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13 — Injuries Around the Shoulder & Fracture of the Humerus

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1. Shoulder Girdle – Relevant Anatomy

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2. Shoulder Joint – Relevant Anatomy

• Type: Glenohumeral joint — ball and socket, synovial
• Stability: Primarily muscular (rotator cuff: supraspinatus, infraspinatus, teres minor, subscapularis) and labral (glenoid labrum deepens the socket)
• Ligaments: Superior, middle, inferior glenohumeral ligaments; coracohumeral ligament
• Capsule: Lax inferiorly (allows abduction); reinforced anteriorly
• Most mobile but least stable joint in the body

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3. Clavicle Fractures – Pathoanatomy

• Most common fracture in children; most frequent obstetric fracture (90%)
• Middle third = 80% of cases (weakest point, no muscle/ligament attachments)
• Medial fragment pulled upward by sternocleidomastoid
• Lateral fragment pulled downward by weight of arm + pectoralis major
• Brachial plexus and subclavian vessels at risk with displaced fractures

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4. Clavicle Fractures – Classification

• Group I: Middle third (80%) — commonest
• Group II: Lateral/distal third (15%) — may disrupt coracoclavicular ligaments
• Group III: Medial/proximal third (5%) — rare; beware mediastinal injury

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5. Clavicle Fractures – Diagnosis

• Clinical: Pain, swelling, deformity at fracture site; patient supports the elbow; step deformity may be visible
• Radiology:
  • Standard AP view
  • Cephalic tilt views (35–40°) for middle-third
  • Apical oblique view (45° rotation, 20° cephalic tilt)
  • CT for medial third fractures and physeal separations

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6. Clavicle Fractures – Mechanism of Injury

• Indirect: Fall on outstretched hand (FOOSH) — most common; force transmitted via glenohumeral joint
• Direct: Blow to the shoulder or clavicle directly
• Birth injury (obstetric): Direct pressure from symphysis pubis during delivery

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7. Clavicle Fractures – Clinical Evaluation

• Pain, tenderness, swelling, crepitus at fracture site
• Patient holds arm adducted, supporting elbow with opposite hand
• Visible/palpable step deformity
• Tenting of skin by proximal fragment
• Examine neurovascular status (brachial plexus, subclavian vessels)
• Check for pneumothorax (associated rib fractures)

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8. Clavicle Fractures – Treatment

• Conservative (standard): Broad arm sling for 3–6 weeks; analgesia; early pendulum exercises
• Operative indications:
  • Absolute: Open fractures, neurovascular compromise
  • Relative: Non-union, >2 cm shortening/displacement, floating shoulder, skin tenting
• Surgery: Plate fixation (ORIF) or intramedullary nailing

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9. Clavicle Fractures – Complications

• Non-union (1–3%): Risk ↑ with displacement and shortening
• Mal-union: Cosmetic deformity, shoulder weakness
• Neurovascular injury: Brachial plexus, subclavian artery/vein
• Pneumothorax (with high-energy injury)
• Post-traumatic shoulder stiffness
• Thoracic outlet syndrome (rare)

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10. Scapula Fractures – Mechanism of Injury

• High-energy trauma: high-speed MVAs, falls from height, crush injuries
• Rare (1% of all fractures) due to the scapula's protected position and mobility
• Often part of multi-system trauma (75–98% associated with major injuries)

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11. Scapula Fractures – Signs & Symptoms

• Severe shoulder pain; arm held adducted close to body
• Tenderness, swelling, hematoma over scapula
• Crepitus on movement
• Limited shoulder range of motion
• May mimic rotator cuff tear clinically
• Check for associated injuries: pneumothorax, rib fractures, brachial plexus injury

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12. Scapula Fractures – Diagnosis

• Plain X-rays: 3-view trauma shoulder series (AP, lateral, axillary); visible on chest X-ray
• CT scan: Best for defining extent and classification; request 3D reconstruction
• Note: Os acromiale (unfused epiphysis, 3% population) — do not confuse with fracture
• Always search for associated thoracic, neurovascular, and intracranial injuries

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13. Scapula Fractures – Classification

• Extra-articular: Body (most common), neck, acromion, coracoid, spine
• Intra-articular: Glenoid involvement (partial or total)

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14. Scapula Fractures – Treatment

• Most fractures: Conservative — sling for 2–4 weeks, analgesia, early passive ROM, physiotherapy
• Operative indications (rare): Intra-articular glenoid fractures with >5 mm displacement, >25% glenoid articular surface involved, scapular neck fractures with severe angulation, or floating shoulder (ipsilateral clavicle + scapula neck fracture)

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15. Acromioclavicular (AC) Joint Dislocation – Pathoanatomy

• Force disrupts ligaments in sequence: acromioclavicular ligaments first → then coracoclavicular (trapezoid + conoid) ligaments → then deltotrapezial fascia
• Scapula and arm sag downward while clavicle appears elevated ("high-riding clavicle")

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16. AC Joint Dislocation – Mechanism of Injury

• Direct blow to the point of the shoulder with the arm adducted (fall from bicycle, contact sport tackle) — most common
• The scapula and arm are driven downward and medially
• Also: fall on outstretched hand (indirect)

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17. AC Joint Dislocation – Diagnosis

• Tenderness over AC joint; pain with arm overhead and cross-body adduction
• "Step deformity" (prominent lateral clavicle)
• Examine both shoulders upright (supine can mask deformity)
• X-ray: AP view bilateral shoulders with and without weights (stress views)

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18. AC Joint – AC Separation (Clinical Features by Grade)

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19. AC Joint Dislocation – Treatment

• Types I & II: Conservative — sling 2–3 weeks, analgesia, early mobilisation
• Type III: Controversial; many treated conservatively; surgery for young active patients
• Types IV, V, VI: Operative — ORIF; reconstruction of coracoclavicular ligaments (e.g., Weaver-Dunn procedure, hook plate, coracoclavicular screw)

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20. AC Joint Dislocation – Classification

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21. Shoulder Dislocation – Shoulder Instability

1. Traumatic (TUBS): Traumatic onset; Unidirectional; Bankart lesion; Surgery usually needed
2. Atraumatic (AMBRI): Atraumatic; Multidirectional; Bilateral; Rehabilitation first; Inferior capsular shift if surgery needed
3. Habitual/Voluntary: Voluntary; painless; surgery contraindicated

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22. Shoulder Dislocation – Mechanism of Injury

• Anterior: Forced abduction + external rotation (ABER) — most common (95%)
• Posterior: Forced internal rotation: epileptic fit, electric shock, "half-Nelson" hold
• Inferior (luxatio erecta): Extreme abduction/hyperabduction

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23. Shoulder Dislocation – Anterior Dislocation

• Most common dislocation overall
• Humeral head lies anterior to glenoid, usually subcoracoid (most common), also subclavicular or intrathoracic
• Arm held in slight abduction and external rotation
• Loss of shoulder contour ("squaring of the shoulder")
• Hollow below the acromion
• Assess axillary nerve (sensation over regimental badge area)

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24. Shoulder Dislocation – Classification

• Anterior (95%): Subcoracoid, subclavicular, intrathoracic
• Posterior (2–4%): Subacromial, subglenoid, subspinous
• Inferior (luxatio erecta): Rare
• Superior: Very rare

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25. Shoulder Dislocation – Posterior

• Rare (~2%); frequently missed
• Causes: Epilepsy, electrocution, severe forced internal rotation
• Arm held in adduction and internal rotation
• AP X-ray may appear normal ("lightbulb sign" — rounded humeral head)
• Axillary/lateral view or CT essential to confirm
• High index of suspicion from history

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26. Shoulder Dislocation – Inferior and Superior

• Inferior (Luxatio erecta):
  • Arm locked in full abduction above head
  • Caused by extreme hyperabduction; humeral head inferior to glenoid
  • High risk of axillary artery and brachial plexus injury
  • Reduction: traction–countertraction with slow adduction
• Superior: Extremely rare; arm forced superiorly; associated with massive rotator cuff tear; clavicle and acromion fractures

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27. Pathological Changes – Bankart's Lesion

• Detachment of the anteroinferior glenoid labrum from the glenoid rim
• ± avulsion of periosteum (soft tissue Bankart)
• ± fracture of anteroinferior glenoid margin (bony Bankart)
• Major cause of recurrent anterior instability
• Seen on MR arthrography or CT arthrography

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28. Pathological Changes – Hill-Sachs Lesion

• Posterolateral compression fracture of the humeral head caused by impaction against the anterior glenoid rim during anterior dislocation
• Seen on AP X-ray with internal rotation or axillary view
• Large Hill-Sachs lesions ("engaging") contribute to recurrent instability
• May require grafting (e.g., remplissage procedure)

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29. Pathological Changes (General) in Anterior Dislocation

• Bankart lesion (labral detachment)
• Hill-Sachs lesion (humeral head impaction fracture)
• Stretching/tearing of anterior capsule and inferior glenohumeral ligament
• Rotator cuff tears (especially in older patients >40 years)
• Axillary nerve injury (~5–10%)
• Bony Bankart (glenoid rim fracture)
• Greater tuberosity fracture (~15% of anterior dislocations)

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30. Types of Anterior Dislocation

1. Subcoracoid — most common; head below coracoid
2. Subclavicular — head medial to coracoid, under clavicle
3. Intrathoracic — rare; head between ribs
4. Subglenoid — head below glenoid fossa

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31. Shoulder Dislocation – Diagnosis

• Clinical: Pain, loss of shoulder contour, arm held in ER + abduction (anterior), IR + adduction (posterior)
• Neurological exam: Axillary nerve (sensation over deltoid), radial nerve, brachial plexus
• Vascular exam: Axillary artery (especially inferior dislocation)
• Radiology: AP + axillary (or Y-view) X-rays mandatory; CT if glenoid fracture suspected

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32. Dugas' Test

• The patient places their hand on the opposite shoulder and tries to touch the ipsilateral elbow to the chest
• Positive result (abnormal): Patient cannot bring elbow to touch chest — confirms shoulder dislocation
• (Normal shoulder: elbow can touch chest)

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33. Hamilton Ruler Test

• A straight ruler is placed along the lateral aspect of the arm from the lateral epicondyle to the acromion
• Normal: Ruler touches both points (deltoid contour is curved)
• Positive (abnormal): Ruler can rest straight against the arm, touching both — indicates loss of normal shoulder contour confirming dislocation (humeral head displaced medially)

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34. Kocher's Manoeuvre

1. Traction — downward traction on the arm with elbow at 90°
2. External rotation — slowly externally rotate the arm
3. Forward flexion — bring elbow across the chest (adduction)
4. Internal rotation — internally rotate arm (hand to opposite shoulder)

• Avoid in elderly (risk of humeral neck fracture)

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35. Hippocrates Manoeuvre

• Surgeon places their unshod foot in the patient's axilla as counter-traction
• Sustained traction applied along the axis of the arm
• Gentle internal/external rotation as reduction occurs
• Risk: axillary nerve/vessel injury with excess foot pressure
• Requires adequate analgesia/sedation

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36. Shoulder Dislocation – Complications

• Immediate: Axillary nerve injury (most common, 5–10%), axillary artery tear, brachial plexus injury, fractures (greater tuberosity, glenoid rim, surgical neck)
• Short-term: Rotator cuff tear (especially >40 years)
• Late: Recurrent instability (risk highest in young males <25 years — up to 90%), avascular necrosis (rare), post-traumatic osteoarthritis, shoulder stiffness

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37. Putti-Platt Operation

• Procedure for recurrent anterior dislocation
• Mechanism: The subscapularis tendon and anterior capsule are overlapped and shortened (imbricated) to reinforce the anterior capsule
• Limits external rotation
• Disadvantage: Excessive restriction of ER → increased risk of early osteoarthritis

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38. Bankart's Operation

• Repair of the Bankart lesion (detached anteroinferior labrum)
• Labrum is reattached to the glenoid rim using sutures or anchors
• Open approach via deltopectoral interval
• Retensioning of anterior capsule is also performed
• Success rate ~95% for preventing recurrence

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39. Bristow's (Latarjet) Operation

• Transfer of the coracoid process (with attached conjoint tendon) to the anterior glenoid rim
• Provides:
  1. Bone block to restore glenoid bone loss
  2. Sling effect of conjoint tendon in abduction/ER (dynamic stabilizer)
• Used when there is significant glenoid bone loss (bony Bankart)

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40. Arthroscopic Bankart Repair

• Minimally invasive repair of the Bankart lesion
• Labrum reattached using suture anchors placed at glenoid rim under arthroscopic guidance
• Advantages: Less morbidity, faster recovery, preserves ER (cf. Putti-Platt)
• Success rate similar to open Bankart (~90–95%)
• Contraindicated with significant glenoid bone loss (>25%) → Latarjet preferred

