Chapter 31 Drawings for the FRCS (Tr & Orth)

James Widnall, Catherine McCauley and Lyndon Mason

Drawing has always been an integral part of the FRCS examination, be it as a method to understand a complex process during revision or as a tool for explanation in the viva itself. In order to use drawings in the viva exam the candidate must be able to draw, explain and answer questions simultaneously. Thus, practice and understanding are essential.

In this chapter, we have selected the drawings that we think are most useful, having recently been through the examination ort aught on this subject for many years.

By no means are you expected to turnout a quality piece of art, and these drawings are not intended as such. Some of the drawings are deliberately schematic in order to simplify the subject matter and reinforce key points.

We hope, though, that by using these drawings to either act as an aide memoir during revision, or indeed to explain difficult concepts in the viva, the time saved and level of understanding shown will allow you to showcase your knowledge in pursuit of the higher marks.

Good luck.

Tips on drawing#

An exam is not just about knowledge but the presentation of that knowledge. Playing the game is important. There is a lot of paper at every station, and sometimes it’s useful to draw even if not asked to do so. Remember the old adage ‘a picture is worth a 1000 words’. If you are not the first at the viva table, there are often ‘paper scars’, tales of the last viva! Do not let these distract you.

If using a drawing in the viva, whether as an aid to explain an answer or as the result of being asked to do so, then here are some tips.

1. Draw big. Fill the page. Drawing small does not show confidence.

2. Work from the outside in. Simplify to the bare image. For example, if drawing a cross-section of a limb, first draw a circle to illustrate the skin then add in the bones, then compartments, then muscles, then NV structures.

3. Draw schematic . The examiners will not be assessing you on your artistic skill.

4. Speak while you draw. You have limited timet o earn marks, so do not lose this time by drawing in silence.

Anatomy#

Anatomy is assumed knowledge for surgeons; it is, after all, a subject matter we deal with everyday. Thus, an anatomy question in the exam should be dealt with confidently and efficiently, otherwise the examiner may prod more deeply to assess the true level of knowledge. Anatomy will also be the subject that most examiners will revert to if you are struggling with a question.

NB: some of the illustrations below are of cross-sectional anatomy in the limbs. Not only do these convey a knowledge of surrounding structures and relative anatomy of vessels and nerves, but they can be used very succinctly to demonstrate approaches, as seen by the numbered arrows where appropriate.

We have given you both anatomically correct and schematic diagrams for these, and it is best to familiarize yourself with one or the other.

Upper limb

Brachial plexus (Figure 31.1)

Figure 31.1 R, roots; T, trunks; D, divisions; C, cords; B, branches. P, phrenic nerve (contribution); DS, dorsal scapularS, suprascapular; LP, lateral pectoral; MC, musculocutaneous; US, upper subscapular; T, thoracodorsal; LS, lower subscapular; AX, axillary; R, radial; MP, medial pectoral; MBC, medial brachial cutaneous (of arm); MAC, medial antebrachial cutaneous (of forearm); U, ulnar; 1st IC: first intercostal; LT, long thoracic nerve (of Bell).

The candidate not only needs to know the anatomy of the brachial plexus but also how to apply it to a clinical picture/examination. Once familiar with the above illustration, the candidate can then picture where the lesion is inaccordance to which muscle groups have been affected. There are a number of

Youtube videos that teach you how to draw this very quickly.

The candidate can also demonstrate whether the lesion has occurred before (pre-ganglionic) or after

(post-ganglionic) the dorsal root ganglion (see Figure 31.2).

Dorsal root ganglion (Figure 31.2)

Figure 31.2 DRG, dorsal root ganglion.

Figure 31.2 clearly shows where the division between pre- and post-ganglionic injuries exists. Pre-ganglionic injuries may present with Horner’s syndrome, periscapular wasting (rhomboids affected from dorsal scapula nerve) or medial scapula winging (long thoracic nerve). Pre-ganglion injuries carry a poorer prognosis.

Erb’s point (Figure 31.3)

Figure 31.3 Erb’s point.

Not to be confused with the cardiology Erb’s point (third intercostal space on the left sternal border where S2 heart sound is best auscultated) or the head and neck Erb’s point (posterior border of the sternocleidomastoid muscle where four superficial branches of the cervical plexus emerge from). The

Erb’s point that concerns us is a site at the upper trunk of the brachial plexus located 2–3 cm above the clavicle. It is named for Wilhelm Heinrich Erb, a nineteenth-century German neurologist. Erb’s point is formed by the union of the C5 and C6 nerveroot sAt the nerve trunk, branches of suprascapular nerve and the nerve to the subclavius also merge. The merged nerve divides into the anterior and posterior division of C5 and C6. Due to this convergence, it is an area that can betorn relatively easily, as its mobility is limited.

Humeral spaces (Figure 31.4)

Figure 31.4 Humeral spaces.

A useful aide memoir for this is to place the index and middle fingers of your right hand at right angles to your left hand index and middle fingers to create the same shape. Thus, your left middle finger is teres minor, left index finger teres major. Your right index is longhead of triceps and your right middle the humerus.

Clinically, these spaces are important when performing the posterior approach to the shoulder, knowing that finding the interval between infraspinatus and teres minor prevents you from straying too low and thus endangering the axillary nerve and posterior circumflex humeral artery.

Humerus cross-section (Figure 31.5)

Figure 31.5 CV, cephalic vein; MC, musculocutaneous nerve; BA, brachial artery; BV, basilica vein; UN, ulnar nerve; MN, median nerve; RN, radial nerve; PB, profunda brachii.

LHB, longhead biceps; SHB, shorthead biceps; B, brachialis.

Lateral T, lateral head of triceps; MT, medial head of triceps; Long T, longhead of triceps.

The above illustration can be used to succinctly demonstrate the approaches to the humerus.

1. Anterior – retract biceps laterally, identify radial nerve distally, split dually innervated brachialis.

2. Posterior – develop interval between long and lateral heads of triceps, split medial head, protect radial nerve as it sits in the spiral groove.

Schematic drawing (Figure 31.6)

1. First draw a large circle and label the anterior and posterior.

2. Add the humerus centrally and divide the cross-section in to anterior and posterior compartments.

It initially looks like a Pokemon ball. By drawing the mid-humeral cross-section you avoid complications of coracobrachialis and deltoid insertions proximally and the forearm musculature distally.

3. In the anterior compartment, divide between the biceps superficially and the brachialis deep. The musculocutaneous nerve lies in the plane between these muscles and supplies the medial half of the muscle.

4. In the posterior compartment the three heads of triceps are drawn easily: medial, long and lateral heads.

5. The radial nerve runs in the spiral groove and supplies the muscles of the posterior compartment.

The ulnar nerve, median nerve and medial cutaneous nerve of the forearm run medially with the brachial artery within their own neurovascular compartment.

Figure 31.6 Schematic drawing of humerus cross-section.

Mid-forearm cross-section (Figure 31.7)

Figure 31.7 RN, radial nerve; LCNF, lateral cutaneous nerve of the forearm; RA, radial artery; MN, median nerve; UA, ulnar artery; UN, ulnar nerve; PIA, posterior interosseous artery; PIN, posterior interosseous nerve.

BR, brachioradialis; FCR, flexor carpi radialis; FDS, flexor digitorum superficialis; PL, palmaris longus; FPL, flexor pollicis longus; FDP, flexor digitorum profundus; FCU, flexor carpi ulnaris.

ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; EDM, extensor digift minimi; E CU, extensor carpi ulnaris.

Schematic drawing (Figure 31.8)

Figure 31.8 Schematic drawing of mid-forearm cross-section.

Drawing the forearm cross-section (Figure 31.8) is a daunting task but can be approached in a similar way to the upper arm.

1. Again, draw a large circle.

2. Draw the radius and ulna and divide the forearm into three compartments – anterior, posterior and the mobile wad.

3. Divide the compartments into superficial and deep and then divide the anterior superficial into four, deep into three; and both in the posterior compartment into three; the mobile wad into three.

4. Fill the mobile wad first – all muscles supplied by the radial nerve. BR lies anterior-most, followed byE CRL and ECRB.

5. Thinking of Henry’s approach, FCR can then be added. FCU lies next to FC Ron the opposite side.

The other superficial muscles are the palmaris longus and FDS.

6. We know the SRN and radial artery lie between FC Rand BR.

7. The deep anterior compartment is next, with FDP below FDS. As half of the FDP is supplied by the ulnar nerve, this is where the ulnar nerve and artery lie.

8. The remainder of the deep compartment depends on the level, so considering the scotiy dog picture in the next section, P T and FP Lare drawn here.

9. The median nerve lies deep to palmaris longus and the AIN on the anterior aspect of the interosseous membrane.

10. Posteriorly, start with the superficial compartment. ECU lies adjacent to FCU. On the other side of the superficial compartment lies EDC, which forms the interval for Thompson’s posterior approach to the radius.

11. The remaining extensors depend on the level being sectioned. EDM lies centrally.

12. In the deep layer, the supinator lies around the radius; it is likely to only be partially present at this level, but worth drawing for its importance for approaches; EP Land APL fill the other two spaces.

13. The PIN lies within the supinator.

14. Finally, the common approaches to the forearm can be added – Henry’s between FC Rand BR;

Thompson’s between ECRB and EDC.

Approaches to the midshaft radius (Figure 31.9)

Figure 31.9 Approaches to the midshaft radius.

1. Henry’s approach – the true Henry’s approach develops the plane between the brachioradialis and the radial artery. The modified Henry’s approach (which we use for distal radius fractures) differs bygoing through the bed of the FCR, creating a plane between the FC Rand radial artery.

2. Thompson’s approach – develop the interval between ECRB and EDC.

Radius muscle insertions

Radius muscle insertions are often combined with the cross-section of the forearm. This is especially true if Henry’s approach is being discussed. The muscles’ insertion on the anterior aspect of the radius are simple to understand. There is one supinator (excluding the biceps attachment), two pronators, and two interspersing long flexors to the digits. If you turn the radius on its side the insertions look like a scotiy dog. The supinator for the ears, the flexors (FP Land FDS) for the body and the pronators (PQ and PT) for the legs (Figure 31.10).

Figure 31.10 Radius muscle insertions.

The deep dissection of Henry’s approach to the radius requires the supinator to be incised at its insertion on the radius, when the forearm is in full supination to displace the PIN laterally, away from the operative field. The FDS insertion begins just distal to the bicipital tuberosity and is ulnar to the supinator.

Pronator teres in the middle third of the radius is dissected by pronating the arm to better expose its insertion.

Hand and wrist

Carpal tunnel

Figure 31.11 UN, ulnar nerve; UA, ulnar artery; MN, median nerve; FDS, flexor digitorum superficialis; FDP, flexor digitorum profundus; FPL, flexor pollicis longus.

H, hamate; Tq, triquetrum; L, lunateS scaphoid.

The contents of the carpal tunnel are easily tested. This diagram (Figure 31.11) can be a quick way to detail the necessary knowledge. The ulnar nerve and artery are clearly shown not to be in the carpal tunnel, instead lying separately in Guyon’s canal.

The carpal tunnel spans from the scaphoid tubercle and trapezium ridge to the hook of hamate and pisiform. The roof is the transverse carpal ligament with the floor being the proximal carpal row. The contents are the median nerve, FPL tendon, four FDS tendons and four FDP tendons.

As well as the cross-sectional anatomy the candidate should be familiar with the branches of the median nerve, e.g. palmar cutaneous branch and recurrent motor branch and their anatomical variations

(recurrent motor branch – extraligamentous 75% of time, sub ligamentous 13%, transligamentous 12%).

Extensor compartments (Figure 31.12)

Figure 31.12 Compartment 1: APL, abductor pollicis longus; EPB, extensor pollicis brevis.

Compartment 2: ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis.

Compartment 3: EPL, extensor pollicis longus.

Compartment 4: EDC, extensor digitorum communis; EIP, extensor indicis propius.

Compartment 5: EDM, extensor digift minimi.

Compartment 6: ECU, extensor carpi ulnaris.

Clinically, this illustration can be used to demonstrate approaches to the wrist. It also details the proximity of EPL to Lister’s tubercle, which can contribute to atiritional rupture of the tendon.

Ulnar canal (Figure 31.13)

The ulnar canal or ulnar tunnel (also known as Guyon’s canal or tunnel) is a semi-rigid longitudinal canal in the wrist that allows passage of the ulnar artery and ulnar nerve into the hand. The roof of the canal is made up of the superficial palmar carpal ligament (PC Land floor by the transverse carpal ligament (TCL).

Anatomy is a possible question especially duet ozones of injury.

Zone 1: proximal to bifurcation of nerve (mixed motor and sensory, usually hamate pathology or compression in canal).

Zone 2: Surrounds deep motor branch (motor only, usually hamate pathology).

Zone 3: Surrounds superficial sensory branch (sensory only, usually ulnar artery pathology).

Figure 31.13 Ulnar canal.

Sites of ulnar nerve compression (Figure 31.14)

Management of ulnar nerve compression depends on an accurate diagnosis, yet localizing the site of nerve compression can be challenging. The accepted sites of potential ulnar nerve compression are depicted here: arcade of Struthers, the medial intermuscular septum, the bony retrocondylar groove and the overlying cubital tunnel retinaculum, Osborne’s band, the volar antebrachial fascia just proximal to the wrist crease (proximal Guyon’s canal), and the leading edge of the hypothenar musculature overlying the deep motor branch of the ulnar nerve (distal Guyon’s canal).

