hi friends I'm Dr basel your orthopedics faculty now let's start with the essential image based discussions in orthopedics orthopedics you know is a very visual subject where you see a lot of images in the exam so we are trying to cover as many important images as necessary for your exam and we will try to understand how to differentiate from something that will probably look similar and understand how to read the X-rays and make avoid making those silly mistakes that we can so let's start with the first image this is a device here what is this uh this is thmus splint there is a ring here and there is an inner rod and outer rod and they are connected here and there is a notch over here to accommodate the greater trocanter this is thmus splint now can you tell me where is the thus splint used it is used in lower limb fractures particularly femur fracture very good what about this what is this this is also a splint very good very good which splint obviously it's for lower limb fractures this is bowler and brown splint bowler and brown splint you would have seen this in your casualty right bowler and brown splint it has three pulleys 1 2 3 right this is bowler and brown splint again used for lower limb fracture particularly femur fracture but can also be used for tibia fracture and can also be used to prevent aquinus deformity in foot drop patients right very good right next what is this this is green stick fracture green stick fracture two important hints first it is an X-ray where you see two bones here so obviously wherever you see two bones it's either the forearm or the leg here in this case it's the forearm this is radius this is alna and it's an extra of a child because the growth plate is still visible and you notice that there is only one cortical fracture it's a unicortical fracture unicortical fracture on the other side the cortex is intact so unicortical fracture green stick fracture right and the fracture the green stick fracture occurs on which side of the bone the convex side of the bone under which force the destructive force right it occurs in children most commonly in the forearm radius more than Allah right what about this the bulge or the buckling here that you notice this is your Taurus fracture this is also seen in children but green stick fracture is the most common fracture in children very good now look at this this is an X-ray of one bone right so one bone is either in the arm or in the thigh thigh means femur arm means humorus so here you can see this head and an egg this long shaft so this is femur this is femur so this is a normal exit of the femur what am I showing you here this is a fracture of the shaft of the femur please learn to identify this this is a fracture shaft of the femur so far you've understood that this is normal femur and this is a fracture shaft of the femur and now what are you seeing here this fracture shaft of the femur has been reduced and fixed has been reduced and fixed and what is the device that is used to stabilize this fracture it's an intramedularary nail or rod right it's an intramularary nail or rod my question to you here is what type of fracture healing will you see with this device primary healing or secondary healing yes secondary healing right so for primary healing what do you need you need compression plates or lag screw this is secondary healing secondary healing is healing with callus so callus will form here and the fracture will heal callus will form here the cartilagenous callus will form here which will become bony later and this is secondary healing this is secondary healing or enchondral healing very good what about this one what is this x-ray showing you this is an X-ray of the forearm where you see two bones radius and both of them have been stabilized by a plate right plate with screws so this is a compression plating device compression plating device my question to you is what type of healing will you see here in this type of fixation you will see primary healing primary healing right in primary healing it is nothing but intramembranous healing this heals without callus and this healing occurs in compression plating and lag screws tick right next look at this this is a spotter nothing special here you will be shown an image of a child where there is an angulation at the leg angulation at the leg so you can clearly see there is an antrolateral angulation of the leg everything else seems to be fine the foot seems to be fine the finger seems to be fine there is no other congenital anomaly and the child would be like this since birth this is congenital pseudoarthosis of tibia okay this is congenital pseudoarthosis of tibia the patient will have angulation of the leg also cafe spots on the thigh and the abdomen and this condition is usually associated with neuro fibromyitosis why does it occur we don't know it is assumed to be an intrauterine fracture which has gone into non-unit it's assumed to be that but we are not so sure but here what happens is this is not united and this allows for the movement at the tibia here like a joint so that is why it's called pseudo arthosis pseudo joint so it's congenital pseudoarthosis usually occurs in the tibia and the deformity is anterateral angulation deformity now gustilo Anderson's classification I'm sure all of you should be familiar with this you know this now right so this is a classification for which fractures open fractures so now they can show you the images and give you some clinical hints and features to ask you which type of gustillo Anderson it belongs to so just quickly recall what is gust Anderson's classification it's a classification for open fractures where a type one injury is a fracture with a wound of size less than 1 cm very good two fracture with a wound size between 1 to 10 cm very good what about three all three have 3 A 3 B and 3 C they are usually more than 10 cm in size they're usually more than 10 cm in size so 3A specific points to remember here is that it occurs in farm or a sewage or occurs by a firearm or a contaminated object so contaminated environment 3b what do you need to remember here the perryioium of the bone is also stripped the open fracture is such that the wound has stripped everything from the bone the bone is bare and in 3C the vascularity is also compromised so now if they give you these two images if they give you two one of these two images and you're confused whether it is 3B or 3C if they say that there is perostile stripping or if they say there is bone bear there is no covering over the bone look for a hint where they're talking about pulse or vascularity if they say pulse is maintained vascularity is good then it is 3B but if they say there is no distal pulsations there is injury to the vessel then you can say 3 C are you understanding are you understanding this is Gustil Anderson's classification a very important classification of open fractures for air exam now what is the treatment for open fractures we use external fixators right so this is the image of external fixator here the patient has a wound and obviously there is a fracture in the wound and we have stabilized this fracture with external fixator what do you use you use shan spins and you connect them with rods connecting rods this is an external fixator straightforward uni planar external fixator with multiple pins and one connecting rod there are modifications of all these external fixators remember one of these is rail fixator or limb reconstruction system also known as LRS what do you do here you use pins and to connect those pins instead of using just a rod you use a sliding device which allows for compression or a distraction at the fracture site it allows for compression distraction at the fracture site what is this this is Ilizerov's ring fixator which is also an external fixator where instead of using pins and rods you're using rings rings and rods rings so what is the advantage of using rings when you use rings you can put pins into the bone from any angle you want so this is a multiplenar external fixator it is the most