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41. Fracture of the Surgical Neck of Humerus

• Common in elderly osteoporotic women (fragility fracture)
• Also in young adults with high-energy trauma
• Mechanism: FOOSH or direct blow
• Proximal fragment: pulled into abduction + ER by rotator cuff
• Distal fragment: pulled into adduction + medial rotation by pectoralis major
• Classified by Neer classification (based on number of parts and displacement)
• Check axillary nerve and axillary artery

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42. Fracture of Surgical Neck of Humerus – Treatment

• Undisplaced/minimally displaced: Collar and cuff sling 3–6 weeks; early pendulum exercises; physiotherapy
• Displaced/unstable:
  • Elderly: Hemiarthroplasty or reverse total shoulder arthroplasty (4-part fractures)
  • Young: ORIF to preserve the humeral head

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43. Methods of Fixation of Surgical Neck of Humerus

1. Percutaneous Kirschner wire (K-wire) fixation: Minimally invasive; for 2-part fractures
2. ORIF with locking plate (proximal humeral locking plate, PHILOS): Most common; allows early mobilisation
3. Intramedullary nail: Antegrade nailing; good for 2–3 part fractures
4. Hemiarthroplasty: Head replacement; for 3–4 part fractures in elderly
5. Reverse shoulder arthroplasty: For comminuted 4-part fractures with rotator cuff compromise in elderly

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Chapter 13 (Remaining) — Fracture Humerus

44. Fracture of the Greater Tuberosity of the Humerus

• Occurs with anterior shoulder dislocation (~15%) or direct blow
• Avulsed by rotator cuff (supraspinatus, infraspinatus, teres minor)
• Undisplaced: Sling 3–4 weeks
• Displaced >5 mm: ORIF with suture anchors or cancellous screws (impairs shoulder abduction if untreated)
• Beware: persistent pain after shoulder reduction → check for associated greater tuberosity fracture

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45. Fracture of the Shaft of Humerus – Relevant Anatomy

• Radial nerve winds around the posterior aspect in the spiral groove (between anterior and posterior compartments) at the junction of middle and distal thirds
• Profunda brachii artery accompanies radial nerve
• Brachialis anteriorly, triceps posteriorly
• Deltoid inserts at deltoid tuberosity (mid-shaft)
• Nutrient artery enters anteromedially in the proximal third

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46. Fracture of the Shaft of Humerus – Pathoanatomy

• Above deltoid insertion: Proximal fragment adducted by pectoralis major; distal pulled up by deltoid
• Below deltoid insertion: Proximal fragment abducted by deltoid; distal pulled up by biceps/triceps
• Radial nerve at risk — runs in spiral groove at junction of middle/distal thirds

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47. Displacement in Fracture Shaft of Humerus

• Depends on level relative to deltoid insertion and muscle pull:
  • Above deltoid insertion: Proximal → adducted; distal → abducted/elevated
  • At/below deltoid insertion: Proximal → abducted; distal → shortened (biceps/triceps shortening)
• Gravity aids reduction (hanging cast uses this principle)

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48. Fracture of the Shaft of Humerus – Diagnosis

• Pain, swelling, deformity, abnormal mobility, crepitus at fracture site
• Radial nerve assessment: Wrist drop, loss of finger extension, numbness over dorsum of hand/first web space
• X-ray: AP and lateral views including shoulder and elbow joints
• Vascular assessment: radial and brachial pulses

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49. Fracture of the Shaft of Humerus – Treatment

• Most fractures: Conservative — acceptable in most cases (shoulder has compensatory motion)
• Sarmiento functional brace (U-slab → functional brace at 1–2 weeks) — gold standard conservative
• Operative: IMN (antegrade/retrograde) or plate fixation

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50. Fracture of the Shaft of Humerus – Conservative Methods

1. Collar and cuff (gravity traction): For undisplaced fractures; hanging weight of arm aids alignment
2. U-slab (coaptation splint): Initial immobilisation
3. Sarmiento functional brace: Applied at 1–2 weeks; allows elbow + shoulder motion; most preferred non-operative method
4. Hanging cast: Weight of cast provides traction; patient must remain semi-upright

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51. Fracture of the Shaft of Humerus – Mechanism of Injury

• Direct violence: Road traffic accidents, direct blow → transverse or comminuted fracture
• Indirect violence: Fall on outstretched hand or elbow → spiral/oblique fracture
• Twisting injury: Spiral fracture (arm wrestling — classic "arm wrestling fracture")
• Pathological fracture: In metastatic disease or primary bone tumour

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52. Fracture of the Shaft of Humerus – Complications

• Radial nerve palsy (most common, ~12–18%): Wrist drop; most recover spontaneously (90%)
• Non-union: High in mid-shaft; risk ↑ with distraction or inadequate immobilisation
• Mal-union: Usually tolerated due to shoulder compensatory motion
• Vascular injury: Brachial artery (rare, more with open fractures)
• Infection (open fractures)

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53. Fracture of the Shaft of Humerus – Surgical Management

• Open fractures
• Radial nerve palsy after manipulation
• Vascular injury
• Floating elbow (ipsilateral radius/ulna fracture)
• Bilateral humerus fractures
• Polytrauma/pathological fracture
• Failed conservative treatment (non-union)

1. Plate fixation (ORIF): Anterior/posterior approach; 4.5 mm broad plate
2. Intramedullary nail (IMN): Antegrade (from shoulder) or retrograde (from elbow)
3. External fixation: Temporary for open/contaminated fractures

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Chapter 14 — Injuries Around the Elbow

1. Elbow – Anatomy

• Hinge (ginglymoid) joint — trochlea + capitellum articulate with ulna + radial head
• Medial epicondyle: origin of common flexors; cubital tunnel (ulnar nerve)
• Lateral epicondyle: origin of common extensors
• Anterior capsule attachment at coronoid fossa; posterior at olecranon fossa
• 3 key relations: Radial nerve (lateral), Ulnar nerve (medial, posterior), Median nerve + brachial artery (anterior)

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2. Three Bony Points Relationship

• In the extended elbow: medial epicondyle, lateral epicondyle, and olecranon tip form a straight line
• In 90° flexion: They form an isoceles triangle (equilateral triangle)
• This relationship is preserved in supracondylar fractures but disrupted in elbow dislocations
• Distinguishes supracondylar fracture (relationship preserved) from posterior elbow dislocation (relationship lost)

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3. Elbow – Carrying Angle

• Angle between the long axis of humerus and ulna when the elbow is fully extended and forearm supinated
• Normal: Males ~5–10°; Females ~10–15° (valgus)
• Cubitus valgus: Increased valgus → late ulnar nerve palsy (tardy ulnar nerve palsy)
• Cubitus varus (gunstock deformity): Due to malunion of supracondylar fracture → most common late complication

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4. Ossification Around the Elbow (CRITOE)

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5. Elbow – Mechanism of Injury

• FOOSH (fall on outstretched hand): Most common → supracondylar fracture, radial head fracture
• Direct blow: Olecranon fracture, condylar fractures
• Valgus stress: Medial collateral ligament injury, medial epicondyle avulsion
• Varus stress: Lateral collateral ligament injury

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6. Supracondylar Fracture of Humerus – Mechanism

• Extension type (98%): FOOSH with elbow hyperextended → distal fragment driven posteriorly
• Flexion type (2%): Direct blow or fall on flexed elbow → distal fragment driven anteriorly
• Most common fracture around the elbow in children (5–10 years)

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7. Supracondylar Fracture – Types

• Type I: Undisplaced
• Type II: Displaced, posterior cortex intact (hinged)
• Type III: Completely displaced (posteromedial or posterolateral displacement)
• Type IV: Multidirectional instability (rare)

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8. Supracondylar Fracture – Diagnosis

• X-ray: AP + lateral views
• Lateral view: Anterior humeral line should pass through middle third of capitellum (posterior displacement = passes anterior to capitellum)
• Fat pad sign: Posterior fat pad elevation = haemarthrosis (even if fracture not visible)
• Baumann's angle: Between the capitellar physis and humeral shaft axis; normally ~70–75° (assesses varus/valgus alignment)

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9. Supracondylar Fracture – Clinical Features

• Pain, swelling, deformity around elbow
• S-shaped deformity of the arm (elbow appears shortened)
• Elbow held in slight flexion (patient refuses to extend)
• Skin puckering anteriorly (proximal fragment buttonholed through brachialis)
• Assess neurovascular status urgently — pulseless pale hand is an emergency

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10. Supracondylar Fracture – Nerve Injury

• Anterior interosseous nerve (AIN) — branch of median nerve: Most common; loss of FPL + FDP to index finger → cannot make "OK" sign
• Radial nerve: Loss of wrist/finger extension
• Ulnar nerve: Less common; loss of intrinsics
• Overall: Median nerve most commonly injured in extension type

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11. Supracondylar Fracture – Treatment

• Type I: Above-elbow backslab in 90° flexion; 3 weeks
• Type II: Closed reduction under GA + percutaneous K-wire fixation (2 lateral pins)
• Type III: Closed reduction + percutaneous K-wire fixation (standard of care); open reduction if closed fails
• Pulseless hand: Urgent closed reduction; if pulse returns → K-wire stabilise; if pulseless after reduction → surgical exploration of brachial artery

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12. Supracondylar Fracture – Complications

• Early: Vascular injury (brachial artery), nerve injury (AIN/radial/ulnar), compartment syndrome
• Late:
  • Cubitus varus (most common late complication — malunion)
  • Cubitus valgus (less common)
  • Stiffness
  • Myositis ossificans (rare)
  • Volkmann's ischaemic contracture (compartment syndrome untreated)

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13. Supracondylar Fracture – Injury to Artery

• Brachial artery at risk (anterior to fracture)
• Proximal fragment can perforate or lacerate brachial artery
• 3 P's of vascular compromise: Pain, Pallor, Pulselessness + paraesthesia, paralysis
• Management: Closed reduction first → if pulse returns, K-wire fixation; if still absent → surgical exploration, vascular repair

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14. Volkmann's Ischaemic Contracture

• Result of unrecognised/untreated compartment syndrome of the forearm after supracondylar fracture
• Ischaemia → necrosis of flexor muscles (FDP, FPL, flexor carpi) → fibrosis and contracture
• Classical deformity: Elbow flexed, forearm pronated, wrist flexed, fingers flexed (intrinsic minus hand)
• 3 grades: Mild (localized, 2–3 digits), Moderate, Severe (all flexors involved)
• Prevention: Early recognition; fasciotomy if compartment pressure >30 mmHg or within 30 mmHg of diastolic
• Treatment (established): Physiotherapy (mild); muscle slide (moderate); free muscle transfer/tendon lengthening (severe)

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15. Malunion – Cubitus Varus (Gunstock Deformity)

• Most common late complication of supracondylar fracture
• Caused by malunion with medial rotation and adduction of distal fragment
• Reduced carrying angle (varus)
• Cosmetic deformity primarily; rarely causes functional deficit
• Tardy radial nerve palsy possible
• Treatment: Lateral closing wedge osteotomy of the distal humerus (French osteotomy)

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16. Fracture of the Lateral Condyle – Pathoanatomy

• Second most common elbow fracture in children (after supracondylar)
• Peak age: 5–10 years
• Involves the capitellar ossification centre and part of trochlea
• Mechanism: FOOSH or varus stress → avulsion by common extensor origin
• Milch Classification: Type I (fracture line into lateral trochlear ridge — stable); Type II (through trochlear groove — unstable, risks displacement)
• Risk of non-union if displaced and not fixed

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17. Fracture of Lateral Condyle – Diagnosis

• Pain and swelling at lateral elbow
• Lateral tenderness; possible valgus instability
• X-ray: Look carefully — fragment may be only cartilaginous (difficult to see)
• Arthrogram or MRI to assess displacement if unclear
• Displacement >2 mm = surgical threshold

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18. Fracture of Lateral Condyle – Treatment

• Undisplaced (<2 mm): Above-elbow cast 3–4 weeks; serial X-rays to check displacement
• Displaced (>2 mm): ORIF with K-wires or cannulated screws
• Early mobilisation after fixation

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19. Fracture of Lateral Condyle – Complications

• Non-union: Most important; leads to progressive cubitus valgus → tardy ulnar nerve palsy (decades later)
• Avascular necrosis of lateral condyle
• Cubitus valgus deformity
• Lateral condyle prominence ("fish-tail deformity")
• Stiffness

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20. Intercondylar Fracture – Types

