2. โข Chronic pyogenic osteomyelitis
โข Developing countries
โข Other causes of chronic osteomyelitis are tuberculosis, fungal
infections
โข Three types - secondary to acute osteomyelitis, Garreโs osteomyelitis ,
Brodieโs abscess
Chronic osteomyelitis
3. Acute to chronic
โข Delayed and inadequate treatment - sequestrum formation - โnon-
collapsingโ bone cavities and sequestra are responsible for persistent
infection
โข Type and virulence of organism - highly virulent organism
โข Reduced host resistance - Malnutrition compromises the bodyโs
defense mechanism
4. โข Response to infection -host bone responds by generating more and
more sub-periosteal new bone
โข Sub-periosteal bone is deposited in an irregular fashion
โข Continuous discharge of pus results in the formation of a sinus
โข With time the sinus tract gets fibrosed and the sinus becomes fixed to
the bone
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18. Sequestrum
โข Piece of dead bone
โข Surrounded by infected granulation tissue trying to โeatโ the
sequestrum away
โข appears pale and has a smooth inner and rough outer surface
โข Outer roughness is due to constant erosion by the surrounding
granulation tissue
19.
20.
21. โข Involucrum is the dense sclerotic bone overlying a sequestrum
โข There may be some holes in the involucrum for pus to drain out -
cloacae
โข The bony cavities are lined by infected granulation tissue
22. DIAGNOSIS
โข Suspected clinically but can be confirmed radiologically
โข The lower-end of the femur is the commonest site
โข A chronic discharging sinus is the commonest presenting symptom
โข Sinuses heal for short periods, only to reappear with each acute
exacerbation
โข Discharge can vary from โ sero purulent to thick pus
โข Generalised symptoms of infection such as fever during acute
exacerbations
23. Examination
โข Chronic discharging sinus - sinus fixed to the underlying bone
โข Sprouting granulation tissue at its opening - indicating a sequestrum
within the bone
โข Sequestrum may be visible at the mouth of the sinus itself
โข Sinus may be surrounded by healed puckered scars
โข Thickened, irregular bone
โข Tenderness - on deep palpation, in some cases
โข Adjacent joint โ stiff,
24. INVESTIGATIONS
โข Radiological examination - Thickening and irregularity of the cortices,
Patchy sclerosis, Bone cavity, Sequestrum (denser than the surrounding
normal), Involucrum and cloacae
โข Sinogram - sterile thin catheter is introduced into the sinus as far as it can
go, radio-opaque dye is injected, X-rays taken
โข CT scan and MRI
โข Blood , Pus
26. TREATMENT
โข Principles of treatment - primarily surgical
โข Antibiotic โ during acute stage and post operative period
โข Aim of surgical intervention - removal of dead bone- elimination of dead
space and cavities - removal of infected granulation tissue and sinuses
โข Operative procedures โ Sequestrectomy, Saucerisation, Curettage, Excision
of an infected bone, Amputation
โข After surgery the wound is closed over a continuous suction irrigation
system
27.
28. COMPLICATIONS
โข An acute exacerbation or โflare upโ of the infection
โข Growth abnormalities โ Shortening, Lengthening, Deformities
โข Pathological fracture
โข Joint stiffness
โข Sinus tract malignancy
โข Amyloidosis
33. โข SUBGLENOID POSITION IN AXILLA
โข LUXATIO ERECTA---HUMERAL HEAD IS SUBLUXATED INFERIORLY & SHAFT POINTS
ERECTED UPWARDS
โข ARM IS LOCKED IN ALMOST FULL ABDUCTION/ELEVATION
โข ARM FIXED BY THE SIDE OF HEAD
โข MAXIMUM NEURO VASCULAR DAMAGE( AXILLARY N):60%
โข TREATMENT: REDUCED BY PULLING UPWARDS IN LINE OF ABDUCTED ARM WITH
DOWNWARD COUNTER TRACTION
36. โข ANT DISLOCATION MC
โข SUB CORACOID MC
โข MOI: ER /HORIZONTAL ABD FORCE ON HUMERUS
โข DIRECT POST BLOW ON SHOULDER
โข BANKART LESION
โข HILL SACH LESION
37. CLINICAL FEATURES
โข ABD,ER, AND EXTENSION ATTITUDE
โข HELD IN SLIGHTLY ABD HANGING BY THE SIDE OF BODY
โข NORMAL CONTOUR LOST
โข BULGE BELOW CLAVICLE
โข DUGAS TEST, CALLWAY TEST AND HAMILTON RULER TEST
โข AP XRAY: OVERLAPPING SHADOW OF HUMERAL HEAD AND
GLENOID FOSSA
โข REDUCTION:
KOCHERS METHOD(TEAR),STIMSON METHOD,HIPPOCRATIC
METHOD
38. Dreamz Learning Innovations_____________________________________________ Page 38
o Shoulder is the commonest joint in the
human body to dislocate.(MCQ)
o It occurs more commonly in adults, .(MCQ)
o Anterior dislocation is much more common
than posterior dislocation. .(MCQ)
o Shoulder instability: head of the humerus is
not stable in the glenoid.
o A fall on an out-stretched hand with the
shoulder abducted and externally rotated, is
the most common mechanism of injury.
