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ORTHOPEDICS
COD FISH VERTEBRAE:

The MRI of the spine shows decreased bone density with biconcave appearance of
vertebrae known as codfish vertebrae. The given clinical scenario and the MRI
findings are suggestive of osteoporosis.

A patient of osteoporosis most commonly presents with chronic back pain or

pathological fractures. The most common osteoporotic fractures are compression
fractures of vertebrae which lead to the development of kyphosis. Fractures are also
seen in the distal radius (Colles' fracture) and proximal femur.

FLUOROSIS:

The image shows interosseous membrane ossification characteristic of fluorosis.

Fluorosis stimulates osteoblastic activity, fluorapatite crystals are laid down in bone
and these are usually resistant to secondary osteoclastic resorption.

This leads to calcium retention, osteosclerosis, and osteophytosis. Ossification of

ligaments and fascial attachments is characteristic.

VON ROSEN SPLINT:

* The above image shows Von Rosen splint which is used to treat unstable hip joints
caused by congenital dysplasia.
* The splint is made of aluminium and covered with ethylene vinyl acetate which is
soft non- allergic and waterproof foam.
Thomas splint: It is a traction
splint which has a long leg splint
It is used for immobilization extending from a ring at the hip
and reduction of lower limb to beyond the foot, allowing
fractures and treatment of traction to a fractured leg.
other lower limb Used for emergencies and
pathologies. transportation.

SALTER HARRIS FRACTURE:

The fracture line shown in the above image passes through the growth plate and
epiphysis, sparing the metaphysis which is classified as type III Salter Harris fracture.
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ORTHOPEDICS
GALEAZZI FRACTURE:

* The X-ray image shows Galeazzi fracture-dislocations which consists of fracture of

the distal part of the radius with dislocation of distal radioulnar joint and an intact
ulna. Galeazzi fractures are primarily encountered in children, with a peak incidence
at age 9-12 years. Galeazzi fracture-dislocations occur due to a fall on an
outstretched hand (FOOSH) with the elbow in flexion.
Operative fixation is usually required to reduce and fix the radial fracture, with arm
immobilisation in pronation. The exact mode of fixation depends on the location of
the radial fracture:
* Diaphysis: elastic nail
* Metaphyseal-diaphyseal junction: plate and screw
* Distal radius: Kirschner wires (K-wires)

JONES FRACTURE: fracture in the meta-diaphyseal junction of the fifth metatarsal of

the foot

It is a transverse fracture at the base of the fifth metatarsal, 1.5 to 3 cm distal to the
proximal tuberosity at the meta-diaphyseal junction, without distal extension.
Mechanism: The fracture is believed to occur as a result of significant adduction force
to the forefoot with the ankle in plantar flexion.
Treatment: As displacement of the fracture can be increased with persistent weight
bearing, immobilization is important as part of the initial therapy, with a non-weight
bearing cast for 6-8 weeks.
* Internal fixation and even bone grafting may be required in cases of non-union, or
where the fracture is significantly displaced.

DUVERNEY FRACTURE: Isolated pelvic fractures involving only the iliac wing.

Mechanism of trauma: Direct Blow/trauma over the ilium. It is regarded as a stable

injury.
Diagnosis: Duverney fractures can usually be seen on pelvic X-rays, but CT scans are
required to completely delineate the fracture.
Complications:
* Malunion and deformity of the iliac wing can occur.
* Injury to the internal iliac artery can occur, which leads to hypovolemic shock.
* Perforation of the bowel may occur, which can cause sepsis.
* Damage to the adjacent nerves of the lumbosacral plexus has also been described
in some cases.

MONTEGGIA FRACTURE:

Monteggia fracture-dislocations is defined as fracture of the ulnar shaft along with

concomitant dislocation of the radial head.

Mechanism: Monteggia fracture-dislocations occur as the result of a fall onto an

outstretched hand (FOOSH).
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ORTHOPEDICS
MONTEGGIA FRACTURE:

Classification: The Bado classification is used to subdivide the fracture-dislocation

into four types
* Type I: anterior dislocation of radial head (Most common)
* Type II: posterior dislocation of radial head
* Type llI: lateral dislocation of radial head
* Type IV: anterior radial head dislocation as well as proximal third ulnar and radial
shaft fractures.
Treatment: All four types of Monteggia fracture-dislocations are treated with open
reduction and internal fixation.
* Types |, lll, IV are cast at 110 degrees of flexion.
* Type Il is cast at 70 degrees of flexion.