• Type I: Undisplaced
• Type II: Separated but not rotated
• Type III: Separated and rotated
• Type IV: Severe comminution of articular surface

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21. Intercondylar Fracture – Diagnosis

• Usually in adults (high-energy) or elderly (osteoporotic)
• Severe pain, swelling, marked deformity ("bag of bones" appearance)
• X-ray AP + lateral: T/Y intercondylar split with condylar separation
• CT scan: For surgical planning — assesses comminution and articular step

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22. Intercondylar Fracture – Treatment

• Undisplaced (Type I): Collar and cuff; early mobilisation
• Displaced:
  • ORIF via posterior (Bryan-Morrey) approach with olecranon osteotomy — double plating (medial + lateral)
  • Elbow arthroplasty (total elbow replacement) in elderly/severe comminution
  • "Bag of bones" technique: in very frail elderly — sling, early mobilisation

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23. Intercondylar Fracture – Complications

• Elbow stiffness (most common)
• Non-union
• Heterotopic ossification (myositis ossificans)
• Post-traumatic osteoarthritis
• Ulnar nerve injury
• Infection (after ORIF)

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24. Fracture of Medial Epicondyle

• Common in children/adolescents (apophysis unfused until ~15–17 years)
• Mechanism: Valgus stress or avulsion by common flexor origin; associated with elbow dislocation (50%)
• The fragment may become trapped inside the joint after dislocation reduction
• Ulnar nerve runs directly behind medial epicondyle → at risk
• Undisplaced: Conservative (collar and cuff 2–3 weeks)
• Displaced >5 mm / incarcerated in joint / valgus instability: ORIF with screw

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25. Dislocation of the Elbow Joint

• 2nd most common dislocation (after shoulder) in adults; most common in children
• Posterior dislocation = most common (95%)
• Mechanism: FOOSH with elbow partially flexed → olecranon driven posterior
• Three bony points relationship is LOST (distinguishes from supracondylar fracture)
• Treatment: Closed reduction under sedation/GA — flex elbow + distract + correct mediolateral displacement; above-elbow backslab 2–3 weeks then early mobilisation
• Complications: Stiffness (most common), heterotopic ossification, neurovascular injury, "terrible triad" (dislocation + coronoid + radial head fracture)

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26. Pulled Elbow (Nursemaid's Elbow)

• Age: 2–6 years
• Mechanism: Sudden longitudinal traction on the forearm/wrist (lifted by the hand)
• Pathology: Radial head slips through/under annular ligament → annular ligament interposed in radiohumeral joint
• Child holds arm adducted, elbow slightly flexed, forearm pronated; refuses to use arm
• X-ray: Normal
• Treatment: Supination + flexion of elbow (or hyperpronation technique) → palpable/audible click → immediate recovery

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27. Fracture of the Olecranon

• Mechanism: Direct blow to the posterior elbow OR avulsion by triceps (eccentric contraction)
• Comminuted = direct; transverse/oblique = avulsion
• Elbow extension weak or absent; gap palpable at fracture
• Mayo Classification: Type I (undisplaced), Type II (displaced, stable), Type III (unstable/comminuted)

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28. Fracture of Olecranon – Treatment by Type

• Undisplaced (Type I): Above-elbow cast 3–4 weeks in 90° flexion
• Displaced transverse (Type II): Tension band wiring (TBW) — converts triceps pull into compression force; 2 K-wires + figure-of-eight wire
• Comminuted (Type III): Plate fixation (pre-contoured locking plate) OR partial/total olecranon excision + triceps advancement (elderly)

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29. Fracture of Olecranon – Complications

• Stiffness (most common)
• Prominent metalwork (K-wires/TBW backing out) — may need removal
• Non-union
• Post-traumatic osteoarthritis
• Ulnar nerve injury

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30. Fracture of the Radial Head – Types and Diagnosis

• Type I: Undisplaced crack (<2 mm)
• Type II: Marginal/segmental, displaced >2 mm
• Type III: Comminuted (whole radial head)
• Type IV (Johnston): Any radial head fracture + elbow dislocation

• Lateral elbow pain after FOOSH
• Pain on supination/pronation (more sensitive than flexion/extension)
• Positive posterior fat pad sign on lateral X-ray (haemarthrosis)
• Check for associated Essex-Lopresti lesion (radioulnar dissociation)

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31. Fracture of Radial Head – Treatment and Complications

• Type I: Collar and cuff 1–2 weeks; aspiration of haemarthrosis ± local anaesthetic; early mobilisation
• Type II: ORIF with mini-fragment screws if >2 mm displacement or >30% articular involvement
• Type III: Radial head excision (in isolation) or radial head replacement (if Essex-Lopresti or MCL injury)

• Stiffness (most common)
• Post-traumatic arthritis
• Proximal radial migration (after excision without MCL/IOM injury assessment)
• Non-union, AVN (rare)

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32. Plan of Treatment of Supracondylar Fracture

1. Assess neurovascular status (radial pulse, capillary refill, nerve function)
2. Type I → Above-elbow backslab 90° + review X-rays
3. Type II/III → Closed reduction under GA; percutaneous K-wire fixation (2 lateral K-wires)
4. Post-reduction X-ray: check anterior humeral line, Baumann's angle
5. Above-elbow backslab 3 weeks; K-wires removed at 3–4 weeks
6. Pulseless limb → close reduction first; if remains pulseless → surgical exploration of brachial artery ± vascular repair

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Chapter 15 — Injuries of the Forearm and Wrist

1. Forearm – Relevant Anatomy

• Two bones: radius and ulna, connected by interosseous membrane (IOM)
• IOM: central band runs obliquely — important for longitudinal force transmission; intact IOM prevents proximal radial migration after radial head excision
• Proximal radioulnar joint (PRUJ) and distal radioulnar joint (DRUJ) — allow pronation/supination
• Radial bow must be restored anatomically for full pronation/supination

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2. Forearm Muscles and Displacements After Fracture

• Biceps + supinator: Supinate the proximal radius
• Pronator teres (inserts mid-radius): Pronates
• Pronator quadratus (distal): Pronates

• Above pronator teres insertion: Proximal fragment supinated (biceps + supinator); distal pronated (PT + PQ)
• Below pronator teres: Proximal fragment neutral (PT partially balances); distal still pronated

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3. Forearm Fractures – Displacements and Diagnosis

• Both-bone forearm fractures: Shortening, angulation, rotational deformity
• Loss of radial bow → restricted supination
• Full-length X-rays including wrist and elbow (to exclude DRUJ/PRUJ injury)
• Assess for Monteggia (proximal ulna + radial head dislocation) and Galeazzi (distal radius + DRUJ dislocation)

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4. Forearm Fractures – Treatment

• Children: Closed reduction + above-elbow plaster (remodelling capacity); acceptable angulation ~10–15°
• Adults: ORIF with 3.5 mm DC plate — gold standard (both radius and ulna plated separately)
• Forearm "acts as a joint" — anatomical restoration of length, alignment, and radial bow essential

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5. Forearm Fractures – Complications

• Cross union (synostosis): Bridging bone between radius and ulna → loss of pronation/supination
• Non-union: More common in radius
• Mal-union: Loss of radial bow → restricted rotation
• Compartment syndrome (especially high-energy)
• Infection (after open fracture or surgery)
• Refracture (after plate removal too early)

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6. Forearm Fractures – Cross Union

• Osseous bridge between radius and ulna (radioulnar synostosis)
• Causes: High-energy injury, single incision approach for both bones, periosteal stripping, head injury (HO)
• Prevents pronation/supination (fixed in one position)
• Treatment: Surgical excision of bridge + interposition (fat/muscle) after at least 1 year; ± postoperative radiotherapy to prevent recurrence

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7. Plan of Treatment of Forearm Bone Fractures

1. Full clinical + neurovascular assessment
2. X-rays including elbow and wrist (exclude Monteggia/Galeazzi)
3. Children: Closed reduction + above-elbow plaster; operative if irreducible or >10° angulation
4. Adults: ORIF with 3.5 mm DCP (both bones separately)
5. Above-elbow cast post-op 6 weeks
6. Return to function with physiotherapy

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8. Monteggia Fracture-Dislocation – Types

• Type I (60%): Fracture of proximal/middle third ulna + anterior radial head dislocation — most common
• Type II: Ulna fracture + posterior radial head dislocation
• Type III: Ulna fracture + lateral radial head dislocation (children)
• Type IV: Fractures of both radius and ulna + anterior radial head dislocation

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9. Monteggia – Diagnosis, Treatment, Complications

• Diagnosis: Ulna fracture + line through radial head on lateral view should pass through capitellum — if not, radial head is dislocated
• Treatment:
  • Adults: ORIF of ulna (restores radial head) ± open reduction of radial head if irreducible
  • Children: Closed reduction + above-elbow cast (in most cases)
• Complications: Missed diagnosis, posterior interosseous nerve (PIN) injury, chronic radial head dislocation, stiffness

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10. Galeazzi Fracture-Dislocation

• Fracture of distal third of the radius + disruption of DRUJ (distal radioulnar joint)
• Called "fracture of necessity" — requires surgery
• Displacement: DRUJ disrupted; ulna appears prominent at the wrist; radius shortened
• Diagnosis: AP and lateral X-ray wrist; widened DRUJ; ulnar head prominent; distal radius fracture
• Treatment: ORIF of radius with 3.5 mm DCP; usually DRUJ reduces → immobilise in supination; if unstable DRUJ → K-wire stabilisation of DRUJ

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11. Colles' Fracture – Relevant Anatomy

• Fracture of the distal radius within 2.5 cm (1 inch) of the wrist joint
• Extra-articular fracture of the distal radius metaphysis
• Named after Abraham Colles (1814)
• Normal distal radius: Radial inclination 22–23°; volar tilt 11°; radial height 11 mm; ulnar variance 0
• Fracture disrupts these normal parameters

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12. Colles' Fracture – Displacements (Dinner Fork / Garden Spade Deformity)

1. Dorsal displacement of distal fragment
2. Dorsal angulation (loss of volar tilt → dorsal tilt)
3. Radial shift and shortening
4. Supination of distal fragment
5. Associated avulsion of ulnar styloid (50%) → Produces the "dinner fork" or "bayonet" deformity

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13. Colles' Fracture – Clinical and Radiological Features

• Pain, swelling, dinner fork deformity
• Tenderness at distal radius
• Restricted wrist motion
• Check for median nerve (CTS) and extensor pollicis longus tendon status

• Distal fragment: dorsally angulated, radially displaced, shortened
• Loss of radial inclination and volar tilt
• Ulnar styloid fracture
• Normal volar tilt 11° → reversed (dorsal tilt) in Colles'

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14. Colles' Fracture – Treatment

• Undisplaced/minimally displaced: Plaster backslap → full below-elbow cast; 5–6 weeks
• Displaced: Closed reduction under haematoma block/Bier's block/GA:
  1. Disimpact by traction + pronation
  2. Re-create the deformity then reduce
  3. Flex, ulnar deviate, pronate → well-moulded plaster in Cotton-Loder position
• Unstable/severely comminuted: ORIF with volar locking plate (now standard); external fixator; K-wires (Kapandji technique)

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15. Smith's Fracture

• "Reverse Colles'" — distal radius fracture with volar displacement (opposite of Colles')
• Mechanism: FOOSH on a dorsiflexed hand OR fall on the back of the hand (palm down)
• Deformity: "Garden spade" deformity in reverse — volar/anterior angulation
• X-ray: Volar tilt increased; distal fragment shifted anteriorly
• Treatment: Closed reduction difficult to maintain → ORIF with volar locking plate (standard)

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16. Barton's Fracture

• Intra-articular fracture of the distal radius with carpal subluxation
• Dorsal Barton's: Fracture of dorsal rim → dorsal subluxation of carpus
• Volar (reverse) Barton's: Fracture of volar rim → volar subluxation of carpus (more common)
• Mechanism: High-energy dorsiflexion or shear force
• Treatment: ORIF essential (intra-articular, unstable subluxation) — volar plate or dorsal buttress plate

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17. Scaphoid Fracture

• Most common carpal fracture (70% of all carpal fractures)
• Mechanism: FOOSH in dorsiflexion + radial deviation
• Anatomical zones: Waist (most common, 70%), proximal pole (15%), distal pole (10%)
• Blood supply enters distally → proximal pole at risk of AVN
• Clinical: Tenderness in anatomical snuffbox; pain on axial loading of thumb; scaphoid compression test
• X-ray may be normal initially → if suspected, treat as fractured; repeat X-ray at 10–14 days or obtain MRI/CT (MRI is gold standard for early diagnosis)

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18. Scaphoid Fracture – Complications

