By – Nikita Singh (MPT Ortho.

)
 Amputation of limb is one of the oldest surgical
procedure in medical science. It was even in practice
during prehistoric time when many limbs were lost in
battles or removed surgically after serious injuries.
 Survival rate of amputees were not good
previously, but with advances in medical science
more and more lives have been saved, leaving
more and more number of survivors without
limbs.
 Definition - an amputation is the severing of a part
of body in order to save the rest of body.
 Ambrose pare was the surgeon who introduced
amputation surgery and therefore called as father of
amputation.
 Causes of amputation – there are two main causes of
amputation –
 Congenital –
 Acquired –
 Congenital – conditions in which children are born
without limbs, or just flippers like tags attached to the
body is the main cause of amputation due to
congenital cause. These condition is called as
phocomelia.
 Acquired causes – many conditions result in
amputation of limb. Main conditions are as following

 Vascular cause – it is the most common cause of

amputation. There are many vascular conditions that
cause amputation –
1. Diabetes mellitus
2. Frost bite
3. Gangrene
4. Artriosclerosis
5. Thromboangitis obliterans (TAO)

• Infection – conditions such as osteomyelitis, insect

bites, septic ect.
• Neoplasm – tumors of bone or soft tissue.
• Trauma – RTA, industrial accidents, burns, non
union of fractures, knife or gun wound injuries.
 Types of amputation – amputations are classified
according to the surgical procedure or the emergency
of situation.
 Provisional amputation – it is also known as guillotine
amputation or open amputation. In this type of
amputation all structures are being cut at the same
level without any anatomical level or skin flaps.
 It is done as an emergency or life saving procedure.
 Definitive amputation – it is also known as closed
amputation, it may be used after provisional
amputation as an elective surgery. In this amputation
anatomical levels are well defined and proper soft
tissue and skin flaps are taken to give proper shape to
stump.
 Amputation surgery is no longer a life saving
procedure but it is a refined reconstruction surgery,
the remaining part of limb or stump is used for motor
function such as standing, balancing or gait training
and for sensory feedback as well and also for
cosmesis.
 In general surgeon tries to save as much limb length
as possible and as much joints as possible. So that
patient can tolerate stress of weight bearing and
prosthetic fitting becomes easy.
 Surgeon dissects the bone at first, then dissects the
soft tissue at least 5 to 10 cms inferior to bone and
dissects the skin most inferiorly that is at least 5 to 10
cms inferiorly to the soft tissue. So that stump
becomes soft and to prevent direct pressure over the
bony end.
 There are two surgical procedures for skin closure. In
most of nondyvascular transtibial amputation or
transfemoral amputation equal anterior posterior skin
flaps are taken.
 These procedure places the suture in center of stump.
 In case of dyvascular amputation or most of the
transtibial amputation long posterior flap is taken and
short anterior flaps are taken because posterior flaps
are having better blood supply.
 This procedure places the suture in anterior aspect of
stump.
 The long posterior flap is used for better blood supply
to the stump, but still it has a major disadvantage. As
the suture is in anterior aspect of stump it may get
adhere with the underlying bone and result in fibrosis
of skin with the underlying bone.
 This complication may affect the prosthetic fitting.
 To avoid this complication a new technique was
developed known as a SKEW flap.
 In SKEW flap an angular medial lateral insicion is
made that places the suture away from the bony end
and prevents sutures to get adhere with bony end.
 There are many methods of muscle closure, mainly
myodesis, myoplasty or tenodesis procedures are used
after amputation.
 In myodesis the muscles and fasciae are sutured or
attached directly to the distal end of bone through drill
holes.
 The muscle inserted into bone functions better and
provide very good prosthetic control, but this
procedure compromises blood supply to the muscles
so this procedure is contraindicated in patients with
severe peripheral vascular diseases.
 In myoplasty the muscles of anterior and posterior
compartment are sutured to each other at the junction
and then they are attached with the distal end of bone .
 The muscles must be stretched enough that so that
they provide better control on residual limb. This type
of surgical procedure provides distal soft tissue
padding over the stump.
 In tenodesis tendon tendon of major muscle is inserted
over the end of bone.
 Major nerves and vessels are identified, pulled gently
and being cut neatly so that it retracts well and
provide proper sensation to stump.
 Amputations are performed at different levels of of
upper limb and lower limb –
 Levels in upper limb –
 Forequarter – in this clavicle and scapula are removed
partially along with entire upper limb.
 Shoulder disarticulation – in this the entire upper limb
is removed from the shoulder joint.
 Neck of humereus amputation – in this the amputation
is performed through neck of humereus.
 Above elbow amputation – it is performed above the
elbow, it may be of two types – long above elbow and
short above elbow.
 Elbow disarticulation – it is performed through the
elbow joint.
 Below elbow amputation – it is performed through
forearm. Like above elbow amputation it may be long
below elbow or short below elbow.
 Wrist disarticulation – it is performed through the
wrist joint.
 Transmetacarpal amputation – performed through
metacarpals.
 Transphalangeal – it is performed through fingers,
also known as ray amputation.
 Hemipelvictomy – in this type of amputation partial
parts of pelvic bone are removed along with entire
lower limb.
 Hip disarticulation – in this technique amputation is
performed through the hip joint.
 Above knee amputation – in this amputation is
performed through the shaft of femur. It may be long
above knee or short above knee. It is also known as
transfemoral amputation.
 Knee disarticulation – in this procedure amputation is
performed through the knee joint.
 Below knee amputation – in this procedure
amputation is performed below the knee through the
tibia and fibula. Also know as transtibial amputation.
 Syme s amputation – it is a type of below knee
amputation just above the distal part of tibia and
fibula and the heel pad is reattached to the stump, to
provide proper cushion and prosthetic fitting.
 Lisfranc amputation – it is an amputation through
tarsometatarsal joint and in this sole of foot is being
preserved to make a flap, to provide better blood
supply.
 Chopart amputation – it is articulation through
midtarsal joint, it means the forefoot and midfoot is
removed and hindfoot is being preserved.
 Boyds amputation –it is an amputation through ankle
joint with fusion of calcaneum to tibia.
 Complications of amputation surgery are of two types
–
 Immediate complication –
• Late complication –

• Immediate complication – an immediate complication

is one that occurs immediately after an amputation
surgery.
• It may be of following types –
 Failure of healing.
 Infection in suture.
 Recurrence of disease or neoplasm.
 Painful neuroma.
 Phantom limb pain.

