Essential Orthopedics-Maheshwari

Recent Advances in the Treatment of Fractures | 33 to be mechanically superior to a conventional hydraulic pressure within the brace, which helps plate. LCP can be used as a compression plate, in maintaining the fracture alignment. In long as a neutralisation plate, as a buttress plate, series of cases treated this way, it was found that as a bridging plate, and as a locked plate. It is shortening and angulation was not a significant particularly suitable for peri-articular fractures and problem. fractures in osteoporotic bones. Bracing may not reduce the time taken by the Carbon plates and bio-degradable* implants fracture to unite, but it markedly reduces the are also being used. They do not show up on the stiffness and wasting of muscles caused by X-rays, and get 'absorbed' after sometime. These immobilisation in traction or plaster. It also have yet not been widely accepted. drastically reduces the length of rehabilitation. Functional bracing is used for simple fractures FUNCTIONAL BRACING where the reduction is stable. It is also useful for a fracture fixed internally where internal fixation is Sarmiento (1973) popularized functional bracing inadequate. In such cases, a guarded mobilisation technique for treating fractures. In principle, the may be done using a brace, and thus strain on technique consists of applying an external splint the implant is avoided. In severely compound (called a brace) to a fractured limb. The brace fractures, after initial treatment with external provides adequate support to the fracture while fixator or traction, brace can be used to allow permitting function of that limb, until the union functional use of the limb. is complete. Bracing is done if the reduction of the fracture is satisfactory, and the swelling has Overall, bracing is most popular for fractures of the subsided – usually 2-3 wee s after the injury. shaft of the tibia, humerus, and femur. ILIZAROV'S TECHNIQUE (Ring fixator) Gavril A. Ilizarov, a Russian surgeon revolu- tionized the application of external fixation in the management of difficult non-unions and limb lengthening (Fig-5.11). These used to be some of the most difficult orthopaedic problems before the advent of Ilizarov's technique. The basic premise of lizarov’s technique is that osteogenesis requires dynamic state. The dynamic state means that the site of osteogenesis (e.g., a fracture) requires either a controlled distraction or a controlled compression. This dynamic force, .1 al b a – e le. T e a l pressure generated within the braced compartment immobilises the fracture It seems likely that the brace works by supporting the soft tissues in a tight compartment (Fig-5.10). As the limb is put to use, the axial pressure on the limb (caused by weight bearing or due to muscle contraction) tends to shorten the bone segment, producing a ‘bulging effect’ on the soft tissues. Since the whole leg is enclosed in a confined space (the brace), there develops a sort of * These are implants made of special plastic, which 'dissolves' Fig-5.11 Ilizarov's fixation applied to thigh and leg over a period of time. https://kat.cr/user/Blink99/

34 | Essential Orthopaedics Fig-5.12 Ilizarov's technique: The fragments can be transported up or down by turning the bolts on the fixator when properly applied, causes the dormant or down, and the fracture distracted or compressed. mesenchymal cells at the non-union site to Ilizarov technique is useful in the management of differentiate into functioning osteoblasts. This the following conditions: results in bone synthesis and fracture healing. The a) Limb lengthening, especially when the concept that compression enhances bone healing, was known even prior to Ilizarov, but the concept shortening is associated with deformity. In this of distraction osteogenesis was put on a sound situation the fixator assembly is so designed footing by Ilizarov. According to his theory in that it corrects the deformity and produces wider perspective, any living tissue when subjected lengthening at the same time. Massive limb to constant stretch under biological conditions, can lengthening (even up to 18 inches) have been performed by using this technique. The fixator ro to an e tent. The biological conditions are provides a stable biological environment to the provided by: (i) aligning the fracture with minimal new bone at the site of lengthening (Fig-5.13). damage to its vascularity, and (ii) performing an b) Non-union, especially those resistant to ‘osteotomy’ of the bone (e.g., in limb lengthening conventional methods of treatment or those surgeries), without damaging its periosteal and associated with deformity or shortening. By endosteal blood supply. Such an ‘osteotomy’ was this method, non-union, deformity as well termed corticotomy by Ilizarov. Fig-5.13 Correction of a deformity and The whole segment of the limb is stabilised lengthening done simultaneously by a specially designed fixation system called ring i ator This protects the growing tissues from bending or shearing forces, but permits loading in the long axis of the limb. Distraction or compression can be applied at the fracture or corticotomy site by twisting nuts on the fixation system (Fig-5.12). Distraction or compression is carried out at the rate of 1 mm per day. This is done in four sittings— ¼ mm, four times a day. Ring fixator application consists of inserting thin (1.5 or 1.8 mm) stainless steel wires through the bone. Outside the limb, the wires are attached to steel rings with the help of bolts. Before fixing the wire to the ring, the wire is put under tension so as to ma e it ‘stiff’, and thus impart stability to the fixator. The rings are interconnected with the help of threaded rods with nuts on either ends. It is by twisting these nuts that the rings can be moved up

shortening can be treated by one-stage fixator Recent Advances in the Treatment of Fractures | 35 application. Non-unions requiring skin cover and bone grafting operations can be managed • Correction of more than one problems by one- by using Ilizarov technique without subjecting stage operation. the patient to staged surgeries. c) Deformity correction, which may be congenital DISADVANTAGES OF ILIZAROV'S TECHNIQUE or acquired can be corrected by Ilizarov's • Inconvenience, as the external fixator hampers technique. d) Osteomyelitis can be treated, as this technique normal activity offers the possibility of liberal excision of • Long duration of treatment necrotic bone. The gap thus created can • Pin tract infection subsequently be made up by transporting a • Nerve palsy by pin insertion or traction segment of bone from either end. • Joint stiffness caused by transfixation of the soft e) Arthrodesis can be performed by crushing the articular surfaces against each other, and thus tissues by the external fixator. stimulating union between opposite bones. Further Reading ADVANTAGES OF ILIZAROV'S TECHNIQUE • Muller M , Allgower M, Schreider , Willenegger H: • mmediate load bearing an al o nternal i ation Springer- Verlag, 1990. • A healthy viable bone in place of devascularized • Sarmiento A, atta , Sinclair WF: Functional bracing of bone fractures In: Instructional Course Lectures, American Academy of Orthopaedic Surgeons 25. C.V. Mosby St. Louis, Ch9, pp 184-239, 1976. • lizarov A: Transosseous Osteosynthesis. Springer Verlag 1992. What have we learnt? • The AO methods of internal xation are based on achieving inter-fragmentary compression or splintage or both. lates and scre s can be used to achieve this. ailing is a splintage device, interlock nailing being a recent modi cation. • In the treatment of diaphyseal fracture, emphasis has shifted from rigid (absolute) stability to relative stability. Anatomical reduction has been replaced by functional reduction. • late xation has undergone changes to make it a more 'biological' implant. ocking compression plate ( ) is a recent addition to plating techni ues. • unctional bracing is a non-operative method of treating fractures of the long bones. • Ili arov method is a type of external xator system hich is versatile in its application, particularly suited for dif cult non-unions, malunions and limb length discrepancies. https://kat.cr/user/Blink99/

CHAPTER Approach to a Patient with Limb Injury TOPICS • Clinical examination • Radiological examination • Old fracture • Approach to a polytrauma patient While examining a case of injury to the musculo- This will be missed if a clinical examination is skeletal system, answers to the following questions not carried out. are sought: Thus, a thorough clinical examination must precede • s there a fracture* an X-ray in all cases of musculo-skeletal injury. The • s it a closed or an open fracture following questions should be kept in mind while • s it a traumatic or a pathological fracture performing the clinical examination: • Are there any complications associated with IS THERE A FRACTURE? the fracture Most often a fracture can be diagnosed on the CLINICAL EXAMINATION basis of history and clinical examination. The following points in clinical examination need to With widespread availability of X-ray facilities, be considered: diagnosis of fractures and dislocations has become easy. But the clinical examination still continues to Age of the patient: Fractures occur at all ages but be important, especially in the following situations: dislocations are uncommon in children**. Some fractures are common in a particular age group, a) To decide whether an X-ray examination is as shown in the Table– .1. needed. This is particularly relevant when a patient has to travel to far off places for X-ray. Table– .1: Common fractures at different ages b) To ascertain whether the injury under Age group Fractures consideration needs a special view. For example, an oblique view of the wrist best • At birth Clavicle, Humerus shows a scaphoid fracture. • n children Supracondylar fracture of c) To avoid making a wrong diagnosis, by • n adults humerus correlating the clinical findings with the • n elderly people Epiphyseal injuries radiological findings. This way, some artifacts otherwise li ely to be diagnosed as fracture , Fractures of shafts of long are recognised. bones d) To detect complications associated with a Colles fracture fracture e.g., injury to the neurovascular bundle. Fracture neck of femur * For ease of discussion, the term ‘fracture’is used for both, fracture Mechanism of injury: The mechanism by which and dislocation. the patient sustains the injury often gives an idea ** In children, force around a joint produces an epiphyseal injury through the epiphyseal plate, and not a dislocation.

Approach to a Patient with Limb Injury | 37 Table– .2: Mechanisms of injury and fractures/ • Swelling: Though most fractures are accompanied dislocations with swelling at the site, it can be a misleading sign as there may be minimal visible swelling in Mechanism Common injuries the presence of a serious fracture (e.g., fracture of the neck of the femur); on the other hand, a • Fall on an out-stretched Fracture clavicle massive swelling may be present in the absence hand Fractures around the of a fracture (e.g., in cases of ligament sprain elbow and muscle injuries). The swelling may be due • Fall with spine forced to a haematoma, prominence of the bone ends in a particular direction Flexion injuries, or passive oedema. Extension injuries etc. • Slipping in the • Deformity: An obvious deformity of a body bathroom (trivial trauma) Fractures nec of the part is a very specific sign of a fracture or femur dislocation. So characteristic is the deformity in • Dashboard injury some fractures and dislocations that a diagnosis osterior dislocation of can be made just by looking at the deformity • Fall onto the heel hip (Table– .3). Deformity may be absent if there is • Hit by a stic an impacted fracture. Fracture calcaneum Fracture ulna about the expected fracture/dislocation. For Table– .3: Injuries with characteristic deformities example, in a fall from some height onto the heels, one is likely to sustain a fracture of the calcaneum, Deformity Injury fracture of lumbar vertebrae and fracture of pubic rami. Some common injuries and mechanisms • Flattening of shoulder Shoulder dislocation involved are shown in Table– .2. (anterior) • Dinner for deformity Presenting complaints: A patient with suspected • Mallet finger Colles fracture fracture may present with the following com- plaints: • Flexion, adduction and Avulsion of the insertion internal rotation of the hip of the extensor tendon • Pain: t is the commonest presenting complaint from the distal phalanx in cases of musculo-skeletal injury. The severity • Abduction, external of pain has no bearing on the diagnosis. Sprains rotation of the hip osterior dislocation of and strains can be as painful as fracture. the hip • xternal rotation • Swelling: Fractures are usually accompanied of the leg Anterior dislocation of with swelling. The swelling may be slight if the hip patient presents immediately after the injury; but in those presenting late, the whole limb Fracture nec of femur may be swollen, mostly because of gravitational Trochanteric fracture oedema. • Tenderness: ain elicited by direct pressure at the • Deformity: A fractured bone may result in fracture site or by indirect pressure may suggest deformity of that part of the body. a fracture. Direct Pressure: A localised tenderness on a • Loss of function: Following a fracture, the patient subcutaneous bone, elicited by gently running may* be unable to use the affected limb. the bac of the thumb (Fig- .1a) may suggest an underlying fracture. The site of maximum Examination: A proper exposure of the body part tenderness helps in differentiating ligament is crucial to an accurate examination. At times the injuries from that of fractures around a joint (e.g., findings are subtle, and comparison of the injured ankle injuries). One may feel or hear a crepitus limb with the opposite normal extremity may be while eliciting tenderness. useful. Joints proximal and distal to the injured bone should always be examined. n a patient of Indirect Pressure: t may be possible to elicit road traffic accident with multiple injuries, it is pain at the fracture site by applying pressure at wise to expose the patient completely and examine a site away from the fracture. Some examples each body part in a systematic manner. One should are given below: look for the following signs: • Springing test: t may be possible to elicit * Ability to keep using the limb after an injury is not conclusive pain from a fracture of the forearm bones of no fracture, especially in children. https://kat.cr/user/Blink99/

38 | Essential Orthopaedics .1 l e e e a ba eb under the wound. Sometimes it may be difficult to b ea say whether a wound is communicating with the fracture or not, in which situation, it should be taken as an open fracture. t must be ascertained whether the compounding is internal or from outside. IS IT A PATHOLOGICAL FRACTURE? A pathological fracture must be suspected if: (i) the force producing the fracture is insignificant (trivial trauma); (ii) there is a history of pain or swelling in the affected bone prior to the occurrence of fracture; (iii) there is history suggestive of frequent fractures in the past (e.g., osteogenesis imperfecta); and (iv) the patient is suffering from a debilitating systemic illness known to weaken bones (e.g., rheumatoid arthritis). ANY ASSOCIATED COMPLICATION? Complications such as injuries to the nerves and vessels etc. may be associated with a fracture. These can be diagnosed on clinical examination (see Chapter 10). by pressing the two bones towards each RADIOLOGICAL EXAMINATION other at a distance away from the fracture (Fig- .1b). A radiological examination helps in: (i) diagnosis of a • Axial pressure: An axial pressure along the fracture or dislocation; (ii) evaluation of displacements, second metacarpal may elicit pain in the if any; and (iii) studying the nature of the force scaphoid fossa, in a case of scaphoid fracture. causing fracture. The following are some of the points to be remembered in a radiological • Bony irregularity: t is possible to feel bony examination of a case of skeletal injury: elevations and depressions in fractures of subcutaneous bones such as the tibia. This is a ASKING FOR AN X-RAY definite sign of fracture. Before asking for an X-ray, the following points • Abnormal mobility: n any limb, movements should be kept in mind: occur only at joints. f one can elicit mobility at sites other than the joints (say in the middle • Both, antero-posterior and lateral views should of the arm), or an abnormal range of movement be requested in most situations. at a joint, a fracture or dislocation is efinite One may hear or feel a crepitus while doing this. • Joint above and below should be included in the X-ray. • Absence of transmitted movements: Normally, if a bone is moved holding it at one end, the • Special views show fractures better in some cases movement can be felt at the other end. This (Table– .4). transmitted movement will be absent in case of a displaced fracture. n case the fracture is Table– . : Some commonly used special views undisplaced or impacted, the movement will be transmitted even in the presence of a fracture. Oblique view wrist Scaphoid fracture Judet view Acetabular fracture IS IT AN OPEN FRACTURE? Merchant view Whenever there is a wound in the vicinity of a frac- Skyline view atello-femoral joint ture, it is important to ascertain whether the wound Calcaneum fracture is communicating with the fracture. This is done by examination of the wound under strict aseptic con- • -ray requisition must specify the area of ditions. Usually it is easy, as one may see the bone suspicion e.g., if an injury to D12 vertebra is suspected, ask for an X-ray of the dorso-lumbar spine focussing D12. • -ray of the pelvis wtih both hips should be asked for in all cases of suspected pelvic injury. Major

injuries of the thigh are often associated with Approach to a Patient with Limb Injury | 39 fractures of the pelvis, hence an X-ray of the pelvis must be taken as a routine in cases with • At what level is the fracture i.e., whether the major fractures of the leg. fracture is in the upper, middle or lower third. • For an -ray evaluation of the hands and feet, • What is the pattern of the fracture i.e., whether antero-posterior and oblique views (not lateral) the fracture is transverse, oblique etc. are required. • s the fracture displaced f yes, in what direction, READING AN X-RAY i.e., whether it is a shift (antero-posterior, An -ray view box should be used in all cases. f sideways), a tilt, or angulation in any direction, or a a fracture is obvious, one must make a note of the rotational displacement. Rotational displacement following points: is sometimes not visible on X-rays, and can only • Which bone is affected be diagnosed clinically. • Which part of the bone is affected e.g., shaft • s the fracture line extending into the nearby joint etc. • Does the underlying bone appear pathological e.g., a cyst, abnormal texture of the whole bone, etc. l a .1 a a ae lb https://kat.cr/user/Blink99/

