Rush nail: for diaphyseal fractures of the long bone • al la l la e: for inter-trochanteric SPECIAL VIEWS fracture e e : for acetabular fracture • a l: for fracture neck of the femur e e : for ankle injuries • Seidel nail: for fracture of the shaft of humerus bl e e e : for fracture scaphoid •e e : for elbow replacement e l e: hip X-ray in CDH • e la e: for fixation of the spine e e : for patello femoral dysplasia • Steinmann pin: for skeletal traction e e : for CDH • Swanson prosthesis: for finger joint replacement • Talwalkar nails: for fracture of radius and ulna ANGLES • Thompson prosthesis: for fracture neck of the femur le a le: fracture of the calcaneum a a le: elbow OPERATIONS BY NAME e a le: Talo-navicular angle in CT • aa e e: for recurrent dislocation of the e a a le: of the femoral neck • a el a le: fracture neck of the femur shoulder • e e: for recurrent dislocation of the shoulder CLASSIC FEATURES •l a e a : for correction of CT • Aneurysmal sign: TB spine (anterior type) • ee : for varus of heel in CT • Febella: sesamoid bone in the lateral head of gastronemius • le e a la : for TB hip • Onion-peel appearance: wing’s Sarcoma • e ee e a : for subtalar arthrodesis •a al a : Chondrosarcoma • a e e a : for recurrent dislocation of patella •e : Epiphysis of iliac bone • e e a : for foot deformity in polio

370 | Essential Orthopaedics • Sagging rope sign: erthes’ disease • ee : for upper end of humerus fractures • a el : for fracture neck of the femur • ee e : Fibrous dysplasia • Salter and Harris: for epiphyseal injuries • Soap-bubble appearance: Osteoclastoma • Spondylolisthesis: slip of one vertebra over other • Spondylolysis: break in posterior elements (at pars inter- MISCELLANEOUS articularis) • Spondylosis: degenerative spine disease • e a : A technique where ‘spare’ bone is ta en • Sun-ray appearance: Osteosarcoma from some part and put where required. •T e eb a: Morquio-Brails disease • Delayed union: A fracture not uniting in expected time • Te a : Slipped capital femoral epiphysis • a e e e : A modified portable X-ray machine, • Wormian bones: Osteogenesis imperfecta where a much clearer X-ray image of a part can be seen on a T screen. adiation exposure is much less than a GAITS conventional X-ray exposure. • Antalgic gait: occurs in painful condition of lower limb • Malunion: A fracture united in unacceptable alignment. • Charlie Chaplin gait: occurs in tibial torsion • Circumduction gait: occurs in hemiplegia • Nail: A rod made of steel, usually hollow, used for internal • Duck waddling gait: occurs in bilateral CDH • High stepping gait: occurs in foot drop fixation of fractures • a l a : occurs in bilateral CDH • Scissoring gait: occurs in CP • Non-union: Failure of a fracture to unite • a : occurs in ankylosis of the hip • Trendelenburg gait: occurs in an unstable hip due to CDH, • Osteoarthritis: Wear and tear arthritis gluteus medius weakness etc. • Osteophyte: A bony spur at the margin of an osteoarthritic joint • la e: A thick strip of a metal (usually steel) with holes, used for internal fixation of fractures • ea : Painless, mobility at a fracture due to non-union (as if a ‘false’ joint has formed) • Spica: is a plaster cast in which a limb and a part of the CLASSIFICATIONS trunk are included (e.g., shoulder spica) • a e : for fracture neck of the femur • al e : The distal part goes outwards (e.g. • l : for open fractures • Lauge-Hansen: for ankle injuries noc nee – enu valgus). •a e : The distal part goes inwards (e.g. bow legs – enu varum) https://kat.cr/user/Blink99/

Annexure - III Orthopaedic Instruments and Implants INSTRUMENTS PERIOSTEUM ELEVATOR The periosteum elevator is used to elevate the periosteum. Elevation of the periosteum is necessary in all operations on the bone because all the important structures such as vessels, nerves, tendons, etc. are outside the periosteum, and therefore, once the periosteum is elevated, the surgeon is in a safe plane. All the muscles of the extremity are attached to the periosteum, and are lifted off the bone with periosteum. 1 e e ele a a abea 3 a ble a b e bble e (b) Double-action bone cutter The periosteum is not elevated in some operations such as excision of osteochondroma, where the periosteum is excised OSTEOTOME with the osteochondroma to avoid recurrence. Periosteum elevators are of different shapes and sizes depending upon t is used for osteotomy – cutting a bone. ts both edges are their uses (Fig-1). bevelled (Fig-4a). t is available in different widths of the blade. Some of the osteotomies commonly performed are: (i) BONE LEVER McMurray’s osteotomy for fracture of the nec of the femur; (ii) corrective osteotomy for deformities such as genu varum It is used to lever out a bone from the depth of a wound after (bow legs), genu valgum (knock knees), etc. the periosteum has been elevated (Fig-2). t is placed between the bone and the periosteum, and thus retracts the soft tissues. ae e 2 ee e b e le e b e el e e ee BONE NIBBLER BONE CHISEL t is used for nibbling the bone (Fig-3a). t is available in It is like an osteotome except that only one of its surfaces is various sizes and with different angle of the nose. Some of the bevelled (Fig-4b). t is used for removing a protruding bone common bone nibblers are: (i) straight nibbler – for general or levelling a bone surface e.g., for levelling excessive callus, use; (ii) curved nibbler – for spinal surgery; and (iii) double removing an osteochondroma, etc. action nibbler – straight or curved. The double-action nibblers are mechanically superior. MALLET BONE CUTTER t is used for hammering osteotome, chisel etc. (Fig-5). It is used for cutting a bone into small pieces e.g., for cutting BONE CURETTE bone grafts (Fig-3b). t is also available with straight or curved ends, and with double-action type. This is used for curetting a cavity in the bone or for removing fibrous tissue from fracture ends of an old fracture (Fig- ).

