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Fracture of the femur neck is considered a "fracture of necessity" as it necessitates an open surgery for optimal results. It is usually seen in elderly individuals as a result of a fall and those who have an unsteady movement or walk and have weak bones. It can also occur in younger individuals due to high velocity injuries like motor vehicle accidents.
For elderly individuals, fracture of the femur neck can be a major cause for morbidity since it leaves most patients motionless. This can further worsen the situation due to pressure sores, chest infections, lack of proper nutrition and minerals and depression. Surgery is recommended as a logical choice even in elderly individuals with multiple disorders to increase mobility which can prevent other medical complications related to being confined to a bed. Studies have shown that in spite of risks, the benefits of surgery are far superior to non-operative treatment.
Classification
Fracture neck of femur is broadly classified as intracapsular and extracapsular fractures.
•    Intracapsular fractures: are those where the fracture occurs within the joint capsule. These fractures are associated with a higher risk since the union of the fracture is required for necessary blood supply to the femoral head, the highest part of the thigh bone connected to the hip.
•    Extracapsular fractures: on the other hand, occurs outside the joint capsule, usually in an area of superior blood supply and hence fracture union is usually not an issue. However, the fractures do have a tendency to unite in the wrong position.
Investigation
•    X-rays help in diagnosis.
•    Further information can be obtained by doing CT scans. This is however, not always necessary.
The surgeon decides on the appropriate surgical choice based on several factors, most important of which is position of the fracture.
Treatment Procedures
Intracapsular fractures in elderly individuals are usually treated by hemiarthroplasty which is essentially a half hip replacement where the femoral head (ball) is replaced by a metallic prosthesis. Recent studies have shown that a total hip replacement may be superior to hemiarthoplasty, but results of long term studies are still awaited.
In younger individuals, an attempt can be made at internal fixation which is a better option than hemiarthroplasty in this age group particularly because of high physical demand. Patients should be informed of the risk of avascular necrosis or non-union which may require further operative interventions. Internal fixation is generally by using screws which are passed across the fracture site. Post-operatively, the patient is mobilised non-weight bearing (till fracture union) if the fracture has been fixed and can be allowed full weight bearing if the femoral head has been replaced.
Extracapsular fractures on the other hand, owing to the superior blood supply in the region of fracture, are amenable to internal fixation. Depending on fracture geometry and stability of the fracture, the fracture may be fixed with a plate and screws called a dynamic hip screw or a nail fixed into the bone, medically called an intra-medullary device. Patients are usually mobilised partial weight bearing after surgery and the results are generally goo

HIP DISLOCATION
The hip joint is formed between the 'ball' of the femoral head and the 'socket' of the acetabulum (hipbone) or the socket in the pelvis, which is surrounded by a cartilage. Strong supporting muscles and ligaments at the joint capsule make this a stable joint. Extreme force is required to cause hip dislocation (except in prosthetic hips) and this means that such injury may be associated with other life-threatening injuries and other fractures. Diagnosing it during the early stages can be beneficial.
Mechanism of injury
Direct trauma, especially road traffic accidents and falls, is the most common cause of hip dislocation. Dashboard injuries have been implicated in this injury as well. Hip dislocation due to car accidents have come down with the development of air bags and use of seat belts.
Congenital dislocation of the hip in infants is a different entity and has been discussed separately in the paediatric orthopaedic section.
Types of Hip Dislocations
Depending on the direction in which the femoral head (ball) moves out of the acetabulum (socket in the pelvis) dislocations are classified as anterior, posterior or central dislocations. Of these, posterior dislocation occurs in 90% of cases.
Investigation
•    Can be diagnosed by x-rays
•    CT scans may be ordered if there is suspicion of an associated fracture. Central dislocations are associated with fracture of the floor of the acetabulum
Treatment Procedures
Hip dislocations are associated with a high incidence of avascular necrosis of the femoral head, a condition where the blood supply to the bone is interrupted due to the injury. Here, the blood supply to the femoral head is disrupted as a result of the dislocation and leads to a slow death of the bone. This then leads to the bone collapsing and eventually leads to arthritis of the hip. This may then require a total hip replacement procedure if the pain doesn't respond to conservative treatment. Hence hip dislocations are treated as an orthopaedic emergency.
Treatment of hip dislocations is by emergency closed reduction. If this fails, the surgeon may need to open the hip joint surgically and reduce the dislocation under vision. This may be all that's necessary for treatment as long as the hip is stable. In central fracture dislocations, once the dislocation is reduced, the acetabulum may need to be reduced and stabilised surgically using plates and screws.