40 | Essential Orthopaedics .2 a e l a e. e ee • s it a fresh or an old fracture An -ray of a fresh fracture shows a soft tissue shadow resulting OLD FRACTURE from haematoma, and the fracture ends are sharp. An old fracture shows callus formation After 2-3 wee s, signs of a fresh fracture li e pain, and disuse osteoporosis and the fracture ends soft tissue swelling, tenderness etc. diminish are smoothened. markedly. On X-ray examination, the fracture ends will not appear sharp. Callus may be present. f the fracture is not obvious immediately, all When a patient with fracture presents late after the bones and joints seen on the X-ray must be injury, to decide further treatment, it is important examined systematically for a break in the cortex to ascertain: (i) whether the position of the fracture or loss of joint congruity. fragments is acceptable; and (ii) at what stage of union is the fracture e.g., united, uniting or non- X-ray findings should be correlated with clinical union (Fig- .2). findings, so as to avoid error because of some artifacts which may mimic a fracture. Also one APPROACH TO A POLYTRAUMA PATIENT must ensure that the part under question is visible on X-ray. An X-ray of a bone must include the joints An isolated skeletal injury rarely poses any proximal and distal to the bone. Do loo for an threat, but in association with multiple injuries, associated injury to all the other bones and joints musculo-skeletal injuries assume great significance visible on the X-ray. in terms of morbidity and mortality. roper, well-articulated, early management plays a vital One must be aware of some normal X-ray findings role in improving the outcome of these patients. which are often misinterpreted as fracture e.g., The following constitute the key points in the epiphyseal lines, vascular markings on bones, management. accessory bones etc. A comparison with the X-ray of the opposite limb helps in clearing any doubt. FIELD TRIAGE There are some injuries particularly liable to be deally, the management of a multiple injured missed by a novice (Table– .5). Before an -ray should begin at the scene of accident where the is passed as normal, one must carefully look for medical technician should be able to work in these injuries. coordination with the doctors. He should be able to provide basic life support and help in A diagrammatic presentation of approach to transportation. He should be able to decide, on the a patient with a limb injury is as shown in basis of the level of injury, whether the victim needs Flow chart- .1. to be transferred to the local hospital or a hospital with developed trauma services. n the present Table– . : Fractures commonly missed day context, trauma services are not so well Upper Limb - reater tuberosity: n A view of the shoulder, fracture of greater tuberosity is missed, as the fragment gets displaced behind the head of humerus. - AC joint subluxation - osterior dislocation of shoulder - Head of radius, neck of the radius - Capitulum - Scaphoid Lower Limb - Fracture nec of femur ( mpacted) - Acetabulum - atella - Calcaneum - Dislocation of foot Other - Epiphyseal injuries

developed in countries li e ndia, but this is Approach to a Patient with Limb Injury | 41 something to aspire for. lar injuries – so chec all peripheral pulses and TREATMENT IN THE EMERGENCY DEPARTMENT capillary circulation; (ii) nerve injuries – chec peripheral nerves and correct malposition of Once the patient reaches the emergency depart- the fractures to relieve pressure or stretch on ment, management consists of the following: the affected nerve; (iii) dislocation or sublux- ation – these need to be corrected early. All other • Primary survey: This constitutes rapid orthopaedic injuries can be treated once other assessment of vitals of the patient and ensuring systems have been stabilised. patent airway, adequate breathing, circulation and control of external bleeding. • Definitive treatment: From orthopaedic view point, this consists of planning whether some • Resuscitation: This is conducted on established fractures need internal fixation. Those being lines of ABCD (please refer to boo on treated coservatively, need to be reduced and Anaesthesia for details). immobilised. Current trend is to internally fix as many fractures as possible in a polytrauma •e a e : Once the patient is stable, patient, often in one sitting. This has been shown to help in nursing care, and has resulted in proper neurologic assessment, thoraco-abdom- decrease in mortality and morbidity. inal assessment, genito-urinary assessment and e ea • oc wood CA ( r.), reen D , ( ds.): Fractures in Adults; Vols musculo-skeletal assessment is carried out. As 1 and 2, 2nd edn. hiladelphia: B ippincott Co., 1 4. is obvious from the above sequence, musculo- • Wilson ( d.): Watson-Jone's Fractures and Joint Injuries, skeletal assessment is not high on priority. The th edn. dinburgh: Churchill ivingstone. only injuries related to musculo-skeletal system which are important at this stage are: (i) vascu- What have we learnt? • hen evaluating a fracture, a correlation bet een clinical ndings and -ray ndings is a must. • herever possible take A and lateral -rays. • Think of the possibility of a background pathological process hich may have contributed to the fracture. • roper -ray re uisition can prevent a lot of problems. • omparative -ray of the normal, opposite side may help in diagnosing a doubtful fracture. https://kat.cr/user/Blink99/

7C H A P T E R Complications of Fractures TOPICS • Injury to viscera • Infection – osteomyelitis • Classification • Compartment syndrome • Hypovolaemic shock • Delayed and non-union • Adult respiratory distress syndrome • Malunion • Fat embolism syndrome • Shortening • Deep vein thrombosis • Avascular necrosis • Crush syndrome • Stiffness of joints • Injury to major blood vessels • Sudeck‘s dystrophy • Injury to nerves • Myositis ossificans • Injury to muscles and tendons • Injury to joints Complications inevitably occur in a proportion of major vessel of the limb. Internal haemorrhage is fractures. With early diagnosis and treatment, the more difficult to diagnose. It is usually massive disability caused by these complications can be bleeding in the body cavities such as chest or greatly reduced. abdomen. Significant blood loss may occur in fractures of the major bones like the pelvis CLASSIFICATION (1500–2000 ml), and femur (1000–1500 ml). Complications of fractures can be classified into Management: This begins even before the cause three broad groups depending upon their time of can be ascertained. An immediate step is to put in occurrence. These are as follows: at least two large bore intravenous cannulas ( o. 1 a) Immediate complications – occurring at the time or o. 14). f there is peripheral vasoconstriction, no time should be wasted in performing a cut of the fracture. down. 2000 ml of crystalloids (preferably inger b) Early complications – occurring in the initial lactate), should be infused rapidly, followed by colloids (Haemaccel) and blood. At the earliest few days after the fracture. opportunity, effort is made to localize the site of c) Late complications – occurring a long time after bleed – whether it is in the chest or in the abdomen. Needle aspiration from the chest, and diagnostic the fracture. peritoneal lavage provide quick information to this effect. If possible, a plain X-ray chest, and X-ray Some of the complications of the fractures seen in abdomen may be done. A chest tube for chest day-to-day practice are given in Table–7.1. bleeding, laparotomy for abdominal bleeding, may be required. HYPOVOLAEMIC SHOCK Excessive blood loss from fractured bone may be Hypovolaemic shock is the commonest cause of prevented by avoiding moving the patient from death following fractures of major bones such one couch to another. For fractures of the pelvis, as the pelvis and femur. Its frequency is on the temporary stabilisation with an external fixator increase due to a rise in the number of patients has been found useful in reducing haemorrhage. with multiple injuries. In advanced trauma centres, an emergency angiography and embolisation of the bleeding Cause: The cause of hypovolaemia could be external haemorrhage or internal haemorrhage. External haemorrhage may result from a compound fracture with or without an associated injury to a

Table– .1: Complications of fractures Complications of Fractures | 43 Immediate complications not detected early, patient's condition deteriorates Systemic rapidly, he develops cardio-respiratory failure and • Hypovolaemic shoc dies. Local FAT EMBOLISM SYNDROME • njury to major vessels • njury to muscles and tendons This is one of the most serious complications, the • njury to joints essential feature being occlusion of small vessels • njury to viscera by fat globules. Early complications Causes: The fat globules may originate from Systemic bone marrow or adipose tissue. Fat embolism • Hypovolaemic shoc is more common following severe injuries with • A DS multiple fractures and fractures of major bones. • Fat embolism syndrome The pathogenesis of the syndrome is not clear, • D T and ulmonary embolism but it seems likely that two events occur: (i) • Aseptic traumatic fever release of free fatty acids (by action of lipases on • Septicaemia (in open fractures) the neutral fat), which induces a toxic vasculitis, • Crush syndrome followed by platelet-fibrin thrombosis; and (ii) actual obstruction of small pulmonary vessels by Local fat globules. • nfection • Compartment syndrome Consequences: Symptoms are evident a day or so after the injury. Presenting features are in the Late complications form of two, more or less distinct types: (i) cerebral; Imperfect union of the fracture and (ii) pulmonary. In the cerebral type, the • Delayed union patient becomes drowsy, restless and disoriented • on-union and gradually goes into a state of coma. In the • Malunion pulmonary type, tachypnoea and tachycardia are • Cross union the more prominent features. The other common feature of fat embolism is a patechial rash, usually Others on the front of the neck, anterior axillary folds, • Avascular necrosis chest or conjunctiva. If untreated, and sometimes • Shortening despite treatment, the patient develops respiratory • oint stiffness failure and dies. • Sudec ’s dystrophy ( eflex Sympathetic Dystrophy) • Osteomyelitis Diagnosis: In a case with multiple fractures, early • schaemic contracture diagnosis may be possible by strong suspicion. In • Myositis ossificans addition to the classic clinical features, signs of • Osteoarthritis retinal artery emboli (striate haemorrhages and exudates) may be present. Sputum and urine may vessel is performed to control bleeding from deeper reveal the presence of fat globules. X-ray of the vessels. chest may show a patchy pulmonary infiltration (snow storm appearance). Blood PO2 of less than 50 ADULT RESPIRATORY DISTRESS SYNDROME mmHg may indicate impending respiratory failure. Adult respiratory distress syndrome (A DS) can be Treatment: This consists of respiratory support, a sequelae of trauma with subsequent shock. The heparinisation, intravenous low molecular exact mechanism is not known, but it is supposed weight dextran ( omodex-20) and corticosteroids. to be due to release of inflammatory mediators An intravenous 5 percent dextrose solution with which cause disruption of microvasculature of the 5 percent alcohol helps in emulsification of fat pulmonary system. The onset is usually 24 hours globules, and is used by some. after the injury. The patient develops tachypnoea and laboured breathing. X-ray chest shows diffuse pulmonary infiltrates. Arterial PO2 falls to less than 50. Management consists of 100 percent oxygen and assisted ventillation. t ta es from 4-7 days for the chest to clear, and the patient returns to normal. If https://kat.cr/user/Blink99/

44 | Essential Orthopaedics Table– .2: Vascular injuries and skeletal trauma DEEP VEIN THROMBOSIS (DVT) AND Vessel injured Trauma PULMONARY EMBOLISM Femoral Fracture lower third of femur Deep vein thrombosis (D T) is a common Popliteal Supracondylar fracture of the femur complication associated with lower limb injuries Dislocation of the nee, Fracture tibia and with spinal injuries. osterior tibial Fracture of the clavicle Subclavian Fracture-dislocation of the shoulder Cause: Immobilisation following trauma leads to Axillary Supracondylar fracture of the venous stasis which results in thrombosis of veins. Brachial humerus D T proximal to the nee is a common cause of life threatening complication of pulmonary embolism. Treatment: In a case with crushed limb, first D T can be recognised as early as 4 hours after aid treatment may necessitate the application the injury. mbolism occurs, usually 4-5 days after of a tourniquet, which is gradually released, so the injury. that deleterious substances are released into the circulation in small quantities. If oliguria develops, Consequences: D T can be diagnosed early with the patient is treated as for acute renal failure. high index of suspicion. The group of patients ‘at ris ’ include the elderly and the obese patients. eg INJURY TO MAJOR BLOOD VESSELS swelling and calf tenderness are usual signs. The calf tenderness may get exaggerated by passive Blood vessels lie in close proximity to bones, and dorsiflexion of the ankle (Homan’s sign). Definitive hence are liable to injury with different fractures diagnosis can be made by venography. One should and dislocations (Table–7.2). The popliteal artery is the most frequently damaged vessel in musculo- eep a patient of D T on constant watch for skeletal injuries. development of pulmonary embolism. This can be suspected if the patient develops tachypnoea Causes: The artery may be damaged by the object and dyspnoea, usually 4-5 days after the accident. causing the fracture (e.g., bullet), or by a sharp edge There may be chest pain or haemoptysis. of a bone fragment (e.g., supracondylar fracture of the humerus). The damage to the vessel may vary Treatment of D T is elevation of the limb, elastic from just a pressure from outside to a complete bandage and anticoagulant therapy. For pulmo– rupture. nary embolism, respiratory support and heparin therapy is to be done. Early internal fixation of e e e . Obstruction to blood flow will fractures, so as to allow early, active mobilisation not always lead to gangrene. Where the collateral of the extremity is an effective means of prevention circulation is good, the following may result: of D T, and hence of pulmonary embolism. • No effect: If collateral circulation of the limb CRUSH SYNDROME around the site of vascular damage is good, there will be no adverse effect of the vascular injury. This syndrome results from massive crushing of • Exercise ischaemia: The collaterals are good the muscles, commonly associated with crush enough to keep the limb viable but any injuries sustained during earthquakes, air raids, further demand on the blood supply during mining and other such accidents. A similar effect exercise, causes ischaemic pain (vascular may follow the application of tourniquet for an claudication). excessive period. • Ischaemic contracture: If the collaterals do not provide adequate blood supply to the muscles, Causes: Crushing of muscles results in entry there results an ischaemic muscle necrosis. of myohaemoglobin into the circulation, which This is followed by contracture and fibrosis precipitates in renal tubules, leading to acute renal of the necrotic muscles, leading to deformities tubular necrosis. (e.g., ol mann’s ischaemic contracture, see page 102). Consequences: Acute tubular necrosis produces • Gangrene: If the blood supply is grossly signs of deficient renal functions such as scanty insufficient, gangrene occurs. urine, apathy, restlessness and delirium. It may ta e 2-3 days for these features to appear.