stable external fixator in fact once you apply this you can make the patient walk on it and it also allows for the manipulation at the fracture site can bring about compression and distraction deformity correction any of that right very good now what is this you see one external fixator here on the thigh another on the tibia and both of these are connected by a rod in the middle and this is passing over the knee joint this is known as spanning external fixator spanning external fixator is an external fixator that spans over a joint so this is a knee spanning external fixator similarly you will have an elbow spanning external fixator so external fixators that are used for fractures that are pericular around the joint so say this is your distal femur and this is your proximal tibia and this is your fibula if there is an open fracture in this vicinity that is pericular fractures then you will put put an external fixator in the femur another external fixator in the tibia and then connect both external fixators with a rod that is spanning over the joint this is known as spanning external fixator otherwise remember what was a conventional external fixator a conventional external fixator was just pins in the same bone connected by a rod so if there is an open fracture in the middle of the femur in the middle of the thigh you will use a conventional external fixator okay simple enough next look at this X-ray this is an X-ray of which part of your anatomy foot now what I've noticed is many students get confused between a normal and abnormal X-ray so that is why I have kept a normal X-ray as a reference point for you to identify abnormality right so this is a normal X-ray here of the foot you can clearly see this is the first second third fourth and fifth metatarscel these are the fallenes right and these are the tarsel bones nicely all of them are in place you should know where they are based on your anatomy what are you noticing here you're noticing here that there is a fracture in the second metatarscel particularly in the neck region this is our march fracture this is our march fracture very nice very nice clearly understood now this stress fracture occurs in the foot march is in the neck of the second more than third minute darel it can also occur in the shaft but neck is the most common location what about this one again for reference I have kept the normal exo of the foot here and what are you noticing here right looks like the first metatarsal is fine second metatarsal also is fine third is fine fourth is fine fifth may you're noticing a fracture at the base of the fifth metatarsal fracture at the base of the fifth metadatars right what is this this is Jones fracture this is Jones fracture which occurs at the base of the fifth metadatars very important fracture it has not very good healing potential so you have to immobilize this fracture for a very long time how long minimum 6 to 8 weeks because this fracture is in the waterershed zone vascular it is compromised okay so this is your Jones fracture clear moving on this is a normal X-ray of your shoulder you can see nicely the head of the humorris here then the gleenoid this is your clavicle and this is the acromian process and this is corocoid okay are you noticing you're noticing the head of the humorus is inside the glenoid nice everything looks normal now in this X-ray what do you notice very nice this is a fracture of the clavicle fracture of the clavicle where is it occurring it's occurring at the junction of the medial 2/3 and lateral 1/3 very good it's occurring here very nice again you can see this is the normal head of the humorris is it completely spherical no it's not okay the the contoured part is medial side and the flattened part is on the lateral side right now what is this image all these images are there now first of all what are you noticing you're noticing that this side of the shoulder of this patient is spherical contoured here it is flattened so external appearance I'm not talking about X-ray i'm talking about external appearance of the shoulder is flattened why is it flattened again you notice here that the shoulder is flattened why is it flattened because the head of the humorus it's not in its place that is why it is flattened as head of the humorous is not in its place where did it go it has been dislocated so in shoulder dislocation you will have a flattened shoulder contour and you can clearly see this on X-ray also i've put a normal X-ray here for reference this is your glenoid this is your head of the humorus nice nice right and again here is the glenoid but look at where the head of the humorus is it is not inside the genoid which means there is a dislocation right this is your anterior dislocation of the shoulder ideally to diagnose it on X-ray you need a lateral V also but clinically you will have a flattening of the shoulder which is also a feature of anterior shoulder dislocation okay now look at this this is a normal X-ray and this is the abnormal X-ray what are you noticing in abnormal X-ray again look at this this is the normal genoid and the normal head of the humorus contoured end towards the genoid and the flat end towards the lateral side here what you're noticing is the genoid appears fine but look at the head of the humorus it appears spherical on both the sides this has been described as the light bulb sign or electric bulb sign which is seen in posterior dislocation of shoulder so this is light bulb or electric bulb sign seen in posterior dislocation of shoulder right take now this is a normal X-ray of your arm which bone do you see in the arm humorous only one bone so arm and thigh one bone humorous and femur forearm and leg two bones radial line in the forearm tibia and fibula in the leg so this is only one bone now so this has to be humorous this is the arm this is the head of the humorus this is inside the genoid this is acromian this is the lateral part of the clavicle right and what is this this is the medial condile because the medial condile is towards the body and this is the lateral condile which is on the lateral side so far so good this is AP view of the humorris and this is your lateral view again what are you noticing this is humorous single bone and you see two bones in the forearm can you tell me what is the bone that is articulating with the humorris right very good alna allah articulates with humorus and this part which articulates with the humorus is olicrrono process and what are these ends of the humorris that articulates known as condile condile which condile articulates medial and lateral is on the medial side so middle contact excellent excellent right now what is this fracture this is a fracture shaft of the humorris right where is it occurring it's occurring at the junction of the upper 2/3 shaft and lower one/3 shaft this is holstein louisis fracture and which is the most commonly injured nerve in this fracture radial nerve radial nerve please do not confuse holin lewis fracture with supraondil humorous fracture supracondular humorous fracture just occurs above the condiles of the humorus this is a shaft of humorous fracture okay this is a shaft of humorous fracture let's move on to elbow again you see one bone here so must be arm so this must be humorous and two bones here this is and radius two bones in the forearm and what are you noticing alna is articulating with the humorus that must be the medial condile very nice and radius on the lateral condile but please remember elbow joint is the alno hummeral joint radial head does not participate at the elbow joint so if the fracture occurs here just above the medial and the lateral condile what is it it is a superrachondellular humorous fracture right and if the fracture occurs in the shaft of the humorus at the junction of the upper 2/3 and lower 1/3 it is a holstein fracture so supraondular humorous fracture so this is AP view of the elbow let me show you the lateral view of the elbow again lateral view of the elbow single bone humorous shaft two bones the bone that articulates with