Bone :

What is bone?
Bone is a highly vascular,constantly changing living mineralized special form of
connective tissue.

Principal of fracture management

1. Indication of internal fixation
a) Displaced intraarticular fracture
b) Irreducible, unstable fracture
c) Open fracture
d) Polytrauma
e) Asso neurovascular injury
f) Pathological fracture
g) Early mobilization, nursing care
2. What are the benefits of internal fixation
a) Earlier functional recovery
b) More predictable fracture alignment
c) Potentially faster time of healing
3. Tell the orthopaedic emergency fracture
The fractures require surgical treatment
a) Displaced intraarticular fracture
b) Failed conservative treatment
c) Displaced pathological fracture
d) Poor result with conservative treatment-galeazzi, montezzia, neck of
femur
e) Avulsion fracture
f) Displaced physeal fracture
g) Fracture with compartment syndrome
h) Nonunion
i) Neurovascular injury
Relative indication
a)
b)
c)
d)
e)
f)

Unstable pelvic fracture

Long bone fracture
Pathological fracture
Impending pathological fracture
Fracture with complex soft tissue loss
Needs prolong immobilization

Minor indication
a) Cosmetic problem-clavicle fracture
b) Earlier rehabilitation

Fracture shaft of radius and ulna:

Present ur case?
Tell the diagnosis?
Q1. What is the AO type?
-ao surgery reference
Q2. What is seen in Xray?
-apley 767
Q3. What are the changes can be seen in Xray?
-apley 689
Q4. Rules of Xray?
-apley 693
Q5. Forces causes fracture pattern?
-apley 687
Q6. What is your plan?
-orif by small dcp.
Q7. Why operative?
-apley 768
Q8. what is the complication of this fracture? And their management.
-apley 769
Q9? What is your approach?
Anterior henry approach.campbell vol 1a 118
Thompson approach Campbell vol 1a 117
Campbell vol 3b 2888
Q10.What is the danger of operation and how will you prevent it?
Campbell vol 1a 117

Leash of blood vessels passes from radial artery to muscles. It should be

ligated.
Q. what is arcade of frohsi
The supinator tunnel through which posterior interosseous nerve travels
Q. tell about the radial artery in forearm
Datta 72

Q11 . What is post operative care?

Campbell vol 3b 2888

Q12.what is DCP? How many types? Describe them?

Ao asif 84
3 types
Small
Types
Small
Narrow
Borad

Width mm
10
12
16

Thickness mm
3
3.6
4.5

Q13. What is drill bit and screw size,screw driver size?

AO-ASIF 191,189
Cortical screw 3.5 mm, hence the name 3.5 mm DCP(Small DCP)
Drill bit 2.5 mm
Screw driver 2.5
Q14. Course of radial nerve in arm and forearm?
Datta 101
Q15. Location of nutrient artery of radius and ulna?

Datta 15
Middle of the shaft in the anterior surface from ant interosseous artery
For ulna NF on the anterior surface about 7 cm from Ulnar tuberosity.
Q16.Tell the anatomy of radius and ulna
Datta 16
Q17. Tell the development of radius and ulna
Datta 18
Q18.Describe supinator muscle
Datta 81
Q.19How many cortex should be fixed with screw?
Ao asif 110
Forearm bone 6 cortex
Humerus 7 cortex
Tibia 7 cortex
Femur 8 cortex
Q20.Which surface plate should be fixed?
Q21.What is role of DCP?
To provide compression at fracture site
Provide stability at fracture site
Hold the bone
Bears the load
Q 22. How compression helps in union?
Thakur 79

1. Fracture radial head

1. What is AO type?
Ao surgery ref , apley 752-mason classification
2. What is the force caused this fracture?
Apley 752
3. What is the complication?
Apley 752
4. What is your plan?
Apley 752
5. What are the treatment options?
Apley 752
Ibnezar 162
6. What is the optimum time for operation?
2 to 3 wks after injury. Early excision of the head of the radius is asso
with high incidence of subluxation of inferior radioulnar joint.
(watsonzones 578)
7. What is your approach?
Campbell 116
8. Tell about postoperative care?
Campbell 2872
Monteggia fracture dislocation
1. what is monteggia fracture dislocation
Ebnezar 173
2. why it is called treacherous?
Ebnezar 173
3. what is Mclaughlins line?
In order to assess the radiocapitellar joint, a line should be drawn parallel to the long axis of the radius. This line
should point directly at the capitellum on any projection of the elbow.

4.

What is the mechanism of injury?

Ebnezar 173

5. classify it?
Ebnezar 174
6. tell the clinical feature?
Ebnezar 174
7. what are the monteggia equivalent?
Ebnezar 174
8. tell the treatment option?
In case of children, close reduction, if fail open reduction

In case of adult, open reduction and close reduction of head of

radius, if fail open reduction.
9. how will u operate
10. tell the postoperative care
11. complication of monteggia fracture
ebnezar 175
(ebnezar)
FRACTURE CAPITULUM
1. Present ur case?
2. What is the name of OCD of capitulum?
Panner's Disease

3. What is the mechanism of injury

Fall on hand in elbow straight
4. Classify the fracture?
Bryan and morrey classification apley 752,ebnezar 165. AO
13B3.1
5. What is the radiological feature?
Apley 752,ebnezar 165
6. What is ur plan?
Apley 752
7. Tell the approach?
All cases were operated under general anaesthesia, sterile tourniquet was applied in all cases and assessment for
ligament instability was done. Lateral Kaplan approach was used in all the patients. Incision was taken approximately
5 cm proximal to the lateral epicondyle of the humerus; it was carried distally approximately 5 cm distal to the
epicondyle along the lateral surface of the forearm. Subcutaneous tissues were dissected and retracted. Interval
between the triceps posteriorly and origins of the extensor carpi radialis longus and brachioradialis anteriorly was
developed. The forearm was kept in full pronation in order to avoid injury to the radial nerve in the proximal aspect of
the incision where it enters the interval between brachialis and brachioradialis muscles. The brachioradialis and
extensor carpi radialis muscles along with the anterior capsule were subperiosteally elevated to create an anterior full
thickness flap which was connected distally to the Kocher interval. This exposed the capitellum and the lateral aspect
of the humerus. A full thickness flap was raised posteriorly which was also required for the placement of cannulated
cancellous screws. Fracture site was cleared of haematoma and soft tissue debris for better identification of the
fracture fragments which were reduced and fixed temporarily with Kirschner wires (K wires). Reduction was
confirmed under image intensifier, definitive fixation was done using 4 mm cannulated cancellous screws which were
directed from posterior to anterior direction, head of the screw was placed in such a manner so as to avoid the
olecranon fossa with certain amount of countersinking. Bone grafts were not used in any of the patients.
8.

Postoperatively, patients were immobilised in an above elbow slab for 5 -7 days following which gentle active
mobilization was started. None of the patients were subjected to passive mobilization. Patients were followed up
regularly for a minimum of 6 months to assess the functional (MEPI) and radiological outcome.

9.
Lateral approach AO surgery ref
10.
Tell the open reduction procedure?
Ao surgery ref

11.
12.
13.

What is ur implant?
Tell the postoperative care?
Tell the complication of this fracture?

OLD ELBOW DISLOCATION

1. Present ur case
2. What are the causes of recurrent elbow dislocation?
3. What is ur plan
4. Tell the treatment options
5. Tell the operative procedure
6. Tell the postoperative care
7. What is the complication of unreduced dislocation
8. What is the complication of treatment
9. Tell the attachment of capsule
10.
Tell the attachment of medial and lateral collateral ligament
Fracture coronoid process
1.
2.
3.
4.

Classify coronoid process fracture

Tell its importance
What is the treatment option
Tell the postoperative care

Intertrochanteric fracture femur

1. What is ur diagnosis?
-intertrochanteric fracture kyle type 3
2. Tell ur plan
-close reduction and internal fixation by dynamic hip screw
2. How many classification for trochanteric fracture?
Intertrochanteric Fractures
Kyle classification:
apley 853
Boyd and Griffin Classification (Figure 3.8)

Type I: A single fracture along the intertrochanteric line, stable

and easily reducible.