• Avascular necrosis (AVN) of proximal pole (15–30% in waist fractures): Risk ↑ with proximal pole fractures, delayed treatment, displacement
• Non-union (5–10%): Pain, swelling; treated with Herbert screw + bone graft
• SNAC wrist (Scaphoid Non-union Advanced Collapse): Progressive radiocarpal arthritis → pain, stiffness
• Malunion: "Humpback deformity" — DISI (dorsal intercalated segment instability)

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19. Lunate and Peri-Lunate Dislocation

• Lunate stays in place; carpus dislocates dorsally relative to lunate
• On lateral X-ray: Capitate lies dorsal to lunate

• Lunate dislocated volarly into the carpal tunnel
• Lateral X-ray: Lunate "spills" anteriorly (looks like a cup spilled)
• Median nerve compression common (acute CTS)
• Treatment: Urgent closed reduction (or open); K-wire stabilisation; repair scapholunate and lunotriquetral ligaments

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Chapter 16 — Hand Injuries

1. Bennett's Fracture-Dislocation

• Intra-articular fracture of the base of 1st metacarpal with dislocation of the CMC joint
• Small volar fragment held by AOL (anterior oblique ligament); large fragment pulled radially and proximally by APL
• Mechanism: Axial blow along thumb (punch)
• Treatment: Closed reduction + percutaneous K-wire fixation; occasionally ORIF

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2. Rolando's Fracture

• Comminuted intra-articular fracture of base of 1st metacarpal (T or Y pattern)
• Worse prognosis than Bennett's due to comminution
• Treatment: ORIF if 3 large fragments; external fixator (traction-distraction) if severely comminuted; conservative if very comminuted (early mobilisation)

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3. Fractures of the Metacarpals

• Boxer's fracture: Neck of 5th metacarpal; dorsal angulation; mechanism = punch
  • Accept up to 40° angulation in 5th, 30° in 4th
  • Treatment: Neighbour strapping; rarely ORIF
• Shaft fractures: Transverse or spiral; rotational deformity must be corrected
• Base fractures: Check for CMC dislocation; ORIF if needed
• Finger metacarpals: Less shortening/rotation acceptable in border digits

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4. Fractures of the Phalanges

• Proximal phalanx: Flexed by intrinsics; distal pulled by extrinsics → apex volar angulation
• Middle phalanx: Depends on level relative to FDS insertion
• Distal phalanx: Tuft fracture (crush injury) — treated conservatively; beware subungual haematoma
• Principles: Correct rotational deformity; neighbour strap; operative if unstable/intra-articular → K-wire or plate

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5. Mallet Finger (Baseball Finger)

• Rupture or avulsion of extensor tendon at distal phalanx (DIP joint)
• ± avulsion fracture of dorsal base of distal phalanx
• Mechanism: Forced flexion of extended DIP joint (ball hitting fingertip)
• Deformity: DIP joint in flexion (cannot actively extend); PIP may hyperextend (swan neck)
• Treatment: Stack splint (DIP in full extension) for 6–8 weeks continuously; bony mallet with >1/3 articular surface displaced → ORIF

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6. Dislocation of MCP Joints

• Dorsal dislocation = most common (proximal phalanx dorsal to metacarpal)
• Index finger MCP: May become complex/irreducible (volar plate interposition + wrapped by flexor tendons, lumbricals, NV bundles)
• Simple dislocation: Hyperextension → closed reduction
• Complex dislocation: Open reduction required
• Clinical clue: Bayonet deformity; puckering of volar skin; do not attempt repeated closed reduction if irreducible

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7. Testing for Flexor Tendons

• FDP (Flexor digitorum profundus): Hold PIP extended → test DIP flexion (FDP only)
• FDS (Flexor digitorum superficialis): Hold all other fingers extended → test PIP flexion of individual finger (FDS tested in isolation)
• FPL (Flexor pollicis longus): Hold MCP of thumb extended → test IP flexion of thumb
• Note: FDS of little finger may be absent in 15–20% of people

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8. Tendon Injuries of the Hand – Treatment

• Zone II ("No man's land"): Between A1 pulley and FDS insertion — historically poor results; now primary repair standard
• Primary repair within 12–24 hours if clean wound
• Technique: Core suture (e.g., modified Kessler, Tajima) + epitendinous suture; minimum 4-strand core repair
• Post-op: Early active mobilisation (e.g., Kleinert or Belfast protocol)
• Extensor tendons: Simpler anatomy; dorsal splintage after repair

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9. Considerations for Amputation

• Thumb, multiple fingers, child's hand
• Single digit distal to FDS insertion
• Clean-cut mechanism (guillotine)

• Severe crush/avulsion, multilevel injury
• Prolonged ischaemia (>6 h warm)
• Significant comorbidities
• Single finger proximal to FDS insertion (poor function)

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10. Position of Immobilisation of the Hand

• Wrist: 20–30° extension
• MCP joints: 70–90° flexion
• IP joints: Full extension (0°)
• Thumb: Abducted and opposed

• MCP collateral ligament shortening (MCPs must be held in flexion — collaterals are taut)
• PIP flexion contracture (PIPs in extension)

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Chapter 18 — Injuries Around the Hip

1. What Injuries are Discussed

• Dislocations of the hip (anterior, posterior, central fracture-dislocation)
• Fractures of the neck of the femur (intracapsular)
• Intertrochanteric fractures (extracapsular)
• Subtrochanteric fractures

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2. Relevant Anatomy of the Hip

• Ball and socket joint: Femoral head (2/3 sphere) + deep acetabulum; enhanced by labrum
• Acetabulum: Formed by ilium, ischium, pubis (triradiate cartilage in children)
• Ligaments: Iliofemoral (Y ligament of Bigelow — strongest), pubofemoral, ischiofemoral
• Capsule: Attaches anteriorly at intertrochanteric line, posteriorly ~1.5 cm proximal to intertrochanteric crest → intracapsular vs extracapsular distinction
• Muscles: Gluteus medius/minimus (abductors — insert greater trochanter); iliopsoas (flexor — inserts lesser trochanter); short external rotators posteriorly

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3. Calcar Femorale

• Dense vertical plate of cortical bone within the femoral neck, running from posterior femoral shaft to the posteroinferior femoral neck
• Provides compressive strength to the femoral neck (like a bony internal strut)
• Important in assessing fracture stability (if intact, fracture more stable)
• Must be considered in fracture classification and implant placement

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4. Blood Supply of the Femoral Head

• Medial femoral circumflex artery (MFCA) — main supply (via retinacular vessels in posterosuperior capsule)
• Lateral femoral circumflex artery (LFCA) — minor
• Ligamentum teres artery (obturator artery) — minor; only significant in children
• Retinacular vessels (Weitbrecht's retinaculum) run along femoral neck → most vulnerable in intracapsular fractures → AVN

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5. Abductor Mechanism of the Hip

• Gluteus medius + minimus (abductors) insert on greater trochanter
• Normal: In single-leg stance, abductors contract to keep pelvis level (Trendelenburg negative)
• Trendelenburg positive: When abductors fail (paralysis, pain, malunion of greater trochanter, AVN) → pelvis tilts to unsupported side
• Important for walking efficiency; damage causes Trendelenburg gait (lateral trunk lurch to affected side — compensatory gait)

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6. Dislocations of the Hip

• Mechanism: Forced abduction + ER (e.g., head-on impact with thigh abducted, driver's leg braced)
• Types: Pubic (superior, flexion) and Obturator (inferior, extension)
• Limb: Abducted, externally rotated, may be flexed
• Femoral nerve/vessels at risk

• Acetabular fracture + medial displacement of femoral head
• Mechanism: Axial blow along femur (dashboard, fall)
• Treatment: Traction initially; ORIF of acetabulum; THA if severe articular damage

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7. Posterior Dislocation – Mechanism, Clinical, Radiological

• Most common dislocation (90%)
• Mechanism: Dashboard injury — axial force through flexed, adducted hip (knee hits dashboard)
• Clinical: Limb shortened, adducted, internally rotated, flexed; patient cannot weight-bear; sciatic nerve injury (10%)
• Radiological: AP pelvis — femoral head above and lateral to acetabulum; smaller appearing head (magnification); associated posterior acetabular wall fracture

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8. Posterior Dislocation – Treatment and Complications

• Urgent closed reduction under GA (within 6 hours — reduces AVN risk)
• Bigelow, Allis, or Stimson technique
• Post-reduction CT to check for intra-articular fragments; ORIF if posterior wall fracture >40–50% of articular surface
• Traction 2–3 weeks, then mobilise

• Avascular necrosis (10–20%; risk ↑ with delay >6 h)
• Sciatic nerve injury (10%; usually recovers)
• Post-traumatic OA (most common long-term complication)
• Heterotopic ossification
• Recurrent dislocation (rare)

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9. Fracture of Neck of Femur – Pathoanatomy

• Subcapital, transcervical, basicervical
• Disrupts retinacular blood supply → high risk of AVN and non-union
• Haemarthrosis within closed capsule

• Intertrochanteric, subtrochanteric
• Blood supply to head not usually disrupted
• Bleeding into thigh → significant haemorrhage possible
• Lower risk of AVN; good union potential

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10. Fracture of Neck of Femur – Classifications

• Subcapital, transcervical, basicervical (intracapsular)
• Intertrochanteric, subtrochanteric (extracapsular)

• Type I: <30° (compression — most stable)
• Type II: 30–50°
• Type III: >50° (shear — most unstable, highest AVN risk)

• Type I: Undisplaced, incomplete (impacted valgus)
• Type II: Complete, undisplaced
• Type III: Partial displacement (trabecular pattern disrupted)
• Type IV: Complete displacement (no alignment of trabeculae)
• Clinically grouped: Garden I & II = undisplaced; Garden III & IV = displaced

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11. Fracture of Neck of Femur – Mechanism, Clinical, Radiological

• Elderly: Low-energy fall from standing height (fragility fracture)
• Young: High-energy trauma

• Shortened, externally rotated limb (displaced)
• Pain in groin/hip; unable to weight-bear
• Undisplaced: May still bear weight; groin pain only

• AP pelvis + lateral hip X-ray
• Shenton's line disrupted (displaced)
• Garden alignment index on AP and lateral
• MRI if X-ray normal but high suspicion

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12. Treatment Plan of Fresh Intracapsular Fracture (<3 weeks)

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13. Fracture Neck of Femur – Treatment by Displacement

• May treat conservatively (traction) but risk of displacement
• Preferred: Percutaneous cannulated screw fixation (3 screws) — early mobilisation

• Elderly: Hemiarthroplasty (unipolar Austin Moore or bipolar)
• Fit, active elderly / acetabular disease: Total hip replacement (better long-term function)
• Young patient: ORIF urgently with dynamic hip screw or cannulated screws (attempt to preserve head)

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14. McMurray's Osteotomy and Hemiarthroplasty

• Intertrochanteric medial displacement osteotomy
• Brings intact medial cortex and calcar under the fracture → better load transmission
• Rarely used now; historical procedure for medial femoral neck fractures in younger patients

• Replacement of femoral head only (acetabulum preserved)
• Austin Moore: Unipolar (fixed head), press-fit/fenestrated stem
• Thompson: Unipolar, cemented
• Bipolar: Inner + outer head (reduces acetabular erosion)
• Indications: Displaced intracapsular fracture in elderly patient

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15. Devices Used for Fixation of Neck of Femur Fractures

1. Cannulated screws (3 screws in triangle): For undisplaced intracapsular fractures
2. Dynamic Hip Screw (DHS): Lag screw + plate; for basicervical and stable intertrochanteric
3. Proximal Femoral Nail (PFN / PFNA): Intramedullary; for unstable intertrochanteric and subtrochanteric
4. Multiple Moore pins: Historical
5. Hemiarthroplasty: For displaced fractures in elderly

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16. Treatment of Cases Presenting Late / Complications

• Young: Valgus osteotomy (McMurray) + bone graft
• Elderly: Total hip replacement (THA)

• Early: Core decompression ± vascularised fibular graft (young)
• Advanced: THA

• Corrective valgus osteotomy if symptomatic

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17. Intertrochanteric Fractures – Pathoanatomy, Clinical, Radiological

• Extracapsular; between greater and lesser trochanters
• Abundant blood supply → non-union rare; AVN rare
• Significant blood loss into thigh (up to 1–2 L)
• Greater trochanter pulled superiorly by abductors; lesser trochanter by iliopsoas

• Shortened, externally rotated, and painful hip
• More swelling/bruising than intracapsular (extracapsular bleeding)
• Unable to straight leg raise

• AP pelvis + lateral hip
• Evans classification on AP view

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18. Intertrochanteric Fractures – Treatment

