LMCC Orthopedic Review Lecture
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Transcript of LMCC Orthopedic Review Lecture
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!