🩺 Orthopedic Ultimate Exam Guide

• Nicolas Andry coined the term. Orthos = straight, Paedics = child (Straight child).
• Branch of surgery dealing with prevention or correction of injuries/disorders of skeletal system, muscles, joints, and ligaments.

• Symptoms (Orthopaedic Complaints): Pain, Swelling, Weakness, Paresthesia, Stiffness, Deformity, Instability, Loss of function.
• Pain Evaluation: Measured on a Visual Analogue Scale (0-10) or graded 0 (No) to 4 (Excruciating - totally incapacitating). Check referred pain (e.g., Hip pain can refer to the knee, Cervical spine to shoulder, Lumbar spine to leg).
• Stiffness:
  • Generalized: Rheumatoid Arthritis (Morning stiffness > 1 hour), Ankylosing Spondylitis (Stiffness relieved by exercise).
  • Localized: Osteoarthritis (Morning stiffness < 1 hour), Post-traumatic arthritis.
• Deformity: Causes pain, unsightly appearance, loss of function, and can be progressive.
• Examination Sequence: LOOK (Skin, Soft tissue, Bone), FEEL, MOVE (Active, Passive), STABILITY. Then special tests, neurological, and vascular assessment.

• Synovial Fluid Analysis:
  • Normal / Osteoarthritis: Clear yellow, High Viscosity, Few white cells.
  • Septic Arthritis: Purulent, Low Viscosity, Low Glucose, +++ Bacteriology.
  • Tuberculous Arthritis: Turbid, Low Viscosity, Low Glucose.
  • Gout: Cloudy, Normal Viscosity, + Urate crystals.
  • Pseudogout: Cloudy, Normal Viscosity, + Pyrophosphate crystals.
• Bloodless Field (Tourniquet): Cuff width should be as wide as the limb diameter. Exsanguination (draining blood) done by elevation for 5 mins or sequential squeezing. Tourniquet Pressure: 80-100 mmHg above systolic for Upper Limb (UL), and 100-150 mmHg above systolic for Lower Limb (LL). Maximum time: 2 hours.

• Bone Grafts (Actions):
  • Osteoinductive: Stimulation of osteoprogenitor cells by bone morphogenic proteins.
  • Osteoconductive: Provide linkage across defects & a scaffold upon which new bone can form.
  • Osteogenic: Surviving cells on the graft surface.
• Bone Grafts (Sources):
  • Autograft: Same individual (immunologically acceptable, but limited amount).
  • Allograft: Same species, another individual (unlimited, but immunologically unacceptable).
  • Xenograft: Other mammalian (rarely used).
• Implant Materials:
  • Metal: Iron based (Stainless steel), Cobalt based (Vitallium), Titanium based.
  • High Density Polyethylene (HDPE): Inert thermoplastic ideal for joint replacement.
  • Silicone compound: Silastic (flexible, inert for finger/toe hinges).

• Definition: Fracture is a break in the structural continuity of bone.
  • Closed (Simple): Overlying skin intact.
  • Open (Compound): Skin or body cavity is breached.
• Indirect Forces (High Yield MCQ):
  • Bending force → Transverse with Butterfly fragment.
  • Twisting (Torsion) force → Spiral fracture.
  • Compression force → Short Oblique fracture.
  • Tension (Distraction) force → Transverse or Avulsion fracture.
• Incomplete Fracture: Involves one cortex.
  • Greenstick Fracture: Bone is buckled/bent (in children), intact periosteum, heals quickly.
  • Compression Fracture: Crumpled cancellous bone (e.g., vertebral bodies in adults).

1. Hematoma formation: Vessels torn, necrosis at bone ends (1-2mm).
2. Cellular proliferation: Inflammatory reaction, capillaries grow in.
3. Callus formation: Chondrogenic and osteogenic cells form woven bone (immature) and cartilage.
4. Consolidation: Woven bone transforms into lamellar bone via osteoblast/osteoclast activity.
5. Remodeling: Reshaping of bone, medullary cavity reformed (takes months to years).