 Phantom limb pain – majority of patients after

amputation surgery complaint phantom limb pain
sensations.
 It is simply defined as sensation of limb that is no
longer a part of body.
 This sensation might be felt by patient immediately
after surgery or after few days of surgery.
 Patient often describe it as tingling, burning, itching,
pressure or sometimes a numbness sensation.
 Late complications – they occur after four weeks of
surgery. They may be –
 Improper shaped stump or dog ear stump.
 Contracture of residual limb.
 Decreased ROM.
 Decreased Muscle power.
 Psychologically demotivation.
By – Dr. Ankit Gaur (MPT Ortho.)
 Definition – in common language a fracture is a
cracked or broken bone following trauma, accident,
hit, fall ect.
 In proper terms a fracture is defined as a break in the
continuity of a bone or a structure of body.
 It usually occurs due to direct trauma or indirect
trauma.
 Sometimes a fracture may occur during normal
activities of daily living or minute trauma, these
fractures are called as pathological fracture.
 Classification of fractures – fractures are of two types
–

 Simple or closed fracture –

 Compound or open fracture –
 Simple or closed fracture – in this type of fracture
there is no wound directly over the fracture site and
the fractured bone does not communicate with the
outer environment.
 Compound or open fracture – in this type of fracture
there is always a wound over the fracture site and
fractured bone communicates with the outer
environment. They are difficult to treat because of
extensive skin and soft tissue loss.
 Patterns of fracture – a bone may get fractured in
various patterns. Mainly a bone gets fractured in
following pattern –
 Transverse Fracture – the fracture line is placed
transversely in this type of fracture. It results from a
direct injury or trauma.
 Oblique Fracture – the fracture line is placed
obliquely and this fracture results from indirect
injuries.
 Spiral Fracture – it results from a twisting or
rotational force to the bone. The fracture line is
spirally placed and they are undispalced fractures.
 Impacted Fracture – in this type of fracture both ends
of fractured bone are driven into each other.
 Comminuted Fracture – in this type of fracture bone is
broken into more than two pieces.
 Segmental fracture – it is also known as double
fracture. In this bone is fractured at two different
levels.
 Incomplete fracture – in this type of fracture only one
cortex of bone is fractured without any change in the
alignment of the bone. In children an incomplete
fracture is called as greenstick fracture.
 Compression fracture – in this type of fracture one
bone is being compressed between two bones. It is
common in cancellous bones vertebral bodies.
 Avulsion fracture – sudden and forceful contraction of
a muscle when it is not prepared to take it, may result
in fracture.
 Ex. – fracture of patella by sudden contraction of
quadriceps femoris, fracture of greater tubercle by
contraction of suprasinatus.
 Displacement – a fracture may be either displaced or
undisplaced. In undisplaced fracture bone remains in
its anatomical allignment, but in displaced fracture
bone does not remain in its alignment and gets
displaced from its place.
 The displacement may occur due to pull of attached
muscles or gravity.
 Following types of displacement may occur -
 Lateral displacement – in this fragments of fratcured
bone get displaced laterally.
 Angular displacement – where fragments of fractured
bone form an angle with each other.
 Overriding – in this type of displacement fractured
fragments overlap each other.
 Rotational displacement – in this fragments rotate in
relation to each other.
 Diagnosis of fracture – the diagnosis of fracture can
be made from the following points –
 History – there is always a history of sudden trauma
or accident in fracture, except in case of pathological
fractures.
 Symptoms of fracture –
 Pain is the most consistent feature of fracture.
 Localized swelling is also a common symptom of
fracture.
 Swelling may occur either from haemorrhage or
inflammation.
 Deformity occurs in case of displaced fractures or in
dislocations.
 Loss of movements is also a consistent feature of
fracture.
 Inability to bear weight in case of lower limb
fractures, the patient is not at all able to bear body
weight.
 Signs of fracture – after fracture patient may get
following signs –
 Muscle spasm and tenderness.
 Oedema
 Warmth
 Crepitus
 Deformity and abnormal mobility
 Investigations of fracture –
 Radiography – it is the most commonly used tool in
the diagnosis of fractures. Plain AP view and lateral
view radiographs are routinely taken in every case.
Sometime special view is also required like sunrise
view in case of patellar fracture.
 CT Scan or MRI Scan are also performed in special
cases such as fracture of small bones or vertebral
fractures or skull fractures.
 Fracture healing – the healing of fracture occurs in
three phases –
 Inflammatory phase
 Cellular proliferation phase
 Remodelling phase
 Inflammatory phase – in this phase a haematoma or a
clot is formed between and around the broken bone
ends. Then it is followed by vasodilation and release
of blood cell and protein around the bone ends. The
new granulation tissue is formed due to cell
proliferation between the bone ends.
 Soft tissue proliferation – in this stage granulation
tissue is formed between the bony ends and it fills the
gap between the fractured ends. Once the granulation
tissue is formed the calcium deposits around the
granulation tissue and it is called as callus formation.
 The external and medullary calus meet and unite the
fracture. At this point fracture is called united
clinically but weight bearing is not allowed at this
stage.
 Remodelling phase – in this phase of healing normal
ossification of callus takes place and the soft callus
gets consolidated by the deposition of bone salts. This
process is carried out by the osteoblast cells.
 The medullary cavity is reproduced and marrow cells
reappears in this phase.
 The process of remodelling ends with the
reconstruction of new bone similar to the one before
injury.
By –

Ankit Gaur (MPT Ortho.)

 Fractures of upper extremity are very common
following RTA, fall on outstretched hand, hit or after a
bone disease or pathology.
 Fractures of upper extremity unite faster than fractures
of lower extremity.
 Upper limb fractures are of following types –
 Fracture of clavicle is one of the commonest injury of
upper limb around shoulder and it is seen at all age
groups.
 The clavicle is only long horizontal bone of body.
 It is commonly fractured at the junction of its middle
and lateral third .
 Mode of injury – fractures of clavicle are usually seen
in its junction between middle and lateral one third
from a fall on outstretched hand or by direct hit over
the clavicle.
 Diagnosis – the clinical diagnosis of clavicular
fracture is not difficult because it is a subcutaneous
bone and the fractured shoulder drops downwards by
pull of gravity and the upper fragment is pulled
upwards by pull of SCM muscle.
 A radiograph confirms the fracture of clavicle. An AP
view is sufficient to find the fracture.
 Treatment of clavicular fracture – a clavicle fracture
can be treated conservatively or surgically depends on
the condition of bone. Most of the clavicular fracture
are treated conservatively.
 A figure of eight bandage is used and it is tied around
the shoulder blade to brace up both shoulder girdles
 A cotton pad is placed in the axilla to avoid
compression by bandage or to avoid discomfort.
 Bandage may get loosened after few weeks so regular
inspection of bandage is necessary and needs to be
tightened or changed.
 Surgical treatment – in case of sever or communited
fractures conservative treatment is not possible so
fracture needs to reduced surgically by open reduction
and internal fixation ORIF, by using plates and
screws.
 In conservative treatment after placing a figure of
eight bandage hand is supported by a triangular sling.

