Prelims

Fundamentals of ORTHOPEDICS

Second Edition

Mukul Mohindra MS (Orthopaedics) DNB MNAMS Dip SICOT (Belgium) FNB (Arthroscopy and Sports Medicine) Specialist CGHS Specialist Wing and Central Institute of Orthopaedics Vardhman Mahavir Medical College and Safdarjung Hospital New Delhi, India Jitesh Kumar Jain MS (Orthopaedics) FNB (Arthroscopy and Sports Medicine) Registrar Institute of Orthopaedics and Traumatology Sawai Man Singh Medical College, Jaipur, Rajasthan, India Words of Wisdom Deepak Chaudhary Forewords Ramesh Kumar RC Meena Himanshu Kataria

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Fundamentals of Orthopedics

First Edition: 2016

Second Edition: 2018

9789352701322

Printed at:

My mom and dad, for their blessings; my wife Bhumika, for her unconditional love; and my family, for always being there to my support.

—Mukul Mohindra

My parents, whose nurturing gave me courage to dream; my wife Zeepee, who strengthened me to realize my dreams; and, my brother Manish, who has always been there, whenever I needed support.

—Jitesh Kumar Jain

Contributors

Ammar Aslam MS (Orthopaedics)
Assistant Professor
Department of Orthopaedics
Hamdard Institute of Medical Sciences and Research
Jamia Hamdard University
New Delhi, India
(Spondyloarthropathies)

Ankit Thora MS (Orthopaedics) DNB
Consultant Orthopaedics and
Joint Replacement Specialist
Shalby Hospital
Indore, Madhya Pradesh, India
(Electrodiagnostic Studies, Compression Neuropathies)

Ankur Wadera MD (Radiodiagnosis) DNB
Consultant Radiologist
Deepak Hospital
New Delhi, India
(Imaging in Orthopedics)

Anurag Tiwari MS (Orthopaedics) DNB
Assistant Professor
Department of Orthopaedics
All India Institute of Medical Sciences
Bhopal, Madhya Pradesh, India
(Osteomyelitis and Septic Arthritis and Skeletal Tuberculosis)

Ashish Rana Dip Orthopaedics DNB (Ortho) Consultant Orthopaedics and
Joint Replacement Specialist
NIMS University
Jaipur, Rajasthan, India
(Rickets and Osteomalacia)

Balaji Sambandam MS (Orthopaedics) DNB Assistant Professor
Department of Orthopaedics
Sri Manakula Vinayagar Medical College
and Hospital, Puducherry, India
(Injuries around Ankle, Orthopedic Instruments and Implants)

Milind Tanwar MS (Orthopaedics)
Senior Resident
Sports Injury Centre
Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
(Amputations, Orthotics and Prosthotics Splints and Tractions)

Paritosh Gogna MS (Orthopaedics) DNB
Dip SICOT (Belgium)
Consultant Orthopaedics
Artemis Hospitals
Gurugram, Haryana, India
(Ligament Injuries of Knee,
Latest Trends in Orthopedic Surgery)

RC Meena MS (Orthopaedics)
Head of the Department
Institute of Orthopaedics and Traumatology Sawai Man Singh Medical College
Jaipur, Rajasthan, India
(Management of Polytrauma Patients)

RL Dayma MS (Orthopaedics)
Professor
Institute of Orthopaedics and Traumatology Sawai Man Singh Medical College
Jaipur, Rajasthan, India
(Upper Limb Traumatology)

Ruchi Dudeja MD (Paediatrics)
Consultant Paediatrician and Neonatologist Krishna Medicare Centre
Gurugram, Haryana, India
(Skeletal Dysplasias)

Sahil Batra MS (Orthopaedics) DNB FNB (Spine)
Consultant Spine Surgeon
Caremax Superspeciality Hospital
Jalandhar, Punjab, India
(Spinal Injuries)

