LMCC Orthopedic Review LectureLMCC Orthopedic Review LectureApril, 2013April, 2013

““Back to Basics”Back to Basics”

Dr. P.R. ThurstonDr. P.R. Thurston

&&FracturesFractures

DislocationsDislocations

DefinitionsDefinitions

Fracture:-Fracture:- A discontinuity in the A discontinuity in the structuralstructural integrity of a bone.integrity of a bone.

Infraction:-Infraction:- An incomplete fracture.An incomplete fracture.

Dislocation:-Dislocation:- Complete loss of contact of the Complete loss of contact of the articular surfaces of a articular surfaces of a joint.joint.

Subluxation:-Subluxation:- Non-concentric joint surfaces.Non-concentric joint surfaces.

Reduction:-Reduction:- Returning a fracture or dislocation to Returning a fracture or dislocation to an an anatomical alignment.anatomical alignment.

Comminution:-Comminution:- Multiple fragments.Multiple fragments.

FracturesFractures

A discontinuity in the structural integrity of a bone.

Definition :-

A fracture occurs because the force applied A fracture occurs because the force applied exceeds the breaking strength of the bone so that the exceeds the breaking strength of the bone so that the LoadLoad can no longer be transferred across that zone can no longer be transferred across that zone of the bone.of the bone.

FracturesFractures

All fractures ultimately begin with kinetic energy, All fractures ultimately begin with kinetic energy, released by misadventure and applied to the human released by misadventure and applied to the human body.body.

Some of that energy is absorbed and some is Some of that energy is absorbed and some is transmitted to the surroundings.transmitted to the surroundings.

Absorbed energy must be Absorbed energy must be dissipated, dissipated, ie. distributed, ie. distributed, through the soft tissues and bones. through the soft tissues and bones.

Fractures occur when the bone can not dissipate all of Fractures occur when the bone can not dissipate all of the energy absorbed.the energy absorbed.

FracturesFractures

Bone is a two-phase material :-Bone is a two-phase material :-

Calcium HydroxyApatite CaCalcium HydroxyApatite Ca1010(PO(PO44))66(OH)(OH)22 = mineral = mineral

Osteoid Osteoid Collagen type I and IIICollagen type I and III = = fibrousfibrous

Calcium is strong in compression, but Calcium is strong in compression, but weak in tensionweak in tension..

Osteoid is strong in tension, but Osteoid is strong in tension, but weak in compressionweak in compression..

Mechanical Properties of BoneMechanical Properties of Bone

FracturesFractures

BUT :-BUT :- (for adult bone)(for adult bone)

Calcium is stronger in Calcium is stronger in compression compression than Osteoid is in than Osteoid is in tensiontension

And therefore :-And therefore :-

Bone always fails first in tensionBone always fails first in tension

FracturesFractures

A bone consists of three A bone consists of three areas :- areas :-

the Diaphysisthe Diaphysis

the Metaphysis the Metaphysis

the Epiphysis.the Epiphysis.

Each region has its own Each region has its own fracture characteristics.fracture characteristics.

FracturesFractures

BendingBending

TorqueTorque

DirectDirect

TractionTraction

CompressionCompression

Intra-articularIntra-articular

PediatricPediatric

DiaphysealDiaphyseal

MetaphysealMetaphyseal

EpiphysealEpiphyseal

ObliqueOblique

SpiralSpiral

TransverseTransverse

MixedMixed

FracturesFractures Salter-Harris ClassificationSalter-Harris Classification

II IIII IIIIII

IVIV VV

FracturesFractures Salter-Harris ClassificationSalter-Harris Classification

1) Fractures interfering with growing bones.

2) Worse prognosis with increasing number.

3) Probability of surgery increases with number.

FracturesFractures

A fracture can occur in :-A fracture can occur in :-

normal bone subject to abnormal forces.normal bone subject to abnormal forces.= Traumatic Fractures.= Traumatic Fractures.

abnormal bone subject to normal forces.abnormal bone subject to normal forces. = Pathologic Fractures.= Pathologic Fractures.

normal bone subject to cyclic forces.normal bone subject to cyclic forces.= Fatigue or Stress Fractures.= Fatigue or Stress Fractures.

Fracture DescriptionFracture Description

ThisThis fracturefracture is is angulatedangulated laterally, since it points laterally, since it points laterally.laterally.

The The distal fragmentdistal fragment is is tiltedtilted mediallymedially

DescriptionDescription

Medially DisplacedMedially Displaced

ClosedClosed

ComminutedComminuted

Short ObliqueShort Oblique

Fracture of the Fracture of the

Proximal HumerusProximal Humerus

Caused by a direct fallCaused by a direct fall

Fracture DescriptionFracture Description

1)1) The distal fragment is always described with The distal fragment is always described with relation to the proximal segment.relation to the proximal segment.

2)2) Displacement =Displacement = Translation of bone ends.Translation of bone ends.

3)3) Angulation = Orientation of bone ends.Angulation = Orientation of bone ends.

4)4) Angulation identifies to where the fracture Angulation identifies to where the fracture pointspoints..

5)5) For clarity, the tilt of the distal fragment is For clarity, the tilt of the distal fragment is often used to describe angulation.often used to describe angulation.

Indications for Closed ReductionIndications for Closed Reduction

There is significant displacement.There is significant displacement.

Reduction is possible.Reduction is possible.

The reduction, if gained, can be held.The reduction, if gained, can be held.

The fracture has The fracture has notnot been produced by a been produced by a traction force.traction force.

The Periosteal Bridge

The Periosteal Bridge is The Periosteal Bridge is intact on the concave intact on the concave side of the fracture.side of the fracture.

Reversal of the Reversal of the mechanism of the mechanism of the fracture tightens the fracture tightens the bridge and stabilizes bridge and stabilizes the fracture.the fracture.

The Periosteal BridgeThe Periosteal Bridge

Tightening the periosteal Tightening the periosteal bridge locks the fracture bridge locks the fracture together.together.

Holding the bridge tight Holding the bridge tight requires three point requires three point fixation.fixation.

““It takes a bent cast to It takes a bent cast to produce a straight bone”produce a straight bone”

J. CharnleyJ. Charnley

Indications for Open ReductionIndications for Open Reduction

1 ) There is a significant Displacement.1 ) There is a significant Displacement.