 Complications of Clavicular Fracture –

 Injury to brachial plexus by fractured ends.
 Malunion
 Nonunion
 Fracture of scapula is rare and easy to reduce because
it is supported by large muscles group.
 Scapula may get fractured through –
 The body
 The neck
 The spine
 The coracoid process
 Treatment – the fracture of scapula is generally treated
conservatively by supporting the limb in a sling for
two weeks, these fractures does not need any special
method of immobilization because the scapula is
surrounded by major muscle groups so these muscles
support the scapula.
 It is of three types –
 Anterior dislocation –
 Posterior dislocation –
 Luxatio Erecta –

 Out of these three types of dislocations the anterior

dislocation is the most common.
 The anterior dislocation is most common and it results
from fall on the outstretched hand with limb in lateral
rotation and abduction. In this position the shoulder is
in closed pack position and the head of humerus thrust
against the tight joint capsule and may slip out of the
joint cavity. The anterior dislocation is again divided
into three types -
 Subcoracoid –
 Subglenoid –
 Subclavicular –
 Posterior dislocation – it is not as common as anterior
dislocation. In this type of dislocation the head of
humerus is dislocated posteriorly from the glenoid
cavity.
 Luxatio Erecta – it is a rare kind of dislocation in
which the head of humerus is dislocated inferiorly and
is pushed beneath the glenoid cavity and the arm is
held fixed in wide abduction, elevation.
 This results when the limb is strongly abducted ex. –
holding a branch of tree while falling down from tree.
 Treatment – shoulder dislocation is reduced or
relocated conservatively by using a kochers maneuver.
 After reduction the arm is immobilized in full internal
rotation and adduction by bandaging the arm to
thorax.
 It is of two types –
 Cotusion faracture –
 Avulsion fracture –
 Fall on an outstretched hand may result in a contusion
fracture of greater tuberosity of humerus.
 Direct blow at the side of shoulder may also result in
similar fracture. A contusion fracture is comminuted
fracture but fragments are undisplaced.
 Avulsion fracture – this injury results from fall on
outstretched hand when supraspinatus muscle
contracts against the outstretched force and it results
in avulsion fracture of greater tuberosity of humerus.
 Treatment – for undisplaced contusion fractures
support the limb in a triangular sling for two to three
weeks but in case of avulsion fractures internal
fixation is required.
 Fractures of neck of humerus occur in middle aged or
elderly patients following small velocity traumas such
as fall on outstretched hand or simple fall on side of
arm.
 Classification – these fractures are classified into two
types –
 According to pattern.
 According to displacement.
 According to pattern they are classified into 4 types by
neers classification. This classification involves four
major segments of proximal end of humerus
 The head
 The grater tuberosity
 The lesser tuberosity
 The neck
 One part fratcure – in this all fragments are
undisplaced.
 Two part fracture – in this one segment is separated
from the others.
 Three part fracture – in this two segments are
displaced from remaining two fragments.
 Four part fracture – in this type of fracture all
segments are separated from each other.
 According to displacement they are divided into two
types –
 Abduction type of fracture –
 Adduction type of fracture –
 Treatment – minimally displaced fractures are treated
conservatively by closed manipulation and
immobilization by POP U slab for 4 weeks.
 Displaced fractures such as two part or three part
fractures are treated by ORIF using plates and screws.
 In case of four part fractures joint replacement of
arthoplasty is performed.
 Fracture of shaft of humerus is common in all age
groups, it could be transverse, oblique, spiral,
comminuted or segmental.
 The mode of injury may be either Direct or Indirect.
Direct injury results in either a comminuted or
transverse fracture, while an indirect injury results in
spiral or oblique fracture.
 Pathological fractures are also seen in shaft of
humerus.
 Treatment – the fracture of shaft of humerus may be
treated by following methods –
 Conservative management –
 By POP U Slab - in this technique the fracture is
manipulated and elbow is held in 90 degree of flexion
and a downward pull to distal fragment corrects the
overriding of fragments, the arm is immobilized in
POP U slab with arm at side of body.
 Operative management – it may be done by ORIF or
CRIF.
 In ORIF fracture is fixed by using plates and screws.
 In CRIF fracture is reduced by using intramedullary
nail (kuntschers nail).
 Supracondylar fracture is seen just above the humral
condyles. It is commonest fracture in children, this
fracture results from direct injuries such as fall on the
pointed elbow or indirect injuries such as fall on the
outstretched hand.
 In this fracture the distal fragment may get displaced
either posteriorly or anteriorly.
 If gets displaced posteriorly it is called as an
Extension fracture.
 If it gets displaced anteriorly it is called as flexion
fracture.
 The extension type of fracture is more common than
the flexion type fracture.
 This fracture may result in neurovascular injury by
sharp edges of proximal fragment. Injury to median
nerve or brachial artery is very common in this type of
fracture, so test for neurovascular status is important.
 Treatment –
 Conservative treatment – the conservative treatment
includes –
 Closed reduction – it is done by manipulation under
the effect of anesthesia, after reduction of fracture the
hand is immobilized in an above elbow plaster cast
with elbow in flexion for extension type of fracture
and in extension for flexion type of fracture.
 Traction – in case of failed closed manipulation or late
cases the fracture is treated with Dunlop traction
technique.

 Surgical treatment – it includes ORIF in which the

fracture is reduced by using plates and screws or K
wire.
 An intercondylar fracture is a fracture through the
condyles of humerus, it is a type of intraarticular
fracture because articular surface is disturbed in this
fracture.
 This fracture is common in all age group and it results
from a fall on pointed elbow, the olecranon process is
driven between the condyles and results in fracture of
condyles.
 An intercondylar fracture is of two types according to
the placement of fracture line –
 T shape fracture –
 Y shape fracture –

