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Unformatted text preview: Essential Orthopaedics Promoted by Knee & Shoulder Clinic New Delhi Essential Orthopaedics (Including Clinical Methods) FIFTH EDITION J. Maheshwari MS Orth (AIIMS) Formerly Additional Professor of Orthopaedics All India Institute of Medical Sciences New Delhi, India Presently Director Knee and Shoulder Clinic, New Delhi, India Vikram A Mhaskar MS Orth, MCh Orth (UK) Consultant Orthopaedic Surgeon Knee and Shoulder Clinic, New Delhi, India The Health Sciences Publisher New Delhi | London | Philadelphia | Panama Published by J. Maheshwari MS Orth (AIIMS) Flat No. 541, Type-IIIA Category SFS-III Seventh Floor, East of Kailash New Delhi, India Essential Orthopaedics © 2015, J. Maheshwari All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author. This book has been published by the author. Every effort is made to ensure accuracy of material, but the author, distributor and printer will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition Second Edition Third Edition Third Edition (Revised) Fourth Edition Reprint : : : : : : Fifth Edition : 2015 ISBN : 978-93-5196-808-5 Printed in India 5 Reprints 5 Reprints Aug. 2001 (6 Reprints) May 2005 (7 Reprints) 2011 2014 Dedicated to My patients for giving me an opportunity to make a difference in their lives and My family & friends for continuous support at all times FOREWORD TO THE FIRST EDITION This book written by Dr Maheshwari, is designed to introduce the trainee doctor and the young surgeon to orthopaedic surgery as he will meet it in the developing countries. There have been many good books on orthopaedic surgery and trauma written by experienced authors from Britain and America but their exposure to the real orthopaedic problems experienced in developing countries has often been limited, and today the difference in presentation of orthopaedic surgery in these countries and the presentation of conditions in developing countries like India and Africa is so different that this book, written by a surgeon with a good grounding of clinical experience in India, is most appropriate for the trainee from the developing countries. I have read a number of chapters and have been impressed with the simple text and clarity with which the different conditions are explained. Dr Maheshwari has visited my centre in Nottingham for a period of two months. I was impressed with his clarity of thought and his depth of understanding of orthopaedic conditions. I anticipate that this book will be one of many that he writes in future years and is likely to be a major contribution to orthopaedic training in developing countries. WA Wallace Professor of Orthopaedic and Accident Surgery University Hospital, Queen's Medical Centre Nottingham NG7 2UH United Kingdom PREFACE TO THE FIFTH EDITION The unique position of this book is, that it is meant for undergraduate medical students and those preparing for PG entrance exam. We have had temptation to expand various chapters every time we are called upon to revise the book. But, we keep reminding ourselves of a medical student who has to cover so much curriculum while he is in final year or preparing for PG entrance exam, and thus restrain ourselves from adding ‘too much’. Though there are rapid advances in medicine, but only few qualify place in a basic book such as this. Every few years when we look at the book we find that some concepts have changed. What was being practiced in only big cities and was mentioned only for the sake of completion in the earlier edition, has become a routine. Also, since the book has remained a popular choice for those appearing for PG entrance, we have added a section on MCQ’s after each chapter. Like as we would, to add a lot of new information, but all such thoughts go through the mental screening whether it is required for the target audience! We are cognisant of the fact that no change should be made for the heck of it. We hope the essential changes in this new edition would be appreciated by the readers. Feedback welcome. Knee and Shoulder Clinic F-7, East of Kailash New Delhi, India drjmaheshwari.com [email protected] J. Maheshwari Vikram A Mhaskar PREFACE TO THE FIRST EDITION What was the thought behind this book in 1993 As an undergraduate, though exposed to orthopaedics only for a short period, I was impressed by the ease with which I could understand the wonderful texts I studied. The problems were that their contents did not exactly meet the requirements of an undergraduate, and most of these books, written by authors from developed countries, did not provide adequate information about diseases peculiar to tropical and underdeveloped countries. Above all, I thought that the concepts could be presented with still more clarity, and improved by way of presentation. This feeling continued to haunt me everytime I was called upon to teach undergraduates. A couple of years later, an experience at home helped me give a practical shape to this feeling. My wife, who was preparing for PG entrance examination, expected me to teach her orthopaedics. I tried out my ideas on her, and the result was extremely gratifying. Soon after, many more such occasions of teaching undergraduates gave me further opportunities for refining the material. It was on the request of the students that I decided to give it the shape of a book. The book is primarily addressed to undergraduates and those preparing for the postgraduate entrance tests. General practitioners, particularly in the early stage of their practice would find it useful reference. It would enable nurses and physiotherapists to understand the basic concepts in orthopaedics. Junior postgraduates would find it an enjoyable reading. Following are the salient features of the book: 1. Most chapters begin with a brief review of the relevant anatomy. This is because by the time a student comes to clinical departments, he has forgotten most of the anatomy he had learnt in the dissection hall. 2. While discussing treatment of a condition, a brief mention of principles is made first, followed by various methods and their indications. This is followed by treatment plan; a practical plan of treatment which is either being followed or can be developed in an average hospital. A brief mention of recent developments is also made. 3. The book has three additional chapters. These are "Approach to a Patient with Limb Injury", "Approach to a Patient with Back Pain", and "Recent Advances in Treatment of Fractures". The first two present a practical approach to handling these frequently encountered emergencies, and the third chapter updates the reader with the latest in this rapidly developing field. Due emphasis has been given to aspects of rehabilitation, considering the recent recommendations of Medical Council of India for including 'rehabilitation' in undergraduate curriculum. 