Sahil Gaba MS (Orthopaedics)
Senior Resident
Department of Orthopaedics
All India Institute of Medical Sciences
New Delhi, India
(Pediatric Orthopedics)

Saurabh Agarwal MS (Orthopaedics)
Consultant Orthopaedics
Indraprastha Apollo Hospital
New Delhi, India
(Anatomy and Composition of Bone
and Bone Growth)

Shivali Arya MBBS
Maulana Azad Medical College
New Delhi, India
(Sketches)

Simran Kaur MBBS
Pandit Bhagwat Dayal Sharma University of Health Sciences
Rohtak, Haryana, India
(Multiple Myeloma and Soft Tissue Sarcomas, Osteoporosis)

Words of Wisdom

‘Hard work beats talent when talent fails to work hard, is a universal truth. The master key to success is determination, to do that extra bit and to go that extra mile. But effort should always be well disciplined. Discipline means persistence and perseverance—the ability to continue through bad times, obstacles and problems in a competent manner. This book is a diligent effort by a team of people to share the knowledge and experience they gained over the sleepless nights of hard work to give you the best. So, get set to reach your goals with a mentor to guide, and steer yourself through till you reach what you deserve.

Always remember the 6Ps that demarcate the bridge between mediocrity and excellence.

Proper

Prior

Planning

Prevents

Poor

Performance

Deepak Chaudhary

Director

Sports Injury Centre

Vardhman Mahavir Medical College and Safdarjung Hospital

New Delhi, India

Foreword

In today's world, where each of us wants to contribute his/her share towards having a healthy and better life, this book does complete justice. It has covered all the basic and advanced topics in the minutest of details, while maintaining the length to an extent as not to lose interest of the reader. The pictorial insets are the catchpoints to explain the synonyms used, in the best possible manner making the related topic not only interesting but also enhancing the visual memory.

The simplicity of the words is a complete feast for the reader. It is a must read not only for undergraduates but also for those pursuing higher studies. The entire effort makes the subject simplified, interesting, reproducible and applicable, getting the best out of you, for you and your patients. I congratulate the authors and offer my best wishes!

Ramesh Kumar

Director

Central Institute of Orthopaedics

Vardhman Mahavir Medical College and Safdarjung Hospital

New Delhi, India

Foreword

During undergraduation, orthopedics is one among the least read subjects and this is such a specialty in India, where the undergraduates and postgraduates read different books as most of the books meant for undergraduates are insufficient; and, those for postgraduates, are indigestible for undergraduates. After going through this book, I believe that this is a fine balance between undergraduate and postgraduate teachings. It is an extensively illustrated book—full of diagrams, X-rays, flow charts and high-yield points. Of late, sports medicine has emerged as a subspecialty of orthopedics, and I am happy to see a separate chapter on sports injuries and their rehabilitation in an orthopedic textbook for undergraduates. What makes it desirable for all medical students is that the book contains so much updated information, and covers all important and rare topics of orthopedics that the students will not require any other book for preparation of their postgraduate entrance examination. I wish all the best to the authors!

RC Meena

Head of the Department

Institute of Orthopaedics and Traumatology

Sawai Man Singh Medical College

Jaipur, Rajasthan, India

Foreword

Teaching methodology and orthopedics course curriculum have undergone plethora of changes in the past decade. The quantum jump in orthopedic technology witnessed in diagnosis and management of various orthopedic pathologies and procedures calls for a compact reading material, which keeps pace with the change.

Fundamentals of Orthopedics by Drs Mukul Mohindra and Jitesh Kumar Jain has narratively and comprehensively explained the basic concepts, diagnosis and management of key orthopedic conditions, which the undergraduates must know as a part of their MBBS curriculum. The inclusion of excellent X-rays, clinical photographs and box depictions, besides elaborating high-yield points after each relevant pathology or concept, are highly informative, with an eye on postgraduate entrance examination.