• Traction (Russell's or skin traction) for 6–12 weeks
• High morbidity in elderly (pressure sores, DVT, pneumonia)

• Stable fractures: Dynamic Hip Screw (DHS) — extramedullary fixation
• Unstable fractures (reverse oblique, subtrochanteric extension): Proximal Femoral Nail (PFN/PFNA) — intramedullary device
• Goal: Early mobilisation, weight-bearing to prevent complications of immobility

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19. Devices for Intertrochanteric Fixation + Complications

1. DHS (Dynamic Hip Screw): Sliding lag screw + plate; allows controlled collapse
2. PFNA (Proximal Femoral Nail Antirotation): IM nail + helical blade; preferred for unstable and reverse oblique fractures
3. Condylocephalic (Ender's) nails: Historical
4. Hemiarthroplasty: For severe comminution in very elderly

• Cut-out (lag screw through femoral head) — most common implant failure; poor TAD (>25 mm)
• Non-union (rare — good blood supply)
• Malunion (coxa vara — if fixed with varus)
• DVT/PE (prophylaxis essential)
• Wound infection
• Implant failure (reverse oblique treated with DHS → medialization failure)

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Chapter 19 — Fracture Shaft of Femur

1. Mechanism of Injury and Force

• Requires high-energy force (road traffic accident, fall from height, gunshot)
• Children: May occur with lesser force
• Direct: Transverse fracture (lateral blow to thigh)
• Indirect: Torsional → spiral fracture; bending → oblique fracture
• Pathological: Metastatic bone disease, Paget's

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2. Pathoanatomy and Displacement

• Proximal fragment: Flexed (iliopsoas) + abducted (abductors) + externally rotated
• Distal fragment: Pulled posteriorly by gastrocnemius (posterior angulation of distal fragment)
• Shortening: Quadriceps + hamstrings
• Blood loss: Up to 1.5–2 L into thigh (closed) → risk of hypovolaemic shock

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3. Diagnosis – Clinical and Radiological

• Severe thigh pain, marked swelling
• Deformity, shortening, abnormal mobility, crepitus
• Thigh compartment syndrome possible
• ATLS assessment — haemodynamic status critical

• AP + lateral femur (full-length including hip and knee)
• Check for ipsilateral neck of femur fracture (~5% — often missed)
• AP pelvis

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4. Treatment – Conservative Methods

• Traction (mainly now for temporisation/children):
  • Skin traction (Bryant's/Gallows): Infants/children <2 years
  • Thomas splint + skin traction: Splintage for transfer/temporary
  • Skeletal traction (tibial pin): Temporising in ICU/polytrauma
• Definitive conservative only in young children (<5 years) — spica cast after reduction

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5. Treatment – Operative Methods

1. Intramedullary nail (IMN): Antegrade or retrograde; gold standard in adults
2. External fixation: Temporary (damage control in polytrauma; open contaminated fractures)
3. Plate fixation (ORIF): Subtrochanteric/periprosthetic fractures; when IMN contraindicated
4. Flexible nails (ESIN): Children 5–12 years (titanium elastic nails)
5. Hip spica cast: Children <5 years

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6. Preferred Method in Adults

• Closed antegrade intramedullary nailing (IMN) — gold standard
• Allows early mobilisation and weight-bearing
• Minimally invasive (closed technique preserves biology)
• Reduces blood loss compared to open plating
• Rotational and length control with interlocking screws

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7. Preferred Method in Children

• <2 years: Gallows traction → spica cast
• 2–5 years: Closed reduction + hip spica cast
• 5–12 years: Elastic Stable Intramedullary Nailing (ESIN/TEN) — titanium elastic nails
• >12 years / near-skeletal maturity: Locked IMN (adult technique)

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8. Deciding Treatment Plan

• Age (child vs adult)
• Fracture pattern (transverse/comminuted/subtrochanteric)
• Soft tissue (open vs closed)
• Associated injuries (polytrauma — damage control philosophy)
• General condition (haemodynamic stability)
• Ipsilateral hip/knee pathology

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9. Late Complications

• Malunion (shortening, angulation, rotation)
• Non-union (atrophic or hypertrophic; treat with exchange nail + bone graft)
• Post-traumatic OA of knee (intra-articular extension or retrograde nail)
• Knee stiffness (distal fractures)
• Leg length discrepancy
• Fat embolism syndrome (early)
• Implant failure (broken nail if dynamised too early)

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10. Early Complications

• Haemorrhagic shock (up to 2 L blood loss in closed fracture)
• Fat embolism (24–72 hours; hypoxia, confusion, petechiae)
• Compartment syndrome of thigh (rare)
• Neurovascular injury (femoral artery, sciatic nerve)
• DVT/PE
• Associated injuries: Ipsilateral femoral neck fracture, knee ligament injury

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Chapter 20 — Injuries Around the Knee

1. Types of Knee Injuries

• Fractures: Patella, tibial plateau (condylar), distal femur (condylar/supracondylar)
• Ligament injuries: MCL, LCL, ACL, PCL
• Meniscal tears
• Extensor mechanism injuries (quadriceps tendon, patellar tendon, patella fracture)
• Dislocations: Knee joint, patella

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2. Functions of the Knee Ligaments

• MCL: Resists valgus stress; secondarily resists ER
• LCL: Resists varus stress; works with posterolateral corner
• ACL: Prevents anterior tibial translation; controls ER in extension (primary); resists hyperextension
• PCL: Prevents posterior tibial translation (primary); most important rotational stabilizer
• Ligaments provide static stability; muscles provide dynamic stability

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3. Extensor Apparatus of the Knee and Extensor Lag

• Extensor lag: Inability to actively extend the knee to the last few degrees despite full passive extension
• Causes: Quadriceps weakness, patella fracture, patellar tendon rupture, quadriceps tendon rupture
• Measured: Difference between active and passive extension (e.g., lag of 20° = can actively extend to only 20° short of full)

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4. Mechanism of Knee Injuries

• Valgus force: MCL tear, medial tibial plateau fracture
• Varus force: LCL + posterolateral corner injury
• Anterior force on tibia / hyperextension: ACL tear
• Posterior force on proximal tibia: PCL tear (dashboard injury)
• Twisting/rotation: Meniscal tears, ACL tears
• Direct blow to patella: Patellar fracture, haemarthrosis
• O'Donoghue's Triad (Unhappy Triad): ACL + MCL + medial meniscus (now known to be ACL + MCL + lateral meniscus more commonly)

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5. Condylar Fractures of the Femur

• Distal fragment pulled into flexion by gastrocnemius → risk of popliteal vessel injury
• Treatment: ORIF with locking plate (LISS); early mobilisation

• Coronal (Hoffa fracture) or sagittal plane; articular surface involved
• Treatment: ORIF essential (articular step >2 mm)

• Most complex; require anatomical ORIF
• AO Type C; double plating

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6. Condylar Fractures – Complications

• Post-traumatic osteoarthritis
• Knee stiffness/loss of movement
• Malunion (varus/valgus malalignment)
• Non-union
• Popliteal artery injury (supracondylar — at risk due to gastrocnemius tethering)
• DVT/PE
• Infection (after ORIF)

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7. Fractures of the Patella – Mechanism and Types

• Direct blow to patella (dashboard, fall): Comminuted or stellate fracture
• Indirect (avulsion by quadriceps): Transverse fracture with separation

• Transverse (most common — indirect)
• Stellate/comminuted (direct)
• Vertical (rare)
• Upper or lower pole avulsion
• Osteochondral fracture (patellar dislocation)

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8. Patellar Fractures – Clinical and Radiological Features

• Pain, swelling (haemarthrosis), tenderness over patella
• Gap palpable between fragments (displaced transverse)
• Inability to straight leg raise (extensor mechanism disrupted if displaced)
• Assess skin integrity (Morel-Lavallée lesion)

• AP + lateral X-ray: Assess displacement and articular step
• Bipartite patella (superolateral fragment, smooth edges — normal variant) vs fracture
• Skyline view for vertical fractures

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9. Patellar Fractures – Treatment

• Undisplaced (<2 mm, extensor intact): Cylinder cast or brace 4–6 weeks; quads exercises
• Displaced (>2–3 mm articular step, extensor disrupted): Operative treatment

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10. Patellar Fractures – Non-operative Treatment

• Undisplaced fractures with intact extensor mechanism
• Cylinder cast knee in extension or hinged brace
• 4–6 weeks immobilisation
• Progressive weight-bearing; physiotherapy
• Serial X-rays to confirm no displacement

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11. Patellar Fractures – Operative Treatment: TBW for Transverse Fracture

• 2 parallel K-wires + figure-of-eight wire loop anteriorly
• Converts quadriceps distraction force into compression at the articular surface
• Allows early mobilisation and weight-bearing
• Indicated: Displaced transverse fracture with intact retinaculum

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12. Patellar Fractures – Operative Treatment: Comminuted Fracture

• Partial patellectomy: If only one pole is comminuted → excise polar fragment, reattach patellar/quadriceps tendon
• Total patellectomy: Severely comminuted, unreconstructable → remove entire patella + repair extensor mechanism (poor long-term outcome: ↓ quads power, OA)
• ORIF with small fragment screws ± cerclage wire: For reconstructable comminution

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13. Patellar Fractures – Complications

• Post-traumatic chondromalacia / OA (most common long-term)
• Extensor lag (residual)
• Hardware prominence (K-wire/TBW backing out — often needs removal)
• Skin necrosis (if open wound or Morel-Lavallée)
• Infection
• Quads weakness

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14. Ligament Injuries – Mechanism and O'Donoghue's Triad

• O'Donoghue's Triad ("Unhappy triad"):
  • Originally described as: ACL + MCL + medial meniscus
  • Modern evidence: More commonly ACL + MCL + lateral meniscus (O'Brien's modification)
  • Mechanism: Valgus + external rotation force to the knee (e.g., clip from the side in football)

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15. Haemarthrosis, Ligaments, and Anatomy

• Immediate haemarthrosis (within 2 hours): ACL tear (70%), patellar dislocation, peripheral meniscal tear, osteochondral fracture
• Delayed effusion (12–24 hours): Meniscal tear, ligament sprain without complete tear

• ACL: Anteromedial + posterolateral bundles; resists anterior drawer + IR
• PCL: Anterolateral + posteromedial bundles; most isometric ligament
• MCL: Superficial (primary valgus restraint) + deep (capsular)
• LCL: Part of posterolateral corner complex

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16. Mechanism – MCL and LCL Injuries

• Valgus stress (direct blow to lateral knee or ER force)
• Grades: I (sprain), II (partial tear), III (complete tear)
• Most heal with conservative treatment (hinge brace)

• Varus stress ± hyperextension
• Often associated with common peroneal nerve injury
• Grade III → reconstruct if combined with cruciate injury

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17. Mechanism – ACL and PCL Injuries

• Non-contact (most common): Landing from jump, cutting/pivoting → tibial IR + valgus
• Contact: Valgus force with ER
• Patient hears/feels a "pop"; immediate haemarthrosis; knee gives way

• Dashboard injury: Posterior force on proximal tibia (knee flexed)
• Fall on flexed knee with foot plantarflexed
• Posterior sag of tibia; step-off lost

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18. Anterior Drawer Test

• Patient supine; hip 45°, knee 90° flexion; examiner sits on foot
• Grasp proximal tibia and pull anteriorly
• Positive: >5 mm anterior translation of tibia = ACL tear
• Check: Hamstrings relaxed; posterior sag ruled out (else falsely positive anterior drawer)

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19. Lachman Test

• Most sensitive test for ACL (sensitivity 85–99%)
• Knee 20–30° flexion; one hand stabilises femur, other pulls tibia anteriorly
• Positive: Increased anterior translation + soft/absent end-point
• Better than anterior drawer at 90° (hamstrings do not mask the laxity)

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20. Posterior Drawer Test

• Same position as anterior drawer
• Push tibia posteriorly
• Positive: Posterior translation of tibia = PCL tear
• Also look for "posterior sag sign" (gravity causes posterior sagging of tibia when knee flexed 90°)

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21. Stress Tests

• Valgus stress test at 30° and 0°:
  • Positive at 30° only: Isolated MCL tear
  • Positive at 0° and 30°: MCL + cruciate + capsule injury
• Varus stress test:
  • Positive at 30°: LCL + posterolateral corner
  • Positive at 0°: LCL + PCL + posterior capsule
• Grading: Grade I (pain, no laxity), II (laxity, endpoint), III (no endpoint)

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22. Tibial Plateau Fractures – Schatzker Classification