 Treatment –
 It is treated either conservatively or surgically.
 This fracture is relatively less common and results
from fall on outstretched hand.
 The force is transmitted through the head of radius to
the capitulum and results in fracture of it. This
fracture results from an indirect injury and commonly
associated with fracture of head of radius.
 A minimally displaced fracture is missed on
radiograph may times, so special investigations may
be required.
 Treatment – this fracture is reduced by following
methods –
 Conservative treatment –
 Surgical treatment –
 Excision of fragment – in chronic case or severely
displaced fractures the capitulum is excised surgically,
this procedure reduces the chance of stiffed elbow but
results in unstable elbow.
 Fracture of lateral or medial condyle of humerus is
rare but is commonly seen in children.
 Fracture of medial condyle is more common, because
it is more exposed and larger than the lateral condyle.
 This fracture is always displaced fracture by the pull
of common flexors or extensors.
 Treatment – like most of the fractures it may be
treated conservatively or surically.
 Tardy ulnar nerve palsy is a common complication of
medial condylar fracture.
 Fracture of Olecranon Process of Ulna is common and
it results from direct injury such as fall on pointed
elbow or indirect injury such as fall on hand when
elbow is slightly flexed.
 The proximal fragment very often get displaced by the
pull of Tricep Brachi muscle.
 This fracture may be a transverse fracture or
communited fracture.
 Treatment – if fracture is undisplaced it is treated
conservatively by an above elbow POP cast with
elbow in 90 degree flexion.
 In case of displace fracture ORIF is done by bone
screws or K wire.
 If fracture is comminuted excision of proximal
fragment is done and insertion of triceps is replaced to
the proximal end of distal fragment.
 There are many complications after fractures around
elbow and arm, but mainly there are 5 complications –
 Volkman Ischaemic Contracture –
 Injury to peripheral nerves –
 Malunion –
 Myositis ossification –
 Osteoarthritis –
 VIC – this is the most common complication
following fractures around elbow and arm. It occurs
as result of occlusion of arterial circulation to distal
joints. Either due to arterial injury by fractured bone
or compression by tight POP cast that reduces the
blood supply to distal part of arm and results in
muscular ischaemia of forearm flexors.
 This muscular ischaemia may progress to the
deformity of flexion of the wrist and fingers.
 If it is not detected at this stage this ischaemia may
progress into fibrosis of flexors of forearm and fixed
flexion deformity of finger and wrist.
 In typical VIC deformity wrist, PIP and DIP joints are
in fixed flexion, the MCP joint is fixed in extension.
 In last stage ischaemia of median and ulnar nerve
occurs and it results in sensory loss at forearm and
hand.
 Ultimately it results in a nonfunctional deformed
hand.

 Sign and symptoms of VIC –

 Sever and continues pain all along the distal site of
occlusion.
 Fingers become swollen and discoloured, first pale
and then blue.
 Absence of radial pulse.
 Muscular spasm.
 Loss of muscle extensibility.
 Gradual loss of sensory and motor functions.
 VIC deformity.
 Treatment – prevention of VIC is only the cure.
 Regularly inspect the fingers and thumb for any
change in colour.
 Check the radial pulse.
 Check the extensibility of muscle.
 If a tight POP or brace is causing the compression
discard it immediately.
 Check the motor and sensory status of limb.
 Injury to peripheral nerves – injury to radial, ulnar or
median nerve is very common complication of various
fractures around arm and elbow.
 Malunion – malunion is also a common complication
that results in deformities such as cubitus valgus or
varus.
 Myositis ossification – it is deposition of calcium over
the muscles around the fracture site, it common
around the joints like elbow or wrist.
 Myositis ossification results in stiffness around the
joint.
 Osteoarthritis – if fracture is through the articular
surface it may lead to osteoarthritis as late
complication.
 Posterior dislocation of elbow is common in children
and it is commonly seen following a fall on
outstretched hand with elbow slightly flexed.
 Posterior dislocation of elbow is most common but
rarely anterior, medial or lateral dislocation may be
seen.
 In posterior dislocation the radius and ulna are pushed
backwards resulting in injuries to the surrounding
structures of elbow.
 The dislocation of elbow may be associated with
fracture of coronoid process of ulna or head of radius,
less commonly with fracture of condyles of humerus.
 The ulnar nerve may get injured in elbow dislocation,
therefore clinical examination of ulnar nerve function
must be performed.
 Treatment – elbow dislocation may be treated
conservatively or operatively.
 In conservative treatment closed manipulation is done
under general anesthesia and after reduction of
dislocation the elbow is immobilized in an above
elbow POP cast with elbow in flexion and forearm in
supination for 4 weeks.
 Operative management is required in late cases or
sever dislocations.
 Complications of elbow dislocation –
 Stiffness of elbow – it is common complication of
elbow dislocation.
 Myositis ossification – excessive stretching of elbow
may result in myositis ossification of brachialis
muscle and causes chronic elbow stiffness.
 Ulnar nerve palsy
 Fracture of head and neck of radius is rare and the
fracture of head of radius is common in adults while
the fracture of neck of radius is common in children.
 These fractures may result from a valgus strain on
elbow during fall on outstretched hand.
 Fracture of head of humerus may be a minimally
displaced fracture, displaced fracture or comminuted
fracture.
 Treatment –
 Like other fracture it may be treated conservatively or
operatively.
 In conservative treatment the fractured part is
immobilized by above elbow plaster cast for two to
three weeks.
 Surgical treatment – in case of severe displaced
fracture or communited fractures surgical treatment is
needed. It is of two types –
 ORIF – by using plates and screws.
 In case of severe communited fractures where ORIF is
not possible excision of head of radius is done or
elbow arthroplasty is performed in which head of
radius is replaced by metal prosthesis.
 There are two types of injuries where fracture of one
of the forearm bone is associated with dislocation of
radioulnar joint.
 These injuries are –

 Monteggia fracture and dislocation –

 Galeazzi fracture and dislocation –
 Monteggia fracture – in this type of injury fracture of
upper half of ulna is associated with anterior
dislocation of the radial head.
 Galeazzi fracture – it is opposite to the Monteggia
Fracture. In this type of injury, there is fracture of
lower one third of radial shaft associated with
dislocation of inferior radioulnar joint.
• Both fractures are treated conservatively and
operatively.
• In conservative treatment the fracture of ulna and
dislocation of radius both are reduced by closed
manipulation, after reduction the immobilization is
carried out in an above elbow POP cast with elbow in
flexion and supination in case of Monteggia Fracture.
• In sever communited fracture ORIF of ulna and
excision of radial head may be done.
 In case of Galeazzi Fracture conservative treatment
rarely succeeds so ORIF is performed with the help of
plates and screws.
 As Galeazzi Fracture is below the elbow joint, so
return of elbow movements is faster than Monteggia
and complications as elbow stiffness is not seen.
 This is a fracture of lower end of radius within one
inch of distal articular surface of radius. This fracture
occurs at cortico cancellous junction of bone and it
unites always.
 This fracture is commonly seen in middle age and
elderly patients, particularly in females following a
fall on the outstretched hand with wrist in extension.
 In this fracture the distal fragment is diplaced and
tilted dorsally.
 Because of dorsal displacement of distal fragment the
wrist joint assumes a typical deformity called as the
DinnerFork deformity.