Having gone through a few chapters, I am fully convinced that this book with its lucidity and in-depth elaboration of orthopedic pathologies, will be an asset to every undergraduate student.

Drs Mukul Mohindra and Jitesh Kumar Jain have worked with me at the Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India, and have an amazing clarity of clinical foundations of orthopedics. I strongly feel that the book is a must on the shelf of every undergraduate student of medicine. I am sure that the authors will further justify every subsequent edition, keeping in mind the fast-changing orthopedic technology.

I wish the book and the authors all success in furthering the knowledge of orthopedics among the undergraduate students.

Himanshu Kataria

Professor

Sports Injury Centre

Vardhman Mahavir Medical College and Safdarjung Hospital

New Delhi, India

Preface

‘When the going gets tough, the tough gets going’. This perspective well holds its worth in today's era where the examination system has undergone a paradigm shift. To keep pace with the growing expectations of the varied examiners, what is required from a medical student, today, is extreme versatility. Not only it is important to acquire sound principles to attempt the subjective papers and pass the clinical examinations, but it is also equally mandatory to build an elaborative knowledge bank that is accurate and up-to-date with the current trends to score well in the objective examinations. This book is just a perfect answer to this tough task that time has posed to a medical aspirant.

The book has been written to offer an all-in-one package to conquer every version of the examination system. The information given in the book is elaborate yet it is concise and to the point. Latest trends in the field have well been addressed by addition of units such as Sports Injuries and their Rehabilitation. A number of contributors have shared their knowledge and concepts to ensure the material delivered is highly accurate. Considering the paucity of time that lies with an aspirant, the contributors have especially worked hard to ensure complete delivery of the material in topics such as polytrauma management, arthritis, metabolic bone diseases, spinal injuries, etc. that lie sandwiched between orthopedics and other branches.

Since we have been actively involved in teaching for many years, we were well versed with the changing recent trends. All topics have an incredible touch of simplicity yet they are comprehensive. An amazing feature of the book is the vast collection of images. Almost every clinical sign, clinical test, radiological sign, an instrument or an implant has been depicted in the form of a well-labeled figure. Similes have been drawn to enable clear and easier understanding of all fancy signs in the subject—an idea that is first of its kind. We remember well our times as undergraduates when looking at them we would ponder as what to look for. We are hopeful that this addition will not only enhance the practical skills of the readers but also help them steer through the increasing image-based puzzles being put up to them in the online versions. The book features the first-ever introduced image-based quiz section to help to understand the matter.

Keeping in mind the objective entrance pattern, well-sorted statements have been added at the end of all topics as ‘High-yield Points’ to facilitate answering the multiple choice questions. We have not only ensured that nothing is missed but also confirmed that information is highly accurate, for we understand well enough the worth every single correct answer holds in shaping your future.

When we sit back and share memories of times we used to prepare, we would often smile together at some common moments—that around 20 different subjects and all to be mastered for just one exam. It is indeed a herculean task for which we have jotted an excellent and well-organized Synopsis of Orthopedics with efforts that spanned over sleepless nights. This chapter has all that you need to brush up a day before the examination when the adrenaline rush is high but the brain glucose is low.

‘All is well that ends well’, a quote that needs no description. So to ensure the end is just not dump, rather just perfect, a smartly prepared MCQs collection comprising both controversial and non-controversial questions from all recent examinations have been sorted and jotted to rightly make this edition an “All-in-One” book. These MCQs are just the perfect feast for the hungry PG aspirants.

And, to sum up, we will share with you a quote well said, “You seldom improve when you have no role models but yourself to copy.” This book has been written to give you just a perfect mentor that will teach you sound principles and practices of orthopedics, make you versatile to an extent the trend demands, and simply make you the best what you really deserve to be, for you have proven you are different from the lot by choosing a profession that is one of the most noble ones.