Diagnosis: The pulses distal to the injury Complications of Fractures | 45 should be examined in every case of a fracture or dislocation. Some of the features which suggest a • ain – crampli e possible vascular injury of a limb are listed below: • ulse – absent • Pallor a) Signs at the fracture site: The following signs may • Paraesthesias be present at the fracture site: • Paralysis • apidly increasing swelling As a matter of rule, absent peripheral pulses in • Massive external bleeding (in open fractures) an injured limb should be considered to be due to vascular damage unless proved otherwise. The • A wound in the normal anatomical path of confirmation of obstruction to blood flow in a the vessel vessel and its site can be easily done by Doppler study. In the absence of such a facility, there is b) Signs in the limb distal to the fracture: The no need to waste crucial time by ordering an following signs may be present in the limb angiogram merely for confirmation of diagnosis. distal to the fracture (five ’s): l a .1 a a e e a la lb https://kat.cr/user/Blink99/

46 | Essential Orthopaedics the type of damage is generally neurapraxia or axonotmesis, and nerve recovery is good with An angiogram may be justified in cases with conservative treatment. In case the fracture per se multiple fractures in the same limb, where it may needs open reduction for other reasons, the nerve help in localising the site of the vascular injury. should also be explored. When associated with an open fracture, the type of nerve damage is often Treatment: Early diagnosis and urgent treatment neurotmesis. In such cases, the nerve should be are of paramount importance because of the serious explored and repaired as per need, and the fracture consequences that may follow. Correct treatment at fixed internally with nail, plate etc. the site of first contact (Flow chart-7.1), followed by referral to a centre equipped with facilities to treat INJURY TO MUSCLES AND TENDONS vascular injuries is essential. In case exploration of the vessel is required, the fracture should be Some degree of damage to muscles and tendons suitably stabilised using internal or external occurs with most fractures. It may result from fixation. the object causing the fracture (e.g., an axe), or from the sharp edge of the fractured bone. Often INJURY TO NERVES these injuries are overshadowed by more alarming fractures, and are detected only late, when Nerves lie in close proximity to bones, and hence the joint distal to the fracture becomes are liable to damage in different fractures or stiff and deformed due to scarring of the injured dislocations (Table–7.3). The radial nerve is the muscle. most frequently damaged nerve in musculo- skeletal injuries. Nerves and vessels lie together in est to the injured muscle and analgesics is enough limbs, and so are often injured together. in cases with partial rupture. A complete rupture requires repair. arely, if rupture of a tendon or Causes: A nerve may be damaged in one of the muscle is detected late, reconstruction may be following ways: required. • By the agent causing the fracture (e.g., bullet). INJURY TO JOINTS • By direct pressure by the fracture ends at the Fractures near a joint may be associated time of fracture or during manipulation. with subluxation or dislocation of that joint. • Traction injury at the time of fracture, when the This combination is becoming more frequent due to high-velocity traffic accidents. Early open fracture is being manipulated or during skeletal reduction and stabilisation of the fracture to permit traction. early joint movements has improved the results. • Entrapment in callus at the fracture site. INJURY TO VISCERA Consequences: Damage to the nerve may be neurapraxia, axonotmesis, or neurotmesis. It may isceral injuries are seen in pelvic and rib fractures. result in a variable degree of motor and sensory loss Their management is discussed in Surgery along the distribution of the nerve (see Chapter 10, textbooks. Peripheral Nerve Injuries). Treatment: This depends upon the type of fracture, whether it is closed or open. When the nerve injury is associated with a closed fracture, Table– .3: Nerve injuries and skeletal trauma Nerve Trauma Effect • Axillary nerve Dislocation of the shoulder Deltoid paralysis • adial nerve Fracture shaft of the humerus Wrist drop • Median nerve Supracondylar fracture of humerus • lnar nerve Fracture medial epicondyle humerus ointing index • Sciatic nerve Claw hand osterior dislocation of the hip Foot drop due to wea ness of dorsiflexors of the foot • Common peroneal nerve Knee dislocation Foot drop Fracture of neck of the fibula

Complications of Fractures | 47 INFECTION – OSTEOMYELITIS .2 a a ee le ae e Causes: Infection of the bone is an early complication leading to contractures. Nerve damage may result of fractures. It occurs more commonly in open in motor and sensory loss. In an extreme case, fractures, particularly in those where compounding gangrene may occur. occurs from outside (external compounding). The increasing use of operative methods in the Diagnosis: Compartment syndrome can be treatment of fractures is responsible for the rise diagnosed early by high index of suspicion. in the incidence of infection of the bone, often Excessive pain, not relieved with usual doses of years later. Infection may be superficial, moderate analgesics, in a patient with an injury known to (osteomyelitis), or severe (gas gangrene). cause compartment syndrome must raise an alarm Treatment: Proper care of an open fracture can in the mind of the treating doctor. Injuries with a prevent osteomyelitis. Once infection occurs, it high risk of developing compartment syndrome should be adequately treated. are as follows: COMPARTMENT SYNDROME • Supracondylar fracture of the humerus • Forearm bone fractures The limbs contain muscles in compartments • Closed tibial fractures enclosed by bones, fascia and interosseous • Crush injuries to leg and forearm. membrane (Fig-7.1). A rise in pressure within these compartments due to any reason may jeopardize Stretch test: This is the earliest sign of impending the blood supply to the muscles and nerves within compartment syndrome. The ischaemic muscles, the compartment, resulting in what is known as when stretched, give rise to pain. It is possible to compartment syndrome . stretch the affected muscles by passively moving Causes: The rise in compartment pressure can be the joints in direction opposite to that of the due to any of the following reasons: damaged muscle’s action. (e.g., passive extension • Any injury leading to oedema of muscles. of fingers produces pain in e or compartment of • Fracture haematoma within the compartment. the forearm). • Ischaemia to the compartment, leading to muscle Other signs include a tense compartment, hypo- oedema. aesthesia in the distribution of involved nerves, Consequences: The increased pressure within muscle weakness etc. Compartment syndrome can the compartment compromises the circulation be confirmed by measuring compartment pressure. A pressure higher than 40 mm of water is indica- .1 e a al compartment tive of compartment syndrome. Pulses may remain palpable till very late in impending compartment leading to further muscle ischaemia. A vicious cycle syndrome, and should not provide a false sense of is thus initiated (Fig-7.2) and continues until the security that all is well. total vascularity of the muscles and nerves within the compartment is jeopardized. This results in Treatment: A close watch for an impending ischaemic muscle necrosis and nerve damage. The compartment syndrome and effective early necrotic muscles undergo healing with fibrosis, preventive measures like limb elevation, active finger movements etc. can prevent this serious complication. Early surgical decompression https://kat.cr/user/Blink99/

48 | Essential Orthopaedics Table– . : Causes of delayed and non-union, and their common sites is necessary in established cases. This can be performed by the following methods: Causes related to the patient • Fasciotomy: The deep fascia of the compartment Age: Common in old age is slit longitudinally (e.g., in forearm). Associated systemic illness: Malignancy, Osteomalacia • Fibulectomy: The middle third of the fibula is a e ela e ae excised in order to decompress all compartments of the leg. Distraction at the fracture site DELAYED AND NON-UNION • Muscle pulling the fragments When a fracture takes more than the usual time to – Fracture patella unite, it is said to have gone in delayed union. A large percentage of such fractures eventually unite. In – Fracture olecranon some, the union does not progress, and they fail to unite. These are called non-union. Conventionally, it • ravity is not before months that a fracture can be declared as non-union. It is often difficult to say whether the – Fracture shaft of humerus fracture is in delayed union, or has gone into non- Soft tissue interposition union. Only progressive evaluation of the X-rays over a period of time can solve this issue. Presence • Fracture shaft of humerus of mobility at the fracture after a reasonable period is surely a sign of non-union. Presence of pain at • Fracture shaft of femur the fracture site on using the limbs also indicates non-union. Non-union may be painless if • Fracture medial malleolus (abduction type) pseudo joint forms between the fracture ends Bone loss at the time of fracture (pseudoarthrosis). • Fracture tibia (open type) Causes: Some of the factors responsible for delayed union are given in Table–7.4. n any given case, • Fracture ulna (open type) there may be one or more factors operating. Infection from an open fracture Types of non-union: There are two main types of • Fracture tibia non-unions (Fig-7.3): Damage to blood supply of fracture fragments • Atrophic, where there is minimal or no attempt • Fracture nec of femur at callus formation. • Fracture lower third of tibia Pathological fracture • Fracture of the shaft of the femur • Fracture of humerus Causes related to treatment Inadequate reduction • Fracture shafts of long bones Inadequate immobilisation • Fracture shafts of long bones • Fracture nec of femur Distraction during treatment • Fracture shaft of femur (a) (b) • Hypertrophic, where though the callus is present, it does not bridge the fracture site. .3 T e .a b e Common sites: Sites where non-union occurs commonly are neck of the femur, scaphoid, lower third of the tibia, lower third of the ulna and lateral condyle of the humerus. Consequences: Delayed and non-union can re s u l t i n p e r s i s t e n t p a i n , d e f o r m i t y, o r abnormal mobility at the fracture site. A fracture in delayed union, if stressed, can lead to refracture. Diagnosis: Delayed union is a diagnosis in relation to time. The fracture may not show any abnormal signs clinically, but X-rays may fail to show bony union. The following are some of the clinical findings which suggest delayed union and non-union:

• ersistent pain Complications of Fractures | 49 • ain on stressing the fracture • Mobility (in non-union) excised for non-union of the fracture of the • ncreasing deformity at the fracture site (in non- distal-end of the ulna without much loss. In non-union of fracture of the neck of femur in an union). elderly, the head of the femur can be replaced by a prosthesis (replacement arthroplasty). The following are some of the radiological features suggestive of these complications: • No treatment: Some non-unions do not give • Delayed union: The fracture line is visible. There rise to any symptoms, and hence require no treatment, e.g., some non-unions of the fracture may be inadequate callus bridging the fracture scaphoid. site. • Non-union: The fracture line is visible. There is • Ilizarov’s method: Prof. Ilizarov from the former little bridging callus. The fracture ends may be SS designed a special external fixation rounded, smooth and sclerotic. The medullary cavity may be obliterated. apparatus for treating non-union (see page 33). It is sometimes very difficult to be sure about MALUNION union of a fracture where internal fixation has been used. Evaluation of serial X-rays may help When a fracture does not unite in proper detect subtle angulation, non-progress of bridging position, it is said to have malunited. A slight callus, resorption of callus, loosening of screws and degree of malunion occurs in a large proportion bending of the nail or plate. Excessive rotation may of fractures, but in practice the term is reserved be the only abnormal mobility in a case with intra- for cases where the resulting disability is of medullary rod in situ. Oblique views, done under clinical significance. fluoroscopy may show an unhealed fracture better than conventional AP and lateral X-rays. It may be Causes: Improper treatment is the commonest possible to demonstrate mobility at the fracture by cause. Malunion is therefore preventable in most stress -rays or weight bearing -rays. 3-D CT scan cases by keeping a close watch on position of the is sometimes helpful in differentiating between fracture during treatment. Sometimes, malunion is delayed and non-union. inevitable because of unchecked muscle pull (e.g., fracture of the clavicle), or excessive comminution Treatment: Most fractures in delayed union (e.g., Colles’ fracture). unite on continuing the conservative treatment. Sometimes, this may not occur and the fracture Common sites: Fractures at the ends of a bone always may need surgical intervention. Bone grafting unite, but they often malunite e.g., supracondylar with or without internal fixation may be required. fracture of the humerus, Colles’ fracture etc. Treatment of non-union depends upon the site of non-union and the disability caused by it. The Consequences: Malunion results in deformity, following possibilities of treatment should be shortening of the limb, and limitation of movements. considered, depending upon the individual cases. Treatment: Each case is treated on its merit. A • en re ction internal fi ation an bone grafting: slight degree of malunion may not require any This is the commonest operation performed for treatment, but a malunion producing significant non-union. The grafts are taken from iliac crest. disability, especially in adults, needs operative Internal fixation is required in most cases. intervention. The following treatment possibilities can be considered: • Excision of fragments: Sometimes, achieving union is difficult and time consuming compared a) Treatment required: Malunion may require to excision of one of the fragments. This can only treatment because of deformity (e.g., be done where excision of the fragment will not supracondylar fracture of the humerus), cause any loss of functions. An excision may or shortening (e.g., fracture of the shaft of the may not need to be combined with replacement femur) or functional limitations (e.g. limitation with an artificial mould (prosthesis). For of rotations in malunion of forearm fractures). example, the lower-end of the ulna can be Some of the methods for treating malunion are as follows: https://kat.cr/user/Blink99/

50 | Essential Orthopaedics the two bones unite with each other. For details please refer to page 110. • Osteoclasis (refracturing the bone): It is used for correction of mild to moderate angular SHORTENING deformities in children. nder general an- aesthesia the fracture is recreated, the angu- Causes: It is a common complication of fractures, lation corrected, and the limb immobilised resulting from the following causes: in plaster. • Malunion: The fracture unites with an overlap • Redoing the fracture surgically: This is the or marked angulation e.g., most long bone most commonly performed operation for fractures. malunion. The fracture site is exposed, the malunion corrected and the fracture • Crushing: Actual bone loss e.g., bone loss in fixed internally with suitable implants. gunshot wounds. Bone grafting is also performed, in addition, in most cases e.g., malunion of long • Growth defect: Injury to the growth plate may re- bones. sult in shortening (see Salter-Harris classification of epiphyseal injuries, page 5 ). • Corrective osteotomy: In some cases, redoing the fracture, as discussed above may not be Treatment: A little shortening in upper limbs goes desirable due to variety of reasons such as unnoticed, hence no treatment is required. For poor skin condition, poor vascularity of bone shortening in lower limbs, treatment depends upon in that area etc. In such cases, the deformity the amount of shortening. is corrected by osteotomy at a site away from the fracture as the healing may be quicker at • Shortening less than 2 cm is not much noticeable, this new site, e.g. supra-malleolar corrective hence can be compensated by a shoe raise. osteotomy for malunion of distal-third tibial fractures. • Shortening more than 2 cm is noticeable. In elderly patients, it may be compensated for by raising • Excision of the protruding bone: In a fracture the shoe on the affected side. In younger patients, of the clavicle, a bone spike protruding correction of angulation or overlap by operative under the skin may be shaved off. Same may method is necessary. Limb length equalisation be required in a spikey malunion of fracture procedure is required to correct shortening in an of the shaft of the tibia. old, healed, remodelled fracture. b) No treatment: Sometimes malunion may not AVASCULAR NECROSIS need any treatment, either because it does not cause any disability, or because it is expected Blood supply of some bones is such that the to correct by remodelling. emodelling of a vascularity of a part of it is seriously jeopardized fracture depends on the following factors. following fracture, resulting in necrosis of that part. • Age: emodelling is better in children. Common sites: Some of the sites where avascular • Type of deformity: Sideways shifts are well necrosis commonly occurs are given in Table–7.5. corrected by remodelling. Five to ten degrees Consequences: Avascular necrosis causes of angulation may also get corrected, but deformation of the bone. This leads to secondary mal-rotation does not get corrected. • Angulation in the plane of movement of the Table– . : Common sites of avascular necrosis adjacent joint is remodelled better than that in other planes e.g., posterior angulation in Site Cause a fracture of the tibial shaft remodels better. • Location of fracture: Fractures near joints • Head of the femur Fracture neck of the femur. remodel better. Posterior dislocation of the hip • roximal pole of Cross union is a special type of malunion which scaphoid Fracture through the waist occurs in fractures of the forearm bones, wherein of the scaphoid • Body of the talus Fracture through nec of the talus osteoarthritis a few years later, thus causing painful limitation of joint movement.

