Maheswari ortho

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34 | Essential Orthopaedics

Fig-5.12 Ilizarov's technique: The fragments can be transported up or down by turning the bolts on the fixator

when properly applied, causes the dormant or down, and the fracture distracted or compressed.
mesenchymal cells at the non-union site to Ilizarov technique is useful in the management of
differentiate into functioning osteoblasts. This the following conditions:
results in bone synthesis and fracture healing. The a) Limb lengthening, especially when the
concept that compression enhances bone healing,
was known even prior to Ilizarov, but the concept shortening is associated with deformity. In this
of distraction osteogenesis was put on a sound situation the fixator assembly is so designed
footing by Ilizarov. According to his theory in that it corrects the deformity and produces
wider perspective, any living tissue when subjected lengthening at the same time. Massive limb
to constant stretch under biological conditions, can lengthening (even up to 18 inches) have been
grow to any extent. The biological conditions are performed by using this technique. The fixator
provided by: (i) aligning the fracture with minimal provides a stable biological environment to the
damage to its vascularity, and (ii) performing an new bone at the site of lengthening (Fig-5.13).
‘osteotomy’ of the bone (e.g., in limb lengthening b) Non-union, especially those resistant to
surgeries), without damaging its periosteal and conventional methods of treatment or those
endosteal blood supply. Such an ‘osteotomy’ was associated with deformity or shortening. By
termed corticotomy by Ilizarov. this method, non-union, deformity as well
The whole segment of the limb is stabilised
by a specially designed fixation system called Fig-5.13 Correction of a deformity and
ring fixator. This protects the growing tissues lengthening done simultaneously
from bending or shearing forces, but permits
loading in the long axis of the limb. Distraction
or compression can be applied at the fracture or
corticotomy site by twisting nuts on the fixation
system (Fig-5.12). Distraction or compression is
carried out at the rate of 1 mm per day. This is
done in four sittings— ¼ mm, four times a day.
Ring fixator application consists of inserting thin
(1.5 or 1.8 mm) stainless steel wires through the
bone. Outside the limb, the wires are attached to
steel rings with the help of bolts. Before fixing the
wire to the ring, the wire is put under tension so
as to make it ‘stiff’, and thus impart stability to the
fixator. The rings are interconnected with the help
of threaded rods with nuts on either ends. It is by
twisting these nuts that the rings can be moved up

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Recent Advances in the Treatment of Fractures | 35

shortening can be treated by one-stage fixator • Correction of more than one problems by one-
application. Non-unions requiring skin cover stage operation.
and bone grafting operations can be managed
by using Ilizarov technique without subjecting DISADVANTAGES OF ILIZAROV'S TECHNIQUE
the patient to staged surgeries. • Inconvenience, as the external fixator hampers

c) Deformity correction, which may be congenital normal activity
or acquired can be corrected by Ilizarov's
technique. • Long duration of treatment
• Pin tract infection
d) Osteomyelitis can be treated, as this technique • Nerve palsy by pin insertion or traction
offers the possibility of liberal excision of • Joint stiffness caused by transfixation of the soft
necrotic bone. The gap thus created can
subsequently be made up by transporting a tissues by the external fixator.
segment of bone from either end.
e) Arthrodesis can be performed by “crushing” the Further Reading
• Muller ME, Allgower M, Schreider R, Willenegger H:
articular surfaces against each other, and thus
stimulating union between opposite bones. Manual of Internal Fixation. Springer- Verlag, 1990.
• Sarmiento A, Latta L, Sinclair WF: Functional bracing of
ADVANTAGES OF ILIZAROV'S TECHNIQUE
• Immediate load bearing fractures In: Instructional Course Lectures, American Academy
• A healthy viable bone in place of devascularized of Orthopaedic Surgeons 25. C.V. Mosby St. Louis, Ch9, pp
184-239, 1976.
bone • Ilizarov GA: Transosseous Osteosynthesis. Springer Verlag
1992.

  What have we learnt?

• The AO methods of internal fixation are based on achieving inter-fragmentary compression
or splintage or both. Plates and screws can be used to achieve this. Nailing is a splintage
device, interlock nailing being a recent modification.

• In the treatment of diaphyseal fracture, emphasis has shifted from rigid (absolute) stability
to relative stability. Anatomical reduction has been replaced by functional reduction.

• Plate fixation has undergone changes to make it a more 'biological' implant. Locking

compression plate (LCP) is a recent addition to plating techniques.

• Functional bracing is a non-operative method of treating fractures of the long bones.
• Ilizarov method is a type of external fixator system which is versatile in its application,

particularly suited for difficult non-unions, malunions and limb length discrepancies.

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6C H A P T E R

Approach to a Patient with
Limb Injury

TOPICS

• Clinical examination
• Radiological examination
• Old fracture
• Approach to a polytrauma patient

While examining a case of injury to the musculo- This will be missed if a clinical examination is
skeletal system, answers to the following questions not carried out.
are sought: Thus, a thorough clinical examination must precede
• Is there a fracture*? an X-ray in all cases of musculo-skeletal injury. The
• Is it a closed or an open fracture? following questions should be kept in mind while
• Is it a traumatic or a pathological fracture? performing the clinical examination:
• Are there any complications associated with
IS THERE A FRACTURE?
the fracture? Most often a fracture can be diagnosed on the
basis of history and clinical examination. The
CLINICAL EXAMINATION following points in clinical examination need to
be considered:
With widespread availability of X-ray facilities, Age of the patient: Fractures occur at all ages but
diagnosis of fractures and dislocations has become dislocations are uncommon in children**. Some
easy. But the clinical examination still continues to fractures are common in a particular age group,
be important, especially in the following situations: as shown in the Table–6.1.

a) To decide whether an X-ray examination is Table–6.1:  Common fractures at different ages
needed. This is particularly relevant when a Age group Fractures
patient has to travel to far off places for X-ray. •  At birth Clavicle, Humerus
•  In children Supracondylar fracture of
b) To ascertain whether the injury under humerus
consideration needs a special view. For Epiphyseal injuries
example, an oblique view of the wrist best •  In adults Fractures of shafts of long
shows a scaphoid fracture. bones
•  In elderly people Colles' fracture
c) To avoid making a wrong diagnosis, by Fracture neck of femur
correlating the clinical findings with the
radiological findings. This way, some artifacts Mechanism of injury: The mechanism by which
otherwise likely to be diagnosed as 'fracture', the patient sustains the injury often gives an idea
are recognised.
** In children, force around a joint produces an epiphyseal injury
d) To detect complications associated with a through the epiphyseal plate, and not a dislocation.
fracture e.g., injury to the neurovascular bundle.

* For ease of discussion, the term ‘fracture’is used for both, fracture
and dislocation.

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Approach to a Patient with Limb Injury | 37

Table–6.2: Mechanisms of injury and fractures/ • Swelling: Though most fractures are accompanied
with swelling at the site, it can be a misleading
dislocations sign as there may be minimal visible swelling in
the presence of a serious fracture (e.g., fracture
Mechanism Common injuries of the neck of the femur); on the other hand, a
massive swelling may be present in the absence
• Fall on an out-stretched of a fracture (e.g., in cases of ligament sprain
hand and muscle injuries). The swelling may be due
• Fall with spine forced Fracture clavicle to a haematoma, prominence of the bone ends
in a particular direction Fractures around the or passive oedema.
elbow
• Deformity: An obvious deformity of a body
Flexion injuries, part is a very specific sign of a fracture or
Extension injuries etc. dislocation. So characteristic is the deformity in
• Slipping in the Fractures neck of the some fractures and dislocations that a diagnosis
bathroom (trivial trauma) can be made just by looking at the deformity
femur (Table–6.3). Deformity may be absent if there is
• Dashboard injury an impacted fracture.
• Fall onto the heel Posterior dislocation of
• Hit by a stick hip

Fracture calcaneum
Fracture ulna

about the expected fracture/dislocation. For Table–6.3: Injuries with characteristic deformities
example, in a fall from some height onto the heels,
one is likely to sustain a fracture of the calcaneum, Deformity Injury
fracture of lumbar vertebrae and fracture of pubic
rami. Some common injuries and mechanisms • Flattening of shoulder Shoulder dislocation
involved are shown in Table–6.2. • Dinner fork deformity (anterior)
Presenting complaints: A patient with suspected
Colles' fracture
­fracture may present with the following com • Mallet finger
Avulsion of the insertion
plaints: of the extensor tendon
from the distal phalanx
• Pain: It is the commonest presenting complaint • Flexion, adduction and
in cases of musculo-skeletal injury. The severity internal rotation of the hip
of pain has no bearing on the diagnosis. Sprains • Abduction, external Posterior dislocation of
and strains can be as painful as fracture. rotation of the hip the hip

• Swelling: Fractures are usually accompanied • External rotation Anterior dislocation of
with swelling. The swelling may be slight if of the leg the hip
patient presents immediately after the injury;
but in those presenting late, the whole limb Fracture neck of femur
may be swollen, mostly because of gravitational Trochanteric fracture
oedema.
• Tenderness: Pain elicited by direct pressure at the
• Deformity: A fractured bone may result in fracture site or by indirect pressure may suggest
deformity of that part of the body. a fracture.

• Loss of function: Following a fracture, the patient Direct Pressure: A localised tenderness on a
may* be unable to use the affected limb. subcutaneous bone, elicited by gently running
the back of the thumb (Fig-6.1a) may suggest
Examination: A proper exposure of the body part an underlying fracture. The site of maximum
is crucial to an accurate examination. At times the tenderness helps in differentiating ligament
findings are subtle, and comparison of the injured injuries from that of fractures around a joint (e.g.,
limb with the opposite normal extremity may be ankle injuries). One may feel or hear a crepitus
useful. Joints proximal and distal to the injured while eliciting tenderness.
bone should always be examined. In a patient of
road traffic accident with multiple injuries, it is Indirect Pressure: It may be possible to elicit
wise to expose the patient completely and examine pain at the fracture site by applying pressure at
each body part in a systematic manner. One should a site away from the fracture. Some examples
look for the following signs: are given below:
• Springing test: It may be possible to elicit
* Ability to keep using the limb after an injury is not conclusive pain from a fracture of the forearm bones

of no fracture, especially in children.

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38 | Essential Orthopaedics

Fig-6.1 Eliciting tenderness (a)  With back of the thumb under the wound. Sometimes it may be difficult to
(b) Springing of forearm say whether a wound is communic­ating with the
fracture or not, in which situation, it should be taken
by pressing the two bones towards each as an open fracture. It must be ascertained whether
other at a distance away from the fracture the compounding is internal or from outside.
(Fig-6.1b).
• Axial pressure: An axial pressure along the IS IT A PATHOLOGICAL FRACTURE?
second metacarpal may elicit pain in the A pathological fracture must be suspected if:
scaphoid fossa, in a case of scaphoid fracture. (i) the force producing the fracture is insignificant
• Bony irregularity: It is possible to feel bony (trivial trauma); (ii) there is a history of pain or
elevations and depressions in fractures of swelling in the affected bone prior to the occurrence
subcutaneous bones such as the tibia. This is a of fracture; (iii) there is history suggestive of
definite sign of fracture. frequent fractures in the past (e.g., osteogenesis
• Abnormal mobility: In any limb, movements imperfecta); and (iv) the patient is suffering from
occur only at joints. If one can elicit mobility a debilitating systemic illness known to weaken
at sites other than the joints (say in the middle bones (e.g., rheumatoid arthritis).
of the arm), or an abnormal range of movement
at a joint, a fracture or dislocation is definite. One ANY ASSOCIATED COMPLICATION?
may hear or feel a crepitus while doing this. Complications such as injuries to the nerves and vessels
• Absence of transmitted movements: Normally, etc. may be associated with a fracture. These can be
if a bone is moved holding it at one end, the diagnosed on clinical examination (see Chapter 10).
movement can be felt at the other end. This
transmitted movement will be absent in case RADIOLOGICAL EXAMINATION
of a displaced fracture. In case the fracture is
undisplaced or impacted, the movement will be A radiological examination helps in: (i) diagnosis of a
transmitted even in the presence of a fracture. fracture or dislocation; (ii) evaluation of displacements,
IS IT AN OPEN FRACTURE? if any; and (iii) studying the nature of the force
Whenever there is a wound in the vicinity of a frac- causing fracture. The following are some of
ture, it is important to ascertain whether the wound the points to be remembered in a radiological
is communicating with the fracture. This is done by examination of a case of skeletal injury:
examination of the wound under strict aseptic con-
ditions. Usually it is easy, as one may see the bone ASKING FOR AN X-RAY
Before asking for an X-ray, the following points
should be kept in mind:
• Both, antero-posterior and lateral views should

be requested in most situations.
• Joint above and below should be included in

the X-ray.
• Special views show fractures better in some cases

(Table–6.4).

Table–6.4: Some commonly used special views

Oblique view wrist Scaphoid fracture
Judet view Acetabular fracture
Merchant view Patello-femoral joint
Skyline view Calcaneum fracture

• X-ray requisition must specify the area of
suspicion e.g., if an Xin-rjuayryoftotheDd12ovrseor-tleubmrabaisr
suspected, ask for an
spine focussing D12.
• X-ray of the pelvis wtih both hips should be asked
for in all cases of suspected pelvic injury. Major

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Approach to a Patient with Limb Injury | 39

injuries of the thigh are often associated with • At what level is the fracture? i.e., whether the
fractures of the pelvis, hence an X-ray of the fracture is in the upper, middle or lower third.
pelvis must be taken as a routine in cases with
major fractures of the leg. • What is the pattern of the fracture? i.e., whether
the fracture is transverse, oblique etc.
• For an X-ray evaluation of the hands and feet,
antero-posterior and oblique views (not lateral) • Is the fracture displaced? If yes, in what direction,
are required. i.e., whether it is a shift (antero-posterior,
sideways), a tilt, or angulation in any direction, or a
READING AN X-RAY rotational displacement. Rotational displacement
An X-ray view box should be used in all cases. If  is sometimes not visible on X-rays, and can only
a fracture is obvious, one must make a note of the be diagnosed clinically.
following points:
• Is the fracture line extending into the nearby joint?
• Which bone is affected? • Does the underlying bone appear pathological?
• Which part of the bone is affected? e.g., shaft
e.g., a cyst, abnormal texture of the whole bone,
etc. etc.

Flow chart-6.1 Approach to a patient with limb injury

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40 | Essential Orthopaedics

• Is it a fresh or an old fracture? An X-ray of a fresh Fig-6.2 X-rays showing old fractures.
fracture shows a soft tissue shadow resulting (Note smoothening of the ends)
from haematoma, and the fracture ends are
sharp. An old fracture shows callus formation OLD FRACTURE
and disuse osteoporosis and the fracture ends
are smoothened. After 2-3 weeks, signs of a fresh fracture like pain,
soft tissue swelling, tenderness etc. diminish
If the fracture is not obvious immediately, all markedly. On X-ray examination, the fracture
the bones and joints seen on the X-ray must be ends will not appear sharp. Callus may be present.
examined systematically for a break in the cortex When a patient with fracture presents late after
or loss of joint congruity. injury, to decide further treatment, it is important
to ascertain: (i) whether the position of the fracture
X-ray findings should be correlated with clinical fragments is acceptable; and (ii) at what stage of
findings, so as to avoid error because of some union is the fracture? e.g., united, uniting or non-
artifacts which may mimic a fracture. Also one union (Fig-6.2).
must ensure that the part under question is visible
on X-ray. An X-ray of a bone must include the joints APPROACH TO A POLYTRAUMA PATIENT
proximal and distal to the bone. Do look for an
associated injury to all the other bones and joints An isolated skeletal injury rarely poses any
visible on the X-ray. threat, but in association with multiple injuries,
musculo-skeletal injuries assume great significance
One must be aware of some normal X-ray findings in terms of morbidity and mortality. Proper,
which are often misinterpreted as fracture e.g., well-articulated, early management plays a vital
epiphyseal lines, vascular markings on bones, role in improving the outcome of these patients.
accessory bones etc. A comparison with the X-ray The following constitute the key points in the
of the opposite limb helps in clearing any doubt. management.

