Ebook Textbook of orthopedics (4/E): Part 1

Textbook of Orthopedics


A Thought from the Student
God created the doctor and his patient. 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.

Dr K Sarawana


Textbook of Orthopedics
Fourth Edition

John Ebnezar
MBBS D’Ortho, DNB (Ortho), MNAMS (Ortho), DAc, DMT, PhD (Yoga)
Sports Medicine (Australia), INOR Fellow (United Kingdom)

Consulting Orthopedic and Spine Surgeon and Holistic Orthopedic Expert, Sports Specialist
Formerly
Assistant Professor of Orthopedics
Devaraj Urs Medical College
Kolar, Karnataka
Senior Specialist in Orthopedics
Department of Orthopedics
Victoria Hospital
Bangalore Medical College
Currently
Chief Consulting Orthopedic Surgeon
and Medical Director
Parimala Health Care Services, An ISO 9001:2000 hospital

Bengaluru

Chairman
The Physically Handicapped and Paraplegic Charitable
Trust of Karnataka
President
The Karnataka Orthopedic Academy

Chairman
Ebnezar Orthopedic Center, Bengaluru

Director
Bangalore Holistic Orthopedic Centre, Bengaluru

Chairman
Dr Ebnezar’s Medical Institute
President
Geriatric Orthopedic Society

President
Vaidya Kala Ranga, Bengaluru

President
All India Medical Author’s Association

Chairman
Rakesh Cultural Academy

®

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Textbook of Orthopedics
© 2010, John Ebnezar
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means:
electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of
material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal
matters are to be settled under Delhi jurisdiction only.
First Edition: 1996
Second Edition: 2000

Third Edition: 2006
Fourth Edition: 2010
ISBN 978-81-8448-744-2
Typeset at JPBMP typesetting unit
Printed at


To
My mother (Late) Sampath Kumari
who taught me that life is more than self and there
Is more joy in giving and sharing than taking?
My wife Dr Parimala, my lovely children Rakesh and Priyanka
Who are an epitome of love, sacrifice, encouragement and inspiration?
All my teachers
Who made me what I am today
&
all my students past and present



Foreword
With hardly a handful of orthopedic surgeons taking to writing books, I have
watched Dr John Ebnezar silently grow over the decade to become a leading author
in the field of Orthopedics. He has so far authored a mind boggling 17 orthopedic
books single handedly, and still counting — truly a global record. John has a natural
flair for writing and his books are liked by all, from medical students, teachers, to
the general public. This book is a well accepted orthopedic textbook in the country
and has a global presence too with an Italian edition and the book being stocked in
prestigious NHS Trust libraries across UK, a high honor. The book is very
informative, thought provoking and entertaining. In this is blended scientific

knowledge and life philosophy in a very subtle way, which makes the book unique.
I had always told John to write a book for postgraduate students in orthopedics for I felt that a small
comprehensive book dealing with postgraduate orthopedics is the need of the hour. I am happy he has acted
on my advice. His textbook though originally meant for undergraduate students, inadvertently went on to
become a book popular with postgraduate students. They felt it extremely useful to them but rather short,
and undergraduate students felt the book to have a bit more than needed for them. He has now corrected this
imbalance by upgrading this book into a full-fledged small textbook for postgraduate students in orthopedics.
Accordingly you will find new chapters and sections on trauma, geriatric orthopedics, arthroplasty,
arthroscopy, surgical techniques and even on Evidence Based Orthopedics, the latest significant development
in the world of orthopedics. I was supposed to write a chapter on Pediatric Orthopedics for this edition but
could not do so due to paucity of time. However I promise to add this chapter for the next edition.
Like all the previous editions, Dr John Ebnezar has maintained all those ingredients that have made the
book so popular with everyone for over a decade and half now. Simple writing, lucid language, clarity of
thought, good and innovative diagrams, clinical photographs, good X-rays are all there in plenty. To spice
up, are the mnemonics, anecdotes and his philosophical touch to the subject. He has successfully tried and is
successful in unconventional ideas in textbook writing like autobiographical anatomy which is a bold
experiment.
I congratulate Dr John Ebnezar on his stupendous efforts and the very fact that the book is seeing its 4th
edition is undoubtedly a matter of great pride and honor for him. I am sure that the readers will extend the
same support and encouragement to this edition like all his previous editions. John is a good trendsetter as


