ORTHOPEDICS

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Subject Outline

es
Important Points about Various
ot
Skeletal Diseases.......................................................... 640
N
Orthopaedics Oncology............................................ 650

Miscellaneous Topics.................................................. 657

EE

Miscellaneous Important Images.......................... 659

M
PG
y
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Notes
Orthopedics

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Osteology
es
ot
N
zz Osteon
 The Basic unit of bone.
EE

 Consists of lamellae arranged around Haversian canals

 Rich in glycoproteins & proteoglycans – highly basophilic
Central Haversian canal: neurovascular canal containing 1 or 2 capillaries
M



 Haversian canals communicate with each other via Volkmann’s canal(nutrient/vascular

perforating channels)
PG

zz Epiphysis ossifies from secondary centres

zz Epiphyseal growth plate (physis): part b/w epiphysis & metaphysic, zones of maximum growth
zz Diaphysis is the strongest part of the bone and ossifies from primary centres
y

zz Diaphyseal nutrient arteries are directed away from the dominant growing epiphysis.
M

zz Metaphysis: Zone of active growth

 Highly vascularised zone
 Hair pin arrangement of blood vessels
 More prone for injury
 Most common site for osteomyelitis in children
zz Bone receives 5% to 10% of the cardiac output (o5-TEoN)
zz Long bones receive blood flow from three sources:
 The nutrient blood vessel that enter the diaphysis through nutrient foramen,
 The metaphyseal complex,
 The periosteal capillaries
zz The epiphyseal and metaphyseal arterial supply is richer than the diaphyseal supply
636 zz Normally Humerus has Retroversion of 30o [ 25-35o]
zz Normally Femur has Anteversion of 8-15o
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TABLE:  Hormones Involved in Bone Growth and Maintainence

Hormone Primary Source Effects on Skeletal System

Orthopedics
Calcitriol Kidneys Promotes calcium and phosphate ion absorption along the
digestive tract
Growth hormone Pituitary gland Stimulates osteoblast activity and the synthesis of bone
matrix
Thyroxine Thyroid gland With growth hormone, stimulates osteoblast activity and the
(follicle cells) synthesis of bone matrix
Sex hormones Ovaries (estrogens) Stimulate osteoblast activity and the synthesis of bone
Testes (androgens) matrix; estrogens stimulate epiphyseal closure earlier than
androgens
Parathyroid Parathyroid glands Stimulates osteoclast (and osteoblast) activity: elevates
hormone calcium ion concentrations in body fluids
Calcitonin Thyroid gland (C cells) Inhibits osteoclast activity; promotes calcium loss by kidneys;

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reduces calcium ion concentrations in body fluids
Best site for bone formation:

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zz
 In normal adult bone is HOWSHIP’S LACUNAE
In a Fractured bone is Inner periosteal cambium layer.

es


Osteomyelitis ot
MC causative organism
N
zz

overall and in immunocompromised and post traumatic / post surgical Staphylococcus.

EE

in sickle cell anemia patients Salmonella

drug abusers Anaerobes in diabetic ulcer Pseudomonas aeroginosa

M

zz lower end of femur > upper end of tibia is the Most common location in children; and thoracolumbar
spine in adults
PG

zz Infection always starts in metaphysic because of rich blood supply, hair pin bend vessels and
defective phagocytosis
zz Loss of soft tissue planes is the first change seen in
y

Xray (Xray in <24 hours is normal)

M

zz First bony change in Xray is Periosteal reaction seen

on 2nd week
zz Detected earlier in MRI (Marrow changes in
Metaphysic seen best with MRI)
zz Morrey and Peterson’s Criterion → for diagnosis
of acute osteomyelitis
zz Cierney and Miller classification → for chronic
osteomyelitis
zz Sequestrum: Avascular piece of bone surrounded
by granulation tissue, pathognomonic of chronic
osteomyelitis
637
Figure: Sequestrum [2018]

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zz Involucrum: dense sclerotic new bone

Ring sequestrum Seen in amputation stump
surrounding the sequestrum
Orthopedics

and insertion site of

zz Brodie’s abscess: long standing pyogenic Schanz pin or Steinmann
abscess in the bone gets walled off with pin
sclerotic margins; most common site is Tubular sequestrum Seen in Diaphyseal
upper end of tibia Osteomylitis
zz Garre’s osteomyelitis: non suppurative, Sand like sequestrum Viral Osteomylitis
sclerosing, chronic osteoyelitis characterised Feathery sequestrum TB osteomylitis
by marked sclerosis and cortical thickening.
Coke like/ Black Actinomycosis
MC site- Mandible.
sequestrum
zz Antibiotics are given for 6 weeks
zz PAPRIKA SIGN: Appearance of blood on reaching healthy bone during removal of sequestrum
for treatment.
zz Tom smith arthritis → Pyogenic infection of Infancy, Hypermobile Hip due to complete destruction

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of femoral epiphysis.
Jaccoud’s arthritis: Non erosive arthritis occuring in SLE

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zz

Tuberculosis of Bones and Joints

zz

es
Most common site of skeletal TB: spine (Affects both Disc + Disc space)
ot
zz Usually Lung is the primary site
N
zz Most common location of Pott’s spine: Dorsolumbar region
zz Paradiscal type > Central (vertebral body) > Anterior > Appendiceal / posterior Earliest feature
EE

of spinal tuberculosis is reduction of intervertebral space

zz Most common clinical feature of spinal TB is kyphosis
Alderman’s gait is seen in TB affecting dorsolumbar spine
M

zz

zz 1st radiological sign of active Tubercular arthritis is Localised Osteoporosis.

