1. Tuberculosis of the spine, also known as Pott's disease, is the most common form of skeletal tuberculosis. It accounts for 50% of all bone and joint tuberculosis cases.
2. Characteristic features on radiology include destruction of the intervertebral disc space and adjacent vertebral bodies, resulting in collapse and kyphotic deformity.
3. Treatment involves a prolonged course of multi-drug anti-tuberculosis therapy to prevent neurological complications and disabling deformities. With modern treatment, patients can often heal with minimal residual deformity.
Principle of tension band wiring n its applicationRohit Kansal
1. The tension band technique converts tensile forces into compressive forces through the application of a tension band on the tension side of a bone.
2. Examples of where tension band fixation is commonly used include patella and olecranon fractures, as well as fractures of the greater tuberosity and greater trochanter.
3. Tension band wiring, plating, and external fixation can all function as tension bands by applying a compressive force across a fracture to promote healing.
This document discusses knee dislocations, including their epidemiology, stabilizers of the knee joint, clinical features, associated injuries, imaging, and classifications. It also reviews treatment indications and options for knee dislocations, such as early open repair, acute reconstruction, staged reconstruction, and use of an external fixator. Complications include stiffness, which can be addressed through early range of motion exercises and manipulation if needed.
Tuberculosis is a common infection that can involve bones and joints. The spine is the most common site affected, accounting for about 50% of cases. Symptoms include constitutional symptoms like fever as well as localized pain, stiffness, and deformity. Diagnosis involves imaging like x-rays, CT, or MRI as well as tests like tuberculin skin tests or sputum/synovial fluid analysis. Treatment involves chemotherapy and sometimes surgery to treat deformities, abscesses, or neurological complications. The goal is to heal the infection and achieve a good functional outcome.
This document discusses nonunion fractures, including definitions, causes, classification, evaluation, and management. Some key points:
- Nonunion occurs when a fracture fails to heal in the expected time and is unlikely to heal without further intervention. Delayed union is when healing is delayed but still possible with treatment.
- Causes of nonunion include poor vascularity, instability, infection, and patient factors like smoking or diabetes. Types of nonunion include hypertrophic, atrophic, necrotic, and defect.
- Evaluation involves standard radiographs and stress views. Treatment includes non-operative options like bracing or stimulation, or operative options like plating, nailing, bone grafting, and correction
This document discusses neck of femur fractures (NOF), also known as hip fractures. It covers the epidemiology, risk factors, anatomy, classification, diagnosis, and treatment of NOF fractures. NOF fractures typically occur in elderly patients from low-energy falls and are associated with osteoporosis, while in younger patients they usually result from high-energy injuries. Treatment depends on factors like the patient's age, health, and fracture classification, and may involve closed or open reduction, fixation with screws or nails, or arthroplasty. Complications can include nonunion, osteonecrosis, fixation failure, dislocation, and increased mortality risk especially in older or less healthy patients.
Cubitus varus is a deformity of the elbow where there is a decreased carrying angle, causing the forearm to deviate medially when extended. It is commonly caused by malunion of a supracondylar fracture of the humerus in children. Corrective options include observation with expected remodeling, hemiepiphysiodesis to alter growth, and corrective osteotomy. The French osteotomy technique involves a lateral closed wedge osteotomy held with screws or wires and remains a popular surgical approach. Complications can include stiffness, nerve injuries, recurrent deformity, nonunion and malunion.
The hip joint is a ball and socket synovial joint that connects the femur to the acetabulum. It is the largest and most stable joint in the body. The hip joint allows for flexion, extension, abduction, adduction, and rotation. Several strong ligaments reinforce the hip joint capsule to provide stability, including the iliofemoral, ischiofemoral, and pubofemoral ligaments. The main muscles that act on the hip joint are the gluteal muscles, iliopsoas, quadriceps femoris, hamstrings, and adductors.
Tuberculosis of the hip joint is the second most common site of bone and joint TB after the spine. It typically affects people in their first three decades of life. The infection spreads from a primary focus such as the lungs to the hip joint via the bloodstream. It can initially involve different areas of the hip and pelvis before spreading to the joint. Patients present with hip pain, limping, and constitutional symptoms. Treatment involves anti-TB drugs along with rest, traction, and surgery if needed to address complications like joint destruction and deformity. Surgical options depend on the stage of disease and can include synovectomy, arthrodesis, osteotomy, or arthroplasty.
Principle of tension band wiring n its applicationRohit Kansal
1. The tension band technique converts tensile forces into compressive forces through the application of a tension band on the tension side of a bone.
2. Examples of where tension band fixation is commonly used include patella and olecranon fractures, as well as fractures of the greater tuberosity and greater trochanter.
3. Tension band wiring, plating, and external fixation can all function as tension bands by applying a compressive force across a fracture to promote healing.
This document discusses knee dislocations, including their epidemiology, stabilizers of the knee joint, clinical features, associated injuries, imaging, and classifications. It also reviews treatment indications and options for knee dislocations, such as early open repair, acute reconstruction, staged reconstruction, and use of an external fixator. Complications include stiffness, which can be addressed through early range of motion exercises and manipulation if needed.
Tuberculosis is a common infection that can involve bones and joints. The spine is the most common site affected, accounting for about 50% of cases. Symptoms include constitutional symptoms like fever as well as localized pain, stiffness, and deformity. Diagnosis involves imaging like x-rays, CT, or MRI as well as tests like tuberculin skin tests or sputum/synovial fluid analysis. Treatment involves chemotherapy and sometimes surgery to treat deformities, abscesses, or neurological complications. The goal is to heal the infection and achieve a good functional outcome.
This document discusses nonunion fractures, including definitions, causes, classification, evaluation, and management. Some key points:
- Nonunion occurs when a fracture fails to heal in the expected time and is unlikely to heal without further intervention. Delayed union is when healing is delayed but still possible with treatment.
- Causes of nonunion include poor vascularity, instability, infection, and patient factors like smoking or diabetes. Types of nonunion include hypertrophic, atrophic, necrotic, and defect.
- Evaluation involves standard radiographs and stress views. Treatment includes non-operative options like bracing or stimulation, or operative options like plating, nailing, bone grafting, and correction
This document discusses neck of femur fractures (NOF), also known as hip fractures. It covers the epidemiology, risk factors, anatomy, classification, diagnosis, and treatment of NOF fractures. NOF fractures typically occur in elderly patients from low-energy falls and are associated with osteoporosis, while in younger patients they usually result from high-energy injuries. Treatment depends on factors like the patient's age, health, and fracture classification, and may involve closed or open reduction, fixation with screws or nails, or arthroplasty. Complications can include nonunion, osteonecrosis, fixation failure, dislocation, and increased mortality risk especially in older or less healthy patients.
Cubitus varus is a deformity of the elbow where there is a decreased carrying angle, causing the forearm to deviate medially when extended. It is commonly caused by malunion of a supracondylar fracture of the humerus in children. Corrective options include observation with expected remodeling, hemiepiphysiodesis to alter growth, and corrective osteotomy. The French osteotomy technique involves a lateral closed wedge osteotomy held with screws or wires and remains a popular surgical approach. Complications can include stiffness, nerve injuries, recurrent deformity, nonunion and malunion.
The hip joint is a ball and socket synovial joint that connects the femur to the acetabulum. It is the largest and most stable joint in the body. The hip joint allows for flexion, extension, abduction, adduction, and rotation. Several strong ligaments reinforce the hip joint capsule to provide stability, including the iliofemoral, ischiofemoral, and pubofemoral ligaments. The main muscles that act on the hip joint are the gluteal muscles, iliopsoas, quadriceps femoris, hamstrings, and adductors.
Tuberculosis of the hip joint is the second most common site of bone and joint TB after the spine. It typically affects people in their first three decades of life. The infection spreads from a primary focus such as the lungs to the hip joint via the bloodstream. It can initially involve different areas of the hip and pelvis before spreading to the joint. Patients present with hip pain, limping, and constitutional symptoms. Treatment involves anti-TB drugs along with rest, traction, and surgery if needed to address complications like joint destruction and deformity. Surgical options depend on the stage of disease and can include synovectomy, arthrodesis, osteotomy, or arthroplasty.
This document discusses various osteotomies around the hip joint. It begins with defining osteotomy and providing a brief history of important developments. It then explains the biomechanics of the hip joint and why osteotomies are effective. Several types and classifications of osteotomies are outlined. Specific procedures like McMurray's displacement osteotomy, Pauwel's varus osteotomy, and Schanz angulation osteotomy are described in detail. Contraindications and postoperative care are also mentioned.
This document discusses nonunion of femoral neck fractures, which have a higher incidence in young patients compared to elderly patients. It defines nonunion and outlines the vascular anatomy and causes of nonunion. Classification systems for femoral neck fractures are described. Symptoms, investigations, and radiographic signs of nonunion are provided. Treatment options are discussed, including head-salvaging versus head-sacrificing procedures based on factors like patient age and viability of the femoral head. The Sandhu classification system for staging nonunion is presented along with recommended treatment approaches for each stage.