Figure 31.14 Sites of ulnar nerve compression.

Finger cross-sectional anatomy

Figure 31.15 TRL, transverse retinacular ligament.

This axial section (Figure 31.15) shows the relationship of the neurovascular bundles to that of the fascial sheets in the finger. This is particularly important in Dupuytren’s disease where a diseased

Grayson’s ligament (remember Cleland’s ligament is not involved in Dupuytren’s disease) can cause an aberrant path of the neurovascular bundle which the surgeon must be aware of.

Nail anatomy (Figure 31.16)

Figure 31.16 Nail anatomy.

Nail tip injuries are commonly seen in orthopaedic practice hence the need for accurate knowledge of the relevant anatomy. With relative ease this viva topic could quickly proceed to high levels talking about potential incisions to extend wounds, nail bed repair or flap coverage.

Lower limb

Blood supply to neck of femur (Figure 31.17)

Figure 31.17 LT, ligamentum teres; PT, psoas tendon; PF, profunda femoris; MC, medial circumflex; LC, lateral circumflex.

The blood supply to the femoral head is a large part of what we base our decision-making on when dealing with fractures to the neck of the femur. It is therefore essential knowledge.

The profunda femoris splits into medial and lateral circumflex arteries (so named in their relationship to the psoas tendon as shown). These form an extracapsular ring from which ascending cervical branches travel proximally to supply the femoral head. The posterior superior and posterior inferior branches arise from the medial circumflex. The anterior arises from the lateral circumflex.

A small branch from the obturator artery passes through the ligamentum teres, but the blood supply is negligible in adults.

Femoral triangle (Figure 31.18)

Figure 31.18 ASIS, anterior superior iliac spine.

The femoral triangle (Figure 31.18) is a common testing question given the importance of the structures that lie within.

Boundaries: lateral – medial border of sartorius; medial – medial border of adductor longus; superior

– inguinal ligament.

Roof: fascia lata.

Contents: femoral nerve, artery, vein, inguinal lymph nodes.

Floor: iliacus, psoas, pectineus, adductor longus.

Hip cross-section anatomy (Figure 31.19)

Using the retained knowledge from the femoral triangle, we already have the medial aspect of the cross-section of the hip. The only structure not represented is the adductor longus, but this is due to its origin being located below the hip, at the anterior inferior iliac spine. Tensor fascia lata originates next to the sartorius, off the anterior superior iliac spine. The rectus femoris, the gluteal muscles and short rotators can then be added.

Figure 31.19 TFL, tensor fascia lataS, sartorius; Pe, pectineus; P , psoas; I, iliacus; RF, rectus femoris; GMI, gluteus minimus; GME, gluteus medius; SER, short external rotators; GM, gluteus maximus; SN, sciatic nerve.

Approaches to the hip (Figure 31.20)

Figure 31.20 Approaches to the hip.

Again, this knowledge of cross-sectional anatomy can be applied to quickly explain the differences between the various approaches to the hip joint.

1. Smith Peterson – superficial plane developed between the sartorius and tensor fascia lata, being mindful of the lateral cutaneous nerve of the thigh and the ascending branch of lateral circumflex.

Deeper dissection is between the gluteus medius and rectus femoris.

2. Watson-Jones – develops the plane between the tensor fascia lata anteriorly and the gluteus medius posteriorly.

3. Lateral approach – after incising the fascia lata the abductors (gluteus medius/minimus) are reflected from the greater trochanter to allow access to the anterior capsule.

4. Posterior (southern): split the gluteus maximus to gain access to the short external rotators. The short external rotators can then be elevated from the insertion to gain access to the posterior capsule, protecting thes cia tic nerve throughout.

Adductor/Hunter’s canal (Figure 31.21)

Figure 31.21 Adductor/Hunter’s canal.

The adductor canal, or Hunter’s (John Hunter, Scotish surgeon, 1728–1793) canal extends from the apex of the femoral triangle to the adductor hiatus. It is located in anterior compartment of the thigh.

Contents: superficial femoral artery, femoral vein, saphenous nerve and nerve to vastus medialis.

Boundaries: medial wall – sartorius; posterior wall – adductor longus (and magnus); lateral wall –vastus medialis.

Mid-thigh cross-section (Figure 31.22)

Figure 31.22 FA, femoral artery; SN, saphenous nerve; FV, femoral vein; SN, sciatic nerve; Post OB, posterior branch of obturator; Ant OB, anterior branch of obturator; PF, profunda femoris.

S, sartorius; P, pectineus; VM, vastus medialis; VI, vastus intermedius; VL, vastus lateralis; RF, rectus femoris.

AL, adductor longus; AB, adductor brevis; AM, adductor magnus; G, gracillis; SM, semimembranosus; ST, semitendinosus; LHB, longhead biceps femoris; SHB, shorthead biceps femoris.

The most common approach to the thigh is that of direct lateral where the surgeon incises the fascia before either litiing or spliting the vastus lateralis to gain access to the femoral shaft. This approach is widely used for DHS fixation.

Schematic (Figure 31.23)

1. Draw a large circle and add the femur centrally.

2. Divide the circle into three compartments: posterior, anterior and adductor. On the peripheries either side of the adductor compartment, add the sartorius and gacillis muscles, which lie in their own muscle fascia.

3. Divide the adductor compartment into two and both the posterior and anterior compartments into four.

4. Add in the muscles, with the adductor compartment containing adductor longus and magnus, the anterior compartment containing the quadriceps (vastus medialis, intermedius, lateralis and rectus femoris) and the posterior compartment the semimembranosus, semitendinosus and two heads of biceps femoris.

5. Add NV structures as shown.

Figure 31.23 Schematic drawing of mid-thigh cross-section.

Lower leg cross-section (Figure 31.24)

Figure 31.24 Anterior compartment: PT, peroneus tertius; EHL , extensor halluces longus; EDL, extensor digitorum longus; TA, tibialis anterior; DPN, deep peroneal nerve; AT, anterior tibial artery.

Posterior compartment (deep): TP, tibialis posterior; FHL, flexor hallucis longus; FDL, flexor digitorum longus; PA, peroneal artery; PT, posterior tibial artery; PTN, posterior tibial nerve.

Posterior compartment superficialS, soleus; P, plantaris; G, gastrocnemius.

Lateral compartment: PL, peroneus longus; PB, peroneus brevis; SPN, superficial peroneal nerve.

It is important to note that while the peroneal artery runs in the deep posterior compartment, it actually supplies the lateral compartment via perforators. It’s called the peroneal artery due to its close relation to the fibula (Greek: perone).

The compartments of the lower limb are often asked in the context of the trauma viva as part of wider questioning of compartment syndrome or open fracture management.

Schematic (Figure 31.25)

Figure 31.25 Schematic drawing of lower leg cross-section.

1. Draw a circle and add the tibia subcutaneously and fibula.

2. Add the intermuscular septum.

3. Divide and label the four compartments (anterior, peroneal, superficial posterior, deep posterior).

4. Divide the anterior and posterior deep compartment into three, and the posterior superficial and peroneal compartment into two.

5. Add in the muscles; anterior compartment (tibialis anterior, extensor hallucis longus and extensor digitorum longus), deep posterior compartment (tibialis posterior, flexor digitorum longus, flexor hallucis longus). Note the FDL is on the opposite side to the ED Land the same is true for EH Land

FHL), peroneal compartment (peroneus longus and peroneus brevis, B close to bone) and posterior superficial (soleus and gastrocnemius).

6. Add in the anterior tibial nerve and artery (anterior to intraosseus membrane), posterior tibial nerve and artery (between the superficial and deep compartments) and peroneal nerve and artery.

For extra marks, add in the short and long saphenous veins and the saphenous nerve.

Basic science#

Biological materials

Articular cartilage (Figure 31.26)

Figure 31.26 Articular cartilage.

Articular cartilage is a common viva question given that it is at the heart of one of the commonest disease processes we treat – osteoarthritis.

The structure can be easily memorized. There is an outer protective layer of the lamina splendens.

This covers the superficial layer where the collagen fibres are parallel to the articular surface in order to resist shear forces. This layer has the highest collagen and water but the lowest proteoglycan concentration. The middle layer allows transition from the superficial to the deep layers. In the deep layers the fibres are arranged parallel in order to resist compressive forces. Here, the proteoglycan concentration is the highest, with there being the fewest collagen fibres and water molecules. The tidemark migrates superficially with age, as the cartilage thins. The calcified zone anchors the cartilage to bone via hydroxyapatite crystals. This zone is mostly type X collagen, unlike the other zones which are mainly type II.

Most trainees memorize the histological features with the zones representing columnar areas, cross-hatching and parallel fibres. This truly represents the Arcades of Benninghoff, where the cross-hatching shows the crossings of these arcades.

The candidate needs to know the difference between OA and ageing as well as potential treatment options for varying sizes or cartilage defects.

Differences in ageing and osteoarthritis

This is best remembered if you imagine an elderly individual who is stiff and dry (Figure 31.27). For extra marks, the elderly may have solar keratosis (which will allow you to differentiate with keratin sulphate being high and chondroitin sulphate being low). This is the opposite for OA.

Figure 31.27 Differences in ageing and osteoarthritis.

Proteoglycans (Figure 31.28)

Figure 31.28 Proteoglycans.

Proteoglycans are responsible for around 10% of articular cartilage They are made of a core of hyaluronate with binding proteins anchoring a feather of keratin sulphate and chondroitin sulphate.

These are hydrophilic (i.e. they atir act water). This gives the cartilage volume. Without it the collagen would be flat, like the analogy of oranges in a net bag, with the proteoglycans being the oranges.

Bone (cortical Figure 31.29)

Candidates must know about the biological material we treat. It is simply inexcusable not to. One must know the functions, the structure, the composition, the cell types, the blood supply, the regulation mechanisms and the system of remodelling in order topass a basic science viva on bone.

With regards to cortical bone, one type of lamellar bone (with the other being cancellous), we found the above drawing (Figure 31.29) to be of most use.

Figure 31.29 Bone (cortical).

It clearly shows the arrangement of haversian systems, which are supplied by a nutrient artery.

Within the haversian system there are central Haversian canals surrounded by concentric lamellar sheets, or rings, made of collagen. These haversian canals act as neurovascular channels and the Volkmann canals carry capillaries to and from this central source. Within the lamellae sit osteocytes, which are connected by cannaliculi.

Overlying structure of nerve/muscle/tendon

All these structures can be drawn the same basically as they are all made up of epi-, peri- and endo-(epineural/epitenon/epimysium, etc.). This can be easily drawn as shown (Figure 31.30).

Figure 31.30 Overlying structure of nerve/muscle/tendon.

Nerve

Figure 31.31 Nerve.

Nerves can open a multitude of avenues of questioning from basic anatomy and physiology to nerve injury and nerve repair. The structure of a standard axon connecting a cell body to terminal endings is a common starting point Figure 31.31).

Nerve cross-section (Figure 31.32)

Figure 31.32 Nerve cross-section.

For a nerve this can be more specifically drawn as shown (Figure 31.32). The three covering layers include epineurium as the external layer, perineurium covering nerve fascicles and the endoneurium covering axons. The blood supply is both carried intrinsically within the endoneurium and extrinsically from the vasa nervorum.

Nerve action potential (Figure 31.33)

Figure 31.33 Nerve action potential.

The action potential is the mechanism of acft on of the nerve fibre. It is a rapid depolarization across the membrane which then propagates along the neuron.

The resting potential of the membrane is –70 mV. A threshold stimulus must first be reached (–55 mV) to trigger an action potential. Once triggered, sodium channels open to allow sodium into the cell.

This propagates from cell to cell, causing more and more sodium channels to open. The passing of sodium

(a positively charged ion) into the cell causes the membrane potential to become positive. As this occurs, the sodium channels close and potassium channels open to allow potassium to leave the cell. This allows the negative resting potential to be restored. For cardiac muscle, the depolarization is halted temporarily by a plateau caused by calcium ions from the sarcoplasmic reticulum.

Nerve injuries (Figure 31.34)

Figure 31.34 Nerve injuries.

Nerve injuries can be classified inaccordance with the mechanism of injury (crush, traction, laceration, thermal, etc.), histologically inaccordance with Seddon (1943) or anatomically as per

Sunderland (1951).

The above illustration detailsS underland’s anatomical classification.

1: disruption to myelin/ischaemia to nerve – a block to conduction, no Wallerian degeneration.

2: axonal discontinuity – leads to Wallerian degeneration.

3: endoneurium damage (as well as axon) – leads to Wallerian degeneration.

4: perineurium damage (as well as endoneurium and axon) – leads to Wallerian degeneration.

5: total transection of nerve (epi-, peri-, endo- and axon all involved) – leads to Wallerian degeneration Worst prognosis.

NB: Wallerian degeneration – discovered by Waller in 1850, a process by which damaged axons and myelin are removed via phagocytosis.

Muscle (Figure 31.35)

Figure 31.35 Muscle.

As with nerves there are three layers of connective tissue when looking at the macroscopic structure of muscle. The external layer is the epimysium, the perimysium surrounds muscle fascicles (as it surrounds nerve fascicles) and the endomysium surrounds muscle fibres.

Muscle fibres are made from multiple myofibrils, which themselves are made from sarcomeres containing actin and myosin.

Actin and myosin (Figure 31.36)

Figure 31.36 Actin and myosin .

Z disc – attachment between adjacent sarcomeres.