There are some injuries particularly liable to be FIELD TRIAGE
missed by a novice (Table–6.5). Before an X-ray
is passed as normal, one must carefully look for Ideally, the management of a multiple injured
these injuries. should begin at the scene of accident where the
A diagrammatic presentation of approach to medical technician should be able to work in
a patient with a limb injury is as shown in coordination with the doctors. He should be
Flow chart-6.1. able to provide basic life support and help in
transportation. He should be able to decide, on the
Table–6.5: Fractures commonly missed basis of the level of injury, whether the victim needs
to be transferred to the local hospital or a hospital
Upper Limb with developed trauma services. In the present
- Greater tuberosity: In AP view of the shoulder, fracture of day context, trauma services are not so well

greater tuberosity is missed, as the fragment gets displaced
behind the head of humerus.
- AC joint subluxation
- Posterior dislocation of shoulder
- Head of radius, neck of the radius
- Capitulum
- Scaphoid

Lower Limb
- Fracture neck of femur (Impacted)
- Acetabulum
- Patella
- Calcaneum
- Dislocation of foot

Other
- Epiphyseal injuries

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Approach to a Patient with Limb Injury | 41

developed in countries like India, but this is ­lar injuries – so check all peripheral pulses and
something to aspire for.
capillary circulation; (ii) nerve injuries – check
TREATMENT IN THE EMERGENCY DEPARTMENT peripheral nerves and correct malposition of
the fractures to relieve pressure or stretch on
­Once the patient reaches the emergency depart the affected nerve; (iii) dislocation or sublux-
ation – these need to be corrected early. All other
ment, management consists of the following: orthopaedic injuries can be treated once other
systems have been stabilised.
• Primary survey: This constitutes rapid
assessment of vitals of the patient and ensuring • Definitive treatment: From orthopaedic view
patent airway, adequate breathing, circulation point, this consists of planning whether some
and control of external bleeding. fractures need internal fixation. Those being
treated coservatively, need to be reduced and
• Resuscitation: This is conducted on established immobilised. Current trend is to internally fix
lines of ABCDE (please refer to book on as many fractures as possible in a polytrauma
Anaesthesia for details). patient, often in one sitting. This has been shown
to help in nursing care, and has resulted in
• Secondary survey: Once the patient is stable, decrease in mortality and morbidity.
proper neurologic assessment, thoraco-abdom-
­inal assessment, genito-urinary assessment and Further Reading
musculo-skeletal assessment is carried out. As
is obvious from the above sequence, musculo- • Rockwood CA (Jr.), Green DP, (Eds.): Fractures in Adults; Vols
skeletal assessment is not high on priority. The 1 and 2, 2nd edn. Philadelphia: JB Lippincott Co., 1984.
only injuries related to musculo-skeletal system
which are important at this stage are: (i) vascu- • Wilson JN (Ed.): Watson-Jone's Fractures and Joint Injuries,
6th edn. Edinburgh: Churchill Livingstone.

  What have we learnt?

• When evaluating a fracture, a correlation between clinical findings and X-ray findings is a
must.

• Wherever possible take AP and lateral X-rays.
• Think of the possibility of a background pathological process which may have contributed to

the fracture.
• Proper X-ray requisition can prevent a lot of problems.
• Comparative X-ray of the normal, opposite side may help in diagnosing a doubtful fracture.

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7C H A P T E R

Complications of Fractures

TOPICS • Injury to viscera
• Infection – osteomyelitis
• Classification • Compartment syndrome
• Hypovolaemic shock • Delayed and non-union
• Adult respiratory distress syndrome • Malunion
• Fat embolism syndrome • Shortening
• Deep vein thrombosis • Avascular necrosis
• Crush syndrome • Stiffness of joints
• Injury to major blood vessels • Sudeck‘s dystrophy
• Injury to nerves • Myositis ossificans
• Injury to muscles and tendons
• Injury to joints

Complications inevitably occur in a proportion of major vessel of the limb. Internal haemorrhage is
fractures. With early diagnosis and treatment, the more difficult to diagnose. It is usually massive
disability caused by these complications can be bleeding in the body cavities such as chest or
greatly reduced. abdomen. Significant blood loss may occur
in fractures of the major bones like the pelvis
CLASSIFICATION (1500–2000 ml), and femur (1000–1500 ml).

Complications of fractures can be classified into Management: This begins even before the cause
three broad groups depending upon their time of can be ascertained. An immediate step is to put in
occurrence. These are as follows: at least two large bore intravenous cannulas (No. 16
a) Immediate complications – occurring at the time or No. 14). If there is peripheral vasoconstriction,
no time should be wasted in performing a cut
of the fracture. down. 2000 ml of crystalloids (preferably Ringer
b) Early complications – occurring in the initial lactate), should be infused rapidly, followed by
colloids (Haemaccel) and blood. At the earliest
few days after the fracture. opportunity, effort is made to localize the site of
c) Late complications – occurring a long time after bleed – whether it is in the chest or in the abdomen.
Needle aspiration from the chest, and diagnostic
the fracture. peritoneal lavage provide quick information to this
effect. If possible, a plain X-ray chest, and X-ray
Some of the complications of the fractures seen in abdomen may be done. A chest tube for chest
day-to-day practice are given in Table–7.1. bleeding, laparotomy for abdominal bleeding, may
be required.
HYPOVOLAEMIC SHOCK Excessive blood loss from fractured bone may be
prevented by avoiding moving the patient from
Hypovolaemic shock is the commonest cause of one couch to another. For fractures of the pelvis,
death following fractures of major bones such temporary stabilisation with an external fixator
as the pelvis and femur. Its frequency is on the has been found useful in reducing haemorrhage.
increase due to a rise in the number of patients In advanced trauma centres, an emergency
with multiple injuries. angiography and embolisation of the bleeding
Cause: The cause of hypovolaemia could be
external haemorrhage or internal haemorrhage.
External haemorrhage may result from a compound
fracture with or without an associated injury to a

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Complications of Fractures | 43

Table–7.1: Complications of fractures not detected early, patient's condition deteriorates
rapidly, he develops cardio-respiratory failure and
Immediate complications dies.

Systemic FAT EMBOLISM SYNDROME

• Hypovolaemic shock This is one of the most serious complications, the
Local essential feature being occlusion of small vessels
by fat globules.
• Injury to major vessels
• Injury to muscles and tendons Causes: The fat globules may originate from
• Injury to joints bone marrow or adipose tissue. Fat embolism
• Injury to viscera is more common following severe injuries with
multiple fractures and fractures of major bones.
Early complications The pathogenesis of the syndrome is not clear,
Systemic but it seems likely that two events occur: (i)
release of free fatty acids (by action of lipases on
• Hypovolaemic shock the neutral fat), which induces a toxic vasculitis,
• ARDS followed by platelet-fibrin thrombosis; and (ii)
• Fat embolism syndrome actual obstruction of small pulmonary vessels by
• DVT and Pulmonary embolism fat globules.
• Aseptic traumatic fever
• Septicaemia (in open fractures) Consequences: Symptoms are evident a day or
• Crush syndrome so after the injury. Presenting features are in the
form of two, more or less distinct types: (i) cerebral;
Local and (ii) pulmonary. In the cerebral type, the
patient becomes drowsy, restless and disoriented
• Infection and gradually goes into a state of coma. In the
• Compartment syndrome pulmonary type, tachypnoea and tachycardia are
the more prominent features. The other common
Late complications feature of fat embolism is a patechial rash, usually
Imperfect union of the fracture on the front of the neck, anterior axillary folds,
chest or conjunctiva. If untreated, and sometimes
• Delayed union despite treatment, the patient develops respiratory
• Non-union failure and dies.
• Malunion
• Cross union Diagnosis: In a case with multiple fractures, early
diagnosis may be possible by strong suspicion. In
Others addition to the classic clinical features, signs of
retinal artery emboli (striate haemorrhages and
• Avascular necrosis exudates) may be present. Sputum and urine may
• Shortening reveal the presence of fat globules. X-ray of the
• Joint stiffness chest may show a patchy pulmonary infiltration
• Sudeck’s dystrophy (Reflex Sympathetic Dystrophy) (snow storm appearance). Blood PO2 of less than 50
• Osteomyelitis mmHg may indicate impending respiratory failure.
• Ischaemic contracture
• Myositis ossificans Treatment: This consists of respiratory support,
• Osteoarthritis heparinisation, intravenous low molecular
weight dextran (Lomodex-20) and corticosteroids.
vessel is performed to control bleeding from deeper An intravenous 5 percent dextrose solution with
vessels. 5 percent alcohol helps in emulsification of fat
globules, and is used by some.
ADULT RESPIRATORY DISTRESS SYNDROME

Adult respiratory distress syndrome (ARDS) can be
a sequelae of trauma with subsequent shock. The
exact mechanism is not known, but it is supposed
to be due to release of inflammatory mediators

­which cause disruption of microvasculature of the

pulmonary system. The onset is usually 24 hours
after the injury. The patient develops tachypnoea
and laboured breathing. X-ray chest shows diffuse
p50u.lMmaonnaagryeminefnilttrcaotnessi.sAtsrtoefr1ia0l0PpOer2cfeanlltsotxoylegsesntahnadn
assisted ventillation. It takes from 4-7 days for the
chest to clear, and the patient returns to normal. If

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44 | Essential Orthopaedics

DEEP VEIN THROMBOSIS (DVT) AND Table–7.2: Vascular injuries and skeletal trauma
PULMONARY EMBOLISM
Vessel injured Trauma
Deep vein thrombosis (DVT) is a common
complication associated with lower limb injuries Femoral Fracture lower third of femur
and with spinal injuries.
Popliteal Supracondylar fracture of the femur
Cause: Immobilisation following trauma leads to
venous stasis which results in thrombosis of veins. Posterior tibial Dislocation of the knee, Fracture tibia
DVT proximal to the knee is a common cause of life
threatening complication of pulmonary embolism. Subclavian Fracture of the clavicle
DVT can be recognised as early as 48 hours after
the injury. Embolism occurs, usually 4-5 days after Axillary Fracture-dislocation of the shoulder
the injury.
Brachial Supracondylar fracture of the
Consequences: DVT can be diagnosed early with humerus
high index of suspicion. The group of patients ‘at
risk’ include the elderly and the obese patients. Leg Treatment: In a case with crushed limb, first
swelling and calf tenderness are usual signs. The aid treatment may necessitate the application
calf tenderness may get exaggerated by passive of a tourniquet, which is gradually released, so
dorsiflexion of the ankle (Homan’s sign). Definitive that deleterious substances are released into the
diagnosis can be made by venography. One should circulation in small quantities. If oliguria develops,
keep a patient of DVT on constant watch for the patient is treated as for acute renal failure.
development of pulmonary embolism. This can
be suspected if the patient develops tachypnoea INJURY TO MAJOR BLOOD VESSELS
and dyspnoea, usually 4-5 days after the accident.
There may be chest pain or haemoptysis. Blood vessels lie in close proximity to bones, and
hence are liable to injury with different fractures
Treatment of DVT is elevation of the limb, elastic and dislocations (Table–7.2). The popliteal artery
bandage and anticoagulant therapy. For pulmo–­ is the most frequently damaged vessel in musculo-
nary embolism, respiratory support and heparin skeletal injuries.
therapy is to be done. Early internal fixation of
fractures, so as to allow early, active mobilisation Causes: The artery may be damaged by the object
of the extremity is an effective means of prevention causing the fracture (e.g., bullet), or by a sharp edge
of DVT, and hence of pulmonary embolism. of a bone fragment (e.g., supracondylar fracture of
the humerus). The damage to the vessel may vary
CRUSH SYNDROME from just a pressure from outside to a complete
rupture.
This syndrome results from massive crushing of
the muscles, commonly associated with crush Consequences. Obstruction to blood flow will
injuries sustained during earthquakes, air raids, not always lead to gangrene. Where the collateral
mining and other such accidents. A similar effect circulation is good, the following may result:
may follow the application of tourniquet for an • No effect: If collateral circulation of the limb
excessive period.
around the site of vascular damage is good, there
Causes: Crushing of muscles results in entry will be no adverse effect of the vascular injury.
of myohaemoglobin into the circulation, which • Exercise ischaemia: The collaterals are good
precipitates in renal tubules, leading to acute renal enough to keep the limb viable but any
tubular necrosis. further demand on the blood supply during
exercise, causes ischaemic pain (vascular
Consequences: Acute tubular necrosis produces claudication).
signs of deficient renal functions such as scanty • Ischaemic contracture: If the collaterals do not
urine, apathy, restlessness and delirium. It may provide adequate blood supply to the muscles,
take 2-3 days for these features to appear. there results an ischaemic muscle necrosis.
This is followed by contracture and fibrosis
of the necrotic muscles, leading to deformities
(e.g., Volkmann’s ischaemic contracture, see
page 102).
• Gangrene: If the blood supply is grossly
insufficient, gangrene occurs.

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Complications of Fractures | 45

Diagnosis: The pulses distal to the injury • Pain – cramplike
should be examined in every case of a fracture or • Pulse – absent
dislocation. Some of the features which suggest a • Pallor
possible vascular injury of a limb are listed below: • Paraesthesias
• Paralysis
a) Signs at the fracture site: The following signs may
be present at the fracture site: As a matter of rule, absent peripheral pulses in
an injured limb should be considered to be due
• Rapidly increasing swelling to vascular damage unless proved otherwise. The
• Massive external bleeding (in open fractures) confirmation of obstruction to blood flow in a
• A wound in the normal anatomical path of vessel and its site can be easily done by Doppler
study. In the absence of such a facility, there is
the vessel no need to waste crucial time by ordering an
angiogram merely for confirmation of diagnosis.
b) Signs in the limb distal to the fracture: The
following signs may be present in the limb
distal to the fracture (five P’s):

Flow chart-7.1 Management of vascular injury to limb

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46 | Essential Orthopaedics

An angiogram may be justified in cases with the type of damage is generally neurapraxia or
multiple fractures in the same limb, where it may axonotmesis, and nerve recovery is good with
help in localising the site of the vascular injury. conservative treatment. In case the fracture per se
needs open reduction for other reasons, the nerve
Treatment: Early diagnosis and urgent treatment should also be explored. When associated with an
are of paramount importance because of the serious open fracture, the type of nerve damage is often
consequences that may follow. Correct treatment at neurotmesis. In such cases, the nerve should be
the site of first contact (Flow chart-7.1), followed by explored and repaired as per need, and the fracture
referral to a centre equipped with facilities to treat fixed internally with nail, plate etc.
vascular injuries is essential. In case exploration
of the vessel is required, the fracture should be INJURY TO MUSCLES AND TENDONS
suitably stabilised using internal or external
fixation. Some degree of damage to muscles and tendons
occurs with most fractures. It may result from
INJURY TO NERVES the object causing the fracture (e.g., an axe), or
from the sharp edge of the fractured bone. Often
Nerves lie in close proximity to bones, and hence these injuries are overshadowed by more alarming
are liable to damage in different fractures or fractures, and are detected only late, when
dislocations (Table–7.3). The radial nerve is the the joint distal to the fracture becomes
most frequently damaged nerve in musculo- stiff and deformed due to scarring of the injured
skeletal injuries. Nerves and vessels lie together in muscle.
limbs, and so are often injured together. Rest to the injured muscle and analgesics is enough
in cases with partial rupture. A complete rupture
Causes: A nerve may be damaged in one of the requires repair. Rarely, if rupture of a tendon or
following ways: muscle is detected late, reconstruction may be
required.
• By the agent causing the fracture (e.g., bullet).
• By direct pressure by the fracture ends at the INJURY TO JOINTS

time of fracture or during manipulation. Fractures near a joint may be associated
• Traction injury at the time of fracture, when the with subluxation or dislocation of that joint.
This combination is becoming more frequent
fracture is being manipulated or during skeletal due to high-velocity traffic accidents. Early open
traction. reduction and stabilisation of the fracture to permit
• Entrapment in callus at the fracture site. early joint movements has improved the results.

Consequences: Damage to the nerve may be INJURY TO VISCERA
neurapraxia, axonotmesis, or neurotmesis. It may
result in a variable degree of motor and sensory loss Visceral injuries are seen in pelvic and rib fractures.
along the distribution of the nerve (see Chapter 10, Their management is discussed in Surgery
Peripheral Nerve Injuries). textbooks.