Type II: Major fracture line along the intertrochanteric line with
comminution in the coronal plane.
Type III: Fracture at the level of the lesser trochanter with
variable comminution and extension into the subtrochanteric
region (reverse obliquity).
Type IV: Fracture extending into the proximal femoral shaft in
at least two planes.
46 FRACTURE CLASSIFICATIONS IN CLINICAL PRACTICE
FIGURE

FIGURE 3.8. The Boyd and Griffin classification of trochanteric fractures:

Type I (top left), Type II (top right), Type III (bottom left), Type IV (bottom
right). (From Boyd HB, Griffin LL. Classification and treatment of
trochanteric fractures. Arch Surg 1949;58:853866.)

Evans Classification (Figure 3.9)

Type I:
Stable:
_ Undisplaced fractures.
_ Displaced but after reduction overlap of the medial
cortical buttress make the fracture stable.
Unstable:
_ Displaced and the medial cortical buttress is not
restored by reduction of fracture.
_ Displaced and comminuted fractures in which the
medial cortical buttress is not restored by reduction
of the fracture.
Type II: Reverse obliquity fractures.

FIGURE 3.9. Trochanteric fractures. (Reproduced with permission andcopyright of the British Editorial Society of Bone and Joint
Surgery.
Ewans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg 1949;31-B:190203.)

3. What are the forces causes this fracture

Apley 853
4. What is the clinical feature?
Apley 853
5. Tell how will u insert the guide wire?
Kakkad 171
6. What is tip apex distance?
Apley 854
7. What is the measurement of triple reamer?
Ao asif 137
8. What is the benefit of DHS?
Sura 7:130
9. What are the components of DHS?
Sura 7: 130
10.
What is the role of compression screw?

Ao asif 140
11.
Tell the entry point of DCS?
Ao asif implant 150,sura 7:131
12.
What is the TAD for DCS?
<20 mm
13.
Tell the difference between DCS and DHS?
Sura 7:132
14.
Why it is called Dynamic condylar screw?
15.
Tell about postoperative care
Non wt bearing walk 06 wk(but 2-3 days afer can be) then full weight
bearing
What is wards triangle?
Triangular area in betwn primary compressive, 2ndary compressive and
primary tensile trabeculae. Here purchase will not be good.
16.
Tell the treatment options
Apley 856
17.
Tell the complication of trochanteric fracture
Apley 856

Subtrochanteric fracture
1. What is your diagnosis?
04 days old subtrochanteric fracture seinsheimer type 2 in a
70 yrs old male patient
2. Tell ur treatment plan
ORIF by long DHS
3. Classify this fracture
Ebnezar 226
4. What are the treatment options?
Conservative-traction
OperativeIntramedullary- prox femoral nail, gamma nail, russel taylor
nail
Extramedullay- prox femoral locking plate, DHS,blade plate
5. Tell about post operative care?
Knee bending and quadriceps from 1st POD
Non wt bearing walk for 06 wks
After seeing radiological evidence of union partial weight
bearing
6. What is trochanteric plate?

Cobra head plate slot for 7 screw

7. What is trochanteric stabilization plate?
8. Why nonunion is common in subtrochanteric fracture?
-reduction and maintenance of reduction is difficult
-fracture through the most stressed area
-fracture through the most cortical area
-less vascular area
-less muscular area

9. What is proximal femoral locking plate?

10.
How many screws are in prox femoral locking plate and
their function?
The proximal portion of the plate is precontoured for the proximal femur. The two proximal screw holes
are
designed for 7.3 mm cannulated locking screws and the third locking hole is designed for 5.0 mm
cannulated locking
screws.

The three proximal screw holes are at the following angles to the plate shaft:
First proximal hole (7.3 mm): 95 for derotation
Second proximal hole (7.3 mm): 120 for purchase
Third proximal hole (5.0 mm): 135 for weight bearing

11.
How will u enter guide pin in DCS?
-2 cm distal to tip of trochanter or 2 cm proximal to vastus
ridge
-At the junction of anterior 1/3rd and posterior 2/3rd of anteroposterior side of greater trochanter.
Kakkad 175
Version guide wire
Through the centre of neck and inferior part of head
In lateral view it should go through the centre of the head.
12.
Tell the operative procedure
13.
14.

Tell the difference between DHS and DCS

Tell the parts of DCS

18.
Fracture distal radius with intra articular extension
What is your diagnosis?
What is the mode of injury?
Tell the AO classification?
Ao surgery reference
What is your plan?
Open reduction and internal fixation by volar plating.
What is colless fracture?
Apley 772
What is volar burton and dorsal burton fracture?
Apley 776
What is smith fracture?
Apley 774
Tell about the approach?
Campbell 2899
Postoperative care?

Campbell 2900
Tell the anatomy of distal radius.
Datta 16
What implant u will use?
Volar plate
What is the drill bit, plate and screw size?
Campbell 2899
What is the plate size?
Campbell 2899
What is the function of plate?
Hold fragments
Stabilizes the fragments
Bears weight
Tension band
Neutralization
Protection
Compression
What is buttress plate?
Kakkad 145
What is the role of buttress plate?
Kakkad 145
19.
Fracture distal tibia
What is your diagnosis?
Ao surgery reference
What is your plan
Orif by distal tibial lateral metaphyseal plate
Tell the approach
Campbell 2648
What is the drill bit?
2.8 mm
What is the plate size?
Combihole plates
What is the screw size?
3.5 mm cortical screw/locking screw
4 mm cancellous screw
Tell the anatomy of tibia
datta 146
Tell the attachment of extensor retinaculum
Datta 216
Tell course of common peroneal nerve and superficial and deep
peroneal nerve?
Datta 218,221

What is the benefit of this approach?

Well soft tissue coverage
Does not disrupt the medial subcutaneous border.
Tell the function of plate
Hold fragments
Stabilizes the fragments
Bears weight
Tension band
Neutralization
Protection
Compression
buttressing
Where is the nutrient artery located?
Nutrient artery of tibia is the largest nutrient artery in the body. Arises
from anterior or posterior tibial artery. It pierces tibialis posterior and
enters at prox third of tibia.nutrient foramen is located immediately
distal to soleal line.

Fracture tibial shaft

What is your diagnosis?
Ao surgery reference
Tell your treatment plan
ORIF by lateral locking plate
What are the other treatment options?
Ao surgery reference
How will u operate?
Campbell 2648
Ao surgery reference
Tell the screw size
4.5 mm cortical screw
Drill bit size
3.2 mm
No of screw
4 on each side
Plate
4.5 mm DCP
Tell about postoperative care
Campbell 2649
Function of plate
Compression principal
Acute angle neutral then obtuse angle compression
We can bend the plate as convex to compress the far cortex

Tell the function of a plate

Apley 702

Hold fragments
Stabilizes the fragments
Bears weight
Tension band
Neutralization
Protection
Compression
Buttressing
Antiglide
Types of plate?
Campbell 2597

Spine fracture
1. Tell the direction of pedicle screw
Campbell 1527
2. What is long segment and short segment fusion?
Short- 1 vertebra above and below
Long->1 vertebra above and below
3. What is the problem of long segment fusion/
Facet joint arthropathy
Disc prolapse
4. Tell the blood supply of spinal cord
Campbell 1528
5. Tell the development of spinal cord
Langman 63
6. Which spinal segment lies on which level
Ebnezar 314
7. What is complete and incomplete spinal cord injury

Asia grading
8. Tell the plan
Decompression and stabilization
9. Tell ur approach
Campbell 1612
10. What is the size of screw and rod
11. What is asia and frankel grading and tell their difference
Asia grading
Campbell 1568
12. What is the outcome of surgery
One grade improvement
13. Explain the findings with spinal cord compression
14. What is reflex?
Involuntary motor response to a sensory stimulus
15. What is superficial and deep reflex?
These are elicited by stimulating appropriate receptors of skin and
mucous membrane
Deep reflexes : these are stretch reflexes produced by tapping over
a tendon.
16. What is clonus?
Alternate contraction and relaxation of skeletal muscle in rapid
succession
17. Tell the various cord compression syndrome.
Apley 826
18. What is cauda equina syndrome?
Bowel bladder incontinence
Perineal numbness
Bil sciatica
Lower limb weakness
Cross SLR positive
19. What is spinal shock and neurogenic shock
Campbel 1570
20. How long u will give tong traction?
Atleast 06 wks

Cervical spine injury

1. Present ur case
2. What is the AO type
Spine 5

Classification
Type A: Compression injuries of the body (compressive forces)

Type A1: Impaction fractures

Type A2: Split fractures

Type A3: Burst fractures

Type B: Distraction injuries of the anterior and posterior elements (tensile forces)