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far as orthopedic writing is concerned and is worthy of emulation. He has truly put India on the global map
and deserves praise and accolades for all his efforts.
I wish him and the book all the best and feel privileged to write this foreword for the fourth edition.
Prof Dr Ashok N Johari

Pediatric Orthopedic and Spine Surgeon
Lilavati, Bombay and Nanavati Hospitals,
BJ Wadia Hospital for Children
Sir JJ Hospital and Grant Medical College, Mumbai
President Elect, Indian Orthopedic Association
President, Pediatric Orthopedic Society of India
President, Indian Academy of Cerebral Palsy
Editor-in-chief, Journal of Pediatric Orthopedics (B)
Chairman, The Child Foundation


Forewords
FOREWORD TO THE FIRST EDITION
I sincerely admire the efforts of Dr John Ebnezar. It is an excellent book for the undergraduates and
postgraduate students (their teachers too!). I like the style of his writing.
My heartiest congratulations on his solo Herculean efforts.
With best wishes
GS Kulkarni
MS, MS (Ortho), FICS
Professor of Orthopedics and Director
Orthopedics Hospital and Postgraduate Institute of Orthopedics
Swasthiyog Pratishthan, Miraj
(Recognized for MS (Ortho), D (Ortho), Courses by
Shivaji University and Medical Council of India,
Delhi and Recognized for Dip NB (Ortho), MNAMS
By National Board of Examinations, Delhi
Editor, Clinical Orthopedics India
Secretary ASAMI-India (Ilizarov Association)
Chief Research Director, Sandhata Medical Research Society, Miraj

FOREWORD TO THE SECOND EDITION
I am very glad that Dr John Ebnezar has written an excellent book on Orthopedics.
The book is extremely informative and is most up-to-date. It is very stylishly written and is neatly designed.
It has so many unique features which is hitherto unprecedented in the history of textbook writing.
What makes this book stand out from the rest is that, it never provides the reader with a single dull
moment and makes the reading very interesting and thought provoking. It keeps the reader engrossed and
the students will find it very gripping and absorbing.
I am sure students will enjoy reading this book and will find it very useful in their preparation for the
examination.
I wish him all the success.
Dr N Ramesh
Former Head of the Department and Prof of Orthopedics
Bowring and Lady Curzon Hospital
Bangalore Medical College
Bengaluru
Karnataka, India


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FOREWORD TO THE THIRD EDITION
Dr John Ebnezar has been my assistant and has worked with me for over two years. Knowing him it is hardly
surprising that he has written a textbook on Orthopedics for such is his keenness and interest in teaching the
students. He enjoys teaching and is tremendously popular among the students.
The book is very comprehensive, simple and is neatly written. Never before any book on Orthopedics has
come out with so many innovations and this kindles and sustains the interest in the readers. A good book is
one which apart from evincing interest in the readers about the subject, makes them desirous to know more
and more about it. This book does that and I am sure students will enjoy reading it and the roller coaster

experience it provides. The practical approach and suggestions will help the students in their preparations
for the examination.
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.
Dr YA Somasundara
Former Senior Professor and Head of the
Department of Orthopedics
Bangalore Medical College
Bengaluru
Karnataka, India


Preface to the Fourth Edition
When the textbook of orthopedics was released for the first time in 1996, I never in my wildest dream ever
fathomed that the book will reach this far. 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.
The book has gone global and occupies a proud possession in prestigious NHS Trust libraries across UK and
has an Italian Edition too. 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.
During conferences, workshops, CME’s, teaching courses, seminars, personal and private meetings when I
meet medical students and teachers, they all tell how much they love my book. 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. 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


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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:
• Each and every chapter has been thoroughly revised and updated where ever necessary.
• New sections have been created.
• Many line diagrams have been either redrawn or improved upon.
• Plenty of new diagrams and X-rays have been added.
• Lots of relevant clinical photographs have been incorporated.
• For certain practical application in orthopedics like reduction of a fracture or a dislocation, I have actually
added the live practical steps and done away with inadequate and misleading line diagrams. They will
enable the student to understand and grasp these steps better.
• Global trauma is on the rise, hence a new chapter on trauma is added.
• Due to the ever increasing life span of the population, orthopedic problems in the elderly people are on
the rise. Hence a whole new section on geriatric orthopedics has been added.
• A new section on common surgical techniques enables a student to know and understand back surgical
techniques so essential for learning and for their future practice.
• Minimally invasive surgeries like Arthroscopy have revolutionized the treatment in orthopedics. 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.
• No postgraduate book can be complete without a section on Arthroplasty. A section on Arthroplasty that
caters more to the practical than theoretical aspects has been added.
• Evidence based orthopedics has arrived in a very big way in the field of medicine. 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. 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.
Regards and thanks,
John Ebnezar


