Environment Ebnezar Orthopaedics Pdf


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PDF Drive is your search engine for PDF files. As of today we have 78,, eBooks for you to download for free. No annoying ads, no download limits, enjoy . John Ebnezar-Textbook of Orthopedics-Jaypee Brothers () - dokument [*.pdf ] Textbook of Orthopedics A Thought from the Student God. To save John Ebnezar CBS Handbooks in Orthopedics and Fractures: Orthopedic Trauma: Injuries of Upper Limb: Injuries of distal forearm and wrist.

Ebnezar Orthopaedics Pdf

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Textbook of Orthopedics, 4E {John Ebnezar} () [PDF] [UnitedVRG] - Free ebook download as PDF File .pdf), Text File .txt) or read book online for free. ebnezar of orthopedics - pdfsdocuments2 - john ebnezar of textbook of orthopaedics by (author) john ebnezar deveraj urs medical college. john ebnezar of free download here bio- data of rtn. john ebnezar textbook of orthopaedics by (author) john ebnezar deveraj urs medical.

Together they created many hospitals and Medical Institutions. A happy world is what it would have been, had it not been the emergencies in between. Let this book come in handy when it matters the most. Vincent Road Kochi , Kerala Phones: All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means:

It pays to know, at the beginning itself, that the reverse is not true. A look at the injury epidemiology could help you to understand the enormity of the situation. There young are due to injuries. It is said that 99 percent Fifty percent of deaths occur at the scene within of the accidents are man made and only 1 percent is minutes or en route to the hospital. The reasons are not far to seek. Road failure within days or weeks. Intolerance, hatred and injury. Add to this instances of assaults, hospital discharges, 37 percent of emergency falls, train, air and other accidents not to forget department visits and 35 percent of all emergency natural calamities like floods, quakes, etc.

With sports and games and high costs accrued to the health care system, gaining world wide propularity, injuries due to these employers and society in general. Suddenly injuries have Persons less than 45 years account for 60 percent gained the tag of a modern international epidemic that of all injury fatalities and hospitalization and is ravaging young lives like never before.

Persons more than 65 years account for 25 percent Global Scenario of all injury deaths and 30 percent of injury related Leading cause of injury deaths. Second leading cause of nonfatal injury. Seventy percent of injury deaths and more than Male: Female ratio in injury deaths is 2: Rate of nonfatal injury in male: Causes of accidents include speed, alcohol, poor But over 65 years male: The above statistics are frightening and calls for More than 1.

Mechanism of Injury Leading to Death One child is killed every 3 minutes in the world. Various mechanisms of injuries lead to death or Total worldwide death toll of Tsunami in is nonfatal injuries.

Let us try and analyze the figures. Twenty-nine percent are due to motor vehicle So, the annual death toll due to RTAs is 5 times accidents. Eighteen percent are due to firearm injuries. Eleven percent are due to falls. Poisonings lead to 17 percent of all deaths. Fifty million people worldwide are injured in Thirty percent of all injury deaths are intentional. RTAs every year and 15 million seriously. After having identified various mechanisms of Low and middle income countries account for injury deaths, a look at the causes of death shows more than 85 percent of global deaths.

One person dies from injury every minutes. Hemorrhage percent. Presently more than 86, people die annually. Multiple organ failure percent. There are , accidents each year. Mechanism of Trauma Social cost due to road accidents is crore The three leading mechanisms of trauma are motor annually. Now let India accounts for 10 percent of the 1. Now let us analyze the other mechanism of Increased movements, crazy driving, alcohol, injuries.

People tend to forget that motor vehicles are meant for commuting and are for their convenience Liberal laws and misuse are leading to increased and not for adventure and thus end up with shoot-out deaths particularly in the western increased instances of accidents Fig. Let us have countries. While most of them are suicides, homicides a look at the Global and Indian scenario. Violent high speed accidents like these can result in fatal injuries.

Here are a few chilling statistics related to firearm Death from falls is less 0. In the elderly falls is important cause of death.

They are responsible for 18 percent of all injury Thirty-four percent in greater than 65 years and deaths and is the 2nd leading cause. Fifty-six percent were suicides and 39 percent It accounts for 80 percent of all injury related were homicides. Female ratio is 7: Overall Falls Now after analyzing each mechanism of injury in These are mainly accidental and rarely intentional.

Accounts for 11 percent of injury deaths. Eleven percent of the global burden of disease. Under less than 5 years, falls are the leading cause Violence will rise from 19th place to the 12th of nonfatal injury, 50 percent at home less than place.

