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MS Orthopedics Study Plan - Dr. Devadutt

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Overview Strategy

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Phase 1 - Foundation (Weeks 1-4)

Week 1 - Trauma (High-yield, always heavily tested)

Week 2 - Upper Limb + Hand

Week 3 - Pediatric Orthopedics

Week 4 - Infections + Metabolic Bone Disease

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Phase 2 - Weak Areas Deep Dive (Weeks 5-7)

Week 5 - Spine (Your weak area)

Week 6 - Arthroplasty (Your weak area)

Week 7 - Sports Medicine & Arthroscopy (Your weak area)

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Phase 3 - Revision & Exam Prep (Weeks 8-10)

Week 8 - Rapid Revision Round 1

• 2 major topics per day, purely from PYQs
• Focus on writing structured answers (intro - definition/classification, body - clinical features/investigations/management, complications)
• Revise important tables, classifications, implant names

Week 9 - Rapid Revision Round 2 + Mock Papers

• Do at least 2 full mock theory papers (3-hr timed)
• Identify gaps and fill them
• Start viva preparation: instruments, X-rays, short cases

Week 10 - Final Sprint (Pre-exam week)

• Revise all classifications (keep a dedicated notebook/sheet)
• Revise operative approaches + steps
• Viva practice with seniors/colleagues
• Day before exam: sleep well, no new topics

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Daily Schedule Template (3-4 hrs)

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High-Yield Classifications to Master

• Neer (proximal humerus), Garden (NOF), Evans (IT fractures)
• Schatzker (tibial plateau), Weber/Lauge-Hansen (ankle)
• Tscherne, Gustilo-Anderson (open fractures)
• AO/OTA fracture classification
• ASIA grading, TLICS, Denis (spine)
• Ficat-Arlet (AVN), Paprosky (bone defects in revision)
• Enneking (bone tumors), Campanacci
• Cierny-Mader (chronic osteomyelitis)

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Resources Recommendation

• PYQs: Go through the last 5-7 years of Rajiv Gandhi University of Health Sciences (RGUHS) MS Ortho papers - Mysore Medical College falls under this
• Videos: OrthopaedicPrinciples.com, Armando Hasudungan (anatomy/basic science), AO Surgery Reference (free, excellent for fracture management)
• Quick reference: Maheshwari's "Essential Orthopaedics" for structured short answers; Apley & Solomon for depth on weak areas

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Weekly Check-in Reminder

• Quiz you on the week's topics
• Help you write model answers to PYQ questions
• Explain any concept in depth
• Generate practice viva questions

• "Teach me" - I'll give you a structured, exam-focused breakdown of the topic
• "Quiz me" - I'll ask you questions to test what you already know
• "Model answer" - I'll write a model long/short answer for a PYQ on this topic
• "PYQs" - I'll list likely exam questions on this topic

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FRACTURE NECK OF FEMUR

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DEFINITION

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INCIDENCE & ETIOLOGY

• Elderly population: Most common cause is a low-energy fall in osteoporotic bone (predominantly postmenopausal women)
• Young patients: High-energy trauma (road traffic accidents)
• Pathological fractures: Secondary to metastases, Paget's disease, osteomalacia
• Predisposing factors: Osteoporosis, female sex, age >60 years, corticosteroid use, alcohol, decreased bone mineral density

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SURGICAL ANATOMY (Important for Viva)

1. Medial and lateral circumflex femoral arteries - via retinacular vessels (most important; run subsynovially in the capsule)
2. Artery of ligamentum teres (foveal artery) - minor contribution, attenuates with age
3. Medullary vessels - minor, attenuate with age due to fatty marrow replacement

Key point: In a displaced FNF, the retinacular vessels are torn, cutting off the primary blood supply to the femoral head - hence the high risk of avascular necrosis (AVN).