Treatment: This depends upon the type of
fracture, whether it is closed or open. When the
nerve injury is associated with a closed fracture,

Table–7.3: Nerve injuries and skeletal trauma

Nerve Trauma Effect

•  Axillary nerve Dislocation of the shoulder Deltoid paralysis
•  Radial nerve Fracture shaft of the humerus Wrist drop
•  Median nerve Supracondylar fracture of humerus Pointing index
•  Ulnar nerve Fracture medial epicondyle humerus Claw hand
•  Sciatic nerve Posterior dislocation of the hip Foot drop due to weakness of
dorsiflexors of the foot
•  Common peroneal nerve Knee dislocation Foot drop
Fracture of neck of the fibula

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Complications of Fractures | 47

INFECTION – OSTEOMYELITIS Fig-7.2 Eaton and Green cycle for compartment syndrome

Causes: Infection of the bone is an early complication leading to contractures. Nerve damage may result
of fractures. It occurs more commonly in open in motor and sensory loss. In an extreme case,
fractures, particularly in those where compounding gangrene may occur.
occurs from outside (external compounding). Diagnosis: Compartment syndrome can be
The increasing use of operative methods in the diagnosed early by high index of suspicion.
treatment of fractures is responsible for the rise Excessive pain, not relieved with usual doses of
in the incidence of infection of the bone, often analgesics, in a patient with an injury known to
years later. Infection may be superficial, moderate cause compartment syndrome must raise an alarm
(osteomyelitis), or severe (gas gangrene). in the mind of the treating doctor. Injuries with a
Treatment: Proper care of an open fracture can high risk of developing compartment syndrome
prevent osteomyelitis. Once infection occurs, it are as follows:
should be adequately treated.
• Supracondylar fracture of the humerus
COMPARTMENT SYNDROME • Forearm bone fractures
• Closed tibial fractures
The limbs contain muscles in compartments • Crush injuries to leg and forearm.
enclosed by bones, fascia and interosseous
membrane (Fig-7.1). A rise in pressure within these Stretch test: This is the earliest sign of impending
compartments due to any reason may jeopardize compartment syndrome. The ischaemic muscles,
the blood supply to the muscles and nerves within when stretched, give rise to pain. It is possible to
the compartment, resulting in what is known as stretch the affected muscles by passively moving
“compartment syndrome”. the joints in direction opposite to that of the
Causes: The rise in compartment pressure can be damaged muscle’s action. (e.g., passive extension
due to any of the following reasons: of fingers produces pain in flexor compartment of
the forearm).
• Any injury leading to oedema of muscles.
• Fracture haematoma within the compartment. ­Other signs include a tense compartment, hypo
• Ischaemia to the compartment, leading to muscle
aesthesia in the distribution of involved nerves,
oedema. muscle weakness etc. Compartment syndrome can
Consequences: The increased pressure within be confirmed by measuring compartment pressure.
the compartment compromises the circulation A pressure higher than 40 mm of water is indica-
tive of compartment syndrome. Pulses may remain
Fig-7.1 Osseo-fascial compartment palpable till very late in impending compartment
syndrome, and should not provide a false sense of
leading to further muscle ischaemia. A vicious cycle security that all is well.
is thus initiated (Fig-7.2) and continues until the Treatment: A close watch for an impending
total vascularity of the muscles and nerves within compartment syndrome and effective early
the compartment is jeopardized. This results in preventive measures like limb elevation, active
ischaemic muscle necrosis and nerve damage. The finger movements etc. can prevent this serious
necrotic muscles undergo healing with fibrosis, complication. Early surgical decompression

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48 | Essential Orthopaedics

is necessary in established cases. This can be Table–7.4: Causes of delayed and non-union, and their
performed by the following methods: common sites
• Fasciotomy: The deep fascia of the compartment
Causes related to the patient
is slit longitudinally (e.g., in forearm). Age: Common in old age
• Fibulectomy: The middle third of the fibula is Associated systemic illness: Malignancy, Osteomalacia

excised in order to decompress all compart­ments Causes related to fracture
of the leg. Distraction at the fracture site
• Muscle pulling the fragments
DELAYED AND NON-UNION – Fracture patella
– Fracture olecranon
When a fracture takes more than the usual time to • Gravity
unite, it is said to have gone in delayed union. A large – Fracture shaft of humerus
percentage of such fractures eventually unite. In Soft tissue interposition
some, the union does not progress, and they fail to • Fracture shaft of humerus
unite. These are called non-union. Conventionally, it • Fracture shaft of femur
is not before 6 months that a fracture can be declared • Fracture medial malleolus (abduction type)
as non-union. It is often difficult to say whether the Bone loss at the time of fracture
fracture is in delayed union, or has gone into non- • Fracture tibia (open type)
union. Only progressive evaluation of the X-rays • Fracture ulna (open type)
over a period of time can solve this issue. Presence Infection from an open fracture
of mobility at the fracture after a reasonable period • Fracture tibia
is surely a sign of non-union. Presence of pain at Damage to blood supply of fracture fragments
the fracture site on using the limbs also indicates • Fracture neck of femur
non-union. Non-union may be painless if • Fracture lower third of tibia
pseudo joint forms between the fracture ends Pathological fracture
(pseudoarthrosis). • Fracture of the shaft of the femur
Causes: Some of the factors responsible for delayed • Fracture of humerus
union are given in Table–7.4. In any given case,
there may be one or more factors operating. Causes related to treatment
Types of non-union: There are two main types of Inadequate reduction
non-unions (Fig-7.3): • Fracture shafts of long bones
• Atrophic, where there is minimal or no attempt Inadequate immobilisation
• Fracture shafts of long bones
at callus formation. • Fracture neck of femur
Distraction during treatment
(a) (b) • Fracture shaft of femur
Fig-7.3 Types of non-union. (a) Atrophic (b) Hypertrophic
• Hypertrophic, where though the callus is
present, it does not bridge the fracture site.

Common sites: Sites where non-union occurs
commonly are neck of the femur, scaphoid, lower
third of the tibia, lower third of the ulna and lateral
condyle of the humerus.

Consequences: Delayed and non-union can
re s u l t i n p e r s i s t e n t p a i n , d e f o r m i t y, o r
abnormal mobility at the fracture site. A
fracture in delayed union, if stressed, can lead to
refracture.

Diagnosis: Delayed union is a diagnosis in
relation to time. The fracture may not show
any abnormal signs clinically, but X-rays may fail
to show bony union. The following are some of
the clinical findings which suggest delayed union
and non-union:

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Complications of Fractures | 49

• Persistent pain excised for non-union of the fracture of the
• Pain on stressing the fracture distal-end of the ulna without much loss. In
• Mobility (in non-union) non-union of fracture of the neck of femur in an
• Increasing deformity at the fracture site (in non- elderly, the head of the femur can be replaced
by a prosthesis (replacement arthroplasty).
union).
• No treatment: Some non-unions do not give
The following are some of the radiological features rise to any symptoms, and hence require no
suggestive of these complications: treatment, e.g., some non-unions of the fracture
scaphoid.
• Delayed union: The fracture line is visible. There
may be inadequate callus bridging the fracture • Ilizarov’s method: Prof. Ilizarov from the former
site. USSR designed a special external fixation
apparatus for treating non-union (see page 33).
• Non-union: The fracture line is visible. There is
little bridging callus. The fracture ends may be MALUNION
rounded, smooth and sclerotic. The medullary
cavity may be obliterated. When a fracture does not unite in proper
position, it is said to have malunited. A slight
It is sometimes very difficult to be sure about degree of malunion occurs in a large proportion
union of a fracture where internal fixation has of fractures, but in practice the term is reserved
been used. Evaluation of serial X-rays may help for cases where the resulting disability is of
detect subtle angulation, non-progress of bridging clinical significance.
callus, resorption of callus, loosening of screws and
bending of the nail or plate. Excessive rotation may  Causes: Improper treatment is the commonest
be the only abnormal mobility in a case with intra-
medullary rod in situ. Oblique views, done under cause. Malunion is therefore preventable in most
fluoroscopy may show an unhealed fracture better cases by keeping a close watch on position of the
than conventional AP and lateral X-rays. It may be fracture during treatment. Sometimes, malunion is
possible to demonstrate mobility at the fracture by inevitable because of unchecked muscle pull (e.g.,
stress X-rays or weight bearing X-rays. 3-D CT scan fracture of the clavicle), or excessive comminution
is sometimes helpful in differentiating between (e.g., Colles’ fracture).
delayed and non-union.
Common sites: Fractures at the ends of a bone always
Treatment: Most fractures in delayed union unite, but they often malunite e.g., supracondylar
unite on continuing the conservative treatment. fracture of the humerus, Colles’ fracture etc.
Sometimes, this may not occur and the fracture
may need surgical intervention. Bone grafting Consequences: Malunion results in deformity,
with or without internal fixation may be required. shortening of the limb, and limitation of movements.
Treatment of non-union depends upon the site
of non-union and the disability caused by it. The Treatment: Each case is treated on its merit. A
following possibilities of treatment should be slight degree of malunion may not require any
considered, depending upon the individual cases. treatment, but a malunion producing significant
disability, especially in adults, needs operative
• Open reduction, internal fixation and bone grafting: intervention. The following treatment possibilities
This is the commonest operation performed for can be considered:
non-union. The grafts are taken from iliac crest.
Internal fixation is required in most cases. a) Treatment required: Malunion may require
treatment because of deformity (e.g.,
• Excision of fragments: Sometimes, achieving supracondylar fracture of the humerus),
union is difficult and time consuming compared shortening (e.g., fracture of the shaft of the
to excision of one of the fragments. This can only femur) or functional limitations (e.g. limitation
be done where excision of the fragment will not of rotations in malunion of forearm fractures).
cause any loss of functions. An excision may or Some of the methods for treating malunion are
may not need to be combined with replacement as follows:
with an artificial mould (prosthesis). For
example, the lower-end of the ulna can be

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50 | Essential Orthopaedics

• Osteoclasis (refracturing the bone): It is used the two bones unite with each other. For details
for correction of mild to moderate angular please refer to page 110.
deformities in children. Under general an-
aesthesia the fracture is recreated, the angu- SHORTENING
lation corrected, and the limb immob­ ilised
in plaster. Causes: It is a common complication of fractures,
resulting from the following causes:
• Redoing the fracture surgically: This is the
most commonly performed operation for • Malunion: The fracture unites with an overlap
malunion. The fracture site is exposed, or marked angulation e.g., most long bone
the malunion corrected and the fracture fractures.
fixed internally with suitable implants.
Bone grafting is also performed, in addition, • Crushing: Actual bone loss e.g., bone loss in
in most cases e.g., malunion of long gunshot wounds.
bones.
• Growth defect: Injury to the growth plate may re-
• Corrective osteotomy: In some cases, redoing sult in shortening (see Salter-Harris classi­fication
the fracture, as discussed above may not be of epiphyseal injuries, page 58).
desirable due to variety of reasons such as
poor skin condition, poor vascularity of bone Treatment: A little shortening in upper limbs goes
in that area etc. In such cases, the deformity unnoticed, hence no treatment is required. For
is corrected by osteotomy at a site away from shortening in lower limbs, treatment depends upon
the fracture as the healing may be quicker at the amount of shortening.
this new site, e.g. supra-malleolar corrective
osteotomy for malunion of distal-third tibial • Shortening less than 2 cm is not much noticeable,
fractures. hence can be compensated by a shoe raise.

• Excision of the protruding bone: In a fracture • Shortening more than 2 cm is noticeable. In elderly
of the clavicle, a bone spike protruding patients, it may be compensated for by raising
under the skin may be shaved off. Same may the shoe on the affected side. In younger patients,
be required in a spikey malunion of fracture correction of angulation or overlap by operative
of the shaft of the tibia. method is necessary. Limb length equalisation
procedure is required to correct shortening in an
b) No treatment: Sometimes malunion may not old, healed, remodelled fracture.
need any treatment, either because it does not
cause any disability, or because it is expected AVASCULAR NECROSIS
to correct by remodelling. Remodelling of a
fracture depends on the following factors. Blood supply of some bones is such that the
vascularity of a part of it is seriously jeopardized
• Age: Remodelling is better in children. following fracture, resulting in necrosis of that part.

• Type of deformity: Sideways shifts are well Common sites: Some of the sites where avascular
corrected by remodelling. Five to ten degrees necrosis commonly occurs are given in Table–7.5.
of angulation may also get corrected, but
mal-rotation does not get corrected. Consequences: Avascular necrosis causes
deformation of the bone. This leads to secondary
• Angulation in the plane of movement of the
adjacent joint is remodelled better than that Table–7.5: Common sites of avascular necrosis
in other planes e.g., posterior angulation in
a fracture of the tibial shaft remodels better. Site Cause

• Location of fracture: Fractures near joints • Head of the femur Fracture neck of the femur.
remodel better. Posterior dislocation of the hip
• Proximal pole of Fracture through the waist
Cross union is a special type of malunion which scaphoid of the scaphoid
occurs in fractures of the forearm bones, wherein • Body of the talus Fracture through neck of the talus

osteoarthritis a few years later, thus causing painful
limitation of joint movement.

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Complications of Fractures | 51

Diagnosis: Avascular necrosis should always • Excision of the avascular segment of bone where
be suspected in fracture where it is known to doing so does not hamper functions e.g. fracture
occur. Pain and stiffness appear rather late. of the scaphoid.
Radiological changes as given below appear
earlier (Fig-7.4). • Excision followed by replacement e.g., in fracture
of the neck of the femur, the avascular head can
• Sclerosis of necrotic area: The avascular bone is be replaced by a prosthesis.
unable to share disuse osteoporosis as occurs in
the surrounding normal bones. Hence, it stands • Total joint replacement or arthrodesis may be
out densely on the X-ray. required once the patient is disabled because of
pain from osteoarthritis secondary to avascular
• Deformity of the bone occurs because of the necrosis.
collapse of necrotic bone.
STIFFNESS OF JOINTS
Fig-7.4 Avascular necrosis of the femoral head after a
neck fracture fixed with screws It is a common complication of fracture treatment.
Shoulder, elbow and knee joints are particularly
• Osteoarthritis supervenes giving rise to prone to stiffness following fractures.
diminished joint space, osteophytes (lipping of Causes: The following are some of the causes of
bone from margins) etc. joint stiffness:
It is possible to diagnose avascular necrosis
on bone scan before changes appear on plain • Intra-articular and peri-articular adhesions
X-rays. It is visible as ‘cold area’ on the bone scan. secondary to immobilisation, mostly in intra-
Treatment: Avascular necrosis may be prevented articular fractures.
by early, energetic reduction of susceptible
fractures and dislocations. Once it has occurred, • Contracture of the muscles around a joint
the following treatment options remain: because of prolonged immobilisation.

• Delay weight bearing on the necrotic bone until it • Tethering of muscle at the fracture site (e.g.
is revascularised, thereby preventing its collapse. quadriceps adhesion to a fracture of femoral
It takes anywhere from 6-8 months for the bone shaft).
to revascularise.
• Myositis ossificans (refer page 52).
• Revascularisation procedure by using vascularised
bone grafts (e.g. vascularised bone pedicle graft Consequences: Stiff joints hamper normal physical
from greater trochanter in an avascular femoral activity of the patient.
head in fracture of the neck of the femur). Treatment: The treatment is heat therapy (hot
fomentation, wax bath, diathermy etc.) and
exercises. Sometimes, there may be a need for
manipulating the joint under general anaesthesia.
Surgical intervention is required in the following
circumstances:

• To excise intra-articular adhesions, preferably
arthroscopically.

• To excise an extra-articular bone block which
may be acting as a 'door stopper'.

• To lengthen contracted muscles.
• Joint replacement, if there is pain due to

secondary osteoarthritis

REFLEX SYMPATHETIC DYSTROPHY
(SUDECK’S DYSTROPHY)

This is a term given to a group of vague painful
conditions observed as a sequelae of trauma. The
trauma is sometimes relatively minor, and hence
symptoms and signs are out of proportion to the
trauma.