Preface to the First Edition
While I was a final year MBBS student, I fell in love with Orthopedics lock stock and barrel. 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? They said that, they wanted a book which
is comprehensive and at the same time examination oriented. I learnt that my notes were actively being
circulated among the students and after each examination; students came back to me and told that they had
done extraordinarily well after reading my notes. This surprised me as I had always taught them more than
required. I was a firm believer of the fact that by pruning the subject one cannot do justice to it. Examination
should be a part of the learning process and not vice versa. I then decided to write a book for them which was
adequate, neither less nor more. Little did I realize then that I was embarking on a journey which was arduous
and tumultuous? I slogged for three long years to bring out this book. Hope students find my effort informative
and useful.
Despite being meticulous, I am sure there will be plenty of mistakes in the book. I request the students to
point them out unhesitatingly so that I can improve upon. This book will be a useful handbook for postgraduate
students also.
Now about the highlights of this book:
To make the book more educative and also to present an enjoyable reading, I have tried certain innovative
methods which hitherto have not been attempted in textbook writing. I am confident that it will be received
well.
• Autobiographical anatomy: I have noticed that majority of students skip anatomy for reasons of monotony.

To assure that they read anatomy, I planned to make it different. So I decided to let the structures talk
about themselves. I hope this self-talking anatomy appeals.
• Good illustrative diagrams.
• Differential shading of the tables and columns to highlight the facts in their order of importance.
• Quick short summaries during each chapter to make the student focus their attention towards the important
and salient features of the topic concerned.
• Useful mnemonics wherever feasible to enable the students to remember and recall easily.
• Diagrams have been put in tabulated columns with suitable description to make it more useful and
attractive.


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• Orthopedics is a part of life and not vice versa. The philosophies of life apply to it also. Hence, an attempt
is made to view orthopedics in a philosophical angle.
• Anecdotes, jokes and a word of caution wherever found necessary.
• Good flow charts to convey the ideas effectively.
• Though examination is not everything, but still it is an inescapable inevitability in any student life. On
their request, a list of examination short cases and relevant points has been given at the end of the book.
It will be of use if only the subject has been studied properly. It will be complementary and not a substitute
for good reading.
• X-rays are put in the end of chapters so that students can browse through it, especially during examinations.
• The chapter on instruments is prepared with great care to maximally benefit the students.
• History of orthopedics is given equal weightage as much as the recent advances. I firmly believe that it is
to the solid foundation laid down by our forefathers we owe our present-day success. It is our duty to
remember and know their contributions and build upon it.
• Chapter on low backache is written to educate the students about their back. It is a common problem
which every student needs to know irrespective of the subject of interest in future. Hence, an attempt is

made to present it more realistically.
• More importantly, I have used the services of my students rather than professionals and I hope they have
done a commendable job, as they know the requirements and pulse of the students better.

John Ebnezar


Acknowledgments
Fourth edition of the Textbook of Orthopedics is a special book as it is now updated into a full-fledged short
textbook for postgraduate students. This was in the offing for a very long time now as my book was most
popular among them. Believe me it was one hell of an effort as it was a gigantic task. I had to seek the
opinions of my friends, teachers and post-graduate students in creating a book that would cater to all their
requirements. I feel this is the first short postgraduate text book of orthopedics. I would like to recall the role
played by so many friends and well wishers who made this dream of mine into a reality.
My beloved mother late Smt Sampath Kumari deserves a very special thanks for instilling right values in
me that guided me to undertake ventures like books, teaching and social service. She was a disciplinarian
and idealistic mother to the core. I owe my very existence and success to her. I thank my wife Dr Parimala,
my son Rakesh who is now doing his houseman ship at Mysore Medical College and my beautiful and lovely
daughter Priyanka for their unstinted and unflappable love, warmth, encouragement and support.
I thank all my teachers who shaped my personality and career right from primary school to my postgraduation in orthopedics, especially the staff of JN Medical College, Belgaum. I thank all the colleagues of
Victoria Hospital, Bangalore Medical College for their cooperation. I thank my artist friend Mr. Linus for
creating such beautiful diagrams as desired by me whose creativity in imagining and translating my thoughts
into pictures and producing the right impressions are worthy of praise. But for his skill, the book would not
have been what it is today. Dr KR Raghavi and Dr Raghvendra were two of my best students and have
motivated and helped me in bringing out the first edition of this book. I also thank my Junior Research
Assistant Dr Yogita who actively supported me in bringing out this edition. I also thank all the staff of my
hospital for helping me.
I thank Shri Jitendar P Vij (Chairman and Managing Director), M/s Jaypee Brothers Medical Publishers
(P) Ltd, and his entire team for the hard work, cooperation, support and commitment in bringing out this
book for postgraduate orthopedic students. My special thanks to Mr. Tarun Duneja, Director (Publishing),

