87 - Haglund's deformity (Pump Bump)

*A Haglund deformity, or pump bump, is caused by chronic inflammation of the adventitious superficial pretendinous Achilles bursa that separates the Achilles tendon from the overlying skin.

*According to Jones, this bursa is present in about 50% of patients. This pretendinous bursitis usually is caused by chronic irritation from a shoe heel counter, and modification of shoe wear usually relieves symptoms. This deformity usually occurs in young women in their 20s or 30s. Surgery is infrequently required.

*The following technique is recommended if conservative measures fail :

1. Place the patient prone. After administration of general or local anesthesia, make a longitudinal lateral incision 1 cm lateral to the Achilles tendon, extending distally from 3 to 4 cm proximal to the superior tuberosity of the calcaneus to 2 to 3 cm distal to the superior tuberosity of the calcaneus.

2. Plantar flex the ankle joint and by sharp and blunt dissection, identify the Achilles tendon.

3. Place a right-angle retractor between the Achilles tendon and posterior and superior borders of the calcaneal tuberosity. With the foot plantar flexed, this usually affords enough exposure to remove the superior border of the calcaneal tuberosity without raising any of the Achilles tendon off the calcaneus. However, the Achilles tendon has such an extensive insertion into the posterior and plantar aspect of the calcaneal tuberosity that raising a 1- to 2-cm-long portion of the tendon may be necessary to resect the bone adequately.

4. Remove the superior aspect of the tuberosity with a microsagittal saw or an osteotome. Placement of several drill holes along the proposed osteotomy site makes this resection easier.

5. If an area of ossification remains, split the Achilles tendon in a coronal plane distally with the anterior third or half to free up enough to excise the calcified tendon.

6. Lavage the wound and close in layers.

7. Apply a well-padded, short leg, non–weight bearing cast with the ankle in approximately 20 degrees of plantar flexion.

AFTER TREATMENT:
*The cast and sutures are removed at 3 weeks. The sutures may be removed earlier if indicated, but the non–weight bearing cast remains on for 3 weeks. Then a removable weight bearing cast boot is applied, and active plantar flexion and dorsiflexion exercises are begun. It is important in the preoperative counseling to explain to a young woman with a pump bump that it might be 3 to 6 months before she can wear a stylish shoe and that there is no guarantee that she will ever be able to do so comfortably.

86 - Mangled Extremity Severity Score

*LIMB SALVAGE Vs AMPUTATION :

*To predict which limbs will be salvageable after trauma, available scoring systems include the predictive salvage index, the limb injury score, the limb salvage index, the mangled extremity syndrome index, and the mangled extremity severity score. Of these, the Mangled extremity severity score was found to be most useful.

*This system, which is easy to apply, grades the injury on the basis of the energy that caused the injury, limb ischemia, shock, and the patient's age.

*The system was subjected to retrospective and prospective studies, with a score of 6 or less consistent with a salvageable limb. With a score of 7 or greater, amputation was the eventual result.

*Although we do not strictly follow these guidelines in all patients, we do calculate and document a mangled extremity severity score in the chart whenever we are considering primary amputation versus a complicated limb salvage.

*Mangled Extremity Severity Score

Type	Characteristics	Injuries	Points
1	Low energy	Stab wounds, simple closed fractures, small-caliber gunshot wounds	1
2	Medium energy	Open or multiple-level fractures, dislocations, moderate crush injuries	2
3	High energy	Shotgun blast (close range), high-velocity gunshot wounds	3
4	Massive crush	Logging, railroad, oil rig accidents	4
Shock Group
1	Normotensive hemodynamics	BP stable in field and in OR	0
2	Transiently hypotensive	BP unstable in field but responsive to intravenous fluids	1
3	Prolonged hypotension	Systolic BP <90 mm Hg in field and responsive to intravenous fluid only in OR	2
Ischemia Group
1	None	Pulsatile limb without signs of ischemia	0[*]
2	Mild	Diminished pulses without signs of ischemia	1[*]
3	Moderate	No pulse by Doppler, sluggish capillary refill, paresthesia, diminished motor activity	2[*]
4	Advanced	Pulseless, cool, paralyzed, and numb without capillary refill	3[*]
Age Group
1	<30 y		0
2	>30 – <50 y		1
3	>50 y		2

BP, blood pressure; OR, operating room.