2 ) Open Fractures.2 ) Open Fractures.

3 ) Intra-articular Fractures.3 ) Intra-articular Fractures.

4 ) Un-reducible Fractures4 ) Un-reducible Fractures

5 ) Reductions that cannot be maintained in a cast.5 ) Reductions that cannot be maintained in a cast.

6 ) Comminuted or Segmental Fractures.6 ) Comminuted or Segmental Fractures.

7 ) Floating Joints.7 ) Floating Joints.

8 ) Fractures with Neurovascular damage.8 ) Fractures with Neurovascular damage.

Open FracturesOpen Fractures

Classification :-Classification :-

1.1. < 1 cm., inside-out, little soft tissue damage.< 1 cm., inside-out, little soft tissue damage.

== low potential for infection.low potential for infection.

2.2. 1 cm. – 10 cms., outside-in, requires 1 cm. – 10 cms., outside-in, requires debridement, but no flap or skin graft.debridement, but no flap or skin graft.

== moderate potential for infection.moderate potential for infection.

3.3. > 10 cms., outside-in, high energy, devitalized > 10 cms., outside-in, high energy, devitalized muscle, comminution or bone loss, soft muscle, comminution or bone loss, soft

tissue tissue loss.loss.

Open FracturesOpen Fractures

Classification :-Classification :-

3A.3A. No loss of soft tissue cover, no flap No loss of soft tissue cover, no flap required.required.

3B.3B. Flap required due to soft tissue stripping.Flap required due to soft tissue stripping.

3C.3C. Associated vascular injury.Associated vascular injury.

Type 1. Open Fracture =Type 1. Open Fracture = 6 mm, extend & debride6 mm, extend & debride

Degloving MechanismDegloving Mechanism

Degloving Mechanism

Type III C Injuries – Vascular InjuryType III C Injuries – Vascular Injury

Note pallor of the ankleNo pulses

Fracture ComplicationsFracture Complications

1. Pulmonary Fat Emboli1. Pulmonary Fat Emboli

2. Compartment Syndromes2. Compartment Syndromes

3. Stress Fractures3. Stress Fractures

4. Pathologic Fractures4. Pathologic Fractures

Pulmonary Fat Emboli :- A.R.D.S.Pulmonary Fat Emboli :- A.R.D.S.

- Long bone fractures, burns, contusions.- Long bone fractures, burns, contusions.

- Interstitial pneumonitis due to free fatty acids- Interstitial pneumonitis due to free fatty acids

- S.O.B. & confusion in young adults.- S.O.B. & confusion in young adults.

- Axillary & Subconjunctival Petechiae.- Axillary & Subconjunctival Petechiae.

- Serum lipase elevated.- Serum lipase elevated.

- pAO- pAO2 2 reduced – if < 50 – 20% mortality.reduced – if < 50 – 20% mortality.

- Ventillatory support- Ventillatory support

- Dexamethazone.- Dexamethazone.

- 5 day course.- 5 day course.

Compartment SyndromesCompartment Syndromes

- increased interstitial tissue pressure.- increased interstitial tissue pressure.- fractures, burns, tight dressings.- fractures, burns, tight dressings.

- normal pressure < 25 mm. Hg.normal pressure < 25 mm. Hg.- when the tissue pressure > venous capillary pressure, when the tissue pressure > venous capillary pressure,

but less than the arteriolar pressure.but less than the arteriolar pressure.- 5 P’s5 P’s

- pain.- pain.- pallor.- pallor.- pulselessness.- pulselessness.- paresthesias.- paresthesias.- paralysis.- paralysis.

Compartment SyndromeCompartment Syndrome

Symptom: Pain out of proportion to that

expected for the injury.

Signs: 1. Loss of function of muscle due to

ischemia within the compartment.

2. Pain with passive stretch

3. Numbness etc. are LATE findings!

4. If neuro symptoms present, potential

for full neuro recovery is only 10 %

Rx Compartment SyndromeRx Compartment Syndrome

Release all compressive dressings / plaster.

Elevate extremity to heart level.

Fasciotomies.

4 compartment fasciotomy

Compartment SyndromeCompartment Syndrome

Careful monitoring.

Recognise it - 5 P’s

Call Orthopaedic Surgeon

Pressure measurements

Stress or Fatigue Stress or Fatigue FractureFracture

Repeated loading below acute failure threshold.

Eventual fatigue failure.

Military recruits, runners, aerobics.

Tibia, metatarsals, femoral neck.

Initial x-ray can be negative.

Bone tenderness – Bone scan.

Pathologic FracturesPathologic Fractures

Failure through abnormally weakened bone

Minimal trauma – BEWARE

Osteoporosis Metastasis Tumour:- Benign,

Malignant (Myeloma).

Metabolic Bone Disease

Pathologic FracturesPathologic Fractures

Metastases:Metastases:

LyticLytic -- LungLung

ColonColon

ThyroidThyroid

RenalRenal

BreastBreast

BlasticBlastic -- ProstateProstate

Pathologic FracturesPathologic Fractures

Metastases:Metastases:

- require fixation to prevent fracture if they are > 1/3.- require fixation to prevent fracture if they are > 1/3.

- produce pain on weight bearing in the lower limb.- produce pain on weight bearing in the lower limb.

- survival > 3 months.- survival > 3 months.

- cannot be managed by medical therapy.- cannot be managed by medical therapy.

- radiotherapy - radiotherapy afterafter fixation (2 weeks) fixation (2 weeks)

(radiotherapy induced osteonecrotic fractures)(radiotherapy induced osteonecrotic fractures)

Pathologic FracturesPathologic Fractures

DislocationsDislocations

The articular surfaces are no longer in contact.The articular surfaces are no longer in contact.

Commonly affects - Commonly affects -

Shoulders > PIP joints > Elbows > Ankles.Shoulders > PIP joints > Elbows > Ankles.

Often associated with fractures.Often associated with fractures.

Often associated with neurologic injuriesOften associated with neurologic injuries

Shoulder DislocationsShoulder Dislocations95 % anterior95 % anterior

1 % posterior1 % posterior

Luxatio erectaLuxatio erecta

MedialMedial

Axillary nerve injuryAxillary nerve injury

Rapid reductionRapid reduction

Shoulder DislocationsShoulder Dislocations

Conscious sedation. Conscious sedation.

