Part 2 book “Textbook of orthopedics” has contents: Regional conditions of the neck, regional conditions of the neck, congenital disorders, developmental disorders, metabolic disorders, skeletal tuberculosis, rheumatic diseases, neuromuscular disorders, distal forearm fractures, fracture neck of femur,… and other contents.
29 • • • • Regional Conditions of the Neck Torticollis (Wryneck) Thoracic outlet syndrome Cervical rib Cervical disk syndromes Regional orthopedics deals with a vast array of interesting orthopedic problems Each region has its own peculiar problems depending on various factors like anatomical, physiological, occupational and others operating in that region An effort is made in this section to highlight the various regional orthopedic problems However, a detailed description of the regional disorders is avoided as it is outside the scope of this book The student is requested to refer bigger books in orthopedics in case he or she desires a detailed study of the regional problems TORTICOLLIS (WRYNECK) Torticollis is defined as the rotational deformity of cervical spine that causes turning and tilting deformity of the head and neck (Fig 29.1) • Unilateral muscle paralysis, e.g polio • Neuritis of spinal accessory nerve • Ocular disturbances: Child turns head to one side to compensate for defective vision Clinical Features Head of the patient is tilted towards the affected side while the chin points to the other side Sternocleidomastoid muscle is prominently seen In the later stages, the patient may develop facial asymmetry and macular disturbances in the eye Among the acquired causes of torticollis, spasmodic muscle contraction of the sternocleidomastoid is the most common cause Management Conservative Initially conservative line of treatment is observed This consists of nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants drugs, etc Causes • Congenital: (See Chapter 35, Congenital Disorders for description) • Infective: Tuberculosis of cervical spine, acute respiratory tract infection, etc • Traumatic Sprain, dislocation and fracture of the cervical spine • Myositis or fibromyositis of sternocleidomastoid, exposure to cold causes myositis • Spasmodic: Painful, persistent or intermittent sternomastoid muscle contraction Fig 29.1: Features of wryneck 374 Nontraumatic Orthopedic Disorders Physiotherapy like ultrasound, heat, massage is advocated In acute pain, the patient is encouraged to wear a collar Gradual neck stretching exercises are advised once the acute symptoms subside Surgical Management is advised after the failure of conservative treatment It consists of release of sternomastoid muscle from its clavicular attachment as in congenital torticollis and intradural section of both spinal accessory and three cervical roots in cases of torticollis due to spasmodic or neural causes THORACIC OUTLET SYNDROME The space at the thoracic outlet or inlet when it is less than adequate, subjects the neurovascular structures seeking to gain entry into the upper limbs via this space, to undue pressure (Fig 29.2) The blame for the neurovascular complaints should be placed at the doorstep of the decreased space and not at the structures producing the problems This syndrome results from the compression of neurovascular bundle comprising of subclavian artery and vein, axillary artery and vein and brachial plexus at the thoracic outlet Thoracic outlet is a space between the first rib, clavicle and the scalene muscles The above structures are liable to be compressed (Fig 29.3) when this space gets narrowed either due to hypertrophy of the existing muscles or due to any other cause like congenital, trauma, etc Fig 29.2: Anatomy of the thoracic outlet Fig 29.3: Abnormal scalene muscle insertion causing compression of neurovascular structures Sites of Compression The sites of compression could be either supraclavicular, subclavicular or infraclavicular Supraclavicular: Interscalene triangle between the anterior scalene muscles Subclavicular: Interval between the second thoracic rib, clavicle and subclavius Infraclavicular: Beneath an enclosure formed by the coracoid process, pectoralis minor, and costocoracoid membrane Rare Cause Scissor-like encirclement of axillary artery by the median nerve Contributing Factors Dynamic Factors Arm when in full abduction pulls up the artery by 180° causing compression in the short retroclavicular space Regional Conditions of the Neck Static Factors Tests Vigorous occupation: Increases the muscle bulk and thereby decreases the space Intermittent Claudication Test Inactive occupation: Decreases the muscle bulk and thereby increases the space Congenital: Cervical rib decreases the interscalene space and thereby decreases the retroclavicular space Traumatic: Malunion or nonunion of fracture clavicle Arteriosclerosis Anomalies of the first thoracic rib Miscellaneous • Tumor arising from the upper lobe of the lung • Cervicothoracic scoliosis • Abnormal variations of the scalene muscles Clinical Features Obviously, this syndrome poses two major problems The first one relates to the compression of the major vessels and secondly to the compression of the nerves The first problem has a definite clinical entity, while the second one presents a vague picture and makes an accurate diagnosis difficult Vascular Problems Here the compression could be arterial or venous During the arterial compression, which is mild in the early stages the patient complains of numbness of the whole arm with rapid fatigue during overhead exercises If the compression is significant, the patient will complain of cold, cyanosis, pallor and Raynaud’s phenomenon Venous compression leaves the limb swollen and discolored after exercises, which disappears slowly with rest The arm is abducted and elevated and fingers are exercised The inference: • If pain develops after minute; it is negative (normal) • If pain develops before minute; the test is positive Compression of subclavian artery in the neck: Radial pulse decreases Allen’s Test To determine the adequacy of radial and ulnar arteries, by compressing each one at a time and checking for adequacy Costoclavicular Maneuvers The patient’s shoulder is braced down and back The reproduction of the symptoms, change in the radial pulse, bruit heard in infraclavicular area are the positive findings Provocative Tests Adson’s test: The radial pulse is felt and the patient is asked to take a deep breath and turn the head to the same side (Fig 29.4B) Decrease in the radial pulse indicates positive test Wright’s test: The same maneuver as above but the head is tilted towards the opposite side (Fig 29.4A) It should be noted that thoracic outlet syndrome is a diagnosis of exclusion First, the cervical pathology Neurogenic Problems This involves C8 T1 segment (Klumpke’s paralysis) Patients complain of par esthesia along the medial aspect of the arm, hand, little and ring fingers There is weakness of the hand also 375 Fig 29.4: Methods of performing: (A) Wright’s test, (B) Adson’s test 376 Nontraumatic Orthopedic Disorders should be excluded and later the above tests should be performed as the initial screening procedures Complications Subclavian artery compression → results in poststenotic dilatation → stasis favors thrombosis → the thrombi break and migrate distally causing embolization → these results in the distal artery blockade causing ischemia and gangrene of the upper limbs Investigations X-ray neck: To rule out intrinsic causes like cervical spondylosis, cervical rib, etc Nerve conduction studies: Difficult to determine the nerve conduction velocity through the thoracic outlet, but its biggest value is to rule-out problems like entrapment, e.g ulnar nerve at elbow, wrist, etc Treatment • Conservative treatment: Consists of rest, physiotherapy, exercises like shoulder shrugging, etc • Surgical treatment CERVICAL RIB Cervical rib problem is akin to the story of the “Return of the Prodigal Son” However, unlike the chastened prodigal son, cervical rib returns to torment the unfortunate victim! It is a rib arising from the 7th cervical vertebra, rarely 6th and 5th cervical vertebra Incidence: It is 0.46 percent Nearly 50 percent of those are unilateral Side: It is more frequent on the right side Developmental Factors In the embryo nerves larger than the ribs interfere with the development of the costal process When brachial plexus is prefixed, well-developed 4th cervical root and small 2nd thoracic root offer little resistance to the costal process at the 7th cervical root In postfixed brachial plexus, well-developed 1st thoracic root offers resistance to costal process of 7th cervical root Obviously, cervical rib is more common in prefixed variety Types Indications: Gangrene and poststenotic dilatation Four varieties are described: Methods Complete: The cervical rib reaches up to the first thoracic rib • Removal