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52 | Essential Orthopaedics

Consequences: Clinical features consist of pain, Fig-7.5 X-ray of the elbow showing myositis ossificans
hyperaesthesia, tenderness and swelling. Skin
becomes red, shiny and warm in early stage. extreme cases, the bone bridges the joint resulting
Progressive atrophy of the skin, muscles and nails in complete loss of movements (extra-articular
occur in the later stage. Joint deformities and ankylosis).
stiffness ensues. X-ray shows characteristic spotty Radiologically, an active myositis and a mature
rarefaction. myositis have been identified. In the former, the
Treatment: It is a difficult condition to explain to margins of the bone mass are fluffy (Fig-7.5); in
the patient, and also the treatment is prolonged. the latter the bone appears trabeculated with well-
Physiotherapy constitutes the principle modality defined margins.
of treatment. Further trauma in the form of an Treatment: Massage following injury is strictly
operation or forceful mobilisation is detrimental. prohibited. In the early active stage of myositis
In some cases, beta blockers have been shown the limb should be rested, and NSAID is given. In
to produce good response. In resistant cases, late stages, it is possible to regain movement by
sympathetic blocks may aid in recovery. Prolonged physiotherapy. In some cases, once the myositic
physiotherapy and patience on the part of the mass matures, surgical excision of the bone mass
doctor and the patient is usually rewarding. may help regain movement.

MYOSITIS OSSIFICANS (POST-TRAUMATIC Further Reading
OSSIFICATION) • Wilson JN (Ed.): Watson Jone's Fractures and Joint Injuries,

This is ossification of the haematoma around a 6th edn. Edinburgh: Churchill Livingstone, 1982.
joint, resulting in the formation of a mass of bone • Gustilo RB, Merkow RL, Templeman D: The Management of
restricting joint movements, often completely.
Causes: It occurs in cases with severe injury Open Fractures. J.B.J.S. (A) 1990; 72: 299.
to a joint, especially when the capsule and the • Charnley J: The Closed Treatment of Common Fractures. E&S
periosteum have been stripped from the bones
by violent displacement of the fragments. It Livingstone Ltd. 1968.
is common in children because in them the
periosteum is loosely attached to the bones. It
is particularly common around the elbow joint.
There is also a relatively high incidence in patients
with prolonged or permanent neuronal damage
from head injury, and in patient with paraplegia.
Massage following trauma is a factor known to
aggravate myositis.
Consequences: The bone formation leads to
stiffness of the joint, either due to thickening of the
capsule or due to the bone blocking movement. In

  What have we learnt?
• A neurovascular examination of the limb distal to the fracture is a must in every patient

with fracture. It is a disasterous complication, if not attended to in time.
• Not all delayed union, non-union and malunion need surgical treatment. Some are quite

compatible with normal functions. Treatment has to be tailored to patient's need.
• Active joint mobilisation is necessary to prevent joint stiffness.
• No massage after a fracture or joint injury. It can lead to myositis ossificans.

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Complications of Fractures | 53

Additional information: From the entrance exams point of view

• Basic pathology in myositis ossificans lies in the muscle fibres.
• Most common location for mysositis ossificans is elbow, next common is hip.
• In myositis ossificans mature bone is seen in the periphery and immature bone in the centre.
• Myositis ossificans progressiva (fibrodysplasia): The life expectancy decreases and the most

common cause of death is lung disease. It affects children before the age of 6 and involoves
deformities of spine, hands and feet.
• Bone scan (Tc99 three phase scan) is the most sensitive for early detection of heterotropic
ossification.
• Alkaline phosphatase and 24 hrs PGE2 urinary excretion are screening tests for heterotropic
ossification.

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8C H A P T E R

Injury to Joints: Dislocation
and Subluxation

TOPICS • Diagnosis
• Complications
• Relevant anatomy • Treatment
• Definitions
• Classification

• Pathoanatomy

RELEVANT ANATOMY DEFINITIONS

It is important to first understand the factors Dislocation: A joint is dislocated when its articular
responsible for the stability of a joint in order surfaces are completely displaced, one from the other,
to understand why a particular joint dislocates so that all contact between them is lost (see Fig-1.4,
more often than another. Normally, a joint is held page 5).
in position because of the inherent stability in its Subluxation: A joint is subluxated when its articular
design, by the ligaments, and by the surrounding surfaces are only partly displaced and retain some
muscles, as discussed below: contact between them.

The shape of a joint: The shape of the articulating CLASSIFICATION
surfaces in themselves may provide great security
against displacement, e.g., the hip joint with its deep Dislocations and subluxations may be classified on
socket (the acetabulum) and an almost spherical the basis of aetiology into congenital or acquired.
ball (the femoral head) is a good design from the Congenital dislocation is a condition where a joint
stability viewpoint. On the other hand, the shoulder is dislocated at birth e.g., congenital dislocation of
joint with its shallow socket (the glenoid) and a the hip (CDH). Acquired dislocation may occur
large ball (the humeral head) is a poor design and at any age. It may be traumatic or pathological as
therefore dislocates more easily than the hip joint. discussed below.

The ligaments: These prevent any abnormal Table–8.1: Common dislocations at different joints
mobility of a joint and are called static stabilisers.
The role of the ligaments in providing stability to • Spine Cervical spine
a joint is variable. In some joints (e.g., the knee and (anterior C5 over C6)
finger joints), ligaments form the main stabilising • Hip
structures, whereas in others (e.g., the hip or Posterior, anterior
shoulder) they do not play an important role. • Shoulder
Anterior (commonest overall),
The muscles: A strong muscle cover around a • Elbow posterior
joint gives it stability. Muscles may also provide • Wrist Posterior, postero-lateral
a supporting function to the ligaments by reflexly • MP joint Lunate, perilunate
contracting to protect the ligaments, when the latter • Knee Dorsal (index finger)
come under harmful stresses. These are, therefore, • Patella Posterior
called the dynamic stabilisers of a joint. • Ankle Lateral
• Foot Antero-lateral

  Inter-tarsal Chopart's dislocation
  Tarso-metatarsal Lisfranc's dislocation

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Injury to Joints: Dislocation and Subluxation | 55

Fig-8.1 Pathoanatomy of dislocations PATHOANATOMY

Traumatic dislocation: Injury is by far the Dislocation cannot occur without damage to the
protective ligaments or joint capsule. Usually
­commonest cause of dislocations and sub-luxations the capsule and one or more of the reinforcing
ligaments are torn, permitting the articular end of
at almost all joints (Table–8.1). The force required to the bone to escape through the rent. Sometimes,
dislocate a particular joint varies from joint to joint. the capsule is not torn in its substance but is
The following are the different types of traumatic stripped from one of its bony attachments
dislocations seen in clinical practice: (Fig-8.1). Rarely, a ligament may withstand the force
of the injury so that instead of ligament rupture, a
a) Acute traumatic dislocation: This is an episode fragment of bone at one of its attachments may be
of dislocation where the force of injury is chipped off (avulsed).
the main contributing factor e.g., shoulder At the time of dislocation, as movement occurs
dislocation. between the two articulating surfaces, a piece of
articular cartilage with or without its underlying
b) Old unreduced dislocation: A traumatic dislo- bone may be ‘shaved off’ producing an osteochondral
cation, not reduced, may present as an old fragment within the joint. This fragment may lie
unreduced dislocation e.g., old posterior dislo- loose inside the joint and may cause symptoms
cation of the hip. long after the dislocation is reduced (Fig-8.2).

c) Recurrent dislocation: In some joints, proper Fig-8.2 X-ray showing osteochondral fragment
healing does not occur after the first dislocation.
This results in weakness of the supporting DIAGNOSIS
structures of the joint so that the joint dislocates
repeatedly, often with trivial trauma. Recurrent Clinical examination: In most cases of dislocation,
dislocation of the shoulder and patella are the clinical features are sufficiently striking
common.
­and make the diagnosis easy. Never-theless, a
d) Fracture-dislocation: When a dislocation is
associated with a fracture of one or both of dislocation or subluxation is sometimes overlooked,
the articulating bones, it is called fracture- especially in a multiple injury case, an unconscious
dislocation. A dislocation of the hip is often patient or in a case where the bony landmarks
associated with a fracture of the lip of the
acetabulum. are obscured by severe swelling or obesity. Some
Pathological dislocation: The articulating
surfaces forming a joint may be destroyed by an dislocations, which are particularly notorious for
infective or a neoplastic process, or the ligaments getting overlooked are: (i) posterior dislocation
may be damaged due to some disease. This results of the shoulder especially in an epileptic; and (ii)
in dislocation or subluxation of the joint without dislocation of the hip associated with a fracture of
any trauma e.g., dislocation of the hip in septic the shaft of the femur on the same side. The classic
arthritis. deformity of a hip dislocation does not occur, and
the attention is drawn on the more obvious injury
– the femoral shaft fracture. Some of the salient
clinical features of dislocation are as follows:

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Table–8.2: Typical deformities in dislocations vascular bundle of the limb. Early complications
are: (i) recurrence; (ii) myositis ossificans; (iii)
Joint (dislocation) Deformity
persistent instability; and (iv) joint stiffness. Late
• Shoulder (anterior) Abduction
• Elbow (posterior) Flexion complications are: (i) recurrence; (ii) osteoarthritis;
• Hip and (iii) avascular necrosis.
Posterior Flexion, adduction,
internal rotation TREATMENT
Anterior Abduction, external rotation
Flexion, external rotation Treatment of a dislocation or subluxation depends
• Knee Varus upon its type, as discussed below:
• Ankle Acute traumatic dislocation: In acute traumatic
dislocation, an urgent reduction of the dislocation
• Pain: Dislocations are very painful. is of paramount importance. Often it is possible
• Deformity: In most dislocations the limb attains to do so by conservative methods, although
sometimes operative reduction may be required.
a classic attitude (Table–8.2).
• Swelling: It is obvious in the dislocation of a a) Conservative methods: A dislocation may be
reduced by closed manipulative manoeuvres.
superficial joint, but may not be so in a joint Reduction of a dislocated joint is one of the most
located deep. gratifying jobs an orthopaedic surgeon is called
• Loss of movement because of severe pain and upon to do, as it produces instant pain relief to
muscle spasm and loss of articulation. the patient. Prolonged traction may be required
for reducing some dislocations.
­• Shortening of the limb occurs in most dislocations
except in anterior dislocation of the hip where b) Operative methods: Operative reduction may be
lengthening occurs. required in some cases. Following are some of
• Telescopy: In this test, it is possible to produce an the indications:
• Failure of closed reduction, often because
abnormal to and fro movement in a dislocated the dislocation is detected late.
joint (see Annexure-III). • Fracture-dislocation: (i) if the fracture has
As with all limbs injuries, specific tests to establish produced significant incongruity of the joint
the integrity or otherwise of major nerves and surfaces; (ii) a loose piece of bone is lying
vessels of the extremity must be established in all within the joint; and (iii) the dislocation is
cases of dislocation. difficult to maintain by closed treatment.
Radiological examination: In doubtful cases, the Old unreduced dislocations: This often needs
diagnosis must finally depend on adequate X-ray operative reduction. In some cases, if the function
examination. The following principles should be of the dislocated joint is good, nothing needs to be
remembered: done. These are discussed in the respective chapters.
• X-ray should always be taken in two planes at Recurrent dislocations; An individual episode is
right angles to each other, because a dislocation treated like a traumatic dislocation. For prevention
may not be apparent on a single projection.
• If in doubt, X-rays of the opposite limb may be ­of recurrences, reconstructive proce-dures are
taken for comparison. CT scan may also be of help.
• An associated fracture or an osteochondral required. These are discussed in the respective
fragment must always be looked for. chapters.

COMPLICATIONS Further Reading
• Wilson JN (Ed.): Watson-Jone's Fractures and Joint Injuries,
As with a fracture, complications following
a dislocation can be immediate, early or late. 6th edn. Edinburgh: Churchill Livingstone, 1982.
Immediate complication is an injury to the neuro- • Gustilo RB, Kyle RF, Templeman D: Fractures and

Dislocations, St. Louis: Mosby-Year Book. Inc., 1992.

  What have we learnt?

• Dislocation means complete loss of contact between articulating bones.
• Treatment of acute dislocation is an emergency.
• Shoulder is the joint to dislocate most often.

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9C H A P T E R

Fractures in Children

TOPICS

• Relevant anatomy
• Types of fractures
• Diagnosis
• Treatment
• Complications

RELEVANT ANATOMY Table–9.1: Fractures* common in children

Fractures in children are different from those in  • Forearm bones fractures
adults, mostly because of some anatomical and  • Supracondylar fracture of the humerus
physiological differences between a child's and an  • Fracture of lateral condyle of the humerus
adult's bone. Some of these are discussed below:  • Epiphyseal injuries
• Growing skeleton: Bones in children are  • Spiral fracture of tibial shaft
* Dislocations are uncommon in children. Fractures of hands
growing. At each end of major long bones, and
usually at only one end of short bones, there is and feet are also uncommon in children.
a cartilaginous growth plate. This is a potential
weak point giving rise to different types of • Remodelling: Fractures in children have greater
epiphyseal injuries. In some injuries through the remodelling potential; so much so that any
epiphyseal plate, the growth of the limb may be evidence of a past fracture may be absent after
affected. a few months. The remodelling potential varies
• Springy bones: Bones in children are more with the: (i) age of the child; (ii) location of the
resilient and springy, withstanding greater de- fracture; and (iii) degree and type of angulation.

­formation without fracture. This characteristic is TYPES OF FRACTURES

responsible for ‘greenstick’ fractures in children. Fractures in children can be conveniently considered
Such fractures do not occur in adults. under four headings: (i) birth fractures and related
• Loose periosteum: The periosteum is attached injuries; (ii) epiphyseal injuries; (iii) fractures of
loosely to the diaphysis in a child's bones. This shafts of long bones in older children; and (iv)
results in easy stripping of the periosteum pathological fractures.
over a considerable part following fracture.
The haematoma soon gets calcified to become Birth fractures: Three types of fractures may occur
callus, therefore a child's bone unites with a lot in a newborn. These are as follows:
of callus.
• Site of fractures: Some fractures are more a) Fracture or epiphyseal separation sustained
common in children than in adults as given in during a difficult delivery: These are the commonest
Table–9.1. fractures seen at birth. Fracture of the shaft of
• Healing of fractures: Fractures unite quickly in the humerus occurs most frequently; others
children, taking almost half the time taken in are fracture of the shaft of the femur, fracture
adults. clavicle etc. Simple strapping of the fracture may
be sufficient. Union occurs rapidly with a lot of

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58 | Essential Orthopaedics

 Fig-9.1 Salter and Harris classification of epiphyseal injuries

callus. Remodelling occurs during the first few the more severe the injury. The incidence of growth
years of life. disturbance is common in types III, IV and V
(Table–9.2).
b) Multiple fractures associated with the congenital
Shaft fractures in older children: Although,
fragility of bones e.g., osteogenesis imperfecta fractures of the shaft of long bones have many
(see page 316). similarities in children and adults, the following are
some of the features peculiar to children:
c) Pseudoarthrosis of tibia: This is a pathological
a) Displacement is less: Fractures of the shaft of long
entity, very different from a simple fracture or bones in children often do not displace much. A
birth injury mentioned above. In this type, there special type called ‘greenstick fracture’ occurs
is an inherent indolence of the fracture to unite. only in children. In this type, the bones being
resilient, do not break completely. The inner
Epiphyseal injuries: This is a group of injuries cortex bends, while the outer cortex breaks
seen in a growing skeleton. An injury involving (Fig-9.2). Such fractures occur commonly in the
the growth plate may result in deformities due to shafts of forearm bones.
irregular growth. Shortening may occur because of
premature epiphyseal closure. b) Alignment: Perfect, end-to-end alignment is not
mandatory. Some amount of ‘mal-alignment’ is
Salter and Harris classification (Fig-9.1): Epiphyseal corrected with growth.
injuries have been classified into 5 types based on
their X-ray appearance. The higher the classification, c) Union: Fractures unite faster in children.