Diagnosis: Avascular necrosis should always Complications of Fractures | 51 be suspected in fracture where it is known to occur. Pain and stiffness appear rather late. • Excision of the avascular segment of bone where doing so does not hamper functions e.g. fracture adiological changes as given below appear of the scaphoid. earlier (Fig-7.4). • Excision followed by replacement e.g., in fracture • Sclerosis of necrotic area: The avascular bone is of the neck of the femur, the avascular head can unable to share disuse osteoporosis as occurs in be replaced by a prosthesis. the surrounding normal bones. Hence, it stands out densely on the X-ray. • Total joint replacement or arthrodesis may be required once the patient is disabled because of • Deformity of the bone occurs because of the pain from osteoarthritis secondary to avascular collapse of necrotic bone. necrosis. . a la e e e al ea a e a STIFFNESS OF JOINTS e a ee e It is a common complication of fracture treatment. Shoulder, elbow and knee joints are particularly • Osteoarthritis supervenes giving rise to prone to stiffness following fractures. diminished joint space, osteophytes (lipping of bone from margins) etc. Causes: The following are some of the causes of joint stiffness: It is possible to diagnose avascular necrosis on bone scan before changes appear on plain • ntra-articular and peri-articular adhesions secondary to immobilisation, mostly in intra- -rays. t is visible as ‘cold area’ on the bone scan. articular fractures. Treatment: Avascular necrosis may be prevented • Contracture of the muscles around a joint by early, energetic reduction of susceptible because of prolonged immobilisation. fractures and dislocations. Once it has occurred, the following treatment options remain: • Tethering of muscle at the fracture site (e.g. quadriceps adhesion to a fracture of femoral • Delay weight bearing on the necrotic bone until it shaft). is revascularised, thereby preventing its collapse. t ta es anywhere from - months for the bone • Myositis ossificans (refer page 52). to revascularise. Consequences: Stiff joints hamper normal physical • Revascularisation procedure by using vascularised activity of the patient. bone grafts (e.g. vascularised bone pedicle graft from greater trochanter in an avascular femoral Treatment: The treatment is heat therapy (hot head in fracture of the neck of the femur). fomentation, wax bath, diathermy etc.) and exercises. Sometimes, there may be a need for manipulating the joint under general anaesthesia. Surgical intervention is required in the following circumstances: • To excise intra-articular adhesions, preferably arthroscopically. • To excise an extra-articular bone bloc which may be acting as a 'door stopper'. • To lengthen contracted muscles. • oint replacement, if there is pain due to secondary osteoarthritis REFLEX SYMPATHETIC DYSTROPHY (SUDECK’S DYSTROPHY) This is a term given to a group of vague painful conditions observed as a sequelae of trauma. The trauma is sometimes relatively minor, and hence symptoms and signs are out of proportion to the trauma. https://kat.cr/user/Blink99/

52 | Essential Orthopaedics .a e elb a Consequences: Clinical features consist of pain, extreme cases, the bone bridges the joint resulting hyperaesthesia, tenderness and swelling. Skin in complete loss of movements (extra-articular becomes red, shiny and warm in early stage. ankylosis). Progressive atrophy of the skin, muscles and nails occur in the later stage. oint deformities and adiologically, an active myositis and a mature stiffness ensues. X-ray shows characteristic spotty myositis have been identified. In the former, the rarefaction. margins of the bone mass are fluffy (Fig-7.5); in the latter the bone appears trabeculated with well- Treatment: It is a difficult condition to explain to defined margins. the patient, and also the treatment is prolonged. Physiotherapy constitutes the principle modality Treatment: Massage following injury is strictly of treatment. Further trauma in the form of an prohibited. In the early active stage of myositis operation or forceful mobilisation is detrimental. the limb should be rested, and SA D is given. In In some cases, beta blockers have been shown late stages, it is possible to regain movement by to produce good response. In resistant cases, physiotherapy. In some cases, once the myositic sympathetic blocks may aid in recovery. Prolonged mass matures, surgical excision of the bone mass physiotherapy and patience on the part of the may help regain movement. doctor and the patient is usually rewarding. Further Reading MYOSITIS OSSIFICANS (POST-TRAUMATIC OSSIFICATION) • Wilson ( d.): Watson Jone's Fractures and Joint Injuries, th edn. dinburgh: Churchill ivingstone, 1 2. This is ossification of the haematoma around a joint, resulting in the formation of a mass of bone • ustilo B, Mer ow , Templeman D: The Management of restricting joint movements, often completely. Open Fractures. .B. .S. (A) 1 0; 72: 2 . Causes: It occurs in cases with severe injury • Charnley : The Closed Treatment of Common Fractures. E&S to a joint, especially when the capsule and the ivingstone td. 1 . periosteum have been stripped from the bones by violent displacement of the fragments. It is common in children because in them the periosteum is loosely attached to the bones. It is particularly common around the elbow joint. There is also a relatively high incidence in patients with prolonged or permanent neuronal damage from head injury, and in patient with paraplegia. Massage following trauma is a factor nown to aggravate myositis. Consequences: The bone formation leads to stiffness of the joint, either due to thickening of the capsule or due to the bone blocking movement. In What have we learnt? • A neurovascular examination of the limb distal to the fracture is a must in every patient ith fracture. It is a disasterous complication, if not attended to in time. • ot all delayed union, non-union and malunion need surgical treatment. ome are uite compatible ith normal functions. Treatment has to be tailored to patient's need. • Active joint mobilisation is necessary to prevent joint stiffness. • o massage after a fracture or joint injury. It can lead to myositis ossi cans.

Complications of Fractures | 53 Additional information: From the entrance exams point of view • asic pathology in myositis ossi cans lies in the muscle bres. • ost common location for mysositis ossi cans is elbo , next common is hip. • In myositis ossi cans mature bone is seen in the periphery and immature bone in the centre. • yositis ossi cans progressiva ( brodysplasia) The life expectancy decreases and the most common cause of death is lung disease. It affects children before the age of and involoves deformities of spine, hands and feet. • one scan (Tc three phase scan) is the most sensitive for early detection of heterotropic ossi cation. • Alkaline phosphatase and hrs urinary excretion are screening tests for heterotropic ossi cation. https://kat.cr/user/Blink99/

CHAPTER Injury to Joints: Dislocation and Subluxation TOPICS • Relevant anatomy • Diagnosis • Definitions • Classification G• Pathoanatomy • Complications • Treatment VRRELEVANT ANATOMY dIt is important to first understand the factors DEFINITIONS responsible for the stability of a joint in order Dislocation: A joint is dislocated when its articular surfaces are completely displaced, one from the other, iteto understand why a particular joint dislocates so that all contact between them is lost (see Fig-1.4, page 5). more often than another. Normally, a joint is held in position because of the inherent stability in its Subluxation: A joint is subluxated when its articular surfaces are only partly displaced and retain some ndesign, by the ligaments, and by the surrounding contact between them. Umuscles, as discussed below: CLASSIFICATION The shape of a joint: The shape of the articulating Dislocations and subluxations may be classified on -surfaces in themselves may provide great security the basis of aetiology into congenital or acquired. Congenital dislocation is a condition where a joint against displacement, e.g., the hip joint with its deep is dislocated at birth e.g., congenital dislocation of the hip (CDH). Acquired dislocation may occur 9socket (the acetabulum) and an almost spherical at any age. It may be traumatic or pathological as ir9ball (the femoral head) is a good design from the discussed below. stability viewpoint. On the other hand, the shoulder Table– .1: Common dislocations at different joints joint with its shallow socket (the glenoid) and a hlarge ball (the humeral head) is a poor design and therefore dislocates more easily than the hip joint. taThe ligaments: These prevent any abnormal mobility of a joint and are called static stabilisers. • Spine Cervical spine The role of the ligaments in providing stability to a joint is variable. In some joints (e.g., the knee and • Hip (anterior C5 over C6) finger joints), ligaments form the main stabilising • Shoulder Posterior, anterior structures, whereas in others (e.g., the hip or Anterior (commonest overall), posterior shoulder) they do not play an important role. • lbow Posterior, postero-lateral The muscles: A strong muscle cover around a • Wrist unate, perilunate joint gives it stability. Muscles may also provide • M joint Dorsal (index finger) • Knee a supporting function to the ligaments by reflexly • atella osterior ateral contracting to protect the ligaments, when the latter • An le Antero-lateral come under harmful stresses. These are, therefore, • Foot Chopart's dislocation called the dynamic stabilisers of a joint. Inter-tarsal isfranc s dislocation Tarso-metatarsal

.1 a a a la Injury to Joints: Dislocation and Subluxation | 55 Traumatic dislocation: Injury is by far the PATHOANATOMY commonest cause of dislocations and sub-luxations at almost all joints (Table– .1). The force required to Dislocation cannot occur without damage to the dislocate a particular joint varies from joint to joint. protective ligaments or joint capsule. Usually The following are the different types of traumatic the capsule and one or more of the reinforcing dislocations seen in clinical practice: ligaments are torn, permitting the articular end of the bone to escape through the rent. Sometimes, a) Acute traumatic dislocation: This is an episode the capsule is not torn in its substance but is of dislocation where the force of injury is stripped from one of its bony attachments the main contributing factor e.g., shoulder (Fig- .1). arely, a ligament may withstand the force dislocation. of the injury so that instead of ligament rupture, a fragment of bone at one of its attachments may be b) Old unreduced dislocation: A traumatic dislo- chipped off (avulsed). cation, not reduced, may present as an old unreduced dislocation e.g., old posterior dislo- At the time of dislocation, as movement occurs cation of the hip. between the two articulating surfaces, a piece of articular cartilage with or without its underlying c) Recurrent dislocation: In some joints, proper bone may be ‘shaved off’ producing an osteochondral healing does not occur after the first dislocation. fragment within the joint. This fragment may lie This results in weakness of the supporting loose inside the joint and may cause symptoms structures of the joint so that the joint dislocates long after the dislocation is reduced (Fig- .2). repeatedly, often with trivial trauma. Recurrent dislocation of the shoulder and patella are .2 a e al a e common. DIAGNOSIS d) Fracture-dislocation: When a dislocation is associated with a fracture of one or both of Clinical examination: In most cases of dislocation, the articulating bones, it is called fracture- the clinical features are sufficiently striking dislocation. A dislocation of the hip is often and make the diagnosis easy. Never-theless, a associated with a fracture of the lip of the dislocation or subluxation is sometimes overlooked, acetabulum. especially in a multiple injury case, an unconscious patient or in a case where the bony landmarks Pathological dislocation: The articulating are obscured by severe swelling or obesity. Some surfaces forming a joint may be destroyed by an dislocations, which are particularly notorious for infective or a neoplastic process, or the ligaments getting overlooked are: (i) posterior dislocation may be damaged due to some disease. This results of the shoulder especially in an epileptic; and (ii) in dislocation or subluxation of the joint without dislocation of the hip associated with a fracture of the shaft of the femur on the same side. The classic any trauma e.g., dislocation of the hip in septic deformity of a hip dislocation does not occur, and the attention is drawn on the more obvious injury arthritis. – the femoral shaft fracture. Some of the salient clinical features of dislocation are as follows: https://kat.cr/user/Blink99/

56 | Essential Orthopaedics Table– .2: Typical deformities in dislocations vascular bundle of the limb. arly complications are: (i) recurrence; (ii) myositis ossificans; (iii) Joint (dislocation) Deformity persistent instability; and (iv) joint stiffness. ate • Shoulder (anterior) Abduction complications are: (i) recurrence; (ii) osteoarthritis; • lbow (posterior) Flexion and (iii) avascular necrosis. • Hip Flexion, adduction, TREATMENT osterior internal rotation Abduction, external rotation Treatment of a dislocation or subluxation depends Anterior Flexion, external rotation upon its type, as discussed below: • Knee • An le arus Acute traumatic dislocation: In acute traumatic • Pain: Dislocations are very painful. dislocation, an urgent reduction of the dislocation • Deformity: In most dislocations the limb attains is of paramount importance. Often it is possible to do so by conservative methods, although a classic attitude (Table– .2). sometimes operative reduction may be required. • Swelling: It is obvious in the dislocation of a a) Conservative methods: A dislocation may be superficial joint, but may not be so in a joint reduced by closed manipulative manoeuvres. Reduction of a dislocated joint is one of the most Glocated deep. gratifying jobs an orthopaedic surgeon is called upon to do, as it produces instant pain relief to • Loss of movement because of severe pain and the patient. rolonged traction may be required for reducing some dislocations. Rmuscle spasm and loss of articulation. b) Operative methods: Operative reduction may be required in some cases. Following are some of • Shortening of the limb occurs in most dislocations the indications: • Failure of closed reduction, often because Vexcept in anterior dislocation of the hip where the dislocation is detected late. lengthening occurs. • Fracture-dislocation: (i) if the fracture has d• Telescopy: In this test, it is possible to produce an produced significant incongruity of the joint iteabnormal to and fro movement in a dislocated surfaces; (ii) a loose piece of bone is lying within the joint; and (iii) the dislocation is joint (see Annexure-III). difficult to maintain by closed treatment. As with all limbs injuries, specific tests to establish Old unreduced dislocations: This often needs operative reduction. In some cases, if the function nthe integrity or otherwise of major nerves and of the dislocated joint is good, nothing needs to be done. These are discussed in the respective chapters. vessels of the extremity must be established in all Recurrent dislocations; An individual episode is Ucases of dislocation. treated like a traumatic dislocation. For prevention -Radiological examination: In doubtful cases, the of recurrences, reconstructive proce-dures are required. These are discussed in the respective diagnosis must finally depend on adequate X-ray 9examination. The following principles should be remembered: ir9• -ray should always be ta en in two planes at right angles to each other, because a dislocation may not be apparent on a single projection. h• f in doubt, -rays of the opposite limb may be tataken for comparison. CT scan may also be of help. • An associated fracture or an osteochondral fragment must always be looked for. chapters. COMPLICATIONS Further Reading • Wilson ( d.): Watson-Jone's Fractures and Joint Injuries, As with a fracture, complications following a dislocation can be immediate, early or late. th edn. dinburgh: Churchill ivingstone, 1 2. Immediate complication is an injury to the neuro- • ustilo B, Kyle F, Templeman D: Fractures and Dislocations, St. ouis: Mosby- ear Boo . nc., 1 2. What have we learnt? • Dislocation means complete loss of contact bet een articulating bones. • Treatment of acute dislocation is an emergency. • houlder is the joint to dislocate most often.

CHAPTER Fractures in Children TOPICS • Relevant anatomy • Types of fractures • Diagnosis • Treatment • Complications RELEVANT ANATOMY Table– .1: Fractures* common in children Fractures in children are different from those in • Forearm bones fractures adults, mostly because of some anatomical and • Supracondylar fracture of the humerus physiological differences between a child's and an • Fracture of lateral condyle of the humerus adult's bone. Some of these are discussed below: • piphyseal injuries • Spiral fracture of tibial shaft • Growing skeleton: Bones in children are growing. At each end of major long bones, and * Dislocations are uncommon in children. Fractures of hands usually at only one end of short bones, there is and feet are also uncommon in children. a cartilaginous growth plate. This is a potential weak point giving rise to different types of • Remodelling: Fractures in children have greater epiphyseal injuries. In some injuries through the remodelling potential; so much so that any epiphyseal plate, the growth of the limb may be evidence of a past fracture may be absent after affected. a few months. The remodelling potential varies with the: (i) age of the child; (ii) location of the • Springy bones: Bones in children are more fracture; and (iii) degree and type of angulation. resilient and springy, withstanding greater de- formation without fracture. This characteristic is TYPES OF FRACTURES responsible for ‘greenstic ’ fractures in children. Such fractures do not occur in adults. Fractures in children can be conveniently considered under four headings: (i) birth fractures and related • Loose periosteum: The periosteum is attached injuries; (ii) epiphyseal injuries; (iii) fractures of loosely to the diaphysis in a child's bones. This shafts of long bones in older children; and (iv) results in easy stripping of the periosteum pathological fractures. over a considerable part following fracture. The haematoma soon gets calcified to become Birth fractures: Three types of fractures may occur callus, therefore a child's bone unites with a lot in a newborn. These are as follows: of callus. a) Fracture or epiphyseal separation sustained • Site of fractures: Some fractures are more rin a i fic lt eli er : These are the commonest common in children than in adults as given in fractures seen at birth. Fracture of the shaft of Table– .1. the humerus occurs most frequently; others are fracture of the shaft of the femur, fracture • Healing of fractures: Fractures unite quickly in clavicle etc. Simple strapping of the fracture may children, taking almost half the time taken in be sufficient. Union occurs rapidly with a lot of adults. https://kat.cr/user/Blink99/

