NAME: HASSAN JAVED

ROLL NO: 217

DISCIPLINE: BS MIT (6TH SEMESTER)
SUBJECT: GENERAL SURGERY II
SUBMITTED TO: MR. RIAZ
TOPIC: DISEASES OF BONES AND
JOINTS
 1. Acute Osteomyelitis

1. Definition:

Acute osteomyelitis is defined as a bone infection of less than two weeks’ duration,
characterized by inflammation, suppuration, vascular compromise, and possible bone
necrosis if untreated.

2. Etiology and Causative Organisms:

Common Causative Organisms:

• Staphylococcus aureus (most common)

• Streptococcus species
• Gram-negative bacilli (e.g., E. coli, Pseudomonas)
• Salmonella species (especially in sickle cell disease)

Sources of Infection:

• Hematogenous spread (most common in children)

• Direct inoculation
• Open fractures
• Orthopedic surgery
• Contiguous spread
• From soft tissue infections
• Diabetic foot ulcers

3. Pathophysiology:

The infection usually begins in the metaphysis of long bones due to sluggish blood flow and
absence of phagocytic cells.

• Bacteria lodge in metaphyseal capillaries

• Acute inflammatory response causes pus formation
• Increased intramedullary pressure leads to:
• Vascular thrombosis
• Bone ischemia
 • Necrotic bone fragment forms (sequestrum)
• New bone formation around necrotic bone (involucrum)
• If untreated, this progresses to chronic osteomyelitis.

4. Epidemiology:

• More common in children and adolescents

• Male predominance
• Frequently affected bones:
• Femur
• Tibia
• Humerus
• In adults: vertebrae and pelvic bones

5. Clinical Features:

General Symptoms:

• Fever and chills

• Malaise
• Toxic appearance in severe cases

Local Symptoms:

• Severe bone pain

• Swelling and tenderness
• Redness and warmth
• Restricted movement of nearby joint

Special Presentations:

• Infants: irritability, pseudoparalysis

• Adults: back pain (vertebral osteomyelitis)

6. Investigations:

Laboratory Tests:

• Raised ESR and CRP

 • Leukocytosis
• Blood cultures (positive in ~50%)

Imaging:

• X-ray: normal in early stages; later shows bone destruction

• MRI: investigation of choice (early detection)
• CT scan: helpful for cortical bone involvement
• Bone scan: useful when MRI is unavailable

Definitive Diagnosis:

• Bone biopsy and culture (gold standard)

7. Management:

Medical Management:

• Immediate IV broad-spectrum antibiotics

• Later adjusted according to culture
• Common regimens:
• Anti-staphylococcal penicillins
• Cephalosporins
• Vancomycin (MRSA)
• Duration: 4–6 weeks

Surgical Management:

Indications:

• Failure of medical treatment

• Abscess formation
• Presence of sequestrum
• Raised intramedullary pressure

Procedures:

• Surgical drainage
• Debridement of necrotic bone
• Sequestrectomy (if required)
8. Complications:

• Chronic osteomyelitis
• Growth plate damage (children)
• Pathological fractures
• Septicemia
• Amyloidosis (rare, long-standing cases)

9. Prevention:

• Prompt treatment of infections

• Proper wound care in trauma
• Strict aseptic techniques during surgery
• Early management of diabetic foot infections

2. Tuberculosis arthritis

1. Definition:

Tuberculous arthritis is a chronic granulomatous infection of a joint, caused by

Mycobacterium tuberculosis, characterized by synovial inflammation, cartilage
destruction, and gradual joint deformity.