H band – only myosin filaments.

M line – connections between adjacent myosin filaments.

A band – both actin and myosin filaments (so-called as it is ‘A’nisotropic on electronmicroscopy).

I bands – only actin filaments (so-called as they are ‘I’sotropic on electronmicroscopy).

The sarcomere is the motor unit responsible for contraction in the muscle fibre. Each sarcomere consists of actin myosin, tropomyosin and troponin.

Neuromuscular junction (Figure 31.37)

Figure 31.37 ACH, acetylcholine (neurotransmift er).

The candidate needs to know the mechanism of muscle contraction.

When an action potential is delivered to a neuromuscular junction, acetylcholine is released from presynaptic vesicles across the synaptic cleft. Arrival of acetylcholine at postsynaptic receptors triggers calcium release by the sarcoplasmic reticulum. The calcium enters the muscle via T tubules.

In the sarcomeres themselves, tropomyosin blocks binding sites on myosin filaments. The arriving calcium forms with troponin to make troponin C. This troponin C then alters the shape of tropomyosin and thus reveals the myosin binding sites. The myosin filaments then rotate to bindwith actin and ATPase activity permits conformational change in the actin which generates the sliding of the two filaments, causing muscle contraction.

Embryology – spinal development (Figure 31.38)

Embryology is a complex subject, but FRCS candidates only need a basic understanding.

There are three germ layers responsible for embryo growth in the body:

Ectoderm (‘outer’) – forms the skin and nerves.

Mesoderm (‘middle’) – forms muscles and cartilage.

Endoderm (‘inner’) – forms organs.

Figure 31.38 shows a cross-section of an embryo at around day 30. It shows the neural tube and neural crest (both ectoderm) and somites and notochord (both mesoderm).

Figure 31.38 Embryology – spinal development.

At day 25, a process called neurulation occurs where the notochord sends messengers to the neural tube (which starts on the outside of the embryo) to fold in on itself, forming a tube, in order to look like it does in Figure 31.38. The neural crest is responsible to ensure that when the neural tube folds in, the skin closes normally above it. If neurulation does not happen correctly, spina bifida occurs.

Following this, spinal development is controlled by the homeobox gene group. The neural tube is responsible for the spinal cord, the neural crest for the sympathetic chain, basal ganglia and peripheral nervous system. The notochord forms the anterior vertebral bodies and nucleus propulsus and the somites form the rest of the vertebral bodies and annulus fibrosis.

Embryology – limb bud development (Figure 31.39)

Figure 31.39 AER, apical ectodermal ridge; ZPA, zone of polarizing activity .

Limb development starts at around 4 weeks. At 8 weeks the limb buds rotate, which is why our thumbs are lateral in the anatomical position but our big t oes are medial.

There are three axes of growth:

1: Proximal to distal – controlled by the homeobox gene and performed by the AER. If this axis fails then there is transverse limb arrest (i.e. symbrachydactyly).

2: Radial to ulna – controlled by the sonic hedgehog gene and performed by the ZPA. If this axis fails there is longitudinal arrest, e.g. radial longitudinal deficiency.

3: Dorsal to ventral – controlled by the WnT gene and performed by the surface ectoderm. This isless important regarding anomalies, but explains the bowing of our long bones as dorsal grows quicker than ventral.

The cartilage and muscle are derived from the mesoderm of the somites which invade the limb bud.

Implant science

Stress–strain curve (Figure 31.40)

Figure 31.40 Stress–strain curve.

Stress–strain curves are commonplace in the FRCS. Start by drawing and labelling the two axes –stress (N/m2) and strain (change in length / original length). In the elastic region, the stress–strain relationship is linear inaccordance with Hooke’s law. The material will undergo recoverable deformation.

In this region a specific stress–strain point reveals the material’s Young’s modulus, a measure of how stiff the material is.

The yield point heralds the change from elastic to plastic region. The yield point is actually made of three points that are very close together:

Proportionality limit – the highest point at which stress is proportional to strain.

Elastic limit – the point at which the forces change from elastic to plastic deformation.

Yield stress – the amount of stress necessary to produce 0.2% deformation.

When looking at metals, strain hardening occurs early in the plastic region. This is where the grains in the metal dislocate and slip, paradoxically increasing the resistance to further strain.

Ultimate tensile strength is the amount of stress that can be applied to the material before fracturing. Necking is where further strain occurs but in a relatively small area of the material, resulting in a decreasing surface area. This occurs until the material breaks, or fractures.

S-N curve (Figure 31.41)

Figure 31.41 S-N curve.

The S-N curve demonstrates the endurance limit of a material and is clinically relevant in fatigue failure of orthopaedic implants. The axes are first drawn with stress (N/m2) and number of cycles of stress application. The stress is always below that of the ultimate tensile stressor else the material would break on the first cycle of loading. A point is then made for each level of stress and the amount of times it can be applied before the material reaches fatigue failure and breaks. Unsurprisingly, as you decrease the stress, you can apply the load more times before fracturing the material. A line of best fit is then drawn.

Where the line plateaus out corresponds to 10 million cycles of loading for that level of stress without fracturing. This is called the endurance limit. With osteosynthesis it is a race against time between the bone healing and the implant undergoing fatigue failure at that repeated level of stress.

Viscoelastic behaviour (Figure 31.42)

Figure 31.42 Viscoelastic behaviour.

Viscoelastic behaviour demonstrates time-dependen t deformation. We encounter four common behaviours in orthopaedics:

Creep – a change in strain over time, under a constant stress. This clinically translates into plaster cast treatment of clubfoot via Ponseft method and the gradual correction off oot shape.

Hysteresis – a different stress–strain relationship is seen between loading and unloading a material. This is often down to energy being lost (often as heat). The more a substance is loaded/unloaded the two curves become more reproducible, hence the cycling of ACL gratis prior to implantation.

Stress relaxation – a change in stress over time, under a constant strain. This can beseen when implanting uncemented femoral stems, with the surgeon waiting between impactions to allow the stress to dissipate through the bone and prevent an intraoperative fracture.

Time-dependent behaviour – this demonstrates a different stress–strain curve depending upon how quickly the stress is applied.

Time-dependent behaviour explains why low-energy injuries result in simpler fracture patterns and high-energy injuries result ingross comminution.

Screws (Figure 31.43)

Figure 31.43 Screw.

Screws are a mechanical device used to convert torque (rotatory load) into linear motion. An FRCS candidate should be able to talk in depth about this common orthopaedic implant. First, the screw itself can be made out of various metals, such as titanium or stainless steel. It can also be cannulated or non-cannulated. The head can be of multiple shapes (hexagonal, star, cross-head, etc.) and on metalwork removal it is imperative to have the correct screwdriver. The neck is often countersunk. The pitchis the frequency of threads and defines the rate of linear motion per 360° turn. The core diameter and the thread depth make up the total diameter. The tip can be blunt, self-tapping or self-drilling. Self-tapping screws are often fluted to remove excess bone chaff. Factors affecting pullout strength (i.e. screw diameter, working length, locking screws, quality of bone) could all be discussed further in a viva scenario.

Tension band (Figure 31.44)

Candidates could be asked to explain the principle behind a tension band fixation (of an olecranon, for example). We found this easiest when utilizing an illustration such as the one in Figure 31.44. The first picture shows a column (or bone) being loaded eccentrically, creating a compression (C) and tension (T)

side. Eccentric loading occurs incurved bones. By applying a tension band (in this case a figure-of-eight wire, similar to that seen in olecranon fracture fixation), the tensile forces from the eccentric load have now been converted to compressive forces. This can be done in a static manner such as in a medial malleolar fixation or in a dynamic fashion such as in patellar fixation. It should be noted that for the fixation to work there must be cortical contact on the compression side to prevent bending stresses.

Figure 31.44 Tension band.

Cement zones (Figure 31.45)

Figure 31.45 Cement zones.

Cemented total hips can be assessed radiographically using Gruen’s zones in the femur and

Charnley’s zones in the acetabulum.

Gruen’s zones are 1–7. Zones 1 and 7 are at the level of the greater trochanter and lesser trochanter, respectively Zone 4 is to the tip of the prosthesis but within the cement tail. It should be remembered that zones 8–14 exist in a similar manner on the lateral view.

Charnley’s zones are in relation to a line drawn vertically from the centre of the femoral head and a line perpendicular from this. Zone 1 is the superior third, zone 2 is the middle third and zone 3 is the medial third.

Spinal pathology#

Spinal cord anatomy (Figure 31.46)

Figure 31.46 can be used not only to demonstrate both the anatomy of the spinal tracts but also their clinical implications. On one half the ascending sensory tracts are seen:

Dorsal columns – deep touch, proprioception vibration. These tracts cross at the level of the medulla.

Lateral spinothalamic tracts – pain and temperature. These tracts cross at the spinal cord, explaining the clinical picture seen in

Brown–Sequard syndrome from a cord hemitransection where the ipsilateral side experiences loss of motor, vibration and proprioception functions and the contralateral side demonstrates a loss of pain and temperature modalities.

Ventral spinothalamic tracts – these carry light touch.

Figure 31.46 Spinal cord anatomy.

On the opposite side the motor tracts are shown:

Lateral corticospinal tracts – carry motor pathways distally. The fibres are arranged with cervical root values carried most centrally, then thoracic root values, then lumbar with sacral fibres being towards the periphery. This explains why in central cord syndrome, the patient will retain more function in their lo wer limbs than their upper limbs.

Ventral corticospinal tracts – carry motor pathways distally. Both sets of corticospinal tracts cross at the level of the medulla.

Schematic (Figure 31.47)

1. Draw a dumbell shape, and label anterior and posterior.

2. Draw a buft erfly within the dumbell shape and label it as ‘grey matter’ with anterior and posterior horn. Outside the buft erfly is ‘white matter’ because the nerves are myelinated.

3. Divide the spinal cord into halves. On one half, split the posterior part into two, lateral into two and anterior into two.

4. These are then labelled from posterior to anterior with ‘GCCSSC’. This is like the GCS ort heUK school exam GCSE. This is from the Gracilis, Cuneatus, lateral Corticospinal tract, lateral

Spinothalamic tract, anterior Spinothalamic and anterior Corticospinal tract.

Figure 31.47 Schematic drawing of spinal cord anatomy.

5. Topography of corticospinal tracts. This is an important distinction to know as this determines the defects seen incertain spinal cord syndromes. This can be remembered as ‘SaLT lake City’ if it is located on the right side of the cord (i.e. looking from ground to cephalad) or with some imagination

ATLS (if on left side of c ord). This is important in the defects it causes in central cord syndrome, where the upper elements are more affected than the lower (i.e. ‘man in a barrel’) (Figure 31.48).

Figure 31.48 Topography of corticospinal tracts.

Vertebral disc (Figure 31.49)

Intervertebral discs consist of an outer fibrous ring, the anulus fibrosus, consisting of several layers

(laminae) of fibrocartilage made up of type I collagen, which are obliquely orientated, alternating every layer. This has high tensile strength, like the metal bars on an old wooden barrel.

The inner gel-like centre, the nucleus pulposus, is composed of type II collagen. The nucleus pulposus helps to distribute pressure evenly across the disc. This prevents the development of stress concentrations, which could cause damage to the underlying vertebrae or to their endplates. The nucleus pulposus is a remnant of the notochord.

Figure 31.49 Vertebral disc.

Prolapsed intervertebral discs (Figure 31.50)

Figure 31.50 Prolapsed intervertebral discs.

Patients with nerveroot signs are often seen on the clinical day of the FRCS (Tr & Orth). It is important for the candidate to switily determine the level of pathology and be aware of the different potential clinical presentations depending on the location of the disc prolapse, if that is the pathology in question.

At each lumbar level there is an exiting root and a traversing root. For example, at the L4/5 disc, the

L4 rootis exiting and the L5 rootis traversing.

A far lateral disc prolapse will affect the exiting root. Hence a far lateral L4/5 disc will cause L4 root signs. This pathology, if treated surgically, may be best accessed via a Wiltse approach as opposed to the standard posterior approach to the lumbar spine.

A paracentral disc will affect the traversing (in this case, L5) root, leaving the exiting L4 root free from compression.

Paediatrics#

Physis (Figure 31.51)

Figure 31.51 EA, epiphyseal artery; PA, perichondrial ring artery; MA, metaphyseal artery; NA, nutrient artery.

R, reserve zone – low oxygen tension, stores glycogen and lipids.

P, proliferative zone – proliferation of chondrocytes.

M, maturation z one – chondrocyte growth.

D, degenerative zone – continued chondrocyte growth (×5 in size), type X collagen produced.

C, calcification z one – chondrocyte death permits calcification.

NB: hypertrophic zone includes maturation, degenerative and calcification z ones.

The successful candidate needs to have knowledge both about the physis in health, with regards to structure and blood supply, but also in sickness. One should be aware of the various diseases that can affect each zone of the physis, either from hypo- or hyperactivity , and the clinical manifestations.

Salenius and Vankka graph (Figure 31.52)

Figure 31.52 Salenius and Vankka graph.

Assessing limb deformities is commonplace in the paediatric clinical cases. Thus an understanding of normality is essential. The causes of genu varu mand valgus are multiple, but most are physiological.

Following a good history and thorough examination, reproduction of the above graph can be useful to further back your diagnosis of either physiological, or indeed, pathological deformity.

Essentially , newborns exhibit roughly 15° of varus which corrects to neutral by around the age of 2.

