ORTHOPAEDIC NOTES Dr.

Raju Karuppal

1. Indications of surgical fixation in fracture Clavicle:

1. Nonunion. 2. Neurovascular involvement 3. Fracture of the lateral end near the acromioclavicular joint in an adult 4. A persistent wide separation of the fragments with interposition of soft tissue 5. Floating shoulder. 2.
Normal intra compartment pressure is Zero mm of Hg at physiologically inactive state Fasciotomy is indicated when the pressure reaches at 30 mm of Hg Deepest muscles are the earliest to get involved MC muscle involved in Upper limb is FDP 3. recurrent dislocation of shoulder Classification of recurrent shoulder dislocation is into two types (by Matsen) TUBS 1. T for traumatic meaning after an accident 2. U for unidirectional meaning either anterior or posterior and unilateral meaning either left or right 3. B for Bankart lesion is present 4. S for surgery is usually required for stability AMBRI 1. A for atraumatic meaning mild or no injury causes the initial dislocation 2. M for multi-directional meaning both in anterior and posterior directions 3. B for bilateral meaning both shoulders usually involved 4. R for rehabilitation meaning physiotherapy is the main treatment

5. I for if surgery is required then an inferior capsular shift type of surgery is done
Dugas test, Hamiltons test, Callaways test are the tests for Anteriorly dislocated of shoulder Apprehension test is for the assessment of recurrent dislocation of shoulder 4. Avulsion fractures of the lateral aspect of the proximal tibia below the articular surface are called Segond fractures Segond fractures may be accompanied by other injuries: Tear of the anterior cruciate ligament (75-100%). Injuries of the medial and lateral menisci (66-70%).

The Pellegrini-Stieda sign is a finding seen on x-rays of the knee. The Pellegrini-Stieda sign is a calcium deposit seen on the medial (inside) side of the knee, where the MCL attaches to the femur.

5. Baumann's Angle: - humeral capitellar angle: angle between long axis of humeral shaft & a line through
physis of lateral condyle. Baumans Angle increases in cubitus varus Q angle is the angle formed by the line of pull of the quadriceps mechanism and that of the patellar tendon as they intersect at the center of the patella. Clinically, it is represented by the intersection of a line drawn from the anterior superior iliac spine to the center of the patella with a second line drawn from the center of the tibial tuberosity to the center of the patella Bohlers angle: angle formed by intersection of line drawn from most cephalic point on tuberosity to highest point of posterior facet . normal range is 20-40 deg Cobb's angle, a measurement used for evaluation of curves in scoliosis on an AP radiographic projection of the spine

6. The most common type of epiphyseal injury is SH type 2. Thurston Holland sign- hallmark of type 2
epiphyseal injury, it is the metaphyseal fragment separated along with the epiphysis seen in x ray

7. The Morel-Lavalle lesion is a rare condition that was first described by the French physician Maurice
Morel-Lavalle The lesion is caused by forces of pressure and shear stress at the borders of subcutaneous tissue to the muscle fascia or bone as they are seen in run-over accidents. It leads to a shear of skin and subcutaneous tissue from the neighboring fascia followed by the development of a blood-filled hollow space at predestined regions of the body. If therapy is insufficient, large areas of necrosis can form, which will negatively influence operative measures. 8. Fracture dislocation at Tarso metatarsal joint is the Lisfrank fracture Fracture of the base of first metacarpal bone- bennets fracture Tibial Plafond fracture pilon fracture Fracture of radial styloid process chauffers fracture 9. GustilloAnderson classification of open fractures Grade I The wound is less than 1cm long. It is usually a moderately clean puncture, through which a spike of bone has pierced the skin. There is little soft-tissue damage and no sign of crushing injury. The fracture is usually simple, transverse, or short oblique, with little comminution. Grade II The laceration is more than 1 cm long, and there is no extensive soft-tissue damage, flap, or avulsion. There is slight or moderate crushing injury, moderate comminution of the fracture, and moderate contamination. Grade III

These are characterized by extensive damage to soft-tissues, including muscles, skin, and neurovascular structures, and a high degree of contamination. The fracture is often caused by high velocity trauma, resulting in a great deal of comminution and instability. III A Soft tissue coverage of the fractured bone is adequate III B Extensive injury to, or loss of soft tissue, with periosteal stripping and exposure of bone, massive contamination, and severe comminution of the fracture. After debridement and irrigation a local or free flap is needed for coverage. III C Any open fracture that is associated with an arterial injury that must be repaired, regardless of the degree of soft tissue injury.

