Osteosarcoma,extradural haematoma, sclerosis,kyphosis,osteoma,subdural haemorrhage,osteogenesis imperfecta, sciatica, amputation,pronychia,ancylosis,malunion fracture, fracture of femur,pott's spine, rheumatoid arthritis, septic arthritis. Give all topics in exam reading format in short

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Orthopedic & Surgical Topics - Exam Reading Notes

1. OSTEOSARCOMA

Definition: Malignant osteoid-producing spindle cell neoplasm - most common primary bone tumour in children/young adults.

Types:

High-grade intramedullary (conventional) - most common (75%)
Parosteal (low-grade surface)
Periosteal
Telangiectatic
Small cell
Secondary (Paget's disease, post-irradiation)

Age/Site: Peak - adolescent growth spurt (2nd decade); second peak in late adulthood. Most common site - around the knee (distal femur > proximal tibia > proximal humerus).

Clinical Features:

Pain (most common)
Pathologic fracture
Soft tissue swelling/mass

Investigations:

X-ray: bone destruction + bone formation; "Codman's triangle" (periosteal elevation); "sunburst" pattern
MRI/CT: intramedullary extent, neurovascular and soft tissue involvement
Histology: malignant stromal cells + osteoid production
IHC: SATB2 positive, MDM2 positive

Genetics: Associated with mutation of tumour suppressor genes - RB1 (retinoblastoma gene) and TP53 (Li-Fraumeni syndrome)

Treatment:

Neoadjuvant chemotherapy (8-12 weeks) → Wide-margin surgical resection → Adjuvant chemotherapy (8-12 weeks)
Chemotherapy agents: Doxorubicin (cardiac toxicity), Cisplatin (neurotoxicity), High-dose Methotrexate + Leucovorin rescue
Limb salvage preferred over amputation

Metastasis: Lung (most common), then bone

Prognosis: 5-year survival ~60-70% with multimodal treatment

(Miller's Review of Orthopaedics 9th Ed)

2. EXTRADURAL HAEMATOMA (EDH)

Definition: Collection of blood between skull and dura mater, usually arterial.

Cause: Tear of the middle meningeal artery (most common) - typically from lateral blow causing temporal bone fracture. Anterior fossa bleeding: internal maxillary or anterior meningeal vessels.

Classic Presentation (Triad):

Head injury → brief loss of consciousness (concussion)
Lucid interval (patient temporarily conscious/alert)
Sudden rapid deterioration - confusion, drowsiness, hemiplegia (contralateral), ipsilateral pupil dilation (3rd nerve compression by uncus herniation)

Key Signs: Ipsilateral dilated pupil, contralateral hemiplegia, raised ICP, decerebrate rigidity (late)

Diagnosis of side: Side of skull fracture + boggy temporal swelling + initial pupil dilation

CT Scan: Biconvex (lenticular/lens-shaped) hyperdense lesion between skull and dura; constrained by dural attachments; midline shift; skull fracture usually evident

Treatment: Urgent transfer to neurosurgical unit; surgical evacuation (craniotomy/burr hole) for significant bleeds

Prognosis: Excellent if promptly evacuated without associated primary brain injury

(Bailey & Love's Surgery 28th Ed; S Das Clinical Surgery 13th Ed)

3. SCLEROSIS (Osteosclerosis)

Definition: Abnormal increase in bone density due to increased calcification/mineralization.

Types:

Osteosclerosis - increased bone density (radiopaque on X-ray)
Systemic sclerosis (scleroderma) - connective tissue disorder with skin/organ fibrosis

Causes of bone sclerosis:

Paget's disease (mixed lytic + sclerotic)
Osteoblastic metastases (prostate, breast cancer)
Osteopetrosis ("marble bone disease")
Fluorosis
Renal osteodystrophy

X-ray: Increased radiodensity of bone

4. KYPHOSIS

Definition: Excessive forward (anterior) curvature of the thoracic spine (humpback/gibbus).