Type B1: Posterior disruption predominantly ligamentous (flexion-distraction injury)

Type B2: Posterior disruption predominantly osseous (flexion-distraction injury)

Type B3: Anterior disruption through the disk (hyperextension-shear injury)

Type C: Multi-directional injuries with translation affecting the anterior and posterior elements (axial torque causing
rotation injuries)

Type C1: Rotational wedge, split, and burst fractures

Type C2: Flexion subluxation with rotation

Type C3: Rotational shear injuries (Holdsworth slice rotation fracture)

Explanation

3. Tell the clinical findings

4. What is spinal shock and neurogenic shock
Spinal shock: temporary reversible loss of all functions of
spinal cord which usually lasts for 24 hrs-48hrs.
Neurogenic shock: loss of sympathetic pathway in the
spinal cord dilates peripheral vessels causing hypotension
and bradicardia. Paralysis with warm,well perfused
peripheral areas, bradicardia, hypotension with low
diastolic pressure suggests neurogenic shock.
5. Tell ur management plan
Decompression and stabilization by cervical plate and
screw with fusion by strut graft. 1599
6. Tell the postoperative care
Campbell 1601
7. What is stable and unstable fracture\
Spine is unstable when
a) Both column is involved
b)4 lines ant surface of vertebral body, post surface of
vertebral body, posterior border of lateral mass and the
bases of spinous process-should lie parallel.
c) Forward or backward displacement >3.5 mm

d)Rotation 110
e) 50% translation of body
8. What is the goal of treatment?
To improve neurological status
To prevent further progression of neurological deficit
For improve nursing care and rehabilitation
9. Tell the measurement of tricortical graft?
Height=body height+disc height, anteriorly more than posterior
to maintain cervical lordosis.

Fracture patella
Q1. Tell ur diagnosis
Q2. Classify patellar fracture
Fracture Classification 55
Ao surgery reference
Q3. What is your treatment plan?
Magnuson wiring
Q4. Why
As the distal fragment is small
Q5. Tell the principals of tension band wiring
By placing circlage wire in tensile surface we are converting distracting
force into compressive force
Sura 7: 126
Q6. Tell the anatomy of patella
Datta 145, sura 7:124
What is Q angle?
Sura 7:124
What is the percentage of patella fracture?
1%
Q7. What injury caused this?
Apley 887
Q8. What are the treatment options?
Ebnezar 260
Q. problems of k wire
Ebnezar 261

Q. extensor lag and patella?

Ebnezar 262
Q. advantage of cannulated screw fixation?
Ebnezar 261
Q9 tell the approach
Ao surgery reference
Campbell 2685
Q. incision for patella fracture?
Sura 7: 126
Q10 indication of operation
Gustillo 899
Q. what are the advantage and disadvantage of transverse patellar
incision
Sura 7: 126
Q. what are the methods of operative treatment?
Sura 7: 126
Q. what will happen if fracture is not operated?
Sura 7: 127
Q what are postoperative complication?
Sura 7: 127
Q. what is the treatment of vertical fracture of patella?
Ao surgery ref
Q. indication of patellectomy?
Sura 7: 128

Q11.How fracture patella heals

Heals by primary union
Q7. What is the function of patella?
3 important function
-increases the strength of quadriceps
-protective shield for condyles
-cosmetic appearance of knee.

Q. when patella engages in intercondylar notch

1350 extension
Q. tell the biomechanics of patella
By virtue of its thickness patella displaces the quadriceps tendon away
from the center of rotation of knee, thereby increases its moment arm,
which increases the force of knee extension around 50% . patellectomy
losses 50% of its strength.

Moment arm= force x distance

Q8. Tell the postoperative care?
Campbell 2686
Sura 7: 127
Q tell about the extensor mechanism
Ebnezar 262
Q what is bipartite patella, patella alta and patella baja

A bipartite patella (two-part patella) is a patella with an unfused accessory

ossification center at the superolateral aspect. The superolateral accessory
ossification center of the patella is usually present by 12 years of age and may
persist into adult life. Prevalence of a bipartite patella occurs in approximately 2%
of the population. It occurs bilaterally in about 43% of cases.
It is nine times more common in males than in females 2.

Sura 7:124

What will u do if distal fragment is very small?

Magnuson technique if fail

Vertical wiring can be done in case of small fragments

How the rest of the patella is attached after distal patellectomy?

Sura 7: 126
How much patella should be kept during partial patellectomy?
At least prox third

26 days old fracture, will u give bone graft?

Why or why not?
No. it does not req
What are sesamoid bones in the body?
Sesamoid bones develop in tendons which are subject to friction
during the movement of joints. Sesamoid bones act as pulleys for
muscular contraction.
Example:
a. Patella in quadriceps femoris
b. Pisiform in flexor carpi ulnaris
c. Two bones beneath the head of 1st metatarsal, in flexor hallucis
brevis
d. One bone known as fabella, in the lateral head of
gastrocnemius
e. One at cuboid bone, in peroneus longus
f. Riders bone, in tendinous origin of adductor longus.

Special feature of sesamoid bone?

a.Develop in the tendon of muscles
b. ossify after birth
c. devoid of periosteum
d. absence of haversian system
special characteristics of patella?
Sura 7:124

What is bluemensaat line?

Blumensaat line corresponds to the roof of intercondylar notch of the femur as seen
on lateral radiograph of knee joint. It has been used for:
indicating relative position of patella (normally this line just touches the lower
pole of patella)
suggesting ACL injury (normal ACL Blumensaat angle is less than or equal to
15o)

What is merchant view for patella?

Axial view

Knee Xray

Weight-Bearing
P/A (Rosenberg)

Demonstrate
s: femorotibial
articulation

Helpful
for: Knee
Arthritis, Tibial
Plateau
Fracture, Distal
Femur Fracture,
Position: Standing
with knees flexed
45 with grid in
front of knees
Beam directed 10
caudal from the
horizontal plane
through the knee
joint.

A/P Knee View

Demonstrate
s: femorotibial
articulation.

Helpful
for:Knee
Arthritis, Tibial
Plateau
Fracture, Distal
Femur Fracture,
Position: supine
with cassette
under knee and
femoral condyles
parelll to cassette.
Beam directed to
point 1-2cm distal
to the patella.

Lateral Knee
View

Demonstrate
s: femorotibial
articulation,
patellofemoral
articulation.
Femoral condyles
should be
superimposed.

Helpful
for:Knee
Arthritis, Tibial
Plateau
Fracture, Distal
Femur
Fracture, Patellar
Fracture, Patellofe
moral Arthritis
Position: lateral
with affected side
down and flexed
30 at the knee.
The contralateral
leg is shifted
posteriorly out of
the way.

Beam directed at
knee joint with
5cephalad
angulation.
Tunnel View
(Intercondylar
notch view)

Demonstrate
s: posterior aspect
of femoral
condyles,
intercondylar
notch,
intercondylar
eminence of tibia

Helpful
for:Tibial
Eminence
Fx, Tibial Spine
Fx, Distal Femur
Fracture,
Position: prone,
knee flexed 40
Beam directed
caudally toward
the knee joint at a
40 angle from

vertical.
Sunrise View

Demonstrate
s: tangential view
of patella;
femoropatellar
articulation

Helpful
for: Patellofemoral
Arthritis, Patellar
Fracture,Patellofe
moral Pain.
Position: Prone;
knee flexed 115
Beam directed
toward patella with
15 cephalad
angulation

Merchant View

Demonstrate
s: patellofemoral
articulation.
Centrial ridge of
patella should lie
at or medial to the
bisector of the
trochlear angle.

Helpful for:
Evaluating patellar
tilt. Not very
sensitive,Patellofe
moral
Arthritis, Patellar
Fracture, Patellofe
moral Pain.
Position:supine
knee flexed 45;
Beam directed
caudally toward
patella at a 60
angle (30 from
the horixontal
plane).
(Merchant A,
JBJS 1974;

56A:1391)
Patellar Alta,
Patllar Baja

Insall-Salvati
Ratio

BlackburnePeel Ratio:
<0.8=patella baja,
>1.2=patella alta.
Image= lateral
view of patient
with patellar
tendon rupture
demonstrating
patella alta.
Radiology
References

Frank ED,
Merrill's Atlas of
Radiographic
Positioning and
Procedures,
2007(link is
external)

Fracture lateral malleolus

Tell ur diagnosis
Plan
Xray findings
AO classification?
Ao surgery ref
Indication of operation
If ankle mortice is disturbed.
Approach
Lateral approach
Principal of tension band wiring
By k wire and wiring applying distracting force is converted into
compressive force
Other option of treatment
plate
Postoperative mx
Laugihenson type

Galeazzi fracture
Tell ur diagnosis
What is galeazzi fracture?
Fracture radial shaft with distal radioulnar joint dislocation
Apley 25
Classification ?
AO surgery ref
Tell the anatomy of radius
Datta 14
Tell the development of radius
Datta 17
Course of radial nerve?
Datta 106
Course of radial artery
Datta 73
Leash of blood vessel?
Branch from radial artery which supplies brachioradialis,
which should be ligated.