PG

zz Tuberculosis with polyarthritis is known as Poncet’s disease

zz Tuberculosis of shoulder is dry with no effusion – Caries sicca
zz TB dactylitis is also known as spina ventosa
y

zz Most common site affected in TB hip is roof of acetabulum

M

zz Radiological features : mortar pestle appearance, wandering acetabulum, protrusio acetabuli etc
zz Phemister triad of tubercular arthritis includes juxtaarticular osteoporosis, peripheral osseous
erosions and narrowing of joint space
zz Triple deformity is seen in Tuberculosis of knee which includes: flexion, + external rotation of tibia
+ posterior subluxation
zz Fibrous ankylosis is seen in infections like TB.
zz ANEURYSMAL SIGN is (+) in X ray Pott’s spine
TULI'S CLINICAL STAGING OF POTT S PARAPLEGIA
• Grade I: No symptoms only signs
• Grade II: Clumsiness, incordination, spasticity. Manages to walk with minimum support. No sensory
complaints.
• Grade Ill: not able to walk. Paraplegia in extension. Partial sensory loss.
638
• Grace IV: paraplegia in flexion. Sphincter disturbances. Complete loss of sensation.
• Finally: Flaccid Paraplegia
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Orthopedics
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zz Most consisTent sign of Fracture → Tenderness remember them by spelling them
Most Pathognomic sign of Fracture → CrePitus by stressing on letters in bold
zz
ot
zz Surest sign of FractureloSS of tranSmitted movement
N
zz 1st radiological sign of Union → Provisional/ Soft callus
zz 1st Clinical sign of Union woven bone / Hard callus
EE

zz MC bone to fracture overall/ newborn/ delivery → Clavicle

zz MC carpel bone to get fractured → Scaphoid
zz MC tarsel bone to get fractured → Calcaneum.
M

zz Most common bone to get fractured in fall on outstretched hand is radius[2018]

zz MC site of spinal #/ Compression # → D12
PG
y
M

639

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IMPORTANT POINTS ABOUT VARIOUS SKELETAL DISEASES

Orthopedics

Paget’s Disease [POPCHIC Maal]

zz Pelvis MC site
zz Osteosclerosis +, Osteosarcoma risk
zz Picture frame vertebra
zz Candle flame/ Blade of grass appearance
zz High output cardiac failure is a complication
zz Ivory vertebra
zz Cotton ball appearance Figure:  Mosaic pattern in Paget’s disease
zz Mosaic pattern in bone marrow biopsy[2018]

Madelung Deformity

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zz Failure of normal growth of medial & palmer halves of distal radial physis
zz Ulna is relatively long and prominent dorsally

es
zz Wedge shaped Wrist bones
zz 1o locus of Madelung deformity is Distal end Radius. ot
Osteoarthritis Rheumatoid Arthritis
N
• Degenerative (shows sclerosis in X-ray) • Inflammatory(shows rarefaction in X-ray)
• Osteophytes+ • Osteophytes
HD
• Small joint affected • Large joint affected
EE

(High definition)
• MCP and wrist soared • DIP usually spared.
Heberden - DIP
• Elderly affected • involves cervical vertebra
• Heberden nodes → Distal IP BP • Middle aged female
M

joint (Blood pressure) • ESR, CRP, RA↑

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• Bouchard nodes → Proximal IP Bouchard PIP • Boutoniere deformity → Flexion contracture

joint. at PIP & extension at DIP. seen in inflammatory
conditions like Rheumatoid arthritis.
• Swan neck deformity → Hyperextension of PIP
y

& Flexion at DIP. seen in inflammatory conditions

M

like Rheumatoid arthritis.

• Windswept deformity

Perthes Disease/Coxa plana

zz MC in males
zz AVN of femoral epiphysis, Widening of femoral neck
zz Increased medial joint space
zz metaphyseal cysts and rarefaction
zz ABduction, Internal rotation and Extension are limited
zz 4-8 years are affected [Explained by TRUETTA'S HYPOTHESIS]
zz GAGE sign+
640
zz Sagging Rope sign+ Figure:  Cotton wool skull of Pagets disease

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CTEV

Orthopedics
zz Articular malalignment + Contracted Poster0-medial soft tissues
zz Occurs in 1 in 1000 live births[MC congenital foot deformity], MC in Males.
zz 1o clubfoot is MC due to Idiopathic reasons
zz 2o Clubfoot occurs due to Paralytic disorder and Arthrogryposis Multiplex congenital.
zz Diagnosed by viewing Kite’s angle of <35o X ray of Foot [ Normally >35o]
zz Pirani Score → a simple easy to use tool for assessing severity of Clubfoot
Till 1 year Ponset’s serial manipulation + casting in order of Cavus → Adduction → Varus → Equinus
old [otherwise will result in Rockerbottom Feet]
Maintainance by CTEV shoes (if child is walking) or Dennis brown Splint (if child hasn’t
started walking)
1-5 years Postero medial soft tissue release[PMSTR] → Lenthen tendoachilles and release talofibular
old and calcaneo fibular ligaments

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5-10 years PMSTR + Bony Osteotomies[ Dilwyn Evan’s procedure(Calcaneo cuboid fusion) or Wedge

