Gopalan’s

Evidence based
ORTHOPAEDIC PRINCIPLES

Hitesh Gopalan U, MS Orth.

Consultant Orthopaedic Surgeon and
Clinical Assistant Professor,
MOSC Medical College,
Ernakulam, Kerala, India

Editor:
www.orthopaedicprinciples.com
Expert Advisor, OrthoEvidence
Visiting Lecturer: Centre for Evidence Based Orthopaedics,
McMaster University, Ontario, Canada
SICOT India ICL- Scientific Chairman
Editorial Board Member, Journal of Orthopaedics,
Indian Journal of Orthopaedics

Orthopaedic Principles • 1
 Copyright © Hitesh Gopalan U

International Edition

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Disclaimer:
The publisher or the Editors are not responsible (as a matter
of product liability, negligence or otherwise) for any injury,
resulting from any material contained herein. This publication
contains general information containing principles of medical
care which should not be constructed as specific instruction
for individual patients. Manufacturer’s product information
should be consulted for current information, including
contraindications, dosage and precautions.
This book is a multiauthored book, with significant
contributions from every contributor. The content accuracy of
a topic largely depends on the proficiency of the contributor,
who has been chosen based on his experience in the topic.
The publisher and contributors have made every effort to
trace copyright holders for borrowed material. If they have
inadvertently overlooked any, they will be pleased to make the
necessary arrangements at the first opportunity.
2 • Orthopaedic Principles
Associate Editors:
1. Senthilnathan. MS Orth, Leatherman Spine Fellow
Consultant, UAE
2. Vaibhav Bagaria. MS Orth
Arthroplasty Surgeon
CARE Hospital, Nagpur
3. Sujit Kumar Tripathy, Assistant Professor, AIMS, Bhubhaneshwar
4. Vishal Kumar, Assistant Professor, PGI, Chandigarh
5. Pankaj Patni, Arthroplasty Surgeon, Vadodara

Contributors
 Renjit Thomas Isaac, Asst Professor, MOSCMM, Kolenchery
 Tarun Goyal, AIMS, Rishikesh
 Brijesh P.V, Calicut, Kerala
 S. Marimuthu. , Tirunelveli, Tamilnadu
 Sanjay Chawra, New Delhi
 Hrutvij Bhatt , Vadodara
 Ramesh Dalwai , UK
 Shamshul Hoda, Katihar, Bihar
 Sangeet Gangadharan , Vellore
 Milin Jaiswal , Chennai
 Harish Palvai, Chennai
 Ashok Sunil Gavaskar, , Chennai
 Rishi Mugesh Kanna, Ganga Hospital, Coimbatore
 Alankar Ramteke, Nagpur
 Preteek Behera, PGI Chandigarh
 Kishan Bhagwat, PGI Chandigarh
 Prasoon Kumar, PGI Chandigarh
 Nitesh Gahlot, PGI Chandigarh
 Kedar Padhye, Chennai
 Kedar Phadke, Miraj
 Damandeep Singh, Delhi
 Rajat Malot, Paediatric Orthopaedic Fellow, USA
 Nishanth Singh,Max Hospital, NewDelhi
 Mayur Patil, Mumbai
 Nilesh Nangre, Pune
 Sobin Sunny,MOSC Medical College, Kolenchery
 Sridevi Rajeeve, MOSC Medical College, Kolenchery
 Vikas Bachhal, Chandigarh
 Ratna Johari, Mumbai
 Rajiv Goel, Pune
 Saseendar Sundaram, Pondicherry
 Ratna Johari, Mumbai
 Payal Jain, Vadodara
 Ashok Shyam, Thane

Orthopaedic Principles • 3
 ACKNOWLEDGEMENTS:
• J Senthilkumar, Madurai
• Akhil Chaudhury, Aurangabad
• Shikhil, ACME, Kannur
• Subhash, ACME, Kannur
• Sherwin Shareef, ACME, Kannur
• Feroz Khan, Mumbai

MOSC Medical College, Kolenchery, Kerala 2008 batch

• Aryasree Ram
• Asha Ouseph
• Divya Giridhar
• Fatimah Hasna
• Arya Ramachandran
• Ann Mary Thomas
• Anjana M S
• Jayashankar Ajayan

2007 batch
• Anjana Babu
• Preethi Nair
• Meera Rajan
• Mary Veena
• Jerry Antony
• Malini Kunnath
• Elvin Cherian
• Iby Ann Xavier

2006 batch
• Tinu Sara Abraham
• Mathew Varghese
• Paul Babu
• Rejitha Varghese
• Manju Oommen