Table–9.2: Essential features of epiphyseal injuries (Salter and Harris classification)

Type Treatment Prognosis
Example

I Radial neck epiphysis separation Closed reduction Good
II Lower end radius epiphysis Closed reduction
III Medial malleolus epiphysis Open reduction Good
IV Lateral condyle of humerus Open reduction Growth disturbance can occur
V Lower tibial epiphysis injury Conservative Growth disturbance common

Growth disturbance always

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Fractures in Children | 59

Fig–9.2 X-ray of the forearm of a child showing a greenstick TREATMENT
fracture. (Note that the outer cortex breaks, and the inner
cortex bends) Most fractures in children can be successfully
treated by non-operative methods like plaster
d) Treatment: Fractures in children can usually be immobilisation, traction, sling etc.
treated by conservative methods. An operation
is rarely necessary. Following are some facts about fractures in children
Pathological fractures: These are uncommon in • Fractures in children heal faster.
children. However, there are some diseases which • Fractures close to the joint heal faster.
are particularly common in children and result • Sideways displacement will remodel.
in pathological fractures. These are: (i) fractures • Angulation in the plane of the adjacent joint is
through infected bones; (ii) fractures through cysts;
and (iii) fractures associated with osteogenesis acceptable.
imperfecta. • Rotational malalignment will never remodel.
• Physis subjected to compressive forces inhibits
DIAGNOSIS
growth.
Diagnosis of fractures in children is often missed
for the following reasons: Operative intervention is necessary in some
fractures, as listed below:
a) History of trauma is either concealed, or the • Fracture of the neck of the femur, displaced.
child is not old enough to communicate. • Fracture lateral condyle of the humerus (Type IV

b) The more dramatic signs of fracture may be epiphyseal injury).
absent, especially in incomplete fractures. • Fracture of the shaft of femur, in an adolescent.
Thus, there may be no deformity, no abnormal • Wherever operation is considered necessary for
mobility, no crepitus etc.
some other reason such as vascular injury, the
c) Parents may attempt to conceal the fact that an fracture is also fixed internally.
infant has been injured, especially when there
has been abuse (battered baby syndrome). With the availability of image intensifier and
development of percutaneous methods of fixation,
d) Undisplaced fractures are often missed on operative fixation of unstable fractures in children,
X-ray, unless carefully looked for. using TENS nails or rush nails has become popular.
Therefore, irrespective of the history, possibility of This makes treatment of an unstable fracture more
an injury should always be considered whenever predictable.
marked loss of function, pain and tenderness, and
unwillingness to use a limb occurs in children. On COMPLICATIONS
the other hand, trauma may be falsely implicated
as a cause, in some non-traumatic diseases; the Fractures in children are associated with few
episode of trauma being often days or weeks complications. Union of a fracture is generally
earlier. not a problem; non-union being very rare. Some
complications relatively important in children's
fractures are:
• Growth disturbances in epiphyseal injuries.
• Brachial artery injury in supracondylar fracture

of the humerus.
• Myositis ossificans in injuries around the elbow.
• Avascular necrosis in fracture of the neck of the

femur.

Further Reading
• Staheli LT: Fundamentals of Paediatric Orthopaedics. Raven

Press: New York, 1992
• Wober BG, Brunner C, Freular F (Eds.): Treatment of

Fractures in Children and Adolescents. Springer – Verlag:
Berlin, 1980.

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60 | Essential Orthopaedics

  What have we learnt?

• Fractures in children are easier to treat.
• A special category, i.e. epiphyseal injuries, occur in children, and can lead to growth

disturbances.
• History of injury has to be carefully probed, as often non-traumatic problems such as infection

or tumour, may be erroneously linked to an unrelated episode of 'injury'.

Additional information: From the entrance exams point of view

• Distal radius and ulna are the most common fracture locations in children followed by the
clavicle.

• Most common bone fractured during birth is the clavicle.
• Injury to the perichondrial ring is type VI Salter Harris fracture or Rang’s injury.
• Multiple fractures at various stages of healing in a child, always consider battered baby

syndrome.
• Epiphyseal enlargement seen in haemophilia.
• Epiphyseal dysgnesis seen in Hypothyroidism.

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10C H A P T E R

Peripheral Nerve Injuries

TOPICS • Diagnosis
• Electrodiagnostic studies
• Relevant anatomy • Treatment
• Pathology • Prognosis
• Mechanism of injury
• Classification

RELEVANT ANATOMY Fig-10.2 Sensory innervation of the hand. The picture in
the box shows autonomous sensory zones in the hand
Structure of a peripheral nerve: A peripheral
nerve consists of masses of axis cylinders supply to the limbs. The anatomy of individual
(axons), each with a neurilemmal tube (Fig-10.1). nerves will be discussed in respective sections.
An individual nerve fibre is enclosed in a
collagen connective tissue known as endoneurium. Motor innervation of limb muscles: A knowledge
A bundle of such nerve fibres are further bound of motor innervation of different muscles in the
together by fibrous tissue to form a fasciculus. The limb is essential for diagnosis of a nerve injury.
binding fibrous tissue is known as perineurium. A The following knowledge of anatomy is often
number of fasciculi are bound together by a fibrous required when dealing with a case of nerve injury,
tissue sheath known as epineurium. An individual and is discussed subsequently in the sections on
nerve, therefore, is a bundle of a number of fasciculi. individual nerve injuries:
Formation of a peripheral nerve: These are
formed from nerves arising from the spinal cord a) What is the nerve supply of a particular
(spinal nerves). There are 31 pairs of spinal nerves muscle?
in the body, each representing a segment of the
spinal cord. These, either through direct branching
or through a network of nerves (plexus), give rise
to peripheral nerves. Peripheral nerves are mixed
nerves carrying motor, sensory and autonomous

Fig-10.1 Structure of a nerve

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62 | Essential Orthopaedics PATHOLOGY

b) What are the different muscles supplied by a Nerve degeneration: The part of the neurone
nerve? distal to the point of injury undergoes secondary
or Wallerian degeneration; the proximal part
c) What is the action of a muscle and by what undergoes primary or retrograde degeneration
manoeuvre can one appreciate its action in upto a single node.
 isolation ? Only such muscles, whose action can Nerve regeneration: As regeneration begins, the
be elicited in isolation are suitable for testing. axonal stump from the proximal segment begins
to grow distally. If the endoneural tube with its
Sensory innervation of limbs: The area of contained Schwann cells is intact, the axonal sprout
hypoaesthesia resulting from a nerve injury may may readily pass along its primary course and
be less than the area of skin innervated by that reinnervate the end-organ. The rate of recovery of
nerve because of the overlap of sensory supply by axon is 1 mm per day. The muscle nearest to the site
different nerves. A relatively small area supplied of injury recovers first, followed by others as the
exclusively by a single nerve, called autonomous nerve reinnervates muscles from proximal to distal,
zone, is found in all nerve injuries (Fig-10.2). The the so-called motor march. If the endoneural tube is
sensory innervation by different nerves of the limbs interrupted, the sprouts, as many as 100 from one
is discussed in the section on individual nerve axonal stump, may migrate aimlessly throughout
injuries. the damaged area into the epineural, perineural or
adjacent tissues to form an end-neuroma or a neuroma
Anatomical features relevant to nerve injuries: in continuity (Fig-10.3). An end-neuroma may form
There are some features related to the anatomy of when the proximal-end is widely separated from
a nerve which make a particular nerve more prone the distal-end. A side neuroma usually indicates a
to injury. These are as follows: partial nerve cut.

a) Relation to the surface: Superficially placed nerves Fig-10.3 Types of neuromas
are more prone to injury by external objects e.g.,
the median nerve at the wrist often gets cut by MECHANISM OF INJURY
a piece of glass.
Fractures and dislocations are the commonest cause
b) Relation to bone: Nerves in close proximity to
a bone or a joint are more prone to injury e.g. ­of peripheral nerve injuries. Some other mecha-
radial nerve injury in a fracture of the shaft of
the humerus. nisms by which a nerve may be damaged are:
(i) direct injury – cut, laceration; (ii) infections –
c) Relation to fibrous septae: Some nerves pierce leprosy; (iii) mechanical injury – compression,
fibrous septae along their course. They may traction, friction and shock wave; (iv) cooling
get entrapped in these septae (entrapment and freezing – ‘frost bite’ etc.; (v) thermal injury;
neuropathies). (vi) electrical injury – electric shock; (vii) ischaemic
injury–Volkmann's ischaemia; (viii) toxic agents –
d) Relation to major vessels: Nerves in close relation injection tetracycline resulting in radial nerve palsy;
to a major vessel run the risk of ligation during and (ix) radiation – for cancer treatment.
surgery, or damage by an aneurysm.

e) Course in a confined space: A nerve may
travel in a confined fibro-osseous tunnel
and get compressed if there is a compromise
of the space, e.g., median nerve compression in
carpal tunnel syndrome.

f) Fixation at points along the course: Nerves are
relatively fixed at some points along their
course and do not tolerate the stretch they may
be subjected to, e.g., the common peroneal
nerve is relatively fixed over the neck of
the fibula, and any stretching of the sciatic
nerve often leads to isolated damage to this
component of the nerve.

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Peripheral Nerve Injuries | 63

Table–10.1: Seddon's classification of nerve injuries

Type of injury Pathology Degeneration Neuroma Prognosis
Recovery complete
Neurapraxia within 6 weeks
Physiological Nil Nil
interruption, Recovery +/-,
anatomically Neuroma Motor march +
normal in continuity Recovery poor
Axonotmesis Axons broken,
nerve intact
Proximally + distally

Neurotmesis Axons as well End or side
as nerve broken
Proximally + distally neuroma

CLASSIFICATION In case the cause is obvious, say a penetrating wound
along the course of a peripheral nerve (e.g., glass
Seddon's classification: Seddon classifies cut injury to the median nerve), the nerve affected
nerve injuries into three types: (i) neurapraxia; and its level is easy to decide. Similarly, nerve in-
(ii) axonotmesis; and (iii) neurotmesis. jury may occur during an operation as a result of
stretching or direct injury.
• Neurapraxia: It is a physiological disruption of When the cause is not obvious, an inquiry must be
conduction in the nerve fibre. No structural made regarding any history of injection in the
changes occur. Recovery occurs spontaneously proximity of the nerve. Neurotoxic drugs such
within a few weeks, and is complete. as quinine and tetracycline are known to damage
nerves. Medical causes of nerve affection like
• Axonotmesis: The axons are damaged but the leprosy, diabetes should be considered in patients
internal architecture of the nerve is preserved. who do not give a history of injury.
Wallerian degeneration occurs. Recovery may Examination: Often, the clinical findings in a
occur spontaneously but may take many months. case of nerve palsy are very few. Therefore, it is
Complete recovery may not occur. essential to perform a systematic motor and
sensory examination of the involved limb. Classic
• Neurotmesis: The structure of a nerve is damaged deformities may not be present in an early case or
by actual cutting or scarring of a segment. in a case with partial nerve injury. A combination of
Wallerian degeneration occurs. Spontaneous nerve injuries and anatomical variation in the nerve
recovery is not possible, and nerve repair is supply may distort the clinical picture of a classic
required. nerve lesion. The following observations must be
made during examination:
Most nerve injuries are a combination of these.
WHICH NERVE IS AFFECTED?
­Table–10.1 compares the essential features of the Attitude and deformity: Patients with some
peripheral nerve injuries present with a classic
three types of nerve injuries. attitude and deformity of the limb. Some such
attitudes in different nerve injuries are as follows:
DIAGNOSIS
• Wrist drop: The wrist remains in palmar flexion
In a case of peripheral nerve injury, the following due to weakness of the dorsiflexors. It is seen in
information should be obtained by careful history radial nerve palsy.
and examination:
• Foot drop: The foot remains in plantar flexion
a) Which nerve is affected? due to weakness of the dorsiflexors. It occurs in
b) At what level is the nerve affected? common peroneal nerve palsy.
c) What is the cause?
d) What type of nerve injury (neurapraxia etc.) is • Winging of scapula: The vertebral border of the
scapula becomes prominent when the patient
it likely to be? tries to push against a wall. It occurs in paralysis
of the serratus anterior muscle in long thoracic
e) In case of an old injury, is the nerve recovering? nerve palsy.

History: A patient with a nerve injury commonly
presents with complaints of inability to move a part
of the limb, weakness and numbness. The cause of
nerve injury may or may not be obvious.

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64 | Essential Orthopaedics Wasting of muscles: This will be obvious some time
after the paralysis. It may be slight and become
• Claw hand (Main-en-griffe): Claw hand means apparent only on comparing the affected limb with
hyperextension at the metacarpo-phalangeal the sound limb. Some examples of this are given in
joints and flexion at the proximal and distal Table–10.2.
inter-phalangeal joints (Fig-10.4). This occurs
due to paralysis of the lumbricals, which flex Table–10.2: Muscle wasting in nerve injuries
the metacarpo-phalangeal joints and extend the
inter-phalangeal joints. Paradoxically, clawing Muscle wasting Nerve
is more marked in low ulnar nerve palsy than
in high ulnar nerve palsy. This is because in the • Flat shoulder Axillary nerve
latter, flexors of the fingers (both profundus and (Deltoid M.) Median nerve
superficialis), which cause clawing affect are also • Thenar eminence Ulnar nerve
paralysed. In ulnar nerve palsy, only the medial (Thenar M.) Ulnar nerve
two fingers develop clawing while all the four • Hypothenar eminence
fingers develop clawing in combined median and (Hypothenar M.) Femoral nerve
ulnar nerve palsies. Clawing may not become • Hollowing between Sciatic nerve
apparent in the early post-injury period. metacarpals
(Interossei M.)
• Thigh wasting
(Quadriceps M.)
• Calf wasting
(Gastrosoleus M.)

Fig-10.4 Claw hand (hyperextension at the MP joint) Skin: The skin becomes dry (there is no sweating
due to the involvement of the sympathetic nerves),
• ‘Ape thumb’ deformity: In this deformity the thumb glossy and smooth. In partial lesions, there may be
is in the same plane as the wrist. It occurs due vasomotor changes in the form of pallor, cyanosis,
to paralysis of the opponens pollicis muscle in or excessive sweating. There may be trophic
median nerve palsy. disturbances such as ridged and brittle nails, shiny
atrophic skin, trophic ulcers etc.
• ‘Pointing index’: On asking the patient to make Temperature: A paralysed part is usually colder and
a fist, it is noticed that the index finger remains drier because of loss of sweating, best appreciated
straight. This is due to paralysis of both the by comparing it with normal skin.
flexors (digitorum superficialis and lateral half Sensory examination: The different forms of
of the digitorum profundus) of the index finger, sensation to be tested in a suspected case of
which occurs in median nerve palsy at a level nerve palsy are touch, pain, temperature and
proximal to the elbow. The other fingers can be vibration. The area of sensory loss may be smaller
flexed by the functioning medial side of the flexor than expected. If it is so, look for sensation in the
digitorum profundus, supplied by the ulnar autonomous zone (Fig-10.2, page 61).
nerve. Reflexes: Reflexes in the area of nerve distribution
are absent in cases of peripheral nerve injuries.
• ‘Policeman tip' deformity: In this deformity, the Sweat test: This is a test to detect sympathetic
arm hangs by the side of the body with elbow function in the skin supplied by a nerve. Sympathetic
extended and forearm fully pronated. This is fibres are among the most resistant to mechanical
because of the paralysis of the abductor and trauma. The presence of sweating within an
external rotators of the shoulder alongwith autonomous zone of an injured peripheral nerve
flexors and supinators of the elbow. reassures the examiner that complete interruption
of the nerve has not occurred. Sweating can be
determined by the starch test or ninhydrin print
test. In these tests, the extremity is dusted with an

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Peripheral Nerve Injuries | 65

agent that changes colour on coming in contact Branches of the radial nerve are as given in
with sweat. Table–10.3.

Motor examination: For evaluation of motor Table–10.3: Major motor branches of radial nerve
functions, clear concepts about the anatomy, as to
which nerve supplies which muscle is essential. • Before the radial Long and medial heads
The muscles which are exclusively supplied by groove of triceps
a particular nerve are most suitable for motor Lateral head of triceps,
examination. The tests are nothing but manoeuvres • After the radial groove,
to make a muscle contract. One must carefully watch anconeus, brachioradialis,
for trick movements—the movement produced by before crossing extensor carpi
the adjacent muscles, often substituting for the the elbow
paralysed muscle. The contraction of the muscle radialis longus
must be appreciated, wherever possible, by • After crossing the Extensor carpi radialis brevis,
feeling its belly or its tendon getting taut. Motor the supinator
examination conducted for different nerves is elbow, before piercing
discussed below. the supinator Other extensor muscles
• After piercing the of the forearm and hand
RADIAL NERVE
supinator
Anatomy: This nerve is a continuation of the
posterior cord of the brachial plexus. In the axilla, Tests: Various muscles supplied by the radial nerve
it gives off a branch to the long head of triceps, and will be affected according to the level of radial nerve
enters the arm. injury i.e. high or low.