Mr. K.K. Raman (Production Manager), Mr. Venugopal (Branch Manager) and all the Bengaluru Branch staff
and Mr. Bharat Bhushan (DTP Operator), Mrs Sonia Mehta (Graphic Designer) for their hard work and
dedication. I reserve my special thanks to Mr. Akhilesh Kumar Dubey and Mr. Aravind Kumar for interacting
with me continuously and putting in a lot of effort into creating a very good book.
I express my sincere gratitude to all the teachers and students for patronizing and supporting my book. I
am grateful to all my critics who helped me see and overcome all the mistakes in my book. For all the
blessings and the gift of life, I remain indebted to God the Almighty.



Contents
SECTION 1: TRAUMATOLOGY
1. Trauma—A Modern International Epidemic ________________________________________________ 3
2. Know Your Skeletal System _______________________________________________________________ 8
3. General Principles of Fractures and Dislocations ___________________________________________ 15
4. Complications of Fractures ______________________________________________________________ 30
5. Emergency Care of the Injured ___________________________________________________________ 50
6. Fracture Treatment Methods: Then, Now and Future _______________________________________ 55
7. Recent Advances in Fracture Treatment ___________________________________________________ 81
8. Fracture Healing Methods _______________________________________________________________ 90
9. Soft Tissue Injuries ______________________________________________________________________ 93
10. Fractures in Special Situations ___________________________________________________________ 105

SECTION 2: REGIONAL TRAUMATOLOGY
11. Injuries Around the Shoulder ___________________________________________________________ 119
12. Injuries of the Arm _____________________________________________________________________ 140
13. Injuries Around the Elbow ______________________________________________________________ 146
14. Injuries of the Forearm _________________________________________________________________ 170
15. Injuries to the Wrist ____________________________________________________________________ 183
16. Hand Injuries _________________________________________________________________________ 194

17. Dislocations and Fracture Dislocations of the Hip Joint _____________________________________ 211
18. Fracture Femur ________________________________________________________________________ 226
19. Injuries of the Knee ____________________________________________________________________ 245
20. Fracture of Tibia and Fibula _____________________________________________________________ 264
21. Injuries of the Ankle ___________________________________________________________________ 274
22. Injuries of the Foot _____________________________________________________________________ 283
23. Pelvic Injuries, Rib and Coccyx Injuries __________________________________________________ 300
24. Injuries of the Spine ____________________________________________________________________ 310
25. Peripheral Nerve Injuries _______________________________________________________________ 329


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SECTION 3: NONTRAUMATIC ORTHOPEDIC DISORDERS
26. Approach to Orthopedic Disorders ______________________________________________________ 355
27. Deformities and their Management ______________________________________________________ 362
28. Treatment of Orthopedic Disorders ______________________________________________________ 365
29. Regional Conditions of the Neck ________________________________________________________ 373
30. Regional Conditions of the Upper Limb __________________________________________________ 378
31. Regional Conditions of the Spine ________________________________________________________ 397
32. Regional Conditions of the Lower Limb __________________________________________________ 409
33. Disorders of the Hand __________________________________________________________________ 452

SECTION 4: COMMON BACK PROBLEMS
34. Low Backache and Repetitive Stress Injury (RSI) __________________________________________ 461

SECTION 5: GENERAL ORTHOPEDICS
35. Congenital Disorders __________________________________________________________________ 487