Healing Time Rule: "Bones unite in 6 weeks, double for the lower limb (12 weeks), half for children (3 weeks)."

Crucial for pediatric fractures. Injuries from Type III upwards affect growth.

• Type I: Transverse fracture directly through the physis (hypertrophic/calcific zone).
• Type II: Through physis and exiting through the Metaphysis (Most common).
• Type III: Through physis and exiting through the Epiphysis (Intra-articular, affects growth).
• Type IV: Through all three elements (Metaphysis, Physis, Epiphysis).
• Type V: Crush/compression injury of the growth plate (worst prognosis for growth arrest).
• Type VI: Injury to the perichondrial ring (Ranvier zone).

• Reduce: Not always necessary (e.g., clavicle, no displacement, or ribs/vertebra where impossible).
  • Closed Reduction: Used for most pediatric fractures and minimally displaced adult fractures.
  • Open Reduction Indications: Failure of closed, Intra-articular fractures, Avulsion fractures, Associated vascular damage.
• Hold (Fixation):
  • Internal Fixation (ORIF) indications: Cannot be reduced closed, inherently unstable, multiple fractures, pathological fractures, fracture neck of femur (unites poorly). Complications: Infection, Non-union, Implant failure.
  • External Fixation (Ex-Fix) indications: Open fractures, severely comminuted/unstable, pelvic fractures, infected fractures, bone lengthening. Complications: Pin-track infection.
• Exercise: Essential to reduce edema, prevent stiffness, and restore muscle power.

Requires rapid assessment, tetanus prophylaxis, antibiotics, debridement, and stabilization.

• Grade I: Low energy, small clean wound < 1 cm.
• Grade II: Moderate energy, wound > 1 cm, without significant soft tissue stripping.
• Grade III: High energy, extensive skin/soft tissue damage, highly contaminated.
  • Type IIIA: Adequate soft tissue coverage of the fractured bone despite extensive laceration.
  • Type IIIB: Extensive soft tissue stripping; cannot cover the bone (requires flap).
  • Type IIIC: Associated with Major Arterial Injury requiring repair, regardless of the soft tissue wound size.

• Shock: Cardiogenic, Neurogenic, Hypovolemic (requires IV fluids, Ringer Lactate, Blood. Even closed fractures can lose 2-3 units of blood into tissues), Septic.
• Adult Respiratory Distress Syndrome (ARDS): Fluid leaks into lung sacs preventing gas exchange. Progressive severe hypoxemia & Multiple Organ Failure.
• Fat Embolism: Blockage of vessels by fat globules (10-40µm) from bone marrow after closed long bone fractures. Causes respiratory distress, petechiae in axilla/conjunctiva (↓ PO2).
• Crush Syndrome (Reperfusion Injury): Traumatic rhabdomyolysis. Caused by crushing muscle or prolonged tourniquet (> 6 hours). Release causes acid-myohematin release → blocks kidney tubules → Acute Renal Failure (ARF). If tourniquet > 6h, amputation *before* release is indicated to save life.
• Disseminated Intravascular Coagulation (DIC): Release of tissue thromboplastins. Leads to ↓ Platelets, ↓ Fibrinogen, ↑ Prothrombin time. Excessive oozing.

• Vascular Injury: Intimal damage or transection. Requires arteriogram if pulse absent.
• Compartment Syndrome: Increased pressure within osteofascial space compromising microcirculation.
  • Clinical Features (The 6 Ps): Pain (earliest sign, bursting sensation), Paresthesia, Pallor, Paralysis, Polar (cold), Pulselessness (late sign - presence of pulse does NOT exclude diagnosis).
  • Stretch Test: Passive hyperextension of fingers/toes causes excruciating pain (highly sensitive).
  • Diagnosis: Delta P (Diastolic BP - Compartment Pressure) < 30 mmHg indicates immediate Fasciotomy.
  • Late Consequence: Muscle necrosis leading to inelastic fibrous tissue → Volkmann's ischemic contracture.
• Hemarthrosis: Blood in joint (must be aspirated before dealing with intra-articular fracture).
• Gas Gangrene: Caused by Clostridium perfringens (Cl. Welchii).
• Fracture Blisters: Elevation of superficial skin by edema. Do NOT puncture. Cover with dry dressing.