Mukul Mohindra

Jitesh Kumar Jain

Acknowledgments

“Where there is will, there is a way and to steer you through that way, there are always these hands disguised as teachers, colleagues, juniors and friends.” To accomplish the herculean task of concisely and comprehensively compiling the knowledge yet keeping it simple to understand and memorize, there were so many brains and hands working day and night selflessly behind the stage. This book was a dream project started and thought by us but a long list of people got involved along, in one way or the other. It is our pleasure to acknowledge them, though their support and our gratitude cannot be justified by these words, and it is not a single word of exaggeration to say that this project would have not reached its final destination, had these people not been the silent and the strongest pillars.

Our journey kickstarted in Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India, where the thought of this venture first striked. It was the vision of our Director, Dr Deepak Chaudhary, who motivated us to step forward. Problems unfolded as we traveled the path but the guidance and blessings by our teachers Dr Himanshu Kataria, Dr Deepak Joshi and Dr Vineet Jain helped us pave our way through. Drs Ankit Goyal, Nitin Mehta, Pallav Mishra, Himanshu Gupta, Ajay Lal, Vivek Shankar and Ashutosh Jha were all a source of motivation whenever we got into any dilemma. Our co-fellows, Drs Mohd Shafi Bhat, Navdeep, Naveen MG, Lalit Bafna, and our colleagues Drs Darsh Goyal, Rahul, Manoj Arya, Shiv Chouksey, Parth Chaudhary, Sanjay Ramavat, Rakesh Daripa, Himanshu Bhargava, Brahma Prakash, Pawan Sharma, Utkarsh, Atul Mahajan, Pankaj, Sunny, Rajat, Prashant, Sunil, Mukul Mittal, Sushmita, Rafat, and Shikha, all deserve special thanks for sharing our load of responsibilities and taking over the work so that we could give our best.

I, Dr Mukul Mohindra, would take this pleasure to thank my teachers whom I owe what I am today. Orthopedics for me started with Dr Mohammed Yamin, Head, Department of Orthopaedics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India, and other mentors from the institute, to name a few, Drs Rajoo Singh Chhina, Sandeep Puri, Hemlata Badyal, Sunil Juneja, Harpal Singh Selhi, Rajneesh Garg, Poonam Singh, Lily Walia, Jagjiv Sharma, Alka Dogra, Bajwa, Hitant Vohra, Deepinder Chhina, Sarit Sharma, and Harpreet Puri, who made me worth to a level that I could make it my choice. The Department of Orthopaedics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, carved a stone which had no meaning into a well-shaped, knowledgeable youth well deserved to serve. I am short of words to thank Dr SS Sangwan (Professor) (former Vice-Chancellor, University of Health Sciences, Rohtak) who was not just my guide but my mentor and Senior Dr RC Siwach (Professor) and Dr NK Magu (Professor) for they have always been my role models. I also offer my thanks to Drs ZS Kundu, A Devgun, Roop Singh, R Gupta, R Rohilla, Pradeep Kamboj, Amit Batra, Vineet Verma, Sanjay Arora, and Gaurav Saini for getting the right concepts and the right surgical skills into me. I would be failing in my duty if I do not thank my teachers at Maulana Azad Medical College, New Delhi, Drs VK Gautam (Professor), AK Dhal, AK Gupta, Lalit Maini, Vinod Kumar, Manoj, Sumit Sural, and Dhananjay Sabat, who gave me the space to grow and allowed my skills to flourish. I am also thankful for the constant support provided by Dr Ramesh Kumar, Director, Central Institute of Orthopaedics and also the faculty and seniors at Vardhman Mahavir Medical College and Safdurjung Hospital from various specialties, Drs R Wadhwa, SP Singh, Shayama Gupta, BP Sharma, LG Krishna, RK Chopra, Vikas Gupta, R Beniwal, Hitesh Lal, Ashish Jainum, Sandeep Shaina, Anurag Jain, SK Pandey, and Ankit Ruhella. Equally supportive were my colleagues and junior Drs Sahu, Heemendra, Amit, Ashwani, Ratish, and Pankaj. No point of missing Dr George Macheras and his team who provided me the golden opportunity to train at KAT Hospital, Athens, Greece, and sharpen my concepts on joint replacement surgeries. I would also extend my thanks to my motivators Dr Mukesh Bhatia and Dr Sumer Sethi. Last but not least, my friends for being physical, emotional and professional pillars to hold on to whenever I needed them, Drs Kamal Bali, Rishav Gupta, Dickey Richard, Ashwani Singh, Chandan Jasrotia, Vikas Kataria, Kulbhushan Kamboj, Rohit Singla, Milind Tanwar, Vivek Bansal, Anish Aggarwalla, Tushar Mehta, and Pritish Singh. Thank you is a very petite word to express my heartfelt gratitude for that every moment you invested in me and trusted me and my decisions.