humorus is alna and the bone that does not articulate is radius it has a radial head like this okay clear very good so these are the condiles can you see the condiles fracture occurring here is supraondiler humorous fracture fracture occurring here is Olin Lewis fracture are you able to appreciate are you able to understand now tell me what is the muscle that comes and attaches to the tip of the olicrronon behind yes triceps triceps so if you have a supraondular humorous fracture what will happen the triceps will pull these fragments posteriorly right so look at this now right so supraondilar humorous fracture and triceps triceps has pulled the fragment posteriorly again fracture is just above the condiles of the humorus and so the triceps have pulled the olronon posterly so supercondal humorous fracture posterior displace is the most common few more points in supercondal humorous fracture what happens to the three-point bony relationship so what are the three points tip of the medial condile tip of the lateral condile and the tip of the olronon which you feel right tip of the olronon they are forming a straight line when the elbow is extended and they form a triangle when the elbow is flexed if the fracture is above those three points will it be disturbed no in superond humorous fracture the three-point relationship remains undisturbed if it is a lateral condile humorous fracture yes the three-point relationship should be disturbed right are you understanding this so superond humorous fracture has a classification called gartland's classification three types now in type one it is an undisplaced fracture you can't see the fracture line so you see fat pat or sail sign in type two only the anterior cortex is broken but the posterior cortex remains intact right in type three both the anterior and the posterior cortices are broken so superchondal humorous fracture which is completely fractured and displaced it's a type three gartland supraondular humorous fracture is it okay now if you want to temporarily stabilize the superchondellular humorous fracture what is the name of the splinter traction device that you use right it's called Dunlop traction dunlop traction looks something like this do you know this and also now tell me what is the most common complication most common complication of supraondular humorous fracture it is mal union which malunion cubitus vary deformity cubitus that is elbow vus that is forearm going towards the medial side see this is the normal side in normal human beings there is slight vus that is known as carrying angle but because of the malunion of the superrachondial humorous fracture the forearm is deviated medially giving you your cubitus vary deformity so cubitus vis deformity also known as guntock deformity are you understanding this very very important image for your exam cubitus vary deformity or guntock deformity right what is this you see a bony mass that has formed around the elbow region and in this question usually there will be history of massage following a fracture what are you thinking right it is myioitis oificance myiocitis oificance this is one of the rare complications of supraondular humorous fracture when patient underos massage right clear very simple now look at this image just read the X-ray which part of the body single bone so humorous this is Allah this is radius adult or a child it's an X-ray of a child right anything wrong here what is this fragment that is sitting here alone away from the lateral condile okay if you did not understand that let me show you the normal X-ray see now for reference here you have your medial condile here you have your lateral condile here you have your radial head so here there is a bony fragment freely moving away proximal to the radial head so which condile are we talking about lateral condile so it is a lateral condile humorous fracture lateral condile humorous fracture where the threepoint bony relationship should be disturbed threepoint bony relationship is disturbed this is lateral condile humorous fracture now for context quick review which salter harris type fracture is lateral condile humorous fracture and which salter harris type fracture is supracondular humorous fracture i'll show you the diagram here say this is your humorris right this is alna and say this is your radial head okay and this is the growth plate remember this is the growth plate subraondular humorous fracture goes like this threepoint bone relationship is not disturbed it's not disturbed right so what is it it's either type two solder harris or type one solder haris injury whereas lateral condile humorous fracture lateral condile humorous fracture goes like this what type of solder haris injury it is it is a type four alteraris injury type four salter hararis injury very good very nice so what happens in a type four haris injury the growth plate gets injured because of that the lateral condile will not grow and the medial condile will continue to grow causing a deformity and what will be the eventual deformity cubitus vgus deformity so look at this so look at this this patient cubitus vgus deformity normal human beings have slight vgus that is known as carrying angle males have less females have more but here the vgus is so much so this is cubitus vgus deformity this occurs because of which fracture this occurs because of a lateral condile humorous fracture and this is cubitus vary deformity this occurs because of which fracture supraondellar humorous fracture please please don't make mistakes on this these are very very important images now moving on to forearm this is a normal of the forearm you see two bones it's either forearm or the length this is forearm you have radius and you have all sir how to identify radius and all very simple the bone that articulates with the humorris is Allna okay and the bone that has a bigger base and articulates with the carpal bones is radius okay bigger base articulates with the carpal bones radius this is in AP view what about in lateral view see again the one that has olicron and articulating with the humorus is alna and the other one is the radius so you have identified the bones please learn to identify the bones once you've identified the bones then you will know it is fractured now look at this x-ray here the bone that is articulating with the humorris is fractured and the radial head doesn't seem to be in its place so this is an allna fracture with radial head dislocation friends what is this this is Montasia fracture very very important okay again you can see the one that is articulating with the humorus is fractured that is all fracture and the radial head is dislocated so Allnah fracture with a radial head dislocation is Montasia fracture is montageia fracture is this clear i'm not going to too much detail i'm not confusing you i'm trying to keep things as simple as possible so that you can please identify this on the exam right very very important now on the other hand if we fracture the radius look at this bone the bigger base articulating with the wrist and the carpal bones that bone is fractured that is your radius fracture and if the radius is fractured in the shaft immediately look at the distal radialar joint if this dist radial joint is also displaced or not in its normal position which is supposed to be close to each other where was it supposed to be it was supposed to be close to each other but here what has happened the distal radial joint is disrupted this is known as galazi fracture galazi fracture radius fracture with druj disruption is galazi fracture okay friends now look at this this is an x-ray of your wrist with the carpal bones very simple large based bone here this is radius and this is scaffoid and this is lunate these are the two important bones you should know scaffoid and lunate right scaffoid and lunate right now in lateral view of the wrist what will you notice again these radius and are over overlapped what will you notice this articular surface this distal articular surface of the radius has a unique articular facing