• Malunion: Bone unites in unacceptable position (Shift is accepted; Angulation/Rotation often needs osteotomy).
• Delayed Union & Non-union:
  • Delayed: Persistent pain/tenderness on stress. X-ray shows little callus.
  • Non-union: Movement is painless (pseudoarthrosis).
    • Hypertrophic Non-union: Enlarged bone ends (active osteogenesis but cannot bridge gap due to excessive movement). Tx: Rigid internal fixation.
    • Atrophic Non-union: Tapered/rounded ends, no new bone. Tx: Fixation + Bone Graft.
• Avascular Necrosis (AVN): Ischemia of bone part. Common in: Head of femur, Lunate, Proximal pole of Scaphoid.
• Myositis Ossificans: Heterotopic ossification in muscles after damage (common around elbow). Tx: Gentle active movement, completely avoid forceful passive movement, Indomethacin, Excision of mass after 8 weeks if mature.
• Complex Regional Pain Syndrome (CRPS / Sudeck's Atrophy): Continuous burning pain, redness, stiffness, followed by pale/atrophic skin and severe osteoporosis.

• Anatomy: A ball-and-socket joint between the large head of humerus and small/shallow glenoid fossa. The socket is deepened by the cartilaginous Glenoid Labrum.
  • The joint capsule is lax. It extends down onto the diaphysis medially, so osteomyelitis of the upper humerus can spread directly into the joint.
  • Synovium communicates with the Subscapular bursa beneath the subscapularis tendon.
  • Rotator Cuff Muscles: Subscapularis, Teres minor, Supraspinatus, Infraspinatus. They stabilize the humeral head by pulling it into the glenoid. They pass under the coraco-acromial arch (acromion, coracoid, coraco-acromial ligament) separated by the Subacromial bursa.
• Examination:
  • Look: Contour, swelling, deformity.
  • Feel: Clavicle, AC joint, SC joint, Greater tuberosity.
  • Move: Flexion, extension, abduction, adduction, external/internal rotation, circumduction.

There are 3 basic pathological processes affecting the cuff:

1. Degeneration (WEAR): With age, minute tears develop. Fibrocartilaginous metaplasia or calcification occurs in the Critical Zone (1cm from insertion, which is avascular).
2. Trauma & Impingement (TEAR): Tendon contracts against resistance (lifting) or repetitive impingement against coraco-acromial arch.
3. Vascular Reaction (REPAIR): New blood vessels grow to repair the tear, resorbing calcium deposits. Causes congestion and pain.
   • In Young patients: Repair is vigorous → Severe pain.
   • In Elderly: Tears are larger, but reaction is low → Often Painless but with loss of movement.

• Acute Calcific Tendinitis:
  • Pathology: Deposition of Calcium hydroxyapatite in supraspinatus tendon. Swelling causes severe impingement.
  • Clinical: Young patient (30-40 yrs), severe ache radiating to the Deltoid insertion. Arm held immobile.
  • X-Ray: Calcification above Greater Tuberosity. Resorbs rapidly in weeks.
  • Tx: Sling, NSAID, Shockwave, Steroid injection. Needle Aspiration (Barbotage). Last choice is Surgery (Acromioplasty).
• Chronic Tendinitis (Impingement Syndrome):
  • Pathology: Chronic vascular response. Caused by osteophytes under the AC joint.
  • Clinical: 40-60 yrs. Pain worse at night. Scapulo-humeral rhythm disturbed.
  • Pathognomonic Sign: Pain is aggravated as the arm arcs between 60° - 120° (Painful Arc). Repeating movement with external rotation abolishes/lessens the pain.
  • Tx: Same as acute, plus Surgical Decompression (excision of coraco-acromial ligament and AC osteophytes).
• Tears of Rotator Cuff:
  • Clinical: 50-75 yrs. After a sprain/lift, immediate pain and inability to abduct.
  • Differentiating Partial vs. Complete Tear: Inject local anesthetic into the subacromial space. If active abduction returns → Partial Tear. If active abduction is still impossible → Complete Tear.
  • Complete Tear Signs:
    • Abduction Paradox: Active abduction impossible, but if examiner lifts arm above 90°, patient can hold it up using the Deltoid.
    • Drop-Arm Sign: When lowering the arm sideways, it suddenly drops.
  • Tx: Young (Surgical repair), Elderly (Conservative).