36. Developmental Disorders ______________________________________________________________ 515
37. Metabolic Disorders ___________________________________________________________________ 527
38. Osteomyelitis _________________________________________________________________________ 540
39. Skeletal Tuberculosis ___________________________________________________________________ 551
40. Disorders of Joints (Arthritis) ___________________________________________________________ 575
41. Rheumatic Diseases ____________________________________________________________________ 581
42. Neuromuscular Disorders ______________________________________________________________ 600
43. Bone Neoplasias _______________________________________________________________________ 615

SECTION 6: GERIATRIC ORTHOPEDICS
44. Distal Forearm Fractures _______________________________________________________________ 643
45. Fracture Neck of Femur ________________________________________________________________ 654
46. Osteoporosis __________________________________________________________________________ 668
47. Osteoarthritis _________________________________________________________________________ 674
48. Cervical Disk Syndromes _______________________________________________________________ 690
49. Lumbar Disk Disease and Canal Stenosis _________________________________________________ 694


Contents

xix

SECTION 7: COMMON SURGICAL TECHNIQUES
50. Common Surgeries of the Humerus ______________________________________________________ 699
51. Common Forearm Surgeries ____________________________________________________________ 717
52. Common Hip Surgeries ________________________________________________________________ 722
53. Common Surgery of the Femur __________________________________________________________ 734
54. Common Surgery of the Patella _________________________________________________________ 741
55. Common Surgery of the Tibia ___________________________________________________________ 743
56. Turco’s One Stage Posteromedial Release for CTEV ________________________________________ 755

57. Common Surgery of the Spine __________________________________________________________ 756
58. Common Finger and Toe Surgery (Percutaneous Fixations) _________________________________ 770
59. External Fixation ______________________________________________________________________ 780

SECTION 8: MISCELLANEOUS
60. Amputations __________________________________________________________________________ 787
61. Prosthetics and Orthotics _______________________________________________________________ 792
62. Sports Injuries _________________________________________________________________________ 801
63. Arthroscopy __________________________________________________________________________ 806
64. Standard Arthroscopy Portals ___________________________________________________________ 809
65. 9-Point Diagnostic Knee Arthroscopy ____________________________________________________ 812
66. Arthroplasty __________________________________________________________________________ 816
67. Evidence Based Orthopedics ____________________________________________________________ 842

APPENDICES
Appendix I: Instruments and Implants in Orthopedics _____________________________________ 859
Appendix II: Guidelines for Practical Examinations ________________________________________ 872

Glossary ______________________________________________________________________________ 877

Index _________________________________________________________________________________ 883



Introduction
Orthopedics has come a long way since the days of Nicholas Andry, a French physician, who is credited for
coining the term, orthopedics from two words, Ortho = straight and Pedics = child in 1741.
What was a primitive branch then restricted to correcting deformities in children, has developed into a
full-fledged specialty with diverse scope ranging from simple treatment, as done by traditional bonesetters
to highly advanced joint, spine and hand surgeries.

The development of orthopedics as a specialty was pedestrian till 18th century. The discovery of anesthesia
and aseptic surgical techniques opened-up new avenues of treatment like open reduction, debridement, etc.
The discovery of X-rays by Roentgen and the introduction of the usage of Plaster of Paris by Albert Mathysen
in 1852 revolutionized the diagnosis and management of orthopedic disorders. Thus, orthopedics started
breaking through the deadlocks of a crude branch to that of a science.
But what really set the ball rolling was the sudden surge of orthopedic cases firstly by the two World
Wars and of late by the road traffic accidents which is on the rise, both in the developed and developing
countries.
Polytrauma, multiple fractures and high-velocity injuries severely exposed the limitations of the
conventional treatment in orthopedics, as the fracture patterns were bizarre and complicated. Thus newer
modalities of treatment like improved methods of internal fixation, the AO systems, the interlocking nail
system, Ilizarov's method, etc. were introduced into orthopedic management. Suddenly, orthopedics was
being considered a highly specialized branch with vast scope.
Needless to say many pioneers both at the international and national level have contributed enormously
for the development of this branch to the present what is today. We salute them for their contribution. A
fitting tribute to them is to carry on the good work done by them and to raise the level of this branch to such
dizzy heights so that the sufferings of mankind due to orthopedic disorders are mitigated.
There is a strong notion among the students that orthopedics is all about trauma. Nothing can be farther
from the truth. Though trauma contributes to a major chunk of orthopedic-related conditions yet it is not the
sole contributor. Like any other system in the body, bones and joints are affected by a plethora of disease
conditions ranging from congenital disorders, infections, tumors, etc. Degenerative disorders that seem to
ravage the musculoskeletal system in old age complete the cup of misery. Needless to say one needs to be
equipped both with knowledge and skill to gear up oneself to face the orthopedic challenges being hurled at
surgeons in double quick time of late.
Through this book, I endeavor to arm my students with the all important knowledge so essential to
understand and unravel the mysteries surrounding orthopedic-related conditions. Based on this knowledge,
the necessary skills can be acquired through various stages of practical exposures. It always helps to know
the common orthopedic terminologies, tests, surgical procedures, etc. for better and easy understanding.