372 | Essential Orthopaedics Plate-holding forceps: Once the reduction is achieved, a plate of Curettage is performed for: (i) benign tumours such as suitable size is placed over the fracture and held with the help enchondroma, giant cell tumour; and (ii) infections such as of the following plate holding forceps: (i) owman’s clamp; tubercular cavity of the bone, osteomyelitis, etc. and (ii) AO type self-retaining forceps (Fig-10). alle AO type forceps e ee BONE GOUGE owman s clamp This is a concave bladed chisel used for cutting on round 1 la e l e bone surfaces (Fig-7), or sometimes for ma ing a round hole in the bone. TRACTION INSTRUMENTS ee Kirschner wire: This is thin, straight steel wire, of diameter BONE AWL ranging from 1 to 3 mm (Fig-11a). t is used (i) for internal fIxation of small bones; (ii) for giving traction e.g., for applying This is a pointed thin instrument for making a hole in the bone traction through the olecranon; (iii) for fixing fractures in (Fig- ). There is an eye at its tip to thread a wire through the children; and (iv) for lizarov’s fixation system. bone e.g., for tendon attachment. Steinmann pin: This is a stout, straight steel rod, of diameter ea l ranging from 3 to mm (Fig-11b). t is used for s eletal traction— BONE HOLDING FORCEPS common sites being upper end of tibia, supracondylar region of the femur and calcaneum. There are different types of forceps for holding a bone (Fig- ). These are: (i) ane’s forceps – for holding the femur, tibia, Bohler's stirrup: This is a device used for holding a Steinmann etc.; (ii) lion-toothed forceps; and (iii) self-retaining – AO type forceps. pin and applying traction (Fig-11c). The screws on the sides of the stirrup are used to hold the pin. It is possible to change ane s forceps the direction of traction without moving the pin inside the bone, thus avoiding loosening of the pin. Fergusson's forceps K-wire stirrup with tensioner: When skeletal traction is to be applied with the help of K-wire, the strength of the wire is increased by subjecting it to an axial tension by a tensioner (Fig-11d). Skull traction tongs: These are tongs to apply skull traction in cases of cervical spine injury or disease (Fig-11e). xamples are Crutchfield tongs, Blackburn tongs, etc. IMPLANTS NAILS ails are devices used for the intra-medullary fixation of fractures of long bones. Some of the nails used commonly are as follows: e a l: This is used for internal fixation of fracture of the femoral shaft. ee e al a l : This is used for internal AO type forceps fixation of fracture of the femoral neck. el e • a l: This is used for internal fixation of fracture of the tibial shaft. https://kat.cr/user/Blink99/

Annexure III | 373 11 T a e Tal al a a l: This is used for fractures of forearm bones. The nail can be inserted by two techniques. In the first a l: This is used for some special situations in long technique, the nail is inserted from the fracture site, and is hammered proximally till it comes out of the trochanter. The bone fractures. fracture is reduced and the nail driven back into the distal • e a l: This is used for internal fixation of inter- fragment. This is called retrograde nailing. In the second technique, the nail is introduced from the greater trochanter trochanteric fractures of the femur. over a guide-wire passed from the fracture site. Once, the nail comes up to the fracture site, the guide-wire is removed, Kuntscher's cloverleaf intra-medullary nail (K-nail): Kuntscher, a the fracture reduced under vision, and the nail driven home. About 2 cm nail is left protruding at the trochanter to facilitate German surgeon devised the intramedullary nail for internal removal usually a minimum two years after operation. For fixation of femoral fractures. The nail is a hollow tube with a this, the hook of an extractor is engaged into the nail at the slot on one side (Fig-12). t is cloverleaf shape in cross section. ‘eye’ and the nail pulled out by outward stro ing of the The fixation by K-nailing is based on the concept of three extractor. point fixation i.e., when a straight rod passes through the curved medullary cavity of the femur, it fixes the bone at Some common complications of K-nailing are: (i) nail getting three points — at either ends and at the isthmus (Fig-12a). The stuck; (ii) splintering of the cortex while hammering the nail; cloverleaf shape is designed to give good rotational stability to (iii) proximal migration of the nail, leading to bursitis over the fracture (Fig-12b). The nail has an ‘eye’at its either end; in its protruding end; (iv) distal migration of the nail leading to which the hook of the extractor is introduced while removing stiffness of the knee; and (v) infection. the nail (Fig-12c). Smith-Peterson nail (SP nail): Smith eterson (Fig-12) The size of a K-nail required for a particular case is found by determining the length and diameter of the nail required. The cannulated triflanged nail is an implant used for internal length is measured from the tip of the greater trochanter to fixation of a fracture of the neck of the femur. The advantages the lateral joint line of the nee, and subtracting 2 cm from of its triflanged shape are that: (a) it prevents axial rotation it. The diameter is determined on an X-ray, from the width of the medullary cavity at the isthmus.