• Adhesive Capsulitis (Frozen Shoulder):
  • Progressive pain and stiffness, resolving spontaneously after ~18 months.
  • Risk factors: Diabetes Mellitus (DM), CVA, MI, Alcoholism.
  • Clinical: 40-60 yrs. Extreme stiffness. Prevents sleeping on affected side.
  • DDx: Post-traumatic stiffness, Disuse stiffness, Regional pain syndrome.
  • Tx: NSAID, steroid injection, Manipulation under GA, Operative release of interval between supra/infraspinatus.
• Biceps Tendinitis & Tear:
  • Tendinitis: Localized tenderness at bicipital groove.
  • Torn Long Head of Biceps: Middle-aged/elderly snaps tendon lifting heavy object. Pain subsides, belly of muscle contracts into prominent lump (Popeye Sign). Treatment is completely unnecessary (function returns).

Shoulder has high mobility but low stability. Regulated by:

• Static Restraints: Intracapsular negative pressure, Glenoid labrum ("plunger/chock block" increasing depth by 50%), Adhesion-cohesion, Humeral retroversion, Ligaments (SGHL, MGHL, IGHLC).
• Dynamic Constraints: Rotator Cuff, Proprioception, Long head of biceps.

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• 1. Anterior Instability (95% of cases):
  • Follows acute anterior dislocation. Detachment of glenoid labrum.
  • Clinical: Recurrent dislocation. Subluxation causes Dead Arm Sign (numbness/weakness).
  • Pathognomonic Test: Apprehension Test (Abduction + External Rotation + Extension causes fear of dislocation).
  • Imaging: Hill-Sachs Lesion (depression on postero-lateral humeral head), Bankart Lesion (labrum detachment).
  • Surgical Options:
    • Bankart operation: Repair detached labrum.
    • Putti-Plat operation: Shortening anterior capsule & subscapularis.
    • Bristow operation: Coracoid transfer to reinforce capsule.
• 2. Posterior Instability: Usually subluxation. Diagnosed by lateral X-ray/CT. Tx: Conservative (muscle strengthening).
• 3. Multidirectional Instability: Associated with generalized joint laxity. Surgery not needed; use muscle strengthening.

• Allman Classification:
  • Group I (Midshaft): 75-80%. Most common. Deforming forces: Medial pulled superiorly by SCM, Lateral pulled inferiorly by arm weight & inferomedially by Pectoralis Major. Tx: Arm sling or figure-of-eight (both have similar union rates). Operative if short > 15-20mm or severely displaced.
  • Group II (Distal third): 15-25%. Classified by Neer (Type I: CC ligaments intact, Type II: CC ligaments torn from medial fragment - high risk of non-union, Type III: Intra-articular AC joint).
  • Group III (Proximal third): < 5%. Uncommonly displaced.

• AC Joint: Fall on outstretched hand.
  • Grade I (Sprain): Partial tear of AC ligament.
  • Grade II (Subluxation): Complete tear of AC, Coracoclavicular (CC) intact.
  • Grade III (Dislocation): Tear of both AC and CC ligaments. Clavicle is highly elevated.
• Sternoclavicular Joint:
  • Anterior Dislocation: Inner clavicle springs forward. Easy closed reduction.
  • Posterior Dislocation: Rare but dangerous! Compresses large vessels/trachea in neck. Urgent reduction required (sandbag between scapulae, pull arm extended).