so where is it facing it will face towards the thumb so this is the thumb friends this is the thumb this is how the image is this is how the image is so distal radius articular surface is facing towards the thumb this singular finger here is the thumb again you can notice the thumb here now this is the singular finger here thumb so distal radius articular surface where is it facing it is facing towards the thumb clear are you able to appreciate this is normal because if you know normal then you will know abnormal now look at this always look for the thumb always look for the thumb in the lateral view for reference now look at this first image this also is an X-ray of the wrist lateral view very good and here is the thumb and now where is the articular surface of the radius it is not facing towards the thumb and there looks like to be a fracture of the distal radius so distal radius is it intra articular or extra articular extra articular because intra articular means suppose this is the distal radius now intraarticular fracture has to go into the joint this is not going intratically it is an extra articular fracture it's an extra articular fracture of the distal radius and the distal fragment is going dorsally so this side is called dorsal thumb side is vententral or palmer dist fragment is going dorsally so what is it it is kis fracture kis fracture on the same context this is again an extra articular fracture with distal end of the radius here where is the distal fragment going it is going towards the thumb it is going ventrally it is going ventrally this is reverse kies or Smith's fracture smith's fracture and here in APV water you're noticing that distal radius articular surface there is a fracture here of this fragment of the distal radius this fragment of the distal radius is called radius styloid so radial styloid fracture this is known as chauffeur's fracture chauffeur's fracture driver's fracture okay so distal radius extra articular fracture with distal articular surface facing dorsally away from the thumb it is koh fracture extra articular fracture with distal articular surface facing towards the thumb or ventrally it is Smith's fracture again let me show you an X-ray here AP view lateral what are you noticing distal end articular surface is fine but there is a fracture extra articularly so it's an extra articular fracture very good in the lateral view What are you noticing the distal articular surface is not facing the thumb it is facing upwards dorsally this is your kles fracture let me show you the graphic image here extra articular fracture distal articular surface facing dorsally and this clinically gives you your dinner fork deformity again dist articular surface facing dorsally this is your thumb the lone finger okay again this articular surface facing dorsally you have thumb here that is the image right this is your kis fracture on the other hand if the distal articular surface is facing towards the thumb is facing towards the thumb then what is it then it is Smith's fracture which gives you which deformity garden spade deformity garden spade deformity and here in this x-ray AP view and lateral view what are you noticing this is an isolated fracture of the radial styloid this is known as chauffeur's fracture articular surface is exactly fine facing where it's supposed to no problem here this is your chauffeur's fracture now coming to the wrist again the carpal bones this is the normal X-ray distal articular surface of the radius is fine here and this is your scaffoid the this is your lunate and this large bone is capitate on this X-ray what are you noticing again this is your scaffoid but there is a fracture in the scaffoid this is a fracture of the waist of the scaffoid clinically what will be the complaints of the patient pain tenderness or fullness in the anatomical snuff box taken now again x-rays of the hand with wrist and the carpal bones thumb is the first metacarpal second third fourth and fifth metacarpal right so this is a everything is fine and you look that look at the carpal bones this is scaffoid and this is lunate they're potentially very close to each other but if the gap between scaffoid and lunate is increased it's called scaffol lunate dissociation and this is a radological sign that has been described as termus sign termus sign scaffold lunate dissociation exaggerated gap between scaffoid and lunate somewhere between more to more than 3 to 4 mm now what is This is an X-ray of the hand first metacarpal second third fourth and there seems to be a fracture of the fifth metacarpal here what is this this is your boxer's fracture this is your boxer's fracture right very nice what is this image spotter image see here only one finger they will show the finger that is injured where there is a flexion at the DIP and everything seems to be fine this is your mallet finger this is your mallet finger or baseball finger occurs because of the hyper flexion injury to the dip joint what is the treatment you will use a mallet splint or frog splint or a stax splint do not confuse mallet finger with swan neck deformity i've told you this in the regular videos as well as in the revision videos don't do that now look at this image this is patient number one looks like he's lying right can you describe the attitude of his lower limbs the left lower limb seems to be flexed at the hip right and seems to be abducted very good and there seems to be an external rotation of the limb how can you say external rotation we can say that because the lateral part of the foot is touching the couch there seems to be an external rotation so flexion abduction external rotation okay what about the attitude in this second photograph the patient is lying down there is flexion at the hip but now there is an adduction of the thigh adduction and there seems to be an internal rotation how can you say it's internal rotation because the knee is falling on the or pointing towards the opposite side or the opposite knee here the knee is pointing towards the same side here it's pointing opposite side so there is some internal rotation so clinically you have identified so here can you describe this attitude as flexion abduction external rotation here can you describe it as flexion adduction internal rotation does it ring any bell where do you see these attitudes of the hip in hip dislocations father is for posterior dislocation of hip and fab is for anterior dislocation of hip you know right very good super so let's review the normal X-ray of the hip right so this is the head of the femur inside the catabulum nice neck of the femur the greater and the lesser trocanter opterator forammen pubic symphysis superior pubic ramis inferior pubic ramis this is the sacrum this is the ilium this joint is the sacro iliac joint okay so far so good right now read this x-ray here this side is normal this side is abnormal what are you noticing in the abnormal side first of all the head of the femur is not inside the cabulum so straightforward diagnosis hip dislocation what type of hip dislocation so first draw the reference line what is that normal reference line shent line shentan's line is a line that you draw on the inferior margin of the superior pubic ramis running laterally towards the medial part of the head and the neck this line should be continuous here try to draw the same line what will you notice that it is disrupted which means there is something wrong at the hip and it is obvious there is a hip dislocation the thigh looks like it is adducted and the tip of the greater trocanter has proximally migrated suggesting that the limb is shortened so adducted and shortening this is your posterior dislocation of hip because you remember the attitude of the posterior dislocation of hip was flexion adduction internal rotation with limb shortening and the mass that is the head of the femur will be palpable in the glutial region glutial region is this clear right what about this again shent line is normal here that is fine but here it is broken the thigh looks like it is abducted And