This progresses to 10° valgus at 3 years and resolves to adult values (5–7°) by 7 years of age. It is important to remember there is wide variability in these milestones, demonstrated by the values covered by one standard deviation.

Index

Page numbers followed by n refer to notes.

AAOS classification (acetabular defects) 30

AAOS classification femoral defects) 29 abdominal injuries 306, 324 abrasive wear 46, 534 abscesses local anaesthesia 581 spinal 124, 127 accuracy 699 acetabular cup removal 33–34 acetabular lines 293 acetabulum bilateral fracture dislocation 303–304 classification of defects 30–31

DDH 51–55, 417 exposure in THA 432 fracture 299–301 fragment in a dislocated hip 245 periprosthetic fracture revision 57 acetylcholine 525–526

Achilles tendon 106, 109, 395 achondroplasia 641–642 acidosis 308

ACL. See anterior cruciate ligament acromioclavicular joint (ACJ) dislocation 276–277 actin 499, 500, 727 action potentials 523–525, 661–662, 664–666, 726

Adams’ forward bending test 150 adductor canal 722 blocks 568 adhesive wear 46–46, 533, 534 adipose tissue lipoma 596–597 and steroid use 39 adolescents

Blount’s disease 408, 411 scoliosis 149–151 adrenaline 444, 579, 581 advanced glycosylation end products 479–480 adverse reactions to metal debris (ARMD) 23–26, 44 age. See elderly patients air filters 613–614, 686 alendronate 611, 657–658 alkaline phosphatase 50 allogratis 82, 602–604 α-defensin 19, 75 amitriptyline 570 amputation prosthetics) 562–566 anaesthesia general 581–584 local 579–581 regional 573–575, 584 analgesia aspirin 378 neuropathic pain 570 postoperative 568–569

WHO pain ladder 570–571 See also anaesthesia anaphylaxis 581 anatomical drawings 713–723 anatomy questions 429

Anderson and D’Alonzo classification 319–320, 321 aneurysm clips 655–656 aneurysmal bone cyst 132–135, 594–595 angiography knee dislocation 222 pelvic injuries 309 angle of Herzog 193 animal bites 287–288 anisotropic materials 453–454, 498, 619 ankle arthritis 98–100 fractures and dislocation 227–229, 260–264 leading to growth arrest 414–417 multiple 239–243 talar 241, 242–243, 654 trimalleolar 438–441 triplane 347–348 lateral ligament instability 96–98 surgical approaches anterolateral 242 posterolateral 263–264, 438–441 tarsal tunnel 448–449 ankle–brachial pressure index (ABPI) 222 ankylosing spondylitis 146–149 annulus fibrosus 490–491, 497 anterior cervical discectomy and fusion 313 anterior cord syndrome 316, 527 anterior cruciate ligament (ACL)

anatomy 82 and meniscal tears 485, 489 reconstruction 71, 82–83 stress–strain curve 516 anterior drawer test 96 anterior talofibular ligament 96 antibiotics 612 arthroplasty prophylaxis 612 bites 288, 291 discitis 124 mechanisms of action 612, 684 open fractures 223, 224 prosthetic joint infections 22–22 resistance 612, 684 anticoagulants 58, 616, 687 antidromic action potential 664–665

AO classification 324, 325–326

AORI classification 85 arch index 111 area moment of inertia (bending stiffness)

nails 183, 185, 186–187 plates 190–191

ARMD (adverse reactions to metal debris) 23–26, 44 arterial blood gases 256–257, 308 artery of Adamkiewicz 154 arthritis ankle 98–100 ankylosing spondylitis 146–149 elbow

OA 175–179

RA 172–175, 178 foot 100–103 hand 363–364, 376–378

CMC thumb joint 364–366

MCP joints 291–292, 363, 364 hip

OA 34–38 septic arthritis 10–11, 399, 432–433 knee 67–69, 232, 483–484

RA an dOA compared 174 wrist 362–363 See also osteoarthritis arthrodesis ankle 99, 100 first MTPJ 118 foot arthritis 102, 103 cavus foot 106 flafooot 111, 112

Lisfranc injuries 236

MCP joints 291–292 spine

C1/C2 320 cervical facet dislocation 313 lumbar interbody fusion 144, 145 scoliosis 150–151, 153 stem cell therapy 648 thumb CMC joint 366 arthrograms 419, 656 arthroplasty ankle distraction 99 replacement 99–100 antibiotics 22–22, 612 elbow 173, 174, 175, 177–178 first MTPJ 118–119 hip hemiarthroplasty 212–213

MoM resurfacing 23–27, 43 total. See total hip arthroplasty implant materials 554–555, 557, 605, 627–629 See also polyethylene knee total. See total knee arthroplasty unicondylar 77–78, 79–80

MCP joints 292, 364 postoperative analgesia 568–569 shoulder 160, 167, 278 arthroscopy ankle 99 capsular release 163–164 elbow 175–177 knee 232, 607 articular cartilage 469, 606–608 ageing 37, 64n, 475, 479–480, 607, 724 chondrosarcoma 591–592 drawing 724 enchondroma 369–370, 588–589 function 469–470 osteoarthritis 37–38, 475–476, 479–480, 607, 724 repair 476–477, 607–608, 648 structure/composition 466–467, 470–475, 600–601, 606–607 collagen 466–467, 472, 473 tidemark 471, 607

AS IT GRIPS 3Cs 39 aseptic loosening 29, 90, 532–533 See also wear

ASIA scale 325, 330

Aspen collars 320 aspirin 378, 616 assessors (in exams) 4 atlanto-axial joint odontoid peg fracture 321 and RA 173, 174

ATLS protocols 294, 304–305 spinal trauma 311, 329

ATMIST 307

ATP (adenosine triphosphate) 501–502 atypical lipoma 596–597 autogratis 82, 602 autologous chondrocyte implantation 608 avascular necrosis (AVN)

hip 38–45, 211, 648 in SUFE 382, 385 humeral head/neck 278 lunate (Kienbock’s disease) 373–375 navicular 252 axillary nerve 333 axis (C2)

hangman’s fracture 321–322 odontoid peg fracture 321 axonotmesis 521–522 back braces 153–154 back pain disc disease 122, 494 lumbago 496 metastases 127 bacterial culture techniques 19 balance, loss of 138 bamboo spine 146

Baxter nerve 449 bell-shaped curves 689–690 bending stiffness (area moment of inertia)

nails 183, 185, 186–187 plates 190–191 benign tumours aneurysmal bone cyst 132–135, 594–595 enchondroma 369–370, 588–589 lipoma 596–597 non-ossifying fibroma 590–591 osteochondroma 587–588

Berger flap technique 282 best-practice tariffs 213 bias (statistics) 696, 697–698 biceps tendon rupture 278–279

Bier’s blocks 573–575

Bigelow manoeuvre 214–215, 243 bioabsorbable materials 205 biofilms 260 biologic agents and surgery 102, 364, 378 for tumours 594, 595 biomechanics bone 455, 461, 623 cartilage 477–479 femoral stems 546–547, 604–605 free-body diagrams 629–638 intervertebral discs 490, 491–492, 494, 495–497 ligament 515–516, 520, 623, 629 meniscus 483–485, 488 muscle 502–503, 508–509 nails 181–185, 186–189, 192–194, 217 plates 185–186, 190–192, 195, 204–204, 249

S-N curves 182, 624–625, 729 screws 199, 608–609 tendon 516, 520, 623, 629 viscoelasticity 477, 484, 512, 625–626, 627, 730–731

Young’s modulus 605, 618, 619 See also stress and strain biopsy 130, 586–587 bisphosphonates 340, 464

CRPS 572 osteoporosis 611, 657–658

Paget’s disease 50–50 bites cat 287–288 human 290–292 blast injuries 255–257

Bleck classification 396 blood loss hypovolaemic shock 255–256, 305–306, 307–308, 331 peri operative 687–688 blood supply bone (in general) 456–457, 602 femoral head 210, 296, 720 humeral head 278 interrupted ankle fracture–dislocation 227–228 at fracture sites 259 knee dislocation 221–222 intervertebral discs 154–155, 492 lunate 374 meniscus 72, 485 scaphoid 359 spinal cord 154 tendons 517 blood transfusions 305–306

Blount’s disease 411

BOAST guidelines 222–223, 295 bone 452–469, 601–602 biomechanics 455, 461, 623 blood supply 456–457, 602 cell types 454–455, 462–464, 466, 601–602 collagen 457–458, 459–461, 642 densitometry 610, 611, 657–659 drawing 725 dysplasia 462 function 452 growth plates 467–469, 648, 734–735 healing 194–197, 259–260, 464–466, 609 in plate fixation 275 primary 196, 272, 464, 608 secondary 196–197, 464–465 stem cell therapy 648 See also non-union of fractures loss. See osteolysis structure 452–454, 459, 462–464, 601 bone cement. See cement bone gratis 232, 602–604 bone patella–bone tendon 82 in DDH 53 fibular (VFG) 41 in PPFs 58 bone marrow oedema 61–63 bone morphogenic proteins (BMPs) 469 bone scans 62–62, 63n, 659–661

‘bone-healing organ’ 465–466

Boneloc cement 60, 551

Boston brace 153–154, 562 boundary lubrication 600

Boutonnière deformity 363, 376 bowed legs (genu varum) 411, 735 box plots 692, 693 boxer’s fracture 288–289 brachial artery 339, 388–390 brachial plexus 265, 677, 714 brachioradialis 268 britile materials 622, 623, 625

Broström/modified Broström procedures 97

Brown–Sequard syndrome 316, 527

BSSH classification 372 bucket handle tears 72–73

Budapest criteria 572 bulbocavernosus reflex 318 bunions (hallux valgus) 100, 112–116 bupivacaine 580

Butler’s procedure 390 but iress plates 232

C-reactiv e protein (CRP) 399 calcaneal fracture 237–239 calcaneal osteotomy 106, 111 calcaneal pitch angle 106, 107 calcaneocavus foot 104 calcaneofibular ligament 96 calcaneovalgus foot, congenital 410–412 calcific tendonitis (shoulder) 164–165 calcium role in muscle contraction 500–501, 505, 526 supplements 611 calcium phosphate cement 232, 604 callus (secondary bone healing) 185, 196–197, 275, 464–465 canaliculi 464 cancellous bone 453, 623 cancellous screws 195, 200–200, 609 cancer bone scans 660 chondrosarcoma 591–592

Ewing’s sarcoma 595–596 osteosarcoma 593–594 spinal metastases 123, 127–132 staging and grading 130, 587 candidates, advice for 5–6, 7–8, 14–15, 64n, 65n, 167 discussing controversial issues 14–15, 262 drawing 617, 713 quoting the literature 15, 65n, 465 tact 219 cannulated screws 200

Cannulok hip 57

Canterbury scale 675

Capener’s sign 380 cardiac pacemakers/defibrillators 656 carpal bones. See lunate; scaphoid carpal tunnel anatomy 718 carpal tunnel syndrome 449–451, 674–676 carpometacarpal (CMC) joint (thumb) 364–366 cartilage See articular cartilage; meniscus cat bites 287–288 categorical data 690

Caton–Deschamps method 87 caudae quina syndrome 138–142, 327–329

CAVE deformity (clubfoot) 391–395, 397 cavovarus foot 104 cavus foot 103–106 cefuroxime 612 cell savers 32 cement (bone cement) 605 bone loss rectification 548 cement mantle failure 58–61, 548–551 cementing techniques 28, 60, 550–551

Gruen zones 45, 535–536, 732 removal 33, 432 spacers 22 tibial plateau fractures 232, 604 censored data 707, 709 central cord syndrome 314–316, 526–527 cephalic vein 444 cephalomedullary nails 245–247 ceramic implants

CoC arthroplasty 43, 44

CoP arthroplasty 43 liner removal 34 wear 557 cervical spine anatomy 490

C6 neuropathy 441 facet dislocation 311–314 halo jackets 320, 322, 326–327 hangman’s fracture 321–322 odontoid peg fracture 321 prolapsed disc 154–157

RA 173, 174, 378 spinal cord injuries 314–316, 526–527 spondylotic myelopathy 135–138 surgical approaches 316, 441–443 cervical traction 157, 312 chairlift t est 170

Chance fracture 323–324

Charcot–Marie–Tooth (CMT) disease 104

Charnley THA implants 544, 546–547, 605

Charnley zones 732 chauffeur’s fracture 267–268 cheilectomy 118 chemical shift artefacts 657 chemotherapy 594, 596 chondrocytes 471–472, 608 chondroitin sulphate 472, 724 chondrosarcoma 591–592 chronic (complex) regional pain syndrome (CRPS) 352, 353, 571–573 circular frames 227, 249–250 clavicle

ACJ dislocation 276–277 fracture 275–276 clinical trials critical analysis 699–702 design 693–698 clopidogrel 687–688 clothing in the exam 7 in theatre 652, 687 clubfoot 391–395, 397

CMAPs (compound muscle action potentials) 661–662, 665–666 coagulation 309, 687 cobalt chromium 554

Cobb angle 150

Codman’s triangle 593

Coleman block test 104–105 collagen in bone 457–458, 459–460 osteogenesis imperfecta 460–461, 642 in cartilage 472, 473 in meniscus 481–481, 487 structure 457–458, 466–467, 512 synthesis 473, 510 in tendons and ligaments 510, 511–512, 514, 519 collagenase injections 373 common peroneal nerve 69, 679 communication skills 10–11, 14, 65n compartment syndrome