10. Complications of the Colles fracture include:

malposition-malunion persistent neuropathies of the median, ulnar, or radial nerves radiocarpal or radio-ulnar arthrosis tendon ruptures- EPL Volkmann's ischemia finger stiffness shoulder-hand syndrome

11. separation of the glenoid labrum from the margin of the glenoid cavity called Bankart lesion
Hill Sachs- Defect in the posterolateral aspect of humeral head 12. Malunion is the most common complication of supracondylar fracture in children. Malunion results: 1. deformity(gun stoke), 2. ulnar nerve neuropathy, 3. high chance of fracture to lateral condyle of humerus on fall Other complications are: Acute:Compartment syndrome Myositis ossificans B artery injury Nerve injury- MC: Median

13. SUPPURATIVE ARTHRITIS usually ends with Bony ankylosis and the TB arthritis end up with fibrous
ankylosis except in Vertebral column

14. Rush pin has a role for temporary bone fixation.

Skeletal traction is given by putting a Steinmanns pin or a K wire through the bone which is connected to the bohlers stirrup 15. sudden increase in pain in osteochondroma seen in sarcomatous change , indications for surgery in osteochondroma are: bursitis fracture of osteochondroma Malignant transformation Neurovascular compression Mechanical block to the nearby joint movement

16. vacant glenoid" sign. And Electric bulbs sign on X-ray axillary view in posterior dislocation of shoulder
Posterior dislocation of shoulder is rare, the causes are congenital electric shock epilepsy

17. Floating knee: Concomitant ipsilateral fractures of the femur and tibia
Floating elbow-Concomitant ipsilateral fractures of the distal humerus and distal forearm Floating shoulder: Concomitant ipsilateral fractures of the clavicle and scapular neck 18. Gait cycle: STANCE PHASE = LIMB LOADING STANCE ( support) PHASE - Begins when the heel of the forward limb makes contact with the ground and ends when the toe of the same limb leaves the ground. a. Heel Strike - heel of forward / reference foot touches the ground b. Mid Stance - foot is flat on the ground and the weight of the body is directly over the supporting limb. c. Toe Off - Only the big toe of the forward / reference limb in contact with the ground.

60% OF GAIT CYCLE

SWING PHASE = LIMB ADVANCEMENT SWING ( unsupported ) PHASE - Begins when the foot is no longer in contact with the ground. The limb is free to move.

a. Acceleration - the swinging limb catches up to and passes the torso b. Deceleration - forward movement of the limb is slowed down to position the foot for heel strike MUSCLE ACTIVITY DURING GAIT INTERVAL JOINT POSITION MUSCLE ACTIVITY Gluteus Maximus Hip Acceleration to Heel Strike Knee Ankle Hip Knee Heel Strike to Midstance Ankle Tarsal Midstance to Toe Off Hip Knee Ankle Flexed Neutral Neutral Extended Flexed Hamstrings Gluteus medius & minimus Quadriceps femoris Anterior crural muscles Gluteus medius & minimus Quadriceps femoris

Dorsiflexed Gastrocnemius; soleus Inverted Extended Flexed Plantar flexed Everted Tibialis anterior Tibialis posterior Gastrocnemius Gastrocnemius; soleus Fibularis longus Fibularis brevis Iliopsoas

Tarsal

Toe Off to Acceleration

Hip

Flexed

Adductors longus, brevis, magnus

Knee Ankle Tarsal

Flexed Neutral Neutral

Gastrocnemius Anterior crural muscles -

19. Radial head excision contraindicated in children because

Maximum growth of radius is at pxoxiaml end It can cause valgus instability and valgus deformity

20. Stroncium Ranilate acts by Increasing the osteoid formation and Decreasing the osteoclast mediated
resorption of bone 21.

# neck of talus Aviators fracture 2 nd metatarsal # - March fracture 5th metatarsal base # - bar room fracture/ Boxer;s fracture Stress fracture of fibula Runners fracture (ref: Essentials of Skeletal Radiology (3rd. Ed.), page916

22. Fracture consist of both pubic rami plus posterior fracture of SI complex or sacrum:
- there is vertically oriented fracture through anterior and posterior pelvis together with superior displacement of lateral "acetabulum-containing" fragment of pelvis; Ischeal tuberosity fractures are usually avulsion fracture.

23. Articular cartilage is a highly organized avascular tissue composed of chondrocytes embedded within an
extracellular matrix of collagens, proteoglycans and noncollagenous proteins. Its primary functions are:

To enable the smooth articulation of joint surfaces, To cushion compressive, tensile and shearing forces.