Traction reduction.Traction reduction.

Immobilization.Immobilization.

Recurrent.Recurrent.

VoluntaryVoluntary

Habitual.Habitual.

Multiaxial instability.Multiaxial instability.

Elbow DislocationElbow DislocationPosterolateral.Posterolateral.

Median nerve injury.Median nerve injury.

Ulnar nerve injury.Ulnar nerve injury.

Rapid reduction.Rapid reduction.

Early mobilization.Early mobilization.

Back PainBack Pain

Classification: Mechanical Classification: Mechanical (MacKenzie)(MacKenzie)

Postural syndromePostural syndrome• normal tissues become painful by the application of normal tissues become painful by the application of

prolonged stresses (sitting, bending etc)prolonged stresses (sitting, bending etc)

Dysfunction syndromeDysfunction syndrome• soft tissues are shortened and stiff. Usually >30 year soft tissues are shortened and stiff. Usually >30 year

old, poor posture, under exercised, reduced mobilityold, poor posture, under exercised, reduced mobility

Derangement syndromeDerangement syndrome• Disc derangement (tears and herniation)Disc derangement (tears and herniation)

Causes and Classification of Causes and Classification of Back Pain: McNabBack Pain: McNab

ViscerogenicViscerogenic VasculogenicVasculogenic NeurogenicNeurogenic PsychogenicPsychogenic SpondylogenicSpondylogenic

SpondylogenicSpondylogenicOsseus:Osseus:

• TraumaTrauma

• InfectionInfection

• NeoplasmsNeoplasms

• InflammatoryInflammatory

• Metabolic (eg.Pagets)Metabolic (eg.Pagets)

• DeformitiesDeformities Soft tissues:Soft tissues:

• MusclesMuscles

• SI jointsSI joints

• DiscDisc

• FacetsFacets

Non operative Treatment of Non operative Treatment of Back PainBack Pain

Do nothingDo nothing

Activity modificationActivity modification

MedicationsMedications

Exercise and physiotherapyExercise and physiotherapy

BracesBraces

ManipulationManipulation

Massage therapyMassage therapy

Traction/inversion therapyTraction/inversion therapy

Vitamins/Supplements/DietsVitamins/Supplements/Diets

Weight controlWeight control

Every Suzanne Summers sponsored abs exerciserEvery Suzanne Summers sponsored abs exerciser

AnatomyAnatomy

Extension Flexion

Three joint complexThree joint complex(Kirkaldy Willis, Farfan)(Kirkaldy Willis, Farfan)

C ap su la r laxity

E n la rg em en t o f a rt icu la r p rocess

S u b lu xa tion

O s teop h yte fo rm ation

C artilag e d es tru c tion

S yn ovia l reac tion face t jo in t

D isc h ern ia tion

os teop h ytes

d ec rease d isc h e ig h t

In te rn a l d isc d is ru p tion

rad ia l tea r

D isc c ircu m feren c ia l tea rs

R ecu rren t ro ta tion a l s tra in

Instability

Lateral n. ent

Central stenosis

Disc herniationDisc herniation

Ms J.H. 25 y.o. female presented with cauda equina syndrome

Cauda Equina SyndromeCauda Equina Syndrome

Sciatica associated with bowel or bladder dysfunction.Sciatica associated with bowel or bladder dysfunction.

Perineal numbness.Perineal numbness.

Low or Sequestrated Lumbar Disc.Low or Sequestrated Lumbar Disc.

Pressure on SPressure on S11, S, S22 and/or S and/or S33 nerve roots. nerve roots.

Requires immediate Decompression to avoid Requires immediate Decompression to avoid permanent disability.permanent disability.

Spinal stenosisSpinal stenosis

Symptoms:Symptoms: unilateral radicular painunilateral radicular pain bilateral claudicationbilateral claudication better with forward better with forward

flexion of trunkflexion of trunk better walking uphillbetter walking uphill rare bowel/bladder rare bowel/bladder

involvementinvolvement

Signs:Signs: usually no neuro signsusually no neuro signs look for pulseslook for pulses stress teststress test

Investigations:Investigations: XRXR CTCT Myelo-CTMyelo-CT MRIMRI

Time for a 10 minute break!Time for a 10 minute break!

1. 1. Talipes Equinovarus is the proper Talipes Equinovarus is the proper name for :-name for :-

a.a. Flat feetFlat feet

b.b. In-toeingIn-toeing

c.c. Club feetClub feet

d.d. Knock kneesKnock knees

e.e. Wry neckWry neck

1.1. Talipes Equinovarus is the proper Talipes Equinovarus is the proper name for :-name for :-

a.a. Flat feetFlat feet

b.b. In-toeingIn-toeing

c.c. Club feetClub feet

d.d. Knock kneesKnock knees

e.e. Wry neckWry neck

Pes Planus

Metatarsus Adductus

Genu Valgus

Torticolis

Talipes EquinovarusTalipes Equinovarus

congenital deformity of the footcongenital deformity of the footEquinus, Inversion, Adduction, SupinationEquinus, Inversion, Adduction, Supination2 per 1000 live births2 per 1000 live births50% bilateral50% bilateralM >F 2:1M >F 2:1Serial corrective casts at birthSerial corrective casts at birthSurgery if resistantSurgery if resistant