Types:

Type	Cause
Postural	Poor posture; flexible; correctable
Structural (Scheuermann's)	Anterior wedging of ≥3 consecutive vertebrae; rigid
Pathological	TB spine (Pott's), fracture, tumour, osteoporosis
Congenital	Failure of formation/segmentation

Clinical Features: Forward stoop, back pain, restrictive respiratory disease (severe cases), neurological deficits (if severe spinal cord compromise)

Investigations: X-ray (lateral view - Cobb angle measurement), MRI for cord compression

Treatment:

Postural: exercises, bracing
Structural: bracing (Milwaukee brace) if growing; surgery (spinal fusion) if >70° or progressive
Pathological: treat underlying cause

5. OSTEOMA

Definition: Benign, slow-growing tumour composed of dense mature bone. Most common in skull/paranasal sinuses.

Types:

Compact osteoma - dense cortical bone (ivory osteoma) - most common in paranasal sinuses
Cancellous osteoma - spongy bone
Osteoid osteoma - small benign lesion with central nidus (<1.5 cm); long bones; night pain relieved by aspirin
Osteoblastoma - similar to osteoid osteoma but >2 cm; vertebrae/long bones

Osteoid Osteoma - Key Points:

Age: 10-30 years, males > females
Site: proximal femur, tibia
Pain: worse at night, dramatically relieved by NSAIDs/aspirin
X-ray: central radiolucent nidus surrounded by reactive sclerosis
Treatment: NSAIDs; radiofrequency ablation; surgical excision

Gardner Syndrome: Multiple osteomas + colonic polyposis + soft tissue tumours (AD)

6. SUBDURAL HAEMORRHAGE (SDH)

Definition: Collection of blood between dura and arachnoid mater, usually venous (bridging veins).

Types:

	Acute	Chronic
Onset	Hours	Weeks-months
Cause	High-energy trauma, cortical vessel rupture	Minor/trivial head injury; elderly, alcoholics, anticoagulated
CT appearance	Hyperdense, concave/crescent-shaped	Hypodense or isodense crescentic collection
Presentation	Rapid deterioration, raised ICP, NO lucid interval	Headache, confusion, progressive neurological decline

Key Differences from EDH:

SDH: concave/crescent shape (blood spreads freely over brain surface because dura not adherent to brain)
EDH: biconvex/lenticular shape (blood constrained by dural attachments)
SDH: venous (slower); EDH: arterial (faster)
SDH: no lucid interval; EDH: classic lucid interval

CT: Crescent-shaped hyperdense (acute) or hypodense (chronic) collection following brain contour; midline shift; bilateral in 50% of chronic SDH

Treatment:

Acute (significant): craniotomy/craniectomy; urgent evacuation
Chronic (symptomatic): burr hole drainage (after clot liquefies at 7-10 days)
Conservative: neurologically stable, small bleeds; correct anticoagulation

(Bailey & Love's Surgery 28th Ed)

7. OSTEOGENESIS IMPERFECTA (OI) - "Brittle Bone Disease"

Definition: Genetic disorder of type I collagen synthesis - bones fracture easily due to defective bone matrix.

Genetics: Mutations in COL1A1 or COL1A2 genes (encoding type I collagen); mostly autosomal dominant

Sillence Classification:

Type	Features	Severity
I	Blue sclerae, deafness, fractures in childhood; normal stature	Mild - most common
II	Lethal in utero or neonatal; multiple fractures at birth	Most severe
III	Progressive deformity, short stature, wheelchair-bound	Severe
IV	Reduced stature, some bony deformity, dentinogenesis imperfecta (opalescent teeth)	Moderate

Classic Triad (Type I):

Fragile bones (multiple fractures from minimal trauma)
Blue sclerae (thin sclera allows choroidal pigment to show through)
Conductive deafness (otosclerosis - otospongiosis of ossicles)

Additional Features:

Dentinogenesis imperfecta (opalescent teeth that wear easily)
Ligamentous laxity/joint hypermobility
Short stature, kyphoscoliosis
Wormian bones on skull X-ray
"Popcorn calcifications" on X-ray (severe types)

Investigations:

X-ray: osteopenia, multiple fractures at various stages of healing, wormian bones
Bone biopsy (rarely needed)
Genetic testing

Treatment:

Bisphosphonates (pamidronate IV) - reduce fracture rate
Intramedullary rodding (Sofield-Millar procedure) for long bone deformities - "telescopic rods" in growing children
Physiotherapy, bracing
Hearing aids for deafness

(Goldman-Cecil Medicine; Campbell's Orthopaedics 15th Ed)

8. SCIATICA

Definition: Pain radiating along the distribution of the sciatic nerve (buttock → posterior thigh → calf → foot), caused by compression or irritation of L4, L5, or S1 nerve roots.

