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KNOW YOUR ORTHOPAEDICS…
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Publishing-in-support-of,
EDUCREATION PUBLISHING
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Website: www.educreation.in ________________________________________________________________
© Copyright, Author
All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form by any means, electronic, mechanical, magnetic, optical, chemical, manual, photocopying, recording or otherwise, without the prior written consent of its writer.
ISBN: 978-93-85247-31-6
Price: ` 299.00
First Published 2015
Medical knowledge is getting expanded day by day as medical science is an ever dynamic subject. The authors, contributors and the publishers have taken their best care to incorporate up to date information. Due to possibility of human error and continued advances in medical science, neither the authors nor the publisher warrant that the information contained herein is complete and accurate in every respect. The readers are strongly advised to confirm that the information herein complies with the current standards of recommendation and practice.
Printed in India
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KNOW YOUR ORTHOPAEDICS
Dr. Imran Sajid Asst. Professor
Dept of Orthopaedics
FH Medical College & Hospital
Agra
Dr. Sukhvinder Singh Basran Asst. Professor
Dept of Orthopaedics
HIMSR & HAHC Hospital
New Delhi
Editors
Dr Dhawal Bakhda Dr Nitin Maruti Adsul
EDUCREATION PUBLISHING (Since 2011)
www.educreation.in
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FORWARD
The well-known saying “Tough gets Tougher with Time” holds true for the theory
examinations of Orthopaedics, as so much advancement has been made in this particular
field of medicine over the years, that the scope of examination, seem to broaden with
every passing year. The DNB Orthopaedic exams especially have a different format,
which focuses lot on the theory part, along with the practical and hence the DNB
residents find it particularly tough to clear these exams which may be due to the lack of
proper guidance.
There are a large number of books available in the markets for reference used by
students, but mostly all of them focus more on the practical aspect of the examination. A
book solely aimed at helping the students with the theory exams have been missing all
these years, and hence students have to hunt for all the information they need from
number of books available in the market, wasting precious time before exam.
I am delighted to know that ORTHOPG has come up with this concept and this book,
which is primarily focusing on providing the relevant information, in ready to use answer
format, which I am sure will make the life of many aspiring Orthopaedicians much easier.
In order to maintain the authenticity of the matter in the book, relevant references have
also been given at as many places as possible and hence students can refer to them when
needed.
The authors of this book have gone through the gruelling orthopaedic examination at
their time and are well aware of the difficulties that a student has to face in order to
prepare the best answers of the most important questions expected in examination. And
hence, they have put in the best of their efforts and gathered all their knowledge that they
have gained over these years of their practice.
Although, the material given in this book is authentic and to the best knowledge of the
authors, I advise the students to use this book solely as a reference book and not as their
syllabus book and to read the text books thoroughly. ORTHOPG surely believes in
“Bringing the education to you rather than making you hunt for it”, but even for that you
need to put in some efforts.
All the Best
With Best Regards
Prof Dr. R.K. Goyal Ex HOD, S.N. Medical College, Agra
Ex HOD, RIMSNR, Saifai, Etawah
HOD, FH Medical College, Agra
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FROM THE AUTHOR’S PEN
COMPETITION..!!! This is one word, which haunts us all throughout our lives. Since the
day we are born, all we see is competition. In every field and in every place, we see it and
soon realise that this is an eternal part of everyone’s life. Even a sperm has to compete to
reach his destination. And this is when one hasn’t even entered the world.
In today’s time life is more a race and we are all running to win it, just to prove
ourselves. Even though we had realised it long back in our lives, but the true realisation
came to us when we were preparing to get into a Medical College. Getting in was a tough
task no doubt, but getting through was even tougher. Life in a Medical college is surely
not easy. Nobody is told about the amount of hard work needed to clear the exams
especially final post-graduation examination.
The syllabus is wide and time is limited. There are days when more than 24 hours are
required to meet daily targets of studies, leave alone eating and other things. Even while
you sleep, some or the other topic is constantly going on in our heads (this has happened
with all of us before our exams). The only discussions (if at all we have any) are about
the exam preparations and the books being referred.
During one such day of exam preparation we realised that life will be much easier if we
all got ready-made notes and we just had to read them. We all tried to hunt for such exam
notes, but could hardly find any book which could help us and provide us with ready-
made answers. All we got were thick books and vast syllabus, the ones which could
practically never come to an end. Although there were few xeroxed notes available in
market but deciphering the hand writing was a task in itself. Plus lack of references made
us doubt its authenticity at times.