Nonfatal Injuries In injury related events those who are fortunate to survive deaths or near deaths, may have to face an equally disturbing events in the form of nonfatal injuries. These could range from simple fracture, sprain, strain to major and multisystem injuries.

Any possibility of single or combination injuries are possible depending upon the type and severity of accidents. Nonfatal injuries are more morbid and could prove to be an enormous burden in terms of cost and time to the patient, relative, society, country and the world at large. Among the fatal injuries leading to deaths, motor vehicle accidents rank first. However, a study of non-fatal injuries shows a different scenario. RTAs account for 18 percent of the hospitali- Fig.

Sports injuries lead to nonfatal zations. Thirty percent of all injury deaths are intentional. Sports Injuries percent injury hospitalizations are intentional. These are the important contributors of nonfatal injuries. Due to increased popularity of major Interesting Statistics of Nonfatal Injuries sporting events like football, tennis, cricket, Upper and lower limb injuries leading cause of basketball, swimming, etc.

However, deaths Moderately severe and severe injuries of the due to sports are far and few and are not of concern. Primary mechanism of injury accounting for To have the best choice of survival, grievously hospitalization is falls accounting for 30 percent injured victims should receive top quality care from of all upper extremity injuries and percent the earliest moments of the accident from the of all lower limb injuries.

Pick and dump RTAs are leading to increased hospitalizations attitude by these personnel could spell disaster. Proper first aid, skillful CPR and intelligent handling Twenty percent of all hospitalizations due to and shifting of the injured victims by the paramedics upper limb injuries are due to accidents following or general public can make a world of difference machinery and tools.

Management during the golden percent and is the 2nd leading cause. Thus, Other leading causes are spinal cord injuries and prehospital care assumes extreme importance in musculoskeletal injury of the back. Administering first aid and CPR to an accident Fig.

Shifting an injured victim to the nearest well-equipped victim at the scene of accident hospital is the prime responsibility of trauma care systems EMRI in India. The following trauma care system in India.

It has well-equipped preventive steps are suggested: It is responsible for administering other disease. Once the patient is stabilized by these proper Research into the preventive and treatment PHTLS program effort is made to execute definitive aspects of tackling injuries also helps. The problems being There is no running away from the fact that injuries faced by the trauma care systems in India are: It has all the Lack of physical resources features of an epidemic and needs to be tackled as Lack of organizational resources such.

Here are certain injury related vital issues: Lack of trauma care system.

Trauma is a major public health problem. For effective management of the injured all the Primary prevention should be emphasized. Trauma is called the neglected disease of the modern society. Prevention of Injury It is now the costliest medical problem in the Now that injury is considered a major public health world.

However, earlier it was thought problem posed by injuries. Various combinations that there is no role of prevention in the case of injury of nonfatal musculoskeletal injuries could occur. But now fortunately The general principles and individual treatment of people have started realizing that preventive these injuries will now be dealt in the ensuing measures have a very important role to play in chapters.

From this condensation, I rapidly form a. Between the cartilaginous bone and About joints plates, I form small clefts for the future joints. During this Fibrous joints period of 12 weeks, I am particularly vulnerable to Cartilaginous joints teratogenic influences. During the late fetal stages or early few years. Bone Development Growth plate, which keeps the primary and secondary centers of ossification separated from each other until I am a specialized connective tissue.

By providing a. I am proud to be entrusted the job of periosteum. In addition, I keep remodeling myself from the protecting vital structures like brain, lungs and heart. I am also concerned with hemopoiesis. I give attachment to the muscles. I am made-up of 30 percent Bone development starts as a condensation of organic material mainly type I collagen and mesenchyme.

Later a cartilaginous model develops. There are two types of ossificationendochondral and membranous. Remember the functions of bone There are three types of bone cells. Protection of vital organs Support to the body Hemopoiesis About Osteon Movement and locomotion Now let me tell you how exactly I am made-up of Mineral storage internally.

I am made-up of many units called osteon. I have three types of cells, osteoblasts that How do I start developing? There are certain exceptions which are the resting cells. Volkmanns canal which has the nutrient vessel and About Cortex each lamellae is interconnected by the canaliculi Cortex gives me the remarkable strength, which you through which the nutrients pass.

Osteoblasts lay all admire particularly during compression. Its down uncalcified matrix, which is subsequently periosteal cover allows remodeling throughout life. These various osteons It also gives attachments to ligaments, tendons and amalgamate to form large haversian systems, loosely muscles through the Sharpes fibers. Stores 95 percent of body calcium. Also plays a structural role. It stores more than 95 Now let me explain to you my general structure.