BOAST 10 guidelines 254 definition 446 foot 236 forearm 254 leg 224, 445–448, 723 complex (chronic) regional pain syndrome (CRPS) 352, 353, 571–573 complex repetiv e discharges 670–671 compound muscle action potentials (CMAP s) 661–662, 665–666 compression screws 207–207 computed tomography (CT)

angiography 222, 309 ankle 241, 263, 348, 654 foot 237 hip 53, 209–210, 215, 244 knee 90–91, 222, 224–225, 230 lung cancer 129 pelvis 300, 309 principles 654 spine 134, 318, 330 timing 294 trauma scans 256 wrist 285 computer navigation in TKA 542–543 conductance 525 conduction velocity 663–664 conduit gratis 530 confidence interval (CI) 699–701 conformity 542 congenital calcaneovalgus foot 410–412 congenital scoliosis 151–152 consent 252 contrast agents 655

Coonrad–Morrey total elbow 173, 175 coracoid osteotomy 444 corrosive wear 533 cortical bone 453–454, 462–464, 601, 623, 725 cortical screws 200–201, 609 corticospinal tracts 733 corticosteroids See steroids cotyloplasty 53 countersinking a screw 201–201, 205 cover-up test 406–407 crack propagation 182, 195, 625 crammer courses 7, 13–14 creep 477, 478–479, 541, 555, 626, 627 crescent sign 38, 40 cross-bridge cycle 501, 505, 526

Crowe classification 52

CRP (C-reactiv e protein) 399 crystalloids 306

CT. See computed tomography cubital tunnel syndrome 676–677 cytokines 38, 47, 51

DAIR procedure 20 damage control orthopaedics (DCO) 256–257, 308 data handling. See statistics day case surgery 568–569

DDH. See developmental dysplasia of the hip

De Quervain’s tenosynovitis 449 debridement arthritis 99, 175–177 open fractures 223–224, 256–257, 269 pseudotumours 26 degenerative spondylolisthesis 143, 146 deltopectoral approach 443–444

Denis Browne boots 395

Denis classification 303 denosumab 595 developmental dysplasia of the hip (DDH)

in adults 51–55 in children 417–426, 698–699 dislocation 52, 417–426

DEXA (dual-energy X-ray absorptiome try) scans 610, 611, 657–659 diabetes mellitus 18, 101 diagnostics biopsy 586–587 electromyography 662, 668–674 imaging 650–661 nerve conduction studies 522, 661–668, 674–679 statistics 698–699 dial test 71 diathermy 683 diffuse idiopathic skeletal hyperostosis (DISH) 147

DIPJ. See distal interphalangeal joint discitis 122–127, 154–155, 498 discs. See intervertebral discs disease modifying anft-rheuma toid drugs (DMARDs) 102, 364, 378 dislocation

ACJ 276–277 cervical facet 311–314 hip 214–216, 243–245, 303–304 knee 220–222, 436–438 patella 86–88

PE spacer 79–80 radius

Galeazzi fracture 272–273

Monteggia fracture 270–271, 335 shoulder 265–266 wrist 281–282, 358 distal interphalangeal joint (DIPJ)

Boutonnière deformity 363, 376 mallet finger 286–287 swanneck deformity 363, 377, 378 distal metatarsal articular angle 113–115 distal radioulnar joint dislocation (Galeazzi fracture) 272–273 distraction arthroplasty 99 divot sign 23

DNA, structure 639

Dorr grade of femur 35 dorsal root ganglion 714 dosimeters 651–652 double tourniquets 574 dowagers’ hump 154

Doyle’s classification 287

Drehmann sign 379

Duchenne muscular dystrophy 645–646 ductile materials 622, 625

Dupuytren’s disease 163, 371–373 duty of candour 22, 685 dynamic condylar screw (DCS) implants 206–207 dynamic hip screw (DHS) implants 206, 211

‘early appropriate care’ 308

Eaton and Litiler classification 365 effective joint space 46, 537

Eikenella corrodens 291 elastic limit 619 elastic materials 627 elastic nails 333–335, 342–343 elastin 510 elastohydrodynamic lubrication 600 elbow 168 arthroplasty 173, 174, 175, 177–178 fractures humeral comminuted 268–270 lateral condylar 335–337

Monteggia 270–271, 333–335 supracondylar 337–339, 385–390 free-body diagram 630–632 osteoarthritis 175–179 osteochondritis dissec ans 170–172 paediatrics 333–339, 385–390 pulled elbow 179, 180 posterolateral rotatory instability 179–180 rheumatoid arthritis 172–175, 178 tennis elbow 168–170 ulnar nerve compression 676–677 elderly patients acetabular fracture 300–301 cartilage 37, 64, 475, 479–480, 607, 724 falls 135, 212, 300–301 hip fracture 212–214, 233–234, 245–247 intervertebral discs 154, 492, 494–495 multiple injuries 248–250 odontoid peg fracture 319, 321 osteoporosis 154, 609–612 electromyography (EMG) 662, 668–674 and nerve injuries 521, 522, 673–674 electrosurgery 683

Elson’s test 376 embolization pelvic injuries 306 spinal metastases 131 embryology 728 emergency surgery ankle reduction 415 caudae quina syndrome 141, 328–329 flexor sheath infections 288, 367 hip dislocation 243 See also damage control orthopaedics enchondroma 369–370, 588–589 endplates (discs) 491, 495 endplates (nerves) 525–526, 668 enhanced recovery after surgery (ERAS) 568–569

Enneking staging system 587 entrainment 686 epidural anaesthesia 585 epiphyseal–metaphyseal angle 408

Erb’s point 715 erosive wear 533 ethics of surgeons carryingS. aureus 22, 685 etomidate 582 evidence levels 694–695, 710–711

Ewing’s sarcoma 595–596 examiners 3–4, 14, 629 exchange nailing, tibial 258–259

Exeter THA implants 17, 35–36, 604–605 explant acetabular cup removal system 34 explosion injuries 255–257 extended trochanteric osteotomy (ETO) 432 extensor carpi radialis brevis (ERCB) 169 extensor digitorum communis (EDC) 169 extensor pollicis longus (EPL) tendon 354–356, 449 extensor tendon compartments 354–355, 718 extensor tendon rupture 173, 449 external fixation ankle 228, 241, 262 foot 236 knee 225, 227 external iliac artery 303–304 extracellular matrix (ECM)

bone 459 cartilage 471, 472–475 meniscus 72, 487 tendon/ligament 510–510, 519

F waves 666–667 falls caudae quina syndrome 138 in the elderly 135, 212, 300–301 from a height 237, 301–302 fasciculations 670 fasciectomy (for Dupuytren’s disease) 373 fasciotomy (for compartment syndrome) 254, 446–448 fatigue w ear/failure 182, 533, 534, 540–541, 552–554

S-N curves 182, 624–625, 729

FATSAT images 656 femoral locking plates 219, 246, 249, 344 femoral nails 184, 193–194, 217 breakage 181, 182 femoral nerve 53, 432 block 568 femoral stems

Cannulok 57

Charnley 544, 546–547, 605

Exeter 17, 35–36, 604–605 failure 45, 547, 606 femoral triangle 720–721 femoral varus derotation osteotomy 402–403 femur blood supply to head 210, 296, 720 bone loss classification 29–30

DD Hin adults 51–55 in children 417–426, 698–699 dislocation 214–216, 243–245 fracture dislocation 214–216 fractures at site of a bone tumour 591–592

DCS/DHS implants 206–207, 211 inter-trochanteric 245–247 near physis 343–345 neck, in the elderly 212–214, 233–234 neck, plus shaft 217–218 neck, in young adults 209–211 osteogenesis imperfecta 340 paediatric 340–345 periprosthetic (hip) 55–58 periprosthetic (knee) 218–220 shaft 216–218, 249, 342–343 supracondylar 248

Legg Calvé Perthes disease 399–404 osteonecrosis 38–45, 211, 648

Paget’s disease 49 shape (Dorr grade) 35

SUFE 384–385 and TK Ain valgus knee 68–69 fever 127 fibrillations 668 fibrochondrocytes 487 fibroxanthoma (non-ossifying fibroma) 590–591 fibula 438–439, 440–441

Ficat classification 40 fight bites 290–292 fingers anatomy 719–720

Boutonnière deformity 363, 376 enchondroma 369–370

FDP avulsion (jersey finger) 283–284 flexor sheath infections 287–288, 366–368 inability to extend MCP joints 174 mallet finger 286–287 swanneck deformity 363, 376–378 See also thumb flail elbow 178 flare phenomenon 660 flafooot 106–112, 562 flexor digitorum longus (FDL) tendon transfer 111–112 flexor digitorum profundus (FDP) tendon 283–284, 368 flexor digitorum superficialis (FDS) 283 flexor digitorum superficialis (FDS) tendon 368, 378 flexor sheath infections 287–288, 366–368 flexor tendon injuries 368–369 fluid resuscitation 255–256, 305–306 fluid-film lubrication 600 foot arthritis 100–103 calcaneal fracture 237–239 calcaneovalgus foot 410–412 cavus foot 103–106 clubfoot 391–395, 397 flafooot 106–112, 562 hallux rigidus 117–119 hallux valgus 100, 112–116 hallux varus 115–116

Lisfranc tarsometatarsal fracture dislocation 234–236 metatarsus adductus 395–397 navicular fracture 250–252 overlapping fitih toe 390 postoperative foot drop 58 prosthetics 564 vertical talus 410 force–elongation curves 516–517 forearm anatomy 716–717 compartment syndrome 254 fractures 252–254, 256, 339–340 distal radius malunion 351–353

Galeazzi 272–273

Monteggia 270–271, 333–335 surgical approaches 352–353, 433–436, 717 forest plots 702–704 fracture gaps 194–195, 464 fracture point of a material 618, 622 fractures bone scans 659 functional bracing 562 healing. See bone, healing implant removal 339–340 non-union. See non-union of fractures open. See open fracturesSee also individual bones

FRAX score 658 free body diagrams (FBDs) 629–638

French paradox 60, 551 freting w ear 46 frozen shoulder 162–164 functional bracing 562 funnel plots 705 gabapentin 570, 572 gadolinium contrast agent 655

Galeazzi fracture 272–273 gallium imaging 660 galvanic corrosion 195 gamekeeper’s thumb 376 ganglion 370–371

Garden Alignment Index 210

Gartland classification 387 gastrocnemius lengthening 106 gate theory of pain 575 general anaesthesia 581–584 genetics 639–640 autosomal dominant 640–642 autosomal recessive 642–643

X-linked dominant 643–645

X-linked recessive 645–646 genitourinary system caudae quina syndrome 327–328 trauma 306 genu varum (bowed legs) 411, 735 golfer’s elbow 168 governance

Bier’s blocks in A&E 574–575 breakdown in infection control 22, 684–685

GRAFO orthosis 561–562 gratis bone. See bone graft ligament (hamstring gratis) 82, 98

Gram stain 684 grind test 366

Gross and associates classification 30–30 ground substance 510 growth factors 468–469, 513, 514 growth plates 467–468, 648, 734–735 fracture near 343–345

Gruen zones 45, 535–536, 732

Gustilo ’s classification 19

Guyon’s (ulnar) canal 718

H reflex 667–668 haematogenous spread of bacteria 125 haematoma, postoperative 58 haemorrhage 687–688 haemorrhagic shock 255–256, 305–306, 307–308, 331 hallux rigidus 117–119 hallux valgus angle 113–115 hallux valgus (bunions) 100, 112–116 hallux valgus interphalangeus angle 114 hallux varus 115–116 halo jackets/vests 320, 322, 326–327 halo traction 157, 312 halogenated anaesthetics 583 hammer finger (mallet finger) 286–287 hamstring gratis 82, 98 hand anatomy 719–720 arthritis 291–292, 363–364, 376–378 thumb CMC joint 364–366 boxer’s fracture 288–289 carpal tunnel syndrome 449–451, 674–676

Dupuytren’s disease 163, 371–373 enchondroma 369–370

EPL tendon rupture 354–356, 449

FDP avulsion 283–284 fight bites 290–292 flexor sheath infections 287–288, 366–368 flexor tendon injuries 368–369 inability to extend MCP joints 174 mallet finger 286–287 and RA elbow 173, 174 trigger thumb 397–398

UCL injury (thumb) 375–376 handover protocol 307 hangman’s fracture 321–322

Hardinge approach 36, 430–431, 432 hardness 618–619

Harris and Barrack scale 28

Hartofilakidis classification 52

Haruguchi classification 263

Hatirup and Johnson grading system 117

Haversian system 454, 462–464

Hawkins’ sign 242–243 health and safety 651–652 heel bone (calcaneus)

fracture 237–239 osteotomy 106, 111 hemiarthroplasty 212–213 hemivertebrae 151

Henry’s approach 352–353, 433–436, 717 hereditary sensorimotor neuropathy (HSMN) 104

Herring classification 400–401 heterogeneity 703, 704–705 heterotopic ossification 50, 51, 215

Hibb’s angle 105–106 high tibial osteotomy (HTO) 76–77, 78–79, 92–93 hindfoot arthritis 103 calcaneal fracture 237–239 calcaneal osteotomy 106, 111 hip anatomy 720–721 ankylosing spondylitis 148 arthroplasty hemiarthroplasty 212–213

MoM resurfacing 23–27, 43 total. See total hip arthroplasty aspiration 18–19 bone marrow oedema 61–63 capsulotomy 211