PROXIMAL HUMERUS FRACTURES
A proximal humerus fracture is the most common fracture of the shoulder which occurs at the upper end of the arm bone. Fractures to this region are common both with high-energy injuries in people of all ages, as well as with simple falls usually onto an outstretched hand, in older people with osteoporosis, a condition where the bone density decreases. The upper end of the humerus will break if sufficient force is directed towards it. This fracture in an elderly individual is usually called a "fragility fracture". In younger people, fractures of the shoulder usually occur from high-energy trauma or from a fall from a height.
 
Symptoms
•    General complain of shoulder pain after a fall
•    Swelling and ecchymosis (bruise) in shoulder which can expand into chest wall and lower arm
•    Numbness over the outside of the shoulder indicating auxiliary nerve injury
•    Assess for head injury, Loss of conscious (LOC), cardiac/neurologic reasons for fall.
The fracture may be a simple 2-part one where there is one break and 2 fragments. However, most of the times, the fracture is multi-fragmentary and complicated. The head of the humerus (ball part of the joint) may sometimes be dislocated or even split. Generally these types of fractures are associated with poorer outcomes than the 2-part fractures.
Investigation
•    X-rays are helpful for basic diagnosis of the injury.
•    CT scans provide the surgeon with a 3D picture of the fracture and helps your surgeon plan for surgery.
•    MRI scans, although not routinely necessary, are useful to delineate the soft tissues and in particular the rotator cuff to decide if there is an injury which can be concomitantly repaired.
Treatment Procedures
Non-Surgical:
This is considered in cases where the fracture is undisplaced or in patients who are not medically fit for surgery. It can also be considered in unwilling patients after thoroughly explaining the problems of non-operative management. Treatment is generally by a sling or arm pouch.

Surgical:
Surgery is recommended if the fragments are displaced or comminuted (crushed or splintered bone) or if there is an associated dislocation. There are several different options when surgery is considered and this can be done post diagnosis by the surgeon depending on the age of the patient, fracture configuration, comminution of the fracture and several other important factors. The various options include:
•    Closed reduction and percutaneous pinning (is a technique used for the stabilisation of unstable fractures)
•    Open reduction and internal fixation with plate and screws
•    Hemiarthoplasty- in this the ball part of the joint is replaced with a metallic prosthesis
•    Total shoulder arthroplasty- Both the ball and socket are replaced
•    Reverse total shoulder arthroplasty- this is performed when the rotator cuff is severely damaged or deficient and consists of reversing the ball and socket articulation of the shoulder joint. Hence, the ball shaped prosthesis is fixed to the glenoid and the socket shaped prosthesis is fixed to the upper humerus.
Patients will require a sling post operation until advised by the surgeon. This may be for several weeks. Sometimes metal-work such as pins / wires, plates and screws may need removal once the basic job of the implant is complete. The surgeon will be able to provide more details regarding this.
Rehabilitation post operation is extremely important to the outcome of these injuries. In severe fractures, the expected outcome may be poor with some limitation to shoulder movement. Physical therapy helps reduce the disability to a minimum. These fractures generally require 6-12 weeks to heal completely; however it may take 6 months or more to recover useful function.

WRIST FRACTURE
A wrist fracture is actually a fracture in one of the two bones present in the forearm close to the wrist and is a very common injury. It is particularly more common in patients over 60 years of age due to osteoporosis, a condition where the bone density decreases making it weak. It is believed that about one of every six fractures treated in an emergency room is a wrist fracture. A bone fracture in the radius of the forearm is known as Distal Radius Fracture.
 