the head of the femur looks like it is dislocated and GT is slightly at a lower level which means the limb is lengthening lengthening so flexion abduction external rotation with limb lengthening what is the likely diagnosis it is anterior dislocation of hip okay now again what are these images these are X-rays of which part the hip joint very good here you're noticing that this is a head of the femur the neck of the femur but there seems to be a fracture of the neck of the femur here also this is the head of the femur the neck of the femur but there is a fracture of the inter trocanteric region right so both of these are fractures around the neck of the femur right so if you remember the capsule of the hip joint attaches to the hip like this so the neck of the femur is an intracapsular fracture intracapsular necur fracture and the inter trocanteric fracture is basically an extra capsular necur fracture right it's a extra capsular neof fracture right very straightforward very straightforward you should know this you should identify them both of them are very important otherwise everything is almost similar they occur in elderly population but their outcomes and complications are different we have read this in great detail so what is the management of interrocandric or extra capsular neck femur fracture you want to maintain the neck shaft angle so that coxava doesn't occur and if coxava occurs what is the problem tendalan burket so in order to prevent coxava we use proximal femoral nail or a dynamic hip screw which is nothing but devices that maintain the neck shaft angle you see there is a screw that goes into the neck to maintain the neck shaft angle and a plate here to stabilize the bone here also you can use a rod that goes into the femur with screws that maintain the neck shaft angle proximal femoral nail and dynamic hip screw okay clear now what about this image you can clearly see here that the head and the neck of the femur has been replaced this is hemiarthroplasty that we perform for necurmur fracture in patients more than 65 years of age very good and what is this again the head and the neck of the femur has been replaced with an acetabular cup this is total hip replacement that we perform again for patients with neco fracture or any other pathology of the hip right beyond 65 years is that clear but if the patient has avascular necrosis or destruction of the hip joint also you can use a total replacement now if the neck shaft angle is not maintained as in intracantric fracture malunions then it will lead to coxava and the problem of coxava is trenderalenberg limp or trendelenberg gate there are many MCQs that are asked based on this so if you recall Trenleenberg limb trenberg gate it was a failure of abductors what were the abductors glutius medius and glutius minimus never maximus and glutius medius and minimus is supplied by which nerve superior glutial nerve never inferior glutial nerve so the side that has a problem when the patient stands on that side the opposite healthy side or the sound side sinks so when the patient is standing on the problem side the healthy side sinks so you have to first identify which side sinks the moment you know which side sings know that it is the healthy side it is the sound side immediately understand that the problem is on the other side and what could be the problem the problem could be superior glutial nerve palsy or glutius medius or minimus palsy or cox of the affected side so in this case this is the left hip of the child and this is the right hip of the child the right side is sinking so right side is the healthy side the problems are the left side what are the problems of the left side either the left side have coxa vera or glutius medius and minimus palsy or superior glutial nerve palsy these are the problems and the patient will have tenderberg test positive for left side tendelber test positive is that clear very very important concept so remember the pneumonic sound side sinks or the healthy side sinks that is not the problem side the problem side is the other side the side that is not sinking what about this image this is thus test it is for flexion contraure or flexion deformity of hip if patient has a flexion deformity or flexion contracture of the hip the test that will help us make the diagnosis is thus test in thus test what do you do you flex the normal hip it's also known as thomas well test you flex the normal hip when you flex the normal hip the pathological side the deformity will be revealed the hidden deformity will be revealed and now you can understand flexion contraure or flexion deformity okay is that clear you understood tendelber test concept you understood thus test what is this traction what are we doing with this child we are hanging both the limbs this is known as gallows traction gallow traction and it is used in children for femur fracture children who are less than 2 years of age right children who are less than 2 years of age very nice and you hang both the limbs again normal X-ray of the knee joint i want you to understand and appreciate this is femur this is tibia and fibula and in the lateral view you can clearly see this is patella femur tibia and fibula what is this part this labeled part this prominence where the patella ligament attaches it's called tibial tuberosity this is the head of the fibula this is the neck of the fibula this is the fibula in the lateral view is this clear this was asked recently they pointed an arrow here and ask you to identify what that structure is now what is this this looks like a transverse fracture of the patella this is the most common pattern of fracture of the patella transverse fracture of patella can you tell me the treatment tension band wiring beautiful tension band wiring with K wires but the principle is tension band wiring this is the best treatment so if both of the options are given tension band wiring with K wires or tension band wiring with something else prefer tension band wiring with K wires if tension band wiring is given and K wires is also given you use tension band wiring as the answer very good what is this this was an image given on your exam here the fracture usually of the patella occurs in the transverse plane transverse fracture here there looks like a fragment of the patella that is separated from the normal bone this is bipartite patella bipartite patella it is a congenital anomaly where this part of the patella has not fused with the remaining patella it's an accessory nucleus of the patella it's a rare thing a rare entity and patients usually just complain of knee uh pain and when you do an X-ray you see this usually it's bilateral 50% of the cases are bilateral nothing to worry about this is bipartite but x-rays of the ankle again you see two bones here and ankle here this is tibia and this is fibula this is the medial malulus which is a part of tibia lateral malulus which is part of fibula in lateral view what do you see you see the head neck and the body of the talis and this bone is calccanium and tibia and fib are overlapping but at the posterior aspect of the tibia you have posterior malulus this makes the ankle ankle a view and lateral view here what do you notice fracture of the medial malulus and lateral malulus this is balular fracture also known as ports fracture and here what do you notice medial lateral and posterior malular fracture this is tralular fracture also known as cotton fracture cotton fracture take now again x-ray of the foot AP view and lateral view i'm sure you have identified all the bones and understood what is normal so yeah there looks like a fracture of the calccanium clear cut so this is a calccanium fracture right and this bone is talis bone this is talis and here there is a fracture of the neck of talis this is a fracture of the neck of talis what is the classification for neck of talis fractures hawkins classification right hawkins classification this was asked this was asked now what is this spotter you see a bulge in the arm bulge of the biceps in the arm this is