2. Etiology and Risk Factors:

Causative Organism:

• Mycobacterium tuberculosis.
• Mode of Spread
• Hematogenous spread from a primary focus (lungs, lymph nodes)
• Reactivation of latent infection
• Direct extension from adjacent tuberculous osteomyelitis (rare)

Risk Factors:

• Pulmonary tuberculosis
• Malnutrition
• Immunosuppression (HIV, steroids)
 • Diabetes mellitus
• Low socioeconomic status
• Children and elderly patients

3. Pathophysiology:

• Tuberculous arthritis usually begins in the synovium, which has rich blood supply.
• Bacilli lodge in synovial membrane
• Chronic granulomatous inflammation develops
• Formation of caseating granulomas
• Progressive synovial hypertrophy (pannus formation)
• Cartilage erosion and bone destruction
• Fibrosis leading to joint stiffness and deformity
• The disease progresses slowly, often leading to late diagnosis.

4. Epidemiology:

• Common in developing countries

• Accounts for ~15% of extrapulmonary TB
• Monoarticular involvement is typical
• Most commonly affected joints:
• Knee (most common)
• Hip
• Ankle
• Wrist
• Elbow
• Spine involvement is termed Pott’s disease (separate entity)

5. Clinical Features:

General Symptoms:

• Low-grade fever
• Weight loss
• Night sweats
• Fatigue
Local Joint Symptoms:

• Gradual onset joint pain

• Swelling and stiffness
• Reduced range of motion
• Cold abscess formation
• Minimal redness and warmth (unlike pyogenic arthritis)

Late Features:

• Joint deformity
• Muscle wasting
• Sinus tract formation (rare)
• Limb shortening (children)

6. Stages of Tuberculous Arthritis:

• Synovitis stage – mild pain, effusion

• Early arthritis stage – cartilage destruction
• Advanced arthritis stage – joint space narrowing
• Fibrous ankylosis stage – joint stiffness
• Bony ankylosis stage – complete joint fusion

7. Investigations:

Laboratory Tests:

• Raised ESR
• Mild anemia
• Positive Mantoux test
• Interferon Gamma Release Assays (IGRA)

Imaging:

• X-ray findings (Phemister’s triad):

• Juxta-articular osteopenia
• Peripheral bone erosions
• Gradual joint space narrowing
• MRI: investigation of choice
 • Early synovial involvement
• Bone marrow edema
• Soft tissue abscess

Definitive Diagnosis:

Synovial biopsy showing:

Caseating granulomas, Langhans giant cells, Ziehl–Neelsen staining for AFB, Culture on
Lowenstein–Jensen medium

7. Differential Diagnosis:

• Rheumatoid arthritis
• Septic (pyogenic) arthritis
• Osteoarthritis
• Gouty arthritis
• Synovial tumors

8. Management:

Medical Management:

The cornerstone of treatment is anti-tuberculous therapy (ATT).

Standard Regimen:

Intensive phase (2 months):

• Isoniazid
• Rifampicin
• Pyrazinamide
• Ethambutol

Continuation phase (10 months):

• Isoniazid + Rifampicin
• Total duration: 12 months

Surgical Management:

Indications:
 • Diagnostic uncertainty
• Failure of medical therapy
• Large abscess or sinus
• Severe joint destruction

Procedures:

• Synovectomy
• Drainage of cold abscess
• Debridement
• Arthrodesis in advanced cases
• Joint replacement (selected cases after disease control)

9. Complications:

• Permanent joint deformity

• Fibrous or bony ankylosis
• Secondary bacterial infection
• Limb length discrepancy (children)
• Functional disability

10. Prevention:

• Early detection and treatment of pulmonary TB

• BCG vaccination
• Improved nutrition and living conditions
• Screening of high-risk individuals

3. Tenosynovitis

1. Definition:

Tenosynovitis is a pathological condition characterized by inflammation of a tendon and its

surrounding synovial sheath.
2. Etiology (Causes):

Tenosynovitis may be classified based on etiology into infective and non-infective types.

