Chronic osteomyelitis is a persistent bone infection that can develop after an initial bout of acute osteomyelitis is inadequately treated, allowing bacteria to remain in the bone. It is characterized by the formation of dead bone (sequestra) surrounded by infected granulation tissue, as well as abnormal thickening and irregularity of the bone. Chronic osteomyelitis is diagnosed based on symptoms like a discharging sinus, examination findings revealing irregular thickened bone, and confirmation via imaging tests showing features like sequestra and bone cavities. Treatment involves surgical removal of infected and dead bone along with antibiotics to eliminate the infection.

1. CHRONIC OSTEOMYLITIS

2. • Chronic pyogenic osteomyelitis
• Developing countries
• Other causes of chronic osteomyelitis are tuberculosis, fungal
infections
• Three types - secondary to acute osteomyelitis, Garre’s osteomyelitis ,
Brodie’s abscess
Chronic osteomyelitis

3. Acute to chronic
• Delayed and inadequate treatment - sequestrum formation - ‘non-
collapsing’ bone cavities and sequestra are responsible for persistent
infection
• Type and virulence of organism - highly virulent organism
• Reduced host resistance - Malnutrition compromises the body’s
defense mechanism

4. • Response to infection -host bone responds by generating more and
more sub-periosteal new bone
• Sub-periosteal bone is deposited in an irregular fashion
• Continuous discharge of pus results in the formation of a sinus
• With time the sinus tract gets fibrosed and the sinus becomes fixed to
the bone

18. Sequestrum
• Piece of dead bone
• Surrounded by infected granulation tissue trying to ‘eat’ the
sequestrum away
• appears pale and has a smooth inner and rough outer surface
• Outer roughness is due to constant erosion by the surrounding
granulation tissue

21. • Involucrum is the dense sclerotic bone overlying a sequestrum
• There may be some holes in the involucrum for pus to drain out -
cloacae
• The bony cavities are lined by infected granulation tissue

22. DIAGNOSIS
• Suspected clinically but can be confirmed radiologically
• The lower-end of the femur is the commonest site
• A chronic discharging sinus is the commonest presenting symptom
• Sinuses heal for short periods, only to reappear with each acute
exacerbation
• Discharge can vary from – sero purulent to thick pus
• Generalised symptoms of infection such as fever during acute
exacerbations

23. Examination
• Chronic discharging sinus - sinus fixed to the underlying bone
• Sprouting granulation tissue at its opening - indicating a sequestrum
within the bone
• Sequestrum may be visible at the mouth of the sinus itself
• Sinus may be surrounded by healed puckered scars
• Thickened, irregular bone
• Tenderness - on deep palpation, in some cases
• Adjacent joint – stiff,

24. INVESTIGATIONS
• Radiological examination - Thickening and irregularity of the cortices,
Patchy sclerosis, Bone cavity, Sequestrum (denser than the surrounding
normal), Involucrum and cloacae
• Sinogram - sterile thin catheter is introduced into the sinus as far as it can
go, radio-opaque dye is injected, X-rays taken
• CT scan and MRI
• Blood , Pus

25. DIFFERENTIAL DIAGNOSIS
• Tubercular osteomyelitis
• Soft tissue infection
• Ewing’s sarcoma

26. TREATMENT
• Principles of treatment - primarily surgical
• Antibiotic – during acute stage and post operative period
• Aim of surgical intervention - removal of dead bone- elimination of dead
space and cavities - removal of infected granulation tissue and sinuses
• Operative procedures – Sequestrectomy, Saucerisation, Curettage, Excision
of an infected bone, Amputation
• After surgery the wound is closed over a continuous suction irrigation
system

28. COMPLICATIONS
• An acute exacerbation or ‘flare up’ of the infection
• Growth abnormalities – Shortening, Lengthening, Deformities
• Pathological fracture
• Joint stiffness
• Sinus tract malignancy
• Amyloidosis

31. SHOULDER DISLOCATION
30.04

33. • SUBGLENOID POSITION IN AXILLA
• LUXATIO ERECTA---HUMERAL HEAD IS SUBLUXATED INFERIORLY & SHAFT POINTS
ERECTED UPWARDS
• ARM IS LOCKED IN ALMOST FULL ABDUCTION/ELEVATION
• ARM FIXED BY THE SIDE OF HEAD
• MAXIMUM NEURO VASCULAR DAMAGE( AXILLARY N):60%
• TREATMENT: REDUCED BY PULLING UPWARDS IN LINE OF ABDUCTED ARM WITH
DOWNWARD COUNTER TRACTION

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Dislocation of the shoulder
A very High yield topic for MD Entrance

36. • ANT DISLOCATION MC
• SUB CORACOID MC
• MOI: ER /HORIZONTAL ABD FORCE ON HUMERUS
• DIRECT POST BLOW ON SHOULDER
• BANKART LESION
• HILL SACH LESION

37. CLINICAL FEATURES
• ABD,ER, AND EXTENSION ATTITUDE
• HELD IN SLIGHTLY ABD HANGING BY THE SIDE OF BODY
• NORMAL CONTOUR LOST
• BULGE BELOW CLAVICLE
• DUGAS TEST, CALLWAY TEST AND HAMILTON RULER TEST
• AP XRAY: OVERLAPPING SHADOW OF HUMERAL HEAD AND
GLENOID FOSSA
• REDUCTION:
KOCHERS METHOD(TEAR),STIMSON METHOD,HIPPOCRATIC
METHOD

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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)

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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)

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o Classification:
n Anterior dislocation
• head of the humerus comes out of the
glenoid cavity and lies anteriorly.
• further classified into three subtypes -
Preglenoid Subcoracoid(m.c) ,Subclavicular
nPosterior dislocation
nInferior dislocation

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o Pathological changes
in anterior dislocation
n Bankart's lesion:
(MCQ)
• Dislocation causes
stripping of the
glenoidal labrum
along with the
periosteum from the
anterior surface of the
glenoid and scapular
neck.