58 | Essential Orthopaedics G.1 al e a a la a e eal e VRcallus. Remodelling occurs during the first few dyears of life. the more severe the injury. The incidence of growth iteb) Multiple fractures a ociate it t e con enital disturbance is common in types III, IV and V (Table– .2). ra ilit of bones e.g., osteogenesis imperfecta (see page 31 ). Shaft fractures in older children: Although, fractures of the shaft of long bones have many nc) e oart ro i o tibia: This is a pathological similarities in children and adults, the following are Uentity, very different from a simple fracture or some of the features peculiar to children: a) i lace ent i le : Fractures of the shaft of long birth injury mentioned above. In this type, there bones in children often do not displace much. A -is an inherent indolence of the fracture to unite. special type called ‘greenstic fracture’ occurs 9eal e : This is a group of injuries only in children. In this type, the bones being resilient, do not break completely. The inner seen in a growing skeleton. An injury involving cortex bends, while the outer cortex breaks (Fig- .2). Such fractures occur commonly in the ir9the growth plate may result in deformities due to shafts of forearm bones. b) Ali n ent: Perfect, end-to-end alignment is not irregular growth. Shortening may occur because of mandatory. Some amount of ‘mal-alignment’ is premature epiphyseal closure. corrected with growth. tahalter an arri cla ification (Fig- .1): piphyseal injuries have been classified into 5 types based on their X-ray appearance. The higher the classification, c) nion: Fractures unite faster in children. Table– .2: Essential features of epiphyseal injuries (Salter and Harris classification) e a le reat ent ro no i I Radial neck epiphysis separation Closed reduction Good II Lower end radius epiphysis Closed reduction Good III Medial malleolus epiphysis Open reduction Growth disturbance can occur IV Lateral condyle of humerus Open reduction Growth disturbance common V Lower tibial epiphysis injury Conservative Growth disturbance always

– .2 a e ea al a ee Fractures in Children | 59 ae a e. e a e e e b ea e TREATMENT e be Most fractures in children can be successfully treated by non-operative methods like plaster d) reat ent: Fractures in children can usually be immobilisation, traction, sling etc. treated by conservative methods. An operation is rarely necessary. Following are some facts about fractures in children Fractures in children heal faster. Pathological fractures: These are uncommon in Fractures close to the joint heal faster. children. However, there are some diseases which Sideways displacement will remodel. are particularly common in children and result Angulation in the plane of the adjacent joint is in pathological fractures. These are: (i) fractures through infected bones; (ii) fractures through cysts; acceptable. and (iii) fractures associated with osteogenesis Rotational malalignment will never remodel. imperfecta. Physis subjected to compressive forces inhibits DIAGNOSIS growth. Diagnosis of fractures in children is often missed Operative intervention is necessary in some for the following reasons: fractures, as listed below: • Fracture of the nec of the femur, displaced. a) History of trauma is either concealed, or the child is not old enough to communicate. • Fracture lateral condyle of the humerus (Type epiphyseal injury). b) The more dramatic signs of fracture may be absent, especially in incomplete fractures. • Fracture of the shaft of femur, in an adolescent. Thus, there may be no deformity, no abnormal mobility, no crepitus etc. • Wherever operation is considered necessary for some other reason such as vascular injury, the c) Parents may attempt to conceal the fact that an fracture is also fixed internally. infant has been injured, especially when there has been abuse (battered baby syndrome). With the availability of image intensifier and development of percutaneous methods of fixation, d) Undisplaced fractures are often missed on operative fixation of unstable fractures in children, X-ray, unless carefully looked for. using T S nails or rush nails has become popular. This makes treatment of an unstable fracture more Therefore, irrespective of the history, possibility of predictable. an injury should always be considered whenever marked loss of function, pain and tenderness, and COMPLICATIONS unwillingness to use a limb occurs in children. On the other hand, trauma may be falsely implicated Fractures in children are associated with few as a cause, in some non-traumatic diseases; the complications. Union of a fracture is generally episode of trauma being often days or weeks not a problem; non-union being very rare. Some earlier. complications relatively important in children's fractures are: • rowth disturbances in epiphyseal injuries. • Brachial artery injury in supracondylar fracture of the humerus. • Myositis ossificans in injuries around the elbow. • Avascular necrosis in fracture of the nec of the femur. Further Reading • Staheli T: n a ental o ae iatric rt o ae ic . Raven ress: ew or , 1 2 • Wober B , Brunner C, Freular F ( ds.): reat ent o ract re in il ren an A ole cent . Springer – erlag: Berlin, 1 80. https://kat.cr/user/Blink99/

60 | Essential Orthopaedics What have we learnt? • ractures in children are easier to treat. • A special category, i.e. epiphyseal injuries, occur in children, and can lead to gro th disturbances. • istory of injury has to be carefully probed, as often non-traumatic problems such as infection or tumour, may be erroneously linked to an unrelated episode of 'injury'. Additional information: From the entrance exams point of view • Distal radius and ulna are the most common fracture locations in children follo ed by the clavicle. G• ost common bone fractured during birth is the clavicle. • Injury to the perichondrial ring is type VI alter arris fracture or ang s injury. R• ultiple fractures at various stages of healing in a child, al ays consider battered baby Vsyndrome. • piphyseal enlargement seen in haemophilia. tahir99 - United• piphyseal dysgnesis seen in ypothyroidism.

10C H A P T E R Peripheral Nerve Injuries TOPICS • Diagnosis • Electrodiagnostic studies • Relevant anatomy • Treatment • Pathology • Prognosis • Mechanism of injury • Classification RELEVANT ANATOMY Structure of a peripheral nerve: A peripheral Fig-10.2 Sensory innervation of the hand. The picture in nerve consists of masses of axis cylinders the box shows autonomous sensory zones in the hand (axons), each with a neurilemmal tube (Fig-10.1). An individual nerve fibre is enclosed in a collagen connective tissue known as endoneurium. A bundle of such nerve fibres are further bound together by fibrous tissue to form a fasciculus. The binding fibrous tissue is known as perineurium. A number of fasciculi are bound together by a fibrous tissue sheath known as epineurium. An individual nerve, therefore, is a bundle of a number of fasciculi. Formation of a peripheral nerve: These are formed from nerves arising from the spinal cord (spinal nerves). There are 31 pairs of spinal nerves in the body, each representing a segment of the spinal cord. These, either through direct branching or through a network of nerves (plexus), give rise to peripheral nerves. Peripheral nerves are mixed nerves carrying motor, sensory and autonomous supply to the limbs. The anatomy of individual nerves will be discussed in respective sections. Motor innervation of limb muscles: A knowledge of motor innervation of different muscles in the limb is essential for diagnosis of a nerve injury. The following knowledge of anatomy is often required when dealing with a case of nerve injury, and is discussed subsequently in the sections on individual nerve injuries: Fig-10.1 Structure of a nerve a) What is the nerve supply of a particular muscle? https://kat.cr/user/Blink99/

62 | Essential Orthopaedics b) What are the different muscles supplied by a PATHOLOGY nerve? Nerve degeneration: The part of the neurone c) What is the action of a muscle and by what distal to the point of injury undergoes secondary manoeuvre can one appreciate its action in or Wallerian degeneration; the proximal part isolation ? Only such muscles, whose action can undergoes primary or retrograde degeneration be elicited in isolation are suitable for testing. upto a single node. Sensory innervation of limbs: The area of Nerve regeneration: As regeneration begins, the axonal stump from the proximal segment begins hypoaesthesia resulting from a nerve injury may to grow distally. If the endoneural tube with its be less than the area of skin innervated by that nerve because of the overlap of sensory supply by contained Schwann cells is intact, the axonal sprout different nerves. A relatively small area supplied may readily pass along its primary course and exclusively by a single nerve, called autonomous reinnervate the end-organ. The rate of recovery of zone, is found in all nerve injuries (Fig-10.2). The sensory innervation by different nerves of the limbs axon is 1 mm per day. The muscle nearest to the site is discussed in the section on individual nerve of injury recovers first, followed by others as the nerve reinnervates muscles from proximal to distal, Ginjuries. the so-called motor march. If the endoneural tube is interrupted, the sprouts, as many as 100 from one Anatomical features relevant to nerve injuries: axonal stump, may migrate aimlessly throughout the damaged area into the epineural, perineural or RThere are some features related to the anatomy of adjacent tissues to form an end-neuroma or a neuroma in continuity (Fig-10.3). An end-neuroma may form a nerve which make a particular nerve more prone when the proximal-end is widely separated from the distal-end. A side neuroma usually indicates a Vto injury. These are as follows: partial nerve cut. da) Relation to the surface: Superficially placed nerves iteare more prone to injury by external objects e.g., Fig-10.3 Types of neuromas the median nerve at the wrist often gets cut by a piece of glass. nb) Relation to bone: Nerves in close proximity to a bone or a joint are more prone to injury e.g. Uradial nerve injury in a fracture of the shaft of -the humerus. c) elation to fibro e tae: Some nerves pierce 9fibrous septae along their course. They may get entrapped in these septae (entrapment ir9neuropathies). d) Relation to major vessels: Nerves in close relation hto a major vessel run the risk of ligation during surgery, or damage by an aneurysm. tae) Course in a confined space: A nerve may travel in a confined fibro-osseous tunnel MECHANISM OF INJURY and get compressed if there is a compromise Fractures and dislocations are the commonest cause of the space, e.g., median nerve compression in of peripheral nerve injuries. Some other mecha- carpal tunnel syndrome. nisms by which a nerve may be damaged are: f) Fixation at points along the course: Nerves are (i) direct injury – cut, laceration; (ii) infections – relatively fixed at some points along their leprosy; (iii) mechanical injury – compression, course and do not tolerate the stretch they may traction, friction and shock wave; (iv) cooling be subjected to, e.g., the common peroneal and freezing – ‘frost bite’ etc.; (v) thermal injury; nerve is relatively fixed over the neck of (vi) electrical injury – electric shoc ; (vii) ischaemic the fibula, and any stretching of the sciatic injury– ol mann s ischaemia; (viii) toxic agents – nerve often leads to isolated damage to this injection tetracycline resulting in radial nerve palsy; component of the nerve. and (ix) radiation – for cancer treatment.

Peripheral Nerve Injuries | 63 Table–1 .1: Seddon's classification of nerve injuries Type of injury Pathology Degeneration Neuroma Prognosis Nil Recovery complete Neurapraxia Physiological Nil within 6 weeks interruption, Neuroma Axonotmesis anatomically Proximally + distally in continuity Recovery +/-, Neurotmesis normal Proximally + distally End or side Motor march + neuroma Recovery poor Axons broken, nerve intact Axons as well as nerve broken CLASSIFICATION In case the cause is obvious, say a penetrating wound along the course of a peripheral nerve (e.g., glass Seddon's classification: Seddon classifies cut injury to the median nerve), the nerve affected nerve injuries into three types: (i) neurapraxia; and its level is easy to decide. Similarly, nerve in- (ii) axonotmesis; and (iii) neurotmesis. jury may occur during an operation as a result of stretching or direct injury. • Neurapraxia: It is a physiological disruption of conduction in the nerve fibre. No structural When the cause is not obvious, an inquiry must be changes occur. Recovery occurs spontaneously made regarding any history of injection in the within a few weeks, and is complete. proximity of the nerve. Neurotoxic drugs such as quinine and tetracycline are known to damage • Axonotmesis: The axons are damaged but the nerves. Medical causes of nerve affection like internal architecture of the nerve is preserved. leprosy, diabetes should be considered in patients Wallerian degeneration occurs. Recovery may who do not give a history of injury. occur spontaneously but may take many months. Complete recovery may not occur. Examination: Often, the clinical findings in a case of nerve palsy are very few. Therefore, it is • Neurotmesis: The structure of a nerve is damaged essential to perform a systematic motor and by actual cutting or scarring of a segment. sensory examination of the involved limb. Classic Wallerian degeneration occurs. Spontaneous deformities may not be present in an early case or recovery is not possible, and nerve repair is in a case with partial nerve injury. A combination of required. nerve injuries and anatomical variation in the nerve supply may distort the clinical picture of a classic Most nerve injuries are a combination of these. nerve lesion. The following observations must be Table–10.1 compares the essential features of the made during examination: three types of nerve injuries. WHICH NERVE IS AFFECTED? DIAGNOSIS Attitude and deformity: Patients with some In a case of peripheral nerve injury, the following peripheral nerve injuries present with a classic information should be obtained by careful history attitude and deformity of the limb. Some such and examination: attitudes in different nerve injuries are as follows: • Wrist drop: The wrist remains in palmar flexion a) Which nerve is affected? b) At what level is the nerve affected? due to weakness of the dorsiflexors. It is seen in c) What is the cause? radial nerve palsy. d) What type of nerve injury (neurapraxia etc.) is • Foot drop: The foot remains in plantar flexion due to weakness of the dorsiflexors. It occurs in it likely to be? common peroneal nerve palsy. e) In case of an old injury, is the nerve recovering? • Winging of scapula: The vertebral border of the scapula becomes prominent when the patient History: A patient with a nerve injury commonly tries to push against a wall. It occurs in paralysis presents with complaints of inability to move a part of the serratus anterior muscle in long thoracic of the limb, weakness and numbness. The cause of nerve palsy. nerve injury may or may not be obvious. https://kat.cr/user/Blink99/

64 | Essential Orthopaedics Wasting of muscles: This will be obvious some time after the paralysis. It may be slight and become • Claw hand (Main-en-griffe): Claw hand means apparent only on comparing the affected limb with hyperextension at the metacarpo-phalangeal the sound limb. Some examples of this are given in joints and flexion at the proximal and distal Table–10.2. inter-phalangeal joints (Fig-10.4). This occurs due to paralysis of the lumbricals, which flex Table–1 .2: Muscle wasting in nerve injuries the metacarpo-phalangeal joints and extend the inter-phalangeal joints. Paradoxically, clawing Muscle wasting Nerve is more marked in low ulnar nerve palsy than in high ulnar nerve palsy. This is because in the • Flat shoulder Axillary nerve latter, flexors of the fingers (both profundus and (Deltoid M.) Median nerve superficialis), which cause clawing affect are also paralysed. In ulnar nerve palsy, only the medial • Thenar eminence lnar nerve two fingers develop clawing while all the four (Thenar M.) lnar nerve fingers develop clawing in combined median and ulnar nerve palsies. Clawing may not become • Hypothenar eminence Femoral nerve apparent in the early post-injury period. (Hypothenar M.) Sciatic nerve • Hollowing between metacarpals (Interossei M.) • Thigh wasting (Quadriceps M.) • Calf wasting (Gastrosoleus M.) Fig-10.4 Claw hand (hyperextension at the MP joint) Skin: The skin becomes dry (there is no sweating due to the involvement of the sympathetic nerves), • ‘Ape thumb’ deformity: In this deformity the thumb glossy and smooth. In partial lesions, there may be is in the same plane as the wrist. It occurs due vasomotor changes in the form of pallor, cyanosis, to paralysis of the opponens pollicis muscle in or excessive sweating. There may be trophic median nerve palsy. disturbances such as ridged and brittle nails, shiny atrophic skin, trophic ulcers etc. • ‘Pointing index’: On asking the patient to make a fist, it is noticed that the index finger remains Temperature: A paralysed part is usually colder and straight. This is due to paralysis of both the drier because of loss of sweating, best appreciated flexors (digitorum superficialis and lateral half by comparing it with normal skin. of the digitorum profundus) of the index finger, which occurs in median nerve palsy at a level Sensory examination: The different forms of proximal to the elbow. The other fingers can be sensation to be tested in a suspected case of flexed by the functioning medial side of the flexor nerve palsy are touch, pain, temperature and digitorum profundus, supplied by the ulnar vibration. The area of sensory loss may be smaller nerve. than expected. If it is so, look for sensation in the autonomous zone (Fig-10.2, page 61). • ‘Policeman tip' deformity: In this deformity, the arm hangs by the side of the body with elbow Reflexes: Reflexes in the area of nerve distribution extended and forearm fully pronated. This is are absent in cases of peripheral nerve injuries. because of the paralysis of the abductor and external rotators of the shoulder alongwith Sweat test: This is a test to detect sympathetic flexors and supinators of the elbow. function in the skin supplied by a nerve. Sympathetic fibres are among the most resistant to mechanical trauma. The presence of sweating within an autonomous zone of an injured peripheral nerve reassures the examiner that complete interruption of the nerve has not occurred. Sweating can be determined by the starch test or ninhydrin print test. In these tests, the extremity is dusted with an