This document provides an overview of Legg Calve Perthes disease, including its definition, demographics, risk factors, pathogenesis, clinical features, investigations, classifications, management, and surgical procedures. Some key points:
- It is avascular necrosis of the femoral head in children, most common in ages 4-8 years. Positive family history and low birth weight are risk factors.
- Clinical features include hip/thigh pain aggravated by movement. Imaging shows stages from avascular necrosis to fragmentation to regeneration/healing.
- Conservative management includes bracing for young/mild cases. Surgical containment is used for more severe/older cases to encourage spherical remodeling.
- Procedures
This document discusses the anatomy, classification, causes, investigation, and treatment of non-union of femoral neck fractures. It begins with an introduction describing the anatomy of the femoral neck blood supply. It then describes Sandhu's classification system for neglected femoral neck fractures into 3 stages based on radiological findings. Common causes of non-union are discussed. Investigation methods like x-rays, CT, MRI, and bone scans are outlined. Treatment options aim to either preserve the femoral head through procedures like valgus osteotomy and bone grafting, or sacrifice the head through arthroplasty. Head preserving procedures like valgus osteotomy, muscle pedicle bone grafting, and cortical/cancellous grafting are detailed.
1) Tuberculosis of the knee joint is the third most common site of osteoarticular tuberculosis, accounting for around 10% of skeletal tuberculosis cases.
2) Initial pathology involves hematogenous spread to the synovium or subchondral bone, forming tubercles. Advanced cases involve erosion of joint surfaces and destruction of bones.
3) Clinical features include knee swelling, warmth, effusion, tenderness, and restricted painful movement. Advanced cases develop triple deformity of flexion, adduction, and internal rotation.
This document discusses septic arthritis of the hip in children. It defines septic arthritis and notes that the hip is the most commonly infected joint in children. Early diagnosis and treatment is important to prevent joint damage. Signs include limping, groin pain, and limited hip movement. Treatment involves identifying the organism, administering sensitive antibiotics, and potentially surgery. Long term sequelae can include joint deformities, leg length discrepancies, and arthritis. Various classification systems and treatment approaches are presented. Prevention of septic arthritis through early diagnosis and management is emphasized.
Legg - Calve - Perthes disease is a self-limiting disorder of the hip caused by reduced blood flow and necrosis of the femoral head. It most commonly affects boys ages 4-8 and is characterized by pain and limping. While the exact cause is unknown, factors such as blood clotting disorders, abnormal arterial or venous blood flow, growth delays, trauma, genetics, and environmental influences may play a role in reducing blood supply to the femoral head. Treatment aims to allow the femoral head to remodel itself through non-weight bearing or minimal weight bearing methods.
This document discusses the clinical examination of the hip joint, including inspection, palpation, range of motion testing, special tests, and gait analysis. Key examination findings are described for various hip pathologies like developmental dysplasia of the hip, arthritis, fractures, and dislocations. Landmark bony anatomy, compensations, and fallacies of certain examination maneuvers are also outlined.
Idiopathic chondrolysis of the hip is a rare condition characterized by the destruction of articular cartilage in the hip of unknown cause, mainly affecting adolescent females. It presents with insidious hip, thigh, or knee pain and radiographic evidence of joint space narrowing. While the etiology is unknown, theories include abnormal cartilage metabolism triggered by an environmental event, abnormal intra-articular pressure, or mechanical insult to the cartilage. Treatment focuses on NSAIDs, protected weight bearing, range of motion exercises, and in some cases surgery such as distraction arthroplasty or arthroplasty.
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
This document discusses several types of hand injuries including Bennett's fracture, Rolando's fracture, and tendon injuries. Bennett's fracture is a fracture of the base of the first metacarpal bone that extends into the carpometacarpal joint, often accompanied by subluxation or dislocation. Rolando's fracture is an intra-articular fracture of the base of the first metacarpal bone that extends into the carpometacarpal joint. Tendon injuries can involve the flexor or extensor tendons and are classified based on the zone of injury. Treatment depends on the specific injury but may involve closed or open reduction, internal fixation, splinting, or surgery.
1. This document discusses hip fractures, specifically subtrochanteric fractures. It notes that 10-30% of hip fractures are subtrochanteric and they have a bimodal age distribution in those 20-40 years old from high-energy injuries and those over 60 from low-energy falls.
2. It reviews treatment options for subtrochanteric fractures including traction, extramedullary fixation with plates, and intramedullary fixation with nails. Intramedullary nails are preferred as they better resist axial loads and torsion compared to plates.
3. Complications of treatment include infection, malunion, nonunion, and implant failure. Proper reduction and fixation are important to
This document summarizes information about congenital pseudoarthrosis of the tibia (CPT), including:
1. CPT is characterized by a spontaneous fracture that heals poorly, often associated with anterolateral bowing of the tibia. While the term is a misnomer, an alternative name has not been established.
2. Key aspects of CPT include nonunion of a tibial fracture that develops spontaneously or after minor trauma in a dysplastic bone segment. It usually develops in the first two years of life and commonly affects the tibia and fibula.
3. Treatment approaches aim to achieve union at the fracture site while preventing refracture, correcting limb length inequality and growth abnormalities, and preventing
The document provides information on clinical examination of the hip joint. It begins with anatomy of the hip joint and associated muscles and ligaments. It then discusses elements of history taking including pain characteristics. The physical examination section covers inspection of gait, limb posture and length, palpation of bony landmarks and muscles, range of motion testing, and special tests like Trendelenburg test. Measurements of limb length discrepancies both apparent and true are also described.
1. The document summarizes a seminar on tuberculosis of the hip joint. It discusses the history, epidemiology, pathogenesis, clinical features, stages, differential diagnosis, investigations and management of tuberculosis of the hip. 2. Key points include that tuberculosis of the hip is caused by Mycobacterium tuberculosis and spreads hematogenously from a primary focus. It presents with limping and pain and progresses through stages of synovitis, arthritis, advanced arthritis and destruction of the joint. Investigations include hematological tests, radiology and synovial fluid analysis.
The document discusses classifications and treatment approaches for subtrochanteric fractures of the femur. It describes Fielding and Seinsheimer classifications which categorize fractures based on their location and number of fragments. Temporary options include a Thomas splint for unstable patients. Surgical treatments involve plates, intramedullary nails, or external fixators. Precise surgical approaches depend on the fracture location and stability. Potential complications are also noted.
This document provides information on congenital pseudarthrosis of the tibia (CPT), including:
- CPT is a nonunion of the tibia that develops spontaneously in early life and is associated with bowing of the tibia. It occurs more commonly in patients with neurofibromatosis type 1.
- Surgical treatment aims to completely excise fibrous tissue, correct deformity, stimulate bone healing, and properly fix bone fragments. Options include bone grafting, internal fixation, Ilizarov fixation, vascularized fibular grafting, and amputation in severe cases.
- Classification systems divide CPT into types based on clinical features and radiographic findings to help determine prognosis and guide treatment
This document discusses mallet finger injuries, which involve disruption of the extensor tendon mechanism at the distal interphalangeal joint. It covers the anatomy of the finger extensor mechanism, classification of mallet finger injuries, clinical evaluation, treatment options including nonsurgical management with splinting and surgical repair or fixation, and management approaches for different types of acute mallet finger injuries.
This document discusses congenital vertical talus (CVT), a rare foot deformity. It begins by defining CVT and providing background information. It then describes the anatomy and pathoanatomy of CVT. Key points include that CVT results in an almost vertical talus bone and rigid flatfoot deformity. Treatment involves serial casting and manipulation to prepare for surgery, with the goal of restoring normal anatomical relationships in the foot. Surgical techniques described include open reduction and percutaneous fixation of the talonavicular joint with K-wires. Complications of surgery can include wound issues and stiffness.
This document provides an overview of tuberculosis (TB) of the spine and Pott's paraplegia. It discusses the microbiology of Mycobacterium tuberculosis, predisposing factors for spinal TB, the surgical anatomy of the spine, pathology and signs/symptoms of spinal TB. Diagnosis involves clinical features, lab investigations like ESR, imaging studies. Treatment involves managing any Pott's paraplegia as well as surgical or nonsurgical management of the spinal TB.
Pott's disease- tuberculosis of the spineSummu Thakur
This document provides information about Pott's disease (spinal tuberculosis), including its epidemiology, sites of involvement within the spine, routes of infection and spread, clinical features, neurological complications, and classifications of spinal cord involvement. Some key points are:
- Spinal tuberculosis most commonly involves the lower thoracic and upper lumbar vertebrae.
- It spreads via hematogenous or lymphatic routes from a primary infection, most often in the lungs or abdominal lymph nodes.
- Clinical features include chronic back pain, stiffness, deformity and cold abscesses. Advanced cases can cause paraplegia from spinal cord compression.
- Paraplegia is most common when the thoracic spine is involved due to the
This document discusses various osteotomies around the hip joint. It begins with defining osteotomy and providing a brief history of important developments. It then explains the biomechanics of the hip joint and why osteotomies are effective. Several types and classifications of osteotomies are outlined. Specific procedures like McMurray's displacement osteotomy, Pauwel's varus osteotomy, and Schanz angulation osteotomy are described in detail. Contraindications and postoperative care are also mentioned.