of the first thoracic rib: This is the most effective treatment as it deals with both supraclavicular and infraclavicular etiological factors in this syndrome • Removal of cervical rib: If this is the cause of compression • Scalenotomy is indicated in scalenus anticus syndrome Quick facts • Sites of compression could be supra, sub, or infraclavicular • Clinical manifestation could be neural, vascular or both • Diagnosis is usually by exclusion and the screening test helps • Excision of the first thoracic rib is the most effective surgical procedure Bulbous end: In this, the cervical rib has a bulbous end Tapering end: In this, the cervical rib tapers Fibrous band: In this, the rib is represented by a thick fibrous band Pathological Anatomy The neurovascular structures, the brachial plexus and subclavial vessels are up by the cervical rib that is inserted into the scalene tubercle of the 1st rib space Pronounced drooping of the shoulder in women after middle age, trauma, unusual lifting operations, acute illness make the muscles weak, pulling the plexus and artery distally giving rise to symptoms Regional Conditions of the Neck 377 the first thoracic nerve root The patient complains of paresthesia along the medial aspect of the arm, hand and little fingers There is weakness of the hand muscles also Radiograph X-ray of the neck (AP and lateral views) helps to detect the presence of cervical rib (Fig 29.5) However, the absence of the rib on the X-ray does not rule out the possibility of the presence of cervical rib Fig 29.5: Radiograph showing unilateral cervical rib Clinical Features Cervical rib with local symptoms: Show presence of a lump and tenderness in the supraclavicular fossa Cervical rib with vascular symptoms: This gives rise to pain in the upper limbs, temperature and color changes, radial pulse is feeble or absent and a feeling of numbness is present Cervical rib with nerve pressure symptoms: The nerve pressure symptoms are due to the angulations of Treatment In mild cases, sling exercises often help In more severe cases, scalenotomy (resection of scalenus anterior muscle) may be required and is successful in 70 percent of the cases In troublesome cases, removal of the cervical rib or the first rib surgically with its periosteum to prevent its regeneration is advocated CERVICAL DISK SYNDROMES This has been dealt in section on Geriatric Orthopedics 30 • • • Regional Conditions of the Upper Limb Regional conditions of the shoulder – Frozen shoulder – Rotator cuff lesions – Rotator cuff tears – Deltoid contracture Regional conditions of the elbow – Tennis elbow – Golfer’s elbow – Olecranon bursitis Regional conditions of the wrist and hand – De Quervain’s disease – Trigger fingers and thumb – Ganglia – Dupuytren’s contracture – Carpal tunnel syndrome – Compound palmar ganglion REGIONAL CONDITIONS OF THE SHOULDER FROZEN SHOULDER (Syn: Periarthritis, Adhesive Capsulitis) Paradoxically shoulder joint privileged as the most mobile joint in the body has its nemesis because of this very advantage Its mobility makes it very vulnerable to problems, which ultimately “freezes” its movements Unable to come to terms with the paucity of liberal movements hitherto enjoyed, the hapless patient resigns himself or herself to suffer the agony in silence! It is defined as a clinical syndrome characterized by painful restriction (Figs 30.1A and B) of both active and passive shoulder movements due to causes within the shoulder joint or remote (other parts of the body) History Dupley first described it in 1872 and called it as humeroscapular periarthritis In 1934, Codman coined Figs 30.1A and B: Test to detect frozen shoulder (note the distance between the thumbs): (A) Frozen shoulder, (B) Normal the term Frozen shoulder, and in 1945, Neviaser gave the name adhesive capsulitis Epidemiology of Frozen Shoulder • • • • • Incidence in general population is percent Incidence in diabetics is 10-35 percent More common in females than males Mean age is 40-60 years Bilateral 12 percent Causes The causes for frozen shoulder could be: • Primary: Here the exact cause is not known and it could be idiopathic • Secondary: According to Lumberg, the secondary causes could be: – Shoulder causes: Problems directly related to shoulder joint which can give rise to frozen shoulder are tendonitis of rotator cuff, bicipital tendinitis, fractures and dislocations around the shoulder, etc Regional Conditions of the Upper Limb 379 Figs 30.2A and B: (A) Normal capsular pattern, (B) shrinkage of the capsule in frozen shoulder – Nonshoulder causes: Problems not related to shoulder joint like diabetes, cardiovascular diseases with referred pain to the shoulder, which keeps the joint immobile, reflex sympathetic dystrophy, frozen hand shoulder syndrome, a complication of Colles’ fracture, can all lead to frozen shoulder The reason could be prolonged immobilization of the shoulder joint due to referred pain, etc Pathology • During abduction, and repeated overhead activities of the shoulder, long head of biceps and rotator cuff undergo repeated strain This results in inflammation, fibrosis and consequent thickening of the shoulder capsule, which results in loss of movements (Figs 30.2A and B) If the movements are continued, then the fibrosis gradually breaks, movements return but never come back to normal • Prolonged activity causes small scapular and biceps muscles to waste faster, load on joint increases and degenerative changes sets in Capsule is fibrosed and shoulder movements are decreased Clinical Features A patient with frozen shoulder clinically presents as follows: • Decreased range of both active and passive shoulder movements • The patient demonstrates a capsular pattern of movement restrictions (i.e external rotation > abduction > internal rotation) • Pain is noted at the end stage of stretch Fig 30.3: A patient of frozen shoulder is unable to the daily routine activities like these • Accessory joint play is reduced • Resistive tests are generally pain free in the available range of motion • Patient is unable to routine daily activities like combing the hair, in case of women wearing the buttons of their blouse, (Fig 30.3), doing overhead activities, etc Facts you must know Diagnosis of frozen shoulder is primarily by clinical examination which records capsular type of restriction of both the active and passive range of motion of the shoulder Clinical Stages There are three classical stages in frozen shoulder, according to Reeves: Stage I (stage of pain): Patient complains of acute pain, decreased movements, external rotation greatest followed by loss of abduction and then forward flexion Internal rotation is least affected This stage lasts for 10-36 weeks Note: Pain in frozen shoulder does not radiate below the elbow (Fig 30.4) Stage II (stage of stiffness): In this stage, pain gradually decreases and the patient complains of stiff shoulder Slight movements are present This lasts for 4-12 months Stage III (stage of recovery): Patient will have no pain and movements would have recovered but will never be regained to normal It lasts for months to years 380 Nontraumatic Orthopedic Disorders Stage II: In this stage, since the pain will have reduced considerably, exercises both active and passive are gradually begun followed by physiotherapy, ultrasound, heat and shoulder wheel exercises The role of manipulation of the shoulder is controversial but can be attempted under general anesthesia in this stage Stage III: In this stage, active and passive exercises, physiotherapy consisting of short wave diathermy, ultrasound, etc are continued Treatment pearls Fig 30.4: Region of distribution of pain in frozen shoulder • Exercises are most effective than modalities, drugs and steroid injection • Mobilization techniques are the other effective method • Traditional manipulation under GA is a previous successful method • Traditional manipulation under GA is more successful than traction manipulation • Arthroscopic distension (Bruisement technique): This helps to increase ROM after several weeks or months • Arthroscopic releases: This is indicated in recalcitrant cases where the above measures have all failed ROTATOR CUFF LESIONS This includes both rotator cuff tears and impingement syndrome Fine adjustments of the humeral head within the glenoid is achieved by coordinated activity of four interrelated muscles (Fig 30.6) arising from the scapula and is called rotator cuff Note: Rotator cuff comprises supraspinatus, infraspinatus, subscapularis and teres minor (Mnemonic SITS) Fig 30.5: Radiographs showing features of frozen shoulder Radiology X-ray of the shoulder is usually normal; but in a few cases, ‘sclerosis’ may be seen on the outer edge of greater tuberosity (Golding’s sign) (Fig 30.5) Treatment Stage I: In this stage, long acting once a day NSAIDs are usually preferred as this condition