Hyaline cartilage has one of the lowest coefficients of friction known for any surface to surface contact. Cartilage is unique as it is an avascular, aneural tissue, in which cells survive for a lifetime, without intercellular connections. Articular cartilage is hyaline type cartilage

24. De Quervain syndrome; also known as washerwoman's sprain, radial styloid tenosynovitis. De
Quervain's tenosynovitis is inflammation of tendons on the side of the wrist at the base of the thumb. These tendons include the extensor pollicis brevis and the abductor pollicis longus tendons. Finkelstein's Test. The patient is asked to make a fist with the thumb tucked inside the palm. Stabilize the patient's distal forearm with one hand, and ulnar deviate the wrist with your other hand. Sharp pain induced in the area of the first wrist tunnel (radial side) strongly points toward de Quervain's disease. Finsterer's Test. This is a two-phase test for Kienbock's disease: (1) If the normal prominence of the middle knuckle during clenching the fist firmly is not produced, the test is initially positive. (2) If percussion of the 3rd metacarpal just distal to the dorsal aspect of the midpoint of the wrist elicits abnormal tenderness, the sign is confirmed.

25. Galeazzi's test- affected thigh is shortened when the knees & hips are flexed to 90 degrees .
The Galeazzi test, also known as the Allis sign, is used in the assessment of congenital dislocation/developmental dysplasia of the hip. It is performed by flexing an infant's knees in the supine position so that the ankles touch the buttocks. If the knees are not level then the test is positive, indicating a potential congenital hip malformation Von Rosen's sign : With the baby lying supine and the pelvis steadied with one hand, the hip being tested is gently adducted and backward pressure is applied to the head of the femur. If the hip is dislocatable, a clunk will be felt and sometimes heard (Von Rosen's sign). If the hip is gently abducted, it will usually relocate Tinel's sign is a way to detect unmyelinated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve.It takes its name from French neurologist Jules Tinel (1879-1952). 26. Complications of scaphoid fractures are: Nonunions Avascular Necrosis Arthritis

Lunate is the most commonly dislocating carpal bone

27. Discoid meniscus is a rare human anatomic variant that usually affects the lateral meniscus of the knee.
A discoid meniscus is a congenital anomaly of the knee found in 3% of the population. It typically affects the lateral meniscus and may be found bilaterally (20%). Instead of the narrow crescent shape, as seen in a normal meniscus above, a discoid meniscus is thickened, and has a fuller crescent shape The Watanabe classification of discoid lateral meniscus is: (A) Incomplete Tear, (B) Complete Tear, and C) Wrisberg-ligament variant. 28. When a patient gets up to gain an erect posture the knee joint must maintain a position of full extension. This is achieved by locking at the knee joint which occurs from internal rotation of femur on the fixed tibia. The Muscle which helps in locking is Quadreceps femoris. How does the locking occurs: The articular surface of the medial femoral condyle is prolonged anteriorly,when compared to articular surface of lateral condyle. As the knee comes in to full extension,lateral condylar articular surface is fully used up but part of the medial condylar surface remains unused.at this stage the femur rotates internally until the remaining articular surface of the medial condyle is in contact. Unlocking of knee is required when flexion is initiated from a fully extended position. Unlocking is brought about by the action of Popliteus muscle

Plica Syndrome occurs when the plica (membranes that separate the knee into compartments during fetal development. These plica normally diminish in size during the second trimester of fetal development. In adults, they exist as sleeves of tissue called "synovial folds," or plica becomes irritated or inflamed

29. Operative correction congenital Talipes equino varus is basically the posteromedial release(Turco;s
procedure)

30. Plantar calcaneonavicular ligament is the (spring) ligament.

The ankle joint is bound by the strong deltoid ligament and three lateral ligaments: the anterior talofibular ligament, the posterior talofibular ligament, and the calcaneofibular ligament. The deltoid ligament supports the medial side of the joint, and is attached at the medial malleolus of

the tibia and connect in four places to the sustentaculum tali of the calcaneus, calcaneonavicular ligament, the navicular tuberosity, and to the medial surface of the talus. The anterior and posterior talofibular ligaments support the lateral side of the joint from the he The calcaneofibular ligament is attached at the lateral malleolus and to the lateral surface of the fibula to the dorsal and ventral ends of the talus. calcaneus.

31. The coronary ligament of the liver refers to parts of the peritoneal reflections that hold the liver to the
inferior surface of the diaphragm The coronary ligaments of the knee (also known as meniscotibial ligaments) are portions of the joint capsule which connect the inferior edges of the fibrocartilaginous menisci to the periphery of the tibial plateaus.