374 | Essential Orthopaedics 12 la of the fragments; and (b) it cuts only a little bone to provide PLATES AND SCREWS good stability. The nail is cannulated because it is threaded over a guide-wire introduced at the correct site under X-ray These are used for fixing two bony fragments. Different types control. t can be used along with a Mc aughlin’s plate for the of plates are available; these may be heavy duty broad and fixation of inter-trochanteric fractures (Fig-12). narrow plates or semi-tubular plate (Fig-13). Dynamic Hip Screw (DHS): This is a device used for the Screws may be used alone or in combination with a plate. Different types of screws used in orthopaedic practice are as internal fixation of trochanteric fractures (Fig-12). t has two shown in Fig-13. n the past, machine screws (self-tapping screws) components – the lag screw and the barrel. The lag screw were used, but now AO screws (non-tapping screws) are used. A slides freely inside the barrel, so that if there is collapse at non-tapping screw is better than a self tapping screw because in the fracture site, the screw does not cut out of the cortex; it the latter, while tightening, heat is produced at the bone–screw telescopes into the barrel. interface causing necrosis of the bone, and thus loosening of the https://kat.cr/user/Blink99/

Annexure III | 375 13 la e a e ee e 1e 1 b ea femur. The acetabulum is replaced by a plastic (polyethylene) acetabulum cup, and the head by a steel component. The screws. For a non-tapping screw, threads are cut in the bone with diameter of the head of the prosthesis is 22 mm. Both the a special instrument, called a bone tap (Fig-14). components are fixed to respective bones by bone cement (Polymethylmethacrylate). PROSTHESES Muller's total hip prosthesis: t is essentially similar to Charnley’s Austin-Moore prosthesis: This is used for replacement of femoral prosthesis except that the size of the head of this prosthesis head in a case of fracture of the neck of the femur in elderly is 32 mm, and the stem is available in different thic nesses. persons. The prosthesis has a head with a small neck and a stem (Fig-15a). t is available in head sizes ranging from 35 Total knee prosthesis: There are several designs available (Fig- to 5 mm (odd numbers). There is a small hole at the top of the stem for the hook of the extractor, used while removing 1 ). Total condylar designs are most popular. n this type, the the prosthesis. The stem has two fenestrations in its middle, articular surfaces of femur, tibia and patella are replaced by through which the bone supposedly grows and helps in metallic (for femur) and polyethylene (for tibia and patella) fixation of the prosthesis. This prosthesis can thus be used prosthesis. Common prosthesis used are Insall-Burstin knee, only without cement because the use of cement would make Freeman-Samuelson knee, etc. its removal, if required, difficult. 1 T al ee e Thompson prosthesis: This is a prosthesis for the head of the femur, similar to AM prosthesis (Fig-15b). t is especially indicated in cases where the neck of the femur is absorbed e.g. in old fractures of the femoral neck. It can be used with or without cement. Charnley's total hip prosthesis: This is a prosthesis for the replacement of both, the acetabulum and the head of the

376 | Essential Orthopaedics Non-metals: The most common non metal material is IMPLANT MATERIAL IN ORTHOPAEDICS some form of plastic. Following non-metals are commonly A number of implants are used in orthopaedics. These may used: be used as a temporary device, e.g., a steel rod used for fixation of a fracture; or as a permanent, device, e.g. a total • la e l e le e : This is used hip prosthesis used for replacing a damaged hip joint. The material used for these implants is foreign for the body, for making acetabular cup for total hip, and the plastic and is subjected to harsh chemical environment of the body. A usual foreign body, subjected to this environment insert for knee replacement. shall evoke a reaction from the body which may range from a benign to a chronic inflammatory response. To • e e e : This is used as an anchoring agent to avoid this, the implant materials used in our body are so designed that they have suitable mechanical strength and fix metallic components to the bone. Chemically it is are biocompatible. Implant materials can be divided in the following categories: polymethylmethacrylate. On mixing the monomer, Metals: These have been used for fixation of fractures, for powder form of polymethacrylate with liquid a long time. The most common one is stainless steel. The methylmethacrylate, a dough like material is formed surgical grade stainless is SS 31 . Other metal used for fracture fixation is titanium based alloy. Titanium is stronger which sets in 5 to 7 minutes into a hard material. t is and lighter than steel. For manufacturing components for joint replacement, cobalt based alloys are preferred as these have something like an ordinary cement which sets on adding high resistance to corrosion. water. This process is exothermic and irreversible. • Ceramics: Ceramics have been used to design articulating surfaces of artificial joints. These are more resistant to wear, but disadvantage is that these are brittle. • Silicon: Silicon implants are used for artificial inter- phalangeal joints in the form of silicon elastomer (silastic). • l e e be : This is used for manufacturing artificial ligaments. https://kat.cr/user/Blink99/