 Management – Colles fracture is treated either

conservatively or surgically depends on the type of
fracture. If fracture is minimally displaced then it is
treated conservatively by closed manipulation under
general anaesthesia and limb is immobilized in below
elbow plaster cast for 4 to 6 weeks.
 In case of severly displaced fracture surgical treatment
is required. This fracture can be treated surgically by –
 Internal fixation – severly displaced fractures are
reduced by ORIF with the help of plates and screws.
 External fixation – stabilization of communited
fracture is provided by an external fixation.
 Cummon We really hate revision of previous
class………………………….
 Complications –
 Stiffness – stiffness of fingers, wrist and elbow is
most common complication of Colles fracture. The
patient is encouraged to perform active movements of
finger wrist and elbow right from second day of
injury.
 Malunion – malunion of Colles fracture is very
common, a malunion results in permanent dinner fork
deformity at wrist and limited wrist motions as well as
limited supination, pronation.
 Sudeck osteodystrophy – it is characterized by pain
and stiffness in the wrist joint and fingers with
osteoporosis of bones of fingers and wrist and the skin
over the wrist, fingers appear shiny red. The main
problem of Sudeck Osteodystrophy is stiffness of
finger joints and oedema of hand.
 Carpal tunnel compression – the median nerve may
get compressed in carpal tunnel following Colles
fracture. This is due to reduction in space within the
tunnel.
 Rupture of tendons – tendons surrounding the wrist
may get rupture after Colles fracture, mainly the
tendon of Extensor Pollicis Longus may get rupture
by the fractured fragment.
 it is also an extra articular fracture of distal end of
radius. This fracture is also known as reverse Colles
fracture.
 In Smiths fracture the distal fracture fragment gets
displaced volarly or anteriorly unlike dorsal
displacement in Colles fratcure.
 Treatment and complications of smith fracture is same
as Colles fracture.
 It is an intra articular fracture of distal end of radius.
In this type of fracture the fracture line is present
through the articular surface of lower radius.
 In Barton fracture the fracture line is placed obliquely
and it separates either a large volar fragment or a large
dorsal fragment.
 If a large volar fragment is displaced it is called Volar
Barton fracture.
 If a large dorsal fragment is displaced it is called as
Dorsal Barton Fracture.

 Treatment – like most of the fractures of upper limb

Barton fracture is treated either conservatively or
operatively.
 Conservative treatment – in this fracture is
manipulated under anaesthesia and immobilized in
below elbow POP cast for 4 to 6 weeks.
 Surgical treatment – in severly displaced fractures
ORIF is done by using plates and screws.
 Complications of barton fracture is same like Colles
and Smith fracture.
 Fracture of carpal bones is common following fall on
wrist. Fracture of Scaphoid, Lunate and Pisiform are
frequently seen.
 Fracture of Scaphoid – fracture of scaphoid is the
commonest amongst all carpal bones. It is seen in
adults following fall on the outstretched hand with
wrist in slight extension.
 The bone may get fractured at 3 anatomical sites -
 At the distal pole (the tubercle) –
 At middle part (waist) –
 At the proximal pole –
 Out of all three sites fracture of waist is frequently
seen.
 The blood supply to distal pole is better so union is
good at distal pole, but blood supply at waist and
proximal pole is poor and may result nonunion.
 Treatment – like other fractures it can be treated
conservatively or surgically.
 In conservative treatment a Scaphoid POP cast is
applied. A Scaphoid POP cast is applied with wrist in
slight dorsiflexion and radial deviation. The thumb is
held away from the palm in Glass Holding position.
The thumb is fully covered by POP cast while the
knuckles and fingers are kept free.
 Surgically – severely displaced scaphoid fractures are
treated by ORIF.

 Complication –
 Nonunion
 Avascular necrosis
 O.A. of wrist joint.
 Fracture of Lunate is next commonly fractured carpal
bone after Scaphoid. Fracture of Lunate is often
missed on radiograph if not investigated carefully.
 Traetment of Lunate fracture is same as Scaphoid
fracture.
 Avascular Necrosis of Lunate is very common after
fracture and this condition is called as Kienbock
Disease. It is characterized by sclerosis and collapse of
the Lunate.
 As the Piciform is the most exposed carpal bone it may
get fractured by direct hit over the medial side of
dorsal aspect of wrist.
 Fracture of metacarpals is seen in crush injuries or
direct fall over the tip of fingers or thumb.
 Fracture commonly occurs at three sites –
 At base –
 At shaft –
 At neck –
 Fracture of first metacarpal is most common. There
are two types of fractures frequently seen at first
metacarpal –
 Bennett fracture –
 Rolando fracture –
 Bennett fracture – it is also known as Bennett
fracture and dislocation because it is associated with
dislocation of first carpo metacarpal joint.
 It is an intra articular fracture of base of the first
metacarpal or thumb.
 This fracture results following fall on the tip of
thumb, when the force is transmitted from tip of
thumb to the base of first metacarpal it results in
fracture of the latter.
 In Bennett fracture a single fragment is displaced and
the first metacarpal is dislocated radially or laterally
by the pull of APL tendon.
 A Bennett fracture is never a comminuted fracture it is
either a transverse or oblique fracture.

 Treatment – as it is an unstable injury with dislocation

it has to be reduced surgically by ORIF with K wire or
screws.
 Rolando fracture – like Bennett fracture the Rolando
fracture is also an intra articular fracture at the base of
first metacarpal.
 There are following differences between Bennett and
Rolando fracture –
 A rolando fracture is undisplaced while bennett is
displaced.
 A rolando fracture is comminuted intra articular
fracture while bennett is either transverse or oblique.
 Fracture line of Rolando fracture is either T shaped or
Y shaped.
 Rolando fracture is less common than Bennett
fracture.
 It was first described by Silvio Rolando in 1910.

 Treatment of Rolando fracture is same like Bennett

fracture.
 Fracture of other metacarpals – fracture of fifth
metacrapal is common after first metacarpal, because
the fifth metacarpal is also somewhat mobile.
 Apart from first and fifth fracture of second, third and
fourth metacarpal is only seen following crush injury
of hand or direct hit over the dorsum of hand.
 Like first metacarpal fracture of other metacarpal is
seen over three sites -
 The base –
 The shaft –
 The neck –
 Fracture of neck of fifth metacarpal is known as the
Boxer Fracture, it common in young adults after direct
hit over the fifth knuckle.

 Treatment – like fracture of first metacarpal fractures

of other metacarpal are also treated surgically by ORIF
with help of K wire or screws.
 Phalanges are fractured due to direct trauma or
twisting force at the fingers.
 Comminuted fractures of phalanges result from crush
injuries.
 Just like fracture of metacarpals phalanges may get
fractured from base, shaft or neck.
 Fracture of distal phalanx is commonest as it is most
exposed and distal most part of finger.
 Treatment – phalanges fractures are commonly treated
conservatively by closed manipulation and
immobilization.
 Immobilization is achieved by using POP cast or
splints.
 In case of severely displaced fractures or comminuted
fractures ORIF may be required.
Thank you so much
for tolerating me
………………………………
……………………………..
• You can never be overdressed or
overeducated.”
 Live as if you were to die tomorrow. Learn
as if you were to live forever.”

