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Soft Tissue Sarcoma — Enneking
Malignant tumors of mesenchymal origin; >50 histological subtypes. Enneking staging: based on grade (low/high), compartment (intra/extra), metastasis (I–III). Presentation: painless enlarging mass, often deep to fascia. MRI is imaging of choice; biopsy planned along resection line. Treatment: wide surgical excision ± radiotherapy; chemo for select subtypes.
Open topicSolitary Plasmacytoma
Localized malignant proliferation of plasma cells in bone or soft tissue without systemic myeloma. Common in vertebrae, pelvis, ribs, femur. Symptoms: pain, swelling, pathological fracture, neuro deficits if spine involved. Diagnosis: biopsy + immunohistochemistry, normal marrow (
Open topicSpinal Infections — Pyogenic vs TB
Pyogenic: acute pain, fever, rapid neuro deficit; disc involvement early. TB: insidious course, night sweats, cold abscess, vertebral collapse, gibbus deformity. MRI: pyogenic—disc + endplates; TB—paradiscal, large abscesses, skip lesions. Management: pyogenic—IV antibiotics, drainage; TB—ATT + bracing, surgery for neuro deficit/instability. Complications: kyphotic deformity, chronic pain, neuro sequelae.
Open topicSpinal TB (Pott’s) — Anterior vs Posterior
First-line treatment is ATT with rest and bracing per Tuli’s 'middle path'. Surgical indications: neurological deficit not improving, instability/deformity, large abscess, severe pain, diagnostic uncertainty. Approach selection depends on pathology location and kyphosis: anterior debridement/fusion vs posterior decompression with instrumentation or combined 360°. Posterior‑only circumferential decompression via costotransversectomy/retropleural approaches is increasingly favored for multi‑level...
Open topicSpondylolisthesis — Wiltse Classification
Wiltse etiologic types: I dysplastic, II isthmic (IIA lytic, IIB elongated pars, IIC acute pars), III degenerative, IV traumatic (other than pars), V pathologic, VI iatrogenic. Meyerding grades I–V (25% increments) quantify slip; slip angle and pelvic incidence inform reduction strategy. Adult degenerative L4–5 listhesis: decompression with fusion when instability/foraminal stenosis present. High‑grade isthmic L5–S1 in adolescents may need reduction and circumferential fusion; monitor for L5 neu...
Open topicSterility & Theatre Protocols
Goal: prevent surgical site infections (SSI). Airflow: laminar, HEPA, positive pressure. Staff: gown, glove, mask, restrict movement. Instruments: autoclave, ETO, H2O2 plasma. Preop: antibiotics within 60 min, skin prep with chlorhexidine-alcohol.
Open topicSternoclavicular Injuries
SC joint dislocations: anterior (more common, often stable after reduction) vs posterior (rare but life‑threatening due to mediastinal compression). Posterior dislocation red flags: dyspnea, dysphagia, venous congestion, neurologic symptoms—urgent reduction under anesthesia with cardiothoracic standby. Imaging: CT with contrast preferred; plain X‑rays often inadequate. Management: sling and rehab for sprain/anterior dislocation; posterior often requires closed/open reduction and stabilization (f...
Open topicSubtrochanteric Femur — Fixation
Deforming forces: flex-abd-ER proximal; add distal. Implant: CMN gold standard. Reduction aids: Schanz, cerclage, clamps. Entry point crucial (piriformis/trochanteric). Complications: malreduction, implant failure.
Open topicSupraspinatus — Anatomy & Clinical Tests
Origin: supraspinous fossa; insertion: superior facet of greater tuberosity; innervation: suprascapular nerve (C5–6). Action: initiates abduction, contributes to humeral head depression and centering. Blood supply: suprascapular artery; critical zone of hypovascularity near tendon insertion (degeneration site). Impingement & tears: subacromial impingement (Neer), degenerative & traumatic tears; clinical tests for integrity. Tests: Jobe (empty can), full can, drop‑arm, external rotation lag (for...
Open topicSwan Neck Deformity
Hyperextension of PIP with flexion of DIP joint. Caused by RA (most common), trauma, chronic mallet finger, spasticity. Clinical: finger looks like swan neck, loss of grip strength. Treatment: splints, silver rings, tendon balancing procedures, arthrodesis in severe cases. Differentiate from boutonniere (opposite deformity).
Open topicSyme's amputation
Syme's amputation is a through-ankle amputation in which the foot is removed while preserving the heel pad and distal tibia-fibula, allowing end-bearing ambulation. Originally described by James Syme in 1843, it provides a durable weight-bearing stump with minimal limb-length discrepancy compared with more proximal amputations. The procedure is most commonly indicated for severe foot trauma, infection, congenital deformities, and selected diabetic foot conditions when the heel pad and posterior...
Open topicSynovial Sarcoma
High-grade soft tissue sarcoma, often near large joints of extremities (knee, ankle). Affects adolescents and young adults (15–40 years). Histology: biphasic (epithelial + spindle cells) or monophasic; SYT-SSX fusion gene (t[X;18]). Imaging: calcification may be seen on X-ray; MRI shows heterogeneous mass. Treatment: wide excision with radiotherapy; chemotherapy (ifosfamide, doxorubicin) improves survival in advanced cases.
