KNOW YOUR ORTHOPAEDICS… - Educreation · 17 Damage Control Orthopaedics 64 18 Coverage Options...

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KNOW YOUR ORTHOPAEDICS…

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ISBN: 978-93-85247-31-6

Price: ` 299.00

First Published 2015

Medical knowledge is getting expanded day by day as medical science is an ever dynamic subject. The authors, contributors and the publishers have taken their best care to incorporate up to date information. Due to possibility of human error and continued advances in medical science, neither the authors nor the publisher warrant that the information contained herein is complete and accurate in every respect. The readers are strongly advised to confirm that the information herein complies with the current standards of recommendation and practice.

Printed in India

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KNOW YOUR ORTHOPAEDICS

Dr. Imran Sajid Asst. Professor

Dept of Orthopaedics

FH Medical College & Hospital

Agra

Dr. Sukhvinder Singh Basran Asst. Professor

Dept of Orthopaedics

HIMSR & HAHC Hospital

New Delhi

Editors

Dr Dhawal Bakhda Dr Nitin Maruti Adsul

EDUCREATION PUBLISHING (Since 2011)

www.educreation.in

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FORWARD

The well-known saying “Tough gets Tougher with Time” holds true for the theory

examinations of Orthopaedics, as so much advancement has been made in this particular

field of medicine over the years, that the scope of examination, seem to broaden with

every passing year. The DNB Orthopaedic exams especially have a different format,

which focuses lot on the theory part, along with the practical and hence the DNB

residents find it particularly tough to clear these exams which may be due to the lack of

proper guidance.

There are a large number of books available in the markets for reference used by

students, but mostly all of them focus more on the practical aspect of the examination. A

book solely aimed at helping the students with the theory exams have been missing all

these years, and hence students have to hunt for all the information they need from

number of books available in the market, wasting precious time before exam.

I am delighted to know that ORTHOPG has come up with this concept and this book,

which is primarily focusing on providing the relevant information, in ready to use answer

format, which I am sure will make the life of many aspiring Orthopaedicians much easier.

In order to maintain the authenticity of the matter in the book, relevant references have

also been given at as many places as possible and hence students can refer to them when

needed.

The authors of this book have gone through the gruelling orthopaedic examination at

their time and are well aware of the difficulties that a student has to face in order to

prepare the best answers of the most important questions expected in examination. And

hence, they have put in the best of their efforts and gathered all their knowledge that they

have gained over these years of their practice.

Although, the material given in this book is authentic and to the best knowledge of the

authors, I advise the students to use this book solely as a reference book and not as their

syllabus book and to read the text books thoroughly. ORTHOPG surely believes in

“Bringing the education to you rather than making you hunt for it”, but even for that you

need to put in some efforts.

All the Best

With Best Regards

Prof Dr. R.K. Goyal Ex HOD, S.N. Medical College, Agra

Ex HOD, RIMSNR, Saifai, Etawah

HOD, FH Medical College, Agra

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FROM THE AUTHOR’S PEN

COMPETITION..!!! This is one word, which haunts us all throughout our lives. Since the

day we are born, all we see is competition. In every field and in every place, we see it and

soon realise that this is an eternal part of everyone’s life. Even a sperm has to compete to

reach his destination. And this is when one hasn’t even entered the world.

In today’s time life is more a race and we are all running to win it, just to prove

ourselves. Even though we had realised it long back in our lives, but the true realisation

came to us when we were preparing to get into a Medical College. Getting in was a tough

task no doubt, but getting through was even tougher. Life in a Medical college is surely

not easy. Nobody is told about the amount of hard work needed to clear the exams

especially final post-graduation examination.

The syllabus is wide and time is limited. There are days when more than 24 hours are

required to meet daily targets of studies, leave alone eating and other things. Even while

you sleep, some or the other topic is constantly going on in our heads (this has happened

with all of us before our exams). The only discussions (if at all we have any) are about

the exam preparations and the books being referred.

During one such day of exam preparation we realised that life will be much easier if we

all got ready-made notes and we just had to read them. We all tried to hunt for such exam

notes, but could hardly find any book which could help us and provide us with ready-

made answers. All we got were thick books and vast syllabus, the ones which could

practically never come to an end. Although there were few xeroxed notes available in

market but deciphering the hand writing was a task in itself. Plus lack of references made

us doubt its authenticity at times.