usually runs a long course (10-36 weeks) Intra-articular steroids may help to provide transient relief of pain only Fig 30.6: Muscles of the rotator cuff Regional Conditions of the Upper Limb 381 Figs 30.7A and B: Anatomy of the shoulder joint (internal structures): (A) Shoulder joint opened (lateral view) (B) Coronal section through shoulder joint Role of Rotator Cuffs SUPRASPINATUS TENDINITIS In the movement of abduction, supraspinatus steadies the head from above, infraspinatus depresses the head, and subscapularis steadies the head in front paralleling the action of the infraspinatus This combined action allows the deltoid muscle to swing up the arm from a steady fulcrum irrespective of the position of the scapula (Figs 30.7A and B) Among the various causes mentioned above, supraspinatus tendinitis is the one that is commonly encountered and this gives rise to the impingement syndrome Impingement occurs beneath the coracoacromial arch The most vulnerable structures for impingement between the undersurface of the acromion and the head of the humerus are the greater tuberosity, the overlying supraspinatus tendon (Fig 30.8) and the long head of biceps The major site of compression is anterior to the angle of the acromion Hence, the proper term is anterior impingement syndrome or painful arc syndrome (Fig 30.9) Impingement Syndrome It is a problem, which is commonly associated with supraspinatus tendon Other causes like bicipital tendonitis, and intraspinatus tendonitis, subacromial bursitis, etc may give rise to rotator cuff problems, but they are not that common (see box) Causes of impingement syndrome • • • • • • • • Complete or partial rupture of rotator cuff Supraspinatus tendonitis Calcific deposits Subacromial bursitis Subdeltoid bursitis Periarthritis Bicipital tenosynovitis Fracture greater trochanter Fig 30.8: Supraspinatus tear 382 Nontraumatic Orthopedic Disorders • Overhead sports and athletes like throwers, swimmers, tennis players, etc • Degenerative etiology is the major cause • Dislocation of shoulder joint in 40-60 years of age • About 2/3rd cases are seen in male population Classification of Rotator Cuff Tears Fig 30.9: Anterior impingement syndrome (According to American Arthroscopic Orthopedics) • Small tear (< cm) • Medium tear (1-3 cm) • Large tears (3-5 cm) Neer’s stages of impingement syndrome Clinical Tests • • • • Special shoulder tests that are helpful in diagnosing rotational, cuff tears and the impingement syndrome, is the painful arc sign (It is 81% specific) There are innumerable other tests but is outside the scope of this book Edema stage Tendinitis and fibrositis Rotator cuff tears and rupture of biceps tendon Bone changes Types of Impingement Syndrome Primary: Here impingement occurs beneath the coracoacromial arch and is due to subacromial overloading Secondary: This is due to relative decrease in the subacromial arch and is due to microinstability of the glenohumeral joint or scapulothoracic instability Posterior (Internal): Seen in overhead athletes like throwers, swimmers and tennis players Here the supra- and infraspinatus tendons are pinched between the posterior and superior aspects of the glenoid when the arm is in elevated and externally rotated position Among the three, primary impingement is more common ROTATOR CUFF TEARS Note: Incidence of rotator cuff tear, less than 70 years— 30 percent; 71-80 years—60 percent; more than 89 years— 70 percent About Rotator Cuff Tears The causes for rotator cuff tears, partial or full, are as follows: • Age > 40 years • Occupations requiring repetitive and excessive overhead movements Interesting facts Do you know the clinical facts leading to the diagnosis of RCL tear? • Age > 40 years • Previous history of minor trauma • Degenerative changes on the X-rays • Various clinical tests How accurate are these tests? There are 91 percent sensitive and 75 percent specific Pearl: Clinical tests are more accurate and cost effective than a battery of investigations in diagnosing an RCL Clinical Features All patients with impingement syndrome have similar clinical features like pain, swelling, limitation of shoulder movements, muscle atrophy (supraspinatus and infraspinatus), and tenderness over the greater tuberosity, etc The following grades are described in anterior impingement syndrome Grade I: This is common in young adults and athletes in the age group of 18-30 years Due to overstress and repeated overhead activity, impingement occurs and supraspinatus is inflamed The painful arc appears here (Fig 30.11) Grade II: This is seen in age group of 40-45 years and may be due to supraspinatus tendinitis or Index A Achondroplasia 517 clinical features 517 radiograph 517 treatment 518 Acute dislocation of knee 263 Acute dislocation of patella 263 treatment 263 Acute respiratory distress syndrome 30 classification 31 classical type 31 fulminating type 31 incomplete type 31 etiology 30 historical facts 30 investigations 32 management 32 pathogenesis 31 role of antiplatelets in ARDS 32 Adson’s test 375 Albright’s syndrome 524 laboratory investigation 524 radiology 524 treatment 524 Allen’s test 375 Allis method 216 Amputations 787 amputations of lower extremity 789 amputation through the thigh 790 below knee amputation 790 knee disarticulation 790 Syme’s amputation 790 complications 791 contractures 791 hematomas 791 infections 791 incidences 787 indications 787 principles 788 types 787 amputation levels 788 closed amputation 787 open amputation 788 Ankle-foot orthosis 798 Ankylosing spondylitis 593 causes 593 clinical features 593 differential diagnosis 594 investigations 594 pathology 593 treatment 596 Anterior dislocation of shoulder 129 clinical features 129 mechanism of injury 129 radiographs 129 treatment 132 Anterior dislocation of the hip 220 classification 220 clinical features 221 complications 222 delayed complications 222 immediate complications 222 Epstein’ classification 221 investigations 221 mechanism of injury 220 treatment 221 Apert’s syndrome 525 Apical subungual infection 454 Approach to orthopedic injury 17 Arches of the foot 435 longitudinal arch 435 transverse arches of the foot 435 Arthritic hand 457 gout 457 lupus erythematosus 457 osteoarthritis 457 psoriasis 457 Reiter’s syndrome 457 rheumatoid arthritis 457 Arthrodesis 568 Arthroplasty 568, 816 hip and knee arthroplasty 816 complications 817 contraindications 817 indications 817 surgical steps of total knee replacement 828 components 828 types 828 Arthroscopy 806 advantages 808 indications 807 cartilage conditions 807 joints pathology 807 ligament structures 807 loose bodies 807 meniscal pathology 807 patellar problems 807 procedure 807 synovium conditions 807 limitations 808 Asif plates 72 principles 72 axial compression 72 buttress plate 72 neutralization plate 72 tension band principle 72 types 72 Avascular necrosis 40 causes clinical features 41 investigations 41 treatment 41 Axillary nerve injury 351 clinical features 351 treatment 351 B Backache in children 479 features 480 prevention 480 Bankart’s lesion 136 Barton’s fracture 180 dorsal Barton 180 clinical features 180 mechanism 180 884 Textbook of Orthopedics radiograph 180 treatment 181 volar Barton 181 clinical features 181 mechanism 181 radiograph 181 treatment 182 Baumann’s angle 150 Bigelow’s method 216 Bluemensaat’s line 425 Bone grafting method 88 Bone tumors 618 cartilaginous origin 618 chondroblastoma 620 chondroma 619 chondrosarcoma 621 osteochondroma 618 giant cell tumor 631 benign giant cell tumor 631 malignant giant cell screen 631 osseous origin 623 osteogenic sarcoma 624 osteoid osteoma 623 osteoma 623 resorptive bone tumors 629 aneurysmal bone cyst 629 unicameral bone cyst 629 tumors of nonosseous origin 633 Ewing’s sarcoma 633 multiple myeloma 635 Boxer’s fracture 206 clinical features 206 mechanism of injury 206 radiographs 206 treatment 206 Boyd dual onlay graft 502 Brachial plexus injuries 348 causes 348 clinical assessment 349 investigations 349 supraclavicular lesion 348 treatment 349 Brand’s operation 340 Brodie’s abscess 550 clinical presentation 550 etiology 550 radiograph 550 treatment 550 Buck’s extension skin traction 66 Bunnel’s operation 339 Bursae around the knee 422 C Calcaneal spurs 443 causes 443 clinical features 443 radiographs 443 treatment 444 Canal stenosis 694 causes 694 classification 694 clinical features 695 investigations 695 treatment 696 conservative methods 696 surgical methods 696 Capitellum fractures 165 classification 165 comminuted fracture 165 Hahn-Steinthal variety 165 Kocher-Lorenz variety 165 clinical features 166 mechanism of injury 165 radiographs 166 treatment 166 Carpal tunnel syndrome 393 anatomy 393 causes 394 clinical stages of features 394 clinical tests 394 contents 393 treatment 395 Carpenter’s syndrome 525 Cauda equina syndrome 327 causes 328 clinical features 328 symptoms 328 prognosis 