 ThaT’s why learning continues

……………………………………………………………………………
……………………………………………………
By – Dr. Ankyyt Gaur (MPT Ortho. & Traumatology)
 The term Scoliosis comes from the greek word
meaning a curvature of spine. It is now specially used
specifically for lateral spinal curvatures.
 Scoliosis is a deformity of vertebral coloumn and it is
seen as deformed vertebrae when the vertebral bodies
of a particular area are not in anatomical alignment
they shift laterally either to right or left side.
 This deformity is the most common spinal deformity
affecting all age groups.
• The scoliosis is defined as a lateral curvature of
spine that exceeds more than 10 degree from frontal
view.
• This deformity is very common in young adults or
school going children, it may result from postural
abnormality, paralysis of spinal muscles or in
conditions like CP, Muscular Dystrophy ect.
• In scoliosis the vertebral body shifts towards the
convexity and spinous process shifts toward
concavity.
 The scoliosis is named according to the side of
convexity and region where it is affecting.
 Example – if scoliosis curvature is convex towards the
right side it is called as right side scoliosis, and if it is
on left then vice versa.
 Scoliosis curve is also named according to the area it
is affecting, like if a scoliosis is at cervical spine it
called as cervical scoliosis, if in lumbar region called
as lumbar scoliosis.
 If scoliosis is present at the junction between two
vertebral regions then it is named according to the
cranial and caudal region.
 Example if scoliosis is present at Cervical and
Thorasic junction it is called as a Cervicothorasic
Scoliosis, if it is at Thorasic and Lumbar region it is
called as Thoracolumbar Scoliosis.
 The scoliosis is classified into two types according to
the type of deformity –
 Non structural or flexible –
 Structural or fixed –

 Non structural – this type of scoliosis is also know as

flexible scoliosis, because there are no structural or
bony changes occur in the vertebrae. This results
because of poor postural habits.
 Non structural scoliosis could be managed
conservatively by correcting postural habits of patient
and using orthotic devices.

 Structural scoliosis – this is also known as fixed

scoliosis because in this type there is defect in the
bone, which result in contracture of the soft tissues at
the side of concavity.
 It can not be treated conservatively and often require
surgical management.
 Scoliosis is also classified according to the cause of
scoliosis into three types –
 Idiopathic Scoliosis –
 Paralytic Scoliosis –
 Congenital Scoliosis –

 Out of these three the Idiopathic is commonest.

 The Idiopathic Scoliosis is again divided into four
types –

 Infantile –
 Juvenile –
 Adolescent –
 Adult –
 Infantile Idiopathic Scoliosis – the onset of this type
of scoliosis is seen by the age of 3. usually there is
spontaneous resolution of curve, but surgery is needed
when curve progress rapidly.
 Juvenile Idiopathic Scoliosis - the onset is between
3 to 10 years of age. Rapid progression of curve occur
due to growing age of child. Surgery is performed in
most of the cases.
 Adolescent Idiopathic Scoliosis – the age of onset is
between 10 and 20 years. If detected earlier it could
be managed by bracing.
 Adult Idiopathic Scoliosis – the age of onset is over
20 years. In this age surgery is the only option with
athrodesis.
 Conditions such as Poliomyelitis, CP, Muscular
Dystrophy or Spina Bifida may result in scoliosis by
paralysis of spinal muscles. Scoliosis is seen because
of muscular imbalance of spine.
 If detected early it could be treated conservatively or
else surgery is required.
 Congenital abnoramalities of the vertebrae may result
in congenital scoliosis. Conditions like hemivertebra
or block vertebrae may result in congenital scoliosis.
 It needs to be treated surgically.
 In scoliosis there is always a primary curve, which is
present at the area or region of deformity.
 Apart from primary curve there might be a secondary
curve that is known as compensatory curve, this
compensatory curve is present beneath the primary
curve.
 In presence of primary curve in erect standing posture
the body is under great gravitational force over the
side of convexity.
 To avoid this imbalance, muscular strain or fatigue a
compensatory curve may develop in other region.
 Soft tissues towards the concave side are under
compression, while structures towards convex side are
under distraction.
 Evaluation of scoliotic curve – a complete evaluation
of scoliosis curve is important to find out the degree
of curve and to make proper treatment plan.
 The evaluation of scoliotic curve is done by critical
evaluation of spine at various level. The examination
is done by –
 Curve Measurement –
 Inspection of spine –
 Measurement of scoliosis – the scoliotic curve is
measured by a standard method. This method is called
as the Cobb Method.
 In Cobb method a posteroanterior radiograph of spine
is taken in standing position for measurement. Then
end vertebras are taken for the reference, the end
vertebras are the one that tilt towards the side of
concavity of curve at either ends (cranial and caudal
end).
 After finding the end vertebras a straight line is drawn
from superior border of upper end vertebra, and from
the inferior border of lower end vertebra.
 After drawing two straight lines, two perpendicular
lines are drawn from these lines.
 Angle which is formed between these two
perpendicular lines is known as the Cobb angle, and
this this angle is used for the measurement of
scoliosis.
 If the angle is more than 60 degrees then it is a n
absolute indication of surgery.
 In scoliosis of Thorasic spine patient may develop
respiratory insufficiency such as reduction in vital
capacity and chest expansion. This complications
result because of limited rib cage movement.
 Apart from these complications patient may devlop a
rib hump at the side of convexity in case of Thorasic
spine scoliosis.
 The rib hump is visible when patient bends forward.
This rib hump results because of distortion of the
vertebra. In Scoliosis the vertebral body is distorted
towards the side of convexity, this pushes the rib
posteriorly towards the side of convexity.
 The spinous process is distorted towards the side of
concavity, this pushes the rib anteriorly and laterally
at concave side.
 Inspection – the general outline of the spine is
observed, and the various anatomical levels are
identified –
 Level of Shoulder –
 Scapular level –
 Level of waist line –
 Level of Hip –
 Thorax –
 Level of Ears and Neck -
 Apart from inspection of various anatomical levels,
respiratory status of patient and ROM of all spinal
movements must be inspected.
 Milwaukee brace – this brace is used for growing
children with dynamic scoliosis and is used to prevent
lateral movement of spine and to correct the
deformity.
 Boston Brace – the boston brace provides great
restriction of movement and it is mainly used for the
treatment of scoliosis.
 It is made up of semi rigid plastic and supports the
lower trunk by controlling lumbosacral motion.
 Uses of lumbosacral orthosis –
 Low back pain.
 Spondylolisthesis.
By – Dr. Ankit Gaur (MPT Advance Ortho., Trauma.)
 Ligament is a type of connective tissue, they are
pliable structures consisting of longitudinally arranged
fibrous tissue, these fibrous bands are reinforced by
joint capsule and muscles.
 A ligament connects one bone to another, usually at or
near a joint. Some ligaments are difficult to identify as
they are blend with joint capsule and appears as
thickening of capsule(Inferior Glenohumeral
Ligament). While others are distinct and easily
recognizable (ACL).
 Ligaments are usually named according to their
location, shape, bony attachment and relation to each
other. The Anterior Longitudinal Ligament is an
example of ligament that appears both from location
and shape. Medial and lateral collateral ligament is
named only according to location. The Coracohumeral
and Radioulanr Ligament according to bony
attachment. Deltoid ligament is named according to
shape. Ligament of Biglow is named according to the
inventor of the ligament.
 Ligament injuries are one of the commonest injury in
soft tissue. Ligaments are dense and fibrous structure
and they are strong structure, but still ligaments are
more prone to injury because –
 They do not have tone like muscle, which makes them
more prone to injury.
 As they connect two bone and movement between
two bony ends put them under lot of shear stress
especially at mobile joints such as knee, ankle or
wrist.
 The vascular supply to ligaments are not adequate,
hence they can be injured easily and once ligaments
get injured healing takes a long time (6 to 7 months).
 If ligaments are not healed properly it results in sever
joint instability.
 Ligament injuries are classified into 3 categories –