This document discusses nonunion of femoral neck fractures, which have a higher incidence in young patients compared to elderly patients. It defines nonunion and outlines the vascular anatomy and causes of nonunion. Classification systems for femoral neck fractures are described. Symptoms, investigations, and radiographic signs of nonunion are provided. Treatment options are discussed, including head-salvaging versus head-sacrificing procedures based on factors like patient age and viability of the femoral head. The Sandhu classification system for staging nonunion is presented along with recommended treatment approaches for each stage.
This document provides an overview of Legg Calve Perthes disease, including its definition, demographics, risk factors, pathogenesis, clinical features, investigations, classifications, management, and surgical procedures. Some key points:
- It is avascular necrosis of the femoral head in children, most common in ages 4-8 years. Positive family history and low birth weight are risk factors.
- Clinical features include hip/thigh pain aggravated by movement. Imaging shows stages from avascular necrosis to fragmentation to regeneration/healing.
- Conservative management includes bracing for young/mild cases. Surgical containment is used for more severe/older cases to encourage spherical remodeling.
- Procedures
This document discusses the anatomy, classification, causes, investigation, and treatment of non-union of femoral neck fractures. It begins with an introduction describing the anatomy of the femoral neck blood supply. It then describes Sandhu's classification system for neglected femoral neck fractures into 3 stages based on radiological findings. Common causes of non-union are discussed. Investigation methods like x-rays, CT, MRI, and bone scans are outlined. Treatment options aim to either preserve the femoral head through procedures like valgus osteotomy and bone grafting, or sacrifice the head through arthroplasty. Head preserving procedures like valgus osteotomy, muscle pedicle bone grafting, and cortical/cancellous grafting are detailed.
1) Tuberculosis of the knee joint is the third most common site of osteoarticular tuberculosis, accounting for around 10% of skeletal tuberculosis cases.
2) Initial pathology involves hematogenous spread to the synovium or subchondral bone, forming tubercles. Advanced cases involve erosion of joint surfaces and destruction of bones.
3) Clinical features include knee swelling, warmth, effusion, tenderness, and restricted painful movement. Advanced cases develop triple deformity of flexion, adduction, and internal rotation.
This document discusses septic arthritis of the hip in children. It defines septic arthritis and notes that the hip is the most commonly infected joint in children. Early diagnosis and treatment is important to prevent joint damage. Signs include limping, groin pain, and limited hip movement. Treatment involves identifying the organism, administering sensitive antibiotics, and potentially surgery. Long term sequelae can include joint deformities, leg length discrepancies, and arthritis. Various classification systems and treatment approaches are presented. Prevention of septic arthritis through early diagnosis and management is emphasized.
Legg - Calve - Perthes disease is a self-limiting disorder of the hip caused by reduced blood flow and necrosis of the femoral head. It most commonly affects boys ages 4-8 and is characterized by pain and limping. While the exact cause is unknown, factors such as blood clotting disorders, abnormal arterial or venous blood flow, growth delays, trauma, genetics, and environmental influences may play a role in reducing blood supply to the femoral head. Treatment aims to allow the femoral head to remodel itself through non-weight bearing or minimal weight bearing methods.
This document discusses the clinical examination of the hip joint, including inspection, palpation, range of motion testing, special tests, and gait analysis. Key examination findings are described for various hip pathologies like developmental dysplasia of the hip, arthritis, fractures, and dislocations. Landmark bony anatomy, compensations, and fallacies of certain examination maneuvers are also outlined.
Idiopathic chondrolysis of the hip is a rare condition characterized by the destruction of articular cartilage in the hip of unknown cause, mainly affecting adolescent females. It presents with insidious hip, thigh, or knee pain and radiographic evidence of joint space narrowing. While the etiology is unknown, theories include abnormal cartilage metabolism triggered by an environmental event, abnormal intra-articular pressure, or mechanical insult to the cartilage. Treatment focuses on NSAIDs, protected weight bearing, range of motion exercises, and in some cases surgery such as distraction arthroplasty or arthroplasty.
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
This document discusses several types of hand injuries including Bennett's fracture, Rolando's fracture, and tendon injuries. Bennett's fracture is a fracture of the base of the first metacarpal bone that extends into the carpometacarpal joint, often accompanied by subluxation or dislocation. Rolando's fracture is an intra-articular fracture of the base of the first metacarpal bone that extends into the carpometacarpal joint. Tendon injuries can involve the flexor or extensor tendons and are classified based on the zone of injury. Treatment depends on the specific injury but may involve closed or open reduction, internal fixation, splinting, or surgery.
1. This document discusses hip fractures, specifically subtrochanteric fractures. It notes that 10-30% of hip fractures are subtrochanteric and they have a bimodal age distribution in those 20-40 years old from high-energy injuries and those over 60 from low-energy falls.
2. It reviews treatment options for subtrochanteric fractures including traction, extramedullary fixation with plates, and intramedullary fixation with nails. Intramedullary nails are preferred as they better resist axial loads and torsion compared to plates.
3. Complications of treatment include infection, malunion, nonunion, and implant failure. Proper reduction and fixation are important to
This document summarizes information about congenital pseudoarthrosis of the tibia (CPT), including:
1. CPT is characterized by a spontaneous fracture that heals poorly, often associated with anterolateral bowing of the tibia. While the term is a misnomer, an alternative name has not been established.
2. Key aspects of CPT include nonunion of a tibial fracture that develops spontaneously or after minor trauma in a dysplastic bone segment. It usually develops in the first two years of life and commonly affects the tibia and fibula.
3. Treatment approaches aim to achieve union at the fracture site while preventing refracture, correcting limb length inequality and growth abnormalities, and preventing
The document provides information on clinical examination of the hip joint. It begins with anatomy of the hip joint and associated muscles and ligaments. It then discusses elements of history taking including pain characteristics. The physical examination section covers inspection of gait, limb posture and length, palpation of bony landmarks and muscles, range of motion testing, and special tests like Trendelenburg test. Measurements of limb length discrepancies both apparent and true are also described.
1. The document summarizes a seminar on tuberculosis of the hip joint. It discusses the history, epidemiology, pathogenesis, clinical features, stages, differential diagnosis, investigations and management of tuberculosis of the hip. 2. Key points include that tuberculosis of the hip is caused by Mycobacterium tuberculosis and spreads hematogenously from a primary focus. It presents with limping and pain and progresses through stages of synovitis, arthritis, advanced arthritis and destruction of the joint. Investigations include hematological tests, radiology and synovial fluid analysis.
The document discusses classifications and treatment approaches for subtrochanteric fractures of the femur. It describes Fielding and Seinsheimer classifications which categorize fractures based on their location and number of fragments. Temporary options include a Thomas splint for unstable patients. Surgical treatments involve plates, intramedullary nails, or external fixators. Precise surgical approaches depend on the fracture location and stability. Potential complications are also noted.
This document provides information on congenital pseudarthrosis of the tibia (CPT), including:
- CPT is a nonunion of the tibia that develops spontaneously in early life and is associated with bowing of the tibia. It occurs more commonly in patients with neurofibromatosis type 1.
- Surgical treatment aims to completely excise fibrous tissue, correct deformity, stimulate bone healing, and properly fix bone fragments. Options include bone grafting, internal fixation, Ilizarov fixation, vascularized fibular grafting, and amputation in severe cases.
- Classification systems divide CPT into types based on clinical features and radiographic findings to help determine prognosis and guide treatment
This document discusses mallet finger injuries, which involve disruption of the extensor tendon mechanism at the distal interphalangeal joint. It covers the anatomy of the finger extensor mechanism, classification of mallet finger injuries, clinical evaluation, treatment options including nonsurgical management with splinting and surgical repair or fixation, and management approaches for different types of acute mallet finger injuries.
This document discusses congenital vertical talus (CVT), a rare foot deformity. It begins by defining CVT and providing background information. It then describes the anatomy and pathoanatomy of CVT. Key points include that CVT results in an almost vertical talus bone and rigid flatfoot deformity. Treatment involves serial casting and manipulation to prepare for surgery, with the goal of restoring normal anatomical relationships in the foot. Surgical techniques described include open reduction and percutaneous fixation of the talonavicular joint with K-wires. Complications of surgery can include wound issues and stiffness.
This document provides an overview of tuberculosis (TB) of the spine and Pott's paraplegia. It discusses the microbiology of Mycobacterium tuberculosis, predisposing factors for spinal TB, the surgical anatomy of the spine, pathology and signs/symptoms of spinal TB. Diagnosis involves clinical features, lab investigations like ESR, imaging studies. Treatment involves managing any Pott's paraplegia as well as surgical or nonsurgical management of the spinal TB.
Pott's disease- tuberculosis of the spineSummu Thakur
This document provides information about Pott's disease (spinal tuberculosis), including its epidemiology, sites of involvement within the spine, routes of infection and spread, clinical features, neurological complications, and classifications of spinal cord involvement. Some key points are:
- Spinal tuberculosis most commonly involves the lower thoracic and upper lumbar vertebrae.
- It spreads via hematogenous or lymphatic routes from a primary infection, most often in the lungs or abdominal lymph nodes.
- Clinical features include chronic back pain, stiffness, deformity and cold abscesses. Advanced cases can cause paraplegia from spinal cord compression.