328 Causes of backache 476 biochemical causes 478 common causes 476 investigations 479 neurogenic claudication 478 facet syndromes 478 neurological symptoms 478 neurological examination 478 other complaints 478 physical signs 478 other examinations 479 pain 478 presenting complaints 477 spondylolisthesis 479 treatment 479 uncommon causes 477 Central dislocation of hip 223 classification 224 clinical features 224 complications 225 delayed complications 225 early complications 225 investigations 224 mechanism of injury 223 Cervical disk syndromes 377, 690 clinical features 690 signs 690 symptoms 690 investigations 691 treatment 691 types 690 hard disk lesions 690 soft disk lesions 690 Cervical rib 376 clinical features 377 development factors 376 investigations 377 pathological anatomy 376 treatment 377 types 376 Chemonucleolysis 475 Chondromalacia patella 426 clinical features 426 differential diagnosis 427 investigations 426 treatment 427 Chronic compartmental syndrome 36 Chronic synovitis 101 Classical Watson-Jones method 216 Claw toes 447 causes 447 clinical features 448 radiographs 448 treatment 448 Cleidocranial dysostosis 490 clinical features 490 etiology 490 radiograph 491 treatment 491 types 490 Cleidocranial dysplasia 525 Cobb’s method 399 Collateral ligament injury 247 classification 247 clinical features 247 clinical tests 247 investigations 248 mechanism of injury 247 treatment 248 types 247 Colles’ fracture 17, 19, 177, 643 classification 645 clinical features 18 deformity 18 inability 18 pain 18 swelling 18 clinical features 644 complications 651 Index features about the clinical signs 19 clinical manifestations due to neurovascular injuries 19 mechanism of injury 18, 643 radiology 644 relevance of clinical signs 20 treatment 652 treatment methods 645 conservative methods 645 Common forearm surgeries 717 Darrach’s operation 721 approach 721 indication 721 surgical steps 721 excision of the radial head 717 approach 717 indications 717 steps 717 forearm DCP plating 717 approaches 717 indications 717 surgical steps 717 medullary fixation for fracture of radius and ulna 720 indications 720 surgical steps 720 Common hip surgeries 722 dynamic hip screw technique 729 approach 729 indications 729 surgical steps 729 hemireplacement arthroplasty 722 advantages 722 approaches 722 complications 722 disadvantages 722 indications 722 surgical steps 722 internal fixation of fracture neck of femur 733 choice of implants 733 indication 733 surgical steps 733 surgical technique of AMP prosthesis 723 Compartmental syndrome or forearm 33 clinical features 33 etiology 33 incidence 33 investigations 34 management 34 pathology 33 Compound palmar ganglion 396 clinical features 396 investigation 396 treatment 396 Computers in orthopedics 89 Congenital absence of 512 fibula 512 treatment 512 tibia 512 Congenital absence of radius (radial club-hand) 493 clinical features 493 radiograph 493 treatment 493 Congenital anomalies of hand 452 camptodactyly 452 cleft hand 453 congenital absence of radius or ulna 453 congenital radioulnar synostosis 453 congenital trigger digits 452 Kirner’s deformity 453 macrodactyly 452 mirror hand 453 polydactyly 452 Streeter’s dysplasia 452 syndactyly 452 Congenital dislocation of knee 501 clinical features 501 pathology 501 radiograph 501 treatment 501 mild to moderate 501 severe 501 Congenital dislocation of radius 494 clinical features 494 radiology 494 treatment 494 Congenital pseudarthrosis of tibia 501 classification 502 clinical features 502 incidence 501 radiograph 502 treatment 502 Congenital radioulnar synostosis 491 classification 491 clinical features 491 radiograph 491 treatment 492 Congenital talipes equinovarus 503, 755 approach 755 classification 506 clinical features 504 indications 755 investigation 506 management 507 885 pathology 504 surgical steps 755 theories 503 types 503 Congenital torticollis (Wryneck) 488 clinical features 488 etiology 488 radiograph 489 treatment 489 Congenital vertical talus 513 clinical presentation 513 radiographs 513 treatment 513 Coronoid fractures 164 clinical features 165 mechanism of injury 165 radiograph 165 treatment 165 Coxa vara 409 classification 410 acquired 410 congenital 410 clinical features 410 disadvantages 410 radiography 410 Cruciate ligament injuries 248 anterior cruciate ligament tear 248 clinical examination 249 clinical features 249 clinical tests 249 investigations 249 treatment 251 combined knee ligament injuries 252 posterior cruciate ligament tear 252 clinical features 252 investigations 252 Crush injuries of the hand and amputations 209 Crush syndrome 47, 49 Crystalline arthropathies 597 Cubitus varus (Gunstock elbow) 155 clinical tests 156 complications 157 pathomechanics 155 radiographs 156 treatment 156 Cuboid fractures 290 classification 290 clinical features 290 mechanism of injury 290 treatment 290 Cuneiform injuries 290 classification 291 clinical features 291 investigations 291 treatment 291 886 Textbook of Orthopedics D Dancer tendinitis 445 DCP plating 740 approach 740 indication 740 surgical steps 740 DCP plating for fracture shaft of humerus 699 approach 699 indications 699 surgical steps 699 DCP plating for tibia 743 approaches 743 indications 743 surgical steps 743 De Quervain’s disease 103, 378, 389 clinical features 389 etiology 389 treatment 390 Deep vein thrombosis and pulmonary embolism 44 clinical features 44 complications 44 investigations 44 treatment 44 Deformities and their management 362 bone causes 363 bone disorders 363 fractures 363 growth disturbances 363 classification 362 acquired deformities 362 congenital 362 joint causes 363 arthritis 363 dislocation or subluxation 363 idiopathic 363 muscle imbalance 363 postural 363 tethering of muscles and tendons 363 soft tissue causes 363 treatment options 363 conservative measures 363 surgical measures 363 Deltoid contracture 384 causes 384 clinical presentations 384 treatment 384 Developmental dysplasia of hip 494 clinical features 495 pathology 494 risk factors 494 theories of etiology 494 treatment 498 Diaphyseal dysplasia 523 craniodiaphyseal dysplasia 523 progressive diaphyseal dysplasia 523 Dislocation of elbow joint 157 classification 157 clinical features 157 complications 160 mechanism of injury 157 radiographs 158 treatment 158 Dislocations 28 clinical features 28 complications 29 acute 29 chronic 29 investigations 29 pathology 28 treatment 29 types 28 congenital or acquired 28 Dislocations of IP joint 199 clinical features 199 clinical tests 199 radiographs 199 salient features 199 treatment 200 nonoperative management 200 operative management 200 types 199 Distal interphalangeal joint injuries 198 salient features 198 Distal pulp space infection 454 clinical features 454 treatment 454 Distal radial fracture 175 treatment plan in a nutshell 176 Distal tibial fractures 272 open tibial fractures 273 pilon fractures 272 classifications 272 clinical features 273 incidence 272 investigations 273 treatment 273 Dunlop’s traction 66 Dupuytren’s contracture 378, 392 causes 392 clinical features 392 pathogenesis 392 prognosis 392 treatment 393 Dynamic compression plates 73 advantages 73 disadvantages 73 Dyschondroplasia (Ollier’s disease) 521 clinical features 522 E Ely’s test 432 Emergency care 50 first aid 50 goals 50 initial care 50 modus operandi 50 airway 50 bleeding 51 cardia 51 examine vital structures 52 Epiphyseal dysplasia hemimelia 523 Epiphyseal dysplasias 523 Conradi’s disease 523 epiphyseal dysplasia multiplexa 523 epiphyseal dysplasia punctata 523 Epiphyseal injuries 112 causes 112 clinical features 113 incidence 112 investigations 113 treatment 113 types 112 Erb’s palsy 350 effects of injury 350 at the elbow 350 at the forearm 350 at the shoulder 350 management 350 splinting 350 Essex-Lopresti fracture 178 clinical features 178 mechanism of injury 178 radiograph 179 treatment 179 Evidence based orthopedics 842 communication to a patient 853 tools for communication 853 cost effectiveness analysis 849 decision analysis study 850 quality of reporting 851 quality of research 845 studies other than RCT 850 case series 850 Cohort study 850 diagnostic study 850 type of study 846 user’s guide 846 Extensor tendon injuries 208 External fixation 78 biotechnical principles 80 clamps 80 pin number 80 pin placement 80 pin size 80 rod placement 80 Index complications 80 types of external fixators 79 mode of action 79 External fixation 780 surgical technique 780 F Fat pad insufficiency 444 clinical features 444 treatment 444 Fatigue or stress fractures 115 clinical features 115 radiograph 115 bone scan 115 MRI and CT scan 115 treatment 116 Fibromyalgia 596 causative factors 596 clinical features 596 diagnostic criteria 596 incidence 596 treatment 597 Fibrous dysplasia 523 clinical features 524 etiology 523 pathology 523 gross 523 microscopy 524 Fifth metatarsal injuries 287 classification 