 Grade 1 – it is also known as mild sprain or minimum

sprain. These injuries are also referred as one plus.
The characteristics of grade one tear are –
 Local Tenderness +
 No instability
 Stress test causes pain
 Joint separation up to 5 mm
 Grade 2 – it is also known as moderate tear. These
injuries are also referred as three plus. The
characteristics of grade 2 injury are –
 Local tenderness ++
 Localized oedema +
 Minimum instability
 Stress test causes moderate pain
 Joint separation between 5 to 10 mm
 Grade 3 – they are known as complete tear, and also
referred as five plus. Characteristics are –
 Local Tenderness +++
 Local oedema ++
 Marked joint instability
 Stress test causes sever or excruciating pain
 Joint separation more than 20 mm
 Mainly Ligament injuries are seen at following joints-

 Ligament Injuries of Knee Joint –

 Ligament Injuries of Ankle Joint –
 Ligament Injuries of Wrist Joint –
 In knee joint injuries are seen at following ligaments –

 Medial Collateral Ligament –

 Lateral Collateral Ligament –
 Anterior Cruciate Ligament –
 Posterior Cruciate Ligament –
 Meniscal Injuries -
 The Medial Collateral Ligament is thick connective
tissue at the medial aspect of knee joint. It origins
from the medial condyle of Femur and inserts over the
medial aspect of proximal tibia just distal to Pes
Anserinus. It has two portions the superficial and
deep.
 The MCL is the primary restraints to valgus strain at
knee joint, prevents the medial opening of knee joint.
 The MCL injury results from direct trauma to the
lateral aspect of knee joint, results in sever valgus
stress over the knee and tear of MCL.
 Patient complains pain, swelling and oedema over the
medial aspect of knee joint. In case of Grade 2 and
Grade 3 injury patient may report a popping or tearing
sensation over the medial aspect of knee joint.
 The physical examination of MCL is done by using
Valgus Stress Test.
 A Valgus Stress test is performed with patient in
supine lying and knee in full extension, therapist holds
the tested leg by placing one hand over the ankle joint
and other hand over the knee joint.
 Therapist applies a valgus stress over the lateral aspect
of knee joint. If patient complains pain and joint
opening occurs more than normal then test is
considered positive.
 If no symptom appears in full extension, then the test
is again performed with knee in 30 degree of flexion.
When the knee is in initial flexion surrounding
structures around knee are relaxed and more stress
comes over the MCL.
 Treatment – grade one tear is treated conservatively
by immobilization of knee joint for 4 to 6 weeks.
 For grade 2 and 3 operative treatment is required by
using Arthroscopy.
 The Lateral Collateral Ligament is present over the
lateral aspect of knee joint. It begins proximally from
the lateral femoral condyle and runs vertically
downwards till the fibular head.
 It provides lateral stability knee joint by restricting the
varus stress over knee joint.
 Lateral Collateral Ligament injury is not as common
as MCL injury.
 LCL injury results from the sever varus stress from
the medial aspect of knee joint, results in lateral
opening of knee joint.
 LCL injury is examined by using Varus Stress Test.
 In Varus Stress Test position and procedure is similar
to Valgus Stress Test, the only difference is stress is
applied from the medial aspect of knee joint.
 Patient complains pain, oedema and instability over
the lateral aspect of knee joint.
 Most of LCL injuries are treated conservatively,
because complete tear of LCL is very rare and it is
associated with PCL injury.
 The Anterior Cruciate Ligament is the most important
ligament of knee joint and most commonly injured
ligament around knee joint.
 The Anterior Cruciate Ligament origins from the
anterior tibial spine and it extends superiorly
posteriorly to attach posteriomedial aspect of lateral
femoral condyle.
 It has two bands the Anteromedial Band and the
Posterolateral Band.
 The ACL prevents the excessive anterior translation of
tibia over the femur by restricting the anterior
translation.
 Injury to ACL results from when knee is in partial
flexion and body rotates internally over the stationary
foot. The rotation may occur in Tibia over Femur or in
Femur over Tibia.
 It may also get injured from a fall from height with
knee in partial flexion and internal rotation.
 When ACL is torn the tibia moves excessive
anteriorly and results in instability of the knee joint.
 Patient complains pain, swelling over the knee joint
with inability to bear weight over the injured leg.
 The ACL is examined by following special tests –
 Lachman Test –
 Anterior Drawer Test –
 Pivot Shift Test –
 Lachman Test – it is a standard test for ACL injuries.
Patient is in supine position and the tested leg is in 20
to 30 degree of flexion. Therapist stabilizes the distal
end of Femur with one hand and other hand is placed
over the proximal end of tibia by grasping the leg
from calf region.
 Therapist applies anterior force over the proximal
tibia, increased anterior translation or soft end feel
indicates ACL injury.
 Anterior Drawer Test – patient is in supine lying
with tested knee in 70 to 80 degree of flexion,
therapist stabilizes the foot of the tested leg by sitting
on it.
 Then therapist pushes the tibia anteriorly with both
hands. If tibia translates anteriorly more than normal it
indicates ACL injury.
 Grade 1 ACL tear can be treated conservatively by
applying POP or Knee brace to immobilize the knee
joint for 4 to 6 weeks.
 For Grade 2 and 3 injuries surgical treatment is
needed by using arthroscopy.
 Tendon Grafting is also used for surgical management
of ACL. In this surgery a strap from Quadriceps or
Hamstrings is taken and is used to replace the torn
ACL.
 Posterior Cruciate Ligament origins from the posterior
end of proximal tibia and it travels superiorly and
anteriorly and get its distal attachment over the medial
aspect of Femur.
 It prevents the excessive posterior translation of Tibia
over the femur.
 The PCL injury is not as common as ACL injury.
 The PCL may get injured from a direct blow over the
anterior aspect of the proximal Tibia, or from the
hyperflexion injury of knee with anterior directed
force on the Femur.
 Patient complains pain, swelling and inability to bear
weight over the injured leg.
 The PCL injury is examined by Posterior Drawer Test.
It opposite to the Anterior Drawer test.
 Treatment is same as ACL injury.
 The Ankle Joint is also called as the Talocrural joint,
it is formed by articulation between the distal tibia,
fibula proximally and the body of talus distally. The
Ankle joint is a Hinge joint with joint capsule and
associated ligaments.
 The capsule of ankle joint is fairly thin and weak
especially anteriolaterally. Therefore the stability of
ankle joint depends on the ligamentous structures.
 The Ankle joint is mainly supported by two major
ligaments –
 The Medial Collateral Ligament –
 The Lateral Collateral Ligament –
 Along with Ankle joint these ligaments also provide
support to the Subtalar joint.
 Medial Collateral Ligament – the MCL of Ankle
joint is also called as the Deltoid ligament. It is a fan
shape ligament that has two fibers, superficial and
deep.
 This ligament origins from the borders of tibial
malleolus and inserts in a continues line on the
navicular bone anteriorly, on talus and calcaneus
posteriorly. It provides medial stability to ankle joint.
 Lateral Collateral Ligament – the LCL of Ankle
joint supports the lateral aspect of ankle, it is
composed of three separate bands that are commonly
reffered as different ligaments –
 The Anterior Talofibular –
 The Posterior Talofibular –
 The Calcaneofibular –
 The ankle joint is a fairly unstable joint and depends
largely on the ligaments for the stability. Therefore
ligaments of ankle joint are highly susceptible to
injuries.
 Ligament injuries around ankle joint may result from
awkward movement of ankle joint, mainly it results
from combination of plantar flexion with pronation
and supination.
 Supination – supination of ankle joint is a coupled
movement of subtalar joint. In non weight bearing
supination following movements occur –
 Calcaneal Inversion, Calcaneal Adduction, Calcaneal
Plantarflexion.
 In weight bearing supination following movements
occur –
 Calcaneal Inversion, Talar Abduction, Talar
Dorsiflexion.
 Pronation – in non weight bearing pronation
following movements occur –
 Calcaneal Eversion, Calcaneal Abduction, Calcaneal
Dorsiflexion.
 In weight bearing pronation following movements
occur –
 Calcaneal Eversion, Talar Adduction, Talar
Plantarflexion.
 Medial Collateral ligament sprain or Deltoid ligament
sprain is not as common as LCL injury. This injury
results from sudden forceful eversion or pronation of
ankle over a fixed foot.
 The MCL is one of the strongest ligament of body and
it may be associated with fracture of medial malleolus
of tibia or injury to interosseous membrane.
 Like other ligament injuries, MCL injury is also of 3
types, Grade 1,2 and 3.
 Patient complains pain, swelling over the ligament.
All the movements of ankle joint are extremely
painful and patient is unable to bear weight over the
injured leg.
 In case of Grade 3 injury instability of joint is seen.
 The MCL injury is not more common.
 Treatment – in case of Grade 1 and Grade 2 injury
PRICE protocol is used along with support over the
ankle joint with crepe bandage.
 In case of Grade 3 injury surgical management is
required.
 The Lateral Collateral Ligament is known as LCL
Complex because three ligaments make the complete
LCL.
 The LCL Complex is most commonly involved in
ankle sprain, in fact 85% of Ankle sprains are LCL
sprain.
 The LCL Complex has three components –
 ATFL (Anterior Talofibular Ligament)
 CFL (Calcaneo Fibular Ligament)
 PTFL (Posterior Talofibular Ligament)