EARLY TREATMENT IS ESSENTIALEARLY TREATMENT IS ESSENTIAL

2.2. A Trendelenburg sign refers A Trendelenburg sign refers to :-to :-

a.a. Leg length discrepancyLeg length discrepancy

b.b. Gait abnormalityGait abnormality

c.c. Knee recurvatumKnee recurvatum

d.d. ScoliosisScoliosis

e.e. Hip ContractureHip Contracture

2.2. A Trendelenburg sign refers A Trendelenburg sign refers to :-to :-

a.a. Leg length discrepancyLeg length discrepancy

b.b. Gait abnormality - Trendelenburg gaitGait abnormality - Trendelenburg gait

c.c. Knee recurvatumKnee recurvatum

d.d. ScoliosisScoliosis

e.e. Hip ContractureHip Contracture

3.3. All of these are signs of All of these are signs of D.D.H. D.D.H. except :-except :-

a.a. Limited AbductionLimited Abduction

b.b. Ortolani SignOrtolani Sign

c.c. Asymmetric Skin FoldsAsymmetric Skin Folds

d.d. Galeazzi’s SignGaleazzi’s Sign

e.e. McMurray SignMcMurray Sign

3.3. All of these are signs of All of these are signs of D.D.H. D.D.H. except :-except :-

a.a. Limited AbductionLimited Abduction

b.b. Ortolani SignOrtolani Sign

c.c. Asymmetric Skin FoldsAsymmetric Skin Folds

d.d. Galeazzi’s SignGaleazzi’s Sign

e.e. McMurray SignMcMurray Sign

Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip

Acetabular dysplasiaAcetabular dysplasia

Femoral anteversionFemoral anteversion

Adduction ContractureAdduction Contracture

50% bilateral, F > M 8:150% bilateral, F > M 8:1

Test Test ALLALL newborns at birth newborns at birth

Conservative Rx at birth – Pavlik, D.diaperConservative Rx at birth – Pavlik, D.diaper

Surgical Rx if resistantSurgical Rx if resistant

44.. The most common congenital The most common congenital spinal abnormality is :-spinal abnormality is :-

a.a. ScoliosisScoliosis

b.b. Spina BifidaSpina Bifida

c.c. TorticolisTorticolis

d.d. Klippel – Feil SyndromeKlippel – Feil Syndrome

e.e. Multiple Hereditary OsteochondromaMultiple Hereditary Osteochondroma

44.. The most common congenital The most common congenital spinal abnormality is :-spinal abnormality is :-

a.a. ScoliosisScoliosis

b.b. Spina BifidaSpina Bifida

c.c. TorticolisTorticolis

d.d. Klippel – Feil SyndromeKlippel – Feil Syndrome

e.e. Multiple Hereditary OsteochondromaMultiple Hereditary Osteochondroma

Spinal BifidaSpinal Bifida

defect of neural tube closuredefect of neural tube closure

Lumbar spine, commonly low Lumbar spine, commonly low

2 per 1000 2 per 1000

myelodysplasiamyelodysplasia

Mild to complete paraplegiaMild to complete paraplegia

Occulta, meningocoele, MyelomeningocoeleOcculta, meningocoele, Myelomeningocoele

Bowel and bladder dysfunctionBowel and bladder dysfunction

5.

5. PolydactylyPolydactyly

6.

6. SyndactylySyndactyly

7.

7. Sprengel’sSprengel’s DeformityDeformity

Omovertebral Bone

8.8. A 6 year old boy with delayed physical A 6 year old boy with delayed physical development, convulsions, tetany, development, convulsions, tetany, weakness, weakness, blue sclera and bony deformities blue sclera and bony deformities is is most likely most likely suffering from :-suffering from :-

a.a. Physical AbusePhysical Abuse

b.b. Ehlers – Danlos SyndromeEhlers – Danlos Syndrome

c.c. Osteogenesis ImperfectaOsteogenesis Imperfecta

d.d. Multiple Hereditary ExostosesMultiple Hereditary Exostoses

e.e. Myositis OssificansMyositis Ossificans

8.8. A 6 year old boy with delayed physical A 6 year old boy with delayed physical development, convulsions, tetany, development, convulsions, tetany, weakness, weakness, blue sclera and bony deformities blue sclera and bony deformities is is most likely most likely suffering from :-suffering from :-

a.a. Physical AbusePhysical Abuse

b.b. Ehlers – Danlos SyndromeEhlers – Danlos Syndrome

c.c. Osteogenesis ImperfectaOsteogenesis Imperfecta

d.d. Multiple Hereditary ExostosesMultiple Hereditary Exostoses

e.e. Myositis OssificansMyositis Ossificans

9.9. A 6 year old boy with delayed physical A 6 year old boy with delayed physical development, a rachitic rosary, weakness and development, a rachitic rosary, weakness and bony deformities is most likely suffering from :-bony deformities is most likely suffering from :-

a.a. Physical AbusePhysical Abuse

b.b. RicketsRickets

c.c. ScurvyScurvy

d.d. Osteitis DeformansOsteitis Deformans

e.e. Myositis OssificansMyositis Ossificans

9.9. A 6 year old boy with delayed physical A 6 year old boy with delayed physical development, a rachitic rosary, weakness and development, a rachitic rosary, weakness and bony deformities is most likely suffering from :-bony deformities is most likely suffering from :-

a.a. Physical AbusePhysical Abuse

b.b. RicketsRickets

c.c. ScurvyScurvy

d.d. Osteitis DeformansOsteitis Deformans

e.e. Myositis OssificansMyositis Ossificans

9. Rachitic Rosary

9.Delayed Ossification

Etiology Alkaline Calcium Phosphate Urea Phosphatase

Vitamin D Up Down Normal NormalDeficiencyRickets

Renal Up Down Up UpInsufficiency(Renal Rickets)

Renal Up Down Down NormalTubular Insufficiency(HypoPhosphatemia)

10. This is :-10. This is :-

a.a. OsteomyelitisOsteomyelitis

b.b. OsteomalaciaOsteomalacia

c.c. OsteoporosisOsteoporosis

d.d. Osteitis DeformansOsteitis Deformans

e.e. LeprosyLeprosy

10. This is :-10. This is :-

a.a. OsteomyelitisOsteomyelitis

b.b. OsteomalaciaOsteomalacia

c.c. OsteoporosisOsteoporosis

d.d. Osteitis DeformansOsteitis Deformans

e.e. LeprosyLeprosy

Osteitis DeformansOsteitis DeformansPaget’s DiseasePaget’s Disease

4% of pop. Over 40 yrs.4% of pop. Over 40 yrs.

accelerated bone turnoveraccelerated bone turnover

often assymptomaticoften assymptomatic

monostotic > polyostoticmonostotic > polyostotic

loss of statureloss of stature

AV shuntingAV shunting

pathologic bonepathologic bone

11.11. A child with knee pain has a ____ A child with knee pain has a ____ problem until proven otherwise.problem until proven otherwise.

a.a. KneeKnee

b.b. FemoralFemoral

c.c. TibialTibial

d.d. HipHip

e.e. PatellaPatella

11.11. A child with knee pain has a ____ A child with knee pain has a ____ problem until proven otherwise.problem until proven otherwise.