popo sign can you tell me it occurs because of the rupture of which tendon long head of biceps it occurs because of the rupture of long head of biceps right now look at this what is happening here it looks like the patient is trying to extend the finger but the finger is stuck and then suddenly the finger opens like a snap or a trigger this is your trigger finger trigger finger usually most commonly occurs at which finger ring finger although the video here is of middle finger what can I do the patient came with middle finger trigger finger but usually occurs in the ring finger and what is the structure involved it is the A1 pulley which is located over which joint metacarpo felangel joint very very important what is this image it looks like there is a swelling around the elbow and there is redness here must be inflammation it's olicronon berscitis also known as student's elbow student's elbow right when you study in the library for long hours when you crush your elbow the olron bersa gets inflamed ocrrono berscitis okay the proximal femur looks like is bent like this and what this structure question mark this is your shepherd crook deformity shepherd crook deformity occurs in which condition fibrous dysplasia very good fibrous dysplasia look at this image this is an image of the humorus and there looks like a lesion or a cavity in the humorris and the piece of cortex is freely falling down this is known as fallen leaf or fallen fragment sign it's seen in which condition this seen in simple bone cyst or unicameal bone cyst unicameal bone cyst or solitary bone cyst one more sign was here in radiology trap door sign right right take they go now what do you see here there looks like a bony pedicle and a cartilagenous gap that is growing from the bone away or towards the joint line away so this is the direction so what grows in this direction from epipesis to metaphysis the growth plate right so this is your osteoondroma or exotosis it's an apparent development of the growth plate where the bone grows away from the joint it's a normal growth but in abnormal direction normal bone but in an abnormal direction this is osteocondroma exotosis there looks like a lesion in the metacarpal lucent with some calcifications here and there so must be a cartilagenous lesion this is enondroma this is enchondroite occurs in the small bones of hand and feet now if a patient has multiple of these enchondroas with heangiomas then that is known as mafuchi syndrome that is known as mafui syndrome now this next image is very very important very important for your exam this is an X-ray of a wrist right radius Allah uh-huh adult or a child it is definitely adult because the growth rate is not receible and there looks like a lesion in the radius or radius now which part of the radius epime metadia so it seems to be involving both epifises and metaphysis but how can you be so sure it's epifisal because it's involving under the articular surface also it is just under the articular surface also so any lesion that is just under the articular surface also is epifisal leion so epifio metaphisal lesion this is soap bubble appearance and this is your giant cell tumor please remember this also known as osteoclasstoma very very important let's practice a few more giant cell tumors all of these are giant cell tumors that I'm showing you this is an X-ray of the knee joint ap view skeletally mature individual no growth plate is visible lesion is in the tibia and in the tibia where just under the articular surface so it is epifisial lesion in an adult joint circ tube again x-ray of the knee the lesion is in the femur not tibia not fibula it's in the femur where in the femur just under the articular surface must be epifisal adult epifisal leion giant cell tumor again x-ray of the wrist radius and alna adult no growth plate lesion is in the distal end of the radius just under the articular surface so must be giant cell tumor this image is also giant cell tumor this image is also giant cell tumor this image is also giant cell tumor and this image is also giant cell tumor you have seen potentially all types of giant cell tumors so please do not make mistake on the exam this is a very very important topic now look at this what are you noticing here you're noticing that there is some bone formation here just adjusting to the cortical surface in the shape of a triangle in the shape of a triangle this is Godman's triangle it is seen in aggressive malignant lesions usually osteocaroma but can be seen in other aggressive lesions also here what do you notice you know this something that is traversing horizontally like this yes sunray sunburst appearance sunray sunburst appearance and also you can notice this bone forming in the shape of a triangle adjacent to the cortex this is codman's triangle again cordman's triangle this is sun ray appearance or sunbur burst appearance both of these are seen in aggressive lesions usually osteocaroma but can be seen in other malignant tumors also what about this one this is an x-ray of the leg with tibia and fibula and there seems to be some perostial reaction where there are layers of the tibia again this is an x-ray of the femur of a child and there seems to be bone formation in layers appears this is lamolated appearance or layered appearance known as onion peel appearance onion peel appearance usually seen in aggressive malignant lesions say for example saroma but can it be seen in other aggressive lesions also yes they are not pathogic so how do you diagnose saroma with help of hisystologology you see you will pick up transllocation 1122 mto gene mutation CD9 positivity and small round blue cells with sudorets what is this image what are you noticing here first of all you're noticing that the hypoththena region is flattened and wasted and the fourth and the fifth digits fourth and the fifth digits the MCP the knuckles are extended and the PIP and DIP are flexed what is this it looks like a partial claw hand partial claw hand occurs in which nerve paly nerve paly and on the other hand here what do you notice here you're noticing this all the fingers are affected this looks like a complete clawing of hand this looks like a complete clawing of hand complete glowing of hand occurs in alna and media nerve palsy so in alna nerve palsy the knuckles are extended right the knuckles are extended so what is the splint you will use knuckle bender splint so you're bending the knuckles the mcp joints you're bending so knuckle bender splint so ala nerve palsy knuckle bender splint what is the test that is being performed in image A it looks like the examiner is holding a card or a piece of paper between the fingers to assess palmaric pad adductors of the finger this is card test for which nerve alarnara for which muscles palmer intro here what is the examiner doing the examiner is trying to abduct the fingers against resistance dab dorsal interro dorsal interr what is this test this isa test eigava test performed for which nerve alnara for which muscle dorsal inter very good what is this deformity the thumb seems to be adducted to the other fingers and everything else seems to be fine this is ape hand deformity ape hand deformity ape hand and ape hand deformity occurs in which nerve paly median nerve paly it occurs in median nerve paly and what is this test being performed here the patient is doing this maneuver of the thumb to touch the pen this is abduction of the thumb to test which muscle abductor policis brevis muscle and the test is pen test pen test is performed for which nerve media nerve for which muscle abductor policis bravis muscle very good what is this right every finger is flexed except this is it claw hand is it claw hand this is claw hand where the knuckles are extended but what is this there is flexion at the MCP no no this is pointing index this is claw hand this is pointing index and pointing index occurs because of which nerve paly median nerve palsy this is pointing index also known as benediction sign ashner clasp sign or pope sign very good what is this okay