.(MCQ)
40. Dreamz Learning Innovations_____________________________________________ Page 40
o Occasionally, it results from a direct force
pushing the humerus head out of the glenoid
cavity.
o A posterior dislocation may result from
n a direct blow on the front of the shoulder,
driving the head backwards. (MCQ)
n More commonly as a consequence of an
electric shock or an epileptiform convulsion.
(MCQ)
42. Dreamz Learning Innovations_____________________________________________ Page 42
o Classification:
n Anterior dislocation
โข head of the humerus comes out of the
glenoid cavity and lies anteriorly.
โข further classified into three subtypes -
Preglenoid Subcoracoid(m.c) ,Subclavicular
nPosterior dislocation
nInferior dislocation
46. Dreamz Learning Innovations_____________________________________________ Page 46
o Pathological changes
in anterior dislocation
n Bankart's lesion:
(MCQ)
โข Dislocation causes
stripping of the
glenoidal labrum
along with the
periosteum from the
anterior surface of the
glenoid and scapular
neck.
47. โข The head comes to lie in front of the scapular neck, in
the pouch thereby created.
โข In severe injuries, it may be avulsion of a piece of
bone from antero-inferior glenoid rim, called bony
Bankart lesion.
Dreamz Learning Innovations_____________________________________________ Page 47
54. โข A BANKART LESION IS AN
INJURY OF THE ANTERIOR
(INFERIOR) GLENOID LABRUM
OF THE SHOULDER DUE TO
ANTERIOR SHOULDER
DISLOCATION. WHEN THIS
HAPPENS, A POCKET AT THE
FRONT OF THE GLENOID
FORMS THAT ALLOWS THE
HUMERAL HEAD TO
DISLOCATE INTO IT.
55. โข A BANKART LESION IS
AN INJURY OF
THE ANTERIOR (INFERIOR) G
LENOID LABRUM OF THE
SHOULDER DUE TO
ANTERIOR SHOULDER DISLO
CATION.
Dreamz Learning Innovations_____________________________________________ Page 55
58. โข A HillโSachs lesion, or HillโSachs
fracture, is a cortical depression in the
posterolateral head of the humerus.
โข It results from forceful impaction of
the humeral head against the antero-
inferior glenoid rim when the
shoulder is dislocated anteriorly
59. Reverse Hill-
Sachs lesion
โข REVERSE HILL-SACHS LESION,
ALSO CALLED
A MCLAUGHLIN LESION, IS
DEFINED AS AN IMPACTION
FRACTURE OF
ANTEROMEDIAL ASPECT OF
THE HUMERAL HEAD
FOLLOWING POSTERIOR
DISLOCATION OF
THE HUMERUS.
โข IT IS OF SURGICAL
IMPORTANCE TO IDENTIFY
THIS LESION AND CORRECT IT
TO PREVENT AVASCULAR
NECROSIS.
60.
61. Dreamz Learning Innovations_____________________________________________ Page 61
n Rounding off'of the anterior glenoid rim
(MCQ)
โข Occurs in chronic cases as the head
dislocates repeatedly over it.
n Associated injuries(MCQ)
โข Fracture of greater tuberosity
โข rotator-cuff tear,
โข chondral damage
62. Dreamz Learning Innovations_____________________________________________ Page 62
o Diagnosis
n Presenting complaints
โข patient enters the casualty with his shoulder
abducted and the elbow supported with
opposite hand(MCQ)
โข There is a history of a fall on an out-
stretched hand followed by pain and inability
to move the shoulder. (MCQ)
63. Dreamz Learning Innovations_____________________________________________ Page 63
n On examination:
โข The patient keeps his arm abducted(MCQ)
โข The normal round contour of the shoulder
joint is lost, and it becomes flattened. (MCQ)
โข On careful inspection, one may notice
fullness below the clavicle due to the
displaced head. This can be felt by rotating
the arm.
65. Dreamz Learning Innovations_____________________________________________ Page 65
His shoulder re-
located with in 5
seconds of giving
an anaesthetic
agent.
only applied
moderate traction
to the limb. In this
photograph, chest
arm strapping has
been done after re-
location of his
shoulder
67. โข Hamilton ruler
test: (MCQ)
o Because of the
flattening of the
shoulder, it is
possible to place
a ruler on the
lateral side of the
arm. that
touches the
acromion and
lateral condyle of
the humems
simultaneously.