a.a. KneeKnee

b.b. FemoralFemoral

c.c. TibialTibial

d.d. HipHip

e.e. PatellaPatella

Obdurator Nerve

11.11. All of the following are part of All of the following are part of the the differential of hip pain in a 6 year old, differential of hip pain in a 6 year old, except :-except :-

a.a. Femoral OsteomyelitisFemoral Osteomyelitis

b.b. Septic HipSeptic Hip

c.c. Transient SynovitisTransient Synovitis

d.d. Legg-Perthes OsteochondritisLegg-Perthes Osteochondritis

e.e. Slipped Capital Femoral EpiphysisSlipped Capital Femoral Epiphysis

11.11. All of the following are part of All of the following are part of the the differential of hip pain in a 6 year old, differential of hip pain in a 6 year old, except :-except :-

a.a. Femoral OsteomyelitisFemoral Osteomyelitis

b.b. Septic HipSeptic Hip

c.c. Transient SynovitisTransient Synovitis

d.d. Legg-Perthes OsteochondritisLegg-Perthes Osteochondritis

e.e. Slipped Capital Femoral EpiphysisSlipped Capital Femoral Epiphysis

Ages for Hip DiseaseAges for Hip Disease

D.D.H.D.D.H. BirthBirth

Septic HipSeptic Hip Birth – 11Birth – 11

Legg-PerthesLegg-Perthes 3 – 113 – 11

Transient SynovitisTransient Synovitis 3 – 113 – 11

S.C.F.E.S.C.F.E. 11 - 1611 - 16

12.12. Osteomyelitis in children is Osteomyelitis in children is produced by what route of infection?produced by what route of infection?

a.a. Direct extension from another focusDirect extension from another focus

b.b. Hematogenous spreadHematogenous spread

c.c. Perforating woundsPerforating wounds

d.d. Lymphatic spreadLymphatic spread

e.e. Septic hipSeptic hip

12.12. Osteomyelitis in children is Osteomyelitis in children is produced by what route of infection?produced by what route of infection?

a.a. Direct extension from another focusDirect extension from another focus

b.b. Hematogenous spreadHematogenous spread

c.c. Perforating woundsPerforating wounds

d.d. Lymphatic spreadLymphatic spread

e.e. Septic hipSeptic hip

OsteomyelitisOsteomyelitis

Acute infection,metaphysealAcute infection,metaphyseal

90% Staph., 20% mortality90% Staph., 20% mortality

100% growth abnormality100% growth abnormality

Periosteal elevation, osteolysisPeriosteal elevation, osteolysis

Sequestrum, InvolucrumSequestrum, Involucrum

13.

13.

Paronychia

14.

14.

FelonA pulp space infection

15.15. All of these are findings of a All of these are findings of a herniated Lherniated L55-S-S11 disc, except :- disc, except :-

a.a. Absent Achilles reflexAbsent Achilles reflex

b.b. Lateral foot numbnessLateral foot numbness

c.c. SciaticaSciatica

d.d. Low back painLow back pain

e.e. Extensor Hallucis Longus weaknessExtensor Hallucis Longus weakness

15.15. All of these are findings of a All of these are findings of a herniated Lherniated L55-S-S11 disc, except :- disc, except :-

a.a. Absent Achilles reflexAbsent Achilles reflex

b.b. Lateral foot numbnessLateral foot numbness

c.c. SciaticaSciatica

d.d. Low back painLow back pain

e.e. Extensor Hallucis Longus weaknessExtensor Hallucis Longus weakness

15.15. All of these are findings of a All of these are findings of a herniated Lherniated L55-S-S11 disc, except :- disc, except :-

a.a. Absent Achilles reflexAbsent Achilles reflex

b.b. Lateral foot numbnessLateral foot numbness

c.c. SciaticaSciatica

d.d. Low back painLow back pain

e.e. Extensor Hallucis Longus weaknessExtensor Hallucis Longus weakness

15.15. All of these are findings of a All of these are findings of a herniated Lherniated L55-S-S11 disc, except :- disc, except :-

a.a. Absent Achilles reflexAbsent Achilles reflex SS11

b.b. Lateral foot numbnessLateral foot numbness SS11

c.c. SciaticaSciatica SS11

d.d. Low back painLow back pain

e.e. Extensor Hallucis Longus weaknessExtensor Hallucis Longus weakness LL55

16.16. Avascular necrosis of the femoral Avascular necrosis of the femoral head is associated with all of the following head is associated with all of the following except :-except :-

a.a. Steroid useSteroid use

b.b. AlcoholAlcohol

c.c. Deep sea divingDeep sea diving

d.d. Lipid storage diseaseLipid storage disease

e.e. DiabetesDiabetes

16.16. Avascular necrosis of the femoral Avascular necrosis of the femoral head is associated with all of the following head is associated with all of the following except :-except :-

a.a. Steroid useSteroid use

b.b. AlcoholAlcohol

c.c. Deep sea divingDeep sea diving

d.d. Lipid storage diseaseLipid storage disease

e.e. DiabetesDiabetes

17.

8 year old boy

What is the What is the Diagnosis?Diagnosis?

17.

8 year old boy

Legg – Perthes

Osteochondosis

Legg-Perthe’s DiseaseLegg-Perthe’s Disease

Osteochondrosis (avascular necrosis)Osteochondrosis (avascular necrosis)

Proximal Femoral EpiphysisProximal Femoral Epiphysis

Necrosis, revascularization, fragmentation, healingNecrosis, revascularization, fragmentation, healing

3 – 11 yrs., M > F 4:1, 15% bilat.3 – 11 yrs., M > F 4:1, 15% bilat.

Subluxation laterally, Coxa plana, Coxa magnaSubluxation laterally, Coxa plana, Coxa magna

Osteoarthritis 50 yrs.Osteoarthritis 50 yrs.

19. Diagnosis?

19. Gout

GoutGout

Urate crystalopathic arthritisUrate crystalopathic arthritis

Crystals in periarticular tissuesCrystals in periarticular tissues

Inconsistant elevated serum urate Inconsistant elevated serum urate

Allopurinol and colchicineAllopurinol and colchicine

Tophi in periarticular soft tissuesTophi in periarticular soft tissues

Deposits in non-articular cartilageDeposits in non-articular cartilage

Juxta-articular erosionsJuxta-articular erosions

20.