DD Hin adults 51–55 in children 417–426, 698–699 dislocation 243–245 and acetabular fractures 303–304

DDH 52, 417–426 fracture dislocation 214–216 fractures

DHS 206, 211 in the elderly 212–214, 233–234, 245–247 inter-trochanteric 245–247 periprosthetic 55–58 with shaft fracture 217–218 in young adults 209–211 free body diagram 632–636

Legg Calvé Perthes disease 399–404 osteoarthritis 34–38 osteonecrosis 38–45, 211, 648 in SUFE 382, 385

Paget’s disease 48 pain 25 aseptic loosening 29 osteoarthritis 35 osteonecrosis 40

Paget’s disease 50

PJI 18 periprosthetic infection 17–23 septic arthritis 10–11, 399, 432–433

SUFE 384–385 surgical approaches 11, 721 for dislocations 215 for drainage 432–433 for fracture reduction 211, 245 for THA 36, 429–432 zone of safety 419

Hoffmann’s sign (H reflex) 667–668

Hooke’s law 618 hoop stresses

IM nails 188, 193 intervertebral discs 495–496 meniscus 484, 485, 488

Hounsfield units 654

Hueter–Volkman law 455 human bites 290–292 humeral spaces 715 humerus anatomy 715–716 distal fractures comminuted 268–270 lateral condylar 335–337 supracondylar 337–339, 385–390 plating 190–191 proximal fractures 277–278, 332–333 greater tuberosity 266–267 shaft fractures 273–275

Hunter’s (adductor) canal 722 blocks 568

HXLPE (highly cross-linked PE) 26, 539–540, 545–546, 553, 556 hyaluronic acid 480 hydrodynamic lubrication 600 hydroxyapatit e-coated implants 628 hypophosphataemic rickets 644 hypotension after pelvic injury 297, 305–306 permissive 306 hypothesis testing 702 hypovolaemic shock 255–256, 305–306, 307–308, 331 hysteresis 477, 478, 626, 627 idiopathic scoliosis 149–151, 562 idiopathic transient osteoporosis of the hip (ITOH) 61–63

IL-1 (interleukin-1) 38

IL-6 (interleukin-6) 18, 51 iliac oblique view (Judet) 298 ilioischial line 293 iliopectineal line 293

IM (intramedullary) nails. See nails implants failure. See wear materials 554–555, 557, 605 See also specific types induction agents 582 infection control 22, 612, 684–685 sterilization 681 in theatre 22, 614, 685–687 infections bites 287–288, 290–292 discitis 122–127, 154–155, 498 flexor sheath 287–288, 366–368 fracture non-union 258–259, 260 gallium imaging 660 periprosthetic 17–23, 74–76 septic arthritis (hip) 10–11, 399, 432–433 surgical wounds 239 tuberculosis shoulder 158–160 inflammatory markers 18, 399 informed consent 252 inhalation agents 583 inheritance patterns autosomal dominant 640–642 autosomal recessive 642–643 pedigree charts 640

X-linked dominant 643–645

X-linked recessive 645–646 insertional activity on EMG 668 intention-t o-treat (ITT) 698 interleukin-1 (IL-1) 38 interleukin-6 (IL-6) 18, 51 interlocking screws 188–189, 199 intermetatarsal angle 113–115 interphalangeal joint (finger). See distal interphalangeal joint; proximal interphalangeal joint interphalangeal joint (toe) 117 intervertebral discs 489 age-related changes 154, 492, 494–495 blood supply 154–155, 492 discitis 122–127, 154–155, 498 function 490, 491–492, 494, 495–497 nerve supply 492, 497–498 pain 122, 494 prolapse/herniation 492–494, 495, 734 cervical 154–157 in facet dislocation 312–314 lumbar 138–142 stem cell therapy 648 structure 490–491, 494, 497, 733–734 intramedullary (IM) nails. See nails intravenous induction agents 582 irritable hip (transient synovitis) 398, 399 isometric muscle contraction 502 isotonic muscle contraction 502–503 isotropic materials 453–454, 498, 619 isthmic spondylolisthesis 142–146 jersey finger 283–284

Johnson and Strom classification 109 joint aspiration 18–19 joint reaction force 630, 631, 632, 636

Judet and Letournel classification 300

Judet view 298

K-wires ankle injuries 417 upper limb injuries 333, 338, 388

Kanavel’s signs 287

Kaplan–Meier survival curve 709

Kaplan’s line 451

Keller’s arthroplasty 118

Kerboull necrotic angle 41

Kessler technique 369 ketamine 582 kidney disease 378, 655

Kienbock’s disease 373–375

Klein’s line 379–380 knee anatomical and mechanical axes 68–69, 78, 92, 407 anatomy 70, 82 angles 90–91, 92, 93, 405–406, 407–408, 411, 735 arthritis 67–69, 232, 483–484 arthroplasty, total. See total knee arthroplasty arthroplasty, unicondylar 77–78 dislocated spacer 79–80 below-knee prostheses 562–565 dislocation 86–88, 220–222, 436–438 high tibial osteotomy 76–77, 78–79, 92–93 ligaments 70

ACL 71, 82–83, 485, 489, 516 in dislocation 221, 222 and the menisci 483, 489

MPFL 87, 88

PCL 71, 80–82 meniscus. See meniscus paediatric injuries 83, 345–347 pain after TKA 88–91 patellar instability 86–88 periprosthetic fracture 218–220

PLC injury 70–71, 222 surgical approaches 80–82, 232, 436–438 tibial plateau fracture 224–227, 230–233, 608–609 tibial tubercle fracture 345–347 knot of Henry 111–112

Kocher–Langenbeck approach 215, 245 posterior 295–296

Kocher’s criteria 10–11, 398, 399, 433 kyphoplasty 131 kyphosis 154 lactate 256–257, 308 lag screws 200–202, 203, 608 lambda ratio 600 lamellar bone 453–454, 462–464, 601 laminar flow ventilation 613–614, 685–686 laminectomy 137 laminoforaminotomy 157

Langenskiold classification 410 large fragment screws 201

Larmor equation 656

LARS reconstruction 277 lateral collateral ligament (LCL) 179 lateral condylar fracture 335–337 lateral epicondylitis tennis elbow) 168–170 lateral meniscus 72, 482–483, 489 meniscectomy 483–484 lateral pillar (Herring) classification 400–401 lateral spinothalamic tracts 577–578, 732 lateral ulnar collateral ligament (LUCL) 180 lead aprons 652

Leadbetter technique 210

Leddy and Packer classification 283 leg length discrepancy (LLD) 54, 345, 411–, 416–417, 556

Legg Calvé Perthes disease (LCPD) 399–404 levels of evidence 694–695, 710–711

Levine and Edwards classification 322 levo-bupivacaine 580

Lewis and Rorabeck classification 219

Lichtman classification 374 lidocaine 580 ligaments 509–521 ankle 96–98 attachment to bone 518 elbow 179, 180 failure 512, 514–515 healing 513–514 knee. See knee, ligaments

LARS reconstruction 277 ligamentum flavum 516 stem cell therapy 648 stress–strain curves 515–516, 520, 623, 629 structure and function 509–510, 512, 514, 518–519 likelihood ratio (LR) 699 limb bud development 728 limbus 424 limping child 398–404 lipid metabolism, and steroid use 39 lipoma 596–597

Lisfranc tarsometatarsal fracture dislocation 234–236 local anaesthesia 579–581 locking screws for nails (interlocking screws) 188–189, 199 for plates 200, 203

Loder classification 382 lower limb anatomy 70, 720–723 bowed legs 411, 735 compartment syndrome 224, 236, 445–448, 723 embryology 728 length discrepancy 54, 345, 411–, 416–417, 556 nerve conduction studies 677–679 prostheses 562–565 trauma 209

VTE prophylaxis 615–616 See also ankle; femur; foot; hip; knee; tibia lubrication in synovial joints 599–601 lumbago 496 lumbar spine anatomy 490 aneurysmal bone cyst 132–135 caudae quina syndrome 138–142, 327–329 discitis 123, 125

L3–L5 burst fractures 318

L5 transverse process fracture 297

L5/S1 radiculopathy 677–679 metastases 128, 129

MRI 655

Paget’s disease 49 spondylolisthesis 142–146 See also thoracolumbar spine lumbrical plus finger 284 lunate dislocation 281–282, 358

Kienbock’s disease 373–375 transscaphoid perilunate fracture–dislocation 356–358 lung disease 129, 378 macrophages 536–537, 553–554

Mafucci’s syndrome 370, 589 magic angle artefact 657 magnetic resonance imaging (MRI)

BMES 62 caudae quina syndrome 140–141, 328 flafooot 111 hip dislocation 244

MARS 44

Kienbock’s disease 374 osteosarcoma 593 principles 654–657 spine 655 aneurysmal bone cyst 133 cervical disc prolapse 156 cervical facet dislocation 312–314 cervical spondylotic myelopathy 137 discitis 123, 125 metastases 129, 131 scoliosis 150, 151 spondylolisthesis 143–144 trauma 318 wrist 285 major haemorrhage protocol 305–306 malignant tumours. See cancer malleolar fracture 260–264, 438–441 mallet finger 286–287 margins (oncology) 587 marking of the exam 2, 4–5

Masquelet technique 260 matrix glycoproteins 473–474 matrix metalloproteinases (MMPs) 37, 291, 474

Maudley’s test 170

Mayfield classification 356

McKellop’s classification 538

McPherson staging 74

MCPJ. See metacarpophalangeal joint

Meary’s angle 105 mechanical axis (knee) 68–69, 78, 92, 407 medial circumflex femoral artery 210, 217, 296 medial collateral ligament (MCL) 179 medial meniscus 72, 483, 489 bucket handle tear 72–73 meniscectomy 483–484 medial patellofemoral ligament (MPFL) 87, 88 median nerve 253–254, 282, 283, 527–528 carpal tunnel syndrome 449–450, 674–676 medical errors 568 megaprostheses 548 meniscus 72–73 blood supply 72, 485 composition 72, 466, 487 function 72, 483–485, 488 growth 489 and ligaments 483, 489 and osteoarthritis 483–484 structure 72, 480–483, 487–488 tears 72–73, 485–486, 488, 489, 648 mesenchymal stem cells 466, 514 meta-analysis 702–706 metabolic acidosis 308 metacarpal fracture (boxer’s fracture) 288–289 metacarpophalangeal joint (MCPJ)

inability to extend 174 infections 288, 290–291

OA 291–292

RA 363, 364, 377, 378 thumb 366, 375 metal artifact reduction sequence (MAR S) 44 metal AVN rods 42, 43 metal on metal (MoM) hips resurfacing 23–27, 43

THA 44–44 metals 554–555 and MRI 655–656, 657 stress–strain curves 617, 621, 629 See also stainless steel titanium metaphyseal diaphyseal angles 409 metaphyseal filling titanium cones 548 metaphyseal sleeves 548 metastases 123, 127–132 metatarsophalangeal joint (MTPJ)

arthritis 100–103 hallux rigidus 117–119 hallux valgus 100, 112–116 metatarsus adductus 395–397 methotrexate 364

Meyerding’s grading system 142

MHRA (Medicines and Healthcare Products Regulatory Agency) 24

Michon classification 368 mini fragment screws 201

Mitchell osteotomy 115

Modified New York Criteria 147 modulus of resilience (MR) 619

MoM (metal on metal) hips resurfacing 23–27, 43

THA 44–44 moment of inertias tiffness/rigidity)

nails 183–184, 185, 186–188 plates 190–191

Monteggia fracture dislocation 270–271, 333–335 motor endplates 525–526, 668 motor unit action potentials (MU APs) 672–674

MRI. See magnetic resonance imaging

MRSA (methicillin-resistant S. aureus) 612, 684–685

MSIS definition of P JI 20

MTPJ. See metatarsophalangeal joint multiple injuries in the elderly 248 explosions 255–257 falls from height 237, 301–302 osteogenesis imperfecta 340 pelvic 306, 307 muramyl tripeptide 594 muscle 498 contraction 499–503, 505–509, 526 drawing 727–728 electromyography 662, 668–674 structure 498–499, 503–505 types 502–503, 504 muscle relaxants 582–583 muscular dystrophy 645–646 musculocutaneous nerve 444 myasthenia gravis 526 myeloma 132 myokymic discharges 670 myopathy 672–673 myosin 499, 500, 727 nails (finger) 720 nails (implants) 184–185 biomechanics 181–185, 186–189, 192–194, 217 cephalomedullary 245–247 elastic 333–335, 342–343 failure 181–183, 188 femoral 182, 184, 193–194, 217 locking screws 188–189, 199 periprosthetic knee fracture 220 reaming 187, 193, 258–259 sloft ed 188 stiffness/rigidity 183–184, 185, 186–188 working length 186, 187

‘Napoleon Hat’ sign 142 navicular fracture 250–252 neck. See cervical spine necking 621 needle biopsy 586–587 negative predictive value (NPV) 699 neostigmine 583 nerve conduction studies (NCS) 522, 661–668 carpal tunnel syndrome 674–676 cubital tunnel syndrome 676–677

L5/S1 radiculopathy 677–679 lower limb 679 lower trunk brachial plexopathy 677 and type of nerve injury 521, 522 nerve conduits 530 nerves 523–526 drawing 725–727 injuries 521–522, 529–530, 673–674, 726–727 local anaesthetic mode of action 579–580 pain pathways 575, 576–579 regeneration/r epair 521–522, 528, 530 structure 522–523, 528–529