Dreamz Learning Innovations_____________________________________________ Page 67
69. The diagnosis is easily confirmed on an antero-
posterior X-ray of the shoulder
o An axillary view is sometimes required. (MCQ)
Dreamz Learning Innovations_____________________________________________ Page 69
70. Dreamz Learning Innovations_____________________________________________ Page 70
o Treatment
n Acute dislocation
โข reduction under sedation or general
anaesthesia, followed by immobilisation of
the shoulder in a chest-arm bandage for
three weeks. (MCQ)
โข After the bandage is removed, shoulder
exercises are begun.
76. Dreamz Learning Innovations_____________________________________________ Page 76
o Complications
n Early complications: Injury to the axillary nerve
(MCQ)
โข result in paralysis of the deltoid muscle(MCQ)
โข result in a small area of anaesthesia over the
lateral aspect of the shoulder. (MCQ)
โข result in inability to abduct the shoulder. (MCQ)
โข Treatment is conservative, and the prognosis is
good.
n Late complications: recurrent dislocation
โข shoulder is the commonest joint to undergo
recurrent dislocation.
79. Dreamz Learning Innovations_____________________________________________ Page 79
n Operations for Recurrent shoulder
dislocation
โข Putti-Platt operation: (MCQ)
o Double-breasting of the
subscapularis tendon is performed
o It prevents external rotation and
abduction, thereby preventing
recurrences.
81. โข Bankart's operation: (MCQ)
o glenoid labrum and capsule are re-
attached to the front of the glenoid rim.
Dreamz Learning Innovations_____________________________________________ Page 81
82. Dreamz Learning Innovations_____________________________________________ Page 82
โข Bristow's operation: (MCQ)
o In this operation, the coracoid process, along
with its attached muscles, is osteotomized at
its base and fixed to lower-half of the
anterior margin of the glenoid.
o The muscles attached to the coracoid
provide a dynamic anterior support to the
head of the humerus.
85. BANKARTS REPAIR DETACHED ANTERIOR STRUCTURES ARE ATTACHED
TO RIM OF GLENOID WITH SUTURE
PUTTI PLATS OPERATION SUBSCAPULARIS TENDON AND CASPULE IS
OVERLAPPED AND TIGHTENED
LATARJET BRISTOW OPERATION CORACOID SHIFT TO ANTERIOR RIM OF GLENOID
NEERS CAPSULAR SHIFT M.D.I
FAILED RECONSTRUCTIONS GLENOID DEFICIENCY TREATED WITH
LATARJET/ILIAC BONE GRAFT
NEGLECTED SHOULDER DISLOCATION OPEN REDUCTION
Dreamz Learning Innovations_____________________________________________ Page 85
87. Dreamz Learning Innovations_____________________________________________ Page 87
@ most common mechanism of injury in
anterior shoulder disclocation
a) fall on an out-stretched hand with the
shoulder abducted and externally rotated
b) fall on an out-stretched hand with the
shoulder adducted and externally rotated
c) fall on an out-stretched hand with the
shoulder abducted and internally rotated
d) fall on an out-stretched hand with the
shoulder aducted and internally rotated
88. Dreamz Learning Innovations_____________________________________________ Page 88
@ A posterior dislocation is common in
a) fall on an out-stretched hand with the
shoulder abducted and externally rotated
b) a direct blow on the back of the shoulder
c) epileptiform convulsion
d) All of above
90. Dreamz Learning Innovations_____________________________________________ Page 90
@ False regarding anterior shoulder
disclocation except
a) patient keeps his arm adducted
b) normal round contour of the shoulder joint is
lost
c) fullness below the clavicle appear
d) patient shows Inability to touch the opposite
shoulder
92. Page 92
137. Most common joint to undergo recurrent
dislocation is- (PGMEE 2014)
a. Shoulder joint
b. Patella
c. Knee joint
d. Hip joint
93. Page 93
133. Puttiplat operation is done for- (PGMEE
2015)
a. Elbow instability
b. Shoulder instability
c. Rotator cuff tear
d. Biceps Tendinitis
Ans.b
94. Page 94
141. A 20-years old male presents with anterior
shoulder dislocation. This injury is usually
caused as a combination of which of the
following- (ARMS Nov 11)
a. Abduction & external rotation
b. Adduction & external rotation
c. Abduction & internal rotation
d. Adduction & internal rotation
95. Page 95
132. Treatment of choice of anterior dislocation
of shoulder:-
a. Physiotherapy(PGMEE 2016-17)
b. Reduction by Kocher's manoeuvre
c. Manipulation under general anaesthesia
d. Reduction followed by splinting