 Out of these three ligaments the ATFL is most

commonly injured ligament, followed by combined
tear of AFTL and CFL.
 Like other ligament injuries the LCL Complex injury
is also classified into 3 grades –
 Grade 1 – Mild Ankle Sprain (Stretch in ligament)
 Grade 2 – Moderate Ankle Sprain (Partial Tear)
 Grade 3 – Severe Ankle Sprain (Complete Tear)
 Mechanism of Injury – LCL sprain occurs as result of
sudden and forceful inversion or supination of ankle
over a fixed foot.
 This inversion movement puts stress over the
talofibular ligament mainly at ATFL, and results in
injury of the same.
 Secondly, stress comes over the CFL and results in
injury of CFL.
 Patient complains pain, swelling over the lateral
aspect of ankle joint with popping or tear sensation
felt by the patient. In grade 2 minimum instability is
seen, in grade 3 severe instability is seen.
 Physical Examination – the Anterior Drawer test and
Talar Tilt test is used to indicate the LCL injury and
ankle instability.
 Anterior Drawer Test – patient is in supine or short
sitting position. Therapist holds the patient’s foot from
the heel with one hand, and other hand is used to
support or fix the distal tibia.
 While maintaining the fixed position therapist
translate the heel anteriorly over the tibia.
 If translation occurs greater than 3 mm and patient
complains pain test is considered positive.
 Talar Tilt Test - The patient lies in supine or side
lying position with foot relaxed. This test is used to
determine injury to calcaneofibular ligament (CFL) .
The foot is held in anatomic position which brings
calcaneofibular ligament (CFL) perpendicular to long
axis of talus .
 The talus is tilted sideward's into adduction which
increases stress on the ligament . The test is positive
when there is abnormal titing of talus.
 Treatment – PRICE protocol is used for grade 1 and
2 injuries, along with immobilization using ankle
brace or crepe bandage for 1 to 2 weeks.
 For Grade 3 injury immobilization is done for longer
period up to 4 weeks.
 Sometimes surgical management is required for
management of recurrent ankle sprain.
 The wrist joint consists of extrinsic and intrinsic
ligaments.

 Extrinsic ligaments consist of following ligaments –

 Radial Collateral Ligament
 Ulnar Collateral Ligament
 Intrinsic Ligaments include following ligaments –
 Volar Carpal Ligament –
 Dorsal Carpal Ligament –
 Injuries to these ligaments may result from sudden fall
on wrist or forceful movements of wrist joint.
 Mechanism of injury, characteristics of injury and
grades of injury are same as above discussed
ligaments.
 So, far we have discussed
 Amputation
 Fractures
 Scoliosis
 Osteotomy
 Arthrodesis
 Arthroplasty
 Arthroscopy
 Bone graft
 Tendon transfer surgery
 Mcl injury
 Lcl injury
 Acl injury
 Pcl injury
 Ankle sprain
 Wrist sprain
 Phewwwwwwwwwwwww…………………….
 That’s It from me for this
session …………………

 C u and again will drain ur

blood in next session