A. Infective Tenosynovitis:

Usually caused by bacterial infection. Common organisms:

• Staphylococcus aureus (most common)

• Streptococcus species

Routes of infection:

• Penetrating trauma
• Animal or human bites
• Spread from adjacent infection
• Hematogenous spread (rare)

B. Non-Infective Tenosynovitis:

• Repetitive strain or overuse

• Rheumatoid arthritis
• Gout
• Diabetes mellitus
• Occupational activities (e.g., typing, manual labor)
• Degenerative changes

3. Types of Tenosynovitis:

1. Acute Pyogenic (Suppurative) Tenosynovitis

• Surgical emergency
• Common in flexor tendons of the hand
• Rapid onset and severe symptoms

2. Chronic Tenosynovitis

• Gradual onset
• Often associated with systemic diseases
• Thickening of tendon sheath

3. De Quervain’s Tenosynovitis

• Affects abductor pollicis longus and extensor pollicis brevis

 • Common in middle-aged women
• Associated with repetitive thumb movements

4. Stenosing Tenosynovitis (Trigger Finger)

• Thickened tendon sheath causes locking of finger

• Common in diabetics

4. Clinical Features:

General Symptoms:

• Pain along the tendon and Restricted movement

• Swelling and Tenderness
• Specific Features of Acute Flexor Tenosynovitis (Kanavel’s Signs)
• Fusiform swelling of the finger
• Finger held in slight flexion
• Severe pain on passive extension.

5. Diagnosis:

A. Clinical Examination

• Primary and most important tool

• History of trauma, overuse, or infection

B. Laboratory Investigations

• Raised ESR and CRP

• Elevated white blood cell count (in infective cases)

C. Imaging

• Ultrasound: Fluid collection, thickened sheath

• MRI: Gold standard for detailed soft tissue evaluation
• X-ray: To rule out foreign body or bony involvement

6. Management:

A. Conservative Treatment (For non-infective cases)

 • Rest and immobilization
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Physiotherapy
• Corticosteroid injections (with caution)

B. Surgical Treatment (Indicated in infective or refractory cases)

• Emergency incision and drainage

• Synovectomy
• Tendon sheath irrigation
• Broad-spectrum antibiotics followed by culture-guided therapy

7. Complications:

• Tendon rupture
• Joint stiffness and Chronic pain
• Spread of infection
• Permanent loss of function
• Septicemia (in severe infective cases)

8. Prevention:

• Early treatment of hand injuries

• Proper wound care
• Ergonomic workplace practices
• Control of systemic diseases (e.g., diabetes)
• Avoid repetitive strain without rest

4. Tumors of Bones
1. Introduction:

Bone tumors are abnormal proliferations of cells arising from bone tissue or its constituent
elements such as osteoid, cartilage, fibrous tissue, bone marrow, or vascular components.

2. Classification of Bone Tumors:

Bone tumors are classified according to biological behavior and tissue of origin.
A. Benign Bone Tumors:

1. Osteoma:

• Composed of mature bone

• Common in skull and facial bones
• Usually asymptomatic

2. Osteoid Osteoma:

• Small, painful lesion

• Pain worse at night
• Relieved by NSAIDs
• Common in young adults

3. Osteoblastoma:

• Larger and less painful than osteoid osteoma

• Common in vertebrae

4. Chondroma (Enchondroma)

• Benign cartilage tumor

• Common in small bones of hands and feet
• Giant Cell Tumor
• Locally aggressive
• Occurs near epiphysis
• Common around knee

B. Malignant Bone Tumors:

1. Osteosarcoma

• Most common primary malignant bone tumor

• Occurs in adolescents and young adults
• Arises from metaphysis of long bones
• Highly aggressive

2. Chondrosarcoma

• Malignant cartilage-forming tumor

• Common in middle-aged and elderly
• Pelvis, ribs, shoulder girdle commonly affected
3. Ewing’s Sarcoma

• Highly malignant round cell tumor

• Common in children and adolescents
• Diaphysis of long bones affected

4. Fibrosarcoma

• Rare malignant tumor of fibrous tissue

C. Secondary (Metastatic) Bone Tumors:

• Most common malignant tumors of bone

• Common primary sites:
• Breast, Lung
• Prostate, Kidney
• Thyroid
• Usually affect spine, pelvis, ribs