What is the approach?

Anterior henry approach.campbell vol 1a 118
Thompson approach Campbell vol 1a 117

What will be postoperative care

1.

Following stable fixation, with or without transfixion of the DRUJ, postoperative treatment
consists of immobilization in a long cast for 3 weeks in the position of forearm rotation that
at operation was determined to give maximal stability of the DRUJ (allowing the disrupted
ligaments to heal). The operated arm is elevated and active mobilization of the fingers is
started within the first week.
2.
In cases where the distal ulna is transfixed to the radius by a K-wire, the wire is to be
removed after 3 weeks.
3.
After cast and K-wire removal, elbow, forearm, and wrist mobilization exercises are
started.

Piano key sign?

Distal end of ulna will be protruded, when pressed it goes
down and spring after release of pressure like piano key.
Mechanism of injury?
Apley 771
What is the clinical feature?
Apley 771
Treatment
Apley 772
What are the radiographic finding suggestive of distal radio
ulnar joint dislocation?
Campbell 2888
Type of galeazzi fracture?
Campbell 2891
Bone graft
What is the function of bone graft?
Campbell 12
How will you take bone graft?
Campbell 14
Fate of bone graft

Hrs: inflammation
Days: profibroblast
Wks: proosteoblast
Months:scaffolds-creeping substitution
Yrs: remodeling and incorporation of graft

Fracture dislocation of shoulder

Present ur case?
What is ur diagnosis?
What is ur treatment plan?
ORIF by Philos plate.
What is the mode of injury?
Appley 744
Classify prox humeral fracture?
Apley 744
Treatment option
Campbell 2841
What is Hertel radiographic criteria
Campbell 2841
Relation between combined cortical thickness and treatment
Campbell 2841
What will be ur approach?
Campbell 91

Deltopectoral approach
Operative procedure
Campbell 2849

How will ur insert the plate?

Ao surgery reference

Correct plate position

The correct plate position is:
1.
about 5-8 mm distal to the top of the greater tuberosity
2.
aligned properly along the axis of the humeral shaft
3.
slightly posterior to the bicipital grove (2-4 mm)
Pitfall 1: plate too close to the bicipital groove
The bicipital tendon and the ascending branch of the anterior humeral circumflex artery are at
risk if the plate is positioned too close to the bicipital groove. (The illustration shows the plate in
correct position, posterior to the bicipital groove).
Pitfall 2: plate too proximal
A plate positioned too proximal carries two risks:
1.
The plate can impinge the acromion
2.
The most proximal screws might penetrate or fail to securely engage the humeral head

Size of screw and drill bit?

2.8 mm drill,
What will be the post op care?
Ao surgery ref
What is the complication of this fracture?

Appley 747
What is the complication of this operation?
Campbell 2483
What is Philos plate?
Proximal Humeral Internal Locking System plate

Say the course of axillary nerve.

Datta 52
Blood supply of humeral head
Apley 747
What is calcar of humerus

Fracture shaft of humerus

Tell your diagnosis
What is the AO type?
Ao surgery ref
What are the treatment options?
What is the indication of operations?
Campbell 2853
Tell the approach

Post operative management

Back slab 21 days
Elbow and shoulder movement then
Size of plate, drill bit, screw

What are the parts of a screw?

Tell the approach of bone graft?
What is the function of bone graft?
Sites from where bone can be taken
Tell the radiological feature
Complication of this fracture
Complication of operation

Tell the course of radial nerve

Tell the anatomy and development of humerus
Fracture distal humerus
1. Tell
2. Tell
3. Tell
4. Tell
5. Tell

ur diagnosis
the treatment plan
the approach
the implant screw and drill bit
the postoperative care

Fracture lateral condyle of humerus

1. Present ur case?
2. Tell the type?
Milch type II, Salter-harris type 2
3. What is the clinical feature?
Apley 762
4. What is the mechanism of injury?
Fall on hand, elbow extended and forced into varus
5. What will be the complication?
Apley 762
6. Tell the treatment option
ORIF by K wire
7. What is ur plan
ORIF by K wire
8. What is ur approach
Posterior kocher j approach
9. What are the complications of this fracture

Apley 762
10. What are the complication of treatment
Malunion, nonunion, delayed union, infection, haemorrhage.
11. Tell about the postoperative care
Campbell 1399
12. Tell the anatomy of distal humerus
Datta
13. Tell the development of distal humerus
Datta

Fracture neck of femur

1. Present ur case?
2. Diagnosis?
3. Classify neck fracture?
Apley 847, ao surgery ref 31B2, fracture classification 54
4. Treatment plan?
Replacement hemiarthroplasty by Austin moore
prosthesis/bipolar prosthesis
5. Treatment protocol of fracture neck of femur?
Gustillo 800
6. Tell the anatomy of neck of femur?
Datta 139
7. What is anteversion?
Angle of femoral neck with coronal plane-10-12
8. Tell the development of femur?
Datta 144
9. Tell the blood supply of femoral head?
Apley 847
According to age:
At birth: medial ascending cervical (inferior metaphyseal
vessel of Trueta)
Lateral ascending cervical (lateral epiphyseal vessel of
Trueta)
Vessels of ligamentum teres.
0-4 months: a. metaphyseal vessels which penetrates growth
disc
b. lateral epiphyseal vessels running in the
retinacula

c. scanty vessels in the ligamentum teres.

4 months to 4 yrs: vertical metaphyseal vessels decrease in
size and number. Lateral epiphyseal vessels major role.
4yrs-7 yrs: lateral epiphyseal vessels
After 7 yrs: lateral epiphyseal vessels +ligamentum teres has
developed.
Pre-adolescent(9-10 yrs): after 7 yrs, ligamentum teres
vessels become prominent and termed as medial epiphyseal
vessels.
Adolescent: lateral epiphyseal vessel and arteria ligamentum
teres femoris. Epiphyseal and metaphyseal vessels from
nutrient artery anastomose with each other.
Adult: lateral epiphyseal and medial epiphyseal vessels.
Superior and inferior metaphyseal vessels.
10.
What will be the clinical feature?
Gusillo 796
11.
Mode of injury?
Apley 847
12.
Why the affected limb is shortened and externally
rotated?
Shortened due to pull of strong muscles of thigh ie rectus
femoris, adductor muscles and hamstring muscles and
gluteus maximus, piriformis, obturator internus, the gemilli
and quadrates femoris causes lateral rotation.
13.
What is the difference between clinical features of
trochanteric fracture and neck fracture?
In trochanteric fracture, there will be bruise in the skin,
patient may be unstable, there may be more shortening and
external rotation of the affected limb but less in case of neck
fracture due to capsular attachment
14.
What is the x ray feature?
Apley 848
15.
Why Austin moore prosthesis?
non ambulatory and bed ridden patient
16.
Why not bipolar?
Ambulatory patient bipolar is good. More mobility
17.
Tell the advantage and disadvantage of Austin moore
and bipolar prosthesis

Austin mooreAdvantage- low cost

Disadvantage-thigh pain, acetabular protrusion
BipolarAdvantagedecrease rate of acetabular protrusion
less thigh pain
wide range of mobility
18.
Tell the parts of Austin moore and bipolar prosthesis

Head, neck , collar, shoulder and stem with fenestration

19.
Prerequisite of Austin moore prosthesis:
At least 1.25 cm calcar must be present, if not then Thomson
20.
Tell the types of bipolar prosthesis
Fenestrated, nonfenestrated
Hydroxyapetite coated or not coated
Modular or nonmodular
21.
What will be ur approach?
Posterior moore approach Campbell 70
Lateral hardinge approach Campbell 64
Ao surgery ref
22.
Tell the approaches of hip and their indication?
Anterior: smith Peterson-femoral neck fracture repair
Somerville-congenital dislocation of hip

Lateral :hardinge-hemiarthroplasty
Posterior: Moore- hemiarthroplasty
Medial :Ferguson, hoppenfield, deboer-DDH
23.
Tell the surgical technique
Gustillo 812
Ao surgery ref
24.