32. .Non union is the most common complication of fracture NOF

Other complications are: AVN OA Hip

33. walking cycle has two phases-swing phase and stand phase 34. most common type of meniscal tear is Longitudinal tear

35. Lachmans test- most specific test for ACL tear. The Lachman test is recognized by most authorities as
the most reliable and sensitive clinical test for the determination of anterior cruciate ligament integrity. Put the patient's knee in about 20-30 degrees flexion, also according to Bates' Guide to Physical Examination

the leg should be externally rotated. The examiner should place one hand behind the tibia and the other on the patient's thigh. It is important that the examiner's thumb be on the tibial tuberosity. On pulling anteriorly on the tibia, an intact ACL should prevent forward translational movement of the tibia on the femur ("firm endpoint"). Anterior Drawers test :The test is performed as follows: the patient is positioned lying supine with the hip flexed to 45 and the knee to 90. The examiner positions themselves by sitting on the examination table in front of the involved knee and grasping the tibia just below the joint line of the knee. The thumbs are placed along the joint line on either side of the patellar tendon. The index fingers are used to palpate the hamstring tendons to ensure that they are relaxed; the hamstring muscle group must be relaxed to ensure a proper test. The tibia is then drawn forward anteriorly. An increased amount of anterior tibial translation compared with the opposite limb or lack of a firm end-point indicates either a sprain of the anteromedial bundle of the ACL or a complete tear of the ACL. An instrument called a "KT-1000" can be used to determine the magnitude of movement in mm.

36. Subacromial bursitis is a condition caused by inflammation of the bursa that separates the superior
surface of the supraspinatus tendon (one of the four tendons of the rotator cuff) from the overlying coracoacromial ligament, acromion, coracoid (the acromial arch) and from the deep surface of the deltoid muscle Causes: Primary inflammation Autoimmune inflammatory conditions (rheumatoid arthritis) Crystal deposition (Gout or Pseudo gout) Calcific loose bodies (rheumatoid arthritis) Infection More commonly,as a result of complex factors, thought to cause shoulder impingement symptoms.

These factors are broadly classified as: Intrinsic (intratendinous) Extrinsic (extratendinous). They are further divided into primary or secondary causes of impingement. Secondary causes are thought to be part of another process such as shoulder instability or nerve injury Impingement syndrome, also called painful arc syndrome is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the

subacromial space, the passage beneath the acromion. This can result in pain, weakness and loss of movement at the shoulder Causes: Anything which causes further narrowing of subacromial space can result in impingement syndrome. This can be caused by: Bony structures such as subacromial spurs Osteoarthritic spurs on the acromioclavicular joint Variations in the shape of the acromion. Thickening or calcification of the coracoacromial ligament Loss of function of the rotator cuff muscles Subacromial bursitis

Frozen shoulder is when the shoulder is painful and loses motion because of inflammation. Most of the time there is no cause for frozen shoulder. However, risk factors include: Cervical disk disease of the neck Diabetes Shoulder injury Shoulder surgery Open heart surgery Hyperthyroidism 37. Arteries of the knee The femoral artery and the popliteal artery help form the arterial network surrounding the knee joint There are 6 main branches: 1. Superior medial genicular artery 2. Superior lateral genicular artery 3. Inferior medial genicular artery 4. Inferior lateral genicular artery

5. Descending genicular artery 6. Recurrent branch of anterior tibial artery The medial genicular arteries penetrate the knee joint The middle genicular artery is a small branch, arising opposite the back of the knee-joint. It pierces the oblique popliteal ligament, and supplies the ligaments and synovial membrane in the interior of the articulation. 38. Osteporosis: Symptoms occurring late in the disease include: Tests Bone mineral density testing-DEXA scan). A special type of spine CT , quantitative computed tomography (QCT),that can show loss of bone mineral density In severe cases, a spine or hip x-ray may show fracture or collapse of the spinal bones. Treatment The goals of osteoporosis treatment are to: Control pain from the disease Slow down or stop bone loss Prevent bone fractures with medicines that strengthen bone Minimize the risk of falls that might cause fractures Bone pain or tenderness Fractures with little or no trauma Loss of height (as much as 6 inches) over time Low back pain due to fractures of the spinal bones Neck pain due to fractures of the spinal bones Stooped posture or kyphosis, also called a "dowager's hump"

Medications are used to strengthen bones when: Osteoporosis has been diagnosed by a bone density study.

Osteopenia (thin bones, but not osteoporosis) has been diagnosed by a bone density study, if a bone fracture has occurred.

BISPHOSPHONATES Bisphosphonates are the primary drugs used to both prevent and treat osteoporosis

Alendronate Ibandronate Risedronate

CALCITONIN Calcitonin is a medicine that slows the rate of bone loss and relieves bone pain. It comes as a nasal spray or injection. HORMONE REPLACEMENT THERAPY Estrogens or hormone replacement therapy (HRT) PARATHYROID HORMONE Teriparatide is approved for the treatment of severe osteoporosis RALOXIFENE (selective estrogen receptor modulator (SERM) Raloxifene is used for the prevention and treatment of osteoporosis. Raloxifene is similar to the breast cancer drug tamoxifen.