- Paraplegia is most common when the thoracic spine is involved due to the
This document provides information on Potts spine, including its pathophysiology and management principles. It discusses how tuberculosis spreads to the spinal column, causing destruction of vertebral bodies and discs, collapse, and deformity. Risk factors, symptoms, investigations, classifications of lesions and paraplegia, medical management using antitubercular therapy, and indications for surgical treatment are summarized. The goals of surgery are decompression, deformity correction, and spinal stabilization.
Pott's disease, or tuberculosis of the spine, is an extrapulmonary form of tuberculosis that infects the spine. It was first described in 1779 by Sir Percival Pott. Infection can spread to the spine hematogenously or contiguously from other sites. This leads to destruction of vertebral bodies and discs, causing spinal deformities like kyphosis. Advanced cases can cause paraplegia through cord compression. Diagnosis involves imaging and microbiological tests. Prompt treatment is needed to prevent neurological deficits and deformities.
Spinal tuberculosis and spinal infectionsVijay Anand
Tuberculosis of the spinal column, also known as Pott's disease, is caused by infection with Mycobacterium tuberculosis bacteria. It most commonly affects the lower thoracic and thoracolumbar regions of the spine. Clinical features include back pain, spinal deformity, and possible paralysis. Diagnosis involves x-rays, CT scans, MRI, and microbiological testing. Treatment consists of a lengthy multi-drug antibiotic regimen lasting 18 months or longer to prevent disability and complications like abscesses. Proper treatment is important to avoid development of multi-drug resistant tuberculosis strains.
This document provides information on tuberculosis of the skeletal system (Potts disease). It discusses the history, epidemiology, pathogenesis, clinical presentation, investigations including imaging findings, microbiological studies, treatment including medical management and surgical options, as well as outcomes of skeletal tuberculosis. Key points include that India accounts for a large portion of global tuberculosis cases, it most commonly involves the thoracic spine, and treatment involves a combination of anti-tubercular medications and surgery in some cases to address complications or deformities.
Pathophysiologic aspects, clinical manifestation a nd management ofSushant Yadav
The examiner passively abducts the patient's shoulder to 90 degrees, flexes the elbow to 90 degrees, and positions the forearm in neutral. The examiner then applies a gentle, sustained posteroanterior glide to the wrist while maintaining the shoulder and elbow positions.
- A positive test reproduces symptoms in the median nerve distribution.
- This test is useful for evaluating cervical radiculopathy involving C6 nerve root as it innervates the median nerve. A positive test suggests nerve root compression.
- The test is considered positive if symptoms are reproduced or increased with the maneuver.
- It has a sensitivity of 80-90% and specificity of 70-80% for cervical radiculo
This document discusses spinal tuberculosis (TB), including:
1) Tissue diagnosis or culture growth is needed to confirm spinal TB diagnosis. MRI and GeneXpert can aid in early detection and treatment.
2) Uncomplicated spinal TB often responds well to multi-drug chemotherapy. Surgery is only needed for neurological complications, deformity, or instability.
3) Atypical presentations of spinal TB are rising, and improper treatment can lead to drug-resistant strains. Early diagnosis and treatment to prevent complications is key.
This document provides an overview of the examination of the spine. It describes the key structures of the vertebrae and spinal column. It outlines the arteries, nerves, and meninges surrounding the spinal cord. The document discusses evaluating the spine through inspection, palpation, and range of motion tests. It also covers assessing the spine based on the patient's history, including common conditions that affect different age groups. Special tests are mentioned to help evaluate the cervical spine region.
1) Dr. U. Jagadish presented on the X-ray findings of tuberculosis (TB) of the spine.
2) The most common sites of spinal involvement in TB are the dorsolumbar spine. Common X-ray findings include narrowing of the disc space and loss of disc margins indicating paradiscal involvement.
3) Other findings include paravertebral shadows produced by tuberculous granulation tissue and abscesses, as well as central lesions causing vertebral body collapse and deformity with minimal disc space narrowing.
The document provides an overview of the anatomy of the vertebral column. It discusses the 33 vertebrae that make up the spine, their typical features, and variations in different regions. It describes the protective, supportive, and weight-bearing functions of the vertebral column. Key structures like the intervertebral discs, spinal cord, meninges, nerve roots, and blood supply are summarized. Considerations for regional anesthesia techniques and anatomical variations are also covered at a high level.
This document discusses osteochondritis, specifically Legg-Calvé-Perthes disease which is osteonecrosis of the femoral head in children. It covers the anatomy of long bones and epiphyses, risk factors for LCPD including age and activity level, stages of the disease process, classification systems for extent of involvement, imaging findings at each stage, and prognostic factors.
The document provides information on the anatomy and physiology of the spinal cord and vertebral column. It discusses the parts of the vertebrae including the body, pedicles, lamina, processes and joints. It describes the ligaments that support the spine like the supraspinous, interspinous and ligamentum flavum. It details the characteristics of cervical, thoracic, lumbar and sacral vertebrae. It also discusses the meninges layers, cerebrospinal fluid, vertebral anomalies and embryology of spinal development.
The hip joint is a ball and socket synovial joint that allows high mobility. It has an articular femoral head that fits into the acetabulum of the hip bone. Strong ligaments like the iliofemoral ligament provide stability. Blood is supplied by various arteries and it is innervated by nerves from the lumbar and sacral plexuses. Common conditions affecting the hip joint include congenital dislocation, Legg-Calve-Perthes disease, osteoarthritis, and fractures of the femoral neck.
This document discusses the anatomy of the vertebral column and spinal canal. It describes the individual vertebrae, curves of the vertebral column, structures within the vertebral canal including the meningeal spaces, abnormalities, blood supply, the intervertebral disc, and changes that occur with aging. Key points include there being 33 vertebrae grouped into cervical, thoracic, lumbar, sacral and coccygeal sections, and the presence of primary and secondary curves forming the cervical, thoracic, lumbar and pelvic curves. The vertebral canal contains the spinal cord and meninges, and is protected anteriorly and posteriorly. The intervertebral disc acts as a shock absorber and its structure and function changes
Pott's disease, or spinal tuberculosis, is caused by Mycobacterium tuberculosis infection of the spine. It spreads hematogenously from a primary site, usually the lungs. Common presentations include localized or radicular back pain, stiffness, and the development of cold abscesses. Radiographically, Pott's disease most often appears as paradiscal involvement, showing narrowing of the disc space between two adjacent vertebrae. Other patterns include central lesions within a single vertebral body or anterior lesions along the vertebral edge. Advanced cases result in vertebral collapse and kyphotic deformity.
1. Spinal tuberculosis commonly affects the thoracic and lumbar spine in young adults. It can cause neurological deficits through mechanisms such as inflammatory edema, extradural masses, and meningeal involvement.
2. Diagnosis is based on imaging findings on X-ray, CT, or MRI showing bone destruction and abscesses. Treatment involves chemotherapy and sometimes surgery to debride tissue, drain abscesses, or correct deformities.
3. Complications of spinal tuberculosis include paraplegia, cold abscesses, spinal deformities, and recurrence which may require longer treatment or surgical intervention.
This document provides information on tuberculosis of the skeletal system, with a focus on vertebral tuberculosis. It begins with an introduction and history of the topic. It then discusses the epidemiology, pathogenesis, clinical presentation, investigations including imaging findings, laboratory tests, classifications, treatment approaches including drug regimens and surgical indications and techniques. Key points covered include the high prevalence of skeletal TB in India, typical radiological features, classification of neurological deficits, Tuli's middle path treatment regime, and various surgical approaches for abscess drainage and spinal decompression/stabilization.
Congenital anomalies and degenerative conditions of vertebraBipulBorthakur
This document summarizes CT findings related to congenital anomalies, infections, and degenerative conditions of the spine. It describes common congenital anomalies such as spina bifida occulta, coronal cleft vertebra, and block vertebra. It also discusses spinal infections including bacterial spondylodiskitis caused by pathogens like Staphylococcus aureus and tuberculous spondylitis. Finally, it reviews degenerative changes in the spine seen with aging and conditions like ankylosing spondylitis. CT is useful for evaluating bony abnormalities, spinal infections, and the extent of fusion in diseases like ankylosing spondylitis.
This document provides an overview of the management of open fractures. It defines an open fracture as a soft tissue injury complicated by a broken bone with communication to the external environment. The history of open fracture treatment is discussed, from ancient practices like debridement to modern advances with antibiotics and fixation methods. Classification systems for open fractures are presented, including the Gustilo-Anderson classification which correlates the degree of soft tissue injury with infection risk. Key steps in managing open fractures are described, including thorough debridement and irrigation, antibiotic administration, fracture stabilization options like external or internal fixation depending on the injury, and wound management. Overall infection rates and healing times are correlated with the classification of the soft tissue injury.
1. Fat embolism syndrome is a serious manifestation of fat embolism that can cause multi-system dysfunction, most commonly affecting the lungs and brain.
2. It occurs most often after long bone fractures, especially femur fractures, when fat droplets enter the bloodstream and lodge in the pulmonary capillaries or brain vasculature.