Index Page numbers followed by f refer to figure, t refer to table and fc reffer to ow chart A rheumatic 177 Biopsy, synovial 289 rheumatoid 286 Bladder Abduction injuries 161, 161f types of 286 Abductor lever arm 130 Arthrodesis 78, 83, 216 care of 279 Acetabular reconstruction procedures 223, ankle 163 rupture of 128 of joints, position of 84t Blood 173, 176, 288 223f triple 216f examination 184 Achondroplasia 316, 316f types of 83f Blount’s disease 320, 325 Acromioclavicular injury, grades of 89t Arthrography 152 Bohler-Braun splint 26, 26f Acute arthritis, causes of 176 Arthrogryposis multiplex 320 Bone 307 Adult respiratory distress syndrome 43 congenita 211, 212, 213, 218 anatomy of 8 Alandronate 309 Arthrolysis 144 banks 85 Albers-Schonberg disease 317 Arthropathy, neuropathic 294 benign tumours of 236f Albright’s syndrome 249, 320 Arthroplasties 78, 84 biopsy 309, 312 Amputations 119, 174, 328 types of 84f blood supply of 9 Arthroscopic surgery 152, 334, 335, 335t cells 9 closed 329 limitations of 336 chip, avulsion of 6f guillotine 328 Arthroscopy 152, 334 constitution of 307, 307fc indications for 328 Articulation 266 cyst 249f level of 329 Artificial nee joint, parts of f nomenclature of 329 Ascorbic acid 315 aneurysmal 249 types 328 Ash brace 191 simple 248 Amyloidosis 174 Ataxia 229 deformities 311 Anaemia 290 Athetosis 229 forearm 109 Androgens 309 Atlanto-axial fracture-dislocation 272 formation, heterotrophic 340 Ankle Atlanto-axial injuries 272f grafts, types of 85fc ligaments of 159, 159f Autonomous bladder 279 haemangioma of 236 sprain 164 Autosomal recessive 310t inorganic constituents of 307 stiffness of 163 Avascular necrosis 50, 115, 131, 138, 166, matrix, loss of 308 X-ray of 162f 318 metastasis in 246 Ankylosis 176, 183 Aviator’s fracture 3 morphogenic protein 85 fibrous 2 Axonotmesis 63 organic constituents of 307 types of 183f pains 312, 313 Annulus fibrosus 2 2, 266 B scan 170, 247f Anorexia 313 scaphoid 115f Anterior dislocation of shoulder Bamboo-spine appearance 293 sequestra 172f pathoanatomy of 90f Bankart’s lesion 90 structural composition of 9 types of 90f Bankart’s operation 91 subcutaneous 155 AO method 29 Barely visible scars 334 tumours of fracture treatment 29 Barlow’s test 220, 220f benign 235 principles of 29f Barton’s fracture 3, 114f common 244t Apert syndrome 320 metastasis 235 Apophysis 9 aseball finger nomenclature and classification of Arthralgia 286 Batchelor’s cast 222 Arthritis 175, 286 Batson’s plexus 186 236t alkaptonuric 294 Bence-Jones proteins 245 primary malignant 235 haemophilic 294 Bennett’s fracture 117, 117f uncommon benign tumour of 236 mono 286 Bilateral total hip replacement 339f Bony ankylosis 287 poly 286 Book test 68, 68f

378 | Essential Orthopaedics Club hand, radial 225 Decompression, anterolateral 194 Clubfoot 210 Deep palmar abscess 208 Boston brace 282 Deep palmar spaces 207f Bow legs 325 calcaneal angles in 213f Deep venous thrombosis 339, 341 Bowel, care of 279 idiopathic 211 Deformities 37, 56, 64, 75, 76t, 102, 104, Braces, common 25t management of 214f Bracing, functional 18, 33, 33f Clutton’s joints 178 112, 177, 179, 227, 311 Breech malposition 219 Cobalt-chromium alloy 339 causes of 76f Bristow’s operation 91 Cobb’s angle 281 correction of 34f, 78, 82 Brodie’s abscess 175, 175f od fish appearance dinner fork 112f Brown’s tumour 313 Codman’s triangle 240 methods of correction of 214 Bursa, radial 208 Cold abscess 187 prevention of 289 Bursites, common 301t Collar, cervical 272 Degenerative disorders 262 Bursitis 301 Collateral ligament Denis brown splint 216f lateral 148 Densitometry 309 infective 301 medial 148 Diaphragms, rupture of 128 irritative 301 Colles’ cast 113f Diaphysial aclasis 317 Colles’ fracture 3, 112, 112f Diaphysis 8 C displacement in 112f Diastematomyelia 225 technique of reduction of 113f Dilwyn Evan’s operation 215f Caffey’s disease 319 Compartment syndrome 47, 158 Dilwyn-Evan’s procedure 215 Calcaneum 164 Eaton and Green cycle for 47f Disability in leprosy, pathogenesis of Compound palmar ganglion 302 X-ray of 203f Compression, inter-fragmentary 29 180fc Calcar femorale 129 Conduction velocity 71 Disc 252 Calcitonin 309 Conservative methods 141, 285, 294, 311 Calcium supplementation 309 Continuous suction irrigation system 174, prolapse 257 Callot’s cast 322 174f pathology of 253f Callus 11 Convex 281 Calve’s disease 318 Cord 276 space calcification 2 Cancellous bone 11 anterior 277 Discectomy, percutaneous 257 central 277 Discharging sinus 172 chips 175 concussion 276 Dislocation Capitulum 107 lesion 277 Card test 67 posterior 277 congenital 219 Caries sicca 202 spinal shock 276 posterior 91 Carpal tunnel syndrome 303, 322 Cortico-cancellous junction 