GARDEN CLASSIFICATION OF NECK OF FEMUR:

* Garden stage I: Undisplaced Incomplete, including valgus impacted fractures

* Garden stage II: Undisplaced Complete
* Garden stage lll: Complete fracture, incompletely displaced
* Garden stage IV: Complete fracture, completely displaced

FRACTURE OF NECK OF TALUS — Aviator’s fracture

MAISONNEUVE FRACTURE:

Maisonneuve Fracture is a spiral fracture of the upper third of fibula with disruption
of the distal tibiofibular syndesmosis and associated injuries like fracture of medial
malleolus or deltoid ligament rupture. It results from external rotation injuries.

Other named fractures

* Malagaigne’s #- fracture of pelvis having a combination of ipsilateral fracture of
pubic rami anteriorly and sacro-iliac joint disruption posteriorly.
* Pilon # - a comminuted intra-articular # of distal end of tibia and fibula.
* Straddle #- bilateral superior and inferior pubic rami fractures of pelvis.
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ORTHOPEDICS
BANKART LESION:

The X-ray radiograph shows bony Bankart lesion seen as a fracture of the
anteroinferior aspect of the glenoid.
* Bankart lesions are a common complication of anterior shoulder dislocation and are
usually seen in association with a Hill-Sachs lesion.
* They result due to detachment of the anterior inferior labrum from the underlying
glenoid as a direct result of the anteriorly dislocated humeral head compressing
against the labrum.
* The detachment may be labral only (known as "soft Bankart"), or may involve the
bony glenoid margin (impaction fracture) and this is called a "bony Bankart".
* Soft Bankart lesions are more common than bony Bankart lesions.

MALLET FINGER: - Disruption of the terminal extensor tendon distal to DIP joint.

Mechanism of injury: Traumatic impaction blow (i.e., sudden forced flexion) to the
tip of the finger in the extended position. This results in either a tear of the tendon or
the tendon pulling off a bit of bone. The disruption may be bony or tendinous.
Signs & Symptoms: Painful and swollen DIP joint following impaction injury to finger.
The fingertip is usually at rest at ~45° of flexion, with lack of active DIP extension.
Diagnosis: The diagnosis is generally based on symptoms and supported by X-
rays.The X-ray reveals bony avulsion of distal phalanx or may be a ligamentous injury
with normal bony anatomy.
Treatment: lt includes extension splinting of DIP joint for 6-8 weeks, and/or surgical
reconstruction of terminal tendon.

HILL SACHS LESION: Fracture of the base of the first metacarpal bone

* Bennet's fracture is defined as an intra-articular two-part fracture of the base of the

first metacarpal bone which may occur due to forced abduction of the first
metacarpal.
* When an intra-articular fracture of the 1st metacarpal is comminuted, producing at
least three parts, it is referred to as a Rolando fracture which has a worse prognosis.
* The fracture requires open reduction and fixation if there is significant
displacement (>3 mm).
* If malunion or non-union occurs, a pseudoarthrosis may result.

SLIPPED CAPITAL FEMORAL EPIPHYSIS: Trethowan's sign

* Klein's Line: Aline drawn along superior border of femoral neck should cross at least
a portion of the femoral epiphysis
* Trethowan's sign is positive when Klein's line does not intersect the lateral part of
the superior femoral epiphysis on an AP radiograph of the pelvis.

* Slipped capital femoral epiphysis, is a medical term referring to a fracture through

the growth plate (physis), which results in slippage of the overlying end of the
femur (epiphysis). Normally, the head of the femur, called the capital, should sit
squarely on the femoral neck. Abnormal movement along the growth plate results in
the slip.
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ORTHOPEDICS
HILL SACHS LESION:

* The above X-ray image shows Hill-Sachs lesion, which is characterized by cortical
depression in the posterolateral head of the humerus as a result of forceful impaction
of the humeral head against the anteroinferior glenoid rim due to recurrent anterior
shoulder dislocations.
* Inreverse Hill-Sachs lesion, the humeral head is dislocated posteriorly, resulting in
the anteromedial defect in the humeral head.
* In Bankart’s lesion there is injury to the anterior glenoid labrum due to anterior
shoulder dislocation.