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CLASSIFICATION

1. Anatomical (by location)

• Subcapital - just below the head (most common)
• Transcervical - through the mid-neck
• Basicervical - at the base of the neck (behaves more like an intertrochanteric fracture)

2. Garden Classification (Most widely used)

Exam tip: Garden I & II = undisplaced (can fix); Garden III & IV = displaced (consider arthroplasty in elderly)

3. Pauwels Classification (by angle of fracture line to horizontal)

• Type I: <30° (most stable, compressive forces)
• Type II: 30-50° (shear forces begin to dominate)
• Type III: >50° (most unstable, pure shear - high non-union risk)

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CLINICAL FEATURES

• Elderly woman, trivial fall
• Immediate pain in hip/groin, unable to weight-bear

• Limb shortened and externally rotated (due to psoas major pulling femur proximally into ER when femoral neck is detached)
• Tenderness over anterior hip/femoral triangle
• Any rotation of hip is painful
• Exception: Garden I (impacted) - patient may still walk, limb not externally rotated

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INVESTIGATIONS

1. X-ray pelvis with both hips (AP + lateral) - first line
2. MRI hip - gold standard for occult FNF (if X-ray negative but high clinical suspicion)
3. CT scan - evaluates comminution, part of trauma workup
4. Pre-operative: CBC, serum electrolytes, ECG, Echo, blood grouping & cross-matching
5. DEXA scan - post-treatment for osteoporosis management

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TREATMENT

Principles

• Operative treatment is mandatory except in highly unusual circumstances (non-ambulatory patients, severe comorbidities)
• Goal: early mobilization to prevent complications of prolonged recumbency

Treatment Algorithm

FNF
├── UNDISPLACED (Garden I & II)
│   └── Internal fixation (all ages)
│       → 3 cannulated cancellous screws (inverted triangle)
│       → Dynamic Hip Screw (basicervical type)
│
└── DISPLACED (Garden III & IV)
    ├── YOUNG (<60 yrs, physiologically)
    │   └── Urgent reduction + Internal fixation
    │       (within 6-12 hours - "hip within a hip" principle)
    │
    └── ELDERLY (>60 yrs, physiologically)
        ├── Active, ambulatory community walker
        │   └── Total Hip Replacement (THA)
        └── Limited ambulator / medically unfit
            └── Hemiarthroplasty
                (Austin Moore - uncemented / Thompson - cemented)
                (Bipolar preferred over unipolar for active patients)

Internal Fixation - Cannulated Screw Technique

• Patient supine on fracture table
• Closed reduction using Whitman technique (traction, abduction, internal rotation)
• Quality of reduction assessed by Garden Alignment Index (160-180° on AP, 180° on lateral)
• Three 6.5/7.0/7.3 mm partially threaded screws in inverted triangle configuration

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COMPLICATIONS

Early

• DVT / Pulmonary embolism
• Urinary tract infection
• Pressure sores
• Pneumonia (due to immobility)
• Fat embolism

Late

1. Avascular Necrosis (AVN) - most feared; incidence 15-35% in displaced fractures
2. Non-union - incidence 10-30%; higher with Pauwels III, poor reduction
3. Implant failure / Cut-out - especially with varus malreduction
4. Peri-prosthetic fracture (post-arthroplasty)
5. Dislocation (post-THA - 1-3%)
6. Leg length discrepancy
7. Infection - superficial/deep, periprosthetic joint infection (PJI)

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PROGNOSIS

• Mortality: 20-30% in the first year following hip fracture in the elderly
• 50% never return to pre-fracture functional level
• Early surgery (<48 hours) and multidisciplinary orthogeriatric care significantly improve outcomes

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References: Campbell's Operative Orthopaedics, 15th Ed. 2026 | Gray's Anatomy for Students

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Garden Classification - Femoral Neck Fractures

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Garden Stage II - Complete, Undisplaced

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Garden Stage III - Complete, Partially Displaced

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Garden Stage IV - Complete, Fully Displaced

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"S-Sign" / Shenton's Line - Normal vs Disrupted

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Quick recall trick:

• Garden 1 & 2 = Undisplaced = Fix it (cannulated screws)
• Garden 3 & 4 = Displaced = Replace it (hemiarthroplasty/THA) in elderly