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old Tarsectomy]
>10 year old Triple Arthrodesis

es
Developmental Dysplasia of Hip[DDH]
zz Risk factors are :Female, First born, famalial, Breech presentation and oligohydramnios
ot
zz Occurs due to shallow acetabulum and excessively anteverted Femoral neck
N
zz Limb is in ADduction, Internal rotation and Flexion
zz Ortolani test - For dislocated hip, May be (+)
EE

zz Barlow test- for dislocatable hip

zz Waddling gait is seen
Galleazi/Allis sign (+)
M

zz

zz Klisic test (+)

PG

Pyle Disease

zz Also called as PYLE COHN syndrome/Bakwin Krida syndrome

y

zz AR disorder
M

zz Mild Genu Valgum

zz Mental and Physical development is Normal
zz Dental caries & prognathism present
Osteogenesis Imperfecta/Brittle Bone Disease/Vrolik’s
Disease

zz Both intramembranous and enchondral ossification is affected

zz Multiple pathologic long bone fractures in different stages of healing
zz Dysmorphic Triangle shaped facies and Blue sclera
zz Poor and delayed dentition
zz No local signs of violence or trauma [as in battered baby syndrome]
zz Fracture location in Xray is Diaphyseal Figure:  Osteogenesis Imperfecta 641
zz Silence Classification and Shapiro classification are applied for classifying the disease.
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Osteopetrosis/Marble Bone Disease/Albert Schonberg’s Disease

Orthopedics

zz Occurs due to excessive bone deposition due to failure of Osteoclastic

resorption.
zz ↑ bone density
zz Bone within Bone appearance
zz Rugger jersey spine
zz Benign form → AD inheritance → doesn’t need treatment unless
there is a fracture.
zz Malignant form → AR inheritance → treated with BM transplantation

Other Important Points

zz Trigger finger → affects MCP

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zz Jersey finger → Avulsion of FDP from Volar aspect of base of distal Phalynx.

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zz Mallet Finger → Avulsion of central slip of Extensor tendon from dorsal aspect of base of distal
Phalynx.
Gamekeeper’s / Skier’s Thumb → Avulsion of Ulnar carpel Ligament from base of 1st MCP joint

es
zz

due to forceful outward deviation

Cubitus vaLgus # Lat condyle humerus/Jupiter's fracture.
zz →
ot
zz Cubitus Varus- MC deformity after fracture SCH
N
zz Looser zones are hallmark of Osteomalacia.
zz Bag of bones appearance is seen with Neuropathic arthropathy/ Charcoat’s joint.
EE

zz Cinema theatre sign is seen with Chondromalacia Patellae

zz Anterolateral Port in Arthroscopy is for Vision (Remember it as Right handed surgeon opearting
M

on right knee of patient)

zz Arthroscope has an angle of 30o and diameter of 4mm.
PG

zz Bisphosphonates are DOC for Paget’s disease and Osteoporosis.

zz Zolendronate is most potent and Longest acting Bisphosphonate
zz SYNOVIAL FLUID
y

 It is an ultrafiltrate of plasma
M

 Has no clotting factors

 Secreted by Type B cell of Intima of Synovium by “STRING PHENOMENON”
 0-300/mm3 → Normal WBC count
 300-3000 → Degenerative arthritis
 3000-1 lac → Inflammatory arthritis
 >1 lac → Septic Arthritis.

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Specific x Ray Spine Appearances of Some Diseases

Orthopedics
BAMBOO SPINE VERTEBRA SQUARING OF VERTEBRA

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Ankylosing spondylitis Ankylosing spondylitis

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es
ot
N
EE

H-SHAPED
M

VERTEBRA SEEN IN
IVORY VERTEBRA
CODFISH VERTEBRA Sickle cell disease
PG

Paget's disease and

Osteoporosis, & SCD
Lymphoma
y
M

PICTURE FRAME VERTEBRA
Paget's disease
SCHMORI’S NODES
Indentations of the IV discinto
the end plates of the vertebral
RUGGER JERSEY SPINE bodies
Renal Osteodystrophy and
Osteopetrosis
643

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Orthopedics

VERTEBRA PLANA
H-Histiocytosis X
O-Osteochondritis
T-TB
Maal-Mets, MM,
Ewings
H-Hemangioma
L-Leukemia,
Lymphoma
T-Trauma
CORDUROY CLOTH APPEARENCE
Haemangioma of vertebra, usually cavernous;
vertically striped orientation of bone trabeculae

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• TRUMPET SIGN → (enlargement of nerve root secondary to
edema) → Disc herniation
• Beheaded scottish dog appearance → spondylolisthesis

es
• Jigsaw Vertebra/ Tumbling block spine → Charcoat Joint(due
to Multiple#)
ot
• TROLLY TRACT SIGN → Ankylosing Spondylitis
N
SCOTTISH DOG APPEARENCE
EE

Inter-peduncular region in oblique view of

spine, in a normal vertebra
M

Disease and Most Common Joint Involvements

PG

Disease Joint involvement

Actinomycosis Mandible
y

Amyloidosis Peroneal muscle atrophy

M

Ankylosing spondylitis Sacroiliac joint

Diabetes Midtarsal (most common) > tarsometatarsal > MTP
Gout MP joint of big toe
Leprosy Hand and foot joints
Myelomeningocele Ankle and foot
Paget’s disease Pelvis
PSEUDOgout Knee Remember it as Pseudo HOST MC
Hemophilic arthropathy Knee (ankle in children) in Knee

Osteochondritis dissecans Knee

Septic arthritis Knee
Tabes dorsalis Knee (most common) > hip
644
Syringomelia Shoulder, elbow

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Fathers of Pioneers/First To Use or Describe