As they say, “Necessity is the mother of all inventions”, it was after that day, that we
thought of making the lives of others easy by helping them and providing them all the
study material needed in the form of notes along with a collection of our practical
learning that have been put together in this book, to provide the best answers to the most
critical questions for exam preparation. This book is a collection of the hard work we did
as student’s ourselves, notes made at that time along with all the practical knowledge that
we have gained over the period of time.
The compilation of this book was not an easy task. The notes we had made during our
preparation days, had to be revised and upgraded and additional information had to be put
in. Past year’s question papers had to be taken up to find out the most critical questions
for the preparation of the students and the best answers to these questions had to be
compiled together. Working in a hospital, and studying at the same time doesn’t leave
much time to anyone for doing such things, and writing a book, in itself is a big task,
requiring vast knowledge and a lot of hard work. Many-a-times, we had to undo and redo
the same answers again and again as we ourselves were not satisfied with the answers,
but the end result is surely much better than what you will find in any other book. The
material is simple and yet lucrative, which is sure to help you clear all your concepts
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from the core. References have been given at all possible places for further reading and to
give credit to original authors.
This book is intended to make your life easier, by bringing the knowledge to you rather
than making you hunt for it and hence helps you save a lot of time and effort. It is the
quality of study material that has been the main focus in this book rather than the
quantity, and it is not just the bookish knowledge that you will get from this book; it is
also the practical experience that has been penned down for your reference.
We are really thankful to ORTHOPG for coming up with this concept and helping us
realise our dreams and letting us help the students in their preparation.
Hope this book serves its purpose to its best. All the Best with the preparations future
Orthos..!!!
Dr Imran Sajid Dr Sukhvinder Singh Basran
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ACKNOWLEDGEMENTS
A book is not just words put together, it is much more than that. It is the time and efforts
of people combined with the knowledge gathered at the same place. My intent to write
this book was clear from beginning, I wanted to help the orthopaedic residents, and make
their lives easy by providing them all that they need to prepare for their exam at a single
place.
But to make my life easy, while I was working on this book, I had people around me,
without whose support I would not have completed this book so smoothly. I would like to
express my gratitude and indebtedness to those who assisted me and were always there to
encourage me. Their contributions are sincerely appreciated and gratefully
acknowledged. I would like to express deep appreciation and indebtedness to the
following:
I am deeply indebted to Dr Dhawal Bakhda and Dr Nitin Maruti Adsul for their sincere
efforts in editing the manuscript and for their valuable suggestions.
For her perseverance in getting me to complete this book, my eternal gratitude goes to my
friend, editor, counsellor, Ashima Malhotra. Her keen interest and encouragement were a
great help throughout the course of preparation of this book.
For their continuous inspiration and moral support to achieve this task, I am also thankful
to my parents, Dr Sajid Husain and Dr Noorjahan Sajid.
Special thanks to my wife Dr Priyangee Imran for her invaluable support and untold
hours of solitude she had to bear due to my devotion to the book.
A special mention goes to ORTHOPG TEAM for coming up with this concept and
providing us with this opportunity.
And most of all to our great creator Almighty, the author of knowledge and wisdom who
made this possible
- Dr Imran Sajid
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DEDICATION
Dedicated to all the exam going orthopods.