47. • The head comes to lie in front of the scapular neck, in
the pouch thereby created.
• In severe injuries, it may be avulsion of a piece of
bone from antero-inferior glenoid rim, called bony
Bankart lesion.
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54. • 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. • A BANKART LESION IS
AN INJURY OF
THE ANTERIOR (INFERIOR) G
LENOID LABRUM OF THE
SHOULDER DUE TO
ANTERIOR SHOULDER DISLO
CATION.
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n Hill-Sachs lesion: (MCQ)
• a depression on the humeral head in its
postero-lateral quadrant
• caused by impingement by the anterior edge
of the glenoid on the head as it dislocates.

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58. • A Hill–Sachs lesion, or Hill–Sachs
fracture, is a cortical depression in the
posterolateral head of the humerus.
• 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
• 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.
• IT IS OF SURGICAL
IMPORTANCE TO IDENTIFY
THIS LESION AND CORRECT IT
TO PREVENT AVASCULAR
NECROSIS.

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n Rounding off'of the anterior glenoid rim
(MCQ)
• Occurs in chronic cases as the head
dislocates repeatedly over it.
n Associated injuries(MCQ)
• Fracture of greater tuberosity
• rotator-cuff tear,
• chondral damage

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o Diagnosis
n Presenting complaints
• patient enters the casualty with his shoulder
abducted and the elbow supported with
opposite hand(MCQ)
• There is a history of a fall on an out-
stretched hand followed by pain and inability
to move the shoulder. (MCQ)

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n On examination:
• The patient keeps his arm abducted(MCQ)
• The normal round contour of the shoulder
joint is lost, and it becomes flattened. (MCQ)
• On careful inspection, one may notice
fullness below the clavicle due to the
displaced head. This can be felt by rotating
the arm.

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40 year male who
has a right
shoulder
dislocation. He is
supporting his
right limb with his
left hand. You
can also see the
loss of contour
of the right upper
arm

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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

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n signs, associated with anterior dislocation
• Dugas' test: (MCQ)
• Inability to touch the opposite shoulder.

67. • 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.
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69. The diagnosis is easily confirmed on an antero-
posterior X-ray of the shoulder
o An axillary view is sometimes required. (MCQ)
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o Treatment
n Acute dislocation
• reduction under sedation or general
anaesthesia, followed by immobilisation of
the shoulder in a chest-arm bandage for
three weeks. (MCQ)
• After the bandage is removed, shoulder
exercises are begun.

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• A fracture of the
greater tuberosity
o often associated
with an anterior
dislocation
o usually comes
back to its
position as the
head is reduced
o needs no special
treatment. (MCQ)

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o Complications
n Early complications: Injury to the axillary nerve
(MCQ)
• result in paralysis of the deltoid muscle(MCQ)
• result in a small area of anaesthesia over the
lateral aspect of the shoulder. (MCQ)
• result in inability to abduct the shoulder. (MCQ)
• Treatment is conservative, and the prognosis is
good.
n Late complications: recurrent dislocation
• shoulder is the commonest joint to undergo
recurrent dislocation.

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o Recurrent shoulder
dislocation.
n Causes (MCQ)
• anatomically unstable
joint
• Marfan's syndrome
• inadequate healing
after the first
dislocation
• an epileptic patient.

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n Operations for Recurrent shoulder
dislocation
• Putti-Platt operation: (MCQ)
o Double-breasting of the
subscapularis tendon is performed
o It prevents external rotation and
abduction, thereby preventing
recurrences.

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81. • Bankart's operation: (MCQ)
o glenoid labrum and capsule are re-
attached to the front of the glenoid rim.
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• 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.

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84. • Arthroscopic Bankart repair
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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
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4.Shoulder dislocation MCQs
@ commonest joint in the human body to
dislocate
a) Hip
b) Shoulder
c) Knee
d) Ankle

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@ 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

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@ 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

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@ a depression on the humeral head in its
postero-lateral quadrant in shoulder
dislocation is called
a) Bankart's lesion
b) Hill-Sachs lesion
c) Mc murray’s sign
d) Hingarani sign

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@ 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

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@ Injury to the ------- nerve occur in anterior
shoulder disclocation
a) radial nerve
b) axillary nerve
c) median nerve
d) musculocutaneous nerve

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137. Most common joint to undergo recurrent
dislocation is- (PGMEE 2014)
a. Shoulder joint
b. Patella
c. Knee joint
d. Hip joint

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133. Puttiplat operation is done for- (PGMEE
2015)
a. Elbow instability
b. Shoulder instability
c. Rotator cuff tear
d. Biceps Tendinitis
Ans.b

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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

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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