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23. Extensor Weakness

• Causes: Patella fracture, patellar tendon rupture, quadriceps tendon rupture, tibial tubercle avulsion, femoral nerve injury
• Assessment: Ability to perform straight leg raise; active ROM
• Patellar tendon rupture: Young patients; palpable gap below patella; patella alta on lateral X-ray
• Quadriceps tendon rupture: Older patients; gap above patella; patella baja

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24. Dial Test

• Assesses posterolateral corner (PLC) integrity
• Patient prone; knees at 30° and 90°
• Externally rotate both feet; measure tibial ER
• Positive at 30° only: Isolated PLC injury
• Positive at both 30° and 90°: PLC + PCL injury

• 10° asymmetry = positive

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25. Medial Meniscus

• C-shaped; larger than lateral; covers ~50% of medial tibial plateau
• Firmly attached peripherally (joint capsule, MCL)
• Functions: Load transmission (50% medial compartment load), shock absorption, joint stability, proprioception
• Blood supply: Peripheral third (red-red zone) — heals; inner two-thirds (white-white) — avascular; tears in inner zone do not heal

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26. Lateral Meniscus

• O-shaped (more circular); covers ~70% of lateral tibial plateau
• Less firmly attached (popliteus hiatus; no attachment to LCL)
• More mobile → less commonly torn than medial
• Discoid lateral meniscus (variant) → Wrisberg lesion (snapping knee)

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27. Apley's Compression Test

• Distinguishes meniscal from ligament injury
• Patient prone; knee 90° flexion
• Compression test: Axillary pressure through tibia + rotation → if pain = meniscal injury
• Distraction test: Lift tibia upward (distract) + rotation → if pain = ligament injury
• "Apley SQUASH = meniscus; Apley STRETCH = ligament"

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28. Osteoarthritis of the Knee

• Most common indication for knee replacement
• Medial compartment OA most common → varus deformity
• Clinical: Pain, stiffness (worse after rest and end of day), deformity (varus/valgus), reduced ROM, crepitus
• X-ray: Joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts
• Treatment: Conservative (physio, NSAIDs, weight loss, brace); Injection (steroid, hyaluronate); Surgery: HTO (younger), unicompartmental or total knee replacement (elderly)

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29. Knee Dislocation

• High-energy injury; tibiofemoral dislocation
• Popliteal artery injury in 30–40% — most critical
• Peroneal nerve injury ~25%
• Anterior dislocation (hyperextension) and posterior (dashboard) most common
• All suspected knee dislocations require vascular assessment (ABI; CT angiography if ABI <0.9)
• Treatment: Immediate reduction; vascular surgery if arterial injury; ligament reconstruction staged

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30. Patellar Dislocation

• Lateral dislocation (almost always)
• Mechanism: Twisting on planted foot; direct blow; hypoplastic trochlea/patella alta predisposes
• Immediate haemarthrosis; patella visible laterally; knee held in flexion
• Osteochondral fracture common
• Medial retinaculum torn (medial tenderness)
• Reduction: Extend knee + medial pressure on patella
• Recurrence high (~30%); MPFL repair/reconstruction for recurrent dislocation

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31. Bursae of the Knee

• Prepatellar bursa: In front of patella; "housemaid's knee" — kneeling work
• Infrapatellar bursa: "Clergyman's knee" — below patella; kneeling more upright
• Semimembranosus bursa (Baker's cyst): Behind knee; communicates with joint in OA → bulge in popliteal fossa
• Pes anserine bursa: Medial proximal tibia; in obese patients/OA
• Treatment: Aspiration ± steroid; excision if persistent

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32. Meniscus Treatment

• Red-red zone (peripheral, vascular): Repair (arthroscopic or open); good healing
• Red-white zone (mid): Repair possible (variable outcome)
• White-white zone (inner, avascular): Partial meniscectomy (meniscal repair will not heal)
• General principle: Preserve as much meniscus as possible (loss → accelerated OA)
• Post-op: Crutches 2–6 weeks (repair); physiotherapy

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33. Meniscus Diagnosis

• History: Twisting injury; medial/lateral joint line pain; locking (bucket handle tear); giving way
• McMurray's test: Flexion + rotation; click or pain at joint line = positive
• Thessaly test: Standing single-leg squat at 20° knee flexion → pain/clicking = positive (high sensitivity)
• Apley's test: Compression + rotation prone (see Q27)
• MRI: Gold standard for meniscal diagnosis; sagittal images; "bow-tie sign" = normal meniscus (>2 slices); bucket-handle = absent bow-tie

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34. Meniscus Arthroscopy

• Diagnostic + therapeutic gold standard
• Portals: Standard anterolateral + anteromedial
• Partial meniscectomy: Unstable flap/radial tear in white-white zone; minimise tissue removed
• Meniscal repair: Vertical tears in red zone; techniques — inside-out, outside-in, all-inside (rapid fixators)
• Meniscal transplant: Young patients after total meniscectomy; cadaveric allograft
• Post-op: Partial meniscectomy → weight-bear immediately; repair → protected weight-bearing 6 weeks

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Chapter 21 — Injuries to the Leg, Ankle and Foot

1. Tibia and Fibula – Relevant Anatomy/Characteristics

• Tibia: Weight-bearing bone; anteromedial surface subcutaneous (no muscle protection → poor healing, higher open fracture risk)
• Fibula: Non-weight-bearing; provides ankle stability (lateral malleolus)
• Nutrient artery: Tibia — enters posteromedially in proximal third
• Compartments of leg: 4 compartments (anterior, lateral, superficial posterior, deep posterior) — compartment syndrome risk
• Periosteum thin anteriorly → more open fractures; poor blood supply → non-union common

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2. Tibial Fractures – Mechanism

• Bumper/road traffic injury → transverse or comminuted; often open; high risk of compartment syndrome
• High-energy: Complex comminution

• Torsional force (skiing, twisting) → spiral fracture
• Fibula may be intact or fracture at a different level (Maisonneuve equivalent)

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3. Tibial Fractures – Pathoanatomy and Patterns

• Transverse: Direct blow
• Spiral: Torsional (clean fracture, good union potential)
• Oblique: Combined bending + compression
• Comminuted: High-energy; poor blood supply → higher non-union risk
• Segmental: Very high non-union and soft tissue complication risk
• Fibula fractures alter stability and classification

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4. Tibial Fractures – Clinical Features

• Severe leg pain, deformity, swelling
• Open wounds (subcutaneous tibia — Gustilo classification)
• Compartment syndrome signs: Pain out of proportion, pain on passive stretch (most sensitive early sign), tense/woody compartments, paraesthesia
• Neurovascular assessment: Dorsalis pedis, posterior tibial pulses; peroneal nerve (foot drop)

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5. Tibial Fractures – Radiological Features

• AP + lateral tibia (full length including knee + ankle)
• Define fracture pattern, level, comminution
• Check for associated fibula fracture (level — proximal fibula fracture + ankle injury = Maisonneuve)
• CT for periarticular/plateau or pilon fractures

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6. Tibial Fractures – Treatment: Closed Fractures

• Conservative: Long leg cast → short leg walking cast at 4–6 weeks (for stable, undisplaced spiral fractures; children)
• Functional bracing (Sarmiento brace): For stable isolated tibia fractures
• Operative (standard for displaced): Intramedullary nailing (closed, locked) — gold standard for adult diaphyseal fractures; allows early weight-bearing

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7. Tibial Fractures – Treatment: Open Fractures

• ATLS; ABC
• Gustilo classification (I, II, IIIa, IIIb, IIIc)
• Wound photograph, saline dressing cover; IV antibiotics (co-amoxiclav ± gentamicin) within 1 hour
• Emergency surgery: Wound debridement + external fixator (damage control or definitive for IIIb/c)
• "Fix and flap within 72 hours" principle
• IIIb: Free flap coverage (latissimus dorsi, anterolateral thigh)
• IIIc: Vascular repair + orthopaedic fixation

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8. Tibial Fractures – Closed Reduction, Wedging, Operative Role

• Traction + correction of angulation; mould cast in 3-point fixation
• Acceptable: <5° angulation in any plane; <1 cm shortening; <10° rotation

• If angulation recurs after plastering, opening/closing wedge of cast to correct deformity

• Displaced/unstable fractures; open fractures; segmental fractures; bilateral; floating knee; polytrauma

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9. Tibial Fractures – Complications

• Compartment syndrome (most important early complication)
• Non-union (most common late; particularly distal third — watershed area)
• Malunion (especially in conservative management)
• Infection (especially open fractures)
• Fat embolism
• DVT/PE
• Peroneal nerve injury (foot drop)
• Knee/ankle stiffness

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10. Tibial Fractures – Treatment of Non-union

• Exchange nailing (larger nail): Stimulates biology + provides better stability
• Bone grafting (iliac crest): Standard for atrophic non-union

• Onlay bone graft (cortical + cancellous chips) placed along the fracture site; minimal disruption to fracture
• Useful for hypertrophic/oligotrophic non-union

• Circular external fixator with thin wires
• Distraction osteogenesis: For non-union + bone loss + limb length discrepancy
• Can simultaneously correct deformity, achieve union, and restore length

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11. Ankle Injuries – Anatomy and Ligaments

• ATFL (anterior talofibular) — most commonly torn in inversion sprain
• CFL (calcaneofibular)
• PTFL (posterior talofibular)

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12. Forces at the Ankle

• Inversion: Supination of forefoot; ATFL → CFL → PTFL injured
• Eversion: Pronation; deltoid ligament ± medial malleolus
• Supination: Foot turns sole inward
• Pronation: Foot turns sole outward
• External rotation: Fibula fractures propagate proximally; Maisonneuve risk
• Internal rotation: Medial structures at risk

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13. Lauge-Hansen Classification of Ankle Injuries

1. Supination-Adduction (SA): Transverse fibula fracture below plafond + medial malleolus vertical fracture
2. Supination-External Rotation (SER): Most common; AITFL → lateral malleolus (spiral, at/above plafond) → PITFL/posterior malleolus → medial malleolus/deltoid
3. Pronation-Abduction (PA): Deltoid/medial malleolus → syndesmosis → comminuted fibula fracture
4. Pronation-External Rotation (PER): Deltoid → syndesmosis → high fibula fracture (Maisonneuve)

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14. Adduction Injuries (SA Type)

• Foot supinated + adduction force
• Stage 1: Lateral ligament rupture or transverse fibula fracture below joint line
• Stage 2: Medial malleolus vertical fracture
• Treatment: If isolated lateral → conservative; combined → ORIF medial malleolus

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15. Abduction Injuries (PA Type)

• Pronated foot + abduction
• Medial malleolus fracture (or deltoid rupture) → syndesmosis disruption → comminuted fibula fracture (at/above plafond, butterfly fragment)
• Treatment: ORIF if displaced; syndesmosis fixation if disrupted

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16. Pronation-External Rotation (PER) Injuries

• Pronated foot + ER of tibia/body
• Deltoid/medial malleolus → AITFL → interosseous membrane → very high fibula fracture (Maisonneuve — at or near fibula head)
• Maisonneuve fracture: High fibula fracture + ankle instability (medial + syndesmotic disruption)
• Must X-ray full fibula in all ankle fractures
• Treatment: Syndesmosis fixation + medial repair ± ORIF

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17. Supination-External Rotation (SER) Injuries

• Most common ankle fracture (Lauge-Hansen SER)
• Supinated foot + external rotation
• Typical fracture: Oblique/spiral fibula fracture at level of plafond (bimalleolar pattern)
• 4 stages: AITFL → fibula → PITFL/posterior malleolus → medial malleolus
• Weber B fracture pattern

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18. Vertical Compression Injuries (Pilon Fractures)

• Axial load on talus → driven into tibia
• Pilon fracture: Distal tibial articular comminution
• Mechanism: Fall from height, road accident
• Severe soft tissue injury
• Treatment: Two-stage: 1st → spanning external fixator + fibula ORIF; 2nd (10–14 days when swelling resolved) → ORIF of tibia with locking plate

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19. Ankle Injuries – Clinical Features

• Pain, swelling, bruising around malleoli/ankle
• Point tenderness over malleoli (bony injury) vs. ligament attachment
• Weight-bearing ability (Ottawa rules)
• Examine entire fibula (Maisonneuve)
• Medial ankle tenderness → deltoid/medial malleolus
• Syndesmosis: Squeeze test (compress fibula + tibia at mid-calf → ankle pain), external rotation stress test

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20. Radiological Examination – X-rays