Orthopedics
Orthopedics Nicolas Andry Barton’s Fracture John Rhea Barton
Modern Orthopedics Robert Jones[ Nephew Colle’s fracture Abraham colles
of H O Thomas] Distraction Osteogenesis Gavriil Abramovich
Antisepsis Joseph Lister ILIZAROV
Arthroplasty/Joint Sir. John Charnley Jaipur foot P K Sethi
replacement surgery JESS[Joshi’s External B B Joshi
Arthroscopy Masaki Watanbe stabilising system]
Internal fixation Albin Lambotte K wire Martin Kirschner
Orthopedic oncology William F enneking Küntscher’s Nail Gerhard Küntscher
Sports orthopaedics Galen Plaster of Paris Antonius Mathijsen
Traumatology/Trauma Lorenz Bohler Ponseti method Ignacio Ponseti

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surgery X ray William C Roentgen

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Nerve Trauma Effect/tests +

es
Anterior interosseous nerve Supracondylar fracture of humerus Kiloh nevin sign
Axillary nerve Dislocation of shoulder (Anterior
ot Deltoid palsy Regimental badge palsy
and inferior)
Common peroneal nerve Knee dislocation / Fracture of neck Foot drop
N
of fibula
Median nerve Supracondylar fracture of humerus Pointing index finger, Ape thumb
EE

deformity, Pen test

Posterior interosseous Monteggia fracture Finger drop
M

nerve
Radial nerve Fracture shaft of humerus(lower Wrist drop
PG

third)
Sciatic nerve Posterior dislocation of hip Foot drop
Ulnar nerve Fracture medial epicondyle of Claw hand, Froment’s sign/Book test,
y

humerus Jeanne sign, Egawa test, Card test

M

Entrapment Syndrome Nerve Involved

Carpal tunnel syndrome
Cheralgia parasthetica
CUbital tunnel syndrome
GUyon’s canal syndrome
Meralgia paraesthetica
Morton’s metatarsalgia
Piriformis syndrome
Pronator syndrome
Tarsal tunnel syndrome
Thoracic outlet syndrome
Median nerve (at wrist)
Superficial radial nerve
Ulnar nerve (between two heads of flexor carpi ulnaris)
Ulnar nerve (at wrist)
Lateral cutaneous nerve of thigh
Interdigital nerve compression (usually of 3rd and 4th toe)
Sciatic nerve
Median nerve
Posterior tibial nerve (behind and below medial malleolus)
Lower trunk of Brachial plexus (C8, T1)- between clavicle and 1st rib 645

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Tests Done For

Orthopedics

Adson test Thoracic outlet obstruction

Belly press test, Lift off test Subscapularis
bryANT’s test ANTerior dislocation of shoulder
Bryant’s Triangle Supratrochanteric shortening
Chiene’s test, Nelaton’s line, Shoemaker’s line Supratrochanteric shortening
Cozen test Tennis elbow
Jobe test Supraspinatus
McMurrey, Apley’s Grinding test Meniscal tear
Ortolani test[to examine & reduce dislocated hip] Developmental Dysplasia of Hip
Barlow test [to examine Dislocatable hip]
Galleazi sign
Speed test, yergason Biceps

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Squaring of Pelvis Adduction/Abduction deformity

Marfan’s syndrome

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Steinberg’s thumb signal test
M
Walker urdoch Wrist sign
Telescoping + in DDH

es
Thomas test Fixed flexion deformity
Trendlenburg test
ot
Failure of abductor mechanism
Valgus test Medial collateral ligament
N
Verus test Lateral collateral ligament

Plaster Casts and their Uses

EE

Name of the cast Use

M

Colle’s cast Fracture lower end of radius

Cylinder cast/Tube cast Fracture of patella
PG

Glass holding cast Fracture scaphoid [Dorsiflexion & Radial deviation]

Hip spica Fracture of femur
Minerva cast Cervical spine disease
y

Patellar Tendon Bearing cast Fracture of tibia

M

Risser’s cast Scoliosis

Shoulder spica Shoulder immobilization
Thumb spica splint Scaphoid fracture / Metacarpal fracture / Game keeper’s thumb
Turn-buckle cast Scoliosis
U slab / Hanging cast Fracture of humerus
• COLLE’S CAST → 10o-20o palmer flexion and 15o -20o ulnar flexion
• PLASTER OF PARIS → Hemihydrous CaSO4
ƒƒ Not applied on extreme swelling

ƒƒ Complications:
ff Gangrene
ff Compartment syndrome (>30mm Hg pressure--> fasciotomy (skin + SC Tissue+ superficial fascia +
deep fascia is cut)[2018]
646
ff Plaster sores

ƒƒ Warm water hastens & Cold water slows setting time.

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Common Splints/Braces/Tractions and Their uses

Orthopedics
Name Use
90 -90 Femoral traction
o o
fracture shaft femur in 10-15 year old children
Aeroplane splint Brachial plexus injury
Bohler-Braun splint Fracture Femur, Knee, Tibia
Buck’s traction Conventional skin traction
Buddy strapping Phalangeal injuries
Cock up splint Radial nerve palsy
Crutch field traction Cervical spine injuries
Dennis Brown splint CTEV
Dunlop, Smith traction Supracondylar fracture of humerus

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Figure of 8 Bandage Clavicle
Gallow’s tracton Fracture shaft of femur in children <2years

,1
Gutter splint Phalangeal and metacarpal fractures
Knuckle bender splint Ulnar nerve / Median nerve palsy

es
Lumbar corset Backache
Perkin’s traction Fracture shaft of femur in adults
ot
Splint russel traction fracture shaft femur in 2-10 year old children
N
Thomas splint Fracture femur and knee immobilization
Volkmann’s splint / Turn buckle splint Volkmann’s ischemic contracture
EE

• Functional bracing done for # humerus

• Pelviacetabular # are associated with High Morbidity and mortality
• Scaphoid ossification appears in 4-6 years
M

• MCC of AVN Hip- Idiopathic.