4. Simple line diagrams have been used to supplement the text. Most of them have been developed by myself while teaching the undergraduates. Simplified line diagrams, rather than photographs, enable students understand the basic concepts better. 5. Self-explanatory flow charts are made use of wherever they would help to develop a concept in decisionmaking. 6. Tables have been used liberally. These serve two purposes: Firstly, they present the text matter in a concentrated form and allow review at a glance. Secondly, they permit quick and easily understandable comparison between related conditions. 7. Necessary information on instruments and implants commonly used in orthopaedics has been provided as an appendix, purely considering the requirement of such knowledge for final professional examination. New Delhi September 1993 J. Maheshwari CONTENTS 1. Orthopaedic Trauma: Introduction ...................... 1 7. Complications of Fractures ................................. 42 • Classification of fractures ................................... 1 • Classification ..................................................... 42 • Fractures with eponyms ...................................... 2 • Hypovolaemic shock ......................................... 42 • Pathological fractures .......................................... 3 • Adult respiratory distress syndrome ................. 43 • Injuries to joints ................................................... 5 • Fat embolism syndrome .................................... 43 • Injuries to ligaments ............................................ 5 • • Injuries to muscles and tendons .......................... 6 Deep vein thrombosis (DVT) and pulmonary embolism .................................... 44 • Crush syndrome ................................................ 44 2. Anatomy of Bone and Fracture Healing .............. 8 • Injury to major blood vessels ............................ 44 • Anatomy of bone ................................................. 8 • Injury to nerves ................................................. 46 • Growth of a long bone ........................................ 9 • Injury to muscles and tendons .......................... 46 • Blood supply of bones ......................................... 9 • Injury to joints ................................................... 46 • Fracture healing ................................................. 10 • Injury to viscera ................................................ 46 • Healing of cancellous bones .............................. 11 • Infection — osteomyelitis ................................. 47 • Primary and secondary bone healing ................. 11 • Compartment syndrome .................................... 47 • Factors affecting fracture healing ..................... 11 • Delayed and non-union ...................................... 48 3. Treatment of Fractures: General Principles ..... 13 • Malunion ............................................................ 49 • Phase I Emergency care ............................... 13 • Shortening ......................................................... 50 • Phase II Definitive care .................................. 14 • Avascular necrosis ............................................. 50 • Phase III Rehabilitation of a fractured limb ..... 19 • Stiffness of joints .............................................. 51 • Management of open fractures ......................... 21 • Reflex sympathetic dystrophy (Sudeck‘s dystrophy) .................................. 51 4. Splints and Tractions ............................................ 25 • • Splints ................................................................ 25 Myositis ossificans (Post-traumatic ossification) ................................................. 52 • Tractions ........................................................... 26 8. Injury to Joints: Dislocation and Subluxation .. 54 5. Recent Advances in the Treatment of Fractures ........................................................... 29 • Relevant anatomy .............................................. 54 • Definitions ......................................................... 54 • AO method of fracture treatment ...................... 29 • Classification ..................................................... 54 • Changing AO concepts ...................................... 31 • Pathoanatomy .................................................... 55 • Functional bracing ............................................. 33 • Diagnosis ........................................................... 55 • Ilizarov's technique ............................................ 33 • Complications .................................................... 56 • Treatment .......................................................... 56 6. Approach to a Patient with Limb Injury ............ 36 • Clinical examination ........................................... 36 9. Fractures in Children ........................................... 57 • Radiological examination ................................... 38 • Relevant anatomy .............................................. 57 • Old fracture ....................................................... 40 • Types of fractures ............................................. 57 • Approach to a polytrauma patient ..................... 40 • Diagnosis ........................................................... 59 xiv | Essential Orthopaedics • Treatment .......................................................... 59 • Dislocation of the elbow joint .......................... 105 • Complications .................................................... 59 • Pulled elbow .................................................... 105 • Fracture of the olecranon ................................ 105 • Fracture of the head of the radius ................... 106 • Fracture of neck of the radius ......................... 107 • Fracture of the capitulum ................................ 107 10. Peripheral Nerve Injuries .................................... 61 • Relevant anatomy .............................................. 61 • Pathology ........................................................... 62 • Mechanism of injury.......................................... 