EWING’S SARCOMA:

* The above image shows multilayered periosteal reaction, also known as a

lamellated or onion skin periosteal reaction, is characteristic feature of Ewing’s
sarcoma. It is less frequently seen in osteosarcoma.
* The periosteal reaction, demonstrates multiple concentric parallel layers of new
bone adjacent to the cortex, reminiscent of the layers on an onion.
The following are the conditions associated with onion skin appearance of the bone
* Ewing sarcoma
* Osteosarcoma
* Acute osteomyelitis
* Langerhans cell histiocytosis
* Hypertrophic osteoarthropathy

CHAUFFEUR’S FRACTURE:

The fracture shown in the X-ray radiograph is known as Chauffeur's fracture (also
known as Hutchinson fracture or backfire fracture).
Definition: Chauffeur fractures are the intra-articular fractures of the radial styloid
process.
Mechanism: The injury is typically caused by compression of the scaphoid bone of
the hand against the styloid process of the distal radius.
It can be caused by falling onto an outstretched hand (FOOSH)

Diagnosis can be made on a plain X-ray radiograph of the forearm.

Treatment: These fracture fragment is usually undisplaced but unstable. It can be
fixed by percutaneous lag-screw fixation.

JEFFERSON FRACTURE: The CT radiograph shows burst fracture of C1 vertebra.

Mechanism of Injury: It usually results from an axial load on the back of the head or
hyperextension of the neck (as caused by diving), causing a posterior break, and may
be accompanied by a break in other parts of the cervical spine.
Diagnosis: CT demonstrates the fracture line which usually involves both the
anterior and posterior arches. MRI may reveal localised soft-tissue injury, and may
also be associated with ligamentous injury.
Treatment: The fracture is treated conservatively, by hard collar immobilisation,
provided the transverse atlantal ligament is intact. In cases where the ligament is
thought to be disrupted, the injury is considered unstableand more aggressive
management techniques which include halo immobilisation, posterior C1-C2 lateral
mass internal fixation or transoral internal fixation may be done.
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ORTHOPEDICS
CLAVICULAR FRACTURE:

The middle third of the clavicle is most commonly fractured.

The middle third of the clavicle is narrowest and has the least amount of surrounding
soft tissue structures. Therefore, 80% of fractures are seen in this area.

Within the middle-third of the clavicle, the junction of the medial 3/5t" and the
lateral 2/5™ has been described to be the weakest point. Lateral third fractures are
the second most common type of clavicular fractures.

Fall on the shoulder (direct impact) and fall on the outstretched hand are the most
common causes of clavicle fracture.

DISPLACING FORCE IN FRACTURE CLAVICLE:

The lateral fragment in a clavicle fracture is displaced inferiorly due to the force of
gravity acting on the ipsilateral arm. The medial fragment is held up by the action of
the sternocleidomastoid muscle.

(Note: Both Pectoralis muscle and the weight of arm are responsible, but since the
weight of arm is superior to the muscle bulk and even as per standard reference we
would go with the rational explanation.)

INTRAMEDULLARY FIXATION OF CLAVICULAR FRACTURE:

Non-union is a relatively rare complication in clavicle shaft fracture. Malunion is the

most common complication in clavicle fractures.
The most common bone to be fractured is the clavicle. It is also the most common
bone to be fractured during birth. Neurological deficit is rare in clavicular shaft
fractures.
Undisplaced fractures are treated with a sling or figure of eight bandages for 2-3
weeks. This is followed by mobilization
of the limb as the pain subsides.

Displaced fractures are treated with internal fixation either by contoured locking
plates or intramedullary nails.