• Anterior Dislocation (90-98%): Forced abduction/external rotation. Humeral head goes subcoracoid.
  • Clinical: Loss of shoulder contour, flattened laterally.
  • Reduction Methods: Hippocratic (traction + counter-traction in axilla), Kocher's (flex elbow, rotate laterally 75°, lift elbow forward, rotate medially), Stimson's (prone, arm hanging with weight).
  • Complications: Axillary Nerve Injury (test deltoid & sensation over lateral shoulder), Vascular injury.
• Posterior Dislocation: Severe internal rotation (Electric shock, Seizures).
  • Clinical: Arm locked in medial rotation. Frequently missed on AP X-ray (looks globular). Lateral view is essential.

• Most common pediatric elbow fracture. Fall on outstretched hand.
• Wilkin's Classification:
  • Type I: Undisplaced.
  • Type IIa: Angulated, posterior cortex intact.
  • Type IIb: Displaced & rotated.
  • Type III: Completely displaced (Posterior displacement most common, S-deformity). Needs crossed K-wire fixation.
• Complications:
  • Vascular Injury: Brachial artery. If absent pulse → Arteriogram/Doppler.
  • Compartment Syndrome: Leads to Volkmann's ischemia.
  • Nerve Injury: Median nerve (5-20%).
  • Malunion: Causes Cubitus Varus (Gunstock deformity). Does not remodel with growth; requires French corrective osteotomy.

The elbow is a single synovial cavity comprising 3 distinct articulations:

• Humero-ulnar Joint: Between humeral trochlea and ulnar trochlear notch (Hinge Joint).
• Humero-radial Joint: Between capitulum and concave radial head (Ball & Socket joint).
• Superior Radio-ulnar Joint: Between radial head and ulnar radial notch, secured by Annular Ligament (Pivot joint).
• Movements: Flexion/Extension (humero-ulnar/radial), Pronation/Supination (proximal radio-ulnar).

• Examination: Look for the Carrying Angle (normal is 5-10° in males, 15-20° in females) and the Isosceles Triangular relationship between epicondyles and olecranon (disturbed in dislocations, intact in supracondylar fractures).
• Cubitus Valgus: Carrying angle > 20°.
  • Cause: Non-union of lateral condyle fracture.
  • Complication: Stretching of the ulnar nerve causing Delayed Ulnar Nerve Palsy (numbness in ring/little finger).
  • Treatment: Deformity needs no Tx, but nerve requires Anterior Transposition.
• Cubitus Varus (Gun-stock deformity):
  • Cause: Malunited supracondylar fracture. Tri-plane deformity (varus, rotation, anterior angulation).
  • Treatment: Supracondylar corrective osteotomy (French Operation).

• Olecranon Bursitis: Enlarged bursa due to friction (Student's Elbow), Gout, or RA. Treat with excision if infected/enlarged.
• Tennis Elbow (Lateral Epicondylitis):
  • Pathology: Inflammation/overload of the Common Extensor Origin at the lateral epicondyle.
  • Clinical: Pain on outer elbow, radiating to forearm. Worsened by pouring tea or shaking hands.
  • Provocation Test: Pain reproduced by active Extension of the wrist against resistance or passive flexion of the wrist (stretching extensors).
• Golfer's Elbow (Medial Epicondylitis):
  • Pathology: Inflammation of the Common Flexor Origin at the medial epicondyle.
  • Provocation Test: Pain reproduced by passive Extension of the wrist (stretching flexors).
• Treatment for both: Rest, NSAID, Steroid injection. Surgery (detachment of common tendon) if refractory.

• Results from rupture of collateral ligaments, usually post-dislocation. Posterolateral Rotatory Instability (PLRI) is common.
• Mechanism: Supination, axial loading, and valgus stress causes posterior subluxation of the radial head. Also iatrogenic (arthroscopy going too far posterior).
• Clinical: Mechanical clicking/catching when extending the elbow (e.g., pushing off a chair).
• Examination: Apprehension Test (pivot-shift). Patient supine, arm extended overhead, supinated, valgus stress applied while flexing.
• Management of Instability:
  • Non-operative: Posterior splint for 5-7 days at 90° flexion.
    • LCL disrupted, MCL intact: Splint in pronation (protects lateral side).
    • LCL intact, MCL disrupted: Splint in supination (protects medial side).
  • Operative: LUCL (Lateral Ulnar Collateral Ligament) reconstruction indicated for chronic PLRI or when stability cannot be achieved.