PG

Bursitis

Bunion Medial side of great toe (1stmetatarsal head bursitis)

y
M

Bunionette 5th toe of foot (5th metatarsal head bursitis)

Clergyman’s knee Infrapatellar bursitis
Housemaid’s knee Prepatellar bursitis (commonest)
Morrant Baker cyst / Popliteal Pressure diverticulum of synovial membrane
cyst Prominent on extension and reduced on flexion
Secondary to Osteoarthritis/Rheumatoid arthritis/Meniscal injury
Soft and fluctuant swelling with no transilluminancy
Student’s elbow / Miner’s elbow Olecranon bursitis
Tailor’s ankle Lateral malleolus bursitis
Tubercular bursitis Trochanteric bursa > Bursa anserine > Compound palmar bursa
Weaver’s bottom Ischial bursitis

647

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Classifications
Orthopedics

SPINE
Anderson and Occipital condyle #
Montisano
Anderson and D'Alonzo Occipital condyle
# (Type-II is most
dangerous)
Levine & Edwards Hangman’s fracture
[Traumatic spondylisthesis
of Axis] WINQUEST AND HANSEN CLASSIFICATION-
# shaft Femur
Allen classification Teardrop fractures
Anatomical
McAfee Thoracolumbar spine #
Denis Sacral fractures

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SHOULDER AND UPPER LIMB

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Craig CLavicLe
aLLman
SHOULDER AND UPPER LIMB

es
Mateson Recurrent shoulder ot
dislocation.
Neer’s Fracture proximal
N
humerus
AO classification Fracture diaphysis
EE

humerus # Neck of Femur

Riseborough and Radin Intercondylar # Humerus Evans Intertrochanteric #

Mehne & Matta’s Boyd’s & Griffiths Femur
M

Gartland # Supracondylar humerus Fielding Subtrochanteric # femur

Seinsheimer
PG

Milch # lateral condyle Humerus

Snowdy’s Stress# Neck of Femur
Bado Monteggia #
Letts’ Epstein Anterior hip dislocation
Thompson & Epstein Posterior hip dislocation
y

Frychmaan, Colle’s fracture

Melone’s, Pipkin’s Femoral head #
M

Fernendes Fractures in Children

Modified Thomas Smith # Delbet Pediatric Hip #
Mason’s # head of Radius Delbet & collana’s # proximal femur in
Russe Scaphoid # children
PELVIS AND LOWER LIMB
Ruedi’s & Allgower’s Pilon’s #
Pappa’s
Tile’s # pelvis
Hawkin’s # neck of talus
Essex Lopresti # calcaneum
648 Souer And Remy
Sander’s
Salter harris classification-Physeal injury

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PERIPROSTHESIS FRACTURES Angles, Triangles and Arcs

Orthopedics
Vancouver Classification Periprosthetic Hip #
Johansson Classification Bohler’s angle # calcaneum
Cooke And Newman (decreases in
fracture calcaneum)
Lewis and Rorabeck Periprosthetic Knee #
Gissane’s angle
Classification
(increases in
Neer Classification,
fracture calcaneum)
With Modification by
Merkel Powel’s angle, # neck of Femur
Garden’s angle
Osteochondritis of Different Bones Bowman’s angle Supracondylar # humerus
Fairbank's angle Infantile coxa vara
BlounT’s Tibia Mc Laughlin’s line # head of Radius
Frieberg 2nd metatarsal head Cobb’s Angle Scoliosis

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Haas Head of Humerus Kite’s angle CTEV
I5lene 5 metatarsal base Q angle Recurrent patellar dislocation

,1
th

Johansen-Larsen’s lower pole of patella K angle, Dickson’s Pott’s spine

KieNbock LuNate angle

es
KohLER NavicuLAR Hilgenreiner angle Coxa vera
Osgood Schattler Tibial tuberosity Shenton’s arc Medial aspect of Head & Neck
ot
Panner’s Capitulum of elbow of Femur to Inferior margin
N
Perthes Femoral head of Superior Pubic ramus
[Broken in supratrochanteric
PrieSer’s Scaphoid pathologies]
EE

Scheurmann Ring epiphysis of vertebra

Babcock’s triangle # neck of Femur / TB
Sever’s Calcaneum
Hip[starting point]
M

Ward’s triangle Neck of Femur/ Grading of

osteoporosis
PG

Meary’s triangle Pes cavus/planus

Dennis Three Column Concept of Spinal Stability

y
M

649

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ORTHOPAEDICS ONCOLOGY
Orthopedics

MOST COMMONS MOST COMMON SITES

Chondrosarcoma Commonest malignant AdamanTinoma Tibia
bone tumor of flat bone Ameloblastoma Mandible
Hemangioma (striated Most common benign Aneurysmal bone cyst Lower end metaphysis
vertebra seen) tumor of spine (Tibia and femur)
Ivory osteoma / Commonest tumor of skull Chondrosarcoma Pelvis
Compact osteoma vault
Enchondroma Short bones of hand
Multiple myeloma Most common primary
Ewing’s sarcoma Femur
malignant bone tumor
Fibrous dysplasia Craniofacial
Neuroblastoma Most common cause of
(polyostotic); Upper
secondaries in children