weak okay okay weak okay this is kilo nevin sign or okay sign or o sign or weak okay sign this occurs because of injury to which nerve anterior intro nerve which is a branch of media nerve why because anterior interroious nerve supplies flexor policysus longus which flexes the thumb and flexor digtorum profundus that flexes the dip of the finger so these two movements are affected so instead of this movement possible it goes into like this this is weak okay sign this is the normal side this is the normal side what is this it looks like the wrist has dropped the patient is unable to extend the wrist wrist drop wrist drop occurs because of vision nerve palsy radial nerve paly and radial nerve paly occurs because of which fracture usually ostein leis fracture or humorous shaft fracture what is the treatment of wrist drop you use splint where you up the wrist so this is cockup splint there are two types of cockup splint a static cockup splint and a dynamic cockup splint right static and a dynamic cockup split look at this deformity in this child the shoulder looks like it's adducted internally rotated elbow extended and forearm pronated this is policeman's tip policeman's tip waiter's tip or porter's tip deformity this is herb spaly herbs spy very good now look at this there seems to be a fracture where is the fracture this is the femur this is the patella seems fine this is tibia seems fine this is tibial tuberosity seems fine and there seems to be a fracture in the fibula which part around the proximal fibula the neck of fibula fracture this region if you have a fracture of the fibula in this region there is a high chance of injury to which nerve common peronial nerve and if the common peronial nerve is injured what will happen the patient will have foot drop the patient will be unable to ankle dorsif flex and ever the foot will be dropped this is foot drop foot drop occurs because of common peronial nerve palsy which occurs because of neciula fracture and if the patient has a foot drop what will be his gate his gate will be this which is known as high stepping gate he will exaggerate the flexion of the hip and the knee to lift off the dropped foot what is the splint you will use you will use toe raising or foot drop or ankle foot orthosis this is it ankle foot orthos here a patient is performing this maneuver and this maneuver what is this test test is performing the purpose of this maneuver is to impinge a nerve which nerve media nerve so this is falance test fallance test and reverse valance test which is performed for which nerve fallon reverse fallon it is performed for which nerve media nerve media nerve very good so which condition are you testing you're testing for carpal tunnel syndrome carpel tunnel syndrome carpel tunnel syndrome take what is happening here here the doctor is compressing over this aspect with the thumb only okay so there is no two compressions radius radial and allar artery are not getting compressed there is only one compression one point of compression they are compressing the median enough this is durkan test durkan test durkens test is the best clinical test to diagnose carpal tunnel syndrome what if they show you an image where there is a compression of the radial artery and allar artery together that is Allen's test that is performed to assess the patency of the vessels that is different this is Durkens test and what is this this one right it's been asked right this is Roose test roose test performed to diagnose thoracic outlet syndrome roose test by performing this maneuver you're basically increasing the oxygen demand of the muscles or of the hand and if there is claudication or compression because of thoracic outlet syndrome the patient would feel pain or parthesis okay now look at this this is a normal X-ray of the wrist in the hand of a child and here what are you noticing you're noticing cupping spllaying fraying and widening what is this this is ricketetts friends if they show you X-ray of a wrist of a child on the exam probably they are showing you ricketetts here what are you noticing there is a white line of calcification this is suggestive of healing ricketetts this is healing ricketetts once you start the patient on treatment the ricketetts will start to heal huh so this is healing ricketetts white line of frankle it's known as white line of frankle okay now these are the obvious deformities you know this is bilateral genu deformity also known as noches this is bilateral genu deformities also known as bolex this is windswept deformity where one side is in vgus other side is in vus can you tell me what are the most common causes of all these things bilateral genoval think idiopathic more than ricketetts very good bilateral genovirus ricketetts more than idiopathic very good and windswep deformity ricketetts very good very good you know this same thing scurvy what are we trying to understand this is a normal X-ray of the knee of a child and what is the problem in scurvy it's a collagen problem right so these are the deformities you will see on the X-ray you will see the white line of frankle white line of frankle and you will see vimberger ring sign sclerosis around the epiphis vimberger ring sign this is normal x-ray for you to identify as reference of the abnormalities here what are you noticing there is by concavity of the end plates of the vertebra right by concavity of the end plates of the vertebra this is normal this is normal side this side is normal side this is abnormal side what is this by concavity this is known as codfish vertebrae or fish mouth vertebrae the most common cause being osteoporosis but it can also occur in osteomalian other conditions this is codfish vertebrae and fish mouth vertebrae friends what is this this is normal vertebrae right anterior wall posterior wall superior plate inferior plate here what are you noticing the anterior wall is shorter positive always is longer it means it looks like the vertebrae has compressed this is a compression fracture or wedge fracture compression or wedge fracture of the spine this occurs because of a flexion injury in osteoporotic individuals giving your wedge compression fracture okay here you see sclerosis lucency and sclerosis in vertebra this is ruggar jersey spine seen in renal osteodistrophe it can be seen in other conditions also one more condition is osteopeterosis osteopetrosis here what are you noticing there is sclerosis at the end plates in the anterior and the posterior wall this is picture frame vertebra picture frame vertebrae in which condition do you see picture frame vertebra yes pedett's disease very good pett's disease what else do you see ivory vertebra this is ivory vertebra what do you see in the skull cotton wool skull this is cotton wool skull right and finally in the blastic phase of the disease what do you see you see deployic swelling of the skull now thickening of the skull swelling of the skull this is known as tam oanter skull tamosanter skull all of these are seen in petties if you see a patient with blue sclera and deformed bones bent bones like this then clearly it is osteoggenesis imperfect no doubt about it osteogenesis imperfect if you see a child with an actively discharging sinus and on x-ray you have characteristic loss of cortico medularary differentiation with is with a dense sclerotic sequesterum in the center this is nothing but chronic osteomiitis actively discharging sinus from the limb of a child classically chronic osteomiitis right so on an x-ray you will lose the corticome differentiation and there will be a dense sclerotic bone that is the squest the new bone that is formed on the surface is involucrum surface is involucrum it is the perostial reaction the dead bone in the center is sequester the dead bone in the center is sequester and there will be loss of corticoary differentiation look at this X-ray the cortex and the medula seems to have been fused together there is a loss of corticomedary differentiation and there's a dense sclerotic bone in the center sitting that is your squestrum and the