• Elbow Dislocation: Posterior dislocation is most common (90%). Isosceles triangle of epicondyles/olecranon is disturbed.
  • Sideswipe Injury: Driver's elbow struck while protruding from window. Severe comminution/forward dislocation.
  • Reduction: Pull forearm with slight flexion, push olecranon forward.
  • Complications: Brachial artery injury, Median/Ulnar nerve injury, Myositis ossificans, Stiffness.

• Olecranon Fracture: Intra-articular. Triceps inserts here. Disrupts the triceps extensor mechanism (patient cannot actively extend elbow against gravity).
  • Tx: Almost always surgical. Transverse fractures require 2 K-wires + Tension Band Wiring (TBW) to neutralize triceps pull. Comminuted requires plate/screws.
• Radial Head Fracture: Fall on outstretched hand. Affects radio-capitellar joint.
  • Type I: Undisplaced (Splint).
  • Type II: Displaced with mechanical block (ORIF with screws).
  • Type III: Comminuted (Excision of radial head).
  • Type IV: Fracture + Dislocation.

• Monteggia Fracture/Dislocation: Fracture of proximal 1/3 of Ulna + Dislocation of Radial Head.
  • Bado Classification: Type I (Anterior), Type II (Posterior), Type III (Lateral), Type IV (Both bones fractured + radial head dislocation).
  • Tx: Rigid internal fixation (Plate) of Ulna; radial head usually reduces spontaneously.
• Galeazzi Fracture/Dislocation: Fracture of distal 1/3 of Radius + Subluxation/Dislocation of Distal Radioulnar Joint (DRUJ).
  • Clinical: "Piano-key sign" of prominent distal ulna.
  • Tx: ORIF of Radius. If DRUJ unstable, pin it with a K-wire in supination.

• Anatomy: The wrist is a Condyloid Joint.
  • Proximal face: Distal end of radius + Articular disc of inferior radio-ulnar joint (covers ulnar head).
  • Distal surface: Proximal row of carpal bones (Scaphoid, Lunate, Triquetrum).
  • Movements: Flexion, extension, abduction, adduction, circumduction. Due to distal projection of radial styloid, Ulnar deviation is considerably greater than Radial deviation.
• Examination: Look, Feel, Move. To test ROM, ask patient to place palms together in Position of Prayer (elevating elbows) to test extension, then wrists back-to-back to test flexion. Normal range is 80-90° for both.

• De Quervain's Tenosynovitis:
  • Pathology: Inflammation of the tendon sheaths of the thumb (Abductor Pollicis Longus & Extensor Pollicis Brevis) on the radial side of the wrist.
  • Epidemiology: Women aged 30-50 yrs. Follows unaccustomed activity (e.g., pruning roses, wringing out clothes).
  • Pathognomonic sign: Finkelstein's Test (Tuck thumb into palm, ulnar deviate the wrist sharply → sharp stab of pain at the radial styloid).
  • Tx: Splint, NSAID, Local steroid, Surgical release.
• Ganglion:
  • Pathology: Cystic degeneration in joint capsule or tendon sheath containing Glairy fluid.
  • Clinical: Painless lump usually on the back of the wrist in young adults.

• Carpal Tunnel Syndrome: Compression of the Median Nerve within the carpal tunnel (bounded by carpal bones and transverse carpal ligament).
• Clinical: Numbness and tingling in median nerve distribution (thumb, index, middle, half ring finger). Wakes patient at night.
• Signs: Tinel's sign, Phalen's test. Late sign includes Thenar Atrophy (wasting of the thumb base muscles).
• Treatment: Splinting, steroid injection, Open or Endoscopic Carpal Tunnel Release.