9, 9f Dislocations 54, 89, 116, 130, 131, 152 Corticotomy 34 pathoanatomy of 55f causes of 304t Costo-transversectomy 194 Distal third of shaft of femur, fracture of Cast, scaphoid 115 Coxa plana 318 CDH, pathology of 220f Coxa vara 323, 323f 142f Central fracture-dislocation 131f congenital 225 Dorsal spine, X-ray of 309f Cerebral palsy infantile 323 Dorsolateral wedge 216f Cramer-wire splint 25, 25f Dorso-lumbar lesion 277 causes of 229 Cramps, abdominal 313 Dorso-lumbar spine injury 274fc pattern of 229 Craniotabes 310 Drain 330 severity of 229 Cruciate ligament Drawer test treatment 230 anterior 148 Cervical spine injuries posterior 149 anterior 149 common 272 Crush injury 120 posterior 149 treatment of 271 rutchfield tongs traction 2 f Drugs 296 Charcot’s CT scan 173, 190, 190f, 255f, 261, 270, antibacterial 82 arthropathy 325 277 anti-tubercular 184 joint 178, 294 CTEV shoes 216, 216f cytotoxic 82 Chemonucleosis 257 Cubitus valgus 104 Dugas’ test 90 Chemotherapy 241 Cylinder cast 147 Dupuytren’s contracture 302, 302t Chest-arm bandage 94 Cyst warfism Child’s bone, parts of 8f popliteal 326 causes of 316 Chondroid 239 subchondral 295 Dwyer’s osteotomy 215f Chondrosarcoma 246 Dynamic hip screw 136, 139 Chopart fracture-dislocation 3 D Dysostosis 320 Chronaxie 70 Dysplasia Chronic osteomyelitis, treatment of 173 Day-care surgery 334 fibrous 249 Chymopapain 257 De Quervain’s tenosynovitis 303f metaphyseal 320 Claudication 322 De Quervain’s tenovaginitis 303 Dystrophy, muscular 232, 233fc Clavicle fracture, displacement of 88f Claw hand 64, 64f https://kat.cr/user/Blink99/ E Clergyman’s knee 301 Closed reduction, technique of 130, 156 Easy fractures causes of 317 Club feet, primary and secondary 213t Egawas’ test 67 Egg-shell crackling 237

Elbow, X-ray of 52f causes of 326 Index | 379 Electromyography 69, 70f, 256, 261 congenital 326 Enchondroma 248 infantile 327 patterns of 2 Ender’s nails 139 Fle’che test 292 pelvic 123 Engelmann’s disease 319 Flexion distraction injury 268, 270t reduction of 15 Epicondyle, medial 105 Flexion rotation injury 267, 267f, 270t scaphoid 115 Epicondylitis Flexor tendons 119, 208f shaft of Fluid aspiration, synovial 184 lateral 302 Fluorosis 314 femur, displacement in 141f medial 302 dental 314 humerus, displacement in 93f Epiphyseal growth, selective retardation of radiological features of 314f site of 57 skeletal 314 splintage of 13f 78 Foot 212 spontaneous 312 Epiphyseal injuries, Salter and Harris arches of 326f stellate 147 deformities, types of 211f supracondylar 146 classification of f drop 63, 179 treatment, philosophy of 14 Epiphyseal plates, widening of 311 joint of 210, 210f types of 57 Epiphyses 8 ligaments of 210f undisplaced 118, 147, 164, 165 X-ray of 166f unimpacted 135 delayed appearance of 311 Forearm wedge compression 272 Equinus 211 bone fractures, plan of treatment Fragilitas ossium 316 Freiberg’s disease 318 rlenmeyer as 2 of 110fc Frog hand 208 Esmarch bandage 329 X-ray of 111f Froment’s sign 68, 68f Estrogens 309 Fractures 1, 40, 55, 88, 92, 97, 103, 104, Frozen’ shoulder 304 Ewing’s sarcoma 173, 243 Fungal infections 178 Exacerbation 174 132, 138, 145, 155, 164, 339 Fusion, inter-transverse 285 Excision 84 acetabular 125 Exercise atlas 272 G bumper 3 neck muscle 298 burst 3, 267, 272 Gaenslen’s test 291 therapy 81 calcaneum 165f Gait 69, 221 Exostoses, multiple 317, 317f Galeazzi fracture-dislocation 3, 108, 111, Extensor apparatus, disruption of 152 types of 164f Extensor hallucis longus 229 chance 3, 268f 111f Extensor lag 147 classification of Galeazzi sign 221f, 221 Extensor tendons 120 clay Shoveller’s 273 Gallow’s traction 143f Extensor weakness 148 closed 156 Ganglion 303 Extradural pus 192 comminuted 148 common 36t arden s classification , f F complication of 42, 43t Garre’s osteomyelitis lies 175 compression 165, 269f GCT, treatment of 239t Facet joints, direction of 266f disease 29 Genu recurvatum 325 Fairbank’s triangle 323f dislocation 272f Genu valgum, causes of 325t Fasciotomy 48 displaced 118, 135 Giant cell tumour 237 Fat embolism syndrome 43 displacement in 2f Girdlestone arthroplasty 198, 199f Fatigue 166 extra-articular 164 Gleno-humeral joint 88 Felon 206 healing of 10, 57 Glycoproteins 307 Femoral artery, injury to 143 immobilisation of 16 Golfer’s elbow 302 Femoral head, avascular necrosis of 51f impacted 134, 135 Gonococcal arthritis 178 Femur 145 intercondylar 146 Granulation tissue 192 inter-trochanteric 134t, 138f Granuloma, eosinophilic 317 chondrosarcoma of 246f intra-articular 165 Greenstick fracture 59f, 109 condylar fractures of 146f isolated 124 Ground-glass appearance 309 fracture neck of 132f, 134t Jefferson’s 272 Gypsum salt 17 neck of 132 line 162 osteosarcoma of lower end of 240f management of 278 H X-ray of 240f, 243f march 166 Fenestration 256 neck of Haematoma 330 Fibrillation 295 Haemophilia 177 Fibromyalgia 305 femur, displacement in 132f Hair-pin arrangement 168 Fibrositis 304 talus, mechanism of injury of 166f Hallux rigidus 327 Fibula, Ewing’s sarcoma of 243f of leg, technique of reduction of 156f Hallux valgus 327 Figure-of-8 bandage 88f of tibial shaft, X-ray of 11f Halo-pelvic traction 272f Fine needle aspiration cytology 240 open 156 Hamilton ruler test 91 Finger strapping 118 pathological 59, 171, 174, 245, 313 Hammer toe 327 Finkelstein’s test 303 Hammock-sling 126 Fixator 34 Flat foot 326 acquired 327