3. Clinical features include a triad of respiratory distress, neurological changes like confusion, and petechial rash. Diagnosis is based on clinical criteria and imaging may show changes in the lungs and brain. Treatment is supportive with oxygen, ventilation if needed, IV fluids and steroids. Prognosis is generally good if respiratory failure can be prevented.
This document discusses the investigation profile for acute hematogenous osteomyelitis. It notes that C-reactive protein levels and bacterial cultures from aspirated bone or tissue are important for diagnosis. Imaging plays a key role as well, with X-rays able to detect bone changes within a few days while MRI is most sensitive for detecting early bone marrow changes. The presentation reviews the typical findings and timeline of changes seen on various imaging modalities in the evaluation of acute osteomyelitis.
- A sequestrum is a separated, necrotic fragment of bone surrounded by infected tissue and pus. It acts as a nidus for bacteria to thrive.
- Sequestra come in different shapes, sizes, colors and consistencies depending on the underlying condition. Common types include pencil-like in infants and cylindrical in tuberculosis.
- Identifying sequestra involves injecting dyes like methylene blue which will stain live bone gray but leave dead bone blue. Removal of sequestra via sequestrectomy eliminates the infection and aids healing.
- Conditions that can mimic sequestra on imaging include radiation necrosis, bone tumors and mineralization of other lesions.
This document summarizes a presentation on malignancy in chronic osteomyelitis given by Dr. Kiran. It discusses chronic osteomyelitis as a long-lasting bone infection caused by biofilm-protected microorganisms. Malignant changes can develop due to factors like chronic inflammation, poor vascularization, and treatment failure. The most common malignancy is aggressive squamous cell carcinoma of the skin near the infected bone. Clinical features include ulceration, bleeding, and bone destruction visible on imaging. Diagnosis involves biopsy and imaging tests. Management may include amputation and adjuvant therapies depending on the malignancy.
Tuberculosis of the hip is a rare form of skeletal tuberculosis that can lead to significant deformity if not treated properly. It typically begins as a tuberculous synovitis that can progress to arthritis and destruction of the hip joint if left untreated. Treatment involves a combination of anti-tubercular medications for at least one year as well as rest and traction to prevent deformities. For more advanced cases, surgical procedures like synovectomy, osteotomies or arthrodesis may be needed. With adequate treatment, outcomes can be good, especially if caught early, but significant deformity can negatively impact function.
This document provides information about Dupuytren's contracture, including its history, definition, epidemiology, associated conditions, pathogenesis, treatment options, and complications. Specifically, it describes how Dupuytren's contracture results from abnormal proliferation of fibroblasts in the palmar fascia, which can cause fingers to bend into the palm. Treatment involves nonsurgical options like collagenase injections or surgery to release contracted tissues through techniques like fasciectomy. Postoperative rehabilitation with splinting and range of motion exercises aims to prevent recurrence of contractures.
Tarsal coalition is a congenital condition caused by abnormal fusion of two or more tarsal bones, most commonly the calcaneus and navicular. It is usually asymptomatic but can cause a flatfoot deformity or recurrent ankle sprains. Imaging such as x-rays, CT, or MRI is used to identify the specific bones fused and determine if the coalition is fibrous, cartilaginous, or bony. Treatment options include conservative management or surgical resection or fusion of the bones.
This document provides information on vacuum-assisted closure (VAC) dressing for wound management. It begins by describing standard wound care and the development of VAC therapy. It then explains the mechanism of action of VAC, which uses subatmospheric pressure to remove fluid, decrease edema, and increase blood flow to promote healing. Components of the VAC system and application process are outlined. The document discusses the range of pressures used, indications, advantages, and complications of VAC therapy. It also addresses interventions to maximize healing and future developments.
This document discusses physeal injuries in children. It begins by describing the anatomy and zones of the physis. The most common causes of physeal injuries are fractures, but other mechanisms include infection, tumors, and vascular issues. It then details the Salter-Harris classification of physeal fractures in 5 types based on the location of the fracture plane. Treatment depends on the type, with types I and II generally treated non-operatively and types III and IV requiring anatomic reduction and potential internal fixation. Complications can include growth disturbances leading to angular deformity or limb length discrepancy.
A 19-year-old male presented with knee pain after falling during a basketball game. Radiographs revealed a bipartite patella, which is a congenital condition where the patella fails to fuse, seen in 2-3% of the population. It is typically asymptomatic but can cause anterior knee pain aggravated by activity. Non-operative management is indicated initially but surgical excision may be needed if non-operative treatment fails after 6 months or for displaced fragments. The main risk of surgery is patellofemoral maltracking.
1. The epiphysis are the cartilaginous ends of growing bones that consist of spongy bone with a thin outer wall of compact bone.
2. There are different types of epiphysis including pressure, traction, and aberrant epiphysis that develop in response to stresses on the bone.
3. Epiphysis develop through enchondral ossification from secondary ossification centers and injuries involving the epiphyseal growth plate are classified using the Salter-Harris classification system.
This document discusses the treatment of scaphoid non-union bone fractures. Scaphoid non-union can be caused by delayed diagnosis, displacement of the fracture, smoking, and other factors. Treatment options include traditional bone grafting, vascularized bone grafting, fragment excision, and wrist fusion or replacement. The Matti-Russe and Fernandez techniques use bone grafts to fill the fracture site and stabilize the bone fragments, while vascularized grafts from the radius or iliac crest aim to improve healing rates. Postoperative immobilization lasting several months is usually needed to allow the bone to fuse.
Heterotopic ossification refers to bone formation in soft tissues. It commonly occurs after trauma, burns, or head injuries. Surgical excision is recommended if the extra bone limits elbow motion or function. The document describes techniques for excising heterotopic ossification around the elbow through various approaches. Postoperative care involves physical therapy and sometimes manipulation under anesthesia to improve range of motion outcomes. Recurrence is more common in patients with central nervous system injuries.
Supracondylar humerus fracture percutaneous pinning video demoAnil Kumar Prakash
Supracondylar humerus fractures are common pediatric elbow fractures that are usually caused by a fall onto an outstretched hand. They are classified using the Gartland or modified Gartland classification. Type I fractures are nondisplaced, while Type III have complete displacement. Type III and unstable fractures are typically treated with closed reduction and percutaneous pinning (CRPP) or open reduction if needed. CRPP involves realigning the bones under imaging guidance and inserting two divergent lateral pins. Complications can include pin migration, infection, and nerve injury.
The document provides guidelines for writing prescriptions. It outlines that prescriptions should have 3 parts: general patient information, the list of prescribed medications, and a conclusion. The content section explains what information should be included for each prescribed medication such as name, strength, route, dose, frequency, and duration. The conclusion should have the consultant's signature, department, unit, and date. Key points are to use legible handwriting and proper formatting while common mistakes to avoid are missing the diagnosis or seals/dates.
1) The physis, also known as the growth plate, is located between the epiphysis and metaphysis of growing bones. It is responsible for the longitudinal growth of bones.
2) The physis contains several zones, including a germinal zone, proliferative zone, hypertrophic zone, and zone of provisional calcification. Blood is supplied to the physis from epiphyseal, perichondrial, and metaphyseal arteries.
3) Physeal injuries are classified using the Salter-Harris system. Type 1 and 2 fractures can usually be treated non-operatively, while more severe types often require open reduction and internal fixation.
This document provides an overview of tendons, including:
- Tendons are dense fibrous tissues that connect muscle to bone and transmit muscle forces to produce joint movements.
- Tendons are composed of collagen fibrils bundled into fascicles surrounded by endotendon tissue and epitenon sheath.
- Muscle and tendon attach through interdigitation of collagen fibrils. Peritendonous structures like bursae and sheaths facilitate tendon gliding.
- Tendons insert directly into bone through four stiffening zones or indirectly by joining the periosteum. Blood vessels and nerves course through tendons.
Dr. Tarun gave an 8 minute lesson on compartment syndrome. He discussed what compartment syndrome is, its etiology and pathophysiology. There are two main types - acute and chronic. Acute compartment syndrome is a medical emergency caused by severe injury that can lead to permanent muscle damage if not treated urgently. Chronic compartment syndrome is known as exertional compartment syndrome and is not an emergency, often caused by athletic exertion. Management involves reducing intra-compartmental pressure through fasciotomy, hydration, and positioning the affected limb above the heart level. Complications include permanent nerve and muscle damage if not treated promptly.