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CONTENT LIST
S.NO Topic PAGE
1 Primary Vs Secondary Bone Healing 1
2 Functional Cast Bracing 4
3 Biomechanics Of Hip 8
4 Ganga Hospital Injury Severity Score 15
5 Spine At Risk Sign 18
6 Principles Of Sonography 20
7 Plagiarism 24
8 Impact Factor 25
9 Teriperatide 26
10 Gate Control Theory Of Pain 28
11 Botulinum Toxin 31
12 Tribology 35
13 Foot Drop 38
14 Femoroacetabular Impingement 42
15 Carpal Tunnel Syndrome 53
16 Pathophysiology Of Trauma 59
17 Damage Control Orthopaedics 64
18 Coverage Options Post Primary Malignant Bone Tumor
Excision 66
19 Extra Corporeal Irradiated Tumor Bone 69
20 Dislocation Of Patella 71
21 Gout 75
22 Pseudo Gout 79
23 Case Sheet Writing – Hip Case 82
24 Case Sheet Writing – Spine Case 93
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Know Your Orthopaedics
1 Sample copy. Not for distribution.
PRIMARY VS SECONDARY BONE HEALING _____________________________________________________________
PRIMARY SECONDARY
Callus Absent Present
Fixation Rigid (Plating) Not rigid (IM Nailing)
Cortex Well apposed/ unicortical fracture Not well apposed
Mechanism Cutting Cone mechanism
Endochondral /
Intramembranous Ossification or
combination of both
Stages Osteoclastic followed by osteoblastic
activity
5 stages – Hematoma,
Inflammation, callus,
consolidation, remodeling
Quality of bone
formed Inferior Superior
PRIMARY BONE HEALING:
1. Callus is not formed at all.
2. Requires rigid stabilization with or without compression of the bone ends.
3. Rigid stabilization suppresses the formation of a callus in either cancellous or cortical
bone.
GAP HEALING CONTACT HEALING
GAP HEALING – when there is gap between fracture fragments
Occurs in two stages.
1. Width of the gap is filled by direct bone formation.
An initial scaffold of woven bone is laid down, followed by formation of lamellar
bone as support.
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The orientation of the new bone formed in this first stage is transverse to that of
the original lamellar bone orientation.
2. After several weeks - longitudinal Haversian remodeling reconstructs the necrotic
fracture ends and the newly formed bone to replace the woven bone with osteon
of the original orientation. In the end, the normal bone structure results.
CONTACT HEALING – Fracture fragments are in direct apposition.
a) Fragments are in direct apposition and osteons can grow across the fracture site,
parallel to the long axis of the bone.
b) When fracture fragments are in contact, osteoclasts on one side of the fracture
undergo a tunneling resorptive response, forming cutting cones that cross the
fracture line.
c) Osteoclasts at the front of the cutting cone remove bone.
d) Trailing osteoblasts lay down new bone.
e) This tunneling allows the penetration of capillaries and eventually the formation
of new haversian systems.
The cutting/filling cone has a head of osteoclasts that cut through the bone and a tail of
osteoblasts that form a new secondary osteon.
SECONDARY BONE HEALING:
It occurs when there is no rigid fixation of the fractured bone ends, which leads to the
development of a fracture callus.
Divided into 5 stages by Frost HM .(The biology of fracture healing. An overview for
clinicians -Part I. ClinOrthopRelat Res. 1989 Nov;(248):283-93.)
a) Hematoma
b) Inflammation
CUTTING CONE
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c) Callus
d) Consolidation
e) Remodeling – Wolff’s Law
WOLFF’S LAW –
Every change in form and function of a bone, or in its function alone, is followed by
certain definite changes in its internal architecture and equally definite secondary
alteration in its mathematical laws
OR
Bone is deposited and resorbed in accordance with the stresses placed upon it. (J.
Wolff:DasGesetz der Transformation der Knochen. Berlin, A. Hirschwald, 1892.
Published with support from the Royal Academy of Sciences in Berlin. English
translation by P. Maquet and R. Furlong.Belin, Springer-verlag, 1986.)
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Know Your Orthopaedics
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FUNCTIONAL CAST BRACING _____________________________________________________________
DEFINITION: It’s a type of bracing where the limb is able to do restricted function
while in a brace.
PRINCIPLE: Continuing function while a fracture is uniting, encourages osteogenesis,
promotes the healing of tissues and prevents the development of joint stiffness, thus
accelerating rehabilitation.
• The fracture healing in FCB is mainly by External Bridging Callus formation.
• It has greater mechanical advantage over Medullary callus.
• The intermittent loading of the # area, by muscle activity & weight bearing,
promotes local blood flow & development of electrical fields which are beneficial
for healing.The FCB allows movement at the joint & some movement at # site.
• This transmits a measurable load which decreases as the # progresses to union.
• The muscle compartments act as a fluid mass surrounded by deep fascia.
• Fluid is not compressible & fascia cannot be stretched beyond the confines of the
cast. (“Hydraulic container theory”; Sarmiento et al 1974)
• Thus after a certain degree of displacement, pressure & load is transmitted
without further deformation.
• This causes the bony fragments to be held more firmly.
• Rotation is resisted by components of the brace.