Most Common Cause: Prolapsed intervertebral disc (PID) - L4/L5 or L5/S1 levels (>90% of cases)

Other Causes:

Spinal stenosis
Piriformis syndrome
Tumour (spinal or pelvic)
Spondylolisthesis
Pregnancy

Disc Level vs. Signs:

Disc Level	Root Affected	Pain	Weakness	Reflex Lost
L3/L4	L4	Medial leg/foot	Knee extension	Knee jerk
L4/L5	L5	Lateral leg, dorsum of foot	Foot dorsiflexion (foot drop)	None (or tibialis posterior)
L5/S1	S1	Posterior calf, sole, lateral foot	Plantar flexion	Ankle jerk

Clinical Features:

Radiating pain worse on coughing/sneezing/straining (Valsalva)
Positive Straight Leg Raise (SLR) test (Lasegue's sign) - pain 30-70°
Crossed SLR: highly specific for disc prolapse

Cauda Equina Syndrome (emergency): Bilateral leg weakness, saddle anaesthesia, bladder/bowel dysfunction - needs urgent MRI + surgery

Investigations: MRI lumbar spine (gold standard), plain X-ray, CT myelogram

Treatment:

Conservative (most resolve in 6-12 weeks): rest, NSAIDs, physiotherapy
Epidural steroid injection
Surgery: microdiscectomy/discectomy (if conservative fails or cauda equina)

(Bailey & Love's Surgery; S Das Clinical Surgery)

9. AMPUTATION

Definition: Surgical removal of a limb or part of a limb.

Indications (6 D's):

Dead (ischaemia - irreversible)
Dangerous (malignancy - prevent spread)
Damned nuisance (chronic infection - osteomyelitis, gangrene)
Dreadful (severe trauma - crush injury, degloving)
Deformed (congenital deformity - non-functional limb)
Dead weight (paralysed useless limb)

Levels of Lower Limb Amputation:

Level	Name	Notes
Hindfoot	Syme's	Through ankle; end-bearing stump
Below knee	Trans-tibial (BKA)	Best functional outcome; 15 cm below tibial tuberosity
Through knee	Gritti-Stokes	Supracondylar; better stump for prosthesis
Above knee	Trans-femoral (AKA)	Increased energy expenditure for ambulation
Hip	Hip disarticulation	For tumour/trauma

Principles of Surgery:

Flaps: long posterior flap (BKA); equal anterior/posterior flaps (AKA)
Bone: bevelled to prevent skin pressure necrosis
Nerves: ligated under tension, cut cleanly to prevent neuroma
Vessels: double-ligated
Muscles: myodesis/myoplasty (secure over bone end)
Closed over drain; no skin tension

Complications:

Phantom limb pain (pain in amputated part - treat: mirror therapy, gabapentin)
Stump neuroma
Wound infection/dehiscence
Flexion contracture
Poor prosthetic fit

Rehabilitation: Early mobilisation, physiotherapy, prosthetic limb fitting

10. PARONYCHIA (Pronychia)

Definition: Infection/inflammation of the nail fold (perionychium) surrounding the nail.

Types:

	Acute	Chronic
Cause	Staphylococcus aureus (most common)	Candida albicans; repeated moisture exposure
Onset	Rapid	Gradual, recurrent
Features	Red, swollen, painful nail fold; pus	Nail fold thickened, nail ridging/dystrophy
Treatment	Incision & drainage (I&D) + antibiotics	Antifungals (topical/oral); keep hands dry

Clinical Features:

Throbbing pain and swelling at the nail fold
Pus may track under the nail (subungual abscess)
Nail may be lost in severe/chronic cases

Treatment of Acute Paronychia:

Early (no pus): warm soaks + antibiotics (flucloxacillin)
With pus: I&D (lateral nail fold incision) ± partial nail avulsion
If subungual abscess: nail removal

11. ANKYLOSIS (Ancylosis)

Definition: Stiffness or immobility of a joint due to fusion of joint surfaces (bony or fibrous).