Dr. Kiran Theja presented on synovium, the tissue that lines joints. The synovium has two layers - an outer subintima layer and inner intima layer. It secretes synovial fluid which lubricates and nourishes joints. Synovial fluid contains hyaluronic acid and lubricin. The synovium can develop disorders like infections, inflammation from arthritis, trauma, tumors, and degeneration. Treatment involves eliminating abnormal synovial tissue through nonsurgical or surgical methods.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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1. TB SPINE AND POTT’S
PARAPLEGIA
PRESENTER : DR. KARTHIK S J
JUNIOR RESIDENT
MODERATOR : DR. PRABHU E
PROFESSOR AND HOU
DEPT OF ORTHOPAEDICS
RLJALAPPA HOSPITAL KOLAR
2. GLOBAL TUBERCULOSIS - REPORT
• WHO reports 10 million new cases of tuberculosis and 1.2 million
people die due to disease every year ( 0.17 million – CORONA)
• Eight countries accounted for 66 % new cases : India, China,
Indonesia, Phillipines, Pakistan, Nigeria, Bangladesh and South Africa
• 4.8 lakh have MDR TB with only 56% treatment success
3. HISTORY:
• Percival Pott first described Tuberculosis of
Spinal column in 1779, stating a classical
description as a destruction of disc space and
the adjacent vertebral bodies, collapse of
spinal element and kyphotic deformity
• It is estimated that India alone got one fifth of
the total world population of tuberculous
patients
• Nearly 6 million radiologically proven cases are
found in India and 1 to 3 percent has
involvement of skeletal system
4. MICROBIOLOGY
Mycobacterium tuberculosis:
Bacillus with high lipid and Peptidoglycan rich cell wall
Slow growing, aerobic organism
Acid and alkali fast
In favourable conditions, doubling time is 20 hours
In unfavourable conditions, it can grow only intermittently or remain
dormant for a prolonged period
This explains why TB is difficult to diagnose, treat and eradicate
6. SURGICAL ANATOMY: VERTEBRAL BODIES
• It is compared to a compressed long
bone with intervertebral disc interposed
• Hyaline cartilage intervenes between
• 6 years : Ring or annular epiphysis
appears on the periphery of cephalic and
caudal surface
• 8 years : Calcification in the ring
epiphysis starts
• 18 years : Fuse with the vertebral bodies
7. SURGICAL ANATOMY : INTERVERTEBRAL JOINT
Second Cervical to first Sacral vertebra :
Articulations
Series of fibro cartilagenous joints formed by
intervertebral discs between the vertebral bodies
Series of paired synovial joints between the
posterior articular process
A typical vertebra articulates at 6 articulating
surfaces
Two discs, Two proximal facet joints, Two distal
facet joints
8. SURGICAL ANATOMY : INTERVERBRAL DISC
• Lies between the bodies of vertebra
• Central portion : Semigelatinous – nucleus pulposus
• Peripheral ring : Lamellated fibrous tissue – Annulus
fibrosus
• Schmorl’s node : If there is deficiency in the hyaline
cartilage and the bone end plate, nucleus pulposus
herniates into the cancellous bone of vertebral
bodies where it may encircled by the reactive bone
• Fetal life: Small blood vessels penetrate the annulus.
It regress soon after birth; 18 years – discs are
relatively avascular
9. BLOOD SUPPLY OF VERTEBRAL COLUMN:
• Branches from each segmental
intercostal artery or lumbar artery
supplying adjacent halves of two vertebra
( lower half of one above and upper half
of one below)
• Inside the vertebral body the arterioles
ends as tortuous loops under the
epiphyseal end plates
• Juxta epiphyseal , paradiscal areas – more
vascular
10. BATSON’S PLEXUS
• Batson’s perivertebral plexus of veins : Veins from
the vertebral column drains here.
• Emerge from the posterior aspect of vertebral
bodies to form postcentral anastomosis
• It has ramifications into the base of brain and chest
wall and has free anastomosis with the intercostal,
lumbar and pelvic veins
• Retrograde flow of blood from the viscera to the
spine may be responsible for the spread of infection
• It is responsible for the association of chest wall
abcess with vertebral TB or tuberculous meningitis
with spinal tuberculosis
11. BLOOD SUPPLY TO SPINAL CORD
• One anterior and two posterior spinal arteries
• Anterior spinal A : Union of terminal branches
of vertebral artery at level of foramen magnum
( Anterior 2/3)
• Posterior spinal A : Branches of Vertebral artery
at the level of Medulla oblongata ( Remaining
posterior part )
• Anterior and Posterior Radicular arteries which
enters through the intervertebral foramina
• Artery of Adamkiewicz : Originates from left
intercostal or left lumbar artery between 10th
thoracic and 2nd lumbar segents
12. TUBERCULOSIS OF SPINE
• Vertebral tuberculosis is the commonest form of skeletal tuberculosis
• It constitutes 50 percent of all tuberculosis of bones and joints
• It is most common during the first 3 decades
13. PATHOLOGY:
TB of spine is
always secondary
Bacteria reach the spine via
hematogenous route
Spreads via para-vertebral
plexus of veins i.e., BATSON’S
PLEXUS
14. Tubercle:
Accumulation of PMN cells(Released by macrophage and monocytes)
Transformation to Epitheloid cells
Formation of Langhans giant cells(Occurrence of caseation necrosis)
Lymphocytes appear and form a ring around the peripheral part of lesion
Tubercle formation
15.
16. COLD ABCESS:
• Marked exudative reaction is a common feature of Tuberculosis in
skeletal system
• Cold abcess : Formed by collection of products of liquefaction and the
reactive exudation
• Components: Serum, Leukocytes, Caseous material, Bone debris,
Tubercle bacilli
• Migrates in various directions
• Feels warm ( not as such in pyogenic infections )
• It may burst to form a sinus or ulcer ( undermined edges )
17. TUBERCULAR SEQUESTRA:
• Osseus destruction : lysis of bone leading to compression /collapse/
deformation
• Necrosis : due to ischemic infarction of segments of bones
• Due to loss of nutrition the adjacent articular cartilage or intervening
disc degenerates and become separated as sequestra
• Intervertebral disc is not involved primarily ( Relatively avascular
structure)
• The early involvement of the paradiscal regions of vertebra
jeoparadizes the nutrition to the disc
18. Tuberculous granulomatous debris and abcess
may be compressed between the sound
vertebra above and below
Local extension, retropulsion and propulsion of
the material may occur
Spreading and extending due to
osteoperiosteal infiltration, passing along deep
to anterior longitudinal ligament
19. TUBERCLE : FUTURE COURSE
It may resolve completely
The disease may heal completely with varying degrees of residual
deformities or/and loss of function
Lesion may be completely walled off and caseous necrosis may get
calcified
Low grade chronic fibromatous granulating and caseating lesion may
still persist
Infection may spread locally or via bloodstream
20. TALL VERTEBRA:
• Pott’s disease which had healed with ankylosis and appreciable
kyphosis : considerable increase in height of vertebral bodies of
lumbar spine may be present
• “Tall Vertebra” : Develops when disease occurs in the growth period
• As the deformity develops gradually, neural elements tolerate the
progressive kyphosis for several years
• They reach adulthood with intact neural status
21. SIGNS AND SYMPTOMS:
ACTIVE STAGE HEALED STAGE
1. Symptoms are insidious but sometimes acute 1. Regains the lost weight
Symptoms: malaise, loss of weight, loss of appetite,
night sweats and evening rise of temperature
2. No evening rise of temperature or night cries
2. Localised kyphotic deformity which is tender on
percussion
3. Deformity persists
3. Spasm of vertebral muscles present 4. ESR falls and radiological evidence of bone healing
present
4. Night cries
5. Knuckle kyphosis may be detected by palpation
22. ABCESS AND SINUS:
• Abcess from cervical or dorsal regions can present themselves far
away from the vertebral column along the fascial planes or course of
neuro vascular bundles
• Present at paraspinal regions at back/ posterior or anterior cervical
triangles/ along the brachial plexus/ along intercostal spaces in chest
wall
• From dorsolumbar and lumbar spine : psoas abcess – palpable in iliac
fossa/ lumbar triangle or in upper part of thigh or even track towards
upto knee ( Hip flexion/ Pseudo hip flexion deformity)
24. RADIOLOGY:
• Spinal TB is difficult to diagnose radiologically
in early stages
4 sites :
Paradiscal
Central
Anterior
Appendical
3
25. PARADISCAL TYPE:
• Commonest type
• The paradiscal lesion begins in the vertebral
metaphysis, erodes the cartilage plate and
destroys the disc.
• The cartilaginous end plate acts as a barrier, but
once invaded, destruction of the disc progresses
rapidly due to its relative avascularity, and the
infection goes on to involve the adjacent
vertebrae.
• The early resorption of the disc leads to
narrowing of the disc space
26. PARAVERTEBRAL SHADOWS:
• Extension of tuberculous granulation tissue and the collection of abcess
in the paravertebral region
• In cervical region, it presents as a shadow between vertebral bodies,
pharynx and trachea
• Upper thoracic abcess – V shaped shadow stripping over the lung apices
laterally and downwards
• Abcess below the level of 4th dorsal vertebra : typical fusiform shape
(bird nest appearance)
27.
28.
29. • Abcess above the level of vertebral attachment of diaphragm :
Remain within thorax
• Below the diaphragm : Extend along the course of psoas muscle
• Psoas abcess : Widening of psoas shadow
• Abcess under tension : Globular shape
• Psoas abcess can be aspirated through Petit’s triangle while iliopsoas
abcess can be aspirated through Petit’s triangle as well as iliac fossa
30.