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femur (monostotic)
Osteoid osteoma Commonest true benign
Multiple myeloma Lumbar vertebra

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tumor
Osteoblastoma Vertebrae
Osteosarcoma Second most common
Osteochondroma Distal femur

es
primary malignant bone
tumor Osteoclastoma Lower end of femur
Secondaries Most common bone Osteoid osteoma Femur > Tibia
ot
tumors Osteoma Skull and facial bones
N
Enchondroma MC benign tumor of hand Unicameral bone cyst Upper end of humerus
EE

CLASSICAL RADIOLOGICAL FEATURES

Ground glass appearance Fibrous dysplasia
M

Homogenous calcification Osteogenic tumors

PG

Onion peel appearance Ewing sarcoma

Patchy calcification Chondrogenic tumors
Soap bubble appearance Osteoclastoma, Adamantinoma
y

Sun ray appearance / Codman’s triangle Osteosarcoma (not specific)

M

Location of Bone Tumors

zz Enneking classification system is used for classification of bone tumors

EPIPHYSEAL METAPHYSEAL DIAPHYSEAL
• Chondroblastoma • Osteosarcoma • AdMANtinoma
• Osteoclastoma / Giant cell tumor • Ostoblastoma • Multiple myeloma
• Articular osteochondroma • Enchondroma • Osteoid Osteoma
• Clear cell chondrosarcoma • Osteochondroma • CHondrosarcoma
• Ewing’s sarcoma

650

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Benign Bone Tumors

Orthopedics
Chondroblastoma/Codman”S Tumor

zz Arises from epiphysis of a long bone, usually

upper end Humerus.
zz Calcification present giving ‘chicken wire
appearance’ in histopathology studies.

Enchondroma

zz Most common tumor of small bones of hands and feet

zz Arises from remnants of epiphyseal cartilage
Biopsy shows presence of Hyaline cartilage.

/e
zz

zz Ollier’s disease: nonfamilial multiple enchondromas [Only enchondroma-Alone-only-no family]

,1
zz Maffucci syndrome: familial multiple enchondroma with cavernous hemangiomas and phlebolith
[Multiple problems-multiple-many-famalial)]

es
Fibrous Cortical Defect
MC benign lesion of Bones
zz
ot
zz Affects metaphysic usually in 1st decade.
N
zz Self resolving.

Osteochondroma (Exostoses)
EE

zz MC benign growth of bones.

Diaphyseal achlasia, a developmental malformation
M

zz

zz Arises from metaphyses of long bones

PG

zz MCC is Overlying bursitis.

zz Mature bone with cartilaginous cap seen
zz Treatment if indicated is extra periosteal resection of the tumo[removing
y

tumor + periosteum]
M

zz Trevor’s disease: Osteochondroma on epiphyseal side of growth plate

Osteoclastoma/Giant Cell Tumor

zz Affects epiphysis of long bones (MC – distal femur)
zz Mostly benign
zz Egg shell crackling on palpation
zz Soap bubble lesion on X-ray
zz Malignancy in GCT Osteosarcoma / Malignant fibrous Histiocytoma /
Fibrosarcoma
zz Tumors with giant cells: Brown tumor, Aneurysmal bone cyst, Non ossifying Figure:  Soap Bubble
fibroma (MC), MFH, Fibrosarcoma, Clear Cell Chondrosarcoma [BAN MFC appearance-Osteclastoma
Chicken chilly] 651
zz Goltz syndrome: Multiple Giant cell like bone tumor
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Osteoid Osteoma
Orthopedics

zz MC benign tumor of bones

zz Affects diaphysis of long bones
zz Pain worse at night RELIEVED BY ASPIRIN
zz X-ray shows radiolucent nidus surrounded by sclerosis

Unicameral Bone Cyst (UBC)/Simple bone cyst(SBC)

zz Age & sex prediliction: 5–15 years, more common in Males

zz Involves Proximal humerus Most commonly followed by proximal femur
zz Detected incidentally except in cases with pathological fracture where
patient presents with pain
zz The fallen fragment sign seen in X-ray stands for presence of a bone

/e
zz Fragment in the dependant portion of cyst ( Occurs due to fluid filled
in space of cyst)

,1
zz Usually resolve spontaneously, those not resolving need total excision and
bone grafting

es
Aneurysmal Bone Cyst (ABC) ot
zz Age & sex prediliction : 10–20 years, Slightly more common in females
N
zz Involves metaphysis of long bones.
zz Presents with Pain and swelling + pathological fracture.
EE

zz "Finger in Balloon" sign seen in X-ray

zz Surgical excision and bone grafting is the treatment of choice
M
PG

Malignant Bone Tumors

Chondroma
y
M

zz Arises from notochordal remnants

zz MC seen in sacrum
zz PHYSALLIFEROUS CELLS are Present
zz 2nd MC malignancy of spine after MM

Enchondroma

zz Most common tumor of small bones of hands and feet

zz Arises from remnants of epiphyseal cartilage
zz Ollier’s disease: nonfamilial multiple enchondromas
zz Mafucci syndrome: familial multiple enchondroma with cavernous hemangiomas and phlebolith
652