Types:

Type	Pathology	Cause
Bony ankylosis (true)	Bony union across joint space	Septic arthritis, TB, rheumatoid arthritis, ankylosing spondylitis
Fibrous ankylosis (false)	Fibrous tissue union	Prolonged immobilisation, mild septic arthritis

Clinical Features:

Complete loss of joint movement
Bony ankylosis: painless (bone is stable)
Fibrous ankylosis: may have residual pain on attempted movement

Complications: Muscle wasting, limb shortening, osteoporosis, functional disability

Treatment:

Prevention: early mobilisation, treatment of underlying disease
Established bony ankylosis: arthroplasty (joint replacement) or arthrodesis if pain-free position not maintained

12. MALUNION FRACTURE

Definition: A fracture that has healed in a non-anatomical position - with deformity (angulation, rotation, shortening, or overlapping).

Causes:

Inadequate reduction of fracture
Loss of reduction after immobilisation
Poor splinting/casting
Excessive traction

Types of Deformity:

Angulation (varus/valgus)
Rotation (internal/external)
Shortening (overlap)
Translation (displacement)

Clinical Features:

Visible deformity
Abnormal limb length
Rotational malalignment
Joint dysfunction, premature osteoarthritis

Investigations: X-ray (AP + lateral views)

Treatment:

Mild/asymptomatic: conservative (acceptable in children - remodelling potential)
Symptomatic/significant deformity: corrective osteotomy (cut and realign bone) + internal or external fixation

(Note: Distinguishing terms - Malunion = healed in wrong position; Non-union = failed to heal; Delayed union = slower than expected healing)

13. FRACTURE OF FEMUR

Types by Location:

Region	Common Type	Notes
Femoral neck (intracapsular)	Subcapital, transcervical, basicervical	Risk of avascular necrosis (AVN) of femoral head; non-union
Intertrochanteric (extracapsular)	Between trochanters	Blood supply preserved; better healing
Subtrochanteric	Below lesser trochanter	Difficult to fix; high energy
Shaft (diaphyseal)	Transverse, oblique, spiral, comminuted	1-2L blood loss; traction + nail
Distal femur/supracondylar	Supracondylar	Popliteal artery at risk

Femoral Neck Fracture - Key Points:

Common in elderly osteoporotic women
Garden's Classification (I-IV based on displacement)
Undisplaced (Garden I-II): internal fixation (screws)
Displaced (Garden III-IV): hemiarthroplasty (elderly) or total hip replacement

Shaft of Femur:

Blood loss: 1000-2000 mL (can cause hypovolemic shock)
Treatment: intramedullary interlocking nail (IMN) - gold standard
Traction (Thomas splint) as temporising measure

Complications:

Fat embolism syndrome
DVT/PE
Compartment syndrome
AVN (neck fractures)
Non-union/malunion
Knee stiffness

14. POTT'S SPINE (Tuberculous Spondylitis)

Definition: Tuberculosis of the spine (vertebral TB); named after Sir Percivall Pott.

Pathology:

Haematogenous spread from primary TB (lung/kidney)
Commonly affects anterior vertebral bodies (paradiscal pattern)
Disc destroyed early (distinguishes from pyogenic)
Spreads to adjacent vertebrae → vertebral collapse → angular kyphosis (gibbus deformity)
Cold abscess forms (paravertebral → psoas abscess)

Common Site: Thoracic spine (T10-L2 most common)

Clinical Features:

Back pain (insidious onset)
Gibbus deformity (sharp angular kyphosis)
Constitutional symptoms: fever, night sweats, weight loss, anorexia
Neurological deficits (Pott's paraplegia) - from cord compression by:
- Abscess
- Granulation tissue
- Vertebral collapse/instability (late)

Pott's Paraplegia:

Early onset: due to oedema/abscess (better prognosis - reversible)
Late onset: due to bony destruction, kyphosis (worse prognosis)

Investigations:

X-ray: disc space narrowing, vertebral body destruction, parrot-beak deformity, gibbus, paravertebral shadow (abscess)
MRI spine: gold standard - shows extent of cord compression, abscess
CT guided biopsy + culture (confirm TB)
ESR elevated; Mantoux test positive; CXR (primary focus)

Treatment:

Anti-TB drugs (ATT): 6-12 months (HRZE for 2 months + HR for 4-10 months)
Surgery indications: Pott's paraplegia not responding to conservative, spinal instability, large abscess, diagnostic doubt
Surgery: anterior decompression + bone grafting (Hodgson's operation) ± posterior instrumented fusion

(Campbell's Orthopaedics 15th Ed; Adams & Victor's Neurology 12th Ed)

15. RHEUMATOID ARTHRITIS (RA)

Definition: Chronic systemic autoimmune inflammatory disease primarily affecting synovial joints (symmetrical polyarthritis).