LL55

LL44

20.

LL55

LL44

Spondylolytic Spondylolisthesis

SpondylolisthesisSpondylolisthesis

Lumbosacral junction defectLumbosacral junction defect

Spondylolysis of Pars InterarticularisSpondylolysis of Pars Interarticularis

Traumatic or congenitalTraumatic or congenital

Acute – immobilizeAcute – immobilize

Chronic - surgeryChronic - surgery

21.21. The Salter- Harris Classification is The Salter- Harris Classification is used to assess the severity of :-used to assess the severity of :-

a.a. Epiphyseal FracturesEpiphyseal Fractures

b.b. Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip

c.c. Legg – Perthe’s DiseaseLegg – Perthe’s Disease

d.d. Club FootClub Foot

e.e. OsteomyelitisOsteomyelitis

21.21. The Salter- Harris Classification is The Salter- Harris Classification is used to assess the severity of :-used to assess the severity of :-

a.a. Epiphyseal FracturesEpiphyseal Fractures

b.b. Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip

c.c. Legg – Perthe’s DiseaseLegg – Perthe’s Disease

d.d. Club FootClub Foot

e.e. OsteomyelitisOsteomyelitis

22. What is this deformity?

22. A Diner Fork DeformityA Diner Fork Deformity

Probable Diagnosis?Probable Diagnosis?

22.22. Colles Colles FractureFracture

22.22. Colle’s Fracture Colle’s Fracture

distal radial fracturedistal radial fracture

FOOSHFOOSH

occurs at all agesoccurs at all ages

commonly 60 yrs. +commonly 60 yrs. +

osteoporosisosteoporosis

intra-articularintra-articular

CR & K-WiresCR & K-Wires

External vs Internal FixationExternal vs Internal Fixation

23. The common complication of this fracture is :-

23.23. Proximal pole Avascular Necrosis Proximal pole Avascular Necrosis due to a Scaphoid Fracturedue to a Scaphoid Fracture

24. This is a :-

a. Buckle Fracture

b. Greenstick Fracture

c. Stress Fracture

d. Pathologic Fracture

e. Growth Arrest line

24. This is a :-

a. Buckle Fracture

b. Greenstick Fracture

c. Stress Fracture

d. Pathologic Fracture

e. Growth Arrest line

This is a :-

24.

a. Buckle Fracture

b. Greenstick Fracture

c. Stress Fracture

d. Pathologic Fracture

e. Growth Arrest line

This is a :-

24.

a. Buckle Fracture

b. Greenstick Fracture

c. Stress Fracture

d. Pathologic Fracture

e. Growth Arrest line

25. Is this fracture treated by Closed or 25. Is this fracture treated by Closed or Open Reduction?Open Reduction?

ORIFORIF

25.25.

25. Fractures of Necessity25. Fractures of Necessity

26. What is the Diagnosis?

26. Posterolateral Dislocation of the Elbow

26. Reduction by traction.26. Reduction by traction.

TRACTION

27. What is the Diagnosis?27. What is the Diagnosis?

27. 27. Anterior Dislocation of the Anterior Dislocation of the ShoulderShoulder

27. Reduction by traction

28.

This is a :-

a. Supracondylar #

b. Olecranon #

c. Dislocation

d. Forearm #

e. Radial Head #

28.

This is a :-

a. Supracondylar #

b. Olecranon #

c. Dislocation

d. Forearm #

e. Radial Head #

28. Supracondylar Fracture28. Supracondylar Fracture

29.29. The complications of a Supracondylar The complications of a Supracondylar fracture in children include all of the fracture in children include all of the following except :-following except :-

a. Maluniona. Malunion

b. Volkmann’s Ischemic Contractureb. Volkmann’s Ischemic Contracture

c. Compartment Syndromec. Compartment Syndrome

d. Cubitus Varusd. Cubitus Varus

e. Peripheral Nerve Injuriese. Peripheral Nerve Injuries

f. Pulmonary Fat Embolusf. Pulmonary Fat Embolus

29.29. The complications of a Supracondylar The complications of a Supracondylar fracture in children include all of the fracture in children include all of the following except :-following except :-

a. Maluniona. Malunion

b. Volkmann’s Ischemic Contractureb. Volkmann’s Ischemic Contracture

c. Compartment Syndromec. Compartment Syndrome

d. Cubitus Varusd. Cubitus Varus

e. Peripheral Nerve Injuriese. Peripheral Nerve Injuries

f. f. Pulmonary Fat EmbolusPulmonary Fat Embolus

30. The only sign of a Compartment 30. The only sign of a Compartment Syndrome that is always present Syndrome that is always present is :- is :-

a. Paina. Pain

b. Pallorb. Pallor

c. Pulselessnessc. Pulselessness

d. Paresthesiasd. Paresthesias

e. Paralysise. Paralysis

30. The only sign of a Compartment 30. The only sign of a Compartment Syndrome that is always present Syndrome that is always present is :- is :-

a. a. Pain out of proportionPain out of proportion

b. Pallorb. Pallor

c. Pulselessnessc. Pulselessness

d. Paresthesiasd. Paresthesias

e. Paralysise. Paralysis

31.31. Compartment pressures Compartment pressures indicating the need for indicating the need for fasciotomy :-fasciotomy :-

a. 0 – 15 mms. Hga. 0 – 15 mms. Hg

b. 15 – 25 mms. Hgb. 15 – 25 mms. Hg

c. > 25 mms. Hgc. > 25 mms. Hg

d. > 50 mms. Hgd. > 50 mms. Hg

e. > 75 mms. Hge. > 75 mms. Hg

31.31. Compartment pressures Compartment pressures indicating the need for indicating the need for fasciotomy :-fasciotomy :-

a. 0 – 15 mms. Hga. 0 – 15 mms. Hg

b. 15 – 25 mms. Hgb. 15 – 25 mms. Hg

c. c. > 25 mms. Hg> 25 mms. Hg

d. > 50 mms. Hgd. > 50 mms. Hg

e. > 75 mms. Hge. > 75 mms. Hg

32.32. A 20 yr. old male with a fractured A 20 yr. old male with a fractured femur has findings of confusion, femur has findings of confusion,