How will u dislocate the head?

Flex hip and knee to 900 and adduct and internally rotate25.
How will u maintain anteversion?
Putting the stem along the calcar or 10-15o anterior to lesser
trochanter
26.
What is 3 point fixation?
proximal stem laterally, and its distal tip close to the medial femoral
cortex and collar on medial cortex along calcar.

27.
Will u use cement?
No austin moore
28.
Why?
For better fitting
29.
Tell about postoperative care
st
1 pod-drain off, breathing exercise, quadriceps exercize,
2nd pod- walk with walker
Avoid squatting, adduction and internal rotation,

30.

Tell the complication of the fracture?

Apley 852
31.

Tell the complication of treatment

Sura 7: 157
32.

What is garden index?

Apley 850
33.
What are the treatment options of fracture neck of
femur according to age?
Older patient >75-replacement hemiarthroplasty

Younger age-close reduction and internal fixation by

cannulated hip screw
34.
Which type of traction is given?
Surface traction
35.
How much weight can be given in surface traction?
6.7 kg/ 15 pound
36.
What is the complication of surface traction?
Vascular damage, skin slough out
37.
Why surface traction?
Reduction of pain
Prevent vascular and bony damage
38.
Tell the postop care of cannulated hip screw ?
Campbell-2730
39.
Why this fracture has occurred?
Osteoporosis
40.
How will u diagnose osteoporosis?
Apley 133
41.
How much bone need to be lost for osteoporosis?
25-30%
42.
What is the treatment of osteoporosis?
Apley 133
43.
Tell about the trabecular pattern of prox femur
Apley add 847
44.
What is the reduction technique for fracture neck of
femur?
Apley 849
45.
What are the close reduction techniques?
Apley 849 notes
Green-gay: traction and internal rotation
Lead-better: apley 849
46.
What are the open reduction techniques?
Gustillo 802,Campbell 2730
47.
What are the outcome of cannulated cancellous screw?
Failure of fixation
Nonunion
Osteonecrosis
48.
Cause of failure of fixation?

Campbell 2733
49.
What are the treatment options for AVN?
Realignment or rotational osteotomy relatively small
necrotic fragment
Joint replacement
50.
Causes of nonunion?
Poor blood supply
Imperfect reduction
Inadequate fixation
Tardy healing of intra articular fracture
51.
Treatment option of nonunion?
Apley 852
52.
What is calcar?
Datta 144
53.
What is linea aspera?
Datta 141
54.
Tell the biomechanics of hip
Sura 7:154
55.
Muscle pedicle graft indication and procedure?
Post communation and nonunion
Gustillo 803
56.
Tell the complication of hemiarthroplasty
iiGustillo 813
57.
Tell the generation of cementing technique
Cementing techniques First generation Original technique of Charnley: Hand mixing of the
cement Finger packing of cement in an unplugged and uncleaned femoral canal and acetabulum
No cement restrictor, no cement gun and no reduction in porosity
Second generation Femoral canal plug Cement gun to allow retrograde filling Pulsatile lavage
Cement restrictor
Third generation Pressurization of cement after insertion Some form of cement porosity reduction
(vacuum or centrifugation) Stem centraliser
Cartridge mixing and delivery Latest advancement in bone cement mixing technique It is a simple,
universal power mixer that quickly mixes and then mechanically injects all types of bone cement.
This type of device reduces mix times, as it requires fewer steps to load, mix, and transfer the
cement. The rotary hand piece reduces variability, which results in consistent mix times and built-in
charcoal filter reduces harmful fumes.

58.
What are the technique of improved cemented femoral
fixation?
Injection of low viscosity cement
Occlusion of medullary canal

Reduction of porosity
Pressurization of cement
Centralization of stem
Replacement of conventional ultra-high molecular weight
polyethylene to highly cross linked polyethylene.
59.
Tell the monomer and dimer of cement
Monomer-liquid form
Dimer-powder form
60.
How much weight the total hip component to withstand?
At least 3 times the body weight.
61.
Biomechanics of hip
Campbell 159
62.
Classify proximal femur according to cortical thickness
and canal dimension
Campbell 161
63.
Types of femoral component
Campbell 170
64.
Tell the exposure and prep of acetabulum
Campbell 187
65.

Shoulder dislocation
In which disease shoulder may dislocate?
epilepsy

Fracture tibial plateau

1. What is ur diagnosis?
17 days old tibial plateau fracture
2. Tell the classification of tibial plateau fracture?
Apley 890 campbell 2671
Hohl and Moore Classification of proximal tibia fracture-dislocations
Type I

Coronal split fracture

Type II

Entire condylar fracture

Type III

Rim avulsion fracture of lateral plateau

Type IV

Rim compression fracture

Type V

Four-part fracture

Classification useful for

1) true fracture-dislocations
2) fracture patterns that do not fit into the Schatzker classification (10% of all tibial
plateau fractures)
3) fractures associated with knee instability

3. What is ur treatment plan?

Apley 892
4. Tell the anatomy of prox tibia
Datta 147
5. Tell the development of prox tibia?
Datta 149
6. Tell the difference between medial and lateral tibial condyle?
a. Medial condyle is oval with ant-post axis lateral condyle is
circular
b. Lat condyle is little smaller than medial condyle
c. Lat condyle receive weight 40%, medial 60%
d. Lat condyle is a bit higher than med condyle
e. The medial plateau is the larger of the two articular surfaces and is concave in both
transverse planes. The lateral plateau is smaller and convex and lies slightly higher than the
medial joint surface, which helps in identifying it on the lateral x-ray.

7. What is buttress plate?

Thakur 82
8. Function of buttress plate?
Thakur 82
9. Tell the mechanism of injury
Apley 891
10.
Screw size?
6.5 mm cancellous screw
7 mm cannulated screw with washer
Ao asif 108
11.
Part of a screw?
Head, shaft, thread and tip-4 parts
12.
What will be ur approach?
Campbell 2677,2679

13.
Postoperative care?
Campbell 2677
14.
Complication of this fracture?
Apley 895
15.
Complication of operation?
Injury to common peroneal nerve
16.
Course of common peroneal nerve?
Datta 219,221,198
17.
Tell the anastomosis around knee?
Netter 481
18.
What are the structures injured along with tibial plateau?
Sura 7: 164
19.
Tell the incidence of tibial plateau fracture?
Sura 7: 164
20.
Fate of bone graft?
Turek 68
21.
How will u do X ray?
o
15 caudal AP view, as there is 150 posterior tilt
22.
Tell the conservative protocol of tibial plateau fracture

Fracture distal femur

1. Tell ur diagnosis
T or Y condylar fracture of distal femur
2. Tell the ao classification
Ao surgery ref
3. Tell the anatomy of distal femur
Datta 144
4. Tell the development of distal femur
Datta 144
5. Tell the complication of fracture
Apley 871
6. What is ur treatment plan?
ORIF by distal femoral locking plate
7. What is the screw size and drill bit?
Drill 3.5 mm cancellous locking screw 5.9 mm
Drill 3.2 mm cortical screw 4.5 mm
8. How many holes are there?
9 locking hole for metaphyseal region

9. What will be the postoperative care?

Campbell 2699
10.
What is floating knee?
Ipsilateral femur and tibial shaft fracture Floating knee is a flail knee
joint resulting from fractures of the shafts or adjacent metaphyses of the femur and
ipsilateral tibia (see image below). Floating knee injuries may include a combination
of diaphyseal, metaphyseal, and intra-articular fractures
Stage ; Fraser et al classified floating knee injuries in a similar way by analyzing
knee involvement

Fracture shaft of femur

1) What is ur diagnosis?
Fracture shaft of femur AO type-, winquist type2) What is ur treatment plan?
Close reduction and internal fixation by interlocking
intramedullary nail
3) Tell the fracture classification
Ao surgery ref
Campbell 2705-winquist classification
4) Tell the force causing this fracture
Apley 859
5) What is the benefit of im nail?