As they say, “Necessity is the mother of all inventions”, it was after that day, that we

thought of making the lives of others easy by helping them and providing them all the

study material needed in the form of notes along with a collection of our practical

learning that have been put together in this book, to provide the best answers to the most

critical questions for exam preparation. This book is a collection of the hard work we did

as student’s ourselves, notes made at that time along with all the practical knowledge that

we have gained over the period of time.

The compilation of this book was not an easy task. The notes we had made during our

preparation days, had to be revised and upgraded and additional information had to be put

in. Past year’s question papers had to be taken up to find out the most critical questions

for the preparation of the students and the best answers to these questions had to be

compiled together. Working in a hospital, and studying at the same time doesn’t leave

much time to anyone for doing such things, and writing a book, in itself is a big task,

requiring vast knowledge and a lot of hard work. Many-a-times, we had to undo and redo

the same answers again and again as we ourselves were not satisfied with the answers,

but the end result is surely much better than what you will find in any other book. The

material is simple and yet lucrative, which is sure to help you clear all your concepts

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from the core. References have been given at all possible places for further reading and to

give credit to original authors.

This book is intended to make your life easier, by bringing the knowledge to you rather

than making you hunt for it and hence helps you save a lot of time and effort. It is the

quality of study material that has been the main focus in this book rather than the

quantity, and it is not just the bookish knowledge that you will get from this book; it is

also the practical experience that has been penned down for your reference.

We are really thankful to ORTHOPG for coming up with this concept and helping us

realise our dreams and letting us help the students in their preparation.

Hope this book serves its purpose to its best. All the Best with the preparations future

Orthos..!!!

Dr Imran Sajid Dr Sukhvinder Singh Basran

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ACKNOWLEDGEMENTS

A book is not just words put together, it is much more than that. It is the time and efforts

of people combined with the knowledge gathered at the same place. My intent to write

this book was clear from beginning, I wanted to help the orthopaedic residents, and make

their lives easy by providing them all that they need to prepare for their exam at a single

place.

But to make my life easy, while I was working on this book, I had people around me,

without whose support I would not have completed this book so smoothly. I would like to

express my gratitude and indebtedness to those who assisted me and were always there to

encourage me. Their contributions are sincerely appreciated and gratefully

acknowledged. I would like to express deep appreciation and indebtedness to the

following:

I am deeply indebted to Dr Dhawal Bakhda and Dr Nitin Maruti Adsul for their sincere

efforts in editing the manuscript and for their valuable suggestions.

For her perseverance in getting me to complete this book, my eternal gratitude goes to my

friend, editor, counsellor, Ashima Malhotra. Her keen interest and encouragement were a

great help throughout the course of preparation of this book.

For their continuous inspiration and moral support to achieve this task, I am also thankful

to my parents, Dr Sajid Husain and Dr Noorjahan Sajid.

Special thanks to my wife Dr Priyangee Imran for her invaluable support and untold

hours of solitude she had to bear due to my devotion to the book.

A special mention goes to ORTHOPG TEAM for coming up with this concept and

providing us with this opportunity.

And most of all to our great creator Almighty, the author of knowledge and wisdom who

made this possible

- Dr Imran Sajid

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DEDICATION

Dedicated to all the exam going orthopods.

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CONTENT LIST

S.NO Topic PAGE

1 Primary Vs Secondary Bone Healing 1

2 Functional Cast Bracing 4

3 Biomechanics Of Hip 8

4 Ganga Hospital Injury Severity Score 15

5 Spine At Risk Sign 18

6 Principles Of Sonography 20

7 Plagiarism 24

8 Impact Factor 25

9 Teriperatide 26

10 Gate Control Theory Of Pain 28

11 Botulinum Toxin 31

12 Tribology 35

13 Foot Drop 38

14 Femoroacetabular Impingement 42

15 Carpal Tunnel Syndrome 53

16 Pathophysiology Of Trauma 59

17 Damage Control Orthopaedics 64

18 Coverage Options Post Primary Malignant Bone Tumor

Excision 66

19 Extra Corporeal Irradiated Tumor Bone 69

20 Dislocation Of Patella 71

21 Gout 75

22 Pseudo Gout 79

23 Case Sheet Writing – Hip Case 82

24 Case Sheet Writing – Spine Case 93

Know Your Orthopaedics

1 Sample copy. Not for distribution.

PRIMARY VS SECONDARY BONE HEALING _____________________________________________________________

PRIMARY SECONDARY

Callus Absent Present

Fixation Rigid (Plating) Not rigid (IM Nailing)