287 mechanism of injury 287 treatment 287 Finger fracture 770 surgical technique of K-wire fixation of a metacarpal fracture 774 surgical technique of percutaneous fixation of toe fractures 777 technique of fixation of ipsilateral phalangeal fractures 771 technique of K-wire stabilization of compound proximal phalanx fracture 770 Fixation techniques by noncompression methods 77 bioabsorbable fixation 78 biologic fixation 77 composite fixation 78 hybrid fixation 78 internal splints 77 Flexor tendon injuries 207 Foot pain 438 Forefoot injuries 283 classification 283 treatment 283 Fowler’s operation 340 Fracture both bones of the forearm 171 clinical features 171 complications 172 mechanism of injury 171 radiographs 171 treatment 171 Fracture clavicle 119 classification 120 clinical features 120 complications 122 functions 119 mechanism of injury 119 principles of treatment 120 radiographs 120 sites of fracture 120 treatment plan 121 Fracture healing 90 methods 90 direct 91 distraction histogenesis 91 indirect 90 Fracture immobilization 26 Fracture neck of femur 654 classification 656 broad classification 656 structural classification 656 clinical features 657 complications 662 etiology 656 investigations 658 mechanism of injury 656 other investigations 658 treatment 659 Fracture neck talus 297 classification 297 clinical features 298 complications 298 mechanism of injury 297 radiography 298 treatment 298 Fracture of olecranon 163 clinical features 163 Colton’s classification 163 complications 164 mechanism of injury 163 radiographs 163 treatment 164 Fracture of patella 258 classification 259 clinical features 259 complications 262 functions of patella 258 incriminating facts 259 887 investigations 259 management 260 mechanism of injury 258 Fracture of scapula 138 classification 138 clinical features 138 functions 138 incidence 138 mechanism of injury 138 radiographs 139 treatment 139 Fracture pelvis 300 stability of the pelvis 300 classification 301 clinical features 303 complications 306 investigations 303 management 304 mechanism of injury 301 stable pelvic fracture 300 unstable pelvic fracture 300 Fracture treatment methods 55 AO group 58 early fracture surgery 57 external fixation 57 functional brace 57 history 55 intramedullary fixation 57 open fractures 57 plaster bandages 56 thomas splint 56 traction 56 Fractures in children 105 clinical features 106 complications 112 etiology 105 incidence 105 investigations 106 treatment 106 types 106 buckle fracture 106 greenstick fractures 106 plastic bowing 106 Fractures of body of talus 299 types 299 Fractures of middle phalanx 198 clinical features 198 management 198 radiographs 198 Fractures of tibia and fibula 266 classifications 267 clinical features 267 features of tibial fractures 266 interesting facts 267 mechanism of injury 267 methods of treatment 267 radiographs 267 888 Textbook of Orthopedics Fractures shaft femur 229 classification 230 clinical features 230 complications 236 management 230 mechanism of injury 229 radiographs 230 Fractures talus 297 blood supply of talus 297 Frozen shoulder 378 causes 378 primary 378 secondary 378 clinical features 379 clinical stages 379 epidemiology 378 history 378 pathology 379 radiology 380 treatment 380 Functional cast brace 62 mode of action 62 G Galeazzi’s fracture 177 clinical features 178 complications 178 mechanism of injury 178 radiograph 178 treatment 178 Gallow’s traction 66, 111 Ganglion cyst 391 clinical features 391 treatment 392 Gas gangrene 48 incidence 48 investigations 48 prevention 48 treatment measures 48 General principles of methods of fracture treatment 59 conservative or nonoperative methods 59 no treatment 59 plaster treatment methods 59 slings 59 strapping 59 functional cast bracing 60 nonoperative methods 59 advantages 59 disadvantages 59 operative methods 60 advantages 60 disadvantages 60 operative treatment of fractures 59 intramedullary (IM) nails 60 plates 60 screws 60 treatment of fractures by external fixators 60 Genu recurvatum 421 causes 421 clinical tests 421 radiographs 421 treatment 421 Genu valgum 418 clinical features 418 incidence 418 radiographs 419 treatment 419 types 418 Genu varum 420 causes 420 clinical features 420 clinical measurements 420 radiographs 420 treatment 420 types 420 Gluten-sensitive enteropathy 535 clinical features 535 etiology 535 investigations 535 treatment 535 Golfer’s elbow 378, 388 Growth alterations 47 H Hallux rigidus 447 causes 447 clinical features 447 radiographs 447 treatment 447 mild cases 447 severe cases 447 Hallux valgus 445 causes 446 clinical features 446 radiographs 446 secondary problems 445 treatment 446 mild cases 446 severe cases 446 Hammer toes 447 clinical features 447 radiographs 447 treatment 447 Hangman’s fracture 319 Hemophilic arthritis 579 clinical features 580 investigations 580 laboratory tests 580 pathology 579 treatment 580 Hereditary multiple exostosis 521 clinical features 521 radiology 521 treatment 521 Hindfoot injuries 292 extra-articular fractures 294 classification 295 clinical features 294 mechanism of injury 294 radiography 294 treatment 295 fracture calcaneum 292 classification 293 functions 293 intra-articular fractures 295 clinical features 295 clinical signs 295 complications 297 mechanism of injury 295 radiography 296 treatment 296 Hip surgery 87 Hoffa’s syndrome 430 clinical features 430 treatment 430 Homocystinuria 525 Hunter’s disease 521 Hurler’s (Gargoylism) 521 Hyperparathyroidism 537 primary hyperparathyroidism 537 causes 537 clinical features 537 differential diagnosis 538 laboratory investigation 537 pathogenesis 537 pathology 537 radiographs 537 treatment 537 secondary hyperparathyroidism 538 I Ilio-tibial band (ITB) syndrome 429 Ilizarov’s technique 84 principles 84 corticotomy 85 law of tension force 84 use of unique ring fixator 84 Index Implant failure 47 Implants 69 general principles 69 types 69 cobalt based 69 iron based 69 metallic 69 titanium based 69 varieties 70 Important internal fixation methods 75 circlage 75 staples 76 suture anchors 77 indications 77 transfixion 76 Important splints in orthopedics other than POP 63 Böhler-Braun splint 64 care of splints 65 indications 65 problems 65 Thomas splint 63 parts 64 uses 64 Inclusion tumors 638 synovioma 638 clinical features 638 pathology 638 radiographs 638 treatment 639 India’s pride 794 Infantile quadriceps contracture 430 causes 430 acquired 430 congenital 430 clinical features 431 clinical signs 431 clinical tests 432 radiographs 432 treatment 432 conservative methods 432 surgical methods 433 Infections of hand 453 Infective arthritis 575 gonococcal arthritis 577 clinical features 577 pathology 577 treatment 577 neuropathic joints 578 clinical features 578 pathology 578 radiograph 578 treatment 579 septic arthritis 575 causative organisms 575 clinical features 576 complications 577 investigations 576 pathology 576 predisposing factors 575 radiogaphs 576 treatment 577 syphilis of joints 578 investigations 578 treatment 578 Inferior dislocation (luxatio erecta) 138 Injuries of acromioclavicular joint 122 classification 123 clinical features 122 complications 124 management 123 mechanism of injury 122 radiographs 123 Injuries of arm 140 distal humerus fractures 143 classification 143 clinical features 143 mechanism of injury 143 radiographs 143 treatment 145 fracture shaft humerus 140 anatomic considerations 140 clinical features 141 complications 142 mechanism of injury 140 radiographs 141 treatment methods 141 Injuries of carpometacarpal joints of thumb 187 Bennett’s fracture 187 characteristics 187 clinical features 188 mechanism of injury 187 radiograph 188 treatment 188 Injuries of the ankle 274 ankle injuries 274 classification 275 clinical features 276 complications 278 investigations 276 mechanism of injury 275 treatment 277 ankle sprains 278 clinical features 281 clinical tests 282 lateral ligament sprain 279 clinical features 279 radiograph 279 mechanism of injury 281 acute rupture 281 chronic rupture 281 medial ligament sprain 280 tendo-Achilles injury 280 889 treatment 282 trimalleolar fracture 278 Injuries of the cervical spine 312 causes 312 mechanism of injury 312 Injuries sternoclavicular joint 124 causes 124 classifications 124 anatomical 124 etiological 124 clinical features 124 management 125 mild sprain 125 subluxation 125 mechanism of injury 124 radiographs 125 Injuries to joints 97 ligament injury 97 anatomy 97 functions 98 problems of healing 98 Injuries to the phalanx 195 distal phalanx fractures 195 clinical features 196 mechanism of injury 195 radiograph 196 salient features 195 treatment 196 Injuries to wrist 183 carpal injuries 183 clinical features 184 general principles 183 investigations 184 mechanism of injury 183 treatment 184 scaphoid fracture 184 classification 185 clinical features 185 complications 187 etiology 185 investigations 185 Injury