*	Points × 2 if ischemic time exceeds 6 hours.

85 - Enneking staging of bone tumors

Enneking System for Staging Benign and Malignant Musculoskeletal Tumors

BENIGN

1.    Latent

2.    Active

3.    Aggressive

MALIGNANT

Stage	Grade	Site	Metastases
IA	Low	Intracompartmental	None
IB	Low	Extracompartmental	None
IIA	High	Intracompartmental	None
IIB	High	Extracompartmental	None
III	Any	Any	Regional or distant metastases

84 - Gustilo's classification of open fractures

Gustilo Classification
I	Low energy, wound less than 1 cm
II	Wound greater than 1 cm with moderate soft tissue damage
III	High energy wound greater than 1 cm with extensive soft tissue damage
	IIIA	Adequate soft tissue cover
	IIIB	Inadequate soft tissue cover
	IIIC	Associated with arterial injury

83 - Ilizarov External Fixator

The Ilizarov apparatus is named after the orthopedic surgeon, Gavril Abramovich Ilizarov, from Siberia who pioneered the technique. It is used in surgical procedures to lengthen or reshape limb bones; treat complex and/or open bone fractures; and in cases of infected non-unions of bones that are not amenable with other techniques.

Professor Gavril Abramovich Ilizarov invented this procedure in the 1950s after having to treat orthopedic conditions in the Kurgan region of Siberia. The procedure, and the first apparatus he designed for it, was inspired by a shaft bow harness on a horse carriage.[1] Originally bicycle parts were used for the frame.

This novel technique was introduced to the West in the 1980s, predominantly via Italian surgeons. It gained popularity in the 1990s, and has been used successfully by many surgeons throughout the world. In most developing countries it is a highly specialised technique used mainly for deformity correction by experienced surgeons due to its complexity. Further development of the ring construct led to the Taylor Spatial Frame which is more versatile and far easier to use, but very costly. Though nowadays intramedullary limb lengthening devices are also available, they are not suitable for deformity correction of bones.

The device is a specialized form of external fixator, a circular fixator, modular in construction. Stainless steel rings are fixed to the bone via stainless heavy-gauge wire (called "pins" or Kirschner wires). The rings are connected to each other with threaded rods attached through adjustable nuts. The circular construction and tensioned wires of the Ilizarov apparatus provide far more structural support than the traditional monolateral fixator system. This allows early weightbearing. The frame can be used to support a fractured limb, but it is most commonly used to correct deformity through distraction osteogenesis.

The procedure consists of an initial surgery, during which the bone is surgically fractured and the ring apparatus is attached. As the patient recovers, the fractured bone begins to grow together. While the bone is growing, the frame is adjusted by means of turning the nuts, thus increasing the space between two rings. As the rings are connected to opposite sides of the fracture, this adjustment, done four times a day, moves the now-healing fracture apart by approximately one millimeter per day. The incremental daily increases result in a considerable lengthening of the limb over time. Once the lengthening phase is complete, the apparatus stays on the limb for a consolidation period. The patient is able to fully weight bear on the Ilizarov frame, using crutches initially and pain is lessened. Once healing is complete, a second surgery is necessary to remove the ring apparatus. The result is a limb that is significantly longer. Additional surgery may be necessary, in the case of leg lengthening, to lengthen the Achilles tendon to accommodate the longer bone length. The major advantage of this procedure is that because the apparatus provides complete support while the bone is recovering the patient can remain active aiding recovery.

A further use is of bone transport, whereby a defect in a long bone can be treated by transporting a segment of bone, whilst simultaneously lengthening regenerate to reduce the defect and finally dock with the other segment, producing a single bony unit.

While the Ilizarov apparatus is minimally invasive (no large incisions are made,) it is not free of complications. Pain is common and can be severe, but is treatable with analgesics. Careful attention to cleaning and hygiene is necessary to prevent pin site infection. Other complications include swelling and muscle transfixion.