The other important component disappears with growth , metaphysis and diaphysis of the medulla is the marrow between the medullary Fig. Initially present throughout, it Epiphysis is an expanded portion at the end. It is easily affected by deve-. The result is distorted joints due to avascular and clearly identifies itself into compression and necrosis and degenerative changes.

Growth plate physis though mechanically weak it. It responds to growth and sex hormones. It is affected by conditions like. Bone cross-section showing its internal structure Fig.

Bones in the axial skeleton short stature or deformed growth or growth arrest. Skull Cranium 8 Metaphysis is concerned with remodeling of bone. Face 14 It is the cancellous portion and heals readily. It gives Vertebral column attachment to ligament and tendons. It is vulnerable Cervical vertebrae 7 to develop osteomyelitis, dysplasias and tumors Thoracic vertebrae 12 resulting in distorted growth and altered bone Lumbar vertebrae 5.

Sacrum 1 5 fused bones Coccyx 1 fused bones Diaphysis is a significant compact cortical bone Sternum 1 which is strong in compression and which gives Ribs 24 12 pairs. It forms the shafts of the bones. Ear ossicles. Malleus 2 In remodeling, it can remodel angulations but not Incus 2.

It may develop fractures, dysplasias, Stapes 2 infection and rarely tumors. Remember Table 2. Bones of the appendicular skeleton. Humerus 2 Ulna 2.

Textbook of Orthopedics, 4E {John Ebnezar} (2010) [PDF] [UnitedVRG]

Phalanges Axial skeleton80 bones Table 2. Hip girdle Os coxa 2 2. Appendicular skeleton bones Table 2. Lower extremity Axial skeleton forms the upright axis of the body Femur 2. Patella 2 Tarsal We have different shapes.

The shape and Phalanges 28 size depend upon the functions attributed to us. Short bones These are generally cube-shaped and are found in areas where limited movements are Irregular bones These have a peculiar and irregular required Fig. Their primary role is to provide shape and are unique in their appearance and strength.

Organization of bones: Axial and appendicular skeleton. Sesamoid bones: These are small, rounded or derived from their resemblance to sesame seeds, triangular bones, which develop within the e.

Their name is sesamoid bones. You need to take good nutritious diet rich in calcium and vitamins to keep me healthy. Proper exercises, protection against injuries and infection enhance my efficiency in serving you, but there are certain inherent problems in me in which you can do precious little.

Congenital problems, hormonal problems, metabolic problems, tumor conditions, etc. Nevertheless, the problem that poses a serious threat to my integrity. As a child, you are more. Types of bones: A Flat bone, playful and more prone to fall and this breaks me B Irregular bone, and C Long bone quite often.

As an adult, you are more prone for. Though you pride in the fast-paced life of yours, I grieve at my misfortune and at my vulnerability to. As you age, my faithful friends, proteins and. I cannot provide you.

In this phase, even trivial forces pathological fractures easily overcome. I am sad that I cannot provide you the same privileges as before but I hope you can realize that I am not being unfaithful to you, but I am made. Foot is an assembly of short bones of various sizes A joint exists where two or more skeletal compo- nents whether bone or cartilage, come together to meet. Without joints in between the bones, your. The Types of bones existence of these joints makes movement of the Long bones body parts possible.

Joints are classified into three Short bones major groups: Axial80 bones In these, there are three varieties: Appendicular bones Syndesmosis: This is characterized by a dense fibrous Thus, my duty is to serve you to the best of my membrane that binds the articular bone surfaces very ability, so that you lead a healthy skeletal life.

Much closely and tightly to each other, e. True sutures are found in the skull. Here the adjoining bone margins are united into rigid, jagged interlocking processes, e. Here a conical peg or projection that fits into a socket, e. Different types of joints: Here movement takes place around a horizontal axis, e. These are slightly movable joints with either hyaline or fibro cartilage in between.

Two varieties are Pivot joints: Here movement takes place around a described: Here hyaline cartilage is posed in between, e. Biaxial joints: Here movement occurs in two planes and two axes that are at right angles to each other. Here the fibrocartilage is interposed in Two types are described: Saddle joint: Here the articular surface is concave in one direction and convex in the other while the. In this, an oval condyle fits into an. They form the most mobile joints in the body elliptic socket or cavity, e.

It consists of a fibrous joint capsule that helps to Multiaxial joints: Here there are two or more axes hold the articulating bones together.