Peripheral Nerve Injuries | 65 agent that changes colour on coming in contact Branches of the radial nerve are as given in with sweat. Table–10.3. Motor examination: For evaluation of motor Table–1 .3: Major motor branches of radial nerve functions, clear concepts about the anatomy, as to which nerve supplies which muscle is essential. • Before the radial ong and medial heads The muscles which are exclusively supplied by groove of triceps a particular nerve are most suitable for motor examination. The tests are nothing but manoeuvres • After the radial groove, ateral head of triceps, to make a muscle contract. One must carefully watch before crossing anconeus, brachioradialis, for tric movements—the movement produced by the elbow extensor carpi the adjacent muscles, often substituting for the radialis longus paralysed muscle. The contraction of the muscle • After crossing the must be appreciated, wherever possible, by elbow, before piercing xtensor carpi radialis brevis, feeling its belly or its tendon getting taut. Motor the supinator the supinator examination conducted for different nerves is discussed below. • After piercing the Other extensor muscles supinator of the forearm and hand RADIAL NERVE Tests: arious muscles supplied by the radial nerve Anatomy: This nerve is a continuation of the will be affected according to the level of radial nerve posterior cord of the brachial plexus. In the axilla, injury i.e. high or low. it gives off a branch to the long head of triceps, and enters the arm. a) High radial nerve palsy: This occurs if the nerve is injured in the radial groove. In this type, all Course in the arm: As it comes into the arm, the the muscles supplied by radial nerve except radial nerve gives off the posterior cutaneous the triceps and anconeus are paralysed. nerve of the arm and a branch to the medial head Occasionally, the radial nerve may be injured of the triceps. It now travels infero-laterally into still higher up, in which case even the triceps the groove for the radial nerve on the posterior may be paralysed. This is called very high radial surface of the humerus, winding spirally around nerve palsy. the bone. In the groove, it gives branches to the lateral head of triceps and anconeus muscles, b) Low radial nerve palsy: This occurs if the nerve and cutaneous branches to the arm and forearm. is injured around the elbow so that the muscles After winding around the humerus, the nerve supplied by the radial nerve in the distal arm pierces the lateral intermuscular septum from (brachioradialis, extensor carpi radialis longus behind, at the junction of the middle and lower- and brevis) are spared. third of the arm. In the distal-third of the arm it comes to lie in the anterior compartment, between From proximal to distal, the following muscles can the brachialis muscle on the medial side and be examined: brachioradialis and extensor carpi radialis longus on the lateral side. • Triceps: The patient is asked to extend his elbow against resistance applied by the examiner, Before it crosses the elbow in front of the lateral whose other hand feels for triceps contraction. condyle, it divides into two branches – superficial and deep. The superficial branch is primarily • Brachioradialis: The patient is asked to flex the sensory and travels along side the radial artery into elbow from 90o onwards, keeping the forearm the forearm. The deep branch is primarily motor. It midprone. As he does so against resistance, the gives branches to the extensor carpi radialis brevis brachioradialis stands out, and can be felt. and the supinator. It then pierces the supinator and emerges in the posterior compartment of • Wrist extensors: The patient with paralysed wrist the forearm to become the posterior interosseous extensors has ‘wrist drop . n case the paralysis nerve, which divides immediately into branches is partial, the contraction of the extensor carpi supplying the extensor muscles of the forearm. radialis and extensor carpi ulnaris muscle can be felt, though actual movement may not occur. • Extensor digitorum: It causes extension at the metacarpo-phalangeal joints. The patient cannot do so if it is paralysed (finger drop). The examiner https://kat.cr/user/Blink99/

66 | Essential Orthopaedics should not be misled by the ability of the patient Table–1 . : Major motor branches of the median nerve to extend the fingers at the inter-phalangeal joints (function performed by the lumbricals). • n the arm il • Extensor pollicis longus: This causes extension • n the forearm All the flexor muscles of the at the inter-phalangeal joint of the thumb. Proximal 1 forearm, except the flexor It is examined by stabilising the metacarpo- carpi ulnaris and medial-half phalangeal joint of the thumb, while the patient 3 of the flexor digitorum is asked to extend the inter-phalangeal joint. profundus Distal 1 Nil MEDIAN NERVE 3 Thenar muscles* (three) Anatomy: This nerve is formed by the joining • n the hand First two lumbricals of branches from the lateral and medial cords of brachial plexus. In the arm, the median nerve * The three muscles are flexor pollicis brevis, opponens descends adjacent to the brachial artery. pollicis and abductor pollicis. Adductor pollicis is not supplied by median nerve. Course in the forearm: The nerve enters the forearm between the two heads of the pronator teres. It then will be paralysed. In addition, there will be passes deep to the tendinous bridge of the origin of anaesthesia over the median nerve distribution the flexor digitorum superficialis, in the proximal- in the hand. third of the forearm. In the mid-forearm it descends between the flexor digitorum superficialis and From proximal to distal, the following muscles can flexor digitorum profundus. About 5 cm above the be examined: wrist, it comes to lie on the lateral side of the flexor digitorum superficialis. It becomes superficial just • Flexor pollicis longus: The patient is asked to above the wrist, where it lies between the tendons flex the terminal phalanx of the thumb against of the flexor digitorum superficialis and flexor carpi resistance while the proximal phalanx is kept radialis. steady by the examiner. Course in the hand: The nerve passes deep to the • le or i itor erficiali an lateral al o e or flexor retinaculum and enters the palm. Here a digitorum profundus: If the patient is asked to clasp short and stout muscular branch from it supplies his hand, the index finger will remain straight, the muscles of the thenar eminence (abductor the so-called pointing index . This occurs because pollicis brevis, opponens pollicis and flexor pollicis both the finger flexors, superficialis as well as brevis). The median nerve finally divides into 4 to the profundus of the index finger are paralysed; 5 palmar digital branches supplying the area of though the available medial-half of the flexor skin shown in Fig-10.2. Also, motor branches are digitorum profundus (supplied by the ulnar given to the first and second lumbrical muscles nerve) makes flexion of the other fingers possible. at this level. The nerve supply to various muscles by the median nerve along its course is given in • Flexor carpi radialis: Normally, the palmar Table–10.4. flexion at the wrist occurs in the long axis of the forearm. In a patient with paralysed flexor Tests: The various muscles supplied by the median carpi radialis, the wrist deviates to the ulnar nerve will be affected according to the level of side while palmar flexion occurs. In addition, median nerve injury i.e. high or low. one cannot feel the tendon of the flexor carpi radialis getting taut. a) High median nerve palsy (injury proximal to the elbow): This will cause paralysis of all the • Muscles of the thenar eminence: Out of the three muscles supplied by the median nerve in the muscles of the thenar eminence, only two can forearm and hand. In addition, there will be be examined for their isolated action. These are sensory deficit in the skin of the hand. as follows: (i) abductor pollicis brevis (Fig-10.5): The action of this muscle is to draw the thumb b) Low median nerve palsy (injury in the distal-third forwards at right angle to the palm. The patient of the forearm): There will be sparing of the is asked to lay his hand flat on the table with forearm muscles, but the muscles of the hand palm facing the ceiling. A pen is held above the thumb and the patient is asked to touch the pen with tip of his thumb. This is called the 'pen test'; (ii) opponens pollicis: The function of this

Peripheral Nerve Injuries | 67 muscle is to appose the tip of the thumb to other Table–1 . : Major motor branches of the ulnar nerve fingers. Apposition is a swinging movement of the thumb across the palm and not a simple • n the arm il adduction. The latter movement is by the adductor pollicis muscle supplied by the ulnar • n the forearm Flexor carpi ulnaris, nerve. Proximal 1 medial half of flexor digitorum profundus 3 Nil Distal 1 Hypothenar muscles Adductor pollicis, 3 all interossei and medial two lumbricals • n the hand Superficial branch Deep branch 1. T e e e muscles supplied by the ulnar nerve in the forearm and hand. In addition, there will be a ULNAR NERVE sensory deficit in the skin of the hand. Anatomy: This nerve arises from the medial cord b) Low ulnar nerve palsy (injury in distal-third of the brachial plexus. In the arm, it lies on the of forearm): There will be sparing of forearm medial side of the axillary artery. At the junction muscles but the muscles of the hand will be of the middle and lower-third of the arm, it pierces paralysed. Sensory deficit will be same as in the medial intermuscular septum and comes to lie high ulnar nerve palsy. in the posterior compartment. It becomes more and more superficial as it approaches the elbow, where Individual muscles which could be examined in a it lies behind the medial epicondyle. case of ulnar nerve palsy are given below: Course in the forearm: The ulnar nerve enters the • Flexor carpi ulnaris: The patient is asked to forearm between the two heads of the flexor carpi palmar flex the wrist against gravity. In doing ulnaris, and descends along the medial side of the so, the hand deviates towards the radial side. forearm. Here it lies anterior to the flexor digitorum The tendon of flexor carpi ulnaris just above the profundus, along with the ulnar vessels. pisiform, does not stand out. On performing the same test against resistance, the tendon cannot Course at the wrist: It passes in front of the flexor be felt. retinaculum just lateral to the pisiform bone. On entering the palm, the ulnar nerve finally divides • Abductor digiti minimi: The patient is asked to into superficial and deep terminal branches abduct the little finger against resistance while supplying the hand muscles. The nerve supply to keeping the hand flat on the table (in order to various muscles by the ulnar nerve along its course avoid action of flexors of the finger). are given in Table–10.5. • Interossei: Palmar interossei do adduction (PAD), Tests: arious muscles supplied by ulnar nerve will the dorsal interossei do abduction (DAB) of the be affected according to the level of ulnar nerve fingers at metacarpo-phalangeal joints. These can injury i.e., high or low. be tested as follows: Egawa's Test (Fig-10.6a): This is for dorsal a) High ulnar nerve palsy (injury proximal to the interossei (abductors) of the middle finger. elbow): This will cause paralysis of all the With the hand kept flat on a table palmar surface down, the patient is asked to move his middle finger sideways. Card Test (Fig-10.6b): This is for palmar interossei (adductors) of the fingers. In this test, the examiner inserts a card between two extended fingers and the patient is asked to hold it as tightly as possible while the examiner https://kat.cr/user/Blink99/

68 | Essential Orthopaedics Fig-10.6 Tests for ulnar nerve tries to pull the card out. The power of examiner tries to pull the book out while the adductors can thus be judged. In case of weak patient tries to hold it. This sign is known as palmar interossei, it is easy to pull out the Froment s sign or the boo test. card. First dorsal interosseous muscle can be separately examinated by asking the patient ACCESSORY NERVE to abduct the index finger against resistance (Fig-10.6c). This supplies the trapezius muscle. • The lumbricals: These are mainly responsible for flexion at the metacarpo-phalangeal joints but Test: The trapezius muscle is tested by asking the their isolated action cannot be tested. patient to elevate his shoulder against resistance. • Adductor pollicis: The patient is asked to grasp One can see and feel the trapezius belly stand out. a book between the thumb and index finger. Similarly, the patient is asked to brace his shoulder Normally, a person will grasp the book firmly backward and depress it to examine middle and with thumb extended, taking full advantage lower part of the muscle. of the adductor pollicis and the first dorsal interosseous muscles. If the ulnar nerve is LONG THORACIC NERVE injured, the adductor pollicis will be paralysed and the patient will hold the book by using Anatomy: The nerve arises from the ventral rami the flexor pollicis longus (supplied by median of C5, C6 and C7. It descends behind the brachial nerve) in place of the adductor. This produces plexus on the lateral surface of the serratus anterior, flexion at the inter-phalangeal joint of the thumb. which it supplies. (Fig-10.7). This becomes more pronounced if the Test: The serratus anterior muscle can be examined Fig-10.7 Froment's sign (book test) by asking the patient to push against a wall with both hands. The medial border of the scapula on the affected side will become prominent (winging of scapula, Fig-10.8). AXILLARY NERVE Anatomy: The axillary nerve arises from the posterior cord of the brachial plexus and curves backwards on the lower border of the subscapularis. It crosses the quadrangular space and comes to lie on the medial side of the surgical neck of the humerus, medial and inferior to the capsule of the shoulder joint. Here it divides into anterior and posterior branches. The posterior branch supplies

the teres minor and posterior part of the deltoid and Peripheral Nerve Injuries | 69 terminates as the cutaneous nerve which supplies the skin over the lower-half of the deltoid. The THE CAUSES OF INJURY anterior branch continues horizontally between the deltoid and the surgical neck of the humerus, and Once it is decided on clinical examination, which supplies the rest of the deltoid. nerve is affected and at what level, one must look for a tell tale signs along the course of the nerve for Fig-10.8 Winging of the scapula the cause. This may be in the form of an injury such as displaced bone fragments or a scar to suggest an Test: The surgeon stabilises the scapula with one old external injury. The nerve may be thickened (e.g. hand while the other hand is kept on the deltoid leprosy). If no such exteral evidence is present, the to feel for its contraction. The patient is asked paralysis could be due to some medical cause such to abduct his shoulder. Inability to abduct the as neuropathy, myelopathy etc. (Refer to a Textbook shoulder, and the absence of the deltoid becoming of Medicine). taut indicates deltoid paralysis. SCIATIC NERVE THE TYPE OF INJURY Anatomy: The sciatic nerve consists of two Once the cause of nerve injury is established, one anatomically distinct components – the tibial and must make an attempt to evaluate the predo-minant common peroneal nerves. The common peroneal type of nerve injury (Seddon s classifi-cation). component is more frequently affected than the The nature of the causative factor, a period of tibial. Complete lesion of the sciatic nerve is rare. observation and electrodiagnostic studies may help Tests: The common peroneal nerve supplies the in deciding this. extensors and the evertors of the foot. Paralysis of these muscles results in foot drop. The patient walks SIGNS OF REGENERATION with a high-step gait , i.e. while wal ing he has to lift the foot high in order to clear the ground. The Whenever a case of nerve injury is seen some plantar flexors of the foot are normal. time after the injury or following a repair, signs The tibial nerve supplies the plantar flexors of the of regeneration of the nerve should be looked for foot. One can test for weakness of these muscles by during examination. These are as follows: asking the patient to plantar-flex the ankle and toes. • Tinel's sign: On gently tapping over the nerve The function of the hamstring group of muscles, also supplied by the sciatic nerve, can be tested by along its course, from distal to proximal, a pins flexing the knee against resistance. and needle sensation is felt in the area of the skin supplied by the nerve. A distal progression of the level at which this occurs, suggests regeneration. • Motor examination: The muscle supplied nearest to the site of injury is the first to recover, noticed clinically by the ability of the muscle to contract. The muscles in the more distal area begin to contract as they are reinnervated one after another (motor march). This phenomenon is absent in neuropraxia where all muscles recover together. • Electrodiagnostic test: This can help in predicting nerve recovery even before it is apparent clinically. ELECTRODIAGNOSTIC STUDIES Electromyography: Electromyography (EMG) is a graphic recording of the electrical activity of a muscle at rest and during activity. Normal muscle: A normal muscle at rest shows no electrical activity. With voluntary contraction, https://kat.cr/user/Blink99/