39. The clay-shoveler's fracture is an oblique fracture of a lower cervical spinous process, commonly C7
Hangmans fracture: Traumatic spondylo listhesis of Axis Chance fracture- horizondal fracture through the spinous process

40. Simmonds-Thompson test is to test for the rupture of the achilles tendon.The patient lies face down
with feet hanging off the edge of the bed. If the test is positive, there is no movement of the foot on squeezing the corresponding calf, signifying likely rupture of the achilles tendon. Biceps brachi rupture causes Popeye deformity

41. Tendo Achillis tendinitis can be: Non insertional tendinitis: The main complaint associated with Achilles tendonitis is pain behind the heel. The pain is often most prominent in an area about 2-4 centimeters above where the tendon attaches

to the heel. In this location, called the watershed zone of the tendon, the blood supply to the tendon makes this area particularly susceptible Insertional tendinitis: Due to overuse Haglund's deformity may be related to this condition 42. Jons tendon transfer for radial nerve injury, Palmaris longus to substitute EPL Pronator teres to substitute ECRB FCU to substitute ED 43. spinal shock UM type palsy Spinal shock is the loss of sensation accompanied by motor paralysis with initial loss but gradual recovery of reflexes, following a spinal cord injury (SCI) -- most often a complete transection. Reflexes in the spinal cord caudal to the SCI are depressed (hyporeflexia) or absent (areflexia), while those rostral to the SCI remain unaffected 44. In cervical injury traction is given to Disengage inter locked articular process 45. As per 1987 Criteria for the Classification of Acute Arthritis of Rheumatoid Arthritis -The 14 possible areas are right or left PIP, MCP, wrist, elbow, knee, ankle, and MTP joints

In 2010 the 2010 ACR / EULAR Rheumatoid Arthritis Classification Criteria were introduced.These new classification criteria overruled the "old" ACR criteria of 1987 and are adapted for early RA diagnosis. The "new" classification criteria establish a point value between 0 and 10. Every patient with a point total of 6 or higher is unequivocally classified as an RA patient, provided he has synovitis in at least one joint and given that there is no other diagnosis better explaining the synovitis. Four areas are covered in the diagnosis: Joint involvement, designating the Metacarpophalangeal joints, Proximal interphalangeal joints, Interphalangeal joint of the thumb, Second through third metatarsophalangeal joint Wrist as small joints, Elbows, hip joints Knees as large joints:

Involvement of 1 large joint gives 0 points Involvement of 2-10 large joints gives 1 point Involvement of 1-3 small joints (with or without involvement of large joints) gives 2 points Involvement of4-10 small joints (with or without involvement of large joints) gives 3 points Involvement of more than 10 joints (with involvement of at least 1 small joint) gives 5 points

serological parameters including the rheumatoid factor as well as ACPA "ACPA" stands for "anticitrullinated protein antibody":

Negative RF and negative ACPA gives 0 points Low-positive RF or low-positive ACPA gives 2 points High-positive RF or high-positive ACPA gives 3 points

Acute phase reactants: 1 point for elevated erythrocyte sedimentation rate, ESR, or elevated CRP value (c-reactive protein)

Duration of arthritis: 1 point for symptoms lasting six weeks or longer

46. Radiological signs in scurvy are Wimberger line,Pelken Spur,Frenkels line

47. The position of lower limb in Synovitis hip joint is Flexion abduction external rotation
The position of lower limb in OA hip joint is Flexion adduction external rotation The position of lower limb in Posterior dislocation hip joint is Flexion adduction internal rotation

48. Trendelenburg's sign is found in people with weak or paralyzed abductor muscles of the hip, namely
gluteus medius and minimus. It is named after the German surgeon Sup GLUTEAL N (innervating the glu medius, which is the abductor of hip joint) 49. Most common complication of fracture lateral condyle of humerus is non union 50. Acramans zonal effect in HPR and Spotted veil in X Ray is in Myositis ossificans Heterotopic ossification two types 1.Dystrophic:serum ca and ALP are not non specific .but ALPmis the single most important investigation, as it is the measure of Osteoblastic activity 2.Metastaic :Serum ca level is very important investigation

51. Treatment of the Fracture neck of femur:

in young patients is - Closed pinning with screws Old age: hemiarthroplasty Any age with OA THR