The synovial of rotation and movement takes place in three or. Two varieties are described:. This fluid serves to lubricate the joints Ball and socket joint: In this a ball-shaped head of and provides nourishment for the articular cartilage. Of all. Types of Synovial Joints Gliding joints: These are numerous, gliding move-. These permit movement in only one ments occur in all planes, e.

In this, there carpal and tarsal bones, and all the joints between are two types: Management of fractures The bone can break within its soft tissue envelope. In both. Bone has devised its own mechanism to ward factors, different fracture patterns are produced and off the unnatural forces and keep itself intact.

But each one poses a problem peculiar to its own. Simple or compoundthis has been already explained rature Figs 3. Fracture is a break in the surface of a bone, either Incomplete fracturesit involves only one across its cortex or through its articular surface. Complete fracturehere the fracture involves Dislocation is a complete and persistent displace- both the cortices and the entire bone.

A complete fracture could be undisplaced or Subluxation is partial dislocation of a joint. Simple and compound fractures. Figs 3. Types of fractures based on fracture patterns:. Improper handling of the fracture. These could be transverse,. Any fracture that forms an angle less than 30 with the horizontal line is called transverse.

Angle equal to or more than. Comminuted fractures: Here the fracture fragments are more than two in number. Butterfly-shaped fractures are also included in this group and could be less Figs 3. Atypical fractures: Segmental fractures: A fracture can break into Atypical Fractures Figs 3.

Greenstick fractures: It is seen exclusively in comminuted. Here the bone is elastic and usually Bone loss: This is called a greenstick complete bone loss. Impacted fractures: Here the fracture fragments are Anterior angulation or displacement. Varus or medial angulation or displacement.

Stress or fatigue fractures: It is usually an incomplete Valgus or lateral displacement or angulation. Pathological fractures: The force required Orthopedic injuries encompass a wide range of to bring about a pathological fracture is trivial. Hairline or crack fracture: It is a very fine break in. The value of a systematic clinical approach to f.

Torus fracture: This is just a buckling of the outer unravel the myth and mysteries of orthotrauma. Time-honored and time-. Fatigue fracturesin occupations like police, nurse, History: Contrary to popular beliefs, a proper history gives vital clues and goes a long way in arriving at a. Pathological fracturesusually seen in elderly proper diagnosis. Certain fractures have predilection age groups. Hairline or crack fractureis a special variety of incomplete fracture.

Table 3. Hence, the practice of first enquiring. A complete fracture usually gets displaced due to Sex: Colles fracture is more common in females and. Depending on supracondylar fracture humerus, posterior the direction of force, mode of injury, pull of the dislocations of elbow are more common in males. Relationship of age and fractures Age Fractures and dislocations. Early childhood Supracondylar fracture of humerus. Epiphyseal injuries. Late childhood Posterior dislocations of elbow.

Slipped capital femoral epiphysis. Monteggia fractures. Adult Fracture of long bones. Hip and shoulder dislocations. Elderly Colles fracture. Fracture neck femur. In spite of age predilections, any fracture can be Figs 3.

Types of angulation in fractures: Mechanism of Injury Inability: To use the affected part is another This could be different in different age groups as frequent complaint. Having made a note of the history and presenting complaints, effort is now directed towards eliciting Clinical Features the clinical signs, some of which are general and A patient with limb injuries may present with the some are injury specific.

This is an important clinical sign in bone and joint injuries and is usually seen after. This is a very subjective symptom and is invariably the first and the most important trauma.

Importance of tenderness, methods of complaint. It may be mild, moderate and severe elicitation and grading is mentioned in the box refer p. The swelling is examined for shape,. It is due to soft tissue injury, medullary cystic, soft, hard , tenderness see the grades ,. Swelling fluctuation, etc. This is usually seen in displaced. Undisplaced Deformity: Patients with displaced fractures and fractures, mild strains and sprains usually show no deformities.

Some of the deformities are. Relationship of age, types of fractures Abnormal mobility: Between fracture fragments. Age Common modes Examples of injury. Adults Fall from height Upper limb injuries, spine injuries, etc. Diving injuries Cervical spine injuries. Whiplash injury. Dashboard injuries.

Sports injuries Ankle and shoulder, elbow and knee joint injuries. Assaults Long bone fractures e. Elderly Trivial fall Colles fracture Fracture neck femur, etc.

Some important deformities in orthopedics: Wry neck Cervical spine injuries. Tenderness may be the only evidence of fracture in: Drooping of shoulder Clavicle fracture. Crack fracture. Flat shoulder Anterior dislocation of Hairline fracture.