to blood vessels 45 causes of injury 45 clinical features 46 effects of injury 45 investigations 46 treatment 46 Injury to coccyx 307 clinical features 307 investigations 307 mechanism of injury 307 treatment 307 Injury to nerves 46 incidence 46 mechanism of injury 46 types 46 890 Textbook of Orthopedics Injury to sciatic nerve 344 foot-drop 345 causes 345 clinical features 346 treatment 246 meralgia paresthetica 347 clinical features 347 diagnostic test 347 treatment 347 types 347 Injury to the bursa 101 causes 102 clinical features 102 common sites 102 functions 101 treatment 102 types 102 Injury to the synovium 99 causes 99 clinical features 100 functions 99 methods 100 relevant anatomy 99 treatment 100 types 99 Intercondylar fracture humerus 712 approach 712 indications 712 Interlocking nailing 735 approach 735 indications 735 surgical steps 739 Interlocking nailing of tibia 747 indications 747 surgical steps 747 Interlocking nails 82 Interphalangeal joint dislocations 285 clinical features 285 investigation 285 salient features 285 treatment 285 Intramedullary nail 73 mode of action 75 requirements 74 types 74 Intramedullary nailing 734 indications 734 approach 734 Intramedullary nails 82 Investigations in orthotrauma 20 CT scan 21 MRI 21 radiography 20 Ipsilateral fractures of femoral shaft and neck 239 causes 240 clinical features 241 complications 242 epidemiology 240 investigations 241 mechanism of injury 240 methods of treatment 241 Isolated distal ulnar fracture 172 clinical features 172 radiograph 173 treatment 173 J Jaipur foot 794 Joint stiffness 47 Joints 12 cartilaginous joints or amphorthosis 14 symphysis 14 synchondroses 14 fibrous joint or synarthrosis 12 gomphosis 13 sutures 13 syndesmosis 12 synovial joints or diarthrosis 14 ball and socket joint 14 biaxial joints 14 condyloid joint 14 gliding joints 14 hinge joints 14 multiaxial joints 14 pivot joints 14 saddle joint 14 uniaxial joints 14 Jones fracture 287 clinical features 288 mechanism of injury 287 radiology 288 treatment 288 Jumper’s knee 428 clinical features 428 treatment 428 K Kaplan’s lesion 202 clinical features 202 diagnostic clues 203 radiographs 203 treatment 203 Kirschner’s wire 59 Klumpke’s paralysis 351 Knee ligament injuries 246 general principles 246 etiology 246 goals of treatment 246 mechanism of injury 246 Kuntscher’s nail 734 Kyphosis 407 causes 407 investigations 408 methods of examination 408 tests for mobility 408 treatment 408 types 408 angular 408 knuckle 408 round 408 L Laminectomy 756 aftercare 756 approach 756 indications 756 surgical steps 756 Lateral condyle of humerus 166 classification 166 anatomical location 166 stages of displacement 166 clinical features 167 complications 167 radiographs 167 treatment 167 Legg-Calvé-Perthes disease 410 classification 413 clinical features 411 signs 412 symptoms 412 clinical tests 412 etiology 411 management 414 predisposing factors 411 prognosis 415 radiographic characteristics 412 treatment methods 414 Long thoracic nerve injury 351 causes 351 relevant clinical findings 352 treatment 352 conservative treatment 352 surgical treatment 352 Loose bodies in the knee 427 clinical features 428 investigations 428 Index Low backache 461 epidemiology 461 pathological physiology 462 functional anatomy 462 posture 461 Lower limb orthosis 797 Lumbar canal stenosis 408 Lumbar disk disease 463 classification of prolapsed intervertebral disk 464 clinical features 466 definitive causes 466 differential diagnosis 470 extrinsic causes 470 intrinsic causes 471 disk anatomy 463 disk physiology 463 etiology of disk herniation 465 examination of the back 466 investigations 469 natural history 464 treatment 471 M Madelung’s deformity 492 causes 492 clinical features 492 other features 492 treatment 493 Maffucci’s disease 522 radiographs 522 Malleolar fixations 750 approach 750 indications 750 Mallet finger 196 clinical features 197 mechanism of injury 197 radiographs 197 several types 197 tendon origin 197 treatment 197 Malunion 43 causes 43 classification 43 types 43 clinical features 44 insignificant malunion 43 radiograph 44 significant malunion 43 treatment 44 Management of fractures 21 approach in compound fractures 23 investigations 24 fracture management by open reduction 22 contraindications 22 disadvantages 23 indications 22 methods 22 principles 22 management of fractures by closed reduction 21 reduction 21 resuscitation 21 management of simple fractures 21 conservative methods 21 management principles 24 considerations 24 external fixation in open fractures 26 internal fixation in open fractures 26 treatment plan 24 open fractures 23 classification 23 Marble bone disease Albers-Schönberg disease 522 clinical features 522 complications 522 etiololgy 522 pathology 522 prognosis 523 radiographs 522 March fracture 288 Marfan’s syndrome 524 McFarland’s bone grafting 502 Meckel’s cartilage Medial condyle of humerus 167 classification 168 stages of displacement 168 clinical features 168 complications 168 radiograph 168 treatment 168 Medial meniscus injury 254 clinical features 255 differential diagnosis 255 investigations 255 mechanism of injury 255 Smillie’s classification 254 treatment 256 Metabolic disorders leading to osteosclerosis 539 fluorosis 539 clinical features 539 investigations 539 treatment 539 891 Metacarpal fracture of thumb 206 salient features 206 Metacarpal fractures of fingers 204 clinical features 204 radiographs 205 salient features 204 treatment methods 205 Metacarpal head fractures 206 Metacarpophalangeal joint dislocations 202 clinical features 202 radiographs 202 salient features 202 treatment 202 Metaphyseal dysplasias 523 craniometaphyseal dysplasia 523 metaphyseal chondrodysplasia 523 metaphyseal dysplasia 523 Metastatic tumors of bone 637 clinical features 637 laboratory diagnosis 637 treatment 637 Metatarsal fractures 286 classification 287 clinical features 286 investigations 287 mechanism of injury 286 treatment 287 Metatarsalgia 439 clinical features 439 treatment 439 types 439 Metatarsophalangeal joint injuries 285 classification 286 clinical features 285 investigation 285 mechanism of injury 285 treatment 286 Meyer’s muscle 371 Middle and proximal volar space infection 455 deep palmar abscess 455 clinical features 455 diagnostic test 456 surgical anatomy 455 treatment 456 infection of web spaces 455 clinical features 455 treatment 455 tenosynovitis 456 clinical features 457 etiology 456 surgical anatomy 456 treatment 457 892 Textbook of Orthopedics Midfoot injuries 288 mechanism of injury 289 treatment goals 289 Mill’s maneuver 387 Monosodium urate arthropathy (Gout) 597 clinical features 598 incidence 597 investigations 598 radiology 598 treatment 598 Monteggia’s fracture 173 classification 173 clinical features 174 complications 175 mechanism of injury 173 treatment 175 Morquio-Brailsford disease 521 Morton’s neuroma 439 clinical features 439 treatment 440 Mucopolysaccharide disorders 520 Murel-Lavallee lesion 303 Muscle injury (strains) 94 pathophysiology 95 severity of strain 95 types 95 acute strain 95 chronic strain 95 Muscular dystrophies 610 Duchenne muscular dystrophy 610 clinical features 611 investigations 611 facioscapulohumeral muscular dystrophy 611 limb girdle muscular dystrophy 611 treatment 611 N Nail-patella syndrome 524 Navicular bone fractures 289 clinical features 290 complications 290 investigations 290 mechanism of injury 289 OTA classification 289 treatment 290 Nerve injuries 329 classification 330 Seddon’s classification 330 Sunderland’s classification 330 clinical diagnosis 331 diagnostic tests 332 electromyography 332 utility of strength duration curve 333 electrical stimulation 333 etiology 331 general causes 331 local causes 331 management 333 conservative management 334 general principles 333 operative management 334 methods of closing the gaps 334 nerve conduction studies 333 nerve degeneration 330 nerve regeneration 330 skin resistance test 333 sweat test 333 techniques 334 endoneurolysis 334 neurorrhaphy and nerve grafting 334 partial neurorrhaphy 334 Tinel’s sign 333 types 331 primary 331 secondary 331 types of nerve repair 334 delayed primary repair 334 primary repair 334 secondary repair 334 Neural tube defects 611 spina bifida 611 spina bifida occulta 612 treatment 612 Neuromuscular disorders 600 cerebral palsy 600 causes 600 clinical features 600 orthopedic deformities 601 leprosy in orthopedics 607 classification 608 investigations 608 treatment 608 multiple congenital contractures 606 causes 606 classification 606 clinical features 607 investigations 607 treatment 607 poliomyelitis 603 clinical features 603 differential diagnosis 604 pathogenesis 603 treatment 605 9-point diagnostic knee arthroscopy 812 eighth point: lateral gutter 815 fifth point: medial compartment 813 first point: suprapatellar pouch 812 fourth point: medial gutter 813 ninth