3. Etiology and Risk Factors:

• Genetic mutations
• Ionizing radiation
• Paget’s disease of bone
• Chronic osteomyelitis
• Previous trauma (controversial)
• Age-related factors

4. Clinical Features:

A. General Symptoms:

• Persistent bone pain

• Swelling or palpable mass
• Pathological fractures
• Restricted movement (near joints)

B. Features Suggestive of Malignancy:

• Progressive pain and fever

• Night pain
• Weight loss and Anemia
5. Diagnostic Evaluation:

A. Clinical Examination:

• Inspection and palpation

• Assessment of tenderness and swelling
• Evaluation of limb function

B. Radiological Investigations

• X-ray: Initial investigation

• Lytic or sclerotic lesions
• Periosteal reaction (sunburst, Codman triangle)
• CT Scan: Cortical involvement
• MRI: Soft tissue extension (gold standard)
• Bone Scan: Metastasis detection

C. Laboratory Tests

• Elevated alkaline phosphatase

• ESR and CRP

D. Biopsy

• Core needle or open biopsy

• Must follow oncological principles

6. Staging of Bone Tumors:

Enneking staging system. Based on:

• Grade
• Local extent
• Presence of metastasis

7. Management:

A. Benign Bone Tumors

• Observation
• Curettage
 • Bone grafting
• Radiofrequency ablation (osteoid osteoma)

B. Malignant Bone Tumors

• Neoadjuvant chemotherapy
• Wide surgical excision
• Limb salvage surgery
• Radiotherapy (selective cases)
• Amputation (advanced disease)

C. Metastatic Bone Disease

• Palliative radiotherapy
• Surgical stabilization
• Bisphosphonates
• Pain management

8. Complications:

• Pathological fractures
• Recurrence
• Metastasis (lungs common)
• Growth disturbances (children)
• Neurovascular compromise

5. Tumors of Joints
1. Introduction:

Tumors of joints are uncommon pathological entities that arise from the tissues forming or
surrounding a joint, including synovium, cartilage, bone, ligaments, and periarticular soft
tissues.

2. Classification of Joint Tumors:

Joint tumors are classified based on tissue of origin and biological behavior.
A. Benign Tumors of Joints

1. Synovial Chondromatosis

• Benign metaplastic condition of synovium

• Formation of cartilaginous nodules within joint
• Commonly affects knee and hip

2. Pigmented Villonodular Synovitis (PVNS)

• Locally aggressive benign synovial tumor

• Characterized by hemosiderin deposition
• Common in knee, hip, and ankle

3. Ganglion Cyst

• Cystic swelling near joint capsule or tendon sheath

• Contains gelatinous fluid
• Common around wrist and ankle

4. Lipoma Arborescens

• Rare benign synovial lesion

• Villous lipomatous proliferation
• Associated with chronic joint disease

B. Malignant Tumors of Joints

1. Synovial Sarcoma

• Most common malignant periarticular tumor

• Occurs in young adults
• Often near knee or ankle
• Highly aggressive with metastatic potential

2. Chondrosarcoma

• Malignant cartilage-forming tumor

• May involve joint cartilage or adjacent bone
• Slow growing but locally destructive

3. Osteosarcoma (Juxta-articular)

• Arises near metaphysis close to joint

• Aggressive and rapidly progressive
C. Secondary (Metastatic) Tumors

• Spread from primary malignancies such as:

• Breast, Lung, Prostate, Rarely present as primary joint pathology

3. Etiology and Risk Factors:

• Genetic mutations
• Chronic inflammation
• Previous radiation exposure
• Trauma (controversial association)
• Degenerative joint disease
• Age and sex predilection