Stress fracture. S-shaped deformity Supracondylar fracture Fatigue fracture. Torus fracture. Dinner fork deformity Colles fracture. Pathological fracture. Boutonnire deformity Rupture of central Method of eliciting Proceed from normal area to the extensor slip of finger. Mallet finger Rupture of distal end of Grading index extensor. Grade Ijust a suspect.

Jersey finger Rupture of distal end of Grade IIpatient winces on pressure. Grade IVpatient will not allow to touch. Flexion, adduction Posterior dislocation of hip This grading of tenderness is superior to the and internal rotation conventional mild, moderate and severe grading.

Flexion, abduction Anterior dislocation of hip and external rotation About crepitus It is defined as an abnormal grating of lower limb Incomplete external Fracture neck femur intra- sensation either felt or heard. It could be: Complete external Trochanteric fractures, shaft Coarse, e. S-shaped ankle Ankle dislocations. Remember it is unkind to elicit a crepitus in a fracture for fear of hurting the patient. Loss of transmitted movements: When one end About deformity, It is defined as deviation of the of the limb is rotated, it automatically is normal anatomy of a bone or joint.

Due to the break in the continuity this is no longer possible in Remember displaced fractures. D in fracture: This is an abnormal grating sensation Deformity is seen often in displaced fractures. Obviously, or lateral. It Distal fragment is the reference point to suggest the should be elicited very gently and at the end type of displacement. Dislocation of joints usually presents a deformity.

Limb shortening of various degrees is common in bone and joint injuries. Interesting Features about the Clinical Signs Various clinical signs are described in fractures. They Note: Creptius, abnormal mobility, deformity and loss of transmitted movements cannot be elicited in can be best represented as follows in order of their undisplaced fractures, stress fractures, impacted importance Table 3.

Clinical manifestations due to neurovascular injuries: Certain fractures are known to cause neurovascular Remember damage quite frequently, e. The familiar five Ps detects Fracture per se impending vascular damage and nerve injuries are Its complications detected by the classical deformities and screening Or both tests as described in peripheral nerve injuries.

Relevance of clinical signs required as bone is a cylinder. Sometimes, an oblique view and other special views are required depending Unfailing signs Abnormal mobility Crepitus upon the clinical situations and bone under study. Reliable signs Tenderness Shortening Vital facts: About plain X-ray Important signs Bruise Radiological clues one should look for on plain X-rays for Swelling diagnosis of fractures: Other signs Loss of function Where is the fracture? Deformity Situations: Whether it is in the diaphysis, metaphysis, Late or inconstant signs Blisters epiphysis and the articular surface.

Ecchymosis Anatomy: Look for the fracture line, whether it is Swelling due to callus transverse, oblique, spiral, segmental, comminuted, etc. Also look for the alignment, angulation, displacement, rotation, etc. About Five Ps Number: How many fragments are seen? In detecting impending vascular damage in musculo- Bone condition: Identify whether the bone is normal or skeletal trauma pathological.

Pain Joint involvement: Look for the extension of the fracture Pallor line into the joint, joint swelling and for evidence of Paresthesia dislocation. Pulselessness Soft tissue swelling: The extent of the soft tissue swelling Paralysis indicates the severity of the injury. Pitfalls of X-ray There are certain bones in the body, the fractures Presence of a fracture line on an X-ray helps confirm of which are usually missed in the initial examination the diagnosis but its absence does not rule out a fracture.

These are known to cause Hairline fractures tend to be missed e. Some dislocations, if associated with fractures could be missed e. Monteggia fracture. Missing Facts In comminuted fractures the number of fragments could Do you know the fractures, which can give a slip to the be misleading. Beware of artifacts they could mislead you.

Zygoma Be careful in interpreting fracture-like appearances, e. Base of skull apophysis. Odontoid process Avoid interpreting a low quality X-ray. Impacted fracture neck of femur Helps study the fracture anatomy. Undisplaced pelvic fracture Helps study the fracture displacement. Scaphoid fracture Helps to detect crack and stress fractures. Carpal dislocations Helps to plan the treatment.

Tarsometatarsal joints Helps to detect fracture dislocation combinations, e. Talus fracture Monteggia. March fracture Helps to ascertain post-reduction status of fractures. Among these, scaphoid tops the list.

Helps in medicolegal study. Radiography X-ray is a shadow. It conceals and distorts. Hence, interpret X-rays with caution. It is an important diagnostic tool for fractures. A joint above and joint below should be included Minimum two views, anteroposterior and lateral are with the fracture under study.