Early wt bearing
Short hospital stay
Rapid return of motion in all joints
Prompt return to walking
Relatively short total disability time
Allows some movement at fracture site and ensures callus
formation
It shares load
Prevent angulation, translation and some rotatory movement
6) What is the complication of im nail?
Damage the nutrient artery
Damage to neck or shaft
Fat embolism
Loose fitting nail-delayed or non union
Infection
Implant failure
7) How will u measure the length of im nail?
a. Tip of greater trochanter to joint line, then subtract 20-30
mm
b. Length of reaming rod-exposed portion
c. With the help of guide wire of same length of reaming rod
and parallel to exposed rod
8) Tell about the generation of nail?
4 generation
a. Ist generation: prox locking bolts are directed downwards
and medially from greater trochanter to lesser trochanter.
Ex. Grosse-kempe, AO transverse
b. 2nd generation: prox locking bolts are directed from greater
trochanter below upwards and medially towards the head
of the femur. Russel Taylor nail
c. 3rd generation: distal and prox locking screw. Ex- trigen nail
system
d. 4th generation: slot for segmental fracture fragment

9) Tell the treatment option of this fracture

Apley 860
10)
What is working lenth? Tell its importance
Thakur 136
Distance between proximal and distal screw.
Importance-

The more working length, the more stable

The more micromovement and callus formation
The more healing.
11)
How will u operate
Campbell 2712
12)
Problem of pyriform fossa insertion
Neck fracture, disturbance in the anastomosis
13)
Problem of tip of greater trochanter insertion
Lateral cortex fracture
14)
Tell the postoperative care
Campbell 2713
15)
Tell the anatomy of femur
Datta 139
16)
Tell the development of femur
Datta 139
17)
Tell the complication of this fracture?
Apley 867
18)
Which anastomosis lie in pyriform fossa?
Datta 190
19)
Which anastomosis around greater trochanter
Datta 190
20)
Tell the screw size and drill bit
21)
What are the characteristics of kuntscher nail
-invented in 1930 by Gerhard Kuntscher.
Nail has a slot which can be compressed during insertion.
After insertion it expand
22)
How will you insert it?
23)
How to dynamise?
By removing screw distal from fracture site. The screw should
be placed on upper border of oblong hole.
24. what do u mean by sign nail?
Surgical implant generation networks
24)
Tell the entry point of DFN
Intercondylar area just anterior to attachment of PCL

Nonunion:
1.What is non union?
Campbell 2982
2.Types of nonunion?
Campbell 2983

Types of nonunion
Septic and aseptic nonunion
Aseptic:
2 classification:
a) AO Classification
b) Paleys modification of ilizarovs classification
AO classification(Weber)
Hypertrophic(reactive, hypervascular):1)elephant foot 2)Horse hoof
3)oligotrophic
Atrophic : 1)torsion wedge 2)comminuted 3)defect 4)atrophic
Paleys classification:
Type A: nonunion with bone loss less than 1 cm. A1: nonunion with mobile
deformity A2: nonunion with fixed deformity. A2-1: stiff nonunion without
deformity. A2-2: stiff nonunion with a fixed deformity
Type B: bone loss more than 1 cm.
B1:nonunion with a bone defect
B2: loss of bone length(shortening)
B3: both

Classification of infected nonunion: (Rosen classification)

-infected draining nonunion
-infected nondraining nonunion: a)quiescent(dry, nondraining for at least for
03 months) b)active:nondraining but with abscess and fever
Kulkarnis classification of infected nonunion:
3 types:
Type1: fragments in apposition with mild infection and with or without
implant,

Stable implant in situ with mild infection.

On pressing the wound, a bead of pus may observe at the sinus. Type 1 also
includes nondraining, dry for at least 03 months(rosen type 1a)
There is no gap, shortening or deformity
Type 2: fragments in apposition with severe infection with a large or small
wound. If the wound is large, plastic surgical procedures may be needed to
cover the wound.
Active nondraining with abscess and fever (rosen type 1b)
No gap, shortening or deformity
Type 3: severe infection with a gap or deformity or shortening or
combination
3A: defect with full circumference of the cortex
3B: defect more than one third of the cortex. Papineau type bone grafting is
very useful.
3C: with deformity. Fracture gap less than 2 cm is also included in this type.
Can be satisfactorily treated by ilizarov technique.
3. Cause of nonunion?
Campbell 2982
4. What is pseudoarthrosis?
Formation of abnormal joint like structure in case of nonunion is called
pseudoarthrosis
5. Mechanism of formation of pseudoarthrosis
Abnormal mobility converts pleuripotential mesenchymal cells into
fibroblast and synoviocyte instead of osteoblast.
6. How bony union occurs?
Apley 690
7. How will u diagnose nonunion?
Clinically history of fracture
On exam-painless abnormal movement
X ray-gap, margin will be sclerosed, smoothened, obliteration of
medullary cavity no evidence of callus formation.
8. Tell the difference between nonunion and delayed union

Point
Clinically
Pain
Radiograph shows

Change in treatment
Gap

Nonunion
Delayed union
Duration more than 08 Duration less than 6-8
months, mobility
months mobility
Slight
More
Sclerosed ends
No sclerosis of the
ends
Closed medullary
Open medullary cavity
cavity
Usually required
May unite without
change
Gap usually present
Gap usually present

Implant failure:
Causes of implant failure?
Surgeon factor1.
2.
3.
4.
5.
6.

Improper choice of implant

Inadequate fixation
Use bad quality implant
Improper bending
Unclean operation
Maximum soft tissue and periosteum stripping

Patient factor
1.
2.
3.
4.
5.

Anaemia
Poor nutritional status
DM
Tuberculosis
AIDS

6. Immunosuppressive agent
7. Steroid
8. Connective tissue disease
9. Renal failure
10.
Osteoporosis
Implant factor:
1. Dissimilar metal
2. Corrosive material
3. Faulty manufacturing
What is implant failure?
Giving way of implant before serving definitive purpose

Bone graft:
1. What is bone graft
2. Tell how to take bone graft
Campbell 21
3. Function of bone graft
Campbell 15
4.

Xray findings
Gap
Sclerosed margin
Obliteration of medullary cavity

5. Fate of bone graft

Turek 74
6. Radiological feature of bone graft
Chip autografts initially look like osseous fragments on radiographs.

Ilizarov :
1.
a.
b.
c.
d.

Tell the principal of illizarove

Law of tension stress
Distraction osteogenesis
Mechanical induction of new bone formatin
Neovascularization

e. Stimulation of biosynthetic activity

f. Activation and recruitment of osteoprogenitor cells
g. Intramembranous ossification

2. What is law of tension stress?

Process of new bone formation and soft tissue regeneration under
effect of tension stress caused by slow and gradual distraction.
3. What is wolffs law
Wolff's law is a theory developed by the German anatomist and surgeon Julius Wolff (18361902) in
the 19th century that states that bone in a healthy person or animal will adapt to the loads under which it
is placed.[1] If loading on a particular bone increases, the bone will remodel itself over time to become
stronger to resist that sort of loading.[2][3] The internal architecture of the trabeculae undergoes adaptive
changes, followed by secondary changes to the external cortical portion of the bone, [4] perhaps becoming
thicker as a result. The inverse is true as well: if the loading on a bone decreases, the bone will become
weaker due to turnover, it is less metabolically costly to maintain and there is no stimulus for
continued remodeling that is required to maintain bone mass.[5]

4. Where the rings will be placed in tibia and downwards.

Proximal ring:
1st: at the level of fibular head. Through the head of the fibula to a
point just posterior to a vertical line drawn from the medial border of
patella parallel to joint line.
2nd: anterolateral surface just behind and 5 mm below to point drawn
by the horizontal line from the head of fibula and vertical line drawn
from the lateral border of patella emerge just anterior to medial
border.
Middle ring:at the junction of prox and middle third
1st: 2cm lateral and behind the shin of tibia emerge just anterior to
medial border
2nd: 2cm anterior to anterior border of fibula 5mm below the 1 st wire
2 cm posteromedial to the shin of tibia.
Distal ring:
1st: at the junction of middle and distal third. Through fibula through
tibia to 2cm posteromedial to the shin of tibia
2nd: 5 mm below the first wire through middle safe zone(ant border
of tibia and fibula divided into 3 zone) emerge just anterior to medial
border.
Calcaneal wire: behind and parallel to calcaneal surface of heel
1st wire:

3 cm behind the artery is the safe zone in the medial surface. 2cm
above the undersurface of calcaneum and 2 cm in front of
tendoachilis insertion emerge 4-6 cm behind the posterior border of
post malleolus.
Calcaneal pins ideally should be inserted as far posterior as possible while still engaging sound bone.
The tendons and neurovascular bundle passing behind the malleoli and the subtalar joint are to be
avoided.
Halett et al suggests for a calcaneal pin place it 2 cm below and behind the lateral malleolus or 3 cm
below and behind the medial malleolus BEWARE Tornetta et al show no position is completely safe
when placing a medial calcaneal pin or transcalcaneal pin. Ensure you are as far posterior as
possible yet still engaging bone.