380 | Essential Orthopaedics Iliac wing fracture 125 arthrodesis of 83f Ili aro s fixation f arthroscopic examination of 152f Hand Ilizarov’s technique 33, 34f, 79 arthroscopic surgery 334f, 336f bones, enchondromas of 248f deformities of 324, 325f deformities in 179 principles of 216 extensor apparatus of 145, 145f sensory innervation of 61f Immobilisation of hand, position of 121f injuries, mechanism of 145, 146f tendon injuries of 119 Infected bone, excision of 174 instability 150 X-ray of 248f Infection 47, 143, 330 internal derrangement of 152 Infective arthritis, early 323 ligament 145, 148, 149t Hand-Schuller Christian disease 317 In ammation, syno ial 2 stiffness 144, 148, 341 Hanging cast 94 Injuries tuberculosis of 201f X-ray of 83f, 148f, 153f, 201f, 248f, arrington rod fixation 2 f adduction 160, 160f Harrison’s sulcus 311 ankle 159, 162f 317f, 341f biomechanics of 266 Knock knee 324 artshill rectangle fixation 2 f causes of 69 Kohler’s disease 318 Haversion canal 8 dashboard 130 Kyphosis 283 Head of femur epiphyseal 58, 58t extension 268, 270t angular 283 avascular necrosis of 319f types of 69 compensatory 283 blood supply of 129f unstable 272, 274 Gibbus 283 Head, femoral 131 vascular 339 knuckle 283 Heat therapy 80 Intercondylar notch, widening of 294 postural 283 Heel pain 304 Interlock nailing 32, 32f round 283 Hemiarthroplasty 84, 136, 338 Internal fixation of spine, methods of 2 f Scheurmann’s disease 283 Hemilaminectomy 257 Intertrochanteric fracture, internal fixation Kyphotic deformities 188 Hemi-replacement arthroplasty 136f Kyphus 187 Herbert’s screw 115 of 139f High protein diet 309 Intervertebral disc, displacement of 273 L Hill-Sach’s lesion 90 Ischiopubic rami fracture 124 Hindfoot 210 Lachmann test 149 Hinge joints 155 J Lamina dura 313 Hip 130, 194, 296 Laminectomy 257 abductor mechanism of 129, 130f Jame’s position 121 Laminotomy 256 congenital dislocation of 54, 178, Jefferson’s fracture 3 Large central disc prolapse 255f ess fixation 2 Lasegue test 255 219, 224f Joints 178, 198 coxa vara of 323f atex fixation test 2 deformities 196t acromioclavicular 87, 89 auge ansen classification , 2 dislocatable 219 aspiration 176 dislocated 219 better assessment of 334 of ankle injuries 160t dislocations of 130 damage, repair of 289 Leg dysplastic 219 debridement 297 observation 323 deformities of 330 bone of 155 replacement, type of 338f elbow 105 X-ray of 170f spica 142, 142f facet 266 Leprosy 179 X-ray of 131f, 134f, 138f ail 22 Ligament Histiocytosis X 317 functions, preservation of 289 complex, posterior 266 Homan’s sign 44 injury to 5, 46 deltoid 159, 210 Hong Kong operation 194 involvement 183 interosseous 210 Hormone 82 metacarpophalangeal 118 sprain, degrees of 5f induced joint laxity 219 mobilising 81 Ligamentoraxis 114 Housemaid’s knee 301 replacement 297 Ligaments Humerus 97 socket 155 calcification of 2 2f greater tuberosity of 92 sternoclavicular 87, 89 injury to 5 shafts of 93 stiffness of 51, 174 igamentum a um 2 surgical neck of 92 tuberculosis of 202 Limb Hunter’s disease 319 Jones’ fracture 3, 166, 166f muscles, motor innervation of 61 Hurler’s disease 319 Juxta-articular rarefaction 288f sensory innervation of 62 Hydrotherapy 81 shortening of 56 Hydroxyapatite 9 K upper 225 crystals 307 Litterer-Siwe disease 317 Hyperextension injury 268f Kanavel’s sign 209, 209f Looser’s zone 312 Hyperparathyroidism 312 Keller’s operation 327 Low back pain 258 Hypotonia, muscular 311 Kienbock’s disease 318 approach to 263 Kirschner wire 18 causes of 258, 258t, 261 I Kite’s philosophy 214 investigations 261 Knee 152, 199, 296, 324 treatment 261 Ice therapy 80 Idiopathic scoliosis, radiological features https://kat.cr/user/Blink99/ of 282f

Low backache 254 Mitchell’s osteotomy 327 Index | 381 Low velocity injury 2 Mobility, abnormal 38 Lower limb 225 Neurapraxia 63 Lower motor neurone 232 odified ustilo and Anderson Neuritis 181 Lumbar spine, X-ray of 284f, 292f classification 2 t Lumbar spondylosis 298 Monteggia fracture dislocation 108, 110 eurofibromatosis Lumbar vertebrae, tonguing of 319 Morquio’s disease 319 Neurolysis 73 Lunate dislocations 116 Morrant-Baker’s cyst 326 Neuroma 330 Luxatio erecta 90 Moth-eaten appearance 246 Motor march 62 types of 62f M Motor weakness 179 Neuromuscular junction 232 Movement, loss of 56 Neurotmesis 63 Madelung’s deformity 225 MRI 190, 270 Night cries 195 Madura foot 178 scan 173, 256f, 261, 277 Night-stick 3 Maffucci syndrome 248 Mucoproteins 307 Ninhydrin print test 64 Malformations, congenital 224 Muscle 54, 329 Malgaigne’s fracture 3 atrophy 179 on steroidal anti in ammatory drugs 2 Malignant tumours, primary 239 curv 71 Nucleus pulposus 252, 266 Malleolus fracture disorders of 232 Nutrient artery 9 pedicle bone graft 137 lateral 163 strengthening 81 O medial 163 wasting of 64 