70 | Essential Orthopaedics c) Whether any regeneration occurring: The earliest evidence of reinnervation of a muscle is action potentials develop in the motor units. In a the appearance of reinnervation potentials weak contraction, these may be recordable as single on attempted voluntary contraction of the motor unit potentials in the vicinity of the recording muscle. These potentials appear weeks before electrode. In a strong contraction, impulses of a a contraction can be noticed clinically. The number of motor units firing simultaneously are progress of a nerve recovery can thus be superimposed, giving rise to an interference pattern monitored. (Fig-10.9) d) Level of nerve injury: By performing an EMG Fig-10.9 Electromyography of all the muscle supplied by a nerve, one can decide the level of nerve injury. Muscles Denervated muscle. The denervated muscle has supplied distal to the site of nerve injury would spontaneous electrical activity at rest. This is called show changes of denervation. denervation potentials. These potentials represent the embryonic electrical activity of a muscle, which Strength-duration curve: This is a graphic is normally suppressed by stronger nerve action representation of the excitability of muscle and potentials. These appear at around 15-20 days after nerve tissue under test. A small strength of the muscle denervation. As nerve degeneration current can excite a normal muscle. This occurs by progresses, more and more denervation potentials excitation of the muscle through neuromuscular appear. If these potentials have not appeared by junction, which needs a weaker current. In a the end of the 2nd week after a nerve injury, it is a denervated muscle, the excitation is possible only good prognostic sign. on direct stimulation of the muscle fibres, which Electromyography is useful in deciding the following: need a higher strength of current. a) Whether or not a nerve injury is present: It helps A very low-strength current is given for a duration in differentiating a muscle paralysis because of of 300 milliseconds and its response noted. The nerve injury from that due to other causes such strength of the current is gradually increased until as myopathy. a minimal visible contraction of the muscle is b) Whether it is a complete or incomplete nerve injury: observed. This minimal current strength, required If the nerve supply of a muscle is partially cut, to elicit muscle contraction, is called the Rheobase, there will be evidence of residual innervation of and is measured in milliamperes. The Chronaxie is the muscles. This may be too small to produce the duration of current required to excite a muscle any clinically detectable muscle contraction, but with a current-strength of double the rheobase. It is can be picked up on the EMG. Also, if a group of measured in milliseconds. These two are the basic muscles supplied by a nerve do not show signs parameters of excitability of a muscle. of denervation, it indicates a preserved nerve supply to these muscles, hence an incomplete For knowing excitability of a muscle in relation nerve injury. to current-strength and its duration, the muscle is stimulated by reducing the duration of the current from 300 milliseconds, gradually to a 1 millisecond or even lower. A corresponding increase in strength of the current required is detected. A graph is plotted between current-duration and corresponding current-strength. This is called a strength-duration curve (Fig-10.10). Interpretation: The pattern of the strength-duration curve of an innervated muscle is different from that of a denervated muscle or regenerating muscle, as discussed below: • Normal strength-duration curve: A normal muscle will respond to stimuli varying in duration

Peripheral Nerve Injuries | 71 a) Whether a nerve injury is present: If a nerve injury is present there will be no conduction of the impulse across the suspected level. b) Whether it is a complete or partial nerve injury: Absence of any transmitted impulse across the suspected site is an indicator of a complete nerve injury. c) Compressive lesion: The conduction velocity may simply be delayed in compressive nerve lesions such as carpal tunnel syndrome, etc. Fig-10.10 Strength-duration curve TREATMENT a) Nerve curve b) Muscle curve c) Partial denervation General consideration: In fresh nerve injuries, the from 300 milliseconds to as low as 3 or even 1 general condition of the patient must be evaluated millisecond without any increase in the strength of before undertaking a nerve repair. Arterial, bone the current. If the duration of current is decreased and joint repair takes precedence over nerve repair. beyond it, a progressive increase in the strength The treatment of nerve injuries may be conservative of current is required in order to produce a or operative. Though conservative treatment yields contraction. A strength-duration curve plotted good results, in selected cases an operation should from such a muscle is termed a nerve curve, because not be delayed in the hope of spontaneous recovery. the muscle contraction is caused by stimulation of the motor nerve entering the muscle. CONSERVATIVE TREATMENT This alone or in addition to operative treatment is • Denervated muscle: A totally denervated muscle required in all types of nerve injuries. The aim of will need current either of more strength or for conservative treatment is to preserve the mobility a longer duration. A curve from such a muscle of the affected limb while the nerve recovers. is termed a muscle curve. The following are the essential components of • A partially denervated muscle: The curve of conservative treatment: a partially denervated muscle or a muscle recovering after nerve injury lies between the • Splintage of the paralysed limb: The first procedure normal and the curve of denervation, and is to be adopted in every case of nerve injury is to characterised by an upward kink. The kink splint the limb in the position which will most denotes the superimposition of the two basic effectively relax the affected muscles. The type types of curves. of splints used for common nerve injuries are as given in Table–10. . • Assessment of recovery by the strength-duration curve: If progressive recovery is occurring the • Preserve mobility of the joints: Every joint of the curve will, on serial examination, become flatter affected limb must be put through full range of with a shift to the left. On the other hand, if the movement at least once every day. process of denervation is progressive, the curve will become steeper and will shift to the right. • Care of the skin and nails: Since the skin is anaesthetic, it should be protected from trauma, Nerve conduction studies: It is a measure of the velocity of conduction of impulse in a nerve. A Table–1 . : Splints used for various nerve injuries stimulating electrode is applied over a point on the nerve trunk and the response is picked up Nerve injured Splint by an electrode at a distance or directly over the muscle. The velocity of the conduction of the • Axillary nerve Aeroplane splint impulse between any two points of the nerve can be (deltoid paralysis) Coc -up splint calculated. The normal nerve conduction velocity of motor nerve is 70 metres/second. This conduction • adial nerve palsy Knuc le-bender splint study helps in the following: (extensors of wrist & Foot drop splint MP joints paralysed) • lnar nerve palsy (lumbricals paralysis) • Sciatic . palsy or common peroneal N. palsy https://kat.cr/user/Blink99/

72 | Essential Orthopaedics burn or pressure sores. Trophic ulcers should be d) Failure of conservative treatment: If a nerve injury meticulously treated. Nails should be cleaned is treated conservatively and no improvement and cut with care. occurs within 3 weeks, one should proceed to electrodiagnostic studies, and if required, nerve • Physiotherapy: Physiotherapeutic measures exploration. consist of (i) massage of the paralysed muscles; (ii) passive exercises to the limb; (iii) building up Techniques of nerve repair: Nerve repair can be either of the recovering muscles; and (iv) developing end-to-end or by using a nerve graft. the unaffected or partially affected muscles. a) Nerve suture: When the nerve ends can be Attempts were made in the past to preserve tone and functions of denervated muscles by electrical brought close to each other, they may be stimulation, but it has been found to be of no use. sutured by one of the following techniques (Fig-10.11): • Relief of pain: Suitable analgesics are prescribed • Epineural suture for relief of pain. • Epi-perineural suture • Perineural suture OPERATIVE TREATMENT • Group fascicular repair Operative procedures for nerve injuries consist of Methods of closing nerve gaps: Sometimes, the loss nerve repair, neurolysis, and tendon transfers. of nerve tissue is so much, that an end-to-end suture cannot be obtained. In such a situation, Nerve repair: It may be performed within a few the following measures are adopted to gain days of injury (primary repair) or later (secondary length and achieve an end-to-end suture: repair). Fig-10.11 Techniques of nerve repair. (a) Epineural Primary repair: It is indicated when the nerve is cut (b) Perineural (c) Epi-perineural d) Nerve grafting by a sharp object, and the patient reports early. In such cases an immediate primary repair is the best. • Mobilisation of the nerve on both sides of the One needs experience in the use of the fine sutures lesion. and operative microscope for this kind of surgery. In case the wound is contaminated or the patient • elaxation of the nerve by temporarily reports late, a delayed primary repair is better. In positioning the joints in a favourable position. this, in the first stage, the wound is debrided and the two nerve ends approximated with one or two • Alteration of the course of the nerve, e.g. the fine silk sutures so as to prevent retraction of the ulnar nerve may be brought in front of the cut ends. This also makes identification of the cut medial epicondyle (anterior transposition). ends easy at a later date. After two weeks, once the wound heals, a definitive repair is done. Some • Stripping the branches from the parent nerve surgeons routinely perform a delayed primary without tearing them. repair because they feel that the epineurium gets thickened in two weeks and sutures hold better. • Sacrificing some unimportant branch if it is hampering nerve mobilisation. Secondary repair: It is indicated for the following cases: a) Nerve lesions presenting some time after injury: Often nerve injuries are missed at the time of injury, or it may not have been possible to treat them early for reason, such as poor general condition of the patient. b) Syndrome of incomplete interruption: If no definite improvement occurs in 6 weeks in cases with an apparently incomplete nerve injury, nerve exploration, and if required secondary repair should be carried out. c) Syndrome of irritation: Cases with signs of nerve irritation need exploration and sometimes a secondary repair.

Peripheral Nerve Injuries | 73 b) Nerve grafting: When the nerve gap is more the nerve (intra-neural fibrosis). This is called than 10 cm or end-to-end suture is likely to result internal neurolysis. in tension at the suture line, nerve grafting may be done. In this, an expandable nerve (the sural Reconstructive surgery: These are operations nerve) is taken and sutured between two ends of performed when there is no hope of the recovery the original nerve as shown in Fig-10.11d. of a nerve, usually after 18 months of injury. After this time even if the nerve recovers, transmission Neurolysis: This term is applied to the of impulses across the neuromuscular junction operation where the nerve is freed from does not occur because the neuromuscular function enveloping scar (perineural fibrosis). This is itself has degenerated. Operations included in this called external neurolysis. In many cases, the group are tendon transfers, arthrodesis and muscle nerve sheath may be dissected longitudinally transfer. Rarely, an amputation may be justified for to relieve the pressure from the fibrous tissue within an anaesthetic limb or the one with causalgia. Flow chart-10.1 Treatment plan for management of peripheral nerve injury https://kat.cr/user/Blink99/

74 | Essential Orthopaedics A practical plan for management of nerve injury is shown in Flow chart-10.1. DECISION MAKING IN NERVE INJURIES PROGNOSIS It is often difficult to decide when to operate in a case of nerve injury. This is especially so if there The following factors dictate recovery following a is a partial lesion or partial recovery has taken nerve repair: place. Electrodiagnostic studies are helpful in these cases. a) Age: The lower the age, the better the prognosis. b) Tension at the suture line: The more the tension, nless the nature of the nerve injury is nown before the operation, the appearance of the involved the poorer the prognosis. nerve is often the best guide to deciding on the type c) Time since injury: After 18 months only sensory of operative procedure. Where the nerve ends are visibly apart, nerve repair is the only choice. Where functions can be expected. the nerve is in continuity, it is often difficult to d) Location of injury: The more proximal the decide the further course. A fusiform thickening of a nerve (neuroma in continuity) indicates a partial injury, the worse the prognosis. cut. A nerve stimulator may be used to find if there e) Type of nerve: A primarily motor nerve, like is any continuity of the nerve. If there is a brisk response in the muscles supplied by the nerve on radial nerve, has a better prognosis than a mixed stimulating the nerve proximal to the neuroma, nerve. there is no need for nerve suture; neurolysis may f) Condition of the nerve ends: The more the suffice. In case there is little or no response, the crushing and infection, the poorer the prognosis. neuroma should be excised and the nerve repaired. g) Associated conditions: Infection, ischaemia etc. indicate poor prognosis. What have we learnt? • There are three types of nerve injuries eurapraxia, Axonotmesis, eurotmesis. • erve recovers at the rate of mm day. • o to diagnose a nerve injury, clinical signs their explanation. • o to monitor nerve regeneration, and role of electrodiagnostic studies. • ethods of nerve repair. • Decision making in nerve injury. • o to predict hether a nerve ill recover or not Additional informationL: From the entrance exams point of view • Tinel s sign indicates regeneration of nerves. • rognosis after nerve suturing radial nerve ulnar nerve peroneal nerve sciatic nerve femoral nerve. • rb s palsy is the most common neurological de cit in the upper limb. • rb s palsy is injury to upper , roots of brachial plexus. • lumpke s palsy is injury to the lo er trunk and partially T . • rutch palsy is injury to the radial nerve. • la hand due to leprosy is classi ed as rade II O grading. • udden hyper exion of the thigh over the abdomen ( c obert s procedure) done on the mother for delivery of babies ith shoulder dystocia leads to injury to the lateral cutaneous nerve of thigh (meralgia paresthetica).

11C H A P T E R Deformities and Their Management TOPICS • Causes • Treatment CAUSES subluxations seen in day-to-day practice) or pathological (e.g., following acute septic Deformities may arise from an abnormality in arthritis). Classic deformities are produced in the bone (e.g., a malunited fracture), joint (e.g., some subluxation or dislocation (Table– .2, tuberculosis of the knee), or soft tissues (e.g., page 56). clubfoot). These may be either congenital or acquired. b) Muscle imbalance: All joints are spanned by two opposing groups of muscles. Normally, these CONGENITAL DEFORMITIES muscles maintain a balance so that the joint can be kept in any position. In some diseases, These are deformities or malformations present at an unbalanced action of the muscles may hold birth (e.g., clubfoot). Some of these malformations, the joint in a particular position. With time the though present at birth, may become apparent other soft tissues around the joint (the capsule, only later in life (e.g. spina bifida). The deformity ligaments etc.) also contract and prevent the may be severe and incompatible with life (e.g., joint from returning to its neutral position. The osteogenesis imperfecta congenita), and can only muscle imbalance may arise from paralysis of a be found in stillborn infants. On the other hand, it group (e.g., polio) or overactivity (e.g., spasticity may be very minor and have no practical significance. in cerebral palsy). The underlying causative factors may be: (i) a c) Tethering or contracture of muscles and tendons: genetic abnormality (e.g., diaphysial aclasis, Joint movement is associated with contraction mongolism etc.); (ii) environmental factors (e.g., of a group of muscles and elongation of phocomelia); and (iii) combined – genetic and opposing group. To and fro gliding of tendons environmental factors (e.g., congenital dislocation also happens in this process. If by some of the hip, clubfoot). disease, these functions are interrupted, the joint is prevented from moving full range. ACQUIRED DEFORMITIES For example, the muscles or tendons, may get tethered to the underlying bone (e.g., tethering Deformities acquired later in life may be divided of the quadriceps to the femur in a fracture). into those arising at a joint or in a bone (Fig-11.1), The muscle may get contracture (e.g., Volkmann's as discussed below: ischaemic contracture of the flexor muscles of forearm, leading to flexion deformity of the Deformities arising at a joint: A joint may become wrist and fingers). deformed because of any of the following factors: a) Dislocations and subluxations: These may be traumatic (e.g., most dislocations and https://kat.cr/user/Blink99/