tachypnea and conjunctival petechia. tachypnea and conjunctival petechia. The The most likely diagnosis is :-most likely diagnosis is :-

a. Pneumoniaa. Pneumonia

b. Pulmonary Fat Embolib. Pulmonary Fat Emboli

c. Cerebral Contusionc. Cerebral Contusion

d. Cardiac Contusiond. Cardiac Contusion

e. Transient Stress Reactione. Transient Stress Reaction

32.32. A 20 yr. old male with a fractured A 20 yr. old male with a fractured femur has findings of confusion, femur has findings of confusion,

tachypnea and conjunctival petechia. tachypnea and conjunctival petechia. The The most likely diagnosis is :-most likely diagnosis is :-

a. Pneumoniaa. Pneumonia

b. b. Pulmonary Fat EmboliPulmonary Fat Emboli

c. Cerebral Contusionc. Cerebral Contusion

d. Cardiac Contusiond. Cardiac Contusion

e. Transient Stress Reactione. Transient Stress Reaction

35.35. What fracture is this? What fracture is this?

35.35. A fracture of the Humerus A fracture of the Humerus

35.35. The commonest complication The commonest complication of this fracture is :- of this fracture is :-

35.35. A Radial Nerve Palsy A Radial Nerve Palsy

36.36. Does this fracture Does this fracture require surgery?require surgery?

36.36. Does this fracture Does this fracture require surgery?require surgery?

YES

38.38. This patient This patient most likely most likely

has a fracture has a fracture of of the ….?the ….?

38.38. This patient This patient most likely most likely

has a fracture has a fracture of of the --------.the --------.

HipHip

38.38. This patient This patient most likely most likely

has a fracture has a fracture of of the hip.the hip.

External RotationExternal Rotation

ShorteningShortening

Hip FlexionHip Flexion

38.38.

39.39. What’s the Diagnosis? What’s the Diagnosis?

39. Sub-Capital Hip Fracture.39. Sub-Capital Hip Fracture.

40.40. All of the following are All of the following are complications of this fracture except :-complications of this fracture except :-

a. Malunion a. Malunion

b. Avascular necrosisb. Avascular necrosis

c. Fat embolic. Fat emboli

d. Non-uniond. Non-union

e. Thrombophlebitise. Thrombophlebitis

40.40. All of the following are All of the following are complications of this fracture except :-complications of this fracture except :-

a. Malunion a. Malunion

b. Avascular necrosisb. Avascular necrosis

c. c. Fat emboliFat emboli

d. Non-uniond. Non-union

e. Thrombophlebitise. Thrombophlebitis

40. Blood Supply of Femoral Head40. Blood Supply of Femoral Head

40. Save Head versus Replacement40. Save Head versus Replacement

40. Subcapital Hip Fractures40. Subcapital Hip Fractures

1. Avascular Necrosis - 30%

2. Malunion - 30%

3. Non-union - 30%

4. Surgery required

5. Older population

6. Pathologic - Osteoporotic

Properties

41. What’s the Diagnosis?41. What’s the Diagnosis?

41. 41. Intertrochanteric Hip FractureIntertrochanteric Hip Fracture

41. Intertrochanteric Fractures41. Intertrochanteric Fractures

Properties

1. Varus deformity

2. Well - Healing

3. Traumatic + Osteoporosis

4. Surgery required

5. Mid-range Age population

43.43.

Surgery Surgery or not?or not?

43.43.

Surgery Surgery or not?or not?

YesYes

44.44. Surgery or not? Surgery or not?

44.44. Surgery or not? Surgery or not?

YesYes

23 y.o. male

Basketball injury

Open fracture

Numbness dorsum toes

45. What is the approach to this fracture?45. What is the approach to this fracture?

Reduce dislocation

Sterile dressing

Splint extremity

Re-check NV status

IV Antibiotics

Tetanus

Surgery

45.45.

48.48. A 45 yr. old male, who was previously in good health, A 45 yr. old male, who was previously in good health, has sudden onset of transverse low back pain and right has sudden onset of transverse low back pain and right sided sciatica to his foot, after chopping wood at the sided sciatica to his foot, after chopping wood at the cottage. Upon arising the following morning, he notices cottage. Upon arising the following morning, he notices numbness on the outer border of his numbness on the outer border of his right foot and right foot and

some weakness in the right leg. He has no bowel or some weakness in the right leg. He has no bowel or bladder bladder problems.problems.

The most likely diagnosis would be:-The most likely diagnosis would be:-

a.a. Lumbar Muscular Strain.Lumbar Muscular Strain.b.b. Herniated Lumbar Disc.Herniated Lumbar Disc.c.c. Herniated Lumbosacral Disc.Herniated Lumbosacral Disc.d.d. Cauda Equina Syndrome.Cauda Equina Syndrome.e.e. Spinal Stenosis.Spinal Stenosis.

48.48. A 45 yr. old male, who was previously in good health, A 45 yr. old male, who was previously in good health, has sudden onset of transverse low back pain and right has sudden onset of transverse low back pain and right sided sciatica to his foot, after chopping wood at the sided sciatica to his foot, after chopping wood at the cottage. Upon arising the following morning, he notices cottage. Upon arising the following morning, he notices numbness on the outer border of his numbness on the outer border of his right foot and right foot and

some weakness in the right leg. He has no bowel or some weakness in the right leg. He has no bowel or bladder bladder problems.problems.

The most likely diagnosis would be:-The most likely diagnosis would be:-

a.a. Lumbar Muscular Strain.Lumbar Muscular Strain.b.b. Herniated Lumbar Disc.Herniated Lumbar Disc.c.c. Herniated Lumbosacral Disc.Herniated Lumbosacral Disc.d.d. Cauda Equina Syndrome.Cauda Equina Syndrome.e.e. Spinal Stenosis.Spinal Stenosis.