2nd wire: 1 cm anterior to 1st wire angle 300

Tarsal wire:
1st wire: medial surface of navicular to the summit of the cavus
2nd wire: centre of outer surface of cuboid to summit of cavus
Metatarsal wire:
1st: outer side of distal part of 5th metatarsal between head and neck
and pierce 3rd, 4th and 5th MT just proximal to their head emerge on
the dorsum of foot.
2nd: medial surface distal to 1st MP joint prox to its head and advance
obliquely to emerge on the dorsum of foot after piercing 2 nd
metatarsal.
5. What is the site for corticotomy?
.5 to 2 cm below the tibial tuberosity

Calcaneal fracture
1. What is bohler angle?
Bhler angle (also written as Bohler angle or Boehler angle) is the angle between two lines tangent to
the calcaneus on the lateral radiograph. These lines are drawn tangent to the anterior and posterior
aspects of the superior calcaneus.

Bohler's angle
Severe injury may result in flattening of the calcaneus. This results in a reduction of 'Bohler's angle'.

On a lateral view this angle is formed by the intersection of two lines. The first line is drawn from (1) - the upper
edge of the calcaneal body posteriorly to (2) - the upper edge of the posterior articular facet of the calcaneus at
the subtalar joint. From this point another line is drawn to (3) - the upper edge of the anterior process of the
calcaneus.
Bohler's angle is normally between 28-40 degrees.
2. Present ur case
3. What is the type of this fracture
Apley 924
4. Tell the complication of this fracture
Apley 928
5. Tell the treatment option
Apley 926
6. Tell ur plan
7. Tell the operative procedure
8. Tell the postoperative care

Fracture proximal humerus:

T-Y condylar fracture humerus:

Hip dislocation:
1. Present ur case:

2. What is ur diagnosis?
Posterior dislocation of lt hip
3. Classify hip dislocation?
Ebnezar 213

Modified Garrets classification

Group 1-3 days to 3 wks
Group 2-3 wks to 3 months
Group 3-3 months to 1 yr
Group 4-more than 1 yr
4. What is ur plan?
Open reduction and maintenance of reduction by UTST
5. Why posterior dislocation is common?
Usually due to dashboard injury where femur is pushed upwards
6. Tell the anatomy of hip joint
Datta 226
7. Tell the development of hip
Datta 138
8. What is the mechanism of injury?
RTA
9. What will be the clinical feature?
Posterior-shortened, adducted, flexed and internally rotated
Anterior-shortened, abducted, flexed and externally rotated
10.

Why u want to go for open reduction?

After 03 months close reduction and heavy traction usually fails, as the
acetabulum may fill with fibrous tissue.
11.

What is seen in x-ray?

Dislocation of hip
12.

What is seen in CT?

Dislocation of hip with intact acetabulum.

13.

What are the reduction technique?

Campbell 2764
14.

What are the complication of dislocation?

Ebnezar 219
15.

What are the treatment options

Close reduction
Open reduction
Heavy traction and abduction
Subtrochanteric osteotomy
Excision arthroplasty
Replacement arthroplasty
THR
Arthrodesis
16.

Tell ur approach

Kocher-langenbeck approach: Campbell 77

17.

Tell the post operative care?

Ebnezar 219
18.

Tell the complication of treatment?

Sciatic nerve injury

Injury to vessels
19.

What is the incidence of sciatic nerve injury in posterior dislocation?

10-15%

89% knee injury

20.

Tell the biomechanics of hip

Gustillo 792
21.

Name the factors giving stability to hip?

Bony factor-head and acetabulum

Soft tissue- capsule
Ligament-illeofemoral
Ischiofemoral
Pubofemoral
Muscles surrounding hip
22.

Weight bearing part of acetabulum and head of femur

Superior portion of the lunate surface

Superior portion of head

Pelvic fracture
1. Present ur case?
2. Tell the classification
Campbell 2783
3. Tell the tiles classification?
Campbell 2803
4. Tell the mechanism of injury
Apley 837
5. What are the clinical features

Apley 839
6. What is ur plan

7. What is column and what is wall?

Apley 837
Pelvic ring has two arches:
(a) posterior arch is behind acetabular surface and includes sacrum, sacroiliac joints and their
ligaments and posterior ilium, and
(b) anterior arch is in front of acetabular surface and includes pubic rami bone and symphyseal joint.
Anterior column of acetabulum extends from the anterior half of the iliac crest to the pubis
(iliopubic). Posterior column of acetabulum extends from the greater sciatic notch to the ischium
(ilioischial).

8. What is cotyloid fossa?

Acetabular fossa
9. Tell the indication of surgery?
Campbell 2787

10.

Where to do conservative approach?

Campbell 2784
11.

Tell ur approach

Posterior kocher langenbeck approach for post column and wall campbell 77
Anterior ilio-inguinal approach: hoppenfield
12.

Draw spring plate

13.

Tell about ur implant

Recon plate 88, 108 dia, drill 2.5, screw 3.5 cortical screw
14.
15.

Tell the windows in anterior approach:hoppenfield

Tell about postoperative care

Campbell 2795
16.

What are the views do u require for pelvic fracture?

AP view and Judet views

17.

What is spur sign

Campbell 2783

18.

What is the rule of 80 in case of acetabulum fracture

a) 80% diagnosed by xray

b) 80% can be treated conservatively
c) 80% posterior approach
19.

Tell the important landmarks in pelvic Xray.

20.

What is the treatment for iliac blade fracture?

Skin grafting
1. From where we can take full thickness skin graft?
Upper part of arm, supraclavicular fossa, back of the ear
2. Tell the process of graft take?
Imbibitions: within 24-48 hrs. adhesion of graft to bed by fibrin layer
Inosculation: alignment of graft-host vessels
Revascularization: connection of graft host vessels. Formation of new
blood vessels, combined old and new vessels.
3. Indication of skin grafting

When primarily cant be closed

Deep dermal or full thickness burn
Scar contracture release
Defects after resection of superficial lesions
Congenital syndactyly
If there is no epithelialization even after 14 daysskin grafting.

4. What will u do in case of palm skin loss?

Full thickness skin grafting
5. Types of graft contraction
a. Primary-immediately after harvesting
b. 2ndary-after healing in recipient site
FTSG loses 40% after primary contraction. STSG usually no primary
contraction, there is 2ndary contraction.

6. What is the time of skin ischemia?

06 hrs to develop and 06 months to heal.

Polytrauma:
1. Tell the priority of OT list
a.open fracture
b. fracture-dislocation
c. intraarticular fracture
d. polytrauma

2. If a patient with bleeding come to u and u get blood and fluid? What
will u give?
Fluid first to compensate the extravascular shift.

3. Where will u give short wide bore needle?

2-one above diaphragm and one below diaphragm to pass fluid
through both superior and inferior vena cava.
4. What is the meaning of saphena?
Easily seen
TRACTION
Osteoporosis
1. What is osteoporosis?
2. What are the difference between osteoporosis and osteomalacia
3. How will u diagnose osteoporosis?
4. How will u treat it
5. What are the causes of 2ndary osteoporosis?