point: patellar tracking 815 second point: patella 812 seventh point: lateral compartment 814 sixth point: intercondylar notch and anterior cruciate ligament 813 third point: trochlea 813 Nonunion 36 causes 38 classification 37 avascular nonunion 37 hypervascular nonunion 37 clinical features 38 history 38 signs 38 symptoms 38 investigations 38 management 38 role of bone grafting in nonunion 39 cancellous bone graft 39 cortical bone graft 40 phemister bone graft 40 role of electrical stimulation in nonunion 40 role of Ilizarov’s technique in nonunion 40 Nonunion 662 causes 662 clinical features 662 radiograph 662 treatment 662 O Olecranon bursitis 388 clinical features 388 investigations 388 treatment 389 Orthopedic affections in leprosy 608 foot-drop 608 treatment 609 plantar ulcers 609 treatment 609 Orthopedic disorders 355 examination 357 clinical examination 358 examination of gait 357 general physical examination 358 history 355 diagnostic facts 357 importance in the history 355 traumatic point 356 investigations 361 laboratory investigation 361 special investigations 361 Index Orthotics 795 classification 795 types 796 corrective spinal orthosis 797 orthosis for cervical spine 797 supportive spinal orthosis 796 Osgood-Schlatter disease 428 clinical features 428 treatment 428 Osteoarthritis of other regions 687 osteoarthritis of the small joints 687 osteoarthritis spine 687 Osteoarthritis of the hip 683 primary osteoarthritis of the hip 683 secondary osteoarthritis of the hip 683 clinical features 683 pathology 683 radiographs 683 treatment 683 Osteoarthritis of the knee 674 primary osteoarthritis of the knee 674 alternative therapies 681 clinical features 676 features 674 investigations 678 Kellegren and Lawrence radiological grading 678 mechanical aids 681 pharmacologic drugs 680 physiotherapy 680 treatment 679 secondary osteoarthritis of the knee 682 Osteochondritis dissecans 429 causes 429 clinical features 429 investigations 429 treatment 430 Osteogenesis imperfecta 518 classification 519 clinical features 519 etiology 519 investigations 520 pathogenesis 519 pathology 519 treatment 520 Osteomalacia 536 clinical features 536 etiology 536 laboratory investigation 536 pathogenesis 536 pathology 536 radiographs 536 treatment 537 Osteomyelitis 47, 540 acute osteomyelitis 540 agent factors 541 clinical signs 543 complications 546 differential diagnosis 545 environmental factors 541 etiology 540 host factors 541 investigations 543 management 543 pathophysiology 542 prognosis 546 chronic osteomyelitis 546 classification 547 clinical features 547 complications 549 management 548 residual osteomyelitis 549 subacute osteomyelitis 546 Osteoporosis 668 causes 668 clinical features 669 drug therapy 671 exercises 671 investigation 669 management 671 types 669 Osteotomy 568, 662 incidence 664 investigations 664 treatment 664 P Paget’s disease 525, 695 clinical features 526 investigations 526 radiograph 526 treatment 526 Painful heel 440 Paralytic hand 458 Paronychia 453 clinical features 454 treatment 454 Patellectomy 741 aftercare 741 approach 741 indication 741 surgical steps 741 Pathological fractures 113 clinical features 114 investigations 114 treatment 114 893 Pes cavus 435 classification 436 clinical features 436 radiographs 436 theories of pathogenesis 435 treatment 436 Pes planus 436 clinical features 437 radiograph 438 surgical correction 438 treatment plan 438 types 437 Phalangeal fractures 283 classification 285 clinical features 284 investigation 284 mechanism of injury 284 salient features 283 treatment 285 Physeal fractures 166 Plantar fascitis 441 clinical features 442 clinical tests 442 radiogaphs 442 rehabilitation methods 442 treatment 442 Plantar fibromatosis 445 presentation 445 treatment 445 Plates 71 methods of providing compression 71 types 71 AO plates 71 ordinary plates 71 Plica syndrome 429 Ponseti technique 508 benefits 509 treatment phase 508 Popliteal cyst (Baker’s cyst) 423 clinical features 424 investigations 424 treatment 424 Posterior decompression and surgical stabilization 764 aftercare 769 approach 764 indications 764 instrumentation 764 surgical steps 764 Posterior hip dislocations 213 classification 213 clinical features 214 goal of treatment 215 investigations 214 after reduction 215 before reduction 214 management 215 894 Textbook of Orthopedics Posterior instrumentation for vertebral compression fractures 759 aftercare 760 approach 759 indications 759 surgical steps 759 Post-traumatic osteoarthritis 47 Potts’ disease 407 Prosthesis for below knee amputations 793 Prosthesis for Syme’s amputation 794 Prosthesis for the lower limbs 793 Prosthetics 792 classification 792 endoprostheses 792 exoprostheses 792 types 792 permanent prosthesis 792 temporary prosthesis 792 Proximal femur fractures 226 subtrochanteric fracture 226 classification 226 clinical features 227 mechanism of injury 226 radiographs 227 treatment 227 Proximal humeral fractures 125 classification 125 clinical features 126 complications 127 investigations 126 management 126 nonoperative treatment 126 operative treatment 126 mechanism 125 Proximal phalanx fractures 200 classifications 200 clinical features 200 radiographs 200 salient features 200 treatment methods 200 Proximal tibial fractures 264 causes 264 clinical features 265 incidence 264 investigation 265 management 265 mechanism of injury 264 types 264 Pseudogout (CPPD) 599 Pump-bump 445 salient features 445 Q Quadriceps strain 262 causes 262 symptoms 263 treatment 263 R Radial head fracture 162 clinical features 162 complications 163 investigation 162 Mason’s classification 162 mechanism of injury 162 treatment 162 Radial nerve injury 340 causes 341 general 341 local 341 clinical features 342 investigation 343 treatment 343 Radial styloid fracture 179 clinical features 179 mechanism 179 radiographs 179 treatment 179 Radiocarpal dislocation 189 capitate fractures 192 clinical features 192 investigation 192 mechanism of injury 192 treatment 192 dorsal trans-scaphoid perilunar dislocation 190 clinical features 190 investigations 190 treatment 191 hamate fractures 192 clinical features 192 investigations 192 mechanism of injury 192 treatment 192 lunate fractures 191 clinical presentation 191 complications 191 investigations 191 treatment 191 pisiform fractures 191 clinical features 192 investigations 192 mechanism of injury 191 treatment 192 trapezium fracture 193 classifications 193 clinical features 193 investigations 193 mechanism of injury 193 treatment 193 trapezoid fracture 193 clinical features 193 investigations 193 mechanism of injury 193 treatment 93 triquetral fractures 191 clinical features 191 investigations 191 mechanism of injury 191 treatment 191 volar trans-scaphoid perilunar dislocation 189 clinical features 189 investigations 190 mechanism 189 treatment 190 Radiocarpal injuries 189 anterior dislocation of lunate 189 clinical features 189 mechanism of injury 189 radiograph 189 treatment 189 Recent trends in limb salvage surgery 639 Recurrent anterior dislocation of the shoulder 135 causes 135 clinical features 136 clinical tests 136 investigations 137 mechanism of dislocation 135 pathological anatomy 136 treatment 137 Recurrent dislocation of patella 424 clinical features 425 radiographs 425 treatment 425 Reflex sympathetic dystrophy 47 Renal osteodystrophy 532 causes 532 clinical features 532 investigations 533 treatment 534 Repetitive stress injury 480 incidence 480 investigations 481 presentation 481 Index stages 481 treatment 481 curative measures 482 health education 482 role of the institutions 482 Rheumatoid arthritis 581 clinical features 583 differential diagnosis 586 etiology 582 investigation 585 management 587 microscopy 582 orthopedic deformities 583 pathology 582 Rib fractures 308 clinical features 308 principles of treatment 308 radiology 308 Rickets 529 causes 529 clinical features 530 differential diagnosis 532 investigations 531 pathology 531 treatment 532 types 530 infantile rickets 530 late rickets 530 Ring fixator 85 benefits 85 complications 86 indications 86 Riordan’s operation 340 Rolando’s fracture 188 clinical features 188 radiograph 189 treatment methods 189 Rotator cuff lesions 380 impingement syndrome 381 causes 381 role of rotator cuffs 381 Rotator cuff tears 382 classification 382 clinical features 382 clinical tests 382 management 383 conservative treatment 383 surgical treatment 383 S SACH foot 794 ankle units and artificial feet 794 Sclerotic osteomyelitis of garre 550 clinical features 550 investigations 550 treatment 550 Scoliosis 397 clinical features 398 compensation 401 radiology 399 scoliotic facts 399 treatment 401 varieties 397 Scurvy 538 clinical features 538 differential diagnosis 539 etiology 538 investigations 539 pathology 538 radiographs 539 treatment 539 Semilunar cartilage injuries 254 anatomy 254 functions of the menisci 254 Seronegative