4 • Orthopaedic Principles
INTERNATIONAL COMMITTEE

Canada
Mohit Bhandari
Michael Mckee (Toronto)

United States
Sureshan Sivananthan (Editor, Mercer’s Textbook of Orthopaedics)
Selene G Parekh(North Carolina)
Shaji Kumar (Mayo Clinic, Rochester)

United Kingdom
Nicola Maffulli
Kartik Hariharan
Vikas Khanduja
Manoj Ramachandran
Bijayendra Singh

India
Ashok Johari
Jacob Varghese
Rajesh Maniar
Vijay Shetty
Gopinathan P
John Ebnezar
Murali Poduval

Egypt
Hatem Galal Said

South Korea
In-Ho Choi

Brazil
Sergio Rowinski

Mexico
Alberto Padilla
Rafael Inigo Pavlovich

Russia
Alexander Chelnokov
Orthopaedic Principles • 5
 Special Thanks to our Advisors:
• Prof S Rajasekaran, Coimbatore, India
• Prof GS Kulkarni, Miraj, India
• Prof Mandeep Dhillon, Chandigarh, India
• Prof Rajesh Purushothaman, Calicut, India
• Dr Amr Abdelgawad, University of Texas, El Paso, USA
• Dr Prasoon Mohan, Interventional Radiologist, Miami, Florida, USA
• Dr Jinson Jose, Infection Control Specialist, Detroit, Michigan
• Prof A Riyaz, Professor of Paediatrics, Calicut Medical College, India
• Prof NS Laud, BreachCandy Hospital, Mumbai
• Prof A Devadoss, Madurai, India
• Dr Mangal Parihar, Mumbai, India
• Prof Milind Kulkarni, Miraj, India
• Prof T Prabhakaran, Madurai, India
• Prof R Sivakumar, Madurai, India
• Dr Rahul Katta, Jaipur, India
• Prof S Shanmgunathan, Madurai, India
• Dr Pramod Achan, St Bart’s, London
• Prof Jagdish Menon, Pondichery, India
• Prof Lalit Maini, NewDelhi, India
• Prof Parag Sancheti, Pune, India
• Dr Taral Nagda, Mumbai
• Dr Swapnil Keny, JJ Hospitals, Mumbai
• Dr Manish Agarwal, Hinduja Hospital, Mumbai
• Prof Vinod Panchbavi, Foot and Ankle Surgeon, Texas, USA

6 • Orthopaedic Principles
PREFACE
There are so many books available in the market to learn Orthopaedics
and one may wonder where does Evidence Based Orthopaedic Principles
stand! There are countless number of articles being published every
month across a vast number of orthopaedic journals. But the million
dollar question is: “How do you integrate these Principles into Evidence
and solve a Clinical Scenario?” That is what we offer in Evidence Based
Orthopaedic Principles . With our high profile Editorial Panel, we have
tried our best to answer most of the burning questions in Orthopaedics!
It must be remembered that Orthopaedic Principles is not a panacea to
solve everything. After reading all the Principles and Evidence discussed,
the reader has to make his clinical judgement while applying to his
patient.

At our website, we continuously strive to make Orthopaedics simpler

by frequent updates. On our online discussion forum, we apply these
principles to solve real life clinical problems. Every chapter in this book
has undergone multiple revisions to provide the best clinical solution.
Nevertheless mistakes would have inadvertently crept in. The readers
are requested to go into detail and then pose your questions via our
website.

At Orthopaedic Principles, we rely on your contributions to make it a

valuable resource. Do write to us, with your Questions, suggestions and
perhaps we might invite you to join our prestigious Editorial Board!

Hitesh Gopalan U
Email: arthritis.research.kochi@gmail.com
Web: www.orthopaedicprinciples.com
Orthopaedic Principles • 7
 TABLE OF CONTENTS

Paediatric Orthopaedics 34. Paediatric Spine .............................................. 645