62 • Classification ..................................................... 63 • Diagnosis ........................................................... 63 • Relevant anatomy ............................................ 108 • Electrodiagnostic studies ................................... 69 • Fractures of the forearm bones ....................... 109 • Treatment .......................................................... 71 • Monteggia fracture-dislocation ........................ 110 • Prognosis ........................................................... 74 • Galeazzi fracture-dislocation ............................ 111 • Colles' fracture ................................................. 111 • Smith's fracture (Reverse of colles' fracture) .... 114 11. Deformities and Their Management .................. 75 15. Injuries of the Forearm and Wrist ................... 108 • Causes ............................................................... 75 • Barton's fracture .............................................. 114 • Treatment .......................................................... 77 • Scaphoid fracture ............................................ 115 • Lunate dislocations .......................................... 116 12. Treatment of Orthopaedic Disorders: A General Review ................................................. 80 16. Hand Injuries ...................................................... 117 • Non-operative methods of treatment ................. 80 • Bennett's fracture-dislocation .......................... 117 • Operative methods of treatment ........................ 82 • Rolando's fracture ........................................... 118 • Fractures of the metacarpals ........................... 118 • Fractures of the phalanges .............................. 118 • Dislocation of the metacarpo-phalangeal joints ... 118 • Amputation of fingers: Principles of treatment ..................................................... 119 13. Injuries Around the Shoulder, Fracture Humerus ................................................ 87 • Relevant anatomy .............................................. 87 • Fracture of the clavicle ...................................... 88 • Fractures of the scapula .................................... 89 • Tendon injuries of the hand ............................. 119 • Dislocation of the sterno-clavicular joint ........... 89 • Crush injury to the hand .................................. 120 • Subluxation or dislocation of the acromio-clavicular joint ..................................... 89 17. Pelvic Fractures .................................................. 123 • Dislocation of the shoulder ................................ 89 • Relevant anatomy ............................................ 123 • Fracture of the surgical neck of the humerus ... 92 • Classification ................................................... 124 • Fracture of the greater tuberosity of the humerus .................................................. 92 • Pathoanatomy .................................................. 125 • Diagnosis ......................................................... 125 Fracture of the shaft of the humerus ................ 93 • Treatment ........................................................ 126 • Complications .................................................. 127 • 14. Injuries Around the Elbow ................................... 96 18. Injuries Around the Hip ..................................... 129 • Relevant anatomy .............................................. 96 • Supracondylar fracture of the humerus ............ 97 • Relevant anatomy ............................................ 129 • Fracture of the lateral condyle of the humerus .. 103 • Disclocation of the hip .................................... 130 • Intercondylar fracture of the humerus ............ 104 • Posterior dislocation of the hip ........................ 130 • Fracture of the medial epicondyle of the humerus ................................................ 105 • Anterior dislocation of the hip ......................... 131 • Central fracture-dislocation of the hip ............. 131 Contents | xv • Fracture of the neck of the femur ................... 132 • Pott's paraplegia ............................................... 191 • Inter-trochanteric fractures ............................. 138 • TB of the hip ................................................... 194 • TB of the knee ................................................. 199 • TB of other joints ............................................ 202 • TB osteomyelitis .............................................. 203 19. Fracture Shaft of Femur .................................... 141 • Pathoanatomy .................................................. 141 • Diagnosis ......................................................... 141 • Treatment ........................................................ 141 • Complications .................................................. 143 • Classification ................................................... 205 20. Injuries Around the Knee .................................. 145 • Aetiopathology ................................................. 205 24. Infections of the Hand ....................................... 205 • Relevant anatomy ............................................ 145 • Acute paronychium ......................................... 205 • Mechanism of knee injuries ............................. 145 • Apical subungual infection .............................. 206 • Condylar fractures of the femur ..................... 145 • Terminal pulp space infection .......................... 206 • Fractures of the patella .................................... 147 • Middle volar space infection ............................ 206 • Injury to the ligaments of the knee .................. 148 • Proximal volar space infection ........................ 207 • Tibial plateau fractures .................................... 150 • Web space infection ........................................ 207 • Meniscal injuries of the knee ........................... 150 • Deep palmar abscess ....................................... 208 • Rare injuries around the knee .......................... 152 • Acute suppurative tenosynovitis ...................... 208 21. Injuries to the Leg, Ankle and Foot ................. 155 25. Congenital Talipes Equino Varus (CTEV) ........ 210 • Fractures of shafts of tibia and fibula ............. 155 • Relevant anatomy ...........................................
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