The fracture should be in the middle of the film. Plaster slabs: Plaster of Paris slabs can be used Exposure should be adequate and the soft tissue to support the injured limb usually as a first shadow should be delineated properly.

X-rays should be read by holding the film in an anatomical position. For pain relief and to reduce the be adopted. Avoid unnecessary X-rays.

Masterly inactivity in certain cases like Check X-rays are to be taken without disturbing the impacted fracture neck of femur, etc. For displaced fractures here the aim is to restore back the normal anatomy of the bone by either CT Scan and MRI closed or open reduction.

These are the most sophisticated investigative methods available now in orthopedics. Both are Management of Fractures noninvasive and are extremely useful in detecting by Closed Reduction both soft tissue and bony injuries. This consists of resuscitation, reduction, retention Note: CT scan: This is helpful in detecting fracture of skull, 1.

Resuscitation is the topmost priority pelvis, spine and identifying loose bodies in the joint. This is useful to diagnose any fracture. In to be followed in all situations of emergencies addition, it helps to identify soft tissue and ligament refer p. It is certainly the Gold Standard but has 2. Reduction of the fracture fragments if its Achilles heel in being expensive.

Usually it is done under general anesthesia after adequate radiographic study. The goal of fracture management is to restore the a. Closed reduction: It is adopted usually for simple anatomy back to its normal or as near to normal as fractures. The technique followed is traction possible. It is a blind The responsibility of an orthopedic surgeon is to technique and needs considerable skill and ensure that there is no functional disability to the expertise.

It commonly results in malunion. Continuous traction: Certain examples where Management of fracture can be broadly classified continuous traction can be used for reduction and discussed under the following heads: Management of complicated fractures.

Open reduction: It is done when the above methods fail or if there are specific, indications Management of Simple Fractures see box. Once the fracture fragments are Simple fractures are managed by conservative and reduced, it has to be retained in that position till operative methods. For undisplaced fractures, incomplete fractures, Retention methods after closed reduction are: By plaster of Paris splints this is the most a.

Cuff and collar sling: For upper limb fractures. It could be a slab b. For fracture clavicle, fracture ribs, encircles half the limb or a cast encircles the finger or toe fractures, etc.

Principles of open reduction as suggested by b. By continuous traction to overcome the muscle Lambotte includes: The traction Exposure: The fracture is adequately exposed could be skin or skeletal traction and is through a proper approach. Reduction of the fracture fragments under direct c.

Use of functional braces this can be used after vision is carried out. K-wire is done first if necessary. Rehabilitation is by way of physiotherapy and exercises both active and passive. Definitive stabilization of the fracture using plate and screws or intramedullary nail, etc.

Fracture Management by Open Reduction Retention after open reduction: After open Operative Management reduction the fracture fragment invariably needs to As mentioned earlier, open method is indicated be fixed internally by various implants see box. These indications could be Choice of Implants absolute, relative or rare as mentioned below: K-wire For epiphyseal injuries and for fractures of small bones of hand and feet diameter of the K-wires varies Indications from mm.

Absolute Screws For avulsion fractures and butterfly fragments. Failed closed reduction Intramedullary nails For fracture through the narrowest Displaced intra-articular fractures portion of a medullary canal of a long bone. Replantation of extremities Interlocking nails For segmental fractures comminuted Relative fractures, etc. Multiple fractures Delayed union Hip implants For fracture neck femur. Smith Petersons Loss of reduction nail, Richards compression screw, multiple cannulated Pathological fractures screws, etc.

Monteggia fracture, femoral neck fracture, etc. Steel Wires No gauges Useful for tension band Questionable wiring for fracture of patella, olecranon, etc. Neurovascular injury Open fractures The rehabilitation process is the same as for closed Cosmetic reasons management of fractures. Economic consideration Contraindications for open reduction Methods of open reduction: After the exposure, Infection the fracture is reduced by direct methods and in the Small fragments indirect methods the fracture is reduced without Weak and porotic bone exposing by positioning and traction over the Soft tissue damage fracture tables, skeletal traction, tensioner, lamina Undisplaced or impacted fractures spreader, etc.

Disadvantages of open reduction Closed fracture converted into an open fracture. Fracture hematoma is disturbed. Scar tissue. Anesthetic problems. Foreign body reaction due to metals. Remember Success by open reduction depends on: Proper indications. Proper timing. Proper surgical approach. Proper technique. Proper selection of implant. Proper surgeon. Varieties of open fractures: Plaster of Paris external fixators Internal: Extensive soft tissue damage and loss.