Distal Radius Fractures can be termed as follows:
•    Intra-Articular (Joint) Fracture: A fracture that extends into the wrist joint.
•    Extra-Articular Fracture: A fracture that does not extend into the joint.
•    Open Fracture: When a fractured bone breaks the skin, it is called an open fracture. These types of fractures require urgent medical attention because of the risk for infection.
•    Comminuted Fracture: When a bone is broken into more than two pieces, it is called a comminuted fracture.
A fracture is displaced when the fracture fragments are not properly aligned. It is important to classify the type of fracture, because it is a fact that some fractures are more difficult to treat than others. Intra-articular fractures, open fractures, comminuted fractures and displaced fractures are more difficult to treat. In some cases the other bone of the forearm, the ulna or the elbow bone is also broken. This is called a distal ulna fracture.
Causes for Distal Radius Fracture
The most common cause of a distal radius fracture is a fall onto an outstretched arm and it can happen even in healthy bones, if the force and the momentum of the fall are sufficient enough. Therefore, a car accident or a fall off a two-wheeler may generate enough force to break a wrist. In most cases a broken wrist immediately causes pain, tenderness, bruising, and swelling. In a big number of cases, the wrist hangs in an odd or bent way causing gross deformity.
Treatment Procedures
The treatment of broken bones follows just one fundamental principle and that is to put the broken pieces back into position and prevent them from moving out of place until they are healed through natural processes. There are several known treatment options for distal radius fracture which may either be through a surgical or a non-surgical mode. Choice of treatment also depends on several other factors line comminution, nature of the fracture, age of the patient, activities he/she most commonly indulges in and to a big extent upon the personal preference of the surgeon at hand.
Undisplaced fractures can be treated in a cast for about 4-6 weeks. Doctors usually recommend surgery when the fracture is displaced. Surgery is generally to realign the fracture and stabilise the fracture. This can be done using wires which are passed through the skin without a surgical incision.
Depending on the nature of the fracture, the doctor may recommend fixation using a plate and screws. After surgery patients will require a plaster splint for a few weeks. Wires are generally removed after 4-6 weeks. After the fracture has united, physical therapy is needed to help regain wrist movements.
ANKLE FRACTURES
A fracture around the ankle joint is a common injury. It is especially important to treat these fractures properly since our feet and ankles are necessary for walking and weight bearing.
 
The foot itself contains 26 bones and the ankle joint actually involves three bones. A broken ankle can involve one or more bones, as well as injuring the surrounding connecting tissues such as ligaments and capsule.
Mechanism and Symptoms
Fractures around the ankle can occur as a result of a fall, twisting injury, a motor vehicle accident or some other trauma to the ankle. Because a severe sprain can often mask the symptoms of a broken ankle, every injury to the ankle should be examined by a physician.
Symptoms of a broken ankle include:
•    Immediate and severe pain
•    Swelling
•    Bruising
•    Tender to the touch
•    Inability to put any weight on the injured foot
•    Deformity, particularly if there is a dislocation of the joint as well as a fracture
Investigation
•    X-rays help in identifying the exact location of the fracture. In children an x-ray of the opposite normal ankle may be asked for a comparison to see subtle changes in growth plates due to injury.
•    Sometimes a CT (computed tomography) scan or a bone scan will also be needed to better understand the anatomy of the injury to plan for further treatment
Treatment Procedures
Ankle fractures may be treated non-operatively using a splint device to restrict movement of the fracture area, the use of pain killers to subdue the pain, or a rest and limb elevation which allows you lie down on a bed with a sling rest lifting the leg in a position above the heart. A cast may be used for definitive treatment when fractures are relatively undisplaced for about 4-6 weeks depending on the severity of the fracture.
Surgery may be indicated for most ankle fractures particularly if they are displaced. The goal is always to achieve anatomical reduction which means the optimal reformation of the fracture bones to maintain alignment of the broken bones. The surgeon may use a plate, metal or absorbable screws or wires to hold the bones in place.
After surgery, patients will be placed into a splint to rest the ankle and allow the tissues to settle down and to aid in healing. Patients will be provided with crutches and taught how to walk without putting any weight on your operated ankle (non-weight bearing). Patients will be put into physiotherapy later on to rehabilitate the ankle joint and strengthen it. This improves range of motion of the joint.
Recovery time varies depending upon the type of fracture or need for surgery. The average fracture requires 6-8 weeks for the bone to heal, after which weight bearing may be allowed in a gradual manner. Sometimes fractures may need a longer time to heal and may require secondary surgical procedures particularly if the bones fail to heal or to remove the metal-work.
Fractures of any type increase the likelihood of developing arthritis in the affected joint. The more severe the fracture, the higher the risk of developing some degree of arthritis.
ANKLE SPRAIN
An ankle sprain refers to stretching or tearing of the ligaments of the ankle. Most common ankle sprain occurs on the lateral or outside part of the ankle. It can also be associated with fracture of the ankle occasionally.
 