76 | Essential Orthopaedics Fig-11.1 Causes of deformities at joints d) Contracture of soft tissues other than muscles: Apart Deformities arising in a bone: Three major causes from muscles, contracture of other soft-tissues of deformity arising in a bone are fractures, bone like skin, deep fascia etc. may account for the diseases and abnormally growing bones. deformity. For example, contracture of palmar aponeurosis may pull the metacarpo-phalangeal a) Fracture: This is the commonest cause of and proximal inter-phalangeal joints of one deformity of a bone. This results when a fracture or more fingers (Dupuytren's contracture). unites in a mal-aligned position. Some of the Similarly, contracture of the scarred skin on the common deformities resulting from malunion flexor aspect of the elbow or knee following a of fractures are given in Table–11.1. burn, may result in a flexion deformity of the respective joint. b) Bone diseases: Some diseases of the bone result in a softening and bending of the bones. Most e) Arthritis: Joint deformity may result from of these are generalised disorders where several arthritis. This may occur: (i) because of sustained or all of the bones are affected. The following spasm of a group of muscles in response to are some examples: pain; or (ii) as a result of damage to important structures like ligaments, cartilage etc., by the Table–11.1: Deformities due to fractures arthritic process. Deformity Fracture f) Posture: The habitual keeping of a joint in a deformed position may result in a deformity, • un stoc deformity Supracondylar fracture of for example, lateral deviation of the great toe (cubitus varus) the humerus (hallux valgus) is seen in women who wear Fracture of lateral condyle narrow pointed high-heeled shoes. • Cubitus valgus of humerus Colles fracture g) Unknown factors: Some deformities of joints • Dinner for deformity Avulsion of the extensor result from no apparent reason. For example, • Mallet finger tendon from base of distal knock knees deformity (genu valgum) phalanx commonly seen in children, often has no • Coxa vara nter-trochanteric fracture cause. • enu valgum Condylar fractures of tibia (e.g., bumper fracture) • arus-valgus An le injuries at ankle

Deformities and Their Management | 77 • Metabolic disorders – ric ets, osteomalacia. and have to be corrected. Some deformities (e.g. bow legs), may not be of immediate functional • ndocrine disorders – parathyroid osteodys- concern, but may cause problem in long term, and trophy, Cushing's syndrome. thus may need to be corrected. The methods used for correction of deformities may be non-operative • Disorder of un nown aetiology – aget s dis- or operative. ease, fibrous dysplasia, senile osteoporosis. NON OPERATIVE METHODS c) Abnormal bone growth: Bone deformity may Wherever possible, non-operative methods are result from uneven growth occuring at the attempted first. These are suitable for deformities epiphyseal plate. Unequal growth of one of the due to soft tissue contracture. The method two bones in a part of the limb with two bones essentially consists of stretching the contracted (e.g. forearm or leg), may result in deformity soft tissue, and then maintaining the correction by at the joint adjacent (e.g. wrist or ankle). The splints. The disadvantage of this method is that the common causes of uneven growth at the treatment is long drawn, and an equally prolonged epiphyseal plate are as follows: effort at maintenance is required. Recurrence of deformity is common. Correction of deformity by • Crushing fracture involving the epiphyseal non-operative methods is done by the following plate ( rade- , Salter and Harris epiphyseal ways: injury). a) Manipulative correction: The contracture is • Infection from a nearby osteomyelitis or gently manipulated, so as to stretch it. Once arthritis, spreading to the epiphyseal plate, corrected, it is maintained in the corrected and damaging it. position in a plaster cast or splint. An example of use of this method is treatment of a club foot • A tumour may retard the growth of a nearby by manipulation and PoP. epiphyseal plate (e.g., enchondroma as in Ollier's disease). Occasionally, the tumour b) Wedging cast: In this technique, a cast is applied may stimulate uneven growth of the adjacent on the limb with deformed joint. A wedge of plate by causing local hyperaemia (e.g., plaster is cut out on the convex side of the haemangioma). deformity, the wedge closed by forcing the part, thus achieving correction. • Dysplasia: In some epiphyseal dysplasias, abnormal growth at the epiphysis results in c) Traction: radual traction can stretch out joint deformities. contracted soft tissues. The correction is subsequently maintained in a splint or calipers. TREATMENT d) Splints: These are special splints which permit Many deformities do not need treatment, as they gradual stretching of the soft tissues, leading to are of no significant functional or cosmetic concern. the correction of deformities (e.g., turn-buckle A simple reassurance and watchful neglect may be splint for VIC see page 103). appropriate in these cases. Most other deformities cause functional impediment or cosmetic concerns, Fig-11.2 A child with bilateral genu valgum corrected by supracondylar osteotomy on both the sides https://kat.cr/user/Blink99/

78 | Essential Orthopaedics Flow chart-11.1 Plan of management of a deformed joint OPERATIVE METHODS limb), and arthrodesis remains the only option. The procedure involves opening up the joint, In cases where the non-operative methods fail removing its cartilage, and immobilizing it in or the deformity is primarily bony, operative functional position. The raw bone ends unite correction may be required. The following (as in a fracture), resulting in fusion. methods are used: a) Soft tissue release: The contracted soft d) Arthroplasty: The term arthroplasty means 'reconstructing a joint'. Reconstruction can be tissues are released. Tethering of soft tissues done by two methods: (i) by excising a part is removed. of the deformed joint, thereby relaxing the b) Osteotomy (Fig-11.2): It is used for correcting surrounding soft tissues, and thus correcting bony deformity. The deformed bone is cut and deformity or (ii) by replacing the joint with suitably realigned in a corrected position (e.g., artificial components. The former is called for genu varum and genu valgum). excision arthroplasty, and is done for joints damaged due to infection. The latter is called c) Arthrodesis (fusion of joint): This method is replacement arthroplasty (joint replacement), and adopted where a joint is not only deformed, is done for most other damaged and deformed but also its articulating surfaces damaged joints (e.g. osteoarthritis knee). See also Chapter beyond repair. Arthrodesis is suitable for 42. joints where loss of motion at the joint does not produce much functional disability (e.g. e) Correction of deformity by selective retardation wrist). In other situations, such as hip and knee, of epiphyseal growth: This is useful in cases joint replacement is a better option. With the where the cause of deformity is unequal availability and better longevity of artificial epiphyseal growth, and the child has residual joints, arthrodesis has become less popular. growth potential. Here, the faster growing side There are situations where joint replacement of the epiphysis is temporarily or permanently cannot be done (e.g. joint infection, paralysed

Deformities and Their Management | 79 stopped by surgical means (stapling, direct than one plane. The apparatus provides an damage etc.). Over a period of time, the slower opportunity for correcting the deformity very growing side keeps growing, while the stapled accurately (see also page 33) A comprehensive side does not, resulting in correction of the plan of management of a deformed joint is given deformity. This is performed in selected cases in Flow chart-11.1. of genu varum or valgum in a growing child. It is a minimally invasive operation, but a little Further Reading unpredictable. • Weinstein SL, Buckwalter JA (Eds.): Turek's Orthopaedics: f) Ilizarov's technique: This is a versatile Principles and their Applications, 5th ed. Philadelphia: JB technique of correcting deformity. Its utility Lippincott Co, 1994. is more when the deformity is associated • Nickel VL (Ed.): Orthopaedic Rehabilitation. Churchill with shortening, or if the deformity is in more Livingstone, ew or , 1 2. What have we learnt? • Deformities may be since birth, or develop later. • The cause of deformity may be bone (e.g. malunion), joint (e.g. OA knee), or soft tissue contracture (e.g. Volkmann's contracture). • Initial treatment of deformity is by non-operative methods, and thereafter operative methods. • Different operative methods of correction of deformity exist. https://kat.cr/user/Blink99/

12C H A P T E R Treatment of Orthopaedic Disorders: A General Review TOPICS • Non-operative methods of treatment • Operative methods of treatment Orthopaedic treatment can be broadly divided permanent or prolonged support may be required into two types, non-operative and operative. At in some cases, in the form of life time appliances times a patient needs no definite treatment except called orthoses (see page 332). reassurance. Whenever treatment is required, it is preferable to try non-operative methods first, PHYSIOTHERAPY though there are occasions when early or an immediate operation must be advised. This includes a variety of treatment modalities based on physical methods of treatment such as heat NON-OPERATIVE METHODS OF TREATMENT therapy, exercises etc. It may be aimed at alleviation of pain, restoration of functions, or both. It may REST be used as a primary treatment modality (e.g., for backache etc.) or in conjunction with other methods Since olden times, rest has been the mainstay of treatment (e.g., post-operative physiotherapy). of orthopaedic treatment. It helps in reducing inflammation and pain. The word ‘rest’ could When appropriately prescribed and adequately mean complete inactivity or immobility, as pursued under the supervision of a skilled is sometimes required in acute inflammatory physiotherapist, it can perform wonders. On the conditions like acute osteomyelitis etc. But, more other hand, an unskilled physiotherapist by his over often than not, it means no more than ‘relative enthusiastic approach may retard rather than hasten rest’, implying simply a reduction of activity and patient's recovery. The following are the common avoidance of strain. With advances in orthopaedic methods used in physiotherapy: treatment, more and more methods have been devised by which the period of rest could be Ice therapy: Ice therapy is beneficial during the reduced significantly (e.g., by internal fixation for first 24-72 hours after injury. It causes relief in most fractures). pain, reduces haematoma formation and reduces inflammation. The pain relieving effect of cold SUPPORT therapy is appreciated more after the application than during it. A limb or a joint not capable of functioning because of inadequate muscle power needs Heat therapy: Heat produces a soothing effect on support (e.g., a polio limb). Temporary support many aches and pains, probably by increasing the may be given with a splint made from Plaster blood flow, or possibly by some other mechanism. of Paris or other plastic splinting material. A

Treatment of Orthopaedic Disorders: A General Review | 81 Heat application is done for 15 to 20 minutes 2 or 3 • Static or isometric exercises i.e., the muscle times a day. Heat must not be applied to insensitive contracts while its length remains the same or ischaemic skin, and if there is underlying acute e.g., muscle contraction while pushing a infection or neoplastic tissue. Depending upon the wall. depth of penetration of the heat, it can be either surface heat i.e., only the skin and subcutaneous • Dynamic or isotonic exercises i.e., the tissues are heated, or deep heat i.e. deeper structures muscle contracts and produces movement. are heated. These exercises could be: (i) active — the patient does the movements himself; a) Surface heat: This can be provided by (i) hot water (ii) active-assisted — the patient does bottle (rubber-bottle); (ii) warm bath; (iii) hot the movement while the physiotherapist soaks or compresses; (iv) infra-red lamp; and helps; or (iii) active-resisted — the patient (v) wax bath. does the movement against resistance. The last is the most effective in gaining muscle b) Deep heat: This can be provided by (i) short- strength. wave diathermy—heat generated by a high frequency alternating current (frequency 27 c) Exercises to improve coordination: These are mega cycles/second) using a short-wave special exercises, useful in polio and cerebral diathermy emitter; (ii) ultrasonic therapy – palsy patients. these waves (a million cycles/second) are projected as a beam from a transducer; and Tractions: In physiotherapy, traction is applied: (iii) microwave. The ultrasonic waves and (i) to separate joint surfaces while giving passive microwaves penetrate to a considerable depth. movements to a joint; (ii) to obtain the relaxation of When the waves strike the tissues, energy muscles which are in spasm (e.g., by giving cervical is converted into heat. It is most useful for or lumbar traction); or (iii) to correct deformities by localised tender fibrous nodules. gentle continuous traction. For details please refer to Chapter 4. Exercise therapy: These are given for three purposes: (i) to mobilise joints; (ii) to strengthen Massage: This is a systematic and scientific muscles; and (iii) to improve coordination and manipulation of the skin and the underlying balance. soft tissues which gives rise to relief of pain and a) Joint mobilising exercises: The following exercises the relaxation of muscles. Most massage and mani-pulations are soothing except for frictions may be advised: which are painful, and are used to breakdown • Passive joint movements: These are used to adhesions. preserve joint mobility when the patient is Hydrotherapy: The principles of buoyancy help unable to move the joint himself (e.g., when to reduce pain by relaxation of the muscles, the muscles are paralysed). mobilisation of stiff joints, and thereby assist in the development of muscle power. This is useful as it • Active joint movements: The patient moves produces a general sense of well-being. his joints actively so as to gain more and more range of movement. Sometimes, a patient's Occupational therapy: Occupational therapy aims active efforts may be assisted by gentle at enabling the person to become as independent pressure from the physiotherapist. as possible, inspite of the disability he may have. A person needs independence in following day-to- • Continuous passive mobilisation (CPM): The day activities: joint is fitted in a machine which moves the a) Activities of daily living (ADL): These constitute joint slowly through a predetermined arc of motion. Since the motion produced is very activities such as self care, bathing, eating, wear- slow, it is tolerated by the patient in even the ing clothes etc. very early post-operative period. b) Work related activities: These constitute employ- ment related and home management related b) Muscle strengthening exercises: These are used to activities. preserve or improve the strength of the muscles. c) Leisure time activities: These constitute sports These may be of the following types: and social activities. https://kat.cr/user/Blink99/

82 | Essential Orthopaedics MANIPULATION This is a term used for a manoeuvre whereby Initial emphasis in rehabilitation is on restor- passive movements of joints, bones or soft tissues ing the abilities of the person by physiotherapy are carried out with or without an anaesthetic, and measures such as exercises, positioning etc. Even often forcefully, as a deliberate step in treatment. during this period, occupational therapy helps the It may be done for: (i) correction of deformity; (ii) patient to be as independent as possible. When it is improving the range of movement of a stiff joint; or not possible to achieve any further improvement, (iii) relief of chronic pain in or about a joint. adaptation is done in the patient’s environment, so that he is able to maintain independence. Psycho- a) Manipulation for the correction of a deformity: logical adaptation constitutes an important part of In this category, manipulation has its most this. Use of adaptive devices such as walking aids, obvious application in the reduction of fractures adaptive clothing etc. is encouraged. The person and dislocations. It is also used to correct a is also trained to perform purposeful activities of deformity due to contracted soft tissues, as in daily living (ADL), and activities related to work CTEV. and play environment. All these make him inde- pendent inspite of his disability. b) Manipulation for stiff joints: In the treatment of stiff joints, while efforts being made to achieve DRUGS movements by joint mobilising exercises, manipulation under anaesthesia may speed up Drugs have a limited role in orthopaedic disorders. the process of recovery. The joint most amenable Those used may be placed in five categories as to manipulation is the knee. Manipulation is given below: strictly contraindicated in the elbow because it may lead to increased stiffness due to ‘myositis’. a) Analgesics anti-inflammatory: These are the most important group of drugs. They c) Manipulation for the relief of pain: The role are broadly divided into non-steroidal anti- of manipulation in some chronic painful inflammatory drugs (NSAIDs) and steroids. conditions is empirical. It has been shown to be Depending upon the need, the choice varies effective in some conditions like tennis elbow, from a primarily analgesic to a mainly anti- low backache etc. inflammatory drug. In long standing illnesses, it is desirable to use single daily-dose drugs e.g., RADIOTHERAPY Coxibs and slow release (SR) formulations. Radiotherapy is useful in the following orthopaedic b) Antibacterial drugs: These drugs are of disorders: immense value in acute infective conditions such as septic arthritis, acute osteomyelitis etc. a) Malignant tumours: Ewing's sarcoma is a It is important to start with a broad-spectrum highly radiosensitive malignant bone tumour. drug and change over to specific drug after a Radiotherapy is also used for other malignant culture-sensitivity report. tumours, either pre or post surgery. c) Hormones: The main drugs in this group are b) Benign tumours: Giant cell tumours of the anabolic steroids, estrogens (for osteoporosis) bone which are unsuitable for excision can be and stilbesterol (for metastasis from prostate). irradiated. d) Specific drugs: These are used in certain specific c) Other conditions: Recalcitrant ankylosing disorders e.g., vitamin D for rickets, vitamin C spondylitis. for scurvy, etc. OPERATIVE METHODS OF TREATMENT e) Cytotoxic drugs: These are used in the treatment of malignant bone tumours. An operation is a useful yet serious undertaking. A trained surgeon, modern operation theatre and f) Local injections of a depot preparation of adequate instruments are essential before one hydrocortisone or methylprednisolone are used ventures to perform an orthopaedic operation. to control non-specific inflammation of a joint or an extra-articular lesion like tennis elbow.