Malleolus, posterior 163 Musculo-skeletal structures 182 O’Donoghue triad 149 allet finger , Musculo-skeletal system 183 OA Malunion 49, 139, 144 Musculo-skeletal tuberculosis 182t Mantoux test 184 Myalgia 298 of hip, secondary 295 Manus valgus 225 Mycetoma 178 primary 295 Marble bones 317 Mycobacterium tuberculosis 182 Occupational therapy 81, 289 Marfan’s syndrome 320, 325 Myelocele 231 Ocronosis 294 Marie Strumpell disease 290 Myelography 190 edema, in ammatory 2 Maxpage operation 103 Myeloma, multiple 243, 245f Olecranon 105 Mayo’s operation 327 Myodesis 329 Ollier’s disease 248, 319 McMurray’s osteotomy 83, 136f Myoplasty 329 Onion-peel appearance 243 Mechanism of injury 36, 37t, 62, 130 yositis ossificans 2, 2f, 320 Open-book injury, treatment of 126f Median nerve, major motor branches of 66t Open fractures infection of bone, Melon seed bodies 201 N management of 21 Melorrheostosis 319 Opponens weakness 179 Membrana reuniens 231 Nail Orthopaedic disorders 82 Meningocele 231 intramedullary 18 Orthopaedic practice, orthoses in 332 Meningomyelocele 231 patella syndrome 320 Orthopaedic trauma 1 Meniscal injuries 150 Orthopaedic treatment 231, 289, 310, 311, eniscus calcification 2 Nausea 313 Meniscus tear, types of 151f Neck 314 Meralgia paraesthetica 305 Orthoses 332 Mermaid splints 311 of femur, fracture of 132, 135fc Metabolic bone diseases 307, 308f reconstruction 137 common 333f mixed 308 X-ray of 322f dynamic 332 osteomalacic 308 Nerve nomenclature of 332 osteopenic 308 accessory 68 static 332 osteosclerotic 308 axillary 68 uses of 332 Metacarpal index 309 conduction studies 71 Ortolani’s test 221 Metaphysis 8, 168 curve 71 Osgood-Shlatter’s disease 318 cupping of 311 grafting 73 Osseo-fascial compartment 47f splaying of 311 injuries 46t, 74, 94 Osteitis deformans 317 types of 168f Osteoarthritis 138, 139, 148, 150, 163, Metatarsal bones, fracture of 166 muscle wasting in 64t Metatarsal shafts, fracture of 166 Seddon s classification of t 165, 166, 178, 289, 295, 296 Meyer’s procedure 137, 137f knee, surgical treatment of 297f Middle volar space infection 206 median 66 Osteoarthrosis 295 Mid-palmar space 208 palsies 339 Osteoblastoma 236 Milwaukee brace 282, 283f radial 65 Osteoblasts 9 Minerva jacket 272, 272f repair 72 Osteochondral fragment 55f, 153 Minimally invasive technique 334 intra-articular 153f technique of 72f Osteochondritis 317 sciatic 69 crushing type 318 structure of 61f osteochondritis dissecans 318 suture 72 traction osteochondritis 318 Neural arch, posterior 265 Osteochondroma 247 Neural injury, pathology of 276f Osteoclasis 50 Osteoclastic resorption 308 Osteoclastoma 237 Osteoclasts 9

382 | Essential Orthopaedics Pen test 66, 67f Pseudofractures 312 Periarthritis shoulder 304 Pseudogout 293 Osteocytic osteolysis 308 Periosteal reaction 169 Psoas 190 Osteogenesis imperfecta 316 Peripheral nerve injury, management of Psoriatic arthropathy 289, 294 Osteoid 240 Pubic rami 312f 73fc Pump-handle test 292 osteoma 235 Peripheral neuropathies Putti-Platt operation 91 Osteoma 235 Pyogenic arthritis 171 Osteomalacia 310, 312 cause 234 Osteomyelitis 47, 168, 171, 173, 203 treatment 234 Q types 233 of tibia 170f Peripheral polyneuropathies, common Quadriceps-plasty 144 sequestra in 169f Quadriparesis 276 Osteon 8 causes of 234t Quadriplegia 276 Osteopathia striata 319 Perthes’ disease 318, 323 steoperiosteal aps R Osteopetrosis marble-bone disease 317 of hip 318f Osteopoikilosis 319 Peyronie’s disease 302 Rachitic rosary 311 Osteoporosis 308, 309f Phalanges 118, 167 Radial nerve, major motor branches of 65t causes of 308 Phantom sensation 330 Radiotherapy 82 Osteosarcoma 239, 241t, 242fc Phemister grafting 158, 158f Radioulnar articulation 108 Osteosclerosis 314 Pigeon-chest 311 Radioulnar synostosis 225 Osteotomy 50, 78, 83, 136, 297, 318 Pilon fracture 3, 161 Radius causes of 318 Pin and plaster method 23f Chiari’s 223 head of 106 common 83t in fixator f neck of 107 containment 318 Plantar fasciitis 304 normal distal articular surface of 112f Dwyer’s 215 Plantar ligaments 211 osteomyelitis of 171f Pemberton’s 223 Plaster cast 17t Reconstructive surgery 73, 290 Salter’s 223 e ex sympathetic dystrophy varus-derotation 223 disastrous complication of 17f Rehabilitation 279, 289 Plaster of Paris 17 Reisser’s sign 281 P Pointing index 64 Reisser’s turn-buckle cast 282 Policeman tip 64 Renal colics 313 Paget’s disease 317 Poliomyelitis 170, 226 Reticulum cell sarcoma 246 Pain 37, 56, 297 Retrolisthesis 283, 284 bulbar 227 Rheumatic arthritis 170 radiating 298 bulbo-spinal 227 Rheumatoid arthritis 286, 286t, 287, 289, relief of 82 clinical features 226 sciatic 254 pathogenesis 226 290t Painful arc syndrome 304, 305f principles of treatment 228 deformities in 288, 288f Palmar aponeurosis, contracture of 302 stages of 226f diagnosis 287 Panner’s disease 318 Polyarthritis, symmetrical 287 extra-articular manifestations of 288, Pannus 183, 287 Polyaxial ball 155 Paraesthesia 298 olyostotic fibrous dysplasia 2 288t Paralysis, incomplete 278 Ponsetti’s philosophy 214 joints 287 Paraparesis 276 Postero-lateral disc prolapse 253f stages