Symptoms and Clinical Presentation
Most patients present with a twisting injury of the ankle. This is mostly an inversion injury, which means the foot rolls underneath the ankle or leg which can commonly occur during sports. There is pain on the outside of their ankle along with some swelling and bruising. Depending on the severity of the sprain, a person may or may not be able to put weight on the foot and walk.
Diagnosis
It can be diagnosed fairly easily given that they are common injuries. The location of pain on the outside of the ankle with tenderness and swelling just below the prominent bone on the outside of the ankle called the lateral malleolus. Normal x-rays suggest that the bone has not been broken and instead the ankle ligaments have been torn or sprained.
An ankle sprain is graded based on severity of injury. It may only involve stretching of a few fibres, may be partially or completely torn. A complete tear of the ligaments is uncommon.
However it is very important, not to simply regard any ankle injury as an "ankle sprain" because other injuries can occur as well, for example, the peroneal tendons (the tendons that are behind the outer ankle bone) can be torn, fractures in other bones around the ankle could be a possibility.
In some cases, an MRI may be warranted to rule out other problems in the ankle such as damage to the cartilage (a flexible connecting tissue). An MRI, however, is not necessary to diagnose a sprain.
Treatment Procedures
The grade of the sprain will dictate treatment. Surgery is not required in the vast majority of ankle sprains. Primary treatment of ankle sprains includes RICE which is a combination of rest, ice, compression bandaging and limb elevation. A temporary cast may also be required in order to provide immobilization of the ankle joint. Physiotherapy to strengthen the muscles around the ankle may be necessary after the primary treatment.
Minor injuries recover quickly within a few weeks. More severe injuries and injuries in athletic individuals, may take a longer time to recover. Outcome is generally good and most patients heal from an ankle sprain and are able to get back to their normal lives, sports, and activities. Some people, however, who do not properly rehabilitate their ankle or have had a severe sprain, may go on to have ankle instability. Repeated episodes can be dangerous because they can lead to cartilage damage within the ankle and may require surgery.
Surgery is rarely indicated when in spite of appropriate conservative treatment and physical therapy, the ankle joint continues to feels unstable and frequently gives way. Here, the ligaments are either repaired or reconstructed (using tendon grafts which involves replacing damaged tendons by borrowing them from a different area in the body)