4. Clinical Presentation:

A. Common Symptoms:

• Persistent joint pain

• Swelling or mass near joint
• Reduced range of motion
• Joint stiffness

B. Mechanical symptoms (locking, clicking):

• Features Suggestive of Malignancy

• Rapid increase in size
• Night pain, Weight loss and Local warmth
• Neurovascular compromise

5. Diagnostic Evaluation:

A. Clinical Examination

• Inspection and palpation of joint

• Assessment of movement
• Neurovascular status

B. Imaging Studies

• X-ray: Bony erosion, calcification

 • Ultrasound: Soft tissue masses, cystic lesions
• MRI: Gold standard for joint tumors
• CT Scan: Bone involvement and staging

C. Laboratory Investigations

• ESR and CRP (inflammatory markers)

• Alkaline phosphatase (bone tumors)

D. Biopsy

• Core needle or open biopsy

• Must be planned carefully to avoid tumor spread

6. Management:

A. Benign Tumors

• Observation in asymptomatic cases

• Surgical excision
• Arthroscopic synovectomy
• Physiotherapy post-surgery

B. Malignant Tumors

• Wide surgical excision

• Limb-salvage surgery
• Chemotherapy
• Radiotherapy (adjuvant or neoadjuvant)
• Amputation (in advanced cases)

7. Complications:

• Joint stiffness
• Recurrence
• Pathological fracture
• Metastasis (lungs most common)
• Neurovascular injury
5. Spinal Deformity
1. Introduction:

Spinal deformity refers to abnormal curvature or alignment of the vertebral column,

resulting in altered posture, imbalance, and sometimes neurological compromise. The
normal spine has physiological curves that help maintain balance and distribute
mechanical stress. Any exaggeration, reduction, or lateral deviation of these curves
constitutes a spinal deformity.

2. Normal Anatomy and Curvatures of the Spine:

The vertebral column consists of:

• 7 cervical vertebrae
• 12 thoracic vertebrae
• 5 lumbar vertebrae
• Sacrum and coccyx

Physiological Curves:

• Cervical lordosis
• Thoracic kyphosis
• Lumbar lordosis

These curves maintain upright posture and balance.

3. Classification of Spinal Deformities:

Spinal deformities are classified according to plane of deformity and etiology.

A. Based on Plane of Deformity

1. Scoliosis

• Lateral curvature of the spine >10°

• Associated with vertebral rotation
• Most common spinal deformity

2. Kyphosis

• Exaggerated posterior convexity

 • Common in thoracic spine

3. Lordosis

• Exaggerated anterior curvature

• Commonly affects lumbar spine

B. Based on Etiology

1. Congenital

• Vertebral formation or segmentation defects

• Present at birth

2. Idiopathic

• Most common cause

• Adolescent idiopathic scoliosis

3. Neuromuscular

• Due to muscle imbalance

• Seen in cerebral palsy, poliomyelitis

4. Degenerative

• Seen in elderly
• Due to disc degeneration and osteoporosis

5. Post-traumatic

• Following vertebral fractures

6. Infective

• Spinal tuberculosis (Pott’s disease)

4. Etiology and Risk Factors:

• Genetic predisposition
• Congenital vertebral anomalies
• Neuromuscular disorders
• Trauma
• Infections
 • Poor posture
• Osteoporosis

5. Clinical Features:

A. General Symptoms

• Visible spinal curvature

• Unequal shoulder or hip height
• Back pain
• Fatigue
• Cosmetic deformity

B. Neurological Symptoms

• Weakness
• Sensory loss
• Bowel or bladder dysfunction (severe cases)

C. Systemic Effects

• Respiratory compromise (severe kyphoscoliosis)

• Reduced exercise tolerance

6. Examination of a Patient with Spinal Deformity:

• Inspection from front, side, and back

• Adam’s forward bend test (for scoliosis)
• Palpation of spinous processes
• Assessment of limb length
• Neurological examination