• Ottawa Ankle Rules (to guide X-ray use):
  • X-ray if: Tenderness at posterior edge or tip of malleoli OR unable to bear weight (4 steps)
  • Foot X-ray if: Tenderness at navicular or base of 5th metatarsal OR unable to bear weight
• 3 views: AP (mortise), lateral, AP with 15° internal rotation (true mortise view)
• Mortise view: Check medial clear space (normal ≤4 mm); tibiofibular overlap (normal >10 mm on AP)

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21. Stress X-rays and MRI

• Stress views: Varus stress (lateral ligament integrity); external rotation stress (syndesmosis, deltoid)
• Gravity stress view: AP with leg in 90° ER to assess medial clear space without manual stress
• MRI: Gold standard for ligament injuries, osteochondral lesions, occult fractures
• CT: For pilon fractures, complex intra-articular injuries, pre-operative planning

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22. Ankle Fractures Without Displacement – External Fixation

• Undisplaced fractures: Below-elbow walking cast 4–6 weeks
• External fixation in ankle fractures is mainly used as:
  1. Temporary spanning fixation for pilon fractures (swelling)
  2. Damage-control in polytrauma
  3. Definitive treatment in contaminated/infected open fractures

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23. Displaced Fractures – Medial Malleolus Fracture

• Large fragment: ORIF with 2 partially threaded cancellous screws or tension band wire
• Small/comminuted fragment: Suture or K-wire; occasionally excised if tiny
• Deltoid ligament repair: Usually not repaired; indirect reduction by fibula fixation restores medial space

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24. Displaced Fractures – Lateral Malleolus Fracture

• Weber A (below plafond): ORIF only if displaced; tension band wire or screw; syndesmosis usually intact
• Weber B (at plafond, SER): ORIF with 1/3 tubular plate or lag screw + neutralisation plate; check syndesmosis (Cotton test, ER stress test)
• Weber C (above plafond, PER): ORIF fibula + syndesmosis fixation (1–2 cortical screw through plate/separate; positional screw, knee at 90°)

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25. Displaced Fractures – Posterior Malleolus

• Third malleolus = posterior tibial lip
• Significant if >25–33% of articular surface
• Treatment: ORIF (posterior AP lag screws or posterior plate)
• If >25% articular surface involved or posterior subluxation of talus → fixation mandatory
• Small fragments: Usually reduce when fibula fixed

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26. Tibiofibular Syndesmosis Disruption

• Indicates ankle instability (mortise widened)
• Clinical: Squeeze test; ER stress test
• Radiological: Medial clear space >4 mm; tibiofibular overlap <10 mm; tibiofibular clear space >5 mm
• Treatment: Syndesmotic screw (positional screw through fibula into tibia; knee at 90° dorsiflexion); remove at 8–12 weeks before weight-bearing
• Alternative: TightRope (suture-button device) — allows physiological motion; no need for removal

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27. Ankle Fractures – Complications

• Post-traumatic osteoarthritis (most common long-term)
• Malunion (loss of mortise congruency)
• Wound complications/infection (especially after ORIF with compromised skin)
• DVT/PE
• Stiffness
• Chronic ankle instability (after ligament injury)
• Reflex sympathetic dystrophy (CRPS)
• Delayed/non-union (medial malleolus)

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28. Sprained Ankle – Diagnosis, Radiology, Treatment

• Most common musculoskeletal injury
• Lateral sprain (ATFL most common)
• Grade I: Stretch, no laxity; Grade II: Partial tear, mild laxity; Grade III: Complete tear, significant laxity
• Ottawa rules to exclude fracture

• PRICE: Protection, Rest/Relative rest, Ice, Compression, Elevation
• Grade I/II: Functional rehabilitation; physiotherapy (proprioception training)
• Grade III: Functional brace (6 weeks) vs. below-knee cast; rarely surgery acutely; Brostrom repair for chronic instability

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29. Chronic Ankle Sprain

• Recurrent instability, giving-way, pain after repeated sprains
• Mechanical instability (stretched/torn ligaments)
• Functional instability (proprioceptive deficit)
• Investigations: Stress X-rays, MRI
• Treatment:
  • Conservative: Physiotherapy (muscle strengthening, proprioception); brace
  • Surgical: Brostrom procedure (direct repair + augmentation with inferior extensor retinaculum — Gould modification); ligament reconstruction with tendon graft (Evans procedure — peroneus brevis)

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30. Fractures of the Calcaneus

• Undisplaced: Conservative; below-knee cast/functional brace; early ROM
• Displaced intra-articular: Controversial; ORIF (extended lateral approach) in young active patients; conservative in elderly/diabetic/smokers
• Wound complications (lateral approach) are the major concern

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31. Fractures of the Talus

• Type I: Undisplaced → AVN <10%
• Type II: Subtalar dislocation → AVN 20–50%
• Type III: Tibiotalar + subtalar dislocation → AVN 20–100%
• Type IV: Talonavicular dislocation also → AVN nearly 100%

• Type I: Conservative (non-weight-bearing cast 8–10 weeks)
• Types II–IV: Urgent ORIF

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32. Fracture of the Base of 5th Metatarsal and March Fracture

• Zone 1 (Pseudo-Jones): Avulsion fracture at styloid process; avulsed by peroneus brevis + plantar fascia; mechanism: inversion; very common
  • Treatment: Hard-soled shoe or below-knee walking cast 3–6 weeks; excellent prognosis
• Zone 2 (Jones fracture): Fracture at metaphyseal-diaphyseal junction (4 cm from base); watershed area → poor blood supply → risk of non-union
  • Treatment: Non-weight-bearing cast 6 weeks; consider IM screw for athletes (faster return to sport)
• Zone 3: Diaphyseal stress fracture

• Fatigue fracture from repetitive loading without adequate rest
• Common: 2nd and 3rd metatarsal necks (prolonged marching, military recruits, athletes)
• X-ray may be negative initially (2–3 weeks before callus visible)
• MRI/bone scan for early diagnosis
• Treatment: Rest, hard-soled shoe; rarely surgical

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Chapter 25 — Congenital Talipes Equinovarus (CTEV / Club Foot)

54. Congenital Clubfoot – Relevant Anatomy

• Complex 3D deformity of foot and ankle
• Involves all structures: Bones, joints, muscles, tendons, capsule, ligaments, skin
• Deformity centred primarily at the talonavicular, subtalar, and calcaneocuboid joints
• Talus is dysplastic: short, plantar flexed, medially rotated neck
• Navicular, cuboid, and calcaneus all displaced medially relative to the talus

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55. Foot Deformity Terminology

• Equinus: Plantar flexion at the ankle (↑ plantar flexion, ↓ dorsiflexion)
• Calcaneus: Excessive dorsiflexion at the ankle (opposite of equinus)
• Varus: Heel/forefoot turned inward (inversion + supination)
• Valgus: Heel/forefoot turned outward (eversion + pronation)
• Cavus: High arch (excessive plantar flexion of forefoot on hindfoot)
• Planus: Flat foot (loss of medial arch)
• Splay foot: Widened forefoot (splaying of metatarsals)

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56. Congenital Clubfoot – Aetiology

• Multifactorial/idiopathic (most common, 75%): Genetic + environmental
• Genetic: First-degree relative affected → 10-fold ↑ risk; polygenic inheritance
• Environmental/intrauterine: Oligohydramnios, fibrous bands, amniocentesis
• Neuromuscular: Spina bifida, arthrogryposis, cerebral palsy
• Syndromic: Down syndrome, constriction band syndrome
• Male:Female = 2:1; Bilateral in 50%

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57. Congenital Clubfoot – Pathoanatomy

• Bones: Talus — shortened, neck deviated medially and plantarly; navicular displaced medially; calcaneus inverted + adducted
• Joints: Talonavicular and subtalar subluxation/dislocation; calcaneocuboid medialized
• Muscles and tendons: Shortened and fibrotic posteromedially (tibialis posterior, FHL, FDL, triceps surae)
• Capsule and ligaments: Talonavicular, subtalar, posterior ankle capsules thickened and contracted
• Skin: Creases on medial and posterior aspects; thin atrophic skin posteromedially
• Secondary changes: If untreated, progressive bony changes; walking on dorsum of foot

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58. Congenital Clubfoot – Clinical Features

• Foot held in equinus + varus + adductus (heel in varus, forefoot adducted, ankle plantarflexed)
• Calf muscles atrophied (smaller calf)
• Medial skin creases; posterior skin crease
• Skin folds on medial and posterior aspect
• Stiff, rigid deformity (true CTEV) vs. postural (corrects easily)

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59. Congenital Clubfoot – Examination

• Assess rigidity (passive correction attempt)
• Assess the 4 components (equinus, varus, adductus, cavus)
• Skin condition and creases
• Calf wasting
• Neurological examination (to rule out neuromuscular cause)
• Whole spine examination (sacral dimple → spina bifida occulta)
• Pirani scoring system (0–6) and Dimeglio classification used to quantify severity

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60. Congenital Clubfoot – Diagnosis

• Primarily clinical at birth
• Prenatal: Ultrasound from 12–14 weeks
• X-ray (not routine in infants; bones largely cartilaginous):
  • Kite's angles: Talocalcaneal (TC) angle (normal 20–40°); reduced in clubfoot on AP and lateral
  • Lateral X-ray: Talus and calcaneus parallel (TC angle reduced)
• MRI: For surgical planning in resistant cases
• Distinguish from: Positional clubfoot (corrects passively), metatarsus adductus, congenital vertical talus

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61. Differences Between Primary and Secondary Club Feet

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62. Treatment – Non-operative: Kite's and Ponseti Methods

• Serial plaster casts; abduction of forefoot against fulcrum at calcaneocuboid joint
• Less effective; higher surgery rates; largely replaced by Ponseti

• Start within first week of life; serial manipulation + plaster casts (above-knee)
• 5–6 casts applied weekly
• Order of correction: Cavus → Adductus → Varus → Equinus (CAVE)
• Percutaneous Achilles tenotomy (in clinic) for residual equinus (in ~90%)
• Then: Denis Browne boots and bar (foot abduction brace) 23 hrs/day × 3 months → nighttime only until age 4–5 years
• ~90% success rate; recurrence ~10–20% → repeat casts ± tibialis anterior transfer

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63. Operative: Posteromedial Soft Tissue Release (PMSTR)

• For cases failing Ponseti or presenting late
• Cincinnati incision (circumferential posterior incision)
• Structures released: Posterior capsulotomy (ankle + subtalar), Achilles tendon lengthening (Z-plasty), plantar fascia, tibialis posterior lengthening, medial capsulotomy of talonavicular joint, calcaneocuboid capsulotomy
• Peabody & Myer's or Carroll's release
• Cast post-op; then bracing
• Overcorrection (calcaneo-valgus) is a complication

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64. Limited Soft Tissue Release and Tendon Transfers

• For milder deformity or isolated residual component
• e.g., Posterior release alone for equinus
• Tibialis posterior lengthening for residual adduction

• Tibialis anterior transfer (split or whole) to dorsolateral foot: For dynamic supination/varus recurrence
• Peroneus longus-to-brevis transfer
• Indicated: Dynamic deformity driven by muscle imbalance (particularly after Ponseti in walking-age child)

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65. Dwyer's Osteotomy and Dilwyn Evans Procedure

• Lateral closing wedge osteotomy of the calcaneum
• Corrects residual heel varus when it is bony (rigid)
• Bone wedge excised laterally; heel shifts to neutral

• Lateral column shortening: Excision of calcaneocuboid joint + fusion (corrects adductus + varus)
• Or lateral column lengthening via calcaneal osteotomy (for flat foot — less relevant here)
• Addresses midfoot adductus resistant to soft tissue methods

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66. Wedge Tarsectomy and Triple Arthrodesis

• For resistant/recurrent clubfoot in older child (5–10 years)
• Wedge of bone removed from tarsus (dorsolateral) to correct deformity
• Beak tarsectomy (Lichtblau) or midtarsal wedge

• Fusion of subtalar + talonavicular + calcaneocuboid joints
• For skeletally mature patients (>12 years) with rigid, painful deformity
• Corrects deformity and eliminates painful arthritic joints
• Foot rigid post-procedure; risk of ankle OA long-term

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67. Ilizarov's Technique for Clubfoot

• Circular external fixator with gradual distraction/correction
• Used for: Severe rigid CTEV, recurrent deformity after multiple surgeries, older children/adults
• Gradual correction over 6–12 weeks by adjusting wires
• Minimises surgical scarring; preserves length
• Advantage: Corrects all planes simultaneously; skin not compromised

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68. Operative Methods (Summary)

• 0–6 months: Ponseti casts ± Achilles tenotomy
• 6 months–2 years: PMSTR (if Ponseti failed)
• 2–4 years: Limited release + tibialis anterior transfer
• 5–10 years: Dwyer osteotomy, Evans procedure, wedge tarsectomy
• >12 years (mature skeleton): Triple arthrodesis