Paediatrics:
FLAT FOOT
When you stand up, if the entire inner border of foot touches the ground it is called flatfoot. Flatfeet are common in children, almost universal before 3 years of age.
Most flatfeet in children are flexible, i.e the curvature of inner border of feet is re-formed when the child is off the feet or stands on tip of toes. It is considered normal (physiological) and is because of laxity (looseness) of kids' ligaments and excess fat underneath the skin of foot.
If the flatfeet are rigid (inflexible) or painful, you should consult your doctor to rule out serious causes, prominent being abnormal bony connection between feet bones (tarsal coalition) and tight heel cord due to neurological problems (cerebral palsy, hereditary neuropathies). Problems with ligaments, muscles, joints, bones and the nervous system can all contribute to flat feet. Many syndromes have flatfeet as a component.
Besides flatness of feet, parents complain about abnormal way of walking (foot turned out) or abnormal shoe wear. When the child complains of pain in feet, especially dull ache at the end of playing, it is preferable to consult the doctor. Pain in knee / hips might also be due to flatfeet.
Investigations are not required in flexible flatfeet. Relevant investigations will be required when other causes are suspected.
Most flexible flatfeet will correct by around 10 years. No shoe modifications / inserts or special shoes (orthotics) are needed unless the flatfeet are inflexible or painful. Please note that special shoes do not change the shape of bones, but only relieve pain. Surgery might be needed depending on the symptoms and underlying causes, if any that warrants such treatment.
IN-TOEING & OUT-TOEING
In-toeing and out-toeing is one of the common causes for referrals to the paediatric orthopaedic surgeon. In-toeing is more common than out-toeing, with most cases being benign afflictions with no functional consequences.
When a child presents with toeing in/out problems, evaluation focuses on ruling out any underlying cause before labelling it as benign. Most children however have what is called physiological (normal) flatfeet due to looseness (laxity) of ligaments or excess chubby fat underneath the skin, which is normal. Unilateral or asymmetrical deformities are more likely to be secondary to underlying diseases/ defects. Diseases affecting bones, ligaments, muscles, joints or nerves may all cause flatfeet. Problems in knee/hip or rarely back also may masquerade as toeing problems
Age at presentation gives a rough idea of the most probable site of affection. For example, in-toeing presenting before 3 years of age is most likely to be due to the shin bone turning in (tibial intorsion), whereas, beyond 3 years, excessive thigh bone rotation (femoral anteversion) is a more common cause.
Investigation
Investigations are not required for diagnosing toeing in/out. They are required only when other problems are suspected to be causing them.
Management
Management depends on the age at presentation, the level at which the deformity occurs and the underlying cause, if any, braces and special shoes are universally ineffective. Reassurance explaining the natural course of resolution of the problem, is enough most of the times, besides regular (usually yearly) reviews. The need for surgery is mainly dictated by the functional impairment caused by these deformities, rarely ever for cosmetic concerns.
DISLOCATION OF HIP
Congenital dislocation of hip (recently called developmental dysplasia of hip or DDH) is detected quite late in the Indian scenario. It is not very common in India, incidence being approximately 0.1% (1 per 1000) in South India. What causes DDH is largely unknown; if someone in family has it, others are more likely to get it (genetic predisposition). Also, some other risk factors have been identified (first born female child with breech (bottom down) presentation at birth).
DDH encompasses a wide spectrum of disorders which presents itself at different ages with different symptoms.
Especially when a child is affected parents are always on the run for the best spine surgeons in Bangalore. In a non walking child, DDH usually presents as shortness of thigh compared to the opposite side, additional skin creases on the thigh on affected side or reduced outward movement at hip (abduction) specially noticed while changing diapers.
When the child with DDH starts walking, parents notice either a lurch to one side or duck like waddle (when problem is on both sides). Besides, parents also bring children with complaints of out-toeing (feet turned out- Like Charlie Chaplin). The affected leg is short; may manifest as lurch, toe walking on one side or abnormal curvature of spine.
Before 6 months of age, Ultrasound is effective in diagnosing the problem. Afterwards, X- rays are helpful.
When detected early, treatment is simple. Special belts (Pavlik harness) or braces are effective in newborns. Special plasters (hip spica) are required at a later age while surgery is often required when it is detected very late.
JOINT REPLACEMENTS
Manipal hospital, established in 1991 has all specialties under one roof which allows comprehensive multidisciplinary care of polytrauma patients. The departments of Emergency Services & Intensive Care units are well equipped to receive poly trauma patients.
Manipal Hospital's Joint Replacement Center performs hundreds of joint replacements each year and earns high praise from patients and their families. We offer a comprehensive program with personalized care, excellent outcomes, and superior satisfaction.
Working in collaboration with national joint care experts and area orthopedic specialists, Manipal Hospital is renowned for Joint replacement surgeries across India and overseas. The infrastructure and facilities are world-class within the joint replacement surgery centre.
The foot itself contains 26 bones and the ankle joint actually involves three bones. A broken ankle can involve one or more bones, as well as injuring the surrounding connecting tissues such as ligaments and capsule.
The foot itself contains 26 bones and the ankle joint actually involves three bones. A broken ankle can involve one or more bones, as well as injuring the surrounding connecting tissues such as ligaments and capsule.
Our Exclusive Joint Replacement Operation Theater has:
•    Custom built Vertical Laminar Airflow (Air Handling Unit) with Imported HEPA filers with 150 feet/min. air velocity
•    State of the Art Ortho Navigation System
•    Internal Positive Pressure within Operation Theatre
•    State of the Art C-arm with 9 inch (IITV), Rotating Anode Tube
•    Advanced Orthopedic Table with all accessories
•    Arthroscopes
•    Imported surgical instruments Conforming to International Standards
If you have chronic joint pain, life's simple tasks can become major challenges. While medication and targeted exercise can offer temporary comfort, joint replacement is often the best choice for lasting pain relief and return to an active, independent lifestyle. We offer a range of options to relieve joint pain and restore mobility including: Our panel of consultant comprises of highly qualified General Physicians. Their clinical skills are supported by excellent laboratory and investigatory facilities. A brief of the various services offered by this unit include -
•    Total Knee Replacement
•    Partial Knee Replacement
•    Custom fit Knee Replacement
•    Minimally invasive Knee replacement
•    Computer Assisted Knee Replacement
•    Total Hip Replacement
•    Hip Resurfacing
•    Shoulder Replacements
•    Elbow Replacements
•    Wrist Replacements
Joint Replacement Center gets patients moving again in a supportive environment. Exercise and therapy are provided in a group setting so patients can encourage each other on the road to recovery. Family members and friends are welcome to serve as coaches to motivate patients during their stay and assist when they return home.
Over time, cartilage that cushions joint bones can wear, cause discomfort, and make simple activities like walking difficult. Knee replacement can reduce or eliminate pain, allow easier movement and help restore an active, independent life. Knee replacement surgery may be considered for patients with arthritic knee pain that severely limits their daily activities. Many types of knee implants are available today. Your surgeon will select an implant that best suits your needs, taking into consideration such factors as age, activity level and the implant's characteristics.