VELPEAU BANDAGE: Velpeau bandaging is done by keeping the patient's elbow

flexed and the forearm placed against the chest. A sling is then applied to support
the weight of the arm. Several layers of restrictive bandages are then applied around
the arm and the torso.
Velpeau bandage is commonly used for:
« Acromioclavicular dislocations
« Humeral shaft fractures
« After open reduction of posterior shoulder dislocation
Acromioclavicular joint injuries are usually seen with direct injury to the lateral
shoulder. They are also seen after fall on an outstretched arm with the elbow locked
in extension.
They are classified into six types using the Rockwood classification. Type 1-3 is
managed conservatively using the Velpeau bandage. Type 4-6 is treated by open
reduction and internal fixation.
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ORTHOPEDICS
SHOULDER JOINT STABILIZERS: The inferior glenohumeral ligament is the most
important in maintaining shoulder joint stability. It is the main stabilizer when the
shoulder is abducted and in extreme ranges of motion. The shoulder joint is
anatomically unstable. Only 25% of the humeral head articulates with the glenoid.
The joint is reinforced by:
« Static stabilizers (3 capsular thickenings or ligaments);
o Superior glenohumeral ligament (SGHL)
o Middle glenohumeral ligament (MGHL)
o Inferior glenohumeral ligament (IGHL)
« Dynamic stabilizers (rotator cuff muscles):
o Supraspinatus o Subscapularis
o Infraspinatus o The long head of biceps
o Teres minor

HILL SACH LESION: This radiograph shows anterior dislocation of the shoulder. The
nerve commonly injured in anterior dislocation is the axillary nerve, not the radial
nerve. The radiograph shows the disturbed articulation between the humeral head
and glenoid fossa. The humeral head is seen below and medial to the glenoid socket.
This suggests anterior dislocation of the shoulder joint.
Common cause for anterior dislocation:
« Young adults - athletic injuries
« Elderly - falls
Bankart lesion is a tear in the anteroinferior part of the glenoid labrum caused by
the head of the humerus during anterior dislocation. Hill-Sachs lesion is a
compression fracture on the posterolateral aspect of the humeral head. It is caused
by the pressure of the anterior glenoid rim on the humeral head in recurrent
dislocations.

BANKART LESION:

The bony Bankart lesion is a small, avulsion fracture of the glenoid rim.

During an anterior shoulder dislocation, the head of the humerus can tear the
anteroinferior part of the glenoid labrum. This is known as Bankart lesion. In some
cases, a small fragment of bone from the glenoid rim can also get avulsed. This is
known as bony Bankart lesion.

Avulsion of posterior capsular periosteum is seen in reverse Bankart lesion.

CHAUFFEUR’S FRACTURE:

The fracture shown in the X-ray radiograph is known as Chauffeur's fracture (also
known as Hutchinson fracture or backfire fracture).
Definition: Chauffeur fractures are the intra-articular fractures of the radial styloid
process.
Mechanism: The injury is typically caused by compression of the scaphoid bone of
the hand against the styloid process of the distal radius.
It can be caused by falling onto an outstretched hand (FOOSH)

Diagnosis can be made on a plain X-ray radiograph of the forearm.

Treatment: These fracture fragment is usually undisplaced but unstable. It can be
fixed by percutaneous lag-screw fixation.
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ORTHOPEDICS
BRYANT’S TEST:

In anterior shoulder dislocation, Anterior axillary fold is at a lower level on the

dislocated side.

DUGAS TEST:

The patient is made to place the hand on the opposite shoulder. The examiner then
applies gentle pressure on the flexed elbow to make it touch the chest.

In anterior shoulder dislocation, the elbow cannot be made to touch the chest.

HAMILTON RULER TEST:

In a normal shoulder, a ruler (scale) placed on the lateral side of the arm will not
touch the lateral condyle of the humerus and the acromion at the same time.

In anterior shoulder dislocation, the ruler will simultaneously touch the lateral
condyle of the humerus and the acromion.

CALLWAY TEST:

The vertical circumference of the axilla is increased on the dislocated side as

compared to the normal side.
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ORTHOPEDICS
KOCHER’S MANOEUVRE: TEAM (Traction — External Rotation — Adduction — Medial Rotation)

HIPPOCRATIC METHOD:

The doctor applies a firm and steady pull on the semi-abducted arm of the patient by
keeping his foot on the axilla against the chest wall. The foot is used as the fulcrum.

STIMSON’S GRAVITY TECHNIQUE:

Patient is left prone and weight is attached to the elbow or wrist on the affected
side. Gravity strefches the muscle and reduction occurs in 15-20 minutes.

PUTTI PLATT’S OPERATION:

Putti-Platt’s operation for shoulder

instability involves overlapping and
tightening of the subscapularis tendon
and capsule. Itis not commonly done
anymore.