Course in the arm: As it comes into the arm, the a) High radial nerve palsy: This occurs if the nerve
radial nerve gives off the posterior cutaneous is injured in the radial groove. In this type, all
nerve of the arm and a branch to the medial head the muscles supplied by radial nerve except
of the triceps. It now travels infero-laterally into the triceps and anconeus are paralysed.
the groove for the radial nerve on the posterior Occasionally, the radial nerve may be injured
surface of the humerus, winding spirally around still higher up, in which case even the triceps
the bone. In the groove, it gives branches to the may be paralysed. This is called very high radial
lateral head of triceps and anconeus muscles, nerve palsy.
and cutaneous branches to the arm and forearm.
After winding around the humerus, the nerve b) Low radial nerve palsy: This occurs if the nerve
pierces the lateral intermuscular septum from is injured around the elbow so that the muscles
behind, at the junction of the middle and lower- supplied by the radial nerve in the distal arm
third of the arm. In the distal-third of the arm it (brachioradialis, extensor carpi radialis longus
comes to lie in the anterior compartment, between and brevis) are spared.
the brachialis muscle on the medial side and
brachioradialis and extensor carpi radialis longus From proximal to distal, the following muscles can
on the lateral side. be examined:

Before it crosses the elbow in front of the lateral • Triceps: The patient is asked to extend his elbow
condyle, it divides into two branches – superficial against resistance applied by the examiner,
and deep. The superficial branch is primarily whose other hand feels for triceps contraction.
sensory and travels along side the radial artery into
the forearm. The deep branch is primarily motor. It • Brachioradialis: The patient is asked to flex the
gives branches to the extensor carpi radialis brevis elbow from 90o onwards, keeping the forearm
and the supinator. It then pierces the supinator midprone. As he does so against resistance, the
and emerges in the posterior compartment of brachioradialis stands out, and can be felt.
the forearm to become the posterior interosseous
nerve, which divides immediately into branches • Wrist extensors: The patient with paralysed wrist
supplying the extensor muscles of the forearm. extensors has ‘wrist drop'. In case the paralysis
is partial, the contraction of the extensor carpi
radialis and extensor carpi ulnaris muscle can
be felt, though actual movement may not occur.

• Extensor digitorum: It causes extension at the
metacarpo-phalangeal joints. The patient cannot
do so if it is paralysed (finger drop). The examiner

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66 | Essential Orthopaedics

should not be misled by the ability of the patient Table–10.4: Major motor branches of the median nerve
to 'extend the fingers' at the inter-phalangeal
joints (function performed by the lumbricals). • In the arm Nil

• Extensor pollicis longus: This causes extension • In the forearm All the flexor muscles of the
at the inter-phalangeal joint of the thumb.   Proximal   1 forearm, except the flexor
It is examined by stabilising the metacarpo-  3 carpi ulnaris and medial-half
phalangeal joint of the thumb, while the patient of the flexor digitorum
is asked to extend the inter-phalangeal joint. profundus
Nil
MEDIAN NERVE   Distal   31 Thenar muscles* (three)
First two lumbricals
Anatomy: This nerve is formed by the joining • In the hand
of branches from the lateral and medial cords
of brachial plexus. In the arm, the median nerve
descends adjacent to the brachial artery. * The three muscles are flexor pollicis brevis, opponens
pollicis and abductor pollicis. Adductor pollicis is not supplied
Course in the forearm: The nerve enters the forearm by median nerve.
between the two heads of the pronator teres. It then
passes deep to the tendinous bridge of the origin of will be paralysed. In addition, there will be
the flexor digitorum superficialis, in the proximal- anaesthesia over the median nerve distribution
third of the forearm. In the mid-forearm it descends in the hand.
between the flexor digitorum superficialis and
flexor digitorum profundus. About 5 cm above the From proximal to distal, the following muscles can
wrist, it comes to lie on the lateral side of the flexor be examined:
digitorum superficialis. It becomes superficial just
above the wrist, where it lies between the tendons • Flexor pollicis longus: The patient is asked to
of the flexor digitorum superficialis and flexor carpi flex the terminal phalanx of the thumb against
radialis. resistance while the proximal phalanx is kept
steady by the examiner.
Course in the hand: The nerve passes deep to the
flexor retinaculum and enters the palm. Here a • Flexor digitorum superficialis and lateral half of flexor
short and stout muscular branch from it supplies digitorum profundus: If the patient is asked to clasp
the muscles of the thenar eminence (abductor his hand, the index finger will remain straight,
pollicis brevis, opponens pollicis and flexor pollicis the so-called 'pointing index'. This occurs because
brevis). The median nerve finally divides into 4 to both the finger flexors, superficialis as well as
5 palmar digital branches supplying the area of the profundus of the index finger are paralysed;
skin shown in Fig-10.2. Also, motor branches are though the available medial-half of the flexor
given to the first and second lumbrical muscles digitorum profundus (supplied by the ulnar
at this level. The nerve supply to various muscles nerve) makes flexion of the other fingers possible.
by the median nerve along its course is given in
Table–10.4. • Flexor carpi radialis: Normally, the palmar
flexion at the wrist occurs in the long axis of
Tests: The various muscles supplied by the median the forearm. In a patient with paralysed flexor
nerve will be affected according to the level of carpi radialis, the wrist deviates to the ulnar
median nerve injury i.e. high or low. side while palmar flexion occurs. In addition,
one cannot feel the tendon of the flexor carpi
a) High median nerve palsy (injury proximal to radialis getting taut.
the elbow): This will cause paralysis of all the
muscles supplied by the median nerve in the • Muscles of the thenar eminence: Out of the three
forearm and hand. In addition, there will be muscles of the thenar eminence, only two can
sensory deficit in the skin of the hand. be examined for their isolated action. These are
as follows: (i) abductor pollicis brevis (Fig-10.5):
b) Low median nerve palsy (injury in the distal-third The action of this muscle is to draw the thumb
of the forearm): There will be sparing of the forwards at right angle to the palm. The patient
forearm muscles, but the muscles of the hand is asked to lay his hand flat on the table with
palm facing the ceiling. A pen is held above the
thumb and the patient is asked to touch the pen
with tip of his thumb. This is called the 'pen
test'; (ii) opponens pollicis: The function of this

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Peripheral Nerve Injuries | 67

muscle is to appose the tip of the thumb to other Table–10.5: Major motor branches of the ulnar nerve
fingers. Apposition is a swinging movement
of the thumb across the palm and not a simple • In the arm Nil
adduction. The latter movement is by the Flexor carpi ulnaris,
adductor pollicis muscle supplied by the ulnar • In the forearm medial half of flexor
nerve.     Proximal 1 digitorum profundus
  Distal 3 Nil
Hypothenar muscles
1 Adductor pollicis,
3 all interossei and
medial two lumbricals
• In the hand

  Superficial branch
  Deep branch

Fig-10.5 The pen test muscles supplied by the ulnar nerve in the
forearm and hand. In addition, there will be a
ULNAR NERVE sensory deficit in the skin of the hand.
Anatomy: This nerve arises from the medial cord
of the brachial plexus. In the arm, it lies on the b) Low ulnar nerve palsy (injury in distal-third
medial side of the axillary artery. At the junction of forearm): There will be sparing of forearm
of the middle and lower-third of the arm, it pierces muscles but the muscles of the hand will be
the medial intermuscular septum and comes to lie paralysed. Sensory deficit will be same as in
in the posterior compartment. It becomes more and high ulnar nerve palsy.
more superficial as it approaches the elbow, where
it lies behind the medial epicondyle. Individual muscles which could be examined in a
Course in the forearm: The ulnar nerve enters the case of ulnar nerve palsy are given below:
forearm between the two heads of the flexor carpi
ulnaris, and descends along the medial side of the • Flexor carpi ulnaris: The patient is asked to
forearm. Here it lies anterior to the flexor digitorum palmar flex the wrist against gravity. In doing
profundus, along with the ulnar vessels. so, the hand deviates towards the radial side.
Course at the wrist: It passes in front of the flexor The tendon of flexor carpi ulnaris just above the
retinaculum just lateral to the pisiform bone. On pisiform, does not stand out. On performing the
entering the palm, the ulnar nerve finally divides same test against resistance, the tendon cannot
into superficial and deep terminal branches be felt.
supplying the hand muscles. The nerve supply to
various muscles by the ulnar nerve along its course • Abductor digiti minimi: The patient is asked to
are given in Table–10.5. abduct the little finger against resistance while
Tests: Various muscles supplied by ulnar nerve will keeping the hand flat on the table (in order to
be affected according to the level of ulnar nerve avoid action of flexors of the finger).
injury i.e., high or low.
• Interossei: Palmar interossei do adduction (PAD),
a) High ulnar nerve palsy (injury proximal to the the dorsal interossei do abduction (DAB) of the
elbow): This will cause paralysis of all the fingers at metacarpo-phalangeal joints. These can
be tested as follows:
Egawa's Test (Fig-10.6a): This is for dorsal
interossei (abductors) of the middle finger.
With the hand kept flat on a table palmar
surface down, the patient is asked to move his
middle finger sideways.

Card Test (Fig-10.6b): This is for palmar
interossei (adductors) of the fingers. In this
test, the examiner inserts a card between two
extended fingers and the patient is asked to
hold it as tightly as possible while the examiner

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68 | Essential Orthopaedics

Fig-10.6 Tests for ulnar nerve

tries to pull the card out. The power of examiner tries to pull the book out while the
adductors can thus be judged. In case of weak patient tries to hold it. This sign is known as
palmar interossei, it is easy to pull out the 'Froment's sign' or the 'book test.'
card. First dorsal interosseous muscle can be
separately examinated by asking the patient ACCESSORY NERVE
to abduct the index finger against resistance
(Fig-10.6c). This supplies the trapezius muscle.
• The lumbricals: These are mainly responsible for
flexion at the metacarpo-phalangeal joints but Test: The trapezius muscle is tested by asking the
their isolated action cannot be tested. patient to elevate his shoulder against resistance.
• Adductor pollicis: The patient is asked to grasp One can see and feel the trapezius belly stand out.
a book between the thumb and index finger. Similarly, the patient is asked to brace his shoulder
Normally, a person will grasp the book firmly backward and depress it to examine middle and
with thumb extended, taking full advantage lower part of the muscle.
of the adductor pollicis and the first dorsal
interosseous muscles. If the ulnar nerve is LONG THORACIC NERVE
injured, the adductor pollicis will be paralysed
and the patient will hold the book by using Anatomy: The nerve arises from the ventral rami
the flexor pollicis longus (supplied by median of C5, C6 and C7. It descends behind the brachial
nerve) in place of the adductor. This produces plexus on the lateral surface of the serratus anterior,
flexion at the inter-phalangeal joint of the thumb. which it supplies.
(Fig-10.7). This becomes more pronounced if the
Test: The serratus anterior muscle can be examined
Fig-10.7 Froment's sign (book test) by asking the patient to push against a wall with
both hands. The medial border of the scapula on
the affected side will become prominent (winging
of scapula, Fig-10.8).

AXILLARY NERVE

Anatomy: The axillary nerve arises from the
posterior cord of the brachial plexus and curves
backwards on the lower border of the subscapularis.
It crosses the quadrangular space and comes to
lie on the medial side of the surgical neck of the
humerus, medial and inferior to the capsule of the
shoulder joint. Here it divides into anterior and
posterior branches. The posterior branch supplies

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Peripheral Nerve Injuries | 69

the teres minor and posterior part of the deltoid and THE CAUSES OF INJURY
terminates as the cutaneous nerve which supplies
the skin over the lower-half of the deltoid. The Once it is decided on clinical examination, which
anterior branch continues horizontally between the nerve is affected and at what level, one must look
deltoid and the surgical neck of the humerus, and for a tell tale signs along the course of the nerve for
supplies the rest of the deltoid. the cause. This may be in the form of an injury such
as displaced bone fragments or a scar to suggest an
Fig-10.8 Winging of the scapula old external injury. The nerve may be thickened (e.g.
leprosy). If no such exteral evidence is present, the
Test: The surgeon stabilises the scapula with one paralysis could be due to some medical cause such
hand while the other hand is kept on the deltoid as neuropathy, myelopathy etc. (Refer to a Textbook
to feel for its contraction. The patient is asked of Medicine).
to abduct his shoulder. Inability to abduct the
shoulder, and the absence of the deltoid becoming THE TYPE OF INJURY
taut indicates deltoid paralysis. Once the cause of nerve injury is established, one
SCIATIC NERVE must make an attempt to evaluate the predo-minant
Anatomy: The sciatic nerve consists of two type of nerve injury (Seddon's classifi-cation).
anatomically distinct components – the tibial and The nature of the causative factor, a period of
common peroneal nerves. The common peroneal observation and electrodiagnostic studies may help
component is more frequently affected than the in deciding this.
tibial. Complete lesion of the sciatic nerve is rare.
Tests: The common peroneal nerve supplies the SIGNS OF REGENERATION
extensors and the evertors of the foot. Paralysis of
these muscles results in foot drop. The patient walks Whenever a case of nerve injury is seen some
with a 'high-step gait', i.e. while walking he has to time after the injury or following a repair, signs
lift the foot high in order to clear the ground. The of regeneration of the nerve should be looked for
plantar flexors of the foot are normal. during examination. These are as follows:
The tibial nerve supplies the plantar flexors of the
foot. One can test for weakness of these muscles by • Tinel's sign: On gently tapping over the nerve
asking the patient to plantar-flex the ankle and toes. along its course, from distal to proximal, a pins
The function of the hamstring group of muscles, and needle sensation is felt in the area of the skin
also supplied by the sciatic nerve, can be tested by supplied by the nerve. A distal progression of the
flexing the knee against resistance. level at which this occurs, suggests regeneration.

• Motor examination: The muscle supplied nearest
to the site of injury is the first to recover, noticed
clinically by the ability of the muscle to contract.
The muscles in the more distal area begin to
contract as they are reinnervated one after
another (motor march). This phenomenon is
absent in neuropraxia where all muscles recover
together.

• Electrodiagnostic test: This can help in predicting
nerve recovery even before it is apparent
clinically.

ELECTRODIAGNOSTIC STUDIES

Electromyography: Electromyography (EMG) is
a graphic recording of the electrical activity of a
muscle at rest and during activity.
Normal muscle: A normal muscle at rest shows
no electrical activity. With voluntary contraction,

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70 | Essential Orthopaedics

action potentials develop in the motor units. In a c) Whether any regeneration occurring: The earliest
weak contraction, these may be recordable as single evidence of reinnervation of a muscle is
motor unit potentials in the vicinity of the recording the appearance of reinnervation potentials
electrode. In a strong contraction, impulses of a on attempted voluntary contraction of the
number of motor units firing simultaneously are muscle. These potentials appear weeks before
superimposed, giving rise to an interference pattern a contraction can be noticed clinically. The
(Fig-10.9) progress of a nerve recovery can thus be
monitored.
Fig-10.9 Electromyography
d) Level of nerve injury: By performing an EMG
Denervated muscle. The denervated muscle has of all the muscle supplied by a nerve, one
spontaneous electrical activity at rest. This is called can decide the level of nerve injury. Muscles
denervation potentials. These potentials represent the supplied distal to the site of nerve injury would
embryonic electrical activity of a muscle, which show changes of denervation.
is normally suppressed by stronger nerve action
potentials. These appear at around 15-20 days after Strength-duration curve: This is a graphic
the muscle denervation. As nerve degeneration representation of the excitability of muscle and
progresses, more and more denervation potentials nerve tissue under test. A small strength of
appear. If these potentials have not appeared by current can excite a normal muscle. This occurs by
the end of the 2nd week after a nerve injury, it is a excitation of the muscle through neuromuscular
good prognostic sign. junction, which needs a weaker current. In a
Electromyography is useful in deciding the following: denervated muscle, the excitation is possible only
a) Whether or not a nerve injury is present: It helps on direct stimulation of the muscle fibres, which
need a higher strength of current.
in differentiating a muscle paralysis because of
nerve injury from that due to other causes such A very low-strength current is given for a duration
as myopathy. of 300 milliseconds and its response noted. The
b) Whether it is a complete or incomplete nerve injury: strength of the current is gradually increased until
If the nerve supply of a muscle is partially cut, a minimal visible contraction of the muscle is
there will be evidence of residual innervation of observed. This minimal current strength, required
the muscles. This may be too small to produce to elicit muscle contraction, is called the Rheobase,
any clinically detectable muscle contraction, but and is measured in milliamperes. The Chronaxie is
can be picked up on the EMG. Also, if a group of the duration of current required to excite a muscle
muscles supplied by a nerve do not show signs with a current-strength of double the rheobase. It is
of denervation, it indicates a preserved nerve measured in milliseconds. These two are the basic
supply to these muscles, hence an incomplete parameters of excitability of a muscle.
nerve injury.
For knowing excitability of a muscle in relation
to current-strength and its duration, the muscle
is stimulated by reducing the duration of the
current from 300 milliseconds, gradually to a 1
millisecond or even lower. A corresponding increase
in strength of the current required is detected. A
graph is plotted between current-duration and
corresponding current-strength. This is called a
strength-duration curve (Fig-10.10).