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Ewing’s Sarcoma

Orthopedics
zz Affects boys <15 years
zz Arises from diaphysis of long and flat bones (pelvis)
zz Arises Marrow cells
zz Onion peel appearance (characteristic)
zz Sunray appearance & Codman's triangle may also be seen
zz > 15 year at presentation, male gender and distant metastasis
are poor prognostic factors
zz Highly radiosensitive tumor but best results with combination of
chemotherapy + wide excision + postoperative radiotherapy Figure:  Onion Peel Diaphysis- Ewing’s Sarcoma

Osteosarcoma

/e
zz 2nd MC primary malignant bone tumor [MC is Multiple Myeloma]
zz occurs MC in 10-25 years age group

,1
zz Predisposing factors: Paget’s disease of bone, Familial Retinoblastoma, Bone infarcts, Radiotherapy
zz Affects metaphysis of long bones

es
zz MC metastasises to lungs
zz Xray appearances:
ot
N
EE
M
PG
y
M

Lytic lesion moth eaten Sunburst appearance Codman's triangle

appearance

zz Extremely radioresistant
zz Rosen T-10 protocol used in chemotherapy

Synovial Cell Sarcoma

zz Occurs due to Characterstic translocation [X:18] → SVT-SSX fusion genes
zz Has mesenchymal + Epithelial component → Biphasic tumor
zz Misnomer → does not involve synovium. 653

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Eponymous Fractures
Orthopedics

BENNET’S FRACTURE
Oblique intra articular # BOSWORTH FRACTURE
of base of 1st metacarpal Fracture-dislocation of the ankle BOXER’S FRACTURE
with subluxation of 1st carpo in which there was fracture of the Ventrally displaced # through neck

/e
metacarpal joint fibula and posterior dislocation of of 5th metacarpal
the talus

,1
es
ot
N
JONE’S FRACTURE
BARTON’S FRACTURE
avulsion # of base of 5th tarsal
EE

Displaced articular lip fracture BURST FRACTURE

of the distal radius. It may Fracture of the vertebral body
be associated with carpal from axial load, usually with
M

subluxatioin outward displacement of the

fragment
PG
y
M

CHOPART’S FRACTURE AND

CHAUFFER’S FRACTURE DISLOCATION
CHANCE FRACTURE # of radius just above the styloid Fracture and/or dislocation
Horizontal # through vertebral process, Intrarticular fracture involving Chopart’s joints
body (talonavicular and calcaneocuboid)
of the foot.

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Orthopedics
CLAY-SHOVELER’S (COAL- COLLE’S FRACTURE
SHOVELER’S) FRACTURE Distal end of radius # with posterior displacement
Spinous process fracture of the
lower cervical or upper thoracic
vertebrae

/e
,1
GALEAZZI FRACTURE

es
# distal third of radius with dislocation of distal RUJ
ot
N
COTTON’S FRACTURE
Trimalleolar # ankle
EE

GREEN STICK FRACTURE bending of bone with incomplete Transverse # involving convex side of
curve only
HANGMAN’S FRACTURE Traumatic spondylolisthesis of C2
M

HOFA'S FRACTURE Coronal fracture in distal femur, is Intrarticular

JEFFERSON’S FRACTURE
PG

Burst fracture of atlas (MC # of Atlas)

JUMPER'S FRACTURE Lateral condylar fracture of Humerus
JUPITER'S FRACTURE Fracture Sacrum with H/V shaped fracture line
BUMPER FRACTURE Comminuted depressed # of lateral tibial condyle
y
M

LISFRANC FRACTURE
# dislocation of Tarsometatarsal
joint MONTEGGIA’S FRACTURE
# of proximal third of ulna with dislocation of head of radius
[Remember it as Monteggia → Blow to Medial bone (Ulna) from
Medial side]
655

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MALGAIGNE FRACTURE I/L # of pubic rami anteriorly + sacroiliac joint disruption posteriorly
Orthopedics

MARCH FRACTURE Fatigue # of shaft of 2nd & 3rd metatarsal

NIGHTSTICK FRACTURE Isolated fracture of the ulna secondary to direct trauma
PIEDMONT FRACTURE closed # of radius at the junction of middle and distal thirds
PILON FRACTURE comminuted # of tibial articular surface with # of tibia
POND’S FRACTURE depressed fracture in skull of infants
POSADAS" FRACTURE Transcondylar humeral fracture with anterior displacement of distal
fragment and dislocation of radius and ulna

/e
,1
POTT’S FRACTURE
bimalleolar # ankle

es
ROLANDO FRACTURE SEGOND'S FRACTURE
Three part # (Comminuted) of
ot Avulsion fracture of lateral tibial
base of 1st MC condyle from the bony insertion of
Iliotibial band
N
SHEPHERD'S FRACTURE Fracture of lateral tubercle of the posterior talar process
EE

SMITH’S FRACTURE reverse of Colle’s fracture

STIEDA'S FRACTURE avulsion fracture of medial femoral condyle at origin of medial collateral
ligament
M

STRADDLE FRACTURE B/L superior & Inferior pubic rami # in pelvis

TEARDROP FRACTURE
PG

Flexion fracture/Dislocation of cervical spine with Triangular anterior fragment

of involved vertebra
TILLAUX FRACTURE Fracture of lateral half of distal Tibial epiphysis with medial part already fused
TORUS FRACTURE Impaction fracture of childhood, bone just buckles instead of fracturing
y

completely
M

WALTHER'S FRACTURE Ischioacetabular fracture passing through pubic rami and extending to
sacroiliac joint with inward displacement of medial wall of acetabulum