spondyloarthropathies 591 diagnosis 593 CAT scan 593 HLA-B27 593 radiological diagnosis 593 etiology 592 signs 592 symptoms 592 Sesamoid bone injuries 286 clinical features 286 functions 286 investigations 286 mechanism of injury 286 treatment 286 Sesamoiditis 448 associated problem 448 clinical features 448 Shock 47 clinical features 47 investigations 48 treatment 48 Side swipe injuries 168 clinical features 168 investigations 169 mechanism of injury 168 methods of treatment 169 Shorbe’s classification 168 Sinding-Larsen-Johansson syndrome 428 Skeletal system bone development cortex diaphysis 10 epiphysis growth plate metaphysis 10 895 functions of bone hemopoiesis mineral storage movement and locomotion protection of vital organs support to the body medulla organization of the bones 10 appendicular skeleton 10 axial skeleton 10 osteon types of bones 10 flat bones 10 irregular bones 10 long bones 10 sesamoid bones 11 short bones 10 Skeletal tuberculosis 551 chemotherapy 553 clinical features 552 constitutional symptoms 552 monoarticular 552 etiology 551 investigations 552 pathology 552 changes in the marrow 552 lamellae 552 principles of treatment 553 prognosis 555 Slipped capital femoral epiphysis 416 clinical features 416 complications 417 etiology 416 investigations 416 Smith’s fracture 179 clinical features 180 complications 180 mechanism of injury 180 radiograph 180 treatment 180 Soft tissue injuries 93 approach to a patient with soft tissue injury 93 goal setting 94 patient’s story 93 classification 94 mechanism of injury 93 direct trauma 93 indirect trauma 93 treatment goals 94 immediate goals 94 Soft tissue injuries of the hand 209 Soft tissue problems 104 lower limbs 104 ankle and foot 104 hip and pelvis 104 896 Textbook of Orthopedics knee and leg 104 tendons and nerves 104 upper limbs 104 elbow 104 shoulder 104 wrist 104 Special types of muscle injuries 103 intermuscular hematoma 103 intramuscular hematoma 103 Spinal cord injury 324 clinical assessment 324 clinical classification 324 incidence 324 investigations 325 pathology 324 treatment 325 Spine surgery 87 Splints 60 conventional plaster splints 61 chemical formula 61 complications of POP 62 POP types 61 stages of plastering 62 various forms 61 unconventional splint 60 Spondylolisthesis 404 classification 404 clinical features 405 investigations 405 treatment 406 types 405 Sports injuries 801 classification 802 common sports injuries 802 investigations 803 treatment 804 Sprengel’s deformity 489 clinical features 489 etiology 489 pathology 489 radiograph 490 treatment 490 Standard arthroscopy portals 809 lateral port 809 medial port 809 other ports 811 midpatellar port 811 patient positioning 809 superolateral port 809 superolateral port 810 Steindler’s flexorplasty 350 Stimson’s gravity method 217 Supracondylar fracture 148 classification 149 clinical features 149 complications 154 management 152 mechanism of injury 149 radiographs 150 Supracondylar fracture humerus 707 indications 707 surgical steps 707 technique 707 Supracondylar fracture of femur 236 classification 237 Müller’s AO classification 237 Neer’s classification 237 OTA classification 237 clinical features 237 complications 239 mechanism of injury 237 radiographs 237 treatment 237 Supraspinatus tendinitis 381 T Tarsometatarsal injuries 291 classification 292 clinical features 291 investigations 291 mechanism of injury 291 treatment 292 TB spine with paraplegia 562 classification 562 clinical features 562 pathology 562 treatment 564 Tendon injuries 206 Tennis elbow 385 lateral tennis elbow 385 causes 385 clinical features 386 clinical tests 386 etiology 386 treatment 387 Tenosynovitis 102 treatment 103 types 102 infective 102 irritative 102 Tenovaginitis 103 Tension band wiring 741 aftercare 742 approach 741 indications 741 surgical steps 741 Tetanus 49 clinical presentation 49 investigations 49 pathogenesis 49 prevention 49 treatment 49 Thomson’s test 432 Thoracic and lumbosacral spine injuries 319 clinical features 320 investigations 320 management 321 McAfee’s classification 319 chance fracture 320 flexion distraction injury 320 stable burst fractures 320 translational injuries 320 unstable burst fractures 320 wedge compression 319 mechanism of injury 319 modified Magerl classification 320 Thoracic outlet syndrome 374 clinical features 375 neurogenic problem 375 vascular problems 375 complications 376 contributing factors 374 dynamic factors 374 static factors 375 investigations 376 sites of compression 374 infraclavicular 374 subclavicular 374 supraclavicular 374 tests 375 treatment 376 Thromboembolism 662 Torticollis (Wryneck) 373 causes 373 congenital 373 infective 373 myositis or fibromyositis 373 ocular disturbances 373 spasmodic 373 traumatic 373 unilateral muscle paralysis 373 clinical features 373 management 373 conservative 373 surgical 374 Total hip replacement 568 Traction in orthopedics 65 methods of traction 65 important skin tractions 66 skeletal traction 66 skin traction 65 types of skin traction 66 uses of traction 65 Index Trauma epidemiology fatal injuries mechanism motor vehicle accidents global scenario Indian scenario nonfatal injuries mechanism prehospital care prevention of injury sports injuries Traumatic disturbances 441 partial tears of tendo-Achilles 441 treatment 441 trauma around the region of tendo-Achilles 441 bursa enlargements 441 Hageland’s disease 441 treatment 441 Traumatic myositis ossificans 41 causes 41 classification 42 clinical features 42 pathology 41 radiograph 42 treatment 42 Treatment of orthopedic disorders 365 arthrodesis 369 combined arthrodesis 370 extra-articular arthrodesis 370 intra-articular arthrodesis 369 arthroplasty 370 excision arthroplasty 371 hemireplacement arthroplasty 371 total replacement arthroplasty 371 bone grafting operations 371 allografts or homograft or homogeneous grafts 371 autogenous gafts or autografts 371 xenografting 372 conservative methods 365 physiotherapy 365 radiotherapy 368 indications 372 masterly inactivity 365 operative treatment methods 368 osteotomy 368 role of a bone graft 372 tendon surgeries 372 Trigger fingers and thumb 390 treatment 391 Trochanteric fracture 664 clinical features 664 complications 666 mechanism 664 radiograph 665 treatment 665 Tubercular osteomyelitis 550, 572 spina ventosa type 572 radiographs 573 treatment 574 tuberculosis of tubular bones 572 tubercular osteomyelitis without joint involvement 572 clinical features 572 radiographs 572 Tuberculosis of hip joint 564 clinical features 565 investigations 566 laboratory tests 566 radiograph of the hip 566 other investigations 567 pathogenesis 565 treatment 567 Tuberculosis of knee 569 clinical features 569 investigations 569 treatment 570 Tuberculosis of the ankle 571 clinical features 571 radiographs 571 treatment 571 Tuberculosis of the shoulder 570 clinical features 571 pathology 570 radiographs 571 treatment 571 Tuberculosis spine 555 clinical features 557 complications 561 investigations 558 laboratory tests 558 physical findings 557 radiographs 558 sequences of pathological events 556 sites of involvement within the vertebra 556 treatment 561 Turco’s procedure 509 Types of fractures 15 atypical fractures 16 greenstick fractures 16 hairline or crack fracture 17 897 impacted fractures 17 pathological fractures 17 stress or fatigue fractures 17 torus fracture 17 based on fracture patterns 16 based on the extent of fracture line 15 complete fracture 15 incomplete fractures 15 displacement of fractures 17 linear fractures 16 bone loss 16 comminuted fractures 16 segmental fractures 16 simple or compound 15 U Ulnar nerve injury 335 causes 335 general causes 335 local causes 335 claw hand 336 causes 336 clinical features 337 clinical tests 337 pathomechanics 336 problems 336 types 336 treatment of ulnar nerve injury 339 Unreduced dislocation of elbow 161 clinical features 161 treatment methods 161 Upper limb orthosis 800 V Vitamin D-resistant rickets 534 clinical features 534 prognosis 534 radiography 534 treatment 534 Volkmann’s ischemia 32 Volkmann’s ischemic contracture 35 Von Recklinghausen’s disease 525 clinical features 525 radiographs 525 treatment 525 W Whiplash injury 313 clinical features 313 incidence 313 investigations 313 treatment 313 Wright’s test 375 ... release of epicondylar muscles • Bosworth technique of excision of the proximal portion of the annular ligament, release of the origin of the extensor muscles, excision of the bursa and excision of. .. Abduction of contracture of shoulder from contracture of intermediate part of deltoid Report of cases J Bone Joint Surg (BE) 1966; 48B: 127 -31 Shanmugasundaram TK Postinjection, fibrosis of keletal... ( 42% ) • Onset is usually less than 40 years of age 2Baron Fig 30 .28 : Contractures of MCP and PIP joints of ring and little fingers in Dupuytren’s disease (Clinical photo) Guillaume Dupuytren of