Interpretation: The pattern of the strength-duration
curve of an innervated muscle is different from that
of a denervated muscle or regenerating muscle, as
discussed below:

• Normal strength-duration curve: A normal muscle
will respond to stimuli varying in duration

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Peripheral Nerve Injuries | 71

a) Whether a nerve injury is present: If a nerve injury
is present there will be no conduction of the
impulse across the suspected level.

b) Whether it is a complete or partial nerve injury:
Absence of any transmitted impulse across
the suspected site is an indicator of a complete
nerve injury.

c) Compressive lesion: The conduction velocity may
simply be delayed in compressive nerve lesions
such as carpal tunnel syndrome, etc.

     Fig-10.10 Strength-duration curve TREATMENT

a) Nerve curve b) Muscle curve c) Partial denervation General consideration: In fresh nerve injuries, the
general condition of the patient must be evaluated
from 300 milliseconds to as low as 3 or even 1 before undertaking a nerve repair. Arterial, bone
millisecond without any increase in the strength of and joint repair takes precedence over nerve repair.
the current. If the duration of current is decreased The treatment of nerve injuries may be conservative
beyond it, a progressive increase in the strength or operative. Though conservative treatment yields
of current is required in order to produce a good results, in selected cases an operation should
contraction. A strength-duration curve plotted not be delayed in the hope of spontaneous recovery.
from such a muscle is termed a nerve curve, because
the muscle contraction is caused by stimulation of CONSERVATIVE TREATMENT
the motor nerve entering the muscle. This alone or in addition to operative treatment is
• Denervated muscle: A totally denervated muscle required in all types of nerve injuries. The aim of
will need current either of more strength or for conservative treatment is to preserve the mobility
a longer duration. A curve from such a muscle of the affected limb while the nerve recovers.
is termed a muscle curve.
• A partially denervated muscle: The curve of The following are the essential components of
a partially denervated muscle or a muscle conservative treatment:
recovering after nerve injury lies between the
normal and the curve of denervation, and is • Splintage of the paralysed limb: The first procedure
characterised by an upward kink. The kink to be adopted in every case of nerve injury is to
denotes the superimposition of the two basic splint the limb in the position which will most
types of curves. effectively relax the affected muscles. The type
• Assessment of recovery by the strength-duration of splints used for common nerve injuries are as
curve: If progressive recovery is occurring the given in Table–10.6.
curve will, on serial examination, become flatter
with a shift to the left. On the other hand, if the • Preserve mobility of the joints: Every joint of the
process of denervation is progressive, the curve affected limb must be put through full range of
will become steeper and will shift to the right. movement at least once every day.
Nerve conduction studies: It is a measure of the
velocity of conduction of impulse in a nerve. A • Care of the skin and nails: Since the skin is
stimulating electrode is applied over a point on anaesthetic, it should be protected from trauma,
the nerve trunk and the response is picked up
by an electrode at a distance or directly over the Table–10.6: Splints used for various nerve injuries
muscle. The velocity of the conduction of the
impulse between any two points of the nerve can be Nerve injured Splint
calculated. The normal nerve conduction velocity of
motor nerve is 70 metres/second. This conduction • Axillary nerve Aeroplane splint
study helps in the following: (deltoid paralysis)

• Radial nerve palsy Cock-up splint

(extensors of wrist &
MP joints paralysed)

• Ulnar nerve palsy Knuckle-bender splint
(lumbricals paralysis)

• Sciatic N. palsy or common Foot drop splint
peroneal N. palsy

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72 | Essential Orthopaedics d) Failure of conservative treatment: If a nerve injury
is treated conservatively and no improvement
burn or pressure sores. Trophic ulcers should be occurs within 3 weeks, one should proceed to
meticulously treated. Nails should be cleaned electrodiagnostic studies, and if required, nerve
and cut with care. exploration.
• Physiotherapy: Physiotherapeutic measures
consist of (i) massage of the paralysed muscles; Techniques of nerve repair: Nerve repair can be either
(ii) passive exercises to the limb; (iii) building up end-to-end or by using a nerve graft.
of the recovering muscles; and (iv) developing a) Nerve suture: When the nerve ends can be
the unaffected or partially affected muscles.
Attempts were made in the past to preserve tone brought close to each other, they may be
and functions of denervated muscles by electrical sutured by one of the following techniques
stimulation, but it has been found to be of no use. (Fig-10.11):
• Relief of pain: Suitable analgesics are prescribed • Epineural suture
for relief of pain. • Epi-perineural suture
• Perineural suture
OPERATIVE TREATMENT • Group fascicular repair
Operative procedures for nerve injuries consist of Methods of closing nerve gaps: Sometimes, the loss
nerve repair, neurolysis, and tendon transfers. of nerve tissue is so much, that an end-to-end
Nerve repair: It may be performed within a few suture cannot be obtained. In such a situation,
days of injury (primary repair) or later (secondary the following measures are adopted to gain
repair). length and achieve an end-to-end suture:

Primary repair: It is indicated when the nerve is cut Fig-10.11 Techniques of nerve repair. (a) Epineural
by a sharp object, and the patient reports early. In (b)  Perineural (c) Epi-perineural d) Nerve grafting
such cases an immediate primary repair is the best.
One needs experience in the use of the fine sutures • Mobilisation of the nerve on both sides of the
and operative microscope for this kind of surgery. lesion.
In case the wound is contaminated or the patient
reports late, a delayed primary repair is better. In • Relaxation of the nerve by temporarily
this, in the first stage, the wound is debrided and positioning the joints in a favourable position.
the two nerve ends approximated with one or two
fine silk sutures so as to prevent retraction of the • Alteration of the course of the nerve, e.g. the
cut ends. This also makes identification of the cut ulnar nerve may be brought in front of the
ends easy at a later date. After two weeks, once medial epicondyle (anterior transposition).
the wound heals, a definitive repair is done. Some
surgeons routinely perform a delayed primary • Stripping the branches from the parent nerve
repair because they feel that the epineurium gets without tearing them.
thickened in two weeks and sutures hold better.
Secondary repair: It is indicated for the following • Sacrificing some unimportant branch if it is
cases: hampering nerve mobilisation.
a) Nerve lesions presenting some time after injury:

Often nerve injuries are missed at the time of
injury, or it may not have been possible to treat
them early for reason, such as poor general
condition of the patient.
b) Syndrome of incomplete interruption: If no definite
improvement occurs in 6 weeks in cases with
an apparently incomplete nerve injury, nerve
exploration, and if required secondary repair
should be carried out.
c) Syndrome of irritation: Cases with signs of nerve
irritation need exploration and sometimes a
secondary repair.

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Peripheral Nerve Injuries | 73

b) Nerve grafting: When the nerve gap is more the nerve (intra-neural fibrosis). This is called
than 10 cm or end-to-end suture is likely to result internal neurolysis.
in tension at the suture line, nerve grafting may Reconstructive surgery: These are operations
be done. In this, an expandable nerve (the sural performed when there is no hope of the recovery
nerve) is taken and sutured between two ends of of a nerve, usually after 18 months of injury. After
the original nerve as shown in Fig-10.11d. this time even if the nerve recovers, transmission
Neurolysis: This term is applied to the of impulses across the neuromuscular junction
operation where the nerve is freed from does not occur because the neuromuscular function
enveloping scar (perineural fibrosis). This is itself has degenerated. Operations included in this
called external neurolysis. In many cases, the group are tendon transfers, arthrodesis and muscle
nerve sheath may be dissected longitudinally transfer. Rarely, an amputation may be justified for
to relieve the pressure from the fibrous tissue within an anaesthetic limb or the one with causalgia.

Flow chart-10.1 Treatment plan for management of peripheral nerve injury

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74 | Essential Orthopaedics A practical plan for management of nerve injury is
shown in Flow chart-10.1.
DECISION MAKING IN NERVE INJURIES
It is often difficult to decide when to operate in a PROGNOSIS
case of nerve injury. This is especially so if there
is a partial lesion or partial recovery has taken The following factors dictate recovery following a
place. Electrodiagnostic studies are helpful in nerve repair:
these cases.
Unless the nature of the nerve injury is known a) Age: The lower the age, the better the prognosis.
before the operation, the appearance of the involved b) Tension at the suture line: The more the tension,
nerve is often the best guide to deciding on the type
of operative procedure. Where the nerve ends are the poorer the prognosis.
visibly apart, nerve repair is the only choice. Where c) Time since injury: After 18 months only sensory
the nerve is in continuity, it is often difficult to
decide the further course. A fusiform thickening of functions can be expected.
a nerve (neuroma in continuity) indicates a partial d) Location of injury: The more proximal the
cut. A nerve stimulator may be used to find if there
is any continuity of the nerve. If there is a brisk injury, the worse the prognosis.
response in the muscles supplied by the nerve on e) Type of nerve: A primarily motor nerve, like
stimulating the nerve proximal to the neuroma,
there is no need for nerve suture; neurolysis may radial nerve, has a better prognosis than a mixed
suffice. In case there is little or no response, the nerve.
neuroma should be excised and the nerve repaired. f) Condition of the nerve ends: The more the
crushing and infection, the poorer the prognosis.
g) Associated conditions: Infection, ischaemia etc.
indicate poor prognosis.

  What have we learnt?
• There are three types of nerve injuries: Neurapraxia, Axonotmesis, Neurotmesis.
• Nerve recovers at the rate of 1 mm/day.
• How to diagnose a nerve injury, clinical signs & their explanation.
• How to monitor nerve regeneration, and role of electrodiagnostic studies.
• Methods of nerve repair.
• Decision making in nerve injury.
• How to predict whether a nerve will recover or not?

Additional informationL: From the entrance exams point of view

• Tinel’s sign indicates regeneration of nerves.
• Prognosis after nerve suturing: radial nerve > ulnar nerve > peroneal nerve> sciatic nerve>

femoral nerve.
• Erb’s palsy is the most common neurological deficit in the upper limb.
• Erb’s palsy is injury to upper C5,6 roots of brachial plexus.
• Klumpke’s palsy is injury to the lower trunk C8 and partially T1.
• Crutch palsy is injury to the radial nerve.
• Claw hand due to leprosy is classified as Grade II WHO grading.
• Sudden hyperflexion of the thigh over the abdomen (McRobert’s procedure) done on the

mother for delivery of babies with shoulder dystocia leads to injury to the lateral cutaneous
nerve of thigh (meralgia paresthetica).

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11C H A P T E R

Deformities and Their
Management

TOPICS

• Causes
• Treatment

CAUSES subluxations seen in day-to-day practice)
or pathological (e.g., following acute septic
Deformities may arise from an abnormality in arthritis). Classic deformities are produced in
the bone (e.g., a malunited fracture), joint (e.g., some subluxation or dislocation (Table–8.2,
tuberculosis of the knee), or soft tissues (e.g., page 56).
clubfoot). These may be either congenital or
acquired. b) Muscle imbalance: All joints are spanned by two
opposing groups of muscles. Normally, these
CONGENITAL DEFORMITIES muscles maintain a balance so that the joint
These are deformities or malformations present at can be kept in any position. In some diseases,
birth (e.g., clubfoot). Some of these malformations, an unbalanced action of the muscles may hold
though present at birth, may become apparent the joint in a particular position. With time the
only later in life (e.g. spina bifida). The deformity other soft tissues around the joint (the capsule,
may be severe and incompatible with life (e.g., ligaments etc.) also contract and prevent the
osteogenesis imperfecta congenita), and can only joint from returning to its neutral position. The
muscle imbalance may arise from paralysis of a
 be found in stillborn infants. On the other hand, it group (e.g., polio) or overactivity (e.g., spasticity
in cerebral palsy).
may be very minor and have no practical significance.
The underlying causative factors may be: (i) a c) Tethering or contracture of muscles and tendons:
genetic abnormality (e.g., diaphysial aclasis, Joint movement is associated with contraction
mongolism etc.); (ii) environmental factors (e.g., of a group of muscles and elongation of
phocomelia); and (iii) combined – genetic and opposing group. To and fro gliding of tendons
environmental factors (e.g., congenital dislocation also happens in this process. If by some
of the hip, clubfoot). disease, these functions are interrupted, the
joint is prevented from moving full range.
ACQUIRED DEFORMITIES For example, the muscles or tendons, may get
Deformities acquired later in life may be divided tethered to the underlying bone (e.g., tethering
into those arising at a joint or in a bone (Fig-11.1), of the quadriceps to the femur in a fracture).
as discussed below: The muscle may get contracture (e.g., Volkmann's
Deformities arising at a joint: A joint may become ischaemic contracture of the flexor muscles of
deformed because of any of the following factors: forearm, leading to flexion deformity of the
wrist and fingers).
a) Dislocations and subluxations: These may
be traumatic (e.g., most dislocations and

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76 | Essential Orthopaedics

Fig-11.1  Causes of deformities at joints

d) Contracture of soft tissues other than muscles: Apart Deformities arising in a bone: Three major causes
from muscles, contracture of other soft-tissues of deformity arising in a bone are fractures, bone
like skin, deep fascia etc. may account for the diseases and abnormally growing bones.
deformity. For example, contracture of palmar
aponeurosis may pull the metacarpo-phalangeal a) Fracture: This is the commonest cause of
and proximal inter-phalangeal joints of one deformity of a bone. This results when a fracture
or more fingers (Dupuytren's contracture). unites in a mal-aligned position. Some of the
Similarly, contracture of the scarred skin on the common deformities resulting from malunion
flexor aspect of the elbow or knee following a of fractures are given in Table–11.1.
burn, may result in a flexion deformity of the
respective joint. b) Bone diseases: Some diseases of the bone result
in a softening and bending of the bones. Most
e) Arthritis: Joint deformity may result from of these are generalised disorders where several
arthritis. This may occur: (i) because of sustained or all of the bones are affected. The following
spasm of a group of muscles in response to are some examples:
pain; or (ii) as a result of damage to important
structures like ligaments, cartilage etc., by the Table–11.1: Deformities due to fractures
arthritic process.
Deformity Fracture
f) Posture: The habitual keeping of a joint in a
deformed position may result in a deformity, • Gun stock deformity Supracondylar fracture of
for example, lateral deviation of the great toe (cubitus varus) the humerus
(hallux valgus) is seen in women who wear Fracture of lateral condyle
narrow pointed high-heeled shoes. • Cubitus valgus of humerus
Colles' fracture
g) Unknown factors: Some deformities of joints Avulsion of the extensor
result from no apparent reason. For example, • Dinner fork deformity tendon from base of distal
knock knees deformity (genu valgum) • Mallet finger phalanx
commonly seen in children, often has no Inter-trochanteric fracture
cause. Condylar fractures of tibia
• Coxa vara (e.g., bumper fracture)
• Genu valgum Ankle injuries

• Varus-valgus
at ankle

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• Metabolic disorders – rickets, osteomalacia. Deformities and Their Management | 77
­• Endocrine disorders – parathyroid osteodys
and have to be corrected. Some deformities (e.g.
trophy, Cushing's syndrome. bow legs), may not be of immediate functional
concern, but may cause problem in long term, and
• Disorder of unknown aetiology – Paget's dis- thus may need to be corrected. The methods used
­ease, fibrous dysplasia, senile osteoporosis. for correction of deformities may be non-operative
or operative.
c) Abnormal bone growth: Bone deformity may
result from uneven growth occuring at the NON OPERATIVE METHODS
epiphyseal plate. Unequal growth of one of the Wherever possible, non-operative methods are
two bones in a part of the limb with two bones attempted first. These are suitable for deformities
(e.g. forearm or leg), may result in deformity due to soft tissue contracture. The method
at the joint adjacent (e.g. wrist or ankle). The essentially consists of stretching the contracted
common causes of uneven growth at the soft tissue, and then maintaining the correction by
epiphyseal plate are as follows: splints. The disadvantage of this method is that the
• Crushing fracture involving the epiphyseal treatment is long drawn, and an equally prolonged
plate (Grade-V, Salter and Harris epiphyseal effort at maintenance is required. Recurrence of
injury). deformity is common. Correction of deformity by
• Infection from a nearby osteomyelitis or non-operative methods is done by the following
arthritis, spreading to the epiphyseal plate, ways:
and damaging it.
• A tumour may retard the growth of a nearby a) Manipulative correction: The contracture is
epiphyseal plate (e.g., enchondroma as in gently manipulated, so as to stretch it. Once
Ollier's disease). Occasionally, the tumour corrected, it is maintained in the corrected
may stimulate uneven growth of the adjacent position in a plaster cast or splint. An example
plate by causing local hyperaemia (e.g., of use of this method is treatment of a club foot
haemangioma). by manipulation and PoP.
• Dysplasia: In some epiphyseal dysplasias,
abnormal growth at the epiphysis results in b) Wedging cast: In this technique, a cast is applied
joint deformities. on the limb with deformed joint. A wedge of
plaster is cut out on the convex side of the
TREATMENT deformity, the wedge closed by forcing the part,
thus achieving correction.
Many deformities do not need treatment, as they
are of no significant functional or cosmetic concern. c) Traction: Gradual traction can stretch out
A simple reassurance and watchful neglect may be contracted soft tissues. The correction is
appropriate in these cases. Most other deformities subsequently maintained in a splint or calipers.
cause functional impediment or cosmetic concerns,
d) Splints: These are special splints which permit
gradual stretching of the soft tissues, leading to
the correction of deformities (e.g., turn-buckle
splint for VIC see page 103).