Wallerian degeneration 521, 526, 528 neurofibromatosis 152–154 neurogenic shock 317, 330–331 neuroma 653 neuromuscular blocking agents 582–583 neuromuscular junctions (NMJs) 526, 668, 727–728 neuromuscular scoliosis 152 neuropathic pain 569–570 neuropraxia 521 neurotmesis 522

‘NHS working environment’ 64n

NICE guidelines 234 major trauma 257 osteoarthritis 365 nickel 554, 627 nociception 572, 575–579 See also pain non-normal distribution 692–693 non-ossifying fibroma 590–591 non-union of fractures clavicle 276 hip 246 humerus 275 odontoid peg 320 scaphoid 285–286, 360–361, 362 tibia 257–260 normal distribution 689–690, 691 notch sensitivity 625

NSAIDs 378, 570 nuclear medicine imaging 63n, 659–661 bone marrow oedema 62–62 nucleus pulposus (NP) 491, 494, 497 null hypothesis 702 number needed to treat (NNT) 692

OA. See osteoarthritis obesity 67, 77, 455 obturator oblique view (Judet) 298 occupational safety 651–652 odds ratio (OR) 692 odontoid peg fracture 321 offset yield stress 620 olecranon osteotomy 270

Ollier’s disease 370, 589 oncology aneurysmal bone cyst 132–135, 594–595 biopsy 130, 586–587 chondrosarcoma 591–592 definitions 586 enchondroma 369–370, 588–589

Ewing’s sarcoma 595–596 lipoma 596–597 metastatic bone disease 123, 127–132 non-ossifying fibroma 590–591 osteochondroma 587–588 osteosarcoma 593–594 staging and grading 130, 587 open book pelvis 304–306 open fractures at site of a bone tumour 591–592 femur 217 humerus 268 tibia 222–224, 256–257 operating theatres design 613–615, 685 infection control 22, 614, 685–687 ventilation 613–614, 685–686 opioid mechanism of pain 576–576 opioids 570, 583 organ, definition 452 orthodromic action potential 664–665 orthotics 559–562 for bowed legs 409 for flafooot 111, 562

OSCAR system 33 osteoarthritis (O A)

ankle 98–100 compared with RA 174 elbow 175–179 hip 34–38 knee 67–69, 232, 483–484

MCP joints 291–292 non-surgical treatments 67, 99, 476, 480 pathology 37–38, 475–476, 479–480, 607, 724 stem cell therapy 648 thumb CMC joint 364–366 osteoblastic jumping distance 260 osteoblastic regulators 47, 455, 466, 534 See also RANKL osteoblasts 455, 462, 466 osteochondral autograft transfer system 477 osteochondral gratis 100 osteochondritis dissec ans 170–172 osteochondroma 587–588 osteoclastic cuting c ones 196, 456, 459, 464 osteoclastogenesis 458–459 osteoclasts 455, 456, 462, 466, 601–602 in Paget’s disease 49, 51 osteocytes 455, 462–464, 466 osteogenesis imperfecta 340, 460–461, 642 osteolysis 47–48, 532–533, 534–537, 553–554, 599 classification 29–31

Paget’s disease 51 revision knee replacement 83–86 osteon Haversian system) 454, 462–464 osteonecrosis (ON)

hip 38–45, 211, 648 in SUFE 382, 385 humeral head/neck 278 lunate 373–375 navicular 252 osteoporosis 609–612

DEX Ascans 610, 611, 657–659

FRAX score 658

ITOH 61–63

Singh index 659 spine 154 osteoporosis circumscripta 49 osteoprogenitor cells 455, 466 osteoprotegerin (OPG) 48 osteosarcoma 593–594 osteotomy ankylosing spondylitis 148 calcaneal 106, 111 coracoid 444 extended trochanteric 432 hallux valgus 115–116 high tibial 76–77, 78–79, 92–93 olecranon 270 for osteonecrosis of the hip 42–42

Paget’s disease 50 shortening of the femur 54 osteotropic factors 459 outcome measures 697, 710–711 outliers 692 oxidized zirconium 543, 555 oxygen saturation 308

P values 696, 700–701

Padua grade (ulnar nerve compression) 677

Padua scale (carpal tunnel syndrome) 675 paediatrics 379 ankle 347–348, 414–417

Blount’s disease 411 bowed legs 411, 735 discitis 127, 154–155, 498 elbow lateral condyle fracture 335–337

Monteggia fracture 333–335 pulled elbow 179, 180 supracondylar fracture 337–339, 385–390 femur 340–345 foot clubfoot 391–395, 397 congenital calcaneovalgus foot 410–412 congenital vertical talus 410 metatarsus adductus 395–397 overlapping fitih toe 390 forearm 333–335, 339–340 growth plates 467–468, 734–735 hip

DDH 417–426, 698–699

LCPD 399–404 septic arthritis 10–11, 399, 432–433

SUFE 384–385 knee

ACL injury 83 tibial tubercle fracture 345–347 limps 398–404 neurofibromatosis 152–154 osteogenesis imperfecta 340 rheumatoid arthritis 173 rickets 644 scoliosis 149–151, 152–154, 562 shoulder 332–333 trigger thumb 397–398 tumours 587–588, 590–591, 593–594, 595–596

Paget’s disease 48–51 pain acute vs. chronic 568 analgesia aspirin 378 local anaesthetics 579–581 neuropathic pain 570 postoperative 568–569

WHO pain ladder 570–571 See also anaesthesia assessment 122, 567–568

CRPS 352, 353, 571–573 definition 567 exam questions 567 knee 88–91 mechanisms 572, 575–576 neuropathic 569–570 pathways 575, 576–579 pamidronate 50–50

Paprosky classification (acetabular defects) 30

Paprosky classification femoral defects) 29, 30 paracetamol 570

Park Harris growth arrest lines 340

Pasteurella multocida 288 patellar instability 86–88 patellofemoral maltracking 90 patient safety 429, 568

PCL (posterior cruciate ligament) 71, 80–82

PD weighted images 656

PE. See polyethylene pedigree charts 640, 641, 643, 644, 645, 646, 647 pelvic anatomy 293, 297–298 pelvic binders 305, 308–309 pelvic fractures 293 acetabulum 299–301, 303–304 and bilateral dislocation 303–304 classification 297 lateral compression 307–310 open book 304–306 posterior wall 293–297 unstable 301–303 vertical shear 297–299 pelvic incidence 144–145 pelvic packing 309–310 pennate muscles 503, 504 percutaneous biopsy 586–587 percutaneous fixation of the scaphoid 360–361 periosteum 457 peripheral neuropathy (diabetic) 101 periprosthetic fractures ankle 248–249 hip 55–58 knee 218–220 periprosthetic joint infection (P JI) 17–23, 74–76 permissive hypotension 306 peroneal nerve 69, 242, 679 peroneus longus tendon 106

Perren’s strain theory 194, 465, 609 pes cavus 103–106 pes planus (flafooot) 106–112, 562

PET scans (positron emission tomography) 64n, 659 phosphate metabolism 455 physis. See growth plates pigeon toe (metatarsus adductus) 395–397 pilon fracture 227–229, 239–243 pinning in situ (PIS) 382–383, 384–385

PIPJ. See proximal interphalangeal joint (PIPJ)

Pipkin classification 215

Pirani score 391–394 piriformis 430 piriformis entry point 217 pivot-shift t est 180 plantar fascia release 106 plastic deformation 618, 620–621 plastic orthotics 560–561 platelet-rich plasma (PRP) injections 99, 112, 480, 517–518 plates biomechanics 185–186, 190–192, 195, 204–204, 249 bridging 185, 609 but iress 232 and callus formation 185, 275 clavicle 276 design 207–208 elbow 269–270 femoral locking plates 219, 246, 249, 344 humerus 190–191 posterior malleolus fracture 263

PLC (posterolateral corner) 70–71, 222

PMMA (polymethylmethacrylate) 605, 624 polar moment of inertia torsional stiffness) 183–184, 186, 187 polyethylene (PE) 544, 622

CoP arthroplasty 43

HXLPE 26, 539–540, 545–546, 553, 556 liner removal 34 manufacture 48–48, 544–545 shelf life 546, 556 sterilization 539, 546, 556 wear/failure 47, 48, 539–544, 552–554, 555 polymethylmethacrylate (PMMA) 605, 624

Ponseft serial casting 395 popliteal artery 222, 438 popliteal fossa 437–438 popliteal vein 438 positive predictive value (PPV) 699 positive sharp waves 668–670 positron emission tomography (PET) 64n, 659 post-tourniquet syndrome 682 post-traumatic arthritis 98, 175–179, 232 posterior cruciate ligament (PCL) 71, 80–82 posterior distal tibiofibular ligament 96 posterior interosseous nerve (PIN) 173, 174, 435, 436 posterior Kocher–Langenbeck approach 295–296 posterior laminoforaminotomy 157 posterior malleolus 263–264, 438–441 posterior sloping angle 383–384 posterolateral corner (PLC) 70–71, 222 postsynaptic membrane 526 power (statistics) 696–697 prilocaine 573–574 procalcitonin (PCT) 399

PROMs (patien t-reported outcome measures) 710

Propionibacterium acnes 19 propofol 582 proportionality limit 619 proprioception 135, 484 prosthetics 559, 562–566 proteoglycans 472, 474–475, 491, 496–497, 510, 519 drawing 466–467, 724 protrusio acetabuli 49, 50 proximal femoral replacement 58 proximal interphalangeal joint (PIPJ)

Boutonnière deformity 363, 376 swanneck deformity 363, 376–377, 378 pseudotumours 23–26

Punneft squares 640, 642, 643, 645 pyrexia 127 quadrangular space 445 quadregia effect 284 qualitativ e/quantit at ive data 690–691

RA. See rheumatoid arthritis radial artery 435 radial nerve 435 radiofrequency ablation 683 radioimaging 659–661 radiology 650–661 See also individual techniques radiotherapy 131 radius anatomy 717 distal fracture and malunion 351–353 fractures 254, 256

Galeazzi fracture 272–273

Monteggia fracture dislocation 270–271, 335 styloid fracture 267–268 surgical approaches 352–353, 433–436, 717 randomized controlled trials RCTs) 696–698

RANKL (receptor activator of nuclear factor-κβ ligand) 47, 51, 455, 534, 553–554, 595 reaming 187, 193 exchange tibial nailing 258–259 recurrent laryngeal nerve 443 reflexes 122, 123, 141–142 refractory period 525 regional anaesthesia 573–575, 584 renal disease 378, 655 resting potential 523 resuscitation 255–256, 305–306, 307–308 reverse pivot shift t est 71 reverse self-cuting screws 205 reverse shoulder arthroplasty 167, 278 revision for the exam 6–7, 9–14 rheumatoid arthritis (RA)

compared with OA 174 elbow 172–175, 178 foot 100–103 hand 363–364, 376–378 medications 102, 364, 378 preoperative assessments 173, 174, 378 rickets 644 rigidity. See stiffness risk ratio (RR)/risk difference (RD) 691–692

Risser grading 149–150

RNA, structure 639

Robert’s view of the thumb 364

ROC (receiver operating characteristic) curves 699 rocker boft om foot 410

Romberg’s test 135 ropivacaine 580 rotator cuff tears 160–162, 165–167, 648, 656

Ruedi–Allgower classification 240–241

S-N curves (stress cycle curves) 182, 624–625, 729

SACH (solid ankle cushioned heel) prosthesis 564 sacroiliac joint 147 sacrum 301–302, 303 sagift al balance 154

Salenius and Vankka graph 405–406, 735

Salter Harris classification 467 sample size 696–697

Sanders classification 237–238

Sangeorzan classification 250–251 sarcoma chondrosarcoma 591–592

Ewing’s 595–596 osteosarcoma 593–594 sarcomere 498 scaphoid non-union of fractures 285–286, 360–361, 362 proximal pole fracture 284–286, 361–363 transscaphoid perilunate fracture–dislocation 356–358 waist fracture 358–361 scapholunate angle 358 scapular manipulation technique 265–266 scarf osteotomy 115–116

Schatzker classification 224

Schenk classification 221

Scho tiles point 88 sciatic nerve

DDH 53, 54 foot drop 58 hip dislocation 215–216, 243

THA 36, 432 scintigraphy technetium bone sc ans) 62–62, 63n, 659 scoliosis

Boston brace 562 idiopathic 149–151 non-idiopathic 150, 151–154 screening tests 698–699 screws 186, 195, 197–207, 608–609, 731

DCS/DHS implants 206–207, 211 locking screws 188–189, 199, 200, 203 pull-out 195, 199, 205 stripping 186, 205 scrubbing up 687 seatbelt injuries 323–324

Seddon classification 529–530 self-tapping screws 205 sensitivity 698, 699 sensory nerve action potentials (SNAP s) 661, 662, 665 sepsis 123 septic arthritis 10–11, 399, 432–433 shock hypovolaemic 255–256, 305–306, 307–308, 331 neurogenic 317, 330–331 spinal 312, 317–318, 331 shoulder 158

ACJ dislocation 276–277 anatomy 444–445 arthroplasty 160, 167, 278 calcific tendonitis 164–165 fracture dislocation 265–267, 443–445 frozen 162–164 paediatric fracture 332–333 rotator cuff tears 160–162, 165–167, 648, 656 subacromial impingement 164–167 surgical approaches 443–445 tuberculosis 158–160 sickle cell disease 643