of 287 Paraplegia 191 Postero-medial soft-tissue release 214 Rib, cervical 322, 322f Parathyroid hormone 308, 312 Post-polio paralysis 227t Rickets 310 Paravertebral abscesses, types of 189f Pott’s disease 185 radiological features of 311f Pars interarticularis 285 Pott’s paraplegia 194 types of 310 Partial joint replacement 338, 341 grades of 192 Ring disruption injuries 125 Patella 147, 152, 153 types of 192 ing fixator f fractures, types of 147f Pressure, axial 38 Rolando fracture 3, 117f skyline view of 147f Pronation-external rotation injuries 161, Root cut-off sign 255 Patellectomy 148 Root transection 277 Pathological fractures, causes of 4t 161f Rose-Waaler test 289 auwel s classification 2, f Prostheses Rotation 160 Pauwel’s osteotomy 137f Pelvic compression test 125 body powered 331 S Pelvic injuries, classification of 124t common 331f Pelvic ring 123, 123f Prosthesis 331 Sacral sparing 277 disruption injuries 127fc cosmetic 331 Sacro-iliac compression 291 Pelvis 314 functional 331 Sacro-iliac joint affections 291f injury 124f parts of 331 Salter and arris classification , t stability of 123 Prosthetic, uses of 331 Salt-pepper appearance 313 triradiate 312 Protrusio-acetabuli 312 Sarcoma, synovial 246 X-ray of 38, 221f, 249f, 292f, 312f, Protrusion 253 Proximal volar space infection 207 323f Pseudarthrosis 137 Pseudocoxalgia 318 https://kat.cr/user/Blink99/

Index | 383 Scaphoid, fracture of 115f infection 173 Stress Scapula 87, 89 release 78 avoidance of 297 swelling 162 test 6 winging of 63, 68, 69f Solitary bone lesion 237t X-rays 149 Scheurmann’s disease 283, 318 Soutters’ release 229 Sciatic nerve, injury to 143 Spider fingers 2 Stretch test 47 Scoliosis 280 Spina bifida 2 , 2 Stryker frame 279 types of 231f Student’s elbow 301 compensatory 280 Spina ventosa 203 Stump, revision of 328 congenital 280, 280f Spinal cord Subluxation, posterior 162 diagnosis 281 infarction of 192 Subungual infection, apical 206, 206f idiopathic 280, 280f injury, medical management of 271 Sudeck’s dystrophy 51 infantile 280 lesions 322 Sun-ray appearance 240 non-structural 280 Spinal injuries 277 Supination-external rotation injuries 161, paralytic 281 centres 279 pathology of 281f classification 2 161f postural 280 mode of injury 266 Suppurative tenosynovitis 208 principles of treatment 282 stable and unstable 266 Surgical neck of humerus, methods of progressive 280 types of 270t resolving 280 Spine 314 fixation of 2f sciatic 280 anatomy of 265f Sweat test 64 structural 280 care of 190 Swelling 37 treatment of 283f cervical 277 Syndesmophytes 293 Scottish dog sign 285f examination of 269 Syndrome Scurvy 170, 315 injury, cervical 273fc Seddon s classification involvement, cervical 292 Brown-Sequard 277 Septic arthritis 170 lesions, cervical 322 hemi-section 277 in infancy 178 MRI of 190f Klippel-Feil 224 of hip, sequelae of 178f X-ray of 274f, 280f Synovitis 323 Sequestra, types of 172t Splint 25 Syphilis 178 Sequestrectomy 173 common 25t Syringomyelocele 231 Seronegative spond-arthritis 259 Denis-brown 216 Systemic lupus erythematosus 289 Serum alkaline phosphatase 240 Von Rosen’s 222 Sever’s disease 318 Spondylitis, ankylosing 283, 290-292, T Sharpe s fibres Shenton’s line 130, 222, 222f 292f, 293t Tailor’s ankle 301 Shock, hypovolaemic 42 Spondyloepiphyseal dysplasia 320 Talipes equinovarus, congenital 210 Short bones, tuberculosis of 203 Spondylolisthesis 225, 262, 283, 284f, 285 Talus 159, 165 Short femur, congenital 225 Tarsal bones, injury of 166 Shoulder arthroscopy 336 categories 284 TB hip 195f, 200fc Shoulder dislocation degenerative 284 arthroscopic repair of 92f dysplastic 284 radiological features of 197f technique of reduction of 91 isthmic 284 stages of 196f Shoulder lytic 284 TB knee 202fc anatomy of 87f pathological 284 TB osteomyelitis 183 anterior dislocation of 91f principles of treatment 285 TB spine 188f, 191, 191t, 193 dislocations of 90 traumatic 284 Teeth eruption, delayed 311 girdle 87 Spondylolysis 224, 262, 285 Telescopy 56 joint 88 Spondylosis, cervical 297 Tendon X-ray of 91f Sprain 5 rupture, common sites of 6t Singh’s index 309 Spread of tumour, evaluation of 240 synovial lining of 301t Sinus tract malignancy 174 Sprengel’s shoulder 224 transfer 86 Skeletal traction 27f Spring ligament 210 Tennis elbow 302 Skeletal trauma 46t Stable injury 266, 274 Tenosynovitis 206, 301 Skin 27 Staphylococcus aureus 168, 175, 205 infective 301 ap 2 Starch test 64 irritative 301 Starting pain 195 Tension-band principle 30 necrosis 330 Steindler’s release 229 Tension-band wiring 148 ischaemic 81 Sternomastoid tumour 321 Terminal pulp-space infection 206, 206f traction 27f Stiff spine 291 Testing exor tendons of finger, methods Slipped capital femoral epiphysis 323 Stiffness 165, 177, 296, 297 Smith’s fracture 3, 114 Straddle fracture 124 of 119f Soap-bubble appearance 238 Straight leg raising test 255, 291, 260, 299 Tetanus prophylaxis 22 Soft dressing 330 Strength-duration curve 70, 71f Thenar space 208 Soft tissue Thomas splint 26f Thoracic and lumbar spine injuries, treatment of 274 Thoracic lesion 277 Thoracic nerve 68