52. Classification of supracondylar fracture in children:

- 2 types: extension type (95%) & flexion type; Most common type of supracondylar fracture of humerus is Extension type Gartland classification for extension fractures: - recognizes that anterior cortex fails first w/ resultant posterior displacement of distal fragment; - type I: non-displaced frx; - type II: displaced with intact posterior cortex; - type III: displaced with no cortical contact 53. Names of the surgeries: Genu valgum deformity - Mc Evens femoral osteotomy Perthes disease Varus derotation surgery by Axer C. Clubfoot deformity Turcos Posteromedial release Hip diseases- Watson Jones operation 54. In C5-6 disc prolapse,nerve injury seen is C6. C5-6 disc prolapse is the commonest site of IVDP at cervical spine 55. Pulled elbow is the is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn. This condition has been described by HUGH OWEN THOMAS( Hence called Thomas Elbow) 56. Follows a fall from height There is more association of the fractures of Calcaneum,vertebra and Base of skull. This areas are important in the skeletal survey 57. Osteomyelitis Subacute osteomyelitis is a distinct form of osteomyelitis, and Brodie abscess is one type of subacute osteomyelitis. Treatments:

Prolonged antibiotic therapy Surgical debridement. Open surgery is needed for chronic osteomyelitis, whereby the involucrum is opened and the sequestrum is removed or sometimes

Hyperbaric oxygen therapy in treatment of refractory osteomyelitis Ilizarov technique

58. Crush syndrome results from Massive crushing of muscles release of large amount of myohemoglobin in to the circulation,which is excreted in the urine (Myohemoglobinuria)

59. Slipped capital femoral epiphysis Symptoms

Difficulty walking, walking with a limp Knee pain Hip pain Hip stiffness Outward-turning leg - Axis deviation Restricted hip movements Treatment Surgery to stabilize the bone with pins or screws will prevent further slippage or displacement of the ball of the hip joint.

60. Ulnar nerve injury Froment's sign: when the patient is asked to adduct the thumb (such as holding a pencil in the web space), patient will instead hyperflex the IP joint to compensate for loss of the adductor wartenberg's sign (little finger abduction) due to unopposed ulnar insertion of extensor digiti quinti; little finger more often has more severe claw deformity, as opposed to ring finger, because of inherent increased laxity in little finger MP joint volar plate; in addition, approx 50% of pts have median nerve cross innervation to lumbricals to ring finger, thus preventing claw deformity of the ring finger; - Clawing - also known as Duchenne's sign;

Operative Procedures:

Adductor pollicis deficit: - adductor pollicis substitution by FDS of long finger passed thru interosseous membrane, over & under ECU as distal pulley; Byles procedure: transfer of BR (reroute around 3rd MC to adductor pollicis); - intrinsic muscles deficit: APL transfer to first dorsal interosseous MP joint arthrodesis

61. Mechanism of violence in burst fracture is axial Compression violence axial Compression violence alone or along with flexion , rotation or lateral flexion CHANCE FRACTURE- Horizondal avulsion injuru of vertebral bodies MC force involved in the fracture of the spine is Flexion

62. Gardens Classification of fracture femoral neck is:

Type I = Partial fracture Type II = Complete fracture and undisplaced Type III = Complete fracture with partial displacement Type IV = Complete fracture and fully displaced 63. Brachial pluxes injury can be pre ganglionic or post ganglionic Pre ganglionic lesions= o o o Poor prognosis, Surgically irreparable Histamine test is +ve

64. Medial meniscus injury is more common than Lateral meniscus, because of various reasons. The most
important is the medial meniscus is less mobile due to its attachment to the MCL. The ligaments in relation to menisci are: 1. Menisco femoral ligaments 2. Coronary Ligament Attach periphery of meniscus to tibial condyle 3. Transverse ligaments Attach the anterior edges of the medial and lateral meniscus Ligament of Wrisberg & Humphrey are the menisco femoral ligaments.They are extendingfrom the posterior part of the lateralmeniscus and ends on the femoral medial condyle in association with the PCL

Lig of Humphrey =Anterior menisco femoral lig. Lig of Wrisberg = Posterior menisco femoral lig Locking and giving way are very commonly seen with meniscus tear Indications for meniscus tear repair are: Peripheral tear-RR RW Zone Acute tears should be repaired Longitudinal tears should be repaired Associated ACL injury

65. Airplane splint is used in Brachial plexus palsy to prevent the deformities 66. Lateral condyle humerus excition can cause lateral instability of elbow with cubitus valgus deformity 67. . There are two types of traction: skin traction and skeletal traction.
Maximum weight that can be used in skin traction is 1/10 of body Wt. Bryant's traction - in young children who have fractures of the femur Buck's traction - hip fractures Dunlop's traction - humeral fractures in children Russell's traction- Fracture femur