Singh and Maini index 659 single photon emission tomography (SPECT) 659

SIRS (systemic inflammatory response syndrome) 123, 257 skeletal dysplasias 462 skeletal maturity 149–150 skewed distribution 692–693 skull, Paget’s disease 49 slipped upper femoral epiphysis (SUFE) 384–385 sloft ed nails 188 small fragment screws 201

Smith Peterson approach 211, 433, 721

SNAC wrist 362–363

SNAPs (sensory nerve action potentials) 661, 662, 665

SOCRATES 567 soleus bridge 447

Southwick angle 381 specificity 698, 699

SPECT (single photon emission tomography) 659 spilled teacup sign 358 spinal anaesthesia 585 spinal arteries 154 spinal shock 312, 317–318, 331 spine 121–122 anatomy 154, 489–490, 732–733 aneurysmal bone cyst 132–135 ankylosing spondylitis 146–149 caudae quina syndrome 138–142, 327–329 cervical facet dislocation 311–314 cervical spondylotic myelopathy 135–138 classification of injuries 324, 325–326 discs. See intervertebral discs embryology 728 fractures in AS 148

Chance 323–324 hangman’s 321–322

L5 transverse process 297 odontoid peg 321 thoracolumbar burst 316–319 free-body diagram 636–638 function 490, 497 fusion. See arthrodesis, spine halo jackets 320, 322, 326–327 incomplete cord injuries 314–316, 325–326

L5/S1 radiculopathy 677–679 ligamentum flavum 516 metastatic disease 123, 127–132 nociceptive pathways 575, 576–579 osteoporosis 154

Paget’s disease 49 scoliosis 149–154, 562 spinal cord syndromes 314–316, 325–326, 526–527 spondylolisthesis 142–146, 321–322 stable 316–317, 331 stem cell therapy 648 stenosis 49, 328 surgical approaches (cervical) 316, 441–443 trauma assessment 329–331 spiral cords 372 splintage 184 spondylolisthesis 142–146, 321–322 spur sign 297

Spurling’s sign 155 staging of tumours 130, 587 stainless steel 343, 546, 554, 605, 627 stress–strain curves 617, 621, 629 standard deviation (SD) 690

Stanmore THA implants 27–28

Staphylococcus aureus

MRSA 612, 684–685 surgeons as carriers 22, 685 statistics 689 clinical trials 693–698, 699–702 diagnostic tests 698–699 distribution 689–693 meta-analysis 702–706 outcome measures 697, 710–711 survival analysis 706–710 types of data/tests 690–691

Steel’s blanch sign 380

Steinberg classification 40 stem cells 42, 646–649

Stener lesion 375 sterilization 681 of PE 539, 546, 556 steroids elbow injections 170 joint infections 159–160 osteonecrosis 39 shoulder injections 159–160, 162, 165, 166 spinal cord injuries 315, 324, 326 and surgery in RA 378 stiffness (rigidity) 187, 618 nails 183–184, 185, 186–188 plates 190–191

STIR images 656 strain 617 in fracture healing 194, 465, 609 See also stress and strain strain hardening 621–622 strength 618, 626 stress corrosion 195 stress relaxation 477, 478, 626, 627 stress risers 182, 195 stress and strain 617–629, 729–731 implant materials 617, 621, 629 tendons and ligaments 515–517, 520, 623, 629 structured oral exam 9–15 assessors 4 candidates. See candidates, advice for examiners 3–4, 14, 629 format 1–3, 9 marking 2, 4–5 preparation for 6–7, 9–14 study groups 11–13

Stulberg classification (modified) 401, 404 subacromial impingement 164–167 subtalar joint 109, 239 sufentanil sublingual tablet system 568 suitcases, carrying 634–635

Sunderland classification 529–530, 726–727 superficial peroneal nerve 242 superficial radial nerve 435 superior gluteal nerve 432 supervisors 13 sural nerve 440 surgical approaches 429 ankle anterolateral 242 posterolateral 263–264, 438–441 cervical spine 316, 441–443 forearm 352–353, 433–436, 717 hand/fingers 355, 368 hip 11, 721 for dislocations 215 for drainage 432–433 for fracture reduction 211, 245 for THA 36, 429–432 knee 80–82, 232, 436–438 leg fasciotomy 446–448 navicular 252 pelvis 295–296, 310 shoulder 443–445 tarsometatarsal joints 236 wrist 358, 360 surgical instrument sterility 22, 681 surgical timeouts 435 survival analysis 706–710 sutures 682–683 suxamethonium 582–583 swanneck deformity 363, 376–378 synovial cyst (ganglion) 370–371 synovial fluid 599 aspiration in diagnosis of P JI 18–19 systemic inflammatory response syndrome (SIRS) 123, 257

T score 610, 657

T1/T2-weighted images 654–655 talar fracture 241, 242–243, 654 talar tilt t est 96 talipes equinovarus (clubfoot) 391–395, 397 talonavicular joint 103 tantalum 555

AVN rods 42, 43 tapping 195, 201 self-tapping screws 205 tarsal tunnel 448–449 tarsometatarsal fracture dislocation 234–236

TE (timet o echo) 656 technetium bone sc ans 62–62, 63n, 659 telescopic rods 340 tendoachillis tenotomy 395 tendons attachment to bone 518 blood supply 517 healing 513–514 magic angle artefact 657 stem cell therapy 648 stress–strain curves 516, 520, 623, 629 structure and function 509–512, 514, 518–519 tendinopathy 164–165, 168–170, 517–518 transfers 106, 111–112, 355 trauma 354–356, 368–369 tennis elbow 168–170 tenodesis test 173 tenosynovitis

De Quervain’s 449 infections 287–288, 366–368 tensegrity architecture 474–475 tension banding 731

THA. See total hip arthroplasty thigh, anatomy 722 thiopentone 582 thoracic outlet syndrome 677 thoracic spine 129, 490 thoracolumbar spine burst fracture 316–319

Chance fracture 323–324 incomplete cord injuries 325–326 three-point pressure principle 561 threshold stimulus 524 thromboelastography (TEG) 309 thromboembolism 90, 615–616, 682 thumb

CMC joint arthritis 364–366

EPL tendon rupture 354–356, 449 trigger thumb 397–398

UCL injury 375–376 tibia

Blount’s disease (tibia v ara) 411 distal fractures 227–229, 239–243, 347–348 non-union 257–260 open fractures 222–224, 256–257 periprosthetic (ankle) fracture 248–249 posterior malleolus fracture 263–264, 438–441 posteromedial bowing 411–proximal fractures 224–227, 230–233, 345–347, 608–609 spiral fractures 183 tibial nails 193 tibial nerve 438, 448, 449 tibial osteotomy (HTO) 76–77, 78–79, 92–93 tibialis anterior 104 tibialis posterior tendon 106–109, 110 tibiofemoral angle (TFA) 405–406, 407, 408, 735 timing of C T scans 294 timing of surgery acute spinal cord injuries 316 ankle fractures 261–262, 415 caudae quina syndrome 141, 328–329 flexor sheath infections 288, 367 hip dislocation 243 hip fractures 210, 213, 234 titanium 184, 193, 205, 554, 627–628

TKA. See total knee arthroplasty

TLICS scale 325 toes complications of VF Gs 41 after FDL transfer 111–112 hallux rigidus 117–119 hallux valgus 100, 112–116 hallux varus 115–116 overlapping fitih toe 390

Tokuhashi staging 130, 132 torsional stiffness (polar moment of inertia) 183–184, 186, 187 total ankle replacement 99–100 total elbow replacement (TER) 173, 174, 175, 177–178 total hip arthroplasty (THA)

for acetabular fracture 301 bone scans 660–661 cement mantle failure 58–61, 548–551 cemented vs. uncemented 33, 35, 51 ceramic on ceramic 43, 44 ceramic on PE 43

Charnley implants 544, 546–547, 605 compared with hip resurfacing 27

DDH 53–54

Exeter implants 17, 35–36, 604–605 failure 27–34, 45, 547, 606, 625 femoral head size 556–557, 599 femoral neck fracture 213, 233–234

Gruen zones 45, 535–536, 732 impingement 23, 555–556 implant design 537, 604–605 lubrication 600 metal on metal 44–44 osteoarthritis 35–37 osteonecrosis 43–45

Paget’s disease 50–51 periprosthetic fracture 55–58 periprosthetic infection 17–23 revision surgery

DDH 54 periprosthetic fracture 56–58

PJI 21–22, 26–26

Stanmore prosthesis 28–28, 29, 31–34 squeaking 43 stem biomechanics 546–547, 604–605 surgical approaches 36, 429–432 uncemented 605–606

VTE prophylaxis 615–616 wear 46–48, 532–539, 546–547, 553–554, 555–558, 598–599 total intravenous anaesthesia (TIVA) 583–584 total knee arthroplasty (TKA)

computer navigation 542–543 after HTO 78–79 implant design 85–86, 541–542, 543 implant materials 554–555 lubrication 600 pain following 88–91 periprosthetic infection 74–76 postoperative analgesia 568 revision surgery 75–76, 83–86 tibial bone loss/ augmentation 547–548 after tibial plateau fracture 232 in valgus knee 67–69

VTE prophylaxis 615–616 wear/failure 534, 539–544, 552, 625 toughness 618, 619, 627 tourniquet paralysis syndrome 682 tourniquets 573–574, 682 traction cervical 157, 312 pelvic 296 traction/ counter-traction method 266 tramadol 570 tranexamic acid 32, 257, 306, 688 transcription factors 455–456 transcutaneous electrical nerve stimulation (TENS) 575 transscaphoid perilunate fracture–dislocation 356–358 trapdoor procedure 42 trapeziectomy 365–366 trauma team 305, 307 handover to 307

Trethowan’s sign 379–380 triangular interval 445 triangular space 445 tribology. See wear triceps tendinosis 169 tricyclic antidepressants 570 trigger thumb 397–398 trimalleolar fracture 438–441 trochanteric entry point 217 tropocollagen 457–458, 512 tropomyosin 499 troponin 499, 505 tuberculosis of the shoulder 158–160 tumours. See benign tumours; cancer type I/type II errors 696–697, 701–702

UCLB orthosis 562

UHMWPE. See polyethylene ulna fracture 254, 256

Monteggia fracture dislocation 270–271, 333–335 olecranon osteotomy 270 ulnar canal 718 ulnar collateral ligament (UC Lof thumb 375–376 ulnar minus variant (Kienbock’s disease) 373–375 ulnar nerve 253–254, 283, 450 compression 676–677, 719 ultimate tensile strength (UTS) 182, 618 ultrasound 652–653 hip 44, 653, 698 shoulder 161, 653 unicondylar knee arthroplasty (UKA) 77–78 dislocated spacer 79–80

Unified Classification System (UCS) (Vancouver) 55 upper limb anatomy 714–720 embryology 728 nerve conduction studies 674–677 prostheses 565–566 See also elbow; forearm; hand; humerus; shoulder; wrist upper motor neuron lesions 122, 674 valgus heel 112 valgus knee 67–69

Vancouver classification 55–55 varus knee 70–71, 92–93 vascular anatomy. See blood supply vascularized fibular graft (VF G) 41

Vaughan–Jackson syndrome 174, 449 venous thromboembolism (VTE) 90, 615–616, 682 ventilation in theatres 613–614, 685–686 vertebral artery 443 vertebroplasty/kyphoplasty 131 viscoelasticity 477, 484, 512, 625–626, 627, 730–731 vitamin C 572 vitamin D 602, 611 vitamin E-impregnated UHMWPE 48 viva. See structured oral exam volar locking plates 355–356 walkingsticks 632–634

Wallerian degeneration 521, 526, 528 warfarin 58 washers 204 water, in cartilage 467, 472, 474–475, 607

Watson Jones anterolateral approach 431, 721

Watson Jones classification (modified) 345–346 wear definition 46, 533 in hip implants 46–48, 532–539, 546–547, 553–554, 555–558, 598–599 and implant materials 554–555, 557

PE 47, 48, 539–544, 552–554, 555 in knee implants 534, 539–544, 552, 625 measurement 557, 599 osteolysis 47–48, 534–537, 553–554, 599 types/modes 46–46, 533–534, 538, 540–541, 552, 598–599

Weber classification 438 weeping lubrication 600 well-differentia ted liposarcoma 596–597 white cell count in PJI 19

WHO pain ladder 570–571 neuropathic pain 570

WHO Safer Surgery checklist 429

Wilson radiological grade 380–381

Wiltse–Newman classification 142–143

Wolf flaw 455 wounds animal bites 287–288 fight bites 290–292 open fractures 217, 224, 268 surgical 239 woven bone 453, 601 wrist anatomy 718–719 arthritis 362–363 carpal tunnel syndrome 449–451, 674–676

CRPS 571–573 dislocation 281–282, 358 extensor tendon compartments 354–355, 449

Galeazzi fracture 272–273 ganglion 370–371

Kienbock’s disease 373–375 radial styloid fracture 267–268 scaphoid non-union 285–286, 360–361, 362 scaphoid proximal pole fracture 284–286, 361–363 scaphoid waist fracture 358–361 surgical approaches 358, 360 transscaphoid perilunate fracture–dislocation 356–358

X-linked disorders dominant 643–645 recessive 645–646

X-rays 121–122, 650–652 yield point 618, 619–621

Young and Burgess classification 297

Young’s modulus 605, 618, 619 z-plasty 373 zirconium oxide 543, 555