31. • Long standing paravertebral abcess : Scalloping effect / Aneurysmal
phenomenon as concave erosions along the anterior margins of
vertebral bodies
• Healthy discs, because of their elasticity : Saw tooth apperance
32. KYPHOTIC DEFORMITY:
• Paradiscal bodies shows areas of destruction and one or both bodies
are usually wedged with forward angulation
• Involvement of large number of vertebra : Severe kyphotic deformity
• Forward wedging of one or two vertebra : Knuckle kyphos
• Wedge collapse of 3 or more vertebral bodies : Angular kyphosis
• Moderate wedging of large number of vertebra : Round kyphosis
Gibbus deformity / Kyphotic deformity are interchangeable expressions
33.
34. CENTRAL TYPE:
• In the central type of lesion the infection begins in the midsection ofthe body.
It extends centrifugally to involve the wholebody.
• The infection ususally spreads through Batson plexus of veins or through
branches of posterior vertebral artery
• Following the infection, marked hyperemia and osteoporosis occur
• The body, which is thus softened, easily yields under gravity andmuscle
action, leading to compression, collapse and bony deformation.
• Diminution of disc space is minimal and paravertebral shadow is not marked
35.
36. ANTERIOR TYPE:
• This lesion occurs when infection starts beneath the anterior
longitudinal ligament.
• Peripheral portion of the vertebral body shows erosion in lateral or
oblique views as shallow excavations
• More common in thoracic spine
• More erosion is caused when the abcess is near the aorta permitting
the transmission of aortic pulsation to the abcess
37. APPENDICIAL TYPE:
• Isolated tuberculous infection of the pedicles, lamina, transverse
process, spinous process
• Uncommon
• Radiologically : Appreciated by erosive lesions, paravertebral shadows
and intact disc space
• CT/ MRI are best modalities to diagnose Appendicial type
38. LATERAL SHIFT AND SCOLISIS:
• Lateral curvature and lateral deviation : Rare deformity
• It occurs in those patients where there is involvement of posterior
spinal articulations in addition to the usual paradiscal lesions
• Majority of cases donot have neurological complications
39. NATURAL COURSE OF DISEASE :
• Before the modern anti TB drugs : Patients developed crippling
deformities, cold abcess, multiple discharging sinus, spread of
infection to other parts of body, paraplegia and amyloidosis
• In modern era : If adequately treated in early stage, healing takes
place well with a little radiological deformity
• IVORY VERTEBRA : In the healing stage, new bone formation occurs as
a result of secondary infection usually associated with sinus formation
40. MODERN IMAGING TECHNIQUES: CT SCAN
• It is useful tool in assessing the destructive lesions of the vertebral
column
• It is of special help for posterior spinal disease, TB of cranio vertebral
and cervico dorsal region, sacro iliac joints and sacrum
• Delineation of shape, extent and route of spread of cold abcess can
be visualized by CT scan
41.
42.
43. MRI SCAN:
• It is useful in the diagnosis of tuberculous infection of difficult and
rare sites like
cranio vertebral region
cervico dorsal region
disease of posterior elements and vertebral appendages
infections of sacro iliac region
sacrum and coccyx
44.
45. ULTRASOUND ECHOGRAPHS:
• To diagnose the presence of tubercular abcess in lumbar vertebral
disease
• To assess the composition of iliopsoas mass and the quantity of the
liquid material contained therein
In case of doubt for confirmation a biopsy of small prevertebral abcess or
of atypical vertebra may be obtained by core biopsy needle under
fluoroscopic control
Open biopsy with debulking/ decompression is mandatory if semi invasive
techniques donot prove the pathology
46. CLINICO RADIOLOGICAL CLASSIFICATION:
STAGE CLINICO RADIOLOGICAL FEATURES USUAL DURATION
I : PRE DESTRUCTIVE Straightening of curvatures, spasm of
prevertebral muscles, MRI shows
marrow edema
< 3 months
II : EARLY – DESTRUCTIVE Diminished disc space + paradiscal
lesion ( knuckle < 10 deg) ; MRI :
shows marrow edema; CT : marginal
erosions or cavitations
2 – 4 months
III, IV, V – all have vertebral body destruction + collapse + appreciable kyphosis
III – Mild angular kyphos 2 -3 vertebra involved (K: 10 -30
deg)
3 -9 months
IV – Moderate angular kyphos > 3 vertebra ( K : 30 to 60 deg ) 6 – 24 months
V – Severe kyphos ( Humpback
deformity )
> 3 vertebra involved ( K: > 60 deg) > 2 years
47. BIOLOGICAL HEALING AND IMAGING
• Radiological evidence of healing : lags behind the biological process
in spinal TB.
• If images donot show improvement when repeated after 6 months of
therapy, one should consider the possibility of alternative pathology
or therapeutically refractory disease
• Once the disease is healed, bony architecture is restored
48. DIFFERENTIAL DIAGNOSIS:
• Clinical and radiological re examinations after 6 to 12 weeks are of
great help in arriving final diagnosis
• In case of doubt, histological and micro biological investigations
should be sent
49. CONSIDERATION OF AGE:
• Congenital defects of spine
• Calves disease in young children
• Schmorl’s disease
• Scheuerman’s disease in adolescent
All these conditions may have no constitutional symptoms but a
characteristic radiological appearance
Primary tumour of vertebra
Metastasis should be considered in adults
50. PYOGENIC INFECTIONS:
• Onset is sudden with severe localised pain, spasm and swinging
temperature
• Early stages: Bone destruction present, rapidly replaced with sclerosis
and new bone formation
• IVD shows varying degrees of destruction
• ASO titre/ Microbiological investigations : Final diagnosis
51. TYPHOID SPINE:
• Most cases present in the time interval of 4 weeks to few months
after the disappearance of typhoid fever
• Radiological picture : Resembles that of tuberculosis and low grade
pyogenic spondylitis
• Confirmations: Agglutination test, Therapeutic trial or by biopsy
52. SYPHILITIC INFECTION OF SPINE:
• Arthralgic type
• Gummatous type
• Charcoat’s disease
Most common site: Thoraco lumbar and Lumbar spine
Diagnosis : Serological tests, Tissue biopsy or response to Anti syphilitic
treatment
53. TUMOUROUS CONDITIONS:
• Hemangioma: most common beningn tumour (D12 to L4)
Radiologically : Pin head appearance
Involved vertebra shows characteristic coarsening of vertebral
trabeculations and more prominent in vertical than in horizontal
trabeculae ( Corduroy appearance )
• Giant cell tumour and Aneurysmal Bone cyst:
Osteolytic expansile and usually eccentric growth on radiological
examination; Disc space is not involved in early stages
RESPPONSE TO RADIATION TREATMENT IS OBSERVED IN THESE CASES
54. MULTIPLE MYELOMA:
• There is involvement of only one or two vertebra and there is collapse
and eccentric destruction
• Involvement of multiple bones, High ESR, Anemia, reversal of AG
ratio, Urine Bence Jones Proteins are the charecteristics
• Diagnosis : Confirmation of myeloma cells in the bone marrow
56. NEUROLOGICAL COMPLICATIONS- POTT’S
PARAPLEGIA
• It is the most dreaded and crippling complication of spinal
tuberculosis
• Incidence : 10 to 30 percent
• Paraplegia most commonly results due to the involvement of the
spinal cord, thus below the level of first lumbar vertebra rarely causes
paraplegia due to the involvement of cauda equina
• Pathology : Compression paraplegia
57. TUBERCULOUS PARAPLEGIA- CLASSIFICATION:
GROUP A : EARLY ONSET PARAPLEGIA :
Occurs during the active phase of the disease
Within first 2 years of onset
Underlying pathology : Inflammatory edema, Tuberculous granulation
tissue, Tubercular abcess, Tuberculous caseous tissue or ischemic
lesion of spinal cord
Good prognosis
58. GROUP B : LATE ONSET PARAPLEGIA:
Appears > 2 years after the disease
Underlying pathology : Tuberculous caseous tissue, Tubercular debris,
Sequestra from vertebral body and disc, internal gibbus, stenosis of
vertebral canal or severe deformity
Prognosis is less favourable
59. STAGE CLINICAL FEATURES
I Negligible Patient unaware of neural deficit, physician detects plantar
extensor/ ankle clonus
II Mild Patient aware of deficit but manages to walk with support
III Moderate Non ambulatory because of paralysis(in extension), sensory
deficit < 10 %
IV Severe Stage III + Flexor spasm/ paralysis in flexion/ flaccid/ sensory
deficit > 10%/ sphincters involved
60. PATHOLOGY OF TUBERCULOUS PARAPLEGIA:
• Inflammatory edema:
Due to vascular stasis and due to toxins from the tuberculous
inflammation in the neighbouring vertebrae
• Extradural mass :
A state of tuberculous osteitis of the vertebral bodies with an abcess
in the extradural space causing compression of the cord from the
anterior aspect
Components : Fluid, Pus, Granulation tissue, Caseous material
Best visualised by MRI
61. • Bony disorders:
Sequestra from avascular portions may be responsible for narrowing
of the spinal canal and pressure on the cord
Angulation of the diseased spine : Due to the formation of bony ridge
called internal Gibbus on the anterior wall of spinal canal
Concomitant mechanical instability can produce neural complications
in TB or in pathological subluxation or dislocation
62. • Meningeal changes:
Thick layer of tuberculous granulation tissue lying outside the dura
Extra dural granulation : May contract and undergo cicatrisation in
long standing cases
Peri dural fibrosis : Responisble for recurrence of paraplegia
63. • Infarction of Spinal cord:
Caused by : Endarteritis, Periarteritis or thrombosis of any tributary to
the anterior spinal artery caused by inflammation reaction
Paralysis caused by infaraction is irreversible
Rarely it may occur because of surgery or due to thrombo embolic
phenomenon
64. • Changes in spinal cord:
Unrelieved compression of the spinal cord shows loss of neurons and
white matter in the damaged segment
The lost cells and fibres are replaced by gliosis and loss of myelin may
be seen
Neuronal plasticity : It is induced when compression or deformation of
the cord takes place slowly over a length of time. A sudden
compression or gross deformation would almost lead to near
transection of the neural elements
65. EXTRADURAL GRANULOMA:
• It may be responsible for the neurological complications without any
radiological evidence of involvement of vertebra
• These cases are called as “ Spinal tumour syndrome”
• The patients who did not recover after satisfactory decompression
may be persumed to have these factors
MRI is the investigation of choice.