• Colles' Fracture: Described by Abraham Colles (1814). Transverse fracture of distal radius.
  • Mechanism: Fall on extended wrist.
  • Deformity: Dorsal displacement & dorsal tilt, causing Dinner-fork Deformity.
  • Tx: Dis-impaction via traction, then flexion, ulnar deviation, and pronation in POP cast.
  • Complications: Median nerve compression, Sudeck's atrophy, Malunion, Extensor Pollicis Longus (EPL) tendon rupture.
• Smith's Fracture (Reverse Colles):
  • Mechanism: Fall on the back of the hand (flexed wrist).
  • Deformity: Anterior (Volar) displacement & tilt, causing Garden spade deformity.
• Barton's Fracture: Intra-articular fracture of the distal radius with dislocation of the radiocarpal joint (volar or dorsal). Tx: ORIF using buttress plate.

• Scaphoid Fracture: 75% of carpal fractures. Lays obliquely across the carpal rows.
  • Mechanism: Fall on dorsiflexed hand.
  • Clinical: Pain/tenderness in the Anatomical Snuffbox. Painful fist.
  • X-Ray: May not be visible initially. Repeat X-ray after 2 weeks. Transverse fracture through the waist is most common.
  • Complications: Avascular Necrosis (AVN) - Blood supply enters distally and flows proximally. 40% risk in proximal 1/3 fractures. Non-union (tx with ORIF + Bone Graft).

• Boxer's Fracture: Fracture of the metacarpal neck (usually 4th or 5th), caused by punching. Can accept up to 40° angulation in 4th/5th, but Rotational deformity is serious (causes finger overlap in fist).
• Bennett's Fracture/Subluxation: Intra-articular fracture of the base of the thumb metacarpal. Small fragment stays with trapezium, metacarpal subluxes proximally. Tx: Pull, abduct, extend + POP cast; ORIF if unstable.
• Mallet Finger: Inability to actively extend the Distal Interphalangeal Joint (DIPJ). Caused by avulsion of extensor tendon or fracture. Tx: Splint DIPJ in extension for 8 weeks.

Feature	Monteggia Fracture / Dislocation	Galeazzi Fracture / Dislocation
Fractured Bone	Ulna (Proximal 1/3)	Radius (Distal 1/3)
Dislocated Joint	Radial Head (Proximal Radioulnar Joint)	DRUJ (Distal Radioulnar Joint)
Key Sign / Classification	Bado Classification (Types I-IV)	Piano-Key Sign (prominent distal ulna)
Treatment Focus	ORIF of Ulna. (Radial head often reduces spontaneously)	ORIF of Radius. (If DRUJ unstable, pin it with K-wire in supination)

Feature	Tennis Elbow (Lateral Epicondylitis)	Golfer's Elbow (Medial Epicondylitis)
Pathology	Inflammation of Common Extensor Origin	Inflammation of Common Flexor Origin
Pain Location	Outer side of the elbow	Inner side of the elbow
Provocation Test	Pain on active Extension of the wrist against resistance	Pain on passive Extension of the wrist (stretching flexors)

Feature	Hypertrophic Non-union	Atrophic Non-union
Bone Ends (X-Ray)	Enlarged (Elephant foot appearance)	Tapered or rounded
Biological Activity	Osteogenesis is Active	No suggestion of new bone formation (Inactive)
Underlying Cause	Excessive movement / Poor Fixation	Poor Blood Supply / Gap at the site
Treatment Required	Needs Rigid Internal Fixation only	Needs Fixation + Bone Graft

Feature	Cubitus Valgus	Cubitus Varus (Gun-stock deformity)
Definition	Carrying angle > 20°	Decreased carrying angle (Tri-plane deformity)
Common Cause	Non-union of lateral condyle fracture	Malunited supracondylar humerus fracture
Complication	Delayed Ulnar Nerve Palsy	Mainly cosmetic (unsightly appearance)
Treatment	Anterior transposition of ulnar nerve	French corrective osteotomy