7. Diagnostic Evaluation:

A. Radiological Investigations

• X-ray spine (AP and lateral views): Measurement of Cobb’s angle

• MRI: Spinal cord and soft tissue evaluation
• CT scan: Bony anatomy and deformity details
B. Laboratory Tests

• ESR and CRP (in infective causes)

8. Management:

A. Conservative Management

• Observation and regular follow-up

• Physiotherapy
• Postural training
• Bracing (especially in scoliosis)
• Analgesics

B. Surgical Management (Indicated in severe or progressive deformities)

• Spinal fusion
• Instrumentation with rods and screws
• Decompression in neurological compromise

9. Complications:

• Progression of deformity
• Chronic pain
• Neurological deficits
• Respiratory compromise
• Psychological impact

10. Prevention:

• Early screening in school children

• Proper posture education
• Treatment of spinal infections
• Prevention of osteoporosis
• Early management of trauma
 6. Congenital Disorders

1. Introduction:

Congenital disorders of bones and joints are structural or functional abnormalities present
at birth that affect the skeletal system. These disorders arise due to defective
embryological development, genetic mutations, or intrauterine environmental factors. They
may involve bones, joints, muscles, or connective tissues, leading to deformity, impaired
mobility, and functional disability..

2. Embryological Basis:

The skeletal system develops from mesoderm and neural crest cells. Abnormalities may
occur due to:

• Failure of formation
• Failure of segmentation
• Failure of differentiation
• Disruption during critical stages of embryogenesis results in congenital skeletal
anomalies.

3. Classification of Congenital Disorders:

Congenital disorders of bones and joints may be classified as follows:

A. Congenital Disorders of Bones:

1. Achondroplasia:

• Most common cause of dwarfism

• Autosomal dominant
• Characterized by short limbs, normal trunk

2. Osteogenesis Imperfecta:

• Defective collagen formation

• Brittle bones with frequent fractures
• Blue sclera, hearing loss
3. Congenital Absence or Hypoplasia of Bones:

• Absence of radius, fibula, or digits

• Associated with limb length discrepancy

B. Congenital Disorders of Joints:

1. Congenital Dislocation of the Hip (Developmental Dysplasia of the Hip – DDH):

• Inadequate development of acetabulum

• Common in female infants
• Positive Ortolani and Barlow tests

2. Congenital Talipes Equinovarus (Clubfoot):

• Deformity of foot present at birth

• Components: equinus, varus, adduction, cavus

3. Arthrogryposis Multiplex Congenita:

• Multiple joint contractures at birth

• Due to decreased fetal movement

C. Congenital Spinal Disorders:

1. Congenital Scoliosis:

• Due to vertebral anomalies

• Progressive curvature

2. Spina Bifida:

• Failure of closure of neural tube

• May be associated with bony defects

4. Etiology and Risk Factors:

• Genetic abnormalities
• Chromosomal disorders
• Maternal infections
• Drug exposure during pregnancy
• Radiation exposure
• Nutritional deficiencies (e.g., folic acid)
5. Clinical Presentation:

• Deformity present at birth

• Restricted joint movement
• Limb length discrepancy
• Abnormal gait (older children)
• Delayed milestones

6. Diagnosis:

A. Antenatal Diagnosis

• Ultrasonography
• Genetic screening

B. Postnatal Diagnosis

• Clinical examination
• X-ray of affected bones/joints
• Ultrasound (especially for hip dysplasia)
• MRI or CT scan (selected cases)

7. Management:

A. Conservative Management

• Observation
• Splintage and casting
• Physiotherapy
• Orthotic devices

B. Surgical Management

• Corrective osteotomy
• Joint reduction
• Soft tissue release
• Limb lengthening procedures

Management depends on severity, age, and functional impairment.

8. Complications:

• Permanent deformity
• Joint stiffness
• Early-onset osteoarthritis
• Psychological impact
• Functional disability

9. Prevention:

• Genetic counseling
• Adequate antenatal care
• Avoidance of teratogenic drugs
• Folic acid supplementation
• Early neonatal screening