Partial knee replacement surgery resurfaces worn surfaces of the knee with metal and plastic components. Over time, cartilage that cushions joint bones can wear, cause discomfort and reduced mobility. Partial knee replacement may be an option for patients with arthritis limited to one area of the knee. There are some advantages of partial knee replacement when compared with total knee replacement. Because a smaller area of the knee is affected, the implants are smaller, allowing surgeons to use smaller incisions. In addition, there is less trauma to the bone and surrounding tissue and often a quicker recovery time when compared with total knee replacement. Your surgeon can determine if partial knee replacement is an option for you.
Total hip replacement surgery can reduce or eliminate pain, allow easier movement and help restore an active, independent life. Hip replacement surgery may be considered for patients with arthritic hip pain that severely limits their daily activities

Lasting Pain Relief for Younger, Active People If you're an active adult with chronic hip pain, a procedure called hip resurfacing may be the answer for you. It's a variation of total hip replacement that can provide lasting pain relief and allow you to continue your active life. Physicians often advise patients with hip pain to hold off as long as possible before getting a hip replacement. That's because total hip replacements usually last about 20 years so younger patients may need another replacement later in life. With hip resurfacing, the present arthritis can be effectively treated with an implant that limits the amount of bone removed. This is important in the event future surgery is required. Hip Resurfacing Benefits
•    Bone-Saving - With Hip Resurfacing , the ball and socket are resurfaced rather than completely replaced. The size of the implant may also help retain hip stability and range of movement.
•    Pain Relief - Hip Resurfacing implants offer many years of pain relief.
•    Activities - With Hip Resurfacing, many patients find they are able to resume participation in most low impact activities safely, free from the pain and stiffness they had before surgery.

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