Feature	Colles' Fracture	Smith's Fracture (Reverse Colles)	Barton's Fracture
Mechanism	Fall on Extended wrist	Fall on Flexed wrist (back of hand)	Intra-articular high energy impact
Displacement	Dorsal displacement & tilt	Volar (Anterior) displacement & tilt	Dislocation of radiocarpal joint (Volar or Dorsal)
Classic Deformity	Dinner-fork deformity	Garden spade deformity	Wrist subluxation
Articular Involvement	Usually Extra-articular	Extra-articular	Intra-articular (Volar lip of lower radius)

• Osteoinductive: Stimulation of osteoprogenitor cells (BMP).
• Osteoconductive: Provides a scaffold/linkage across defects.
• Osteogenic: Surviving cells on the graft surface form new bone.

Type	Source	Pros & Cons
Autograft	Same individual	Immunologically acceptable, but limited amount.
Allograft	Same species (another individual/cadaver)	Unlimited amount, but immunologically unacceptable.
Xenograft	Other mammalian (pig/cow)	Rarely used.

Feature	Anterior Dislocation (95%)	Posterior Dislocation (2%)
Mechanism	Forced abduction / external rotation	Severe internal rotation (Seizures, Electric shock)
Clinical Position	Loss of shoulder contour	Arm is locked in medial rotation
X-Ray Diagnosis	Obvious on AP view	Frequently missed on AP (globular head). Lateral view is essential!
Nerve at Risk	Axillary Nerve (Test Deltoid)	Less common nerve injury

مقارنة هامة جداً للإصابات الوعائية والعصبية المرافقة للكسور المختلفة والتي تتكرر كثيراً في الامتحانات:

Fracture / Dislocation	Associated Nerve / Vessel Injury	Clinical Note / Management
Anterior Shoulder Dislocation	Axillary Nerve	Must test Deltoid muscle function and lateral shoulder sensation.
Humeral Shaft Fracture (esp. Holstein-Lewis)	Radial Nerve	Causes Wrist Drop & loss of MCP extension. Mostly neuropraxia (Wait 12 weeks).
Supracondylar Humerus Fracture (in children)	Brachial Artery & Median Nerve	High risk of Compartment Syndrome & Volkmann's Ischemic contracture.
Cubitus Valgus (Non-union of lateral condyle)	Ulnar Nerve (Delayed Palsy)	Numbness in ring/little fingers. Needs Anterior Transposition of the nerve.
Colles' Fracture / Wrist Injuries	Median Nerve	Can cause acute compression mimicking Carpal Tunnel Syndrome.
Monteggia Fracture / Dislocation	Radial Nerve	Usually neuropraxia caused by the dislocated radial head.
Pelvic / Rib Fractures	Visceral Injuries	Bladder, Urethra, Lung (Pneumothorax). Treated BEFORE the fracture.

Feature	Closed Reduction (الرد المغلق)	Open Reduction (الرد المفتوح)
Indications	All displaced fractures, most fractures in Children, stable after reduction, before fixation.	Failure of closed reduction, Intra-articular fractures, Avulsion fractures, Associated vascular damage, Requires internal fixation anyway.
Technique / Principles	Traction, Dis-impaction, Reduction, Alignment.	Surgical exposure, direct visual alignment.
Subsequent Holding	Can often be held in a cast/splint.	Often accompanied by internal/external fixation.

Feature	Internal Fixation (ORIF)	External Fixation (Ex-Fix)
Major Indications	Cannot be reduced closed, inherently unstable/prone to re-displacement, unites poorly (e.g., Neck of femur), pathological fractures, multiple fractures.	Open fractures, severely comminuted/unstable, pelvic fractures, infected/non-united fractures, Bone elongation/transport.
Major Complications	Infection (deep), Non-union, Implant failure, Re-fracture.	Pin-track infection (at site of pin insertion), damage to soft tissue (nerves/vessels), Over-distraction.
Application Method	Plates, screws, nails applied directly to bone under skin.	Pins inserted into bone, connected to external frame outside the skin.