Intradural tuberculomas can be managed by ATT drugs; But extradural
tuberculoma has to be managed by surgical decompression
66. SIGNS AND SYMPTOMS:
• In a paraplegia of slow onset : Spontaneous twitching of muscles in
the lower limbs, clumsiness in walking, extensor plantar response and
exaggerated reflexes
• Sustained clonus of ankle and patella may be present
• Motor functions are affected more than sensory because the
diseased area lies nearer to the motor tracts
67. PARAPLEGIA STAGES:
• Spastic motor paralysis
• Spastic paraplegia in extension
• Spastic paraplegia in flexion
As the compression increases the patient develops flexor spasms which in
later stages remains established in flexion
In very advanced cases bladder and anal sphincters may be involved
In extremely severe cases spasticity disappers and paralysis become flaccid
68. MYELOGRAPHY:
• In cases of Spinal Tumour syndrome / cases with multiple vertebral
lesions myelography is indicated
• It is useful in assessing the level of obstruction
• It is also used in conditions where patients donot recover after
decompression
69. CLINICAL FACTORS INFLUENCING PROGNOSIS
CORD INVOLVEMENT BETTER PROGNOSIS RELATIVELY POOR PROGNOSIS
Degreee Partial ( Stage I, II, III) Complete ( Stage IV)
Duration Shorter Longer (> 12 months)
Type Early onset Late onset
Speed of onset Slow Rapid
Age Younger Older
General condition Good Poor
Vertebral disease Active Healed
Kyphotic deformity < 60 degree > 60 degree
Cord on MRI Normal Myelomalcia
Preoperative Wet lesion Dry lesion
71. USUAL CAUSES AND MANAGEMENT
PROTOCOL
INFLAMMATORY
1. Inflammatory edema Recovers by rest and drug therapy
2. Tuberculous granulation tissue Mostly recovers by rest and drug therapy
3. Tubercular abcess Conservative management ; Rarely requires decompression
4. Tuberculous caseous tissue Rarely by conservative ; Requires Evacuation and Decompression
72. MECHANICAL
1. Tubercular debris Operative removal and decompression
2. Sequestra from vertebral body and disc Operative removal and decompression
3. Constriction of cord due to stenosis Operative decompression
4. Localised pressure Operative decompression
73. Intrinsic
1. Prolonged stretching of cord Decompression, Release of cord and anterior
transposition may lead to recovery
2. Infective thrombosis Difficult to recover
3. Pathological dislocation of spine Rare complication; Indiscriminate laminectomy and
irrepairable severance of cord
4. Tuberculous meningomyelitis Myelitis doesnot recover completely
5. Syringomyelic changes Poor recovery
SPINAL TUMOUR SYNDROME
Diffuse extradural granuloma/ tuberculoma Laminectomy
74. MANAGEMENT OF TB SPINE:
BASIC PRINCIPLES OF MANAGEMENT:
Early diagnosis
Aggressive medical treatment
Surgical approach
Prevent Deformity
Best outcome
75. MIDDLE PATH REGIMEN:
A. Rest in hard bed or Plaster of Paris Bed
In cases of cervical and cervico dorsal lesions, traction is used to
put the diseased part in rest
POP bed is used for children or for a few un co operative patients
76. B.DRUGS:
INTENSIVE PHASE
( 5 to 6 months)
CONTINUATION PHASE
( 7 to 8 months )
PROPHYLACTIC PHASE
Isoniazid 300 to 400mg Isoniazid and Pyrazinamide
(1500mg) for 3 to 4 months
Isoniazid and Ethambutol (
1200mg) fot 4 to 5 months
Rifampicin 450 to 600mg Isoniazid and Rifampicin for
another 4 to 5 months
Ofloxacin 400 to 600mg
For hospitalised patients Streptomycin replaces
one of the drugs except Isoniazid
Supportive therapy with Multivitamins, Hematinics may be added if necessary
77. C. Radiographs and ESR are taken at 6 months interval.
For Cranio vertebral/ cervicodorsal/ Lumbosacral regions, CT or MRI
has to be repeated at 6 to 12 months interval
D. General mobilization of the patient is encouraged in the absence of
neural deficit with the help of suitable spinal braces
78. • 3 to 9 weeks : Patient is put on back extension exercises for 5 to 10
minutes ( 3 to 4 times a day )
• Spinal brace is continued for 18 months to 2 years
E. Abcess are drained when near the surface and one gram of
streptomycin with or without INH is instilled at each aspiration
F. Sinus may heal within 6 to 12 weeks of treatment; Some may require
longer treatment and excision
79. G. Neural complications : Patients who are on triple drug regimen and
shows recovery of neurological complications within 3-4 weeks,
Surgical decompression is not indicated.
Surgical Decompression should be performed if the patient donot
recover after a fair trial of conservative therapy
In patients with motor, sphincter, sensory involvement or having severe
flexor spasms, operative management should not be delayed
80. H. Excisional surgery : Recommended for posterior spinal disease
associated with abcess or sinus formation
I : Operative management : Adviced for cases who donot show arrest of
activity of spinal lesions after 3 to 6 months of chemo therapeutic
regimen
J. Posterior Spinal Arthrodesis : For symptomatic unstable spinal lesions
These lesions show significant destruction of more than 2 vertebra and
lack of regeneration of vertebral bodies during the process of healing
81. K. Post operative : Patient should be nursed on a hard bed for 2 to 3
weeks; In cases with neural complications, 3 to 5 months after the
operation when the patient had a good recovery, patient is mobilized
out with spinal braces
The spinal brace is discarded after 12 to 24 months of surgery
82. INDICATIONS FOR VARIOUS SURGICAL
PROCEDURES:
• Decompression ± fusion : Neurological complications which failed to
response after 3 to 6 weeks of treatment’
• Debridement ± fusion : Failure of response after 3 to 6 months of non
operative management
• Debridement ± Decompression ± fusion : Recurrence of neurological
complications
• Prevention of severe kyphosis by posterior fusion ± debridement :
Young children with extensive dorsal lesions
• Anterior transposition of cord : Neural complications due to severe
kyphosis
83. TUBERCULSOSIS OF SACRUM AND COCCYX:
• Rare localisation of tuberculous infection (<1%)
• Tuberculous abcess may form anteriorly in pre sacral space
• Persistent pain in sacro coccygeal region with local warmth and
tenderness may be present
• In neglected cases it may form sinus and drains in the gluteal region
or peri anal areas
85. Posterior fixation
Fixation of posterior element of diseased vertebra by instrumentation
are done:
1.Toprevent and correct kyphotic deformity.
2. Tomaintain stability of the spine
86. SURGERIES:
• Antero lateral decompression : Spine is exposed from the anterior
and the lateral side; Cord is laid free from the granulation tissue/
sequestrum/ caseous material. It is the most commonly used method
• Costo – transversectomy : Ribs and the transverse process of vertebra
is removed and the pus is drained
• Radical debridement and arthrodesis
• Laminectomy and posterior stabilisation : In cases of Spinal cord
syndrome and in cases where neural complications present
87. TREATMENT OF PARAPLEGIA IN SEVERE KHYPHOSIS
Griffiths et al (1956) :anterior transposition ofcord through laminectomy
Rajasekaran (2002): posterior stabilization followed by anterior
debridement and bone grafting ( titanium cages) in active stage of disease
and vice versa for healed disease
88. SURGICAL CORRECTION OF SEVERE KYPHOTIC
DEFORMITY
Fundamentals of correction:
1. to perform an osteotomy on the concave side of the curve and
wedge it open ( secured with strong autogenous iliac grafts) .
2. to remove a wedge on the convex side and close this wedge (
Harrington compression rods and hooks)
89. Drainage of paravertebral abscess
•Through lumbodorsal fascia
between Erector spinae and
quadratus lumborum muscle.
•7 cm longitudinal paraspinal
incision
90. DRAINAGE OF PSOAS ABCESS:
• Through lateral incision –
along the middle third ofthe
crest of the ilium
• Through Petit’s triangle
91. SPINAL BRACES:
• For diseases from fourth dorsal to second lumbar vertebra :
Traditional braces extending from seventh cervical vertebra to lower
end of sacrum is used