The Ilizarov method is widely used to treat complex and/or open bone fractures. This method is preferred over conventional treatment options (such as internal fixator or cast) where there is a high risk of infection or the fracture is of such severity that internal fixators are unworkable.

82 - Hanging arm cast

*A hanging arm cast is used in Humerus fractures. Other casts used in humerus fractures are U-Slab and Collar and cuff cast

81 - Patellar Tendon bearing brace

*A patellar tendon bearing brace is used in Tibial fractures.

80 - Hip spica

*A hip spica is used in femoral fractures.

79 - Aeroplane splint

*The above picture shows the AEROPLANE SPLINT, which is used in brachial plexus injury.

78 - Knuckle bender splint

*These are used in ULNAR NERVE PALSY.

77 - Russell traction

*Etymology: R. Hamilton Russell, Australian surgeon, 1860-1933;

*Most commonly used in flexion deformity of KNEE.

*A unilateral or a bilateral orthopedic mechanism that combines suspension and traction to immobilize, position, and align the lower extremities in the treatment of fractured femurs, hip and knee contractures, and disease processes of the hip and knee. Russell's traction is applied as adhesive or nonadhesive skin traction and uses a sling to relieve the weight of the lower extremities subjected to traction pull. A jacket restraint is often incorporated to help immobilize the patient.

76 - Gallows traction

*This is used in infants and children with femoral fractures.

*Indications Gallows Traction
- Child must weigh less than 12 kg
- Femoral fractures
- Skin must be intact

*Both the fractured and the well femur are placed in skin traction and the infant is suspended by these from a special frame. Vascular compromise is the biggest danger. Check the circulation twice daily. The buttocks should be just off the bed.

75 - Thomas splint

Older children with femur fractures can be treated with skin traction in a Thomas splint. Unlike the adult the knee must be kept straight in the Thomas Splint.

The ring of the Thomas splint must allow two finger clearance on all sides- try it on the well leg for fit before applying. The skin strapping is applied and the Thomas Splint fitted. The ropes from the strapping are tied to the end of the Thomas splint. The outer one is passed under the Thomas splint bar and the inner one Over. This rotates the foot internally. The limb is rested on three flannel strips secured by safety pins. The Master sling is the flannel strip directly distal to the fracture.

These slings can be adjusted so that he fracture ends align in the vertical plane. The longitudinal traction needs adjustment every day in the first week. The knot at the end of the Thomas splint is loosened and the slack taken up. The quality of reduction is confirmed by regular X rays.

The Thomas splint is suspended from a Balkan Frame. This is a frame attached to the bed. To allow the patient to move about in the bed e.g. to use a bed pan. The limb with the Thomas splint is suspended from the top of the Thomas Splint by means of a counter weight. The longitudinal traction exerts pressure on the groin and a further weight is placed over a pulley on the balkan frame. It is in line with the long axis of the limb at the foot of the bed. This counter acts the reactive force on the groin generated by the skin traction.

Overgrowth Slight overlapping (up to 2 cm) of the bones is acceptable, as the fracture stimulates overgrowth in the local growth plates. End-on-end reduction, as with plating and other internal fixations, sometimes results in the injured limb growing more then the uninjured. Most of the overgrowth takes place in the first year after fracture.

A Thomas splint, (check it fits, by trying on the well leg) is applied. Three flannel slings are secured by safety pins under the thigh. The "Master splint" is the one under the fracture. The correct tension on this sling will align the fracture in the lateral plane. The knee can be flexed by using a Pearson flexion splint attached to the Thomas splint at the knee. The desired knee flexion can be maintained by a rope at its end leading from the Thomas splint to the Pearson attachment. Ropes from the Denham pin can either be tied distally to the Thomas splint (static traction) or they can be led over a pulley on the end of the Balkan frame (dynamic Traction) In either case start with 7 kg ( or 10% body weight) in the long axis of the femur. This opposes the pull of the thigh muscles. As with the child, the traction is made balanced by a system of pulleys on the horizontal limb of the Balkan frame to allow the patient to move his limb. A "monkey chain" hung above the arms also allows the patient to transfer himself onto a bedpan. as he moves in the bed.