 Fig-11.2 A child with bilateral genu valgum corrected by supracondylar osteotomy on both the sides

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78 | Essential Orthopaedics

Flow chart-11.1 Plan of management of a deformed joint

OPERATIVE METHODS limb), and arthrodesis remains the only option.
In cases where the non-operative methods fail The procedure involves opening up the joint,
or the deformity is primarily bony, operative removing its cartilage, and immobilizing it in
correction may be required. The following functional position. The raw bone ends unite
methods are used: (as in a fracture), resulting in fusion.
a) Soft tissue release: The contracted soft
d) Arthroplasty: The term arthroplasty means
tissues are released. Tethering of soft tissues 'reconstructing a joint'. Reconstruction can be
is removed. done by two methods: (i) by excising a part
b) Osteotomy (Fig-11.2): It is used for correcting of the deformed joint, thereby relaxing the
bony deformity. The deformed bone is cut and surrounding soft tissues, and thus correcting
suitably realigned in a corrected position (e.g., deformity or (ii) by replacing the joint with
for genu varum and genu valgum). artificial components. The former is called
excision arthroplasty, and is done for joints
c) Arthrodesis (fusion of joint): This method is damaged due to infection. The latter is called
adopted where a joint is not only deformed, replacement arthroplasty (joint replacement), and
but also its articulating surfaces damaged is done for most other damaged and deformed
beyond repair. Arthrodesis is suitable for joints (e.g. osteoarthritis knee). See also Chapter
joints where loss of motion at the joint does 42.
not produce much functional disability (e.g.
wrist). In other situations, such as hip and knee, e) Correction of deformity by selective retardation
joint replacement is a better option. With the of epiphyseal growth: This is useful in cases
availability and better longevity of artificial where the cause of deformity is unequal
joints, arthrodesis has become less popular. epiphyseal growth, and the child has residual
There are situations where joint replacement growth potential. Here, the faster growing side
cannot be done (e.g. joint infection, paralysed of the epiphysis is temporarily or permanently

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stopped by surgical means (stapling, direct Deformities and Their Management | 79
damage etc.). Over a period of time, the slower
growing side keeps growing, while the stapled than one plane. The apparatus provides an
side does not, resulting in correction of the opportunity for correcting the deformity very
deformity. This is performed in selected cases accurately (see also page 33) A comprehensive
plan of management of a deformed joint is given
 of genu varum or valgum in a growing child. in Flow chart-11.1.

It is a minimally invasive operation, but a little Further Reading
unpredictable. • Weinstein SL, Buckwalter JA (Eds.): Turek's Orthopaedics:

f) Ilizarov's technique: This is a versatile Principles and their Applications, 5th ed. Philadelphia: JB
technique of correcting deformity. Its utility Lippincott Co, 1994.
is more when the deformity is associated • Nickel VL (Ed.): Orthopaedic Rehabilitation. Churchill
with shortening, or if the deformity is in more Livingstone, New York, 1982.

  What have we learnt?

• Deformities may be since birth, or develop later.
• The cause of deformity may be bone (e.g. malunion), joint (e.g. OA knee), or soft tissue

contracture (e.g. Volkmann's contracture).
• Initial treatment of deformity is by non-operative methods, and thereafter operative methods.
• Different operative methods of correction of deformity exist.

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12C H A P T E R

Treatment of Orthopaedic
Disorders: A General Review

TOPICS
• Non-operative methods of treatment
• Operative methods of treatment

Orthopaedic treatment can be broadly divided permanent or prolonged support may be required
into two types, non-operative and operative. At in some cases, in the form of life time appliances
times a patient needs no definite treatment except called orthoses (see page 332).
reassurance. Whenever treatment is required, it
is preferable to try non-operative methods first, PHYSIOTHERAPY
though there are occasions when early or an
immediate operation must be advised. This includes a variety of treatment modalities
based on physical methods of treatment such as heat
NON-OPERATIVE METHODS OF TREATMENT therapy, exercises etc. It may be aimed at alleviation
of pain, restoration of functions, or both. It may
REST be used as a primary treatment modality (e.g., for
Since olden times, rest has been the mainstay backache etc.) or in conjunction with other methods
of orthopaedic treatment. It helps in reducing of treatment (e.g., post-operative physiotherapy).
inflammation and pain. The word ‘rest’ could
mean complete inactivity or immobility, as When appropriately prescribed and adequately
is sometimes required in acute inflammatory pursued under the supervision of a skilled
conditions like acute osteomyelitis etc. But, more physiotherapist, it can perform wonders. On the
often than not, it means no more than ‘relative other hand, an unskilled physiotherapist by his over
rest’, implying simply a reduction of activity and enthusiastic approach may retard rather than hasten
avoidance of strain. With advances in orthopaedic patient's recovery. The following are the common
treatment, more and more methods have been methods used in physiotherapy:
devised by which the period of rest could be
reduced significantly (e.g., by internal fixation for Ice therapy: Ice therapy is beneficial during the
most fractures). first 24-72 hours after injury. It causes relief in
pain, reduces haematoma formation and reduces
SUPPORT inflammation. The pain relieving effect of cold
A limb or a joint not capable of functioning therapy is appreciated more after the application
because of inadequate muscle power needs than during it.
support (e.g., a polio limb). Temporary support
may be given with a splint made from Plaster Heat therapy: Heat produces a soothing effect on
of Paris or other plastic splinting material. A many aches and pains, probably by increasing the
blood flow, or possibly by some other mechanism.

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Treatment of Orthopaedic Disorders: A General Review | 81

Heat application is done for 15 to 20 minutes 2 or 3 • Static or isometric exercises i.e., the muscle
times a day. Heat must not be applied to insensitive contracts while its length remains the same
or ischaemic skin, and if there is underlying acute e.g., muscle contraction while pushing a
infection or neoplastic tissue. Depending upon the wall.
depth of penetration of the heat, it can be either
surface heat i.e., only the skin and subcutaneous • Dynamic or isotonic exercises i.e., the
tissues are heated, or deep heat i.e. deeper structures muscle contracts and produces movement.
are heated. These exercises could be: (i) active —
the patient does the movements himself;
a) Surface heat: This can be provided by (i) hot water (ii) active-assisted — the patient does
bottle (rubber-bottle); (ii) warm bath; (iii) hot the movement while the physiotherapist
soaks or compresses; (iv) infra-red lamp; and helps; or (iii) active-resisted — the patient
(v) wax bath. does the movement against resistance. The
last is the most effective in gaining muscle
b) Deep heat: This can be provided by (i) short- strength.
wave diathermy—heat generated by a high
frequency alternating current (frequency 27 c) Exercises to improve coordination: These are
mega cycles/second) using a short-wave special exercises, useful in polio and cerebral
diathermy emitter; (ii) ultrasonic therapy – palsy patients.
these waves (a million cycles/second) are
projected as a beam from a transducer; and Tractions: In physiotherapy, traction is applied:
(iii) microwave. The ultrasonic waves and (i) to separate joint surfaces while giving passive
microwaves penetrate to a considerable depth. movements to a joint; (ii) to obtain the relaxation of
When the waves strike the tissues, energy muscles which are in spasm (e.g., by giving cervical
is converted into heat. It is most useful for or lumbar traction); or (iii) to correct deformities by
localised tender fibrous nodules. gentle continuous traction. For details please refer
to Chapter 4.
Exercise therapy: These are given for three
purposes: (i) to mobilise joints; (ii) to strengthen Massage: This is a systematic and scientific
muscles; and (iii) to improve coordination and manipulation of the skin and the underlying
balance. soft tissues which gives rise to relief of pain and
the relaxation of muscles. Most massage and
a) Joint mobilising exercises: The following exercises mani-pulations are soothing except for frictions
may be advised: which are painful, and are used to breakdown
adhesions.
• Passive joint movements: These are used to
preserve joint mobility when the patient is Hydrotherapy: The principles of buoyancy help
unable to move the joint himself (e.g., when to reduce pain by relaxation of the muscles,
the muscles are paralysed). mobilisation of stiff joints, and thereby assist in the
development of muscle power. This is useful as it
• Active joint movements: The patient moves produces a general sense of well-being.
his joints actively so as to gain more and more
range of movement. Sometimes, a patient's Occupational therapy: Occupational therapy aims
active efforts may be assisted by gentle at enabling the person to become as independent
pressure from the physiotherapist. as possible, inspite of the disability he may have.
A person needs independence in following day-to-
• Continuous passive mobilisation (CPM): The day activities:
joint is fitted in a machine which moves the
joint slowly through a predetermined arc of a) Activities of daily living (ADL): These constitute
motion. Since the motion produced is very activities such as self care, bathing, eating, wear-
slow, it is tolerated by the patient in even the ing clothes etc.
very early post-operative period.
b) Work related activities: These constitute employ-
b) Muscle strengthening exercises: These are used to ment related and home management related
preserve or improve the strength of the muscles. activities.
These may be of the following types:
c) Leisure time activities: These constitute sports
and social activities.

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82 | Essential Orthopaedics MANIPULATION
This is a term used for a manoeuvre whereby
Initial emphasis in rehabilitation is on restor- passive movements of joints, bones or soft tissues
ing the abilities of the person by physiotherapy are carried out with or without an anaesthetic, and
measures such as exercises, positioning etc. Even often forcefully, as a deliberate step in treatment.
during this period, occupational therapy helps the It may be done for: (i) correction of deformity; (ii)
patient to be as independent as possible. When it is improving the range of movement of a stiff joint; or
not possible to achieve any further improvement, (iii) relief of chronic pain in or about a joint.
adaptation is done in the patient’s environment, so
that he is able to maintain independence. Psycho- a) Manipulation for the correction of a deformity:
logical adaptation constitutes an important part of In this category, manipulation has its most
this. Use of adaptive devices such as walking aids, obvious application in the reduction of fractures
adaptive clothing etc. is encouraged. The person and dislocations. It is also used to correct a
is also trained to perform purposeful activities of deformity due to contracted soft tissues, as in
daily living (ADL), and activities related to work CTEV.
and play environment. All these make him inde-
pendent inspite of his disability. b) Manipulation for stiff joints: In the treatment of
stiff joints, while efforts being made to achieve
DRUGS movements by joint mobilising exercises,
manipulation under anaesthesia may speed up
Drugs have a limited role in orthopaedic disorders. the process of recovery. The joint most amenable
Those used may be placed in five categories as to manipulation is the knee. Manipulation is
given below: strictly contraindicated in the elbow because it
may lead to increased stiffness due to ‘myositis’.
a) Analgesics anti-inflammatory: These are
the most important group of drugs. They c) Manipulation for the relief of pain: The role
are broadly divided into non-steroidal anti- of manipulation in some chronic painful
inflammatory drugs (NSAIDs) and steroids. conditions is empirical. It has been shown to be
Depending upon the need, the choice varies effective in some conditions like tennis elbow,
from a primarily analgesic to a mainly anti- low backache etc.
inflammatory drug. In long standing illnesses,
it is desirable to use single daily-dose drugs e.g., RADIOTHERAPY
Coxibs and slow release (SR) formulations.
Radiotherapy is useful in the following orthopaedic
b) Antibacterial drugs: These drugs are of disorders:
immense value in acute infective conditions
such as septic arthritis, acute osteomyelitis etc. a) Malignant tumours: Ewing's sarcoma is a
It is important to start with a broad-spectrum highly radiosensitive malignant bone tumour.
drug and change over to specific drug after a Radiotherapy is also used for other malignant
culture-sensitivity report. tumours, either pre or post surgery.

c) Hormones: The main drugs in this group are b) Benign tumours: Giant cell tumours of the
anabolic steroids, estrogens (for osteoporosis) bone which are unsuitable for excision can be
and stilbesterol (for metastasis from prostate). irradiated.

d) Specific drugs: These are used in certain specific c) Other conditions: Recalcitrant ankylosing
disorders e.g., vitamin D for rickets, vitamin C spondylitis.
for scurvy, etc.
OPERATIVE METHODS OF TREATMENT
e) Cytotoxic drugs: These are used in the treat­ment
of malignant bone tumours. An operation is a useful yet serious undertaking.
A trained surgeon, modern operation theatre and
f) Local injections of a depot preparation of adequate instruments are essential before one
hydrocortisone or methylprednisolone are used ventures to perform an orthopaedic operation.
to control non-specific inflammation of a joint
or an extra-articular lesion like tennis elbow.

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Treatment of Orthopaedic Disorders: A General Review | 83

Failing this, one may have to face serious
complications like osteomyelitis etc. The
following are some of the common orthopaedic
operations:

OSTEOTOMY Fig-12.2 X-rays of the knee, AP and Lateral views, showing
It means the cutting of a bone (Fig-12.1). Indications arthrodesis of the knee
for performing osteotomy are as follows:
when the advantages of eliminating the joint are
• To correct excessive angulation, bowing or more than disadvantages of keeping a joint. For
rotation of long bone. example a stiff, painful ankle may be more disabling
than an arthrodesed (fused) ankle (stiff but painless).
• To correct mal-alignment of a joint. An arthrodesis is used most often for a painful, stiff
• To permit elongation or shortening of a bone in joint. It is also performed for grossly unstable joints
in polio etc.
cases of leg length inequality. Types of arthrodesis: An arthrodesis may be intra-
articular, extra-articular or combined (Fig-12.3).
• Special indications where osteotomy is performed In an intra-articular arthrodesis, the articulating
for purposes other than above e.g., McMurray's surfaces are made raw and the joint immobilised
osteotomy. in the position of optimum function until there is a
bony union between the bones. In an extra-articular
Fig-12.1 Types of osteotomies

ARTHRODESIS
In this operation, fusion is achieved between the
bones forming a joint so as to eliminate any motion
at the joint (Fig-12.2). Although fusing a joint has
its disadvantages, this operation becomes necessary

Table–12.1 gives some of the commonly performed
osteotomies and their indications.

Table–12.1: Common osteotomies and their indications

Name Indication

• McMurray's osteotomy Fracture neck of femur Fig-12.3 Types of arthrodesis
• Pauwel's osteotomy Osteoarthritis of the hip
• High tibial osteotomy Fracture neck of femur
• French osteotomy Osteoarthritis of the knee
• Spinal osteotomy Correction of cubitus
varus deformity
Ankylosing spondylitis