Prima facie, I, Dr Jitesh Kumar Jain, would be grateful to Lord Mahavira and Shiva for catering me good mental and physical health that made timely completion of this book possible. I owe my success to Department of Orthopaedics, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India, for sculpturing me into an orthopedic surgeon and shaping me into what I'm today. I would extend my gratitude to my teachers, Drs RC Meena (Professor), Mahesh Bansal (Professor), RL Dayma (Professor), SL Sharma (Professor), Anurag Dhakad (Professor), Ravinder Lamoria, Prashant Modi, Umesh Meena, Arun Sharma, Rajkumar (all from Swai Man Singh Medical College, Jaipur, Rajasthan, India), Professor M Zahid, MKA Sherwani (Professor), Mazhar Abbas (Professor), Naiyer Asif (Professor), AQ Khan, Lateef Z Jeelani, S Ahmad, Owais A Qureshi, Yasir S Siddqui, Zulfqar, Hatif, and Matloob Rehman (all from Jawaharlal Nehru Medical College and Hospital, Aligarh) for seeding in me the aptitude and the ethics of this field. I owe my practicing skills to my mentor Dr JVS Vidyasagar, Head of Department, Global Hospital, Hyderabad, Telangana, India, and Dr Rajeev K Sharma, Senior Consultant, Indraprastha Apollo Hospital, New Delhi, India. I also thank my close inmates, Drs Sachin Khurana, Kushesh Gupta, Himanshu Gupta, and Varun Mittal for always being a backing to fall on. I would like to include a special note of thanks to my friend Nitesh Patni and Dr Praveen Sharma in encouraging me to start, endure and finally publish this book. I fail in my duty if I do not thank Drs Rahul Upadhyay, Vijay Yadav, Vaibhav Agarwal, Gaurav Deshwar, Divyansh, Mahaveer Mali, Rahul Temani, Rohit Kavishwer, Ashwini Kumar, Sheshkant, Amit Jain, Deepak Beniwal, Chandan, Jalaj, Jaskaran, Gaurav Gupta, Faizan, Ravish Chabra, Nitin Agarwal, Deepak Raghav, Sachin Ingole, Hiren Patel, and Matad Lokeshwaraiah Chetan for their valuable help and critical comments.

The contributors of this book deserve special thanks for their immense patience, hard work, time and energy they have put in. Despite their busy schedules, they stood by us to write the chapters comprehensively at a single call. Guys this project would never have been accomplished without your efforts. We also thank Radiopedia.org. Learning Radiology.com, The Radiology Assistant and Dr Charlie Goldburg (UCSD, California, US) for providing the image banks that has made this book different and unique.

Last but not least, we extend our thanks to our little artist Dr Shivali Arya, for her amazing sketches that gave real shapes to our weird ideas and words and to Ms Ritu, Ms Preeti and the staff at Sports Injury Centre, who helped us even beyond the working hours. We sincerely thank M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, and their wonderful team for accepting our work and making sincere efforts to let our work come down to reality.

Chapter Notes