K-wire, etc. Bone cannot be covered and is exposed to the Traction: By skin and skeletal traction atmosphere. Compound fractures with arterial injuries. Open fracture is a surgical emergency and presents No classification invites so much of debate as for as a problem that is much more difficult than closed open fractures with only 60 percent of the surgeons fractures.

It is defined as a fracture, which communi- across the globe accepting it. Hence, newer cates with the external atmosphere due to break in modifications are now being suggested like: The break in the soft tissues a.

The modified Gustillo Andersons classification. The Trafton classification this combines the Gustillo Andersons and Tscherne classification. Type I: Wound is less than 1 cm in size. It is usually due to a low-velocity trauma.

Wound is more than 1 cm and less than 10 are due to high-velocity trauma. These are multiskeletal injuries. The approach should be more due to high-energy trauma. Type III: Wounds moderate and severe in size General physical examination: Levels of consciousness, pulse, blood pressure, breathing, etc. Type IIIA: Extensive soft tissue injury but with Examination of other systems: Examinations should adequate soft tissue to cover the fractured bone.

Examination of the compound injury: This usually proceeds in the same line as mentioned in examination of closed fractures but here the assessment of the general physical condition of the patient assumes great importance. In addition to the usual clinical features, one should look for soft tissue injury and wound, bone loss, absence of bone pieces, distal neurovascular status of the limb, etc.

The term open fracture is more preferable than the old out fashioned term compound fractures. Investigations General investigations: Laboratory tests like Hb percentage, blood group, bleeding time and clotting Fig. X-ray of the part as for other fractures and in addition look for missing pieces of bone in open fractures Figs 3. Management Principles Aims of treatment To convert a contaminated wound into a clean wound and thus help to convert an open fracture into a closed one.

To establish union in a good position. To prevent pyogenic and clostridial infections. Considerations First to stabilize the general condition of the patient as the patient is usually in shock. This consists of resuscitation, blood transfusion, intravenous fluids, antibiotics, oxygen administ- ration, etc.

To keep the wound covered with proper sterile bandages until the patient is ready for surgery. Open fractures are surgical emergencies and surgery is to be done as soon as the patient is fit. Compound both bones fractures of the leg. Treatment Plan and of course the orthopedic surgeon. Once these It is a team work and involves a battery of specialists specialists manage the injuries to the vital organs like the vascular surgeon, plastic surgeon, thoracic and the general condition of the patient is stabilized, surgeon, general surgeon, faciomaxillary surgeon, the fractures are dealt by the orthopedic surgeon.

Technique of debridement Fig. Irrigation set used in open fractures. After stabilizing the general condition of the Nerves and vessels: Primary repair is done if the patient, surgical debridement is planned under strict wound is clean. In contaminated wounds, they aseptic measures in a major operation theater. Evacuation of foreign bodies like dirt, glass, Debridement known as unbridling this is the most stones, pebbles, etc.

These foreign bodies are a important step in the management of compound source for infection and may invite a foreign body fractures. It consists of the following steps 4 Es reaction. Hence, they have to be removed by a Fig. Exploration of the wound: The wound should be 3.

Dilution is the solution of pollution. Excision of all nonviable structures is important Single most essential step. The recognition of nonviable Minimum 10 liters of saline is used. The tissues are dealt with as follows: Swirling movements of the irrigation fluid is Skin: Here the plan is to excise all the dead preferred. Irrigation or wound toilet helps to clear the foreign skin and yet be conservative. Nonviable muscles should be removed contamination.

Antiseptic additives kill the bacteria. Small bits of loose bones devoid of soft Detergent irrigation aims to remove than kill tissues are removed. Large fragments with bacteria. External fixators are used to fix the fracture fragment after debridement. Plaster of Paris and Table 3. Criteria to evaluate tissue status internal fixation devices have little and Features Viable Nonviable controversial role in the fracture management of compound fractures.

Preferred method: Interlocking nailing is emerging as a better alternative than plating for internal fixation in open fractures. Limited internal fixationin grade I and some grade II, grade IIIC fractures Skeletal tractionoverhead olecranon traction for compound supracondylar fractures.

Bhler-Braun Fig. External fixators preferred method of skeletal traction for open femoral shaft fractures immobilization in open fractures is some of the examples.

Plaster of Paris casts practically have no role. This is the first ever textbook written by an Orthopedic Surgeon from Karnataka and I am happy that it comes from my assistant. It is indeed befitting that I write a foreword for his book. I wish him all the best. Year after year, edition after edition, it has grown from strength to strength and today I am extremely pleased to place the fourth edition in your hands. The entire credit of making this book a runaway success belongs to the undergraduate and postgraduate students, and teachers.