PATELLAR TENDON BEARING CAST(SARMIENTO CAST):
Described by Sarmiento
(Sarmiento A. A functional below-the-knee cast for tibial fractures. JBJS [Am] 1967; 49-
A: 855-75.)
In principle it is a below-knee cast extending to the upper pole of the patella and with a
firm moulding over the medial flare of the tibia, the patellar tendon, and the popliteal
space, and shaped in a triangular manner at the upper end of the tibia.
Sarmiento (1967) stated that the PTB cast stabilized the proximal fragment of a tibial
fracture, left the knee free to move, and allowed early ambulation as weight-bearing
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forces should be transmitted from the ground to the proximal end of the tibia, virtually
bypassing the fracture site and suspending the fractured bones.
INDICATION:
1. Lower tibial shaft fractures
WHEN TO APPLY:
1. 5 – 6 weeks after initial trauma.
2. Fracture ends sticky.
3. Minor movements at the fracture site painless.
ACCEPTABLE REDUCTION:
- 50% of cortical contact; < 5-10° of varus / valgus angulation when comparing
tibial plateau to tibial plafond;
- < 10-15 deg of anterior or posterior bowing on lateral film;
- < 5 - 7 deg of internal or external rotation, varus or valgus; no more than 10-15
mm of shortening;
CONTRAINDICATIONS:
1. Lack of patient co-operation.
2. Patients with spastic disorders.
3. Deficient sensibility of the limb.
4. Isolated tibial fractures.
BASIC TECHNIQUE:
1. Patient positioning
a. Patient is sitting off the end of bed with at least half the thigh off the bed to
allow for space between leg and bed.
b. Alternatively, patient may be prone with the knee flexed to 900.
2. Starting point: Metatarsal head
3. End point : Proximal patellar tendon
4. Moulding area: tibial flares, the patellar tendon, and the popliteal space
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UNLOADING EFFECT OF THE PATELLAR TENDON BEARING CAST:
According to Sarmiento weight-bearing forces are transmitted from the ground to the
proximal end of the tibia, virtually bypassing the fracture site and suspending the
fractured bones thereby effectively unloading the fracture.
(The effect of the patellar tendon-bearing cast on loading; H. Tanaka, JBJS (Br) VOL.
82-B, NO. 2, MARCH 2000)
Conventional PTB cast only achieves unloading of 30% of the body-weight. It can be
improved by producing a space between the sole of the foot and the cast, and is
adjustable by altering the depth of this space. When the depth of the free space under the
foot inside the PTB cast is 1, 2 and 3 cm, the unloading effect is 60%, 80% and 98%,
respectively.
When there is an adequate space under the foot, sliding of
the leg occurs in the cast on loading until complete
suspension. Weight-bearing is relieved and complete
unloading occurs.
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The contribution from each part of
the PTB cast to the overall
unloading effect.
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BIOMECHANICS OF HIP _____________________________________________________________
The study of the forces exerted by muscles and gravity on the hip joint
HIP - 1st class Lever with fulcrum at its centre.
1. The lever rotates about the axis as a result of a force (from muscle contraction)
2. The force acts against a resistance (weight, gravity)
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FORCES EXERTED ON THE HIP JOINT:
Joint Reaction Force (JRF) = force generated within a joint in response to the forces
acting on it
JRF = Body wt + Abductor force
JRF = K * h’ + M * h
MANAGEMENT OF PAINFUL HIP: - REDUCE JRF
This can be achieved by:
1. Reducing body weight or its moment arm (Body weight difficult to reduce)
2. Help abductor for or its moment arm (can be managed easily)
Moment arm Abductor force
Use of cane (C/L leg) Suitcase (I/L Leg)
1. K- Force exerted by the body weight.
2. h’- Lever arm of K.
3. M – Force exerted by the abductor muscles.
4. h – Lever arm of M
5. R – Force transmitted across the joint
(Resultant of forces of K and M = JOINT
REACTION FORCE)
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Cane – used on the opposite leg (Normal side)
(Copied from Anatomy & Biomechanics of the Hip; Damien P. Byrne*, Kevin J. Mulhall
and Joseph F. Baker; The Open Sports Medicine Journal, 2010, 4, 51-57)
WALKING STICK:
1. On opposite side increases the lever arm thus decreases the joint reaction force.
2. Opposes body weight by transferring body weight to stick
3. Brings the centre of gravity closer to the body
SUITCASE IN IPSILATERAL LEG: - Helps the abductor force
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