new bone that is formed on the periphery is involum and you see an opening here through which pus escapes out that opening is called cloa so can you see this loss of cortical medillary differentiation thick bone formed on the periphery that is involucrum and this dense bone in the center that is sequester is this clear very very important subaccute osteomiat is brood absis broodies absis is a localized absess at the metaphysis of a tibia or femur where you will see a central lucency surrounded by dense sclerotic rim patient will have lowrade fever if you aspirate the content of the broad absis you will find pus you'll find pus what is this it looks like an avulsion fracture of spinus process of the cervical vertebrae this is clay shovelers's fracture okay because of aggressive use of upper limb muscles while shoveling it causes averulsion of the prominent spinus process this is clay shovelers fracture what is this here this is an image of a CT scan of your spine where there is a fracture or disruption going all the way from posterior to anterior this was an image that was given on your exam this is chance fracture or seat belt fracture chance fracture or seat belt fracture in contrast if the anterior wall is shortened the posterior wall is tall enough there is a wedge compression fracture seen in flexion injuries in osteoporotic individuals this is compression fracture what is a burst fracture if there is an axial loading of the spine say imagine a heavy object falling on your head and your spine is axilially loaded then you will have a burst fracture where the fragment is burst away from the spine they burst away that is burst fracture what is this usually I'll tell you one thing important a chance fracture seat belt fracture there chance fracture seat belt fracture burst fracture all these require CT scan to make an appropriate diagnosis so the examiner can either give you CT scan u but sometimes they give you X-ray so the chance fracture that was given in the recent exam was an X-ray so please take what is it this is an MRI sagittal view of the spine lumbar spine and you can see the vertebral bodies and the intervening intervertebral discs so look at this image this is an MRI sagittal view of your spine and you can see the vertebral bodies and the intervening intervertebral discs normally the discs should remain in alignment with the vertebral bodies and here you notice slide bulge but here there is a protrusion altogether so first of all what do you need to know you need to identify which disc right which disc is protruding out posteriorly so the numbering of the disc is very simple it is the number between the vertebral bodies so if this is L4 vertebrae L5 vertebrae this is L4 L5 disc and if this is L5 obviously this is S1 so this is L5 S1 disk here L5 S1 disc is protruding out if the numbers are not given on your exam please remember the last square vertebra is the L5 vertebrae after that the sacrum is usually fused like this so if this is the last square vertebra it is L5 based on that reference point you can go up and down to identify the level so this is L5 S1 disc prolapse in L5 S1 disc prolapse which nerve do you think will be compressed s1 okay now again this is in X-ray lateral view of the spine and you would want to see the spine is in alignment or not so what do you do you draw a line on the posterior wall of the vertebrae extended downwards it should be straight but here what do you notice suddenly there is a step here which means the spine is not in alignment which means there is a slip this is spondylothesis this was an image that was asked on your exam spondylothesis what is this test being performed where the patient is asked to bend forward is it showber test no shber test there is a limitation of spine movement so the patient will be unable to bend forward so the length that will be marked on the lumbar spine will not increase here what you're noticing is there is this deformity of the spine this is known as Adam's forward bending test adam's forward bending test which is performed for scoliosis this is performed for scoliosis so the braces that you use in scoliosis Milwaukee brace and Boston brace milwaukee brace has one rod in front two rods behind and they are supporting the spine to prevent or progression of the deformity this is Boston's brace what is this this is Bard's nodes and heard nodes seen in degenerative joint disease of the elderly this is heard and bard's nose seen osteoarthritis osteoarthritis degenerative joint disease and this destruction of the joint will lead to swelling of the joint the DIP joint is a classically involved joint dip swelling and PIP swelling dip swelling is known as heed nodes pip swelling is known as Bshart right what is this boutiner deformity and swan neck deformity this is seen in rheumatoid arthritis this is seen in rheumatoid arthritis and remember I told you the difference in a swan neck deformity versus mallet finger in mallet finger only one finger that is injured will be shown on the image whereas in swan neck deformity multiple fingers will be affected because rheumatoid arthritis multiple joints involved peripheral joints involved symmetrical joint involves so here the dip will be flexed and the PIP will remain in extension of multiple fingers so swan neck deformity what is bhutiner deformity there is flexion of the pip and extension of the tip bamboo spine where do you see this bamboo spine fusion of the spine by vertical synindises this is seen in ankyloing spondilitis ankylosing spondilitis what are the other radological signs that you will see in the spine of a patient of ankylosing spondilitis dagger sign and trolley track sign it's a calcification of the ligaments trolley track sign have these three lines and dagger sign has this one calcification of the interpinus ligaments giving you an appearance of a dagger what do you see here you see needle-shaped negatively bringerent crystals here what do you see polygonal shaped positively by refringerent crystals this is gout monosodium urate crystals this is pseudo gout calcium pyrophosphate dihydrate crystals what is this deformity the foot looks like it's in the shape of a club golf club this is club foot or CTV club foot or CTV what is a splint you use in CTV dennis Brown splint where there are two shoes which are connected by a rod connected by a bar this is important otherwise you use CTV shoes also once the child starts walking what is this image here in this image one scapula is at a higher level compared to another this is springle shoulder sprangle shoulder right springle shoulder deformity now which test is the examiner performing here what do you notice that the knee is flexed to 90° and the examiner is sitting on the foot to stabilize it hip is flexed to 45° and the examiner is translating the tibia anteriorly pulling the tibia anteriorly this is anterior drawer test it is performed for which ligament acl this is painful so in an acute knee injury acute ACL tear which test will you perform you'll perform lacman's test where the knee is just flexed to 20 to 30° and the tibia is translated anteriorly okay just similar to anterior draw test if instead of pulling the tub anteriorly the examiner pushes the tibia posterly would perform posterior draw test and posterior draw test is performed for PCL for PCL and lastly I want to show you a few instruments that are likely to show up on your exam this is bone to plate holding forceps bone because one side is serrated plate because other side is smooth and if both sides are serrated it is bone holding forceps this is doubleaction bone enabler this is bone cutter and this is another bone holding forceps known as Ferguson's forceps and this is a bone chisel this is a bone osteotome bone chisel and bone osteotome so these are some of the important images that are recommended to be revised before the exam i wish you all the best and I'm sure that you have understood the concepts and you have revised well for the exam i wish you all the best and I will see you on the other side bye-bye