68. Subperiosteal new bone formation is not a feature of Eosinophilic granuloma Periosteal reaction can result from a large number of cause: 1.Trauma - bone healing in response to fracture, subperiosteal hematomas 2.chronic irritation due to a medical condition such as hypertrophic osteopathy, 3.osteomyelitis, 4.cancer of the bone. 5.as part of thyroid acropachy, 6.a severe sign of the autoimmune thyroid disorder Grave's disease. 7.Menkes kinky hair syndrome 8. hypervitaminosis A. It can take about three weeks to appear. 69. Subtrochanteric fracture fixation methods EXTRAMEDULLARY fixation methods = DHS & Condylar butress plate

Intramedullary fixation methods = Russel Tayler nail,Gamma nai &Ender nail

70.

Locking and giving way are very commonly seen with meniscus tear Indications for meniscus tear repair are: 1. Peripheral tear-RR RW Zone 2. Acute tears should be repaired 3. Longitudinal tears should be repaired 4. Associated ACL injury

71. Organism causing Osteomyelitis Age group Newborns (younger than 4 mo) Most common organisms S. aureus, Enterobacter species, and group A and B Streptococcus species S. aureus, group A Streptococcus species, Haemophilus influenzae, and Enterobacter species

Children (aged 4 mo to 4 y)

Children, adolescents (aged 4 y S. aureus (80%), group A Streptococcus species, H. influenzae, and to adult) Adult Sickle Cell Anemia Patients Enterobacter species S. aureus and occasionally Enterobacter or Streptococcus species Salmonella species

Commonest organism causing osteomyelitis in children under 3 years is Staphylococcus aureus 72. In COMPARTMENT SYNDROME the deepest muscles are first to get involved 73. . Brachialis is a muscle with dual nerve supply Brachialis is supplied by Radial and musculocutaneous nerve 74. Ulnar nerve It is the terminal branch of the medial cord, root value C8, T1 but sometimes it is joined by fibers of C7 which arises from the lateral cord. It runs along the medial border of the axillary artery up to the medial aspect of the brachial artery to the middle of the arm were it pierces the medial intermuscular septum to enter the extensor compartment of the arm. 75. Aaaaa

76. Spinal tumors are neoplasms located in the spinal cord. They are mostly metastases from primary
cancers elsewhere (commonly breast, prostate and lung cancer). Primary tumors may be benign (e.g. hemangioma) or malignant in nature. Depending on their location, the spinal cord tumors can be: Extradural - Metastasis, meningioma Intradural - neuro fibroma Intramedullary - ependymoma,neuro fibroma Commonest intramedullary spinal tumour is: Ependymoma

77. Tennis elbow is an overuse injury occurring in the lateral side of the elbow region, but more specifically,
occurs at common extensor tendon that originates from the lateral epicondyle. Tests for Tennis elbow are Cozen & Mills The pathology of tennis elbow is Angio fibroblastic hyperplasia at the origin of the extensor carpi radialis brevis

78. A fat embolism is a type of embolism that is often caused by physical trauma such as fracture of long
bones, soft tissue trauma and burns The pathogenesis occurs due to both mechanical obstruction and biochemical injury. The microemboli cause pulmonary and cerebral microvasculature occlusion. It is aggravated by local platelet and erythrocyte aggregation. The release of free fatty acids from the fat globules causes local toxic injury to endothelium. The vascular damage is aggravated by platelet activation and recruitment of granulocytes. Clinical Manifestations are Neurological (Brain) Dematological Ocular Respiratory

79. Bone tumour metastasizing to bone is Ewing's sarcoma

80. Giant-cell tumor of the bone is characterized by the presence of multinucleated giant cells (osteoclastlike cells). On x-ray, giant-cell tumors (GCTs) are lytic/lucent lesions that have a epiphyseal location and grow to the articular surface of the involved bone. Radiologically the tumors may show characteristic 'soap bubble' appearance] They are distinguishable from other bony tumors in that GCTs usually have a non-sclerotic

and sharply defined border. 5% of giant-cell tumors metastatise, usually to lung, which may be benign metastasis Osteoclastoma is common in age group of: 20 to 40 years 81. Name of cast and its use Risser/turn buckle cast used for scoliosis U cast/hanging cast- #humerus Minerva cervical spine injury PTB cast - #tibia

82. The most common cause of a sprained ankle is injury of: Anterior Talofibular ligament

83. Flexion abduction position of proximal fragment in subtrochanteric fracture is due to the pull of iliopsoas
anteriorly and the gluteus medius laterally