49.49. Your Your initialinitial approach to this problem would approach to this problem would

include some or all of the following:-include some or all of the following:-

a.a. Bedrest.Bedrest.

b.b. Anti-inflammatories.Anti-inflammatories.

c.c. Muscle Relaxants.Muscle Relaxants.

d.d. Spinal X-rays.Spinal X-rays.

e.e. Physiotherapy.Physiotherapy.

f.f. Orthopedic/Neurosurgical referral.Orthopedic/Neurosurgical referral.

g.g. CT-Myelogram or MRICT-Myelogram or MRI

h.h. DiscectomyDiscectomy

49.49. Your Your initialinitial approach to this problem would approach to this problem would

include some or all of the following:-include some or all of the following:-

a.a. Bedrest.Bedrest.

b.b. Anti-inflammatories.Anti-inflammatories.

c.c. Muscle Relaxants.Muscle Relaxants.

d.d. Spinal X-rays.Spinal X-rays.

e.e. Physiotherapy.Physiotherapy.

f.f. Orthopedic/Neurosurgical referral.Orthopedic/Neurosurgical referral.

g.g. CT-Myelogram or MRICT-Myelogram or MRI

h.h. DiscectomyDiscectomy??

50.50. During the work-up for this problem, the patient During the work-up for this problem, the patient complains that he has unaccountably soiled his complains that he has unaccountably soiled his underwear, without knowing it. Your response to this underwear, without knowing it. Your response to this would be to:-would be to:-

a.a. Reassure the patient that this is not seriousReassure the patient that this is not serious

b. b. Order an urgent MRIOrder an urgent MRI

c.c. Get an urgent referral to Neuro/OrthopedicsGet an urgent referral to Neuro/Orthopedics

d. d. Place the patient on immediate bedrest.Place the patient on immediate bedrest.

50.50. During the work-up for this problem, the patient During the work-up for this problem, the patient complains that he has unaccountably soiled his complains that he has unaccountably soiled his underwear, without knowing it. Your response to this underwear, without knowing it. Your response to this would be to:-would be to:-

a.a. Reassure the patient that this is not seriousReassure the patient that this is not serious

b. b. Order an urgent MRIOrder an urgent MRI

c.c. Get an urgent referral to Get an urgent referral to Neuro/OrthopedicsNeuro/Orthopedics

d. d. Place the patient on immediate bedrest.Place the patient on immediate bedrest.

51.51. A lumberjack felling a tree is unfortunately A lumberjack felling a tree is unfortunately struck on the back by the tree, knocking him to the struck on the back by the tree, knocking him to the ground and injuring his left lower extremity. In the ground and injuring his left lower extremity. In the ER, his left hip is in flexion, adduction and internal ER, his left hip is in flexion, adduction and internal rotation. The most likely diagnosis is:-rotation. The most likely diagnosis is:-

a.a. Fracture of the Hip.Fracture of the Hip.b.b. Fracture of the Femur.Fracture of the Femur.c.c. Anterior Hip Dislocation.Anterior Hip Dislocation.d.d. Posterior Hip Dislocation.Posterior Hip Dislocation.e.e. Fracture of Pelvis.Fracture of Pelvis.

51.51. A lumberjack felling a tree is unfortunately A lumberjack felling a tree is unfortunately struck on the back by the tree, knocking him to the struck on the back by the tree, knocking him to the ground and injuring his left lower extremity. In the ground and injuring his left lower extremity. In the ER, his left hip is in flexion, adduction and internal ER, his left hip is in flexion, adduction and internal rotation. The most likely diagnosis is:-rotation. The most likely diagnosis is:-

a.a. Fracture of the Hip.Fracture of the Hip.b.b. Fracture of the Femur.Fracture of the Femur.c.c. Anterior Hip Dislocation.Anterior Hip Dislocation.d.d. Posterior Hip Dislocation.Posterior Hip Dislocation.e.e. Fracture of Pelvis.Fracture of Pelvis.

52.52. Which of the following signs and symptoms are consistent with a torn medial meniscus of the knee:-

a.a. Inability to squatInability to squat

b.b. Pain on descending stairsPain on descending stairs

c.c. LockingLocking

d.d. Recurrent effusionsRecurrent effusions

e.e. All of the above.All of the above.

52.52. Which of the following signs and symptoms are consistent with a torn medial meniscus of the knee:-

a.a. Inability to squatInability to squat

b.b. Pain on descending stairsPain on descending stairs

c.c. LockingLocking

d.d. Recurrent effusionsRecurrent effusions

e.e. All of the above.All of the above.

53. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle.

Your response to this situation would be to:-

a. a. Re-X-ray the ankle.Re-X-ray the ankle.

b.b. Remove the cast.Remove the cast.

c.c. Measure the compartment pressures.Measure the compartment pressures.

d.d. Instruct the patient to elevate the Instruct the patient to elevate the limb and prescribe an limb and prescribe an anti-inflamatory.anti-inflamatory.

53. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle.

Your response to this situation would be to:-

a. a. Re-X-ray the ankle.Re-X-ray the ankle.

b.b. Remove the cast.Remove the cast.

c.c. Measure the compartment pressures.Measure the compartment pressures.

d.d. Instruct the patient to elevate the Instruct the patient to elevate the limb and prescribe an limb and prescribe an anti-inflamatory.anti-inflamatory.

54.54. The most common dislocations of the The most common dislocations of the shoulder are:-shoulder are:-

a.a. Medial.Medial.

b.b. Posterior.Posterior.

c.c. Luxatio Erecta.Luxatio Erecta.

d.d. Anterior.Anterior.

54.54. The most common dislocations of the The most common dislocations of the shoulder are:-shoulder are:-

a.a. Medial.Medial.

b.b. Posterior.Posterior.

c.c. Luxatio Erecta.Luxatio Erecta.

d.d. Anterior.Anterior.

55.55. Metastatic lesions to bone, of the Metastatic lesions to bone, of the following tumours, usually produce lytic following tumours, usually produce lytic defects except:-defects except:-

a.a. Thyroid.Thyroid.

b.b. Pancreas.Pancreas.

c.c. Prostate.Prostate.

d.d. Kidney.Kidney.

e.e. Lung.Lung.

55.55. Metastatic lesions to bone, of the Metastatic lesions to bone, of the following tumours, usually produce lytic following tumours, usually produce lytic defects except:-defects except:-

a.a. Thyroid.Thyroid.

b.b. Pancreas.Pancreas.

c.c. Prostate.Prostate.

d.d. Kidney.Kidney.

e.e. Lung.Lung.

Th - Tha – That’s all folks!Th - Tha – That’s all folks!