xxii

Textbook of Orthopedics

This is presented in the glossary. It is imperative to know about the fundamentals of bones and joints before
undertaking the arduous journey of problems afflicting the musculoskeletal system. Thus basics of this systems
are talked about in relevant sections. The chapters deal extensively first with the traumatic conditions and
related problems, followed by non-traumatic conditions.
The tools required to acquire the all necessary skills are mentioned in the final chapters on instruments
and implants. I fervently urge my students to be a stickler for basics and sophistication automatically follows.
It pays to know, at the beginning itself, that the reverse is not true.


SECTION 1

Traumatology

• Trauma—A Modern International Epidemic
• Know Your Skeletal System
• General Principles of Fractures and Dislocations
• Complications of Fractures
• Emergency Care of the Injured
• Fracture Treatment Methods: Then, Now and Future
• Recent Advances in Fracture Treatment
• Fracture Healing Methods
• Soft Tissue Injuries
• Fractures in Special Situations

1
•
•
•
•

Trauma—A Modern
International Epidemic

Introduction
Epidemiology
Prehospital care
Conclusion

EPIDEMIOLOGY
Injuries due to various causes could be either fatal
or nonfatal. A look at the injury epidemiology could
help you to understand the enormity of the situation.

INTRODUCTION

Fatal Injuries

When man was basking in the glory of conquering
killer disease like tuberculosis, smallpox, polio,
typhoid, plague and other infective diseases that
threatened to wipe out the human race in the past,
cutting short the euphoria are certain modern causes
of death and morbidity like injuries, HIV, etc. There
is, however, one difference that these modern

problems are man made and thus offers a greatest
hope of conquering these. It is said that 99 percent
of the accidents are man made and only 1 percent is
providential.
Injuries due to trauma are on an unprecedented
high across the globe more so in developing nations
like India. The reasons are not far to seek. Road
traffic accidents are on the rise, so are the industrial
and agricultural accidents. Intolerance, hatred and
unrest have caused escalation in terrorist activities
across the world leading to increased mortality and
bizarre injuries that could maim and make one
disabled for life. Add to this instances of assaults,
falls, train, air and other accidents not to forget
natural calamities like floods, quakes, etc. and war,
all this lead to a plethora of injuries that could be a
burden to the entire mankind. With sports and games
gaining world wide propularity, injuries due to these
events are also on the rise. Suddenly injuries have
gained the tag of a modern international epidemic that
is ravaging young lives like never before.

• Injuries are the 4th leading cause of death over
all ages (6%).
• Between 1-44 years of age, it is the leading cause
of death.
• Between 15-24 years, 8 out of every 10 deaths in
young are due to injuries.
• Injuries account for more premature deaths than
cancer, heart disease or HIV.

• Fifty percent of deaths occur at the scene within
minutes or en route to the hospital.
• 20-30 percent die of neurological dysfunction
within several hours to 2 days post-injury.
• 10-20 percent die of infection or multiple organ
failure within days or weeks.
• Every year 1.9 million are hospitalized due to
injury.
• Twenty-seven million are treated in the
emergency department.
• Injuries account for an estimated 8 percent of all
hospital discharges, 37 percent of emergency
department visits and 35 percent of all emergency
medical services transport.
• Nonfatal injures lead to reduced quality of life
and high costs accrued to the health care system,
employers and society in general.
• Persons less than 45 years account for 60 percent
of all injury fatalities and hospitalization and
78 percent of all causality department visits.