Cortex Well apposed/ unicortical fracture Not well apposed

Mechanism Cutting Cone mechanism

Endochondral /

Intramembranous Ossification or

combination of both

Stages Osteoclastic followed by osteoblastic

activity

5 stages – Hematoma,

Inflammation, callus,

consolidation, remodeling

Quality of bone

formed Inferior Superior

PRIMARY BONE HEALING:

1. Callus is not formed at all.

2. Requires rigid stabilization with or without compression of the bone ends.

3. Rigid stabilization suppresses the formation of a callus in either cancellous or cortical

bone.

GAP HEALING CONTACT HEALING

GAP HEALING – when there is gap between fracture fragments

Occurs in two stages.

1. Width of the gap is filled by direct bone formation.

An initial scaffold of woven bone is laid down, followed by formation of lamellar

bone as support.

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The orientation of the new bone formed in this first stage is transverse to that of

the original lamellar bone orientation.

2. After several weeks - longitudinal Haversian remodeling reconstructs the necrotic

fracture ends and the newly formed bone to replace the woven bone with osteon

of the original orientation. In the end, the normal bone structure results.

CONTACT HEALING – Fracture fragments are in direct apposition.

a) Fragments are in direct apposition and osteons can grow across the fracture site,

parallel to the long axis of the bone.

b) When fracture fragments are in contact, osteoclasts on one side of the fracture

undergo a tunneling resorptive response, forming cutting cones that cross the

fracture line.

c) Osteoclasts at the front of the cutting cone remove bone.

d) Trailing osteoblasts lay down new bone.

e) This tunneling allows the penetration of capillaries and eventually the formation

of new haversian systems.

The cutting/filling cone has a head of osteoclasts that cut through the bone and a tail of

osteoblasts that form a new secondary osteon.

SECONDARY BONE HEALING:

It occurs when there is no rigid fixation of the fractured bone ends, which leads to the

development of a fracture callus.

Divided into 5 stages by Frost HM .(The biology of fracture healing. An overview for

clinicians -Part I. ClinOrthopRelat Res. 1989 Nov;(248):283-93.)

a) Hematoma

b) Inflammation

CUTTING CONE

http://www.ncbi.nlm.nih.gov/pubmed/2680202



c) Callus

d) Consolidation

e) Remodeling – Wolff’s Law

WOLFF’S LAW –

Every change in form and function of a bone, or in its function alone, is followed by

certain definite changes in its internal architecture and equally definite secondary

alteration in its mathematical laws

OR

Bone is deposited and resorbed in accordance with the stresses placed upon it. (J.

Wolff:DasGesetz der Transformation der Knochen. Berlin, A. Hirschwald, 1892.

Published with support from the Royal Academy of Sciences in Berlin. English

translation by P. Maquet and R. Furlong.Belin, Springer-verlag, 1986.)

*********



FUNCTIONAL CAST BRACING _____________________________________________________________

DEFINITION: It’s a type of bracing where the limb is able to do restricted function

while in a brace.

PRINCIPLE: Continuing function while a fracture is uniting, encourages osteogenesis,

promotes the healing of tissues and prevents the development of joint stiffness, thus

accelerating rehabilitation.

• The fracture healing in FCB is mainly by External Bridging Callus formation.

• It has greater mechanical advantage over Medullary callus.

• The intermittent loading of the # area, by muscle activity & weight bearing,

promotes local blood flow & development of electrical fields which are beneficial

for healing.The FCB allows movement at the joint & some movement at # site.

• This transmits a measurable load which decreases as the # progresses to union.

• The muscle compartments act as a fluid mass surrounded by deep fascia.

• Fluid is not compressible & fascia cannot be stretched beyond the confines of the

cast. (“Hydraulic container theory”; Sarmiento et al 1974)

• Thus after a certain degree of displacement, pressure & load is transmitted

without further deformation.

• This causes the bony fragments to be held more firmly.

• Rotation is resisted by components of the brace.

PATELLAR TENDON BEARING CAST(SARMIENTO CAST):

Described by Sarmiento

(Sarmiento A. A functional below-the-knee cast for tibial fractures. JBJS [Am] 1967; 49-

A: 855-75.)