1. Congenital Anomalies ........................................ 1 35. Spinal Rehabilitation....................................... 644
2. Osteochondrosis............................................... 41 36. Rheumatology................................................. 649
3. Neuromuscular Disorders ................................. 61
37. Musculoskeletal Oncology.............................. 682
4. Skeletal Dysplasias............................................ 78
5. Endocrine and Metabolic Disorders ................. 94 38. Endocrine and Metabolic Disorders in Adults. 743
6. Fractures in children........................................ 112 Orthopaedic Principles
7. Epiphyseal Injuries.......................................... 133 39. Surgical Approaches........................................ 757
8. Syndromes of Orthopaedic Importance.......... 137 40. Principles of Surgery....................................... 768
Sports Medicine 41. Gait.................................................................. 793
9. Knee ............................................................... 138 42. Arthrodesis ..................................................... 798
10. Shoulder ......................................................... 174 43. Bone and Joint Infections ............................... 809
11. Ankle .............................................................. 197 44. Tuberculosis ................................................... 830
12. Hip .................................................................. 207 45. Sternoclavicular Joint Disorders...................... 844
13. Elbow .............................................................. 217 Basic Sciences
46. Applied Basic Sciences.................................... 848
Joint Reconstruction
47. Implants.......................................................... 871
14. Total Hip Replacement.................................... 227
48. Biomaterials.................................................... 884
15. Total Knee Replacement.................................. 238
49. History of Orthopaedics.................................. 896
16. The Hip............................................................ 261
50. Physical Therapy.............................................. 903
17. The Knee......................................................... 278 51. Rehabilitation.................................................. 910
18. The Shoulder................................................... 288 52. Principles of Statistics and
19. The Elbow........................................................ 295 Orthopaedic Research..................................... 925
Fractures in Adults 53. Applied Anatomy and Biomechanics............... 934
20. Upper Limb fractures...................................... 299 54. Applied Physiology.......................................... 941
21. Lower Limb fractures...................................... 336 Orthopaedic Pharmacology
22. Malunion and Nonunion................................. 383 55. Analgesics-Anti inflammatory drugs,
23. Trauma Life Support........................................ 406 skeletal muscle relaxants................................ 952
56. Antibiotics....................................................... 960
Hand and Wrist
57. Miscellaneous................................................. 969
24. Hand ............................................................... 439
25. Wrist................................................................ 459 Radiology
26. Miscellaneous hand and wrist disorders......... 476 58. Orthopaedic Radiology................................... 977
27. Hand trauma................................................... 512
Clinical Examination
28. Hand Infections............................................... 521 59. Hip................................................................... 984
Foot and Ankle 60. Knee................................................................ 992
29. Adult foot........................................................ 525 61. Ankle............................................................... 998
30. Paediatric foot ................................................ 545 62. Shoulder........................................................ 1000
31. Trauma............................................................ 551 63. Elbow............................................................ 1006
64. Wrist.............................................................. 1010
Spine 65. Spine............................................................. 1018
32. Spine Trauma................................................... 567 Index.............................................................. 1025
33. Disorders Affecting ......................................... 586 Appendix....................................................... 1032

8 • Orthopaedic Principles
FOREWORD & MESSAGE- CHAIRMAN EDUCATION SICOT

22nd November, 2014

It is my good fortune to write this foreword for Dr. Hitesh Gopalan’s new
edition of Orthopaedic Principles. I wrote the foreword to Orthopaedic
Principles A Review 5 years ago.
In the meantime, Hitesh has been working hard to make this book one of the
most valuable resource for postgraduates and exam going young surgeons,
fellows and practicing surgeons.
The thrust of this edition of Evidence Based Orthopaedic Principles has
been ‘evidence based orthopaedics’ in keeping with the demands of the
modern times. The chapters are very well structured to cover anatomy and
biomechanics, indications and management principles and details. They talk of
pitfalls, complications and special situations, evidence base for management
and new research. As such, each chapter provides a comprehensive approach
and coverage of the topic which would be very useful to the target audience.
Orthopaedics and trauma has been covered very widely and this will be of
great use to the young surgeon.
Whilst congratulating Hitesh and his team, I wish to compliment them for this
mammoth work. I am sure that Evidence Based Orthopaedic Principles will
be a valuable addition to individual and institutional libraries.

Dr. Ashok N. Johari

M.S.Orth., M.Ch.Orth.(Liv)., D.N.B.Orth., D.Ortho.,
F.C.P.S. Orth., F.R.C.S. (Lon)., F.A.M.S.
Director, Children’s Orthopaedic Centre, Mumbai
Editor in chief: Journal of Pediatric Orthopaedics(B)
Chairman, Education and Vice President, SICOT
President: SICOT Orthopaediic World Congress, 2013
Past President: Asia Pacific Knee Society
Indian Orthopaedic Association
Indian Academy of Cerebral Palsy
Paediatric Orthopaedic Society of India

Orthopaedic Principles • 9
 Dedication

“To my teachers, mentors and students who constantly inspire me to write”

H Gopalan

10 • Orthopaedic Principles