NIDEMO-nutritional, inflammatory, drug, endocrine,

malignancy,others-immobilization, cigarette, alcohol

NERVE INJURY
1.what are the nerves can be used as graft?
Sural nerve
Medial cutaneous nerve of arm
Superficial radial nerve
Lateral cutaneous nerve of forearm
TENDON TRANSFER IN HAND
6. Why we dont choose FCU transfer?
FCU is the main wrist flexor. If FCU is transferred, power grip
will be lost.
Flap:
Q1. Tell the flap of different site of leg
-upper 1/3rd: gastrocnemius flap
-middle 1/3rd: soleal flap
-lower 1/3rd: distally based fasciocutaneous flap
2. what is island flap?
only based on blood vessel-all attachment should be freed
pedicle flap: some attachment remains

Talus fracture:
1. Tell the blood supply of talus?
Blood Supply of The Talus

Extraosseous Blood Supply

Posterior Tibial Artery

o

1. Artery of the Tarsal Canal

Arises from Posterior Tibial A 1cm proximal to division

Passes anterior to FDL

Enters Tarsal Canal (only other structure present is the Interosseous Ligament)

Branches then enter Talus

From medial side

Inferiorly from the canal

Continues to Tarsal Sinus

Anastomosis with arteries in Tarsal Sinus to produce vascular sling

2. Deltoid Branch

Important branch from the artery of the Tarsal Canal (occasionally directly from the Posterior
Tibial A)

Between the leaves of the Deltoid ligament

Sends branches that enter via medial side of the talar body

Responsible for supply to the medial 1/2 of the talar body

Anterior Tibial Artery

o

1. Superior Neck Branches

From the Dorsalis Pedis

2. Artery of Tarsal Sinus

Formed by anastomosis of branch of the Dorsalis Pedis that crosses the navicular (lateral
tarsal branch), the branch of the Perforating Peroneal A

Supplies the lateral 1/2 of the talar body

Peroneal A
o

Unimportant

Contributes to plexus around the posterior talus around the posterior tubercle area

Perforating branch to artery of the Tarsal Sinus

Intraosseous

Head of Talus
o

Medially from branches of the Dorsalis Pedis

Laterally from the artery of the Tarsal Sinus

Body of talus
o

Laterally from the artery of the Tarsal Sinus (Lateral 1/3)

Middle part from branches of the anastomosis between the arteries of Tarsal Sinus & Tarsal Canal

Medial part from Deltoid artery (Medial 1/3)

- See more at: http://www.orthofracs.com/basic-science/anatomy/blood-supply/blood-supplytalus.html#sthash.oW6WlMJs.dpuf

2. Why avn is common?

3. Classify talus fracture
Apley 922
4. What are the treatment option
5. Tell the post operative care?
6. Tell the mechanism of injury?
Apley 921
7. The snow boarders fracture
Fracture of lateral process of talus due to everting force.

AVN OF HIP:

1. What is the clinical feature of AVN

Apley 528
2. When both hip is involved how will u do trendelenberg test
and Thomas test
Thomas test: both hip flexed to obliterate lumbar lordosis and
one hip is gradually extended.(crex 112)
Trendelenberg test: sound side sag
3. What are the D/D?
TB hip
Septic hip
OA hip
4. Tell the difference between TB hip, septic hip, OA hip and AVN
Points

TB

Septic

OA

Rheumatoi
d

AVN

Clinically

Constitutional

History of high
fever.
Usually in
children. In
aduld after a
procedure.

Occurs after
periods of
activity.
Internal
rotation,
abduction
and external
rotationusually
affected first

Activity
decreases
pain.

Increased
pain over a
period of 2
yrs.

Initially

Initially

Initially

Symptom
Initially flexed
and abducted
and in late
stage flexed,
adducted and
medially
rotated.

Radiologicall

Initially

Progressive
destruction Sectoral
on both
sign may
side of the
be positive
joint
without any
reactive
bone
formation.hall mark of
the
disease.

Early stage

general
rarefaction
but with
normal joint
line and
space. Bone
abscess.
Later
destruction of
acetabular
roof and
femoral head.
Bones
recalcify.

displacement
of femoral
head, vacuum
sign in the
joint.
Later bone
destruction,
bony ankylosis

decreased
joint space
specially in
superior
weight
bearing
zone. Later
subarticualr
sclerosis,
cyst
formation
and
osteophytes.

osteoporosi
s and
diminution
of joint
space.

plain xray
normal. 6-9
months
after bone
death
reactive
Later
changes in
acetabulum surrounding
and
bone
femoral
increased
head are
densityeroded.
sclerosis.
Protrusion
acetabuli is Later
common. If subchondra
patient on
l fracture
steroid
linegross bony crescent
destruction sigh, slight
and floor of flattening
acetabulum of the
may be
weight
perforated. bearing
zone,
increased
distortion
with
eventual
collapse of
the
articular
surface of
femoral
head.
Dense band
between
dead bone
and new
bone
formation.

Other inv

5. Tell the points of rheumatoid arthritis

See orthopaedic

6. Tell what is osteoarthritis

See orthopaedic
7. What is the stage of the disease?
Apley 108,532
8. Tell the staging
9. What is crescent sign
Apley 106
10.

What is avn?

Death of a part of the body due to severance of its blood

supply.

11.

What is necrosis and apoptosis?

Necrosis refers to a spectrum of morphologic changes that follow cell death in living tissue,
largely resulting from the progressive degradative action of enzymes on the lethally injured cell
12.

What is the cause of avn

Apley 103

13.

Tell the pathogenesis of avn\

Apley 104,105
14.

What are the treatment option for avn

15.

Apley 109

16.

How to take lateral view of hip and frog leg view?

A frog leg lateral view is a special type radiographic view to evaluate the hip. Joints
and femoral necks are better visualised and can be compared. Technique
the patient is usually positioned supine on the x-ray table with the affected limb
flexed at the knee approximately 30 to 40 and the hip abducted 45.
the heel of the affected limb should rest against the medial aspect of the
contralateral knee
the cassette is placed so that the top of the film rests at the anterior superior
iliac spine.
the crosshairs of the beam are then directed at a point midway between the
anterior superior iliac spine and the pubic symphysis. the x-ray tube-to-film
distance should be approximately 40 in (102 cm)

TOTAL HIP REPLACEMENT

1. What is arthroplasty?
Surgical replacement of a part or whole of the joint or excision
of the diseased part to obtain pain free functional movement.
Surgical refashioning of a joint to relieve pain and restore
function
2. What are the types of arthroplasty
4 types: a. excisional arthroplasty b. surface arthroplasty c.
replacement hemiarthroplasty d. total hip replacement

3. What is surface arthroplasty?

Covering the diseased hip with thick skin or ivory or metallic
cup. But foreign material causes osteolysis. It can be done in
young people.
4. Tell the approach
Campbell 65
5. What will u do if u cant reduce femoral head?
Cut capsule
Cut iliopsoas
Abductor release from ilium
6. Tell the procedure
Campbell 188
7. Tell the direction of acetabular screw
Campbell 188: 11 and 1 oclock
8. What is the benefit of thin neck?
The more the neck is thin, the more is the arch of movement.
9. Tell the postoperative care
Campbell 300
10.

Tel l the postoperative complication

a. Mortality- within 90 days 1% in primary THR and 2.6% in revision

surgery. In hospital 0.33%.
b. Haematoma formation-from obturator vessels when ligamentum
teres, transverse ligament and osteophytes removed from inferior
aspect of acetabulum.
First perforating branch of the profunda femoris deep to
gluteus maximus

Branches of femoral vessels near ant capsule

Branches from sup and inf gluteal vessels.
c. Heterotropic ossification
d. Thromboembolism
e. Nerve injury
f. Vascular injury
g. Limb length discrepancy
h. Dislocation
i. Fractures
j. Infection
k. Loosening of implant
l. Osteolysis
11.
Tell the indication and contraindication of total hip
replacement
Campbell 179
12.

What are the various offset

Campbell 164
13.

What are the various femoral and acetabular component

Campbell 166
Femoral component:
a. Cemented: polished surface
Nonpolished
PMMA coated
Modular

Nonmodular
b. Noncemented
Titanium alloy
Cobalt-chromium alloy
Surface modification:
-porous coating
-grit blasting: pressurized spray of aluminium
-plasma spraying: high velocity application of molten metal
-hydroxyapatite coated
Stem type:
-single wedge: type 1
-double wedge: type 2
Type 3: double wedge and more fixation at metaphysiodiaphyseal junction
Type 4: extensively coated implant
Type5: modular
Type 6: anatomical

Acetabular component:
Cemented:
Thick walled polyethylene cup: vertical and horizontal groove
and spacer

Noncemented:

Metal shell with modular liner

-modular , non modular
-metal-metal
-ceramic-ceramic
14.

Tell the preoperative templating

Campbell 182
15.
What will u think if femoral head is good but acetabulum
is diseasesed?
Neoplasm

TENDOACHILIS INJURY
1. What is modified tauffer technique and tauffer technique?
2. Tell the postoperative care
TORTICOLIS
1. What are the treatment options?
2. What is the complication of proximal release?
Injury to spinal accessory nerve
3.