In principle it is a below-knee cast extending to the upper pole of the patella and with a

firm moulding over the medial flare of the tibia, the patellar tendon, and the popliteal

space, and shaped in a triangular manner at the upper end of the tibia.

Sarmiento (1967) stated that the PTB cast stabilized the proximal fragment of a tibial

fracture, left the knee free to move, and allowed early ambulation as weight-bearing

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forces should be transmitted from the ground to the proximal end of the tibia, virtually

bypassing the fracture site and suspending the fractured bones.

INDICATION:

1. Lower tibial shaft fractures

WHEN TO APPLY:

1. 5 – 6 weeks after initial trauma.

2. Fracture ends sticky.

3. Minor movements at the fracture site painless.

ACCEPTABLE REDUCTION:

- 50% of cortical contact; < 5-10° of varus / valgus angulation when comparing

tibial plateau to tibial plafond;

- < 10-15 deg of anterior or posterior bowing on lateral film;

- < 5 - 7 deg of internal or external rotation, varus or valgus; no more than 10-15

mm of shortening;

CONTRAINDICATIONS:

1. Lack of patient co-operation.

2. Patients with spastic disorders.

3. Deficient sensibility of the limb.

4. Isolated tibial fractures.

BASIC TECHNIQUE:

1. Patient positioning

a. Patient is sitting off the end of bed with at least half the thigh off the bed to

allow for space between leg and bed.

b. Alternatively, patient may be prone with the knee flexed to 900.

2. Starting point: Metatarsal head

3. End point : Proximal patellar tendon

4. Moulding area: tibial flares, the patellar tendon, and the popliteal space



UNLOADING EFFECT OF THE PATELLAR TENDON BEARING CAST:

According to Sarmiento weight-bearing forces are transmitted from the ground to the

proximal end of the tibia, virtually bypassing the fracture site and suspending the

fractured bones thereby effectively unloading the fracture.

(The effect of the patellar tendon-bearing cast on loading; H. Tanaka, JBJS (Br) VOL.

82-B, NO. 2, MARCH 2000)

Conventional PTB cast only achieves unloading of 30% of the body-weight. It can be

improved by producing a space between the sole of the foot and the cast, and is

adjustable by altering the depth of this space. When the depth of the free space under the

foot inside the PTB cast is 1, 2 and 3 cm, the unloading effect is 60%, 80% and 98%,

respectively.

When there is an adequate space under the foot, sliding of

the leg occurs in the cast on loading until complete

suspension. Weight-bearing is relieved and complete

unloading occurs.



*********

The contribution from each part of

the PTB cast to the overall

unloading effect.



BIOMECHANICS OF HIP _____________________________________________________________

The study of the forces exerted by muscles and gravity on the hip joint

HIP - 1st class Lever with fulcrum at its centre.

1. The lever rotates about the axis as a result of a force (from muscle contraction)

2. The force acts against a resistance (weight, gravity)

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FORCES EXERTED ON THE HIP JOINT:

Joint Reaction Force (JRF) = force generated within a joint in response to the forces

acting on it

JRF = Body wt + Abductor force

JRF = K * h’ + M * h

MANAGEMENT OF PAINFUL HIP: - REDUCE JRF

This can be achieved by:

1. Reducing body weight or its moment arm (Body weight difficult to reduce)

2. Help abductor for or its moment arm (can be managed easily)

Moment arm Abductor force

Use of cane (C/L leg) Suitcase (I/L Leg)

1. K- Force exerted by the body weight.

2. h’- Lever arm of K.

3. M – Force exerted by the abductor muscles.

4. h – Lever arm of M

5. R – Force transmitted across the joint

(Resultant of forces of K and M = JOINT

REACTION FORCE)



Cane – used on the opposite leg (Normal side)

(Copied from Anatomy & Biomechanics of the Hip; Damien P. Byrne*, Kevin J. Mulhall

and Joseph F. Baker; The Open Sports Medicine Journal, 2010, 4, 51-57)

WALKING STICK:

1. On opposite side increases the lever arm thus decreases the joint reaction force.

2. Opposes body weight by transferring body weight to stick

3. Brings the centre of gravity closer to the body

SUITCASE IN IPSILATERAL LEG: - Helps the abductor force



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