84. Scurvy characterized by metaphyseal enlargement . In spondylo-epiphyseal dysplasia and rickets the
epiphysis is the main area of involvement. 85. Colles fracture has six components - Proximal impaction, Lateral rotation, Dorsal angulation, dorsal tilt,lateral angulation ,lateral tilt

86. Bryants triangles A triangle drawn in order to determine the upward displacement of the trochanter in
fracture of the neck of the femur. Its dimensions are changed in supratrochanteric pathology

87. In Hemophilia, pseudotumour is most often found in Ilio psoas 88. Osteogenesis imperfecta hallmark is h/o multiple fracture with deformities 89. Injury of median nerve at wrist is best detected by Action of abductor pollicis brevis because it is solely
supplied by the median and can test very easily and reliably

90. Excition of olecranone is indicated in:

Non articular fractures Fracture in elderly Fracture with extensive comminution(orif not amenable) Old ununited fracture

91. Multiple exostosis usually presents at: Puberty because its the time of maximum bone growth. 92. Gate control theory asserts that activation of nerves which do not transmit pain signals, called
nonnociceptive fibers, can interfere with signals from pain fibers, thereby inhibiting pain. Afferent pain-receptive nerves, those that bring signals to the brain, comprise at least two kinds of fibers a fast, relatively thick, myelinated "A" fiber that carries messages quickly with intense pain, and a small, unmyelinated, slow "C" fiber that carries the longer-term throbbing and chronic pain. Large-diameter A

fibers are nonnociceptive (do not transmit pain stimuli) and inhibit the effects of firing by A and C fibers.The peripheral nervous system has centers at which pain stimuli can be regulated. Some areas in the dorsal horn of the spinal cord that are involved in receiving pain stimuli from A and C fibers, called laminae, also receive input from A fibers. The nonnociceptive fibers indirectly inhibit the effects of the pain fibers, 'closing a gate' to the transmission of their stimuli. In other parts of the laminae, pain fibers also inhibit the effects of nonnociceptive fibers, 'opening the gate'.

93. Maximum shortening of limb is seen in Posterior dislocation hip due to the proximal migration of the femur
when it is out of the acetabulam.

94. Collapsed dorsal vertebra with disc space narrowing is the radiological sign infection of spine 95. Synovial fluid is a viscous, non-Newtonian fluid
Synovial tissue is a vascularized connective tissue that lacks a basement membrane. Two cell types (type A and type B) are present: Type B produces synovial fluid. Synovial fluid is made of hyaluronic acid and lubricin, proteinases, and collagenases. Synovial fluid exhibits non-Newtonian flow characteristics; the viscosity coefficient is not a constant and the fluid is not linearly viscous. Synovial fluid has thixotropic characteristics; viscosity decreases and the fluid thins over a period of continued stress. Normal synovial fluid contains 34 mg/ml hyaluronan which is synthesized by the synovial membrane and secreted into the joint cavity to increase the viscosity and elasticity of articular cartilages and to lubricate the surfaces between synovium and cartilage Synovial fluid contains lubricin secreted by synovial cells. Chiefly, it is responsible for so-called boundary-layer lubrication, which reduces friction between opposing surfaces of cartilage.

96. Deep heat is produced when energy is converted into heat as it passes through body tissues.Energy
sources include high-frequency currents (shortwave diathermy) electromagnetic radiation (microwaves) ultrasound (high-frequency sound).

The best method for large-area deep heating is shortwave diathermy. This modality is useful for various indications. 97. fixed flexion deformity of a joint Complete extension is not possible

98. Hunter described the 4 classic stages of natural bone repair:

Inflammation Soft callus Hard callus Remodeling.

The inflammation stage begins soon after injury and appears clinically as swelling, pain, erythema, and heat. After the initial inflammatory phase, the soft callus stage begins with an infiltration of fibrous tissue and chondroblasts surrounding the fracture site. Soft callus is then converted into rigid bone, the hard callus stage, by enchondral ossification and intramembranous bone formation. Once the fracture has united, the process of remodeling begins. Fibrous bone is eventually replaced by lamellar bone. This process has been called secondary bone union or indirect fracture repair, it is the natural and expected way fractures heal. Anatomic reduction and absolute stabilization of a fracture by internal fixation alter the biology of fracture healing. Absolute stability with no fracture gap (eg, via ORIF using interfragmental compression and plating) presents a low strain and results in primary healing (cutting cone) without the production of callus. 99. CARPEL TUNNEL SYNDROME is the most common peripheral nerve compression neuropathy 100. A popular form of muscle stimulation, Faradic current( intermittent and nonsymmetrical alternating current) is an alternating current that affects the muscle only and causes no reaction in the skin. Galvanic current is using for nerve stimulation