Indian medical authors penetrating the impregnable western market and carving a niche for themselves is a rare spectacle. The hitherto unthinkable in the not so distant past is a reality now. What makes this book so successful when most of the books released stay in the racks and sink without a trace or rarely go beyond the first edition? I feel more than the support, patronage and encouragement from all concerned, it is the love of the students and teachers that has brought the book this far.

Yes I re-iterate it is the overwhelming love that is the secret of the longevity of this book. My book has received tremendous love from all quarters. Medical books are known to survive because of their scientific content presented well. But in my case I feel it is the unconditional love that has made it stand the test of time. Be it undergraduate students, teachers, postgraduate students, orthopedic surgeons, physiotherapy students, it is a hit with all.

One lady medical student from Gulbarga has written to me saying that she has totally fallen in love lock, stock and barrel with my book. Another postgraduate student said that my book has shaped his life more than his career. This I consider a very high praise and an ultimate complement.

Shaping lives is a far bigger achievement than shaping careers. This is the job of self development books and not medical books. If my book has achieved this unique dual distinction then I feel my life is fulfilled as I have touched the lives of my readers. One medical student recently, who bumped into me in a private wedding party, said that he has read each and every word in my book and even the prelims and hence knows the names of my wife and children too!

A very senior orthopedic surgeon and teacher also told me that he was very impressed with the last few sentences in my acknowledgments and this motivated him. An ophthalmologist spoke about the preface in glowing terms. A book is normally judged by its contents and not by its preface or preliminary pages. But my book has broken this traditional benchmark and has been equally appreciated for its preliminary pages!

I feel happy, proud and privileged to hear such glowing tributes from everyone about my book.

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It is not that my book has no flaws. In fact it has in plenty. But just as parents overlook the follies of their children and love them unconditionally, my readers have overlooked and forgiven all my lapses.

Fourth edition has corrected one major anomaly of the previous editions. It was slightly bigger for undergraduate and smaller for postgraduate students. Undergraduate students told me that the book is very good and they want to read it but regretted its size while the postgraduate students felt the book to be very good but inadequate for them. I had the option of downsizing the book to undergraduate expectations or raise the book to postgraduate expectations.

I noticed that this book, written originally for undergraduates, was embraced more by postgraduate students. Though not totally unexpected it indeed was a pleasant surprise. After a lot of deliberations and interaction with students, teachers and publishers, I decided to xii Textbook of Orthopedics choose the latter course of action and have now upgraded the book into a full-fledged small textbook for postgraduate students in orthopedics.

I as an orthopedic PG student had read big textbooks with several volumes and found the necessity of having a small book that could be handy to read during the course, exams, bed side discussions, etc. This book precisely achieves that long pending need of orthopedics postgraduates. To attain this objective I have strived for the following things in this new edition: They will enable the student to understand and grasp these steps better.

Hence a whole new section on geriatric orthopedics has been added. Hence a new chapter on Arthroscopy has been added. This section is the contribution of the internationally renowned knee surgeon Dr Kirti Moholkar of UK. A section on Arthroplasty that caters more to the practical than theoretical aspects has been added. Hence a chapter on Evidence based orthopedics has been added after receiving lots of requests from the postgraduate students.

Apart from all these new developments, I have retained the old flavor that has made this book such a huge success. With this book I have tried to set right one anomaly mentioned previously by giving the postgraduate students a small comprehensive and compact book. I eagerly await their response. Undergraduate students need not be disappointed that this book has now totally gone beyond their reach.

I am coming out shortly with a compact, neat very interesting smaller version which will fulfill all their aspirations and expectations. Wait for it. The book has grown because of your love, patronage and support. I hope you will extend the same for the fourth edition too.

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Please do not hesitate to criticize or correct me. I request you to write to me with all the corrections and suggestions so that I can rectify my flaws. Looking forward to your reaction. The subject fascinated me so much that I was drawn towards it like a magnet. I always wanted to do something to the subject I loved most. This book is a small effort on my part in this regard.

Students often questioned me during my undergraduate teaching sessions as to which book they should read for Orthopedics. Whenever I suggested the standard books written for them, they said they found them too inadequate and that the bigger books were too much for them. So they were in a situation of either too little or too much. I then asked them as to what sort of book they need?

MARGURITE from Louisiana
I fancy reading comics shakily . Look through my other articles. One of my hobbies is beach soccer.