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MISCELLANEOUS TOPICS

Orthopedics
Shoulder Dislocation

zz MC Joint to undergo traumatic and recurrent dislocation

ANTERIOR DISLOCATION POSTERIOR INFERIOR DISLOCATION
DISLOCATION
• MC type of dislocation(90%) • occurs due to force • called Luxatio erecta
• Types: producing marked with Humeral head
ƒƒ Subcoracoid(MC) Internal rotation and subluxation
ƒƒ Subglenoid ADduction • occurs due to Severe
ƒƒ Intrathoracic • Signs observed are : ABduction force
• occurs due to force causing abduction and External ƒƒ Light bulb sign • Treated with
rotation ƒƒ Positive rim sign reduction under

/e
• Most commonly causes Axillary nerve injury ƒƒ Vacant glenoid sign General anesthesia
• Lesions are: • Treated with

,1
ƒƒ Bankart's lesion reduction under
ƒƒ Hilsach's lesion General anesthesia
• Tests done are:

es
ƒƒ Bryant's test
ƒƒ Callaway's test
ƒƒ Duga's test
ƒƒ Hamilton ruler test
ot
• Treatment:
N
ƒƒ Hippocratic method
ƒƒ Kocher's method
ƒƒ Stimson's gravity method
EE

BANkart's lesion Hilsach's lesion

M

 Injury to ANtero-inferior  injury in form of cortical depression in Postero-

glenoid labrum lateral Head of Humerus due to injury by
PG

 due to ANterior dislocation of antero-inferior glenoid rim

shoulder  due to Anterior dislocation of shoulder.
y

HIP DISLOCATIONS
M

Features Anterior Posterior (Most Central

common)
occurs due to dashboard injury direct force on
trochanter
position of Femoral head groin gluteal region perrectal
Thus, palpated on PR
examination
deformity Flexion Flexion remains in position
ABduction ADduction without any changes
External Rotation Internal Rotation
hip movement decreased increased decreased
nerve injured femoral sciatic
657
vascular sign of narath negative positive negative

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Elbow Disloaction
Orthopedics

zz Second MC joint to undergo dislocation

zz occurs due to fall on outstretched hand
zz disruption of three point bony relationship
zz Types:
 Anterior
 Medial
 Lateral
 Posterior(Most common)
 Posterolateral
 Posteromedial
zz treated with closed reduction

Carpal Dislocation

/e
zz Lunate dislocation- the lunate is dislocated in a volar direction and no longer has normal

,1
radiolunate articulation
zz Perilunate dislocation[2018]-involve dislocation of the carpus(all other Carpal bones except
Lunate) relative to the lunate but Lunaye remains in normal alignment with the distal radius

Knee Dislocation
es
ot
zz occurs due to direct impact by a force of large magnitude in the front of knee
N
zz Cruciate Ligaments+ >1collateral ligaments are torn
zz With respect to Tibia,Femur pushed Posteriorly
EE

zz ANTERIOR dislocation is Most common and is associated with Popliteal artery injury.
zz It is an Emergency thus reduced as soon as possible, keeping an eye on vascularity of limb
zz De Quervains disease- tenosynovitis of APL and EPB due to repeated gliding movements between
M

two tendons[2018]
PG

Rotator Cuff Injury

zz Muscles forming rotator cuff
Supraspinatus
y



Infraspinatus
M



 Teres Minor
 Subscapularis(forgotten muscle of Rotator cuff)
zz MC muscle affected- Supraspinatus
zz Comma Sign in Arthroscopy
zz Decreased subacromian space and Hooking of Acromian seen on X-ray
zz conservative treatment done in milder cases, while severe cases need arthroscopic repair

Impingement syndrome/Swimmer's shoulder

zz Compression of Supraspinatus between Humerus, Acromian process and Coracoacromian ligament
zz Tests used: Neer's test and Hawkin's test
zz Confirmation of Diagnosis done by MRI
658 zz Treated mainly with conservative techniques(analgesics, steroids, exercises), Acromioplasty done in cases
not responding to conservative approach
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MISCELLANEOUS IMPORTANT IMAGES

Orthopedics
DOUBLE LINE SIGN ON MRI TEAR DROP SIGN (ANKLE)
Avascular necrosis, commonly of the femoral head Ankle effusion

/e
,1
es
HEEL PAD SIGN SEEN IN ot
Acromegaly TRUMBLING BULLET SIGN
Post traumatic bone cyst
N
EE
M
PG
y

ILIAC HORNS ARE SEEN IN METACARPAL SIGN

M

Nail patella syndrome (SHORT FOURTH META CARPAL)

Turner’s syndrome

WIMBEREGER’S SIGN
(SEEN IN CONGENITAL
SYPHILIS)
Symmetrical focal
bone destruction of
the medial portion
of the proximal tibial
epiphysis
WIMBEREGER’S RING SIGN- → Denser white line
659
of calcification encircling osteoporotic Epiphysis in
SCURVY
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Orthopedics

TERRY THOMAS SIGN

Widened space between the scaphoid and lunate
bones on a frontal view of wrist secondary to
scapholunate dislocation MELORRHOESTOSIS

/e
Candle bone disease

,1
zz Bone within bone appearance → Osteopetrosis
zz Head at risk sign → Perthes disease

es
zz Licked Candy Appearance of Bone → Leprosy
zz PLAIN X-RAY FINDING OF OSTEOMYELITIS DEVELOPS → 7-10 days after infection
ot
zz Sausage Finger Appearance → Psoriatic Arthritis
N
EE
M
PG
y
M

660

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