Surgeries done for shoulder instability include:

« Bankart’s operation (most common): The glenoid labrum and the capsule are re-attached to the front of the glenoid rim.
« Laterjet-Bristow’s operation: The coracoid process is osteotomized and transplanted along with its muscle attachments
to the anterior rim of the glenoid.
« Neer’s capsular shift: The shoulder joint capsule is detached from the neck of the humerus and shifted inferior to the
neck.
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ORTHOPEDICS
POSTERIOR DISLOCATION OF SHOULDER:

Posterior dislocation of the shoulder usually occurs with an indirect force causing
marked internal rotation and adduction. This condition can be seen after a
convulsion, or an electric shock. It can also occur after a fall on the flexed and
adducted arm, or after a direct blow to the front of the shoulder.

The classical attitude of the arm is internal rotation and locked in that position. The
examiner will be unable to externally rotate the arm back to normal position.

LIGHT BULB SIGN: The light bulb sign can be seen on the given AP radiograph of the
left shoulder. It is seen in cases of posterior dislocation of the shoulder. In posterior
dislocation of the shoulder, the humerus rotates internally. This causes changes to
the normal radiographic contour of the head of the humerus. The humerus appears
similar to a lightbulb in AP views.

Other radiological signs described in posterior dislocation of the shoulder in the AP

view are as follows:
« The rim sign: Widening of the glenohumeral joint space > 6 mm
« The vacant glenoid sign: The glenoid fossa looks empty as the humeral head has
moved away from it
« The trough sign: A vertical line is seen on the anteromedial part of humeral head
due to the impression fracture by the glenoid labrum

REVERSE HILL-SACH LESION:

The reverse Hill-Sachs lesion is seen on the anteromedial aspect of the humeral
head.

It is also known as McLaughlin lesion. it refers to an impaction fracture of the

anteromedial aspect of the humeral head. It is seen following a posterior dislocation
of the humerus. This occurs due to the impact of the glenoid rim on the humeral
head.

INFERIOR DISLOCATION: Also known as luxatio erecta.

Inferior dislocation is rare and occurs when the arm is forcefully pulled up when in
full abduction (hyper-abduction force).

The head of the humerus gets forced out of the inferior part of the capsule and
comes to lie below the glenoid.The patient will present with the arm locked in
abduction. On examination, the humeral head may be felt in or below the axilla.

The X-ray below shows disturbed articulation between the humeral head and
glenoid. The humeral head is seen below the glenoid. The humerus shaft is in the
abducted position. This is characteristic of luxatio erecta.
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ORTHOPEDICS
SURGICAL NECK OF HUMERUS FRACTURE: It is most commonly seen in osteoporotic,
postmenopausal women. The most common mechanism of injury in fracture of the
proximal humerus is falling on the outstretched hand. The patient usually presents with
localized shoulder pain and limitation of movement in the affected arm.

Clinical features:
« Soft tissue swelling and ecchymosis
« Bony tenderness over the upper part of the humerus
« Normal contour of the shoulder is retained
« Axillary nerve is the most common nerve to be injured in proximal humerus fractures
Management:
« Undisplaced proximal humerus fractures are treated using an arm pouch or sling.
« Displaced and unstable fractures are treated by open reduction and internal fixation.

SHAFT OF HUMERUS FRACTURE (CLOSED): The radial nerve is commonly damaged

in this condition. It manifests as an inability to dorsiflex the wrist and digits (wrist
drop and finger drop). Numbness occurs on the dorsoradial aspect of the hand and
the dorsal aspect of the radial 3 1/2 digits.
Management of humerus shaft fractures:
« Conservative management using a hanging cast or U-slab for 2-3 weeks followed
by functional bracing
« Surgical fixation by compression plating, interlocking intramedullary nail, semi-
flexible pins, or an external fixator is indicated in:
- Open fractures
- Pathological fractures
- Unstable humeral and forearm fractures (floating elbow)
- Radial nerve palsy

HOLSTEIN LEWIS FRACTURE:

The radiograph shows a displaced spiral fracture of the humerus at the junction of
the middle-third and distal-third. This is known as Holstein-Lewis fracture.

There is a high risk of entrapment of the radial nerve in the bone fragments of this
fracture. Hence this fracture is associated with radial nerve injury (wrist drop).

INFERIOR DISLOCATION:
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ORTHOPEDICS
POSTERIOR DISLOCATION OF SHOULDER:

LIGHT BULB SIGN:

REVERSE HILL-SACH LESION:

INFERIOR DISLOCATION:
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ORTHOPEDICS
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ORTHOPEDICS
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ORTHOPEDICS
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ORTHOPEDICS