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69. Methods of Maintenance of Correction

• Denis Browne boots and bar (Ponseti): Foot abduction brace; 23 hrs/day for 3 months → nights until age 4–5
• Serial plaster casts: Maintenance after surgical correction
• Orthoses: AFO (ankle foot orthosis), supramalleolar orthosis for dynamic deformity
• Footwear modifications: Outflare shoes
• Compliance with bracing is the most critical factor in preventing recurrence

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Chapter 26 — Congenital Dislocation of the Hip (CDH / DDH)

1. Aetiology

• Developmental Dysplasia of the Hip (DDH) — spectrum from dysplasia → subluxation → dislocation
• Multifactorial:
  • Genetic: Family history (first-degree relative → 12× ↑ risk)
  • Hormonal: Maternal oestrogen/relaxin → ligamentous laxity in neonate
  • Mechanical: Breech presentation (most important), oligohydramnios, first-born (uterine wall tight)
  • Physiological: Female:Male = 4–6:1 (ligamentous laxity)
  • Left hip > Right hip (3:1); Bilateral in 20%

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2. Pathology

• Acetabulum: Shallow, dysplastic; increased acetabular index (>30° in newborn)
• Femoral head: Not in contact with acetabulum → secondary dysplastic changes
• Capsule: Stretched and redundant; "hourglass" capsule in complete dislocation
• Labrum (limbus): Inverted or hypertrophied → blocks reduction
• Ligamentum teres: Elongated
• Pulvinar: Fibrofatty tissue fills acetabulum
• Muscles: Iliopsoas, adductors, hamstrings shortened → block reduction
• Late untreated: False acetabulum, coxa valga, femoral head deformity

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3. Diagnosis

• Neonatal screening (Ortolani + Barlow tests)
• Ultrasound (Graf's method): Under 4 months (before femoral head ossifies); measures alpha angle (>60° = normal) and beta angle
• X-ray: After 4–6 months when femoral head starts to ossify; Hilgenreiner's, Perkin's, Shenton's lines; acetabular index

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4. Clinical Features and Examination – Ortolani and Barlow Tests

• Hips and knees at 90°; abduct hip while lifting greater trochanter anteriorly
• Positive ("clunk of entry"): Dislocated hip reduces → palpable clunk = positive Ortolani

• Adduct hip while applying posterior pressure
• Positive ("clunk of exit"): Dislocatable hip → femoral head slips out posteriorly = positive Barlow

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5. Galeazzi's Sign and Trendelenburg's Test

• Supine; hips flexed 90°, knees bent; feet flat on table
• Positive: Apparent shortening of femur (knee level lower on dislocated side)
• Useful from 3 months onwards (unilateral DDH)

• Patient stands on one leg
• Positive: Pelvis sags to the unaffected side (abductors on standing leg are inadequate)
• Indicates abductor weakness due to hip dislocation, subluxation, coxa vara, or previous surgery

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6. Radiological Features

• Hilgenreiner's line: Horizontal through triradiate cartilages
• Perkin's line: Vertical through lateral acetabular edge, perpendicular to Hilgenreiner's
• Normal: Femoral head in lower medial quadrant
• DDH: Femoral head in upper lateral quadrant
• Shenton's line: Curved line from medial femoral neck to inferior pubic ramus — disrupted in dislocation
• Acetabular index: Angle of acetabular roof to Hilgenreiner's line; normal <30°; ↑ in dysplasia

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7. Principles of Treatment

• Reduce femoral head into acetabulum
• Maintain reduction (concentric reduction stimulates acetabular development)
• Early treatment: Better acetabular remodelling; avoid AVN
• Treatment depends on age at diagnosis
• Avoid: Forced abduction (risk of AVN — position of safety is 100° flexion + 40–50° abduction)

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8. Methods of Reduction

• Birth–6 months: Pavlik harness (dynamic abduction splint); maintains hips flexed 90°, abducted 40–60°; success 90–95% if started early; check ultrasound weekly
• 6–18 months: Closed reduction under GA + arthrogram (check concentric reduction + tear-drop distance); if successful → hip spica cast
• >18 months: Usually open reduction required (tight capsule, fibrofatty tissue); via medial or anterior (Smith-Petersen) approach

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9. Maintenance of Reduction

• Pavlik harness: Birth–6 months
• Hip spica cast: After closed/open reduction; "human position" (100° flexion, 40–50° abduction); 12 weeks, changed at 6 weeks
• Abduction orthosis (Craig or von Rosen splint): For milder dysplasia
• Follow-up: Serial X-rays/ultrasound to confirm maintained reduction and acetabular development

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10. Acetabular Reconstruction Procedures

• Salter osteotomy: Single innominate osteotomy; rotates acetabulum forward and laterally; for <6 years
• Triple osteotomy (Tonnis/Steel): 3 pelvic cuts → greater mobility; for adolescents/adults
• Periacetabular osteotomy (Ganz/PAO): For adolescents/adults; maximum reorientation; preserves acetabular blood supply

• Staheli shelf: Bone graft shelf above acetabulum; for uncorrectable dysplasia; older patients
• Chiari osteotomy: Medial displacement of acetabulum; salvage procedure; creates bone shelf; for adults with dysplasia/subluxation

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11. Treatment Plan

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Chapter 33 — Scoliosis and Other Spinal Deformities

1. Scoliosis – Classification

• Functional (non-structural): No fixed structural change; corrects on bending
• Structural: Fixed, does not correct fully on bending; vertebral rotation present

• Idiopathic (80%)
• Congenital (failure of formation/segmentation)
• Neuromuscular (CP, Duchenne MD, spina bifida)
• Syndromic (Marfan's, NF1, Ehlers-Danlos)
• Secondary (leg length discrepancy, pain)

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2. Functional Scoliosis (Non-structural)

• Curve that disappears on forward bending (Adam's forward bend test — no rib hump)
• No vertebral rotation
• Causes: Leg length discrepancy (most common), painful paraspinal muscle spasm, poor posture, sciatic scoliosis (disc prolapse)
• Treatment: Address underlying cause

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3. Structural Scoliosis (Permanent)

• Fixed curve with vertebral rotation; does not fully correct
• Vertebral bodies rotate toward the convexity of the curve (ribs follow → "rib hump" on forward bending)
• Compensatory curves develop above and below primary curve
• Progressive if Cobb angle >25–30° during growth

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4. Idiopathic Structural Scoliosis

• Infantile (0–3 years): Rare in West; males > females; rib-vertebra angle difference (RVAD) determines prognosis
• Juvenile (4–10 years): Males = females; high progression risk
• Adolescent (>10 years, during puberty): Most common (AIS); females > males (7:1 for curves needing treatment); thoracic curve (right convexity most common)

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5. Scoliosis – Pathology

• Primary curve: Vertebrae rotate + wedge; ribs on convex side pushed posteriorly → rib hump
• Vertebral bodies rotate toward convexity; spinous processes rotate toward concavity
• Discs: Wedge-shaped; compressed on concave side
• Compensatory curves: Develop to maintain upright posture
• Thoracic curve → decreased chest volume → restrictive lung disease (Cobb >70°)

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6. Scoliosis – Clinical Features

• Asymmetry of shoulders, waist, hips
• Rib hump on Adam's forward bend test (hallmark)
• Trunk shift/imbalance
• Unequal iliac crest height (leg length check)
• Back pain: Not usually prominent in AIS (pain = investigate for secondary cause)
• Cardiorespiratory compromise (severe curves >90–100°)
• Neurological symptoms (congenital or atypical curves)

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7. Scoliosis – X-ray

• Full-length standing AP + lateral spine (scoliosis series)
• Bending films: Right and left lateral bending (assess curve flexibility for surgical planning)
• Measure Cobb angle
• Assess Risser sign (iliac apophysis ossification — maturity indicator; Risser 0–5; 0 = immature, 5 = mature)
• MRI: For all pre-surgical cases; atypical curves (left thoracic, painful, rapid progression); rule out syrinx, Chiari, cord lesion

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8. Scoliosis – Cobb Method

• Measure degree of scoliosis on AP X-ray
• Upper end vertebra: Most tilted vertebra at top of curve (superior endplate perpendicular drawn)
• Lower end vertebra: Most tilted at bottom (inferior endplate perpendicular drawn)
• Angle between these two lines = Cobb angle
• Or: Angle formed by perpendiculars to the end vertebrae
• Significant: >10° = scoliosis; >25° = consider brace; >45–50° = consider surgery

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9. Scoliosis – Conservative Treatment

• Observation: Cobb <25° (or <20° in immature); X-rays every 6 months during growth
• Bracing: Cobb 25–45° in skeletally immature patient (Risser 0–2)
  • Milwaukee brace (for high thoracic curves; 16–23 hrs/day)
  • Boston brace (TLSO; for thoracolumbar/lumbar curves; most commonly used)
  • Goal: Prevent progression (does not correct deformity)
• Physiotherapy (Schroth method): Adjunct to bracing

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10. Scoliosis – Surgical Treatment

• Cobb >45–50° in skeletally immature
• Progressive curve despite bracing
• Cosmetically unacceptable
• Cardiorespiratory compromise

• Posterior spinal fusion with instrumentation (pedicle screw systems — e.g., CDI/Cotrel-Dubousset): Gold standard; corrects in all planes; fusion with bone graft
• Anterior spinal fusion: For thoracolumbar/lumbar curves; shorter fusion (preserves lumbar motion)
• Growing rods: For young children (<10 years) — non-fusion; lengthened every 6 months; VEPTR (vertical expandable prosthetic titanium rib)
• Risks: Neurological injury, infection, implant failure, flat-back syndrome

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11. Kyphosis – Causes

• Postural kyphosis: Most common; adolescent; corrects on extension
• Scheuermann's disease: Osteochondrosis of vertebral endplates; thoracic kyphosis >45°; anterior wedging ≥5° of 3 consecutive vertebrae; rigid
• Congenital: Failure of vertebral formation/segmentation
• Tuberculosis (Pott's disease): Angular kyphosis (gibbus) — destruction of vertebral bodies
• Osteoporotic compression fractures: Elderly
• Ankylosing spondylitis: Fixed kyphosis
• Post-laminectomy

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12. Kyphosis – Symptoms

• Back pain (especially Scheuermann's)
• Cosmetic deformity
• Respiratory compromise (severe curves)
• Neurological symptoms (cord compression — especially congenital or TB)
• Fatigue from paraspinal muscle overload

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13. Kyphosis – Clinical Features

• Increased thoracic kyphosis (rounded back)
• Postural: Flexible, corrects on extension
• Scheuermann's: Rigid; cannot correct on extension; tight hamstrings; apical tenderness
• X-ray (Scheuermann's): Anterior wedging ≥5° of ≥3 consecutive vertebrae; Schmorl's nodes; endplate irregularity
• Normal thoracic kyphosis: 20–45°; Scheuermann's: >45–50°

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14. Spondylolisthesis – Pathology

• Spondylolisthesis: Anterior displacement of one vertebra on the vertebra below
• Spondylolysis: Defect in the pars interarticularis (without slip)

• Type I (Dysplastic): Congenital; sacral/L5 facet dysplasia
• Type II (Isthmic): Pars defect; most common; subtypes: IIa (stress fracture), IIb (elongated), IIc (acute)
• Type III (Degenerative): Facet arthrosis without pars defect; L4-L5 most common; elderly
• Type IV (Traumatic): Acute fracture
• Type V (Pathological): Tumour/disease

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15. Spondylolisthesis – Diagnosis

• Clinical: Low back pain; tight hamstrings; waddling gait; step deformity at L4-L5; "spondylolisthesis body type" (short trunk, vertical sacrum, heart-shaped buttocks)
• Radiology:
  • Lateral X-ray: Anterior slip of vertebra; grade the slip (Meyerding)
  • Oblique X-ray: "Scottie dog" sign — pars defect = collar/fracture of neck of Scottie dog
  • CT: Best for pars defect
  • MRI: Nerve root compression, disc degeneration, stenosis

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16. Spondylolisthesis – Treatment

• Activity modification, physiotherapy (core strengthening, hamstring stretching)
• NSAIDs, analgesia
• Brace: For symptomatic spondylolysis in young athletes (Boston TLSO 6–12 months)

• Repair of pars defect (Buck's screw repair): For young patients with spondylolysis only; no slip
• Posterior spinal fusion (PLIF/TLIF or posterolateral): L5-S1 most commonly; with/without reduction
• Reduction + fusion: For high-grade slips; controversial (nerve root injury risk)
• Decompression ± fusion: If neurogenic claudication (degenerative type)

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