Open topicTalar Neck Fractures — Hawkins
Hawkins classification I–IV based on displacement/dislocation. AVN risk increases with stage: I 90%. Urgent reduction and fixation critical to preserve talar blood supply. Fixation: screws/plates, often dual incision approach. Hawkins sign (subchondral lucency) = revascularization on X-ray at 6–8 weeks.
Open topicTarsal Tunnel Syndrome
Entrapment neuropathy of the posterior tibial nerve under the flexor retinaculum behind the medial malleolus. Symptoms: burning dysesthesia/paresthesia in plantar foot, worse at night or with prolonged standing; positive Tinel’s sign posterior to medial malleolus. Etiologies: space‑occupying lesions (ganglion, varicosities), tenosynovitis, trauma, hindfoot valgus/flatfoot causing traction, systemic neuropathies. NCS/EMG supports diagnosis; ultrasound/MRI detects masses and tendon pathology. Trea...
Open topicTB Hip
Second most common osteoarticular TB after spine; insidious monoarthritis progressing through stages. Typical deformity: flexion, adduction, external rotation; muscle spasm and night cries common in children. Shanmugasundaram radiographic stages (synovitis → arthritis → advanced arthritis → ankylosis) guide treatment. Diagnosis: ESR/CRP, MRI for early synovitis/marrow edema; confirm with biopsy/AFB smear/culture/GeneXpert. Treatment: ATT for 9–12 months; traction/physiotherapy early; synovectomy...
Open topicTB Knee
Common site of osteoarticular TB after spine and hip; presents with chronic monoarthritis. Phemister triad on X‑ray: peri‑articular osteopenia, marginal erosions, gradual joint‑space narrowing. MRI shows synovitis, cartilage loss, and bone marrow edema—useful for early disease. Confirm by biopsy/AFB/GeneXpert; ESR/CRP typically raised. Treatment: ATT 9–12 months; synovectomy in persistent synovitis; arthrodesis/arthroplasty after disease quiescence for end‑stage joints.
Open topicTendon Healing and Rehabilitation
Phases: inflammatory (days 1–7), proliferative (days 3–21), remodeling (weeks–months). Intrinsic (tenocyte) vs extrinsic (synovial/paratenon) healing; adhesion formation from extrinsic fibroblasts. Early controlled mobilization enhances tensile strength and reduces adhesions in flexor tendons. Suture techniques: core locking (e.g., 4–6 strand) + epitendinous running improves gap resistance. Rehab protocols: Kleinert, Duran (flexor); early active motion in selected repairs.
Open topicTendon to Bone Fixation methods
Tendon-to-bone fixation is the process of securely attaching a tendon or ligament graft to bone using devices such as bone tunnels, suture anchors, interference screws, cortical buttons, and suspensory fixation systems until biological healing occurs. Successful repair depends on both strong initial mechanical fixation and gradual tendon-to-bone biological incorporation at the enthesis. The choice of fixation method varies according to the procedure, tendon quality, bone quality, and biomechanic...
Open topicTennis & Golfer’s Elbow
Tennis elbow = lateral epicondylitis (ECRB tendon origin degeneration). Golfer’s elbow = medial epicondylitis (flexor-pronator origin). Clinical: pain, tenderness, weakness of grip; Cozen’s, Mill’s, Maudsley’s test for tennis elbow. Investigations: clinical diagnosis; USG/MRI may show tendon degeneration. Management: rest, activity modification, NSAIDs, physiotherapy, injections; surgery if refractory.
Open topicTerrible Triad of the Elbow — Pattern (Not Graded)
Posterior elbow dislocation + radial head fracture + coronoid tip fracture. Requires concentric reduction, radial head fixation/replacement, coronoid/LCCL repair.
Open topicTFCC Injuries
TFCC stabilizes the distal radioulnar joint and dissipates ulnar‑sided load. Palpable 'fovea sign', ulnar grind, and DRUJ shift test support diagnosis. MRI useful; wrist arthroscopy remains gold standard for diagnosis and treatment. Central tears → arthroscopic debridement; peripheral tears → repair; positive ulnar variance → consider ulnar shortening osteotomy. Failure to treat instability leads to chronic pain and DRUJ arthritis.
Open topicThomas Splint — Indications & Technique
Indications: femoral shaft fractures, temporary stabilization. Provides traction + splintage. Structure: proximal ring, side bars, distal crossbar. Complications: sores, nerve palsy, inadequate traction.
Open topicThoracolumbar Burst Fractures — Load Sharing
Assess stability and neurology with TLICS; Load Sharing Classification (McCormack) predicts need for anterior support. High load‑sharing score (≥7) → consider anterior column reconstruction with corpectomy/cage in addition to posterior fixation. Posterior pedicle screw constructs (short vs long segment) are standard; add intermediate screws at the fractured level to improve stability. Canal compromise alone is not an absolute indication for laminectomy—retropulsed fragments resorb over time if P...
Open topicTibia Shaft Fractures — Compartment Risk
Tibia shaft → highest risk of compartment. Signs: pain out of proportion, stretch pain. ΔP
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