Pathology:

Autoantibodies: Rheumatoid Factor (RF) - IgM anti-IgG; Anti-CCP (anti-cyclic citrullinated peptide) - more specific
Synovitis → pannus formation → cartilage/bone erosion → joint destruction

Clinical Features:

Joint disease: symmetrical polyarthritis - MCPs, PIPs, wrists, knees, cervical spine; DIP joint spared
Morning stiffness >1 hour (hallmark)
Characteristic deformities: Boutonnière, Swan-neck, Z-thumb, ulnar deviation at MCPs
Extra-articular: Rheumatoid nodules, pulmonary fibrosis, pericarditis, vasculitis, Felty's syndrome (RA + splenomegaly + leucopenia), scleritis, anaemia of chronic disease

Investigations:

RF positive (70-80%)
Anti-CCP positive (most specific ~95%)
X-ray: periarticular osteopenia → joint space narrowing → erosions → subluxation
CRP/ESR elevated

2010 ACR/EULAR Classification Criteria: Score ≥6/10 (joint involvement, serology, acute phase reactants, symptom duration)

Treatment:

Stage	Treatment
DMARDs	Methotrexate (first-line), Hydroxychloroquine, Sulfasalazine, Leflunomide
Biologics (if DMARDs fail)	Anti-TNF (Etanercept, Adalimumab, Infliximab), Anti-IL-6 (Tocilizumab), Anti-CD20 (Rituximab)
Symptomatic	NSAIDs, corticosteroids (bridging/acute flares)
Surgery	Synovectomy, arthroplasty, arthrodesis

16. SEPTIC ARTHRITIS

Definition: Bacterial (or other infectious) invasion of a joint with organism proliferation and associated acute inflammation. Orthopaedic emergency - can destroy joint in 24-48 hours.

Causative Organisms:

Neonates (<3 months): S. aureus, Group B Strep, Gram-negatives
Children: S. aureus (most common)
Young adults (sexually active): Neisseria gonorrhoeae (most common in adults <30 years)
Elderly/immunocompromised: S. aureus, Gram-negatives

Common Sites: Hip and knee (most common); shoulder, wrist

Clinical Features:

Acutely swollen, warm, red, tender joint
Restricted movement (any movement extremely painful)
Fever, systemic illness
Patient lies with hip flexed, abducted, externally rotated (hip septic arthritis)

Investigations:

Arthrocentesis (joint aspiration) - most important: turbid fluid, WBC >50,000/mm³ (>90% PMNs), glucose low, Gram stain + culture
Blood cultures (positive in 50%)
WBC, CRP, ESR (elevated)
X-ray: soft tissue swelling (early); joint space widening; later joint destruction
Ultrasound: joint effusion (especially hip)

Kocher's Criteria (paediatric hip - distinguishes from transient synovitis):

Fever >38.5°C
Non-weight-bearing
ESR >40 mm/h
WBC >12,000/mm³ (4 criteria = 99% probability of septic arthritis)

Treatment:

Urgent joint washout (arthroscopic or open) + antibiotics
Empirical IV antibiotics: Flucloxacillin (staph) ± Gentamicin; adjust per culture
Duration: IV 2 weeks → oral 4 weeks (total 6 weeks)
Hip septic arthritis: open surgical drainage (arthrotomy) - preferred over aspiration alone

Complications: AVN (hip), joint destruction, osteomyelitis, chronic septic arthritis, growth disturbance (children)

(Tintinalli's Emergency Medicine; Rosen's Emergency Medicine)

Sources: Miller's Review of Orthopaedics 9th Ed | Bailey & Love's Surgery 28th Ed | Campbell's Operative Orthopaedics 15th Ed | S Das Clinical Surgery 13th Ed | Goldman-Cecil Medicine | Tintinalli's Emergency Medicine | Rosen's Emergency Medicine | Adams & Victor's Neurology 12th Ed

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